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PubMed1999

Thoracoscopic surgery in a general surgical service.

Following the great success and wide acceptance of laparoscopic surgery, the mini-invasive approach has been adopted for use in thoracic surgery. Thoracoscopic surgery is gaining acceptability as the procedure of choice for the treatment of recurrent pneumothorax and bullous lung disease, peripheral benign and malignant lesions, diffuse pulmonary infiltrates, mediastinal and pleural lesions, esophageal surgery, and major pulmonary resections for primary lung tumors. We present the 4-year experience of a general surgery service that extended the use of its advanced laparoscopic skills to the performance of thoracoscopic surgery in 80 patients. Using thoracoscopy, we performed biopsy or excision of pulmonary lesions (23 patients), spontaneous pneumothorax (14 patients), thoracic sympathectomy (41 patients), and Heller's esophagomyotomy and pericardiotomy (1 patient each). The results are excellent, and we believe the procedures presented in this series, and similar ones, can be accomplished safely and successfully by well-trained laparoscopic surgeons.

Adult↗
PubMed1999

Is laparoscopic reoperation for failed antireflux surgery feasible?

HYPOTHESIS: Laparoscopic techniques can be used to treat patients whose antireflux surgery has failed. DESIGN: Case series. SETTING: Two academic medical centers. PATIENTS: Forty-six consecutive patients, of whom 21 were male and 25 were female (mean age, 55.6 years; range, 15-80 years). Previous antireflux procedures were laparoscopic (21 patients), laparotomy (21 patients), thoracotomy (3 patients), and thoracoscopy (1 patient). MAIN OUTCOME MEASURES: The cause of failure, operative and postoperative morbidity, and the level of follow-up satisfaction were determined for all patients. RESULTS: The causes of failure were hiatal herniation (31 patients [67%]), fundoplication breakdown (20 patients [43%]), fundoplication slippage (9 patients [20%]), tight fundoplication (5 patients [11%]), misdiagnosed achalasia (2 patients [4%]), and displaced Angelchik prosthesis (2 patients [4%]). Twenty-two patients (48%) had more than 1 cause. Laparoscopic reoperative procedures were Nissen fundoplication (n = 22), Toupet fundoplication (n = 13), paraesophageal hernia repair (n = 4), Dor procedure (n = 2), Angelchik prosthesis removal (n = 2), Heller myotomy (n = 2), and the takedown of a wrap (n = 1). In addition, 18 patients required crural repair and 13 required paraesophageal hernia repair. The mean +/- SEM duration of surgery was 3.5+/-1.1 hours. Operative complications were fundus tear (n = 8), significant bleeding (n = 4), bougie perforation (n = 1), small bowel enterotomy (n = 1), and tension pneumothorax (n = 1). The conversion rate (from laparoscopic to an open procedure) was 20% overall (9 patients) but 0% in the last 10 patients. Mortality was 0%. The mean +/- SEM hospital stay was 2.3+/-0.9 days for operations completed laparoscopically. Follow-up was possible in 35 patients (76%) at 17.2+/-11.8 months. The well-being score (1 best; 10, worst) was 8.6+/-2.1 before and 2.9+/-2.4 after surgery (P<.001). Thirty-one (89%) of 35 patients were satisfied with their decision to have reoperation. CONCLUSIONS: Antireflux surgery failures are most commonly associated with hiatal herniation, followed by the breakdown of the fundoplication. The laparoscopic approach may be used successfully to treat patients with failed antireflux operations. Good results were achieved despite the technical difficulty of the procedures.

Adolescent↗
PubMed2001

Penetrating trauma to the diaphragm: natural history and ultrasonographic characteristics of untreated injury in a pig model.

HYPOTHESIS: Recent use of minimally invasive techniques to evaluate the chest and abdomen in patients with penetrating thoracoabdominal trauma has led to the discovery of many occult diaphragm injuries. Surgical repair of these injuries is relatively straightforward. However, diagnosis can be difficult, and the natural history of these injuries is controversial. By developing a penetrating diaphragm injury model, the ultrasonographic characteristics and natural history of this injury can be better understood. SETTING: Surgical laboratory of a tertiary care hospital. SUBJECTS: Seven pigs (Sus scrofa), weighing between 55 and 80 kg, received a 3-cm right-sided (n = 3) or left-sided (n = 4) diaphragm injury via thoracoscopy. INTERVENTIONS: Thoracoabdominal x-ray and ultrasonographic examinations were performed preoperatively; at 2, 4, 8, and 12 weeks postoperatively; and when symptoms related to the diaphragm injury occurred. At 12 weeks, or at the time of earlier death, a postmortem thoracoabdominal examination was performed. MAIN OUTCOME MEASURES: x-Ray and ultrasonographic characteristics, and evidence of wound healing, in a penetrating diaphragm injury model. RESULTS: Perioperative recovery occurred in all pigs. No pigs had radiographic evidence of immediate postoperative herniation. Pigs in the right-sided injury group died early (</=10 days postoperatively). At the time of death, x-ray and ultrasonographic examination revealed hollow viscus herniation into the thorax (n = 2). Pigs in the left-sided injury group remained asymptomatic, without radiographic evidence of herniation, although subtle ultrasonographic signs of diaphragm injury were seen at the 2-week (n = 2), 4-week (n = 2), and 8-week (n = 3) intervals. Postmortem examination of the right-sided injury group revealed the liver afforded no protection against herniation. Right-sided defects (n = 3) did not change size or character despite small-bowel herniation. Conversely, the left hemidiaphragm was well protected by the relatively fixed liver, spleen, and large stomach. The 4 left-sided defects (100%) spontaneously healed. CONCLUSIONS: We developed a penetrating diaphragm injury model with high and low risk of herniation. Ultrasonography may prove to be an important diagnostic adjunct in evaluating diaphragm injuries with and without herniation. Moreover, since the "protected" diaphragm injuries in our model healed spontaneously, a role may exist for the nonoperative treatment of diaphragm injuries in clinical practice. This pig model may prove useful in further defining future management and repair techniques for such injuries.

Animals↗
PubMed2001

Transxiphoid bilateral palpation in video-assisted thoracoscopic lung metastasectomy.

OBJECTIVE: To evaluate indications, limits, and merits of transxiphoid bilateral palpation during video-assisted thoracoscopy (VAT) lung metastasectomy. DESIGN: Survey retrospective study with a minimum follow-up of 1 year. SETTING: University hospital. PATIENTS: From December 1995 to September 1999, 29 of 45 patients operated on for pulmonary metastasectomy were approached through a transxiphoid VAT. Primary sites were colon-rectum (n = 13), kidney (n = 4), limb osteosarcoma (n = 3), uterus (n = 2), larynx (n = 2), breast (n = 1), skin melanoma (n = 1), prostate gland (n = 1), back fibrosarcoma (n = 1), and ovary (n = 1). Bilateral palpation was performed in 23 patients, although only 10 had radiological evidence of bilateral disease. RESULTS: No perioperative or 30-days postoperative mortality was recorded. Acute and chronic pain was similar to that of other VATs and significantly less than sternotomy. Mean +/- SD chest-drain time and hospital stay were 2.8 +/- 1.19 days and 4.3 +/- 1.78 days, respectively. Sixty-nine lesions, 60 of them metastatic, were resected by laser (n = 29) or stapler (n = 40). Bilateral exploration permitted the discovery of 15 radiologically undetected lesions, 11 of which were found to be malignant. Contralateral metastases were found in 5 patients predicted to have unilateral disease. Mean +/- SD follow-up was 22.89 +/- 10.87 months (range, 9-60 months). Six patients developed new pulmonary metastases after a mean interval of 13.6 months; 3 of these patients relapsed in the unexplored hemithorax after 6, 9, and 12 months, respectively. CONCLUSIONS: The use of the transxiphoid VAT approach was safe, applicable in many instances, and effective in detecting occult metastases by manual bilateral palpation. The advantages of a VAT procedure can be coupled with those provided by a radical operation.

Adult↗
PubMed1997

Laparoscopic total esophagectomy.

OBJECTIVE: To evaluate early results with laparoscopic total esophagectomy for benign and malignant disease of the esophagus. DESIGN: Case series involving 9 patients with mean follow-up of 13 months. SETTING: An advanced endoscopic surgery unit at a tertiary referral teaching hospital. PATIENTS: Between December 12, 1993, and December 1, 1996, 9 patients with a mean age of 61 years underwent laparoscopic esophagectomy. Indications were adenocarcinoma in 5, squamous cell carcinoma in 1, dysplastic Barrett esophagus in 2, and refractory stricture with severe shortening in 1. INTERVENTIONS: Gastroduodenal mobilization, transhiatal wide esophageal dissection, gastric tube formation (8 cases), pyloromyotomy (2 cases), cervical anastomosis (8 cases), and laparoscopic jejunal feeding tube placement (8 cases). OUTCOME MEASURES: Operative time, amount of blood loss, operative complications, length of hospital stay, postoperative complications, dysphagia rates, and survival. RESULTS: All procedures were completed endoscopically. Operative time was 6.5 hours (range, 4 3/4 to 9 1/4). Average blood loss was 290 mL. One patient required a right thoracoscopy for an intrathoracic anastomosis because of questionable viability of the gastric tube. Mean hospital stay was 6.4 days (range, 4-9 days). Hospital complications included subclavian vein thrombosis (1 patient), dysphonia (6 patients), and atelectasis (5 patients). There were no anastomotic leaks. Three patients subsequently died: 2 of distant metastatic cancer (at 13 months and 33 months) and 1 of cardiac failure at 10 months. The 6 surviving patients were cancer free at a mean follow-up of 13 months. One patient had left vocal cord paralysis. All patients were doing well and had Visick scores of I or II. CONCLUSIONS: Laparoscopic esophagectomy is a technically feasible but difficult procedure. Despite the long operative times, patients do well and benefit from a shorter hospital stay and more rapid recovery compared with open esophagectomy. Its role as a curative cancer procedure remains unknown, but it may have a place on the basis of its palliative superiority.

Adult↗
PubMed2001

Hyperthermic pleural perfusion with cisplatin: early clinical experience.

BACKGROUND: The preferred treatment for patients with pleural tumors or tumors with pleural extension has not been determined. Systemic and local modalities were studied, including intrapleural chemotherapy and hyperthermia, which mainly have been investigated separately. The objective of this study was to investigate the feasibility, toxicity and early results of a multimodality treatment consisting of surgery, chemotherapy, and hyperthermia in one session for the treatment of patients with pleural malignancies. METHODS: From November 1994 to September 1998, 26 patients (7 patients with mesothelioma, 11 patients with thymic neoplasms, and 8 patients with other tumors) underwent intraoperative hyperthermic pleural perfusion (HPP). Perfusion was performed with a roller pump and a heat exchanger. Cisplatin was added when the temperature stabilized to a mean of 40.8 degrees C (range, 40.2-41.5 degrees C). Dosages of cisplatin used were 60 mg in 2 patients, 100 mg in 2 patients, 120 mg in 1 patient, 150 mg in 18 patients, and 200 mg in 3 patients. The patients underwent the following associated surgeries: extended extrapleural pneumonectomy in 8 patients, resection of tumor without pleurectomy in 4 patients, resection of tumors with pleurectomy in 10 patients, and exploration and HPP only in 4 patients (thoracotomy in 2 patients and video-assisted thoracoscopy in 2 patients). RESULTS: There were no technical problems during the perfusion period. The systemic temperature rose to a maximum of 38 degrees C. There was no renal or hematologic toxicity, except in one patient who experienced thrombocytopenia. One patient died from complications related to a technical error. Eight patients had complications; the most bothersome were in four patients with empyema (early in two patients and late in two patients). The median postoperative hospital stay was 7 days (range, 2-50 days). Ten patients were alive 28-69 months after surgery. The overall 1-year, 2-year, and 3-year survival rates were 72%, 65%, and 44%, respectively. Complete ipsilateral pleuropulmonary control was achieved in 17 patients (9 patients who are alive and 8 patients who have died). CONCLUSIONS: Intraoperative HPP with cisplatin is feasible, easy to perform, and relatively safe. This method may offer excellent local control for patients with pleural tumors.

Adult↗
PubMed1989

Diffuse malignant pleural mesothelioma in an urban hospital: clinical spectrum and trend in incidence over time.

This retrospective analysis reviews the clinical experience of a major urban referral hospital with diffuse malignant pleural mesothelioma during the 14-year period from 1973 through 1986. Seventy-five cases of definite or equivocal mesothelioma were identified. There were four cases of primary malignant peritoneal mesothelioma, seven cases of benign fibrous mesothelioma, and 64 cases of diffuse malignant pleural mesothelioma. In 43 cases (67%) of diffuse malignant pleural mesothelioma, there was historic evidence of asbestos exposure. In 21 cases (33%), there was no known history of asbestos exposure. An increase in annual incidence of diffuse malignant pleural mesothelioma was observed over the study period, from three cases in 1973 to ten cases in 1986. Despite greater awareness of this disease, the diagnosis remains a difficult one to establish given the nonspecific symptoms, signs and radiographic appearance, variable histologic appearance, and poor diagnostic sensitivity and specificity of thoracentesis and closed pleural biopsy. Thoracotomy, thoracoscopy, and CT-guided needle biopsies gave higher yields and are the diagnostic measures of choice when diffuse malignant pleural mesothelioma is suspected.

Asbestos↗
PubMed1982

The pattern of metastatic disease in patients with pleural effusions secondary to breast cancer.

The pattern of pleural metastases in women with effusions secondary to breast cancer was evaluated by thoracoscopy in a series of 46 patients with previously untreated effusions. Metastases involving the visceral pleural were seen in 59 per cent of patients whereas parietal deposits were found in only 15 per cent. No tumour deposits were seen in 26 per cent of cases. No patients had both visceral and parietal tumour secondaries. Patients within each of these groups showed differences in rates of positive effusion cytology, chest wall recurrence and previous evidence of recurrent breast cancer.

Breast Neoplasms↗
PubMed1983

Propagation of a poorly differentiated human pulmonary adenocarcinoma in nude athymic rats.

Nude athymic rats of Rowett genetic background were injected subcutaneously with cells from a poorly differentiated human pulmonary adenocarcinoma, following propagation in nude mice. The tumour cells were obtained by thoracentesis and by pleural biopsy during thoracoscopy. So far, we have heterotransplanted 13 different malignant human tumours including malignant mesothelioma, pulmonary adenocarcinoma, malignant melanoma and malignant lymphoma. Subcutaneous tumour growth was seen in all inoculated animals, with an exponential tumour growth pattern and with tumour volume doubling times of approximately 8 days. After two initial passages in nude athymic mice of BALB/c genetic background, the human tumour so far has undergone 9 passages in athymic rats, i.e. collection of tumour material by biopsy from the preceding tumour-bearing rat generation, processing and inoculation of tumour brei with subsequent tumour growth have been repeated 8 times. Four-to-8-week-old rats of both sexes were used throughout and tumour growth was controlled by palpation twice a week. Routine histopathological sections were prepared from the tumour at various passages to assess similarity to the original tumour in the patient. The growth pattern of the xenografts remained similar at all passages just as the remarkable similarity of the heterotransplanted tumours to the original adenocarcinoma was retained at all passages. No spontaneous regressions of heterotransplanted tumours could be demonstrated. Electron microscopical analysis revealed numerous blunt microvilli and lumina partly filled with conglomerates of mucigen granules and small glycocalyceal bodies associated with external superficial microvilli. Scantiness of dark secretory granules together with free and membrane-bound polyribosomes were seen in the cytoplasm. We believe that the nude athymic rat is a valuable research tool and that the permanently transplantable human tumour reported here could be of value in delineating further the mechanisms for tumour take, growth and control.

Adenocarcinoma↗
PubMed2001

Malignant pleural mesothelioma.

Malignant pleural mesothelioma remains a difficult tumor to treat, much less cure. Currently, the best chance for long-term survival lies with early diagnosis and aggressive surgical extirpation, but given the typically long delay between the onset of symptoms and diagnosis, this is only possible with a high index of suspicion and an aggressive diagnosis workup. Early referral to a tertiary center experienced in the treatment of MPM may be important for several reasons: (1) decreased risk of tumor spread along multiple thoracenesis/biopsy tracts, (2) the availability of specialized pathologic assays for definitive diagnosis, (3) the availability of critical staging modalities (aggressive mediastinoscopy +/- thoracoscopy, MRI scans performed according to specific mesothelioma protocols, and perhaps PET scans), (4) surgical experience with pleurectomy/decortication and/or extrapleural pneumonectomy, that may decrease morbidity and mortality, and (5) the availability of novel adjuvant protocols. Single-modality therapy is unlikely to result in long-term survival. Aggressive surgery is required for optimal debulking, and extrapleural pneumonectomy may offer better local control compared with pleurectomy/ecortication. Delivery of optimal radiation schedules, which may involve large fractions as well as large total doses, is limited by the presence of nearby dose-limiting structures. Current chemotherapy is severely lacking in producing objective responses and improved survival although gemcitabine and IL-2 may be active agents to be combined with radiation and/or other agents. Hyperthermia, photodynamic therapy, intracavitary therapy, and gene therapy are all relatively new techniques under active investigation that should be supported by enrollment in on-going protocols. Predictably, many of these techniques provide greater benefit when used in the setting of adjuvant protocols or minimal residual disease, emphasizing the importance of multimodality therapy.

Adult↗
PubMed1989

[Pleural mesothelioma--problems in diagnosis and clinical course in 25 patients].

Patients with benign pleurafibromas should undergo surgery as suspect thoracic tumors have the potential to become malignant. In benign cases diagnosis can easily be made during the operation. In such a case the prognosis is good and it is seldom necessary to undergo repeated surgery due to recurrence. In the case of malignant pleuramesothelioma the preoperative diagnosis with an exact staging of the tumor is very important to determine an adequate therapeutic regimen. X-ray, CT-scanning, tapping of the pleura fluid and biopsy of the pleura are together insufficient to diagnose a pleuramesothelioma correctly. Since it is not always possible to diagnose a malignant pleuramesothelioma even at thoracoscopy, one should not hesitate to perform an open lung biopsy in order to obtain enough material under adequate vision.

Adult↗
PubMed1991

The influence of the diagnostic technique on the histopathological diagnosis in malignant mesothelioma.

In the histopathology of malignant mesotheliomas three different types (epithelial, connective tissue and mixed type) are distinguished. Some authors believe all tumours to be of mixed type, but consider that due to inadequate sampling or small biopsies this may be missed frequently. In this study the relationship between the histopathological diagnosis and the amount of tissue examined was investigated. In a series of 124 cases of malignant pleural mesothelioma a high percentage of mixed type tumours was found (55%). In cases where the decisive diagnostic procedure had been an Abrams biopsy (the "small-specimen" technique) mixed-type histology was found in 36%. If thoracoscopy, thoracotomy or autopsy (the "large-specimen" techniques) had delivered a definite diagnosis, mixed-type histology was found in 63%. Apparently diagnosing the mixed-type variety depends on the amount of tumour tissue obtained. However, the assumption that all mesotheliomas are of mixed type cannot be confirmed.

Autopsy↗
PubMed1996

Intrapleural administration of streptokinase in complicated purulent pleural effusion: a CT-guided strategy.

OBJECTIVE: To determine the usefulness and the results of a strategy using intrapleural streptokinase (SK) instillation guided by repeated computed tomography (CT) scan examinations in pleural empyemas unresponsive to chest tube drainage. DESIGN: A retrospective chart review. SETTING: The medical Intensive Care Unit and Department of Radiology, in a university hospital. PATIENTS: Sixteen patients with empyema who had a persistent pleural effusion despite drainage, among 37 patients with infectious pleural effusion. INTERVENTIONS: In the 16 patients, CT examination was performed before and at least once after SK. Intrapleural SK was instilled, either through the chest tube or via a needle puncture, according to the CT scan results. RESULTS: The first CT scan confirmed a persistent effusion in all, showing a multiloculated effusion in 13 patients, and an ectopic loculus in one. The first SK instillation resulted in a dramatic increase of fluid drained per day (from 68 +/- 28 ml to 567 +/- 262 ml; p < 0.001), leading to complete resolution in 11 patients, while the others required a second CT scan-guided procedure. In one, the chest tube was misplaced, while in two, transparietal injection was needed. Finally, a complete resolution was observed in 14 (87.5%) of the patients. Two patients had a poor initial response to SK and were eventually scheduled for video-thoracoscopy. A single episode of chills and fever was observed among 32 SK instillations. CONCLUSION: CT-guided SK instillation in pleural empyema appears to be safe, and allowed complete resolution in 87.5% of our patients.

Adult↗
PubMed1995

Use of fluorine-18 fluorodeoxyglucose positron emission tomography in the detection of thymoma: a preliminary report.

Thymomas are lacking in malignant cytological features. Their staging is defined by the invasiveness of the tumour. This study aimed to analyse the uptake patterns of fluorine-18 fluorodeoxyglucose (FDG) in thymomas of different stages. FDG positron emission tomography (PET) scan was performed in 12 patients suspected of having thymoma and in nine controls. Qualitative visual interpretation was used to detect the foci with FDG uptake higher than that of normal mediastinum. Tumour/lung ratio (TLR) was calculated from the counts of ROIs over the mass and over comparable normal lung tissue in thymoma patients. Mediastinum/lung ratio (MLR) was calculated from the counts of ROIs over the anterior mediastinum and lung in controls. The PET scan patterns of distribution of foci with FDG uptake and TLRs were correlated with the computed tomography (CT) or magnetic resonance imaging (MRI) findings, and staging of the thymomas. Thymectomy was performed in ten patients and thoracoscopy was done in two patients. The results revealed ten thymomas (two stage I tumours, two stage II, four stage III and two stage IV, according to the Masaoka classification), and two cases of thymic hyperplasia associated with myasthenia gravis. Myasthenia gravis was also noted in four thymoma patients. FDG studies showed (a) diffuse uptake in the widened anterior mediastinum in patients with thymic hyperplasia, (b) confined focal FDG uptake in the non-invasive or less invasive, stage I and II thymomas, and (c) multiple discrete foci of FDG uptake in the mediastinum and thoracic structures in stage III and IV advanced invasive thymomas. The thymomas had the highest TLRs, followed by the TLRs of thymic hyperplasia and the MLRs of control subjects (P <0.005). No significant difference was found between thymomas in different stages or between thymomas with and thymomas without myasthenia gravis. In comparison with CT and/or MRI, FDG-PET detected more lesions in patients with invasive thymomas and downgraded the staging of thymoma in four patients. Our preliminary results suggest that FDG-PET is useful in the assessment of the invasiveness of thymomas, and may have the potential to differentiate thymomas from thymic hyperplasia.

Adult↗
PubMed1993

Bubbly intrapleural mucous simulating congenital lobar emphysema.

A neonate presented for an esophageal atresia repair and developed respiratory distress in the immediate post-operative period. The initial conventional chest radiographs suggested that there was a right sided pneumothorax; however, this did not resolve, even after the placement of two chest tubes. A CT examination suggested that the findings were due to hyperinflation of the right upper lobe. Thoracoscopy was performed and revealed a complex pneumothorax composed of bubbly mucous from a post-operative pleuro-esophageal fistula.

Cystic Adenomatoid Malformation of Lung, Congenita↗
PubMed1999

Pseudomyxoma peritonei in the pleural cavity: report of a case.

PURPOSE: Pseudomyxoma peritonei is a rare disease characterized by mucinous ascites and associated with ruptured mucocele, cystadenoma, and low-grade carcinoma arising from the appendix, ovaries, or colon. Metastases and extraperitoneal involvement are extremely rare events. METHOD: This is a case report of a patient with pseudomyxoma peritonei with pleural involvement. RESULTS: A 38-year-old male patient with a pseudomyxoma peritonei from appendiceal origin underwent an extensive cytoreduction procedure. During the operation pleural involvement was noted. This was later confirmed by thoracoscopy. An expectant policy was followed until the patient became symptomatic with progressive disease in the abdomen and both pleural cavities. With systemic chemotherapy (5-fluorouracil and leucovorin), a good clinical response was obtained, and the patient was alive with stable disease 2.5 years after the first diagnosis. CONCLUSIONS: Involvement of the pleural cavity by pseudomyxoma peritonei is rare and carries an unfavorable prognosis. Whenever possible, the same guidelines as for intra-abdominal disease should be followed: extensive cytoreductive procedures with local and/or systemic chemotherapy. In our patient we hope to achieve a prolonged palliation with systemic chemotherapy.

Adult↗
PubMed2002

Pleural gas gangrene secondary to esophageal injury by an ingested fish bone.

We report a 73-year-old woman with right pleural gas gangrene, treated successfully by thoracoscopic debridement. The clinical course and chest computed radiography and thoracoscopy findings suggested that her condition resulted from a relatively rare esophageal injury after she accidentally ingested a fish bone. Video-assisted thoracoscopic intervention has proved useful in cases involving pleural gas gangrene.

Aged↗
PubMed1997

[Problems in diagnosis and therapy of malignant pleural mesothelioma].

The incidence of malignant pleural mesothelioma increased continuously during recent years. This is related to widespread use and processing of asbestos in the last decades. Characteristical symptoms like dyspnea, cough and thoracic pain are common in almost all pulmonal diseases. Therefore the possible occurrence of a pleural tumor is often neglected. This leads to a delay between onset of symptoms and the establishment of diagnosis. With X-ray and computed tomography 80% of the pleural tumors can be proved. Only in few cases the histopathological analysis of the pleural fluid leads to diagnosis. However, thoracoscopy or thoracotomy remain the most reliable means of obtaining a definitive tissue diagnosis. At the time of operation advanced stages are found in many cases, therefore palliative surgery is indicated. Due to high morbidity and mortality pleuropneumonectomy should be done only in selected patients. Pleurectomy or pleurodesis is often sufficient to release patients' symptoms. Chemotherapy and radiation have not proven effective in controlling malignant mesothelioma. In conclusion pleural mesothelioma remains a tumor with a very poor prognosis. Long term survival is occasional even in case of multimodal treatment.

Adult↗