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The clinical significance of multifocal pulmonary neuroendocrine proliferation (MNEP), including tumorlets and pulmonary neuroendocrine cell hyperplasia, in association with typical carcinoid (TC), is still debated. We evaluated a retrospective series of TC with long-term follow-up data prospectively collected from 2 institutions and compared the outcome between TC alone and MNEP plus TC. Several baseline covariates were imbalanced between the MNEP plus TC and TC groups; therefore, we conducted 1:1 propensity score matching and inverse probability of treatment weighting in the full sample. In the matched group, the association of clinical, respiratory, and work-related factors with the group was determined through univariable and multivariable conditional logistic regression analysis. A total of 234 TC patients underwent surgery: 41 MNEP plus TC (17.5%) and 193 TC alone (82.5%). In the MNEP plus TC group, older age (P <.001), peripheral tumors (P =.0032), smaller tumor size (P =.011), and lymph node spread (P =.02) were observed compared with the TC group. Relapses occurred in 8 patients in the MNEP plus TC group (19.5%) and 7 in the TC group (3.6%). After matching, in 36 pairs of patients, a significantly higher 5-year progression-free rate was observed for the TC group (P <.01). Similar results were observed using inverse probability of treatment weighting in the full sample. The odds of being in the MNEP plus TC group was higher for those with work-related exposure to inhalant agents (P =.008), asthma or bronchitis (P =.002), emphysema, fibrosis, and inflammatory status (P =.032), or micronodules on the chest computed tomography scan and respiratory insufficiency (P =.036). The association with MNEP seems to represent a clinically and prognostic relevant factor in TC. Hence, careful preoperative workup, systematic pathologic evaluation, including nontumorous lung parenchyma, and long-term postoperative follow-up should be recommended in these patients. [Display omitted] [ABSTRACT FROM AUTHOR]

Therapy for end-stage achalasia is debated, and data on long-term functional results of myotomy and esophagectomy are lacking. We compared quality of life and objective outcomes after pull-down Heller-Dor and esophagectomy. The study included 32 patients, aged 57 years (interquartile range [IQR], 49-70 years), who underwent the Heller-Dor operation with verticalization of the distal esophagus in case of first instance treatment or failed surgery caused by insufficient myotomy, and 16 patients, aged 58 years (IQR, 49-67 years; P =.806), who underwent esophagectomy after failed surgery for other causes. Data were extracted from a database designed for prospective clinical research. Postoperative dysphagia, reflux symptoms, and endoscopic esophagitis were graded by semiquantitative scales. Quality of life was assessed with the 36-Item Short Form Health Survey questionnaire. The median follow-up period was 68 months (IQR, 40.43-94.48 months) after pull-down Heller-Dor and 61 months (IQR 43.72-181.43 months) after esophagectomy (P =.598). No statistically significant differences were observed for dysphagia (P =.948), reflux symptoms (P =.186), or esophagitis (P =.253). No statistically significant differences were observed in the domains physical functioning (P =.092), bodily pain (P =.075) or general health (P =.453). Significant differences were observed in favor of pull-down Heller-Dor for the domains role physical (100 vs 100, P =.043), role emotional (100 vs 0, P =.002), vitality (90 vs 55, P<.001), mental health (92 vs 68, P =.002), and social functioning (100 v s75, P =.011). The pull-down Heller-Dor achieved objective results similar to those of esophagectomy with a better quality of life. This technique may be the first choice for end-stage achalasia in patients with null or low risk for cancer or after recurrent dysphagia caused by insufficient myotomy. [Display omitted] [ABSTRACT FROM AUTHOR]

Background To evaluate prognostic factors based on the number of resected lymph nodes, we considered 202 patients who underwent radical resection and “total lymphadenectomy” for esophageal adenocarcinoma according to a prospective protocol. Methods Fifty-eight tumors surrounded by Barrett’s epithelium underwent esophagectomy and esophagogastrostomy, and 144 tumors without Barrett’s epithelium underwent esophageal resection at the azygos vein level, total gastrectomy, and Roux-en-Y esophagojejunostomy. All nodes and fat tissue were resected at the following stations: chest 4L and R3, R4, R7, R8, and R9 (TNM seventh edition) and abdomen 1–12 according to the Japanese Classification of Gastric Carcinoma (1998). The nodes were counted, excluding fragments. The correlations between the number of nodes yielded and the ratio of the metastatic lymph nodes/lymph nodes yielded with pT stage, grading measurements, and cancer-specific survival (CSS) were calculated. Results A total of 6,270 nodes were yielded (interquartile range per patient, 22–38; minimum, 4 nodes; maximum, 61 nodes). In 3 of 21 (14%) stage pT1 cases, less than 10 nodes were counted, in 2 of 27 (8%) stage pT2 cases, less than 20 were counted, and in 73 of 154 (47%) stage pT3-4 cases, less than 30 nodes were counted. The lymph node yield (LNY) and T stage were not correlated ( r = 0 .048; p = 0.5). The metastatic lymph nodes to lymph nodes yielded ratio was correlated with pT stage ( r = 0.272; p = 0.0001), and G ( r = 0.385; p = 0.0001). CSS positively correlated with pT stage ( p = 0.02), G ( p = 0.001), and metastatic lymph nodes/lymph nodes yielded ratio ( p = 0.01) (multivariate analysis). Conclusions The total number of lymph nodes to be removed in total and within each T stage indicated as thresholds could not be reached in up to 38.6% of patients. The metastatic lymph nodes/lymph nodes yield ratio not the total LNY, did correlate with cancer-specific survival. [ABSTRACT FROM AUTHOR]

Background: Immunohistochemical profiles of esophageal and cardia adenocarcinoma differ according to the presence or absence of Barrett''s epithelium (BIM) and gastric intestinal metaplasia (GIM) in the fundus and antrum. Different lymphatic spreading has been demonstrated in esophageal adenocarcinoma. We investigated the correlation among the presence or absence of intestinal metaplasia in the esophagus and stomach and lymphatic metastases in patients who underwent radical surgery for esophageal and cardia adenocarcinoma. Methods: The mucosa surrounding the adenocarcinoma and the gastric mucosa were analyzed. The BIM+ patients underwent subtotal esophagectomy and gastric pull up, and the BIM– patients underwent esophagectomy at the azygos vein, total gastrectomy, and esophagojejunostomy. The radical thoracic (station numbers 2, 3, 4R, 7, 8, and 9) and abdominal (station numbers 15 through 20) lymphadenectomy was identical in both procedures except for the greater curvature. Results: One hundred ninety-four consecutive patients were collected in three major groups: BIM+/GIM–, 52 patients (26.8%); BIM–/GIM–, 90 patients (46.4%); BIM–/GIM+, 50 patients (25.8%). Two patients (1%) were BIM+/GIM+. A total of 6,010 lymph nodes were resected: 1,515 were recovered in BIM+, 1,587 in BIM–/GIM+, and 2,908 in BIM–/GIM– patients. The percentage of patients with pN+ stations 8 and 9 was higher in BIM+ (p = 0.001), and the percentage of patients with pN+ perigastric stations was higher in BIM– (p = 0.001). The BIM–/GIM– patients had a number of abdominal metastatic lymph nodes higher than did the BIM–/GIM+ patients (p = 0.0001). Conclusions: According to the presence or absence of BIM and GIM in the esophagus and cardia, adenocarcinoma correspond to three different patterns of lymphatic metastasization, which may reflect different biologic and carcinogenetic pathways. [Copyright &y& Elsevier]

Objective: To define the frequency and predictors of short esophagus in a case series of patients undergoing antireflux surgery. Method: An observational prospective study from September 10, 2004, to October 31, 2006, was performed at 8 centers. The distance between the esophagogastric junction as identified by intraoperative esophagoscopy and the apex of the diaphragmatic hiatus was measured intraoperatively before and after esophageal mediastinal dissection; a distance of 1.5 cm was arbitrarily determined to categorize cases as long (>1.5 cm) or short (≤1.5 cm). Results: One hundred eighty patients were enrolled; the mean age of patients was 49.3 ± 15.3 years. At the first measurement (after isolation of the esophagogastric junction), the median distance between the esophagogastric junction and the apex of the hiatus was equal to or shorter than 1.5 cm in 68 (37.7%) patients; at the second measurement (after full mediastinal isolation), the measurement of the distance was still shorter than 1.5 cm in 34 (18.8%) patients and between 1.5 and 2.5 cm in 24 (13.4%) patients. The median length of the mediastinal esophageal dissection was 6 cm (range 1–12 cm). An esophageal lengthening procedure was performed in 26 (14.4%) patients. The duration of symptoms (P = .047), the General Health domain of the SF-36 questionnaire (P = .001), and an x-ray barium swallow (P = .000) are predictive factors for a “true” short esophagus. Conclusions: True short esophagus is present in about 20% of patients undergoing routine antireflux surgery. Radiology, severity, and duration of symptoms are predictors of true foreshortening. [Copyright &y& Elsevier]

Background: The morphologic and immunohistochemical profiles of gastric mucosa and of the tumor were assessed in Siewert type I, type II, and gastric antrum adenocarcinomas. Methods: Sixty-two patients, prospectively operated upon, were included in the study: 37 type II, 15 type I, and 10 antrum adenocarcinoma. Samples of the tumor, the surrounding area, and the gastric corpus and antrum were analyzed histologically, and immunostained for cytokeratins (CK)7/20 (staining positive for cells labeled ≥50%). Results: Among the 37 type II adenocarcinomas were the following: (1) 13 of 37 (35%) had intestinal metaplasia (IM) in the stomach; (2) 24 of 37 (65%) did not show IM at any level; (3) 34 of 37 (92%) had Helicobacter Pylori (HP) infection; (4) 13 of 37(35%) had CK7/20 expression of “Barrett’s type” (CK7+/20−); 24 of 37 (65%) had a “no Barrett’s type” profile (10 of 37 with CK7−/CK20+ and 14 of 37 with CK7+/CK20+); (5) 100% showed the same CK immunoprofile, both in IM and adenocarcinoma (measure of agreement k = 1, p = 0.000). Type I adenocarcinomas showed the following: (1) 87.5% CK Barrett’s type, both in the tumor, and in the surrounding IM; (2) 100% gastric samples devoid of both IM and HP infection. Comparison between CK immunoprofiles in type I and type II tumors showed a difference within the two groups (p = 0.002). One hundred percent of antrum adenocarcinomas showed a no Barrett’s type CK profile, both in the tumor and in the IM of the entire stomach. Conclusions: Data suggest that type II adenocarcinoma cannot be always considered a gastroesophageal reflux disease-related tumor; other pathogenetic pathways should be taken into consideration. [Copyright &y& Elsevier]

Background: Transthoracic ultrasonography has been advocated for the localization of lung nodules during video-assisted thoracoscopic surgery (VATS) for nonperipheral nodules. Methods: Video-assisted thoracoscopic surgery for lung nodules was performed in 54 consecutive patients. Preoperative computed tomography (CT) diagnosed 65 lesions. Positron emission tomography (PET) identified 2 lesions not revealed by CT. All nodules were judged whether visible and/or palpable. Diameter and distance of the nodule from the anterior, lateral, and posterior chest wall were measured on CT scan and served in a discriminant analysis to predict which nodule would be neither visible nor palpable. The deflectable multifrequency (7.5 to 10 MHz) endosonography probe was used to identify the nonvisible and nonpalpable nodules. Results: Resected nodules were 69; 67 diagnosed preoperatively, and 2 intraoperatively by ultrasonography. At VATS exploration 16 of 65 (25%) of the CT diagnosed nodules were nonvisible and nonpalpable. The discriminant analysis failed to predict correctly whether nodules would be visible and/or palpable in 33% because of surrounding severe emphysema, proximity to a fissure, or to the hylum. The endosonography identified 15 out of 16 of the nonvisible and nonpalpable nodules, thus conversion to thoracotomy was necessary for one nodule. The combination of video, palpatory, and endosonographic inspections had 98% sensitivity and 100% specificity in localizing the nodules. Conclusions: Intraoperative transthoracic ultrasonography is useful to guide VATS resection of lung nodules. It is a bedside tool, not requiring planning and coordination with the interventional radiology suite, thus you use it if you need it. It has no related morbidity, and may also have a role in revealing lesions occult at preoperative work-up. [Copyright &y& Elsevier]