Pulmonary Sarcomatoid carcinoma: a surgical diagnosis and prognostic factors.

INTRODUCTION: Pulmonary Sarcomatoid Carcinoma (PSC) is a rare group of tumors accounting for about 0.4% of non-small cell lung carcinoma (NSCLC). Five subtypes were described: pleomorphic carcinoma, spindle cell carcinoma, carcinosarcoma, giant cell carcinoma and pulmonary blastoma. The diagnosis is pathological but requires a good quality sampling of the tumor. METHODS: On a series of 1582 patients operated on for lung cancer from 1992 to 2016, 43 patients were retrospectively identified as having been treated surgically for pulmonary sarcomatoid carcinoma. RESULTS: The population consisted of 33 males and 10 females with mean age of 55 years. Imaging findings showed a peripheral mass in the majority of cases (n=29). Careful investigation failed to discover a primitive lesion elsewhere. Six patients received induction therapy for wall involvement. Lobectomy or bilobectomy was performed in 30 patients and pneumonectomy in 11 patients. A wedge resection was performed in one patient and an exploratory thoracotomy in another. In macroscopy, the mean tumor's size was 5.2 cm (1-17.5cm). The histologic diagnoses were: pleomorphic carcinoma (n=30), carcinosarcoma (n=5), spindle cell carcinoma (n=1), giant cell carcinoma (n=3) and blastoma (n=4). Two patients died within 1 month of surgical complications and 5 died of disease within 17 months. Adjuvant therapy was performed in 6 patients. Recurrence happened in 4 patients within 12 months after operation. Median survival for all patients was 8months. CONCLUSIONS: Resection of primary pulmonary sarcomatoid carcinoma is associated with an acceptable survival rate if the resection is complete. The size of the tumor is the most important prognosis factor. Nevertheless, a carefully follow-up is essential.

Sleeve Right Lower Lobectomy: a Rarely Performed Extended Resection.

Sleeve resection is a valid option in the surgical treatment of lung tumors, avoiding large resection. To ensure a good functional result and avoid post-operative complications like recent broncho-pleural fistulas and long-term stenosis, anastomosis between bronchi must be well performed. We report two cases of sleeve resection of the right lower lobe and show how we managed caliber discrepancy between the middle lobe bronchus and the truncus intermedius.

Evaluation of the microvessel density and the expression of metalloproteases 2 and 9 and ttf1 in the different subtypes of lung adenocarcinoma in Tunisia: a retrospective study of 46 cases.

Despite the new available histologic classification of lung cancers, it remains difficult to assess the real prognostic relevance of the different subtypes of lung adenocarcinomas. Facing the prognostic relevance of microvessel density (MVD) and the expression of metalloproteases and thyroid tyrosine factor 1 (TTF1) in different cancers, we tried to compare these parameters in the different subtypes of lung adenocarcinomas. We conducted a retrospective study of 46 adenocarcinomas surgically resected. An immunohistochemical study using the cluster of differentiation 34 (CD34), TTF1, metalloproteases 2 (MMP2), and metalloproteases 9 (MMP9) antibodies was performed on all samples while MVD was evaluated using CD34 antibody. The analyzed cases included 19 acinar, 7 papillary, 1 lepidic, and 19 solid predominant American Thoracic Classification of lung adenocarcinomas (ASK). The higher MVD levels were observed in papillary and acinar subtypes types and a statically significant difference in the MVD was observed in the different subtypes (p< 0,001). This study didn't show significant statistical results concerning MMP and TTF1 expression but it revealed a tendency to an equal expression of these antibodies in the different subtypes. The difference in the MVD between the different subtypes of adenocarcinoma puts emphasis on their prognostic relevance.

Brief original scientific report: a new surgical approach for the treatment of left pulmonary and hepatic hydatid disease.

BACKGROUND: The combination of pulmonary and hepatic hydatid cysts is frequently encountered, and poses a challenge in terms of surgical accessibility. The surgical treatment of the two locations by the same incision (thoracotomy with phrenotomy) has been proposed, but always from the right side. However, applying this technique to the left side seems to be more difficult and unusual. We herein describe a new left-sided technique that was used to treat two patients with pulmonary and hepatic hydatid cysts. METHODS: The first patient was 14-year-old; he had bilateral pulmonary hydatid cysts and one type I cyst of the left lobe of the liver. The second patient was a 10-year-old female who had a hydatid cyst of the upper left lobe with one type III cyst of hepatic segments 2 and 3. RESULTS: Both patients were operated on via a left lateral thoracotomy through the sixth intercostal space. They underwent cystectomy for the left pulmonary hydatid cysts, followed by padding, and then the hepatic cyst was treated by Lagrot's method via a radial phrenotomy. The postoperative course was uneventful in both cases, with postoperative hospital stays of 3 and 5 days, respectively. CONCLUSION: This combined treatment of pulmonary and hepatic hydatid cysts by the left-sided thoracic approach is feasible and provides a good outcome. It should be indicated under the same conditions of accessibility and feasibility applied for the right thoracic side.

Major pulmonary resections by exclusive VTS. a first in Tunisia.

Although thoracoscopic surgery had been introduced in Tunisia since 1993, there were no anatomical resections performed that way. We report herein the first 3 cases of lobectomy performed by exclusive video-thoracoscopic surgery (VTS). Three female patients presenting with bronchiectasis (2 cases) and cystic adenomatoid malformation (1 case) have underwent a thoracoscopic lobectomy with different outcomes.

Conservative management of postoperative bronchopleural fistulas.

OBJECTIVE: A bronchopleural fistula (BPF) is a serious complication after pulmonary resection and carries a high mortality rate. It remains a therapeutic challenge. The lack of a consensus suggests that no optimal therapy is available; however, endoscopic closure of a fistula may avoid extensive and potentially risky surgery. METHODS: Seventeen patients (15 men and 2 women) with a BPF after a pneumonectomy (n = 2) or a lobectomy (n = 15), seen between 1995 and 2010, were reviewed. Their median age was 50 years (range, 14-75 years). Underlying diseases were malignant (n = 4) and nonmalignant (n = 13). RESULTS: The mean interval between surgery and fistula development was 20 days (range, 5-270 days). Clinical symptoms leading to a diagnosis of BPF were a persistent air leak (n = 2), a persistent air leak associated with pleural empyema (n = 3), pleural empyema alone (n = 11), and dyspnea (n = 1). Mean fistula size was 3.3 mm (range, 2-9 mm). Treatment consisted of oriented pleural drainage, adequate antibiotic therapy, and endoscopic closure of the fistula with local application of silver nitrate through a flexible bronchoscope (3-15 sessions, 3 times per week). Fistula closure was successful in 16 patients, but failed in 1 patient, who died from acute respiratory distress. CONCLUSIONS: BPF is a severe complication in thoracic surgery. The combination of pleural drainage, adequate antibiotic treatment, and mucosal application of silver nitrate, through a flexible bronchoscope, is an efficient alternative and avoids extensive surgical intervention.

Elastofibroma of scapula: a case report and literature review.

Elastofibromas are benign soft tissue tumors. They occur mostly in the infrascapular region between the thoracic wall, the serratus anterior and the latissimus dorsi muscle, with a prevalence of up to 24% in the elderly. The etiology of this lesion remains uncertain and is a source of ongoing debate. We herein report a 54-year-old female patient, manual worker who presented with bilateral subscapular slow growing tumors for 7 months. Physical examination showed two masses of 4 cm in diameter on the right, and 8 cm on the left, both located inferior to the inferior margin of the scapula. They were more or less firm and mobile on palpation. Computed tomography scan showed large fusiform subscapular soft tissue heterogeneous solid masses with linear areas of low density secondary to fat. The lesions measured 5 cm × 4 cm on the right side and 8 cm × 8 cm on the left. Resection of the largest left tumor was achieved. Macroscopic and histological findings were consistent with elastofibroma.

What outcome after the prescription of neoadjuvant chemotherapy in lung cancer?

BACKGROUND: The treatment of patients with locally advanced non-small-cell lung cancer is controversial. Surgery remains the gold standard, even in this group. Neoadjuvant chemotherapy could allow surgical resection in patients initially judged inoperable. METHODS: From January 2009 to May 2010, neoadjuvant chemotherapy was indicated in 27 patients with NSCLC (25 men, 2 women). Their mean age was 65 years. The stages were: IIB in 5, IIIA in 17 (6 in stage IIIAN2), IIIB in 2, and IV in 3. RESULTS: 23 patients received neoadjuvant chemotherapy, 2 refused induction treatment, and 2 had impaired status. The neoadjuvant chemotherapy regimen was gemcitabine-cisplatin in 17 patients and vinorelbine-cisplatin in 6. Only 5 patients underwent complete surgical treatment after induction: 1 in stage IIB, 1 in stage IIIAN0, 1 in IIIB, and 2 in stage IV (1 operated brain metastasis, and 1 operated adrenal metastasis). Surgical treatment was not achieved after neoadjuvant chemotherapy in 18 patients because of progressive disease. CONCLUSION: Neoadjuvant chemotherapy offers several potential benefits, but it may delay surgery or eliminate eligibility as a surgical candidate. Rigorous patient selection for this type of multimodal treatment is essential.

Surgical management of pulmonary large cell neuroendocrine carcinomas: a 10-year experience.

OBJECTIVES: Large cell neuroendocrine carcinoma (LCNEC) represents a relatively rare and poorly studied entity whose management is not clearly established. The aim of this study was to assess clinico-pathological characteristics, treatment modalities and outcomes of LCNEC. METHODS: A retrospective study of patients operated on for LCNEC between 2000 and 2010 was carried out. RESULTS: Sixty-three patients (49 men, median age 64 years) with pathologically confirmed LCNEC of the lung were operated on between 2000 and 2010. Neoadjuvant chemotherapy was administered in 16 cases. Standard lobectomy, sleeve lobectomy, bilobectomy and pneumonectomy were performed in 63.5%, 9.5%, 1.6% and 15.8% of cases. There were two cases of extended resection. Sublobar resections were performed in four patients. Postoperative mortality was 1.6%. Postoperative staging was IA, IB, IIA, IIB, IIIA, IIIB and IV in 15.9%, 19%, 20.6%, 4.8%, 34.9%, 4.8% and 0% of cases, respectively. Adjuvant treatments were administered in 70% of cases. Overall 5-, and 8- year survival rates were 49.2% (37-61.6%) and 42% (28.8-56.4%), respectively. Multivariate analysis, including age >64 years, cumulative tobacco consumption, size of tumour, pT and pN parameters showed that only age (P = 0.05, RR 2.1 [0.99-4.43]) and pT parameter (P = 0.0078, RR 2.93[1.33-6.46]) were independent predictors of survival. CONCLUSIONS: Surgery may achieve satisfactory results in terms of survival, in spite of the similarities of LCNEC with small cell lung cancer. Multimodality management seems necessary.

Posterior mediastinal angiomyxolipoma with spinal canal extension.

BACKGROUND: Angiomyxolipoma is a benign tumor considered as a variant of lipoma and that occurs mainly in the subcutis. The mediastinal location hasn't been previously reported. AIM: To describe the radiological features of this tumor in its posterior mediastinal location and to confront them to the pathological features. CASE REPORT: We report the case of a 49-year-old woman who was admitted for chest wall pain and neurologic disturbance of her two lower limbs. The chest X-ray showed a posterior mediastinal opacity. On CT examination, this mass contained some small areas of fat and enhanced intensely. Microscopic examination of the excised mass confirmed the diagnosis of posterior mediastinal angiomyxolipoma. CONCLUSION: Mediastinal location of angiomyxolipoma hasn't been previously reported. Clinicians and radiologists should be aware that this diagnosis should be suggested, among others, when there is a posterior mediastinal mass that contains fat and that intensely enhances with a possible spinal cord extension.

Surgery in thoracic actinomycosis.

BACKGROUND: Diagnosis and treatment of thoracic actinomycosis is difficult. In most cases, surgery is performed to rule out lung cancer or to control severe symptoms such as hemoptysis. METHODS: 6 patients with a mean age of 42 years underwent pulmonary resection and were given a pathologic diagnosis of thoracic actinomycosis at our institution between 2003 and 2010. We reviewed preoperative clinical characteristics, computed tomography findings, surgical indication, postoperative clinical course and outcome. RESULTS: All patients were symptomatic. One patient had a history of cervical actinomycosis. The mean interval between radiographic identification of the abnormality and surgical intervention was 8 months (range, 4-17 months). Radiographic findings in all cases included a mass-like appearance, simulating lung malignancy or chronic suppuration. The various histological and bacteriological examinations had failed to make the diagnosis. Thoracic actinomycosis was confirmed after thoracic surgery. All patients received penicillin-based antibiotic treatment for at least 2 to 3 months. Good clinical results were observed in 5 patients. In one patient, we noted recurrence of actinomycosis after 10 months; it was a multidrug-resistant form. CONCLUSION: Diagnosis of actinomycosis can be problematic because of difficulty in isolating actinomyces. In these cases, surgery is very helpful.

[Iatrogenic gas embolism after use of hydrogen peroxide in the treatment of lung hydatid cyst: a report of 2 cases]. / Embolie gazeuse iatrogène après utilisation de peroxyde d'hydrogène dans le traitement du kyste hydatique du poumon: a propos de deux cas.

BACKGROUND: Echinococcus disease is endemic in our country. Surgical resection of the hydatid cyst with the use of a protoscolicidal solution in the operative field remains the standard treatment. The degradation of hydrogen peroxide results in considerable amounts of gaseous oxygen witch has proven protoscolicidal properties. This gas can enter the circulation and determine severe embolism. AIM: We report two cases of severe oxygen embolism with neurological signs during surgical treatment of thoracic hydatid cysts. CASES REPORT: We report 2 cases of embolic events with neurological signs. The first, during a pleural cleaning with hydrogen peroxide after cystectomy of a pulmonary hydatic cyst at the right upper lobe. The second case, after a pleural washing during the treatment of hepatitic hydatidosis complicated by a ruptured cyst in the thorax. CONCLUSION: The most important diagnostic criterion is the patient's history, because the clinical suspicion of embolism is based on the initial neurologic or cardio-respiratory symptoms and the direct relation between these symptoms and the use of hydrogen peroxide and imposes appropriate treatment before further examination including brain imaging. The treatment with hyperbaric oxygen is the first line treatment, thus, transfer to a hyperbaric oxygen facility should be accomplished without delay. The possibility of such serious complication leads us to use hydrogen peroxide with great care or to use other protoscolicidal solutions.

Resection of pulmonary metastases from sarcoma: can some patients benefit from a less invasive approach?

BACKGROUND: Although video-assisted metastasectomy has been proposed for some solitary metastases, its value has not been investigated in patients with pulmonary metastases from sarcoma for which open resection remains the usual approach. METHODS: In all, 113 consecutive patients underwent curatively intended lung resection for metastases from sarcomas. Of these 113 patients, 31 were selected for a thoracoscopic wedge resection (group TS). These patients were compared with 29 patients operated on by thoracotomy but whose features could have made them possible candidates for a thoracoscopic resection (group TT). Follow-up was complete for all patients (mean follow-up, 34 months). RESULTS: No mortality occurred. No morbidity was observed in group TT, and 1 complication occurred in group TS. The mean postoperative hospital stay was 3.7 days for group TS and 6.2 days for group TT (p < 0.0001). Overall survival rates at 1, 3, and 5 years were, respectively, 87.4%, 70.9%, and 52.5% in group TS, and 82.3%, 63.6%, and 34% in group TT (p = 0.20). Disease-free survival rates at 1 and 3 years were, respectively, 50.5% and 26.4% in group TS and 60% and 24.8% in group TT (p = 0.74). Local recurrence occurred in 1 patient in each group. Survival without a homolateral recurrence (i.e., in the operated lung) at 1 and 3 years was 66.7% and 44.4% in group TS and 83.5% and 45% in group TT, respectively (p = 0.54). CONCLUSIONS: In selected patients with a maximum of two pulmonary nodules, thoracoscopic resections yield survival rates similar to open resections while being less invasive and preserving the patient's ability to undergo possible repeat operations.

Pitfalls related to the use of endostaplers during video-assisted thoracic surgery.

BACKGROUND: The use of staplers during thoracoscopic pulmonary resections has entailed several incidents. This study aimed to evaluate the rate of adverse events related to the use of an endostapler during video-assisted thoracic surgery (VATS). METHODS: All thoracoscopic procedures involving the use of an endostapler were prospectively studied. The study was based on the analysis of data prospectively entered into a database and the review of videotapes recorded during the procedure. The video clip of each incident was included into the database. The following events were recorded: oozing or hemorrhage on the staple line, partial or total disruption of the staple line, and any other technical issue. RESULTS: A total of 434 firings were made during 130 thoracoscopic operations. The operations involved 77 wedge resections of lung nodules, 11 pulmonary biopsies, 34 bullectomies, and 8 thoracoscopic lobectomies. Although firing was uneventful for most patients, a minor or major problem was encountered during 34 firings (7.6%). Two technical malfunctions of the device occurred, both of them noticed by the scrub nurse before introduction of the stapler into the trocar. The other pitfalls were oozing (13 cases) and active hemorrhages (5 cases) on the staple line and disruption of the staple line, either partial (13 cases) or total (1 case). Conversion to thoracotomy was never necessary. Whereas no specific action was imposed by the pitfall in 12 cases, the incident led to a repair in 22 cases. None of the incidents had a clinical consequence in the postoperative course. The video tapes were reviewed to check whether the accident was unpredictable or due the surgeon's misuse or misjudgment. In 14 cases, no cause was found. In 5 cases, the lung parenchyma probably was too thick for the staples chosen, whereas no technical error was found in the remaining 15 cases. CONCLUSION: Although some adverse events are attributable to surgical errors, many are linked to the device. This underscores the need for improving staplers and evaluating new technologies.

Endobronchial sclerosing hemangioma: a rare presentation of a parenchymal tumor.

Endobronchial localization of sclerosing hemangioma is extremely rare. Exact localization of lesion at preoperative work-up allows parenchymal-sparing procedures. We report a case of endobronchial sclerosing hemangioma diagnosed preoperatively and treated by lingular-sparing upper lobectomy with nodal dissection.

Totally endoscopic anatomic pulmonary segmentectomies.

Although some series of video-assisted major pulmonary resections have been reported, very few series of totally endoscopic lobectomies have been published and - to our knowledge - none of totally endoscopic anatomic segmentectomies. We have recently performed five anatomic segmentectomies using this approach. The video demonstrates the main steps of the procedure, based on the recordings of three different operations: a lingulectomy, a left basilar segmentectomy and a resection of the right lower lobe superior segment.

Hemothorax as the clinical presentation of a pancreaticopleural fistula: report of a case.

Pancreaticopleural fistula is a rare complication of acute pancreatitis with pancreatic pseudocyst. We report the case of a 39-year-old man admitted for respiratory distress. Chest X-ray showed a pleural effusion, and thoracentesis yielded bloody fluid. Computed tomography (CT) scan showed a multiloculated pleural effusion and sagittal reconstruction revealed a fistulous tract between the pleura and a pancreatic pseudocyst. We treated the acute hemothorax complicating the pancreaticopleural fistula by performing urgent thoracotomy with the evacuation of blood and clots and lung decortication. We also gave the patient somatostatin and performed endoscopic retrograde cholangiopancreatography with sphincterotomy, and placed a pancreatic stent. The patient recovered well.

Tuberculosis of the trachea.

Tracheal tuberculosis is an uncommon localized form of tuberculosis with fewer than 150 reported cases in the literature. We report a case of tracheal stenosis caused by tuberculosis in which the diagnosis was suggested by the patient's past medical history. This patient was successfully treated with tracheal resection, adjuvant steroids and anti-tuberculous therapy. This report will review the various types of tuberculosis of the trachea and their clinical features in addition to discussing the different available treatment modalities.