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Objectives: Our goal was to evaluate the association between the distance of the tumour to the visceral pleura and the rate of local recurrence in patients surgically treated for stage pI lung cancer., Methods: We conducted a single-centre retrospective review of 578 consecutive patients with clinical stage IA lung cancer who underwent a lobectomy or segmentectomy from January 2010 to December 2019. We excluded 107 patients with positive margins, previous lung cancer, neoadjuvant treatment and pathological stage II or higher status or for whom preoperative computed tomography (CT) scans were not available at the time of the study. The distance between the tumour and the closest visceral pleura area (fissure/mediastinum/lateral) was assessed by 2 independent investigators who used preoperative CT scans and multiplanar 3-dimensional reconstructions. An area under the receiver operating characteristic curve analysis was performed to determine the best threshold for the tumour/pleura distance. Then multivariable survival analyses were used to assess the relationship between local recurrence and this threshold in relation to other variables., Results: Local recurrence occurred in 27/471 patients (5.8%). A cut-off value of 5 mm between the tumour and the pleura was determined statistically. In the multivariable analysis, the local recurrence rate was significantly higher in patients with a tumour-to-pleura distance ≤5 mm compared to patients with a tumour-to-pleura distance >5 mm (8.5% vs 2.7%, hazard ratio 3.36, 95% confidence interval: 1.31-8.59, P = 0.012). Subgroup analyses of patients with pIA and tumour size ≤2 cm identified local recurrences in 4/78 patients treated with segmentectomy (5.1%), with a significantly higher occurrence with tumour-to-pleura distances ≤5 mm (11.4% vs 0%, P = 0.037), and in 16/292 patients treated with lobectomy (5.5%) without significant higher occurrence in tumour-to-pleura distances of ≤5 mm (7.7% vs 3.4%, P = 0.13)., Conclusions: The peripheral location of a lung tumour is associated with a higher rate of local recurrence and should be taken into account during preoperative planning when considering segmental versus lobar resection., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The aim of this study was to describe the epidemiology of patients undergoing diagnostic and/or curative surgical pulmonary resections for lung opacities suspected of being localized primary lung cancers without preoperative tissue confirmation., Methods: We performed a single-centre retrospective study of a prospectively implemented institutional database of all patients who underwent pulmonary resection between January 2010 and December 2020. Patients were selected when surgery complied with the Fleischner society guidelines. We performed a multivariable logistic regression to determine the preoperative variables associated with malignancy., Results: Among 1392 patients, 213 (15.3%) had a final diagnosis of benignancy. We quantified futile parenchymal resections in 29 (2.1%) patients defined by an anatomical resection of >2 lung segments for benign lesions that did not modified the clinical management. Compared with patients with malignancies, patients with benignancies were younger (57.5 vs 63.9 years, P < 0.001), had lower preoperative risk profile (thoracoscore 0.4 vs 2.1, P < 0.001), had a higher proportion of wedge resection (50.7% vs 12.2%, P < 0.01) and experienced a lower burden of postoperative complication (Clavien-Dindo IV or V, 0.4% vs 5.6%, P < 0.001). Preoperative independent variables associated with malignancy were (adjusted odd ratio [95% confident interval]) age 1.02 [1.00; 1.04], smoking (year-pack) 1.005 (1.00; 1.01), history of cardiovascular disease 2.06 [1.30; 3.30], history of controlled cancer 2.74 [1.30; 6.88] and clinical N involvement 4.20 [1.11; 37.44]., Conclusions: Futile parenchymal lung resection for suspicious opacities without preoperative tissue diagnosis is rare (2.1%) while surgery for benign lesions represented 15.3% and has a satisfactory safety profile with very low postoperative morbi-mortality., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Surgical approach for resection of tumours involving the thoracic inlet has largely been developed in the context of lung cancer of the superior sulcus. Therefore, initial anterior approaches included a thoracotomy associated with a longitudinal cervicotomy. Here, we describe a variation of the previously described anterior surgical approaches of the thoracic inlet that we performed for the resection of a primary mesenchymal tumour of the left middle scalenus muscle secreting fibroblast growth factor-23 responsible for tumour-induced osteomalacia. This approach allowed a safe control of the great vessels phrenic nerve and brachial plexus as well as a comfortable access to the middle scalenus muscle through an L-shaped incision with a cervico-manubriotomy without thoracotomy. The tumour was resected entirely with the middle scalenus. After 3 months of follow-up, the symptoms resolved entirely., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: To compare outcomes at 12 months between video-assisted thoracic surgery (VATS) and open thoracotomy (OT) in patients with non-small-cell lung cancer (NSCLC) using real-world evidence., Methods: We did a nationwide propensity-matched cohort study. We included all patients who had a diagnosis of NSCLC and who benefitted from lobectomy between 1 January 2015 and 31 December 2017. We divided this population into 2 groups (VATS and OT) and matched them using propensity scores based on patients' and hospitals' characteristics. Unplanned readmission, mortality, complications, length of stay and hospitalization costs within 12 months of follow-up were compared between the 2 groups., Results: A total of 13 027 patients from 180 hospitals were included, split into 6231 VATS (47.8%) and 6796 OT (52.2%). After propensity score matching (5617 patients in each group), VATS was not associated with a lower risk of unplanned readmission compared with OT [20.7% vs 21.9%, hazard ratio 1.03 (0.95-1.12)] during the 12-months follow-up. Unplanned readmissions at 90 days were mainly due to pulmonary complications (particularly pleural effusion and pneumonia) and were associated with higher mortality at 12 months (13.4% vs 2.7%, P < 0.0001)., Conclusions: VATS and OT were both associated with high incidence of unplanned readmissions within 12 months, requiring a better identification of prognosticators of unplanned readmissions. Our study highlights the need to improve prevention, early diagnosis and treatment of pulmonary complications in patients with VATS and OT after discharge. These findings call for improving the dissemination of systematic perioperative care pathway including efficient pulmonary physiotherapy and rehabilitation., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: We investigated on the benefit/risk ratio of surgery in octogenarians with early-stage non-small cell lung cancer (NSCLC)., Material and Methods: From 2005-2020, 100 octogenarians were operated on for a clinical stage IA to IIA NSCLC. All patients had undergone whole body PET -scan and brain imaging. Operability was assessed according to current guidelines regarding the cardiopulmonary function. Since 2015, patients followed a dedicated geriatric evaluation pathway. Minimally invasive approaches were used in 66 patients, and a thoracotomy in 34., Results: Clavien-Dindo grade ≥ 4 complications occurred in 15 patients within 90 days, including 7 fatalities. At multivariable analysis, the number of co-morbidities was their single independent prognosticator. Following resection, 24 patients met pathological criteria for adjuvant therapy among whom 3 (12.5 %) received platinum-based chemotherapy. Five-year survival rates were overall (OS) 47 ± 6.3 %, disease-free (DFS) 77.6 ± 5.1 %, and lung cancer-specific (CSS) 74.7 ± 6.3 %. Diabetes mellitus impaired significantly long-term outcomes in these 3 dimensions. OS was improved since the introduction of a dedicated geriatric assessment pathway (72.3 % vs. 6.4 %, P = 0.00002), and when minimally invasive techniques were used (42.3 % vs. 11.3 %; P = 0.02). CSS was improved by the performance of systematic lymphadenectomy (55.3 % vs. 26.9 %; P = 0.04). Multivariable and recursive partitioning analyses showed that a decision tree could be built to predict overall survival on the basis of diabetes mellitus, high co-morbidity index and low ppoDLCO values., Conclusions: The introduction of a dedicated geriatric assessment pathway to select octogenarians for lung cancer surgery was associated with OS values that are similar to outcomes in younger patients. The use of minimally invasive surgery and the performance of systematic lymphadenectomy were also associated with improved long-term survival. Octogenarians with multiple co-morbid conditions, diabetes mellitus, or low ppo DLCO values may be more appropriately treated with SBRT., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objectives: Health care-associated infections (HAIs) are serious issues following lung cancer surgery, leading to an increased risk of morbidity and hospital cost burden. The aim of this study was to evaluate the impact on postoperative outcomes of a preoperative screening and decolonization strategy of nasal carriers for Staphylococcus aureus prior to lung cancer surgery., Methods: We performed a retrospective study comparing 2 cohorts of patients undergoing major lung resection: a control group of patients from the placebo arm of the randomized Clinical Study to Evaluate the Efficacy of Chlorhexidine Mouthwashes operated on between July 2012 and April 2015 without any nasopharyngeal screening (N = 224); an experimental group, with preoperative screening for S. aureus of nasal carriers and selective 5-day decolonization in positive carriers using mupirocin ointment between January 2017 and December 2017 (N = 310). The 2 groups were matched according to a propensity score analysis with 1:1 matching. The primary outcome was the rate of postoperative HAIs, and the secondary outcome was the need for postoperative mechanical ventilation after surgery., Results: After matching, 2 similar groups of 108 patients each were obtained. In the experimental group, 26 patients had positive results for nasal carriage, and a significant decrease was observed in the rate of overall postoperative HAIs [control n = 19, 17.6%; experimental group n = 9, 8.3%; P = 0.043; relative risk 0.47 (0.22-1)] and in the rate of postoperative mechanical ventilation [control n = 12, 11.1%; experimental group n = 4, 3.7%; P = 0.038; relative risk 0.33 (0.11-1)]. After logistic regression and multivariable analysis, screening of S. aureus nasal carriers reduced the rate of HAIs [odds ratio (OR) 0.29, 95% confidence interval (CI) 0.11-0.76; P = 0.01] and reduced the risk of the need for postoperative mechanical ventilation (OR 0.19, 95% CI 0.05-0.74; P = 0.02). There was no significant statistical difference between the 2 groups regarding the rate of postoperative S. aureus-associated infection (control group n = 6, 5.6%; experimental group n = 2, 1.9%; P = 0.28)., Conclusions: Identification of nasal carriers of S. aureus and selective decontamination using mupirocin appeared to have a beneficial effect on postoperative infectious events after lung resection surgery., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Purpose: Respiratory complications are the leading causes of morbidity and mortality after lung cancer surgery. We hypothesized that oropharyngeal and nasopharyngeal decontamination with chlorhexidine gluconate (CHG) would be an effective method to reduce these complications as reported in cardiac surgery., Methods: In this multicenter parallel-group randomized double-blind placebo-controlled trial, we enrolled consecutive adults scheduled for anatomical pulmonary resection for lung cancer. Perioperative decontamination consisted in oropharyngeal rinse solution (0.12% CHG) and nasopharyngeal soap (4% CHG) or a placebo. The primary outcome measure was the proportion of patients requiring postoperative invasive and/or noninvasive mechanical ventilation (MV). Secondary outcome measures included occurrence of respiratory and non-respiratory healthcare-associated infections (HAIs) and outcomes within 90 days., Results: Between July 2012 and April 2015, 474 patients were randomized. Of them, 24 had their surgical procedure cancelled or withdrew consent. The remaining 450 patients were included in a modified intention-to-treat analysis: 226 were allocated to CHG and 224 to the placebo. Proportions of patients requiring postoperative MV were not significantly different [CHG 14.2%; placebo 15.2%; relative risks (RRs) 0.93; 95% confidence interval (CI) 0.59-1.45; P = 0.76]. Neither of the proportions of patients with respiratory HAIs were different (CHG 13.7%; placebo 12.9%; RRs 1.06; 95% CI 0.66-1.69; P = 0.81). The CHG group had significantly decreased incidence of bacteremia, surgical-site infection and overall Staphylococcus aureus infections. However, there were no significant between-group differences for hospital stay length, change in tracheal microbiota, postoperative antibiotic utilization and outcomes by day 90., Conclusions: CHG decontamination decreased neither MV requirements nor respiratory infections after lung cancer surgery. Additionally, CHG did not change tracheal microbiota or postoperative antibiotic utilization., Trial Registration: This study is registered on ClinicalTrials.gov, number NCT01613365.

Objectives: Large retrospective series have indicated lower rates of cN0 to pN1 nodal upstaging after video-assisted thoracic surgery (VATS) compared with open resections for Stage I non-small-cell lung cancer (NSCLC). The objective of our multicentre study was to investigate whether the presumed lower rate of N1 upstaging after VATS disappears after correction for central tumour location in a multivariable analysis., Methods: Consecutive patients operated for PET-CT based clinical Stage I NSCLC were selected from prospectively managed surgical databases in 11 European centres. Central tumour location was defined as contact with bronchovascular structures on computer tomography and/or visibility on standard bronchoscopy., Results: Eight hundred and ninety-five patients underwent pulmonary resection by VATS (n = 699, 9% conversions) or an open technique (n = 196) in 2014. Incidence of nodal pN1 and pN2 upstaging was 8% and 7% after VATS and 15% and 6% after open surgery, respectively. pN1 was found in 27% of patients with central tumours. Less central tumours were operated on by VATS compared with the open technique (12% vs 28%, P < 0.001). Logistic regression analysis showed that only tumour location had a significant impact on N1 upstaging (OR 6.2, confidence interval 3.6-10.8; P < 0.001) and that the effect of surgical technique (VATS versus open surgery) was no longer significant when accounting for tumour location., Conclusions: A quarter of patients with central clinical Stage I NSCLC was upstaged to pN1 at resection. Central tumour location was the only independent factor associated with N1 upstaging, undermining the evidence for lower N1 upstaging after VATS resections. Studies investigating N1 upstaging after VATS compared with open surgery should be interpreted with caution due to possible selection bias, i.e. relatively more central tumours in the open group with a higher chance of N1 upstaging., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

A quarter of patients with clinical N1 (cN1) non-small cell lung cancer (NSCLC) based on positron emission tomography-computed tomography (PET-CT) imaging have occult mediastinal nodal involvement (N2 disease). In a prospective study, endosonography alone had an unsatisfactory sensitivity (38%) in detecting N2 disease. The current prospective multicentre trial investigated the sensitivity of preoperative mediastinal staging by video-assisted mediastinoscopy (VAM) or VAM-lymphadenectomy (VAMLA).Consecutive patients with operable and resectable (suspected) NSCLC and cN1 after PET-CT imaging underwent VAM(LA). The primary study outcome was sensitivity to detect N2 disease. Secondary endpoints were the prevalence of N2 disease, negative predictive value (NPV) and accuracy of VAM(LA).Out of 105 patients with cN1 on imaging, 26% eventually developed N2 disease. Invasive mediastinal staging with VAM(LA) had a sensitivity of 73% to detect N2 disease. The NPV was 92% and accuracy 93%. Median number of assessed lymph node stations during VAM(LA) was 4 (IQR 3-5), and in 96%, at least three stations were assessed.VAM(LA) has a satisfactory sensitivity of 73% to detect mediastinal nodal disease in cN1 lung cancer, and could be the technique of choice for pre-resection mediastinal lymph node assessment in this patient group with a one in four chance of occult-positive mediastinal nodes after negative PET-CT., Competing Interests: Conflict of interest: Disclosures can be found alongside this article at erj.ersjournals.com, (Copyright ©ERS 2017.)

Objective: Despite recent advances in imaging and core or endoscopic biopsies, a percentage of patients have a major lung resection without diagnosis. We aimed to assess the feasibility of a rapid tissue preparation/analysis to discriminate cancerous from non-cancerous lung tissue., Methods: Fresh sample preparations were analyzed with the Microflex LTTM MALDI-TOF analyzer. Each main reference spectra (MSP) was consecutively included in a database. After definitive pathological diagnosis, each MSP was labeled as either cancerous or non-cancerous (normal, inflammatory, infectious nodules). A strategy was constructed based on the number of concordant responses of a mass spectrometry scoring algorithm. A 3-step evaluation included an internal and blind validation of a preliminary database (n = 182 reference spectra from the 100 first patients), followed by validation on a whole cohort database (n = 300 reference spectra from 159 patients). Diagnostic performance indicators were calculated., Results: 127 cancerous and 173 non-cancerous samples (144 peripheral biopsies and 29 inflammatory or infectious lesions) were processed within 30 minutes after biopsy sampling. At the most discriminatory level, the samples were correctly classified with a sensitivity, specificity and global accuracy of 92.1%, 97.1% and 95%, respectively., Conclusions: The feasibility of rapid MALDI-TOF analysis, coupled with a very simple lung preparation procedure, appears promising and should be tested in several surgical settings where rapid on-site evaluation of abnormal tissue is required. In the operating room, it appears promising in case of tumors with an uncertain preoperative diagnosis and should be tested as a complementary approach to frozen-biopsy analysis.

Background: Pre-therapeutic pathological diagnosis is a crucial step of the management of pulmonary nodules suspected of being non small cell lung cancer (NSCLC), especially in the frame of currently implemented lung cancer screening programs in high-risk patients. Based on a human ex vivo model, we hypothesized that an embedded device measuring endogenous fluorescence would be able to distinguish pulmonary malignant lesions from the perilesional lung tissue., Methods: Consecutive patients who underwent surgical resection of pulmonary lesions were included in this prospective and observational study over an 8-month period. Measurements were performed back table on surgical specimens in the operative room, both on suspicious lesions and the perilesional healthy parenchyma. Endogenous fluorescence signal was characterized according to three criteria: maximal intensity (Imax), wavelength, and shape of the signal (missing, stable, instable, photobleaching)., Results: Ninety-six patients with 111 suspicious lesions were included. Final pathological diagnoses were: primary lung cancers (n = 60), lung metastases of extra-thoracic malignancies (n = 27) and non-tumoral lesions (n = 24). Mean Imax was significantly higher in NSCLC targeted lesions when compared to the perilesional lung parenchyma (p<0,0001) or non-tumoral lesions (p<0,0001). Similarly, photobleaching was more frequently found in NSCLC than in perilesional lung (p<0,0001), or in non-tumoral lesions (p<0,001). Respective associated wavelengths were not statistically different between perilesional lung and either primary lung cancers or non-tumoral lesions. Considering lung metastases, both mean Imax and wavelength of the targeted lesions were not different from those of the perilesional lung tissue. In contrast, photobleaching was significantly more frequently observed in the targeted lesions than in the perilesional lung (p≤0,01)., Conclusion: Our results demonstrate that endogenous fluorescence applied to the diagnosis of lung nodules allows distinguishing NSCLC from the surrounding healthy parenchyma and from non-tumoral lesions. Inconclusive results were found for lung metastases due to the heterogeneity of this population.

Background: Bronchial resection and reimplantation in surgical management of lung cancer is intended to spare lung parenchyma, with curative intent. We studied the incidence and management of anastomotic complications after such procedures., Methods: We retrospectively reviewed charts of patients referred to our center for lung tumors who underwent bronchial resection and reimplantation from 1992 to 2011., Results: A total of 108 patients were included. Sixty-eight percent were male, and mean age was 58 years. Sleeve lobectomies were performed in 100 patients, bronchial resections without lung parenchymal resection in 8 patients. Squamous cell carcinoma represented 46.3% of cases, carcinoid tumors 22.2%, and adenocarcinoma 18.5%. Mean time between surgery and first bronchoscopic examination was 4.47 days. During the follow-up, anastomotic abnormalities were detected in 23 patients (21.3%): malacic or fibrotic bronchial stenoses in 9 cases (39.1%), dehiscences in 7 (30.4%), obstructive granulomas in 4 (17.4%), and bronchopleural fistulas in 3 (13.0%). Endoscopic treatment was indicated in 14 patients (13%) and consisted of stent placement in 6 cases (26%), mechanical dilations in 3 (13%), laser treatment for 1 case of bronchomalacia (4.3%), and resection of granulomas in 4 (17.4%). No risk factors were identified as predisposing for bronchial complications. There was a trend toward lower 1-year survival in patients with bronchial complications compared with those without (71.9% versus 83.4%; p = 0.114)., Conclusions: Bronchial resection and reimplantation is a surgical procedure associated with an anastomotic complication rate of 21.3%, but only 13% required endoscopic management. Regular endoscopic surveillance is advised to detect and treat early complications., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Recently, tissue-based methods for proteomic analysis have been used in clinical research and appear reliable for digestive, brain, lymphomatous, and lung cancers classification. However simple, tissue-based methods that couple signal analysis to tissue imaging are time consuming. To assess the reliability of a method involving rapid tissue preparation and analysis to discriminate cancerous from non-cancerous tissues, we tested 141 lung cancer/non-tumor pairs and 8 unique lung cancer samples among the stored frozen samples of 138 patients operated on during 2012. Samples were crushed in water, and 1.5 µl was spotted onto a steel target for analysis with the Microflex LT analyzer (Bruker Daltonics). Spectra were analyzed using ClinProTools software. A set of samples was used to generate a random classification model on the basis of a list of discriminant peaks sorted with the k-nearest neighbor genetic algorithm. The rest of the samples (n = 43 cancerous and n = 41 non-tumoral) was used to verify the classification capability and calculate the diagnostic performance indices relative to the histological diagnosis. The analysis found 53 m/z valid peaks, 40 of which were significantly different between cancerous and non-tumoral samples. The selected genetic algorithm model identified 20 potential peaks from the training set and had 98.81% recognition capability and 89.17% positive predictive value. In the blinded set, this method accurately discriminated the two classes with a sensitivity of 86.7% and a specificity of 95.1% for the cancer tissues and a sensitivity of 87.8% and a specificity of 95.3% for the non-tumor tissues. The second model generated to discriminate primary lung cancer from metastases was of lower quality. The reliability of MALDI-ToF analysis coupled with a very simple lung preparation procedure appears promising and should be tested in the operating room on fresh samples coupled with the pathological examination.

Background: Whereas proximal airways of patients undergoing lung cancer surgery are known to present specific microbiota incriminated in the occurrence of postoperative respiratory complications, little attention has been paid to distal airways and lung parenchyma considered to be free from bacteria. We have hypothesized that molecular culture-independent techniques applied to distal airways should allow identification of uncultured bacteria, virus, or emerging pathogens and predict the occurrence of postoperative respiratory complications., Methods: Microbiological assessments were obtained from the distal airways of resected lung specimens from a prospective cohort of patients undergoing major lung resections for cancer. Microorganisms were detected using real-time polymerase chain reaction (PCR) assays targeting the bacterial 16s ribosomal RNA gene and Herpesviridae, cytomegalovirus (CMV), and herpesvirus simplex. All postoperative microbiological assessments were compared with the PCR results., Results: In all, 240 samples from 87 patients were investigated. Colonizing agents were exclusively Herpesviridae (CMV, n=13, and herpesvirus simplex, n=1). All 16s ribosomal RNA PCR remained negative. Thirteen patients (15%) had a positive CMV PCR (positive-PCR group), whereas the remaining 74 patients constituted the negative-PCR group. Postoperative pneumonia occurred in 24% of the negative-PCR group and in 69% of the positive-PCR group (p=0.003). Upon stepwise logistic regression, performance status, percent of predicted diffusion lung capacity for carbon monoxide, and positive PCR were the risk factors of postoperative respiratory complications. The CMV PCR had a positive predictive value of 0.70 in prediction of respiratory complications., Conclusions: When tested by molecular techniques, lung parenchyma and distal airways are free of bacteria, but CMV was found in a high proportion of the samples. Molecular CMV detection in distal airways should be seen as a reliable marker to identify patients at risk for postoperative respiratory complications., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Lung cancer remains the main leading cancer-related cause of death in the world. For early-stage tumor, surgery stands out as the best curative option offering the greatest chance for cure. Despite improvement of per- and postoperative management, surgery continues to carry a high morbidity with a significant mortality. Among postoperative complications, respiratory failures (nosocomial pneumonia and acute respiratory distress syndrome) are currently the most frequent and serious, as well as being the primary cause of hospital death, after a lung resection for cancer. Because infectious etiologies have been highly incriminated in the development of these pulmonary complications, microbial airways colonizations (AWCs) are supposed to be an essential first step in the pathogenesis of these failures occurring in hospitalized and chronically ill individuals. These patients fulfill all the predisposing factors to bronchial colonizations and are particularly exposed to the development of respiratory failures in the postoperative setting, when secretion clearance and cough reflex are impaired. Under immunosuppressive conditions, AWC should act in a manner that increases its ability to stimulate microorganisms and increase the risks of superimposed infections. Few studies have addressed the problem of AWCs in patients submitted for lung cancer surgery. Because of several limitations, especially the lack of exhaustive microbiological studies, the conclusions that can be reached remain inconclusive. This review aims to report the existing literature on this critical and controversial issue, focusing on their specific incidence, their predisposing factors, their correlation with development of respiratory failures, and, in turn, the reliability of the current antibiotic prophylaxis for their prevention., (Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)