Leiomyoma of the Esophagus

A review of the clinical records from 1947 to 1984 of the Istituto Nazionale Tumori of Milan provided 20 cases (14 males and 6 females) of esophageal leiomyoma. Eighteen of the tumors were in the thoracic esophagus and 2 were at the cardiac level. The most frequent symptoms were dysphagia, slight epigastralgia and odynophagia. Differential diagnosis should be made with mediastinic neoplasms and esophageal cancer. Barium swallow and esophagoscopy are the most sensitive procedures for a correct preoperative diagnosis. Surgery is mandatory because of the tendency to a continuous endoluminal growth (in 97% of the cases) and a possible malignant transformation. However, surgery is conservative: extramucosal enucleation of the leiomyoma is the procedure of choice. The long-term results are excellent, and morbidity is acceptable.

Late Results after Sleeve or Wedge Lobectomies for Non-Small-Cell Lung Carcinoma

From January 1971 to June 1983, 35 lobectomies with bronchoplastic procedures for invasive non-small-cell lung carcinoma were performed. Sleeve lobectomy was carried out in 21 cases, wedge lobectomy in 11, and upper sleeve bilobectomy in 3. There were 23 stage I, 10 stage II, and 2 stage IIIa tumors. Completion pneumonectomy was required in 1 case for anastomotic fistula and in 2 for atelectasis of residual lung. One of these patients died later due to empyema. The 5-year probability of death with recurrence was 31.98%. The 5-year disease-free survival was 58.57%. Metastatic relapse was observed in 8 cases and locoregional recurrence in 5. A new primary lung tumor occurred in 2 patients.

Efficacy and safety of fibrin sealant patch in the treatment of air leakage in thoracic surgery

AIM

Air leakage represents a major problem in lung surgery. Absorbable fibrin sealant patch (AFSP), a collagen sponge coated with human fibrinogen and thrombin, can be used as an adjunct to primary stapling or suturing. This study compared the efficacy of AFSP with manual suturing after primary stapling.

METHODS

This was a prospective, multicenter, randomized study. Patients undergoing lobectomy, bilobectomy, anatomical segmentectomy for lung cancer or wedge resection for pulmonary metastasis with air leakage grade 1 or 2 according to Macchiarini scale after stapler suture were randomized to receive AFSP or standard surgical treatment (ST). The primary endpoint was the reduction of intraoperative air leakage intensity. Duration of postoperative air leakage and number of days until removal of last chest drain were secondary endpoints. Safety was recorded for all patients.

RESULTS

A total of 346 patients were enrolled in 14 centres, 179 of whom received AFSP and 167 ST. Intraoperative air leak intensity was reduced in 90.5% of AFSP patients and 82% of ST patients (P=0.03). A significant reduction in postoperative air leakage duration was observed in the AFSP group (P=0.0437). The median number of days until removal of last drainage was 6 (3-37) in the AFSP group and 7 (2-27) in the ST (P=0.38). Occurrence of adverse events was comparable in both groups.

CONCLUSION

AFSP was more efficacious than standard ST as an adjunct to primary stapling in reducing intraoperative air leakage intensity and duration of postoperative air leakage in patients undergoing pulmonary surgery. AFSP was well tolerated.

Penetration of amphotericin B in human lung tissue after single liposomal amphotericin B (AmBisome) infusion

The distribution of amphotericin B in lung tissue was studied in 18 patients with primary or secondary lung cancer who underwent thoracotomy and pulmonary resection. At different times before surgery the patients were treated with liposomal amphotericin B 1.5 mg/kg by i.v. infusion over 1h. Blood and lung tissue samples were collected during surgery (one subject for each collecting time) and assayed for amphotericin B levels by HPLC. Due to surgical requirements, it was possible to obtain data from the 10th to the 25th h after the end of infusion. Plasma amphotericin B concentrations progressively decreased from 3.4 microg/ml at the 10th h to 1 microg/ml at the 25th h after the end of intravenous infusion. In lung tissue samples the lowest amphotericin B concentration (about 1 microg/g) was observed at the 10th h, then a progressive increase was observed with the highest value (2.5 microg/g) determined at the 25th h.

Minimally Invasive Thoracic Surgery for Diagnostic Assessment and Palliative Treatment in Recurrent Neoplastic Pleural Effusion

BACKGROUND

We evaluated the effectiveness of VATS in the diagnosis and palliative treatment of recurrent neoplastic pleural effusions.

METHODS

From 1987 to 2001, we performed 325 VATS chemical pleurodesis for malignant pleural effusions. We used talc in 253 subjects (78 %) and alcohol in 72 (22 %) as the sclerosant agent. In 226 patients (68 %) we performed biopsies because the histology was unknown.

RESULTS

Mean operating time was 33.38 +/- 9.77 minutes (median: 32; range: 19 - 58), and the mean duration of chest intubation was 3.78 +/- 1.33 days (median: 4; range 2 - 8). Complications occurred in 2 % of patients. Thirty-day mortality was 2 %. Mean postoperative in hospital stay was 5.53 +/- 1.90 days (median 6; range: 2 - 11). We obtained 264 (81 %) therapeutic successes (no effusion recurrence within 4 months), and 55 relapses of which 32 had talc insufflation (13 % of talc group) and 23 alcohol instillation (32 % of alcohol group).

CONCLUSIONS

VATS chemical pleurodesis is a safe, useful, versatile procedure for oncological pleural effusion management. The use of talc rather than alcohol significantly increased the therapeutic success rate. VATS should be considered the treatment of choice in patients with advanced neoplasm to obtain good palliation and a better quality of life.

The difficult approach to neoplastic superior vena cava syndrome: surgical option

AIM

Superior vena cava syndrome is a dramatic event that can be cured in specialized centers.

METHODS

Between 1989 and 1995 6 patients with superior vena cava syndrome underwent surgical treatment for thoracic tumors. In all cases the vena was restricted by a neoplastic sleeve. A median sternotomy was performed in all cases. Two patients received an associated right anterolateral thoracotomy to obtain good surgical exposure for tumor resection and grafting. A 12 mm diameter polytetrafluoroethylene graft was inserted in all cases. The tumor resection was radical in 4 cases (2 thymic carcinomas, 2 malignant germ cell tumors) and palliative in 2 (1 non-small cell lung cancer and 1 mediastinal fibrosis).

RESULTS

We had no in-hospital mortality. All patients had immediate relief of obstruction after by-pass. Three patients were alive without disease at the end of follow-up (40-96 mo), one patient died of postoperative complications after 4 mo, 2 patients died of disease after 4 and 12 mo.

CONCLUSION

PTFE by-pass graft for treatment of the obstructed SVC relieves SVC syndrome and has good medium term patency.

[The role of surgical therapy for esophageal microcytoma. Experience of there clinical cases and results analysis]

Small cell carcinoma of the esophagus is a rare tumor. It was described for the first time in 1952 by McKeown and 200 cases have been reported till now. Because of its similarity with small cell carcinoma of the lung, the treatment of this tumor is controversial. In our Institute we treated three patients with small cell carcinoma of the esophagus. All subjects underwent subtotal esophagectomy with esophagogastroanastomosis through laparotomic and thoracotomic approach. Histologically, the tumor was classified as pure SCEC in one patient and mixed SCEC in the other two. The stage I and II patients received operation as single treatment. The two patients are alive and disease free 219 and 193 months after surgery. The third patient, classified at stage III, underwent postoperative chemotherapy but local and distant recurrence was observed 11 months after surgical resection. He was submitted to a second choice chemotherapy, but he died 24 months after the operation. The long-term survival observed in our two patients treated by surgery is the longest described in literature. Our experience seems to demonstrate that an early diagnosis and oncological radical resection, may be helpful in the long-term prognosis even in presence of a very aggressive neoplasm.

[Biphasic blastoma of the lung. Report of 4 consecutive cases and evaluation of long-term prognosis]

Pulmonary blastoma is a rare malignant disease and it can occur in adults and in children. In 1952, Barnard reported the first case classified as pulmonary embryoma while in 1961 Spencer reported the first case as pulmonary blastoma. Since then 200 cases were described in literature. Four patients with adult primary pulmonary blastoma were treated in our Institute. The tumor was right sided in all cases; it belonged to upper lobe in 1 patient, to middle in 1 and to lower in 2. The patients underwent middle lobectomy in 1 case, lower lobectomy in 2 and upper lobe typical segmentectomy in one (the subject previously operated for lung adenocarcinoma). Histology detected primary pulmonary biphasic blastoma in all the cases. In only one case it was associated with hilar lymph nodal metastases. She received adjuvant chemotherapy, but after 17 months she developed distant metastases and she died 22 months after operation. About the other 3 patients: one patient died 6 months after intervention for acute cardiac disease, while two subjects are still alive and disease free 158 and 70 months after surgery. Surgical resection, when radicality could be ensured, is considered the treatment of choice, in absence of other curative therapies. The analysis of our experience confirms surgery to be a good therapeutic choice permitting to obtain long term survivals. The patient, alive ten years after the operation, is one of the longest survival case for pulmonary blastoma reported in literature.

Unsuspected residual disease at the resection margin after surgery for lung cancer: fate of patients after long-term follow-up

OBJECTIVE

This retrospective study evaluates the survival impact of the residual margin disease after bronchial resection for cancer and suggests tactics in cases of microresidual disease.

METHODS

Between March 1988 and 1998, 4530 consecutive patients underwent surgery for non-small cell lung cancer at our institution. Only incomplete resections after microscopic evaluation (R1) were included in the study. Residual tumour cells were found on the bronchial resection margins of 39 lobectomies, 12 pneumonectomies, 4 segmental resections and one bilobectomy. Histological findings were: squamous cell carcinoma in 38 cases, adenocarcinoma in 15 and large cell carcinoma in three. In all 56 cases, invasive mucosal carcinoma was found exclusively on the bronchial resection margin. Nineteen tumours were stage I; 12, stage II; 17, stage IIIa; 5, stage IIIb; and three, stage IV. Nineteen patients (59.3%) with early stage tumours (I and II) received adjuvant radiation therapy and only three chemotherapy.

RESULTS

The prognosis in these cases was disease-stage related (21 and 38.4% of deaths due to the disease). Forty-one percent of the stage IIIa patients received radiation therapy and 17.6% chemotherapy: 70.6% died of tumour relapse. Forty percent of the stage IIIb patients received radiation therapy and 20% chemotherapy: 60% died of disease progression. All of the stage IV patients died within 3 months from surgical resection. At the end of the study, 21 patients were alive after an interval of 22-142 months (18 in stage I or II). The 10-year actuarial survival rate was 44%. The percentage survival for stage IIIa was 16.8, after 10 years, and fell to 45 months for stage IIIb.

CONCLUSIONS

The prognosis of our stage I or II patients with microresidual tumour on the bronchial resection margin (R1) was similar to that of the patients in the same disease stage, whose resection was microscopically radical (R0) and the same was true of the patients in stage III. In patients with residual tumour cells on the bronchial stump we did not observe worsened long-term survivals.

[Use of the skin-closure system Medizip in median sternotomy in oncological patients. Evaluation of results obtained in 30 patients]

BACKGROUND

The authors evaluate effectiveness, safety and cosmetic results obtained using the new skin closing system Medizip.

METHODS

At the Thoracic Surgery Department of the National Cancer Institute (Milan) between June 1999 and March 2001, in 30 patients who underwent median sternotomy for bilateral pulmonary wedge resections, Medizip a new skin-closing system to suture the sternal wounds has been used. Twenty patients were under 30 (66%) and 6 of the 10 remaining were females. The average age was 34.25+/-21.60 years, (median: 25, range: 12-72). It took about half a minute (average time: 30.00+/-10.54 seconds) to perform all the application manoeuvres. In order to better evaluate the cosmetic results obtained, a scale of three levels was created: level 1: very good, level 2: satisfactory, level 3: inadequate.

RESULTS

Twenty-eight 20 cm-long zippers, one 25 cm-long and one 30 cm-long were employed. Medizip has been kept in site for 9.88+/-2.12 days on average (median: 9; range: 8-12). The time employed for each dressing was on average 70.00+/-21.35 seconds (median: 70, range: 46-128). No wound infections were observed even if all the patients were affected by neoplastic diseases and were immunocompromised because of lots of antiblastic treatments. The quick removal (few seconds) and the non-invasiveness of the disposal constitutes remarkable advantages. Using the criteria previously described, 26 patients at level 1 (87%), and 4 (13%) at level 2 were classified.

CONCLUSIONS

Medizip is considered to be an effective skin-closure system easy and quick to handle, assuring very good cosmetic results, with non-invasive removal, particularly useful in pediatric patients and in young adults affected by neoplastic diseases undergone to a lot of combined treatments.

A particular case with long-term follow-up of rare malignant hemangiopericytoma of the lung with metachronous diaphragmatic metastasis

The authors report the case of a woman with a primary hemangiopericytoma of the lung and successive metachronous diaphragmatic metastasis treated with surgery only according to the patient's decision. The patient was first submitted to left lower lobectomy with resection of diaphragm and three ribs en-bloc for pulmonary sarcoma. One year later, a chest computed tomography (CT) scan showed a small lesion above the diaphragm on the left side. She refused the proposed operation and returned fifteen months later with a new thorax CT, and told us that she had in the meantime become pregnant and given birth. A rethoracotomy to remove the metastatic diaphragmatic tumor was performed. Chemotherapy with anthracycline and iphosphamide was proposed, but the patient again refused therapy for fear of side effects impairing another pregnancy. Currently, the patient is alive and disease-free, 68 months after the first treatment. The authors emphasize the long-term follow-up obtained with surgery alone in this kind of rare sarcoma.

Major surgery in lung cancer in elderly patients? Risk factors analysis and long-term results

BACKGROUND

In the Oncological Thoracic Surgery Department of the Istituto Nazionale Tumori of Milan a retrospective study was performed on lung cancer patients 70 years old or more with the aim of evaluate the role of surgical treatment and to analyse long-term results.

METHODS

In our Institute from January 1988 to December 1993, 151 lung cancer patients 70 years old or more underwent surgery for lung cancer. One hundred and twenty-six of them (83%) were males and 25 were females (17%), the average age was 73.09+/-2.91 years (median: 77; range: 70-82). All the subjects were completely staged preoperatively. In order to establish operability criteria, we considered some selection parameters. Patients general conditions were evaluated using Karnofsky score accepting only the ones with 70% or more for surgery, all the cases performed cardio-respiratory functional evaluation. Patients with: a) FEV1 <60% of predicted value or FEV1 <1 l; b) PaO2 <60 mmHg e PaCO2 >40 mmHg were excluded from surgery.

RESULTS

The operations performed were: 23 pneumonectomies, 6 bilobectomies, 93 lobectomies, 13 segmentectomies and 16 wedge resections. Eight cases were submitted to thoracectomy in association to pulmonary resection. Peroperative mortality was 3% and morbidity was 10%. Histological examination showed 69 adenocarcinomas, 65 squamous carcinomas, 4 large cells carcinomas, 4 typical carcinoids, 5 small cells carcinomas, 2 mucoepidermal carcinomas and 2 adenosquamous carcinomas. Eighty-six patients were classified at stage I, 38 at stage II, 24 at stage III and 3 at stage IV (multifocal disease). The actuarial 4-years global survival predicted with Kaplan Meier method was 40%, in particular it was 75% for stage I patients.

CONCLUSIONS

In case of resectable primary pulmonary neoplasm, surgery represents the first choice therapy; patient's age doesn't seem to be an absolute contraindication, but it has to be evaluated with biological and not with age criteria. Using adequate selection criteria, it's possible to obtain, in patients older than 70 years, long-term survivals that don't seem to differ from global survivals.

Clinical and pathologic predictors of survival in patients with thymic tumors

BACKGROUND

The aim of this study is to evaluate the impact of thymectomy in patients with thymic neoplasms and to identify clinical and histopathological factors associated with improved long-term outcome of surgery.

METHODS

We treated 74 patients between February 1987 and July 1993. There were 29 total and 36 simple thymectomies. These last cases, all non-myasthenic, had benign thymomas (n=30) but 6 had thymic carcinomas. Nine tumors were no-resected (5 thymomas and 4 thymic carcinomas). Minimum follow-up by Department of Thoracic Surgery Istituto Nazionale Tumori was 60 months after thymectomy. We divided the specimens according to Marino and Muller-Hermelink's classification: 54 thymomas, 18 thymic carcinomas and 2 no-diagnosis specify thymomas. There were 53 stage I, 1 stage II, 13 stage III, 5 stage IVa and 2 stage IVb according to Masaoka.

RESULTS

Forty-six patients with treated thymoma were alive without disease at the end of follow-up, the remaining 8 died from recurrence in 6, a new tumor in 1 and a heart attack in the last. Of 18 thymic carcinomas 9 were alive at the end of follow-up (1 with recurrence), only 4 dead from recurrence. The actuarial survival of patients with thymomas was 88.5% at 5 years, (73.6% in cortical type, 85.7% in medullary type, 93.9% in mixed type, 100% in predominantly cortical type). Myasthenia gravis didn't influence the survival: 87.3 (no MG) vs 90%. Advanced stage thymomas significantly increased the risk of death from early stage I: 32.4 vs 100% at 5 years. In thymic carcinoma patients with well-differentiated thymic carcinoma (WDTC) died less than others: the actuarial probability of survival at 5 years was 90 vs 68%.

CONCLUSIONS

Thymectomy was the best treatment to long term outcome. In our experience, survival was related to histotype and to local extension of tumor.

Video-assisted thoracoscopic surgery for diagnosis, staging, and management of lung cancer with suspected mediastinal lymphadenopathy

The aim of this report was to evaluate the effectiveness of video-assisted thoracoscopic surgery (VATS) in staging, diagnosis, and treatment of lung cancer. Fifty-two patients were scheduled for mediastinal lymph node VATS biopsy at the Oncologic Thoracic Surgery Department of the National Cancer Institute in Milan. Fifty patients underwent lymph nodal thoracoscopic biopsy (96%), whereas for the other 2 patients, histologic diagnosis was done by pleural metastatic nodule thoracoscopic biopsy (4%). We performed 17 lymph nodal biopsies in level 5 (33%), 14 in level 6 (27%), 12 in level 7 (23%), and 7 in level 8 (13%). No postoperative complications were observed, and 19 subjects (36%) underwent open lung resection. The histologic diagnosis was adenocarcinoma in 25 cases (48%), epidermoid carcinoma in 14 (27%), microcytoma in 9 (17%), and giant-cell lung carcinoma in 4 (8%); 10 patients were at stage I (19%), 9 at stage II (17%), 31 at stage III (60%), and 2 at stage IV (4%). The use of VATS allowed diagnosis of the suspected involved mediastinal lymph nodes in lung cancer patients and obviated the need for painful thoracotomy, enabling accurate staging and thus selection of the optimal treatment.

[Analysis and long-term survival in sternectomy with plastic reconstruction for primary and secondary neoplasms of the sternum]

From January 1980 to December 1999, 88 patients underwent surgical resection for tumours involving the sternum. Thirty were males, aged 16 to 76 years, and 58 females, aged 23 to 78 years (mean ages: 48 and 53 years, respectively). There were 30 primary malignant tumours, 28 local recurrences or distant metastases from breast cancer, 16 other tumours, and 14 radionecroses. Total sternectomy was performed in 8 cases, subtotal (> 50%) in 32, and partial (< 50%) in 48. Concurrent en-bloc resection of the anterior ribs was performed in 61 patients, and of the clavicle in 13. Resection was extended to the lung in 22 patients, to the pericardium in 17, to both in 2, to the diaphragm and pericardium in 4. Bone and soft tissue defects were repaired with prosthetic material associated with a muscular or myocutaneous flap in 55 patients, with prosthetic material alone in 13 cases, with a muscular or myocutaneous flap in 5 cases, and with other techniques in the remaining patients. The resection was considered to be macroscopically radical in 78 patients and palliative in 10 cases. There was one perioperative mortality and significant morbidity was limited to 13 cases. Among the patients treated with a radical intent, 48 were alive and disease-free at the end of follow-up. The 10-year survival rate was 85% in primary tumours. For breast cancer relapses, 10-year survival was the same as 5-year survival (41.8%). In our experience, an en-bloc sternal resection for a primary or secondary tumour, followed by plastic repair using prosthetic material and/or a myocutaneous flap, is a safe, effective treatment. This intervention permits the execution of extensive radical resections for sternal neoplasms, as well as enabling the patient to obtain a better quality of life. Long-term survival after radical sternectomy also depends on the histological type of the tumour.

[Significance of video-assisted thoracoscopic surgery in the diagnosis and staging of primary pulmonary neoplasms]

The authors describe the usefulness of video-assisted thoracoscopic surgery (VATS) in the staging and diagnosis of primary lung cancer. In the Oncological Thoracic Surgery Department of Milan's National Cancer Institute, over the period from January 1995 to January 2000, 46 patients, suspected of having mediastinal lymphadenopathies in the presence of lung cancer, were proposed for a VATS biopsy. Forty-four patients underwent a thoracoscopic lymph node biopsy (95%), while in 2 subjects, in whom pleural metastases were found, the histological diagnosis was established by pleural metastatic nodule thoracoscopic biopsy (5%). A VATS lymph node biopsy was performed in 16 cases at level 5 (35%), in 13 at level 6 (28%), in 9 at level 7 (19%) and in 6 at level 8 (13%). Lymph node biopsies were ipsilateral in 37 patients (80%) and contralateral in 7 (15%). No postoperative complications were observed. Histological examination revealed adenocarcinoma in 23 cases (50%), epidermoid carcinoma in 12 (26%), microcytoma in 8 (17%) and giant-cell lung carcinoma in 3 (7%). Two patients were classified as stage IV (5%), 7 as stage III B (15%) and 21 as stage III A (45%). The subsequent treatment was neoadjuvant chemotherapy for stage III A patients and chemotherapy in association with radiotherapy for stage III B subjects. The patients with microcytoma underwent integrated radiotherapy and chemotherapy and pan-encephalic radiotherapy. Sixteen patients, with negative frozen-section histological findings for mediastinal lymph node neoplastic disease, underwent pulmonary resection after thoracotomy in the same operating session (35%) and were subsequently classified as stages I and II. In conclusion, VATS proved extremely useful in the diagnosis and staging of patients affected by lung cancer with synchronous lymph node enlargement. This procedure allowed the diagnosis of suspect involved mediastinal lymph nodes in all cases thus affected and the exclusion of lymph node disease in patients subsequently treated by lung resection in a single session. The precise staging obtained then made it possible to direct the patients towards the most appropriate form of treatment.

A rare complication of surgical management for esophageal tumor: a non neoplastic belated fistula between stomach and main right bronchus

The fistula between stomach and bronchus after surgery for cancer of the esophagus is a rare occurrence. We describe a gastric non neoplastic ulceration that arose late after six years from an esophagectomy, with an end-side cervical esophagogastrostomy, for a spino-cellular carcinoma. After the partial failure of surgical technique, of the endoscopic treatment and for the bad general conditions of patient we decided to treat the fistula by transluminal drainage. This technique involved a progressive resolution of the fistula, becoming, nowadays, in our division, the preferred treatment for these kinds of postoperative complications.

[Surgery in the treatment of metachronous homolateral non-small cell lung cancer]

The authors describe their experience with the surgical treatment of metachronous homolateral lung cancer by completion pneumonectomy. In the Department of Thoracic Surgery of the National Cancer Institute of Milan, over a period ranging from 1982 to 1996, 30 completion pneumonectomies were performed for local relapses or second primary tumors. The patients submitted to this intervention had a lobectomy as their first operation in 23 cases (77%), a bilobectomy in 4 (13%) and a typical segmentectomy in 3 (10%). Associated with these interventions we performed 2 en bloc chest wall resections and a contralateral wedge resection. Two subjects received neoadjuvant chemo-therapy. Histology revealed squamous carcinoma in 14 cases (47%) and adenocarcinoma in 16 (53%). Seventeen patients (57%) were classified as stage I, 8 as stage II (26%), 4 as stage III (13%) and 1 as stage IV (4%). Four patients received adjuvant chemotherapy and/or radiotherapy. Lung cancer relapse occurred as a single lesion in 27 cases (90%) and as multiple lesions in 3 (10%). We performed 18 right (60%) and 12 left (40%) completion pneumonectomies. In 1 case (4%) a sleeve pneumonectomy was necessary. Associated with these interventions we performed 5 en bloc chest wall resections. The perioperative mortality was 10% and the postoperative morbidity 40%. Histological tests showed 12 squamous carcinomas (40%) and 18 adenocarcinomas (60%). Two patients (7%) had a different histology. Disease was classified as stage I in 13 cases (44%), as stage II in 9 (30%) and as stage III in 8 (26%). Four patients received adjuvant chemotherapy and/or radiotherapy. Two subjects developed a metachronous contralateral tumor (7%). The disease-free interval was 22.70 +/- 14.69 months, with a median value of 17 months (range: 7-53 months). Mean survival after completion pneumonectomy was 49.77 +/- 49.29 months, with a median value of 26.5 months (range: 4-190 months). The 5-year actuarial survival rate, calculated using the Kaplan-Meier method, was 30%. Completion pneumonectomy is a technically very demanding intervention carrying a high risk of morbidity. On the basis of the analysis of our data, we can affirm that mean postoperative survival seems to be satisfactory and to justify this aggressive attitude towards recurrent tumor. We should stress the importance of careful evaluation of indications and precise selection of patients.

[Pulmonary metastasis of basal cell carcinoma of the skin. 3 case reports]

The Authors describe three cases of lung metastasis from a basal cell carcinoma of the skin observed in the Department of Thoracic Surgery of the National Cancer Institute in Milan. The incidence of this rare occurrence reported in the literature is approximately 0.1%, The aim of the study was to evaluate the therapeutic treatment adopted in these unusual situations. In all cases the primary basal cell carcinoma of the skin was located in the head. All three patients had several local and regional recurrences and underwent multiple surgical excisions and subsequent plastic procedures. In each case complementary radiotherapy was implemented. The metastases appeared in the lung 9, 17 and 21 years, respectively, after onset of the primary tumour as bilateral nodules in two cases and as a single nodule in one. Curative surgery was possible only in one subject, consisting in a bilateral metastasectomy via a midline sternotomy, with 5-year survival. Surgery was withheld in the other two subjects owing to advanced age and the presence of bilateral nodules with concomitant bone metastasis, respectively. Both were treated by chemotherapy and the patient with synchronous bone metastasis also received radiotherapy. The elderly subject died after six months, and the other patient after 19 months despite partial remission of disease. In our experience, curative therapy proves difficult due to multiple metastases. In the literature there are few reports regarding this rare type of metastatic lung disease, but surgical intervention would appear to be the therapy offering the best chance of long-term survival while chemotherapy constitutes the second-choice treatment.

Bcl-2 protein and prognosis in patients with potentially curable non-small-cell lung cancer

The bcl-2 proto-oncogene functions as a cell death suppressor, and its expression prolongs cell survival by blocking apoptosis. Data available on the clinical relevance of bcl-2 protein expression in patients with non-small-cell lung cancer (NSCLC) are controversial. We analysed the role of bcl-2 protein expression on 6-year relapse-free survival in 229 patients with stage I-IIIa NSCLC (101 squamous cell carcinomas and 128 adenocarcinomas) subjected to surgery, with curative intent. Immunohistochemical analysis was performed on archival material by using a monoclonal antibody anti-bcl-2 (clone 124). Bcl-2 protein expression, which was detected in 22% of the cases, was significantly related to stage, histology and grading, and was an indicator of clinical outcome. The probability of relapse-free survival at 6 years was longer for patients with bcl-2-positive tumours (74%) than for those with bcl-2-negative tumours (57%) (P=0.02). This finding was mainly evident for the subgroups of patients with stage IIIa tumours (P=0.05), squamous cell carcinoma (P=0.03) or moderately/poorly differentiated tumours (P=0.02). However, multivariate analysis by Weibull's regression model indicated that bcl-2 protein expression was not an independent prognostic risk factor in patients with curable NSCLC when the information provided by stage was available.

Sternal resection for primary or secondary tumors

METHODS

From January 1980 to December 1993, 52 patients underwent surgical-resection for tumors involving the sternum. The series included 20 primary malignant tumors, 4 desmoid tumors, 2 malignant tumors infiltrating the sternum from adjacent organs, 19 local recurrences or metastases of breast tumors, and 7 metastases of other tumors. Total sternectomy was performed in 5 patients, subtotal sternal resection in 19, and partial resection (less than 50% of the sternum) in 28. Concurrent en bloc resection included anterior ribs in 37 patients, clavicle in 11, lung in 12 patients, pericardium in 7, and diaphragm in 2. The chest was reconstructed with prosthetic material and a myocutaneous flap in 26 patients (50%), prosthetic material only in 12 patients (23%), a myocutaneous flap in 5 patients (10%), and other techniques in the remaining patients. In 47 patients (90%) the resection was radical, and in the remaining 5 patients it was palliative.

RESULTS

No perioperative deaths occurred. After a median follow-up of 39 months, the overall 3-year survival was 58% and the 5-year survival 46%, with a median survival of 50 months. In 24 patients with primary tumor the 5-year survival after radical resection was 63%, and in 23 patients with secondary invasion (direct extension or metastasis) the 5-year survival was 38% (median 35 months). In recurrent breast cancer the 5-year survival was 48% in patients with direct extension to the chest wall and 60% in patients with distant bone metastasis.

CONCLUSIONS

Our experience demonstrates that sternal resection is a safe and effective treatment, which may improve the patient's quality of life and achieve a long-term survival not only in primary tumors but also in selected secondary malignant tumors of the sternum.

P53 expression, DNA ploidy and S-phase cell fraction in operable locally advanced non-small-cell lung cancer

The identification of biomarkers to complement pathological stage for a more accurate prognosis and help clinicians decide on treatment is still an open problem for patients with lung cancer. Expression of P53 protein was detected by an immunohistochemical approach using the monoclonal antibody PAb1801 on paraffin-embedded sections of tumours obtained surgically from 102 stage II - IIIa patients with non-small-cell lung cancer (52 squamous cell carcinomas, 50 adenocarcinomas). [3H]Thymidine labelling index, an indicator of the S-phase cell fraction, was evaluated on histological sections of [3H]thymidine-labelled tumour samples. DNA ploidy was defined by flow cytometric analysis on frozen tumour tissue. The biomarkers, histology and pathological stage were analysed in relation to relapse-free survival in univariate and multivariate analyses. Stage and interaction between [3H]thymidine labelling index and histology provided significant prognostic information for the overall series. [3H]thymidine labelling index was an independent prognostic indicator of 3 year relapse-free survival in patients with adenocarcinoma. The results indicate the importance of cell proliferation to complement prognostic information provided by pathological stage in patients with stage II-IIIa adenocarcinomas.

Ambulatory low-toxicity chemotherapy in non-small-cell lung carcinoma by continuous 28-day infusion of alternating cisplatin and 5-fluorouracil

BACKGROUND

One regimen consisting of a continuous infusion of cisplatin and fluorouracil was designed to be minimally toxic, and suitable for application with radiotherapy in non-small-cell lung carcinoma (NSCLC).

PATIENTS AND METHODS

Forty-four NSCLC patients received daily 8 mg/m2 of cisplatin on days 1-2, 8-9, 15-16, 22-23, and 300 mg/m2 of fluorouracil on days 3-7, 10-14, 17-21, 24-28 (35-day courses).

RESULTS

Two patients experienced grade 3-4 toxicities. Eleven achieved objective responses. The median progression-free and observed survival was 22 and 39.5 weeks.

CONCLUSIONS

The schedule management was fully ambulatory. Toxicity was negligible. The activity was moderate, but the combination with radiotherapy is advisable due to the radioenhancing properties of both of the drugs.

Cyfra 21-1 - a new tumor-marker for lung-cancer

Among 20 known cytokeratins, cytokeratin fragment 19 is a 40 kD acidic molecule whose distibution is restricted to simple or pseudo-stratified epitelia, such as the epithelial layer of the bronchial tree. An immunoradiometric assay, CYFRA 21-1, was used to detect a fragment of cytokeratin 19 in the serum of 90 subjects and compared with serum levels of CEA, NSE and TPA. Sixty-seven consecutive patients with lung cancer and 23 healthy subjects were tested. Cut-off values for tumor markers were considered as the 95% of specificity versus controls. There were 32 adenocarcinomas, 29 squamous carcinomas and 6 other tumors. Increased serum levels of CYFRA 21-1 were found in lung cancer patients compared to controls [1.6 (0.2-3.2) versus 0.5 (0.2-1.8): p<0.001]. In our study TPA was more sensitive than CYFRA 21-1: 49% versus 40%; when we combined both markers the sensitivity increased to 63%. Significant difference in values were found before and after surgery in serum levels of 34 operated patients: p<0.01. We found higher levels of soluble cytokeratin 19 in lung cancer patients and in the adenocarcinoma subgroup. This study does not support the exclusive use of soluble cytokeratin 19 as a specific marker of lung cancer and not only in squamous carcinoma subgroup. This suggested that diagnostic and prognostic sensitivity increase when CYFRA 21-1 and TPA or other markers are combined.

Correlation between first disease-free interval from mastectomy to second disease-free interval from chest wall resection

Between 24 November 1977 and 16 September 1988, 18 consecutive chest wall resections for recurrent breast cancer after failure of radiotherapy, were evaluated as of 1 January 1990. Chest wall involvement was the only site of recurrence in 14 patients (Group I), and the most painful of the multiple recurrences in the remaining four (Group II). Of Group I, chest wall recurrence was local in eight patients (four with necrosis after radiotherapy), regional in four, and distant in two. Chest wall reconstruction was effected by contralateral breast flap in six, by random cutaneous flap in seven and by myocutaneous flap in the remaining five. Cosmetic results were better if both marlex mesh and myocutaneous flap were used. Of Group I, at surgical/pathological staging, one recurrence with sarcomatous findings, two multiple recurrences and residual cancer in all necrosed local recurrences were found: in three of these cases radionecrosis was prominent. Mortality was 0% and surgical morbidity 5%. For Group I, median disease-free interval from mastectomy was extended from 1611 days to 3220 by recurrence resection, and disease-free interval from chest wall resection was 28% cancer-free at 1657 days, without any difference between the local vs regional-distant recurrence. Correlation factor between first and second disease interval was 0.99 and R2 was 0.98. For Group II, survival was 0% at 635 days. Chest wall resection must be considered as an important part of palliative treatment in breast cancer, but the results reflects the biology of the disease more than the chest wall surgery.

Prognosis of resected well-differentiated neuroendocrine carcinoma of the lung

Among lung tumors, well-differentiated neuroendocrine carcinomas are often misdiagnosed or may go unrecognized. Nineteen cases of well-differentiated neuroendocrine carcinoma (WDNC) were assessed at the National Cancer Institute of Milan over a ten-year period. There was only one woman and the age range was 50 to 77 years. Most of the patients were smokers (83 percent). All tumors were radically resected. There were 12 lobectomies, two sleeve-lobectomies, three bilobectomies, one pneumonectomy, and two segmentectomies (one patient had two synchronous WDNCs). There was neither operative mortality nor major complications. Sixteen tumors were stage 1, three were stage II, and one was stage IIIa. Five patients had adjuvant chemotherapy (cyclophosphamide, doxorubicin, and vincristine [CAV] regimen). One patient was given local or regional radiotherapy. In ten patients the tumors recurred, even though four had had adjuvant treatment. The brain was the first site of metastasis in seven cases. The pathologic stage seemed not to be closely related to the appearance of metastases (six patients with stage I disease had recurrences). Only two patients with recurrence were still alive 12 and 103 months after the procedure. The percentage of survival for patients with stage I disease after more than 100 months was 68 percent. WDNC is similar to small-cell lung carcinoma (SCLC) with regard to the neurotropism of metastases. Surgery is curative for more than one half of the patients with localized disease. Therefore, multimodal therapy, probably based on tumor behavior and investigations of tumor markers, is advisable.

Perioperative blood transfusion and prognosis of resected stage Ia lung cancer

Based on the experience of blood-related immunosuppression in kidney transplants, some retrospective studies have reported an adverse relationship between blood transfusion and survival after curative resection for cancer. In order to confirm these findings, we have retrospectively evaluated our population of resected stage Ia non-small cell lung cancers (years 1974-79). Two hundred and eighty-three patients were included in this analysis: 65 underwent pneumonectomy (23%), 205 lobectomy (72%) and 13 sublobar resections (5%). Patients submitted to perioperative blood transfusions were 157 (55%), without major differences according to surgery or tumour extent. The cumulative survival at 8 yr was 40% for transfused patients and 41% for nontransfused, relapse-free survival was respectively 36% and 34%; no differences were detectable stratifying for the amount of blood transfused or the extent of operation. Our experience does not support the hypothesis of an adverse prognosis related to perioperative blood transfusion.

A Fifteen Years’ Experience in the Diagnosis and Treatment of Benign Lung Tumors

Even the most sophisticated examinations, such as computerized tomography and percutaneous fine needle biopsy, often do not allow a certain preoperative diagnosis of benign lung cancer. The clinical history may also be deceiving: a smoker over 35 years of age need not necessarily have a primary lung cancer, but this event is frequent enough to justify a diagnostic thoracotomy. In our series, chest tomography proved to be useful and sometimes revealed unsuspected lesions. In contrast, bronchoscopy is useful only for centrally located lesions, and the same is true for bronchial washing and brushing. Finally, thoracotomy, possibly an axillary one with enucleation or possibly transegmentary resection, is the most frequent operation in benign lung tumors, because of the unfailing diagnosis and for the minimal functional damage to the patient. A diagnostic thoracotomy may also avoid the psychologic stress suffered by a patient with a simple but undiagnosed benign lung tumor.