Mediastinoscopy in superior vena cava obstruction: analysis of 80 consecutive patients

BACKGROUND

Prejudices against mediastinoscopy in superior vena cava obstruction still remain. Hereby we analyze risk/benefit balance in a large series of patients.

METHODS

Eighty consecutive patients underwent cervical mediastinoscopy for caval obstruction, 51 after uncertain diagnosis obtained by lesser techniques, 17 after ineffective chemotherapy (n = 9) or radiotherapy (n = 8). In 12 patients we immediately performed mediastinoscopy as an urgent procedure. In addition the examination was combined with left anterior mediastinotomy (n = 7) for staging purposes.

RESULTS

No perioperative mortality was recorded. Five patients had significant bleeding, but only one required sternotomy. Definitive diagnosis was obtained in all patients: 50 lung cancer, 17 lymphoma, 7 invasive thymoma, 3 postradiation fibrosis, 2 metastatic lymph nodes from renal carcinoma, and 1 fibrosing mediastinitis. Specific therapy had excellent effects in 71 patients, negligible in 7, and adverse in 2. Postmediastinoscopy brachial venous pressure had a mean significant decrease (p < 0.0001). Lung cancer was the sole variable significantly associated with unfavorable outcome (p < 0.0004).

CONCLUSIONS

Mediastinoscopy should be routinely included after less invasive procedures in the diagnostic program because it is simple, low risk, and effective.

Video-assisted approach for transxiphoid bilateral lung metastasectomy

Radical resection has proved to be the most effective treatment of lung metastases, and manual palpation is considered the most accurate method for detection of occult metastases. To allow bilateral manual palpation during video-assisted metastasectomy, we developed a transxiphoid approach without sternotomy. Twenty-one lesions were successfully resected in 6 patients without mortality or morbidity. This approach allows easy manual palpation of the lungs and facilitates bilateral video-assisted metastasectomy.

[Planning a statistical inquiry for evaluation of patient information]

This article deals with the patient package insert and the information to the patient-consumer. The law in force states that the patient package insert is an informative instrument for the consumer so it should be exhaustive, comprehensible and immediate. A statistical investigation has been performed in order to evaluate the clearness of patient package insert and the quality of the drug information. The protocol consists of the methodology of the investigation, the study pilot, the sampling and, finally, the questionnaire.

The value of the Nd:YAG laser for the surgery of lung metastases in a randomized trial

OBJECTIVE

A prospective randomized trial was established in our department to compare the usefulness of the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser in resection of lung metastases. We report the results of the first 45 patients after a minimum of 2 years of follow-up.

DESIGN

Randomized prospective trial from March 1987 to March 1995.

SETTING

University teaching hospital.

PATIENTS

Forty-five patients underwent resection for pulmonary metastases with two different techniques chosen at random: 23 patients were treated with an Nd:YAG laser (group A) and 22 patients with a traditional diathermic device (group B).

INTERVENTIONS

A total of 71 pulmonary lesions were resected by minimal excision, 41 by laser and 30 by diathermy. Sixty-three lesions were diagnosed as active metastases from various sites.

RESULTS

No deaths occurred during surgery. Eight patients (6 in group B) developed minor complications. In two patients from group B, lesions recurred at the resection site. The use of Nd:YAG laser was not associated with a significantly longer survival (log rank test, p=0.49). Laser resection allowed more tissue sparing (mean ratio lesion diameter/volume resected, 0.94 vs 1.11, p<0.008). Univariate and multivariate analyses revealed the importance of laser use in reducing the number of days of postoperative air leakage (3.91 vs 5.00 days) and hospital stay (7.50 vs 9.90 days).

CONCLUSIONS

Laser use significantly reduced tissue loss, postoperative air leakage, and hospital stay. Influence on long-term survival was not statistically proven.

Synthesis and antimicrobial activity of some new derivatives of 6,12-dihydroindolo[2,1-b]quinazolin-6,12-dione

Some derivatives of tryptantrine were prepared in order either to increase solubility and to study structure-activity relationship. All synthesized compounds were tested for antimicrobial activity.

Studies on annelated 1,4-benzothiazines and 1,5-benzothiazepines. XI. Synthesis and biological activity of several naphtho- and quinolino-1,4-thiazine and -1,4-thiazepine derivatives containing the imidazole ring

Several derivatives of naphthol[1,2-b]imidazo[1',2'-d]-1,4-thiazine and -1,4-thiazepine and imidazo[1',2'-4,5]-1,4-thiazino[3,2-c]quinoline and -1,4-thiazepino[3,2-c] quinoline have been synthesized. These compounds and other imidazo[2,1-d][1,5]benzothiazepine derivatives, previously synthesized, have been tested for their possible pharmacological activities. One of these substances displayed inhibitory activity on CNS, others showed an appreciable antiinflammatory effect. None of the naphtho and quinolino derivatives showed affinity for the benzodiazepine receptor.

Factors influencing long-term survival after lung metastasectomy

BACKGROUND

Disease-free interval, histology of primary tumor, and number and size of metastases resected (at first metastasectomy) were studied after resection of pulmonary metastases.

METHODS

Between 1980 and 1993, 276 consecutive patients underwent lung resections for curative removal of metastatic disease. At subsequent relapse, 63 patients had a second-stage metastasectomy, 12 went on to a third phase, and 2 patients had four stages.

RESULTS

The primary tumor was sarcoma in 126 cases (46%), teratoma in 88 (32%), carcinoma in 53 (19%), melanoma in 5, and miscellaneous in 4. Actuarial survival was 69% at 2 years (95% confidence interval 62% to 74%), 48% at 5 years (40% to 55%), and 35% at 10 years (23% to 44%).

CONCLUSIONS

Survival was not related to disease-free interval. Multivariate analysis showed that nearly all predictive information can be obtained through histologic studies (p < 0.0001); inclusion of the number of metastases resected contributed to a lesser degree (p = 0.032). Short disease-free intervals, numerous lung metastases, or even deposits recurring after a first or second metastasectomy should not preclude patients from operation.

En bloc minimal laser resection for T3-chest wall lung cancer in patients with poor pulmonary function

OBJECTIVE

To analyze the value of en bloc minimal laser resection in patients with marginal function with non-small cell lung cancer invading the chest wall.

DESIGN

Retrospective study from March 1987 to December 1993.

SETTING

University teaching hospital.

PATIENTS

Study group consists of 10 patients with impaired pulmonary function (FEV1 < or = 1.3 L and forced expiratory flow between 25% and 75% < or = 0.8 L/s) operated on for lung cancer invading the chest wall. There were 7 men and 3 women; ages ranged between 51 and 77 years (mean, 66.2 years). None of the patients had tumors greater than 3 cm or involving the first 2 ribs as well as clinical N2 or T4 disease.

INTERVENTIONS

All patients underwent en bloc chest wall combined with minimal resection. Parenchyma dissection was accomplished by Nd:YAG laser encompassing the lesion at distance of 2.0 cm. The median number of ribs resected was 1.6 and no patients required chest wall reconstruction. Local postoperative radiation therapy beginning within 1 month after resection was always performed.

RESULTS

Tumor resection was considered complete in every case. Four patients had adenocarcinoma, three had squamous cell carcinoma, and three had large cell carcinoma. Currently, 7 patients had NO, 2 had N1, and 1 had N2 disease. There was no perioperative mortality. Postoperative complications were prolonged air leak (n = 2) and atelectasis (n = 1). At the present moment, 6 patients are alive, 5 of whom are free from tumor, 2 with a follow-up longer than 5 years. Three patients died: 2 from disseminated disease, after 47 months and 32 months, respectively, and the third at 27 months from another cause. One patient was unavailable for follow-up. Only 1 patient had a local recurrence, 15 months later, and he underwent a new, successful, limited resection.

CONCLUSIONS

These findings suggest that en bloc minimal laser resection can offer an acceptable risk/benefit ratio in the case of patients who cannot tolerate a lobectomy.

Adjuvant pneumomediastinum in thoracoscopic thymectomy for myasthenia gravis

To facilitate initial visualization and subsequent mobilization of the thymus, adjuvant pneumomediastinum was preoperatively induced in 4 patients who underwent video-assisted thoracoscopic thymectomy. Neither mortality nor technique-related morbidity was observed. This experience shows video-assisted thoracoscopic thymectomy to be a safe and reliable procedure. In addition, we believe that adjuvant pneumomediastinum seems to facilitate the dissection maneuvers and could shorten operative time.

Synthesis and SAR study of imidazo[2,1-b]benzothiazole acids and some related compounds with anti-inflammatory and analgesic activities

Some (un)substituted imidazo[2,1-b]benzothiazole carboxylic or acetic acids and some related compounds, i.e. imidazo[2,1-b]naphthol[2,1-d]thiazole, 4H-imidazo[2,1-c][1,4]benzothiazine, 4,5-dihydroimidazo[2,1-d][1,5]benzothiazepine carboxylic and acetic acids were synthesized and tested in vivo in order to study the structure-activity relationships (SAR) of their antiinflammatory and analgesic activities. Pharmacological assays confirmed the interest of this class of compounds as potential antiinflammatory and analgesic drugs with low side effects.

Studies on annelated 1,4-benzothiazines and 1,5-benzothiazepines. X--Synthesis and inhibition of benzodiazepine receptor binding of new 1,4-thiazine and 1,5-thiazepine polycondensed heterocycles with steroidal structure

Some naphtho[1,2,-b]-s-triazolo[4,3-d]-1,4-thiazine and 1,5-thiazepine and s-triazolo[4', 3'-4,5]-1,4-thiazino[3,2-c]quinoline derivatives have been synthesized and tested for their ability to displace [3H]RO 15-1788 binding from bovine brain membranes. Several compounds showed moderate binding affinity for the benzodiazepine receptor.

Early closure of the postpneumonectomy bronchopleural fistula by pedicled diaphragmatic flaps

In the past, several methods for closure of postpneumonectomy bronchopleural fistula have been proposed. Herein we describe a technique to close a bronchopleural fistula using a mobilized diaphragmatic flap sutured directly to the fistula edges. This maneuver improves the blood supply to the bronchial stump and may reduce residual pleural cavity. To prevent bacterial contamination of the pleural space, the procedure should be performed immediately after the diagnosis.

Studies on annelated 1,4-benzothiazines and 1,5-benzothiazepines. VIII-Synthesis and inhibition of benzodiazepine receptor binding of some derivatives of triazino[3,4-c]-1,4-benzothiazine and triazino[3,4-d]-1,5-benzothiazepine, two new heterocyclic ring systems

Several series of triazino[3,4-c]-1,4-benzothiazines and triazino[3,4-d]-1,5-benzothiazepines were synthesized. Tentative syntheses performed to obtain 5H-as-triazino[3,4-c]-1,4-benzothiazin-1,2-diones and 5,6-dihydro-as-triazino[3,4-d]-1,5-benzothiazepin-1,2-diones gave rise to s-triazolo derivatives. Only in one case was the reaction successful, affording the 3,5-dihydro-as-triazino[3,4-c]-1,4-benzothiazin-1,2-dione 9a. All the final compounds were tested for their ability to displace [3H]flunitrazepam from bovine brain membranes.

Studies on annelated 1,4-benzothiazines and 1,5-benzothiazepines. VI. Synthesis and preliminary pharmacological evaluation of 1-alkylaminomethyl-4,5-dihydro-s-triazolo[3,4-d]-1,5-benzothiazepines

A series of new 1-alkylaminomethyl derivatives of 4,5-dihydro-s- triazolo[3,4-d]-1,5-benzothiazepines has been prepared using chloromethyltriazolobenzothiazepines 4a-g as key intermediates. The 1-alkylaminomethyl derivatives were tested for CNS activity on mice and some of them caused remarkable decrease of spontaneous motor activity.

Studies on annelated 1,4-benzothiazines and 1,5-benzothiazepines. VII. Synthesis and inhibition of benzodiazepine receptor binding of some 4,5-dihydro-tetrazolo[5,1-d]-1,5-benzothiazepines and 5-phenyl-s-triazolo[3,4-d]-1,5-benzothiazepines

The 4,5-dihydro-tetrazolo[5,1-d]-1,5-benzothiazepines 3a-k and the 5-phenyl-s-triazolo[3,4-d]-1,5-benzothiazepines 6a-f and 11a-c have been prepared and tested for their ability to displace [3H] flunitrazepam binding from bovine brain membranes. Some of the triazoloderivatives showed moderate binding affinity for the benzodiazepine receptor.

Synthesis and antimicrobial activity of some new indolo[2,1-b]quinazolin-6(12H)ones

A series of indolo[2,1-b]quinazolin-6(12H)ones 4a-i was prepared and tested for the antimicrobial activity. The synthesis of the new compounds and the results of the antimicrobial screening are reported.

Thymectomy as treatment of autoimmune diseases other than myasthenia gravis

This paper reviews the different series of thymectomies performed in patients with autoimmune diseases other than myasthenia gravis. It is possible that thymectomy can decrease the activity of T-helper lymphocytes or, alternatively, it may enhance the activity of T-suppressor lymphocytes, whose function is depressed in autoimmune diseases. Thymectomy was performed empirically for systemic lupus erythematosus and rheumatoid arthritis. The therapeutic benefits were questionable. Conflicting results were reported for thymectomy against autoimmune hemolytic anemia. Several trials were conducted to assess the therapeutic value of thymectomy in multiple sclerosis. Benefits were achieved only in relapsing-remitting but not in chronic-progressive multiple sclerosis. The effect of thymectomy in autoimmune diseases associated with myasthenia gravis were also reported. The authors conclude that thymectomy as treatment for autoimmune diseases other than myasthenia gravis is not elective therapeutic choice and it is acceptable only in selected cases.

Synthesis and pharmacological activity of imidazo[2,1-b]benzothiazole acids

We have prepared twelve imidazo[2,1-b]benzothiazole carboxylic and acetic acids by reaction of substituted 2-aminobenzothiazoles with ethyl bromopyruvate and 4-chloroacetoacetate, respectively. The acids, obtained from esters by hydrolysis, were tested for their antiinflammatory, analgesic and ulcerogenic activities.

[Study of mediastinal lymph nodes in lung cancer using transesophageal ultrasonography]

Evaluation of mediastinal lymph nodes in patients with lung cancer is fundamental for their treatment and prognosis. Chest computed tomography (CT) is presently the most utilized diagnostic modality. In recent years endoscopic ultrasound (EUS) is being employed for this purpose. We retrospectively compared the results of CT and EUS staging of 35 selected patients with postsurgical stage. A total of 175 lymph node sites were examined. Results CT vs EUS were as follows: specificity 92% vs 98%, sensitivity 88% vs 84%, positive predicted accuracy 80% vs 96%, negative predicted accuracy 95% vs 94%, overall accuracy 92% vs 95%. The region most accessible by EUS evaluation were the paraesophageal lymph nodes; the most difficult were the right superior mediastinal nodes which cannot be imaged for anatomic reasons. EUS not only allows one to arrive at correct diagnosis with less false positive results, but also permits evaluation of lymph nodes which are not enlarged. We think that EUS, in combination with CT, is an appropriate modality for staging of mediastinal lymph nodes in patients with lung cancer.

Studies on annelated [1,4]benzothiazines and [1,5]benzothiazepines, V. Synthesis and biological activity of N-2 alkylamino derivatives of 4,5-dihydro-s-triazolo[3,4-d]-1,5-benzothiazepine

The synthesis of a new series of N-2 alkylamino derivatives of 4,5-dihydro-s-triazolo[3,4-d]-1,5-benzothiazepine has been accomplished starting from 2,3-dihydro-1,5-benzothiazepin-4(5H)ones and their 2-methyl and 2-aryl derivatives. All the compounds were tested in vitro for their antimicrobial activity, but none of them showed remarkable activity. The tricyclic compounds 7a-j, 8a-j, 9a-j, 10a-j, and 11a-j were also screened for their CNS activity in mice and several of them showed interesting activity.

The development of a light curing prosthesis for chest wall replacement

In conjunction with colleagues in the chemical industry, we have developed and evaluated a new plastic prosthesis which we hope will supplant presently used materials for chest wall replacement. We have modified the basic chemical of a reactive resin routinely used in orthopaedic and dental work by the inclusion of a polypropylene mesh. The resultant material is thin enough to cut with scissors and yet supple enough to shape to fit the defects. It is hardened by exposure to UV light and has a practical cure time when exposed to normal light in the operating theatre. When set it is strong and rigid. The mechanical properties have been studied with the Flexural 3-point bend test and compared with the best of the presently available prostheses. The inert nature of the material was studied in a subcutaneous implant in 29 rats over 3 months. Histology has shown a lack of reactivity. The stability in vivo was studied using the material to replace portions of the chest wall in rabbits for up to 6 months. Subsequent histology and in-vitro testing have proved satisfactory. The ability of this material to withstand the dynamic stresses of the chest wall have been studied by its implantation into the chest wall of 3 minipigs for 6 months. The material looks promising and has proved more "user friendly" than existing prostheses for flat bone replacement. We hope to refine its production to allow its use in humans.

[Short-term prophylaxis with erythromycin lactobionate in patients undergoing lung surgery]

The efficacy of short term prophylaxis with erythromycin lactobionate in the peri-operative treatment in patients undergoing pulmonary surgery is examined.

[Immunohistochemical demonstration of neuropeptide Y in the normal human thymus and in thymoma]

The distribution of neuropeptide Y-like immunoreactivity in normal thymic parenchyma and in thymoma was evaluated in order to characterize the typical aspects of the thymic peptidergic pattern of innervation in normal and pathological conditions. The possible role of neuropeptide Y in neuromodulation of the immunological response is discussed.

The role of the thymus in multiple sclerosis

The presence of numerous changes in T lymphocyte activity found in MS patients points to the involvement of the thymus in multiple sclerosis. The etiophathogenetic mechanism of MS is probably an autoimmune reaction that is triggered by a viral infection caused by one or more viruses and that perpetuates itself, causing the disease to progress. It has been proved that the thymus maintains its immunocompetence even in adulthood and that it has a role in the pathogenesis in several autoimmune diseases. In exacerbations of MS there is a decrease in T suppressor lymphocytes while histological and lymphocyte subset changes have been demonstrated in the thymus of MS patients. The lymphocyte response to mitogens is also depressed in MS. The clinical results of thymectomy in MS are not uniform and are on the whole inconclusive, probably through the lack of criteria of selection of patients for surgical treatment. We consider that the morphological and functional study of the thymus biopsy specimen should supply the appropriate criteria of suitability for surgical treatment.

Studies on annelated 1,4-benzothiazines and 1,5-benzothiazepines. III--Synthesis and CNS activity of some 1-substituted derivatives of the novel heterocyclic system 4,5-dihydro-s-triazolo [3,4-d]-1,5-benzothiazepine

A series of new 4,5-dihydro-s-triazolo [3,4-d]-1,5-benzothiazepines has been prepared. All the described compounds are representative of a novel ring system. Some of these compounds were tested for their CNS activity and effects comparable with the ones of diazepam were observed.

Studies on annelated 1,4-benzothiazines and 1,5-benzothiazepines. II. Synthesis of new series of 1- or 2-substituted 4H-s-triazolo[3,4-c]-1,4-benzothiazines and related compounds with potential CNS activity

New series of 1- or 2-substituted 4H-s-triazolo[3,4-c]-1,4-benzothiazines have been prepared. The 1-substituted products were obtained starting from 3-hydrazino-2H-1,4-benzothiazine derivatives (III) by treatment with chloroacethyl chloride followed by cyclization of the resulting chloroacethylderivatives into the chloromethyltriazolobenzothiazines (IV a-e), which were then reacted with the appropriate amines to give the desired compounds (V a-n). Other 1-substituted compounds were prepared by ring closure of (III) with cyanogen bromide, affording 1-amino-4H-s-triazolo [3,4-c]-1,4-benzothiazines (XI a-e). The 2-substituted compounds (VIII) were prepared from 2,4-dihydro-1H-s-triazolo [3,4-c]-1,4-benzothiazin-1-ones (VII), synthesized from (I) by reaction with ethyl carbazate. The aminoalkyl side chain was introduced into (VII) in two steps: first by treatment with 1-bromo-3-chloropropane, then by refluxing the resulting product with the appropriate amine. Some 4H-tetrazolo[5,1-c]-1,4-benzothiazines (XII) were also synthesized from (III). Preliminary pharmacological data on the CNS activity of the synthesized tricyclic compounds are reported.

Synthesis and in vitro cytotoxic activity of semisynthetic derivatives in the santonin series

The synthesis of two new santonin derivatives namely 3-oxo-6 beta-H-11 beta-phenylselenoeudesm-1,4-dien-6,13-olide and 3-oxo-6 beta H-eudesm-1,4,11-trien-6,13-olide is reported along with the results of a series of santonins tested for activity against the growth of KB cells in vitro, a human epidermoid nasopharynx carcinoma. Select compounds were found to be active at concentrations lower than 5 X 10(-5) M. In particular, the compound 2 alpha-bromo-3 beta-hydroxy-6 beta H-eudesm-11-en-6,13-olide exhibits an extremely low ID50 value at 0.33 X 10(-6) M. Some relationships between chemical structure and cytotoxic activity are suggested, i.e. the alpha-methylene-gamma-lactone moiety appears to be necessary for cytotoxic activity toward KB cells growth in vitro by santonin derivatives.

Studies on the antibacterial and antifungal properties of 1, 4-naphthoquinones

1. New halogenated 1,4-naphthoquinones were synthesized and together with other known 1,4-naphthoquinones, were screened for antibacterial activity by a turbidimetric method, and for antifungal activity by the diffusion method on agar plates.2. The half-wave potentials and the influence on the oxidative phosphorylation of some of these compounds were determined.3. 2-chloro-3,2'-chloro-ethyl-1,4-naphthoquinone (half-wave potential=-187 mV) was the most active compound, completely inhibiting cell respiration.4. While the natural active naphthoquinones, vitamin K and ubiquinones, possess, as substituent, the electron repelling methyl group, the microbiologically active 1,4-naphthoquinones are substituted, in the quinone moiety, with electron attracting groups such as OH or Cl.5. The half-wave potentials can give only an initial indication of the activity of the compounds studied; a good correlation, on the contrary, can be found between the ultraviolet spectra of such compounds and their activity which seems to depend on the ability of active compounds to exist in an extensively conjugated structure and to form hydrogen bonds.