[Hospital LOS, medical complexity and deprivation indicators]. / Lien précarité - durée et complexité des séjours hospitaliers en secteur de court séjour.

BACKGROUND: Several studies have shown that socioeconomic deprivation is associated with increased hospitalization lengths of stay (LOS) and costs. Yet, the French DRG-based information system (PMSI) does not take deprived situations into account. Hence, we aimed at extracting routinely available variables measuring deprivation from the Hospital Information System and at assessing their association with severity of illness and hospital LOS. METHODS: We performed record linkage between the PMSI database concerning stays of patients aged more than 16years in the short-stay sector of Assistance publique-Hôpitaux de Paris in 2007 and an administrative database which provided the following deprivation measures: recipients of Couverture Médicale Universelle (basic or complementary health insurances adapted for underprivileged French citizens) or Aide Médicale d'Etat (health and medical emergency insurances adapted for underprivileged non French citizens living in France) and homeless patients. We compared length of stays showing a deprivation measure to others after adjustment on morbidity, age and sex. RESULTS: Among 352,721 stays, the prevalence of the deprivation measures ranged from 0.71% for "homelessness" to 6.24% for complementary Couverture Médicale Universelle. Stays showing a deprivation measure had specific illnesses and had more frequently associated comorbidities or complications than others. After adjustment, deprivation measures were associated with significantly increased LOS (by 5% for Couverture Médicale Universelle to 48% for emergency Aide Médicale d'Etat. CONCLUSION: Routine extraction of deprivation measures from Hospital Information Systems is feasible. Age, sex and illness being equal, these deprivation measures were associated with more complicated cases and increased LOS. We recommend that case mix-based hospital prospective payment systems take socioeconomic deprivation into account.

Visceral pleura invasion by non-small cell lung cancer: an underrated bad prognostic factor.

BACKGROUND: Visceral pleura invasion (VPI) by non-small cell lung cancer is a factor of poor prognosis. A tumor of any size that invades the visceral pleura is classified as T2. Few studies have been conducted concerning the prognostic significance of VPI relative to other staging factors. METHODS: Between April 1984 and December 1996, 1,281 patients with T1 (n = 430) and T2 (n = 851) non-small cell lung cancer underwent curative surgical resection. Adjuvant radiation therapy was performed in 455 patients. There were 176 women and 1,105 men aged 30 to 86 years (mean, 60.9 years). Five hundred nineteen pneumonectomies, 742 lobectomies, and 20 segmentectomies were performed. In all patients, a complete mediastinal lymph node dissection was performed. International staging was stage IA and B (n = 697); stage II A and B (n = 247), and stage III A (n = 337). The patients were divided into two groups according to the existence of VPI (group I without, group II with). Both groups were compared with regard to the size of the tumors, histology, associated lymph node involvement, survival rates, and cause of death. Univariate and multivariate analyses were conducted. RESULTS: VPI (group II) was identified in 19.1% of the resected specimens: group I, n = 1036; group II, n = 245. The VPI was present in only 10% of non-small cell lung cancer 3 cm or less in size, reaching 33% of patients with non-small cell lung cancer larger than 5 cm (p = 0.0001). Squamous non-small cell lung cancer were significantly less accompanied by VPI (13.5%) than the other histologic categories. The VPI was associated with a higher frequency of N2 involvement (group I = 24.6%, group II = 33.4%, p = 0.01) and N2 involvement was more extensive (two or more N2 involved stations: group I = 8.2%, group II = 15.6%, p = 0.003). Actuarial survival rates were 51.8% at 5 years and 33.8% at 10 years in group I (median, 66 months), and 34.6% at 5 years and 27.9% at 10 years in group II (median, 30 months) (p = 0.000002). Long-term survival rates significantly decreased for larger tumors. Even in patients with N2 stage tumors, the difference of survival curves between the two groups was statistically significant. Cancer-related deaths were more frequent in group II and were mainly caused by distant metastases. By multivariate analysis, visceral pleura invasion proved to be a significant independent factor of poor prognosis. CONCLUSIONS: The VPI is a factor of poor prognosis. Its frequent association with extensive N2 involvement supports the hypothesis that exfoliated tumor cells are drained through the pleural lymphatics by the mediastinal lymphatic pathways and then into the bloodstream. The VPI is an important prognostic factor and, as such should stimulate more studies to better select the patients who could benefit from adjuvant therapy.

Prognostic significance of surgical-pathologic N1 disease in non-small cell carcinoma of the lung.

BACKGROUND: N1 disease represents a heterogeneous group of non-small cell lung carcinoma with varying 5-year survival rates. Specific types of N1 lymph node involvement need to be further investigated and their prognostic significance clarified. METHODS: From 1984 to 1993, 1,174 patients with non-small cell lung cancer had complete mediastinal lymph node dissection: N0, 50.25% (n = 590); N1, 21.8% (n = 256); and N2, 27.95% (n = 328). The N1 subgroup cases were reviewed. Four levels of N1 nodes were identified using the New Regional Lymph Node Classification for Lung Cancer Staging. Their prognostic significances were tested and 5-year survival rates were compared with those of N0 and N2 patients of the whole group. RESULTS: The overall 5-year survival rate of N1 patients was 47.5%. Survival was not related to site of the primary lung cancer, pathologic T factor, histologic type, type of resection, number of N1 station involved, nor type of N1 involvement (direct extension or metastases). Five-year survival was significantly better when N1 involvement was intralobar (levels 12 and 13, n = 102), as compared with extralobar (hilar) involvement (levels 10 and 11, n = 154): 53.6% versus 38.5% (p = 0.02). Intralobar N1 5-year survival was similar to that of N0 (53.6% vs 56.5%, p = 0.01), and extralobar 5-year survival with that of N2 (38.5 vs 28.3%, p = 0.01) when N2 was present in only one station in the ipsilateral mediastinum. CONCLUSIONS: N1 disease is a compound of two subgroups: one located inside the lobes is related to N0, and the other (extralobar or hilar) behaves like an early stage of N2 disease. This offers further information for clinical, therapeutic, and research purposes.

Cold abscess of the chest wall: a surgical entity?

BACKGROUND: Cold abscesses of the chest wall are rare tuberculous locations. Because of the resurgence of tuberculosis, this diagnosis must be considered more frequently. METHODS: During a 15-year period (1980 to 1995), 18 patients with one or more cold abscesses of the chest wall were managed in our department. Epidemiologic characteristics, indications, methods and results of operation, and pathogenesis of the abscesses were considered in this retrospective study. RESULTS: Most of the patients were immigrant men. A previous history of tuberculosis was noted in 15 cases (83%). Six patients had concomitant active pulmonary tuberculosis. There was mostly a solitary lesion in the chest wall, the most frequent location being the rib shaft (60%). Before operation the diagnosis was confirmed only in 4 patients (by needle aspiration of the abscess) and presumed in 4 others: an antituberculous chemotherapy was therefore given preoperatively to 8 patients. One patient did not undergo operation after a favorable response to medical treatment. In the other patients, an operation was indicated because of lack of response in 5 patients and the absence of diagnosis in 12 patients. Adequate debridement and a postoperative antituberculous regimen were performed with recurrence prevention in mind. A follow-up was obtained in 11 of the 17 patients undergoing operation. The only patient who required a second operation because of a recurrence at the same location had refused the antituberculous therapy after the first surgical procedure. Locations of the abscesses, computed tomographic scan results, and histologic examinations are in favor of a lymph-borne dissemination of tubercle bacilli. CONCLUSIONS: Because fine-needle aspiration remains an inaccurate diagnostic tool and antituberculous medical treatment is not always efficient, chest wall tuberculous cold abscesses remain in most cases a surgical entity.

Prognostic value of T and N in non small cell lung cancer three centimeters or less in diameter.

OBJECTIVE: Peripheral tumors 3 cm or less in diameter are classified T1, T2 when rupturing the visceral pleura, T3 when invading parietal pleura, chest wall, mediastinal pleura or pericardium and T4 when invading vertebra or mediastinal structures. Our objective was to assess the prognostic significance of T and N status according to the size of such tumors. PATIENTS AND METHODS: Patients (918) were operated upon between April 1984 and December 1991. Surgery included complete resection and mediastinal lymphadenectomy. Tumors 3 cm or less were studied concerning T, N status, histology and survival. RESULTS: There were 314 such tumors (T1 = 215, T2 = 64, T3 = 35, T4 = 6); N status was N0 60.2%, N1 21%, N2 18.8%. Global 5-year survival was 52.59%. In case of N0, survival was 64.63%: T1 = 63.76%, T2 = 71.48%, T3 = 45.71%, T4 = 66.6%; which was not significant. There were 48 tumors 1.0 cm or less in diameter (G1), 111 tumors 1.1-2.0 cm in diameter (G2) and 155 tumors 2.1-3 cm in diameter (G3). The incidence of N0, N1 and N2 disease was 77.1, 10.4 and 12.5%, respectively in G1, 64, 18 and 18% in G2, and 52.3, 26.5 and 21.3% in G3. The 5-year survival rate was 62.46% for G1, 52.91% for G2 and 49.36% for G3 (NS). In cases of N1 and N2, survival was 48.41% and 20.2% which was significant (P < 0.05) but differences between each T and each G were not significant. CONCLUSIONS: Small peripheral cancers spread into mediastinal nodes in 12.5-21.3% of cases, according to the size. This is a warning to perform nodes resections in cases where surgeons intend a videothoracoscopic approach. N2 status is not only an indicator but also a governor of prognosis. Neither T status nor size are determinants of prognosis as far as tumors 3 cm in diameter or less are concerned.

Factors determining survival in resected N2 lung cancer.

This retrospective study was based on 237 patients with non-small cell lung cancer (NSCLC) and nodal N2 disease. All accessible mediastinal lymph nodes (LN) were removed and classified according to their anatomical location in LN chains. The pulmonary resections performed were: pneumonectomy (n = 187), lobectomy (n = 44) and segmentectomy (n = 4). There was solitary nodal chain involvement by metastasis in 141 cases, two chains in 72 cases and three or more in 24; "skip" metastases were present in 26.6%. N2 disease would have been missed in 45 cases of single chain involvement (31.9%) if routine removal of mediastinal nodes had not been performed. The overall 5-year survival rate was 18.8%. Survival was not influenced by site, size or extension (T) of tumor, tumor histology or the presence of vascular invasion. The prognosis was significantly worsened by the presence of microscopic residual disease (30 cases) and of satellite nodules (23 cases). Survival was significantly improved when metastases involved a single LN chain (26.3 versus 8.3%, P = 0.0003). The location and number of involved nodes in the chain, "skip" metastases and the presence of extracapsular spread of carcinoma did not influence the prognosis. Routine mediastinal LN dissection is necessary to improve survival and for classification of lung cancer. Anatomic description allows better understanding of N2 disease which is not a contraindication to surgery when a gross complete resection can be achieved.

[Place of radical surgery in the treatment of non-small cell lung cancer. Apropos of 969 cases]. / Place de la chirurgie à visée curative dans le traitement du cancer bronchique non à petites cellules. A propos de 969 cas.

PURPOSE: Retrospective analysis of the results of radical surgery in a series of 969 patients presenting with non-small cell lung cancer. PATIENTS AND METHODS: From April 1984 to December 1981, 969 patients underwent radical surgery with mediastinal node dissection for non-small cell lung cancer. Surgery included 507 pneumonectomies, 447 lobectomies and 15 segmentectomies (for patients suffering from respiratory failure). RESULTS: The rate of intrahospital mortality was 4.3%. The rate of crude survival at 5-years was 45.8%. The tumor size (P = 0.004) and visceral pleura ruptures (P = 0.01) were significantly correlated to the 5-year survival rate that was reaching 56% for patients with no demonstrable metastasis to regional lymph nodes (NO), 46.6% for patients with metastasis to lymph nodes in the peribronchial or the ipsilateral hilar region (N1), and 20.8% for patients with metastasis to the ipsilateral mediastinal and subcarinal lymph nodes (N2) (P = 0.001). In case of stage N2 cancer, the 5-year survival rate was 28.7% when only one anatomical level was involved, and 8.7% when more than one anatomical level was involved (P < 0.0001). CONCLUSION: The main prognostic factor was nodal involvement.

[Prognostic factors of survival in resected N2 bronchial cancer]. / Facteurs pronostiques de survie des cancers bronchiques N2 réséqués.

This study was based on 206 patients with non small cell lung cancer and N2 nodal disease submitted to curative surgery: pneumonectomy 163, lobectomy 39 and segmentectomy 4. All accessible mediastinal lymph nodes were removed and classified according to their anatomical location in lymph node chains; "skip" metastases were present in 24.8% of cases. N2 disease would have been missed in 20% of cases if routine removal of mediastinal nodes had not been performed. There was solitary nodal chain involvement by metastasis in 126 cases (61.2%). Overall 5-year survival was 18.3% +/- 3. Survival was not influenced by site, size or extension (T) of tumor, adjuvant radiotherapy, tumor histology or presence of vascular invasion. The prognosis was significantly worsened by the presence of microscopic residual disease (22 cases) and of satellite nodules (18 cases). Survival was significantly improved when metastases involved a single node chain (25% versus 8.5%). The location and number of involved nodes in the chain, "skip" metastasis and presence of extracapsular spread of carcinoma did not influence prognosis. Routine mediastinal lymph node dissection is necessary to improve survival and for classification of lung cancer. Anatomical description allows better understanding of N2 disease which is not a contraindication to surgery when a complete gross resection can be achieved.

[Esophago-bronchial fistula in adults]. / Les fistules oeso-bronchiques de l'adulte.

The authors report five cases of benign oesophago-bronchial fistula in adults. These chronic bronchitic patients presented with recurrent episodes of secondary lung infections (or even haemoptysis). Questioning of the patients revealed a history of coughing when swallowing liquids in three cases. Two women concealed this symptom, which was only revealed retrospectively. The fistula was detected by upper GI series in three cases and by oesophageal fibroscopy in one case. In the remaining case, it was discovered at operating for severe haemoptysis. In four of the five cases, the fistula was situated on the right and was of post-tuberculous origin. In one case of post-traumatic fistula, it involved the left main bronchus. All of the patients were operated: a resection-suture of the fistula was performed via the oesophageal approach and, via the bronchial approach, simple suture of the fistula was possible in two cases, while resection of the destroyed pulmonary parenchyma was necessary in three cases (one right lower lobectomy, two bilobectomies). Demonstration of the oesophago-bronchial fistula, definition of its site and assessment of the condition of the pulmonary parenchyma are essential steps to be performed prior to surgery.

[Mucoepidermoid tracheobronchial tumors. Apropos of a series of 11 cases]. / Tumeurs muco-épidermoïdes trachéobronchiques. A propos d'une série de 11 cas.

Mucoepidermoid tumours (TME) are rare tumours which develop at the level of the submucous bronchial glands of the tracheobronchial tree. The majority of these tumours develop in a benign fashion but some of them are malign. Amongst these many are probably confused with adenosquamous bronchial cancers. We have reviewed eleven patients suffering from TME who were observed over a period of twelve years. Two of these tumours were at the level of the trachea: nine others were at the level of the bronchial cartilaginous trachea. Seven of these tumours had the macroscopic and histological criteria of low grade malignancy and four corresponded to those tumours said to show high grade malignancy. The only death concerned a patient with a tracheal tumor of high grade malignancy but the death occurred immediately after laser therapy to relieve obstruction in a patient with acute asphyxia. None of the other patients died of tumour progression and the longest follow up (eleven years of survival) involved a patient with a bronchial form and a high grade malignancy with glandular invasion. Even mucoepidermoid tumours of high grade malignancy have a good prognosis and it is a cardinal point to clearly distinguish these forms from adenosquamous cancers. Nevertheless it has been suggested that adenosquamous and mucoepidermoid carcinomas could have a common origin and be the extremes of the same overall disorder just as the image we have of neuroendocrine tumours whose spectrum extends from carcinoid tumours to small cell cancers.

[Non-small cell lung cancer: surgical trends as a function of age]. / Cancer pulmonaire non à petites cellules: particularités chirurgicales en fonction de l'âge.

Most of the studies on lung cancer and age are usually done on very young or very old populations. We conducted a study of the evolution of surgical features over time in a population aged 24 to 89 years. The series included 1,809 men and 287 women (n = 2,096) who had undergone surgery between April 1984 and December 1990 (n = 1,026) and between January 1991 and December 1996 (n = 1,996). Patients were divided into 7 age groups with 2 subgroups for patients with or without prior medical history of cancer. We analyzed the type of surgery and pathology findings by age. Morbidity was recorded according to state of previous cardiovascular disease and long-term survival was analyzed. A significant increase in the number of female patients was noted during the last ten years. Adenocarcinomas were more frequent in young patients. Exploratory interventions, partial tumor resections and lung resections for metastasis were more frequently performed in young patients than in older patients. Excision of mediastinal nodes was less performed often in old patients. In case of curative resection, postoperative pTNM was not modified with age. Morbidity increased with age; mortality was more frequent in the elderly even when comorbidity was taken into account. Mortality was not related significantly with cardiovascular morbidity factors despite an increased frequency of previous cardiovascular disease with age. Survival according to age showed 3 main types of population: patients aged under 64 years, those between 65 and 74, and those over 75 years of age. Mortality increased with time but was less often related to recurrence of lung cancer. Nevertheless, survival for stage III and stage IV patients older than 75 years demonstrated that surgery was not indicated for these patients. This study shows that indications for surgery should not vary with age except for patients over 75 years who have locally advanced cancer and a risk of surgical death greater than the chances of survival. All non-small-cell lung cancers should be resected with no delay, even in the elderly population.

[The surgical management of pneumothorax in patients with AIDS]. / Prise en charge chirurgicale des pneumothorax chez les patients au stade de SIDA.

The occurrence of a pneumothorax occurring as a complication of AIDS is a poor prognostic sign. We have undertaken a review of 26 patients admitted to hospital for a pneumothorax of whom 25 were admitted for therapy: five resolved under simple drainage; twenty required a pleurodesis which was performed on thirteen under video thoracoscopy: these were recurrent pneumothoraces and were bilateral in half the patients; all had failed under simple drainage. The hospital mortality was 30%; the follow-up was unusually long in the majority of cases and only 20% had a simple follow-up. The analysis of this population showed that the results were not tied to the proposed treatment but to the state of the disease and to the pre-existence of pulmonary lesions most often in relation to pneumocystis. Video thoracoscopy enables one to inspect the lung and to resect the diseased area at the origin of the air leak. The technique also enables the pleurodesis to be achieved and a pleural or lung biopsy to be obtained in a relative non-invasive fashion.

[Purulent pleurisy and lung cancer. Non-iatrogenic forms and therapeutic management]. / Pleurésies purulentes et cancer du poumon. Formes non iatrogènes et prise en charge thérapeutique.

Thoracic empyemas may occur during the course of lung cancer as a post-thoracotomy complication, or after pleural drainage and/or chemotherapy in cases when surgery was unfeasible, or may complicate the natural history of the disease and appear as the clinical event that led to its discovery. This latter situation is a challenge requiring to cure the infection in order to further treat the underlying lung cancer. We reviewed the cases of 18 men aged between 46 and 79 years that were referred to our surgical department from 1984 to 1996 for management of a thoracic empyema with an underlying lung cancer. Initial presentation of empyemas, lung tumor characteristics, treatments performed and their results were analyzed so as to formulate guidelines if possible. Mean duration of 17 empyemas before arrival was 26 days (8 to 60 days) and in one case empyema occurred during diagnostic work-up of an excavated lesion. Frank pus was observed in all cases and micro-organisms were identified in 13 cases. Empyema and diagnosis of lung cancer were concomitant in 15 cases: in 3 cases lung neoplasia was already diagnosed but patients had refused surgery. Empyema was treated by under water-seal chest tube drainage with adjunct fibrinolytic therapy in all cases; 2 elderly and cachectic patients suffering metastatic diffusion died rapidly. The other 16 recovered within one month. In 7 cases management was limited to medical treatment (palliative n = 2, chemotherapy n = 1, chemo combined radiotherapy n = 2 and radiotherapy alone n = 2) but only short survivals were observed (inferior to 10 months). Surgery was possible in 9 (pneumonectomy n = 8, lobectomy n = 1); there was no death; postsurgical empyemas complicated the cause twice but were easily cured by drainage; long term survivals were observed in 3 cases that were p NO. Pleural empyema complicating lung cancer is a rare but challenging situation. Once the pleural empyema has been controlled, surgical resection must be performed when indicated: postoperative complications are rare and long-term survival is possible.

[Surgery of bronchial cancer in patients aged 75 and over]. / Chirurgie du cancer bronchique chez les sujets âgés de 75 ans et plus.

From April 1984 to December 1990, 66 patients 75 years of age or older underwent curative mediastinal lymph node dissection. There were 37 pneumonectomies. Post-operative mortality was 12% and was not affected by the type of dissection. Five-year survival was 16.2 +/- 6.29% (median 23 months) and was more than 45% in less elderly patients. Survival rate was highly affected by presence of metastasis in the mediastinal nodes and was zero in N2 cases. More than half of the patients died from cancer-related causes. Generally, we operate all the N2 cases which appear technically dissectable. Retrospectively, we think that N2 stage detected, and confirmed histologically in patients over 75, would be the only contra-indication for this attitude.

[Tuberculous adenopathies of the mediastinum: surgical experience in adults]. / Adénopathies tuberculeuses du médiastin: expérience chirurgicale chez l'adulte.

Fifty eight patients were treated for mediastinal tuberculous adenopathies in the thoracic surgery department from 1986 to 1992. Surgery was diagnostic in 49: mediastinoscopy n = 42, left anterior mediastinotomy n = 3, thoracotomy n = 3 and video assisted surgery n = 1. Surgery was in view of cure in 9: bronchial fistula despite medical treatment n = 6, recurrence under medical treatment n = 3. Mediastinal tuberculous adenopathies rarely complicate in adults. Surgical treatment is quickly effective in prolonging and complicating cases under medical treatment and also probably diminishes the risk of bronchial and pulmonary sequellaes.

[Prognostic factors of operated non-small-cell bronchogenic cancer: critical analysis of T.N.M]. / Facteurs pronostiques du cancer bronchique non à petites cellules opéré: étude critique du T.N.M.

A prospective study of prognosis factors for operated non-small-cell bronchogenic cancer was conducted to assess those proposed by the T.N.M. classification. From April 1984 to December 1993, 918 patients aged 32 to 83 years underwent surgery: 389 stage I; 367 stage II; 367 stage IIIa; and 25 stage IIIb. Macroscopic exeresis was satisfactory in all patients and node dissection of the mediastinum was performed. Post-operative mortality was 4%. Overall actuarial survival at 5 years was 43.9%, stage I 59.5%; stage II 53.8%; stage IIIa 25.1%; stage IIIb 29.3%. Tumor size, presence of visceral pleural invasion, and presence of local invasion (T3 and T4) worsened prognosis (concerning T). The prognosis value of N was the determining element: survival at 5 years, 56.3% for N0; 47.5% for N1 and 20% for N2. When metastases invaded two node chains in combinaison with T3, prognosis was poor. These cancers were stage IV.

[Intrathoracic coelomic cysts]. / Kystes coelomiques intrathoraciques.

Intrathoracic coelomic cysts are benign embryonic tumors with a mesothelial lining. The aim of this work was to review possible localizations (pleuropericardic and other), the remaining surgical indications, and the current situation of minimally invasive techniques. We reviewed retrospectively, 28 cases of intrathoracic coelomic cysts in 12 men and 16 women, mean age 44 years. We recorded the cyst localization, clinical signs, indication for surgery, access routes used, and outcome. Twenty-one cysts were pleuropericardial cysts and 7 were ectopic mediastinal cysts. In all 7 of the ectopic mediastinal cysts and 4 of the pleuropericardial cysts surgery was indicated for diagnosis; for the other pleuropericardial cysts the indication was based on clinical signs (n = 4), large volume (n = 4), progressing volume (n = 7), no apparent reason (n = 1) and association with surgery for pneumothorax (n = 1). Assess was by mediastinoscopy (n = 1), mediastinotomy (n = 1), sub-xyphoid route (n = 1), thoracotomy (n = 18), and videothoracoscopy (n = 7). Long-term outcomes (mean follow-up 4 years 4 months) were good with no recurrences. Postoperative sequelae were observed in 6 cases after thoracotomy and in 1 case after videothoracoscopy. In summary, pleuropericardial cysts warrant surveillance without surgery unless their volume increases or clinical signs develop. Ectopic mediastinal cysts usually require surgery for diagnosis. It would appear advisable to prefer videothoracoscopy which allows diagnosis and excision of pleuropericardial cysts. Minimal thoracotomy may be helpful for ectopic mediastinal cysts.