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OBJECTIVES: While the short-term results of lung volume reduction surgery are known, follow-up over several years has not often been described. The purpose of the present study was to describe results in terms of functional improvement, dyspnea, quality of life, and mortality over a 4-year period in patients with advanced emphysema. PATIENTS AND METHODS: Fourteen successive patients were enrolled between 1996 and 2000 and studied prospectively for 4 years. All patients served as their own controls and initially received pulmonary rehabilitation and medication. Preoperative data were used as baseline and were compared to postoperative data over 4 years. The data analyzed were: functional improvement (forced expiratory volume in 1 second [FEV 1 ]), quality of life, dyspnea, and patient loss due to death or referral to a lung transplantation program. RESULTS: Patients with advanced emphysema (mean FEV 1 [SD]: 22.8% [11%] of predicted) were studied. Postoperative mortality was 14%. Overall mortality (postoperative plus deaths due to respiratory insufficiency) was 28% at 1 year and 35% at 4 years. Two patients died of cancer and 5 were referred for transplantation. At 3 months, FEV 1 had improved more than 15% in 9 patients (64%); the improvement was maintained in 43% of patients at 1 year and 7% at 4 years. Improvement in dyspnea paralleled improvement in FEV 1. Overall, at 3 months mean FEV 1 had improved 41.9% (68%), transitional dyspnea index 2.7 (3), and quality of life questionnaire score 1 (0.9). Thus, improvements were considerable, but there was great variation. Preoperative mean decrease in FEV 1 was 50 (32) mL/y, and postoperative decrease 194 (70) mL/y. CONCLUSIONS: With the inclusion criteria used, there was considerable variation in the results. Significant overall functional improvement was maintained in 50% of the patients 1 year following surgery and in 7% 4 years after surgery. Given such results, together with a surgical mortality rate of 14% and overall mortality of 28% in the first year, we believe that the criteria for using lung reduction surgery should be revised.

Objetivos: Aunque se conocen los resultados de la cirugia de reduccion de volumen a corto plazo, son pocas las series que describen el seguimiento durante varios anos. El proposito de este estudio es describir los resultados, en relacion con la mejoria funcional, disnea, calidad de vida y mortalidad, a lo largo de 4 anos en pacientes con enfisema avanzado. Pacientes y metodos: Se ha estudiado de forma prospectiva a 14 pacientes incluidos sucesivamente entre los anos 1996 y 2000, y seguidos a lo largo de 4 anos. Cada paciente fue su propio control y recibio inicialmente tratamiento rehabilitador y farmacologico. Se utilizaron los datos preoperatorios como basales y se compararon con los postoperatorios a lo largo de 4 anos. Los datos analizados fueron: mejoria mecanica --volumen espiratorio forzado en el primer segundo (FEV1)--, calidad de vida, disnea y perdida del paciente, tanto por fallecimiento como por remitirlo a un programa de trasplante pulmonar. Resultados: Se incluyo a pacientes con enfisema avanzado (FEV1: 22,8 ± 11%). La mortalidad postoperatoria fue del 14% y, unida a la originada por la insuficiencia respiratoria, del 28 y el 35% al ano y a los 4 anos, respectivamente. Dos pacientes murieron por cancer y 5 se remitieron a trasplante. A los 3 meses, 9 pacientes (64%) habian mejorado mas del 15% el FEV1 y esta mejoria se mantuvo en el 43% al ano y en el 7% a los 4 anos. La mejoria de la disnea fue paralela a la mejoria del FEV1. Globalmente, a los 3 meses el FEV1 habia mejorado un 41,9 ± 68%, el indice transicional de disnea un 2,7 ± 3 y la calidad de vida 1 ± 0,9, es decir, mejorias importantes pero con mucha dispersion. La caida del FEV1 prequirurgica fue de 50 ± 32 ml/ano, y la posquirurgica de 194 ± 70 ml/ano. Conclusiones: Con los criterios de inclusion seguidos, hay una importante variabilidad en los resultados y, globalmente, se mantiene una mejoria funcional significativa en el 50% de los pacientes al ano de la cirugia y del 7% a los 4 anos. Estos hechos, unidos a una mortalidad operatoria del 14% y global del 28% en el primer ano, hacen que se tengan que revisar los criterios de indicacion de esta cirugia.

Objetivos . La cirugia de reduccion de volumen se ha introducido recientemente como tratamiento paliativo del enfisema evolucionado. Algunos pacientes mejoran y otros permanecen en la misma situacion; sin embargo, los factores que predicen la mejoria estan todavia en debate. El proposito de este trabajo es encontrar que factores discriminan que un paciente responda positivamente con esta cirugia. Material y metodos . Se han comparado en nuestra serie de cirugia de reduccion de volumen (12 pacientes) a los respondedores (7 pacientes) y los no respondedores (5 pacientes). Se definio la respuesta a la cirugia como un Δ FEV1 ≥ 15%, indice transicional de disnea (escala de Mahler) ≥ 3 y mejoria en la puntuacion del cuestionario de calidad de vida para enfermedad respiratoria cronica (Guyatt y Guell) ≥ 1,5 a los 3 meses de la cirugia. Se han comparado los valores basales del FEV1, FEF50/FIF50%, grado de hiperinsuflacion, heterogeneidad, PaO2, PaCO2, tipo de cirugia, indice de masa corporal, indice basal de disnea y puntuacion del cuestionario de calidad de vida. Resultados . Los no respondedores se han diferenciado de los respondedores unicamente porque partian de un indice de masa corporal, indice basal de disnea y puntuacion del cuestionario de calidad de vida menores. El resto de parametros estudiados (si bien la poblacion era bastante homogenea) no mostro diferencias significativas entre los dos grupos. Conclusiones . Los pacientes con mayor afectacion subjetiva (disnea y calidad de vida) y mas desnutridos son lo que menos se benefician de la cirugia de reduccion de volumen.

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.

Lung volume reduction surgery has recently been proposed as a palliative treatment for advanced emphysema. Some patients improve and others remains the same, being debated at this time the factors that predict improvement. The purpose of this work is to find predictive factors for positive response in patients operated with this surgery.Patients with positive response (7 patients) and patients without positive response (5 patients) have been compared in our series of lung volume reduction surgery (12 patients). Positive response to surgery was defined as Delta FEV1or = 15%, dyspnea transitional index (Mahler scale)or = 3, and improvement in the scoring surgery of quality of life for chronic respiratory disease questionnaire (Guyatt and Güell)or = 1.5 3 months after the surgery. Basal values of FEV1, FEF50/FIF50%, hyperinsufflation degree, heterogeneity, PaO2, PaCO2, type of surgery, body mass index (BMI), dyspnea basal index (DBI) and quality of life questionnaire score (QLQS).Patients without and with positive response were different only because their baseline BMI, DBI and QLQS were lower. Other parameters studied (although the population was rather homogeneous) did not show significant differences between the two groups.Patients with higher subjective problems (dyspnea and quality of life) and more malnourished are those with less benefit from surgery for pulmonary volume reduction.

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.

While the short-term results of lung volume reduction surgery are known, follow-up over several years has not often been described. The purpose of the present study was to describe results in terms of functional improvement, dyspnea, quality of life, and mortality over a 4-year period in patients with advanced emphysema.Fourteen successive patients were enrolled between 1996 and 2000 and studied prospectively for 4 years. All patients served as their own controls and initially received pulmonary rehabilitation and medication. Preoperative data were used as baseline and were compared to postoperative data over 4 years. The data analyzed were: functional improvement (forced expiratory volume in 1 second [FEV1]), quality of life, dyspnea, and patient loss due to death or referral to a lung transplantation program.Patients with advanced emphysema (mean FEV1 [SD]: 22.8% [11%] of predicted) were studied. Postoperative mortality was 14%. Overall mortality (postoperative plus deaths due to respiratory insufficiency) was 28% at 1 year and 35% at 4 years. Two patients died of cancer and 5 were referred for transplantation. At 3 months, FEV1 had improved more than 15% in 9 patients (64%); the improvement was maintained in 43% of patients at 1 year and 7% at 4 years. Improvement in dyspnea paralleled improvement in FEV1. Overall, at 3 months mean FEV1 had improved 41.9% (68%), transitional dyspnea index 2.7 (3), and quality of life questionnaire score 1 (0.9). Thus, improvements were considerable, but there was great variation. Preoperative mean decrease in FEV1 was 50 (32) mL/y, and postoperative decrease 194 (70) mL/y.With the inclusion criteria used, there was considerable variation in the results. Significant overall functional improvement was maintained in 50% of the patients 1 year following surgery and in 7% 4 years after surgery. Given such results, together with a surgical mortality rate of 14% and overall mortality of 28% in the first year, we believe that the criteria for using lung reduction surgery should be revised.

Lung tumorlets are small collections of neuroendocrine cells derived from Kulchitsky cells of the bronchial epithelium. Such cells are usually found by chance, are considered benign and rarely metastasize. We describe 5 cases of tumorlets diagnosed by chance in patients with prior lung disease requiring histology. Even though the behavior of tumorlets is benign, patients in whom they have been found should receive follow-up X-rays, as lymphatic metastasis in the region has occasionally been described.

Pulmonary neoplasms can deposit malignant cells in the pleural cavity by a variety of mechanisms, depending not only on histological type but also on clinical stage. We investigated the effect on survival rate of a finding of malignant cells in pleural lavage. We also investigated the effect of the presence of pleural metastasis on postoperative course of disease. Two hundred surgical patients at Hospital General Universitario in Valencia between 1 February 1990 and 30 March 1993 were studied. Two groups were formed. Group one: 150 patients with lung cancer, none of whom had had pleural effusion prior to suffering transthoracic puncture during the preoperative study. Patients treated with parallel chemotherapy or radiotherapy were excluded in order to circumvent false positives. Group two: 50 patients with no tumors who underwent thoracotomy for reasons other than lung cancer. All patients underwent pleural lavage with saline before and after lung exeresis. We found 26.6% (40/150) positive cytologies in the pre-and postoperative lavages in the first group. None were found in the control group.

A 41-years-old woman with multiple arteriovenous lung malformations in a context of Rendu-Osler-Weber disease is described. The patient had a history of cutaneous and mucosal telangiectasia, frequent epistaxis and one episode of central artery embolism in the right retina. Malformations in the vascular territories of both lungs (right lower lobe and lingula) were detected by X-rays and magnetic resonance. Progressive dyspnea along with serious antecedents indicated that aggressive treatment was required. The malformations were embolized in the vascular radiology treatment center.