Anticipating pulmonary complications after thoracotomy: the FLAM Score

OBJECTIVE: Pulmonary complications after thoracotomy are the result of progressive changes in the respiratory status of the patient. A multifactorial score (FLAM score) was developed to identify postoperatively patients at higher risk for pulmonary complications at least 24 hours before the clinical diagnosis. METHODS: The FLAM score, created in 2002, is based on 7 parameters (dyspnea, chest X-ray, delivered oxygen, auscultation, cough, quality and quantity of bronchial secretions). To validate the FLAM score, we prospectively calculated scores during the first postoperative week in 300 consecutive patients submitted to posterolateral thoracotomy. RESULTS: During the study, 60 patients (20%) developed pulmonary complications during the postoperative period. The FLAM score progressively increased in complicated patients until the fourth postoperative day (mean 13.5 ± 11.9). FLAM scores in patients with complications were significantly higher (p < 0.05) at least 24 hours before the clinical diagnosis of complication, compared to FLAM scores in uncomplicated patients. ROC curves analysis showed that the cut-off value of FLAM with the best sensitivity and specificity for pulmonary complications was 9 (area under the curve 0.97). Based on the highest FLAM scores recorded, 4 risk classes were identified with increasing incidence of pulmonary complications and mortality. CONCLUSION: Changes in FLAM score were evident at least 24 hours before the clinical diagnosis of pulmonary complications. FLAM score can be used to categorize patients according to risk of respiratory morbidity and mortality and could be a useful tool in the postoperative management of patients undergoing thoracotomy

Multidisciplinary Management of Lung Cancer: How to Test Its Efficacy?

The multidisciplinary management of lung cancer has been universally accepted. In France, the multidisciplinary approach for cancer patients is established by law. However, the efficacy of this approach remains theoretical, given that no evaluation criteria have been made available and no previous reports have been published on the prospective follow-up of these patients. The Groupe d' Oncologie Thoracique Azuréen carried out a 1-year prospective study on patients discussed during its multidisciplinary weekly meetings, to analyze the concordance between the proposed and administered treatment, the delay of treatment, and the 1-year actuarial survival. Of the 344 patients discussed during the period considered, the therapeutic decision was chemotherapy in 183 patients, surgery in 93, radiochemotherapy in 42, radiotherapy in 14, and supportive care 12. Therapeutic discordance between the planned and the administered treatment was recorded in 15 cases (4.4%), mainly for patient's refusal (seven cases) or poor performance status (five cases). The median delay of treatment was 20 days, shorter for chemotherapy (16 days), and longer for radiotherapy (27 days). The overall 1-year survival rate was 51.4%: 80.4% for stage I, 50.3% for stage II, 37.5% for stage III, and 27.2% for stage IV. For patients for whom discordance of treatment was recorded, a lower survival rate was recorded, without reaching statistical significance (0.07). In conclusion, the efficacy of the Groupe d' Oncologie Thoracique Azuréen multidisciplinary management was confirmed, as we believe that a discordant rate of less than 5% and a delay of treatment of 4 weeks can be considered acceptable. Furthermore, a periodic survival evaluation of the population as a whole could provide additional useful information for multidisciplinary groups

"Sentinel" circulating tumor cells allow early diagnosis of lung cancer in patients with chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is a risk factor for lung cancer. Migration of circulating tumor cells (CTCs) into the blood stream is an early event that occurs during carcinogenesis. We aimed to examine the presence of CTCs in complement to CT-scan in COPD patients without clinically detectable lung cancer as a first step to identify a new marker for early lung cancer diagnosis. The presence of CTCs was examined by an ISET filtration-enrichment technique, for 245 subjects without cancer, including 168 (68.6%) COPD patients, and 77 subjects without COPD (31.4%), including 42 control smokers and 35 non-smoking healthy individuals. CTCs were identified by cytomorphological analysis and characterized by studying their expression of epithelial and mesenchymal markers. COPD patients were monitored annually by low-dose spiral CT. CTCs were detected in 3% of COPD patients (5 out of 168 patients). The annual surveillance of the CTC-positive COPD patients by CT-scan screening detected lung nodules 1 to 4 years after CTC detection, leading to prompt surgical resection and histopathological diagnosis of early-stage lung cancer. Follow-up of the 5 patients by CT-scan and ISET 12 month after surgery showed no tumor recurrence. CTCs detected in COPD patients had a heterogeneous expression of epithelial and mesenchymal markers, which was similar to the corresponding lung tumor phenotype. No CTCs were detected in control smoking and non-smoking healthy individuals. CTCs can be detected in patients with COPD without clinically detectable lung cancer. Monitoring "sentinel" CTC-positive COPD patients may allow early diagnosis of lung cancer