Direct lymphatic drainage of lung segments to the mediastinal nodes. An anatomic study on 260 adults.

The subpleural lymphatics of 483 lung segments were injected in cadavers of 260 adult subjects. The injected lymph vessels corresponded to the pulmonary segmentation in 91% of the cases and remained close by in the other cases. Direct passages to the mediastinal nodes were observed in 54 of 243 right lung segments injected (22.2%) and 60 of 240 left lung segments (25%). Among a total of 114 direct passages observed, 99 remained superficial in the pleura, half of them composed of a single vessel. These passages have been observed more frequently in the segments of the upper lobes. Injections of basal segments in the right and left lower lobes showed fewer of these direct passages to the mediastinal lymph nodes and also demonstrated direct lymph vessels to lymph nodes located at the origin of the upper lobar bronchi. In two dissections of the right upper lobe, the drainage went directly to the right venous jugular-subclavian junction, and in three dissections from three right terminal basal segments the lymph vessel went directly to the thoracic duct in its mediastinal passage. Direct contralateral lymph pathways were observed five times, four of them from basal segments of lower lobes.

Elective drainage of the apical chest by posterior approach.

Pneumothorax due to incomplete reexpansion of remaining lung after a thoracic operation is difficult to drain via standard access routes. Apical chest drainage can be placed through a upper posterior point of the back, located in the laterovertebral area at the level of the first or second intercostal space. This technique, which is very safe and well tolerated, avoids the necessity to use thoracoplasty or muscle flap plombage of those residual cavities.

Cold abscess of the chest wall: a surgical entity?

BACKGROUND: Cold abscesses of the chest wall are rare tuberculous locations. Because of the resurgence of tuberculosis, this diagnosis must be considered more frequently. METHODS: During a 15-year period (1980 to 1995), 18 patients with one or more cold abscesses of the chest wall were managed in our department. Epidemiologic characteristics, indications, methods and results of operation, and pathogenesis of the abscesses were considered in this retrospective study. RESULTS: Most of the patients were immigrant men. A previous history of tuberculosis was noted in 15 cases (83%). Six patients had concomitant active pulmonary tuberculosis. There was mostly a solitary lesion in the chest wall, the most frequent location being the rib shaft (60%). Before operation the diagnosis was confirmed only in 4 patients (by needle aspiration of the abscess) and presumed in 4 others: an antituberculous chemotherapy was therefore given preoperatively to 8 patients. One patient did not undergo operation after a favorable response to medical treatment. In the other patients, an operation was indicated because of lack of response in 5 patients and the absence of diagnosis in 12 patients. Adequate debridement and a postoperative antituberculous regimen were performed with recurrence prevention in mind. A follow-up was obtained in 11 of the 17 patients undergoing operation. The only patient who required a second operation because of a recurrence at the same location had refused the antituberculous therapy after the first surgical procedure. Locations of the abscesses, computed tomographic scan results, and histologic examinations are in favor of a lymph-borne dissemination of tubercle bacilli. CONCLUSIONS: Because fine-needle aspiration remains an inaccurate diagnostic tool and antituberculous medical treatment is not always efficient, chest wall tuberculous cold abscesses remain in most cases a surgical entity.

Factors determining survival in resected N2 lung cancer.

This retrospective study was based on 237 patients with non-small cell lung cancer (NSCLC) and nodal N2 disease. All accessible mediastinal lymph nodes (LN) were removed and classified according to their anatomical location in LN chains. The pulmonary resections performed were: pneumonectomy (n = 187), lobectomy (n = 44) and segmentectomy (n = 4). There was solitary nodal chain involvement by metastasis in 141 cases, two chains in 72 cases and three or more in 24; "skip" metastases were present in 26.6%. N2 disease would have been missed in 45 cases of single chain involvement (31.9%) if routine removal of mediastinal nodes had not been performed. The overall 5-year survival rate was 18.8%. Survival was not influenced by site, size or extension (T) of tumor, tumor histology or the presence of vascular invasion. The prognosis was significantly worsened by the presence of microscopic residual disease (30 cases) and of satellite nodules (23 cases). Survival was significantly improved when metastases involved a single LN chain (26.3 versus 8.3%, P = 0.0003). The location and number of involved nodes in the chain, "skip" metastases and the presence of extracapsular spread of carcinoma did not influence the prognosis. Routine mediastinal LN dissection is necessary to improve survival and for classification of lung cancer. Anatomic description allows better understanding of N2 disease which is not a contraindication to surgery when a gross complete resection can be achieved.

Prognostic value of T and N in non small cell lung cancer three centimeters or less in diameter.

OBJECTIVE: Peripheral tumors 3 cm or less in diameter are classified T1, T2 when rupturing the visceral pleura, T3 when invading parietal pleura, chest wall, mediastinal pleura or pericardium and T4 when invading vertebra or mediastinal structures. Our objective was to assess the prognostic significance of T and N status according to the size of such tumors. PATIENTS AND METHODS: Patients (918) were operated upon between April 1984 and December 1991. Surgery included complete resection and mediastinal lymphadenectomy. Tumors 3 cm or less were studied concerning T, N status, histology and survival. RESULTS: There were 314 such tumors (T1 = 215, T2 = 64, T3 = 35, T4 = 6); N status was N0 60.2%, N1 21%, N2 18.8%. Global 5-year survival was 52.59%. In case of N0, survival was 64.63%: T1 = 63.76%, T2 = 71.48%, T3 = 45.71%, T4 = 66.6%; which was not significant. There were 48 tumors 1.0 cm or less in diameter (G1), 111 tumors 1.1-2.0 cm in diameter (G2) and 155 tumors 2.1-3 cm in diameter (G3). The incidence of N0, N1 and N2 disease was 77.1, 10.4 and 12.5%, respectively in G1, 64, 18 and 18% in G2, and 52.3, 26.5 and 21.3% in G3. The 5-year survival rate was 62.46% for G1, 52.91% for G2 and 49.36% for G3 (NS). In cases of N1 and N2, survival was 48.41% and 20.2% which was significant (P < 0.05) but differences between each T and each G were not significant. CONCLUSIONS: Small peripheral cancers spread into mediastinal nodes in 12.5-21.3% of cases, according to the size. This is a warning to perform nodes resections in cases where surgeons intend a videothoracoscopic approach. N2 status is not only an indicator but also a governor of prognosis. Neither T status nor size are determinants of prognosis as far as tumors 3 cm in diameter or less are concerned.

[Place of radical surgery in the treatment of non-small cell lung cancer. Apropos of 969 cases]. / Place de la chirurgie à visée curative dans le traitement du cancer bronchique non à petites cellules. A propos de 969 cas.

PURPOSE: Retrospective analysis of the results of radical surgery in a series of 969 patients presenting with non-small cell lung cancer. PATIENTS AND METHODS: From April 1984 to December 1981, 969 patients underwent radical surgery with mediastinal node dissection for non-small cell lung cancer. Surgery included 507 pneumonectomies, 447 lobectomies and 15 segmentectomies (for patients suffering from respiratory failure). RESULTS: The rate of intrahospital mortality was 4.3%. The rate of crude survival at 5-years was 45.8%. The tumor size (P = 0.004) and visceral pleura ruptures (P = 0.01) were significantly correlated to the 5-year survival rate that was reaching 56% for patients with no demonstrable metastasis to regional lymph nodes (NO), 46.6% for patients with metastasis to lymph nodes in the peribronchial or the ipsilateral hilar region (N1), and 20.8% for patients with metastasis to the ipsilateral mediastinal and subcarinal lymph nodes (N2) (P = 0.001). In case of stage N2 cancer, the 5-year survival rate was 28.7% when only one anatomical level was involved, and 8.7% when more than one anatomical level was involved (P < 0.0001). CONCLUSION: The main prognostic factor was nodal involvement.

[Thoracic duct collaterals of lymphatic and pulmonary origin. Anatomy and chylothorax after pulmonary surgery]. / Les collatérales du canal thoracique d'origine ganglio-pulmonaire. Etude anatomique et chylothorax après chirurgie pulmonaire.

Dye injection of lung segments reveals the existence of lymphatic drainage of the lungs generally into cervical venous confluents and more rarely into the arch of the thoracic duct in the neck and also occasionally into the thoracic duct in the mediastinum. Direct drainage of the lymph into the thoracic duct was observed in 10 cases out of a series of 589 injections of lung segments in adult cadavers. In one half of cases, the thoracic duct was injected from the left suprabronchial lymph node chain, the origin of the left recurrent chain, and in one quarter of cases from the lateral anteroposterior right major azygos and left azygo-aortic lymph node chains, not recognised by the classical authors. More rarely, direct lymphatic collaterals drained certain segments of the lower lobes into the thoracic duct via the triangular ligament. Analysis of cases of chylothorax occurring after lung resection and observed in the authors' department or in the literature reveals that most of them can be attributed to a chyle leak from one of these pulmonary lymph collaterals. These pathways are probably also involved in the development of medical or idiopathic chylothorax.

[Apropos of 6 para-esophageal cysts. A discussion about their origins]. / A propos de six kystes para-oesophagiens. Discussion sur leurs origines.

Para-oesophageal cyst is a rare lesion which can be classified, by its origin, as a gastrointestinal duplication. It is mostly encountered in children. Since 1977, we have observed 6 cases in adults, and 5 out of 6 presented as postero-inferior mediastinal tumors. Pre-operative diagnosis is difficult: when the lesion is intramural, the only other diagnosis is leiomyoma; in other cases, a bronchogenic cyst or a posterior mediastinal enteric formation can be discussed. Surgical findings and histological criteria allow a precise definition of these cysts, which lie at least partially in the wall of the oesophagus. They are a histological association of respiratory mucosa and muscular, either of type or associated with cartilaginous islets. The definition of the clinical classification is easier with a good knowledge of the histogenesis.

[Radiation-induced sternal tumors: value of myocutaneous flap of the latissimus dorsi]. / Tumeurs sternales radio-induites: intérêt du lambeau myocutané du grand dorsal.

Two patients treated by radiotherapy, one 13 years previously for Hodgkin's thymoma and the other 10 years previously for breast cancer, presented with a radiation-induced sternal tumour. The first case had undergone manubriectomy for fibrosarcoma complicated by dehiscence of the skin wound one year prior to referral to our unit: she presented with a haemorrhagic ulcerated recurrence. The lesions were widely excised (skin defect: 13 x 13 cm). The second patient underwent "en bloc" cutaneo-osteomyopericardectomy with omentoplasty onto the pericardium and sternal prosthesis (skin defect: 12 x 7 cm). These tumours are rare, but the radiation-induced skin damage requires wide excision. In both cases, the skin defect was easily repaired by means of a latissimus dorsi myocutaneous flap.

[Prognostic factors of survival in resected N2 bronchial cancer]. / Facteurs pronostiques de survie des cancers bronchiques N2 réséqués.

This study was based on 206 patients with non small cell lung cancer and N2 nodal disease submitted to curative surgery: pneumonectomy 163, lobectomy 39 and segmentectomy 4. All accessible mediastinal lymph nodes were removed and classified according to their anatomical location in lymph node chains; "skip" metastases were present in 24.8% of cases. N2 disease would have been missed in 20% of cases if routine removal of mediastinal nodes had not been performed. There was solitary nodal chain involvement by metastasis in 126 cases (61.2%). Overall 5-year survival was 18.3% +/- 3. Survival was not influenced by site, size or extension (T) of tumor, adjuvant radiotherapy, tumor histology or presence of vascular invasion. The prognosis was significantly worsened by the presence of microscopic residual disease (22 cases) and of satellite nodules (18 cases). Survival was significantly improved when metastases involved a single node chain (25% versus 8.5%). The location and number of involved nodes in the chain, "skip" metastasis and presence of extracapsular spread of carcinoma did not influence prognosis. Routine mediastinal lymph node dissection is necessary to improve survival and for classification of lung cancer. Anatomical description allows better understanding of N2 disease which is not a contraindication to surgery when a complete gross resection can be achieved.

[Lobectomies enlarged to the main bronchus in the conservative treatment of lung carcinoma. Apropos of 75 cases]. / Lobectomies élargies à l'axe bronchique principal dans le traitement conservateur du carcinome bronchique. A propos de soixante-quinze cas.

From february 1965 to march 1990, 70 squamous cell carcinomas, 3 adenocarcinomas and 2 undifferentiated lung cancer were operated by lobectomy extended to the main bronchus: 44 right upper lobectomies, 22 left upper lobectomies, 5 left lower lobectomies, 2 right lower lobectomies, 1 middle lobectomy and one lower and middle bilobectomy. Respiratory function prevented pneumonectomy in 1 out of 3 patients. The postoperative mortality related to surgery (2.7%) has been eliminated since the introduction of systematic protection of the pulmonary artery from the bronchial suture (1976). The sutures are performed with very fine suture material. Endoscopic follow-up is essential: 11 cases of suture granuloma (1 laser) and 4 cases of fibrotic stenoses, including 1 post-irradiation stenosis (2 lasers). Fifty-three patients were N0 (28 T1, 22 T2, 3 T3) and 22 were T+ (including 4 N2). The actuarial survival for the N0 was 91% at 1 year and 60% at 5 years and decreased to 63% and 40% for N+. Eighty-three percent of the late cancer-related deaths had metastatic disease. Lobectomies extended to the main bronchus do not appear to compromise the oncological value of the resection and they offer the possibility of resection in some respiratory failure patients.

[Esophago-bronchial fistula in adults]. / Les fistules oeso-bronchiques de l'adulte.

The authors report five cases of benign oesophago-bronchial fistula in adults. These chronic bronchitic patients presented with recurrent episodes of secondary lung infections (or even haemoptysis). Questioning of the patients revealed a history of coughing when swallowing liquids in three cases. Two women concealed this symptom, which was only revealed retrospectively. The fistula was detected by upper GI series in three cases and by oesophageal fibroscopy in one case. In the remaining case, it was discovered at operating for severe haemoptysis. In four of the five cases, the fistula was situated on the right and was of post-tuberculous origin. In one case of post-traumatic fistula, it involved the left main bronchus. All of the patients were operated: a resection-suture of the fistula was performed via the oesophageal approach and, via the bronchial approach, simple suture of the fistula was possible in two cases, while resection of the destroyed pulmonary parenchyma was necessary in three cases (one right lower lobectomy, two bilobectomies). Demonstration of the oesophago-bronchial fistula, definition of its site and assessment of the condition of the pulmonary parenchyma are essential steps to be performed prior to surgery.

[Percutaneous parietal pleurectomy using video-endoscopy. Modern treatment of spontaneous recurrent pneumothorax]. / La pleurectomie pariétale percutanée par vidéo-endoscopie. Le traitement moderne du pneumothorax spontané récidivant.

The best prevention of recurrent spontaneous pneumothorax is obtained with a parietal pleurectomy, the recurrence rate being below 0.5%. The sequelae on the muscles and the aesthetic result of a thoracotomy favour a pleurodesis using a closed chest technique. Video-endoscopy enables us to perform 16 percutaneous parietal pleurectomies (PPP) without thoracotomy in 14 patients. 11 cases were idiopathic spontaneous recurrent pneumothoraces and in 3 cases the recurrent pneumothorax occurred in patients suffering from AIDS with progressive pulmonary lesions. PPP was performed under general anaesthetic with selective intubation. The posterior incision of 2-3 cm did not involve any muscular section and the dissection was performed throughout using video-endoscopy which enabled perfect control of haemostasis. PPP achieves a sub-total pleurectomy. The hospital stay was on average for five days. Those operated on did not suffer from immediate post operative pain and shoulder mobility was excellent from the moment at which the patient awoke. The advantages of PPP are: perfect haemostasis and the absence of muscular sequelae or unpleasant aesthetic sequelae. These benefits now make us consider that percutaneous parietal pleurectomy may be the treatment of choice in spontaneous recurrent pneumothoraces.

[Pseudotumoral lambda chain pulmonary amyloidosis]. / Amylose pulmonaire pseudo-tumorale à chaîne lambda.

A case is described of primary multi-nodular pulmonary amyloidosis which was "pseudotumoral" and its progress had been under observation for eight years. Protein analysis revealed that it was a monoclonal light chain and there was no evidence of myeloma. It appears to be of a local pathology and is of the same type as amyloid tumors of the bronchi.

[Postoperative pain after thoracotomy. A study of 116 patients]. / Douleur post-opératoire au décours d'une thoracotomie. Etude de 116 malades.

We have studied post-operative pain in 116 patients who underwent a thoracotomy. The pains were assessed using a visual analogue scale and were significant and identical whatever type of operation was used and irrespective of sex or diagnostic disease category. On the operative day only the surgeon seemed to have any influence. On the first post-operative day the pain was influenced by age and on the eighth day by socio-professional category. The insertion of drains had no influence on the pain. Massage and physiotherapy decreased the pain in a significant fashion. The importance of taking account of post-operative pain is underlined.

[A rare tumor of the thoracic wall: synovial sarcoma]. / Une tumeur rare de la paroi thoracique: le synovialosarcome.

The synovial sarcoma is a tumour of the soft tissues. Its thoracic localisation is unusual. The authors report a case of a recurrent tumour of the scapula, whose excision required major plastic surgery to the dorsal chest wall. The diagnosis was revealed by the biphasic histological nature which was confirmed on immunological studies. Such tumours give rise to discussions on their histogenesis; their subsequent progress is slow and recurrences are common. Healing depends on the radical nature of their excision.

[Chylomediastinum after mediastinoscopy. Apropos of a case]. / Chylomédiastin après médiastinoscopie. A propos d'une observation.

A mediastinal chylous effusion occurred in a young woman after a mediastinoscopy. This effusion healed rapidly with medical treatment. An understanding of the anatomy of these intra-thoracic/lymphatic channels explains that intra-thoracic chylous effusions may occur in case of incontinence of the lymphatic vessels which connect the tracheo-bronchial nodes to the thoracic duct in the mediastinum. This is very important following the surgical excision of a node because incontinent lymphatic vessels are directly sectioned. When the lymph nodes are biopsied in an enclosed cavity such as the mediastinum, the quantity of lymphoid tissue acts as an obstacle to reflux of the lymph which is thus less significant and more easily controlled.

[Excision of mediastinal nodes using video-thoracoscopy]. / Exérèse d'adénopathie médiastinale sous vidéothoracoscopie.

A man of seventy-one years with gross respiratory failure was suspected of having a cancer of the right upper lobe with metastases to the right pretracheal and intertracheobronchial nodes. A diagnostic mediastinoscopy did not achieve a diagnosis, and a right sub-bronchial node biopsy was performed, using videothoracoscopy and this revealed the presence of tuberculosis without any further delay.

[Mesothelial cyst of pleuro-parietal origin]. / Kyste mésothélial à développement pleuro-pariétal.

This is a case report of two mesothelial cysts, both with liquid contents. They had developed in the thoracic wall; in spite of their perfectly benign character, both were eroding the ribs at the point of contact. These ectopic cysts are probably of coelomic origin.

[Surgically-treated small size non-small cell bronchopulmonary cancers without adenopathies (T1NO). 5-year survival and site of recurrences]. / Cancers bronchopulmonaires "non à petites cellules", de petite taille et sans adénopathie (T1N0) opérés. Survie à 5 ans et siège des rechutes.

From October, 1976 to February, 1982, 48 patients with T1N0 non-small cell bronchopulmonary carcinoma were operated upon at the Laennec Hospital, Paris. Their characteristics were: mean age 57 years (range: 43-80 years); sex ratio 23; type of surgery: 35 lobectomies, 11 pneumonectomies, 2 bilobectomies; histology: 30 epidermoid carcinomas, 15 adenocarcinomas, 3 bronchoalveolar carcinomas. On 1st January, 1983, 10 patients had relapsed after a mean complete remission period of 20 months (range: 2-29 months); 5 only had a local relapse. The actuarial probability of relapse at 5 years is 45%. Twelve patients died after a median survival of 21 months (range: 0-44 months). Of these, 3 died post-operatively, 8 after relapse and 1 of infarction during a first complete remission. Most relapses involved the mediastinum (50%) and the brain (30%). As the preventive role of mediastinal and cerebral irradiation has now been demonstrated in more extensive forms of non-small cell carcinomas, such irradiations would be justified in the T1N0 forms.