Lars Ladegaard

A national study of nodal upstaging after thoracoscopic versus open lobectomy for clinical stage I lung cancer.

BACKGROUND Nodal upstaging after surgical intervention for non-small cell lung cancer (NSCLC) occurs when unsuspected lymph node metastases are found during the final evaluation of surgical specimens. Recent data from The Society of Thoracic Surgery (STS) database demonstrated significantly lower nodal upstaging after thoracoscopic (VATS) lobectomy than after thoracotomy. STS data, however, may be biased from voluntary reporting, and survival was not investigated. We used a complete national registry to compare nodal upstaging and survival after lobectomy by VATS or thoracotomy. METHODS The Danish Lung Cancer Registry was used to identify patients who underwent lobectomy for clinical stage I NSCLC from 2007 to 2011. Patient demographics, comorbidity, preoperative staging, surgical approach, number of lymph nodes harvested, final pathology, and survival were evaluated. Nodal upstaging was identified by comparing cT N M with pT N M. RESULTS Lobectomy for clinical stage I NSCLC was performed in 1,513 patients: 717 (47%) by VATS and 796 (53%) by thoracotomy. Nodal upstaging occurred in 281 patients (18.6%) and was significantly higher after thoracotomy for N1 upstaging (13.1% vs 8.1%; p<0.001) and N2 upstaging (11.5% vs 3.8%; p<0.001). Overall unadjusted survival was significantly higher after VATS, but after adjusting for differences in sex, age, comorbidity, and pT N M by Cox regression analysis, we found no difference between VATS and thoracotomy (hazard ratio, 0.98; 95% confidence interval, 0.80 to 1.22, p=0.88). CONCLUSIONS National data confirm that nodal upstaging was lower after VATS than after open lobectomy for clinical stage I NSCLC. Multivariate survival analysis, however, showed no difference in survival, indicating that differences in nodal upstaging result from patient selection for reasons not captured in our registry.

Sympathicotomy for isolated facial blushing: a randomized clinical trial.

BACKGROUND Facial blushing is one of the most peculiar of human expressions. The pathophysiology is unclear, and the prevalence is unknown. Thoracoscopic sympathectomy may cure the symptom and is increasingly used in patients with isolated facial blushing. The evidence base for the optimal level of targeting the sympathetic chain is limited to retrospective case studies. We present a randomized clinical trial. METHODS 100 patients were randomized (web-based, single-blinded) to rib-oriented (R2 or R2-R3) sympathicotomy for isolated facial blushing at two university hospitals during a 6-year period. Quality of life (QOL) was investigated preoperatively and after 12 months by Short Form 36. Local effects and side effects were assessed by questionnaire. RESULTS The male/female ratio was 27/73. The median age was 29 years (range, 18-56 years. The response rate was 93%. QOL increased significantly in all social and mental domains in both groups. Overall, 85% of the patients had an excellent or satisfactory result, with no significant difference between the R2 procedure and the R2-R3 procedure. Mild recurrence of facial blushing occurred in 30% of patients within the first year. One patient experienced Horners syndrome. Compensatory sweating occurred in 93% of patients, gustatory sweating 36%, and dry hands in 66%; 13% of patients regretted the operation despite thorough preoperative selection and information. CONCLUSIONS There were no significant differences in local effects or side effects between R2 and R2-R3 sympathicotomy for isolated facial blushing. Both were effective, and QOL increased significantly. Despite very frequent side effects, the vast majority of patients were satisfied. Surprisingly, many patients experienced mild recurrent symptoms within the first year; this should always be discussed with patients preoperatively.

Isolated pleural metastases from renal cell carcinoma

A 71-year-old female was referred with three right-sided intrathoracic tumours. In 2003, she underwent radical left nephrectomy for renal cell cancer (RCC) clinical stage 1. She was since followed at her local hospital with annual computed tomography (CT)-scans during the first five years and did not present any symptoms until October 2009 when she was admitted with shortness of breath, cough and tiredness. The patient was scheduled for a diagnostic thoracoscopy when it was discovered that her lesions were not located in the lung parenchyma but were protruding nodules from the parietal pleura. Histology demonstrated metastases from RCC which apparently can reach the parietal pleura without lung metastases.