[A case of diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) syndrome]

INTRODUCTION

DIPNECH is a strictly histological entity according to the WHO 2015 classification and is considered to be at pre-neoplastic risk. It has been proposed that DIPNECH syndrome should be used to describe patients have clinical symptoms, an obstructive ventilatory disorder and compatible radiological abnormalities. The diagnosis is histological and usually based on a surgical lung biopsy.

CASE REPORT

We report the case of a 58-year-old woman with a chronic cough for over 20years who had an obstructive airway pattern on spirometry. Diagnoses of asthma and COPD had been discussed. After 7years of follow-up, the DIPNECH hypothesis was evoked on the scanning aspect of mosaic attenuation, expiratory trapping and micronodules, which was subsequently confirmed by surgical pulmonary biopsy.

CONCLUSION

It is necessary to consider the possibility of this rare disease in order to avoid inappropriate treatments and in the hope that future therapeutic advances (somatostatin analogs, mTOR inhibitors) improve patients' experience and the progression of respiratory function.

[Assessment of muscular toxicity due to chemotherapy by cardio-pulmonary exercise testing]

INTRODUCTION

Cardio-pulmonary exercise testing (CPET) is frequently used to assess aerobic capacity, to evaluate respiratory tolerance and to provide prognostic information. Therefore, CPET is often incorporated in the preoperative assessment of cancer patients. This clinical case report presents the preoperative assessment of a patient before thoracic surgery, in whom an important decrease of aerobic capacity was noted, possibly because of muscular toxicity linked to chemotherapy.

CASE REPORT

This clinical case concerns a fit, 66-year-old man with a large cell carcinoma of the bronchus. He had received 2 cycles of adjuvant chemotherapy. Subsequently, a left pneumonectomy had been proposed and preoperative assessment performed. CPET showed no further increase in oxygen uptake after the first ventilatory threshold, in spite of increases in carbon dioxide output, minute ventilation and heart rate. Moreover, maximal oxygen uptake was low and there was a decrease of oxygen pulse at maximal effort.

CONCLUSION

We suggest that the limitation of effort was due to a limitation of muscular oxygen extraction, which could be explained by possible muscular toxicity due to chemotherapy.

[Evolution of species: Lung cancer evolution over one third of a century]

INTRODUCTION

Management of non-small cell lung cancer (NSCLC) is getting better and results on long-term survival have improved. We reviewed the modifications observed in surgery over a 32-year time period.

PATIENTS AND METHOD

Data of 6105 patients who underwent surgery from 1979 to 2010 were analyzed over three equal time-periods: gender, age, type of surgery, histology, pTNM, tobacco addiction, comorbidity and time periods.

RESULTS

Age, number of females and high-risk patients with comorbidity (including the history of a previous cancer) increased with time periods. Number of exploratory thoracotomy (7.7 % to 1.6 %) and pneumonectomy (48 % to 18 %) decreased. Number of wedge resection (0.5 % to 6 %) and lobectomy (42 % to 64 %) increased. Rates of the other types of resection were unchanged. Neoadjuvant treatments accounted for more than 20 % of patients in the last time period. Postoperative mortality (4 %) did not vary but non-lethal complication rates increased (16.9 % to 27.7 %). Global 5-year survival rates dramatically increased with time going from 37.4 % to 49.8 % (P<10(-6)). Survival improvement was observed in the different components of the pTNM and whatever the type of treatment. However, survival was affected by increasing age and multiplication of comorbidities but without impairing the general better outcome trend.

CONCLUSION

NSCLC itself, its diagnostic and therapeutic management, and patient's characteristics evolved with time. Survival improved in most studied prognosis factors. Time period factor was of paramount importance and might be included in research dealing with NSCLC.

[Lung cancer measuring 1cm or less: A miniature subset requiring surgery]

INTRODUCTION

Lung cancer measuring 1cm or less has an apparently very good outcome. However, the characteristics permitting their oncological management are unappreciated.

PATIENT AND METHOD

We reviewed 187 patients with such a cancer (145 men and 42 women, mean age 60.2years) and studied the type of surgery performed, the pTNM, and the histological features.

RESULTS

Surgery (19 wedge-resections, 12 segmentectomies, 136 lobectomies, 20 pneumonectomies) was complete (R0) in 97.3%. The tumors, each precisely defined among 98 adenocarcinomas (52.4%), 83 squamous cell carcinomas (44.4%), and 6 others, measured 1mm to 10mm:<5mm (n=41), 6 to 9mm (n=43), and 10mm (n=103). There were 161 pT1 (86.1%), 22 pT2 (11.8%) and 4 pT3; 148 pN0 (79.6%), 18 pN1 (9.7%) and 20 pN2 (10.7%). pN1 and pN2 were present in tumors<5mm (12/41, 29.3%) as well as in the others (26/146, 17.8% P=0.11). Histological examination frequently discovered visceral pleura involvement (tumors:<5mm 12.2% (5/41), 6 to 9mm 7% (3/43), 10mm 13.6% (14/103), P=0.53) and lympho-vascular invasion (12.9%). Five-year survival rate (66.4%) was adversely influenced by age, type of resection, pN and histological features. The survival rate was not better in tumor<5mm.

CONCLUSION

Surgical resection allows the local control of lung cancers<1cm and their complete histological study, a key issue in the therapy of the future, which renders surgery an absolute must even in very small tumors.

[Clinical and paraclinical prognostic factors in non-small cell lung cancer surgery]

INTRODUCTION

Lung cancer prognosis is mainly based on the TNM, histology and molecular biology. Our aim was to analyze the prognostic value of certain clinical and paraclinical variables.

PATIENTS AND METHODS

We studied among 6105 patients operated on, divided during 3 time-periods (1979 to 2010), the following prognostic factors: type of surgery, pTNM, histology, age, sex, smoking history, clinical presentation, and paraclinical variables.

RESULTS

Postoperative mortality was 4% (243/6105), rate of complications was 23.3% (1424/6105). The 5-year overall survival was 43.2% and 10-year was 27%. Best survival was observed after complete resection (R0) (P<10(-6)), lobectomy (P<10(-6)), lymph node dissection (P=0.0006), early pTNM stages (P<10(-6)), absence of a solid component in adenocarcinoma. Other pejorative factors were: male gender (P=10(-5)), age (P=0.0000002), comorbidity (P=0.016), history of cancer (P<10(-5)), postoperative complications (P=0.0018), FEV lower than 80% (P=0.0000025), time-periods (P<10(-6)). All these factors were confirmed by multivariate analysis, except gender. Smoking was not poor prognostic factor in univariate analysis (P=0.09) but became significant in the multivariate one (P=0.013).

CONCLUSION

Medical and human factors, and the general physiological state, play an important role in prognosis after surgery. We do not know their exact meaning and, like studies on chemotherapy, they justify special research.

[Place of limited resections and prognostic factors in non-small lung cancer]

INTRODUCTION

Results of surgery for non-small-cell lung cancer (NSCLC) are poorer after limited resection, wedge and segmentectomy, than after lobectomy. Guidelines recommend avoiding wedge-resection, which new techniques (radiofrequency ablation and cyberknife) tend to replace. This work aimed to study the wedge-resection carcinological value.

PATIENTS AND METHODS

NSCLC without previous other cancer history and neoadjuvant therapy measuring less than 31 millimetres and operated from 1980 to 2009 were reviewed. Analyzed variables were: location, gender, age, FEVS, type of resection, histology, pT and pN.

RESULTS

There were 66 wedge-resections (10.9%), 32 segmentectomies (5.3%), 507 lobectomies (83.8%), nine postoperative deaths (1.5%), 136 complications (22.5%), 557 complete resections (R0=92%); 72.2% of NSCLC upper lobe location (437/605). Age was more advanced in wedge-resection and segmentectomy, FEVS lower and NSCLC most often a squamous cell pN0 and pStage I carcinoma than in lobectomy. Lymphadenectomy was not performed in half the wedge-resections. Five-year survival rates were poorer after wedge-resection: 50% versus segmentectomy 59.8% (P=0.09), and lobectomy 66% (P=0.0035), but the number of recurrences was similar. Multivariate analysis demonstrated that age, FEVS, type of surgery and lymphadenectomy, pN in pTNM were the only prognosis factors.

CONCLUSION

Wedge-resection is less carcinological than segmentectomy when the patient-status and NSCLC location allow performing the latter, but more than the new techniques, because of its pathological yield, when the patient-status and nodule peripheral location allow wedging.

[Lung cancer surgery and cirrhosis]

INTRODUCTION

Lung cancer is the leading cause of death by cancer and cirrhosis is the fourteenth, all causes included. Surgery increases postoperative risks in cirrhotic patients. Our purpose was to analyze this point in lung cancer surgery.

METHODS

We collected, among 7162 patients, the data concerning those operated for lung cancer (n=6105) and compared patients with hepatic disease (n=448) to those presenting other medical disorder (n=2587). We analyzed cirrhotic patients' characteristics (n=49).

RESULTS

Five-year survival of patients with hepatic disease was lower (n=5657/6105): 35.3% versus 43.8% for patients with no hepatic disease, P=0.0021. Survival of cirrhotic patients was not statistically different from the one of patients with other hepatic disorder, but none survived beyond 10 years (0% versus 26.4%). Surgery in cirrhotic patients consisted in one explorative thoracotomy, three wedges resections, two segmentectomies, 33 lobectomies and 10 pneumonectomies. Postoperative mortality (8.2%; 4/49) was not different for patients without hepatic disease (4.2%; 239/5657) (P=0.32), as well as the rate of complications (40.8%; 20/49 and 24.8%; 1404/5657, P=0.11). Only one postoperative death was associated to a hepatic failure. Multivariate analysis pointed age, histological subtype of the tumour and stage of disease as independent prognosis factors.

CONCLUSION

When cirrhosis is well compensated, surgical resection of lung cancer can be performed with acceptable postoperative morbidity and satisfactory rates of survival. Progressive potential of this disease is worse after five years.

[Mucoepidermoid tracheo-bronchial tumors in adulthood. A series of 22 cases]

INTRODUCTION

Mucoepidermoid tumours (TME) are rare tumours arising from the submucosal glands of the tracheobronchial tree. The majority of these tumours develop in a benign fashion but some of them are malignant. The latter can be easily mistaken for adenosquamous carcinomas.

PATIENTS AND METHOD

We have reviewed 22 patients suffering from TME observed over a period of 25 years. Two arose from the trachea and 20 from the cartilaginous bronchi; 12 of these tumours had macroscopic and histological criteria of low-grade malignancy, 4 had macroscopic and 6 macroscopic and microscopic criteria of high grade malignancy.

RESULTS

Prognosis of the latter was very poor and no survival observed after 6 years follow-up, a behavior similar to that observed in non-small cell lung carcinomas and adenosquamous carcinomas.

CONCLUSION

The best treatment of these orphan tumours remains surgery.

[Lung cancer surgery in a single-lung]

INTRODUCTION

The diagnosis of a second lung cancer in a patient with a previous medical history of lung cancer is no longer a rarity. Also, it is possible to observe a new location in a patient who underwent pneumonectomy in the past. Surgery remains the best treatment. Our objective was to overview this subject.

PATIENTS AND METHODS

Among 5611 patients operated in our institution, 186 (3.3%) had metachronous cancer and 17 had previous pneumonectomy (0.7% of pneumonectomies and 0.2% of NSCLC treated in our department). The procedure was diagnostic and therapeutic in 88% of cases (n=15).

RESULTS

There were 16 males and 1 female, mean age was 62.5-years. All were smokers (11 were former smokers) and 6 had other medical history. Mean FEV was 52% (range 35-95%). Types of resection were 2 lobectomies, 4 segmentectomies, and 11 wedge resections. There were no postoperative deaths, but two complications. Histological subtype of the first and second cancer was the same in 11 patients. All patients were pN0 after second surgery. The long-term survival (median 33 months) was 35.3% at 5-years and 14.1% at 10-years. Two patients treated with pneumonectomy for their first cancer were pN2. Patients who underwent upper right lobectomy for treatment of their second cancer survived longer than 5-years.

CONCLUSION

Surgical resection for lung cancer on single-lung is associated with acceptable morbidity and mortality. Prolonged survival can be achieved in selected patients.

[Place and role of the pleura in non-small cell lung cancer dissemination]

INTRODUCTION

The pleural involvement (PLI) in non-small cell lung cancer (NSCLC) has a poor prognosis, even though it might be very heterogeneous.

PATIENTS AND METHODS

A multicentric retrospective descriptive study was performed over 2329 patients who were operated for NSCLC between 1979 and 2010. The patients with PLI were classified in P(Parietal)PLI and V(visceral)PLI and then each subdivided : VPLI to peripheric (VPLI-P) and fissural (VPLI-F) and PPLI to mediastinal (PPLI-M) and costal (PPLI-C). Characteristics and survival were compared between the subgroups as well as with patients without PLI (WPLI, n=1439).

RESULTS

The sex-ratio was 2.8 (males: n=1713). The PLI patients were significantly younger, with a less sex-ratio, less R0 resections (96% versus 98.7%, P=0.000076), and less N0 (60% vs 70%, P<10(-6)) as their 5-year survival (45.7% vs 55.5%, P<10(-6)). The PLI was related to the size of NSCLC (P<10(-6)) and N2 involvement (P=0.0020). It was less frequent after neoadjuvant treatment (36.2% vs 39.1% P=0.03). In the VPLI-F or PPLI-M, pneumonectomies were more frequent (P<10(-6)). In VPLI-P (n=196/561), there were more pN1 and pN2 (P=0.0065) with a 5-year survival of 42.9% vs 54.4%, P=0.013. In multivariate analysis, the PLI was not an independent prognostic factor contrary to age, sex, type of resection, pT and pN.

CONCLUSION

The pleura play a major role in NSCLC dissemination. Its involvement affects pN, the type of surgical resection and justifies the use of neoadjuvant treatment.

[Place of bilobectomy in pulmonary oncology and prognostic factors in NSCLC]

INTRODUCTION

Bilobectomy may be performed for different reasons and lung tumors. There are still controversies regarding the results of this procedure. We reviewed our experience of bilobectomy to evaluate the particularities of this resection.

METHODS

The clinical files of patients operated on for lung tumors in two French centers between 1980 and 2009 were prospectively recorded and retrospectively analyzed. The characteristics, management, pathology, and survival after right-sided resections for non-small cell lung cancer (NSCLC) were then compared.

RESULTS

During the study period, 3280 right-sided resections were performed, including 235 bilobectomy (7%), for NSCLC in 192 cases (82%). Lower-middle lobectomy (LML) represented 60% of bilobectomy, with carcinoid tumors and squamous cell carcinoma being more frequent in this group. Upper-middle lobectomy (UML) represented 40% of bilobectomy, with less postoperative complications and mortality in this group. In N0-NSCLC, the rate of postoperative mortality and 5-year survival rates after bilobectomy (4.7% and 46.1%, respectively) were intermediate between lobectomy (2.7% and 52.6%) and pneumonectomy (9.6% and 31.7%, P<10(-6) for both comparisons). There was no significant difference in 5-year survival rates according to the type of bilobectomy and the performance of any induction therapy.

CONCLUSION

Bilobectomy is associated with acceptable in-hospital mortality and encouraging 5-year survival rates despite an increased incidence of postoperative complications. Approximation in survival of UML and pneumonectomy and of LML and lobectomy may be due to differences in histologic features with different fissure extension and interlobar node involvement.

[Major pulmonary resections for lung cancer and thoracoscopic approach: some reflections on published data]

Video-assisted thoracic surgery has a renewed topicality in treating early stage non-small cell lung cancer. Numerous publications show the benefits of this surgical technique in comparison with conventional thoracotomy. However, some surgeons are still apprehensive for its validity in lung cancer. Few works were dedicated to the critical aspect of this new technique which generates silent controversy and is far from having the general approval of all surgical teams. A critical review of several papers disclosed some concerns related to this approach, notably the risk of intra-operative technical problems and the possibility of questionable results concerning cancer dissection and clearance. A randomized clinical trial is now mandatory to confirm the safety and usefulness of this technique.

[pT4 non-small cell lung cancer: Surgical characteristics in present practice]

INTRODUCTION

pT4 is a group of miscellaneous tumors: our goal was to revisit their surgical reality.

METHODS

The different characteristics and prognostic factors of lung pT4 (n=403) were analysed according to three subgroups: G1 - by direct extension; G2 - by nodule in other ipsilateral lobe; G3 - because of both.

RESULTS

There were 332 males and 71 females mean aged 61.5 years. Surgery [exploratory: 89 (22.1 %), lobectomy: 149 (37 %), pneumonectomy: 169 (41.9 %)] was followed by 26 postoperative deaths (6.5 %), 82 complications (20.3 %) and concerned few pN0 (47.6 %). G1 (n=196) and G3 (n=53) were not different. By comparison with them, G2 (n=53) were mainly females (24\13 %), with less explorative thoracotomy (2.6\34 %), more complete R0 resections (77\29 %), less pneumonectomy (31\47 %), more small sized tumors (mean: 37\57 mm), more adenocarcinoma (67\32 %), more N0 tumors (48\31.7 %) and stages IIIA disease (46.7\56 %). G2 5-year survival rates were higher (G2: 22 %; G1: 13 %; G3: 15 %); G1 rates depended of the invaded structure (20.9 % for the vertebra down to 0 % for the esophagus and carina). pN2 rates were not very high but not different between groups (G1: 13.6 %; G2: 15.6 %; G3: 14.3 %; P=0.52). Multivariate analysis demonstrated completeness and type of resection, stage and age as independent factors of prognosis.

CONCLUSION

Surgery for pT4 is justified provided rigorous selection of extension forms. However, assimilating extension and ipsilateral lobe nodule in a same group does not obey to surgical reality.

[Impact of induction therapies on pathology and outcome after surgical resection of non-small lung cancer: a 30-year experience of 859 patients]

The management of localized non-small cell lung cancer (NSCLC) has been modified over the last decades, with induction therapies being increasingly recommended as a prerequisite to surgical resection. However, the relative impact of chemo- and chemoradiotherapy on tumours' pathology and patients' survival is still discussed.

METHODS

We set a retrospective study including every patient who underwent surgical resection for NSCLC in 2 French centres from 1980 to 2009. We then compared the tumours' pathology and patients' survival according to the use of induction chemotherapy (group 1) or induction chemoradiotherapy (group 2).

RESULTS

There were 733 patients in group 1 and 126 patients in group 2. In group 1, 669 patients (91%) had platinum-based chemotherapy, for 2 to 3 cycles in 564 cases (77%). In group 2, chemoradiotheray was concomitant in 68 patients (54%), and sequential in 58 patients (46%). As compared with group 1, group 2 was characterized by younger age (mean 59.8±9.5 vs 56.4±9.6, respectively, P<.001), a higher rate of tumours deemed unresectable before induction treatment (25% vs 44%, P<.001), and a higher proportion of T4 (25% vs 44%, P<.001) or N2 diseases (56% vs 69%, P=.005). The type of resection, postoperative complications, and postoperative mortality were not significantly different between groups. On final pathologic report, as compared with group 1, there were more N0 and N1 disease in group 2 (N0: 43% vs 58%, P=.002; N1: 22% vs 10%, P=.002) while the rate of N2 disease was comparable (34% vs 32%, P=ns). The median, 5-, and 10-year survivals were 28 months, 35%, and 21% for group 1, and 29 months, 36%, and 23% for group 2, respectively (P=ns).

CONCLUSION

As compared with induction chemotherapy, induction chemoradiotherapy was performed in more advanced NSCLC, and resulted in better downstaging, similar postoperative course, and comparable long-term outcome after surgical resection.

[Lung cancer in women: surgical aspects related to gender]

INTRODUCTION

Lung cancer is becoming more and more common in women where it presents significant differences at both clinical and therapeutic levels. Our purpose was to study those associated with surgical treatment.

PATIENTS AND METHODS

2972 patients were operated on between 1984 and 2002: 2480 men and 492 women. These two populations were compared (age, past history, investigations, interventions, TNM stage, long term survival and causes of death).

RESULTS

The number of women increased with time; they were younger than the men, smoked less, had the same past history of cancer but less past medical history, and comorbidity. They underwent less pneumonectomies and had a lower postoperative mortality. Tumour size was smaller (39.5 vs 43.5cm, p=0.0001); N0 and stage I tumours were more frequent (52.6% vs 46% p=0.0074). Long term survival was better (48.6% vs 43.1%, p=0.016), particularly in stage I and with a past history of cancer. It was identical in stage III despite a higher incidence of multisite N2 disease. Smoking and adenocarcinoma were more frequent before the menopause and N2 prognosis deteriorated with age.

CONCLUSION

These results confirm characteristics peculiar to lung cancer in women and warrant further investigation aimed at their better understanding. However, in multivariate analysis gender does not appear to be an independent prognostic factor.

[Postoperative risk after induction treatment on surgery in non-small cell lung cancer]

Induction treatments in non-small cell lung cancer are usually discussed. Long-term survival after surgery and resecability are enhanced in locally advanced cancers. Morbidity and mortality observed after surgery limit the use of these treatments, despite they depend on many other factors: comorbidities in patient, smoking status, cancer staging, and type of surgery. Right pneumectomy enhances this risk more than left pneumectomy or other limited resections allowed by neoadjuvant treatments, especially in case of downstaging.

Pulmonary resection for Mycobacterium xenopi pulmonary infection

BACKGROUND

Results of medical therapy for Mycobacterium xenopi pulmonary infection remain unreliable. Pulmonary resection may be beneficial to patients whose disease is localized and who can tolerate a resectional operation.

METHODS

Eighteen patients underwent pulmonary resection between 1991 and 2000: 14 men and 4 women, with a mean age of 50 +/- 12 years (range 27 to 68 years). Indications for operation were either therapeutic (n = 9) or diagnostic (n = 9). Four patients received antimycobacterial chemotherapy before their operation and 2 patients were HIV positive.

RESULTS

Therapeutic procedures included completion pneumonectomy (n = 1), lobectomy (n = 6), segmentectomy (n = 1), and bilateral wedge resection (n = 1). Diagnostic procedures included lobectomy (n = 1) and wedge resection (n = 8). Complete resection could be achieved in 15 patients (83%). There was no in-hospital mortality. Postoperative complications included prolonged air leak (5 of 18 patients, 27.7%) and pleural effusion requiring insertion of a new chest tube (3 of 18 patients, 16.6%). Mean hospital stay was 14 +/- 8 days. Follow-up was 100% complete. Eleven patients received antimycobacterial chemotherapy for 4 to 24 months, postoperatively. Late mortality was 11% and was unrelated to progression of mycobacterial disease. After the operation, the sputum remained positive in only 2 patients (11%) with incomplete resections. Fourteen patients were asymptomatic with no relapse at a mean follow-up of 38 +/- 22 months (range 85 to 13 months).

CONCLUSIONS

Resection represents an important adjunct to chemotherapy for the treatment of M. xenopi pulmonary disease. In the setting of localized nodular or cavitary disease, failure to respond to medical therapy, relapse after treatment discontinuation, coexistent aspergilloma or polymicrobial contamination, or patient intolerance of medical therapy, pulmonary resection can be undertaken with acceptable morbidity and mortality.

Patterns of relapse of N2 nonsmall-cell lung carcinoma patients treated with preoperative chemotherapy: should prophylactic cranial irradiation be reconsidered?

BACKGROUND

Although it induces a relevant reduction in the risk of both visceral metastases and locoregional recurrences, the combination of chemotherapy and surgery only marginally improves the survival of patients with Stage IIIA(N2) (International Union Against Cancer staging and classification system) nonsmall-cell lung carcinoma (NSCLC). The purpose of the current study was to analyze the patterns of relapse in these patients.

METHODS

In this study, the authors compared the patterns of relapse in 81 patients with clinically detectable N2 NSCLC who had been treated with preoperative chemotherapy with the relapse patterns of 186 comparable patients who had been treated with primary surgery. Clinically detectable N2 (cN2) denotes mediastinal lymph node enlargement on computed tomography scan, which then is confirmed by mediastinoscopy.

RESULTS

Overall 20% of patients developed a locoregional recurrence. Chemotherapy decreased the risk of visceral metastasis as 28% of the patients preoperatively treated and 38%of those not treated with preoperative chemotherapy presented a visceral metastasis (P < 0.05). Preoperative chemotherapy and adenocarcinoma subtypes were associated with a higher rate of brain metastasis (P < 0.05). Thirty-two percent of the patients treated preoperatively and 18% of those not treated with preoperative chemotherapy presented a brain metastasis (P < 0.05), which was isolated in 22% and 11% of the patients, respectively (P < 0.05).

CONCLUSION

The current study found that preoperative chemotherapy for cN2 decreases the risk of visceral metastasis but is associated with a high rate of isolated brain metastases. Prophylactic cranial irradiation may need to be reinvestigated in clinical trials, especially in patients who present with an adenocarcinoma.

Visceral pleura invasion by non-small cell lung cancer: an underrated bad prognostic factor

BACKGROUND

Visceral pleura invasion (VPI) by non-small cell lung cancer is a factor of poor prognosis. A tumor of any size that invades the visceral pleura is classified as T2. Few studies have been conducted concerning the prognostic significance of VPI relative to other staging factors.

METHODS

Between April 1984 and December 1996, 1,281 patients with T1 (n = 430) and T2 (n = 851) non-small cell lung cancer underwent curative surgical resection. Adjuvant radiation therapy was performed in 455 patients. There were 176 women and 1,105 men aged 30 to 86 years (mean, 60.9 years). Five hundred nineteen pneumonectomies, 742 lobectomies, and 20 segmentectomies were performed. In all patients, a complete mediastinal lymph node dissection was performed. International staging was stage IA and B (n = 697); stage II A and B (n = 247), and stage III A (n = 337). The patients were divided into two groups according to the existence of VPI (group I without, group II with). Both groups were compared with regard to the size of the tumors, histology, associated lymph node involvement, survival rates, and cause of death. Univariate and multivariate analyses were conducted.

RESULTS

VPI (group II) was identified in 19.1% of the resected specimens: group I, n = 1036; group II, n = 245. The VPI was present in only 10% of non-small cell lung cancer 3 cm or less in size, reaching 33% of patients with non-small cell lung cancer larger than 5 cm (p = 0.0001). Squamous non-small cell lung cancer were significantly less accompanied by VPI (13.5%) than the other histologic categories. The VPI was associated with a higher frequency of N2 involvement (group I = 24.6%, group II = 33.4%, p = 0.01) and N2 involvement was more extensive (two or more N2 involved stations: group I = 8.2%, group II = 15.6%, p = 0.003). Actuarial survival rates were 51.8% at 5 years and 33.8% at 10 years in group I (median, 66 months), and 34.6% at 5 years and 27.9% at 10 years in group II (median, 30 months) (p = 0.000002). Long-term survival rates significantly decreased for larger tumors. Even in patients with N2 stage tumors, the difference of survival curves between the two groups was statistically significant. Cancer-related deaths were more frequent in group II and were mainly caused by distant metastases. By multivariate analysis, visceral pleura invasion proved to be a significant independent factor of poor prognosis.

CONCLUSIONS

The VPI is a factor of poor prognosis. Its frequent association with extensive N2 involvement supports the hypothesis that exfoliated tumor cells are drained through the pleural lymphatics by the mediastinal lymphatic pathways and then into the bloodstream. The VPI is an important prognostic factor and, as such should stimulate more studies to better select the patients who could benefit from adjuvant therapy.

[Non-small cell lung cancer: surgical trends as a function of age]

Most of the studies on lung cancer and age are usually done on very young or very old populations. We conducted a study of the evolution of surgical features over time in a population aged 24 to 89 years. The series included 1,809 men and 287 women (n = 2,096) who had undergone surgery between April 1984 and December 1990 (n = 1,026) and between January 1991 and December 1996 (n = 1,996). Patients were divided into 7 age groups with 2 subgroups for patients with or without prior medical history of cancer. We analyzed the type of surgery and pathology findings by age. Morbidity was recorded according to state of previous cardiovascular disease and long-term survival was analyzed. A significant increase in the number of female patients was noted during the last ten years. Adenocarcinomas were more frequent in young patients. Exploratory interventions, partial tumor resections and lung resections for metastasis were more frequently performed in young patients than in older patients. Excision of mediastinal nodes was less performed often in old patients. In case of curative resection, postoperative pTNM was not modified with age. Morbidity increased with age; mortality was more frequent in the elderly even when comorbidity was taken into account. Mortality was not related significantly with cardiovascular morbidity factors despite an increased frequency of previous cardiovascular disease with age. Survival according to age showed 3 main types of population: patients aged under 64 years, those between 65 and 74, and those over 75 years of age. Mortality increased with time but was less often related to recurrence of lung cancer. Nevertheless, survival for stage III and stage IV patients older than 75 years demonstrated that surgery was not indicated for these patients. This study shows that indications for surgery should not vary with age except for patients over 75 years who have locally advanced cancer and a risk of surgical death greater than the chances of survival. All non-small-cell lung cancers should be resected with no delay, even in the elderly population.

Survival of patients with resected N2 non-small-cell lung cancer: evidence for a subclassification and implications

PURPOSE

Patients who suffer from non-small-cell lung cancer (NSCLC) with ipsilateral mediastinal lymph node involvement (N2) belong to a heterogeneous subgroup of patients. We analyzed the prognosis of patients with resected N2 NSCLC to propose homogeneous patient subgroups.

PATIENTS AND METHODS

The present study comprised 702 consecutive patients from six French centers who underwent surgical resection of N2 NSCLC. Initially, two groups of patients were defined: patients with clinical N2 (cN2) and those with minimal N2 (mN2) disease were patients in whom N2 disease was and was not detected preoperatively at computed tomographic scan, respectively.

RESULTS

The median duration of follow-up was 52 months (range, 18 to 120 months). A multivariate analysis using Cox regression identified four negative prognostic factors, namely, cN2 status (P <. 0001), involvement of multiple lymph node levels (L2+; P <.0001), pT3 to T4 stage (P <.0001), and no preoperative chemotherapy (P <. 01). For patients treated with primary surgery, 5-year survival rates were as follows: mN2, one level involved (mN2L1, n = 244): 34%; mN2, multiple level involvement (mN2L2+, n = 78): 11%; cN2L1 (n = 118): 8%; and cN2L2+ (n = 122): 3%. When only patients with mN2L1 disease were considered, the site of lymph node involvement according to the American Thoracic Society numbering system had no prognostic significance (P =.14). Preoperative chemotherapy was associated with a better prognosis for those with cN2 (P <.0001). Five-year survival rates were 18% and 5% for cN2 patients treated with and without preoperative chemotherapy, respectively.

CONCLUSION

This study has identified homogeneous N2 NSCLC prognostic subgroups and suggests different therapeutic approaches according to the subgroup profile.

Thoracoscopic excision of mediastinal bronchogenic cysts: results in 20 cases

BACKGROUND

We present our experience with thoracoscopic resection of mediastinal bronchogenic cysts in adults.

METHODS

From November 1990 to September 1993, 20 patients with mediastinal bronchogenic cysts were operated on by thoracoscopy. The average cyst size was 4.9 cm, and the largest diameter was 10 cm. Ten cysts were located in the middle mediastinum and 10 in the posterior mediastinum. Two cysts were complicated.

RESULTS

Thirteen bronchogenic cysts were resected completely by thoracoscopy. We had to convert thoracoscopy into thoracotomy because of bleeding in two cases and because of major adhesions to vital structures in five cases. There were no operative deaths and no postoperative complications. Mean hospital stay was significantly less in the completely thoracoscopically treated group. Long-term follow-up (range, 4.5 to 7.5 years) showed no late complications and no recurrence.

CONCLUSIONS

Preoperative complications, intraoperative injuries, and major adhesions to vital structures seem to be the only unfavorable conditions to thoracoscopic treatment of bronchogenic cysts. This study found encouraging results for thoracoscopic excision of mediastinal bronchogenic cysts in selected patients.

[Primary pleural lymphoma after collapse therapy: modern aspects of an historic disease]

INTRODUCTION

Pleural lymphomas after long standing pyothorax due to pulmonary tuberculosis are now well identified. Most cases have been described by Japanese investigators and it seems rare or unrecognised in Western countries. We report the study of six cases observed in a single institution.

PATIENTS AND METHODS

Six pyothorax-associated pleural lymphomas, among 1,038 lymphoma (0.6%) collected during a period from 1989 to 1998, are described. Diagnosis was established by two pathologists with the usual histologic and immunohistochemical methods, according to the working formulation. The in situ hybridization method for Epstein-Barr virus was performed.

RESULTS

The average age of the patient was 73 years. Presenting symptoms combined chest pain and constitutional symptoms more than 45 years after artificial pneumothorax or tuberculous pleuritis. Computerized tomography revealed a pleural mass which involved the adjacent chest wall. Open biopsy by thoracotomy show a diffuse B-cell non-Hodgkin-lymphoma in all cases. Though the lymphoma was initially localized, many poor prognostic factors (age, performance status, LDH, histology) explain the pejorative evolution (average survival of five months). Patients died from an uncontrolled tumoral proliferation or by infectious complications. In situ hybridization confirms the presence of Epstein-Barr virus in tumoral cells.

CONCLUSION

Pleural lymphoma is an established complication of artificial pneumothorax. Even if the Epstein-Barr virus plays a crucial role in the pathogenesis, and despite the number of artificial pneumothorax operations that have been widely performed, this lymphoma remains rare, suggesting additional oncogenic factors.

Usefulness of video thoracoscopy in the management of spontaneous and postoperation chylothorax

BACKGROUND

The aim of this study was to evaluate indications and results of video thoracoscopy (VATS) in the management of nine chylothorax cases.

METHODS

Four spontaneous chylothorax cases were treated by VATS and talc pleurodesis with immediate positive results. Among five postoperation chylothorax cases, two were treated early by VATS and selective lymphatic clipping (VATS group), and three had medical treatment (MT group).

RESULTS

Duration of drainage was 4 days for the VATS group versus 15.3 days for MT group. Amount of collected chyle was 2.4 l versus 5.7 l, respectively.

CONCLUSIONS

We suggest that VATS should be considered the treatment of choice for spontaneous chylothorax and could be indicated earlier in postoperation chylothorax.

Prognostic significance of surgical-pathologic N1 disease in non-small cell carcinoma of the lung

BACKGROUND

N1 disease represents a heterogeneous group of non-small cell lung carcinoma with varying 5-year survival rates. Specific types of N1 lymph node involvement need to be further investigated and their prognostic significance clarified.

METHODS

From 1984 to 1993, 1,174 patients with non-small cell lung cancer had complete mediastinal lymph node dissection: N0, 50.25% (n = 590); N1, 21.8% (n = 256); and N2, 27.95% (n = 328). The N1 subgroup cases were reviewed. Four levels of N1 nodes were identified using the New Regional Lymph Node Classification for Lung Cancer Staging. Their prognostic significances were tested and 5-year survival rates were compared with those of N0 and N2 patients of the whole group.

RESULTS

The overall 5-year survival rate of N1 patients was 47.5%. Survival was not related to site of the primary lung cancer, pathologic T factor, histologic type, type of resection, number of N1 station involved, nor type of N1 involvement (direct extension or metastases). Five-year survival was significantly better when N1 involvement was intralobar (levels 12 and 13, n = 102), as compared with extralobar (hilar) involvement (levels 10 and 11, n = 154): 53.6% versus 38.5% (p = 0.02). Intralobar N1 5-year survival was similar to that of N0 (53.6% vs 56.5%, p = 0.01), and extralobar 5-year survival with that of N2 (38.5 vs 28.3%, p = 0.01) when N2 was present in only one station in the ipsilateral mediastinum.

CONCLUSIONS

N1 disease is a compound of two subgroups: one located inside the lobes is related to N0, and the other (extralobar or hilar) behaves like an early stage of N2 disease. This offers further information for clinical, therapeutic, and research purposes.

[Intrathoracic coelomic cysts]

Intrathoracic coelomic cysts are benign embryonic tumors with a mesothelial lining. The aim of this work was to review possible localizations (pleuropericardic and other), the remaining surgical indications, and the current situation of minimally invasive techniques. We reviewed retrospectively, 28 cases of intrathoracic coelomic cysts in 12 men and 16 women, mean age 44 years. We recorded the cyst localization, clinical signs, indication for surgery, access routes used, and outcome. Twenty-one cysts were pleuropericardial cysts and 7 were ectopic mediastinal cysts. In all 7 of the ectopic mediastinal cysts and 4 of the pleuropericardial cysts surgery was indicated for diagnosis; for the other pleuropericardial cysts the indication was based on clinical signs (n = 4), large volume (n = 4), progressing volume (n = 7), no apparent reason (n = 1) and association with surgery for pneumothorax (n = 1). Assess was by mediastinoscopy (n = 1), mediastinotomy (n = 1), sub-xyphoid route (n = 1), thoracotomy (n = 18), and videothoracoscopy (n = 7). Long-term outcomes (mean follow-up 4 years 4 months) were good with no recurrences. Postoperative sequelae were observed in 6 cases after thoracotomy and in 1 case after videothoracoscopy. In summary, pleuropericardial cysts warrant surveillance without surgery unless their volume increases or clinical signs develop. Ectopic mediastinal cysts usually require surgery for diagnosis. It would appear advisable to prefer videothoracoscopy which allows diagnosis and excision of pleuropericardial cysts. Minimal thoracotomy may be helpful for ectopic mediastinal cysts.

[Cystic lymphangioma of the neck and mediastinum: are there acquired forms? Report of 37 cases]

BACKGROUND

In 9 out of 10 cases, lymphangiomas are observed during the first years of life, generally located in the neck. Rare lymphangiomas have been reported in adults, usually in an intrathoracic localization, raising the hypothesis of an acquired origin.

PATIENTS AND METHODS

A retrospective analysis of patients undergoing surgery for lymphanioma of the neck or mediastinum was conducted. Pathology reports, clinical data and medical imaging (CT) were reviewed and operative and post-operative findings were analyzed in order to determine whether the cases could be divided into congenital and non-congenital forms.

RESULTS

Data were obtained on 37 patients (23 men and 14 women, mean age 45 years, range 8-77). Four lesions (11%) were located in the neck: 3 in children and one in an elderly subject (77 yrs). Thirty-three tumors (89%) were located in the mediastinum. In 5 cases, the tumor was located in the phrenic nodes of the anterior mediastinum. These lymphangiomas occurred in young adults, had a CT density less than liquid with enhancement after contrast injection, and had a malformative vascular component proven anatomically and histologically (hemolymphangioma). These elements favored a congenital orgin. In 28 cases (76.6%) the tumor involved nodes in the posterior or middle mediastinum. They occurred in older adults and were purely liquid with no vascular component. These lymphangiomas were undoubtedly acquired.

CONCLUSION

In children, adolescents and young adults, lymphagiomas are found in the neck or anterior mediastinum and have a tissular component. These tumors should be considered as congenital lymphangiomas. In older adults, lymphangiomas are found in the posterior or middle mediastinum and are purely liquid cysts suggesting an acquired origin.

[Video-guided surgical resection of solitary pulmonary nodules. Significance of thoraco-conversion in cancer cases. Apropos of 34 cases]

The use of video-guides surgery for major pulmonary resections in cancer patients raises a problem of safety and oncological quality. The aim of this prospective study was to demonstrate the oncological contribution of systematic thoracotomy in suspected stage I cancer patients. Between February 1993 and December 1996, we operated 34 consecutive patients with a solitary primary neoplastic lung nodule using normal fibroscopy and preoperative CT scan to detect mediastinal nodes. The nodules measured a mean 18.5 mm. Diagnosis was confirmed at peroperative pathology examination of the video-guided surgical resection, generally leading to thoracotomy for lobectomy-dissection. The final tumoral stage affirmed the initial diagnosis (stage I) in only 19 cases (56%). Peroperative findings showed that the other patients had more advance disease: 2 stage II (T1N1) (6%), 11 stage IIa (T1N2) (32%) and 2 stage IIIb (satellite nodule in the remaining lobe measuring 6 and 7 cm) (6%). These findings emphasize the importance of complete node dissection as well as the need to carefully palpate the entire lung. Thoracotomy remains the most reliable and reproducible method for safely fulfilling the oncological requirements.

Prognostic value of T and N in non small cell lung cancer three centimeters or less in diameter

OBJECTIVE

Peripheral tumors 3 cm or less in diameter are classified T1, T2 when rupturing the visceral pleura, T3 when invading parietal pleura, chest wall, mediastinal pleura or pericardium and T4 when invading vertebra or mediastinal structures. Our objective was to assess the prognostic significance of T and N status according to the size of such tumors.

PATIENTS AND METHODS

Patients (918) were operated upon between April 1984 and December 1991. Surgery included complete resection and mediastinal lymphadenectomy. Tumors 3 cm or less were studied concerning T, N status, histology and survival.

RESULTS

There were 314 such tumors (T1 = 215, T2 = 64, T3 = 35, T4 = 6); N status was N0 60.2%, N1 21%, N2 18.8%. Global 5-year survival was 52.59%. In case of N0, survival was 64.63%: T1 = 63.76%, T2 = 71.48%, T3 = 45.71%, T4 = 66.6%; which was not significant. There were 48 tumors 1.0 cm or less in diameter (G1), 111 tumors 1.1-2.0 cm in diameter (G2) and 155 tumors 2.1-3 cm in diameter (G3). The incidence of N0, N1 and N2 disease was 77.1, 10.4 and 12.5%, respectively in G1, 64, 18 and 18% in G2, and 52.3, 26.5 and 21.3% in G3. The 5-year survival rate was 62.46% for G1, 52.91% for G2 and 49.36% for G3 (NS). In cases of N1 and N2, survival was 48.41% and 20.2% which was significant (P < 0.05) but differences between each T and each G were not significant.

CONCLUSIONS

Small peripheral cancers spread into mediastinal nodes in 12.5-21.3% of cases, according to the size. This is a warning to perform nodes resections in cases where surgeons intend a videothoracoscopic approach. N2 status is not only an indicator but also a governor of prognosis. Neither T status nor size are determinants of prognosis as far as tumors 3 cm in diameter or less are concerned.

[Place of radical surgery in the treatment of non-small cell lung cancer. Apropos of 969 cases]

PURPOSE

Retrospective analysis of the results of radical surgery in a series of 969 patients presenting with non-small cell lung cancer.

PATIENTS AND METHODS

From April 1984 to December 1981, 969 patients underwent radical surgery with mediastinal node dissection for non-small cell lung cancer. Surgery included 507 pneumonectomies, 447 lobectomies and 15 segmentectomies (for patients suffering from respiratory failure).

RESULTS

The rate of intrahospital mortality was 4.3%. The rate of crude survival at 5-years was 45.8%. The tumor size (P = 0.004) and visceral pleura ruptures (P = 0.01) were significantly correlated to the 5-year survival rate that was reaching 56% for patients with no demonstrable metastasis to regional lymph nodes (NO), 46.6% for patients with metastasis to lymph nodes in the peribronchial or the ipsilateral hilar region (N1), and 20.8% for patients with metastasis to the ipsilateral mediastinal and subcarinal lymph nodes (N2) (P = 0.001). In case of stage N2 cancer, the 5-year survival rate was 28.7% when only one anatomical level was involved, and 8.7% when more than one anatomical level was involved (P < 0.0001).

CONCLUSION

The main prognostic factor was nodal involvement.

Complications of video-assisted thoracic surgery: a five-year experience

BACKGROUND

Although thoracoscopy was originally described in 1910, recent developments in video-assisted surgical techniques and endoscopic equipment has expanded the application of video-assisted surgical procedures in the field of thoracic surgery.

METHODS

In an effort to define both high-risk patients for video-assisted thoracic procedures and high-risk video-assisted thoracic surgical procedures, we reviewed the experience of four surgical institutions from June 1991 through May 1995. We looked specifically at complications resulting from the 937 video-assisted thoracic procedures performed during this period.

RESULTS

Perioperative incidents or complications occurred in 35 patients (3.7%), and 116 procedures (12.4%) were converted to a thoracotomy. The in-hospital mortality rate was 0.5%, and death occurred principally in patients operated on for malignant pleural effusion. The overall incidence of postoperative complications was 10.9%, and the most prevalent complications were prolonged air leak (6.7%) and pleural effusion (0.7%).

CONCLUSIONS

The incidence of complications was acceptable and, except for that of prolonged air leak, did not differ significantly from that resulting from analogous open procedures. Video-assisted thoracic surgery appears safe and particularly useful for some indications. However, the possibility of dramatic life-threatening perioperative complications requiring emergency conversion to thoracotomy justifies the fact that only trained thoracic surgeons should perform video-assisted thoracic surgical procedures.

[Incidents and complications of therapeutic thoracoscopy. Apropos of 898 operated patients]

The exceptional interest in endoscopic surgery, both in laparoscopic surgery and video-assisted thoracoscopic surgery have led many teams to widen their indications. This movement has developed into a revolution in techniques demanded by patients, the public, and the medias, requiring many practicians to use these techniques more and more often and consequently to attempt very delicate operations. This "explosion" of endoscopic techniques has largely benefited from advances in equipment development (optics, video instrumentation) but has also required that operators acquire rigorous procedures for the proposed techniques. With the development of new thoracoscopic techniques for therapeutic indications, there are an unavoidable number of incidents and complications. These incidents and complications are related both to the use of instruments undoubtedly not well enough adapted to the procedures used and also to "forced" indications. We humbly recognize that a certain number of incidents are related to the necessarily inadequate experience of the operators during the "run in" period. We emphasize that video-assisted thoracoscopic surgery is a complementary technique among the available therapeutic armamentarium. We evaluated the mid and long term results of cancerology exeresis with these two techniques and underscore that morbidity and complications are rare but sometimes unacceptable. In conclusion, whatever the form of the technique used, it is an important evolution in surgery which must abide by the classical rules, in particular for indications in cancer surgery.

[Prognostic factors of operated non-small-cell bronchogenic cancer: critical analysis of T.N.M]

A prospective study of prognosis factors for operated non-small-cell bronchogenic cancer was conducted to assess those proposed by the T.N.M. classification. From April 1984 to December 1993, 918 patients aged 32 to 83 years underwent surgery: 389 stage I; 367 stage II; 367 stage IIIa; and 25 stage IIIb. Macroscopic exeresis was satisfactory in all patients and node dissection of the mediastinum was performed. Post-operative mortality was 4%. Overall actuarial survival at 5 years was 43.9%, stage I 59.5%; stage II 53.8%; stage IIIa 25.1%; stage IIIb 29.3%. Tumor size, presence of visceral pleural invasion, and presence of local invasion (T3 and T4) worsened prognosis (concerning T). The prognosis value of N was the determining element: survival at 5 years, 56.3% for N0; 47.5% for N1 and 20% for N2. When metastases invaded two node chains in combinaison with T3, prognosis was poor. These cancers were stage IV.

Videothoracoscopic excision of thoracic neurogenic tumors

BACKGROUND

Videothoracoscopic surgery is a new procedure for treating neurogenic tumors of the thorax. Feasibility and utility of this technique are not yet well defined.

METHODS

Over a 26-month period, 26 neurogenic tumors of the thorax were treated in five general thoracic surgery centers performing videothoracoscopic surgery. Indications and contraindications for this new procedure and initial results were retrospectively studied.

RESULTS

Contraindications to videothoracoscopy included intraspinal extension of the tumor (n = 3), spinal artery involvement (n = 2), tumors more than 6 cm in diameter borderline located within the thorax (n = 2), and middle mediastinal location (n = 1). Videothoracoscopy was performed in 18 patients. Conversion to thoracotomy was required in 3. In 1 patients, subsequent chest wall resection was performed because of malignancy. Postoperative hospital stay was uneventful. It was shorter after videothoracoscopy. Postsurgical pain was more acute in patients who had thoracotomy or conversion to thoracotomy.

CONCLUSIONS

Videothorascopy is a good alternative for managing neurogenic tumors of the thorax when deemed feasible. There is a tendency toward a shorter hospital stay with less pain in patients treated by this new procedure.

Factors determining survival in resected N2 lung cancer

This retrospective study was based on 237 patients with non-small cell lung cancer (NSCLC) and nodal N2 disease. All accessible mediastinal lymph nodes (LN) were removed and classified according to their anatomical location in LN chains. The pulmonary resections performed were: pneumonectomy (n = 187), lobectomy (n = 44) and segmentectomy (n = 4). There was solitary nodal chain involvement by metastasis in 141 cases, two chains in 72 cases and three or more in 24; "skip" metastases were present in 26.6%. N2 disease would have been missed in 45 cases of single chain involvement (31.9%) if routine removal of mediastinal nodes had not been performed. The overall 5-year survival rate was 18.8%. Survival was not influenced by site, size or extension (T) of tumor, tumor histology or the presence of vascular invasion. The prognosis was significantly worsened by the presence of microscopic residual disease (30 cases) and of satellite nodules (23 cases). Survival was significantly improved when metastases involved a single LN chain (26.3 versus 8.3%, P = 0.0003). The location and number of involved nodes in the chain, "skip" metastases and the presence of extracapsular spread of carcinoma did not influence the prognosis. Routine mediastinal LN dissection is necessary to improve survival and for classification of lung cancer. Anatomic description allows better understanding of N2 disease which is not a contraindication to surgery when a gross complete resection can be achieved.