Publications by authors named "Gilles Missenard"

14 Publications

  • Page 1 of 1

Can MRI differentiate surrounding vertebral invasion from reactive inflammatory changes in superior sulcus tumor?

Eur Radiol 2021 May 15. Epub 2021 May 15.

Department of Radiology, Gustave Roussy Cancer Campus, 114 Rue Edouard Vaillant, Villejuif, 94800, Paris, France.

Objectives: Vertebral invasion is a key prognostic factor and a critical aspect of surgical planning for superior sulcus tumors. This study aims to further evaluate MRI features of vertebral invasion in order to distinguish it from reactive inflammatory changes.

Methods: Between 2000 and 2016, a retrospective study was performed at a single institution. All patients with superior sulcus tumors undergoing surgery, including at least two partial vertebrectomies, were included. An expert radiologist evaluated qualitative and quantitative MRI signal intensity characteristics (contrast-to-noise ratio [CNR]) of suspected involved and non-involved vertebrae. A comparison of CNR of invaded and sane vertebrae was performed using non-parametric tests. Imaging data were correlated with pathological findings.

Results: A total of 92 surgical samples of vertebrectomy were analyzed. The most specific sequences for invasion were T1 and T2 weighted (92% and 97%, respectively). The most sensitive sequences were contrast enhanced T1 weighted fat suppressed and T2 weighted fat suppressed (100% and 80%). Loss of extrapleural paravertebral fat on the T1-weighted sequence was highly sensitive (100%) but not specific (63%). Using quantitative analysis, the optimum cut-off (p < 0.05) to distinguish invasion from reactive inflammatory changes was CNR > 11 for the T2-weighted fat-sat sequence (sensitivity 100%), CNR > 9 for contrast-enhanced T1-weighted fat-suppressed sequence (sensitivity 100%), and CNR < - 30 for the T1-weighted sequence (specificity 97%). Combining these criteria, 23 partial vertebrectomies could have been avoided in our cohort.

Conclusion: Qualitative and quantitative MRI analyses are useful to discriminate vertebral invasion from reactive inflammatory changes.

Key Points: • Abnormal signal intensity in a vertebral body adjacent to a superior sulcus tumor may be secondary to direct invasion or reactive inflammatory changes. • Accurate differentiation between invasion and reactive inflammatory changes significantly impacts surgical planning. T1w and T2w are the best sequences to differentiate malignant versus benign bone marrow changes. The use of quantitative analysis improves MRI specificity. • Using contrast media improves the sensitivity for the detection of tumor invasion.
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May 2021

Video-Assisted Thoracoscopic En Bloc Vertebrectomy for Spine Tumors: Technique and Outcomes in a Series of 33 Patients.

J Bone Joint Surg Am 2021 Jun;103(12):1104-1114

Orthopedic and Trauma Surgery Department, Kremlin Bicêtre Hospital and Paris Saclay University, Le Kremlin Bicêtre, France.

Background: In en bloc vertebrectomy, the posterior approach is associated with limited access to anterior structures (vertebral body, esophagus, aorta, azygos vein). Video-assisted thoracoscopic surgery (VATS) might prove to be advantageous during thoracic en bloc vertebrectomy by allowing a combined anterior-posterior access in the prone position. We describe the technique and review the outcomes of 33 cases of video-assisted thoracoscopic en bloc vertebrectomy.

Methods: A retrospective, single-center cohort study included all cases of VATS with a minimum follow-up of 1 year. A team of thoracic and orthopaedic surgeons performed the surgical procedure with the patient in a single, prone position. Anterior release was carried out thoracoscopically, followed by posterior en bloc tumor removal.

Results: From 2003 to 2019, 33 patients were included. Nine patients underwent total vertebrectomy (8 had single-level and 1 had 3-level), and 24 patients underwent partial vertebrectomy (1 had single-level, 8 had 2-level, 13 had 3-level, and 2 had 4-level). Ten patients had pulmonary resection. Histology revealed 18 cases (55%) of primary bone tumors, 6 cases (18%) of lung cancer invading the spine, 6 cases (18%) of solitary metastasis, and 3 other cases (9%). The margins were tumor-free in 28 cases (85%). The median operative time was 240 minutes (range, 150 to 510 minutes), with a median blood loss of 1,200 mL (range, 400 to 6,700 mL), and there were 2 cases of conversion to thoracotomy. A total of 33 complications occurred in 18 patients (55%), and these were predominantly pulmonary. One death was surgery-related (infection). One patient had a persistent monoplegia. At a median follow-up of 63 months (range, 12 to 156 months), there were 21 surviving patients (64%) with 2 local recurrences and 1 distant recurrence, and 2 patients (6%) were lost to follow-up. The survival rates were 94% at 1 year, 71% at 2 years, and 68% at 5 years.

Conclusions: VATS en bloc vertebrectomy may be indicated for T2-to-T11 spine tumors with the exception of massive tumors, substantial chest wall and/or mediastinal invasion, and lung cancer exceeding 7 cm. The technique yielded satisfactory surgical and oncologic outcomes.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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June 2021

Surgical strategies for primary malignant tumors of the thoracic and lumbar spine.

Orthop Traumatol Surg Res 2020 02 13;106(1S):S53-S62. Epub 2019 Dec 13.

Université Paris Sud, hôpital Bicêtre, 78, rue du Général-Leclerc, 94275 Le Kremlin-Bicêtre cedex, France.

Background: Primary malignant tumors of the thoracic and lumbar spine are rare. They are mainly hematologic malignancies and more rarely sarcomas or chordomas. Giant-cell tumors and osteoblastomas, while benign, are locally very aggressive and their excision should be discussed as an option. Other possibilities are tumors from nearby organs invading the spine, which are actually carcinomas, but may benefit from radical excision in select cases.

Methods: Excision of these tumors is complex and must be integrated in the diagnostic and therapeutic strategy established by a specific multidisciplinary tumor board at a designated cancer center. Surgical resection must combine tumor excision with long-lasting reconstruction of the spine and neighboring soft tissues. The initial excision must be as complete as possible as the possibilities of repeat excision are nearly impossible if the first resection is not complete.

Results: An exhaustive preoperative imaging workup is essential for determining the tumor's spread and for determining the best surgical strategy. This will often require participation of other surgical specialties, which are well versed in teamwork. Thanks to this multidisciplinary care, especially the participation of thoracic and plastic surgeons, significant progress has been made recently. The first is the possibility of doing very extensive tumor excisions at the spine and in the neighboring organs, thus expanding the surgical indications to patients who were previously considered as being inoperable. We will discuss the surgical strategy and surgical approaches by spine level. Bone and soft tissue reconstruction is more effective thanks to the introduction of new spinal instrumentation and coverage flaps, which have drastically reduced the intra- and postoperative complications. Lastly, the risk factors for neurological complications are better understood, making them easier to prevent and to treat, if they were to occur.

Conclusion: These advances have translated to better cancer outcomes, especially better control of the tumor with neoadjuvant therapies (targeted chemotherapy) and preoperative conformal radiotherapy.
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February 2020

Use of morselized allografts for acetabular reconstruction during THA revision: French multicenter study of 508 cases with 8 years' average follow-up.

Orthop Traumatol Surg Res 2019 09 27;105(5):957-966. Epub 2019 May 27.

56, rue Boissonnade, 75014 Paris, France.

Background: In the context of acetabular reconstruction, bone defects can be filled with processed or unprocessed bone allografts. Published data are often contradictory on this topic and few studies have been done comparing processed allografts to fresh-frozen ones. This led us to conduct a large study to measure the factors impacting the survival of THA revision: (1) type of allograft and cup, (2) technical factors or patient-related factors.

Hypothesis: Acetabular reconstruction can be performed equally well with frozen or processed morselized allografts.

Materials And Methods: This retrospective, multicenter study of acetabular reconstruction included 508 cases with a minimum follow-up of 5 years. The follow-up for the frozen grafts was shorter (7.86 years±1.89 [5-12.32]) than that of the processed grafts (8.22 years±1.77 [5.05-15.48]) (p=0.029). However, the patients were younger at the time of the primary THA procedure in the frozen allograft group (51.5 years±14.2 [17-80]) than in the processed group (57.5 years±13.0 [12-94]) (p<0.001) and were also younger at the time of THA revision (67.8 years±12.2 [36.9-89.3] versus 70 years±11.7 [25-94.5]) (p=0.041).

Results: There were more complications overall in the frozen allograft group (46/242=19.0%) than the processed allograft group (35/256=13.2%) (p=0.044) with more instances of loosening in the frozen group (20/242 [8.2%]) than in the processed group (6/266 [3.3%])(p=0.001). Conversely, the dislocation rate (16/242=6.6% vs. 17/266=6.4%) (p=0.844) and infection rate (18/242=7.4% vs. 15/266=5.7%) (p=0.264) did not differ between groups. The subgroup analysis reveal a correlation between the occurrence of a complication and higher body mass index (BMI) (p=0.037) with a higher overall risk of complications in patients with a BMI above 30 or under 20 (p=0.006) and a relative risk of 1.95 (95% CI: 1.26-2.93). Being overweight was associated with a higher risk of dislocation (relative risk of 2.46; 95% CI: 1.23-4.70) (p=0.007). Loosening was more likely to occur in younger patients at the time of the procedure (relative risk of 2.77; 95% CI: 1.52-6.51) (p=0.040) before 60 years during the revision. Lastly, patients who were less active preoperatively based on the Devane scale had an increased risk of dislocation (relative risk of 2.51; 95% CI: 1.26-8.26) (p=0.022).

Discussion: Our hypothesis was not confirmed. The groups were not comparable initially, which may explain the differences found since the larger number of loosening cases in the frozen allograft group can be attributed to group heterogeneity. Nevertheless, morselized allografts appear to be suitable for acetabular bone defect reconstruction. A randomized study would be needed to determine whether frozen or processed allografts are superior.

Level Of Evidence: III, comparative retrospective study.
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September 2019

Ewing Sarcoma of the Chest Wall: Prognostic Factors of Multimodal Therapy Including En Bloc Resection.

Ann Thorac Surg 2018 07 15;106(1):207-213. Epub 2018 Mar 15.

Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Marie-Lannelongue Hospital, Le Plessis-Robinson, France; Institute of Thoracic Oncology, Paris-Sud University, Orsay, France.

Background: Radiotherapy has long been the treatment of choice for local control of Ewing sarcoma of the chest wall (ESCW). However, there is debate regarding the use of surgery versus radiotherapy. The objective of this study was to identify risk factors that may affect long-term outcomes of nonmetastatic ESCW treated with preoperative chemotherapy (CT) followed by en bloc resection and adjuvant CT or chemoradiation.

Methods: Between 1996 and 2014, 30 patients with a median age of 25 years (SD ± 8.9 years) were treated at Marie-Lannelongue Hospital in Le Plessis-Robinson, France. Adjuvant therapy was used in 27 patients: CT for 6, chemoradiation for 20, and radiotherapy for 1. Patients' demographics, treatment data, tumor features, and outcomes were collected.

Results: In this cohort of patients who received multimodal therapy, including neoadjuvant CT and en bloc resection, there was no postoperative mortality. Eight patients (27%) experienced postoperative complications. Resection included at least one rib (n = 27) and the sternum (n = 1) or the spine (n = 8). Negative and microscopic disease resections were achieved in 28 and 2 patients, respectively. Tumor viability (TV) was ≤5% in 18 patients (60%). In patients with TV >5% at definitive histologic examination, adjuvant chemoradiation was associated with a better long-term outcome than was treatment with adjuvant CT alone. The 5-year overall survival and disease-free survival rates were 60.7% and 41.0%, respectively, with a median survival of 87 months. By univariate analysis, TV >5% and pleural extension at diagnosis were associated with poorer long-term survival (p < 0.05).

Conclusions: Multimodality treatment of ESCW, including neoadjuvant CT followed by en bloc resection and adjuvant CT or chemoradiation, is associated with excellent long-term outcomes.
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July 2018

Long-term functional and radiological outcomes of allograft hip prosthesis composite. A fourteen -year follow-up study.

Int Orthop 2017 07 3;41(7):1337-1345. Epub 2016 Dec 3.

Orthopaedic Department, Tumor and Spine Unit, Bicêtre University Hospital, AP-HP Paris, 78 rue du Général Leclerc, Le Kremlin-Bicêtre, France, F-94270.

Purpose: Allograft hip composite prosthesis (APC) is a type of reconstruction after resection of the proximal femur. This study aimed to assess long-term outcomes after an APC reconstruction.

Materials And Methods: Forty-six patients were retrospectively included (14 revision total hip replacements, 30 primary malignant bone tumors, two metastasis).

Results: The mean length of femoral bone resection was 16.4 cm (7 to 27). With a mean follow-up of 14.7 years (6.3 to 32.6), Postel-Merle d'Aubigné score was 15.7 (8 to 21), Musculoskeletal Tumor Society score at 23.1 or 77% (15 to 29), and abductor strength at 3.4 (2 to 5). Allograft resorption was minor for 20 patients (44.4%), moderate for 13 patients (28.9%), and severe for 12 patients (26.7%). Host-allograft shaft bone fusion was achieved in 37 cases (84.1%). Trochanteric fracture occurred in 26 cases (59.1%). Length of femoral resection, allograft bone resorption, and trochanteric fracture did not have an effect on functional outcomes. At ten years follow-up, overall revision-free and femoral stem survivals were 54.1 ± 0.8% and 81.4 ± 0.6% respectively. No parameter evaluated influenced the survivorship.

Conclusion: APC is a reliable reconstruction adapted for huge proximal femoral bone resections. Trochanteric fracture and allograft bone resorption do not seem to influence functional results.

Level Of Evidence: Level IV.
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July 2017

Interest of Denosumab for the Treatment of Giant-cells Tumors and Aneurysmal Bone Cysts of the Spine. About Nine Cases.

Spine (Phila Pa 1976) 2016 Jun;41(11):E654-E660

Orthopaedic Department, Tumor and Spine Unit, Bicêtre University Hospital, AP-HP Paris, JE 2494 Univ Paris-Sud Orsay, Le Kremlin-Bicêtre, France.

Study Design: A prospective cohort study.

Objective: The aim of this study was to evaluate the interest of denosumab in the treatment of spinal giant-cells tumors (GCTs) and aneurysmal bone cysts (ABCs).

Summary Of Background Data: To treat GCTs and ABCs, surgical resection remains the best treatment to limit local recurrence (LR) but constitutes an aggressive treatment with potential morbidity. Denosumab, a human antibody anti-RankL, inhibiting the differentiation of osteoclasts, could be an alternative treatment to avoid aggressive surgery.

Methods: Patients suffering from GCTs and ABCs of the spine were included. Patients received a monthly subcutaneous injection of denosumab (120 mg) during a minimum of 6 months either as a neoadjuvant or as an adjuvant therapy. In association with denosumab, an osteosynthesis was added in case of vertebral fracture and a laminectomy in case of spinal cord compression. Clinical and computed tomography (CT)-scan outcomes were analyzed.

Results: Eight GCTs and one ABC were included. The mean age was 35 years (range: 22-55 yr). Five patients had neurologic deficit. All patients were operated: six osteosynthesis, one "en bloc" resection, four curettages, and two of them associated with an osteosynthesis. Average duration of denosumab therapy was 12.9 months (range: 3.2-24 months). Among them, four patients began denosumab 6 months at least before the surgery. With a mean follow-up of 19.3 months (range: 3.2-52.4 months), back pain and neurologic deficit improved for all patients. Systematic CT-scan at 6 months showed decrease of tumor size and bone consolidation. Regarding patients treated by neoadjuvant denosumab treatment, intraoperative histologic analysis showed an absence of giant cells and a maximum of 10% of alive tumor cells.

Conclusion: Denosumab allows bone formation and tumor regression with a maximum efficacy after 6 months of treatment without widely substituting surgery. Long-term results are mandatory to confirm the interest of denosumab and to evaluate LR when stopping denosumab.

Level Of Evidence: 3.
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June 2016

Interest of Laparoscopy for "En Bloc" Resection of Primary Malignant Sacral Tumors by Combined Approach: Comparative Study With Open Median Laparotomy.

Spine (Phila Pa 1976) 2015 Oct;40(19):1542-52

*Orthopaedic Department, Tumor and Spine Unit, Bicêtre University Hospital, AP-HP Paris, JE 2494 Univ Paris-Sud Orsay, F-01405, 78 Rue du Général Leclerc, Le Kremlin-Bicêtre 94270, France; and †General Surgery Department, Bicêtre University Hospital, AP-HP Paris, JE 2494 Univ Paris-Sud Orsay, F-01405, 78 Rue du Général Leclerc, Le Kremlin-Bicêtre 94270, France.

Study Design: Retrospective case-control study.

Objective: To compare laparoscopy with open median laparotomy for anterior approach in "en bloc" resection of primary malignant sacral tumors (PMST) in combined approach strategy.

Summary Of Background Data: Wide margin surgical resection is the "gold standard" treatment of PMST.

Methods: Two groups of patients suffering from PMST and operated for "en bloc" resection by combined approach (anterior and posterior) only differencing for the anterior approach were constituted: "laparoscopy" group (n = 11) and "laparotomy" group (n = 22). Intraoperative morbidity (blood loss, red blood cell transfusion (RBC transfusion), surgical procedure duration) and postoperative morbidity (surgical-site infection (SSI), perineal dysfunctions, local recurrence) were analyzed. Surgical margins were studied. Data of both groups were compared using nonparametric Mann-Whitney test for continuous data and Fisher test for categorical data. Overall survival (OS) and Disease-free survival (DFS) were analyzed by Kaplan-Meier method.

Results: Blood loss during anterior approach was less important in "laparoscopy" group 71.9 mL (range 0-400 mL) as compared with 2140 mL (range 0-9000 mL) for "laparotomy" group (P = 0.019). Blood loss during posterior approach was not different between the 2 groups. Total blood loss including anterior and posterior approach was inferior in "laparoscopy" group 2208 mL (range 230-4800 mL) versus 5385.7 mL (range 1400-11500 mL) for "laparotomy" group (P = 0.026). We reported significant difference on blood transfusion (3.7 RBC transfusions (range 0-8) for "laparoscopy group" versus 10.1 RBC transfusions (range 0-35) for "laparotomy" group (P = 0.025)). Surgical duration, quality of surgical margins, perineal dysfunctions and SSI were equivalent for both groups. At a follow-up of 36.6 months for "laparoscopy" group and 115.3 months for "laparotomy" group, OS and DFS were equivalent.

Conclusion: Use of laparoscopy for anterior approach decreases intraoperative blood loss and intraoperative RBC transfusion without increasing surgical duration, without altering the quality of surgical margins and without impairing long-term outcomes.

Level Of Evidence: 4.
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October 2015

"En bloc" resection of sacral chordomas by combined anterior and posterior surgical approach: a monocentric retrospective review about 29 cases.

Eur Spine J 2014 Sep 28;23(9):1940-8. Epub 2014 Jan 28.

Orthopaedic Department, Tumor and Spine Unit, Bicêtre University Hospital, AP-HP Paris, 78 Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France,

Purpose: "En bloc" resection of sacral chordomas (SC) with wide margins is statistically linked with a decrease of local recurrence (LR). Nevertheless, surgery potentially leads to complications and neurological deficits. The effectiveness of radiotherapy (RT) and chemotherapy (CT) remains controversial. The aim of the study was to evaluate the margins of tumor resection, the morbidity of "En bloc" resection of SC by combined anterior and posterior surgical approach and to look for predictive factors on survival and LR.

Methods: We performed sacrococcygectomy by surgical combined approach in 29 SC between 1985 and 2012. We analyzed overall survival and survival to LR with survival analysis using Kaplan-Meier method. Complications and morbidity were reported.

Results: The mean follow-up was of 77.9 months (0-241 months). We found 18 (62.1%) postoperative infections and 7 (24.1%) wound dehiscences. Eighteen patients had tumor wide margins (62.1%), 6 marginal (20.7%) and 4 intralesional (13.8%). Seven patients had a LR (24.1%). OS rate was 84.4% at 5 and 10 years, survival rate with LR was 64 and 56%, respectively, after 5 and 10 years. Quality of margins (p = 0.106), tumor volume (p = 0.103), postoperative RT (p = 0.245) and postoperative local infection (p = 0.754) did not have effect on LR.

Conclusion: "En bloc" resection by combined surgical approach seems to be a relevant alternative especially for SC invading the high sacrum above S3. Nevertheless, it yet remains the problem of postoperative infection. Systematic Adjuvant RT might allow better control on LR in association with surgery.
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September 2014

How to read a pathology report of a bone tumor.

Eur J Radiol 2013 Dec 4;82(12):2092-9. Epub 2012 Jan 4.

Department of Pathology, Hôpital René-Huguenin, Institut Curie, 35 rue Dailly, 92210 Saint Cloud, France. Electronic address:

The interpretation of a biopsy specimen involving bone is one of the most challenging feats for a pathologist, as it is often difficult to distinguish between benign or reactive lesions and malignant tumors on microscopic analysis. Therefore, correlation with the clinical data and imaging is essential and sometimes it is only the evolution of certain characteristics over time or information garnered from molecular analysis that can provide an accurate diagnosis. The pathology report is critical in that it will define subsequent patient management; its wording must precisely reflect those elements that are known with certainty and those that are diagnostic hypotheses. It must be systematic, thorough, and complete and should not be limited to a simple conclusion. The pathologist must first ensure the completeness and correct transcription of the information provided with the specimen, then describe and analyze the histology as well as the quality and representative nature of the sample (as they relate to the radiographic findings and preliminary/final diagnoses), and finally, compare what is seen under the microscope with the assessment made by the radiologist and/or surgeon. This analysis helps to identify difficult cases requiring further consultation between the radiologist and pathologist. There are multiple reasons for misinterpretation of a pathology report. An important and largely underestimated reason is varied interpretations of terms used by the pathologist. Standardized pathology reports with concise phrases as well as multidisciplinary meetings may limit errors and should be encouraged for optimal diagnostic accuracy.
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December 2013

Long-term outcomes of en bloc resection of non-small cell lung cancer invading the thoracic inlet and spine.

Ann Thorac Surg 2011 Sep;92(3):1024-30; discussion 1030

Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, Le Plessis Robinson, France.

Background: The purpose of this study was to determine whether en bloc resection of non-small cell lung cancer (NSCLC) invading the thoracic inlet (TI) and spine can provide good long-term outcomes.

Methods: We studied 54 consecutive patients treated with en bloc resection of NSCLC invading the TI and spine between 1992 and 2009 at our center. There were 36 men and 18 women with a mean age of 51 years (range, 37 to 71 years). Tumor resection involved at least 2 vertebral levels. We divided the patients into 3 groups based on whether vertebral invasion involved the transverse process only, the intervertebral foramina, requiring hemivertebrectomies with spinal fixation, or the vertebral body, requiring total vertebral body resection with spinal fixation.

Results: Induction chemotherapy was given to 27 (50%) patients including 3 who also received induction radiotherapy. Nine (17%) patients were in the transverse process group, 42 (78%) in the intervertebral foramina group, and 3 (6%) in the vertebral body group. Resection involved the subclavian artery in 19 (35%) patients. Complete resection was achieved in 49 (91%) patients. There were no perioperative deaths or residual neurologic impairments. Recurrence occurred in 31 (57%) patients and was local (n=6), systemic (n=24), or both (n=1). Local recurrence was more common in patients with N2-3 disease (p=0.0008) and subclavian artery involvement (p=0.031). There was a nonsignificant increase in local recurrence in patients with positive resection margins (40% vs 10%, p=0.058). The 1-, 5-, and 10-year survival rates were 82%, 31%, and 31%, respectively. The 1-, 5- and 10-year disease-free survival rates were 63%, 28%, and 28%, respectively. Five patients are alive and free of disease 10 years after surgery. By multivariate analysis, factors that independently affected survival were incomplete (R1) resection (p=0.006; odds ratio 67; 95% confidence interval 1.5 to 11.3) and subclavian artery involvement (p=0.037; odds ratio 0.46; 95% confidence interval 0.2 to 0.9).

Conclusions: Good long-term survival can be achieved in highly selected patients with NSCLC invading the TI and spine, provided complete en bloc resection is performed.
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September 2011

Preoperative imaging study of the spinal cord vascularization: interest and limits in spine resection for primary tumors.

Eur J Radiol 2011 Jan 18;77(1):26-33. Epub 2010 Dec 18.

Hôpital Universitaire de Bicetre, AP-HP, Bicetre F-94270, Université Paris-Sud, Department of Orthopaedic Surgery, Le Kremlin-Bicetre, France.

The necessicity to localize the anterior spinal arteries before anterior approach of the spine stays controversial by orthopaedic surgeons. On the other hand the surgical treatment of thoracoabdominal aneurisms routinely sacrifices many segmental arteries pairs without spinal arteries localization. This, associated with spinal cord protection, results to few neurological complication. However, during vertebrectomies, the roots ligation completely interrupts the spinal cord blood supply at this level. In our experience the spinal arteries localization was systematically done before ninety-eight spine resections. In five cases an anterior radiculomedullary artery was ligated (four anterior radiculomedullary and one great anterior radiculomedullary arteries) without neurological complication, in two cases of extended resection (more than four levels) a neurological complication occurred. No spinal artery was identified at the resection level and the neurological complications were resolutive and did not seem related to definitive vascular problem. These accomplishments lead to discuss the importance of spinal arteries localization and preservation in this surgery. The discovery of an anterior radiculomedullary artery is not a contraindication to en-bloc vertebrectomy at this level, nevertheless in the case of great anterior radiculomedullary artery (Adamkiewicz) the surgical indication must be seriously debated. In fact, this case and those where multilevel resections (more than three levels) are indicated seem the most dangerous situations and the use of the different means of spinal cord protection could be indicated to decrease neurological risk. So before spine resection the spinal arteries localization could improve patient information and give more deciding factors for planning treatment.
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January 2011

[Place and technical aspects of external beam radiation therapy in the treatment of adult soft tissue sarcomas].

Cancer Radiother 2006 Feb-Mar;10(1-2):50-62. Epub 2005 Dec 27.

Département de Radiothérapie, Institut Gustave-Roussy, 94805 Villejuif, France.

In soft tissue sarcoma, surgical resection remains the cornerstone of therapy for localized disease. Quality of margins is very important to evaluate. In case of marginal or incomplete resection, a new enlarged surgical resection should always be discussed before administration of any adjuvant treatments. Many retrospective studies and 2 randomized studies (one of adjuvant brachytherapy and one of external beam radiotherapy) have shown that adjuvant radiotherapy after complete surgery reduces significantly the risk of local recurrence in extremity soft tissue sarcomas. Combination of surgery and pre- or postoperative radiotherapy has therefore become the standard treatment with a local recurrence rate
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May 2006

En bloc resection of non-small cell lung cancer invading the thoracic inlet and intervertebral foramina.

J Thorac Cardiovasc Surg 2002 Apr;123(4):676-85

Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, Le Plessis Robinson, Paris-Sud University, France.

Objective: In patients with non-small cell lung cancer invading the thoracic inlet, the transcervical approach does not permit removal of tumor in the intervertebral foramina. We report a variant that lifts this limitation.

Methods: Through the transcervical approach, resectability was assessed and tumor-bearing structures were removed, leaving tumor-free margins. Standard upper lobectomy was performed, leaving the lobe in place. A posterior midline approach was used for multilevel unilateral laminectomy, nerve root division inside the spinal canal, and vertebral body division along the midline. The tumor was removed en bloc with the lung, ribs, and vessels through the posterior incision. Fixation of the spine was performed. Medical charts of patients treated with this technique between October 1994 and April 2001 were reviewed retrospectively.

Results: Seventeen patients (mean age 45 years) were treated. Resection of the upper lobe and T1 root was done in all 17 cases; 3- and 4-level hemivertebrectomies were done in 13 and 3 cases, respectively; 2-level total vertebral body resection and 2-level hemivertebrectomy were done in 1 case; and resections of the phrenic nerve and subclavian artery were done in 7 and 6 patients, respectively. There were no perioperative deaths or residual neurologic impairments. Postoperative complications were pneumonia (n = 6), cerebrospinal fluid leakage (n = 1), wound breakdown (n = 1), and bleeding necessitating reoperation (n = 1). The overall 3- and 5-year survivals were 39% and 20%, respectively.

Conclusions: Non-small cell lung cancers invading the thoracic inlet and intervertebral foramina can be removed completely through a combined anterior transcervical and posterior midline approach, with good results.
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April 2002