[The role of the intensive care unit after thoracic surgery]. / Place de la réanimation après chirurgie thoracique.

Lung (bronchial) cancer is the leading cause of cancer-related death in Western countries today. Thoracic surgery represents a major therapeutic strategy and the various advances made in recent years have made it possible to develop less and less invasive techniques. That said, the postoperative period may be lengthy, post-surgical approaches need to be more precisely codified, and it matters that the different interventions involved be supported by sound scientific evidence. To date, however, there exists no evidence that preventive postoperative admission to intensive care is beneficial for patients having undergone lung resection surgery without immediate complications. A stratification of the risk of complications taking into consideration the patient's general state of health (e.g., nutritional status, degree of autonomy, etc.), comorbidities and type of surgery could be a useful predictive tool regarding the need for postoperative intensive care. However, serious post-operative complications remain relatively frequent and post-operative management of these intensive care patients is liable to become complex and long-lasting. In the aftermath of the validation of "enhanced recovery after surgery" (ERAS) in thoracic surgery, new protocols are needed to optimize management of patients having undergone pulmonary resection. This article focuses on the main postoperative complications and more broadly on intensive care patient management following thoracic surgery.

[Lung cancer screening with low dose computed tomography : a systematic review]. / Dépistage du cancer bronchique par tomodensitométrie à faible dose : une revue systématique des essais contrôlés randomisés.

INTRODUCTION: Bronchial cancer, often diagnosed at a late stage, is the leading cause of cancer death. As early detection could potentially lead to curative treatment, several studies have evaluated low-dose chest CT (LDCT) as a screening method. The main objective of this work is to determine the impact of LDCT screening on overall mortality of a smoking population. METHODS: Systematic review of randomised controlled screening trials comparing LDCT with no screening or chest x-ray. RESULTS: Thirteen randomised controlled trials were identified, seven of which reported mortality results. NSLT showed a significant reduction of 6.7% in overall mortality and 20% in lung cancer mortality after 6.5 years of follow-up. NELSON showed a significant reduction in lung cancer mortality of 24% at 10 years among men. LUSI and MILD showed a reduction in lung cancer mortality of 69% at 8 years among women and 39% at 10 years, respectively. CONCLUSION: Screening for bronchial cancer is a complex issue. Clarification is needed regarding the selection of individuals, the definition of a positive result and the attitude towards a suspicious nodule.

[Immune checkpoint inhibitors (antibodies to PD1 and PD-L1), a new therapeutic weapon against non-small cell bronchial carcinoma]. / Les inhibiteurs des freins immunitaires (anticorps anti-PD1 et anti-PD-L1), une nouvelle arme thérapeutique dans les cancers bronchiques non à petites cellules.

INTRODUCTION: Classical therapeutic strategy for advanced and metastatic non-small cell lung cancer, without activable oncogenic driver mutation, has been based mainly on cytotoxic chemotherapy with modest benefits in terms of increased survival. BACKGROUND: A better understanding of the mechanisms involved in the regulation of the immune system led to the development of antibodies directed against immune checkpoints such as PD-L1. The first encouraging clinical data from phase I studies assessing anti-PD1 and anti-PD-L1 antibodies have been confirmed in randomised phase III trials. CONCLUSIONS: These new drugs now constitute a standard second-line treatment for metastatic tumours and in the future, at least for pembrolizumab, in the first line. Their adjuvant role after locoregional treatment with curative intent is currently under investigation.

Implementing EBUS TBNA: first experience and review of literature.

Lung cancer has a very dismal prognosis and careful diagnosis and staging is of outmost importance. EBUS has become a cornerstone investigation for diagnosis and staging and current guidelines stress that there is a steep learning curve when introducing this tech- nique in practice (only 30 procedures are considered necessary). Over a period of 10 months a total of 21 patients have been addressed to our unit for an EBUS TBNA procedure. Only three were referred for staging purposes (for lung, digestive and cervix cancers) the others being primary diagnostic approaches where simpler procedures had previously failed. Procedures were initially performed under local anesthesia (3 cases) then under general anesthesia and jet ventilation using a laryngeal mask approach. Mediastinal lymph node group 7 was the most frequent target (9 cases) followed by group 4R (8 cases) and peribronchial tumoral processes (7 cases); one case did not required any needle-aspiration. On average each examination resulted in the sampling of 1.4 targets. There were no significant procedure related severe adverse events. Although 21 G cytology needles were used, adequate histological samples were obtained for 11 cases and cytology was the examination of choice for 9 cases. The pathology/cytology results were retrospectively assessed as satisfactory for 15 cases (confirmed neoplastic or other disease) and inconclusive for 5 cases. Non neoplastic disorders were represented by sarcoidosis, tuberculosis and bronchogenic cyst (3 cases). The procedure can be considered fast and safe; trained pathology personnel play an extremely important role: presently referrals are rare for staging purposes.

EGFR MUTATIONS IN NON-SMALL CELL LUNG CANCER: LOCAL EPIDEMIOLOGY AND CLINICAL IMPORTANCE.

INTRODUCTION: Lung cancer's dismal prognosis led to new therapeutic approaches among which TKIs being among most promising; MATERIAL AND METHOD: Retrospective study at the Regional Institute of Oncology Iasi of non small cell lung cancer patients which underwent molecular investigations between November 2013 - September 2014. EGFR mutation status (positive, negative, undetermined) was assessed with an Entrogen EGFR kit using DNA extracted from paraffin embedded samples (surgical or endobronchial biopsies) with the Macherey-Nagel "NucleoSpin FFPE DNAkit" and then amplified on a Applied Biosystem 7500 Real Time PCR System. RESULTS: There were 63 adenocarcinoma samples (17 females, mean age 60,9 +/- 9 years): 49 primary lung tumors and 14 secondary lesions (brain, lymph nodes, pleural). There was insufficient bioptic material for three cases. TTF1 status was determined for 46 patients--six were negative. There were twelve mutations identified (7 female subjects, 5 male)--six L858R, five Del 19 and one G719X; ten were TTF1 positive for the remaining two TTF1 status was unknown. Female sex predominance was statistically significant (p = 0.02, chi squared). Mean age for mutation positive patients was 64 +/- 10 years; there were three never smokers, three active smokers and no data on smoking status was available for six subjects. CONCLUSION: Although small dimension of the study group precludes statistical significance EGFR mutations seem to correlate with TTF1 status.

[Management of extensive disease small cell lung cancer. Guidelines of clinical practice made by the European Lung Cancer Working Party]. / Traitement des cancers bronchiques à petites cellules: maladies étendues. Recommandations de pratique clinique de I'European Cancer Working Party.

The present updated guidelines on the management of extensive disease small cell lung cancer (SCLC) formulated by the ELCWP are designed to answer the following questions : 1) What is the definition of extensive disease? 2) What are the active drugs? 3) What is the best induction regimen? 4) Is there a role for maintenance chemotherapy? 5) Is there a role for dose-intensive chemotherapy (without administration of hematopoietic growth factors)-? 6) Is there a role for the use of haematopoietic growth factors and stem cells support? 7) Is there a role for alternating or sequential chemotherapy? 8) Is there a role for biological treatments? 9) Is there a place for second-line chemotherapy? 10) Is there a role for preventive brain irradiation (PCI)?

Detection of Mycobacterium tuberculosis growth by direct microscopic observation has a lower cost, higher sensitivity and higher diagnostic value than liquid and solid media cultures.

BACKGROUND: Culture is needed to confirm tuberculosis but results are generally obtained after several weeks. OBJECTIVES: We compared a direct microscopic observation technique for detection of mycobacterial culture positivity (MODS) with the classic solid and MB/BacT cultures in terms of sensitivity, contamination rate, speed and cost on 488 samples. RESULTS: The sensitivity of the MODS technique--99,2% (162 positive samples) was higher than MB/BacT 78,4% (125 positive samples) and solid culture 69,6% (113 positive samples) P<0.005 for all comparisons. The median times to positivity were 21, 13.3 and 3 days on solid media, B/BacT and MODS respectively. CONCLUSIONS: The MODS technique is faster and more sensitive than both solid media and MB/BacT culture.

Clinical utility of diagnostic markers for malignant pleural mesothelioma.

Malignant mesothelioma has a very dismal prognosis with very few patients surviving one year after diagnosis. Early multimodal treatment, however, is expected to improve the outcome. Today, there is a strong need to have disease markers which could be used for screening, diagnosing, and/or monitoring tumour response to treatment. Old markers such as hyaluronic acid, various cytokeratin fragments (CYFRA 21.1, TPA) and other cancer antigens (CA 15.3, CA 125 or CA 19.9 or CEA) are not sensitive or specific enough and cannot be used in practice. More recently new molecules, such as soluble mesothelin and osteopontin, have been proposed for diagnostic purposes. Soluble mesothelin has a good specificity but has a sub-optimal sensitivity being negative in all sarcomatoid and in up to one half of epithelioid mesothelioma. On the contrary osteopontin has an inadequate specificity. Combining different markers together does not lead to an improvement in diagnostic accuracy. Neither marker can be used for screening purposes, the main limitation being the very low incidence of the disease in the at-risk, asbestos exposed population. Mesothelin is also a promising marker for monitoring response to treatment but published data is still insufficient to make recommendations. There is still a strong need for research is this area both in order to discover new markers as well as to correct the positioning of each existing molecule (alone or in combination) is the evaluation of the patients with a mesothelioma.

[Other thoracic cancers. Malignant pleural mesothelioma: biology and diagnosis]. / Mésothéliome pleural malin: biologie et diagnostic.

Malignant pleural mesothelioma (MPM) is a serious issue worldwide because of its increasing incidence and poor prognosis despite real recent improvements in the disease management. Most of the patients are diagnosed late in the course of the disease when radical treatment is no more an option. Therefore an earlier diagnosis of MPM is needed to significantly increase the survival of patients. Some soluble markers, including soluble mesothelin and osteopontin, have been previously proposed for MPM diagnosis but none has been validated yet. Soluble mesothelin, assessed in blood and in pleural effusion, seems to be the most promising candidate. However, even if it has a good diagnostic and prognostic value, it is quite specific for the epithelioid subtype, the most frequent one of mesothelioma, thus limiting its usefulness in practice. Despite sometimes a good sensitivity, other potential markers as osteopontin are of little interest for MPM diagnosis because of a low specificity. In conclusion, the present data do not justify the use of biology for MPM diagnosis in routine yet but rather suggest a need for a continuing evaluation of soluble mesothelin in clinical studies and the search for other potential tumor markers.

[Disseminated tuberculosis with severe multi- organ failure in a patient with AIDS]. / Tuberculose disséminée avec défaillance multiviscérale foudroyante au cours d'un sida.

INTRODUCTION: Tuberculosis is the most common infectious complication in HIV infected patients. The incidence of tuberculosis and the proportion of disseminated disease increase with more severe immuno-suppression. Septic shock and multiple organ failure are uncommon but are of markedly bad prognostic significance. CASE REPORT: A forty-four year old HIV seropositive man was admitted to the intensive care unit (ICU) with acute respiratory distress. The patient had been febrile for the previous two weeks. His thoracic radiograph showed a discrete interstitial infiltrate and at bronchoscopy small whitish granulations were observed in the main bronchi. All bacteriological investigations remained negative at the time of ICU admission. The patient died sixteen hours later due to multiple organ failure. Mycobacteria were identified after patient's death on the smear from BAL, from blood cultures, and in a postmortem liver biopsy. CONCLUSIONS: Septic shock is an infrequent complication of disseminated tuberculosis. Mortality is very high. Treatment should be started early in cases with a high diagnostic suspicion.

[Pulmonary disease in dental laboratory technicians]. / Manifestations pulmonaires des prothésistes dentaires.

INTRODUCTION: The manufacture of dental prostheses exposes the technician to inhalation of various potentially dangerous dusts (silica, hard metals, dental alloys and acrylic resins). BACKGROUND AND VIEWPOINT: Inhalation of dusts produced by the technician in the work place may lead to several respiratory disorders (pneumoconiosis, hypersensitivity pneumonitis, asthma, lung cancer). The continuous development of new materials leads to further manifestations of these disorders and justifies their notification, even in the absence of an accepted occupational disease. This step is taken inconsistently as many dental technicians are not salaried or insured. CONCLUSION: The seriousness of some of these disorders and the absence of effective treatment makes it important to develop effective methods of prevention for the protection of individuals and groups, and for early detection.

Tracheo-bronchial foreign bodies.

Suspicion of foreign bodies inhalation is a frequent problem in clinical practice. Despite the fact that the parents or the patients themselves easily notice symptoms, the delay in initiating diagnostic procedures is important. Delaying diagnosis and extraction results in potential severe complications. Diagnosis and treatment rely on invasive bronchoscopic procedures and therefore a careful designed standardized evaluation should be employed in order to decrease unnecessary bronchoscopies. Classical clinical signs of foreign body inhalation have low positive predictive values and every attempt to confirm or exclude the diagnosis should be done. Patients should be addressed to experienced centers for evaluation and treatment. Confirmation of the diagnosis should be done by flexible bronchoscopy. Extraction generally relies on rigid bronchoscopy, which seems to be more secured. Flexible bronchoscopy can also be used for extraction but rigid bronchoscopy should be always immediately available. Extraction failure rate and complications are rare in hands of experienced individuals and surgical removal is seldom necessary.

[Myocardial bridging and sudden death]. / Puntea miocardica si moartea subita.

Myocardial bridging (MB) has been described more than 200 years ago. However it's implications on the genesis of myocardial ischaemia were not studied until recently. Little is known about the real incidence, survival in people with this entity and pathophysiology. Data found in the literature are prone to bias since all studies published are retrospective and the populations studied are limited and very selectioned. Most authors agree that most MB is rather frequent and seldom generates ischaemia. A significant clinical effect of myocardial bridging implies a thick MB with at least 75% coronary systolic obstruction associated with ventricular hypertrophy and/or rapid tachycardia. In the peculiar case of sudden death, we think that to consider MB as a cause of this sudden death we need more than a simple necroptic finding of a MB. A history of clinical and/or electrocardiographic confirmed ischaemia or the presence of histological abnormalities suggesting myocardial ischaemia can be helpful.