Antonio Arnau

Role of major resection in pulmonary metastasectomy for colorectal cancer in the Spanish prospective multicenter study (GECMP-CCR)

BACKGROUND Patients with pulmonary metastases from colorectal cancer (CRC) may benefit from aggressive surgical therapy. The objective of this study was to determine the role of major anatomic resection for pulmonary metastasectomy to improve survival when compared with limited pulmonary resection. PATIENTS AND METHODS Data of 522 patients (64.2% men, mean age 64.5 years) who underwent pulmonary resections with curative intent for CRC metastases over a 2-year period were reviewed. All patients were followed for a minimum of 3 years. Disease-specific survival (DSS) and disease-free survival (DFS) were assessed with the Kaplan-Meier method. Factors associated with DSS and DFS were analyzed using a Cox proportional hazards regression model. RESULTS A total of 394 (75.6%) patients underwent wedge resection, 19 (3.6%) anatomic segmentectomy, 5 (0.9%) lesser resections not described, 100 (19.3%) lobectomy, and 4 (0.8%) pneumonectomy. Accordingly, 104 (19.9%) patients were treated with major anatomic resection and 418 (80.1%) with lesser resection. Operations were carried out with video-assisted thoracoscopic surgery (VATS) in 93 patients. The overall DSS and DFS were 55 and 28.3 months, respectively. Significant differences in DSS and DFS in favor of major resection versus lesser resection (DSS median not reached versus 52.2 months, P = 0.03; DFS median not reached versus 23.9 months, P < 0.001) were found. In the multivariate analysis, major resection appeared to be a protective factor in DSS [hazard ratio (HR) 0.6, 95% confidence interval (CI) 0.41-0.96, P = 0.031] and DFS (HR 0.5, 95% CI 0.36-0.75, P < 0.001). The surgical approach (VATS versus open surgical resection) had no effect on outcome. CONCLUSION Major anatomic resection with lymphadenectomy for pulmonary metastasectomy can be considered in selected CRC patient with sufficient functional reserve to improve the DSS and DFS. Further prospective randomized studies are needed to confirm the present results.

Clinical-therapeutic management of thoracoscopy in pleural effusion: a groundbreaking technique in the twenty-first century.

IntroductionThe aim of this study was to investigate the effectiveness of thoracoscopy in the diagnosis of non-affiliated pleural effusions (PE).Material and methodsA five-year prospective study including data from 110 patients that were clinically diagnosed as benign (14.5%), malign (34.5%) and non-affiliated (50.9%). PE in patents without oncology disease and negative biopsy or cytology were considered as benign. Malignant diagnosis was established according to a pleural biopsy, compatible cytology and/or clinical features. Remaining cases were considered as non-affiliated. Thoracoscopy was done under local anaesthesia and sedation.ResultsThoracoscopy confirmed previous clinical diagnosis of benignity and malignity. Regarding non-affiliated patients, 30.35% were diagnosed after thoracoscopy as unspecific pleuritis, 17.86% mesothelioma and 1.79% pleural tuberculosis (TBC). The other 48.21% of patients reported as non-affiliated were diagnosed with pleural carcinoma. Statistical analysis did not reveal differences between frequencies analysed.ConclusionsOur results indicate that thoracoscopy is a cost-effective and reliable technique for obtaining histological diagnosis in PE and also allows a directed pleurodesis if indicated.

Oxidative lung injury correlates with one-lung ventilation time during pulmonary lobectomy: a study of exhaled breath condensate and blood

OBJECTIVES During lung lobectomy, the operated lung is collapsed and hypoperfused; oxygen deprivation is accompanied by reactive hypoxic pulmonary vasoconstriction. After lung lobectomy, ischaemia present in the collapsed state is followed by expansion-reperfusion and lung injury attributed to the production of reactive oxygen species. The primary objective of this study was to investigate the time course of several markers of oxidative stress simultaneously in exhaled breath condensate and blood and to determine the relationship between oxidative stress and one-lung ventilation time in patients undergoing lung lobectomy. METHODS This single-centre, observational, prospective study included 28 patients with non-small-cell lung cancer who underwent lung lobectomy. We measured the levels of hydrogen peroxide, 8-iso-PGF2α, nitrites plus nitrates and pH in exhaled breath condensate (n = 25). The levels of 8-iso-PGF2α and nitrites plus nitrates were also measured in blood (n = 28). Blood samples and exhaled breath condensate samples were collected from all patients at five time points: preoperatively; during one-lung ventilation, immediately before resuming two-lung ventilation; immediately after resuming two-lung ventilation; 60 min after resuming two-lung ventilation and 180 min after resuming two-lung ventilation. RESULTS Both exhaled breath condensate and blood exhibited significant and simultaneous increases in oxidative-stress markers immediately before two-lung ventilation was resumed. However, all these values underwent larger increases immediately after resuming two-lung ventilation. In both exhaled breath condensate and blood, marker levels significantly and directly correlated with the duration of one-lung ventilation immediately before resuming two-lung ventilation and immediately after resuming two-lung ventilation. Although pH significantly decreased in exhaled breath condensate immediately after resuming two-lung ventilation, these pH values were inversely correlated with the duration of one-lung ventilation. CONCLUSIONS During lung lobectomy, the operated lung is collapsed and oxidative injury occurs, with the levels of markers of oxidative stress increasing simultaneously in exhaled breath condensate and blood during one-lung ventilation. These increases were larger after resuming two-lung ventilation. Increases immediately before resuming two-lung ventilation and immediately after resuming two-lung ventilation were directly correlated with the duration of one-lung ventilation.

Combined thoracotomy and laminectomy for spinal cavernomas with intrathoracic growth

Dumbbell shaped epidural cavernomas are uncommon lesions. Of these, the extraforaminal extension is usually limited, and the lesions are removed surgically by an extended laminectomy. We present two cases of dumbbell shaped epidural cavernomas with a considerable intrathoracic growth. They were resected through a combined thoracotomy and laminectomy. Only in the case in which a wide approach to the posterior mediastinum was performed it was possible to completely remove the lesion. Since it is possible to anticipate this histological diagnosis by the magnetic resonance imaging characteristics, we propose that a wide transthoracic approach should be performed associated to a laminectomy if a complete resection of the lesion is the goal.

Agreement Between Computed Tomography and Pathologic Nodule Counts in Colorectal Lung Metastases

BACKGROUND Computed tomography is the most common technique used to estimate the number of pulmonary metastases and their resectability. A lack of agreement between radiologic and surgical pathologic findings could potentially lead to incomplete resection or to rejection of patients for potentially curative treatments. The objective of this study was to estimate the disagreement between the number of radiologic lesions and the number of histologically confirmed malignant lesions excised from patients with pulmonary metastases from colorectal cancer. METHODS This was a multicenter longitudinal study using a national registry. All patients underwent open surgery for pulmonary metastasectomy. RESULTS Radiologic unilateral involvement was documented in 345 of 404 patients (85%); 253 (73%) presented with single nodules. The radiologic and malignant pathologic findings were concordant in 316 (78%) patients. The two independent predictors of discordance between computed tomography and the number of pathologic metastases were the bilateral involvement and the number of radiologic nodules. This model explained 28% of the variability in the disagreement frequency and discriminated between agreement and disagreement in 85% of the patients. Discrepancies increased with the nodule count with an odds ratio of 6.17 (95% confidence interval, 4.08 to 9.33) per additional nodule. For similar nodule counts, a lower disagreement frequency was observed among bilateral cases (odds ratio, 0.2; 95% confidence interval, 0.07 to 0.55). CONCLUSIONS Differences between the radiologic and pathologic findings were documented in 1 of every 5 patients. The correlation was very accurate in patients with single radiologic nodules. However, half of the patients with more nodules showed discrepancies.

Carta científicaTumor de células gigantes de arco anterior costal, una localización poco habitualGiant cell tumour of the anterior costal margin: A rare location

crecimiento de tipo infiltrativo. La forma de presentación intraductal presenta un crecimiento papilar intraluminal con una incidencia de afectación nodular menor que en el tipo infiltrativo. Si bien puede presentarse con colestasis, lo más frecuente es que el diagnóstico se plantee en el diagnóstico diferencial del tumor hepático. La hemobilia es la presencia de sangre en las vı́as biliares, y suele acompañarse de uno o más de los siguientes signos y sı́ntomas: dolor, hemorrágia gastrointestinal alta (hematemesis o melenas) o ictericia. Encontrar la trı́ada completa sólo aparece en el 22% de los pacientes. El colangiocarcinoma es una causa bien establecida de hemobilia, aunque la hemobilia por causa tumoral ocurre en menos del 10% de los casos. Ası́ pues, los 2 casos que se presentan muestran una posible manifestación del colangiocarcinoma intraductal que debe ser considerada en el diagnostico diferencial de la hemorragia digestiva asociada a obstrucción biliar. b i b l i o g r a f í a

Tumor de células gigantes de arco anterior costal, una localización poco habitual

crecimiento de tipo infiltrativo. La forma de presentación intraductal presenta un crecimiento papilar intraluminal con una incidencia de afectación nodular menor que en el tipo infiltrativo. Si bien puede presentarse con colestasis, lo más frecuente es que el diagnóstico se plantee en el diagnóstico diferencial del tumor hepático. La hemobilia es la presencia de sangre en las vı́as biliares, y suele acompañarse de uno o más de los siguientes signos y sı́ntomas: dolor, hemorrágia gastrointestinal alta (hematemesis o melenas) o ictericia. Encontrar la trı́ada completa sólo aparece en el 22% de los pacientes. El colangiocarcinoma es una causa bien establecida de hemobilia, aunque la hemobilia por causa tumoral ocurre en menos del 10% de los casos. Ası́ pues, los 2 casos que se presentan muestran una posible manifestación del colangiocarcinoma intraductal que debe ser considerada en el diagnostico diferencial de la hemorragia digestiva asociada a obstrucción biliar. b i b l i o g r a f í a

Metástasis pulmonares precoces y tardías de fibrohistiocitoma maligno. Tratamiento quirúrgico

Resumen El fibrohistiocitoma maligno (FHM) constituye la variante histologica del grupo de los sarcomas de partes blandas mas frecuente diagnosticada en el adulto. Es una neoplasia poco comun que se localiza, generalmente, en las extremidades inferiores. Son tumores agresivos, con gran tendencia a la recidiva local y a las metastasis sistemicas tardias. El pulmon y el higado son las localizaciones mas frecuentes. Presenta supervivencias cortas. La cirugia radical es el tratamiento de eleccion. Los pacientes con metastasis pulmonares se benefician de la cirugia. Actualmente la ablacion con radiofrecuencia (RFA) de las metastasis pulmonares es una opcion terapeutica en pacientes en los que la quirurgica se desestima. Presentamos un caso clinico de fibrohistiocitoma maligno pleomorfico inguinal con metastasis pulmonares bilaterales precoces y tardias tratado mediante cirugia.