P. Berna

Value of cancer antigen 125 for diagnosis of pleural endometriosis in females with recurrent pneumothorax

The thorax is the most frequent extrapelvic location of endometriosis. Thoracic endometriosis is probably responsible for the high rate of recurrent pneumothoraces in females. The goal of the present prospective study was to assess the value of cancer antigen (CA)125 measurement in the detection of endometriosis in order to further enable early and adequate treatment of catamenial pneumothorax. Between January 2004 and March 2006, 31 females (mean age 32u2005yrs) underwent pneumothorax surgery. The control group comprised 17 males (mean age 27u2005yrs), who underwent videothoracoscopic pleural abrasion. Serum CA125 was measured around a menstrual period in females and before surgery in males. Videothoracoscopically diagnosed endometriosis occurred in 29% of females. The CA125 concentration was significantly higher in females with endometriosis compared to disease-free females (76.1 versus 16u2005U·mL−1). The mean value in males was similar to that observed in disease-free females. The frequency of thoracic endometriosis-related pneumothorax corresponds to, on average, a third of females presenting with recurrent pneumothorax. Early detection can be achieved with serum cancer antigen 125 measurement and may be helpful in indicating videothoracoscopic surgery.

Intrathoracic Lymph Node Metastases From Extrathoracic Carcinoma: The Place for Surgery

BACKGROUNDnIntrathoracic hilar or mediastinal lymph node metastases (HMLNMs) of extrathoracic carcinomas are infrequent. Their treatment strategy is not established and their prognosis poorly known. We reviewed the place of surgical intervention in their management.nnnMETHODSnAmong 565 patients with mediastinal lymph node enlargement, 37 had a history of extrathoracic carcinoma. The enlargement consisted in HMLNMs in 26 (15 men, 11 women), with a mean age of 57.6 (range 19-78) years. Surgical procedures were reviewed.nnnRESULTSnDiagnostic procedures, comprising mediastinoscopy in 9, anterior mediastinotomy in 2, and video-assisted thoracic surgery (VATS) in 4, were performed mainly because of unresectability due to diffuse and bilateral HMLNMs. Cancer location was breast in 6, kidney or prostate in 2 each, and bladder, rectum, testis, melanoma, and larynx in 1 each. Median survival was 21 months. Resection was performed in 11 patients, comprising posterolateral thoracotomy in 6, muscle sparing thoracotomy in 2, and VATS in 3. Seventeen involved LN stations were removed; of these, primary were kidney in 3, testis or thyroid in 2 each, and larynx, nasopharynx, and intestinum in 1 each. Five-year survival was 41.6% (median, 45 months).nnnCONCLUSIONSnHMLNMs of extrathoracic carcinoma may be isolated, probably in the context of a particular lymphatic mode of spread. Our experience demonstrates that operation is mainly diagnostic but resection may safely achieve local control of the disease and deserves being advocated in patients with isolated and resectable HMLNMs.

Lung cancer invading the fissure to the adjacent lobe: more a question of spreading mode than a staging problem

OBJECTIVESnLung cancer invading beyond the interlobar pleura, classified as T2a in the new TNM, is a rare entity with a poor outcome. Our purpose was a better understanding of the mechanisms of this particular behaviour and its prognostic value.nnnMETHODSnPatients who underwent surgery between 1984 and 2007 were reviewed. We focused on T1 and T2 tumours. Tumours not traversing the pleural elastic layer were defined as PL0, extending through the layer as PL1 and extending to the surface of the visceral pleura as PL2. We considered three groups: group 1, tumours invading the lobar fissure, group 2, PL0-tumours and group 3, PL1 + PL2 tumours and studied their pathology and prognostic characteristics.nnnRESULTSnThe distribution was as follows: group 1 n = 154, group 2 n = 2310 and group 3 n = 651. Pneumonectomy was necessary in 55.2% and bilobectomy in 19.5% of group 1, and N-involvement was present in 55.8% (significantly more than other groups). The mean tumour size (42.7 ± 12 mm) was bigger in group 1. Post-operative mortality was as follows: -5.2, -3.5 and 3.2% in groups 1, 2 and 3, respectively (P = 0.49). Five-year survival rates were: group 1: 38.9%, group 2: 52.5% and group 3: 43.4%; P = 0.00002. Survival was not different between groups concerning pN1 and pN2, but poorer in groups 1 and 3 than in group 2 in pN0 patients, P = 0.0057. Survival was 48.1, 37.9 and 38.4% for tumours between 31 and 70 mm in groups 2, 1 and 3, respectively, P = 0.0024 (but P = 0.65 between groups 1 and 3). Pneumonectomy was a poor prognostic factor in all groups, but survival between pneumonectomy and bilobectomy was not different in group 1. Multivariate analysis confirmed intralobar invasion to be an independent factor of poor prognosis, as well as visceral pleura invasion.nnnCONCLUSIONSnTumours invading through the fissure have a significant effect on long-term survival in the first stages of lung cancer but also in all stages because of their size and important locoregional spread. Their prognostic value is due to pleural invasion, whose role in lung cancer dissemination is worth further research.

Cancer du poumon chez la femme : aspects chirurgicaux liés au sexe

Resume Introduction Le cancer du poumon est de plus en plus frequent chez la femme ou il presente des differences significatives sur les plans clinique et therapeutique. Notre propos etait de rechercher celles associees au traitement chirurgical. Patients et methodes 2 972 patients ont ete operes de 1984 a 2002 : 2 480 hommes et 492 femmes. Ces 2 populations ont ete comparees (âge, antecedents, examens paracliniques, interventions, TNM, survie a long terme et causes de deces). Resultats Le nombre des femmes augmente ; elles sont plus jeunes, moins tabagiques et ont autant d’antecedents de cancer, moins d’antecedents medicaux, de comorbidites, de pneumonectomies, de mortalite postoperatoire. La taille de la tumeur est plus petite, les N0 et les stades I sont plus frequents. La survie a long terme est meilleure, notamment en cas d’antecedent de cancer et de stade I, et identique dans les stades III malgre une plus grande frequence de N2 multisites. Avant la menopause, tabagisme et adenocarcinomes sont plus frequents. Le pronostic des N2 s’assombrit avec l’âge. Conclusion Ces resultats confirment des particularites propres au cancer du poumon chez la femme et justifient la poursuite de recherches visant a mieux les comprendre. Toutefois, en analyse multivariee, le sexe n’apparait pas etre un facteur independant de pronostic.

Three-dimensional computed tomography angiography of the pulmonary veins and their anatomical variations: involvement in video-assisted thoracoscopic surgery-lobectomy for lung cancer

BACKGROUNDnIdentification and section of pulmonary veins are an essential part of anatomical pulmonary resections. Intraoperative misunderstandings of pulmonary venous anatomy can lead to serious complications such as bleeding and delayed lung infarction or necrosis. We evaluated principally the rate of pulmonary veno-us anatomical variations, and secondarily the reliability and clinical outcomes of a preoperative morphological analysis.nnnMATERIALS AND METHODSnBetween November 2012 and October 2013, we studied 100 consecutive patients with highly suspected or diagnosed stage I-II primitive lung cancer lesion. The surgical procedure initially retained was video-assisted thoracoscopic surgery (VATS) pulmonary resections and we studied preoperatively the proximal pulmonary venous anatomy using 64 channels multi- -detector computed tomography (CT)-scan angiography to describe the venous anatomical variations.nnnRESULTSnThere were 65 men and 35 women with a mean age of 63 years. A pulmonary venous anatomical variation was present in 36 (36%) patients, and right-sided anatomical variations were more frequent than on left-sided ones (25% vs. 11%). The most frequent variation encountered on the right side was the existence of three separate pulmonary veins (16%), and on the left side a single pulmonary vein (8%). Surgical conversion occurred in 21% and we didnt experience a pulmonary venous lesion (0%) or a post-operative lung infarction (0%).nnnCONCLUSIONSnWe described pulmonary venous anatomical variations and their frequency. Anatomical variations exist and preoperative assessment of pulmo-nary venous anatomy using CT scan is a useful tool in VATS lobectomy to avoid unnecessary extension of pulmonary resections or iatrogenic complications in lung cancer surgery.