Bilateral oblique approach to parathyroid glands.

OBJECTIVE: To propose a simple and minimally invasive approach for parathyroid surgery. SUMMARY BACKGROUND DATA: Minimally invasive approaches to the parathyroid glands may involve preoperative morphologic explorations, perioperative biologic controls, or videocervicoscopy, a new method. METHODS: The authors describe 597 patients who underwent parathyroidectomy through an original bilateral oblique approach between 1976 and 1997. None underwent morphologic exploration or biologic perioperative monitoring. In primary hyperparathyroidism, the four glands are controlled and it is possible to check their abnormalities of location or number. In secondary hyperparathyroidism and multiple endocrine neoplasia (MEN), a total or subtotal parathyroidectomy is performed. RESULTS: The results and vocal morbidity are the same as that from authors using transverse cervicotomy, but this approach is more comfortable for the patient and allows total exploration of the location through short incisions without bleeding, visceral contusions, or muscle lesion. CONCLUSIONS: This cervicotomy is easy and secure even if the surgeon is not trained in this approach because it uses and respects the anatomy of the cervical fasciae. It can be used without preoperative localization, intraoperative monitoring, or specialized material. But this approach could be also proposed for unilateral exploration guided by these methods and for surgical treatment of recurrent hyperparathyroidism after a transverse cervicotomy.

[Giant thymic lipoma: anatomical, radiologic and clinical aspects]. / Thymolipome géant: aspect anatomo-radio-clinique.

We report the case of a 51-year-old man who presents with worsening dyspnea at exercise caused by a large thymic lipoma (6 kg). We present the clinical, radiological, and spiral CT scan features of this rare and benign tumor and correlate them with the pathologic findings.

Two-step immunoscintigraphy for non-small-cell lung cancer staging using a bispecific anti-CEA/anti-indium-DTPA antibody and an indium-111-labeled DTPA dimer.

UNLABELLED: Immunoscintigraphy (IS) using anti-CEA F(ab')2 monoclonal antibody (MAb) is useful for improving mediastinal staging of nonsmall cell lung cancer (NSCLC), but the technique was limited because of an insufficient contrast between tumor and normal tissues. The aim of this study was to determine if the method could be improved by a two-step method which uses a bispecific anti-CEA/anti-di-DTPA antibody (Bs-MAb) and 111In-labeled di-DTPA-tyrosyl-lysine bivalent hapten. METHODS: Twelve patients were intravenously given a 30 min Bs-MAb infusion (0.1 mg/kg). Four days later, they were injected intravenously with 0.1 microgram/kg hapten labeled with 185 MBq 111In (5 mCi). Images were recorded immediately and 6 and 24 hr after hapten injection. A pharmacokinetic analysis was performed. Surgery was performed 3 days after 111In-hapten injection, and samples of tumor and normal tissues were collected for immunohistochemical and biodistribution studies. IS results were classified as true-positive (TP), false-positive (FP), true-negative (TN) or false-negative (FN) according to the surgical data. RESULTS: Primary tumors were visualized in nine patients. The contrast was excellent, generally higher than that obtained with direct labeling of anti-CEA. In the mediastinum, IS results were (after surgery) five TN, two TP and one FP. One case remains undetermined. The FP result was due to a Bs-MAb uptake in intrapulmonary lymph nodes. IS was in agreement with preoperative staging in six of these nine patients and discordant in three. CONCLUSION: Our study confirmed that the two-step method with a bispecific antibody could greatly improve the performances of IS for lung cancer staging.

[Mediastinal metastasis of differentiated thyroid cancers. Treatment by total mediastinal curettage in 9 cases]. / Les métastases médiastinales des cancers différenciés de la thyroïde. Traitement par curage médiastinal total sur 9 cas.

Nine patients with mediastinal lymph node metastasis in differentiated thyroid carcinoma (7 papillary carcinomas, 1 Hürtle's cells carcinoma, 1 insular carcinoma) have been treated by systematic mediastinal dissection, 2 cases arose 6 and 10 years after the initial surgery, 2 cases after 18 and 20 months, but 5 revealed their metastases at the moment of the diagnosis or 3 months later. Investigations caused by a rise in thyroglobuline level (4 cases) necessarily involve a mediastinal CT scan, which always proved conclusive. All the patients underwent a median total sternotomy associated with a cervicotomy either for total thyroidectomy with conservative bilateral neck dissection, or for revision of the initial dissection. We describe the technique of mediastinal dissection allowing the resection of all the mediastinal lymph nodes. Mortality was zero and morbidity remained reasonable. 3 patients had recurrences: 2 died from multiple diffused metastases 18 months later, the third has pulmonary and mediastinal metastases well controlled by radio-iodine and external radiotherapy with a 5 years follow-up 6 are under total remission without sequel with a follow up ranging from 6 months to 8 years. Rather uncommon, total mediastinal dissection gives a long lasting remission with good living conditions to patients unresponsive to other therapies.

Feasibility of retroperitoneal pelvic lymph node exploration in cervical carcinoma. Assessment of morbidity in 33 cases treated by combined radio-surgery or definitive radiotherapy.

BACKGROUND AND PURPOSE: Laparoscopic modalities by selective biopsies permit a better assessment of the pelvic lymph nodes status than imaging procedures in cervix carcinoma. They could enable the radiation oncologist to adapt the target volume of external irradiation, provided the feasibility of such procedures is good and the toxicity reduced as much as possible. MATERIAL AND METHODS: From June 1980 to May 1993, 52 women with a mean age of 49, underwent a retroperitoneal pelvic lymph node laparoscopic procedure for cervix carcinoma classified according to FIGO as stages IA2 (14), IB (12), IIA (6), IIB (14), IIIB (3) and IVA (3). Two techniques were used: retroperitoneoscopy (RPS) in 16 cases, and a panoramic retroperitoneal pelviscopy (PRPP) in 36 cases. RESULTS: Intra-operative and post-surgical morbidity were equivalent in the two procedures. Among the 33 patients who had external irradiation, one Grade 3 urinary late morbidity (3%) due to an overtreatment was observed; no Grade 3/4 morbidity of the gastro-intestinal tract, no lymphoedema of the lower extremities, no parietal tumor cells implantation were noticed. CONCLUSIONS: These procedures can be used safely to better know the prognosis and to define the pelvic lymph node planning target volume and its radiation management with accuracy.

[Traumatic rupture of the bladder. Apropos of 26 cases]. / Les ruptures traumatiques de la vessie. A propos de 26 cas.

26 patients were seen with ruptured bladders at Grenoble Hospital during the last 15 years. Pelvic fractures were present in 95% of the cases. Bladder injuries were extraperitoneal (58%), intraperitoneal (27%), intraperitoneal and extraperitoneal (15%). Patients were hospitalised in Urological Department (40%) or General Surgical and Intensive Care (60%). All patients with intraperitoneal bladder injury, 61% with extraperitoneal ruptures were treated by surgical repair. 4 patients died, secondary to visceral associated injuries.

[Place of computer-assisted surgery in the evaluation of lymphatics metastases in pelvic cancers. Exploration by retroperitoneoscopy]. / Place des gestes médicochirurgicaux assistés par ordinateur dans le bilan d'extension ganglionnaire des cancers pelviens. Exploration par rétropéritonéoscopie.

Extraperitoneal pelvioscopy is a surgical endoscopy without insufflation which enables exploration of the extraperitoneal space in order to obtain biopsy specimens of adenopathies and tumors. 189 extraperitoneal endoscopy have been performed since 1976. When made through an iliac approach, the Extraperitoneal Endoscopy explores iliac and pelvic lymph nodes. It is an indication when checking the extension of uterine, prostatic and bladder cancers. Recently, a system of computerized assistance has been added to the initial method. Its aim is to guide the movements of the surgical tool when the indication is difficult: overweight patient, small tumors, risky tumoral environment. The basic principle is to show recalculated RMI or CT scan sections of the patient during the intervention, on which appear in real time the positions of the endoscope and that of the target to biopsy. The authors describe the technical ways of the method, the system of tridimensional localisation included in the operating room and the sort of interface given to the surgeon. In the future, the realisation of a simulator of intervention will allow diffusion and teaching of this intervention.

[Unusual use of a tissue expander]. / Utilisation inhabituelle d'un expandeur tissulaire.

Postpneumonectomy syndrome is a rare but serious complication. Mediastinal shift leads to compression of the remaining main bronchus. Repositioning of the mediastinum in the midline allows partial or total recovery. To maintain mediastinal position, the pneumonectomy space must be filled by a tissue expander.

Therapy program for patients with advanced stages of chronic lymphocytic leukemia. Chlorambucil, splenectomy, and total lymph node irradiation.

BACKGROUND: The clinical course of chronic lymphocytic leukemia (CLL) is variable. Staging systems define high risk groups, such as patients with Rai's Stage III and IV and Binet's stage C disease, as having a poor overall median survival. Most combination therapy programs have resulted in similar results. Chlorambucil remains the most commonly used drug, and new drugs, such as fludarabine, are promising. METHODS: Fifty-three patients with poor prognosis CLL (Stage III and IV) underwent chlorambucil treatment at a high intermittent dose. When Stage 0 was obtained, patients were considered responders and kept under surveillance. When the patients stopped responding after one or several courses of chlorambucil, further therapy was performed, including splenectomy (29 patients) and total lymph node irradiation (9 of the 29 splenectomized patients). RESULTS: The overall median survival was 60 months. Thrombocytopenia and anemia were resolved in 55% and 82% of the patients, respectively, after chlorambucil therapy and in 85% and 100%, respectively, after splenectomy. Complications occurred in 34% of the splenectomized population. Total lymph node irradiation was poorly tolerated in 66% of the patients. When this analysis was performed, 24 patients were classified as having Stage 0 disease with no disease progression for a mean of 21 months. CONCLUSIONS: Therapy programs allowing the selection of responders by the successive use of high intermittent dose chlorambucil and splenectomy may be beneficial in treating patients with advanced stage CLL. Because of its toxicity, total lymph node irradiation has no significant therapeutic effect.

[Feasibility of retroperitoneal pelvic lymph node exploration in cancers of the cervix treated by radiosurgery association or radiotherapy alone. Apropos of a series of 52 cases]. / Faisabilité de l'exploration ganglionnaire pelvienne rétropéritonéale dans les cancers du col utérin traités par association radiochirurgicale ou radiothérapie exclusive. A propos d'une série de 52 cas.

From June 1980 to May 1993, 52 patients with a mean age of 49, underwent a retroperitoneal pelvic lymph node laparoscopic procedure for cervix carcinoma classified as stage IA (14), IB (12), IIA (6), IIB (14), IIIB (3), IVA (3). Two techniques were used: a retroperitoneoscopy in 16 cases and a panoramic retroperitoneal pelviscopy (PRPP) in 36 cases. The aim was to define, with a better accuracy, the pelvic lymph node status, to adapt the target volume, and to estimate the morbidity. More nodes were biopsied with PRPP than with retroperitoneoscopy (p < 0.05). There was a disagreement between the conventional radiologic assessment and the histological results in 28.6%. Specificity is 100%. Intra-operative and post-surgical morbidity was equivalent in the two procedures. One grade 3 urinary late morbidity (3%) was observed among the 33 patients who underwent a pelvic external irradiation. There was no morbidity of the gastro-intestinal tract. Discussion deals with the support offered by the two laparoscopic procedures to define the pelvic lymph node status, to choose the planning target volume, and to precise the lymph node boost.

Comparison of epidural analgesia and cryoanalgesia in thoracic surgery.

A prospective study was carried out in 120 patients undergoing elective thoracotomy for parenchymal disease. Patients were randomized into three groups: A (control group), B (epidural analgesia), C (freezing of intercostal nerves). Subjective pain relief was assessed on a linear visual analog scale. Analgesic requirements were evaluated during the 12 days following surgery, or until discharge if earlier. The vital capacity (VC) and forced expiratory volume in 1 s (FEV1) were measured on the day before operation and on the 1st, 2nd, 3rd and 7th postoperative days (POD). Subjective pain relief was significantly better in Group B in comparison with Group A (P < 0.05) or C (P < 0.05). Group C had the lowest score on the 11th and 12th POD but differences were not statistically significant. Requirements for intravenous analgesics were lower in Group B than in the control group (P < 0.05) during the first 3 POD, and in group C than in the control group the day of operation (P < 0.05). Oral analgesic requirements, when compared with controls, were lower in group B during the first 5 POD, and lower in group C on the 3rd and the 4th POD (P < 0.05). Cryoanalgesia led to a slight but not significant increase in VC and FEV1. Epidural analgesia led to a significant increase when compared with controls in FEV1 during the first 3 POD, and in FVC on the 7th POD (P < 0.05). It is concluded that epidural analgesia led to the best pain relief and restoration of pulmonary function after thoracotomy.(ABSTRACT TRUNCATED AT 250 WORDS)

[Mediastinoscopy]. / La médiastinoscopie.

Mediastinoscopy was initiated by E. Carlens in 1959 and enabled the exploration of the mediastinal tissues, above all the lymphatics with both a diagnostic and a prognostic aim. Surgical intervention was performed most often under general anaesthesia and cervical mediastinoscopy was carried out under direct visual inspection thanks to a thoracoscope with its own light source so that the mediastinal axis, the thymic area and also the peripheral mediastinum could be examined. The examination can be completed or even replaced by antero-lateral mediastinoscopy. Biopsies with forceps are in general of good quality. Side effects or complications are rare (1-3.8%) and the mortality is practically nil (0-0.5%). Diagnostic mediastinoscopy is indicated in cases of isolated or multiple mediastinal adenopathy, mediastinal tumours in particular those of the thymus whose extent is not evident. And finally certain miscellaneous pulmonary conditions. The sensitivity is 95-99% in sarcoidosis or metastatic lymphadenopathy and a little less in malignant lymphomas or thymic tumours. Mediastinoscopy is used to assess prognosis as regards the extension of broncho-pulmonary cancer. The existence and the site of metastatic nodes can be precisely assessed possibly on the contralateral side too, and influences the therapeutic orientation. The rare failures of mediastinoscopy leave a remaining 5% for an exploratory thoracotomy. Computered tomography does not seem to replace mediastinoscopy but rather guides its application. It is also part of the assessment of malignant lymphomas in certain situations.

[Primary liposarcoma of the mediastinum: contribution of MRI to the diagnosis. Apropos of a case]. / Liposarcome primitif du médiastin: apport de l'IRM au diagnostic. A propos d'un cas.

An exceptional case of liposarcoma arising in posterior mediastinum is reported in a young woman. CT fails in diagnosis because no area of fatty density was found. MR features were suggestive of this etiology.

[Benign pleural fibroma. An anatomo-clinical study of 10 cases]. / Les fibromes pleuraux bénins. Etude anatomo-clinique de 10 cas.

We present an anatomical-clinical analysis of ten cases of benign pleural fibroma. This tumour was discovered in a systematic fashion in 8 of the 10 cases and fortuitously in one. Recent radiological examinations enabled the diagnosis to be suspected. Computerised tomography most often precisely identified the pleural topography and imagery by nuclear magnetic resonance in one case visualised fibrous tissue (with a zone of low signals on the scale in T2). The final diagnosis was achieved at the same time as the treatment when an exploratory thoracotomy was performed. In all the cases there was a tumour composed of fusiform cells covered by normal epithelium coming from the viscera pleura 8 times out of 10. The ultrastructure examination and immunohistochemistry of the fusiform cells (Vimentin plus, EMA-, KL1-) allowed for a differentiation of these tumours of connective tissue origin from tumours of mesothelial origin. These analyses constitute an argument in favour of the fibroblastic origin of pleural fibromas.

[Therapeutic strategy in adrenal tumor]. / Stratégie thérapeutique devant une tumeur surrénalienne.

The therapeutic strategy to be adopted when confronted with an adrenal tumor is schematically presented for the various situations which may occur: --pheochromocytomas, where the principal problems are the blood pressure and the localization and volume of the tumors(s); --Conn's syndrome, where a bilateral tumor should not be missed; --Cushing's syndrome, where bilateral total adrenalectomy via a posterior approach would seem to be the treatment of choice; --non secreting and secreting adrenal tumors, which usually pose the problem of volume and possibility of malignancy. The ideal surgical approach is discussed for each of the above cases.