[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.

[Surgery for small-cell lung cancer]. / Chirurgie du cancer pulmonaire à petites cellules.

Small-cell lung cancer (SCLC) is a high-grade neuroendocrine carcinoma, metastatic at the time of initial diagnosis in 70% of cases. Within the 30% of localised tumours only 5% of patients are eligible for surgical treatment according to the recommendations of learned societies. These recommendations are mainly based on old phase II and III randomised prospective trials and more recent registry studies. Surgical care is only possible within a multimodal treatment and essentially concerns small-sized tumours without involvement of hilar or mediastinal lymph nodes. As with non-small cell lung cancer (NSCLC), lobectomy with radical lymph node removal is the recommended procedure to achieve complete tumour resection. Patient selection for surgery includes age, performance status and comorbidity factors. Adjuvant chemotherapy combining Platinum salts and Etoposide for resected stage I tumours is recommended by ASCO, ACCP and NCCN. The precise sequence of neo-adjuvant or adjuvant treatments remains controversial because of the large heterogeneity in clinical practice reported in the studies and the context at the time of SCLC discovery. The 5-year survival rate of patients with early stage disease (pT1-2N0M0) treated by lobectomy and adjuvant chemotherapy is between 30% and 58%, which validates the primary place that surgery must have in these early forms. There is certainly little or even no place for such a therapeutic sequence in locally advanced stages (T3-T4 or N2). However, the stage heterogeneity, as in NSCLC, makes final conclusions difficult. In fact, some registry studies with pairing scores reported a median survival of more than 20 months in N2 SCLC. So, all files of SCLC must be evaluated in a multidisciplinary meeting in order to find the optimal solution for patients with rare and heterogeneous tumours.

Rasmussen aneurysm in a patient from the Ukraine: A diagnostic challenge.

A patient diagnosed with multi-drug resistant tuberculosis presented with a massive haemoptysis linked to a Rasmussen aneurysm. Failure to occlude the feeding artery via coil embolization was successfully managed with lung surgery.

Diaphragm pacing restores olfaction in tetraplegia.

High cervical spinal cord injuries induce extreme handicap and tactile isolation. Tracheotomised tetraplegic patients are also bound to be olfaction deprived. By restoring negative pressure inspiration, diaphragm pacing (DP) should improve olfaction. We tested olfaction in 10 consecutive tetraplegics during positive pressure mechanical ventilation and DP, using the University of Pennsylvania Smell Identification Test (UPSIT). Quality of life was assessed using the Satisfaction with Life Scale (SWLS). Self-perceived benefits of DP were studied using an in-house questionnaire. Olfaction was very poor during positive pressure mechanical ventilation (UPSIT, mean+/-SD 17.1+/-6.4, anosmia or severe microsmia). It improved during DP (35.2+/-1.9, normosmia or mild microsmia; p<0.0001) and SWLS was 18.5+/-4.2. Nine patients stated that DP had improved their quality of life. This was driven by better mobility (ranked first), improved self-image and relationships with others (ranked second), improved olfaction and better feeling of security (both ranked third). Improved olfaction is among the benefits of DP and should be mentioned to patients considered for this therapy. Furthermore, attention to olfaction is warranted in tracheotomised ventilator-dependent patients, as a putative path towards improvement of quality of life.

[Relevance of surgery in small cell lung cancer]. / Intérêt de la chirurgie dans le cancer bronchique à petites cellules.

Surgery is the most effective treatment of lung cancer provided that there is complete resection. Even though the results in the early stages of small cell lung cancers (SCLC) are encouraging, many oncologists still consider SCLC a contra-indication. The authors report their experience. They retrospectively reviewed the clinical and pathological characteristics and long-term results of 104 patients (mean age: 58.6, male: N=82 and female: N=22) who underwent lung resection with mediastinal lymphadenectomy (lobectomy: N=51 and pneumonectomy: N=53) for small cell lung cancer between 1984 and 2006. The diagnosis was established before the operation in 49 patients (47.1%) of whom 61.2% (N=30) received neoadjuvant therapy. The survival (5-year survival rate 21.7%, median=18 months), postoperative mortality (deaths: N=6) included, depended on the stage: stage I: N=39, 5-year, 34.3%, median=29; stage II: N=23, 5-year, 26.1%, median=12; stage III: N=37, 5-year, 2.7%, median=12 (p=0.000067). There were no 5-year survivors among the N2 patients. The survival did not depend on the diagnostic aspect of the resection, the non-small cell lung cancer histological patterns or perioperative neoadjuvant and adjuvant therapy. The pneumonectomies were more frequent in case of neoadjuvant treatment (23/30 versus 30/47, p=0.00084). The results and the review of the literature indicate that surgery for small cell lung cancer may provide a cure in stages I and II and should not to be ruled out. The only contra-indication is proven pN2. A multicentre, randomised study on surgery versus medical treatment in the early stages should confirm this conclusion.

Cumulative radiation dose after lung transplantation in patients with cystic fibrosis.

PURPOSE: The purpose of this study was first to evaluate the imaging-related cumulative post-transplantation radiation dose in cystic fibrosis (CF) lung transplantation (LT) recipients and second, to identify the occurrence and type of malignancies observed after LT. MATERIALS AND METHODS: A total of 52 patients with CF who underwent LT at our institution between January 2001 and December 2006 with at least 3 years of survival were retrospectively included. There were 27 men and 25 women with a mean age of 24.4±9.2 (SD) years (range: 7.6-52.9 years) at the time of LT. Calculation of cumulative effective and organ doses after LT were based on dosimetry information and acquisition parameters of each examination. Cumulative radiation doses were calculated until June 2016, but stopped at the time of de novomalignancy diagnosis, for patients developing the condition. RESULTS: Patients received a mean cumulative effective dose of 110.0±51.6 (SD) mSv (range: 13-261.3 mSv) over a mean follow-up of 8.1±3.6 (SD) years (range: 0.5-13.5 years), with more than 100mSv in 5 years in 19/52 patients (37%). Chest CT accounted for 73% of the cumulative effective dose. Mean doses to the lung, breast and thyroid were 152.8±61.1 (SD) mGy (range: 21.2-331.6 mGy), 106.5±43.2 (SD) mGy (range: 11.9-221.4 mGy) and 72.7±31.8 (SD) mGy (range: 9.5-165.0 mGy), respectively. Nine out of 52 patients (17%) developed a total of 10 de novo malignancies, all but one attributable to immunosuppression after a mean post-transplantation follow-up period of 11.1±3.5 (SD) years (range: 3.7-16.3 years). Six-month cumulative effective dose was not greater in patients with de novomalignancies than in those without de novomalignancies (28.9±14.5 (SD) mGy (range: 13.0-53.4) vs 25.6±15.3 (range: 5.0-69.7), respectively, P>0.05). CONCLUSION: The cumulative effective dose exceeded 100 mSv in 5 years in 37% of LT recipients, the reason why continuous efforts should be made to optimize chest CT acquisitions accounting for 73% of the radiation dose.

Value of cancer antigen 125 for diagnosis of pleural endometriosis in females with recurrent pneumothorax.

The thorax is the most frequent extrapelvic location of endometriosis. Thoracic endometriosis is probably responsible for the high rate of recurrent pneumothoraces in females. The goal of the present prospective study was to assess the value of cancer antigen (CA)125 measurement in the detection of endometriosis in order to further enable early and adequate treatment of catamenial pneumothorax. Between January 2004 and March 2006, 31 females (mean age 32 yrs) underwent pneumothorax surgery. The control group comprised 17 males (mean age 27 yrs), who underwent videothoracoscopic pleural abrasion. Serum CA125 was measured around a menstrual period in females and before surgery in males. Videothoracoscopically diagnosed endometriosis occurred in 29% of females. The CA125 concentration was significantly higher in females with endometriosis compared to disease-free females (76.1 versus 16 U x mL(-1)). The mean value in males was similar to that observed in disease-free females. The frequency of thoracic endometriosis-related pneumothorax corresponds to, on average, a third of females presenting with recurrent pneumothorax. Early detection can be achieved with serum cancer antigen 125 measurement and may be helpful in indicating videothoracoscopic surgery.

[Cardiac compression of hydatid origin]. / Compression cardiaque d'origine hydatique.

INTRODUCTION: Cardiac hydatid disease is uncommon and occurs in 0.5 to 2% of patients with hydatidosis. Isolated intrapericardial hydatid cystic disease is extremely rare. OBSERVATION: We report the case of a young woman with cardiac compression due to multiple primary intrapericardial hydatid cysts. Since 1 year, she had gradual general health deterioration including dyspnoea, sweats and weight loss of 8kg. A widening of the mediastinum was observed on chest X-ray. The CT-scan, echocardiography and the dynamic IRM showed multiple mediastinal cysts with mass effect on the heart and main pulmonary artery. The size of the main pulmonary artery was reduced to 5 mm in diameter and the right upper pulmonary vein was nearly closed by posterior cysts. The right and left ventricular ejection fractions were estimated at about 34%. A complete resection of the cysts was performed by sternotomy. The surgical procedure was technically difficult because of major local inflammatory process. The postoperative outcome after an initial pulmonary embolism event was finally favourable. CONCLUSION: Hydatidosis can lead to severe cardiac involvement. These rare forms of hydatid cystic disease must be known even in non endemic regions by surgeons because of increasing mobility of the world's population.

[Lung cancer in women: surgical aspects related to gender]. / Cancer du poumon chez la femme: aspects chirurgicaux liés au sexe.

INTRODUCTION: Lung cancer is becoming more and more common in women where it presents significant differences at both clinical and therapeutic levels. Our purpose was to study those associated with surgical treatment. PATIENTS AND METHODS: 2972 patients were operated on between 1984 and 2002: 2480 men and 492 women. These two populations were compared (age, past history, investigations, interventions, TNM stage, long term survival and causes of death). RESULTS: The number of women increased with time; they were younger than the men, smoked less, had the same past history of cancer but less past medical history, and comorbidity. They underwent less pneumonectomies and had a lower postoperative mortality. Tumour size was smaller (39.5 vs 43.5cm, p=0.0001); N0 and stage I tumours were more frequent (52.6% vs 46% p=0.0074). Long term survival was better (48.6% vs 43.1%, p=0.016), particularly in stage I and with a past history of cancer. It was identical in stage III despite a higher incidence of multisite N2 disease. Smoking and adenocarcinoma were more frequent before the menopause and N2 prognosis deteriorated with age. CONCLUSION: These results confirm characteristics peculiar to lung cancer in women and warrant further investigation aimed at their better understanding. However, in multivariate analysis gender does not appear to be an independent prognostic factor.

[Evaluation of thoracic surgical practice. The impact of specialisation and the effect of volume on the results of cancer treatment: resectability, post-operative mortality, and long-term survival]. / Evaluation des pratiques en chirurgie thoracique.

INTRODUCTION AND METHODS: The impact of the volume of activity and the specialisation of the surgeon and the hospital on the quality of health care for patients with non-small cell lung cancer (NSCLC) was evaluated from the publications over the last 20 years. RESULTS: The statistics, based mainly on administrative data, identified a significant decrease in post operative mortality (5 out of 7 studies) and improved long-term survival (2 out of 3 studies) in establishments undertaking large numbers of lung resections. The threshold for defining high volume groups varied from study to study (from 28 to 128 procedures per year). The same tendency was seen among the surgeons where specialisation in thoracic surgery led to higher levels of resectability and parenchymal preservation. CONCLUSIONS: These results should be interpreted with caution on account of the nature of the data and the methodology employed. A certification of referral centres, validated by the French Thoracic and Cardiovascular Surgical Society, based on the training, level of activity in cancer surgery, and the infrastructure of the hospital should lead to a more even standard of care for patients with NSCLC.

[Surgical diagnosis of pleural disease]. / Le diagnostic chirurgical en pathologie pleurale.

Videothoracoscopy is a minimally invasive techinique providing a direct view of the pleural cavity. It enables complete exploration of the cavity with biopsies of pathological zones. The indication, based on clinical or radiographic findings, is retained when less invasive methods have been unable to establish the diagnosis and a specific pleural disease (tumor or other) is suspected. Depending on the observations at videothoracoscopy and the suspected disease, deep biopsies to the subpleural fat can be made with a forceps if nodules have been identified. If the pleura is uniformly thin, a small flap can be detached for the biopsy. Several pleura sites are biopsied and a direct pathology examination can be performed on certain specimens. Videothoracoscopy enables careful hemostasis of biopsied zones and symphysis (generally with talc) if needed. The perioperative mortality is low (<0.5%) with good sensitivity greater than 90% and excellent specificity at 100%. The presence of complete pleural symphysis counterindicates videothoracoscopy. In such patients, direct access via an intercostal incision is needed to obtain localized biopsies.

[Surgery for pulmonary metastases from colorectal cancer: Predictive factors for survival]. / Chirurgie des métastases pulmonaires des cancers colorectaux : facteurs prédictifs de survie.

INTRODUCTION: Colorectal cancer is the 3rd commonest cause of death from cancer: 5% of patients will develop lung metastases. The management of oligometastatic disease is based on the objective of optimal local control. STATE OF THE ART: To date, no results from randomized control trials support the resection of pulmonary metastases in oligometastastic colorectal cancer patients. However, numerous series, mainly retrospective, report long-term survival for highly selected patients, with 5-year survival ranging from 45 to 65% in the most recent series. The consensual predictive factors of a good prognosis are: a disease free-interval>36 months, a number of metastases≤3, a normal level of carcino-embryonic antigen and the absence of hilar or mediastinal lymph node involvement. PERSPECTIVES: Around 20 to 40% of patients will develop recurrence, probably linked to the presence of undetectable micrometastases. Therefore, experimental work is being undertaken to develop new treatment techniques such as isolated lung perfusion, radiofrequency ablation and stereotactic radiation therapy. CONCLUSION: Highly selected patients suffering from colorectal cancer lung metastases could benefit from resection with improved survival and disease-control.

[Consequences of tobacco smoking on lung cancer treatments]. / Le tabac et ses conséquences dans le cadre du traitement du cancer bronchique.

In France, in 2010, tobacco induced 81% of deaths by lung cancer corresponding to about 28,000 deaths. Continued smoking after diagnosis has a significant impact on treatment. In patients with lung cancer, the benefits of smoking cessation are present at any stage of disease. For early stages, smoking cessation decreases postoperative morbidity, reduces the risk of second cancer and improves survival. Previous to surgery, smoking cessation of at least six to eight weeks or as soon as possible is recommended in order to reduce the risk of infectious complications. Tobacco could alter the metabolism of certain chemotherapies and targeted therapies, such as tyrosine kinase inhibitors of the EGF receptor, through an interaction with P450 cytochrome. Toxicity of radiations could be lower in patients with lung cancer who did not quit smoking before treatment. For patients treated by radio-chemotherapy, overall survival seems to be better in former smokers but no difference is observed in terms of recurrence-free survival. For advanced stages, smoking cessation enhances patients' quality of life. Smoking cessation should be considered as full part of lung cancer treatment whatever the stage of disease.

[Evolution of species: Lung cancer evolution over one third of a century]. / De l'évolution des espèces : évolution du cancer du poumon en un tiers de siècle.

INTRODUCTION: Management of non-small cell lung cancer (NSCLC) is getting better and results on long-term survival have improved. We reviewed the modifications observed in surgery over a 32-year time period. PATIENTS AND METHOD: Data of 6105 patients who underwent surgery from 1979 to 2010 were analyzed over three equal time-periods: gender, age, type of surgery, histology, pTNM, tobacco addiction, comorbidity and time periods. RESULTS: Age, number of females and high-risk patients with comorbidity (including the history of a previous cancer) increased with time periods. Number of exploratory thoracotomy (7.7 % to 1.6 %) and pneumonectomy (48 % to 18 %) decreased. Number of wedge resection (0.5 % to 6 %) and lobectomy (42 % to 64 %) increased. Rates of the other types of resection were unchanged. Neoadjuvant treatments accounted for more than 20 % of patients in the last time period. Postoperative mortality (4 %) did not vary but non-lethal complication rates increased (16.9 % to 27.7 %). Global 5-year survival rates dramatically increased with time going from 37.4 % to 49.8 % (P<10(-6)). Survival improvement was observed in the different components of the pTNM and whatever the type of treatment. However, survival was affected by increasing age and multiplication of comorbidities but without impairing the general better outcome trend. CONCLUSION: NSCLC itself, its diagnostic and therapeutic management, and patient's characteristics evolved with time. Survival improved in most studied prognosis factors. Time period factor was of paramount importance and might be included in research dealing with NSCLC.

[Lung cancer measuring 1cm or less: A miniature subset requiring surgery]. / Cancers du poumon de 1 à 10millimètres : des cancers miniatures à opérer.

INTRODUCTION: Lung cancer measuring 1cm or less has an apparently very good outcome. However, the characteristics permitting their oncological management are unappreciated. PATIENT AND METHOD: We reviewed 187 patients with such a cancer (145 men and 42 women, mean age 60.2years) and studied the type of surgery performed, the pTNM, and the histological features. RESULTS: Surgery (19 wedge-resections, 12 segmentectomies, 136 lobectomies, 20 pneumonectomies) was complete (R0) in 97.3%. The tumors, each precisely defined among 98 adenocarcinomas (52.4%), 83 squamous cell carcinomas (44.4%), and 6 others, measured 1mm to 10mm:<5mm (n=41), 6 to 9mm (n=43), and 10mm (n=103). There were 161 pT1 (86.1%), 22 pT2 (11.8%) and 4 pT3; 148 pN0 (79.6%), 18 pN1 (9.7%) and 20 pN2 (10.7%). pN1 and pN2 were present in tumors<5mm (12/41, 29.3%) as well as in the others (26/146, 17.8% P=0.11). Histological examination frequently discovered visceral pleura involvement (tumors:<5mm 12.2% (5/41), 6 to 9mm 7% (3/43), 10mm 13.6% (14/103), P=0.53) and lympho-vascular invasion (12.9%). Five-year survival rate (66.4%) was adversely influenced by age, type of resection, pN and histological features. The survival rate was not better in tumor<5mm. CONCLUSION: Surgical resection allows the local control of lung cancers<1cm and their complete histological study, a key issue in the therapy of the future, which renders surgery an absolute must even in very small tumors.

[Obesity and lung cancer: incidence and repercussions on epidemiology, pathology and treatments]. / Obésité et cancer bronchique: incidences épidémiologiques, pathologiques et thérapeutiques.

INTRODUCTION: Obesity and lung cancer are major public health problems. The purpose of this work is to review the data concerning this association. METHOD: We report clinical and epidemiological data on obesity and discuss the impact on the incidence of lung cancer, as well as the safety and efficiency of anti-tumor treatments. RESULTS: Obesity does not contribute to the occurrence of lung cancer, unlike other malignancies. Patients may be more likely to undergo treatment at lower risk. Regarding surgery, obesity makes anaesthesia more difficult, increases the operative duration but does not increase postoperative morbidity and mortality. Chemotherapy and radiotherapy seem to be administered according to the same criteria as patients with normal weight. Paradoxically, survival rates of lung cancer are better in obese patients as well after surgery than after non-surgical treatment. CONCLUSION: Obesity is related to many neoplasms but not to lung cancer. Regarding long-term survival all treatments combined, it has a favorable effect: this is the "obesity paradox".

[Lung cancer surgery in a single-lung]. / Chirurgie du cancer bronchique sur poumon unique.

INTRODUCTION: The diagnosis of a second lung cancer in a patient with a previous medical history of lung cancer is no longer a rarity. Also, it is possible to observe a new location in a patient who underwent pneumonectomy in the past. Surgery remains the best treatment. Our objective was to overview this subject. PATIENTS AND METHODS: Among 5611 patients operated in our institution, 186 (3.3%) had metachronous cancer and 17 had previous pneumonectomy (0.7% of pneumonectomies and 0.2% of NSCLC treated in our department). The procedure was diagnostic and therapeutic in 88% of cases (n=15). RESULTS: There were 16 males and 1 female, mean age was 62.5-years. All were smokers (11 were former smokers) and 6 had other medical history. Mean FEV was 52% (range 35-95%). Types of resection were 2 lobectomies, 4 segmentectomies, and 11 wedge resections. There were no postoperative deaths, but two complications. Histological subtype of the first and second cancer was the same in 11 patients. All patients were pN0 after second surgery. The long-term survival (median 33 months) was 35.3% at 5-years and 14.1% at 10-years. Two patients treated with pneumonectomy for their first cancer were pN2. Patients who underwent upper right lobectomy for treatment of their second cancer survived longer than 5-years. CONCLUSION: Surgical resection for lung cancer on single-lung is associated with acceptable morbidity and mortality. Prolonged survival can be achieved in selected patients.

Prognostic factors after surgical resection of N1 non-small cell lung cancer.

OBJECTIVES: Non-small cell lung carcinoma (NSCLC) with N1 involvement is associated with 5-year survival rates ranging from 7% to 55%. Numerous factors have been independently reported to explain this heterogeneous prognosis, but their relative weight on long-term survival is unknown. METHODS: Patients who underwent surgical resection for NSCLC in two French centers from 1993 to 2010 were prospectively recorded and retrospectively reviewed. The overall survival (OS) of patients undergoing first-line surgery for pN1 disease was analyzed according to the type of extension, number of metastatic LN, number and anatomic location of metastatic stations. RESULTS: The study group included 450 patients (male 80.2%, mean age 63.3 ± 9.9 years, 5-year overall survival 46%). The number of metastatic station was 1 in 340 (75.6%, single-station disease) and ≥2 in 110 patients (24.4%, multi-station disease). The number of metastatic stations was correlated with the number of metastatic LN (p < .001), and associated with adverse OS (p = .0014). The presence of intralobar metastatic LN (station 12-13-14) was associated with a mechanism of direct extension (p < .001), but did not impact OS (p = .71). The location of metastatic stations was of prognostic significance only in case of multi-station disease, with hilar (station 10) involvement being associated with adverse OS (p = .005). The 110 patients with multi-station pN1 disease and the 134 patients operated on for single-station pN0N2 (skip-N2) disease during the study period yield comparable outcome (p = .52). CONCLUSIONS: In patients with resected pN1 NSCLC, the number of metastatic stations and their location in case of multi-station disease have a prognostic value.

[Pneumonectomy for benign disease: indication and factors affecting the postoperative course]. / Pneumonectomie pour lésions bénignes: indications et facteurs affectant les suites opératoires.

Pneumonectomy for benign disease is rare but may generate more postoperative morbimortality than when performed for lung cancer. We questioned this assessment and retrospectively reviewed 1436 pneumonectomies and 54 completions of which 82 and 10 performed for benign disease (5.7% and 18.5%, respectively): left n=65 and right n=27. Indications were: post-tuberculosis destroyed lung (n=37), aspergilloma (n=18), bronchiectasis (n=19), infection (n=5), congenital malformations (n=5), inflammatory pseudotumor (n=3), trauma (n=2), post-radiation (n=2) and mucormycosis (n=1). Pneumonectomy consisted of 48 standard and 44 pleuro-pneumonectomies. Stump coverage by flaps was performed in 66.3% (61/92). Complications occurred in 21.7% (20/92) and postoperative deaths in 7.6% (7/92, of which 5 with fungal infections), which was not different than what was observed in lung cancer. There was no difference in fistula formation and mortality regarding the side, the type of resection and the protective role of stump coverage. Considering patients with fungal infections versus others, mortality was 26.3% (n=5/19) and 2.7% (n=2/74), respectively (P=0.0028). Pneumonectomy for benign disease achieves cure with acceptable mortality and morbidity. However, presence of fungal infection should raise the attention for possibility of increased postoperative risks.