Predicting brain metastasis in early stage non-small cell lung cancer patients by gene expression profiling

Background

Non-small cell lung cancer (NSCLC) is the most common cause of cancer-death due to early metastatic spread, in many cases primarily to the brain. Organ-specific pattern of spread of disease might be driven by the activity of a specific signaling pathway within the primary tumors. We aimed to identify an expression signature of genes and the relevant signaling associated with the development of brain metastasis (BM) after surgical resection of NSCLC.

Methods

Rapidly frozen NSCLC surgical specimens were procured from tumor banks. RNA was extracted and analyzed by RNA-sequencing (Illumina HiSeq 2500). Clinical parameters and gene expression were examined for differentiating between patients with BM, patients with metastases to sites other than brain, and patients who did not develop metastatic disease at a clinically significant follow up. Principal component analysis and pathway enrichments studies were done.

Results

A total of 91 patients were included in this study, 32 of which developed BM. Stage of disease at diagnosis (P=0.004) and level of differentiation (P=0.007) were significantly different between BM and control group. We identified a set of 22 genes which correlated specifically with BM, and not with metastasis to other sites. This set achieved 93.4% accuracy (95% CI: 86.2–97.5%), 96.6% specificity and 87.5% sensitivity of correctly identifying BM patients in a leave-one-out internal validation analysis. The oxidative phosphorylation pathway was strongly correlated with BM risk.

Conclusions

Expression level of a small set of genes from primary tumors was found to predict BM development, distinctly from metastasis to other organs. These genes and the correlated oxidative phosphorylation pathway require further validation as potentially clinically useful predictors of BM and possibly as novel therapeutic targets for BM prevention.

Neoadjuvant pembrolizumab (Pembro) for early stage non-small cell lung cancer (NSCLC): Updated report of a phase I study, MK3475-223

8534

Background: Resected NSCLC clinical stage I or II harbor a 5 year survival of only 30-50%. Immunotherapy might be more effective in low-burden disease. We hypothesized that neo-adjuvant immunotherapy is a feasible, safe and effective treatment (Tx) for early stage NSCLC. Methods: MK3475-223 is an ongoing phase I study of neoadjuvant pembrolizumab in stage I-II NSCLC. All Pembro Txs are 200mg q 3 weeks (wks). Objectives: determine safety; recommended phase 2 dose/schedule; pathological & radiological response. Doses-schedule limiting toxicities (DLT) were defined as significant surgical complications (bleeding, delayed wound healing, ARDS, prolonged air-leak) or a significant delay of surgery. The doses-schedule escalation cohorts were (i) single pembro dose 3 wk prior to surgery; (ii) 2 pembro doses, 2 wks later surgery; (iii) 2 pembro doses, 1 wk later surgery. Expansion cohort received the doses-schedule of cohort (iii). Percentages of remaining viable tumor in the post-Tx were assessed, 10% or less was considered amajor pathological response (MPR). IHC for pre-Tx PDL1 was done. Efficacy was evaluated for the patients who had received 2 doses of pembrolizumab. Results: No DLT occurred in the dose-schedule escalation cohorts. 10 patients received 2 cycles of neo-adjuvant pembrolizumab. 4 patients achieved a MPR (4/10 who received 2 cycles of pembro; 40%; 95% C.I. 16.7-68.8%). No correlation is seen between the levels of PDL1 pre-Tx and the pathologic response. Size of the tumor and N status was also not in any apparent correlation with MPR (data not shown). Interestingly, all of the MPR cases had a relatively long interval from 1st Tx till surgery. Clinical trial information: NCT02938624. Conclusions: Neo-adjuvant pembro is safe and feasible. A promising sign of efficacy is seen. Achieving MPR might require a longer 1st-Tx-surgery interval. Predictive biomarkers for response might be different from those in advanced disease. Recruitment and correlative studies are ongoing.[Table: see text]

Comparative effectiveness of intensity modulated radiation therapy to 3-dimensional conformal radiation in locally advanced lung cancer: pathological and clinical outcomes

OBJECTIVE

Intensity-modulated radiotherapy (IMRT) has better normal-tissue sparing compared with 3-dimensional conformal radiation (3DCRT). We sought to assess the impact of radiation technique on pathological and clinical outcomes in locally advanced non-small cell lung cancer (LANSCLC) treated with a trimodality strategy.

METHODS

Retrospective review of LANSCLC patients treated from August 2012 to August 2018 at Sheba Medical Center, Israel. The trimodality strategy consisted of concomitant chemoradiation to 60 Gray (Gy) followed by completion surgery. The planning target volume (PTV) was defined by co-registered PET/CT. Here we compare the pathological regression, surgical margin status, local control rates (LC), disease free (DFS) and overall survival (OS) between 3DCRT and IMRT.

RESULTS

Our cohort consisted of 74 patients with mean age 62.9 years, male in 51/74 (69%), adenocarcinoma in 46/74 (62.1%), stage 3 in 59/74 (79.7%) and chemotherapy in 72/74 (97.3%). Radiation mean dose: 59.2 Gy (SD ± 3.8). Radiation technique : 3DCRT in 51/74 (68.9%), IMRT in 23/74 (31%). Other variables were similar between groups.Major pathological response (including pathological complete response or less than 10% residual tumor cells) was similar: 32/51 (62.7%) in 3DCRT and 15/23 (65.2%) in IMRT, p=0.83. Pathological complete response (pCR) rates were similar: 17/51 (33.3%) in 3DCRT and 8/23 (34.8%) in IMRT, p=0.9. Surgical margins were negative in 46/51 (90.1%) in 3DCRT vs. 17/19 (89.4%) in IMRT (p=1.0).The 2-year LC rates were 81.6% (95% CI 69-89.4%); DFS 58.3% (95% CI 45.5-69%) and 3-year OS 70% (95% CI57-80%). Comparing radiation techniques, there were no significant differences in LC (p=0.94), DFS (p=0.33) and OS (p=0.72).

CONCLUSION

When used to treat LANSCLC in the neoadjuvant setting, both IMRT and 3DCRT produce comparable pathological and clinical outcomes.

ADVANCES IN KNOWLEDGE

This study validates the real-world effectiveness of IMRT compared to 3DCRT.

Neo-adjuvant Chemo-Radiation to 60 Gray Followed by Surgery for Locally Advanced Non-Small Cell Lung Cancer Patients: Evaluation of Trimodality Strategy

BACKGROUND

Neoadjuvant chemo-radiation therapy (CRT) dosages in locally advanced non-small cell lung cancer (NSCLC) were traditionally limited to 45 Gray (Gy).

OBJECTIVES

To retrospectively analyze outcomes of patients treated with 60 Gy CRT followed by surgery.

METHODS

A retrospective chart review identified patients selected for CRT to 60 Gy followed by surgery between August 2012 and April 2016. Selection for surgery was based on the extent of disease, cardiopulmonary function, and response to treatment. Pathological response after neoadjuvant CRT was scored using the modified tumor regression grading. Local control (LC), disease free survival (DFS), and overall survival (OS) were estimated by the Kaplan-Meier method.

RESULTS

Our cohort included 52 patients: 75% (39/52) were stage IIIA. A radiation dose of 60 Gy (range 50-62Gy) was delivered in 82.7%. Surgeries performed included: lobectomy, chest-wall resection, and pneumonectomy in 67.3%, 13.4%, and 19.2%, respectively. At median follow-up of 22.4 months, the 3 year OS was 74% (95% confidence interval [CI] 52-87%), LC was 84% (95%CI 65-93), and DFS 35% (95%CI 14-59). Grade 4-5 postoperative complications were observed in 17.3% of cases and included chest wall necrosis (5.7%), bronco-pleural fistula (7.7%), and death (3.8%). A major pathologic regression with < 10% residual tumor occurred in 68.7% of patients (36/52) and showed a trend to improved OS (P = 0.1). Pneumonectomy cases had statistically worse OS (P = 0.01).

CONCLUSIONS

Major pathologic regression was observed 68.7% with 60 Gy neoadjuvant CRT with a trend to improved survival. Pneumonectomy correlated with worse survival.

Stereotactic Ablative Body Radiation for Stage I Lung Cancer in Israel: A Retrospective Single-Center Report

BACKGROUND

Stereotactic ablative radiation therapy (SABR) is the application of a very high radiation dose to a small treatment volume. It is the new standard of care in medically inoperable early-stage lung cancer.

OBJECTIVES

To report the outcomes of SABR in stage I lung cancer at Sheba Medical Center since its introduction in 2009.

METHODS

We conducted a retrospective chart review of patients with stage I lung cancer treated during the period 2009-2015. Survival status was retrieved from the electronic medical records and confirmed with the national registry. Local failure was defined as increased FDG uptake on PETCT scan within a 2 cm radius of the treated region. Toxicity was estimated from medical records and graded according to common toxicity criteria for adverse events (CTCAE) version 4.03. Overall survival and local control were estimated by the Kaplan-Meier method.

RESULTS

During the study period 114 patients were treated for 122 stage I lung cancer lesions. Median follow-up time was 27 months (range 8.2-69.5 months), median age was 76 years. Eighty-two percent of the tumors were stage IA (size ≤ 3 cm). Median survival was 46 months; estimated 3 year overall survival was 59% (95%CI 47-69%) and local control was 88% (95%CI 78-94%). Toxicity included chest wall pain in 8.4% of patients, rib fracture in 0.9%, grade 1-2 pneumonitis in 12%, grade 3 in 12% and grade 5 (death) in 0.9%.

CONCLUSIONS

SABR has been successfully implemented at Sheba Medical Center for the treatment of stage I lung cancer in inoperable patients. It is associated with excellent local control, minor toxicity and an acceptable overall survival.

Abstract 4910: Modeling immunotherapy in ex vivo organ culture of non-small cell lung cancer (NSCLC)

PD1-PDL1 interaction is one mechanism of tumor evasion of the immune system, and inhibitors of this interaction can allow cancer cell killing by cytotoxic T cells. In NSCLC as well as in most other cancers, the clinical benefit from such inhibitors is far from universal; around 20% of tumors respond to this treatment. Response of tumors to anti-cancer agents depends on interactions of epithelial tumor cells and the microenvironment, including stromal cells such as fibroblasts, immune cells and extracellular matrix. Studying cell signaling and drug-sensitivity of cancer should take into consideration the different compartments of an individual tumor. Regarding immunotherapy, manipulating regulators of PDL1 expression might augment the activity of these drugs, or possibly be active as an immunotherapy on its own. Specifically, little is known about the impact of chemotherapy, radiotherapy or targeted agents on the expression and activity of the PD1-PDL1 signaling in human cancer. Combining such treatments with immunotherapy is a potentially promising approach that is currently investigated clinically. However, the number of potential combinations is vast, and no valid and convenient experimental model exists to test candidate treatments and combinations. Experimental procedures: Ex vivo organ cultures (EVOC) were directly established from fresh NSCLC tissues, as a model that recapitulates real tumor and its microenvironment, including immune cells. Tissue elements were mechanistically dispersed to cell clumps (30-100 cells per clump), or cut to one cubic mm pieces and placed in culture. LDH release was used as a surrogate of cell death. Samples were analyzed by formalin fixation and paraffin embedment, sectioning and hematoxilin and eosin visualization of cells. PDL1 mRNA and protein levels were measured by RT-PCR and western blots. Results: Cell viability of NSCLC EVOC is maintained over a time window of at least 4-7 days. Cytotoxic drugs evoke cell death. PDL1 mRNA and protein levels are elevated in NSCLC EVOC in response to inflammation signals as Interferon gamma. Glucocorticoid steroidal drugs causes reduction in PDL1 mRNA and protein in NSCLC EVOC. Cisplatin treatment causes elevation in PDL1 protein. Variability in basal and induced PDL1 protein levels was detected in response to inflammation signals in EVOCs generated from different patients. Conclusions: Our results indicate the feasibility of EVOC for NSCLC and the potential to use it as a model to study the impact of immunotherapy agents, alone or in combination with other therapeutic tools such as chemotherapy or radiotherapy.

Citation Format: Jair Bar, Inbal Daniel-Meshulam, Amir Onn, Alon Ben-Nun, David Simansky, Nona Zeitlin, Nir Golan, Meirav Rokah, Ronni Ben-Avi, Iris Kamer. Modeling immunotherapy in ex vivo organ culture of non-small cell lung cancer (NSCLC). [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 4910.

Tracheostomy after cardiac surgery: timing of tracheostomy as a risk factor for mortality

OBJECTIVES

The optimal timing for tracheostomy after cardiac surgery in patients undergoing prolonged ventilation is controversial. The aim of this study was to assess the effect of tracheostomy timing on short- and long-term mortality of these patients.

DESIGN

Retrospective study of prospectively collected data.

SETTING

Cardiac surgical intensive care unit (ICU) in a tertiary-care, university-affiliated hospital.

PARTICIPANTS

All patients undergoing tracheostomy after cardiac surgery between September 2004 and March 2013 were included.

INTERVENTIONS

The authors compared the outcome in 2 groups of patients according to the timing of tracheostomy: Group I, early-intermediate tracheostomy (0-14 days) and Group II, late tracheostomy (≥15 days).

MEASUREMENTS AND MAIN RESULTS

During the study period, 6,069 patients underwent cardiac surgery; among them, 199 patients (3.26%) received a tracheostomy. There were 90 patients in Group I and 109 patients in Group II. There was no significant difference in the severity of the patients' illness between the groups. The mortality rate at 3 months, 6 months, 1 year, and 2 years was 37%, 48%, 56%, and 58% in Group I, respectively, and 58%, 70%, 74%, and 77% in Group II, respectively (p< 0.01).

CONCLUSIONS

Early-intermediate (0-14 days) tracheostomy after cardiac surgery in patients requiring prolonged mechanical ventilation was associated with reduced mortality compared with late tracheostomy (≥15 days).

Genetic mutation screen in early non--small-cell lung cancer (NSCLC) specimens

BACKGROUND

Testing for genetic abnormalities in epithelial growth factor receptor (EGFR), anaplastic lymphoma receptor tyrosine kinase (ALK), and potentially additional genes is a critical tool in the care of advanced NSCLC. There is conflicting evidence for the role of such tests in early NSCLC. We report a single-institute Sequenom testing for a wide range of mutations and their clinical correlations in early-resected NSCLC specimens.

MATERIALS AND METHODS

Early NSCLC paraffin-embedded, formalin-fixed (FFPE) specimens were collected, DNA extracted, and using Sequenom-based matrix-assisted laser desorption/ionization-time of flight analysis, mutations in 22 oncogenes and tumor suppressor genes were evaluated. Clinical data was collected retrospectively.

RESULTS

The technique was found to be feasible. Thirty-six of 96 patients (37.5%) had any genetic abnormality identified, and 8 (8.3%) had 2 or more mutations. Kirsten rat sarcoma viral oncogene homolog (KRAS) and EGFR were the most common genes to appear mutated (15.6%); phosphatidylinositol-4,5-bisphosphate 3-kinase, catalytic subunit alpha (PIK3CA) was the gene to be found most commonly in tumors with co-mutations. Transversions were found mostly in KRAS gene mutations and to be nonprognostic. No difference in the spectrum of mutations was found between squamous-cell and non-squamous-cell lung cancers. Ever-smokers showed a trend for worse prognosis, with a similar spectrum of mutations.

CONCLUSION

Sequenom-based mutation screen is feasible using FFPE samples. More than a third of the patients were found to harbor some genetic abnormality, and 8% were found to have more than a single mutated gene. Wide-range gene screens using large sample depositories are required for further insight into the important genes at play in early NSCLC.

Fluorodeoxyglucose--positive internal mammary lymph node in breast cancer patients with silicone implants: is it always metastatic cancer?

OBJECTIVES

Patients with breast cancer following mastectomy and silicone implant reconstruction may have enlarged internal mammary lymph nodes with pathological uptake on positron emission tomography with (18)F-fluorodeoxyglucose. This lymphadenopathy is usually considered as metastatic in nature, but has also been reported to be related to other conditions, including silicon migration. The purpose of this study was to determine the rate of metastatic disease in this unique group of patients.

METHODS

A retrospective comparative study of 12 female patients with breast cancer with silicone implants referred for biopsy due to isolated internal mammary lymph node fluorodeoxyglucose uptake on positron emission tomography.

RESULTS

Five patients (41.6%) had histological findings related to silicone (n = 4) or non-specific inflammation (n = 1). The remaining 7 (58.3%) had histological evidence of cancer recurrence. There was no significant difference in the fluorodeoxyglucose-standardized uptake value between the two groups.

CONCLUSIONS

Fluorodeoxyglucose-positive mammary lymph nodes in patients with breast cancer following silicone implant reconstruction may be due to metastatic deposits, non-specific inflammation or silicone migration. Clinical and imaging characteristics are insufficient in differentiating between these conditions. Biopsy is recommended prior to initiation of further treatment.

Abstract 5301: Blood vessel structure and expression of permeability related factors in advanced lung cancer complicated with pleural effusion

Background. Malignant pleural effusion (MPE) is a common and debilitating condition in patients with lung cancer. For unknown reasons, some tumors are more strongly associated with the condition than others. The pathophysiology of this condition has not been fully determined and to date no specific medical treatment is available. Our goal was to study the structure and assess the permeability related factors in MPE associated blood vessels to better understand the mechanisms of this condition. Methods. Immunohistochemical analysis of human NSCLC formalin-fixed paraffin-embedded specimens from patients who underwent lobectomy (MPE- cases) or pleural biopsy (MPE+ cases) was employed. Nine adenocarcinomas (AC) and eight squamous cell carcinomas (SCC) with and without MPE were studied. For endothelial cell (EC) staining and microvessel density (MVD) determination, the anti-CD31 Abs was employed. Pericytes were stained by aSMA Abs. Coexpression of some of receptor tyrosine kinases (PDGFR, VEGF/VEGFR, Tie-2) was also evaluated. Results. In SCC complicated with MPE a narrow, clogged and fibrotic vessels were seen in tumors located near the pleura (pleura involved). In MPE positive AC specimens there were regions of tumor vessels where ECs were irregularly laminated and hardly noticed. This observation was also confirmed by CD31 staining where lower number of positive vessels related to the total number of vessels was observed (88.4% in MPE+ vs. 94.8% in MPE- cases, p&lt;0.05). Regarding the vessel coverage by pericytes, the pericyte expression (aSMA staining) was shown to be less extensive in cases with than without effusion (59.1% vs 96.2%, p&lt;0.001) probably because of their thinning or even detachment. This clarification could also explain the finding that the PDGFR was more expressed on ECs on MPE - tumors than on MPE + ones. For VEGF and VEGFR staining, the staining index was more prominent in tumors with than without effusion, for both staining area and staining intensity (1.7 and 1.9, respectively). However, in distinction to the staining of tumor cells almost no vessel EC staining by VEGFR Abs was seen, while staining by anti-VEGF Abs was substantial. Similarly, the staining of Ang-2 receptor (Tie-2) was found in the cytoplasm of the tumor cells, but not in the vascular endothelium, regardless the pleura effusion positive or negative features. Conclusions. To our knowledge this is one of the first studies on structural abnormalities of blood vessels in human lung cancer malignant pleural effusion. For now, because of the relatively small number of cases analyzed no single mechanism was found able to explain the occurrence of a pleural effusion, and it is likely that multiple factors contribute to effusion formation. This formulation may also better explain why some patients with pleural metastases have malignant effusions while others do not.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 5301. doi:1538-7445.AM2012-5301

Chromosomal aberrations and gene expression profiles in non-small cell lung cancer

Alterations in genomic content and changes in gene expression levels are central characteristics of tumors and pivotal to the tumorigenic process. We analyzed 23 non-small cell lung cancer (NSCLC) tumors by array comparative genomic hybridization (array CGH). Aberrant regions identified included well-characterized chromosomal aberrations such as amplifications of 3q and 8q and deletions of 3p21.31. Less frequently identified aberrations such as amplifications of 7q22.3-31.31 and 12p11.23-13.2, and previously unidentified aberrations such as deletion of 11q12.3-13.3 were also detected. To enhance our ability to identify key acting genes residing in these regions, we combined array CGH results with gene expression profiling performed on the same tumor samples. We identified a set of genes with concordant changes in DNA copy number and expression levels, i.e. overexpressed genes located in amplified regions and underexpressed genes located in deleted regions. This set included members of the Wnt/beta-catenin pathway, genes involved in DNA replication, and matrix metalloproteases (MMPs). Functional enrichment analysis of the genes both overexpressed and amplified revealed a significant enrichment for DNA replication and repair, and extracellular matrix component gene ontology annotations. We verified the changes in expressions of MCM2, MCM6, RUVBL1, MMP1, MMP12 by real-time quantitative PCR. Our results provide a high resolution map of copy number changes in non-small cell lung cancer. The joint analysis of array CGH and gene expression analysis highlights genes with concordant changes in expression and copy number that may be critical to lung cancer development and progression.

Mediastinal dissection in head and neck cancer

The superior mediastinum contains a considerable number of lymph nodes. Although occasionally involved in head and neck cancer, there are not many reports of mediastinal dissection in the practice of head and neck surgery. We present a group of seven patients with head and neck tumours that underwent mediastinal dissection in our department. Three patients are alive and free of disease six months to three years after the operation, two are alive with disease four and five years after the procedure, and two patients died peri-operatively. According to reviewed current literature, direct invasion of cancer of the head and neck to the mediastinum or mediastinal lymph node involvement is uncommon. Yet, mediastinal dissection provides the only chance for cure in selected cases.

Cryptogenic organizing pneumonia: variety of radiologic findings

BACKGROUND

Cryptogenic organizing pneumonia is increasingly being recognized as a major cause of diffuse infiltrative lung disease. The differential diagnosis of non-infectious diseases that resemble pneumonia should include this entity. Understanding the radiologic features of this entity will help in defining the correct diagnosis, although lung biopsy is needed to provide histopathologic confirmation. Treatment with steroids achieves an excellent response.

OBJECTIVES

To present a variety of radiologic findings on high resolution computerized tomography in eight sequential patients with COP, together with clinical and pathologic correlation.

METHODS

Sequential HRCT examinations of eight patients (four males) aged 53-80 years (mean 65.5 years) with pathologcally proven COP were retrospectively analyzed by a consensus of two experienced chest radiologists for the existence and distribution of airspace consolidation, ground-glass opacities, nodular thickening along bronchovascular bundles and small (<1 cm) and large (>1 cm) nodules. The distribution of radiologic findings was classified as unilateral or bilateral, located in the upper, lower or middle lobe, and central or peripheral. Also recorded was the presence or absence of mediastinal lymphadenopathy and pleural effusion. Correlation with clinical symptoms was analyzed.

RESULTS

All eight patients had bilateral airspace consolidations. in two cases consolidations were limited to central fields, in four they were peripheral, and in the remaining two cases they were both central and peripheral. Small nodules were noted in six cases and large nodules in three. Ground-glass opacities were found ln four cases. All patients had enlarged lymph nodes (1-1.5 cm) in the mediastinum. Radiologic abnormalities resolved or improved after steroid treatment in all patients.

CONCLUSIONS

HRCT findings of bilateral multiple heterogenic lung infiltrates and nodules associated with mild mediastinal lymphadenopathy in a patient with non-specific clinical symptoms are suggestive of COP; in such cases lung biopsy is indicated. Radiologic resolution of abnormalities correlates well with clinical improvement under adequate steroid treatment.

Major Bronchial Trauma in the Pediatric Age Group

Tracheobronchial injuries are rare among all age groups and are extremely rare among the pediatric age group. Yet, the incidence has seemed to increase. Most of these patients die before reaching the hospital from severe associated injuries. Isolated bronchial injury is even more rare than tracheal injury, and it is the focus of the present study. A retrospective national survey was conducted among all tertiary referral and trauma centers in Israel regarding the period between the years 1983 and 1998. Only six cases (3 males and 3 females) of isolated bronchial rupture were found the throughout the country. Ages of the patients ranged from 2 to 14 years; all were involved in motor vehicle accidents, four of them as pedestrians. Ruptures occurred in the bronchus intermedicus (2 cases), left and right main bronchus (2 cases each). All but one patient went through primary repair. We give a full description of the procedure and discuss the literature regarding incidence, diagnosis, treatment, and outcome.

Major bleeding complicating deep sternal infection after cardiac surgery

OBJECTIVES

This study was undertaken to determine the incidence and outcome of major bleeding complicating deep sternal infection after cardiac surgery, to identify predisposing factors and means of prevention, and to clarify management options.

METHODS

This was a retrospective study of 10,863 consecutive patients, of whom 213 (2.18%) acquired deep sternal infection. With 43 additional referrals, the total number of patients with deep sternal infection was 280. Deep sternal infection was managed by a two-stage scheme. Major bleeding was considered to be bleeding that occurred during or after operation for deep sternal infection from the heart, great vessels, or grafts, or bleeding requiring urgent exploration.

RESULTS

Fifteen patients (5.36%) had major bleeding. The incidences of deep sternal infection and bleeding were highest among patients undergoing coronary artery bypass grafting. Thirteen patients had underlying diseases (type 2 diabetes in 9 cases). Deep sternal infection was diagnosed a median of 15 days after reoperation. Bleeding originated from the right ventricle in 9 patients. In 4 patients bleeding was iatrogenic during surgery for wire removal (n = 2) or reconstruction (n = 2). In 11 it occurred 15 minutes to 15 days (median 2 days) after wire removal, as a result of shearing forces in 7 cases and of infection only in 4 cases. Three patients died immediately. The other 12 were operated on, 6 with complete cardiopulmonary bypass, 2 with femoral cannulation, and 4 without cardiopulmonary bypass. The immediate mortality was 26.7%; the overall mortality was 53.3%. The median length of hospitalization of surviving patients was 38 days.

CONCLUSIONS

The probability of development of major bleeding in patients with deep sternal infection was unrelated to the primary operation. The mortality associated with this complication was high. Meticulous technique during wire removal may decrease the risk of major bleeding. The impacts of cardiopulmonary bypass and of the technique and timing of sternal reconstruction remain undetermined.

[Surgery and hyperthermic pleural perfusion--a new approach for malignancies with pleural involvement]

BACKGROUND

Malignant neoplasms involving the pleura have a poor prognosis. In some cases the main symptoms and the cause of death are due to local spread, whereas metastases, if at all, develop late. The preferred treatment of these tumors is not clear.

GOALS

To evaluate whether regional therapy that includes resection, local chemotherapy and hyperthermia is feasible, safe and effective for tumors with pleural spread.

MATERIAL & METHODS

Forty-three patients undergoing surgery and hyperthermic pleural perfusion were studied retrospectively. The majority had mesothelioma, or thymic malignancies with pleural spread. Twenty-five patients received previous treatment. The extent of resection was dictated by tumor type and patients condition. Perfusion was performed with a roller pump and heat exchanger plus cisplatinum in a dose of 60-200 mg.

RESULTS

Intrapleural temperature exceeded 40 degrees C in all patients. There were no hemodynamic, or respiratory problems related to perfusion. There was neither intraoperative mortality nor hematologic, renal or systemic toxicity. Three patients died (7% mortality) and 14 had complications. The overall 1, 2, 3, and 5-year survival rates ware 78%, 72%, 50% and 36% respectively. The best survival was for thymoma patients--70% after 3 and 5 years, and the worst for metastatic tumors--31% 3-year survival. Among 39 patients followed-up for more than 1 year (24 alive, 15 dead), 28 (72%) were free of ipsilateral pleuro-pulmonary recurrence.

CONCLUSIONS

Surgery and hyperthermic pleural perfusion is feasible and relatively safe. This method offers a good chance of complete midterm local eradication of neoplasms with pleural spread. A survival benefit over other modalities is suggested in patients with thymoma. Other drugs, alone or in combinations, should be studied.

[Video-assisted thoracoscopic lobectomy--preliminary experience]

BACKGROUND

Video-assisted thoracoscopic surgery has become routine worldwide. On the basis of accumulating experience and technologic improvements, more complex operations can be performed. Until recently, thoracoscopic lobectomy has not been performed in Israel.

GOALS

To describe the initial experience with thoracoscopic lobectomy in Sheba Medical Center, and discuss the advantages, disadvantages and indications for its use.

MATERIAL & METHODS

From June 2000 to January 2001, five patients (3 male, 2 female) 22-72 year-old underwent thoracoscopic lobectomy. Four had malignant neoplasms (3 lung primary) and one a benign process. Preparations for surgery, anesthesia and monitoring were standard as for open lobectomy. Surgery was done through 3 ports and a 5-7 cm auxiliary thoracotomy. The majority of the operation was performed with staplers. In patients with lung tumors the regional lymph nodes were sampled. Pulmonary function tests were evaluated prior to surgery and in the immediate postoperative period.

RESULTS

Lobectomy was completed in all patients according to preoperative planning without conversion to open thoracotomy. Operative time was 120-160 minutes. Blood transfusion was not required in any patient during or after the lobectomy. There was no operative mortality and only two minor complications in one patient. Narcotic requirement did not exceed 40 mg of morphine in any patient. Pulmonary function tests revealed a smaller than expected decrease compared to open thoracotomy. The cosmetic results were excellent.

CONCLUSIONS

Thoracoscopic lobectomy is feasible in Israel too. It is an acceptable alternative for patients needing this operation. Thoracoscopic lobectomy causes less surgical trauma, better functional result and expectance for lowered mortality and morbidity. Its main disadvantage is its high cost.

Main bronchial rupture from blunt trauma in a 2-year-old child

The authors report on a 2 year old who sustained a bronchial rupture after a motor vehicle accident and was operated on soon after admission. This injury is very unusual in young children.