Sukru Dilege

The additional value of FDG PET imaging for distinguishing N0 or N1 from N2 stage in preoperative staging of non-small cell lung cancer in region where the prevalence of inflammatory lung disease is high.

Purpose: The aim of this study was to evaluate the efficacy of PET imaging and compare it with the performance of CT in mediastinal and hilar lymph node staging in potentially operable non-small cell lung cancer (NSCLC). Methods: Fifty-nine patients with potentially resectable NSCLC who underwent preoperative PET and CT imaging were enrolled into this prospective study. All patients underwent surgical evaluation by means of mediastinoscopy with mediastinal lymph node sampling (14 patients) or thoracotomy (45 patients). Results: The prevalence of lymph node metastases was 53%. Overall, the sensitivity, specificity, accuracy, PPV, and NPV of PET were 79%, 76%, 78%, 86%, and 76% for N0 and N1 lymph nodes and 76%, 79%, 80%, 67%, and 83% for N2 lymph nodes, while those values for CT were 66%, 43%, 58%, 68%, and 43% for N0 and N1 stations and 43%, 66%, 54%, 41%, and 66% for N2 lymph nodes, respectively. PET correctly differentiated cases with mediastinal lymph node involvement (N2) from those without such involvement (N0 or N1) in 76% of cases. Statistical analysis of the diagnostic accuracy of nodal involvement showed that PET improves diagnostic accuracy significantly in the detection of both N0 or N1 and N2 status in the individual patient based on analysis, compared with CT (P < 0.01 and P < 0.01, respectively). When preoperative nodal staging was compared with postoperative histopathological staging, 38 (65%) patients were correctly staged, 9 (15%) were overstaged, and 12 (20%) were understaged by PET, while 29 patients (49%) were correctly staged, 13 (22%) were overstaged, and 17 (29%) were understaged by CT. Conclusion: It has been clearly shown that PET is more accurate than CT for the differentiation of N0 or N1 from N2 disease in patients with NSCLC. However, PET imaging alone does not appear to be sufficient to replace mediastinoscopy for mediastinal staging in patients with lung cancer, especially in geographic regions with high granulomatous or inflammatory mediastinal disease prevalence.

Vascular Reconstruction in Buerger's Disease : Is it Feasible?

Abstract.Purpose: Thromboangiitis obliterans (Buergers disease) is a clinical syndrome characterized by segmental occlusions of the distal vessels. Although a cessation of using nicotine products usually helps, nevertheless a surgical revascularization may be needed in cases of stage III and IV limbs. Because of the distal and segmental nature of the disease, these procedures are rarely feasible. This article focuses on the feasibility of performing a vascular reconstruction in thromboangiitis obliterans. Methods: Thirty-six of 94 patients (38.3%) who were followed by the Peripheral Vascular Unit of Istanbul Medical Faculty were selected for revascularization and 27 of 36 (81%) patients underwent revascularization procedures. Results: During a 36-month follow-up, the patency rates at the 12th, 24th, and 36th months were 59.2%, 48%, and 33.3%, respectively. The limb salvage rate was 92.5%. Conclusions: Since patients affected by Buergers disease consist a group of young population who are still in their productive stages, every effort should be taken to obtain a limb salvage in the ischemic period. Although the patency rates do not seem promising, the limb salvation rate was quite satisfactory.

Major retroperitoneal vascular injuries during laparoscopic cholecystectomy and appendectomy.

BACKGROUND Serious complications may occur during laparoscopic surgery, as in any surgical procedure. Injuries of major retroperitoneal vascular structures are uncommon but important complications of laparoscopy. METHODS We report on 9 major vascular injuries in 8 patients in the course of 8 laparoscopic procedures between 1994 and 2002. RESULTS The primary operations were cholecystectomy in 7 patients and appendectomy in one patient. Six vascular injuries occurred during placement of the first umbilical trocar, two in the course of the insertion of a Veress needle, and one during the insertion of the second trocar. A laparotomy was performed immediately in all cases. Left common iliac arteries were injured in two patients, aorta in three patients, right common iliac vein in one patient, both right common iliac artery and vein in one patient, and inferior vena cava in one patient. Polytetrafluoroethylene (PTFE) graft interposition was employed in two common iliac arteries and a tubular PTFE graft in one aortic injury, and Dacron patchplasty in one common iliac artery injury. Two aortic, two common iliac vein, and an inferior vena cava injury were repaired primarily. There were also four visceral organ injuries, which were repaired primarily. The major retroperitoneal vascular complication rate was 0.07%. An average of 3.5 units of whole blood were transfused in each case and the average stay in hospital was 6.8 days. There was no mortality. CONCLUSIONS The surgeons experience and knowledge are the essential factors for prevention of major vascular injuries during laparoscopic procedures. In case of an injury, immediate laparotomy must be performed to achieve hemostasis and a surgeon who is familiar with vascular surgery should employ the definitive treatment.

Surgical treatment and prognosis of primitive neuroectodermal tumors of the thorax.

Introduction: Primitive neuroectodermal tumors (PNETs) are rare, rapidly progressive, small- round cell tumors with a poor prognosis despite multimodal therapy, including surgery and chemoradiotherapy. The treatment of choice was unknown since no clinical series with surgical therapy had been reported. We evaluated the impact of multimodal treatment in patients with PNETs located in the thoracic region. Methods: Between 1998 and 2006, 25 patients with PNETs in the thoracic region were treated in 3 tertiary-care hospitals. The patients consisted of 15 males and 10 females with a mean age of 27.2 years (range, 6-60). The tumor was in the chest wall in 20 (involving the costovertebral junction in 9), the lung in four, and the heart in one patient. Twelve patients received neoadjuvant chemotherapy (54.5%), and 22 of 25 patients underwent surgery. Results: In patients who received neoadjuvant treatment, the mean regression rate was 65.4% (range, 30-100%). Eighteen (82%) patients underwent chest wall resection, while 7 (32%) had vertebral resections, and the remaining 4 (16%) had pulmonary resections. A complete resection was possible in 18 of 22 patients (82%). Patients with incomplete and complete resections had 25% and 56% 5-year survival rates, respectively (p = 0.13). The progression-free 3-year survival rate was 36% and the median survival time was 13 months. The complete resection rate was significantly higher in patients receiving neoadjuvant therapy (p = 0.027). The 5-year survival rate of the patients with or without neoadjuvant therapy was 77% and 37%, respectively (p = 0.22) although it prolonged the disease-free survival (p = 0.01). The 5-year survival rate of patients without costovertebral junction involvement was 66%, whereas patients with PNETs involving the costovertebral junction had a 21% 3-year survival. The difference was statistically significant (p = 0.01). The 5-year progression-free survival rate of patients without costovertebral junction involvement was 58%, whereas patients with PNETs involving the costovertebral junction had a 14% 1-year progression-free survival (p = 0.004). Conclusions: PNET is an aggressive malignancy that often requires multimodal therapy. Induction chemotherapy leads to a greater complete resection rate and better disease-free survival, while involvement of the costovertebral junction indicates a poorer survival.

Oxygen uptake kinetics during cardiopulmonary exercise testing and postoperative complications in patients with lung cancer.

It is accepted that cardiopulmonary exercise testing is one of the most valuable parameters, especially peak oxygen uptake (VO(2)), for the evaluation of risk assessment in lung cancer surgery. It therefore represents an attractive way of identifying a patient at high risk for postoperative complications. However, many patients do not achieve the maximal or predictive level during an incremental exercise testing. The purpose of the current investigation was to study the value of the oxygen uptake efficiency slope (OUES), which shows exercise capacity during submaximal testing, in predicting postoperative mortality in patients with bronchogenic carcinoma scheduled for lung resection. Forty-nine patients with bronchogenic carcinoma participated in studies with exercise tests as a preoperative evaluation. The peak VO(2) was calculated for each subject by averaging values obtained during the final 10s of exercise. The following equation was used to determine OUES: VO(2)/log(10)VE. Peak VO(2) without postoperative complication was 22.8+/-3.3 ml/(kg min), however, peak VO(2) in patients with present complications was 19.1+/-4.2 ml/(kg min) (p=0.001). In addition, although the mean OUES in patients with present complications was 11.1+/-1.2, the mean OUES in the absent group was 13.3+/-2.1 (p<0.001). Although peak VO(2) is useful in evaluating selected patients with bronchogenic carcinoma, OUES is also a beneficial parameter and should be calculated and recorded with peak VO(2), a better predictor of poor surgical outcome than absolute values, and should be integrated into preoperative decision making.

Hydatid Cystic Disease of the Soft Tissues with Pulmonary and Hepatic Involvement: Report of a Case

Abstract.Hydatid disease, which is caused by the Echinococcus granulosis parasite, is endemic in certain parts of the world where close contact between humans and sheep exists. The disease most commonly involves the liver and other solid organs. This report describes the case of a teenage girl with hydatid disease involving the right axilla and various other sites concomitantly. The patient was admitted to hospital with a mass in the right axillary region, and further examinations revealed that the liver and right lung were also involved. We report this case to emphasize that hydatid disease should be considered in the differential diagnosis of patients from endemic areas who present with soft tissue masses.

An unusual intrapleural foreign body: ignored aspiration

A 54-year-old male patient was admitted to our department with fever, dyspnea and chest pain. Left pleural effusion and destroyed left lower lobe was noticed in his computerized chest tomography. After chest tube drainage, massive hemoptysis developed. An emergency thoracotomy was performed. A bronchopleural fistula, destroyed left lower lobe and the head of an oat were detected in the pleural space. Left lower lobectomy and perioperative pneumoperitoneum were performed. The patient had an uneventful postoperative (p.o.) course and was discharged on p.o. day 6. We present this case because of the rarity and to emphasize the clinical presentation. The physicians should be aware of life threatening complications of oat head aspiration.

Induction Chemotherapy With Triweekly Docetaxel and Cisplatin Followed by Concomitant Chemoradiotherapy With or Without Surgery in Stage III Non-Small-Cell Lung Cancer: A Phase II Study

BACKGROUND The main goal of this study was to evaluate the feasibility and effectivity of triweekly docetaxel/cisplatin followed by weekly docetaxel/cisplatin concomitantly with radiotherapy with or without surgery in locally advanced non-small-cell lung cancer (NSCLC) patients. MATERIALS AND METHODS Thirty five patients with locally advanced NSCLC were enrolled. Combination chemotherapy with triweekly docetaxel/cisplatin (75 mg/m(2)) was administered as induction regimen. After induction chemotherapy, patients were evaluated for surgery if their disease subsequently downstaged. Six cycles of weekly docetaxel/cisplatin (20 mg/m(2)) concurrently with radiotherapy up to a 60 Gy were administered after induction chemotherapy with or without surgery. Response, toxicity, time-to-progression and overall survival were evaluated. RESULTS Twelve patients with stage IIIA-N2 and 23 patients with stage IIIB-T4N0-2 were evaluated (median age, 54 years). After 94 cycles of induction chemotherapy, partial response was achieved in 20 patients, 9 patients had stable disease and six had progressive disease. After overall treatment, 6 patients achieved complete response, 19 patients had partial response, 8 patients had progressive disease, and 2 patients had stable disease. Two patients experienced grade 3-4 pulmonary toxicity and 1 patient experienced grade 3 esophageal toxicity. Six patients underwent surgery. Median overall survival for all patients was 15 months and time-to-progression was 13 months with a median follow-up of 22 months. CONCLUSION Triweekly docetaxel plus cisplatin followed by weekly docetaxel plus cisplatin concomitantly with radiotherapy is effective and feasible and seems to be an alternative option for patients who have locally advanced NSCLC. Surgery may provide additional benefit for patients whose disease adequately downstaged after induction chemotherapy.

Reimplantation of the Left Lung 17 Years After a Bronchial Rupture

We describe a 37-year-old female patient who had a major vehicle accident 17 years ago. A chest tube had been inserted through the left side of the chest to treat pneumothorax. She was readmitted to the hospital with dyspnea 17 years later. Her examinations, including fiberoptic bronchoscopy, revealed total atelectasis of the left lung with a blind-ending left main bronchus. Anastomosis of the left distal main bronchus to left main bronchus was performed. She had no complications and was discharged on postoperative day 8. Follow-up demonstrated a perfectly functioning left lung with nuclear and tomographic investigations performed on the first postoperative year.

Hyperhomocysteinemia in patients with arterial occlusive disease.

PurposeHyperhomocysteinemia (HHCA) is defined as an independent risk factor for atherothrombotic vascular disease; therefore, screening for HHCA is recommended. However, the incidence and characteristics of HHCA in patients with vascular disease remain unclear. We conducted this study in an attempt to resolve these issues.MethodsThis nonrandomized prospective study included 56 patients who were admitted with occlusive arterial disease (group I), and 39 control patients without occlusive arterial disease (group II). We recorded all the demographic data of both groups and collected blood samples for fasting homocysteine, vitamin B12, and folic acid. All of the patients were followed up and the results were compared.ResultsThe mean concentration of homocysteine was 12.69 ± 3.82 µmol/l in group I and 10.46 ± 5.08 µmol/l in group II (P = 0.00048). In group I, the mean homocysteine levels for patients aged ≥70 years and those aged <70 years were 13.74 ± 3.02 and 11.55 ± 4.15 µmol/l, respectively (P = 0.021). There was no significant difference in mortality between the patients with HHCA and those with normal homocysteine levels during follow-up.ConclusionThe incidence of hyperhomocysteinemia was higher in the patients with occlusive vascular disease than in the control patients. More evidence of the association with vitamins B12 and folate and the benefits of homocysteine-lowering therapy is needed since we found no relationship between these vitamins and homocysteine in this study.