Antoine Legras

Pneumothorax Recurrence After Surgery in Women: Clinicopathologic Characteristics and Management

BACKGROUND Our aim was to study the clinical, surgical, and pathological characteristic of women with homolateral recurrence of pneumothorax despite previous surgery. METHODS This study is a retrospective analysis of the clinical and pathological records of all consecutive women of reproductive age hospitalized in a thoracic surgery department for surgical treatment of pneumothorax recurrence despite previous surgery between 2000 and 2009. RESULTS During the study period, 35 women were operated on. Their mean age was 37 years. Twenty-nine pneumothoraces (83%) were right sided. In 20 women, the recurrence occurred during the menstrual period. At initial surgery, 5 cases had been catamenial with evidence of thoracic endometriosis, 12 were catamenial with no evidence of endometriosis, 5 were noncatamenial with thoracic endometriosis, and 13 were idiopathic. At repeat surgery the figures were 18, 4, 5, and 8 cases, respectively. Repeat operation was carried out by video-assisted thoracoscopy in 13 cases, video-assisted minithoracotomy in 10, and standard thoracotomy in 12. Partial diaphragmatic resection was performed at repeat surgery in 16 patients (45.7%). Talc pleurodesis and pleural abrasion were carried out in 20 (57.1%) and 15 patients (42.9%), respectively. No major morbidity was observed. After repeat surgery, hormonal treatment was prescribed in 24 cases. Median follow-up was 40 months (range, 1.5 to 138 months). In 6 women, further homolateral recurrence of pneumothorax occurred (17.1%) and required surgery in 3 cases. CONCLUSIONS Repeat surgery can be safely performed in women with recurrence of pneumothorax despite previous surgery, and frequently shows initially missed endometriosis.

Long-Term Survival of Patients With pN2 Lung Cancer According to the Pattern of Lymphatic Spread

BACKGROUND N2 involvement has dramatic consequences on the prognosis and management of patients with non-small cell lung cancer (NSCLC). N2-NSCLC may present with or without N1 involvement, constituting non-skip (pN1N2) and skip (pN0N2) diseases, respectively. As the prognostic impact of this subclassification is still a matter of debate, we analyzed the prognosis of pN2 patients according to the pN1-involvement and the number of N2-stations concerned. METHODS The medical records of consecutive patients who underwent surgery for pN2-NSCLC in 2 French centers between 1980 and 2009 were prospectively collected and retrospectively reviewed. Patients undergoing induction therapy, exploratory thoracotomy, incomplete mediastinal lymphadenectomy, or incomplete resections were excluded. The prognoses of pN1N2 and pN0N2 patients were first compared, and then deciphered according to the number of N2 stations involved (single-station: 1S, multi-station: 2S). RESULTS All together, 871 patients underwent first-line complete surgical resection for pN2-NSCLC during the study period, including 258 pN0N2 (29.6%) and 613 pN1N2 (70.4%) patients. Mean follow-up was 72.8±48 months. Median, 5- and 10-year survivals were, respectively, 30 months, 34%, and 24% for pN0N2 and 20 months, 21%, and 14% for pN1N2 patients (p<0.001). Multivariate analysis revealed 3 different prognostic groups; ie, favorable in pN0N2-1S disease, intermediate in pN0N2-2S and pN1N2-1S diseases, and poor in pN1N2-2S disease (p<0.001). CONCLUSIONS Among pN2 patients, the combination of N1 involvement (pN0N2 vs pN1N2) and number of involved N2 stations (1S vs 2S) are independent prognostic factors. These results might be taken into consideration to sub-classify the heterogeneous pN2-NSCLC group of patients.

Number of mediastinal lymph nodes in non-small cell lung cancer: a Gaussian curve, not a prognostic factor.

BACKGROUND It has been proposed that examining a greater number of lymph nodes (LNs) in patients with non-small-cell lung cancer (NSCLC) treated by surgical resection may increase the likelihood of proper staging and affect outcome. Our purpose was to evaluate the interindividual variability and prognostic relevance of the number of LNs harvested during complete pulmonary and mediastinal lymphadenectomy performed for NSCLC. METHODS We prospectively collected and retrospectively reviewed the data from 1,095 patients who underwent lung cancer resection in association with systematic lymphadenectomy and pulmonary and mediastinal LN counts from 2004 to 2009. We analyzed the interindividual variability and prognostic impact of the number of LNs on overall survival (OS). RESULTS The mean number of harvested pulmonary and mediastinal LNs was 17.4±7.3 (range, 1-65) and was higher in male patients, right lung surgical procedures, lobectomy and pneumonectomy, N2 disease, and pIII stage. The mean number of harvested mediastinal LNs was 10.7±5.6 and was normally distributed (range, 0-49; median, 10). The 5-year survival rate was 53.8%. Overall survival was influenced by the number of involved stations (single-station versus multi-station disease, 5-year survival rates 31.5% versus 16.9%, respectively; p=0.041) but not by the number of harvested LNs, the number of harvested mediastinal LNs, or the number of positive mediastinal LNs. CONCLUSIONS After lung cancer resection and complete lymphadenectomy, the number of LNs is subject to normally distributed interindividual variability, with no significant impact on OS. Recommending an optimal number of nodes is therefore arbitrary. Instead, our recommendation is to perform a complete systematic pulmonary and mediastinal lymphadenectomy following established anatomical boundaries.

Pneumothorax in Women of Child-Bearing Age: An Update Classification Based on Clinical and Pathologic Findings

BACKGROUND A significant percentage of pneumothorax in women is due to thoracic endometriosis. Pathophysiologic mechanisms continue to be debated, and pathologic aspects are poorly known. METHODS Clinical and pathologic records of all consecutive women of reproductive age operated on for pneumothorax between 2000 and 2011 were retrospectively reviewed. RESULTS Two hundred twenty-nine women (mean age, 33 years) underwent surgery. One hundred forty-four cases (63%) were right-sided, and pneumothoraces were catamenial for 80 women (35%). Diagnosed pelvic endometriosis was associated in 29 cases. At pathology, thoracic endometriosis was diagnosed in 54 cases (24%). Endometrial glands were observed in 33 of 54 cases and were often cystic (16 of 33). Stroma was observed in 51 of 54 cases and endometrial stroma without glands in 21 cases. Hemosiderin-laden macrophages were observed in 27 of 54 cases. All cases of thoracic endometriosis were positive for progesterone and/or estrogen receptors (intense and nuclear). Catamenial pneumothoraces (n = 80, 34.9%) were endometriosis related in 50% of cases (n = 40, 17% of the whole population). Pneumothoraces were noncatamenial but endometriosis related in 6% of cases (n = 14) and merely idiopathic in 60% of patients (n = 135). Multivariate analysis showed that right side, presence of diaphragmatic abnormalities, relapse after unilateral surgery, and presence of hemosiderin-laden macrophages were independent variables associated with thoracic endometriosis (all, P < .02). Apical emphysema-like changes were found in 184 of the 213 patients (86%) with apical resection and were significantly associated with the absence of thoracic endometriosis (P < .001). CONCLUSIONS In women with surgically treated pneumothorax, prevalence of catamenial/endometriosis-related pneumothorax is high. Clinicians and pathologists must be aware to recognize such a difficult diagnosis.

A review of 250 ten-year survivors after pneumonectomy for non-small-cell lung cancer.

OBJECTIVES During the last decades, pneumonectomy has been increasingly seen as a risky procedure, first reserved for tumours not amenable to lobectomy, and now discouraged even in advanced stages of non-small-cell lung cancer (NSCLC). Our purpose was to assess the long-term survival following pneumonectomy for NSCLC and its prognostic factors. METHODS We set a retrospective study including every patient who underwent a pneumonectomy for NSCLC in 2 French centres from 1981 to 2002. We then described the demographic and pathological characteristics of patients who survived >10 years, and studied the prognostic factors of long-term survival. RESULTS During the study period, 1466 pneumonectomies were performed for NSCLC, including 1121 standard and 345 extended, and accounted for the overall population. Postoperative complications occurred in 396 patients (27%), including 93 deaths (6.3%). Five- and 10-year survival rates were 32 and 19%, respectively. Two-hundred and fifty patients survived >10 years after surgery, and accounted for the study group. The study group included a majority of males (n = 230, 92%), a mean age of 57 ± 9.2 years and a majority of clinical stage IIIA (n = 117, 46.8%). Induction, right-sided pneumonectomy, extended resection and adjuvant therapy were performed in 41 (16.4%), 109 (43.6%), 40 (16%) and 97 patients (38.8%), respectively. Histology revealed a majority of squamous cell carcinoma (n = 181, 72.4%), T2 tumours (n = 117, 36.8%) and N1 disease (n = 105, 42%). In multivariate analysis, factors associated with adverse outcomes included older age, advanced stage, extended resection, non-lethal postoperative complication, adenocarcinoma, lymphatic vessel microinvasion, N1 and N2 disease and R1 and R2 resection. CONCLUSIONS During the last 30 years, pneumonectomy was effectively performed for advanced NSCLC, allowing a 10-year survival rate of 19%. Such results have not been reported with other non-surgical treatments and confirm that pneumonectomy is still an essential weapon in the armamentarium against lung cancer.

Surgical treatment of bronchiectasis: early and long-term results

Management of bronchiectasis remains controversial and information on long-term results of surgical treatment is poor. Clinical records of 45 patients, who underwent surgery for bronchiectasis in an 8-year period, were retrospectively reviewed. Bronchiectasis focus was isolated in 24 cases, associated with a limited homolateral or controlateral focus in 9 and 11, respectively; two patients had bilateral evident foci. Bronchiectasis was responsible for lobe destruction in 23 cases. All patients had symptoms: haemoptysis (n=7), recurrent pneumonia (n=7), persistent bronchorrea with recurrent infection (n=15), hemoptysis and recurrent infection (n=16). A total of 23 lobectomies, 11 lobectomies+segmentectomies, 2 bi-lobectomies, 9 segmentectomies and 1 pneumonectomy were carried out. There were no perioperative deaths; complications occurred in 5 patients (postoperative pneumonia in 2, prolonged air-leak, residual air-space and bronchial infection 1 each). Symptoms disappeared in 32 patients, 10 patients experienced a significant improvement. Exercise tolerance remained stable or improved in 33 and 2 cases, respectively, a slight impairment was observed in 9. Out of 32 evaluable patients 11 had an unchanged FEV(1), 15 had a limited FEV(1) lowering (<15%), and 9 had a more important functional loss. Surgical treatment of bronchiectasis obtains satisfactory long-term results, with acceptable morbidity rates.

Diaphragm pacing: the state of the art

Diaphragm pacing (DP) is an orphan surgical procedure that may be proposed in strictly selected ventilator-dependent patients to get an active diaphragm contraction. The goal is to wean from mechanical ventilation (MV) and restore permanent efficient breathing. The two validated indications, despite the lack of randomised control trials, concern patients with high-level spinal cord injuries (SCI) and central hypoventilation syndromes (CHS). To date, two different techniques exist. The first, intrathoracic diaphragm pacing (IT-DP), based on a radiofrequency method, in which the electrodes are directly placed around the phrenic nerve. The second, intraperitoneal diaphragm pacing (IP-DP) uses intradiaphragmatic electrodes implanted through laparoscopy. In both techniques, the phrenic nerves must be intact and diaphragm reconditioning is always required after implantation. No perioperative mortality has been reported and ventilator-weaning rate is about 72% to 96% in both techniques. Improvement of quality of life, by restoring a more physiological breathing, has been almost constant in patients that could be weaned. Failure or delay in recovery of effective diaphragm contractions could be due to irreversible amyotrophy or chest wall damage. Recent works have evaluated the interest of IP-DP in amyotrophic lateral sclerosis (ALS). After some short series were reported in the literature, the only multicentric randomized study including 74 ALS patients was prematurely stopped because of excessive mortality in paced patients. Then, another trial analysed the place of IP-DP in peripheral diaphragm dysfunction but, given the multiple biases, the published results cannot validate that indication. Reviewing all available literature as in our experience, shows that DP is an effective method to wean selected patients dependent on ventilator and improve their daily life. Other potential indications will have to be evaluated by randomised control trials.

Radiofréquence sur les métastases pulmonaires : un pneumothorax initial pourrait-il prédire un échec thérapeutique ?

In the management of lung metastases originating from colorectal cancer, RFA is particularly indicated in case of major comorbidities contraindicating thoracic surgery or recurrent disease after previous ipsilateral resection. The most frequent complication of RFA is pneumothorax, requiring chest tube insertion in 5% of cases. Interestingly, this proportion is very close to the rate of local recurrence, suggesting a possible association. We report a case of RFA followed by intractable pneumothorax requiring surgical management, and leading to the diagnosis of residual tumour. This case report illustrates this association and questions its relevance.

Lung transplantation in childhood and adolescence: unicentric 14-year experience with sex matching as the main prognosticator.

OBJECTIVES Lung transplantation (LTx) is an accepted therapy for selected infants, children and adolescents with end-stage lung and pulmonary vascular disease. It remains a challenge for a selected group of patients. In 2011, the number of paediatric lung transplantations (PLTxs) worldwide was 107. In France, a total of 131 PLTxs have been performed since 2000 (data from ABM: Agence de biomédecine), 65 of which were conducted at our institution. METHODS All patients under 18 (4.8-17.11) years of age matching inclusion and exclusion criteria, who underwent LTx at our institution were included in this study (n = 58). We analysed the outcomes of these patients in terms of survival rates, controlling for indications for transplantations and surgical procedures. Secondary outcomes were analysis of surgical and medical complications and identification of prognostic factors in the field of LTx in these categories of ages. RESULTS The 30-day mortality rate was 10%. Kaplan-Meier survival rates at 1 month, 1, 3, 5 and 10 years were 90, 81, 66, 60 and 57%, respectively; the median survival was 91 months. Reduced-size transplantation was performed in 33% of double-lung transplantation (DLTx) patients without negatively impacting survival. In our series, female sex, the presence of a sex mismatching and, in particular, the occurrence of a male donor to a female recipient (F/M group) have been poor prognostic factors after PLTx. CONCLUSIONS The overall survival after PLTx was encouraging (57% at 10 years). A PLTx should be offered to the small number of patients with end-stage pulmonary disease. The limited number of paediatric donor organs can be overcome by using reduced-size organs without a survival disadvantage to the patients. In our series, male sex and sex matching seemed to be positive predictive prognostic factors after PLTx but further studies are required to confirm these results and to also clarify the role of age of donor, time of cold ischaemia and body mass index in PLTx.

Systemic Artery to Pulmonary Vein Fistula After Right Upper Lobectomy Demonstrated by 4-Dimensional Flow Magnetic Resonance Imaging

Postoperative systemic artery to pulmonary vein fistula is very rare. In this report, we describe an exceptional condition of both intrapulmonary arteriovenous fistula and systemic artery to pulmonary vein fistula, involving all right hemithoracic systemic arteries, inducing left-to-left shunt. This condition was responsible for heart failure, 24 years after a right upper lobectomy for inflammatory tumor. Investigations included computed tomographic angiography, arteriography, and four-dimensional flow magnetic resonance imaging. Differential diagnosis and management are discussed.