[Chronic superficial urticaria associated with solid cancers: Case report and literature review]. / Urticaire chronique superficielle associée aux cancers solides : un cas et revue de la littérature.

BACKGROUND: Chronic urticaria is common and is generally idiopathic ("spontaneous"). Links between solid cancer and chronic urticaria have been mentioned in the literature. PATIENTS AND METHODS: We report the case of a 63-year-old man presenting with superficial chronic urticaria associated with adenocarcinoma of the ethmoid sinus. We discuss the possibility of systemic origin in light of the severity of the disease and its resistance to treatment. Only recurrent ethmoidal cancer was highlighted. Curative care resulted in complete resolution of the urticaria without relapse at 32 months of follow-up. DISCUSSION: In a literature review, we collected 17 cases of superficial chronic urticaria associated with cancer. These cases were marked by synchronous progression and by the inefficacy (86%) of anti-histamines and systemic corticosteroids. Although cases of chronic superficial urticaria associated with cancer remain rare, the condition merits discussion due to its severity and significant resistance to therapy.

[Treatment of ITP and AIHA in CVID: A systematic literature review]. / Traitement du PTI et de l'AHAI au cours du DICV : revue systématique de la littérature.

INTRODUCTION: Ten to 15% of common variable immunodeficiencies (CVID) develop auto-immune hemolytic anemia (AIHA) and immune thrombocytopenia (ITP). Treatment is based on immunosuppressants, which produce blocking effects in the CVID. Our objective was to assess their risk-benefit ratio in these immunocompromised patients. METHODS: We identified 17 articles detailing the treatment of AIHA and/or ITP in patients suffering from CVID through a systematic review of the MEDLINE database. RESULTS: The increased infectious risk with corticosteroids does not call into question their place in the first line of treatment of ITP and AIHA in CVID. High-doses immunoglobulin therapy remain reserved for ITP with a high risk of bleeding. In second-line treatment, rituximab appears to be effective, with a lower infectious risk than the splenectomy. Immunosuppressants (azathioprine, methotrexate, mycophenolate, cyclophosphamide, vincristine, ciclosporine) are moderately effective and often lead to severe infections, meaning that their use is justified only in resistant cases and steroid-sparing. Dapsone, danazol and anti-D immunoglobulins have an unfavorable risk-benefit ratio. The place of TPO receptor agonists is still to be defined. The establishment of immunoglobulin replacement in the place of immunosuppressants (except for short-term corticotherapy) or splenectomy appears to be essential to limit the risk of infections, including in the absence of previous infections. CONCLUSION: The presence of CVID does not mean that it is necessary to give up on corticosteroids as a first-line treatment and rituximab as a second-line treatment for AIHA and ITP, but it should be in addition to immunoglobulin replacement. A splenectomy should be reserved as a third-line treatment.

Prognostic value of initial fluorodeoxyglucose-PET in esophageal cancer: a prospective study.

OBJECTIVES: Esophageal cancer outcome greatly depends on the pathological stage. Our objectives were to assess prognosis on the basis of the initial fluorodeoxyglucose (FDG)-PET scan, focusing on the correlation between overall survival and FDG uptake in the primary, as well as the presence of FDG-positive lymph nodes or distant metastases. METHODS: Fifty-two esophageal cancer patients undergoing FDG-PET as part of initial routine staging procedure before treatment were included. The maximum standardized uptake value (SUV max) was determined in each primary lesion and the number of abnormalities including primary, lymph nodes, or distant metastases was recorded. Correlation with overall survival was performed using Kaplan-Meier method and Cox regression analysis was used to assess the prognostic value of PET parameters. RESULTS: Half of the patients were planned for initial curative surgery (52%). Using univariate survival analysis, either surgery, SUV max >9, two or more PET abnormalities or the presence of FDG-positive nodes were significant overall survival prognostic predictors. After multivariate analysis, only SUV max >9 and FDG-positive lymph nodes were found as independent predictors of poor outcome. CONCLUSION: In this prospective study, FDG-PET was found to provide prognostic information supporting a new indication for initial FDG-PET examination in esophageal cancer.

TP53 gene mutation profile in esophageal squamous cell carcinomas.

Esophageal squamous cell carcinoma is a form of cancer occurring most commonly in males, particularly those living in some areas of Asia, Africa, and western Europe. In some of these tumors, a sequence alteration has been identified in the coding region of the TP53 gene which is known to inactivate the tumor suppressor function of its product. Using a GC clamp (i.e., a GC rich domain) denaturing gradient gel electrophoresis assay we have been able to identify sequence modifications in 27 of the 32 tumor samples analyzed (84%). Most of the mutations occur in exon 6, a region of the gene which has not previously been reported as being a hot spot for the mutations of other cancers. Twelve of the mutations reported here have not been described in other types of tumors and these consist mostly of frameshift or splice mutations. The distribution of mutations [transitions (45%), transversions (34%), and frameshift (21%)] suggests that the etiological contribution of genotoxic factors might be complex and might associate different exogenous and endogenous mutagen exposures.

Tisseel versus tack staples as mesh fixation in totally extraperitoneal laparoscopic repair of groin hernias: a retrospective analysis.

BACKGROUND: The laparoscopic repair of groin hernias generally involves mesh fixation to avoid displacement and recurrence. Fixation usually uses staples that can lead to nerve injury and chronic postoperative pain. Laparoscopic repairs are associated with a risk of chronic pain of up to 22.5%. The use of fibrin glue (Tisseel) may represent an alternative method of mesh fixation preventing the risk of nerve injury. METHODS: Sixty-six patients had groin hernia repair using a totally extraperitoneal (TEP) laparoscopic procedure. Mesh fixation was achieved using 2 ml of fibrin glue. Comparison was made with an earlier series of 102 patients operated on according to the same procedure in which mesh fixation used tack staples. Complications, length of stay, recurrence, and postoperative chronic pain were assessed. RESULTS: No difference was found between the two series, except there was a significantly higher rate of postoperative chronic pain in the staples series (14.7 vs 4.5%, p = 0.037) and there was one recurrence (1.5%) in the fibrin glue group of patients. CONCLUSIONS: Fibrin glue achieved an adequate mesh fixation with a lower incidence of chronic postoperative pain. Although a prospective randomized study is needed, Tisseel appears to be an alternative to staples for mesh fixation and may help reduce the postoperative pain problems after hernia repair.

Laparoscopic ventral hernia repair with the Goretex Dualmesh: long-term results and review of the literature.

Since 1993 laparoscopy has become a popular technique of repair of ventral hernias. The authors review the long-term results of a systematic laparoscopic repair of ventral hernias and discuss the current problems compared to open repair. Between 1997 and 2003, 146 patients had a laparoscopic ventral hernia repair using an intraperitoneal Goretex Dualmesh with a 3-5-cm mesh overlap secured with a combination of nonabsorbable sutures and staples. A total of 155 attempts of laparoscopic repair was performed with four conversions. The 151 laparoscopic operations were completed in 105.8 min with a mesh implant being of 341 cm(2). There were two postoperative deaths and two patients had to be reoperated on. Mesh infection was diagnosed in two cases. Mean length of stay was 4.9 days. During a follow- up of 26.6 months eight patients (5.8%) developed a recurrence. Laparoscopic ventral hernia repair is a reproducible technique. Most of the comparative studies have shown an overall lower rate of complications after laparoscopic repair compared to open but with a 2-4% risk of bowel injury. The two other benefits of the laparoscopy are reduced postoperative pain and shorter hospital stay. The recurrence rate is usually between 2 and 7% but no difference has been found compared to open repair. Laparoscopic ventral hernia repair using the Goretex Dualmesh is a reliable operation with a low rate of conversion to open. Despite the risk of serious bowel injury, laparoscopy achieves as good results as the mesh open repair on the long term with the benefit of a decreased complication rate and a shorter hospital stay.

Preoperative concomitant radiochemotherapy in squamous cell carcinoma of the esophagus: results of a study of 56 patients.

PURPOSE: Today the prognosis for patients with esophageal carcinoma still remains quite poor. In the last few years interesting results have been obtained by associating radio- and chemotherapy with or without surgery with this type of cancer. In this work we report the results of concomitant radio- and chemotherapy in a split-course schedule preceeding surgery for the treatment of squamous cell carcinomas of the esophagus. METHODS AND MATERIALS: Fifty-six patients with squamous cell carcinomas of the esophagus were treated between April 1989 and September 1993 in the Centre Hospitalier Universitaire in Brest, France with two courses of preoperative concomitant radiochemotherapy, separated by a 2-week interval, and followed by surgery (each course 18.5 Gy in five fractions, days 1-5 with continuous infusion 5-fluorouracil (5-FU) 800 mg/m2 days 1-5 and cisplatinum 70 mg/m2 day 2). Patients who had responded well to preoperative treatment (response > 50%) received four more courses of chemotherapy alone. The two patients who were not operated and those with palliative surgery received a third course of radiochemotherapy (radiotherapy 12 Gy in five fractions, days 1-5). RESULTS: Fifty-four patients were operated on. Twenty-one showed histological complete response at surgery (37.5% of the whole group). Actuarial survival for the 56 patients was 55% at 3 years and 30% at 4 years, with a median survival of 37.4 months (40.4 months for complete responders to preoperative treatment). Toxicity of preoperative concomitant radio-chemotherapy was low (5-FU had to be stopped in one patient because of cardiac rythm disturbances and in another patient because of aplasia Grade 4 associated with infection after the first course). Postoperative mortality was 11% (six patients). CONCLUSION: This combination of preoperative radiochemotherapy followed by surgery seems to improve both response rates and survival in patients with esophageal cancer when compared with previous patients treated with surgery alone in our hospital or with results found in literature and it warrants further studies.

Ivor Lewis operation for epidermoid carcinoma of the esophagus.

One hundred patients, 95 men and 5 women with a mean age of 59 years (age range, 35 to 77 years), were treated by the same initiate surgeon in practice from 1982 to 1988 for epidermoid carcinoma of the lower two-thirds of the esophagus using the Ivor Lewis procedure. Fifty-eight tumors were located in the middle third of the esophagus and 42, in the lower third. Postoperative staging revealed 30 stage I/II and 70 stage III carcinomas (ie, tumors extending beyond the esophageal wall or lymph node extension). Operative procedure was considered curative in 70 patients and palliative in 30 patients. The same procedure has been used for all patients. In all patients we were able to perform extended esophagectomy with anastomosis located 3 to 7 cm under the pharyngoesophageal junction. Postoperative mortality was 4%. Morbidity due to leakage was 7%; proper drainage enabled spontaneous healing in 5 patients. Fifteen patients had pulmonary complications, none of which fatal, Median actuarial survival was 17 months. Actuarial survival at 24 months is significantly higher for patients in stage I and II (68.4%) than for patients in stage III (23.2%) (p less than 0.01). The Ivor Lewis procedure is a safe surgical approach for the treatment of the esophageal carcinoma that has a high survival rate and allows a good quality of life.

[Split-course concomitant radiochemotherapy plus surgery vs. surgery alone in squamous cell carcinoma of the esophagus. A non-randomized retrospective study of 184 patients]. / Radiochimiothérapie concomitante en split-course plus chirurgie contre chirurgie seule pour les carcinomes épidermoïdes de l'oesophage. Etude rétrospective non randomisée de 184 patients.

From April 1989 to October 1995, 184 patients with squamous cell carcinomas of the esophagus were treated either with surgery alone (112 patients) or with preoperative concomitant radiochemotherapy (72 patients) (2 courses of 18.5 Gy in 5 fractions, days 1-5 with continuous infusion 5-fluorouracil (5-FU) days 1-5 and cisplatinum day 2, separated by a 2-week interval) followed by surgery, and by 4 more courses of chemotherapy alone for good responders. Twenty-seven of these last 72 patients showed histological complete response at surgery (37.5%). There was no statistically significant difference in overall survival between the 2 groups although there were much more T1 patients (small tumors < or = 5 cm in the previous TNM classifications) and less T3 patients (evidence of spread beyond the esophagus) in the surgery alone group, and nevertheless, median survival was better in the combined treatment group (33.6 months versus 21.8 months). However, considering tumor size, there was a statistically significant difference in median survival in favor of the combined treatment group for all T2 patients (> 5 cm without evidence of spread beyond the esophagus in the previous TNM classification) (48.6 months versus 13.8 months), both for T2N0 and T2N1 patients, but also for T1N1 patients (< or = 5 cm with nodal involvement). For the few T3 patients (evidence of spread beyond the esophagus in the previous TNM classification), there was no statistically significant difference between the 2 groups, but the survival curves seemed to show some advantage in favor of the combined treatment group for T3N1 patients. The sex of the patients and the third of the esophagus involved by the tumor did not seem to be of any influence on survival. On the other hand, patients 70-year-old and older showed a poorer survival than other patients. Finally, significantly less patients died with loco-regional recurrences in the preoperatory radiochemotherapy group (32% versus 48%) than in the group treated by surgery alone.

[Results of surgical resection of squamous cells carcinoma of the oesophagus with or without preoperative radiochemotherapy: comparative and retrospective study]. / Résultats de la radiochimiothérapie préopératoire dans les cancers épidermoïdes de l'oesophage: étude rétrospective et comparative.

AIM OF THE STUDY: The aim of the study was to assess preoperative radio-chemotherapy for squamous cell carcinoma of the esophagus. MATERIAL AND METHODS: This study was a retrospective comparison between radio-chemotherapy followed by surgical resection (RCPO) and surgery alone. The RCPO group included patients with tumor located in the middle or lower third of the esophagus, staged T2 or T3 tumors without distant metastases by pretherapeutic assessment. These patients were matched with patients who underwent immediate surgery, who constituted the surgical group (CHIR). Both groups were matched for gender, age, tumor localization (middle or lower third), T stage, and surgical procedure. Each group included 77 men and 9 women, 50 tumors of the middle third and 36 of the lower third of the oesophagus, and 19 tumors T2 and 67 T3 ones. RESULTS: Morbidity of both groups was not significantly different. The mortality was 4% in the group CHIR and 12% in the group RCPO (P =0.07). The rate of radical resection (R0) was significantly higher in the RCPO group (74% vs. 51%; P =0.001). The overall 5-year survival rate was 38% after R0 surgery and 11% after R1 or R2 surgery (P <0.0001). After R0 surgery, the 5-year survival rate was 47% in the CHIR group and 32% in the RCPO group (P =0.06). CONCLUSION: Preoperative radiochemotherapy increases the rate of radical surgical resection without significant increase in postoperative morbidity and mortality.

[Chronic segmental pancreatitis and the annular pancreas: apropos of a case]. / Pancréatite chronique segmentaire et pancréas annulaire: à propos d'un cas.

In a young patient, stenosis due to annular pancreas was revealed by an attack of pancreatitis. The patient already had segmental chronic pancreatitis. Etiological considerations are proposed, based on an embryological approach with special attention to duct anomalies.

[Primary malignant melanoma of the esophagus]. / Le mélanome malin primitif de l'oesophage.

The primary malignant melanoma of the esophagus is a rare tumor. The study aim was to report two cases, one treated by esophagectomy without thoracotomy and the other one by Lewis-Santy type esophagectomy. Both patients had recurrence. One died at the 24th month with liver metastases. The other one who had a cervical invaded lymph node, treated by radio-chemotherapy, is actually in complete remission 9 years after the diagnosis.

[Value of x-ray computed tomography in evaluating the operability of esophageal cancer. Results of a prospective study]. / Intérêt de la tomodensitométrie dans le bilan d'extirpabilité d'un cancer de l'oesophage. Résultats d'une étude prospective.

The authors report their results of a prospective double-blind study of 35 patients with squamous cell carcinoma of the esophagus conducted between February 1987 and February 1988. As all the patients were operated upon, we were able to define diagnostic accuracy (DA) of CT in determining the upper pole of the tumour, position of the tumour, invasion of trachea and bronchi, aorta, left auricle, vertebral column, pleura, pericardium and also abdominal invasion or thoracic lymph node. CT scanning slightly improved pre-operative evaluation of resectability of tumours when compared with routine barium swallow, abdominal US and bronchoscopy. It is not of great help for tumours smaller than 5 cm. CT scanning is particularly useful in evaluation of response to pre-operative chemotherapy.

[Adenocarcinoma of the gastric stump]. / Adénocarcinome sur moignon gastrique.

Cancer of the gastric stump is a classical late complication of gastrectomy for benign lesion. This tumor is defined by various criteria, including a minimal delay of 5 years since the initial gastrectomy and the benignity of the initial lesion. Early diagnosis is difficult since suggestive clinical signs are usually associated with advanced tumors. Prognosis is globally bad and theoretically justifies routine endoscopic screening. For tumors which can be radically resected, completion gastrectomy with lymphadenectomy is indicated and allows a 40% 5-year survival. In other cases, palliative treatment remains a major concern.

[Ivor Lewis' operation for epidermoid cancer of the esophagus. Immediate and late results. Apropos of 168 cases]. / Intervention d'Ivor Lewis pour cancer épidermoïde de l'oesophage. Résultats immédiats et tardifs. A propos de 168 cas.

168 Ivor Lewis operations for squamous carcinoma of the lower esophagus are reviewed. 155 men and 13 women with a mean age of 59 years were operated on. 46 tumors were stage I and II, and 122 were stage III. Operations were considered to be curative for 120 patients and only palliative for 48. An esophagectomy associated with lymphadenectomy was performed through laparotomy and right thoracotomy. Feeding jejunostomy and pyloroplasty were routine. EEA or ILS 25 staplers were used to perform esophagogastric anastomosis and the gastroplasty tube was fashioned by TA 90 stapler. In every case an extended esophagectomy was performed with anastomosis between 3 ans 7 cm below the pharyngo-esophageal junction. Postoperative mortality was 4.7%. There were 10 leaks (6%) and 28 pulmonary complications. Median actuarial survival is 17 months. Actuarial survival at 2 years is significantly greater for stages I and II (68.4%) than for stage III (23.2%) (p < 0.01). Ivor Lewis esophagectomy is a reliable procedure to treat squamous carcinoma of the lower two thirds of the esophagus ensuring a good quality of life.

[Spontaneous giant intramural hematoma of the esophagus. Apropos of a case]. / Hématome géant intra-mural spontané de l'oesophage. A propos d'un cas.

Spontaneous esophageal hematoma is rare, occurring in a context of high esophageal pressure with abnormalities of hemostasis in some cases. We report a case involving the whole length of the esophagus with no evidence of any etiologic factor. The value of CT Scan is reviewed comparatively with esophageal barium examination and endoscopy. CT Scan confirms the diagnosis and the absence of true esophageal perforation. The general course monitored by CT scanning is uneventful, even in the case of extensive mucosal lesions. This justifies the nonaggressive attitude advocated by the majority of authors.

[Vascular deficit is the major cause of fistula in esophageal surgery]. / Le déficit vasculaire est la cause majeure des fistules en chirurgie oesophagienne.

AIM OF THE STUDY: The aim of this retrospective study was to find a link between vascularization failure and fistula in esophageal surgery. The originality of this study was to be based on hyperselective arteriogaphy of the artery vascularizing the gastric plasty, showing all vascular network of the plasty. PATIENTS AND METHODS: Hyperselective arteriography was carried out in 14 patients operated for esophagus cancer with a gastric plasty replacement. All these patients had a postoperative leakage or a bad vascularization of the gastric plasty during the operation. RESULTS: The vascularization of the gastric plasty was organized from the gastro-epiploic artery by anastomotic transversal network, depending on the left gastro-epiploic artery and left gastric artery. For the 14 patients, a constant link between leakage and vascularization failure could be proved. CONCLUSION: Esophageal surgery is dependent on the vascular status of the patient. The type of gastric plasty with large or narrow tubulization does not interfere with the quality of vascularization at the top of the plasty due to the preservation of a corporeal low branch.

[Complications of colostomies. Follow-up study of 500 colostomized patients]. / Les complications des colostomies. Suivi de 500 patients colostomisés.

The complications of colostomies may constitute a handicap for patients: their prevalence severity and methods of treatment remain poorly known. 500 colostomy patients, with a mean age of 66 +/- 14 years, were retrospectively reviewed. The mean follow-up of the study was 6 +/- 5 years. Colorectal cancers represented 65% of the initial diseases. 59.5% of colostomies were terminal. They were performed for resection of the colon and or rectum in 56.5% of cases. 30.5% of patients (n = 152) presented complications (n = 235). The early complications (n = 147) observed in 29.5% of patients were mostly benign (20 required emergency operations). The late complications (n = 88), observed in 22.5% of 391 patients with a follow-up of more than one year required another operation in 1/3 of cases (11 cases of stenosis, 9 incisional hernias and 8 prolapses). Complications of colostomies remain frequent (one out of every 4 stomies ends in a complication) and the reoperation rate is situated between 13 and 33%. The therapeutic success rate of late reoperation is between 63 and 74%. When a reoperation is necessary, it should be ideally radical via a midline incision. The transposition technique gives better results than the repositioning technique via a local approach.

[Current perspectives in the treatment of epidermoid cancer of the esophagus]. / Perspectives actuelles dans le traitement du cancer épidermoíde de l'oesophage.

Prior to the eighties, most patients with a diagnosis of epidermoid oesophageal cancer only received palliative symptomatic care. To date, most all undergo either surgery or medical treatment or both. Late diagnosis due to lack of clinical signs in the early phases of the disease, and perhaps insufficient attempts at identifying patients at risk who could benefit from systematic screening, is still an important problem although the number of diagnosed cases continues to rise (from 104 in 1985 to 151 in 1989 in Finistere in western France). Two different therapeutic attitudes could improve the prognosis: extensive surgery as proposed by the Japonese with dissection of all invaded lymph nodes whatever the localization and a multimodal approach combining radiochemotherapy and surgery. Although outcome can apparently be improved in certain types of oesophageal cancer, the proposal of aggressive extensive dissection could have an effect on respiratory complications and would not necessarily be adapted to the risk involved in western patients. Certain teams have nevertheless taken this route and will soon report their results. In France two phase II trials combining radiotherapy, chemotherapy (cisplatinum) and surgery have reported encouraging results with complete sterilization in 24% of the cases and 50% survival at 18 months. In our own series of 68 patients, we have obtained 41% sterilization and 56.3% survival at 3 years with the multi-modal protocol. The high number of non-responders to chemotherapy emphasies the importance of maintaining surgical resection whenever possible. The discouraging reports published before 1980 have been contradicted by improvements in outcome achieved over the last decade. Today, all patients with a diagnosis of epidermoid cancer of the oesophagus should benefit from either palliative or curative care based on the latest advances in radiotherapy, chemotherapy and surgery.