Alessandro Baisi

Pulmonary lobectomy for lung cancer: a prospective study to compare patients with forced expiratory volume in 1 s more or less than 80% of predicted.

OBJECTIVE To compare post-operative course, lung function and survival of lung cancer patients with a forced expiratory volume in 1 s (FEV1) more or less than 80% of predicted submitted to lobectomy. METHODS The data of patients undergoing lobectomy for non small cell carcinoma at the Thoracic Surgery Unit of the Ospedale Maggiore Policlinico of Milan, Italy, were prospectively collected. Inclusion criteria were a radical resectable tumor with size less than 2.5 cm, negative mediastinal nodes, capability to complete pulmonary function tests, Exclusion criteria were FEV1 <40% of predicted, pre- or post-operative chemo or radiotherapy, lobe to be resected receiving more than 30% of the perfusion, incapacity to quit smoking. RESULTS Eighty-eight patients entered the study and were divided into two groups according to their FEV1%: 45 patients were included in control group (mean FEV1: 92.2%) and 42 in chronic obstructive pulmonary disease group (mean FEV1: 64.2%). Post-operative complications, operative mortality and actuarial survival were the same in the 2 groups. Six months after lobectomy, the mean changes in FEV1 were -14.9% for first group and -3.2% for second group (P<0.001). CONCLUSION Lobectomy for cancer can be performed successfully also in selected patients with chronic obstructive pulmonary disease. Post-operative course and survival of these patients is not different from that of patients with normal FEV1, on the contrary, patients with low FEV1 may lose less pulmonary function or even mend it.

Analgesia in patients undergoing thoracotomy: Epidural versus paravertebral technique. A randomized, double-blind, prospective study

BACKGROUND Pain control after thoracotomy prevents postsurgical complications and improves respiratory function. The gold standard for post-thoracotomy analgesia is the epidural catheter. The aim of this study was to compare it with a new technique that involves placement of a catheter in the paravertebral space at the end of surgery under a surgeons direct vision. METHODS From November 2011 to June 2012, 52 patients were randomized into 2 groups depending on catheter placement: an epidural catheter for group A and a paravertebral catheter for group B. At 12, 24, 48, and 72 hours after surgery, the following parameters were recorded: (1) pain control using the patients completion of a visual analog scale module, (2) respiratory function using forced expiratory volume in 1 second and ambient air saturation, and (3) blood cortisol values as an index of systemic reaction to pain. RESULTS Statistically significant differences (P < .05) were found in favor of group B for both cough and rest pain control (P = .002 and .002, respectively) and respiratory function in terms of forced expiratory volume in 1 second and ambient air saturation levels (P = .023 and .001, respectively). No statistically significant differences were found in blood cortisol trends between the 2 groups (P > .05). Collateral effects such as vomiting, nausea, low pressure, or urinary retention were observed only in group A. No collateral effects were recorded in the paravertebral group. CONCLUSIONS According to our data, drugs administered through a paravertebral catheter are very effective. Moreover, it does not present contraindications to its positioning or collateral effects. More studies are necessary to confirm data we collected.

Muscle sparing versus posterolateral thoracotomy for pulmonary lobectomy: randomised controlled trial

Muscle sparing thoracotomy (MST) has been proposed as an alternative to posterolateral thoracotomy (PLT) for pulmonary lobectomy. This issue has been addressed by few clinical reports. To explore that subject, a prospective, controlled randomised, double-blind trial comparing MST through the auscultatory triangle and PLT was planned. The study included patients scheduled for pulmonary lobectomy for stage I or II non-small-cell lung cancer and were followed for three years. The primary endpoints were pain, analgesic consumption and post-thoracotomy pain syndrome. The secondary endpoints included morbidity plus shoulder and pulmonary functions. The trial randomised 100 patients into two groups. Postoperative pain results were similar, although analgesic consumption was higher in the PLT group (P=0.001). The MST group had a shorter hospital stay (P=0.003). Three years post-thoracotomy syndrome was unaffected by the type of incision. The women suffered more than men during the early and late postoperative time. An inverse correlation between incision length and pain was found. Immediate shoulder strength was significantly better in the MST group (P=0.004) but postoperative pulmonary function and complications were comparable. The two incisions results were very similar in the patient outcome, however, few aspects indicated the MST as the more suitable incision for pulmonary lobectomy.

Thermal ablation in the treatment of lung cancer: present and future.

Surgery is considered the best choice for stage I non-small cell lung cancer and also in treatment of selected patients with lung metastasis. However, surgery is often a high-risk procedure because of severe medical comorbidities affecting this cohort of patients. Thermal ablation (TA) has recently been proposed to achieve destruction of lung tumours whilst avoiding the use of general anaesthesia, thereby limiting the invasiveness of the procedure. For pulmonary malignancies, there are two methods of TA based on tissue heating: radio frequency ablation (RFA) and microwave ablation (MWA). Both are mini-invasive procedures, delivering energy to the tumour through single or multiple percutaneous needles introduced under guidance of computed tomography. The procedure may be performed under conscious sedation or general anaesthesia to avoid pain caused by needle insertion and tissue heating. Local efficacy is directly correlated to tumour target size: for RFA, tumours smaller than 2 cm can be completed ablated in 78-96% of cases; for MWA-according to the largest available study-95% of initial ablations are reported to be successful for tumours smaller than 5 cm. Very few series provide survival data beyond 3 years. For nodules smaller than 3 cm, the registered survival rate is higher: 50% at five years. The data collected in the last 10 years allow us to conclude that TA is an established alternative treatment for patients who cannot undergo surgery because of their compromised general condition. In the case of pulmonary metastasis, most authors agree to offer TA only if lesions are smaller than 5 cm.

Clinical management of atypical carcinoid and large-cell neuroendocrine carcinoma: a multicentre study on behalf of the European Association of Thoracic Surgeons (ESTS) Neuroendocrine Tumours of the Lung Working Group †

OBJECTIVES In 2012, the European Society of Thoracic Surgeons (ESTS) created the Lung Neuroendocrine Tumors Working Group (NETs-WG) with the aim to develop scientific knowledge on clinical management of such rare neoplasms. This paper outlines the outcome and prognostic factors of two aggressive NETs: atypical carcinoids (ACs) and large-cell neuroendocrine carcinomas (LCNCs). METHODS Using the ESTS NETs-WG database, we retrospectively collected data on 261 patients in seven institutions in Europe, between 1994 and 2011. We used a Cox regression model to evaluate variables affecting patient survival and disease-free survival. Univariate and multivariate analysis were also carried out. RESULTS Five-year overall survival rates for ACs and LCNCs were 77 vs 28% (P < 0.001), respectively. We found that for ACs, age (P < 0.001), tumour size (P = 0.015) and sub-lobar surgical resection (P = 0.005) were independent negative prognostic factors; for LCNCs, only pTNM stage III tumours (P = 0.016) negatively affected outcome in the multivariate analysis. Local recurrences and distant metastases developed in 93 patients and were statistically more frequent in LCNCs (P = 0.02). CONCLUSIONS The biological aggressiveness of ACs and LCNCs has been demonstrated with this study. Our aim is to confirm these results with enhanced data collection through the ESTS NETs database.

Primary multifocal angiosarcoma of the pleura.

Angiosarcoma is a malignant soft tissue tumor usually located in the dermis of the extremities. It rarely involves the respiratory system, or the pleura, and the prognosis is extremely poor. We present the case of a patient who had a primary multifocal angiosarcoma of the pleura with left-sided chest pain.

Palliative role of percutaneous radiofrequency ablation for severe hemoptysis in an elderly patient with inoperable lung cancer

From the Thoracic Surgery Unit, Ospedale San Paolo, and the Department of Surgery, Fondazione IRCCS Ospedale Maggiore Policlinico Mangiagalli e Regina Elena, University of Milan, Milan, Italy. Disclosures: None. Received for publication Nov 17, 2009; revisions received Jan 8, 2010; accepted for publication Jan 18, 2010; available ahead of print July 2, 2010. Address for reprints: Alessandro Baisi, MD, Thoracic Surgery Unit, Ospedale San Paolo, Via A. di Rudini, 8, 20142 Milano, Italy (E-mail: alessandro.baisi@unimi.it). J Thorac Cardiovasc Surg 2010;140:1196-7 0022-5223/

Relapsing cutaneous Mycobacterium chelonae infection in a lung transplant patient

36.00 Copyright 2010 by The American Association for Thoracic Surgery doi:10.1016/j.jtcvs.2010.01.049

Ground glass opacity and T-factor in staging lung adenocarcinoma.

Lung transplant is a successful method for treating end-stage respiratory failure. Patients with immunosuppression or chronic lung diseases are accepted to be at augmented risk of infection [1]. The association of lung disease and pharmacological immunosuppression in lung transplant patients is associated with a major risk of infection that is one of the leading causes of morbidity and mortality in this group [2]. Mycobacterial infections and, in recent years, nontuberculous mycobacteria (NTM) represent a dangerous complication for solid organ transplanted recipients [3]. Treatment of NTM infection is more challenging in these patients because of drug resistance and interaction with immunosuppressive agents and enhanced toxicity. Several NTM can produce disease in solid organ transplant patients [4]. A small group of NTM is represented by rapidly growing mycobacteria as Mycobacterium fortuitum, Mycobacterium chelonae (MC)/Mycobacterium abscessus (MA) and Mycobacterium smegmatis. Known collectively, being almost identical, MC and MA were identified only with bio-molecular technology evolution, introducing ribosomal gene sequencing [5]. A review of the literature suggests that MC causes localized skin infection in immunocompetent hosts and disseminated disease in immunocompromised patients [6]. In these patients, cutaneous lesions present as red to violaceous subcutaneous nodules that evolve in abscess with multiple fistulas oozing serous or purulent fluid. Lesions can become painful only when large. Generalized symptoms of infection are typically absent [2]. Pulmonary lesions occur in about one-third of patients with cutaneous disease. Diagnosis is made by tissue culture or pathology, but is rarely immediate because of the great variability of pattern, partially depending on host’s immunological status [7]. In January 2002, a 58 years old man, underwent a single lung transplant because of rapidly progressive chronic obstructive pulmonary disease (COPD). He had complicated postoperative course including reperfusion injury, critical illness polyneuropathy and renal impairment, requiring assisted ventilation and haemodialysis for 3 months. On 97th postoperative day, thoracotomic scar presented a painless nodular cutaneous lesion 10 cm in length, with overlying pustules discharging purulent exudate 4 days later (Fig. 1). Physical examination evidenced no sign of systemic infection. At that time he was on cyclosporine 175 mg (2.4 mg/kg), prednisone 25 mg and azathioprine 100 mg, with a serum creatinine of 3.1 mg/dl and a creatinine clearance of 12.21 ml/min. Cyclosporine concentration was maintained around 300 ng/ml. Histopathology of skin biopsies showed polymorphonuclear infiltrate, mimicking bacterial infection. Cultures prepared for bacteria, fungi and mycobacteria were negative. Bronchoscopy with bronchoalveolar lavage and transbronchial biopsies (TBB) excluded rejection and pulmonary infection. Conservative treatment was performed. Affected skin excision and ‘wet to dry’ dressings were repeated twice a day until the 15th day, when skin lesion appeared completely healed. As renal function was still impaired (creatinine clearance of 20 ml/min), empiric antibiotic therapy was postponed. Cyclosporine predose ‘trough’ (C0) level was tapered down from 300 to 180 ng/ml.

Successful primary treatment of bronchial fistula complicating esophagogastrectomy

We have read with interest the paper by Murakawa et al. [1] about the role of ground glass opacity (GGO) on T-factor assessment of lung adenocarcinoma. According to the seventh edition of the TNM classification of the Union for International Cancer Control, the measurement of the diameter of the tumour must include GGO [2]. The GGO component of an adenocarcinoma reflects a non-invasive carcinoma in situ [3] and, including that component, the measurement of the T-factor could be overestimated. To investigate this hypothesis, the authors evaluated the effect of the GGO component of adenocarcinoma on the survival of patients T1–2, N0, M0. The data, supported by four different types of statistical analysis, showed that the recurrence-free survival was dependent on the solid component of the tumour, and that the GGO component has no impact on prognosis. They concluded by suggesting that the T-factor must be measured only on the solid component of the tumour, changing the current TNM classification. We must congratulate the authors for the idea, the complexity of the study and the accurate statistical analysis. However, some criticism can also be presented. The study includes, in the same group, T1–T2 patients (they have a different prognosis), and they are never divided when studying the GGO and solid component. Was the GGO component equally distributed between T1 and T2 tumours? It would be interesting as well, to have some information on the grading of the tumours that also have an impact on survival. The authors assert that the fluorodeoxyglucose-positron emission tomography (FDG-PET) scan was not considered because it was not available for all patients. However, nowadays, we cannot exclude FDG-PET scan results in evaluating lung cancer patients [4, 5] and, in this particular study, we are very curious about the uptake eventually present in GGO and its effect on patient survival. Lastly, it is not reported how the M parameter was studied before surgery, whether all patients were staged in the same way, and whether bone scan and brain evaluation were included. The TNM classification is the more diffuse and accepted staging system of lung cancer, and is commonly used to suggest therapies, compare patient data and make a prognosis. It is also well known that this staging system is not totally affordable. We must keep in mind that patients with very early stage lung cancer can survive for only a few months, while patients with advanced stage lung cancer survive for years despite their dramatic prognosis. This mainly means that lung cancer is a complex entity with a different biological behaviour, and many relevant factors are still unknown. TNM is currently the best way to stage lung cancer patients, but the clinical experience shows that it is not perfect. Any suggestion for improving TNM staging, such as that of Murakawa et al. is therefore welcome, but must be introduced only after a deeper evaluation.