[Recurrent hemoptysis in a 29-year old woman]. / Rezidivierende Hämoptysen bei einer 29-jährigen Patientin.

A 29-year old woman was admitted with recurrent hemoptysis. Due to the combination of hemoptysis, alveolar infiltrates and anemia a diffuse alveolar hemorrhage syndrome was suspected. After exclusion of underlying diseases and due to the typical histology we confirmed the diagnosis of an idiopathic pulmonary hemosiderosis. In consequence of an acute progression of the disease with pulmonary hemorrhage and severe anemia an empiric therapy with corticosteroids and azathioprine was initiated, resulting in a distinct recovery.

Chest wall infiltration by lung cancer: value of thin-sectional CT with different reconstruction algorithms.

The aim of this investigation was to evaluate whether thin-sectional CT with different reconstruction algorithms can improve the diagnostic accuracy with regard to chest wall invasion in patients with peripheral bronchogenic carcinoma. Forty-one patients with intrapulmonary lesions and tumor contact to the thoracic wall as seen on CT staging underwent additional 1-mm CT slices with reconstruction in a high-resolution (HR) and an edge blurring, soft detail (SD) algorithm. Five criteria were applied and validated by histological findings. Using the criteria of the intact fat layer, HRCT had a sensitivity of 81 % and a specificity of 79 %, SD CT had a sensitivity of 96 % and a specificity of 78 %, and standard CT technique had a sensitivity of 50 % and a specificity of 71 %, respectively. Regarding changes of intercostal soft tissue, HRCT achieved a sensitivity of 71 % and a specificity of 96 %, SD CT had a sensitivity of 94 % and a specificity of 96 % (standard CT technique: sensitivity 50 % and specificity 96 %). For the other criteria, such as pleural contact area, angle, and osseous destruction, no significant differences were found. Diagnostic accuracy of chest wall infiltration can be improved by using thin sectional CT. Especially the application of an edge-blurring (SD) algorithm increases sensitivity and specificity without additional costs.

Thoracic cancer surgery in the elderly.

The risk of thoracic cancer surgery in patients of advanced age, i.e. 75 years or older, was analysed by reviewing 119 consecutive patients from August 1986 to May 1998 with bronchial carcinoma (n = 87), pulmonary metastases (n = 22), mesothelioma and pleural carcinosis (n = 7) and mediastinal or chest wall tumours (n = 3). Repeated surgery in one case of bronchial carcinoma and in another of metastases gave a total of 124 operations. Of the patients, 22 were 80 years or older (21%) and 32% were female. The median age was 77 years (range 75-87 years). Six fatalities occurred within 30 days or during hospitalization. This corresponds to a 4.8% mortality for the whole series and 6.8% for the subgroup of bronchial carcinoma. The causes of death were surgical complications in two patients, one died from heart failure after simultaneous combined coronary artery bypass grafting and left lower lobectomy 2 hours after the operation from heart failure refractory to resuscitation. With this exception all these patients had stage II (n = 2) or stage III A (n = 3) bronchial carcinoma. It is concluded that cancer surgery in the elderly is safe provided appropriate selection is observed. Indications should be very restrictive for advanced cancer and for pneumonectomy.

Results after surgery in stage-I bronchogenic carcinoma.

BACKGROUND: The aim of this retrospective study was to evaluate prognostic factors for recurrence-free survival in stage-I non-small-cell bronchogenic carcinoma. METHODS: During 9 years, 338 consecutive patients were operated on for stage-I bronchogenic carcinoma. Patients with small-cell carcinoma (n = 14), prior malignancies in locations other than pulmonary (n = 41), and patients with incomplete data on prognostic factors (n = 11) were excluded. Of the remaining 272 patients 226 were men. Mean age was 63 years (40 to 81 years). The resections performed comprised 215 lobectomies and bilobectomies, 36 segmentectomies and wedge resections, and 21 pneumonectomies. According to the number of sites of dissected lymph nodes 3 subgroups were formed: group A with 0 to 4 (n = 71), B with 5 to 6 (n = 118), and C with 7 to 10 sites (n = 83). Median follow-up was 46 months. RESULTS: Three patients (1.1 %) died within 30 days of operation. In 3 patients the resection was revealed to be not radical (R1). At the end of follow-up, 191 patients were alive, 174 of these without recurrence. Eighty-one patients had died, 53 associated with tumor recurrence. Four patients had died of non-pulmonary malignancies. Twenty-two patients died of causes not related to tumor disease. In 2 patients the cause of death could not be determined retrospectively. Overall 5-year survival was 65% (95% confidence interval [CI] 58-72%), recurrence-free survival 59% (CI 51-66%). Significant prognostic factors for recurrence-free survival were T stage (relative risk [RR] 1.7 for T2 vs. T1, CI 1.0-3.0), age (RR 1.9 for >70 years vs. < or =70 years, CI 1.1-3.1), adeno cell type (RR 2.3 vs. squamous cell, CI 1.4-4.0), as well as lymphangiosis carcinomatosa (RR 2.3, CI 1.2-4.4). Extent of operative resection, extent of lymphadenectomy, and sex did not influence survival. CONCLUSION: 5-year survival of our patients was in the range reported in literature. Most patients died of distant metastases. Our retrospective study probably underestimated the occurrence of second primary cancers of the lung. Limited resection in poor-risk patients showed equivalent results to lobectomy. The extent of lymph-node resections had no influence on survival of stage-I patients, however, it must be remembered that positive results in lymph nodes shift patients to higher stages.

Experimental gluing of the bronchial stump after pneumonectomy in rats.

OBJECTIVE: The objective of this experimental study was to evaluate the usefulness of gelatin-resorcinol-dialdehyde adhesive in sutureless closure of bronchial stumps. METHODS: In 40 male Wistar rats bronchial stumps after left-sided pneumonectomy were closed by gluing with gelatin-resorcinol-dialdehyde adhesive. For macroscopic and microscopic examination four animals were sacrificed on postoperative days 2, 7 and 14 each, 14 animals on postoperative days 28 and 120 each. RESULTS: On macroscopic examination the gelatin-resorcinol-dialdehyde adhesive proved in all cases effective in tight bronchial stump closure. The adhesive did not cause local infection or necrosis of the bronchial stump nor other intrathoracic inflammatory complications. All animals survived and made an uncomplicated postoperative recovery. Microscopic examination revealed that the gelatin-resorcinol-dialdehyde adhesive initially evoked an acute inflammatory response with polymorphonuclear neutrophils predominating. After an intermediate stage characterized by a granulomatous reaction and resorption of the adhesive by multinucleated giant cells, 120 days postoperatively the bronchial stumps at the sites of previous gluing showed a regular fibrous scar tissue without inflammatory cells. CONCLUSION: The gelatin-resorcinol-dialdehyde adhesive showed effective in closing bronchial stumps after pneumonectomy in rats. The clinical extrapolation of this effect to thoracic surgical patients is uncertain at this time.

Experimental gluing of lung parenchyma in rats.

Gelatin-resorcinol-dialdehyde adhesive has been developed from a gelatin-resorcinol-formaldehyde adhesive by replacing the formaldehyde with two less histotoxic dialdehydes, ethandial and pentandial. The aim of the present study was to evaluate the usefulness of this modified composition in gluing defects in lung parenchyma. In 40 male Wistar rats a standardized lung incision 1.0 cm in length and 0.8 cm in depth were closed by application of gelatin-resorcinol-dialdehyde adhesive. For macroscopic and microscopic examination 4 animals were sacrificed on each of postoperative days 2, 7, and 14 and 14 animals on each of postoperative days 28 and 120. Macroscopic examination revealed a tight closure of the parenchymal defects in all postoperative stages. Initially by an adhesive layer and later on by granulation tissue and scar tissue respectively. On microscopic examination an inflammatory tissue response with polymorphonuclear neutrophils and macrophages predominating was found 2 days postoperatively. After 7 days multinucleated giant cells appeared. On postoperative day 14 the tissue response presented a distinct granulomatous character with multinucleated giant cells persisting. After 28 days remnants of adhesive surrounded by granulation tissue were detectable. On postoperative day 120 the adhesive had been completely resorbed and the parenchymal defect was replaced by fibrous scar tissue. The gelatin-resorcinol-adhesive proved effective in tight closure of lung parenchyma in rats. The adhesive is resorbed completely and does not interfere with parenchymal healing.

Comparison of the sensitivity of sputum and brush cytology in the diagnosis of lung carcinomas.

OBJECTIVE: To describe the role of sputum and brush cytology in the diagnosis of lung carcinoma and to elucidate the influence of tumor location, histologic tumor type and stage on the sensitivity of both methods. STUDY DESIGN: Retrospective and performed on 415 lung cancer patients. Two hundred of them were investigated only by sputum collection, 119 only by brushing and 96 by both methods. RESULTS: The overall sensitivity of the sputum technique was 0.403 and that of the brush method 0.500, while a combination of both showed a sensitivity of 0.640. The diagnostic yield depended on tumor location, histologic tumor type and stage. Sputum specimens were most valuable in the detection of early and peripheral carcinomas, whereas brushing was superior in finding more advanced and centrally located malignancies. Regarding tumor type, squamous cell carcinomas were diagnosed to the greatest extent by both methods. CONCLUSION: A complementary role of both cytologic techniques can be postulated by our data as well as by a literature review.

Long-term survival after repetitive surgery for malignant hemangiopericytoma of the lung with subsequent systemic metastases: case report and review of the literature.

Malignant hemangiopericytoma represent less than 1% of all vascular and about 5% of all sarcomatous tumors. We are reporting the uncommon clinical case of primary pulmonary localization, of which approximately 100 cases have been published in the literature. A 54-year-old male underwent left upper lobectomy seven years ago for a tumor which proved to be a malignant hemangiopericytoma. Six months later a metastasis in the abdominal wall in the epigastrium appeared and was completely excised without further treatment. During a follow-up of 16 months another metastasis developed in the mesenterium causing ileus and leading to laparotomy with resection of 120 cm small bowel. After this procedure followed by two cycles of chemotherapy the patient remained free of disease. Details of the clinical course and a review of the literature are presented.

Results after surgery in undifferentiated large cell carcinoma of the lung: the role of neuroendocrine expression.

OBJECTIVE: The objective of this study was to define the incidence of light microscopically undifferentiated large cell carcinomas, to analyze tumor stages, types of resections necessary and postsurgical survival. Additionally we tried to evaluate whether or not neuroendocrine expression influences the biological behavior of these tumors. METHODS: Light microscopic specimens of 105 patients having undergone surgery for undifferentiated large cell carcinoma were reviewed following the 1981 WHO criteria. Fifty eight cases were excluded because elements of adeno- or squamous cell carcinoma, neuroendocrine or combined patterns of histological differentiation were observed. The remaining 47 cases of pure undifferentiated large cell carcinoma were evaluated immunohistochemically for neuroendocrine differentiation using a combination of the markers neuron specific enolase, synaptophysin and chromogranin A. The hospital charts of the patients were analyzed retrospectively recording tumor stage, operative procedure, postoperative complications, postoperative adjuvant treatment procedures, actual tumor state and survival time. RESULTS: Thirteen patients (27.7%) had postsurgical tumor stage I, 5 (10.6%) stage II, 15 (31.9%) stage IIIA, 9 (19.1%) stage IIIB, and 5 (10.6%) stage IV. In 46 of 47 patients resections of lung parenchyma were performed (wedge resection n = 5, segmental resection n = 1, lobectomy n = 27, bilobectomy n = 3, pneumonectomy n = 10), in 6 patients combined with broncho- and/or angioplastic procedures. At the time of chart review 20 (42.5%) patients were still alive. The cause of death in the remaining patients was recurrent lung cancer in the majority of cases (24 or 92.30%). The overall mean survival of the 46 patients undergoing parenchymal resections was 19 months, the 3-year survival rate 31.7%. The immunohistochemical examination demonstrated expression of neuron specific enolase in 15 cases. Synaptophysin and chromogranin A were not detected in any case. For these 15 patients the mean survival was 25.6 months (+/- 4.3) and the 1-year survival rate 67% (confidence interval 43-91%) compared to 13.8 (+/- 2.1) months and 33.5% (confidence interval 15.3-51.7%) in the remainder. The difference was not significant (P = 0.06). CONCLUSIONS: The light microscopic diagnosis of undifferentiated large cell carcinoma revealed to be subject to considerable interobserver variability. Undifferentiated large cell carcinoma takes a more unfavorable clinical course than other non-small cell carcinomas. Despite lack of statistical significance, expression of neuron specific enolase appeared to be associated with less aggressive biological behavior of the respective neoplasms. Immunohistochemical evaluation of undifferentiated large cell carcinomas using a combination of neuron specific enolase, chromogranin A, and synaptophysin did not provide more therapeutically relevant information than that obtained by light microscopic assessment.

[Surgical treatment of bronchial carcinoma in advanced age]. / Chirurgische Behandlung des Bronchialkarzinoms im höheren Alter.

As live expectancy increases, the number of elderly patients 70 and more years of age are also increasingly represented in a thoracic surgical series. The preponderance of malignant disease in this group, particularly lung cancer, is common. Progress in anesthesia, intensive care and operative techniques in recent years has reduced the risk of morbidity and operative mortality in this age group. Operative and 30-day hospital mortality was 4.8% in our series.

Lectin binding sites and immunocytochemical characterization of normal pleural mesothelium.

20 specimens of normal pleural mesothelium were investigated with six lectins using isolated cells and tissue specimens as well as two different fixation techniques (glutaraldehyde and formaldehyde) and 10 monoclonal antibodies (MAb) on cytologic preparations only. Lectin binding sites for ConA, WGA, and PNA were present in all cases, whereas binding sites for the lectins HPA, SBA, and UEA-I could never be found. There was no staining difference with the two preparation and fixation techniques proving that they may be used to compare directly histologic and cytologic studies. Ten of fourteen histologic specimens were positive for the blood group antigen Lewis(y), three of them were positive for the antigen Lewis(b), all fourteen specimens were negative for Lewis(a) and Lewis(x). In all cases, mesothelial cells expressed ICAM1 and pancytokeratin. The antibodies against EMA, CEA, CD24, CD15, CD20, CD5, and HEA125 showed no reaction in mesothelial cells. Because HPA, UEA-I, SBA as well as CEA and HEA125 react in a high percentage with adenocarcinomas, non reactive cells of pleural effusions negative with these markers may be confidentially considered to be mesothelial in origin.

[Recurrent intervention in surgery of pulmonary metastases]. / Rezidiveingriffe in der pulmonalen Metastasenchirurgie.

Pulmonary resection for recurrent metastatic disease in 39 patients undergoing 52 thoracotomies resulted in a cumulative survival rate of 75% at 3 years an 52% at 5 years, with no operative mortality. A significant factor influencing survival was duration of disease-free interval after treatment of primary tumor and the time interval between the first pulmonary metastasectomy and the appearance of recurrent pulmonary metastases. The route of metastatic spreading and the number of metastases were of no prediction for postthoracotomy survival.

[Thoracic surgery in advanced age. Indications and results with special reference to bronchial cancer]. / Thoraxchirurgie im Alter. Indikationsstellung und Resultate unter besonderer Berücksichtigung des Bronchialkarzinoms.

BACKGROUND: As the life expectancy in the general population increases, a constant rise in the number of patients of advanced age undergoing thoracic surgery is also observed. MAJOR TOPICS DISCUSSED: Among the indications for operations on the chest, malignant diseases head the list. Thanks to advances in anesthesia, intensive care and surgical techniques, the peri-operative mortality rate in this age group has been appreciably reduced in recent years. In our own patient material, the relevant figure was 4.37%, and is thus in the lower range of internationally comparable mortality associated with major oncological operations on the chest. CONCLUSION: Patients in their seventies or eighties should not be denied thoracic surgery for age reasons; the decisive factors are the general level of activity of the patient and his/her motivation.

[Tracheal and bronchial rupture after blunt thoracic trauma]. / Tracheal- und Bronchusruptur nach stumpfen Thoraxtrauma.

Airway disruptions after blunt chest trauma are rather infrequent with an incidence of about 1%. Even in large centers with many such casualties they are episodical. The clinical picture is not an uniform one, and typical clinical signs occur often without an airway lesion. Therefore, the correct diagnosis may be delayed. Two case reports, one with a tracheal rupture, the other with complete disruption of the main right bronchus are presented. Both patients showed significant soft tissue emphysema, increasing dyspnea and hypoxia respectively within a few hours after their accident. The diagnosis was established bronchoscopically after time intervals of 8 and 32 hours respectively, followed by immediate surgical correction. Both patients experienced a smooth recovery with good longterm results. In blunt chest trauma presenting with subcutaneous emphysema, pneumomediastinum, pneumothorax, hemoptysis and respiratory distress, tracheobronchial disruption should be considered. In this case, expert bronchoscopy, preferably by a surgeon with large thoracic experience, is mandatory.

Perioperative antibiotic prophylaxis in general thoracic surgery.

A prospective study of the efficacy of ampicillin in combination with sulbactam, a beta-lactamase inhibitor, (A/S) in perioperative prophylaxis was performed. The study consisted of two independent parts performed at the same time. Part I included 60 patients with lobectomies and segmentectomies. Group A (A/S 1 x 3 g "single shot") was compared with group B (A/S 3 x 3 g). Superficial wound infections occurred in 3 patients of group A and in 2 patients of group B. There was no empyema. Bronchitis and pneumonia were found in 10 patients of group A and in 7 patients of group B. Part II examined 25 pneumonectomies receiving A/S 3 x 3 g for 3 days. Concentrations of ampicillin and sulbactam in serum and lung tissue were determined and showed adequate levels to cope with usual bacteria in lung surgery. There was one superficial wound infection, 2 cases of bronchitis, and 2 cases of pneumonia.

[New developments in surgery of pulmonary metastases]. / Neue Entwicklungen in der pulmonalen Metastasenchirurgie.

Two groups of patients, 107 between 1977-1986 and 122 between 1987-1991, who underwent surgery for pulmonary metastases, were compared with each other. The most frequent primary sites were the kidney and the testes in the first and the kidney and the colon-rectum in the second group. We recorded a 1-year survival rate of 79% and a 5-year survival rate of 37% in the first group. In the second group there was a 3-year survival rate of 53%. Our analyses are showing that more metastatic lesions are usually found at operation than indicated by CT scan preoperatively. The discrepancy amounts to 19% in presumably solitary metastases and increases to 50% and more if two or more lesions were identified preoperatively. Therefore, bilateral exploration is advocated as a standard procedure in pulmonary metastatic surgery.