To evaluate type of surgery, long-term survival and factors influencing outcome in pulmonary carcinoid tumors. We reviewed data of 252 patients who underwent surgery for carcinoid tumor in 1968-1989 (Group A) and in 1990-2005 (Group B). All cases were reviewed and classified as typical (TC) or atypical carcinoid (AC) according to WHO criteria (1999). There were 174 (69%) patients with TC (167 N0, 6 N1 and 1 N2) and 78 (31%) with AC (56 N0, 13 N1, 9 N2). Surgery consisted of 163 (64.7%) formal lung resections (121 lobectomies, 18 bilobectomies, 14 segmentectomies, 10 pneumonectomies), 76 (30.1%) sleeve or bronchoplastic resections and 13 (5.2%) wedge resections. No perioperative mortality occurred, 17 (6.7%) patients experienced complications. Overall 5, 10 and 15-year survival rate was 90%, 83% and 77%. TC showed a more favourable prognosis than AC (10-year survival rate 93% and 64%; p=0.00001) as well as N0 patients in comparison with N1-2 patients (10-year survival rate 87% and 50%; p=0.00005). Group A received lymph-node sampling, Group B received a systematic lymphadenectomy. No difference was found between Group A and B in detection of nodal metastases (10.9% versus 11.9%; p=0.79), but in Group A we observed 2 lymph-node relapses. In Group B number of sleeve resections significantly increased (2.7% versus 20.4%; p=0.0001) and number of pneumonectomies showed a significant reduction (7.2% versus 1.4%; p=0.01). Typical histology and N0 status were important prognostic factors in carcinoid tumors. Parenchyma-sparing procedures must be considered the treatment of choice with systematic lymphadenectomy.

The aim of this study is to analyze long-term survival and the prognostic significance of some factors after surgical resection of thymic epithelial tumours. We performed a retrospective analysis of clinical and histopathological data on 132 patients operated on for thymic tumours, from 1970 and 2001. Histologic diagnosis based on the new WHO classification system was made by a single pathologist. A univariate and multivariate analysis of prognostic factors predicting survival was carried out. There were: 108 complete resections (81.8%), 12 partial resections (9.1%) and 12 biopsies (9.1%). Overall 5, 10 and 15-year survival rate was 72, 61 and 52.5%, respectively. The Masaoka staging system showed 44 stage I, 18 stage II, 52 stage III and 18 stage IV. Histologic results were: 14 subtype A, 31 AB, 20 B1, 28 B2, 29 B3 and 10 C; the respective proportions of invasive tumour (stage II-IV) was 28.6, 58.1, 50, 75, 86.2 and 100%. There were 16 tumour recurrences (14.8%) of 108 radically resected thymomas, 10 were treated with radical re-resection. In univariate analysis, four prognostic factors were statistically significant: radical resection, Masaoka clinical staging, WHO histologic subtype and resectable tumour recurrence. In multivariate analysis, the independent factors predicting long-term survival were WHO histology and Masaoka stage. The WHO histologic classification seems to be the most significant prognostic factor reflecting the invasiveness of the thymic tumour. Completeness of resection and Masaoka stage I and II assure a better survival. Unresectable recurrence of thymic tumour predicted a worse prognosis.

Benign tracheal stenoses remain the most common indications for tracheal resection. We report lessons learned with surgical management of tracheal stenoses in a consecutive series of 65 patients from the beginning of our experience to date. From December 1991 to January 2001 65 patients underwent primary tracheal and laryngotracheal resection and reconstruction for non-neoplastic stenoses. There were 39 males and 26 females with a median age of 33 years (range 14-74 years). There were 58 cases of postintubation and seven of idiopathic stenosis. A cervical approach was used in 60 patients, and a cervical incision with sternal split in four and with sternotomy in one. We performed 45 (69.2%) tracheal resections and 20 (30.8%) laryngotracheal resections. The length of resection ranged between 1.5 and 4 cm (median 2.5 cm). The range of resected rings was two to eight (median five). Fifty-four patients received a preoperative treatment. Preoperative procedures consisted of laser therapy (37), tracheostomy (38) and endotracheal prosthesis (16). We had major complications in eight patients (12.3%) and minor complications in 15 patients (23%). The most frequent complications were: temporary vocal cord dysfunction (eight patients), wound infection (five patients), anastomotic dehiscence (four patients), vocal cord paralysis (two patients), granulation tissue (two patients), deglutition dysfunction (one patient) and restenosis (one patient). Perioperative mortality was 1.5% (one patient). In classifying final results obtained, 54 patients achieved an excellent result, eight a good result and two satisfactory. The strategy for treatment of airway stenoses is now well established and leads to a high level of success with minimal or no sequelae. Meticulous preoperative assessment and preparation associated with a perfect surgical technique is mandatory to obtain good results. Preoperative treatments (laser and/or endotracheal prosthesis) could increase the extent of injury and the length of stenosis.

Background: Apoptosis has recently been proposed to contribute to the pathogenesis of emphysema. Methods: In order to establish if cell fate plays a role even in end-stage disease we studied 16 lungs (9 smoking-associated and 7 α1antitrypsin (AAT)-deficiency emphysema) from patients who had undergone lung transplantations. Six unused donor lungs served as controls. Apoptosis was evaluated by TUNEL analysis, single-stranded DNA laddering, electron microscopy and cell proliferation by an immunohistochemical method (MIB1). The role of the transforming growth factor (TGF)-β1 pathway was also investigated and correlated with epithelial cell turnover and with the severity of inflammatory cell infiltrate. Results: The apoptotic index (AI) was significantly higher in emphysematous lungs compared to the control group (p ≤ 0.01), particularly if only lungs with AAT-deficiency emphysema were considered (p ≤ 0.01 vs p = 0.09). The proliferation index was similar in patients and controls (1.9 ± 2.2 vs 1.7 ± 1.1). An increased number of T lymphocytes was observed in AAT-deficiency lungs than smoking-related cases (p ≤ 0.05). TGF-β1 expression in the alveolar wall was higher in patients with smoking-associated emphysema than in cases with AAT-deficiency emphysema (p ≤ 0.05). A positive correlation between TGF-βRII and AI was observed only in the control group (p ≤ 0.005, r² = 0.8). A negative correlation was found between the TGF-β pathway (particularly TGF-βRII) and T lymphocytes infiltrate in smoking-related cases (p ≤ 0.05, r² = 0.99) Conclusion: Our findings suggest that apoptosis of alveolar epithelial cells plays an important role even in end-stage emphysema particularly in AAT-deficiency disease. The TGFβ-1 pathway does not seem to directly influence epithelial turnover in end-stage disease. Inflammatory cytokine different from TGF-β1 may differently orchestrate cell fate in AAT and smoking-related emphysema types.