Tamas Szöke

Prognostic significance of endogenous adhesion/growth-regulatory lectins in lung cancer

Objective: To determine the expression of endogenous adhesion/growth-regulatory lectins and their binding sites using labeled tissue lectins as well as the binding profile of hyaluronic acid as an approach to define new prognostic markers. Methods: Sections of paraffin-embedded histological material of 481 lungs from lung tumor patients following radical lung excision processed by a routine immunohistochemical method (avidin-biotin labeling, DAB chromogen). Specific antibodies against galectins-1 and -3 and the heparin-binding lectin were tested. Staining by labeled galectins and hyaluronic acid was similarly visualized by a routine protocol. After semiquantitative assessment of staining, the results were compared with the pT and pN stages and the histological type. Survival was calculated by univariate and multivariate methods. Results: Binding of galectin-1 and its expression tended to increase, whereas the parameters for galectin-3 decreased in advanced pT and pN stages at a statistically significant level. The number of positive cases was considerably smaller among the cases with small cell lung cancer than in the group with non-small-cell lung cancer, among which adenocarcinomas figured prominently with the exception of galectin-1 expression. Kaplan-Meier computations revealed that the survival rate of patients with galectin-3-binding or galectin-1-expressing tumors was significantly poorer than that of the negative cases. In the multivariate calculations of survival lymph node metastases (p < 0.0001), histological type (p = 0.003), galectin-3-binding capacity (p = 0.01), galectin-3 expression (p = 0.03) and pT status (p = 0.003) proved to be independent prognostic factors, not correlated with the pN stage. Conclusion: The expression and the capacity to bind the adhesion/growth regulatory galectin-3 is defined as an unfavorable prognostic factor not correlated with the pTN stage.

Surgical intervention for pulmonary tuberculosis: analysis of indications and perioperative data relating to diagnostic and therapeutic resections

OBJECTIVE To analyze the data on patients operated on for pulmonary tuberculosis (TB) with (Group I) or without (Group II) a correct TB diagnosis and preoperative anti-TB treatment. METHODS Between 1980 and 1997, 144 resections for TB (Groups I+II) were performed. The 80 patients in Group I underwent therapeutic resections: 32 cases involved recurrent cavities or tuberculomas, three involved post-TB bronchiectasis, 13 involved progression of cavities or tuberculomas, and 32 involved persistent tuberculomas after 6 months of anti-TB therapy. The 64 patients in Group II were operated on for a suspicion of malignancy in 49 cases, for cavitary lesions with haemophthysis in six cases, for multiple lesions in seven cases, and for recurrent hydrothorax in two cases. RESULTS Groups I and II included 0 and five pneumonectomies, 32 and 29 lobectomies, 48 and 20 wedge resections, 0 and nine videothoracoscopic biopsies, and 0 and one hilar lymphadenectomy, respectively. In Groups I and II, the mean duration of postoperative hospitalization was 13.2 and 10.4 days, and the frequency of postoperative pneumothorax was 11.25 and 4.6%, respectively. The incidence of bronchopleural fistula was 1.25 and 0%, the mortality was 0 and 3.1%, and the morbidity was 53.7 and 35.9% in Groups I and II, respectively. Two patients with active disease died in Group II. Pathology demonstrated that the frequency of acid-fast bacilli in Groups I and II was 40 and 25%, respectively. CONCLUSIONS Patients without a correct preoperative TB diagnosis underwent more extensive parenchyma resection. Postoperative complications increased when acid-fast bacilli were present. The lack of preoperative anti-TB treatment did not involve a higher risk of minor complications, but death occurred only in this group.

Complex pleural empyema can be safely treated with vacuum-assisted closure

ObjectiveFor patients with postoperative pleural empyema, open window thoracostomy (OWT) is often necessary to prevent sepsis. Vacuum-assisted closure (VAC) is a well-known therapeutic option in wound treatment. The efficacy and safety of intrathoracal VAC therapy, especially in patients with pleural empyema with bronchial stump insufficiency or remain lung, has not yet been investigated.MethodsBetween October 2009 and July 2010, eight consecutive patients (mean age of 66.1 years) with multimorbidity received an OWT with VAC for the treatment of postoperative or recurrent pleural empyema. Two of them had a bronchial stump insufficiency (BPF).ResultsVAC therapy ensured local control of the empyema and control of sepsis. The continuous suction up to 125 mm Hg cleaned the wound and thoracic cavity and supported the rapid healing. Additionally, installation of a stable vacuum was possible in the two patients with BPF. The smaller bronchus stump fistula closed spontaneously due to the VAC therapy, but the larger remained open.The direct contact of the VAC sponge did not create any air leak or bleeding from the lung or the mediastinal structures. The VAC therapy allowed a better re-expansion of remaining lung.One patient died in the late postoperative period (day 47 p.o.) of multiorgan failure. In three cases, VAC therapy was continued in an outpatient service, and in four patients, the OWT was treated with conventional wound care. After a mean time of three months, the chest wall was closed in five of seven cases. However, two patients rejected the closure of the OWT. After a follow-up at 7.7 months, neither recurrent pleural empyema nor BPF was observed.ConclusionVAC therapy was effective and safe in the treatment of complicated pleural empyema. The presence of smaller bronchial stump fistula and of residual lung tissue are not a contraindication for VAC therapy.

Is the mediastinal lymphadenectomy during pulmonary metastasectomy of colorectal cancer necessary

The aim of study was to investigate the pattern of mediastinal lymph node metastases in patients with colorectal cancer metastasis. Twenty-four pulmonary metastasectomies with mediastinal lymphadenectomies were performed on 19 patients (14 unilateral and five bilateral operations). The metastases were centrally localised in eight cases; the primary tumour was colon cancer in 15 patients and rectal cancer in nine cases. The number and the localisation of metastases were recorded, as the clinico-pathological data of the primary tumours. The results were compared with the pattern of metastases in mediastinal lymph nodes. The data were subjected to statistical processing with the chi(2)-test and Mann-Whitney test. Mediastinal lymph node metastases were confirmed in eight cases (33.3%). The proportion of positive lymph nodes was significantly higher for central metastases (62.5% vs. 18.8%, P=0.032). When the pathological stage of the primary tumour was more advanced, the proportion of lymph node metastases displayed a statistically not significant increase. The pattern of lymph node metastases did not correlate with the localisation of the lung metastases, disease-free interval and the diameter of the greatest pulmonary metastasis. The frequency of lymph node metastasis is relatively high, therefore, mediastinal lymphadenectomy during the resection of colorectal cancer metastases is necessary.

Vacuum-Assisted Closure of Pleural Empyema Without Classic Open-Window Thoracostomy

A 64-year-old man was diagnosed with complex empyema after a second course of palliative chemotherapy for metastatic lung cancer. Because of the poor general condition of the patient, the decision was made to proceed with vacuum-assisted closure (VAC) therapy of the empyema without Eloesser or Clagett open-window thoracostomy (OWT). Installation and changing of the VAC sponge were performed using the ALEXIS Wound Protector/Retractor (Applied Medical, Rancho Santa Margarita, CA), a flexible polymer membrane tube. After 10 days of VAC treatment, the pleural cavity was sterile and was closed with single stitches. Chemotherapy was resumed 1 week later.

Minimally Invasive Vacuum-Assisted Closure Therapy With Instillation (Mini-VAC-Instill) for Pleural Empyema

Enthusiasm for minimally invasive thoracic surgery is increasing. Thoracoscopy plays a significant therapeutic role in the fibrinopurulent stage (stage II) of empyema, in which loculated fluid cannot often be adequately drained by chest tube alone. For some debilitated and septic patients, further procedures such as open-window thoracostomy (OWT) with daily wound care or vacuum-assisted closure (VAC) therapy are necessary. In the present article, we propose a new option of minimally invasive VAC therapy including a topical solution of the empyema without open-window thoracostomy (Mini-VAC-instill). Three patients who underwent surgery using this technique are also presented. The discussion is focused on the advantages and disadvantages of the approach.

Minimally invasive vacuum-assisted closure therapy in the management of complex pleural empyema

OBJECTIVES The pool of potential candidates for pleural empyema is expanding. In a previous technical report, we tested the feasibility of the minimally invasive insertion of a vacuum-assisted closure (Mini-VAC) system without the insertion of an open-window thoracostomy (OWT). In this study, we describe a consecutive case series of complex pleural empyemas that were managed by this Mini-VAC therapy. METHODS In this retrospective study, we investigated 6 patients with multimorbidity (Karnofsky index ≤ 50%) who were consecutively treated with Mini-VAC for a primary, postoperative or recurrent pleural empyema between January 2011 and February 2012. RESULTS Local control of the infection and control of sepsis were satisfactory in all 6 of the patients treated by Mini-VAC therapy. The suction used did not create any air leaks or bleeding from the lung or mediastinal structures. Mini-VAC therapy allowed a reduction of the empyema cavity and improved the re-expansion of the residual lung. Mini-VAC therapy resulted in a rapid eradication of the empyema. The chest wall was closed in all patients during the first hospital stay. All patients left the hospital in good health (Karnofsky index >70%) and with a non-infected pleural cavity at a mean of 22 ± 11 days after Mini-VAC installation. Pleural empyema was not detected in any of the 6 patients at the 3-month follow-up appointment. CONCLUSIONS The Mini-VAC procedure with the abdication of an OWT offers a rapid treatment for complex pleural empyema with minimal surgical effort and the opportunity for a primary closure of the empyema cavity.

Mini-open vacuum-assisted closure therapy with instillation for debilitated and septic patients with pleural empyema.

OBJECTIVES This prospective study is an evaluation of the mini-open vacuum-assisted closure with instillation (Mini-VAC-Instill) therapy for the treatment of complicated pleural empyema. METHODS We investigated septic patients in poor general physical condition (Karnofsky index ≤50%) with multimorbidity and/or immunosuppression who were treated by minimally invasive intrathoracic VAC-Instill therapy without the insertion of an open-window thoracostomy (OWT) between December 2012 and November 2014. All patients underwent mini-thoracotomy with position of a tissue retractor, surgical debridement and local decortication. Surgery was followed by intrathoracic vacuum therapy including periodic instillation using antiseptics. The VAC dressings were changed under general anaesthesia and the chest wall was closed during the same hospital stay. All patients received systemic antibiotic therapy. RESULTS Fifteen patients (13 males, median age: 71 years) underwent intrathoracic Mini-VAC-Instill dressings for the management of pleural empyema without bronchopleural fistula. The median length of vacuum therapy was 9 days (5-25 days) and the median number of VAC changes per patient was 1 (1-5). In-hospital mortality was 6.7% (n = 1) and was not related to Mini-VAC-Instill therapy or intrathoracic infection. Control of intrathoracic infection and closure of the chest cavity was achieved in 85.7% of surviving patients (12 of 14). After the follow-up at an average of 13.2 months (range, 3-25 months), we observed recurrence once, 21 days after discharge. Two patients died in the late postoperative period (Day 43 and Day 100 after discharge) of fulminant urosepsis and carcinoma-related multiorgan failure, respectively. Analysis of the follow-up interviews in the outpatient clinic showed a good quality of life and a subjectively good long-term aesthetic result. CONCLUSIONS Mini-VAC-Instill therapy is an upgrade of Mini-VAC, which guarantees the advantage of an open treatment, including flushing but without OWT. This procedure is minimally invasive, highly compatible especially with patients in poor general condition and may be an alternative to the OWT in selected patients. Consequently, a very short course of therapy results in good patient acceptance.

Prospective, comparative study of the On-Q® PainBuster® postoperative pain relief system and thoracic epidural analgesia after thoracic surgery.

OBJECTIVE Pain after thoracotomy is associated with intense discomfort leading to impaired pulmonary function. DESIGN Prospective, non-randomized trial from April 2009 to September 2011. SETTING Department of Thoracic Surgery, single-center. PARTICIPANTS Thoracic surgical patients. INTERVENTIONS Comparison of thoracic epidural analgesia (TEA) with the On-Q® PainBuster® system after thoracotomy. MEASUREMENTS AND MAIN RESULTS The TEA group (n=30) received TEA with continuous 0.2% ropivacaine at 4 mL-to-8 mL/h, whereas Painbuster® patients (n=32) received 0.75% ropivacaine at 5 mL/h until postoperative day 4 (POD4). Basic and on-demand analgesia were identical in both groups. Pain was measured daily on a numeric analog scale from 0 (no pain) to 10 (worst pain) at rest and at exercise. There were no significant differences regarding demographic and preoperative data between the groups, but PainBuster® patients had a slightly lower relative forced expiratory volume in 1 second (FEV1) (71±20% versus 86±21%; p=0.01). Most common surgical procedures were lobectomies (38.8%) and atypical resections (28.3%) via anterolateral thoracotomy. Most common primary diagnoses were lung cancer (48.3%) and tumor of unknown origin (30%). At POD1, median postoperative pain at rest was 2.1 (1; 2.8) in the TEA group and 2 (1.5; 3.8; p=0.62) in the PainBuster® group. At exercise, median pain was 4.3 (3.5; 3.8) in the TEA group compared to 5.0 (4.0; 6.5; p=0.07). Until POD 5 there were decreases in pain at rest and exercise but without significant differences between the groups. CONCLUSIONS Sufficient analgesia after thoracotomy can be achieved with the intercostal PainBuster® system in patients, who cannot receive TEA.

Radiotherapy in the treatment of postoperative chylothorax

BackgroundChylothorax is characterized by the presence of chyle in the pleural cavity. The healing rate of non-operative treatment varies enormously; the maximum success rate in series is 70%. We investigate the efficacy and outcomes of radiotherapy for postoperative chylothorax.MethodsChylothorax was identified based on the quantity and quality of the drainage fluid. Radiation was indicated if the daily chyle flow exceeded 450 ml after complete cessation of oral intake. Radiotherapy consisted of opposed isocentric portals to the mediastinum using 15 MV photon beams from a linear accelerator, a single dose of 1–1.5 Gy, and a maximum of five fractions per week. The radiation target area was the anatomical region between TH3 and TH10 depending on the localization of the resected lobe. The mean doses of the ionizing energy was 8.5 Gy ± 3.5 Gy.ResultsThe median start date of the radiation was the fourth day after chylothorax diagnosis. The patients’ mediastinum was radiated an average of six times. Radiotherapy, in combination with dietary restrictions, was successful in all patients. The median time between the end of the radiation and the removal of the chest tube was one day. One patient underwent wound healing by secondary intention. The median time between the end of radiation and discharge was three days, and the overall hospital stay between the chylothorax diagnosis and discharge was 18 days (range: 11–30 days). After a follow-up of six months, no patient experienced chylothorax recurrence.ConclusionsOur results suggest that radiotherapy in combination with dietary restriction in the treatment of postoperative chylothorax is very safe, rapid and successful. This novel interventional procedure can obviate repeat major thoracic surgery and shorten hospital stays and could be the first choice in the treatment of postthoracotomy chylothorax.