- Email: [email protected]
455 Bronchoplastic procedures for centrally located tumors
Therapy
- Combined
were performed in 148 patients with metastatic pulmonary tumors. To assess both the number and the size of the metastasis, we introduced the Number Size score (NS score) index, which was the sum of the diameters of all metastatic lesions. The overall 5-year survival rate was 33%. A significant detnmental influence on survival was recognized for each of the following: metastases from a sarcoma; multiple metastases; the presence of symptoms due to the pulmonary metastases; incomplete or extended resection of metastasis; disease-free interval of less 1 year; a tumor larger than 50 mm; and an NS score of ?6. A multivariate analysis identified the NS score (relative risk 2.1, p = 0.008) and resectability (relative risk 1.8, p = 0.022) as significant independent prognostic factors. Resection of pulmonary metastases has become an accepted therapeutic modality, but the selection of surgical candidates and the operative planning should be individualized. The application of these prognostic factors preoperatively may identify patients who will benefit optimally from thoracotomy.
455
I
Bronchopiastic tumours
procedures
for centrally
located
T. Testa, E. Spinelli. A. Gasparo. E. deBernardis, E. Carbone, M.A. Nahum, G. Motta. University of Genoa, ltaly From 1978 to 1996, 65 bronchoplastic lobectomies were performed with a rate of about 6% as to the whole amount of lung cancer operated patients. Mean age was 61 (range: 18-77). Males were 61 (94%) and females 4 (6%). 34 sleeve lobectomies. 20 wedge lobectomies and, finally, 11 lower lobectomies with turn up of upper residual lobe were performed. Squamous cell carcinoma was detected in 42 cases (65%) adenocarcinoma in 9 (14%), small cell cancer in 5 (7.5%) adenosquamous carcinoma in 3 (4.5%) carcinoid in 2 (3%), while bronchioloalveolar carcinoma, WDNC, anaplastic and carcinosarcoma in one (1.5%). Pre-operative bronchoscopic assessment as well as surgical procedures and postoperative bed-side bronchoscopic follow-up were performed by the same surgical team. In 18 cases (28%) the bronchoplastic procedure recognized an absolute indication due to a severe ventilatory insufficiency (FEVI less than 60%). 9 patients registered FEVl values between 60% and 50%, 5 values between 50% and 40% and in 4 cases FEVI was less than 40%. The right side was involved in 50 cases (77%) with respectively 16 sleeve upper lobectomies, 11 sleeve bilobectomies, 10 upper wedge lobectomies, 5 wedge bilobectomies and 8 turn up lower bilobectomies. On the lefl side (23%), 7 patients underwent a sleeve upper lobectomy, 5 a wedge lobectomy and 3 a lower lobectomy with turn up of the upper lobe. Extended lymphoadenectomy demonstrated 19 patients as NO (29%) 28 (43%) as Nl and 18 as N2 (28%). New Staging System was systematically adopted except for 17 cases where the tumour was over 5.5 cm in maximum diameter. They were overstaged as T3 Stage IIIA (6 in TBNOMO and 11 in T3Nl MO subset) according to the survival rate and considering mediastinal proximity as the complementary negative factor of prognosis. 9 patients were in Stage I (14%) 10 in stage II (16%), 38 in stage IIIA (58%) 6 in stage IIIB (9%) while 1 belonged to stage 0 and another 1 to stage IV (1.5% respectively). Operative mortality was 7%, marginal infiltration 4% while only 2 local recurrences were discovered (3%). A minimum of 1 year follow-up was available for 58 patients. 5 yr actuarial survival, calculated wrth Kaplan-Meier method, was 66% in stage I, 56% in stage II, 7% in stage IIIA. In this latter group, 3 subsets were defined: i) T3NO-1 MO because of size, ii) TSNO-IMO where T3 was independent from dimension and, finally, iii) Tl-3N2MO. 5 yr survival was, respectively 6%, 24% and 0%. No patients in stage IIIB survived over 18 months. This study was supported by CNR-ACRO Contract No.95.00403.PF39
I
456
Evaluation of multiple tumor markers and biological parameters in early-stage NSCLC: A new prognostic tool
M. Lucchi, A. Mussi, A. Chella, G. Fontanini ‘, M. Ferdeghini 2, G. Bevilaqua ’ , CA. Angeletti. ‘Service of Thoracic Surgery Department of Surgery, Services of Pathology; 2 Nuclear Medicine, Department of Oncology University of Piss, lfaly Objective: A multiple serum tumor markers assay and a careful ical examination of patients with NSCLC Stage I was performed, establish a substaging model in the traditional TNM classrfication.
pathologaiming to
Modali
117
Therapy
Methods: We prospectively investigated 133 patients (118 males - 15 females; median age 66 years) with Stage I NSCLC treated only by radical surgery between September 1992 and December 1994 preoperatively assaying multiple tumor markers (CEA, SCC, NSE, TPA, CYFRA 21.1) and considering some pathological characteristics (~53 protein expression, proliferative activity, blood vessel invasion and angiogenesis). Results: There were 76 squamous and 57 non-squamous tumors with a median size of 4 cm. Twenty-three tumors had a positive blood vessel invasion. The median proliferative activity was 28 (range 0.8-80), while the median p53 expression and microvessel count (MC) were 7% and 17, respectively. The median values of such pathological characteristics and established levels for the serum tumor markers (CEA = 10 rig/ml; NSE = 13 @ml; SCC = 2 @ml; TPA = 100 U/ml; CYFRA 21.1 = 1.6 rig/ml) were chosen as cut-off values for statistical analysis. As regards correlations between pathological and serum characteristics we found a significative correlation of TPA and CYFRA 21.1 levels with tumor load expressed by the maximum diameter (p = 0.05 and p = 0.02, respectively) and with PCNA (p = 0.04 and p = 0.03, respectively). Survival was calculated from the date of operation until death or the date of last follow-up (censored). The median follow-up was 36 months. Univariate analysis revealed that T factor (Tl vsT2) [p = 0.0003], MC (low vs high) [p = 0.021, TPA (low vs high) [p = 0.051 and the CYFRA 21 .l (low vs high) [p = 0.051 were significant predictor of survival. The T factor, the MC, the TPA were also significant predictors of long Disease Free Survival (p = 0.001; p = 0.05; p = 0.006 respectively). On multivariate analysis only the T factor and the MC maintained their level of significance as regards overall survival (p = 0.01 and p = 0.03) and Disease Free Survival. (p = 0.03 and p = 0.04). Conclusions: Preoperative serum tumor markers evaluation has a potential utility for screening, diagnosis and follow-up of early stage NSCLC, but not for establishing prognosis. Following surgical treatment, the Tfactor and, most importantly, the microvessel count may identify patients who could benefit by adjuvant treatments.
I457
Management of postoperative by means of endoscopy
bronchopleural
F. Ferro, P.P. Brega Massone, G. Orlandoni, E. Forni. Genera/ Clinic, /RCCS San Matte0 Hospital, University of Pavia, ltaly
fistula Surgical
In spite of continuous improvement of surgical techniques, bronchopleural fistula (BPF) still represents a major complication after lung resection. In some cases it may be associated with empyema of the remaining empty pleural. The reoperation with closure of the fistula and reinforcement of bronchial suture with well vascularized flap of pericardial fat or intercostal muscle or omentum may be utilized, in accordance with modified techniques described, especially in early fistulas. However, owing to the high risks correlated wtth reoperation and with the direct closure of the fistula. alternative methods have been proposed. The apposition of tissucol by endoscopic means represents, nowadays, a successful technique for the closure of postoperative fistulas with marked risks reduction with respect to a surgical treatment. At the General Surgical Clinic of the University of Pavia, in the period going from November 1989 to October 1995, 523 patients have been undergone to surgical treatment for lung cancer. In 5 patients (1%) postoperative course was complicated by arising of a BPF; 2 were submitted to left pneumonectomy, 1 to right pneumonectomy, 1 to bilobectomy and 1 to left lower lobectomy. Other 2 patients, operated in other hospital with BPF after left pneumonectomy, were treated in our Institute. All 7 fistulas, composing our series of cases, were incomplete; for that reason we decided for a conservative endoscopic treatment. After the introduction of the bronchoscope and visualization of the fistula, a thin catheter is introduced along the operative channel of the bronchoscope. The tip of the catheter is placed at about 1 cm from the opening of the fistula. A dose of 5 cc of tissucol is injected through the catheter and the correct apposition is controlled. A mean of 5.3 treatment, in a range form 4 to 7, were required to obtain a correct healing of the fistula. In all cases we achieved the aim of the fistula closure. In conclusion, considering our experience, we can assert that the endoscopic closure with tissucol represents a valid therapeutic option in patients with bronchopleural fistula that can be proposed as a first-line measure and, in selected cases, allows the solution of the problem.
- Combined
were performed in 148 patients with metastatic pulmonary tumors. To assess both the number and the size of the metastasis, we introduced the Number Size score (NS score) index, which was the sum of the diameters of all metastatic lesions. The overall 5-year survival rate was 33%. A significant detnmental influence on survival was recognized for each of the following: metastases from a sarcoma; multiple metastases; the presence of symptoms due to the pulmonary metastases; incomplete or extended resection of metastasis; disease-free interval of less 1 year; a tumor larger than 50 mm; and an NS score of ?6. A multivariate analysis identified the NS score (relative risk 2.1, p = 0.008) and resectability (relative risk 1.8, p = 0.022) as significant independent prognostic factors. Resection of pulmonary metastases has become an accepted therapeutic modality, but the selection of surgical candidates and the operative planning should be individualized. The application of these prognostic factors preoperatively may identify patients who will benefit optimally from thoracotomy.
455
I
Bronchopiastic tumours
procedures
for centrally
located
T. Testa, E. Spinelli. A. Gasparo. E. deBernardis, E. Carbone, M.A. Nahum, G. Motta. University of Genoa, ltaly From 1978 to 1996, 65 bronchoplastic lobectomies were performed with a rate of about 6% as to the whole amount of lung cancer operated patients. Mean age was 61 (range: 18-77). Males were 61 (94%) and females 4 (6%). 34 sleeve lobectomies. 20 wedge lobectomies and, finally, 11 lower lobectomies with turn up of upper residual lobe were performed. Squamous cell carcinoma was detected in 42 cases (65%) adenocarcinoma in 9 (14%), small cell cancer in 5 (7.5%) adenosquamous carcinoma in 3 (4.5%) carcinoid in 2 (3%), while bronchioloalveolar carcinoma, WDNC, anaplastic and carcinosarcoma in one (1.5%). Pre-operative bronchoscopic assessment as well as surgical procedures and postoperative bed-side bronchoscopic follow-up were performed by the same surgical team. In 18 cases (28%) the bronchoplastic procedure recognized an absolute indication due to a severe ventilatory insufficiency (FEVI less than 60%). 9 patients registered FEVl values between 60% and 50%, 5 values between 50% and 40% and in 4 cases FEVI was less than 40%. The right side was involved in 50 cases (77%) with respectively 16 sleeve upper lobectomies, 11 sleeve bilobectomies, 10 upper wedge lobectomies, 5 wedge bilobectomies and 8 turn up lower bilobectomies. On the lefl side (23%), 7 patients underwent a sleeve upper lobectomy, 5 a wedge lobectomy and 3 a lower lobectomy with turn up of the upper lobe. Extended lymphoadenectomy demonstrated 19 patients as NO (29%) 28 (43%) as Nl and 18 as N2 (28%). New Staging System was systematically adopted except for 17 cases where the tumour was over 5.5 cm in maximum diameter. They were overstaged as T3 Stage IIIA (6 in TBNOMO and 11 in T3Nl MO subset) according to the survival rate and considering mediastinal proximity as the complementary negative factor of prognosis. 9 patients were in Stage I (14%) 10 in stage II (16%), 38 in stage IIIA (58%) 6 in stage IIIB (9%) while 1 belonged to stage 0 and another 1 to stage IV (1.5% respectively). Operative mortality was 7%, marginal infiltration 4% while only 2 local recurrences were discovered (3%). A minimum of 1 year follow-up was available for 58 patients. 5 yr actuarial survival, calculated wrth Kaplan-Meier method, was 66% in stage I, 56% in stage II, 7% in stage IIIA. In this latter group, 3 subsets were defined: i) T3NO-1 MO because of size, ii) TSNO-IMO where T3 was independent from dimension and, finally, iii) Tl-3N2MO. 5 yr survival was, respectively 6%, 24% and 0%. No patients in stage IIIB survived over 18 months. This study was supported by CNR-ACRO Contract No.95.00403.PF39
I
456
Evaluation of multiple tumor markers and biological parameters in early-stage NSCLC: A new prognostic tool
M. Lucchi, A. Mussi, A. Chella, G. Fontanini ‘, M. Ferdeghini 2, G. Bevilaqua ’ , CA. Angeletti. ‘Service of Thoracic Surgery Department of Surgery, Services of Pathology; 2 Nuclear Medicine, Department of Oncology University of Piss, lfaly Objective: A multiple serum tumor markers assay and a careful ical examination of patients with NSCLC Stage I was performed, establish a substaging model in the traditional TNM classrfication.
pathologaiming to
Modali
117
Therapy
Methods: We prospectively investigated 133 patients (118 males - 15 females; median age 66 years) with Stage I NSCLC treated only by radical surgery between September 1992 and December 1994 preoperatively assaying multiple tumor markers (CEA, SCC, NSE, TPA, CYFRA 21.1) and considering some pathological characteristics (~53 protein expression, proliferative activity, blood vessel invasion and angiogenesis). Results: There were 76 squamous and 57 non-squamous tumors with a median size of 4 cm. Twenty-three tumors had a positive blood vessel invasion. The median proliferative activity was 28 (range 0.8-80), while the median p53 expression and microvessel count (MC) were 7% and 17, respectively. The median values of such pathological characteristics and established levels for the serum tumor markers (CEA = 10 rig/ml; NSE = 13 @ml; SCC = 2 @ml; TPA = 100 U/ml; CYFRA 21.1 = 1.6 rig/ml) were chosen as cut-off values for statistical analysis. As regards correlations between pathological and serum characteristics we found a significative correlation of TPA and CYFRA 21.1 levels with tumor load expressed by the maximum diameter (p = 0.05 and p = 0.02, respectively) and with PCNA (p = 0.04 and p = 0.03, respectively). Survival was calculated from the date of operation until death or the date of last follow-up (censored). The median follow-up was 36 months. Univariate analysis revealed that T factor (Tl vsT2) [p = 0.0003], MC (low vs high) [p = 0.021, TPA (low vs high) [p = 0.051 and the CYFRA 21 .l (low vs high) [p = 0.051 were significant predictor of survival. The T factor, the MC, the TPA were also significant predictors of long Disease Free Survival (p = 0.001; p = 0.05; p = 0.006 respectively). On multivariate analysis only the T factor and the MC maintained their level of significance as regards overall survival (p = 0.01 and p = 0.03) and Disease Free Survival. (p = 0.03 and p = 0.04). Conclusions: Preoperative serum tumor markers evaluation has a potential utility for screening, diagnosis and follow-up of early stage NSCLC, but not for establishing prognosis. Following surgical treatment, the Tfactor and, most importantly, the microvessel count may identify patients who could benefit by adjuvant treatments.
I457
Management of postoperative by means of endoscopy
bronchopleural
F. Ferro, P.P. Brega Massone, G. Orlandoni, E. Forni. Genera/ Clinic, /RCCS San Matte0 Hospital, University of Pavia, ltaly
fistula Surgical
In spite of continuous improvement of surgical techniques, bronchopleural fistula (BPF) still represents a major complication after lung resection. In some cases it may be associated with empyema of the remaining empty pleural. The reoperation with closure of the fistula and reinforcement of bronchial suture with well vascularized flap of pericardial fat or intercostal muscle or omentum may be utilized, in accordance with modified techniques described, especially in early fistulas. However, owing to the high risks correlated wtth reoperation and with the direct closure of the fistula. alternative methods have been proposed. The apposition of tissucol by endoscopic means represents, nowadays, a successful technique for the closure of postoperative fistulas with marked risks reduction with respect to a surgical treatment. At the General Surgical Clinic of the University of Pavia, in the period going from November 1989 to October 1995, 523 patients have been undergone to surgical treatment for lung cancer. In 5 patients (1%) postoperative course was complicated by arising of a BPF; 2 were submitted to left pneumonectomy, 1 to right pneumonectomy, 1 to bilobectomy and 1 to left lower lobectomy. Other 2 patients, operated in other hospital with BPF after left pneumonectomy, were treated in our Institute. All 7 fistulas, composing our series of cases, were incomplete; for that reason we decided for a conservative endoscopic treatment. After the introduction of the bronchoscope and visualization of the fistula, a thin catheter is introduced along the operative channel of the bronchoscope. The tip of the catheter is placed at about 1 cm from the opening of the fistula. A dose of 5 cc of tissucol is injected through the catheter and the correct apposition is controlled. A mean of 5.3 treatment, in a range form 4 to 7, were required to obtain a correct healing of the fistula. In all cases we achieved the aim of the fistula closure. In conclusion, considering our experience, we can assert that the endoscopic closure with tissucol represents a valid therapeutic option in patients with bronchopleural fistula that can be proposed as a first-line measure and, in selected cases, allows the solution of the problem.