Radical Pneumonectomy Research Articles

Giant Bronchial Arteriovenous Malformation Managed with Embolization and Radical Pneumonectomy.

Giant Bronchial Arteriovenous Malformation Managed with Embolization and Radical Pneumonectomy.

Effect of lidocaine perioperative infusion on chronic postsurgical pain in patients undergoing thoracoscopic radical pneumonectomy

BackgroundThoracoscopic radical pneumonectomy is associated with a high incidence of postoperative chronic pain. Studies on the benefits of lidocaine intravenous infusion during the perioperative period were still controversial in thoracoscopic surgery.MethodsSixty-four lung cancer patients scheduled for thoracoscopic radical pneumonectomy were randomly divided into two groups: normal saline group (control group) or lidocaine group. In the lidocaine group, 1.5 mg/kg lidocaine was administered during the anesthesia induction, and 2 mg·kg−1·h−1 lidocaine was continuously intravenous infused until the end of the surgery. After the surgery, a mixture of 2 μg/kg sufentanil and 10 mg/kg lidocaine was continuously intravenous infused by postoperative patient-controlled intravenous analgesia pump (100 ml). In the control group, the same volume of normal saline was administered according to the calculation of lidocaine during anesthesia induction, maintenance and postoperative patient-controlled intravenous analgesia. The primary outcome was the incidence of chronic postoperative pain at 3 months after the surgery. The secondary outcomes include the incidence of chronic postoperative pain at 6 months after the surgery; the effect of lidocaine on postoperative pain within the first 24 and 48 h; total amount of sufentanil administered during entire procedure and the number of PCA triggers within 48 h after surgery.ResultsCompared with the control group, the incidence of chronic pain at 3 months after the surgery was significantly lower (13 cases, 46.4% vs. 6 cases, 20.7%, p < 0.05), but no significant difference at 6 months between two group. The cumulative dosage of sufentanil in perioperative period was significantly lower (149.64 ± 18.20 μg vs. 139.47 ± 16.75 μg) (p < 0.05), and the number of PCA triggers (8.21 ± 4.37 vs. 5.83 ± 4.12, p < 0.05) was significantly greater in the control group. The NRS pain scores at 24 h (1.68 ± 0.72 vs. 1.90 ± 0.86) and 48 h (1.21 ± 0.42 vs. 1.20 ± 0.41) after the operation were no significant difference.ConclusionPerioperative infusion lidocaine significantly reduced the number of PCA triggers and the incidence of chronic postoperative pain at 3 months after the thoracoscopic radical pneumonectomy.Trial registrationhttp://www.chictr.org.cn: ChiCTR1900024759, frist registration date 26/07/2019.

Relationship between molecular changes in epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) mutations in lung adenocarcinoma*

Abstract Objective This study aimed to analyze the relationship between the mutations in epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) and their impact on the prognosis and treatment of lung adenocarcinoma. Methods A total of 158 cases of lung adenocarcinoma reported between January 2007 and January 2014 were retrospectively analyzed. These tumors were resected using radical pneumonectomy and underwent pathology-based diagnosis at our institution (Inner Mongolia People’s Hospital, Hohhot, China). The tissue sections were evaluated using the updated World Health Organization classification of lung adenocarcinomas (2015 version), with each histological component recorded in 5% increments. The histological subtypes were classified, and any surviving cases were followed up. The reverse transcription-polymerase chain reaction (RT-PCR) and direct DNA sequencing were used to evaluate mutations in exons 18, 19, 20, and 21 in the EGFR gene, and the echinoderm microtubule-associated protein-like 4 gene-ALK variant (EML4-ALK) fusions were detected using sequencing. Results Our cohort included 25 patients with pre-invasive adenocarcinoma, 13 patients with lepidic, 66 patients with acinar, 13 patients with papillary, and 25 patients with solid infiltrative adenocarcinoma with the remaining cases presenting with a variety of pathological subtypes. The prognosis of each histological subtype was different with the 5-year disease-free survival and 5-year overall survival (OS) of pre-invasion adenocarcinoma at 100%; the 5-year OS of lepidic, acinar, and papillary adenocarcinoma patients was only 84.6%, 72.7%, and 76.9%, respectively. The 5-year OS of solid and mucinous adenocarcinomas were 32.0% and 36.4%, respectively. EGFR mutation was detected in 69 cases with a mutation rate of 43.7% and majority of these mutations were found in exons 19 (50.6%) and 21 (37.9%), with women and non-smokers shown to experience a higher mutation rate (P &lt; 0.05). However, histological subtype analysis showed that EGFR mutations were primarily found in adenocarcinomas. Most of these mutations were found in lepidic (53.8%) or acinar adenocarcinomas (50.0%), whereas these mutations were rare in both solid (28.0%) and mucinous adenocarcinoma (27.2%). The fusion mutation rate in the EML4-ALK gene was 5.69%, and was most common in young, nonsmoking patients (P &lt; 0.05). Conclusion The prognosis of patients in each lung adenocarcinoma subtype is different, and these outcomes are likely related to mutations in the EGFR and EML4-ALK genes. EGFR mutation rates are higher in lepidic and acinar adenocarcinomas, whereas EML4-ALK gene fusion mutations are more common in solid and mucinous adenocarcinoma. EGFR mutations are more common in female and non-smoking patients, whereas EML4-ALK fusions are more common in young, non-smoking patients.

The B7-H4 gene induces immune escape partly via upregulating the PD-1/Stat3 pathway in non-small cell lung cancer

Non-small cell lung cancer (NSCLC) is associated with high mortality rates worldwide. The costimulatory molecule, B7-H4, a member of the B7 family, plays an important role in immune regulation, mainly by inhibiting the proliferation of T cells to achieve a negative regulatory T cell immune response. The mechanism of action of B7-H4 in non-small cell lung cancer is unknown at present. Tumor tissues from 71 patients subjected to radical pneumonectomy were examined, along with NSCLC cells and BALB/c mice. Among the 71 NSCLC cases, overall and recurrence-free survival rates were significantly lower in those displaying high B7-H4 expression. Mechanistic analyses showed that B7-H4 promoted the growth and metastasis of non-small cell lung cancer tumor tissues in mice through effects on CD8+ T cell apoptosis. Data from western blot experiments further suggested that B7-H4 induced CD8+ T cell death, both in vitro and in vivo, and affecting the PD-1/Stat3 pathway and promoting immune escape of tumor cells. Our collective findings support the potential utility of B7-H4 gene expression as a marker of NSCLC prognosis and provide a novel strategy for targeted therapy.

LEFT ATRIAL EXTENSION OF PRIMARY LUNG SARCOMA VIA THE PULMONARY VEIN

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Metastatic neoplasms to the heart are much more common than primary cardiac tumors.[1, 2] Primary lung tumors often invade the heart locally, spread to the heart via the blood, lymphatics, or both. However, extension of primary lung sarcoma to the left heart chamber via the pulmonary vein is a rare occurrence and has only been reported in limited cases.[1, 3-9] Here, we present a case of a primary lung sarcoma extending into the left atrium via the left superior pulmonary vein. CASE PRESENTATION: A 78-year-old F with a PMH of breast cancer s/p lumpectomy, radiation, and chemotherapy, hyperlipidemia, hypothyroidism, and left bundle branch block who presented to the ER for non-exertional chest pain and dry cough for six weeks. She also reported 9 lb unexplained weight loss in the last three months. Initial vital signs and physical exam was unremarkable. Lab workup revealed mild leukocytosis. EKG was non-ischemic and revealed LBBB, unchanged from prior. Chest x-ray showed a mass in left upper lobe. CT Chest revealed a 9.5cm x 8.5 cm x 7.2 cm left upper lobe mass with extension into the left atrium via left superior pulmonary vein. (Figure 1). TTE confirmed the left atrial tumor invasion. PET scan revealed large hypermetabolic left upper lobe lung mass with extension into the left atrium and anterior mediastinum (Figure 2). CT guided biopsy of the mass was performed, and pathology showed differentiated neoplasm. Immunohistochemistry analysis was suggestive of sarcoma. The patient remained afebrile and hemodynamically stable throughout the hospitalization, was treated with a short course of levofloxacin, and was discharged with outpatient Oncology follow up. DISCUSSION: Primary lung sarcomas are very rare, accounting for only 0.013 to 0.4% of lung tumors.[10] Extension of lung tumors into the left atrium via pulmonary veins occur most frequently in NSCLC; however, it is extremely rare in primary lung sarcomas. The clinical features of cardiac metastasis are variable and depend on the size of the tumor, location of the tumor, and the invasion of adjacent tissues. Patient may present with chest pain, shortness of breath, cough, hemoptysis, weight loss, and those of heart failure such as dyspnea on exertion and peripheral edema. These symptoms are often a result of the direct obstruction of cardiac or valve function, blockage of coronary blood flow, dysfunction of cardiac electrical system, and/or pericardial effusion.[11] Management of patients with cardiac metastasis should include a thorough assessment of all surgical options as these patients generally have poor clinical outcomes and high postoperative mortality.[12, 13] Usually, the treatment of choice is complete resection in combination with chemotherapy or radiotherapy.[14] CONCLUSIONS: Cardiac extension of lung sarcoma is possible via pulmonary vein and familiarity with it is of paramount importance to ensure proper management. Reference #1: Dogan, A., et al., Metastatic atrial sarcoma extending from the lung into the left atrium via a pulmonary vein. Exp Clin Cardiol, 2012. 17(2): p. 77-8. Reference #2: Paraskevaidis, I.A., et al., Cardiac tumors. ISRN Oncol, 2011. 2011: p. 208929. Reference #3: Shuman, R.L., Primary pulmonary sarcoma with left atrial extension via left superior pulmonary vein. En bloc resection and radical pneumonectomy on cardiopulmonary bypass. J Thorac Cardiovasc Surg, 1984. 88(2): p. 189-92. DISCLOSURES: No relevant relationships by Krishna Akella, source=Web Response No relevant relationships by Kashif Hussain, source=Web Response No relevant relationships by Gunjan Joshi, source=Web Response No relevant relationships by Howard Sklarek, source=Web Response

Prognostic Value of Neutrophil-to-lymphocyte Ratio in Patients with Lung Adenocarcinoma Treated with Radical Dissection

背景与目的已有的研究表明中性粒细胞计数/淋巴细胞计数比（neutrophil-to-lymphocyte ratio, NLR）对胃癌、结直肠癌、胰腺癌等多种恶性肿瘤的预后有显著影响，但是其对可切除肺腺癌患者预后影响目前研究较少。本研究旨在分析NLR与肺腺癌患者术后临床病理特征及预后的关系。方法回顾性分析163例经病理确诊为肺腺癌并行肺腺癌根治切除术患者的临床随访病理资料。根据术前1周内化验结果计算NLR值。通过对受试者工作特征曲线（receiver operating characteristic curve, ROC）的分析得出NLR的临界值（cut-off值）。采用Kaplan-Meier生存曲线和Cox比例风险模型研究NLR对肺腺癌术后患者预后的影响。结果采用5年生存作为终点绘制NLR值的ROC曲线，当NLR值为2.96时，正确指数（Youden指数）最大，敏感度为77.5%，特异度为75.9%。低NLR组累计5年生存率显著高于高NLR组（P < 0.05）。单因素及多因素生存分析显示：TNM分期和NLR水平与生存率显著相关（P < 0.05）。结论NLR值作为一项便捷且有效的指标，可用于初步判断肺腺癌术后患者预后状况。

VATS pneumonectomy and sleeve carinal resections—full thoracoscopic and uniportal approach

Advantages of thoracoscopic pulmonary resections can’t be doubted and are confirmed by numerous studies. These procedures allow significantly reducing surgical trauma and blood loss, decreasing the length of hospital staying and less the need for anesthetics. Other benefits include early recovery, rapid rehabilitation and improvement of quality of life. Moreover, if needed, adjuvant chemotherapy might be provided earlier. Despite the high incidence rates of lung cancer in the world and the fact, which most patients present with stage II or, predominantly, stage III of the disease, there has been a decrease in the number of pneumonectomies over the past years. It is attributed to novel neoadjuvant schemes of treatment, which has recently come into play, as well as to the emphasis on organ sparing surgeries with angioplasty and bronchoplasty. However, for some patients with centrally located lung tumors or with tumor infiltrating of hilar structures or interlobar fissure, the only possible surgical procedure is radical pneumonectomy. One of the major problems in selecting patients for thoracoscopic pneumonectomy is unavailability of palpation and lack of full intraoperative revision in order to evaluate tumor spreading. Nevertheless, there is a small group of patients for whom broncho-angioplasty is not possible and who require radical lung removal often with the resection of the surrounding structures and sleeve carinal resections.

Distant outcomes of chemoimmunotherapy with recombinant interferon-gamma for acinar-type adenocarcinoma of the lung.

e20090 Background: We performed a comparative analysis of disease-free survival (DFS) after adjuvant chemoimmunotherapy (ACIT) with recombinant interferon-gamma in combination therapy and standard adjuvant chemotherapy (ACT) of patients with acinar-type adenocarcinoma of the lung. Methods: The study included 63 patients who received radical surgery for stage I-IIIA adenocarcinoma in 2009-2012. Group 1: 33 patients with ACIT after radical pneumonectomy, carboplatin AUC = 5 on day 1 and etoposide 100 mg/m2 on days 1, 3 and 5; i.v. ingaron 500 000 IU/m2 but no more than 1 million IU for one injection on days 2, 4 and 6. Carboplatin was replaced by cisplatin 100 mg/m2 in ACIT after lobectomy. Group 2: 30 patients with similar ACT without ingaron. The interval between courses was 21 days. Survival was estimated by Kaplan-Meier method, and differences were compared using log-rank test. Results: Group 1: 28 (84.8%) patients received 3 ACIT courses, 5 (15.2%) – 2 courses. Group 2: 27 (90%) patients received 3 ACT courses and 3 (10%) – 2 courses. Analysis of the Kaplan-Meier curves showed a tendency to a 8% increase in 5-year DFS that was 58% in Group 1 and 50% in Group 2 (p = 0.064). Conclusions: 5-year DFS increase by 8% demonstrates the expediency of further studies involving more patients which will allow revealing statistically significant differences in long-term results of treatment.

P1.31: Pleural Empyema and Broncho Pleural Fistula After Lung Resection: Analyses of 29 Patients Treated in our Clinic

Broncho pleural fistula (BPF) and pleural empyema are seriously complications after anatomical and non anatomical lung resection although is rare. But with high mortality rate particularly after radical pneumonectomy. a BPF may arise either from dehiscience or disruption of a bronchial closure after anatomical lung resection (segmentectomy, lobectomy; bilobectomy, pneumonectomy)or bronchoplastic sleeve resection and nonanatomical lung resection (wedge resection).Postoperative bronchopleural fistula is classified based in time of onset after surgery; as early (within first week); Intermediate (between 7 and 30 days);and late after (30 days). Malnutrition, imunosuppressive steroids therapies, prior thoracic radiation therapy, poorly controlled lung and pleural infection, active smokers, and the use of induction of chemotherapy are a number of predisposing factors that may developing bronchial fistula and subsecuent pleural empyema. Also others factors related with technical side are, long bronchial stump, large diameter bronchial stump, positive resection margin of bronchial stump, devascularisation of bronchial stump from cauter or unappropriate sutures during bronchial closure. Also risk factors for bronchopleural fistula are right Pneumonectomy, Diabetes, Completion Pneumonectomy, Active TB, Extrapleural Pneumonectomy, COPD, positive pressure ventilation, large postoperative fluid requirement, benign diagnosis prolonged chest tube utiliz. Empyema and BPF are extremely uncommon after lobetomy in contemporary series, particularly after thoracoscopic lobectomy. Empyema is seen in less than 2% of cases, and BPF in less than 1%. Post-pneumonectomy BPF and empyema are associated with mortality rates that vary from 5% up to nearly 50%. We are analysing our patients treated with pleural empyema and bronchopleural fistula, treated previously with lung resection,anatomical und non anatomical for malignant und benignen lung disease.Its retrospective study for period of time 2005-2015.The number of patients treated during 2005-2016 with pulmonary rezexion is 560.Mean age of patients 58±5.6 years (ranging from 13-87 years old).Male 420 patients and female 140 patients. Realized of kind Interventi are 47 patients pneumonectomy, 448 patiens anatomical lobectomy, 12 patients segmentectomy, 18 patients bilobectomy, 35 patients non anatomical resection (wedge lung resection). Bronchial fistula as a major complication occurred in 29 patients after lobectomy in 16 patients, after pneumonectomy in 8 patients, in 5 patients after right pneumonectotmise and 3 after left pneumonectomy, in 3 patients after segmentectomy, in 2 patients after wedge lung resection. Fistul bronchial pulmonary without pleural empyema 3 patients. Treated only pleural dranage for a long time 11 patients. In 2 patients are treated by using of fibrin glue bronchoscopicaly in bronchial fistulae under 5 mm and without infection. By open window are treated 18 patients according Elosser and Clagett –Virculla. Mean time hospital stay of patients treated with bronchial fistula et pleural empyema is 25 ± 5 days (average 5-90 days). 90 days mortality was in 5 patients in 2 patents post after lower bilobectomy and in 2 patients after right and left pneumonectomy, 1 patient after wedge lung resection. Cause of deaths, respiratory failure, sepsis, toxic shock. The diagnosis and management of bronchopleural fistula (BPF) remain a major therapeutic challenge for clinicians and surgeons. It is associated with significant morbidity and mortality.

Ex situ reimplantation technique, in central lung tumors.

The parenchyma-sparing resection is most often performed in patients with impaired preoperative lung or cardiovascular function who would not be able to tolerate a pneumonectomy. Our experience on the ex situ reimplantation procedure and the outcome of patients with lung malignancies, who underwent upper or upper-middle lobectomy, with reimplantation of the lower lobe was reported. We present 9 patients mean age 62.6+16.2 years (7 males/2 females) underwent ex situ reimplantation due to extensive lung tumor of upper lobes. The surgical technique precludes IV heparinization and then radical pneumonectomy. The entire lung was immersed in Ringer's solution (temperature 4 degrees centigrade) and bench surgery was performed. The involved upper (or upper-middle) lobes with involved lymph nodes were resected, thus leaving the healthy lower lobe of the lung. Pneumoplegia solution, named "Papworth pneumoplegia", was administered (1,473 mL) through catheterization of the pulmonary artery and vein stumps (ante grade and retrograde) along with 250 mL of prostaglandin E1. Re-implantation of the lower lobe was performed (I) on the right side, implantation involved the anastomosis of lower pulmonary vein in the site of the cuff of left atrium, followed by suturing the stump of the intermedius pulmonary artery to the right main pulmonary artery and finally the bronchial stumps-intermedius bronchus to the right main bronchus; (II) on the left side the pulmonary vein was anastomosed first, followed by the bronchial stumps and finally by the pulmonary artery. The graft ischemia time was 70.2+8.4 minutes ranged between 55 and 80 minutes. Re-implantation or auto-transplantation should be considered as a safe option for the appropriate patient with lung cancer. The ex situ separation of the cancerous lobes is technically feasible and allows extensive pulmonary resection while minimizing the loss of pulmonary reserve. Based on our work, the major factors that play a role for the survival of initially resected and then re-implanted lung graft, are: (I) the ischemia time of the re-implanted lobe; (II) the proper use of pneumoplegia solutions, along with prostaglandin E1 and heparin; (III) the occurrence of pulmonary vein thrombosis; and (IV) the bronchial anastomosis.

Incomplete (R1) Resection for Early Stage Non Small Cell Lung Cancer (Nsclc): a Single Institution Experience from the University Hospital of South Manchester (Uhsm)

ABSTRACT Aim: Radical lobectomy or pneumonectomy is the standard of care for operable early stage NSCLC. Incomplete (R1) resection occurs in about 9% of patients (pts) and is a known negative prognostic factor for recurrence and survival (OS). There is limited evidence to guide the use of adjuvant chemotherapy (CT) and post-operative radiotherapy (PORT) in this setting. Methods: We reviewed all consecutive pts who underwent surgery for early stage NSCLC at UHSM, between January 2008 and September 2013. Data collected: demographics, stage, type of surgery, histology, resection margins, adjuvant treatment, follow up (f-up) and OS. Primary outcome: percentage (%) of pts who underwent an R1-resection. Secondary outcomes: % of pts who received adjuvant CT and PORT, recurrence rate and OS. Results: Out of 1190 operated pts, we identified 144 (12%) with an R1 resection. Male 51%, median age 66 yo (range 37 – 81 years). Surgery: pneumonectomy/lobectomy/wedge: 21%/76%/3%. Histology: squamous/adenocarcinoma/large cell/adenosquamous/large cell neuroendocrine: 51%/40%/4%/3%/1%. Stage: IA/IB/IIA/IIB/IIIA/IIIB: 5%/8%/17%/28%/ 40%/1%. Post-operative PS: 0-1 (62%), 2 (20%) and 3 (14%). Adjuvant CT and PORT were given to 60% and 66% of pts, respectively. Adjuvant CT regimen: cisplatin/vinorelbine, carboplatin/vinorelbine, cisplatin/etoposide: 76%, 23% and 1% respectively. Median number of cycles given was 4. Reason for not giving adjuvant CT: poor PS (31%), stage 1A-1B (27%), co-morbidities (24%), patient refusal (2%), neoadjuvant CT (4%). PORT was administered to 75%/66%/60%/57% who had bronchial/medial/vascular/chest wall resection margins involved. Median f-up was 15.5 months (mos) and recurrence rate was 46%. Median OS was 23.8 mos for all pts and was 40, 37 and 20 mos for stage I, II and III respectively. Conclusions: In our series, 12% of pts had an R1 resection and this was more common for pts with stage IIIA disease. Our practice was to recommend CT (if indicated) regardless of R1 resection and the majority of pts received PORT. PORT post CT was well tolerated. OS by stage was in keeping with the literature. Median f-up is not long enough to comment on 5-year OS. Disclosure: All authors have declared no conflicts of interest.

Anesthetic Management of a Malnourished, 7-Year-Old Child in Malawi Undergoing a Pneumonectomy

In this report, we describe the case of a 7-year-old girl presenting to Queen Elizabeth Central Hospital, Blantyre, Malawi, with hypoxia and respiratory distress. Investigations demonstrated an endobronchial tumor, and she underwent a radical left-sided pneumonectomy. This case highlights the challenges of anesthesia in a resource-depleted setting.

Significance of Follow-up in Detection of Pulmonary Metastasis of Colorectal Cancer

PurposeThis study was performed to evaluate the effectiveness of conventional chest radiography, carcinoembrionic antigen (CEA) level and abdominal computed tomography (CT) or chest CT for early detection of pulmonary metastasis after a curative resection of colorectal cancer.MethodsWe retrospectively reviewed 84 cases of pulmonary metastasis from a group of colorectal cancer patients who had a curative surgical resection from 2000 to 2006 at the Korea University Medical Center.ResultsStage I tumors were detected in 4 patients, stage II tumors in 18, stage III tumors in 43 and stage IV tumors in 19. The detection rates for pulmonary metastasis were 28.5% by conventional chest radiography, 40.5% by increased CEA level and 28.5% by abdominal CT or chest CT. Among them, fourteen patients underwent a radical pneumonectomy. After detection of pulmonary metastasis, the survival outcome for the patients who underwent a resection of the lung was superior to the survival outcome of the patients who did not undergo a resection of the lung (43.7 months vs. 17.4 months, P = 0.001). For patients who underwent resections of the lung, pulmonary metastasis was detected by conventional chest radiography in 2 (14%) patients, by elevated CEA level in 6 (42%) patients, and by abdominal CT or chest CT in 6 (42%) patients.ConclusionConventional chest radiography is no more useful in detecting early pulmonary metastasis after a curative colorectal surgery than a routine chest CT. Thus, we propose the use of routine chest CT for screening for lung metastasis.

Cardiac Herniation after Intrapericardial Pneumonectomy and Subsequent Cardiac Tamponade

The first case of postpneumonectomy cardiac herniation was described in 1948. Despite advances in surgical technique and patient care, this very rare, potential surgical catastrophe may still be seen today. We present a similar case to that of the original description, but furthermore accentuated by an additional unsuspected surgical complication. This case involves a 59-year-old African-American man initially treated with radical pneumonectomy to resect an invasive T3 squamous cell lung cancer. After surgical resection, the patient developed both clinical and radiographic manifestations of cardiac herniation. Primary suture repair of the pericardial sac led to subsequent cardiac tamponade necessitating correction with Prolene mesh.

Long survival after operation for cancer of the lung

A survey is presented of 293 cases of lung cancer operated on by one surgeon over a period of 35 years. Lobectomy was done in 86 cases with a mortality of 3.5 per cent. Simple pneumonectomy was done in 89 cases with a mortality of 20 per cent, and radical pneumonectomy in 118 cases with a mortality of 15-25 per cent. The survival rate after 5 or more years for lobectomy was 41 per cent (34 patients). After simple pneumonectomy 21 patients (30 per cent) lived 5 years or more, and after radical pneumonectomy 39 patients (39 per cent) lived 5 years or more. The survival of the patients in whom the excised lymph nodes were involved by growth is presented. It is pointed out that at least 1 in 3 patients with cancer of the lung treated by operation was alive 5 years later. The very good long term results are presented including the 10-year and 20-year survival rate. Two patients are still alive after 30 and 34 years respectively. One patient is alive 29 years after a lobectomy and 13 years after a contralateral lobectomy for a new primary cancer. A second new cancer occurred in 9 patients. Continuance of smoking is shown to be harmful. The factors affecting the long term freedom from recurrence are discussed. The cell type of the cancer is shown to be important. Squamous-celled growths have the best results and oat-celled and small-celled the worst, although long term survival can follow operation for both these. The occurrence of a pleural infection after operation may be favourable to long term freedom from recurrence and this way probably so in 2 patients who lived 25 and 27 years respectively and 1 patient who is still alive after 34 years. On the whole the evidence is unconvincing that much benefit may follow radiotherapy combined with operation.

Radical pneumonectomy for bronchial carcinoma.

Radical pneumonectomy for bronchial carcinoma.

Surgical treatment of central lung cancer by lobar replantation

To explore the feasibility, indication and method of surgical treatment of central-type lung cancer by lobar replantation. A retrospective study on the radical resection of 6 patients with stage III central-type lung cancer of the upper lobe by lobar replantation was made. Two patients underwent double-sleeve right upper and middle lobectomy, firstly. Since the length of resected bronchus or pulmonary artery involved by tumor was too long to perform tension-free anastomosis, we had to transplant the inferior pulmonary vein to the proximal stump of the supperior pulmonary vein, so the lower lobe was preserved. Another four patients underwent radical pneumonectomy, because the tumor had extended through the oblique fissure to the margin of the lower lobe. Subsequently, the lower lobe was isolated from the resected lungs and perfused with heparin solution ( 12 500 U/ 500 ml normal saline) for later replantation. After a radical systematic en-bloc mediastinal lymphadenectomy was performed, the preserved lower lobewas replanted. Followed up to Dec 2000, 3 patients had been alive for 43, 12 and 8 months separately with a good living quality. One case had tumor recurrence at 19th month and died at 23rd month postoperatively. One case died of tension pneumothorax caused by bronchopleural fistula on the 19th postoperative day. Another case received resection of the replanted lung for pulmonary arteriobroncho-pleural fistula on the 42nd day and died of respiratory failure caused by pulmonary infection on 14th month postoperatively. Lobar replantation is an alternative procedure of parenchyma-sparing in patients with stage III central lung cancer of the upper lobe whose cardiopulmonary function is too poor to undergo pneumonectomy.

Limited Resection for Lung Cancer in High-Risk Patients

Background. Radical lobectomy and pneumonectomy are the treatment of choice for most patients with lung cancer and have been traditionally thought to be the only chance for cure. However, limited resection is sometimes considered as a compromise in high-risk patients. Methods. We retrospectively reviewed our experiences in performing limited resections for patients with clinical T1 or T2 lung cancers who were poor surgical risks. Data were collected from 51 patients that received wedge (37 patients) or segmental (14 patients) resections due to either advanced age (35 patients were 70 years or older), poor pulmonary function (23 patients with FEV1 (forced expiratory volume in first second) equal to or less than 1.2 L) or concomitant serious diseases (24 patients). Results. No hospital deaths occurred but three patients had prolonged air leak after operations and two patients developed respiratory failure with good recovery using ventilator support. The follow-up period ranged from 0.5 to 4.9 years (median, 3.1 years). The 1-year, 2-year and 3-year survival rates were 91%, 76%, and 51%, respectively. The median survival time of patients met one, tow, or three criteria of high-risk factors were 36.0, 34.9, and 32.8 months, respectively (p=0.4231). Recurrence of disease developed in 21 (41%) of 51 patients. Five patients (10%) had local recurrence along; 13(26%) had distant metastasis alone; while three (6%) had both local recurrence and distant metastasis. Conclusions. Limited resection in selected high-risk patients with lung cancer may achieve acceptable operative mortality (0%) and morbidity rates (9.8%), however, both local (9.8%) and distal metastasis (31.4%) rates seemed relatively high and the long-term survival needs further evaluation.

Bronchogenic carcinoma in young patients.

Some investigators have suggested that lung cancer in young patients has a more aggressive course and poorer prognosis than lung cancer in older patients. A retrospective review is presented of patients less than 40 years of age with bronchogenic carcinoma treated at Roswell Park Cancer Institute between 1984 and 1994, with comparison to a cohort of patients treated in the previous decade. There were 76 patients (41 male and 35 female). Mean age was 35 years (range, 26-39). Adenocarcinoma in 33 patients (43%) and undifferentiated large-cell carcinoma in 22 patients (29%) were the predominant histologic types. Stage IIIa or greater disease was present in 63 (83%) patients. Treatment consisted of chemotherapy (55 patients), radiation therapy (54 patients), and surgery (33 patients). Surgical procedures included pneumonectomy (14 patients), lobectomy (11 patients), wedge resection (1 patient), and thoracotomy only for unresectable disease (7 patients). Operative mortality was 6% (two patients who had radical pneumonectomy for T4 cancer). Median survival for the entire group of patients was 10.4 months, and 5-year survival was 8%. Univariate analysis identified acute presentation (P = 0.02), no resection (P = 0.0001), and higher stage (P = 0.0001) as negative prognostic factors. On multivariate analysis, stage of disease was the only independent predictor of survival (P = 0.005). Resectability was slightly higher (34%, 26/76, vs. 21%, 19/89; P = 0.06) and survival was marginally better (median 10.4 vs. 7.5 months; P = 0.05) than that seen at our institution in the previous decade. Young patients with lung cancer often have advanced disease at the time of presentation. Nevertheless, they should be treated in accordance with standard stage-specific treatment guidelines.

High resolution computed tomography in patients referred for intraluminal bronchoscopic therapy with curative intent.

In patients with so-called roentgenologically occult intraluminal lung tumours, an accurate assessment of tumour size, its location and peribronchial tumour extent is important prior to any intraluminal bronchoscopic therapy (IBT) with curative intent. In twenty patients with so-called occult early-stage lung cancers, clinical outcome was compared to high resolution computed tomography (HRCT) findings prior to IBT. HRCT showed peribronchial tumour extension or nodal enlargement in 7 of the 20 patients (35%), and consequently treatment policy was changed. Five of the seven died 1.5-6 months after diagnosis, one patient underwent a radical pneumonectomy after induction chemotherapy, and the remaining patient is alive with pleural metastasis. HRCT showed intraluminal tumours in 11 of the 20 patients and IBT with curative intent was given. Complete response (CR) was achieved in 10 of the 11 patients, follow-up has been 4-26 months. One patient underwent a radical lobectomy, pathological stage T1NO, after 3 months because of tumour recurrence. HRCT was inconclusive in 2 of the 20 patients with postobstructive infiltrates. IBT was unsuccessful in both these cases. High resolution computed tomography may provide supportive evidence of intra-and extraluminal tumour; thereby, helping in the assessment of patients who were judged to be suitable for intra-luminal bronchoscopic therapy with curative intent. This may lead to a change in the treatment policy. High resolution computed tomography findings are complementary to bronchoscopic, histological and cytological examinations for the proper evaluation of treatment indications in patients with occult lung cancer.