Utilidad de la tomografía por emisión de positrones en la detección de metástasis ocultas extratorácicas en el carcinoma broncogénico no células pequeñas

Introduction

Positron emission tomography combined with computed axial tomography (PET/CT) is used for staging non small cell lung cancer (NSCLC). This study aims to describe PET/CT findings of unsuspected extrathoracic metastasis when used in mediastinal evaluation of patients with apparently resectable NSCLC.

Patients and method

Prospective and concurrent study including all NSCLC patients between June 2004 and November 2006 who underwent PET/CT after considering them as candidates for surgery, with resectable disease after bronchoscopy, thorax and abdominal CT, brain CT and bone gammagraphy evaluation, if metastasis at these locations were suspected. Metastasis were confirmed histopathologically or assumed when they had a compatible evolution.

Results

A total of 91 patients with NSCLC underwent PET/CT. In 24 of them (26%) at least one suspicious extrathoracic uptake was seen. In 7 patients (7.7%) those uptakes were NSCLC extrathoracic metastasis hidden from conventional staging. In 3 of these cases (13.1%) extrathoracic uptakes corresponded to metacrhonous tumours or pre-malignant conditions. Benign lesions were found in 12 patients (13.1%), and in 2 cases (2.2%) the uptake origins were undetermined.

Conclusions

PET/CT is a complementary diagnosis method for assessing hidden metastases which could modify the therapeutical approach in patients otherwise suitable for surgery.     

Análisis de supervivencia de la cirugía de resección de metástasis pulmonares de cáncer colorrectal

Introduction

The publication of the International Registry of Lung Metastases (IRLM) in 1997 was a turning point in favor of surgical resection of lung metastases. Prognostic groups were defined according to resectability, number of metastases, and disease-free interval. The objective of this study was to determine survival in patients who underwent resection of lung metastases from colorectal carcinoma and to evaluate how applicable the prognostic factors established by the IRLM are in this specific patient group.

Patients and Methods

Patients with lung metastases from colorectal carcinoma who underwent resection between January 1, 2000, and November 30, 2006, were retrospectively analyzed. Survival was calculated using the Kaplan-Meier method, with log-rank comparisons between groups.

Results

Survivals at 1, 3, 5, and 6 years was 92%, 75%, 54%, and 43%, respectively. The main finding was that 3-year survival was better in patients who underwent atypical resection of the metastasis (75%) than those who required lobectomy (55%). There were no significant differences in survival in terms of number of lung metastases resected or disease-free interval.

Conclusions

Survival in patients requiring lobectomy for resection of lung metastases from colorectal carcinoma was worse than in those who underwent atypical resection. The number of metastases and disease-free interval may be questionable prognostic factors in the case of lung metastases from colorectal carcinoma.     

Experiencia y desarrollo de la técnica de lobectomía por cirugía torácica videoasistida: estudio comparativo con cirugía convencional en estadio i de cáncer de pulmón no microcítico

Background

Surgical treatment of stage I non-small cell lung cancer (NSCLC) can be performed either by thoracotomy or by employing video-assisted thoracic surgery (VATS). The aim of this study was to compare long and short-term results of conventional surgery (CS) vs. VATS lobectomy in the treatment of stage I NSCLC.

Materials and methods

We performed a retrospective, analytical study of patients undergoing surgery for stage I NSCLC during the period January 1993 to December 2005. The variables analyzed were overall survival, recurrence, distant metastasis, morbidity, mortality and hospital stay. During this period, 256 anatomic lung resections were performed: 141 by CS and 115 by VATS.

Results

There were statistically significant differences in: (i) mean hospital stay in patients with no complications (VATS group: 4.3 days vs. CS group: 8.7 days, P = .0001); (ii) mean hospital stay in patients with complications (VATS: 7.2 days vs. CS: 13.7 days, P = .0001), and (iii) morbidity (VATS: 15.6% vs. CS: 36.52%, P = .0001). No statistically significant differences were found in: (i) mortality (VATS: 2.17% vs. CS: 1.7%, P = .88); (ii) 5-year overall survival (VATS: 68.1% vs. CS: 63.8%), and (iii) local recurrence and distant metastasis (P = .82).

Conclusions

VATS lobectomy is a safe and effective approach, with a shorter hospital stay and lower morbidity than CS; no statistically significant differences were observed in survival in patients undergoing surgery for stage I NSCLC.     

Relación entre las calcificaciones ateroscleróticas en el tórax detectadas mediante tomografía computarizada y la función pulmonar

Background and objectives

A few recent epidemiological findings indicate a link between atherosclerosis and some lung functions. We studied further the relation between calcified chest atherosclerosis as seen in computed tomography (CT) and several lung functional parameters.

Patients and methods

Male construction workers originally screened for occupational lung cancer with CT had their chest atherosclerosis (aorta, the origins of its cervical branches, the coronary arteries and heart valves) visually classified. The relation between the atherosclerotic calcification scores and lung function (total lung capacity [TLC], forced expiratory volume in one second [FEV₁%], forced vital capacity [FVC%], maximal expiratory flow when 50% of FVC remains to be exhaled, total and specific diffusing capacities; all above expressed as percent of predicted value, and the FEV₁/FVC% ratio) were studied with the general linear model adjusted for smoking, exposure years for asbestos, and body mass index (n=432).

Results

All lung functions except TLC showed significant negative associations with calcifications in aorta and in its branches. TLC showed such association only with atherosclerosis in the ascending aorta.

Conclusions

Aortic atherosclerosis seems to be related with poor lung function. This may be due to deteriorated bronchial circulation, but other mechanisms can also be involved. Lung function poorer than would be expected due to pulmonary reasons may indicate aortic atherosclerosis.     

Metástasis exclusivas en el timo de un cáncer de pulmón no microcítico resecado

Primary thymic tumors are rare, but secondary ones are exceptionally uncommon. We report the case of a single metastasis within the thymic gland from a lung adenocarcinoma that had been completely resected 3 years before. There was high diagnostic doubt because the thymic lesion was not associated with the recurrence of the paraneoplastic syndrome or the increased CEA levels described at the moment of the treatment of the primary tumor. The lesion was diagnosed and treated at the same time by transcervical thymectomy. At the one-year follow-up, the patient is alive and disease-free.     

Tratamiento quirúrgico de lesiones pulmonares en pulmón único

We performed surgery on 4 patients who had previously undergone left pneumonectomy and presented a second pulmonary lesion (3 lung cancers; 1 metastasis from colon cancer). Patients were aged between 52 and 79 years; 3 were men. Wedge resection was performed in 3 patients and segmentectomy in the other. Preoperative forced expiratory volumes in the first second were 1940 mL (72%), 576 mL (29%), 1390 mL (63%), and 2370 mL (63%). There was no perioperative mortality; 1 patient presented an air leak for 7 days. Two patients were alive and disease-free at 12 and 15 months, and 2 died from causes unrelated to the tumor at 52 and 183 months. There was no deterioration in the quality of life. In selected cases, patients with a second tumor in a single lung can be treated surgically with little or no mortality and with a prolonged survival.     

Tuberculosis latente en la artritis reumatoide. Evaluación de la respuesta celular y tomografía computarizada de alta resolución

Introduction

The diagnosis of latent tuberculosis (LTB) in patients with rheumatoid arthritis (RA) has become important with the introduction of anti-tumor necrosis factor (anti-TNF-α) agents and the appearance of active tuberculosis cases in these patients. The tuberculin skin test (TST) has limited value in patients with RA. Tests based on the release of interferon-gamma (IFN-γ) are being studied, but their role has not been well established for this group of patients.

Objectives

To compare the diagnosis of LTB in patients with RA by using cellular immune response to the TST and T.SPOT-TB. Additionally, findings of tomography studies compatible with LTB were used.

Methods

Clinical evaluation, TST, T.SPOT-TB and high-resolution computed tomography (HRCT) in a group of patients with RA at the University Hospital of the Federal University of Goiás.

Results

Response to the TST was lower in patients with RA (13.5%) compared to the predicted values of the general population. T.SPOT-TB identified a higher number of patients with LTB than the TST (36.8%). HRCT showed changes compatible with LTB in 52.9% of the patients, including 8 of the 11 patients with negative TST and T.SPOT-TB.

Conclusions

The TST by itself is insufficient to diagnose LTB. A higher number of positive results were obtained with T.SPOT-TB when compared to the TST. Nevertheless, it was negative in a large percentage of patients with tomography findings consistent with LTB. HRCT is readily available in most large health-care centers and it could be incorporated into the diagnostic strategy for LTB in patients with RA.     

Comparación de las sondas M y XL para estimar la rigidez hepática por medio de elastografía de transición

The FibroScan^® XL probe has been specifically designed for obese patients to measure liver stiffness by transient elastography, but it has not been well tested in non-obese patients. The aim of this study was to compare the M and XL FibroScan^® probes in a series of unselected obese (body mass index above 30 kg/m²) and non-obese patients with chronic liver disease.     

Uso combinado de aspiración por punción transbronquial y tomografía computarizada de emisión fotónica única con Tc-2-metoxi-isobutil-isonitrilo para el diagnóstico de ganglios linfáticos mediastínicos agrandados

Background

To demonstrate the diagnostic accuracy of an integrated approach of blind trans-bronchial needle aspiration (TBNA) and ^99mTc-2-methoxy-isobutyl-isonitrile single photon emission computed tomography (^99mTc-MIBI-SPECT) in diagnosing mediastinal lymph adenopathy.

Methods

Sixty one consecutive patients with mediastinal lymph adenopathy undergoing both TBNA and ^99mTc-MIBI-SPECT were prospectively enrolled. Mediastinoscopy was attended in case of negative TBNA.

Results

Eighty three adenopathies were sampled (73 malignant and 10 benign). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) of TBNA was 74%, 100%, 100%, and 34%, respectively; and of ^99mTc-MIBI-SPECT was 96%, 80%, 97%, and 73%, respectively. Combining TBNA and ^99mTc-MIBI-SPECT results sensitivity, specificity, PPV, NPV of 97%, 100%, 100%, and 83%, respectively, was obtained. TBNA alone avoided medistianoscopy in 65% of cases, while an integrated approach could have potentially obviated mediastinoscopy in 76%.

Conclusions

^99mTc-MIBI-SPECT improved the sensitivity and the NPV of TBNA, reducing the need of mediastinoscopy.     

Valoración externa de las recomendaciones de la GEMA2009 por un panel multiprofesional de expertos en asma

Objectives

To assess the level of agreement on the GEMA 2009 clinical recommendations by a Spanish expert panel on asthma.

Materials and methods

The study was divided into four stages: 1) establishment of a 9 member scientific committee (GEMA authors) for selection of GEMA recommendations to use in the survey; 2) formation of a panel of 74 professionals with expertise in this field (pulmonologists, allergists, family doctors, ear, nose and throat and paediatric specialists); 3) Delphi survey in two rounds, sent by mail, with intermediate processing of opinions and a report to the panel members; and 4) analysis and discussion of results for the Scientific Committee.

Results

Seventy four participants completed the two rounds of survey. During the first round, a consensus was reached in 49 out of 56 questions analysed. Following discussion by the panel, the consensus was increased to a total of 53 items in the survey. With respect to the remaining questions, Insufficient consensus was obtained on the rest of the questions, due to differing views between sub-specialists, or lack of criteria by most of the experts.

Conclusions

The external analysis by asthma experts from different specialities showed a high level of professional agreement with the GEMA 2009 recommendations in Spain (96.5%). The disagreement shown in three recommendations reflect the lack of a high level evidence. These issues represent areas of interest for future research.     

Dismorfología de las deformidades de la pared torácica: distribución de frecuencias de los subtipos de pectus excavatum típico y subtipos poco comunes

Background/Purpose

More than forty percent of patients with pectus excavatum have a family history of chest deformity. However, no studies of the frequency of the different phenotypes of pectus excavatum have been published.

Methods

A random sample of 300 non-syndromic pectus excavatum patients, from the chest wall deformities clinic at Children's Hospital of The King's Daughters in Norfolk, Va., was studied and classified according to a previously described classification system. Photographs and computed tomography (CT) scans were utilized.

Results

Typical pectus excavatum. Photo data: localized deep depression (cup-shaped) deformity occurred in 67%; diffuse (saucer-shaped) 21%, trench-like (furrow-shaped) 10%, and Currarino-Silverman (mixed pectus excavatum/chondromanubrial carinatum) 1%. The deepest point was to the right of midline in 80%, left in 10% and central in 10%. By photo, the deepest point was in the lower sternum in 75%. When asymmetric, the deepest point of the deformity was to the right of midline in 90%. CT data: the average Haller index was 4.9. Severe sternal torsion (> 30 degrees) was associated with greater Haller index (6.3) than mild torsion (4.5). The deepest point of the depression was at the mid- or lower sternum in more than 99%. It proved impossible to estimate width or length of the depression because of poorly defined borders.

Conclusions

Typical PE is cup-shaped in 67% of cases, to the right of the midline in 80%, and involving the mid-to-lower sternum in 99%. However, other phenotypes, like the saucer and long trench, comprised one-third. Definition of the deformity is more reliable by CT scan.     

Efectos de la antibioterapia y la técnica fisioterápica respiratoria en pacientes con fibrosis quística tratados por exacerbación pulmonar aguda: estudio experimental

Introduction

Intravenous antibiotics in combination with intensive respiratory physiotherapy were evaluated for acute lung exacerbations in chronic infections of Pseudomonas aeruginosa in cystic fibrosis patients. Forced expiratory technique (FET) was assessed during hospital stay and discharge. The aim of this study was 1) to evaluate the immediate effects of FET and of 2) Intravenous antibiotics in combination with daily respiratory physiotherapy (IA+RPT) on parameters of lung function, body anthropometry and clinical scores of cystic fibrosis patients with acute lung exacerbation with chronic infection by Pseudomonas aeruginosa, during hospital stay and at hospital discharge after clearing the infection.

Patients and method

Eighteen patients between 7–28 years old were included in a prospective non-controlled clinical study. Body anthropometry values, Cystic Fibrosis Clinical Score (CFCS) exacerbation, Cystic Fibrosis Foundation Score (CFFS), and severity scores (SS) were evaluated before and after admission. Oxygen saturation (SpO₂), heart (HR) and respiratory rate (RR) were evaluated before and after FET.

Results

CFCS (32.4+7.2) and CFFS (6.4+1.7) had decreased at hospital discharge for 18.9+3.3 and 0.3+0.5, respectively (p<0.001). IA+ RPT reduced RR means (p=0.003) and increased SpO₂ (p=0.006), forced expiration volume at 1 min (FEV₁) (p=0.021) and nutritional values (p=0.002). During admission, FET immediately improved HR (p=0.028), RR (p=0.001) and SpO₂ (p=0.015), despite significant maximum voluntary ventilation reduction (p=0.028); after the infection was treated the FET did not significantly alter parameters.

Conclusion

IA+RPT improved clinical conditions of cystic fibrosis patients. FET improved cardiorespiratory variables of patients at risk for infection.     

Primera fase de validación del algoritmo europeo de evaluación funcional previa a la resección pulmonar: cuantificación del cumplimiento de las recomendaciones en la práctica clínica real

Objective

To quantify the degree of compliance with the recommendations of the clinical practice guidelines published in 2009 by the ERS and the ESTS regarding the preoperative assessment of risk of lung resection in daily clinical practice at a tertiary hospital.

Method

A prospective, observational study of real-time data collected from consecutive patients who had been referred for evaluation from September 2009 to December 2010. We recorded the presence or absence of the recommended studies included in the algorithm, their results and, when a test was missing, the reasons why it was not performed. Hospital mortality and cardio-respiratory morbidity rates are also presented.

Results

173 patients were evaluated. In 171 cases, lung resection was performed, with a mortality of 1.2% and a cardio-respiratory morbidity of 11.7%. The failure rate of the first level of the algorithm was 4.6% and for the second level (VO_2max test) it was 26%. The absence of exercise tests was mainly due to hospital structural problems and the patients’ inability to perform it. Out of the patients who performed the exercise testing, 31 reached a VO_2max of 20 ml/kg-min or more and underwent surgery without calculation of FEV₁ppo and DCLOppo; 35 patients required the calculation to determine their operability and in 2 cases the intervention was not recommended due to functional inoperability of the patient.

Conclusions

The validation process found lack of compliance with the proposed algorithm in 18.5% of the cases basically due to the absence of the exercise tests. The rate of adherence to the algorithm recommendations should be improved before performing any other validation studies.