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Aim: We reviewed our ten-year experience with surgical en-bloc chest wall and vertebral resection for sarcoma invading the spine, and verified five-year survival and feasibility of this aggressive surgery., Methods: From 1994 to 1999, 13 patients underwent surgical en-bloc resection for primary sarcoma of the chest wall involving the spine. Concurrent pulmonary resection was performed in 12 cases. A single hemi-vertebrectomy was performed in 2 patients, a triple hemi-vertebrectomy in 2, a complete vertebrectomy in 4, a triple complete vertebrectomy in 5., Results: Significative morbidity occurred in 1 patient who had lower limbs paralysis (9%). Perioperative mortality occurred in 2 patients (15.4%): 1 operative death for bleeding and 1 patients for a adult respiratory distress syndrome (ARDS). The overall five-year survival was 30.8%, excluding the 2 perioperative deaths the five-year survival resulted 36.4%., Conclusions: In spite of the limited number of patients, the morbidity and mortality outcome and the five-year survival leads us to think that surgery is the main therapy for primary chest wall sarcomas involving the spine. En-bloc chest wall and vertebral resection is a safe and effective treatment.

The authors describe their experience with the surgical treatment of metachronous homolateral lung cancer by completion pneumonectomy. In the Department of Thoracic Surgery of the National Cancer Institute of Milan, over a period ranging from 1982 to 1996, 30 completion pneumonectomies were performed for local relapses or second primary tumors. The patients submitted to this intervention had a lobectomy as their first operation in 23 cases (77%), a bilobectomy in 4 (13%) and a typical segmentectomy in 3 (10%). Associated with these interventions we performed 2 en bloc chest wall resections and a contralateral wedge resection. Two subjects received neoadjuvant chemo-therapy. Histology revealed squamous carcinoma in 14 cases (47%) and adenocarcinoma in 16 (53%). Seventeen patients (57%) were classified as stage I, 8 as stage II (26%), 4 as stage III (13%) and 1 as stage IV (4%). Four patients received adjuvant chemotherapy and/or radiotherapy. Lung cancer relapse occurred as a single lesion in 27 cases (90%) and as multiple lesions in 3 (10%). We performed 18 right (60%) and 12 left (40%) completion pneumonectomies. In 1 case (4%) a sleeve pneumonectomy was necessary. Associated with these interventions we performed 5 en bloc chest wall resections. The perioperative mortality was 10% and the postoperative morbidity 40%. Histological tests showed 12 squamous carcinomas (40%) and 18 adenocarcinomas (60%). Two patients (7%) had a different histology. Disease was classified as stage I in 13 cases (44%), as stage II in 9 (30%) and as stage III in 8 (26%). Four patients received adjuvant chemotherapy and/or radiotherapy. Two subjects developed a metachronous contralateral tumor (7%). The disease-free interval was 22.70 +/- 14.69 months, with a median value of 17 months (range: 7-53 months). Mean survival after completion pneumonectomy was 49.77 +/- 49.29 months, with a median value of 26.5 months (range: 4-190 months). The 5-year actuarial survival rate, calculated using the Kaplan-Meier method, was 30%. Completion pneumonectomy is a technically very demanding intervention carrying a high risk of morbidity. On the basis of the analysis of our data, we can affirm that mean postoperative survival seems to be satisfactory and to justify this aggressive attitude towards recurrent tumor. We should stress the importance of careful evaluation of indications and precise selection of patients.

To elaborate any protocol treatment it is vitally important to start therapy with the aim of resolving the etiological factor in order to avoid the risk of recidivation. For this purpose the stages which have led to the loss of functional equilibrium must be traced backwards. The most striking symptoms of this damage are represented by the altered occlusal ratios, but the etiopathogenesis must be sought not only in occlusal causes but, more often, in dysmorphic, postural or neuro-muscular causes. It is necessary to start working backwards having restored the spatial position of the jaw in all three dimensions. In order to achieve this for the past three years the authors have routinely used an occlusal plate that they have perfected in the treatment of the majority of patients with dysfunctional syndrome of the stomatognathic apparatus. Over 70% of approximately 600 cases referred to the authors during the same period were treated in this way. The choice of these cases was conditioned by the facial typology of patients. In fact, these patients were characterised by a facial typology which tended to be hypo-divergent. This provoked a condition of "mandibular imprisonment" with an occlusal ratio which locks the jaw in a retruded position. This condition is identified by the authors as the factor that triggers the syndrome not only in those patients in which it is clearly possible to diagnose occlusal diagnosis, but also in those cases in which the pathogenetic motive has a number of causes, for example, poor posture and cases of dysmorphosis.(ABSTRACT TRUNCATED AT 250 WORDS)