Synchronous Oligometastatic Lung Cancer Deserves a Dedicated Management

BACKGROUND

Oligometastatic stage IV non-small lung cancer (NSCLC) patients have a 5-year overall survival of 30% versus 4% to 6% in historical cohorts of stage IV NSCLC patients. We reviewed data and patterns of care of patients affected by oligometastatic NSCLC in our center between 2001 and 2017.

METHODS

We retrospectively reviewed clinical and pathological files of all patients with lung cancer and synchronous isolated adrenal or brain metastases, or both, treated by locally ablative treatments (surgery or radiotherapy, or both) of both primary cancer and distant metastasis. Statistical analysis was performed to assess the effect on overall survival of patient- and tumor-related characteristics and therapeutic approaches. Overall survival was assessed by the Kaplan-Meier method. Survival rates were compared by log-rank test. Significance was accepted at a level of p of less than 0.05.

RESULTS

Our department treated 51 patients affected by NSCLC and synchronous brain metastasis (n = 41), adrenal metastasis (n = 9), or both (n = 1). Median survival was 42 months (95% confidence interval, 22.3 to 63.7). Overall survival was 62% at 2 years and 34.4% at 5 years. A univariate and multivariate analysis the positive prognostic factors for survival was cessation of smoking (p = 0.006) and lymphovascular and perineural spreading in the tissues (p = 0.024).

CONCLUSIONS

In selected oligometastatic synchronous NSCLC patients, a multimodality approach encompassing radical treatment of the primary tumor and ablative treatment of concurrent metastases is recommended, with encouraging results. Smoking cessation is a part of the treatment sequence.

CT-guided percutaneous core biopsy for assessment of morphologically normal adrenal glands showing high FDG uptake in patients with lung cancer

OBJECTIVE:

Increased fludeoxyglucose (FDG) uptake in morphologically normal adrenal glands on positron emission tomography-CT (PET-CT) is a diagnostic challenge with major implications on treatment. The purpose of this retrospective study was to report our experience of CT-guided percutaneous core biopsy of morphologically normal adrenal glands showing increased FDG uptake in a context of lung cancer.

METHODS:

Biopsies for non-enlarged adrenal glands showing increased FDG uptake in lung cancer patients performed at our institution from December 2014 to December 2016 were retrospectively analyzed. Six biopsies were performed in five patients during the study period. All procedures were performed with the patients in the prone position, using a posterior approach and coaxial 17-gauge needles with 18-gauge automated cutting needles. Patient characteristics, procedural details and final pathological diagnosis were analyzed, as well as the duration of hospitalization.

RESULTS:

Five of the six biopsies (83.3%) confirmed adrenal metastasis from the primary lung cancer. No complications were reported and the patients were discharged the day after the procedure.

CONCLUSION:

The high confirmation rate of metastasis and lack of complications support performing CT-guided percutaneous biopsy of non-enlarged adrenal glands showing increased FDG uptake, for optimal management in lung cancer patients.

ADVANCES IN KNOWLEDGE:

Morphologically normal adrenal glands showing high FDG uptake in patients with lung cancer are metastasis. This manuscript shows that CT-guided percutaneous biopsy should be proposed. Increased FDG uptake in morphologically normal adrenal glands may indicate metastasis.

Risk factors for hemoptysis complicating 17-18 gauge CT-guided transthoracic needle core biopsy: multivariate analysis of 249 procedures

PURPOSE

We aimed to identify modifiable and nonmodifiable risk factors for hemoptysis complicating computed tomography (CT)-guided transthoracic needle biopsy.

METHODS

All procedures performed in our institution from November 2013 to May 2015 were reviewed. Hemoptysis was classified as mild if limited to hemoptoic sputum and abundant otherwise. Presence of intra-alveolar hemorrhage on postbiopsy CT images was also evaluated. Patient- and lesion-related variables were considered nonmodifiable, while procedure-related variables were considered modifiable.

RESULTS

A total of 249 procedures were evaluated. Hemoptysis and alveolar hemorrhage occurred in 18% and 58% of procedures, respectively, and were abundant or significant in 8% and 17% of procedures, respectively. Concordance between the occurrence of significant alveolar hemorrhage (grade ≥2) and hemoptysis was poor (κ=0.28; 95% CI [0.16-0.40]). In multivariate analysis, female gender (P = 0.008), a longer transpulmonary needle path (P = 0.014), and smaller lesion size (P = 0.044) were independent risk factors for hemoptysis. Transpulmonary needle-path length was the only risk factor for abundant hemoptysis with borderline statistical significance (P = 0.049).

CONCLUSION

The transpulmonary needle path should be as short as possible to reduce the risk of abundant hemoptysis during CT-guided transthoracic needle biopsy.

Prognostic factors after pulmonary metastasectomy of colorectal cancers: a single-center experience

Background

Surgical resection has been widely admitted as the treatment of choice for pulmonary metastases of colorectal cancer (CRC). Nevertheless, this practice is not supported by high level of evidence and patients' eligibility remains controversial. Aim of this study was to evaluate long terms results and factors influencing survival after lung metastasectomy of CRC.

Methods

A single-center retrospective analysis of patients with pathologically proven colorectal metastasis, operated from 2004 to 2013, was performed. Patients were treated with a multidisciplinary approach and selected for surgery if complete resection was considered feasible.

Results

Three hundred and six patients were considered for analysis. Mean number of lesions at CT scan was 2.6±2.3. Ratios of each largest resection type at first side surgery were: segmentectomy 20.6%, lobectomy 12.9%, bilobectomy 1.2%, pneumonectomy 1.2% and sub-lobar resection 64.1%, respectively. No in-hospital death occurred. At pathology, mean number of resected metastasis was 2.6±2.3, ranging from 1 to 12. Resection was complete in 92.5% of patients. Nodal involvement was proven in 40 (12.9%) patients. The initially planned complete resection could not be achieved in 23 (7.5%) cases. Mean follow-up was 3.06±2.36 years. Kaplan-Meier analysis revealed that recurrence-free survival (RFS) was 76.3% [95% confidence interval (95% CI), 71-80.7%], 38.9% (95% CI, 33-44.7%), 28.3% (95% CI, 22.5-34.4%) and 22.7% (95% CI, 16.5-29.5%) at 1, 3, 5 and 7 years, respectively. Overall survival (OS) estimates were 77.8% (95% CI, 72.7-82.7%), 59.0% (95% CI, 51.2-66.4%), and 56.9% (95% CI, 48.4-65.0%) at 3, 5 and 7 years, respectively. Multivariate analysis, including pT parameter of the primary tumor, number of lesions, one-sided versus bilateral lung disease, and body mass index (BMI) (all significant at univariate analysis), showed that bilateral disease (P<0.001) and pT4 primary (P=0.005) were independent pejorative predictors of OS, whereas BMI ≥25 was protective (P=0.028).

Conclusions

Bilateralism and primary tumor local extension influence the prognosis of patients surgically treated for pulmonary colorectal metastases. Specifically designed randomized trials are necessary.

Thoracic Endometriosis Syndrome Other Than Pneumothorax: Clinical and Pathological Findings

BACKGROUND

Thoracic endometriosis syndrome refers to a broad spectrum of clinical manifestations related to the presence of ectopic intrathoracic endometrial tissue. Few studies have reported on manifestations other than pneumothorax.

METHODS

Clinical, surgical, and pathology records of all consecutive women of reproductive age referred to our institution from September 2001 to August 2016 for clinically suspected thoracic endometriosis syndrome were retrospectively reviewed. After excluding women with pneumothorax, we enrolled 31 patients, divided into three subgroups: catamenial chest pain (n = 20), endometriosis-related diaphragmatic hernia (n = 6), and endometriosis-related pleural effusion (n = 5).

RESULTS

Surgery was performed in 11 patients with catamenial thoracic pain (median age, 30 years; range, 23 to 42). Median pain intensity assessed on the 0 to 10 Visual Analogue Scale was 8 (range, 8 to 9) before surgery. At surgery, 8 patients had diaphragmatic endometriosis implants, which were resected with direct suture of diaphragm. At follow-up, median pain score was 3 (range, 0 to 8). In the group presenting with diaphragmatic hernia (median age, 36 years; range, 29 to 50), diaphragm was repaired by direct suture or placement of prosthesis in 4 and 2 cases, respectively. At follow-up, no sign of recurrent hernia was observed. Finally, among women with endometriosis-related pleural effusion (median age, 30 years; range, 25 to 42), surgical treatment was represented by evacuation of the pleural effusion and biopsy (n = 4) or removal (n = 1) of visible endometrial foci.

CONCLUSIONS

Thoracic endometriosis syndrome is a poorly recognized entity responsible for various manifestations other than pneumothorax. In case of catamenial thoracic pain, diaphragmatic hernia and catamenial pleural effusion surgery should be advised in a multidisciplinary setting.

Indications and Results of Reconstructive Techniques with Flaps Transposition in Patients Requiring Complex Thoracic Surgery: A 12-Year Experience

BACKGROUND

Flap transposition is an infrequent but far from exceptional thoracic surgical procedure. The aim of this retrospective study was to report our experience in a referral unit of general thoracic surgery analyzing the early results after flap transposition.

METHODS

We retrospectively analyzed the clinical records, surgical notes, and postoperative results of a cohort of patients who underwent flap transposition in our unit from November 2000 to February 2013.

RESULTS

Overall, a surgical approach adopting flap reconstruction techniques was performed in 81 patients (54 males, 27 females) with a median age of 62 years (range 20-87). Flap transposition was necessary to reconstruct chest wall after resection for malignancy (27 patients), to repair intrathoracic viscera perforation (15 patients), and to fill residual cavities secondary to pulmonary/pleural infection (39 patients). A pedicle muscle flap was transposed in most of cases (64 pts, 79 %), while in the remaining 17 cases (11 %), an omental flap was used. There were no immediate postoperative complications, while three in-hospital deaths occurred due to respiratory or multiorgan failure. Among patients undergone flap transposition to fill a residual cavity, we observed a recurrent bronchopleural fistula in three patients (7.7 %); such patients were treated by repeat flap transposition (2 cases) and by repeat cavernostomy (1 case).

CONCLUSION

Flap transposition may be indicated as part of a multimodal treatment for severely ill patients requiring complex thoracic surgery.

Presence of B cells in tertiary lymphoid structures is associated with a protective immunity in patients with lung cancer

RATIONALE

It is now well established that immune responses can take place outside of primary and secondary lymphoid organs. We previously described the presence of tertiary lymphoid structures (TLS) in patients with non-small cell lung cancer (NSCLC) characterized by clusters of mature dendritic cells (DCs) and T cells surrounded by B-cell follicles. We demonstrated that the density of these mature DCs was associated with favorable clinical outcome.

OBJECTIVES

To study the role of follicular B cells in TLS and the potential link with a local humoral immune response in patients with NSCLC.

METHODS

The cellular composition of TLS was investigated by immunohistochemistry. Characterization of B-cell subsets was performed by flow cytometry. A retrospective study was conducted in two independent cohorts of patients. Antibody specificity was analyzed by ELISA.

MEASUREMENTS AND MAIN RESULTS

Consistent with TLS organization, all stages of B-cell differentiation were detectable in most tumors. Germinal center somatic hypermutation and class switch recombination machineries were activated, associated with the generation of plasma cells. Approximately half of the patients showed antibody reactivity against up to 7 out of the 33 tumor antigens tested. A high density of follicular B cells correlated with long-term survival, both in patients with early-stage NSCLC and with advanced-stage NSCLC treated with chemotherapy. The combination of follicular B cell and mature DC densities allowed the identification of patients with the best clinical outcome.

CONCLUSIONS

B-cell density represents a new prognostic biomarker for NSCLC patient survival, and makes the link between TLS and a protective B cell-mediated immunity.

Systematic lymph node dissection in lung metastasectomy of renal cell carcinoma: an 18 years of experience

BACKGROUND

Pulmonary metastasectomy of renal cell carcinomas (RCC) remains controversial. Thoracic lymph node involvement (LNI) is a known prognostic factor. The aim of our analysis is to evaluate whether patients with LNI, and particularly N2 patients, should be excluded from surgical treatment.

METHODS

We retrospectively reviewed data from 122 patients who underwent operations at two French thoracic surgery departments between 1993 and 2011 for RCC lung metastases.

RESULTS

The population consisted of 38 women and 84 men; the average age at time of metastasectomy was 63.3 years (min: 43, max: 82). LNI was identified as a prognostic factor using univariate and multivariate analysis (median survival: 107 months vs. 37 months, P = 0.003; HR = 0.384 (0.179; 0.825), P = 0.01, respectively). Although differences in survival between metastases at the hilar and mediastinal locations were not significant (median survival: 74 months vs. 32 months, respectively, P = 0.75), length of survival time was associated with disease-free interval less than 12 months (median survival: 23 months vs. 94 months, P < 0.0001; HR = 3.081 (1.193; 7.957), P = 0.02).

CONCLUSION

Although LNI has an adverse effect on survival; long-term survival can be achieved in pN+ patients. Consequently, these patients should not be excluded from surgery. Systematic lymphadenectomy should be performed to obtain more accurate staging and to determine appropriate adjuvant treatment.

Does nodal status influence survival? Results of a 19-year systematic lymphadenectomy experience during lung metastasectomy of colorectal cancer

OBJECTIVES

Resection of pulmonary metastases originating from colorectal cancer is increasingly considered. While several adverse risk factors for long-term outcome are known, the selection of patients who may benefit from surgery remains unclear. In particular, few studies have addressed the impact of lymph node involvement, and signification of the hilar or mediastinal level of extent.

METHODS

We retrospectively reviewed the data of 320 patients operated in two thoracic departments between 1992 and 2011. Appropriate statistical tests were used to compare groups at risk.

RESULTS

There were 105 women and 215 men with a mean age of 63.3 years (range: 27-86) at the time of metastasectomy. Lymph node involvement appeared as a significant prognostic factor in both the univariate and multivariate analyses [median survival: 94 months N0 vs 42 months N+, P < 0.0001; OR = 0.573 (0.329-1), P = 0.05]. Survival was similar for hilar and mediastinal locations (median survival: 47 months vs 37 months, respectively, P = 0.14). Associated hepatic metastases had a negative impact on survival in both univariate and multivariate analyses [median survival: 74 months vs 47 months, P < 0.01; OR = 0.387 (0.218-0.686), P = 0.001]. Multiple lung metastases significantly decreased survival in univariate analysis only (median survival: 81 months vs 55 months, P < 0.01). Disease-free survival and preoperative carcinoembryonic antigen had no impact on survival.

CONCLUSIONS

While lymph node involvement was associated with decreased survival, the impact of mediastinal location on survival did not differ from that of hilar location. Consequently, these patients should not be excluded from surgical treatment.

Surgical management of pulmonary large cell neuroendocrine carcinomas: a 10-year experience

OBJECTIVES

Large cell neuroendocrine carcinoma (LCNEC) represents a relatively rare and poorly studied entity whose management is not clearly established. The aim of this study was to assess clinico-pathological characteristics, treatment modalities and outcomes of LCNEC.

METHODS

A retrospective study of patients operated on for LCNEC between 2000 and 2010 was carried out.

RESULTS

Sixty-three patients (49 men, median age 64 years) with pathologically confirmed LCNEC of the lung were operated on between 2000 and 2010. Neoadjuvant chemotherapy was administered in 16 cases. Standard lobectomy, sleeve lobectomy, bilobectomy and pneumonectomy were performed in 63.5%, 9.5%, 1.6% and 15.8% of cases. There were two cases of extended resection. Sublobar resections were performed in four patients. Postoperative mortality was 1.6%. Postoperative staging was IA, IB, IIA, IIB, IIIA, IIIB and IV in 15.9%, 19%, 20.6%, 4.8%, 34.9%, 4.8% and 0% of cases, respectively. Adjuvant treatments were administered in 70% of cases. Overall 5-, and 8- year survival rates were 49.2% (37-61.6%) and 42% (28.8-56.4%), respectively. Multivariate analysis, including age >64 years, cumulative tobacco consumption, size of tumour, pT and pN parameters showed that only age (P = 0.05, RR 2.1 [0.99-4.43]) and pT parameter (P = 0.0078, RR 2.93[1.33-6.46]) were independent predictors of survival.

CONCLUSIONS

Surgery may achieve satisfactory results in terms of survival, in spite of the similarities of LCNEC with small cell lung cancer. Multimodality management seems necessary.

Fully endoscopic major pulmonary resection for stage I bronchial carcinoma: initial results

INTRODUCTION

Several case-series studies of major pulmonary resection (MPR) by video-assisted thoracic surgery (VATS) for non-small-cell lung cancer (NSCLC) have been published, but fully endoscopic MPR is still very rarely performed. Our objective here was to report the outcomes in 71 patients recently managed using fully endoscopic MPR for NSCLC.

METHODS

From 2007 to 2009, 635 patients with NSCLC underwent MPR (pneumonectomy, lobectomy or segmentectomy). Among them, 71 (11%) had features strongly suggesting clinical stage I NSCLC and were managed by fully endoscopic MPR, with no utility incision. Lobectomy was performed in 63 patients and segmentectomy in eight patients. Conversion to thoracotomy was required in two (2.8%) patients, because of a fused fissure in one and tight pleural adhesions in the other. Radical lymphadenectomy was performed in all patients.

RESULTS

Of the 69 patients managed endoscopically, none died and none experienced intraoperative complications. Mean operating time was 226±38 minutes (range, 137-307 minutes) and mean intraoperative blood loss was 111±93mL (range, 0-450mL). The final histological examination showed stage I NSCLC in 52 patients, NSCLC with node involvement in nine patients (pN1 in 6 and pN2 in 3) and other types of malignancies in eight patients. Mean number of nodes removed was 21±8 after right-sided lymphadenectomy and 23±8 after left-sided lymphadenectomy and the mean number of dissected node sites was 3 (range, 2-5). The postoperative morbidity rate was 23%. Mean postoperative hospital stay length was 6.9±2 days (range, 3-12).

CONCLUSION

Fully endoscopic MPR is safe and meets the criteria for oncological surgery.

Characterization of chemokines and adhesion molecules associated with T cell presence in tertiary lymphoid structures in human lung cancer

De novo formation of tertiary lymphoid structures (TLS) has been described in lung cancers. Intratumoral TLS seem to be functional and are associated with a long-term survival for lung cancer patients, suggesting that they represent an activation site for tumor-specific T cells. Here, we characterized T-cell recruitment to TLS in human lung cancer to identify the adhesion molecules and chemoattractants orchestrating this migration. We found that most TLS T cells were CD62L+ and mainly of CD4+ memory phenotype, but naive T cells were highly enriched in these structures as compared with the rest of the tumor. A specific gene expression signature associated with T cell presence was identified in TLS, which included chemokines (CCL19, CCL21, CXCL13, CCL17, CCL22, and IL16), adhesion molecules (ICAM-2, ICAM-3, VCAM-1, and MAdCAM-1) and integrins (alphaL, alpha4, and alphaD). The presence of the corresponding receptors on TLS T cells was confirmed. Intratumoral PNAd+ high endothelial venules also were exclusively associated with TLS and colocalized with CD62L+ lymphocytes. Together, these data bring new insights into the T-cell recruitment to intratumoral TLS and suggest that blood T cell enter into TLS via high endothelial venules, which represent a new gateway for T cells to the tumor. Findings identify the molecules that mediate migration of tumor-specific T cells into TLS where T cell priming occurs, suggesting new strategies to enhance the efficacy of cancer immunotherapies.

[Primary myxoid mediastinal liposarcoma]

Mediastinal liposarcomas (LPS) are rare tumours. We report a case of primary myxoid LPS in a 22-year-old woman suffering from cough, dyspnoea on exercise and asthenia for 3 weeks. Thoracic MRI showed a large tumour on the right side. After neoadjuvant chemotherapy, a complete resection was performed, followed by adjuvant thoracic irradiation. Eighteen months after the diagnosis, no sign of recurrence was detected. Mediastinal LPS include a heterogeneous group of bulky tumours, the progression of which depends on the histological type. The prognosis is dominated by the operability of the tumour. Adjuvant therapies are not established.

[Pleuropulmonary involvement leading to bilateral pneumothorax in a patient being treated for rheumatoid arthritis]

INTRODUCTION

Rheumatoid arthritis (RA) is a systemic illness where the development of pulmonary nodule has been described in from 4 to 20% of patients. Symptomatic pleural manifestations occur in 3 to 5% of cases. Rarely, pulmonary nodules become necrotic and lead to pleural complications. Bilateral pneumothorax has only rarely been described.

CASE REPORT

We report the case of a 64-year-old woman, who had been treated for RA for several years and presented with bilateral pneumothorax secondary to necrobiosis of one or several pulmonary rheumatoid nodules. The management of the pneumothorax was very prolonged and difficult, and despite surgical pleurodesis, the lung did not reexpand fully. Pathological examination of the pleura revealed a noncaseating granulomatous pattern. The diagnosis of a sarcoidosis like disease, possibly induced by anti-TNFα, or of pleural tuberculosis were suggested, but we concluded that the final diagnosis was of pleural rheumatoid involvement.

CONCLUSION

Bilateral pneumothorax secondary to rheumatoid nodule is a rare entity. The management of such a complication is difficult, particularly in patients who receive an immunosuppressant regimen. A granulomatous pattern has been described rarely in the pleural tissue of these patients. Specific RA pleural involvement has to be taken in consideration when other diagnoses are eliminated, especially tuberculosis or sarcoidosis-like disease.

Which patients should be operated on after induction chemotherapy for N2 non-small cell lung cancer? Analysis of a 7-year experience in 175 patients

OBJECTIVE

The role of surgery in patients with N2 non-small cell lung cancer is debated. The aim of this study was to evaluate the results of surgical resection after induction chemotherapy.

METHODS

We retrospectively reviewed the cases of patients with N2 non-small cell lung cancer who underwent neoadjuvant chemotherapy followed by resection between 2001 and 2007. They all had tumors deemed resectable.

RESULTS

One hundred seventy-five patients entered the study. Most of them received 2 or 3 cycles of chemotherapy (81%), in all cases platinum-based regimens. Chemotherapy response rate was 62%. Operations included 96 lobectomies/bilobectomies and 79 pneumonectomies. Complete resection rate was 94%, and perioperative mortality was 4.5%. A pathologic mediastinal downstaging was found in 39% of patients. Overall median survival time and 5-year survival were 34.7 months and 30%, respectively. Survival was affected by clinical response (median survival time 51 months and 5-year survival 42% for responders versus 19 months and 10% for nonresponders) and by nodal downstaging (51 months and 45% versus 25% and 22%). In the group of responders, nondownstaged patients showed satisfying survival (median survival time 30 months, 5-year survival 30%). In the group of nonresponders, survival was unsatisfactory when a lobectomy was performed (median survival time 20 months, 5-year survival 13%) and poor in case of pneumonectomy (15 months and 6%). Multivariate analysis found 4 factors significantly affecting survival: clinical response, nodal downstaging, number of chemotherapy cycles, and histopathologic response.

CONCLUSIONS

Surgery after chemotherapy could be effective for selected patients with N2 non-small cell lung cancer. Survival for responders is satisfactory, even in case of persistent N2 disease. Prognosis for nonresponders is disappointing.

Triggering of TLR7 and TLR8 expressed by human lung cancer cells induces cell survival and chemoresistance

Compelling evidence suggests that inflammation, cell survival, and cancer are linked, with a central role played by NF-kappaB. Recent studies implicate some TLRs in tumor development based on their ability to facilitate tumor growth; however, to our knowledge, involvement of neither TLR7 nor TLR78 has yet been demonstrated. Here we have demonstrated expression of TLR7 and TLR8, the natural receptors for single-stranded RNA, by tumor cells in human lung cancer in situ and in human lung tumor cell lines. Stimulation with TLR7 or TLR8 agonists led to activated NF-kappaB, upregulated expression of the antiapoptotic protein Bcl-2, increased tumor cell survival, and chemoresistance. Transcriptional analysis performed on human primary lung tumor cells and TLR7- or TLR8-stimulated human lung tumor cell lines revealed a gene expression signature suggestive of chronic stimulation of tumor cells by TLR ligands in situ. Together, these data emphasize that TLR signaling can directly favor tumor development and further suggest that researchers developing anticancer immunotherapy using TLR7 or TLR8 agonists as adjuvants should take into account the expression of these TLRs in lung tumor cells.

Totally endoscopic anatomic pulmonary segmentectomies

Although some series of video-assisted major pulmonary resections have been reported, very few series of totally endoscopic lobectomies have been published and - to our knowledge - none of totally endoscopic anatomic segmentectomies. We have recently performed five anatomic segmentectomies using this approach. The video demonstrates the main steps of the procedure, based on the recordings of three different operations: a lingulectomy, a left basilar segmentectomy and a resection of the right lower lobe superior segment.

Thoracoscopic resection of bulky intrathoracic benign lesions

BACKGROUND

Video-assisted thoracic surgery (VATS) is used for the diagnosis and treatment of some mediastinal lesions. However, large-size tumours are usually approached by thoracotomy or sternotomy. We report our experience of a full thoracoscopic approach for bulky intrathoracic lesions.

METHODS

From November 2002 to March 2007, 14 patients with a bulky intrathoracic mass were referred for resection. The study group consisted of eight females and six males with a mean age of 44 years (range: 13-74). We defined as bulky a mass with a minimal cross-sectional diameter equal to or larger than 50 mm, as measured on the specimen by the pathologist.

RESULTS

Thoracoscopic resection was completed in all patients. In 4 cases, the mass originated from the pleura, and in 10 cases from the mediastinum. The larger diameter of the lesion ranged from 50 mm to 160 mm, with a median of 90.2 mm. Operative time, calculated from insertion of the first trocar to skin closure, ranged from 40 to 190 min (mean: 102). Mean chest drain duration was 2.1 days (range: 1-4 days) and the mean hospital stay was 4.3 days (range: 3-11 days). There were no major postoperative complications. The final pathological diagnoses were the following: solitary fibrous tumours of the pleura (4), benign thymic cysts (2), teratomas (2), bronchogenic cyst (1), benign thymoma (1), pleuropericardial cyst (1) and benign neurogenic tumours (3).

CONCLUSIONS

With experience and use of appropriate instrumentation, resection of bulky intrathoracic lesions by thoracoscopy is feasible and safe. It should be considered as a reliable alternate for tumours that are benign and most often asymptomatic.

The transmanubrial approach: A new operative approach to cervicothoracic neuroblastoma in children

BACKGROUND

Cervicothoracic neuroblastoma originates from the cervical sympathetic nerves and ganglia and thus presents a problem when dissecting the vascular and nervous elements of the subclavian region. The standard operation is based on thoracotomy or dual cervicotomy/thoracotomy, but these approaches do not provide optimal control of the subclavian vessels. We report our experience in children with cervicothoracic neuroblastoma by using a technique usually performed for apical lung cancer.

METHODS

Four patients with localized cervicothoracic neuroblastoma with no N-myc amplification were resected after chemotherapy by this approach. The anatomic evaluation was performed preoperatively with angio-magnetic resonance imaging. This transmanubrial approach, performed through a manubrial L-shaped transection and first costal cartilage resection, affords excellent access to the subclavian region with safe control of the vessels and nerves and exposure of the first 4 thoracic intervertebral foramina.

RESULTS

Removal of more than 90% of the tumor was possible in all cases. The postoperative course was uneventful in 3 cases, and the fourth patient with a left-sided tumor had a transient chylothorax. No recurrence occurred with a follow-up period of 8 to 32 months.

CONCLUSIONS

The transmanubrial approach is an osteomuscular-sparing technique that seems particularly suitable for the treatment of these tumors, which require a resection that is as complete as possible to avoid postoperative chemotherapy and tumor relapse.

Resection for Tumors With Carinal Involvement: Technical Aspects, Results, and Prognostic Factors

BACKGROUND

Resection of tumors with carinal involvement remains a challenge because of specific problems of operative technique and airway management. We reviewed our experience with carinal resection and studied factors influencing postoperative course and long-term survival.

METHODS

Between 1983 and 2002, 65 patients underwent a carinal resection for non-small-cell lung cancers involving the carina (54 squamous cell carcinomas and 11 adenocarcinomas).

RESULTS

Fifty-eight right sleeve pneumonectomies and 2 left sleeve pneumonectomies were performed. In addition, five tracheocarinal resections with double bronchial reimplantation (no lung resection) were also performed. The intraoperative airway management consisted of high-frequency jet ventilation in 83% of patients and intermittent conventional ventilation through the operative field in the remaining 17% of patients. Operative mortality was 7.7%. Resection was complete in 61 patients. The overall 5-year and 10-year survival rates were 26.5% and 10.6%, respectively. Patients with N0 or N1 disease had a 5-year survival of 38% compared with 5.3% for those with N2 disease (p < 0.01). At multivariate analysis only nodal status (N0, N1 versus N2; p = 0.0046) had a significant impact on long-term survival.

CONCLUSIONS

Carinal resection provides acceptable results in terms of operative mortality and long-term survival rates. Patients should be carefully selected and probably enrolled in a multimodality treatment program in case of anticipated mediastinal lymph node involvement.

Variable sensitivity and specificity of TTF-1 antibodies in lung metastatic adenocarcinoma of colorectal origin

Thyroid transcription factor-1 (TTF-1) is considered as a reliable marker for differential diagnosis in distinguishing primary adenocarcinomas of the lung from extrathoracic origins. We previously reported the first case of lung metastasis of colorectal origin, with nuclear expression of TTF-1. As most previous studies were performed on series of extrathoracic primary tumors, we raised the question of a possible role of lung microenviroment in TTF-1 expression. We investigated the rate of TTF-1 expression in lung metastases of extrathoracic adenocarcinomas and compared results of immunohistochemistry performed with different primary antibodies. Two different clones of antibodies (8G7G1/1 from Dako, SPT24 from Novocastra) raised against TTF-1 were used on 56 lung-metastatic malignant tumors, 41 from colorectal origin. A series of primary colorectal (90 cases) and primary pulmonary adenocarcinomas (86 cases) were also investigated. Four of 41 (10%) lung metastases of colorectal adenocarcinomas displayed a nuclear staining for TTF-1 with SPT24 clone. Three of the four positive cases displayed similar nuclear staining in primary and/or other extrathoracic metastatic sites as well as four of 90 (5%) primary colorectal adenocarcinomas, ruling out the role of lung microenvironment. None of them was positive with 8G7G1/1 clone. Sensitivity between two sets of antibodies was compared in 86 primary pulmonary adenocarcinomas. Nuclear staining was detected in 72 cases (84%) with Novocastra's antibody and 56 cases (65%) with Dako's. Significant discordance was observed (P < 0.01). These results suggest that the diagnostic virtue of TTF-1 detection depends on the used antibody's clone. The SPT24 clone seems to have a stronger affinity for TTF-1 protein but may lead to a few positive colorectal adenocarcinomas.

Perioperative analysis of biopsies issued from mediastinoscopy

BACKGROUND

The objective of this study was to evaluate frozen sections of samples obtained at mediastinoscopy for their clinical usefulness.

METHODS

This study retrospectively reviewed the records of all patients who underwent mediastinoscopy with perioperative frozen sections in a 1-year period.

RESULTS

A total of 123 consecutive patients underwent the procedure. There were no false-positive results. Of the 71 malignant proliferations, 67 were diagnosed from frozen sections. The technique never failed to establish the absence of mediastinal nodal involvement in patients with suspected or proven lung tumors and enlarged nodes (n = 18) who underwent immediate thoracotomy. Frozen sections allowed recognition (n = 36) or strong suspicion (n = 4) of N2 disease in patients subsequently treated by induction chemotherapy. The technique never failed to establish the nonresectability of lung cancer in patients for whom this condition was suspected perioperatively (clinical stage IIIb; n = 10).

CONCLUSIONS

Mediastinoscopy with frozen sections remains an extremely useful tool for the management of paratracheal or subcarinal mediastinal disease.

Résultats de la TEP [18F]-FDG dans la stadification préopératoire des tumeurs pulmonaires

BACKGROUND

Positron emission tomography (PET) with [18F]fluorodeoxyglucose (FDG) has recently established itself as an important imaging strategy in the management of respectable non-small cell bronchial carcinoma (NSCLC). In this study we report our experience of the impact of FDG-PET in the pre-operative assessment of NSCLC.

METHODS

In a single centre retrospective study between 01 January 2000 and 31 Dec 2002, 108 FDGPET scans were performed during the preoperative assessment of histologically proven or strongly suspected NSCLC.

RESULTS

The sensitivity, specificity and accuracy of FDG-PET for the characterization of a parenchymatous opacity were 96%, 71% and 92% respectively (4 false negatives, 5 false positives). The sensitivity, specificity and accuracy for mediastinal node involvement were 62%, 94% and 84% respectively (10 false negatives and 4 false positives). The sensitivity, specificity and accuracy for the characterization of adrenal nodules were 88%, 100% and 97% (1 false negative) and for satellite pulmonary nodules 50%, 75% and 64% (2 false negatives and 3 false positives).

CONCLUSION

FDG-PET is a useful imaging modality in the pre-operative management of NSCLC but is limited particularly in the characterization of lesions less than 10 mm in diameter and in the evaluation of mediastinal lymph nodes.

Early and long-term results of lung resection for non-small-cell lung cancer in patients with severe ventilatory impairment

OBJECTIVE

To study clinical characteristics, surgical treatment modalities, early and long-term outcome of patients with severe ventilatory impairment undergoing lung resection for NSCLC.

METHODS

We performed a retrospective review of clinical records of all patients with severe chronic ventilatory impairment (FEV1 and/or FVC< or =50% of predicted values) operated on for NSCLC in a 21-year period (1983-2003).

RESULTS

One hundred and six patients were operated on. Mean FEV1 and FVC were 40% (range 23-50%) and 69% (17-117%), respectively. An obstructive pattern was observed in 87 cases (82%). Extent of maximal exeresis was based on the assessment of predicted post-operative FEV1 (ppoFEV1). Major resections were contraindicated if ppoFEV1 was lower than 30%. Sixteen pneumonectomies, 73 lobectomies and 17 sublobar resections were carried out. Pathologic stages were I, II, IIIA and IIIB in 58, 26, 18 and 4 cases, respectively. Resection was complete in 104 patients. Operative mortality and morbidity were 8.5% (n=9) and 70% (n=74), respectively. Twenty-two patients needed prolonged (>48 h) mechanical ventilation. Overall mean ppoFEV1 loss was 9.1% (0-34%). If ppoFEV1 loss was >15%, the morbidity rate was 100%. Mean PaCO2 and ppoFEV1 loss were higher among patients who died (41 mmHg versus 37 mmHg, P=0.02 and 13.2% versus 8.5%, P=0.025, respectively) as compared with operative survivors. Among patients with PaCO2>39 mmHg and ppoFEV1 loss>15% (n=9), mortality rate was 33%. Overall 1-year and 5-year survival rates were 82 and 33%, respectively. Respiratory failure was the cause of late death in 2 patients. Among patients available at follow-up (n=85), respiratory function was considered subjectively improved, stable and worsened in 6 (7%), 62 (73%) and 17 (20%) cases, respectively. Eleven patients needed continuous oxygen therapy.

CONCLUSIONS

Lung resection should not be denied a priori in patients with severe ventilatory impairment. Evaluation of predicted post-operative function often allows major resections, which are functionally economic, at the price of a high operative morbidity. Operative mortality, long-term survival and respiratory function are acceptable in the absence of a valid therapeutic alternative.

Results of superior vena cava resection for lung cancer

AIMS

The benefits of superior vena cava (SVC) resection for lung cancer remain controversial. Data obtained in four international centers were analyzed in order to identify prognostic factors and thus guide in future patient selection.

MATERIALS AND METHODS

Retrospective study. Prognostic factors were examined by logistic regression for postoperative morbidity/mortality using the Kaplan-Meier method (log rank test) and the Cox proportional-hazard model for survival.

RESULTS

From 1963 to 2000, 109 patients underwent SVC resection. Induction treatment was given to 23 (21%) patients. The SVC was resected for T involvement in 78 (72%) cases and for N involvement in 31 (28%) cases. Fifty-five (50.5%) patients underwent pneumonectomy (20 with carinal resection), while the remaining underwent lobar resections. Prosthetic SVC replacement was performed in 28 (26%) patients; partial resection with running suture (53%), vascular stapler (13%), or patch (7%) was performed in 80 patients; 1 patient did not undergo reconstruction. Pathological examination identified direct involvement (T4) in 66 (60%) patients and N2 disease in 55 (50%) patients. Major postoperative morbidity and mortality were 30 and 12%, respectively. Median intensive care unit stay was 3 days, while median hospital stay was 16 days. Five-year survival was at 21%, with median survival at 11 months. In multiple regression analysis, induction treatment was associated with an increased risk of major complications (P = 0.016). None of the factors assessed demonstrated an association with postoperative death. In multivariate survival analysis, both pneumonectomy and complete resection of the SVC with prosthetic replacement were associated with a significant increased risk of death (P = 0.0013 and 0.014, respectively).

CONCLUSIONS

The radical resection of lung cancer involving the SVC may result in a permanent cure in carefully selected patients. The type of pulmonary resection (i.e., pneumonectomy) and the type of SVC resection (i.e., complete resection with prosthetic replacement) are the prognostic factors with the greatest adverse effect on survival.

Peroperative frozen section analysis of TTF-1 antigen expression

BACKGROUND

The assessment of thyroid transcription factor 1 (TTF-1) expression is a useful way to investigate the origin of lung adenocarcinomas or large cell carcinomas when dealing with a solitary lung nodule in a patient with a history of extrathoracic cancer. However, if immunohistological analysis has not been performed before surgery, a peroperative frozen section may be insufficient to distinguish between a primary pulmonary tumour and a metastatic tumour.

AIMS

To develop a technique for the rapid assessment of TTF-1 expression that could improve the ability of frozen section peroperative histological diagnosis to answer such questions.

METHODS

A rapid immunohistochemical technique (lasting 30 minutes) to assess the expression of TTF-1 was developed and tested.

RESULTS

Among the 45 interpretable cases, results of frozen section immunohistochemistry were similar to those found by the standard immunohistochemical technique for the expression of TTF-1.

CONCLUSIONS

This technique enables TTF-1 to be analysed peroperatively, but further prospective studies are needed to assess its usefulness in routine practice.

Surgical treatment of superior sulcus tumors: results and prognostic factors

OBJECTIVES

To study the clinical characteristics, treatment modalities, and outcome of patients with superior sulcus tumors who underwent surgery over a 15-year period.

DESIGN

Retrospective clinical study.

METHODS

Clinical records of all patients operated on for superior sulcus tumors by the same surgical team between 1988 and 2002 were reviewed retrospectively.

RESULTS

Sixty-seven patients were operated on in this period. All the patients underwent en bloc lung and chest wall resection. Surgical approaches were as follows: posterolateral thoracotomy according to Paulson (n = 33), combined transcervical and transthoracic approach (n = 33), and isolated transcervical approach (n = 1). Types of pulmonary resection included lobectomies (n = 59), pneumonectomies (n = 2), and wedge resections (n = 6). Pathologic stages were IIB, IIIA, and IIIB in 49 cases, 12 cases, and 6 cases, respectively. Resection was complete in 55 patients (82%). Operative mortality was 8.9% (n = 6). Postoperative treatment was administered in 53 patients (radiotherapy, n = 42; chemoradiotherapy, n = 9; and chemotherapy, n = 2). Overall 2-year and 5-year survival rates were 54.2% and 36.2%, respectively. Five-year survival was significantly higher after complete resection than after incomplete resection (44.9% vs 0%, p = 0.000065). The presence of associated major illness negatively affected the outcome (5-year survival, 16.9% vs 52%; p = 0.043). Age, weight loss, respiratory impairment, tumor size, presence of nodal disease, and histologic type did not influence the long-term outcome. At multivariate analysis, only the completeness of resection and the absence of associated major comorbidities had an independent positive prognostic value.

CONCLUSIONS

Superior sulcus tumor remains an extremely severe condition, but long-term survivals may be achieved in a large percentage of cases. The presence of associated major illness and the completeness of resection are the two most important factors affecting the long-term outcome.

Catamenial pneumothorax: a prospective study

OBJECTIVES

To evaluate the incidence of catamenial pneumothorax (CP) among women who have been referred for the surgical treatment of spontaneous pneumothorax (SP) and to study its pathogenic mechanisms.

DESIGN

A prospective study of women of reproductive age who have been referred to our center for the surgical treatment of SP. Patients with pneumothorax secondary to a known lung disease were excluded.

SETTING

A university hospital.

METHODS

At the preoperative evaluation, special attention was given to the investigation of a possible temporal relationship between pneumothorax and menses. Video-assisted thoracoscopy constituted the operative technique of choice. The lung was inspected to identify blebs or bullae and the origin of possible air leaks. Signs of thoracic endometriosis were also carefully searched for. The diaphragm was systematically inspected to search for holes and/or endometrial implants. When limited diaphragmatic abnormalities were found, a partial diaphragmatic resection was carried out using an endoscopic stapler. In case of lesions that were not accessible by a purely endoscopic approach, a utility minithoracotomy was used.

RESULTS

In an 18-month period, 32 women with SP were referred for surgery. In eight cases, the catamenial character of the pneumothorax was recognized by clinical history. In all these patients, the following diaphragmatic abnormalities were found at surgery: holes (one patient); endometrial implants (three patients); and both (four patients). Visceral pleural endometriosis was found in one patient. During pathologic examination, diaphragmatic endometriosis was confirmed in seven of the eight cases. In one patient, it was associated with pulmonary and pleural endometriosis. In only one patient (with multiple diaphragmatic holes and a pulmonary nodular brown lesion), endometriosis could not be confirmed at histology, but signs of parenchymal focal hemorrhages were found.

CONCLUSIONS

Our experience shows that (1) CP is more frequent than expected and (2) diaphragmatic abnormalities seem to play a fundamental role in its pathogenesis.

Superior vena cava resection with prosthetic replacement for non-small cell lung cancer: long-term results of a multicentric study

OBJECTIVES

Superior vena cava (SVC) resection with prosthetic replacement for non-small cell lung cancer (NSCLC) is infrequently performed and oncological results are unclear. To establish a historical benchmark for this extended surgery, we have updated and reviewed data from four international centers.

METHODS

Data were obtained through retrospective chart review. Prognostic factors were analyzed using first univariate techniques and subsequently multiple regression (logistic regression). Kaplan-Meier overall survival was calculated and prognostic factors examined by log-rank test and the estimation of hazard ratios using Cox regression.

RESULTS

From 1985 to 2000, 28 patients underwent SVC resection with prosthetic replacement for NSCLC. During the same period, 65 patients underwent partial SVC resection. Induction treatment was performed in 25% of patients. The resection was done for T involvement in 22 patients (79%), and for N2 involvement in the remaining. There were 12 tracheal sleeve resections, four pneumonectomies, and 12 lobar or sublobar resections with or without bronchoplasty. The median clamping time was 40 min. The median diameter of the prosthesis used was No. 14. Pathological examination showed direct SVC invasion (T4) in 79% of patients, whereas N2 disease was present in 50% of patients. Median intensive care unit and hospital stay were 3 and 20 days, respectively. The postoperative morbidity and mortality were 39 and 14%, respectively. The overall 5-year probability of survival was 15% (median of 9 months, range 0-105 months). Patients who underwent partial SVC resection during the same period had a significantly higher probability of survival (P=0.03). Induction chemotherapy was associated with a significant increase of postoperative morbidity in multivariate analysis. None of the potential prognostic factors analyzed in multivariate analysis were associated with survival, but the type of resection (sleeve pneumonectomy/pneumonectomy) were borderline significant.

CONCLUSIONS

SVC resection with prosthetic replacement should not be considered an absolute contraindication in patients with NSCLC; however, the poor oncological results suggest more restrictive and severe criteria of patient selection (mediastinoscopy, induction treatment, no pneumonectomy, no N2 disease).

Solitary fibrous tumors of the pleura: clinical characteristics, surgical treatment and outcome

OBJECTIVE

The aim of this paper is to study clinical characteristics, surgical treatment and outcome of patients with solitary fibrous tumor of the pleura operated in our institutions in a 20-year period.

METHODS

Clinical records of all patients operated for solitary fibrous tumors of the pleura between 1981 and 2000 were reviewed retrospectively. Tumors were classified as malignant in the presence of at least one of the following criteria: (1) high mitotic activity; (2) high cellularity with crowding and overlapping of nuclei; (3) presence of necrosis; (4) pleomorphism; otherwise they were considered as benign.

RESULTS

Sixty patients (mean age 55 years) were operated in this period. None had asbestos exposure. Symptoms were present in 31 cases. Surgical approaches included thoracotomy (n=53), video-assisted thoracoscopy (n=6), and median sternotomy (n=1). Tumors originated from visceral pleura in 48 cases, from parietal, mediastinal or diaphragmatic pleura in seven, two and three cases, respectively; their mean diameter was 8.5 cm. Tumors could be resected with their implantation basis in 49 patients. In the remaining 11, extended resections were performed, including lung parenchyma (lobectomy, n=4, pneumonectomy, n=2), osteomuscular chest wall structures (n=2), diaphragm (n=2), and pericardium (n=1). Two postoperative deaths (due to myocardial infarction and pulmonary embolism, respectively) occurred. Tumors were pathologically benign in 38 cases and malignant in 22 cases. Mean follow-up was 88 months. Resection was complete in all the patients with benign tumors and no recurrence occurred. Resection was considered as complete in 21/22 malignant tumors. Local recurrence was observed in two cases. Both could be successfully managed by iterative exeresis (no extended resection had been initially performed). Metastatic disease (responsible for patient's death) was observed following the only incomplete resection. Actuarial 5- and 10-year survival rates were 97% for benign tumors and 89% for malignant ones.

CONCLUSIONS

Surgical resection provided cure in all the patients with benign tumors. As insufficiency of exeresis is associated with all recurrences in malignant tumors, completeness of resection is in our experience the best prognostic factor in these forms.