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P Goldstraw

Publications and source records attributed to P Goldstraw.

At least 55 records · Page 3Linked to original sources
PubMed2000

The effect of lung biopsy on lung function in diffuse lung disease.

The aim of this study was to investigate the effect on lung function of lung biopsy used in the diagnosis of diffuse lung disease carried out by an open procedure or by video-assisted thoracoscopy. One hundred and sixteen patients with diffuse lung disease who attended the Royal Brompton Hospital were studied retrospectively. Thirty five patients underwent open lung biopsy, and 33 video-assisted thoracoscopic biopsy and 48 had their diagnosis made without biopsy. All patients underwent lung function tests before and after surgery, or at an interval of 3-6 months in those who did not undergo biopsy. No significant differences were found in changes in lung function between those who had and had not undergone biopsy, and the proportions of patients whose lung function improved or deteriorated were similar. Lung biopsy by an open procedure or by video-assisted thoracoscopy did not differ in its effects on lung function. The results for older patients, those with severe disease and those with fibrosing alveolitis were the same as for the whole group. Open lung biopsy for the diagnosis of diffuse lung disease does not deleteriously affect lung function whether carried out by an open or a minimally invasive procedure.

Adult↗
PubMed2000

Evaluation of patients undergoing lung volume reduction surgery: ancillary information available from computed tomography.

AIM: A number of imaging techniques have been used for the pre-operative assessment of patients for lung volume reduction surgery (LVRS). We evaluated whether data currently acquired from perfusion scintigrams and cine MR of the diaphragm are obtainable from high resolution CT (HRCT) of the thorax. MATERIALS AND METHODS: Thirty patients taking part in a randomized controlled trial of LVRS against maximal medical therapy were evaluated. HRCT examinations (n= 30) were scored for (i) the extent and distribution of emphysema; (ii) the extent of normal pulmonary vasculature; and (iii) diaphragmatic contour, apparent defects and herniation. On scintigraphy, (n= 28), perfusion of the lower thirds of both lungs, as a proportion of total lung perfusion (LZ/T(PERF)), was expressed as a percentage of predicted values (derived from 10 normal control subjects). On cine MR (n= 25) hemidiaphragmatic excursion and coordination were recorded. RESULTS: Extensive emphysema was present on HRCT (60% +/- 13.2%). There was strong correlation between the extent of normal pulmonary vasculature on HRCT and on perfusion scanning (r(s)= 0.85, P< 0.00005). Hemidiaphragmatic incoordination on MR was weakly associated with hemidiaphragmatic eventration on HRCT (P= 0.04). CONCLUSION: The strong correlation between lung perfusion assessed by HRCT and lung perfusion on scintigraphy suggests that perfusion scintigraphy is superfluous in the pre-operative evaluation of patients with emphysema for LVRS.

Adult↗
PubMed2000

Lung metastases from melanoma: when is surgical treatment warranted?

Surgical treatment of lung metastases from melanoma is highly controversial as the expected outcome is much poorer than for other primary tumours and a reliable system for selecting patients is lacking. This study evaluated the long-term results of lung metastasectomy for melanoma, with the aim of defining a subset of patients with better prognosis. By reviewing the data of the International Registry of Lung Metastases (IRLM), we identified 328 patients who underwent lung metastasectomy for melanoma in the period 1945-1995. Survival was calculated by Kaplan-Meier estimate, using log-rank test and Cox regression model for statistical analysis. After complete pulmonary metastasectomy (282 patients) the 5- and 10-year survival was 22% and 16%, respectively. In this group of patients, a time to pulmonary metastases (TPM) shorter than 36 months or the presence of multiple metastases were independent unfavourable prognostic factors. There were no long-term survivors after incomplete resection (46 patients, P< 0.01). Using the IRLM grouping system, patients without risk factors (TPM > 36 months and single lesion) experienced the best survival (29% at 5 years), followed by those with one risk factor only (20% at 5 years). On the other hand, those with two risk factors or incomplete resection showed a significantly poorer survival (7% and 0% at 5 years). Surgery plays an important role in carefully selected cases of pulmonary metastatic melanoma. The prognostic grouping system proposed by the International Registry of Lung Metastases provides a simple and effective method for improving the selection of surgical candidates.

Adolescent↗
PubMed2000

Pleurectomy in primary pneumothorax: is extensive pleurectomy necessary?

BACKGROUND: The aim of the study was to evaluate the results of parietal pleurectomy in patients with primary spontaneous pneumothorax comparing extensive pleurectomy performed by thoracotomy versus more limited pleurectomy performed by VATS. METHODS: Records of the patients operated on for primary pneumothorax at Royal Brompton Hospital from January 1994 to April 1997 were retrospectively reviewed. A follow-up questionnaire was sent to patients asking about further pneumothorax and the presence of long-term chest problems on the operated side. A statistical uni- and multivariate analysis was performed searching predictors for postoperative complications, recurrence and chronic chest problems. RESULTS: Thirty-six patients underwent extensive pleurectomy through a limited postero-lateral thoracotomy (40%, group A), 54 patients had a limited pleurectomy (60%, group B), 50 by VATS and 4 by axillary thoracotomy. Overall, 11 patients had postoperative complications (12.2%). In group A, 4 patients (11.1%) had complications (2 reoperation, 2 air leak >7 days). In group B, 7 patients (12.9%) had complications (1 reoperation, air leak >7 days, 1 wound infection). Two patients experienced recurrent ipsilateral pneumothorax after surgery, both belonging to group B (overall recurrence rate 2.5%, group B 4.1%). Thirteen patients in both groups (respectively 41.9% in group A and 27% in group B) admitted chest problems on the operated side. From statistical analysis, "indication" resulted a predictor of complications (p=0.03) and "thoracotomy" a predictor of long-term chest problems (p=0.03). CONCLUSIONS: Many theoretical advantages of limited VATS pleurectomy have still to be confirmed and it is reasonable to use it in uncomplicated primary pneumothorax. The superb exposure obtained with thoracotomy and the superiority of extensive pleurectomy in terms of recurrence indicate this approach in case of complicated pneumothorax or when long-term security is of paramount importance.

Adolescent↗
PubMed1999

Anterior cervical-transsternal approach for resection of benign tumors at the thoracic inlet.

BACKGROUND: Neural tumors at the thoracic apex, even when benign, present technical problems for the surgeon because of their inaccessibility. The standard approach from below, using a posterolateral thoracotomy, offers suboptimal access to the vascular and neural structures of the thoracic inlet. METHODS: We present a new technique for the resection of benign tumors of the thoracic inlet, combining an anterior cervical approach with a limited median sternotomy. We do not find it necessary to resect any part of the clavicle or to add a thoracotomy. We used this technique in 4 patients with apical tumors. In 3 patients the tumor arose from the sympathetic chain and in 1 patient from the T1 component of the brachial plexus. RESULTS: The tumors ranged from 30 to 70 mm in diameter, and histologic findings were neurilemoma in 3 cases and ganglioneuroma in 1. There were no complications or deaths. All 4 patients were discharged 3 to 6 days postoperatively. CONCLUSIONS: In our experience this new technique provides improved exposure, good control of the neurovascular bundle, and less morbidity than that associated with thoracotomy. For malignant Pancoast's tumors we would still advocate the approach of Dartevelle or Grunenwald, supplemented by lateral thoracotomy to facilitate systematic intrathoracic evaluation.

Aged↗
PubMed1999

Tracheobronchial sleeve resection with the use of a continuous anastomosis: results of one hundred consecutive cases.

OBJECTIVE: We have used a continuous suture technique for all tracheal and bronchial anastomoses with satisfactory results in our institution. The objective of this article is to review our experience with sleeve resections using this technique and report the associated morbidity and mortality in 100 consecutive cases. METHODS: Our experience with sleeve resection using a continuous suture (3-0 polypropylene) technique was reviewed in 100 consecutive cases. The median age of the patients was 53.3 years with a range of 21 to 81 years. There were 54 male patients and 46 female patients. Resection was undertaken for malignant disease in 81 patients, acquired stricture in 14 patients, benign tumor in 4 patients, and trauma in 1 patient. Among 28 patients in whom lung parenchyma was not resected, 16 patients had tracheal resection and 12 had bronchial sleeve resection. Sleeve pneumonectomy was undertaken in 2, sleeve lobectomy in 66, and sleeve segmentectomy in 4. RESULTS: There were 12 postoperative complications (12%) and 2 postoperative deaths resulting from bronchoatrial fistula and pneumonia (2%). Stricture as a late complication occurred in 5 patients, 2 of whom required a bronchial stent. Other late complications were bougienage, reanastomosis, and completion pneumonectomy (1 each). CONCLUSION: Our experience suggests that the results of continuous suture technique are comparable with those from reported series using interrupted suture technique for tracheal and bronchial anastomosis.

Adult↗
PubMed1999

Systematic nodal dissection in the intrathoracic staging of patients with non-small cell lung cancer.

OBJECTIVE: Although systematic nodal dissection is accepted as an important component of the intrathoracic staging of disease in patients undergoing thoracotomy for lung cancer, many surgeons still do not routinely perform it. We reviewed our practice to assess the information provided by its routine application even when lymph node metastases are considered unlikely. METHODS: The records of 240 patients undergoing thoracotomy for clinically staged cT1-3 N0-1 non-small cell lung cancer were reviewed. In 5 cases (2%) mediastinal dissection was not performed because of specific contraindications and in 8 cases (3%) exploratory thoracotomy was performed. The pathologic findings in the 227 patients who underwent pulmonary resection with systematic nodal dissection were analyzed. RESULTS: The median number of nodal stations, including N1 and N2, examined and submitted separately for histologic assessment was 7 per patient (range 3-13). N2 disease was disclosed in 46 patients overall (20%), including 41 of the 227 patients undergoing pulmonary resection (18%) and 5 of those undergoing exploratory thoracotomy (62.5%). No subgroup had a 0% incidence of N2 metastases. Multivariate analysis showed that younger age, increasing tumor size, left lower lobe origin, and bronchial origin were significant independent variables for prediction of lymph node metastases at the N1 level, the N2 level, or both. CONCLUSIONS: Because no clinical or pathologic subset of patients with a negligible incidence of N2 disease could be discriminated, systematic nodal dissection must be routinely employed for accurate intrathoracic staging of non-small cell lung cancer.

Adenocarcinoma↗
PubMed1999

Antero-superior approaches in the practice of thoracic surgery.

OBJECTIVE: To review our experience using antero-superior approaches for resection of a heterogeneous group of tumors, both benign and malignant, involving the thoracic inlet and adjacent structures. These included Pancoast type bronchial carcinomas, primary neurogenic tumors, soft-tissue neoplasms, and metastases from a variety of primary sites. METHODS: Between October 1993 and January 1998 we undertook 22 operations on 21 patients using a variety of antero-superior approaches. The anterior cervical-transsternal approach was used in 11 operations, the Dartevelle technique was used in five cases, the modification described by Nazari in one patient and that described by Grunenwald in five cases. RESULTS: 21 of the 22 operations were considered to be complete resections with negative margins. There were no intraoperative or postoperative deaths. Major complications occurred in five patients; acute respiratory distress syndrome (n = 4), and thrombosis of the arterial graft and acute respiratory distress syndrome (n = 1). Chronic morbidity was observed in 12 patients; prolonged arm pain (n = 1), arm edema (n = 2), motor and sensory deficits (n = 2), phrenic nerve paresis (n = 1), disfigurement and instability of the pectoral girdle (n = 4), and disturbances in shoulder girdle function (n = 2). CONCLUSIONS: The anterior cervical-transsternal approach we previously described provides adequate exposure for the resection of neurogenic tumors originating in the brachial plexus and sympathetic chain, and for metastatic nodal disease at the base of the neck or in the superior mediastinum. We have found it to be associated with little morbidity, the postoperative stay has been short, and it has proven flexible enough to cope with the changed circumstances found at surgery. For Pancoast type bronchogenic carcinomas and other malignancies with extensive invasion of major structures at the thoracic inlet, we believe the best present option is the clavicle sparing antero-superior technique described by Grunenwald as a modification of the Dartevelle approach. When operating for lung cancer we presently feel that the antero-superior approach should be combined with a posterolateral thoracotomy, to accomplish complete intraoperative staging and undertake anatomical pulmonary resection under optimal conditions.

Adult↗
PubMed1999

Lung injury following pulmonary resection in the isolated, blood-perfused rat lung.

Lung resection may be complicated by postpneumonectomy pulmonary oedema. Oxidant generation following surgery-induced ischaemia-reperfusion may be responsible. This hypothesis was tested utilizing isolated, in situ, blood perfused rodent lungs subjected to continuous perfusion (control subjects); one lung ventilation followed by pneumonectomy (group 1); or one lung ventilation followed by reinflation of the collapsed lung (group 2). In control subjects, no significant changes in markers of oxidant damage, oxygenation, pulmonary artery pressure or extravascular albumin extravasation were detected. In group 1 lungs, hydroxyl radical-like damage was detected in association with impaired oxygenation (p<0.05), and increased pulmonary artery pressure and extravascular albumin accumulation in both lungs. In group 2, there was evidence of hydroxyl radical-like damage, and a fall in oxygenation (p<0.05) occurred during one lung ventilation. There was a transient rise in pulmonary artery pressure following lung reinflation and extra vascular albumin accumulation was significantly increased in both lungs (right>left, p<0.05). Both changes were attenuated (p<0.05) following treatment with the reactive oxygen species (ROS) scavenger superoxide dismutase (group 2a) and the nitric oxide synthase inhibitor N(G)-nitro-L-arginine methyl ester (group 2b). Hydroxyl radical-like damage was undetectable following nitric oxide synthase inhibition. Oxidant stress may contribute to the pathologies seen in this model of lung injury.

Animals↗
PubMed1999

Open lung biopsy for diffuse interstitial lung disease in children.

The aim of the study was to investigate the contribution that open lung biopsy makes to the management of children with diffuse interstitial lung disease and to review the procedure-related morbidity in comparison with published literature on other biopsy techniques. The authors reviewed the case notes and histology of patients under 18 yrs who had had an open lung biopsy in 1991-1998 for investigation of diffuse interstitial lung disease. The majority of patients returned from theatre breathing spontaneously and without an intercostal drain. Three out of 27 suffered a complication related to the biopsy that required intervention. A clear histological diagnosis was reached in 25/27 patients resulting in a change of management in 15/27. The most common histological patterns were nonspecific interstitial pneumonitis which generally had a favourable prognosis and follicular bronchiolitis/lymphocytic interstitial pneumonitis where prognosis was largely dependent on that of an underlying systemic disorder. It is concluded that open lung biopsy makes a substantial contribution to the management of diffuse interstitial lung disease in children and considering both diagnostic yield and safety, remains the biopsy technique of choice.

Adolescent↗
PubMed1999

Pre-operative chemotherapy in early stage resectable non-small-cell lung cancer: a randomized feasibility study justifying a multicentre phase III trial.

Surgical resection offers the best chance for cure for early stage non-small-cell lung cancer (NSCLC, stage I, II, IIIA), but the 5-year survival rates are only moderate, with systemic relapse being the major cause of death. Pre-operative (neo-adjuvant) chemotherapy has shown promise in small trials restricted to stage IIIA patients. We believe similar trials are now appropriate in all stages of operable lung cancer. A feasibility study was performed in 22 patients with early stage (IB, II, IIIA) resectable NSCLC; randomized to either three cycles of chemotherapy [mitomycin-C 8 mg m(-2), vinblastine 6 mg m(-2) and cisplatin 50 mg m(-2) (MVP)] followed by surgery (n = 11), or to surgery alone. Of 40 eligible patients, 22 agreed to participate (feasibility 55%) and all complied with the full treatment schedule. All symptomatic patients achieved either complete (50%) or partial (50%) relief of tumour-related symptoms with pre-operative chemotherapy. Fifty-five per cent achieved objective tumour response, and a further 27% minor tumour shrinkage; none had progressive disease. Partial pathological response was seen in 50%. No severe (WHO grade III-IV) toxicities occurred. No significant deterioration in quality of life was detected during chemotherapy. Pre-operative MVP chemotherapy is feasible in early stage NSCLC, and this study has now been initiated as a UK-wide Medical Research Council phase III trial.

Adult↗
PubMed1999

Isoprostanes and PGE2 production in human isolated pulmonary artery smooth muscle cells: concomitant and differential release.

The isoprostanes are a group of biologically active arachidonic acid metabolites initially thought to be formed under conditions of oxidative stress and independently of cyclooxygenase. However, recent studies have demonstrated isoprostane production under conditions in which cyclooxygenase is intentionally activated/induced. Here we describe for the first time formation of isoprostanes by human vascular cells via independent pathways of oxidative stress and cyclooxygenase induction. We compared the release of the isoprostane with that of the traditional prostaglandin, prostaglandin E2. Cyclooxygenase-2 induction was confirmed by Western blot. When cells were stimulated with cytokines, the release of isoprostanes was inhibited by the cyclooxygenase-1 and -2 inhibitor indomethacin as well by as the cyclooxygenase-2 selective inhibitor L-745,337. However, treatment of cells with the superoxide-producing enzyme xanthine oxidase also resulted in isoprostane release, which was not affected by cyclooxygenase inhibition, unlike PGE2 release under the same condition. Thus, two independent pathways relating to oxidative stress and cyclooxygenase-2 induction form isoprostanes. These findings may have particular importance in diseases such as sepsis and ARDS in which oxidant stress occurs and cyclooxygenase is induced.

Cells, Cultured↗
PubMed1999

Autocrine function of inducible nitric oxide synthase and cyclooxygenase-2 in proliferation of human and rat pulmonary artery smooth-muscle cells: species variation.

Pulmonary hypertension is characterized by hypertrophy and hyperplasia of vascular smooth muscle occurring via an unknown mechanism. Cyclooxygenase (COX)-2 and inducible nitric oxide synthase (iNOS) are expressed under inflammatory conditions and produce mediators that regulate growth in some tissues. We have therefore addressed the question of COX-2 and iNOS involvement in proliferation of human and rat pulmonary artery (PA) smooth-muscle cells (SMC). Interleukin (IL)-1beta suppressed proliferation of both human and rat PA SMC. Moreover, IL-1beta induced COX-2 expression in both cell types. By contrast, IL-1beta stimulated the expression of iNOS protein in rat cells only. COX-2 induced in human cells inhibited proliferation, whereas COX-2 products in rat cells were without affect. However, iNOS activity in rat cells suppressed their proliferation. We conclude that human and rat evolution has diverged such that COX-2 and iNOS, although induced by the same mediator, have different levels of activity and functions in the two species. In humans, induction of COX-2 during pulmonary hypertension may be beneficial for long-term treatment of this disease.

Animals↗
PubMed1999

[Resection of lung metastases: long-term results and prognostic analysis based on 5206 cases--the International Registry of Lung Metastases].

The International Registry of Lung Metastases was established in 1991 to asses the long-term results of pulmonary metastasectomy. The Registry has accrued 5206 cases of lung metastasectomy, from 18 departments of thoracic surgery in Europe (n = 13), USA (n = 4) and Canada (n = 1). Of these patients 4572 (88%) underwent complete surgical resection. The primary tumor was epithelial in 2260 (43%), sarcoma in 2173 (42%), germ cell in 363 (7%), and melanoma in 328 (6%) patients. The disease-free interval was 0 to 11 months in 1729 (33%) cases, 12 to 35 months in 1857 (36%) and more than 36 months in 1620 (31%). Single metastases accounted for 2383 (46%) cases and multiple lesions for 2726 (52%). Mean follow up was 46 months. Analysis was performed by Kaplan-Meier estimates of survival, relative risk of death and multivariate Cox model. The actuarial survival after complete metastasectomy was 36% at 5 years, 26% at 10 years and 22% at 15 years (median 35 months); the corresponding values for incomplete resection were 13% at 5 years and 7% at 10 years (median 15 months). Among complete resections, the 5-year survival was 33% for patients with a disease free-interval of 0 to 11 months and 45% for those with a disease-free interval of more than 36 months; 43% for single lesions and 27 for four or more lesions. Multivariate analysis showed a better prognosis for patients with germ cell tumors, disease-free interval of 36 months and more and single metastases. These results confirm that lung metastasectomy is a safe and potentially curative procedure.

Adolescent↗
PubMed1999

Detection of microsatellite alterations in plasma DNA of non-small cell lung cancer patients: a prospect for early diagnosis.

A major problem in lung cancer is the lack of clinically useful tests for early diagnosis and screening of an asymptomatic population by non-invasive diagnostic procedures. Recent studies have demonstrated the possibility to detect genetic alterations in plasma or serum DNA from patients with various cancers. However, these data rely on small series of aggressive tumors with advanced-stage disease. To determine whether genetic changes in plasma are also detectable in patients with limited disease and thereby potentially useful for early detection, we looked for microsatellite instability (allele shift) and loss of heterozygosity in plasma DNA of 87 stage I-III non-small cell lung cancers and 14 controls. Combining two markers with a high rate of instability (D21S1245) and loss of heterozygosity (FHIT locus), a microsatellite alteration was observed in 49 of 87 (56%) non-small cell lung cancer tumors and in 35 of 87 (40%) plasma samples. Thirty of 49 (61%) of the cases showing tumor alterations also displayed a change in plasma DNA; in addition, 5 patients displayed alterations in plasma samples only. None of the control individuals had genetic changes in plasma. No association was found between the frequency of microsatellite alterations in plasma and tumor stage or histology. Of interest, plasma DNA abnormalities were detectable in 43% of pathological stage I cases and in 45% of tumors up to 2 cm in maximum diameter. These findings highlight new prospects for early tumor detection by noninvasive screening procedures based on the analysis of genetic changes in plasma.

Adult↗
PubMed1998

Selective use of PET scan in the preoperative staging of NSCLC.

Positron emission tomography (PET) is a imaging technique which identifies abnormalities by utilising their metabolic properties rather than their anatomical density. In this study, we evaluated the place of PET scanning for the characterisation of additional abnormalities discovered on routine, preoperative CT evaluation of patients with proven NSCLC. A total of 21 patients underwent PET scanning using fluorodeoxyglucose (FDG). In these patients, routine CT scans had found 26 concomitant lesions which were in lung, adrenal gland, liver, kidney, spleen and pleura. FDG uptake was positive at the primary site in all patients. FDG uptake in 13 of the concomitant lesions suggested malignancy. Malignancy was confirmed at all of these foci by histology in eight (six at thoracotomy, fine needle aspiration biopsy (FNAB) and open biopsy) and by clinical and radiological follow-up for 1-15 months in five. In 13 lesions, PET suggested benign disease. Histology reported no evidence of malignancy in five and the six foci followed on clinical and radiographic follow-up for 2-16 months had no evidence of malignancy. PET was falsely negative in only one site where malignancy was proven by thoracotomy. PET failed to detect the remaining lesion which was an unassociated primary kidney tumour in a patient with Li-Fraumeni syndrome. The accuracy of PET scanning in the assessment of those additional lesions found on CT evaluation of otherwise operable NSCLC was found to be 96% with a sensitivity of 93% and specificity of 100%. These results indicate that PET is useful to characterise additional lesions found on CT scan of patients with NSCLC.

Adult↗