Prognostic impact of weight loss in 1-year survivors after transthoracic esophagectomy for cancer.

Malnutrition is common 1 year after esophageal cancer surgery. However, the prognostic impact of this malnutrition on long-term outcome has been poorly reported. This study aims at determining the potential effect on disease-free survival (DFS) of weight loss observed at 1 year in disease-free survivors after curative esophageal resection. From a prospective single-institution database, 304 patients having undergone a transthoracic esophagectomy with two-field lymphadenectomy and gastric reconstruction between 1996 to 2008 were identified. Patients who died during the postoperative course (n= 24), patients who died within the first postoperative year (n= 12), patients who presented with an early recurrence within the first postoperative year (n= 20), and those who were lost to follow-up (n= 22) were excluded from the study, as well as those for whom the follow-up was shorter than 1 year (n= 21). The remaining 205 patients constituted a homogeneous group of 1-year disease-free survivors after full postoperative work-up and formed the material of the present study. Body weight (BW) values were collected before any treatment at the onset of symptoms (initial BW) and 1 year after esophagectomy. A 1-year weight loss (1-YWL) exceeding 10% of the initial BW defined an important malnutrition. Impact of the 1-YWL ≥ or <10% of the initial BW on DFS was investigated. Logistic regression was performed to identify factors affecting DFS. The mean initial BW was 69.1 ± 12 kg, corresponding to a mean body mass index (BMI) of 23.8 ± 3 kg/m(2) . Preoperatively, 32 (15%) patients were in the underweight category (BMI < 20 kg/m2), 110 (54%) were in normal (BMI = 20-24 kg/m2), and 63 (31%) were in the overweight category (BMI ≥ 25 kg/m2). Mean 1-year BW was 63.5 ± 12 kg. 1-YWL was <10% of the initial BW in 92 patients (45%) and ≥ 10% in 113 patients (55%). Accordingly, 5-year DFS rates were 66% (median: 80 months) and 48% (median: 51 months), respectively (P= 0.005). On multivariate analysis, only three independent variables affected the DFS significantly: clinical N stage (cN) status (P= 0.007; odds ratio: 1.99, 1.2-3.3), incomplete resection (P= 0.008, OR: 3.6, 1.3-9.3), and 1-YWL ≥ 10% (P= 0.004, OR: 2.1: 1.2-3.4). 1-YWL of or exceeding 10% of the initial BW in 1-year disease-free survivors has a negative prognostic impact on DFS after esophagectomy for cancer. This information offers another view on the objectives of the perioperative nutritional care of these patients. Special vigilance program on the nutritional status in post-esophagectomy patients should be the rule.

[Respiratory complications after oesophagectomy for cancer]. / Complications respiratoires de l'oesophagectomie pour cancer.

Surgery is the cornerstone of treatment for resectable tumours of the oesophagus. Recent advances of surgical techniques and anaesthesiology have led to a substantial decrease in mortality and morbidity. Respiratory complications affect about 30% of patients after oesophagectomy and 80% of these complications occur within the first five days. Respiratory complications include sputum retention, pneumonia and ARDS. They are the major cause of morbidity and mortality after oesophageal resection and numerous studies have identified the factors associated with these complications. The mechanisms are not very different from those observed after pulmonary resection. Nevertheless, there is an important lack of definition, and evaluation of the incidence is particularly difficult. Furthermore, respiratory complications are related to many factors. Careful medical history, physical examination and pulmonary function testing help to identify the risk factors and provide strategies to reduce the risk of pulmonary complications. Standardized postoperative management and a better understanding of the pathogenesis of pulmonary complications are necessary to reduce hospital mortality. This article discusses preoperative, intraoperative, and postoperative factors affecting respiratory complications and strategies to reduce the incidence of these complications after oesophagectomy.

[Pulmonary epithelioid haemangioendothelioma: two different clinical courses]. / Hémangioendothéliome épithélioïde pulmonaire: à propos de deux observations.

The first case report concerns a 59-year-old man presenting a chronic cough and the second a 23-year-old woman farmer presenting with worsening dyspnoea associated with cough, expectoration and haemoptysis. In the second case, the woman died 7 months after the onset of the respiratory symptoms. In both cases, chest radiography and thoracic CT scans showed multiple, bilateral pulmonary nodules, bronchial endoscopy was normal and surgical biopsy revealed epithelioid haemangioendothelioma. It is a rare primary pulmonary tumour which is usually found in soft tissue, bone or liver. Epithelioid haemangioendothelioma is a vascular tumour usually affecting women less than 40 years of age. The histological appearance is characteristic and may be confirmed by immunohistochemistry. Chemotherapy and radiotherapy are generally ineffective and surgery is sometimes impossible because of the multifocal lesions. Epithelioid haemangioendothelioma is considered a sarcoma without precise histological prognostic criteria. In its pulmonary location it is responsible for death due to respiratory failure in 50% of cases.

[Bronchial fistula postpneumonectomy: predictive factors]. / Fistule bronchiques postpneumonectomies: facteurs prédictifs.

OBJECTIVE: To determine predictive factors of bronchial fistula following pneumonectomy. PATIENTS AND METHODS: In 14 years (1989-2003), we collect 58 cases of bronchial fistula following 725 consecutive pneumonectomy in the service of thoracic surgery of the Sainte Marguerite Hospital in Marseilles. There were 53 cases (91.4%) of cancers and 5 cases (8.6%) of various pathology. The average age of the patients was of 61 +/- 10 years (range 24 to 80 years). The sex ratio M/F was 8.7. The software of regression SPSS (version11.5) was used to identify the factors risk of a bronchial fistula after a univariate and multivariate analysis. RESULTS: The prevalence of the bronchial fistula after a pneumonectomy was 8%.The preoperative factors which increased to a significant degree the incidence of the bronchial dent to the univariate analysis were the chronic smoking (P < 0.001), the existence of COPD (P = 0.001) and of a previous thoracic surgery (P = 0.01). Operational data like a right- side pulmonary resection (P < 0.001), the type of bronchial stup carried out (P = 0.03) as and an extended pneumonectomy to the auricule (P = 0.03) were significant risk factors. With the logistic regression the significant risk factors were the chronic smoking (P = 0.002), the existence of COPD (P = 0.003), a previous pulmonary surgery (P = 0.03) and the right - side of the pneumonectomy (P < 0.001). The indication of the pneumonectomy was retained neither by the univariate analysis, nor by the logistic regression significant risk factors. CONCLUSION: The predictive factors of a bronchial fistula after a pneumonectomy are dominated by respiratory co-morbidities. To prevent this complication, we insist on the stop of the tobacco, a better respiratory preparation and the acquisition of a protocol adapted of the bronchial stub after a pneumonectomy particularly on the right side.

[Bronchoscopy in the diagnosis of lung cancer: an evaluation of current practice]. / L'endoscopie bronchique pour le diagnostic de cancer: évaluation des pratiques.

INTRODUCTION: Bronchoscopy is frequently practised by respiratory physicians, particularly when there is a suspicion of lung cancer. However, few guidelines are available and practice varies widely. BACKGROUND: Studies of current practice are few and unstandardised. Few data are available regarding equipment or procedure (information, prior investigations, environment, standardised reporting etc.). The evaluation of new techniques such as endobronchial ultrasound, autofluorescence bronchoscopy, transbronchial needle aspiration (TBNA) has been covered in recent publications. These evaluations are often undertaken without rigourous methodology (retrospective studies) but underline the feasibility of these techniques. Some, especially TBNA are nevertheless underused in practice. In the published studies evaluating practice the results of these investigations are often similar to those obtained in clinical trials even if a learning period is necessary. Complications are rare. Few studies of cost effectiveness are available but they support the use of these new techniques. VIEWPOINT: A national study under the aegis of the SLPF (French Respiratory Society) is necessary to obtain comprehensive and reliable data on the practice of bronchoscopy in the investigation of lung cancer. CONCLUSIONS: Studies evaluating current practices are few and unstandardised, and probably give only a partial survey of the success achieved and the difficulties encountered by respiratory physicians in their clinical routine.

[Phase III randomised trial of adjuvant chemotherapy with cisplatin plus docetaxel versus cisplatin plus gemcitabine in resected non-small cell bronchial carcinoma with quality of life as the primary objective]. / Essai randomisé de phase III de chimiothérapie adjuvante par CDDP/docetaxel versus CDDP/gemcitabine dans les cancers bronchiques non à petites cellules réséqués avec la qualité de vie comme objectif principal.

BACKGROUND: Adjuvant chemotherapy improves survival of completely resected non-small cell lung cancer (NSCLC). However the regimen of choice is not yet defined. METHODS: The primary objective of this comparative, open, randomised multicentre trial is to compare two chemotherapy regimens (cisplatin/docetaxel versus cisplatin/gemcitabine) in the management of resected NSCLC with quality of life (QoL) evaluated at the end of treatment as the primary objective. The secondary objectives are to study the impact of these two chemotherapy regimens on overall and relapse free survival, hematological and non-hematological toxicities, and costs. The primary judgement criterion will be the assessment of end of treatment QoL by the standardised questionnaire, EORTC QLQ-C30. Secondary judgement criteria will be Qol measured by EORTC QLQ-LC13 and SF36, overall and relapse free survival, tolerance and costs. The number of subjects needed is 75 in each group, 150 in total, to detect a difference of 10 points on the EORTC QLC-C30 scores with a standard error of 20 points (alpha 0.05; power 80%). EXPECTED RESULTS: This trial will provide clinicians with data on the impact of two currently unexplored adjuvant chemotherapy regimens on quality of life, tolerance and costs in NSCLC.

[Spontaneous pneumomediastinum in young adults: a benign clinical entity]. / Pneumomédiastin spontané du jeune adulte: une entité clinique bénigne.

INTRODUCTION: Spontaneous pneumomediastinum is a little known cause of chest pain in young adults. The prognosis is invariably good. CASE REPORT: The authors report two cases of spontaneous pneumomediastinum with different aetiologies developing in young adults. The first occurred during strenuous sport and the second during an asthma attack. CONCLUSION: The discussion stresses the frequency of this condition in young men, its pathogenesis and natural history. In particular the authors draw on the current scientific data to explain the absence of predisposing factors and the extreme rarity of relapse of this benign disorder. Poor acquaintance with this clinical entity may lead to unnecessary diagnostic and therapeutic actions. The authors suggest a guideline for the management of this disorder.

[Validation of the French version of the Princess Margaret Hospital Patient Satisfaction with their Doctor Questionnaire]. / Validation de la version française du Princess Margaret Hospital Patient Satisfaction with Doctor Questionnaire (PMH/PSQ-MD): le F-PMH/PSQ MD.

BACKGROUND: The evaluation of patient satisfaction receives increasing attention partly due to pressure from state agencies involved in the administration of health care. Outpatients' satisfaction with their doctor is a major component of total patient satisfaction. However, a validated instrument for assessing this has not previously been available in French. PATIENTS AND METHODS: The Princess Margaret Hospital Patient Satisfaction with Doctor Questionnaire (PMH/PSQ-MD) is a recently validated tool available in English for this purpose. A three-step procedure was conducted to obtain a validated French translation of the PMH/PSQ-MD. Subsequently, outpatients receiving chemotherapy, symptomatic treatment or attending a follow-up clinic were approached to participate in the study and complete the questionnaire. Acceptability and reliability (Cronbach's alpha score), as well as internal and external (Pearson correlation coefficient with the Patient Satisfaction Questionnaire IV) validities were studied. RESULTS: 137 patients were approached and 116 fully completed the study. The PMH/PSQ-MD's acceptability was high (<10% of non-responders). Internal validity was also high (Cronbach's alpha score > 0.7 for each dimension). External validity in comparison with the PSQ IV was high as well. Women demonstrated higher satisfaction scores, while age had no influence on patient satisfaction. CONCLUSIONS: The F-PMH/PSQ-MD is a questionnaire which addresses outpatients' satisfaction with their doctor, and is now available for research purpose as well as for daily practice.

[Quality of life: attitudes and perspectives of doctors in a thoracic oncology regional care network]. / Qualité de vie: attitudes et perceptions des médecins d'un réseau régional de soins en oncologie thoracique.

BACKGROUND: The evaluation of health-related quality of life (HRQOL) of lung cancer patients is significant given their poor prognosis. Consequently, HRQOL is often currently assessed throughout clinical trials and sometimes in daily medical practice. The objective here was to determine physicians' perspectives on evaluating HRQOL. MATERIAL AND METHODS: The team carried out a prospective study of physicians belonging to a thoracic oncology network using an original questionnaire of 33 items. RESULTS: 102 physicians were questioned and 51 responded. Physicians' knowledge on HRQOL was frequently of a low level and incomplete, but most of them considered HRQOL as important HRQOL assessment in daily practice was often done intuitively. Many physicians noted that they lacked adequate time to explore and integrate all of the fields which should be covered by HRQOL in their clinical practice, but they felt overall that the HRQOL study improved doctor/patient communication and interaction. Physicians described an "ideal" HRQOL questionnaire as one containing 10-15 items within 6 domains (physical, psychological, general health, respiratory symptoms, family and social) and which could be completed in 5-8 minutes. In addition, such a questionnaire might integrate an opportunity for patients to isolate and identify items and issues that they consider to be most important to them. CONCLUSIONS: Physicians' will to consider and integrate the evaluation of HRQOL in the management of lung cancer patients is strong but meets some structural challenges (related to HRQOL assessment and interpretation of data) but also conjectural difficulties (with respect to a lack of knowledge). Training efforts are needed as well as the development of easier tools to facilitate the evaluation of HRQOL.

[Use of 153Sm-EDTMP to relieve pain from bone metastasis in lung cancer]. / 153Samarium-EDTMP et contrôle de la douleur liée aux métastases osseuses des cancers bronchiques.

INTRODUCTION: The treatment of bone metastasis from lung cancer is palliative in nature with elimination of pain being the primary goal. Management is based on pharmacologicalmethods (steroids, morphine, and pamidronate) and radiotherapy. However, other treatments have been developed including the systemic radiopharmaceutical 153Sm-EDTMP. CASE REPORTS: We report data from 6 lung cancer patients with bone metastases treated with 153Sm-EDTMP. Demographic and therapeutic data, pain evaluation by visual analogue scale (VAS) and change in opioid analgesia requirements (expressed as intravenous morphine equivalent) as well as survival were studied. Pain associated with bone metastasis (median VAS = 8 [7-9], median morphine dose = 167 mg [100-800 mg]) did not significantly improve (median VAS after 153Sm-EDTMP = 8.5 [5-10], median morphine dose after 153Sm-EDTMP = 185 mg [30-2 200 mg]) in this group of patients. CONCLUSION: Our results combined with current data in the literature concerning the use of this treatment in the treatment of bone pain associated with metastatic lung cancer suggest that at present its use cannot be recommended outside the context of clinical of clinical trials.

[Acute respiratory distress syndrome following inhalation of barium sulfate]. / Syndrome de détresse respiratoire aiguë après inhalation de sulfate de baryum.

INTRODUCTION: Barium sulfate (BS) is chosen to explore swallowing disorders because of its reduced osmolality allowing no adverse reaction if aspirated in the bronchial tree. CASE REPORT: A 66-years old man treated for an advanced stage mesothelioma experienced a BS aspiration during an esophagography. He developed 3 days after an acute respiratory distress syndrome (ARDS) and deceased. The post-mortem examination revealed a diffuse alveolar damage (DAD). CONCLUSION: Whereas BS aspiration is generally well tolerated, serious adverse event as a DAD would exceptionally occurs. Thus, a close watch over respiratory symptoms has to be kept after BS administration, especially in debilitated and elderly patients.

Surgical management of metachronous bronchial carcinoma.

OBJECTIVE: To assess the results of surgery for the treatment of metachronous bronchial carcinoma. METHODS: From 1985 to 1999, 38 patients were operated on for a metachronous lung carcinoma, accordingly to the criteria of Martini. All tumors were staged using the new International Classification System revised in 1997. RESULTS: Diagnosis of the second cancer was done at radiological follow-up in 30 asymptomatic patients. Seventeen metachronous locations were ipsilateral. Histology of the metachronous lesion was the same as that of the first tumour in 23 patients (60%). The first resection was a lobectomy (n=35), a pneumonectomy (n=2) and a carinal resection (n=1). The second one was a wedge resection (n=7), a segmentectomy (n=3), a lingulectomy (n=2), a lobectomy (n=9), a bilobectomy (n=1), and a pneumonectomy (n=16). There were five in-hospital deaths (13%). Completion pneumonectomy was performed in 15 patients, with one postoperative death (7%). The overall estimated 5 and 10-years actuarial survival rates from the treatment of the first cancer were 70 and 47% respectively. The 5-year survival rate after the treatment of the second cancer was 32% (median survival: 31 months), including the operative mortality. Survival was negatively affected by a resection interval of less than 2 years and the performance of atypical lung sparing pulmonary resection for the treatment of the second cancer. CONCLUSIONS: Good long-term results are achievable by the means of a second pulmonary resection in selected patients with metachronous lung cancer. Optimal cancer operations should be applied whenever functionally possible.

Is lung cancer surgery justified in patients with direct mediastinal invasion?

OBJECTIVE: To assess the results of the surgical treatment of patients with stage IIIB non-small cell lung carcinoma (NSCLC) invading the mediastinum (T4). METHODS: Twenty-nine patients were operated on from 1986 to 1999. Histology was squamous cell carcinoma in 17 patients, adenocarcinoma in eight, large cell carcinoma in two and neuroendocrinal carcinoma in two. Three patients received a preoperative chemotherapy (n = 2) or radiochemotherapy (n = 1). The lung resection consisted of a pneumonectomy in 25 patients and a lobectomy in four. The procedure was extended to one of the following structures: superior vena cava (SVC) (n = 17), aorta (n = 1), left atrium (n = 5) and carina (n = 6). Seventeen patients had a postoperative regimen including radiochemotherapy (n = 12), radiotherapy (n = 4), or chemotherapy (n = 1). RESULTS: Complete R0 resection was achieved in 25 patients, whereas four patients had a microscopically (n = 1) or macroscopically (n = 3) residual disease. The operative mortality rate was 7% (n = 2). Non-fatal major complications occurred in eight patients (28%). Overall 5-year survival rate was 28% (median 11 months), including the operative mortality. The median survival of the 18 patients with an N0 or N1 disease was 16 months whereas the median survival of the 11 patients with an N2 disease was 9 months. At completion of the study, 22 patients have died, two postoperatively and 10 from pulmonary causes without evidence of cancer. CONCLUSIONS: Surgical management of T4 NSC lung cancer invading the mediastinum should be considered, in the absence of N2 disease, when a complete resection is achievable.

Postoperative complications in relation with induction therapy for lung cancer.

OBJECTIVES: The purpose of this study was to evaluate the risk of lung cancer surgery following induction chemotherapy and/or radiotherapy. METHODS: This retrospective study included 69 patients treated from January 1990 to January 1998 for a primary lung cancer in whom surgery had been performed after induction treatment. Surgery had not been considered initially for the following reasons: N2 disease (IIIA, n = 25); temporary functional impairment (two stages IB and two stages IIIA (N2), n = 4); and doubtful resectability (stage IIIB (T4), n = 40). The medical regimen resulted in combined radio-chemotherapy in 43 patients who received two to four cycles of chemotherapy (average 2.9 +/- 0.8 cycles) and 43 +/- 8 Gy (range 20--60 Gy), or chemotherapy alone in 26 patients (3 +/- 0.7 cycles). RESULTS: Exploratory thoracotomy was performed in four patients (6%). The in-hospital mortality was 9% (n = 6) from respiratory origin in all cases. There were four re-operations (6%): three for bronchial fistula and one for bleeding. Thirty-five patients (51%) required blood transfusion (4.5 +/- 3.8 cell packs). The incidence of early and delayed bronchial fistula after pneumonectomy was 15%. Thirteen patients had a postoperative pneumonia (19%). CONCLUSIONS: Surgery for lung cancer after induction chemotherapy and/or radiotherapy is associated with an increased risk. If the mortality seems 'acceptable', the morbidity rate, however, is high.

VATS is an adequate oncological operation for stage I non-small cell lung cancer.

OBJECTIVES: This study was designed to determine the long-term prognosis of video-assisted thoracic surgery (VATS) vs. open lung resections for patients with pathological stage I non-small cell lung cancer (NSCLC). MATERIALS AND METHODS: The medical records of all patients who underwent lung resection for a pathological stage I NSCLC were reviewed for the period from 1990 to 1999, by screening of a database into which data were entered prospectively. There were 511 patients (430 males and 81 females) whose age averaged 63+/-10 years who underwent 515 lung resections. Our VATS experience began in 1993 with selected stage I patients, and since that date an average of one patient on four was managed with VATS. Lung resections consisted of 25 wedge resections or segmentectomies (seven VATS), 390 lobectomies (92 VATS), 19 bilobectomies (one VATS) and 81 pneumonectomies (ten VATS). Lymph node dissection was performed in all cases. RESULTS: There were significantly more females (P=0.01) and adenocarcinoma (P=0.02) in the VATS group (n=110) when compared to the open group (n=405). Tumour size averaged 4+/-2 cm in the open group and 3+/-2 cm in the VATS group (P=0.04). The distribution of T1/T2 tumours was 97/308 and 50/60, respectively (P=0.0001). At follow-up, cancer recurrence could be documented in 117 patients, with no difference of incidence between the two groups (22.5 vs. 24.5%; P=0.64). Estimated Kaplan-Meier 5-year survival rates, including the operative mortality as well as any cancer-related and unrelated death, were 62.8% (confidence interval (CI): 56.8-68.7%) vs. 62.9% (CI: 51.4-74.4%), respectively (P=0.60). The advent of VATS did not influence the patients' survival: 5-year survival rate was 63.9% (CI: 55.3-72.5%) for the period from 1990 to 1992, and 58.8% (CI: 51.7-65.9%) for the period from 1993 to 1999 (P=0.65). Subgroups survival analysis according to the T status did not show any statistically significant difference between the two groups. CONCLUSIONS: VATS lung resection with lymph node dissection achieved a 5-year survival similar to that achieved by the conventional approach. VATS is a valuable option for the management of selected patients with an early-stage NSCLC.

Bilateral bronchioloalveolar lung carcinoma: is there a place for palliative pneumonectomy?

OBJECTIVE: Bronchioloalveolar lung carcinoma (BAC) is characterized by bronchial and lymphatic dissemination explaining multifocal and bilateral spreading. Bilateral BAC is usually considered as a contraindication to surgery. Regarding poor efficacy of symptomatic and oncological treatments, we hypothesized that surgery might play a role to palliate hypoxemia associated with serious intrapulmonary shunting, as well as continuous bronchorrhea. METHODS: We retrospectively studied here four consecutive patients, who underwent palliative pneumonectomy. RESULTS: The shunt was confirmed again at the time of the surgery by a pulmonary artery occlusion demonstrating immediate improvement in arterial oxygen saturation from 89% at baseline to 98% after occlusion. Lung resections consisted of a left pneumonectomy in three cases and a right pneumonectomy in one. PaO(2) levels under 5l/min oxygen therapy improved dramatically when comparing preoperative data (mean 50.5 mmHg) to post-operative results (mean 150 mmHg). One patient died postoperatively. Three patients, who experienced an uneventful immediate post-operative course, received chemotherapy after surgery. Improvement of quality of life is testified by the absence of both symptoms and any need for oxygen therapy for few months. Disabling symptoms reappeared at 1, 8 and 10 months. Survival of these patients was 3, 12 and 18 months. CONCLUSIONS: These results support the interest of consideration of a surgical resection for highly selected patients presenting with bilateral BAC and severe intrapulmonary shunting.

Prognostic implications of a positive bronchial resection margin.

OBJECTIVE: This retrospective study evaluates probability of survival and mode of recurrence in patients with a microscopically positive bronchial resection margin following resection for primary bronchogenic carcinoma, as well as influence of radiotherapy on survival. METHODS: From January 1986 to July 1997, 40 patients had a microscopically positive bronchial resection margin following a macroscopically complete resection (17 lobectomies, three bilobectomies, four sleeve-lobectomies, and 16 pneumonectomies). Tissue diagnosis was squamous cell carcinoma in 32 patients, adenocarcinoma in four, adenosquamous carcinoma in two and neuroendocrine carcinoma in two. Lymph node status was N0 in 14 patients, N1 in 10, and N2 in 16. The bronchial margin contained carcinoma in situ in 20 patients, invasive mucosal carcinoma in five, and peribronchial infiltration in 15. All patients except the three most recent underwent adjuvant radiation therapy. RESULTS: At the conclusion of the study (January 31st, 1999), 30 patients had died: two with post-operative complications, 17 with progressive disease, ten without relation to cancer, and one under undefined circumstances. Six of 10 unrelated deaths were interpreted as respiratory complications of radiotherapy. Recurrent disease appeared in 24 patients (60%). Nineteen had progression of initial disease (47.5%): metastatic spread in 12 (30%), isolated local recurrence in four (10%), and combined local recurrence and metastases in three (7.5%). Five patients developed metachronous cancer, with bronchial location in four (10%) and laryngeal in one (2.5%). 5-year survival (Kaplan-Meier) in 20 patients with carcinoma in situ was 38.7+/-13.7% (median 31 months), but rose to 55.0+/-16. 6% when excluding seven deaths not related to cancer (five of whom were secondary to radiotherapy) (chi(2)=3.080; P=0.0792). Survival in 13 patients classified N0 was 51.3+/-16.3% (median 61 months), and 71.1+/-18.0% following exclusion of unrelated deaths (chi(2)=3. 939; P=0.0472). Adverse prognosis of peribronchial infiltration was correlated to a positive N status (13 N2 and 2 N1), 5-year survival being 20.0+/-10.3% (median: 18 months). CONCLUSIONS: Prognosis of peribronchial infiltration is similar to N2 disease. In situ carcinoma does not influence survival per se. Local control of disease is probably in part due to radiotherapy. However, the high prevalence of unrelated late deaths suggests an adverse impact of radiotherapy on survival.

Esophageal cancer resection in the elderly.

OBJECTIVE: Esophageal cancer is a disease whose prognosis is dismal and its surgery involves considerable risks, consequently the opportunity of esophageal resection in elderly patients with esophageal cancer is questionnable. The aim of this study was to analyze, with respect to their age, the outcome of 386 consecutive patients who underwent esophagectomy and simultaneous replacement for cancer. METHODS: A chart review of all patients with esophageal carcinoma admitted to our institution was undertaken for the period January 1979-December 1994. RESULTS: The portion of patients of 70 years of age and older (14.5%) has slightly increased during the period. Location to the lower third of the esophagus and adenocarcinoma type were prevalent in the 56 elderly patients (group I), but their postsurgical TNM staging was identical to that of the 330 younger patients (group II). Other clinical features, i.e. preoperative weight loss and the presence of co-morbid diseases, however, were comparable in the two groups. Pulmonary function, as assessed by spirometry, was significantly worse among the older patients, but blood gas determinations were not different. Operative mortality was comparable, between the two groups (10.7% vs 11.2%). Major morbidity included anastomotic leak (10.7% vs 13.6%) and pulmonary complications (17.9% vs 20.6%) in both groups. Excellent palliation of dysphagia was achieved in 92% of the 50 group I patients who survived the operation. Long-term survival was not different in elderly patients (5-year rate: 17%) when compared with that of younger patients (18.9%). CONCLUSION: These data suggest that esophagectomy can be performed safely in selected septuagenarian patients, thus allowing a substantial survival with excellent functional status in a portion of these patients.

[Induction treatment of locally advanced operable cancers of the esophagus. Prognostic significance of the histologic response]. / Traitement d'induction des cancers de l'oesophage opérables localement avancés. Signification pronostique de la réponse histologique.

OBJECTIVE: The purpose of this study was to determine the prognostic significance of the histopathological response to preoperative radio-chemotherapy in patients with locally advanced oesophageal cancer. METHODS: Among the 57 patients included in this open prospective study, the disease-free survival of 48 patients (8 females 40 males; mean age: 56.6 years +/- 8.4) who underwent an oesophagectomy after induction therapy for oesophageal squamous cell (n = 38) or adenocarcinoma (n = 10) was correlated with the histopathological findings. Chemoradiation included 2 cycles associating continuous 5 FU from D1 to 5 and from D22 to 26, cisplatyl on D1 and D22, 15 Gy/5d from D1 to 5 and from D22 to 26. Histopathological response was assessed on the operative specimens by routine examination of serial thin sections each 5 mm along the full oesophageal length, the resection margins and the lymph node dissection. RESULTS: A wide interindividual variability was seen regarding tissue changes related to induction therapy, with a grading in tumor regression and the possibility of dissociated effects on the various treatment targets: tumor, adenopathy and vessel invasion. The 5-year probability of disease-free survival was 22% for the 48 resected patients. The presence of a complete histopathological response (n = 12) did not preclude metastatic spread in half the cases. Furthermore, it did not result in improved survival when compared to that of non-responder patients. Survival of patients who had a complete or major oesophageal response (n = 29, 35% at 5 years) was significantly lower than that of patients who were operated on during the same period for a superficial oesophageal cancer at presentation (n = 29, 57% at 5 years; P = 0.03). After multivariate analysis according to the Cox model, downstaging of the primary tumor was not identified as an independent predictor of disease-free survival. CONCLUSIONS: Pathologic assessment of tumor regression on the operative specimen provides little prognostic information.

[Surgery for oesophageal cancer: current controversies]. / Chirurgie du cancer de l'oesophage : controverses actuelles.

Any attempt to define the present role of surgery in the treatment of oesophageal cancer should integrate the dramatic changes that occurred within this disease over the last 2 decades: major shift in the histologic type of tumours, improved staging methods, spectacular reduction of operative risks, standardization of oncologic principles focusing on the completeness of resection, and development of multimodality therapeutic strategies. Surgery has still a pivotal role. Esophagectomy should be performed by trained surgeons in high-volume institutions. Radical surgery with en-bloc resection and 2 fields lymphadenectomy, should be encouraged in low-risk patients with subcarinal tumors. Although multimodality treatment strategy is commonly applied for locally advanced disease, few data support its superiority over surgical resection alone, followed by adjuvant therapy when appropriate. One may thus hypothesize that the risk/benefit ratio of such strategies is probably optimal in case of early stage tumors, and future studies may further clarify this issue. Conversely, locally advanced tumors, particularly those located in the upper mediastinum and the neck, may be managed alternatively without surgery. However, surgery remains an important tool to ensure optimal palliation of dysphagia, to achieve local control, and finally to improve quality of life. In that way, video-assisted techniques and/or trans hiatal approaches aiming to minimize the surgical insult may have a place in the treatment of patients who have substantially responded to induction therapy. Tumors located close to the pharyngo-oesophageal junction are best managed with chemotherapy and radiotherapy. Finally, salvage surgery may be considered in highly selected patients in case of non-response or local relapse without distant metastases.