Severe haemoptysis due to subclavian arteritis.

Severe haemoptysis due to infective subclavian arteritis has, to our knowledge, never been documented. We report a case of subclavian arterial vasculitis that eroded into the left lung apex, causing a large intraparenchymal mycotic pseudoaneurysm. The patient presented with high fever and blood expectoration. An emergent left lateral thoracotomy was performed. The inflamed segment of the subclavian artery was resected and continuity was restored with a reversed saphenous vein graft. The postoperative course was uneventful and the patient was discharged on the 10th postoperative day.

Resection of left anterior descending coronary artery aneurysm on a beating heart.

We report on the case of a 65-year-old man with unstable angina due to a left anterior descending (LAD) coronary artery single aneurysm. On a beating heart, the aneurysm was partially resected and the left internal thoracic artery was grafted in situ as a patch to the LAD opening. The patient remains well and free of symptoms two years after the operation.

Primary myofibrosarcoma of the lung. A rare case with challenging diagnosis.

Primary myofibrosarcoma (MFS), or myofibroblastic sarcoma of the lung, is a rare tumor. A 47-year-old man with a history of melanoma presented with a central tumor of the left lung. The initial diagnosis was inflammatory myofibroblastic tumor but after extensive pathologic analysis MFS of the lung was confirmed. He underwent left pneumonectomy and died on the 6th postoperative month. This is the second case of primary pulmonary MFS to be reported.

Prognosis of stage pIIIA non small cell lung cancer after mediastinal lymph node dissection or sampling.

PURPOSE: The aim of this study was to define the impact of systematic mediastinal lymph node dissection (MLD) and mediastinal lymph node sampling (MLS) on the long-term results of patients suffering from non-small cell lung cancer (NSCLC) with N2 disease (pIIIA/N2). PATIENTS AND METHODS: From 1999 to 2002, patients with NSCLC in stage pIIIA/N2 were retrospectively classified according to MLD or MLS procedure. Several clinical and pathological factors such as overall survival, disease-free interval, and complications were recorded and analyzed. RESULTS: Ninety-seven (64%) patients were subjected to MLD and 54 (35%) to MLS. Comparison between the two studied groups disclosed more frequent detection of one station pN2 nodes in MLS specimens (p <0.001), while skip metastasis was more often encountered after MLD (p=0.05). Duration of the operation, amount of postoperative bleeding and incidence of prolonged air leak were not significantly different between MLD and MLS groups. Cox regression analysis of all cases disclosed squamous histology as the only favorable factor of survival. The disease-free interval was significantly longer after MLD (p <0.001). CONCLUSION: Although radical lymphadenectomy did not offer significant prolongation of survival, the disease-free interval was significantly longer after MLD compared with MLS.

Surgical management of lung cancer invading the aorta or the superior vena cava.

OBJECTIVE: Invasion of mediastinal structures (T4) is considered as an absolute contraindication to surgical management of non-small cell lung cancer (NSCLC). The authors studied the role of surgical treatment in case of direct aortic and superior venous caval involvement. PATIENTS: From 1995 to 2000, 13 patients with left lung NSCLC invading descending aorta and 9 patients with right upper lobe NSCLC and superior vena cava (SVC) invasion were subjected to thoracotomy for lung resection. Surgery was indicated in case of absence of intraluminal extension. All patients were cN2 negative. The pathology results and 5-year survival were recorded and analyzed. RESULTS: In three cases (23%) the tumor was adhered to the parietal pleura overlying descending aorta, which was resected en block with tumor-associated lung parenchyma. Aortic adventitia invasion by tumor led to local resection of adventitia (<1cm(2)) in nine patients (69%). Invasion deeper than adventitia was encountered in one case (8%), which was managed with aortic partial occlusion, resection of aortic wall and repair of the defect with Gore graft patch. In three patients (33%) the SVC wall was involved by the tumor 1-3cm in length and 2-4mm of the circumference. The defect was repaired with direct suturing. In five patients (56%) the area of SVC wall that was invaded was 3cmx2cm. The defect was repaired with Dacron patch. In 1 patient (11%) an arterial 14 graft was end-to-end interposed. All resections were radical (R0). Neither associated postoperative complications nor operative mortality was recorded. Five-year survival was 30.7% for the cases with aortic invasion and 11% for the ones with SVC involvement. CONCLUSIONS: Radical surgical resection of lung tumors with localized aortic invasion can be considered after exclusion of N2 involvement.

Early detection of occult bronchopleural fistula after routine standard pneumonectomy.

OBJECTIVE: The aim of this study was to define symptoms and signs for early diagnosis of occult bronchopleural fistula (OBPF) after routine pneumonectomy. PATIENTS AND METHOD: From 1999 to 2003, 301 pneumonectomies for malignancy were performed. The records of these patients were retrospectively analyzed for several clinicopathologic factors. All patients (group A) that presented postoperatively with one or more suspicious symptoms and signs were recorded. These cases were grouped according to bronchopleural fistula documentation (group A1) or not (group A2). Both groups were subjected to multivariate analysis. RESULTS: In 10 cases (3.3%) bronchopleural communication was confirmed (group A1). The most frequent signs included the lack of contracture or even enlargement of postpneumonectomy space (52.7%), subcutaneous emphysema (33.3%), fever (27.7%), respiratory insufficiency (27.7%), and cough (22.2%). Multivariate analysis disclosed failure of the postpneumonectomy space to contract as an independent prodromal sign for bronchopleural communication (P=0.03, odds ratio 58.3, 95% CI: 1.45-2335.9). CONCLUSION: Chest radiology proved to be the diagnostic modality of choice for early detection of bronchopleural fistula.

Surgical management of late postpneumonectomy bronchopleural fistula: the transsternal, transpericardial route.

BACKGROUND: Late postpneumonectomy bronchopleural fistula (LBPF) is a serious complication. 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. OBJECTIVES: The goal of this study was to estimate the effectiveness of the transsternal, transpericardial approach for bronchial stump repair in case of LBPF. METHODS: From 1996 to 2002, 1,294 lung resections for non-small cell lung cancer were performed at our department. Out of 412 pneumonectomies, 16 patients (3.8%) presented with LBPF after right pneumonectomy for non-small cell lung cancer. Thirteen of these patients were subjected to transsternal, transpericardial bronchial stump repair. They were followed postoperatively, and morbidity and mortality rates were recorded. RESULTS: The interval between pneumonectomy and fistula diagnosis lasted from 12 to 85 months. The estimated sizes of the fistulae ranged from 5 to 21 mm, and the length of the bronchial stump was >1 cm only in 2 patients (15.3%).Due to persistent empyema, open-window thoracostomy was performed for definite treatment immediately after the operation for bronchial stump reamputation in 6 cases (46.1%). One patient (7.6%) died 3 months postoperatively due to bronchopleural fistula recurrence. This was also the only case of fistula recurrence. CONCLUSION: LBPF usually needs definite management to save the patient's life. The transsternal, transpericardial approach is a safe and effective method.

Postresectional pulmonary oxidative stress in lung cancer patients. The role of one-lung ventilation.

OBJECTIVE: The authors conducted a prospective analysis in order to investigate through lipid peroxidation metabolites the generation of oxygen free radicals after one-lung ventilation (OLV). METHODS: From 2001 to 2003, 212 patients were prospectively studied for lung reexpansion/reperfusion injury. They were classified in six groups. Group A, non-OLV lobectomy group; B, OLV pneumonectomy group; C-E, OLV lobectomy of 60, 90, and 120 min duration, respectively; F, normal subjects as baseline group. Preoperative, intraoperative and postoperative strict blood sampling protocol was followed. Malondialdehyde (MDA) plasma levels were measured. The recorded values were analyzed and statistically compared between groups and within each one. RESULTS: Comparison of groups C-E (OLV) to all other documented significant (P<0.001) increase of MDA levels during lung reexpansion and for the following 12h. The magnitude of oxidative stress was related to OLV duration (group E>D>C, all P<0.001). The removal of cancer-associated parenchyma led to MDA level decrease postoperatively (P<0.001) especially after pneumonectomy (A vs. B, P<0.001). CONCLUSIONS: (1) Lung reexpansion provoked severe oxidative stress. (2) The degree of the amount of generated oxygen free radicals was associated to the duration of OLV. (3) Patients with lung cancer had a higher production of oxygen free radicals than normal population. (4)Tumor resection removes a large oxidative burden from the organism. (5) Mechanical ventilation and surgical trauma are weak free radical generators. (6) Manipulated lung tissue is also a source of oxygen free radicals, not only intraoperatively but also for several hours later.

Late postpneumonectomy bronchopleural fistula.

OBJECTIVE: The incidence of late postpneumonectomy bronchopleural fistula (PBPF) is very small after the 3rd postoperative week due to the existence of fibrothorax providing an effective natural protection against fistula formation. However, the development of late PBPF is a serious complication characterized by high morbidity and mortality. We present our modest experience in treating 11 patients with late PBPF using the transsternal transpericardial approach. MATERIAL: Between 1996 and 1999, 11 male patients with a mean age of 61 years were treated in our department for late PBPF (diameter > 5 mm). The interval between pneumonectomy and fistula creation ranged from 1 to 10 years. The initial operation was right pneumonectomy in all cases due to lung cancer. pTNM stage was either II or IIIA. Bronchoscopically no recurrence was observed and empyema was present in all cases. RESULTS: The initial treatment consisted of tube thoracostomy. We proceeded to direct bronchial stump repair transpericardially with omental flap coverage and finally open window thoracostomy. Neither deaths nor major complications occurred perioperatively. The ICU and hospital stay ranged from 5 to 10 and 30 to 45 days, respectively. During a follow-up of 10 to 28 months no recurrence was observed. CONCLUSIONS: 1. The management of late large PBPF can be only surgical. 2. Fibrothorax and empyema makes the approach through thoracotomy impossible and dangerous for dissection and repair. 3. Bronchial stump repair through the transpericardial approach by median sternotomy is very effective in late PBPF cases where the patient's general condition is good, allowing a major intervention.

A prospective analysis of occult pneumothorax, delayed pneumothorax and delayed hemothorax after minor blunt thoracic trauma.

OBJECTIVES: A prospective analysis was conducted to define the incidence of occult pneumothorax (OPX), delayed pneumothorax (DPX) and delayed hemothorax (DHX) and to propose an algorithm for surveillance. METHODS: During the last 2 years 709 consecutive patients who did not fulfill the indications for intrahospital management were examined at our emergency department for blunt thoracic injury. All patients were subjected to expiration posteroanterior chest radiograph (eCXR) and were scheduled for reevaluation after 24, 48 h and at 7, 14 and 21 days. RESULTS: OPX was present in 28 patients (4%) detected only with eCXR on admission, 14 patients developed DPX (2%) at 24-48 h later, and 52 patients presented up to 14 days later with DHX (7.4%). Of all DHX 42 (80.7%) required chest tube drainage, eight thoracentesis (16%) and only two (4%) were subjected after 1 month to decortication. No related morbidity was recorded. All the patients with the DHX had at least one rib fractured. Only one death among the DHX patients was documented. CONCLUSIONS: A safe algorithm is recommended: eCXR for every patient who suffered blunt thoracic injury with at least one rib fracture detected and is treated as an outpatient or in case his/her compliance with the reevaluation schedule will be suboptimal. Close follow-up is also suggested since these entities do exist, cannot be ignored and their treatment is early evacuation of the pleura cavity.

Skip metastases: analysis of their clinical significance and prognosis in the IIIA stage of non-small cell lung cancer.

OBJECTIVE: To determine the clinical significance of skip metastases (pN2/S) in patients with resected pIIIA/N2 NSCLC. The incidence of pN2/S after mediastinal lymph node dissection (MLD) and sampling (MLS) were compared. METHOD: From 1997 to 2000, 580 lung resections for NSCLC performed at our department. The 151 patients (26.5%) at stage IIIA/N2 (pN2+) were grouped according to their skip metastases status. Group A included the ordinary pN2 (pN2/O) cases (71%) and group B the pN2/S (29%). Age, gender, type of resection, right or left lesion, histology, tumor lobe predilection, MLD or MLS pathologic results, the level and the number of node stations involved and survival were analyzed. RESULTS: In 44 patients (29%) pN2/S disease was present. Statistical analysis revealed significant difference between pN2/O and pN2/S for the following: (1) pN2/S was more common for right-sided lesions (P=0.007); (2) Squamous carcinoma was the main type of pN2/S (P=0.007) and (3) pN2/S was more frequently detected after MLD than after MLS (P=0.001). Although pN2/S involved more often upper mediastinal lymph nodes (Nos. 2, 3) and one station level (pN2/S: 41 vs. pN2/O: 19.6%, P=0.228) was not found statistically significant. pN2/O was more common after right upper lobectomy and pN2/S after right lower lobectomy. The 3-year survival was more favorable for the pN2/S group (A: 24 vs. B: 36%, P=0.07). CONCLUSION: (1) MLD was found to be more reliable for pN2/S detection than MLS. (2) The presence of pN2/S proved to be a less aggressive form of lymphatic spread that should be taken into account in the future. (3) Strong correlation between right lower lobe tumors and pN2/S was demonstrated. (4) Different routes of cancer lymphatic spread between pN2/S and pN2/O are suggested.

Sweat gland carcinoma with multiple local recurrences: a case report.

We report a case of primary, high grade sweat gland carcinoma, a rare tumor, occurring in the skin of the left axilla. The patient, a 54-year-old man, was treated with wide surgical excision and lymph node dissection; he had developed metastatic deposits in one regional lymph node. The neoplasm relapsed locally thrice in a period of 10 years; however, distant metastases were not found. The differential diagnosis of sweat gland tumors is discussed in the present article.