Jan Schutzner

Management of Benign Stenoses of the Large Airways in the University Hospital in Prague, Czech Republic, in 1998–2003

Background: Clinically significant benign stenoses of the large airways develop in about 1% of patients after intubation. The management of benign stenoses is not unified around the world, nor are there any accepted methods for their screening. Objectives: The purpose of this study is to describe and compare results of interventional bronchoscopy and surgical therapy of benign stenoses as well as to propose an algorithm for the management of this airways disorder. Methods: Prospective study on 80 consecutive patients with benign stenoses of the large airways admitted to the Pulmonary Department of the University Hospital of Prague-Motol. Results: Sixty-two patients developed stenoses after endotracheal intubation or tracheostomy, in 18 patients the stenosis was caused by other diseases or pathological situations. Thirty-eight patients were sent for surgical resection of the stenotic part of the airways. 2 surgically treated patients developed recurrence of the stenosis and had to be reoperated on. Narrowing of the trachea at the site of end-to-end anastomosis developed in 6 other patients and was cured by interventional bronchoscopy. The remaining 42 patients were treated by interventional bronchoscopy (Nd-YAG laser, electrocautery, stent) which was curative in 35 patients. Sixty-five patients were alive at the time of evaluation, 15 patients died. Five of them died between 3 and 14 (median 4) months after surgery from a disease other than airway stenosis. Ten nonresected patients also died, with 1 exception, due to a disease other than airway stenosis; the median survival was 9 months. Conclusions: We recommend to assess the patient for surgery after the initial diagnosis and therapeutic bronchoscopy with dilatation of the stenosis. If the patient is not a suitable candidate for resection, interventional bronchoscopy is an appropriate alternative for the management of benign stenoses of the large airways.

Cultivation of circulating tumor cells in esophageal cancer

The presence of circulating tumor cells (CTCs) in patients with metastatic carcinoma is generally associated with poor clinical outcome. There have been many investigations showing a possible use of CTCs as minimally invasive predictive and prognostic biomarker in cancer medicine. In this report a size-based method (MetaCell®) for quick and easy enrichment and cultivation of CTCs is presented to enable possible CTCs use in esophageal cancer (EC) management. In total, 43 patients with diagnosed EC, 20 with adenocarcinoma (AdenoCa) and 23 with squamous cell carcinoma (SCC), were enrolled into the adaptive prospective-like study .All the patients were candidates for surgery. The CTCs were detected in 27 patients (62.8%), with a higher rate in adenocarcinoma (75%) than SCC (52%). Finally, there were 26 patients with resectable tumors exhibiting CTCs-positivity in 69.2% and 17 patients with non-resectable tumors with 41.7% CTCs-positivity. Interestingly, in the patients undergoing neoadjuvant therapy, the CTCs were detected at time of surgery in 55.5% (10/18). The overall size-based filtration approach enabled to isolate viable CTCs and evaluate to their cytomorphological features by means of vital fluorescent staining. The CTCs were cultured in vitro for further downstream applications including immunohistochemical analysis. This is the first report of the successful culturing of esophageal cancer CTCs. The detection of CTCs presence could help in the future to guide timing of surgical treatment in EC patients.

Muscle lymphocytic infiltrates in thymoma-associated myasthenia gravis are phenotypically different from those in polymyositis.

The aim of the study is to provide evidence that the lymphocytic infiltration of myasthenia gravis (MG) muscle do not represent a true autoimmune myositis, rather an infiltration by naive lymphocytes derived from lymphocyte-rich thymomas. Muscle biopsies from 179 patients with pure MG, 6 thymoma patients without MG and 15 patients with definite polymyositis were analyzed. In 18 patients with MG (all associated with lymphocyte-rich thymomas) and in two thymoma patients without MG, lymphocytic infiltrates were identified in muscles. By use of immunohistochemistry, we demonstrated that the lymphocytes in MG differ from those in polymyositis, being mature but in contrast to polymyositis naive CD45RA+ T lymphocytes. We suggest that the lymphocytic infiltrates in patients with MG and thymoma represent an infiltration of muscle by thymoma-derived mature but naive T cells. The finding of CD8+CD45RA+ lymphocytes in muscle may signify an underlying thymoma and should not be misdiagnosed as polymyositis.

Myasthenia gravis, castleman disease, pemphigus, and anti-phospholipid syndrome

Introduction: Myasthenia gravis is an autoimmune disease marked by neuromuscular transmission failure at the neuromuscular junction. Castleman disease is a rare lymphoproliferative disease characterized by non‐cancerous angiofolicular hyperplasia of lymphatic tissue. Methods and results: We describe a young man with rapid, successive manifestations of myasthenia gravis, a solitary form of Castleman disease, pemphigus vulgaris, and anti‐phospholipid syndrome, which resulted in 2 ischemic cerebrovascular events that caused a severe central neurological deficit. Discussion: We were unable to find a similar case in the literature, but we hypothesize that the temporal concidence of these clinical entities may be related to a common immunological pathway, such as B‐cell activation. Therefore, we treated the patient with an immunosuppressant and anticoagulant treatment, as well as rituximab, a monoclonal antibody therapy against CD20+. Muscle Nerve 47:447‐451, 2013

Predictors of atelectasis after pulmonary lobectomy

PurposeTo define the incidence of and factors predisposing to postlobectomy atelectasis (PLA).MethodsThe subjects were 412 patients who underwent pulmonary lobectomy at our hospital between January 2004 and April 2007. This study was performed as a retrospective analysis of our prospective database. Postlobectomy atelectasis was defined as ipsilateral opacification of the involved lobe or segment with an ipsilateral shift of the mediastinum on chest radiograph, requiring bronchoscopy.ResultsPostlobectomy atelectasis developed in 27 patients (6.6%), accounting for 29% of all postoperative pulmonary complications. There were no significant differences between the PLA and no-PLA groups in age, sex, American Society of Anesthesiology performance status, cardiovascular comorbidity, or operation time. Chronic obstructive pulmonary disease (COPD) was the only preoperative variable predictive of PLA (P < 0.05). Right upper lobectomy (RUL), either alone or in combination with right middle lobectomy, was associated with a significantly higher incidence of PLA than any other type of resection (P < 0.05).ConclusionsPostlobectomy atelectasis is an important postoperative complication. Patients with COPD and those undergoing RUL are at higher risk of this complication. Although often isolated, PLA is associated with longer hospital stay.

Jet Ventilation for Fiberoptic Bronchoscopy

ACUTE pulmonary or lobar collapse is a troublesome complication after thoracic surgery and may mandate aggressive intervention. Therapeutic fiberoptic bronchoscopy is a standard intervention for the treatment of atelectasis in the intensive care setting. After tracheal resection, airway management for fiberoptic bronchoscopy in patients with general anesthesia is frequently difficult, particularly in cases in which the resected tracheal segment is long (e.g., 4-5 cm) and the degree of postoperative neck flexion is necessarily extreme. We report a case of intermittent low-frequency jet ventilation, applied via the instrument channel of a flexible fiberoptic bronchoscope (FFB), for the emergency treatment of postoperative atelectasis after tracheal reconstruction.

Long-term outcomes and prognostic factors of patients with pulmonary carcinoid tumors.

The aim of the study was to evaluate type of surgery, long-term survival and factors influencing outcome of pulmonary carcinoid tumors. We reviewed our database of 137 patients surgically treated for typical or atypical carcinoid tumors at our department between 1998 and 2013. There were 95 (69%) patients with typical carcinoid (87 N0, 6 N1, 2 N2) and 42 (31%) with atypical carcinoid (26 N0, 8 N1, 8 N2). Patients with atypical carcinoid were older than those with typical carcinoid (median age of 57±8.1 and 50.5±15.8 years, respectively, p<0.00001). The resection performed consisted of 6 (4.4%) pneumonectomies, 110 (80.1%) lobectomies and bilobectomies, 15 (11%) sleeve lobectomies, 2 (1.5%) resections of main bronchus and 4 (3%) wedge resections. Overall 5- and 10-year survival rates for different tumors were as follows: typical carcinoid: 97.2% and 89.9%, respectively; atypical carcinoid 71.1% and 62.2%, respectively. Statistical analyses indicated that histology (typical carcinoid, p<0.00001), age (less than 45 years, p=0.004) and nodal status (N0, p=0.0002) were significant prognostic factors for better prognosis. Histological sub-type and nodal involvement appear as the most important factors influencing the prognosis. Systemic lymphadenectomy is recommended and should always be performed.

Atrophy of type II fibres in myasthenia gravis muscle in thymectomized patients: steroid-induced change with prognostic impact

Selective atrophy of type II muscle fibres has been long recognized as an enigmatic but consistent feature of myasthenia gravis (MG) muscle; however, the pathophysiology and the mechanism of that change have remained obscure. In the present study, the results of histomorphometric analysis performed on muscle biopsies from 207 thymectomized seropositive MG patients were correlated with clinical features of MG to demonstrate possible pathophysiological associations and potential prognostic impact. The atrophy of type II fibres was verified in 35 cases (16.9%), being more pronounced in fibres of IIB subtype. It was neither significantly associated with the duration and severity of MG nor with the age of the patients. On the other hand, we demonstrated that the atrophy associated with long‐term treatment with corticosteroids, and correlated with increasing doses. Thus, we suppose that the atrophy of type II muscle fibres in seropositive MG is steroid induced rather than MG‐associated event. Although the MG patients with atrophy of type II fibres did not differ from the remaining MG cases in terms of improvement in the disease during the follow‐up period, our analysis provides clear evidence that they presented a significantly slower tendency to reach an asymptomatic state after thymectomy. Therefore, the steroid‐induced atrophy of type II fibres in MG muscle might be considered to be an unfavourable prognostic factor.

The results of surgical treatment of non-small cell lung cancer at the Pneumological Clinic in Prague, Czech Republic 1985-1990.

In the Czech Republic, lung cancer is the most frequent malignant tumor in men. In 1990 the incidence was 99.6/100,000 for men and 15.8/100,000 for women. Neither diagnostic nor therapeutic approaches have changed significantly in the last 10 years. Patients undergoing lung resection have a chance of long-term survival. In this retrospective study, the authors analysed the data of 252 patients undergoing the operation for non-small cell lung cancer (NASCL) in the period 1985-1990. Of all patients who in that period had lung cancer diagnosed in our clinic, only 22% were operated on. Lobectomy was the most frequent type of operation (45%), and exploratory thoracotomy was carried out in 13%. The epidermoid type of cancer was the most frequent one (62%). Comparing cTNM with pTNM, concordant results were found in 55% of the series, 39% were clinically underestimated and 6% overestimated. By the time of the evaluation (31 December 1992), 78% of all patients who had undergone surgery during the study period had died. The most frequent cause of death was lung cancer metastasis. In the subseries of patients who died within 1 month after surgery (10% of all patients), the most frequent cause of death was pneumonia. The survival curve shows the best prognosis for patients in the Ist TNM stage, with 40% surviving 5 years. The authors consider the results of this study to favour aggressive surgical treatment of NSCLC patients.

Comparison of postoperative complications of 60- and 70-year-old patients after lung surgery

This study investigated the association of age and postoperative complications in two different age groups undergoing thoracotomy and pulmonary resection. We retrospectively reviewed the medical records of all patients (n=150) older than 60 years who underwent pulmonary operations between January 2000 and December 2001. Group A consisted of 91 patients at the age of 60-69 years. In group B, there were 59 patients older than 70 years. We recorded preoperative assessment, clinical parameters, pre- and postoperative complications. The incidence of postoperative complications were compared between the two age groups using univariate and multivariate analysis. The incidence of postoperative complications in group A was 30% compared to 35.6% in group B. The most frequent complications were: cardiac arrhythmias 9.9% in group A vs. 15.2% in group B, and prolonged air leak 8.8% in group A vs. 8.5% in group B. Thirty days mortality was 0 vs. 1.2%. We concluded that there was no significantly higher incidence of postoperative complications in these two age groups.