Surgical management for metachronous bronchogenic cancer occurring after pneumonectomy.
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Carcinoma, Bronchogenic↗
Biomedical subjects
G Massard
Publications and source records attributed to G Massard.
Hemodilution is an effective treatment for reperfusion edema after lung transplantation.
A 38-year-old patient underwent left single-lung transplantation for end-stage histiocytosis with secondary pulmonary hypertension and polycythemia. Despite use of an optimal lung graft and a total ischemia limited to 250 minutes, major pulmonary edema developed postoperatively. Hemodilution resulted in a quick recovery of lung function. We speculate that blood hyperviscosity was a major factor of pulmonary edema in this patient.
Adult↗
[Surgical treatment of pneumothorax. Study of a series of 400 cases].
Surgical management is indicated for recurrent forms of pneumothorax as well as for failures of tube drainage. We report a series of 400 patients treated surgically mainly by pleural abrasion over the past 17 years. Statistical analysis of the results identifies two groups: 308 patients under the age of 45 years had surgery mainly for spontaneous idiopathic pneumothorax, where as 92 patients over the age of 45 years had surgery mainly for emphysema. In young patients, the axillary incision was preferred due to the lack of muscular sequelae and to avoid unpleasant aesthetic sequelae. Postoperative complications occurred in 60 patients (15%). The main complication was a residual pneumothorax after drain removal requiring further drainage (10%). A single recurrence occurred (0.25%). Pleural abrasion is a very effective way to treat recurrent forms of pneumothorax.
Adolescent↗
[Results of repeated pulmonary resection in new homolateral neoplastic localization after conservative resection].
From 1978 through 1992, 93 patients with a previous lobectomy for bronchogenic cancer were referred for homolateral cancer recurrence. Forty-six patients were contraindicated for carcinologic reasons (30 stage IIIb and 16 stage IV). Forty-seven patients (50.5%) were resectable, but 17 did not undergo surgery for associated medical problems (n = 11) or refusal (n = 6). The remaining 30 patients form the population of the present study: 29 males and 1 female; mean age of 61 years (range 47-72). The previous cancer was stage I in 26 and stage II in 4. The mean interval between the 2 cancer diagnoses was 30 months (range 6-97). Three patients underwent an exploratory thoracotomy (10%): 2 had mediastinal involvement and 1 had pleural metastases. Twenty-two (73%) underwent a completion pneumonectomy, and 5 had miscellaneous conservative resections. There were 4 operative deaths (13%): one intraoperative bleeding, 1 postoperative bleeding, 1 pulmonary embolism, 1 pneumonia. Four patients had nonfatal surgical complications: 2 clottings (reexploration), 1 empyema (lavage) and 1 bronchopleural fistula (thoracoplasty). Resected patients were staged as follows: 13 stage I, 4 stage II, 10 stage III. Survival following resection including operative mortality at 3 an 5 years was estimated as 52.5% and 44% for the whole series (72% for stage I). We conclude that repeat surgery conveys an increased risk, but may achieve valuable long-term results.
Aged↗
[Contribution of an induction treatment in the surgical treatment of locally advanced non-small-cell cancers].
From October 1988 to July 1990, 18 patients with marginally resectable non-small cell cancer (10 stage IIIa and 8 stage IIIb) were entered in a phase-II trial combining induction therapy with a subsequent thoracotomy. Induction therapy included 2 courses of chemotherapy (5-FU and cisplatinum) and radiotherapy (30 Gray in split course). Partial response was observed in 10 patients, and minimal response in 3. Thoracotomy disclosed unresectability in 3 patients. Fifteen complete resections consisted in 1 lobectomy and 14 pneumonectomies. There were no operative deaths (30 days). Postoperative recovery was uneventful in 3 patients with exploratory thoracotomy and in 1 patient with lobectomy. Following pneumonectomy, we observed 2 bronchopleural fistulae and 1 empyema. On pathology, 10 patients were stage IIIa, and 3 were stage I, whereas no residual tumor was found in 2 patients. During follow-up, local recurrence occurred in 2, and metastases in 8. On December 31st, 1993, 3 patients were alive at 44, 52, and 62 months respectively. Nine patients had died from cancer, and 3 from unrelated causes. Estimated survival was 66.7% at 1 year, 33.3% at 3 years, and 20% at 5 years. We conclude that induction therapy allowed satisfactory resection for marginally resectable tumors. Operative morbidity was increased in this group. However, the 5-year survival was similar to resectable stage IIIa cancer.
Adult↗
Airway complications in lung transplantation.
This article reviews the literature on airway healing after lung transplantation. From a historical point of view, this has been the Achilles' heel of lung transplantation through two decades, from the first attempt at single-lung transplantation in 1963 to the clinical successes in the early 1980s. The overall incidence of lethal airway complications is estimated to be 2% to 3%, whereas that of late stricture is 7% to 14%. Comparison of experiences has been difficult without a universal classification; a new classification for airway and anastomotic complications and healing is proposed. Ischemia appears to be the most important factor influencing airway healing. Low-pressure collateral bronchial blood flow from the pulmonary artery may be affected by low cardiac output, reperfusion edema, or rejection; mucosal injury may be further increased by prolonged positive-pressure ventilation. Good bronchial healing appears to be possible without a protective wrap and with early use of steroids. The management of bronchial complications is challenging and requires endoscopic skills including knowledge of endobronchial laser photocoagulation and stent insertion techniques.
Anastomosis, Surgical↗
Esophagopleural fistula: an early and long-term complication after pneumonectomy.
Over a 14-year period, we observed eight cases of esophagopleural fistula after pneumonectomy for cancer (n = 7) or infectious lung disease (n = 1). In 2 patients, the fistula was probably related to an intraoperative esophageal injury. Two others had mediastinal cancer recurrence, whereas a fistula developed in 4 without any malignancy. Patients presented with empyema, and a contrast swallow procedure disclosed an esophagopleural fistula. Two patients with recurrent cancer were managed conservatively with chest tube insertion and died within 3 months. A patient with chronic empyema had a delayed diagnosis of esophagopleural fistula 2 years after a presumed intraoperative injury; he was managed with thoracoplasty and feeding gastrostomy and died 12 months later. Five patients had an attempt at curative treatment. A single patient underwent thoracoplasty and bipolar exclusion of the esophagus and had secondary reconstruction with a coloplasty; he died with postoperative peritonitis. Four patients underwent thoracoplasty and muscle flap repair of the esophagus. There was 1 operative death from pulmonary embolism, whereas 3 patients recovered and are well with follow-up of 18 months, 2 years, and 5 years, respectively. We conclude that the prognosis of esophagopleural fistula is ominous when associated with cancer recurrence. A curative approach should combine direct repair of the esophagus with a muscle flap and eradication of the associated empyema with thoracoplasty. This aggressive treatment is addressed to debilitated patients and carries high rates of mortality and morbidity.
Aged↗
[Lung transplantation. Contraindications and new indications].
The authors review the recent changes observed in the indications for lung transplantation. Several classical contra-indications have been alleviated or even cancelled. Chronic infection presenting as cystic fibrosis has become one of the first indications for lung replacement. Respirator-dependent patients are at an operative risk comparable to the overall results. Long-term corticosteroid therapy and pleural adhesions are no longer formal contraindications but should be approached with extreme caution. In recent years, single lung transplantation has been extended to diseases, such as emphysema and pulmonary hypertension, which were formerly indications for double-lung or heart-lung transplantation. The reasons for this include donor shortage and the better 1-year survival following single lung transplantation. The most recent development is paediatric lung transplantation. The legitimacy of redo transplantation is controversial.
Adolescent↗
Pulmonary distribution of vinorelbine in patients with non-small-cell lung cancer.
Vinorelbine (Navelbine, NVB) is a new semi-synthetic vinca alkaloid that is currently used in the treatment of advanced breast cancer and advanced non-small-cell lung cancer (NSCLC). In this study we investigated the tumoral and healthy pulmonary tissue concentrations of NVB in previously untreated NSCLC patients undergoing surgery. A total of 13 patients (mean age, 60 years; range, 42-70 years) were included and received NVB (20 mg/m2) at 1 h (mean, 1.1 h; SD, 0.2 h; n = 6 patients) and 3 h (mean, 3.0 h; SD, 0.6 h; n = 7 patients) before tumor resection. A tumoral and adjacent healthy lung-tissue specimen as well as simultaneously sampled serum were analyzed for NVB by high-performance liquid chromatography (HPLC). NVB levels were much higher in tissue than in serum (up to 300-fold). The tissue/serum ratio increased between the 1-h sampling time (range, 0.1-100) and the 3-h time point (range, 10-300). In all patients but two, NVB concentrations were lower in tumors than in healthy lung tissue. The tumor/healthy tissue ratio ranged from 0.06 to 1.3 (median, 0.09) at 1 h and from 0.18 to 1.1 (median, 0.55) at 3 h. This ratio increased between the 1-h sampling time and the 3-h time point as a consequence of increasing tumor levels (median, 50.4 ng/g at 1 h and 278 ng/g at 3 h). In four patients, concentrations could be measured in necrotic and peripheral tumor zones, showing lower values in necrotic areas. Thus, these data indicate that NVB is highly distributed in lung tissue, with the disposition rate being slower in tumor tissue than in healthy parenchyma during the first 3 h.
Adult↗
Double-lung transplantation in mechanically ventilated patients with cystic fibrosis.
Many lung transplant programs consider ventilator dependence as a contraindication for transplantation. Among 54 patients in whom bilateral lung transplantations for cystic fibrosis were performed by the Joint Marseille-Montreal Lung Transplant Program, 10 were ventilator dependent. Three of them died in the early postoperative period (30%): 2 as a result of cerebral anoxia and sepsis, 1 of Pseudomonas cepacia pneumonia. Two patients died at 15 and 19 months after transplantation of obliterative bronchiolitis and secondary bacterial pneumonitis. Another 2 patients in whom obliterative bronchiolitis developed underwent retransplantation with a heart-lung block; 1 of those was operated on at 12 months and is well at 29 months after his initial transplantation; the second was operated on at 34 months and died of primary graft failure. Three other patients are alive and well at 3, 11, and 14 months after transplantation. Actuarial survival at 1 year was 70%. The postoperative course and the infectious and rejection complications were no different from those in patients who underwent transplantation while spontaneously breathing. Obliterative bronchiolitis developed in 66% of patients at risk (2 of 6 patients surviving more than 6 months). We conclude that transplantation in mechanically ventilated patients with cystic fibrosis is not associated with an increase in morbidity or mortality after bilateral lung transplantation. Long-term survival, as in patients who undergo transplantation while spontaneously breathing, is limited by the development of obliterative bronchiolitis.
Adolescent↗
Resection of mycotic lung sequestra after invasive aspergillosis.
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Adult↗
Tracheobronchial healing after lung and heart-lung transplantation. A critical review of 64 anastomoses. The Joint Marseille-Montréal Lung Transplant Program.
The authors report on an analysis concerning the healing of tracheobronchial anastomoses after lung and heart-lung transplantation. The present study includes 64 anastomoses selected from a total of 80. Sixteen were excluded because of early postoperative death; none of these deaths was related to an airway complication. Bronchial healing was assessed with bronchoscopic follow-up; the aspect of the suture line was classified according to the grades of Couraud. The initial reference was the examination at 2 weeks postoperatively, which was compared to subsequent follow-ups. At the initial assessment, 42 anastomoses were grade I, 4 were grade II, and 18 were grade III. The subsequent anatomic result was satisfactory for 52 sutures (81%). The complications observed in the remaining patients were malacia in 2, stenosis treated with a stenting device in 4 and dehiscence in 6. The duration of ischemia and postoperative mechanical respiratory support, as well as the proximal or distal location of the anastomosis appeared to be of significant prognostic value.
Adolescent↗
[Result of surgery of esophageal cancer. Analysis of a series of 349 cases based on resection methods].
Despite obvious improvements in operative and postoperative management after esophageal resection, surgical treatment of esophageal cancer is still disappointing in terms of long term results. The purpose of the present study was to verify these poor results statistically and to discuss the value of a modified therapeutic approach. Our experience covers 349 esophageal resections performed between 1979 and 1992. These patients were predominantly males (93%) with squamous cell carcinoma (86%). The majority of the patients underwent either an Ivor-Lewis (52%) or an Akiyama procedure (36%). Survival was estimated according to the Kaplan-Meier model. Influence of parameters such as sex, histology, type of resection and TNM-staging was assessed with the "log-rank" test. The perioperative mortality was 10%. The non-fatal morbidity rate was 34%, and was most often related to anastomotic leaks. Pathological staging disclosed a majority of T3 tumors (71%). The overall survival rate was 54% at one year, 28% at 2 years and 9% at 5 years. This survival was not influenced by either histology (squamous cell or adenocarcinoma), the type of resection (Ivor-Lewis or Akiyama procedure). A slightly superior survival rate was observed after Ivor-Lewis procedure and is explained by a lower postoperative complication rate. In particular, diffuse N2 disease (abdominal and mediastinal) had a worse prognosis than localized N2. N1 disease was probably understaged, since survival was comparable to localized N2. The natural history was characterized by development of metastases (43%) rather than by local recurrence. We conclude that these results may justify surgery for palliation of dysphagia in so far as the post-operative morbidity is reduced, as we observed with Ivor-Lewis procedures. However, improvement of long-term survival requires a multimodality oncologic approach.
Adenocarcinoma↗
[Surgical treatment of pulmonary and bronchial aspergilloma].
From 1974 to 1990, 61 patients were admitted for pulmonary (55) or bronchial (6) aspergilloma; 50 were treated by surgery. Operative treatment was mandatory because of disabling symptoms in 17 patients, rapid growth on radiological survey in 7 others, diagnostic doubt in 10 and association with bronchogenic cancer in 2. 14 were operated on in order to prevent evolutive complications. Complete resection was possible in 39 patients: with lobectomy or segmentectomy in 34 and with pleuro-pneumonectomy in 5. In 10 others, respiratory failure only allowed speleotomy and thoracoplasty. One thoracotomy was exploratory because of an associated unresectable cancer. Postoperative complications frequently occurred with pulmonary aspergilloma: 4 postoperative deaths, 33 experienced non-fatal complications (28 major bleedings, 16 rehabititation defects, 6 empyemas, 5 respiratory failures). Nevertheless, among 10 patients with either bronchial aspergilloma or pulmonary aspergilloma without underlying disease, only one had a complicated outcome. In conclusion, surgical treatment is well tolerated in the absence of underlying parenchymal disease. However, despite the major operative risk, surgery remains the only efficient treatment in symptomatic patients.
Adolescent↗
Bronchogenic cancer associated with head and neck tumors. Survival analysis of 194 patients.
We reviewed a series of 194 lung opacities presumed to be bronchogenic carcinomas occurring either simultaneously with (n = 46) or metachronously to (n = 148) a head and neck cancer. The purpose of the study was to evaluate the operative mortality and morbidity and to assess with a survival analysis whether the lung lesions actually were primary carcinomas or metastases of the head and neck cancer. Operation was contraindicated in 77 patients: 36 for metastatic spread, 5 for small-cell carcinoma, and 35 for respiratory insufficiency. The remaining 118 underwent operation: lobectomy for 82, pneumonectomy for 30, wedge resection for 1, and exploratory thoracotomy for 5. The operative mortality was 5%, and the nonfatal morbidity was 22%. The survival at 5 years for patients who underwent operation for bronchogenic cancer was 19.7% (27.2% for stage I, 19% for stage II, 4.5% for stage IIIA, and 0% for stage IIIB). The survival of these patients was not significantly different with respect to the synchronous or metachronous occurrence or the histologic classification (squamous or non-squamous). We conclude that, despite the poor survival, several of these lung lesions associated with a head and neck cancer were most likely a primary bronchogenic cancer. Surgical management is justified because of the observed postoperative mortality.
Adult↗
Lung size matching for double lung transplantation based on the submammary thoracic perimeter. Accuracy and functional results. The Joint Marseille-Montreal Lung Transplant Program.
The present study evaluates the accuracy of submammary thoracic perimeter for lung size matching between donor and recipient and analyzes the influence of donor lung size discrepancies on functional outcome after double lung transplantation. The population is composed of 18 double lung graft recipients, 16 of whom had cystic fibrosis. The lung size match was assessed by comparison of predicted total lung capacity of donor and recipient: five patients were matched in a 10% confidence interval; four received smaller lungs, and nine received larger ones. The functional outcome was assessed with the spirometric values measured at 3 and 6 months after transplantation. The final functional result was not influenced by the lung size (r = 0.142 for total lung capacity; r = 0.372 for vital capacity; r = 0.378 for forced expiratory volume in 1 second). For larger lungs the final result tended to the recipient's predicted, whereas for smaller lungs, spirometry tended to the donor's predicted (r = 0.906 for total lung capacity; r = 0.875 for vital capacity; r = 0.874 for forced expiratory volume in 1 second). The thoracotomy effect, that is, restrictive syndrome at 3 months that resolves at 6 months, was not correlated with the lung size (r = 0.07 for total lung capacity; r = 0.436 for vital capacity). It is concluded that respiratory functional result is not affected by larger lungs; despite the wide range of error, the submammary thoracic perimeter appeared to be a satisfactory selection parameter in this group of patients.
Adolescent↗
Pleuropulmonary aspergilloma: clinical spectrum and results of surgical treatment.
From 1974 to 1991, 77 patients were admitted for pulmonary (55), pleural (16), or bronchial (6) aspergilloma. About 50% were asymptomatic. Sixty-three underwent operation. Pulmonary aspergillomas were operated on for therapeutic need in 26 and on principle in 18; the procedures were 28 lobar or segmental resections, 10 thoracoplasties, and 5 pleuropneumonectomies (1 patient had exploration only). Pleural aspergillosis was treated by operation on principle in 5 and for therapeutic need in 8 patients; 10 thoracoplasties, 1 attempt at pleuropneumonectomy, and 2 decortications were performed. All six bronchial lesions were operated on as a rule. Overall postoperative mortality was 9.5%. Major complications were bleeding (n = 37), pleural space problems (n = 24), respiratory failure (n = 6), and postpneumonectomy empyema (n = 4). All patients with pleural disease experienced complications. The outcome was better after lobar or segmental resection than after thoracoplasty (mortality, 6% versus 15%). Asymptomatic and nonsequellary pulmonary or bronchial aspergilloma also had an improved outcome. We conclude that operation is at low risk in pulmonary or bronchial locations in asymptomatic patients and in the absence of sequellae; the risk is high in symptomatic patients for whom operation is the only definite treatment. Pleuropneumonectomy should be avoided. Only symptomatic pleural aspergilloma should be operated on.
Adolescent↗
Extrapleural hematoma as a late complication of collapse therapy for tuberculosis.
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Aged↗