Julio Astudillo

Preoperative Chemotherapy Plus Surgery Versus Surgery Plus Adjuvant Chemotherapy Versus Surgery Alone in Early-Stage Non–Small-Cell Lung Cancer

PURPOSE To address whether preoperative chemotherapy plus surgery or surgery plus adjuvant chemotherapy prolongs disease-free survival compared with surgery alone among patients with resectable non-small-cell lung cancer. PATIENTS AND METHODS In this phase III trial, 624 patients with stage IA (tumor size > 2 cm), IB, II, or T3N1 were randomly assigned to surgery alone (212 patients), three cycles of preoperative paclitaxel-carboplatin followed by surgery (201 patients), or surgery followed by three cycles of adjuvant paclitaxel-carboplatin (211 patients). The primary end point was disease-free survival. RESULTS In the preoperative arm, 97% of patients started the planned chemotherapy, and radiologic response rate was 53.3%. In the adjuvant arm, 66.2% started the planned chemotherapy. Ninety-four percent of patients underwent surgery; surgical procedures and postoperative mortality were similar across the three arms. Patients in the preoperative arm had a nonsignificant trend toward longer disease-free survival than those assigned to surgery alone (5-year disease-free survival 38.3% v 34.1%; hazard ratio [HR] for progression or death, 0.92; P = .176). Five-year disease-free survival rates were 36.6% in the adjuvant arm versus 34.1% in the surgery arm (HR 0.96; P = .74). CONCLUSION In early-stage patients, no statistically significant differences in disease-free survival were found with the addition of preoperative or adjuvant chemotherapy to surgery. In this trial, in which the treatment decision was made before surgery, more patients were able to receive preoperative than adjuvant treatment.

La ultrasonografía endobronquial lineal como instrumento de diagnóstico inicial en el paciente con ocupación mediastínica

BACKGROUND AND OBJECTIVE Linear endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has proven useful for sampling mediastinal masses and nodes and for staging lung cancer. The aim of this study was to assess the usefulness of this diagnostic tool in patients with indications of mediastinal disease that could not be diagnosed by noninvasive methods or white light bronchoscopy. PATIENTS AND METHODS All patients undergoing linear EBUS-TBNA for the diagnosis of mediastinal masses and/or adenopathy at our endoscopy unit were included in the study. Diagnoses obtained by linear EBUS-TBNA or any surgical technique performed after a nondiagnostic EBUS-TBNA were considered as final. RESULTS In the study population of 128 patients with a mean (SD) age of 62.0 (11.2) years, a total of 294 TBNAs were performed on 12 masses and 282 nodes. Satisfactory samples were obtained in 11 cases (91.7%) from masses and in 233 cases (82.6%) from nodes. Linear EBUS-TBNA was diagnostic, obviating the need for mediastinoscopy in 115 patients (diagnostic sensitivity, 89.8%). The technique confirmed the diagnosis in 85 of the 94 patients with cancer (90.4%), in 8 of the 10 patients with tuberculosis (80.0%), and in the 5 patients with sarcoidosis. CONCLUSIONS Linear EBUS-TBNA is a useful diagnostic tool in patients with mediastinal disease for whom a pathologic diagnosis is not achieved by noninvasive methods or white light bronchoscopy.

Experiencia piloto de benchmarking en cirugía torácica: comparación de la casuística e indicadores de calidad en resección pulmonar

Objetivo En el presente articulo se describen los metodos y las conclusiones del primer estudio espanol de benchmarking en cirugia toracica. Los objetivos propuestos fueron: describir la casuistica de reseccion pulmonar desarrollada en 9 hospitales espanoles, comparar indicadores de calidad entre los 9 centros participantes e identificar y proponer areas de mejora comunes para los procesos de reseccion pulmonar. Metodos Se utilizo como fuente de informacion el conjunto minimo basico de datos de los anos 2002 y 2003 de los procesos de lobectomia o neumonectomia. Los indicadores de resultados seleccionados fueron: mortalidad hospitalaria, morbilidad, estancia y readmisiones urgentes en los 30 dias siguientes al alta, ajustadas por complejidad de los casos. Una vez presentados los resultados entre los participantes, se identificaron las unidades con mejores resultados y se discutieron diversas propuestas de mejora. Resultados Se ha estudiado un total de 1.666 procedimientos (1.276 lobectomias y 390 neumonectomias). Se detectaron diferencias en estancia media, mortalidad, tasa de readmisiones y morbilidad, que permitieron identificar unidades, de complejidad equiparable o superior, con baja mortalidad y estancia. Sin embargo, en estas unidades se apreciaron tasas de morbilidad y readmision mas elevadas. Conclusiones Se propusieron medidas encaminadas a registrar todos los diagnosticos relevantes en los informes de alta, disminuir las estancias inadecuadas y estandarizar los procedimientos que permitiran en el futuro establecer criterios fiables para mejorar la calidad de los procesos de reseccion pulmonar.

Sensitivity of linear endobronchial ultrasonography and guided transbronchial needle aspiration for the identification of nodal metastasis in lung cancer staging.

The aim of this study is to determine the sensitivity of real-time endobronchial ultrasonography (EBUS)-guided transbronchial needle aspiration (TBNA) in lung cancer staging. Short- and long-axis node diameters were measured during EBUS in patients referred for lung cancer staging and sensitivities for the identification of nodal malignancy at TBNA determined. Three hundred fifteen real-time EBUS-guided TBNA nodal sampling procedures were performed in 161 patients and in 87 of them, N2/N3 metastasis was confirmed (50.9%), eliminating the need for mediastinoscopy. The median (interquartile range [IQR]) short-axis diameters of the sampled mediastinal and lobar nodes were 11 (8-15) and 8 (7-12) mm, respectively. TBNA provided satisfactory samples from 269 nodes (85.4%) and a sensitivity of 100% for the identification of malignant TBNA samples was reached for a short-axis diameter cut-off of 5 mm and a short- to long-axis ratio of 0.5. The probability of malignancy was over 90% for nodes with a short-axis diameter >20 mm and 55% for round nodes (short- to long-axis ratio of 1). In 18 out of 50 patients with a normal mediastinal computed tomography (CT) scan, the technique identified enlarged nodes in the mediastinum (36%), mainly in the subcarinal region and confirmed mediastinal malignancy in 8 (10%). Real-time EBUS-guided TBNA obtains satisfactory node samples in almost 90% of cases and improves the identification of enlarged nodes in patients with a normal mediastinum at CT. If sampling all nodes with a short-axis diameter of > or =5 mm and a short- to long-axis ratio > or =0.5, a sensitivity of 100% for the cytologic identification of malignant nodes can be expected.

Randomized double-blind comparison of phrenic nerve infiltration and suprascapular nerve block for ipsilateral shoulder pain after thoracic surgery

OBJECTIVE Despite the use of thoracic epidural analgesia, a constant severe ache occurs in the ipsilateral shoulder of almost 75% of patients after thoracotomy. The aim of this prospective-randomized study was to investigate the effect of phrenic nerve infiltration (PNI) compared with suprascapular nerve block (SNB) on ipsilateral shoulder pain after thoracic surgery. METHODS After Local Research Ethics Committee approval, written informed consent was obtained from 90 adult patients undergoing thoracotomy for pulmonary resection. Patients were excluded if they had preexisting shoulder pain, were unable to understand the visual analog scale (VAS) scoring system or due to failure of epidural analgesia. The phrenic group (PNI) received 10 ml of 2% lidocaine infiltrated into the periphrenic fat pad, 1-2 cm close to the diaphragm, just before chest closure. The suprascapular group (SNB) received 10 ml of 0.5% plain bupivacaine injected into the suprascapular fossa once the surgery was finished. A blinded observer to the study group assessed the patients shoulder and thoracotomy pain, using the VAS score and a five-point observer verbal rating score (OVRS), at 0.5, 1, 2, 3, 4, 5, 6, 12, 48, and 72 h after surgery and at discharge. The time and dose of any administered analgesic medication were recorded. RESULTS Finally, 74 patients were included (37 per group). Sixteen patients were excluded (unable to understand scoring system, failure of the epidural technique, and lost data). There were no significant differences in age, gender, body mass index, type/duration of operation, and pain scores at rest, between the two groups. Shoulder pain intensity was significantly lower in the PNI group compared with the SNB group (median value of VAS area under the curve for the PNI group: 8.1 (0-70.9)cm vs 114.3 (43.8-193.8)cm for the SNB group; p < 0.001). There were no significant differences between the two groups according to postoperative thoracotomy pain. CONCLUSIONS Phrenic nerve block with 2% lidocaine should be performed in all patients undergoing a major thoracic surgery procedure. These results strongly support the hypothesis that irritation of the pericardium and/or mediastinal-diaphragmatic pleural surfaces results in pain that is referred to the shoulder via the phrenic nerve.

Linear Endobronchial Ultrasound as the Initial Diagnostic Tool in Patients With Indications of Mediastinal Disease

Abstract Introduction Linear endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has proven useful for sampling mediastinal masses and nodes and staging lung cancer. The aim of this study was to assess the usefulness of this diagnostic tool in patients with indications of mediastinal disease that could not be diagnosed by noninvasive methods or white light bronchoscopy. Patients and Methods All patients undergoing linear EBUS-TBNA for the diagnosis of mediastinal masses and/or adenopathy at our endoscopy unit were included in the study. Diagnoses obtained by linear EBUSTBNA or any surgical technique performed after a nondiagnostic EBUS-TBNA were considered as final. Results In the study population of 128 patients with a mean (SD) age of 62.0 (11.2) years, a total of 294 TBNAs were performed on 12 masses and 282 nodes. Satisfactory samples were obtained in 11 cases (91.7%) from masses and in 233 cases (82.6%) from nodes. Linear EBUS-TBNA was diagnostic, obviating the need for mediastinoscopy in 115 patients (diagnostic sensitivity, 89.8%). The technique confirmed the diagnosis in 85 of the 94 patients with cancer (90.4%), in 8 of the 10 patients with tuberculosis (80.0%), and in the 5 with sarcoidosis. Conclusions Linear EBUS-TBNA is a useful diagnostic tool in patients with mediastinal disease for whom a pathologic diagnosis is not achieved by noninvasive methods or white light bronchoscopy.

Bloqueo lobular selectivo mediante el bloqueador bronquial de Arndt en 2 pacientes con compromiso respiratorio sometidos a resección pulmonar

En cirugia toracica el bloqueo lobular selectivo representa una alternativa a la ventilacion unipulmonar. Se presentan 2 casos de cirugia de reseccion pulmonar con un compromiso respiratorio grave. El primero, sometido anteriormente a una lobectomia inferior izquierda y 2 resecciones atipicas en lobulos superiores izquierdo y derecho, se programo para una nueva lobectomia del lobulo inferior derecho. El Segundo paciente, que presentaba una enfermedad pulmonar obstructive cronica grave con una capacidad vital forzada de 1.200 ml (26%) y volumen espiratorio forzado en el primer segundo de 820 ml (25%), se programo para reseccion atipica del lobulo superior izquierdo con abrasion pleural. En ambos casos se consiguieron bloqueos lobulares selectivos con el bloqueador endobronquial de Arndt. La ventilacion fue adecuada durante la intervencion. La cirugia transcurrio sin incidencias en ambos casos y el colapso lobular fue correcto.

Pilot Benchmarking Study of Thoracic Surgery in Spain: Comparison of Cases of Lung Resection and Indicators of Quality

OBJECTIVE This article describes the methods and conclusions of the first Spanish benchmarking study of thoracic surgery. The proposed aims were to describe cases of lung resection in 9 Spanish hospitals, compare indicators of quality among the 9 participating centers, and identify and propose common areas where lung-resection processes could be improved. METHODS Information was taken from the minimum basic data set for lobectomy and pneumonectomy processes performed in 2002 and 2003. The chosen outcome indicators were in-hospital mortality, morbidity, length of hospital stay, and emergency readmissions within 30 days of discharge, adjusted according to surgical complexity. Once the results had been analyzed, the participating centers with best outcomes were identified and a variety of proposed improvements were discussed. RESULTS A total of 1666 procedures (1276 lobectomies and 390 pneumectomies) were studied. We found differences in mean length of stay, mortality, readmission rate, and morbidity that identified centers with lower mortality or shorter hospital stay for comparable or more complex surgical procedures. However, higher morbidity and readmission rates were found in these centers. CONCLUSIONS Measures were proposed to ensure that relevant diagnostic information is recorded on discharge. It was also proposed to reduce unnecessarily long hospital stays and to standardize the procedures. With such an approach, reliable criteria that improve the quality of lung-resection processes can be established in the future.

Pseudotumor associated with polytetrafluoroethylene sleeves

We report the case of a patient who was operated on in February 2001. We performed a wedge resection of the upper right lobe. The pathologic examination demonstrated a lung adenocarcinoma (pT2N0M0, R0). We used staple line reinforcement material (ePTFE) during the operation because the patient had an important emphysema. We re-operated in January 2005 because during follow-up we observed a suspicious image that suggested a tumoral relapse. Histopathological study showed extrinsic material compatible with the one used in the original resection.

False positive endobronchial ultrasound-guided real-time transbronchial needle aspiration secondary to bronchial carcinoma in situ at the point of puncture: a case report

Since the development of endobronchial ultrasound-guided real-time needle aspiration (EBUS-rt-TBNA) no false positive (FP) cases have been described. We present the first FP case for EBUS-rt-TBNA secondary to a carcinoma in situ (CIS) in the bronchial point of puncture. A 66-years-old male was referred to our Institution because of a mass in left lower lobe. The bronchoscopy did not show any endobronchial lesion. The cytology of the washing confirmed an unspecified non-small cell lung cancer. An EBUS-rt-TBNA for staging was carried out. No mediastinal nodes over 5 mm length were found but one single left hilar node at station 11 L was sampled. The cytology of the TBNA showed lymphocytes and neoplastic squamous cells. The patient underwent thoracotomy. On the surgical specimen no metastasis on any of the nodes resected were detected but a CIS on the bronchial resection margin was described. A bronchial biopsy confirmed CIS on the bronchial stump. The reported case depicts an unusual situation, we consider EBUS-rt-TBNA an accurate technique if minimal requirements are met