Background The oncologic value of superior vena cava (SVC) resection for lung and mediastinal malignancies remains controversial. In this context, we have reviewed our experience in the treatment of ...locally advanced lung and mediastinal tumor invading the SVC system, analyzing postoperative outcome and long-term oncologic results. Methods The clinical data of patients who underwent SVC resection were retrospectively analyzed to assess postoperative mortality, and overall and procedure-specific morbidity. Overall survival was calculated for mediastinal and lung tumor groups. Results From 1998 to 2004, 70 consecutive patients (52 with lung cancer and 18 with mediastinal tumors) underwent SVC system resection. There were 25 replacements (36%) of the SVC system by prosthesis, whereas the remaining underwent partial resection. Major postoperative morbidity and mortality rates in lung cancer patients were 23% and 7.7%, respectively (50% and 5.6% in mediastinal tumors). In the lung cancer group, 5-year survival probability was 31%, and it was affected by mediastinal nodal status (5-year survival in N0–N1 patients 52%, 21% in N2 patients, 0 in N3 patients). Median survival for mediastinal tumors was 49 months. Conclusions In conclusion, SVC resection may achieve permanent cure in patients who would have been defined as inoperable 10 years ago. In the case of mediastinal tumors, the need for SVC resection alone should not be considered a contraindication for surgery when prosthetic replacement is feasible. In the case of lung tumors, infiltration of SVC can achieve satisfactory long-term results after neoadjuvant chemotherapy, only when pathologic N2 disease is excluded by preoperative mediastinoscopy.
Prognostic role of lymph node involvement in lung metastasectomy Veronesi, Giulia, MD; Petrella, Francesco, MD; Leo, Francesco, MD ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
04/2007, Letnik:
133, Številka:
4
Journal Article
Recenzirano
Odprti dostop
Objective The impact of lymph node involvement in lung metastasectomy from extrapulmonary malignancies is uncertain. We assessed the prognostic value of lymph node status in lung metastasectomy and ...the prevalence of unexpected mediastinal lymph node involvement after lymph node sampling or dissection. Methods From May 1998 to October 2005, 388 patients underwent 430 pulmonary metastasectomies with curative intent. The clinical records of all patients who underwent radical lymph node dissection or sampling were reviewed retrospectively. Survival was evaluated using the Kaplan–Meier method and comparison of survival curves by log–rank test. Results A total of 124 patients (61 men, mean age 59 years) underwent 139 pulmonary metastasectomies (56 wedge resections, 30 segmentectomies, 49 lobectomies, and 4 pneumonectomies with radical lymph node dissection 88 or sampling 51). Means of 9.4 lymph nodes and 2 lung metastases per intervention were removed. The median disease-free interval from primary treatment to lung metastasectomy was 49 months. Lymph node involvement was present in 25 patients (20%), in 10 (8%) at N1 stations (hilar or peribronchial) and in 15 (12%) at N2 stations (mediastinal), and in 7 (12.5%) after atypical resection and in 19 (23%) after typical resection. In 15 patients (12%) (60% of N+ patients), lymph node involvement was unexpected. Estimated overall 5-year survival was 46%: It was 60% for subjects with no lymph node metastasis and 17% and 0% for those with N1 and N2 disease, respectively ( P = .01). Conclusions Lymph node involvement heavily affects prognosis after pulmonary metastasectomies. In most patients, lymph node involvement was not revealed by preoperative workup.
Background Robotic lobectomy with radical lymph node dissection is a new frontier of minimally invasive thoracic surgery. Series of sublobar anatomic resection for primary initial lung cancers or for ...metastasis using video-assisted thoracic surgery have been reported but no cases have been so far reported using the robot-assisted approach. We present the technique and surgical outcome of our initial experience. Methods Clinical data of patients undergoing robotic lung anatomic segmentectomy were retrospectively reviewed. All cases were done using the DaVinci System. A 3- or 4-incision strategy with a 3-cm utility incision in the anterior fourth or fifth intercostal space was performed. Individual ligation and division of the hilar structures was performed using Hem-o-Lok (Teleflex Medical, Research Triangle Park, NC) or endoscopic staplers. The parenchyma was transected with endovascular staplers introduced by the bedside assistant mainly through the utility incision. Systematic mediastinal lymph node dissection or sampling was performed. Results From 2008 to 2010, 17 patients underwent a robot-assisted lung anatomic segmentectomy in two centers. There were 10 women and 7 men with a mean age of 68.2 years (range, 32 to 82). Mean duration of surgery was 189 minutes. There were no major intraoperative complications. Conversion to open procedure was never required. Postoperative morbidity rate was 17.6% with pneumonia in 1 case and prolonged air leaks in 2 patients. Median postoperative stay was 5 days (range, 2 to 14), and postoperative mortality was 0%. Final pathology was non-small cell lung cancer in 8 patient, typical carcinoids in 2, and lung metastases in 7. Conclusions Robotic anatomic lung segmentectomy is feasible and safe procedure. Robotic system, by improving ergonomic, surgeon view and precise movements, may make minimally invasive segmentectomy easier to adopt and perform.
Objective Pneumonectomy is not always sufficient for the radical resection of cancer. In the present study, pneumonectomy may be associated with an extended resection of mediastinal or parietal ...structures. The postoperative risk and the oncologic benefits of such an extended procedure have not been sufficiently demonstrated. Methods We have defined “extended” pneumonectomy (EP) as the removal of the entire lung, associated with one or more of the following structures: superior vena cava, tracheal carina, left atrium, aorta, chest wall, or diaphragm. Our clinical database was retrospectively reviewed to identify patients who underwent EP to assess their postoperative morbidity, mortality, and long-term survival. Results Between 1998 and 2005, 47 EPs were performed. The “extended” procedure included left atrium resection in 15 patients, combined SVC and carinal resection in 9 patients, aortic resection in 8 patients (in 3 patients with prosthetic replacement), chest wall or diaphragmatic resection in 6 patients, SVC resection in 4 patients, and carinal resection in 4 patients. A partial esophageal muscular resection was performed in 1 patient. Overall 60-day mortality was 8.5%. Major postoperative complications occurred in 8 patients (17%). The 2- and 5-year survival rates for the overall population were 42% and 22.8%, respectively. Interestingly, long-term survivors were recorded only in the group of patients who received induction treatment. Conclusions Extended pneumonectomy is a feasible procedure with an acceptable risk factor. To improve the selection of patients, all candidates should undergo preoperative mediastinoscopy and induction chemotherapy. In patients with positive response to chemotherapy or stable disease, extended pneumonectomy may afford a radical resection in more than 80% of cases and may result in a permanent cure in some instances.
Background The aim of our study was to evaluate retrospectively in a large single institution setting all cases of lung resections for colorectal metastases from 1998 to 2008 and to assess ...clinicopathologic factors influencing outcome. Methods In all, 199 patients, 125 men and 74 women, with lung metastases of colorectal cancer, 120 colon and 79 rectum, underwent resection with curative intent; mean interval between primary surgery and lung metastasis was 35 months. Carcinoembryonic antigen preoperative value was abnormal in 52 patients; K-RAS wild-type was detected in 60 of 97 examined cases; 75 patients received preoperative or postoperative chemotherapy or both. A solitary lesion was described in 95 patients (47.7%), two or three metastases in 72 (36.2%), and more than three metastases in 26 (13.1%). Nodal status was reported in 130 patients (73%). One hundred twenty patients (60.3%) underwent wedge resection, 27 (13.6%) underwent segmentectomy, and 52 (26.1%) had lobectomy. An R0 resection was achieved in 178 cases (89.4%). Results Median overall survival was 4.2 years (95% confidence interval: 3.1 to 5.1) with a 5-year overall survival of 43% (95% confidence interval: 36% to 50%). An R1 resection (log rank p = 0.0001), thoracic nodal involvement (log rank p = 0.0002), and preoperative abnormal carcinoembryonic antigen value (log rank p < 0.001) were significantly associated with poor outcome in univariate analysis. In multivariate analysis, the same variables plus the number of lesions (single versus multiple, p = 0.04) were shown to affect outcome. Conclusions An R0 resection, preoperative carcinoembryonic antigen, nodal involvement, and number of lesions represent strong prognostic factors in patient with lung metastases of colorectal cancer. The role of systemic treatments and biomolecular tests deserve future prospective investigations.
Background Bronchopleural fistulas are a major therapeutic challenge. We have reviewed our experience to establish the best choice of treatment. Methods From January 2001 to December 2013, the ...records of 3,832 patients who underwent pulmonary anatomic resections were retrospectively reviewed. Results The overall incidence of bronchopleural fistulas was 1.4% (52 of 3,832): 1.2% after lobectomy and 4.4% after pneumonectomy. Pneumonectomy vs lobectomy, right-sided vs left-sided resection, and hand-sewn closure of the stump vs stapling showed a statistically significant correlation with fistula formation. Primary bronchoscopic treatment was performed in 35 of 52 patients (67.3%) with a fistula of less than 1 cm and with a viable stump. The remaining 17 patients (32.7%) underwent primary operation. The fistula was cured with endoscopic treatment in 80% and with operative repair in 88.2%. Cure rates were 62.5% after pneumonectomy and 86.4% after lobectomy. The cure rate with endoscopic treatment was 92.3% in very small fistulas, 71.4% in small fistulas, and 80% in intermediate fistulas. The cure rate after surgical treatment was 100% in small fistulas, 75% in intermediate fistulas, and 100% in very large fistulas. Morbidity and mortality rates were 5.8% and 3.8%, respectively. Conclusions The bronchoscopic approach shows very promising results in all but the largest bronchopleural fistulas. Very small, small, and intermediate fistulas with a viable bronchial stump can be managed endoscopically, using mechanical abrasion, polidocanol sclerosing agent, and cyanoacrylate glue. Bronchoscopic treatment can be repeated, and if it fails, does not preclude subsequent successful surgical treatment.
Background Bronchopleural fistula after lung resection still represents a challenging life-threatening complication for thoracic surgeons. Considering its extremely high mortality rate, an effective ...treatment is urgently required. Our project investigated the hypothesis of experimental bronchopleural fistula closure by bronchoscopic injection of autologous bone marrow–derived mesenchymal stem cells into the cavity of the fistula, evaluating its feasibility and safety in a large animal model. Methods An experimental bronchopleural fistula was created in 9 goats after right upper tracheal lobectomy. The animals were randomly assigned to two groups: one received autologous bone marrow–derived mesenchymal stem cell bronchoscopic transplantation; the other received standard bronchoscopic fibrin glue injection. Results All animals receiving bronchoscopic stem cell transplantation presented fistula closure by extraluminal fibroblast proliferation and collagenous matrix development; none (0%) died during the study period. All animals receiving standard treatment still presented bronchopleural fistula; 2 of them (40%) died. Findings were confirmed by pathology examination, computed tomography, and magnetic resonance imaging. Conclusions Bronchoscopic transplantation of bone marrow–derived mesenchymal stem cells effectively closes experimental bronchopleural fistula by extraluminal fibroblast proliferation and collagenous matrix development. Stem cells may play a crucial role in the treatment of postresectional bronchopleural fistula after standard lung resection. Although these results provide a basis for the development of clinical therapeutic strategies, the exact mechanism by which they are obtained is not yet completely clear; further studies are required to understand exactly how stem cells work in this field.
Postsurgical intrapericardial adhesions are still considered an unavoidable consequence of cardiothoracic operations. They increase the technical difficulty and the risk of reoperations. The ...pathogenesis of postsurgical adhesions is a multistep process, and the main key players are (1) loss of mesothelial cells, (2) accumulation of fibrin in areas devoid of mesothelial cells, (3) loss of normal pericardial fibrinolysis, and (4) local inflammation. Today, very promising methods to reduce adhesions are available for clinical use. This report reviews the process of formation of adhesions and the methods to prevent them, classified according to the mechanism of action.
Background Pulmonary artery (PA) reconstruction for lung cancer is technically feasible with low morbidity and mortality. We assessed our experience with partial or circumferential resection of the ...PA during lung resection. Methods Between 1998 and 2013, we performed PA angioplasty in 150 patients with lung cancer. Partial PA resection was performed in 146 patients. PA reconstruction was performed by running suture in 113 patients and by using a pericardial patch in 33. A circumferential PA resection was performed in 4 patients, and reconstruction was made with polytetrafluoroethylene and by a custom-made bovine pericardial conduit. Bronchial sleeve resection was associated in 56 patients. Stage I disease was present in 32 patients, stage II in 43, stage IIIA in 51, and stage IIIB in 17. Seventy-five patients received induction chemotherapy, and 7 patients had a complete response. Results Thirty-day mortality was 3.3% (n = 5); two of these patients died of a massive hemoptysis. Pulmonary complications occurred in 33 patients, cardiac in 28, and air leaks in 17. Overall 5-year and 10-year survival was 50% and 39%, respectively. Survival at 5 and 10 years for stages I and II vs stage III was, respectively, 66% vs 32% and 56% vs 20% ( p < 0.0001). Five-year survival was 61% for N0 and N1 nodal involvement vs 28% for N2, and the respective 10-year survival was 45% vs 28% ( p = 0.001). Induction chemotherapy did not influence survival. Multivariate analysis yielded advanced stage, N2 status, and squamous cell carcinoma as negative prognostic factors. Conclusions PA reconstruction is safe, with excellent long-term survival. Our results support this technique as an effective option to pneumonectomy for patients with lung cancer.
“Circular clamp” excision: A new technique for lung metastasectomy Petrella, Francesco, MD; Leo, Francesco, MD, PhD; Dos Santos, Nelson Alves, MD ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
07/2009, Letnik:
138, Številka:
1
Journal Article
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