Debulking of stage IVA thymoma.

We present a debulking procedure for the removal of a stage IVA thymoma in a patient with myasthenia gravis (MG). This included thymectomy to remove the primary thymoma, resection of an anterior paracardial mass, a posterior pleural mass, partial pleurectomy, resection of phrenic nerve and wedge excisions of the right upper, middle and lower lobes.

Surgery for oligometastatic disease in non-small-cell lung cancer.

In general, patients with additional metastatic nodules or distant metastases of a non-small-cell lung cancer (NSCLC) have a poor prognosis. However, published results suggest that in carefully selected patients with synchronous or metachronous metastatic lesions, long-term survival can be obtained when a complete resection of the primary site and metastasis - mostly single brain or adrenal - is achieved. Different subgroups of patients with metastatic NSCLC exist and a distinction should be made between additional malignant nodules in the ipsilateral and contralateral lung, malignant pleural effusion and extrathoracic, single or multiple metastases. Patients with additional malignant nodules in the same lobe or ipsilateral nonprimary lobe have a better prognosis than suggested by the current tumor-node-metastasis (TNM) classification. The other subgroups have a poor prognosis. In view of recent data from a large, international database, proposals have been made for the new TNM classification that will be introduced in 2009.

Isolated lung perfusion and related techniques for the treatment of pulmonary metastases.

Surgical resection is a widely accepted treatment for pulmonary metastases on the condition that a complete resection can be obtained. However, many patients will develop recurrent disease in the thorax despite the use of systemic chemotherapy, dosage of which is limited because of systemic toxicity. Similar to the basic principles of isolated limb and liver perfusion, isolated lung perfusion is an attractive and promising surgical technique for the delivery of high-dose chemotherapy with minimal systemic toxicity. The use of biological response modifiers, like tumour necrosis factor, is also feasible. Other related methods of delivering high-dose locoregional chemotherapy include embolic trapping (chemo-embolisation) and pulmonary artery infusion without control of the venous effluent. Isolated lung perfusion has proven to be highly effective in experimental models of pulmonary metastases with a clear survival advantage. Lung levels of cytostatic drugs are significantly higher after isolated lung perfusion compared to intravenous therapy without systemic exposure. Phase I human studies have shown that isolated lung perfusion is technically feasible with low morbidity and without compromising the patient's pulmonary function. Further clinical studies are necessary to determine its definitive effect on local recurrence, long-term toxicity, pulmonary function and survival.

Is there a role for surgery in stage IIIA-N2 non-small cell lung cancer?

The role of surgery in stage IIIA-N2 non-small cell lung cancer (NSCLC) remains controversial. Most important prognostic factors are mediastinal downstaging and complete surgical resection. Different restaging techniques exist to evaluate response after induction therapy and these are subdivided into non-invasive, invasive and alternative or minimally invasive techniques. In contrast to imaging or functional studies, remediastinoscopy provides pathological evidence of response after induction therapy. Although technically more challenging than a first procedure, remediastinoscopy can select patients for subsequent thoracotomy and provides prognostic information. An alternative approach consists of the use of minimally invasive staging procedures as endobronchial or endoscopic esophageal ultrasound to obtain an initial proof of mediastinal nodal involvement. Mediastinoscopy is subsequently performed after induction therapy to evaluate response. In this way, a technically more difficult remediastinoscopy can be avoided. Stage IIIA-N2 NSCLC represents a heterogenous spectrum of locally advanced disease and different subsets exist. When N2 disease is discovered during thoracotomy after negative, careful preoperative staging a resection should be performed if this can be complete. Postoperative radiotherapy will decrease local recurrence rate but not overall survival. Adjuvant chemotherapy increases survival and is presently recommended in these cases. Most patients with pathologically proven N2 disease detected during preoperative work-up will be treated by induction therapy followed by surgery or radiotherapy. In two large, recently completed, phase III trials there was no difference in overall survival between the surgical and radiotherapy arm, but in one trial there was a difference in progression-free survival in favor of the surgical arm. In the surgery arm the rate of local recurrences was also lower in both trials. Surgical resection may be recommended in those patients with proven mediastinal downstaging after induction therapy who can preferentially be treated by lobectomy. Pneumonectomy has a significantly higher mortality and morbidity rate, especially after induction chemoradiotherapy. Patients with bulky N2 disease are mostly treated with combined chemoradiotherapy although the precise treatment scheme has not been determined yet.

Early and late complications of silicone patch saphenoplasty at the saphenofemoral junction.

BACKGROUND: To reduce the incidence of postoperative recurrence after great saphenous vein (GSV) surgery, various barrier techniques have been introduced, aiming at containment of postoperative neovascularization at the saphenofemoral junction in the groin. Interposition of a prosthetic barrier (patch saphenoplasty) may be useful for this purpose; however, the incidence of postoperative complications after patch saphenoplasty is unknown. A prospective study examined the incidence of complications after patch saphenoplasty in primary and repeat varicose vein surgery. METHODS: Silicone patch saphenoplasty was performed in a consecutive series of 462 limbs (primary GSV surgery in 380, repeat surgery in 82) in 387 patients. Early and late complications in the groin potentially related to patch saphenoplasty were registered at clinical follow-up after 1 week and at clinical and duplex ultrasound examination after 2 months, 1 year, and later in case of new symptoms. RESULTS: Complications occurred in 44 limbs (9.5%), 28 (7.4%) after primary GSV surgery and 16 (19.5%) after repeat surgery (P < .01). After repeat surgery, half of the complications were lymphatic problems. Nine limbs (2.0%) developed a complication after >2 months. Wound infection was registered in 13 limbs (2.8%), lymphocele or lymphedema in the groin or thigh in 15 limbs (3.2%), symptomatic or asymptomatic proximal venous thromboembolism in 14 limbs (3.0%), and swelling of the thigh due to important stenosis of the common femoral vein visible on duplex scan in 4 limbs (0.9%). Two of the latter remained symptomatic even after venoplasty and stenting of the pinpoint stenosis of the common femoral vein. CONCLUSION: Patch saphenoplasty can cause early and late postoperative complications in the groin, which are usually minor. In exceptional cases, major complications may cause important morbidity and may be difficult to handle.