S9900: Surgery alone or surgery plus induction (ind) paclitaxel/carboplatin (PC) chemotherapy in early stage non-small cell lung cancer (NSCLC): Follow-up on a phase III trial

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Background: Small randomized and non-randomized studies suggest induction chemotherapy may improve survival in early stage NSCLC. The primary objective of this study was to determine if induction PC could improve survival over surgery alone. Preliminary results of this trial were reported at ASCO 2005 (J Clin Oncol, ASCO Proc 23(16S) 2005:7012). Median time for patients alive at last contact is now 46 months (mos). Methods: Consenting patients with clinical stage T2N0, T1–2N1 and T3N0–1 NSCLC (excluding superior sulcus tumors) were stratified by clinical stage (IB/IIA vs. IIB/IIIA) and randomized to induction PC (P:225 mg/m2 over 3 hours, C:AUC=6) on day 1, every 3 weeks × 3 or surgery alone. Eligible patients had a performance status 0–1, age =18 years (yrs), predicted post- resection FEV1 =1.0L. Surgery was at least a lobectomy and mediastinal nodal sampling. The primary endpoint was a 33% increase in overall survival over expected 2.7 yrs median for surgery. Planned sample size was 600 patients, 81% power, 1-sided test, 0.025 significance. Results: S9900 closed 07/04 when adjuvant chemotherapy became standard. 354 patients had accrued; 174-surgery alone, 180- induction PC; 19 were ineligible. Median age 65 yrs, 66% male, 70% IB/IIA, 30% IIB/IIIA. Major radiographic response to induction PC was 41%. Treatment-related deaths: 3 during induction PC, 11 within 30 days of surgery (7-induction PC arm, 4-control). Progression-free survival (PFS), overall (OS) survival rates and hazard ratios (HR) are shown. Conclusions: PFS and OS continue to trend in favor of induction PC with HR similar to those observed in adjuvant trials, supporting the role of chemotherapy in operable NSCLC. Randomized trials comparing induction to adjuvant chemotherapy are warranted. Supported by SWOG CA30102.

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Interferon treatment of multiple pulmonary malignancies associated with papilloma virus

Over a period of four years, beginning in spring 1988, a previously healthy man developed a primary squamous cell carcinoma of the tonsil, treated with radiotherapy, followed by 10 distinct, primary bronchial squamous cell carcinomas. Four of the cancers were surgically resected, all of which were positive by hybridization for human papilloma virus (type 16). Following the institution of alpha interferon, three smaller lesions disappeared and a larger one shrank in size, facilitating surgical resection. Over the following seven years no new ones have appeared. The finding of papilloma virus in malignancies should prompt consideration of antiviral therapy.

Reconstruction of irradiated postpneumonectomy empyema cavity with chain-link coupled microsurgical omental and TRAM flaps

We present the first case of complete hemithoracic reconstruction of an irradiated postpneumonectomy recurrent empyema cavity that was unresponsive to multiple conventional treatments. The procedure described used a chain-link of two coupled free flaps consisting of an omental and TRAM flap. A single abdominal donor site and single operative position are other advantages of this technique that provides sufficient volume to obviate the need for thoracoplasty even in the largest wounds.

Bronchial-atrial fistula after lung transplant resulting in fatal air embolism

We describe a rare case of fatal air embolism in a patient in whom a left atrial-bronchial fistula developed 1 month after single lung transplant. The cause was a combination of mediastinal infection and bronchial necrosis.

A comparison of rigid -v- video thoracoscopy in the management of chest trauma

Between December 1, 1994 and April 1,1998, 44 thoracoscopic procedures were performed in 42 patients following chest injuries. Indications included exploration in 15, retained haemothorax in 10, continued bleeding after chest tube placement in 3, air leak in 5 and empyema in 11. Video thoracoscopy was used in 24 cases and rigid thoracoscopy in 20, including 14 patients in whom video thoracoscopy was contraindicated. There was no difference in the operative times, length of stay or incidence of complications. Two formal and 3 "mini" thoracotomies were used in the video thoracoscopy group. Three "mini" thoracotomies were required in the rigid thoracoscopy group. Rigid thoracoscopy is an effective tool that, in selected cases, increases the utility of thoracoscopy in the management of chest trauma and its complications.

Optimal treatment of descending necrotising mediastinitis

BACKGROUND

Descending necrotising mediastinitis is caused by downward spread of neck infection and has a high fatality rate of 31%. The seriousness of this infection is caused by the absence of barriers in the contiguous fascial planes of neck and mediastinum.

METHODS

The recent successful treatment of seven adult patients with descending necrotising mediastinitis emphasises the importance of optimal early drainage of both neck and mediastinum and prolonged antibiotic therapy. The case is also presented of a child with descending necrotising mediastinitis, demonstrating the rapidity with which the infection can develop and lead to death. Twenty four case reports and 12 series of adult patients with descending necrotising mediastinitis published since 1970 were reviewed with meta-analysis. In each case of confirmed descending necrotising mediastinitis the method of surgical drainage (cervical, mediastinal, or none) and the survival outcome (discharge home or death) were noted. The chi 2 test of statistical significance was used to detect a difference between cases treated with cervical drainage alone and cases where mediastinal drainage was added.

RESULTS

Cervical drainage alone was often insufficient to control the infection with a fatality rate of 47% compared with 19% when mediastinal drainage was added (p < 0.05).

CONCLUSIONS

Early combined drainage with neck and chest incisions, together with broad spectrum intravenous antibiotics, should be considered standard care for this disease.

Cell kinetics analysis of surgically resected non-small cell carcinoma of the lung using the AgNOR silver stain

Cell kinetics analysis of lung carcinoma using DNA flow cytometry has shown a significant correlation with the biological behavior of these neoplasms. Ploidy has shown a more significant association with aggressive behavior. The method may however not be available in all centers. Two counts of the AgNOR silver stain have been correlated with ploidy and proliferative activity (PA). The first count, which is the mean number of AgNOR granules (mAgNOR), correlates with ploidy. The second count is the percentage of cells with > 5 AgNORs/nucleus (pAgNOR), reflects PA. We performed the AgNOR silver stain using the two above-mentioned counts in 41 cases of surgically resected nonâsmall cell carcinoma of the lung. The cases included 14 adenocarcinomas, 24 squamous cell carcinomas, and three undifferentiated nonâsmall cell carcinomas. Follow-up data were available on 36 of the patients, ranging from 10 to 31 months (median 18 months). Thirteen of these patients (36%) developed progressive disease. Adenocarcinomas showed mAgNOR counts suggestive of aneuploidy (> 2.4) in nine of the 14 patients (64%) and 16 of the 24 squamous carcinomas (66%). The adenocarcinomas showed high pAgNOR counts (> 8%) in eight of the 14 cases (57%), in contrast to 15 of the 24 squamous carcinomas (62%). The AgNOR counts did not show any statistically significant correlation with tumor type, grade or stage of disease. The mAgNOR counts were aneuploid in all 13 progressive cases and in only 10 of the 23 stable cases (43%)(P=0.001). The pAgNOR counts were high in 12 of the 13 cases that progressed (92%), in contrast to 10 of the 23 stable cases (43%)(P=0.01). There is no significant evidence that squamous carcinoma of the lung may have a higher incidence of aneuploidy and high PA than adenocarcinoma. Our data also confirm previous data showing that aneuploid lung carcinomas have more aggressive behavior than diploid ones. This study also indicates that, despite the short-term follow-up data, the use of the AgNOR silver stain for cell kinetics analysis of nonâsmall cell carcinoma of the lung may potentially provide useful predictive information on the biologic behavior of lung carcinoma. Long-term follow-up may provide more significant information.

The effect of high dose vitamin A on the morphology and proliferative activity of xenograft lung and head and neck cancer

In vitro studies have suggested that vitamin A lowers invasive potential of squamous cell carcinoma. Epidemiological data have also indicated that high dose vitamin A may improve survival in patients with previously resected lung carcinoma. To our knowledge, no studies have attempted to test the in vivo effect of vitamin A on the morphology and growth rate of lung and head and neck cancer. Freshly resected tumor cell suspensions were obtained by ex vivo fine needle aspiration and injected subcutaneously in duplicate in athymic male nude mice. Two to six weeks post-engraftment tests and controls were separated for each xenograft. Mice with test xenografts were given water soluble vitamin A (Aquasol ATM, Astra pharmaceutical, Westborough, MA, U.S.A) at a dose of 10,000 U/Kg/day intraperitoneally for 6 to 10 weeks (median 8 weeks). One to two hours prior to sacrifice bromodexouridine (BrdU) was injected intraperitoneally to assess the S-phase fraction in both test and control xenografts. Blood vitamin A levels in test and control animals were measured after sacrifice using high performance liquid chromatography (HPLC). Sections of test and control xenografts were routinely stained to assess morphologic differentiation and mitotic counts. Unstained sections of xenografts were immunostained by the antibody to BrdU to test for BrdU labeling index (BLI) reflecting S-phase fraction (SPF) and also by the MIB-1 antibody to assess proliferative activity. Eighteen tumors were studied. These included 9 squamous cell carcinomas of the lung, 5 squamous cell carcinomas of the head and neck, and 4 adenocarcinomas of the lung. Blood levels of vitamin A in test animals were 7 to 23 times those of the control animals (median 13 times). Neovascularization of the xenografts was seen in all cases. The morphology and mitotic activity of the test and control xenografts showed no significant difference. SPF and proliferative activity measured by BrdU and MIB-1 immunolabelling respectively showed no significant difference between test and control xenografts. Our study suggests that there is no significant in vivo effect of high dose vitamin A on the morphology and growth rate of xenografted non small cell carcinoma of the lung or squamous cell carcinoma of the head and neck.

Fine-needle aspiration cytology of bronchocentric granulomatosis: a potential diagnostic pitfall

Bronchocentric granulomatosis (BCTG) is a rare disease associated with bronchial asthma and bronchopulmonary aspergillosis. Idiopathic forms are rarely encountered. We report on a case of BCTG showing clinical, radiological, and cytological evidence suggestive of adenocarcinoma of the lung. The patient is a 69-yr-old female, lifetime nonsmoker with multiple sclerosis who was admitted with a history of ascending cholangitis. Admission chest X-ray documented a 1.5-cm nodule in the left upper lobe of the lung. This was confirmed by CT scan. The lesion was slowly growing. Bronchoscopic examination was normal. Bronchial brushings were inconclusive. A transthoracic fine-needle aspiration showed sheets of highly atypical epithelium with occasional small dyshesive clusters. There was an inflammatory background that was believed to represent tumor diathesis. The cytological interpretation was "suspicious for adenocarcinoma." The patient underwent left upper lobectomy. The lung showed multiple peribronchial granulomas with intense peribronchial lymphoid infiltrate extending into the bronchial mucosa, causing cytological atypia and focal ulceration. Special stains for microorganisms were negative. The patient recovered from surgery and shows no signs of infection. We conclude that BCTG and related lesions can give cytological features that are suggestive of malignancy. Cytological material obtained from these lesions should be interpreted with caution.

Colobronchial fistula due to Crohn's disease

Enteropulmonary fistulas may present as recurrent localized pneumonia. A case of one such fistula originating from the colon in a patient with Crohn's disease is discussed.

Open tube thoracoscopy for removal of intrapleural foreign bodies

Failure to remove all sponges and surgical instruments from the operative field after thoracic surgical procedures can lead to serious complications. Fortunately this occurrence is rare and preventable. Two patients are described in whom intrapleural foreign bodies were successfully removed by open tube thoracoscopy, a technique that the authors recommend as the procedure of choice in such cases.

Postpneumonectomy chylothorax

Chylothorax complicating pulmonary resections is exceptional and management of this complication remains controversial. We report a case of chylothorax after a right pneumonectomy and radical subcarinal nodal dissection. Successful nonoperative management consisted of controlled tube drainage, fasting, and total parenteral nutritional support for a period of 2 weeks. A review of the literature reveals 27 other cases of this complication after intrapleural pneumonectomy: 12 were treated by conservative measures alone and 15 required surgical intervention. Factors that will determine the management and the ultimate success of conservative management include (1) a relative delay in initial occurrence, (2) a decrease in or complete cessation of leakage while receiving total parenteral nutrition, and (3) favorable lymphangiographic findings.

Bronchial revascularization in double-lung transplantation: a series of 8 patients. Bordeaux Lung and Heart-Lung Transplant Group

Donor airway ischemia is the main cause for defective tracheal or bronchial healing after double-lung transplantation. Anatomical studies and bronchial arteriograms have shown that the right intercostal bronchial artery is constant (95% of instances) and provides an important blood supply to the distal trachea, the carina, and the right bronchial tree as well as to the left side through a subcarinal and periadventitial anastomostic network. To maintain this important bilateral bronchial circulation, it is of capital importance not to mobilize the arteries individually and to avoid large dissections around the carina. Both bronchi can thus be revascularized by indirect aortic reimplantation using a bypass graft to a single aortic patch that includes the origin of the right intercostal bronchial artery. Furthermore, the origin of other vessels (a common trunk and left arteries) can be found within a short distance of the right intercostal bronchial artery and possibly be contained within the same aortic patch. From a series of 56 lung transplantations, 8 patients underwent restoration of the bronchial vascularization using a recipient saphenous vein graft between the donor bronchial arteries and the anterior aspect of the recipient's ascending aorta. A lower tracheal anastomosis was performed. Bronchial arterial blood supply was evaluated both by endoscopy and by arteriography at about the 15th postoperative day. The bronchial circulation was visualized at this time in five of seven arteriographies, and this was associated with excellent tracheal healing in all 8 patients.

Pancreatoduodenal necrosis after endoscopic injection of cyanoacrylate to treat a bleeding duodenal ulcer: a case report

N-butyl 2-cyanoacrylate monomer was injected at endoscopy in an attempt to control arterial bleeding from a duodenal ulcer crater. Segmental infarction of the duodenum and pancreatic head followed and necessitated pancreatoduodenectomy. Butyl 2-cyanoacrylate monomers have been used with angiography as embolization agents and with endoscopy to control variceal bleeding. To our knowledge, there are no reports of its use by endoscopic injection to stop arterial bleeding. Its potential for embolism in nonselective endoscopic injections may minimize the clinical application of butyl 2-cyanoacrylate monomers in the treatment of arterial gastrointestinal bleeding.

Influence of phasic afferent information on phrenic neural output during hypercapnia

We measured the moving time average (MTA) of the phrenic neurogram before and after removal of phasic afferent information from the lungs, chest wall, and oscillations in blood gases by using constant-flow ventilation (CFV). Anesthetized dogs were studied at various levels of steady-state and progressive hypercapnia during spontaneous breathing and during CFV. When steady-state and progressive hypercapnia were compared, the frequency and height of the MTA phrenic neurogram were independent of the rate of induction of hypercapnia during each mode of ventilation. During spontaneous ventilation, the response to hypercapnia comprised mainly an increase in frequency with only a slight increase in the amplitude of the MTA phrenic waveform. During muscular paralysis and CFV, the responses were similar to those observed after vagotomy with mainly an increase in the amplitude and only a small increase in frequency. For both spontaneous breathing and CFV, increases in frequency were achieved mainly by a shortening in expiratory time with the inspiratory time remaining relatively constant. Our data support the concept of a centrally patterned respiratory generator, whose inherent pattern is modified by phasic feedback from peripheral receptors mainly of vagal origin.

Incarcerated parahiatal hernia with gastric necrosis

A parahiatal diaphragmatic hernia developed five years after transthoracic Heller myotomy. Failure to recognize this complication resulted in strangulation and necrosis of the gastric fundus. To our knowledge, this is the first reported case of a postoperative parahiatal hernia that did not follow the use of a diaphragmatic counterincision. Prompt recognition of this complication will prevent unnecessary morbidity and mortality.