BACKGROUND:Operative management of patients with persistent N2 disease after induction therapy is still debated.METHODS:One hundred fifty-three consecutive patients underwent pneumonectomy from January 1999 until July 2005; 28 patients (18.3%) had persistent N2 disease after induction therapy (group 1), 32 patients (20.9%) had pathologic stage N0 or N1 after induction therapy (group 2), and 93 patients (60.8%) with pathologic N2 disease underwent immediate surgery (group 3). Short-term end points were operative mortality at 30 and 90 days and major complications. Long-term end points were 5-year survival and disease-free survival rates.RESULTS:Demographics of the three groups were similar (age, sex, side of operation, type of chemotherapy, smoking status, and comorbidity such as coronary artery disease, diabetes, and chronic obstructive pulmonary disease). Thirty-day postoperative mortality was 10.7% in group 1, 3.1% in group 2 (p = 0.257), and 4.3% in group 3 (p = 0.201); 90-day postoperative mortality was 10.7% in group 1, 12.5% in group 2 (p = 0.577), and 9.7% in group 3 (p = 0.558). Incidence of major postoperative complications was similar. Five-year survival rate was 32.2% (median, 28 months; 95% confidence interval, 7 to 43) in group 1, 34.8% (median, 27 months; 95% confidence interval, 7 to 47) in group 2 (p = 0.685), and 12.4% (median, 15 months; 95% confidence interval, 11 to 19) in group 3 (p = 0.127). No statistical difference was found in terms of 5-year event-free survival, or regarding the side of pneumonectomy.CONCLUSIONS:Our results suggest that pneumonectomy is justified in patients with persistent N2 disease after induction chemotherapy.

SUMMARY The aim of the present study was to evaluate whether tumor markers Cyfra 21 and NSE may contribute to staging and evaluation of prognosis in patients with op-erable lung cancer. 432 operated patients (mean age 61±9) were involved in the study. There were 278 (bi)lobectomies, 120 pneumonectomies, 12 segmental resections and 22 explorative thoracotomies. Pathologic staging was stage I in 195, stage II in 86, and stage IIIA in 151. The relationship between the level of tumor markers and the postoperative pathologic staging was studied. Survival estimates (Kaplan Meier) were made with reference to the preoperative level of Cyfra-21, crossed with TNM stage and type of resection. Relative risk was estimated with the Cox proportional hazard model. Cyfra-21 was increased in 32% of patients, 69% of whom had squamous cell carcinoma (SCC). NSE was elevated in 57, 40% of whom had adenocarcinoma. De-spite a low sensitivity, there was a correlation to tumor size and N-stage: sensitivity for both markers was high-est in stages T3/T4, or N2. Elevated Cyfra-21 levels her-alded a poor prognosis in patients with stage I or III disease, and following (bi)lobectomy, (mean survival 101 and 46 months respectively, p<0.005). Relative risk for death in presence of elevated Cyfra 21 level was 1.4. Low sensitivity makes that Cyfra-21 and NSE are inappro-priate tools for staging of operable lung cancer. An ele-vated Cyfra-21 level indicates a poor prognosis. гG.V.Nikolaev, V.K.Kossenok, E.A.Kochetkova, P.Meyer,X.Ducrocq, J.M.Wihlm, pE.Quoix, G.Massard

Background : There is an ongoing debate whether induction therapy increases post-operative mortality and morbidity, especially when performing pneumonectomy. We therefore reviewed a consecutive series of patients having undergone pneumonectomy in a single center. Methods: The charts of 298 patients operated on from January 1999 till July 2005 were reviewed. Patients were divided into 2 groups: group 1 included those who received induction chemotherapy (60 patients, 20.1%), and group 2 included those who underwent surgery alone (238 patients, 79.9%). Endpoints were operative mortality at 30 and at 90 days, and major complications such as empyema, bronchial fi stula and ARDS. Statistical analyses were performed using SPSS 11.0 software. Results: Demographic data were similar for both groups when considering side of operation, comorbidity and weaning from tobacco; group 2 included older patients (61.83±9.58 years versus 57.75±8.94 years; p=0.003), more female patients in group 2 (17.2% versus 5.0%; p= 0.010), and more diabetic patients (13.4% versus 5.0 % ; p = 0.048). Post-operative mortality at 30 days was 6.7% in group 1 and 5.5% in group 2 (p=0.458), and 11.7% for group 1 and 10.9% in group 2 at 90 days (p=0.512). Incidence of empyema was 1.7% in group 1 and 2.1% in group 2 (p=0.652); incidence of bronchopleural fi stulas was 1.7% in group 1 and 5.5% in group 2 (p=0.188); incidence of acute respiratory distress syndrome was 3.3% in group 1 and 3.4% in group 2 (p=0.675). Conclusion: In opposition to previous reports, induction chemotherapy did not signifi cantly jeopardize post-operative outcome following pneumonectomy in our experience. Key-words: Ilung cancer, induction chemotherapy, pneumonectomy

Background : There is an ongoing debate whether induction therapy increases post-operative mortality and morbidity, especially when performing pneumonectomy. We therefore reviewed a consecutive series of patients having undergone pneumonectomy in a single center. Methods: The charts of 298 patients operated on from January 1999 till July 2005 were reviewed. Patients were divided into 2 groups: group 1 included those who received induction chemotherapy (60 patients, 20.1%), and group 2 included those who underwent surgery alone (238 patients, 79.9%). Endpoints were operative mortality at 30 and at 90 days, and major complications such as empyema, bronchial fi stula and ARDS. Statistical analyses were performed using SPSS 11.0 software. Results: Demographic data were similar for both groups when considering side of operation, comorbidity and weaning from tobacco; group 2 included older patients (61.83±9.58 years versus 57.75±8.94 years; p=0.003), more female patients in group 2 (17.2% versus 5.0%; p= 0.010), and more diabetic patients (13.4% versus 5.0 % ; p = 0.048). Post-operative mortality at 30 days was 6.7% in group 1 and 5.5% in group 2 (p=0.458), and 11.7% for group 1 and 10.9% in group 2 at 90 days (p=0.512). Incidence of empyema was 1.7% in group 1 and 2.1% in group 2 (p=0.652); incidence of bronchopleural fi stulas was 1.7% in group 1 and 5.5% in group 2 (p=0.188); incidence of acute respiratory distress syndrome was 3.3% in group 1 and 3.4% in group 2 (p=0.675). Conclusion: In opposition to previous reports, induction chemotherapy did not signifi cantly jeopardize post-operative outcome following pneumonectomy in our experience. Key-words: Ilung cancer, induction chemotherapy, pneumonectomy

BACKGROUND: Although thoracic epidural analgesia (TEA) is considered superior to IV opioids for postoperative analgesia after thoracic surgery, a few studies clearly demonstrate an improvement in pulmonary function attributable to TEA using a local anesthetic in combination with an opioid.METHODS: In this prospective, randomized, double-blind study, we compared the effects of TEA with ropivacaine and sufentanil (TEA group) to IV morphine (IV group), as they affected pain and pulmonary function after lobectomy in 68 patients. Pain intensity, forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC ratio, forced expiratory flows, and sniff nasal inspiratory pressure as a marker of inspiratory muscle strength were measured from the first to the fourth postoperative day.RESULTS: Pain relief was better in the TEA group at rest and on coughing (P < 0.001). The impairment of FVC and FEV1 was less in the TEA group when compared with that in the IV group (P < 0.001 and P = 0.003, respectively). Sniff nasal inspiratory pressure, FEV1/FVC ratio, and expiratory flow values decreased similarly in both groups. In-hospital mortality, as well as postoperative pulmonary complications, was not different between groups.CONCLUSION: After lobectomy, TEA enables a significant increase in pulmonary function concomitant with better pain relief than systemic morphine, although a modest intercostal motor block may occur.

Background: There is an ongoing debate whether induction therapy increases post-operative mortality and morbidity, especially when performing pneumonectomy. We therefore reviewed a consecutive series of patients having undergone pneumonectomy in a single center. Methods: The charts of 298 patients operated on between January 1999 and July 2005 were reviewed. Patients were divided into two groups: group 1 included those who received induction chemotherapy (60 patients, 20.1%), and group 2 included those who underwent surgery alone (238 patients, 79.9%). Endpoints were operative mortality at 30 and at 90 days, and major complications such as empyema, bronchial fistula and acute respiratory distress syndrome. Statistical analyses were performed using SPSS 11.0 software. Results: Demographic data were similar for both groups when considering side of operation, comorbidity and weaning from tobacco; patients were older in group 2 (61.83 +/- 9.58 years vs 57.75 +/- 8.94 years; p = 0.003) and there were more female patients in group 2 (17.2% vs 5.0%; p = 0.010). Postoperative mortality at 30 days was 6.7% in group 1 and 5.5% in group 2 (p = 0.458), and 11.7% for group 1 and 10.9% in group 2 at 90 days (p = 0.512). Incidence of empyema was 1.7% in group 1 and 2.1% in group 2 (p = 0.652); incidence of bronchopleural fistulas was 1.7% in group 1 and 5.5% in group 2 (p = 0.188); incidence of acute respiratory distress syndrome was 3.3% in group 1 and 3.4% in group 2 (p = 0.675). Conclusion: In opposition to previous reports, induction chemotherapy did not significantly jeopardize post-operative outcome following pneumonectomy in our experience. (c) 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

OBJECTIVE:To investigate on the feasibility, safety, and effectiveness of a new bioabsorbable material for lung staple-line reinforcement. METHODS:This prospective open trial included 66 patients (mean age of 56+/-17 years) who underwent various types of lung resection using staplers with knitted calcium alginate sleeves for buttressing (FOREseal, Laboratoires Brothier, Nanterre, France) at three academic centers: 29 lobectomies, 22 emphysema surgeries, 15 wedge resections or lung biopsies. Intraoperative air leakage was assessed at a mean respiratory peak pressure of 30 cmH2O, and rated as grade 1, 2, or 3. Persistent air leakage in the postoperative course, as well as any relevant event, was assessed daily. The follow-up period was of 6 months. RESULTS:No technical problem linked to the device occurred. Hemostasis of the cutting edges was completed in all patients. Fifty-six percent of the patients had no intraoperative air leak and 27.3% had grade 1 leaks. Mean postoperative air leaks and thoracic drainage times were 1.9+/-2.3 days and 6+/-5.3 days, respectively. In-hospital mortality was nil. There was no empyema. Mean hospital stay was 9.1+/-6.6 days. At follow-up, one patient underwent lung transplantation, and pathology of the explanted specimen showed the absence of device-related foreign-body inflammation. One patient complained from metalloptysis, and another one, with a metastatic invasive aspergillosis, developed an infectious recurrence that required reoperation. CONCLUSIONS:FOREseal is an ergonomic, safe, and promising new material instead of nonabsorbable materials and xenomaterials for staple-line reinforcement. A randomized comparative study is now in progress.

Background: This study evaluates the impact of the underlying disease upon the surgical outcome of bronchoplastic lobectomy, comparing typical carcinoid tumours with primary lung carcinoma. Patients and methods: This retrospective study includes 98 consecutive patients (78 mates, 20 females). Eighteen patients had a typical carcinoid tumour (group 1), and 80 had a primary bronchial carcinoma (group2). Fifty-six patients underwent bronchoplasty with full sleeve resection (10 patients from group 1, 46 from group 2) and 42 patients had a bronchoplasty with bronchial wedge resection (8 from group 1 and 34 from group 2). Right upper lobectomy was the most common procedure. We compared demographic data, surgical indications, the type of bronchoplasty and postoperative complications. Results: The average age in group 1 (38.5 +/- 16.3 years; range 15-77) was significantly tower than in group 2 (61.4 +/- 9.5 years; range 14-75) (p < 0.001). There were no postoperative deaths. Procedure-specific complications (anastomotic dehiscence and atetectasis) were found in 7 patients (8.75%) in group 2 (of which, three had a combination of two of the above-mentioned complications) but none (0%) in group 1 (p = 0.23). Seven patients from group 2 (8.75%) required treatment for a residual pneumothorax for none (0%) in group 1 (p = 0.23). The mean duration for air teak was comparable in both groups (p = 0.366). Three patients (16.67%) from group 1 had non-surgical complications compared to 17 (21.25%) in group 2 (of which, one had a combination of two non-surgical complications) (p = 0.35). Conclusion: Bronchoplastic resection is a safe operation in patients with carcinoid tumours and should be the reference for treatment. (c) 2006 Elsevier B.V. All rights reserved.

Objective: This study compares accuracy of sampling versus format node dissection in patients with primary lung cancer. Patients and methods: During a 4-month period, 208 consecutive patients (172 men, 36 women) without bulky disease underwent resection for primary lung cancer in three centers. The surgeon first sampled the main lymph node stations, and subsequently performed a radical mediastinal dissection. Endpoints were accuracy of prediction for stage N2 and radicality of node sampling compared to dissection. Results: Resection consisted of 1 segmentectomy, 142 standard lobectomies, 6 bitobectomies, 14 sleeve-lobectomies, and 45 pneumonectomies. There were 108 squamous cell carcinomas, 621 adenocarcinomas, 18 bronchoalveolar carcinomas, 8 large cell carcinomas, 4 adenosquamous carcinomas and 8 neuroendocrine carcinomas. Primary tumor was stage T1 in 49 patients, T2 in 110, T3 in 43, and T4 in 6. Lymph node status (dissection) was NO in 113, N1 in 35, and N2 in 60 patients. N2 disease concerned a single node in 16, a single node station in 19, and multiple levels in 25. Both N1 and N2 nodes were diseased in 36 patients. Sampling adequately recognized N2 disease in 31 patients (52%). Multiple level N2 was accurately identified in 10 patients (40%). Resection based on sampling would have been incomplete in 53 patients (88%). Conclusion: Radical mediastinal dissection is a mandatory adjunct to resection for lung cancer with curative attempt. (c) 2006 Elsevier B.V. All rights reserved.

Objectives : Treatment of persistent N2 disease following induction therapy remains controversial. The aim of this study was to evaluate the operative risk and long term survival in patients who underwent pneumonectomy. Methods : We included 153 patients who underwent pneumonectomy from January 1999 to July 2005 ; 28 patients (18.3 %) had persistent N2 disease following induction therapy (group 1), 32 patients (20.9 %) were pN0 or pN1 following induction chemotherapy (group 2), and 93 patients (60.8 %) with stage pN2 underwent primary surgery (group 3). Endpoints were 30 day and 90 day mortality, major complications, rough survival and survival free of disease. Statistical analysis was made with SPSS 11.5 software. Results : Thez 3 groups were similar for demographics (age, gender, side of operation, type of chemotherapy, smoking, comorbidities such as coronary artery disease, diabetes, COPD). 30-day mortality was 10.7% in group 1, 3.1% in group 2 (p=0.257), and 4.3% in group 3 (p=0.201) ; 90-day mortality was 10.7% in group 1, 12.5% in group 2 (p=0.577), and 9.7% in group 3 (p=0.558). Major complication rate was similar. 5-year survival was 32.2% (median = 28 months ; 95% CI : 7-43) in group 1, 34.8% (median = 27 months ; 95% CI : 7-47) in group 2 (p=0.685), and 12.4% (median = 15 months ; 95% CI : 11-19) in group 3 (p=0.127). 5-year survival without recurrence was 43.3% (median = 18 months ; 95% CI : 0-41) in group 1, 48.3% (median = 47 months) in group 2 (p=0.480), and 23.3% (median = 12 months ; 95% CI : 9-15) in group 3 (p=0.336). Conclusion : Our results suggest that pneumonectomy is a valuable option in patients with persistant N2 disease after induction chemotherapy. We did not observe any increased operative risk, and 5-year survival was satisfactory.