B. Grand

Adenosquamous Carcinoma of the Lung: Surgical Management, Pathologic Characteristics, and Prognostic Implications

BACKGROUNDnAdenosquamous carcinoma (ASC) is a mixed glandular and squamous cell carcinoma with a more aggressive behavior than the other histologic subtypes of lung cancer. We revisited the pathologic characteristics and surgical results associated with ASC.nnnMETHODSnPatients who underwent surgical resection of non-small cell lung cancer in two French centers were retrospectively reviewed. Patients presenting with ASC (n=141) were compared to those with adenocarcinomas (AC, n=2415) and squamous cell carcinomas (SCC, n=2662) regarding preoperative data, histologic characteristics, and outcome.nnnRESULTSnThe frequency of ASC and SCC decreased over time. ASC patients were similar to AC patients regarding age, sex, and smoking habits. The type of resections performed in ASC patients was intermediary between SCC (more pneumonectomy) and AC (more lobectomy) patients. ASC was associated with larger size, more frequent visceral pleura invasion, microinvasion of the lymphatic vessels, and ipsilateral second nodules, compared with SCC and AC. Among the 135 patients with documented ASC, 48% presented with a combination of AC and SCC tumor cells ranging between 40% and 60% of each component, and 55% of cases were associated with undifferentiated large cells. ASC was associated with a lower 5-year survival rate (37%) than SCC and AC (43.4% and 42.8%, respectively, p=0.017). For ASC patients, survival was better during the last decade or in cases of balanced AC/SCC components.nnnCONCLUSIONSnASC is characterized by both histologic aggressiveness and adverse prognosis. In this setting, the impact of adjuvant therapies needs to be reevaluated.

High grade neuroendocrine lung tumors: Pathological characteristics, surgical management and prognostic implications

Among non-small cell lung cancers (NSCLC), large cell carcinoma (LCC) is credited of significant adverse prognosis. Its neuroendocrine subtype has even a poorer diagnosis, with long-term survival similar to small cell lung cancer (SCLC). Our purpose was to review the surgical characteristics of those tumors. The clinical records of patients who underwent surgery for lung cancer in two French centers from 1980 to 2009 were retrospectively reviewed. We more particularly focused on patients with LCC or with high grade neuroendocrine lung tumors. High grade neuroendocrine tumors were classified as pure large cell neuroendocrine carcinoma (pure LCNEC), NSCLC combined with LCNEC (combined LCNEC), and SCLC combined with LCNEC (combined SCLC). There were 470 LCC and 155 high grade neuroendocrine lung tumors, with no difference concerning gender, mean age, smoking habits. There were significantly more exploratory thoracotomies in LCC, and more frequent postoperative complications in high grade neuroendocrine lung tumors. Pathologic TNM and 5-year survival rates were similar, with 5-year ranging from 34.3% to 37.6% for high grade neuroendocrine lung tumors and LCC, respectively. Induction and adjuvant therapy were not associated with an improved prognosis. The subgroups of LCNEC (pure NE, combined NE) and combined SCLC behaved similarly, except visceral pleura invasion, which proved more frequent in combined NE and less frequent in combined SCLC. Survival analysis showed a trend toward a lower 5-year survival in case of combined SCLC. Therefore, LCC, LCNEC and combined SCLC share the same poor prognosis, but surgical resection is associated with long-term survival in about one third of patients.

History of multiple previous malignancies should not be a contraindication to the surgical resection of lung cancer.

BACKGROUNDnPatients with a history of previous malignancy are often encountered in a discussion of surgical resection of non-small-cell lung cancer (NSCLC). The outcome of patients with 2 or more previous cancers remains unknown.nnnMETHODSnWe performed a retrospective study including all patients undergoing resection for NSCLC from January 1980 to December 2009 at 2 French centers. We then compared the survival of patients without a history of another cancer (group 1), those with a history of a single malignancy (group 2), and those with a history of 2 or more previous malignancies (group 3).nnnRESULTSnThere were 5,846 patients: 4,603 (78%) in group 1, 1,147 (20%) in group 2, and 96 (2%) in group 3. The proportion of patients included in group 3 increased from 0.3% to 3% over 3 decades. Compared with groups 1 and 2, group 3 was associated with older age, a larger proportion of women, earlier tumor stage, less induction therapy, and fewer pneumonectomies. Despite this, postoperative complications and mortality were similar in groups 2 and 3, and higher than in group 1. Five-year survival rates were 44.6%, 35.1%, and 23.6% in groups 1, 2, and 3, respectively (p < 0.000001 for comparison between 3 groups; p = 0.18 for comparison between groups 2 and 3). In multivariate analysis, male sex, higher T stage, higher N stage, incomplete resection, and study group were significant predictors of adverse prognosis.nnnCONCLUSIONSnDespite earlier diagnosis and acceptable long-term survival, patients operated on for NSCLC after 2 or 3 previous malignancies carried a worse prognosis than did those undergoing operation after 1 malignancy or if there was no previous diagnosis of cancer.

Prognosis of lung cancer resection in patients with previous extra-respiratory solid malignancies

OBJECTIVESnNon-small-cell lung cancer (NSCLC) following pulmonary or pharyngolaryngeal malignancies has been widely studied, but only a few articles have focussed on lung cancers following other solid malignancies. Our purpose was to compare the characteristics and prognosis of patients with NSCLC according to the medical history of the extra-pulmonary and extra-pharyngolaryngeal solid malignancy.nnnMETHODSnPatients who underwent surgery for NSCLC from January 1980 to December 2009 in two French thoracic centres were reviewed. We compared patients with no history of cancer (Group 1) and patients with a history of extra-pulmonary and extra-pharyngolaryngeal solid malignancy (Group 2).nnnRESULTSnThere were 4992 patients: 4603 (92%) in Group 1 and 389 (8%) in Group 2. In comparison with Group 1, Group 2 showed an increasing incidence over the last 3 decades (2-8%), an older population (65.9 vs 61 years, P < 0.001), a higher proportion of women (34 vs 18%, P < 0.001), non-smokers (20 vs 10%, P < 0.001), adenocarcinomas (53 vs 40%, P < 0.001), T1 (16 vs 14%, P = 0.047) and second nodule in the same lobe (4 vs 2%, P < 0.001). The overall survival was not significantly different between the two groups (P = 0.09). In multivariate analysis, older age, male gender, pneumonectomy, higher T, higher N, incomplete resection and history of extra pulmonary-extra pharyngolaryngeal solid malignancy were significantly associated with a worse prognosis.nnnCONCLUSIONSnDespite an earlier diagnosis, a history of extra-pulmonary and extra-pharyngolaryngeal solid malignancy is associated with a worse prognosis in patients with NSCLC undergoing surgical resection. Overall survival is particularly low after a history of bladder and upper gastrointestinal malignancies.

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

OBJECTIVESnOnly 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.nnnMETHODSnA 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.nnnRESULTSnET 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.nnnCONCLUSIONSnET 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.

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.

Aspetti chirurgici della tubercolosi polmonare e dei micobatteri atipici

Descritta nel 1819, la tubercolosi polmonare ha accompagnato lo sviluppo della chirurgia toracica. Dopo l’abbandono delle tecniche di collassoterapia nel 1945 e il minor ricorso alla toracoplastica dopo gli anni ′80, le resezioni parenchimali restano il solo trattamento curativo possibile di situazioni cliniche complesse. La tubercolosi multiresistente (multidrug-resistant tuberculosis [MDR-TB]) deve beneficiare di una gestione chirurgica all’interno di equipe specializzate. Le caverne post-tubercolari, le distruzioni parenchimali e le dilatazioni dei bronchi da postumi possono complicarsi con un’emottisi e un’infezione da aspergillus o con infezioni recidivanti e devono, allora, essere operate. In queste indicazioni difficili, una preparazione preoperatoria rigorosa, una tecnica sistematica e delle cure postoperatorie vigili consentono di ottenere delle guarigioni definitive, al prezzo di una morbimortalita operatoria accettabile. Queste situazioni devono, quindi, essere conosciute dai chirurghi toracici, per non prolungare inutilmente dei trattamenti medici inefficaci e/o tossici.