A novel pleural-bladder pump for the management of recurrent malignant pleural effusions: a feasibility animal study.

BACKGROUND: Recurrent malignant pleural effusions (MPE) are common and associated with significant morbidity in cancer patients. A new pump connecting the pleural cavity and the bladder may have application for the management of recurrent MPE. In a pre-clinical study, we investigated the utility of this pump in healthy pigs. METHODS: A novel pump system (Pleurapump® system) was inserted into four pigs under general anaesthesia. A tunnelled-pleural catheter was connected to a subcutaneously implanted pump while the urinary bladder was connected by percutaneous technique. Animals were ventilated mechanically and pump functioning was tested using a range of ventilation parameters and spontaneous breathing. Fluid was added to the pleural space to mimic pleural effusion and to assess the effectiveness of the pump at removing fluid to the bladder. RESULTS: The 'pleurapump' system successfully transported fluid from the pleural cavity to the bladder. Pressure variations caused by respiration and variations in the amount of fluid in the pleural cavity had no impact on the pumping. Pumping stopped when the pleural cavity was drained. CONCLUSION: This pump can be implanted into pigs and successfully removed fluid from the pleural cavity to the bladder and may represent a new treatment for management of recurrent MPE. Evaluation in humans is planned.

[Trans-vocal cord prostheses - preliminary experience treating benign laryngotracheal stenosis in adults]. / Sténoses laryngotrachéales bénignes de l'adulte : place des prothèses transcordales. Expérience préliminaire.

INTRODUCTION: Benign laryngotracheal stenosis is a rare pathology with multiple etiologies, the management of which is complex. This is because of the configuration and proximity of the larynx and the difficulty with surgical approaches, which are potentially mutilating, especially for the management of a benign disease. When surgery is challenging, iterative dilatations of the stricture or the fashioning of a definitive tracheotomy are therapeutic alternatives. Advances in rigid bronchoscopy and the evolution of prosthetic silicone material allow a new approach in the management of benign laryngotracheal stenosis, by placing flexible silicone prostheses which cover all the stenosis from the arytenoids to the trachea. This preliminary work aims to evaluate the feasibility, effectiveness, tolerance and complications of the implementation of this type of prosthesis. PATIENTS AND METHODS: This is a retrospective single-centre study which analyzed the records of patients with symptomatic benign laryngotracheal stenosis who underwent placement of a transcordial prosthesis over a period of three years. The prosthesis used, inserted under general anesthesia during a rigid tube interventional bronchoscopy, was either a straight silicone prosthesis or a Montgomery T-tube for those with a pre-existing tracheotomy. RESULTS: Six patients were included. Five are still alive, one patient died from a cause unrelated to the placement of the prosthesis. Four have no tracheostomy and two now have no transcordal prosthesis. The data collected on tolerance found, for three patients, two cases of minor aspiration and one case of transient cough. All patients had whispered voice dysphonia. We did not observe prosthesis migration or obstruction. CONCLUSION: These preliminary results are encouraging. Transcordal prostheses in benign laryngotracheal stenosis have a complementary or alternative role compared to surgery with a palliative or even curative objective.

[Management of a tracheal adenoid cystic medico-surgical carcinoma]. / Prise en charge médico-chirurgicale d'un carcinome adénoïde kystique trachéal : l'union fait la force.

Adenoid cystic carcinoma or cylindroma is a rare tumor of the trachea which arises from mucous secreting cells. Its evolution and growth are slow but it is often fatal in the absence of radical treatment. The latter relies on a surgical sleeve resection of the pathological area, with a tracheo-tracheal anastomosis. Therapeutic bronchoscopy plays a crucial role in the clinical improvement of patients before surgery which will be performed under better conditions. For inoperable patients, radiotherapy has proved its efficacy, unlike conventional chemotherapy. The finding of biomarkers expressed by tumor cells could lead to target therapies. This case report illustrates the efficient combination of therapeutic bronchoscopy and surgery for the treatment of adenoid cystic carcinoma affecting central airways.

[Blue rubber bleb naevus syndrome involving the pleura]. / Syndrome de Bean (« blue rubber bleb naevus syndrome ¼) avec localisation pleurale.

Bean's syndrome ('blue rubber bleb nevus syndrome') is a rare disease characterized by venous malformations involving various organs. Most often these lesions are localized to the skin and the digestive system. Gastro-intestinal bleeding is the most frequent presentation. Though other organs can be affected, chest localizations are infrequent and pleural localization is exceptional. We report the case of an asbestos-exposed patient with Bean's syndrome with characteristic skin lesions, smoker, hospitalized for the investigation of a hemorrhagic pleural effusion. A medical thoracoscopy revealed pleural lesions similar to the cutaneous lesions and compatible with a pleural localization of the disease. This is the first documented case of this disease involving the pleura. A review of the literature was carried out on account of this clinical case.

Malignant transformation of a tracheal chondroma: The second reported case and review of the literature.

Tracheal tumors are rare, representing only 0.2% of the respiratory tract malignancies. Chondrosarcoma arising in the trachea was first described in 1959 by Jackson et al. and since then only 20 cases have been described. We report the second documented case of malignant transformation from an endotracheal chondroma, in a 75-year-old woman, and review the literature.

[Pleuro-pneumonia revealing septic thrombophlebitis of the jugular vein: Think about the Lemierre's syndrome]. / Pleuro-pneumopathie révélant une thrombophlébite septique de la veine jugulaire : pensez au syndrome de Lemierre.

INTRODUCTION: Infection by Fusobacterium necrophorum, a Gram negative anaerobic bacteria, can lead to the development of Lemierre's syndrome, an uncommon but potentially fatal infection of the internal jugular vein. Since the introduction of antibiotics, the morbidity and mortality associated with this syndrome have been dramatically reduced. This syndrome is characterized by a pharyngeal infection, which leads to the development of septic thrombophlebitis of the internal jugular vein with septic emboli, which usually spread into the lung. Sometimes the syndrome can be revealed by other unusual clinical symptoms. CASE REPORT: We present the case of a young patient with an atypical pleural infection associated with pharyngeal infection and thrombosis from the internal jugular vein. CONCLUSIONS: The diagnosis of Lemierre's syndrome is mainly clinical, based on a range of suggesting symptoms. Confirmation and monitoring of the condition can be done by ultra-sound and/or contrast enhanced computed tomography. Treatment is based on long-term, high-dose antibiotic therapy and eventually surgical drainage of the infected collection with surgical excision of the internal jugular vein where there is extensive thrombosis. The important message is that in the context of a young patient without comorbidity, who presents with a significant infectious pleurisy, it is important to consider this clinical complication.

[Endobronchial ultrasound in the diagnosis of malignant pleural mesothelioma]. / Échoendoscopie bronchique pour le diagnostic de mésothéliome pleural malin.

The diagnosis of malignant pleural mesothelioma relies mostly on the pathological examination of pleural samples, validated by a panel of experts and generally obtained during medical or surgical thoracoscopy performed for the management of an exudative pleural effusion. In the absence of pleural effusion (dry-type mesothelioma), the diagnostic approach depends on the features of the lesions (pleural thickness, nodules and/or masses) and their pleural location. Ultrasound and CT-guided needle aspiration represent recognized alternative diagnostic techniques in these situations. We present the case of a patient, presenting a dry-type mesothelioma, whose diagnosis was obtained by endobronchial ultrasound (EBUS)-guided needle aspiration of a pleural mediastinal mass and confirmed by a CT-guided needle aspiration of another pleural mass in close contact with the chest wall. The samples have been compared and show quantitative and qualitative similarities. EBUS represents a minimally invasive alternative diagnostic technique for dry-type mesothelioma, showing thickness of the mediastinal pleura in contact with a central airway or when thoracoscopy, which remains the "gold standard" diagnostic approach, is not feasible.

"Dancing eye syndrome" secondary to opsoclonus-myoclonus syndrome in small-cell lung cancer.

Among paraneoplastic neurologic disorders (PND), opsoclonus-myoclonus syndrome, so-called "dancing eye syndrome," is a rare disorder combining multivectorial eye movements, involuntary multifocal myoclonus, and cerebellar ataxia. Although several paraneoplastic antibodies against postsynaptic or cell-surface antigens have been reported, usually most patients are serum antibody negative. We report a 65-year-old patient with opsoclonus-myoclonus syndrome revealing a small-cell lung carcinoma. If serologic antineuronal anti-body screening was negative, autoantibodies against glutamic acid decarboxylase (anti-GAD) were positive. Despite the specific anticancer treatment and high dose corticosteroids, the patient developed a severe and progressive encephalopathy and died 10 days later.

[The French mesothelioma network from 1998 to 2013]. / Mésothéliome: les dispositifs en place en France « le réseau mésothéliome ¼ 1998-2013.

Mesothelioma is a rare disease less than 0.3% of cancers in France, very aggressive and resistant to the majority of conventional therapies. Asbestos exposure is nearly the only recognized cause of mesothelioma in men observed in 80% of case. In 1990, the projections based on mortality predicted a raise of incidence in mesothelioma for the next three decades. Nowadays, the diagnosis of this cancer is based on pathology, but the histological presentation frequently heterogeneous, is responsible for numerous pitfalls and major problems of early detection toward effective therapy. Facing such a diagnostic, epidemiological and medico-legal context, a national and international multidisciplinary network has been progressively set up in order to answer to epidemiological survey, translational or academic research questions. Moreover, in response to the action of the French Cancer Program (action 23.1) a network of pathologists was organized for expert pathological second opinion using a standardized procedure of certification for mesothelioma diagnosis. We describe the network organization and show the results during this last 15years period of time from 1998-2013. These results show the major impact on patient's management, and confirm the interest of this second opinion to provide accuracy of epidemiological data, quality of medico-legal acknowledgement and accuracy of clinical diagnostic for the benefit of patients. We also show the impact of these collaborative efforts for creating a high quality clinicobiological, epidemiological and therapeutic data collection for improvement of the knowledge of this dramatic disease.

Occupational and non-occupational attributable risk of asbestos exposure for malignant pleural mesothelioma.

OBJECTIVES: To estimate the proportion of pleural mesothelioma cases that can be attributed to asbestos exposure in France including non-occupational exposure. METHODS: A population-based case-control study including 437 incident cases and 874 controls was conducted from 1998 to 2002. Occupational and non-occupational asbestos exposure was assessed retrospectively by two expert hygienists. ORs of pleural mesothelioma for asbestos-exposed subjects compared to non-exposed subjects, and population-attributable risk (ARp) of asbestos exposure were estimated using a conditional logistic regression. RESULTS: A clear dose-response relationship was observed between occupational asbestos exposure and pleural mesothelioma (OR=4.0 (99% CI 1.9 to 8.3) for men exposed at less than 0.1 f/mL-year vs. 67.0 (99% CI 25.6 to 175.1) for men exposed at more than 10 f/mL-year). The occupational asbestos ARp was 83.1% (99% CI 74.5% to 91.7%) for men and 41.7% (99% CI 25.3% to 58.0%) for women. A higher risk of pleural mesothelioma was observed in subjects non-occupationally exposed to asbestos compared to those never exposed. The non-occupational asbestos ARp for these subjects was 20.0% (99% CI -33.5% to 73.5%) in men and 38.7% (99% CI 8.4% to 69.0%) in women. When considering all kinds of asbestos exposure, ARp was 87.3% (99% CI 78.9% to 95.7%) for men and 64.8% (99% CI 45.4% to 84.3%) for women. CONCLUSIONS: Our study suggests that the overall ARp in women is largely driven by non-occupational asbestos exposure arguing for the strong impact of such exposure in pleural mesothelioma occurrence. Considering the difficulty in assessing domestic or environmental asbestos exposure, this could explain the observed difference in ARp between men and women.

[Pseudotumoral pulmonary AL amyloidosis]. / Amylose AL pulmonaire de forme pseudo-tumorale.

INTRODUCTION: Thoracic involvement in amyloidosis is rare. An isolated pseudotumor without extra-thoracic disease suggests a malignant process. We present the case of a patient with pseudonodular AL amyloidosis, confirmed by lobar lung resection. CASE REPORT: A 57-year-old woman, with a 25-pack-year smoking history, presented with a nodular opacity on chest x-ray. Physical examination was normal. Thoracic CT-scan revealed an isolated spiculated nodule in the right upper lobe. A whole body positron emission tomography (PET) scan revealed high FDG activity in this nodule, without evidence of metastatic disease. Bronchoscopy was negative. Lobectomy revealed lambda L-chain amyloidosis. Investigation for systemic extension was negative. Follow up has been unremarkable. CONCLUSION: A spiculated lung nodule on conventional imaging (radiography, scanner) is cancer until proven otherwise. The use of PET scan in this context is sensitive but not specific. Definitive diagnosis must be obtained by histological examination. Nodular lung amyloidosis must be included in the differential diagnosis of lung nodules and false-positive FDG PET.

[Tracheobronchomalacia in adults: breakthroughs and controversies]. / Trachéobronchomalacie de l'adulte: avancées et controverses.

Tracheobronchomalacia (TBM) in adults is a disease defined by a reduction of more than 50% of the airway lumen during expiration. It encompasses many etiologies that differ in their morphologic aspects, pathophysiological mechanisms and histopathologies. TBM is encountered with increasing frequency, as it is more easily diagnosed with new imaging techniques and diagnostic bronchoscopy, as well as because of its frequent association with Chronic Obstructive Pulmonary Disease (COPD), which represents the most frequent etiology for acquired TBM in adults. A distinction between TBM in association with failure of the cartilaginous part of the airways and TBM affecting only the posterior membranous part is emerging since their physiopathology and treatment differ. The therapeutic management of TBM should be as conservative as possible. Priority should be given to identification and treatment of associated respiratory diseases, such as asthma or COPD. Surgery addressing extrinsic compression (thyroid goiter or tumor, for example) may be necessary. Noninvasive ventilation can be considered in patients with increasing symptoms. Endoscopic options, such as the placement of stents, should only be used as palliative or temporary solutions, because of the high complication rates. Symptomatic improvement after stenting might be helpful in selecting patients in whom a surgical management with tracheobronchoplasty can be useful.

Temporary endobronchial embolization with silicone spigots for moderate hemoptysis: a retrospective study.

BACKGROUND: The management of airway bleeding is generally performed in an emergency to prevent hypoxemia and lung flooding. When the bleeding arises from peripheral lesions that are not visible endoscopically, bronchoscopic options have limited curative intents. Endobronchial embolization using silicone spigots (EESS) is a novel approach. OBJECTIVES: We analyzed the efficacy and safety of EESS in a retrospective study. METHODS: We retrospectively reviewed charts of patients referred to our center for moderate hemoptysis (MH) who underwent EESS. Successful management is defined as immediate bleeding cessation. RESULTS: From December 2008 to January 2012, 9 patients were treated with EESS in our endoscopy unit. The MH originated from the left upper lobe in 4 cases, the right upper lobe in 3 cases and the right middle lobe and left lower lobe in 1 case each. Thirteen spigots were inserted. The success rate was 78%. Of the 9 patients, 7 were referred to interventional radiology for bronchial artery embolization, with a success rate of 86%, and 2 were referred for thoracic surgery. One patient had EESS as definitive treatment; the silicone spigots were bronchoscopically removed after a median of 4 days in 6 of the remaining 8 patients. Only 2 patients had hemoptysis recurrence after a median follow-up of 107 days (ranging from 13 to 1,017 days). None of the patients died from hemoptysis. CONCLUSION: EESS is an original, temporary technique that requires only a flexible bronchoscope and biopsy forceps for placement and removal. EESS ensures airway protection while waiting for definitive management.

Malignant pleural mesothelioma: from the bench to the bedside.

Optimal management of malignant pleural mesothelioma (MPM), which is mainly based on patient characteristics and clinical stage, is not clearly defined yet, although detailed, practical guidelines for these patients have been proposed by some scientific societies. Translational research, in the field of this disease, is currently in progress and different molecular oncogenic pathways leading to the growth and progression of MPM have been characterized with recent pharmaceutical developments. However, further in-depth analysis still needs to be done for a more advanced deciphering of the step-by-step process leading from early increased mesothelial cell proliferation to invasive mesothelioma, from which we are expecting the development of definitively effective therapy. Thus, this review is an overview of the recent advances in the biology of MPM and their potential therapeutic applications in the field of MPM diagnosis and treatment.

Short-term safety of thoracoscopic talc pleurodesis for recurrent primary spontaneous pneumothorax: a prospective European multicentre study.

The safety of talc pleurodesis is under dispute following reports of talc-induced acute respiratory distress syndrome (ARDS) and death. We investigated the safety of large-particle talc for thoracoscopic pleurodesis to prevent recurrence of primary spontaneous pneumothorax (PSP). 418 patients with recurrent PSP were enrolled between 2002 and 2008 in nine centres in Europe and South Africa. The main exclusion criteria were infection, heart disease and coagulation disorders. Serious adverse events (ARDS, death or other) were recorded up to 30 days after the procedure. Oxygen saturation, supplemental oxygen use and temperature were recorded daily at baseline and after thoracoscopic pleurodesis (2 g graded talc). During the 30-day observation period following talc poudrage, no ARDS (95% CI 0.0-0.9%), intensive care unit admission or death were recorded. Seven patients presented with minor complications (1.7%, 95% CI 0.7-3.4%). After pleurodesis, mean body temperature increased by 0.41°C (95% CI 0.33-0.48°C; p<0.001) at day 1 and returned to baseline value at day 5. Pleural drains were removed after day 4 in 80% of patients. Serious adverse events, including ARDS or death, did not occur in this large, multicentre cohort. Thoracoscopic talc poudrage using larger particle talc to prevent recurrence of PSPS can be considered safe.