Does adjuvant radiation therapy improve disease-free survival in completely resected Masaoka stage II thymoma?

OBJECTIVE

To determine whether or not patients with completely resected Masaoka stage II thymoma benefit from postoperative radiotherapy (RT).

METHODS

We retrospectively review the case records and compared the long-term outcomes of patients affected by Masaoka stage II thymoma treated by resection alone with same stage thymoma patients submitted to resection and RT. Surgical specimens were reviewed to confirm pathological stage, negative resection margins and histological subtype.

RESULTS

Between 1988 and 2000, we performed 197 resections for thymoma; 58 patients resulted to be affected by completely resected tumours with microscopic transcapsular invasion (stage IIA, n=25) or macroscopic invasion into the surrounding fatty tissue with or without adhesion to the mediastinal pleura (stage IIB, n=33). Thirty-two patients underwent only complete surgical resection (14 stage IIA and 18 stage IIB); 26 patients underwent complete resection and subsequent mediastinal RT (11 stage IIA and 15 stage IIB). RT dosages were 45-54grays (Gy), in 25-30 fractions. Histological subtypes were similarly represented in both groups. Median follow-up was 91 months (range 9-170). Five intrathoracic recurrences occurred: three radiated patients (2 stage IIB - 1 AB and 1 B2 thymoma; 1 stage IIA B1 thymoma) and two not-radiated patients (1 stage IIA AB thymoma and 1 stage IIB B1 thymoma). Disease-free survival rate at 5- and 10-year were 94% and 87%, respectively. Log-rank test showed no difference in Kaplan-Meier survival curves (p=0.432) between radiated and not-radiated patients.

CONCLUSIONS

These data support the concept that radical surgical resection alone should be considered a sufficient treatment for stage II thymoma.

Pulmonary metastases from epithelial tumours: late results of surgical treatment☆

OBJECTIVE

Development of distant metastases is one of the primary characteristics of malignant tumours. During the last decades, lung metastasectomy has been progressively accepted as a therapeutic option in oncology patients. The present paper aims to evaluate the long-term results and factors influencing prognosis in patients submitted to lung resection for metastases from extrapulmonary epithelial tumours.

METHODS

We retrospectively analysed data of 202 patients undergoing 207 procedures of lung metastasectomy between January 1980 and December 2003. Factors that may influence long-term prognosis such as completeness of resection, histology of the tumour, disease-free interval, number of resected lesions, involvement of hilar or mediastinal lymph nodes, systemic treatments were investigated.

RESULTS

Complete resection was carried out in 169 patients (83.7%). The more frequent lung resection was sublobar in 67.6% of cases, but rarely in selected patients bilobectomy or pneumonectomy has been carried out too. Perioperative morbidity and mortality were 7.7% and 0.9%. Mean disease-free interval was 49+/-48 months. Mean follow-up was 33+/-31 months, 5-year and 10-year survival rates for completely resected patients were 43% and 17%, respectively. By univariate and multivariate analyses, completeness of resection, disease-free interval of 36 months or more, and single resected metastasis were found to be significant prognostic factors.

CONCLUSIONS

Resection of epithelial lung metastases allows an acceptable prognostic result in appropriately selected patients with very low perioperative morbidity and mortality. Factors such as high disease-free interval, single metastasis and completeness of resection are demonstrated and confirmed to be significantly associated with long-term survival.

Subarachnoid-pleural fistula due to blunt chest trauma. A case report

Subarachnoid pleural fistula (SPF) due to blunt chest trauma is rare. When SPF isn't associated with any neurological deficits, its clinical diagnosis is possible only with high degree of suspicion. Presentation symptoms include dyspnea and respiratory distress caused by the collection of cerebral-spinal fluid in the pleural cavity. Computed tomography scan after myelography is helpful in confirming the site of the fistula. Possible dangerous complications are infections or pneumoencephalus. Some cases resolved spontaneously after bed rest or pleural drainage alone, while others required surgical repair. We report a case of spontaneous closure after pleural drainage and a brief period of mechanical ventilation.

World Health Organization histologic classification: An independent prognostic factor in resected thymomas

The histologic classification of thymoma remained controversial since 1999, when the World Health Organization (WHO) Consensus Committee published a histologic typing system for tumours of thymus. Clinical features, postoperative relapsing rates, and survival of patients with thymoma were evaluated with reference to the WHO histologic classification, based on a series of 178 patients, submitted to surgery between 1988 and 2000. There were 21 type A, 49 type AB, 45 type B1, 50 type B2 and 13 type B3 tumours. The invasiveness of tumours was 23.8%, 51%, 73.3%, 82% and 100% for types A, AB, B1, B2 and B3 tumours, respectively. The frequency of invasion of the great vessels increased according to the tumour type in the order A (0%), AB (4%), B1 (6.6%), B2 (22%), and B3 (23%). The 10-year disease-free survival was 95%, 90%, 85%, 71% and 40% for types A, AB, B1, B2 and B3, respectively. According to the Masaoka staging system, the disease-free survival rates were 94%, 88% and 66% for stages I, II and III, respectively, at 10 years. No stage IVA thymomas reached 10 years follow-up. Overall survival at 10 years were 88% and 25% when complete and incomplete resection were considered. By multivariate analysis, Masaoka staging system, WHO histologic classification and complete resection were significant independent prognostic factors, whereas age- and sex-associated myasthenia gravis were not. The present study demonstrated the World Health Organization histologic classification a good prognostic factor, such as completeness of surgical resection and Masaoka staging system.

Schwannoma of thyroid bed. A case report and considerations on interdisciplinary collaboration

Schwannoma of the thyroid bed is extremely rare, but is known to simulate a thyroid nodule. A retrospective review is reported of a 64-year-old female patient with a thyroid nodule who had been submitted to pre-operative fine-needle aspiration biopsy, judged inadequate, following which total thyroidectomy was performed. On histological examination, the nodule (in the thyroid bed) was found to be a schwannoma. This case report stresses the importance of interdisciplinary collaboration. Better co-operation between surgeon, pathologist and radiologist may have led to correct pre-operative diagnosis with sparing of at least half the thyroid.

Large-cell neuroendocrine carcinoma of the lung: A clinicopathologic study of eighteen cases and the efficacy of adjuvant treatment with octreotide

OBJECTIVE

This study was undertaken to evaluate the efficacy of a new adjuvant protocol with octreotide, alone or in combination with radiotherapy, in radically resected large cell neuroendocrine carcinomas of the lung.

METHODS

Between 1990 and 2001, a total of 18 consecutive patients affected by large cell neuroendocrine carcinomas of the lung were operated on. Lobectomy and systemic lymphadenectomy were performed in all cases. Postoperative radiotherapy was performed when stage was higher than Ib. Ten patients with positive results of preoperative indium In-111 pentetreotide scintigraphy received octreotide after the operation.

RESULTS

Nine patients (50%) had local recurrences or distant metastases (mean recurrence time 14 months); palliative chemotherapy was given, but all patients died. In 10 cases (55.5%) octreotide alone or in combination with radiotherapy was administered as adjuvant treatment; 9 of these patients (90%) are alive and free of disease ( P = .0007), and the other had liver and brain metastases 21 months after surgery.

CONCLUSIONS

Our preliminary results seem to demonstrate the efficacy of octreotide as adjuvant therapy in large cell neuroendocrine carcinomas of the lung when results of preoperative indium In-111 pentetreotide scintigraphy were positive. Further study are required to assess the utility of octreotide in patients with negative results of indium In-111 pentetreotide scintigraphy.

Minimal and small size invasive breast cancer with no axillary lymph node involvement: the need for tailored adjuvant therapies

BACKGROUND

Prognosis of patients with node-negative disease and tumor size <1 cm is a matter of controversy. While data exist to clearly correlate small tumor size to better prognosis, the fact that very small breast cancers may express biological markers of dire prognosis leads many to ignore small tumor size during treatment decision-making.

PATIENTS AND METHODS

Data from 425 patients classified as having node-negative pT1mic, pT1a or pT1b after surgery (from April 1997 to December 2001) at the European Institute of Oncology, were analyzed to be described as disease-free according to prognostic variables including: Ki-67 (<20% versus > or =20% of the cells), ER (absent versus positive > or =1% of the cells), PgR (absent versus positive > or =1% of the cells), grade, overexpression or amplification of HER2/neu, presence of peritumoral vascular invasion and age (by decade). The median follow-up for this cohort of patients was 43 months.

RESULTS

No local or distant relapse was observed for patients with pT1mic breast cancer; 4-year disease-free survival for pT1a and pT1b was 97.0% and 97.6%, respectively. In both univariate and multivariate analyses the most relevant prognostic factor for this low-risk population was Ki-67 labeling. The 4-year disease-free survival was 99.2% for tumors with low Ki-67 and 93.3% for tumors with high Ki-67 (> or =20%) labeling. The hazard ratio (HR) for patients with high Ki-67 was 12.9 (95% CI 1.5-112.0, P=0.02).

CONCLUSIONS

Within the first 4 years, microinvasive breast cancer parallels ductal carcinoma in situ (DCIS) rather than invasive carcinoma. Costs and benefits of adjuvant therapy should be accurately weighted in these patients. Patients with pT1a and pT1b, node-negative disease have a limited but substantial risk of recurrence and therefore adjuvant therapy, according to endocrine responsiveness of the tumor and patient preference, should continue to be offered as a reasonable treatment option.

Multimodal management of stages III–IVa malignant thymoma

PURPOSE

The optimal therapy for locally advanced malignant thymoma is controversial. We review our experience with a multimodal approach in 63 consecutive cases.

PATIENTS AND METHODS

Forty-three patients had stage III and 20 stage IVa disease. Surgery with radical intent was initially performed in 30 cases, while 33 cases not amenable to radical surgery underwent neoadjuvant treatment (radiotherapy in 8 and chemotherapy in 25) before surgical reassessment. All patients, whether or not surgically resected, received radiation therapy.

RESULTS

Radical resection (RR) was performed in 20 patients ab initio (all stage III) and in 12 patients after neoadjuvant treatment (eight stage III and four stage IVa). With the addition of patients radically operated with neoadjuvant treatment, the radical resection rate increased from 46 to 65% in stage III patients, and from 0 to 20% in those with stage IVa disease, respectively. Radical surgery was associated with longer progression free survival and overall survival according to both univariate analysis ( P< 0.001 and P<0.01, respectively) and multivariate analysis after adjustment for age, gender, histology and disease stage ( P<0.001 and <0.02, respectively). Progression free survival (median 56.9 months) was slightly lower in patients undergoing radical surgery after neoadjuvant approaches than in those radically resected ab initio (median not achieved), but overall survival (median not achieved) was similar in both groups. Subtotal surgical resection promoted complete response to subsequent radiation therapy. This condition significantly correlated with a better outcome.

CONCLUSIONS

Complete surgical resection is an independent prognostic parameter in locally advanced thymoma treated with a multimodal approach. Preoperative treatment to increase the complete resection rate could improve the overall survival of these patients.

Solitary pericardial hydatid cyst

Hydatid cyst of the heart is an uncommon presentation of human echinococcosis which may lead to life-threatening conditions. Diagnosis should be suspected in every case of cyst-like mass in persons coming from areas where echinococcus granulosus is endemic. Echocardiography, computed tomography and magnetic resonance imaging can help in the differential diagnosis of the lesion. Even if some reports of successful therapy with benzimidazoles have been described, the treatment of choice is the surgical excision of the cyst. Pericardiectomy with cyst removal is feasible with low morbidity and mortality rates even in elder patients. The authors describe the successful surgical management of a single giant pericardial hydatid cyst in a 78-year-old woman from North Africa.

Stage I pure bronchioloalveolar carcinoma: recurrences, survival and comparison with adenocarcinoma of the lung

OBJECTIVE

Bronchioloalveolar carcinoma (BAC) is considered a subtype of adenocarcinoma of the lung, without pleural, stromal or vascular invasion (World Health Organization (WHO) classification). Previous reports had demonstrated a better prognosis following surgery for patients affected by early stage BAC than those affected by other type of non-small cell lung cancer (NSCLC). We aim to analyse differences between stage I peripheral nodular BAC and stage I peripheral adenocarcinoma of the lung,

METHODS

From January 1, 1993 to December 31, 1999, 1158 patients were submitted to surgical resection for NSCLC. Out of them, 28 patients (2.4%) resulted affected by stage I peripheral pure BAC and 80 (6.9%) by stage I peripheral adenocarcinoma. We made a comparison between these two groups.

RESULTS

The percentage of females in BAC patients was similar to that registered in adenocarcinoma patients (21.4 vs. 17.5%). No differences were detected between smokers in BAC and adenocarcinoma patients (P=0.331). The upper lobes were the most common sites of the primary tumour in both tumour subtypes (71.4 vs. 67.5%). Relapse of disease was less frequent in BAC than in adenocarcinoma patients (14.2 vs. 33.7%); recurrent disease developed intrathoracic with higher frequency in BAC patients (75 vs. 33.3%). Both 5-year disease-free and long-term survival were significantly higher in patients affected by BAC (81 vs. 51% and 86 vs. 71%, respectively) (P<0.05); when analysis is performed by dividing stage IA from IB tumours, BAC patients resulted to have higher DFS (stage IA, 93 vs. 58% - P=0.044; stage IB, 61 vs. 32.5%) and higher long-term survival (stage IA, 92 vs. 79%; stage IB, 75 vs. 56%).

CONCLUSION

Patients with stage I pure BAC have significantly longer disease-free and overall survival than those with similar stage adenocarcinoma. Even if classified as subtype of adenocarcinoma, BAC is characterised by clinical behaviour less aggressive than similar stage adenocarcinoma.

Human pulmonary dirofilariasis: uncommon cause of pulmonary coin-lesion

Pulmonary dirofilariasis is a rare entity caused by Dirofilaria, a dog worm that is transmitted to humans by mosquitoes. The filarial nematode enters the subcutaneous tissue, travels to the right ventricle, dies and then embolizes the pulmonary vessels causing a small pulmonary infarction, which subsequently appears as a solitary nodule. Although these nodules are usually identified incidentally by chest radiography in asymptomatic patients, the lesion is generally presumed to be neoplastic. Diagnosis is made by surgical excision. Awareness of this benign entity is important in the differential diagnosis of pulmonary coin-lesions.

Pulmonary resection for metastases from colorectal cancer: factors influencing prognosis. Twenty-year experience

OBJECTIVE

We reviewed our experience in the surgical management of 80 patients with colorectal pulmonary metastases and investigated factors affecting survival.

MATERIAL AND METHODS

From January 1980 to December 2000, 80 patients, 43 women and 37 men with median age 63 years (range 38-79 years) underwent 98 open surgical procedure (96 muscle-sparing thoracotomy, one clamshell and one median sternotomy) for pulmonary metastases from colorectal cancer (three pneumonectomy, 17 lobectomy, seven lobectomy plus wedge resection, six segmentectomy, three segmentectomy plus wedge resection and 62 wedge resection). Pulmonary metastases were identified at a median interval of 37.5 months (range 0-167) from primary colorectal resection. Second and third resections for recurrent metastases were done in seven and in four patients, respectively.

RESULTS

Operative mortality rate was 2%. Overall, 5-year survival was 41.1%. Five-year survival was 43.6% for patients submitted to single metastasectomy and 34% for those submitted to multiple ones. Five-year survival was 55% for patients with disease-free interval (DFI) of 36 months or more, 38% for those with DFI of 0-11 months and 22.6% for those with DFI of 12-35 months (P=0.04). Five-year survival was 58.2% for patients with normal preoperative carcino-embryonic antigen (CEA) levels and 0% for those with pathologic ones (P=0.0001). Patients submitted to second-stage operation for recurrent local disease had 5-year survival rate of 50 vs. 41.1% of those submitted to single resection (P=0.326).

CONCLUSIONS

Pulmonary resection for metastases from colorectal cancer may help survival in selected patients. Single metastasis, DFI>36 months, normal preoperative CEA levels are important prognostic factors. When feasible, re-operation is a safe procedure with satisfactory long-term results.

Stapler blebectomy and pleural abrasion by video-assisted thoracoscopy for spontaneous pneumothorax

BACKGROUND

This study aims to evaluate the efficacy of video-assisted thoracoscopic surgery (VATS) pleurodesis in the treatment of spontaneous pneumothorax with particular reference to the postoperative period and the rate of recurrence after pleural abrasion.

METHODS

One hundred and thirty-three patients who underwent VATS management of primary spontaneous pneumothorax were retrospectively reviewed. They were 113 males and 20 females with median age of 26 (range 12-37). Among these patients, 114 underwent VATS for recurrent pneumothorax and 19 for persistent air-leakage at the first episode. During surgical procedure, in 78% of cases, parenchymal blebs were identified and resected by stapler resection. All patients were submitted to pleural abrasion.

RESULTS

No intra- or postoperative deaths occurred. Postoperative complications were persistent air-leak for more than 7 days in 6 patients (4.3%) bleeding in 3 patients (2.2%). The median chest-tube duration and hospital stay were 2 (range 2-11) and 3 (range 3-12) days, respectively. Median follow-up period of 53 (range 6-96) months was complete for all patients. Five episodes of recurrent pneumothorax were encountered and 4 of them, because of major entity, required re-do VATS with stapler resection and pleural abrasion: their postoperative period and residual follow-up was uneventful.

CONCLUSIONS

The goal in the surgical management of spontaneous pneumothorax, which often affects "apparently healthy" young patients, is to secure the less recurrence rate with no mortality and quite null morbidity and functional impairment. VATS stapler resection and pleural abrasion is a safe procedure allowing a good management of the disease with low complication rate, short chest-drain duration, hospital stay and recurrence rate quite similar to those referred for other procedures such as pleural poudrage or limited pleurectomy.

Bronchial carcinoid tumors: surgical management and long-term outcome

OBJECTIVE

We sought to determine the variables influencing long-term survival of patients treated for bronchial carcinoid tumors.

METHODS

A retrospective, mono-institutional review of patients subjected to surgical treatment since 1977 was conducted.

RESULTS

Over 22 years, 126 patients with a final histologic diagnosis of bronchial carcinoid tumors were assessed for surgery. The group comprised 72 men (57%) and 54 women (43%) with a mean age at presentation of 47 +/- 16 years (range 11-77 years). Symptoms were present in 65 (53%) patients. Operations included lobectomy or bilobectomy in 88 (with 4 bronchoplastic procedures), pneumonectomy in 15, segmentectomy in 3, wedge resection in 16, and bronchial sleeve resection in 3 patients. One patient (0.7%) died in the perioperative period. Eighty-two patients (65%) had typical and 44 (35%) had atypical carcinoid tumors. Postoperative staging was complete for 113 of 126 patients (13 patients did not undergo lymphadenectomy): 90 patients had stage I disease, 6 had stage II, 15 had stage III, and 2 had stage IV disease. A typical subtype was stage I in 70 and more advanced (II-IV) in 5, whereas an atypical subtype was stage I in 20 and more advanced in 18 (P <.05). Mean follow-up was 99 +/- 73 months (range 6-282 months) during which 19 (15%) patients died (12 of recurrent disease). Recurrent tumor developed in 4 (5.5%) of 72 patients affected by typical subtypes and 8 (19.5%) of 41 by atypical subtypes with complete follow-up. Overall survival at 15 years was 74%; survival related to histologic type and nodal status at 15 years was significant (P <.05).

CONCLUSIONS

Biologic behavior and prognosis for bronchial carcinoid tumors are better than for other lung cancers. Surgical treatment requires radical excision and lymph node sampling. Survival and long-term outcome are significantly related to the histologic type, nodal status, and pathologic stage.

Descending necrotizing mediastinitis: surgical management

OBJECTIVE

Descending necrotizing mediastinitis (DNM) is a primary complication of cervical or odontogenical infections that can spread to the mediastinum through the anatomic cervical spaces.

METHODS

Between April 1994 and April 2000, 13 patients, mean age 39.23+/-18.47 (median 38, range 16-67) years, with DNM were submitted to surgical treatment. Primary odontogenic abscess occurred in six, peritonsillar abscess in five and post-traumatic cervical abscess in two patients. Diagnosis was confirmed by computed tomography (CT) of the neck and chest. All patients underwent surgical drainage of the cervico-mediastinal regions by a bilateral collar incision associated with right thoracotomy in ten cases.

RESULTS

Six patients out of 13 required reoperation. Two patients previously submitted only to cervical drainage required thoracotomy; four patients, which have been submitted to cervico-thoracic drainage, underwent contralateral thoracotomy in two cases and ipsilateral reoperation in two cases. Ten patients evolved well and were discharged without major sequelae; three patients died of multiorgan failure related to septic shock. Mortality rate was 23%.

CONCLUSION

Early diagnosis by CT of the neck and chest suggest a rapid indication of surgical approach to DNM. Ample cervicotomy associated with mediastinal drainage via large thoracotomic incision is essential in managing these critically ill patients and can significantly reduce the mortality rate for this condition, often affecting young people, to acceptable values.

Supraventricular arrhythmias after resection surgery of the lung

OBJECTIVE

Two hundred consecutive patients undergoing resection surgery of the lung during 1999 were retrospectively reviewed to define prevalence, type, clinical course and risk factors for postoperative supraventricular arrhythmias (SVA) with particular reference to atrial fibrillation or flutter (AF).

METHODS

Records of 200 lung patients were collected and analysed with particular attention to preoperative physiologic values and associated pathologies, lung functional status, electrocardiogram registration, extent of surgical resection of the lung and were also analysed to confirm or exclude correlation between them and postoperative AF; three patients were excluded as they were affected preoperatively by SVA.

RESULTS

Forty-five episodes of SVA, 41 of AF were identified in 197 patients (22%) and were more prevalent in several groups of patients such as those with increased age, pneumonectomy and superior lobectomy. Rhythm disturbances were most likely to develop on the second day after surgery. Ninety-eight percent of AF disappeared within a day of discharge and sinus rhythm was restored with digitalis or other antiarrhythmic drugs in all patients except one who was discharged with persistent atrial fibrillation. Arrhythmias were not direct causes of any in-hospital deaths. There is a tendency in the difference of the AF rate between pneumonectomy and upper lobectomy patients versus inferior lobectomy ones, probably related to the different anatomic structure of the proximal trunks of the upper and inferior veins of the lung, respectively.

CONCLUSIONS

Statistical analysis revealed that increased age, extent and type of pulmonary resection, such as pneumonectomy and superior lobectomy were significant risk factors. Despite these factors, arrhythmias after lung surgery could be managed easily and were not closely related to higher mortality. Direct cause of AF after lung resection surgery remains unclear; anatomical substrate such as surgical damage to the cardiac plexus or to the proximal trunks of the pulmonary veins covered by myocardial sleeves with electrical properties are to be considered.

Response expectancies in placebo analgesia and their clinical relevance

Response expectancies have been proposed as the major determinant of placebo effects. Here we report that different expectations produce different analgesic effects which in turn can be harnessed in clinical practice. Thoracotomized patients were treated with buprenorphine on request for 3 consecutive days, together with a basal intravenous infusion of saline solution. However, the symbolic meaning of this basal infusion was changed in three different groups of patients. The first group was told nothing about any analgesic effect (natural history). The second group was told that the basal infusion was either a powerful painkiller or a placebo (classic double-blind administration). The third group was told that the basal infusion was a potent painkiller (deceptive administration). Therefore, whereas the analgesic treatment was exactly the same in the three groups, the verbal instructions about the basal infusion differed. The placebo effect of the saline basal infusion was measured by recording the doses of buprenorphine requested over the three-days treatment. We found that the double-blind group showed a reduction of buprenorphine requests compared to the natural history group. However, this reduction was even larger in the deceptive administration group. Overall, after 3 days of placebo infusion, the first group received 11.55 mg of buprenorphine, the second group 9.15 mg, and the third group 7.65 mg. Despite these dose differences, analgesia was the same in the three groups. These results indicate that different verbal instructions about certain and uncertain expectations of analgesia produce different placebo analgesic effects, which in turn trigger a dramatic change of behaviour leading to a significant reduction of opioid intake.

Castleman's disease: unusual intrathoracic localization

Chest-wall is a rare localization of Castleman's disease. The tumour is often diagnosed after onset of non-specific thoracic symptoms but can be occasionally detected in asymptomatic patients. Surgical removal is curative and should be conservative with no recurrences. We report a new case and we review the international literature.