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Background: Surgical lung biopsy is essential in the diagnostic algorithm of interstitial lung disease (ILD) of unknown cause. Safety concerns have been recently reiterated. This study prospectively assessed the yield of diagnosis and safety of video-assisted thoracoscopic surgical lung biopsy (VATS-LB) for ILD diagnosis., Methods: This prospective study, conducted in 6 ILD-referral Paris hospitals, included 103 patients with ILD. VATS-LB was proposed after initial multidisciplinary discussion. A final diagnosis was made after the procedure, during a second multidisciplinary discussion. The main outcome was to determine the final diagnoses and their proportion after VATS-LB. Other outcomes were the percentage of change in diagnosis and treatment propositions after VATS-LB and adverse events during 3 months after the operation, postoperative pulmonary function, quality of life, and pain., Results: A definite diagnosis was reached in 87 patients (84.4%), and 16 remained unclassifiable (15.6%). After VATS-LB, the hypothesized diagnosis changed in 65 patients (63.1%) and treatment changed in 41 patients (39.8%). One patient died of acute exacerbation. In-hospital complications were predicted by a shorter preoperative 6-minute walking test distance and by forced vital capacity lower than 77%. Postoperative quality of life was not modified at 3 months, whereas forced vital capacity decreased slightly. Postoperative neuropathic pain was revealed in 5% of patients at 1 month and in 2% at 3 months., Conclusions: VATS-LB dramatically changed preoperative hypothetical diagnoses and treatment in ILD of unknown cause, with good patient survival in ILD referral centers., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The coronavirus disease 2019 (COVID-19) outbreak was officially declared in France on March 14, 2020. The objective of this study is to report the incidence and outcome of COVID-19 after surgical resection of non-small cell lung cancer in Paris Public Hospitals during the pandemic., Methods: We retrospective analyzed a prospective database including all patients who underwent non-small cell lung cancer resection between March 14, 2020, and May 11, 2020, in the 5 thoracic surgery units of Paris Public Hospitals. The primary endpoint was the occurrence of SARS-CoV-2 infection during the first 30 days after surgery., Results: Study group included 115 patients (male 57%, age 64.6 ± 10.7 years, adenocarcinoma 66%, cT1 62%, cN0 82%). During the first month after surgery, 6 patients (5%) were diagnosed with COVID-19. As compared with COVID-negative patients, COVID-positive patients were more likely to be operated on during the first month of the pandemic (100% vs 54%, P = .03) and to be on corticosteroids preoperatively (33% vs 4%, P = .03). Postoperative COVID-19 was associated with an increased rate of readmission (50% vs 5%, P = .004), but no difference in 30-day morbidity (for the study group: grade 2, 24%; grade 3, 7%; grade 4, 1%) or mortality (n = 1 COVID-negative patient, 0.9%). Immediate oncologic outcomes did not differ significantly between groups (R0 resection 99%, nodal upstaging 14%, adjuvant chemotherapy 29%)., Conclusions: During the COVID-19 pandemic, surgical treatment of non-small cell lung cancer was associated with a rate of postoperative COVID-19 of 5% with a significant impact on readmissions but not on other outcomes studied., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Postoperative systemic artery to pulmonary vein fistula is very rare. In this report, we describe an exceptional condition of both intrapulmonary arteriovenous fistula and systemic artery to pulmonary vein fistula, involving all right hemithoracic systemic arteries, inducing left-to-left shunt. This condition was responsible for heart failure, 24 years after a right upper lobectomy for inflammatory tumor. Investigations included computed tomographic angiography, arteriography, and four-dimensional flow magnetic resonance imaging. Differential diagnosis and management are discussed., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Heart transplantation after lung cancer surgery can be questionable because of the high risk of cancer recurrence. We report the results of two patients. The first underwent right lobectomy in 2008 for pT1N0 adenocarcinoma, heart-transplantation in 2010, and surgery for synchronous adenocarcinoma and squamous-cell carcinoma in 2012. The second underwent left segmentectomy for pT1aN0 adenosquamous carcinoma and transplantation in 1995 and then surgery for pT1aN1 adenocarcinoma in 2013. Posttransplantation lung cancer histologic analysis results were different in both cases, demonstrating the absence of metastatic recurrence. Thus, early stage lung cancer might not be a contraindication to heart transplantation, nor are long delays be necessary before registering on a waiting list., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study was to evaluate the clinical characteristics and factors that influence the long-term outcomes of solitary fibrous tumors of the pleura., Methods: We conducted a retrospective study in 2 centers and reviewed 80 patients who underwent surgery between May 1984 and April 2011., Results: Of the 80 patients (29 male; median age, 60 years [33 to 85 years]), 47 were symptomatic (59%). The tumors originated from the visceral pleura in 62 cases (79%) and from the parietal pleura in 18 cases (22%). The tumors were pedunculated in 66 cases (83%) and sessile in 20 cases (17%). Surgical resection with histologically free margins was accomplished in 76 of 79 patients (93%). The tumors were classified as benign in 51 cases (65%) and as malignant in 28 (35%). The factors that were significantly associated with malignant tumors were the presence of symptoms (p = 0.03), a mean diameter 10 cm or greater (p = 0.0004), fibrous adherences (p = 0.003), pleural effusion (p = 0.003), and a Ki67 10% or greater (p = 0.003). The median follow-up was 69 months (range, 1 to 315). Local recurrence occurred in 3 cases. The overall 5- and 10-year survival rates were 90% and 86%, respectively, and the mean survival time was 255 ± 15 months. There were no differences between the benign and malignant tumors., Conclusions: The recurrence rates are low after surgeries for both benign and malignant solitary fibrous tumors of the pleura. However, the factors that are predictive of recurrence have yet to be specified and require additional immunohistochemical and genetic investigations., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Few randomized controlled trials have been published on outcomes after treatment of spontaneous pneumothorax. The objective of this study was to assess recurrence, pulmonary complications, prolonged air leak, and hospital duration of stay in patients undergoing videothoracoscopic surgery (VATS) or thoracotomy for spontaneous pneumothorax., Methods: From January 2005 to December 2012, 7,396 patients underwent operations for spontaneous pneumothorax and were entered into the French national database. The propensity score, which is the conditional probability of assignment to a particular treatment given a vector of observed covariates, was used for the analysis. Three statistical analyses were performed: matching, subclassification, and the inverse probability of treatment weighting. The primary end point was recurrence, defined as a pneumothorax requiring a chest tube or new operation. The secondary end point was pulmonary complications, prolonged air leak, and hospital duration of stay., Results: VATS was performed in 6,419 patients and thoracotomy in 997 patients. Pleurodesis was performed by abrasion or pleurectomy in 5,873 patients (79%) and by using a chemical agent in 1,523 patients (21%). The median time to recurrence was 3 months (range, 1 to 76 months). The recurrence rate was higher in the VATS group regardless of the statistical analysis that was used: 2.1 for unmatched samples, 2.5 for matched samples, 2.3 for subclassification, and 1.7 for the inverse probability of treatment weighting. VATS significantly reduced the hospital duration of stay by 1 day but did not significantly reduce pulmonary complications or prolonged air leak., Conclusions: VATS reduced the hospital duration of stay, but the risk of recurrence was higher. This information should be delivered to patients before pneumothorax operations., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: It has been proposed that examining a greater number of lymph nodes (LNs) in patients with non-small-cell lung cancer (NSCLC) treated by surgical resection may increase the likelihood of proper staging and affect outcome. Our purpose was to evaluate the interindividual variability and prognostic relevance of the number of LNs harvested during complete pulmonary and mediastinal lymphadenectomy performed for NSCLC., Methods: We prospectively collected and retrospectively reviewed the data from 1,095 patients who underwent lung cancer resection in association with systematic lymphadenectomy and pulmonary and mediastinal LN counts from 2004 to 2009. We analyzed the interindividual variability and prognostic impact of the number of LNs on overall survival (OS)., Results: The mean number of harvested pulmonary and mediastinal LNs was 17.4±7.3 (range, 1-65) and was higher in male patients, right lung surgical procedures, lobectomy and pneumonectomy, N2 disease, and pIII stage. The mean number of harvested mediastinal LNs was 10.7±5.6 and was normally distributed (range, 0-49; median, 10). The 5-year survival rate was 53.8%. Overall survival was influenced by the number of involved stations (single-station versus multi-station disease, 5-year survival rates 31.5% versus 16.9%, respectively; p=0.041) but not by the number of harvested LNs, the number of harvested mediastinal LNs, or the number of positive mediastinal LNs., Conclusions: After lung cancer resection and complete lymphadenectomy, the number of LNs is subject to normally distributed interindividual variability, with no significant impact on OS. Recommending an optimal number of nodes is therefore arbitrary. Instead, our recommendation is to perform a complete systematic pulmonary and mediastinal lymphadenectomy following established anatomical boundaries., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: N2 involvement has dramatic consequences on the prognosis and management of patients with non-small cell lung cancer (NSCLC). N2-NSCLC may present with or without N1 involvement, constituting non-skip (pN1N2) and skip (pN0N2) diseases, respectively. As the prognostic impact of this subclassification is still a matter of debate, we analyzed the prognosis of pN2 patients according to the pN1-involvement and the number of N2-stations concerned., Methods: The medical records of consecutive patients who underwent surgery for pN2-NSCLC in 2 French centers between 1980 and 2009 were prospectively collected and retrospectively reviewed. Patients undergoing induction therapy, exploratory thoracotomy, incomplete mediastinal lymphadenectomy, or incomplete resections were excluded. The prognoses of pN1N2 and pN0N2 patients were first compared, and then deciphered according to the number of N2 stations involved (single-station: 1S, multi-station: 2S)., Results: All together, 871 patients underwent first-line complete surgical resection for pN2-NSCLC during the study period, including 258 pN0N2 (29.6%) and 613 pN1N2 (70.4%) patients. Mean follow-up was 72.8±48 months. Median, 5- and 10-year survivals were, respectively, 30 months, 34%, and 24% for pN0N2 and 20 months, 21%, and 14% for pN1N2 patients (p<0.001). Multivariate analysis revealed 3 different prognostic groups; ie, favorable in pN0N2-1S disease, intermediate in pN0N2-2S and pN1N2-1S diseases, and poor in pN1N2-2S disease (p<0.001)., Conclusions: Among pN2 patients, the combination of N1 involvement (pN0N2 vs pN1N2) and number of involved N2 stations (1S vs 2S) are independent prognostic factors. These results might be taken into consideration to sub-classify the heterogeneous pN2-NSCLC group of patients., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Historically, right middle lobe (RML) non-small cell lung cancer (NSCLC) has been reported to be associated with a higher rate of pneumonectomy than other right-sided locations. Because this would discourage minimally invasive approaches in RML-NSCLC, we sought to update this assertion through the study of a large surgical series., Methods: Clinical records of patients who underwent operations for right-sided NSCLC in 2 French surgical centers were prospectively entered and retrospectively reviewed. Demographic and pathologic characteristics of RML NSCLC were compared with other right-sided NSCLC., Results: This study included 3,234 right-sided and 211 RML (6.5%) NSCLC patients. After exclusion of 14 patients who underwent exploratory thoracotomy, patients were a mean age of 61.5 years, most RML resections occurred in men (134 [72.8%]), and most were lobectomies (wedge, n=4; lobectomy, n=102; bilobectomy, n=22; pneumonectomy, n=56). Pathologic analysis revealed adenocarcinoma in 88 patients (47.8%) and squamous cell carcinoma in 80 (43.5%). pStaging was stage I in 86 patients (46.7%), II in 42 (22.8%), III in 47 (25.5%), and IV in 9 (4.9%). Superior and inferior mediastinal N2 were found in 45.4% and 54.6% of patients, respectively, when 1 station was involved. When compared with other right-sided NSCLC, RML was characterized by higher T status and higher rates of bilobectomy (10.9% vs 5.6%, p=0.0017) and pneumonectomy (30.3% vs 22.3%, p=0.0071) but similar 5-year survival (47.4%)., Conclusions: Compared with other right-sided NSCLC, RML location is associated with a higher albeit limited rate of pneumonectomy., (Copyright © 2014. Published by Elsevier Inc.)

Background: Adenosquamous carcinoma (ASC) is a mixed glandular and squamous cell carcinoma with a more aggressive behavior than the other histologic subtypes of lung cancer. We revisited the pathologic characteristics and surgical results associated with ASC., Methods: Patients who underwent surgical resection of non-small cell lung cancer in two French centers were retrospectively reviewed. Patients presenting with ASC (n=141) were compared to those with adenocarcinomas (AC, n=2415) and squamous cell carcinomas (SCC, n=2662) regarding preoperative data, histologic characteristics, and outcome., Results: The frequency of ASC and SCC decreased over time. ASC patients were similar to AC patients regarding age, sex, and smoking habits. The type of resections performed in ASC patients was intermediary between SCC (more pneumonectomy) and AC (more lobectomy) patients. ASC was associated with larger size, more frequent visceral pleura invasion, microinvasion of the lymphatic vessels, and ipsilateral second nodules, compared with SCC and AC. Among the 135 patients with documented ASC, 48% presented with a combination of AC and SCC tumor cells ranging between 40% and 60% of each component, and 55% of cases were associated with undifferentiated large cells. ASC was associated with a lower 5-year survival rate (37%) than SCC and AC (43.4% and 42.8%, respectively, p=0.017). For ASC patients, survival was better during the last decade or in cases of balanced AC/SCC components., Conclusions: ASC is characterized by both histologic aggressiveness and adverse prognosis. In this setting, the impact of adjuvant therapies needs to be reevaluated., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Patients with a history of previous malignancy are often encountered in a discussion of surgical resection of non-small-cell lung cancer (NSCLC). The outcome of patients with 2 or more previous cancers remains unknown., Methods: We performed a retrospective study including all patients undergoing resection for NSCLC from January 1980 to December 2009 at 2 French centers. We then compared the survival of patients without a history of another cancer (group 1), those with a history of a single malignancy (group 2), and those with a history of 2 or more previous malignancies (group 3)., Results: There were 5,846 patients: 4,603 (78%) in group 1, 1,147 (20%) in group 2, and 96 (2%) in group 3. The proportion of patients included in group 3 increased from 0.3% to 3% over 3 decades. Compared with groups 1 and 2, group 3 was associated with older age, a larger proportion of women, earlier tumor stage, less induction therapy, and fewer pneumonectomies. Despite this, postoperative complications and mortality were similar in groups 2 and 3, and higher than in group 1. Five-year survival rates were 44.6%, 35.1%, and 23.6% in groups 1, 2, and 3, respectively (p < 0.000001 for comparison between 3 groups; p = 0.18 for comparison between groups 2 and 3). In multivariate analysis, male sex, higher T stage, higher N stage, incomplete resection, and study group were significant predictors of adverse prognosis., Conclusions: Despite earlier diagnosis and acceptable long-term survival, patients operated on for NSCLC after 2 or 3 previous malignancies carried a worse prognosis than did those undergoing operation after 1 malignancy or if there was no previous diagnosis of cancer., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The influence of nutritional status on outcome after major lung resection remains controversial. Nutritional assessment is not included as a major recommendation in lung cancer guidelines. The purpose of this study was to assess the nutritional status of patients referred for pneumonectomy and to assess the predictive value of malnutrition in determining the surgical outcome., Methods: This study was a multicenter observational trial. The eligibility criterion for participants was pneumonectomy for lung cancer. Criteria for group classification according to nutritional status were albumin and transthyretin levels. Predicted outcomes were major infectious and noninfectious complications and 90-day mortality. Univariate analysis identified independent variables for the predictive model of age, sex, induction chemotherapy, extended resections, treatment side, smoking, and malnutrition. Predictive variables were then included in a logistic regression model., Results: Between January 2010 and December 2011, 86 (mean age, 61.5 years) consecutive patients referred for pneumonectomy (left side, n = 58; right side, n = 28) at 4 thoracic surgery centers were included. The malnutrition group included 33 patients (39%) and the normal nutritional status group included 53 patients. Univariate analysis elected malnutrition, recent active smoking, and extended resection to be included in a multivariate analysis. Multivariate analysis identified malnutrition, recent smoking, and extended resection as predictive variables for major complications and mortality., Conclusions: The frequency of malnutrition detected by biological markers was dramatically high. Malnutrition, as well as recent active smoking and extended resection, is a predictive factor for infectious complications and mortality after pneumonectomy. Nutritional assessment with appropriate markers should be considered before pneumonectomy., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study was to revisit the characteristics and outcomes of adrenocorticotropin-secreting bronchial carcinoid tumor (BCT) responsible for Cushing's syndrome (CS)., Methods: We conducted a single-institution retrospective review of 14 patients who underwent pulmonary resection for BCT that presented as CS from October 1993 to November 2011., Results: The group consisted of 8 male patients (57%) and 6 female patients. The mean age was 40 years (range, 16-63 years). Three patients (21%) underwent unnecessary adrenalectomy or hypophysectomy, or both, before diagnosis of the main cause. The mean interval between clinical presentation and the chest operation was 33 months (range, 3-136 months). Operations included 12 lobectomies (86%), 1 segmentectomy, and 1 wedge excision. All patients underwent radical lymph node dissection. Histologic examination showed 11 typical carcinoids (79%) and 3 atypical carcinoids. Twelve patients were classified pT1 (86%) and 2 patients were classified pT3 because of the presence of 2 tumors in the same lobe. Lymph node metastases were found in 7 patients (50%) (3 pN1 and 4 pN2). The mean follow-up was 59 months (range, 3-174 months). No recurrence was observed., Conclusions: Early detection of adrenocorticotropin-secreting BCTs is challenging. However, it avoids adrenalectomy and unnecessary hypophysectomy, limits the deleterious effects of chronic hypercortisolism, and reduces the risk of metastasis. The high prevalence of lymph node involvement confirms the aggressiveness of these tumors and justifies anatomic resection and radical lymph node dissection. Under these circumstances, the prognosis remains favorable, even in cases of N2 disease., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The prognostic value of vascular microinvasion (VMI) in non-small cell lung cancer (NSCLC) has been a matter of discussion in recent decades. The last T N M classification does not take VMI into account, but many points remain questionable., Methods: A retrospective study was performed of patients undergoing operations for NSCLC during a 20-year period. Lymphatic VMI (LVMI) was classified as group (G) 1, blood VMI (BVMI) as G2, LVMI and BVMI as G3, and no VMI as G4. The demographic, pathologic, T N M characteristics, and long-term survival of each group were analyzed., Results: A total of 3,868 patients (G1, 334; G2, 642; G3, 172; G4, 2,720), mean age 61.9 ± 10.1 years, underwent different types of resection, with complete lymphadenectomy in 88.5%. Adenocarcinomas were more frequent in G1 and G3, and squamous cell carcinomas in G2. In G2, more N1 tumors needed more extensive resections. G1 was equally distributed regardless of tumor size, but G2 prevalence increased with augmenting size. Nodules in the same lobe were significantly more frequent in LVMI than in BVMI. After exclusion of patients with R1 and R2 resections, multivariate analysis confirmed that LVMI and BVMI were independent prognostic factors as well as age, sex, type of resection, T extension, and N involvement., Conclusions: VMI is generally associated with a poorer prognosis. LVMI is less frequent than BVMI but has lower survival rates. The benefit of adjuvant therapy in VMI patients needs to be evaluated., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Lung cancer may invade the pericardium (T3) and the intrapericardial pulmonary veins and left atrium (T4). Our purpose was to analyze the characteristics of this invading process in search of the reasons explaining its poor prognosis., Methods: The clinical records of 4,668 patients who underwent surgery for lung cancer between January 1983 and December 2006 in two thoracic surgery centers were retrospectively reviewed. The epidemiology, pathology, and prognostic characteristics of the tumors invading the pericardium alone (T3) or with pulmonary veins and atrium (T4) were analyzed and compared with all other tumors., Results: There were 75 male and 16 female patients, with 85 pneumonectomies and 6 lobectomies that proved R0 in 59.3% of patients, and contained 69 squamous cell cancers, 11 adenocarcinomas, and 13 miscellaneous tumors; 12 were N0 (13.2%), 31 were N1 (34.1%), and 48 were N2 (52.8%). Pericardium alone was invaded in 32 patients (35.2%), and with pulmonary vein and atrium in 34 (37.3%) and 25 (27.5%), respectively. Patient characteristics were similar in each group. Five-year and 10-year survival rates were 15.1% and 10.4%, respectively. Frequency of pneumonectomy, R1-2 resection, and N1-2 involvement were significantly more important compared with noninvading tumors (p < 10(-6))., Conclusions: Reports on T3 and T4 cancer with pericardial involvement are few, but also stress that pulmonary vein and left atrium invasion does not worsen the prognosis more than pericardial invasion alone. The rich pericardial lymph drainage might enhance the spread of tumor cells, explaining excessively high N1-N2 rates and pericardial invasion-related poor prognosis., (Copyright © 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Many studies focus on bronchial microscopic residual disease (R1) after resection for lung cancer, although R1 also concerns vascular and soft tissues. Our purpose was to study the R1 prognosis at different resection margins and to compare it with the prognosis for those having complete resection (R0)., Methods: We reviewed the clinical records of 4,026 patients from two centers who underwent surgery in view of cure. Despite perioperative frozen section, 216 patients (5.4%) proved R1 and were classified into seven types according to R1 anatomic site: bronchus, peribronchus, great vessels and atrium, mediastinum and pericardium, chest wall, lung tissue, and lymph nodes. Patients who were classified as R0 and R1 were compared, and R1 patients were further studied according to R1 margins., Results: Frequency of R1 increased with the T and N values and type of resection (lobectomies, 3.3% [70 of 2,041 patients]; pneumonectomies, 8.8% [126 of 1,308 patients]; p < 10(-6)). Five-year survival rates for R1 patients were lower than those for R0 patients (20% versus 46%; p < 10(-6)), and were not modified by the degree of T and N involvement or adjuvant therapy, but were better in bronchial and peribronchial (48.4% of R1 patients) than in extrabronchial R1 (26.3% versus 15.6%; p = 0.023). Multivariate analysis confirmed R1 to be an independent factor of poor prognosis (p = 0.0008), after N, T, and age., Conclusions: Long-term survival is possible in case of an R1 margin, but 5-year survival rates are jeopardized. Poor efficacy of adjuvant therapy and global outcome indicate advanced disease or reflect tumor cell aggressiveness, rather than surgical insufficiency, when prevention of R1 margins is guided by frozen-section examination and scrupulously respected., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Surgery is a safe and effective treatment for patients with lung metastases from colorectal carcinoma. Combining chemotherapy and surgery seems to prolong survival time after metastasectomy. Our purpose was to review the effectiveness of surgery with time and evolving managements., Methods: The records of 127 patients were retrospectively analyzed. The characteristics of primary cancer, lung metastases, resections, and associated therapy were studied according to their incidence on survival., Results: There were 74 male and 53 female patients (mean age, 65 years); 223 operations were performed and 314 metastases were resected. Completeness of surgery (n = 117) was the main factor for prolonged survival (5- and 10-year survival, 41% and 27%, versus 0%). There was no factor of significantly better prognosis, but a tendency to higher survival rates was observed in cases of single metastasis, in patients undergoing several lung operations, and in patients in whom liver metastases were previously removed. Three of 7 patients with mediastinal lymph node involvement survived more than 5 years; 58 patients were operated on before January 2000, and 59 between January 2000 and December 2007. Five-year survival rates were 35.1% versus 63.5%, respectively (p = 0.0096), probably related to better selection with modern workup, more frequent use of chemotherapy, and repeated pulmonary resections., Conclusions: Different treatment protocols were reported in the literature and in our series with time, resulting in better survival rates and a more aggressive surgical tendency. The beneficial role of such combined therapy justifies further research, including prospective trials., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Induction chemotherapy does not increase the morbidity and mortality rates of bronchoplastic procedures, but the long-term efficiency remains unclear. The purpose of this retrospective study was to analyze the impact of chemotherapy on resectability and long-term survival., Methods: From 1984 to 2005, 159 consecutive patients with non-small cell lung cancer underwent sleeve lobectomy without (n = 117) or with induction chemotherapy (n = 42). Indications for chemotherapy were N2 lymph node involvement (n = 15), T3 or T4 tumor invasion with doubtful resectability (n = 13), need for tumor size reduction (n = 8), lung function precluding pneumonectomy (n = 4), and brain metastasis (n = 2). None of the patients received induction radiation therapy. We studied tumor characteristics and immediate and long-term results in both groups., Results: Clinical stage III was predominant in the induction chemotherapy group whereas stage II was predominant in the surgery-only group. Complication rates in the induction chemotherapy group and in the surgery-only group were 23.8% and 24.7%, respectively. We observed a greater rate of 1-month-delay smoking cessation before surgery in the induction chemotherapy group (40% versus 22%). The 5-year survival rates were 65.4% in the surgery-only group and 73.4% in the induction chemotherapy group (p = 0.5). The tumor size in the induction chemotherapy group was lower (17.5 versus 30.6 mm; p = 0.01), which reflected the positive impact of chemotherapy on sleeve resection feasibility., Conclusions: Induction chemotherapy before sleeve lobectomy achieves good long-term results. Tumor reduction and limited resection feasibility seemed to be increased, which justify further prospective trials.

Background: Intrathoracic hilar or mediastinal lymph node metastases (HMLNMs) of extrathoracic carcinomas are infrequent. Their treatment strategy is not established and their prognosis poorly known. We reviewed the place of surgical intervention in their management., Methods: Among 565 patients with mediastinal lymph node enlargement, 37 had a history of extrathoracic carcinoma. The enlargement consisted in HMLNMs in 26 (15 men, 11 women), with a mean age of 57.6 (range 19-78) years. Surgical procedures were reviewed., Results: Diagnostic procedures, comprising mediastinoscopy in 9, anterior mediastinotomy in 2, and video-assisted thoracic surgery (VATS) in 4, were performed mainly because of unresectability due to diffuse and bilateral HMLNMs. Cancer location was breast in 6, kidney or prostate in 2 each, and bladder, rectum, testis, melanoma, and larynx in 1 each. Median survival was 21 months. Resection was performed in 11 patients, comprising posterolateral thoracotomy in 6, muscle sparing thoracotomy in 2, and VATS in 3. Seventeen involved LN stations were removed; of these, primary were kidney in 3, testis or thyroid in 2 each, and larynx, nasopharynx, and intestinum in 1 each. Five-year survival was 41.6% (median, 45 months)., Conclusions: HMLNMs of extrathoracic carcinoma may be isolated, probably in the context of a particular lymphatic mode of spread. Our experience demonstrates that operation is mainly diagnostic but resection may safely achieve local control of the disease and deserves being advocated in patients with isolated and resectable HMLNMs.

Bronchioloalveolar carcinoma is a rare, but well-known disease that symptomatically worsens with intrapulmonary shunting and consequent hypoxemia. Surgical resection of the involved area offers relief from disabling hypoxemia and may improve survival. We present 3 patients with intrapulmonary shunting.

Thoracic duct ligation for chylothorax is considered a safe and efficient procedure. However, we observed two cases that were complicated by intractable chylous ascites. Refractory chylous ascites are usually cured by surgical peritoneovenous shunting, but in both patients successful treatment required peritoneoatrial shunting. Actually, a peritoneovenous shunt was impossible because of extensive venous thrombosis in jugular and superior vena cava in one patient and failed because of constrictive pericarditis requiring pericardectomy in the other, both underlying diseases also accounting for the thoracic duct ligation complications.

Background: Non-small cell lung cancer (NSCLC) mediastinal (N2) metastases are indicators of poor prognosis. Survival rates decrease with increasing number of N2 stations and involved lymph nodes as well as lymph node size and capsular invasion. Our purpose was to elucidate the impact lymph node-related variables on the outcome after surgical resection., Methods: We reviewed data of 2344 NSCLC patients who underwent curative resections with mediastinal lymphadenectomy, and 586 (25%) had N2 metastases. We studied the overall survival of N2 patients according to some important covariates., Results: Metastases involved single N2 stations in 386 patients (66%) and two or more in 200 (34%). Survival was not related with histology or pathologic tumor (pT), but was better when only one N2 station was involved (5-year overall survival 28.5% [median, 24 months] versus 17.2% [median, 14 months] respectively; p = 0.0002. For single N2 stations, capsular rupture, number, and size of lymph nodes were not significant prognostic factors. When the size of lymph node was analyzed (micrometastases, 53; nonbulky, 207; or bulky metastases, 126), overall survival differences between nonbulky and bulky N2 were significant: 5-year overall survival was 34% (median, 28 months) versus 23% (median, 23 months), respectively (p = 0.026). Presence of micrometastases was associated with a poor prognosis: 5-year overall survival of 21.4% (median, 23 months)., Conclusions: Prognosis was better for patients with single N2 stations when metastatic lymph nodes were not enlarged. However, the presence of lymph nodes micrometastases does not seems associated with a better outcome.

Background: Pulmonary epithelioid hemangioendothelioma is a rare vascular tumor of low-grade malignancy, the prognosis of which remains unpredictable. The purpose of this analysis based on 80 patients was to determine prognostic factors and to evaluate results of surgery., Methods: We recorded data of 75 patients from reports published in the English and French literature using the terms "intravascular bronchoalveolar tumor" or "pulmonary epithelioid hemangioendothelioma" or a combination of both. We added to this database 5 more cases of pulmonary epithelioid hemangioendothelioma operated on in our thoracic surgery department from 1989 to 2005. Univariate and multivariate analyses of prognostic factors were performed using the log rank test and the Cox model. The factors we tested were age, sex, clinical symptoms, biologic and radiologic findings, and surgical treatment., Results: There were 49 women and 31 men with a mean age of 39.7 years (range, 7 to 72 years). The 5-year survival probability was 60% (range, 47% to 71%). Univariate analysis showed that loss of weight, anemia, pulmonary symptoms, and more particularly pleural hemorrhagic effusions were significant factors of poor prognosis, with a median survival of less than 1 year. Multivariate analysis showed a statistically worse survival in patients with hemorrhagic symptoms (hemoptysis, p < 0.0001; pleural effusion, p < 0.0001)., Conclusions: Pulmonary epithelioid hemangioendothelioma typically occurs among young patients. Surgery can be proposed in cases of unilateral single or multiple nodules. There is no single effective treatment in cases of bilateral multiple nodules. Lung transplantation should be evaluated in patients with vascular aggressivity with pleural hemorrhagic effusion and anemia.

Background: Sleeve lobectomy (SL) seems to have better results than pneumonectomy. Some authors propose to extend its indications. The aim of this study was to compare postoperative results, locoregional recurrence, and survival after sleeve lobectomy and pneumonectomy in focusing on right upper lobe cancer., Methods: From 1984 to 2002, 973 lung resections were performed for T1, T2, and bronchial T3 right upper lobe non-small cell lung cancer. There were 756 lobectomies (L group), 151 pneumonectomies (RP group), and 66 sleeve lobectomies (SL group). The RP group was further divided with regard to intrapulmonary lymph node involvement. Pneumonectomy 1 (RP1) was a group of N0, intralobar N1, and skip metastasis involvement (N0-N2). Pneumonectomy 2 (RP2) was a group of extralobar N1 and nonskip metastasis involvement (N1-N2). Postoperative results were compared among SL, L, and RP groups. Survival was compared between the two homogeneous groups for oncologic characteristics (SL, RP1)., Results: Statistical comparison of 5-year actuarial survival showed a significant difference favoring SL (SL: 72.5%/ RP1: 53.2%; p = 0.0025). Postoperative mortality was higher after RP (L: 2.9% / SL: 4.5%/ RP: 12.6 %). Significant factors limiting SL were tumor size, extralobar N1, and main bronchus involvement (p = 0.000026, 0.0002, and 0.005, respectively)., Conclusions: Immediate and long-term survival appears better after sleeve lobectomy than right pneumonectomy for comparable stages of right upper lobe cancer. For frequency to increase by systematic attempt at SL, limited by large tumors and extralobar N1 involvement, the only way should be after favorable response to induction chemotherapy.

Background: Factors influencing survival of patients with a nonsmall-cell lung cancer (NSCLC) invading the parietal pleura or the chest wall are still controversial. The aim of this study was to assess prognostic factors in completely resected pT3 chest wall NSCLC patients., Methods: We retrospectively reviewed a three-center experience between 1984 and 2002 with 309 patients., Results: There were 269 male and 40 female patients. Pulmonary resections consisted of 13 wedge resections or segmentectomies, 211 lobectomies, 6 bilobectomies, and 79 pneumonectomies. One hundred patients underwent extrapleural mobilization, and 209, en-bloc resection. Tumors were staged as stages IIB (n = 212) and IIIA (n = 97). Overall 5-year survival rates were 40% and 12% for stage IIB and IIIA, respectively (p < 10(4)). Multivariate analysis shows male sex and bigger tumor size as independent indicators of poor prognosis in stage IIB patients. In stage IIB patients with a chest wall invasion limited to the parietal pleura, en-bloc resections provided higher 5-year survival rates when compared with extrapleural resections (60.3% versus 39.1%; p = 0.03). In stage IIIA patients, multivariate analysis disclosed two independent prognostic factors: the number of resected ribs and adjuvant parietal and mediastinal radiotherapy., Conclusions: The presence of lymph node metastases has a disastrous impact on survival in this subset of patients. En-bloc resection is strongly suggested to be the standard of surgical care, and adjuvant radiotherapy does not seem to be necessary in N0 patients when a complete R0 resection has been achieved. For huge tumors (larger than 6 cm), this report suggests that the role of perioperative chemotherapy needs further evaluation.

Background: Lung cancer observed after heart transplantation is considered to have a poor prognosis. However, the results of surgical treatment have not yet been significantly evaluated. This retrospective study analyzed the immediate and long-term results after surgery., Methods: From May 1990 to December 2003, 25 heart transplant recipients underwent surgery for lung cancer. There were 22 men and 3 women, the mean age was 60.7 years (49-72). All patients had a smoking history. Lung tumors were discovered by routine chest roentgenograms and computed tomography scans in 17 patients (68%), because of clinical symptoms in 7 (28%), and incidentally in 1 (4%). The surgical procedures consisted of 23 lobectomies and 2 wedge resections., Results: The mean postoperative hospital stay was 14.2 days (5-34). The morbidity rate was 28% (n = 7 patients). The mortality rate was 12% patients (n = 3 patients). The postoperative complications in 7 of 10 patients were mainly from infectious origin. Five-year survival rate was 40.9% with a median survival of 45 months. Seven patients died during follow-up (3 from cancer and 4 from other diseases). Significant better survival was observed in N0 patients than in N+ patients (median survival of 56.8 months in N0 vs 13.5 months in N+ patients (p = 0.017)., Conclusions: Long-term results after surgery were satisfactory in early stage disease, despite a high risk for postoperative infection. Our results underline the efficiency of a close follow-up for transplant recipients with a smoking history, leading to cancer detection at an early stage.

Background: Lymph node (LN) metastases from lung cancer may skip the intrapulmonary nodes directly to the mediastinum ([N1-]N2 vs [N1+]N2). This phenomenon is frequent. Patients with such a metastatic pattern appear to have a better prognosis following surgery. Our purpose was to further study the clinical significance and prognostic value of this particular group of (N1-)N2 patients., Methods: We retrospectively analyzed the data of 731 patients with a pN2 stage who underwent resection for non-small cell lung cancer. Patients with (N1-)N2 metastases (n = 209) were compared to patients with intrapulmonary (N1+)N2 (n = 522)., Results: In the (N1-)N2 group, lobectomies were more frequent (54% vs 33%, p = 0.00), metastases more frequently involved a single LN station (79.4% vs 56.3%, p < 0.000001), and primary tumor was more often located in the upper lobes (67.4% vs 55.6%, p = 0.0066). (N1-)N2 was a factor of better prognosis (5 year survival rates 34.4% vs 18.5%, p = 0.00006), which proved also significant when only a single station was involved (38.4% vs 24%, p = 0.0005). These results were confirmed by multivariate analysis., Conclusions: (N1-)N2 skip metastasis is a unique subgroup of pN2 disease. Lung lymph drainage anatomy may explain the occurrence of these metastases. They form an independent prognostic factor of survival suggesting the need for further study, the results of which may lead to better knowledge of lung cancer, improved classification, and adapted adjuvant therapy.

Background: Catamenial pneumothorax is a rare entity characterized by recurrent accumulation of air in the thoracic space during menstruation. Catamenial pneumothorax is also associated with a high rate of postoperative recurrence. The aim of this study was to discuss the etiology and to determine the optimal surgical treatment of this entity., Methods: From December 1991 to September 2000, 10 patients with catamenial pneumothorax were treated at our institution. Median age at time of operation was 37 years (range, 21 to 44 years). We retrospectively evaluated the pathologic findings, the operation performed, and the results in all patients. The mean follow-up was 55.7 months., Results: Pleurodesis alone was performed in 5 patients and an associated diaphragmatic procedure was performed in 5 patients. In 5 patients, no diaphragmatic anomaly was discovered: 3 experienced one or more recurrences and all still suffer from chronic catamenial chest pain. Hormonal therapy temporarily improved outcome for 6 months in 2 patients. On the contrary, in 5 patients surgical pleurodesis was associated with the repair of diaphragmatic defects (simple closure or coverage by a polyglactin mesh): these patients experienced no recurrence (n = 0/5, p = 0.0016) and no subsequent catamenial chest pain., Conclusions: The postoperative outcome is influenced by the diagnosis of diaphragmatic defects with or without endometriosis. Surgical treatment should be accomplished during menstruation for an optimal visualization of pleurodiaphragmatic endometriosis. Because diaphragmatic lesion is frequent and may be occult, we propose the systematic coverage of the diaphragmatic surface by a polyglactin mesh to prevent catamenial pneumothorax recurrence even when the diaphragm appears normal.

Background: Despite an early-stage diagnosis, lung cancer presenting with visceral pleura invasion (VPI) or malignant pleural lavage cytology (PLC) has a poor prognosis. The purpose of this study was to correlate VPI to malignant PLC., Methods: One hundred forty-three consecutive patients scheduled for surgical lung resection having undergone preresectional pleural lavage cytology were reviewed. There were 121 malignant and 22 nonmalignant lesions. All cases were studied by pathology, histology, previous transthoracic puncture, VPI, and presence of pleural lymphatic involvement., Results: PLC was positive (n = 13) or suspected (n = 5) for malignant cells in, respectively, 10.7% and 4.1% of patients with lung cancer. There was no positive PLC in cases of nonmalignant disease. PLC was positive only in pT2 tumors and almost always when the tumor was exposed on the pleural surface, thus possibly exfoliating within the pleural space (12/17 patients, 70.6%; p < 0.01). Positive PLC was obtained whatever the histology but did not appear related to previous transthoracic puncture or involvement of pleural lymphatics by tumor cells., Conclusions: VPI and positive PLC are linked, and the appearance of tumor cells within the pleural cavity can be explained by tumor desquamation. The role that visceral pleura involvement and parietal pleura reabsorption play in lung cancer is of paramount importance and deserves further research. A better understanding of their relationship could have major implications in the therapeutic management of non-small cell lung cancer.

The simultaneous occurrence of bronchopleural fistula (BPF) and esophagopleural fistula (EPF) after pneumonectomy is very rare. We describe a 60-year-old man who developed empyema associated with bronchopleural fistula as a complication of a right pneumonectomy. Initial chest tube drainage and antibiotic therapy were ineffective. Five months later ingested food particles appeared in the drainage fluid. Esophagoscopy revealed an esophageal fistula of 10 mm in diameter. After nutritional support by feeding jejunostomy both BPF and EPF were repaired by subscapular muscle myoplasty and extensive thoracoplasty through a right thoracotomy. Endoscopic examination performed 1 month after surgery showed complete closure of both fistulas and 9 months after surgery the patient was eating and gaining weight. The patient's death was due to aspiration pneumonia of another origin.

Background: Chylothorax complicating pulmonary resection (CCPR) is infrequent and surgical treatment is for the most part avoided. The purpose of this study is to analyze the clinical and therapeutic characteristics of this complication., Methods: From March 1981 to June 2001, 26 cases of CCPR (24 men and 2 women; mean age 57 years) were treated in two departments of thoracic surgery. Twenty-five cases complicated lung resection for lung cancer (lobectomy n = 14, bilobectomy n = 3, pneumonectomy n = 8) and 1 case followed lobectomy for a benign lesion. Medical history, location, and characteristics of the chylothorax, lymphography, and clinical evolution after medical or surgical therapy were studied., Results: Medical history was never predictive of CCPR. Chylothorax was right sided in 18 cases and left sided in 8 cases. The total amount of chyle ranged from 1.9 L to 27.9 L per patient with a mean of 7.9 L (pneumonectomy 12.3 L and lobectomy 6.3 L). In 15 patients (pneumonectomy n = 2 and lobectomy n = 13) mean quantity of daily chyle was 0.3 L. All these patients recovered with conservative therapy except for 2 patients who underwent drainage and talc slurry (n = 1) and video-assisted lysis of adhesions (n = 1). In the remaining 11 patients (pneumonectomy n = 6 and lobectomy n = 5) mean quantity of daily chyle was 1 L. The chylous leak was seen at lymphography (n = 4), during reoperation (n = 2), or at lymphography and reoperation (n = 3). The location was clearly identified at the level of thoracic duct tributaries in all cases. In 4 postlobectomy cases (4 of 7), surgery was not performed because of the therapeutic usefulness of lymphography. Reoperation was necessary in 6 cases (postpneumonectomy n = 5, postlobectomy n = 1) and consisted of duct ligation (n = 2), leak/suture (n = 3), and fibrin glue (n = 1)., Conclusions: CCPR is rare and appears to respond well to medical treatment owing to the fact that the thoracic duct is generally patent as the leak is due to injury of its tributaries. When surgery is considered, lymphography may help to select cases in which conservative medical therapy should be continued. However, in a small number of cases, usually after pneumonectomy, surgery remains mandatory.

Splanchnicectomy has been known for years as a treatment for refractory pain in patients with pancreatic cancer or chronic pancreatitis. We report herein the performance of a videothoracoscopic left splanchnicectomy in a patient with a previous right pneumonectomy who suffered intractable pain from an irresectable left adrenal metastasis associated with metastatic retroperitoneal lymph nodes. Immediate pain relief was obtained, but abdominal pain of middle intensity recurred 6 weeks later. Although infrequently required, this procedure might be of value in some patients with refractory pain.

Background: The thoracic duct (TD) is the main collecting vessel of the lymphatic system. Little is known about the intrathoracic tributaries of the TD, which are named intercostal, mediastinal, and bronchomediastinal trunks. The purpose of the study was to identify the lymphatic tributaries from intrathoracic organs to the thoracic duct., Methods: The study was performed on 530 adult cadavers. The lymphatics of different organs were catheterized and injected with a dye: lungs (n = 360), heart (n = 90), esophagus (n = 50), and diaphragm (n = 30). The lymphatic tributaries draining the lymph from these organs to the thoracic duct were dissected along their course to the thoracic duct and classified., Results: The TD tributaries were observed in 147 cases: right lung (n = 46), left lung (n = 69), heart (n = 8), esophagus (n = 13), and diaphragm (n = 11). Connections with the TD were observed at its origin (n = 13), within the mediastinum (n = 87), and at the level of the TD arch (n = 47). Tributaries from the lung issued from lower paratracheal nodes 4 R (n = 14) and 4 L (n = 31), subaortic 5 (n = 4), subcarinal 7 (n = 18), pulmonary ligament 9 (n = 7), upper tracheal 2 L (n = 28), paraortic 6 (n = 11), and celiac nodes (n = 2). Tributaries from the heart connected with the TD in the mediastinum in 1 case (4 L) and with the TD arch in 7 cases. Tributaries from the esophagus connected with the thoracic duct within the mediastinum in 13 cases; anodal routes were frequent (n = 5). The TD tributaries from the diaphragm were observed in 11 cases, always connecting with the TD at its origin., Conclusions: Injection of intrathoracic organs permits visualization of TD tributaries. These tributaries appear located at unchanging levels. Lymph of intrathoracic organs may thus drain into the general circulation through the TD. The tributaries may represent a potential route for tumor cells dissemination. When incompetent, due to valve insufficiency, they permit chylous lymph to backflow into the intrathoracic lymph nodes. Injury at this level may lead to intrathoracic chylous effusions.

Background: Results of medical therapy for Mycobacterium xenopi pulmonary infection remain unreliable. Pulmonary resection may be beneficial to patients whose disease is localized and who can tolerate a resectional operation., Methods: Eighteen patients underwent pulmonary resection between 1991 and 2000: 14 men and 4 women, with a mean age of 50 +/- 12 years (range 27 to 68 years). Indications for operation were either therapeutic (n = 9) or diagnostic (n = 9). Four patients received antimycobacterial chemotherapy before their operation and 2 patients were HIV positive., Results: Therapeutic procedures included completion pneumonectomy (n = 1), lobectomy (n = 6), segmentectomy (n = 1), and bilateral wedge resection (n = 1). Diagnostic procedures included lobectomy (n = 1) and wedge resection (n = 8). Complete resection could be achieved in 15 patients (83%). There was no in-hospital mortality. Postoperative complications included prolonged air leak (5 of 18 patients, 27.7%) and pleural effusion requiring insertion of a new chest tube (3 of 18 patients, 16.6%). Mean hospital stay was 14 +/- 8 days. Follow-up was 100% complete. Eleven patients received antimycobacterial chemotherapy for 4 to 24 months, postoperatively. Late mortality was 11% and was unrelated to progression of mycobacterial disease. After the operation, the sputum remained positive in only 2 patients (11%) with incomplete resections. Fourteen patients were asymptomatic with no relapse at a mean follow-up of 38 +/- 22 months (range 85 to 13 months)., Conclusions: Resection represents an important adjunct to chemotherapy for the treatment of M. xenopi pulmonary disease. In the setting of localized nodular or cavitary disease, failure to respond to medical therapy, relapse after treatment discontinuation, coexistent aspergilloma or polymicrobial contamination, or patient intolerance of medical therapy, pulmonary resection can be undertaken with acceptable morbidity and mortality.

Background: Visceral pleura invasion (VPI) by non-small cell lung cancer is a factor of poor prognosis. A tumor of any size that invades the visceral pleura is classified as T2. Few studies have been conducted concerning the prognostic significance of VPI relative to other staging factors., Methods: Between April 1984 and December 1996, 1,281 patients with T1 (n = 430) and T2 (n = 851) non-small cell lung cancer underwent curative surgical resection. Adjuvant radiation therapy was performed in 455 patients. There were 176 women and 1,105 men aged 30 to 86 years (mean, 60.9 years). Five hundred nineteen pneumonectomies, 742 lobectomies, and 20 segmentectomies were performed. In all patients, a complete mediastinal lymph node dissection was performed. International staging was stage IA and B (n = 697); stage II A and B (n = 247), and stage III A (n = 337). The patients were divided into two groups according to the existence of VPI (group I without, group II with). Both groups were compared with regard to the size of the tumors, histology, associated lymph node involvement, survival rates, and cause of death. Univariate and multivariate analyses were conducted., Results: VPI (group II) was identified in 19.1% of the resected specimens: group I, n = 1036; group II, n = 245. The VPI was present in only 10% of non-small cell lung cancer 3 cm or less in size, reaching 33% of patients with non-small cell lung cancer larger than 5 cm (p = 0.0001). Squamous non-small cell lung cancer were significantly less accompanied by VPI (13.5%) than the other histologic categories. The VPI was associated with a higher frequency of N2 involvement (group I = 24.6%, group II = 33.4%, p = 0.01) and N2 involvement was more extensive (two or more N2 involved stations: group I = 8.2%, group II = 15.6%, p = 0.003). Actuarial survival rates were 51.8% at 5 years and 33.8% at 10 years in group I (median, 66 months), and 34.6% at 5 years and 27.9% at 10 years in group II (median, 30 months) (p = 0.000002). Long-term survival rates significantly decreased for larger tumors. Even in patients with N2 stage tumors, the difference of survival curves between the two groups was statistically significant. Cancer-related deaths were more frequent in group II and were mainly caused by distant metastases. By multivariate analysis, visceral pleura invasion proved to be a significant independent factor of poor prognosis., Conclusions: The VPI is a factor of poor prognosis. Its frequent association with extensive N2 involvement supports the hypothesis that exfoliated tumor cells are drained through the pleural lymphatics by the mediastinal lymphatic pathways and then into the bloodstream. The VPI is an important prognostic factor and, as such should stimulate more studies to better select the patients who could benefit from adjuvant therapy.

Background: N1 disease represents a heterogeneous group of non-small cell lung carcinoma with varying 5-year survival rates. Specific types of N1 lymph node involvement need to be further investigated and their prognostic significance clarified., Methods: From 1984 to 1993, 1,174 patients with non-small cell lung cancer had complete mediastinal lymph node dissection: N0, 50.25% (n = 590); N1, 21.8% (n = 256); and N2, 27.95% (n = 328). The N1 subgroup cases were reviewed. Four levels of N1 nodes were identified using the New Regional Lymph Node Classification for Lung Cancer Staging. Their prognostic significances were tested and 5-year survival rates were compared with those of N0 and N2 patients of the whole group., Results: The overall 5-year survival rate of N1 patients was 47.5%. Survival was not related to site of the primary lung cancer, pathologic T factor, histologic type, type of resection, number of N1 station involved, nor type of N1 involvement (direct extension or metastases). Five-year survival was significantly better when N1 involvement was intralobar (levels 12 and 13, n = 102), as compared with extralobar (hilar) involvement (levels 10 and 11, n = 154): 53.6% versus 38.5% (p = 0.02). Intralobar N1 5-year survival was similar to that of N0 (53.6% vs 56.5%, p = 0.01), and extralobar 5-year survival with that of N2 (38.5 vs 28.3%, p = 0.01) when N2 was present in only one station in the ipsilateral mediastinum., Conclusions: N1 disease is a compound of two subgroups: one located inside the lobes is related to N0, and the other (extralobar or hilar) behaves like an early stage of N2 disease. This offers further information for clinical, therapeutic, and research purposes.

Pneumothorax due to incomplete reexpansion of remaining lung after a thoracic operation is difficult to drain via standard access routes. Apical chest drainage can be placed through a upper posterior point of the back, located in the laterovertebral area at the level of the first or second intercostal space. This technique, which is very safe and well tolerated, avoids the necessity to use thoracoplasty or muscle flap plombage of those residual cavities.

Background: Cold abscesses of the chest wall are rare tuberculous locations. Because of the resurgence of tuberculosis, this diagnosis must be considered more frequently., Methods: During a 15-year period (1980 to 1995), 18 patients with one or more cold abscesses of the chest wall were managed in our department. Epidemiologic characteristics, indications, methods and results of operation, and pathogenesis of the abscesses were considered in this retrospective study., Results: Most of the patients were immigrant men. A previous history of tuberculosis was noted in 15 cases (83%). Six patients had concomitant active pulmonary tuberculosis. There was mostly a solitary lesion in the chest wall, the most frequent location being the rib shaft (60%). Before operation the diagnosis was confirmed only in 4 patients (by needle aspiration of the abscess) and presumed in 4 others: an antituberculous chemotherapy was therefore given preoperatively to 8 patients. One patient did not undergo operation after a favorable response to medical treatment. In the other patients, an operation was indicated because of lack of response in 5 patients and the absence of diagnosis in 12 patients. Adequate debridement and a postoperative antituberculous regimen were performed with recurrence prevention in mind. A follow-up was obtained in 11 of the 17 patients undergoing operation. The only patient who required a second operation because of a recurrence at the same location had refused the antituberculous therapy after the first surgical procedure. Locations of the abscesses, computed tomographic scan results, and histologic examinations are in favor of a lymph-borne dissemination of tubercle bacilli., Conclusions: Because fine-needle aspiration remains an inaccurate diagnostic tool and antituberculous medical treatment is not always efficient, chest wall tuberculous cold abscesses remain in most cases a surgical entity.

Background: Axillary lymph node metastases (ALNMs) from bronchogenic carcinoma are rare and their significance may be questioned. A surgical approach may allow a better understanding of the mechanism of their occurrence., Methods: A retrospective study of 1,486 cases of surgically removed non-small cell lung carcinoma was performed. Twenty-two patients (1.5%) had extrathoracic nodal metastases. Nine of them were ALNMs (<1%). These cases form the basis of this study., Results: In 1 patient ipsilateral ALNM was removed during a lung operation. It was a left non-small cell lung carcinoma invading the chest wall (T3 N2). In the other patients (n = 8) ALNMs were observed during postoperative follow-up; 4 underwent ALNM resection, 2 had radiotherapy, and 2 had symptomatic treatment only. For these 8 patients, in the TNM classification performed after an initial bronchogenic carcinoma operation, the lymph node status was, respectively, N0 in four cases, N1 in three cases, and N2 in one case. Survival ranged from 1 to 10 months, except for one patient who is still alive after more than 5 years. In this case, the ALNM was discovered 4 months after a right lower lobectomy for a T2 N0 adenocarcinoma., Conclusions: Axillary lymph node metastases may be involved through direct chest wall invasion of bronchogenic carcinoma or retrograde spread from supraclavicular lymphnode block. However, another mechanism seems to be the systemic vascular route.

Background: Pain is the most distressing feature of pancreatic cancer. Thoracoscopic splanchnicectomy, first performed in 1993, has caused a resurgence of interest in surgical treatment of such excruciating pain., Methods: Twenty patients underwent splanchnicectomy for pancreatic cancer pain over a period of 50 months. All were opiate dependent and unable to pursue normal daily life activities. We evaluated the type of splanchnicectomy performed and the long-term results procured., Results: The number of splanchnicectomies was 24: unilateral videothoracoscopic splanchnicectomy, n = 11; unilateral videothoracoscopic splanchnicectomy with associated vagotomy, n = 5; and bilateral videosplanchnicectomy, n = 4. There was no postoperative complication. Pain was totally relieved and drug addiction stopped in 16 patients: 10 with unilateral videothoracoscopic splanchnicectomy, 2 with unilateral videothoracoscopic splanchnicectomy and associated vagotomy, and 4 with bilateral videosplanchnicectomy. Pain was not relieved after 4 unilateral videothoracoscopic splanchnicectomies, but bilateralization was not attempted in that subgroup., Conclusions: Unilateral videothoracoscopic splanchnicectomy is the treatment of choice of intractable pancreatic pain, affording drug cessation and recovery of daily activity in most patients. Failure may be treated secondarily by bilateralization with excellent results. Bilateral videosplanchnicectomy need not be performed by first intention.

Lymphangiohemangiomas of the mediastinum are exceedingly rare. Clinically they tend to behave like lymphangiomas. We report 3 new cases. All 3 cases showed both lymphatic and vascular components. One case was associated with a left superior vena cava. In both other cases computed tomography with dynamic scans demonstrated the vascular components. Combined lymphatic venous malformation was thus evidenced in the 3 cases and supports that lymphangiohemangiomas are malformative in origin.

Cases of hyperinflation of native emphysematous lung have been reported in the early period after single-lung transplantation. We report a case of a similar complication that occurred 2 years after transplantation and was successfully treated by lobectomy.