Outcomes of lung transplantation for pleuroparenchymal fibroelastosis: A French multicentric retrospective study.

BACKGROUND: Pleuroparenchymal fibroelastosis (PPFE) has no currently available specific treatment. Benefits of lung transplantation (LT) for PPFE are poorly documented. METHODS: We conducted a nation-wide multicentric retrospective study in patients who underwent lung or heart-lung transplantation for chronic end-stage lung disease secondary to PPFE between 2012 and 2022 in France. RESULTS: Thirty-one patients were included. At transplantation, median age was 48 years [IQR 35-55]. About 64.5% were women. Twenty-one (67.7%) had idiopathic PFFE. Sixteen (52%) had bilateral LT, 10 (32%) had single LT, 4 (13%) had lobar transplantation and one (3%) had heart-lung transplantation. Operative mortality was 3.2%. Early mortality (<90 days or during the first hospitalization) was 32%. Eleven patients (35.5%) underwent reoperation for hemostasis. Eight (30.8%) experienced bronchial complications. Mechanical ventilation time was 10 days [IQR 2-55]. Length of stay in intensive care unit and hospital were 34 [IQR 18-73] and 64 [IQR 36-103] days, respectively. Median survival was 21 months. Post-transplant survival rates after 1, 2, and 5 years were 57.9%, 42.6% and 38.3% respectively. Low albuminemia (p = 0.046), FVC (p = 0.021), FEV1 (p = 0.009) and high emergency lung transplantation (p = 0.04) were associated with increased early mortality. Oversized graft tended to be correlated to a higher mortality (p = 0.07). CONCLUSION: LT for PPFE is associated with high post-operative morbi-mortality rates. Patients requiring high emergency lung transplantation with advanced disease, malnutrition, or critical clinical status experienced worse outcomes. GOV IDENTIFIER: NCT05044390.

[Hamartochondroma: An unusual cause of endobronchial obstruction in smoking patients]. / L'hamartochondrome : cause inhabituelle d'obstacle endobronchique chez des patients fumeurs.

Endobronchial hamartochondroma is a rare benign tumor which differs from the parenchymal form in its symptomatology and also by its treatment which should be as conservative as possible. The endobronchial location is exceptional. Here we present the cases of two patients with endobronchial hamartochondroma associated with clinical manifestation, chest pain and repeated pulmonary infections, respectively. The diagnosis was made after performing a CT-scan, a PET-SCAN and histological analysis. After discussion in a multidisciplinary staff meeting, conservative treatment was chosen in both cases.

External validation of a risk score in the prediction of the mortality after esophagectomy for cancer.

This study was designed as an external evaluation of the Steyerberg score in the prediction of different categories of postoperative mortality after esophagectomy on a large nationwide database of thoracic surgeons. Data collection was obtained from the Epithor national database encompassing the majority of thoracic procedures performed in France. We retrospectively compared the predicted to the observed postoperative 30-day (30DM), 90-day (90DM) and in-hospital mortality (IHM) rate in each decile of equal patient. Patients included in the study were operated for an esophageal cancer and Gastroesophageal junction (GEJ). Steyerberg score was determined according to its logarithmic formula obtained from a sum score including age, comorbidities, neoadjuvant treatment and hospital volume. Deviation of observed from theoretically expected number of deaths was investigated using the calibration test of Hosmer-Lemeshow. Discrimination of the score was determined using the measure of the area under the receiver operating characteristic curve (AUC) of each category of mortality. Over a 9-year period, 1039 consecutive patients underwent an esophagectomy over 42 centers. Among them, 18 centers were considered as intermediate or high-volume institutions, and 24 were low-volume institutions. There were 841 males (81%) with a mean age of 62.3 ± 10 years. Preoperative treatment was allocated to 420 patients (40%). Numbers of comorbidity was: 1 in 261 patients (25%), 2 in 264 patients (25%), 3 in 383 patients (36%) and 4 in 5 patients (1%). The 30DM, 90DM and IHM rate were, respectively, 5.6%, 9.2% and 9.6%. The main causes of postoperative deaths were related to pulmonary complications (44%), complications of the gastric interposition (28%), cardiologic and thromboembolism events (10%). For 30DM, there were significant differences between predicted/observed mortalities in four deciles, whereas there was no significant difference for 90DM and for IHM. In term of calibration, there was a fair agreement of the Steyerberg score with observed 30DM. Predictions were above 20% for seven deciles. Calibration seemed more adequate for 90DM and for IHM. Predictions were above 20% for only three deciles but deviations were not significant. In terms of discrimination, for the 30DM the Steyerberg score overpredicted, the observed mortality rate and AUC was 0.64 (CI 95%: 0.57-0.71). For the 90DM, AUC indicated 0.63 (CI 95%: 0.57-0.68). For the IHM, AUC indicated 0.63 (CI 95%: 0.58-0.68). Steyerberg scoring system seems to be a moderate risk score of the prediction of the IHM and 90DM. This score appears to have a fair discrimination for the 30DM. Nevertheless, because of its simplicity, we believe that this simple predictive score is relevant and transportable to others institution performing such surgery for benchmarking purposes. A reappraisal of the score adapted to current surgical cohort is required.

Impact of donor-to-recipient weight ratio on survival after bilateral lung transplantation.

BACKGROUND: The aim of this study was to investigate the relationship between donor-to-recipient weight ratio and post-transplantation survival. METHODS: From February 1988 to November 2006, 255 adult bilateral lung transplantation patients from 2 different centers were retrospectively analyzed. The cohort was divided into 4 groups depending on the quartile ranges of the donor-to-recipient weight ratio. A time-to-event analysis was performed for risk of death after transplantation conditional on 5-year survival using Kaplan-Meier and Cox proportional hazards models. RESULTS: The mean weight ratio for the study cohort was 1.23 ± 0.39. For all lung transplant recipients during the study period, survival rate at 5 years was 58%. Median survival was 6.3 years in the cohort subgroup with weight ratio <1.23, whereas the median survival was 7.7 years for the cohort subgroup with weight ratio >1.23. Weight ratio >1.23 recipients had a significant survival advantage out to 5 years compared with weight ratio <1.23 recipients (66.1% vs 51.1%, P = .0126). With the aim to assess underweight and overweight donors vs recipients, we have divided all patients into 4 groups, from quartile 1 to 4, based on donor-to-recipient weight ratio. Weight ratio strata affected overall survival, with quartile 1 (lower weight ratio recipients) experiencing the lowest 5-year survival (39.1%), followed by quartile 2 (57.8%), quartile 4 (68.2%), and quartile 3 (70.3%) recipients. The effect of weight ratio strata on survival was statistically significant for the quartile 1 recipients (lower quartile) as compared with the 3 other quartiles. CONCLUSIONS: Our findings show a statistically significant effect of donor-to-recipient weight ratios on bilateral lung transplantation survival. A higher donor-to-recipient weight ratio was associated with improved survival after bilateral lung transplantation and likely reflects a mismatch between a relatively overweight donor vs recipient. In contrast, a lower donor-to-recipient ratio was associated with increased mortality after bilateral lung transplantation.

Pulmonary aspergilloma in a cavity formed after percutaneous radiofrequency ablation.

We report two cases of pulmonary aspergilloma (PA) in a cavity formed after percutaneous radiofrequency ablation (PRFA), a rare complication that has only been described once in the literature. The first patient was a 59-year-old white woman treated for a secondary lung nodule of an advanced hepatocellular carcinoma. One month after PRFA, a consolidation of a cavity was noticed with an "air crescent sign," and aspergilloma serology was highly positive. A bisegmentectomy was performed due to the proximity of the lesion to mediastinal vessels and the absence of significant regression after antifungal treatment. Histological examination confirmed the diagnosis of PA. The second patient was a 61-year-old white man followed-up for a non-small-cell lung cancer. A cavitation with thick margins in the ablation zone was noticed 6 months after PRFA. A biopsy was performed, and aspergilloma was diagnosed. Medical treatment with itraconazole was administered for 13 months, and there was significant regression.

[Place of traditional CBP in bipulmonary transplantation]. / Place de la CEC traditionnelle en transplantation bipulmonaire.

Initially double-lung transplantation (DLT) was performed with airway anastomosis at the tracheal bifurcation requiring a cardiopulmonary bypass (CBP). Complications related to ischemia of the bronchi and trachea around the carina prompted adoption of sequential single lung implantations as the method of choice for DLT. In different studies, CPB was associated with an increase in postoperative morbidity but this was probably due to the selection of more severe patients. Moreover, important progress in the technology of CPB has occurred. Therefore, the systematic use of CPB during sequential lung transplantation might have some interest by limiting the occurrence of ventilation and perfusion injuries. This article discusses the potential beneficial effects of CPB during double-lung transplantation.

Influence of gender donor-recipient combinations on survival after human lung transplantation.

BACKGROUND: In the current practice of lung transplantation, donor and recipient genders are neither directly considered nor matched. However, some data have suggested a possible effect of gender combinations on survival following lung transplantation. METHODS: A total of 249 adult lung transplant recipients at a single center between February 1988 and December 2008, were analyzed retrospectively for donor-recipient gender matching. We compared the mortality by calculating one-term survival rates after transplantation using the Kaplan-Meier method with comparisons using the log-rank (Mantel-Cox) test. Statistical significance of the mean effects of size matching was assessed by paired Student t tests and Wilcoxon signed rank tests. RESULTS: Kaplan-Meier survival analysis shown that male compared to female recipients did not have an effect on outcomes after lung transplantation at 5 years (P=.5379), 10 years (P=.107), 15 years (P=.0841), 20 years (P=.0711). No effect of gender on lung transplantation outcomes was observed with donor-recipient gender mismatches at 5 years (P=.1804), 10 years (P=.1457), 15 years (P=.0731), or 20 years (P=.0629). Similarly, no differences were observed for each gender combination. The degree of size matching was defined as the ratio of donor-to-recipient predicted total lung capacity. The ratios were similar for the donor-recipient gender match and significantly different for the donor-recipient gender mismatch. CONCLUSIONS: These analyses suggested that gender was not a significant independent risk factor affecting survival after lung transplantation. Size mismatch caused by gender mismatch did not increase mortality.

[Lung cancer in the elderly subject]. / Cancer bronchique du sujet âgé.

INTRODUCTION: In France, the average age for the diagnosis of bronchial carcinoma is 64. It is 76 in the population of over 70. In fact, its incidence increases with age linked intrinsic risk of developing a cancer and with general ageing of the population. Diagnosis tools are the same for elderlies than for younger patients, and positive diagnosis mainly depends on fibreoptic bronchoscopy, complications of which being comparable to those observed in younger patients. STATE OF THE ART: The assessment of dissemination has been modified in recent years by the availability of PET scanning which is increasingly becoming the examination of choice for preventing unnecessary surgical intervention, a fortiori in elderly subjects. Cerebral imaging by tomodensitometry and nuclear magnetic resonance should systematically be obtained before proposing chirurgical treatment. An assessment of the general state of health of the elderly subject is an essential step before the therapeutic decision is made. This depends on the concept of geriatric evaluation: Geriatric Multidimensional Assessment, and the Comprehensive Geriatric Assessment which concerns overall competence of the elderly. PERSPECTIVES: This is a global approach that allows precise definition and ranking of the patient's problems and their impact on daily life and social environment. Certain geriatric variables (IADL, BADL, MMSE, IMC etc) may be predictive of survival rates after chemotherapy or the incidence of complications following thoracic surgery. The main therapeutic principles for the management of bronchial carcinoma are applicable to the elderly subject; long term survival without relapse after surgical resection is independent of age. Whether the oncological strategy is curative or palliative, the elderly patient with bronchial carcinoma should receive supportive treatments. They should be integrated into a palliative programme if such is the case. In fact, age alone is not a factor that should detract from optimal oncological management. CONCLUSIONS: The development of an individual management programme for an elderly patient suffering from bronchial carcinoma should be based on the combination of oncological investigation and comprehensive geriatric assessment.

[Massive haemoptysis: management and treatment. What is the role of surgery?]. / L'hémoptysie massive: prise en charge et traitement. Quelle est la place de la chirurgie?

OBJECTIVE: To define the role of interventional radiology and surgery respectively, in the treatment of massive haemoptysis. GENERAL CONSIDERATIONS: For the management of massive haemoptysis in non-terminal pathologies an intensive care facility and a multi-disciplinary team are necessary. It is of paramount importance to identify rapidly the pulmonary or bronchial source of the bleeding. CT scanning and bronchoscopy are essential to localise the bleeding and determine its cause. Initial management. An attempt to control the initial bleeding to allow localisation of its origin and determine the treatment. TREATMENT: Bronchial or systemic embolisation and surgery are the only effective medium and long-term treatments. Embolisation achieves excellent results in bleeding from bronchial or parietal systemic arteries prior to surgery and may be the only technique possible in the presence of major co-morbidity. Surgery is necessary in the case of failure, in certain specific conditions, and in the case pulmonary artery haemorrhage from a proximal lesion. Various surgical techniques are available depending on the type of lesion encountered and the facilities for post-operative care. Emergency surgery carries a high risk and deferred surgery gives better results. CONCLUSION: The management of massive haemoptysis should be multi-disciplinary. Intensive care, respiratory and radiological diagnosis, Surgical management and interventional radiology should be combined to improve the prognosis of this grave condition. Pulmonary arterial haemorrhage from a necrotic tumour constitutes a surgical emergency and should be operated on without delay.

Liposarcoma of the pleural cavity. An exceptional tumour.

Primitive liposarcomas of the pleura are exceptional tumours. We report a new case of primitive liposarcoma of the pleura revealed by chest pains in a 50 year old man. Computed tomography showed a large fat density mass in the left pleural cavity. Surgical resection was performed, completed with adjuvant radiotherapy. Few reports are available in the literary world. We present our case, review previously reported cases and discuss treatment.

[Diagnostic and therapeutic value of lymphography in persistent postoperative chylothorax]. / Intérêt diagnostique et thérapeutique de la lymphographie dans un chylothorax postopératoire persistant.

Chylothorax is a rare but generally severe complication of surgery of congenital heart disease. The authors report the clinical history of a young boy with complex congenital heart disease operated on several occasions and who developed severe and recurrent unilateral chylothorac after a bicavo-bipulmonary derivation. Conservative treatment followed by continuous somatostatin infusion was ineffective. Diagnostic Lipiodol lymphography was required before the chylothorax was cured. The authors describe management of this difficult case and discuss the therapeutic possibilities with reference to a brief review of the literature.

[Plea in favour of external cervicotomy approach of Zenker's diverticulum: 73 cases reported]. / Plaidoyer pour un abord externe par cervicotomie du diverticule de Zenker: à propos de 73 cas.

INTRODUCTION: Zenker's diverticulum can be treated surgically or endoscopically. The aim of this study was to assess results of surgical approach with cervicotomy and diverticulectomy. PATIENTS AND METHODS: We retrospectively studied the data of 73 patients (50 men and 23 women; mean age, 69 ans; extrêmes: 43-98) consecutively operated on for a Zenker's diverticulum between 1987 and 2000. Surgical procedure included diverticulectomy associated with a large myotomy and oesophageal calibration. Both early and long-term results were compared with those of published series of patients treated by stapled esophagodiverticulostomy. RESULTS: Clinical manifestations were: dysphagia (97%), regurgitations (76%), aspirations (45%), weight loss (28%), lung infection (21%), or halitosis (3%). No patient died postoperatively. The early morbidity rate was 4% (3 patients). The mean delay for return of oral feeding and the mean length of hospital stay were respectively 6 and 8 days. At follow-up (mean follow-up, 6 years; extremes: 3 months-13 years), 72 patients (99%) were satisfied and 1 patient felt partially improved. Analysis of published results of series of endoscopic treatment revealed shorter lengths of hospital stay but less favourable long-term results. CONCLUSIONS: Early morbidity of surgical treatment of Zenker's diverticulum is low. Long term functional results could be better after surgical diverticulectomy with myotomy than after endoscopic stapled esophagodiverticulostomy.

Diffusion of oral and intravenous 400 mg once-daily moxifloxacin into lung tissue at pharmacokinetic steady-state.

The degree of penetration of an antibiotic into the infection site is an important factor for its therapeutic efficacy, particularly in respiratory tract infections. In the present study, we examined the lung tissue diffusion of moxifloxacin at a dose of 400 mg administered intravenously or orally once-daily, and the results were correlated to microbiological data to estimate the clinical efficacy of moxifloxacin in lower community-acquired respiratory infections. This was a prospective, randomized, parallel-group trial, open-label, single-center study. Patients undergoing lung surgery for bronchial cancer which necessitates the removal of an anatomical piece of lung tissue were randomized into twelve treatment groups, dependent upon the time of surgery and the moxifloxacin formulation, i.v. or oral, administered. During surgery, one blood sample was taken at the time of tissue collection to determine moxifloxacin plasma concentration. At the same time, tissue samples were taken by pulmonary exeresis. A validated new high performance liquid chromatography assay was used to determine moxifloxacin concentrations in plasma and lung tissue. A total of 49 patients (25 for i.v. administration, 24 for oral administration, 44 men and 5 women, mean age, 61 years, mean body weight, 72 kg, mean creatinine clearance was 84 ml/min/1.73 m2) were enrolled. The mean +/- SD steady-state moxifloxacin ratios between lung and plasma concentrations were respectively: 3.53 +/- 1.89 and 4.36 +/- 1.48 for i.v. and oral administration. The mean steady-state moxifloxacin maximal lung concentrations (Cmax) were respectively 12.37 microg/g and 16.21 microg/g for i.v. and oral administration. Moxifloxacin both intravenously and orally exhibits high penetration in lung tissue, with tissue concentrations far above the MIC90s for most of the susceptible pathogens commonly involved, thus underlining its suitability for the treatment of community-acquired, lower respiratory tract infections.

Detection of circulating cells expressing chromogranin A gene transcripts in patients with lung neuroendocrine carcinoma.

High grade lung neuroendocrine carcinomas, like small and large cell neuroendocrine carcinomas, pose therapeutic problems. Most initially respond to chemotherapeutic agents, but early relapses are frequent and are resistant to the presently available treatments. Our study reports for the first time the development and evaluation of a test for detecting the presence of circulating tumour cells by measuring chromogranin A gene transcripts with reverse transcriptase-polymerase chain reaction (RT-PCR) and Southern blotting. The test is specific and sensitive (detection of 10 cancer cells/ml blood), and only minimally invasive. Positivity is statistically correlated to high grade neuroendocrine carcinomas and to a poor prognosis with a 3-fold higher lethal risk. The test now needs to be assessed for its usefulness as a tool in the initial staging procedures and follow-up by comparison with the recent immunoradiometric assay (RIA) for detection of chromogranin A in the serum.

[Thoracoplasty: the current role]. / La toracoplastica: il ruolo attuale.

The Authors report a retrospective analysis of 29 patients who underwent thoracoplasty between 1990 and 1999. The mean follow-up period was 30 months. The median age was 55 years. The peri-operative mortality rate was 6.8%. The control of space obliteration, space infection and closure of the bronchopleural fistula was achieved in 27 patients. This article also discusses surgical history of thoracoplasty, technique adopted and its current application.

[Solitary fibrous thoracic tumor: a rare tumor with unpredictable course]. / Tumeur fibreuse solitaire de la plèvre.

A 68-year-old woman presented chest pain and exercise-induced dypnea for one year. Diagnosis was a thoracic solitary fibrous tumor. These tumors are very rare. Clinical outcome is generally good except in 13% of the cases with a malignant component. Complete surgical resection is required.

Infected mediastinitis secondary to perforation of superior vena cava by a central venous catheter.

We describe the first case of infected mediastinitis associated with central venous catheter insertion. The rare occurrence of this complication may be explained by the fact that it results from central venous catheter-related bloodstream infection and catheter perforation of superior vena cava. The symptoms of this complication (chest pain, dyspnoea) are not specific. Diagnosis should be confirmed by chest x-ray and computerized tomography which show hydromediastinum and pleural effusion. Removal and subsequent culture of the catheter tip will confirm infection. Appropriate antibiotic therapy, guided by sensitivities of the cultured organisms, should be commenced. Any pleural effusion should be drained by thoracocentesis, and the pleural fluid cultured. In case of fever, bacteraemia or shock, a thoracotomy to drain mediastinal and pleural effusions may be considered.

[Mortality from iatrogenic esophageal perforations is high: experience of 54 treated cases]. / La mortalité des perforations instrumentales de l'oesophage est élevée: expérience de 54 cas traités.

OBJECTIVE: To underline the severity of instrumental esophageal perforations and to discuss their management. PATIENTS AND METHODS: Data from patients treated for instrumental esophageal perforation were collected retrospectively from 1980 to 1995 then prospectively since 1995 to 2000. RESULTS: Fifty-four patients were treated for instrumental perforations. Perforation occurred after exploratory endoscopy (n = 24), endoscopic dilation (n = 13), attempted tracheal intubation (n = 5), foreign body extraction (n = 5), treatment of esophageal varices (n = 4), trans-esophageal echocardiography (n = 2), and duodenal prosthesis implantation (n = 1). Clinical manifestations were immediate in 18 cases and delayed in all others, with an interval before treatment ranging from 2 hours to 45 days (mean = 70 hours). All patients were operated after large spectrum antibiotherapy and intensive care, except 3 who were treated medically due to their poor general condition. Fourteen (26%) patients died, including the 3 non-operated ones. CONCLUSION: Instrumental esophageal perforations are associated with a high mortality, probably due to the poor general condition of the patients. Diagnosis of these perforations is often delayed. A good experience of endoscopic maneuveurs and adequate post-endoscopic monitoring could allow earlier surgical treatment with lower mortality.