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.

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.

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)

[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.

[Results of the physiotherapy of arterial disease at the stage of intermittent claudication by programmed efforts training (author's transl)]. / Résultats de la rééducation des artériopathies au stade de la claudication intermittente, par entrainement programmé à l'effort.

The results of treatment of intermittent claudication by a physical training programmed during 30 to 45 days in a rehabilitation center, are assessed on 148 patients of whom 105 have followed a full program at first (32 cases) or after surgery (73 cases). Ankle pressures are not altered. Irrigraphy shows a significant increase of 10 to 14% of the proximal indexes. Walking distance is greatly increased. 13 patients had a walking distance of about 900 m at the beginning and 31 patients at the end of the course ("functional remission"). Out of 105 patients, 98 showed improvement, 4 remained unchanged and 3 slightly worsened. The appreciation of his own progress is a strong psychological stimulation for the patient, this helping him to accent his illness, and to fight the corrigible risk factors of atherosclerosis, all significantly reduced. The interpretation of the results is discussed and shows the importance of non-hemodynamic factors in the achieved progress. The programmed exercise training is one of the best non surgical symptomatic treatments of intermittent claudication.

[Amelioration of the diagnostic possibilities of irrigraphy by a new index, I0]. / Amélioration des possibilités diagnostiques de l'irrigraphie par un nouvel indice I0.

Irrigraphie (segmental impedance plethysmography) is a reliable non invasive method for the positive and topographic diagnosis of arterial occlusive disease and for its prognosis (5, 8, 9, 12, 13). The method is based on pulse volume recordings at six different positions of the leg (from 1 = proximal to 6 = distal). The amplitude of the signal is related to heart rate and to the basic impedance of the segment of the leg. The diagnosis of aorto-iliac disease is proposed when the upper extremity index (I1MS) over the lower extremity proximal index (I1) ratio (ITA) is increased (greater than 1.4), or when the I1 value is lower than 1.9. The diagnosis of femoro-popliteal disease is proposed when there is a significant drop between I1 and the above knee index I3. However in a recent study we found that I1 value drops when there is a severe femoro-popliteal lesion. In this case, irrigraphie proposes erroneously the diagnosis of aorto-iliac and femoro-popliteal diseases. In order to improve the method, we thought that a new electrod position (I0) over the iliac region would give to irrigraphie a more reliable topography diagnosis possibility. In this study 32 patients were analysed with angiography and irrigraphy, and divided into 3 groups: group I = isolated iliac disease (19); group F = isolated femoral diseases (22); group IF = ilio-femoral diseases (12). We observe from the ROC analysis, that I0 has a sensitivity of 84% and a specificity of 86%, when the iliac lesions are isolated whereas I1 and ITA give a lower specificity (52%). However, when aorto-iliac lesions are combined with femoro-popliteal lesions the irrigraphie is a little less sensitive (71%). In conclusion I0 index is more reliable for the topographical diagnosis of obstructive disease of the iliac artery than I1 index and we suggest to replace I1 by I0 whenever it is possible.

[Computed tomography of the mediastinum: normal anatomy and non pathologic variations in the adult (author's transl)]. / Aspects normaux et variations non pathologiques en tomodensitométrie du médiastin chez l'adulte.

This work is based on the separate study of a triple material: axial gross body sections from cadavers (4); normal and conventional radiographs with or without opacification; in vivo scans (210). Authors have selectionned thriteen scans patterns according to several regional levels: supra-aortic scans (n08 1, 2, 3); scan through the horizontal part of aortic arch (n0 4B); the scan of the aorto-pulmonary window (n0 4B); supra-cardiac scans through intra and extra-pericardic parts of great vessels: vena cava, aorta and pulmonary artery (n08 5, 6, 7); heart and cardiac cavities scans (n08 8, 9, 10, 11); scan through the retro-crural space (n0 12). Knowing these regional scan patterns, makes it possible to the radiologist to manage a topographic approach quite adapted to the technical mode of direct scannography through the area of interest, already tested by some constructors. The non pathologic variations are numerous. Mediastinal lipomatosis, dilated and tortuous great vessels in the older and atheromatic individual, constitutional variations of the vessels topography. Limits found out during this work concern heart examination and hilum study; great strides are to be achieved in these fields because of the unceasing technical improvments.

[Oesophageal cancer extension. Diagnostic contribution and effects on therapy of computed tomography. Report on 40 cases (author's transl)]. / L'apport de la tomodensitométrie au bilan d'extension des cancers de l'oesophage. Incidences thérapeutiques. A propos de 40 observations.

Based on a homogeneous series of 40 cases of thoracic or abdominal oesophageal cancer, of which 23 had been confirmed by operation, the authors analyse the contribution of the CT scan to the diagnosis of the extension of the cancer, and evaluate the effects on therapy of this technique. Computed tomography supplies much more precise and complete details of possible cancer extension than any other pre-operative investigation. Conducted after radiological and endoscopic examination of the oesophagus, it supplies rapid, perfectly readable, irreplaceable information on local, regional, and metastatic spread of the cancer. This only slightly aggressive examination enables evaluation of the size of the tumour and its direct relationships, effective exploration of the mediastinal and coeliac glands regions, and detection of possible pleural, pulmonary, or hepatic metastases. Its role in the decision to operate is a considerable one: true assessment of of local, regional, or metastatic extension assists the surgeon in his choice of either curative or palliative therapy. Better still, it enables a route of approach to be decided as a function of data concerning possible extension, as well as the best surgical tactic. As a support for radiotherapy or chemotherapy for this type of cancer, computed tomography greatly assists follow-up supervision.

[MRI and tumors of the mediastinum. Correlation with CT x-ray]. / IRM et tumeurs du médiastin. Confrontation avec la TDM.

This correlative study concerns the investigation of 22 mediastinal tumors by MRI and CT, subsequently verified by biopsies or surgery. It allows us to better define the technical aspects in the realization of MRI, including an assessment of the use of ECG gating. It also permits an appreciation of the respective performances of these 2 imaging methods: there is a good correlation between the two technics for both the positive and etiologic diagnosis of mediastinal tumors: in etiologic diagnosis, the same limitations were encountered with the two technics. However, MRI offers some advantages in the evaluation of tumoral extension. So, we suggest once a mediastinal mass has been shown using plain films, when available, MRI alone should be performed.

[The value of tomodensitometry in the diagnosis of dermoid cysts. Apropos of 5 cases]. / Apport de la tomodensitométrie au diagnostic des kystes dermoïdes. A propos de 5 observations.

Results of computed tomography before operation in 5 cases of dermoid cysts (mediastinal: 3; retroperitoneal: 1; ovarian: 1) are employed to assess the contribution of this technique, and to define its place in relation to other diagnostic radiological procedures (straight radiographs and ultrasonography). The CT scan enables three morphological types to be distinguished, and also supplies very precise data on the extension, limits, and relationships of the tumor. The effective place of this examination in the diagnosis of dermoid cysts depends upon two factors: data obtained from the straight radiograph and the initial site of the lesion. When the former supplies specific information, the only role of the CT scan and ultrasonography is to determine the precise extent of the tumor pre-operatively, the CT scan being superior to ultrasonography for this purpose. When straight radiographs do not reveal characteristic signs, the diagnostic assistance of the scanner appears to be irreplaceable, even in those abdominal or pelvic regions where ultrasonography is best conducted.

[Mediastinal lymph node extension in primary bronchial cancer: correlation of x-ray computed tomography, magnetic resonance imaging and mediastinoscopy. Apropos of 50 cases]. / L'extension ganglionnaire médiastinale dans le cancer primitif des bronches: corrélations entre la tomodensitométrie, l'imagerie par résonance magnétique et la médiastinoscopie. A propos de 50 observations.

Based on a homogeneous series of 50 cases investigated within less than a week by CT scan and NMR imaging with mediastinoscopic correlation, and in 32 of theses cases with correlation with operative findings, a critical study was carried out of modern imaging methods for detection of mediastinal gland invasion from primary bronchial cancer. Axial mediastinoscopy presented absolute specificity and very high sensitivity (93%) markedly superior to those of CT scan and NMR imaging. The two latter examinations were practically of equal efficacy: sensitivity of NMR (80%) was somewhat higher than that of CT scan (70%) whereas specificity of CT scan was 83% as against 70% for NMR. Lack of efficacy of axial mediastinoscopy was in cases with extra-axial lymphatic extension (anterior mediastinal chains) from primary cancer. These results suggest that, in view of current inconveniences of NMR imaging, the best means for local and regional exploration of primary bronchial cancer preoperatively is combined CT scan and mediastinoscopy. The diagnosis of glandular enlargement of anterior mediastinal lymphatic chains should lead to performance of an anterolateral mediastinoscopy.

[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.

[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.

[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.

[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.

[Comparative study of magnetic resonance imaging and tomodensitometry in the diagnosis of locoregional extension in 61 patients with bronchial cancers]. / Etude comparative de l'imagerie par résonance magnétique et de la tomodensitométrie dans le diagnostic d'extension locorégionale de 61 patients porteurs de cancers bronchiques.

In order to assess the value of nuclear magnetic imagery NMR in the diagnosis of the extent of bronchial cancers, 61 patients with operable bronchial carcinoma had both a CT scan and an NMR scan pre-operatively. Fifty one mediastinoscopies were performed. Twelve times there were mediastinal glandular enlargement. Ten times the thoracotomy was performed straight away. After pathological studies of the biopsy, 24 patients were N2, 25 N1, 12 N0; the sensibility of NMR to foresee lymph node invasions was 83% (specificity 70%), for CT scanning 75% (specificity 81%). Thirteen patients presented with a direct mediastinal or parietal invasion. The sensibility of detecting these invasions was only 38% for NMR (specificity 94.5%) and for CT scanning 54% (specificity 94.5%). There is little difference in the results and no statistical difference. This leads us to conclude that at present, NMR does not give more information than TDM in the diagnosis of operability in bronchial cancers.

[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.

[Value of rheoplethysmographic methods in the etiological diagnosis of leg ulcers]. / Apport des méthodes rhéopléthysmographiques au diagnostic étiologique des ulcères de jambe.

Two recently introduced impedance plethysmographic methods have been used in the etiologic diagnosis of 100 leg ulcers: the occlusive rheoplethysmography (RPO) and the irrigraphy. RPO investigates the venous part of the lower limb circulation and irrigraphy the arterial blood flow. These two quantitative methods associated with Doppler examination of venous system allow to point out the type and the topography of the vascular alterations. The value of rheoplethysmographic methods in etiological leg ulcers investigation is reported.

[The role of anastomosis resection in the treatment of stenosis of cervical trachea after resuscitation]. / La place de la résection anastomose dans le traitement des sténoses de la trachée cervicale après réanimation

The authors describe a group of 9 resection anastomoses with end-to-end sutures of the cervical portion of the trachea after resuscitation. The operative results are analyzed first: in 8 cases the trachea recovered almost normal function in a very short time; one failure occurred : this was with a patient with considerable neuro-psychic sequelae following serious cranial traumatism. These results are then compared with 7 laryngo-tracheal plasties carried out according to the principles of Rethi's operation; it emerges from this study that circumferential resection followed by end-to-end anastomosis is still the ideal form of treatment for tracheal stenoses in view of the quality and consistency of the results. Operative technique is then described and, in giving their operative indication, the authors stress the need for medical and endoscopic treatment during the asphyxial crisis; this treatment is then suggested for removing the tube in open tracheal stenoses and in order to allow resection anastomosis with the trachea closed several weeks later.

[The lymphatic drainage of the stomach (author's transl)]. / Le drainage lymphatique de l'estomac.

The authors became interested in the lymphatic drainage of the stomach in order to attempt to determine for each region the type of drainage and the risk of cancer spread. They studied 132 dissections including 97 injections, 210 cases records of gastric carcinoma, 8 lymphographies by ultrafluid Lipiodol and 17 peroperative injections of vital staining. The system of drainage proposed by Rouvière was on the whole confirmed; however, one should emphasise the doubling of the hepatic chain, the existence of long collectors which bypass a relay in the left gastric artery, the importance of the posterior gastric artery which transmits the lymphatics of the splenic chain. Finally, the authors emphasise the existence of 3 longitudinal areas on the stomach where the presence or agsence of valvules in the subserous collectors orients the lymph towards the lesser or greater curvature of the stomach, which easily explains the onset of isolated carcinomatous adenopathy, situated on the curvature opposite the neoplasm.