Neoadjuvant docetaxel-cisplatin is effective and tolerable in stage IIIA pN2 NSCLC. Resection is recommended only for patients with mediastinal downstaging after chemotherapy.

The aim was to investigate the efficacy of neoadjuvant docetaxel -cisplatin and identify prognostic factors for outcome in locally advanced stage IIIA (pN2 by mediastinoscopy) non-small-cell lung cancer (NSCLC) patients. In all, 75 patients (from 90 enrolled) underwent tumour resection after three 3-week cycles of docetaxel 85 mg m À2 (day 1) plus cisplatin 40 or 50 mg m À2 (days 1 and 2). Therapy was well tolerated (overall grade 3 toxicity occurred in 48% patients; no grade 4 nonhaematological toxicity was reported), with no observed late toxicities. Median overall survival (OS) and event-free survival (EFS) times were 35 and 15 months, respectively, in the 75 patients who underwent surgery; corresponding figures for all 90 patients enrolled were 28 and 12 months. At 3 years after initiating trial therapy, 27 out of 75 patients (36%) were alive and tumour free. At 5-year follow-up, 60 and 65% of patients had local relapse and distant metastases, respectively. The most common sites of distant metastases were the lung (24%) and brain (17%). Factors associated with OS, EFS and risk of local relapse and distant metastases were complete tumour resection and chemotherapy activity (clinical response, pathologic response, mediastinal downstaging). Neoadjuvant docetaxel -cisplatin was effective and tolerable in stage IIIA pN2 NSCLC, with chemotherapy contributing significantly to outcomes.

Diagnosis and treatment of invasive pulmonary aspergillosis in neutropenic patients. F. Reichenberger, J.M. Habicht, A. Gratwohl, M. Tamm. #ERS Journals Ltd 2002. ABSTRACT: Invasive pulmonary aspergillosis is a major cause of morbidity and mortality in neutropenic patients.Microbiological and serological tests are of limited value. The diagnosis should be considered in neutropenic patients with fever not responding to antibiotics, and typical findings on thoracic computed tomography scan. Whenever possible, diagnosis should be confirmed by tissue examination. Newer techniques, such as polymerase chain reaction may change the current diagnostic approach.Therapeutic strategies consist of prophylaxis in risk groups and the early application of antifungal agents in suspected or probable disease. Amphotericin B as desoxycholate or lipid formulation is the current standard medication in invasive infection, although it has major side effects. Its role is challenged by the new azole derivates, such as itraconazole and voriconazole, and the new echinocandins. Additional therapies with cytokines, such as granulocyte macrophage colony stimulating factor and interferon-c, and with granulocyte transfusions are under evaluation. In selected cases lung resection is of proven diagnostic and therapeutic value.This paper analyses the current understanding of the pathogenesis and epidemiology of invasive aspergillosis and reviews the actual diagnostic and therapeutic strategies for invasive pulmonary aspergillosis in neutropenic patients.

Background and Objectives: We prospectively compared five techniques to estimate predicted postoperative function (ppo F) after lung resection: recently proposed quantitative CT scans (CT), perfusion scans (Q), and three anatomical formulae based on the number of segments (S), functional segments (FS), and subsegments (SS) to be removed. Methods: Four parameters were assessed: FEV₁, FVC, DL_CO and VO_2max, measured preoperatively and 6 months postoperatively in 44 patients undergoing pulmonary resection, comparing their ppo value to the postoperatively measured value. Results: The correlations (r) obtained with the five methods were for CT: FEV₁ = 0.91, FVC = 0.86, DL_CO = 0.84, VO_2max = 0.77; for Q: 0.92, 0.90, 0.85, 0.85; for S: 0.88, 0.86, 0.84, 0.75; for FS: 0.88, 0.85, 0.85, 0.75, and for SS: 0.88, 0.86, 0.85, 0.75, respectively. The mean difference between ppo values and postoperatively measured values was smallest for Q estimates and largest for anatomical estimates using S. Stratification of the extent of resection into lobectomy (n = 30) + wedge resections (n = 4) versus pneumonectomy (n = 10) resulted in persistently high correlations for Q and CT estimates, whereas all anatomical correlations were lower after pneumonectomy. Conclusions: We conclude that both Q- and CT-based predictions of postoperative cardiopulmonary function are useful irrespective of the extent of resection, but Q-based results were the most accurate. Anatomically based calculations of ppo F using FS or SS should be reserved for resections not exceeding one lobe.

Patients with impaired pulmonary function are at increased risk for the development of postoperative complications. Recently exercise testing and predicted postoperative (ppo) function have gained increasing importance in the evaluation of lung resection candidates. We prospectively evaluated an algorithm for the preoperative functional evaluation that was developed at our institution. This algorithm incorporated the cardiac history including an electrocardiogram (ECG), and the three parameters FEV 1 , diffusing capacity of the lungs for carbon monoxide (D L CO ), and maximal oxygen uptake ( O 2 max), as well as their respective ppo values (FEV 1 -ppo, D L CO -ppo, and O 2 max-ppo) calculated based on radionuclide perfusion scans. A consecutive group of 137 patients (mean age 62 yr; range 23 to 81; 102 males, 35 females) with clinically resectable lesions underwent assessment according to our algorithm. Five patients were deemed functionally inoperable, 132 passed the algorithm and underwent pulmonary resections with standard thoracotomy: 9 segmental or wedge resections, 85 lobectomies (inclusive 3 bilobectomies), and 38 pneumonectomies. All patients were extubated within 24 h. The mean stay in the ICU was 1.4 ( Ϯ 1.8) d, and the mean hospital stay was 14.6 ( Ϯ 5) d. Postoperative complications (within 30 d) occurred in 15 patients (11%), of whom two died (overall mortality rate 1.5%). In comparison to our previous series this meant a 50% reduction in complications whereas the percentage of inoperable patients remained unchanged (4% now, 5% before). We conclude that adherence to our algorithm resulted in a very low complication rate (morbidity and mortality), and excluded more rigorous patient selection as a bias for the improved results. . V . VPatients with lung cancer who undergo evaluation for lung resection are usually smokers and therefore often have concomitant heart and lung disease. This puts them at increased risk for the development of postoperative complications, including permanent respiratory disability and death. Therefore, the functional assessment of their cardiorespiratory reserves is very important. This assessment has recently undergone major changes; apart from preoperative measurement of pulmonary function (FEV 1 , diffusing capacity of the lungs for carbon monoxide [D L CO ]), exercise testing with the determination of maximal oxygen uptake ( O 2 max) has gained increasing importance. Recently the emphasis has shifted to the prediction of postoperative function (predicted postoperative = ppo). The parameter, most firmly established, is the FEV 1 -ppo, but also D L CO -ppo (1-3), and most recently O 2 max-ppo (3) have been suggested.Despite increasing enthusiasm for exercise testing and split function studies, one has to remember that many patients undergoing lung resections up to pneumonectomy do not need extensive tests for the assessment of their cardiorespiratory reserves. We therefore developed an algorithm for the preoperative functional evaluation (Figure 1) incorporating the cardiac...

Summary:Invasive pulmonary aspergillosis (IPA) is a life-threatening infectious complication in neutropenic patients after high-dose chemotherapy or hematopoietic stem cell transplantation. Its diagnosis is mainly based on clinical symptoms, and radiological signs on thoracic CT scan. The value of bronchoscopy is controversial. We analyzed the diagnostic yield of bronchoscopy in 23 consecutive patients with histologically proven invasive pulmonary aspergillosis. In seven patients (30%) bronchoscopically obtained specimens were diagnostic for pulmonary fungal infection. Typical hyphae were detected by cytology in six patients and fungal cultures were positive in four cases. Patients with a positive bronchoscopic result presented more often with multiple changes on thoracic CT scan (71%; 5/7), but had received a lower median cumulative dose of amphotericine B (300 mg; 168-3010 mg) compared to patients with non-diagnostic bronchoscopy (25% multiple lesions (4/16); amphotericine dose 1100 mg, 260-2860 mg). The diagnostic yield of bronchoscopy was not associated with clinical symptoms or duration of neutropenia. Bronchoscopy allows the diagnosis of IPA in about one third of patients. Fungal cultures and cytological examination of intrabronchial specimens obtained during bronchoscopy have a high specificity, but its sensitivity is low. It is advisable to perform diagnostic bronchoscopy before starting antifungal therapy. Better diagnostic tools are urgently needed.

Invasive pulmonary aspergillosis (IPA) is associated with a high mortality. In 27 consecutive neutropenic patients who underwent lung resection for suspected IPA, we analyzed preoperative diagnostic evaluation, operative procedure, perioperative management, histological findings, outcome concerning recurrence of aspergillosis, and survival to evaluate the morbidity and mortality of a surgical treatment of IPA. Seventeen patients with hematologic diseases had previously undergone high-dose chemotherapy and four stem cell transplantation. Six patients with aplastic anemia were treated with antilymphocyte globulin. IPA was suspected if localized infiltrates developed on thoracic CT scan, and fever persisted under antibiotic therapy in neutropenic patients. In only one case a diagnosis of IPA could be made preoperatively. Twenty patients underwent lobectomy and seven wedge resection. At day of surgery the neutrophil count was below 500 x 10(9)/L in 78% of patients, and the platelet count below in 50 x 10(9)/L in 58% of patients. Invasive fungal infection was confirmed histologically in 22 of 27 patients (81.5%); in five patients no fungal infection was documented. The median duration of surgery was 120 min. Postoperatively, patients stayed one night in the intensive care unit, and chest tubes were removed after 2 d. Within 7 d a median of four erythrocyte packs and two platelet packs per patient were replaced. Major surgical complications occurred in two patients (bronchial dehiscence; pleural aspergillosis). Minor surgical complications included prolonged chest tube drainage (recurrent pneumothorax, n = 2; air leakage, n = 1; hematothorax, n = 1), pleural effusion (n = 4), and seroma (n = 2). Postoperatively, two patients suffered from histologically proven disseminated aspergillosis (pleural aspergillosis, renal aspergilloma) and another patient from suspected orbital aspergillosis. At 30 d postoperative mortality was 11% and 3-mo survival was 77%. After lung resection, seven patients underwent stem cell transplantation without recurrence of IPA. In conclusion, we suggest lung resection is a therapeutic option for invasive pulmonary aspergillosis in neutropenic patients with hematologic diseases and is associated with a low surgery-related morbidity and mortality.

Pulmonary embolectomy in the treatment of acute massive pulmonary embolism (PE) is the subject of considerable controversy with regard to indication, technique of embolectomy and perioperative management. Since 1968 50 patients have undergone surgery for massive PE in our unit. Inflow occlusion technique and cardiopulmonary bypass were used in 33 and 17 patients, respectively. The overall operative mortality was 46%. Univariate analysis disclosed age (< 60 vs > 60), preoperative hemodynamics (cardiogenic shock vs cardiac arrest), location of emboli (peripheral vs central), duration of symptoms (hours vs days vs weeks) and number of episodes (first episode vs recurrent pulmonary emboli) as predictive factors of the post-operative outcome. The results of the retrospective analysis show that pulmonary embolectomy remains an acceptable procedure in patients with acute massive pulmonary emboli who are in refractory cardiogenic shock or who need intermittent resuscitation.