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PDF file - 83K, Baseline characteristics of 52 patients with RCC lung metastasis. * determined by Heng et al.

PDF file - 90K, Baseline characteristics of 140 patients with CRC lung metastasis. The stage was determined by pathological examination at the time of diagnosis.

Purpose: If immune cells are involved in tumor surveillance and have a prognostic impact in most primary tumors, little is known about their significance in metastases. Because patients' survival is heterogeneous, even at metastatic stages, we hypothesized that immune cells may be involved in the control of metastases. We therefore characterized the tumor immune microenvironment and its prognostic value in colorectal and renal cell carcinoma (RCC) metastases, and compared it to primary tumors.Experimental Design: We analyzed by immunohistochemistry (n = 192) and qPCR (n = 32) the immune environments of colorectal carcinoma and RCC lung metastases.Results: Metastases from colorectal carcinoma and RCC have different immune infiltrates. Higher densities of DC-LAMP+ mature dendritic cells (P < 0.0001) and lower densities of NKp46+ NK cells (P < 0.0001) were observed in colorectal carcinoma as compared to RCC metastases, whereas densities of T cells were similar. High densities of CD8+ and DC-LAMP+ cells correlated with longer overall survival (OS) in colorectal carcinoma (P = 0.008) and shorter OS in RCC (P < 0.0001). High NK-cell densities were associated with improved survival in RCC (P = 0.002) but not in colorectal carcinoma. Densities of immune cells correlated significantly from primary to relapsing metastases for the same patient. A TH1 orientation was found in colorectal carcinoma metastases, whereas a heterogeneous immune gene expression was found in RCC metastases.Conclusions: Our results show a major prognostic value of the immune pattern (CD8+/DC-LAMP+ cell densities) in colorectal carcinoma and RCC, reproducible from primary to metastatic tumors, although with opposite clinical impacts, and highlight the role of the tumor cell in shaping its immune environment. Clin Cancer Res; 19(15); 4079–91. ©2013 AACR.

PDF file - 101K, Influence of pre-operative patient treatments on the distribution of CD8+, DC-LAMP+ and NKp46+ immune cells in CRC (a, b and c) and RCC lung metastases (d, e and f). 63/140 patients with CRC lung metastases have been treated with neo-adjuvant chemotherapy and 9/52 patients with RCC lung metastases have been treated with IL2/IFN. Whiskers length represents 10-90 percentile. ns, not significant (Mann-Whitney test).

PDF file - 88K, Gene expression in lung metastases from CRC and RCC. Expression of genes related to (a) immune cell populations, (b) Th1/Th2 orientations, (c) inflammation and angiogenesis, (d) immunosuppression, (e) cytotoxicity, (f) chemokines/chemokine receptors in lung metastases from CRC (grey bars) and RCC (white bars). Expression levels of genes were determined using threshold cycle (Ct) values normalized to actin B ACTB (ΔCt). Whiskers length represents 10-90 percentile. ns, not significant; *P

PDF file - 107K, Kaplan-Meier curves for the duration of OS according to the presence of CD8+ T cells in the center of the tumor (CT) (a), in the invasive margin (IM) (b) and in combined regions (CT+IM) (c) of CRC lung metastases. Statistical comparison was performed by the log-rank test.

PDF file - 56K, P values corresponding to different cutoff (minimum P value, first, second and third quartile) in CRC and RCC lung metastases. {section sign}P values were corrected by the formula proposed by Altman et al.

PDF file - 148K, Kaplan-Meier curves for the duration of OS according to the presence of CD8+ T cells in the center of the tumor (CT) (a), in the invasive margin (IM) (b) and in combined regions (CT+IM) (c) of RCC lung metastases. Representation of the Kaplan-Meier curves for the duration of OS according to the presence of NKp46+ cells in the CT (d), in the IM (e) and in combined region (CT+IM) (f) of RCC lung metastases. Statistical comparison was performed by the log-rank test.

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BACKGROUND: The assessment before surgical plication for unilateral hemidiaphragm (HD) eventration is not clearly defined and no precise criteria exist to really understand which patient is operated with which results depending on the technique used. The goal of this study was to evaluate the place of dynamic magnetic resonance imaging (dMRI) before and after plication by developing measurement criteria. METHODS: Between 2006 and 2017, 18 patients (group1: Gp1) were operated for eventrations, 15 left-sided (Gp1L) and 3 right-sided (Gp1R). All had preoperative and postoperative evaluations including dMRI and pulmonary function tests. Five healthy volunteer subjects (group2: Gp2) had the same imaging protocol. For each HD, we measured the respiratory excursion at three fixed points (S1, S2, S3) and the height of curvature on sagittal plane. We also searched for upward paradoxical diaphragm movements. RESULTS: Before surgery, no excursion (n=13) or extremely reduced excursion (n=5) was detected on the injured HD (IHD) in Gp1. Upward paradoxical movements were identified only in Gp1L (n=6). Compared with Gp2 subjects, the healthy HD for Gp1L patients had significantly reduced excursion values at three sites S1 (P=0.038), S2 (P=0.006), and S3 (P=0.004). After plication, the decreasing height of curvature confirmed a tightening of the IHD in all patients (median value from 100 to 39.5 mm in Gp1L and 92 to 74 mm in Gp1R, P=0.0001). All upward paradoxical movements disappeared. Healthy HD excursions in Gp1L normalised their values. All those imaging improvements were correlated with postoperative improvements of dyspnoea score (P

In 1883, Leyden successfully performed percutaneous transthoracic needle biopsy (PTNB) of the lung in three patients with pneumonia according the records (1); three years later, Menetrier was the first recorded to employ this technique for the diagnosis of lung cancer (2).

Resume Introduction La maladie hydatique cardiaque est rare et touche 0,5 a 2 % des patients atteints d’hydatidose. L’hydatidose intrapericardique isolee est quant a elle extremement rare. Observation Nous rapportons le cas d’une jeune femme souffrant de compression cardiaque due a de multiples kystes hydatiques primaires intrapericardiques. Depuis un an, elle presentait une alteration progressive de l’etat general, une dyspnee, des sueurs et une perte de poids de 8 kg. Un elargissement du mediastin etait visible sur la radiographie du thorax. La tomodensitometrie, l’echocardiographie et l’IRM dynamique montraient des kystes mediastinaux multiples avec un effet de masse sur le cœur et le tronc de l’artere pulmonaire. La taille de l’artere pulmonaire principale etait reduite a 5 mm de diametre et la veine pulmonaire superieure droite etait presque obliteree par des kystes posterieurs. Les fractions d’ejection ventriculaire droite et gauche etaient estimees a 34 %. Une resection complete par sternotomie des kystes a ete effectuee. L’intervention chirurgicale fut difficile techniquement, en raison d’un processus inflammatoire local majeur. Les resultats postoperatoires apres un episode initial d’embolie pulmonaire localisee etaient finalement satisfaisants. Conclusion L’hydatidose peut entrainer une atteinte cardiaque severe. Ces formes rares de maladie hydatique doivent etre connues, meme dans les regions non endemiques, par les chirurgiens en raison de l’importance des flux migratoires actuels.

Background: Unicentric mediastinal Castleman disease (CD) is a rare condition, poorly characterized due to the small number of cases and the absence of genomic study. We analyzed clinical, radiological, histological and genomic patterns associated with mediastinal CD in a substantial case series. Methods: We retrospectively reviewed cases of unicentric mediastinal CD managed in 2 French thoracic surgery departments between 1988 and 2012. Clinical, radiological, surgical and pathological data were recorded. On available FFPE blocks we performed mutation screening by next-generation-sequencing, using AmpliSeq™ Cancer Hotspot v2 (Life Technologies) and immunohistochemistry (IHC) (AKT-mTOR pathway). Results: Eleven patients were identified (mean age 41±15 years, sex-ratio 0.8, median follow-up 78 months). Surgical approach was thoracotomy (n=6), sternotomy (n=4), and VATS (n=1). Additional procedures included thymectomy in three cases, mediastinal lymphadenectomy in two cases, and bilobectomy in one case. One patient presented local relapse as a follicular dendritic cell sarcoma, leading to death 48 months after the first resection. Within 9 patients whose FFPE blocks were available, 2 mutations were found: VHL (p.F119L, 35%, n=1) and JAK3 (p.V718L, 53%, n=1). Phospho-AKT and phospho-mTOR stainings were negative in all cases, whereas phospho-S6RP staining was positive in eight cases, mainly in interfollicular cell cytoplasm. Conclusions: From this series of patients with unicentric mediastinal CD, we observed 2 cases of potential driver mutations and 8 cases of phospho-S6RP activation not related to AKT-mTOR. Larger studies are required to decipher more precisely the molecular abnormalities and potential therapeutic targets underlying this uncommon condition.

N1 disease represents a heterogeneous group of non-small cell lung carcinoma (NSCLC). Pathologic N1 disease may involve one or more lymph node (LN) in the lung classified by Mountain and Dressler (1) in five stations corresponding to their anatomical locations: the hilar LNs, the Interlobar LNs, the lobar LNs, the segmental LNs and the subsegmental LNs being termed station 10, 11, 12, 13 and 14, respectively. In the seventh edition of the TNM classification for lung cancer (2), N1 disease was classified in two zones, hilar/interlobar zone regrouping stations 10 and 11 and peripheral zone regrouping stations 12, 13 and 14.

Occult pN2 disease is the discovery of non-small-cell lung cancer (NSCLC) metastases in mediastinal lymph nodes (LNs) considered clinically disease free (cN0) after clinical staging (cTNM) established by increasingly precise work procedures, such as current imaging studies [computed tomography (CT) and positron emission tomography (PET)] and bronchoscopy or esophagoscopy with ultrasound directed biopsies (EBUS, EUS).

Background Pulmonary inflammatory pseudotumors are rare lesions that remain problematic in several aspects, especially regarding the therapeutic strategy. The goal of this study was to evaluate long-term survival in a multicenter series of patients who required surgery for pulmonary inflammatory pseudotumors. Methods Thirty-six cases of pulmonary inflammatory pseudotumors, operated on in 3 French thoracic surgery departments between 1989 and 2015, were studied retrospectively. We recorded pre-, peri- and postoperative data for each patient, and long-term survival was analyzed. Results There were 22 men and 14 women. Mean age was 53.5 years (range 14–81 years). Three pneumonectomies, 1 bilobectomy, 19 lobectomies, 2 segmentectomies, 10 wedge resections, and 1 biopsy were performed. Complete resection was carried out in 32 (88.8%) patients. Median follow-up was 76 months. Five-year and 10-year survival rates were respectively 86.8% and 81.7% (96% and 90% for patients with R0 resection). Conclusions Long-term survival was excellent for patients with pulmonary inflammatory pseudotumors who benefited from surgery, especially when surgical resection was complete. These results confirm that surgical resection must be proposed as the first-line treatment for patients with pulmonary inflammatory pseudotumors.

The greater the number of lymph node (LN) sampled (NLNsS) during lung cancer surgery, the lower the risk of underestimating the pN-status and the better the outcome of the pN0-patients due to stage-migration. Thus, regarding LN sampling “to be or not to be”, number is the question. Recent studies advocate removing 10 LNs. The most suitable NLNsS is unfortunately impossible to establish by mathematics. A too high NLNsS variability exists, based on anatomy, surgery and pathology. The methodology may vary according to Inter-institutional differences in the surgical approach regarding LN inspection and number sampling. The NLNsS increases with the type of resection: sublobar, lobectomy or pneumonectomy. Concerning pathology, one LN may be divided into several pieces, leading to number overestimation. The pathological examination is limited by the number of slices analyzed by LN. The examined LNs can arbitrarily depend on the probability of detecting nodal metastasis. In fact, the only way to ensure the best NLNsS and the best pN-staging is to remove all LNs from the ipsilateral mediastinal and hilar LN-stations as they are discovered by thoroughly dissecting their anatomical locations. In doing so, a deliberate lack of harvest of LNs is unlikely, number turns out not to be the question anymore and a low NLNsS no longer means incomplete surgery. This prevents from judging as incomplete a complete LN dissection in a patient with a small NLNsS and from considering as complete a true incomplete one in a patient with a great NLNsS. Precise information describing the course of the operation and furnished in the surgeon's reports is also advisable to further improve the quality of LN-dissection, which ultimately might be beneficial in the long-term to patients. However, that procedure is of limited interest in pN-staging if LNs are not thoroughly examined and also described by the pathologist.

Resume Introduction Les prises en charge des cancers bronchiques non a petites cellules (CBNPC) n’ont cesse de progresser et les resultats sur la survie de s’ameliorer. Nous avons revu les changements apparus en chirurgie sur une periode de 32 ans. Patients et methodes Les donnees de 6105 patients operes de 1979 a 2010 ont ete analyses sur trois periodes egales : sexe, âge, type de chirurgie, histologie, pTNM, tabagisme, comorbidites, et periodes de temps. Resultats L’âge, le nombre de femmes, les patients avec co-morbidites et antecedents de cancer et les cancers non epidermoides ont augmente entre la premiere et la troisieme periode. Le nombre des thoracotomies exploratrices a diminue (7,7 % a 1,6 %), ainsi que celui des pneumonectomies (48 % a 18 %) alors que celui des wedges (0,5 % a 6 %) et des lobectomies (42 % a 64 %) s’est accru. Les traitements neo-adjuvants representaient dans la derniere periode plus d’un patient sur cinq. La mortalite postoperatoire (4 %) ne variait pas mais le taux des complications non letales s’est aggrave (16,9 % a 27,7 %). Les taux de survie globale a 5 ans sont passes de 37,4 % a 49,8 % ( p −6 ). L’allongement de survie a interesse les differents composants du pTNM et s’observait quelles que soient les modalites therapeutiques. L’accroissement de l’âge et des comorbidites affectaient le pronostic. Conclusion Les caracteristiques des CBNPC et des patients, leurs prises en charge diagnostiques et therapeutiques ont evolue avec le temps. La survie s’ameliore sur l’ensemble des facteurs consideres. Le facteur periodes de temps est tres important et devrait etre inclus dans l’analyse des etudes cliniques sur le CBNPC.

Resume Introduction Les cancers du poumon de 1 cm ou moins sont en apparence de bon pronostic. Toutefois, les caracteristiques permettant leur traitement carcinologique sont mesestimees. Patients et methodes Nous avons etudie chez 187 patients operes d’un tel cancer (145 hommes et 42 femmes, âge moyen 60,2 ans) le type de la chirurgie, le pTNM et l’histologie. Resultats Les exereses (19 wedge-resections, 12 segmentectomies, 136 lobectomies, 20 pneumonectomies) etaient completes (R0) dans 97,3 % des cas. Les tumeurs, 98 adenocarcinomes (52,4 %), 83 cancers epidermoides (44,4 %), 6 carcinomes autres, mesuraient de 1 mm a 10 mm : n = 41), 6 a 9 mm ( n = 43) et 10 mm ( n = 103). Il y avait 161 pT1 (86,1 %), 22 pT2 (11,8 %) et 4 pT3 ; 148 pN0 (79,6 %), 18 pN1 (9,7 %) et 20 pN2 (10,7 %). pN1 et pN2 etaient presents aussi bien dans les tumeurs p = 0,11). L’histologie retrouvait souvent un envahissement de la plevre viscerale (12,2 % tumeurs p = 0,53) et des micro-emboles lympho-vasculaires (12,9 % des cas). Le taux de survie a 5 ans (66,4 %) dependait de l’âge, du type d’exerese, du pN et de l’histologie. La survie n’etait pas meilleure quand la taille etait Conclusion L’exerese permet le controle local et l’analyse histologique complete des cancers

In France, in 2010, tobacco induced 81% of deaths by lung cancer corresponding to about 28,000 deaths. Continued smoking after diagnosis has a significant impact on treatment. In patients with lung cancer, the benefits of smoking cessation are present at any stage of disease. For early stages, smoking cessation decreases postoperative morbidity, reduces the risk of second cancer and improves survival. Previous to surgery, smoking cessation of at least six to eight weeks or as soon as possible is recommended in order to reduce the risk of infectious complications. Tobacco could alter the metabolism of certain chemotherapies and targeted therapies, such as tyrosine kinase inhibitors of the EGF receptor, through an interaction with P450 cytochrome. Toxicity of radiations could be lower in patients with lung cancer who did not quit smoking before treatment. For patients treated by radio-chemotherapy, overall survival seems to be better in former smokers but no difference is observed in terms of recurrence-free survival. For advanced stages, smoking cessation enhances patients' quality of life. Smoking cessation should be considered as full part of lung cancer treatment whatever the stage of disease.

// Nicolas Pecuchet 1,2 , Pierre Laurent-Puig 1,3 , Audrey Mansuet-Lupo 4,5 , Antoine Legras 1 , Marco Alifano 6 , Karine Pallier 1 , Audrey Didelot 1 , Laure Gibault 7 , Claire Danel 8 , Pierre-Alexandre Just 4 , Marc Riquet 9 , Francoise Le Pimpec-Barthes 9 , Diane Damotte 4,5,* , Elisabeth Fabre 1,2,* and Helene Blons 1,3,* 1 INSERM UMR-S1147, Paris Sorbonne Cite Universite, Paris, France 2 Department of Medical Oncology, Hopital Europeen Georges Pompidou (HEGP), Assistance Publique, Hopitaux de Paris, Paris, France 3 Department of Biochemistry, Pharmacogenetic and Molecular Oncology Unit, Hopital Europeen Georges Pompidou (HEGP), Assistance Publique, Hopitaux de Paris, Paris, France 4 Department of Pathology, Hopital Cochin, Assistance Publique, Hopitaux de Paris, Paris, France 5 INSERM U1138, Paris Sorbonne Cite Universite, Paris, France 6 Department of Thoracic Surgery, Hopital Cochin, Assistance publique Hopitaux de Paris, Paris, France 7 Department of Pathology, Hopital Europeen Georges Pompidou (HEGP), Assistance Publique, Hopitaux de Paris, Paris, France 8 Department of Pathology, Hopital Bichat, Assistance Publique, Hopitaux de Paris, Paris, France 9 Department of Thoracic Surgery, Hopital Europeen Georges Pompidou (HEGP), Assistance Publique, Hopitaux de Paris, Paris, France * These authors share senior authorship for this manuscript Correspondence: Helene Blons, email: // Keywords : lung cancer, STK11, LKB1, isoforms, prognosis Received : July 20, 2015 Accepted : October 09, 2015 Published : November 25, 2015 Abstract STK11 is commonly mutated in lung cancer. In light of recent experimental data showing that specific STK11 mutants could acquire oncogenic activities due to the synthesis of a short STK11 isoform, we investigated whether this new classification of STK11 mutants could help refine its role as a prognostic marker. We conducted a retrospective high-throughput genotyping study in 567 resected non-squamous non-small-cell lung cancer (NSCLC) patients. STK11 exons 1 or 2 mutations (STK11 ex1-2 ) with potential oncogenic activity were analyzed separately from exons 3 to 9 (STK11 ex3-9 ). STK11 ex1-2 and STK11 ex3-9 mutations occurred in 5% and 14% of NSCLC . STK11 mutated patients were younger ( P = .01 ) and smokers ( P< .0001 ) . STK11 mutations were significantly associated with KRAS and inversely with EGFR mutations. After a median follow-up of 7.2 years (95%CI 6.8-.4), patients with STK11 ex1-2 mutation had a median OS of 24 months (95%CI 15-57) as compared to 69 months (95%CI 56-93) for wild-type (log-rank, P = .005 ) and to 91 months (95%CI 57-unreached) for STK11 ex3-9 mutations ( P = .003 ). In multivariate analysis, STK11 ex1-2 mutations remained associated with a poor prognosis ( P = .002 ). Results were validated in two public datasets. Western blots showed that STK11 ex1-2 mutatedtumors expressed short STK11 isoforms. Finally using mRNAseq data from the TCGA cohort, we showed that a stroma-derived poor prognosis signature was enriched in STK11 ex1-2 mutated tumors. All together our results show that STK11 ex1-2 mutations delineate an aggressive subtype of lung cancer for which a targeted treatment through STK11 inhibition might offer new opportunities.

Nella gestione dei tumori pleurici, la chirurgia ha un duplice interesse: diagnostico e terapeutico, indipendentemente dal fatto che l’obiettivo sia curativo o palliativo. Al di fuori del mesotelioma, un tumore pleurico primitivo si presenta, il piu delle volte, sotto forma di una lesione unica, talvolta molteplice ma raramente diffusa. Al contrario, una metastasi pleurica induce spesso una lesione diffusa dei due foglietti pleurici. Quest’ultima e, in effetti, la prima causa di versamento pleurico dopo i 50 anni. Il carattere resecabile e la natura istologica costituiscono i due fattori essenziali della gestione. Se il tumore e di aspetto benigno e appare resecabile nella sua totalita, la chirurgia e terapeutica fin dall’inizio. Al contrario, un tumore non resecabile e/o di aspetto maligno richiede una resezione dopo una diagnosi preoperatoria o, anche, dopo un trattamento neoadiuvante. Infine, ogni lesione pleurica diffusa richiede una videotoracoscopia a scopo diagnostico, seguita da una sinfisi pleurica palliativa, volta semplicemente a prevenire la recidiva dei versamenti pleurici.

The tumor suppressor gene neurofibromin 1 (NF1) is a major regulator of the RAS‐MAPK pathway. NF1 mutations occur in lung cancer but were not extensively explored. We hypothesized that NF1‐mutated tumors could define a specific population with a distinct clinical and molecular profile. We performed NF1 sequencing using next generation sequencing (NGS) in 154 lung adenocarcinoma surgical specimens with known KRAS, EGFR, TP53, BRAF, HER2, and PIK3CA status, to evaluate the molecular and clinical specificities of NF1‐mutated lung cancers. Clinical data were retrospectively collected, and their associations with molecular profiles assessed. In this series, 24 tumors were NF1 mutated (17.5%) and 11 were NF1 deleted (8%). There was no mutation hotspot. NF1 mutations were rarely associated with other RAS‐MAPK pathway mutations. Most of patients with NF1 alterations were males (74.3%) and smokers (74.3%). Overall survival and disease‐free survival were statistically better in patients with NF1 alterations (N = 34) than in patients with KRAS mutations (N = 30) in univariate analysis. Our results confirm that NF1 is frequently mutated and represents a distinct molecular and clinical subtype of lung adenocarcinoma.

Adequate intra-operative lymph node sampling (LNS) is a fundamental part of non-small cell lung cancer (NSCLC) surgery but adherence to standards is still far from being commonly obtained. Edwards and coworkers (1) reviewed 1,301 surgical resections performed from 2011 to 2014 to identify factors that may be the cause of the LNS inadequacy.

Resume Un homme de 73 ans, insuffisant respiratoire chronique, est admis en urgence dans l’unite de soins intensifs pneumologie pour hemoptysie et hypoxemie majeures. Il presentait une defaillance respiratoire aigue avec hypertension arterielle pulmonaire. Le saignement provenait de la bronche lobaire inferieure gauche. A ce niveau, existaient deux formations nodulaires et une petite fistule arterioveineuse avec shunt. L’embolisation arterielle pulmonaire etait recusee du fait d’une arteriopathie diffuse majeure. Une lobectomie inferieure gauche etait realisee. La veine pulmonaire superieure gauche s’abouchait dans le tronc veineux innomine constituant un retour veineux pulmonaire anormal partiel. Cette anomalie etait corrigee. Les suites operatoires etaient simples. On notait une correction du shunt vasculaire et une amelioration de la surcharge des cavites cardiaques droites. Le patient controle a un an se portait bien, avec une fonction cardiaque amelioree sans recidive de l’hemoptysie. L’anastomose atrio-veineuse etait permeable.

Resume Introduction Le pronostic du cancer bronchique est essentiellement base sur le TNM, l’histologie et la biologie moleculaire. Notre propos a ete d’analyser la valeur pronostique de certaines donnees cliniques et paracliniques. Patients et methodes Nous avons etudie, chez 6105 patients operes repartis en 3 periodes de temps (1979 a 2010), les facteurs pronostiques suivants : type de chirurgie, pTNM, histologie, âge, sexe, tabagisme, antecedents, contexte clinique et paraclinique. Resultats La mortalite postoperatoire etait de 4 % (243/6105), le taux des complications de 23,3 % (1424/6105). Le taux de la survie globale etait de 43,2 % a 5 ans et de 27 % a 10 ans. Les meilleures survies etaient observees apres exerese complete (R0) ( p −6 ), lobectomies ( p −6 ), curage ganglionnaire ( p = 0,0006), petits stades du pTNM ( p −6 ), absence d’une composante solide dans les adenocarcinomes. D’autres facteurs etaient pejoratifs : sexe masculin ( p = 10 −5 ), âge ( p = 0,0000002), comorbidite ( p = 0,016), antecedents de cancer ( p −5 ), complications postoperatoires ( p = 0,0018), VEMS inferieur a 80 % ( p = 0,0000025), periodes de temps ( p −6 ). Tous ces facteurs etaient confirmes par l’analyse multivariee, sauf le sexe. Le tabagisme qui n’etait pas facteur de mauvais pronostic en analyse univariee ( p = 0,09), le devenait en multivariee (0,013). Conclusion Des facteurs medicaux et humains, l’etat general et physiologique, jouent un role, important dans le pronostic apres chirurgie. On ne connait pas leur signification exacte et, a l’instar des etudes sur la chimiotherapie, ils justifieraient des recherches particulieres.

Le indicazioni della chirurgia nei linfedemi restano rare (meno del 2,5% dei linfedemi). E abituale operare soltanto i linfedemi negli stadi ultimi o quelli che resistono alla fisioterapia, casi per i quali la reversibilita delle lesioni e compromessa. Tuttavia, le tecniche di resezione (debulking) sono raramente utilizzate al di fuori dei linfedemi pubici e scrotali e in caso di eccesso cutaneo secondario a un trattamento fisico. I linfedemi di origine iatrogena sono i piu frequenti nei paesi occidentali: l’ideale sarebbe operarli il prima possibile o, meglio, prevenirli. Sono, allora, da privilegiare le tecniche microchirurgiche. Le indicazioni terapeutiche devono essere poste collegialmente dall’equipe pluridisciplinare che ha in carico il paziente (comprendendo medici vascolari, radiologi, medici nucleari, fisioterapisti e chirurghi specializzati). I risultati devono essere valutati considerando l’aspetto estetico e il miglioramento della qualita di vita ottenuto.

Resume Introduction Les resections « limitees » pour cancer bronchique ou wedge-resections, que de nouvelles techniques (radiofrequence et cyberknife) tendent a supplanter, ont des resultats a long terme moins bons que les segmentectomies et lobectomies et les « guidelines » recommandent de les eviter au profit des dernieres. Ce travail proposait d’etudier la valeur carcinologique de ces resections. Patients et methodes Les cancers bronchiques sans traitement d’induction mesurant 30 millimetres ou moins operes de 1980 a 2009 ont ete revus. Les variables etudiees etaient : siege, sexe, âge, VEMS, type de resection, histologie, pT et pN. Resultats Il y eut 66 wedge-resections (10,9 %), 32 segmentectomies (5,3 %), 507 lobectomies (83,8 %), 9 deces postoperatoires (1,5 %), 136 complications (22,5 %), 557 resections completes (R0 = 92 %). Dans les wedge-resections et les segmentectomies l’âge etait plus eleve, le VEMS moyen inferieur et le CBNPC plus souvent un epidermoide pN0 et de pStade I que dans les lobectomies. Le curage manquait dans la moitie des wedge-resections. La survie a 5 ans etait moins bonne apres wedge-resection : 50 % versus segmentectomies 59,8 % (p = 0,09), et lobectomies 66 % (p = 0,0035), mais le taux des recidives n’etait pas superieur. En analyse multivariee, âge, VEMS, qualite de la chirurgie et du curage, et pN du pTNM etaient les seuls facteurs de pronostic. Conclusion La wedge-resection est moins carcinologique qu’une segmentectomie ou lobectomie quand ces dernieres sont possibles, mais permet, a l’inverse des nouvelles techniques qui n’ont pas demontre leur superiorite, une contribution anatomopathologique indeniable qui doit la faire preferer quand elle est realisable.

OBJECTIVES: Lung transplantation (LTx) is an accepted therapy for selected infants, children and adolescents with end-stage lung and pulmonary vascular disease. It remains a challenge for a selected group of patients. In 2011, the number of paediatric lung transplantations (PLTxs) worldwide was 107. In France, a total of 131 PLTxs have been performed since 2000 (data from ABM: Agence de biomedecine), 65 of which were conducted at our institution. METHODS: All patients under 18 (4.8–17.11) years of age matching inclusion and exclusion criteria, who underwent LTx at our institution were included in this study (n= 58). We analysed the outcomes of these patients in terms of survival rates, controlling for indications for transplantations and surgical procedures. Secondary outcomes were analysis of surgical and medical complications and identification of prognostic factors in the field of LTx in these categories of ages. RESULTS: The 30-day mortality rate was 10%. Kaplan–Meier survival rates at 1 month, 1, 3, 5 and 10 years were 90, 81, 66, 60 and 57%, respectively; the median survival was 91 months. Reduced-size transplantation was performed in 33% of double-lung transplantation (DLTx) patients without negatively impacting survival. In our series, female sex, the presence of a sex mismatching and, in particular, the occurrence of a male donor to a female recipient (F/M group) have been poor prognostic factors after PLTx. CONCLUSIONS: The overall survival after PLTx was encouraging (57% at 10 years). A PLTx should be offered to the small number of patients with end-stage pulmonary disease. The limited number of paediatric donor organs can be overcome by using reduced-size organs without a survival disadvantage to the patients. In our series, male sex and sex matching seemed to be positive predictive prognostic factors after PLTx but further studies are required to confirm these results and to also clarify the role of age of donor, time of cold ischaemia and body mass index in PLTx.

Background Induction chemotherapy (ICT) is supposed to reduce the risk of micrometastatic progression and improve resectability of non-small cell lung cancer (NSCLC). However, best indications for ICT strategy remain unclear in published meta-analyses. Based on this observation, an evaluation of daily practice is of importance. Therefore, we reviewed indications and efficacy time trends in our 30-year series. Methods A database including all patients with NSCLC who underwent surgical resection in two French centers from 1980 to 2009 (n = 5563) was prospectively set and retrospectively reviewed. The indications, clinical and pathologic response rates, and overall survival of ICT patients (n = 732) were analyzed during three successive time-periods: P1 from 1980 to 1989, P2 from 1990 to 1999, and P3 from 2000 to 2009. Results The proportion of patients who benefited from ICT increased over time, from 2.8% (n = 35) in P1 to 12.5% (n = 274) in P2, and 20.2% (n = 423) in P3. Indications evolved over time with more N2 patients (n = 211; 49.8%) and less initially unresectable patients (n = 72; 17%) in P3. The clinical response rate between P1 and P2 increased. Five and 10-year survival rates of ICT patients were 35.2% and 21.5%, respectively. In multivariate analysis, time-period, age, type of resection, histology, and pathologic response to chemotherapy were significant prognostic factors. Conclusions Our report on the off-trial use of induction therapy during the last 30 years demonstrates an increased use of ICT, a progressive focus on N2 disease, and improved response rates.

Objectives: Non-small cell lung carcinoma (NSCLC) with N1 involvement is associated with 5-year survival rates ranging from 7% to 55%. Numerous factors have been independently reported to explain this heterogeneous prognosis, but their relative weight on long-term survival is unknown. Methods: Patients who underwent surgical resection for NSCLC in two French centers from 1993 to 2010 were prospectively recorded and retrospectively reviewed. The overall survival (OS) of patients undergoing first-line surgery for pN1 disease was analyzed according to the type of extension, number of metastatic LN, number and anatomic location of metastatic stations. Results: The study group included 450 patients (male 80.2%, mean age 63.3 � 9.9 years, 5-year overall survival 46%). The number of metastatic station was 1 in 340 (75.6%, single-station disease) and � 2 in 110 patients (24.4%, multi-station disease). The number of metastatic stations was correlated with the number of metastatic LN (p < .001), and associated with adverse OS (p ¼ .0014). The presence of intralobar metastatic LN (station 12e13e14) was associated with a mechanism of direct extension (p < .001), but did not impact OS (p ¼ .71). The location of metastatic stations was of prognostic significance only in case of multi-station disease, with hilar (station 10) involvement being associated with adverse OS (p ¼ .005). The 110 patients with multi-station pN1 disease and the 134 patients operated on for single-station pN0N2 (skip-N2) disease during the study period yield comparable outcome (p ¼ .52). Conclusions: In patients with resected pN1 NSCLC, the number of metastatic stations and their location in case of multi-station disease have a prognostic value. 2014 Published by Elsevier Ltd.

Resume Introduction Le cancer du poumon est la premiere cause de deces par cancer et la cirrhose la quatorzieme, toutes causes de deces confondues. La chirurgie chez le cirrhotique fait courir de gros risques. Notre propos a ete d’analyser ses resultats. Methodes Nous avons revu, parmi 7162 patients, ceux operes d’un cancer du poumon ( n = 6105) et compare les porteurs d’une pathologie hepatique ( n = 448) a ceux ayant d’autres antecedents medicaux ( n = 2587) puis analyse les patients cirrhotiques ( n = 49). Resultats La survie des porteurs d’une pathologie hepatique etait moins elevee qu’en son absence ( n = 5657/6105) : 35,3 % contre 43,8 % a 5 ans, p = 0,0021. Celle des cirrhotiques n’etait pas statistiquement differente de celle des autres pathologies hepatiques, mais aucun ne survivait au-dela de 10 ans (0 % versus 26,4 %). Les interventions chez les cirrhotiques ont consiste en 1 thoracotomie exploratrice, 3 resections atypiques, 2 segmentectomies, 33 lobectomies, et 10 pneumonectomies. La mortalite postoperatoire (8,2 % ; 4/49) n’etait pas differente de celle des patients sans antecedent hepatique (4,2 % ; 239/5657) ( p = 0,32), de meme que le taux des complications (40,8 % ; 20/49 et 24,8 % ; 1404/5657, p = 0,11). Un seul deces postoperatoire etait associe a une defaillance hepatique, aucun des complications. En analyse multivariee l’âge, l’histologie, et le stade etaient facteurs independants de pronostic. Conclusion La chirurgie peut etre realisee avec des suites postoperatoires acceptables et des taux de survie honorables quand la cirrhose est compensee, mais le genie evolutif de cette derniere est facteur de plus mauvais pronostic apres 5 ans.

Resume Les pneumonectomies pour lesions benignes sont plus rares que celles pour cancer mais genereraient une plus grande morbimortalite. Nous avons voulu verifier cette allegation en revoyant retrospectivement les dossiers de 1436 pneumonectomies et de 54 totalisations, dont respectivement 82 (5,7 %) et 10 (18,5 %) effectuees pour lesions benignes (65 gauches et 27 droites) : poumon detruit tuberculeux ( n = 37), aspergillome ( n = 18), bronchiectasie ( n = 19), infection ( n = 5), malformation ( n = 5), pseudotumeur inflammatoire ( n = 3), traumatisme ( n = 2), post-radiotherapie ( n = 2) et mucormycose ( n = 1). Les pneumonectomies etaient des pneumonectomies simples ( n = 48) et des pleuro-pneumonectomies ( n = 44) associees a une protection de la suture bronchique dans 61 cas. La morbimortalite postoperatoire a consiste en 20 complications (21,7 %) et 7 deces (7,6 %) et n’etait pas differente de celle observee apres pneumonectomies pour cancer. Le taux de fistule et la mortalite ne dependaient ni du cote opere, ni du type d’exerese, ni de la presence d’un lambeau de protection bronchique. La mortalite en cas d’infection fongique etait de 26,3 % ( n = 5/19), superieure a celle observee en absence de ce type d’infection (2,7 %, n = 2/74), p = 0,0028. Les suites postoperatoires des pneumonectomies pour lesions benignes restent donc tres acceptables. Seules les pneumonectomies pour infection fongique semblent a risque accru de complications postoperatoires.

Resume Introduction Les tumeurs muco-epidermoides (TME) sont des tumeurs rares developpees au niveau des glandes sero-muqueuses peri-bronchiques. Certaines de ces tumeurs evoluent comme des tumeurs malignes. Parmi celles-ci, beaucoup ont ete probablement confondues avec des cancers bronchiques adenosquameux. Patients et methode Nous avons revu 22 patients porteurs de TME observes en 25 ans. Deux de ces tumeurs etaient de siege tracheal ; les 20 autres tumeurs siegeaient au niveau de l’arbre bronchique cartilagineux. Douze de ces TME avaient des criteres macroscopiques et histologiques de bas grade de malignite, 4 avaient des criteres macroscopiques et 6 des criteres macroscopiques et microscopiques de haut grade de malignite. Resultats Les tumeurs muco-epidermoides de haut grade de malignite etaient de mauvais pronostic avec aucune survie au-dela de 6 ans ; ce comportement les rapproche des carcinomes bronchiques « classiques », et notamment des carcinomes adenosquameux. Conclusion Le meilleur traitement de cette maladie orpheline reste la chirurgie.

Resume Introduction La decouverte d’un deuxieme cancer du poumon chez un patient ayant un antecedent de cancer bronchique n’est plus une rarete. Aussi, il est possible d’observer une nouvelle localisation chez un patient ayant ete pneumonectomise. La chirurgie reste le meilleur des traitements. Notre propos a ete de faire un point sur ce sujet. Methode Parmi 5611 malades operes dans notre centre, 186 (3,3 %) presentaient un cancer metachrone et 17 etaient survenus chez des pneumonectomises (0,7 % des pneumonectomies et 0,2 % des CBNPC traites dans notre service). L’intervention etait a visee diagnostique et therapeutique dans 88 % des cas ( n = 15). Resultats Il s’agissait de 16 hommes et 1 femme, d’âge moyen 62,5 ans, tous tabagiques (11 non sevres). Six presentaient d’autres antecedents medicaux. Le VEMS moyen etait de 52 % (extremes 35 a 95 %). Les exereses consistaient en 2 lobectomies, 4 segmentectomies et 11 resections atypiques. Il n’y eut aucun deces postoperatoire, mais 2 complications. L’histologie du premier et du deuxieme cancer etait identique chez 11 patients. Tous les patients etaient pN0 apres traitement du deuxieme cancer. La survie a long terme, (mediane 33 mois) etait de 35,3 % a 5 ans et de 14,1 % a 10 ans. Deux patients etaient pN2 apres pneumonectomie pour leur premier cancer. Les patients ayant eu une lobectomie superieure droite pour traitement de leur deuxieme cancer ont vecu plus de 5 ans. Conclusion La chirurgie d’exerese pour cancer bronchique sur poumon unique est accompagnee d’une morbimortalite acceptable. Une survie prolongee peut etre obtenue chez des patients bien selectionnes.

Resume Objectif Chez les transplantes d’organes, l’incidence des tumeurs broncho-pulmonaires est reputee plus elevee et le pronostic plus mauvais que dans la population generale. Notre propos a ete d’etudier les resultats du traitement chirurgical sur ce terrain. Methodes Nous avons revu les dossiers de 49 hommes et 6 femmes, d’âge moyen 60,6 ans (extremes 38–85). Il s’agissait de greffes cardiaques ( n = 37), renales ( n = 12), hepatiques ( n = 5) et bipulmonaire ( n = 1). Quarante-huit patients etaient tabagiques ; 42 presentaient de lourdes pathologies associees (76,4 %). Les tumeurs etaient decouvertes dans le cadre d’une surveillance (78,2 % des cas, 43 patients), ou devant des symptomes (21,8 % des cas, 12 patients). Nous avons revu les caracteristiques de ces patients (epidermoides n = 23, adenocarcinomes n = 24, autres n = 8). Resultats Il y a eu 2 thoracotomies exploratrices, des resections atypiques chez 6 patients, 1 segmentectomie, 42 lobectomies et 4 pneumonectomies avec 34,5 % de complications postoperatoires ( n = 19 patients) et 7,4 % de mortalite ( n = 4). La survie de la population a ete de 46,4 % a 5 ans (65,4 % au stade I, n = 25) ; 35 patients sont decedes a distance dont 14 de leur cancer (40 %). Parmi eux, 2 avaient ete reoperes d’un autre cancer du poumon : l’un 3 et 8 ans apres (survie 16 ans) et l’autre 2 ans apres (survie 70 mois). Conclusions Les resultats observes apres chirurgie chez ces patients sont bons et les suites acceptables malgre des risques, a priori, majores. Ils demontrent l’interet d’un suivi rapproche chez les transplantes anciens fumeurs permettant de depister le cancer a un stade precoce.

The anatomy of the trachea lymphatics is poorly understood and the only researches date back to more than one century. Tracheal tumors are very rare, miscellaneous and variously lymphophilic. The cancers of the trachea have no TNM and their lymph node metastases are little studied despite their poor prognosis. We observed 2 cases of squamous cell carcinoma, one in the cervical and the other in the intrathoracic trachea. TDM-3D reformats demonstrated metastatic lymph nodes of the right para-tracheal lymph node chain (2R and 4R) in both patients and in the cervical lymph nodes (right recurrent nerve lymph node chain) in the patient with cervical tumor. Right location of the mediastinal metastases may be explained by the anatomy of the lymph node chain drainage of the lung segments, the right para-tracheal chain being the only one to regularly possess lymph nodes at that level. The right recurrent nerve lymph node metastases of the cervical tumor are explained by common lymph drainage of the cervical trachea towards larynx lymph centres. Besides lymph node metastases, cancers prognosis may also depends on its location in the trachea. Thus, the tracheal tumors are complex and constitute quite as many orphan tumors. Multicentric studies are mandatory to better understand their behavior. Means provided by new imaging techniques might permit establishing a veritable TNM lymph node mapping of these tumors.

Resume Objectifs Le traitement chirurgical des aspergillomes pulmonaires permet de controler les symptomes, de prevenir les complications et d’ameliorer la survie. Dans les formes accessibles a la chirurgie, l’impact d’un traitement antifongique demeure controverse. L’objectif de cette etude est d’analyser l’impact d’un traitement antifongique sur la morbidite postoperatoire et la survie globale des patients operes pour un aspergillome pulmonaire. Methodes De janvier 1989 a decembre 2010, 113 patients ont ete operes pour un aspergillome pulmonaire. Parmi eux, 64 patients ont recu un traitement antifongique dans la periode perioperatoire et ont ete inclus dans le groupe 1, 49 patients n’ont pas recu de traitement antifongique et ont ete inclus dans le groupe 2. Resultats Le taux de complications postoperatoires etait de 31,2 % dans le groupe 1 et de 20,4 % dans le groupe 2 ( p = 0,30). En analyse univariee, l’immunodepression ( p p = 0,050), les expectorations purulentes preoperatoires ( p = 0,024) et la pneumonectomie ( p p = 0,23). En analyse multivariee, l’âge superieur a 50 ans, l’immunodepression et la pneumonectomie etaient des facteurs de mauvais pronostic (χ 2 = 6,59, df = 5, p Conclusions La resection chirurgicale des aspergillomes pulmonaires est associee a une morbidite postoperatoire et a une survie a long terme acceptables. Le traitement antifongique perioperatoire n’influence en aucun cas la morbidite postoperatoire ou la survie a long terme.

A 64-year-old man complained of persistent dyspnea and bilateral basi-thoracic pain with shoulder irradiation. Chest computed tomography revealed a heterogeneous left diaphragmatic mass, while magnetic resonance imaging showed hypo-T1 and hyper-T2 signal. Positron-emission tomography did not show any hypermetabolism. Video-assisted thoracic surgery was decided. At inspection, tumour appeared within the posterior costal part of the diaphragmatic muscle. Tumour resection was extended to a 8-cm-long portion of the lumbar part of diaphragm. Diaphragm was repaired with non-absorbable interrupted sutures. Postoperative course was uneventful. Final pathology revealed an intra-diaphragmatic bronchogenic cyst, which is an exceptional condition. Primary diaphragmatic tumours are very rare and preoperative diagnosis cannot be affirmed. Embryologic hypotheses (migration along the oesophagus or envelopment within diaphragmatic precursors of an abnormal supernumerary lung bud) including recent molecular findings of deregulated pathways (fibroblast growth factor-10 and NOTCH) are discussed.

OBJECTIVES: Pneumonectomy for benign disease is rare but is thought to have a higher more postoperative morbidity and mortality than when performed for lung cancer. We questioned this by assessing and analysing indications and postoperative outcomes of patients who underwent this type of resection. METHODS: We used Epithor, the French national thoracic database including 91 public and private institutions with more than 220 000 procedures. We prospectively collected data of 5975 patients who underwent pneumonectomy between January 2003 and June 2013. The 321 patients (5.4%) who underwent pneumonectomy (n= 201) or completion pneumonectomy (n= 120) for benign disease were compared with those treated for malignant disease. RESULTS: The patients’ mean age was 55.2 years (53.5; 56.8) for benign indications vs 61.6 years (61.4; 61.9) for malignant disease; the sex ratio was 1.8 (207 males) and 4 (4543 males), respectively; 53% of patients (n= 169) had an American Society of Anesthesiologist (ASA) score of ≥3 vs 29% (n= 1598) for malignant disease. For benign disease, most frequent indications were infection or abscess (n= 114, 37.1%), post-tuberculosis destroyed lung (n= 47, 15.3%), aspergillosis or aspergilloma (n= 33, 10.7%), bronchiectasis (n= 41, 13.3%), haemorrhage (n= 26, 8.5%) and benign tumour (n= 20, 6.5%). Complications occurred in 53% (n= 170) of patients and the postoperative in-hospital mortality rate was 22.1% (n= 71). These results were significantly worse than those for malignant indications: 38.9% (n= 2198) of morbidity (P< 0.0001) and 5.1% (n= 288) of in-hospital mortality (P< 0.0001). For benign disease, there was no difference in fistula formation regarding side (P= 0.07) or type of resection (P= 0.6). Morbidity was higher for completion pneumonectomy: 62.5 vs 47.3% (P= 0.008). Mortality was significantly higher in case of resection for infection or abscess (P= 0.01) and for haemorrhage (P= 0.002). Emergency procedures were associated with worse postoperative outcomes (P< 0.0001). CONCLUSIONS: Pneumonectomy for benign disease achieves cure with very high levels of morbidity and mortality. This type of surgical treatment should be considered as a salvage procedure.

Il drenaggio della cavita pleurica rappresenta il gesto di base della chirurgia toracica. Peraltro, esso puo essere realizzato da diversi specialisti medici, in particolare in un contesto di urgenza. Per essere efficace, il drenaggio toracico richiede rigore e destrezza. Come ogni gesto tecnico, un errore puo avere delle conseguenze disastrose per il paziente. Dopo un richiamo dell’anatomia e della fisiologia della pleura, gli autori descrivono i materiali attualmente disponibili per assicurare un drenaggio pleurico, cosi come le tecniche di posizionamento. Sono esposte anche la sorveglianza della sua efficacia e le condizioni di asportazione. Sono presi in considerazione i casi particolari del drenaggio pleurico dopo chirurgia toracica. Infine, il drenaggio pericardico e descritto secondo le diverse vie d’accesso utilizzabili.

Descritta nel 1819, la tubercolosi polmonare ha accompagnato lo sviluppo della chirurgia toracica. Dopo l’abbandono delle tecniche di collassoterapia nel 1945 e il minor ricorso alla toracoplastica dopo gli anni ′80, le resezioni parenchimali restano il solo trattamento curativo possibile di situazioni cliniche complesse. La tubercolosi multiresistente (multidrug-resistant tuberculosis [MDR-TB]) deve beneficiare di una gestione chirurgica all’interno di equipe specializzate. Le caverne post-tubercolari, le distruzioni parenchimali e le dilatazioni dei bronchi da postumi possono complicarsi con un’emottisi e un’infezione da aspergillus o con infezioni recidivanti e devono, allora, essere operate. In queste indicazioni difficili, una preparazione preoperatoria rigorosa, una tecnica sistematica e delle cure postoperatorie vigili consentono di ottenere delle guarigioni definitive, al prezzo di una morbimortalita operatoria accettabile. Queste situazioni devono, quindi, essere conosciute dai chirurghi toracici, per non prolungare inutilmente dei trattamenti medici inefficaci e/o tossici.

Data addressing the outcomes and patterns of recurrence after pulmonary metastasectomy (PM) in patients with colorectal cancer (CRC) and previously resected liver metastasis are limited. We searched the PubMed database for studies assessing PM in CRC and gathered individual data for patients who had PM and a previous curative liver resection. The influence of potential factors on overall survival (OS) was analyzed through univariate and multivariate analysis. Between 1983 and 2009, 146 patients from five studies underwent PM and had previous liver resection. The median interval from resection of liver metastasis until detection of lung metastasis and the median follow-up from PM were 23 and 48 months, respectively. Five-year OS and recurrence-free survival rates calculated from the date of PM were 54.4 and 29.3 %, respectively. Factors predicting inferior OS in univariate analysis included thoracic lymph node (LN) involvement and size of largest lung nodule ≥2 cm. Adjuvant chemotherapy and whether lung metastasis was detected synchronous or metachronous to liver metastasis had no influence on survival. In multivariate analysis, thoracic LN involvement emerged as the only independent factor (hazard ratio 4.86, 95 % confidence interval 1.56–15.14, p = 0.006). PM offers a chance for long-term survival in selected patients with CRC and previously resected liver metastasis. Thoracic LN involvement predicted poor prognosis; therefore, significant efforts should be undertaken for adequate staging of the mediastinum before PM. In addition, adequate intraoperative LN sampling allows proper prognostic stratification and enrollment in novel adjuvant therapy trials.

Resume Les exereses majeures du poumon realisees sous video assistance ou par video-thoracoscopie seule, beneficient d’un regain d’actualite dans la chirurgie des cancers bronchiques de stade precoce. La plupart des publications leur sont actuellement favorables, mettant en avant aussi bien leurs resultats immediats que ceux a long terme. Cette nouvelle « technique » fait toutefois l’objet de controverses silencieuses et est encore loin d’avoir l’approbation de l’ensemble des equipes chirurgicales. Une revue critique des principales donnees de la litterature permet de retrouver un certain nombre de risques inherents a cette nouvelle approche : risques immediats, principalement lies aux problemes techniques rencontres en peroperatoire, et aussi risques a distance, en rapport avec des inconnues qui subsistent sur sa valeur carcinologique. Il serait souhaitable que les promoteurs de la technique s’attellent maintenant a l’organisation d’un essai multicentrique randomise afin de prouver l’efficacite de cette voie d’abord.

Resume Les bilobectomies sont indiquees pour differentes tumeurs et differentes contraintes chirurgicales. Dans la litterature, leurs resultats sont souvent contradictoires. Nous avons revu les particularites de cette resection. Patients et methodes Les dossiers des operes pour tumeur du poumon de 1980 a 2009 ont ete analyses : donnees demographiques, indications, histologie, TNM, complications, resultats sur la survie des bilobectomies et compares a ceux des lobectomies et pneumonectomies droites. Resultats Les bilobectomies representaient 7,2 % des resections droites pour tumeurs (235/3280), 82 % (192/235) etant realisees pour cancer pulmonaire non a petites cellules (CBNPC). Les bilobectomies inferieures et moyennes (BIM) realisees le plus souvent pour carcinoides et epidermoides representaient 60 % des cas. Les complications etaient plus frequentes apres bilobectomie qu’apres les autres resections, toutefois moins apres bilobectomies superieures et moyennes (BSM) qu’apres BIM. En cas de CBNPC N0, les taux de survie a 5 ans des bilobectomies (46,1 %) etaient intermediaires entre ceux des lobectomies (52,6 %) et des pneumonectomies (31,7 %), p −6 . La difference des taux de survie entre BSM et BIM n’etait pas significative ( p = 0,09). Il n’y avait pas de difference de survie entre les patients ayant recu ou non un traitement neoadjuvant. Conclusion La bilobectomie permet des taux de survie a long terme satisfaisants, une mortalite postoperatoire acceptable malgre un taux plus important de complications. La survie des BSM tend vers celle des pneumonectomies et celle des BIM vers celle des lobectomies, ce qui semble en rapport avec certains aspects anatomopathologiques differents des tumeurs qui en sont a l’origine.

Resume Introduction L’atteinte pleurale (APL) du cancer bronchique non a petites cellules (CBNPC) serait de mauvais pronostic, hors elle peut etre tres heterogene. Methode Etude retrospective descriptive comparative multicentrique entre 1979 et 2010 concernant 2329 patients operes de CBNPC. Les APL ( n = 890), viscerales (APLV) ou parietales (APLP) ont ete subdivisees en : APLV-P peripherique et APLV-S scissurale, puis en APLP-M mediastinale et APLP-C costale. Leurs caracteristiques et leurs survies ont ete comparees entre elles et a celles d’une population de patients sans APL ( n = 1439). Resultats Le sexe-ratio des patients etait de 2,8 (hommes n = 1713). Les patients APL etaient significativement plus jeunes, leur sexe-ratio plus bas, ils etaient moins souvent R0 (96 % contre 98,7 % p = 0,000076) et N0 (60 % contre 70 %, p −6 ), et leur survie a 5 ans inferieure (45,7 % contre 55,5 % p −6 ). L’APL etait correlee a la taille du CBNPC ( p −6 ) et a l’atteinte pN2 ( p = 0,0020). Apres traitement neoadjuvant, l’APL etait moins frequente (36,2 % contre 39,1 % p = 0,03). En cas d’APLV-S ou d’APLP-M, les pneumonectomies etaient plus frequentes ( p −6 ). Quand APLV-P franchissait la plevre ( n = 196/561), il existait plus de pN1-pN2 ( p = 0,0065) avec une survie a 5 ans de 42,9 % contre 54,4 %, p = 0,013. L’APL n’etait pas un facteur independant du pronostic en analyse multivariee, contrairement a l’âge, le sexe, le type d’exerese, le pT et pN. Conclusion La plevre joue un role majeur dans la dissemination du CBNPC. Son atteinte conditionne le pN, le type de resection chirurgicale et justifie l’usage de traitements neoadjuvants.