Treatment of thymomas. A report of 67 cases.

From 1979 to 1989, 126 patients were treated for thymic tumors. Of these, 67 (53%) had thymomas occurring in 27 men and 40 women; the mean age was 46 years: 24 patients had no symptoms and myasthenia gravis was present in 21 cases. A complete resection was performed in 45 patients, associated in 22 with postoperative adjuvant treatment (radiotherapy, 2; radio- and chemotherapy, 20). Two patients had a partial resection followed by radiotherapy and chemotherapy. Twenty patients had initially only a biopsy and were treated by irradiation in 3 cases, radio- plus chemotherapy in 16, radio- plus chemotherapy and subsequent resection in 1 case. The staging was carried out according to the GETT Classification (stage I A:26; I B:6; II:12; III A:1; III B:18; IVA:4). Thymomas were found to be of predominant epithelial type in 12 cases, predominantly lymphocytic type in 9, and mixed in 46. No recurrence occurred after complete resection. The overall 10-year survival was 71.1%. A good correlation was found according to staging: 96% in stage I; 80% in stage II; 35% in stage III. Presence of myasthenia gravis did not affect the results. The best prognostic factor remains complete resection with postoperative radiotherapy to prevent recurrences. The role of adjuvant chemotherapy needs further evaluation.

[Ectatic tumoral thrombosis of the superior vena cava revealing thyroid cancer]. / Thrombose tumorale ectasiante de la veine cave supérieure révélatrice d'un cancer thyroïdien.

Microscopic angio-invasion by carcinoma of the thyroid is known. Extension into the great veins is much more uncommon. Most of the cases which have been previously described were discovered on post-mortem examination. We report the case of a 55 year-old woman who was found to have an asymptomatic small cervical goiter 6 years ago; during the last 12 months she developed superior vena cave (SVC) syndrome radiological investigation (angiography, CT scan) and surgical exploration showed a carcinoma of the thyroid with intraluminal extension of the tumor leading to thrombosis and ectasia of the SVC. Surgery was performed with resection of the whole thyroid, the SVC and the innominate veins. A double prosthetic venous by pass was then inserted between the innominate veins and right atrium. Five years after resection, the patient has no recurrence or metastatis and no clinical symptom of SVC syndrome. To our knowledge, this is only the third reported case successfully treated by surgery.

[Prolonged epidural analgesia following thoracotomy. Clinical study and serum levels over five days]. / Analgésie péridurale prolongée après thoracotomie. Etude clinique et taux sériques pendant cinq jours.

Prolonged continuous epidural analgesia allows perithecal infusion with fentanyl and bupivacaine for 5 postoperative days after thoracic surgery. This study included 27 thoracotomized patients randomised into two groups: group X consisted of 15 subjects, group Y consisted of 12 subjects. Each patient received 33 micrograms/hr or fentanyl for 48 hours, associated with 0.25% bupivacaine in group X, and 0.125% bupivacaine in group Y. Over the three last days, the infusion rate of both drugs was decreased in the two groups. No significant clinical difference appeared between X and Y. No clinical respiratory depression occurred. In group Y, mean plasma bupivacaine concentrations remained significantly lower (p less than 0.05). Mean fentanyl levels did not increase beyond 0.8 ng/ml. The use of 0.125% bupivacaine improved the margin of safety but did not impair clinical analgesia in the study. This method provides good analgesia for thoracotomized patients.

[Extrapancreatic hypoglycemic tumors. Apropos of a case of pleural fibrosarcoma]. / Tumeurs hypoglycémiantes extra-pancréatiques. Etude à propos d'un cas de fibrosarcome pleural.

The authors report a case of pleural fibrosarcoma associated with severe hypoglycaemia. Chromatography of the patient's serum and tumour fragments revealed a substance with a high molecular weight and an insulin-like activity. Professor Poffengarger's laboratory identified this substance as Non Suppressible Insulin-Like Protein or NSILAp which induces insulin-like effects on various tissues. A review of the literature is presented in the light of this case.

[Non-malignant esophagotracheal fistulas in adults. Experience with 35 cases]. / Les fistules oeso-trachéales non malignes de l'adulte. Expérience de trente-cinq cas.

Esophagotracheal fistula always constitutes a serious, life-threatening complication. Fistulae occurring during medical intensive care with mechanical ventilation are currently the most frequent. Their diagnosis was strongly suspected by clinical examination of the patient, but was always confirmed by endoscopy which revealed their exact site in relation to the vocal cords or carina, essential information for the choice of incision when it is decided to perform surgery. Twenty-five patients were treated medically. Treatment was always combined with gastrointestinal resting, control of gastro-oesophageal reflux and broad-spectrum systemic antibiotics. There were 19 deaths and 6 fistulae closed spontaneously. Three of these 6 patients developed a secondary tracheal stenosis, 2 of which were treated surgically by resection-anastomosis. Ten fistulae were closed surgically with a good long-term result. The indication for surgery was essentially based on the patients general and infectious status and on his or her respiratory autonomy. Technically, we always combined direct suture of the two organs with interposition of muscular or pleural tissue.

[Ectatic tumoral thrombosis of the superior vena cava revealing thyroid cancer]. / Thrombose tumorale ectasiante de la veine cave supérieure révélatrice d'un cancer thyroïdien.

Microscopic angio-invasion by carcinoma of the thyroid is known. Extension into the great veins is much more uncommon. Most of the cases which have been previously described were discovered on post-mortem examination. We report the case of a 55 year-old woman who was found to have an asymptomatic small cervical goiter 6 years ago; during the last 12 months she developed superior vena cave (SVC) syndrome radiological investigation (angiography, CT scan) and surgical exploration showed a carcinoma of the thyroid with intraluminal extension of the tumor leading to thrombosis and ectasia of the SVC. Surgery was performed with resection of the whole thyroid, the SVC and the innominate veins. A double prosthetic venous by pass was then inserted between the innominate veins and right atrium. Five years after resection, the patient has no recurrence or metastasis and no clinical symptom of SVC syndrome. To our knowledge, this is only the third reported case successfully treated by surgery.

Acute Budd-Chiari syndrome with hepatic failure and obstruction of the inferior vena cava as presenting manifestations of hereditary protein C deficiency.

The protein C system is essential in limiting the activation of coagulation in vivo. We report on a 29 year old woman with Budd-Chiari syndrome and occlusion of the inferior vena cava who presented with acute liver failure. She was successfully treated with an emergency mesoatrial shunt. Eight months after surgery, she has no ascites and normal liver function. She had a low concentration of plasma protein C on admission to hospital and during the follow up. Protein C deficiency subsequently was found in her father and two sisters, who were asymptomatic. Hereditary protein C deficiency should be considered in patients with Budd-Chiari syndrome.