Jan W.A. Oosterhuis

Trimodality therapy for superior sulcus tumours: Evolution and evaluation of a treatment protocol

AIM We studied the clinical outcomes of a trimodality protocol used for the treatment of superior sulcus tumours (SST) in a tertiary referral centre. METHODS The details of all patients who underwent treatment for a SST between January 2003 and December 2009 were retrospectively analysed. Following pre-treatment staging, all patients underwent concurrent chemoradiotherapy with cisplatin/etoposide, followed by surgery. Outcomes studied were treatment-related complications, pathological response rates, recurrence rates and survival. RESULTS Fifty-four patients were treated by chemotherapy (cisplatin/etoposide) and concurrent radiotherapy (46-66 Gy) followed by surgical resection. Minimum follow-up was 23 months. No 30-day mortality was observed. A complete (R0) resection was performed in 44 out of 54 patients. None had an R2 resection. Two-year survival was 50% (95%CI: 36.7-63.3). Patients who achieved a pathological complete response (n = 16) had a 2-year survival of 81% (95%CI: 62.1-100.0) versus a 37% 2-year survival (95%CI: 21.5-52.1) in patients with remaining vital tumour in their resection specimens (n = 38; P = 0.003). Five patients developed a local recurrence, and 23 patients a distant metastasis, mainly to the brain (n = 15). Two patients died from causes unrelated to cancer. CONCLUSIONS Trimodality treatment of SST in accordance to our protocol achieved results comparable to previous reports. Pathological response rates to induction were an important prognostic factor, and distant metastasis remains a major problem.

Negative pressure dressing for radiation-associated wound dehiscence after posterolateral thoracotomy

Wound complications following surgical resection in patients treated with neoadjuvant chemoradiation therapy are common and can be a difficult problem to manage. Negative pressure dressing technology appears to be safe and effective in the treatment of radiation-associated wound complications and can be used in the outpatients clinic setting. The presented case demonstrates that negative pressure dressing also manages the hydropneumothorax as a result of the dehiscence of the thoracic wall.

En Bloc Resection of 3 Vertebra in a Pancoast Patient: Long-Term Stability Using a Free Vascularized Fibular Graft

Vertebral involvement is no longer a contraindication for resection in superior sulcus tumors. We describe the reconstruction of thoracic vertebras 2 to 4 using a free vascularized fibular graft combined with dorsal and ventral stabilization using rods, screws, and hooks after resection of a superior sulcus tumor that invaded the thoracic spine. No complications have occurred after 7 years of follow-up, and the reconstruction has been durable and stable.

Evaluation of arm function and quality of life after trimodality treatment for superior sulcus tumours

OBJECTIVES Following trimodality treatment for superior sulcus tumours (SSTs), the 5-year survival rate has significantly improved. Quality of life and potential negative effects of this strategy have become more important. The objective of this study was to investigate the quality of life and the arm and shoulder function after the resection of superior sulcus tumours following neoadjuvant chemoradiation. METHODS Patients were selected from a thoracic surgery database. Between January 2002 and December 2010, 72 patients received trimodality treatment of whom 39 were alive at the start of this study in 2010. The following arm function tests were used: nine-hole peg test, range of motion test and action research arm test. Quality of life was assessed using the Disability of the arm and shoulder and SF-36 questionnaires. Analyses of the arm function were conducted comparing the treated side with the untreated side. For quality of life, patients treated on their dominant side were compared with those treated on their non-dominant side. RESULTS In total, 19 patients participated in this study (15 men and 4 women). The median age was 59 years (range 39-73), median radiation dose 50 Gy (range 39-66) and median follow-up 40 months (range 4-101). There was no statistically significant difference in arm and shoulder function between the treated and the untreated arm. However, statistically significantly less pain was found if patients were treated on their dominant side. CONCLUSIONS After the resection of SSTs following chemoradiotherapy, the arm and shoulder function on the affected side is comparable with the functions at the contralateral side. Patients treated for an SST on their dominant side are less affected in their quality of life regarding pain compared with those treated on their non-dominant side.

Access to the Abdominal and Thoracic Cavity

Safe establishment of a pneumoperitoneum is of paramount importance in minimally invasive surgery. Gas insufflation of the abdominal cavity is necessary to create sufficient working space by suppressing the viscera and elevating the abdominal wall. Variously shaped retractors inserted through a small incision and connected to a lifting device have been employed to elevate the anterior abdominal wall and avoid use of gas. However, this technique, gasless laparoscopy, does provide inferior exposure compared to a pneumoperitoneum, and, therefore, has been largely abandoned.

Severe Kyphosis With Spinal Cord Compression After Resection of a Superior Sulcus Tumor

Vertebral involvement is no longer a contraindication for resection of superior sulcus tumors. We describe a patient who developed a kyphoscoliosis with spinal cord compression after resection of a superior sulcus tumor that invaded the vertebral column. Risk factors for spinal instability and indications for stabilization are discussed.

A Nonresponding Small Cell Lung Carcinoma

We present a case with limited disease small cell lung carcinoma with persisting disease and a troublesome syndrome of inappropriate antidiuretic hormone, despite concurrent chemoradiotherapy and second-line chemotherapy. To gain local control, a lobectomy was performed.