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Background: Traumatic pulmonary pseudocysts (TPPs) are rare sequelae of blunt chest trauma. We present a retrospective review of TPPs observed in our hospital and discuss the diagnosis, treatment, and complications of these unusual lesions. Methods: Between 1991 and 1999, 11 TPPs were diagnosed in 10 patients. None of the lesions was detectable on the chest radiograph obtained on the day of injury. In contrast, computed tomographic scan of the chest always demonstrated the TPPs. Results: in nine cases, spontaneous healing of the lesions was observed. One patient with a large lesion of the left lower lobe developed significant endobronchial bleeding and underwent successful emergency lobectomy. Conclusion: TPPs are often missed by chest radiography, particularly when it is obtained in the supine position, whereas computed tomographic scan allows the identification of these lesions in all cases. TPPs are self-limiting, benign lesions that usually require no specific therapy. Surgical treatment is indicated in rare instances and only when complications occur. RI ciriaco, paola/H-5716-2012

Objective: Pulmonary emphysema is frequently associated with lung cancer and, because of the impaired pulmonary function involved, it may contraindicate surgical treatment. However, improvement of pulmonary function has been observed after surgical resection in patients with advanced emphysema. The aim of this study was to evaluate whether pulmonary emphysema, as assessed by pulmonary function tests and radiological evaluation, can influence postoperative respiratory function after lobectomy for non-small cell lung cancer (NSCLC). Methods: Respiratory function was evaluated before and after lobectomy for NSCLC, Radiological evaluation of emphysema was performed on chest X-ray and CT scan. Patients that had undergone chemo- or radiotherapy or had segmental or lobar atelectasis were excluded from the study. Results: Thirty-five patients entered the study. A decrease in static lung volumes was observed after surgery. Total lung capacity (TLC) decreased from 6.58 +/- 0.92 to 5.46 +/- 0.77 1; functional residual capacity (FRC) from 3.70 +/- 0.88 to 2.96 +/- 0.73 1 and residual volume (RV) from 2.93 +/- 0.78 to 2.2 +/- 0.53 1. However, in a subgroup of 10 patients (Group 1), dynamic volumes after surgery were unchanged or slightly increased (forced vital capacity (FVC) from 3.23 +/- 0.65 to 3.3 +/- 0.68 1; forced expiratory volume in 1 s (FEV 1) from 2.14 +/- 0.51 to 2.25 +/- 0.54 1), and airway resistances (sRaw) decreased from 15.58 +/- 5.18 to 11.42 +/- 5.25 cm H2O/s. Preoperative data showed that these patients had a greater obstruction, with FEV1 changing from 69 +/- 12.42 to 72.70 +/- 13.72% of predicted, as compared with a change from 87 +/- 12.7 to 72.08 +/- 13.10% in the other group of 25 patients (Group 2). Correlation analysis reached statistical significance between FEV1% variation (Delta FEV1%) and preoperative FEV1 and FVC% (r = -0.49, P = 0.002 and r = -0.5, P = 0.001, respectively) and between Delta (FEV1)% and radiological scores for 3-level CT (r = 0.39, P = 0.04) and the sum of chest X-ray, single and 3-level CT scores (r = 0.49, P = 0.01). Conclusions: Pulmonary function may remain unchanged or even increase after lobectomy in patients with a pronounced emphysematous component of airway obstruction. The identification of preoperative parameters that identify this group of patients could extend the indications for the treatment of lung cancer in patients with pulmonary emphysema. (C) 1999 Published by Elsevier Science B.V. All rights reserved.

Postoperative improvement of respiratory function has been reported with lung volume reduction surgery (LVRS) in patients with severe emphysema. Since smoking is an established risk factor for lung cancer, vascular diseases and emphysema, it is not infrequent to find these diseases associated in the same patient. Combined treatment of lung cancer acid emphysema has already been reported. Surgical treatment of vascular diseases in emphysematous patients could also benefit from the application of LVRS techniques. We report resection of an aortic aneurysm combined with LVRS in a patient with concomitant thoracic aortic aneurysm and severe emphysema. Respiratory function improved in the postoperative period. Postoperative improvement of respiratory function has been reported with lung volume reduction surgery (LVRS) in patients with severe emphysema. Since smoking is an established risk factor for lung cancer, vascular diseases and emphysema, it is not infrequent to find these diseases associated in the same patient. Combined treatment of lung cancer and emphysema has already been reported. Surgical treatment of vascular diseases in emphysematous patients could also benefit from the application of LVRS techniques. We report resection of an aortic aneurysm combined with LVRS in a patient with concomitant thoracic aortic aneurysm and severe emphysema. Respiratory function improved in the postoperative period.

In this study all patients observed between January 1993 and October 1997 with malignant pleural mesothelioma (MPM) have been analyzed in order to describe the impact of treatment modality on survival.Medical records of 56 patients with MPM (44 male, 12 female, median age = 59 yrs) were reviewed. In 34 cases the histotype was epithelial, in 4 sarcomatoid, in 4 mixed, in 3 desmoplastic, and in 11 not specified. Four treatment modalities were identified: 1) Surgery (subtotal pleurectomy) = 20 patients; 2) Chemotherapy = 19 patients; 3) Surgery+Chemo-therapy = 8 patients; 4) Supportive care = 9 patients.The median survival was: 1) Surgery = 12.4 months; 2) Chemotherapy = 7.5 months; 3) Surgery+Chemotherapy = 12 months; 4) Supportive care = 11.4 months. Using univariate analysis, 8 prognostic factors were studied (age, sex, asbestos exposure, side, histotype, performance status, stage, treatment). Among these, only the stage and the performance status had shown a prognostic value on survival (p0.05), while the treatment modality had not significantly influenced the prognosis. Using multivariate analysis only performance status showed to be significatively associated with survival (p=0.01 and odds ratio = 1.9, I.C. 1.2-3.2).Despite the limits of a retrospective study, personal experience confirms the ineffectiveness of current therapeutical approaches to MPM. A better understanding of MPM is required to develop new therapeutical approaches and alter the dismal prognosis of this disease.

Background. Indications to surgical treatment of lung cancer in the elderly are still being discussed. The aim of this study was to evaluate postoperative complications and survival after surgery for non-small cell lung cancer (NSCLC) in patients 70 years of age or older. Methods. During a 4 year and 6 month period, 76 patients (67 men and 9 women) entered the study. Results. Postoperative complications occurred in 15 cases (19.7 %) and the 30-day operative mortality was 1.3%. The overall 54 month actuarial survival was 53%. Mortality at 12 months wasn't related to stage of disease, histology or lobectomy versus wedge resection but was higher in those patients who had had postoperative cardiopulmonary complications. Results of preoperative spirometry, blood gas and cardiac status were predictive of mortality at twelve months (p

Emphysematous patients that were once treated with double lung transplantation can now also be treated with single lung transplantation. However, single lung transplantation in emphysematous patients presents problems in lung size matching, choice of side to transplant and post-operative assistance. Analysing their own experience of three single lung transplants performed on emphysematous patients, the Authors evaluate the effectiveness of the operation, the results and the difficulties encountered. Single lung transplantation is a good therapeutic option for end-stage emphysematous patients. In these patients right lung transplantation is preferable and the donor organ should be oversized. Positive end expiratory pressure in the native emphysematous lung should be applied with extreme caution.

Aim. The aim of this study was to analyze our experience with combined treatment of non-small cell lung cancer with synchronous brain metastases. Methods. Between 1992 and 2008, 31 patients were treated by performing neurosurgery (or stereotactic radiosurgery) and lung surgery. Patients were divided into two groups according to their preoperative mediastinal work-up: group A (CT scan) and group B (FDG-PET scan). Results. Twenty-six patients had one brain metastasis and five had two. Neurosurgery was performed in 10 patients, stereotactic radiosurgery in 20 and both approaches in 1. Seven patients underwent chemotherapy after cerebral procedure. Pulmonary resection was complete in 27 cases and incomplete in 4. Histological findings showed: adenocarcinoma in 19 cases, squamous cell carcinoma in 8 and large cell carcinoma in 4. All patients underwent adjuvant chemotherapy. Overall 1, 2 and 5-year survival rates were 83%, 47% and 21%, respectively. The median survival was 22 months. Univariate analysis showed a better prognosis for complete resection (P=0.008), adenocarcinomas (P=0.015), N0 disease (P=0.038), and Group B (P=0.045). Multivariate analysis showed that only the radicality of the resection (P=0.027) and Group B (P=0.047) were independent prognostic factors. Conclusion. Our experience confirms that selected patients with non-small cell lung cancer and synchronous brain metastases may be effectively treated by combined therapy. Complete resection, adenocarcinoma histology and NO disease were prognostic factors. The incorporation of FDG-PET scan into the preoperative work-up may translate into a survival benefit.

March, 1991, to June, 1992, five lung transplantations for end-stage lung disease were successfully performed at the Ospedale Maggiore Policlinico in Milan. All patients underwent high-resolution CT (HRCT) of the lung in a complex follow-up program to identify specific abnormalities of acute and chronic rejection (bronchiolitis obliterans) and to monitor the resolution of the bronchial anastomosis. Twenty-two HRCT exams were performed. In patients with acute rejection HRCT failed to identify specific abnormalities of lung parenchyma. In contrast, in one patient with pathological evidence of early bronchiolitis obliterans HRCT showed decreased peripheral vascularization. In the study of the bronchial anastomosis, HRCT showed optimal anastomosis resolution in 4 patients, whereas in one patient with a granuloma demonstrated by fibrobronchoscopy it confirmed the lesion showing also a small pneumomediastinum. Even though the HRCT finding of decreased peripheral vascularization does not appear to be specific for bronchiolitis obliterans, it may be of value in suggesting the diagnosis of early bronchiolitis obliterans in lung transplant. HRCT should be used in all patients with bronchoscopic diagnosis of bronchial complication to study the lesion and its mediastinal spread.

To assess the potential usefulness of 18F-FDG/PET and spiral-CT images concurrent assessment and coregistration in staging mediastinal lymph node involvement in patients with non small cell lung cancer.28 patients waiting to undergo surgical treatment underwent spiral-CT and PET examinations on the same day. The results of the two studies were interpreted separately, together (CTPET) and following their fusion in a single image (CT+PET). Results of spiral-CT, PET, CTPET and CT+PET were assessed with respect to the histological diagnosis.A correct assessment of mediastinal lymph nodes was achieved by spiral-CT in 21 of the 28 patients, in 22 of the 28 patients by PET, in 24 patients by CTPET and in 25 patients by CT+PET.CT+PET is more accurate than spiral-CT and PET alone in staging mediastinal lymph node involvement in lung cancer patients, with possible implications for their prognosis and therapy.

The recent developments in thoracic surgery have broadened the application spectrum of thoracoscopy. Video-assisted thoracoscopic lung resection is now available both to diagnose and to treat peripheral pulmonary nodules. A major factor limiting the success of thoracoscopic lung resection is the difficult localization of the pulmonary nodule. When lesions are very small and deep inside the lung, their preoperative detection may be difficult. This study was aimed at investigating the effectiveness of hookwires for CT-guided localization of peripheral pulmonary lesions requiring thoracoscopic resection. In 12 patients 12 nodules, previously detected with chest radiography, were localized with hookwires under CT guidance. Ten of 12 patients underwent thoracoscopic resection for diagnostic purposes, while the extant two patients underwent therapeutic wedge resection. In all patients prethoracoscopic hookwire positioning was successful. In 11 of 12 patients the lesion was accurately localized, while in the extant patient the wire tip was inserted deeper than the nodule. In 3 patients the wire was dislodged before surgery: in all of them a small hemorrhage developed on the visceral pleura and wedge resection was likewise possible. Four patients had a small pneumothorax which was not treated before surgery. In conclusion, percutaneous hookwire localization of peripheral lung lesions is an easy and efficacious technique and promotes thoracoscopy as a less invasive alternative to thoracotomy.

Background: Surgery is the primary treatment for patients with stage I, II, or IIIA non-small-cell lung cancer (NSCLC). However, long-term survival of NSCLC patients after surgery alone is largely unsatisfactory, and the role of adjuvant chemotherapy in patient survival has not yet been established. Methods: Between January 1994 and January 1999, 1209 patients with stage I, II, or IIIA NSCLC were randomly assigned to receive mitomycin C (8 mg/m 2 on day 1), vindesine (3 mg/m 2 on days 1 and 8), and cisplatin (100 mg/m 2 on day 1) every 3 weeks for three cycles (MVP group; n = 606) or no treatment (control group; n = 603) after complete resection. Randomization was stratified by investigational center, tumor size, lymph-node involvement, and the intention to perform radiotherapy. The primary endpoint was overall survival and secondary endpoints were progression-free survival and toxicity associated with adjuvant treatment. Survival curves were analyzed using the log-rank test. All statistical tests were two-sided. Results: After a median follow-up time of 64.5 months, there was no statistically significant difference between the two patient groups in overall survival (hazard ratio = 0.96, 95% confidence interval = 0.81 to 1.13; P = .589) or progression-free survival (hazard ratio = 0.89, 95% confidence interval = 0.76 to 1.03; P = .128). Only 69% of patients received the three planned cycles of MVP. Grades 3 and 4 neutropenia occurred in 16% and 12%, respectively, of patients in the MVP arm. Radiotherapy was completed by 65% of patients in the MVP arm and by 82% of patients in the control group. In the multivariable analysis, only disease stage and sex were associated with survival. Conclusion: This randomized trial failed to prospectively confirm a statistically significant role for adjuvant chemotherapy in completely resected NSCLC. Given the poor compliance with the MVP regimen used in this study, future studies should explore more effective treatments.

Background. Post-thoracotomy pain causes severe impairment of the respiratory function, Epidural analgesia is effective in the treatment of post-thoracotomy pain but may give rise to significant side-effects, Other low-risk and cost-effective analgesic treatments are therefore required. Methods. Thirty male patients who had undergone pulmonary Iobectomy entered a prospective, randomized trial to evaluate the efficacy of ketorolac tromethamine (Group 2) and extrapleural intercostal nerve block (Group 3) with intermittent low-dose bupivacaine, Objective and subjective assessment was carried out at 8, 16, 24 and 48 hours postoperatively. Results. There were no significant differences between Groups 1 (control group) and 2, Vital capacity was significantly lower in Group 3 (p

From 1974 through 1984, 24 patients with malignancies of the Oddian region underwent surgery. Four ampullectomies were carried out with one more than 10-year survivor. Nineteen duodenopancreatectomies were performed with no operative mortality, a 21% complication rate and a 4% reoperation rate; mean survival was 42 months; 1-, 3- and 5-year survival was 95%, 53%, and 37% respectively. Nodal metastasis was the major determinant of long-term survival. Duodenopancreatectomy should be considered the operation of choice for malignancies of the Oddian region.

Background: Postintubation stenosis remains the most frequent indication for tracheal surgery. Rigid bronchoscopy has traditionally been considered the technique of choice for the preoperative diagnostic assessment. However, this technique is not routinely available, and new techniques such as flexible videobronchoscopy and spiral computed tomography (CT) scan with multiplanar reconstructions have been proposed as alternatives to rigid bronchoscopy. The aim of this study was to compare these techniques in the diagnostic assessment of patients with tracheal stenosis submitted to surgical treatment. Methods: Twelve patients who underwent airway resection and reconstruction for postintubation tracheal and laryngotracheal stenosis were preoperatively evaluated with rigid and flexible bronchoscopy and with spiral CT scan with multiplanar reconstructions. The following parameters were examined: involvement of subglottic larynx, length of the stenosis, and associated lesions. The results were compared with the intraoperative findings. Results: The accuracy of rigid bronchoscopy, flexible bronchoscopy, and CT scan in the evaluation of the involvement of subglottic larynx was, respectively, 92%, 83%, and 83%. The evaluation of the length of the stenosis was correct in 83%, 92%, and 25% of the patients, respectively, with rigid bronchoscopy, flexible bronchoscopy, and CT scan. A significant correlation was observed between the length of the stenosis measured intraoperatively and preoperatively with rigid (p < 0.001) and flexible bronchoscopy (p < 0.05) but not with CT scan (p = 0.08). The three techniques correctly showed the presence of an associated tracheoesophageal fistula in two patients, but CT scan did not correctly show the exact location of the fistula in relation to the airway. Flexible bronchoscopy was the only effective technique in the assessment of laryngeal function. Conclusions: Rigid bronchoscopy remains the procedure of choice in the evaluation of candidates for tracheal resection and reconstruction for postintubation stenosis, and it should be available in centers that perform surgery of the airway. Flexible bronchoscopy and CT scan have to be considered complementary techniques in the evaluation of laryngeal function and during follow-up. © Springer Science+Business Media, Inc. 2006.

Patients on hemodialysis (HD) who undergo surgery represent a high risk group requiring careful perioperative management to avoid electrolyte imbalance and hemodynamic instability. The aim of the study was to analyze the postoperative outcome in terms of complications and survival of a group of patients on HD who had undergone pulmonary resection for non-small cell lung cancer (NSCLC). Six patients on HD underwent seven pulmonary resections at our institution from 1998 to 2003. The underlying kidney disease was nephrosclerosis in two patients and glomerulonephritis in four. The mean levels of blood urea nitrogen and serum creatinine were 107 +/- 11.5 mg/dl and 7.9 +/- 0.64 mg/dl, respectively. The mean preoperative PO2 and FEV1 were 77.6 +/- 2.4 mmHg and 2.4 +/- 0.16 liters, respectively. The histologic diagnosis was squamous cell carcinoma in four cases and adenocarcinoma in three. One patient underwent two lung resections in 4 years for two primary lung cancers. Five patients underwent lobectomy, one underwent a wedge resection, and in one case pneumonectomy was performed after neoadjuvant chemotherapy. There was no operative mortality. Postoperatively, atrial fibrillation occurred in two patients associated with sputum retention in both, and two other patients had hyperkalemia (complication rate 57%). One patient died of cardiac complications 27 months after surgery. The remaining five patients are currently alive with no evidence of disease. Patients on HD who undergo lung resection have a high rate of postoperative complications. Although the underlying disease influences long-term survival, radical lung resection in NSCLC patients is recommended in selected cases. Careful metabolic, hematologic, and pharmaceutical management is mandatory during the perioperative period. RI ciriaco, paola/H-5716-2012

Introduction In the search of new therapeutical strategies against non-small-cell lung cancer (NSCLC), the identification of new prognostic factors is crucial. Objectives In this study, we analyzed the prognostic value of the liver X receptor-alpha (LXR-alpha), a nuclear receptor of a family of cholesterol derivatives called oxysterols, in patients with radically resected NSCLC. Methods We retrospectively reviewed 140 stage II and III surgically treated NSCLC patients that were grouped by percentage of LXR-alpha-positive cells value above or below its median value. Tumor-related survival was evaluated as primary end point. Results The 5-year overall and tumor-related survival rates were 40% and 46%, respectively. The median percentage of LXR-alpha-positive cells was 20%. Patients with stage II NSCLC had higher LXR-alpha values than those with stage III (P = .04). Univariate analysis demonstrated that both TNM stage and LXR-alpha were significantly related to tumor-related survival (P = .006 and P = .004, respectively). The 5-year tumor-related survival rates in stage II and III NSCLC were 56% and 34%, respectively. The 5-year tumor-related survival rates in high and low LXR-alpha value were 57% and 32%, respectively. The multivariate analysis showed that both TNM stage and LXR-alpha were independent prognostic factors (P = .01 and P = .007, respectively) with hazard ratio of 1.92 and 0.49, respectively. Conclusion LXR-alpha seems to be an independent prognostic factor indicating a better survival in completely resected stage II and III NSCLC patients.

Background Acute posttraumatic tracheobronchial lesions are rare events associated with significant morbidity and mortality. They are caused by blunt and penetrating trauma, or they are iatrogenic, appearing after intubation or tracheotomy. Although surgery has traditionally been considered the treatment of choice for these injuries, recent reports show that conservative treatment can be effective in selected patients. The aim of this study was to evaluate the role of surgical and conservative management of these lesions, differentiated on the basis of clinical and endoscopic criteria. Methods From January 1993 to October 2010, a total of 50 patients with acute posttraumatic tracheobronchial lesions were referred for treatment to our department. In all, 36 patients had iatrogenic injuries of the airway, and 14 had lesions resulting from blunt or penetrating trauma. Results Of the 30 patients who underwent surgery, the lesion was repaired with interrupted absorbable sutures in 29; the remaining patient, with an associated tracheoesophageal fistula, underwent single-stage tracheal resection and reconstruction and closure of the fistula. In all, 20 patients were treated conservatively: clinical observation in 5 patients, airway decompression with a mini-tracheotomy cannula in 4 spontaneously breathing patients, and tracheotomy with the cuff positioned distal to the lesion in 11 mechanically ventilated patients. One surgical and one conservatively-managed patient died after treatment (4% overall mortality). Complete recovery and healing were achieved in all the remaining patients. Conclusions Surgery remains the treatment of choice for posttraumatic lesions of the airway. However, conservative treatment based on strict clinical and endoscopic criteria-stable vital signs; effective ventilation; no esophageal injuries, signs of sepsis, or evidence of major communication with the mediastinal space-enables favorable results to be achieved in selected patients.

Background. Thoracic surgeons have limited experience with treating localized organizing pneumonia owing to its rare occurrence in routine clinical practice. Methods. We retrospectively investigated the clinicopathologic features of 21 patients with localized organizing pneumonia observed between 2001 and 2004. Results. There were 15 men and 6 women. Mean age was 63 years. Eight patients (38%) were symptomatic. Computed tomographic scan showed a single lesion in 17 patients ( 12 nodules and 5 masses) and bilateral lesions in 4. Wedge resection was performed in 16 patients and lobectomy in 5. There was no operative mortality. Followup was complete in all patients ( range, 2 to 46 months; median, 20 months). Surgery was curative in 15 of 17 patients with a single lesion, and no recurrence was observed ( p < 0.005). The remaining 2 patients with a single lesion ( 2 masses) had a local relapse with the appearance of nodular lesions in the residual parenchyma. Both these patients received steroids with resolution of the lesions. All 4 patients with bilateral lesions who underwent surgery for diagnostic purposes received steroids with improvement of the radiologic aspect in 3 and stabilization of the lesions in 1. Conclusions. Clinical and radiologic findings of localized organizing pneumonia are nonspecific, and this unusual entity is difficult to differentiate from a primary or metastatic tumor. Surgical resection allows both diagnosis and cure. However, considering the benignity of the lesion and the efficacy of steroids, major pulmonary resections should be avoided. RI ciriaco, paola/H-5716-2012

Objective: The purpose of this study was to evaluate the effect of lobectomy on pulmonary function in patients with chronic obstructive pulmonary disease. Methods: One hundred thirty-seven patients were analyzed; 49 had normal pulmonary function tests, and 88 had chronic obstructive pulmonary disease. Different functional parameter groups were identified: obstructive (forced expiratory volume in 1 second [FEV1], forced expiratory volume in 1 second/forced vital capacity [FEV1/FVC), and chronic obstructive pulmonary disease index), hyperinflation (residual volume and functional residual capacity), and diffusion (transfer factor of the lung for carbon monoxide). Also, the ratio between observed and predicted postoperative FEV, was calculated. Results: In patients with preoperative FEV, greater than 80% of predicted, postoperative FEV1/FVC slightly but not significantly decreased, and postoperative FEV, significantly decreased. In patients with preoperative FEV1 less than 65%, postoperative FEV, and FEV1/FVC significantly increased. In patients with preoperative FEV1/FVC greater than 70%, postoperative FEV, and FEV1/FVC significantly decreased. In patients with preoperative FEV1/FVC less than 70%, postoperative FEV1/FVC increased, and FEV1 remained unchanged. In patients with a chronic obstructive pulmonary disease index greater than 1.5, postoperative FEV1 and FEV1/FVC significantly decreased, whereas in patients with a chronic obstructive pulmonary disease index less than 1.5, postoperative FEV1/FVC significantly increased and FEV1 remained unchanged. In patients with residual volume and functional residual capacity greater than 115% and transfer factor of the lung for carbon monoxide less than 80% of predicted, postoperative FEV1 diminished less (not significant) compared with patients who had residual volume and functional residual capacity less than 115% (P = .0001). Observed postoperative/predicted postoperative FEV1 was higher if FEV1/FVC was less than 55% (1.46), if FEV1 was less than 80% of predicted (1.21), or if the chronic obstructive pulmonary disease index was less than 1.5 (1.17). Conclusions: Patients with mild to severe chronic obstructive pulmonary disease could have a better late preservation of pulmonary function after lobectomy than healthy patients. Objective: The purpose of this study was to evaluate the effect of lobectomy onpulmonary function in patients with chronic obstructive pulmonary disease.Methods: One hundred thirty-seven patients were analyzed; 49 had normal pulmonaryfunction tests, and 88 had chronic obstructive pulmonary disease. Differentfunctional parameter groups were identified: obstructive (forced expiratory volumein 1 second [FEV1], forced expiratory volume in 1 second/forced vital capacity[FEV1/FVC], and chronic obstructive pulmonary disease index), hyperinflation(residual volume and functional residual capacity), and diffusion (transfer factor ofthe lung for carbon monoxide). Also, the ratio between observed and predictedpostoperative FEV1 was calculated.Results: In patients with preoperative FEV1 greater than 80% of predicted, postoperativeFEV1/FVC slightly but not significantly decreased, and postoperative FEV1significantly decreased. In patients with preoperative FEV1 less than 65%, postoperativeFEV1 and FEV1/FVC significantly increased. In patients with preoperativeFEV1/FVC greater than 70%, postoperative FEV1 and FEV1/FVC significantlydecreased. In patients with preoperative FEV1/FVC less than 70%, postoperativeFEV1/FVC increased, and FEV1 remained unchanged. In patients with a chronicobstructive pulmonary disease index greater than 1.5, postoperative FEV1 andFEV1/FVC significantly decreased, whereas in patients with a chronic obstructivepulmonary disease index less than 1.5, postoperative FEV1/FVC significantly increasedand FEV1 remained unchanged. In patients with residual volume andfunctional residual capacity greater than 115% and transfer factor of the lung forcarbon monoxide less than 80% of predicted, postoperative FEV1 diminished less(not significant) compared with patients who had residual volume and functionalresidual capacity less than 115% (P .0001). Observed postoperative/predictedpostoperative FEV1 was higher if FEV1/FVC was less than 55% (1.46), if FEV1 wasless than 80% of predicted (1.21), or if the chronic obstructive pulmonary diseaseindex was less than 1.5 (1.17).Conclusions: Patients with mild to severe chronic obstructive pulmonary diseasecould have a better late preservation of pulmonary function after lobectomy thanhealthy patients.

Background: We reviewed our experience of the surgical management and follow-up of patients admitted with an isolated traumatic sternal fracture (TSF) to a Thoracic Surgical Unit through the Emergency Department. Methods: During a 5-year period, six patients were surgically treated for an isolated TSF. Presence of physical deformity or acute and persistent pain were considered indications for surgical repair. Surgical repair was performed within 1 week from the trauma by means of a titanium cervical plate system currently in use in spine surgery. Results: There were no postoperative complications. Mean hospital stay was 3 days. All patients showed regular sternal healing at 6 to 8 weeks. In one patient the plate was removed after 3 years because of persistent chest discomfort. Conclusions: Early surgical repair of isolated TSF is advocated in cases of physical deformity or acute and persistent pain. The titanium cervical plate system provides effective repair of the fracture with satisfactory long-term results. RI ciriaco, paola/H-5716-2012

Pleuropulmonary blastoma is a rare and aggressive neoplasm typically occurring in young children, even in newborns. Onset of the disease can be identified in the area of a previously diagnosed lung cyst. We report a case of a child previously diagnosed as having a right congenital lung cyst who had a pleuropulmonary blastoma developing in the same area. He underwent surgical resection of the neoplasm followed by chemotherapy. After 20 months he is alive and well. © 2008 The Society of Thoracic Surgeons.

Background The recurrence rate for stage I non-small cell lung cancer is high, with 20–40% of patients that relapse after surgery. The aim of this study was to evaluate new F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) derived parameters, such as standardized uptake value index (SUV index ), metabolic tumor volume (MTV) and total lesion glycolysis (TLG), as predictive factors for recurrence in resected stage I non-small cell lung cancer. Methods We retrospectively reviewed 99 resected stage I non-small cell lung cancer patients that were grouped by SUV index , TLG and MTV above or below their median value. Disease free survival was evaluated as primary end point. Results The 5-year overall survival and the 5-year disease free survival rates were 62% and 73%, respectively. The median SUV index , MTL and TLG were 2.73, 2.95 and 9.61, respectively. Patients with low SUV index , MTV and TLG were more likely to have smaller tumors ( p ≤ 0.001). Univariate analysis demonstrated that SUV index ( p = 0.027), MTV ( p = 0.014) and TLG ( p = 0.006) were significantly related to recurrence showing a better predictive performance than SUV max ( p = 0.031). The 5-year disease free survival rates in patients with low and high SUV index , MTV and TLG were 84% and 59%, 86% and 62% and 88% and 60%, respectively. The multivariate analysis showed that only TLG was an independent prognostic factor ( p = 0.014) with a hazard ratio of 4.782. Conclusion Of the three PET-derived parameters evaluated, TLG seems to be the most accurate in stratifying surgically treated stage I non-small cell lung cancer patients according to their risk of recurrence.

The presence of emphysema may lead to an underestimation of postoperative respiratory function after lobectomy when evaluated by standard functional assessment. The aim of the study was to assess the correlation between computed tomography (CT) densitometry, pathological grading of emphysema and variation of pulmonary function after lobectomy for lung cancer. Forty-one patients entered the study. Respiratory function was assessed preoperatively and after a mean period of 4.04 months following surgery. Postoperative function remained unchanged or increased after surgery in nine patients (Group A). In the remaining 32 patients (Group B) postoperative function was reduced after surgery. Preoperative forced expiratory volume in 1 s (FEV1)% was 68.5±13.1% in Group A and 91.7±21.0% in Group B. CT densitometry of the lobe to be resected was -877.8±57.6 HU in Group A and -827.5±64.4 HU in Group B. Pathological grading of emphysema of the resected lobe (range 0-10) was 4.1±2.2 in Group A and 3.1±1.2 in Group B. A significant correlation was observed (Spearman rank correlation) between the variation of FEV, and preoperative FEV, (P=0.003; r=-0.455), CT quantitative assessment (P=0.036; r=-0.430) and pathological grading (P=0.008; r=0.673). Patients with a higher degree of emphysema had a lower reduction of respiratory function after lobectomy and CT densitometry and pathological grading of emphysema correlated with the variation in respiratory function. © 2010 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

Introduction: Although surgery remains the gold standard for the treatment of benign tracheal stenosis, airway stenting may be indicated in the event of complex lesions or associated diseases. We retrospectively investigated Montgomery T-tube placement as an alternative or complementary treatment to surgery. Methods: From January 1984 to March 2008, 158 patients were treated for benign tracheal lesions. Eighty-three patients underwent airway resection and reconstruction as the only treatment. Seventy-five other patients with complex lesions or major associated diseases were treated with a T-tube and were retrospectively analysed. Seven of them had undergone unsuccessful treatment with Dumon stents. T-tube placement was the only procedure adopted in 51 patients with a contraindication to surgery (group I), a temporary measure in 15 patients prior to surgery (group II), and in 9 patients (group III) for complications of airway reconstruction, 5 of whom were referred from other institutions. Results: Complications after T-tube placement were: stent dislocation in 3 (4%) patients, endoluminal granulomas in 14 (19%), subglottic edema in 3 (4%), and sputum retention in 7 (9%). Treatment of complications (tracheostomy cannula, steroid infiltration, Argon/LASER coagulation, and bronchoscopy) was required in 20 (27%) patients. In group 1, the tube was removed in 12 (24%) patients after 35.3 +/- 8.2 months following resolution of the stenosis. In group II, the tubes were maintained in place before surgery for 17.1 +/- 4.8months. In group III, three stents were removed following tracheal heating after 115.3 +/- 3.7months. After 5 years the stents were in place in 82%, 7% and 100% of the patients, respectively in groups I, II and III. Conclusions: Montgomery T-tube placement represents a useful option in patients with complex benign tracheal stenosis or associated diseasesas an alternative or complementary treatment to surgery, and is effective even when other types of stents are unsuccessful. (C) 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved. RI ciriaco, paola/H-5716-2012 Introduction: Although surgery remains the gold standard for the treatment of benign tracheal stenosis, airway stenting may be indicated in theevent of complex lesions or associated diseases.We retrospectively investigated Montgomery T-tube placement as an alternative or complementarytreatment to surgery. Methods: From January 1984 to March 2008, 158 patients were treated for benign tracheal lesions. Eighty-three patientsunderwent airway resection and reconstruction as the only treatment. Seventy-five other patients with complex lesions or major associated diseaseswere treated with a T-tube and were retrospectively analysed. Seven of them had undergone unsuccessful treatment with Dumon stents. T-tubeplacement was the only procedure adopted in 51 patients with a contraindication to surgery (group I), a temporary measure in 15 patients prior tosurgery (group II), and in 9 patients (group III) for complications of airway reconstruction, 5 of whomwere referred fromother institutions. Results:Complications after T-tube placement were: stent dislocation in 3 (4%) patients, endoluminal granulomas in 14 (19%), subglottic edema in 3 (4%), andsputum retention in 7 (9%). Treatment of complications (tracheostomy cannula, steroid infiltration, Argon/LASER coagulation, and bronchoscopy)was required in 20 (27%) patients. In group I, the tubewas removed in 12 (24%) patients after 35.3 8.2months following resolution of the stenosis. Ingroup II, the tubes weremaintained in place before surgery for 17.1 4.8months. In group III, three stents were removed following tracheal healingafter 115.3 3.7months. After 5 years the stents were in place in 82%, 7% and 100% of the patients, respectively in groups I, II and III. Conclusions:Montgomery T-tube placement represents a useful option in patients with complex benign tracheal stenosis or associated diseases as an alternative orcomplementary treatment to surgery, and is effective even when other types of stents are unsuccessful.

Introduction: The incidence of lung adenocarci- nomas has steadily increased over the last de- cades. The aim of this study was to assess the re- sults of surgical treatment of multiple primary adenocarcinomas of the lung (MPAL) analyzing the radiological and histological features. Methods: From 1988 to 2005, 26 patients under- went surgical treatment for MPAL at our depart- ment, for a total of 52 tumors. Three patients had synchronous and 23 had metachronous tumors. Results: Thirty-seven tumors were classified as solid, two as ground-glass opacities (GGO) and 13 as mixed solid/GGO tumors on the basis of CT scan evaluation. Histology revealed 26 adenocar- cinomas, five adenocarcinomas with a bronchio- loalveolar (BAC) pattern and 21 BAC. There was no postoperative mortality. Five-year survival of patients with synchronous tumors was 66%. Sur- vival of patients with metachronous tumors was 95% and 70% from the first and second operation. Patients with stage II and IIIa tumors had signifi- cantly reduced survival rates (p< 0.05). Survival was 60% after lobectomy and 78% after wedge re- section. Conclusions: Surgical treatment of MPAL is asso- ciated with favorable results. Sublobar resec- tions, when technically feasible, provide ad- equate oncological management. " thoracic surgery l " pulmonary l " adenocarcinoma

Background. The objectives of this study were to analyze our experience with transbronchial needle aspiration as a minimally invasive procedure alternative to mediastinoscopy in the preoperative staging of non-small cell lung cancer patients with positive mediastinal positron emission tomography and to propose a staging algorithm that combines performance characteristics of these three methods. Methods. Fifty-one patients staged N2 or N3 after positron emission tomography imaging underwent transbronchial needle aspiration. Results. A malignant adenopathy was identified in 26 patients (51%) that were excluded from operation and referred for neoadjuvant chemotherapy or chemoradiotherapy according to the mediastinal status (N2 or N3), as determined on the positron emission tomography image. In the remaining 25 patients (49%), samples were considered adequate negative in 12 patients, inadequate in 11, or inconclusive in 2. These patients underwent mediastinoscopy. Mediastinoscopy showed N2 disease in 19 cases, and the patients received neoadjuvant chemotherapy. In the remaining 6 cases no mediastinal involvement was identified and patients underwent operation. Postoperatively, 5 patients were staged N0 and 1 was staged N2. For transbronchial needle aspiration, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 76%, 100%, 100%, 33%, and 79%, respectively. Conclusions. Transbronchial needle aspiration avoided a mediastinoscopy in approximately half of lung cancer patients referred for operation with positive mediastinal positron emission tomography, sparing the associated costs and risks of more invasive surgical procedures. The minimally invasive mediastinal staging algorithm that we proposed seems to be efficacious and easily applicable in clinical practice. RI ciriaco, paola/H-5716-2012 Background. The objectives of this study were to analyze our experience with transbronchial needle aspiration as a minimally invasive procedure alternative to mediastinoscopy in the preoperative staging of nonsmall cell lung cancer patients with positive mediastinal positron emission tomography and to propose a staging algorithm that combines performance characteristics of these three methods. Methods. Fifty-one patients staged N2 or N3 after positron emission tomography imaging underwent transbronchial needle aspiration. Results. A malignant adenopathy was identified in 26 patients (51%) that were excluded from operation and referred for neoadjuvant chemotherapy or chemoradiotherapy according to the mediastinal status (N2 or N3), as determined on the positron emission tomography image. In the remaining 25 patients (49%), samples were considered adequate negative in 12 patients, inadequate in 11, or inconclusive in 2. These patients underwent mediastinoscopy. Mediastinoscopy showed N2 disease in 19 cases, and the patients received neoadjuvant chemotherapy. In the remaining 6 cases no mediastinal involvement was identified and patients underwent operation. Postoperatively, 5 patients were staged N0 and 1 was staged N2. For transbronchial needle aspiration, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 76%, 100%, 100%, 33%, and 79%, respectively. Conclusions. Transbronchial needle aspiration avoided a mediastinoscopy in approximately half of lung cancer patients referred for operation with positive mediastinal positron emission tomography, sparing the associated costs and risks of more invasive surgical procedures. The minimally invasive mediastinal staging algorithm that we proposed seems to be efficacious and easily applicable in clinical practice.

Background and Objectives: Solitary fibrous tumors of the pleura (SFTP) are rare neoplasms with unusual histological and clinical features. Although surgery is the treatment of choice for SFTP, tumor recurrence may occur after complete resection, even in tumors with benign histological features. The aim of the study was to identify the clinical and pathological features of SFTP that are associated with a higher risk of recurrence after surgical treatment. Methods: From May 1995 to September 2002, 18 patients (10 female, 8 male; mean age 58 years) with SFTP underwent complete surgical treatment at our department. Mean follow-up was 61 months. Mean tumor size was 10 cm. The tumors were pedunculated in 10 patients and sessile in 8. Histological features were benign in 16 patients and malignant in 2. Results: Five-year disease-free survival was 80%. A higher incidence of tumor recurrence was observed when SFTP originated from the parietal pleura, had malignant histological features and a lower expression of progesterone receptors (P < 0.05). Conclusions: Clinical and pathological characteristics, such as malignant histology, sessile morphology, and a lower expression of progesterone receptors identify SFTP with a higher risk of recurrence after surgery, and which thus require strict follow-up. RI ciriaco, paola/H-5716-2012 Background and Objectives: Solitary fibrous tumors of the pleura (SFTP) are rareneoplasms with unusual histological and clinical features. Although surgery is thetreatment of choice for SFTP, tumor recurrence may occur after complete resection,even in tumors with benign histological features. The aim of the study was to identifythe clinical and pathological features of SFTP that are associated with a higher risk ofrecurrence after surgical treatment.Methods: From May 1995 to September 2002, 18 patients (10 female, 8 male; meanage 58 years) with SFTP underwent complete surgical treatment at our department.Mean follow-up was 61 months. Mean tumor size was 10 cm. The tumors werepedunculated in 10 patients and sessile in 8. Histological features were benign in 16patients and malignant in 2.Results: Five-year disease-free survival was 80%. A higher incidence of tumorrecurrence was observed when SFTP originated from the parietal pleura, hadmalignant histological features and a lower expression of progesterone receptors(P

Aim To determine prospectively from the referring physician's point of view the impact of 1 8 F-fluorodeoxyglucose positron emission tomography ( 1 8 F-FDG PET) results on the management decisions in patients with known orsuspected lung cancer. Methods Seventy-five consecutive patients (58 men, 17 women; age range, 33-82 years; mean age, 64 years) with a diagnosis of a pulmonary lesion, obtained by means of morphological imaging studies and/or cytological sampling, were included in the study. The patient population consisted of three groups: (A) patients (n=18) with a solitary lung nodule; (B) patients (n=37) with untreated lung cancer; and (C) patients (n=20) with treated lung cancer. All were referred for whole-body 1 8 F-FDG PET within 15 days (mean, 11 days) of lung lesion detection. To determine whether and how PET findings could modify the treatment strategy, a questionnaire was sent to the referring physician before and after the PET results. With regard to the treatment strategy, four major options were recognized: (1) further diagnostic investigations; (2) medical therapy; (3) surgical treatment; (4) wait-and-see. For data analysis, intermodality changes, defined as changes between treatment strategies related to PET findings, were considered. Results Before the PET study, the planned management for the overall patient population was as follows: further diagnostic investigations in 44 cases (58%), medical therapy in 17 (23%), surgical treatment in nine (12%) and wait-and-see in five (7%). After the PET study, further diagnostic tools were indicated in 27 cases (36%), medical therapy in 17 (23%), surgical treatment in 28 (37%) and wait-and-see in three (4%). Relative to the initially planned strategy, changes in patient management after PET imaging occurred in 34 (45%) cases. Overall, the most relevant variation after PET concerned the surgical treatment strategy. The highest percentage (67%) of changes in management after PET was found in patients with a solitary pulmonary nodule; the percentages of changes of the three patient groups were significantly different (chi-squared test; P=0.021). Conclusions In patients with known or suspected lung cancer, 1 8 F-FDG PET results determined significant variations in major clinical management decisions.

Objectives: In patients with non-small cell lung cancer (NSCLC) the presence of satellite metastatic nodules may he considered a contraindication to surgical treatment. The use of spiral computed tomography (CT) scan has improved the accuracy of the diagnostic assessment of pulmonary diseases. but has also led to the detection of a consistent number of indeterminate satellite lesions. Obtaining a differential diagnosis of these lesions is extremely important in defining the therapeutic strategy. The aim of the study was, to assess the characteristics of satellite nodules in patients with NSCLC and to examine the diagnostic and therapeutic approach used in the presence of indeterminate satellite lesions. Methods: From November 1995 to February, 2001, 29 patients (mean age 64 years) who underwent surgery for NSCLC had indeterminate satellite pulmonary lesions at the preoperative spiral CT scan A differential diagnosis of the nodules was obtained by histological examination in 27 patients and by follow-up (62 and 64 months respectively) in two patients. Positron emission tomography (PET) scan was selectively performed in the preoperative evaluation. Results: Thirty-two satellite nodules were analyzed in the group of 29 patients. The size of the lesions varied from 2 to 15 mm (mean 8 mm). The nodules were ipsilateral to the primary tumor in 25 patients and contralateral in four. They were benign in 22 cases and malignant in ten (metastases from NSCLC in seven patients and second primary lung cancer in three). Nodules with a size equal to or less than 5 mm were more frequently benign. Patients with stage III tumors had a higher incidence of malignant satellite nodules in comparison to earlier stages. although the data did not reach statistical significance, PET scat, correctly differentiated benign and malignant satellite nodules in six patients. Conclusions: Obtaining a differential diagnosis of indeterminate pulmonary nodules associated to NSCLC is of great importance in defining the therapeutic strategy. The results of this study show that indeterminate satellite lesions may be benign or represent a second primary lung cancer, and should not therefore be considered a contraindication to surgical exploration when a preliminary differential diagnosis by other means cannot he obtained. (C) 2002 Elsevier Science B.V. All rights reserved. RI ciriaco, paola/H-5716-2012

BACKGROUND. Brain metastases (BM) are frequent sites of initial failure in patients with locally advanced nonsmall cell lung cancer (LAD-NSCLC) undergoing multi-modality treatments (MMT). New treatment and follow-up strategies are needed to reduce the risk of BM and to diagnose them early enough for effective treatment. METHODS. The incidence rate of BM as the first site of recurrence in 112 patients with LAD-NSCLC treated with the same MMT protocol was calculated. The influence of patient, disease, and treatment-related factors on the incidence of BM and on the time-to-brain recurrence (TBR) was analyzed. RESULTS. BM as the first site of failure was observed in 25 cases (22% of the study population and 29% of all recurrences). In 18 of those cases, the brain was the exclusive site of recurrence. Median TBR was 9 months. The 2-year actuarial incidence of BM was 29%. Central nervous system (CNS) recurrence was more common in patients younger than 60 years (P = 0.006) and in whom bulky (greater than or equal to 2 cm) mediastinal lymph nodes were present (P = 0.02). TBR was influenced by age (P = 0.004) and by bulky lymph node disease (P = 0.003). Multivariate analysis confirmed the prognostic role of age, whereas the presence of clinical bulky mediastinal lymph nodes was of borderline significance. CONCLUSIONS. Our study confirmed a high rate of BM in patients with LAD-NSCLC submitted to MMT. Most of these CNS recurrences were isolated and occurred within 2 years of initial diagnosis. Age younger than 60 years was associated with an increased risk of BM and reduced TBR, whereas the presence of clinical bulky mediastinal lymph nodes was of borderline significance. Although our data require further validation in future studies, our results suggest that additional trials on prophylactic cranial irradiation and on intensive radiologic follow-up should focus on these high-risk populations. (C) 2002 American Cancer Society.

Objective: The incidence of adenocarcinoma and bronchoalveolar carcinoma has increased in recent years. The aim of this study was to retrospectively evaluate radiological and pathological factors affecting survival in patients with bronchoalveolar carcinoma (BAC) or BAC associated with adenocarcinoma who underwent surgical treatment. Methods: From May 1988 to September 1999, 49 patients with BAC or BAC and adenocarcinoma underwent surgical treatment. Complete resection was performed in 42 patients. In these patients the impact of the following factors on survival was evaluated: stage, TNM status, radiological and pathological findings (percentage of bronchoalveolar carcinoma in the turnout, presence or absence of sclerosing and mucinous patterns, vascular invasion and lymphocytic infiltration). Results: Twenty-nine patients were male and 20 female. Mean age was 63 years. Five-year survival was 54%. Univariate analysis of the patients who kunderwent complete resection demonstrated a favourable impact on survival in stages Ia and Ib (P = 0.01) and in the absence of nodal involvement (P = 0.02) and mucinous patterns (P = 0.02). Mucinous pattern was also prognostically relevant at multivariate analysis (P = 0.02). In the 27 patients with stage Ia and Ib disease, univariate analysis demonstrated that the absence of mucinous pattern (P = 0.006) and a higher percentage of BAC (P = 0.01) favourably influenced survival. The latter data were also confirmed by multivariate analysis (P = 0.01). Conclusion: Surgical treatment of early-stage BAC and combined BAC and adenocarcinoma is associated with favourable results. However, the definition of prognostic factors is of utmost importance to improve the results of the treatment. In our series tumours of the mucinous subtype and with a lower percentage of BAC had a worse prognosis. (C) 2001 Elsevier Science B.V. All rights reserved. Objective: The incidence of adenocarcinoma and bronchoalveolar carcinoma has increased in recent years. The aim of this study was to retrospectively evaluate radiological and pathological factors affecting survival in patients with bronchoalveolar carcinoma (BAC) or BAC associated with adenocarcinoma who underwent surgical treatment. Methods: From May 1988 to September 1999, 49 patients with BAC or BAC and adenocarcinoma underwent surgical treatment. Complete resection was performed in 42 patients. In these patients the impact of the following factors on survival was evaluated: stage, TNM status, radiological and pathological findings (percentage of bronchoalveolar carcinoma in the tumour, presence or absence of sclerosing and mucinous patterns, vascular invasion and lymphocytic infiltration). Results: Twenty-nine patients were male and 20 female. Mean age was 63 years. Five-year survival was 54%. Univariate analysis of the patients who underwent complete resection demonstrated a favourable impact on survival in stages Ia and Ib (P = 0.01) and in the absence of nodal involvement (P = 0.02) and mucinous patterns (P = 0.02). Mucinous pattern was also prognostically relevant at multivariate analysis (P = 0.02). In the 27 patients with stage Ia and Ib disease, univariate analysis demonstrated that the absence of mucinous pattern (P = 0.006) and a higher percentage of BAC (P = 0.01) favourably influenced survival. The latter data were also confirmed by multivariate analysis (P = 0.01). Conclusion: Surgical treatment of early-stage BAC and combined BAC and adenocarcinoma is associated with favourable results. However, the definition of prognostic factors is of utmost importance to improve the results of the treatment. In our series tumours of the mucinous subtype and with a lower percentage of BAC had a worse prognosis.

Mediastinal dumbbell tumors can be resected with a variety of open surgical approaches. Recently, thoracoscopic techniques have been suggested for the treatment of benign neurogenic lesions. Over a 5-year period, three patients with a benign mediastinal dumbbell tumor were treated via a combined microneurosurgical and thoracoscopic approach. The neurosurgical phase consisted of a posterior laminectomy to free the tumor from the spinal cord, followed by an intervertebral foraminotomy. Thoracoscopic resection of the lesion was then performed in the same setting. The operative times were 240, 260, and 280 min, and there were no operative complications. The postoperative stays were 6, 7, and 7 days; the postoperative period was uneventful in all three patients. Pathologic examination revealed a benign schwannoma in two cases and an angiolipoma in one case. One patient reported the onset of paraesthesia in the left hypocondrium on the distribution area of the transected T10 and T11 intercostal nerves; slight paraesthesia still remains 15 months from surgery. We conclude that the combined posterior neurosurgical and thoracoscopic approach is a safe and effective method for the removal of benign mediastinal dumbbell tumors, whether neurogenic or nonneurogenic in origin.

Objective: The diagnostic approach to pleural diseases may be difficult. The CT scan, which is the current diagnostic technique, has limited accuracy both in the differentiation between benign and malignant pleural diseases and in the diagnosis of primary and metastatic pleural neoplasms. Invasive procedures, such as thoracoscopy, are therefore frequently required to complete the diagnostic approach. The increasing incidence of malignant pleural mesothelioma has led to the development of new treatment strategies, which still need to be fully validated. There is, therefore, a need for new diagnostic techniques that can lead to a definite diagnosis and a satisfactory evaluation of the response to treatment. Encouraging results have been reported with the F-18-labeled analogue of a-deoxyglucose (18-FDG) positron emission tomography (PET) in the evaluation of chest tumors such as lung cancer. The aim of this study was to evaluate the role of 18-FDG PET in the diagnostic assessment of pleural diseases. Methods: Patients with CT scan evidence of pleural thickening, or fluid, entered a study to evaluate the accuracy of 18-FDG PET in diagnosing pleural diseases. Image analysis was performed both with visual interpretation and using a semiquantitative method, standardized uptake values (SUV), on coronal, sagittal and axial reconstructions. The results of PET imaging were compared to histological data. PET was also performed before and after treatment in patients who underwent chemotherapy to evaluate the accuracy of this technique in the assessment of the response. Results: Fourteen patients entered the study. Histology demonstrated a malignant pleural disease in 13 patients; malignant pleural mesothelioma in ten patients, adenocarcinoma in two and liposarcoma in one. Benign pleural disease was diagnosed in the remaining patient. PET assessment demonstrated significant 18-FDG uptake in 12 of the 13 patients with a malignant disease, also revealing distant metastases in two of them. A false-negative result was observed in a patient with an epithelial mesothelioma. The overall accuracy was 92%. A benign pleural disease without significant uptake was correctly diagnosed in another patient. An aspecific uptake was observed in two patients who had undergone pleurectomy and intrapleural chemotherapy. A decreased tracer uptake was observed after chemotherapy in four patients. Conclusions: These preliminary results demonstrate that 18-FDG PET may have a great potential, both in the differential diagnosis of pleural diseases and in the evaluation of the response to treatment. At present, however, histological thoracoscopic diagnosis remains mandatory before planning treatment. Further studies in larger groups of patients are needed to draw definite conclusions on the role of PET in the assessment of pleural diseases. (C) 2000 Elsevier Science B.V. All rights reserved. Objective: The diagnostic approach to pleural diseases may be difficult. The CT scan, which is the current diagnostic technique, has limited accuracy both in the differentiation between benign and malignant pleural diseases and in the diagnosis of primary and metastatic pleural neoplasms. Invasive procedures, such as thoracoscopy, are therefore frequently required to complete the diagnostic approach. The increasing incidence of malignant pleural mesothelioma has led to the development of new treatment strategies, which still need to be fully validated. There is, therefore, a need for new diagnostic techniques that can lead to a definite diagnosis and a satisfactory evaluation of the response to treatment. Encouraging results have been reported with the F-18-labeled analogue of 2-deoxyglucose (18-FDG) positron emission tomography (PET) in the evaluation of chest tumors such as lung cancer. The aim of this study was to evaluate the role of 18-FDG PET in the diagnostic assessment of pleural diseases. Methods: Patients with CT scan evidence of pleural thickening, or fluid, entered a study to evaluate the accuracy of 18-FDG PET in diagnosing pleural diseases. Image analysis was performed both with visual interpretation and using a semiquantitative method, standardized uptake values (SUV), on coronal, sagittal and axial reconstructions. The results of PET imaging were compared to histological data. PET was also performed before and after treatment in patients who underwent chemotherapy to evaluate the accuracy of this technique in the assessment of the response. Results: Fourteen patients entered the study. Histology demonstrated a malignant pleural disease in 13 patients; malignant pleural mesothelioma in ten patients, adenocarcinoma in two and liposarcoma in one. Benign pleural disease was diagnosed in the remaining patient. PET assessment demonstrated significant 18-FDG uptake in 12 of the 13 patients with a malignant disease, also revealing distant metastases in two of them. A false-negative result was observed in a patient with an epithelial mesothelioma. The overall accuracy was 92%. A benign pleural disease without significant uptake was correctly diagnosed in another patient. An aspecific uptake was observed in two patients who had undergone pleurectomy and intrapleural chemotherapy. A decreased tracer uptake was observed after chemotherapy in four patients. Conclusions: These preliminary results demonstrate that 18-FDG PET may have a great potential, both in the differential diagnosis of pleural diseases and in the evaluation of the response to treatment. At present, however, histological thoracoscopic diagnosis remains mandatory before planning treatment. Further studies in larger groups of patients are needed to draw definite conclusions on the role of PET in the assessment of pleural diseases. Copyright (C) 2000 Elsevier Science B.V.

From November 1990 to August 1993, 32 patients with non-small cell lung cancer (NSCLC) entered a multimodality treatment study with neoadjuvant Mitomycin, Cisplatin and Vinblastine (MPV), surgery and radiotherapy at the San Raffaele Hospital in Milan, Italy. Neoadjuvant chemotherapy was performed on an outpatient basis. To date 23 patients (11 stage III a and 12 stage III b) have completed the chemotherapy treatment and are available for evaluation of response, toxicity, surgical eligibility and resection rate. The overall major response to MPV chemotherapy was 87%. The overall resection rate after major response to treatment was 60% (90% in stage III a and 17% in stage III b). After a median follow-up of 21 months (8-31) 17 patients are still alive (74%). Ten patients (83%) who had a complete resection are alive after a median follow-up of 23 months (21-30) and eight of them (66%) are in complete pathological remission. No treatment-related mortality was observed. The authors conclude that MPV is a highly effective neoadjuvant regimen for NSCLC and is feasible on an outpatient basis. Favorable resection rates can be obtained in stage III a patients. Stage III b patients can be downstaged and undergo complete resection. A longer follow-up is needed to assess the impact of this multimodality approach on long-term survival and to evaluate the role of adjuvant radiotherapy.