[Lobectomy performed through a video-assisted mini thoracotomy, as a new technique in our clinical practice]. / Videoasszisztált minithoracotomiából elvégzett lobectomia mint új mutéti eljárás klinikai gyakorlatunkban.

UNLABELLED: In this retrospective study, we present our experiences and results with lobectomy performed through video-assisted mini thoracotomy (VAMT), a technique that we have been using since 2006. METHOD AND PATIENTS: In the first half of 2006 10 video-assisted lobectomies were performed in our department. There were eight women and two men; the mean age was 61.4 (47-68) years. The indications for surgery were the following: benign lesions in three cases, T1N0 squamous lung cancers proved by cytology in six patients, and another case, when the CT suggested - but cytologically not proved - T1N0 lung cancer. After a double lumen endotracheal tube intubation and videothoracoscopic exploration, a 6-8 cm mini thoracotomy was performed. Manual palpation of the lung parenchyma, resection with mediastinal block dissection (in cases of malignancy) was carried out through a 2 cm wide rib spread, without rib resection. Five lower, four upper lobe lobectomies and one upper bilobectomy were performed. There was no perioperative mortality or serious morbidity detected. The mean operative time was 130 (80-200) minutes. The three benign lesions were hamartochondromas. The final histology revealed four T1N0 and two T2N2 stage squamous cell lung cancers, while one T1N2 small cell lung cancer was also found. Lobectomy performed through a video-assisted mini thoracotomy is a safe procedure. The manual palpation, parenchyma resection and mediastinal block dissection can be performed similarly to open procedures.

Lung cancer as a second primary malignant tumor: prognostic values after surgical resection.

Prognostic values of lung cancers as second primary malignant tumors (LC-as-SPTs) developed after a different type of first primary malignant tumor were analyzed. Forty-three patients underwent surgery for first primary malignant tumors and later for LC-as-SPTs. The most frequent first primary tumors were: 14 laryngo-pharyngeals; 7 lungs; and 5 colons. Only metachronous cases were included in our study, and the disease-free intervals (DFI) between the first and second primary tumors were divided into two groups: shorter than 36 months (DFI<36), and longer than 36 months (DFI>36). The survival was calculated from the time of surgery for LC-as-SPT. The 5-year overall survival rate was 38%. By univariate analysis, the 5-year survival was significantly lower in cases with DFI<36 months (25%) than in cases with DFI>36 months (43%) (P=0.045), and in male (27%) than in female (62%) (P=0.032), and in N1 (31%) and N2 (0%) cases than in N0 (49%) cases (P=0.001). Using multivariate analysis with the previous factors, only the lymph node metastasis (P=0.001) had a significant impact on survival. The survival after LC-as-SPTs was shorter than after first primary lung cancer cases, and lymph node involvement had a significant impact on the postoperative survival based on uni- and multivariate analysis.

Visceral pleural infiltration as a negative prognostic factor in lung metastasis.

The prognostic value of visceral pleural infiltration in lung metastasis was analysed. Fifty-two patients (32 males and 20 females) were operated on for lung metastases. The locations of the primary tumours were as follows: 19 colon, 10 kidneys, 8 melanomas, 3 breast, 3 bladder, 2 uterus, 2 osteosarcomas, 1 testis, and 1 parotid, 1 haemangiopericytoma, 1 thyroid gland and 1 larynx. Explorative thoracotomies and incomplete resections were excluded from the study. Visceral pleural infiltration was present in 20 of the 52 cases. There was a significant correlation between the occurrence of pleural infiltration and multiple lesions (P=0.019). The overall five-year survival rate was 33.6%. In a subgroup of 38 patients with N0 and single metastases, the five-year survival rate was 73% and 12% in the cases without and with visceral pleural infiltration, respectively (P=0.003). Multivariate analysis of pleural infiltration, lymph node metastasis, multiple lesions and DFI revealed that only pleural infiltration (P=0.003) had a significant impact on survival. In one-third of the pulmonary metastases, visceral pleural infiltration appeared. There was a significant correlation between the occurrence of visceral pleural infiltration and multiple lesions. Visceral pleural infiltration in lung metastasis is a negative prognostic factor, and in these cases, survival was significantly reduced.

The role of microvascularization and growth/adhesion-regulatory lectins in the prognosis of non-small cell lung cancer in stage II.

OBJECTIVE: To investigate the role of growth/adhesion-regulatory lectins in the prognosis of the stage II non-small cell lung carcinomas (NSCLCs) via quantitative lectinhistochemical examinations and measurement of microvascularization of the tumour. METHODS: In 94 radically operated lung cancer patients, stage II NSCLC was confirmed histologically (T1N1: 6, T2N1: 66, T3N0: 22). Immunohistochemical methods were applied to investigate the galectin-1, galectin-3, CL-16 and hyaluronic-acid-binding capacities of the tumours, and also the expression of galectin-1, -3 and heparin binding lectin. Sections were examined with the aid of qualitative (stained/not-stained) and syntactic structure analysis. The microvessels were detected by staining with anti-factor VIII antibodies. The findings were compared with the survival data. RESULTS: In the univariate survival examinations, the prognosis was poorer for the galectin-1 and -3-expressing tumours (p=0.014 and p=0.003) and in multivariate analysis for the galectin-3-expressing tumours (p=0.046, RR: 2.026). Correlations could be demonstrated between the survival and the distance between the tumour cell for the tumours binding galectin-3 (p=0.039, RR: 5.944) and expressing galectin-3 (p=0.041, RR: 3.335). An elevation of the volume fraction of microvessels was a sign of a poor prognosis (p=0.017, RR: 2.334), however the increase of surface fraction improves the survival (p=0.01, RR: 0.956). CONCLUSIONS: In stage II NSCLC, galectin-3 expression is indicative of a poor prognosis. In tumour expressing and binding galectin-3, the distance between the tumour cells is of prognostic significance. An increase in the microvessel volume fraction points to a poorer survival rate.

[Video-assisted, extended thymectomy for the treatment of myasthenia gravis. Our early experiences]. / Videothoracoscopos, kiterjesztett thymectomia a myasthenia gravis kezelésében. Elso tapasztalataink.

INTRODUCTION: Extended thymectomy is the key-point of the surgical treatment of the myasthenia gravis (MG), when the thymus with the surrounding fatty tissue on the neck and in the mediastinum is removed. In this study we present a new surgical technique introduced into our practice in November 2004, and with that the thymectomy is performed with video-thoracoscopic method, without sternotomy. PATIENTS AND METHODS: Since November 2004, 6 patients (5 females and 1 male) were operated on for MG. Mean age was 26.2 years (17-41). Symptoms of MG was only ocular in 1 case (Stage I) and mild generalized in 5 cases (Stage II/B). The average preoperative period of the MG was 4 months (1-12). At the beginning of the surgery, the superior poles of the thymus were exposed and the fatty tissue surrounding the thymus in front of the trachea was removed. After that, the sternum was elevated with sternal retractors inserted under the sternum in the cervical and in a subxiphoid incisions. The thymectomy with the removal of the mediastinal fatty tissue was performed with bilateral video-assisted method. RESULTS: Mean operative time was 170 (120-210) minutes. There was no conversion to sternotomy, and there were no mortality and serious morbidity. Patients were extubated in the operating room. Chest tubes were removed on the first and second postoperative days. Mean postoperative hospitalization was 6.3 (5-7) days. At the one-month follow-up, there was 1 complete remission and 5 remissions with medication. In 1 case, the pathology revealed extrathymic thymus tissue in the cervical fat. There were 3 thymus hyperplasias, 2 thymitis and 1 thymic cyst as the pathological disorders of the thymus. CONCLUSIONS: The video-assisted extended thymectomy for MG, that was introduced into our practice, is a safe surgical procedure with good results. The postoperative period is easier for the patients, and the MG was improved in each cases.

[Prognostic role of microvascularization in surgically treated lung cancer]. / A mikrovaszkularizáltság prognosztikai jelentôsége operált tüdôrák esetén.

OBJECTIVE: The aim of our study was the determination of microvascularization and its prognostic significance in lung cancer patients. METHODS: Histological sections were prepared from paraffin-embedded tissues removed from the peripheral part of the tumor of 450 radically operated non-small cell and small cell lung cancer patients. Immunohistochemical staining was performed with antibody against factor VIII-associated antigen. During computer imaging, the absolute and relative parameters of vascularization were determined, as was the density of tumor cells situated to the nearest neighboring vessels. The results were compared with TNM status, the cell type and survival. RESULTS: T2 and T4 tumors demonstrated an enhanced vascularization, however, except for the surface fraction, statistically significant difference was not found. The microvascularization parameters did not differ significantly between tumors with different N status. In small cell lung cancer cases, the vascularization was stronger than in non-small cell lung cancer cases, while cell density was lower, however, these differences did not prove statistically significant. The survival rate decreased significantly with the increasing tumor cell density in the interval of 0-20 microm. CONCLUSIONS: A clear connection could not be demonstrated between vascularization and the appearance of lymph node metastases. The density of tumor cells measured in the direct vicinity of vessels proved an important prognostic factor.

Prognostic significance of endogenous adhesion/growth-regulatory lectins in lung cancer.

OBJECTIVE: To determine the expression of endogenous adhesion/growth-regulatory lectins and their binding sites using labeled tissue lectins as well as the binding profile of hyaluronic acid as an approach to define new prognostic markers. METHODS: Sections of paraffin-embedded histological material of 481 lungs from lung tumor patients following radical lung excision processed by a routine immunohistochemical method (avidin-biotin labeling, DAB chromogen). Specific antibodies against galectins-1 and -3 and the heparin-binding lectin were tested. Staining by labeled galectins and hyaluronic acid was similarly visualized by a routine protocol. After semiquantitative assessment of staining, the results were compared with the pT and pN stages and the histological type. Survival was calculated by univariate and multivariate methods. RESULTS: Binding of galectin-1 and its expression tended to increase, whereas the parameters for galectin-3 decreased in advanced pT and pN stages at a statistically significant level. The number of positive cases was considerably smaller among the cases with small cell lung cancer than in the group with non-small-cell lung cancer, among which adenocarcinomas figured prominently with the exception of galectin-1 expression. Kaplan-Meier computations revealed that the survival rate of patients with galectin-3-binding or galectin-1-expressing tumors was significantly poorer than that of the negative cases. In the multivariate calculations of survival lymph node metastases (p < 0.0001), histological type (p = 0.003), galectin-3-binding capacity (p = 0.01), galectin-3 expression (p = 0.03) and pT status (p = 0.003) proved to be independent prognostic factors, not correlated with the pN stage. CONCLUSION: The expression and the capacity to bind the adhesion/growth regulatory galectin-3 is defined as an unfavorable prognostic factor not correlated with the pTN stage.

Prognostic significance of microvascularization in cases of operated lung cancer.

OBJECTIVE: Measurement of microvascularization and determination of its prognostic significance in cases of lung cancer. METHODS: Section prepared from histological material from 432 radically operated non-small cell lung cancer patients were stained with antibodies against factor VIII-associated antigen. During computer imaging, the absolute and relative parameters of the vascularization were determined, as was the density of tumour cells situated in the vicinity of the vessels. The results were compared with the TNM status, the cell type and the survival. RESULTS: Each parameter demonstrated an enhanced vascularization in classifications T2 and T4, but only the surface fraction, the mean vascular circumference and the mean vascular area displayed a significant change. The microvascularization parameters did not differ significantly between with different N status, however, the cell density progressively increased in the areas close to the vessels in advanced pN classifications. Elevation of the tumour cell density within 20 microm distance of the vessels was accompanied by a significantly poorer survival rate. The density of tumour cells within 20 microm region was the second strongest prognostic factor after the N status. CONCLUSIONS: More advanced tumour classifications grow with enhanced vascularization. A clear-cut connection cannot be demonstrated between the vascularization and appearance of lymph node metastases. The density of tumour cells measured in the direct vicinity of vessels is an important prognostic factor.

Lung cancer and its operable brain metastasis: survival rate and staging problems.

BACKGROUND: We assessed the survival rates regarding different stages of operable lung cancers causing operable brain metastasis in patients with or without cancer-related symptoms. The correlation between survival rates and the disease-free interval between lung surgery and metastasectomy was studied. METHODS: Sixty-five patients were operated on for lung cancer and brain metastases. The disease-free interval was divided into 5 subgroups: 0-2 months, 3-5 months, 6-11 months, 12-23 months, and 24 months and beyond. The study group comprised of patients with lung cancer in the following stages: 17 patients in stage I (1 patient in stage IA, 16 patients in stage IB), 16 patients in stage II (2 patients in stage IIA, 14 patients in stage IIB), 9 patients in stage IIIA, 4 patients in stage IIIB, and 19 patients in stage IV. Forty-four patients were symptom-free for lung cancer and 21 patients manifested lung cancer related symptoms. RESULTS: The 5-year survival rates were as follows: stage I = 22%, stage II = 20%, stage IIIA = 22%, stage IIIB = 0%, and stage IV = 23% after lung resections. There were no significant differences in the 5-year survival rates regarding the disease-free interval subgroups after brain metastasectomies (p = 0.19): disease-free interval 0-2 months = 22% and disease-free interval 24 months and beyond = 23%. The 5-year survival rate after metastasectomy was significantly greater (26% vs 5%) in patients without lung cancer related symptoms (p = 0.05). CONCLUSIONS: The 5-year survival rate in stage I, II, IIIA, and IV lung cancer with operable hematogenous brain metastases corresponds to that in the customary stage IIIA (23%). The disease-free interval exhibited no significant impact on the survival rate. The complaint-free status exhibits a significantly greater impact on the survival rate in hematogenic metastasis.

[Results and alternatives in the surgical treatment of lung cancer]. / A sebészi kezelés eredményei es lehetoségei a tüdorák terápiájában.

OBJECTIVE: The aim of our study was to analyse the results of surgical treatment in lung cancer cases. PATIENTS AND METHODS: Between 1990 and 1999, 860 patients were operated on for primary lung cancer. In 775 patients (90.1%), resection was performed, 85 patients underwent explorative thoracotomy. RESULTS: The 5-year survival rate was 45.3%, the mean survival time was 47 months. In the univariate analysis, the radicality of the resection (p < 0.0001), the pT stage (p < 0.0001), the pN stage (p < 0.0001) and the histological type (p = 0.0039) had a significant correlation with the survival. The survival was not influenced whether N2 lymph node metastases were observed at one or more level. In the multivariate survival calculations sex (p = 0.024), histological type (p = 0.006), pT classification (p = 0.002) and the pN classification (p < 0.0001) proved to be independent prognostic factor. The pM status did not affect the survival. Postoperative complications were observed in 242 of patients (28.2%). The most frequent complication were expansions problems (9.7%), bronchial stump insufficiency (3.3%), retention of bronchial secretion (2.1%) and cardiac complications (7.1%). 26 patients died, the 30-day mortality rate was 2.8%. 32 reoperations were necessary (3.7%). CONCLUSIONS: Our results indicate that non-small-cell lung cancer can be operated on with good survival possibilities and limited risk, in selected cases even with more advanced tumour stages.

[Histological and immunohistochemical structure of pulmonary tuberculotic granulomas in untreated cases and cases treated with antitubercular drugs]. / A tüdó tuberkulotikus granulomájának szövettani és immunhisztokémiai szerkezete antituberkulotikummal kezelt és kezeletlen esetekben.

INTRODUCTION: The changes occurring in response to antituberculotic treatment and immune defence were studied in human tuberculotic granulomas. AIMS: To compare the possibilities of detection of Mycobacterium tuberculosis with the Ziehl-Neelsen staining technique and with an immunohistochemical method, and to assess the roles of lymphocytes and heat-shock protein 70. METHOD: 40 patients who had undergone lung resection (the postoperative histology confirmed tuberculosis) were divided into two equal groups, on the basis of whether they had received antituberculotic treatment preoperatively (group I) or not (group II). Customary histology was used to determine the Langhans cells, epitheloid cells and lymphocytes, and an immunohistochemical method was then applied to examine the heat-shock protein 70 production of these cells and the normal lung. The lymphocytes were divided into CD4+ T-helper, CD8+ T-cytotoxic and CD20+ B cells by means of immune examinations. M. tuberculosis was demonstrated by an immunohistochemical method, with antibody against the wall protein. RESULTS: Heat-shock protein 70 was produced by 17.6% of the Langhans cells and 94.4% of the epitheloid cells in group I, and by 100% of both cell types in group II. The bacterium could be detected in 40% of the total number of cases with acid-fast staining, and in 85% by immunohistochemistry. There was no significant difference in the qualitative distribution of the lymphocytes in the granulomas in groups I and II. The heat-shock protein 70 levels of the tuberculotic granuloma and the normal lung were significantly higher in group II. CONCLUSIONS: The production of heat-shock protein 70 is more enhanced in untreated tuberculotic cases. On the basis of their heat-shock protein 70 production, the authors assume that a majority of the Langhans cells have a resting protective function in medically treated cases. Independently of the stage of the infection and of the use or not of antituberculotic treatment, the number of lymphocytes participating in the immune defence is constant. By means of immunohistochemical examination of the wall protein of M. tuberculosis, the presence of the tuberculotic disease can be demonstrated with high reliability.

Bronchioloalveolar lung cancer: occurrence, surgical treatment and survival.

OBJECTIVE: The prevalence of pulmonary adenocarcinoma has risen worldwide. Bronchioloalveolar carcinoma (BAC) was studied with regard to whether it exhibits a similar tendency, and its typical features were analysed. METHODS: Between 1992 and 2001, 278 lung resections were carried out for adenocarcinoma. Of these, 67 (24.1%) proved to involve BAC. Whereas BAC accounted for 6.9% of the cases in 1992, in 2001 the proportion was 46.9%. There were 37 men (55.2%) and 30 women (44.7%); the average age was 60.5 years. 58.2% of them had no complaints. Of the 26 non-smokers, 69.2% were women; of the 41 smokers, 29.2% were women. In consequence of the tumour, 49 lobectomies, three bilobectomies, six pneumonectomies and nine wedge resections were performed. RESULTS: The surgical mortality was 1.6%. The pathology revealed that 26 (38.8%) tumours were in stage I/A. In 15 cases (22.4%), tuberculosis (TB) could be revealed besides the BAC: by skin tests in four cases, by CT in three cases, by case history in four cases, and by pathology in four cases. For the overall group of 67 patients, the 5-year survival rate was 61.9%, and the mean survival time was 75.7 months. The 5-year survival rate among the women (74%) was significantly better than that among the men (37%) (P=0.030). There was no significant difference in survival with regard to the multiple BAC (85%). The 5-year survival rate was significantly worse in the mixed BAC group (20%) than in the non-mucinous (62.7%) and in mucinous (59%) group. The overall 5-year survival rate among the smokers and TB patients was 61 and 79%, respectively, which is higher than that among the non-smokers (47%) and non-TB patients (56%). The survival rate for the wedge resection cases was 37%, which was lower than that for the cases involving major resections (60%) (P=0.939). CONCLUSION: BAC has a favourable survival, particularly in women. In spite of this, resection smaller than lobectomy is recommended only as a compromise. A multiple appearance does not imply a worse survival. The best survival rate was found in the non-mucinous BAC among the histological groups. TB seems to be frequent among BAC patients.

Vascular diffusion density and survival of patients with primary lung carcinomas.

AIM: To investigate the clinical significance of tumour vascularisation in operated lung cancer patients. MATERIALS AND METHODS: Histological slides obtained from 498 patients with potentially curative operated lung carcinomas in two different institutions of thoracic surgery were immunohistochemically stained with an anti-CD34 antibody and subjected to quantitative image analysis. Syntactic structure analysis measured the absolute and relative features of vessels, including the numerical tumour cells densities relative to their nearest neighbouring vessel. These data are associated with tumour volume, post-surgical TNM stage, and each patient's survival. RESULTS: The clinical data, including sex distribution, age of patients, pTNM stages and survival, did not differ between the two institutions. The tumour vascularisation (volume fraction, Vv) amounted to 7% in lung carcinomas, was independent from cell type and increased in advanced tumour stages (pT4, pN3). Advanced tumour stages presented with a higher numerical vascular density and with maintained minimum diameter and circumference of vessels. Each patient's survival was closely associated with the pN stage, tumour volume, cell type and numerical density of tumour cells within a distance less than 20 micro m from the nearest neighbouring vessel due to multivariate statistical analysis. CONCLUSION: Vascularisation of lung tumours becomes altered in advanced tumour stages. Of prognostic significance is the distribution of tumour cells in relation to the nearest neighbouring vessel only.

Development of brain metastasis 5 years before the appearance of the primary lung cancer: "messenger metachronous metastasis".

We report a patient with a brain metastasis that presented 5 years before the primary adenocarcinoma of the lung from which it originated. The metastasis and the primary tumor were removed. To confirm their common origin, we used comparative genomic hybridization. We have named this type of metastasis "messenger metachronous metastasis." The patient remains well 79 months after the brain metastasectomy and 18 months after the lung surgery.

[Pancreas resection for lung cancer metastasis]. / Hasnyálmirigy reszekció tüdórák áttéte miatt.

This case report describes the successful resection of a solitary pancreatic metastasis that developed 21 months following lobectomy of an early pulmonary adenocarcinoma (pT1N0M0). The metastasis caused no complaints. The resected pancreas contained a glucagonoma in addition to the metastasis. In the literature we have found no similar case of simultaneous operable metastatic and a secondary pancreatic tumor.

[The occurrence of bronchioloalveolar lung cancer among our patients]. / Bronchioloalveolaris tüdôrák elôfordulása klinikai anyagunkban.

INTRODUCTION: One of the subtypes of pulmonary adenocarcinoma, bronchioloalveolar carcinoma (BAC), is mentioned as the lung cancer of non-smoking women. We have studied the clinical characteristics of BAC and its surgical treatment. METHODS AND PATIENTS: Between 1992 and 2001, lung resections for BAC were performed on 101 patients: 55 men and 46 women, average age 59.7 years. Thirty-two of the patients were non-smokers, and 69 were active smokers. In 1992 the incidence of BAC was 17.5% of all adenocarcinomas, whereas in 2001 it had risen to 51.6%. The operations involved 76 lobectomies, 12 pulmonectomies, 11 wedge resections and 2 explorative thoracotomies. RESULTS: The surgical mortality was 0.9%. The final histologic findings revealed that 82.1% of the tumours were in stages I or II, with 33.7% of the total in stage I/A. The average 5-year survival was 64.3%. Survival for women 75%, was significantly better than that for men, 51% (p=0.045). A significant difference was not found in the 5-year survival rate for multiple tumours or for BAC cases of different histological types. CONCLUSIONS: The incidence of BAC, which occurs relatively frequently among women, and exhibits a relatively favourable course, has tended to increase in recent years. A majority of these tumours are removed in an early stage. The survival is not significantly poorer in the event of multiple tumours.

[Prognostic significance of intrapulmonary metastases in cases of surgically treated lung cancer]. / Intrapulmonális metasztázisok prognosztikai jelentösége operált tüdörákos esetekben.

OBJECTIVE: The aim of this retrospective study was to establish the prognosis in lung tumour cases in which resection was followed by synchronous or metachronous intrapulmonary metastasis. METHODS: Between 1990 and 1999, 857 patients were operated on for primary lung cancer. Intrapulmonary metastases were observed in 21 patients. 11 cases were in stage III/B (on the basis of T4), and 10 were in stage IV (on the basis of M1). The histologic distribution of the primary tumours was 7 squamous cell carcinomas, 11 adenocarcinomas, 2 large cell carcinomas and 1 carcinoid. In 8 patients, histology demonstrated N1 or N2 lymph node metastasis. In 4 cases, there were more than one metastases. RESULTS: The 5-year survival was 21%, and the mean survival time (MST) was 29.5 months. For both the 5-year survival rate and MST, there was significant difference between the lymph node negative (N0) and lymph node positive (N1/N2) patients (N-: 30.7%, N+: 0%, p=0.017, MST: N-: 38.3 months, N+: 10.5 months, p=0.014), according to the stage (III/B: 30%, IV: 11.1%, p=0.025, III/B: 40.1 months, IV: 17.8 months, p=0.04) and the number of metastases (1 metastasis: 26.6%, more than 1 metastasis: 0%, p=0.036, 1 metastasis: 35.2 months, more than 1 metastasis: 8.5 months, p=0.045). No significant difference was detected on the basis of histological type, pleural, vascular and lymphatic invasion. In patients where 1 metastasis was found within one lobe and there were no lymph node metastases, the 5-year survival rate was 42.8% and MST was 49 months. The complication rate was 28.5% and the 30-day mortality was 4.7% (1 patient). Reoperation was performed in 1 case, for thoracic wall haematoma. CONCLUSION: Primary lung tumours giving intrapulmonary metastases, under certain conditions (lymph node negativity, 1 metastasis in the same lobe), can be operated on with good survival possibilities.