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.

Elective drainage of the apical chest by posterior approach.

Pneumothorax due to incomplete reexpansion of remaining lung after a thoracic operation is difficult to drain via standard access routes. Apical chest drainage can be placed through a upper posterior point of the back, located in the laterovertebral area at the level of the first or second intercostal space. This technique, which is very safe and well tolerated, avoids the necessity to use thoracoplasty or muscle flap plombage of those residual cavities.

[Lung volume reduction surgery in emphysema]. / Chirurgie de réduction de volume dans l'emphysème.

Lung volume reduction surgery in emphysema has, as an objective, the reduction of dyspnoea and an increase in the exercise tolerance in patients with respiratory insufficiency suffering from diffuse emphysema. In principle the resection of the most diseased areas of emphysema leads to improvement in the mechanical properties of the emphysematous lung and correct pulmonary hyperinflation. The respiratory function benefits both objective and subjective, produced by surgery are real but transitory and inconstant depending in particular on the evolutionary profile of the emphysematous disease. The indications should be further refined and an objective comparison of different surgical techniques has not been achieved. The impact on the quality of life for these patients is unknown.

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.

[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.

[Pulmonary emphysema: surgical indications]. / Emphysème pulmonaire: indications chirurgicales.

Surgery for pulmonary emphysema, with the exception of lung transplantation, is limited at present to resection of the emphysematous areas. The resection of a unique bulla within an otherwise healthy parenchyma can be indicated in case of complications but rarely in asymptomatic patients. When the bullae are large (i.e. volume greater than one-third of the hemithorax) in a patient suffering from diffuse emphysema, bullectomy is the ideal indication. Mortality varies from 0 to 10%, essentially due to infection or acute respiratory failure. In most patients, the subjective improvement in terms of dyspnea and the objective improvement as measured by spirometry remains significative up to 5 years after surgery. Inversely, surgical resection is classically considered to be contraindicated in patients with small poorly-limited bullae. Recent data would however question this idea since subjective and objective improvement after reduction of the lung volume is still present 1 year after surgery in most patients, even those with severe obstruction. The mechanism is probably related to increased elastic recoil. Even if only temporary improvement can be achieved for a few years, the persisting course of emphysema would suggest that volume reduction should always be entertained as an alternative before lung transplantation.

[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.

Surgical management of thoracic manifestations in human immunodeficiency virus-positive patients: indications and results.

The records of 97 patients with thoracic complications of human immunodeficiency virus (HIV) were analysed to determine the reasons for surgery and the results of these procedures. Of the patients, 79 underwent surgery; the remaining 18 were managed non-surgically. A total of 36 procedures were performed for diagnostic purposes: mediastinoscopy (21 patients), lung biopsy (15 patients). Therapeutic procedures were performed in 61 patients to treat pneumothorax (23 cases) or empyema thoracis (18 cases), for resection of pulmonary lesions (13 cases), and to treat various other pathologies (seven cases). Ten patients died in hospital: seven after surgery and three after a nonsurgical procedure. Eleven patients developed a postoperative complication. Hospital mortality varied from 0 per cent to 20 per cent, depending on the procedure. The mortality rate appears to be linked to the stage of HIV infection at the time of therapy rather than to the type of procedure performed. Surgical decisions must take into account the patient's Centers for Disease Control stage and physiological status, therapeutic possibilities, and the prognosis of the pathology requiring treatment.

[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.

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.

[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.

[Video thoracoscopy of pulmonary nodules. Can one avoid preoperative markers?]. / Vidéothoracoscopie des nodules pulmonaires. Peut-on se passer d'un repérage pré-opératoire?

For a period of 35 months, 50 patients presenting with a total of 61 peripheral pulmonary nodules were operated on under videothoracoscopy. As a matter of principle none of these nodules were marked radiologically pre-operatively. All the scanners were reviewed retrospectively by a radiologist and a thoracic surgeon without knowing the results of the thoracoscopic intervention: 23 of these patients on the evidence would have quite obviously required preoperative marking (group I), and 27 would have been presented for direct thoracoscopy (group II). In group I there was only one group of nodules which could not be localised and by necessity, a thoracotomy was required. In group II, two nodules could only be localised thanks to a mino-thoracotomy. The level of failure was between 4 and 7%, and was identical to that found in the literature for different techniques of pre-operative radiological marking: these techniques were often complicated by a pneumothorax and intrapulmonary haemorrhage. These techniques for marking are used extensively. Prospective studies based on precise and complete criteria should enable better definition of rare cases which might benefit.

[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.

[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.

[A rare tumor of the thoracic wall: synovial sarcoma]. / Une tumeur rare de la paroi thoracique: le synovialosarcome.

The synovial sarcoma is a tumour of the soft tissues. Its thoracic localisation is unusual. The authors report a case of a recurrent tumour of the scapula, whose excision required major plastic surgery to the dorsal chest wall. The diagnosis was revealed by the biphasic histological nature which was confirmed on immunological studies. Such tumours give rise to discussions on their histogenesis; their subsequent progress is slow and recurrences are common. Healing depends on the radical nature of their excision.

Anatomic basis of lymphatic spread of lung carcinoma to the mediastinum: anatomo-clinical correlations.

Correlation of the anatomic and surgical features in 360 cadavers and in 260 patients operated for bronchial carcinoma reveals that the lymphatics of the lung reach the ipsilateral mediastinum, sometimes directly and sometimes by sites which do not correspond to the anatomic site of the injection or of the pulmonary lesion. This implies the need for systematic eradication of all the lymph nodes of the ipsilateral mediastinum during surgery for bronchial carcinoma. In cases of tumoral lesions (N2), the prognosis is better when only one site is involved, whether the nodal disease is microscopic, uni- or multiglandular, with or without rupture of the capsule and whatever treatment is carried out, even when resection seems macroscopically complete to the surgeon. This is explicable in the light of the anatomic study, which shows that the lymph node chain is a functional entity which channels the lymph into the systemic circulation, either at the venous confluence of the neck or into the thoracic duct in the mediastinum. When only a single chain is affected, there is a greater than 70% chance that systemic metastases are already present, 90% when N2 affects 2 chains, while in N3 cases (lymph passage to contralateral chains) the incidence reaches virtually 100%. However, macroscopically satisfactory excision allows management of the local problem, and involvement of the mediastinal nodes, even with capsular rupture, cannot be considered as a contraindication in the absence of clinically detectable systemic metastases.