Marcel Dahan

Management of superior sulcus tumors: experience with 139 cases treated by surgical resection.

BACKGROUND The management of non-small cell carcinomas of the lung involving the superior sulcus remains controversial. The goal of this retrospective study was to evaluate the role of surgery, radiotherapy, and chemotherapy for the treatment of superior sulcus tumors, to define the best surgical approach for radical resection, and to identify factors influencing long-term survival. METHODS Between 1983 and 1999, 139 patients underwent surgical resection of superior sulcus tumors in seven thoracic surgery centers. According to the classification of the American Joint Committee, 51.1% of cancers were stage IIB, 13.7% stage IIIA, 32.4% stage IIIB, and 2.9% stage IV. RESULTS The resections were performed with 74.1% using the posterior approach and 25.9% using an anterior approach. A lobectomy was accomplished in 69.8% of the cases and a wedge resection in 22.3%. Resection of a segment of vertebrae or subclavian artery was performed, respectively, in 19.4% and 18% of the cases. Resection was complete in 81.3% of cancers. The overall 5-year survival rate was 35%. Preoperative radiotherapy improved 5-year survival for stages IIB-IIIA. Surgical approach, postoperative radiotherapy, or chemotherapy did not change survival. CONCLUSIONS The optimal treatment for superior sulcus tumors is complete surgical resection. The surgical approach (anterior/posterior) did not influence the 5-year survival rate. Preoperative radiotherapy should be recommended to improve outcome of patients with a superior sulcus tumor.

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.

Thoracoscopic excision of mediastinal bronchogenic cysts: results in 20 cases

BACKGROUND We present our experience with thoracoscopic resection of mediastinal bronchogenic cysts in adults. METHODS From November 1990 to September 1993, 20 patients with mediastinal bronchogenic cysts were operated on by thoracoscopy. The average cyst size was 4.9 cm, and the largest diameter was 10 cm. Ten cysts were located in the middle mediastinum and 10 in the posterior mediastinum. Two cysts were complicated. RESULTS Thirteen bronchogenic cysts were resected completely by thoracoscopy. We had to convert thoracoscopy into thoracotomy because of bleeding in two cases and because of major adhesions to vital structures in five cases. There were no operative deaths and no postoperative complications. Mean hospital stay was significantly less in the completely thoracoscopically treated group. Long-term follow-up (range, 4.5 to 7.5 years) showed no late complications and no recurrence. CONCLUSIONS Preoperative complications, intraoperative injuries, and major adhesions to vital structures seem to be the only unfavorable conditions to thoracoscopic treatment of bronchogenic cysts. This study found encouraging results for thoracoscopic excision of mediastinal bronchogenic cysts in selected patients.

Complications of video-assisted thoracic surgery: A five-year experience

BACKGROUND Although thoracoscopy was originally described in 1910, recent developments in video-assisted surgical techniques and endoscopic equipment has expanded the application of video-assisted surgical procedures in the field of thoracic surgery. METHODS In an effort to define both high-risk patients for video-assisted thoracic procedures and high-risk video-assisted thoracic surgical procedures, we reviewed the experience of four surgical institutions from June 1991 through May 1995. We looked specifically at complications resulting from the 937 video-assisted thoracic procedures performed during this period. RESULTS Perioperative incidents or complications occurred in 35 patients (3.7%), and 116 procedures (12.4%) were converted to a thoracotomy. The in-hospital mortality rate was 0.5%, and death occurred principally in patients operated on for malignant pleural effusion. The overall incidence of postoperative complications was 10.9%, and the most prevalent complications were prolonged air leak (6.7%) and pleural effusion (0.7%). CONCLUSIONS The incidence of complications was acceptable and, except for that of prolonged air leak, did not differ significantly from that resulting from analogous open procedures. Video-assisted thoracic surgery appears safe and particularly useful for some indications. However, the possibility of dramatic life-threatening perioperative complications requiring emergency conversion to thoracotomy justifies the fact that only trained thoracic surgeons should perform video-assisted thoracic surgical procedures.

Intrathoracic migration of Kirschner pins

We report two cases of intrathoracic migration of Kirschner pins used for the treatment of sternoclavicular joint dislocation. The migration was asymptomatic in both cases. Treatment involved median sternotomy in one patient and video-assisted thoracoscopy in the other. A favorable outcome was observed in both patients. The reports confirm the potential dangers related to management of sternoclavicular joint dislocation with metallic fixation devices.

Prevention of air leaks after pulmonary wedge resection

Prolonged air leak after a lung volume reduction operation for pulmonary emphysema is a major cause of morbidity and prolonged hospital stay. Staple line reinforcement is recognized as an effective adjunctive technique for decreasing the occurrence of air leaks after pulmonary wedge resection. Numerous materials have been used for staple-line reinforcement. We use expanded polytetrafluoroethylene sleeves that fit over the arms of surgical staplers to facilitate staple-line reinforcement in both thoracoscopic and open lung volume reduction procedures. The expanded polytetrafluoroethylene sleeves do not require rinsing or special handling; they are easy to use and effective in preventing air leaks. We had no prolonged air leaks or infections in any of the cases in which we used the sleeves.

Videothoracoscopic excision of thoracic neurogenic tumors

BACKGROUND Videothoracoscopic surgery is a new procedure for treating neurogenic tumors of the thorax. Feasibility and utility of this technique are not yet well defined. METHODS Over a 26-month period, 26 neurogenic tumors of the thorax were treated in five general thoracic surgery centers performing videothoracoscopic surgery. Indications and contraindications for this new procedure and initial results were retrospectively studied. RESULTS Contraindications to videothoracoscopy included intraspinal extension of the tumor (n = 3), spinal artery involvement (n = 2), tumors more than 6 cm in diameter borderline located within the thorax (n = 2), and middle mediastinal location (n = 1). Videothoracoscopy was performed in 18 patients. Conversion to thoracotomy was required in 3. In 1 patients, subsequent chest wall resection was performed because of malignancy. Postoperative hospital stay was uneventful. It was shorter after videothoracoscopy. Postsurgical pain was more acute in patients who had thoracotomy or conversion to thoracotomy. CONCLUSIONS Videothorascopy is a good alternative for managing neurogenic tumors of the thorax when deemed feasible. There is a tendency toward a shorter hospital stay with less pain in patients treated by this new procedure.

Risk model of in-hospital mortality after pulmonary resection for cancer: A national database of the French Society of Thoracic and Cardiovascular Surgery (Epithor)

OBJECTIVES The estimation of risk-adjusted in-hospital mortality is essential to allow each thoracic surgery team to be compared with national benchmarks. The objective of this study is to develop and validate a risk model of mortality after pulmonary resection. METHODS A total of 18,049 lung resections for non-small cell lung cancer were entered into the French national database Epithor. The primary outcome was in-hospital mortality. Two independent analyses were performed with comorbidity variables. The first analysis included variables as independent predictive binary comorbidities (model 1). The second analysis included the number of comorbidities per patient (model 2). RESULTS In model 1 predictors for mortality were age, sex, American Society of Anesthesiologists score, performance status, forced expiratory volume (as a percentage), body mass index (in kilograms per meter squared), side, type of lung resection,extended resection, stage, chronic bronchitis, cardiac arrhythmia, coronary artery disease, congestive heart failure, alcoholism, history of malignant disease, and prior thoracic surgery. In model 2 predictors were age, sex, American Society of Anesthesiologists score, performance status, forced expiratory volume, body mass index, side, type of lung resection, extended resection, stage, and number of comorbidities per patient. Models 1 and 2 were well calibrated, with a slope correction factor of 0.96 and of 0.972, respectively. The area under the receiver operating characteristic curve was 0.784 (95% confidence interval, 0.76-0.8) in model 1 and 0.78 (95% confidence interval, 0.76-0.797) in model 2. CONCLUSIONS Our preference is for the well-calibrated model 2 because it is easier to use in practice to estimate the adjusted postoperative mortality of lung resections for cancer.

Surgical management and outcomes of elderly patients with early stage non-small cell lung cancer: a nested case-control study.

BACKGROUND The number of oncogeriatric patients with non-small cell lung cancer (NSCLC) is expected to increase in the next decades. METHODS We used the French Society of Thoracic and Cardiovascular Surgery database Epithor that includes information on > 140,000 procedures from 98 institutions. We prospectively collected data from January 2004 to December 2008 on 1,969 patients aged ≥ 70 years with NSCLC stage I or II and matched them with 1,969 control subjects aged < 70 years for sex, American Society of Anesthesia score, performance status, and FEV(1). Surgical treatment and postoperative outcomes were compared between the two age groups. RESULTS The absence of radical lymphadenectomy was more frequent in the older patients (14%, n = 269) than in the younger patients (9%, n = 170) (P < .0001). There was no significant difference in type of resection between older and younger patients, respectively (pneumonectomy, 8% [n = 164] vs 11% [n = 216]; lobectomy, 79% [n = 1,559] vs 77% [n = 1,521]; bilobectomy, 4% [n = 88] vs 5% [n = 97]; sublobar resection, 7% [n = 143] vs 6% [n = 118]; P = .08). Differences in number (P = .07) and severity (P = .69) of complications were not significant. Postoperative mortality was higher in elderly patients at every end point (30-day mortality, 3.6% [n = 70] vs 2.2% [n = 43] [P = .01]; 60-day mortality, 4.1% [n = 80] vs 2.4% [n = 47] [P = .003]; 90-day mortality, 4.7% [n = 93] vs 2.5% [n = 50] [P = .0002]). CONCLUSIONS Elderly patients with NSCLC should not be denied pulmonary resection on the basis of chronologic age alone. Among patients aged ≥ 70 years, 90-day mortality compared acceptably with mortality among younger matched patients. Additionally, the data show that for older patients, a 90-day mortality better represents their real mortality risk than 30- or 60-day figures. Our contemporary, multiinstitutional data importantly reveal that elderly patients, compared with their younger counterparts, do not have increased morbidity, incidence, or severity after pulmonary resection.

Pratiques chirurgicales dans le traitement du cancer primitif non à petites cellules du poumon

Le présent document est limité aux différents aspects techniques qui composent l’acte chirurgical, sans référence directe aux aspects stratégiques et/ou multidisciplinaires de la prise en charge thérapeutique, ni à l’appréciation de l’opérabilité fonctionnelle des candidats à une chirurgie. Il est avant tout destiné aux chirurgiens dans le but de les aider dans leur pratique quotidienne. Il a aussi pour ambition de constituer Correspondance : P. Thomas Service de Chirurgie Thoracique, Hôpital Sainte Marguerite, 13274 Marseille cedex 9.