Quality of life and pre-operative anxiety level in patients scheduled to undergo thoracic surgery.

PURPOSE: Increased preoperative anxiety levels may lead to adverse outcomes. We aimed at assessing the relationship between quality of life (QoL) and preoperative anxiety level during the 4-week preoperative period in patients scheduled to undergo thoracic surgery and we tried to identify patients who could benefit from preoperative supportive measures. METHODS: One hundred patients comprised the study population (52 men and 48 women) out of the initial 136, who were scheduled to undergo thoracic surgery. Mean age was 56±15 years (±SD). After obtaining informed consent, participants were asked to answer a questionnaire, through a personal interview, 12 to 15 h prior to their scheduled thoracic operation. The questionnaire included questions on demographics and incorporated the State Anxiety Inventory (STAI) and SF-36 scales. RESULTS: Female patients (p=0.023), unemployed patients (p=0.01) and patients that were scheduled for a mediastinoscopy (p=0.001) experienced increased anxiety level. Lower scores in several parameters related to the QoL were found to be associated with increased anxiety level. Limitations in patients' ability to work or to perform other everyday activities as a result of mental health problems (p=0.006), low vitality (p<0.001), bad general mood (p<0.001), deteriorated general health (p<0.001) and general mental health (p<0.001) were associated with preoperative anxiety. No differences were found in anxiety level among lung cancer and non-lung cancer patients. CONCLUSION: This study showed an inverse proportional correlation between preoperative QoL and anxiety during the 4-week period prior to thoracic surgery. Appropriate pharmaceutical and psychological support may improve patients' anxiety level.

Suppressors of cytokine signaling as tumor repressors. Silencing of SOCS3 facilitates tumor formation and growth in lung and liver.

The suppressors of cytokine signaling (SOCS) are inhibitors of cytokine signaling that function via the Janus kinase (JAK)/signal transducers and activators of transcription (STAT) pathway. Eight SOCS (SOCS1-SOCS7 and CIS /cytokine-inducible SH2-domain) proteins with similar structures have been identified. Cytokines bind to specifi c sites on the extracellular domains of their cognitive receptor, causing receptor dimerization. This allows the recruitment of JAKs to the receptors, which then cross-phosphorylate each other before phosphorylating the receptor on key tyrosine residues. STAT molecules bind to these phosphorylated docking sites, are in turn phosphorylated, dimerized, and enter the nucleus where they initiate transcription. Some of the genes transcribed by these factors include the SOCS genes. The SOCS proteins then act to negatively regulate activated receptor complexes by inactivating JAKs or blocking recruitment sites for STATs and also may target signaling complexes for ubiquitination and degradation. Lung cancer and hepatocellular carcinoma (HCC) are associated with abnormalities of the JAK/STAT pathway. In conclusion, determining the importance of SOCS family in health and disease will no doubt aid to the development of novel therapeutic strategies in human carcinogenesis.

The influence of local instillation of fusidic acid on the development of microbial complications after lung resection.

The efficacy of local instillation of fusidic acid in the prevention of post-surgical microbial complications during various types of lung resection was studied. Four hundred ninety two consecutive patients who underwent 504 thoracotomies for non-small cell lung carcinoma during April 1998-May 2004 were reviewed. The 290 patients of the first period who underwent 298 thoracotomies received a chemoprophylactic regimen of intravenous cefuroxime while the 202 patients of the second period who underwent 206 thoracotomies were additionally treated with fusidic acid, irrigated with local instillation into the pleural space, for the prevention of postoperative septic complications. Patients were followed postoperatively for development of septic complications (empyema and bronchopleural fistula) as well as of pneumonia and wound infection. Seventeen patients (5.7%) of the first period developed empyema and 13 fistula (4.4%), whereas only 2 patients (1.0%) of the second period developed empyema and fistula (OR = 5.876; 95% CI, 1.343- 25.716; P = 0.008 and OR = 4.193; 95% CI, 1.003-20.130; P = 0.034, respectively). Cases of pneumonia decreased, but not significantly, from 21 (7.0%) during the first period to 9 (4.4%) during the second period (OR = 1.613; 95% CI, 0.724-3.593; P = 0.257) while cases of wound infection decreased significantly from 19 (6.4%) to 2 (1.0%) (OR = 6.567; 95% CI, 1.513-28.510; P = 0.003). During the first period 23 pathogens were found from cases of empyema and 73 pathogens from cases of pneumonia and wound infection, whereas during the second period 3 and 18 pathogens were respectively found (OR = 5.3; 95% CI, 1.570-17.888; P = 0.003, and OR = 2.804; 95% CI, 1.628-4.838; P <0.001, respectively). These results indicate that local instillation of fusidic acid in the pleural space prior to lung resection seems effective in reducing the rate of septic complications as well as of wound infections.

Lung cancer: quality of life after surgery.

PURPOSE: Lung cancer is the most common cause of cancer death in both men and women in our country. It has been estimated that there will be 6,000 lung cancer deaths every year in Greece. However, many patients with bronchogenic carcinoma also have coexistent obstructive lung disease. In these patients, preoperative prediction of functional status after lung resection is mandatory. The aim of our study was to determine the effect of lung resection on postoperative spirometric lung function. PATIENTS AND METHODS: 112 patients underwent spirometric pulmonary tests preoperatively, and at 3 and 6 months after their operation. The predicted postoperative forced vital capacity (FVC) and forced expiratory volume in the first second (FEV1) were calculated using the formula of Juhl and Frost: predicted postoperative FEV1 (or FVC)=preoperative FEV1(or FVC) x[1-(S x 0.0526)], where S=number of segments resected. Statistical significance was defined as a p value < 0.05. RESULTS: The functional percentage losses at 6 months for lobectomies and pneumonectomies were 7.34% and 34.89% for FVC and 7.72%; and 32.53% for FEV, respectively. The linear regression analysis derived from the correlation between predicted and measured FEV1 resulted in 2 equations for lobectomy and pneumonectomy. The first, for lobectomy, was: FEV1POSTOP=0.00211 + 0.896660 x FEV1PREOP; and the second, for pneumonectomy, was: FEV1POSTOP=0.145 + 0.65318 x FEV1PREOP. CONCLUSION: We conclude that our formulas are a reliable method for predicting postoperative respiratory function of the patients with lung cancer.

Expandable wallstents for treatment of tracheoesophageal fistulas of malignant origin.

PURPOSE: To present our experience with endoscopic placement of esophageal endoprosthesis with self-expandable wallstents in patients with malignant tracheoesophageal fistulas. PATIENTS AND METHODS: 16 patients were retrospectively evaluated, in whom 16 stents were positioned at the esophagus because of tracheoesophageal fistulas: 12 of them suffered of malignant tumors of the esophagus and 4 of malignant tumors of the lung. All stents were placed with guide wire. We used self-expandable wallstents with internal silicon-basedcovering with flared ends, made of a stainless-steel alloy woven into a tubular mesh. RESULTS: Stents were successfully places in all patients. No procedure-related mortality or significant morbidity occured. Two patients complained of transient swallowing discomfort, but none of them required any additional analgesia. Thirty-day mortality was nil. Immediate leak occlusion was obtained on erect contrast assessment after the procedure in all patients. CONCLUSION: Self-expandable wallstents endoprosthesis in the esophagus for fistulas of malignant origin is an easy, well tolerated, safe and effective procedure without important complications or mortality.

Nutritional aspects regarding lung cancer chemoprevention.

Lung cancer is still one of the major causes of cancer-related deaths and its mortality figures argue powerfully for new approaches to control this leading cancer threat. Chemoprevention can be defined as the use of specific agents to reverse, or prevent premalignancy from progressing to invasive cancer. The use of foods and dietary supplements present a safe chemopreventive strategy. Data for this review were identified by searches of PubMed and references from relevant articles. Articles were identified by use of the search terms "lung cancer", "chemoprevention", "carcinogenesis", and "retinoids". Only papers published in English were included. Trials in lung cancer chemoprevention have so far produced either neutral or harmful primary endpoint results, whether in the primary, secondary, or tertiary settings. Lung cancer was not prevented by beta-carotene, alpha-tocopherol, retinol, retinyl palmitate, N-acetylcysteine, or isotretinoin in smokers. Ongoing trials may help define new avenues for chemoprevention. The concept of chemoprevention in lung cancer is still in its infancy, but in the future it may have a significant impact on the incidence and mortality of lung cancer. In addition to epidemiologic studies, basic science research to detect mechanisms and evaluate the chemopreventive potential of food components is necessary. The overwhelming evidence of a major role of nutrition in carcinogenesis, the many leads that nutritional intervention may reduce cancer incidence, and the growth and increasing sophistication of clinical trials networks point to a very promising future for nutritional intervention trials leading to substantial public benefit.

Recent aspects regarding carcinogenesis in non-small-cell lung cancer.

Lung carcinogenesis is a field which is yet to be exploited and its molecular mechanisms to be more clearly defined. The goal of this article is to present the major alterations that occur in lung cancer, especially those that happen in the early stages of carcinogenesis. Finally, in this review we present the latest methods that are used to study the cellular/molecular pathophysiology of lung cancer and their clinical appliance.

Chromogenic in situ hybridization analysis of chromosomes 7, 9, and 17 in pancreatic ductal adenocarcinoma based on tissue microarrays.

PURPOSE: Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive neoplasm. Many different chromosomal alterations have been identified including structural or numerical changes. In this study we performed a molecular analysis of chromosomes 7,9, and 17 based on tissue microarrays (TMA). MATERIALS AND METHODS: Using TMA technology, 50 paraffin-embedded tissue samples of histologically confirmed primary PDACs were cored twice and re-embedded to the final recipient block. Chromogenic in situ hybridization (CISH) was performed using centromeric probes of the corresponding chromosomes. SPSS(chi square test and interrater kappa) was performed for statistical analysis. RESULTS: Chromosome 17 analysis detected aneuploidy in 19 (38%) cases. Similarly, aneuploidy regarding chromosome 9 was identified in 9 (18%) cases, whereas 14 (28%) cases were aneuploid, concerning chromosome 7. Statistical significance was assessed, correlating chromosome 7 with grade and stage (p=0.016 and p=0.027, respectively) and chromosome 9 to grade (p=0.023). Similarly, analyzing normal-appearing ductal epithelia adjacent to cancer cell populations, 2 cases were found with alterations regarding chromosome 9 and 17. CONCLUSION: Molecular analysis for chromosomes 7, 9 and 17 in PDAC confirmed that there is a variety of numerical alterations, and some of them represent very early genetic events in the progression of carcinogenetic process. Performance of CISH, also, provides an easy, accurate approach for their detection, even in a small tissue sample, such as TMA cylindrical cores.

Percutaneous stent placement in malignant cases of superior vena cava syndrome.

PURPOSE: Superior vena cava (SVC) syndrome is caused by SVC stenosis or occlusion, frequently as a consequence of lung cancer or a mediastinal tumor. SVC syndrome is characterized by unpleasant symptoms and the condition usually leads to death if untreated. Treatment with radiation therapy and chemotherapy may produce an initial relief, whereas operations with bypass are associated with high mortality and morbidity. The PURPOSE of our study was to show the efficiency of percutaneous stenting in the SVC for relieving SVC syndrome secondary to malignant diseases. PATIENTS AND METHODS: From January 1999 to March 2003, 17 patients with malignant SVC syndrome were evaluated at the "Metaxa" Cancer Hospital. Their caval stenoses were confirmed by means of computed tomography and venography. There were 15 males and 2 females with a median age of 62 years (range 47-79). The SCV syndrome was caused by malignant disease in all patients: bronchogenic carcinoma in 14 and lymphoma in 3. All patients underwent placement of a self-expandable (wallstent) endovascular (vena cava) prosthesis. RESULTS: All procedures were successfully carried out without complications. The average time for wallstent placement was 37 min. There was no sign of bleeding and the wallstent was well positioned on chest roentgenograms. All patients, without exception, noticed an immediate improvement, with relief of dyspnea and rapid resolution of headache. Cyanosis disappeared over the first hour and swelling resolved gradually over the first 24 hours. CONCLUSION: Percutaneous venous wallstent placement in the SVC is a simple, safe and effective technique to rapidly relieve SVC syndrome caused by malignant diseases.

Surgery in small cell lung cancer: when and why.

Small cell lung cancer (SCLC) is considered a systemic disease at diagnosis, because the potential for hematogenous and lymphogenic metastases is very high. For many years, the diagnosis of SCLC was considered a contraindication for surgery because radiotherapy was at least equivalent in terms of local control, and the rate of resectability in SCLC patients was poor. When chemotherapy became the mainstay of treatment for SCLC, radiotherapy was its logical complement, and surgery was progressively abandoned. However, some centers continued to support surgery because experience suggested that in selected patients it was possible to achieve a long-term survival. In the search for predictors of long-term survival it became evident that the TNM staging system was effective for SCLC. The rationale for surgery in the context of SCLC is based on 3 factors: a) Several historical series of patients operated for limited-stage SCLC reported some long-term survivors, showing that cure could be achieved. b) After chemotherapy and radiotherapy, the rate of local relapse is 20%-30%. The assumption that surgical resection might be superior for local disease control has been suggested but not yet proved. c) The surgical intervention can precisely assess pathological (p) response to chemotherapy, identify carcinoids erroneously diagnosed as SCLC, and treat the non-small cell lung cancer (NSCLC) component of tumors with a mixed histology. Even if some controversies exist, it is accepted that surgery can be proposed as the first treatment in patients with T1 or T2 lesions with no evidence of lymph node involvement, followed by adjuvant chemotherapy. In more advanced stages of disease, chemotherapy should be the first step of treatment and surgery can be proposed to responding patients, before radical radiotherapy, depending on the p-stage of disease. Such an intensive multidisciplinary approach should be always employed in the context of controlled clinical trials.

Evaluation of combined telomerase and c-myc expression in non-small cell lung carcinomas using tissue microarrays and computerized image analysis.

PURPOSE: Telomerase activation plays a crucial role in tumorigenesis by sustaining cellular immortality. It consists of two main components which include a RNA subunit (h-TERC) and a catalytic protein subunit (h-TERT). Similarly, amplification or deletion correlating with overexpression of c-myc is a common event in various neoplasias, including non-small cell lung carcinoma (NSCLC). Because c-myc activates telomerase by inducing expression of its catalytic subunit, our aim was to correlate the expression of these two proteins with the biological behavior in NSCLC. MATERIALS AND METHODS: Using tissue microarrays technology (TMA) we evaluated by computerized image analysis (CIA) the results of h-TERT and c-myc immuno-histochemistry (IHC) in 40 NSCLCs, which were cored and re-embedded into one TMA block. RESULTS: Co-overexpression (moderate or high levels of NLI: Nuclear Labeling Index) of h-TERT and c-myc was observed in the majority of cases and found to be statistically significant (p=0.001). The results showed also strong association between c-myc and h-TERT overexpression correlating with stage (p=0.001 for both of them), but not with grade (p=0.206 and p=0.313, respectively). CONCLUSION: Our combined study showed that there is a strong correlation between the activation and expression of these two genes and maybe this co-deregulation could be used as a prognostic factor for the evaluation of biological behavior in NSCLCs.

Solitary fibrous tumor of the pleura: a review.

Solitary fibrous tumor (SFT) of the pleura is a rare neoplasm that arises most commonly within the visceral pleura but may evolve from the parietal pleura of the chest, mediastinum or diaphragm. These tumors are most commonly diagnosed in the 6th to 7th decade of life with equal rates of occurrence for both sexes. In this review we discuss the clinical, radiographic and histological features, the diagnosis and differential diagnosis, prognostic factors and therapy of these rare tumors.

Syndrome after pneumonectomy.

The syndrome after pneumonectomy is an unusual complication of pneumonectomy resulting from excessive displacement of the mediastinal structures toward the empty pleural space. In infants, children, and infrequently in young or middle- aged adults, excessive mediastinal shift after pneumonectomy occurs gradually. The resultant compression of the remaining contralateral bronchus leads to severe respiratory compromise. Development of the syndrome is most common after right pneumonectomy, is infrequently seen after left pneumonectomy in patients with a right-sided aortic arch, and is observed rarely after left pneumonectomy in patients with a normal position of the aortic arch in the left hemithorax. The typical clinical presentation is that of dyspnea, which occurs months or years after surgery, and the diagnosis is confirmed by documenting, on computed tomographic scan or by bronchoscopy, significant tracheobronchial obstruction. The problem can be corrected by restoration of the normal relation of the mediastinal structures, which is best achieved by inserting a tissue expander in the empty chest cavity. Endoluminal stenting seems to offer the most efficient treatment of associated tracheobronchomalacia.

Thoracoscopy, bronchoscopy and mediastinoscopy in the staging of lung cancer.

PURPOSE: To estimate the benefit of Video-Assisted Thoracoscopy (VAT) in the staging of patients with lung cancer. PATIENTS AND METHODS: Between October 1998 and January 2001 VAT was used in 250 patients with histologically proven lung cancer. They were staged by more conventional techniques including magnetic resonance imaging (MRI), bronchoscopy, and mediastinoscopy. RESULTS: As a result of VAT 30 patients were upstaged and spared a thoracotomy receiving neo-adjuvant chemotherapy at that point. In 40 patients the procedure was converted into an open thoracotomy and a curative resection was performed during the same session. The remaining 180 patients were deemed inoperable and they received chemotherapy and radiation treatment. CONCLUSION: VAT enhanced our bronchoscopic and medistinoscopic findings. It was especially useful in assessing the extent of invasion of various thoracic structures amenable to surgical removal "en block" with the tumor, and in differentiating simple contact of the tumor with an intrathoracic structure from tumor invasion. In addition, it allowed access and sampling of lymph nodes in spaces not easily accessible by mediastinoscopy.

Completion pneumonectomy for lung cancer.

PURPOSE: Completion pneumonectomy is a trully challenging operation associated with increased mortality and morbidity. The aim of this study was to present a series of 18 patients who underwent completion pneumonectomy for lung cancer during a 15-year period and to evaluate the postoperative outcomes and long-term results. PATIENTS AND METHODS: Between January 1985 and December 2000,18 patients underwent completion pneumonectomy for lung cancer; 10 for local recurrence ,6 for second primary lung tumor and 2 for lung tumors in patients who had previously been operated on for benign disease. RESULTS: No intraoperative deaths occurred. Postoperative mortality and morbidity were 11.11% and 33.33%, respectively. The median operational time was 212.7 minutes. The mean blood loss during the procedure was 1.042,5 ml. The complication rate was 33.33%. The 5-year survival was 18.75% for all patients. The 5-year survival was 25% for the local recurrence group and 50% for the primary lung cancer group. The 5-year survival of the patients in the second primary tumor group has not been reached yet. CONCLUSION: Completion pneumonectomy can be performed with an acceptable operative mortality rate and offers a second chance for cure to patients with lung cancer. Although complications are common ,they can successfully be managed with proper understanding of them.

Incisional metastasis after cervical mediastinoscopy: a case report.

The risk of iatrogenic tumor seeding from mediastinoscopy is low. The etiology of this complication remains unclear. We present the case of a patient with this condition, discuss the cause and management, and review the literature.

Argon coagulation in laparoscopic cholecystectomy.

BACKGROUND: The purpose of this study is to compare argon coagulation with standard electrocoagulation. METHODS: Twenty-four consecutive patients submitted to laparoscopic cholecystectomy (LC) were divided randomly into two equal groups. Group 1 used standard electrocoagulation and group 2 argon coagulation. The operative time and amount of blood loss were measured. RESULTS: Operative time (minutes): Group 1 65.33 +/- 4.07 SE. Group 2 55.83 +/- 2.82 SE (P < 0.10). Amount of blood loss (ml): Group 1 105.58 +/- 6.37 SE. Group 2 62.92 +/- 5.82 SE (p < 0.001). CONCLUSIONS: Preliminary results support our opinion that argon coagulation is to be favored over standard coagulation.