Reporting of patient safety incidents in minimally invasive thoracic surgery: a national registered thoracic surgeons experience for improvement of patient safety.

OBJECTIVES: The reporting of patient safety incidents (PSIs) occurring in minimally invasive thoracic surgery (MITS) is crucial. However, previous reports focused mainly on catastrophic events whereas minor events are often underreported. METHODS: All voluntary reports of MITS-related PSIs were retrospectively extracted from the French REX database for 'in-depth analysis'. From 2008 to 2019, we retrospectively analysed and graded events according to the WHO classification of PSIs: near miss events, no harm incidents and harmful incidents. Causes and corrective measures were analysed according to the human-technology-organization triad. RESULTS: Of the 5145 cardiothoracic surgery PSIs declared, 407 were related to MITS. Among them, MITS was performed for primary lung cancer in 317 (78%) and consisted in a lobectomy in 249 (61%) patients. PSIs were: near miss events in 42 (10%) patients, no harm incidents in 81 (20%) patients and harmful incidents in 284 (70%) patients (mild: n = 163, 40%; moderate: n = 78, 19%; severe: n = 36, 9%; and deaths: n = 7, 2%). Human factors represented the most important cause of PSIs with 267/407 (65.6%) cases, including mainly vascular injuries (n = 90; 22%) and non-vascular injuries (n = 43; 11%). Pulmonary arteries were the most affected site with 57/91 cases (62%). In all, there were 7 deaths (2%), 53 patients required second surgery (13%) and 30 required additional lung resection (7%). CONCLUSIONS: The majority of reported MITS -related PSIs were non-catastrophic. Human factors were the main cause of PSIs. Systematic reporting and analysis of these PSIs will allow surgeon and his team to avoid a large proportion of them.

Prevalence of Complementary/Alternative Medicine use in Cancer Patients in a Tertiary Hospital in Puerto Rico.

OBJECTIVE: We conducted a study in a tertiary hospital to investigate complementary and alternative medicine (CAM) prevalence in a Puerto Rican population. The study also evaluated demographic and clinical factors in order to correlate them with CAM use. METHODS: Spanish speaking residents with a known diagnosis of cancer being followed in the outpatient facilities at Auxilio Mutuo Cancer Center were invited to participate in the study. Patients who read and signed a consent form were given a questionnaire inquiring, among various things, on their use of any CAM treatment, education level, gender, place of residence and whether they had consulted their oncologist. The questionnaire also asked about their expectations for use of CAM. RESULTS: 215 patients were approached to participate out of which 200 signed the consent and accepted to participate. A total of 95 of 200 patients (47.5%) mentioned that they utilized at least one CAM treatment. Six factors were then analyzed for their correlation with CAM usage and three yielded statistically significant results at p<.05: age group, education level, and area of residence. After multivariate analysis all of these three factors behaved as independent variables. Gender, tumor type and stage were not significantly associated with use of CAM. CONCLUSION: Our data show that CAM use is significantly more common in those with higher education, younger age, and those living in non-metropolitan areas. Vitamin C and soursop (Graviola or guanábana) proved to be the two most common CAM treatments, respectively.

Validation and update of the thoracic surgery scoring system (Thoracoscore) risk model.

OBJECTIVES: The performance of prediction models tends to deteriorate over time. The purpose of this study was to update the Thoracoscore risk prediction model with recent data from the Epithor nationwide thoracic surgery database. METHODS: From January 2016 to December 2017, a total of 56 279 patients were operated on for mediastinal, pleural, chest wall or lung disease. We used 3 recommended methods to update the Thoracoscore prediction model and then proceeded to develop a new risk model. Thirty-day hospital mortality included patients who died within the first 30 days of the operation and those who died later during the same hospital stay. RESULTS: We compared the baseline patient characteristics in the original data used to develop the Thoracoscore prediction model and the validation data. The age distribution was different, with specifically more patients older than 65 years in the validation group. Video-assisted thoracoscopy accounted for 47% of surgeries in the validation group compared but only 18% in the original data. The calibration curve used to update the Thoracoscore confirmed the overfitting of the 3 methods. The Hosmer-Lemeshow goodness-of-fit test was significant for the 3 updated models. Some coefficients were overfitted (American Society of Anesthesiologists score, performance status and procedure class) in the validation data. The new risk model has a correct calibration as indicated by the Hosmer-Lemeshow goodness-of-fit test, which was non-significant. The C-index was strong for the new risk model (0.84), confirming the ability of the new risk model to differentiate patients with and without the outcome. Internal validation shows no overfitting for the new model. CONCLUSIONS: The new Thoracoscore risk model has improved performance and good calibration, making it appropriate for use in current clinical practice.

A New Salvage Regimen for Aggressive Lymphomas Based on Gemcitabine, Rituximab, and Oxaliplatin Followed by Lenalidomide (GROC-Rev).

PURPOSE: To evaluate the impact of lenalidomide in patients with aggressive lymphoma who experienced less than complete response (CR) or as maintenance therapy after CR after gemcitabine, rituximab, and oxaliplatin salvage chemotherapy (GROC-Rev regimen). PATIENTS AND METHODS: Patients with relapsed/refractory non-Hodgkin lymphoma received up to 6 GROC-Rev courses: rituximab (375 mg/m2 provided intravenously) on day 1, oxaliplatin (100 mg/m2 provided intravenously; 2 hours), gemcitabine (provided 1250 mg/m2 intravenously; 30 minutes) on day 2, and pegfilgrastim (6 mg provided subcutaneously) on day 3. Patients switched to lenalidomide if they did not experience at least partial response (PR) after their second GROC-Rev course, or if they experienced less than a CR after 6 courses. RESULTS: In 33 patients, overall response was 61% (CR = 39%). Of 17 patients with PR who continued to 6 courses, 10 (59%) experienced CR and 7 PR as maximum response; of these 7, 1 died before receiving lenalidomide, 1 experienced CR while receiving lenalidomide (17%), and 2 experienced a further PR (33%). Of 16 with disease that failed to respond to GROC-Rev after their second course, 2 died before lenalidomide could be administered, and 2 experienced CR (14%) and 1 PR (7%) after lenalidomide. Overall survival and progression-free survival were 47% and 33% at 2 years. Grade 3/4 adverse events included neutropenia, thrombocytopenia, and/or anemia (n = 5), neutropenic infection (n = 3), urinary tract infection (n = 3), pneumonia (n = 2), cellulitis (n = 2), and seizure (n = 1). Eight went on to receive transplants. CONCLUSION: GROC-Rev is an effective and well-tolerated salvage regimen consisting of chemotherapy followed by lenalidomide maintenance in patients with relapsed/refractory non-Hodgkin lymphoma. Simultaneous administration of these agents is worth exploring in future studies.

Dynamic magnetic resonance imaging in unilateral diaphragm eventration: knowledge improvement before and after plication.

BACKGROUND: The assessment before surgical plication for unilateral hemidiaphragm (HD) eventration is not clearly defined and no precise criteria exist to really understand which patient is operated with which results depending on the technique used. The goal of this study was to evaluate the place of dynamic magnetic resonance imaging (dMRI) before and after plication by developing measurement criteria. METHODS: Between 2006 and 2017, 18 patients (group1: Gp1) were operated for eventrations, 15 left-sided (Gp1L) and 3 right-sided (Gp1R). All had preoperative and postoperative evaluations including dMRI and pulmonary function tests. Five healthy volunteer subjects (group2: Gp2) had the same imaging protocol. For each HD, we measured the respiratory excursion at three fixed points (S1, S2, S3) and the height of curvature on sagittal plane. We also searched for upward paradoxical diaphragm movements. RESULTS: Before surgery, no excursion (n=13) or extremely reduced excursion (n=5) was detected on the injured HD (IHD) in Gp1. Upward paradoxical movements were identified only in Gp1L (n=6). Compared with Gp2 subjects, the healthy HD for Gp1L patients had significantly reduced excursion values at three sites S1 (P=0.038), S2 (P=0.006), and S3 (P=0.004). After plication, the decreasing height of curvature confirmed a tightening of the IHD in all patients (median value from 100 to 39.5 mm in Gp1L and 92 to 74 mm in Gp1R, P=0.0001). All upward paradoxical movements disappeared. Healthy HD excursions in Gp1L normalised their values. All those imaging improvements were correlated with postoperative improvements of dyspnoea score (P<0.0001) and vital capacity (P=0.002). CONCLUSIONS: dMRI and the standardised grid we developed not only improve the knowledge of unilateral diaphragm eventration but also permit to evaluate the quality of its surgical repair. It also demonstrates that a dysfunction of the healthy HD contralateral to eventration is possible and reversible after plication of the IHD.

Guidelines on smoking management during the perioperative period.

Smoking is a public health problem of particular importance during the perioperative period, since it exposes patients scheduled for surgery to risk increases of 20% in hospital mortality and 40% in major postoperative complications. In addition, current smoking increases almost all specific surgical complications. The perioperative period offers a genuine opportunity for smoking cessation. The rate of preoperative smoking cessation can be increased significantly by offering behavior management and the prescription of a nicotine substitute before any scheduled surgical intervention. Preoperative smoking cessation should be routinely recommended independently of the timing of the intervention, even though the benefits increase in proportion with the length of cessation. All professionals of the care pathway (general practitioners, surgeons, anesthetists-intensivists, caregivers) must inform smokers of the positive effects of smoking cessation and offer them dedicated management and personalized follow-up. In children, cessation of parental smoking or removal of the child from environmental tobacco smoke as long before surgery as possible is indispensable.

Lung transplantation in childhood and adolescence: unicentric 14-year experience with sex matching as the main prognosticator.

OBJECTIVES: Lung transplantation (LTx) is an accepted therapy for selected infants, children and adolescents with end-stage lung and pulmonary vascular disease. It remains a challenge for a selected group of patients. In 2011, the number of paediatric lung transplantations (PLTxs) worldwide was 107. In France, a total of 131 PLTxs have been performed since 2000 (data from ABM: Agence de biomédecine), 65 of which were conducted at our institution. METHODS: All patients under 18 (4.8-17.11) years of age matching inclusion and exclusion criteria, who underwent LTx at our institution were included in this study (n = 58). We analysed the outcomes of these patients in terms of survival rates, controlling for indications for transplantations and surgical procedures. Secondary outcomes were analysis of surgical and medical complications and identification of prognostic factors in the field of LTx in these categories of ages. RESULTS: The 30-day mortality rate was 10%. Kaplan-Meier survival rates at 1 month, 1, 3, 5 and 10 years were 90, 81, 66, 60 and 57%, respectively; the median survival was 91 months. Reduced-size transplantation was performed in 33% of double-lung transplantation (DLTx) patients without negatively impacting survival. In our series, female sex, the presence of a sex mismatching and, in particular, the occurrence of a male donor to a female recipient (F/M group) have been poor prognostic factors after PLTx. CONCLUSIONS: The overall survival after PLTx was encouraging (57% at 10 years). A PLTx should be offered to the small number of patients with end-stage pulmonary disease. The limited number of paediatric donor organs can be overcome by using reduced-size organs without a survival disadvantage to the patients. In our series, male sex and sex matching seemed to be positive predictive prognostic factors after PLTx but further studies are required to confirm these results and to also clarify the role of age of donor, time of cold ischaemia and body mass index in PLTx.

Evolution of induction chemotherapy for non-small cell lung cancer over the last 30 years: A surgical appraisal.

BACKGROUND: Induction chemotherapy (ICT) is supposed to reduce the risk of micrometastatic progression and improve resectability of non-small cell lung cancer (NSCLC). However, best indications for ICT strategy remain unclear in published meta-analyses. Based on this observation, an evaluation of daily practice is of importance. Therefore, we reviewed indications and efficacy time trends in our 30-year series. METHODS: A database including all patients with NSCLC who underwent surgical resection in two French centers from 1980 to 2009 (n = 5563) was prospectively set and retrospectively reviewed. The indications, clinical and pathologic response rates, and overall survival of ICT patients (n = 732) were analyzed during three successive time-periods: P1 from 1980 to 1989, P2 from 1990 to 1999, and P3 from 2000 to 2009. RESULTS: The proportion of patients who benefited from ICT increased over time, from 2.8% (n = 35) in P1 to 12.5% (n = 274) in P2, and 20.2% (n = 423) in P3. Indications evolved over time with more N2 patients (n = 211; 49.8%) and less initially unresectable patients (n = 72; 17%) in P3. The clinical response rate between P1 and P2 increased. Five and 10-year survival rates of ICT patients were 35.2% and 21.5%, respectively. In multivariate analysis, time-period, age, type of resection, histology, and pathologic response to chemotherapy were significant prognostic factors. CONCLUSIONS: Our report on the off-trial use of induction therapy during the last 30 years demonstrates an increased use of ICT, a progressive focus on N2 disease, and improved response rates.

Pre- and post- transplantation lung cancer in heart transplant recipients.

Heart transplantation after lung cancer surgery can be questionable because of the high risk of cancer recurrence. We report the results of two patients. The first underwent right lobectomy in 2008 for pT1N0 adenocarcinoma, heart-transplantation in 2010, and surgery for synchronous adenocarcinoma and squamous-cell carcinoma in 2012. The second underwent left segmentectomy for pT1aN0 adenosquamous carcinoma and transplantation in 1995 and then surgery for pT1aN1 adenocarcinoma in 2013. Posttransplantation lung cancer histologic analysis results were different in both cases, demonstrating the absence of metastatic recurrence. Thus, early stage lung cancer might not be a contraindication to heart transplantation, nor are long delays be necessary before registering on a waiting list.

Pneumonectomy for benign disease: indications and postoperative outcomes, a nationwide study.

OBJECTIVES: Pneumonectomy for benign disease is rare but is thought to have a higher more postoperative morbidity and mortality than when performed for lung cancer. We questioned this by assessing and analysing indications and postoperative outcomes of patients who underwent this type of resection. METHODS: We used Epithor, the French national thoracic database including 91 public and private institutions with more than 220 000 procedures. We prospectively collected data of 5975 patients who underwent pneumonectomy between January 2003 and June 2013. The 321 patients (5.4%) who underwent pneumonectomy (n = 201) or completion pneumonectomy (n = 120) for benign disease were compared with those treated for malignant disease. RESULTS: The patients' mean age was 55.2 years (53.5; 56.8) for benign indications vs 61.6 years (61.4; 61.9) for malignant disease; the sex ratio was 1.8 (207 males) and 4 (4543 males), respectively; 53% of patients (n = 169) had an American Society of Anesthesiologist (ASA) score of ≥3 vs 29% (n = 1598) for malignant disease. For benign disease, most frequent indications were infection or abscess (n = 114, 37.1%), post-tuberculosis destroyed lung (n = 47, 15.3%), aspergillosis or aspergilloma (n = 33, 10.7%), bronchiectasis (n = 41, 13.3%), haemorrhage (n = 26, 8.5%) and benign tumour (n = 20, 6.5%). Complications occurred in 53% (n = 170) of patients and the postoperative in-hospital mortality rate was 22.1% (n = 71). These results were significantly worse than those for malignant indications: 38.9% (n = 2198) of morbidity (P < 0.0001) and 5.1% (n = 288) of in-hospital mortality (P < 0.0001). For benign disease, there was no difference in fistula formation regarding side (P = 0.07) or type of resection (P = 0.6). Morbidity was higher for completion pneumonectomy: 62.5 vs 47.3% (P = 0.008). Mortality was significantly higher in case of resection for infection or abscess (P = 0.01) and for haemorrhage (P = 0.002). Emergency procedures were associated with worse postoperative outcomes (P < 0.0001). CONCLUSIONS: Pneumonectomy for benign disease achieves cure with very high levels of morbidity and mortality. This type of surgical treatment should be considered as a salvage procedure.

Is the lymphatic drainage of lung cancer lobe-specific? A surgical appraisal.

OBJECTIVES: Nowadays, early-stage lung cancers are more frequently encountered. Selective lymph node (LN) dissection based on lobe-specific lymphatic pathway has been proposed. Our aim was to study nodal involvement according to tumour location. METHODS: We reviewed 1779 lobectomized patients and analysed their pathological characteristics according to tumour location: Group 1 (G1), right upper lobe; Group 2 (G2), right middle lobe; Group 3 (G3), right lower lobe; Group 4 (G4), left upper division; Group 5 (G5), lingula; Group 6 (G6), left lower lobe. The pN status was recorded for each group to analyse the lymphatic spread of non-small-cell lung cancer (NSCLC) according to tumour location. RESULTS: The numbers and proportions of lobectomies in each group were 613 patients in G1 (59.2%), 64 in G2 (6.4%), 359 in G3 (34.6%), 404 in G4 (54.3%), 54 in G5 (7.3%) and 286 in G6 (38.4%). The rates of pN2 involvement were similar, whatever the group was, even when deciphering single- and multistation diseases. on the right side, single-station N2 disease was mainly found in the superior mediastinum (SM) for G1 (95%), and in the inferior for G3 (90%). On the left side, single-station N2 was mainly found in the SM in G4 (94%), and the inferior in G6 (48%). Whatever the side, in case of two-station involvement, both mediastina were concerned in 40% (in G4) to 81% of the case (in G3). Long-term survival rates were different in skip metastasis, single- and multistation involvement, but not between lobes. CONCLUSIONS: Tumour location is not a predictor of nodal metastasis pattern. In surgical treatment of NSCLC, complete systematic mediastinal LN dissection remains the only acceptable procedure from an oncological point of view.

Postoperative morbidity and mortality after pneumonectomy: a 30-year experience of 2064 consecutive patients.

OBJECTIVES: We examined whether the changes in clinical practice with time correlated with the changes in the 90-day mortality following pneumonectomy. METHODS: The clinical records of consecutive patients undergoing pneumonectomy in two French centres from 1980 to 2009 were prospectively collected. The 90-day postoperative course was retrospectively studied according to clinical characteristics, underlying diseases, type of surgery and time-period (1980-1989; 1990-1999 or 2000-2009). RESULTS: Pneumonectomy was performed in 2064 patients (right n = 948, males n = 1758, mean age 60 ± 10 years). Indications were non-small-cell lung cancer (n = 1805, 87%), mesothelioma (n = 39, 1.8%), other tumours (n = 132, 6.3%) and non-tumour disease (n = 88, 4.2%). The 30- and 90-day mortality were 17.4 and 7.2% in the first decade, 22.3 and 9% in the second decade and 26.4 and 7.3% in the third decade, respectively. In multivariate analysis, older age, right-sided resection, T3-T4 and N2 lung cancer disease were significantly associated with increased overall 90-day mortality, whereas surgery during the last decade was associated with a better outcome when compared with the first decade (RR: 0.63, 95% confidence interval: 0.50-0.80, P = 0.045). When focusing on patients with non-small-cell lung cancer (NSCLC), the 90-day mortality following induction therapy and pneumonectomy decreased from 21.9% in the 1980s to 8.2% in the 2000s (P = 0.038), while such decrease was not found in patients without induction therapy or in patients undergoing a lobectomy. CONCLUSIONS: The overall 90-day mortality after pneumonectomy was not significantly modified over the last 30 years, while the 90-day mortality after induction therapy followed by pneumonectomy for NSCLC decreased significantly.

Number of mediastinal lymph nodes in non-small cell lung cancer: a Gaussian curve, not a prognostic factor.

BACKGROUND: It has been proposed that examining a greater number of lymph nodes (LNs) in patients with non-small-cell lung cancer (NSCLC) treated by surgical resection may increase the likelihood of proper staging and affect outcome. Our purpose was to evaluate the interindividual variability and prognostic relevance of the number of LNs harvested during complete pulmonary and mediastinal lymphadenectomy performed for NSCLC. METHODS: We prospectively collected and retrospectively reviewed the data from 1,095 patients who underwent lung cancer resection in association with systematic lymphadenectomy and pulmonary and mediastinal LN counts from 2004 to 2009. We analyzed the interindividual variability and prognostic impact of the number of LNs on overall survival (OS). RESULTS: The mean number of harvested pulmonary and mediastinal LNs was 17.4±7.3 (range, 1-65) and was higher in male patients, right lung surgical procedures, lobectomy and pneumonectomy, N2 disease, and pIII stage. The mean number of harvested mediastinal LNs was 10.7±5.6 and was normally distributed (range, 0-49; median, 10). The 5-year survival rate was 53.8%. Overall survival was influenced by the number of involved stations (single-station versus multi-station disease, 5-year survival rates 31.5% versus 16.9%, respectively; p=0.041) but not by the number of harvested LNs, the number of harvested mediastinal LNs, or the number of positive mediastinal LNs. CONCLUSIONS: After lung cancer resection and complete lymphadenectomy, the number of LNs is subject to normally distributed interindividual variability, with no significant impact on OS. Recommending an optimal number of nodes is therefore arbitrary. Instead, our recommendation is to perform a complete systematic pulmonary and mediastinal lymphadenectomy following established anatomical boundaries.

Quality of life of surgical oncology residents and fellows across Europe.

BACKGROUND: Data are currently lacking regarding the quality of life of surgical oncology (SO) trainees. We sought to assess the training conditions and quality of life of SO residents and fellows across Europe. MATERIAL AND METHODS: Members of the European Society for Surgical Oncology were invited to complete a Web-based survey that included a questionnaire specifically designed for SO trainees. Demographics, timing, and incentive to choose for SO, quality of life, and symptoms of fatigue, sleepiness, depression, and burnout, as well as self-reported medical errors, were assessed using validated instruments. RESULTS: The survey was completed by 109 residents and 53 fellows (mean age 34.6 ± 8.2). The mean Linear Analog Scale Assessment score for quality of life was 34.8 ± 8.6 out of a possible 50. A low level of fatigue was declared by 60% of the trainees. However, 44% scored an abnormal Epworth Sleepiness score, which was mostly related to in-hospital work time and lack of educational programs. High positive screenings regarding depression (51%) and burnout (25%) were associated with resident status and lack of mentorship, respectively. Major medical errors during the last 3 months were self-reported by 20% of the trainees. CONCLUSIONS: In Europe, the perceived quality of life is overall acceptable among trainees in SO. However, the present study demonstrated a high level of sleepiness, depression, and burnout symptoms. Additional work is required to identify and overcome the underlying causes of these symptoms.

The impact of hospital and surgeon volume on the 30-day mortality of lung cancer surgery: A nation-based reappraisal.

OBJECTIVE: Our objective was to analyze the time trend variation of 30-day mortality after lung cancer surgery, and to quantify the impact of surgeon and hospital volumes over a 5-year period in France. METHODS: We used Epithor, the French national thoracic database and benchmark tool, which catalogues more than 180,000 procedures of 89 private and public hospitals in France. From January 2005 to December 2010, 19,556 patients who underwent major lung resection (lobectomy, bilobectomy, pneumonectomy) were included in our study. Multilevel logistic models were designed to investigate the relationship between 30-day mortality and surgeon (model 1) or hospital (model 2) volumes. The 3 levels considered were the patient, the surgeon, and the hospital. RESULTS: From 2005 to 2007, the 30-day mortality of patients who underwent major lung resection averaged 10%, and then decreased until it reached 3.8% in 2010 (P < .0001). A significant decrease in 30-day mortality was observed over time (P = .0046). During the study period, the mean annual number of procedures per surgeon was 46.1 (standard deviation [SD] = 23.6) and per hospital was 97.9 (SD = 50.8). Model 1 showed that surgeon volume had a significant impact on 30-day mortality (P = .03), whereas model 2 failed to show that hospital volume influenced 30-day mortality (P = .75). CONCLUSIONS: Since 2007, when France's first National Cancer Plan became effective, 30-day mortality of primary lung cancer surgery has decreased and currently measures 3.8%. Low mortality was correlated with higher surgeon volume but was not influenced by hospital volume, which cannot be considered a proxy measure for determining the safety of lung cancer surgery.

Is the rate of pneumonectomy higher in right middle lobe lung cancer than in other right-sided locations?

BACKGROUND: Historically, right middle lobe (RML) non-small cell lung cancer (NSCLC) has been reported to be associated with a higher rate of pneumonectomy than other right-sided locations. Because this would discourage minimally invasive approaches in RML-NSCLC, we sought to update this assertion through the study of a large surgical series. METHODS: Clinical records of patients who underwent operations for right-sided NSCLC in 2 French surgical centers were prospectively entered and retrospectively reviewed. Demographic and pathologic characteristics of RML NSCLC were compared with other right-sided NSCLC. RESULTS: This study included 3,234 right-sided and 211 RML (6.5%) NSCLC patients. After exclusion of 14 patients who underwent exploratory thoracotomy, patients were a mean age of 61.5 years, most RML resections occurred in men (134 [72.8%]), and most were lobectomies (wedge, n=4; lobectomy, n=102; bilobectomy, n=22; pneumonectomy, n=56). Pathologic analysis revealed adenocarcinoma in 88 patients (47.8%) and squamous cell carcinoma in 80 (43.5%). pStaging was stage I in 86 patients (46.7%), II in 42 (22.8%), III in 47 (25.5%), and IV in 9 (4.9%). Superior and inferior mediastinal N2 were found in 45.4% and 54.6% of patients, respectively, when 1 station was involved. When compared with other right-sided NSCLC, RML was characterized by higher T status and higher rates of bilobectomy (10.9% vs 5.6%, p=0.0017) and pneumonectomy (30.3% vs 22.3%, p=0.0071) but similar 5-year survival (47.4%). CONCLUSIONS: Compared with other right-sided NSCLC, RML location is associated with a higher albeit limited rate of pneumonectomy.

Current readings: the most influential and recent studies regarding resection of lung cancer in m1a disease.

M1A disease is a recent concept appearing in the 7th TNM classification of lung cancer. M1A encompasses two different entities, malignant pleural or pericardial effusions and separate tumor nodules in the contralateral lung, who constitute very different diseases, with very different management and prognoses. On one hand, patients with pleural dissemination have extremely poor survival, with median and 5-year survivals of 4 months and 3.1%, respectively. Only selected patients whose limited pleural extension has been diagnosed at the time of thoracotomy and completely resected, may experience prolonged survival. On the other hand, recent progress in molecular biology still failed to establish whether a contralateral lesion is a second primary or a metastasis. These contralateral lesions are now gathered as multiple lung cancers in the surgical literature, and misleadingly classified as M1A disease in the TNM classification. Patients with contralateral nodules may experience prolonged survival after the surgical treatment of both localizations. Changing the staging by establishing the diagnosis of metastasis is probably an important issue warranting further biologic research, but according to current results this diagnosis must not in any case preclude surgery.

Mediastinal lymphadenectomy in elderly patients with non-small-cell lung cancer.

OBJECTIVES: The progressive ageing of the population is accompanied by an increasing incidence of cancer. Our objective was to compare mediastinal lymphadenectomy performed in the surgical treatment of non-small-cell lung cancer (NSCLC) patients between ≥ 70 and <70. METHODS: We performed a retrospective single-centre case-control study, including 80 patients ≥ 70 years of age, surgically treated for NSCLC between January 2008 and December 2010, matched 1:1 to 80 younger controls on gender, American Society of Anesthesia score, performance status and histological subtype of the tumour. The number and type of dissected hilar/intrapulmonary and mediastinal lymph node stations as well as the number of resected lymph nodes were compared between the two age groups. RESULTS: The type of pulmonary resection was significantly different between the two groups (P = 0.03): pneumonectomy 6% (n = 5) for patients ≥ 70 vs 12% (n = 10) for patients <70, lobectomy 85 (n = 68) vs 65% (n = 52), bilobectomy 1 (n = 1) vs 2% (n = 2) and sub-lobar resection 7 (n = 6) vs 20% (n = 16). There was no significant difference in type of mediastinal lymphadenectomy (radical vs sampling; P = 0.6). Elderly patients presented a more advanced N status of lymph node invasion than younger controls (P = 0.02). The number and type of dissected lymph node stations and the number of lymph nodes were not significantly different between the two age groups (P = 0.66 and 0.25, respectively). The mean number of metastatic lymph nodes was higher in patients ≥ 70 (2.3 vs 1.3 in patients <70; P = 0.002). Lymph node ratio between metastatic and resected lymph nodes was higher in elderly patients (0.11 vs 0.07 in younger controls; P = 0.009). CONCLUSIONS: Lymph node involvement in surgically treated NSCLC was more significant in elderly patients ≥ 70 than in younger patients presenting comparable clinical and histopathological characteristics, and undergoing a similar lymphadenectomy.

[Delays in the diagnosis and treatment of lung cancer for patients treated with radiation therapy]. / Délais de prise en charge initiale des patients atteints de cancer bronchique traités en radiothérapie.

OBJECTIVE: To describe delays in diagnosis and treatment of lung cancer in patients treated by radiotherapy from the first abnormal imaging to the first day of treatment. PATIENTS AND METHODS: Our retrospective single-center study included all patients treated for primary lung cancer in our center receiving radiotherapy alone or in association to chemotherapy or surgery, between 1st May and 15th September 2011. RESULTS: We included 40 patients. Mean age was 65.3 years and sex ratio was 4 (32 males). In 72.5% (n = 29) of the cases, the objective of the treatment was palliative. Median delay between the first abnormal imaging to the first day of treatment was 75.5 days (CI 95% [63.6-134.4]). Median diagnostic delay to obtain a pathological proof was 38 days (CI 95% [27.9-100]). Median therapeutic delay to start treatment was 31 days (CI 95% [24.6-38.5]). When considering radiotherapy, median delay between multidisciplinary staff decision and first radiotherapy session was 26 days (CI 95% [22.4-33.3]). CONCLUSION: The study of the delays in diagnosis and treatment is the first step to reduce them. Detailed analysis helps to propose some measures to improve these delays.

[Insights of young French surgical oncologists: motives and training]. / Formation des jeunes chirurgiens inscrits en DESC de cancérologie option II--traitement chirurgical des tumeurs.

INTRODUCTION: In France, surgical oncology is not recognized as a unique specialty, but as a sub-specialization offered to surgeons in training. To date, their motives and training have not been studied. MATERIALS AND METHODS: We set a dedicated online survey suggested to 102 surgeons applying for the specific national degree in surgical oncology. RESULTS: The answer rate was 60%. Responders were constituted of a majority of male (61%), their median age was 31 years. They were mainly residents (33%) and fellows working in university (25%) or non-university (28%) hospitals. Most responders have chosen their organ specialization at the beginning, and their oncologic sub-specialization at the middle of their residency, after a meeting with a senior surgeon. Regarding practical education, 85% used surgical videos, 62% mechanical training devices, 60% animal surgery, and 38% cadaver dissection. Regarding career expectations, 67% would like to work in a cancer centre, 51% in a university hospital, and 26% in a private institution. To explain these choices, 51% referred to research and 65% to teaching interests. CONCLUSION: This study outlines the role of mentorship and the lack of practical teaching outside the operating room during the training in surgical oncology in France.