Intraoperative pleural lavage cytology is an independent prognostic indicator for staging non–small cell lung cancer

AbstractObjectivesFor patients undergoing lung resection for cancer, macroscopic evidence of metastasis is clearly associated with adverse prognosis. However, less is known about the significance of tumor cells detected by using tests such as pleural lavage cytology. To ascertain the frequency and quantify the effect of this finding on survival, we performed a prospective study of intraoperative pleural lavage cytology.MethodsPleural lavage cytology consisted of cytologic analysis of 100 mL of saline irrigated over the lung surface immediately after thoracotomy. Patients were excluded if they had an existing effusion, extreme adhesions, or lateral chest wall invasion or if resection was not performed. Survival was calculated by means of Kaplan-Meier analysis and compared by using log-rank tests. Cox regression was used to ascertain independent predictors of prognosis.ResultsFrom 1995 through 2003, we performed pleural lavage cytology on 292 patients undergoing thoracotomy for lung cancer. The mean age was 64 (SD, 10) years, and 196 (67%) patients were men. Of 292 samples, 13 (4.5%) showed evidence of malignant cells. The median time to follow-up was 15 months (interquartile range, 1-40 months), with a median survival of 49 months for patients with negative pleural lavage cytology results and 13 months for patients with positive pleural lavage cytology results (P = .002). Univariate prognostic predictors were positive pleural lavage cytology status (P = .03), stage (P = .03), adenocarcinoma (P = .06), and parietal pleural involvement (P = .01). In the final multivariate model only positive pleural lavage cytology status (P = .006) and stage (P = .03) remained significant.ConclusionsIntraoperative pleural lavage cytology is a simple addition to intrathoracic staging and an independent predictor of prognosis. Positive results potentially affect survival by upstaging patients to stage IIIB or greater

Fifty Years of Thoracic Surgical Research in South Africa.

We aimed to investigate the scope and trends in clinical research in South African thoracic surgery between 1955 and 2006 and to measure its impact on clinical practice. The vulnerability of a small speciality in a developing country is illustrated by the clear trends that emerged. It provides important indicators for future research, highlights the need for a national database of clinical experience and emphasises the importance of rekindling interest and a culture of research in thoracic surgery

Innate Immune Responses to Bacterial Ligands in the Peripheral Human Lung – Role of Alveolar Epithelial TLR Expression and Signalling

It is widely believed that the alveolar epithelium is unresponsive to LPS, in the absence of serum, due to low expression of TLR4 and CD14. Furthermore, the responsiveness of the epithelium to TLR-2 ligands is also poorly understood. We hypothesised that human alveolar type I (ATI) and type II (ATII) epithelial cells were responsive to TLR2 and TLR4 ligands (MALP-2 and LPS respectively), expressed the necessary TLRs and co-receptors (CD14 and MD2) and released distinct profiles of cytokines via differential activation of MAP kinases. Primary ATII cells and alveolar macrophages and an immortalised ATI cell line (TT1) elicited CD14 and MD2-dependent responses to LPS which did not require the addition of exogenous soluble CD14. TT1 and primary ATII cells expressed CD14 whereas A549 cells did not, as confirmed by flow cytometry. Following LPS and MALP-2 exposure, macrophages and ATII cells released significant amounts of TNFα, IL-8 and MCP-1 whereas TT1 cells only released IL-8 and MCP-1. P38, ERK and JNK were involved in MALP-2 and LPS-induced cytokine release from all three cell types. However, ERK and JNK were significantly more important than p38 in cytokine release from macrophages whereas all three were similarly involved in LPS-induced mediator release from TT1 cells. In ATII cells, JNK was significantly more important than p38 and ERK in LPS-induced MCP-1 release. MALP-2 and LPS exposure stimulated TLR4 protein expression in all three cell types; significantly more so in ATII cells than macrophages and TT1 cells. In conclusion, this is the first study describing the expression of CD14 on, and TLR2 and 4 signalling in, primary human ATII cells and ATI cells; suggesting that differential activation of MAP kinases, cytokine secretion and TLR4 expression by the alveolar epithelium and macrophages is important in orchestrating a co-ordinated response to inhaled pathogens

Integration of robotic surgery into routine practice and impacts on communication, collaboration, and decision making: A realist process evaluation protocol

Background: Robotic surgery offers many potential benefits for patients. While an increasing number of healthcare providers are purchasing surgical robots, there are reports that the technology is failing to be introduced into routine practice. Additionally, in robotic surgery, the surgeon is physically separated from the patient and the rest of the team, with the potential to negatively impact teamwork in the operating theatre. The aim of this study is to ascertain: how and under what circumstances robotic surgery is effectively introduced into routine practice; and how and under what circumstances robotic surgery impacts teamwork, communication and decision making, and subsequent patient outcomes. Methods and design: We will undertake a process evaluation alongside a randomised controlled trial comparing laparoscopic and robotic surgery for the curative treatment of rectal cancer. Realist evaluation provides an overall framework for the study. The study will be in three phases. In Phase I, grey literature will be reviewed to identify stakeholders' theories concerning how robotic surgery becomes embedded into surgical practice and its impacts. These theories will be refined and added to through interviews conducted across English hospitals that are using robotic surgery for rectal cancer resection with staff at different levels of the organisation, along with a review of documentation associated with the introduction of robotic surgery. In Phase II, a multi-site case study will be conducted across four English hospitals to test and refine the candidate theories. Data will be collected using multiple methods: the structured observation tool OTAS (Observational Teamwork Assessment for Surgery); video recordings of operations; ethnographic observation; and interviews. In Phase III, interviews will be conducted at the four case sites with staff representing a range of surgical disciplines, to assess the extent to which the results of Phase II are generalisable and to refine the resulting theories to reflect the experience of a broader range of surgical disciplines. The study will provide (i) guidance to healthcare organisations on factors likely to facilitate successful implementation and integration of robotic surgery, and (ii) guidance on how to ensure effective communication and teamwork when undertaking robotic surgery