Mistletoe preparation (Viscum Fraxini-2) as palliative treatment for malignant pleural effusion: a feasibility study with comparison to bleomycin.

BACKGROUND: Malignant pleural effusion is a common problem in patients with solid tumours. It has a significant impact on quality of life, and, hence, there is a substantial need to investigate new agents to treat it. PATIENTS AND METHODS: This is a prospective randomised controlled study, including patients with symptomatic recurrent malignant pleural effusion of different primaries. Patients were randomised into two groups: the first group received five ampoules of mistletoe preparation with defined lectin content (Viscum Fraxini-2, ATOS Pharma) diluted in 10 cc glucose 5% solution. Re-instillation was repeated every week until complete dryness of the pleural fluid was achieved (the maximum duration of the therapy was eight weeks). The second group received 60 units of bleomycin once intrapleurally. AIMS: The primary aim of this paper was to evaluate the efficacy of mistletoe preparation as a palliative treatment for malignant pleural effusions in comparison with bleomycin. The secondary aim was to evaluate the tolerability of the mistletoe preparation. RESULTS: A total of 23 patients were included and followed up during the study from December 2007 to January 2012: 13 patients received mistletoe preparation, and ten patients received bleomycin. Overall clinical response was reported in 61.5% of the mistletoe preparation arm versus 30% in bleomycin arm (p = 0.2138), 95% CI = (-0.1203, 0.6325). The toxicity of both arms was mild and manageable; the mistletoe preparation arm included fever, chills, headache, malaise, and, in two cases, allergic reaction, which was controlled by discontinuation of the drug and steroid injection. CONCLUSION: Mistletoe preparation is an efficient and well tolerated sclerosant agent which needs further investigation.

Bronchoplasty for primary broncho-pulmonary tumors.

BACKGROUND: Parenchyma-sparing procedures are widely used in patients with low-grade malignancies of the airway when anatomically suited lesions exist. This study was conducted to evaluate the short-term and the long-term results of bronchoplastic procedures for patients with centrally located primary bronchopulmonary tumors. METHODS: Between 2000 and 2009, 36 patients with primary lung tumors required bronchoplasty were retrospectively analyzed. Preoperative assessment included computed tomography (CT) of the chest, bronchoscopy, and spirometry. Pre operative diagnosis was acheived by bronchoscopy for all patients, mediastinoscopy was done for patients with primary lung cancer. Neo adjuvant chemotherapy was given for 6 patients with non small cell lung cancer (NSCLC). RESULTS: We had 15 males and 21 female, the mean age was 37 years and the mean hospital stay was 7.2 days. Operative procedures performed were:Sleeve lobectomy in 30 patients (13 right, 17 left), partial sleeve right pneumonectomy in 3 and bronchial resection with reanastomosis in 3 (2 left, 1 right). Twelve patients (33.3%) suffered post-operative problems. There was one operative related mortality. Post operative pathology revealed: 27 patients with typical carcinoid, 2 with atypical carcinoid, 4 with squamous cell carcinoma, 2 with adenocarcinoma and one with hamartoma. Pathological TNM staging revealed: 17 patients with stage IA, 11 with IB, 5 with IIA and 2 with stage IIIA. Follow-up data were available for all patients except two. Two patients died with disseminated disease 1.5 year and 2 years after surgery. The patient with hamartoma developed local recurrence 5 years later and re-excision was done. One patient with lung cancer developed bone metastases and was alive with disease, while the remaining 30 patients were alive and disease free. The overall 5 years survival was 83.3%. CONCLUSION: Bronchoplastic resections achieve local control and long-term survival comparable to the standard resections in patients with carcinoid tumor and NSCLC in anatomically suited lesions. KEY WORDS: Bronchoplasty - Primary - Lung - Tumors.

Primary yolk sac tumor of the lung.

Yolk-sac tumor mimics the yolk sac of the embryo, and the presence of alpha fetoprotein in the tumor cells is highly characteristic. We present an 18-year-old boy with primary pulmonary yolk-sac tumor diagnosed postoperatively. A computed tomographic scan revealed a huge intrathoracic soft tissue mass 20 x 25 cm occupying most of the left hemithorax. Two trials of computed tomographic-guided needle biopsy were nonconclusive. A left upper lobectomy was performed with a complete tumor resection. Postoperatively, the patient's alpha fetoprotein (AFP) was 10,512 IU/mL with gradual decline under chemotherapy. The patient is alive 10 months after surgery and is disease free.

Delayed bronchial stump dehiscence following trimodality treatment for malignant pleural mesothelioma.

BACKGROUND: Post pneumonectomy bronchopleural fistula represents the most serious complication in thoracic surgery. Delayed fistula following tri modality treatment for mesothelioma is a serious problem regarding diagnosis and treatment. Surgical repair of the bronchial stump through a lateral thoracotomy is a dangerous attempt due to mediastinal fibrothorax and the risk of pulmonary artery stump damage. PATIENTS AND METHODS: Between 2002 and 2007, 85 extra pleural pneumonectomies for mesothelioma were performed. Only 58 patients completed the assigned tri modality treatment, five of them developed delayed bronchial stump dehiscence. The interval between primary surgery and stump dehiscence ranged from 6 months to 2 years. RESULTS: There were 4 right and one left sided fistulae. We had 4 males and one female, the mean age was 41 years. Bronchial stump was stapled in 3 patients and hand sewn closure was used in the remaining 2. By bronchoscopy, no stump recurrence was observed, but all patients with stapled bronchus had longer remaining stump. Empyema was present in all patients. All complicated patients received 2 field post operative radiotherapy with mediastinal dose of 40-45 Grays. The initial treatment consisted of tube thoracostomy followed by exploration through the previous thoracotomy incision with thorough curettage and wash of the infected space and removal of any exposed infected mesh. Bronchial stump was identified and re sutured. Re enforcement of the bronchial stump was done. Three patients required mechanical ventilation and 2 of them died. Surgery was successful in the remaining 3 patients. CONCLUSION: Delayed bronchial stump dehiscence is liable to develop especially for right sided lesions. Prophylactic augmentation of right sided stumps with vascularised muscle flap, shielding of pathology proven negative stumps during radiotherapy and improvement of radiation techniques may improve the dose distribution. KEY WORDS: Delayed - Bronchial - Stump - Fistula - Tri modality - Mesothelioma.

Prevalence and pattern of lymph node metastasis in malignant pleural mesothelioma.

BACKGROUND: The incidence and pattern of nodal metastases in mesothelioma are not well understood. This study was conducted to evaluate the prevalence and pattern of nodal metastasis in mesothelioma patients. METHODS: The study included 53 patients with mesothelioma. The first 37 patients (group I) underwent combined modality treatment without preoperative mediastinoscopy. The second group included 16 patients (group II) with pretreatment mediastinoscopy. RESULTS: A total of 18 patients had positive lymph nodes, 12 in group I and 6 in group II; of the latter, 4 had positive mediastinoscopy and 2 had positive nodes on final pathology. Postoperatively, a mean of 14 nodes were dissected (range, 5 to 34). In the post-pleuropneumonectomy group, 6 of 14 patients had positive hilar node metastases in addition to positive mediastinal lymph nodes. One patient had positive hilar nodes only. Of the 49 patients operated on, only 7 had no lung invasion by pathologic evaluation, and none had positive hilar nodes. The mechanism of spread of the disease to hilar nodes may be through lung invasion and not due to direct spread from the pleura. This observation raises the possibility that mediastinal nodes should be considered the primary station in patients with mesothelioma, whereas hilar node metastasis necessitated lung invasion first. CONCLUSIONS: The pattern of nodal metastases may be different from that of lung cancer, and multicenter studies are needed to evaluate this observation.

Evaluation of simian virus-40 as a biological prognostic factor in Egyptian patients with malignant pleural mesothelioma.

The association between simian virus (SV40) and malignant pleural mesothelioma (MPM) suggests an etiological role for SV40. However, exact pathogenetic mechanisms and possible prognostic value are not clear. The purpose of the present paper was to investigate 40 Egyptian MPM patients for the presence of SV40 DNA, altered Rb expression and p53 gene status using immunohistochemistry and molecular techniques. The relation between SV40, asbestos exposure, Rb, p53 and their contribution to the overall survival (OS) were also assessed. SV40 DNA was detected in 20/40 patients and asbestos exposure in 31 patients; 18 of them were SV40 positive. Altered p53 and Rb expression were detected in 57.5% and 52.5%, respectively, with no p53 mutation. Univariate analysis showed a significant correlation between OS and stage (P = 0.03), performance status (P = 0.04), p53 overexpression (P = 0.05), asbestos exposure (P = 0.002) and SV40 (P = 0.001). Multivariate analysis showed that when SV40 and asbestos exposure were considered together, only combined positivity of both was an independent prognostic factor affecting the OS (P = 0.001). SV40 and asbestos exposure are common in Egyptian MPM, denoting a possible etiological role and a synergistic effect for both agents. Combined positivity for SV40 and asbestos exposure is an independent prognostic factor in MPM, having a detrimental effect on OS.

Posterior mediastinal tumors: outcome of surgery.

BACKGROUND AND PURPOSE: The incidence of posterior mediastinal tumors relative to all tumors of the mediastinum is 23% to 30%. The posterior mediastinum is a potential space along each side of the vertebral column and adjacent proximal portion of the ribs. Primary tumors of posterior mediastinum are usually neurogenic. The aim of this study was to evaluate different surgical approaches used for the resection of posterior mediastinal tumors, and to assess morbidity, mortality and patients' survival. PATIENTS AND METHODS: Between January 2001 and January 2004, 30 patients with posterior mediastinal tumors were included. CT scan of the chest and CT guided biopsy were done for all patients; whereas MRI was done for suspected intraspinal extension. Posterolateral thoracotomy was the approach used in most of the patients. The Akwari approach was used in most of the patients with Dumbbell tumors. RESULTS: Neurogenic tumors constituted 67% of cases, being neuroblastoma in 60%. The non neurogenic tumors included a heterogenous group of rare tumors (n=10). Dumbbell tumors were found in 10 patients. Neuroblastoma was the commonest tumor to cause intraspinal extension (40%). Wide local excision was done in 13 patients; whereas extended resection was done in the remaining 17 patients. The mean intra-operative blood loss was 800cc and the mean hospital stay was 12 days. The size of the resected tumor ranged from 3 X 4 cm to 30 X 22 cm, 80% of tumors were malignant. Morbidity in relation to the procedures developed in 8 patients (atelectasis, meningitis, paraplegia, Horner syndrome and mild wound sepsis in 4, 1, 1, 1 and 1 of the patients; respectively). One postoperative mortality, due to meningitis was recorded. The overall survival by the end of three years was 87.7% with a mean survival of 30.4 months. The overall disease free survival was 55.9% with a mean disease free survival of 26.2 months. CONCLUSIONS: Posterior mediastinal tumors may reach large size before becoming symptomatic. Complete surgical excision (including adjacent invaded organs) mainly by open technique should be the rule for these patients as there is survival benefit. Great care should be taken when dealing with Dumbbell tumors.

Pleurodesis as a palliative treatment of advanced lung cancer with malignant pleural effusion.

PURPOSE: This study was conducted to evaluate the success rate of management of advanced. Lung cancer patients with malignant pleural effusion comparing talc powder with tetracycline for pleurodesis. PATIENTS AND METHODS: We report 60 patients with lung cancer associated with malignant pleural effusion treated in the department of surgery NCI, Cairo University, between January. 1998 and February, 2003. Patients were Divided Into Three Groups: Group I: Pleurodesis using tetracycline (20 patients). Group II: Pleurodesis using talc slurry (20 patients). Group III: Pleurodesis using talc insufflation (20 patients). Good response to pleurodesis is defined as no pleural fluid re-accumulation or minimal pleural fluid re-accumulation not causing symptoms or requiring further aspiration for one month. RESULTS: There were 34 males and 26 females, mean age was 54 years with range of 42-66 years, right sided effusion was present in 32 patients (53%) and left sided in 28 patients (47%). Pathological subtypes were adenocarcinoma in 32 patients, squamous cell carcinoma in 18 and undifferentiated carcinoma in 10 patients. In group I, 12 patients (60%) showed good response to intrapleural tetracycline, 15 patients (75%) responded in group II, while 17 patients (85%) showed good response in group III. Post pleurodesis complications included, fever, chest pain and empyema. CONCLUSION: It is concluded from this study that thoracoscopic talc insufflation was an effective, easy and low cost method for producing pleurodesis in patients with recurrent malignant pleural effusion and proved to be better than talc slurry and tetracycline.