Using patient traffic control to reduce treatment delays for high-risk patients at a VA hospital.

Background: For patients at high risk of function-limiting or life-limiting disease, the time elapsed between first clinical presentation, diagnosis, and treatment can influence the likelihood of treatment success.

Methods: A systematic change in the management of high-risk patients was undertaken. This approach includes identifying primary provider responsibility, establishing communication expectations between providers, developing a tracking system to actively monitor patients (patient traffic control), and using a time guideline to assess patient progression.

Comparison of resident self-assessments with trained faculty and standardized patient assessments of clinical and technical skills in a structured educational module.

Background: This study assessed the reliability of surgical resident self-assessment in comparison with faculty and standardized patient (SP) assessments during a structured educational module focused on perioperative management of a simulated adverse event.

Methods: Seven general surgery residents participated in this module. Residents were assessed during videotaped preoperative and postoperative SP encounters and when dissecting a tumor off of a standardized inanimate vena cava model in a simulated operating room.

Management of adverse surgical events: a structured education module for residents.

Background: This pilot project involved the development of a structured, experiential, educational module using a bench model technical skills simulation and standardized patients. It integrated teaching and assessment of clinical, technical, and interpersonal skills, as well as professionalism within the context of an adverse surgical event.

Methods: General surgery residents (postgraduate year [PGY] 2, 3) were asked to participate in the pre-, intra-, and postoperative management of a patient with a retroperitoneal sarcoma.

Reoperative pulmonary metastasectomy for sarcomatous pediatric histologies.

Background: The role for reoperative pulmonary metastasectomy in patients with "pediatric sarcomas" (osteosarcoma, nonrhabdomyosarcoma-soft tissue sarcoma, and Ewing's sarcoma) is undefined.

Methods: We reviewed our results for patients with these histologic presentations (median age, 17.5 years; range, 6 to 32 years) having two (70), three (27), or four (10) metastasectomies between January 1965 and March 1995 to define postresection survival and potential prognostic factors.

Pharmacokinetics of fentanyl during hyperthermic, isolated lung perfusion.

Background: Hyperthermic, isolated pulmonary perfusion with tumor necrosis factor is a surgical procedure that isolates the pulmonary vasculature from the systemic circulation in patients with unresectable primary or metastatic disease confined to the chest. High drug levels are delivered to the perfused organ, avoiding systemic toxicity, and preventing loss of active drug through metabolism.

Methods: The pharmacokinetics of fentanyl are evaluated in three patients while the operative lung is hyperthermic, ventilated, and perfused with an asanguineous solution during nonpulsatile bypass.

Biology of metastatic disease.

Metastasis is highly organized and organ selective, a process involving multiple sequential steps. It occurs through complex interactions between tumor cells and the host. The surviving metastatic cells have heterogeneous biologic and antigenic or immunogenic properties, and the metastatic cells take over the homeostatic mechanisms of the host.

Preoperative tumor volume is associated with outcome in malignant pleural mesothelioma.

Objectives: Our objective was to analyze the impact of preoperative and postresection solid tumor volumes on outcomes in 47 of 48 consecutive patients undergoing resection for malignant pleural mesothelioma who were treated prospectively and randomized to photodynamic therapy or no photodynamic therapy.

Methods: From July 1993 to June 1996, 48 patients with malignant pleural mesothelioma had cytoreductive debulking to 5 mm or less residual tumor by extrapleural pneumonectomy (n = 25) or pleurectomy/decortication (n = 23). Three-dimensional computed tomographic reconstructions of preresection and postresection solid tumor were prospectively performed and the disease was staged postoperatively according to the new International Mesothelioma Interest Group staging.

Phase I study of paclitaxel as a radiation sensitizer in the treatment of mesothelioma and non-small-cell lung cancer.

Purpose: To determine the maximum-tolerated dose (MTD) and dose-limiting toxicities of paclitaxel with concurrent thoracic irradiation in patients with malignant pleural mesothelioma and locally advanced non-small-cell lung cancer (NSCLC) using a 120-hour continuous infusion regimen. A secondary objective was to assess the effect of paclitaxel on the cell cycle through serial tumor biopsies.

Patients And Methods: Paclitaxel was administered as a 120-hour (5-day) continuous infusion repeated every 3 weeks during the course of radiation therapy.

Phase III randomized trial of surgery with or without intraoperative photodynamic therapy and postoperative immunochemotherapy for malignant pleural mesothelioma.

Background: Patients with malignant pleural mesothelioma (MPM) usually die of progressive local disease. This report describes the results of a Phase III trial comparing maximum debulking surgery and postoperative cisplatin, interferon alpha-2b, and tamoxifen (CIT) immunochemotherapy with and without intraoperative photodynamic therapy (PDT) to determine (1) whether such a multimodal approach can be performed with minimum morbidity and mortality in malignant pleural mesothelioma (MPM), and (2) whether first-generation (i.e.

Nonsurgical therapy for pulmonary hydatid cyst disease.

Therapeutic and diagnostic aspiration of Echinococcus granulosus liver cysts, but not pulmonary cysts, are increasingly being performed. Documented herein is the utility of percutaneous drainage and of albendazole treatment in a patient with a large recurrent, isolated, pulmonary echinococcal cyst for whom traditional therapy would have resulted in severe morbidity. Therapeutic options and possible complications are discussed.

Bilateral lung collapse in an asthmatic patient during thoracotomy.

Bilateral sequential pulmonary atelectasis occurred during median sternotomy for metastasis resection in a 19-year-old women with asthma. Collapse was secondary to mucus plugging and resolved with mechanical ventilation, suctioning, and treatment for bronchospasm.

Surgically debulked malignant pleural mesothelioma: results and prognostic factors.

Background: We analyzed morbidity and mortality, sites of recurrence, and possible prognostic factors in 95 (78 male, 17 female) patients with MPM on phase I-III trials since 1990. A debulking resection to a requisite, residual tumor thickness of < or = 5 mm was required for inclusion.

Methods: Preoperative tumor volumes were determined by three-dimensional reconstruction of chest computerized tomograms.

Somatostatin analogue in the localization and treatment of bronchial carcinoid tumours.

Octreotide scanning is increasingly being used to detect tumours with somatostatin receptors. Moreover, there is growing interest in the use of somatostatin analogues for the treatment of tumours with somatostatin receptors. This review documents the use at our institution of the octreotide scan in three patients with intrathoracic pathology, and comments on overall experience in the literature with this technology.

Phase II trial of 5-fluorouracil, leucovorin, interferon-alpha-2a, and cisplatin as neoadjuvant chemotherapy for locally advanced esophageal carcinoma.

Background: Most patients with esophageal carcinoma present with locally advanced disease and a poor prognosis. Surgery or radiation provides palliation for locally advanced esophageal carcinoma. The role of neoadjuvant therapy remains to be defined.

Isolated lung perfusion with tumor necrosis factor for pulmonary metastases.

Background: A phase I trial was initiated to define the feasibility and safety of single-lung isolation perfusion with tumor necrosis factor-alpha, interferon-gamma, and moderate hyperthermia for patients with unresectable pulmonary metastases.

Methods: Twenty patients with lung metastases (Ewing's, 2; sarcoma, 8; melanoma, 6; other, 4) were considered for single-lung isolation perfusion with 0.3 to 6.

Role of tissue diagnosis in pulmonary involvement in pediatric human immunodeficiency virus infection.

Background: Pulmonary complications occur commonly during HIV infection. The aim of this study was to evaluate the clinical value of lung tissue examination in the diagnosis and treatment of pulmonary disorders in children with HIV infection.

Methods: The medical records of 347 children enrolled between January, 1990, and April, 1994, into various antiretroviral therapy protocols were reviewed to identify patients who underwent a lung biopsy.

Metastasectomy for sarcomatous pediatric histologies: results and prognostic factors.

We reviewed our experience of pediatric metastasectomy to define (1) morbidity/mortality in this population and (2) any preoperative or intraoperative prognostic predictors of survival. One hundred fifty-two patients with median age 19 years (range, 5 to 33 years) had 258 thoracic explorations (Ewing's sarcoma, 28; rhabdomyosarcoma, 6; nonrhabdomyosarcoma soft tissue sarcoma, 42; and osteosarcoma, 76). Resections were accomplished by 218 wedge resections, 19 anatomic resections, 14 wedge and anatomic resections, 4 wedge and chest wall resections, and 3 wedge resections/other procedures.

A phase II trial investigating primary immunochemotherapy for malignant pleural mesothelioma and the feasibility of adjuvant immunochemotherapy after maximal cytoreduction.

Background: The treatment of malignant pleural mesothelioma (MPM) continues to be inadequate with the use of standard techniques, including surgery, radiotherapy and chemotherapy. We initiated a phase II trial of immunochemotherapy with cisplatinum (25 mg/m2 four times weekly), interferon-alpha (5 mU/m2 s.c.

Esophagopleural fistula: a complication of photodynamic therapy.

Mesothelioma of the pleura remains an incurable disease for which novel treatments are being investigated. One of these is intraoperative photodynamic therapy (PDT), using the principle of cell cytotoxicity produced by light-activated sensitization. We report a complication of this therapy that defined the maximal tolerated dose of PDT, ie, esophagopleural fistula, in two consecutive patients who had received the same dose of PDT at the time of extrapleural pneumonectomy.

Pulmonary malignant lymphoma of mucosa-associated lymphoid tissue (MALT) arising in a pediatric HIV-positive patient.

A malignant lymphoma arising in the lung of a pediatric HIV-positive patient exhibited histologic and clinical features of low-grade B-cell lymphoma of mucosa-associated lymphoid tissue (MALT). Clinically, the neoplasm consisted of a 4-cm mass in the left-upper lobe of the lung of a 7-year-old girl. The lung mass was surgically resected.

The macrophage, TNF, and other cytokines.

A complex interplay of peptides known as the cytokines may have a tremendous influence over a number of inflammatory related conditions. Tumor necrosis factor occupies an early and central role in the initiation of cascades that ultimately influences a number of cell types involved in tissue inflammation, tissue rejection, cancer, and injuries from ischemia reperfusion. Only now are the cascades being defined and therapies being designed to interrupt the toxic effects of these cytokines and to treat malignancy.

Intrapericardial pheochromocytoma complicated by massive intraoperative hemorrhage.

Middle mediastinal pheochromocytomas are exceedingly rare. Because so few cases have been reported, consensus has not been reached regarding the anesthetic management of patients with these tumors. The use of cardiopulmonary bypass (CPB) for the resection of intrapericardial pheochromocytomas has met with varied success.

Thoracotomy for pulmonary mycoses in non-HIV-immunosuppressed patients.

Pulmonary mycoses can be life threatening in patients who are in an immunocompromised state stemming from defective host defenses or the use of certain treatment regimens. In 36 immunosuppressed patients undergoing thoracotomy for the treatment of pulmonary fungal disease, the underlying cause of immunosuppression was malignancy (n = 9), Wegener's granulomatosis (n = 4), hematologic disorders (aplastic anemia, 5-Q minus syndrome, or myelofibrosis) (n = 6), or chronic granulomatous disease of childhood (n = 17). The mean age of the patients was 25 years, and 89% were symptomatic (fever, n = 27; cough, n = 20; chest pain, n = 14; and other, n = 13).