[Congenital thoracic deformities and 3D custom-made implants. New classification based on a series of 789 treated cases]

The authors present a new study on 789 cases of congenital thoracic malformations including 638 pectus excavatum and 151 Poland syndromes, according to a new classification which completes Chin's one. All these malformations were treated with silicone elastomer implants. The contribution of computer-aided design and manufacturing (CAD/CAM) since 2008 is essential. The one-stage surgical protocol is precisely described. The results are impressive, permanent, for life, and complications are rare. The authors evoke a common vascular etiopathogenesis theory at the embryonic stage and question the heavy techniques of invasive remodeling that are most often unjustified.

[Thoracic surgery and co-morbid patients]

Patients undergoing lung resection are often active or former smokers who have chronic disease related to tobacco (coronary artery disease, chronic obstructive bronchitis, arteritis of the inferior limbs…). Those co-morbidities increase the operative risk for surgery in which morbi-mortality is relevant. On top of this, we are witnessing an increasing number of non-small cell lung cancers in an aging population that might show signs of frailty. The challenge for the surgeon is to identify early those co-morbid and/or frail patients by using predictive scores like Thoracoscore, mFI (modified frailty index) or MSK-F1 (Memorial Sloan-Kettering Frailty Index). Screening for those high-risk patients implies adapting surgical management through a multidisciplinary approach. That is the objective of co-managment, which allows geriatricians and surgeons to collaborate, or enhanced recovery after surgery which is more accessible to all group ages. The objective of this article is to review the management of co-morbid patients in thoracic surgery, by detailing certain predictive scores available and the multidisciplinary approaches developed to treat the patients screened.

[Transbronchial cryobiopsy in diffuse interstitial lung diseases]

INTRODUCTION

In the diagnostic approach to interstitial lung disease (ILD), the use of transbronchial cryobiopsy (TBC) may offer an alternative to surgical lung biopsy (SLB). We report the diagnostic effectiveness and the safety of TBC in ILD based on the preliminary experience in two French university centers.

METHODS

Twenty four patients underwent TBC for the diagnosis of ILD in the operating room between 2014 and 2017. All the histological diagnoses obtained were then reviewed and validated during multidisciplinary discussions (MDD).

RESULTS

Patients had an average of 3 TBC.TBC samples were analyzable in 22/24 (91.7%) patients. In these, samples allowed a histological diagnosis to be made in 14/22 (63.6%) patients and a diagnosis with certainty in 13/22 (59%) after MDD. The overall diagnostic yield from TBC was 13/24 (54.2%). Nine (37.5%) patients had a pneumothorax. Five (20.8%) patients had a bleeding. There were no deaths. Taking into account a possible initial learning curve and considering only the 15 patients who had their TBC after 2015, we note that a diagnosis could be made after MDD for 12 of them, that is, 80%.

CONCLUSION

A prospective randomized study is needed to evaluate the technique in France in order to specify its diagnostic performance and its safety profile in comparison to SLB.

[Bronchial carcinoid tumor and recurrent pneumothoraxes]

Pneumothorax is a rare clinical manifestation of lung cancer. It can exceptionally reveal a bronchial carcinoid tumor. We present the case of a 27-year-old woman in whom recurrent pneumothoraxes were the clinical manifestation of a bronchial carcinoid tumor. The interest for chest computed tomography and bronchoscopy to identify etiology of secondary pneumothoraxes will be discussed.

2014 update on non-small cell lung cancer (excluding diagnosis)

Lung cancer (LC) is a major public health issue because of its frequency, but especially because of the severity of this disease. The epidemiology has changed with an increased incidence in non-smokers and women. The ATS/ERS/IASLC classification of adenocarcinomas was modified in 2011, and they are now the most frequent histological subtype. More than half the cases of LC are diagnosed at the metastatic stage. Biopsies must provide tissue samples that are quantitatively large enough and of a good enough quality for diagnosis and to search for biomarkers. When the cancer seems to be localized, precise staging must be obtained. Treatment is based on the TNM classification. In localized stages, lobectomy associated with lymph node dissection is the standard therapy. Intraoperative chemotherapy improves survival in case of lymph node infiltration. Stereotactic radiation therapy and radiofrequency can be considered as specific cases. In cases with local progression, treatment is more controversial. In the presence of metastases, the goal is not a cure, but improving survival and quality of life. Numerous advances have been made with personalized treatment, (in particular in relation to the histological type and oncogenic addiction in tumors, access to new drugs, and improved management). Clinical research in thoracic cancer is very active. The fight against tobacco should remain a priority.

[Flexible endoscope in thoracic surgery: CITES or cVATS?]

Early pain and persistent parietal disorders remains a major unresolved problem in thoracic surgery. Thoracotomy and the use of multiple ports in most Video Assisted Thoracic Surgery (VATS) procedures are the major cause of this persistent pain. For the last decade, a few publications describing the use of either single incision VATS and cervical thoracic approaches have been reported without significant results in comparison with current used techniques. Intercostals compression during surgery and early after by intercostals chest tube placement, are probably the major cause of postoperative pain. Flexible endoscope is currently used in several surgeries and will take more and more importance in our daily use in thoracic surgery. Instrument flexibility allows its use through minimally invasive approaches and offers a very interesting intra-thoracic navigation. We describe here the first use in France of a flexible endoscope in thoracic surgery through a single cervical incision to perform simultaneous exploration and biopsies of the mediastinum and right pleura using the original approach of Cervical Incision Thoracic Endoscopic Surgery (CITES).

Value of cancer antigen 125 for diagnosis of pleural endometriosis in females with recurrent pneumothorax

The thorax is the most frequent extrapelvic location of endometriosis. Thoracic endometriosis is probably responsible for the high rate of recurrent pneumothoraces in females. The goal of the present prospective study was to assess the value of cancer antigen (CA)125 measurement in the detection of endometriosis in order to further enable early and adequate treatment of catamenial pneumothorax. Between January 2004 and March 2006, 31 females (mean age 32 yrs) underwent pneumothorax surgery. The control group comprised 17 males (mean age 27 yrs), who underwent videothoracoscopic pleural abrasion. Serum CA125 was measured around a menstrual period in females and before surgery in males. Videothoracoscopically diagnosed endometriosis occurred in 29% of females. The CA125 concentration was significantly higher in females with endometriosis compared to disease-free females (76.1 versus 16 U x mL(-1)). The mean value in males was similar to that observed in disease-free females. The frequency of thoracic endometriosis-related pneumothorax corresponds to, on average, a third of females presenting with recurrent pneumothorax. Early detection can be achieved with serum cancer antigen 125 measurement and may be helpful in indicating videothoracoscopic surgery.

Renal lymphatic drainage and thoracic duct connections: implications for cancer spread

Studies on renal lymph drainage have generally described lymph nodes without further investigation of the lymph vessels. Our purpose was to revisit this organ to study the vessel drainage pattern. This investigation was performed on 16 refrigerated adult cadavers. After both kidneys were injected with a blue modified Gerota mass, lymph vessels were dissected until their termination. From the right kidneys (n = 13), lymphatics (n = 8) traveling on the anterior aspect of the inferior vena cava were dissected, reaching interaortocaval and more distant nodes, aorta bifurcation (n = 1) and left lateroaortic (n = 1); posterior lymphatics were observed in all subjects, uniformly connecting to the thoracic duct, either after crossing nodes (n = 8) or directly (n = 5). From the left kidneys (n = 13), anterior efferents (n = 16) were dissected, reaching left lateroaortic and also celiac (n = 4) and iliac (n = 1) nodes; posterior lymphatics were also demonstrated, always connecting to the thoracic duct (3 directly). Renal lymphatics have been found to reach very distant nodes as well as always connecting to the origin of the thoracic duct. This feature suggests an important role in both the formation of the thoracic duct and in the spread of renal cancer.

[Spontaneous hemothorax: a rare but serious complication of intralobular pulmonary sequestration]

Pulmonary sequestration is a rare congenital malformation characterized by a non-functional portion of pulmonary parenchyma devoid of any connection with the bronchial tree and pulmonary artery. If not identified antenatally or at birth, the sequestration may not be discovered until complications, mainly repeated infections, arise. Hemorrhage is another but much rarer complication which is generally severe. We report a new case of intralobular pulmonary sequestration revealed by hemoptysis then massive hemothroax with shock requiring emergency thoracotomy for hemostasis.

The cutaneo-lymph node flap of the superficial circumflex artery

Upper limb lymphoedema and associated radiation-damaged chest wall are complications occurring after breast cancer treatment. Previous anatomical and clinical studies have demonstrated the usefulness of inguinal lymph node autotransplantation in managing lymphoedema. The present anatomical study is a complement to previous studies about the cutaneous inguinal flap. It has demonstrated the feasibility of using a free inguinal cutaneo-lymph node flap supplied by the superficial circumflex iliac artery. The useful vascularized abdominal skin area ranged from 176 to 288 cm2 and was contained within a vascularized skin area extending up to 928 cm2. However, the vascularization never extended widely beyond the abdominal midline line. Although it mainly remains unilateral, this flap combining skin and lymph nodes may help in the management of lymphoedema and chest wall damage when they occur simultaneously as complications of breast cancer treatment. The French version of this article is available in the form of electronic supplementary material and can be obtained by using the Springer LINK server located at http://dx.doi.org/10.1007/s00276-002-0024-7.