Jacek Alchimowicz

Additional pulmonary resections after pneumonectomy: actual long-term survival and functional results

OBJECTIVE Pulmonary resections after pneumonectomy due to metastases or metachronous non-small cell lung cancer (NSCLC) are rare because of the high potential risk of the second procedure and uncertain long-term results. On the basis of our series (largest in Europe) we tried to assess the long-term survival of patients treated in stage IV NSCLC. METHODS Retrospective analysis was carried out on 18 patients treated at our department by pneumonectomy followed by additional resection in the years 1981-2002 (15 males and 3 females, 44-69 years, mean 57). Eleven pneumonectomies were performed on the right side and seven on the left. Twelve squamous cell carcinomas and six adenocarcinomas were diagnosed. All patients were staged postoperatively as IIB-IIIA (four were N2). Their WHO status ranged between 0 and 1. The second surgical procedure (16 wedge resections, 2 chest wall resections) was performed 4-106 months later (mean 26). The patients staged N2 were radiated postoperatively. RESULTS There were no early postoperative deaths. The morbidity rate after second surgery was comparable to that observed after ordinary wedge resection. Histology of the lesions removed during the second operation was the same as after pneumonectomy in all patients. The pulmonary function tests (PFT) results worsened significantly but still reached 56-63% of the predicted values. Sixteen resected tumors of the remaining lung were staged T1 (<3cm), 2 - T3 (<3cm but infiltration of the parietal pleura on an area of 2-4cm(2)). Three patients revealed N2 disease (they were all N0 after pneumonectomy). All patients were considered M1 after second surgery. WHO status after the second procedure remained the same in 8 patients (44%) and worsened in 10 patients (56%). The survival rates were as follows: 11 patients survived 2 years (61%) while 8 patients survived 5 years (44%). The majority of patients died due to lung cancer (70%) but all the rest (30%) due to circulatory or respiratory insufficiency. There was a significant difference (p<0.05) in 5-year survival for N0-N1 vs N2 status (63% vs 14% - 1 patient) and also regarding the time interval between surgeries: less than 12 months vs more than 12 months (0% vs 63%). CONCLUSIONS Pulmonary resections performed after pneumonectomy due to NSCLC are rare procedures but with an acceptable perioperative risk. The second procedure should be limited to wedge resection. The prognosis is poor for patients with N2 status and for those treated by second surgery earlier than 12 months after the first procedure.

The impact of the sequence of pulmonary vessel ligation during anatomic resection for lung cancer on long-term survival - a prospective randomized trial

PURPOSE The aim of this prospective randomized trial was to assess the influence of the sequence of pulmonary vessel ligation, during anatomic resection, on long term survival in patients with NSCLC. MATERIAL/METHODS This prospective randomized study included 385 patients treated surgically with lobectomy or pneumonectomy and standard lymphadenectomy between 1999 and 2003. Patients were randomly assigned to either primary ligation of the pulmonary artery or arteries (group A - 215 patients) or of the pulmonary vein or veins (group V - 170 patients). Patients were excluded if the sequence of vessel ligation was affected by technical difficulties or anatomic limitations. Univariate and multivariate analyses included: the sequence of vessel ligation, age, gender, tumor histology, stage (TNM), and cause of death (cancer related or non-cancer related). RESULTS Median follow-up was 63 months. The groups were comparable regarding gender, histology, type of resection, and T, N, and overall stage. Overall, 5-year survival reached 50% in group A and 54% in group V (p = 0.82) and did not differ significantly in cancer related and non-cancer related deaths (p = 0.67 and p = 0.26, respectively). Univariate analysis identified higher T and N factors, advanced stage, pneumonectomy, male sex, and older age as negative prognostic factors. Multivariate analysis demonstrated that age, T3-4 disease, and nodal involvement were associated with inferior survival. CONCLUSIONS The sequence of pulmonary vessel ligation during anatomic resection for non-small cell lung cancer does not significantly affect long-term survival.

The assessment of the role of baseline low-dose CT scan in patients at high risk of lung cancer.

Summary Background Despite the progress in contemporary medicine comprising diagnostic and therapeutic methods, lung cancer is still one of the biggest health concerns in many countries of the world. The main purpose of the study was to evaluate the detection rate of pulmonary nodules and lung cancer in the initial, helical low-dose CT of the chest as well as the analysis of the relationship between the size and the histopathological character of the detected nodules. Material/Methods We retrospectively evaluated 1999 initial, consecutive results of the CT examinations performed within the framework of early lung cancer detection program initiated in Szczecin. The project enrolled persons of both sexes, aged 55–65 years, with at least 20 pack-years of cigarette smoking or current smokers. The analysis included assessment of the number of positive results and the evaluation of the detected nodules in relationship to their size. All of the nodules were classified into I of VI groups and subsequently compared with histopathological type of the neoplastic and nonneoplastic pulmonary lesions. Results Pulmonary nodules were detected in 921 (46%) subjects. What is more, malignant lesions as well as lung cancer were significantly, more frequently discovered in the group of asymptomatic nodules of the largest dimension exceeding 15 mm. Conclusions The initial, low-dose helical CT of the lungs performed in high risk individuals enables detection of appreciable number of indeterminate pulmonary nodules. In most of the asymptomatic patients with histopathologically proven pulmonary nodules greater than 15 mm, the mentioned lesions are malignant, what warrants further, intensified diagnostics.

Diagnostic and therapeutic difficulties in mediastinal fibromatosis. Case report

Mediastinal fibromatosis is a very rare mesenchymal tumor originated from fibrous tissue. A case of 26-year old men with mediastinal tumor causes respiratory insufficiency and dysphagia is described. This sympthoms occured due to esophageal impression and infiltration with occlusion of main left bronchus by mediastinal tumor. Ethiology of the tumor was established based on histopathology assesment of the tissue samples taken during explorative thoracotomy after 3 years and many other diagnostic procedures undertaken. The authors describe difficulties in diagnosis of mediastinal tumors, especially those rare observed.

Acquired hemophilia A as a cause of recurrent bleeding into the pleural cavity – and literature review

Acquired hemophilia A is a coagulation disorder caused by autoantibodies against blood coagulation factor VIII. The first sign of this disease is often massive bleeding, which can affect patients after routine procedures. The parameter which indicates the presence of this condition is isolated prolonged activated partial thromboplastin time (APTT). The present article describes a case of a 32-year-old man with acute interstitial pneumonia and pleural effusion, in whom a massive hemothorax appeared after thoracocentesis; active bleeding was observed after the introduction of a chest tube. The patient was operated on, and no pinpoint bleeding was discovered during the procedure. Active bleeding was still taking place postoperatively. The patient underwent another operation after 6 days. Once more, no pinpoint bleeding was found. Prolonged APTT was observed. The activity of blood coagulation factor VIII was 3.04%. The presence of antibodies against factor VIII was confirmed, and acquired hemophilia was diagnosed. The article also includes an analysis of the literature on acquired hemophilia.

Acquired hemophilia A as a cause of recurrent bleeding into the pleural cavity - case report and literature review

Acquired hemophilia A is a coagulation disorder caused by autoantibodies against blood coagulation factor VIII. The first sign of this disease is often massive bleeding, which can affect patients after routine procedures. The parameter which indicates the presence of this condition is isolated prolonged activated partial thromboplastin time (APTT). The present article describes a case of a 32-year-old man with acute interstitial pneumonia and pleural effusion, in whom a massive hemothorax appeared after thoracocentesis; active bleeding was observed after the introduction of a chest tube. The patient was operated on, and no pinpoint bleeding was discovered during the procedure. Active bleeding was still taking place postoperatively. The patient underwent another operation after 6 days. Once more, no pinpoint bleeding was found. Prolonged APTT was observed. The activity of blood coagulation factor VIII was 3.04%. The presence of antibodies against factor VIII was confirmed, and acquired hemophilia was diagnosed. The article also includes an analysis of the literature on acquired hemophilia.

CASE REPORTS Acquired hemophilia A as a cause of recurrent bleeding into the pleural cavity – case report and literature review

Acquired hemophilia A is a coagulation disorder caused by autoantibodies against blood coagulation factor VIII. The first sign of this disease is often massive bleeding, which can affect patients after routine procedures. The parameter which indicates the presence of this condition is isolated prolonged activated partial thromboplastin time (APTT). The present article describes a case of a 32-year-old man with acute interstitial pneumonia and pleural effusion, in whom a massive hemothorax appeared after thoracocentesis; active bleeding was observed after the introduction of a chest tube. The patient was operated on, and no pinpoint bleeding was discovered during the procedure. Active bleeding was still taking place postoperatively. The patient underwent another operation after 6 days. Once more, no pinpoint bleeding was found. Prolonged APTT was observed. The activity of blood coagulation factor VIII was 3.04%. The presence of antibodies against factor VIII was confirmed, and acquired hemophilia was diagnosed. The article also includes an analysis of the literature on acquired hemophilia.