A. Arame

Is the lymphatic drainage of lung cancer lobe-specific? A surgical appraisal

OBJECTIVES Nowadays, early-stage lung cancers are more frequently encountered. Selective lymph node (LN) dissection based on lobe-specific lymphatic pathway has been proposed. Our aim was to study nodal involvement according to tumour location. METHODS We reviewed 1779 lobectomized patients and analysed their pathological characteristics according to tumour location: Group 1 (G1), right upper lobe; Group 2 (G2), right middle lobe; Group 3 (G3), right lower lobe; Group 4 (G4), left upper division; Group 5 (G5), lingula; Group 6 (G6), left lower lobe. The pN status was recorded for each group to analyse the lymphatic spread of non-small-cell lung cancer (NSCLC) according to tumour location. RESULTS The numbers and proportions of lobectomies in each group were 613 patients in G1 (59.2%), 64 in G2 (6.4%), 359 in G3 (34.6%), 404 in G4 (54.3%), 54 in G5 (7.3%) and 286 in G6 (38.4%). The rates of pN2 involvement were similar, whatever the group was, even when deciphering single- and multistation diseases. on the right side, single-station N2 disease was mainly found in the superior mediastinum (SM) for G1 (95%), and in the inferior for G3 (90%). On the left side, single-station N2 was mainly found in the SM in G4 (94%), and the inferior in G6 (48%). Whatever the side, in case of two-station involvement, both mediastina were concerned in 40% (in G4) to 81% of the case (in G3). Long-term survival rates were different in skip metastasis, single- and multistation involvement, but not between lobes. CONCLUSIONS Tumour location is not a predictor of nodal metastasis pattern. In surgical treatment of NSCLC, complete systematic mediastinal LN dissection remains the only acceptable procedure from an oncological point of view.

Current indications and results for thoracoplasty and intrathoracic muscle transposition.

OBJECTIVES Thoracoplasty has lost much of its popularity and is being supplanted by space-reduction operations using muscle flaps. Our purpose is to retrospectively study the remaining indications and the evolving modifications of this ancient technique in our current surgical practice. PATIENTS AND METHODS From 1994 to 2008, 35 patients underwent a thoracoplasty procedure in a single thoracic surgery centre for treatment of infectious complications of previous thoracic surgery. The number and length of ribs excised were dictated by the size and location of the thoracic cavity to obliterate. Muscle flaps were used to buttress bronchial fistulas and to fill out residual spaces. We reviewed the immediate and long-term results concerning infection control and procedure tolerance. RESULTS The infectious complications of previous thoracic surgery were related to cancer in 25, tuberculosis in six, oesophageo-pleural fistula in two, ruptured lung abscess and pleural thickening in one each. The thoracoplasty procedure was performed for: (1) post-pneumonectomy empyema, n=20 (bronchial fistula, n=11; open window thoracostomy, n=14; mean number of resected ribs, n=7.5; associated intrathoracic muscle transposition, n=12; postoperative death, n=3); (2) post-lobectomy empyema, n=8 (bronchial fistula n=8; open window thoracostomy n=1; mean number of resected ribs n=3.6; associated intrathoracic muscle transposition n=7; no death); (3) other indications, n=7 (mean number of resected ribs n=4.8; associated intrathoracic muscle transposition n=3; no death). All patients discharged from the hospital except one were cured and did not complain of symptoms of secondary lung function and shoulder impairment. CONCLUSION Although thoracoplasty is rarely indicated nowadays, this does not imply that the procedure should be avoided. Thoracoplasty may be associated with myoplasty, which permits achieving complete space obliteration by combining resection of a few rib segments and limited intrathoracic muscle transposition.

Non–Small Cell Lung Cancer Invading the Chest Wall

Non-Small cell lung cancer invading the chest wall represents an advanced stage of the disease. Chest wall resection may be achieved in up to 100% of the patients, and the ensuing defect requires to be reconstructed in 40% to 64% of cases. Once a surgical challenge, chest wall resection is no longer a technical problem and en bloc chest wall and lung resections regularly provide good results. However, survival rates are jeopardized by incompleteness of the resection and mediastinal lymph node involvement. Nowadays, the challenge is represented by the use of the other nonsurgical modalities (chemotherapy and radiation therapy) to increase the chance of performing a complete resection, the need to achieve a better control of probable lymphatic or hematogenous spread, and the reduction of the recurrence rate.

Lung cancer invading the fissure to the adjacent lobe: more a question of spreading mode than a staging problem

OBJECTIVES Lung cancer invading beyond the interlobar pleura, classified as T2a in the new TNM, is a rare entity with a poor outcome. Our purpose was a better understanding of the mechanisms of this particular behaviour and its prognostic value. METHODS Patients who underwent surgery between 1984 and 2007 were reviewed. We focused on T1 and T2 tumours. Tumours not traversing the pleural elastic layer were defined as PL0, extending through the layer as PL1 and extending to the surface of the visceral pleura as PL2. We considered three groups: group 1, tumours invading the lobar fissure, group 2, PL0-tumours and group 3, PL1 + PL2 tumours and studied their pathology and prognostic characteristics. RESULTS The distribution was as follows: group 1 n = 154, group 2 n = 2310 and group 3 n = 651. Pneumonectomy was necessary in 55.2% and bilobectomy in 19.5% of group 1, and N-involvement was present in 55.8% (significantly more than other groups). The mean tumour size (42.7 ± 12 mm) was bigger in group 1. Post-operative mortality was as follows: -5.2, -3.5 and 3.2% in groups 1, 2 and 3, respectively (P = 0.49). Five-year survival rates were: group 1: 38.9%, group 2: 52.5% and group 3: 43.4%; P = 0.00002. Survival was not different between groups concerning pN1 and pN2, but poorer in groups 1 and 3 than in group 2 in pN0 patients, P = 0.0057. Survival was 48.1, 37.9 and 38.4% for tumours between 31 and 70 mm in groups 2, 1 and 3, respectively, P = 0.0024 (but P = 0.65 between groups 1 and 3). Pneumonectomy was a poor prognostic factor in all groups, but survival between pneumonectomy and bilobectomy was not different in group 1. Multivariate analysis confirmed intralobar invasion to be an independent factor of poor prognosis, as well as visceral pleura invasion. CONCLUSIONS Tumours invading through the fissure have a significant effect on long-term survival in the first stages of lung cancer but also in all stages because of their size and important locoregional spread. Their prognostic value is due to pleural invasion, whose role in lung cancer dissemination is worth further research.

Lung Cancer Invading the Pericardium: Quantum of Lymph Nodes

BACKGROUND Lung cancer may invade the pericardium (T3) and the intrapericardial pulmonary veins and left atrium (T4). Our purpose was to analyze the characteristics of this invading process in search of the reasons explaining its poor prognosis. METHODS The clinical records of 4,668 patients who underwent surgery for lung cancer between January 1983 and December 2006 in two thoracic surgery centers were retrospectively reviewed. The epidemiology, pathology, and prognostic characteristics of the tumors invading the pericardium alone (T3) or with pulmonary veins and atrium (T4) were analyzed and compared with all other tumors. RESULTS There were 75 male and 16 female patients, with 85 pneumonectomies and 6 lobectomies that proved R0 in 59.3% of patients, and contained 69 squamous cell cancers, 11 adenocarcinomas, and 13 miscellaneous tumors; 12 were N0 (13.2%), 31 were N1 (34.1%), and 48 were N2 (52.8%). Pericardium alone was invaded in 32 patients (35.2%), and with pulmonary vein and atrium in 34 (37.3%) and 25 (27.5%), respectively. Patient characteristics were similar in each group. Five-year and 10-year survival rates were 15.1% and 10.4%, respectively. Frequency of pneumonectomy, R1-2 resection, and N1-2 involvement were significantly more important compared with noninvading tumors (p < 10(-6)). CONCLUSIONS Reports on T3 and T4 cancer with pericardial involvement are few, but also stress that pulmonary vein and left atrium invasion does not worsen the prognosis more than pericardial invasion alone. The rich pericardial lymph drainage might enhance the spread of tumor cells, explaining excessively high N1-N2 rates and pericardial invasion-related poor prognosis.

Prevention of middle lobe torsion or bronchial plication using anti-adhesive membrane: a simple, safe and uncomplicated technique!

Middle lobe torsion after right upper lobectomy is a rare but serious complication. Simple lobar shift may also lead to a bronchial plication, causing iterative pneumopathies. The preventive fixation of middle lobe to lower lobe is indicated to avoid these complications in case of complete major fissure. We performed this fixation, by using a resorbable anti-adhesive membrane, usually indicated in preventing postoperative pleural adhesion. This procedure is simple, effective, quick, and easy to perform without any risk of air leaks.

Unexpected extensions of non-small-cell lung cancer diagnosed during surgery: revisiting exploratory thoracotomies and incomplete resections

OBJECTIVES Only patients with a complete resection of non-small-cell lung cancer (NSCLC) may expect long-term survival. Despite the recent progress in imaging and induction therapy, a thoracotomy may remain exploratory or with incomplete resection (R2). Our purpose was to revisit these situations. METHODS A total of 5305 patients who underwent surgery for NSCLC between 1980 and 2009 were reviewed. We compared the epidemiology, pathology, causes and prognosis characteristics of exploratory thoracotomy (ET) and R2 resections. RESULTS ET and R2 resections were observed in 223 (4%) and 197 (4%) patients, respectively. The frequency of ET decreased with time, while the frequency of R2 resection remained almost stable. The indications for ET and R2 resections were not significantly different. In comparison with ET, R2 resections were characterized by a significantly higher frequency of induction therapy (22 vs 17%, P < 10(-3)), adenocarcinomas (49 vs 15%, P < 10(-6)), T1-T2 (53 vs 29%, P < 10(-6)) and N0-N1 extension (67 vs 42%, P = 10(-6)). R2 resections were also characterized by a higher rate of postoperative complications (19.1 vs 9.9%, P = 0.014), with no significant difference in postoperative mortality (6.9 vs 4.9%, P = non significant). R2 resections resulted in a higher 5-year survival compared with ET (11.1 vs 1.2%, P = 10(-3)). There was no long-term survivor after ET, except during the last decade. CONCLUSIONS ET and R2 remain unavoidable. In comparison with ET, R2 resection is associated with a higher rate of postoperative complications, but a higher long-term survival.

Long-term survival with surgery as part of a multimodality approach for N3 lung cancer

OBJECTIVES The extension of non-small-cell lung cancer (NSCLC) to supraclavicular (SC) and contralateral (CL) mediastinal lymph nodes is termed N3 and usually forbids surgical resection. However, scarce surgical series have reported encouraging results, and we sought to analyse our experience with this particular subgroup of patients. METHODS We retrospectively reviewed the charts of 5857 patients undergoing surgery for NSCLC during the last 30 years in two French centres. Eleven patients presenting with pathological-N3 were found, and more closely analysed concerning lymphatic spread, surgical indication and prognosis. RESULTS N3 consisted of tumoural extension to the SC (n = 5), CL mediastinal (n = 5) or both (SC + CL, n = 1) stations. Patients underwent induction treatment with chemotherapy alone (n = 4), chemoradiotherapy (n = 3) or first-line surgery (n = 4). All patients underwent a complete surgical resection of the tumour associated with ipsilateral systematic mediastinal lymph node dissection. Additional resection of N3 lymph nodes was performed in 8 cases. Adjuvant treatment included chemoradiotherapy (n = 6), chemotherapy alone (n = 1) or radiation therapy alone (n = 1). All 5 patients with SC-N3 presented with ipsilateral disease; 3 of them survived 5 years. Four patients with CL-N3 presented with left-sided tumour and nodal extension to the 4R station, and none of them survived. CONCLUSIONS Some N3-patients with specific anatomical location may benefit from multimodality treatment including surgery. These results support further prospective studies for selected N3-patients.

Facteurs pronostiques cliniques et paracliniques dans la chirurgie du cancer du poumon non à petites cellules

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.

Dysfonctions et paralysies diaphragmatiques : de la physiopathologie au traitement chirurgical

The clinical presentations of diaphragm dysfunctions vary according to etiologies and unilateral or bilateral diseases. Elevation of the hemidiaphragm from peripheral origins, the most frequent situation, requires a surgical treatment only in case of major functional impact. Complete morphological and functional analyses of the neuromuscular chain and respiratory tests allow the best selection of patients to be operated. The surgical procedure may be proposed only when the diaphragm dysfunction is permanent and irreversible. Diaphragm plication for eventration through a short lateral thoracotomy, or sometimes by videothoracoscopy, is the only procedure for retensioning the hemidiaphragm. This leads to a decompression of intrathoracic organs and a repositioning of abdominal organs without effect on the hemidiaphragm active contraction. Morbidity and mortality rates after diaphragm plication are very low, more due to the patients general condition than to surgery itself. Functional improvements after retensioning for most patients with excellent long-term results validate this procedure for symptomatic patients. In case of bilateral diseases, very few bilateral diaphragm plications have been reported. Some patients with diaphragm paralyses from central origins become permanently dependent on mechanical ventilation whereas their lungs, muscles and nerves are intact. In patients selected by rigorous neuromuscular tests, a phrenic pacing may be proposed to wean them from respirator. Two main indications have been validated: high-level tetraplegia above C3 and congenital alveolar hypoventilation from central origin. After progressive reconditioning of the diaphragm muscles following phrenic pacing at thoracic level, more than 90% of patients can be weaned from respirator within a few weeks. This weaning improves the quality of life with more physiological breathing, restored olfaction, better sleep and better speech. The positive impact of diaphragm stimulation has also been evaluated in other degenerative neurological diseases, particularly the amyotrophic lateral sclerosis. For either central or peripheral diaphragm dysfunctions, a successful surgical treatment lies on a strict preoperative selection of patients.