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Background. Solitary fibrous tumor (SFT) is a rare variant of soft tissue sarcoma (STS). Materials and Methods. We reviewed SFT patients (pts) treated at our institution between 12/1990 and 09/2017. Results. We identified 94 pts with a median follow-up (mFU) of 4.7 years (range: 0.1–21.53). Primary sites were the chest (33%), abdomen (21.3%), brain (12.8%), and extremities (9.6%); 6.4% of pts presented with synchronous metastasis. Median overall survival (mOS) from the first diagnosis was 56.0 months (m) (0.3–258.3). Doege–Potter syndrome was seen in 2.1% of pts. Primary resection was performed in 86 pts (91.5%). Median progression-free survival was 34.1 m (1.0–157.1), and 43% of pts stayed SFT-free during FU. Local recurrence occurred in 26.7% after a mFU of 35.5 m (1.0–153.8), associated with an OS of 45.1 m (4.7–118.2). Metachronous metastasis occurred in 30.2% after a mFU of 36.0 m (0.1–157.1). OS in metastatic pts was 19.0 m (0.3–149.0). Systemic therapy was given to 26 pts (27.7%) with inoperable/metastatic disease. The most common (57.7%) upfront therapy was doxorubicin, achieving responses in 13.3% of pts with a PFS of 4.8 m (0.4–23.8). In second line, pts were treated with ifosfamide or pazopanib, the latter achieving the highest response rates. Third-line treatment was heterogeneous. Conclusion. SFT is an orphan malignancy with a highly variable clinical course and a considerable risk of local failure and metachronous metastasis. Surgery is the only curative option; palliative systemic therapy is used in inoperable/metastatic cases but achieves low response rates. The highest response rates are seen with pazopanib in second/third line.

Despite improvements in operative strategies for esophageal resection, anastomotic leaks, fistula, postoperative pulmonary complications, and chylothorax can occur. Our review seeks to identify potential risk factors, modalities for early diagnosis, and novel interventions that may ameliorate the potential adverse effects of these surgical complications following esophagectomy. ispartof: Annals of the New York Academy of Sciences vol:1434 issue:1 pages:254-273 ispartof: location:United States status: Published online

Background Total minimally-invasive transthoracic esophagectomy (ttMIE) faces increasing application in surgical treatment of esophageal cancer. For esophago-gastric reconstruction, different anastomotic techniques are currently used, but their impact on postoperative anastomotic leakage and morbidity has not been investigated. The aim of this retrospective multicenter analysis was to describe anastomotic techniques used for ttMIE and to analyze the associated morbidity. Patients and Methods Patients were selected from a basic dataset, collected over a 5-year period from 13 international surgical high-volume centers. Endpoints were anastomotic leakage rate and postoperative morbidity in correlation to anastomotic techniques, measured by the CD classification and the Comprehensive Complication Index® (CCI). Results Five anastomotic techniques were identified in 966 patients after ttMIE: Intrathoracic end-to-side circular-stapled technique in 427 patients (double-stapling n=90, purse-string n=337), intrathoracic (n=109) or cervical (n=255) side-to-side linear-stapled, and cervical end-to-side hand-sewn (n=175). Leakage rates were similar in intrathoracic and cervical anastomoses (15.9% vs. 17.2%, P=0.601), but overall complications (56.7%% vs. 63.7%, P=0.029) and median 90-day CCI (21 (IQR 0-36) vs. 29 (IQR 0-40), P=0.019) favored intrathoracic reconstructions. Leakage rates after intrathoracic end-to-side double-stapling (23.3%) and cervical end-to-side hand-sewn (25.1%) techniques were significantly higher compared with intrathoracic side-to-side linear (15.6%), end-to-side purse-string (13.9%) and cervical side-to-side linear-stapled esophago-gastrostomies (11.8%) (P Conclusion Results of this analysis present the current status of the technical evolution of ttMIE with anastomotic leakage as predominant surgical complication. However, technique-related morbidity requires cautious interpretation considering the long learning curve of this complex surgical procedure.

Objectives Success of an enhanced recovery program (ERP) is not easily measured/quantified. Can a newly developed measuring instrument help to determine compliance and thus success of an ERP? Methods From the introduction of our ERP (May 2017), 200 consecutive potential curative esophagectomies for cancer were reviewed. A newly developed instrument with 12 prospectively recorded benchmarks was used to measure compliance. Each patient was scored for all benchmarks, reflecting how well the protocol-timeline was followed. A mean score of ≥70% of all benchmarks in a patient is considered compliant with the ERP-protocol. Results Sixty-three percent (125/200) of the patients were compliant (Fig1A). Compliance to the ERP showed significant beneficial effects on clinical outcomes: the comprehensive complications index was significantly lower in the compliant group compared to the not-compliant group: 22.6 versus 43.3; p Conclusion Higher compliance to the ERP protocol helps to reduce postoperative complications and thus shortens the postoperative hospital stay.

Objective Clinical T2N0 esophageal carcinoma is a heterogenous disease frequently complicated by inaccurate staging. Incorrect staging may lead to suboptimal treatment for patients with unidentified local-regionally advanced disease. Therapeutic options for these patients remain controversial. We sought to evaluate the outcomes of patients with cT2N0 who underwent esophagectomy as either primary therapy or after neoadjuvant treatment. Methods This was a multi-institutional collaboration of 26 high-volume esophageal centers. Patients with complete staging who underwent elective resection from 2002 to 2012 were included. Three treatment groups were identified; primary esophagectomy, preoperative chemotherapy, and preoperative chemoradiation (CXRT). Pretreatment variables were explored for independent predictors of long-term outcomes. The primary esophagectomy subgroup was evaluated for stage migration. Results In total, 767 patients were evaluated; 35% (268) had preoperative therapy (195 CXRT, 73 chemotherapy). Staging accuracy was 14% (70/499), with pT 0 in 39% (195). Preoperative treatment modality (none, CXRT, chemotherapy) was not identified as a predictor of outcome (median survival 63, 70, 71 months, respectively, P = .956). Longitudinal tumor length >3.25 cm was predictive of pN+ for the primary esophagectomy cohort as well as adenocarcinoma histology only (odds ratio 2.2 and 2.4, respectively, P Conclusions Current treatment options for patients with cT2N0M0 do not reveal a comparative survival advantage to preoperative therapy. Pretreatment tumor length can identify a subgroup of patients at risk for understaging (pN+). The incidence of overstaging suggests that organ-sparing approaches (endoscopic resection) may play a future role in appropriately selected patients.

Introduction: The M component and TNM stage groupings for malignant pleural mesothelioma (MPM) have been empirical. The International Association for the Study of Lung Cancer developed a multinational database to propose evidence-based revisions for the eighth edition of the TNM classification of MPM. Methods: Data from 29 centers were submitted either electronically or by transfer of existing institutional databases. The M component as it currently stands was validated by confirming sufficient discrimination (by Kaplan-Meier analysis) with respect to overall survival (OS) between the clinical MO (cM0) and cM1 categories. Candidate stage groups were developed by using a recursive partitioning and amalgamation algorithm applied to all cM0 cases. Results: Of 3519 submitted cases, 2414 were analyzable and 84 were cM1 cases. Median OS for cM1 cases was 9.7 months versus 13.4 months (p = 0.0013) for the locally advanced (T4 or N3) cM0 cases, supporting inclusion of only cM1 in the stage IV group. Exploratory analyses suggest a possible difference in OS for single- versus multiple-site cM1 cases. A recursive partitioning and amalgamation generated survival tree on the OS outcomes restricted to cM0 cases with the newly proposed (eighth edition) T and N components indicates that optimal stage groupings for the eighth edition will be as follows: stage IA (T1N0), stage IB (T2-3N0), stage II (T1-2N1), stage IIIA (T3N1), stage IIIB (T1-3N2 or any T4), and stage IV (any M1). Conclusions: This first evidence-based revision of the TNM classification for MPM leads to substantial changes in the T and N components and the stage groupings. (C) 2016 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.

Tumor regression grading (TRG) systems categorize residual tumor volume on the primary tumor after neoadjuvant treatment. Aim was to evaluate the impact of Mandard TRG, residual tumor depth (ypT) and residual lymph node status (ypN) and extent (ELNI) i.e. intracapsular versus extracapsular involvement on overall (OS) and disease-free survival (DFS) in esophageal carcinoma.Between 2005 and 2014, 344 patients receiving R0-esophagectomy after neoadjuvant chemoradiation therapy (nCRT) were selected. Mandard TRG, ypTN and ELNI were prospectively recorded.Mandard TRG1 was found in 110 (32%); TRG2 in 120 (35%); TRG3 in 53 (15%); TRG4 in 54 (16%) and TRG5 in 7 (2%) patients. Both OS and DFS showed no significant difference between TRG1 and 2 (p = 0.059 and 0.105, respectively). Therefore, TRG1/2 was classified together as 'major response', TRG3/4 as 'minor response' and TRG5 as 'no response'. Multivariate analysis showed two independent prognosticators for OS (tumor regression response (TRR) and number of positive lymph nodes) and three independent prognosticators for DFS (TRR, ypT and ELNI).After nCRT followed by surgery for esophageal carcinoma, number of residual positive lymph nodes as well as TRR are prognosticators for OS. Minor TRR, ypT and extracapsular lymph node invasion are prognosticators for recurrence.

Large single-centre institutional series on thymic tumours are rare. Complete resection remains the mainstay of successful treatment. Characteristics and survival were reviewed in all patients treated between 1993-2013.Hospital databases revealed 134 patients with pathologically-proven thymic tumour. Follow-up (median 63 months) was through patient notes and telephone contact with general practitioner.Patients were classified in Masaoka-Koga stages: I: 50 (37%); IIa: 14 (10%); IIb: 14 (10%); III: 27 (20%); IVa: 19 (14%); IVb: 4 (3%); unknown: 6 (5%). According to WHO classification, pathological subtypes were A: 19 (14%); AB: 25 (19%); B1: 21 (16%); B2: 31 (23%); B3: 15 (11%); thymic carcinoma: 23 (17%). Parathymic syndromes were diagnosed in 45 patients : myasthenia gravis (84%); pure red-cell aplasia (4%); hypogammaglobulinemia (2%); and others. 124 patients (93%) underwent surgery with complete resection in 104 (84%). Surgical approach was: sternotomy: 79; thoracotomy: 35; cervicotomy: 2; other/unknown: 8. In 73 patients (59%) no biopsy was taken prior to surgical resection, 25 were treated with induction chemotherapy, 36 received adjuvant radiotherapy. Hospital mortality was 0.81%. 35 patients died during follow-up (13 of tumour or treatment-related causes). Overall and recurrence-free survival at 5, 10, and 15 years were 86%; 64%; 47% and 67%; 49%; and 31%, respectively and were significantly (p0.01) different according to Masaoka-Koga stage. There was a significant association between WHO classification and Masaoka-Koga stages I-IIa-IIb versus III-IVa-IVb (p0.01).Operability and complete resectability of thymic tumours in our experience is high resulting in prolonged overall and recurrence-free survival. Masaoka-Koga stage is an important predictor for survival and shows a significant association with WHO classification.

Background Little is known about recurrence patterns in patients with a pathologically complete response (pCR) or an incomplete response after neoadjuvant chemoradiotherapy (CRT) followed by resection for oesophageal cancer. This study was performed to determine the pattern of recurrence in patients with a pCR after neoadjuvant CRT followed by surgery. Methods All patients who received neoadjuvant CRT followed by oesophagectomy between 1993 and 2009 were identified from a database, and categorized according to pathological tumour response. Recurrences were classified as locoregional or distant. Results One hundred and eighty-eight patients were included. Median potential follow-up was 71·6 months. A pCR was achieved in 62 (33·0 per cent) of 188 patients. Recurrence developed in 24 (39 per cent) of 62 patients with a pCR and 70 (55·6 per cent) of 126 without a pCR (P = 0·044). Locoregional recurrence with or without synchronous distant metastases occurred in eight patients (13 per cent) in the pCR group and 31 (24·6 per cent) in the non-pCR group (P = 0·095). Locoregional recurrences without synchronous distant metastases occurred four (6 per cent) and ten (7·9 per cent) patients respectively (P = 0·945). The overall 5-year survival rate was significantly higher in the pCR group than in the non-pCR group (52 versus 33·9 per cent respectively; P = 0·019). Conclusion Of patients with a pCR, 13 per cent still developed a locoregional recurrence. Although pCR is more favourable for survival, it is not synonymous with cure or complete locoregional disease control.

Posttraumatic complex regional pain syndrome (CRPS) has a strongly negative impact on rehabilitation and activities of daily living. Treatment is most often unrewarding. To analyze the efficacy of endoscopic thoracic sympathectomy (ETS) in reducing pain and disability associated with CRPS prospectively. Over a 5-year period, 12 patients (7 females and 5 males; median age 46.5 [range 34–60 years]) with posttraumatic CRPS underwent unilateral ETS. The median duration of CRPS symptoms before ETS was 3.8 months (range 1.2–19.9). The sympathetic chain was resected from the 2nd to the 5th rib, and the nerve of Kuntz was severed. Median postoperative 16 months (range 12–40). Pain was assessed, at rest (passive) and during movement (active), using a visual analogue scale (VAS) from 0 to 10. One patient (8%) suffered a hydrothorax and 3 patients (25%) complained of contralateral compensatory hyperhydrosis. At 1 month (n = 12), 2 months (n = 7), 6 months (n = 12), and 1 year (n = 12) after ETS, there was a significant decrease in passive and active VAS (P

Oesophageal perforation related to anterior cervical surgery is an uncommon but well recognised and potentially life-threatening complication with an incidence of 0–3.4%. Our experience with this complication and a review of the literature are presented. We retrospectively reviewed our clinical experience over 10 years and found four patients in whom an oesophageal perforation was recognised after anterior surgery for cervical spine trauma. In three patients the perforation was noticed in the early post-operative period and the other had a delayed presentation. In all patients, the hardware was removed, long-term intravenous antibiotics were administered and parenteral nutrition was instituted. In two patients a primary suture of the perforation was performed and in one of these an additional sternocleidomastoid myoplasty was carried out as well. One patient had conservative treatment and one died before closure of the perforation could be performed. The two patients, in whom surgical repair of the perforation was performed, recovered well with residual neurological deficits as expected due to the cervical trauma. In the patient in whom conservative treatment was instituted, healing of the perforation occurred. One patient died due to systemic complications, indirectly related to the perforation. Although not very frequent and sometimes difficult to diagnose, oesophageal perforations after anterior cervical surgery constitute a potentially life-threatening complication. Diagnosis is made by imaging or endoscopic studies, but clinical suspicion is most important. Basic treatment consists of surgery with removal of hardware, drainage of abscesses, primary closure of the perforation if possible, parenteral nutrition and antibiotic therapy. Residual instability should be recognised in time and may be anticipated in patients in whom there has been little time for solid bony fusion. Successful management depends on early diagnosis and immediate institution of treatment.

Objective : To evaluate the frequency and risk of postoperative complications and mortality in patients with IIIa-N2 non small cell lung cancer after induction chemotherapy and surgery. Methods : In a surgical database records from ninety two patients, operated between January 1, 2000 and December 31, 2006 were reviewed. Univariate analysis was used to identify predictors of postoperative complications and in-hospital mortality. Results : All cases were histologically confirmed stage IIIa-N2. All patients received preoperative platinum based chemotherapy without radiotherapy. Pneumonectomy was performed in 20 cases (23.5%), from which 9 right sided. (Bi)lobectomy was performed in 53 cases (62.4%) and sleeve lobectomy in 11 cases (17.2%). One wedge resection was performed (1.2%). In 7 cases (7.6%) only an exploration was done. Complications developed in 35 patients (38%). Major complications in 15 patients (16%). No bronchopleural fistulae were observed. Analysis identified increased age and high physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) as a risk factor to develop complications, and a high simplified comorbidity score as a risk factor to develop a major complica - tion. Higher age, Charlson comorbidity index , simplified comorbidity score and POSSUM were a risk factor for devel- oping pneumonia. Conclusion : Although surgery after induction therapy for IIIa-N2 NSCLC can be done with a morbidity and mortality comparable to surgery alone, it remains a high risk operation. It should therefore be performed in a center with experience. Bronchial stump protection should be used whenever there is an increased risk for developing a broncho - pleural fistula. In deciding whether to do surgery or radiotherapy one should keep in mind the feasibility of performing a complete resection together with a preoperative assessment to predict complications and mortality. For the pre - operative assessment several scoring systems can be used from which we find the simplified comorbidity score most useful .

Introduction: The current T component for malignant pleural mesothelioma (MPM) has been predominantly informed by surgical data sets and consensus. The International Association for the Study of Lung Cancer undertook revision of the seventh edition of the staging system for MPM with the goal of developing recommendations for the eighth edition. Methods: Data elements including detailed T descriptors were developed by consensus. Tumor thickness at three pleural levels was also recorded. An electronic data capture system was established to facilitate data submission. Results: A total of 3519 cases were submitted to the database. Of those eligible for T-component analysis, 509 cases had only clinical staging, 836 cases had only surgical staging, and 642 cases had both available. Survival was examined for T categories according to the current seventh edition staging system. There was clear separation between all clinically staged categories except T1a versus T1b (hazard ratio = 0.99, p = 0.95) and T3 versus T4 (hazard ratio = 1.22, p = 0.09), although the numbers of T4 cases were small. Pathological staging failed to demonstrate a survival difference between adjacent categories with the exception of T3 versus T4. Performance improved with collapse of T1a and T1b into a single T1 category; no current descriptors were shifted or eliminated. Tumor thickness and nodular or rindlike morphology were significantly associated with survival. Conclusions: A recommendation to collapse both clinical and pathological T1a and T1b into a T1 classification will be made for the eighth edition staging system. Simple measurement of pleural thickness has prognostic significance and should be examined further with a view to incorporation into future staging. (C) 2016 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.

Surgical treatment and prognosis is different in esophageal, cardiac and distal gastric adenocarcinomas. Determination of the origin, in particular of adenocarcinomas situated at the gastroesophageal junction, may be difficult. It has been suggested that esophageal adenocarcinomas are characterized by a specific cytokeratin pattern, namely the CK7+/CK20- pattern. According to the same authors, this cytokeratin pattern is absent in gastric adenocarcinomas. The aim of our study is to evaluate if this cytokeratin pattern CK7+/CK20- is absent in cardiac and distal gastric adenocarcinomas. Therefore, we evaluated the combined immunohistochemical expression of CK7 and CK20 on paraffin-embedded material of 214 resection specimens for adenocarcinoma, comprising 66 esophageal, 73 cardiac and 75 distal gastric adenocarcinomas (UICC-classification). The adenocarcinomas were subtyped into intestinal- and diffuse-type according to the Lauren classification. The immunohistochemical staining was considered as positive if 50% or more of the tumor cells were stained. Statistical analysis has been performed applying the chi2-test. The tumors situated at the gastroesophageal junction, esophageal as well as cardiac adenocarcinomas, showed predominantly a CK7+/CK20- expression pattern (67 vs 68%), whereas this cytokeratin pattern is rather uncommon in distal gastric adenocarcinomas (31%, P4 x 10(-5)). Independent of their localization, intestinal- as well as diffuse-type adenocarcinomas have a similar cytokeratin pattern. Our data show that the combined expression of CK7 and CK20 is different for the adenocarcinomas situated on both sides of the gastroesophageal junction compared to the distal gastric adenocarcinomas. However, in contrast to data in the literature, the combined expression of CK7 and CK20 has a low specificity in the distinction between esophageal and cardiac adenocarcinomas. This may suggest a similar origin (cell lineage) and thus may have an impact on therapeutic strategies.

Objective To assess prognosis according to whether lymph node involvement is intracapsular or with extracapsular breakthrough in adenocarcinoma of the distal esophagus and gastroesophageal junction. Materials and methods One hundred ninety-five consecutive patients with T3 adenocarcinoma of the distal esophagus and gastroesophageal junction between 1990 and 1999 were studied. All patients underwent primary R0 esophagectomy. The mean number of resected nodes per patient was 36.9. Survival was analyzed according to intracapsular and extracapsular involvement. Results In N0 patients 5-year survival was 57% and 9-year survival was 38.7%. In patients with positive nodes these figures were 26.2% and 18.1%, respectively ( P = .0069). Intracapsular and extracapsular node involvement showed 5- and 10-year survival of 40.9% and 21.7% versus 18% and 15.7%, respectively. There was no significant difference in 5- and 10-year survival between N0 and intracapsular node involvement ( P = .43). However, there was a significant difference in survival between N0 and extracapsular node involvement ( P = .002) and between intracapsular and extracapsular node involvement ( P = .0001). Conclusions This study shows a significant difference in survival according to whether lymph node involvement was intracapsular or extracapsular. Patients with intracapsular lymph node involvement have similar survival rates as N0 patients. Extracapsular lymph node involvement is a bad prognostic factor, independent of the number of involved lymph nodes. The number of involved lymph nodes has an additive negative effect. These data may have an impact on treatment strategies.

Objective: Very few studies have examined post-operative morbidity after resection of oesophageal carcinoma, especially in patients treated with induction chemo- and radiotherapy for locally advanced stages. This study assessed the effects of induction chemoradiotherapy on post-operative course after resection of locally advanced oesophageal carcinoma (cT3–4 þ cM1lymph). Methods: Induction therapy consisted of 5-fluorouracil days 1 – 5 and days 21 – 25, cisplatin day 1 þ day 21 and concomitant radiotherapy 18 – 20 fractions of 2 Gy (total dose 36 – 40 Gy). Induction chemoradiotherapy was completed in 109 patients. Surgery was performed in 90 patients (operability: 90=109 ¼ 83%): 85 patients underwent resection with curative intent (resectability: 85=109 ¼ 78%), bypass operation was performed in five patients. Nineteen patients could not be operated on. Results were compared to a matched group of pT3M1LYM/pT4 patients (n ¼ 86) who underwent primary surgery in the same period. Results: Resection was complete (R0) in 68 patients (68=90 ¼ 76%). Mean duration of surgery was 428 min (range: 240– 690). Peroperative complications were haemorrhage in three patients (3=90 ¼ 3:3%), tracheobronchial perforation in three patients (3=90 ¼ 3:3%). Median total hospital stay was 20.5 days (range: 8 – 355). Mean duration of intubation was 7 days (range: 1 – 190); 67 patients (67=90 ¼ 74:4%) were intubated for less than 24 h. Non-tumour related hospital mortality after resection was 8.3% (7/84 patients). Mortality after two-field lymphadenectomy was 5.2 versus 11.7% after three-field lymphadenectomy. After primary surgery (n ¼ 86) overall mortality was 2.3% (P ¼ 0:015) and nil after two- and three-field lymphadenectomy (P ¼ 0:011). Medical morbidity consisted of pneumonia in 43 patients (43=90 ¼ 48%), atelectasis in ten patients (10=90 ¼ 11%), dysrhythmia in 21 patients (21=90 ¼ 23%), sepsis in 11 patients (11=90 ¼ 12%) and adult respiratory distress syndrome in ten patients (10=90 ¼ 11%). Surgical morbidity included pleural effusion in 16 patients (16=90 ¼ 18%), tracheal fistula in two patients (2=90 ¼ 2%), chylothorax in two patients (2=90 ¼ 2%) and acute pancreatitis in one patient (1=90 ¼ 1%). Ten patients (10=90 ¼ 11%) had a radiologically confirmed anastomotic leak; however only in four out of them with clinical manifestation; treatment was conservative in all four patients. Major morbidity occurred in 27 patients (27=90 ¼ 30%). Overall rate of morbidity was significantly higher after three-field lymphadenectomy (85%) as compared to two-field lymphadenectomy (68.7%; P ¼ 0:023). Conclusions: Chemoradiotherapy followed by resection of cT3– 4 þ /2 cM1lymph oesophageal carcinoma is feasible with acceptable mortality. Mortality, however, seems to be significantly higher when compared to a group of pT3M1LYM/pT4 patients who underwent primary surgery (8.3 versus 2.3%; P ¼ 0:015) in the same period in our department. q 2003 Elsevier Science B.V. All rights reserved.

Anastomotic complications after esophagectomy continue to be a burden jeopardizing the quality of life and of swallowing. However, incidence, mortality and morbidity of anastomotic complications have substantially decreased in recent years. It seems that this is not so much related to the use of a particular conduit, approach or route for reconstruction, but rather related to refinement in anastomotic techniques and perhaps even more to progress in modern perioperative management. Knowledge of surgical anatomy and meticulous technique are of paramount importance and obviously related to individual expertise. As to the management, most leaks can be treated by conservative measures and reintervention surgery today is rather exceptional. Early endoscopy and dilatation seem to decrease the incidence and severity of anastomotic stenosis.

Purpose To investigate if selective compared to elective pleural irradiation of malignant pleural mesothelioma (MPM) can allow dose escalation. Patients and methods Twelve consecutive stage I-IV MPM patients (6 consecutive left-sided and 6 consecutive right-sided) were retrospectively identified from a prospective institutional database and included. In all patients, the staging computed tomography and the staging magnetic resonance imaging (MRI) were used for gross tumor volume (GTV) definition. The patients had not received chemotherapy. An MRI-based pleural GTV was contoured and a planning target volume (PTV) was generated. Two sets of PTVs were generated for each patient: (1) a “selective” PTV (S-PTV), originating from a 5-mm isotropic expansion from the GTV, and (2) an “elective” PTV (E-PTV), originating from a 5-mm isotropic expansion from the whole ipsilateral pleural space. Two sets of volumetric modulated arc therapy (VMAT) treatment plans were generated for each patient: a “selective” pleural irradiation plan (SPI plan) and an “elective” pleural irradiation plan (EPI plan). Results In the SPI plans, the median dose to the S-PTV was 53.6 Gy (SD: 5.4, range: 41–63.6 Gy). In 4/12 patients it was possible to escalate the dose to the S-PTV to > 58 Gy. In the EPI plans, the median dose to the E-PTV was 48.6 Gy (SD: 5.8, range: 38.5–58.7), with a median dose to the S-PTV of 49 Gy (SD: 6, range: 38.6–59.5 Gy). No significant dose escalation was achievable. Conclusion The omission of elective irradiation of the whole ipsilateral pleural space allows dose escalation from 49 Gy to more than 58 Gy in 4/12 chemo-naive MPM patients. This strategy may form the basis for non-surgical radical combined modality treatment of MPM.

To determine the impact of esophagectomy with 3-field lymphadenectomy on staging, disease-free survival, and 5-year survival in patients with carcinoma of the esophagus and gastroesophageal junction (GEJ).Esophagectomy with 3-field lymphadenectomy is mainly performed in Japan. Data from Western experience with 3-field lymphadenectomy are scarce and dealing with relatively small numbers. As a result, its role in the surgical practice of cancer of the esophagus and GEJ remains controversial.Between 1991 and 1999, primary surgery with 3-field lymphadenectomy was performed in 192 patients, of whom a cohort of 174 R0 resections was used for further analysis.Hospital mortality of the whole series was 1.2%. Overall morbidity was 58%. Pulmonary complications occurred in 32.8%, cardiac dysrhythmias in 10.9%, and persistent recurrent nerve problems in 2.6%. pTNM staging was as follows: stage 0, 0.6%; stage I, 9.2%; stage II, 27.6%; stage III, 28.7%; and stage IV, 33.9%. Overall 3- and 5-year survival was 51% and 41.9%, respectively. The 3- and 5-year disease-free survival was 51.4% and 46.3%, respectively. Locoregional lymph node recurrence was 5.2%; no patient developed an isolated cervical lymph node recurrence. Five-year survival for node-negative patients was 80.2% versus 24.5% for node-positive patients. Five-year survival by stage was 100% in stages 0 and I, 59.1% in stage II, 36.8% in stage III, and 13.3% in stage IV. Twenty-three percent of the patients with adenocarcinoma (25.8% distal third and 17.6% GEJ) and 25% of the patients with squamous cell carcinoma (26.2% middle third) had positive cervical nodes resulting in a change of pTNM staging specifically related to the unforeseen cervical lymph node involvement in 12%. Cervical lymph node involvement was unforeseen in 75.6% of patients with cervical nodes at pathologic examinations. Five-year survival for patients with positive cervical nodes was 27.7% for middle third squamous cell carcinoma. For distal third adenocarcinomas, 4-year survival was 35.7% and 5-year survival 11.9%. No GEJ adenocarcinoma with positive cervical nodes survived for 5 years.Esophagectomy with 3-field lymph node dissection can be performed with low mortality and acceptable morbidity. The prevalence of involved cervical nodes is high, regardless of the type and location of tumor resulting in a change of final staging specifically related to the cervical field in 12% of this series. Overall 5-year and disease-free survival after R0 resection of 41.9% and 46.3%, respectively, may indicate a real survival benefit. A 5-year survival of 27.2% in patients with positive cervical nodes in middle third carcinomas indicates that these nodes should be considered as regional (N1) rather than distant metastasis (M1b) in middle third carcinomas. These patients seem to benefit from a 3-field lymphadenectomy. The role of 3-field lymphadenectomy in distal third adenocarcinoma remains investigational.

Surgical treatment of cancer of the esophagus and gastroesophageal junction (GEJ) remains a complex and challenging task. Quality of care may be improved by concentrating these patients in high volume centres in order to decrease post-operative mortality. However, it appears that hospital mortality is a poor tool to measure the quality. More likely specialisation as well as appropriate hospital environment supporting a dedicated multidisciplinary team are key elements in improving both the short term and long term results. The dedicated specialist surgeon has a key role in improving these results through surgical quality. The most important goal in the surgical treatment of these cancers is to perform a complete resection (R0). Data from literature seem to indicate that R0 resection combined with extensive lymphadenectomy are resulting in improved disease free survival and possibly in improved 5 year survival, often reported to exceed 35% after such interventions. These results suggest that there is a great need for standardisation of surgery. Such a standardisation and the resulting improved quality most likely will result in a significant improvement of outcome of esophagectomy for cancer of the esophagus and GEJ. These improvements in outcome should become the gold standard to which all other therapeutic regimens should be compared. Poor surgical quality and related poor results should not be a justification for multimodality regimen.

Sleeve lobectomy is a procedure in which the involved lobe with part of the main stembronchus is removed. The remaining lobe (s) is reimplanted on the main stembronchus. This procedure is indicated for central tumors of the lung as an alternative to pneumonectomy. It is the aim of this study to describe the technique of sleeve lobectomy and to analyse the early postoperative results and late results (survival-recurrence) after sleeve lobectomy for non-small-cell lung cancer.Between 1985 and 1999, 77 sleeve lobectomies for bronchogenic carcinoma were performed at the University hospitals Leuven. The most common performed sleeve lobectomy is the right upper lobe sleeve lobectomy (67.5%). In 6 patients a combined sleeve resection of the pulmonary artery was performed. The operative mortality was 3.9%. Two patients developed a broncho-pleural fistula. The five-year survival rate was 45.6%. In 5 patients, an anastomotic suture developed which required a completion pneumonectomy in 2. Thirteen patients developed local tumor recurrence.We conclude that sleeve lobectomy can be performed with an acceptable mortality and morbidity. Long term survival rate and recurrence rate are as good as after pneumonectomy. The operative mortality is lower when compared to pneumonectomy, exercise tolerance and quality of life are much better after sleeve lobectomy compared to pneumonectomy. For central tumours we believe that sleeve resection is the procedure of choice.

e14505 Background: To assess the value of early metabolic response with 18-FDG-PET-CT after one cycle of chemotherapy as a tool to predict pathological response and outcome in patients with locally...

Purpose: KL-6 is a glycoprotein expressed on type 2 pneumocytes and respiratory bronchiolar epithelial cells. Serum KL-6 levels have been shown to be elevated in various interstitial lung diseases and correlate with disease activity. We previously reported that serum KL-6 levels were elevated in lung transplant recipients with chronic airway rejection [bronchiolitis obliterans syndrome (BOS)], when compared to recipients who did not have this complication. We therefore concluded that serum KL-6 levels could be used as a diagnostic tool for non-invasive detection of BOS. The drop in lung function that can occur with acute rejection episodes can confound the diagnosis of BOS. Thus, a need to evaluate how serum KL-6 levels would change during acute rejection episodes has emerged. The pathology of acute rejection occurs predominantly around the blood vessels without involvement of the airways or the alveoli where KL-6 is localized. Therefore, we hypothesized that serum KL-6 levels would not be elevated during episodes of acute rejection in lung transplant recipients. Methods and Materials: To test our hypothesis, we collected blood samples from patients undergoing transbronchial lung biopsy (TBB) for surveillance and measured serum KL-6 levels by ELISA. Lung transplant recipients who had BOS or other conditions known to cause elevations of KL-6 were excluded. Mean ( SD) KL-6 levels were calculated for biopsies without rejection and were compared with means for biopsies showing different grades of rejection by using T-test. Results: A total of 68 samples were collected from 34 patients. The mean serum KL-6 for biopsies without acute rejection (A0) was 260 129 U/mL, while levels for A1 and A2 A3 rejections were 218 79 U/mL and 231 91 U/mL, respectively. There were no statistically significant differences between the A0 group and any of the other 2 groups (p0.1 for both comparisons). Conclusions: Our results indicate that serum KL-6 levels do not elevate with episodes of acute vascular rejection in lung transplant recipients.

4045 Background: PET is a non-invasive diagnostic tool in oncology that reflects tissue metabolism by a variable uptake of 18F-fluoro-deoxy-D-glucose (FDG). Glucose metabolism and neovascularization are activated by hypoxia. Hypoxic tumors have a poor prognosis and poor response to radiotherapy. We aimed at correlating the avidity of PET in esophageal and cardiac carcinomas with hypoxia-related markers: glut-1 and glut-3 (glucose transporters); vascular-endothelial growth factor (VEGF), a pro-angiogenic factor; carbonic anhydrase IX (CA IX), a marker for chronic hypoxia. Methods: Our retrospective study comprised 89 patients (65 yr, 32–83 yr, M/F=4.5) treated with primary surgery. Exclusion criteria were neo-adjuvant therapy and a tumor < 1 cm on ultrasound. PET before surgery was scored: PET1 = intense hot spot (n=47), PET2 = limited positivity (n=10), PET3 = inhomogeneous labeling (n=11), PET4 = no hot spot (n=21). Immunohistochemistry was performed on formol-fixed paraffin-embedded samples of resection...