Mariano García-Yuste

Prognostic factors in neuroendocrine lung tumors: a Spanish multicenter study

Background. This study examines the experience of the Spanish Multicenter Study of Neuroendocrine Tumors of the Lung through the clinical data and behavior of patients treated for this pathologic process. Methods. From 1980 to 1997, 361 cases of neuroendocrine carcinomas (NEC) were treated surgically. Patients were enrolled in a protocol using the pathologic and follow-up reports. According to Dreslers’ criteria, the cases were segregated into grade 1 (typical carcinoid), grade 2 (atypical carcinoid), grade 3 large cell type, and grade 3 small cell type. Several variables were reviewed in all patients. Statistical analysis was performed to determine whether clinical characteristics and differentiation were associated with significant differences in the prognosis. Results. A total of 261 cases of NEC were identified with grade 1, 43 with grade 2, and with grade 3: 22 of large and 35 of small cells. Five-year survival for different grades was as follows: grade 1, 96%; 2, 72%; 3 large cell type, 21%; and 3 small cell type, 14%. When a comparative analysis between typical and atypical carcinoids was performed a significant difference for mean age, tumor size, nodal metastases, and recurrence was observed. However, female sex, nodal metastases, and recurrence rate differed between atypical carcinoids and grade 3 NEC of large cells. A difference in recurrence rate was found between patients with both types of grade 3 NEC. Conclusions. The progressive deterioration of tumor organization highlights that neuroendocrine tumors constitute a continuous spectrum. A careful observation of pathologic findings is necessary to individualize their prognostic factors.

Hydatid cyst of the lung: diagnosis and treatment.

Hydatid infestation of the lung can be primary or secondary. In three of four cases the cyst is a single one. Hydatidosis of a different location, particularly the liver, may be associated. The period of initial growth of primary hydatidosis is frequently asymptomatic. Bronchial fistulization is an important event in the evolution of the cyst. Intrapleural rupture constitutes a rare eventuality, but it is often as characteristic as it is severe. Secondary, metastatic hydatidosis, due to breaking of a primary visceral cyst in a vein or heart, is rare. A special form is so-called multiple malignant pulmonary hydatidosis, which causes progressive respiratory deficiency and right ventricular failure. There are a variety of radiographic images. Ultrasonography, computed tomography, and magnetic resonance imaging can recognize certain details of the lesions and discover others that are not visible by conventional radiography. For a specific serologic diagnosis, our experience favors the immunoglobulin G enzyme-linked immunosorbent assay and immunoelectrophoresis. Treatment is essentially surgical. In general, chemotherapy is used as a complement to operative treatment to avoid recurrence. Surgery has two objectives: to remove the parasite and to treat the bronchipericyst pathology and other associated lesions. The prognosis has changed during the last few years, and results are now commonly satisfactory. The most frequent complications are pleural infection and prolonged air leakage. Operative mortality does not exceed 1% to 2%. Despite the low mortality and the limited recurrence rate, it is necessary to remember the invading character of pulmonary hydatid disease, which sometimes makes therapy difficult and questionable. Prophylaxis is essential to eradicate the disease completely. Hydatid disease, still endemic in many countries, is an anthropozoonosis that has been known for centuries [1]. Hence there is no need to emphasize its importance from a sanitary point of view [2, 3]. Humans are accidental intermediary hosts in the biologic cycle of the taenia Echinococcus granulosus, which is the most frequent hydatidosis etiologic agent in our environment [4, 5]. The development of the parasitic larval stage in the host’s organs manifests in the form of a cyst (hydatid); in a way, the expression “hydatid cyst” is redundant, although it has become widespread [1]. Lung involvement, which follows hepatic infestation in frequency, has been seen in 30% of the cases of hydatidosis in some series [6]. It constitutes an important chapter in pathology, as much for the diversity of the anatomoclinical forms it produces as for the problems of diagnosis and therapy it creates. The disease is usually found at an early age; in most cases before 40 years, with all the socioeconomic implications this entails [7]. Regarding gender, like other authors [8–10] we have noted a predominance in males over females; and based on its etiology, there is a higher incidence in rural populations [11]. Pathogenesis, Pathology, Pathologic Physiology

Evaluation of six serological tests in diagnosis and postoperative control of pulmonary hydatid disease patients

Latex agglutination (LA), passive hemagglutination (PHA), immunoelectrophoresis (IEP) and specific IgE, IgM, IgG enzyme-linked immunosorbent assay (ELISA) tests for diagnosis and postoperative follow-up of 79 patients with surgically confirmed pulmonary hydatidosis were evaluated. Specific IgG ELISA was the most sensitive test (83.5%) and the least sensitive tests were specific IgE ELISA (44.3%) and IEP (50.6%). The specificity obtained for all the serologic test was above 97% in all cases. The greatest number of false positives in all tests (except IEP) occurred in patients with Taenia saginata and Taenia solium cysticerci infestations and in patients with lymphoma and leukemia. Specific IgG ELISA demonstrated the highest negative predictive value (93.8%). No statistically significant differences (p > 0.050) were found in the sensitivity of the tests when patients with only one cyst and patients with various cysts were compared. Considering only the patients without relapse, the percentage of seropositive patients increased in all tests at 1 and 3 months after surgery. After that time the percentage of seropositive patients decreased. At 48 months after surgery all patients without relapse became negative in IEP, specific IgE ELISA, and specific IgM ELISA. The antibody titers in all seropositive patients increased during the 3 months after surgery. From these 3 months onward, antibody levels decreased in all serologic tests studied in the group of patients without relapse. The patients who had relapses during the first year after surgery presented persistently elevated antibody titers in all postoperative sera. The antibody titers of the patients who relapsed between the third and fourth years after surgery decreased progressively the third month after surgery, and increased in the serum obtained at the moment of relapse diagnosis. Our results show that persistence of elevated antibody titers in patients with pulmonary hydatidosis in the year after surgery or titer increase after a progressive decrease are indicative of relapse or reinfection.

Open-Window Thoracostomy and Thoracomyoplasty to Manage Chronic Pleural Empyema

BACKGROUND The purpose of this study is to report our 15-year experience treating chronic empyemas after pulmonary resection and tuberculosis. METHODS Open-window thoracostomy and thoracomyoplasty were used to treat 40 patients with chronic pleural empyema characterized by residual empyematic cavity, bronchopleural fistula, and persistent pleural infections that were secondary to tuberculosis (n = 22) or pulmonary resection (n = 18). Between 2 and 7 months after thoracostomy, thoracomyoplasty was performed to eliminate a persistent pleural cavity. In 2 patients with postpulmonary resection empyema and a large bronchopleural fistula, intrathoracic transposition of the latissimus dorsi flap and open-window thoracostomy were performed simultaneously to close the fistula. RESULTS The pleural space was eliminated per primam intentionem in 21 of 22 patients with tuberculosis and in 14 of 18 with a postpulmonary resection empyema. Another myoplasty was performed in an additional 3 patients to eliminate the pleural space. During open-window thoracostomy, the latissimus dorsi muscle was preserved with minimal injury to the anterior serratus muscle. One patient died postoperatively. CONCLUSIONS Successful treatment of chronic pleural empyema requires adequate timing of surgical procedures. Our two-procedure technique is relatively simple and safe.

Neuroendocrine tumors of the lung.

Purpose of review The aim of this article is to answering different questions related to the treatment and prognosis of neuroendocrine lung tumors. Recent findings In neuroendocrine lung tumors, regardless of the grade of tumoral malignancy, the general growth during the past years of the nodal involvement percentage detected in lung neuroendocrine tumors might be explained by accepting surgical treatment as the norm and a complete mediastinal nodal dissection. Among non-small-cell carcinomas, large cell neuroendocrine carcinoma is the tumor with the worst prognosis. Nodal invasion clearly decreases the possibility of long-term survival in these patients, confirming the importance of preoperative and perioperative staging. A definitive survival advantage for postoperative adjuvant therapy has yet to be reported; tumoral genetics studies may contribute to specifying its indication. The importance of neuroendocrine differentiation in non-small-cell lung carcinomas for the treatment and prognosis of these tumors is a reason to intensify research. Summary In the surgical treatment of lung neuroendocrine carcinomas, nodal mediastinal dissection should always be performed. In the large neuroendocrine carcinoma, experience confirms the possibility of surgical treatment in early stages; in all cases, adjuvant treatment should always be established. The presence of synaptophysin in squamous carcinoma tumors and adenocarcinoma tumors in stage I seems to be associated with a worse prognosis.

Hemodynamic and cerebral repercussions arising from surgical interruption of the superior vena cava: Experimental model

This study was designed to analyze the hemodynamic and cerebral repercussions arising from the surgical interruption of the superior vena cava. The experiments were carried out in 12 mongrel dogs under two different conditions: with shunt (group A, n = 6) and without the installation of a shunt (group B, n = 6). The period of occlusion was 35 minutes. The right atrium pressure, pulmonary arterial pressure, and aortic pressure are not significantly modified in the two groups. The intracranial pressure had an important correlation with the central venous pressure (r2 = 0.8572). In group B, the intracranial pressure had a sharp increase between the basal period (6.9 +/- 1.47 mm Hg) and the clamping superior vena cava (17.2 +/- 1.05 mm Hg), accentuated with the interruption of the azygous vein (32.2 +/- 0.7 mm Hg). In group A, the use of a shunt avoided this alteration during clamping of the superior vena cava (6.8 +/- 2.0 mm Hg) and the azygous vein (8.0 +/- 2.24 mm Hg). However, after removal of the clamps in group B, an elevated residual intracranial pressure was observed (21.1 +/- 3.33 mm Hg) in contrast to the central venous pressure, which returned to the basal values (4.4 +/- 0.7 mm Hg). The biomechanic findings of the volume-pressure curves (with Miller and Marmarou-Shapiro tests) and the cerebral necropsy showed brain damage in group B, without the shunt. Three animals had areas of hemorrhagic infarction. Histologic study demonstrated signs the incipient vasogenic edema. In group A, all findings were compatible with the normal. In conclusion, these results suggest the importance of shunting the blood in those cases of a nonobstructed superior vena cava because the clamping and reconstruction produce hemodynamic compromise and brain damage.

Registros de enfermedades respiratorias en España:: fundamentos y organización

This present paper describes the general characteristics, objectives and organizational aspects of the respiratory disease registries in Spain with the aim to report their activities and increase their diffusion. The document compiles information on the following registries: the Spanish Registry of Patients with Alpha-1 Antitrypsin Deficiency, Spanish Registry of Bronchiectasis, International Registry of Thromboembolic Disease, Spanish Registry of Occupational Diseases, Spanish Registry of Pulmonary Artery Hypertension, Registry of Pleural Mesothelioma, Spanish Registry of Tuberculosis and Spanish Multi-center Study of Neuroendocrine Pulmonary Tumors. Our paper provides information on each of the registries cited. Each registry has compiled specific clinical information providing data in real situations, and completes the results obtained from clinical assays. Said information has been published both in national as well as international publications and has lead to the creation of various guidelines. Therefore, the activities of the professionals involved in the registries have spread the knowledge about the diseases studied, promoting the exchange of information among workgroups.

Prognostic significance of synaptophysin in stage I of squamous carcinoma and adenocarcinoma of the lung

The prognostic significance of the presence of a neuroendocrine marker (synaptophysin, SY) was analyzed in stage I of squamous carcinoma and adenocarcinoma of the lung.

Tendencias en los factores pronósticos de los tumores pulmonares neuroendocrinos

Objetivo Este estudio tiene como objetivo determinar la tendencia de distintos factores pronosticos en carcinomas neuroendocrinos del pulmon a traves del analisis de 2 grupos de pacientes tratados quirurgicamente. Pacientes y metodos En el grupo A se incluyeron los primeros 361 casos, tratados entre 1980 y 1997—261 carcinoides tipicos (CT), 43 carcinoides atipicos (CA), 22 carcinomas neuroendocrinos de celulas grandes (CNECG) y 35 carcinomas neuroendocrinos de celulas pequenas (CNECP)—, que se estudiaron retrospectivamente. El grupo B estuvo compuesto por 404 casos, recogidos desde 1998 a 2002 —308 CT, 49 CA, 18 CNECG y 29 CNECP—, que se estudiaron prospectivamente. Las variables clinicas consideradas fueron: sexo, edad media, localizacion tumoral, tamano tumoral, afectacion ganglionar, estadio, metastasis y recurrencia local. Se utilizo la clasificacion TNM del carcinoma broncogenico de 1997 y se practico un estudio de supervivencia y de factores que influyen en ella. Se realizo un analisis estadistico uni y multivariante con los datos obtenidos. Resultados Por lo que se refiere al CT y al CA, se observaron diferencias significativas en los 2 grupos de pacientes en cuanto a la edad media, el tamano tumoral, la afectacion ganglionary la recurrencia. Entre CA y CNECG, el sexo, la afectacion anglionar y la recurrencia difirieron en el grupo A; lo mismo ocurrio en el grupo B, con la excepcion de la afectacion ganglionar. Entre CNECG y CNECP, la diferencia en la afectacion ganglionar observada en el grupo A no estuvo presente en los pacientes del grupo B. Respecto a la supervivencia, global y por afectacion ganglionar, se observaron diferencias significativas en ambos grupos al comparar CT frente a CA y CA frente a CNECG; no se encontraron diferencias entre CNECG y CNECP. El tipo histologico y la afectacion ganglionar mostraron la mayor influencia pronostica en analisis multivariante. Conclusiones En los carcinomas neuroendocrinos de pulmon se observa una tendencia definida en sus factores pronosticos. El tipo histologico y la deteccion de afectacion ganglionar se muestran como los factores con mayor influencia en la supervivencia.

Trends in Prognostic Factors for Neuroendocrine Lung Tumors

OBJECTIVE The aim of this study was to analyze trends in a variety of prognostic factors for neuroendocrine lung carcinomas through analysis of 2 groups of surgically treated patients. PATIENTS AND METHODS Group A contained the first 361 patients, treated between 1980 and 1997. That group was analyzed retrospectively and contained 261 patients with typical carcinoid tumors, 43 with atypical carcinoid tumors, 22 with large-cell neuroendocrine carcinoma, and 35 with small-cell neuroendocrine carcinoma. Group B contained 404 patients enrolled prospectively between 1998 and 2002: 308 with typical carcinoid tumors, 49 with atypical carcinoid tumors, 18 with large-cell neuroendocrine carcinoma, and 29 with small-cell neuroendocrine carcinoma. The following clinical variables were considered: sex, mean age, tumor site, tumor size, lymph node involvement, stage, metastasis, and local recurrence. The 1997 TNM classification was used for staging of lung cancer and survival analysis was performed along with assessment of factors influencing survival. Statistical analysis of the data involved univariate and multivariate analysis. RESULTS In both groups, significant differences were observed between patients with typical and atypical carcinoid tumors in terms of mean age, tumor size, node involvement, and recurrence. In group A, female sex, node involvement, and recurrence differed between patients with atypical carcinoid tumors and those with large-cell neuroendocrine carcinoma; the same was true for group B, with the exception of lymph node involvement. Node involvement differed between patients with small-cell versus large-cell neuroendocrine carcinoma in group A but not group B. Both groups displayed significant differences in overall survival and survival of patients with lymph node involvement between patients with typical and atypical carcinoid tumors and between patients with atypical carcinoid tumors and those with large-cell neuroendocrine carcinoma; no differences were observed between patients with large-cell versus small-cell neuroendocrine carcinoma. Histological type and lymph node involvement had the greatest influence on prognosis in the multivariate analysis. CONCLUSIONS A well-defined trend is observed in prognostic factors for neuroendocrine lung tumors. Histological type and lymph node involvement show the greatest influence on survival.