A case of Solitary fibrous pleura tumor associated with severe hypoglycemia: the Doege-Potter 's Syndrome

Solitary fibrous pleura tumor is a rare primary intrathoracic tumor of the pleura. It usually has an indolent clinical course, but sometimes it can have an aggressive behaviour. In 1930 Doege and Potter independently described this neoplasm, presenting with symptoms of hypoglycemia, hence the eponim of Doege-Potter's Syndrome. In this report, we illustrate a case of Doege Potter's Syndrome, treated with complete surgical resection.

Exhaled breath analysis in suspected cases of non-small-cell lung cancer: a cross-sectional study

Lung cancer is one of the most frequently diagnosed cancers worldwide and is still the leading cause of cancer-related deaths. There is a considerable interest in finding diagnostic methods in the disease's earliest stages. A complementary approach to imaging techniques could be provided by exhaled breath gas phase and exhaled breath condensate (EBC) analysis. The aim of this study was to quantify various biomarkers in the exhaled breath gas phase and EBC in suspected cases of non-small-cell lung cancer (NSCLC). The study involved 138 subjects with suspected lung cancer, 71 of whom had a subsequent diagnosis of NSCLC. The diagnostic power of a combination of hydrogen peroxide (H₂O₂)-EBC, and exhaled pentane, 2-methyl pentane, hexane, ethyl benzene, heptanal, trans-2-nonenal in distinguishing NSCLC and non-NSCLC subjects was poor-to-fair (area under the curve (AUC) = 0.68), similar to that of smoking history alone (expressed as pack-years, AUC = 0.70); a further improvement was observed when smoking history was combined with exhaled compounds (AUC = 0.80). The diagnostic power was increased in those patients with little or no past smoke exposure (AUC = 0.92) or where past smoke exposure was up to 30 pack-years (AUC = 0.85). Exhaled substances had a good accuracy in discriminating suspected cancerous cases only in those subjects with a modest smoking history (≤ 30 pack-years), but the inclusion of other exhaled biomarkers may increase the overall accuracy, regardless of tobacco smoke.

Grading the neuroendocrine tumors of the lung: an evidence-based proposal

Lung neuroendocrine tumors are catalogued in four categories by the World Health Organization (WHO 2004) classification. Its reproducibility and prognostic efficacy was disputed. The WHO 2010 classification of digestive neuroendocrine neoplasms is based on Ki67 proliferation assessment and proved prognostically effective. This study aims at comparing these two classifications and at defining a prognostic grading system for lung neuroendocrine tumors. The study included 399 patients who underwent surgery and with at least 1 year follow-up between 1989 and 2011. Data on 21 variables were collected, and performance of grading systems and their components was compared by Cox regression and multivariable analyses. All statistical tests were two-sided. At Cox analysis, WHO 2004 stratified patients into three major groups with statistically significant survival difference (typical carcinoid vs atypical carcinoid (AC), P=0.021; AC vs large-cell/small-cell lung neuroendocrine carcinomas, P<0.001). Optimal discrimination in three groups was observed by Ki67% (Ki67% cutoffs: G1 <4, G2 4-<25, G3 ≥25; G1 vs G2, P=0.021; and G2 vs G3, P≤0.001), mitotic count (G1 ≤2, G2 >2-47, G3 >47; G1 vs G2, P≤0.001; and G2 vs G3, P≤0.001), and presence of necrosis (G1 absent, G2 <10% of sample, G3 >10% of sample; G1 vs G2, P≤0.001; and G2 vs G3, P≤0.001) at uni and multivariable analyses. The combination of these three variables resulted in a simple and effective grading system. A three-tiers grading system based on Ki67 index, mitotic count, and necrosis with cutoffs specifically generated for lung neuroendocrine tumors is prognostically effective and accurate.

[Early molecular diagnosis of lung cancer: a method to rule out the disease]

Aim of this study was the determination of new markers for the diagnosis of lung cancer. 61 patients with non-small cell lung cancer (NSCLC) and 42 controls were enrolled. In the NSCLC patients the following markers were increased: H2O2 in exhaled breath condensate, pentane, hexane, nonenal, trans-2-heptanal, trans-2-nonenal in exhaled breath, while pentanal was decreased. Using multivariate statistical models, a sensitivity of 73.8% and a specificity of 76.8% were calculated. This study shows that with this non-invasive test followed by a most powerful test on positives (e.g. PET) it is possible to decrease the number of false positives.

Resection of giant typical carcinoid tumor with cardiopulmonary bypass support

Carcinoids, defined as well-differentiated neuroendocrine tumors, are classified as typical or atypical based on their microscopic pathological features. Typical carcinoids have a favorable prognosis after complete resection, with 10-year survival rates of up to 90%. We present the surgical strategy used to achieve a left pneumonectomy and the indications for cardiopulmonary bypass (CPB) support in a patient with a huge typical carcinoid tumor.

Advantages of multidetector-row CT with multiplanar reformation in guiding percutaneous lung biopsies

PURPOSE

This study aimed to assess the usefulness of multiplanar reformations (MPR) during multidetector-row computed tomography (MDCT)-guided percutaneous needle biopsy of lung lesions difficult to access with the guidance of the native axial images alone owing to overlying bony structures, large vessels or pleural fissures.

MATERIALS AND METHODS

MDCT-guided transthoracic needle biopsy (TNB) was performed on 84 patients (55 men and 29 women; mean age 65 years) with suspected lung neoplasm by using a spiral MDCT scanner with the simultaneous acquisition of six slices per rotation. We determined the site of entry of the 22-gauge Chiba needle on native axial images and coronal or sagittal MPR images. We took care to ensure the shortest needle path without overlying large vessels, main bronchi, pleural fissures or bony structures; access to the lung parenchyma as perpendicular as possible to the pleural plane; and sampling of highly attenuating areas of noncalcified tissue within the lesion.

RESULTS

Diagnostic samples were obtained in 96% of cases. In 73 patients, lesions appeared as a solid noncalcified nodule <2 cm; 11 lesions were mass-like. In 22, the biopsy required MPR guidance owing to overlying ribs (18), fissures (2) or hilar-mediastinal location (2).

CONCLUSIONS

MDCT MPR images allowed sampling of pulmonary lesions until now considered unreachable with axial MDCT guidance because of overlying bony structures (ribs, sternum and scapulae) or critical location (hilar-mediastinal, proximity to the heart or large vessels). Compared with the conventional procedure, the use of MPR images does not increase the rate of pneumothorax or the procedure time.

Effect of inducible FHIT and p53 expression in the Calu-1 lung cancer cell line

Loss of FHIT expression and p53 mutations are critical events in the early stages of lung carcinogenesis. The restoration of Fhit function in FHIT-negative cancer cells has been reported to cause tumour suppression by inhibition of cell proliferation and/or activation of apoptotic pathways. However, the studies designed to elucidate the biological role of Fhit and its potential interaction with p53 have produced conflicting results. We investigated here the effects of the simultaneous restoration of FHIT and p53 in Calu-1 cells by using a hormone-inducible gene expression system. We demonstrate that the restoration of FHIT expression reinforces the anti-proliferative effect associated with the simultaneous replacement of p53. Indeed, a more pronounced inhibition of cell proliferation associated with an earlier and higher induction of p21(waf1) mRNA and protein expression was observed in Fhit/p53-expressing cells compared with cells expressing p53 alone. This effect was not due to Fhit-mediated up-regulation of p53 expression; in fact p53 protein was expressed at the same level in both FHIT-positive and FHIT-negative cell clones. Consistent with this result, Fhit did not affect the expression of MDM2, a protein known to interact directly with p53 and target p53 for proteolytic degradation, thus down-regulating its activity.

Endotracheal migration of a central venous catheter

Subcutaneous infusion ports for prolonged central venous access are commonly used for drug administration and parenteral nutrition in a wide range of chronic diseases. The extensive use of these devices has to be balanced against its complications, some of which potentially life-threatening. We describe the case of a patient admitted to our unit with haemoptysis and cough. At bronchoscopy the tip of the central venous catheter was discovered protruding into the tracheal lumen. The catheter was pulled out from the subcutaneous pouch under simultaneous surgical control of the tracheal fistula orifice.

Surgical Outcome of Combined Pulmonary and Atrial Resection for Lung Cancer

OBJECTIVES

The study was carried out to assess the short and long-term outcome of patients with non-small cell lung cancer infiltrating the left atrium treated by surgery.

METHODS

We retrospectively collected the hospital files of twenty-three consecutive patients operated on between 1982 and 2001 in two units of Thoracic Surgery. Four patients received an induction regimen. Fourteen right pneumonectomies, 8 left pneumonectomies and 1 right inferior lobectomy were performed. No cardiopulmonary bypass was employed.

RESULTS

In all patients the diagnosis of T4 atrial invasion was confirmed by pathological examination. A complete resection was achieved in nineteen patients (83%). With respect to nodal staging, there were 13 N0, 5 N1 and 4 N2 cases, respectively. Two deaths occurred during the one month postoperative period (9%). Three patients had postoperative atrial fibrillation. Two other patients had postpneumonectomy empyema without bronchopleural fistula and recovered, one after thoracoscopic debridement and the second after open window thoracostomy. Follow-up was completed on September 2002; only one patient was lost to follow-up. Median survival, excluding the perioperative mortality, was 20 months (range 4 - 62 months). The survival rate, calculated with the Kaplan-Meier method, was estimated as 63% at 1 year, 2 % at 3 years and 10% at 5 years. Using a Cox model analysis, lymph node stage and completeness of resection were not independent prognostic factors.

CONCLUSIONS

In cases of NSCLC with left atrial invasion complete resection is technically feasible in most instances without cardiopulmonary bypass. The acceptable operative risk and the encouraging long-term survival observed in this series suggest that NSCLC invading the left atrium should not be systematically considered as a definitive contraindication to surgery.

[Volatile hydrocarbons in exhaled air: preliminary data on the characteristic profile associated with lung tumors]

The aim of this pilot study was to identify and quantify selected volatile organic compounds (VOCs), such as aliphatic and aromatic hydrocarbons in exhaled air from patients with non small cells lung cancer (NSCLC) as compared to healthy subjects, either smokers or non smokers. Exhaled air has been collected by repeated expirations in Tedlar bags. VOCs were sampled by solid phase micro-extraction (SPME) and analyzed by gascromatography/mass spectometry. NSCLC patients showed higher levels of pentane, 2-metilpentane, 2,4-dimetilheptane in the exhaled air as compared to smokers and non smokers. BTEX (benzene, toluene, etilbenzene and xylenes) concentrations were higher in smokers compared to other groups, whereas no differences were observed between subjects with NSCLC and smokers for heptane and octane. In summary, selected VOCs have sufficient diagnostic power to differentiate among the three groups we examined. These differences might be exploited to identify characteristic fingerprints of various lung diseases.

Histological and immunohistochemical study of the bronchial stump with flap coverage in an animal model

OBJECTIVE

The purpose of our study was to evaluate the healing process of the bronchial stump after pneumonectomy reinforced with different pedicled flaps in an animal model. The specimens were analyzed by means of histology and immunohistochemistry.

MATERIALS AND METHODS

We have considered 45 New Zealand White male rabbits that underwent a left pneumonectomy under general anesthesia. Nine animals had no bronchial coverage and represented the controls. The other 36 rabbits were divided into three groups of 12 and had bronchial coverage with either diaphragmatic, intercostal or pericardial flaps. The histological examinations were performed on the animals sacrificed 7, 14 and 30 days after surgery. Immunohistochemical analyses were done on the specimens on postoperative day 7 and 14. On postoperative day 7, the specimens were examined for expression of proliferating cell nuclear antibody (PCNA) expression. On postoperative day 14, neoangiogenesis was measured by CD31 expression. The measurements of antibody expression were done with a computer-assisted morphometric count and analyzed with the t test.

RESULTS

On postoperative day 14, standard histology showed more evident neoangiogenesis in the bronchial stump specimens covered with intercostal and diaphragmatic flaps compared to pericardial flaps and controls. The immunohistochemical evaluation of PCNA by morphometric computer-assisted analysis did not show any statistically significant differences among the groups. The CD31 morphometric count revealed a higher and statistically significant antibody expression in muscular flaps compared to pericardial flaps and controls.

CONCLUSIONS

Our study showed that bronchial coverage with a pedicled muscular flaps promotes the production of new vessels and gives the possibilities to optimize the healing process of a bronchial stump after pneumonectomy.

Biological markers in non-small cell lung cancer. Retrospective study of 10 year follow-up after surgery

BACKGROUND

The biological markers in non-small cell lung cancer (NSCLC) have been widely studied and encouraging results have shown that products of some oncogenes and other molecular markers can predict the aggressiveness of the disease and the outcome of the patients.

METHODS

To verify the reliability of these prognostic markers we have studied retrospectively the expression of c-erbB-2 and 67Ki (growth regulation), p53 (cell cycle regulation and apoptosis), bcl-2 (apoptosis) and CD31 and CD34 (angiogenesis) in 78 patients operated on for NSCLC with curative intent between January 1987 and December 1988 and followed up for 10 years. For the determination of the biological markers we have used the ABC (Avidin-Biotin-Peroxidase complex) immunohistochemical method. The Cox regression model was used for the univariate and multivariate analysis.

RESULTS

Nineteen patients (24%) were alive after 10 years and 59 (76%) died. The univariate analysis of the relationship between the 10-year survival and the expression of the markers was significant only for p53 (p=0.0097). Stratifying the patients according to the 3 histological subtypes (squamous cell carcinoma, adenocarcinoma and large cell undifferentiated carcinoma) the correlation between markers and survival pointed out that the only significant one was p53 (p=0.0459) in adenocarcinoma. In the same way considering the stages p53 was significant in stage IIIa (p=0.0357). The multivariate analysis emphasized that p53 was the only significant marker with respect to the 10-year survival (p=0.0091). Examining the histological groups significant was only p53 in adenocarcinoma (p=0.0192) and in large cell undifferentiated carcinomas (p=0.0290). This marker is also significant in pathological stage II (p=0.0271) and IIIa (p=0.0402). Apart from histology and staging the 10-year survival was 33% for p53 negative versus 10% for p53 positive. In patients with adenocarcinoma the 10-year survival was 40% for p53 negative and 6% for p53 positive.

CONCLUSIONS

In conclusion our results emphasize the importance of p53 as a prognostic factor in 10-year survival in patients with adenocarcinoma and in stage II and IIIa.

Surgical treatment of primary and metastatic sternal tumours

BACKGROUND

Primary and metastatic malignancies of the sternum are uncommon. Surgery that is the best treatment for the majority of primary sternal tumors, and arguably for metastatic lesions, has improved permitting us to perform wide resection and simultaneous reconstruction safely.

METHODS

From January 1988 to December 1998 we treated 13 patients, 4 with primary chondrosarcoma and 9 with sternal metastasis, 5 breast cancer, 3 kidney cancer and 1 thyroid cancer. In 3 patients total sternectomy was performed and in 10 a partial sternectomy associated with resection of the anterior segment of the ribs in 7 cases and resection of the clavicle in 5 patients. Bone reconstruction was done in the majority of cases (5) with Marlex mesh with methylmethacrylate and in 3 cases rib grafts were used to strengthen a Vicryl mesh. The major pectoralis muscle was the most frequently used soft tissue, 9 of 12.

RESULTS

Our postoperative mortality was 15%, 2 cases. The median overall survival was 48 months. All the primary tumours were alive after a mean follow-up of 34 months (range 4-84 months). While survival of the sternal metastasis was 24 months.

CONCLUSIONS

Surgical resection and reconstruction of sternal lesions represent a basic step in the treatment of the primary tumors with encouraging survival results while in the metastatic lesions surgery can be a part of a multimodality approach with unsatisfactory results.

The bilobectomies for lung cancer

BACKGROUND

The purpose of our retrospective study is to confirm that bilobectomy is a feasible operation with an oncological value.

METHODS

From 1981 to 1998, 46 patients underwent bilobectomy for lung cancer. Eight upper and middle lobectomies (UML) and 38 middle and lower lobectomies (MLL) were performed. Intraoperative pneumoperitoneum was done in 11 MLL. We have considered operative mortality, postoperative complications, the persistence of drainage tubes and the length of hospital stay and the data were statistically compared with those relative to right lobectomies. Survival was estimated with the Kaplan-Meier method and the curves were compared with those of the right lobectomies and right pneumonectomies using the log-rank test.

RESULTS

Overall morbidity was 43.4%. Mortality was 6.5%. Mean chest tube persistence was 7.8 days and mean hospital stay was 14 days. No statistical significance was found about these data comparing the UML and MLL separately and the bilobectomies with the right lobectomies. The pneumoperitoneum done in the MLL enabled a shorter hospital stay, statistically significant, in comparison with MLL without pneumoperitoneum. The overall 5-year survival rate was 38%. Considering the I and the II stages no statistical differences in survival were found considering the right lobectomies and right pneumonectomies.

CONCLUSIONS

The bilobectomies can have a role in treatment of lung cancer that is equal to the other standard major resections.

Unusually located hydatid cysts miming a pulmonary tumor invaliding the spine

Hydatid disease is a worldwide encountered zoonosis but at present very rare in Europe, liver and lungs being the most frequently involved sites. Bone involvement is very uncommon and the vertebral spine is the most common site of skeletal involvement (less than 1% overall). We report a case of vertebral hydatid disease with secondary pleuro-pulmonary involvement successfully treated by emergency spinal decompression followed by lung resection en bloc with chest wall and partial vertebrectomy.

Experimental tracheal transplantation using a cryopreserved aortic allograft

BACKGROUND

The tracheal reconstruction after wide resections remains a critical surgical problem. Our aim was to replace trachea with a tissue easy to vascularize, which allows a simple reconstruction and does not require an immunosuppressive regimen.

MATERIALS AND METHODS

A segment of cryopreserved aorta was used in order to verify its adequacy as tracheal substitute. In phase 1, the thoracic aorta of 10 rabbits was excised, obtaining 20 segments that were cryopreserved. Ten segments were implanted in the omentum of 10 rabbits that were sacrificed on postoperative days 7, 14 and 21, and the grafts were examined histologically. In phase 2, a segment of cryopreserved aorta arranged with a silicone prosthesis was transplanted in 10 rabbits and wrapped with omentum. The animals were sacrificed on postoperative days 7, 14 and 21.

RESULTS

In phase 1, the neovascularization of the grafts was present after 7 days, and after 14 days the fibroblasts invaded the lumen of the aorta. In phase 2, 8 rabbits survived and the histologic examination after 7, 14 and 21 days showed neovascularization, the absence of rejection and the proliferation of fibroblasts inside the lumen of the aorta; this growth has been restrained by an endoluminal prosthesis.

CONCLUSIONS

Our study demonstrated that replacing the trachea with cryopreserved aorta is technically feasible and does not evoke immunologic reactions. It requires, however, a silicone tube inside the allograft to limit the colonization of fibroblasts.

Expression of human CD44v6 in non-small-cell lung cancer

INTRODUCTION

The CD44 is a membrane glycoprotein that functions as lymph node homing receptor in lymphocyte activation and is involved in homo- and heterotypic cell adhesion. In several tumor cell lines the expression of splice variants (CD44v6 and CD44v7) are correlated with the metastatic potential and confer an advantage in the early steps of the metastatic cascade. In our study we examined 35 cases of non-small-cell lung cancers (NSCLC) in order to detect the presence of CD44v6 and to compare its expression with the histologic type, degree of differentiation, stage of the tumor and survival of the patients.

METHODS

CD44v6 expression in frozen tissue sections of 35 patients with NSCLC who underwent pneumonectomy or lobectomy was analyzed with the VFF-7 monoclonal antibody that detected the CD44v6 variant. The data on survival were analyzed by the actuarial method and compared by the log rank test.

RESULTS

The expression of CD44v6 occurred in all the 20 cases of epidermoid carcinomas tested and in 2 out of the 3 cases of undifferentiated large cell carcinoma and was absent in all the 12 adenocarcinomas. No relationship was found between the presence of this marker and the grading or the stage of the pathology. The 3-year survival rate was 73% for CD44v6-positive and 65% for CD44v6-negative cancer and the comparison was not statistically significant.

CONCLUSION

These results suggest that in lung cancer the expression of CD44v6 is not a useful prognostic factor.

Spontaneous intercostal pulmonary hernia

A case of spontaneous intercostal pulmonary hernia as a result of vigorous coughing is reported in a 67-year-old man. The great majority of acquired pulmonary hernias are post-traumatic; rare cases are spontaneous, resulting from prolonged and/or repeated increased intrathoracic pressure. This hernia was successfully repaired with a polyglactin absorbable mesh and approximation of the ribs with heavy stitches. When required, surgical repair is the treatment of choice.

Biological variables in non-small cell lung cancer: comparison between immunocytochemical determination on fine needle aspirates from surgical specimens and immunohistochemical determination on tissue sections

A number of biological and predictive markers of non-small cell lung cancer (NSCLC) have been sought, but these have so far been mainly evaluated on surgically resected specimens. Given that fine needle aspiration biopsy (FNAB) is being increasingly used in the diagnosis of NSCLC, its application could be extended to the immunocytochemical detection of biological parameters at the time of diagnosis before surgery. In order to assess the reliability of estimating biological markers on fine needle aspirates (FNAs) from NSCLC, the aim of this study was to compare Ki67 growth fraction, p53 and bcl-2 protein expression as revealed by the immuncytochemical assessment of FNAs obtained from surgical samples with the immunohistochemical results obtained from the corresponding histological sections. FNAs were performed on surgical specimens obtained from 29 NSCLC patients. Ki67, p53 and bcl-2 were cytologically and histologically evaluable in respectively 25, 27 and 19 cases. Concordance between FNAs and corresponding paraffin sections was 84% for Ki67, 93% for p53 and 95% for bcl-2. All of the specimens whose biological parameters were studied by immunocytohistochemistry also underwent flow cytometric DNA analysis of FNAs taken from fresh surgical specimens. Of the 29 cases, 22 were aneuploid and seven diploid. The S-phase fraction (SPF) was evaluable in 62% of cases. Comparison of SPF results on FNAs with Ki67 values evaluated on the corresponding histologic and cytologic specimens, revealed a significant correlation only with histology. Good reproducibility was also found in relation to the immunocytochemical results obtained on FNAs from different areas of the same tumour, showing that tumour heterogeneity does not affect the method. The concordance between the immunocytochemical and immunohistochemical results suggests that FNAB may be a reliable procedure for the biological characterization of NSCLC. Given its limited invasiveness, FNAB could be used in vivo for the preoperative assessment of biological parameters in patients with operable or metastatic NSCLC.

The modified "hemi-clamshell" approach for tumors of the cervicothoracic junction

The anterior approaches proposed for treatment of the apical chest tumors (anterior transcervical, transmanubrial, and hemi-clamshell) have precise advantages and limits. To avoid these limits we have modified the hemi-clamshell with the resection of the first costal cartilage and the costoclavicular ligament. This allows a wider opening of the sternocostal flap, with safe control of the entire subclavian vessels as well as easier access to the T1 to T3 vertebral bodies and the posterior chest wall.

Postoperative pneumoperitoneum for prolonged air leaks and residual spaces after pulmonary resections

BACKGROUND

Postoperative air leaks and pleural residual spaces are often encountered during partial lung resections and may adversely affect the immediate outcome prolonging the hospital stay. At present the only treatment consists of maintenance of the chest drainage under suction until resolution of the leaks.

METHODS

From January 1995 to December 1997 the authors have operated on and subsequently treated 12 patients presenting prolonged air leaks with residual pleural spaces after lobectomies for lung cancer. The patients underwent respectively: left or right lower lobectomies (n=7), left upper lobectomies (n=3), right upper lobectomies (n=2). In this study the air leak was considered prolonged if it continued and delayed the discharge after surgery beyond the postoperative day 8. The pneumoperitoneum was carried out under local anesthesia. The air was insufflated through a needle inserted just above the umbilical scar as for laparoscopic surgery access up to an amount of about 1200 cc-1300 cc.

RESULTS

We have obtained in all cases and without complications an immediate reduction in the air leaks and a complete resolution of the residual pleural spaces. Chest drainages were removed from 3 to 4 days after the procedure.

CONCLUSIONS

The good results achieved suggest that this procedure might be considered for selected cases, being a minor procedure, performed under local anesthesia and with minimum discomfort for the patient.

Pulmonary abnormalities in Cowden's disease

Cowden's disease is an inheritable multiple neoplastic syndrome represented by benign and malignant lesions of skin, digestive tract, mucosae, breast and thyroid. The syndrome, first described by Lloyd and Dennis in 1963, includes benign lung lesions, described in the literature only as hamartomas. The unusual condition of our case consists of multiple and bilateral lipomatous lesions of the lung and of adipose colonic polyps, diagnosed respectively by video assisted mini-thoracotomy and by endoscopic biopsies.

A standard muscle-sparing utility thoracotomy for VATS procedures

BACKGROUND

Improvements in surgical equipment have rendered video-assisted thoracic surgery (VATS) an effective device for thoracic surgeons and nowadays several intrathoracic diseases can benefit from this approach. This development has expanded potential use and recently the technical feasibility of major lung resections by VATS has been demonstrated. The authors present their experience with a standard muscle-sparing utility thoracotomy (UT) utilized for all VATS procedures, including major lung resections.

METHODS

From November 1996 to October 1997, 30 patients were operated on. There were 22 males and 8 females (medium age 58 years; range 24-78). There were 13 anatomical lung resections (i.e.: 11 lobectomies, 1 left pneumonectomy, 1 segmental resection), 8 wedge resections, 3 lung biopsies, 2 debridements of pleural empyema, 2 mediastinal nodes biopsies, 1 esophageal resection for leiomyoma, 1 excision of benign mediastinal cyst.

RESULTS

No mortality or major morbidity were recorded, as well as no rib fractures due to the rib spreader. Two patients suffered from prolonged air-leaks after respectively left upper lobectomy and lung biopsy and required prolonged chest drainage. Concerning anatomic major lung resections the medium hospital stay was 7.9 days and medium chest tube time was 5.6 days. The utility thoracotomy through the auscultatory triangle proved to be a safe approach and confirmed the technical feasibility of various type of surgical procedures with results comparable to standard open thoracotomy. Our data shows that VATS approach did not seriously affect the duration of hospital stay, chest tube time, the overall morbidity or lung function.

CONCLUSIONS

As the real benefit of this approach remains controversial, the majority of the studies comparing the VATS approach to conventional muscle-sparing thoracotomy neither nor prospective nor randomized, and several parameters are difficult to evaluate in the literature further study are mandatory.

[Bronchiolo-alveolar carcinoma. The clinico-diagnostic and therapeutic considerations and the results of a retrospective study in our experience]

Bronchioloalveolar carcinoma (BAC) is a subtype of adenocarcinoma of the lung that accounts for 3% of the total pulmonary malignancies. On the basis of literature on the topic, the following were taken into consideration, the history, the incidence, the epidemiology, the aetiopathogenesis, the clinical characteristics, the diagnostic as well as the surgical therapy of this kind of cancer. The authors reviewed our surgical experience of 23 patients treated at the Department of General, Thoracic & Vascular Surgery of the University of Parma during a 10-years period from 1985 to 1995.

[Video-assisted major pulmonary resections (lobectomies)]

New applications of the video-assisted technique for the management of intrathoracic diseases continue to be developed, including major lung resections for cancer. The differences in the techniques proposed from various centers reflect the fact that the procedure is not accurately standardized yet and that prospective randomized trials with long-term follow-up data are needed. The authors report the results of their preliminary experience with a mini-invasive modern approach for video-assisted anatomic lobectomy: an utility muscle-sparing minithoracotomy through the auscultatory triangle. Eight patients successfully undergone this surgical procedure (7 for non-small cell lung cancer in early stage, 1 for benign disease). No mortality, nor complications (including minor morbidity: i.e. rib fractures) were recorded. Medium hospital stay time was 9.25 days (range 7-16) and chest drainage time 6 days (range 4-11). This operation proved to be technically feasible, although an accurate selection of patients and an adequate training in thoracoscopic procedures are mandatory. According to the more recent literature no significant differences are noted in operation's time, postoperative pain, chest drainage time, hospital stay compared to the standard posterolateral thoracotomy incisions. Otherwise the approach described enables to perform a truly "conservative" operation in conformity with the philosophy of the minimal invasive surgery and the patient's comfort and functional recover 2-3 weeks after surgery seems to be improved.

[The use of the pleural tent in superior lobectomies]

Persistent pleural space must be considered a possible complication after lung resection surgical treatment. Although in most cases the evolution is favourable, the authors suggest the use of the "pleural tent" technique, that compared to others thoracoplasty procedures offers some advantages. A short historical review of the thoracoplasty techniques is presented together with a detailed description of the above-mentioned technique.

[The transmanubrial approach for tumors of the superior thoracic aperture]

A considerable difficulty in surgical management of apical chest tumors is represented by the potential involvement of the thoracic outlet anatomic structures (i.e.: vertebral body, subclavian vessels, first rib). Among the various techniques proposed, the anterior trans-cervical approach popularized by Dartevelle significantly improved the radical treatment of these tumors. This approach offers a wide access to the thoracic outlet with satisfactory control of subclavian vessels, safe dissection of brachial plexus and upper part of the mediastinum, permitting a radical treatment. However, this approach is associated invariably with aesthetic deformity, severe impairment in shoulder mobility (due to medial half clavicle sacrifice) and respiratory failure in case of chest wall resection. The authors present their experience with an alternative approach, the trans-manubrial osteomuscular sparing approach to anteriorly situated apical chest tumors recently standardized by Grunenwald and Spaggiari. From June 1996 to June 1997 5 patients were operated on through this approach: 3 non-small-cell lung cancer, 1 pseudotumor, 1 desmoid tumor of the first rib. In 2 cases the resection was extended respectively to the vertebral body (D1-2-3 hemivertebrectomy) and to the subclavian vessels. This patient died on 10-postoperative day for massive pulmonary ernbolism, whereas no other complications were recorded. This technique compared to the approach popularized by Dartavelle presents the same oncological radicality, with a better surgical exposure and with the complete sparing of osteomuscular components that allow the maintainance of shoulder girdle movements associated excellent functional and cosmetic results.

The effect of dextran for hypothermic (10 degrees C) preservation of human fetal lung fibroblasts

BACKGROUND

Low-potassium (LP) solution with Dextran (Dx) improves lung preservation. Nevertheless, the role of Dx in simple cold storage is not established yet. This study was designed to investigate the relationship between molecular weight and concentration of Dx in LP solutions and its effects on cell viability after prolonged hypothermic preservation.

METHODS

Human fetal lung fibroblasts (WI-38) were preserved at 10 degrees C for 16 hrs in five solutions containing respectively Dx11, Dx17, Dx39.2, Dx71, Dx178 at 2% and at 5% concentrations and in LP solution without Dx. Cell viability was assessed by means of both the analysis of the total protein content (cytotoxicity index) and the rate of protein synthesis (index of cellular functioning).

RESULTS

No differences were recorded in total protein content among the solutions tested. By contrast, the index of cellular functioning was significantly higher using LPDx178 at both concentrations. However, LPDx178 exerted a more significant cytotoxic effect than did LP alone.

CONCLUSIONS

These effects were not mediated by the variation of osmolarity; two factors probably influenced this protection: the low oncotic pressure of the LPDx178 solution and an effect chemically specific due to the increased molecular weight of Dx still unknown. Nevertheless, during 10 degrees C preservation, WI-38 cells were better preserved with LP solution without Dx confirming, thus, that during simple cold storage the presence of an oncotic pressure might be harmful.

[Experimental tracheal transplantation. Literature review and proposal of an original surgical technique]

The reconstruction of the trachea after wide resections remains a critical surgical problem. Our aim has been to replace trachea with a tissue easy to be vascularized, that permits a simple reconstruction, not requiring an immunosuppressive regimen. We have used a segment of cryopreserved aorta. In the first phase the thoracic aorta of 10 rabbits was excised obtaining 20 segments that were cryopreserved. Ten segments were implanted in the omentum of 10 rabbits that were sacrificed on postoperative day 7, 14 and 21. The histologic examination of the grafts showed the presence of neovascularization after 7 days with obliteration of the lumen by fibroblasts after 14 days. In the next phase the cryopreserved aorta replace an excised segment of trachea. The survived animals were sacrificed 7 and 14 days after the operation. The histologic examination showed the neovascularization of the graft and the absence of rejection.