Philippe Levasseur

Prognostic factors and long-term results after thymoma resection: A series of 307 patients

Three hundred seven cases of patients who underwent operation for thymoma (196 of whom had myasthenia gravis) were analyzed to assess the prognostic values of Masaoka clinical staging, completeness of resection, histologic classification, history of myasthenia gravis, and postoperative radiotherapy. According to the Masaoka staging system, 135 thymomas were stage I, 70 were stage II, 83 were stage III, and 19 were stage IV. According to the Verley and Hollmann histologic classification system, 67 thymomas were type 1, 77 were type 2, 139 were type 3, and 24 were type 4. Two hundred sixty patients underwent complete resection, 30 underwent incomplete resection, and 17 underwent biopsy. Postoperative radiotherapy was performed mainly in cases of invasive or metastatic thymoma. Mean follow-up was 8 years; eight patients were unavailable for follow-up. The overall 10- and 15-year survivals were 67% and 57%, respectively. In univariate analysis, three prognostic factors were established: completeness of resection, Masaoka clinical staging, and histologic classification. Furthermore, among patients with stage III thymomas, survival was significantly higher for patients with complete resection than for patients with incomplete resection (p < 0.001). Completeness of resection should therefore be taken into account in clinical-pathologic staging. We did not find any significant difference with respect to disease-free survival between patients who had postoperative radiotherapy and those who did not. In multivariate analysis, the sole significant prognostic factor was completeness of resection. On the basis of these findings, a new clinical-pathologic staging system is proposed.

Surgical treatment of hepatic and pulmonary metastases from colorectal cancers

BACKGROUND Selected patients with double hepatic and pulmonary metastases from colorectal cancer may benefit from operation. METHODS From 1970 to 1995, 239 patients underwent operation for resection of pulmonary metastases from colorectal cancer at two French surgical centers. Among these patients, 43 (18%) had previously undergone complete resection of hepatic metastases and constitute the subject of this retrospective study. RESULTS The median interval time between hepatic and pulmonary resections was 18 months. Two pneumonectomies, 5 lobectomies, 3 segmentectomies, 6 wedge resections, and 27 metastasectomies were performed. No postoperative mortality was observed. Two patients had major postoperative complications. Seven patients (16%) underwent subsequent pulmonary resection for recurrences. Twenty-one patients were still alive, 14 free of disease. The median survival from pulmonary resection was 19 months and the 5-year probability of survival was 11%. Prethoracotomy carcinoembryonic antigen blood levels and the number of pulmonary resection were found to be significant prognostic factors; the interval time between hepatic and pulmonary resection (> 36 months) was borderline significant (p = 0.06). CONCLUSIONS Selected patients with combined hepatic and pulmonary metastases from colorectal cancer should be considered for surgical resection. Patients with normal prethoracotomy carcinoembryonic antigen levels and late metachronous pulmonary metastasis, appear to be the best surgical candidates.

Immediate and long-term results after surgical treatment of primary spontaneous pneumothorax by VATS

BACKGROUND Video-assisted thoracic surgery has recently evolved as a viable alternative to thoracotomy for spontaneous pneumothorax. METHODS A series of 163 patients with primary spontaneous pneumothorax were treated by video-assisted thoracic surgery. Seventy patients were treated for a recurrent episode, 64 patients for a persistent primary spontaneous pneumothorax, 24 patients for a contralateral episode, and 5 patients for a bilateral primary spontaneous pneumothorax. Stapling of bullae with an Endo-GIA stapler (Auto-Suture, Elencourt, France) was performed in 90% of the cases and parietal pleural abrasion was performed in each case. RESULTS One revisional lateral limited thoracotomy was required for bleeding. Six patients had a prolonged air leak; 2 of them were reoperated on by lateral limited thoracotomy. Two patients have had an incomplete reexpansion of the lung and required a reoperation. The duration of hospitalization was 6.9 +/- 3 days. With a mean follow-up of 24.5 months, three recurrences requiring a reoperation occurred; 3 other patients had a partial recurrence and healed by rest without drainage. The mean time to return to the occupational activity of the patients was 42 +/- 34 days. These results were compared with those of a previous series of 87 patients operated on by lateral limited thoracotomy. CONCLUSIONS With the development of surgical technique and video equipment, video-assisted thoracic surgery will probably become the treatment of choice of primary spontaneous pneumothorax.

Aspergilloma: a series of 89 surgical cases

BACKGROUND Surgery for pleuropulmonary aspergilloma is reputed to be risky. We reviewed our results, focusing attention on the postoperative complications. METHODS During a 20-year period, 87 patients were operated on for pulmonary (86) or pleural (3) aspergillomas. Seventy-two percent of patients were complaining of hemoptysis. Eighty-nine resections were performed because there were two bilateral cases. Seventy percent of aspergillomas had developed in cavitation sequelaes from tuberculosis disease. Thirty-four patients had severe respiratory insufficiency that allowed us to perform only lobectomy (18), segmentectomy (2), or cavernostomy (14). RESULTS Thirty-seven lobectomies (five with associated segmentectomies), two bilobectomies, 21 segmentectomies, 10 pneumonectomies, and 17 cavernostomies were performed. Total blood loss exceeded 1,500 mL in 14 cases, and 71% of patients required blood transfusion. There were five postoperative deaths (5.7%), related to respiratory failure (2), infectious complication (1), pulmonary embolus (1), and cardiorythmic disorder (1). Incomplete reexpansions were frequently seen in patients undergoing lobectomies or segmentectomies. No death or major complications occurred in asymptomatic patients. During follow-up, none of the patients had recurrent hemoptysis. CONCLUSIONS Surgical resection of aspergilloma is effective in preventing recurrence of hemoptysis. It has low risk in asymptomatic patients and in the absence of underlying pulmonary disease. Incomplete reexpansion is frequent after lobectomy and segmentectomy, especially when there is underlying lung disease. Cavernostomy is an effective treatment in high-risk patients. Long-term prognosis is mainly dependent on the general condition of patients.

Results and prognostic factors in resections of primary tracheal tumors: A multicenter retrospective study

To determine long-term survival and prognostic factors, 208 patients with primary tracheal tumors were evaluated in a retrospective multicenter study including 26 centers. Ninety-four patients had squamous cell carcinoma, four had adenocarcinoma, 65 had adenoid cystic carcinoma, and 45 patients had miscellaneous tumors. The following resections were performed: tracheal resection with primary anastomosis, 165; carinal resection, 24; and laryngotracheal resection, 19. Postoperative mortality rate was 10.5% and correlated with the length of the resection, the need for a laryngeal release, the type of resection, and the histologic type of the cancer. Fifty-nine percent of patients with tracheal cancer and 43% of patients with adenoid cystic carcinomas had postoperative radiotherapy. The 5- and 10-year survivals, respectively, were 73% and 57% for adenoid cystic carcinomas and 47% and 36% for tracheal cancers (p < 0.05). Among patients with tracheal cancers, survival was significantly longer for those with complete resections than for those with incomplete resections. On the other hand, the presence of positive lymph nodes did not seem to decrease survival. Postoperative radiotherapy increased survival only in the case of incompletely resected tracheal cancers. Long-term prognosis was worsened by the occurrence of second primary malignancies in patients with tracheal cancers and by the occurrence of late pulmonary metastases in patients with adenoid cystic carcinomas.

Results of re-resection for recurrent thymomas.

BACKGROUND The treatment of recurrent thymomas remains controversial. PATIENTS The place for re-resection was retrospectively studied in 28 consecutive patients operated on during the last 40 years. The initial Masaoka staging of the thymoma was stage I, 4; stage II, 8; stage III, 11; and stage IVa, 3. Postoperatively, 14 have had radiation therapy, 1 chemotherapy, and 13 no adjuvant treatment. Seven patients had development of recurrences, 15 had pleuropulmonary metastases, 5 had both, and 1 had thoracotomy scar recurrence. Nineteen patients had a complete resection and 9 an incomplete one. RESULTS Most local recurrences appeared after resection of stage I or II thymomas. On the other hand, in patients with stage III or IV thymomas pleural or pulmonary metastases mainly developed. No local recurrence occurred in patients who initially received postoperative radiation therapy. Five-year and 10-year survival rates were 51% and 43%, respectively, for the overall population. Among the 19 patients with complete resection, only 3 patients had a subsequent recurrence; 1 of them could be reoperated on and is still alive and free of disease. CONCLUSIONS Thymoma recurrences often appear as a locoregional rather than a hematogenous spread. Reresection can be recommended in selected patients.

Tracheal Sleeve Pneumonectomy for Bronchogenic Carcinoma: Report of 55 Cases

From 1966 to 1986, a total of 55 patients underwent a tracheal sleeve pneumonectomy (53 right and 2 left) for bronchogenic carcinoma. Preoperative radiotherapy was given in only 5 patients. The overall operative death rate was 10.9%, but no patient has died since 1975 (32 survivors). Seven patients had a postoperative empyema (12.7%); 4 of these patients had a bronchopleural fistula. Twenty-five patients had postoperative radiotherapy, 5 of whom also had chemotherapy. The actuarial survival rate, after exclusion of the 6 operative deaths, was 38% at 3 years and 23% at 5 years. Survival was correlated to regional lymph node involvement. The actuarial survival rate among patients with tumoral spread to bronchial lymph nodes was 43% at 3 years. Among the 13 patients with only subcarinal involvement, the actuarial survival rate was 34% at 3 years. None of the 8 patients with paratracheal lymph node involvement survived more than 30 months. These results indicate that tracheal sleeve pneumonectomy for bronchogenic carcinoma with extension to the carina is now fully justified considering the low operative mortality and the good results observed when lateral tracheal lymph nodes were not involved.

Lung metastases of renal cell carcinoma: results of surgical resection.

OBJECTIVE The research was designed to evaluate the results of surgical resection of renal lung metastases. METHODS Between 1960 and 1994, 50 consecutive patients underwent resection for pulmonary metastases from renal cell carcinoma. Mean age was 59 years (range: 40-78 years). Mean time between nephrectomy and pulmonary resection was 3 years (range: 0-18 years). Nineteen patients had solitary metastase, 13 multiple unilateral, and 18 bilateral. Wedge excision was performed in 28 patients, segmentectomy in 3, lobectomy in 17, sleeve lobectomy in 1, pneumonectomy in 5 and biopsy in 3. Twelve patients had repeat resection for recurrent metastases. RESULTS The resection was complete in 45 patients. Three patients also had a complete resection of limited extra-pulmonary disease. There was one postoperative death and 3 complications. Mean follow-up was 42 months without loss of follow-up. The cause of death was always metastatic recurrent disease. Five-year survival in complete resection was 44%. Only one long survivor was observed in the case of incomplete resection in a patient who had a complete response after adjuvant immunotherapy. Five-year survival for the 12 patients with repeat resections was similar to the overall survival rate (42%). CONCLUSIONS Resection of renal lung metastases is a safe and effective treatment. No factor influenced the 5-year survival in this series except the complete resection. Extra-pulmonary metastases does not contra-indicate pulmonary resection. In selected patients, repeat resection for recurrent disease is warranted.

Surgical treatment of lung cancer invading the chest wall: results and prognostic factors

BACKGROUND The study was performed to assess prognostic factors in patients with lung cancer invading the chest wall treated by surgery. METHODS We reviewed retrospectively clinical records of all patients operated on for lung cancer invading chest wall structures between 1984 and 1998. RESULTS Two hundred one patients were operated on in this 14-year period. One hundred thirty-seven lobectomies, 55 pneumonectomies, and 9 wedge resections were performed. Extrapleural resection (when invasion was limited to the parietal pleura) and chest wall resection (in the case of invasion of deeper structures) were combined with pulmonary resection in 79 (39%) and 122 (61%) cases, respectively. Pathologic TNM stages were T3N0 in 116 (57.5%) cases, T3N1 in 52 (26%), T3N2 in 27 (13.5%), and T4N0-N1 in 6 (3%). A complete resection was achieved in 167 (83%) cases. Fourteen postoperative deaths (7%) occurred. One hundred thirty-nine patients (74%) underwent postoperative radiotherapy. Actuarial 5-year survival was 24% and 13% after complete and incomplete resection, respectively (p < 0.05). Actuarial 5-year survival after complete resection was 25% in T3N0 patients, 20% in T3N1, and 21% in T3N2. In completely resected patients, univariate and multivariate analyses identified three independent prognostic factors: nodal involvement, depth of parietal invasion, and age. Radiation therapy did not improve survival if a complete resection was possible. CONCLUSIONS Completeness of resection, nodal involvement, depth of invasion, and age affect survival of patients with lung cancer invading the chest wall. N2 disease should not be considered a contraindication to surgery.

Preoperative Carcinoembryonic Antigen Level as a Prognostic Indicator in Resected Primary Lung Cancer

The aim of this study was to evaluate the prognostic significance of elevated preoperative carcinoembryonic antigen (CEA) levels in cases of resected primary lung cancer. Between 1985 and 1989, 152 patients with tumors and CEA levels above 10 ng/mL underwent operation. One hundred twenty-five of them underwent resection of their tumors and the other 27 underwent exploratory thoracotomy only. Fifty-two percent of cancers were adenocarcinomas and 33% were epidermoid. Forty-two resected tumors were classified as stage I, 29 as stage II, 45 as stage IIIa, 7 as stage IIIb, and 2 as stage IV. The 3-year actuarial survival rate was 54% for patients with stage I tumors, 28% for those with stage II, 18% for those with stage IIIa, 44% for those with stage IIIb, and 0% for those with stage IV tumors. The 5 year actuarial survival was 40% for those with stage I tumors, 28% for those with stage II, 7% for those with stage IIIa, and 0% for those with stage IIIb tumors. Preoperative CEA levels increased from stage I to stage IIIa (p < 0.05). However, based on preoperative CEA levels we were not able to predict resectability, because levels were not significantly different between stage IIIa and exploratory thoracotomy-only groups. Adenocarcinoma was not significantly associated with higher CEA levels than was epidermoid, except in stage IIIa disease (p < 0.05). We found a critical unfavorable level of prognostic significance at 30 ng/mL.(ABSTRACT TRUNCATED AT 250 WORDS)