Surgical treatment of hepatic and pulmonary metastases from colorectal cancers

BACKGROUND

Selected patients with double hepatic and pulmonary metastases from colorectal cancer may benefit from operation.

METHODS

From 1970 to 1995, 239 patients underwent operation for resection of pulmonary metastases from colorectal cancer at two French surgical centers. Among these patients, 43 (18%) had previously undergone complete resection of hepatic metastases and constitute the subject of this retrospective study.

RESULTS

The median interval time between hepatic and pulmonary resections was 18 months. Two pneumonectomies, 5 lobectomies, 3 segmentectomies, 6 wedge resections, and 27 metastasectomies were performed. No postoperative mortality was observed. Two patients had major postoperative complications. Seven patients (16%) underwent subsequent pulmonary resection for recurrences. Twenty-one patients were still alive, 14 free of disease. The median survival from pulmonary resection was 19 months and the 5-year probability of survival was 11%. Prethoracotomy carcinoembryonic antigen blood levels and the number of pulmonary resection were found to be significant prognostic factors; the interval time between hepatic and pulmonary resection (> 36 months) was borderline significant (p = 0.06).

CONCLUSIONS

Selected patients with combined hepatic and pulmonary metastases from colorectal cancer should be considered for surgical resection. Patients with normal prethoracotomy carcinoembryonic antigen levels and late metachronous pulmonary metastasis, appear to be the best surgical candidates.

Bronchioloalveolar lung carcinoma: results of surgical treatment and prognostic factors

STUDY DESIGN

To determine the long-term results after surgical treatment of bronchioloalveolar lung carcinoma (BALC) and to identify prognostic factors.

PATIENTS AND METHODS

A retrospective study of 70 patients (49 men, 21 women), mean age 61+/-10 years, was carried out. Their carcinomas were classified into three clinicopathologic types: nodular or tumoral, pneumonic, and diffuse types. All the diagnosed BALC cases were reviewed and were classified into histologic types: mucinous, nonmucinous (including fibrotic center), and mixed tumors. Univariate and multivariate analyses were carried out.

RESULTS

The nodular or tumoral type was identified in 42 patients, pneumonic in 21, and diffuse in seven. Histologically, there were 36 mucinous, 25 nonmucinous, and nine mixed tumors. Resection was complete in 61 instances (87%) and incomplete in five. The 5-year survival rate was 34% in patients with curative resections. Five prognostic factors were identified by univariate analysis, but in multivariate analysis, only three factors remained significant: the absence of symptoms, the TNM stage, and completeness of resection. Thirty-six patients with curative resection (59%) developed recurrences (in the lung in 26 patients; mediastinal lymph nodes, four; distant metastases, nine). The frequency of recurrence was significantly greater in patients with pneumonic-type BALC than in nodular or tumoral types (p<0.01), and pulmonary recurrences were significantly more frequent in pneumonic than in tumoral types (p<0.02).

CONCLUSIONS

This study confirmed that the overall prognosis of BALC is not significantly different from that of the other non-small cell lung cancers. We found that the lungs are the predominant site of recurrence in BALC, especially in the pneumonic types. The complete surgical resection of localized BALC offers the best chances of long-term survival.

[Current indications for early surgery in stage III non-small-cell bronchial cancer]

In a number of cases, surgery is carried out as the initial procedure in Stage III non small cell carcinoma. For those with Stage IIIA surgery is the initial procedure performed by practically all teams for Stage T3 chest wall and T2 bronchial stump in patients who have non evidence of N2. In Stage IIIA N2 which is histologically confirmed by mediastinoscopy or thoracoscopy surgery is the initial procedure in certain cases if the local conditions are "favourable". The majority of surgical teams however prefer to operate after neo-adjuvant therapy whose long term efficacy still remains to be shown in a formal study. Stage IIIB consists of a very heterogeneous group in whom surgery can be carried out as an initial procedure in a limited number of cases such as involvement of the left auricle, the proximal pulmonary artery, the superior vena cava, the oesophageal muscle as well as at the carina. In all the other cases of IIIB on the CT scanner or MRI scanner where the cancer seems to be non resectable, or resectable in a poor clinical situation, one would envisage surgery only after a re-evaluation secondary to neo-adjuvant therapy.

Results of re-resection for recurrent thymomas

BACKGROUND

The treatment of recurrent thymomas remains controversial.

PATIENTS

The place for re-resection was retrospectively studied in 28 consecutive patients operated on during the last 40 years. The initial Masaoka staging of the thymoma was stage I, 4; stage II, 8; stage III, 11; and stage IVa, 3. Postoperatively, 14 have had radiation therapy, 1 chemotherapy, and 13 no adjuvant treatment. Seven patients had development of recurrences, 15 had pleuropulmonary metastases, 5 had both, and 1 had thoracotomy scar recurrence. Nineteen patients had a complete resection and 9 an incomplete one.

RESULTS

Most local recurrences appeared after resection of stage I or II thymomas. On the other hand, in patients with stage III or IV thymomas pleural or pulmonary metastases mainly developed. No local recurrence occurred in patients who initially received postoperative radiation therapy. Five-year and 10-year survival rates were 51% and 43%, respectively, for the overall population. Among the 19 patients with complete resection, only 3 patients had a subsequent recurrence; 1 of them could be reoperated on and is still alive and free of disease.

CONCLUSIONS

Thymoma recurrences often appear as a locoregional rather than a hematogenous spread. Reresection can be recommended in selected patients.

[Efficacy and tolerability of fraxiparine in the prevention of thromboembolic complications in oncologic thoracic surgery]

A French multicentre, open, randomized trial was conducted in lung cancer surgery in order to test the optimal dosage regimen: Fraxiparine 3075 IU AXa (fixed dosage) and Fraxiparine 4100 or 6150 IU AXa (dosage adjusted for body weight only), over a period of 8 days. 75 patients were allocated to each group. Efficacy (Doppler ultrasonography at D0 and D8, controlled by bilateral ascending phlebography when positive) and safety, i.e. perioperative blood loss and postoperative bleeding complications were the main assessment criteria. The efficacy of the two treatment regimens was confirmed = no deep vein thrombosis and/or pulmonary embolism. No significant difference of safety was observed between the two groups: nevertheless fewer patients developed major bleeding complications in the Fraxiparine fixed dosage group (2 patients) than in the Fraxiparine adjusted dosage group (6 patients). Blood loss was comparable in the 2 groups; a statistical difference (p = 0.09) was showed between D0 and D2 in favour of Fraxiparine fixed dosage group. The results of this trial indicate that Fraxiparine administered at fixed dosage represents an effective and safe prophylaxis against fatal thromboembolism in patients undergoing oncologic thoracic surgery.

Lung metastases of renal cell carcinoma: results of surgical resection

OBJECTIVE

The research was designed to evaluate the results of surgical resection of renal lung metastases.

METHODS

Between 1960 and 1994, 50 consecutive patients underwent resection for pulmonary metastases from renal cell carcinoma. Mean age was 59 years (range: 40-78 years). Mean time between nephrectomy and pulmonary resection was 3 years (range: 0-18 years). Nineteen patients had solitary metastase, 13 multiple unilateral, and 18 bilateral. Wedge excision was performed in 28 patients, segmentectomy in 3, lobectomy in 17, sleeve lobectomy in 1, pneumonectomy in 5 and biopsy in 3. Twelve patients had repeat resection for recurrent metastases.

RESULTS

The resection was complete in 45 patients. Three patients also had a complete resection of limited extra-pulmonary disease. There was one postoperative death and 3 complications. Mean follow-up was 42 months without loss of follow-up. The cause of death was always metastatic recurrent disease. Five-year survival in complete resection was 44%. Only one long survivor was observed in the case of incomplete resection in a patient who had a complete response after adjuvant immunotherapy. Five-year survival for the 12 patients with repeat resections was similar to the overall survival rate (42%).

CONCLUSIONS

Resection of renal lung metastases is a safe and effective treatment. No factor influenced the 5-year survival in this series except the complete resection. Extra-pulmonary metastases does not contra-indicate pulmonary resection. In selected patients, repeat resection for recurrent disease is warranted.

Prognostic factors and long-term results after thymoma resection: a series of 307 patients

Three hundred seven cases of patients who underwent operation for thymoma (196 of whom had myasthenia gravis) were analyzed to assess the prognostic values of Masaoka clinical staging, completeness of resection, histologic classification, history of myasthenia gravis, and postoperative radiotherapy. According to the Masaoka staging system, 135 thymomas were stage I, 70 were stage II, 83 were stage III, and 19 were stage IV. According to the Verley and Hollmann histologic classification system, 67 thymomas were type 1, 77 were type 2, 139 were type 3, and 24 were type 4. Two hundred sixty patients underwent complete resection, 30 underwent incomplete resection, and 17 underwent biopsy. Postoperative radiotherapy was performed mainly in cases of invasive or metastatic thymoma. Mean follow-up was 8 years; eight patients were unavailable for follow-up. The overall 10- and 15-year survivals were 67% and 57%, respectively. In univariate analysis, three prognostic factors were established: completeness of resection, Masaoka clinical staging, and histologic classification. Furthermore, among patients with stage III thymomas, survival was significantly higher for patients with complete resection than for patients with incomplete resection (p < 0.001). Completeness of resection should therefore be taken into account in clinical-pathologic staging. We did not find any significant difference with respect to disease-free survival between patients who had postoperative radiotherapy and those who did not. In multivariate analysis, the sole significant prognostic factor was completeness of resection. On the basis of these findings, a new clinical-pathologic staging system is proposed.

Leiomyosarcoma of the superior vena cava

Leiomyosarcoma of the superior vena cava is exceptional. A case in a 52-year-old man is described. A treatment by means of neoadjuvant chemotherapy, operation, and adjuvant radiotherapy was performed. This aggressive treatment has permitted the patient to obtain a relatively long survival with a good quality of life.

Immediate and long-term results after surgical treatment of primary spontaneous pneumothorax by VATS

BACKGROUND

Video-assisted thoracic surgery has recently evolved as a viable alternative to thoracotomy for spontaneous pneumothorax.

METHODS

A series of 163 patients with primary spontaneous pneumothorax were treated by video-assisted thoracic surgery. Seventy patients were treated for a recurrent episode, 64 patients for a persistent primary spontaneous pneumothorax, 24 patients for a contralateral episode, and 5 patients for a bilateral primary spontaneous pneumothorax. Stapling of bullae with an Endo-GIA stapler (Auto-Suture, Elencourt, France) was performed in 90% of the cases and parietal pleural abrasion was performed in each case.

RESULTS

One revisional lateral limited thoracotomy was required for bleeding. Six patients had a prolonged air leak; 2 of them were reoperated on by lateral limited thoracotomy. Two patients have had an incomplete reexpansion of the lung and required a reoperation. The duration of hospitalization was 6.9 +/- 3 days. With a mean follow-up of 24.5 months, three recurrences requiring a reoperation occurred; 3 other patients had a partial recurrence and healed by rest without drainage. The mean time to return to the occupational activity of the patients was 42 +/- 34 days. These results were compared with those of a previous series of 87 patients operated on by lateral limited thoracotomy.

CONCLUSIONS

With the development of surgical technique and video equipment, video-assisted thoracic surgery will probably become the treatment of choice of primary spontaneous pneumothorax.

Results and prognostic factors in resections of primary tracheal tumors: a multicenter retrospective study. The French Society of Cardiovascular Surgery

To determine long-term survival and prognostic factors, 208 patients with primary tracheal tumors were evaluated in a retrospective multicenter study including 26 centers. Ninety-four patients had squamous cell carcinoma, four had adenocarcinoma, 65 had adenoid cystic carcinoma, and 45 patients had miscellaneous tumors. The following resections were performed: tracheal resection with primary anastomosis, 165; carinal resection, 24; and laryngotracheal resection, 19. Postoperative mortality rate was 10.5% and correlated with the length of the resection, the need for a laryngeal release, the type of resection, and the histologic type of the cancer. Fifty-nine percent of patients with tracheal cancer and 43% of patients with adenoid cystic carcinomas had postoperative radiotherapy. The 5- and 10-year survivals, respectively, were 73% and 57% for adenoid cystic carcinomas and 47% and 36% for tracheal cancers (p < 0.05). Among patients with tracheal cancers, survival was significantly longer for those with complete resections than for those with incomplete resections. On the other hand, the presence of positive lymph nodes did not seem to decrease survival. Postoperative radiotherapy increased survival only in the case of incompletely resected tracheal cancers. Long-term prognosis was worsened by the occurrence of second primary malignancies in patients with tracheal cancers and by the occurrence of late pulmonary metastases in patients with adenoid cystic carcinomas.

[Results of surgical treatment of lung metastases from colorectal cancers]

OBJECTIVE

The aim of this work was to determine the long term results and the prognostic factors after surgical resection of pulmonary metastases from colorectal cancers.

METHODS

Clinical status after surgery and survival were studied in 101 consecutive patients undergoing lung resection for pulmonary metastases from colorectal carcinoma between 1970 and 1993. Prognostic factors were evaluated according to surgical design. Mean interval between colon resection and lung resection was 44 months. Fifty-nine patients had a solitary lesion, 17 had multiple unilateral lesions and 25 multiple bilateral lesions. Eighteen patients had undergone previous surgery for localized extrapulmonary metastases. A wedge resection was performed in 47 patients, lobectomy or bilobectomy in 40, pneumonectomy in 11 and biopsy in 3.

RESULTS

There was no postoperative mortality and 5-year survival in complete resection was 21%; all patients with incomplete resection or biopsy died within 3 years. Significant prognostic factors were: complete resection, metachronous disease (vs synchronous metastases) and absence of lymph node involvement. The extent of the colorectal disease and the number of resected metastases did not influence prognosis. Survival for patients with resected extrapulmonary disease was not significantly different as compared with patients with only pulmonary metastases. Eleven patients had repeat pulmonary resections, 6 of these patients are currently alive, 3 of them more than 3 years after the second pulmonary resection.

CONCLUSIONS

We conclude that resection of colorectal lung metastases is safe and effective, that resectable extrapulmonary disease does not contra-indicate pulmonary resection and that repeat thoracotomy is warranted in selected patients with recurrent lung metastases.

Preoperative carcinoembryonic antigen level as a prognostic indicator in resected primary lung cancer

The aim of this study was to evaluate the prognostic significance of elevated preoperative carcinoembryonic antigen (CEA) levels in cases of resected primary lung cancer. Between 1985 and 1989, 152 patients with tumors and CEA levels above 10 ng/mL underwent operation. One hundred twenty-five of them underwent resection of their tumors and the other 27 underwent exploratory thoracotomy only. Fifty-two percent of cancers were adenocarcinomas and 33% were epidermoid. Forty-two resected tumors were classified as stage I, 29 as stage II, 45 as stage IIIa, 7 as stage IIIb, and 2 as stage IV. The 3-year actuarial survival rate was 54% for patients with stage I tumors, 28% for those with stage II, 18% for those with stage IIIa, 44% for those with stage IIIb, and 0% for those with stage IV tumors. The 5 year actuarial survival was 40% for those with stage I tumors, 28% for those with stage II, 7% for those with stage IIIa, and 0% for those with stage IIIb tumors. Preoperative CEA levels increased from stage I to stage IIIa (p < 0.05). However, based on preoperative CEA levels we were not able to predict resectability, because levels were not significantly different between stage IIIa and exploratory thoracotomy-only groups. Adenocarcinoma was not significantly associated with higher CEA levels than was epidermoid, except in stage IIIa disease (p < 0.05). We found a critical unfavorable level of prognostic significance at 30 ng/mL.(ABSTRACT TRUNCATED AT 250 WORDS)

Utility of C-reactive protein measurements for empyema diagnosis after pneumonectomy

Serum C-reactive protein (CRP) levels were studied serially during the postoperative period in 151 consecutive patients who underwent pneumonectomy. Virtually all patients who had a simple postoperative course (115 of 120), as well as 9 patients who had a bronchial infection of the remaining lung, 3 with a pulmonary embolus, and 2 who suffered postoperative bleeding requiring reoperation, demonstrated a similar postoperative evolution in their CRP values: a rapid postoperative rise until a peak or a plateau (mean peak value, 132 +/- 25 mg/L) was reached within 3 to 6 days, followed by a progressive decline to a value of less than 75 mg/L on day 9, and less than 50 mg/L on day 12. Conversely, all 12 patients who suffered empyema postoperatively, as well as 3 patients with bacterial pneumonia, 1 patient with chylothorax, and 1 patient with inflammatory pericarditis, demonstrated either a markedly persistent elevation in their CRP values or a secondary rise in the levels which exceeded 100 mg/L. Because of the high sensitivity (100%) and specificity (91.4%) of the CRP levels in detecting postpneumonectomy empyema, we recommend the routine use of this measure. Furthermore, a low CRP value after pneumonectomy (less than 50 mg/L) may help in deciding whether to confidently discharge a patient from the hospital in the absence of empyema. The negative predictive value of this method was found to be 100%.

Lung resection after high doses of mediastinal radiotherapy (sixty grays or more). Reinforcement of bronchial healing with thoracic muscle flaps in nine cases

Mediastinal radiotherapy of more than 60 Gy highly compromises bronchial and wound healing after lung resection. Nine patients with primary lung cancers underwent radical resection after high radiation doses. Eight patients had primary lung cancer previously treated by radiotherapy alone (n = 2) or associated with chemotherapy (n = 6). One patient had a tracheal cancer involving the carina that was previously treated by radiotherapy. Seven patients underwent pneumonectomy and one patient underwent lobectomy with reinforcement of bronchial stump closure with use of the serratus anterior muscle. One patient underwent a sleeve lobectomy with bronchial reconstruction wrapped with an intercostal pedicle flap. Five patients had no postoperative complications and four patients had empyema, one associated with a small bronchial fistula. All except one patient were successfully treated by thoracostomy and immediate or secondary transposition of the pectoralis major muscle and the omentum to fill the cavity. These results show that lung resections can be done after high doses of radiotherapy without a high rate of bronchial fistula by using thoracic muscle flaps to reinforce bronchial stumps and anastomoses. In this procedure, surgical dissection is more time-consuming and increases the postoperative empyema rate (4/9). However, the higher long-term survival may justify this choice in selected cases.

Continuous intercostal analgesia with 0.5% bupivacaine after thoracotomy: a randomized study

This study was undertaken to evaluate the effectiveness of 0.5% bupivacaine (360 mg/day) as a continuous infusion through an indwelling intercostal catheter inserted intraoperatively in the management of pain after thoracotomy. Eighty-six patients were randomized into three groups: group 1 = intercostal bupivacaine, group 2 = intercostal saline solution, and group 3 = fixed-schedule intramuscular buprenorphine. Supplementary buprenorphine was given as required. Pain and pulmonary function were assessed throughout the first 5 days after operation. Pain score was lower in group 1 than in group 2 for the first 8 hours after operation (p < 0.02). During the first 3 postoperative days, mean postoperative pain scores of 5 or more were recorded in 9% of group 1 patients versus 40% of group 2 patients (p < 0.05) and 13% of group 3 patients (not significant). Total doses of buprenorphine were lower in groups 1 and 2 than in group 3 (p < 0.001). No between-group differences in pulmonary function were observed. Respiratory complications occurred in no patients in groups 1 and 3 versus 5 in group 2 (p < 0.05). Continuous intercostal bupivacaine provided similar early pain control as compared with fixed-schedule narcotics but induced better analgesia with fewer complications than on-demand narcotics alone (group 2).

Primary mediastinal germ cell tumors. Results of a French retrospective study

Eighty-seven patients with primary mediastinal germ cell tumors treated between 1983 and 1990 were studied. Among the 23 patients classified as pure seminoma, eight (35 percent) underwent surgery followed by radiotherapy (n = 6), radiotherapy and/or chemotherapy (n = 2); two patients underwent radiotherapy; 13 patients (57 percent) underwent induction cisplatin-based chemotherapy (ten complete responses) followed by radiotherapy (n = 9), second line chemotherapy (n = 2) and surgical resection of residual tumor (n = 2). On completion of treatment, 22 patients (96 percent) with seminoma were free of disease. The two-year Kaplan-Meier survival rate of these patients was 86 percent. Among the 64 patients with nonseminomatous germ cell tumor, 19 patients (30 percent) underwent surgery as first treatment (ten complete resections) followed by chemotherapy (n = 17) and radiotherapy (n = 5). On completion of treatment, 12 of 19 patients were disease free. Forty-five patients (70 percent) underwent induction cisplatin-based chemotherapy (ten complete responses), and 22 of them underwent resection of residual tumor (19 complete resections). Twenty-three patients were treated with first line chemotherapy without postchemotherapy surgery (three complete responses). In summary, 33 patients (52 percent) with nonseminomatous germ cell tumors became free of disease, and seven patients (21 percent) relapsed after achieving a complete response. The two-year Kaplan-Meier survival rate of the nonseminomatous germ cell tumor patients was 53 percent (87 percent if a complete response), with a median survival of 28 months. Despite a worse prognosis than nonseminomaous tumors from other primary sites, this series of mediastinal germ cell tumors has confirmed the efficacy of therapy.

Congenital respiratory-esophageal fistula in the adult. Report of nine cases and review of the literature

Congenital tracheoesophageal or bronchoesophageal fistulas, if not associated with esophageal atresia, may not appear initially until adult life. Nine such cases (two tracheoesophageal and seven bronchoesophageal) are reported. The chief presenting symptoms were recurrent bouts of coughing, after drinking, and hemoptysis. In the majority of cases the duration of symptoms exceeded 15 years. The diagnosis was confirmed in seven patients by esophagography, in one patient by bronchoscopy, and in one patient the fistula was discovered incidentally during thoracotomy. The esophageal opening of the fistula was in the lower third in seven patients and in the middle third in two. Bronchoesophageal fistulas communicated with a segmental bronchus in four patients and with a main or lobar bronchus in three. Treatment involved excision of the fistula (five patients) or division and suturing (four patients). Postoperative follow-up revealed no long-term sequelae except persistent chronic respiratory failure in one patient. The respiratory failure had developed before treatment of the fistula. The analysis of this series and a review of the literature underline the high index of suspicion required in all cases of chronic cough and lung suppuration, to diagnose this benign condition before life-threatening complications occur.

Primary lung cancer in young patients: a study of 82 surgically treated patients

The aim of this study was to evaluate the prognosis for surgically treated young patients with primary lung cancer, a prognosis generally considered to be very poor. Eighty-two patients less than 40 years of age were operated on at Marie-Lannelongue Hospital between 1982 and 1990. There were 72 male and 10 female patients. Ten patients (12%) had never smoked, whereas 48 patients (59%) had smoked for more than 20 pack-years. The lung cancer was asymptomatic in 27 patients (33%) and symptomatic in the others. Adenocarcinoma was found in 42% of the patients, epidermoid carcinoma in 28%, mixed cell carcinoma in 16%, small cell carcinoma in 8.5%, and undifferentiated large cell carcinoma in 6%. Among the 69 resected tumors, 22 were stage I, ten were stage II, 32 were stage IIIa, and five were stage IIIb. The resection was considered complete and curative in 56 patients (68%) and noncurative in 26 (32%) either because of an incomplete resection (12 in stage IIIa; 1 in stage IIIb) or because of an exploratory thoracotomy only (13). The overall actuarial 5-year survival rate was 41%, and the actuarial 5-year survival for patients who had a complete resection was 56%. The actuarial 5-year survival rates were as follows: patients in stage I, 70%; stage II, 54%; stage IIIa, 28%; stage IIIb, 0%; and patients having exploratory thoracotomy only, 18%. These survival rates are similar to those of patients older than 40 years with similar stages of disease.(ABSTRACT TRUNCATED AT 250 WORDS)

[Pulmonary and bronchial kinetics of cefuroxime after a single 500 mg intramuscular injection]

Thirty-two patients (28 males; mean age 56 +/- 10 years) who were undergoing bronchopulmonary exeresis surgery were included in this study of the pulmonary (pulm), bronchial (br), and plasma (pl) kinetics of cefuroxime after a single 500 mg intramuscular injection. Twenty-nine bronchial specimens and 38 pulmonary and plasma specimens were taken on average at the following times after the cefuroxime injection: 1 h, 2 h, 3 h, 4 h, 6 h, 8 h, and 10 h. Cefuroxime was assayed using HPLC on ground tissues, with a correction for contamination by blood. Peak concentrations (C) were found after one hour (Cpl = 11.6 +/- 0.8 micrograms/ml; Cpulm = 7.3 +/- 3.3 micrograms/g; Cbr = 3.7 +/- 1.5 micrograms/g) with the following residual values after 8 hours: Cpl = 0.94 +/- 1.04 micrograms/ml, Cpulm = 0.49 +/- 0.45 micrograms/g, Cbr = 0.15 +/- 0.07 micrograms/g (means +/- 1 SD). Elimination kinetics were monoexponential and similar in plasma, lung tissue and bronchial tissue (elimination half-lives: 1.74 h, 1.66 h, and 1.56 h, respectively), suggesting that all three elements belong to the same pharmacokinetic compartment. Mean intrapolated area-under-the-curve values (AUC) were 33.58 micrograms.ml-1.h (plasma), 20.08 micrograms.g-1.h (lung), and 10.22 micrograms/g-1.h (bronchus). The AUCpulm/AUCpl and AUCbr/AUCpl ratios were 0.60 and 0.30, respectively, in agreement with mean values of tissue level/simultaneous plasma level ratios (lung: 0.59; bronchus: 0.33).

Cancer surgery on a single residual lung

A series of nine patients with single lungs operated on for lung cancer is reported. This represents 10% of all the synchronous and metachronous lung cancers operated during the same period. There were three early postoperative deaths and a further three patients died subsequently at 15, 20 and 24 months, respectively, after operation; the remaining three are alive 6, 12 and 29 months, respectively, following their surgery. The analysis of the results of this small series indicates that wedge and segmental resection, when feasible, may be undertaken in patients with a single lung with reasonable life expectancy. The fact that lobectomy is not tolerated in such patients emphasizes the importance of early diagnosis when minimal local excision can be undertaken.

[Surgery of primary bronchial cancer. Different types of excisions: technical problems, follow-up results--status of pneumonectomies extended to the carina and bronchial resection-anastomoses]

Surgery is the best solution for primary lung cancer. Surgery must be very large when necessary and must be as limited as possible when pulmonary function is poor. Surgery obtains the best results in primary lung cancer but must be associated with adjuvant therapy when necessary and specially in N2 tumors. In our experience in Marie Lannelongue Center we operated 5890 primary lung cancers between 1966 and 1987 (2255 lobectomies and 2240 pneumonectomies). Our long-term results are 38% at three years and 31% at five years. Extended surgery has been done in many patients. Chest wall resection is used when necessary associated to the lung resection. Carina resection must be used also if necessary. In our experience of 46 pneumonectomies with carina resection the five-year survival is 20% and 41% only for the N1 tumors. When there is involvement of the mediastinal ipsilateral nodes we try to do surgery as often as possible (mediastinoscopy is used very routinely now). On 284 N2 primary lung tumors operated between 1982 and 1988 the five-year actuarial survival is 18%. When the pulmonary function is poor we perform lung lobectomies with sleeve resection (114 sleeve resections on the 2255 lobectomies). The postoperative morbidity and mortality is very low in our experience, and the five-year survival is very good (about 40%).

[Epithelioid hemangioendothelioma of the azygos vein]

The authors report a case of epithelioid hemangioendothelioma of the azygos vein diagnosed during the investigation of a superior vena cava syndrome. Venography and thoracic CT and nuclear magnetic resonance scans showed an endovenous tumour with spinal and lymph node invasion. Cavographic-controlled biopsies allowed histological identification of the tumour. Palliative therapy consisted in tumour ablation and superior vena cava bypass. Epithelioid hemangioendothelioma is a rare vascular tumour characterised by the presence of epithelioid endothelial cells. It is slowly progressive and its potential malignancy justifies surgical excision whenever possible.

[Antibiotic and antiseptic prophylaxis in thoracic surgery. Controlled study]

The aim of this report was to evaluate perioperative antibiotherapy and antiseptic irrigation of the operative site in the prevention of post-pneumonectomy empyema. From 1984 to 1986, 171 patients undergoing pneumonectomy at our institution for bronchogenic carcinoma were randomly selected in 2 groups: group I (85 patients) received a "classical" prophylaxis: irrigation of the operative site with saline, plus a 7-day antibiotherapy (minocycline 200 mg/24 h) started the evening following surgery; group II (86 patients): irrigation of the operative site was performed with Povidone iodine (dilution 5%); antibiotherapy (cefotiam was given for a short period (2 g intraoperatively, 2 g 12 hours and 24 hours following surgery). We used a "pragmatic" approach in order to choose, whatever the results would be, a type of perioperative antibiotherapy. We thus accepted the choice, without the help of statistical tests, of the therapy that would best prevent infection, and, if both regimens would demonstrate the same efficacy, to leave the choice at random. The only statistical test was to calculate the "gamma-risk" that we choose the worst among the 2 regimens. Although no significant difference in the overall infection rate was observed between the 2 groups, there were 9 empyemas (5 of those with bronchial fistula) in group I and 3 empyemas (2 of those with bronchial fistula) in group II. The cefotiam-povidone iodine regimen is thus better than the minocycline-saline regimen in the prevention of post-pneumonectomy empyema (3.5% v.s. 10.5%). The "gamma-risk", ie the probability that the minocycline-saline regimen is the best, calculated from these percentages, is 0.03.