Background: Substernal hand‐assisted thoracoscopy (HATS) has been proposed as a reliable surgical method with which to perform a bilateral lung metastasectomy. Herein, we review our 15‐year ...experience with this approach for the purpose of understanding the long‐term results in a large study cohort.
Methods: The study cohort was a series of 87 patients that underwent a HATS lung metastasectomy between 1995 and 2010. We focused on the main surgical findings including the ability of this approach to facilitate the detection of unexpected pulmonary lesions. Overall and disease‐free survival rates were analyzed in a long‐term follow up using the Kaplan‐Meier method.
Results: A total of 219 lesions were removed. Of these, 191 proved to be malignant. This figure accounted for 31 (19.3%) unexpected lung metastases not previously identified at imaging work‐up. Eighteen nodules previously suggested as metastatic lesions proved to be benign. On the basis of these findings sensitivity, specificity, positive and negative predictive values for imaging work‐up in detecting lung metastases were 79.6%, 41.3%, 86.4%, and 30.5%, respectively. Lesions sized <7 mm showed the highest false negative rate. Postoperatively no major complications occurred. Overall survival rates at 3 and 5 years were 57.9% and 38.4%, respectively. Disease‐free interval after primary cancer removal, but not all metastases nor bilateral spread, was related to survival (P = 0.015).
Conclusions: In our experience, HATS resulted in a considerable percentage of resected lung metastases not previously detected at imaging work‐up. We recommend this approach whenever feasible as it can conciliate low invasiveness and completeness of surgical resection. Substernal HATS makes it possible to detect a considerable number of unexpected lesions in patients undergoing lung metastasectomy with low surgical trauma. This study reinforces the role of this approach in the setting of lung metastasectomy, due to the large patient series and long‐term follow‐up.
Video-assisted thoracic surgery (VATS) is an interesting and emerging procedure for the diagnosis and treatment of peripheral pulmonary nodules. We developed a new radioguided surgical technique for ...the detection during VATS of pulmonary nodules smaller than 2 cm, situated deep in the lung parenchyma and neither visible nor palpable with endoscopic instruments. The procedure is divided into two phases. Two hours before surgery 0.3 ml of a solution composed of 0.2 mL of 99mTc-labeled human serum albumin microspheres (5-10 MBq) and 0.1 mL of non-ionic contrast is injected into the lesion under CT guidance. Then the patient is submitted to VATS. During thoracoscopy a collimated probe of 11 mm diameter connected to a gamma ray detector is introduced via an 11.5 mm trocar and the pleural surface of the suspected area is scanned. A hot spot indicates the presence of the radiolabeled nodule and hence the area to be resected. We treated 39 patients with small pulmonary nodules (mean size, 8.3 mm; range, 4-19 mm). The patients were 27 men and 12 women (mean age, 60.8 years; range, 13-80 years). Nineteen patients had a history of synchronous or metachronous malignancy. In all cases the nodule was detected and resected and the resection margins were pathologically free of tumor. Histological examination showed 21 benign and 18 malignant lesions (7 metastases and 11 primary lung cancers). Nine patients with a frozen section-based histopathological diagnosis of lung cancer without functional contraindications underwent a completion lobectomy by open surgery in the same surgical session. In conclusion, the radiolocalization of small pulmonary nodules by gamma probe during VATS is a safe and easy procedure, with fewer complications and a lower failure rate than other localization techniques.
Chronic myeloid leukemia (CML) is a clonal hematological disease in which a discordant maturation of cells from the myeloid lineage is present. As a consequence, CML is associated with defective ...neutrophil functions and with several structural abnormalities of apparently mature circulating neutrophils. Several CML patients display a reduced percentage of Fc gamma RIII (CD 16)-positive neutrophils and a lowered expression of Fc gamma RIII mRNA. Since CD16 is expressed at the stage of metamyelocyte, its defective expression seems to be linked to the discordant maturation which characterizes CML. A reduced percentage of CD16-positive neutrophils has been found, both in untreated patients and in patients in hematological remission after treatment with either hydroxyurea or busulfan; however, to the best of our knowledge, no information is available about the effects of recombinant alpha -2a-interferon ( alpha -IFN) on Fc gamma RIII expression by CML neutrophils. We have revised the clinical files of six patients with a documented and significant reduction in the percentage of CD16-positive neutrophils.
FcRIII (CD16) expression on neutrophils from 17 patients with chronic myeloid leukemia (CML) was studied by flow cytometry using monoclonal antibodies. A variable proportion of CD16-negative ...neutrophils were found both in CML patients in chronic phase (3 out of 8 patients) and in CML patients in hematological remission (3 out of 9 patients). Neutrophils with reduced FcRIII expression showed more defective chemiluminescence and phagocytosis than neutrophils with normal FcRIII expression. Circulating myeloid cells from three patients in chronic phase, showing a normal percentage of CD16-positive neutrophils, were isolated and fractionated by discontinuous Percoll gradients. This study showed that CD16 appears at the stage of metamyelocyte, that band cells and segmented neutrophils display an identical pattern of membrane FcRIII, and that the fluorescence intensity shown by metamyelocytes is different from that displayed by more mature cells. The association between low FcRIII expression and function abnormality could be suggestive of a defect in CML neutrophil maturation.
The present paper describes the case of a patient who developed a B-cell chronic lymphocytic leukemia (B-CLL) 15 months after the diagnosis of polycythemia vera, which had been treated only with ...phlebotomies. In spite of lymphocytosis and the clinical signs and symptoms of leukemia, the patient exhibited at the same time presumptive elements of polycythemia (high LAP index levels, a high number of neutrophils). Cytogenetic investigations, carried out after the appearance of B-CLL, revealed the presence of an unusual abnormality (18 p+) both in bone marrow not stimulated by mitogens and in PWM-stimulated circulating lymphocytes. This case, which is the ninth of its kind described in the literature, offers some interesting observations about the association between myeloproliferative and lymphoproliferative syndromes.
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