Prognostic role of clusterin in resected adenocarcinomas of the lung.

RATIONALE: Clusterin expression may change in various human malignancies, including lung cancer. Patients with resectable non-small cell lung cancer (NSCLC), including adenocarcinoma, have a poor prognosis, with a relapse rate of 30-50% within 5 years. Nuclear factor kB (Nf-kB) is an intracellular protein involved in the initiation and progression of several human cancers, including the lung. OBJECTIVES: We investigate the role of clusterin and Nf-kB expression in predicting the prognosis of patients with early-stage surgically resected adenocarcinoma of the lung. FINDINGS: The level of clusterin gradually decreased from well-differentiated to poorly differentiated adenocarcinomas. Clusterin expression was significantly higher in patients with low-grade adenocarcinoma, in early-stage disease and in women. Clusterin expression was inversely related to relapse and survival in both univariate and multivariate analyses. Finally, we observed an inverse correlation between Nf-kB and clusterin. CONCLUSIONS: Clusterin expression represents an independent prognostic factor in surgically resected lung adenocarcinoma and was proven to be a useful biomarker for fewer relapses and longer survival in patients in the early stage of disease. The inverse correlation between Nf-kB and clusterin expression confirm the previously reported role of clusterin as potent down regulator of Nf-kB.

Sleeve resections with unprotected bronchial anastomoses are safe even after neoadjuvant therapy.

OBJECTIVES: Sleeve resection is the operation of choice in patients with centrally located tumours, in order to avoid a pneumonectomy. Most surgeons protect the bronchial anastomoses with tissue to prevent insufficiencies. The purpose of this study is to report on outcome of unwrapped bronchial anastomoses, especially after neoadjuvant chemo- or chemoradiotherapy. METHODS: Between 2000 and 2010, 103 patients [59 years (range 16-80), 40 females] underwent bronchial sleeve resections without coverage of the anastomosis with a tissue flap. We retrospectively reviewed the data for morbidity, mortality and survival, especially with regard to the type of resection, neoadjuvant therapy and stage. RESULTS: Sleeve lobectomy was performed in 88, sleeve bilobectomy in 8, sleeve pneumonectomy in 4 and sleeve resection of the main bronchus in 3 patients. Twenty-seven patients had a combined vascular sleeve resection. Neoadjuvant chemotherapy was performed in 20 and radiochemotherapy in 5 patients. Non-small cell lung cancer (NSCLC) was present in 76 patients (squamous cell carcinoma in 44, adenocarcinoma in 24, large cell carcinoma in 6 and mixed cell in 2) and neuroendocrine tumour in 20 and other histological types in 7 patients. The pathologic tumour stage in NSCLC was stage I in 26, stage II in 26, stage IIIA in 16, stage IIIB in 7 and stage IV in 1 patient. There were no anastomotic complications, especially no fistulas. One patient developed narrowing of the intermediate bronchus without need for intervention. Twenty-four patients had early postoperative complications, including 11 surgery-related complications (air leakage, nerve injury, haemothorax or mediastinal emphysema). The 30-day mortality was 3% (one patient died due to heart failure and two with multiorgan failure). The 5-year survival rate was 63% in NSCLC patients and 86% in neuroendocrine tumour patients. CONCLUSIONS: Sleeve resection without wrapping the bronchial anastomoses with a tissue flap is safe even in patients who underwent neoadjuvant chemo- or chemoradiotherapy. Therefore, wrapping of the bronchial anastomoses is not routinely mandatory.

Long-term functional results after surgical treatment of parapneumonic thoracic empyema.

Retrospective evaluation of long-term functional results of surgical treatment of chronic pleural empyema. Two different surgical procedures (debridement vs. decortication) and approaches (VATS vs. thoracotomy) were analyzed. Three end-points were considered: short-term surgical results, short- and long-term radiological results, clinico-functional long-term results. Fifty-one debridement (52% VATS, 48% thoracotomy) and 68 decortication were performed. Postoperative mortality and morbidity were 1.5% and 24%, respectively. Older age (>70 years old) had worse postoperative morbidity (P=0.048). Video-assisted thoracic surgery (VATS) debridement had lower postoperative hospital stay (P=0.006) and shorter duration of chest drainage (P=0.006). The infectious process was resolved in all patients. All patients presented a postoperative radiological improvement, 63 patients (60%) with a complete pulmonary re-expansion. Sixty patients (58%) referred a complete respiratory recovery. VATS debridement had a greater improvement in subjective dyspnea degree (P=0.041). The long-term spirometric evaluation was normal in 58 patients (56%). Age >70 years old resulted the only variable associated to poor long-term results (FEV(1)% < 60% and/or MRC grade > or = 2) at multivariate analysis. Surgical treatment of pleural empyema achieves excellent long-term respiratory outcomes. VATS is associated to less postoperative mortality and shorter postoperative hospital stay. In elderly patients, postoperative morbidity could be higher and long-term functional improvement less warranted.

Unusual pathogenesis of spontaneous pneumothorax secondary to Wegener's granulomatosis.

Spontaneous pneumothorax represents a rare and potentially severe complication of Wegener's granulomatosis. A 31-year-old man with Wegener's granulomatosis on immunosuppressive therapy was admitted for a right massive spontaneous pneumothorax. After chest drainage he presented with a prolonged air leak that required a surgical treatment. Histologic findings did not reveal any necrotizing granulomatous vasculitis, but only subpleural fibrous tissue. We hypothesize that pneumothorax could be related to the subpleural fibrous retraction induced by immunosuppressive therapy.

Prognostic factors and survival after resection of lung metastases from epithelial tumours.

Lung metastasectomy is an accepted treatment for selected patients with pulmonary metastases. Resectability, disease-free interval and number of metastases are well characterised prognostic indicators after lung metastasectomy. Patients treated with lung metastasectomy for epithelial tumours were retrospectively reviewed. One hundred and forty-two patients were reviewed. The rate of mediastinal node metastases was 12%. Overall 5-year survival rate was 36% with a median survival time of 47 months. Recurrence rate after lung metastasectomy was 50%. Five-year disease-free survival was 26% with a median of 29 months. Mediastinal nodal status negatively affected survival at univariate analysis (5-years 32% for N+ and 40% for N-, P=0.013). Disease-free survival was significantly different according to nodal status: 5-year disease-free survival 17 and 28% for N+ and N-, respectively (P=0.053). Systemic recurrences were more frequent in patients with nodal involvement (P=0.058). Mediastinal nodal involvement resulted in a significant prognostic factor at multivariate analysis (N+: RRD=3.0; 95% CI 1.3-6.7). Patients with pulmonary metastases and nodal involvement had a poor prognosis and relapsed early after pulmonary metastasectomy. Nodal status should be considered in the selection of patients for lung metastasectomy.