Akif Turna

Revised ESTS guidelines for preoperative mediastinal lymph node staging for non-small-cell lung cancer.

Accurate preoperative staging and restaging of mediastinal lymph nodes in patients with potentially resectable non-small-cell lung cancer (NSCLC) is of paramount importance. In 2007, the European Society of Thoracic Surgeons (ESTS) published an algorithm on preoperative mediastinal staging integrating imaging, endoscopic and surgical techniques. In 2009, the International Association for the Study of Lung Cancer (IASLC) introduced a new lymph node map. Some changes in this map have an important impact on mediastinal staging. Moreover, more evidence of the different mediastinal staging technique has become available. Therefore, a revision of the ESTS guidelines was needed. In case of computed tomography (CT)-enlarged or positron emission tomography (PET)-positive mediastinal lymph nodes, tissue confirmation is indicated. Endosonography [endobronchial ultrasonography (EBUS)/esophageal ultrasonography (EUS)] with fine-needle aspiration (FNA) is the first choice (when available), since it is minimally invasive and has a high sensitivity to rule in mediastinal nodal disease. If negative, surgical staging with nodal dissection or biopsy is indicated. Video-assisted mediastinoscopy is preferred to mediastinoscopy. The combined use of endoscopic staging and surgical staging results in the highest accuracy. When there are no enlarged lymph nodes on CT and when there is no uptake in lymph nodes on PET or PET-CT, direct surgical resection with systematic nodal dissection is indicated for tumours ≤ 3 cm located in the outer third of the lung. In central tumours or N1 nodes, preoperative mediastinal staging is indicated. The choice between endoscopic staging with EBUS/EUS and FNA or video-assisted mediastinoscopy depends on local expertise to adhere to minimal requirements for staging. For tumours >3 cm, preoperative mediastinal staging is advised, mainly in adenocarcinoma with high standardized uptake value. For restaging, invasive techniques providing histological information are advisable. Both endoscopic techniques and surgical procedures are available, but their negative predictive value is lower compared with the results obtained in baseline staging. An integrated strategy using endoscopic staging techniques to prove mediastinal nodal disease and mediastinoscopy to assess nodal response after induction therapy needs further study.

Surgical treatment of pulmonary hydatid cysts: is capitonnage necessary?

BACKGROUND Hydatid disease of the lung caused by Echinococcus granulosus is frequently encountered in Mediterranean countries. The ideal surgical method for treating this disease is still unknown. METHODS Between 1994 and 2001, 71 patients with pulmonary hydatid cysts were treated surgically. There were 41 male and 30 female patients with a mean age of 30.2 years (range, 5 to 70 years). Cystotomy and closure of bronchial openings were performed in all patients. Obliteration of the residual cavity by imbricating sutures from within (capitonnage) was achieved in 39 patients (group 1). There were 34 patients with intact cysts and 37 patients with at least one complicated cyst. The average diameter of the cysts was 6.4 cm, and the mean number of cysts per patient was 1.4. The surgical outcome was assessed in group 1 patients and in patients who had undergone closure of bronchial openings without capitonnage (group 2; n = 32). The groups were comparable in regard to clinical characteristics. RESULTS There was no mortality. The total hospitalization time (mean +/- standard error of the mean) was 5.0 +/- 5.0 days for group 1 and 5.9 +/- 6.9 days for group 2 (p = 0.91). Stay in the intensive care unit was 1.64 +/- 1.22 days in group 1 and 1.60 +/- 1.52 days in group 2 (p = 0.90). The duration of air leak was 2.56 +/- 4.73 days in group 1 and 2.38 +/- 4.74 days in group 2 (p = 0.87). There was no significant difference between groups in the development of empyema (1 patient in group 2 only) and prolonged air leak (5 patients in group 1 and 4 in group 2). There was also no significant difference in the rate of recurrence (3 patients in group 1 only). CONCLUSIONS We conclude that capitonnage provides no advantage in operations for pulmonary hydatid cysts.

Bilateral elastofibroma dorsi

Elastofibroma dorsi was diagnosed in a 48-year-old woman with bilateral subscapular tumor masses diagnosed asynchronously in an interval of 4 months in spite of presence of another lesion at first admittance. She underwent subsequent resections of the lesions. They were diagnosed as elastofibroma. Reevaluation of the initial computerized tomography of thorax indicated an omitted small lesion with a 2-cm diameter and 25.2-day doubling time. Although the real neoplastic nature of elastofibroma is unknown, bilateral presence of the masses with different sizes and relatively short doubling times of the lesions must be kept in mind.

Comparison of clinical and surgical-pathologic staging of the patients with non-small cell lung carcinoma

OBJECTIVE Clinical staging of non-small cell lung cancer helps to determine the extent of disease and separate patients with potentially resectable disease from those that are unresectable. Since, clinical staging is based on radiologic and bronchoscopic findings, overstaging or understaging may occur comparing to the final surgical-pathologic evaluation. We aimed to analyze preoperative and postoperative stagings in order to evaluate stage migrations and our surgical strategy for marginally resectable patients. METHODS We did a retrospective analysis of 180 patients with non-small cell lung cancer who underwent resectional surgery between 1994 and 2000. In all patients, a thoracic computerized tomography and bronchoscopy were performed to define clinical staging (cTNM). RESULTS In 86 patients (47.7%) clinical and surgical-pathologic staging concurred. When comparing T subsets alone, correct staging, overstaging and understaging occurred in 133 (73.9%), 28 (15.5%), 47 (26.1%) patients, respectively. Only 13 of 21 patients (61.9%) who were thought to have T4 tumor preoperatively were found to have pT4. Also six patients with cT2 and five patients with cT3 were subsequently found to have T4 disease according to pathology. Clinical staging overestimated the nodal staging in 35 patients (19.4%), while underestimated the lymph node involvement in 45 patients (25%). CONCLUSION Construction of cTNM stage remains a crude evaluation, preoperative mediastinoscopy in every patient must be performed. Preoperative limited T4 disease is not to deny surgery to patients since a considerable number of patients with cT4 are to be understaged following surgery.

What Are the Considerations in the Surgical Approach in Pulmonary Metastasectomy

There are four matters of uncertainty considered in this working group report, which are distilled into four clinical questions: (1) What is the evidence for the need for palpation of the lung in modern era of imaging? (2) Is there evidence of a difference in outcome for an open versus a closed approach? (3) Is there evidence of a difference in outcome for an initial policy of bilateral versus unilateral exploration? (4) In patients with known bilateral disease, is there a difference in outcome with a simultaneous versus a staged approach? We searched the literature formally and supplemented this with knowledge from all other sources. We provide evidence tables on the first two questions by relying on a group consensus and frame recommendations for the other two. There are no randomized trials to guide us but there are comparative studies addressing the need for palpation and the need to and open operation in all cases. The evidence is equivocal, and opinions are divided in the literature. Palpation of the lung is still seen as necessary in a therapeutic metastasectomy as opposed to a diagnostic procedure when videothoracoscopy is adequate. However, the importance of palpation becomes less clear with advances in imaging. Routine bilateral exploration for unilateral disease was not favored. For bilateral disease, an initial median sternotomy has a place for some cases but sequenced thoracotomy was preferred.

Preoperative mediastinal lymph node staging for non-small cell lung cancer: 2014 update of the 2007 ESTS guidelines

Accurate preoperative staging and restaging of mediastinal lymph nodes in patients with potentially resectable non-small cell lung cancer (NSCLC) is of paramount importance. In 2007, the European Society of Thoracic Surgeons (ESTS) published an algorithm on preoperative mediastinal staging integrating imaging, endoscopic and surgical techniques. Over the last years more evidence of the different mediastinal staging technique has become available. Therefore, a revision of the ESTS guidelines was needed. In case of CT-enlarged or PET-positive mediastinal lymph nodes, tissue confirmation is indicated. Endosonography (EBUS/EUS) with fine needle aspiration is the first choice (when available) since it is minimally invasive and has a high sensitivity to rule in mediastinal nodal disease. If negative, surgical staging with nodal dissection or biopsy is indicated. Video-assisted mediastinoscopy is preferred over mediastinoscopy. The combined use of endoscopic staging and surgical staging results in the highest accuracy. When there are no enlarged lymph nodes on CT and when there is no uptake in lymph nodes on PET or PET-CT, direct surgical resection with systematic nodal dissection is indicated for tumors ≤3 cm located in the outer third of the lung. In central tumors or N1 nodes, preoperative mediastinal staging is indicated. The choice between endoscopic staging with EBUS/EUS and fine needle aspiration or video-assisted mediastinoscopy depends on local expertise to adhere to minimal requirements for staging. For tumors larger than 3 cm, preoperative mediastinal staging is advised, mainly in adenocarcinoma with high SUV uptake.

Aprotinin reduces postoperative bleeding and the need for blood products in thoracic surgery: results of a randomized double-blind study

OBJECTIVE Bleeding complications have been a major concern in certain thoracic surgery operations, especially decortication and pulmonary resection for inflammatory pulmonary infection. Prevention of plasminogen activation and fibrinolysis by aprotinin administration has been shown to reduce perioperative bleeding during operations associated with high blood consumption. METHODS Use of blood products (packed red cells, whole blood), chest tube drainage, analgesic requirement, chest tube duration for the patients undergoing major thoracic operations were recorded. In a double blind randomized fashion, patients were assigned to two groups receiving aprotinin (n=51) at a loading dose of 10(6) kallikrein inhibitory units (KIU) followed by an infusion of the same dose during chest closure or receiving placebo (n=52). On a daily basis, red-cell percentages of total fluid from drainage bottles were recorded and using the blood hematocrit level of the patient of the day before, the corrected value for the patients blood volume equivalent of daily drainage was calculated. RESULTS There was a significant reduction in perioperative use of donor blood (0.98+/-0.92 vs. 0.45+/-0.32 unit; P=0.0026), and total chest tube drainage (corrected value for the corresponding blood volume) (28.2+/-36.9 vs. 76.9+/-53.3 ml, P=0.0004) (mean+/-standard deviation) in the aprotinin group. However, aprotinin did not reduce postoperative transfusion or decrease in hematocrit level due to thoracic operations. In high transfusion-risk thoracic surgery patients (patients who underwent decortication, pulmonary resection for inflammatory lung disease and chest wall resection), the perioperative transfusion was only 0.50+/-1.08 units in aprotinin group, compared with 1.94+/-0.52 units in control group (P=0.003). Postoperative transfusion was also reduced in aprotinin administrated group (0.53+/-0.56 vs. 1.38+/-0.97 units; P=0.02). The mean total blood loss was decreased to nearly one third of the blood loss of the control group (41+/-28 ml vs. 121+/-68 ml; P=0.001). CONCLUSION Aprotinin significantly reduced perioperative transfusion requirement and postoperative bleeding during major thoracic operations. Aprotinin decreased perioperative transfusion needs. Moreover, patients who were at risk of greater blood loss during and after certain thoracic operations had a greater potential to benefit from prophylactic perioperative aprotinin treatment.

Nonanatomic prognostic factors in resected nonsmall cell lung carcinoma: The importance of perineural invasion as a new prognostic marker

BACKGROUND A number of prognostic factors have been reported for resected nonsmall cell lung carcinoma. Although none of them reported to have greater prognostic impact than the TNM staging system, which is based on anatomical descriptions of tumors, the prognoses of a significant number of patients are not in agreement with real survival of the patients. Moreover, certain histopathologic properties of the tumor (such as lymphatic and vascular invasion) could help to predict the survival of the patients. METHODS A retrospective study was conducted on 82 surgically resected nonsmall cell lung carcinomas, and the following prognostic factors were evaluated in univariate analysis: age, gender, clinical and surgical-pathologic T and N status, histologic type of tumor, grade of differentiation, lymphatic invasion, vascular invasion, and perineural invasion. RESULTS Lymphatic invasion and perineural invasion of the tumor were found to be significant prognostic factors (p = 0.02 and p = 0004). Blood vessel invasion (venous or arterial involvement) had no prognostic impact (p > 0.05). According to multivariate analyses, three factors were selected as prognostic indicators: (1) clinical N status (p = 0.027), (2) lymphatic invasion (p = 0.027) and (3) perineural invasion (p = 0.0148). By combining these factors we identified a poor prognostic subgroup of patients with stage I disease. CONCLUSIONS Our study showed that lymphatic vessel and perineural invasion of the tumor could be prognostic factors, along with anatomical determinants such as cN and surgical-pathologic stage of the pulmonary carcinoma.

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.