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Place de la chirurgie dans le cancer bronchique non à petites cellules métastatique

Les cancers pulmonaires non à petites cellules métastatiques sont classés M1a pour les métastases controlatérales, pleurales, pleurésie ou péricardite maligne, et M1b pour les métastases systémiques. En théorie, la chirurgie est exclue de leur traitement.

Méthode : Nous avons étudié la prise en charge, la survie et les facteurs pronostiques des patients atteints de tumeurs classées M1a et M1b, en reprenant les dossiers de 4668 patients opérés de 1983 à 2006.

Résultats : Cette série inclut 70 M1a et 94 M1b. Les interventions ont compris 40 thoracotomies exploratrices, 88 lobectomies et 38 pneumonectomies. Les survies médianes et à cinq ans étaient de 14 mois et 13 % dans la série, 15 mois et 9 % en cas de M1a, 11 mois et 15 % en cas de M1b, que la métastase ait été réséquée ou non. Sur l’ensemble des patients, les facteurs pronostiques comprenaient l’instauration d’un traitement néoadjuvant, le type histologique et l’atteinte ganglionnaire.

Conclusion : Dans certains cas de M1a, une résection chirurgicale complète peut être associée à une survie prolongée. En cas de M1b solitaire bénéficiant d’une résection pulmonaire, les effets de la chirurgie de la métastase sont comparables à ceux des traitements non chirurgicaux.

Metastatic lung cancer may be M1a (contralateral lung nodule, malignant pleural or pericardial effusion or pleural nodules) or M1b (distant metastases). Surgery is not usually considered in their treatment.

Method : After exclusion of contralateral lung nodules, we reviewed the demographics, management, survival and prognostic factors in M1 patients, among a total of 4668 patients who underwent surgery for lung cancer between January 1983 and December 2006.

Results : There were 164 patients (70 M1a, 94 M1b). Surgical procedures included exploratory thoracotomy (n = 40), lobectomy (n = 88), and pneumonectomy (n = 38). Histology revealed adenocarcinoma (n = 97), squamous cell carcinoma (n = 36) or other (n = 27). Nodal extension was N0 (n = 60), N1 (n = 23), N2 (n = 64), or not available (n = 17). Overall median survival was 14 months and 5-year survival was 12.7%. In M1a median survival was 15 months and 5-year survival 9%. In M1b, median survival was 11 months and 5-year survival 15%, regardless of whether the metastasis was resected or not. The 5-year survival rates were 0% after exploratory thoracotomy, 3.9% after pneumonectomy, 14.8% after lobectomy; 15.2% in adenocarcinoma, 30.4% after induction chemotherapy, and 31.5% in N0 patients. In cases of M1a disease, complete surgical resection resulted in a 5-year survival rate of 16.2%. In case of M1b disease undergoing pulmonary resection, surgical metastasis management did not change the prognosis, with 5-year survival rates of 16.7% in case of metastasis resection (n = 66) versus 15.6% without resection (n = 19,P = 0.67).

Conclusion : In patients with M1a disease, complete surgical resection allowed some long-term survivals, suggesting that surgery may be underestimated. Conversely, in patients with M1b disease undergoing pulmonary resection, surgical resection of the metastasis is not associated with better survival than non-surgical management, suggesting that surgery may be overestimated.

Fluticasone/Salmeterol Benefits Asthmatic Smokers

Background:Smoking induces airway inflammation and relative resistance to inhaled steroids. The objective of this study was to evaluate the effects on airway hyperresponsiveness of adding salmeterol to fluticasone vs doubling the dose of fluticasone in patients with asthma who smoked and patients with asthma who did not smoke.Methods:Sixteen patients with mild to moderate persistent asthma who did not smoke and 15 such patients who smoked completed a double-blind, randomized, placebo-controlled crossover study. They received either a fluticasone/salmeterol combination (FP/SM) (125/25 μg) two puffs bid (plus fluticasone placebo), or active fluticasone (250 μg) two puffs bid (plus FP/SM placebo), for 2 weeks each, with baselines after 1-week to 2-week run-in and washout periods. The primary outcome was the change from baseline in the provocative concentration of methacholine required to produce a 20% fall in FEV1 (PC20).Results:In the patients who did not smoke, there were similar improvements in the methacholine PC20 with the use of fluticasone and FP/SM. The patients who smoked gained a benefit from FP/SM but not fluticasone, amounting to a PC20 difference of 1.6 doubling dilutions (95% CI, 1.0-2.2), P < .01. The provocative dose of mannitol required to produce a 15% fall in FEV1 (PD15) showed greater improvements with FP/SM than fluticasone in both patients who smoked and did not smoke. Similar differences in airway caliber between those who smoked and did not smoke were observed in FEV1 and airway resistance.Conclusions:FP/SM confers greater improvements in airway hyperresponsiveness and airway caliber in patients with asthma who smoke compared with double the dose of fluticasone. We hypothesize that in the presence of relative steroid resistance, the smooth muscle stabilization conferred by salmeterol is of greater clinical importance in patients who smoke than in those who do not smoke.Trial registry:ClinicalTrials.gov: No.: NCT00830505; URL: www.clinicaltrials.gov

Severity Scoring in the Critically Ill

Part 2 of this review of ICU scoring systems examines how scoring system data should be used to assess ICU performance. There often are two different consumers of these data: lCU clinicians and quality leaders who seek to identify opportunities to improve quality of care and operational efficiency, and regulators, payors, and consumers who want to compare performance across facilities. The former need to know how to garner maximal insight into their care practices; this includes understanding how length of stay (LOS) relates to quality, analyzing the behavior of different subpopulations, and following trends over time. Segregating patients into low-, medium-, and high-risk populations is especially helpful, because care issues and outcomes may differ across this severity continuum. Also, LOS behaves paradoxically in high-risk patients (survivors often have longer LOS than nonsurvivors); failure to examine this subgroup separately can penalize ICUs with superior outcomes. Consumers of benchmarking data often focus on a single score, the standardized mortality ratio (SMR). However, simple SMRs are disproportionately affected by outcomes in high-risk patients, and differences in population composition, even when performance is otherwise identical, can result in different SMRs. Future benchmarking must incorporate strategies to adjust for differences in population composition and report performance separately for low-, medium- and high-acuity patients. Moreover, because many ICUs lack the resources to care for high-acuity patients (predicted mortality >50%), decisions about where patients should receive care must consider both ICU performance scores and their capacity to care for different types of patients.

Surgical Face Masks Worn By Multidrug-Resistant Tuberculosis Patients: Impact on Infectivity of Air on a Hospital Ward.

CONCLUSIONS: Surgical face masks on MDR-TB patients significantly reduced transmission and offer an adjunct measure for reducing TB transmission from infectious patients.

An Official American Thoracic Society Statement: Update on the Mechanisms, Assessment, and Management of Dyspnea.

Conclusions: Progress in treatment of dyspnea has not matched progress in elucidating underlying mechanisms.

There is a critical need for interdisciplinary translational research to connect dyspnea mechanisms with clinical treatment and to validate dyspnea measures as patient-reported outcomes for clinical trials.

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