Search

Introduction Patients with lung cancer who harbor multiple pulmonary sites of disease have been challenging to classify; a subcommittee of the International Association for the Study of Lung Cancer Staging and Prognostic Factors Committee was charged with developing proposals for the eighth edition of the tumor, node, and metastasis (TNM) classification to address this issue. Methods A systematic literature review and analysis of the International Association for the Study of Lung Cancer database was performed to develop proposals for revision in an iterative process involving multispecialty international input and review. Results Details of the evidence base are summarized in other articles. Four patterns of disease are recognized; the clinical presentation, pathologic correlates, and biologic behavior of these suggest specific applications of the TNM classification rules. First, it is proposed that second primary lung cancers be designated with a T, N, and M category for each tumor. Second, tumors with a separate tumor nodule of the same histologic type (either suspected or proved) should be classified according to the location of the separate nodule relative to the index tumor—T3 for a same-lobe, T4 for a same-side (different lobe), and M1a for an other-side location—with a single N and M category. Third, multiple tumors with prominent ground glass (imaging) or lepidic (histologic) features should be designated by the T category of the highest T lesion, the number or m in parentheses (#/m) to indicate the multiplicity, and a collective N and M category for all. Finally, it is proposed that diffuse pneumonic-type lung cancers be designated by size (or T3) if in one lobe, T4 if involving multiple same-side lobes, and M1a if involving both lungs with a single N and M category for all areas of involvement. Conclusion We propose to tailor TNM classification of multiple pulmonary sites of lung cancer to reflect the unique aspects of four different patterns of presentation. We hope that this will lead to more consistent classification and clarity in communication and facilitate further research in the nature and optimal treatment of these entities.

INTRODUCTION: Revisions to the TNM stage classifications for lung cancer, informed by the international database (N = 94,708) of the International Association for the Study of Lung Cancer (IASLC) Staging and Prognostic Factors Committee, need external validation. The objective was to externally validate the revisions by using the National Cancer Data Base (NCDB) of the American College of Surgeons.METHODS: Cases presenting from 2000 through 2012 were drawn from the NCDB and reclassified according to the eighth edition stage classification. Clinically and pathologically staged subsets of NSCLC were analyzed separately. The T, N, and overall TNM classifications were evaluated according to clinical, pathologic, and "best" stage (N = 780,294). Multivariate analyses were carried out to adjust for various confounding factors. A combined analysis of the NSCLC cases from both databases was performed to explore differences in overall survival prognosis between the two databases.RESULTS: The databases differed in terms of key factors related to data source. Survival was greater in the IASLC database for all stage categories. However, the eighth edition TNM stage classification system demonstrated consistent ability to discriminate TNM categories and stage groups for clinical and pathologic stage.CONCLUSIONS: The IASLC revisions made for the eighth edition of lung cancer staging are validated by this analysis of the NCDB database by the ordering, statistical differences, and homogeneity within stage groups and by the consistency within analyses of specific cohorts.

Resumen Fundamento y objetivo Estudios recientes evidencian que la expresion del hypoxia-inducible factor 1α (HIF-1α, «factor inducible por la hipoxia 1α») favorece la expresion del vascular endothelial growth factor A (VEGF-A, «factor de crecimiento endotelial vascular A»), asi como la proliferacion celular, angiogenesis y metastasis en diferentes canceres, incluido el cancer de pulmon. El objetivo de este estudio fue investigar la correlacion de la expresion del VEGF-A y del HIF-1α con las caracteristicas clinicopatologicas y el pronostico de pacientes operados por cancer de pulmon no microcitico. Pacientes y metodo Estudio prospectivo para analizar la expresion de VEGF-A y HIF-1α mediante reaccion en cadena de la polimerasa en tiempo real en 66 pacientes operados de cancer de pulmon no microcitico. Resultados La edad media (DE) fue de 62,7 (9,8) anos y la relacion varon:mujer de 7,3:1. Segun la nueva clasificacion TNM de 2009, los estadios i , ii y iii incluyeron a 27 (40,9%), 21 (31,8%) y 18 (27,3%) pacientes, respectivamente. La histologia fue: 47% carcinomas escamosos, 33,3% adenocarcinomas y 19,7% otros. El seguimiento medio fue de 42,3 meses, la mediana de supervivencia de 43,2 meses y la supervivencia estimada a los 5 anos del 42,4%. No hubo correlacion entre VEGF-A y HIF-1α (p = 0,306). La sobreexpresion de VEGF-A fue mas frecuente en el estadio avanzado y cuando hubo metastasis ganglionares (p = 0,034 y p = 0,059, respectivamente). En el analisis multivariante, el descriptor T y el VEGF-A fueron factores pronostico independientes ( odds ratio [OR] 2,37, p = 0,016, y OR 2,51, p = 0,008, respectivamente), mientras que HIF-1α no mostro significacion estadistica (p = 0,172), con una OR 0,540. Conclusiones La sobreexpresion de VEGF-A resulto ser un factor pronostico independiente adverso en pacientes intervenidos de cancer de pulmon no microcitico. Por el contrario, la sobreexpresion del HIF-1α mostro una tendencia hacia un efecto protector sobre la supervivencia, pero sin significacion estadistica.

Objectives. Recent studies show that expression of hypoxia inducible factor-1alpha (HIF-1α) favours expression of vascular endothelial growth factor A (VEGF-A), and these biomarkers are linked to cellular proliferation, angiogenesis, and metastasis in different cancers. We analyze expression of HIF-1α and VEGF-A to clinicopathologic features and survival of patients operated on stage I non-small-cell lung cancer. Methodology. Prospective study of 52 patients operated on with stage I. Expression of VEGF-A and HIF-1α was performed through real-time quantitative polymerase chain reaction (qRT-PCR). Results. Mean age was 64.7 and 86.5% of patients were male. Stage IA represented 23.1% and stage IB 76.9%. Histology classification was 42.3% adenocarcinoma, 34.6% squamous cell carcinoma, and 23.1% others. Median survival was 81.0 months and 5-year survival 67.2%. There was correlation between HIF-1α and VEGF-A (P=0.016). Patients with overexpression of HIF-1α had a tendency to better survival with marginal statistical significance (P=0.062). Patients with overexpression of VEGF-A had worse survival, but not statistically significant (P=0.133). Conclusion. The present study revealed that VEGF-A showed correlation with HIF-1α. HIF-1α had a tendency to protective effect with a P value close to statistical significance. VEGF-A showed a contrary effect but without statistical significance.

Introduction Stage classification provides a consistent language to describe the anatomic extent of disease and is therefore a critical tool in caring for patients. The Staging and Prognostic Factors Committee of the International Association for the Study of Lung Cancer developed proposals for revision of the classification of lung cancer for the eighth edition of the tumor, node, and metastasis (TNM) classification, which takes effect in 2017. Methods An international database of 94,708 patients with lung cancer diagnosed in 1999–2010 was assembled. This article describes the process and statistical methods used to refine the lung cancer stage classification. Results Extensive analysis allowed definition of tumor, node, and metastasis categories and stage groupings that demonstrated consistent discrimination overall and within multiple different patient cohorts (e.g., clinical or pathologic stage, R0 or R-any resection status, geographic region). Additional analyses provided evidence of applicability over time, across a spectrum of geographic regions, histologic types, evaluative approaches, and follow-up intervals. Conclusions An extensive analysis has produced stage classification proposals for lung cancer with a robust degree of discriminatory consistency and general applicability. Nevertheless, external validation is encouraged to identify areas of strength and weakness; a sound validation should have discriminatory ability and be based on an independent data set of adequate size and sufficient follow-up with enough patients for each subgroup.

The IASLC Staging and Prognostic Factors Committee has collected a new database of 94,708 cases donated from 35 sources in 16 countries around the globe. This has now been analysed by our statistical partners at Cancer Research And Biostatistics and, in close collaboration with the members of the committee proposals have been developed for the T, N, and M categories of the 8th edition of the TNM Classification for lung cancer due to be published late 2016. In this publication we describe the methods used to evaluate the resultant Stage groupings and the proposals put forward for the 8th edition.

Introduction Small cell lung cancer (SCLC) is commonly classified as either limited or extensive, but the Union for International Cancer Control TNM Classification of Malignant Tumours seventh edition (2009) recommended tumor, node, and metastasis (TNM) staging based on analysis of the International Association for the Study of Lung Cancer (IASLC) database. Methods Survival analyses were performed for clinically and pathologically staged patients presenting with SCLC from 1999 through 2010. Prognosis was compared in relation to the TNM seventh edition staging to serve as validation and analyzed in relation to proposed changes to the T descriptors found in the eighth edition. Results There were 5002 patients: 4848 patients with clinical and 582 with pathological stages. Among these, 428 had both. Survival differences were confirmed for T and N categories and maintained in relation to proposed revisions to T descriptors for seventh edition TNM categories and proposed changes in the eighth edition. There were also survival differences, notably at 12 months, in patients with brain-only single-site metastasis (SSM) compared to SSM at other sites, and SSM without a pleural effusion showed a better prognosis than other patients in the M1b category. Conclusion We confirm the prognostic value of clinical and pathological TNM staging in patients with SCLC, and recommend continued usage for SCLC in relation to proposed changes to T, N, and M descriptors for NSCLC in the eighth edition. However, for M descriptors, it remains uncertain whether survival differences in patients with SSM in the brain simply reflect better treatment options rather than better survival based on anatomic extent of disease.

Introduction Separate tumor nodules with the same histologic appearance occur in the lungs in a small proportion of patients with primary lung cancer. This article addresses how such tumors can be classified to inform the eighth edition of the anatomic classification of lung cancer. Separate tumor nodules should be distinguished from second primary lung cancer, multifocal ground glass/lepidic tumors, and pneumonic-type lung cancer, which are addressed in separate analyses. Methods Survival of patients with separate tumor nodules in the International Association for the Study of Lung Cancer database were analyzed. This was compared with a systematic literature review. Results Survival of clinically staged patients decreased according to the location of the separate tumor nodule relative to the index tumor (same lobe > same side > other side) in N0 and N-any cohorts (all M0 except possible other-side nodules). However, there was also a decrease in the proportion of patients resected; among only surgically resected or among nonresected patients no survival differences were noted. There were no survival differences between patients with same-lobe nodules and those with other T3 tumors, between patients with same-side nodules and those with T4 tumors, and patients with other-side nodules and those with other M1a tumors. The data correlated with those identified in a literature review. Conclusions Tumors with same-lobe separate tumor nodules (with the same histologic appearance) are recommended to be classified as T3, same-side nodules as T4, and other-side nodules as M1a. Thus, there is no recommended change between the seventh and eighth edition of the TNM classification of lung cancer.

Amyloidosis is a systemic disease caused by extracellular accumulation of amyloid in different parts of the body. Pulmonary involvement is infrequent and nodular amyloidosis is extremely rare. We present the case of a 72-year-old man with chronic obstructive pulmonary disease in whom a 3-cm pulmonary nodule was discovered during routine radiological follow-up. After various complementary investigations failed to identify the etiology of the nodule, surgical excision was performed. Subsequent histopathological study revealed the presence of amyloid deposits with characteristic apple-green birefringence when stained with Congo-red under polarized light microscopy.

Ocurrieron 24 casos de fistula broncopleural (FBP) confirmados mediante fibrobroncoscopia en 526 pacientes intervenidos consecutivamente por cancer de pulmon con finalidad diagnostica y/o terapeutica entre febrero de 1990 y enero de 1997 en el Hospital General Universitario de Valencia, practicandose exeresis reglada de pulmon en 327. Clinicamente cursaron con fiebre, expectoracion purulenta o hemoptoica, dolor toracico, disnea y malestar general, asociandose el 83,33% de los casos a empiema pleural. El drenaje pleural y la antibioterapia de amplio espectro, junto a un planteamiento quirurgico adecuado a cada paciente, fueron la base del tratamiento. El apartado quirurgico consistio en retoracotomia y cierre bronquial en los casos precoces sin signos de infeccion ( Se estudia la incidencia de FBP analizando los factores asociados a su presentacion y los resultados obtenidos tras las distintas tecnicas quirurgicas aplicadas.

Resumen El quilotorax bilateral posparto es una entidad muy poco frecuente. Presentamos el caso de una mujer de 28 anos que varios meses despues de dar a luz presento disnea progresiva por derrame pleural bilateral de aspecto lechoso y con presencia de quilomicrones en su analisis bioquimico. El tratamiento inicialmente conservador fracaso en 2 ocasiones. El quilotorax fue tratado eficazmente con videotoracoscopia bilateral secuencial con un intervalo de 6 dias entre ambas intervenciones y pleurodesis con talco en aerosol.

Existe la posibilidad de que las neoplasias pulmonares puedan emitir celulas malignas a la cavidad pleural por distintos mecanismos. Esta posibilidad depende no solo del tipo histologico, sino tambien del estadio clinico. Se analiza si la citologia maligna hallada en el lavado pleural influye en la supervivencia y aparicion de metastasis pleurales en su evolucion postoperatoria. Presentamos una serie de 200 pacientes intervenidos quirurgicamente en el Hospital General Universitario de Valencia desde el 1 de febrero de 1990 al 30 de marzo de 1993. Consta de dos grupos: el grupo primero esta formado por 150 pacientes diagnosticados de cancer de pulmon (CP), ninguno de los cuales tuvo derrame pleural previo ni sufrio puncion transtoracica durante su estudio preoperatorio. Se excluyen de este grupo los pacientes tratados con quimioterapia (QT) o radioterapia (RT) neoadyuvantes, con el fin de evitar falsos positivos, y el grupo segundo o grupo testigo estaba formado por 50 pacientes sin patologia tumoral a los que se realizo toracotomia por otras circunstancias. A todos ellos se les practico lavados pleurales con suero fisiologico antes y despues de las maniobras destinadas a la exeresis pulmonar. Encontramos un 26,6% (40/150) de citologias positivas en la totalidad de lavados pre y posquirurgicos del grupo primero. No encontramos citologias positivas en el grupo testigo.

Studies suggest that hypoxia-inducible factor 1α (HIF-1α) expression favours expression of vascular endothelial growth factor A (VEGF-A) involving cellular proliferation, angiogenesis, and metastasis in different cancers including lung cancer. We investigated the correlation of HIF-1α and VEGF-A with clinicopathologic parameters and clinical outcomes in surgically resected non-small cell lung cancer patients.Prospective study to analyze the expression of VEGF-A and HIF-1α with real time-polymerase chain reaction in 66 patients operated on non-small cell lung cancer.Mean age was 62.7±9.8 and male:female ratio was 7.3:1. According to the new 2009 TNM classification, stage i, ii, and iii included 27 (40.9%), 21 (31.8%) and 18 (27.3%) patients, respectively. Histological subtypes were: 47% squamous cell carcinoma, 33.3% adenocarcinoma, and 19.7% others. Mean follow-up time was 42.3 months. Median survival was 43.2 months and 5-year overall survival was 42.4%. There was no correlation between HIF-1α and VEGF-A (P=.306). The overexpression of VEGF-A was found more frequent in advanced stage and in lymph nodes metastasis (P=.034 and P=.059, respectively). In multivariate analysis, T descriptor and VEGF-A overexpression were independent prognostic factors (odds ratio [OR]=2.37, P=.016, and OR=2.51, P=.008, respectively). HIF-1α overexpression showed an OR=0.540, but without statistical significance (P=.172).The present study revealed that VEGF-A overexpression was an adverse independent prognostic factor. On the contrary, HIF-1α overexpression showed a tendency to a protective effect on survival of surgically treated non-small cell lung cancer patients, although without statistical significance.

Las fistulas traqueoesofagicas (FTE) benignas en pacientes intubados, generalmente a traves de un traqueostoma y soportando una sonda nasogastrica con ventilacion mecanica asistida, son secundarias a lesiones producidas por la punta de la canula, por la excesiva insuflacion del manguito o por la incorrecta practica de una traqueotomia que en ocasiones se tiene que realizar en condiciones dificiles dictadas por la situacion de la urgencia quirurgica. La sospecha de su existencia vendra dada por la clinica, la mayoria de veces por el excesivo aumento de secreciones mucosas a traves del traqueostoma o por procesos de broncoaspirado que complican la situacion pulmonar del paciente. El diagnostico de certeza de las FTE, en otro tipo de pacientes, se verifica mediante el transito baritado y la endoscopia, pero en enfermos conectados a un respirador no es facil, por lo que incorporamos la TAC como primer intento diagnostico en los pacientes sospechosos de presentar esta patologia, intentando encontrar signos directos, como la disrupcion parietal esofago-traqueal o indirectos, tales como neumomediastino o extravasacion del contraste. Se describen ocho casos diagnosticados con esta modalidad y se hace referencia a los signos radiologicos mas usuales de FTE que suelen ser la caracterizacion de una imagen de densidad aire que comunica la traquea y el esofago. En nuestra serie, utilizando las tecnicas radiologicas adecuadas y la alta resolucion, la fistula pudo ser apreciada en todos los casos.

Amyloidosis is a systemic disease caused by extracellular accumulation of amyloid in different parts of the body. Pulmonary involvement is infrequent and nodular amyloidosis is extremely rare. We present the case of a 72-year-old man with chronic obstructive pulmonary disease in whom a 3-cm pulmonary nodule was discovered during routine radiological follow-up. After various complementary investigations failed to identify the etiology of the nodule, surgical excision was performed. Subsequent histopathological study revealed the presence of amyloid deposits with characteristic apple-green birefringence when stained with Congo-red under polarized light microscopy.

Se presenta el caso de un paciente con un tumor carcinoide timico atipico diagnosticado por mediastinotomia anterior y biopsia, tras un hallazgo casual en una radiografia del torax. La determinacion de una serie de marcadores neuroendocrinos, destacando la cromogranina, la citoqueratina, la sinaptofisina y la enolasa neuroespecifica, fue reveladora en el diagnostico. El tratamiento efectuado consistio en cirugia de exeresis completa y radioterapia al lecho mediastinico (50 Gy) por su caracter infiltrante. Se estudian y revisan la incidencia, las caracteristicas de presentacion clinica, los metodos diagnosticos y terapeuticos y el pronostico de estos tumores.

We describe the case of a 46-year-old man with lung cancer and simultaneous solitary adrenal metastases. Adrenalectomy was performed 12 weeks after lung resection through a right subcostal laparotomy. Treatment was complemented with chemotherapy. Twelve months after adrenalectomy the patient was found free of signs of disease and was in satisfactory condition. The advantages of and indications for surgical resection of suprarenal metastasis are discussed in the light of published literature. In some cases, survival may improve with exeresis and chemotherapy.

Bilateral chylothorax after delivery is a highly infrequent entity. We present the case of a 28-year-old woman who developed progressive dyspnea due to bilateral milky pleural effusion several months after delivery. The effusion was found to contain chylomicrons in the biochemical analysis. Initial conservative treatment failed twice and the chylothorax was successfully treated through sequential bilateral videothoracoscopy with an interval of 6 days between the two interventions and pleurodesis with spray talc.

El plasmocitoma extramedular se define como un tumor poco frecuente de células plasmáticas originado primariamente en tejidos blandos (extraóseos) en ausencia de enfermedad generalizada. La localización pulmonar es extremadamente rara, supone el 5% de los mismos. Existen pocas aportaciones a la literatura sobre esta entidad. Presentamos un caso clínico de plasmocitoma endobronquial en una mujer de 67 años que debutó con un cuadro de neumonía y derrame paraneumónico de repetición. Fue tratado con ablación con láser mediante broncoscopio rígido. Los controles fibrobroncoscópicos posteriores y el seguimiento clínico y analítico posterior confirman la ausencia de enfermedad 14 meses después de su diagnóstico. Extramedullary plasmacytoma is a little frequent plasma cell tumor originating mainly in the soft tissues (extramedullary) in the absence of generalized disease. Lung localization is very rare, comprising 5% of the cases. There are few literature contributions about this entity. We present a clinical case of endobronchial plasmacytoma of a 67 year old woman presented with a picture of pneumonia and recurrent parapneumonic efussion. She was treated with laser ablation using a rigid bronchoscope. The subsequent fibrobronchoscopic controls and the clinical and analytical follow up confirmed the absence of disease 14 months after the diagnosis.

El plasmocitoma extramedular se define como un tumor poco frecuente de células plasmáticas originado primariamente en tejidos blandos (extraóseos) en ausencia de enfermedad generalizada. La localización pulmonar es extremadamente rara, supone el 5% de los mismos. Existen pocas aportaciones a la literatura sobre esta entidad. Presentamos un caso clínico de plasmocitoma endobronquial en una mujer de 67 años que debutó con un cuadro de neumonía y derrame paraneumónico de repetición. Fue tratado con ablación con láser mediante broncoscopio rígido. Los controles fibrobroncoscópicos posteriores y el seguimiento clínico y analítico posterior confirman la ausencia de enfermedad 14 meses después de su diagnóstico.

Presentamos un paciente con un timoma invasor como hallazgo en un estudio radiológico por disnea progresiva. Tras el diagnóstico histológico fue tratado con quimioterapia (Qt) neoadyuvante consiguiendo una reducción del volumen tumoral del 25%. El tratamiento quirúrgico consistió en una exéresis en bloque del timoma junto con el pulmón izquierdo por afectación de los vasos pulmonares. La combinación de la Qt neoadyuvante con la cirugía posibilitan un tratamiento con intención curativa.

Presentamos un paciente con un timoma invasor como hallazgo en un estudio radiológico por disnea progresiva. Tras el diagnóstico histológico fue tratado con quimioterapia (Qt) neoadyuvante consiguiendo una reducción del volumen tumoral del 25%. El tratamiento quirúrgico consistió en una exéresis en bloque del timoma junto con el pulmón izquierdo por afectación de los vasos pulmonares. La combinación de la Qt neoadyuvante con la cirugía posibilitan un tratamiento con intención curativa. We present a patient suffering from an invasive thymoma discovered in a chest roentgenogram because of progressive dyspnea. Neoadjuvant chemotherapy was used after histological diagnosis, observing a tumor volume decrease of 25 %. The surgical treatment consisted of the thymoma en bloc resection, and a left side pneumonectomy due to affected pulmonary vessels. The combination of neoadjuvant chemotherapy and surgery is applied as a curative intention therapy.

Los tumorlets pulmonares son pequenos agregados de celulas neuroendocrinas derivadas de las celulas de Kulchitsky del epitelio bronquial. Generalmente su hallazgo suele ser casual. Se les considera como lesiones benignas que raramente metastatizan. Presentamos 5 casos de tumorlet diagnosticados de forma casual, en pacientes con patologia pulmonar previa que obligo a un estudio histologico del pulmon. A pesar de tener un comportamiento benigno, conviene realizar un seguimiento evolutivo de los pacientes mediante controles radiologicos ya que, aunque sea excepcional, se han descrito casos de metastasis en los ganglios linfaticos regionales.

Se presenta el caso de una mujer de 41 anos de edad con multiples malformaciones arteriovenosas pulmonares en el seno de la enfermedad de Rendu-Osler-Weber. Tenia antecedentes de telangiectasias cutaneas y mucosas, epistaxis frecuentes y un episodio de embolia de la arteria central de la retina del ojo derecho. A raiz de los estudios radiologicos y de resonancia magnetica practicados se detectaron malformaciones en los territorios vasculares de ambos pulmones (lobulo inferior derecho y Ungula). La aparicion de una disnea progresiva junto con los serios antecedentes forzo el adoptar alguna medida terapeutica. El tratamiento efectuado fue la embolizacion de las malformaciones en una unidad de radiologia vascular intervencionista.

Se presenta el caso de un varon de 15 anos de edad con una fistula traqueoesofagica presumiblemente congenita (tipo H) y antecedentes de bronquitis de repeticion, bronconeumonia y tos frecuente tras la ingestion de liquidos. A raiz de un episodio de esputos hemoptoicos en la fibrobroncoscopia se hallo un orificio traqueal de la pars membranacea que comunicaba con la luz esofagica. Las radiografias simples de torax y abdomen mostraban aireacion esofagica y distension abdominal, respectivamente. El esofagograma reflejaba el paso de contraste al arbol traqueobronquial sin determinar otras lesiones concurrentes. Fue la resonancia magnetica cervical y toracica la que preciso la localizacion, morfologia y relacion anatomica con las estructuras vecinas de la fistula traqueoesofagica. El paciente fue intervenido quirurgicamente, mediante cervicotomia lateral izquierda individualizandose traquea y esofago, reforzando la pared posterior de la traquea con un colgajo muscular. Los resultados fueron optimos.

The aim of this study was to evaluate the effects on pulmonary function and hemodynamics of three different types of analgesia after thoracotomy.Forty-five ASA II-IV patients undergoing thoracotomy (for lobectomy or pneumonectomy) were randomized to three groups (n = 15 each) for double-blind study. After a test dose into the epidural space at T5-7 (groups T-A and T-AL) or L2-3 (group L-A) interspace, 10 micrograms/Kg of alfentanil was administered in all groups, followed by epidural infusion of 400 micrograms/h of alfentanil (group T-A and L-A) or 400 micrograms/h of alfentanil with 50 mg/h of lidocaine (group T-AL) during surgery and 24 hours postoperatively. The patients also used a patient-controlled analgesia device to administer intravenous morphine postoperatively. During the study period the following variables were recorded: hemodynamic parameters, lung function, quality of analgesia and respiratory complications. ANOVA was performed and Scheffé and Chi-square tests were applied with 0.05 as the level of statistical significance.No differences were found between groups with respect to patient characteristics or type of surgery. Rescue analgesia requirements were higher in group L-A than in the other groups. PaO2 (6 and 18 hours) and spirometric parameters (12 and 18 hours) were significantly higher in group T-AL than in the other groups (por = 0.05). No other statistically significant differences were found.Respiratory parameters were better after thoracic epidural analgesia with alfentanil and lidocaine than after the other analgesic techniques studied. Group L-A patients had greater need for rescue analgesia than did patients in the other groups.

To analyze the pleural and mediastinal effect of thoracentesis tumor-positive cytology in pleural effusions (PE) detected by chest X ray of lung cancer patients.The study was performed in patients with lung cancer for whom PE was evident in chest X ray films, who then underwent thoracentesis followed by video-assisted thoracoscopy (VAT) to evaluate direct pleural tumor infiltration, mediastinal node involvement and the existence of pleural metastasis. Patients without contraindication underwent the procedure, even if tumor positive cytology was present. When pleural metastasis was found the treatment employed was talc pleurodesis and chemotherapy. Descriptive statistics were compiled and the validity of VAT for pleural metastasis diagnosis, of thoracentesis pleural cytology to detect infiltration of the tumor-adyacent pleura, N2 disease and pleural metastasis were calculated. Survival was also analyzed.PE was present in 188 of 971 consecutive lung cancer patients. Seventy two PEs were visible in the chest X ray films. Volume exceeded 425 mL. Tumor positive pleural cytology was detected in 29 cases (40%). Pleural metastasis were found in 54 patients, 23 of whom had tumor positive pleural cytology. In the other 6 patients with positive cytology the primary neoplasm infiltrated the visceral pleura, completely in 5. In 4 of those 5, the mediastinal pleura was also involved. The primary tumor and diseased lymph nodes were removed from 11 patients, 3 of them with tumoral pleural cytology. Visual pleural inspection by VAT had a sensitivity of 93%, specificity of 82%, positive predicted value (PPV) of 94% and negative predicted value (NPV) of 78% for the diagnosis of pleural metastasis. Thoracentesis cytology showed a sensitivity of 43%, specificity of 67%, PPV of 79% and NPV of 28% for pleural metastasis. For the evaluation of adjacent pleura infiltration, without pleural metastasis, the sensitivity of cytology was 40%, specificity 100%, PPV 100% and NPV 25%. For mediastinal node invasion clinically evaluated, the sensitivity of cytology was 55%, specificity of 62%, PPV 18% and NPV 90%. Survival after thoracotomy was 39% after 2 years, and the median survival time was 14.5 months. In the 11 resected patients, survival was 53% at two years. The difference in survival between patients treated by thoracotomy and those treated by talc pleurodesis after VAT was significant (p0.01). The 3 resected patients with pleural tumor-positive cytology survived 84, 39 and 25 months.Nineteen percent of patients with lung cancer have PE, of which 7% can be seen in chest X ray films. In such patients the likelihood of pleural metastasis is 75%. Pleural metastasis is not necessarily present when PE cytology indicates that tumor is present. VAT can be considered the ideal technique for the assessment of direct pleural invasion by the tumor or of pleural metastasis.

Sympathectomy of the thoracic chain is an effective surgical procedure for treating axillary and palmar hyperhidrosis. The procedure has been performed with minimal invasion and good results in recent years through the use of videothoracoscopic surgery. This paper describes the technique and our experience with a series of 50 patients between 16 and 48 years old. The earliest approach was unilateral in successive operations. The procedure was later performed bilaterally, at first with the patients in sequential lateral decubitus positions and later in semi-seated position. Complications were 1 case of incomplete Claude-Bernard-Horner syndrome that resolved spontaneously two months after surgery; 1 failure when sympathectomy was performed without location of the chain, obliging rapid re-operation; laminar pneumothorax in 12% of the series; compensatory hyperhidrosis in 26%; 10% with chest pain due to intercostal involvement, resolving with time; and slight bleeding in 8%. Outcome was excellent, with complete disappearance of axillary and palmar perspiration. Patient satisfaction was 9.2/10 one year after surgery. Mean hospital stay was less than 36 h.

To analyze the survival of patients classified N2M0 (N2 cytology/histology)with non-small cell lung cancer treated by surgical resection of the primary tumor, lymphadenectomy and neo-adjuvant therapy.Among 1,043 consecutive patients with lung cancer treated between 1990 and 2000, 155 were classified N2M0 by histology. Of 130 patients undergoing thoracotomy, excision of the primary pulmonary tumor and lymphadenectomy were performed in 116. Among the 116 N2M0patients undergoing surgical resection, 23 were diagnosed N2c(c3)by mediastinoscopy and/or mediastinotomy and received induction chemotherapy (CT) with mitomycin/ifosfamide/cisplatin (3 cycles)and 93 were diagnosed N2pM0 after examination of samples of mediastinal lymph tissue taken during thoracotomy; for 19 of these patients,earlier surgical exploration of the mediastinum had been negative. The patient diagnosed N2p after thoracotomy also received CT and/or radiotherapy (RT). N2p patients who received induction CT also received RT. Those who were negative after lymphadenectomy and severely ill patients received no adjuvant therapy of any type.Mean survival of resected patients (23/49) diagnosed N2(C3) by mediastinoscopy/mediastinotomy and who received induction CT was 18 months. Survival at 1, 2 and 5 years was 80%, 45% and 30%, respectively. No postoperative deaths occurred in this group. One patient developed a bronchopleural fistula. Nine patients showed no signs of residual mediastinal node disease after lymphadenectomy. The mean survival of resected patients (93/106) diagnosed N2p after thoracotomy was 13 months and survival rates at 1, 2 and 5 years were 56%, 31% and 19%,respectively. Fourteen patients in this group died within 30 days of surgery. Nine patient developed bronchopleural fistulas. The difference in survival between the two groups was not significant.Histologic or cytologic confirmation of N2 disease can be considered to indicate poor prognosis. Standard, complete surgery with induction CT in selected patients improves survival for those diagnosed N2 upon thoracotomy, with no statistically significant differences.

To analyze the survival of patients classified as N2M0 (N2 by cytohistology) with non-small cell lung cancer treated by surgical resection of the primary tumor and lymphadenectomy.Among 1043 consecutive patients with lung cancer who were considered for surgery between 1990 and 2000, 155 were classified N2M0 by histology. Surgical exeresis of the primarily pulmonary tumor and lymphadenectomy were performed in 116 patients of the 130 patients who underwent thoracotomy. Among the 116 N2M0 patients undergoing surgical resection, 23 were diagnosed N2c(C3) by mediastinoscopy and/or mediastinotomy and were given induction chemotherapy (ChT) (mitomycin/ifosfami-de/cisplatin, 3 cycles) and 93 were diagnosed N2pM0 based on samples obtained from mediastinal lymph tissue during thoracotomy. Nineteen of the latter had previously been classified negative during surgical exploration. The patients diagnosed N2p after thoracotomy were given adjuvant ChT, radiotherapy or both. N2p patients who received induction therapy were given radiotherapy. Those found negative after lymphadenectomy and patients with severe disease were given no adjuvant treatment.Mean survival was 18 months for resected patients diagnosed N2 by mediastinoscopy/mediastinotomy and with induction ChT and survival at one, two and five years was 80%, 45% and 30%, respectively. No postoperative mortality was recorded in this group. One patient suffered bronchopleural fistula. Nine patients showed no residual mediastinal node disease after lymphadenectomy. The mean survival of resected patients diagnosed N2p by thoracotomy was 13 months, and one, two and five year survival rates were 56%, 31% and 19%, respectively. Fourteen patients died within 30 days of surgery. Nine patients developed a bronchopleural fistula. The difference in survival of the two groups was not significant.The prognosis after cytohistologic confirmation of N2 disease can be considered poor. Standard, complete surgery plus induction therapy in screened patients improved survival for those diagnosed N2 by thoracotomy, with no statistically significant differences.

To evaluate the effects on postoperative pulmonary function and quality of analgesia of two protocols for epidural infusion of alfentanil after lung resection.After informed consent, 30 ASA I-IV patients undergoing chest surgery (lobectomy or pneumonectomy) were randomly assigned to two groups of 15. A catheter was inserted into the epidural space at T5-7 (group T) or L2-3 (group L). After a test dose, an initial bolus of alfentanil (10 micrograms/kg) was administered. After anesthetic induction, epidural analgesia was performed with an infusion of 400 micrograms/h of alfentanil (group L) during and after surgery. Endovenous patent-controlled anesthesia (PCA) was provided with morphine. During the first 24 h after surgery, the following variables were recorded: arterial blood gas concentrations, spirometric parameters, pain on a visual analog scale (VAS) and side effects. ANOVA and Scheffé and chi-square tests were used to analyze the results (por = 0.05).In group T, PaO2 was significantly higher at 6 and 18 h (por = 0.05), while FEV1 and FVC were significantly higher at 12 and 18 h. Pain assessed by VAS and PCA need for morphine was significantly less in group T.Thoracic epidural analgesia with alfentanil and lidocaine improves postoperative lung function and reduces the need for top-up analgesia in comparison with lumbar epidural infusion of alfentanil.

We report a male patient with atypical carcinoid tumor diagnosed by anterior mediastinotomy and biopsy after a mass was observed by chance on a chest film. The presence of neuroendocrine markers, notably chromogranin, cytokeratin, synapto-physin and neuro-specific enolase, facilitated diagnosis. Because the tumor was infiltrative, full surgical excision and radiotherapy to the mediastinum (50 Gy) were provided. We describe the incidence, clinical presentation, diagnosis, treatment and prognosis of these tumors.

We describe the case of a 46-year-old man with lung cancer and simultaneous solitary adrenal metastases. Adrenalectomy was performed 12 weeks after lung resection through a right subcostal laparotomy. Treatment was complemented with chemotherapy. Twelve months after adrenalectomy the patient was found free of signs of disease and was in satisfactory condition. The advantages of and indications for surgical resection of suprarenal metastasis are discussed in the light of published literature. In some cases, survival may improve with exeresis and chemotherapy.

Presentamos el caso clinico de un varon de 29 anos de edad que presento una mediastinitis necrosante descendente con extension infracarinal secundaria a un proceso infeccioso orofaringeo. La infeccion toracica fue tratada mediante un drenaje toracico via transcervical, que se retiro al decimoquinto dia del postoperatorio. La evolucion fue favorable sin necesidad de una reintervencion mas radical. Consideramos que en la mediastinitis necrosante descendente con extension infracarinal sin rotura pleural es util inicialmente el tratamiento con drenaje toracico transcervical.