Awake thoracoscopic sympathectomy

Video-Assisted Thoracic Surgery (VATS) sympathectomy is a safe and effective procedure for treatment of facial, palmar and axillary hyperhidrosis. It can be more rarely used in other conditions. Awake thoracic surgery with epidural anesthesia and spontaneous ventilation has been employed to perform many surgical procedures including VATS sympathectomy. This chapter describes the anatomy of the nerve with the most frequent abnormalities, the indications and contraindication for both sympathectomy and awake surgery, the method for awake anesthesia, a detailed step-by-step description of the surgical technique and postoperative management as well as an analysis of benefits and potential side-effects of awake VATS sympathectomy. Patient selection, choice of the level of sympathectomy and adequate information about anesthesia and side effects of the operation are extremely important for the good result of the procedure. Awake VATS sympathectomy may be considered a globally minimally invasive approach combining avoidance of general anesthesia-related adverse effects with maximum patient satisfaction

May cyclooxygenase-2 (COX-2), p21 and p27 expression affect prognosis and therapeutic strategy of patients with malignant pleural mesothelioma?

The expression of cyclooxygenase-2 (COX-2) and cell-cycle proteins (p21 and p27) proves useful in predicting prognosis and orientating therapy in many malignant tumours. Malignant pleural mesothelioma is an uncommon and lethal cancer for which there are limited treatment options. In this study, we evaluated the impact on prognosis and the influence on therapeutic strategy of immunohistochemical expression of COX-2, p21 and p27 in specimens from patients treated for malignant pleural mesothelioma

New predictors of response to neoadjuvant chemotherapy and survival for invasive thymoma: a retrospective analysis

BACKGROUND: Cell-cycle protein (p27, p21, and p53) expression can predict response to neoadjuvant chemotherapy and prognosis in some neoplasms. This study evaluated whether these markers could also be effective in invasive thymoma during a multimodality treatment. METHODS: Between 1989 and 2008, 33 patients with invasive thymoma underwent surgical resection after neoadjuvant chemotherapy. Expression of p27, p21, and p53 was assessed using immunohistochemistry in specimens retrieved pre and post chemotherapy. Factors influencing response to neoadjuvant chemotherapy and survival were investigated by univariate and multivariate analysis. Good response was defined as complete disappearance of tumor at imaging or necrosis >90% at pathologic studies. RESULTS: Twelve patients disclosed an imaging good response. Complete resection was possible in 17 patients, 9 of whom had presented imaging good response and 11 of whom had revealed pathologic good response. On univariate analysis both imaging and pathologic poor responses were significantly associated with incomplete resection (P = 0.04 and P = 0.03, respectively) and preneoadjuvant triple combination of p27 low, p21 low, and p53 high expressions (P = 0.001 and P < 0.0001, respectively), the last factor being the only one selected on logistic regression (P = 0.01 and P = 0.005, respectively). Long-term survival analysis was negatively influenced by triple combination of p27, p21, and p53 (P < 0.0001) and incomplete resection (P < 0.0001), which were also selected on Cox's regression (P = 0.004 and P = 0.02, respectively). CONCLUSIONS: The triple combination of p27 low, p21 low, and p53 high expressions was the most significant predictor of imaging and pathologic poor responses to neoadjuvant chemotherapy in invasive thymoma. This combination together with incomplete resection was also the most significant negative predictor of long-term survival

Might cyclooxygenase-2 (COX-2), p21 and p27 expression affect prognosis and therapeutic strategy of patients with malignant pleural mesothelioma?

Objectives: To evaluate the impact of immunohistochemical expression of cyclooxygenase-2 (COX-2) and cell-cycle proteins (p21 and p27) in specimens from malignant pleural mesothelioma. Methods: We retrospectively reviewed immunohistochemical expression of COX-2, p21 and p27 dichotomised into high and low expression from specimens of 67 consecutive patients undergoing biopsy plus pleurodesis (n=6), pleurectomy-decortication (n=44) or extrapleural pneumonectomy (n=27) operations for malignant pleural mesothelioma between 1987 and 2007. Histology was epithelioid (n=50), biphasic (n=17) and sarcomatoid (n=10) subtypes. TNM-stage was I (n=21), II (n=36) and III (n=20). Combined therapies were sole adjuvant radiotherapy (n=17), adjuvant radio-chemotherapy (n=36) and neoadjuvant chemotherapy plus adjuvant radiotherapy (n=24). Results were investigated by Kaplan–Meier survival and Cox regression analysis. Results: Median survival was 13 months. Survival was negatively influenced by nonepithelial histology (P<0.01), positive resection margins (P<0.02), metastatic mediastinal lymph nodes (P<0.01), high COX-2 (P=0.001), low p21 (P<0.0001) and p27 (P=0.001) expression. Conversely, neither the type of surgery (biopsy vs. pleurectomy-decortication vs. extrapleural pneumonectomy), nor combined therapies (sole radiotherapy vs. adjuvant radio-chemotherapy vs. neoadjuvant chemotherapy plus adjuvant radiotherapy) reached a significant level of difference. Cox regression analysis showed that only immunohistochemical triple combination of high COX-2 and low p21 and p27 expression influenced survival (P<0.0001, Odds Ratio 4.7, 95% confidence interval 3–11) regardless of kind of treatment. Conclusions: The presence of high expression COX-2 and low p21 and p27 expression significantly influences the prognosis of malignant pleural mesothelioma. Therapeutic strategy should consider these protein expressions, avoiding major operations in cases of combination of these factors

Variations of inflammatory mediators and alpha1-antitrypsin levels after lung volume reduction surgery for emphysema

Rationale: In emphysema,chronic inflammation, including protease– antiprotease imbalance, is responsible for declining pulmonary function and progressive cachexia. Objectives: To evaluate variations of inflammatory mediators and a1-antitrypsin levels after lung volume reduction surgery (LVRS) compared with respiratory rehabilitation. Methods: A total of 28 patients with moderate to severe emphysema, who underwent video-assisted thoracoscopic LVRS, were compared with 26 similar patients, who refused operation and followed a standardized rehabilitation program, and to a matched healthy group. Respiratory function, body composition, circulating inflammatory mediators, and a1-antitrypsin levels were evaluated before and 12 months after treatment. Gene expression levels of inflammatory mediators and protease–antiprotease were assessed in emphysematous specimens from 17 operated patients by matching to normal tissue from resection margins. Measurements and Main Results: Significant improvements were only obtained after surgery in respiratory function (FEV1, 125.2%, P , 0.0001; residual volume [RV], 219.5%, P , 0.0001; diffusing lung capacity for carbon monoxide, 13.3%, P , 0.05) and body composition (fat-free mass, 16.5%, P , 0.01; fat mass, 111.9%, P , 0.01), with decrement of circulating inflammatory mediators (TNF-a, 222.2%, P , 0.001; IL-6, 224.5%, P , 0.001; IL-8, 220.0%, P , 0.001) and increment of antiprotease levels (a1-antitrypsin, 127.0%, P , 0.001). Supportive gene expression analysis demonstrated active inflammation and protease hyperactivity in the resected emphysematous tissue. Reduction of TNF-a and IL-6 and increment of a1-antitrypsin levels significantly correlated with reduction of RV (P 5 0.03, P 5 0.009, and P 5 0.001, respectively), and partially with increment of fat-free mass (P50.03, P50.02, and P5 0.09, respectively). Conclusions: LVRS significantly reduced circulating inflammatory mediators and increased antiprotease levels over respiratory rehabilitation, also improving respiratory function and nutritional status. Correlations of inflammatory mediators and antiprotease levels with RV and, partly, with body composition suggest that elimination of inflammatory emphysematous tissue may explain clinical improvements after surgery