Giovanni Donati

Long-term survival of atypical bronchial carcinoids with liver metastases, treated with octreotide

OBJECTIVE To demonstrate that liver metastases by radically resected atypical carcinoids of the lung can be effectively treated by new somatostatin analogs. METHODS Between January 1977 and December 1999, 126 patients affected by bronchial carcinoids were submitted to a radical resection of the lung. Seven of them (5.5%) presented liver metastases 27, 22, 14, 18, 16, 12 and 9 months after surgery: carcinoid syndrome (CS) was ever present. 111In-DTPA-pentetreotide scintigraphy (Octreoscan) and ultrasound guided biopsy were performed in all cases, and the presence of somatostatin receptors sst2 was demonstrated by polymerase chain reaction (PCR) method. RESULTS Five patients refused the proposed chemotherapy, and liver alcoholization was not feasible. Octreotide was administered at the dose of 1500 microg/daily subcutaneously. CS was controlled and also high urinary 5-hydroxyindoleacetic acid values returned to normal after a median of 7 days (range 4-10 days) of medical treatment. No important side effects were registered, and a good quality of life was observed. The patients are alive and well at 51, 36, 24, 24, 23, 19, and 16 months after the diagnosis of the metastases, respectively. In two cases ultrasounds revealed the reduction and in one case the complete resolution of the liver lesion. CONCLUSIONS Octreotide is effective in controlling symptoms of CS of patients with liver metastases of resected atypical bronchial carcinoid. The efficacy of the drug is due to the presence of sst2 somatostatin receptors in the pathologic tissue, as demonstrated by PCR method. The positivity to Octreoscan depends on the presence of the same receptors. Octreoscan may be used in the follow-up of these neuroendocrine neoplasms of the lung. A positivity to Octreoscan is predictive for an effective therapy with octreotide.

Tumours of the thymus: a cohort study of prognostic factors from the European Society of Thoracic Surgeons database

OBJECTIVES A retrospective database was developed by the European Society of Thoracic Surgeons, collecting patients submitted to surgery for thymic tumours to analyse clinico-pathological prognostic predictors. METHODS A total of 2151 incident cases from 35 institutions were collected from 1990 to 2010. Clinical-pathological characteristics were analysed, including age, gender, associated myasthenia gravis stage (Masaoka), World Health Organization histology, type of thymic tumour [thymoma, thymic carcinoma (TC), neuroendocrine thymic tumour (NETT)], type of resection (complete/incomplete), tumour size, adjuvant therapy and recurrence. Primary outcome was overall survival (OS); secondary outcomes were the proportion of incomplete resections, disease-free survival and the cumulative incidence of recurrence (CIR). RESULTS A total of 2030 patients were analysed for OS (1798 thymomas, 191 TCs and 41 NETTs). Ten-year OS was 0.73 (95% confidence interval 0.69-0.75). Complete resection (R0) was achieved in 88% of the patients. Ten-year CIR was 0.12 (0.10-0.15). Predictors of shorter OS were increased age (P < 0-001), stage [III vs I HR 2.66, 1.80-3.92; IV vs I hazard ratio (HR) 4.41, 2.67-7.26], TC (HR 2.39, 1.68-3.40) and NETT (HR 2.59, 1.35-4.99) vs thymomas and incomplete resection (HR 1.74, 1.18-2.57). Risk of recurrence increased with tumour size (P = 0.003), stage (III vs I HR 5.67, 2.80-11.45; IV vs I HR 13.08, 5.70-30.03) and NETT (HR 7.18, 3.48-14.82). Analysis using a propensity score indicates that the administration of adjuvant therapy was beneficial in increasing OS (HR 0.69, 0.49-0.97) in R0 resections. CONCLUSIONS Masaoka stages III-IV, incomplete resection and non-thymoma histology showed a significant impact in increasing recurrence and in worsening survival. The administration of adjuvant therapy after complete resection is associated with improved survival.

Stage I non-small cell lung carcinoma: really an early stage?

OBJECTIVE We review our results on surgical treatment of patients with stage I non-small cell lung carcinoma and we attempted to clarify the prognostic significance of some surgical--pathologic variables. METHODS From 1993 to 1999, 667 patients received curative lung resection and complete hilar and mediastinal lymphadenectomy for non-small cell lung cancer. Of these, there were 436 Stage I disease (65%), of whom 144 T1N0 and 292 T2N0. No patients had pre- or postoperative radio- or chemotherapy. Prognostic significance of the following independent variables was tested using univariate (log-rank) and multivariate (Cox proportional-hazards) analysis: type of resection (sublobar vs lobectomy vs pneumonectomy), histology (squamous cell vs adenocarcinoma), tumour size (<or=3cm vs >3cm), histologic vascular invasion, visceral pleura involvement, positive bronchial resection margin, general T status. RESULTS Overall 5-year survival was 63%. In both univariate and multivariate survival analysis, significant prognostic factors were histology (adenocarcinoma 65% vs squamous cell carcinoma 51%), tumour size (<or=3cm 67% vs >3cm 46%), and the presence of negative resection margin. Five-year survival by general T status was 66% in T1N0 vs 55% in T2N0 disease (P=0.19). CONCLUSIONS Despite advances in early diagnosis and surgical technique, 5-year survival of stage I non-small cell lung carcinoma remains low as compared to survival of other solid organ neoplasm. Tumour size <or=3cm, adenocarcinoma histologic type and negative bronchial resection margins were associated with a more favourable outcome in our patient population. More effective multimodality treatments are needed to increase survival rates.

Primary malignant melanoma of the bronchus intermedius

Melanoma is widely known as the most lethal of all skin cancers, and pulmonary metastases are the most common presentation of advanced disease. Melanoma of the eye, oral mucosa, genital and perineal areas, subungual and plantar surfaces, scalp, and palms are described, and although rare, they together make up about 10% of melanomas. Primary pulmonary melanoma is the rarest type of visceral melanoma: only 20 cases have been previously reported in the English literature. We describe the case of a patient in whom a primary melanoma of the bronchus was diagnosed and radically resected, and we discuss the cause and outcome of this rare pathology.

Post-traumatic hernia of the lung

A 71-year-old male was referred to us after a steer-wheel blunt trauma of the chest. Computed thomography scan of the chest revealed a posttraumatic pulmonary hernia associated with right haemothorax (Fig. 1). Anterolateral right thoracotomy was performed and herniation through the chest wall of the anterior segment of the upper lobe of the lung was detected. The herniated lung was reduced into the pleural cavity and the chest wall was reconstructed by a Prolene mesh. European Journal of Cardio-thoracic Surgery 19 (2001) 360

Acromegaly as Manifestation of a Bronchial Carcinoid Tumour

We have some questions for the Authors: the pulmonary lesion described is a very large and centrally located within the right lung. Diagnosis of bronchial carcinoid was obtained by a transbronchial lung biopsy. But no data are presented about the endobronchial location of the tumour, and the possible presence of mediastinal lymph node enlargementat the thoracic CT scan; the Authors did not perform a preoperative whole boby.111In-DTPA-pentreotide scintigraphy (Octreoscan), which is recognized to be effective in detecting possible mediastinal or distant metastases of neuroendocrine tumours; an upper right lobectomy was performed: did the patient underwent a radical mediastinal and hilar lymphadenectomy? the tumour was assessed as bronchial carcinoid: was it typical or atypical one? a complete immunohistochemical assessment of the neoplasm was performed; in particular somatostatin receptors were detected. Which kind of somatostatin receptors’ subtype did Authors find?

Distant endoarterial bullet migration following penetrating chest injury

A 61-year-old man was referred to us for massive left haemothorax (Fig. 1) following a penetrating thoracic gunshot wound. The entrance wound was between the scapula and the spine; no exit wound was evident. Left coxofemoral X-ray demonstrated the presence of the retained bullet in the left femoral region (Fig. 2). An emergency left thoracotomy was performed and a small regular round laceration of the thoracic aorta was detected and closed with primary suture; a pulmonary upper lobe laceration was sutured too. No other endothoracic lesions were observed. The bullet was detected in the left superficial femoral artery by ultrasonographic examination, and successfully removed with an arteriotomy. The absence of diaphragmatic and abdominal lesions are suggestive of an endoarterial migration of the bullet. The postoperative course was uneventful and the patient was discharged from the hospital in good general condition. European Journal of Cardio-thoracic Surgery 23 (2003) 242