Luís Eugénio

Lung metastases from colorectal cancer: surgical resection and prognostic factors

OBJECTIVE To analyse our experience with excision of lung metastases from colorectal carcinoma (CRC), and to evaluate clinically relevant prognostic factors, identifying the cluster of patients who would benefit from this procedure. METHODS Sixty-one patients, 42 men (69%), with primary CRC who underwent 94 curative resections of pulmonary metastases were retrospectively reviewed. Age was 30-80 years (mean 61.2+/-15). Population was analysed for age, sex, disease-free interval (DFI), prethoracotomy carcinoembryonic antigen (CEA) level, location and histology of primary tumour, number of lung lesions (and size of largest resected metastasis), type of lung resection, nodal involvement (hilar/mediastinal), use of adjuvant treatment, morbid-mortality and immediate and follow-up survival. RESULTS Mean DFI was 29+/-22 months (range 5-132 months). There was no hospital mortality and significant morbidity occurred in five patients (8.2%). Mean follow-up was 39+/-4 months (range 4-173 months). Mean overall survival and disease-free survival were 67+/-16 months and 52+/-6 months, respectively. Three-, 5- and 10-year survival rates from date of primary colorectal resection were 83%, 71% and 43%, respectively. Three-, 5- and 10-year survival rates from date of lung resection were 61%, 48% and 11%, respectively. Five-year survival was 57% in patients with normal prethoracotomy CEA levels and 18% for those with high levels (>5 ng/ml) (p=0.039). CONCLUSIONS Pulmonary metastasectomy has potential survival benefit for patients with metastatic colorectal carcinoma. Low morbidity and mortality rates, contrasting with lack of any other effective therapy, justify aggressive surgical management. Single deposits, DFI >36 months and normal prethoracotomy serum CEA were significant independent prognostic factors.

Detection of S1 and S2 Heart Sounds by High Frequency Signatures

A new unsupervised and low complexity method for detection of S1 and S2 components of heart sound without the ECG reference is described The most reliable and invariant feature applied in current state-of-the-art of unsupervised heart sound segmentation algorithms is implicitly or explicitly the S1-S2 interval regularity. However; this criterion is inherently prone to noise influence and does not appropriately tackle the heart sound segmentation of arrhythmic cases. A solution based upon a high frequency marker; which is extracted from heart sound using the fast wavelet decomposition, is proposed in order to estimate instantaneous heart rate. This marker is physiologically motivated by the accentuated pressure differences found across heart valves, both in native and prosthetic valves, which leads to distinct high frequency signatures of the valve closing sounds. The algorithm has been validated with heart sound samples collected from patients with mechanical and bio prosthetic heart valve implants in different locations, as well as with patients with native valves. This approach exhibits high sensitivity and specificity without being dependent on the valve type nor their implant position. Further more, it exhibits invariance with respect to normal sinus rhythm (NSR) arrhythmias and sound recording location

Surgery for bronchiectasis.

OBJECTIVE The incidence of bronchiectasis has declined markedly in developed countries. However, a reasonable number of patients still need surgery, despite aggressive physiotherapy and antibiotic therapy. We have reviewed our patients to clarify the benefits from surgery and to analyse the complications. MATERIAL AND METHODS Between 1988 and 1999, we have operated on 119 patients with bronchiectasis, 71 female and 48 male, with a mean age of 42.2 years (range 11--77 years). Surgery was indicated because of unsuccessful medical therapy in 66 patients (55%), 31 (26%) had haemoptysis, 11 (9.2%) had lung abscess, 10 (8.4%) had lung masses, and three (2.5%) had pneumothorax. The most common manifestations were cough with sputum in 90 patients (76%), haemoptysis in 45 (38%) and recurrent infections in 57 (48%). The mean duration of the symptoms was 4 years (range 1--40 years). The lower lobes were diseased in 61 patients and bilateral disease was found in ten. The mean number of involved pulmonary segments was five (range 1-15). A lobectomy was performed in 75 patients (62%), a segmentectomy in 12 (10%), a pneumonectomy in nine (7.4%) and a bilobectomy in four (3.3%). Complete resection of the disease was achieved in 108 cases (91%). RESULTS There was no operative mortality and perioperative morbidity occurred in 15 patients (15%), including temporary broncho-pleural fistulae in 7 (5.8%), and post-operative haemorrhage and atrial arrhythmias in four (3.3%) each. After a mean follow-up was 4.5 years, 73 patients (68%) of this group were asymptomatic, and 31 (29%) had meaningful clinical improvement, while only four (3.7%) maintained or worsened prior symptoms. The best clinical improvement occurred in patients with complete resection of the disease (P=0.008). There were no differences in the respiratory function, comparing pre- and post-operative data, with a 2-year of minimum interval. The VC was 91 and 89% and the FEV1 was 83% and 81% of expected, respectively before and after surgery, (P=NS). CONCLUSION Surgery of pulmonary bronchiectasis has few complications and markedly improves symptoms in the great majority of patients, especially when complete resection of the disease is achieved. Pulmonary resection of bronchiectasis does not alter respiratory function.

Excision of pulmonary metastases of osteogenic sarcoma of the limbs.

OBJECTIVE The combination of surgery and chemotherapy improves the prognosis of patients with osteogenic sarcoma of the limbs without detectable metastases at presentation. However, lung metastases are a frequent complication. To evaluate the role of the resection of pulmonary metastases of osteogenic sarcoma of the limbs, we have reviewed our experience with this type of surgery, combined with a multidrug chemotherapy protocol. PATIENTS AND METHODS From January 89 to December 97, 198 patients operated on for osteogenic sarcomas of the limbs were followed in our centre. Of these, 31 patients (15.7%), with a mean age of 25 years (range 10-54 years), developed lung metastases and had undergone 45 thoracotomies. All patients received chemotherapy, followed by resection of metastatic lesions and additional chemotherapy. The mean time interval between resection of the primary tumour and the diagnosis of lung metastases was 22 months (4-122 months). Eight patients (25.8%) needed more than one (2-4) thoracotomy. The mean time interval between the first and second thoracic surgeries was 9.2 months (2-14 months). RESULTS There was no operative mortality or major morbidity. During the 45 thoracotomies, five lobectomies and 40 wedge resections were necessary. The mean number of metastases resected per thoracotomy was 3.4 (range 1-10). The degree of necrosis was evaluated by seriated sections for a histologic study. In the end the mean necrotic volume was calculated. A strong correlation was found between the degree of necrosis of the metastases and the need for reoperation for new metastatic lesions, because all the patients who needed more than one operation had less than 80% of necrosis of metastases. The patients were followed for a mean period of 28 months (6-72 months). Ten patients (32.2%) died of related causes at a mean of 19.4 months after thoracic surgery, three of whom had more than one operation. The 3-year survival after metastasectomy was 61%. Patients without pulmonary metastases had a 3-year survival of 79%. CONCLUSIONS In patients with lung metastases of an osteogenic sarcoma, the combination of chemotherapy and surgery improves the outcome. In our series the mortality was not influenced by the number or thoracotomies required.

A New Algorithm for Detection of S1 and S2 Heart Sounds

This paper presents a new algorithm for segmentation and classification of S1 and S2 heart sounds without ECG reference. The proposed approach is composed of three main stages. In the first stage the fundamental heart sound lobes are identified using a fast wavelet transform and the Shannon energy. Next, these lobes are validated and classified into S1 and S2 classes based on Mel-frequency coefficients and on a non-supervised neural network. Finally, regular heart cycles are identified in a post-processing stage by a heart rhythm criterion. This approach was tested using sound samples collected from prosthetic valve implanted patients. Results are comparable with ECG based approaches

Low complexity algorithm for heart sound segmentation using the variance fractal dimension

This paper presents an algorithm for S1 and S2 heart sound segmentation using variance fractal dimension. Heart sound is assumed as a non-stationary signal embedding two main sounds S1 arid S2, murmurs and eventually unusual ambient sound. The variance fractal dimension is applied to adaptively identify the boundaries of sound lobes. S1 components are detected using QRS synchronization while for S2 components a non-supervised classification approach is applied, based on temporal features of the lobes. This allows a 2-lead ECG signal to be used for the task. Some preliminary results are presented using recorded heart sounds taken a few days after valve replacement.

Diaphragmmatic eventration: long-term follow-up and results of open-chest plicature

OBJECTIVE Diaphragmmatic eventration is a relatively uncommon entity with a simple surgical correction technique--plication of the diaphragm. This study aims to assess the clinical and ventilatory impact of this technique. MATERIALS From April 1988 to February 2007, we operated on 20 patients (12 men) with diaphragmmatic eventration using the postero-lateral approach and correction by radial plication. The mean age of the patients studied was 56.3+/-15.6 years (range: 13-74 years). A traumatic cause was identified in 13 patients; one patient had a congenital cause and the remainder were of idiopathic origin. Chronic obstructive pulmonary disease and arterial hypertension were present in one-half of the study group, while diabetes mellitus was present in three patients. Dyspnoea was the most common complaint in 75% of the patients, and thoracic pain was present in 25%. The mean forced expiratory volume in 1 s (FEV(1)) and vital capacity (VC) were 66.2+/-15.3% and 70.4+/-16% of the predicted values, respectively. RESULTS There was no operative mortality. Apart from a patient with moderate/severe pain and another who had pneumonia, there were no other important perioperative complications. Average drainage time was 3.3+/-1.6 days (range: 2-7 days). Hospitalisation time was 6.2+/-1.6 days (5-10 days). Follow-up was complete, for a mean of 59.6+/-55.1 months (4-206 months). There were three late deaths (one sudden, one stroke and one trauma). Eight of the 17 survivors (47%) are asymptomatic. According to the MRC/ATS grading system, the dyspnoea score was 2.06+/-0.97 preoperatively and 1.06+/-1.14 postoperatively (p=0.007). At follow-up, the FEV(1) was 76.1+/-20.1% and the VC was 78.4+/-17.3% (p>0.1). Two patients had chronic pain. CONCLUSION Plication of the diaphragm is a safe and efficient procedure. Most patients experienced significant clinical improvement with enhancement of the FEV(1) and VC. Chronic surgical pain still remains a potential problem with the classical approach.

Diagnostic value of surgical lung biopsy: comparison with clinical and radiological diagnosis

OBJECTIVE To determine overall and disease-related accuracy of the clinical/imagiological evaluation for pulmonary infiltrates of unknown aetiology, compared with the pathological result of the surgical lung biopsy (SLB) and to evaluate the need for the latter in this setting. METHODS We conducted a retrospective review of the experiences of SLB in 366 consecutive patients during the past 5 years. The presumptive diagnosis was based on clinical, imagiological and non-invasive or minimally invasive diagnostic procedures and compared with the gold standard of histological diagnosis by SLB. We considered five major pathological groups: diffuse parenchymal lung disease (DPLD), primitive neoplasms, metastases, infectious disease and other lesions. Patients with previous histological diagnosis were excluded. RESULTS In 56.0% of patients (n=205) clinical evaluation reached a correct diagnosis, in 42.6% a new diagnosis was established (n=156) by the SLB, which was inconclusive in 1.4% (n=5). The pre-test probability for each disease was 85% for DPLD, 75% for infectious disease, 64% for primitive neoplasms and 60% for metastases. Overall sensitivity, specificity, positive and negative predictive values for the clinical/radiological diagnosis were 70%, 90%, 62% and 92%, respectively. For DPLD: 67%, 90%, 76% and 85%; primitive neoplasms: 47%, 90%, 46% and 90%; metastases: 99%, 79%, 60% and 99%; infectious disease 38%, 98%, 53% and 96%. CONCLUSIONS Despite a high sensitivity and specificity of the clinical and imagiological diagnosis, the positive predictive value was low, particularly in the malignancy group. SLB should be performed in pulmonary infiltrates of unknown aetiology because the clinical/imagiological assessment missed and/or misdiagnosed an important number of patients.

Adenoma pleomórfico da traqueia. Caso clínico

Resumo Os autores apresentam o caso de um doente com um adenoma pleomorfico da traqueia, diagnosticado no contexto da avaliacao clinica de doenca pulmonar obstrutiva cronica ou neoplasia broncopulmonar, tendo em conta a dimensao dos seus habitos tabagicos e a historia familiar positiva para patologia oncologica. O doente foi submetido a resseccao segmentar da traqueia com excisao total do tumor, antevendo- -se bom prognostico.

C9. Cirurgia do Aspergiloma Pulmonar: Curativa?

Introducao. Nas ultimas decadas, tem vindo a aumentar a importância das doencas provocadas por fungos, em especial as causadas por Aspergillus. Este estudo retrospectivo teve por intencao confirmar ou infirmar que a terapeutica cirurgica do aspergitoma pulmonar pode conduzir a cura ou a paliacao da doenca a longo prazo, com melhoria da qualidade de vida. Material e Metodos. De 1989 a 2001, 23 doentes com idade media de 44,1 anos (limites 18-69 anos) foram submetidos a cirurgia de exerese de aspergiloma pulmonar. Dezasseis doentes (70%) eram do sexo masculino. A indicacao cirurgica mais frequente foi hemoptise em 16 doentes (70%) e expectoracao abundante em 3 doentes (13%). Quatro doentes (17%) estavam assintomaticos. Sequelas de tuberculose (87%) ou abcesso pulmonar (13%), constituiram as condicoes basais para o desenvolvimento de aspergiloma pulmonar e a avaliacao funcional respiratoria preoperatoria, mostrou uma deterioracao funcional, com capacidade vital media de 69,8% (limites 61-84%) e VEMS 66% media (limites de 53-82%). Resultados. Fizeram-se 18 lobectomias (82%), 2 bilobectomias (7%), 2 resseccoes em cunha (7%) e uma pneumonectomia (4%). Nao houve mortalidade operatoria e as complicacoes mais frequentes de pos-operatorio foram: persistencia de fugas aereas em 7 doentes (30%); hemorragia pos-operatoria em 2 doentes (7%) e persistencia de cavidade residual pleural pos-operatoria em 2 doentes (7%). O follow-up medio destes doentes foi de 7,2 anos, (limites de 1,5 a 14 anos) e registaram-se 3 mortes, 2 por neoplasia intestinal e 1 relacionada com a doenca de base, ocorrida 5 anos pos cirurgia. Todos os sobreviventes referem melhoria acentuada dos sintomas e qualidade de vida pessoal. Conclusao. A excisao dos aspergilomas pulmonares pode ser executada com baixa mortalidade e morbilidade. Os pacientes referem uma melhoria acentuada, quer da sintomatologia quer da qualidade de vida, apos a cirurgia. Assim, sugere-se a terapeutica cirurgica, quer em doentes sintomaticos quer nos assintomaticos.