Bone marrow micrometastasis might not be a short-term predictor of survival in early stages non-small cell lung carcinoma.

OBJECTIVE: To determine the presence of occult micrometastasis (OM) in a selected population of surgically resectable patients presenting with non-small cell lung carcinoma (NSCLC) and to evaluate its prognostic value on relapses and survival. METHODS: From February 1996 to December 1999, 99 patients undergoing surgical treatment for NSCLC were prospectively investigated for the presence of occult bone marrow micrometastasis. Tumor cells were detected with monoclonal primary antibodies directed against low molecular weight cytokeratins. RESULTS: Median follow-up time was 14.3 months (range 0.2-45.6 months). Overall prevalence of OM was 22.2% (22 out of 99). The presence of OM was not correlated to pathology, T status, or N status. In survival analysis, the only independent predictors of overall survival were N0 status and Stage I (P=0.016 and 0.004, respectively), while T1 was a predictor of disease-free survival (P=0.044). Metastasis and loco-regional recurrence were observed at follow-up in 18.2 (four out of 22) and 9% (two out of 22) of patients OM(+) and in 14.3 (11 out of 77) and 7.8% (six out of 77) of patients OM(-), respectively (P=not significant). OM was a predictor neither of overall survival nor of disease-free survival (P=0.52 and 0.97, respectively). In Stage I patients, 1-year overall survival and 1-year disease-free survival were 89 and 98% for OM(-) patients and 88 and 90% for OM(+) patients, respectively (P=0.57 and P=0.75). CONCLUSIONS: OM was present in >20% of surgically treated NSCLC patients and did not correlate to pathological variables. In contrast to previous published data, in this study the presence of OM had no influence on overall or disease-free survival.

Retrospective study of somatosensory evoked potential monitoring in deep hypothermic circulatory arrest.

BACKGROUND: We evaluated the efficiency of median-nerve somatosensory evoked potentials (SEPs) monitoring in determining the optimal level of hypothermia in 62 consecutive patients operated on under deep hypothermic circulatory arrest (CA). METHODS: CA was started at 1 degree C below the temperature at which both brainstem and cortical SEP components disappear. No additional method of cerebral protection was used. RESULTS: New neurological complications were observed in 15 patients: long-lasting in 11 and transient in 4. A retrospective analysis of SEP monitoring identified the origin of the complications in 12 cases: early CA with incomplete cooling due to emergency (3 cases); inefficient retrograde perfusion through the femoral artery during cooling due to the dissection flap effect (4 cases); embolism during rewarming (2 cases); delayed embolism (2 cases); hemorrhagic shock (1 case). In 2 cases, neurological sequelae involved the lower limbs (extracerebral origin). One case without intraoperative SEP changes was neurologically abnormal preoperatively and did not change postoperatively. There were no cases with sequelae due to excessive CA duration. CONCLUSIONS: The use of SEP monitoring to determine the optimal level of hypothermia efficiently prevents neurological sequelae of CA. It helps in monitoring the degree of cerebral protection during cooling (flap effect), and rewarming.

Randomized trial of intermittent antegrade warm blood versus cold crystalloid cardioplegia.

BACKGROUND: We performed a prospective randomized trial to compare intermittent antegrade warm blood cardioplegia with intermittent antegrade and retrograde cold crystalloid cardioplegia. METHODS: Two hundred consecutive patients scheduled for isolated coronary bypass surgical procedures were randomized into two groups: Group 1 (n = 92) received cold crystalloid cardioplegia with moderate systemic hypothermia, group 2 (n = 108) received intermittent antegrade warm blood cardioplegia with systemic normothermia. Preoperative, intraoperative, and postoperative data were prospectively collected. RESULTS: For the same median number of distal anastomoses, cardiopulmonary bypass duration and total ischemic arrest duration (57.3 +/- 20.5 versus 75 +/- 22.1 minutes, p < 0.001) were shorter in group 2 than in group 1. Apart from a higher right atrial pressure in the cold cardioplegia group, no hemodynamic difference was observed. Aspartate aminotransferase, creatine kinase-MB fraction, and cardiac troponin I levels were significantly lower in group 2 than in group 1. Outcome variables were not significantly different. CONCLUSIONS: Intermittent antegrade warm blood cardioplegia results in less myocardial cell damage than cold crystalloid cardioplegia, as assessed by the release of cardiac-specific markers. This beneficial effect has only marginal clinical consequences. Normothermic bypass has no deleterious effect on end-organ function.

Recycling of arterial grafts during reoperative coronary artery operations.

BACKGROUND: To overcome problems of lack of conduit and to maximize the number of arterial anastomoses in coronary reoperations we reused previously placed arterial grafts. METHODS: Sixteen patients were identified from February 1994 to July 1997. Mean age was 62.8 years (range, 44 to 75 years). Fifteen (94%) were in Canadian Cardiovascular Society angina class III or IV. The mean interval from primary to secondary operation was 8.5 years (range, 3 to 12 years). Eleven patients had a patent internal mammary artery graft used as the recipient for a proximal Y anastomosis. In 3 cases an arterial graft was reimplanted distally on the same coronary vessel and in 2 onto different coronary vessels. One patient had a combination of these techniques. Five patients required venous conduit. RESULTS: There were no deaths. Mean length of intensive care stay was 69 hours (range, 24 to 144) and mean hospital stay was 14 days (range, 10 to 28 days). All patients were discharged home. Follow-up averages 13 months (range, 2 to 43 months). Twelve patients (75%) are now in Canadian Cardiovascular Society angina class I and 3 (19%) in class II. CONCLUSIONS: Reusing arterial conduits during coronary reoperations is possible with minimal in-hospital morbidity and satisfactory results in terms of freedom from angina. Using these techniques can help overcome the problems of inadequate conduit and maximize the number of arterial anastomoses that can be made per patient.