Dehiscences of the bronchial joining after pneumonectomy for cancers: Incidence, gravity and risk factor

Objectives To assess the incidence, severity and risk factors of bronchial fistula following pneumonectomy for cancer. Patients and methods From 1989 to 2003, 690 consecutive patients underwent a pneumonectomy for thoracic cancer in Sercive of Thoracic Surgery of the Teaching Hospital of Sainte Marguerite in Marseilles (France). The M/F sex ratio was 5,44 . Mean age was 59+/-9,9 years [16 - 81]. Clinical and surgical variables were studied retrospectively, and their possible association with the occurrence of a bronchial fistula was assessed by univariate and multivariate analysis. Results Fifty one patients (7,7%) experienced a bronchial fistula. This complication accounted for 56% (45/80) of the cases of reoperation and 25,5% (13/51) of early deaths. At univariate analysis, the following factors were identified as statistically significant: tobacco consumption (p<0,003), presence of COPD (p =0,02), preoperative radiotherapy (p=0,03), previous thoracic surgery (p=0,03), right side of the resection (p<0,001), hand-fashioned bronchial suture (p=0,05) and squamous cell histology (p= 0,04). Multivariate logistic regression analysis disclosed tobacco consumption (p=0,002), presence of COPD (p=0,01), previous thoracic surgery (p=0,03), extended procedures (p=0,05), right pneumonectomy (p<0,001) and squamous cell histology (p=0,02) as independent predictors of bronchial fistula. Conclusion The occurrence of a bronchial fistula following pneumonectomy is a frequent life threatening event, especially in cases of right sided resections and extended procedures. Tobacco cessation, preoperative rehabilitation, and reinforcement of the bronchial suture are possible means of prevention.

Video-assisted thoracoscopic management of recurrent primary spontaneous pneumothorax after prior talc pleurodesis: a feasible, safe and efficient treatment option

OBJECTIVE

To assess the role of video-assisted thoracoscopic surgery (VATS) in the management of a recurrent primary spontaneous pneumothorax after a prior talc pleurodesis.

METHODS

From 1996 to 2002, we retrospectively reviewed all patients who were treated for a recurrent primary spontaneous pneumothorax after a previous talc pleurodesis. Data on the talc procedure and the recurrent pneumothorax, delay between both, and operative features were studied. Conversion rate to a thoracotomy and postoperative complications as well as long-term outcome were reported.

RESULTS

We collected 39 patients (28 male) with a median age of 25 years (15-41 years). The initial procedure consisted of thoracoscopic talc poudrage in all cases. The median delay between the talc procedure and the recurrence was 23 months [10 days-13 years]. Size of recurrence involved 10-80% of the hemithorax. The VATS procedure was successfully achieved in 27 patients (69%) while 12 required conversion to a thoracotomy. The main cause for conversion was the presence of dense pleural adhesion at the mediastinal part of the pleural cavity. Postoperative morbidity was limited to pleural complications in the VATS group (n=6, 22%). Median follow-up was 26 months [10-38 months]. One patient treated by VATS developed a partial recurrent pneumothorax at 12 months with a favorable outcome without further surgery.

CONCLUSIONS

Feasibility, safety and efficacy of VATS for management of recurrent primary spontaneous pneumothorax following thoracoscopic talc poudrage are strongly suggested.

[Prognostic indicators in stage I non-small cell lung cancer]

INTRODUCTION

Determinating the prognosis of patients with stage I non-small cell lung cancer (NSCLC) is a challenge. Since up to 30% of patients who have undergone surgical resection experience recurrence, generally in distant organs, it is reasonable to postulate that neo-adjuvant or adjuvant treatments might be useful. Better knowledge of prognostic factors could perhaps define which patient populations should be targeted with such treatments.

STATE OF THE ART

Numerous potential prognostic factors, relating to the disease (TNM classification, histology, tumor size, blood vessels invasion, micro-metastasis, serum or molecular markers), the patient (gender, age, co-morbidity) as well as the treatment (delay, resection, lymph node dissection, neo-adjuvant and adjuvant treatments), are discussed.

PERSPECTIVES

These prognostic factors should be integrated into the design of future clinical trials of chemotherapy and/or radiotherapy attempting to evaluate the effectiveness of various combinations of neo-adjuvant or adjuvant therapies.

CONCLUSIONS

These factors may offer the opportunity to clinically and biologically characterize the different subgroups of patients, leading to a more rational, and perhaps individualized, choice of therapy.

Large cell neuroendocrine carcinoma of the lung: an aggressive disease potentially treatable with surgery

BACKGROUND

Assessment of clinical and pathologic features of large cell neuroendocrine carcinoma to confirm its specificity in the setting of high grade neuroendocrine pulmonary tumors.

METHODS

From 1989 to 2001, 123 patients with a neuroendocrine carcinoma were surgically treated in a curative intent at a single institution. According to the 1999 World Health Organization classification, 20 patients were reviewed as having a large cell neuroendocrine carcinoma. Clinical data as well as detailed pathologic analysis and survival were collected.

RESULTS

There were 18 men and 2 women. The median age was 62 years. Four patients had a preoperative diagnosis of large cell neuroendocrine carcinoma. The resections consisted of 14 lobectomies and 6 pneumonectomies. There was no operative death. Complications occurred in 7 patients (35%). Four patients had a stage I of the disease, 4 had stage II, 9 had stage III, and 3 had stage IV. At follow-up (median, 46 months), 13 patients died from general recurrence and 7 patients were still alive. Median time to progression was 9 months (range, 1 to 54 months). The 5-year survival rate was 36% (median, 49 months) and it seemed to be negatively influenced by the disease stage (54% for stage I-II vs 25% for stage III-IV; p = 0.07), the presence of metastatic lymph node (45% for N0/N1 vs 17% for N2; p = 0.12), or vessel invasion (66 vs 25%; p = 0.18).

CONCLUSIONS

Large cell neuroendocrine carcinoma predominantly occurred in men. An accurate tissue diagnosis was rarely obtained preoperatively. Although overall survival after resection was substantial, large cell neuroendocrine carcinoma frequently showed pathologic features of occult metastatic disease, such as lymph node or vessel invasion, or both.

[Surgery for malignant pleural mesothelioma]

Malignant pleural mesothelioma (MPM) is an aggressive cancer of the pleura that is usually caused by exposure to asbestos. The incidence of MPM has risen for some decades and is expected to peak between 2010 and 2020. Current surgical treatment involves in a multimodality regimen with radiation and multiple-drug chemotherapy. All currently proposed therapeutic strategies are in total agreement with the international Mesothelioma Interest Group TNM staging system. Schematically: for stage Ia (early stage disease), the therapeutic approach is generally neo-adjuvant intrapleural treatment using cytikines followed by surgical pleurectomy; for more advanced disease (stage Ib, II and III), a multimodal treatment combining extra-pleural pneumonectomy, radiotherapy and multiple-drug chemotherapy, including in all cases cisplatin, is proposed. Recently, results using this multiple modality approach have been favorable especially for patients with epithelial histology, negative resection margins and no metastases to extrapleural lymph nodes; for stage IV (unresectable tumor), palliative treatment is indicated. Early results have been encouraging and the use of recent drugs should allow more optimal treatment.

Completion pneumonectomy in cancer patients: experience with 55 cases

OBJECTIVE

Analysis of a single institution experience with completion pneumonectomy.

METHODS

From 1989 to 2002, 55 consecutive cancer patients received completion pneumonectomy (mean age 62 years; 25-79). Indications were bronchogenic carcinoma in 38 patients (4 first cancers, 8 recurrent cancers, 26 second cancers), lung metastases in three (one each from breast cancer, colorectal neoplasm and lung cancer), lung sarcoma in one, and miscellaneous non-malignant conditions in 13 patients having been surgically treated for a non-small cell lung cancer previously (bronchopleural fistula in 4, radionecrosis in 3, aspergilloma in 2, pachypleura in 1, massive hemoptysis in 1 and pneumonia in 2). Before completion pneumonectomy, 50 patients had had a lobectomy, three a bilobectomy, and two lesser resections. The mean interval between the two procedures was 51 months for the whole group (1-469), 60 months for lung cancer (12-469), 43 months for pulmonary metastases (21-59) and 29 months for non-malignant disorders (1-126).

RESULTS

There were 35 right (64%) and 20 left (36%) resections. The surgical approaches were a posterolateral thoracotomy in 50 cases (91%) and a lateral thoracotomy in five cases (9%). Intrapericardial route was used in 49 patients (89%). Five patients had an extended resection (2 chest wall, 1 diaphragm, 1 subclavian artery and 1 superior vena cava). Operative mortality was 16.4% (n=9): 11.9% for malignant disease (n=5) and 30.8% for benign disease (n=4) Operative mortality was 20% for right completion pneumonectomies (n=7) and 10% for left-sided procedures (n=2) Twenty-three patients (42%) experienced non-fatal major complications. Actuarial 3- and 5-year survival rates from the time of completion pneumonectomy were 48.4 and 35.2% for the entire group. Three- and five-year survival for patients with bronchogenic carcinoma were 56.9 and 43.4%, respectively.

CONCLUSIONS

These results suggest that completion pneumonectomy in the setting of lung malignancies can be done with an operative risk similar to the one reported for standard pneumonectomy. In contrast, in cancer patients, completion pneumonectomy for inflammatory disorders is a very high-risk procedure.

Somatostatine dans le traitement d’un chylothorax secondaire à une œsophagectomie

Chylothorax is a rare but serious complication after oesophagectomy procedure. We report the case of a 59-year-old man who underwent an oesophagectomy by Akiyama procedure. A persistent postoperative chylothorax occurred requiring drainage and conservative management. After one week, the failure of this management motivated the institution of continuous infusion of somatostatin. This led to a rapid cessation of chyle production without side effect and to the discharge of the patient from the intensive care unit.

Survival and postoperative complication in daily practice after neoadjuvant therapy in resectable stage IIIA-N2 non-small cell lung cancer

Regarding persisting controversies about neoadjuvant treatment (NT), we studied the impact of neoadjuvant therapy in daily practice. Patients with stage IIIA-N2 non-small cell lung cancer (NSCLC) resected after NT were eligible. Data on preoperative treatments, surgical procedure, postoperative complications and survival were collected. Overall, 71 (60 men, median age of 60 years) patients met inclusion criteria. All patients received a two-drug platinum-based regimen (median of 2.5 cycles [2-4 cycles]) and 15 (21%) had an associated radiotherapy (20-40 Gy). Nine complete and 27 partial responses were achieved. Surgical procedure principally was a lobectomy (44%), a left (15.5%) or a right (27%) pneumonectomy. Operative mortality was 4.2% while 21 patients (29%) experienced postoperative complications. Median survival was 17 months (95% CI, 13-21 months) with 3- and 5-year survival rates of 24 and 13%, respectively. Five-year survival was worse if postoperative complication occurred (18 versus 0%, p=0.09). Multivariate analysis showed male gender (RR=0.37, 95% CI, 0.16-0.81, p=0.013) and postoperative positive lymph node (RR=2.7, 95% CI, 1.4-5.2, p=0.002) to influence survival. In conclusion, achievement of a clinical and pathological response after NT for stage IIIA-N2 NSCLC patients enables a better survival. More efficient but also less toxic regimens of chemotherapy should be developed regarding its impact on long-term survival.

[Surgery for oesophageal cancer: current controversies]

Any attempt to define the present role of surgery in the treatment of oesophageal cancer should integrate the dramatic changes that occurred within this disease over the last 2 decades: major shift in the histologic type of tumours, improved staging methods, spectacular reduction of operative risks, standardization of oncologic principles focusing on the completeness of resection, and development of multimodality therapeutic strategies. Surgery has still a pivotal role. Esophagectomy should be performed by trained surgeons in high-volume institutions. Radical surgery with en-bloc resection and 2 fields lymphadenectomy, should be encouraged in low-risk patients with subcarinal tumors. Although multimodality treatment strategy is commonly applied for locally advanced disease, few data support its superiority over surgical resection alone, followed by adjuvant therapy when appropriate. One may thus hypothesize that the risk/benefit ratio of such strategies is probably optimal in case of early stage tumors, and future studies may further clarify this issue. Conversely, locally advanced tumors, particularly those located in the upper mediastinum and the neck, may be managed alternatively without surgery. However, surgery remains an important tool to ensure optimal palliation of dysphagia, to achieve local control, and finally to improve quality of life. In that way, video-assisted techniques and/or trans hiatal approaches aiming to minimize the surgical insult may have a place in the treatment of patients who have substantially responded to induction therapy. Tumors located close to the pharyngo-oesophageal junction are best managed with chemotherapy and radiotherapy. Finally, salvage surgery may be considered in highly selected patients in case of non-response or local relapse without distant metastases.

Bronchioloalveolar carcinoma: myths and realities in the surgical management

Bronchioloalveolar carcinoma (BAC) of the lung is a subtype of adenocarcinoma with pure bronchoalveolar growth pattern and no evidence of stromal, vascular or pleural invasion (1999 WHO criteria), that seems to increase in incidence actually. BAC has its proper clinical spectrum, occurring more frequently in women and in younger patients. BAC also seems to be less dependent on tobacco exposure. Furthermore, original feature of this type of lung cancer is its intrapulmonary spreading and being infrequently systemic. Thus, surgical resection appears to have a pivotal role. This review of the literature attempted to assess whether or not patients with BAC should be treated according to the same oncological principles as those recommended for other non-small cell lung cancers, i.e. performance of anatomical resection combined with lymphadenectomy, and development of multimodality therapeutic strategies. Unilateral multinodular or pneumonic forms are best removed by lobectomy, or pneumonectomy when appropriate, combined with lymphadenectomy. Segmentectomy or wedge resection is a valuable option for the treatment of solitary lung nodules with pure pathological BAC patterns, provided specific conditions based upon computed tomography scan findings are present. The place of multimodality strategies is still unexplored. Treatment of bilateral BAC is challenging. Incomplete resection may be performed to palliate a severe intrapulmonary shunting. However, one hope of cure is provided by lung transplantation, even though disappointing results with disease recurrence on the grafts have been reported. The lack of large studies including only pure BAC gives a place for future biological and clinical research on this cancer.

Transdiaphragmatic hernia 1 year after heart transplantation following implantable LVAD

Complications after ventricular assist devices placement most frequently consist of bleeding, infection, and thromboembolic events. We describe a late complication after transplantation caused by transdiaphragmatic connection of the device placed in the abdominal position that presented as an acute pulmonary syndrome, misleading initial diagnosis.

Upregulation of chemokines in bronchoalveolar lavage fluid as a predictive marker of post-transplant airway obliteration

BACKGROUND

The early stage of post-transplant obliterative bronchiolitis (OB) is characterized by an influx of inflammatory cells to the lung, among which neutrophils may play a role in key events. The potential for chemokines to induce leukocyte accumulation in the alveolar space was investigated. We assessed whether changes in the chemotactic expression profile could be used as sensitive markers of the onset of OB.

METHODS

Serial bronchoalveolar lavage (BAL) fluids from 13 stable healthy recipients and 8 patients who developed bronchiolitis obliterans syndrome (BOS) were analyzed longitudinally for concentrations of interleukin-8 (IL-8), chemokines regulated-upon-activation and normal T-cell expressed and secreted (RANTES) and monocyte chemoattractant protein-1 (MCP-1), soluble intracellular adhesion molecule-1 (sICAM-1) and vascular cell adhesion molecule-1 (VCAM-1). These were assessed by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Significantly elevated percentages of BAL neutrophils and IL-8 levels were found at the pre-clinical stage of BOS, on average 151 +/- 164 days and 307 +/- 266 days, respectively, before diagnosis of BOS. There was also early upregulation of RANTES and MCP-1 in the BOS group (mean 253 +/- 323 and 152 +/- 80 days, respectively, before diagnosis of BOS). The level of MCP-1 was consistently higher than that of RANTES until airway obliteration. BAL sICAM-1 and sVCAM-1 levels were not statistically different between the groups.

CONCLUSIONS

These data support the belief that RANTES, IL-8 and MCP-1 play a crucial role in the pathogenesis of OB. The results show that relevant increased levels of such chemokines may predict BOS, and suggest that there is potential for some of these markers to be used as early and sensitive markers of the onset of BOS. Longitudinal monitoring of these chemokine signals may contribute to better management of patients at risk for developing OB, at a stage when remodeling can either be reversed or altered.

VATS is an adequate oncological operation for stage I non-small cell lung cancer

OBJECTIVES

This study was designed to determine the long-term prognosis of video-assisted thoracic surgery (VATS) vs. open lung resections for patients with pathological stage I non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

The medical records of all patients who underwent lung resection for a pathological stage I NSCLC were reviewed for the period from 1990 to 1999, by screening of a database into which data were entered prospectively. There were 511 patients (430 males and 81 females) whose age averaged 63+/-10 years who underwent 515 lung resections. Our VATS experience began in 1993 with selected stage I patients, and since that date an average of one patient on four was managed with VATS. Lung resections consisted of 25 wedge resections or segmentectomies (seven VATS), 390 lobectomies (92 VATS), 19 bilobectomies (one VATS) and 81 pneumonectomies (ten VATS). Lymph node dissection was performed in all cases.

RESULTS

There were significantly more females (P=0.01) and adenocarcinoma (P=0.02) in the VATS group (n=110) when compared to the open group (n=405). Tumour size averaged 4+/-2 cm in the open group and 3+/-2 cm in the VATS group (P=0.04). The distribution of T1/T2 tumours was 97/308 and 50/60, respectively (P=0.0001). At follow-up, cancer recurrence could be documented in 117 patients, with no difference of incidence between the two groups (22.5 vs. 24.5%; P=0.64). Estimated Kaplan-Meier 5-year survival rates, including the operative mortality as well as any cancer-related and unrelated death, were 62.8% (confidence interval (CI): 56.8-68.7%) vs. 62.9% (CI: 51.4-74.4%), respectively (P=0.60). The advent of VATS did not influence the patients' survival: 5-year survival rate was 63.9% (CI: 55.3-72.5%) for the period from 1990 to 1992, and 58.8% (CI: 51.7-65.9%) for the period from 1993 to 1999 (P=0.65). Subgroups survival analysis according to the T status did not show any statistically significant difference between the two groups.

CONCLUSIONS

VATS lung resection with lymph node dissection achieved a 5-year survival similar to that achieved by the conventional approach. VATS is a valuable option for the management of selected patients with an early-stage NSCLC.

Management of superior sulcus tumors: experience with 139 cases treated by surgical resection

BACKGROUND

The management of non-small cell carcinomas of the lung involving the superior sulcus remains controversial. The goal of this retrospective study was to evaluate the role of surgery, radiotherapy, and chemotherapy for the treatment of superior sulcus tumors, to define the best surgical approach for radical resection, and to identify factors influencing long-term survival.

METHODS

Between 1983 and 1999, 139 patients underwent surgical resection of superior sulcus tumors in seven thoracic surgery centers. According to the classification of the American Joint Committee, 51.1% of cancers were stage IIB, 13.7% stage IIIA, 32.4% stage IIIB, and 2.9% stage IV.

RESULTS

The resections were performed with 74.1% using the posterior approach and 25.9% using an anterior approach. A lobectomy was accomplished in 69.8% of the cases and a wedge resection in 22.3%. Resection of a segment of vertebrae or subclavian artery was performed, respectively, in 19.4% and 18% of the cases. Resection was complete in 81.3% of cancers. The overall 5-year survival rate was 35%. Preoperative radiotherapy improved 5-year survival for stages IIB-IIIA. Surgical approach, postoperative radiotherapy, or chemotherapy did not change survival.

CONCLUSIONS

The optimal treatment for superior sulcus tumors is complete surgical resection. The surgical approach (anterior/posterior) did not influence the 5-year survival rate. Preoperative radiotherapy should be recommended to improve outcome of patients with a superior sulcus tumor.

Stage I non-small cell lung cancer: a pragmatic approach to prognosis after complete resection

BACKGROUND

Long-term results of the surgical treatment of stage I non-small cell lung cancer (NSCLC) are disappointing.

METHODS

Univariate and multivariate analyses were conducted on 515 consecutive lung resections for stage I NSCLC performed from 1990 to 1999 and identified by reviewing a database into which data were entered prospectively. Tumors were staged as stages IA (n = 147) and IB (n = 348) according to the 1997 UICC (Union Internationale Contre le Cancer) pTNM classification.

RESULTS

Operative mortality rates were 6.2%, 5.3%, 2.3%, and 0% for pneumonectomy, bilobectomy, lobectomy, and lesser resections, respectively. Overall survival rate was 61.1% (55.8% to 66.5%) at 5 years. Univariate analysis identified three significant adverse prognosticators: arteriosclerosis as comorbidity, pathologic T2 status, and blood vessel invasion. Male sex (p = 0.056) and performance of pneumonectomy (p = 0.057) were at the threshold of statistical significance. At multivariate analysis, three independent prognosticators entered the model: arteriosclerosis, blood vessels invasion, and performance of pneumonectomy.

CONCLUSIONS

Long-term survival of patients with completely resected stage I NSCLC was adversely influenced in a relatively balanced way by factors related to the clinical status of the patient, to the tumor, and to the treatment.

[Surgery of bronchial cancer after radiochemotherapy or chemotherapy. Risks and benefits]

The purpose of this study was to evaluate the conditions and results of lung cancer surgery, following chemo and/or radiotherapy. This retrospective study included 69 patients treated from January 1990 to January 1998 for a primary lung cancer in whom surgery had been performed after induction treatment. Surgery had not been considered initially for the following reasons: N2 disease (n = 25), temporary functional impairment (n = 4); doubtful resectability (n = 40). The medical regimen resulted in combined radio-chemotherapy in 43 patients who received 2 to 4 sessions of chemotherapy (average = 2.9 +/- 0.8 sessions) and 43 +/- 8 Gy (20 to 60 Gy), or chemotherapy alone in 26 patients (3 +/- 0.7 sessions). Exploratory thoracotomy was performed in 4 patients (6%). There were 33 pneumonectomies, 1 bilobectomy, 23 lobectomies and 8 lung sparing resections. The in-hospital mortality was 9% (n = 6) from respiratory origin in all cases. There were 4 reoperations (6%): 3 for bronchial fistula and 1 for bleeding. Thirty five patients (51%) required blood transfusion (4.5 +/- 3.8 cell packs). The incidence of early and delayed bronchial fistula after pneumonectomy was 15%. Thirteen patients had a postoperative pneumonia (19%). The overall 5 years survival was 22% [19-32]. In the group of patients who had a complete resection, five-years survival for patients classified pathologically as N0 or N1 was 31% and, for those classified as N2, 8% (p = 0.19). Surgical management after induction chemo and/or radiotherapy of NSC lung cancer should be considered, in the absence of N2 disease, when a complete resection is achievable. However this surgery is associated with an increased risk.

Clinical utility of bronchoalveolar lavage cell phenotype analyses in the postoperative monitoring of lung transplant recipients

OBJECTIVE

Bronchoalveolar lavage (BAL) fluid provides a crucial tool for investigation of the cellular component of the deep lung spaces and hence to approach the alloreactive response following lung transplantation. This study investigated whether BAL cell profiles can assist for the diagnosis of certain postoperative complications.

METHODS

We conducted a retrospective analysis of both transbronchial biopsy and bronchoalveolar lavage materials in a series of 26 consecutive lung transplant recipients (LTR) in relationship with their clinical status at the time of the procedure. BAL fluid was subjected to cell morphology as well as flow cytometric phenotypic analyses. The samples were labeled as follows: normal transplant in clinically stable and healthy recipients, n=58; acute rejection (AR), n=58; infection (INF), n=31; and obliterative bronchiolitis/bronchiolitis obliterans syndrome (OB/BOS) n=27.

RESULTS

Total BAL cell counts were the highest in INF. Lymphocytic alveolitis was suggestive of both acute allograft rejection and CMV viral infection, with a combined significant increased HLA-DR positive cells in AR. Alveolar neutrophilia with an increased CD4/CD8 ratio was correlated with the diagnosis of OB. The neutrophil percentages, HLA-DR and CD57 positive cells were significantly higher when an infection was present.

CONCLUSION

These findings suggest that BAL cell analysis could give complementary information of histological data and further insight into immunologic events after lung allograft. A longitudinal surveillance of BAL cell profiles in an individual patient may be suggestive for a preclinical state of posttransplant acute rejection, bacterial infection and obliterative bronchiolitis.

Bilateral bronchioloalveolar lung carcinoma: is there a place for palliative pneumonectomy?

OBJECTIVE

Bronchioloalveolar lung carcinoma (BAC) is characterized by bronchial and lymphatic dissemination explaining multifocal and bilateral spreading. Bilateral BAC is usually considered as a contraindication to surgery. Regarding poor efficacy of symptomatic and oncological treatments, we hypothesized that surgery might play a role to palliate hypoxemia associated with serious intrapulmonary shunting, as well as continuous bronchorrhea.

METHODS

We retrospectively studied here four consecutive patients, who underwent palliative pneumonectomy.

RESULTS

The shunt was confirmed again at the time of the surgery by a pulmonary artery occlusion demonstrating immediate improvement in arterial oxygen saturation from 89% at baseline to 98% after occlusion. Lung resections consisted of a left pneumonectomy in three cases and a right pneumonectomy in one. PaO(2) levels under 5l/min oxygen therapy improved dramatically when comparing preoperative data (mean 50.5 mmHg) to post-operative results (mean 150 mmHg). One patient died postoperatively. Three patients, who experienced an uneventful immediate post-operative course, received chemotherapy after surgery. Improvement of quality of life is testified by the absence of both symptoms and any need for oxygen therapy for few months. Disabling symptoms reappeared at 1, 8 and 10 months. Survival of these patients was 3, 12 and 18 months.

CONCLUSIONS

These results support the interest of consideration of a surgical resection for highly selected patients presenting with bilateral BAC and severe intrapulmonary shunting.

Exsanguinating hemoptysis revealing the absence of left pulmonary artery in an adult

Isolated absence of a pulmonary artery is an exceptional cause of massive hemoptysis. We report a 35-year-old woman with agenesis of the left pulmonary artery who presented with exsanguinating hemoptysis that prompted angiography with the aim to embolize the bleeding vessels selectively. The procedure could not be completed because of the presence of an anterior spinal artery branching from the aberrant systemic-to-pulmonary circulation. The patient successfully underwent an emergent pneumonectomy.

Is lung cancer surgery justified in patients with direct mediastinal invasion?

OBJECTIVE

To assess the results of the surgical treatment of patients with stage IIIB non-small cell lung carcinoma (NSCLC) invading the mediastinum (T4).

METHODS

Twenty-nine patients were operated on from 1986 to 1999. Histology was squamous cell carcinoma in 17 patients, adenocarcinoma in eight, large cell carcinoma in two and neuroendocrinal carcinoma in two. Three patients received a preoperative chemotherapy (n = 2) or radiochemotherapy (n = 1). The lung resection consisted of a pneumonectomy in 25 patients and a lobectomy in four. The procedure was extended to one of the following structures: superior vena cava (SVC) (n = 17), aorta (n = 1), left atrium (n = 5) and carina (n = 6). Seventeen patients had a postoperative regimen including radiochemotherapy (n = 12), radiotherapy (n = 4), or chemotherapy (n = 1).

RESULTS

Complete R0 resection was achieved in 25 patients, whereas four patients had a microscopically (n = 1) or macroscopically (n = 3) residual disease. The operative mortality rate was 7% (n = 2). Non-fatal major complications occurred in eight patients (28%). Overall 5-year survival rate was 28% (median 11 months), including the operative mortality. The median survival of the 18 patients with an N0 or N1 disease was 16 months whereas the median survival of the 11 patients with an N2 disease was 9 months. At completion of the study, 22 patients have died, two postoperatively and 10 from pulmonary causes without evidence of cancer.

CONCLUSIONS

Surgical management of T4 NSC lung cancer invading the mediastinum should be considered, in the absence of N2 disease, when a complete resection is achievable.

Postoperative complications in relation with induction therapy for lung cancer

OBJECTIVES

The purpose of this study was to evaluate the risk of lung cancer surgery following induction chemotherapy and/or radiotherapy.

METHODS

This retrospective study included 69 patients treated from January 1990 to January 1998 for a primary lung cancer in whom surgery had been performed after induction treatment. Surgery had not been considered initially for the following reasons: N2 disease (IIIA, n = 25); temporary functional impairment (two stages IB and two stages IIIA (N2), n = 4); and doubtful resectability (stage IIIB (T4), n = 40). The medical regimen resulted in combined radio-chemotherapy in 43 patients who received two to four cycles of chemotherapy (average 2.9 +/- 0.8 cycles) and 43 +/- 8 Gy (range 20--60 Gy), or chemotherapy alone in 26 patients (3 +/- 0.7 cycles).

RESULTS

Exploratory thoracotomy was performed in four patients (6%). The in-hospital mortality was 9% (n = 6) from respiratory origin in all cases. There were four re-operations (6%): three for bronchial fistula and one for bleeding. Thirty-five patients (51%) required blood transfusion (4.5 +/- 3.8 cell packs). The incidence of early and delayed bronchial fistula after pneumonectomy was 15%. Thirteen patients had a postoperative pneumonia (19%).

CONCLUSIONS

Surgery for lung cancer after induction chemotherapy and/or radiotherapy is associated with an increased risk. If the mortality seems 'acceptable', the morbidity rate, however, is high.

Surgical management of non-small cell lung cancer with synchronous brain metastases

OBJECTIVES

Published series on the synchronous combined resection of brain metastases and primary non-small cell lung cancer are small and scarce. We therefore undertook a multicenter retrospective study to determine long-term survival and identify potential prognostic factors.

DESIGN

Our series includes 103 patients who were operated on between 1985 and 1998 for the following tumors: adenocarcinomas (74); squamous cell carcinomas (20); and large cell carcinomas (9). Three patients had two brain metastases, and one patient had three metastases; the remaining patients had a single metastasis. Ninety-three patients presented with neurologic signs that regressed completely after resection in 60 patients and partially, in 26 patients. Neurosurgical resection was incomplete in six patients. Seventy-five patients received postoperative brain radiotherapy. The time interval between the brain operation and the lung resection was < 4 months. Pulmonary resection was incomplete in eight patients.

RESULTS

The survival calculated from the date of the first operation was 56% at 1 year, 28% at 2 years, and 11% at 5 years. Univariate analysis showed a better prognosis for adenocarcinomas (p = 0.019) and a trend toward a better prognosis for patients with small pulmonary tumors (T1 vs T3, p = 0.068), N0 stage disease (N0 vs N+, p = 0.069), and complete pulmonary resection (p = 0.057). In a multivariate analysis, adenocarcinoma histology also affected the survival rate (p = 0.03).

CONCLUSIONS

It seems legitimate to proceed with lung resection after complete resection of a single brain metastasis, at least in patients with an adenocarcinoma and a small lung tumor and without abnormal mediastinal lymph nodes seen on the CT scan or during mediastinoscopy.