Anna Maria Ciccone

Sleeve resection and prosthetic reconstruction of the pulmonary artery for lung cancer

BACKGROUND Lobectomy associated with reconstruction of the pulmonary artery (PA) is a technically feasible alternative to pneumonectomy in patients with lung cancer. However, concern about postoperative complications and long-term survival limited its acceptance so far. METHODS Between 1989 and 1996, we performed a PA reconstruction in 52 patients (41 men, 11 women; age range 35 to 75 years, mean 60 years) with lung cancer. Eleven patients had induction chemotherapy. We performed 15 PA sleeve resections, 34 PA reconstructions by a pericardial patch, and three PA reconstructions by a pericardial conduit, associated with a bronchial sleeve lobectomy or bilobectomy (33), or with standard lobectomy (19). Immediate and long-term postoperative evaluation included spirometry, echocardiography, perfusion lung scans, computed tomography, and PA angiography. The follow-up ranged between 27 and 96 months and is complete for all patients. RESULTS We had one specific postoperative complication (PA thrombosis) and no mortality. Perfusion scans and PA angiography were normal in all but the 1 patient having thrombosis. Mean forced expiratory volume (FEV) in 1 s and forced vital capacity (FVC) were, respectively, 72% and 80% preoperatively, 65% and 76% 1 month after surgery, and then they plateaued at 70% and 78% after 6 months. Echocardiography showed patterns in the normal range and normal estimates of PA pressures in all but 2 patients. Five-year survival was 38.3% for the entire group, 18.6% for stages IIIA and B, and 64.4% for stages I and II. CONCLUSIONS Morbidity, mortality, and functional data do not differ from what is currently reported for standard lobectomy. Long-term survival is in line with that reported for standard resection. These data support PA reconstruction as a viable option in the treatment of lung cancer.

Thymectomy for myasthenia gravis: a 27-year experience

OBJECTIVE Thymectomy is considered an effective therapeutic option for patients with myasthenia gravis (MG). We reviewed our 27-year experience with surgical treatment of MG with respect to long-term results and factors affecting outcome. METHODS Between 1970 and 1997, we performed 232 thymectomies for MG. Fifteen patients were lost to follow-up; the remaining 217 form the object of our study. Sixty-two patients (28.4%) had thymoma. Myasthenia was graded according to a modified Osserman classification: 51 patients (23.5%) were in class I, 81(37.3%) in class IIA, 52 (24%) in class IIB, 26 (12%) in class III and seven (3.2%) in class IV. Mean duration of symptoms before the operation was 12+/-10 months. Fifty-eight thymectomies for thymoma were performed through a median sternotomy and four through a clamshell incision. Forty-six thymectomies for non-thymomatous MG were performed through a standard cervicotomy, 101 procedures through a partial upper sternal-splitting incision and eight through a complete median sternotomy. RESULTS Operative mortality was 0.92% (two patients). After a mean follow-up of 119 months, 71% of all patients improved their clinical status (25% without medications and asymptomatic; 46% with a reduction of medications and/or clinically improved); 39 (18%) have a stable disease with no clinical modifications; 12 (5%) presented a deterioration of their clinical status with worse symptoms, required more medications, or both. Thirteen patients (6%) died because of MG (mean survival 34.3+/-3.6 months). The presence of a thymoma negatively influenced the prognosis. Younger patients showed a more favorable outcome as well as patients with a shorter duration of symptoms before the operation; patients with lower classes of myasthenia showed a higher rate of remission. CONCLUSIONS Thymectomy is effective in the management of patients with MG at all stages with low morbidity. Patients with thymoma present a less favorable outcome.

Induction chemotherapy for T4 centrally located non–small cell lung cancer

OBJECTIVE We used induction chemotherapy in a prospective, single-institution clinical trial intended to achieve resectability in patients with centrally located, unresectable T4 non-small cell lung cancer. Other types of IIIB disease were excluded. METHODS Between January 1990 and April 1996, we enrolled 57 patients with histologically confirmed non-small cell lung cancer. Eligibility criteria for T4 were clinical (superior vena cava syndrome, 9 patients), vocal cord paralysis (6 patients), dysphagia from esophageal involvement (1 patient), radiologic (computed tomography and magnetic resonance evidence of infiltration, 10 patients), bronchoscopic (tracheal infiltration, 11 patients), and thoracoscopic (histologically proven mediastinal infiltration, 20 patients). After 3 cycles of cisplatin (120 mg/m2), vinblastine (4 mg/m2), and mitomycin (2 mg/m2), patients were reevaluated. RESULTS Forty-two patients (73%; 36 men, 6 women; age range, 42-75 years; mean, 58 years) responded to therapy and underwent thoracotomy; 11 patients did not respond, and 4 patients had major toxicity. Thirty-six patients (63% of the entire group) had complete resection. We performed 4 exploratory thoracotomies, 6 pneumonectomies, 32 lobectomies (20 procedures were associated with reconstruction of hilar-mediastinal structures). Overall, 4 patients had no histologic evidence of disease. We had 2 bronchopleural fistulas with 1 death and 5 other major complications. Overall survival at 1 and 4 years is 61.4% and 19.5%, respectively. Forty-two patients (73%) underwent exploratory operation, with a 4-year survival of 25.9%; 36 patients (63%) had complete resection, with a 4-year survival of 30.5%. CONCLUSIONS Induction chemotherapy is effective for downstaging and surgical reconversion of centrally located T4 non-small cell lung cancer. Survival is promising, especially in patients whose disease becomes resectable.

Preimplantation retrograde pneumoplegia in clinical lung transplantation

Abstract Objective: Retrograde pneumoplegia seems to improve early graft function in experimental and clinical lung transplantation. We evaluated the role of retrograde flushing in addition to antegrade pneumoplegia in clinical lung transplantation. Methods: Fourteen patients undergoing lung transplantation were randomized into 2 groups: in group I we performed antegrade pulmonary artery flushing with alprostadil (prostaglandin E 1 ) and modified Euro-Collins solution at the time of retrieval. In group II additional retrograde flushing through the pulmonary veins was performed at the back table, before reimplantation. Hemodynamic variables, mean airway pressure, and blood gas analysis were monitored at different time points. Postoperative volumetric monitoring was performed to assess extravascular lung water. The reimplantation response was assessed by a radiographic score; extubation time and intensive care unit stay were recorded. Results: During retrograde flushing, blood and clots coming out from the pulmonary artery were observed; 2 lungs harvested from a donor with multiple bone fractures had fat emboli in the retrograde perfusate. Hemodynamic monitoring did not demonstrate any difference between the 2 groups. The ratio of arterial oxygen tension to inspired oxygen fraction, extravascular lung water, duration of intubation, and length of stay in the intensive care unit were improved in group II, but the differences did not reach statistical significance. Intrapulmonary shunt fraction was significantly improved in group II at each time point ( P = .02), as well as indexed alveolar-arterial oxygen tension gradient ( P = .04), mean airway pressure ( P = .04), and chest x-ray score ( P = .03). Conclusions: Preimplantation retrograde flushing is not detrimental and helps to improve early graft function. (J Thorac Cardiovasc Surg 1999;118:107-14)

Reconstruction of the pulmonary artery for lung cancer: Long-term results

OBJECTIVE Reconstruction of the pulmonary artery in association with lung resection is technically feasible with low morbidity and mortality. To assess long-term outcome, we report our 20-year experience. METHODS Between 1989 and 2008, we performed pulmonary artery reconstruction in 105 patients with non-small cell lung cancer (tangential resections not included). Twenty-seven patients received induction therapy. We performed 47 pulmonary artery sleeve resections, 55 reconstructions by pericardial patch (with 3 left pneumonectomies under cardiopulmonary bypass), and 3 by pericardial conduit. In 65 patients, a bronchial sleeve resection was associated; in 6 cases superior vena caval reconstruction was also required. Fifteen patients had stage IB disease, 37 stage II, 31 IIIA, and 22 IIIB. Sixty-one patients had epidermoid carcinoma, and 38 adenocarcinoma. Mean follow-up was 46 +/- 40 months. RESULTS The procedure-related complications were 1 pulmonary artery thrombosis requiring completion pneumonectomy and 1 massive hemoptysis leading to death (operative mortality, 0.95%); 28 patients had other complications, with the most frequent prolonged air leakage. Overall 5-year survival was 44%. Five- and 10-year survivals for stages I and II versus stage III were, respectively, 60% versus 28% and 25% versus 12%. Five-year survivals were 52.6% for N0 and N1 nodal involvement versus 20% for N2; 10-year survivals were 28% versus 3%. Multivariate analysis yielded induction therapy, N2 status, adenocarcinoma, and isolated pulmonary artery reconstruction as negative prognostic factors. CONCLUSIONS Pulmonary artery reconstruction is safe, with excellent long-term survival. Our results support this technique as an effective option for patients with lung cancer.

A prospective randomized study to assess the efficacy of a surgical sealant to treat air leaks in lung surgery

OBJECTIVE A prospective, randomized study to evaluate the effectiveness and safety of a polymeric sealant (Coseal, Baxter Healthcare, Deerfield, IL) to reduce air leaks and to improve postoperative outcome in patients undergoing lung resection. METHODS Between November 2005 and February 2008, 203 (128 M, 75 F) patients showing moderate/severe intraoperative air leaks after pulmonary lobectomy/bilobectomy/sleeve lobectomy (110) or minor resection (segmentectomy/wedge) (93) have been prospectively enrolled and randomly assigned to receive one of the two following management strategies: suture/stapling (101 patients--standard care group (SCG)) or suture/stapling plus Coseal sealant (102 patients--Coseal group (CG)). To assess the effectiveness of the sealant the following data were registered and compared in the two groups: number of patients with air leak cessation intraoperatively, number of patients without air leaks at 24h and 48h, duration of air leaks, length of hospital stay. RESULTS No adverse event related to the sealant application occurred. Intraoperative air leak cessation rate was higher in the CG with a statistically significant difference (85.3% vs 59.4%; p<0.001). Air leaks rate at 24h and 48h was significantly lower in the Coseal group (19.6% vs 40.6%; p=0.001 at 24h and 23.5% vs 41.6%; p=0.006 at 48h). Duration of air leaks was significantly shorter in the Coseal group (p=0.01). The hospital stay was shorter in the Coseal group (mean: 5.7+/-2.3 days vs 6.2+/-2.5 days) but this difference did not reach statistical significance owing to the many known clinical interfering factors. CONCLUSIONS The application of Coseal sealant proved safe and effective in reducing air leaks occurring after lung resection and in shortening the duration of postoperative air leak with a trend towards a shorter postoperative hospital stay.

Pulmonary hemodynamics contribute to indicate priority for lung transplantation in patients with cystic fibrosis

OBJECTIVE Lung transplantation is a viable option for patients with cystic fibrosis. The current strategy of selection, based on spirometry and deterioration of quality of life, results in a high mortality on the waiting list. We reviewed the case histories of patients with cystic fibrosis accepted for lung transplantation to ascertain whether pulmonary hemodynamics could contribute to predict life expectancy. METHODS Forty-five patients with cystic fibrosis were accepted: 11 died on the waiting list (group I), 24 underwent transplantation (group II), and 10 are still waiting (group III). During evaluation we recorded spirometry, oxygen requirement, ratio of arterial oxygen tension to inspired oxygen fraction (PaO (2)/FIO (2)), arterial carbon dioxide tension (PaCO (2)), 6-minute walk test results, right ventricular ejection fraction, echocardiography, and pulmonary hemodynamics. We compared data from group I, II, and III patients. A comparison was also made within group II between the data collected at the time of evaluation and at the time of transplantation to quantify the deterioration during the waiting time. RESULTS The waiting time, spirometry, 6-minute walk test results, and right ventricular ejection fraction did not differ among the three groups. A statistically significant difference was found for PaO (2)/FIO (2), PaCO (2), mean pulmonary artery pressure, cardiac index, pulmonary arterial wedge pressure, and intrapulmonary shunt between groups I and II. Groups I and III showed statistically significant differences for mean pulmonary artery pressure, PaO (2)/FIO (2), and systemic vascular resistance indexed. No differences were observed between groups II and III. The comparison within group II showed a significant deterioration of pulmonary hemodynamics during the waiting time. CONCLUSIONS Pulmonary hemodynamics are worst in patients dying on the waiting list and deteriorate significantly during the waiting time. They may thus contribute to establish priority for lung transplantation in patients with cystic fibrosis.

Lung conservation techniques: bronchial sleeve resection and reconstruction of the pulmonary artery.

Bronchial and vascular reconstructive procedures are a technically feasible alternative to pneumonectomy and have the advantage of sparing functioning lung parenchyma. Between 1989 and 1999, we performed bronchovascular sleeve resection and reconstruction in 145 patients (109 men, 36 women; age range, 26 to 76 years, mean, 56 years) with non-small-cell lung cancer (NSCLCL). Forty-one patients had induction chemotherapy and 3 had pre-operative radiotherapy. Immediate and long-term postoperative evaluation included bronchoscopy, spirometry, electrocardiogram, Doppler echocardiography, and perfusion lung scans, computed tomography and, only recently, angio-magnetic resonance (MR) imaging. Follow-up ranged between 3 months and 10 years (mean, 3.7 years) and is complete for all patients. We report the results of this series and conclude that morbidity, mortality, and functional data indicate that bronchovascular reconstructions are equal to standard lobectomy in terms of pulmonary function. Long-term survival is comparable with that reported for standard resection (lobectomy-pneumonectomy). These findings suggest that even complex lung-sparing operations can be proposed as adequate procedures in the treatment of lung cancer as long as a complete anatomical resection is obtained.

Biopsy of anterior mediastinal masses under local anesthesia

Treatment of most primary mediastinal tumors is based on positive histological diagnosis; we describe a variation of anterior mediastinoscopy under local anesthesia. After infiltration with local anesthetic, a transverse skin incision is made in the second, third, or fourth interspace. The endothoracic fascia is incised vertically adjacent to the periosteum and a mediastinoscope is inserted in the mediastinum. Between 1995 and 2001, we have employed this technique in 46 patients with anterior mediastinal tumors. Histological diagnosis was obtained in all patients. Pneumothorax (2 patients) was drained by a tube removed at the end of the procedures. No other complications occurred and all patients were discharged from hospital within 24 hours. Mediastinoscopy under local anesthesia proved safe and effective for diagnosing anterior mediastinal tumors.

Sleeve Lobectomy Compared with Pneumonectomy after Induction Therapy for Non–Small-Cell Lung Cancer

Background: We compared morbidity, mortality, and oncological results of bronchial and/or vascular sleeve lobectomy (SL) with those of pneumonectomy (PN) after induction therapy for lung cancer. Methods: Between 1998 and 2011, 82 patients receiving induction therapy (chemo or chemo-radiotherapy) for non–small-cell-lung-cancer underwent sleeve lobectomy (n = 39) or pneumonectomy (n= 43). Only patients undergoing preoperative chemotherapy (39 in the SL group and 39 in the PN group) were included in the study. SL was bronchial in 21, vascular in 12, and broncho-vascular in six cases, respectively. Clinical stage before induction therapy was IIb in seven patients (1 in PN group; 6 in SL group), IIIa in 66 (36 in PN group; 30 in SL group), and IIIb in five patients (2 in PN group; 3 in SL group), respectively. N3 patients were not included in this series. Results: The rate of downstaged patients (pathological complete response and stage I–II) was 79.5% in the SL group and 53.8% in the PN group (p = 0.01).Postpneumonectomy mortality rate was 2.6 %. There was no postoperative mortality after SL. Complications occurred in 12 patients (30.8%) after PN and in 11 patients (28.2%) after SL (p = 0.6). Three-year and 5-year survival rates were 68 ± 3% and 64 ± 8% in the SL group; and 59.5 ± 5% and 34.5 ± 8% in the PN group (p = 0.02). The difference in terms of recurrence rate (locoregional and distant) between the two groups was not significant (p = 0.2). Conclusions: SL represents a valid therapeutic option even after induction chemotherapy, providing better long-term survival than PN, with no increase of postoperative complications or recurrence rate. Pathological downstaging is a favorable prognostic factor.