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.