Outcomes after Contralateral Anatomic Surgical Resection in Multiple Lung Cancer.

BACKGROUND: Patients treated surgically for lung cancer may present synchronous or metachronous lung cancers. The aim of this study was to evaluate outcomes after a second contralateral anatomic surgical resection for lung cancer. METHODS: We performed a retrospective two-center study, based on a prospective indexed database. Included patients were treated surgically by bilateral anatomic surgical resection for a second primary lung cancer. We excluded nonanatomic resections, benign lesions, and ipsilateral second surgical resections. RESULTS: Between January 2011 and September 2018, 55 patients underwent contralateral anatomic surgical resections for lung cancer, mostly for metachronous cancers. The first surgical resection was a lobectomy in most cases (45 lobectomies: 81.8%, 9 segmentectomies: 16.4%, and 1 bilobectomy: 1.8%), and a video-assisted thoracic surgery (VATS) procedure was used in 23 cases (41.8%). The mean interval between the operations was 38 months, and lobectomy was less frequent for the second surgical resection (35 lobectomies: 63.6% and 20 segmentectomies: 36.4%), with VATS procedures performed in 41 cases (74.5%). Ninety-day mortality was 10.9% (n = 6), and 3-year survival was 77%. Risk factor analysis identified the number of resected segments during the second intervention or the total number of resected segments, extent of resection (lobectomy vs. segmentectomy), surgical approach (thoracotomy vs. VATS), tumor stage, and nodal involvement as potential prognostic factors for long-term survival. CONCLUSION: A second contralateral anatomic surgical resection for multiple primary lung cancer is possible, with a higher early mortality rate, but acceptable long-term survival, and should be indicated for carefully selected patients.

Usefulness of a routine endoscopic assessment of laryngeal lesions after lung cancer surgery.

BACKGROUND AND OBJECTIVE: Laryngeal pathology following lung cancer surgery is associated with post-operative morbidity and mortality. The aim of our study was to evaluate the usefulness of routine endoscopic assessment. METHODS: We prospectively evaluated vocal cord pathology using laryngeal endoscopy within 24 h post-surgery. Over 25 months, 276 patients underwent thoracic surgery. We excluded 26 patients with previous laryngectomy or vocal cord paralysis, early post-operative reintubation or patients who did not consent to an endoscopy. Endoscopic data were reported using a standardized procedure, recording vocal cord paralysis, swallowing disorders with aspiration, detected using a blue-coloured water test and vocal cord haematoma. RESULTS: Among 250 patients, vocal cord paralysis was diagnosed in 13 patients (5.2%) and was associated with a higher rate of post-operative pneumonia (P = 0.03), post-operative bronchoscopy (P = 0.01), reintubation (P = 0.007) and a trend towards an increased 90-day mortality rate (P = 0.09). Swallowing disorders with aspiration were diagnosed in 18 patients (7.2%) and were associated with a higher rate of post-operative pneumonia (P = 0.007), post-operative bronchoscopy (P = 0.01), reintubation (P = 0.004) and 90-day mortality (P = 0.03). Vocal cord haematomas were diagnosed in 28 patients (11.2%) and were not associated with an increased post-operative morbidity or mortality. CONCLUSION: Post-operative endoscopic laryngeal assessment is effective for diagnosing laryngeal pathology following thoracic surgery. Routine laryngeal endoscopic assessment may detect clinically silent swallowing disorders early to allow prompt treatment, which may prevent respiratory complications.

Lymphatic drainage of lung segments in the visceral pleura: a cadaveric study.

PURPOSE: Although peribronchial lymphatic drainage of the lung has been well characterized, lymphatic drainage in the visceral pleura is less well understood. The objective of the present study was to evaluate the lymphatic drainage of lung segments in the visceral pleura. METHODS: Adult, European cadavers were examined. Cadavers with a history of pleural or pulmonary disease were excluded. The cadavers had been refrigerated but not embalmed. The lungs were surgically removed and re-warmed. Blue dye was injected into the subpleural area and into the first draining visceral pleural lymphatic vessel of each lung segment. RESULTS: Twenty-one cadavers (7 males and 14 females; mean age 80.9 years) were dissected an average of 9.8 day postmortem. A total of 380 dye injections (in 95 lobes) were performed. Lymphatic drainage of the visceral pleura followed a segmental pathway in 44.2% of the injections (n = 168) and an intersegmental pathway in 55.8% (n = 212). Drainage was found to be both intersegmental and interlobar in 2.6% of the injections (n = 10). Lymphatic drainage in the visceral pleura followed an intersegmental pathway in 22.8% (n = 13) of right upper lobe injections, 57.9% (n = 22) of right middle lobe injections, 83.3% (n = 75) of right lower lobe injections, 21% (n = 21) of left upper lobe injections, and 85.3% (n = 81) of left lower lobe injections. CONCLUSION: In the lung, lymphatic drainage in the visceral pleura appears to be more intersegmental than the peribronchial pathway is-especially in the lower lobes. The involvement of intersegmental lymphatic drainage in the visceral pleura should now be evaluated during pulmonary resections (and especially sub-lobar resections) for lung cancer.

Three-dimensional CT angiography of anatomic variations in the pulmonary arterial tree.

PURPOSE: Anatomic variations of the pulmonary arterial tree can cause technical difficulties during pulmonary lobectomy in general and video-assisted thoracic surgery (VATS). Using CT angiography and 3D reconstruction, we sought to identify anatomic variations of the pulmonary arterial tree and assess their respective frequencies. METHODS: We retrospectively studied 88 pulmonary arterial trees in 44 patients having undergone VATS lobectomy for lung cancer over an 18-month period in Amiens University Hospital's Department of Thoracic Surgery. Each CT angiography with 3D reconstruction of the pulmonary arterial tree was performed by two experienced operators, according to a standardized procedure. RESULTS: On the right side, the upper lobe was supplied with blood by a mediastinal artery in 100% of cases and by one or more fissural arteries in 88.6%. The middle lobe was usually supplied by two arteries (54.5%). The upper segment of the right lower lobe was usually supplied by a single artery (90.9%). We identified 11 variations in the vasculature of the basal segments. On the left side, the upper lobe was supplied by four arteries in 50% of cases, three culminal arteries (50%), and a fissural lingular artery (77.3%). The upper segment of the left lower lobe was usually supplied by a single artery (65.9%). We identified 15 anatomic variations in the vasculature of the basal segments. We observed that the origin of the apical artery of the right lower lobe was proximal to the origin of the middle lobe artery in 38.6% of cases. The origin of the apical artery of the left lower lobe artery was proximal to the origin of the lingular fissural artery in 65.9% of cases. CONCLUSION: The findings of the present CT angiography/3D reconstruction study agreed with the reference works on the anatomy of the pulmonary arterial tree and defined the frequency of anatomic variations. It is essential to assess the anatomy of the pulmonary arterial tree before VATS lobectomy.

GLUT1: A novel tool reflecting proliferative activity of lung neuroendocrine tumors?

Lung neuroendocrine tumors (LNT) represents approximately 20% of all lung cancers. The classification of LNT relies upon morphology. Recently, in the World Health Organization (WHO) classification, Ki-67 rate has been proposed for classification. It is, however, known that Ki-67 count has a poor interlaboratory reproducibly. For that reason, our team has looked for a new biomarker. GLUT1 protein a facilitative glucose transporter protein which has ubiquitous expression in mammalian. GLUT1 is overexpressed in many human cancers. But, no study has evaluated the GLUT1 staining as an aid diagnosis in LNT. Our team have assessed the GLUT1 immunohistochemical staining in 36 LNT and to assess its diagnostic value. GLUT1 staining was higher in neuroendocrine carcinoma than in carcinoid tumor. A positive predictive value in a priori and posteriori testing for diagnosis of LNT is demonstrated. GLUT1 staining could aid in the diagnosis and should be validated in a large prospective cohort.

Diagnostic value of systematic bronchial aspirate on postoperative pneumonia after pulmonary resection surgery for lung cancer: a monocentre retrospective study.

OBJECTIVES: Intraoperative bacterial airway colonization seems to be associated with an increased risk of postoperative pneumonia (POP). It can be easily assessed by performing a bronchial aspirate (BA). The objective of this study is to assess the diagnostic performance of the BA to predict POP. METHODS: We conducted a single-centre retrospective observational study over a period of 10 years, from 1 January 2011 to 30 December 2020. The population study included patients admitted for a scheduled pulmonary resection surgery for lung cancer. Patients were classified into 2 populations depending on whether or not they developed a POP. Uni- and multivariable analyses were performed to identify risk factors for developing POP. The diagnostic performance of BA was represented by its sensitivity, specificity and positive and negative predictive values. RESULTS: A total of 1006 patients were included in the study. Uni- and multivariable analyses found that a positive BA was independently associated with a greater risk of developing POP with an odds ratio of 6.57 [4.165-10.865]; P < 0.001. Its specificity was 95%, sensitivity was 31%, positive predictive value was 66% and negative predictive value was 81%. CONCLUSIONS: A positive intraoperative BA is an independent risk factor for POP after lung cancer surgery. Further trials are required to validate the systematic implementation of BA as an early diagnostic tool for POP.

Successful removal of an intra-pericardic Kirschner wire via fluoroscopy-guided minimal invasive approach: a case report.

BACKGROUND: Kirschner wires are widely used in trauma surgery. Their migration into the pericardium is a rare but often fatal phenomenon, requiring urgent management. CASE PRESENTATION: We describe the case of a 65-year-old patient who underwent Kirschner wire placement to treat a humeral head fracture. Three months after the operation, pleural and pericardial effusions with cardiac tamponade were observed, leading to the diagnosis of wire migration within the pericardium. A minimally invasive approach guided by fluoroscopy allowed emergency wire extraction without needing a median sternotomy. The postoperative clinical course was uncomplicated. CONCLUSIONS: The use of pre- and per-operative multimodal imaging allowed for the safe extraction of an intra-pericardial Kirschner wire through a minimally invasive approach.

Intraoperative dexamethasone is associated with a lower risk of respiratory failure in thoracic surgery: Observational cohort study (SURTHODEX).

BACKGROUND: Postoperative complications, particularly respiratory complications, are of significant clinical concern in patients undergoing elective thoracic surgery. Dexamethasone (DXM), commonly administered to prevent postoperative nausea and vomiting (PONV), has potential anti-inflammatory effects that might be beneficial in reducing these complications. We aimed to investigate whether intraoperative DXM administration could mitigate the occurrence of respiratory complications following elective thoracic surgery. METHODS: We conducted a single-center observational study, including patients who underwent elective thoracic surgery from 2012 to 2020. The primary outcome was the onset of acute respiratory failure within 7 days post-surgery. Secondary outcomes encompassed other postoperative complications, duration of hospital stay, and mortality within 30 days post-surgery. An overlap propensity score analysis was employed to estimate the treatment effect. RESULTS: We included 1,247 adult patients, 897 who received dexamethasone (DXM) and 350 who served as controls. Intraoperative dexamethasone administration was associated with a significant reduction in respiratory complications with an adjusted relative risk (RR) of 0.65 (95% CI: 0.43-0.97). There was also a significant decline in composite infectious criteria with an adjusted RR of 0.76 (95% CI: 0.63-0.93). Cardiac complications were also assessed as a composite criterion, and a significant reduction was observed (adjusted RR, 0.68; 95% CI, 0.51-0.9). However, there were no association with mechanical complications, mortality within 30 days (adjusted RR of 0.43, 95% CI: 0.17-1.09) or in the length of hospital stay (adjusted RR of 0.85, 95% CI: 0.71-1.02). CONCLUSIONS: Dexamethasone administration was associated with a reduction in postoperative respiratory complications. Further prospective studies are needed to confirm these findings.

S erratus anterior plane block alone, paravertebral block alone and their combination in video-assisted thoracoscopic surgery: the THORACOSOPIC double-blind, randomized trial.

OBJECTIVES: Serratus anterior plane block (SAPB) and paravertebral block (PVB) are well known to reduce pain levels after video-assisted thoracoscopic surgery (VATS). However, the relative efficacies of each block and a combination of the 2 have not been fully characterized. The objective of the present study was to assess the efficacy of PVB alone, SAPB alone and the combination of PVB and SAPB with regard to the occurrence and intensity of pain after VATS. METHODS: We conducted the THORACOSOPIC single-centre, double-blind, randomized trial in adult patients due to undergo elective VATS lung resection. The participants were randomized to PVB only, SAPB only and PVB + SAPB groups. The primary end-point was pain on coughing on admission to the postanaesthesia care unit. The secondary end-points were postoperative pain at rest and on coughing at other time points and the cumulative opioid consumption. Pain was scored on a visual analogue scale. RESULTS: One-hundred and fifty-six patients (52 in each group) were included. On admission to the postanaesthesia care unit, the 3 groups did not differ significantly with regard to the pain on coughing: the visual analogue scale score was 3 (0-6), 4 (0-8) and 2 (0-6) in the PVB, SAPB and PVB + SAPB groups, respectively (P = 0.204). During postoperative care, the overall pain score was significantly lower in the SABP + PVP group at rest and on cough. CONCLUSIONS: The combination of SABP + PVB could be beneficial for pain management in VATS in comparison to SABP or PVB alone.

Anatomic lung resection after immune checkpoint inhibitors for initially unresectable advanced-staged non-small cell lung cancer: a retrospective cohort analysis.

Background: Patients with initially unresectable advanced non-small cell lung cancer (NSCLC) might experience prolonged responses under immune checkpoint inhibitors (ICIs). In this setting, Multidisciplinary Tumor Board (MTB) seldomly suggest surgical resection of the primary tumor with the ultimate goal to eradicate macroscopic residual disease. Our objective was to report the perioperative outcomes of patients who underwent anatomic lung resection in these infrequent circumstances. Methods: We set a retrospective multicentric single arm study, including all patients with advanced-staged initially unresectable NSCLC (stage IIIB to IVB) who received systemic therapy including ICIs and eventually anatomical resection of the primary tumor in 10 French thoracic surgery units from January 2016 to December 2020. Coprimary endpoints were in-hospital mortality and morbidity. Secondary endpoints were the rate of complete resection of the pulmonary disease, major pathologic response, risk factors associated with post-operative complications, and overall survival. Results: Twenty-one patients (median age 64, female 62%) were included. Eighteen patients (86%) progressed after first line chemotherapy and received second line ICI. The median time between diagnosis and surgery was 22 months [interquartile range (IQR) 18-35 months]. Minimally-invasive approach was used in 10 cases (48%), with half of these requiring conversion to open thoracotomy. Nine patients (43%) presented early post-operative complications, and one patient died from broncho-pleural fistula one month after surgery. Rates of complete resection of the pulmonary disease and major pathologic response were 100% and 43%, respectively. In univariable analysis, diffusing capacity for carbon monoxide (DLCO) was the only factor associated with the occurrence of postoperative complications (P=0.027). After a median follow-up of 16.0 months after surgery (IQR, 12.0-30.0 months), 19 patients (90%) were still alive. Conclusions: Anatomic lung resections appear to be a reasonable option for initially unresectable advanced NSCLC experiencing prolonged response under ICIs. Nonetheless, minimally invasive techniques have a low applicability and post-operative complications remains higher in patients who had lower DLCO values. The late timing of surgery may also contribute to complications.

Patient risk factors for conversion during video-assisted thoracic surgery-the Epithor conversion score.

OBJECTIVES: Intraoperative conversion from video-assisted thoracic surgery (VATS) to thoracotomy may occur during anatomical lung resection. The objectives of the present study were to identify risk factors for intraoperative conversion and to develop a predictive score. METHODS: We performed a multicentre retrospective analysis of French thoracic surgery departments that contributed data on anatomical lung resections to the Epithor database over a 10-year period (from January-2010 to December-2019). Using univariate and multivariate logistic regression analyses, we determined risk factors for intraoperative conversion and elaborated the Epithor conversion score (ECS). The ECS was then validated in a cohort of patients operated on between January- and June-2020. RESULTS: From January-2010 to December-2019, 210,037 patients had been registered in the Epithor database. Of these, 55,030 had undergone anatomical lung resection. We excluded patients who had upfront a thoracotomy or robotic-assisted thoracoscopic surgery (n = 40,293) and those with missing data (6,794). Hence, 7943 patients with intent-to-treat VATS were assessed: 7100 with a full VATS procedure and 843 patients with intraoperative conversion to thoracotomy (conversion rate: 10.6%). Thirteen potential risk factors were identified among patients' preoperative characteristics and planned surgical procedures and were weighted accordingly to give the ECS. The score showed acceptable discriminatory power (area under the curve: 0.62 in the development cohort and 0.64 in the validation cohort) and good calibration (P = 0.23 in the development cohort and 0.30 in the validation cohort). CONCLUSIONS: Thirteen potential preoperative risk factors were identified, enabling us to develop and validate the ECS-an easy-to-use, reproducible tool for estimating the risk of intraoperative conversion during VATS.

Epidemiological impact of lung cancer screening by low dose CT scan in the French Department of the SOMME.

CONTEXT: Lung cancer is the leading cause of cancer death worldwide. In recent years, screening using low-dose CT scan has shown a reduction in lung cancer-related mortality and in all-cause mortality. The DEP KP80 study was implemented in the French department of the Somme with the aim of investigating lung cancer screening in practice. The results of the first round showed a prevalence of 2.7% for lung cancer, with the majority at localized stages (77%). The primary objective of our study was to compare the stage at diagnosis of patients with lung cancer screened as part of DEP KP80 and those who were not screened. The secondary objectives were to describe the epidemiological characteristics of lung cancer in the French department of the Somme for the period in question and to compare survival rates in screened and unscreened patients. METHODS: This retrospective cohort study compared from May 2016 to December 2017 the characteristics of patients with lung cancer screened as part of DEP KP80 and those who were not screened, using data from the Somme Cancer Registry. RESULTS: In total, 644 patients with lung cancer were included (18 in the screened group and 626 in the unscreened group). There was a significant inversion in the stage distribution at diagnosis, with a predominance of metastatic or locally advanced stages (69%) and a minority of early stages (31%) in unscreened patients, and a majority of early stages (77.8%) and a lower proportion of locally advanced or disseminated stages (22.2%) in screened patients (p < 0.01). In the screened group, there was a significant improvement in survival, a higher rate of surgical resection, and a longer time interval between first contact and treatment initiation. CONCLUSION: Lung cancer screening by low-dose CT scan in the French department of the Somme showed an impact on stage at diagnosis, with a majority of early stages in screened patients, allowing for curative treatment with a significant improvement in survival.

Results of Second Round Lung Cancer Screening by Low-Dose CT scan - French Cohort Study (DEP-KP80).

INTRODUCTION: Over the last few years, lung cancer screening by low-dose CT scan has demonstrated a decrease in lung cancer mortality. While this method has been in use since 2013 in the United States of America, no European country has yet implemented a systematic screening program. We hereby report the results from the second round of screening from a French cohort study. PATIENTS AND METHODS: DEP KP80 is a prospective study evaluating lung cancer screening by means of three low-dose computer tomography (CT) scans at 1-year intervals in 1,307 participants, aged 55 to 74 years old, all smokers or former smokers, having quit within the last 15 years, with over 30 pack years. The results of the first round demonstrated it was possible to conduct effective screening in real-life situations. RESULTS: Participation was lower in this second round than in the first (35.3% vs. 73.1%, P < .001). The rate of negative results was significantly higher and that of undetermined results lower than those produced in the first round. Overall, 75% of cancers revealed were Stage 1 and 87.5% benefitted from surgical treatment. The incidence of cancer in the second round was 2.43%. CONCLUSION: As with the first round, the results of this second round confirm the feasibility and efficacy of lung cancer screening. The lower participation rate for this second round is proof of the need to improve awareness among participants and healthcare professionals of the relevance of committing to an annual screening program.

Mortality of COVID-19 Patients Requiring Extracorporeal Membrane Oxygenation During the Three Epidemic Waves.

Clinical presentation and mortality of patients treated with extracorporeal membrane oxygenation (ECMO) for COVID-19 acute respiratory distress syndrome (CARDS) were different during the French epidemic waves. The management of COVID-19 patients evolved through waves as much as knowledge on that new viral disease progressed. We aimed to compare the mortality rate through the first three waves of CARDS patients on ECMO and identify associated risk factors. Fifty-four consecutive ECMO for CARDS hospitalized at Amiens University Hospital during the three waves were included. Patients were divided into three groups according to their hospitalization date. Clinical characteristics and outcomes were compared between groups. Pre-ECMO risk factors predicting 90 day mortality were evaluated using multivariate Cox regression. Among 54 ECMO (median age of 61[48-65] years), 26% were hospitalized during the first wave (n = 14/54), 26% (n = 14/54) during the second wave, and 48% (n = 26/54) during the third wave. Time from first symptoms to ECMO was higher during the second wave than the first wave. (17 [12-23] days vs. 11 [9-15]; p < 0.05). Ninety day mortality was higher during the second wave (85% vs. 43%; p < 0.05) but less during the third wave (38% vs. 85%; P < 0.05). Respiratory ECMO survival prediction score and time from symptoms onset to ECMO (HR 1.12; 95% confidence interval [CI]: 1.05-1.20; p < 0.001) were independent factors of mortality. After adjustment, time from symptoms onset to ECMO was an independent factor of 90 day mortality. Changes in CARDS management from first to second wave-induced a later ECMO cannulation from symptoms onset with higher mortality during that wave. The duration of COVID-19 disease progression could be selection criteria for initiating ECMO.

Intraoperative conversion during video-assisted thoracoscopy resection for lung cancer does not alter survival.

OBJECTIVES: The aim of this study was to assess the long-term outcomes of patients treated by anatomical pulmonary resection with the video-assisted thoracoscopic surgery (VATS) approach, VATS requiring intraoperative conversion to thoracotomy or an upfront open thoracotomy for lung cancer surgery. METHODS: We performed a retrospective single-centre study that included consecutive patients between January 2011 and December 2018 treated either by VATS (with or without intraoperative conversion) or open thoracotomy for non-small-cell lung cancer (NSCLC). Patients treated for a benign or metastatic condition, stage IV disease, multiple primary lung cancer or by resection, such as pneumonectomies or angioplastic/bronchoplastic/chest wall resections, were excluded. RESULTS: Among 1431 patients, 846 were included: 439 who underwent full-VATS, 94 who underwent VATS-conversion (21 emergent, 73 non-emergent) and 313 treated with upfront open thoracotomy. The median follow-up was 37 months. There were no statistical differences in stage-specific overall survival between the full-VATS, VATS-conversion, and open thoracotomy groups, with 5-year OS for stage I NSCLC of 76%, 72.3% and 69.4%, respectively (P = 0.47). There was a difference in disease-free survival for stage I NSCLC, with 71%, 60.2% and 53%, respectively at 5 years (P = 0.013). Fewer complications occurred in the full-VATS group (pneumonia, arrhythmia, length of stay), but complication rates were similar between the VATS-conversion and thoracotomy groups. CONCLUSIONS: VATS resection for NSCLC with intraoperative conversion does not appear to alter the long-term oncological outcome relative to full-VATS or open upfront thoracotomy. Postoperative complications were higher than for full-VATS and comparable to those for thoracotomy. VATS should be favoured when possible.

Lymphatic drainage of lung cancer follows an intersegmental pathway within the visceral pleura.

OBJECTIVES: Lung cancer tumors are known to be highly lymphophilic. There are two different pattern of lymphatic drainage of the lung: one peribronchial lymphatic pathway, and another one within the visceral pleura which appears to be more intersegmental than the peribronchial pathway. We aimed to assess the prevalence of an intersegmental pathway in the lymphatic drainage of lung tumors within the visceral pleura and determine potential influential factors. METHODS: In this prospective study, we included all patients for whom a major pulmonary resection (lobar) was indicated and performed for suspected or proven lung cancer. An immediate ex-vivo evaluation of the surgical specimen after resection was conducted by trans-pleural injection of blue dye within the tumor. The pathways followed by the lymphatic vessels under the visceral pleura were assessed to define the occurrence of an intersegmental pathway, which was defined by the presence of blue dye within the lymphatic vessel crossing to a neighboring pulmonary segment, distinct from the tumorous segment. RESULTS: Fifty-three patients met the inclusion criteria and were assessed over a three-year period. Lymphatic drainage within the visceral pleura followed an intersegmental pathway in 35 of 53 patients (66 %). When the lymphatic drainage of the tumor was intersegmental, it drained in a single other segment in 21/35 cases and two or more in 14/35 cases. Logistic regression with multivariate analysis showed a peripheral location of the tumor to be a risk factor for the intersegmental pathway of visceral pleura lymphatic drainage (OR = 0.87 [079-0.95], p = 0.003). CONCLUSION: These results confirm that lymphatic drainage of lung cancer in the visceral pleura appears to largely follow an intersegmental pathway, especially when the tumor is peripheral, close to the visceral pleura.