Jon Zabaleta

Percutaneous aspiration versus tube drainage for spontaneous pneumothorax: systematic review and meta-analysis

Spontaneous pneumothorax is an extremely frequent pathology. Despite this, there is still no clear consensus on managing these patients. Therefore, we perform a systematic review and meta-analysis of the effectiveness of percutaneous aspiration compared with tube drainage for treating idiopathic spontaneous pneumothorax. Controlled, randomised clinical trials were selected, in which the effectiveness of percutaneous aspiration is compared with that of chest tube drainage, in terms of resolution of the pneumothorax and rates of relapse and hospital admission. Relevant articles were identified by searching electronic databases (e.g., Medline, EMBASE, CENTRAL, mRCT and Pascal), as well as the references of the papers found in this manner, with a cut-off date of April 2009. Quality was assessed by two independent evaluators, using the CASPe appraisal tool. Effectiveness of percutaneous aspiration is compared with that of chest tube drainage, in terms of resolution of the pneumothorax and rates of relapse and hospital admission.

Survival after pulmonary metastasectomy in colorectal cancer patients: does a history of resected liver metastases worsen the prognosis? A literature review

Objective : To assess the impact of past liver metastases on the survival duration of patients who are undergoing surgery for lung metastases. Methods : We conducted a review of literature published from 2007 to 2014. The studies were identified by searching PubMed, MEDLINE, and Embase and were supplemented by a manual search of the references listed by the retrieved studies. The following search terms were used: lung metastasectomy, pulmonary metastasectomy, lung metastases, and lung metastasis. We selected retrospective and prospective studies published from 2007 to 2014 on patients with lung metastases from colorectal cancer and were undergoing surgery with curative intent. We excluded reviews, studies that focused on surgical techniques, patients who were treated non-surgically, analyses of specific subgroups of patients, and those that did not report follow-up of the patients undergoing surgery. Results : We identified 28 papers that assessed survival after lung metastases, 21 of which were mostly retrospective studies that identified previous liver metastases to explore their impact on patient survival. In more than half of the papers analyzed (63.2%), patients with a history of resected liver metastases had a lower survival rate than those who did not have such a history, and the difference was statistically significant in eight of these studies. However, data were presented differently, and authors reported mean survival time, survival rates, or hazard ratios. Conclusions : A history of liver metastases seems to be a negative prognostic factor, but the individual data need to undergo a meta-analysis.

Lesión intraluminal en la arteria pulmonar: un reto diagnóstico

olineuropatía puede preceder en más de un año al diagnóstico el cáncer, como ocurrió en nuestro caso. En un adulto con polineuropatía periférica e historia de taba3. Roberts WK, Deluca IJ, Thomas A, Fak J, Williams T, Buckley N, et al. Patients with lung cancer and paraneoplastic Hu syndrome harbor HUD-specific type 2 CD8+ T cells. J Clin Invest. 2009;119:2042–51. 4. Leroy T, Porte H, Rousselot C, Taieb S, Outteryck O, Dansin E. Anti-Hu antibody synuismo prolongado, la seropositividad de los autoanticuerpos ucleares anti-neuronales tipo 1 (ANNA-1) también denominados nti-Hu es un marcador de carcinoma microcítico de pulmón3. El ecanismo patogénico de estos anticuerpos sería por acumulación drome: Diagnostic and therapeutic difficulties. Rev Mal Respir. 2013;30:563–6. 5. Graus F, Vega F, Delattre JY, Bonaventura I, René R, Arbaiza D, et al. Plasmapheresis and antineoplastic treatment in CNS paraneoplastic syndromes with antineuronal autoantibodies. Neurology. 1992;42:536–40.

The Presence of Mutations in the K-RAS Gene Does Not Affect Survival after Resection of Pulmonary Metastases from Colorectal Cancer

Introduction. Our objective was to identify mutations in the K-RAS gene in cases of pulmonary metastases from colorectal cancer (CRC) and determine whether their presence was a prognostic factor for survival. Methods. We included all patients with pulmonary metastases from CRC operated on between 1998 and 2010. K-RAS mutations were investigated by direct sequencing of DNA. Differences in survival were explored with the Kaplan-Meier method log-rank tests and multivariate Cox regression analysis. Results. 110 surgical interventions were performed on 90 patients. Factors significantly associated with survival were disease-free interval (P = 0.002), age (P = 0.007), number of metastases (P = 0.001), lymph node involvement (P = 0.007), size of the metastases (P = 0.013), and previous liver metastasis (P = 0.003). Searching in 79 patients, K-RAS mutations were found in 30 cases. We did not find statistically significant differences in survival (P = 0.913) comparing native and mutated K-RAS. We found a higher rate of lung recurrence (P = 0.040) and shorter time to recurrence (P = 0.015) in patients with K-RAS mutations. Gly12Asp mutation was associated with higher recurrence (P = 0.022) and lower survival (P = 0.389). Conclusions. The presence of K-RAS mutations in pulmonary metastases does not affect overall survival but is associated with higher rates of pulmonary recurrence.

Mediastinitis as a Complication after Fine Needle Aspiration using Ultrasound Guided Bronchoscopy

Analysis of the mediastinal lymph nodes is a determining factor for lung cancer staging and, until recently, cervical mediastinoscopy was considered the gold standard for mediastinal staging. However, with the advent of endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA), sensitivity of diagnosing mediastinal ganglia using less invasive techniques seems to have increased. We report the case of a 53-year-old woman diagnosed with a carcinoid tumour in the lower left lobe, in which positron emission tomography showed a maximum standardised uptake value (PET SUVmax) of 4 in a high left paratracheal adenopathy (space 2L). Using real-time EBUS (BFUC180F with Aloka ProSound alpha 5) a swollen lymph node was found in the 2L space and the aspiration needle inserted 3 times. The patient tolerated the procedure well and was discharged the same day. After 48 h, she reported to the general hospital emergency department with erythema over the sternal notch, neck pain and fever. Laboratory tests showed high blood inflammatory markers: Creactive protein (CRP) 219.2 and a white blood count (WBC) of 12,280/mm 3 . The chest radiograph showed no alterations, but a CT scan showed acute mediastinitis in the left superior mediastinum, with prevascular fatty infiltration and left pretracheal affection (Figs. 1a and b). Empirical treatment was initiated with piperacillintazobactam, 4/0.5g iv every 8 hours, and clinical improvement was seen after 5 days, with less erythema and pain. The inflammatory parameters also normalised a week after starting the treatment (PCR 67.7 and leukocyte count 7960).

Mediastinitis como complicación después de una punción-aspiración con aguja fina guiada por ecobroncoscopia

Analysis of the mediastinal lymph nodes is a determining factor for lung cancer staging and, until recently, cervical mediastinoscopy was considered the gold standard for mediastinal staging. However, with the advent of endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA), sensitivity of diagnosing mediastinal ganglia using less invasive techniques seems to have increased. We report the case of a 53-year-old woman diagnosed with a carcinoid tumour in the lower left lobe, in which positron emission tomography showed a maximum standardised uptake value (PET SUVmax) of 4 in a high left paratracheal adenopathy (space 2L). Using real-time EBUS (BFUC180F with Aloka ProSound alpha 5) a swollen lymph node was found in the 2L space and the aspiration needle inserted 3 times. The patient tolerated the procedure well and was discharged the same day. After 48 h, she reported to the general hospital emergency department with erythema over the sternal notch, neck pain and fever. Laboratory tests showed high blood inflammatory markers: Creactive protein (CRP) 219.2 and a white blood count (WBC) of 12,280/mm 3 . The chest radiograph showed no alterations, but a CT scan showed acute mediastinitis in the left superior mediastinum, with prevascular fatty infiltration and left pretracheal affection (Figs. 1a and b). Empirical treatment was initiated with piperacillintazobactam, 4/0.5g iv every 8 hours, and clinical improvement was seen after 5 days, with less erythema and pain. The inflammatory parameters also normalised a week after starting the treatment (PCR 67.7 and leukocyte count 7960).

Determinación de grupo de bajo riesgo para tener nódulos metastásicos no detectados por tomografía axial computarizada en la cirugía de las metástasis pulmonares

INTRODUCTION In recent years, there has been debate regarding the diagnostic accuracy of computed tomography (CT) in the identification of lung metastases and the need for lung palpation to determine the number of metastatic nodules. The aim of this study was to determine in which patients the CT scan was more effective in detecting all metastases. METHODS We studied all patients who underwent curative thoracotomy for pulmonary metastasis between 1998 and 2012. All cases were reviewed by two expert pulmonary radiologists before surgery. Statistical analyses were performed using Systat version 13. RESULTS The study included 183 patients (63.6% male) with a mean age of 61.7 years who underwent 217 interventions. The CT scan was correct in 185 cases (85.3%). Discrepancies observed: 26 patients (11.9%) with more metastases resected than observed and 6 cases (2.8%) with fewer metastases. In patients with one or two metastases of colorectal origin or a single metastasis of any other origin, the probability of finding extra nodules was 9.5%. In the remaining patients, the probability was 27.8%, with statistically significant differences (P=.001). The mean age of the patients in whom no unobserved nodules were detected was 62.9 years compared to 56.5 years on average in patients who were free from any metastases (P=.001). CONCLUSIONS Patients older than 60 years, with one or two metastases of colorectal origin or a single metastasis from any other origin were considered to be the group with low probability of having more metastases resected than observed.

Guía de práctica clínica de la SECT sobre el manejo de pacientes con neumotórax espontáneo

This clinical practice guideline (CPG) emerges as an initiative of the scientific committee of the Spanish Society of Thoracic Surgery. We formulated PICO (patient, intervention, comparison, and outcome) questions on various aspects of spontaneous pneumothorax. For the evaluation of the quality of evidence and preparation of recommendations we followed the guidelines of the Grading of recommendations, Assessment, Development and Evaluation (GRADE) working group.

Cirugía torácica video-asistida y resecciones pulmonares anatómicas. ¿Dónde estamos? Encuesta nacional de la Sociedad Española de Cirugía Torácica

INTRODUCTION The objective of this survey is to find out the cumulated experience and the current situation of video-assisted thoracic surgery (VATS) for anatomical lung resections in Spain. METHODS This is a descriptive study performed from two independent surveys designed through the Survey Monkey® web platform. The first survey was aimed at 53 thoracic surgery departments from the public and state-assisted national health system. The second survey, of a personal nature, was directed at 315 thoracic surgeons in active service, including physicians at their residency program. The surveys were kept operative from 18/11/2014 to 15/01/2015. RESULTS The first survey was answered by 32 (60%) departments and the second by 167 (53%) professionals. A total of 29 (91%) of the thoracic surgery departments represented recognized having some level of experience in this technique. However, a great proportion of departments, 15 (52%), counted less than 100 procedures and the cumulated time of experience was lower than 5 years in 19 (66%) departments. Among all the individual respondents, 126 (77%) admitted having performed the procedure at some point. Of those without any experience, at least 36 (95%) of them recognized that future training in this technique is one of their future professional objectives. CONCLUSIONS Waiting for future prospective national registries contribute further information about the expansion of this technique in our country, the results of the current survey show, up to now, the best reflection of clinical practice and opinion of the surgeons involved in the development of VATS.

Actinomicosis sobre cuerpo extraño que simula una neoplasia pulmonar

characteristic, so diagnosis can be difficult: a lymph node biopsy is required for correct identification, since fine needle aspirates tend to be inconclusive.6 Pathogenesis remains unclear to date, but some authors have suggested that both interferon and interleukin-6 (IL-6) or cell apoptosis may play some role, pointing toward viral5,9,10 or autoimmune9,11 etiologies. It seems clear that KFD is an exaggerated T cell-mediated reaction to a variety of mostly infectious stimuli.5,7,8,12 The course is usually benign, and it resolves in a few months without specific treatment, although some more severe cases have occasionally been reported.5,7,13 Histological findings correspond to 3 disease stages (proliferative, necrotizing and xanthomatous), representing progressive pathological changes.14 The typical immunophenotype of this disease consists a predominance of CD8+ cells over CD4+ T cells. Consistent immunohistochemistry results shows CD68 and CD3+, CD20+/− and CD30−. Histiocytes expressing myeloperoxidase and CD68 are characteristic of this disease.14 Chest radiograph must be obtained from all patients to rule out the possibility of other causes such as neoplasms or TB. Multislice spiral tomography is of particular use in locating the most accessible lymph node for biopsy and for determining the extent of the disease.6 In Peru, a country with a very high prevalence of TB, lymph node involvement is found in a good number of cases. Lymph node biopsy studies are included in diagnostic protocols, and epidemiological factors and other laboratory findings are taken into consideration. However, antituberculosis treatment is sometimes prescribed without hard scientific evidence and before the other etiological options, which would include KFD, have been explored. We therefore hold that is important to include this disease in the differential diagnosis of lymphadenopathies, particularly for lymph node TB, and appropriate studies must be conducted to avoid the prescription of costly drugs that might be unnecessary and carry significant risks for the patient.