Gershon Fink

Advanced non-small cell lung cancer: induction chemotherapy and chemoradiation before operation

BACKGROUND Induction chemotherapy before operation is beneficial for patients with advanced locoregional non-small cell lung cancer. However, no optimal regimen has been established. This study assesses feasibility, response, resectability, and survival of chemotherapy followed by chemoradiation before operation in patients with non-small cell lung cancer. METHODS Fifty-seven stage IIIA and selected IIIB patients with non-small cell lung cancer received 2/3 cycles of cisplatin and oral etoposide, followed in 3/4 weeks by chemoradiation with daily cisplatin before each radiation fraction. Patients achieving a resectable status underwent operation. RESULTS Response to induction treatment was documented in 73%; 69% achieved a resectable status and 53% underwent operation. Median survival was 16 months. The 1-, 2-, and 3-year survival rates were 65%, 35% and 22%, respectively. There was no difference in survival between stage IIIA and IIIB disease. Myelotoxicity was moderate to severe (grade III/IV in 61% of patients). Three patients died of late complications of pneumonectomy. CONCLUSIONS Our presurgery chemotherapy and chemoradiation protocol yields high response and resectability rates, with moderate to severe myelotoxicity. Pneumonectomy is associated with a relatively high rate of late complications.

Late postoperative pleural effusion following lung transplantation: characteristics and clinical implications

OBJECTIVE Pleural effusions are extremely common in the early postoperative period after lung transplantation (LTX). It occurs in all transplant recipients, and like pleural fluid following other cardiothoracic surgery is bloody, exudative and neutrophil predominant. There was no information, however, on the characteristics of the late (14-45 days) postoperative pleural fluid after LTX. The purpose of this study was to describe the characteristics and the clinical implications of late postoperative pleural effusion after LTX. METHODS Thirty-five patients underwent TX between May 1997 and May 2001. Seven patients (20%) developed late postoperative pleural effusion. Thoracentesis were performed in these patients and the white blood cell counts, cell differential as well as biochemical parameters were determined. RESULTS The median time for late pleural effusion appearance was 23 days (range, 14-34 days) after TX. The pleural effusions were medium in size (700 ml, range, 100-1300), exudative in all the patients and had lymphocyte predominance. No evidence of fluid recurrence or clinical deterioration was noted in these patients. CONCLUSION Late-onset exudative lymphocytic pleural effusion after LTX is not uncommon. When there is no evidence of rejection or infection, it usually has a benign, favorable outcome.

Contribution of cardiopulmonary indices in the assessment of patients with silent and symptomatic ischemia during exercise testing

Cardiopulmonary and radionuclear indices were used to evaluate and compare cardiac function during exercise testing in patients with symptomatic and silent ischemia. The study comprised 58 patients aged 35-74 years, divided into three groups: Group I-20 patients (controls) with neither ST depression nor chest pain; Group II-22 patients with ST depression > 1 mm and no chest pain; Group III-16 patients with both ST depression and chest pain. All patients in Groups II and III demonstrated significant coronary artery disease. No antianginal medication was taken at least 24 h before testing. All patients underwent a cardiopulmonary exercise test and a multigated acquisition radionuclear study. The following variables were measured: oxygen consumption (VO2), CO2 output (VCO2), minute ventilation (VE), O2-pulse, ventilatory anaerobic threshold (VAT), left ventricular ejection fraction (LVEF) at rest (r) and at maximal effort (ex). Probability values were significant for all variables (P < 0.01-0.0001) except left ventricular ejection fraction-rest (P not significant between the three groups). No significant differences in extent of coronary artery disease were noted between Groups II and III. These findings suggest that during exercise testing patients with silent ischemia have better overall cardiac function than patients with symptomatic ischemia. Their value for both cardiopulmonary and radionuclear indices are closer to those of the control group than to the symptomatic group, regardless of the severity of the coronary artery disease Summary of results: (mean +/- 1 S.D.) Group VO2-max O2-Pulse max VAT (%) VAT (ml/min) LVEF-rest delta LVEF (ex-r) I 25.2 +/- 6.3 15.7 +/- 3.4 51.2 +/- 6.6 1075 +/- 289 54.7 +/- 7 5.4 +/- 4.85 II 22.4 +/- 2.8 14.5 +/- 2 47.0 +/- 5.3 854 +/- 136 52 +/- 10 1.2 +/- 6.7 III 16.0 +/- 2.5 11.4 +/- 2 41.6 +/- 7.7 683 +/- 105 51 +/- 8.5 -5.87 +/- 6.3

Elevation of ELISA D-Dimer Levels in Patients with Primary Pulmonary Hypertension

Background: Vasoconstriction, vascular wall remodeling and thrombosis are considered as possible etiologies of primary pulmonary hypertension (PPH). D-dimer, a degradation product of fibrin, has been increasingly used as a marker and prognostic factor in various diseases. Objective: To assess elevated ELISA D-dimer levels as a marker of endogenous fibrinolysis in patients with PPH. Patients and Methods: Comparison of ELISA D-dimer levels of 12 PPH patients (11 female, 1 male) aged 27–73 years (median 51 years) with those of sex- and age-matched healthy controls. Results: Eleven patients had New York Heart Association (NYHA) class III or IV symptoms, and one patient had NYHA class II symptoms. All patients with PPH were treated with anticoagulants and vasodilators: 5 patients were treated with continuous intravenous prostacyclin, 4 patients with continuous UT-15 and 2 patients with intermittent intravenous iloprost. Mean ELISA D-dimer levels ± SD were significantly higher in the PPH group than in the matched control group (473 ± 109 vs. 182 ± 103 ng/ml; mean difference: 291 ± 79, 95% CI: 240–341, p < 0.0001). Conclusion: These results suggest the possible involvement of endogenous fibrinolysis in the pathophysiology of PPH.

Relation between aerobic capacity and extent of myocardial ischemia in patients with normal cardiac function

BACKGROUND The relation between aerobic capacity and extent of exercise-induced myocardial ischemia has not been investigated. Fifty patients with coronary artery disease (>/=50% stenosis) without myocardial infarction underwent cardiopulmonary exercise testing followed by quantitative thallium perfusion imaging. Results were compared with those of age- and sex-matched healthy controls with a low likelihood of coronary artery disease. Patients with Q-wave infarction, pulmonary disease, and peripheral vascular disease were excluded. Cardiopulmonary exercise testing and thallium perfusion imaging parameters were correlated for extent of global ischemia, occurrence of increased pulmonary thallium uptake, and transient ventricular dilatation during exercise. RESULTS Patients with global ischemia <20% (group 1, n = 25) had normal cardiopulmonary exercise testing results, similar to the control group, except for workload and maximal predicted heart rate, which were reduced. However, patients with ischemia >/=20% (group 2, n = 25) had poor cardiopulmonary exercise testing results compared with the controls. The ventilatory anaerobic threshold showed the most significant decrease of all cardiopulmonary exercise testing parameters (48% +/- 6% vs 57% +/- 6%, P <.0001), and it was the only parameter to correlate with extent of ischemia (r = -0.5; P <.003) as well as frequency of increased pulmonary uptake and transient ventricular dilatation (r = -0.33, P =.03). CONCLUSIONS Ventilatory anaerobic threshold is significantly related to extent of myocardial ischemia and signs of heart failure during exercise. However, patients with mild to moderate exercise-induced ischemia may have normal cardiopulmonary exercise testing performance.

Thoracic Empyema in High-Risk Patients: Conservative Management or Surgery?

We retrospectively analyzed the data of 119 patients who were treated for empyema thoracis from 1999 to 2007. There were 87 men with a mean age of 63.9 years (range, 19–79 years) and 32 women with a mean age 55.2 years (range, 26–78 years). The empyema was right-sided in 73 patients and left-sided in 46. The etiology was parapneumonic in 43.7% of cases, postoperative in 42.0%, posttraumatic in 11.8%, and due to other causes in 2.5%. Eight (6.7%) patients underwent surgery on admission because of unstable clinical status; all 8 survived. Fibrinolysis was used in 111 (93.3%) patients; of these, 88 (73.9%) were successfully treated by intrapleural urokinase instillation, and 23 (19.4%) failed treatment and underwent surgery. All 88 patients who had successful fibrinolytic therapy survived, they accounted for 1.8% of the morbidity. In the 23 patients who underwent surgery after failed treatment, there were 3 deaths, accounting for 2.7% overall mortality and 6.3% morbidity. Treating thoracic empyema in patients with significant comorbidities is challenging. Intrapleural urokinase administration might be beneficial in high-risk patients, but in those without significant comorbidities, early surgery may be considered.

Assessment of Functional Results after Percutaneous Transluminal Coronary Angioplasty by Cardiopulmonary Exercise Test

Twenty-nine patients with documented coronary artery disease underwent cardiopulmonary exercise tests before and following a percutaneous transluminal coronary angioplasty (PTCA). The patients medication regimen and exercise protocols remained the same in both cases. Following PTCA, significant improvement (p < 0.001–0.0001) was noted in oxygen consumption (1,526.8 ± 470.0 vs. 1,686.2 ± 390 ml/min), oxygen pulse (12.40 ± 2.73 vs. 13.44 ± 2.9 ml/beat), oxygen pulse score (7.62 ± 1.29 vs. 8.85 ± 1.26 points) and in the ventilatory anaerobic threshold (993.1 ± 177.6 vs. 1,089.8 ± 150.9 ml/min) but not (p > 0.05) in maximal heart rate (128.7 ± 16.9 vs. 132.0 ± 17.2 beats/min). Thus, a cardiopulmonary exercise test is an effective method to assess functional results following PTCA.

The role of fiberoptic bronchoscopy evaluating transplant recipients with suspected pulmonary infections: analysis of 168 cases in a multi-organ transplantation center

ULMONARY INFECTIOUS complications are common in patients after solid organ transplantation (SOT) or bone marrow transplantation (BMT) and are responsible for significant morbidity and mortality. Early diagnosis of infectious complications is extremely important for the outcome of transplant recipients 1‐3 The purpose of this study was to examine the role of fiberoptic bronchoscopy (FOB) in transplant recipients with suspected pulmonary infections. METHODS The study was conducted at the Institute of Pulmonary Medicine. Rabin Medical Center, Beilinson Campus (a tertiary-care university hospital). We retrospectively examined data of patients posttransplantation who required FOB from May 5, 1999 until May 2002. Indications for FOB were suspected pulmonary infection by either abnormal chest X-ray or respiratory symptoms. Lung transplant recipients with surveillance bronchoscopies were excluded from the study. Patients underwent bronchoalveolar lavage (BAL); specimens were analyzed as bacteriology, virology, fungal, and mycobacterial cultures. In 65% of cases, transbronchial biopsies (TBBs) were done; specimens were sent to pathological examination as well as silver and cytomegalovirus (CMV)-specific stains.

Behçet’ Disease (‘Silk Route Disease’) and Mitral Valve Prolapse

Dear Sir, I read with interest the article on cardiac involvement in Behçet’s disease by Morelli et al. [1]. The finding of a high incidence of mitral valve prolapse in 50% of their patients is not surprising. The association of mitral valve prolapse and Behçet’s disease was first reported from China [2]. Shen et al. [3] from Shanghai reported in 1985 also a 50% incidence of mitral valve prolapse in their patients with Behçet’s disease. Behçet’s disease occurs most frequently in Japan and the Mediterranean countries but also in the population linking these two areas to each other [4]. It occurs most frequently between latitudes 30° and 45° north, in Asian and Eurasian populations. This area coincides with the old Silk Route. Thus, Behçet’s disease is sometimes also called ‘Silk Route disease’ [2, 4]. OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO

Effect of Controlled Exercise Training in Coronary Artery Disease Patients with and without Left Ventricular Dysfunction Assessed by Cardiopulmonary Indices

Cardiopulmonary indices were used to evaluate the effect of controlled exercise training prescribed on the basis of the heart rate at the ventilatory anaerobic threshold in coronary artery disease patients with and without impaired left ventricular function. Fifty-two patients aged 38-75 years were divided into four groups. The first three groups included patients with a left ventricular ejection fraction of > 45% at rest, as follows: group 1, 10 patients with single-vessel disease; group 2, 12 patients with two-vessel disease; group 3, 10 patients with three-vessel disease. Group 4 comprised 20 patients with left ventricular dysfunction (ejection fraction < 35%). The left ventricular ejection fraction was assessed by multigated acquisition radionuclear study. All patients underwent a cardiopulmonary exercise test before and after the program which lasted 6-9 months. The variables measured were oxygen consumption (VO2), CO2 output, minute ventilation, O2 pulse, and ventilatory anaerobic threshold. Significant improvements in maximal VO2, maximal O2 pulse, and ventilatory anaerobic threshold level were observed in groups 1, 2, and 4 (p < 0.1-0.0001), but not in group 3. These findings indicate that the overall cardiac function, as evaluated by cardiopulmonary indices, improves in patients with one- or two-vessel disease with good left ventricular function and in patients with impaired left ventricular function following an exercise training program. Severe coronary disease seems to limit improvement, even in the presence of a good left ventricular function. The results validate the heart rate at the ventilatory anaerobic threshold as the optimal training heart rate in coronary artery disease patients and the cardiopulmonary exercise test as a sensitive tool for evaluating exercise training results.