Prognostic factors for survival after complete resections of synchronous lung cancers in multiple lobes: pooled analysis based on individual patient data.

BACKGROUND: Some reports suggest that patients with synchronous multiple foci of nonsmall-cell lung cancers (NSCLC) distributed in multiple lobes have a poor prognosis, even when there is no extrathoracic metastasis. The vast majority of such patients do not receive surgical treatment. For those who undergo surgery, prognostic factors are unclear. PATIENTS AND METHODS: We systematically reviewed the literature on surgery for synchronous NSCLC in multiple lobes published between 1990 and 2011. Individual patient data were used to obtain adjusted hazard ratios (HRs) in each dataset and pooled analyses were carried out. RESULTS: Six studies contributed 467 eligible patients for analysis. The median overall survival was 52.0 months [95% confidence interval 45.6-63.7]. Male gender and advanced age were associated with a decreased survival: HRs 1.64 (1.22, 2.22) and 1.40 (1.20, 1.80) per 20-year increment, respectively. Patients with cancers distributed in one lung had a higher mortality risk than those with bilateral disease: HRs 1.45 (1.06, 2.00). N1 or N2 had a decreased survival compared with N0: HRs 1.68 (1.12, 2.51) and 1.94 (1.33, 2.82), respectively. There was a trend toward increased mortality among patients with different histology: HRs 1.29 (0.96, 1.75). CONCLUSION: Advanced age, male gender, nodal involvement, and unilateral tumor location were poor prognostic factors.

Colorectal cancer pulmonary oligometastases: pooled analysis and construction of a clinical lung metastasectomy prognostic model.

BACKGROUND: Although resecting colorectal cancer (CRC) pulmonary metastasis is associated with long-term survival, identification of prognostic groups is needed for future randomized trials, and construction of a lung metastasectomy prognostic model (LMPM) is warranted. PATIENTS AND METHODS: We searched the PubMed database for retrospective studies evaluating prognostic factors following resecting CRC lung metastasis. Individual patient data were analyzed. Independent prognostic factors were used to construct an LMPM. RESULTS: Between 1983 and 2008, 1112 metastasectomies were carried out on 927 patients included in eight studies. Five-year survival rate was 54.3% following the first lung resection. Multivariate analysis identified three independently poor prognostic factors: pre-thoracotomy carcinoembryonic antigen ≥5 ng/ml, disease-free interval <36 months, and more than one metastatic lesion. Patients with good-, intermediate-, and high-risk groups according to the LMPM had a 5-year survival of 68.2%, 46.4%, and 26.1%, respectively (P < 0.001). Perioperative chemotherapy and previously resected liver metastasis had no influence on survival. CONCLUSIONS: The low- and intermediate-risk groups have a good chance of long-term survival following metastasectomy. However, more studies are needed to investigate whether surgery offers any advantage over systemic therapy for the poor-risk group.

[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.

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.

[NSCLC of early stage. The place of surgery]. / Place de la chirurgie.

Non-small cell lung cancer (NSCLC) of early stage (stage I and II) form a wide variety of numerous heterogeneous tumors in respect to the T, the N and the histology. However, they share the common characteristic of being resectable, so providing the best chances of cure in patients amenable to surgery. A wide range of resections is available and the tendency at the present time is to favour resections permitting to avoid performing pneumonectomy, an operation whose postoperative mortality may be considerable, particularly on the right side. The place of surgery is of paramount importance in view of cure on condition that the resection is complete, that is without any tumor left behind, and includes a radical mediastinal lymphadenectomy. The place of surgery is also often diagnostic as well as therapeutic, and surgery provides the best histologic classification, the most accurate staging, and thus the best adapted adjuvant therapy and global management.

[Pulmonary malignant superior vena cava obstruction: endovascular stent therapy]. / Obstruction cave supérieure par cancer bronchopulmonaire : traitement endovasculaire par stent.

MATERIALS AND METHODS: Thirty-one patients underwent stent placement between June 1998 and October 2006 for superior vena cava obstruction. The initial effectiveness of the metallic stent therapy and the follow-up results were studied at one, six and 12 months. PURPOSE: We retrospectively studied the utility of metallic stent placement for the treatment of malignant superior vena cava obstruction in 31 patients (SVCO) on the basis of long-term follow-up data. RESULTS: The initial clinical success rate was 100% (31 out of 31), the primary clinical patency rate was 93% (26 out of 28) at six months. The obstruction rate of the stent was 7% (two out of 28) at six months. There was no additional stent used for recurrence. At 12 months, 27 out of 31 patients were deceased in whom there was no recurrence of SVCO until death. CONCLUSION: Stent therapy is an effective treatment for SVCO. Adjuvant therapy must to be evaluated in association with stent therapy.

[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 and lymph drainage]. / Cancer bronchique: le drainage lymphatique.

Lung cancer is lymphophile and may involve lymph nodes (LN) belonging to lung lymph drainage. LN metastases are figured within stations numbered 1 to 14. These stations are located along lymph vessels. The lymph vessels and the LN are forming together anatomical chains. Lymph vessels are valved and pulsatile and travel to the cervical venous confluence where they pour the lung lymph into the blood circulation. They may be totally or partly nodeless along their travel, anastomose with each other around the trachea, and connect with the thoracic duct within the mediastinum. Within the anatomical LN chains, LN are variable in number and in size from one individual to another. They may be absent from one or several stations of the international mapping. Stations are located along the anatomical chains: pulmonary ligament (9), tracheal bifurcation(8 and 7), right paratracheal (4R, 2R and 1), preaortic (5 and 6), left paratracheal (4L, 2L and 1). Station 3 is located on 2 differents chains (phrenic and right esophagotracheal). Station 10 are located at the beginning of the mediastinal lymph nodes chains. Each chain connects with the blood circulation, anastomoses with he neighbouring chains and behave as an own entity whatever the number of its LN. International station mapping misknowns this anatomy and occults the true pronostic value of lung lymph drainage.

[Postoperative risk after induction treatment on surgery in non-small cell lung cancer]. / Retentissement opératoire des traitements néoadjuvants sur la chirurgie dans les cancers bronchiques non à petites cellules.

Induction treatments in non-small cell lung cancer are usually discussed. Long-term survival after surgery and resecability are enhanced in locally advanced cancers. Morbidity and mortality observed after surgery limit the use of these treatments, despite they depend on many other factors: comorbidities in patient, smoking status, cancer staging, and type of surgery. Right pneumectomy enhances this risk more than left pneumectomy or other limited resections allowed by neoadjuvant treatments, especially in case of downstaging.

[Lung cancer before 40 years and after 80 years: surgical aspects]. / Cancer du poumon avant 40 ans et après 80 ans.

Lung cancer rarely affects patients at the extreme ages of life. However, changes in epidemiology and therapy led us to review characteristics of both these younger and older populations. We retrospectively reviewed epidemiologic, clinical and pathological characteristics of patients aged 40 years or less (group 1, n=113) and 80 years or more (group 2, n=78) who underwent surgery between 1983 and 2003. Carcinoid tumors were more frequent in the group 1 (n=59 vs 5). Non small cell lung cancer (NSCLC) occurrence rates decreased with time in group 1, whereas increasing rates were observed in group 2 (p=0.0017). Concomitant diseases were significantly more frequent in group 2. The pneumonectomy rates of non small cell lung cancer were the same in each group (group 1, 35.5%; group 2, 34.8%). Five-year survival rates were better in group 1 (58.9% vs 30%, p=0.0048). No 5-year survival was observed for N2 disease in group 2 and mortality unrelated to cancer was more frequent in this group. Otherwise, both groups were similar except for higher rates of adenocarcinomas in group 1. Lung cancer is more and more frequent in the octogenarians. Surgery remains the best treatment in this population except in case of stage III due to N2 involvement.

Renal lymphatic drainage and thoracic duct connections: implications for cancer spread.

Studies on renal lymph drainage have generally described lymph nodes without further investigation of the lymph vessels. Our purpose was to revisit this organ to study the vessel drainage pattern. This investigation was performed on 16 refrigerated adult cadavers. After both kidneys were injected with a blue modified Gerota mass, lymph vessels were dissected until their termination. From the right kidneys (n = 13), lymphatics (n = 8) traveling on the anterior aspect of the inferior vena cava were dissected, reaching interaortocaval and more distant nodes, aorta bifurcation (n = 1) and left lateroaortic (n = 1); posterior lymphatics were observed in all subjects, uniformly connecting to the thoracic duct, either after crossing nodes (n = 8) or directly (n = 5). From the left kidneys (n = 13), anterior efferents (n = 16) were dissected, reaching left lateroaortic and also celiac (n = 4) and iliac (n = 1) nodes; posterior lymphatics were also demonstrated, always connecting to the thoracic duct (3 directly). Renal lymphatics have been found to reach very distant nodes as well as always connecting to the origin of the thoracic duct. This feature suggests an important role in both the formation of the thoracic duct and in the spread of renal cancer.

[Early stages of non small cell lung cancer (I. II. IIIA). What is the best therapeutic strategy?]. / CBNPC de stades précoces (I. II. IIIA). Quelle est la meilleure stratégie thérapeutique?

NSCLC early stages (I, II, IIIA) may be offered surgery, but the possibilities of resection and cure are decreasing with increasing stages. Surgery may be part of combined therapeutic strategies: it can be sufficient, or benefit neo-adjuvant modalities. Post-operative risk of death is acceptable, but rates following right pneumonectomy are important, and appear favored by neo-adjuvant chemotherapy. However, in case of down-staging, neo-adjuvant chemotherapy offers a better prognosis and can limit the extent of the resection, which may prove beneficial especially for the right side. Surgery is diagnostic and therapeutic in 45% of patients. So neo-adjuvant chemotherapy is theorically available in 55%, but finally remains performed in 40% of these patients (mainly stage IIIA). Randomized trials demonstrated a beneficial effect in case of early NSCLC stages. The improvement is certain for stage II concerning both the quality of resection and the survival. In case of NSCLC stage I, neo-adjuvant chemotherapy is still a matter of debate.

[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.

[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.

[Control of peri-operative smoking: A challenge for the pneumologists]. / Le contrôle du tabagisme péri-opóratoire: un défi pour les pneumologues.

The experts conference on control of smoking in surgical patients led a synthesis of the literature which reveals among smokers 3 times more complications of the surgical site, twice more transfer in intensive care unit, an increase length of hospital stay, a 8-fold increase of the risk of non consolidation of bone, whereas quitting tobacco 6-8 weeks before the surgical procedure and until the end of the consolidation makes disappear surgical over risk related to tobacco smoke. An organization must urgently set up in all surgical units, so that the 2 millions smokers who underwent surgical procedure each year in France may be advertised and help to quit. If the mobilization of the decision makers, health care staff and patient is strong, the excepted health and financial benefit will be high and may contribute to reduce significantly the deficit of French national health insurance organization since 2006. The lung specialists have a key role to play in the implementation of these new practices.

[Pleural endometriosis: an unusual presentation]. / Endométriose pleurale: une présentation inhabituelle.

INTRODUCTION: Numerous conditions can produce chronic exudative pleural effusions. Pleural endometriosis is a rare cause of unilateral effusion with diffuse pleural thickening. CLINICAL CASE: We report the case of chronic pleural effusion in a thirty year old African woman, where pleural endometriosis was diagnosed only following pleuro-pulmonary decortication, with the diagnosis being confirmed by immunohistochemistry. CONCLUSION: Pleural endometriosis must be considered as a possible diagnosis in women with pleural effusions of unknown aetiology. The presence of endometrial glands or of chorionic cells within the pleura is characteristic. Immunohistochemistry is an important diagnostic tool.