A multicenter phase II study of cetuximab in combination with chest radiotherapy and consolidation chemotherapy in patients with stage III non-small cell lung cancer

BACKGROUND

Cetuximab has demonstrated improved efficacy in combination with chemotherapy and radiotherapy. We evaluated the integration of cetuximab in the combined modality treatment of stage III non-small cell lung cancer (NSCLC).

METHODS

Patients with surgically unresectable stage IIIA or IIIB NSCLC were treated with chest radiotherapy, 73.5 Gy (with lung and tissue heterogeneity corrections) in 35 fractions/7 weeks, once daily (63 Gy without heterogeneity corrections). Cetuximab was given weekly during radiotherapy and continued during consolidation therapy with carboplatin and paclitaxel up to a maximum of 26 weekly doses. The primary endpoint was overall survival. Baseline tumor tissue was analyzed for EGFR by fluorescence in situ hybridization (FISH).

RESULTS

Forty patients were enrolled in this phase II study. The median overall survival was 19.4 months and the median progression-free survival 9.3 months. The best overall response rate in 31 evaluable patients was 67%. No grade 3 or 4 esophagitis was observed. Three patients experienced grade 3 rash; 16 patients (69%) developed grade 3/4 neutropenia during consolidation therapy. One patient died of pneumonitis, possibly related to cetuximab. EGFR gene copy number on baseline tumor tissues, analyzed by FISH, was not predictive of efficacy outcomes.

CONCLUSIONS

The addition of cetuximab to chest radiotherapy and consolidation chemotherapy was tolerated well and had modest efficacy in stage III NSCLC. Taken together with the lower incidence of esophagitis, our results support evaluation of targeted agents instead of chemotherapy with concurrent radiotherapy in this setting.

Lung T-cell subset composition at the time of surgical resection is a prognostic indicator in non-small cell lung cancer

NSCLC arises in the complex environment of chronic inflammation. Depending on lung immune polarization, infiltrating immune cells may either promote or suppress tumor growth. Despite the importance of the immune microenvironment, current staging techniques for NSCLC do not take into consideration the immune milieu in which the neoplasms arise. T-cell subset content was compared between paired tumor-bearing and contralateral lungs, patient and control peripheral blood. The relationship between T-cell subset distribution and survival were evaluated. CD4 and CD8+ T cells were subsetted by CD45RA/CD27 and analyzed for expression of activation, adhesion, and homing markers. Strikingly, T-cell content was indistinguishable between lungs. Compared with peripheral blood, naïve CD4 and CD8 T cells were rare in BAL. CD4+ BAL T cells showed increased CD95 (higher apoptotic potential) and CD103 expression (epithelial adhesion), but decreased CD38 (activation) and CCR7 expression (lymph node homing). CD8+ BAL T cells showed increased CD103 expression and decreased CD28 expression (co-stimulation). Differences in CD28, CD95, and CCR7 expression were more pronounced within memory cells, while differences in CD4+ CD103 expression were more prominent in effector/memory cells. Of these populations, the absence of lung CD4 T cells with an effector-like phenotype (CD45RA+/CD27-) emerged as a predictor of favorable outcome. Patients with a low proportion (≤0.44%) had 90% 5-year survival (n = 10, median survival 2,343 days), compared with 0% (n = 9, median survival 516 days) of patients with a higher proportion. Further study is required to confirm this association prospectively and define the function of this subpopulation.

Endoluminal management of bronchogenic carcinoma in 2010: diagnosis, staging, and therapy

Endoluminal bronchogenic carcinoma, though a minority of lung cancer cases, presents a unique opportunity to utilize techniques for the diagnosis and therapy that are unavailable for more peripheral tumors. This review explores current techniques for the diagnosis, staging, and therapy of endoluminal central bronchogenic tumors and also introduces techniques currently under investigation as potential improvements or replacements for current techniques using recent literature. Additionally, the new staging criteria set forth in the 7th edition of the TMN staging system as a result of the American Joint Committee on Cancer (AJCC), International Union Against Cancer (IUCC), and the International Association for the Study of Lung Cancer (IASLC) are discussed with respect to endoluminal bronchogenic carcinoma.

Prognostic significance of CD44 expression in adenocarcinoma of the lung

Aims-To determine whether expression of CD44 in neoplasia is associated with tumour grade, stage and prognosis.Methods-The immunohistochemical expression of CD44 was evaluated using the mouse antihuman monoclonal antibody 3G12 which recognises regions shared by all CD44 isoforms to determine whether expression in formalin fixed, paraffin wax embedded tissue correlates with tumour grade, stage or survival in adenocarcinoma of the lung. Thirty one adenocarcinomas of the lung, 16 T2N0 and 15 T2N1, and their nodal metastases were studied.Results-Of the 31 tumours, 25 were positive for the CD44 antigen. CD44 expression correlated with tumour grade, in that intense staining was seen only in moderately and/or poorly differentiated tumours. CD44 did not correlate with nodal status, tumour size, pleural invasion, angiolymphatic invasion, or host inflammatory response, but did correlate with survival. A median survival of 46 months was observed in patients with moderate to strong CD44 expression compared with 24 months for those with no or weak expression. Nine patients were alive without evidence of disease at a median follow up of 61 months. Six (66%) of these nine patients had strong CD44 expression. This contrasts with strong expression in only three (17%) of the 17 patients dying with a median survival of 28 months.Conclusion-In primary adenocarcinoma of the lung loss of CD44 expression is associated with less favorable outcome and may indicate a more aggressive neoplasm. CD44 may be a useful prognostic marker in lung carcinoma.

Metastasectomy for melanoma in the VATS era

e20001

Background: The role for metastasectomy in the setting of metastatic melanoma remains ill-defined. The aim of this study is to evaluate resection of limited metastases in the setting of melanoma comparing VATS and open approaches, specifically looking at perioperative morbidity and survival. Methods: All patients undergoing metastasectomy for melanoma with curative intent between January 1, 2001 and September 30, 2007 were included. Data was collected retrospectively from the UPMC tumor registry and chart review. Differences between groups were compared with the student's t-test. Results: Of 43 patients undergoing metastasectomy for melanoma, 31 patients were resected with intent to cure (16 VATS, 15 open). Complications were similar between the VATS (12%) and open (13%) groups. There were no perioperative deaths in either group. The median survival in the VATS group was 20.7 months, compared to 26.5 months in the open group (p = 0.17). Importantly, the VATS patients more frequently underwent resection of smaller, peripheral lesions via wedge resection (81%) and only 2 patients (13%) underwent lobectomy. Conversely, patients undergoing open procedures were more likely to have larger, more central lesions and undergo anatomic resections. There were 9 (60%) lobectomies, 3 (20%) segmentectomies 1 (7%) en bloc resection and only 2 (13%) wedge resections in the open group. Conclusions: Metastasectomy for metastatic melanoma in the thoracic cavity can be performed safely by a VATS or open approach. The two approaches have comparable morbidity, mortality and survival outcomes. Careful patient resection remains the hallmark of care in identifying appropriate candidates for metastasectomy. In the setting of patients with short life-expectancy, it may be advantageous to employ a VATS approach when possible to preserve quality of life while achieving similar oncologic outcomes to open procedures. Individuals with a radiographic indication of limited peripheral disease should be considered for a VATS approach to resection of melanoma metastases.

No significant financial relationships to disclose.

The impact of length of hospitalization following surgical resection of stage I non-small cell lung cancer on long-term survival

7584

Background: The aim of this study was to evaluate the impact of length of hospital stay (LOS) following surgical resection of stage I non-small cell lung cancer (NSCLC) on long-term survival. Methods: We reviewed the records of patients undergoing surgical resection for stage I NSCLC at our institution between 1990–2003. Patients not surviving hospitalization related to their surgery were excluded from analysis. Multivariate analysis was utilized to evaluate the impact of age, gender, tumor histology, tumor stage, LOS, and type of operation (lobar or sublobar) on long-term (>5 year) survival. As a secondary analysis, Kaplan-Meier survival curves of patients stratified according to LOS were compared using the log-rank test. Two-tailed p-values less than 0.05 were considered statistically significant. Results: A total of 730 patients underwent lobectomy (n=518) or sublobar resection during the study time period. There were 18 (2.5%) operative or in-hospital mortalities. Median LOS was 6 (range 1–81) and 7 (range 1–46) days in the lobar and sublobar cohorts, respectively. Patients with a longer hospital stay (≥14 days) had significantly worse 5- and 10-year overall survival rates as compared to those with a shorter hospitalization (lobectomy: 5-year- 60.3% vs 33.8%; 10-year-27.3% vs 8.4%; p<0.001; sublobar: 5-year-44.3% vs 11.7%; 10-year-9.9% vs 0%; p=0.006). There were 171 patients with extended clinical follow-up who had survived at least 5 years (mean follow-up = 88.1 ± 2.0 months). Multivariate analysis demonstrated that LOS predicted long-term survival independent of patient age, gender, tumor histology, tumor stage, and type of operation (p=0.013). Conclusions: LOS following surgical resection of stage I NSCLC is an independent predictor of long-term survival. These survival differences related to hospital stay may be related to underlying medical co-morbidities important to the decision making regarding therapy of patients with otherwise resectable stage I lung cancer. Prospective assessment of medical co-morbidities may be an important initiative for future treatment planning of early stage lung cancer patients.

No significant financial relationships to disclose.

Clinical impact of age on outcomes following anatomic lung resection for stage I non-small cell lung cancer

7515

Background: There is an increasing body of evidence that anatomic segmentectomy may represent an equivalent approach compared to lobectomy in the management of stage I NSCLC. Comorbidities associated with age may result in improved survival with sublobar resection for stage I cancer in the elderly. We report our single institution experience with segmentectomy vs. lobectomy for stage I non-small cell lung cancer stratified by age. Methods: A total of 232 consecutive anatomic segmentectomies were performed for stage IA (n=137) or IB (n=95) NSCLC from 2002–2007. Lobectomy was performed in 594 patients for stage IA (n=297) and IB (n=295) during the same period. Results of segmental resection were compared with lobectomy, stratified by the following age groups: <60, 60–69, 70–79 and = 80. Primary outcome variables included complications, mortality, recurrence patterns, and survival. Statistical analysis included t-test and Fisher's exact test. Results: Mean age (69.9 vs. 68.2), gender distribution and tumor histology were similar between the segmentectomy and lobectomy groups. There was no significant difference in complications, mortality, recurrence, and overall survival in the younger age groups (Table). Segmentectomy was associated with reduced mortality (7.8% vs. 2.8%) and improved overall 3-year survival (p=0.02) in patients >80 years old. Conclusions: Anatomic segmentectomy can be performed with similar morbidity, mortality, recurrence, and survival compared to lobectomy in stage I lung cancer. This approach may be particularly advantageous in the elderly age group, achieving comparable oncologic outcomes with less mortality and improved overall survival.

[Table: see text]

No significant financial relationships to disclose.

An increased proportion of inflammatory cells express tumor necrosis factor alpha in idiopathic achalasia of the esophagus

Achalasia is a motility disorder characterized by the absence of coordinated peristalsis and incomplete relaxation of the lower esophageal sphincter. The etiology remains unclear although dense inflammatory infiltrates within the myenteric plexus have been described. The nature of these infiltrating cells is unknown. The aim of this study was to evaluate the expression of proinflammatory cytokines - namely, tumor necrosis factor alpha and interleukin-2 - in the distal esophageal muscle in patients with achalasia. Lower esophageal sphincter muscle from eight patients undergoing myotomy or esophagectomy for achalasia of the esophagus were obtained at the time of surgery. Control specimens consisted of similar muscle taken from eight patients undergoing operation for cancer or Barrett's esophagus. The expression of tumor necrosis factor alpha and interleukin-2 were assessed by immunohistochemistry. The total number of inflammatory cells within the myenteric plexus were counted in five high power fields. The percentage of infiltrating cells expressing tumor necrosis factor alpha or interleukin-2 was calculated. Clinical data including demographics, preoperative lower esophageal sphincter pressure, duration of symptoms, and dysphagia score (1 = no dysphagia to 5 = dysphagia to saliva) were obtained through electronic medical records. Statistical comparisons between the groups were made using the unpaired t-test, Fisher's exact test, or Mann-Whitney U test, with a two-tailed P-value less than 0.05 being considered significant. The total number of inflammatory cells was found to be similar between the groups. A significantly higher proportion of inflammatory cells expressed tumor necrosis factor alpha in achalasia as compared with controls (22 vs. 11%; P= 0.02). A similar percentage of infiltrating cells expressed interleukin-2 (40 vs. 41%; P= 0.87). Age, gender, preoperative lower esophageal sphincter pressure, or dysphagia score were not correlated to expression of these cytokines. There was, however, a significant inverse correlation between duration of symptoms and the proportion of inflammatory cells expressing tumor necrosis factor alpha in achalasia (P= 0.007). In conclusion, a higher proportion of infiltrating inflammatory cells expressed tumor necrosis factor alpha in achalasia. Furthermore, this proportion appears to be highest early in the disease process. Further studies are required to more clearly delineate the role of tumor necrosis factor alpha in the pathogenesis of this idiopathic disease.

Number of lymph nodes harvested from a mediastinal lymphadenectomy: Results of the randomized, prospective ACOSOG Z0030 trial

7555

Background: Lymph node status is a major determinant of stage and survival in patients with lung cancer; however, little information is available about the yield of a mediastinal lymphadenectomy done at the time of pulmonary resection. Methods: The ACOSOG Z0030 trial is a prospective, randomized trial of mediastinal lymph node sampling versus complete mediastinal lymphadenectomy during an operation for early stage lung cancer. Total enrollment from July 1999 to February 2004 was 1,111 patients, of which 1,023 were eligible and/or evaluable. There were 524 patients who underwent complete mediastinal lymph node resection after randomization to this arm that were declared eligible and/or evaluable with lymph node data available. The number of lymph nodes examined from each station was collected beginning in January 2002. Prospectively collected data from these patients was analyzed to determine the number of lymph nodes obtained. Results: Median age was 67 (range 37–87) and 267 (52%) were men. Histology was squamous cell in 141 (27%), adenocarcinoma in 227 (44%), large cell in 22 (4%), bronchoavelolar in 32 (6%) and other non-small cell in 99 (19%). There were 317 right sided cancers and 207 left sided cancers. For lymphadenectomy for cancers in the right lung the yield from station 2R was a median of 2 lymph nodes (range 1 to 15), station 4R was 2 (1 –17), station 7 was 2 (1–24), station 8 was 1 (1–5), station 9 was 1 (1–6) and station 10R was 1 (1–10). For lymphadenectomy for cancers on the left side the yield from station 2L was 2 (1–4), station 4L was 1 (1–12), station 5 was 2 (1–18), station 6 was 2 (1–11), station 7 was 2 (1–16), station 8 was 1 (1–3), station 9 was 1 (1–8) and 10L was 2 (1–12). The total number of lymph nodes or fragments obtained for right sided cancers was a median of 13.5 (range 1 to 56) and for left sided tumors 15 (range 4 to 81). Conclusions: Although high variability exists in the actual number of lymph nodes obtained from various nodal stations, a complete mediastinal lymphadenectomy should obtain one or more lymph nodes from each mediastinal station. Adequate mediastinal lymphadenectomy should include exploration and remove of lymph nodes from stations 2R, 4R, 7, 8, and 9 for right sided cancers and stations 4L, 5, 6, 7, 8 and 9 for left sided cancers.

No significant financial relationships to disclose.

Anatomic segmentectomy for stage I non-small cell lung cancer: Comparison of outcomes with the VATS versus open approach

7616

Background: Anatomic segmentectomy for early-stage NSCLC has been proposed as a means of achieving a complete resection in high-risk patients with poor lung function, who might not otherwise tolerate conventional lobectomy. Historically, anatomic segmentectomy has been associated with increased recurrence rates and postoperative air leaks. In the current study, we present our experience with VATS versus open segmentectomy for stage I NSCLC. Methods: A total of 181 consecutive anatomic segmentectomies (114 Open, 67 VATS) were performed for Stage IA (n=110) or IB (n=71) NSCLC from 2002–2006. A VATS approach was employed in 67 patients, and an open approach in 114 patients. Outcome variables include hospital course, complications, mortality, recurrence patterns and survival. Results: The mean age was 70 years (range: 45–100). Average tumor size was 2.3 cm (2.0 cm VATS; 2.4 cm open, NS). Lymph node sampling or dissection was performed in 169 (93%) of patients with an average node harvest of 8.2 nodes (Open = 9.2; VATS = 6.2, p=0.006). There were two perioperative deaths (1.1%), both open. Complications occurred in 59 patients (33%). Median length of stay was 6 days (VATS=5, Open=7). Mean follow-up was 15.6 months. There were fewer major (7 vs. 31, p=0.005) and infectious (3 vs. 12%, p=0.026) complications in the VATS group, with no significant difference in pulmonary complications or air leaks. Twenty-nine recurrences (16%; VATS=7, Open=22) occurred at a mean of 12.7 months [11 locoregional (6%), 18 distant (10%)]. Overall mortality, complications, recurrence and two-year actuarial survival (78%) were similar between VATS and open segmentectomy. Conclusions: VATS segmentectomy can be performed safely with acceptable morbidity, mortality, recurrence and survival. The VATS approach affords a shorter length of stay and fewer postoperative complications (major and infectious) compared with open techniques. The potential benefits of segmentectomy will need to be further validated by prospective, randomized trials (ACOSOG Z4032). Sublobar resection techniques represent an important adjunct in treating compromised patients with early stage NSCLC.

No significant financial relationships to disclose.

A pilot study of botulinum toxin injection for the treatment of delayed gastric emptying following esophagectomy

OBJECTIVE

Esophagectomy may lead to impairment in gastric emptying, unless a pyloroplasty or pyloromyotomy is performed. These procedures may be technically challenging during minimally invasive esophagectomy, and they are associated with a small but definable morbidity, such as leakage and dumping syndrome. We sought to determine the results of our early experience with injecting the pylorus with botulinum toxin instead of conventional pyloric drainage.

METHODS

Fifteen patients who had undergone esophagectomy and injection of the pylorus with botulinum toxin were identified. Twelve patients had undergone botulinum toxin injection at the time of minimally invasive esophagectomy, and the remaining three had been treated endoscopically after surgery. The latter three patients had undergone esophagectomy with either no pyloric drainage (n = 2) or an inadequate pyloromyotomy (n = 1), and they presented in the postoperative period with delayed gastric emptying. The adequacy of emptying after injection was assessed by the patients' ability to tolerate a regular diet, a barium swallow, and a nuclear gastric emptying study.

RESULTS

No patient injected with botulinum toxin during esophagectomy developed delayed gastric emptying or aspiration pneumonia in the perioperative period. Eight of these patients underwent a nuclear emptying scan at a median of 4.2 months after surgery, which showed a mean emptying half-life of 100 min. With a median follow-up of 5.3 months, one patient (8%) required reintervention for symptoms of gastric stasis, presumably after the effect of the toxin subsided. All three patients injected postoperatively demonstrated an improvement in symptoms of gastric outlet obstruction and were able to resume a regular diet.

CONCLUSIONS

Injection of the pylorus with botulinum toxin can be performed safely in patients undergoing esophagectomy. Longer-term studies are needed to clarify the efficacy and durability of this technique compared to the accepted procedures of pyloromyotomy or pyloroplasty.

Tumorigenic epithelial stem cells and their normal counterparts

ABC transporters are highly conserved and represent a major protective mechanism for barrier tissues as well as adult tissue stem cells. Emerging data support the existence of a cancer stem cell that shares features of tissue stem cells, including the ability to self-renew and undergo dysregulated differentiation. Here we show that a rare population of cells coexpressing MDR transporters and stem cell markers is a common feature across therapy-naive epithelial cancers as well as normal epithelial tissue. MDR+ and MDR- candidate tumor stem and progenitor populations were all capable of generating highly anaplastic transplantable human tumors in NOD/SCID. The finding that rare cells bearing stem cell markers and having intrinsic MDR expression and activity are already present within the tumorigenic compartment before treatment with cytotoxic agents is of critical importance to cancer therapy. Just as damaged normal epithelial tissues regenerate after chemotherapy by virtue of highly protected resting tissue stem cells, the existence of malignant counterparts in therapy-naive epithelial cancers suggests a common mechanism by which normal and tumor stem cells protect themselves against toxic injury.

Bronchoscopic palliation of primary lung cancer: Single or multimodality therapy?

BACKGROUND

An obstructing primary lung cancer is a challenging disease frequently requiring endobronchial interventional therapy. A variety of interventional modalities, including Nd:YAG laser, stenting, photodynamic therapy (PDT), and endoluminal brachytherapy, are utilized to relieve airway obstruction and bleeding. The aim of this study is to compare the effect on patient survival of bronchoscopic palliation for lung cancer utilizing one interventional modality compared to the use of combination of modalities to relieve the airway problem. METHODS. We reviewed our longitudinal experience with interventional bronchoscopy in 75 patients who underwent 176 procedures for the management of endobronchial lung cancer between 1994 and 2002. Indication for intervention was hemoptysis in 24 patients (32%) and airway obstruction in the remaining. Six patients died within 30 days from the first intervention and were excluded. Forty of the surviving 69 patients (58%) were treated with a single interventional modality (group A). In 29 patients (42%) a multimodality endoscopic treatment was utilized (group B). Single-modality treatment in group A included Nd-YAG laser in 60%, stent in 17%, brachytherapy in 20%, and PDT in 3%. A variety of combinations of the aforementioned modalities were used in group B to enhance airway patency. Patient data were compared with the Student's t-test and chi-square test. Survival analysis and the log rank test were used to compare difference in survival between the two groups. A p-value of 0.05 was considered significant.

RESULTS

There were 46 males and 23 females, with a mean age of 67 years. The tumor was located in the trachea 9%, in the carina in 7%, and primary bronchial in 84%. Two patients had complications due to stent malposition. There was no significant difference between the two groups in relation to age, gender, tumor location, histology, and type of previous cancer therapy. There was a significant improvement in survival for the multimodality group (p = 0.04). The 1- and 3-year cumulative survival rate for groups A and B was 51.3% versus 50% and 2.3% versus 22%, respectively.

CONCLUSIONS

Improvement in survival can be seen with diligent airway surveillance after interventional bronchoscopy and liberal use of a variety of endobronchial treatment modalities for airway obstruction or bleeding. Physicians involved in the management of this difficult problem should be versed in the use of all available treatment modalities to enhance therapeutic outcome.

Phase I study of gemcitabine given weekly as a short infusion for non-small cell lung cancer: results and possible immune system-related mechanisms

PURPOSE

To define the maximum tolerated dose (MTD) and the nature of the toxicities associated with gemcitabine given as a short infusion to patients with non-small cell lung cancer (NSCLC). Secondary objectives were to monitor immunologic response, clinical response, and survival.

PATIENTS AND METHODS

Thirty-two patients diagnosed with advanced inoperable NSCLC and performance status of 0 or 1 participated in this study. Patients consisted of 22 males and 10 females whose median age was 62 years (range 32-79). Gemcitabine was administered as a 30 min infusion once weekly for 3 weeks followed by 1 week of rest. Patients were enrolled at six gemcitabine dose levels ranging from 1000 to 3500 mg/m2. Patients completed a median of four cycles (range 1-17). Responses were evaluated after every two cycles.

RESULTS

Toxicity was evaluated in all 32 patients. The MTD was not reached as gemcitabine was well tolerated at all dose levels. Grade 4 toxicity occurred in three (9%) patients: pulmonary and lymphocytopenia in one patient each, and both neurocortical and cardiac in one patient. Grade 3 toxicity was found in a total of 20 (63%) patients: pulmonary in 10 (31%) patients; pain in 6 (19%) patients; liver toxicity in 6 (19%) patients; leukopenia and lymphocytopenia in 5 (16%) patients each; anemia, nausea, and cardiac toxicity in 3 (9%) patients each; proteinuria and infection in 2 (6%) patients each; and hemorrhage in 1 (3%) patient. Of the 29 patients evaluable for response, seven objective responses were achieved: six at the 2200 mg/m2 dose level and one at the 2800 mg/m2 dose level. The distribution of responses differed significantly by dose (P = 0.0124 by the exact chi-square test for independence). The overall response rate was 24.1% (95% CI, 10.3-43.5%). At 6 h post-infusion, there was a significant increase in spontaneous tumor necrosis factor (TNF) release and stimulated interleukin (IL)-2 production, and significant decreases in total white blood cell and lymphocyte counts (CD3+, CD8+, and CD16+ lymphocytes) and resting and stimulated superoxide production by formyl-methionyl-leucyl-phenylalanine (fMLP), phorbol myristate acetate, and opsonized zymosan (OPS-Z). At 24 h post-infusion, there were significant decreases in total lymphocyte count, lymphocyte subsets (CD3+, CD4-, CD8+, CD56+, CD19+), and in resting and stimulated superoxide production by fMLP and OPS-Z. There also appeared to be an association between the levels of spontaneous TNF release and the severity of both gastrointestinal (GI) and pulmonary toxicities.

CONCLUSION

Gemcitabine given as a short infusion was well tolerated at the dose levels of 1000-3500 mg/m2. The MTD was not reached. Toxicities appeared to be cumulative with multiple cycles. Gemcitabine appears to have activity against NSCLC. Although there was a differential dose-response rate among dose levels, increasing the gemcitabine dose beyond 2200mg/m2 did not show increased clinical response. Gemcitabine appears to modulate the immune response, which may in turn mediate both response and toxicity, although no statistically significant correlation between immune and clinical response was detected.

Laparoscopic repair of large paraesophageal hernia is associated with a low incidence of recurrence and reoperation

BACKGROUND

Laparoscopic repair of paraesophageal hernia (LRPEH) is a feasible and effective technique. There have been some recent concerns regarding possible high recurrence rates following laparoscopic repair.

METHODS

We reviewed our experience with LRPEH from 5/1996 to 8/2002. Large paraesophageal hernia (PEH) was defined by the presence of more than one-third of the stomach in the thoracic cavity. Principles of repair included reduction of the hernia, excision of the sac, approximation of the crura, and fundoplication. Pre- and postoperative symptoms were evaluated utilizing visual analogue scores (VAS) on a scale ranging from 0 to 10. Patients were followed with VAS and barium esophagram studies. Statistical analysis was performed using two-tailed Student's t-test.

RESULTS

A total of 166 patients with a mean age of 68 years underwent LRPEH. PEH were type II ( n = 43), type III ( n = 104), and type IV ( n = 19). Mean operative time was 160 min. Fundoplications were Nissen (127), Toupet (23), Dor (1), and Nissen-Collis (1). Fourteen patients underwent a gastropexy. One patient required early reoperation to repair an esophageal leak. Mean hospital stay was 3.9 days. At 24 months postoperatively there was statistically significant improvement in the mean symptom scores: heartburn from 6.8 to 0.5, regurgitation from 5.9 to 0.3, dysphagia from 4.0 to 0.5, chest pain from 3.7 to 0.3. Radiographic surveillance was obtained in 120 patients (72%) at a mean of 15 months postoperatively. Six patients (5%) had radiographic evidence of a recurrent paraesophageal hernia (two required surgery), 24 patients (20%) had a sliding hernia (two required surgery), and four patients (3.3%) had wrap failure (all four required surgery). Reoperation was required in 10 patients (6%); two for symptomatic recurrent PEH (1.2%), four for recurrent reflux symptoms (2.4%), and four for dysphagia (2.4%). Patients with abnormal postoperative barium esophagram studies who did not require reoperation have remained asymptomatic at a mean follow up of 14 months.

CONCLUSION

LPEHR is a safe and effective treatment for PEH. Postoperative radiographic abnormalities, such as a small sliding hernia, are often seen. The clinical importance of these findings is questionable, since only a small percentage of patients require reoperation. True PEH recurrences are uncommon and frequently asymptomatic.

Effectiveness of laparoscopic fundoplication in relieving the symptoms of gastroesophageal reflux disease (GERD) and eliminating antireflux medical therapy

BACKGROUND

Recent reports have suggested that antireflux surgery should not be advised with the expectation of elimination of medical treatment. We reviewed our results with laparoscopic fundoplication as a means of eliminating the symptoms of gastroesophageal reflux disease (GERD), improving quality of life, and freeing patients from chronic medical treatment for GERD.

METHODS

A total of 297 patients who underwent laparoscopic fundoplication (Nissen, n = 252; Toupet, n = 45) were followed for an average of 31.4 months. Preoperative evaluation included endoscopy, barium esophagram, esophageal manometry, and 24-h pH analysis. A preoperative and postoperative visual analogue scoring scale (0-10 severity) was used to evaluate symptoms of heartburn, regurgitation, and dysphagia. A GERD score (2-32) as described by Jamieson was also utilized. The need for GERD medications before and after surgery was assessed.

RESULTS

At 2-year follow-up, the average symptom scores decreased significantly in comparison to the preoperative values: heartburn from 8.4 to 1.7, regurgitation from 7.2 to 0.7, and dysphagia from 3.7 to 1.0. The Jamieson GERD score also decreased from 25.7 preoperatively to 4.1 postoperatively. Only 10% of patients were on proton pump inhibitors (PPI) at 2 years after surgery for typical GERD symptoms. A similar percentage of patients (8.7%) were on PPI treatment for questionable reasons, such as Barrett's esophagus, "sensitive" stomach, and irritable bowel syndrome. Seventeen patients (5.7%) required repeat fundoplication for heartburn ( n = 9), dysphagia ( n = 5), and gas/bloating ( n = 3).

CONCLUSIONS

Laparoscopic fundoplication can successfully eliminate GERD symptoms and improve quality of life. Significant reduction in the need for chronic GERD medical treatment 2 years after antireflux surgery can be anticipated.

Prediction of postoperative gas bloating after laparoscopic antireflux procedures based on 24-h pH acid reflux pattern

BACKGROUND

Postoperative gas/bloating (G/B) is a common sequelae after laparoscopic fundoplication. Patients with "upright" reflux are thought to have more aerophagic tendencies contributing to their GERD symptoms than patients with significant "supine" patterns of reflux. The risk of postoperative G/B developing was analyzed in relation to patient preoperative patterns of upright, mixed, or supine 24-h pH scores.

METHODS

In this study, 339 patients undergoing fundoplication (278 Nissen and 61 Toupet) were evaluated for preoperative G/B symptoms using a 0 to 10 severity visual analogue scale. Reflux patterns were classified as upright, supine, or mixed according to 24-h pH studies.

RESULTS

As compared with preoperative values, 46% of the patients with a preoperative G/B score less than 3 and an upright or mixed reflux pattern had a significant increase in their average G/B score at 2 years (upright, from 0.9 to 4.2; mixed, from 1.1 to 4.1). However, the patients with a supine reflux pattern did not have a statistically significant change (from 2.0 to 2.2; p > 0.05). The patients with established aerophagic tendencies preoperatively (G/B score > 3) showed significant improvement in these symptoms at 2 years across all three reflux patterns (average G/B score, from 7.7 preoperatively to 4.8 at 2 years). There was no gender predisposition, nor was there any difference in the incidence of G/B between complete and partial fundoplication.

CONCLUSIONS

The pattern of 24-h acid reflux can be predictive of G/B after antireflux surgery. Patients with mild preoperative G/B symptoms (score <3) and upright or mixed patterns of 24-h acid reflux appear to have an increased postoperative risk for chronic G/B as compared with patients who have supine reflux and mild preoperative G/B. Patients with moderate to severe preoperative G/B symptoms (score, 3-10) appear to have a general improvement in G/B symptoms at 2 years after fundoplication.

Outcome analysis of laparoscopic Roux-en-Y gastric bypass for morbid obesity. The first 116 cases

BACKGROUND

Morbid obesity has been described as a continuing epidemic affecting a growing portion of our population. We report an outcome analysis of our early experience with laparoscopic Roux-en-Y gastric bypass (LRYGB) in the treatment of morbid obesity.

METHODS

Two surgeons performed 116 consecutive LRYGBs at a single institution, creating a 25-ml pouch and a 90- to 150-cm Roux limb. The prospectively collected data included patient demographics, comorbidities, postoperative weight loss, and complications.

RESULTS

All eight conversions to an open procedure occurred early during the experience of the surgeons. The mean operating room time for the first 50 cases was 272 min, which decreased to 198 min with experience. The mean length of hospital stay was 3 days. There were 34 complications in 27 patients (23.3%), 14 of which (12%) required reoperation. At 18 months postoperatively, the patients had lost 77% of their excess weight, and their body mass index had decreased from a mean of 49.3 to 32.6 kg/m2. As a result of LRYGB, 25% of the patients were rendered completely free of any pharmacologic treatment for their preexisting comorbidities.

CONCLUSIONS

Although technically challenging, LRYGB can be performed safely with excellent long-term results. The mean operating room time and conversion rate improved with experience. As this study showed, LRYGB achieves an excellent rate of weight loss and improvement in preoperative comorbidities with a minimal length of hospital stay and an acceptable complication rate.

Bilateral anterior minithoracotomy with video assistance for lung volume reduction surgery and pulmonary metastasectomy

Incisional access to pulmonary pathology involving both lungs has often involved bilateral standard thoracotomies, median sternotomy, and, recently, sequential lateral video-assisted thoracic surgical approaches. Significant problems are inherent to each of these approaches. We introduce a hybrid technique of bilateral simultaneous minithoracotomy with video assistance as an alternative to these other surgical approaches.

Immediate radiographic assessment following laparoscopic antireflux operations is unnecessary

BACKGROUND

Laparoscopic antireflux operations (LAP) have become increasingly common for the treatment of gastroesophageal reflux disease (GERD). We sought to determine if routine postoperative barium contrast studies following LAP were clinically efficacious in identifying technical problems and life-threatening complications related to the surgical intervention.

METHODS

From January 1996 to December 1997, 112 barium studies were performed following 112 LAP procedures (47 male/65 female patients; mean age, 51 years) (group I). This group was compared to a subsequent cohort of 67 patients who underwent LAP between January 1998 and July 1998 without routine early postoperative barium contrast study (group II).

RESULTS

In 111/112 of the barium studies of group I, no radiographic abnormality was identified. The average length of stay (LOS) for these patients was 2.6 days. Routine barium studies were not utilized in group II. The average length of stay for patients in group II was 1.4 days. Twelve group II patients underwent early postoperative barium studies to evaluate suspicious clinical symptoms. None of these 12 postoperative studies identified important problems, nor did they alter the patients' clinical management. However, because of the barium study, their LOS was equivalent to those patients who had undergone routine barium study (2.4 days). There was an increase of $1451.80 in hospital charges in the group of patients who had a barium study, largely as a result of the increased LOS.

CONCLUSION

The routine use of these studies results in increased patient charges and a prolongation in the length of hospital stay. Immediate postoperative barium studies following laparoscopic antireflux operations are of little value in determining important postoperative problems among patients undergoing LAO.

The Role of Video-Assisted Thoracic Surgery for Pulmonary Metastasectomy

Management of isolated metastatic deposits to the lungs and the role of surgical resection, specifically video-assisted thoracic surgery (VATS) techniques, have been controversial. The inability to perform a detailed bimanual palpation of the lung for occult lesions has been considered an inherent weakness in this approach. We have performed VATS resection for 205 patients with pulmonary metastatic disease and potentially curative VATS resec-tion for 119 patients. VATS resection was successfully performed for all VATS diagnostic and therapeutic patients, with no perioperative deaths. Longitudinal follow-up demonstrated a mean survival of 20 months in the diagnostic group and 32 months in the therapeutic group. In the VATS therapeutic group, 44 (37%) patients remain free of disease at a mean follow-up of 37 months. Of the 69 recurrences, 6% were local, 25% were regional, and 67% were distant. In this review, the present role of VATS pulmonary metastasectomy will be examined.

Laparoscopic management of giant paraesophageal herniation

BACKGROUND

Many surgeons have found laparoscopic fundoplication effective management of medically recalcitrant gastroesophageal reflux disease (GERD) associated with sliding type I hiatal hernias. The anatomic distortion and technical difficulty inherent with repair has limited the use of laparoscopy for repair of "giant" paraesophageal hernias (gPH).

METHODS

Since July 1993, we have accomplished laparoscopic repair of paraesophageal hiatal hernias in 54 of 60 (90%) patients. Five patients had classic type II hernias with total intrathoracic stomachs, and 53 patients had large sliding/paraesophageal type III herniation. Two patients had true parahiatal hernias. None had gastric incarceration. Median age was 53 years and 28 of 60 (47%) were women. Chest pain and dysphagia were primary complaints from 39 of 60 (65%). Heartburn with or without regurgitation was present in 52 of 60 (85%). Preoperative manometry and prolonged pH testing were obtained on 43 of 60 (72%) and 44 of 60 (73%) patients, respectively. Principles of repair included reduction of the hernia, excision of the sac, crural approximation, and fundoplication over a 54F bougie (Nissen, 41; Dor, 1; Toupet, 18) to "pexy" the stomach within the abdomen and to control postoperative reflux.

RESULTS

Mean operative time was 202+/-81 minutes. Conversion to "open" repair was required in 6 patients (iatrogenic esophageal injury in 2 patients and difficult hernia sac dissection in 4 patients). One postoperative mortality occurred as a result of sepsis and multiorgan failure after an intraoperative esophageal perforation. Follow-up barium swallow performed in 44 of 60 patients demonstrated recurrent hiatal hernias in 3 patients. Preoperative symptoms have been relieved in all but 3 patients. Reoperation for recurrent paraesophageal herniation has been required in these latter 3 patients.

CONCLUSIONS

Although technically challenging, laparoscopic repair of paraesophageal hiatal hernias is a viable alternative to "open" surgical approaches. Control of the herniation and the patient's symptoms are equivalent and hospitalization and return to full activity are shorter.

Vascular endothelial growth factor expression in stage I non-small cell lung cancer correlates with neoangiogenesis and a poor prognosis

BACKGROUND

Vascular endothelial growth factor (VEGF) plays an important role in tumor growth and metastasis. We investigated the prognostic significance of VEGF overexpression, intratumoral microvessel density (MVD), and angiolymphatic invasion in stage Ia-b non-small cell lung cancer (NSCLC).

METHODS

Eighty-five patients undergoing complete surgical resection of pathologic stage Ia-b NSCLC were evaluated. The mean and median clinical follow-up were 37.1 and 39.0 months (range, 30-44 months), respectively. Paraffin-embedded tumor specimens were stained with VEGF and CD31 (a specific endothelial marker) using immunohistochemical methods. VEGF staining was evaluated, by combining both percentage of positive tumor cells and staining intensity, as low (negative and < 20% of tumor cells showing weak positivity), or high (> 20% of tumor cells showing strong positivity). CD31 staining was expressed as MVD per high power field at 400x magnification. Angiolymphatic invasion was expressed as either presence or absence.

RESULTS

Low VEGF expression was seen in 25 (29%) patients, and high VEGF expression was seen in 60 (71%) patients. The survival rate in patients with low VEGF expression was significantly higher (80%) than that in those with high VEGF expression (48%, P = .018). The mean MVD in the low VEGF group was 23.7 +/- 5.7 vs. 34.4 +/- 9.3 in the high VEGF group (P = .001). Patients with high MVD also had a significantly lower survival rate than did those with low MVD count (46% vs. 73%, P = .0053). Age, sex, tumor type, and tumor differentiation were not found to be associated with overall survival. The presence of angiolymphatic invasion and T2 stage (i.e., tumor size > 3 cm) were associated with decreased survival. High VEGF expression, tumor size, and angiolymphatic invasion emerged as three independent factors predicting worsening prognosis using multivariate analysis.

CONCLUSION

High VEGF expression within stage I NSCLC is closely associated with high intratumoral angiogenesis and poor prognosis. Immunohistochemical evaluation of T stage and VEGF expression along with examination of angiolymphatic invasion perioperatively may aid in predicting prognosis. Adjuvant therapies aimed at retarding tumor angiogenesis may be considered for stage I NSCLC patients with high VEGF levels.

Experience and technique of stapled mechanical cervical esophagogastric anastomosis

BACKGROUND

Anastomotic leak from cervical esophagogastric anastomoses is a serious problem after esophagectomy. We explored the efficacy of partial or total mechanical anastomoses accomplished with the endoscopic linear cutting and stapling device as an alternative to hand-sewn anastomotic techniques.

METHODS

During a 42-month period, 93 patients undergoing either transhiatal esophagectomy or a three-incisional approach to esophagectomy underwent either hand-sewn (n = 43), partial mechanical (n = 16), or totally mechanical (n = 34) cervical esophagogastric anastomoses. The occurrence of postoperative anastomotic leak and the development of postoperative anastomotic stricturing requiring dilation therapy were analyzed between these groups using chi2.

RESULTS

All patients survived esophagectomy and were available for postoperative follow-up. Anastomotic leak developed in 10 patients (23%) with hand-sewn, 1 patient (6%) with partial mechanical, and 1 patient (3%) with total mechanical anastomoses (p < 0.05). Anastomotic stricture development paralleled the occurrence of anastomotic leak rate with 25 patients (58%) with hand-sewn, 3 patients (19%) with partial mechanical, and 6 patients (18%) with total mechanical anastomoses experiencing strictures requiring dilation therapy (p < 0.05).

CONCLUSIONS

These results suggest that partial or mechanical cervical esophagogastric anastomoses created with the endoscopic stapling device may be superior to hand-sewn anastomotic techniques.

Vascular endothelial growth factor expression in stage I non-small cell lung cancer correlates with neoangiogenesis and a poor prognosis

BACKGROUND

Vascular endothelial growth factor (VEGF) plays an important role in tumor growth and metastasis. We investigated the prognostic significance of VEGF overexpression, intratumoral microvessel density (MVD), and angiolymphatic invasion in stage Ia-b non-small cell lung cancer (NSCLC).

METHODS

Eighty-five patients undergoing complete surgical resection of pathologic stage Ia-b NSCLC were evaluated. The mean and median clinical follow-up were 37.1 and 39.0 months (range, 30-44 months), respectively. Paraffin-embedded tumor specimens were stained with VEGF and CD31 (a specific endothelial marker) using immunohistochemical methods. VEGF staining was evaluated, by combining both percentage of positive tumor cells and staining intensity, as low (negative and < 20% of tumor cells showing weak positivity), or high (> 20% of tumor cells showing strong positivity). CD31 staining was expressed as MVD per high power field at 400x magnification. Angiolymphatic invasion was expressed as either presence or absence.

RESULTS

Low VEGF expression was seen in 25 (29%) patients, and high VEGF expression was seen in 60 (71%) patients. The survival rate in patients with low VEGF expression was significantly higher (80%) than that in those with high VEGF expression (48%, P = .018). The mean MVD in the low VEGF group was 23.7 +/- 5.7 vs. 34.4 +/- 9.3 in the high VEGF group (P = .001). Patients with high MVD also had a significantly lower survival rate than did those with low MVD count (46% vs. 73%, P = .0053). Age, sex, tumor type, and tumor differentiation were not found to be associated with overall survival. The presence of angiolymphatic invasion and T2 stage (i.e., tumor size > 3 cm) were associated with decreased survival. High VEGF expression, tumor size, and angiolymphatic invasion emerged as three independent factors predicting worsening prognosis using multivariate analysis.

CONCLUSION

High VEGF expression within stage I NSCLC is closely associated with high intratumoral angiogenesis and poor prognosis. Immunohistochemical evaluation of T stage and VEGF expression along with examination of angiolymphatic invasion perioperatively may aid in predicting prognosis. Adjuvant therapies aimed at retarding tumor angiogenesis may be considered for stage I NSCLC patients with high VEGF levels.

A comparative study of buttressed versus nonbuttressed staple line in pulmonary resections

BACKGROUND

Prolonged air leak is the major limiting factor in early hospital discharge following pulmonary resection. The purpose of this study was to determine whether the use of bovine pericardial strips as a buttress along the lung staple line would decrease air leaks and hospital stay after lobectomy and segmentectomy.

METHODS

This was a multicenter trial consisting of 80 patients undergoing pulmonary resection, randomly assigned to the control group (40 patients) or treatment group (40 patients). The treatment group had reinforcement with bovine pericardium.

RESULTS

No statistical differences were noted in the mean intensive care unit length of stay (p = 0.9), number of days with a chest tube (p = 0.6), or total length of stay (p = 0.24). Increased air leak duration was associated with assignment to the control group (r = 0.27, p = 0.02). The mean duration of air leak was 2 days and the mean time to chest tube removal was 5.9 days in patients with a buttressed staple line compared to 3 days and 6.3 days, respectively, for patients with nonbuttressed staple lines.

CONCLUSIONS

Within the data of this study, no statistical differences were noted between buttressed and nonbuttressed patients. However, the trend toward shortened air leak time and tube removal time was apparent in the buttressed group. With greater number of patients studied, it is likely that the cost of bovine pericardium would be justified by shorter air leak duration and hospitalization.

Therapeutic video-assisted thoracoscopic surgical resection of colorectal pulmonary metastases

OBJECTIVE

Careful patient selection is vital when video-assisted thoracoscopic surgical (VATS) therapeutic pulmonary metastasectomy of colorectal carcinoma is considered. Complete resection of all metastatic disease remains a vital concept. We reviewed our VATS experience for therapeutic metastasectomy of peripheral colorectal pulmonary metastases.

METHODS

Over 90 months, therapeutic VATS metastasectomy was accomplished upon 80 patients with colorectal metastases. Thin cut computed tomography (CT) was central in identifying lesions. The mean interval from primary carcinoma to VATS resection was 41 months (1-156 months; median, 33). A solitary lesion was resected in 60 patients and multiple (2-7) lesions resected in 20 patients. Statistics were obtained using the Student's t-test.

RESULTS

No operative mortality or major postoperative complications occurred. The hospital stay was 4.5+/-2. 2 days (range, 1-13). All lesions were resected by VATS, with four conversions to thoracotomy to improve the margins. The mean survival of patients with one lesion was 34.8 months compared with 26.5 months for patients with multiple lesions (P=0.37). The mean survival was 20.5 months when metastases occurred <3 years vs. 28.1 months for >3 years from primary carcinoma resection (P=0.20). Twenty-five (31%) patients are disease free; with a mean interval of 38.7 (3-84; median, 35) months. Sixty-nine percent (55/80) of patients developed a recurrence: 6/80 (8%) local; 19/80 (24%) regional (same hemithorax away from resection); and 30/80 (38%) distant. The overall survival at 1 year was 81.2%, 48.4% at 3 years and 30.8% at 5 years.

CONCLUSIONS

Therapeutic VATS resection of colorectal metastases appears efficacious. Preoperative CT can identify peripheral colorectal metastases amenable to VATS. Conversion to thoracotomy is indicated when none of the lesions identified by CT are found or when clear surgical margins are jeopardized.

Splenic rupture as a consequence of giant paraesophageal hernia

Elective surgical repair of "giant" paraesophageal hernias is recommended to prevent the potential complications of gastric volvulus, obstruction, and ischemic perforation. We report the unusual complication of splenic capsular laceration and hemorrhagic shock following forceful retching by a patient with an incarcerated paraesophageal hernia.

Extensive posterior-lateral tracheal laceration complicating percutaneous dilational tracheostomy

BACKGROUND

An extensive posterior-lateral longitudinal tracheal laceration is an uncommon but serious complication of percutaneous dilational tracheostomy (PDT). We report the successful management of three ventilator-dependent patients whose percutaneous tracheostomy was complicated by an extensive longitudinal posterior-lateral tracheal laceration requiring operative repair.

METHODS

A retrospective review of 134 cases of PDT with concurrent bronchoscopy was performed between April 1997 and July 1999 and compared with a review of 124 cases of open tracheostomy. Tracheal lacerations were primarily repaired and augmented with intercostal muscle pedicle buttress.

RESULTS

Three cases of an extensive posterior-lateral longitudinal tracheal laceration that required operative repair were reported in the PDT group. None were reported in the open tracheostomy group. The 3 patients were managed with an adult high-frequency oscillating ventilator or pressure control ventilation during the postoperative period to limit barotrauma, and all healed without evidence of tracheal leak or stenosis.

CONCLUSIONS

The increasing popularity of PDT, particularly among nonsurgical disciplines, may generate an increasing number of complications requiring operative attention. Thoracic surgeons need to be cognizant of the pitfalls of PDT technique and be prepared to manage these difficult clinical scenarios.

Video-assisted thoracic surgery for diseases within the mediastinum

VATS and concepts of minimal access thoracic surgery have revitalized many aspects of general thoracic surgery, including the surgical approach to diseases and conditions of the mediastinum. Proven surgical options that have been shunned by patients and referring physicians because of the perceived morbidity of thoracotomy have been reconsidered with the emergence of these minimal access surgical options. Continued critical review of the accumulating experience in VATS techniques will refine the surgical indications for VATS and open thoracotomy.

Small-cell variant of synovial sarcoma: fine-needle aspiration with ancillary features and potential diagnostic pitfalls

We report a small-cell variant of synovial sarcoma examined by fine-needle aspiration (FNA) biopsy. The patient is a 23-yr-old female who had a synovial sarcoma involving the left infratemporal region, diagnosed at 7 yr of age, followed by a metastatic lesion involving the lung and chest wall 16 yr later. The chest wall metastases was sampled by FNA biopsy. The aspirate consisted of numerous, small, round cells with very high nuclear-to-cytoplasmic ratios. The cytomorphologic features could potentially be confused with other pediatric small round cell tumors. Ancillary studies demonstrated positive staining of the neoplastic cells for cytokeratin, epithelial membrane antigen (EMA), and CD99. The differential diagnosis of other small round cell tumors that may be mistaken for the small-cell variant of synovial sarcoma are presented. We believe that this is the first FNA report detailing the cytologic and ancillary features of the small-cell variant of synovial sarcoma.

Total Videothoracoscopic Lobectomy Versus Open Thoracotomy for Early-Stage Non–Small-Cell Lung Cancer

Lobectomy remains the standard procedure for early-stage non small-cell lung cancer (NSCLC). Advances in minimally invasive surgery allow lobectomy to be performed by videothoracoscopy (VATSLOBE). The objective of this study was to compare open thoracotomy (OPENLOBE) to VATSLOBE in the treatment of early-stage NSCLC. A retrospective review over a 6-year period at a single tertiary care center identified 31 patients treated by VATSLOBE. A comparison was made with 31 patients undergoing OPENLOBE during the same time period. The cases were matched for age, pulmonary function testing, tumor size, and comorbidities. The VATSLOBE technique was carried out using four 1 cm thoracoports, one of which was enlarged to a 4-6 cm access incision for lobe retrieval. OPENLOBE was performed by standard posterolateral thoracotomy. The VATSLOBE group had a longer operative time (214.03 min) compared to OPENLOBE (140.67 min). There was no difference in the extent of lymph node dissection or in morbidity between the two groups. VATSLOBE patients had their chest tubes removed earlier (4.77 vs. 8.16 days) and stayed in the hospital for a shorter time (7.07 vs. 11.94 days) compared to OPENLOBE patients. In this retrospective review, lobectomy performed by the videothoracoscopic approach was comparable to OPENLOBE in terms of lymph node dissection, morbidity, and long-term survival. VATSLOBE had the advantages of a shorter hospital stay and fewer days with a chest tube. Minimally invasive surgery for early-stage lung cancer should be further investigated in multi-institutional controlled trials.

Long-term outcome after resection for bronchial carcinoid tumors

OBJECTIVES

We sought to determine the long-term survival of patients treated for bronchial carcinoid tumors and whether lesser resections have had an effect on outcomes.

METHODS

We conducted a retrospective, multi-institutional review of patients treated surgically for primary bronchial carcinoid tumors since 1980. Operative approach, pathologic stage, histology, surgical complications, tumor recurrence, and long-term survival were assessed.

RESULTS

There were 50 men and 89 women with a mean age of 52.2+/-17.4 and 58.9+/-13.3 years, respectively (P=0.021). Men were more likely to be current or former smokers than were women. Operations included lobectomy or bilobectomy in 110, pneumonectomy in four, wedge resection in 22, and bronchial sleeve resection only in three patients; resection was performed thoracoscopically in six patients. One patient died postoperatively. Stages were I, 121; II, nine; III, six; and IV, three. Typical carcinoid tumors were stage I in 100 and more advanced (stages II-IV) in nine, whereas atypical carcinoid tumors were stage I in 18 and more advanced in eight (P=0. 002). Median follow-up was 43 months (range 1-149) during which 21 (15%) patients died (four from recurrent cancer) and 19 patients (14%) were lost to follow-up. Recurrent cancer developed in 2/98 patients with typical and 5/25 patients with atypical subtypes (P<0. 001; log-rank test). The likelihood of recurrence was related to histological subtype (relative risk 7.9 for atypical carcinoid; 95% confidence interval 1.4-43.5). Five-year survival was 88% for stage I patients and was 70% for patients with more advanced stages. When stratified by stage, survival was related to age (relative risk=1.9 for a 10 year increase in age; 95% confidence interval 1.2-2.9) and possibly to the histological subtype, but not to patient gender, year of operation, or type of operation performed.

CONCLUSIONS

Either major lung resection or wedge resection is appropriate treatment for patients with early stage typical bronchial carcinoid tumors. Survival is favorable for early stage tumors regardless of histological subtype. Local recurrence is more common among patients with atypical subtypes, suggesting that a formal resection may improve long-term outcome.

Risk analysis for thoracoscopic lung volume reduction: a multi-institutional experience

OBJECTIVE

Most reports of thoracoscopic lung volume reduction (TLVR) are relatively small and early experiences from a single institution, factors which limit both the statistical validity and the applicability to the population at large. In order to address these shortcomings we undertook an analysis of the TLVR experience at five separate institutions to assess operative morbidity and identify predictors of mortality.

METHODS

Questionnaires were sent to four groups of surgical investigators at five institutions actively performing TLVR. Data was requested regarding preoperative, operative and postoperative parameters. Twenty-five potential predictors of mortality were analyzed and seven proved to be at least marginally significant (P<0.10). These parameters were entered into a stepwise logistic regression analysis to identify independent predictors.

RESULTS

The 682 patients (415 males, 267 females, mean age 64.0 years) underwent unilateral (410) or bilateral (272) TLVRs. Overall, operative mortality was 6% with half of the deaths resulting from respiratory causes. The remaining patients were discharged to home (88%), a rehabilitation facility (4%) or a ventilator facility (2%). There were 25 perioperative factors chosen representing clinically important indices such as spirometry, oxygenation, functional status, clinical and demographic variables. Univariate analysis identified seven variables as predictors of mortality (P<0.10) and these were entered into a stepwise logistic regression analysis. Only age, 6-min walk, gender (male 8%, female 3% mortality) and the procedure performed (unilateral 4.6%, bilateral 8%) were independent predictors while preoperative steroid therapy, preoperative oxygen administration, and time since smoking cessation dropped out of the model. The specific institution, learning curve (early vs. late experience), type of lung disease, spirometric indices and predicted maximum VO(2) were not significant predictors.

CONCLUSION

This experience suggests that unilateral and bilateral lung volume reduction procedure can be performed with acceptable morbidity and mortality. Although age, gender, exercise capacity and the procedure performed are all independent predictors of mortality, the risk of operative death did not appear excessive in this fragile patient subset.

Comparison of clinical results for unilateral and bilateral thoracoscopic lung volume reduction

BACKGROUND

It is widely believed that bilateral thoracoscopic lung volume reduction (BTLVR) yields superior results when compared with unilateral thoracoscopic lung volume reduction (UTLVR) with regard to spirometry, functional capacity, oxygenation and quality of life results.

METHODS

To address these issues, we compared the results of patients undergoing UTLVR (N = 338 patients) and BTLVR (N = 344 patients) from 1993 to 1998 at five institutions. Follow-up data were available on 671 patients (98.4%) between 6 and 12 months after surgery, and a patient self-assessment was obtained at a mean of 24 months.

RESULTS

It was found that BTLVR provides superior improvement in measured postoperative percent change in FEV1 (L) (UTLVR 23.3% +/- 55.3 vs BTLVR 33% +/- 41, p = 0.04), FVC(L) (10.5% +/- 31.6 vs 20.3% +/- 34.3, p = 0.002) and RV(L) (-13% +/- -22 vs -22% +/- 17.9, p = 0.015). BTLVR also provides a slight improvement over UTLVR in patient's perception regarding improved quality of life (UTLVR 79% vs BTLVR 88%, p = 0.03) and dyspnea relief (71% vs 61%, p = 0.03). There was no difference in mean changes in PO2 (mm Hg) (UTLV 4.5 +/- 12.3 vs BTLVR 4.9 +/- 13.3, p = NS), 6-minute walk (UTLVR 26% +/- 66.1 vs BTLVR 31% +/- 59.6, p = NS) or decreased oxygen utilization (UTLVR 78% vs BTLVR 74%, p = NS).

CONCLUSIONS

These data suggest that both UTLVR and BTLVR yield significant improvement, but the results of BTLVR seem to be superior with regard to spirometry, lung volumes, and quality of life.

Thoracoscopic resection of ectopic parathyroid glands

BACKGROUND

The vast majority of parathyroid glands in hyperparathyroidism can be resected through a cervical approach. In approximately 2% of the cases, the ectopic gland is in the mediastinum in a location that requires a thoracic approach.

METHODS

We report 7 such cases that were resected using video-assisted thoracic surgery to avoid the need for an open surgical procedure.

RESULTS

All glands were successfully identified preoperatively and subsequently resected. Hospital stay averaged less than 3 days with only one minor complication.

CONCLUSIONS

Ectopic mediastinal parathyroid glands may be safely and accurately resected using video-assisted thoracic surgery to avoid open approaches.

Long-term survival after thoracoscopic lung volume reduction: a multiinstitutional review

BACKGROUND

It has been suggested that bilateral thoracoscopic lung volume reduction (BTLVR) yields significantly better long-term survival than unilateral thoracoscopic lung volume reduction (UTLVR).

METHODS

All perioperative data were collected at the time of the procedure. Follow-up data were obtained during office visits or by telephone.

RESULTS

A total of 673 patients underwent thoracoscopic LVR: 343 had either simultaneous or staged BTLVR and 330, UTLVR. As of July 1998, follow-up was available on 667 (99%) of the 673 patients with a mean follow-up of 24.3 months. The patients in the BTLVR group were significantly younger (62.6+/-8.0 years versus 65.4+/-8.1 years; p < 0.0001), had a higher preoperative arterial oxygen tension (69.7+/-12 mm Hg versus 65.3+/-11 mm Hg; p < 0.0001), and had a superior preoperative 6-minute walk performance (279.9+/-93.6 m [933+/-312 feet] versus 244.5+/-101.4 m [815+/-338 feet] p < 0.0001). There was no difference in the operative mortality rate between the two groups (UTLVR, 5.1%, and BTLVR, 7%). Actuarial survival rates for the UTLVR group at 1 year, 2 years, and 3 years were 86%, 75%, and 69%, respectively versus 90%, 81%, and 74%, respectively, for the BTLVR group (p = not significant).

CONCLUSIONS

Contrary to previous reports, survival after BTLVR was not superior to that after UTLVR even though the former group appeared to have a lower risk preoperatively because of younger age, higher arterial oxygen tension, more advantageous anatomy, and better functional status. Despite thoracoscopic LVR, the actuarial mortality rate approached 30% at 3 years, and this calls into question whether this procedure offers any survival advantage to patients with end-stage emphysema.

Thoracoscopic resection of posterior neurogenic tumors

Video-assisted thoracic surgery (VATS) may be used for resection of posterior mediastinal tumors to avoid thoracotomy and shorten hospital stay. Between October 1990 and June 1998, 23 patients had VATS resection of posterior neurogenic tumors. The 14 females and 9 males ranged in age from 14 months to 70 years, with a median of 35 years. Operation time ranged from 30 to 120 minutes (median, 83), and intraoperative complications were limited to minor problems as well as conversion to thoracotomy to enhance complete tumor resection in four cases. Tumor pathology included nerve sheath origin (20) and autonomic ganglia (3). There was only one malignant schwannoma. Tumor size ranged from 0.7 to 13 cm in diameter. Median chest tube days was 1 day (range, 1-4), and hospital stay was 2 days (range, 1-9). Postoperative complications included transient paresthesia (three cases), ileus (two cases), pleural effusion (one case), and transient intercostal pain (one case). Posterior neurogenic tumors may be resected safely using video-assisted techniques. Conversion to thoracotomy to enhance complete resection is both possible and encouraged. The use of VATS seems to decrease hospital stay and minimize postoperative complications. In posterior neurogenic tumors without tumor extension to the spinal canal, VATS has become our preferred method for resection.

The diagnosis and significance of visceral pleural invasion in lung carcinoma. Histologic predictors and the role of elastic stains

Invasion of the visceral pleura is an important component of lung carcinoma staging, and in some studies is an independent prognostic indicator. Evaluation of invasion by H&E may be indeterminate. Elastic stains can be helpful but are performed rarely. We reviewed all lung carcinoma resections from 1993 for 13 histologic features potentially predictive of pleural invasion. Of 57 resections, 20 were indeterminate by H&E. Verhoeff-Van Gieson (VVG) stain revealed invasion in 8 cases, increasing the pathologic stage in 1. VVG stain was negative in 12 cases, 2 of which had been falsely reported as positive, decreasing the stage in 1. Angiolymphatic invasion and single-cell spread were significant predictors of invasion. Absence of both or the presence of intervening aerated parenchyma predicted lack of involvement in all cases. Elastic stains can provide prognostically important information, changing the pathologic stage in 4% of lung carcinoma resections overall and in 10% of cases indeterminate by H&E for pleural invasion.

Video-assisted surgical management of achalasia of the esophagus

PURPOSE

Video-assisted surgical approaches to esophageal achalasia continue to be explored by many surgeons involved in the management of this motor disorder. We report our experience with thoracoscopic and laparoscopic esophagomyotomy to more clearly define the efficacy and safety of these approaches.

PATIENTS

Over 73 months, 58 patients with achalasia underwent thoracoscopic myotomy (n = 19) alone or laparoscopic myotomy (n = 39) with partial fundoplication (anterior = 15; posterior = 24). Mean age was 47.2 years and average length of symptoms was 60 months. Primary symptoms were as follows: dysphagia, 100%; pulmonary abnormalities, 22%; weight loss; 47%, and pain, 45%. Mean esophageal diameter was 6 cm and tortuosity was present in 16% (9/58) of patients. Prior management consisted of dilation (n = 47), botulinum toxin injection (n = 8), and prior myotomy (n = 1).

METHODS

In the operating room all patients underwent endoscopic examination and evacuation of retained esophageal contents. The esophagomyotomy was extended 4 cm superiorly and inferiorly to 1 cm beyond the lower esophageal sphincter. Thoracoscopic and laparoscopic procedures were completed in all patients without conversion to an open operation. Mean operative time was 183 minutes (+/-58.1) and hospital stay averaged 2.3 days (+/-0.8). There was no operative mortality. The 1 operative complication was a perforation that was identified during the operation and repaired thoracoscopically.

RESULTS

Symptoms improved in 97% of patients. Mean dysphagia scores (range 0-10) decreased from 9.8 +/- 1.6 before the operation to 2.0 +/- 1.5 after the operation (P <.001) at a mean follow-up of 6 months. Postoperative reflux symptoms developed in 5% (1/19) of the thoracoscopy group and 8% (4/39) of the laparoscopy group. Nine patients have persistent or recurrent dysphagia (16%). Seven patients have successfully undergone Savary dilation, and 2 required esophagectomy to manage recalcitrant dysphagia.

CONCLUSION

At this intermediate term analysis, video-assisted approaches for management of achalasia are a reasonable alternative to extended medical therapy or open operations.

Diagnostic and therapeutic video-assisted thoracic surgery resection of pulmonary metastases

BACKGROUND

Appropriateness of video-assisted thoracic surgery (VATS) pulmonary metastasectomy for curative intent has been a controversial topic. We reviewed our experience with VATS wedge resection for peripheral lung metastases to determine the efficacy and potential adverse consequences of this approach for pulmonary metastasectomy.

METHODS

One hundred seventy-seven patients underwent VATS resection of pulmonary metastases. Diagnostic resection (VATS-dx) was performed for 78 patients when percutaneous biopsy was unsuccessful or not feasible. Potentially curative resections (VATS-rx) were performed for 99 patients. The histologic findings in this group included colorectal (68), renal (7), sarcoma (6), breast (4), melanoma (3), head/neck (3), lymphoma (2), uterine (1), and "other" (5). The average number of lesions resected was 1.4 (range, 1-7).

RESULTS

VATS resection was successfully performed for all VATS-dx and VATS-rx patients. There were no perioperative deaths. Longitudinal follow-up demonstrated a mean survival of 18 months in the VATS-dx group and 28 months in the VATS-rx group. In the VATS-rx group, 37 (37%) of 99 were free of disease, at a mean follow-up interval of 37 months. Of the 57 recurrences, 5% were local, 26% were regional, and 69% were distant.

CONCLUSIONS

Results with VATS resection of peripheral pulmonary metastases for diagnostic and potentially curative intentions appear comparable with historical results by "open" thoracotomy. Careful patient selection based on high-resolution helical CT scanning is important to avoid compromise of therapeutic intent. Conversion to thoracotomy is indicated when lesions identified preoperatively are not found or when technical problems encountered may compromise surgical margins when resecting lung metastases for potential cure.

Reoperative laparoscopic antireflux surgery

BACKGROUND

Laparoscopic antireflux surgery (LAP) is becoming increasingly used for the surgical treatment of medical recalcitrant gastroesophageal reflux disease (GERD). We sought to determine the utility of remedial LAP approaches to antireflux surgery.

METHODS

From March 1996 to December 1998, 15 patients underwent remedial LAP to manage medically recalcitrant recurrent GERD after LAP (n = 8) or open antireflux procedure (n = 1) and/or troublesome postfundoplication complications (dysphagia 6, gas bloat 4). The remedial LAP surgery consisted of conversion from Nissen to Toupet fundoplication to manage dysphagia or gas bloat symptoms (n = 7), revision of IAP Nissen fundoplication (n = 7) and LAP revision of a failed open Nissen fundoplication (n = 1) for recurrent reflux.

RESULTS

The remedial LAP repair was accomplished in all patients. Findings at operation included disrupted fundoplication (n = 6), incomplete or inappropriately positioned fundoplication (n = 2), paraesophageal hernia (n = 3), or a normal total fundoplication among patients with primary dysphagia (n = 4). Follow-up symptom scoring beyond 3 months of remedial surgery demonstrated a change from the preoperative mean dysphagia, heartburn, gas bloat, and regurgitation score (P < .05). Follow-up GERD testing (manometry, upper gastrointestinal tract, pH testing) was normal in 13 of the 15 patients.

CONCLUSIONS

Reoperative antireflux surgery can be accomplished using LAP approaches without compromise of therapeutic intent or increased surgical morbidity. Surgeons sufficiently experienced with these LAP repairs may consider repeat LAP instead of open surgery for patients with recurrent GERD or postfundoplication problems.

Fine-needle aspiration cytologic features of pseudovascular adenoid squamous-cell carcinoma of the lung

Pseudovascular adenoid squamous-cell carcinoma (PASCC) is an epithelial malignancy with spindle-cell features that can mimic vascular neoplasms, particularly angiosarcoma, in its morphologic characteristics. There have been only a few surgical pathology reports of PASCC arising in the lung, skin, and breast. We describe the fine-needle aspiration (FNA) cytologic and histologic features of a pulmonary PASCC in a 66-yr-old man. The aspiration yielded individually scattered and syncytial fragments of malignant epithelioid-appearing cells with oval to spindle shapes, prominent nucleoli, and a finely vacuolated amphophilic cytoplasm. The core needle biopsy specimen displayed these same cells lining pseudoluminal spaces, with intervening bundles of fibroconnective tissue simulating a vascular neoplasm. The neoplastic cells stained positively with cytokeratin (AE-1/3), epithelial membrane antigen, and vimentin and were nonreactive with S-100, muscle-specific actin, CD31, CD34, and carcinoembryonic antigen. These cytologic, histologic, and immunocytochemical features supported a diagnosis of PASCC. To the best of our knowledge, this is the first report of the FNA cytologic features of this pseudovascular variant of adenoid squamous-cell carcinoma. This FNA case illustrates that the cytologic impression was more accurate and, in fact, that the histologic features of PASCC can be misleading. The correct identification of PASCC and its distinction from angiosarcoma has important clinical ramifications for treatment and prognosis. FNA cytologic examination with ancillary studies is a minimally invasive procedure that can distinguish PASCC from sarcomatous lesions. Diagn. Cytopathol. 1999;21:265-270.