Tiziana Panigalli

Assessment of outcomes in typical and atypical carcinoids according to latest WHO classification

BACKGROUND Pulmonary carcinoid tumors represent a group of malignant neoplasms comprised of neuroendocrine cells. In 1999, the World Health Organization (W.H.O.) proposed the definitive classification of neuroendocrine tumors based on the criteria from Travis and associates. The W.H.O. described two different groups of carcinoid tumors: typical carcinoids (TC) and atypical carcinoids (AC). Few reports have reviewed their data according to the current classification, and therefore, prognosis and standard therapy for TC and AC are still uncertain. METHODS From 1980 to 2001, 98 pulmonary resections have been performed for primary bronchial carcinoid tumors in our Thoracic Department of the University of Milan. We reviewed original histology using the current W.H.O. criteria and identified 88 patients with TC and 10 with AC. We reviewed the outcomes in each group. RESULTS The 5 year-overall survival rate was 91.9% for TC and 71% for AC. The 10-year overall survival rate was 89.7% for TC and 60% for AC. The 5-year TNM-related survival rates in the TC group were: IA-B, 100%; IIA-B, 75%; and IIIA, 50%. At 10 years, they were: IA-B, 100%; IIA-B, 75%; and IIIA, 0%. The 5-year survival rates in the AC group were: IA-B, 100%; IIA-B, 100%; and IIIA, 0%. At 10 years, they were: IA-B, 100%; IIA-B, 66%; and IIIA, 0%. CONCLUSIONS Prognosis is favorable for both subtypes in the early stage. Advanced stages are related to better prognosis in TC. Recurrences rate is worse in the AC subtype. Our data suggest avoiding limited resections when feasible in AC. Parenchyma-sparing resections should be encouraged in TC.

Video-assisted thoracoscopic resection of pulmonary sequestration in an infant

Pulmonary sequestration is a congenital anomaly of lung parenchyma that can be definitively treated only with surgical resection. We report a case of an intralobar sequestration of the right lower pulmonary lobe in an infant successfully treated with video-thoracoscopic surgical removal of the involved lobe at 6 months of age.

Personal experience in lung cancer sleeve lobectomy and sleeve pneumonectomy.

BACKGROUND Sleeve lobectomy (SL) and tracheal sleeve pneumonectomy (TSP) represent valuable alternative techniques to standard resections in the treatment of benign and malignant conditions of the airway and allow preservation of lung parenchyma. METHODS Eighty-three sleeve lobectomies and 27 tracheal sleeve pneumonectomies have been performed for nonsmall cell lung cancer in the thoracic department of the University of Milan from 1979 to 1999. There were 46 upper right lobectomies, 11 upper and middle lobectomies, 18 upper left lobectomies, 8 lower left lobectomies, and 27 right pneumonectomies. RESULTS Mortality rate was 3.6% in SL and 7.4% in TSP. Complications were 10.8% of all SLs and 15% of all TSPs. The overall 5-year survival rate was 43% for SL and 20% for TSP; the 10-year survival rate was 34% and 14%, respectively. There was a highly significant difference in survival between patients with N0 and N1-N2 disease. CONCLUSIONS Sleeve lobectomy is an appropriate surgical procedure and an alternative to pneumonectomy in patients with limited respiratory reserve whenever the situation permits. Trachael sleeve pneumonectomy is associated with more complications and poor survival.

Surgical experience of 15 solitary benign fibrous tumor of the pleura

OBJECTIVE The localized benign fibrous tumor of the pleura represents 8% of all benign pathologies of the chest and 10% of neoplasms of the pleura. The authors review the literature, and report on 15 cases of localized benign fibrous tumors of the pleura surgically treated over a period of 15 years to further knowledge of this pathology, its therapy and prognosis. METHODS With respect to the well-known diffuse malignant mesothelioma, different etiopathogenesis, prognosis, and therapeutic approaches characterize the localized benign fibrous tumor of the pleura. In our experience, 15 patients underwent thoracotomy with excision of a pathological endothoracic mass, then histologically proved to be a localized benign tumor of the pleura. The whole group underwent pre-operative evaluation and, when clinic suggested, stadiation and post-operative frequent follow-up. RESULTS The whole group of 15 patients underwent surgical approach well tolerated the surgical treatment with perfect recovery of post-operative respiratory function. There was no relapse of disease in any patients. At the moment all patients are still alive except one dead of heart failure. CONCLUSION The differential diagnosis of benign fibrous tumor of the pleura and lung and pleural malignancy depends upon immunohistochemistry of the surgical specimen so that prognosis could be formulated only after surgery. We consider surgery as the treatment of choice in this pathology.

Elevaciones de la troponina I cardiaca tras la cirugía torácica. Incidencia y correlaciones con las características clínicas basales, la proteína C reactiva y los parámetros perioperatorios

Resumen Introduccion y objetivos La incidencia real de las elevaciones de la troponina I cardiaca tras la cirugia toracica y su correlacion con otros parametros clinicos no esta plenamente definida. El objetivo de este estudio fue evaluar la frecuencia de las elevaciones postoperatorias de la troponina I cardiaca despues de cirugia pulmonar o pleural por sospecha de cancer e investigar las correlaciones con los perfiles clinicos basales, con la proteina C reactiva y los parametros perioperatorios. Metodos Se registro a 50 pacientes consecutivos y se midieron los siguientes parametros en cada paciente: variables clinicas basales y concentracion de la proteina C reactiva, concentracion de troponina I cardiaca en los dias 1, 3 y 5 del postoperatorio, electrocardiograma, presion arterial, y frecuencia cardiaca diarias desde el dia de la operacion hasta el dia 5 del postoperatorio. Resultados Se produjeron elevaciones postoperatorias de la troponina I cardiaca en el 20% de los pacientes y estas estaban significativamente asociadas con los antecedentes de coronariopatia o mas de 2 factores de riesgo coronario (el 80 frente al 32,5%; p = 0,011), los antecedentes de tratamiento antiagregante plaquetario cronico (el 50 frente al 17,5%; p = 0,046), la neumonectomia comparada con los procedimientos menos invasivos (el 40 frente al 10%; p = 0,041), la pericardiotomia (el 30 frente al 2,5%; p = 0,022) y las modificaciones transitorias del segmento ST en el electrocardiograma perioperatorio (el 60 frente al 20%; p = 0,02). No se observo correlacion significativa entre las elevaciones de la troponina I cardiaca y la proteina C reactiva basal. Conclusiones Las elevaciones de la troponina I cardiaca despues de la cirugia toracica son frecuentes y estan asociadas con marcadores clinicos de coronariopatia, procedimientos quirurgicos extensos y cambios isquemicos en el electrocardiograma perioperatorio.

Cardiac Troponin-I Elevations After Thoracic Surgery. Incidence and Correlations With Baseline Clinical Characteristics, C-Reactive Protein and Perioperative Parameters

INTRODUCTION AND OBJECTIVES The exact incidence of cardiac troponin-I elevation after thoracic surgery and its correlation with other clinical parameters have not been fully described. The aims of this study were to determine the frequency of postoperative cardiac troponin-I elevation following lung or pleural surgery for suspected cancer, and to investigate correlations with baseline clinical characteristics, the C-reactive protein level, and perioperative parameters. METHODS Fifty consecutive patients were enrolled in the study. In each patient, the following parameters were measured: clinical characteristics and C-reactive protein level at baseline, cardiac troponin-I level on postoperative days 1, 3 and 5, and blood pressure, heart rate and ECG parameters every day from the day of the operation until postoperative day 5. RESULTS The cardiac troponin-I level was elevated postoperatively in 20% of patients. There were significant associations with either a history of coronary artery disease or the presence of more than two coronary risk factors (80% vs. 32.5%; P=.011), a history of chronic antiplatelet therapy (50% vs. 17.5%; P=.046), pneumonectomy compared with less invasive procedures (40% vs. 10%; P=.041), pericardiotomy (30% vs. 2.5%; P=.022), and transient ST-segment alterations on perioperative ECGs (60% vs. 20%; P=.02). No significant correlation was found between cardiac troponin-I elevation and the baseline C-reactive protein level. CONCLUSIONS Cardiac troponin-I elevation occurs frequently after thoracic surgery and it is associated with clinical markers of coronary artery disease, extensive surgical procedures, and ischemic changes observed on perioperative ECGs.

1075 Surgical aspects of lung resection for metastases

We report our experience in the surgical treatment of lung metastases from 1976 to 1995. Among 2040 patients who underwent pulmonary resection, we observed 102 cases (5%) in which a metastasectomy was performed. All the patients had neither local nor distant recurrence of the neoplasm. There were no intra or perioperative complications. The 5-year survival rate was 35.4%; we report the 5-year survival rate related to the number, the dimension, the site of the metatases and the surgical technique, which all seem not to be negative prognostic factors. On the contrary the histologic type of the neoplasm seems to the affect the survival.

1066 Surgical management of non small cell lung cancer with invasion of the chest wall

The chest wall is involved by direct lung tumour extension in approximately 2-8% of the patients. Between 1976 and 1989, 1365 patients underwent resection of non small cell lung cancer and this study is concerned with 73 of these patients (5.3%) who required resection of an area of the chest wall including one or more ribs because of direct tumour invasion (T3). The overall 5-year survival rate was 31.5% (23 patients); 17(74%), were N0,5 (21.7%) were N1 and only 1 (4.3%)was N2. Our experience confirms earlier reports: stage IIIA patients T3N0MO have a better 5-year survival rate than NI and N2, indicating a potentially radical tumour excision even in this stage.

1071 Paraneoplastic syndrome in lung cancer

Paraneoplastic syndrome (PS) is sometimes related to lung cancer and often is the first clinical manifestation of the disease. We review our experience from 1967 to 1994: during this period we observed 3012 patients with lung cancer and among them PS was diagnosed in 601 (19.9%). The most frequent clinical manifestations were syndromes involving the bones and the joints (43.4%). We observed a higher incidence of PS (36.7%) in patients with small lung cancer. In 392 patients (13%) PS was the first presenting complaint and in 124 (4.1%) led to correct diagnosis. We studied the relationship between PS and staging of neoplasm, surgical feasibility and 5-year survival rate.