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.

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.

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.

[Results of surgical treatment of lung metastases from colorectal cancers]. / Résultats du traitement chirurgical des métastases pulmonaires des cancers colo-rectaux.

OBJECTIVE: The aim of this work was to determine the long term results and the prognostic factors after surgical resection of pulmonary metastases from colorectal cancers. METHODS: Clinical status after surgery and survival were studied in 101 consecutive patients undergoing lung resection for pulmonary metastases from colorectal carcinoma between 1970 and 1993. Prognostic factors were evaluated according to surgical design. Mean interval between colon resection and lung resection was 44 months. Fifty-nine patients had a solitary lesion, 17 had multiple unilateral lesions and 25 multiple bilateral lesions. Eighteen patients had undergone previous surgery for localized extrapulmonary metastases. A wedge resection was performed in 47 patients, lobectomy or bilobectomy in 40, pneumonectomy in 11 and biopsy in 3. RESULTS: There was no postoperative mortality and 5-year survival in complete resection was 21%; all patients with incomplete resection or biopsy died within 3 years. Significant prognostic factors were: complete resection, metachronous disease (vs synchronous metastases) and absence of lymph node involvement. The extent of the colorectal disease and the number of resected metastases did not influence prognosis. Survival for patients with resected extrapulmonary disease was not significantly different as compared with patients with only pulmonary metastases. Eleven patients had repeat pulmonary resections, 6 of these patients are currently alive, 3 of them more than 3 years after the second pulmonary resection. CONCLUSIONS: We conclude that resection of colorectal lung metastases is safe and effective, that resectable extrapulmonary disease does not contra-indicate pulmonary resection and that repeat thoracotomy is warranted in selected patients with recurrent lung metastases.

[Endo- and exo-bronchial schwannoma treated by resection-anastomosis of the left bronchial stump]. / Schwannome endo- et exobronchique traité par résection-anastomose de la bronche souche gauche.

Bronchial schwannomas are rare tumours. We report a case of an endo and exobronchial schwannoma which presented with dyspnoea and left pulmonary atelectasis. This was treated by complete resection of the tumour with a resection and anastomosis of the left bronchial stump flush with the lobar bifurcation. This tumour is most often benign and a conservative approach should be taken each time that this is permissible anatomically.

Utility of C-reactive protein measurements for empyema diagnosis after pneumonectomy.

Serum C-reactive protein (CRP) levels were studied serially during the postoperative period in 151 consecutive patients who underwent pneumonectomy. Virtually all patients who had a simple postoperative course (115 of 120), as well as 9 patients who had a bronchial infection of the remaining lung, 3 with a pulmonary embolus, and 2 who suffered postoperative bleeding requiring reoperation, demonstrated a similar postoperative evolution in their CRP values: a rapid postoperative rise until a peak or a plateau (mean peak value, 132 +/- 25 mg/L) was reached within 3 to 6 days, followed by a progressive decline to a value of less than 75 mg/L on day 9, and less than 50 mg/L on day 12. Conversely, all 12 patients who suffered empyema postoperatively, as well as 3 patients with bacterial pneumonia, 1 patient with chylothorax, and 1 patient with inflammatory pericarditis, demonstrated either a markedly persistent elevation in their CRP values or a secondary rise in the levels which exceeded 100 mg/L. Because of the high sensitivity (100%) and specificity (91.4%) of the CRP levels in detecting postpneumonectomy empyema, we recommend the routine use of this measure. Furthermore, a low CRP value after pneumonectomy (less than 50 mg/L) may help in deciding whether to confidently discharge a patient from the hospital in the absence of empyema. The negative predictive value of this method was found to be 100%.

Lung resection after high doses of mediastinal radiotherapy (sixty grays or more). Reinforcement of bronchial healing with thoracic muscle flaps in nine cases.

Mediastinal radiotherapy of more than 60 Gy highly compromises bronchial and wound healing after lung resection. Nine patients with primary lung cancers underwent radical resection after high radiation doses. Eight patients had primary lung cancer previously treated by radiotherapy alone (n = 2) or associated with chemotherapy (n = 6). One patient had a tracheal cancer involving the carina that was previously treated by radiotherapy. Seven patients underwent pneumonectomy and one patient underwent lobectomy with reinforcement of bronchial stump closure with use of the serratus anterior muscle. One patient underwent a sleeve lobectomy with bronchial reconstruction wrapped with an intercostal pedicle flap. Five patients had no postoperative complications and four patients had empyema, one associated with a small bronchial fistula. All except one patient were successfully treated by thoracostomy and immediate or secondary transposition of the pectoralis major muscle and the omentum to fill the cavity. These results show that lung resections can be done after high doses of radiotherapy without a high rate of bronchial fistula by using thoracic muscle flaps to reinforce bronchial stumps and anastomoses. In this procedure, surgical dissection is more time-consuming and increases the postoperative empyema rate (4/9). However, the higher long-term survival may justify this choice in selected cases.

[Mediastinoscopy in the evaluation of the extension of primary bronchial cancer. Techniques, indications and therapeutic deductions]. / La médiastinoscopie dans le bilan d'extension du cancer bronchique primitif. Techniques, indications et déductions thérapeutiques.

In order to achieve mediastinal lymph node staging in bronchial cancer, axial mediastinoscopy (combined with left anterior mediastinoscopy for cancers of the left upper lobe) is by far the most efficient and the most reliable technique. Since mediastinoscopy has been part of the investigations that can be made before thoracotomy, the number of exploratory thoracotomies has considerably decreased in all teams, thus reducing intraoperative mortality at the same time. Thoracic CT, which arrived in the diagnostic weaponry against lung cancer a long time after mediastinoscopy, has a major asset in that it allows selecting the patients for whom mediastinoscopy seems to be useful, on the basis of criteria related to the size of mediastinal lymph nodes (10 mm generally being the threshold chosen to perform mediastinoscopy or not). For almost all authors, systematic mediastinoscopy is no longer useful at present. Similarly, positive mediastinoscopic findings must not lead to systematically refuse patients, as the invasion or absence of invasion of a mediastinal lymph node is neither necessary nor sufficient to discuss a surgical indication. While some still automatically refuse all patients with positive mediastinoscopy, most authors still remain very interventionistic for N2 patients selected on the basis of very accurate criteria that are analyzed above, and surgery can then be performed at once or, for some authors, after a "neo-adjunctive" therapy, the long-term efficacy of which has unfortunately not been rigorously demonstrated as yet.

[Percutaneous parietal pleurectomy using video-endoscopy. Modern treatment of spontaneous recurrent pneumothorax]. / La pleurectomie pariétale percutanée par vidéo-endoscopie. Le traitement moderne du pneumothorax spontané récidivant.

The best prevention of recurrent spontaneous pneumothorax is obtained with a parietal pleurectomy, the recurrence rate being below 0.5%. The sequelae on the muscles and the aesthetic result of a thoracotomy favour a pleurodesis using a closed chest technique. Video-endoscopy enables us to perform 16 percutaneous parietal pleurectomies (PPP) without thoracotomy in 14 patients. 11 cases were idiopathic spontaneous recurrent pneumothoraces and in 3 cases the recurrent pneumothorax occurred in patients suffering from AIDS with progressive pulmonary lesions. PPP was performed under general anaesthetic with selective intubation. The posterior incision of 2-3 cm did not involve any muscular section and the dissection was performed throughout using video-endoscopy which enabled perfect control of haemostasis. PPP achieves a sub-total pleurectomy. The hospital stay was on average for five days. Those operated on did not suffer from immediate post operative pain and shoulder mobility was excellent from the moment at which the patient awoke. The advantages of PPP are: perfect haemostasis and the absence of muscular sequelae or unpleasant aesthetic sequelae. These benefits now make us consider that percutaneous parietal pleurectomy may be the treatment of choice in spontaneous recurrent pneumothoraces.