Joseph G. Antkowiak

Operation and photodynamic therapy for pleural mesothelioma: 6-year follow-up

BACKGROUND Conventional therapy for pleural mesothelioma has met with disappointing results. METHODS From 1991 to 1996, 40 patients with malignant pleural mesothelioma were treated with surgical resection followed by immediate intracavitary photodynamic therapy. RESULTS The series included 9 women and 31 men with a mean age of 60 years. Morbidity and treatment-related mortality rates for the entire series, pleurectomy, and extrapleural pneumonectomy were 45% and 7.5%, 39% and 3.6%, and 71% and 28.6%, respectively. Median survival and the estimated 2-year survival rate for the entire series, stages I and II patients (n = 13), and stages III and IV patients (n = 24) were 15 months and 23%, 36 months and 61%, and 10 months and 0%, respectively. Multivariate analysis identified stage, length of hospital stay, photodynamic therapy dose, and nodal status as independent prognostic indicators for survival. CONCLUSIONS Surgical intervention and photodynamic therapy offer good survival results in patients with stage I or II pleural mesothelioma. For patients in stage III or IV, better treatment modalities need to be developed. Improvements in early detection and preoperative staging are necessary for proper patient selection for treatment.

Ischemic conditioning (delay phenomenon) improves esophagogastric anastomotic wound healing in the rat

Esophagogastric anastomotic leaks are a major source of morbidity after esophagectomy. Occult ischemia of the mobilized gastric fundus is an important etiological factor for this failure of healing. To test the hypothesis that ischemic conditioning (delay phenomenon) could improve esophagogastric anastomotic healing, anastomotic healing was studied in a rodent model of partial gastric devascularization.

Primary tumors of the mediastinum

Diagnostic and therapeutic approaches to mediastinal tumors have changed over the past three decades. We reviewed our recent experience with these tumors and assessed the role of a multidisciplinary treatment approach.

Prognostic implications of pulmonary satellite nodules: Are the 1997 staging revisions appropriate?1

In the 1992 AJCC and 1993 UICC staging systems, primary lobe satellite nodules increased the T designation of the primary by one level and ipsilateral non-primary lobe satellite nodules raised the T designation to T4. The recent 1997 UICC and AJCC staging revisions assign a T4 (IIIb) designation to satellite nodules in a primary lobe, and a M1 (IV) designation to satellites in ipsilateral non-primary lobes. There is abundant evidence showing that satellite nodules are negative prognostic factors, but their inclusion in stage IIIb and IV may not be appropriate. The English-language medical literature was searched for papers reporting survival after surgical resection of lung cancer with satellite nodules (primary and non-primary ipsilateral lobe locations). Eleven articles were retrieved and their data pooled for analysis. Of 568 resected patients with satellite nodules, actuarial 5-year survival was 20%. Five articles gave separate survival data for satellite nodules in primary versus ipsilateral non-primary lobes. All five articles showed better survival for satellite nodules in a primary lobe. Satellite nodules in a primary lobe have a better prognosis than those in ipsilateral non-primary lobes. Survival for resected lung cancer with satellite nodules in a primary lobe is better than that usually observed for T4 (IIIB) disease. The 1997 staging revisions may unduly upstage patients with satellite nodules in a primary cancer lobe. However, satellite nodules in ipsilateral non-primary lobes share metastatic mechanisms and have survival results consistent with M1 stage disease. Their 1997 MI designation may be appropriate.

Necrotizing Soft Tissue Infections of the Chest Wall

BACKGROUND Necrotizing soft tissue infections of the chest wall are uncommon, and they have received little discussion in the medical literature. METHODS We performed a collective review of the literature to summarize information on etiology, prevention, treatment, complications, and outcome of chest wall necrotizing soft tissue infections. Manual, Medline, and Current Contents searches of the English-language medical literature were done. RESULTS There were 9 reported cases of necrotizing soft tissue infection of the chest wall. Eight were complications of invasive procedures and operations. Tube thoracostomy for empyema (4 patients) was the most common antecedent procedure. Excessive soft tissue dissection during chest tube insertion was implicated in the genesis of these infections. Necrotizing infections complicated esophageal operations in 2 patients. Overall mortality was 89%. Only 3 of the 9 patients underwent early and adequate debridement. Chest wall stability and wound reconstruction were problematic in patients who survived the initial septic illness. CONCLUSIONS Necrotizing soft tissue infections of the chest wall are highly lethal infections that require urgent and aggressive debridement. Diagnostic delay and inadequate debridement are common reasons for treatment failure. Repetitive surgical debridement is often needed to control sepsis. Wound closure is challenging in patients who survive the initial septic phase of their illness.

Malignant pleural mesothelioma: a problematic review

Malignant pleural mesothelioma is a rare tumor that has been difficult to study. Because of disappointing treatment results, malignant pleural mesothelioma has remained an area of active research and development. A clinicopathologic review is performed in light of several problematic issues involving diagnosis, staging, natural history, and treatment. Multimodality treatment with surgery followed by adjuvant local and systemic therapy remains the most optimal therapy. Many controversial issues still exist in the treatment of malignant pleural mesothelioma. In the ensuing years newer staging systems, better preoperative staging, newer experimental therapies, and the localization of patients at expert centers will undoubtedly have an impact on disease management.

Long-term outcome after pneumonectomy for nonsmall cell lung cancer.

Long‐term survivors (5 or more years) of pneumonectomy for nonsmall cell lung cancer are at risk for late death from cancer recurrence, second primary malignancies, and cardiopulmonary insufficiency related to the adverse physiological effects of pneumonectomy. A retrospective study of pneumonectomy patients was done to quantify the risks of late death from these causes. Of 246 patients treated for nonsmall cell lung cancer by pneumonectomy, medical records of 49 who survived 5 or more years were reviewed. Follow‐up for the 49 long‐term survivors ranged from 60 to 240 months, with a mean of 113 months. Twenty‐five (51%) of the long‐term survivors were alive at the time of the study. Twenty‐four (49%) had died. Causes of death included late lung cancer recurrence (6 patients), second primary malignancies (7 patients), cardiopulmonary insufficiency (4 patients), and miscellaneous causes unrelated to cancer and its treatment (7 patients). Long‐term survival after pneumonectomy for nonsmall cell lung cancer occurs in 20% of patients. Late lung cancer recurrence and second primary malignancies are important causes of death in these patients. Late cardiopulmonary insufficiency related to adverse physiological consequences of pneumonectomy is uncommon. Long‐term follow‐up is recommended after pneumonectomy for nonsmall cell lung cancer.

Bronchogenic carcinoma in young patients.

Some investigators have suggested that lung cancer in young patients has a more aggressive course and poorer prognosis than lung cancer in older patients.