Search

We report a case of malignant pleural mesothelioma with histologically proven spontaneous regression of pleural disease. During a 12-year follow-up there was a single recurrence, which was a lesion in the chest wall at 6 years that was surgically excised. A prominent host response to tumor was seen in both the primary tumor and the recurrence.

Summary Background This study evaluated the results of thoracic meta-stasectomy for germ cell tumours to assess long term survival and identify prognostic factors. Patients and methods A series of 141 consecutive patients who underwent resection of thoracic metastases at Royal Brompton Hospital were retrospectively reviewed. Kaplan–Meier estimates of survival were calculated for clinical variables related to primary tumour and thoracic metastases, using the Cox model for multivariate analysis. Results Complete resection was achieved in 123 cases (87%); pathology showed viable malignant elements in 46 (32%), necrosis or fibrosis in 32, differentiated teratoma in 63. The overall survival was 77% at five years and 65% at 15 years, being significantly shorter in patients with malignant teratomatous elements (51% at five years, P = 0.0001) or incomplete resection (64% at five years, P = 0.019). At multivariate analysis these factors retained their prognostic value, with a relative risk of death of 5.7 for malignant teratomatous elements and 4.0 for incomplete resection. In addition, the Cox model revealed a 3.2 times higher risk of relapse in patients with malignant teratomatuos elements at the time of thoracic metastasectomy. Conclusions These data confirm the value of thoracic metastasectomy to asses pathological response and achieve permanent cure of chemoresistant disease.

The poor surgical curability of most thoracic malignancies and the lack of effective systemic therapies has led to greater emphasis being placed upon palliative management, to control symptoms and thereby improve the quality of life, and treatments aimed at prolonging the survival of those patients who have no chance of cure.

Stage IIIA non–small-cell lung cancer with mediastinal node metastases (N2 non–small-cell lung cancer) is actually a spectrum of diseases with widely divergent prognoses. Each subset has been traditionally defined by the tests that are necessary to detect the N2 disease, which in itself is an indication of the extent and bulk of the nodal deposits. The subset with the worst prognosis has such gross N2 disease that it could be detected clinically as the patient enters the clinic. Survival in such patients is usually measured in months. The subset with the best prognosis has such subtle nodal disease that it eludes clinical examination, chest radiology, CT scanning, and even mediastinoscopy, and it is ultimately called unexpected N2 disease when found at thoracotomy. According to several authors, patients in this subset have a 20% survival at 5 years if, despite the mediastinal nodal disease, complete resection proves feasible. Even this subset is an amalgam of cases. Some unexpected N2 disease is not so much unexpected as unconfirmed; others might have small deposits, even widespread involvement, in nodes below the size threshold that would normally trigger a mediastinoscopy. Some cases are the result of a falsely negative mediastinoscopy, and others involve nodes beyond the reach of the mediastinoscope. The realization that N2 disease might elude even the most diligent preoperative evaluation led surgeons to undertake an increasingly detailed intrathoracic re-evaluation at thoracotomy. A central part of this has become the removal of apparently normal lymph nodes in the mediastinum and hilum for subsequent histologic examination. Such techniques have improved staging and have often discovered N2 disease that was not visualized by naked-eye assessment of the sliced nodal tissue but was discovered on subsequent histologic– even immunohistologic–examination after surgery. All of the component groups within the unexpected N2 subset had one unifying and comforting characteristic: in patients whose disease could not be confirmed before thoracotomy, complete resection was feasible in the majority of cases, and the survival rates justified the added risks of continuing with resection. The widespread use of positron emission tomography (PET) scanning with fluorodeoxyglucose has reshuffled the pack. The greater accuracy with which this technique detects N2 disease compared with computed tomography (CT) scanning and even with mediastinoscopy has resulted in some patients with “unexpected” N2 disease being identified before surgery. These patients, if their disease is confirmed histologically, now join the proven N2 cases, for which the current standard of care is induction therapy. Presumably, those cases of N2 disease that elude PET scanning and are discovered at thoracotomy will have even more subtle nodal disease. The principles of stage migration suggest that both groups should have an improved survival when compared with the older subsets. However, PET scanning has spawned two new problems. The specificity with which PET scanning identifies nodal disease is less than perfect, with around 10% false-positive rates in studies. How do we ensure that these patients proceed appropriately with surgical treatment? In those patients whose PET scan suggestion of N2 disease is confirmed histologically, how do we select patients who should then proceed with resection? The simple answer to the first question is to undertake mediastinoscopy in all PET-positive cases without extrathoracic disease. Studies have shown that the answer to the second question lies in selecting patients in whom induction therapy has downstaged the patients and eradicated the mediastinal nodal deposits. This favorable response in the mediastinal lymph nodes is presumably a surrogate for the eradication of occult distant metastases by induction therapy. Those with persistent N2 disease have low survival chances with surgery and are probably better served by consolidation therapy with chemoradiotherapy. The article by De Leyn et al from the Leuven Lung Cancer Group in Belgium seeks to answer the resulting dilemma. How, after induction chemotherapy, do we identify which patients have persistent N2 disease and should go on to chemoradiotherapy and which have been downstaged and should proceed with second-line surgery? Can further PET scanning undertake this reliably, or do we have to accept the problems inherent in repeat mediastinoscopy? They conclude that the sensitivity and accuracy of PET are sufficiently superior to those of repeat mediastinoscopy to justify its use as the technique of choice in these circumstances. This conclusion, and the magnitude of the difference between the results with these investigations, will surprise many. The sensitivity with which PET scanning after induction therapy identifies residual disease in the mediastinal lymph nodes, summarized in the De Leyn et al Table 6, is around 50% to 60%. This is considerably worse than the 83% sensitivity reported for PET scanning in the primary staging of lung cancer. However, the sensitivity of repeat PET in the study by De Leyn et al is 77%—within the range reported in the primary setting. Is this, as the authors claim, the result of coregistering PET and CT images in the newer generation of scanners? One study suggests that, in the primary setting, integrated PET-CT is superior to the visual correlation of images from separate PET and CT studies. However, in this study, the accuracy JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 24 NUMBER 21 JULY 2

Background. Disease-free interval, histology of primary tumor, and number and size of metastases resected (at first metastasectomy) were studied after resection of pulmonary metastases. Methods. Between 1980 and 1993, 276 consecutive patients underwent lung resections for curative removal of metastatic disease. At subsequent relapse, 63 patients had a second-stage metastasectomy, 12 went on to a third phase, and 2 patients had four stages. Results. The primary tumor was sarcoma in 126 cases (46%), teratoma in 88 (32%), carcinoma in 53 (19%), melanoma in 5, and miscellaneous in 4. Actuarial survival was 69% at 2 years (95% confidence interval 62% to 74%), 48% at 5 years (40% to 55%), and 35% at 10 years (23% to 44%). Conclusions. Survival was not related to disease-free interval. Multivariate analysis showed that nearly all predictive information can be obtained through histologic studies (p < 0.0001); inclusion of the number of metastases resected contributed to a lesser degree (p = 0.032). Short disease-free intervals, numerous lung metastases, or even deposits recurring after a first or second metastasectomy should not preclude patients from operation.

We report the case of a 26-year-old man with diffuse esophageal leiomyomatosis involving the trachea. The tumor was resected by total esophagectomy and partial resection of the trachea and the left main bronchus. The tracheobronchial defect was repaired with a free forearm skin graft with satisfactory outcome. This approach offers good long-term prospects.

Background. Extended resection for pulmonary malignancy frequently leaves a large pericardial defect, sometimes associated with resection of the phrenic nerve. On the left the defect does not require repair; as long as the defect is sufficiently large to avoid constriction, the heart can herniate freely. On the right such herniation is associated with venous inflow occlusion and death. The pedicled diaphragmatic flap has been used in other situations in thoracic surgery. We have modified this to allow closure of the pericardial defect and concurrent plication of the denervated diaphragm. It may also be used to cover the bronchial stump or a bronchial anastomosis. Methods. The flap has been used in 13 patients over an 11-year period. Results. Secure closure of the pericardial defect has been achieved in all patients with satisfactory plication of the diaphragm. Reoperation for bleeding was necessary in 3 patients, but in only 1 was the diaphragm shown to be the site of bleeding. Patients otherwise made an uneventful recovery. Conclusions. A large pedicled flap of redundant diaphragm provides secure closure for large pericardial defects after extended right pneumonectomy.

Further examination of the parameters of oxidative stress, perioperative changes in the vasoregulatory mechanisms of the pulmonary circulation, and characterisation of the endothelial insult that probably occurs in all patients undergoing lung resection is necessary if the operative conditions under which lung surgery is carried out are to be optimised. Perhaps, then, more insight might be gained into how to improve preservation of lungs for transplantation and how to protect the lung from significant injury following resection.

Background. Reconstructive techniques using omental and myocutaneous flaps are widely used in the treatment of infected sternotomy wounds. To illustrate their wider role in thoracic reconstruction, we have retrospectively reviewed our experience over the last 5 years. Methods. We used complex omental and myocutaneous flaps in 30 patients: 19 men and 11 women with a mean age of 53 ± 4 years (range, 43 to 75 years). In 18 patients, these techniques were used to provide softtissue cover after chest wall resection, and in 12 cases complex myocutaneous flaps were used to obliterate chronic intrathoracic cavities. Rectus muscle was used in 11 of 24 muscle flaps, and omentum was used in 12 cases. There were 23 rotational flaps and seven free myocutaneous flaps with microvascular anastomosis. Results. There were no operative deaths, and there were three complications. In 2 patients with infected lesions, loss of the free flap required subsequent revision. In 1 patient, infection developed underneath a prosthesis, which was treated with drainage and rib resection. In all other cases, the primary aim of the operation was achieved without complications. Conclusions. The vascularity of the omentum should encourage its wider use, especially when infection exists preoperatively. Excellent results can be achieved when using the rectus muscle as a complex myocutaneous flap. The use of free flaps should be reserved for difficult cases and used only in the absence of infection.

Dieulafoy's vascular malformation has not been described outside the gastrointestinal tract. Two cases are reported in which this vascular abnormality arose in right lower lobe bronchi, both of which presented with massive haemoptysis.

We would like to thank Dr Dato et al. for their comment [1] on our article [2]. In their letter to the editor [1], the authors are presenting their practice with regard to the management of patients with pectus excavatum (PE) deformity. Our article [2] aimed to present the facts related to the application of minimally invasive repair (MIRPE) for patients with PE in order to help clinicians and patients make a decision based on the best clinical practice. Our article also highlighted conflicts within the literature and pointed out the need for further research based on larger series and rigid protocols, in order to strengthen the published literature. The frequently debated ‘Ravich-versus-Nuss’ and ‘minimally invasive-versus-less invasive’ are discussions that many clinicians enter into with a strong and unwavering opinion. However, it is of paramount importance for clinicians to acknowledge that alternate techniques can provide equally good results and that patients should be allowed the freedom to choose their treatment. The decision for treatment should be unbiased and based on facts and informed consent, especially for clinical conditions where cosmesis is the primary reason behind treatment. The cost of providing these procedures is an important issue and should be carefully considered prior to offering any treatment. MIRPE remains expensive and cannot be offered widely within government-funded health-care systems to everyone in need (the majority of patients live in underdeveloped or developing countries, while countries of the western world are currently faced with economic crisis and limited health budgets). The effectiveness of the Ravich-versus-MIRPE should be the real issue of debate. Effectiveness should be judged not only on the anatomic correction of the deformity, but its ability to treat the underlying cause for these patients who seek medical/ surgical correction, which in the vast majority of cases is cosmetic with social and psychological roots. As such, we talk about a group of patients during their early years of development, where social and psychological problems can have a major impact on their future behaviour and quality of life. We, the medical community, should pay more attention to preventative mechanisms with early and correct medical and psychological counselling of our potential future patients and their families. In their letter to the editor [1], Dr Dato et al. are offering MIRPE to their patients up to the age of 22, while they seem to favour the Ravich repair technique for older patients. It would be interesting to know the basis for this decision and any results they may have to support this decision. On the same ground, and bearing in mind that pain remains the most frequent and difficult to manage issue related to MIRP [3], it is very interesting to know what the authors mean by ‘borderline skeleton age’ and how ‘CT-chest with 3D-reconstruction’ can help us reduce pain, in this particular group of patients. Therefore, it would be of great interest if Dr Dato et al. could share with us their protocol and their results that support this claim. In conclusion, we agree with Dr Dato et al. that careful patient selection is mandatory for chest wall repair and we would like to recommend that informed consent should play a vital role in our discussion with patients who would benefit from the implementation of a repair procedure. Quality data, including patient satisfaction surveys, should play pivotal role in helping to justify any decision regarding the approach used to treat patients with PE. Authors’ contributions: G.K. was responsible for drafting the manuscript. P.G. has revised the manuscript. All authors read and approved the final manuscript. Submission statement: (a) there has been no duplicate publication or submission elsewhere; (b) all authors have read and approved the manuscript; (c) authors do transfer copyright to the Publisher; and (d) there is no ethical problem or conflict of interest.

We have reviewed the incidence of bronchopleural fistula among 530 consecutive pneumonectomies, all carried out by one surgical team using a uniform suture technique between January 1980 and November 1993. There were 7 fistulas (1.3%); all of them occurred within 15 days postoperatively. There were no cases of late fistula during a mean follow-up period of 23 months. The pathology for which pneumonectomy was undertaken was primary lung malignancies in 488 cases (92.1%), metastatic disease in 15 cases (2.8%), and benign diseases in 27 cases (5.1%). All fistulas developed after pneumonectomy for lung cancer. Other risk factors included age, preoperative radiotherapy, and the surgeon's level of experience, as only two fistulas occurred with the consultant who performed 410 pneumonectomies (0.5%). The bronchial stump was free of tumor in all cases. There were no fistulas in the 37 completion pneumonectomies (7%). All fistulas were treated within 2 days of diagnosis by resuturing the stump through the initial thoracotomy incision. That was successful in 5 patients, whereas fatal complications developed in the other 2 patients. We believe that suture closure of the bronchial stump at pneumonectomy provides a cheap and reliable technique that gives good results in all situations.

Between September 1, 1989, and August 31, 1990, 516 patients were admitted to the Royal Brompton National Heart and Lung Hospital for thoracic operations. A prospective audit recorded the nature and extent of operation, the histologic diagnosis, and the number of units of blood prepared and transfused during hospitalization. Cross-matched blood was requested in 243 patients but only 16.1% of these received transfusion. In total, 1,295 units of whole blood or red cell concentrate were cross-matched and made immediately available in the operating suite at the time of operation. Only 322 units were administered (cross-match to transfusion ratio of 4.02:1). Almost half of the patients who received transfusions received 2 units or less, a third received 3 or 4 units, 10% between 5 and 10 units, and 8,4% required more than 10 units during their hospital stay. The nature and extent of resection was an indicator of the need for transfusion. Other important predisposing factors included a previous thoracic operation, resection for inflammatory disease, decortication of empyema thoracis, chest wall resection, or thoracoplasty. Other thoracic procedures such as pleurodesis, pleurectomy, open lung biopsy, pectus correction, operation for bullous lung disease, and mediastinoscopy had a negligible transfusion requirement. The data suggest that understanding risk factors for transfusion requirements of patients undergoing thoracic surgical procedures should optimize present resources. This is critical when exploiting the limited availability of donated blood and blood products. Similarly, anticipation of transfusion requirements takes best advantage of manpower within the blood bank and minimizes unnecessary and avoidable blood wastage and expenditure.

In the treatment of a patient with lung cancer, the clinician must establish diagnosis and stage efficiently (without causing needless delay), practically (without performing unnecessary invasive procedures), and pragmatically (without incurring extra cost). The end result should not rest on inferences of interpretation, but must be established beyond doubt on the basis of pathological material. There is a close relationship between pathological TNM stage and patient prognosis. Dramatic improvements in modern imaging techniques have not resulted in equally impressive improvement in the accuracy of appraising clinical stage. Using present technologies, determination of stage is still based on balancing probabilities, and is very much dependent on the quality of the interpretation. An open diagnostic procedure remains the standard against which all other modalities must be compared.

BACKGROUND--Major airways obstruction is a distressing cause of morbidity and mortality. For disease that is extensive and recurrent, there is a need for a safe and cost effective technique for palliation. METHODS--The results of 29 patients with tracheobronchial obstruction (24 malignant and five benign) treated by diathermy resection alone or in combination with endobronchial stenting have been reviewed. RESULTS--The major site of obstruction was the trachea in 14, main carina in seven, right main bronchus in six, and left main bronchus in two patients. Fifteen had received other forms of treatment beforehand including external radiotherapy, endoscopic dilatation, and laser resection (Nd:YAG). Five patients required two or more treatment sessions for symptom recurrence. Ten patients also received additional treatment with a stent (nine) or insertion of gold grains (one). There were no intraoperative deaths or complications and the average length of stay was five days (range 2-14). Twenty eight patients reported immediate symptomatic relief, and objective improvement in the results of lung function tests was seen in eight patients whose condition was less acute and where preoperative lung function tests could be undertaken (average improvement in FEV1 of 53.1% and in FVC of 20.6%). CONCLUSIONS--Bronchoscopic diathermy resection is an effective and safe method for relieving the symptoms of tracheobronchial obstruction at appreciably less cost than laser resection.

Pleuropulmonary blastomas (PPB) are rare intrathoracic tumors that can develop in children with preexisting pulmonary cystic lesions, inferring that the prophylactic resection of such cysts might prevent the onset of these malignant tumors. We report a patient who went on to develop PPB in the right lung despite having had resections for bilateral congenital pulmonary cysts 23 months earlier. We therefore question the effectiveness of prophylactic resection of congenital lung cysts on this basis.

The case history is presented of a patient in whom an intramural tracheal neurofibroma developed, causing severe airway stenosis. The patient was treated with multiple stents over a period of 5 years because of progression of the disease and associated airflow limitation. Clinicians should be aware of this rare complication of neurofibromatosis.

Pier Giuseppe Agostoni, Milano Marina Aiello, Parma Nicolino Ambrosino, Gussago Eleftherios Anevlavis, Nea Ionia Veena B. Antony, Indianapolis, Ind. Lorenzo Appendini, Veruno Hormoz Ashtyani, Hackensack, N.J. I. Azziz, Edmunds Philip Bardin, Clayton, Melbourne Harry Bassaris, Patra Eric Bateman, Groote Schuur, Cape Town Robert P. Baughman, Cincinnati, Ohio Egmont Baumgartner, Hall, Tirol F. Xaver Baur, Hamburg Robert Berent, Wels Sten Erik Bergstrom, Huddinge Andrea Bianco, Napoli Sebastiano Bianco, Milano Roland Bittner, Berlin Francesco Blasi, Milano Annette Boehler, Zurich Thomas Boehm, Zurich Josef R.M. Bolitschek, Linz T. Bombeli, Zurich Louis-Philippe Boulet, Sainte-Foy Henri Bounameaux, Geneve Demosthenes E. Bouros, Athens Homer A. Boushey, San Francisco, Calif. Lennart Braback, Sundsvall Thomas Brack, Zurich Aidan Bradford, Dublin Christian Brambilla, Grenoble Antonio Braschi, Pavia Otto M. Braun, Horn O. Brandli, Faltigberg Vita Brusasco, Genova Martin H. Brutsche, Basel Jean-Luc Burgaud, Sophia Antipolis Andrew Bush, London Cecilia Calabrese, Napoli Philippe Camus, Dijon Pier Aldo Canessa, Sarzana, La Spezia Laura Carrozzi, Pisa Antonio Castagnaro, Mantova Sergio Cavaliere, Brescia M. Cazzola, Napoli I. Cerveri, Pavia Pascal Chanez, Montpellier Neil S. Cherniack, Newark, N.J. Alfredo Chetta, Parma Gianfranco Chiari, Parma Luke Clancy, Dublin Enrico Clini, Gaiato dei Pavullo Henri Colt, La Jolla, Calif. J.H. Coote, Birmingham Giuseppe M. Corbo, Roma Antonio Corrado, Firenze Paolo Coruzzi, Parma U. Costabel, Essen J. Costello, London Nunzio Crimi, Catania Isidor Dab, Bruxelles Roberto Dal Negro, Bussolengo Filiberto Dalmasso, Torino Peter Dalquen, Basel Peter Davies, Liverpool Fernando De Benedetto, Chieti Francesco de Blasio, Arco Felice Marc Decramer, Leuven P.N. Richard Dekhuijzen, Nijmegen Jose Pablo Diaz Jimenez, Barcelona Robert Dinwiddie, London Peter Dorow, Berlin Keith Dorrington, Oxford Roberto Duranti, Firenze Michael Dusmet, London J. Eckmayr, Wels B. Emmerich, Munchen Armin Ernst, Boston, Mass. Santiago Ewig, Bonn H. Fabel, Hannover A. Fairfax, Stafford Franco Falcone, Bologna Rudolf Ferlinz, Bad Gastein Jean-William Fitting, Lausanne Pierre Fournel, St. Etienne Lutz Freitag, Hemer Dimitris Georgopoulos, Heraklion Vassilis Georgoulias, Heraklion Helen Giamarelou, Marousi, Athens Simon Godfrey, Jerusalem A. Greening, Edinburgh Paul Haber, Wien Dean Handley, Marlborough, Mass. Patricia L. Haslam, London W. Heindl, Wien Arthur Helbling, Bern Bill Hesselmar, West Perth Richard Hodder, Ottawa J.C. Hogg, Vancouver Rudolf Maria Huber, Munchen Gerard Huchon, Paris David W. Hudgel, Detroit, Mich. Stasia Jastrzembski, Newark, N.J. Amal Jubran, Maywood, Ill. Frank Kanniess, Grosshansdorf Jack Kastelik, Cottingham, East Yorkshire Philipp Kaufmann, Zurich Roland Keller, Aarau Frank Kelly, London Paul Kemp, Leeds Ok Hwa Kim, Kyonggi-do Carl M. Kirsch, San Jose, Calif. Nikolaus Konietzko, Essen D. Kohler, Schmallenberg-Grafschaft Richard Kraemer, Bern Claus Kroegel, Jena Friedrich Kummer, Wien Boris Lams, London Irene Lang, Wien Didier Lardinois, Zurich R. Lazor, Geneve Ph. Leuenberger, Lausanne Brian Lipworth, Dundee H. Lode, Berlin Stelios Loukides, Athens Maurizio Luisetti, Pavia Piero Maestrelli, Padova H. Magnussen, Grosshansdorf Katerina Malagari, Papagou, Athens Carlo Manca, Parma Milan Marel, Praha Charles-Hugo Marquette, Lille C. Marriott, London Praveen N. Mathur, Indianapolis, Ind. Heinrich Matthys, Freiburg/Br. Harald Mauch, Berlin Thomas Meisl, Wien Giovanni Migliori, Tradale M. Miniati, Pisa Anna Maria Moretti, Bari A.H. Morice, Cottingham Gianna Moscato, Pavia Michael Rolf Mueller, Wien

7022 Background: A change of staging classification has been associated with improvements in stage-specific survival without improvement of overall survival (Feinstein, 1985). We aim to estimate in patients with resected non-small cell lung cancer (NSCLC), included in the IASLC staging database (Goldstraw, 2006) 1) the magnitude and direction of stage migration between the 6th and 7th editions of the UICC-TNM classification, and 2) its impact on stage-specific outcome. Methods: Resected NSCLC cases were extracted from the IASLC database and classified according to the 6th and 7th editions of UICC-pTNM. Cases having received preoperative chemotherapy and/or radiotherapy were excluded from the set; postoperative deaths were included, as were substages A and B for stage III only. Migration was estimated by calculating the rate of patients classified in any higher or lower UICC-7 p-stage over the corresponding UICC 6 p-stage. Outcome was estimated by the Kaplan-Meier method and expressed as 5-year survival ra...

Gas trapping in emphysema results in resting and dynamic hyperinflation. We tested the hypothesis that a direct connection between the lung parenchyma and the atmosphere could increase expiratory flow and thereby potentially improve dyspnea through the relief of gas trapping.Ex vivo we studied 7 emphysematous lungs and 3 fibrotic lungs (as controls) and measured expiratory flow before and after airway bypass insertion during a forced maneuver in an artificial thorax. Pilot studies were conducted in vivo in 6 patients with advanced emphysema using a size 9 endotracheal tube as a bypass surgically placed through the chest wall into the upper lobe.In the ex vivo emphysematous lungs the volume expelled during a forced expiratory maneuver increased from 169 to 235 mL (p0.05). In the in vivo group 4 patients retained the bypass tube for 3 months or more; total lung capacity was reduced, and the forced expiratory volume in 1 second increased by 23% (mean percent predicted at baseline versus 3 months, 24.4% versus 29.5%).An extrapulmonary airway bypass increases expiratory flow in emphysema. This may be a useful approach in hyperinflated patients with homogeneous emphysema.

Pulmonary torsion is a rare but life-threatening complication of thoracic operations and trauma. A questionnaire was sent to 140 thoracic surgeons in the United Kingdom to examine its incidence, particularly torsion of the middle lobe after right upper lobectomy. The answers from 117 thoracic surgeons (84%) were collected and analyzed. Thirty-five responders (30%) had seen one or more cases of pulmonary torsion. The majority of cases occurred after pulmonary resection, and most of these instances involved middle lobe torsion after right upper lobectomy. In total, 39 cases were reported; 1 (3%) occurred spontaneously in an azygos lobe, 2 (5%) were seen after trauma, 28 (72%) were seen after pulmonary resections and 8 (21%), after other procedures. In this group of responders, 27 (77%) routinely fix the middle lobe to the remaining lobe after right upper or lower lobectomy, upper lobe fixation being required only if the transverse fissure is well developed. Of the 82 responders who had never seen instances of pulmonary torsion, only 47 (57%) routinely do this fixation.

BACKGROUND: The relative proportions of fibrosis and inflammation seen by open lung biopsy examination is a predictor of disease outcome in fibrosing alveolitis. This study was designed to assess the ability of high resolution computed tomography to predict the histological appearance of open lung biopsy specimens from patients with systemic sclerosis. METHODS: Twenty abnormal biopsy specimens from 12 patients were assessed; abnormalities were categorised as fibrotic (fibrosis exceeding inflammation) or inflammatory (inflammation equal to or exceeding fibrosis). Computed tomography appearances were scored for the lobe from which the biopsy specimen was taken; scans were graded from parenchymal opacification alone through to a reticular pattern alone. RESULTS: Two lobar appearances were identified on computed tomograms: amorphous parenchymal opacification equal in extent to reticulation (grade 3) and a predominantly reticular pattern (grade 4). There was a significant association between a fibrotic histological appearance and a grade 4 computed tomogram, and between an inflammatory histological appearance and a grade 3 computed tomogram. Computed tomography grade 4 was associated with a fibrotic histological appearance in 12 out of 13 lobes, and grade 3 with an inflammatory histological appearance in four out of seven lobes. CONCLUSION: Computed tomography discriminated between biopsy specimens that were predominantly fibrotic and a smaller group with a larger amount of inflammation.

The ideal method for obtaining lung tissue for diagnosis should provide high diagnostic yield with low morbidity and mortality. We reviewed all 432 patients (mean age 55 years) who underwent an open lung biopsy at this hospital over a 10-year period. Twenty-four patients (5.5%) were immunocompromised. One hundred and twenty-five patients were on steroid therapy at the time of operation. Open lung biopsy provided a firm diagnosis in 410 cases overall (94.9%) and in 20 out of 24 patients in the immunocompromised group (83.3%). The commonest diagnosis was cryptogenic fibrosing alveolitis (173 patients). Twenty-two patients (5.1%) suffered complications following the procedure: wound infection 11 patients, pneumothorax 9 patients and haemothorax 1 patient. Thirteen patients (3.0%) died following open lung biopsy, but in only 1 patient was the death attributable to the procedure itself. We conclude that open lung biopsy is an accurate and safe method for establishing a diagnosis in diffuse lung disease with a high yield and minimal risk.

People are living longer, a trend that is most marked in developed countries. In 1998 in the UK 7.3% of the population were over 75 years of age compared to only 4% in 1961. It is estimated that this figure will rise to 15% by 2021 [1]. Men in this cohort have the highest incidence of lung cancer [2], and it is only a matter of time before women join them. In one district in the UK 43% of patients diagnosed with lung cancer over a 30 month period starting in 1990 were over 75 years of age [3]. In this issue of The Annals of Thoracic Surgery, Bernet and colleagues [4] make the point that age alone does not rule out successful surgical treatment for lung cancer. They have shown that perioperative mortality and 5-year survival are not statistically different for a group aged over 70 years when compared to a group younger than 50 years. There are several reports, including our own [5], that have shown that pulmonary resection can be undertaken for lung cancer in patients aged over 70 years, even over 80 years [6], with mortality only slightly higher than that in younger people. There is no evidence that lung cancer in the elderly is any less lethal than the disease in the younger population. The effectiveness of pulmonary resection at all ages depends upon stage, and this is unaffected by age.

7519 Background: Pleural lavage cytology (PLC) is the instillation of saline into the chest during surgery for non-small cell lung cancer (NSCLC). The aims of this study were to collate multi-institutional individual patient data to determine independence as a prognostic marker and characterise impact of positive results on stage adjusted survival. Methods: We identified 31 publications from 22 centers/research groups that performed pleural lavage cytology during surgery for NSCLC and invited submission of individual patient data. Actuarial survival was calculated using Kaplan Meier methods and comparisons were performed using the log-rank test. Cox proportional hazards regression was utilised to ascertain the covariates associated with survival. Results: By 1 January 2008, submissions were received internationally from 11 centers with individual data from 8763 patients. In total, 511 (5.8%) patients had a positive pleural lavage cytology result, and this was shown to be an independent predictor of adverse survival associated with a hazard ratio of 1.465 (1.290 - 1.665; P No significant financial relationships to disclose.

22090 Background: Increasing neutrophil to lymphocyte ratio (NLR) has been associated with adverse survival after resection of primary or hepatic metastases of colorectal tumors. We aimed to determ...

7719 Background: Chemoradiation is considered the gold standard for the management of limited disease (LD) small cell lung cancer (SCLC). Surgery has been abandoned due to poor overall survival, but many small series report good results with selected extremely limited disease (in one study without adjuvant treatment). Controversy remains if and when surgery should be considered as a primary modality. We sought to determine the survival and impact of pathologic staging in patients after complete resection of SCLC and the prognostic impact of pathologic stage. Methods: A retrospective review was undertaken of patients who underwent surgery between 1980 and 2003. Patients were staged according to the 6th UICC revision, actuarial survival estimated with Kaplan Meier methods and comparisons were undertaken using Cox regression. Results: We identified 51 patients who underwent complete resection with systematic nodal dissection for SCLC. The mean age (SD) was 61 (11) years and 37 (73%) were men. Complete staging information was available in 47, listed by stage with IA (n=6), IB (n=10), IIA (n=5), IIB (n=15), IIIA (n=10), IIIB (n=1). The median time to follow up (1st to 3rd quartile) was 4.5 (1.3 to 11.9) years with an overall survival (95% CI) at 1 and 5 years of 82% (72, 93) and 61% (48, 76). There were no clear differences in the outcome of patients in T categories 1 and 2 (P=0.411) with good overall results in patients across the spectrum of nodal disease from N0 to N2 (P=0.281). Conclusions: This study shows excellent survival for stage I to III patients who underwent lung resection with complete nodal resection for SCLC. These results, in an era of improved pre-operative and intra-operative staging, suggests that TNM staging is relevant in extremely limited disease SCLC and suggest that the role of surgery in such cases should be re- evaluated. No significant financial relationships to disclose.

An 82-year-old male nonsmoker presented with hemoptysis. He had had a history of pulmonary tuberculosis in 1948 and underwent repeated artificial pneumothorax, pneumoperitoneum, and phrenic nerve crush, followed by extrapleural plombage with polymerized methyl methacrylate (Lucite) balls at the Royal Brompton Hospital. Chest radiograph (Fig 1) shows a number of Lucite balls surrounded by some scar tissue. Computer tomographic scan (Fig 2) of the thorax showed Lucite balls at the right apex. Air can be seen outside the balls, which suggests a communication between the plomb and lung parenchyma. This usually results in infection in the plomb. Bronchoscopy showed partial obstruction of the apical segment of the right lower lobe by granulation tissue with no evidence of malignancy. In this age group, further surgical treatment such as removal of the plombage material, prolonged drainage followed by softtissue transfer is a major undertaking. The patients’ symptoms were not severe and he was content to be followed up without treatment for the present. Plombage, a variant of collapse therapy that uses a variety of foreign materials, including Lucite balls (Fig 3), was undertaken in the late 1940s and ended in the 1950s. In the long term these can erode into the lung parenchyma, allowing infection to enter the plombage space. Eradication requires removal of the plomb and softtissue transfer or thoracoplasty to obliterate the space. Address reprint requests to Dr Tezel, Department of Thoracic Surgery, Royal Brompton Hospital, Sydney St, London SW3 6NP, UK; e-mail: mdcagatay@hotmail.com. Fig 1. Fig 2.

Using a malleable endotracheal tube stylet to shape the chest drain during insertion helps in positioning them in the desired part of the pleural cavity.

BACKGROUND--Postoperative lung injury is a recognised complication of thoracotomy for which there are few data regarding incidence and outcome. METHODS--In a case controlled study the notes of all adult patients who developed acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) following thoracotomy between 1991 and 1994 were examined and classified according to the guidelines of the American Thoracic Society/European Respiratory Society for ALI/ARDS. The predictive value of a routine preoperative assessment and duration of anaesthesia in determining those patients most likely to develop ALI/ARDS was assessed. RESULTS--Between 1991 and 1994 231 lobectomies, 103 pneumonectomies, and 135 wedge resections and segmentectomies were performed. The overall incidence of lung injury was 5.1%; 17 patients developed ARDS (two survived) and seven developed ALI (five survived). There was no significant difference compared with case matched controls in preoperative spirometric values, arterial oxygen tension (PaO2), or duration of anaesthesia. None of these parameters was useful in predicting those patients most likely to develop lung injury. CONCLUSION--Lung injury after thoracotomy is associated with a high mortality. Conventional parameters for preoperative assessment do not predict those patients most likely to develop ALI/ARDS in these circumstances.