OBJECTIVE:To investigate the prognostic significance of location and extent of lymph node metastasis in resected non-small cell lung cancer (NSCLC), and to weigh up the influence of treatment modalities on survival.PATIENTS AND METHOD:On exploratory analysis, patients were grouped according to location and time of diagnosis of nodal metastasis: group I, pN2-disease in the aortopulmonary region (N=14); group II, pN2-disease at other level (N=30); group III, cN2-disease with response to induction treatment (ypN0; N=21); group IV, cN2-disease without response to induction treatment (ypN1-2; N=27); group V, pN1-disease (N=66).RESULTS:From 1999 to 2005, 158 patients (median age: 64 years) with node-positive NSCLC were treated at our institution either by neoadjuvant chemo-radiotherapy plus surgery or by surgery plus adjuvant therapy (chemotherapy, radiotherapy, or both). Operative mortality and major morbidity rates were 2% and 15%. Five-year survival rates were 19% for group I, 12% for group II, 66% for group III, 15% for group IV, and 29% for group V (P<.05). On multivariate analysis, time of N+-diagnosis, extent of nodal involvement and therapy approach were significantly linked to prognosis.CONCLUSION:The survival of patients with node-positive NSCLC does not depend on anatomical location of nodal disease, but strongly correlates to extent of nodal metastases and treatment modality. Combined therapy approaches including chemotherapy and surgery may improve long-term survival.
INTRODUCTION:Pulmonary aspergillosis is a devastating complication in immunocompromised patients. Timing of surgery is controversial and depends on the patients' general condition.METHODS:From 2000 to 2007, 16 patients (mean age 47 years, range 20-64) underwent surgery for pulmonary aspergillosis. All patients were receiving immunosuppressive drugs due to chemotherapy of hematological malignancies, ten with additional bone marrow or stem cell transplantation. Perioperatively, aspergillosis was treated with antifungal agents. If granulocyte numbers in the peripheral blood was below 1.0x10(9)/l, granulocyte stimulating factor and granulocyte transfusions were administered perioperatively.RESULTS:Four patients underwent lobectomy and wedge resections of the same lung, one patient bilobectomy, two patients lobectomy, eight patients wedge resections of one lung, and one patient wedge resections of both lungs. All patients survived surgery without major complications. Five patients were bone marrow or stem cell transplanted 1, 2, 3, 7 and 10 months after surgery. Three of them died due to recurrence of the underlying malignancy. All other patients are alive and free of fungal disease.CONCLUSIONS:Timing of surgery in the context of antifungal therapy and adequate numbers of granulocytes and platelets in the peripheral blood appear essential for successful surgical therapy and avoidance of major complications.
Introduction: Controversy persists about the role of VATS lobectomy for patients with lung cancer. This is particularly true in Europe, where VATS (video assisted thoracic surgery) lobectomy is performed for lung cancer less often than in the USA or Japan. This article reviews existing data comparing the results of VATS vs. open lobectomy for the treatment of lung cancer in order to provide a scientific basis for a rational assessment of this issue. Methods: The review of the data presented here draws heavily from a 2007 metaanalysis by Cheng et al. [1] published in 2007, as it employed rigorous methodology in performing a systematic review and metaanalysis, and involved a detailed analysis of many major and minor endpoints on an intent to treat basis. This included 36 trials, three of them randomized, and 3589 patients, reported between 1995 and 2007. Summary results for individual endpoints are shown as a mean value with 95% confidence intervals (CI). These values are taken from the summary results of the Forrest plots in the source article. Dichotomized variables are expressed as an Odds Ratio, with values <1 being in favor of VATS lobectomy. Continuous variables are reported as weighted mean differences. Results: The operative time for a VATS lobectomy was statistically longer, but only by 16 minutes. The conversion rate from VATS to open was 6%. There was no significant difference in the rates of major bleeding, blood transfusion or re-operation. VATS lobectomy was associated with a significantly lower rate of complications in general and pulmonary complications in particular. Postoperative pain was reduced, functional outcome was better, whereas overall quality of life was not. Mediastinal staging was equal with regard to the number of nodes or the number of nodal stations sampled. The ability of patients to receive adjuvant chemotherapy was improved following VATS. There was no difference in survival at 1 and 3 years for lung cancer (all stages combined). There was no difference in survival at 5 years for each tumor stage, and no difference in the rate of deaths at maximal follow-up. Conclusion: The data suggests that VATS lobectomy for NSCLC is safe, results in fewer complications, less pain, and more rapid return of normal functioning. There appears to be either no difference or a slight benefit in long term survival after VATS lobectomy. These conclusions are demonstrated by a comprehensive, rigorous metaanalysis of the controlled clinical trials, but are weakened by the fact that most of the studies were not randomized. However, because a large randomized trial is not likely to ever be conducted, this represents the best assessment of the value of VATS lobectomy that is available.
BACKGROUND:Surgical treatment of non-small cell lung cancer (NSCLC) with aortic invasion is still debated.METHODS:Thirteen patients with locally advanced (T4) NSCLC and invasion of the descending aorta underwent pneumonectomy (n=9) or lobectomy (n=4) together with aorta en bloc resection and reconstruction (n=8) or subadventitial dissection (n=5), complete lymph node dissection, and had microscopic unsuspected node metastasis at N1 (n=5) and N2/3 (n=8) levels of whom 12 received radiation therapy. Clamp-and-sew was used to resect and reconstruct the aorta.RESULTS:Operative mortality and morbidity rate was 0% and 23%, respectively. Four patients died of systemic tumor relapse and 2 of local recurrence. Six patients were alive after a median follow-up of 40 months (range 15-125 months). Overall 5-year survival rate was 45%. Median survival time and 5-year survival rate of patients after aortic resection was 35 months and 67%, respectively, and was 17 months and 0%, respectively, after aortic subadventi-tial dissection (p=0.001). N1 and N2 nodal status adversely affected survival, but survival difference was not significant (N1 versus N2/3; 52% versus 39% at 5 years; p=0.998).CONCLUSIONS:Aortic resection with single station node positive T4 lung cancer can achieve long-term survival. The data indicate that aortic resection-reconstruction is associated with better outcome than subadventitial dissection.
OBJECTIVE:Perioperative morbidity and mortality in patients receiving pneumonectomy because of non-small cell lung cancer (NSCLC) remains quite high. The aim of this study is to identify risk factors to minimize perioperative mortality and morbidity.PATIENTS AND METHOD:The results of 156 Patients who received pneumonectomy between 1995 and 2004 were reviewed retrospectively. All patients had stage I or II NSCLC. In 81 cases a right sided and in 75 a left sided pneumonectomy was performed. Cardiopulmonary function tests were sufficient for pneumonectomy.RESULTS:Overall perioperative 30-day mortality was 7.1% (n=11), in hospital mortality 8.3% (n=13). The cause was sepsis in 6 cases, cardiac failure in 4 cases, and respiratory insufficiency in 3 cases. In univariable and multivariable regression analysis considering mortality, none of the prognostic factors reached significance. The odds ratio for postoperative death was 1.6 fold for smokers in comparison to non smokers. Complications after pneumonectomy were seen in 34.6%, with arrhythmia in 16.0%, sepsis in 1.9% and bronchopleural fistula (BPF) occurring in 6.4%. Smoking and intraoperative blood loss >500 ml were highly significant perioperative risk factors.CONCLUSION:Smoking until operation and intraoperative blood loss were independent postoperative risk factors leading to complications after pneumonectomy for NSCLC. The risk for complications was 2.8-fold higher for smokers.
Extrinsic oesophageal compression leading to dysphagia is a recognised but uncommon sole presentation of thoracic aortic aneurysms. This has been referred to as Dysphagia Aortica, and is a late presentation of large thoracic aneurysms, or a symptom of impending aorto-oesophageal fistula. We present the case of a 67 year old woman who presented repeatedly with dysphagia and weight loss over a 3 month period to specialists in three different disciplines. Eventually, a type II thoraco-abdominal aortic aneurysm causing extrinsic compression of the oesophagus was discovered. When dealing with patients who present with dysphagia, if no other cause is discovered, a thoracic aortic aneurysm should form part of the differential diagnosis, as this is potentially curable, and delays in diagnosis and treatment predispose to rupture and death.
Benign mesenchymoma is a rare type of germ cell tumour. An extensive literature search revealed only one described case of mediastinal mesenchymoma in Europe and three cases in Asia. We describe our recent experience of a mediastinal mesenchymoma and present the fascinating imaging and operative findings. The preoperative diagnosis of these lesions remains difficult and therefore surgical resection is recommended.
Four cases of thoracic lymphoma mimicking chest wall tumors are presented. As resection is not the treatment of first choice in lymphomas, pretherapeutical evaluation of chest wall tumors should include a thoroughly staging and a biopsy for histopathological diagnosis. Chest wall destruction due to an anterior mediastinal mass, or a chest wall tumor associated with mediastinal lymph node enlargement, could be suspicious of thoracic lymphoma. Lymphoma with chest wall involvement mostly turns out to be Hodgkin's disease or large B-cell lymphoma. Stage and histopathological diagnosis have major impact on treatment and prognosis. Therapy is chemotherapy or chemo-radiation.
Thymic carcinoid tumors belong to the group of mediastinal tumors, but are quite rare and usually carry a very poor prognosis. This report illustrates a case in which a thymic carcinoid tumor that had led to cavernous sinus syndrome was treated successfully. This is the first case report of a thymic carcinoid to metastasize to the cavernous sinus.
OBJECTIVE:Carcinoids are rare neuroendocrine tumors of the bronchial system. Only recently, the histological classification was standardized, and there are varying opinions about the extent of surgical resection. This research reports on the long-term results of 111 consecutive patients, who underwent surgery in a department for thoracic surgery.METHODS:Between 1/1988 and 2/2001, 111 consecutive pulmonary resections were conducted in patients with bronchial carcinoids. Retrospectively, researchers obtained clinical and surgical data and re-classified all histological specimen according to the WHO classification of 1999. Information regarding long-term results was obtained by using data obtained during follow-up visits and by talking to the patient on the phone.RESULTS:97 patients with typical and 14 with atypical carcinoids were identified. The preoperative diagnosis of typical or atypical carcinoid had been correct in 56 patients (50.5%). Surgical procedures included 79 lobectomies, 16 bilobectomies, 8 pneumonectomies, 5 segmental resections, 2 sleeve resections of the main bronchus without parenchymal resection and one exploratory thoracotomy. Mediastinal lymphadenectomies were performed on 105 patients (94.6%). Postoperative staging revealed 91 patients (81.2%) in UICC stage I, 12 (10.8%) in stage II, 7 in stage III and one in stage IV. 97 (87.4%) typical and 14 (12.6%) atypical carcinoids were classified. 30-day mortality was 1.8% (n=2). Mean follow-up was 73.4 months. The total cohort showed a 5-year survival rate of 94% and a 10-year survival rate of 82%. In patients with typical and atypical carcinoids, the 5-year survival rates were 94% and 82%, respectively (n.s.), and the 10-year survival rates were 92% and 62%, respectively (p<0.01). The 5- (10-) year survival rate without lymph node involvement was 96% (85%), with N1 involvement 88% (65%), with N2 involvement 67% (no 10-year survival).CONCLUSIONS:Patients with bronchial carcinoids who underwent a radical oncological resection with mediastinal lymphadenectomy have very good survival chances. There are no prospective randomized studies evaluating the surgical procedures as they relate to the classification. Since a preoperative diagnosis cannot clearly determine if the lymph nodes are involved and what histology type the physician dealing with, a limited resections without lymphadenectomy is insufficient. It is absolutely necessary to conduct retrospective and multi-center studies on the prognostic importance of lymph node involvement and on the impact of adjuvant therapies.
Background: The development of a two-bladed spreadable video-mediastinoscope in 1992 allowed increased exposure and bimanual dissection of mediastinal structures. Concurrent with technical progress in mediastinoscopy, neoadjuvant treatment of stage III lung cancer was introduced, and accuracy of pretreatment mediastinal staging became a topic at issue. In this setting, development of a videomediastinoscopic technique for complete mediastinal lymphadenectomy was the obvious thing to do.Methods: Video-assisted mediastinoscopic lymphadenectomy (VAMLA) dissection is guided by anatomical landmarks, very similar to open lymphadenectomy. It includes en bloc resection of the right and central compartments and dissection and lymphadenectomy of the left-sided compartments. In a preliminary case-control study of 40 patients, VAMLA technique was standardized and evaluated against open lymphadenectomy. A second study investigated 130 patients with resectable lung cancer and radiographically normal mediastinum who underwent VAMLA and consecutive lung resection with mediastinal reexploration.Results: VAMLA harvested significantly more nodes than open lymphadenectomy. With a mean duration of 54 minutes and a complication rate of 4.6%, VAMLA appeared applicable to clinical routine. We noted a sensitivity of 93.8%, a specificity of 100%, and a false-negative rate of 0.9%.Conclusions: In our experience, VAMLA is a feasible method of mediastinal staging. Its accuracy and radicality can equal open lymphadenectomy. However, VAMLA is minimally invasive and therefore pretherapeutically available. Its advantages might be of interest with neoadjuvant strategies, trials, involved field radiation, video-assisted thoroscopic lobectomy, and left-sided tumors.
AIM:In spite of available recommendations, therapeutic procedures of locally recurrent breast cancer are very different. In a retrospective study, the possibilities and results of complete, full-thickness chest wall resection are presented.METHODS:Between 1985 and 2004, 51 women underwent complete, full-thickness chest wall resection with primary coverage. Primary surgical therapy of breast cancer had been mastectomy in 88%. Median age of patients undergoing surgery for a local recurrence was 57 (29 - 81) years. The median interval between surgery of the primary tumour and of the local recurrence was 70.3 (10.7 - 327.2) months; median follow-up was 29.4 (1.8 - 230.9) months. 40 (78.4%) patients required rib resections, 15 (29.4%) of them in combination with partial sternal resection. In 4 (7.8%) patients complete and in 7 (13.7%) patients partial sternal resection without additional rib resection were performed.Coverage was mainly realized using latissimus dorsi myocutaneous flaps (n=44; 86.3%). Survival rates were calculated by means of the Kaplan-Meier method, the relative risk using univariate and multivariate Cox-regression analysis.RESULTS:In the total collective, cumulative 5-, 10- and 15-year survival (YS) rates were 39%, 31% and 23%, respectively, median survival 46.4 months. R0 resection was associated with a 5-YS of 42%. Prognostic factors were age at the time of primary surgery, disease-free interval and tumour invasion of bony structures. Mortality was 2%, morbidity 35%.CONCLUSION:Full-thickness chest wall resection of locally recurrent breast cancer is possible in almost any patient when performed by a team of thoracic and plastic surgeons. Only radical resection provides good long-term results with low mortality and morbidity.
Pyothorax-associated lymphoma (PAL) is a rare haematological malignancy often associated with artificial pneumothorax due to the treatment of pulmonary tuberculosis. A 76 year old man with chronic tube-drained pyothorax and a history of artificial pneumothorax for pulmonary tuberculosis was admitted to our hospital because of progressive right thoracic pain, weight loss, and pyrexia. After clinical examination and imaging processes a chest wall tumour anterior on the right side was diagnosed as well as a persisting pyothorax. Surgery was performed to resect the tumour and drain the pleural cavity. A diagnosis of a high grade B-cell lymphoma was established after histological examination of the surgical biopsy. Epstein-Barr virus (EBV) was identified in the tumour by immunocytochemical and molecular methods. Additional gastric involvement of B-cell lymphoma could be diagnosed by gastroscopy because of postoperative gastrointestinal bleeding. The patient received chemotherapy with 2 courses of cyclophosphamide, doxorubicin, vincristine and prednisolone (CHOP). The response was favourable initially, but 2 months later the patient died because of lymphoma progression.Most cases of PAL have been described by Japanese investigators and only a few cases are reported in Western countries. To the best of our knowledge this case of PAL is the first to be documented in Germany.Awareness of this rare entity, together with diligent histological examination, in patients with chronic pyothorax are essential for a correct diagnosis and correct early treatment.
Text The development of General Thoracic Surgery At the beginning of the 19th century, the development of chest surgery was initiated by the purposeful experimentation of French, German, and other European surgeons. The discovery of the low-pressure method is linked with names such as Brauer, von Mikulicz, and Sauerbruch in 1904. The accurate experiments of the last-mentioned led to the development of the decompression chamber-Sauerbruch´s cabinet. The high-pressure method and the introduction of endo-tracheal anaesthesia by Kuhn in Germany,-Auer, and Meltzer working in the Institute of Physiology at the Rockefeller Institute-followed in the years between 1901 and 1909. Advances in anaesthesia with endotracheal ventilation made increasingly extensive thoracic surgical interventions possible, as positive pressure could be maintained in the lungs and collapse on opening the chest avoided. Following the first atypical pulmonary resections for tuberculosis at the end of the 19th century by Delorme, Doyen, and Tuffier in France-Heidenheim undertook the first lobectomy in Worms in Germany in 1901. In 1931 Nissen successfully performed the first pneumonectomy on a child with bronchiectasis and Graham, in 1933, carried out the first pneumonectomy to remove a bronchial carcinoma. Anatomically isolated preparation of the hilar structures was undertaken by Rienhoff in 1933, whereby considerable reduction in complications was achieved. Lung surgery progressed rapidly so that the anatomical segmental resection was employed clinically by Churchill and Belsey in 1939 in England. Edwards established the thoracic tradition of the Brompton School in London, and his first assistant Price Thomas performed the first bronchial sleeve resection in 1947. An important prerequisite for lobectomy was the introduction of suction drainage of the pleural cavity for the reex-pansion of the residual lung. This was achieved using the siphon drainage developed by von Bülau in 1890. After the Second World War General Thoracic Surgery in Germany advanced. Resection procedures became increasingly important. General Thoracic Surgery comprises operative measures in cases of congenital anomalies, malfunction, diseases and injuries of the thorax, the pleura, the tracheobronchial system, the lungs, the diaphragm, esophagus, and medi-astinal organs. Because of high proportion of cancer patients-about 70%-thoracic surgery today in Europe is a largely onco-logical surgery. Knowledge of the diagnostic procedures in radiology, nuclear medicine, internal medicine, and pneumology is therefore necessary, and evaluation of the relevant findings must be practised so that preoperative tumour-staging can be undertaken. Operative success is depending on the indication and choice of surgical technique. At the beginning the risks …
