Surgical treatment of hepatic and pulmonary metastases from colorectal cancers

BACKGROUND

Selected patients with double hepatic and pulmonary metastases from colorectal cancer may benefit from operation.

METHODS

From 1970 to 1995, 239 patients underwent operation for resection of pulmonary metastases from colorectal cancer at two French surgical centers. Among these patients, 43 (18%) had previously undergone complete resection of hepatic metastases and constitute the subject of this retrospective study.

RESULTS

The median interval time between hepatic and pulmonary resections was 18 months. Two pneumonectomies, 5 lobectomies, 3 segmentectomies, 6 wedge resections, and 27 metastasectomies were performed. No postoperative mortality was observed. Two patients had major postoperative complications. Seven patients (16%) underwent subsequent pulmonary resection for recurrences. Twenty-one patients were still alive, 14 free of disease. The median survival from pulmonary resection was 19 months and the 5-year probability of survival was 11%. Prethoracotomy carcinoembryonic antigen blood levels and the number of pulmonary resection were found to be significant prognostic factors; the interval time between hepatic and pulmonary resection (> 36 months) was borderline significant (p = 0.06).

CONCLUSIONS

Selected patients with combined hepatic and pulmonary metastases from colorectal cancer should be considered for surgical resection. Patients with normal prethoracotomy carcinoembryonic antigen levels and late metachronous pulmonary metastasis, appear to be the best surgical candidates.

Effect of modafinil on plasma melatonin, cortisol and growth hormone rhythms, rectal temperature and performance in healthy subjects during a 36 h sleep deprivation

Modafinil is an alerting substance which has been used successfully to treat narcolepsy. Nothing is known about its effect on hormone secretions. For this purpose, eight healthy young men were enrolled in a double blind trial to test the effects of modafinil on daily plasma melatonin, cortisol and growth hormone (GH) rhythms. Blood was sampled for hormone assays, every hour during the daytime and every 30 min during the nighttime. In addition, rectal temperature and mental performances were determined during the study which comprised 3 sessions, two weeks apart: a 24 h control session including a night with sleep (S1) and two 48 h sessions S2 and S3 with a sleep-deprived night (N1) followed by a recovery night (N2). Modafinil (300 mg x 2) or placebo were randomly attributed during N1 at 22 h and 8 h. As expected, performance was improved after modafinil administration and body temperature was maintained or increased. Plasma melatonin and cortisol profiles were similar after modafinil and placebo administration. The levels observed during the recovery and the control nights (N2) displayed no difference. For GH, during both sleep deprived nights, secretion was dramatically reduced compared with the control one, although the number of secretory episodes was unchanged. These data show that the alerting property of modafinil is not related to an alteration of hormone profiles and suggest that the acute modafinil administration is devoid of short-term side-effects.

[Pulmonary embolism. Current aspects of treatment]

INDICATIONS FOR DRUG THROMBOLYSIS: There has been much debate on the indications for drug thrombolysis in pulmonary embolism. Thrombolysis would not appear to be justified excepting in massive pulmonary embolism when clinical signs or explorations evidence poor hemodynamic tolerance. Current data would confirm its independent effect on reducing mortality in such cases. MECHANICAL THROMBOLYSIS: The clinical efficacy of mechanical thrombolysis has not been demonstrated. It should not be used outside rigorously controlled clinical trials in patients with severe pulmonary embolism and with a formal contraindication for drug thrombolysis or in case of failure. THE PREPIC STUDY: The first controlled prospective trial on caval filters confirmed that indications for caval interruption in patients with proximal deep vein thrombosis should be limited to contraindications and failures of anticoagulant therapy. Other indications for filters, whether temporary or definitive, should be evaluated with specific controlled prospective trials. LOW-MOLECULAR WEIGHT HEPARINS: If this possibility is confirmed for the treatment of pulmonary embolism, it will provide a simple rational treatment for venous thromboembolism. 'SMALL CLOTS': Changing diagnostic strategies, particularly the use of helical CT angiography, has raised the question of therapeutic abstention when "small" clots are undetectable by this exploration.

[Orthostatic hypotension revealing vitamin B12 deficiency]

Neurological manifestations of cobalamin deficiency are well known and various. We describe an uncommon clinical setting where major orthostatic hypotension was the primary symptom. Recovery was rapidly and completely stabilized with parenteral cobalamin substitution. There was no clinical or electrophysiological signs of neuropathic disorder. This entity is rare but few cases are described in literature. All of them were reversible with vitamin substitution treatment.

[Germinal tumor metastases. Case report]

Germinoma is the most frequent type of intracranial germ-cell tumor initial presentation is usually acute intracranial hypertension. MRI investigations are non-specific. Most of the time, only stereotactic surgery is performed before treatment. Metastases are rare but germ cells can disseminate both by infiltration and via ventricular and subarachnoid pathways. Abdominal and pelvic metastases occur in 10 p. 100 of patients who have received ventriculosomatic shunting. Since germinoma is well known to be a very radiosensitive tumor, patients are usually given radiation therapy. Chemotherapy seems to be an interesting alternative treatment.

A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prévention du Risque d'Embolie Pulmonaire par Interruption Cave Study Group

BACKGROUND

The efficacy and safety of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis is still a matter of debate.

METHODS

Using a two-by-two factorial design, we randomly assigned 400 patients with proximal deep-vein thrombosis who were at risk for pulmonary embolism to receive a vena caval filter (200 patients) or no filter (200 patients), and to receive low-molecular-weight heparin (enoxaparin, 195 patients) or unfractionated heparin (205 patients). The rates of recurrent venous thromboembolism, death, and major bleeding were analyzed at day 12 and at two years.

RESULTS

At day 12, two patients assigned to receive filters (1.1 percent), as compared with nine patients assigned to receive no filters (4.8 percent), had had symptomatic or asymptomatic pulmonary embolism (odds ratio, 0.22; 95 percent confidence interval, 0.05 to 0.90). At two years, 37 patients assigned to the filter group (20.8 percent), as compared with 21 patients assigned to the no-filter group (11.6 percent), had had recurrent deep-vein thrombosis (odds ratio, 1.87; 95 percent confidence interval, 1.10 to 3.20). There were no significant differences in mortality or the other outcomes. At day 12, three patients assigned to low-molecular-weight heparin (1.6 percent), as compared with eight patients assigned to unfractionated heparin (4.2 percent), had had symptomatic or asymptomatic pulmonary embolism (odds ratio, 0.38; 95 percent confidence interval, 0.10 to 1.38).

CONCLUSIONS

In high-risk patients with proximal deep-vein thrombosis, the initial beneficial effect of vena caval filters for the prevention of pulmonary embolism was counterbalanced by an excess of recurrent deep-vein thrombosis, without any difference in mortality. Our data also confirmed that low-molecular-weight heparin was as effective and safe as unfractionated heparin for the prevention of pulmonary embolism.

A triple procedure: phacoemulsification, intraocular lens implantation, and scleral buckling surgery

BACKGROUND

To report the technique and results of simultaneous surgery for cataract and retinal detachment.

METHODS

This retrospective study covered 452 cases of phakic detachment. Dense cataract was present in 15 cases that did not need intravitreal surgery. For these, a triple procedure involving phacoemulsification, posterior chamber lens insertion, and scleral buckling surgery was performed. Combined cataract and scleral buckling surgery was carried out after the failure of initial detachment surgery in four cases, including scleral buckling in three and vitrectomy in one.

RESULTS

A clear intraoperative view of the fundus was obtained in all cases and retinal breaks were identified in 13. The retina was reattached by combined surgery in 13 cases (87%) and a final acuity of 20/40 or better was attained in 7 of these 13 reattached cases (54%). There was no instance of visual imbalance due to gross miscalculation of intraocular lens power.

CONCLUSION

Combined cataract and scleral buckling surgery spares the patient repeat surgery and may improve the outcome by avoiding delay for detachment repair. To perform this procedure, however, vitreoretinal surgeons must be familiar with phacoemulsification techniques.

Completion pneumonectomy for lung metastases: is it justified?

OBJECTIVE

To evaluate the postoperative outcome and long-term results of patients who underwent iterative and extended pulmonary resection leading to completion pneumonectomy for pulmonary metastases.

METHODS

From January 1985 to December 1995, 12 patients (mean age 45 years) underwent completion pneumonectomy for pulmonary metastases. These patients represent 1.5% of all pulmonary metastases operated on. There were 5 sarcoma and 7 carcinoma patients. Before completion pneumonectomy, 8 patients had only one pulmonary resection (wedge resection, 2; segmentectomy, 2; lobectomy, 4), 3 patients had two operations and finally, 1 patient had multiple bilateral wedge resections and 1 lobectomy. The median interval time between the last pulmonary resection and completion pneumonectomy was 13.5 months (range 1-24 months).

RESULTS

There were 10 left and two right completion pneumonectomies. Three patients had an extended resection (1 carina; 1 chest wall; 1 pleuropneumonectomy). Intrapericardial dissection was used in 3 patients. Two patients died within 30 days of the operation: 1 died of postoperative complications (8.3%) whereas the other died of rapidly evolving metastatic disease. The remaining 10 patients had an uneventful postoperative course. Only 1 patient is still alive and free of disease 69 months after completion pneumonectomy. One patient is alive with disease, another was lost to follow-up; 9 patients died of metastatic disease. The median survival time after completion pneumonectomy was 6 months (range 0-69 months). The estimated 5-year probability of survival was 10% (95% CI: 2-40%).

CONCLUSIONS

Indications for both iterative and extended pulmonary resection for PM may be discussed only in highly young selected patients; the extremely poor outcome of our subgroup of patients should lead to even more restrictive indications of CP for pulmonary metastatic disease.

[Spontaneous chylothorax. Apropos of a further case]

The authors describe a case of spontaneous chylothorax occurring in a 50-year-old woman after stretching exercises of the upper limbs. A positive diagnosis was made based on pleural aspirate and a biochemical study of the pleural liquid (triglycerides > 3 gm/l). The chylothorax is said to be spontaneous when detailed investigations are negative. The outcome was satisfactory with complete regression of the symptoms after pleural aspirate and a low diet in long chain triglycerides but the authors recall that treatment may be surgical in cases of multiple recurrence.

Completion right lower lobectomy for recurrence after left pneumonectomy for metastases

Resection of pulmonary recurrences on the residual lung after pneumonectomy for metastases is exceptional. A 37-year-old woman was submitted to left extended pleuro-pneumonectomy after left leg amputation for fibrosarcoma. At 43 months later, a wedge resection on the right lower lobe was performed followed 32 months later by a further wedge resection in the same lobe. A completion right lower lobectomy for a new recurrence was performed 17 months after the last pulmonary resection. The patient did not develop postoperative complications. She is still alive and free of disease 10 years and 9 months after pneumonectomy and 36 months after completion lobectomy on the residual lung. In highly selected patients, aggressive surgery for metastases on the residual lung can be successfully performed and it can improve survival.

Should the number of pulmonary metastases influence the surgical decision?

OBJECTIVE

To assess, using a large homogeneous retrospective series, the prognostic value of the number of resected pulmonary metastases, and thus, to determine to what extent the number of resectable metastases should influence the surgical decision.

METHODS

The survival analysis of all patients operated on for pulmonary metastases at a single center, the comparisons of 2 'histologic' groups (sarcoma and carcinoma) and, within each histologic group, of three subgroups with different numbers of resected metastases (1, 2-4, and > or = 5) were performed. The log-rank test was used to compare survival curves.

RESULTS

Among 575 adult patients operated on with curative intent before December 1991, the first operation allowed the complete resection of a known number of histologically proven viable pulmonary metastases in 230 and 151 patients with metastases from carcinoma and sarcoma, respectively. The 5- and 10-year probabilities of survival (Kaplan-Meier) were 37 and 23%, respectively in carcinoma patients, and 31 and 28%, respectively in sarcoma patients (log-rank test: ns). Only the difference between patients with 1 versus 2-4 metastases from carcinoma proved statistically significant (P = 0.02), with 5-year survival estimates of 41 and 25%, respectively. Beside survival, the only significant difference between the subgroups of patients with different numbers of resected metastases was the mean interval between the diagnosis of pulmonary metastases and the resection of pulmonary metastases, which was significantly longer in patients with several metastases in both histologic groups.

CONCLUSIONS

In patients with resectable pulmonary metastases from sarcoma or carcinoma, the number of metastases should have little influence on the surgical decision, except for delaying this decision in patients with several metastases until a significant interval, with or without treatment, has shown that metastatic disease remains resectable and confined to the lungs.

[An unusual cause of aorto-bronchial fistula: tuberculosis aortitis]

The aortic rupture in the pulmonary parenchyma or the bronchi rarely results in an haemoptysis. It means in most of the cases the rupture of an aortica aneurysm. We relate the observation of a aorto-bronchial fistula from a tuberculosa origin in an old woman case. Although the tuberculosa aortitis is becoming very exceptional, it still remains the cause of aorta rupture, with the formation of a false aneurysm which is rapidly fatal and so, it is important to search for it before any capricious haemoptysis.

[New therapeutic strategies and current research in inoperable locally advanced non small-cell lung cancers (stage IIIB)]

Treatment of patients with inoperable locally advanced non small-cell lung cancer (NSCLC) remains disappointing with less of 5% of patients alive at 5 years. Both initial local control and circumvention of concomitant undetectable metastatic chemoresistant cells are the critical targets for the oncologists in charge of this disease. Results of a recent meta-analysis including 22 randomized studies comparing standard treatment (i.e. radiotherapy) to sequential chemoradiotherapy have undoubtabely well defined the role of cisplatine-containing chemotherapy in stage IIIB NSCLC, even if the 5 year survival benefit remains modest. However, high complete response rates and prolonged overall survival were observed with combinations of new promising chemotherapy regimens and new fractionated radiation schedules in several phase II studies. These results have to be corroborated by prospective randomized trials. Integration of more aggressive and more toxic strategies such as radical surgery in these initial inoperable locally advanced NSCLC are evaluating. Around these conventional therapies, the stage IIIB NSCLC represent a favoured target to elaborate innovative therapeutic approaches based on emergence of biotherapies as recombinant cytokines, antitumoral vaccine and gene therapy programs. The contribution of these new therapeutic options opens new directions in the therapeutic strategy and leads to hope a new promising era in the management and outcome of patients with these tumors.

Lung resection for recurrence after pneumonectomy for metastases

Resection of pulmonary recurrences after pneumonectomy for metastases is exceptional. Nevertheless in carefully selected patients surgery on the residual lung might be successfully performed. From January 1987 to February 1996, 5 patients underwent metastasectomy on single lung after pneumonectomy performed for the same metastatic disease. There were 3 male and 2 female with a mean age of 38 years at the time of surgery on single lung. All patients had a FEV1 > 40%. One patient (n degree 1) had 2 consecutive operations (wedge resections) on the right lower lobe followed 17 months later by right inferior lobectomy for metastases of soft tissue sarcoma. Three patients had only an operation on the residual lung (patient n degree 2 had 2 wedge resections for carcinoma; patient n degree 3 had 7 wedge resections for carcinoma; patient n degree 4 had 6 wedge resections for osteogenic sarcoma). The last patient (n degree 5) had 2 wedge resections on the right upper lobe and a large wedge resection on the right lower lobe for metastases of malignant corticosurrenaloma using a cardiopulmonary femoro-femoral by-pass without cardiac arrest. She postoperatively developed a right lower lobe venous infarction treated subsequently with a completion right lower lobectomy. She died in the postoperative course from cardiorespiratory insufficiency. The other patients had an uneventful postoperative course. Two patients (n degree 2 and n degree 4) died of their disease 14 and 12 months respectively after the surgery on the residual lung; by contrast 2 patients (40%) (n degree 1 and n degree 3) are still alive without recurrences 36 and 27 months after the last resection. In selected patients aggressive surgery for metastases on the residual lung can be successfully performed but the benefits in terms of long-term disease-free survival remain to be determined.

Long-term results of lung metastasectomy: prognostic analyses based on 5206 cases

OBJECTIVES

The International Registry of Lung Metastases was established in 1991 to assess the long-term results of pulmonary metastasectomy.

METHODS

The Registry has accrued 5206 cases of lung metastasectomy, from 18 departments of thoracic surgery in Europe (n = 13), the United States (n = 4) and Canada (n = 1). Of these patients, 4572 (88%) underwent complete surgical resection. The primary tumor was epithelial in 2260 cases, sarcoma in 2173, germ cell in 363, and melanoma in 328. The disease-free interval was 0 to 11 months in 2199 cases, 12 to 35 months in 1857, and more than 36 months in 1620. Single metastases accounted for 2383 cases and multiple lesions for 2726. Mean follow-up was 46 months. Analysis was performed by Kaplan-Meier estimates of survival, relative risks of death, and multivariate Cox model.

RESULTS

The actuarial survival after complete metastasectomy was 36% at 5 years, 26% at 10 years, and 22% at 15 years (median 35 months); the corresponding values for incomplete resection were 13% at 5 years and 7% at 10 years (median 15 months). Among complete resections, the 5-year survival was 33% for patients with a disease-free interval of 0 to 11 months and 45% for those with a disease-free interval of more than 36 months; 43% for single lesions and 27% for four or more lesions. Multivariate analysis showed a better prognosis for patients with germ cell tumors, disease-free intervals of 36 months or more, and single metastases.

CONCLUSIONS

These results confirm that lung metastasectomy is a safe and potentially curative procedure. Resectability, disease-free interval, and number of metastases enabled us to design a simple system of classification valid for different tumor types.

Late recurrence of retinal detachment

We reviewed 1,136 cases of retinal detachment in 1,073 patients. Late recurrence was defined as the reappearance of subretinal fluid after at least 6 months of clear, total reattachment. Fifty-one patients (4.75%) had a late recurrence. New or reopened peripheral breaks were either definitely observed or presumed to be present in 40 eyes (78.5%), and none were definite peripheral holes or retinal dialyses. Three macular holes reopened after having initially been managed by vitrectomy. One additional macular hole occurred as a new break. Late severe proliferative vitreoretinopathy occurred in the last 7 cases. Only vitrectomy for initial detachment and lens extraction after reattachment correlated with late recurrence. Vitrectomy was still a significant risk factor when macular holes were excluded.