Daniel Pop

EGFR and KRAS status of primary sarcomatoid carcinomas of the lung: Implications for anti-EGFR treatment of a rare lung malignancy

Sarcomatoid carcinomas (SC) of the lung are uncommon malignant tumors composed of carcinomatous and sarcomatous cell components and characterized by a more aggressive outcome than other histological subtypes of nonsmall cell lung cancer (NSCLC). Although epidermal growth factor receptor (EGFR)‐targeted therapies have emerged as a promising therapeutic approach in patients with advanced typical NSCLC such as adenocarcinoma, the potential clinical activity of these drugs in lung SC is still unknown. To investigate this point, we have analyzed the status of 4 EGFR pathways biomarkers in a series of lung SC. EGFR protein expression, EGFR gene copy number, EGFR mutational status and KRAS mutational status were assessed in a series of 22 consecutive cases of primary lung SC. EGFR protein overexpression was observed in all the cases. High level of polysomy (≥4 copies of the gene in >40% of cells) was detected in 5 cases (23%). No EGFR mutation was detected. KRAS mutations were found in 8 patients (38%; Gly12Cys in 6 cases and Gly12Val in 2 cases). The consistent EGFR protein overexpression and the high rate of KRAS mutation may contribute to the poorer outcome of lung SC in comparison with typical NSCLC. The rare incidence of increased EGFR gene copy number, the lack of EGFR mutation and the high rate of KRAS mutation observed in our series also suggest that most patients with lung SC are not likely to benefit from anti‐EGFR therapies.

Skeletal Muscle Metastasis from Non-small Cell Lung Cancer

Purpose: Skeletal muscle metastases (SMM) from non-small cell lung cancer (NSCLC) are rarely encountered in clinical practice. The prognosis and the adequate treatment are not known. The aim of the study was to report our experience and to make an extensive literature research concerning SMM. Patients and Methods: In our unit, we identified 16 patients with SMM in a 10-year period. The source of our literature search (English and French language) was the international MEDLINE database, and it exhausted all cited publications. Results: We found 114 cases in the international literature (follow-up period mentioned in 72 cases). Pain was the most frequent symptom (83%). A mass was palpable in 78% of cases. The diagnosis was obtained by either fine needle/surgical biopsy or wide exeresis. The 5-year survival time was 11.5% with a median survival of 6 months. The 5-year survival rates: number of SMM − single versus multiple (13.6% [67 patients] versus 0% [21 patients]; p = 0.0022); disease-free interval (DFI) >6 months versus DFI ≤6 months (16.9% [18 patients] versus 9.1% [70 patients ]; p = 0.0458). We built three groups of prognostic significance: group I: DFI >6 months and single metastasis; group II: DFI >6 months or single metastasis; and group III: DFI ≤6 months and multiple metastasis. The 5-year survival rates were: group I (14 patients): group II (57 patients):group III (17 patients) = 28%:6%:0% (p = 0.0000), and the median survival was 19:9:4 months. Conclusion: The presence of SMM suggests an aggressive disease. Selection of patients for a local treatment is an important factor that determines survival. The ideal patient had a unique metachronous metastasic deposit that can be treated by surgery.

Lesson to be learned: beware of lusoria artery during transhiatal esophagectomy.

The presence of an aberrant right subclavian artery represents a potentially risky situation when high mediastinal surgery is planned. We report a case of a patient needing transhiatal esophagectomy for cancer; the presence of the abnormal anatomic arterial situation complicated the postoperative course, when a vascular- digestive fistula appears. We discuss the direct causes and consequences of a rare situation.

Postoperative exacerbation of chronic obstructive pulmonary disease. Does it exist

BACKGROUND One of the characteristics of chronic obstructive pulmonary disease (COPD) is the tendency to develop acute exacerbation, defined by the presence of different clinical findings as worsening dyspnea, increase in sputum purulence and volume. This study was designed to verify if definition of acute COPD exacerbation is applicable to patients who underwent pulmonary surgery, and if it has any impact on postoperative morbidity and mortality. METHODS This study was designed to prospectively enrol 1000 patients undergoing pulmonary resection for lung cancer from five different centres. Postoperative exacerbation of COPD was defined by the concomitant presence of three of the following five signs: deteriorating dyspnea, purulent sputum, bronchial secretion volume >10 ml/24 h, fever without apparent cause, and wheezing. The presence of concomitant pulmonary complications excluded the diagnosis of exacerbation, as they may present one or more of these signs. RESULTS In the absence of respiratory complications, postoperative stay in exacerbated patients was significantly longer as compared to patients without exacerbation (6.3+/-1.3 vs 8.3+/-1.1, p=0.001). A postoperative exacerbation of COPD was recorded in 276 patients and 152 of them (55%) subsequently developed respiratory complications. Multivariate analysis established that risk factors for postoperative exacerbation are sex (female OR 0.54, CI 0.2-0.8), COPD class (OR 1.5, CI 1.1-8.1), and the postoperative prolonged use of antibiotics (OR 0.6, CI 0.2-0.9). CONCLUSIONS Postoperative exacerbation of COPD is an existing, frequent clinical entity after lung resection and, when present, it increases the risk of pulmonary complications. The existing guidelines for the treatment of acute exacerbation should be adapted for the management of patients after lung resection in order to test the hypothesis that they could reduce respiratory morbidity.

Anticipating pulmonary complications after thoracotomy: the FLAM Score

ObjectivePulmonary complications after thoracotomy are the result of progressive changes in the respiratory status of the patient. A multifactorial score (FLAM score) was developed to identify postoperatively patients at higher risk for pulmonary complications at least 24 hours before the clinical diagnosis.MethodsThe FLAM score, created in 2002, is based on 7 parameters (dyspnea, chest X-ray, delivered oxygen, auscultation, cough, quality and quantity of bronchial secretions). To validate the FLAM score, we prospectively calculated scores during the first postoperative week in 300 consecutive patients submitted to posterolateral thoracotomy.ResultsDuring the study, 60 patients (20%) developed pulmonary complications during the postoperative period. The FLAM score progressively increased in complicated patients until the fourth postoperative day (mean 13.5 ± 11.9). FLAM scores in patients with complications were significantly higher (p < 0.05) at least 24 hours before the clinical diagnosis of complication, compared to FLAM scores in uncomplicated patients. ROC curves analysis showed that the cut-off value of FLAM with the best sensitivity and specificity for pulmonary complications was 9 (area under the curve 0.97). Based on the highest FLAM scores recorded, 4 risk classes were identified with increasing incidence of pulmonary complications and mortality.ConclusionChanges in FLAM score were evident at least 24 hours before the clinical diagnosis of pulmonary complications.FLAM score can be used to categorize patients according to risk of respiratory morbidity and mortality and could be a useful tool in the postoperative management of patients undergoing thoracotomy.

Gas gangrene of the breast: management of a potential life-threatening infection

IntroductionGas gangrene of the breast is a rare infection and potentially mortal.Case reportWe report a case of a fast extension of a painful right breast erythema whose starting point was a right parasternal cutaneous abscess. A diagnosis of gas gangrene of the right breast was made. A right mammectomy was carried out in Emergency and an antibiotherapy adapted to the germs was given.ConclusionMixed anaerobic and aerobic florae are often responsible for the infection. Its medico-surgical management is an emergency.

Bronchopleural fistula: the Damocles sword of all pneumonectomies

The postpneumonectomy bronchopleural fistula (BPF) remains a difficult challenge for the thoracic surgeon. We report the case of a very late-onset (60 years) left BPF managed by video-assisted mediastinoscopy discussing the direct consequences of this complication in the postpneumonectomy period.

Late mediastinal hematoma followed by incisional metastasis after video-assisted mediastinoscopy.

Cervical mediastinoscopy plays an important role for diagnosis and staging of lung cancer. Rare complications, mostly bleeding or mediastinal hematoma arrived in the preoperative or immediate postoperative period.1 Distantly, incisional metastases are uncommon.2 We report an unusual case of late compressive mediastinal hematoma revealed by scar bleeding followed by cervical incisional metastasis.

Peroperative fiducial placement for postoperative stereotactic Cyberknife radiosurgery

Radiotherapy is often the treatment used for inoperable early-stage lung cancer as well as pulmonary metastases. In the last decade, efforts were done to increase local control with high-dose radiation without excessive collateral damage. Initially used for cranial lesions, stereotactic radiosurgery enlarged extracranial indications; the Cyberknife radiosurgery system needs metal (gold) markers for image guidance. For lung tumours, fiducials are inserted computed tomography (CT)-guided or bronchoscopy-guided. We describe four patients where fiducial placement was done during surgery.

Pancreatic Adenocarcinoma Arising From Esophageal Duplication

Esophageal duplication is a rare congenital malformation containing different types of tissues. We report the case of a woman with a large mediastinal tumor. After surgical resection, histologic examination showed pancreatic adenocarcinoma arising from esophageal duplication. Adjuvant chemotherapy was given briefly afterward.