Preoperative chemotherapy in early-stage (stage IB-IIIA) resectable non small cell lung cancer. Is it justified?

Only 20-30% of patients with non small cell lung cancer (NSCLC) present with early-stage disease at the time of diagnosis and may benefit by surgical resection. Five-year survival in early-stage disease varies from 38 to 57% for stage IB and from 13 to 23% for stage IIIA according to the clinical and pathological assessment of the patients. Occult micrometastatic disease already present in many patients with resectable NSCLC at the time of diagnosis and surgical treatment leads to local and distant disease recurrence. Therefore a more systemic approach should be considered in early-stage disease. The role of adjuvant chemotherapy has already been established in this field. Within the past decade attention has been focused on the possible beneficial effects of preoperative chemotherapy considering that patients' compliance to the induction treatment can be very high with eventual eradication of micrometastatic disease and primary tumor downstaging. In this review we present the currently available data on induction chemotherapy followed by surgery in early-stage (stages IB-IIIA) NSCLC with a fundamental question to be answered: is this approach justified in current clinical practice?

Surgery after induction chemoradiotherapy for non small cell lung cancer: when and why.

Stages I and II non small cell lung cancer (NSCLC) are primarily treated by anatomic pulmonary resection. Selected patients with stage IIIB disease are still candidates for surgical treatment. Unfortunately most patients with locally advanced NSCLC don't benefit by surgery alone or even by the combination of chemotherapy and radiotherapy. In order to achieve local and distant disease control, which seems to be the cause of failure of the above mentioned treatments, surgery after induction chemoradiotherapy has been proposed. This approach seems to be the state of the art of therapy for these patients improving survival but with eventual increased risks, especially pulmonary and septic complications. This review of previously published studies indicates the important role of this combined treatment in terms of survival and its risks related either to induction treatment or to surgery.

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.

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.

Donor lung pretreatment with surfactant in experimental transplantation preserves graft hemodynamics and alveolar morphology.

In experimental lung transplantation, the reduction of endogenous surfactant properties occurs after graft preservation and transplant reperfusion. The aim of this study was to evaluate the efficacy of donor lung pretreatment with exogenous surfactant on graft damage after ischemia and reperfusion. Fourteen (control group A, n = 8; study group B, n= 6) young female white pigs (mean weight 27 +/- 3.5 kg) were used in a newly developed autotransplantation model within situcold ischemia. In study group B, before thoracotomy, 1.5 ml/kg surfactant apoprotein-A-free surfactant was administrated into the left main bronchus via flexible bronchoscopy. Belzer UW solution was used for lung preservation. Cold ischemia was achieved for 3 hr with interlobar lung parenchyma temperature at 8 +/- 1.3 degrees C, and central temperature maintained at 37.20 +/- 0.5 degrees C. Animals were sacrificed after 3 hr of graft reperfusion. At the end of reperfusion, pulmonary vascular resistance index (was 447.80 dyn/sec.cm(5).m(2)(+/-66.8) in group A vs 249.51 in group B (P< 0.001) and serum nitric oxide was adequately preserved. The mean alveolar surface area estimated by computerized morphometry was 5280.84 (4991.1) microm(2)(group A) vs 3997.89 (3284.70) microm(2)(group B;P< 0.005). Histology revealed milder macrophage and lymphocyte infiltration in group B at the end of reperfusion. Pretreatment of donor lung with an surfactant apoprotein-A -free surfactant agent appears to be beneficial in terms of maintaining serum NO and reducing hemodynamic disturbances. Furthermore, alveolar histology and stereomorphology are better preserved.

Cervical bronchogenic cyst mimicking thyroid adenoma.

Bronchogenic cysts are congenital malformations of the foregut which are generally encountered within the mediastinum. We explored a patient presenting with a cystic, partially calcified tumor in a cervical and retrotracheal location. This lesion was interpreted as a thyroid adenoma preoperatively, but identified as a bronchogenic cyst at pathology.

Bronchopulmonary aspergilloma: a reappraisal.

BACKGROUND: Classically, most complications observed after operations for aspergilloma occurred in patients with sequelae of tuberculosis. Because the incidence of tuberculosis has declined over the past two decades, aspergilloma is expected to develop with increasing frequency in patients without previous tuberculosis. Therefore, our hypothesis was that operative outcome should have improved during the most recent years in comparison with our previous experience. METHODS: Operative outcome of 12 recently accrued patients was evaluated and compared with a historic control group of 55 patients, previously reported by the same center. RESULTS: As expected, only 17% of patients of the present series had a history of tuberculosis, compared with 57% in the former series. Postoperatively, there was no mortality. Major morbidity has decreased, although this difference is not statistically significant: bleeding decreased from 44% to 9% of patients; space problems decreased from 47% to 18%; and prolonged hospital stay (>30 days) decreased from 32% to 9%. CONCLUSIONS: Our results support a trend toward improved postoperative outcome of operations for aspergilloma owing to a decreased incidence of aspergilloma growing in tuberculous cavitations.