A better prognostic value from a modification of lung cancer staging.

This prospective study analyzes the survival rate, according to TNM and staging, of 538 patients who underwent curative pulmonary resection for non-oat cell tumors and who survived the operative period. A total of 279 patients had Stage I disease, 113 Stage II, and 146 Stage III. The overall survival rates were 72% at 1 year, 54% at 2 years, 47% at 3 years, 43% at 4 years, and 39% at 5 years. The survival curves of Stages I, II, and III are significantly different. Nevertheless, in Stage I, T1 N0 tumors presented the best survival rate (71% at 5 years), and this was significantly different from those of all other groups. For Stage II, the survival curves were significantly different according to hilar or lobar location of N1. The survival rate of T2 N1 hilar tumors was similar to that of T2 N2 tumors. In Stage III, the survival of T3 N2 tumors was the worst of all classifications. These results may contribute to a reappraisal of the surgical classification. T1 N0 tumors are worthy, on their own, of forming Stage I. T2 N0, T1 N1 lobar, and T2 N1 lobar can constitute Stage II. Stage III or IIIa would comprise carcinomas classified T2 N1 hilar, T1 N2, T2 N2, and perhaps T3 N0 and T3 N1. T3 N2 should probably be isolated in a IIIb or IV stage.

Postpneumonectomy empyema does not improve survival in bronchogenic carcinoma.

There is much disagreement in the literature about the beneficial effect of postpneumonectomy empyema on survival following operation for bronchogenic carcinoma. We had the opportunity to gather data on 407 patients with this serious complication. The survival data for a group of patients with postpneumonectomy empyema and fistula were compared with those for another group without such complications. Our statistical analysis confirms that postpneumonectomy empyema does not improve life expectancy.

Primary malignant melanoma of the esophagus.

Primary malignant melanoma of the esophagus is rare, and its symptoms are similar to those of squamous cell carcinoma. This tumor tends to be polypoid, pediculated, and irregular. Hematogenic and lymphogenic metastases are common. Surgical resection with reestablished continuity of the gastrointestinal tract is the treatment of choice, and postoperative irradiation may be useful. Despite these measures, however, the prognosis is poor, with a 5-year survival of 4.2%. The case of a 47-year-old man with esophageal melanoma is described, and a review of the world literature is presented.

Pleuropulmonary aspergilloma: clinical spectrum and results of surgical treatment.

From 1974 to 1991, 77 patients were admitted for pulmonary (55), pleural (16), or bronchial (6) aspergilloma. About 50% were asymptomatic. Sixty-three underwent operation. Pulmonary aspergillomas were operated on for therapeutic need in 26 and on principle in 18; the procedures were 28 lobar or segmental resections, 10 thoracoplasties, and 5 pleuropneumonectomies (1 patient had exploration only). Pleural aspergillosis was treated by operation on principle in 5 and for therapeutic need in 8 patients; 10 thoracoplasties, 1 attempt at pleuropneumonectomy, and 2 decortications were performed. All six bronchial lesions were operated on as a rule. Overall postoperative mortality was 9.5%. Major complications were bleeding (n = 37), pleural space problems (n = 24), respiratory failure (n = 6), and postpneumonectomy empyema (n = 4). All patients with pleural disease experienced complications. The outcome was better after lobar or segmental resection than after thoracoplasty (mortality, 6% versus 15%). Asymptomatic and nonsequellary pulmonary or bronchial aspergilloma also had an improved outcome. We conclude that operation is at low risk in pulmonary or bronchial locations in asymptomatic patients and in the absence of sequellae; the risk is high in symptomatic patients for whom operation is the only definite treatment. Pleuropneumonectomy should be avoided. Only symptomatic pleural aspergilloma should be operated on.

Immunotherapy as an adjuvant to surgery in carcinoma of bronchus. Results in three randomised trials.

The results of non-specific immunotherapy adjuvant to surgery in the treatment of non-small cell lung cancer were studied in three separate randomised clinical trials involving 344 patients. The first study involved 126 patients. In 73, intrapleural BCG was given according to McKneally's technique. They were compared to a control group of 63 patients. In the second trial, levamisole was administered to 43 patients who, in addition to surgery, also had radiotherapy. These were compared with 43 control patients. In the third study, 60 patients underwent surgical operation for limited lesions and in addition received Isoprinosine. These were compared with a control group of 60 patients. All patients in the control groups of the three studies had similar surgical operations to their treated counterpart. The overall results showed no difference between those who received immunotherapy and the control groups of patients and that the use of these agents did not alter either the course of the disease or the incidence of its recurrence.

[Granular cell tumors of the esophagus. Apropos of a case associated with bronchial carcinoma and treated by endoscopic excision]. / Les tumeurs à cellules granuleuses de l'oesophage. A propos d'un cas associé à un carcinome bronchique et traité par exérèse endoscopique.

The case of a granular cell tumor of the lower esophagus associated with a bronchial carcinoma is reported. The esophageal tumor was discovered by radiological and endoscopic examination for symptoms of gastroesophageal reflux and caused dysphagia after 6 1/2 years. An associated bronchial carcinoma led to the endoscopic removal of the esophageal tumor immediately prior to the thoracotomy. Eight days after operation the patient presented an hematemesis probably related to the endoscopic polypectomy. The course can be considered favorable after 17 months concerning the esophageal as well as the pulmonary situation. Histologically the esophageal tumor was a typical granular cell tumor and the bronchial tumor a squamous cell carcinoma. Seventy-nine cases of granular cell tumors of the esophagus have been published; 10 p. 100 of the cases are associated with bronchial, digestive or otorhinolaryngeal carcinoma. The onset of the carcinoma is usually subsequent to the esophageal tumor, justifying prolonged surveillance. This is the third case of a granular cell tumor of the esophagus treated by endoscopic polypectomy; this type of treatment requires close short-term follow-up because of the risk of hemorrhage as well as long-term follow-up because of the possibility of a second esophageal localization.

[Analysis of 64 second primary cancers of the bronchi]. / Analyse de soixante-quatre cancers métachrones des bronches.

Sixty-four primary lung carcinomas were observed among 1,039 patients operated for bronchial carcinoma between 1975 and 1984. (Statement: July 1987). The second tumor tended to develop at a distance from the first resection performed for a lesion with good prognostic factors. Their site and histology present no unusual features. 64% appeared in the contralateral lung; 78% had the same histological type as the first cancer. Among 28 patients treated by surgery, 26 had a second resection: there were two peri-operative deaths and 4 major complications. Among the 36 patients rejected for surgery, 21 had excessively altered lung function tests. 30 patients were treated with radiotherapy, 7 with chemotherapy first; one had no treatment. The survival rate for the whole group was quite good: 26% at three years; it was significantly better after a second resection: 41% at three years. Overall survival seems comparable with that of the patients operated upon for a single carcinoma.

[Paraplegia caused by extradural spinal hematoma after radical pulmonary lobectomy in cancer]. / Paraplégie par hématome extra-dural rachidien après lobectomie pulmonaire élargie pour cancer.

The authors report a case of spinal cord complication after surgery for lung cancer. Amongst the 12 cases published in the literature, only one reports spinal cord ischaemia secondary to a compressive mechanism by spinal extradural haematoma. In the present case, due to an identical mechanism, paraplegia developed as a result of intraoperative meningeal rupture during extension of a pulmonary lobectomy for cancer to the adjacent vertebrae. The diagnosis was established by CT scan combined with emergency myelography. Certain preventative measures are proposed based on analysis of the mechanisms of this complication.

[Development of 62 typical carcinoid tumor of the bronchi surgically treated. Prognostic value of histopathological features]. / Evolution de soixante-deux tumeurs carcinoïdes typiques des bronches opérées. Valeur pronostique des caractères histopathologiques.

The pathological and clinical features of 62 carcinoid tumours of the bronchus operated between 1975 and 1987 were reviewed in order to determine the prognostic value of certain parameters: limit of proliferation, vascular invasion, lymph node involvement. This series corresponded to 36 central tumours and 25 peripheral tumours, all treated surgically. One patient was lost to follow-up, 3 developed recurrences, 56 are still alive without recurrence and 3 died from intercurrent causes. The histological appearance of the tumours was homogeneous and typical. Twenty-eight lesions were strictly intrabronchial, 34 invaded the lung with incomplete limits in twenty cases. The tumour showed signs of vascular invasion in ten cases and the adjacent lymph nodes were invaded in eight cases. The local recurrence was undoubtedly related to an excessively conservative primary resection, as the primary tumour did not demonstrate any unusual features. The two tumours which metastasized showed vascular invasion: one metastasized to a hilar node, but these features were observed in other cases which retained a benign course. The standard histological diagnosis of typical carcinoid tumour does not appear to raise any particular difficulties; it is reliable. The course of the disease is sometimes malignant but no histological parameter is able to accurately predict this outcome.

[Perfusion scintigraphy and surgical excision of bronchial cancers]. / Scintigraphie de perfusion et opérabilité dans le cancer bronchique.

In a series of 1,800 operated lung cancers, 93 had a unilateral perfusion scan less than or equal to 20% (36 perfusions = 0, 15 between one and 10% and 42 between 11 and 20%). Major amputations were more frequent on the left side and constituted a pejorative but non-decisive factor for surgical nonintervention although was not synonymous with inoperability. The extent of the resection increased with the severity of the amputation.

[Outcome of 100 necessary exploratory thoracotomies for bronchial cancer]. / Devenir de cent thoracotomies exploratrices de nécessité pour cancer bronchique.

The outcome of one hundred exploratory thoracotomies for lung cancer (9.1% of operations) was studied. There were 4 postoperative deaths. After the operation, 6 patients did not receive any further treatment, 62 received radiotherapy, 25 received a combination of radiotherapy and chemotherapy and 3 received chemotherapy. The disease-free interval was very short with development of metastases (55 cases) and local recurrences (29 cases). The survival was also short: less than 10% at 2 years; it was significantly poorer than that observed in a group of non-operated patients with an equivalent stage of lung cancer. These findings suggest the need for stricter evaluation of operative indications.

[Surgical treatment of pulmonary and bronchial aspergilloma]. / Traitement chirurgical de l'aspergillome pulmonaire et bronchique.

From 1974 to 1990, 61 patients were admitted for pulmonary (55) or bronchial (6) aspergilloma; 50 were treated by surgery. Operative treatment was mandatory because of disabling symptoms in 17 patients, rapid growth on radiological survey in 7 others, diagnostic doubt in 10 and association with bronchogenic cancer in 2. 14 were operated on in order to prevent evolutive complications. Complete resection was possible in 39 patients: with lobectomy or segmentectomy in 34 and with pleuro-pneumonectomy in 5. In 10 others, respiratory failure only allowed speleotomy and thoracoplasty. One thoracotomy was exploratory because of an associated unresectable cancer. Postoperative complications frequently occurred with pulmonary aspergilloma: 4 postoperative deaths, 33 experienced non-fatal complications (28 major bleedings, 16 rehabititation defects, 6 empyemas, 5 respiratory failures). Nevertheless, among 10 patients with either bronchial aspergilloma or pulmonary aspergilloma without underlying disease, only one had a complicated outcome. In conclusion, surgical treatment is well tolerated in the absence of underlying parenchymal disease. However, despite the major operative risk, surgery remains the only efficient treatment in symptomatic patients.

[Postoperative intensive care after thymectomy for myasthenia gravis]. / La réanimation post-opératoire après thymectomie pour myasthénie.

The post-operative management of the myasthenic patient after thymectomy through sternotomy has changed in the last decades. After years of routine preoperative tracheostomies followed by routine prolonged intubation nowadays it is possible to wean the patients from the ventilation and to extubate them early after surgery while reintroducing the acetylcholinesterase inhibitors therapy. A series of 15 patients operated on between 1985 and 1988 for removal of thymic rests or thymoma is presented and confirms this evolution. The clinical and gazometric criteria allowing an early weaning from the ventilator are analyzed. However certain patients with the most severe forms of myasthenic still need prolonged ventilatory support.

[Non-aplastic N2 operated bronchial cancers. Multifactorial analysis of the prognosis]. / Cancers bronchiques non anaplasiques, N2, opérés. Evaluation multifactorielle du pronostic.

The marked disparity of the published 5-year survival rates (0 to 3%) for non-anaplastic, operated N2 lung cancers would suggest the marked heterogeneity of the patients studied. We prospectively studies 97 N2 tumours for which "curative" resection was performed between 1983 and 1986. The overall survival rate was 28% at 3 years, 19% at 4 years and 12% at 5 years. Survival was studied on the basis of several parameters concerning the tumour: histological type and degree of differentiation, T (TNM), modality of invasion (circumscribed, infiltrating), the quality of the stroma (absent, fibrotic, cellular), the mitotic index, the necrosis rate, presence or absence of microscopic invasion of blood vessels; and concerning the nodes: site, number (solitary, multiple), size of the metastasis (massive, microscopic), macroscopic or microscopic invasion of the capsule. We know the outcome for all of our patients: 81 have died and 16 are still alive. Sixty-one have developed metastases, 5 have developed local and regional recurrences and 3 have both a recurrence and metastases. Univariate analysis demonstrated that a small number of parameters significantly influence survival: microscopic invasion of blood vessel (chi 2 = 5.24, p less than 0.02), macroscopic and microscopic invasion of the lymph node capsule. In order to more clearly define the prognostic factors, we used Cox's multidimensional model. This model was applied to the three significant parameters to which we added two other variables which non-significantly tended to be related to survival: tumour necrosis and number of lymph nodes involved.(ABSTRACT TRUNCATED AT 250 WORDS)

[Forgotten mediastinal goiter: seven cases]. / Le goitre médiastinal oublié: sept observations.

The authors relate their experience with 7 cases of mediastinal goiter residual to a subtotal thyroidectomy for substernal goiter. The differential diagnosis with ordinary recurrence was based on the absence of connection with the cervical remnant. The reasons for surgical decision-making was mediastinal compression in 4 patients, hyperthyroidism in 1 patient and absent diagnosis in 1 patient; surgery was systematic in 1 asymptomatic patient. Sternal splitting incision was required in 6 patients: alone in 3, associated with cervical incision in 3 others; excision by an exclusively cervical route was possible in one patient. No malignancy was discovered. Postoperative outcome was uncomplicated in all patients. The residual goiter has the same clinical and paraclinical presentation as the ordinary intrathoracic goiter; treatment should be principally surgical for the same reasons. Nevertheless, for this mediastinal tumor, sternum-splitting incision will be required in most cases.

[Long-term outcome of surgically treated bullous emphysema]. / Evolution à long terme des emphysèmes bulleux opérés.

The long term outcome for 88 patients with bullous emphysema who had operations was analysed from the clinical, respiratory function and occupational point of view. In order to reduce to the minimum any bias which would be likely to appear as a result of a decrease in the number of patients with time respiratory function parameters were compared to those of a restricted number of patients for whom we knew all the values for each period determined. Before the operation all the patients showed radiological signs of bullous emphysema; the respiratory function measurements in 66 of them showed bronchial obstruction with distension, hypoxaemia at rest without hypercapnia. The clinical follow up and respiratory function was spread over more years. It showed a post operative improvement in dyspnoea which was perceptible in 77% of patients at 2 years, 68% at 3 years, 60% at 4 years, 51% at 5 years, 32% at 10 years. 2/3 of the patients who were working before the operation had taken up their normal work following it. the survival levels were 86% at 1 year, 83% at 2 years, 80% at 3 years, 78% at 4 years, 77% at 5 years, 73% at 6 years, 73% at 6 years, 58% at 10 years. Of 20 patients who died 12 had died of respiratory failure. All the spirographic parameters had improved following the operation but a secondary deterioration was noted around the 5th post operative year for the vital capacity, and at the third year for residual volume, FEV 1, and the FEV 1/VC ratio as well as PAO2.(ABSTRACT TRUNCATED AT 250 WORDS)

[Bronchiolo-alveolar carcinoma. Anatomo-pathological and evolutional study of a series of 52 operated cases]. / Carcinome bronchiolo-alvéolaire. Etude anatomo-pathologique et évolutive d'une série de 52 cas opérés.

The postoperative outcome of bronchiolo-alveolar epithelioma (EBA) is unpredictable. We question whether a study of the anatomo-pathological structures would enable us to detect prognostic indicators. The clinical characteristics, histopathology and outcome of 52 cases of EBA were studied. 31 tumours were detected in a systematic fashion; 50 patients had excision of the tumour and in 39 cases there was no invasion of the lymphatics. 10 were of the multicentric variety and 42 were of the nodular variety and 9 of these were the centre of an inflammatory lympho-plasmocytic reaction. 20 cases revealed mucinous differentiation and 32 were non-mucinous. In the latter cases nucleo-cytoplasmic anomalies were only slightly increased or even absent. Blood vessel invasion was present in 12 cases and metastases to the air spaces in 20. The overall survival was 83% in the first year, 65% in the second year, 42% at five years and 26.5% at 10 years. The nodular lesions were compatible with a significantly better survival than the diffuse forms. Other characteristics such as whether the tumour was mucinous or not, inflammatory, showed nuclear anomalies, blood vessel invasion and airborne metastases did not seem to affect survival.

[The risks of surgical training. A study apropos of 348 pneumonectomies]. / Les risques de l'apprentissage de la chirurgie. Etude à propos de 348 pneumonectomies.

On the basis of the retrospective study of a series of 348 pneumonectomies, the authors have attempted to assess whether the risks of postoperative complications were increased if the operation was carried out by trainee surgeons. All operations were performed for cancer, with a stapler being used for bronchial suture. The patients were classified in three groups according to the surgeon: 133 (38%) were operated by an University professor (group I, 2 surgeons), 171 (49%) by chief resident or hospital practitioner (group II, 3 surgeons) and 44 (13%) by an intern (group III, 14 surgeons). The homogeneity of the 3 groups was checked with alpha X2 test. The study dealt with the overall mortality as well as with the specific complications of pneumonia, namely empyema and bronchopleural fistulae. The overall postoperative mortality rate was similar in the 3 groups (respectively 8%, 8% and 5%), as well as the occurrence of empyema (respectively 4%, 3% and 5%). A difference that, though not significant statistically, is not negligible, appears for bronchopleural fistulae, which complicate 9% of the operations carried out by interns vs. 4% in the other 2 categories. These observations challenge a number of studies claiming that surgery performed by inexperienced surgeons is innocuous. However, pneumonectomy is an essential step in the training to thoracic surgery, so that no candidate with sufficient surgical maturity should be prevented from performing it.

[Iatrogenic tracheobronchial lesions during intubation. 5 cases and review of the literature]. / Plaies trachéobronchiques iatrogènes au cours de l'intubation. 5 observations et revue de la littérature.

The authors report about a personal series of 5 cases of tracheal injuries during intubation. One lesion was caused by a Carlens' tube and it was discovered and repaired during thoracotomy. Four wounds resulted from the use of ordinary tubes. Three of them affected only the tracheal membrane. The diagnosis was established with fiberendoscopy after subcutaneous emphysema occurred while the patient was awakening. Two patients underwent surgical repair, and a watch-and-wait policy was applied for another one. The outcome was favorable for these 4 patients. The last patient had a tracheoesophageal wound in a context of irradiated cervical neoplastic recurrence. The diagnosis was suggested by the discovery of major ampents of air in the small bowel during laparotomy for jejunostomy. The outcome was fatal. These cases have been compared with a compilation of the literature, gathering 8 wounds caused by ordinary tubes and 25 caused by Carlens-type tubes.

[Thymoma. Analysis of a series of 42 cases]. / Les thymomes. Analyse d'une série de 42 cas.

The authors have treated 42 patients with thymoma and report on their experience. The mode of discovery, and notably the thymoma-myasthenia association in 8 cases (20%), the diagnostic approach and the management of the disease--surgery alone : 18 cases, surgery combined with radiotherapy : 24 cases and/or with chemotherapy : 5 cases--were analyzed. The thymomas were classified according to the G.E.T.T. system after re-examination of the histological sections. The course of the disease was studied. The overall survival rate, which depends on tumoral stage, was 71% at 4 years and 69% at 10 years; 5 patients died of the disease and 9 of other causes, including 5 who presented with a blood disease. This series is compared with other published series. The frequency of myasthenia and the respective prognostic values of anatomico-surgical, histological and histo-immunological classifications are discussed.