Usefulness of the Nd:Yag Laser in Parenchyma-Sparing Resection of Pulmonary Nodular Lesions

Aims and background

The neodymium: yttrium-aluminium-garnet (Nd:YAG) laser has been successfully employed in parenchyma-sparing resection of pulmonary nodular lesions. We report our experience with limited resection using a noncontact Nd: YAG laser applied through a thoracotomic approach.

Methods

During the period March 1987-October 1993, we performed parenchyma-sparing resections of 66 pulmonary nodular lesions with a noncontact Nd:YAG laser in 47 patients. Nodules were approached through postero-lateral thoracotomy (n= 40), median sternotomy (n= 5) or staged bilateral thoracotomy (n= 2). Fifty-two lesions were located in a peripheral position and the others (n= 14) at various depths within the parenchyma.

Results

Fifteen lesions were benign: hamartoma (n= 5), chronic pneumonic infiltrate (n= 3), tuberculoma (n= 3), asbestosis (n= 2), Wegener's granuloma (n= 1). Twelve lesions were attributable to primary lung cancer and 33 were metastatic lesions. Another 6 lesions turned out to be necrotic metastases following chemotherapy. There were no perioperative deaths. Pulmonary re-expansion was shortly obtained: mean drainage time was 4.31 ± 3.9 days. Only one patient presented a prolonged drainage time (11 days); in this case, the air leak was successfully treated by tissue glue sealant trans-drainage infiltration. Follow-up ranged from 2 to 96 months. No case of relapse on the resection site has been observed.

Conclusions

The results suggest that Nd:YAG laser resection is safe and worthwhile in patients with multiple lesions and borderline pulmonary function.

Soluble Selectin Levels in Patients with Lung Cancer

Increased expression of selectins has been found on endothelial cells of venules and capillaries in the tumor stroma of non-small cell lung cancer, suggesting their functional role in the process of chemotaxis for tumor cells. The present study was aimed at analyzing the role of both soluble (s)P-selectin and sE-selectin levels in association with clinico-pathological variables in 116 patients with lung cancer, 38 patients with benign diseases and 59 healthy donors. The results obtained showed that sP-selectin and sE-selectin levels were higher in patients with lung cancer compared to normal donors (p<0.02 and p<0.005, respectively). No differences were observed among patients with various benign diseases for both selectins. Increased levels of sP-selectin and sE-selectin were significantly associated with squamous lung cancer at late stages (p<0.05), but not adenocarcinoma. Both sP- and sE-selectin were independently related to the stage of squamous lung cancer by stepwise regression analysis (p<0.02 and p<0.03, respectively), while only sE-selectin was independently related to the presence of distant metastasis in the same histotype (p<0.02). These results suggest that measurement of plasma soluble selectins might represent a useful laboratory parameter in the management of patients with squamous lung cancer.

Modeling of Azobenzene-Based Compounds

Azobenzene is by far the most studied photochromic molecule and its applications range from optical storage to bio-engineering. To exploit the great potential of azobenzene, one must achieve deep understanding of its photochemistry as single molecule in solution AS WELL AS in-chain moiety and pendent group in macromolecular structures. With the advent of computer-aided simulation scientists have been able to match experimental data with computational models. In this chapter, a review on the modeling of azobenzene-containing molecules in different conditions and environments IS provided with a special focus on advanced applications of photo-controllable materials, such as molecular machines and photoactivation of bio-molecules.

[Male neurogenic stress urinary incontinence treated by artificial urinary sphincter AMS 800™ (Boston Scientific, Boston, USA): Very long-term results (>25 years)]

OBJECTIVE

The aim of the study was to report the very long-term functional outcomes of artificial urinary sphincter (AUS) in male neurological patients.

MATERIAL AND METHODS

Male neurological patients diagnosed with stress urinary incontinence due to sphincter deficiency and undergoing AUS (AMS 800^®) implantation between 1985 and 1992 were enrolled. Continence, defined by no pad/condom usage, explantation and revision rates were reported.

RESULTS

Fourteen patients with a median age of 27.3 years (IQR: 27.3-40.8) were included: four had a spinal cord injury and ten a spina bifida. Prior continence surgery was reported by 6 patients (42.9 %). Artificial urinary sphincter was implanted in a peribulbar (n=4) or periprostatic position (n=10). Median follow-up was 18.3 years (IQR: 10.1-20.3). At last follow-up, all patients were alive. Three native devices were still in place, eight were revised (four of them were secondarily explanted) and three were explanted due to erosion or infection. The 5-, 10-, 15-, 20-year explantation-free survival rates were respectively 85.7, 62.3, 52.0, 39.0 %. The 5-, 10-, 15-, 20-year revision-free survival rates were respectively 78.6, 42.9, 28.6, 7.1 %. At last follow-up, 50 % patients were continent.

CONCLUSION

In the very long run, AUS provided a 50 % continence rate in male neurological patients but the revision rates were important.

LEVEL OF EVIDENCE

4.

[Placement of tension-free vaginal tape in women with stress urinary incontinence: Long-term functional outcomes in a prospective series]

PURPOSE

To evaluate the long-term functional outcomes after retropubic tension-free vaginal tape (TVT) placement to treat female stress urinary incontinence (SUI).

METHODS

From September 1998 to September 2000, we prospectively enrolled all consecutive women in our center suffering SUI caused by urethral hypermobility. All women had a retropubic TVT inserted by the same surgeon. Patients were evaluated at 1, 3, 6 and 12 months postoperatively, and annually thereafter. Postoperative assessment included a measurement of post-voiding residual volume, urinalysis, a 1-hour pad test, a urinary symptom questionnaire, and an assessment of quality-of-life. Objective continence (defined as no urine leakage at clinical examination) and subjective continence (defined as no urine leakage, whatever the mechanism, reported by the patient) were reported.

RESULTS

Overall, 58 consecutive women (median age 59; IQR 49-67; min 21-max 78) were evaluated. Median follow-up was 10.2years (IQR 1.4-16.0; min 1-max 13.2). At the last follow-up, objective and subjective continence rates were 93% and 78%, respectively and remained stable in the long run. Pad tests, urinary symptom questionnaire scores and quality-of-life were significantly improved. Self-intermittent catheterisation was required by three women. A section of one TVT and removal of another tape was undertaken in two women with chronic pelvic pain. One patient had a chronic urinary infection. Rate of de novo urgency was 10%.

CONCLUSIONS

TVT implantation offered good and stable functional long-term outcomes. This procedure enhanced quality-of-life and had low morbidity.

LEVEL OF EVIDENCE

3.

Patterning of perovskite-polymer films by wrinkling instabilities

Organic-inorganic perovskites are semiconductors used for applications in optoelectronics and photovoltaics. Micron and submicron perovskite patterns have been explored in semitransparent photovoltaic and lasing applications. In this work, we show that a polymeric medium can be used to create a patterned perovskite, by using a novel and inexpensive approach.

Synthesis and adsorption study of hyper-crosslinked styrene-based nanocomposites containing multi-walled carbon nanotubes

New nanocomposite microporous materials obtained by adding functionalized multi-walled carbon nanotubes to styrene/vinylbenzyl chloride/divinylbenzene hyper-crosslinked resins were prepared and characterized.

Care-related pain in hospitalized patients: severity and patient perception of management

BACKGROUND

Hospitalized patients commonly undergo painful procedures, but little is known about care-related pain (CRP) in the overall population of inpatients. We conducted a cross-sectional 1-day survey to assess the prevalence and characteristics of CRP and its management in all units of a university hospital in Paris and determined the factors linked to severe CRP.

METHODS

All patients who were able to communicate and were hospitalized for at least 24 h but not in a day-care or neonatal unit were included.

RESULTS

From 938 patients who completed the questionnaire, 554 patients reported pain within the previous 24 h, for a 59% prevalence of pain, and 540 (58%) had experienced CRP in the previous 15 days (51% males; mean [SD] age 54 [18] years). Of 907 procedures, 330 (37%) resulted in severe pain. The most-often reported painful procedures were vascular punctures and patient mobilization. Severe CRP was associated with long hospitalization; non-vascular invasive punctures, catheterization, mobilization or radiological examination; or pain during the previous 24 h due to surgery or treatment. Only half of the patients declared that they had received information regarding the painful procedure. Treatment for pain was proposed and delivered in less than one quarter of cases.

CONCLUSIONS

Our results of a survey of pain management in hospitalized patients relate to a wide variety of medical conditions and procedures. Health-care workers should be more systematic in managing CRP, and attention should be paid to patients at greatest risk of severe CRP.

Spontaneous assembly of carbon-based chains in polymer matrixes through surface charge templates

Stable chains of carbon-based nanoparticles were formed directly in polymer matrixes through an electrode-free approach. Spontaneous surface charges were generated pyroelectrically onto functionalized ferroelectric crystals, enabling the formation of electric field gradients that triggered the dipole-dipole interactions responsible for the alignment of the particles, while embedded in the polymer solution. The phenomenon is similar to the dielectrophoretic alignment of carbon nanotubes reported in the literature. However, here the electric fields are generated spontaneously by a simple heat treatment that, simultaneously, aligns the particles and provides the energy necessary for curing the host polymer. The result is a polymer sheet reinforced with well-aligned chains of carbon-based particles, avoiding the invasive implementation of appropriate electrodes and circuits. Because polymers with anisotropic features are of great interest for enhancing the thermal and/or the electrical conductivity, the electrode-free nature of this technique would improve the scaling down and the versatility of those interconnections that find applications in many fields, such as electronics, sensors, and biomedicine. Theoretical simulations of the interactions between the particles and the charge templates were implemented and appear in good agreement with the experimental results. The chain formation was characterized by controlling different parameters, including surface charge configuration, particle concentration, and polymer viscosity, thus demonstrating the reliability of the technique. Moreover, micro-Raman spectroscopy and scanning electron microscopy were used for a thorough inspection of the assembled chains.

Effect of gliclazide immobilization into layered double hydroxide on drug release

This paper deals with a new hydrotalcite-like compound used as a matrix to improve dissolution rate of the poorly water-soluble drug gliclazide and to administer at the same time micro- and oligo-elements useful to improve insulin performance. Gliclazide is a second-generation sulfonylurea compound used in the treatment of type II diabetes mellitus. As a consequence of the poor water solubility, its absorption is limited. Thus, a new hydrotalcite-like compound containing Zinc and Chromium, micronutrients directly involved in the physiology of insulin and in the carbohydrate, lipid and protein metabolism, was synthesized. The gliclazide-hydrotalcite-like clay nanohybrid was prepared via ion-exchange in its nitrate form and was characterized by inductively coupled plasma-optical emission spectrometry and thermogravimetric analysis. The drug loading resulted in 42.9% (w/w). As a consequence of the intercalation, the interlayer distance of the host increased from 0.89 nm (interlayer distance of nitrate form) to 1.5 nm. The intercalation product was submitted to solubility measurements and in vitro dissolution test. A remarkable improvement of the apparent solubility and dissolution rate in comparison to the crystalline drug was observed in acid fluids (pH 1.2 and 3). The presence of chromium and zinc cations was also found in the medium. These results showed that the hybrid nanostructure could represent a promising system to improve drug dissolution rate and to release cations involved in the performance of insulin.

Post-irradiation malignant fibrous histiocytoma of the larynx: A case report with an unusual metastatic spread pattern

We report a case of a laryngeal malignant fibrous histiocytoma (MFH) that showed an uncommon clinical behavior. This tumor occurred in a 70-year-old male patient 5 years after radiation treatment for laryngeal squamous cell carcinoma, and unusual metastases were spread unusually to the pleural cavity. The interval between the end of radiotherapy and the onset of MFH can be justified by the development of laryngeal stenosis by fibrotic tissue as a late complication of radiotherapy. Laryngeal fibrosis after radiotherapy probably triggered the MFH. Neither computed tomography nor magnetic resonance imaging differentiate between fibrotic tissue and MFH, and only repeated biopsy was definitive to give us the correct diagnosis.

Improvement of dissolution rate of piroxicam by inclusion into MCM-41 mesoporous silicate

The aim of the present paper was the use of mesoporous silicate MCM-41 to increase the dissolution rate of piroxicam, a non-steroidal anti-inflammatory drug-class II of the Biopharmaceutic Classification System. The inclusion/adsorption compound of piroxicam in MCM-41 was obtained with a drug loading of about 14%. X-ray powder diffraction and differential scanning calorimetry (DSC) revealed the presence of piroxicam not arranged in crystalline form and FT-IR spectroscopy showed the presence of light interactions (hydrogen bonds) between the silicate silanols and the drug. The decrease of Brunauer, Emmett and Teller (B.E.T.) specific surface area and pore volume between free MCM-41 and the inclusion/adsorption compound was a prove of the presence of piroxicam inside the mesopores. The inclusion compound was submitted to in vitro dissolution tests and a remarkable dissolution rate improvement was observed in comparison to the crystalline drug in all tested conditions. The dissolution profile at pH 1.2 was comparable to that of the marketed product Brexin, a formulation with rapid analgesic effect onset. The improvement of dissolution rate is due to both the lack of drug in the crystalline form and to the extremely large surface area of the siliceous support. Physical stability tests of the free drug and the inclusion/adsorption complex were conducted as well over one month storage at 40 degrees C at different relative humidity.

Transthoracic repair of Morgagni's hernia: a 20-year experience from open to video-assisted approach

BACKGROUND

Foramen of Morgagni's hernia is an uncommon congenital diaphragmatic hernia. Repair is mostly performed through laparotomy. We prefer the transthoracic approach, which allows better and safer control during thoracic dissection, although it is considered more painful and related to greater morbidity. In recent years we introduced the transxiphoid hand-assisted videothoracoscopic approach, which combines the advantages of the thoracic route with a mini-invasive procedure facilitated by one hand inside the chest.

METHODS

A retrospective review was performed over a 20-year period (1985-2005). Twenty-two patients who had a foramen of Morgagni's hernia repaired were identified and relevant data were collected. Average age was 57 +/- 10 years and one half of the patients were asymptomatic. Chest roentgenograms, chest computerized tomography, and barium enema were used as diagnostic utilities. Posterolateral thoracotomy was performed in 17 (15 right-sided) patients, whereas in 5 (all right-sided) the defect was repaired by transxiphoid hand-assisted videothoracoscopy. Operative time, pain scored by visual analog scale, hospital stay, and cosmetic results by acceptance score were reviewed for every patient.

RESULTS

Hernial sac was present in all cases and contained only omentum (n = 13), omentum plus transverse colon (n = 7), omentum plus transverse colon and small bowel (n = 2). In 6 patients (2 videothoracoscopy) we repaired the large defects with polypropylene mesh. Videothoracoscopy achieved significant good results compared to thoracotomy in operative time (85 +/- 7.9 versus 110 +/- 11.3 min, p < 0.01), 24-h visual analog scale (3.5 +/- 1.1 versus 6.7 +/- 3.9, p < 0.01), hospital stay (2.6 +/- 0.5 versus 6.4 +/- 1.2 days, p < 0.01), and acceptance score (4.3 +/- 0.5 versus 3.1 +/- 0.8, p < 0.05). Postoperative course was always uneventful. Patients were followed for an average period of 58.6 +/- 14.7 and 109.7 +/- 43.5 months, respectively: no recurrences were found in any group.

CONCLUSIONS

We believe that the transthoracic approach is a safe and effective method for repairing Morgagni's hernia. The videothoracoscopic approach is a promising alternative and it may be facilitated by introducing a hand inside the chest.

Intercalation of the radical scavenger ferulic acid in hydrotalcite-like anionic clays

Hydrotalcite is a biocompatible lamellar anionic clay formed by double hydroxide layers with a metal cation coordinating four OH groups. The different layers are held together by anionic hosts that can be replaced by a simple ion-exchange process. The synthetic Mg-Al-hydrotalcite was used to intercalate ferulic acid, a compound that shows antioxidant properties due to its free radical scavenger capacity. Analysis of the intercalated compound showed a good intercalation percentage (35.53%) accompanied by an increase of the interlayer space from 7.8A (chloride form) to 17.1A due to the presence of the ferulate. The intercalation product was stable in water, did not show any significant degradation after UV-irradiation, had a higher capacity of UV absorption in comparison to both the pure ferulic acid and ferulic acid-hydrotalcite chloride physical mixture. The intercalated compound was formulated in a siliconic cream and the ferulate in vitro release profiles determined.

Impact of lung volume reduction surgery versus rehabilitation on quality of life

This study aims at evaluating the effects of lung volume reduction versus respiratory rehabilitation on quality of life, assessed by three different questionnaires. Sixty emphysematous patients were randomised by computer to receive either surgery (n = 30) or rehabilitation (n = 30). Life quality was evaluated by the Nottingham Health Profile, the Short Form (SF)-36 item and the St George's questionnaires. As reported previously, dyspnoea index, forced expiratory volume in one second, residual volume, 6-min walk test and arterial oxygen tension improved after surgery more than after rehabilitation. Quality of life was significantly improved after surgery as follows Nottingham Health Profile physical mobility; SF-36 physical and social functioning, mental and general health, emotional role; St George's general, activity. At multivariate analysis 6- and 12-month changes after surgery of Short Form-36 physical functioning, general health, and St George's activity domains were significantly correlated with forced expiratory volume in one second, while Short Form-36 social functioning and Nottingham Health Profile isolation correlated with residual volume. Functional and especially symptomatic improvements persisted: dyspnoea index, residual volume, and Short Form-36 and St Georges's physical scores were still significant at 4 yrs. Surgery produces greater and longer effects than rehabilitation on quality of life by improving both physical and psychosocial domains. Symptomatic improvements persisted at 4 yrs.

Prognostic value of immunohistochemical expression of p53, bax, Bcl-2 and Bcl-xL in resected non-small-cell lung cancers

AIMS

Some experimental evidence suggests that in lung cancer, development, progression and an increased proliferation rate can be linked to apoptosis-related factors. In this study we evaluated the possible role of p53 and Bcl-2 gene family members as prognostic factors for non-small-cell lung cancer.

METHODS AND RESULTS

We investigated the immunohistochemical expression of p53 and Bcl-2 gene family members (bax, Bcl-2 and Bcl-xL) in 94 non-small-cell lung cancer specimens to establish the role of these genes in lung cancer pathogenesis, and to evaluate their prognostic importance. The expression of Bcl-2 was correlated with a shorter patient survival time and with the nodal status of the neoplasm. We also found frequent over-expression of bax and Bcl-xL to be of no prognostic significance. Finally, we found no correlation between frequent detection of aberrant p53 protein and expression of either Bcl-2, bax or Bcl-xL or with patient survival time.

CONCLUSIONS

This study confirms a relevant role for apoptosis-regulatory proteins in the pathogenesis of lung cancer, and highlights the possible role of Bcl-2 as a prognostic factor for this tumour.

Prognostic impact of VEGF, CD31, CD34, and CD105 expression and tumour vessel invasion after radical surgery for IB-IIA non-small cell lung cancer

AIMS

To evaluate the prognostic impact of tumour angiogenesis assessed by vascular endothelial growth factor (VEGF), microvessel density (MVD), and tumour vessel invasion in patients who had undergone radical resection for stage IB-IIA non-small cell lung cancer (NSCLC).

METHODS

Fifty one patients (42 men, nine women; mean age, 62.3 years; SD, 6.9) undergoing complete surgical resection (35 lobectomy, 16 pneumonectomy) of pathological stage IB (n = 43) and IIA (n = 8) NSCLC were evaluated retrospectively. No patient underwent postoperative chemotherapy or neoadjuvant treatment. Tumour specimens were stained for VEGF and specific MVD markers: CD31, CD34, and CD105.

RESULTS

VEGF expression significantly correlated with high CD105 expression (p < 0.0001) and tumour vessel invasion (p = 0.04). Univariate analysis showed that those patients with VEGF overexpression (p = 0.0029), high MVD by CD34 (p = 0.0081), high MVD by CD105 (p = 0.0261), and tumour vessel invasion (p = 0.0245) have a shorter overall survival. Furthermore, multivariate Cox regression analysis showed that MVD by CD34 (p = 0.007), tumour vessel invasion (p = 0.024), and VEGF expression (p = 0.042) were significant predictive factors for overall survival. Finally, the presence of both risk factors, tumour vessel invasion and MVD by CD34, was highly predictive of poor outcome (odds ratio, 3.4; 95% confidence interval, 1.7 to 6.5; p = 0.0002).

CONCLUSIONS

High MVD by CD34 and tumour vessel invasion are more closely related to poor survival than the other neoangiogenetic factors in stage IB-IIA NSCLC. This may be because these factors are more closely related to the metastatic process.

Analysis of cell cycle regulator proteins in non-small cell lung cancer

BACKGROUND/AIMS

Abnormalities of the proteins involved in cell cycle checkpoints are extremely common among almost all neoplasms. This study aimed to investigate the expression of four components of the cell cycle machinery-p21, p16, p53, and proliferating cell nuclear antigen (PCNA)-in non-small cell lung cancer (NSCLC).

METHODS

The expression of p21, p16, p53, and PCNA was examined in 68 well characterised NSCLC specimens using immunohistochemistry. The coregulation of these proteins and their influence on survival were analysed using both univariate and multivariate analyses.

RESULTS

By univariate analysis, the expression of all the proteins examined, except for PCNA, was significantly correlated with survival. In multivariate analysis, the only immunohistochemical parameter able to influence overall survival was p16, confirming the hypothesis that the RB-p16 tumour suppressor pathway is inactivated in most lung cancer samples. Finally, the group of patients with NSCLC who were negative for both p21 and p16 had a significantly shorter overall survival.

CONCLUSIONS

These results suggest that loss of control of cell cycle checkpoints is a common occurrence in lung cancers, and support the idea that functional cooperation between different cell cycle inhibitor proteins constitutes another level of regulation in cell growth control and tumour suppression.

Fatal thrombocytopenia and thrombocytopathia: an unusual onset of non-small cell lung cancer

BACKGROUND

Although bone marrow is a common site of micrometastases for non-small cell lung cancer (NSCLC), thrombocytopathia and hemorrhagic diathesis are rare causes of death.

CASE REPORT

A 57-year-old patient was admitted to the emergency room because of massive nosebleeding and hemoptysis. Routine blood analysis showed thrombocytopenia and prolonged bleeding time; results of functional platelet tests suggested concomitant thrombocytopathia. Routine chest X-ray revealed an 18 mm large spot in the right superior lobe. During the first hour of recovery the patient had another episode of nosebleeding. A bone marrow biopsy showed a wide infiltration with neoplastic cells. Histology was compatible with NSCLC. The clinical conditions and hematological parameters progressively deteriorated, and on the third day the patient died because of hypovolemic shock.

CONCLUSION

This is a very rare clinical presentation of NSCLC characterized by massive bleeding due to thrombocytopenia and thrombocytopathia secondary to wide bone marrow infiltration.

Soluble selectin levels in patients with lung cancer

Increased expression of selectins has been found on endothelial cells of venules and capillaries in the tumor stroma of non-small cell lung cancer, suggesting their functional role in the process of chemotaxis for tumor cells. The present study was aimed at analyzing the role of both soluble (s)P-selectin and sE-selectin levels in association with clinico-pathological variables in 116 patients with lung cancer, 38 patients with benign diseases and 59 healthy donors. The results obtained showed that sP-selectin and sE-selectin levels were higher in patients with lung cancer compared to normal donors (p<0.02 and p<0.005, respectively). No differences were observed among patients with various benign diseases for both selectins. Increased levels of sP-selectin and sE-selectin were significantly associated with squamous lung cancer at late stages (p<0.05), but not adenocarcinoma. Both sP- and sE-selectin were independently related to the stage of squamous lung cancer by stepwise regression analysis (p<0.02 and p<0.03, respectively), while only sE-selectin was independently related to the presence of distant metastasis in the same histotype (p<0.02). These results suggest that measurement of plasma soluble selectins might represent a useful laboratory parameter in the management of patients with squamous lung cancer.

Prolonged survival after extracranial metastasectomy from synchronous resectable lung cancer

BACKGROUND

Combined resection of solitary synchronous brain metastases and non-small-cell lung cancer has been shown to be successful. Thus, we proposed combining the surgery of solitary, extracranial metastases, and resectable lung cancer.

METHODS

Between March 1987 and December 1994, surgery was performed on nine patients with non-small-cell lung cancer with synchronous, solitary, extracranial, or distant metastasis: adrenal (n = 5), cutaneous (n = 2), axillary lymph node (n = 1) and kidney (n = 1). Criteria for operating on these patients included: primary tumor that was locally resectable in a radical manner, non-small-cell histology, no preoperative evidence of N2 disease, complete resection of histologically proven metastasis, and absence of other metastases found with computed tomography or bone scan.

RESULTS

Resection of the primary tumor and solitary metastases was achieved in all patients. Primary tumor was always resected by lobectomy. No mortality or major morbidity was reported. Five-year survival rate was 55.6%. Five patients who had adrenal (n = 3), or skin (n = 1), or axillary (n = 1) metastases, survived more than 5 years. All N2 patients (n = 2) died.

CONCLUSIONS

The presence of solitary, distant metastasis should not be considered, per se, a factor for denying surgery for locally resectable, non-small-cell lung cancer. Unexpected, prolonged survival was demonstrated in our limited series.

Postoperative adjuvant therapy for stage IB non-small-cell lung cancer

OBJECTIVE

Although surgical resection alone is considered adequate treatment in stage IB non-small-cell lung cancer (NSCLC), long-term survival is not satisfactory and the recurrence rate is quite high. The validity of postoperative chemotherapy at stage IB in terms of disease-free and overall survival was assessed in a randomised trial.

METHODS

The trial was designed as a randomised, two-group study with postoperative adjuvant chemotherapy versus surgery alone as control group. All patients had stage IB disease (pT2N0) assessed after a radical surgical procedure. Chemotherapy consisted of treatment with cisplatin (100 mg/m(2) on day 1) and etoposide (120 mg/m(2) on days 1--3) for a total of six cycles.

RESULTS

Between January 1988 and December 1994, 66 patients were included in the study. Thirty-three belonged to the adjuvant chemotherapy group and 33 to the control group. Groups were homogeneous for conventional risk factors. There was no clinical significant morbidity associated to chemotherapy. Patients were followed for a minimum period of 5 years. The rates of locoregional recurrence and distant metastases were 18 and 30%, respectively, in the adjuvant chemotherapy group and 24 and 43%, respectively, in the control group. The 5-year disease-free survival rates were 59% in the adjuvant group and 30% in the control group (P = 0.02). The difference in the Kaplan--Meier survival between the groups was significant as assessed using the log-rank test (P = 0.04).

CONCLUSIONS

Our results suggest that adjuvant chemotherapy may reduce recurrences and prolong overall survival in patients at stage IB NSCLC deemed radically operated. Despite being difficult to accept, the use of adjuvant chemotherapy might have better long-term results.

Transxiphoid bilateral palpation in video-assisted thoracoscopic lung metastasectomy

OBJECTIVE

To evaluate indications, limits, and merits of transxiphoid bilateral palpation during video-assisted thoracoscopy (VAT) lung metastasectomy.

DESIGN

Survey retrospective study with a minimum follow-up of 1 year.

SETTING

University hospital.

PATIENTS

From December 1995 to September 1999, 29 of 45 patients operated on for pulmonary metastasectomy were approached through a transxiphoid VAT. Primary sites were colon-rectum (n = 13), kidney (n = 4), limb osteosarcoma (n = 3), uterus (n = 2), larynx (n = 2), breast (n = 1), skin melanoma (n = 1), prostate gland (n = 1), back fibrosarcoma (n = 1), and ovary (n = 1). Bilateral palpation was performed in 23 patients, although only 10 had radiological evidence of bilateral disease.

RESULTS

No perioperative or 30-days postoperative mortality was recorded. Acute and chronic pain was similar to that of other VATs and significantly less than sternotomy. Mean +/- SD chest-drain time and hospital stay were 2.8 +/- 1.19 days and 4.3 +/- 1.78 days, respectively. Sixty-nine lesions, 60 of them metastatic, were resected by laser (n = 29) or stapler (n = 40). Bilateral exploration permitted the discovery of 15 radiologically undetected lesions, 11 of which were found to be malignant. Contralateral metastases were found in 5 patients predicted to have unilateral disease. Mean +/- SD follow-up was 22.89 +/- 10.87 months (range, 9-60 months). Six patients developed new pulmonary metastases after a mean interval of 13.6 months; 3 of these patients relapsed in the unexplored hemithorax after 6, 9, and 12 months, respectively.

CONCLUSIONS

The use of the transxiphoid VAT approach was safe, applicable in many instances, and effective in detecting occult metastases by manual bilateral palpation. The advantages of a VAT procedure can be coupled with those provided by a radical operation.

Intercalation compounds of hydrotalcite-like anionic clays with antiinflammatory agents — I. Intercalation and in vitro release of ibuprofen

Hydrotalcite-like compounds are layered solids having positively charged layers and interlayer charge-compensating anions. The synthetic Mg0.67Al0.33(OH)2 Cl0.33.0.6H2O, which is biocompatible, has been used to intercalate a model drug, ibuprofen, in order to prepare a modified release formulation. The intercalation compound was prepared via ion-exchange starting from the chloride form of hydrotalcite and its composition, determined both by elemental microanalysis and thermogravimetric analysis, was Mg0.67Al0.33(OH)2IBU0.33.0.47H2O, drug content 50% (w/w). As a consequence of the intercalation, the interlayer distance of the host increased from 0.78 nm (interlayer distance of chloride form) to 2.17 nm. The result of dissolution tests at pH 7.5 showed that the in vitro drug release was modified if compared with that obtained with comparative formulations. The mechanism of modified drug release has been interpreted on the basis of the ion exchange process of the ibuprofen anion intercalated in the lamellar host and phosphates contained in the intestinal fluid buffer.

How to improve the readability of the patient package leaflet: a survey on the use of colour, print size and layout

This paper displays the results of the second part of a survey about patient information and the use of the patient package leaflet. The aim of this research is to investigate the consumers' attitude towards written information. As the formal aspects of the written message are very important in communication, we prepared a questionnaire in order to evaluate the attitude of patients towards some typographical modifications. Patients were invited to give indications about which colours could be used in the different paragraphs of the package leaflet and which print size could be easily read. All people interviewed were asked to choose a colour, from six proposed by us, to be used for 'therapeutic indications', 'side effects', 'how to use', 'paediatric use', 'contraindications', 'use in pregnancy' and 'warnings'. Clear suggestions for the choice of colours for therapeutic indications, side effects and contraindications arose from the survey. In the other cases there was no uniformity of answers. All people complained that the print size used in the package leaflet is too small and suggested 10 and 11 points Didot. Finally, from the survey it emerged that people would appreciate a more detailed package leaflet but information should be given in a schematic and concise way.

Microporous material from kanemite for drug inclusion and release

A microporous material obtained from kanemite, a layered polysilicate, was studied in order to investigate its feasibility of including drugs and then releasing them. Diphenydramine hydrochloride was chosen as a model drug. The preparation of the microporous material and its loading with the drug are described. As kanemite is able to intercalate anions between its layers, the intercalation compound of diphenydramine and kanemite was also prepared. Both the drug-loaded microporous material and the intercalation compound were submitted to dissolution tests at pH 7.5. The drug release profiles from these two different materials and from a physical mixture were compared.

Skin metastases in lung cancer: analysis of a 10-year experience

We reviewed our 10-year experience in skin metastases from lung cancer. We identified a total of 26 patients with 49 resected skin metastases. Skin metastases were synchronous in 6 patients, 3 of whom underwent primary simultaneous resection, and solitary in 6 (6/26=23.07%). Negative prognostic factors were primary non-resectability (p=0.001), small cell lung cancer (p=0.032), simultaneous discovery of other cutaneous (p=0.048) or extracutaneous (p=0.0005, Wald test p<0.002, Odds ratio =14.37) metastases. Skin metastasis represented the unique distant localization in almost one quarter of our cases that represent the best-survivor category: in these patients skin metastasectomy is justified.

Pulmonary metastasectomy: might the type of resection affect survival?

BACKGROUND AND OBJECTIVES

Metastasectomy proved to be the choice treatment in the case of pulmonary metastasis. In this study we assessed the impact on survival of three types of resection: minimal by laser or conventional device and lobectomy.

METHODS

We considered 85 patients who underwent lung metastasectomy for tumors that originated from various sites. Fifty-two minimal resections were accomplished in 34 patients by conventional (diathermy dissection or stapler suture line) device, 59 resections in 29 by Nd:YAG laser. Lobectomies were 22. Minimum follow up required was 2 years.

RESULTS

The 3-year Kaplan-Meier survival rate was 63%, 44%, 53% for laser, conventional resections and lobectomy. The 5-year survival was 40%, 28%, 26% respectively. Among the groups there was no significant difference (P = 0.15). Laser patients showed shorter periods of air leakage and hospital stay.

CONCLUSIONS

The type of resection did not disclose statistically significant differences on survival. Minimal surgery, especially by laser device, is recommended for less morbidity.

Transxiphoid video-assisted pulmonary metastasectomy: relevance of helical computed tomography occult lesions

BACKGROUND

The new transxiphoid video-assisted approach allows manual palpation of both lungs, thus permitting better evaluation of helical computed tomography (CT) in detection of pulmonary metastases.

METHODS

From December 1995 to May 1999, 22 patients underwent a transxiphoid video-assisted pulmonary metastasectomy. Manual palpation of both lungs was possible in 18 patients, whereas only 13 had radiologic evidence of unilateral disease. Primaries were colon-rectum (n = 8), kidney (n = 3), uterus (n = 2), larynx (n = 2), limb osteosarcoma (n = 2), and one each of breast, skin melanoma, prostate, fibrosarcoma, and ovary.

RESULTS

No perioperative death occurred. Fifty-eight lesions, 49 metastatic, were resected, whereas only 46 had been predicted by helical CT scan. Twelve occult lesions were discovered, eight of which were malignant. Overall sensitivity for proved metastases was 83.7% (41 of 49) and 75.8% (22 of 29) for those less than or equal to 5 mm. Mean follow-up was 15.27 months. Only 2 patients had pulmonary relapse at 6 and 12 months.

CONCLUSIONS

Despite helical CT, occult metastases may still be identified in almost one-third of the patients. The transxiphoid approach allows routine bilateral palpation and safe resection, and overcomes this critical limitation of video-assisted metastasectomy.

Comprehensibility of the package leaflets of all medicinal products for human use: a questionnaire survey about the use of symbols and pictograms

Directive 92/27EEC establishes that the package leaflet is a document, which must be included in the package of medicinal products for human use in EU countries. This informative leaflet is directed at the users and it must give full and comprehensible information. The Law suggests the use of symbols but it does not give advice about the subjects to be represented. In order to evaluate the attitude of patients towards package leaflets provided with symbols, we planned a survey interviewing 1004 patients in pharmacies. The data suggest that Italian patients usually read the package leaflet but they neither understand it easily nor find the needed information readily. Most respondents (74.3%) considered the use of symbols helpful in finding the needed information. We proposed five symbols for each heading (therapeutic indications, side effects, paediatric use, contraindications, use in pregnancy) and asked to select which symbol could be used. In the case of 'side effects', 'paediatric use', 'use in pregnancy' and 'dose', most of the respondents chose the same symbol. In the case of 'therapeutic indications' and 'contraindications' there was no uniformity in the answers. The choice depends greatly on education, age and employment of respondents.

The diaphragmatic flap: A multiuse material in thoracic surgery

BACKGROUND

The use of diaphragmatic pedicle flaps for reconstructive procedures in thoracic surgery is not very popular. Nevertheless, it provides considerable advantages.

METHODS

Our experience covers 10 years (1987-1997) with a total of 25 patients in whom the diaphragmatic flap was used for different purposes. In 6 patients we used the diaphragmatic flap to protect the bronchopleural fistula at its early onset, which was not beyond 12 hours from the clinical diagnosis. We performed prophylactic suture protection after neoadjuvant therapy in 9 high-risk patients who underwent pneumonectomy and in 2 who underwent sleeve lobectomy. Postpneumonectomy pericardial defect repair was performed in 4 patients. In another 4 patients the diaphragmatic flap was used after spontaneous (n = 2) and iatrogenic (n = 2) lesions of the esophagus after 24 to 72 hours.

RESULTS

No perioperative mortality was recorded. Complications were mainly related to the severe preoperative conditions of the patients: arrhythmia, respiratory insufficiency, and empyema. We report only 2 cases of minimal persistent bleeding from the chest tube, which spontaneously ceased. For those patients who survived for more than 1 year (n = 11), no diaphragmatic hernias were recorded. Bronchopleural fistulas and pericardial defects healed in all instances. The diaphragmatic flap was also effective in bronchopleural fistula. A late fistula caused by cancer relapse at the bronchial stump developed in only one patient. Excellent repair was achieved in all patients with esophageal lesions.

CONCLUSIONS

We conclude that the diaphragmatic flap can be considered a practical, safe, and redundant material particularly indicated for defect or fistula closure and for suture line protection in the thoracic cavity.