Jean Berjaud

Large cell neuroendocrine carcinoma of the lung: pathological study and clinical outcome of 18 resected cases

Large cell neuroendocrine carcinoma of the lung (LCNEC) has been recently redefined by the World Health Organisation (WHO) classification but the appropriate treatment remains unclear. We reviewed 18 consecutive resected cases of LCNEC. Two pathologists assessed diagnosis by applying rigorously the last WHO criteria. We reported the pathological features and the clinical outcome of this particular tumour. All patients were men with a median age of 63 years. Clinicopathologic stages corresponded to stage I (n = 8), II (n = 8) and IIIA (n = 2). All patients were treated as non-small cell lung carcinoma (NSCLC) and underwent surgery without any adjuvant treatment except four post-operative radiotherapy for N2 or T3 disease. The evolution was pejorative for 14 patients: one patient died of post-operative complications and 13 patients relapsed with distant metastases that occurred in 10 cases within 6 months after surgery. One-year survival rate was 27% and survival rate at the end of follow-up was 22%, which were both less than expected for stage-comparable NSCLC. Survival was neither influenced by lymph node status nor by pathological or molecular findings. Among the 10 evaluable patients with metastatic disease that received palliative platin-etoposide chemotherapy only two had partial tumour regressions (20%). Our study suggests that applying to LCNEC the NSCLC standard treatment lead to poor prognosis even in localised disease with a high incidence of early metastatic spread and a low response rate to chemotherapy. This way of relapse underlies the necessity of an efficient chemotherapy in order to improve survival.

Limited operation for severe multisegmental bilateral bronchiectasis

BACKGROUND Some patients exhibiting severe multisegmental bilateral bronchiectasis are no longer improved with antibiotic treatment and drainage and, most of the time, operation is contraindicated. In our institution, limited operation has been offered to select patients for this indication. We report our data regarding the feasibility and utility of such a procedure. METHODS We studied 16 patients who underwent surgical removal of nonlocalized disease between 1990 and 1999. We report the mortality and morbidity rates of this surgical procedure and the clinical, bacteriological, and functional data for each patient. RESULTS There was no mortality and the morbidity was low (18%, all with favorable outcome). Symptoms such as hemoptysis, sputum production, or dyspnea were also improved. The recurring infections decreased in frequency in 8 patients and disappeared completely in 5 others. The bacteriological data assessment revealed disappearance of germs in 4 patients and persistence of chronic colonization in others. Postoperative spirometric data were not worsened and postoperative computed tomographic scans did not show progression of lesions not removed. CONCLUSIONS These results suggest that, in properly selected patients, lasting symptomatic improvement can be achieved by resection. Limited operation may be indicated in nonlocalized bilateral bronchiectasis, provided that a target can be identified. This procedure is supported by physiopathologic arguments and is particularly relevant to patients with bronchiectasis with cystic and functionless territories.

Impact of Induction Treatment on Postoperative Complications in the Treatment of Non-small Cell Lung Cancer

Introduction: A main drawback of neoadjuvant chemotherapy is that it may increase operative morbidity and mortality. The aim of this study was to determine the impact of chemotherapy on these complications. Methods: Patient data were collected from the Epithor database. From June 2002 to June 2004, 3888 successive observations of surgery for lung cancer have been reported from 51 thoracic surgery departments throughout France. Logistic regression analysis was performed to identify preoperative clinical characteristics of patients with significant postoperative complications. Results: Of 3888 patients, 555 (14.3%) received induction chemotherapy. The groups were similar with respect to sex and the number of comorbidities. The in-hospital mortality rate was 3.01%. The multivariate analysis allows us to identify age (older than 65 years), sex (male), preoperative clinical score (moderate and severe), surgical procedure (right pneumonectomy and bilobectomy) as significantly associated with in-hospital mortality. No statistical difference was observed according to the delivery or preoperative chemotherapy. In total, 1219 patients (31.4%) had at least one postoperative complication. Using a multivariate analysis, we observed a significant correlation between morbidity and age (older than 65 years), sex (male), presence of comorbidities (two or more), clinical score (moderate), and type of operation (bilobectomy). Preoperative administration of chemotherapy did not significantly influenced postoperative morbidity. Conclusions: Preoperative chemotherapy is not associated with an increase in either the mortality rate or major surgical complications. Future randomized trials are warranted to confirm the survival benefit of this strategy.

Complete tracheal rupture after a failed suicide attempt

Tracheal rupture is life-threatening and its management poses a considerable challenge to both anesthesiologists and surgeons. We report the case of a 44-year-old patient with a complete tracheal rupture after a failed suicide attempt by hanging. A rare bilateral injury of the laryngeal nerves was associated. An original tracheal intubation was performed using the video unit for thoracoscopy. The severity of the lesions required the placement of a tracheostomy cannula after the tracheal repair. The postoperative course was uneventful. The patient was discharged on the 12th day, with a remaining moderate dysphonia.

Mediastinal Teratoma and Trichoptysis

We report the case of a 22-year-old woman suffering from mature mediastinal teratoma, revealed by trichoptysis, which is an exceptional, but pathognomonic symptom of intrathoracic teratomas. Only eight cases of trichoptysis are reported, none of them involved a mediastinal localization. We present the endoscopic and radiologic presentation, its surgical management, and histologic particularities.

Chirurgia della trachea e dei bronchi (I)

Per comprendere bene le circostanze di comparsa e le possibilita terapeutiche in una patologia tracheobronchiale, questo articolo passa in rassegna l’anatomia descrittiva, i rapporti e la fisiologia dell’albero respiratorio. Inoltre, l’assoluta necessita di mantenere un’ematosi corretta durante le manipolazioni terapeutiche impone dei vincoli anestetici che sono anch’essi considerati.

Chirurgie de l’emphysème

Resume Tout patient emphysemateux presentant une dyspnee invalidante, degradant sa qualite de vie, et ceci en depit d’un traitement maximal, doit beneficier d’un bilan en vue d’une eventuelle intervention. Ce bilan associe : l’appreciation de la gene fonctionnelle percue (echelle de dyspnee, test de marche, qualite de vie), l’evaluation de la reversibilite des lesions (imagerie, EFR, TLCO, gazometrie, scintigraphie, micro-catheterisme droit), et enfin l’evaluation du terrain. En dehors de la transplantation pulmonaire, la seule alternative chirurgicale est la resection qui, selon le parenchyme qu’elle concerne, s’appelle « resection bulleuse » ou « reduction de volume ». Ses modalites sont multiples : resection atypique des deux sommets par sternotomie, resection atypique multiple mais unilaterale, ou enfin simple lobectomie. Le choix de la technique depend en priorite de la repartition des zones de destructuration parenchymateuse et, accessoirement, de la gravite de la maladie emphysemateuse et de l’âge du patient. Avec une mortalite operatoire maintenant largement inferieure a 10 %, la reduction de volume entraine une amelioration significative de la gene fonctionnelle (80 % des patients) mais temporaire (4 a 5 ans). Une mention toute particuliere doit etre faite pour la chirurgie des bulles qui est source d’une recuperation des parametres fonctionnels et spirometriques precoce, constante et durable.