Trimodality management of malignant pleural mesothelioma.

OBJECTIVE: We reviewed our experience with trimodality management of malignant pleural mesothelioma (MPM). METHODS: From September 1998 to August 2000, 32 consecutive patients with histological diagnosis of MPM underwent trimodality therapy, including surgery followed by adjuvant chemotherapy and radiation therapy. Surgery consisted of pleurectomy/decortication (P/D) or pleural-pericardial-pneumonectomy and diaphragm (PPPD). Pre-operative staging according to the Brigham Staging System was accomplished using computed tomography (CT) and magnetic resonance imaging (MRI); patients with evident extrapleural spread were excluded. RESULTS: Our series included 21 men and 11 women with a median age of 53.5 years (range 40-69). Histologically, there were 26 epithelial, four mixed and two sarcomatous MPM. Post-surgical staging was as follows: six patients were at Stage I; of these, two received a P/D and four a PPPD. Ten patients were at Stage II and all received a PPPD; 16 patients were at Stage III (under-staged pre-operatively): of these, nine patients presented extrapleural lymph node metastases (N2) and all received a PPPD, seven patients presented with chest wall or mediastinal invasion (T4) with macroscopic residual tumour, and all received a de-bulking P/D. We observed major complications in ten patients: six bleeding, two respiratory insufficiency and two nerve paralysis. There were two perioperative deaths (6.25% mortality). Twenty-seven patients out of 30 surviving surgery had a follow-up greater than 6 months; 21 patients out of 27 are alive with a median follow-up of 12.5 months. CONCLUSIONS: (1) Trimodality therapy is feasible in selected patients with MPM and has an acceptable operative mortality rate. (2) Our current pre-operative staging based on CT/MRI looks rather inaccurate and needs to be improved. (3) The high rate of post-surgical N2 patients or with diffusion to the inferior surface of the diaphragm may suggest the use of routine mediastinoscopy and laparoscopy for a more appropriate patient selection.     

Multimodality approach in management of malignant pleural mesothelioma.

Malignant pleural mesothelioma (MPM) is a solid, locally aggressive tumor, which has been closely linked to asbestos exposure. The survival rate without treatment ranges from 4 to 12 months. Response to chemotherapy and radiation is poor, and surgery is the most effective therapy. There are currently 3000 new MPM cases per year in the United States, with the peak incidence in the United States and Europe expected to occur in the year 2020. The prognosis depends on the stage of the tumor at the time of diagnosis, its histological type, lymph node status, and resection margins. While the diagnosis is often delayed, earlier intervention may improve life expectancy. Single-modality therapy has not been effective in changing the natural history of MPM. As a result, multimodality regimens involving surgery with radiation, chemotherapy, or immunotherapy have been initiated. Multiple modality approach has demonstrated favorable outcome, particularly in patients with epithelial histology, negative resection margins and presence of no metastases to extrapleural lymph nodes. Cisplatin and mitomycin have demonstrated modest efficacy in management of distant tumor recurrence. Cisplatin and gemcitabine regimen as well as cisplatin/pemetrexed followed by 54 Gy of adjuvant hemithorax radiation have been reported to improve the outcome.     

The management of second primary lung cancers. A single centre experience in 15 years.

OBJECTIVE: In patients treated for an initial lung cancer, the cumulative risk of developing a second primary lung cancer is a recognised occurrence. This study reviews our experience in the clinical assessment and surgical management of second primary lung cancer (SPLC). METHODS: Between 1985-1999 a series of 892 patients with primary carcinoma of lung underwent surgical resection with curative intent in our institution. Using criteria set out by Martini and Melamed (J Thorac Cardiovasc Surg 70 (1975) 606) we were able to identify 51 patients who had developed a SPLC identified as the first site of re-occurrence. RESULTS: Forty-one patients developed a metachronous SPLC within a mean of 46+/-14 months of the first operation while ten patients had synchronous double lung cancer (six unilateral, four bilateral). The cumulative probability of cancer free interval for metachronous cancers was 39% at 3 years, 15% at 5 years and 2% at 10 years. There were three postoperative deaths among the metachronous cancers (7.5%) and there were no operative deaths among patients with synchronous cancers. The overall actuarial 5-year survival for all patients with SPLC was 38% with a median survival of 40 months (range 1-142 months). The actuarial 5-year survival for metachronous SPLC was 44%, median survival of 49 months (range 1-142 months), while the actuarial 5-years survival for synchronous SLPC was 10% with a median survival of 31 months (range 4-78 months). CONCLUSION: Aggressive assessment and surgical intervention is safe, effective and warranted in patients with a second lung primary cancer if they satisfy the usual criteria of operability after full assessment. This is true for patients with metachronous cancers, while patients with synchronous cancers tend to have worse prognosis. A long term follow-up policy after the initial resection of the primary lung cancer is recommended at intervals of 6 months for at least 3-5 years and then annually to enable the early detection of the second cancer.     

Radiation associated malignant pleural mesothelioma.

Malignant pleural mesothelioma of epithelial type developed in a 24 year old woman, 20 years after radiotherapy for Hodgkin's disease. This case and a review of published cases indicate that radiation may induce malignant mesothelioma.     

Extrapleural pneumonectomy of malignant pleural mesothelioma

We analyzed 7 patients with malignant pleural mesothelioma who underwent extrapleural pneumonectomy. Six men and a woman had a mean age of 65 years old. The postoperative mortality rate was 14% (1 death) and morbidity, 43% (3 cases). According to staging of International Mesothelioma Interest Group, 2 patients had stage I disease, 1 did stage II, 3 did stage III and 1 did stage IV. Local recurrences were found in 3 patients and metastasis in 2. In patients with local recurrences, 2 had irradiation with chemotherapy and 1, irradiation. In patients with recurrences of metastasis, 1 had chemotherapy and 1, supportive care. Seven patients with extrapleural pneumonectomy and 10 without surgery had median survivals of 16 months and 10 months, 1-year survival rates of 71% and 40% and 2-year survival rates of 57% and 0% respectively (p=0.071). Extrapleural pneumonectomy with adjuvant therapy could be effective treatment for malignant pleural mesothelioma.     

Histopathologic diagnosis of malignant pleural mesothelioma

Diffuse malignant mesothelioma is a malignant tumor arising in the pleura from mesothelial cells. It has extremely polymorphous varieties of morphological patterns. Thus, confirming histopathologic diagnosis as mesothelioma, it should need not only histological examination but several methods such as special stain, immunohistochemical study, cytology of pleural effusion and electromicroscopy.     

Treatment of malignant pleural mesothelioma]

BACKGROUND: In this study all patients observed between January 1993 and October 1997 with malignant pleural mesothelioma (MPM) have been analyzed in order to describe the impact of treatment modality on survival. METHODS: Medical records of 56 patients with MPM (44 male, 12 female, median age = 59 yrs) were reviewed. In 34 cases the histotype was epithelial, in 4 sarcomatoid, in 4 mixed, in 3 desmoplastic, and in 11 not specified. Four treatment modalities were identified: 1) Surgery (subtotal pleurectomy) = 20 patients; 2) Chemotherapy = 19 patients; 3) Surgery+Chemo-therapy = 8 patients; 4) Supportive care = 9 patients. RESULTS: The median survival was: 1) Surgery = 12.4 months; 2) Chemotherapy = 7.5 months; 3) Surgery+Chemotherapy = 12 months; 4) Supportive care = 11.4 months. Using univariate analysis, 8 prognostic factors were studied (age, sex, asbestos exposure, side, histotype, performance status, stage, treatment). Among these, only the stage and the performance status had shown a prognostic value on survival (p<0.05), while the treatment modality had not significantly influenced the prognosis. Using multivariate analysis only performance status showed to be significatively associated with survival (p=0.01 and odds ratio = 1.9, I.C. 1.2-3.2). CONCLUSIONS: Despite the limits of a retrospective study, personal experience confirms the ineffectiveness of current therapeutical approaches to MPM. A better understanding of MPM is required to develop new therapeutical approaches and alter the dismal prognosis of this disease.     

恶性胸膜间皮瘤治疗新进展

恶性胸膜间皮瘤是一种与石棉接触密切的肿瘤,其侵袭性很强,起病隐匿,发现时已在中晚期,目前的治疗方案尚未能有很好的治疗效果.采用溶瘤细胞性单纯性疱疹病毒和顺铂诱导溶瘤细胞性单纯性疱疹病毒产生GADD34蛋白增量调节方案能对间皮瘤癌细胞有相对的特异性,是一种有前景的治疗方案.     

恶性胸膜间皮瘤的实验模型

恶性胸膜间皮瘤(malignant pleural mesothelioma，MPM)是一种少见的肿瘤，近年来发病率逐渐上升，由于诊断和治疗均较困难，所以迫切需要建立实验模型进行研究。通过对模型的种类、制作方法和各种模型的特点进行综述，归纳出其用途。MPM动物模型是临床研究最常用的实验模型，多用大鼠或裸鼠，以诱发性动物模型和异种移植模型较成熟。目前各种模型均存在一些缺点，或周期长、出瘤率低或与人差异较大等，离理想的模型仍有一定的距离。但随着分子生物学和分子遗传学的发展，利用基因或其它途径减少或消除大动物的个体差异，同时提高实验动物产量；研究裸鼠的繁殖、饲养规律，寻找廉价、饲养方便、体大、生命力强的裸鼠，以及对MPM转基因动物模型的研究，将有希望获得多种满足不同需要的理想MPM实验模型。     

Clinical diagnosis of malignant pleural mesothelioma

Accurate and rapid diagnosis of malignant pleural mesothelioma is important because of its rapid progress. But diagnosis of this disease is often difficult. We reviewed 64 cases with a pathological diagnosis of malignant pleural mesothelioma in the past 14 years in our hospital. We made diagnosis of this disease by cytologic study of pleural fluid (11 cases), percutaneous needle biopsy (16), thoracoscopic biopsy (34), or surgery (2). When cytologic findings are inconclusive, thoracoscopic biopsy is the most effective method for diagnosis and should be done without delay.     

Paediatric cervical spine injures. Nineteen years experience of a single centre

Purpose

This observational study aims to describe pediatric C-spine injuries from a level 1 trauma centre through a period of 19 years.

Methods

Clinical records of pediatric trauma patients admitted to a level 1 trauma centre between 1991 and 2009 were analyzed. Patients were stratified by age into groups A (8 or less) and B (9 to 16), and in lower (C0-C2) and upper (C3-C7) spine injuries. Several variables were studied.

Results

Seventy-five cases of C-spine injuries (nine SCIWORA) were identified. Group A included 23 patients and group B 52. In group A, skeletal injuries at the upper C-spine were more common than injuries at the lower C-spine, whereas in group B, injuries of the lower C-spine were more frequent (p?=?0.035). Motor vehicle accidents were the main cause of injury (44 %); 25.3 % of patients were surgically treated. Thirty-nine patients presented neurologic deficits, 16 of which improved. The overall mortality rate was 18.7 % and significantly higher in patients with neurological damages (p?<?0.001)

Conclusions

This study revealed a low incidence of cervical spine injuries in the paediatric population. As in previous reports younger children mainly sustained injuries at the upper C-spine, higher incidence of spinal injuries, and higher risk of death than older children.

     

Extrapleural pneumonectomy in the treatment of malignant pleural mesothelioma.

A technique for extrapleural pneumonectomy in diffuse, malignant, pleural mesothelioma is described. The technique used in a protocol at Brigham and Women's Hospital has resulted in improved operative mortality figures and length of hospital stay. The right-sided procedure is presented followed by differences in technique required by the left-sided approach.     

The role of video assisted thoracoscopic pleurectomy/decortication in the therapeutic management of malignant pleural mesothelioma.

OBJECTIVE: Extrapleural pneumonectomy (EPP) has high mortality and morbidity; radical pleurectomy decortication (P/D) carries less mortality but still significant morbidity. This surgery is not suitable for many patients with malignant pleural mesothelioma (MPM) for whom video assisted thoracic surgery (VATS) offers a minimally invasive alternative. We aimed to assess the role of VATS decortication for MPM. METHODS: Over a 9-year period 208 patients underwent therapeutic surgery for MPM in our unit. One hundred and twelve of the patients underwent EPP, 29 had a P/D and 67 had VATS decortication. Sixty-three of the 208 patients (EPP n=13, P/D n=8 and VATS decortication n=42) were 65 years of age or older at the time of the operation (57 males and 6 females, age 70 (65-80) years). In this group we analyzed perioperative morbidity and mortality and long-term survival data using the Kaplan-Meier method. RESULTS: Postoperative stay and 30-day mortality was significantly lower for VATS P/D than for EPP (14.3 days vs 36.6 days, p<0.05 and mortality 7.1% vs 23%, respectively). There was no significant difference in the overall mean survival between the two groups (11.5 months for EPP and 14 months for VATS P/D, p=0.6). CONCLUSION: VATS decortication should be considered in the therapeutic strategy for MPM.     

Outcome after extrapleural pneumonectomy for malignant pleural mesothelioma.

BACKGROUND: Malignant pleural mesothelioma is a mainly asbestos-related neoplasm that occurs with increasing frequency and is associated with a poor prognosis. Extrapleural pneumonectomy which was initially performed as a stand-alone treatment in patients with resectable disease is now currently almost uniformly applied as part of a multi-modal approach. Its value and advantage over other therapeutic strategies remain points of discussion. We therefore analysed our experience with extrapleural pneumonectomy in the treatment of malignant pleural mesothelioma. METHODS: We retrospectively reviewed our institutional experience with all consecutive patients undergoing extrapleural pneumonectomy for malignant pleural mesothelioma from 1994 to 2005. Patients were analysed with regard to hospital mortality and morbidity and long-term outcome. RESULTS: Forty-nine patients (10 female/39 male, mean age 58+12 years) underwent extrapleural pneumonectomy during the observation period. Median ICU stay was 1 day, median postoperative length of hospital stay was 13 days. After a mean follow-up of 2573 days, median survival was 376 days (mean 672+121 days, range 9-3384). One-year survival was 53%, 3-year survival 27% and 5-year survival 19%. CONCLUSION: Extrapleural pneumonectomy as part of a multi-modality treatment regimen is a good treatment option for selected patients with malignant pleural mesothelioma. The long-term results of this limited series compare favourably to non-surgical treatment regimens. Larger randomised prospective multi-centre trials are warranted to establish clear guidelines.     

3066 consecutive Gamma Nails. 12 years experience at a single centre

Background  

Fixation of trochanteric hip fractures using the Gamma Nail has been performed since 1988 and is today well established and wide-spread. However, a number of reports have raised serious concerns about the implant's complication rate. The main focus has been the increased risk of a subsequent femoral shaft fracture and some authors have argued against its use despite other obvious advantages, when this implant is employed.     

Ureterocalicostomy in children: 12 years experience in a single centre

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Since 1947 ureterocalicostomy has been a recognised option in the treatment of obstructive systems either as a primary or salvage procedure, however few series specific to the paediatric patient exist. This 12 year review of 13 cases at one tertiary centre demonstrates ureterocalicostomy to be a versatile, reliable means of relieving obstruction for a variety of indications; horseshoe kidney, recurrent PUJ obstruction and gross PUJ obstruction with unfavourable anatomy.

OBJECTIVE

• ? To document the outcome of ureterocalicostomy in children.

PATIENTS AND METHODS

• ? The outcomes of 13 children who had undergone ureterocalicostomy consecutively under the care of two paediatric urologists between 1997 and 2009 were evaluated retrospectively.
• ? Ureterocalicostomy was performed as the primary procedure in four children with horseshoe kidney and four children presenting with gross pelvi‐ureteric junction (PUJ) obstruction.
• ? In the remaining five children, it was performed as a secondary procedure for recurrent PUJ obstruction after previous pyeloplasty.
• ? An open approach was employed in 12 patients, whereas, in one patient, it was performed by a laparoscopically‐assisted technique.

RESULTS

• ? Mean age at operation was 9.3 years and the mean (range) duration of follow‐up was 2.6 (0.3–7.0) years. Twelve children (92%) experienced a good functional outcome following ureterocalicostomy, as defined by reduced dilatation and improved drainage on postoperative ultrasonography and/or isotope imaging.
• ? However one child (8%) developed symptomatic anastomotic obstruction 5 months after primary ureterocalicostomy for obstruction in a horseshoe kidney. Surgical revision was successful, with good drainage, preservation of differential function and relief of symptoms on further follow‐up to 3 years.

CONCLUSIONS

• ? Ureterocalicostomy provides a versatile and reliable means of relieving obstruction for a variety of indications, including horseshoe kidney, recurrent PUJ obstruction and gross PUJ obstruction with unfavourable anatomy.
• ? Approximation of ureteric and caliceal urothelium and excision of renal parenchyma in the proximity to the anastomosis are the key steps for securing a satisfactory outcome.