Impact of surgical approach on 90-day mortality after lung resection for nonsmall cell lung cancer in high-risk operable patients

Introduction

Non-small cell lung cancer (NSCLC) is often associated with compromised lung function. Real-world data on the impact of surgical approach in NSCLC patients with compromised lung function are still lacking. The objective of this study is to assess the potential impact of minimally invasive surgery (MIS) on 90-day post-operative mortality after anatomic lung resection in high-risk operable NSCLC patients.

Methods

We conducted a retrospective multicentre study including all patients who underwent anatomic lung resection between January 2010 and October 2021 and registered in the Epithor database. High-risk patients were defined as those with a forced expiratory volume in 1 s (FEV1) or diffusing capacity of the lung for carbon monoxide (DLCO) value below 50%. Co-primary end-points were the impact of risk status on 90-day mortality and the impact of MIS on 90-day mortality in high-risk patients.

Results

Of the 46 909 patients who met the inclusion criteria, 42 214 patients (90%) with both preoperative FEV1 and DLCO above 50% were included in the low-risk group, and 4695 patients (10%) with preoperative FEV1 and/or preoperative DLCO below 50% were included in the high-risk group. The 90-day mortality rate was significantly higher in the high-risk group compared to the low-risk group (280 (5.96%) versus 1301 (3.18%); p<0.0001). In high-risk patients, MIS was associated with lower 90-day mortality compared to open surgery in univariate analysis (OR=0.04 (0.02-0.05), p<0.001) and in multivariable analysis after propensity score matching (OR=0.46 (0.30-0.69), p<0.001). High-risk patients operated through MIS had a similar 90-day mortality rate compared to low-risk patients in general (3.10% versus 3.18% respectively).

Conclusion

By examining the impact of surgical approaches on 90-day mortality using a nationwide database, we found that either preoperative FEV1 or DLCO below 50% is associated with higher 90-day mortality, which can be reduced by using minimally invasive surgical approaches. High-risk patients operated through MIS have a similar 90-day mortality rate as low-risk patients.

Medico-economic impact of thoracoscopy versus thoracotomy in lung cancer: multicentre randomised controlled trial (Lungsco01)

BACKGROUND

Lungsco01 is the first study assessing the real benefits and the medico-economic impact of video-thoracoscopy versus open thoracotomy for non-small cell lung cancer in the French context.

METHODS

Two hundred and fifty nine adult patients from 10 French centres were randomised in this prospective multicentre randomised controlled trial, between July 29, 2016, and November 24, 2020. Survival from surgical intervention to day 30 and later was compared with the log-rank test. Total quality-adjusted-life-years (QALYs) were calculated using the EQ-5D-3L®. For medico-economic analyses at 30 days and at 3 months after surgery, resources consumed were valorised (€ 2018) from a hospital perspective. First, since mortality was infrequent and not different between the two arms, cost-minimisation analyses were performed considering only the cost differential. Second, based on complete cases on QALYs, cost-utility analyses were performed taking into account cost and QALY differential. Acceptability curves and the 95% confidence intervals for the incremental ratios were then obtained using the non-parametric bootstrap method (10,000 replications). Sensitivity analyses were performed using multiple imputations with the chained equation method.

RESULTS

The average cumulative costs of thoracotomy were lower than those of video-thoracoscopy at 30 days (€9,730 (SD = 3,597) vs. €11,290 (SD = 4,729)) and at 3 months (€9,863 (SD = 3,508) vs. €11,912 (SD = 5,159)). In the cost-utility analyses, the incremental cost-utility ratio was €19,162 per additional QALY gained at 30 days (€36,733 at 3 months). The acceptability curve revealed a 64% probability of efficiency at 30 days for video-thoracoscopy, at a widely-accepted willingness-to-pay threshold of €25,000 (34% at 3 months). Ratios increased after multiple imputations, implying a higher cost for video-thoracoscopy for an additional QALY gain (ratios: €26,015 at 30 days, €42,779 at 3 months).

CONCLUSIONS

Given our results, the economic efficiency of video-thoracoscopy at 30 days remains fragile at a willingness-to-pay threshold of €25,000/QALY. The economic efficiency is not established beyond that time horizon. The acceptability curves given will allow decision-makers to judge the probability of efficiency of this technology at other willingness-to-pay thresholds.

TRIAL REGISTRATION

NCT02502318.

Multimodality therapy for lung cancer invading the chest wall: A study of the French EPITHOR database

OBJECTIVES

According to a nation-based study, we intend to report the data of the patients operated on for lung cancer invading the chest wall, taking into consideration the completion of induction chemotherapy (Ind_CT), induction radiochemotherapy (Ind_RCT) or no induction therapy (0_Ind).

MATERIALS AND METHODS

All patients with a primary lung cancer invading the chest wall who underwent radical resection from 2004 to 2019 were included. Superior sulcus tumors were excluded.

RESULTS

Overall, 688 patients were included: 522 operated without induction therapy, 101 with Ind_CT and 65 with Ind_RCT. Postoperative 90-day mortality was 10.7% in the 0_Ind group, 5.0% in the Ind_CT group, 7.7% in the Ind_RCT group (p = 0.17). Incomplete resection rate was 14.0% in the 0_Ind group, 6.9% in the Ind_CT group, 6.2% in the Ind_RCT group (p = 0.04). In the 0_Ind group, 70% of the patients received adjuvant therapies. Overall survival (OS) analysis disclosed the best long-term outcomes in the Ind_RCT group (5-year OS probability: 56.5% versus 40.0% and 40.5% for 0_Ind and Ind_CT groups, respectively; p = 0.035). At multivariable analysis, Ind_RCT (HR = 0.571; p = 0.008), age > 60 years old (HR = 1,373; p = 0.005), male sex (HR = 1.710; p < 0.001), pneumonectomy (HR = 1.368; p = 0.025), pN2 status (HR = 1.981; p < 0.001), ≥3 resected ribs (HR = 1.329; p = 0.019), incomplete resection (HR = 2.284; p < 0.001) and lack of adjuvant therapy (HR = 1.959; p < 0.001) were associated with OS. Ind_CT was not associated with survival (HR = 0.848; p = 0.257).

CONCLUSION

Induction chemoradiation therapy seems to improve survival. Therefore, the present results should be confirmed by a prospective randomized trial testing the benefit of induction radiochemotherapy for NSCLC invading the chest wall.

Superior vena cava graft infection in thoracic surgery: a retrospective study of the French EPITHOR database

 

OBJECTIVES

To report our experience on the management of superior vena cava graft infection.

METHODS

Between 2001 and 2018, patients with superior vena cava synthetic graft or patch reconstruction after resection of intrathoracic tumours or benign disease were selected retrospectively from the French EPITHOR database and participating thoracic centres. Our study population includes patients with superior vena cava graft infection, defined according to the MAGIC consensus. Superior vena cava synthetic grafts in an empyema or mediastinitis were considered as infected.

RESULTS

Of 111 eligible patients, superior vena cava graft infection occurred in 12 (11.9%) patients with a polytetrafluoroethylene graft secondary to contiguous contamination. Management consisted of either conservative treatment with chest tube drainage and antibiotics (n = 3) or a surgical graft-sparing strategy (n = 9). Recurrence of infection appears in 6 patients. Graft removal was performed in 2 patients among the 5 reoperated patients. The operative mortality rate was 25%.

CONCLUSIONS

Superior vena cava graft infection may develop as a surgical site infection secondary to early mediastinitis or empyema. Graft removal is not always mandatory but should be considered in late or recurrent graft infection or in infections caused by aggressive microorganisms (virulent or multidrug resistant bacteria or fungi).

Characterisation of microbiota in saliva, bronchoalveolar lavage fluid, non-malignant, peritumoural and tumour tissue in non-small cell lung cancer patients: a cross-sectional clinical trial

Background

While well-characterised on its molecular base, non-small cell lung cancer (NSCLC) and its interaction with local microbiota remains scarcely explored. Moreover, current studies vary in source of lung microbiota, from bronchoalveolar lavage fluid (BAL) to tissue, introducing potentially differing results. Therefore, the objective of this study was to provide detailed characterisation of the oral and multi-source lung microbiota of direct interest in lung cancer research. Since lung tumours in lower lobes (LL) have been associated with decreased survival, characteristics of the microbiota in upper (UL) and lower tumour lobes have also been examined.

Methods

Using 16S rRNA gene sequencing technology, we analysed microbiota in saliva, BAL (obtained directly on excised lobe), non-malignant, peritumoural and tumour tissue from 18 NSCLC patients eligible for surgical treatment. Detailed taxonomy, diversity and core members were provided for each microbiota, with analysis of differential abundance on all taxonomical levels (zero-inflated binomial general linear model with Benjamini-Hochberg correction), between samples and lobe locations.

Results

Diversity and differential abundance analysis showed clear separation of oral and lung microbiota, but more importantly, of BAL and lung tissue microbiota. Phylum Proteobacteria dominated tissue samples, while Firmicutes was more abundant in BAL and saliva (with class Clostridia and Bacilli, respectively). However, all samples showed increased abundance of phylum Firmicutes in LL, with decrease in Proteobacteria. Also, clades Actinobacteria and Flavobacteriia showed inverse abundance between BAL and extratumoural tissues depending on the lobe location. While tumour microbiota seemed the least affected by location, peritumoural tissue showed the highest susceptibility with markedly increased similarity to BAL microbiota in UL. Differences between the three lung tissues were however very limited.

Conclusions

Our results confirm that BAL harbours unique lung microbiota and emphasise the importance of the sample choice for lung microbiota analysis. Further, limited differences between the tissues indicate that different local tumour-related factors, such as tumour type, stage or associated immunity, might be the ones responsible for microbiota-shaping effect. Finally, the “shift” towards Firmicutes in LL might be a sign of increased pathogenicity, as suggested in similar malignancies, and connected to worse prognosis of the LL tumours.

Trial registration

ClinicalTrials.gov ID: NCT03068663. Registered February 27, 2017.

[Guidelines for the macroscopic management of surgically resected lung carcinoma]

Gross examination is an essential step for pathological report of a surgical sample. It includes the description of the surgical specimen and their disease(s), the precise and exhaustive sampling of tumoral and adjacent tumoral tissue areas. This examination requires a good knowledge of the updated pTNM classification. Pathologists from the PATTERN group have collaborated with thoracic surgeons, under the auspices of the Sociéte française de pathologie, to propose guidelines for resected specimen management. This approach fits into the context of the elaboration of structured pathological report proposed by the société française de pathologie, which is necessary for a standardized management of patients.

Muscle wasting in patients with end-stage renal disease or early-stage lung cancer: common mechanisms at work

BACKGROUND

Loss of muscle mass worsens many diseases such as cancer and renal failure, contributes to the frailty syndrome, and is associated with an increased risk of death. Studies conducted on animal models have revealed the preponderant role of muscle proteolysis and in particular the activation of the ubiquitin proteasome system (UPS). Studies conducted in humans remain scarce, especially within renal deficiency. Whether a shared atrophying programme exists independently of the nature of the disease remains to be established. The aim of this work was to identify common modifications at the transcriptomic level or the proteomic level in atrophying skeletal muscles from cancer and renal failure patients.

METHODS

Muscle biopsies were performed during scheduled interventions in early-stage (no treatment and no detectable muscle loss) lung cancer (LC), chronic haemodialysis (HD), or healthy (CT) patients (n = 7 per group; 86% male; 69.6 ± 11.4, 67.9 ± 8.6, and 70.2 ± 7.9 years P > 0.9 for the CT, LC, and HD groups, respectively). Gene expression of members of the UPS, autophagy, and apoptotic systems was measured by quantitative real-time PCR. A global analysis of the soluble muscle proteome was conducted by shotgun proteomics for investigating the processes altered.

RESULTS

We found an increased expression of several UPS and autophagy-related enzymes in both LC and HD patients. The E3 ligases MuRF1 (+56 to 78%, P < 0.01), MAFbx (+68 to 84%, P = 0.02), Hdm2 (+37 to 59%, P = 0.02), and MUSA1/Fbxo30 (+47 to 106%, P = 0.01) and the autophagy-related genes CTPL (+33 to 47%, P = 0.03) and SQSTM1 (+47 to 137%, P < 0.01) were overexpressed. Mass spectrometry identified >1700 proteins, and principal component analysis revealed three differential proteomes that matched to the three groups of patients. Orthogonal partial least square discriminant analysis created a model, which distinguished the muscles of diseased patients (LC or HD) from those of CT subjects. Proteins that most contributed to the model were selected. Functional analysis revealed up to 238 proteins belonging to nine metabolic processes (inflammatory response, proteolysis, cytoskeleton organization, glucose metabolism, muscle contraction, oxidant detoxification, energy metabolism, fatty acid metabolism, and extracellular matrix) involved in and/or altered by the atrophying programme in both LC and HD patients. This was confirmed by a co-expression network analysis.

CONCLUSIONS

We were able to identify highly similar modifications of several metabolic pathways in patients exhibiting diseases with different aetiologies (early-stage LC vs. long-term renal failure). This strongly suggests that a common atrophying programme exists independently of the disease in human.

Characterisation of gut, lung, and upper airways microbiota in patients with non-small cell lung carcinoma: Study protocol for case-control observational trial

BACKGROUND

Several studies have confirmed the important role of the gut microbiota in the regulation of immune functions and its correlation with different diseases, including cancer. While brain-gut and liver-gut axes have already been demonstrated, the existence of a lung-gut axis has been suggested more recently, with the idea that changes in the gut microbiota could affect the lung microbiota, and vice versa. Likewise, the close connection between gut microbiota and cancer of proximal sites (intestines, kidneys, liver, etc.) is already well established. However, little is known whether there is a similar relation when looking at world's number one cause of death from cancer-lung cancer.

OBJECTIVE

Firstly, this study aims to characterise the gut, lung, and upper airways (UAs) microbiota in patients with non-small cell lung cancer (NSCLC) treated with surgery or neoadjuvant chemotherapy plus surgery. Secondly, it aims to evaluate a chemotherapy effect on site-specific microbiota and its influence on immune profile. To our knowledge, this is the 1st study that will analyse multi-site microbiota in NSCLC patients along with site-specific immune response.

METHODS

The study is a case-controlled observational trial. Forty NSCLC patients will be divided into 2 groups depending on their anamnesis: Pchir, patients eligible for surgery, or Pct-chir, patients eligible for neoadjuvant chemotherapy plus surgery. Composition of the UAs (saliva), gut (faeces), and lung microbiota (from broncho-alveolar lavage fluid (BALF) and 3 lung pieces: "healthy" tissue distal to tumour, peritumoural tissue and tumour itself) will be analysed in both groups. Immune properties will be evaluated on the local (evaluation of the tumour immune cell infiltrate, tumour classification and properties, immune cell phenotyping in BALF; human neutrophil protein (HNP) 1-3, β-defensin 2, and calprotectin in faeces) and systemic level (blood cytokine and immune cell profile). Short-chain fatty acids (SCFAs) (major products of bacterial fermentation with an effect on immune system) will be dosed in faecal samples. Other factors such as nutrition and smoking status will be recorded for each patient. We hypothesise that smoking status and tumour type/grade will be major factors influencing both microbiota and immune/inflammatory profile of all sampling sites. Furthermore, due to non-selectivity, the same effect is expected from chemotherapy.

Left Brachiocephalic Venous Aneurysm: A Rare Clinical Finding

Brachiocephalic venous aneurysm is an extremely rare condition, with <20 cases reported in the literature. We present a case of a 72-year-old man who was referred to our department owing to a large aneurysm of the left brachiocephalic vein that was incidentally discovered on computed tomography. Further workup confirmed an isolated saccular aneurysm of the left brachiocephalic vein. The patient underwent aneurysmectomy via sternotomy with no requirement for a vascular graft or cardiopulmonary bypass. The postoperative course and follow-up were uneventful.

Early CYFRA 21-1 Variation Predicts Tumor Response to Chemotherapy and Survival in Locally Advanced Non-Small Cell Lung Cancer Patients

We have evaluated CYFRA 21-1 serum level variations as an indicator of tumor response and survival in 44 consecutive patients with locally advanced non-small cell lung cancer (NSCLC) treated with induction chemotherapy (IC). Irrespective of the initial CYFRA 21-1 serum concentration, a more than 65% decrease in the serum level after the first chemotherapy course was significantly predictive of an objective tumor response (p=0.0022). In addition, a more than 80% decrease in this level significantly predicted a better disease-free survival (p=0.039). In patients with initial CYFRA 21-1 serum levels >3.3 ng/mL (n=29), a more than 80% decrease after the first IC course was the most significant predictor of overall survival (p=0.025) in a Cox analysis including initial staging, tumor response and surgery. We conclude that early monitoring of CYFRA 21-1 serum levels may be a useful prognostic tool for tumor response and survival in stage III NSCLC patients treated by induction chemotherapy.

Effect of an intensive 3-week preoperative home rehabilitation programme in patients with chronic obstructive pulmonary disease eligible for lung cancer surgery: a multicentre randomised controlled trial

INTRODUCTION

Surgery is the standard curative treatment for lung cancer but is only possible in patients with local tumour and preserved exercise capacity. Improving fitness before surgery can reduce postoperative complications and mortality. However, preoperative rehabilitation remains difficult to implement for several reasons. We aim to investigate the effectiveness of an intensive 3-week home-based preoperative exercise training programme on hospital discharge ability, postoperative complications and physical performance in patients with chronic obstructive pulmonary disease (COPD) who are eligible for lung cancer surgery.

METHODS AND ANALYSIS

We designed a multicentre randomised controlled trial. The randomisation sequence will be generated and managed electronically by a research manager independent of assessments or interventions. We will recruit 90 patients with COPD and a diagnosis of lung cancer from four university hospitals. The rehabilitation group (R group) will receive a standardised preoperative home exercise programme for 3 weeks, combining both high-intensity training and usual physical therapy. The R group will perform 15 training sessions over 3 weeks on a cycloergometer. A physical therapist experienced in pulmonary rehabilitation will visit the patient at home and supervise one session a week. The R group will be compared with a control group receiving preoperative usual physical therapy only. The primary outcome will be hospital discharge ability assessed with a 10-item list. Secondary outcomes will be postoperative course (complication rate and mortality) as well as pulmonary function, exercise capacity and quality of life assessed 1 month before and the day before surgery.

ETHICS AND DISSEMINATION

This protocol has been approved by the French health authority for research (2016-A00622-49) and the research ethics committee/institutional review board (AU1267). Adverse events that occur during the protocol will be reported to the principal investigator. The results will be published in an international peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT03020251.

Medicoeconomic analysis of lobectomy using thoracoscopy versus thoracotomy for lung cancer: a study protocol for a multicentre randomised controlled trial (Lungsco01)

INTRODUCTION

In the last decade, video-assisted thoracoscopic surgery (VATS) lobectomy for non-small cell lung cancer (NSCLC) has had a major effect on thoracic surgery. Retrospective series have reported benefits of VATS when compared with open thoracotomy in terms of postoperative pain, postoperative complications and length of hospital stay. However, no large randomised control trial has been conducted to assess the reality of the potential benefits of VATS lobectomy or its medicoeconomic impact.

METHODS AND ANALYSIS

The French National Institute of Health funded Lungsco01 to determine whether VATS for lobectomy is superior to open thoracotomy for the treatment of NSCLC in terms of economic cost to society. This trial will also include an analysis of postoperative outcomes, the length of hospital stay, the quality of life, long-term survival and locoregional recurrence. The study design is a two-arm parallel randomised controlled trial comparing VATS lobectomy with lobectomy using thoracotomy for the treatment of NSCLC. Patients will be eligible if they have proven or suspected lung cancer which could be treated by lobectomy. Patients will be randomised via an independent service. All patients will be monitored according to standard thoracic surgical practices. All patients will be evaluated at day 1, day 30, month 3, month 6, month 12 and then every year for 2 years thereafter. The recruitment target is 600 patients.

ETHICS AND DISSEMINATION

The protocol has been approved by the French National Research Ethics Committee (CPP Est I: 09/06/2015) and the French Medicines Agency (09/06/2015). Results will be presented at national and international meetings and conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT02502318.

Combined treatment modalities in Pancoast tumor: results of a monocentric retrospective study

BACKGROUND

A retrospective monocentric study of consecutive patients with superior sulcus tumor non-small cell lung cancer (SS-NSCLC), treated by induction concurrent chemoradiotherapy (CRT), article management.

METHODS

From 1994 to 2005, 36 patients (15 T3, 21 T4 tumors, including N2-N3 node involvement) received induction CRT with cisplatin/vinorelbine/fluorouracil combined with 44 Gy radiotherapy (5 daily 2 Gy fractions/week). After CRT completion, RECIST evaluation and operability were assessed. In resectable patients, surgery was performed one month after CRT. Patients with unresectable disease followed CRT up to 66 Gy. The median of follow-up period was 38.6 months [2-206].

RESULTS

Induction CRT was completed for 94.4% with 71% radiological objective response (OR). Sixteen patients (44%) underwent surgical resection, and pathologic complete resection was performed in 93.8%. There were 7 patients (44%) with pathologic complete response. The median disease-free survival (DFS) time was 12.9 months with DFS rates at 1 and 2 years 53.6% and 39.1% respectively. The median overall survival (OS) was 46.4 months. The OS rates at 2 and 5 years were 68.8% and 37.5% respectively with no difference between T3 and T4 tumors. In unresectable disease, the median DFS time was 8.1 months. The DFS rate at 1 year was 25.2%. The median OS was 9.1 months. The OS rates at 1 and 2 years were 45% and 16.9% respectively. Recurrences were found in 72% of patients. Brain metastasis was the most common site of recurrence. Prognostic factors for OS were the response to induction treatment, the possibility of surgery, and pathologic complete response.

CONCLUSIONS

This trimodality treatment regimen confers a survival outcome in agreement with previous studies. Patients with pretreatment N3 lymph node should be included in trimodality treatment.

Nutritional Intake, Physical Activity and Quality of Life in COPD Patients

In this study, we aimed to document the level of physical activity (PA), quality of life, depression status and nutritional data of 20 individuals with chronic obstructive pulmonary disease (COPD) (mean age 65.0±7.0 years) admitted in hospital for pulmonary rehabilitation and compare these data to those obtained in 20 similarly aged healthy individuals. Nutritional data were collected using a 3-day diet record. COPD patients engaged in significantly less PA than healthy individuals and achieved a significant higher score of Beck Depression Inventory (BDI) than the control group. Their Fat Free Mass Index (FFMI) was significantly lower when compared to the control group (p<0.05). Patients had significantly lower total caloric intake, Vitamins B6, B9, B12, Vitamin E, β carotene and omega 3 than controls. Moreover, patients with low FFMI reported significantly lower mean intake of energy, carbohydrate, vitamin E and vitamin B6 than patients with normal FFMI. Because oxidative stress and inflammation are features of many lung diseases, nutrients with anti-oxidant and anti-inflammatory properties could be useful in prevention or treatment. Further work is needed to explore the possible relationship between the intake of B group vitamins, Vitamin E, n-3PUFAS and the development and progression of lung disease.

Prophylactic tracheotomy and lung cancer resection in patient with low predictive pulmonary function: a randomized clinical trials

BACKGROUND

Whether prophylactic tracheotomy can shorten the duration of mechanical ventilation (MV) in high risk patients eligible for lung cancer resection. The objective was to compare duration of MV and outcome in 39 patients randomly assigned to prophylactic tracheotomy or control.

METHODS

Prospective randomized controlled, single-center trial (ClinicalTrials.gov Identifier: NCT01053624). The primary outcome measure was the cumulative number of MV days after operation until discharge. The secondary outcome measures were the 60 days mortality rate, the ICU and the hospital length of stay, the incidence of postoperative respiratory, cardiac and general complications, the reventilation rate, the need of noninvasive ventilation (NIV), the need of a tracheotomy in control group and the tracheal complications.

RESULTS

The duration of MV was not significantly different between the tracheotomy group (3.5±6 days) and the control group (4.7±9.3 days) (P=0.54). Among patients needing prolonged MV >4 days, tracheotomy patients had a shortened duration of MV than control patients (respectively 11.4±7.1 and 20.4±9.6 days, P=0.04). The rate of respiratory complications were significantly lower in the tracheotomy group than in the control group (28% vs. 51%, P=0.03). Six patients (15%) needed a postoperative tracheotomy in the control group because of a prolonged MV >7 days. Tracheotomy was associated with a reduced need of NIV (P=0.04). There was no difference in 60-day mortality rate, cardiac complications, intensive care unit and hospital length of stay. No death was related with the tracheotomy.

CONCLUSIONS

Prophylactic tracheotomy in patients with ppo FEV1 <50% who underwent thoracotomy for lung cancer resection provided benefits in terms of duration of prolonged MV and respiratory complications but was not associated with a decreased mortality rate, ICU and hospital length of stay and non-respiratory complications.

Extended resection of non-small cell lung cancer invading the left atrium, is it worth the risk?

Only few reports of surgical approach to T4 lung carcinoma invading the heart have been reported in the medical literature. It is also controversial if such cancer should be treated by surgery. The aim of this review is to assess the current risk/benefit ratio of the surgical management of non-small cell lung cancer (NSCLC) invading the left atrium, especially in the light of a multidisciplinary approach. We also expose our surgical experience and the procedure we have developed in order to increase our rate of complete resection as this criterion appears to be mandatory as well as patients' nodal status in order to increase life expectancy.

Lymphovenous anastomosis for recurrent swelling syndrome and chylous effusion due to cervical thoracic duct cyst

Thoracic duct (TD) cyst is an uncommon abnormality that can be manifested as a cervical swelling. Pathogenesis includes congenital or degenerative weakness of the wall of the TD and obstruction of the lymphoid flow. Diagnosis is crucial to eliminate malignant disease or vein thrombosis and can be established by imaging and needle aspiration. We report a case of recurrent cervical swelling with spontaneous chylothorax and chyloperitoneum. A TD cyst with a terminal obstruction of the TD was diagnosed on lymphangiography. Treatment by microsurgical lymphovenous anastomosis was successful, and the patient was free of symptom 3 years later.

Left atrial resection for T4 lung cancer without cardiopulmonary bypass: technical aspects and outcomes

BACKGROUND

Extended resection for lung cancer may improve survival of selected patients. Left-atrial resection is infrequently performed and surgical techniques are rarely reported; thus, oncologic results and survival rates remain uncertain. Our study describes surgical techniques, postoperative outcomes, and oncologic results of patients who received a combined multimodality treatment.

METHODS

Between October 2004 and March 2012 in our institution, 19 patients underwent extended lung resection involving the left atrium without cardiopulmonary bypass. We reviewed perioperative treatments, surgical procedures, and postoperative morbidity, mortality, and long-term survival rates.

RESULTS

Sixteen patients (68.4%) underwent neoadjuvant treatment including chemotherapy or radiotherapy. Eighteen pneumonectomies (94.7%) were performed, of which 12 (63.1%) were right sided. Dissection of the interatrial septum was complete in 4 patients (33.3%). Complete resection was achieved in 17 patients (89.4%) and 2 other patients (10.5%) were considered R1. The T-status was pT4 in all patients. Overall postoperative morbidity was 52.6%. The 30-day mortality rate was 10.5% and the 90-day mortality rate was 15.7%. Fifteen patients (93.7%) underwent adjuvant treatment. The mean follow-up time was 32.5 months. The 5-year probability of survival was 43.7%. Three patients (15.7%) were alive at greater than 6 years postsurgery.

CONCLUSIONS

Extended lung surgery with partial resection of the left atrium is a feasible procedure with acceptable morbidity. An interatrial septum dissection, by increasing the length of the atrial cuff, allows complete resection. Long-term survival can be achieved in highly selected patients who have undergone multimodal therapy.

Lung cancer: what are the links with oxidative stress, physical activity and nutrition

Oxidative stress appears to play an essential role as a secondary messenger in the normal regulation of a variety of physiological processes, such as apoptosis, survival, and proliferative signaling pathways. Oxidative stress also plays important roles in the pathogenesis of many diseases, including aging, degenerative disease, and cancer. Among cancers, lung cancer is the leading cause of cancer in the Western world. Lung cancer is the commonest fatal cancer whose risk is dependent on the number of cigarettes smoked per day as well as the number of years smoking, some components of cigarette smoke inducing oxidative stress by transmitting or generating oxidative stress. It can be subdivided into two broad categories, small cell lung cancer and non-small-cell lung cancer, the latter is the most common type. Distinct measures of primary and secondary prevention have been investigated to reduce the risk of morbidity and mortality caused by lung cancer. Among them, it seems that physical activity and nutrition have some beneficial effects. However, physical activity can have different influences on carcinogenesis, depending on energy supply, strength and frequency of exercise loads as well as the degree of exercise-mediated oxidative stress. Micronutrient supplementation seems to have a positive impact in lung surgery, particularly as an antioxidant, even if the role of micronutrients in lung cancer remains controversial. The purpose of this review is to examine lung cancer in relation to oxidative stress, physical activity, and nutrition.

[Embryology of the heart walls]

Although anatomically simple structures, the atrial septum and the ventricular septum have complex embryological origins. Recent findings in molecular biology allowed better comprehension of their formation. As soon as the heart tube is formed, cells migrate from several cardiogenic fields to take part in the septation. Elongation, ballooning, and later inflexion of the heart tube create chamber separating grooves, facing the future septa. The systemic venous tributaries conflate at the venous pole of the heart; it will partially involute while contributing to the atrial septum. The primary atrial septum grows from the atrial roof towards the atrioventricular canal. It fuses there with the atrioventricular cushions, while its upper margin breaks down to form the ostium secundum. Then a deep fold develops from the atrial roof and partly covers the ostium secundum, leaving a flap-like interatrial communication through the oval foramen. It will close at birth. The interventricular septum has three embryological origins. The ventricular septum primum, created during the ballooning process, origins from the primary heart tube. It will form the trabecular septum and the inlet septum. The interventricular ring, surrounding the interventricular foramen, will participate in the inlet septum and also form the atrioventricular conduction axis. The outflow cushions will separate the outflow tract in the aorta and pulmonary artery, and grow to create the outlet septum. After merging with the atrioventricular cushions, they will also be part of the membranous septum.

Cardiac tamponade after malignant superior vena cava stenting: Two case reports and brief review of the literature

Percutaneous stenting of the superior vena cava (SVC) is usually recommended as a palliative procedure for malignant SVC obstruction with low reported morbidity. Complications are uncommon and usually of minor consequence. We report two unusual cases of cardiac tamponade following SVC stenting in patients with malignant SVC syndrome. Echocardiography allows rapid diagnosis and guides pericardial drainage in the interventional radiology suite.

[Evolution of the early respiratory function after lung resection for cancer]

The assessment of the postoperative risk in lung resection is a major challenge for pneumologists and thoracic surgeons. Restrictive syndromes have been observed along with a disproportionate decrease of FEV1 in lobectomies. The purpose of the present study is to describe the early response of pulmonary function after thoracotomy and resection for lung cancer. In a prospective study, the authors included 31 patients (19 lobectomy patients: mean age 59+/-10 years and 12 pneumonectomy patients: mean age 56+/-9 years) without postoperative complications. Pulmonary function tests were performed before and after surgery on Days 1, 5 (D5), 10 and within the fourth month. The main aspect of the ventilation was an unexpected similarity in subgroups during the early perioperative period up to D5. When compared with the preoperative value, about a 50% decrease in the vital capacity and total lung capacity was observed. In both subgroups about a 40% decrease was noted in the inspiratory and expiratory reserve volume. In the lobectomy sub-group, the change in the forced expiratory volume in one second over forced vital capacity (FEV/FVC) ratio was found to be higher than predicted (52+/-16% at D5 versus 67+/-14% predicted). However, the FEV/FVC ratio did not change, attesting to major restrictive ventilation. Partial recovery of the FEV was dependant on the mobile volume and especially the inspiratory volume. These findings should have implications in patient management.

[Endovascular treatment of SVC syndrome from neoplastic origin: a review of 34 cases]

PURPOSE

To report our experience with the treatment of 34 patients with SVC syndrome from neoplastic origin using the Wallstent.

MATERIALS AND METHODS

Thirty-four patients were treated between January 2000 and February 2007: 21 males and 13 females, aged 44-81 years, with non-small-cell lung carcinoma in 27 cases (79%), small-cell lung carcinoma in 5 cases (15%) and metastatic breast adenocarcinoma to the mediastinum in 2 cases (6%). All patients were treated using the stainless steel self-expanding Wallstent. A dual brachial-femoral access was used in all cases.

RESULTS

Stent placement was possible in all cases. Per procedure acute respiratory distress occurred in 2 cases: 1 case of acute pulmonary edema and 1 case of tamponade. Symptoms resolved within 24 hours. Twenty-six patients died from disease progression, 8 during the first month, and 16 within 32-545 days post-procedure (mean: 213.4 days). Five patients with recurrent SVC syndrome underwent repeat treatment (restenosis in 3 cases, fracture in 1 case, thrombosis in 1 case), for primary and secondary patency rates of 81% and 100%.

CONCLUSION

Palliative stent treatment of neoplastic SVC syndrome is reliable, safe and provides long-standing improvement in quality of life.

Salivary cortisol, heart rate and blood lactate during a qualifying trial and an official race in motorcycling competition

AIM

The study aims to examine the physiological load on motorcycling competitors during a qualifying trial and an official race.

METHODS

Twelve male riders participated in this study, in which their anthropometric data, heart rate, blood lactate (La) and salivary cortisol (C) concentrations were measured. Two saliva samples were taken on a resting day at 8 a.m. (30 min after awakening: [T(0)] and at 8 p.m. [T(1)] and 6 saliva samples were collected on the day of the qualifying trial and on the day of the official race [T(2) through T(7)]).

RESULTS

During the race, as well as during the qualifying trial, heart rate was found to be >80-90% of the maximum heart rate. Blood La increased more than two-fold (peak 5.6+/-2.1 mM) as compared to resting values (2+/-0.1 mM). However, La were not statistically different between qualifying trial and race. C concentrations on the motorcycling day were found to be up to 3 times higher than those measured on the resting day. In fact, there was a progressive increase in the C concentrations on the motorcycling day, the values noted 10 min after the race being the highest. There was a significant decrease in C values 60 min after the race, but the concentration was maintained at a higher level for a longer period; the values reported at T(7) (8 p.m.; 4.3 h after the end of the race) were significantly higher than those reported at the same time on a resting day (T(1)).

CONCLUSION

The examination of heart rate, blood La and salivary C concentrations in motorcycling on a circuit shows that this sport is highly stressful, and also that a metabolic involvement is required to control the motorcycle at a high speed. Thus, riders may benefit from a specific training program aimed at improving their cardiovascular fitness and strength.

Inhaled nitric oxide does not prevent postpneumonectomy pulmonary edema in pigs

OBJECTIVE

Increase in lung permeability is an inevitable consequence of pneumonectomy in relation to inflammatory injury and increased perfusion flow. We tested whether inhaled nitric oxide, a potent vasodilatator and anti-inflammatory agent, prevents postpneumonectomy edema in the first 24 hours after pneumonectomy in pigs.

METHODS

We assessed hemodynamics, gas exchange, extravascular lung water estimated with the double-indicator dilution method, and lung neutrophil sequestration measured on the basis of lung myeloperoxidase activity at 1 and 24 hours after left pneumonectomy in 14 pigs randomly assigned to inhaled nitric oxide (10 ppm) or control groups.

RESULTS

Extravascular lung water content markedly increased at 1 and 24 hours after pneumonectomy, with no difference between the 2 groups. Hemodynamics did not differ between the 2 groups. Myeloperoxidase activity was higher and PaO2 values were lower in the nitric oxide group compared with in the control group.

CONCLUSIONS

Over the 24 hours after pneumonectomy, intraoperative inhaled nitric oxide levels neither improved gas exchange nor attenuated accumulation of lung water. On the contrary, they were associated with an increase in lung neutrophil sequestration and deterioration of arterial oxygenation, suggesting the occurrence of an early and toxic effect of nitric oxide.

Benign mature mediastinal dysembryoma with pulmonary extension revealed by recurrent hemoptysis in a young woman

We report one case of mature mediastinal teratoma with pulmonary extension surgically diagnosed in a 22-year-old woman complaining of recurrent hemoptyses for which no etiological explanation could be found. Thoracic surgery was only decided on after three embolizations proved ineffective.

Evolution of healthy thoracic aortic segment diameter during follow-up of patients with aortic aneurysm or dissection: a magnetic resonance imaging study

We studied the normal evolution over time of the diameter of the healthy descending aorta in patients suffering from aneurysm or dissection of the ascending aorta, in order to anticipate potential complications of endoprosthetic treatment in this aortic segment. During their follow-up (average 35.9 months), 52 patients suffering from aneurysm or dissection of the ascending aorta had 168 aortic MRI examinations (2-7; average 3). Measurements were taken according to conventional reference landmarks making it possible to study the evolution of the diameter of the supposed healthy descending thoracic aorta. The variations in diameter with time were on average 5 mm, and there was no significant variation in this diameter, either for early controls or for the controls carried out after more than 1 year or 3 years, whatever the age group. Thus according to our series it seems that patients with a descending aorta endoprosthesis are not exposed to graft endoleak due to inadequate contact of the prosthesis and aorta within the 5 years following its implantation.

[Compression of the bulbar urethra by transobturator suburethral tape: anatomical study]

INTRODUCTION

The management of female stress urinary incontinence has been markedly improved by the suprapubic tension-free vaginal tape (TVT) and transobturator tape techniques. The objective of our study was to assess the feasibility of this type of technique in males based on cadavre dissection.

MATERIAL AND METHOD

A 300 mm x 15 mm polypropylene tape was inserted via a transobturator approach on a cadavre stored in the refrigerator at 4 degrees C and on three cadavres stored in formalin. The technique was almost identical to that used in females. It requires a midline perineal incision in the raphe and two small lateral incisions. The deep transverse muscle of the perineum was opened with scissors. The needle was introduced via the lateral incisions and its progression was guided by a finger introduced into the perineal orifice. The cadavre was then sectioned sagittally to verify the course of the tape and its relations to adjacent structures.

RESULTS

The operative technique did not raise any particular problems. Dissection revealed that the tape crossed the deep transverse muscle of the perineum and the levator ani muscle, before travelling towards the obturator foramen. The tape avoided the bladder, prostate, corpora cavernosa, and pudendal pedicle.

CONCLUSION

The transobturator tape technique therefore appears to be feasible in males. It does not appear to comprise any particular risks for adjacent organs. This anatomical study appeared to be essential before considering an in vivo application.

Normal diameter of the thoracic aorta in adults: a magnetic resonance imaging study

To determine the evolution of the diameter of the thoracic aorta with age in order to detect dilatation more reliably by imaging, we performed a retrospective analysis of the MRI examinations of the normal thoracic aorta of 66 subjects aged 44.1+/-19.1 years (range 19.1-82.4 years) obtained between 1991 and 2000 on a Magnetom SP 42 1T apparatus (Siemens) using T1-weighted spin echo sequences with electrocardiographic synchronization. Sixteen measurements were made in the axial plane, the oblique sagittal plane in the axis of the aortic arch, and the oblique frontal plane perpendicular to the latter at the level of the ascending aorta, the arch and the descending thoracic aorta. We found an increase in the thoracic aorta diameter and a significant relationship between this diameter and the age of our subjects, wherever the measure was performed. However, there was no systematic correlation between aortic diameter and age. The aortic diameter evolved with age and a marked difference seemed to exist in measurements made in groups younger and older than 40 years. This study, conducted on a small population of 66 patients, thus helps to define a normal aortic diameter, thereby making the diagnosis of pathological dilatation of the aorta more reliable.

Intrathoracic blood supply of the left vagus and recurrent laryngeal nerves

The arteries and veins of the left vagus (VN) and left recurrent laryngeal (RLN) nerves from the thoracic inlet to the subaortic region are described following vascular casting with red colored latex in 6 adult fresh non-embalmed cadavers. In all specimens the anterior bronchoesophageal artery supplied at least one vessel to the VN and RLN in the subaortic region. For the RLN other arterial sources were arteries arising from the aortic arch in 1 specimen, the subclavian artery in 3 specimens, the first intercostal artery in 1 specimen, and the inferior thyroid artery in all specimens. For the VN other arterial sources were arteries arising from the aortic arch in 2 specimens and the inferior thyroid artery in 1 specimen. For both the VN and RLN the veins were located under the pleura and directed towards the internal thoracic vein anteriorly and the thoracic intercostal veins posteriorly. In conclusion, the inferior thyroid artery at the thoracic inlet for the RLN and the anterior bronchoesophageal artery are the more consistent vessels supplying the VN and RLN. Vascular damage occurring during mediastinal lymph node excision to the VN and RLN, especially in the subaortic region, may explain postoperative vocal fold paralysis.

Vocal cord dysfunction after left lung resection for cancer

OBJECTIVES

To evaluate the prevalence, the impact-related postoperative complications and the risk factors of vocal cord dysfunction (VCD) after left lung resection for cancer.

METHODS

From February 1996 to April 1999, a review of prospectively gathered data was performed on 99 consecutive patients who underwent a pneumonectomy (n=50) or a lobectomy (n=49) with a mediastinal lymph node dissection. A fiber optic laryngeal examination was performed preoperatively for all patients and within the first week postoperatively in patients with symptom(s) or sign(s) of VCD or respiratory complications.

RESULTS

Thirty-one patients (31%) had a postoperative VCD (group VCD) and 68 (68%) did not (group non-VCD). Mortality rate was 19% in group VCD and 9% in group non-VCD (P=0.13). Group VCD patients developed more pulmonary complications (P=0.014) and cardiac complications (P<0.001) compared to group non-VCD patients. A higher rate of reintubation (P=0.005), pneumonia (P=0.06), arrhythmia (P=0.002), cardiac failure (P<0.001) was noticeable in group VCD and may account for the higher rate of complications in this group. Using multivariate analysis, preoperative radiotherapy (P=0.001) and pneumonectomy (P=0.008) were predictive of postoperative VCD. Hospital stay was 22+/-16 days in group VCD and 13+/-9 days in group non-VCD (P<0.002).

CONCLUSION

VCD is a frequent event that can lead to dramatic pulmonary complications. We would recommend to track it and to treat it as early as possible.

Visualisation of the portal flows by porto-scanner

This study presents a retrospective analysis of 15 portal vein CT scans, conducted for the evaluation of hepatic metastasis in patients suffering from colorectal cancer, with the aim of verifying in vivo the presence of laminar flow as reported by Pironcof. After selective catheterization of the superior mesenteric artery, CT scans were performed during opacification of the portal vein. Different flows were identified by the incomplete opacification they induced in the portal vein. Splenic flows could always be identified, however right colic and superior mesenteric flows were only seen in 3 cases (20%) and gastrocolic flow in 2 (13.6%). Even though incremental (i.e. slower than helical) the CT acquisitions allowed the flows to be viewed by modifying the visualisation window. In vivo evidence of laminar flow is provided which supports Pironcof's experimental observations.

Concomitant type I thyroplasty and thoracic operations for lung cancer: preventing respiratory complications associated with vagus or recurrent laryngeal nerve injury

OBJECTIVES

We sought to prevent postoperative swallowing disorder, aspiration, and sputum retention in cases of recurrent laryngeal or vagus nerve section occurring during lung cancer resection.

METHODS

In 14 of 25 consecutive patients, type I thyroplasty and thoracic operations were performed during the same period of anesthesia. All patients had a preoperative laryngeal computed tomographic scan providing us with indispensable measurements for vocal fold medialization under general anesthesia (ie, without intraoperative phonatory control). Nine remaining patients had a type I thyroplasty delayed from thoracic operations because of intraoperative doubt about laryngeal innervation injury, and 2 did not need a laryngeal operation. Main postoperative records consisted of swallowing ability, respiratory complications, and quality of voice.

RESULTS

No swallowing disorder, aspiration, or sputum retention occurred in cases of concomitant laryngeal and thoracic operations. Of these 14 patients, a single case (7%) of major complication (vocal fold overmedialization) occurred and required an early and successful revision thyroplasty; one case of cervical hematoma that did not require surgical drainage was considered a minor complication (7%). Twelve (86%) patients who underwent the concomitant association of both operations were fully satisfied with their quality of voice.

CONCLUSIONS

Type I thyroplasty and thoracic operation can be advantageously associated in case of injury to laryngeal motor innervation to prevent postoperative swallowing disability and dramatic respiratory complications.

Influence of the mode of load carriage on the static posture of the pelvic girdle and the thoracic and lumbar spine in vivo

The influence of various modes of carrying a load of 16 kg (15.69 DaN) on the static positioning of the pelvic girdle and the thoracic and lumbar segments of the spine was examined in seven male subjects. The displacement of cutaneous markers attached to easily palpable skeletal landmarks was recorded using 4 CCD cameras; the data acquired were analysed using an optoelectronic technique (SAGA3). The subjects stood upright on an AMTI biomechanical force platform, from which the ground reaction forces enabled displacements of the centre of gravity axis and thus the moment of the mass carried to be determined. The modes of load carriage examined were: 1) in a case in the left hand; 2) in a case in the right hand; 3) equally in two cases; 4) on the head; 5) in a rucksack; and 6) in an anterior bag. The results showed displacements of the pelvic girdle, the caudal and cranial lumbar segments, and the caudal and cranial thoracic segments in the three orthogonal planes (sagittal, frontal and transverse). The influence of the moment created by the load was seen in the statokinesigrams. The use of external markers using an optoelectronic technique, in association with the ground reaction forces, enables the mode of load carriage to be determined. The results show that the influence of the moment exerted by the mode of load carriage on the gravity axis has important ergonomic consequences.

Origin and initial course of the renal arteries a radiological study

The aim of this study was to determine the topography of the origin, implantation angle and initial course of the renal arteries in the transverse and frontal planes, from a prospective analysis of angiograms and helical CT-scans of 40 patients. In the frontal plane, the implantation angles of the right and left renal arteries were 73.8 +/- 17 degrees and 65.6 +/- 16 degrees respectively; 17.9% of the right renal arteries were straight compared with only 5% of the left ones. The first sinuosity was observed to be at a distance greater than the aortic diameter for 43.6% of right renal arteries and at a distance less than the aortic diameter for 62.5% for the left renal a. In the transverse plane, the right renal a. had an implantation angle of 65.6 +/- 15.7 degrees compared with 95.7 +/- 16.85% for the left renal a. The artery was rectilinear in 2.6% of the cases on the right side, and in 2.5% of the cases on the left. The first sinuosity occurred before the lateral margin of the spine was reached in 60.5% of right renal arteries and after the margin of psoas major muscle for 55% of left renal arteries. A knowledge of the anatomy of the origin and initial course of the renal arteries is important when considering vessel dilatation and the implantation of stents in the renal arteries. No correlation was observed between the origin, sinuosity or angulation of the renal arteries which could aid interventional procedures.