[Bevacizumab and invasive procedures: practical recommendations]. / Bevacizumab et actes invasifs: recommandations pratiques.

As first line chemotherapy Bevacizumab, associated with a platinum based regime, improves survival in patients with metastatic, non small cell, non epidermoid bronchial carcinoma. Marketing authorization for this indication was obtained in 2007. This treatment produces specific secondary effects related to its anti-angiogenic action. Physiologically, vascular endothelial growth factor (VEGF) is important in the process of scar formation. Bevacizumab inhibits scar formation and may encourage bleeding. The aim of this article is to analyse the specific risks associated with invasive procedures and to produce practical recommendations. Unfortunately there are few data in the literature. We depend, therefore, principally on studies of neo-adjuvant chemotherapy in metastatic colo-rectal cancer prior to excision of hepatic metastases and on our own experience of excision of pulmonary metastases from solid tumours treated with bevacizumab. We recommend a delay of 2 days between implantation of an intravenous device and the initiation of bevacizumab, a delay of at least 5 weeks between the last injection of bevacizumab and invasive surgery and a delay of 4 weeks between surgery and the initiation of bevacizumab treatment. Obviously, referral to a medico-surgical team experienced in the management of these patients is strongly recommended.

[Exogenous lipoid pneumonia associated with pulmonary and hepatic sarcoidosis]. / Pneumopathie lipidique exogène associée à une sarcoïdose systémique avec atteinte hépatique nodulaire.

INTRODUCTION: In a patient with basal alveolar shadowing the diagnosis of exogenous lipoid pneumonia (ELP) requires a past history of chronic ingestion of liquid paraffin and the presence of numerous macrophages containing oil droplets in the bronchial lavage (BL). Additional radiological abnormalities suggest an associated disease, notably infection or cancer, as has been described in the literature. CASE REPORT: We report the case of a 50 year old woman presenting with alveolar shadowing in the left lung associated with ipsilateral mediastinal nodes and a pleural effusion in addition to two hepatic nodules. As the diagnosis of ELP did not explain the radiological features a thoracotomy and liver biopsies were performed. Histological examination of the hepatic, pulmonary and lymph node biopsies excluded cancer and mycobacterial disease and showed a florid granulomatous foreign body reaction associated with pulmonary and hepatic sarcoidosis. After a 3 month course of oral corticosteroids the mediastinal lymphadenopathy, pleural effusion and hepatic nodules resolved. The patient has maintained her recovery without further treatment for 4 years. CONCLUSION: The final diagnosis was ELP and systemic sarcoidosis with nodular hepatic involvement.

[Tracheal replacement using the abdominal aorta. Comments on a case report]. / Remplacement de la trachée par l'aorte. Réflexions à propos d'un cas.

Tracheal replacement is an uncommon option because of the very limited number of indications and the large number of possibilities for resection anastomosis. There may nevertheless be situations were extensive resection leaves only one solution, tracheal replacement. To date, no prosthesis has provided long-term satisfaction. For tracheal replacement, the prosthesis must provide a large caliber airway which does not collapse during expiration and which enables the development of a ciliary lining, in addition to tolerance without rejection. Recent experimental work, then several clinical cases, would suggest that the abdominal aorta can be successfully transformed into a neotrachea. A temporary endoprosthesis is however necessary to prevent collapse until new tracheal rings develop. Experimental and early clinical work has provided promising results but with problems concerning the endoprosthesis. In our patient, we used the abdominal aorta as a tracheal substitute but replaced the endoprosthesis with an exoprosthesis leaving the aortic lumen free. The result was also encouraging, but the absence of integration of the aortic tissue did not confirm the observations reported by others. Other hypotheses concerning the regeneration of the neotrachea should be put forward.

[Bronchopulmonary aspergillosis infections in the non-immunocompromised patient]. / Infections aspergillaires broncho-pulmonaires du sujet non immunodéprimé.

The definition of broncho-pulmonary aspergillosis infections in non-immunocompromised patients remains vague and a wide range of clinical, radiological and pathological entities have been described with a variety of names, i.e. simple aspergilloma, complex aspergilloma, semi-invasive aspergillosis, chronic necrotizing pulmonary aspergillosis, chronic cavitary and fibrosing pulmonary and pleural aspergillosis, pseudomembranous tracheobronchitis caused by Aspergillus, and invasive aspergillosis. However, these disease entities share common characteristics suggesting that they belong to the same group of pulmonary aspergillosis infectious disorders: 1- a specific diathesis responsible for the deterioration in local or systemic defenses against infection (alcohol, tobacco abuse, or diabetes); 2- an underlying bronchopulmonary disease responsible or not for the presence of a residual pleural or bronchopulmonary cavity (active tuberculosis or tuberculosis sequelae, bronchial dilatation, sarcoidosis, COPD); 3- generally, the prolonged use of low-dose oral or inhaled corticosteroids and 4- little or no vascular invasion, a granulomatous reaction and a low tendency for metastasis. There are no established treatment guidelines for broncho-pulmonary aspergillosis infection in non-immunocompromised patients, except for invasive aspergillosis. Bronchial artery embolization may stop hemoptysis in certain cases. Surgery is generally impossible because of impaired respiratory function or the severity of the comorbidity and when it is possible morbidity and mortality are very high. Numerous clinical cases and short retrospective series have reported the effect over time of the various antifungal agents available. Oral triazoles, i.e. itraconazole, and in particular voriconazole, appear to provide suitable treatment for broncho-pulmonary aspergillosis infections in non-immunocompromised patients.

[Management of severe hemoptysis: experience in a specialized center]. / Prise en charge des hémoptysies graves: expérience d'un centre spécialisé

Bronchiectasis, cancer and tuberculosis account for the majority of haemoptysis requiring intensive care unit admission. Bedside evaluation (volume and bronchoscopic active bleeding) is safe to screen patients for arteriography and bronchial artery embolisation (BAE). First-line interventional arteriography should be favour over surgery in patients with non traumatic life-threatening hemoptysis. Surgery must be reserved in cases of failure or recurrence of bleeding after BAE.

[Spontaneous hemothorax: a rare but serious complication of intralobular pulmonary sequestration]. / Un hémothorax spontané: complication rare mais grave d'une séquestration pulmonaire intra-lobaire.

Pulmonary sequestration is a rare congenital malformation characterized by a non-functional portion of pulmonary parenchyma devoid of any connection with the bronchial tree and pulmonary artery. If not identified antenatally or at birth, the sequestration may not be discovered until complications, mainly repeated infections, arise. Hemorrhage is another but much rarer complication which is generally severe. We report a new case of intralobular pulmonary sequestration revealed by hemoptysis then massive hemothroax with shock requiring emergency thoracotomy for hemostasis.

[Left strangulated diaphragmatic hernia: an unusual complication of gastric bypass]. / L'anneau gastrique: cause inhabituelle de hernie diaphragmatique gauche étranglée.

The appearance of left strangulated diaphragmatic hernia doesn't seem to have been described in the past as a progressive complication after gastric bypass surgery. The authors describe the case of a 54 year old patient suffering from a strangulated gastric hernia pushing through a diaphragm defect located next to the gastric band. The gastric band had been placed two years previously in this patient suffering from morbid obesity. Strangulation of the hernia resulted in the sphacelation of the entire stomach fundus. Therefore a partial gastrectomy and removal of the band was necessary. Recovery from procedure was without complications. The past history of a major spinal trauma in this patient, could have led to a discussion regarding the etiology of this hernia, however the delay between the two events (28 years) makes this unlikely. It seems, therefore, that the placement of a gastric band was the responsible factor. The authors emphasize the importance of pre-procedure pulmonary X-ray, prior to any general anesthesia, as well as a post procedure cliché following any intervention that might have lead to diaphragmatic lesion.

Indirect muscarinic receptor activation by pentamidine on airway smooth muscle.

1. Pentamidine is routinely used to reduce the incidence of Pneumocystis carinii pneumonia in patients infected with human immunodeficiency virus, but it has been described as inducing pulmonary adverse effects, such as cough and bronchospasm. 2. In this paper we have investigated the effects of pentamidine on guinea-pig isolated main bronchi and human isolated bronchi. Pentamidine induced a concentration-dependent contraction in both preparations with pD2 values of 9.64 +/- 0.07 (n = 8) and 9.73 +/- 0.06 (n = 8) and a maximal effect (Emax) of 40 +/- 4% and 34 +/- 5% of the response to acetylcholine (1 mM) in guinea-pig and human bronchi respectively. Atropine (0.01 to 0.1 microM) and the muscarinic M3 receptor antagonist, hexahydro-siladiphenidol (0.1 and 1 microM) inhibited pentamidine-induced concentration-responses in both preparations in a non-competitive manner, whereas only high concentrations of the M1 receptor antagonist pirenzipine (1 microM) inhibited pentamidine concentration-response curves. 3. The cholinesterase inhibitor, tacrine (1 microM), potentiated the effect of pentamidine; in contrast, morphine inhibited pentamidine-induced responses. 4. The bronchoconstrictor effect of pentamidine on guinea-pig and human isolated bronchi was not modified by the H1 histamine receptor antagonist, mepyramine, by indomethacin or by the neurokinin NK1 and NK2 receptor antagonists, CP-96,345 and SR 48969 respectively, suggesting that neither histamine receptor stimulation, arachidonic acid derivative formation, nor tachykinin release are involved in pentamidine-induced contraction of human and guinea-pig airways. 5. Our overall results suggest that pentamidine induces contraction of guinea-pig and human isolated bronchi through prejunctional cholinergic nerve stimulation.

Pulmonary complications following lung resection: a comprehensive analysis of incidence and possible risk factors.

STUDY OBJECTIVES: To assess the incidence and clinical implications of postoperative pulmonary complications (PPCs) after lung resection, and to identify possible associated risk factors. DESIGN: Retrospective study. SETTING: An 885-bed teaching hospital. PATIENTS AND METHODS: We reviewed all patients undergoing lung resection during a 3-year period. The following information was recorded: preoperative assessment (including pulmonary function tests), clinical parameters, and intraoperative and postoperative events. Pulmonary complications were noted according to a precise definition. The risk of PPCs associated with selected factors was evaluated using multiple logistic regression analysis to estimate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Two hundred sixty-six patients were studied (87 after pneumonectomy, 142 after lobectomy, and 37 after wedge resection). Sixty-eight patients (25%) experienced PPCs, and 20 patients (7.5%) died during the 30 days following the surgical procedure. An American Society of Anesthesiology (ASA) score > or= 3 (OR, 2.11; 95% CI, 1.07 to 4.16; p < 0.02), an operating time > 80 min (OR, 2.08; 95% CI, 1.09 to 3.97; p < 0.02), and the need for postoperative mechanical ventilation > 48 min (OR, 1.96; 95% CI, 1.02 to 3.75; p < 0.04) were independent factors associated with the development of PPCs, which was, in turn, associated with an increased mortality rate and the length of ICU or surgical ward stay. CONCLUSIONS: Our results confirm the relevance of the ASA score in a selected population and stress the importance of the length of the surgical procedure and the need for postoperative mechanical ventilation in the development of PPCs. In addition, preoperative pulmonary function tests do not appear to contribute to the identification of high-risk patients.

[Standards, options and recommendations for the management of locally advanced non small cell lung carcinoma]. / Standards, otions et recommandationspour la prise en charge thérapeutique des patients atteints d'un cancer bronchopulmonaire primitif non à petites cellules localement avancé.

CONTEXT: The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the Federation of the French Cancer Centres (FNCLCC), the 20 French Cancer Centres and specialists from French Public Universities, General Hospitals and Private Clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and outcome for cancer patients. The methodology is based on literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery. OBJECTIVES: To develop clinical practice guidelines according to the definitions of the Standards, Options and Recommendations project for the management of locally advanced non small cell lung carcinoma. METHODS: Data were identified by searching Medline and the personal reference lists of members of the expert groups. Once the guidelines were defined, the document was submitted for review to independent reviewers and to the medical committees of the 20 French Cancer Centres. RESULTS: The main recommendations are: 1) The management of the locally advanced non small cell lung carcinoma has two main goals: firstly to obtain local control of the disease (or to at least delay local progression in order to improve the survival or relapse free survival), and secondly to prevent the development of metastases. 2) There is a consensus that locally advanced non small cell lung carcinoma should be irradiated. External beam radiotherapy should be of optimal quality and delivered at a minimal dose of 60 Gy by standard fractionation. For patients with a poor life expectancy, this can be delivered as a split-course or hypofractionated scheme. 3) Treatment for patients with a performance status of 0-1 should consist of short duration induction chemotherapy (with a least two drugs one of which must be cisplatin), combined sequentially with conventional radiotherapy. 4) Surgery is contraindicated in extensive N3 disease. Combined radio-chemotherapy (adjuvant or neoadjuvant) is not indicated outside clinical trials. Surgery is justified in stage N2 disease as good local control can be achieved. T4-N0 disease should be treated surgically with curative intent.

[Standards, Options and Recommendations for the management of stage I or II primary bronchial cancers treated exclusively with radiotherapy]. / Standards, Options et Recommandations pour la prise en charge des patients atteints d'un cancer bronchique primitif de stade I ou II traités par irradiation exclusive.

CONTEXT: The 'Standards, Options and Recommendations' (SOR) project, started in 1993, is a collaboration between the Federation of the French Cancer Centres (FNCLCC), the 20 French cancer centres and specialists from French public universities, general hospitals and private clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and outcome for cancer patients. The methodology is based on literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery. OBJECTIVES: To develop clinical practice guidelines according to the definitions of the Standards, Options and Recommendations project for the management of stage I and II non small cell lung carcinoma treated by radiotherapy alone. METHODS: Data were identified by searching Medline and personal reference lists of members of the expert groups. Once the guidelines were defined, the document was submitted for review to independent reviewers, and to the medical committees of the 20 French cancer centres. RESULTS: The main recommendations for the management of stage I and II non small cell lung carcinoma treated by radiotherapy alone are: 1) The curative external irradiation with a continual course is an alternative to surgery only in the case of medically inoperable tumors or because the patient refuses surgery; 2) The external irradiation of the primary tumor only without the mediastinum could be proposed in peripheral stage IA. In proximal stage IA and IB, external irradiation should be carried out only as part of prospective randomised controlled trials comparing a localised irradiation of the primary tumor with a large irradiation of the mediastinum and the primary tumor. The treated volume must include the macroscopic tumoral volume with or without the microscopic tumoral volume and with a security margin from 1.5 to 2 cm; 3) There is a benefit to delivering a total dose in the primary tumor higher than 60 Gy in so far as the proposed irradiation, taking into account the respiratory function, does not increase the likelihood of severe adverse events due to radiation; and 4) The change in fractionation, the radiochemotherapy combination, the endobronchial brachytherapy with high dose rate alone or with external irradiation could be proposed only as part of prospective controlled trials for tumors classified as stage IB or II.

[Primary pseudo-ovarian peritoneal carcinosis. 4 cases]. / Carcinoses péritonéales primitives pseudo-ovariennes. Quatre observations.

Primary papillary carcinosis of the peritoneum is a rare disease seen in elderly women in whom no digestive or ovarian carcinoma could be detected. Its histological structure is identical with that of papillary carcinoma of the ovary. The 4 cases reported here were treated as advanced ovarian carcinomas, with multiple chemotherapy including doxorubicin and cis-platinum. Three patients were re-operated upon after 6 courses. Complete remission was obtained in all 4 cases, but the patients relapsed under maintenance therapy. The diagnosis must be suspected in elderly women presenting with unexplained carcinosis. This is particularly important since effective treatments can now be proposed, as for advanced ovarian carcinomas.

[Pulmonary bilharziasis caused by Schistosoma mansoni with impairment of general state]. / Bilharziose pulmonaire à Schistosoma mansoni avec altération de l'état général.

The authors report on one case of pulmonary bilharziosis at Schistosoma mansoni observed in a West-Indian female showing an impairing of her general condition with fever and dyspnea. Diagnosis was brought out by a pulmonary biopsy, after thoracotomy. Treatment by praziquantel was remarkably efficient. Scarcity of symptomatic cases and paucity of pulmonary radiological pictures are opposite of the frequency of pathological lesions in this parenchyma. The authors discuss the physiopathology of pulmonary bilharziosis in both their invading phase and state phase, as well as their frequency. They come to the conclusion that both parasitological examination of stools and biopsy of mucous membrane of rectum are simple, reliable and harmless implements of diagnosis.

[Metastatic pulmonary echinococcosis secondary to a primary cardiac lesion situated in the interventricular septum. One case successfully treated surgically (author's transl)]. / Echinococcose pulmonaire métastatique, secondaire à une localisation cardiaque primitive située dans le septum interventriculaire. A propos d'un cas opéré avec succès.

The authors report a case of metastatic pulmonary echinococcosis secondary to a primary cardiac lesion. The diagnosis was made on the basis of round pulmonary lesions developing during an episode of cardiac diseases which had been labelled as idiopathic acute pericarditis. The septal site then suspected on the basis of minor conduction disturbances was confirmed by angiography and could be excised under extracorporeal circulation.

[Surgery of cancers extending to the carina]. / Chirurgie des cancers étendus à la carène.

When small and inextensive these tumours are rare and often surgical; when extensive they are usually unresectable. Owing to the late development of dyspnoea and to the frequent normality of thoracic radiography the endoscopic diagnosis is seldom made at an early stage, which explains why these tumours are often regarded as non surgical. In limited forms the best treatment is resection of the carina with or without reconstruction of the tracheal bifurcation, but this surgical procedure is frequently difficult. However, this type of surgery has benefited from modern imaging for the preoperative evaluation, of advances in anaesthesia and ventilation techniques for the operation itself, and from changes in techniques and strategies by medico-surgical teams specialized in pneumology. The results of this surgery are difficult to evaluate due to the absence of published homogeneous series.

[Factors favoring the choice of classical surgery for the treatment of recurrent idiopathic pneumothorax]. / Pour un maintien du traitement des pneumothorax idiopathiques récidivants par chirurgie classique.

We report 3 cases of recurrent idiopathic pneumothorax treated first by video-surgery then by classical surgery. These cases illustrate the difference in hospital stay and patient satisfaction, which is not always in favor of video-surgery. We also examine our personal experience with a series of 480 cases of pneumothorax treated by surgery, reporting the length of hospital stays and work stoppage. Delays were short with classical surgery and the recurrence rate was very low. In our opinion, the low cost and low rate of re-operations warrants the use of classical surgery.

[An exceptional but serious complication of benign intercostal schwannoma: hemothorax]. / Une complication exceptionnelle mais grave du schwannome intercostal bénin: l'hémothorax.

Spontaneous serious hemothorax has not been described previously as an inaugural signor secondary complication of benign intercostal schwannoma. We report a case in a 45-year-old woman who was hospitalized in an emergency setting after development of massive left hemothorax. After evacuation of the effusion, imaging demonstrated a voluminous apparently neurogenic tumor in an intercostal position. Thoracotomy was required for hemostasis due to persistent bleeding. Tumor resection was performed. At histology, the surgical specimen was found to be a benign schwannoma presenting hemorrhagic remodeling. Resection provided complete cure with no sequelae. This secondary complication favors resection of benign intercostal schwannoma.

[Schwannoma of the endothoracic phrenic nerve. General review apropos of a case]. / Le schwannome du nerf phrénique endothoracique. Revue générale à propos d'un cas.

A new case of schwannoma of the intrathoracic phrenic nerve in a 72-year old woman is reported. A review of the literature shows that this tumour is quite exceptional and that its clinical signs are few and non-specific. The most informative examinations, including MRI, merely provide arguments in favour of the diagnosis prior to surgery. The problems of preservation and repair of the phrenic nerve are discussed in the light of new microsurgical techniques. Our knowledge concerning malignant schwannoma and its recurrent forms is updated.