Three-dimensional computed tomography angiography of the pulmonary veins and their anatomical variations: involvement in video-assisted thoracoscopic surgery-lobectomy for lung cancer.

BACKGROUND: Identification and section of pulmonary veins are an essential part of anatomical pulmonary resections. Intraoperative misunderstandings of pulmonary venous anatomy can lead to serious complications such as bleeding and delayed lung infarction or necrosis. We evaluated principally the rate of pulmonary veno-us anatomical variations, and secondarily the reliability and clinical outcomes of a preoperative morphological analysis. MATERIALS AND METHODS: Between November 2012 and October 2013, we studied 100 consecutive patients with highly suspected or diagnosed stage I-II primitive lung cancer lesion. The surgical procedure initially retained was video-assisted thoracoscopic surgery (VATS) pulmonary resections and we studied preoperatively the proximal pulmonary venous anatomy using 64 channels multi- -detector computed tomography (CT)-scan angiography to describe the venous anatomical variations. RESULTS: There were 65 men and 35 women with a mean age of 63 years. A pulmonary venous anatomical variation was present in 36 (36%) patients, and right-sided anatomical variations were more frequent than on left-sided ones (25% vs. 11%). The most frequent variation encountered on the right side was the existence of three separate pulmonary veins (16%), and on the left side a single pulmonary vein (8%). Surgical conversion occurred in 21% and we didn't experience a pulmonary venous lesion (0%) or a post-operative lung infarction (0%). CONCLUSIONS: We described pulmonary venous anatomical variations and their frequency. Anatomical variations exist and preoperative assessment of pulmo-nary venous anatomy using CT scan is a useful tool in VATS lobectomy to avoid unnecessary extension of pulmonary resections or iatrogenic complications in lung cancer surgery.

Change of paradigm in thoracic radionecrosis management.

Classically, muscular or omental flaps are the gold standard in the management of thoracic defects following radionecrosis debridement. Their vascular supply and antibacterial property was supposed to enhance healing compared with cutaneous flaps. The evolution of reconstructive surgery allowed us to challenge this dogma. Therefore, we present five consecutive cases of thoracic radionecrosis reconstructed with cutaneous perforator flaps. In four patients, we performed a free deep inferior epigastric perforator (DIEP) flap and one patient had a thoracodorsal perforator (TDAP) flap. Median time healing was 22.6 days with satisfactory cutaneous covering and good aesthetic results. There were no flap necrosis, no donor site complications. We believe that perforator flaps are a new alternative, reliable and elegant option that questions the dogma of muscular flaps in the management of thoracic radionecrosis.

Lack of involvement of type 7 phosphodiesterase in an experimental model of asthma.

Type 7 phosphodiesterases (PDE7) are responsible for the decrease of intracellular cyclic AMP (cAMP) in many cells involved in allergic asthma by suppressing their potential to respond to many activating stimuli. The elevation of intracellular cAMP has been associated with immunosuppressive and anti-inflammatory activities and represents a potential treatment of asthma. Our aim was to evaluate the impact of the deletion of the murine phosphodiesterase (PDE)7B gene and then to evaluate the efficacy of a newly described selective PDE7A and -B inhibitor on an ovalbumin (OVA)-induced airway inflammation and airway hyperreactivity (AHR) model in mice. Inflammation was determined 72 h after single OVA challenge or 24 h after multiple challenges by the relative cell influx and cytokine content in bronchoalveolar lavage fluid. AHR and immunoglobulin E levels in serum were determined after multiple challenges. For the first time, we have demonstrated that the deletion of the PDE7B gene or the pharmacological inhibition of PDE7A and -B had no effect on all the parameters looked at in this model. These results highlight the absence of any implication of the PDE7 enzyme in our model.

Predictive factors for the participation of general practitioners in lung cancer screening by low-dose CT scan in the Somme department in northern France.

INTRODUCTION: A study on lung cancer screening using low-dose computed tomography (DEP KP80) was conducted in the Somme department in northern France between May 2016 and December 2018. We conducted a cross-sectional survey of family physicians in that department to identify potential predictive factors for their participation in this pilot study. METHODS: A survey questionnaire was sent to the 545 general practitioners (GPs) of the Somme department. This survey rendered it possible to identify the investigators who were active in the DEP KP80 study. The questionnaire's content was focused on the socio-demographic conditions of GPs, their professional practices, and their medical practice situations. RESULTS: The response rate was 38% (206 completed questionnaires). Active investigators in DEP KP80 accounted for 55% (n=113) of the GPs surveyed, and non-investigators for 45% (n=93). Age, gender, or medical practice situation were not related to the active GPs' participation in DEP KP80. A multivariate analysis revealed that two factors were correlated with active participation in organized screening: (1) prescription of nicotine replacement therapy; (2) smoking history of the GP. CONCLUSIONS: Securing the active involvement of family physicians and of the French regional cancer screening coordination centers seems essential for the future organization of lung cancer screening on a regional or national level. Our results demonstrate that incorporating smoking cessation support structures into the program would maximize the mechanism's potential.

[Esophageal perforation during nasogastric tube insertion in a patient with right-sided aortic arch and thoracic aorta. Pathophysiology and surgical implications]. / Perforation oesophagienne par sonde nasogastrique avec arc aortique droit et aorte descendante à droite. Physiopathologie et particularités chirurgicales.

Esophageal perforation during nasogastric tube insertion is a very unusual occurrence. In this case report, radiologic images revealed a right-sided aortic arch with a right-sided thoracic aorta. This anatomical anomaly probably contributed to the complication and necessitated a modified approach to the surgical repair.

[Esophageal perforation during nasogastric tube insertion in a patient with right-sided aortic arch and thoracic aorta. Pathophysiology and surgical implications]. / Perforation oesophagienne par sonde nasogastrique avec arc aortique droit et aorte descendante à droite. Physiopathologie et particularités chirurgicales.

Esophageal perforation during nasogastric tube insertion is a very unusual occurrence. In this case report, radiologic images revealed a right-sided aortic arch with a right-sided thoracic aorta. This anatomical anomaly probably contributed to the complication and necessitated a modified approach to the surgical repair.

Value of cancer antigen 125 for diagnosis of pleural endometriosis in females with recurrent pneumothorax.

The thorax is the most frequent extrapelvic location of endometriosis. Thoracic endometriosis is probably responsible for the high rate of recurrent pneumothoraces in females. The goal of the present prospective study was to assess the value of cancer antigen (CA)125 measurement in the detection of endometriosis in order to further enable early and adequate treatment of catamenial pneumothorax. Between January 2004 and March 2006, 31 females (mean age 32 yrs) underwent pneumothorax surgery. The control group comprised 17 males (mean age 27 yrs), who underwent videothoracoscopic pleural abrasion. Serum CA125 was measured around a menstrual period in females and before surgery in males. Videothoracoscopically diagnosed endometriosis occurred in 29% of females. The CA125 concentration was significantly higher in females with endometriosis compared to disease-free females (76.1 versus 16 U x mL(-1)). The mean value in males was similar to that observed in disease-free females. The frequency of thoracic endometriosis-related pneumothorax corresponds to, on average, a third of females presenting with recurrent pneumothorax. Early detection can be achieved with serum cancer antigen 125 measurement and may be helpful in indicating videothoracoscopic surgery.

[Pulmonary malignant superior vena cava obstruction: endovascular stent therapy]. / Obstruction cave supérieure par cancer bronchopulmonaire : traitement endovasculaire par stent.

MATERIALS AND METHODS: Thirty-one patients underwent stent placement between June 1998 and October 2006 for superior vena cava obstruction. The initial effectiveness of the metallic stent therapy and the follow-up results were studied at one, six and 12 months. PURPOSE: We retrospectively studied the utility of metallic stent placement for the treatment of malignant superior vena cava obstruction in 31 patients (SVCO) on the basis of long-term follow-up data. RESULTS: The initial clinical success rate was 100% (31 out of 31), the primary clinical patency rate was 93% (26 out of 28) at six months. The obstruction rate of the stent was 7% (two out of 28) at six months. There was no additional stent used for recurrence. At 12 months, 27 out of 31 patients were deceased in whom there was no recurrence of SVCO until death. CONCLUSION: Stent therapy is an effective treatment for SVCO. Adjuvant therapy must to be evaluated in association with stent therapy.

[Endobronchial ultrasound with transbronchial needle aspiration: Evaluation of clinical practice]. / Échobronchoscopie avec ponction transbronchique à l'aiguille : évaluation des pratiques.

INTRODUCTION: Endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) has undergone a large increase in France since 2007. The aim is to study the evolution of the indications for EBUS-TBNA in our region during the period 2008-2013. MATERIAL AND METHODS: We conducted a retrospective observational study including all the patients who underwent an EBUS-TBNA procedure in Picardie from 2008 to 2013. The respective proportion for each indication was noted. RESULTS: During the study period, 1036 EBUS-TBNA procedures were performed with a continuous increase in number (86 in 2008 versus 275 in 2013). We observed an increase in the proportion of procedures performed for a suspected diagnosis of sarcoidosis (OR=1.31; IC 95% [1.09-1.58]; P=0.005) and for the simultaneous diagnosis and staging of lung cancer (OR=1.12; IC 95% [1.02-1.24]; P=0.022). For the diagnosis of sarcoidosis, we observed an improvement in the diagnostic yield between the periods [2008-2010] and [2011-2013] (42.9% versus 72.5%). CONCLUSION: A continuous increase in the number of EBUS-TBNA procedures was observed during the period 2008-2013. It was associated with a modification in practice with an increased proportion of procedures performed for the diagnosis of sarcoidosis.

[Lung cancer before 40 years and after 80 years: surgical aspects]. / Cancer du poumon avant 40 ans et après 80 ans.

Lung cancer rarely affects patients at the extreme ages of life. However, changes in epidemiology and therapy led us to review characteristics of both these younger and older populations. We retrospectively reviewed epidemiologic, clinical and pathological characteristics of patients aged 40 years or less (group 1, n=113) and 80 years or more (group 2, n=78) who underwent surgery between 1983 and 2003. Carcinoid tumors were more frequent in the group 1 (n=59 vs 5). Non small cell lung cancer (NSCLC) occurrence rates decreased with time in group 1, whereas increasing rates were observed in group 2 (p=0.0017). Concomitant diseases were significantly more frequent in group 2. The pneumonectomy rates of non small cell lung cancer were the same in each group (group 1, 35.5%; group 2, 34.8%). Five-year survival rates were better in group 1 (58.9% vs 30%, p=0.0048). No 5-year survival was observed for N2 disease in group 2 and mortality unrelated to cancer was more frequent in this group. Otherwise, both groups were similar except for higher rates of adenocarcinomas in group 1. Lung cancer is more and more frequent in the octogenarians. Surgery remains the best treatment in this population except in case of stage III due to N2 involvement.

[Mediastinitis after endobronchial ultrasound-guided transbronchial needle aspiration]. / Médiastinite secondaire à une ponction transbronchique échoguidée à l'aiguille : étiologie et prise en charge.

INTRODUCTION: Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure used for the diagnosis of mediastinal and hilar lymphadenopathy. OBSERVATION: We describe a case of mediastinitis appearing 15 days after an EBUS-TBNA procedure in a 79 years old male patient. The mediastinitis was treated surgically by thoracotomy with a wide excision of infected tissue requiring transplantation of a serratus anterior muscle flap pedicled on a branch of the thoracodorsal artery. It was coupled with broad spectrum antibiotics. This medico-surgical management led to a favorable outcome. Microbiological analysis of the mediastinal collections revealed two pathogens: Streptococcus constellatus (a germ present in the normal flora of the oral cavity) and Mycobacterium tuberculosis. A standard first line quadruple antituberculous drug regimen was subsequently given to the patient. CONCLUSION: This episode of Streptococcus constellatus mediastinitis was a complication of the EBUS-TBNA procedure. The operating channel of the bronchoscope had probably been contaminated when aspirating the oral cavity secretions with subsequent needle contamination and a direct bacterial inoculation during the transbronchial mediastinal puncture. The severity of such a complication justifies a medical consultation in cases of fever or chest pain following an EBUS-TBNA procedure.

[Lung cancer screening with low-dose thoracic CT-scan in the Somme area]. / Dépistage des cancers bronchopulmonaires par tomodensitométrie thoracique à faible dose dans la Somme.

RATIONALE: This feasibility trial proposes to set up in the department of the Somme an annual screening for lung cancer with low-dose thoracic CT. It responds to the first objective of the third cancer plan and follows the publication of the results of the National Lung Screening Trial in 2011. METHODS: The method of this study is to use the existing networks among and between healthcare professionals and the departmental cancer screening structure. The inclusion criteria will be those of the National Lung Screening Trial. Screening will be proposed by treating physicians and chest physicians. The CT-scan will be performed in radiological centers that adhere to the good practice charter for low radiation scanning. A copy of CT results will be sent to the departmental structure of cancer screening (ADEMA80) which will ensure traceability and will perform statistical analysis. The study received funding from the Agence régionale de santé de la Picardie and la ligue contre le cancer. EXPECTED RESULTS: The primary endpoints of this screening will be the number of cancers diagnosed and the survival of the patients. The follow-up of positive examinations, delays in management and the level of participation will also be assessed.

[Effectiveness of erlotinib in Critical Care Unit in patients with non-small cell lung cancer with EGFR mutation]. / Efficacité de l'erlotinib en réanimation chez les patients présentant un cancer bronchique non à petites cellules avec une mutation de l'EGFR.

INTRODUCTION: The search for mutations epidermal growth factor receptor (EGFR) has changed the therapeutic approach and prognosis of non-small cell lung cancer (NSCLC). The effectiveness of tyrosine kinase inhibitors (TKI) has been demonstrated orally in patients with EGFR mutation. We report the case of a patient for whom treatment with TKI was started effectively in a Critical Care Unit. OBSERVATION: A patient of 59 years is followed for a stage IV lung adenocarcinoma with metastases in liver, brain, adrenal, lung and pleura. After a first course of chemotherapy (cisplatin-gemcitabine), the patient presents a multi-factorial acute respiratory distress. Due to an EGFR mutation, transfer to intensive care is decided then orotracheal intubation with mechanical ventilation. It is decided to initiate treatment with erlotinib via nasogastric tube. The evolution will be marked by a tumor response leading to a favorable issue. CONCLUSIONS: This case shows the value of initiate TKI despite hospitalization in Intensive Care Unit and highlights the question of the transfer in ICU patients with EGFR mutation.

[Early stages of non small cell lung cancer (I. II. IIIA). What is the best therapeutic strategy?]. / CBNPC de stades précoces (I. II. IIIA). Quelle est la meilleure stratégie thérapeutique?

NSCLC early stages (I, II, IIIA) may be offered surgery, but the possibilities of resection and cure are decreasing with increasing stages. Surgery may be part of combined therapeutic strategies: it can be sufficient, or benefit neo-adjuvant modalities. Post-operative risk of death is acceptable, but rates following right pneumonectomy are important, and appear favored by neo-adjuvant chemotherapy. However, in case of down-staging, neo-adjuvant chemotherapy offers a better prognosis and can limit the extent of the resection, which may prove beneficial especially for the right side. Surgery is diagnostic and therapeutic in 45% of patients. So neo-adjuvant chemotherapy is theorically available in 55%, but finally remains performed in 40% of these patients (mainly stage IIIA). Randomized trials demonstrated a beneficial effect in case of early NSCLC stages. The improvement is certain for stage II concerning both the quality of resection and the survival. In case of NSCLC stage I, neo-adjuvant chemotherapy is still a matter of debate.

[Lung cancer in women: surgical aspects related to gender]. / Cancer du poumon chez la femme: aspects chirurgicaux liés au sexe.

INTRODUCTION: Lung cancer is becoming more and more common in women where it presents significant differences at both clinical and therapeutic levels. Our purpose was to study those associated with surgical treatment. PATIENTS AND METHODS: 2972 patients were operated on between 1984 and 2002: 2480 men and 492 women. These two populations were compared (age, past history, investigations, interventions, TNM stage, long term survival and causes of death). RESULTS: The number of women increased with time; they were younger than the men, smoked less, had the same past history of cancer but less past medical history, and comorbidity. They underwent less pneumonectomies and had a lower postoperative mortality. Tumour size was smaller (39.5 vs 43.5cm, p=0.0001); N0 and stage I tumours were more frequent (52.6% vs 46% p=0.0074). Long term survival was better (48.6% vs 43.1%, p=0.016), particularly in stage I and with a past history of cancer. It was identical in stage III despite a higher incidence of multisite N2 disease. Smoking and adenocarcinoma were more frequent before the menopause and N2 prognosis deteriorated with age. CONCLUSION: These results confirm characteristics peculiar to lung cancer in women and warrant further investigation aimed at their better understanding. However, in multivariate analysis gender does not appear to be an independent prognostic factor.

[Surgical diagnosis of pleural disease]. / Le diagnostic chirurgical en pathologie pleurale.

Videothoracoscopy is a minimally invasive techinique providing a direct view of the pleural cavity. It enables complete exploration of the cavity with biopsies of pathological zones. The indication, based on clinical or radiographic findings, is retained when less invasive methods have been unable to establish the diagnosis and a specific pleural disease (tumor or other) is suspected. Depending on the observations at videothoracoscopy and the suspected disease, deep biopsies to the subpleural fat can be made with a forceps if nodules have been identified. If the pleura is uniformly thin, a small flap can be detached for the biopsy. Several pleura sites are biopsied and a direct pathology examination can be performed on certain specimens. Videothoracoscopy enables careful hemostasis of biopsied zones and symphysis (generally with talc) if needed. The perioperative mortality is low (<0.5%) with good sensitivity greater than 90% and excellent specificity at 100%. The presence of complete pleural symphysis counterindicates videothoracoscopy. In such patients, direct access via an intercostal incision is needed to obtain localized biopsies.

[Outpatient thoracic surgery: Evolution of the indications, current applications and limits]. / Chirurgie thoracique ambulatoire : évolution des indications, applications actuelles et limites.

The objectives of outpatient surgery are to reduce the risks connected to hospitalization, to improve postoperative recovery and to decrease the health costs. Few studies have been performed in the field of thoracic surgery and there remains great scope for progress in outpatient lung surgery. The purpose of this article is to present a revue of the current situation and the prospects for the development of out patient thoracic surgery.

[Results of endobronchial ultrasound-guided transbronchial needle aspiration in lung cancer: importance of the lymph node involvement prevalence]. / Résultats des ponctions ganglionnaires transbronchiques sous contrôle d'une écho-endoscopie bronchique: importance de la prévalence.

OBJECTIVE: We studied the non-surgical invasive staging by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and we detailed the differences of our series, in order to understand the criteria allowing to achieve a better performance. METHODS: Retrospective observational study conducted between 2007 and 2011, including all patients with proven NSCLC who underwent EBUS-TBNA. RESULTS: For the 92 EBUS-TBNA performed, we found a sensitivity of 78%, a specificity of 93%, a positive predictive value (PPV) of 98%, a negative predictive value (NPV) of 45%, an accuracy of 80% and a prevalence of lymph node involvement at 84%. A learning curve has been demonstrated and a significant difference was found based on the number of punctures by procedure (P=0.02) or on histological type (P=0.02). By analyzing the data of the literature, we have been able to demonstrate that the accuracy and the negative predictive value are correlated with the prevalence. If we take into account this correlation, we can consider the results of our study close to those of the literature. CONCLUSION: We highlighted a number of criteria that will influence the diagnostic yield of EBUS-TBNA. While some have already been described, other criteria such as histological type or patient selection criteria are less discussed. The key point is the correlation between the prevalence and EBUS-TBNA results. Results of the assessment of lymph node involvement techniques should be interpreted according to the prevalence of lymph node involvement.

Polyol-promoted adsorption of serum proteins to amphiphilic agarose-based adsorbents.

We tested the promotion of protein adsorption onto amphiphilic agarose-based adsorbents by addition of high concentrations of polyols during the adsorption phase. C3- to C5-polyols were inefficient in promoting protein adsorption, whereas some of the C6-polyols studied (sorbitol, dulcitol and mannitol) could promote serum protein adsorption onto mercaptomethylene pyridine-derivatized agarose, octyl- and phenyl-Sepharose. Sorbitol was the most potent protein adsorption promoter, with a direct relation between the amount of protein adsorbed and the concentration of sorbitol. For each chromatographic gel, the effects of increasing concentrations of sorbitol or sodium sulfate on protein adsorption were similar and two-dimensional electrophoresis revealed the preservation of the protein adsorption specificity whether sorbitol or sodium sulfate was used. These results show that a water-structuring salt or a polyol can promote protein adsorption in the same manner, presumably by a related mechanism.

Cyanocarbons as ligands for electron donor acceptor chromatography of human serum proteins.

The adsorption of human serum proteins to mono-, di- and tri-cyanocarbon ligands was studied in the presence of the water-structuring salt Na2SO4. All of the ligands adsorbed proteins to varying degrees when coupled to agarose via a divinylsulfone-derived spacer arm (DVS), whereas an insignificant or very low protein adsorption capacity occurred when the ligands were coupled through the bisoxirane-derived spacer arm. Studies of the DVS-coupled cyanocarbons showed that adsorption capacity increases with the number of cyano substituents carried by the ligand. The selectivity toward human serum proteins appeared to be similar to that of other electron acceptor ligands, but different from that of hydrophobic ligands. Tricyanoaminopropene-DVS-agarose was found to be the most potent protein adsorbent.