Fabio Massera

Results of surgical management of tuberculosis: Experience in 206 patients undergoing operation

Between January 1978 and December 1990, 206 operations for pulmonary tuberculosis were performed at our institution, a former sanatorium located in northern Italy. Patients with tuberculoma and pleural tuberculous disease were excluded from this series. Cavitary sequelae, bronchiectases, and hemoptysis were the most common indications for resection. Scar cancer and mycetoma were associated diseases in more than 60% of the patients. Healing was achieved in 90% of the patients. Operative mortality was 3%. Overall morbidity was 29.1%. Patient stratification showed that sputum-positive patients had a higher morbidity (30%) and a lower healing rate (86.2%). Before operation, an accurate assessment of both the performance status and the functional reserve of the surgical candidates is emphasized. Despite a high complication rate, aggressive surgical treatment of drug-resistant tuberculosis or its stabilized sequelae is warranted to achieve anatomobiological eradication of the disease, thus avoiding long-term troublesome complications.

Surgical pleurodesis for Vanderschueren's stage III primary spontaneous pneumothorax

The aim of the present study was to determine the impact of various pleurodesis procedures on post-operative morbidity and late recurrence rate after surgical treatment of Vanderschueren’s stage III primary spontaneous pneumothorax. Between January 2001 and June 2004, 208 consecutive patients (169 male and 39 female; mean (range) age 25 (12–39) yrs) were submitted to 220 video-assisted thoracoscopic surgical procedures for primary spontaneous pneumothorax. All patients underwent apical lung resection; 112 were assigned at random to mechanical pleural abrasion (group A) and 108 to apical pleurectomy (group B). The two groups of patients showed similar characteristics. No intra- or post-operative deaths occurred. Post-operative morbidity was 6.25% for group A and 12.9% for group B; the two groups exhibited a similar persistent post-operative air leak rate (5.3% in group A and 5.5% in group B), whereas haemothorax was significantly more frequent after apical pleurectomy (eight (7.4%) cases) than after pleural abrasion (one (0.9%) case). The mean duration of follow-up was 46 (24–66) months. Late recurrence occurred in five cases (4.6%) after apical pleurectomy, and in seven (6.2%) after mechanical pleural abrasion. Mechanical pleural abrasion by video-assisted thoracoscopic surgery is safer than apical pleurectomy in the treatment of primary spontaneous pneumothorax. No differences in late recurrence rate were observed between the two procedures.

Prognostic factors after surgical treatment of lung cancer invading the diaphragm

BACKGROUND Diaphragmatic invasion from lung cancer (T3-diaphragm) is a rare occurrence reported to portend a poor prognosis. METHODS Fifteen patients with T3-diaphragm (14 males, 1 female; median age, 64 years) were surgically treated over a twenty-year period by en bloc resection (14 patients). One patient was only explored. Pathologic stage IIB (T3N0) was found in 11 patients. A partial infiltration of the diaphragm was observed in 3 patients, whereas full-depth invasion was found in 12. Diaphragmatic reconstruction was done primarily in 9 patients, and, by prosthetic material in 5. RESULTS Two patients are still alive without evidence of disease at 88, and, 114 months from surgery. Overall median survival was 23 months (range, 3 to 168). The actuarial 5-year survival was 20%, when all patients were considered, and, 27%, for T3N0 patients. Univariate analysis showed that prosthetic replacement of the muscle (p = 0.018) was significantly related to survival. CONCLUSIONS T3-diaphragm is best treated with en bloc resections with wide tumor-free margins and prosthetic replacement of the diaphragm.

Air-leak management after upper lobectomy in patients with fused fissure and chronic obstructive pulmonary disease: a pilot trial comparing sealant and standard treatment

A pilot trial to compare the efficacy of two different procedures to prevent postoperative air-leak in chronic obstructive pulmonary disease (COPD) patients submitted to upper lobectomy for non-small cell lung cancer. Sixty patients with COPD and lung cancer at the upper pulmonary lobes eligible for lobectomy were enrolled and randomly assigned either to standard treatment (ST) with stapling device or to electrocautery dissection and application of a collagen patch coated with human fibrinogen and thrombin (TachoSil) (experimental treatment [ET]) for the intra-operative completion of their fused fissures. Thirty patients were enrolled in each group during a three-year period. Preoperative characteristics were similar between the two groups. Statistically significant reduction of air-leak was registered in the ET group when overall incidence of postoperative air-leak (55% vs. 96%; P=0.03), postoperative air-leak (mean 1.63+/-1.96 vs. 4.33+/-4.12 days; P=0.0018), chest-drain (mean 3.53+/-1.59 vs. 5.90+/-3.72 days; P=0.0021) and hospital stay duration (mean 5.87+/-1.07 vs. 7.50+/-3.20 days; P=0.01) were considered. The use of TachoSil to prevent postoperative air-leak after interlobar fissure completion in patients with COPD submitted to upper lobectomy seems to be safe and more effective than the ST based on stapling device application.

Pulmonary resection for lung cancer in HIV-positive patients with low (<200 lymphocytes/mm3) CD4+ count

The clinical improvement obtained with combination treatment has modified the therapeutic approach of lung cancer in HIV-positive patients. Aggressive surgical treatment has become a viable option for those patients in whom the CD4(+) cell count was greater than 200 lymphocytes/mm(3). We recently extended our surgical indications to include two HIV-positive patients with lung cancer (stage IIIA and IIB) and low (<200 lymphocytes/mm(3)) CD4(+) count. Both patients underwent a lobectomy and mediastinal nodal dissection. The postoperative course was uneventful. No evidence of recurrent cancer was seen at 12 and 20 months after the operation. Based on this limited experience, we conclude that a low CD4(+) count should not represent, per se, an exclusion criterion for the surgical treatment of pleuropulmonary conditions in HIV-positive patients.

Use of the Proposals of the International Association for the Study of Lung Cancer in the Forthcoming Edition of Lung Cancer Staging System to Predict Long-Term Prognosis of Operated Patients

Purpose:To evaluate the utility of the proposals of the International Association for the Study of Lung Cancer (IASLC) in the forthcoming 7th edition of lung cancer staging system to classify patients submitted to radical surgical resection of non–small cell lung cancer and to compare their value in predicting long-term prognosis with the existing 6th edition of the American Joint Committee on Cancer (AJCC)/Union Internationale Contre le Cancer (UICC) TNM classification. Methods:Nine hundred twenty-one patients received an anatomic resection and hilar-mediastinal dissection for primary non–small cell lung cancer during the period 1990 to 2005. Histopathologic staging following the actual AJCC/UICC TNM classification were as follows: 207 T1, 562 T2, 148 T3, and 4 T4; 570 N0, 149 N1, 198 N2, and 4 N3; 163 stage IA, 346 IB, 23 IIA, 157 IIB, 224 IIIA, and 8 IIIB. Stages reclassified using the proposals of IASLC for the new staging system were as follows: 101 T1a, 106 T1b, 400 T2a, 103 T2b, 210 T3, and 1 T4; 163 stage IA, 262 IB, 157 IIA, 106 IIB, 230 IIIA, and 4 IIIB. Results:Follow-up was obtained for 836 patients. Mean follow-up was 46.5 ± 48.9 months. N-status (unchanged between the 2 classifications) was confirmed to be a significant prognostic factor. Significant differences in 10-year disease-related survival were demonstrated between stages IIB and IIIA only (35% vs 14%) of the AJCC/UICC TNM classification and between stages IB and IIA (60% vs 46%) and stages IIB and IIIA (39% vs 15%) of the IASLC proposals for a new classification. Discussion:The proposals of IASLC in the forthcoming 7th edition of the lung cancer staging system are demonstrated to be better able to separate prognostically distinct groups of patients operated for non–small cell lung cancer than the accepted existing 6th AJCC/UICC TNM classification.

Pulmonary Aspergilloma: Clinical Aspects and Surgical Treatment Outcome

Aspergillomas are fungal balls within lung cavities. The natural history is variable. Hemoptysis is a dangerous sequela. Medical therapy is ineffective because of the lack of a lesion blood supply. Randomized trials are lacking. Surgery should be the treatment of choice in cases of hemoptysis, and even in asymptomatic patients, if lung function is not severely compromised. Cavernostomy and cavernoplasty may be options for high-risk patients. Percutaneous therapy should be reserved for patients who are not fit for surgery. Bronchial artery embolization is appropriate for symptomatic patients not suitable for surgery. Embolization could be considered a preoperative and temporary strategy.

Open Window Thoracostomy for Pleural Empyema Complicating Partial Lung Resection

BACKGROUND Although an open-window thoracostomy (OWT) represents the ideal method for drainage of postpneumonectomy empyema, several controversies exist concerning its application to pleural empyema complicating pulmonary resections less than pneumonectomy. METHODS Between January 1993 and December 2003, 19 patients (16 male and 3 female) were treated for a pleural empyema complicating partial lung resection. The median age was 62 years (range, 17 to 79). Five patients (26%) had a bronchopleural fistula. RESULTS In 2 patients (10%), successful control of the infection was achieved with the OWT. In 10 patients (56%), the OWT was closed by obliteration of pleural cavity with antibiotic solution (2 patients) or intrathoracic muscle transposition (8 patients). OWT closure was successfully performed in all of 5 patients with postoperative pleural empyema due to bronchopleural fistula. Prolonged chest drainage was not successful in any patient with late onset postoperative pleural empyema. Univariate analysis revealed that previous left pulmonary resections (p < 0.05) and timing of OWT (p < 0.001) were significant predictors of empyema healing after pulmonary resections smaller than pneumonectomy. CONCLUSIONS Immediate OWT is a significant predictor of empyema healing after partial lung resection. Smaller pleural cavities appeared to increase the likelihood of healing. Prolonged chest tube drainage failed to control the infection in late onset of postoperative pleural empyema due to entrapped lung.

The solitary pulmonary nodule in patients with previous cancer history: Results of surgical treatment

BACKGROUND The present study was carried out to evaluate the characteristics of solitary pulmonary nodule (SPN) in patients with previous cancer(s) and to analyse the outcome of its surgical treatment. METHODS We retrospectively analysed 131 patients with history of previous malignancy submitted to lung surgery for new identified SPN between January 2004 and December 2009. RESULTS The diagnosis was metastasis in 65 patients, primary lung cancer in 57, benign lesion in 9. Primary lung cancers were significantly larger, had higher maxSUV at CT-PET scanning, occurred after a longer disease-free interval in patients older and with worse lung function when compared with metastatic lesions. Overall survival at 5-year was 67% for benign lesions, 62% for primary lung cancer, 48% for metastatic disease. Histological subtype, SPN diameter less than 2 cm and DFI >36 months were factors influencing long-term prognosis of metastatic patients. Histological subtype and pathological staging were factors influencing long-term outcome of primary lung cancer patients. DISCUSSION Surgical resection of solitary pulmonary nodule is essential in patients with history of previous cancer to rule out benign lesions, to offer diagnostic confirmation and local control of the disease in metastatic tumours and to correctly stage and treat primary lung cancer.

Non-small cell lung cancer in surgically treated women.

AIM AND BACKGROUND To determine whether female patients operated on for non-small cell lung cancer (NSCLC) have a survival advantage compared to male patients. METHODS AND STUDY DESIGN We analyzed data from 1,426 prospectively collected patients submitted to lung resection for NSCLC between 1999 and 2008. RESULTS Two groups, including 1,014 male and 412 female patients, were compared. Female patients were significantly younger, were more frequently asymptomatic, were less likely to be smokers, had better preoperative respiratory function, had a lower frequency of COPD, and were less commonly affected by cardiovascular comorbidity than men. Adenocarcinoma was more frequently present and early pathological stage (stage IA) more frequently detected in women at diagnosis. The operative mortality was significantly lower among women (1.6% vs 4.6%) (P = 0.012), and women underwent significantly more segmentectomies and fewer pneumonectomies (P = 0.001). The disease-related 5-year survival rate was significantly higher in women (66% vs 51%) (P = 0.0008). At univariate analysis the absence of symptoms at presentation, lower pathological stage, squamous cell type, and female gender were positive factors influencing long-term survival. At multivariate analysis low pathological stage, squamous cell type and female gender were confirmed as independent positive prognostic predictors. Women had a significant survival advantage irrespective of the histological subtype at pathological stage IA, IB, IIB and IIIA disease (P <0.05). CONCLUSIONS Female gender was confirmed to be a particular subset amongst patients affected by NSCLC and exerted a positive effect on disease-related survival of patients submitted to surgical resection. This important effect of gender should be cautiously kept in mind in analyzing the results of current and future trials for lung cancer therapy.