Nicolas Moreno

Micropapillary lung adenocarcinoma: a distinctive histologic subtype with prognostic significance. Case series

The aims of the present work were to evaluate the prognostic significance of the micropapillary pattern of lung adenocarcinoma and determine whether there are differences in the behavior of this type of tumor according to its immunohistochemical profile. A series of 191 consecutively resected pulmonary adenocarcinomas were divided into those with (n = 62) and those without (n = 129) micropapillary components. The disease was stage I in 38 and 54 patients, respectively. The 5-year survival rates of patients with and without micropapillary components were 54% and 77%, respectively (log rank P = .03). In multivariate survival analysis, the micropapillary component proved to be an independent prognostic factor (hazard ratio, 3.2). Five autopsy cases were used to investigate the immunohistochemical profile. The percentages of cases positive for various markers were 56.7 for p53, 94 for Ki67, 85.1 for c-myc, 2.9 for Bcl-2, 35.8 for epidermal growth factor receptor, 43.3 for cyclin D1, and 46.3 for Bax. The prognostic value was evaluated according to the expression of the different markers in micropapillary carcinomas in stage I. In univariate analysis, only cyclin D1 expression and Bax expression were associated with significantly worse survival (log rank P = .03 and P = .02, respectively). We conclude that it is important to recognize the micropapillary growth pattern in lung adenocarcinoma. Moreover, cyclin D1 and Bax seem to be markers of a poor prognosis.

Early and Long-term Validation of an Algorithm Assessing Fitness for Surgery in Patients With Postoperative FEV1 and Diffusing Capacity of the Lung for Carbon Monoxide < 40%

BACKGROUND There is evidence in the literature that the incidence of pulmonary complications and mortality is fair enough in patients with lower pulmonary function than conventionally accepted. In this article, we validate in patients with low baseline lung function (ie, FEV(1) or diffusing capacity of the lung for carbon monoxide [DLCO] < 80%) an algorithm to evaluate anatomic lung surgery in patients with low predicted postoperative lung function (ie, either FEV(1)-postoperative estimated [ppo] or DLCO-ppo < 40% or both between 30% and 40% predicted) if peak oxygen uptake (VO(2)peak)-ppo > 10 mL/kg/min. METHODS We prospectively studied 126 consecutive patients evaluated for anatomic resection of lung tumors by thoracotomy. RESULTS Ninety-two patients were operated on: age 67 (8 SD) years; FEV(1) 63 (14)% pp; DLCO 71 (19)% pp; VO(2)peak 71 (19)% predicted; and 2-year Kaplan-Meier conditional probability of survival (CPS) 0.62 (0.06). Thirty-day perioperative mortality was 6.4%. Thirty-four patients were not functionally fit, or rejected the procedure: age 69 (8) years; FEV(1) 58 (16)% predicted; DLCO 67 (26)% predicted; VO(2)peak 66 (16)% predicted. In this group, 2-year CPS was 0.18 (0.08), P < .01. Subgroups A (FEV(1)-ppo and DLCO-ppo > 40% predicted) and B (either FEV(1)-ppo or DLCO-ppo < 40% predicted or both between 30% and 40% predicted) were comparable in terms of perioperative morbidity; however, they were different in terms of 30-day mortality (A, 1/53 [1.9%]; B, 5/37 [13.5%]; P = .047; relative risk, 7.2; 95% CI 1.1-27.7). The survival functions of both subgroups were significantly different (P < .01) from nonsurgical subjects. CONCLUSIONS Adherence to the proposed algorithm results in a reasonable preoperative mortality in patients with low preoperative lung function. Although perioperative mortality is significantly higher when predicted postoperative lung function is low, 2-year survival of patients is better than if such patients had not undergone surgery.

Thoracic paravertebral block after thoracotomy: comparison of three different approaches §

BACKGROUND Thoracic paravertebral block (TPVB) is a regional block technique increasingly used for the early management of post-thoracotomy pain. We compare three different postoperative analgesic approaches based on TPVB: anesthetist, anesthetist plus surgeon, and surgeon. MATERIALS AND METHODS We randomized 54 patients undergoing elective thoracotomy to three different postoperative analgesia groups: paravertebral percutaneous catheter (PVA group), paravertebral percutaneous catheter plus incisional (subcutaneous) catheter (PVA+Inc), and paravertebral catheter under direct vision (PVS group). During early postoperative 48h, we measured pain intensity, intravenous morphine afforded by the patient-controlled analgesia pump, and the spirometric test. RESULTS There were no statistically significant differences among the collected preoperative data. No significant differences were observed on postoperative spirometric values. Analgesic quality was better in PVA+Inc group at 12 and 24 postoperative hours. In this group, intravenous morphine use to improve analgesia was significantly lower from 8h until 48h postoperative. CONCLUSIONS Association of thoracic paravertebral block to continuous infusion of a local anesthetic in the surgical incision area affords a better pain relief than paravertebral block alone (introduced by the surgeon or the anesthetist).

Large posterior chest wall defect reconstructed with a de-epithelised trans-thoracic TRAM flap

Extensive posterior chest wall defects, especially those closer to the midline of the trunk, pose surgical challenges in plastic surgery. In these cases, prior to tissue coverage, the status of the pleural cavity and skeletal support need to be addressed to obtain a functional and anatomical reconstruction. We recently operated upon a patient presenting with an aggressive ossifying fibromyxoid tumour located in the lower dorsal paraspinal region on the right side. After ablative surgery and intra-operative radiotherapy, a broad defect in the chest wall of 15 x 10 cm, including the proximal part of five posterior ribs, was presented. It required immediate bony frame reconstruction, which was resolved with a Goretex patch wrapped with a de-epithelised myocutaneous pedicled transverse rectus abdominus myocutaneous (TRAM) flap, transposed through the right hemithorax. The patient was extubated 2 days after surgery and discharged in 10 days. We describe the use of an intra-thoracic TRAM flap to reach the posterior chest wall defects, and we propose its specific indication for reconstruction of extensive posterior chest wall defects when other options are unavailable.

Carcinoma neuroendocrino de células grandes de pulmón: análisis de una serie de once casos en un hospital universitario

Purpose: Lung carcinomas with neuroendocrine differentiation are a heterogeneous group of tumors related to typical and atypical carcinoids, neuroendocrine large-cell carcinomas (NLCC) and small-cell lung cancer (SCLC). NLCC comprises less than 5% of non small-cell lung cancer (NSCLC). In this report, we describe a series of NLCC treated in a single institution in the last ten years. Material and methods: Eleven patients diagnosed as having NLCC (5 of them with mixed histology). Results: At diagnosis, the mean age of the patients was 66 years (5 males and 6 females); 4 had localized disease, 5 locally advanced disease, and 2 metastatic disease. Seven patients underwent initial radical surgery (2 of them followed by adjuvant chemotherapy), 1 patient received chemotherapy and radiotherapy, and 3 patients only chemotherapy. Median overall survival for the whole series was 24 months, and the overall 2-year and 5-year survival were 45% and 27% respectively. Conclusion: Our data corroborate the general recommendation of treating NLCC in a similar way as the rest of the non small-cell lung cancer (NSCLC) are treated. Radical surgery is the main treatment for localized tumors. There are no data indicating a worse response of these tumors to radiation therapy or chemotherapy.