Effects of diaphragm plication on pulmonary function and cardiopulmonary exercise parameters

OBJECTIVES

Paralysis of the diaphragm is an uncommon condition, which may result in dyspnoea on excertion and in orthopnea. In patients who have symptoms, the paralysed diaphragm is often plicated to prevent its paradoxical movement on inspiration. This procedure brings relief to many patients, but the mechanism for this improvement is not well understood.

METHODS

Nine symptomatic patients who underwent plication of a unilateral paralysed hemidiaphragm were prospectively evaluated. All patients underwent pulmonary function tests and cardiopulmonary exercise tests before surgery and repeated them after surgery.

RESULTS

Patients with hemidiaphragm paralysis before surgery were found to have lower tidal volumes at any given ventilation rate during exercise than normal subjects. A clear and consistent change was found in the manner in which patients increased their ventilation during exercise after surgery. All patients showed an increase in tidal volume for a given ventilation rate, which was significant. The plication procedure reduced the respiratory rate for any exercise level in all patients, and this effect was more pronounced during exercise.

CONCLUSIONS

In patients with hemidiaphragm paralysis who underwent a diaphragm plication exercise, tidal volumes increased and the ventilatory frequency decreased. Despite this improvement, maximal exercise capacity remained unaltered.

Evaluation of arm function and quality of life after trimodality treatment for superior sulcus tumours

OBJECTIVES

Following trimodality treatment for superior sulcus tumours (SSTs), the 5-year survival rate has significantly improved. Quality of life and potential negative effects of this strategy have become more important. The objective of this study was to investigate the quality of life and the arm and shoulder function after the resection of superior sulcus tumours following neoadjuvant chemoradiation.

METHODS

Patients were selected from a thoracic surgery database. Between January 2002 and December 2010, 72 patients received trimodality treatment of whom 39 were alive at the start of this study in 2010. The following arm function tests were used: nine-hole peg test, range of motion test and action research arm test. Quality of life was assessed using the Disability of the arm and shoulder and SF-36 questionnaires. Analyses of the arm function were conducted comparing the treated side with the untreated side. For quality of life, patients treated on their dominant side were compared with those treated on their non-dominant side.

RESULTS

In total, 19 patients participated in this study (15 men and 4 women). The median age was 59 years (range 39-73), median radiation dose 50 Gy (range 39-66) and median follow-up 40 months (range 4-101). There was no statistically significant difference in arm and shoulder function between the treated and the untreated arm. However, statistically significantly less pain was found if patients were treated on their dominant side.

CONCLUSIONS

After the resection of SSTs following chemoradiotherapy, the arm and shoulder function on the affected side is comparable with the functions at the contralateral side. Patients treated for an SST on their dominant side are less affected in their quality of life regarding pain compared with those treated on their non-dominant side.

Primary neuroendocrine tumors of the thymus: a multicenter experience of 35 patients

BACKGROUND

Primary neuroendocrine tumors of the thymus (NETT) are rare tumors and represent a distinct category of tumors collectively displaying morphologic and biological neuroendocrine features. We sought to evaluate factors influencing long-term survival in patients with primary NETT.

METHODS

From January 1990 to April 2011, 35 patients (27 male patients and 8 female patients) were surgically treated for primary NETT at 5 institutions.

RESULTS

No operative (30-day) mortality occurred. Morbidity was 37.14% (13/35 patients). All patients were followed for a total of 2,703 months. Fourteen patients had associated paraneoplastic syndrome. Twenty-four patients are alive, 19 of whom are free of disease and 5 of whom continue to have disease. The median overall survival was 153 months. The overall 5-year and 10-year actuarial survival rates were 84.34% and 60.82%, respectively. The 10-year survival was evaluated according to histologic type (typical carcinoid, 77.92%; atypical carcinoid, 54.55%; large-cell neuroendocrine carcinomas, 0%; Masaoka staging (stage I, 100%; stage II, 66.67%; stage III, 61.9%; stage Iva, 25%; stage IVb, 0%), presence of paraneoplastic syndrome (no = 70.67%; yes = 32.14%), postoperative radiotherapy (yes = 39.71%; no = 85.71.%), Surveillance, Epidemiology, and End Results (SEER) staging system (localized disease, 83.3%; regional disease, 53.3%; distant disease, 0%), tumor size (<7 cm = 90.9%; ≥7cm = 28.7%; p = 0.0007), and Ki67 expression, which was available in 23 patients (<10% = 85.71%; ≥10% = 0%; p = 0.0037).

CONCLUSIONS

The prognosis of primary NETT is statistically significantly related to tumor size >7 cm and to the proliferation index (evaluated by Ki67 expression >10%). The histologic type of the neoplasm, the presence of a paraneoplastic syndrome, the Masaoka staging, the evidence of distant disease, and postoperative radiotherapy also impact prognosis.

Severe kyphosis with spinal cord compression after resection of a superior sulcus tumor

Vertebral involvement is no longer a contraindication for resection of superior sulcus tumors. We describe a patient who developed a kyphoscoliosis with spinal cord compression after resection of a superior sulcus tumor that invaded the vertebral column. Risk factors for spinal instability and indications for stabilization are discussed.

Oral nutritional supplements containing n-3 polyunsaturated fatty acids affect quality of life and functional status in lung cancer patients during multimodality treatment: an RCT

Background/Objectives:

Our objective was to investigate effects of an oral nutritional supplement containing n-3 polyunsaturated fatty acids (FAs) on quality of life, performance status, handgrip strength and physical activity in patients with non-small cell lung cancer (NSCLC) undergoing multimodality treatment.

Subjects/Methods:

In a double-blind experiment, 40 patients with stage III NSCLC were randomised to receive 2 cans/day of a protein- and energy-dense oral nutritional supplement containing n-3 polyunsaturated FAs (2.02 g eicosapentaenoic acid+0.92 g docosahexaenoic acid/day) or an isocaloric control supplement, during multimodality treatment. Quality of life, Karnofsky Performance Status, handgrip strength and physical activity (by wearing an accelerometer) were assessed. Effects of intervention were analysed by generalised estimating equations. P-values <0.05 were regarded as statistically significant.

Results:

The intervention group reported significantly higher on the quality of life parameters, physical and cognitive function (B=11.6 and B=20.7, P<0.01), global health status (B=12.2, P=0.04) and social function (B=22.1, P=0.04) than the control group after 5 weeks. The intervention group showed a higher Karnofsky Performance Status (B=5.3, P=0.04) than the control group after 3 weeks. Handgrip strength did not significantly differ between groups over time. The intervention group tended to have a higher physical activity than the control group after 3 and 5 weeks (B=6.6, P=0.04 and B=2.5, P=0.05).

Conclusion:

n-3 Polyunsaturated FAs may beneficially affect quality of life, performance status and physical activity in patients with NSCLC undergoing multimodality treatment.

[Treatment and prognosis of superior sulcus tumours]

Superior sulcus tumours (or Pancoast tumours) are non-small-cell lung carcinomas presenting with specific symptoms and requiring a specific approach to treatment due to their location in the pulmonary apex. Early recognition is rare as a result of the low incidence and the relatively late occurrence of symptoms .Shoulder pain, with or without radiation to the ipsilateral arm or hand, and Horner's syndrome are often presenting symptoms. The current standard of care for patients with resectable tumours is pre-operative chemoradiotherapy, followed by resection of the tumour and affected surrounding structures. This is associated with 5-year survival rates of more than 50%. Invasion of local structures, the presence of mediastinal lymph node metastases and, in a select group of patients, distant metastasis, are not necessarily contra-indications for surgical resection. Patients who have undergone complete resection, or demonstrate a pathologically complete response after induction therapy, have significantly higher survival rates. Treatment of superior sulcus tumours requires a multidisciplinary approach; considering the complexity of the treatment, patients should be referred to a specialised centre.

Gene expression profile in the diaphragm following contractile inactivity during thoracic surgery

Introduction. Recent work revealed the development of marked muscle fiber weakness in the diaphragm, but not in the non-respiratory latissimus dorsi, during thoracic surgery. To disentangle the molecular processes that underlie the development of diaphragm muscle fiber weakness during thoracic surgery, we studied changes in the gene expression profile. Methods. Serial biopsies from the diaphragm and the latissimus dorsi muscle were obtained from four patients during thoracotomy for resection of a tumor in the right lung. Biopsies were taken as soon as the diaphragm had been exposed (t0) and again after two hours (t2). Gobal differences in gene expression in diaphragm biopsies were assessed by microarray analysis. Results. 346 differentially expressed gene transcripts were found in the diaphragm at t2 vs. t0. Pathway analysis revealed that genes associated with inflammation (83 genes; p<0.0001) and cell death (118 genes, p<0.0001) pathways were significantly overexpressed at t2. Of the 346 differentially expressed genes in the diaphragm at t2, 258 were also differential in the latissimus dorsi muscle, with the direction of change being identical for all differentially expressed genes. In addition, latissimus dorsi showed exclusive upregula-ton of negative regulators of cell death. Conclusions. Two hours of thoracic surgery result in rapid and profound changes in expression of inflammatory response and apoptotic genes in the diaphragm. The apoptotic response was stronger in the diaphragm than in the latissiums dorsi. These findings suggest that the development of selective diaphragm muscle fiber weakness in these patients might be related to an exaggerated apoptotic response.

Opposing effects of the angiopoietins on the thrombin-induced permeability of human pulmonary microvascular endothelial cells

Background

Angiopoietin-2 (Ang-2) is associated with lung injury in ALI/ARDS. As endothelial activation by thrombin plays a role in the permeability of acute lung injury and Ang-2 may modulate the kinetics of thrombin-induced permeability by impairing the organization of vascular endothelial (VE-)cadherin, and affecting small Rho GTPases in human pulmonary microvascular endothelial cells (HPMVECs), we hypothesized that Ang-2 acts as a sensitizer of thrombin-induced hyperpermeability of HPMVECs, opposed by Ang-1.

Methodology/Principal Findings

Permeability was assessed by measuring macromolecule passage and transendothelial electrical resistance (TEER). Angiopoietins did not affect basal permeability. Nevertheless, they had opposing effects on the thrombin-induced permeability, in particular in the initial phase. Ang-2 enhanced the initial permeability increase (passage, P = 0.010; TEER, P = 0.021) in parallel with impairment of VE-cadherin organization without affecting VE-cadherin Tyr685 phosphorylation or increasing RhoA activity. Ang-2 also increased intercellular gap formation. Ang-1 preincubation increased Rac1 activity, enforced the VE-cadherin organization, reduced the initial thrombin-induced permeability (TEER, P = 0.027), while Rac1 activity simultaneously normalized, and reduced RhoA activity at 15 min thrombin exposure (P = 0.039), but not at earlier time points. The simultaneous presence of Ang-2 largely prevented the effect of Ang-1 on TEER and macromolecule passage.

Conclusions/Significance

Ang-1 attenuated thrombin-induced permeability, which involved initial Rac1 activation-enforced cell-cell junctions, and later RhoA inhibition. In addition to antagonizing Ang-1, Ang-2 had also a direct effect itself. Ang-2 sensitized the initial thrombin-induced permeability accompanied by destabilization of VE-cadherin junctions and increased gap formation, in the absence of increased RhoA activity.

Fatal hemothorax caused by pseudomesotheliomatous carcinoma of the lung

We present a case of a poorly differentiated pseudomesotheliomatous carcinoma originating in the lung, which was manifested with the distinctly rare complication of massive true hemothorax and persistent blood loss that proved rapidly fatal in spite of surgery. Pseudomesotheliomatous carcinoma of the lung and neoplasia-associated hemothorax are reviewed and discussed.

Diaphragm muscle fiber function and structure in humans with hemidiaphragm paralysis

Recent studies proposed that mechanical inactivity of the human diaphragm during mechanical ventilation rapidly causes diaphragm atrophy and weakness. However, conclusive evidence for the notion that diaphragm weakness is a direct consequence of mechanical inactivity is lacking. To study the effect of hemidiaphragm paralysis on diaphragm muscle fiber function and structure in humans, biopsies were obtained from the paralyzed hemidiaphragm in eight patients with hemidiaphragm paralysis. All patients had unilateral paralysis of known duration, caused by en bloc resection of the phrenic nerve with a tumor. Furthermore, diaphragm biopsies were obtained from three control subjects. The contractile performance of demembranated muscle fibers was determined, as well as fiber ultrastructure and morphology. Finally, expression of E3 ligases and proteasome activity was determined to evaluate activation of the ubiquitin-proteasome pathway. The force-generating capacity, as well as myofibrillar ultrastructure, of diaphragm muscle fibers was preserved up to 8 wk of paralysis. The cross-sectional area of slow fibers was reduced after 2 wk of paralysis; that of fast fibers was preserved up to 8 wk. The expression of the E3 ligases MAFbx and MuRF-1 and proteasome activity was not significantly upregulated in diaphragm fibers following paralysis, not even after 72 and 88 wk of paralysis, at which time marked atrophy of slow and fast diaphragm fibers had occurred. Diaphragm muscle fiber atrophy and weakness following hemidiaphragm paralysis develops slowly and takes months to occur.

Bronchogenic cysts in adults: frequently mistaken for a solid mass on computed tomography

BACKGROUND

Bronchogenic cysts are congenital malformations and are often detected in asymptomatic patients as an incidental finding. Growth can cause compression of airways and vessels, resulting in clinical symptoms and possible complications. On computed tomography (CT) scans, bronchogenic cysts frequently have the appearance of a solid tumor. We describe diagnostic strategy and management for patients with bronchogenic cysts.

METHODS

Retrospective case study of 11 adults diagnosed with a bronchogenic cyst. The CT scan of all patients was revised and localization, size, Hounsfield Units (HU), and appearance (cystic or solid) of the lesions were reported. Lesions were arbitrarily considered cystic or solid when the radiographic density was below or above 20 HU, respectively.

RESULTS

Eleven adults with a bronchogenic cyst were followed for at least 2 years after diagnosis. Eight of 11 detected lesions were judged as a solid lesion, based on the radiographic density (in HU) on CT images. Nine of 11 patients were treated by surgical resection. Two asymptomatic patients were not operated and remained asymptomatic without enlargement of the cysts during 2 years follow-up. Complications of resection were post-operative bleeding (n = 1), recurrent pneumothorax (n = 1), and recurrence of the cyst (n = 1). No mortality was observed.

CONCLUSION

Bronchogenic cysts are frequently mistaken for a solid mass on CT scans. Further differentiation can be made by MRI or EUS when CT is inconclusive.

Weekly chemoradiation (docetaxel/cisplatin) followed by surgery in stage III NSCLC; a multicentre phase II study

BACKGROUND

This prospective study analyzed the feasibility and efficacy of weekly concurrent chemoradiation (docetaxel/cisplatin) followed by surgery. The primary endpoint was radiological response.

PATIENTS AND METHODS

Six chemotherapy (docetaxel/cisplatin) cycles were administered on days 1, 8, 15, 22, 29 and 36 with concurrent thoracic radiotherapy in fractions of 1.8 Gy, to a total dose of 45 Gy. Patients underwent surgery depending on results of invasive mediastinal re-staging.

RESULTS

Forty-two out of 45 NSCLC stage III patients were evaluable. Nineteen patients showed partial/complete response (46%), 14 stable disease (34%) and eight (20%) progressive disease. Toxicity was mild. The 30-day postoperative mortality was 4.2%. Twenty-four patients (59%) proceeded to surgery and 20 (49%) underwent a complete resection (R0).

CONCLUSION

Weekly concurrent chemoradiation (docetaxel/cisplatin) in stage III NSCLC results in a radiological response rate of 46% and mediastinal downstaging in 56%. Complete resection in downstaged patients was achieved in 49% of all patients.

Oral nutritional supplements containing (n-3) polyunsaturated fatty acids affect the nutritional status of patients with stage III non-small cell lung cancer during multimodality treatment

Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), (n-3) fatty acids from fish oil, have immune-modulating effects and may improve nutritional status in cancer. The objective of this study was to investigate the effects of an oral nutritional supplement containing (n-3) fatty acids on nutritional status and inflammatory markers in patients with non-small cell lung cancer (NSCLC) undergoing multimodality treatment. In a double-blind experiment, 40 patients with stage III NSCLC were randomly assigned to receive 2 cans/d of a protein- and energy-dense oral nutritional supplement containing (n-3) fatty acids (2.0 g EPA + 0.9 g DHA/d) or an isocaloric control supplement. EPA in plasma phospholipids, energy intake, resting energy expenditure (REE), body weight, fat free mass (FFM), mid-upper arm circumference (MUAC), and inflammatory markers were assessed. Effects of intervention were analyzed by generalized estimating equations and expressed as regression coefficients (B). The intervention group (I) had a better weight maintenance than the control (C) group after 2 and 4 wk (B = 1.3 and 1.7 kg, respectively; P < 0.05), a better FFM maintenance after 3 and 5 wk (B = 1.5 and 1.9 kg, respectively; P < 0.05), a reduced REE (B = -16.7% of predicted; P = 0.01) after 3 wk, and a trend for a greater MUAC (B = 9.1; P = 0.06) and lower interleukin-6 production (B = -27.9; P = 0.08) after 5 wk. After 4 wk, the I group had a higher energy and protein intake than the C group (B = 2456 kJ/24 h, P = 0.03 and B = 25.0 g, P = 0.01, respectively). In conclusion, a protein- and energy-dense oral nutritional supplement containing (n-3) fatty acids beneficially affects nutritional status during multimodality treatment in patients with NSCLC.

Sentinel node detection in patients with thyroid carcinoma: a meta-analysis

Objective

This study was designed to review the diagnostic performance of sentinel node (SN) detection for assessment of the nodal status in thyroid carcinoma patients and to determine the technique (using blue dye or Technetium-99m colloid (^99mTc)) that demonstrated the highest success rate with regard to the detection rate and sensitivity.

Methods

A comprehensive computer literature search of studies published in English language through December 2007 and regarding SN procedures in patients with thyroid disorders was performed in MEDLINE. Pooled values regarding the SN detection rate and the pooled sensitivity values of the SN procedure were presented with a 95% confidence interval (CI) for the different SN detection techniques.

Results

Ultimately, we identified 14 studies comprising a total of 457 patients. Of these, ten studies (n = 329 patients) used the blue dye technique with a pooled SN detection of 83% (95% CI, 79–87%). The remaining four studies (n = 128) used ^99mTc-colloid with a pooled SN detection of 96% (95% CI, 91–99%; p < 0.05 vs. blue dye technique).

Conclusion

In patients with suspected thyroid carcinoma, SN biopsy demonstrated a higher SN detection rate when ^99mTc was used (96%) instead of the blue dye technique (83%).

[Treatment of patients with stage III non-small cell lung cancer: concurrent high-dose chemotherapy and radiotherapy]

The treatment of patients with locally advanced non-small cell lung cancer (stage III) has changed significantly in the past few years. Patients with a non-resectable stage IIIA/B tumour are given combined treatment consisting ofchemotherapy and radiotherapy. These can be administered sequentially or concurrently. It has been shown recently that concurrent chemoradiotherapy gives a survival advantage in comparison with sequential chemoradiotherapy. Cisplatin and etoposide are usually the drugs of choice for chemotherapy in patients with stage III cancer. A biologically effective dose of radiotherapy equivalent to 60-66 Gy, over a maximum of 6.5 weeks, should be given. Surgery is possible for a selected group of patients, provided a complete objective mediastinal response has been achieved after chemoradiotherapy and a complete resection appears to be technically feasible. It is recommended to apply this treatment in a research setting. High-dose concurrent chemoradiotherapy is advised as the standard treatment for stage III non-small cell lung cancer in patients in good physical condition.

Restaging of mediastinal nodes with transbronchial needle aspiration after induction chemoradiation for locally advanced non-small cell lung cancer

INTRODUCTION

Selecting the appropriate treatment strategy for patients with locally advanced non-small cell carcinoma (NSCLC) is of utmost importance to determine patient outcome. Previous studies have shown that nodal down-staging after induction therapy and definitive local irradiation in these patients better predict survival when combined with surgery. However, nodal restaging can be technically difficult. We investigated the role of transbronchial needle aspiration (TBNA) in mediastinal restaging of patients who had completed induction cytotoxic therapy.

METHODS

A total of 14 patients with proven stage IIIa-N2 NSCLC who received chemotherapy or chemo-radiotherapy as induction regimen between 2005 and 2006 were studied. Outpatient flexible bronchoscopy with TBNA was performed in all patients under local anesthesia, and 17 TBNA procedures were performed. TBNA results were matched against the histopathology of surgical specimens.

RESULTS

Seventeen lymph nodes in 14 patients who had undergone induction therapy were sampled. Positron emission tomography (PET) scan results of 11 patients were also available for comparison. All positive TBNA procedures had positive PET scans. However, for five patients with lymph nodes measuring 9 to 17 mm, the PET scans were falsely positive, as mediastinoscopy and subsequent surgically resected lymph nodes revealed no tumor. TBNA achieved a correct diagnosis in 71% of patients who underwent mediastinal restaging and obviated further need for invasive procedures in 35%.

CONCLUSION

For patients presenting with locally advanced NSCLC who are surgical candidates after induction chemo- and/or radiotherapy, TBNA should be considered as the initial procedure of choice for restaging of the mediastinum.