Utilidad de la videotoracoscopia para una correcta estadificación de tumores T3 por invasión de pared

Convex border of peripheral non-small cell lung cancer on CT images as a potential indicator of pleural invasion

The aim of the study is to evaluate the use of the tumor border in peripheral non-small cell lung cancer (NSCLC) as an indicator of pleural invasion.This retrospective study was performed at a single tertiary center. The analysis of 136 patients with peripheral NSCLC included 101 (74.3%) patients with pathologically proven pleural invasion and 35 (25.7%) patients without pleural invasion. The tumor borders on conventional computed tomography (CT) were classified into 5 types on lung window setting: type 1, S or reverse S border with a blunt angle; type 2, sharp angle; type 3, concave border with a blunt angle; type 4, straight border with a perpendicular angle; and type 5, convex border with a perpendicular or blunt angle. In patients with more than 1 tumor border type, the priority was type 5, 4, 3, 2, and 1. Blunt angle, pleural contact >3 cm, and adjacent pleural thickening were also recorded for comparison with pleural invasion of peripheral tumors.Tumor border types 2 and 5 significantly differed between patients with and without pleural invasion (P = .001 and P < .001, respectively). Patients with and without pleural invasion did not significantly differ in tumor border type 1, tumor border type 3, tumor border type 4, blunt angle, pleural contact >3 cm, or pleural thickening. Tumor border type 5 was a moderate indicator of pleural invasion with positive LR, 5.20; accuracy, 57%; sensitivity, 45%; specificity, 91%; PPV, 94%; and NPV, 36%. Tumor border type 2 was a weak indicator of pleural invasion with positive LR, 0.51; accuracy, 34%; sensitivity, 34%; specificity, 34%; PPV, 60%; and NPV, 15%.Tumor border type 5 has a high PPV and high specificity for predicting pleural invasion by peripheral NSCLC.

Pleural Tags on CT Scans to Predict Visceral Pleural Invasion of Non-Small Cell Lung Cancer That Does Not Abut the Pleura

PURPOSE

To evaluate the association of pleural tags with visceral pleural invasion of non-small cell lung cancer (NSCLC) that does not abut the pleural surface.

MATERIALS AND METHODS

This retrospective study was approved by the institutional review board. Informed consent was waived. The study of NSCLC that does not abut the pleura in 141 patients (44 patients [31.2%] with visceral pleural invasion proved by pathologic analysis and 97 patients [68.8%] without pleural invasion) was conducted at a single tertiary center. The pleural tags were classified into three types (type 1, one or more linear pleural tag; type 2, one or more linear pleural tag with soft tissue component at the pleural end; and type 3, one or more soft tissue cord-like pleural tag) and prioritized into types 3, 2, and 1 when more than one type was present. Diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and positive likelihood ratio (LR) were calculated.

RESULTS

In the absence of pleural tags, no pleural invasion was found. The presence of type 2 pleural tags was moderately associated with visceral pleural invasion with the following results: positive LR, 5.06; accuracy, 71%; sensitivity, 36.4%; specificity, 92.8%; PPV, 76.2%; and NPV, 69.6%. Type 1 pleural tags provided weak evidence to rule out visceral pleural invasion (positive LR, 0.38). Type 3 pleural tags indicated minimal increase in the likelihood of visceral pleural invasion (positive LR, 1.68).

CONCLUSION

Type 2 pleural tags on conventional CT images can increase the accuracy of early diagnosis of visceral pleural invasion by NSCLC that does not abut the pleura.

[Treatment of lung cancer with chest wall invasion]

The aim of this study was to analyze chest wall invasion, the indication and multidisciplinary nature of treatment, the methods used for parietal reconstruction and the technical problems posed by this procedure in patients with lung cancer and chest wall invasion. Chest wall invasion from adjacent malignancies affects 5% of patients with a bronchogenic carcinoma. Preoperative determination of parietal invasion aids the planning of an appropriate therapeutic approach. Positron emission tomography combined with computed tomography (PET/CT) improves the study of T-factor and metastatic nodal involvement and distant metastases. As a rule, surgical treatment should attempt complete tumoral resection: lobectomy, resection of the parietal pleura and/or of the chest wall--ensuring tumor-free margins--and hilar and mediastinal lymphadenectomy. We also analyzed the distinct prognostic factors for survival, as well as the indication for induction or adjuvant therapy. Chest wall reconstruction involves recreating the most anatomical and physiological conditions possible in the chest cavity and surrounding muscles. The ideal reconstruction would achieve adequate parietal stability and coverage to preserve functionality, with the cosmetic result being an important, but secondary, consideration. Many materials are available for reconstruction and the choice of material should be individualized in each patient. A multidisciplinary team able to plan and perform the resection and subsequent reconstruction, oversee postoperative management and treat complications early is essential.

[Incisions and routes of surgical access]

The correct choice of the incision to the chest is essential for surgical success and a favorable postoperative course. The route of access to the thorax must be adapted both to the disease and to the thoracic surgeon's experience, striking a balance between aggressiveness and the safety of the technique. This article describes the characteristics of surgical incisions, including classical thoracotomy, sternotomy and its variants, thoracoscopy and minimally-invasive surgery. The distinct techniques used to explore mediastinal lymphatic areas, including video-assisted mediastinal lymphadenectomy and transcervical extended mediastinal lymphadenectomy, are also described.

[Thoracic surgery 2009]

Started with tuberculosis and developed in parallel with smoking and cancer and under the protection of anaesthesia, thoracic surgery appeared in the 1980's as a specialty with a difficult long-term survival. However, with the development of lung transplant, tracheal surgery, the appearance of video-assisted thoracic surgery, along with the confirmation that despite the excellent progress of chemoradiotherapy, surgery continues to be the best option for curing lung cancer, means that it is currently a specialty of great growth and a wider scope in the future.