Middle lobe suffering due to malposition and 180° tilt of the 2 remaining lobes after right upper lobectomy.

Middle lobe (ML) suffering after right upper lobectomy (RUL) is rare but represents a major complication usually due to lobar torsion. We report 3 atypical consecutive cases of ML suffering due to malposition of the 2 remaining right lobes with a 180° tilt. All 3 female patients had surgery for non-small-cell carcinoma including RUL associated with radical hilar and mediastinal lymph node removal. Postoperative chest X-ray abnormalities appeared at days 1-3 respectively. The diagnosis of malposition of the 2 lobes was done on contrast-enhanced chest CT scan at days 7, 7 and 6, respectively. A reoperation for suspected ML torsion was required in all patients. Three repositionings of the 2 lobes and 1 middle lobectomy were performed. The postoperative courses were then uneventful, and the 3 patients were alive at a mean follow-up of 12 months. Before thoracic approach closure after RUL, systematic check of good positioning of the 2 reinflated remaining lobes is indispensable. It may prevent ML suffering secondary to 180° lobar tilt leading to whole pulmonary malposition.

The role of donor-recipient gender matching in lung transplantation: a systematic review.

INTRODUCTION: Donor to recipient (D-R) matching in lung transplantation (LTx) is firstly directed by blood group (identity or compatibility), immunological status and morphological criteria. Sex matching is ignored and impact on outcome less investigated. EVIDENCE ACQUISITION: Systematic review of English literature using PubMed (1990-2019) was performed to evaluate the potential role of D-R matching in determining long-term outcome in patients after LTx. Search terms included (LTx) AND (sex) OR (gender) OR (matching) OR (mismatch) OR (donor characteristics) and were restricted to articles' title. Only articles directly reporting LTx survival outcome according to gender match/mismatch and D-R gender combination in LTx were included. Two authors independently extracted articles using predefined data fields, including study quality indicators. MOOSE Guidelines for Meta-Analyses and Systematic Reviews of Observational Studies applied. EVIDENCE SYNTHESIS: Nine articles were analyzed and included into this study. All studies analyzed the effect of the different D-R gender combinations on survival while seven of them investigated exclusively the role of sex matching on LTx outcome. In this latter group two out of seven showed a trend towards an overall survival advantage for sex matching LTx combination. The worst survival results were reported for F to M gender combination in 3 studies and for M to F gender combination by 1 study. No differences were reported in remaining 4 studies. CONCLUSIONS: This systematic review suggests that sex matching and several gender combinations could play a role in determining overall survival rate after LTx. Data deriving from unbiased studies supported that matching female-female (F-F) and male-male (M-M) could improve LTx outcome while FD-MR combination should be avoided. Unfortunately, a good part of the analyzed data are affected by bias due to confounding factors. Up-to-date immunological, hormonal and morphological factors could explain the gender-based difference in LTx outcome. Further investigations should clarify their role and importance to define the effects of gender combinations on survival.

Successful Conservative Management of a Rare Surgical Complication of Vascular Ehlers-Danlos Syndrome: A Case Report.

Vascular Ehlers-Danlos syndrome is a hereditary disorder of the connective tissue characterized by a reduction in the production of type III collagen. Clinical evolution of the disease is unpredictable because vascular lesions can occur everywhere in the body. Bruising, arterial and bowel fragility, and uterine fragility during pregnancy are the most common symptoms. Thoracic surgeons should take with these patients because, in rare cases, thoracic complications may occur, such as recurrent pneumothorax or spontaneous hemothorax. We report an extra-pleural hematoma in a patient with vascular Ehlers-Danlos syndrome, an unusual complication treated successfully with conservative management.

Non-small cell lung cancer invading the chest wall.

Non-Small cell lung cancer invading the chest wall represents an advanced stage of the disease. Chest wall resection may be achieved in up to 100% of the patients, and the ensuing defect requires to be reconstructed in 40% to 64% of cases. Once a surgical challenge, chest wall resection is no longer a technical problem and en bloc chest wall and lung resections regularly provide good results. However, survival rates are jeopardized by incompleteness of the resection and mediastinal lymph node involvement. Nowadays, the challenge is represented by the use of the other nonsurgical modalities (chemotherapy and radiation therapy) to increase the chance of performing a complete resection, the need to achieve a better control of probable lymphatic or hematogenous spread, and the reduction of the recurrence rate.

Giant presternal subcutaneous bronchogenic cyst: a rare but possible occurrence.

Bronchogenic cysts are generally detected in the mediastinum, along the tracheobronchial tree, or in the lung parenchyma. Subcutaneous presternal bronchogenic cysts have been rarely described, and they are usually of small size (<3 cm) and reported in children. We report a case of giant presternal subcutaneous bronchogenic cyst in a 20-year-old man. Presternal subcutaneous bronchogenic cysts, despite their rarity, should be considered in the differential diagnosis of all subcutaneous cystic masses, independent of their size and the patient's age.

Mutational Diversity of Lung Cancer and Associated Lymph Nodes. An Exploratory Prospective Study of 4 Resected cIIIA-N2.

Mutational heterogeneity could explain different metastatic patterns among IIIA-N2 lung cancer and influence prognosis. The identification of subclonal mutations using deep sequencing to evaluate the degree of molecular heterogeneity may improve IIIA-N2 classification. The aim of this prospective study was to assess mutational and immunohistochemical characteristics in primary tumours and involved lymph nodes (LN) in operated patients. Four patients operated for primary lung carcinoma and unisite N2 mediastinal involvement were consecutively selected. Samples (tumour and paired LN) were analysed for PD1, PD-L1 and CD8 immunostaining. Somatic mutation testing was performed by deep targeted next generation sequencing (NGS), with the AmpliSeq™ Colon and Lung Cancer Panel (LifeTechnology). A total of 9 primary lung cancer samples and 10 LN stations were analysed. For each cancer, we found 2 mutations, with allelic ratios from 3% to 72%. Mutational patterns were heterogeneous for 2 primary tumours. In 3 cases, mutations observed in the primary tumour were not found in LN metastases (ALK, FGFR3, MET). Inversely, in 1 case, a KRAS mutation was found in LN but not in the primary tumour. All primary tumours were found PD-L1 positive while CD8+ T cells infiltrate varied. In the different examined LN samples, PD-L1 expression, CD8+ and PD1+ T cells infiltrate were not similar to the primary tumour. This preliminary prospective study shows the diversity of intra-tumour and LN mutations using routinely-used targeted NGS, concerning both mutated gene and allelic ratio. Further studies are needed to evaluate its prognostic impact.

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.

Can mathematics replace anatomy to establish recommendations in lung cancer surgery?

The greater the number of lymph node (LN) sampled (NLNsS) during lung cancer surgery, the lower the risk of underestimating the pN-status and the better the outcome of the pN0-patients due to stage-migration. Thus, regarding LN sampling "to be or not to be", number is the question. Recent studies advocate removing 10 LNs. The most suitable NLNsS is unfortunately impossible to establish by mathematics. A too high NLNsS variability exists, based on anatomy, surgery and pathology. The methodology may vary according to Inter-institutional differences in the surgical approach regarding LN inspection and number sampling. The NLNsS increases with the type of resection: sublobar, lobectomy or pneumonectomy. Concerning pathology, one LN may be divided into several pieces, leading to number overestimation. The pathological examination is limited by the number of slices analyzed by LN. The examined LNs can arbitrarily depend on the probability of detecting nodal metastasis. In fact, the only way to ensure the best NLNsS and the best pN-staging is to remove all LNs from the ipsilateral mediastinal and hilar LN-stations as they are discovered by thoroughly dissecting their anatomical locations. In doing so, a deliberate lack of harvest of LNs is unlikely, number turns out not to be the question anymore and a low NLNsS no longer means incomplete surgery. This prevents from judging as incomplete a complete LN dissection in a patient with a small NLNsS and from considering as complete a true incomplete one in a patient with a great NLNsS. Precise information describing the course of the operation and furnished in the surgeon's reports is also advisable to further improve the quality of LN-dissection, which ultimately might be beneficial in the long-term to patients. However, that procedure is of limited interest in pN-staging if LNs are not thoroughly examined and also described by the pathologist.

[Diaphragm disorders in adults]. / Pathologies diaphragmatiques de l'adulte.

Diaphragm disorders in adults. Diaphragm diseases, functional particularly, are little known and often underestimated by clinicians. Whether a fortuitous discovery on a chest x-ray showing an elevation of the hemidiaphragm or revealed by dyspnea, these abnormalities of the diaphragm require further investigations. The objective is to confirm the diagnosis, understanding the mechanism, to clarify the functional consequences and to consider treatment. Some dysfunctions may be temporary, contraindicating any emergency treatment apart from acute ruptures. Only symptomatic cases require a surgical treatment. The type of surgery depends on the cause and can range from simple repair of a diaphragmatic defect, diaphragm plication to restore tensioning and even phrenic pacing in very rare cases.

Pathologies diaphragmatiques de l'adulte. Les pathologies du diaphragme, en particulier fonctionnelles, sont peu connues et souvent sous-estimées par les cliniciens. Qu'elles soient de découverte fortuite sur une radiographie thoracique montrant une surélévation de la coupole diaphragmatique ou révélées par une dyspnée, ces anomalies du diaphragme nécessitent des explorations complémentaires. L'objectif est d'affirmer le diagnostic, de comprendre le mécanisme en cause, de préciser les conséquences fonctionnelles et d'envisager un traitement. Certains dysfonctionnements peuvent être temporaires ce qui contre-indique tout traitement en urgence en dehors des ruptures « aiguës ¼. Seules les formes responsables d'une symptomatologie invalidante justifie d'une prise en charge chirurgicale. Le type de chirurgie dépend de la cause et peut aller de la simple réparation d'un défect diaphragmatique, à la remise en tension de la coupole par une plicature et même l'implantation d'un stimulateur phrénique dans de très rares cas.

Diaphragm pacing: the state of the art.

Diaphragm pacing (DP) is an orphan surgical procedure that may be proposed in strictly selected ventilator-dependent patients to get an active diaphragm contraction. The goal is to wean from mechanical ventilation (MV) and restore permanent efficient breathing. The two validated indications, despite the lack of randomised control trials, concern patients with high-level spinal cord injuries (SCI) and central hypoventilation syndromes (CHS). To date, two different techniques exist. The first, intrathoracic diaphragm pacing (IT-DP), based on a radiofrequency method, in which the electrodes are directly placed around the phrenic nerve. The second, intraperitoneal diaphragm pacing (IP-DP) uses intradiaphragmatic electrodes implanted through laparoscopy. In both techniques, the phrenic nerves must be intact and diaphragm reconditioning is always required after implantation. No perioperative mortality has been reported and ventilator-weaning rate is about 72% to 96% in both techniques. Improvement of quality of life, by restoring a more physiological breathing, has been almost constant in patients that could be weaned. Failure or delay in recovery of effective diaphragm contractions could be due to irreversible amyotrophy or chest wall damage. Recent works have evaluated the interest of IP-DP in amyotrophic lateral sclerosis (ALS). After some short series were reported in the literature, the only multicentric randomized study including 74 ALS patients was prematurely stopped because of excessive mortality in paced patients. Then, another trial analysed the place of IP-DP in peripheral diaphragm dysfunction but, given the multiple biases, the published results cannot validate that indication. Reviewing all available literature as in our experience, shows that DP is an effective method to wean selected patients dependent on ventilator and improve their daily life. Other potential indications will have to be evaluated by randomised control trials.

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.

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.

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.

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.

Long-term survival of patients with pN2 lung cancer according to the pattern of lymphatic spread.

BACKGROUND: N2 involvement has dramatic consequences on the prognosis and management of patients with non-small cell lung cancer (NSCLC). N2-NSCLC may present with or without N1 involvement, constituting non-skip (pN1N2) and skip (pN0N2) diseases, respectively. As the prognostic impact of this subclassification is still a matter of debate, we analyzed the prognosis of pN2 patients according to the pN1-involvement and the number of N2-stations concerned. METHODS: The medical records of consecutive patients who underwent surgery for pN2-NSCLC in 2 French centers between 1980 and 2009 were prospectively collected and retrospectively reviewed. Patients undergoing induction therapy, exploratory thoracotomy, incomplete mediastinal lymphadenectomy, or incomplete resections were excluded. The prognoses of pN1N2 and pN0N2 patients were first compared, and then deciphered according to the number of N2 stations involved (single-station: 1S, multi-station: 2S). RESULTS: All together, 871 patients underwent first-line complete surgical resection for pN2-NSCLC during the study period, including 258 pN0N2 (29.6%) and 613 pN1N2 (70.4%) patients. Mean follow-up was 72.8±48 months. Median, 5- and 10-year survivals were, respectively, 30 months, 34%, and 24% for pN0N2 and 20 months, 21%, and 14% for pN1N2 patients (p<0.001). Multivariate analysis revealed 3 different prognostic groups; ie, favorable in pN0N2-1S disease, intermediate in pN0N2-2S and pN1N2-1S diseases, and poor in pN1N2-2S disease (p<0.001). CONCLUSIONS: Among pN2 patients, the combination of N1 involvement (pN0N2 vs pN1N2) and number of involved N2 stations (1S vs 2S) are independent prognostic factors. These results might be taken into consideration to sub-classify the heterogeneous pN2-NSCLC group of patients.

A review of 250 ten-year survivors after pneumonectomy for non-small-cell lung cancer.

OBJECTIVES: During the last decades, pneumonectomy has been increasingly seen as a risky procedure, first reserved for tumours not amenable to lobectomy, and now discouraged even in advanced stages of non-small-cell lung cancer (NSCLC). Our purpose was to assess the long-term survival following pneumonectomy for NSCLC and its prognostic factors. METHODS: We set a retrospective study including every patient who underwent a pneumonectomy for NSCLC in 2 French centres from 1981 to 2002. We then described the demographic and pathological characteristics of patients who survived >10 years, and studied the prognostic factors of long-term survival. RESULTS: During the study period, 1466 pneumonectomies were performed for NSCLC, including 1121 standard and 345 extended, and accounted for the overall population. Postoperative complications occurred in 396 patients (27%), including 93 deaths (6.3%). Five- and 10-year survival rates were 32 and 19%, respectively. Two-hundred and fifty patients survived >10 years after surgery, and accounted for the study group. The study group included a majority of males (n = 230, 92%), a mean age of 57 ± 9.2 years and a majority of clinical stage IIIA (n = 117, 46.8%). Induction, right-sided pneumonectomy, extended resection and adjuvant therapy were performed in 41 (16.4%), 109 (43.6%), 40 (16%) and 97 patients (38.8%), respectively. Histology revealed a majority of squamous cell carcinoma (n = 181, 72.4%), T2 tumours (n = 117, 36.8%) and N1 disease (n = 105, 42%). In multivariate analysis, factors associated with adverse outcomes included older age, advanced stage, extended resection, non-lethal postoperative complication, adenocarcinoma, lymphatic vessel microinvasion, N1 and N2 disease and R1 and R2 resection. CONCLUSIONS: During the last 30 years, pneumonectomy was effectively performed for advanced NSCLC, allowing a 10-year survival rate of 19%. Such results have not been reported with other non-surgical treatments and confirm that pneumonectomy is still an essential weapon in the armamentarium against lung cancer.

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.