Jean Deslauriers

Role of Mediastinoscopy in Pretreatment Staging of Patients with Primary Lung Cancer

Since the introduction of mediastinoscopy, there has been a great deal of discussion regarding indications for this technique and the significance of positive findings. We undertook this study to determine the role of clinical staging and the value of routine mediastinoscopy in the treatment selection of patients with primary lung cancer. From 1975 to 1983, 1,259 consecutive patients with proven and operable lung cancer underwent preresection mediastinoscopy. Nodes were sampled at three levels, and findings were recorded by location, invasiveness, and histology. There were no operative deaths, but 3 patients had a major complication. Mediastinoscopy was positive in 339 (27%) patients and negative in 920 (73%). In the group with positive findings, 303 patients had no operation because a curative resection was not possible (extranodal metastases, 180; location, 76; histology, 47). No patient survived 5 years, and only 4% survived 2 years. Of the 36 patients considered to have operable disease, 28 underwent resection with a projected 5-year survival of 18%. In the group with negative findings, 89% had a curative resection with a hospital mortality of 3.2% and 5-year survival of 53%. When results of mediastinoscopy were correlated with findings at thoracotomy, the sensitivity of the test was 93% on nodes in the superior mediastinum and the specificity, 100%. This study shows that mediastinoscopy is safe and is an accurate indicator of the presence or absence of tumor in superior mediastinal nodes. If positive nodes are found, a curative resection is generally not possible, thoracotomy is avoided, and the overall survival is low.

Transaxillary pleurectomy for treatment of spontaneous pneumothorax.

In the 16-year period 1962 to 1978, 409 transaxillary apical pleurectomies were carried out for definitive treatment of spontaneous pneumothorax in 362 patients. Surgical indications included recurrence (336), bilaterality of the disease (23), persistent air leak (22), and nonexpansion of the lung (10). There was 1 operative death (unsuspected brain tumor), and 3 patients required reexploration for clot removal. The average postoperative period of hospitalization was 6 days. Three hundred ten patients (86% of all patients) were contacted for follow-up 1 to 16 years after operation (average, 4.5 years). There were two documented episodes of recurrent ipsilateral pneumothorax (0.6%). Postoperative pulmonary function studies were done in 40 patients (unilateral, 29; bilateral, 11) 2 to 5 years after operation. The results indicate that there are no significant abnormalities compared with predicted values.

Technique for the Repair of Diaphragmatic Eventration

In contrast to the large thoracotomy incisions required by standard surgical techniques for repair of diaphragmatic eventration, the procedure we developed can be performed by video-assisted thoracoscopy, thus offering patients the advantages of a minimally invasive operation. Using two superposed series of transverse back-and-forth continuous sutures, the diaphragm is invaginated, then stretched. The first suture line holds the diaphragm down and maintains the excess within the abdomen; the second suture line places the desired tension on the diaphragmatic dome. Successful repair of 3 cases by this technique is described.

Survival related to nodal status after sleeve resection for lung cancer

Sleeve lobectomy is a lung-saving procedure indicated for central tumors for which the alternative is a pneumonectomy. The relation between survival and nodal status is controversial because, in most series, the presence of N1 disease adversely affects the prognosis with few or no long-term survivors. During the period 1972 to 1992, 142 patients underwent sleeve resection for lung cancer at our institution. Mean age (+/- standard deviation) was 60.7 +/- 9.1 years (range 11 to 78 years), and indications for operation were a central tumor in 112 patients (79%), a peripheral tumor in 18 patients (13%), and compromised pulmonary function in 12 patients (8%). Histologic type was predominantly squamous (72.5%) followed by nonsquamous (24.6%) and carcinoid tumors (2.8%). Resection was complete in 124 patients (87%) and incomplete in 18 (13%), and the operative mortality was 2.1% (n = 3). Follow-up was complete for the 139 remaining patients. Including operative deaths, survivals at 5 and 10 years for all patients were 46% (95% confidence intervals 38% to 55%) and 33% (95% confidence intervals 24% to 42%), respectively. For patients with N0 status (n = 73), 5- and 10-year survivals were 57% (95% confidence intervals 45% to 69%) and 46% (95% confidence intervals 32% to 60%); for patients with N1 status (n = 55), these rates were 46% (95% confidence intervals 32% to 60%) and 27% (95% confidence intervals 14% to 40%) (p = 0.13). No patient with N2 status (n = 14) survived 5 years. Local recurrences occurred in 23% of cases, but the prevalence was not statistically different between patients with N0 disease (16.6%) and N1 disease (23.1%) (p = 0.43). These data suggest that sleeve resection is an adequate operation for patients with resectable lung cancer and N0 N1 status. The presence of N2 disease significantly worsens the prognosis and may contraindicate the use of the procedure.

Clinical patterns and trends of outcome of elderly patients with bronchogenic carcinoma

OBJECTIVE To investigate the clinical characteristics and determinants of operative mortality and long-term survival of elderly patients submitted to pulmonary resection for intended cure of lung cancer. METHODS Retrospective analysis of 500 consecutive pulmonary resections performed in patients aged over 70 years from 1975 to 1996. Predictors of in-hospital mortality were identified by univariate and multivariate analyses. Determinants of long-term outcome were investigated in all survivors, with no patient being lost to follow-up. RESULTS Mean age was 74 +/- 3 years (maximum: 90), and 36 patients were octogenarians. The sex-ratio M:F was 5:3. History of combined cardiovascular or previous neoplastic disease was noted in 193 and 63 patients, respectively. The predominant histology was squamous cell carcinoma (n = 243), with a significantly higher incidence in male than in female. Most patients received standard procedures, while 103 patients underwent extended resections for tumors involving the mediastinum (n = 44), the chest wall (n = 33), the carina (n = 2) or had a sleeve resection of the main bronchus (n = 24). Procedures were considered to be complete and curative in 459 patients, among whom 294 had a stage I disease. There were 37 (7.4%) in-hospital deaths. Mortality rates following pneumonectomy, bilobectomy, lobectomy and lesser resection were 11:136, 4:34, 22:291, and 0:39, respectively. Age, male gender, hypertension, low FEV1 and extended procedure were identified as independent predictors of early mortality. Overall survival rates were 33.7 and 12% at 5 and 10 years, respectively. Multivariate analysis demonstrated that the disease stage was the main prognosticator. During the follow-up period, cancer recurrence (n = 183; 39.5%) or second primary lung cancer (n = 20; 4.3%) occurred in 203 patients, among whom 18 (9%) had a second lung resection. Carcinoma in other systems occurred in 25 patients (5.3%), and major cardiovascular event in 51 (11%). CONCLUSIONS Male and squamous cell carcinoma are characteristic of elderly patients with resected lung cancer. Operative mortality is acceptable for standard resection, and survival figures are concordant with those reported in other series which include younger patients.

Long-term results of sleeve lobectomy for lung cancer

OBJECTIVE Sleeve lobectomy is a lung saving procedure indicated for central tumors for which the alternative is a pneumonectomy. Current controversies relate to the safety of the procedure and adequacy as a cancer operation. The aim of the study is to analyze long-term survival after sleeve lobectomy, particularly in relation with nodal status and histological type. The incidence and patterns of recurrences were reviewed. METHODS From 1972 to 1998, 184 patients (male 152, female 32) underwent sleeve resection for lung cancer. The mean age was 60+/-10 years (11-78 years), and the indications for operation were a central tumor (79%), peripheral tumor with nodal involvement (13%) and compromised pulmonary function (8%). The histological type was predominantly squamous (n=125, 68%), followed by non-squamous (n=50, 27%) and carcinoid tumors (n=9, 5%). Resection was complete in 161 patients (87%). RESULTS The operative mortality was 1.6% (n=3). Follow-up was complete for the remaining 181 patients (mean, 5.7 years; range, 1 month-26 years). The survival at 5 and 10 years of all patients was 52 and 33%, respectively. Theses rates for patients with N0 status (n=97) were 63 and 48%, and 48 and 27% for those with N1 status (n=68; N0 vs. N1, P<0.05). An 8% survival rate was observed with N2 status (n=19) at 5 years, with no survivors after 7 years of follow-up. The 5 and 10 year survival was 56 and 34% for squamous carcinoma vs. 33 and 22% for non-squamous carcinoma (P<0.05). These rates were 58 and 38% for complete resection vs. 11 and 6% for incomplete resection at 5 and 10 years, respectively (P<0.05). Local recurrences occurred in 22% of cases, and the prevalence was statistically different between patients with N0 disease (14%) and N1 disease (23%; P=0.03), but not between N1 and N2 disease (42%; P=0.2). When local and distant recurrence were pooled together, the differences were highly significant between N0 (22%) and N1 (41%) disease (P=0.007), and between N0 and N2 (63%) disease (P=0.0002), but not between N1 and N2 disease (P=0.09). CONCLUSION Sleeve lobectomy is a safe and effective therapy for patients with resectable lung cancer. The presence of N1 and N2 disease, or of non-squamous carcinoma significantly worsen the prognosis.

Diagnosis and Long-Term Follow-up of Major Bronchial Disruptions due to Nonpenetrating Trauma

From 1966 through 1978, 13 patients were treated for major bronchial disruptions due to nonpenetrating trauma. In 10 patients the diagnosis was made early, and operation was carried out in all of them. Four of the 6 patients with main bronchus avulsion had primary repair and all 4 patients with lobar rupture underwent lobectomy. One patient had a pneumonectomy. There was 1 operative death. In 3 patients the diagnosis was made more than a month after the injury. A bronchoplastic repair was done in every patient. All 7 patients who had repair of a transected main bronchus were assessed 2 to 14 years after operation (average, 7 1/2 years). Flow-volume curves on air and air-helium were normal, indicating no major airway obstruction; this finding was confirmed by clinical and bronchoscopic examinations. Pulmonary diffusing capacity for carbon monoxide was also normal in all patients. Volume measurements by closed circuit method and by body plethysmography showed restriction in 1 patient but no major air trapping. Perfusion/ventilation scans showed homogeneous distribution of air and blood flow in the lung.

Postpneumonectomy pulmonary edema.

The adult respiratory distress syndrome seen after pneumonectomy is an uncommon but usually lethal complication. Its etiology remains unknown, although several factors such as fluid overload, endothelial damage, lymphatic interruption, and hyperinflation are thought to be involved in its pathogenesis.

Mediastinopleuroscopy: a new approach to the diagnosis of intrathoracic diseases.

With the advent of modern therapy, it has become essential to obtain a tissue diagnosis in all cases of pulmonary and mediastinal disease. Since it is often necessary to resort to thoracotomy as a final step in making such a diagnosis, we have sought a procedure that is simpler while capable of providing the same information. Through a standard cervical mediastinoscopy incision, the mediastinum is first explored; if the diagnosis is not obtained, the mediastinal pleura is digitally opened and lung or pleural biopsies are taken. In the course of 1,100 mediastinoscopies since 1969, 275 pleuroscopies have been done. We were able to obtain a tissue diagnosis in 102 (78%) of 131 patients with bronchogenic carcinoma, in 92 (91%) of 102 with benign pulmonary disease, and in all 20 (100%) with pleural disease.

Sleeve Pneumonectomy for Bronchogenic Carcinoma

Carcinomas of the right upper lobe that locally infiltrate the trachea represent a major challenge with regard to removal and reconstruction. Sixteen patients who had right pneumonectomy with carina resection between 1969 and 1977 were reviewed, and some implications of the surgical and anesthetic techniques were analyzed. The short-term results give merit to this extended procedure, and the fact that there is one long-term survivor suggests that some patients can be cured of their disease.