[Congenital thoracic deformities and 3D custom-made implants. New classification based on a series of 789 treated cases]. / Malformations thoraciques congénitales et implants sur mesure 3D. Nouvelle classification basée sur une série de 789 cas traités.

The authors present a new study on 789 cases of congenital thoracic malformations including 638 pectus excavatum and 151 Poland syndromes, according to a new classification which completes Chin's one. All these malformations were treated with silicone elastomer implants. The contribution of computer-aided design and manufacturing (CAD/CAM) since 2008 is essential. The one-stage surgical protocol is precisely described. The results are impressive, permanent, for life, and complications are rare. The authors evoke a common vascular etiopathogenesis theory at the embryonic stage and question the heavy techniques of invasive remodeling that are most often unjustified.

[The pectus excavatum: Secondary surgery with implants]. / Le pectus excavatum : chirurgie secondaire par implants.

The pectus excavatum affects about one in 500 people. It is the most common malformation of the thorax. Several surgical or medical techniques have been proposed. Some are followed by complications or insufficient results. Secondary surgery with a deep customized 3D implant, may be an elegant and effective solution; it allows to obtain a good aesthetic result expected by patients in the absence of any respiratory or cardiovascular functional context.

From randomized trials to the clinic: is it time to implement individual lung-cancer screening in clinical practice? A multidisciplinary statement from French experts on behalf of the French intergroup (IFCT) and the groupe d'Oncologie de langue francaise (GOLF).

BACKGROUND: Despite advances in cancer therapy, mortality is still high except in early-stage tumors, and screening remains a challenge. The randomized National Lung Screening Trial (NLST), comparing annual low-dose computed tomography (LDCT) and chest X-rays, revealed a 20% decrease in lung-cancer-specific mortality. These results raised numerous questions. The French intergroup for thoracic oncology and the French-speaking oncology group convened an expert group to provide a coherent outlook on screening modalities in France. METHODS: A literature review was carried out and transmitted to the expert group, which was divided into three workshops to tackle specific questions, with responses presented in a plenary session. A writing committee drafted this article. RESULTS: The multidisciplinary group favored individual screening in France, when carried out as outlined in this article and after informing subjects of the benefits and risks. The target population involves subjects aged 55-74 years, who are smokers or have a 30 pack-year smoking history. Subjects should be informed about the benefits of quitting. Screening should involve LDCT scanning with specific modalities. Criteria for CT positivity and management algorithms for positive examinations are given. CONCLUSIONS: Individual screening requires rigorous assessment and precise research in order to potentially develop a lung-cancer screening policy.

[Surgical management of COPD distension]. / Prise en charge chirurgicale de la distension thoracique au cours de la BPCO.

INTRODUCTION: The impressive results seen when giant and compressing lung bullae are resected has inspired pneumonologists and thoracic surgeons to consider the possibility of applying a similar approach to the treatment of respiratory failure due to chronic obstructive pulmonary disease (COPD). STATE OF THE ART: The major problem with this surgical indication lies in our ability to understand fully the pathophysiology of lesions and thus identify which emphysematous patients will have a response most similar to that achieved in purely bullous disease. PERSPECTIVES: At the present time consideration should be given as to whether surgery is the only means of reducing pulmonary distension. Indeed, as endoscopic alternatives develop could they reproduce its beneficial effects and what would be their place compared to the surgery? CONCLUSIONS: While waiting the development of these innovations, if the selection of the candidates is correct, the surgical treatment of lung hyperinflation can temporarily improve the quality of life of these patients by decreasing their dyspnea and increasing their exercise tolerance.

[Different approaches to chest drainage in the management of primary spontaneous pneumothorax]. / Facteurs influençant la réussite du drainage pleural d'un premier épisode de pneumothorax spontané primitif.

Drainage of primary spontaneous pneumothorax (PSP) may be managed by different techniques and with different types of drain. It is mainly performed in the pneumology department or in the emergency department. The aim of the study was to evaluate the factors that influence the success of PSP drainage. This retrospective, monocentric study performed in University Hospital of Toulouse, included patients with a first episode of PSP requiring drainage. The primary outcome was the rate of success according to the techniques of drainage. Data on the size of the drain (>14F or<14F), the drainage technique (small bore catheter or chest tube drainage) and the drainage department (pneumology or emergency) were collected. One hundred and twenty-four patients had a drainage between 2014 and 2016: the late recurrence free success rate was 59% (n=73). Compared with emergency, drainage in pneumology increased the success rate threefold regardless of the drainage technique (P=0.0001) The success rate was similar whatever the technique used (Seldinger or classic technique) (P=0.31). Success and complications rates were similar whether the drain was large (>14F) or small (<14F) (respectively P=0.99 and P=0.58). In our study, the drainage of PSP in the pneumology department, with a small caliber inserted by the Seldinger technique, was associated with a significantly higher success rate.

3-month prognostic impact of severe acute renal failure under veno-venous ECMO support: Importance of time of onset.

PURPOSE: Veno-venous ECMO is increasingly used for the management of refractory ARDS. In this context, acute kidney injury (AKI) is a major and frequent complication, often associated with poor outcome. We aimed to identify characteristics associated with severe renal failure (Kidney Disease Improving Global Outcome (KDIGO) 3) and its impact on 3-month outcome. METHODS: Between May 2009 and April 2016, 60 adult patients requiring VV-ECMO in our University Hospital were prospectively included. RESULTS: AKI occurrence was frequent (75%; n=45), 51% of patients (n=31) developed KDIGO 3 - predominantly prior to ECMO insertion - and renal replacement therapy was required in 43% (n=26) of cases. KDIGO 3 was associated with a lower mechanical ventilation weaning rate (24% vs 68% for patients with no AKI or other stages of AKI; p<0.001) and a higher 90-day mortality rate (72% vs 32%, p=0.002). Multivariate logistic regression suggested that KDIGO 3 occurrence prior to ECMO insertion, as well as PaCO2>57mmHg and mSOFA>12 were independent risks factors for 90-day mortality. CONCLUSION: KDIGO 3 AKI occurrence is correlated with the severity of patients' clinical condition prior to ECMO insertion and is negatively associated with 90-day survival.

[Late complications of a pseudo aneurysm of the left ventricle: thrombus infection and purulent pericarditis]. / Complications tardives d'un faux anévrisme du ventricule gauche: infection du thrombus et péricardite purulente.

Pseudoaneurysm is a rare complication of left ventricle myocardial infarction. Rupture with tamponade and sudden death is the usual outcome. Surgical intervention remains the treatment of choice. Long term survival cases without surgery are rare. Infection of the thrombus is also a possible event. We report the case of a patient with postinfarction left ventricular pseudoaneurysm complicated by infection of the thrombus and purulent pericarditis involving a peptostreptococcus. Infection must be considered a potential complication of left ventricular pseudoaneurysms.

[Lung cancer in women and pregnancy: towards a hormonal origin?]. / Cancer bronchique de la femme et de la femme enceinte: vers une origine hormonale?

INTRODUCTION: The incidence of lung cancer is increasing dramatically in women in France. It is now the leading cause of cancer deaths among women in the USA and the second in France. STATE OF THE ART: Lung cancer occurring in women displays some specific epidemiological, radiological, clinical and pathological characteristics. Moreover, both prognosis and response to treatment appear to be different from men. In line with these findings, lung carcinogenesis is, at least in part, distinct in women and involves different mechanisms and signalling pathways. We emphasize in this review genetic and hormonal specificities based upon epidemiological and biological studies. Moreover, we focus on lung cancer developing during pregnancy by reporting an individual case and discussing the published literature. PERSPECTIVES AND CONCLUSIONS: Recent works suggest that lung cancer in women is a distinct entity with specific carcinogenesis. We propose that a better knowledge of this entity will permit the identification of specific genetic alterations or hormonal profiles that may serve as new therapeutic targets.

[Surgical management and outcomes of lung cancer in women - results from the Epithor database]. / Particularités de la prise en charge chirurgicale du cancer bronchique chez la femme. Données de la base nationale Epithor.

INTRODUCTION: Rates of lung cancer in women have been increasing continually for several years. The basic surgical management of this condition is the same in both sexes but a number of differences are apparent. METHODS: We analysed data entered onto the Epithor database between June 2002 and June 2006 concerning 8535 surgical resections performed in primary lung cancer. RESULTS: 22.5 percent of patients were women. They were significantly younger (59.6 years vs 62.7 years) and had a lower BMI (24.7 kg x m(-2) vs 25.5 kg x m(-2)). They were in a better physical condition in terms of American Society of Anaesthesiology score and performance status, with better preserved lung function and fewer co-morbidities (1.8 vs 2.1) compared to men. The percentage of adenocarcinomas was higher in women and a higher proportion had early stage disease. 30 day mortality was three times as high in men who also experienced much greater post-operative morbidity. Multivariate analysis revealed an odds ratio of 0.49 (95% CI 0.3-0.8) for mortality and 0.54 (95% CI 0.4-0.6) for morbidity in women compared to men. CONCLUSION: Women with lung cancer have less risk of post-operative morbidity and mortality than men. These data suggest that they might be able to benefit from more aggressive perioperative therapy.

Understanding the oestrogen action in experimental and clinical atherosclerosis.

Whereas hormone replacement/menopause therapy (HRT) in postmenopausal women increases the coronary artery risk, epidemiological studies (protection in premenopaused women) suggest and experimental studies (prevention of the development of fatty streaks in animals) demonstrate a major atheroprotective action of oestradiol (E2). The understanding of the deleterious and beneficial effects of oestrogens is thus required. The immuno-inflammatory system plays a key role in the development of fatty streak deposit as well as in the rupture of the atherosclerotic plaque. Whereas E2 favours an anti-inflammatory effect in vitro (cultured cells), it rather elicits in vivo a proinflammation at the level of several subpopulations of the immuno-inflammatory system, which could contribute to plaque destabilization. Endothelium is another important target for E2, as it potentiates endothelial NO and prostacyclin production, thus promoting the beneficial effects as vasorelaxation and inhibition of platelet aggregation. Prostacyclin, but not NO, appears to be involved in the atheroprotective effect of E2. E2 also accelerates endothelial regrowth, thus favouring vascular healing. Finally, most of these effects of E2 are mediated by oestrogen receptor alpha, and are independent of oestrogen receptor beta. In summary, a better understanding of the mechanisms of oestrogen action not only on the normal and atheromatous arteries, but also on innate and adaptive immune responses is required and should help to optimize the prevention of cardiovascular disease after menopause. These mouse models should help to screen existing and future selective oestrogen receptor modulators.

Estradiol accelerates reendothelialization in mouse carotid artery through estrogen receptor-alpha but not estrogen receptor-beta.

BACKGROUND: The atheroprotective effect of 17beta-estradiol (E(2)) has been suggested in women and clearly demonstrated in animals through both an effect on lipid metabolism and a direct effect on the cells of the arterial wall. It has been shown, for example, that E(2) promotes endothelium-dependent relaxation and accelerates reendothelialization in rats. Similar studies have been undertaken in mice to appreciate the molecular mechanism of this process. METHODS AND RESULTS: We report here a model of electric carotid injury adapted from that described by Carmeliet et al (1997) that allows us to precisely evaluate the reendothelialization process. We demonstrate that E(2) accelerates endothelial regeneration in castrated female wild-type mice. In ovariectomized transgenic mice in which either the estrogen receptor (ER)-alpha or ERbeta gene has been disrupted, E(2) accelerated reendothelialization in female ERbeta knockout mice, whereas this effect was abolished in female ERalpha knockout mice. CONCLUSIONS: This study demonstrates that ERalpha but not ERbeta mediates the beneficial effect of E(2) on reendothelialization and potentially the prevention of atherosclerosis.

Survival of patients with resected N2 non-small-cell lung cancer: evidence for a subclassification and implications.

PURPOSE: Patients who suffer from non-small-cell lung cancer (NSCLC) with ipsilateral mediastinal lymph node involvement (N2) belong to a heterogeneous subgroup of patients. We analyzed the prognosis of patients with resected N2 NSCLC to propose homogeneous patient subgroups. PATIENTS AND METHODS: The present study comprised 702 consecutive patients from six French centers who underwent surgical resection of N2 NSCLC. Initially, two groups of patients were defined: patients with clinical N2 (cN2) and those with minimal N2 (mN2) disease were patients in whom N2 disease was and was not detected preoperatively at computed tomographic scan, respectively. RESULTS: The median duration of follow-up was 52 months (range, 18 to 120 months). A multivariate analysis using Cox regression identified four negative prognostic factors, namely, cN2 status (P <. 0001), involvement of multiple lymph node levels (L2+; P <.0001), pT3 to T4 stage (P <.0001), and no preoperative chemotherapy (P <. 01). For patients treated with primary surgery, 5-year survival rates were as follows: mN2, one level involved (mN2L1, n = 244): 34%; mN2, multiple level involvement (mN2L2+, n = 78): 11%; cN2L1 (n = 118): 8%; and cN2L2+ (n = 122): 3%. When only patients with mN2L1 disease were considered, the site of lymph node involvement according to the American Thoracic Society numbering system had no prognostic significance (P =.14). Preoperative chemotherapy was associated with a better prognosis for those with cN2 (P <.0001). Five-year survival rates were 18% and 5% for cN2 patients treated with and without preoperative chemotherapy, respectively. CONCLUSION: This study has identified homogeneous N2 NSCLC prognostic subgroups and suggests different therapeutic approaches according to the subgroup profile.

Estrogens and atherosclerosis.

Numerous epidemiological as well as experimental studies have suggested that estradiol (E2) prevents atherosclerosis development. However two controlled prospective and randomized studies in women using hormone replacement therapy (HRT) did not confirm this beneficial effect. We then decided to use mouse models of atherosclerosis to define the possible mechanisms involved and the reasons for the discrepancy. We have shown that, although serum cholesterol decreases, this influence on lipid metabolism is negligible. Surprisingly, E2 induces an inflammatory-immune response towards a T helper cell (Th1) profile with increasing interferon-gamma production that could destabilize atheromatous plaques, and could account for the increase in the frequency of cardiovascular events in women undergoing HRT. At the level of the endothelium, E2 induces an increase in nitric oxide (NO) biodisponibility, but this phenomenon does not concern the development of fatty streaks. Nevertheless, the atheroprotective effect is apparently mediated at the level of the endothelium by a mechanism that has still to be characterized in molecular terms. These new acquisitions constitute a basis for new pharmacological developments allowing the prevention of deleterious effects and preserving the beneficial ones.

[Estrogens and the arterial wall]. / OEstrogènes et paroi artérielle.

Two isoforms of oestrogens receptor (alpha and B) have been identified in the cells of the arterial wall, and an heterogenity of their expression according to the animal species, to the vascular bed and to sex has been reported. Estrogens can thus directly influence the vascular physiology through a genomic mechanism, but extra-genomic mechanisms responsible for a short-term effect have also been suggested. Endothelium appears to be an important target for estradiol, because this hormone potentiates endothelium-dependant relaxation through an increase in NO bioavailability, and accelerates endothelial regrowth. In the model of apolipoprotein E-deficient mice, as the atrhroprotective effect deposit. The immune system appears to play a key role, as the athroprotective effect of estradiol is absent in mice deficient in T and B lymphocytes. Estrogens potentiate the endothelium-dependant relaxation through the increase in nitric oxide bioavailability. Endothelial dysfunction (abnormality of the endothelium-dependent vasodilation) occurs in atheromatous arteries. Estrogens prevent and even correct this endothelial dysfunction. In monkeys, this beneficial effect of estrogens is not altered by coadministration of progesterone, but is abolished.

[Surgical management of emphysema]. / Chirurgie de l'emphysème.

Surgery is an important therapeutic option for emphysema patients with invalidating dyspnea and poor quality-of-life. Preoperative tests must determine the degree of functional impairment (dyspnea score, walking test, quality-of-life) and evaluate lesion reversibility (imaging, function tests, TLCO, blood gases, scintigraphy, right microcatheterism) and assess the patient's general health status. Besides lung transplantation, the only surgical alternative is resection which, depending on the type of parenchymal damage, can involve excision of bullae or volume reduction. Several modalities can be proposed: atypical resection of the apexes via sternotomy, multiple unilateral atypical resection, simple lobectomy. The choice depends on the distribution of the parenchymal destruction and also on the severity of the emphysema and the patient's age. Operative mortality is now well below 10%. Volume reduction provides significant functional improvement in 80% of patients but with a temporary effect (4-5 years). Bullae excision is particularly important since functional recovery is achieved early and persists.

[Video-guided surgical resection of solitary pulmonary nodules. Significance of thoraco-conversion in cancer cases. Apropos of 34 cases]. / Résection sous vidéo-chirurgie des nodules pulmonaires solitaires. Intérêt d'une thoraco-conversion en cas de cancer. A propos de 34 cas.

The use of video-guides surgery for major pulmonary resections in cancer patients raises a problem of safety and oncological quality. The aim of this prospective study was to demonstrate the oncological contribution of systematic thoracotomy in suspected stage I cancer patients. Between February 1993 and December 1996, we operated 34 consecutive patients with a solitary primary neoplastic lung nodule using normal fibroscopy and preoperative CT scan to detect mediastinal nodes. The nodules measured a mean 18.5 mm. Diagnosis was confirmed at peroperative pathology examination of the video-guided surgical resection, generally leading to thoracotomy for lobectomy-dissection. The final tumoral stage affirmed the initial diagnosis (stage I) in only 19 cases (56%). Peroperative findings showed that the other patients had more advance disease: 2 stage II (T1N1) (6%), 11 stage IIa (T1N2) (32%) and 2 stage IIIb (satellite nodule in the remaining lobe measuring 6 and 7 cm) (6%). These findings emphasize the importance of complete node dissection as well as the need to carefully palpate the entire lung. Thoracotomy remains the most reliable and reproducible method for safely fulfilling the oncological requirements.

[Physiopathology of closed thoracic trauma]. / Physiopathologie des traumatismes fermés du thorax.

Any thoracic trauma causes more or less severe hypoxia, due to pain, pleural effusion, mechanical ventilation disorders and pulmonary contusion. These four factors lead to bronchial congestion, which in turn aggravates hypoxia. More or less rapidly a vicious circle of respiratory failure is created. It can be broken only by early treatment of the cause. Without such treatment, respiratory failure quickly becomes autonomic and treatment of the cause is no longer sufficient.

[An analysis of treatment delays of thoracic cancers: a prospective study]. / Analyse des délais de prise en charge des cancers thoraciques: étude prospective.

INTRODUCTION: Lung cancer is the main cause of cancer death in France. The diagnosis is often late and the delay between the onset of symptoms and management is considered an aggravating factor. MATERIAL AND METHODS: Our prospective study collected the dates of the start of management of 139 consecutive patients receiving first line treatment for thoracic cancer in our hospital between November 2008 and May 2009. The aim of this study was to evaluate the delays in medical or surgical treatments in patients with thoracic cancer and to determine the cause of these delays. RESULTS: The median delay between the first abnormal chest X-ray and treatment was 9.6 weeks. The delays were significantly shorter in the late stages and in small cell cancer (P=0.001). There was a tendency for shorter delays in women and for longer delays in older patients. CONCLUSION: Evaluation of the delays in treatment, particularly in the early stages, is part of the quality control of management of these diseases.

[Evaluation of preoperative non-invasive ventilation in thoracic surgery for lung cancer: the preOVNI study GFPC 12-01]. / Évaluation de la ventilation non invasive préopératoire avant chirurgie de résection pulmonaire. Étude préOVNI GFPC 12-01.

BACKGROUND: Surgical resection is the best treatment for stage I and II non-small cell lung cancer. Despite an improvement in the perioperative management of cancer patients and specialization of surgical teams, morbidity and mortality remains significant. Non-invasive ventilation (NIV) is an effective therapeutic option in hypercapnic respiratory failure. It also improves functional and gasometric parameters when undertaken before surgery. The objective of the preOVNI study is to demonstrate that preoperative non-invasive ventilation for 7 days, at home, reduces the postoperative respiratory and cardiovascular complications of lung resection surgery, in a high-risk population. METHODS: A prospective, randomized, controlled open-labelled multicentric French study, under the supervision of the Groupe Français de Pneumocancérologie (GFPC), comparing 7 days of preoperative non-invasive ventilation with standard treatment. Inclusion criteria are: patients suitable for lobectomy or segmentectomy for primary bronchial carcinoma and presenting with obstructive or restrictive lung disease, obesity or chronic cardiac insufficiency. The primary criterion is a composite one, including all respiratory and cardiac complications. The number of patients is 150 in each treatment arm, 300 in total. EXPECTED RESULTS: We think that preoperative NIV will be able to reduce the rate of postoperative complications. If this objective is achieved, the management of these patients could be changed.