A.F.T.M. Verhagen

Only half of the chronic pain after thoracic surgery shows a neuropathic component.

UNLABELLED Chronic pain is a common complication after thoracic surgery. The cause of chronic post-thoracotomy pain is often suggested to be intercostal nerve damage. Thus chronic pain after thoracic surgery should have an important neuropathic component. The present study investigated the prevalence of the neuropathic component in chronic pain after thoracic surgery. Furthermore, we looked for predictive factors for prevalence and intensity of chronic pain. We contacted 243 patients who underwent a video-assisted thoracoscopy (VATS) or thoracotomy in the period between January 2004 and September 2006 by mail. Patients retrospectively received a questionnaire with the Dutch version of the PainDETECT Questionnaire, a validated screening tool for neuropathic pain. Results were analyzed from 204 patients (144 thoracotomies, 60 VATS). The prevalence of chronic pain was 40% after thoracotomy and 47% after VATS. Definite chronic neuropathic pain was present in 23% of the patients with chronic pain, with an additional 30% having probable neuropathic pain. Greater probability of neuropathic pain (ie, a higher total score of the PainDETECT) correlated with more intense chronic pain. Predictive factors for chronic pain were younger age (P = .01), radiotherapy (P = .043), pleurectomy (P = .04) and more extensive surgery (P < .001). PERSPECTIVE Up to half the chronic pain after thoracic surgery is not associated with a neuropathic component, which has not been reported to date. More extensive surgery and pleurectomy are predictive factors for chronic pain after thoracic surgery, suggesting a visceral component apart from nerve injury.

Differences in metabolism between adeno- and squamous cell non-small cell lung carcinomas: spatial distribution and prognostic value of GLUT1 and MCT4.

BACKGROUND Hypoxia leads to changes in tumor cell metabolism such as increased glycolysis. In this study, we examined the spatial distribution of the glycolysis and hypoxia related markers glucose transporter 1 (GLUT1) and monocarboxylate transporter 4 (MCT4) expression in relation to the vasculature in stage I, II and resectable stage IIIA NSCLC. Furthermore, associations of these markers with survival were investigated. METHODS GLUT1 and MCT4 expression were determined in 90 NSCLC fresh frozen biopsies using immunohistochemical techniques and a computerized image analysis system. Markers were analyzed for adenocarcinomas (n=41) and squamous cell carcinomas (n=34) separately. Eighty-four patients were retrospectively evaluated for relapse and survival. RESULTS Squamous cell carcinomas demonstrated higher GLUT1 expression, relative to adenocarcinomas. Also, in squamous cell carcinomas, GLUT1 and MCT4 expression increased with increasing distance from the vasculature, whereas in adenocarcinomas upregulation of MCT4 was already found at closer distance from vessels. In adenocarcinomas, high GLUT1 expression correlated with a poor differentiation grade and positive lymph nodes at diagnosis. High GLUT1 plus high MCT4 expression was associated with a poor disease-specific survival in only adenocarcinomas (p=0.032). CONCLUSION Analysis of GLUT1 and MCT4 expression on the histological level suggested a different metabolism for adenocarcinomas and squamous cell carcinomas. Likely, adenocarcinomas rely mainly on aerobic glycolysis for ATP production, whereas the behavior of squamous cell carcinomas is more physiologically, i.e. mitochondrial oxidation with anaerobic glycolysis under hypoxic conditions. High GLUT1 plus high MCT4 expression indicated an aggressive tumor behavior in adenocarcinomas. This subgroup of tumors may benefit from new treatment approaches, such as MCT4 inhibitors. Since this study has an exploratory character, our results warrant further investigation and need independent validation.

Modified Robicsek technique for complicated sternal closure

A modification of the technique described by Robicsek and associates for treatment of sternum separation after open heart operation is described. The technique consists of placing four interlocking steel wires parasternally on both sides and then including them in the usual transverse peristernal wires.

Incidence and Treatment of Tracheal Cancer: A Nationwide Study in The Netherlands

BackgroundThe aim of this study was to assess the incidence, characteristics, treatment, and survival of patients with tracheal malignancies in the Netherlands.MethodsAll cases of tracheal cancer entered into the database of the Netherlands Cancer Registry in the period 1989–2002 were selected. Data on histological type, age at time of diagnosis, treatment, and survival were analyzed retrospectively.ResultsThe annual incidence was 0.142 per 100,000 inhabitants (308 cases, of which 15 were found incidentally at autopsy). Of these, 72% were men. In 52.9%, the histological type was squamous cell carcinoma and in only 7.1% adenoid cystic carcinoma (ACC). Mean age at time of diagnosis was 64.3 years. Of the 293 patients diagnosed while alive, 34 patients underwent surgical resection (11.6%), 156 patients received radiotherapy (53.2%), and 103 patients neither (35.4%). Median survival of all 293 patients was 10 months (mean 28 months) with 1-year, 5-year, and 10-year survival rates of 43%, 15%, and 6%, respectively. The prognosis of patients with ACC was significantly better. The 5-year survival rate in patients who underwent surgical resection was 51%, and the 10-year survival rate in these patients was 33%.ConclusionThe prognosis of patients with a tracheal malignancy is usually poor. Surgical treatment, however, can lead to good survival rates; still, this is currently only used in selected patients, even though it would seem to be possible in more cases in view of the technical advances in the field of tracheal surgery. Centralizing the care and treatment of tracheal cancers and implementing a more assertive attitude towards this disease could make surgery accessible to a larger number of patients. Data from the literature show that this would lead to better survival in patients with a tracheal malignancy.

Completeness of lung cancer surgery: is mediastinal dissection common practice?

OBJECTIVES In patients with early-stage non-small cell lung cancer, surgery offers the best chance of cure when a complete resection, including mediastinal lymph node dissection, is performed. A definition for complete resection and guidelines for intra-operative lymph node staging have been published, but it is unclear whether these guidelines are followed in daily practice. The goal of this study was to evaluate the extent of mediastinal lymph node dissection routinely performed during lung cancer surgery, and hereby the completeness of resection according to the guidelines of the European Society of Thoracic Surgery (ESTS) for intra-operative lymph node staging. METHODS In a retrospective cohort study, the extent of mediastinal lymph node dissection was evaluated in 216 patients who underwent surgery for lung cancer with a curative intent in four different hospitals, three community hospitals and one university hospital. Data regarding clinical staging, the type of resection and extent of lymph node dissection were collected from both the patients medical record and the surgical and pathology report. Based on histology, location and side of the primary tumour, the extent of mediastinal dissection was compared with the ESTS guidelines for intra-operative lymph node staging. RESULTS According to the surgical report interlobar and hilar lymph nodes were dissected in one-third of patients. A mediastinal lymph node exploration was performed in 75% of patients; however, subcarinal lymph nodes were dissected in <50% of patients and at least three mediastinal lymph node stations were investigated in 36% of patients. In 35% of the mediastinal stations explored, lymph nodes were sampled instead of a complete dissection of the entire station. A complete lymph node dissection according to the guidelines of the ESTS was performed in 4% of patients. Despite an incomplete dissection unexpected mediastinal lymph nodes were found in 5% of patients. CONCLUSIONS In daily practice, the intended curative resection for lung cancer cannot be considered complete in the majority of patients, because of an incomplete lymph node dissection according to the current guidelines of the ESTS.

Quality of integrated care for patients with nonsmall cell lung cancer: variations and determinants of care.

In the current study, the authors focused on determinants influencing the quality of care and variations in the actual quality of integrated care for patients with nonsmall cell lung cancer (NSCLC) to estimate whether there is room for improvement.

Clinical aspects and treatment of primary tracheal malignancies

Abstract Conclusions: Selecting patients that are candidates for surgical treatment is important in the work-up of patients with tracheal cancer. Toward this goal, centralization of care concerning tracheal tumors is advised. Centralization may increase long-term survival and decrease operative morbidity and mortality even further. Objective: Primary tracheal tumors pose a diagnostic and therapeutic challenge for the physician when confronted with this mostly malignant tumor. Diagnosis is often delayed for months or years due to its aspecific and asthma-mimicking symptoms. Knowledge from retrospective series is limited and few clinicians have gained experience with this tumor. The available literature on the diagnosis and management of this group of tumors is reviewed to summarize the available knowledge about these uncommon tumors. New diagnostic, staging, and treatment guidelines are proposed. Methods: PubMed was searched for English publications from 1960. The available literature was reviewed and summarized. Results: Surgical resection and primary reconstruction is the best curative treatment modality available at present. In centers of experience, more than half of all patients with tracheal cancer may be candidates for surgical resection, although in population-based studies this treatment is applied in only 10–25% of patients.

Retrogastric Versus Antegastric Routing and Histology of the Right Gastroepiploic Artery

To maximize use of the right gastroepiploic artery in myocardial revascularization 11 cadavers were studied to determine the shortest route (retrogastric versus antegastric) of the right gastroepiploic artery from its origin to the recipient coronary artery. Any coronary artery could be reached with an in situ right gastroepiploic artery. There was no significant difference between the retrogastric and antegastric routes for any coronary artery, although the former generally is slightly shorter to the vessels on the posterior surface of the heart and the latter to vessels on the anterior surface of the heart. Histological examination of the right gastroepiploic artery in its proximal, mid, and distal segments showed a similar width of intima and media and invariably an almost purely muscular media. Based on the histological similarity of the right gastroepiploic artery to the coronary artery, some scepticism toward liberal use of the right gastroepiploic artery, especially if used as a free graft, is warranted until clinical studies on its long-term patency have been performed.

Role of FDG-PET in the diagnosis and management of lung cancer

Positron emission tomography (PET) using [18F]-2-deoxy-2-fluoro-d-glucose (FDG) has emerged as a valuable diagnostic modality in patients with non-small cell lung cancer (NSCLC). Data in the literature show that the addition of FDG-PET definitely alters clinical management in patients with potentially resectable NSCLC by adequately staging the mediastinum and detecting previously unknown distant metastases. Thus, the number of noncurative thoracotomies and unnecessary mediastinoscopies is reduced. Furthermore, there is increasing evidence that FDG-PET will change radiation treatment planning by defining a biologic treatment volume, incorporating unsuspected additional locoregional disease, and avoiding overtreatment by identifying computerized tomography abnormalities as benign. For follow-up during systemic therapy, early FDG-PET appears to be predictive for the response to therapy. However, before FDG-PET-induced changes in patient management can be incorporated into clinical practice both for radiation treatment planning and chemotherapy, technical issues must be resolved, validation studies should be performed and, most importantly, randomized trials are necessary to evaluate the effect of FDG-PET on patient outcome parameters.

Undertreatment of Tracheal Carcinoma: Multidisciplinary Audit of Epidemiologic Data

National epidemiologic data were examined to determine the eligibility for curative therapy in tracheal carcinoma. An expert audit of primary tracheal carcinomas registered from 2000 to 2005 with the Netherlands Cancer Registry (NCR) included blinded patient data and radiographic review to assess diagnosis and resectability. Actual treatment was compared with the opinions of a multidisciplinary panel (Radboud panel) and a second reviewer. Of 101 NCR-registered primary tracheal carcinomas, the Radboud panel diagnosis was metastatic disease or local extension of adjacent tumors in 34. Seventeen cases were excluded for missing data. In 50 cases confirmed by panel and a second reviewer, actual treatment consisted of surgery in 12 (24%), radiotherapy in 29 (58%), endobronchial treatment in 6 (12%), and observation in 3 (6%). Both panel and second reviewer identified 16 additional surgical candidates, a total of 28 (56%) of 50. Treatment recommendations of panel and second reviewer disagreed in four cases (8%). One-third of NCR-registered primary tracheal carcinomas were misclassified nontracheal primary tumors involving the trachea. A majority of cases meeting audit criteria for diagnosis and surgical resection was treated with other modalities. Interreviewer disagreement was small. The audit of a national cancer registry suggests that incorrect diagnosis and undertreatment are common in rare airway tumors.