[New developments in staging and prognosis of bronchopulmonary carcinoma. Part I: Epidemiology and diagnostic investigations]

Lung cancer represents a major health problem globally and its surge in incidence is mainly attributed to the increase in the consumption of tobacco-related products. The poor prognosis of this condition is generally related to the advanced stage at the time of the diagnosis; therefore, accurate staging initially as well during the course of the disease seems to be of paramount importance. Unfortunately, in the last half-century, no major breakthroughs occurred in the field of the lung cancer therapy. Beyond the classic investigations and staging strategies, a plethora of new exploratory and staging techniques became available in the last several years. In this review (part I) we present the latest epidemiological data, major shifts in the disease presentation, histologic types and staging modalities and present their possible implications on the way we diagnose and, more importantly, how we treat this condition.

[The early outcome of video-assisted thoracic surgery lobectomy for primary lung carcinoma]

OBJECTIVE

To evaluate the early outcome of patients who underwent video-assisted thoracic surgery (VATS) lobectomy for primary lung carcinoma.

METHODS

The records of 121 patients with lung cancer undergoing VATS lung resection from 1997 to 2004 were reviewed retrospectively, I stage: 101 cases, 34 cases underwent right upper lobectomy, 13 cases underwent right middle lobectomy, 17 cases underwent right down lobectomy, 21 cases underwent left upper lobectomy, 16 cases underwent left down lobectomy. Thirty-eight cases underwent VATS lobectomy without assisted mini-incision.

RESULTS

There were 18 cases of morbidities (15%) and no surgical mortality. The 1-year, 2-year and 3-year survival rates of primary non-small cell lung cancer with I stage is: 99% (76/77), 96% (49/51) and 79% (15/19), respectively. There are statistic difference (P < 0.01) between adenocarcinoma and the others. There are no statistic difference (P > 0.05) between the VATS lobectomy with assisted mini-incision (n = 38) and without (n = 63), also no statistic difference (P > 0.05) between the VATS lobectomy and the standard procedure.

CONCLUSION

Our findings suggest that VATS lobectomy is superior regarding its ability to achieve the same survival rates and little morbidities in comparison with the standard procedure.

Assessment of bolus injection protocol with appropriate concentration for quantitative assessment of pulmonary perfusion by dynamic contrast-enhanced MR imaging

PURPOSE

To determine the appropriate concentration for quantitative assessment of dynamic contrast-enhanced pulmonary MR imaging.

MATERIALS AND METHODS

A total of 40 consecutive patients with small bronchioalveolar carcinoma underwent perfusion single-photon emission tomography (SPECT) and three-dimensional (3D) dynamic MR imaging with a 3D radiofrequency spoiled gradient-echo sequence. In each patient, 5 mL of contrast media with 0.1, 0.3, and 0.5 mmol/mL were administered at a rate of 5 mL/second. All patients were divided into two groups (<70 kg and > or =70 kg) for assessment of appropriate concentration to quantitatively assess regional perfusion parameter in routine clinical practice. Pulmonary blood flow (PBF) in each protocol was calculated from a signal intensity (SI)-time course curve. Differences and limits of agreement of PBF between dynamic MR imaging (PBF(MR)) using three different concentrations and perfusion SPECT (PBF(SPECT)) were statistically compared in both patient groups.

RESULTS

PBF(MR) using 0.3 mmol/mL in the <70-kg group and 0.5 mmol/mL in the > or =70-kg group showed no significant difference compared with PBF(SPECT) (P > 0.05). Limits of agreements in 0.3 mmol/mL in the <70-kg group and 0.5 mmol/mL in the > or =70-kg group were smaller than those of the other concentrations and small enough for clinical purposes.

CONCLUSION

Appropriate concentrations provide accurate and reproducible assessments of regional pulmonary perfusion parameters on 3D dynamic MR perfusion imaging. We suggest using 5 mL of contrast media with 0.3 mmol/mL for patients weighing less than 70 kg and 0.5 mmol/mL for patients weighing 70 kg or more.

A New Catheter Technique for Thoracic Subarachnoid Neurolysis in Advanced Lung Cancer Patients

Subarachnoid neurolytic block (dorsal rhizotomy) was carried out in patients suffering from severe pain unresponsive to analgesic therapy. An intrathecal catheter technique was performed in 20 patients with lung cancer. Visual analog scale (VAS) for pain, patient satisfaction, and complications were recorded at 24 hours, 1 week, and 1, 2, and 3 months after procedure. VAS and patient satisfaction significantly decreased at measured time points (P < 0.05). Duration of procedure was 20.3 +/- 6.4 minutes; no significant complications were reported. This new intrathecal catheter technique for dorsal rhizotomy in advanced lung cancer patients was an easily performed, effective, and safe technique in this setting.

Bronchogenic glomangiomyoma with local intravenous infiltration

Most glomus tumours occur in the dermis and subcutaneous tissues. Lung glomus tumours are quite rare. The current authors present the first reported case of a lung-derived glomangiomyoma, the rarest variant of glomus tumour. A 56-yr-old female was admitted with haemoptysis. Chest computed tomography showed an approximately 5-cm-diameter mass in the right lower lobe with mucoid impaction. After a right lower lobectomy, a diagnosis of glomangiomyoma was made. The tumour had grown endobronchially and its maximal diameter was 5.5 cm. Although cytologically benign, glomus tumour cells had visibly infiltrated neighbouring vessels. These results suggest that a bronchogenic glomangiomyoma has a low-grade malignancy potential and warrants close follow-up.

[Ocular manifestation of bronchogenic carcinoma: simultaneous occurrence of diffuse uveal melanocytic proliferation and uveal metastases]

Systemic cancer may affect the eye and orbit as metastatic disease or paraneoplastic retinal degeneration. This is a case report of a 55-year-old man with unilateral visual loss as the presenting symptom of metastatic adenocarcinoma of lung in one eye and diffuse uveal melanocytic proliferation in the other. Fundoscopy, B-scan ultrasonography, fluorescein angiography and the workup for inflammatory, infectious and neoplastic diagnoses are presented. In heavy smokers, bronchogenic carcinoma should be highly suspected.

High frequency of bronchogenic carcinoma after single-lung transplantation

BACKGROUND

Lung transplantation is a commonly employed therapy in the treatment of patients with advanced lung diseases related to tobacco use. Little is known about the long-term incidence or risk factors for primary lung cancer after lung transplantation. To determine the frequency, clinical features and risk factors for primary bronchogenic malignancy after lung transplantation, we designed a matched cohort study of single and bilateral lung transplant recipients with extended follow-up.

METHODS

We retrospectively reviewed the records of 262 lung transplant recipients who survived > or =90 days post-transplant and assessed for the development of primary lung cancer. One hundred thirty-one consecutive single-lung transplant (SLTx) recipients were matched to 131 consecutive bilateral lung transplant (BLTx) recipients by native disease. Risk factors for lung cancer development were derived using univariate and multivariate proportional hazards models.

RESULTS

Of the SLTx recipients, 6.9% developed primary lung cancer after transplantation as compared with 0% of the BLTx recipients (p = 0.002), after a mean of 52 months. Histologically, non-small-cell cancers were present in the native lung, which led to death in 67% (6 of 9) of the patients despite treatment. Significant risk factors for the development of primary lung cancer were increasing age (p = 0.004), >60-pack-year smoking history (p = 0.03), and SLTx as compared with BLTx (p < 0.001).

CONCLUSIONS

Single-lung transplant confers a significantly elevated risk of developing primary post-transplant lung cancer as compared with BLTx in patients with comparable native disease, age and tobacco history.

Video-assisted mediastinoscopic surgery: clinical feasibility and accuracy of mediastinal lymph node staging

BACKGROUND

This study was conducted to assess indications, procedures, complications, and clinical feasibility of video-assisted mediastinoscopic surgery (VAMS). It also assessed the accuracy of mediastinal lymph node staging by video-assisted mediastinoscopic lymphadenectomy (VAMLA) with bimanual dissection through the twin-bladed, expanding Linder-Dahan mediastinoscope.

METHODS

From 2000 to 2004, we documented and assessed 226 consecutive procedures in a prospective database.

RESULTS

A total of 144 VAMLAs for the staging of resectable bronchial carcinoma, and 82 less extensive procedures for other indications were performed, combined with extended mediastinoscopy in 72 patients and with mediastinoscopic sonography in 26. Mean operation time was 54.1 minutes for VAMLA and 36.6 minutes for less extensive procedures. We observed nine complications: five recurrent nerve paralyses, one arterial and two venous injuries, and one mediastinitis. The complication rate was 3.98%, which dropped from 5.3% to 2.6% with growing experience. VAMS detected mediastinal lymph node involvement in 61 (32.8%) of 186 patients with bronchial carcinoma (N2, 45; N3, 16). Mediastinal reassessment at open surgery was done in the 130 resected patients and showed for VAMLA a specificity of 93.75%, a sensitivity of 100%, and a false-negative rate of 0.9%.

CONCLUSIONS

In our institutional practice, VAMS has replaced conventional mediastinoscopy for reasons of extended surgical options, safety, precision, education, documentation, and enhanced accuracy of pretherapeutic mediastinal staging. Mediastinal staging of resectable bronchial carcinoma is done by VAMLA, because the accuracy is equal to open lymphadenectomy and the access to the left paratracheal and tracheobronchial lymph nodes is improved. No increase in the complication rate was observed. Prolonged operation time was due to more extended procedures not possible with conventional mediastinoscopy, like VAMLA.

Evaluation of lung cancer metastases to the spine

Most metastatic spinal lesions (70%) are found at the thoracic level, 20% in the lumbar region, and 10% in the cervical region. A variety of benign and malignant tumours may arise in the lung, but the vast majority is bronchogenic carcinomas (90 to 95%). The aim of this study was to evaluate the lung cancer metastases to the vertebral column in terms of type, localisation and metastasis pattern. Between the years 1995 and 2003, 168 lung cancer patients with metastatic spinal tumour who had received radiotherapy and chemotherapy were retrospectively evaluated. The total number of vertebrae in which metastases were detected was 328. The most common site for metastasis was the thoracic spine. In 49 (29%) patients, there was only one vertebral involvement. Additional extravertebral bony metastases were present in 37 (22%) patients; the femur (20 patients) was the most common site. Only 25 of 168 patients were operated due to spinal cord compression leading to neurological deficit. The rest of the patients were treated by appropriate chemotherapy and radiotherapy protocols. The mean survival after diagnosis of vertebral metastasis was 7.1 months. Squamous cell carcinoma and adenocarcinoma are the lung cancers that mostly metastasise to vertebrae. Most of the metastases involve multiple spinal levels. After the diagnosis of vertebral metastasis, the mean survival is seven months. Pain relief and maintaining quality of life must be balanced with the patient's life expectancy, comorbidities and immunological, nutritional and functional status in treatment decision.

Pulmonary Resection After Successful Downstaging with Photodynamic Therapy

Photodynamic therapy (PDT) is a treatment option for lung cancer that involves the administration of a photosensitizing agent and selective, bronchoscopic delivery of light to tumor tissue that has retained the agent. Currently, PDT is used either to treat microinvasive endobronchial nonsmall cell lung cancer (NSCLC) or to palliate patients with completely or partially obstructing endobronchial NSCLC. Herein is a case of PDT that successfully downstaged an obstructing endobronchial NSCLC, thereby enabling a complete resection. At 9 months postoperatively, the patient was treated for a chest wall recurrence with no evidence of disease in the airway or mediastinum.

Bronchogenic carcinoma of squamous cells in a young pregnant woman

Lung cancer continues to be the most incident neoplasia in the world and also the most frequent cause of death by cancer, with more than 900000 new cases per year. Women present greater risk of developing bronchogenic carcinoma, possibly because of differences in metabolism of the carcinogens associated with tobacco and also because of hormonal differences because estrogens can promote the appearance of lung cancer, including during pregnancy. We have described the case of a 25-year-old patient who developed squamous cell carcinoma of the lung during her third pregnancy, with a progressive worsening of her general condition and progression until death. We believe that the pregnancy could have contributed to the evolution of the disease, especially because of the increased levels of gestational hormones, particularly the estrogen, because its receptors have an important role in regulating growth and in the differentiation of several tissues facilitating like this, the development of the neoplasia, and complicating its early diagnosis.

[Palliative radiation of bone metastasis in the spine for symptom control and stabilisation: indication and limits]

On the basis of a case study the success of palliative radiation of metastasis of a non-small-cell lung cancer in the spine is demonstrated and the limits of this palliative therapy are discussed. Pain control seems to be the first aim, stabilisation of the spine and myelodecompression to prevent paraplegia could be another.

Surgical Management of Late Postpneumonectomy Bronchopleural Fistula: The Transsternal, Transpericardial Route

BACKGROUND

Late postpneumonectomy bronchopleural fistula (LBPF) is a serious complication. Surgical repair of the bronchial stump through a lateral thoracotomy is a dangerous attempt due to mediastinal fibrothorax and the risk of pulmonary artery stump damage.

OBJECTIVES

The goal of this study was to estimate the effectiveness of the transsternal, transpericardial approach for bronchial stump repair in case of LBPF.

METHODS

From 1996 to 2002, 1,294 lung resections for non-small cell lung cancer were performed at our department. Out of 412 pneumonectomies, 16 patients (3.8%) presented with LBPF after right pneumonectomy for non-small cell lung cancer. Thirteen of these patients were subjected to transsternal, transpericardial bronchial stump repair. They were followed postoperatively, and morbidity and mortality rates were recorded.

RESULTS

The interval between pneumonectomy and fistula diagnosis lasted from 12 to 85 months. The estimated sizes of the fistulae ranged from 5 to 21 mm, and the length of the bronchial stump was >1 cm only in 2 patients (15.3%).Due to persistent empyema, open-window thoracostomy was performed for definite treatment immediately after the operation for bronchial stump reamputation in 6 cases (46.1%). One patient (7.6%) died 3 months postoperatively due to bronchopleural fistula recurrence. This was also the only case of fistula recurrence.

CONCLUSION

LBPF usually needs definite management to save the patient's life. The transsternal, transpericardial approach is a safe and effective method.

[Transbronchial needle aspiration in the diagnosis of bronchogenic carcinoma with enlarged mediastinal and /or hilar lymph nodes]

OBJECTIVE

To evaluate the role of transbronchial needle aspiraion (TBNA) in the diagnosis of bronchogenic carcinoma with enlarged mediastinal and/or hilar lymph node.

METHODS

Patients with mediastinal and/or hilar lymphoadenopathy proven by CT scan were eligible for TBNA as reported by WANG. All specimen was directly and instantly smeared for cytological examination.

RESULTS

From June 2004 to May 2006, 77 such patients were examined: including 38 lung cancers, 35 lung benign diseases and 4 without definite diagnosis. All TBNA procedures were successfully carried out in 222/225 ( 98.7%). Positive TBNA rate was 81.6% (31/38) in patients who had been proven to suffer from bronchogenic carcinoma. The diagnosis of lung cancer was confirmed via TBNA only in 9 patients. A total of 63 lymph nodes in the 38 lung cancer patients were aspirated by TBNA with a positive rate of 65.1% (41/63). The sensitivity of TBNA was significantly correlated with pathology type, lymph node size and experience of the cytologist. Severe complications were rare except small amount of bleeding at the TBNA site (52/77, 67.5%).

CONCLUSION

TBNA is quite safe and helpful in diagnosis and staging of bronchogenic carcinoma, yet it is not helpful in diagnosis of benign lung diseases.

Functional KCa3.1 K+ channels are required for human lung mast cell migration

BACKGROUND

Mast cell recruitment and activation are critical for the initiation and progression of inflammation and fibrosis. Mast cells infiltrate specific structures in many diseased tissues such as the airway smooth muscle (ASM) in asthma. This microlocalisation of mast cells is likely to be key to disease pathogenesis. Human lung mast cells (HLMC) express the Ca2+ activated K+ channel K(Ca)3.1 which modulates mediator release, and is proposed to facilitate the retraction of the cell body during migration of several cell types. A study was undertaken to test the hypothesis that blockade of K(Ca)3.1 would attenuate HLMC proliferation and migration.

METHODS

HLMC were isolated and purified from lung material resected for bronchial carcinoma. HLMC proliferation was assessed by cell counts at various time points following drug exposure. HLMC chemotaxis was assayed using standard Transwell chambers (8 microm pore size). Ion currents were measured using the single cell patch clamp technique.

RESULTS

K(Ca)3.1 blockade with triarylmethane-34 (TRAM-34) did not inhibit HLMC proliferation and clotrimazole had cytotoxic effects. In contrast, HLMC migration towards the chemokine CXCL10, the chemoattractant stem cell factor, and the supernatants from tumour necrosis factor alpha stimulated asthmatic ASM was markedly inhibited with both the non-selective K(Ca)3.1 blocker charybdotoxin and the highly specific K(Ca)3.1 blocker TRAM-34 in a dose dependent manner. Although K(Ca)3.1 blockade inhibits HLMC migration, K(Ca)3.1 is not opened by the chemotactic stimulus, suggesting that it must be involved downstream of the initial receptor-ligand interactions.

CONCLUSIONS

Since modulation of K(Ca)3.1 can inhibit HLMC chemotaxis to diverse chemoattractants, the use of K(Ca)3.1 blockers such as TRAM-34 could provide new therapeutic strategies for mast cell mediated diseases such as asthma.

[Simultaneous cardiac and thoracic operations]

BACKGROUND

Optimal surgical strategy in patients with combined disease of heart (mainly ischemic heart disease or critical valve disease) and other thoracic organs (mainly pulmonary carcinoma) is still controversial.

METHODS

From 1997 to 2004, 13 simultaneous cardiac and thoracic operations were performed in 13 patients. Most of them were necessary for combinations of symptomatic coronary artery disease (CAD) and bronchogenic carcinoma (BCA).

PATIENT CHARACTERISTICS

11 patients showed CAD, mean preoperative LVEF was 44 %.

SURGICAL PROCEDURE

Surgical exposure was performed via sternotomy in 10 patients, the rest of the patients underwent thoracotomy. Seven patients were operated on cardiopulmonary bypass, the others underwent an off-pump procedure. Eleven patients underwent CABG, mean number of anastomoses were 2.1 (range 1-4), two patients underwent aortic valve replacement. One patient underwent radical removal of pulmonary adenocarcinoma with local expansion into the left atrium. For the lung cancer lobectomy was necessary in 8, pneumectomy in 1, extirpation of multiple metastases in 1, resection of the trachea in 1 patient. Histological diagnosis was epidermoid carcinoma in 6, adenocarcinoma in 3, undifferentiated carcinoma in 1, metastasis of Grawitz tumor in 1, pneumoconiosis in 1 patient.

RESULTS

No patient died in hospital. One patient had to be re-explored for bleeding. Mean blood loss, duration of intubation and length of hospital stay were not different from other patients who underwent cardiac operation only.

CONCLUSION

In accordance with the majority of the data published in the literature, combined procedures did not negatively influence hospital morbidity and mortality. Simultaneous operations eliminate the necessity of a second operation and do not delay the postoperative oncological therapy. Long-term results are primarily determined by histological diagnosis and by the extent of the tumor.

Bronchogenic Squamous Cell Carcinoma Presenting as Cicatrizing Conjunctivitis

PURPOSE

To report a case of cicatrizing conjunctivitis as the initial manifestation of a bronchogenic squamous cell carcinoma.

METHODS

Case report of a 57-year-old patient with bilateral history of ocular pain, redness, and discharge, with no apparent predisposing factors. Examination revealed chemosis, pseudomembrane, and symblepharon formation, and multiple ulcerated pustular and vesicular periocular and perioral lesions literature review.

RESULTS

Skin biopsy was compatible with bullous pemphigoid. Two months later he developed respiratory symptoms, and a squamous cell carcinoma was diagnosed.

CONCLUSIONS

This case demonstrates cicatrizing conjunctivitis as a possible paraneoplastic syndrome associated with squamous cell lung carcinoma.

Clinical Experience with Autofluorescence Imaging System in Patients with Lung Cancers and Precancerous Lesions

BACKGROUND

It is important to detect preinvasive bronchial lesions before they become invasive cancer, because detection of early cancer is expected to lead to a cure. Autofluorescence bronchoscopy is a useful device in the detection of preinvasive and cancerous lesions. Recently, a new autofluorescence bronchoscopic system, autofluorescence imaging (AFI) system, has been developed.

OBJECTIVES

We evaluated the efficacy of AFI in the diagnosis of precancerous and cancerous lesions.

METHODS

A total of 31 patients underwent both conventional white-light bronchoscopy (WLB) and AFI from January 2002 to September 2004. We evaluated autofluorescence findings using a four-point scale: AFI-I, II, III, and B. The findings in WLB were evaluated on a three-point scale: WLB-I, II, and III. Abnormal areas by WLB and AFI were biopsied for histopathological examinations.

RESULTS

A total of 64 lesions were evaluated. When the AFI-III finding was regarded as positive in AFI and WLB-III as positive in WLB, sensitivity for severe dysplasia or worse was 94.7% with AFI and 73.7% with WLB, respectively.

CONCLUSIONS

AFI is an effective system for the detection of precancerous and cancerous lesions.

Computed Tomography Appearances of Bronchogenic Carcinoma Associated With Bullous Lung Disease

Bullous lung disease is known to be a risk factor for developing a bronchogenic carcinoma. In this article, computed tomography appearances of 20 patients with histologically proven bronchogenic carcinoma were reviewed retrospectively. On the basis of the previous literatures and our findings, the computed tomography appearances of bronchogenic carcinoma associated with bullous lung disease could be classified into 3 types; nodule or mass extruding from the bullous wall, nodule or mass confined within the bullous lumen, and soft-tissue density extending along the bullous wall. Attention should be paid in the interpretations for mass or nodule in the wall of the bulla because they frequently lack the characteristic appearances of bronchogenic carcinoma.