Éric Fréchette

Randomized, Double-Blind, Placebo-Controlled, Phase III Chemoprevention Trial of Selenium Supplementation in Patients With Resected Stage I Non–Small-Cell Lung Cancer: ECOG 5597

PURPOSE Selenium has been reported to have chemopreventive benefits in lung cancer. We conducted a double-blind, placebo-controlled trial to evaluate the incidence of second primary tumors (SPTs) in patients with resected non-small-cell lung cancer (NSCLC) receiving selenium supplementation. PATIENTS AND METHODS Patients with completely resected stage I NSCLC were randomly assigned to take selenized yeast 200 μg versus placebo daily for 48 months. Participation was 6 to 36 months postoperatively and required a negative mediastinal node biopsy, no excessive vitamin intake, normal liver function, negative chest x-ray, and no other evidence of recurrence. RESULTS The first interim analysis in October 2009, with 46% of the projected end points accumulated, showed a trend in favor of the placebo group with a low likelihood that the trial would become positive; thus, the study was stopped. One thousand seven hundred seventy-two participants were enrolled, with 1,561 patients randomly assigned. Analysis was updated in June 2011 with the maturation of 54% of the planned end points. Two hundred fifty-two SPTs (from 224 patients) developed, of which 98 (from 97 patients) were lung cancer (38.9%). Lung and overall SPT incidence were 1.62 and 3.54 per 100 person-years, respectively, for selenium versus 1.30 and 3.39 per 100 person-years, respectively, for placebo (P = .294). Five-year disease-free survival was 74.4% for selenium recipients versus 79.6% for placebo recipients. Grade 1 to 2 toxicity occurred in 31% of selenium recipients and 26% of placebo recipients, and grade ≥ 3 toxicity occurred in less than 2% of selenium recipients versus 3% of placebo recipients. Compliance was excellent. No increase in diabetes mellitus or skin cancer was detected. CONCLUSION Selenium was safe but conferred no benefit over placebo in the prevention of SPT in patients with resected NSCLC.

Feasibility and effectiveness of a home-based exercise training program before lung resection surgery

BACKGROUND Patients with lung cancer often experience a reduction in exercise tolerance, muscle weakness and decreased quality of life. Although the effectiveness of pulmonary rehabilitation programs is well recognized in other forms of cancers and in many pulmonary diseases, few researchers have studied its impact in patients with lung cancer, particularly in those awaiting lung resection surgery (LRS). OBJECTIVES To investigate the feasibility of a short, home-based exercise training program (HBETP) with patients under investigation for non-small cell lung cancer and potential candidates for LRS, and to determine the effectiveness of this program on exercise tolerance, skeletal muscle strength and quality of life. METHODS Sixteen patients with lung cancer awaiting LRS participated in a four-week HBETP including moderate aerobic activities (walking and cycling) and muscle training performed three times weekly. Before and after the intervention, a cardiopulmonary exercise test, a 6 min walk test and the assessment of muscle strength and quality of life were performed. RESULTS Thirteen patients completed the four-week HBETP and all the patients completed >75% of the prescribed exercise sessions. The duration of the cycle endurance test (264±79 s versus 421±241 s; P<0.05) and the 6 min walk test distance (540±98 m versus 568±101 m; P<0.05) were significantly improved. Moreover, the strength of the deltoid, triceps and hamstrings were significantly improved (∆ post-pre training 1.82±2.83 kg, 1.32±1.75 kg and 3.41±3.7 kg; P<0.05, respectively). CONCLUSION In patients with lung cancer awaiting LRS, HBETP was feasible and improved exercise tolerance and muscle strength. This may be clinically relevant because poor exercise capacity and muscle weakness are predictors of postoperative complications.

Atrophy and hypertrophy signalling of the quadriceps and diaphragm in COPD

Background Factors involved in the regulation of muscle mass in chronic obstructive pulmonary disease (COPD) are still poorly understood. Comparing the signalisation involved in muscle mass regulation between two muscles with different levels of activation within the same subjects is an interesting strategy to tease out the impact of local (muscle activity) versus systemic factors in the regulation of muscle mass. A study was undertaken to measure and compare the protein levels of p-AKT, AKT, Atrogin-1, p-p70S6K, p-4E-BP1, p-GSK3β as well as the mRNA expression of Atrogin-1, MuRF1 and FoxO-1 in the quadriceps and the diaphragm of 12 patients with COPD and 7 controls with normal lung function. Methods Diaphragm biopsies were obtained during thoracic surgery and quadriceps samples were obtained from needle biopsies. Protein content and mRNA expression were measured by western blot and quantitative PCR, respectively. Results Increased mRNA expressions of Atrogin-1, MuRF1 and FoxO-1 were found in the quadriceps compared with the diaphragm only in patients with COPD. The quadriceps/diaphragm ratio for MuRF1 was higher in COPD. The protein level of p-p70S6K was decreased in the quadriceps compared with the diaphragm in patients with COPD. The quadriceps/diaphragm ratios of p-p70S6K and p-GSK3β were lower in patients with COPD than in controls. Conclusions These results indicate a greater susceptibility to a catabolic/anabolic imbalance favouring muscle atrophy in the quadriceps compared with the diaphragm in patients with COPD. The balance between the atrophy and hypertrophy signalling is inhomogeneous between respiratory and lower limb muscles, suggesting that local factors are likely to be involved in the regulation of muscle mass in COPD.

Anatomy and Physiology of the Thoracic Lymphatic System

The thoracic lymphatic system is one of the most complex and poorly understood systems of the human body, and much is still to be learned, especially in lymphatic physiology. Knowledge of the normal anatomy of this system as well as of its variations is nevertheless important for thoracic surgeons investigating and treating patients with lung or esophageal neoplasms.

Surgical site infections following transcatheter apical aortic valve implantation: incidence and management

ObjectiveThe present study was undertaken to examine the incidence and management of surgical site infection (SSI) in patients submitted to transapical transcatheter aortic valve implantation (TA-TAVI).MethodsFrom April 2007 to December 2011, 154 patients underwent TA-TAVI with an Edwards Sapien bioprosthesis (ES) at the Institut Universitaire de Cardiologie et Pneumologie de Québec (IUCPQ) as part of a multidisciplinary program to prospectively evaluate percutaneous aortic valve implantation. Patient demographics, perioperative variables, and postoperative complications were recorded in a prospective registry.ResultsFive (3.2%) patients in the cohort presented with an SSI during the study period. The infections were all hospital-acquired (HAI) and were considered as organ/space SSI’s based on Center for Disease Control criteria (CDC). Within the first few weeks of the initial procedure, these patients presented with an abscess or chronic draining sinus in the left thoracotomy incision and were re-operated. The infection spread to the apex of the left ventricle in all cases where pledgeted mattress sutures could be seen during debridement. Patients received multiple antibiotic regimens without success until the wound was surgically debrided and covered with viable tissue. The greater omentum was used in three patients and the pectoralis major muscle in the other two. None of the patients died or had a recurrent infection. Three of the patients were infected with Staphylococcus epidermidis, one with Staphylococcus aureus, and one with Enterobacter cloacae. Patients with surgical site infections were significantly more obese with higher BMI (31.4±3.1 vs 26.2±4.4 p=0.0099) than the other patients in the cohort.ConclusionsWhile TA-TAVI is a minimally invasive technique, SSIs, which are associated with obesity, remain a concern. Debridement and rib resection followed by wound coverage with the greater omentum and/or the pectoralis major muscle were used successfully in these patients.

Correlative Anatomy for the Sternum and Ribs, Costovertebral Angle, Chest Wall Muscles and Intercostal Spaces, Thoracic Outlet

The structures of the chest wall and thoracic outlet are complex. A working knowledge of their anatomy and of its variations is essential to any thoracic surgeon working in the area. Correlating imaging with anatomy is just as important if one wants to recognize surgical indications, and potential operating difficulties. In the past, conventional radiographic examination was the norm but interpretation was often difficult and incomplete. Currently, CT and MRI are the best available imaging tools, and most times they have complementary roles in the evaluation of chest wall anatomy.

Correlative Anatomy for Thoracic Inlet; Glottis and Subglottis; Trachea, Carina, and Main Bronchi; Lobes, Fissures, and Segments; Hilum and Pulmonary Vascular System; Bronchial Arteries and Lymphatics

Because it is relatively inexpensive and universally available, standard radiographs of the thorax should still be viewed as the primary screening technique to look at the anatomy of intrathoracic structures and to investigate airway or pulmonary disorders. Modern trained thoracic surgeons must be able to correlate surgical anatomy with what is seen on more advanced imaging techniques, however, such as CT or MRI. More importantly, they must be able to recognize the indications, capabilities, limitations, and pitfalls of these imaging methods.

RBC transfusion is associated with increased risk of respiratory failure after pneumonectomy: RBCs & postpneumonectomy respiratory failure

Pneumonectomy is associated with high risk of respiratory complications. Our objective was to determine if transfusions are associated with increased rate of ARDS and respiratory failure in adults undergoing elective pneumonectomy.

Identifying Primary Spontaneous Pneumothorax from Administrative Databases: A Validation Study

Introduction. Primary spontaneous pneumothorax (PSP) is a disorder commonly encountered in healthy young individuals. There is no differentiation between PSP and secondary pneumothorax (SP) in the current version of the International Classification of Diseases (ICD-10). This complicates the conduct of epidemiological studies on the subject. Objective. To validate the accuracy of an algorithm that identifies cases of PSP from administrative databases. Methods. The charts of 150 patients who consulted the emergency room (ER) with a recorded main diagnosis of pneumothorax were reviewed to define the type of pneumothorax that occurred. The corresponding hospital administrative data collected during previous hospitalizations and ER visits were processed through the proposed algorithm. The results were compared over two different age groups. Results. There were 144 cases of pneumothorax correctly coded (96%). The results obtained from the PSP algorithm demonstrated a significantly higher sensitivity (97% versus 81%, p = 0.038) and positive predictive value (87% versus 46%, p < 0.001) in patients under 40 years of age than in older patients. Conclusions. The proposed algorithm is adequate to identify cases of PSP from administrative databases in the age group classically associated with the disease. This makes possible its utilization in large population-based studies.

Repair of Complete Longitudinal Esophageal Rupture With Preservation of Esophageal Motility

There is no consensus on the ideal treatment for esophageal perforation and on the maximal extent of esophageal disruption amenable to primary repair. The effect of extensive esophageal injury on postoperative esophageal motility is also unknown. We report the case of a longitudinal iatrogenic esophageal laceration extending from the hypopharynx to the cardia in a morbidly obese patient treated with primary repair. The patient exhibited no postoperative esophageal leak or stricture and maintained a preserved esophageal peristalsis on manometry at 3 months. An extensively lacerated esophagus can be repaired primarily while maintaining a normal postoperative function.