Diagnosis and First-Line Treatment of Patients with Lung Cancer in Italian General Hospitals

The quality of diagnostic and therapeutic care was examined in a series of 380 consecutive newly diagnosed cases of primary lung cancer seen in 20 Italian general hospitals between January and June 1987. At diagnosis most patients (78%) had one or more symptoms related to the tumor, and in an additional 9 % symptoms were related to the presence of distant metastases. The median diagnostic time lag between first symptoms and final diagnosis was 50 days with a significantly longer delay in patients first seen by their general practitioner compared with those who sought first care in hospital outpatient departments. The diagnostic process was satisfactorily carried out in fewer than two-thirds of the patients leading to complete ascertainment of disease stage and histology in 58% cases with significantly better performance in more specialized institutions. Analysis of the first-line treatment profile indicated a rather aggressive therapeutic attitude In the case of patients with non-small cell lung cancer – 28% of them had chemotherapy despite the lack of any proof of efficacy in controlled clinical trials – and a failure to identify among the patients with small cell disease those amenable to more aggressive treatment. The lack of progress in the treatment of lung cancer over the last decades seems to have resulted in widely varying practice patterns where a mixture of aggressive and laissez-faire attitudes does not take into account that in the absence of effective therapies a more conservative attitude would at least have some advantage in terms of quality of remaining life for many patients.

[The treatment of thoracic empyema by video-assisted thoracic surgery (VATS)]

Despite various treatment options, empyema thoracis remains associated with important morbility and mortality. Diffused or loculated empyema developed through exudative, purulent and organized phases. Clinically, these phases corresponding to the evolution of the disease: acute and chronic one. The treatment of empyema thoracis is also correlated with the general condition of the patient and even if the drainage is satisfactory in the exudative form, these surgical procedure may be not curative in the purulent and chronic phase. In these cases empyemectomy and pleural decortication are treatment of choice. Recently, Video Assisted Thoracic Surgery has assumed greater importance in the management of this pathology. In our Department of General and Thoracic Surgery, on 178 patients with chronic empyema thoracis, 26 were underwent VATS. During the follow-up there was no mortality or recurrence of empyema. The results indicate VATS because of higher efficacy, shorter hospital stay and less cost, is the primary surgical treatment of chronic empyema thoracis.

[Pneumonectomy for benign disease]

Pneumonectomy for benign disease of the lung is a rather infrequent intervention. A retrospective study based on 1900 pulmonary resections performed in our institute up to 1998, identified a total of 15 patients submitted to pneumonectomy for non-neoplastic disease. Indications were chronic infections in 11 cases, congenital malformations in 2 cases, left primary bronchial stenosis caused by closed thoracic trauma one in case and gunshot wound in one case. Access to the lung was obtained in all cases by a classic postero-lateral thoracotomy: intra-pericardial ligature was required in five cases and in one patient an extrapleural pneumonectomy was performed. The intra-operative mortality was 20% and the average time of hospitalization 27 days. One patient, operated for pulmonary tuberculosis, developed a broncopleural fistula requiring a second operation. In conclusion, the use of pneumonectomy for non-neoplastic diseases presents serious problems and may be associated with major complications.

[Magnetic resonance in thoracic pathology: characterization by intensity values]

The authors examined prospectively 100 patients with lung diseases--50 of them benign and 50 malignant. The mean value of all lesions was measured with a constant region of interest (ROI); the muscle was considered as the reference tissue. Histopathology was the gold standard for the patients who underwent CT-guided needle biopsy and/or surgery; clinical-radiologic follow-up (average time: 2 years) was the gold standard for nonsurgical patients. A superconductive 1.5-T magnet with circular polarization body coil was used; T1- and T2-weighted spin echo images were acquired on the coronal and axial planes, respectively. The mean values with the constant ROI were measured both on the lesions and on the reference tissue to calculate and compare the T1-lesion/T1-muscle and T2-lesion/T2-muscle ratios in benign and malignant conditions. The t-test, the linear regression and correlation test and the analysis of variance were used to analyze the data. T1 benign lung disease/T1 muscle ratio was 1.21, while T1 malignant lung disease/T1 muscle ratio was 1.27, with no statistically significant difference. T2 benign lung disease/T2 muscle ratio was 2.63, while T2 malignant lung disease/T2 muscle ratio was 4.80: the difference was statistically significant (p < 0.001). To conclude, in chest diseases, the measurement of mean values in T2 allowed malignancy-indicative values (> 4 ratio) and positively benign values (< 2.5 ratio) to be identified.

[Bouveret's syndrome: unusual variety of biliary ileum]

The authors report one case of Bouveret's syndrome that come to their observation. Physiopathology, clinic and diagnosis are discussed. After the method of stone removal they emphasized the surgical procedure in one stage with enterotomy and stone-removal, cholecystectomy and repair of biliary fistula.

[Intraoperative echography as a therapeutic aid in the treatment of nephrolithiasis]

Intraoperative ultrasonography was performed in 24 patients with intrarenal pelvis or with recurrent or multiple stones. The stones were located by a 22 or 25 gauge needle, manually introduced under ultrasonography: they were then extracted through a small incision performed along the tract of the exploratory needle. This preliminary experience has shown that the real time B-mode intraoperative ultrasound can provide valuable results in urologic surgery.

[Perforations of the colon]

Perforations of the colon are a difficult problem for any surgeon, due the emergency they represent and the multiple clinical and pathological findings. Personal cases are revised and the opportunity of a case-by-case evaluation and of an eclectic surgical choice are stressed.

[Latero-terminal anastomosis in colorectal surgery using a mechanical stapler. Technical note]

Following a discussion of the various methods of colorectal anastomosis in cancer surgery, the Authors describe a technical variant using a mechanical stapler in a high rectal location. The rapidity of anastomosis as well as the decreased risk of dehiscence, fistula and stenosis are underlined.

[Fiber bronchoscopy in the treatment of postoperative complications in thoracic surgery]

Evaluating the records of the Thoracic Endoscopy Unit of the Department of Surgery, University of Chieti, Italy--from November 1987 to November 1991, data related to the use of fiber bronchoscopy in preventing and treating complications after thoracotomy are referred. The usefulness of fiber bronchoscopy as a therapeutic procedure is underlined.

[Parietal infiltration of the superior vena cava during bronchogenic cancer: problems of treatment]

One case of S.V.C.S. pas observed during surgery for cancer of lung, resection was performed and dacron graft was used. Possibilities of vascular graft in such cases, as well as peculiar situation of emergency which create the opportunity for insertion of synthetic graft were discussed.