Vincent Young

Clinical implication and prognostic significance of standardised uptake value of primary non-small cell lung cancer on positron emission tomography: analysis of 176 cases

OBJECTIVE We sought to assess the clinical implication and prognostic significance of maximum standardised uptake value (SUV(max)) of primary non-small cell lung cancer (NSCLC) staged by integrated PET-CT. METHODS A retrospective review was carried out on 176 consecutive patients with histologically proven NSCLC who underwent staging with integrated PET-CT prior to curative intent surgical resection. SUV(max) of primary NSCLC were measured and correlated with tumour characteristics, lymph node involvement, surgical stage, type of surgical resection and survival following resection. RESULTS SUV(max) was significantly higher in centrally located tumours, tumours > or =4.0 cm, squamous cell subtype, poorly differentiated tumours, advanced T stage, advanced nodal stage, pleural invasion, and patients requiring complex surgical resection. SUV(max) value of 15 was the best discriminative cut-off value for survival generated by log-rank test. When patients were stratified based on this value, those with SUV(max) >15 were more likely to have centrally located tumours, squamous cell subtype, advanced T stage, advanced nodal stage, advanced American Joint Committee on Cancer (AJCC) stage, larger tumour size and required more advanced surgical resections than a simple lobectomy. Overall survival was significantly longer for patients with SUV(max) < or =15 than those with SUV(max) >15. Furthermore, nodal stage specific survival following resection (i.e. non-N2 and N2) were significantly better in patients with SUV(max) < or =15 than SUV(max) >15. CONCLUSION SUV(max) correlates with tumour characteristics, surgical stage and prognosis following resection. SUV(max) may be a useful preoperative tool, in addition to other known prognostic markers, in allocating patients with potentially poor prognosis preoperatively to neoadjuvant chemotherapy prior to resection in order to improve their overall survival. Prospective and randomised trials are warranted.

Operation for cavitating invasive pulmonary aspergillosis in immunocompromised patients

Invasive pulmonary aspergillosis is a specific form of pulmonary Aspergillus infection that occurs almost exclusively in immunocompromised patients. It differs both histologically and in its clinical course from classic aspergillomas. During a 5-year period (1986-1990), 8 patients underwent resection for cavitating invasive pulmonary aspergillosis that developed as a consequence of neutropenia during chemotherapy for malignancy. There were no perioperative deaths and no complications. This contrasts with reports of operation for classic aspergillomas. Histologic examination of the resected specimens showed that cavitating invasive pulmonary aspergillosis differed from classic aspergillomas. They consisted of necrotic lung tissue invaded by fungus with separation from the surrounding lung so that the sequestrum had the appearance of a fungus ball. Pulmonary aspergillosis is a common complication of profound neutropenia. The first hemoptysis in this group of patients is often life-threatening. The excellent results of operation in our series of patients may be attributed to their young age, good pulmonary function, and limited operation. This has lead us to recommend early surgical intervention in invasive aspergillosis once cavitation develops.

Effect of Smoking on Short-Term Outcome of Patients Undergoing Coronary Artery Bypass Surgery

BACKGROUND Data on the effect of smoking on short-term outcome in patients undergoing coronary artery bypass graft (CABG) surgery are limited. We sought to assess the morbidity and in-hospital mortality of smokers and former smokers compared with nonsmokers undergoing CABG. METHODS This is a retrospective review of prospectively collected departmental data base. In all, 2,587 consecutive patients underwent isolated CABG between February 2000 and June 2007. Of these, 475 patients were current smokers, 1,364 were former smokers of more than 4 weeks, and 748 were nonsmokers. RESULTS Current smokers had higher rates of postoperative pulmonary complications than former smokers and nonsmokers (30.1% versus 23.3% versus 19.9%, p < 0.001). Blood transfusion requirement was lower for current smokers group than for the other two groups (34.9% versus 37.5% versus 44.1%, p = 0.02). Adjusted odd ratios (OR) for early clinical outcomes showed that current smokers had 59% higher risk of developing pulmonary complications (OR 1.59) than nonsmokers, with former smokers showing an intermediate pattern (OR 1.17). Current smokers had 36% lower risk of postoperative blood transfusion than nonsmokers (OR 0.64), with former smokers showing an intermediate pattern (OR 0.94). Rates of other postoperative complications, intensive care unit readmission, postoperative length of stay, and mortality did not differ among the three groups. CONCLUSIONS Smoking is associated with significant pulmonary complications after CABG. In-hospital mortality is not influenced by smoking. Smokers should be encouraged to quit before undergoing CABG, and a period of 1 month may be beneficial, given that former smokers in our study seem to have better prognosis than current smokers.

Prognostic impact of vascular and lymphovascular invasion in early lung cancer

Background The prognostic significance of vascular and lymphatic invasion in non-small-cell lung cancer is under continuous debate. We analyzed the effect of tumor aggressiveness (lymphatic and/or vessel invasion) on survival and relapse in stage I and II non-small-cell lung cancer. Methods We retrospectively analyzed prospectively collected data of 457 patients with stage I and II non-small-cell lung cancer from 1998 to 2008. Specimens were analyzed for intratumoral vascular invasion and lymphovascular space invasion. Overall survival and disease-free survival were estimated using the Kaplan-Meier method, and differences were determined by the logrank test. Cox regression analysis was performed to identify independent risk factors. Results The incidence of intratumoral vascular invasion was 23.4%, and this correlated significantly with grade of differentiation, visceral pleural involvement, lymphovascular space invasion, and N status. The incidence of lymphovascular space invasion was 5.5%, and this correlated significantly with grade of differentiation, lymph nodes involved, and intratumoral vascular invasion. On multivariate analyses, intratumoral vascular invasion proved to be an significant independent risk factor for overall survival but not for disease-free survival. Lymphovascular space invasion was associated significantly with early tumor recurrence but not with overall survival. Conclusions Vascular and lymphatic invasion can serve as independent prognostic factors in completely resected non-small-cell lung cancer. Intratumoral vascular invasion and lymphovascular space invasion in early stage non-small-cell lung cancer are important factors in overall survival and early tumor recurrence. Further large scale studies with more recent patient cohorts and refined histological techniques are warranted.

Short-term and long-term outcome in low body mass index patients undergoing cardiac surgery

ObjectiveWe sought to assess the effect of low body mass index (BMI) on short- and long-term outcomes following cardiac surgery.MethodsThis is a retrospective review of a prospectively collected departmental database over a 6-year period. Patients were eligible for the study if the BMI was <25 kg/m2. All morbidities, length of hospital stay, and short- and long-term mortality were reviewed.ResultsThere were 704 patients divided into low (n = 71) and normal (n = 633) BMI. Postoperative pulmonary complications were higher in the low BMI group compared to the normal BMI group (24% vs. 11%, P < 0.001) with a higher incidence of in-hospital mortality (10% vs. 5%). Using multiple logistic regression, low BMI was an independent risk factor for in-hospital mortality. The 1-, 3-, and 5-year survivals for the low group were 90%, 78%, and 70% compared to 94%, 86%, and 81% in the normal BMI group.ConclusionLow BMI is associated with increased morbidity and mortality following cardiac surgery. Risk scoring systems should utilize the BMI in the preoperative risk assessment with special attention to low BMI.

Primary leiomyosarcoma of the right atrium: a case report and literature update

Leiomyosarcoma of the right atrium is a very rare cardiac tumor. Various combinations of treatments including resection or transplant surgery and Chemotherapy have been advocated. We report a case of a man who presented with pulmonary embolism secondary to right atrial leiomyosarcoma. He was managed by excision of the tumor and reconstruction of the right atrium with autologous pericardium. Postoperatively tumor dissemination was controlled with adjuvant chemotherapy.A vigorous attempt aiming at tumor clearance followed by adjuvant multimodality therapy along with a tumor surveillance program may improve survival.

Right atrial paraganglioma: an unusual primary cardiac tumour

We present a case of an unusual presentation of a rare primary cardiac tumour. There are no more than 50 previously reported cases of primary cardiac paraganglioma in the world literature and only a small proportion of these involve the right side of the heart. Diagnosis is difficult and surgical management is varied and complex.

Traumatic aortic transection: evidence for the osseous pinch mechanism

Acute traumatic transection of the thoracic aorta is most commonly seen in vehicular trauma and is generally accepted to be due to differential deceleration. A second mechanism is proposed for this injury and that is the osseous pinch mechanism. We report a case where aortic transection occurred due to a crush injury and supports the latter mechanism.

Comparative analysis and outcomes of sleeve resection versus pneumonectomy.

To compare the outcome of sleeve resection or complex sleeve resection versus (Vs) pneumonectomy for lung cancer in a single unit. Between 1998 and 2006, 664 lung resections were carried out. There were 129 (19.4%) pneumonectomies and 79 (11.9%) sleeve resections; Twenty one patients (26.5%) underwent a complex sleeve resection. Operative mortality for the sleeve resections (SR) was 2.5% and for the pneumonectomies 8.53%. Overall 5-year survival after SR was 46.8% and after pneumonectomy 37.1%. The survival curves for the 2 procedures after adjusting for risk factors are different. The area under the curve is higher for the SR (Hazard ratio 1.78 C.I.: 0,92-3,46). The 5-year survival for early stages favors SR. The survival for the complex SR was not influenced by the complexity of the procedure but from the TNM stage of each individual case. Multivariate analysis of risk factors affecting survival after surgery showed: male sex Hazard ratio (HR) 1.19, 0.63–2.27(95%CI), Age >63 1.38(HR), 0.78–2.48, Pneumonectomy 1.78(HR), 0.92–3.46 and stage III 4.44(HR), 1.94–10.16(95% CI). For comparative stages survival appears to be better after sleeves, moreover male sex, sleeve resection, age younger that 63 and early TNM stage are positive predictors for survival.

Lack of correlation between smoking status and early postoperative outcome following valve surgery.

BACKGROUND We sought to assess the effect of smoking on early outcome following valve surgery. METHODS This is a retrospective review of a prospectively collected departmental database of all patients who underwent isolated aortic and/or mitral valve surgery (replacement and/or repair). Our cohort consisted of 590 patients stratified into three groups: current smokers (n = 94), ex-smokers (n = 243), and nonsmokers (n = 253). RESULTS There were no significant differences in the in-hospital mortality between the three groups. Likewise, the length of both hospital and intensive care unit stays were similar among the three groups with a similar rate of postoperative complications. These findings remained statistically not significant, even after adjusting for potential confounders such as age, gender, etc. CONCLUSION Smoking does not seem to be associated with an increased early postoperative risk in patients undergoing valve surgery. However, because of the known effect of smoking on the risk of cardiovascular disease and because the effect of smoking on long-term survival in patients undergoing valve surgery remains unknown, patients should still be encouraged to quit smoking.