Adalet Demir

High levels of oxidative stress in patients with advanced lung cancer.

Background and objective:  The aim of this study was to investigate oxidative stress status in different stages and histological types of lung cancer.

Survival and prognostic factors in surgically resected synchronous multiple primary lung cancers

OBJECTIVE The presence of synchronous multiple primary non-small-cell lung cancers (SMPLC) is a rare condition and the optimal treatment remains unclear. In this study, the survival of surgically treated SMPLC patients and the factors affecting survival were analyzed. METHODS Between 2001 and 2008, 26 consecutive patients diagnosed with SMPLC, who had all of their tumors resected, were retrospectively evaluated. Patients, who had bronchoalveolar carcinoma or carcinoid tumors and satellite nodules, were excluded. Prognostic factors were analyzed using univariate and multivariate analyses. RESULTS The tumors were unilateral in 14 and bilateral in 12 patients. In total, 38 procedures were performed. A complete resection was achieved in 35 (92.1%) procedures. The in-hospital mortality rate was 7.6% (two patients). The overall 5-year survival rate was 49.7%, and the median survival time was 40 months. The 5-year survival rate was 40.6% for unilateral and 62.8% for bilateral SMPLC patients (p = 0.47). Histopathologic tumor type, N1 nodal disease, tumor (T) status, and older age did not influence survival. There was no survival disadvantage for patients, upon whom a sublobar resection had been performed. There was a trend toward poorer survival in patients upon whom a pneumonectomy had been performed (p = 0.12). The 3-year survival rate for patients, who received adjuvant chemotherapy and/or radiotherapy (66.7%), was better than other patients (56.3%). In the multivariate analysis, we found a trend toward poor survival in patients, who received a pneumonectomy, and a trend toward better survival in patients, who received adjuvant therapy (p = 0.05 and p = 0.06). CONCLUSIONS The survival of SMPLC patients, who were treated surgically, was satisfactory. Pneumonectomy was a poor prognostic factor, whereas adjuvant therapy was a good prognostic factor.

Prognostic Significance of Surgical-Pathologic N1 Lymph Node Involvement in Non-Small Cell Lung Cancer

BACKGROUND Patients with N1 non-small cell lung cancer represent a heterogeneous population with varying long-term survival. To better define the importance of N1 disease and its subgroups in non-small cell lung cancer staging, we analyzed patients with N1 disease using the sixth edition and proposed seventh edition TNM classifications. METHODS From January 1995 to November 2006, 540 patients with N1 non-small cell lung cancer who had at least lobectomy with systematic mediastinal lymphadenectomy were analyzed retrospectively. RESULTS For completely resected patients, the median survival rate and 5-year survival rate were 63 months and 50.3%, respectively. The 5-year survival rates for patients with hilar N1 (station 10), interlobar (station 11), and peripheral N1 (stations 12 to 14) involvement were 39%, 51%, and 53%, respectively. Patients with hilar lymph node metastasis showed a shorter survival period than patients with peripheral lymph node involvement (p = 0.02). Patients with hilar zone N1 (stations 10 and 11) involvement tended to show poorer survival than patients with peripheral zone N1 (12 to 14) metastasis (p = 0.08). Multiple-station lymph node metastasis indicated a poorer prognosis than single-station involvement (5-year survival 39% versus 51%, respectively, p = 0.01). Patients with multiple-zone N1 involvement showed poorer survival than patients with single-zone N1 metastasis (p = 0.04). A significant survival difference was observed between N1 patients with T1a versus T1b tumors (p = 0.02). Multivariate analysis revealed that only multiple-station lymph node metastasis was predictive of poor prognosis (p = 0.05). CONCLUSIONS Multiple-station versus single-station N1 disease and multiple-zone versus single-zone N1 involvement indicate poorer survival rate. Patients with hilar lymph node involvement had lower survival rates than patients with peripheral N1. The impact of T factor seemed to be veiled by the heterogenous nature of N1 disease. Further studies of adjusted postoperative strategies for different N1 subgroups are warranted.

Surgical treatment and prognosis of primitive neuroectodermal tumors of the thorax.

Introduction: Primitive neuroectodermal tumors (PNETs) are rare, rapidly progressive, small- round cell tumors with a poor prognosis despite multimodal therapy, including surgery and chemoradiotherapy. The treatment of choice was unknown since no clinical series with surgical therapy had been reported. We evaluated the impact of multimodal treatment in patients with PNETs located in the thoracic region. Methods: Between 1998 and 2006, 25 patients with PNETs in the thoracic region were treated in 3 tertiary-care hospitals. The patients consisted of 15 males and 10 females with a mean age of 27.2 years (range, 6-60). The tumor was in the chest wall in 20 (involving the costovertebral junction in 9), the lung in four, and the heart in one patient. Twelve patients received neoadjuvant chemotherapy (54.5%), and 22 of 25 patients underwent surgery. Results: In patients who received neoadjuvant treatment, the mean regression rate was 65.4% (range, 30-100%). Eighteen (82%) patients underwent chest wall resection, while 7 (32%) had vertebral resections, and the remaining 4 (16%) had pulmonary resections. A complete resection was possible in 18 of 22 patients (82%). Patients with incomplete and complete resections had 25% and 56% 5-year survival rates, respectively (p = 0.13). The progression-free 3-year survival rate was 36% and the median survival time was 13 months. The complete resection rate was significantly higher in patients receiving neoadjuvant therapy (p = 0.027). The 5-year survival rate of the patients with or without neoadjuvant therapy was 77% and 37%, respectively (p = 0.22) although it prolonged the disease-free survival (p = 0.01). The 5-year survival rate of patients without costovertebral junction involvement was 66%, whereas patients with PNETs involving the costovertebral junction had a 21% 3-year survival. The difference was statistically significant (p = 0.01). The 5-year progression-free survival rate of patients without costovertebral junction involvement was 58%, whereas patients with PNETs involving the costovertebral junction had a 14% 1-year progression-free survival (p = 0.004). Conclusions: PNET is an aggressive malignancy that often requires multimodal therapy. Induction chemotherapy leads to a greater complete resection rate and better disease-free survival, while involvement of the costovertebral junction indicates a poorer survival.

The validity of preoperative lymph node staging guidelines of European Society of Thoracic Surgeons in non-small-cell lung cancer patients §

OBJECTIVE The European Society of Thoracic Surgeons (ESTS) has proposed preoperative lymph-node staging guidelines (LNSGs) for non-small-cell lung cancer (NSCLC) based on the introduction of new staging modalities into clinical practice. The validity of these guidelines was assessed. METHODS Among the patients (n=185) with histologically confirmed NSCLC diagnosed between 2007 and 2009, who were suitable for thoracotomy, the 168 who underwent computed tomography (CT) of the chest and CT-integrated positron emission tomography (PET-CT) were included in the study. The preoperative mediastinal stage was confirmed by mediastinoscopy in all patients. A thoracotomy was done for mediastinoscopy-negative patients. The mediastinal staging results were adapted to the ESTS-LNSG (direct thoracotomy for T1-2 N0 tumour according to CT and PET-CT and invasive staging for others) and the validity of the guidelines was tested. RESULTS In this series, the overall mediastinal lymph-node metastasis (MLNM) prevalence was 29.2%. If the guidelines had been applied, thoracotomy without invasive mediastinal staging would have been done in only 11 (6.5%) patients, and no MLNM would have been detected. Mediastinoscopy would have been performed in 157 patients and MLNM would have been found in 41 (26%). In the 116 mediastinoscopy-negative patients, MLNM would have been detected after thoracotomy in an additional eight patients. Thus, the sensitivity, specificity, and positive and negative predictive values of the guidelines were calculated as 84%, 100%, 100% and 94%, respectively. CONCLUSIONS The preoperative LNSGs for NSCLC proposed by the ESTS are effective.

Diagnosis and treatment of spontaneous pneumomediastinum.

BACKGROUND Due to its rarity there is no clear policy on the management of spontaneous pneumomediastinum (SPM). METHODS We treated 23 SPM patients between January 1 996 and November 2 006. There were 20 males and 3 females and their mean age was 27. Clinical records of the patients were collected and analyzed. RESULTS The most frequent symptoms were neck swelling (n = 20) and rhinolalia (n = 15). Onset of the symptoms was acute. A preceding factor was found in 19 (83 %) patients; these included vigorous cough, forced physical activity, vigorous sneezing and enormous efforts during spontaneous vaginal delivery. Chest X-ray was sufficient to show mediastinal free air in 18 patients. Computerized chest tomography showed pneumomediastinum in all patients. Twenty patients were treated expectantly. Subcutaneous air drainage was needed to drain massive subcutaneous emphysema in three patients. CONCLUSIONS Acute onset of typical symptoms, the existence of a preceding factor and the exclusion of other possible causes of pneumomediastinum with the help of CT are sufficient to make a diagnosis of SPM. A surgical intervention is generally not needed for the treatment of this entity.

Analysis of Surgical Treatment for Pulmonary Aspergilloma

Surgery for pulmonary aspergilloma is reputed to be risky. The results of surgical treatment of pulmonary aspergilloma in 41 patients between 1988 and 2003 were evaluated retrospectively. Hemoptysis occurred in 31 patients (75.6%) and it was massive (> 300 mL in 24 hr) in 3. The underlying lung disease was tuberculosis in 35, bullous lung disease in 2, hydatid cyst in 2, and lung carcinoma in 2 patients. Lobectomy, bilobectomy, wedge resection, and pneumonectomy were performed in 27, 4, 6, and 4 patients respectively. The postoperative complication rate was 24.4%. One patient, who had a right pneumonectomy, died due to respiratory failure; the mortality rate was 2.4%. Recurrent hemoptysis was observed in only one patient. Early surgical treatment of patients with pulmonary aspergilloma resulted in a satisfactory outcome with acceptable morbidity, low mortality, and effective prevention of recurrent hemoptysis. Pneumonectomy has a high morbidity, thus it should be avoided if possible.

Role and outcome of surgery for pulmonary tuberculosis.

The need and outcome of surgical intervention in patients with pulmonary tuberculosis were assessed retrospectively. Between 1993 and 2003, 72 major surgical procedures were performed in 57 patients with pulmonary tuberculosis. There were 44 males and 13 females with a mean age of 34 years. Indications for surgery were: trapped lung in 18 (31.6%), multidrug-resistant tuberculosis in 10 (17.5%), aspergilloma in 10 (17.5%), destroyed lung in 5 (8.8%), massive hemoptysis in 4 (7%), bronchopleural fistula in 3 (5.3%), persistent cavity in 2 (3.5%), and undiagnosed nodule in 5 (8.8%) patients. The most common procedure was lobectomy (31.9%). Other procedures included decortication, wedge resection, pneumonectomy, segmentectomy, and myoplasty. There were 28 complications in 18 patients, including prolonged air leak in 12 (21.1%), residual space in 7 (12.3%), empyema in 5 (8.8%), hematoma in 2 (3.5%), chylothorax and bronchopleural fistula in 1 (1.8%) each. There was no operative death, but one patient died from sepsis late in the follow-up period (mortality, 1.8%). As morbidity and mortality rates are acceptable, surgical intervention can be considered safe and effective in patients with pulmonary tuberculosis.

Robotic and video-assisted thoracic surgery lung segmentectomy for malignant and benign lesions

OBJECTIVES The experience with robotic techniques (RATS) and video-assisted thoracic surgery (VATS) in pulmonary segmentectomy is still limited. We evaluated our prospectively recorded database to compare two different minimally invasive techniques. METHODS Between May 2007 and July 2014, a total of 99 patients underwent RATS (n = 34) and VATS (n = 65) pulmonary segmentectomies at two institutions. The median age of patients was 59 ± 15 (16-84) years, and 61% were male. Seventy-six patients were operated on for malignancy and 23 for benign diseases. RESULTS The major morbidity and mortality rates were 24-23% and 0-1.5% for RATS and VATS (P = 0.57) and (P = 0.66), respectively. The mean console time for RATS was longer than the mean operation time for VATS [76 ± 23 (40-150) vs 65 ± 22 (30-120) min (P = 0.018)]. The mean duration of drainage was similar for RATS and VATS [3.53 ± 2.3 (1-10) days vs 3.98 ± 3.6 (1-21) (P = 0.90)], respectively. The duration of postoperative stay for RATS was 4.65 ± 1.94 (2-10) days and for VATS was 6.16 ± 4.7 (2-24) days (P = 0.39). CONCLUSIONS Both RATS and VATS pulmonary segmentectomy operations are performed with similar morbidity and mortality rates. Although the duration of operation is longer in RATS when compared with an established VATS programme, there is a tendency towards a shorter postoperative stay.

The role of GSTM1 gene polymorphisms in lung cancer development in Turkish population.

Background Glutathione S-transferase (GSTs) plays an important role in the detoxification of many xenobiotics involved in the etiology of cancer. In different ethnic groups, variations in null allele frequency have been observed. We have investigated GSTM1 gene polymorphisms in healthy subjects and lung cancer patients in the Turkish population and reviewed the control subjects of the studies performed in the Turkish population. Methods Following blood sampling from patients and controls, DNA samples were extracted from the whole blood and were amplified by using polymerase chain reaction (PCR) method in all of the 256 cases, consisting of 102 previously diagnosed with lung cancer and 154 healthy controls. Results The prevalence of GSTM1-null genotype in the lung cancer patients was 49%, compared to 52.6% in the control group (OR = 1.39, 95% CI = 0.70–1.90, p = 0.57). There were also no significant relationships in GSTM1 genotypes among histopathologic types of lung cancers (p > 0.05). The frequency of GSTM1 was found to be 41.2% (n = 1809) when the control subjects of the studies performed in Turkish population were reviewed. Conclusion We have observed that GSTM1 genotype is not an independent risk factor for lung cancer.