[Primary pulmonary hemangiopericytoma: 2 new cases]. / L'hémangiopéricytome pulmonaire primitif: deux nouvelles observations.

We describe two new resected cases of primary pulmonary hemangiopericytoma and the review of cases published in the period 1954-2002. The first patient has a large pulmonary mass of the right apex revealed by scapular pain. The right upper lobectomy with free margins reveals hemangiopericytoma. Pelvic and pulmonary metastases appear two years after surgery, treated by two series of chemotherapy without clinical response. After acute nephrotoxicity controlled by hemodialysis, the patient dies with distant metastases three years and an half after thoracotomy. The second patient develops dry cough and thoracic pain with discovery of a cavitary mass in the right pulmonary field. Fine needle aspiration cytology suggests a mesenchymatous lesion. Three months after extended pneumonectomy, the intrathoracic tumour relapses and regresses partially under chemotherapy. Femoral and brain metastases are irradiated. The patient dies 22 months after thoracotomy. Histology and immunohistochemistry of both tumours closely related to solitary fibrous tumour confirm malignant hemangiopericytoma. Primary pulmonary hemangiopericytoma is rare and may be benign or malignant. Radical resection is the best treatment. Chemotherapy and radiotherapy may improve the prognosis. Compared with lung cancer, the tumour is a slow growing mass, often voluminous, with delayed symptoms, very few lymph node dissemination, rare brain metastasis, more frequent cutaneous or retroperitoneal dissemination, often after long-term and requiring indeed a 10 to 20 years follow-up.

Induction treatment before surgery for non-small cell lung cancer.

Surgery alone is currently still accepted "standard of care" for patients with operable NSCLC, this includes stages IA and IIB, as well as selected early subsets of IIIA disease. In more advanced and inoperable stage III disease, combinations of chemotherapy and radiotherapy remain the standard treatment approach for patients with good performance status. The role of surgery following induction therapy in these advanced stage III patients is at the moment not conclusively defined. More evidence from randomized trials is clearly needed to tailor treatment for the large number of patients that present in these locally advanced stages. Enrollment of patients into ongoing prospective clinical trials should be encouraged, whenever possible, to further define prognostic factors and improve multimodality strategies in this clinical setting.

Undiagnosed rupture of right hemidiaphragm--hepatothorax: a case report.

A case of late diagnosis of right diaphragmatic rupture due to blunt trauma is presented. Traumatic diaphragmatic rupture is an uncommon but severe problem in a patient with multiple injuries. One third of left-sided ruptures and half of right-sided ruptures have been undetected for several days. Traumatic diaphragmatic rupture should be suspected on the basis of an abnormal chest X-ray in patients with multiple injuries. Imaging studies like computed tomography, scan and magnetic resonance imaging can be helpful for differential diagnosis. Right-sided injuries occur more commonly than previously thought and often require thoracotomy.

Increased expression of high but not low molecular weight heat shock proteins in resectable lung carcinoma.

Strong expression of high-molecular-weight (HMW) heat-shock proteins (HSP) by lung carcinoma has been documented using immunohistochemistry. Far less is known about the expression of low-molecular-weight (LMW) HSP in lung cancer. We compared the quantitative expression of HMW (HSP-60, HSP-70) and LMW (HSP-27, ubiquitin) HSP in tumor and non-tumor lung tissue obtained from 47 patients undergoing surgical resection of lung carcinoma. HSP levels were determined in cell lysates from tissue samples by ELISA using streptavidin-biotin technology. Results were normalized to total protein content measured by spectrophotometry. Compared to disease-free lung tissue, tumor tissue samples showed higher levels of both HSP-60 (median value: 227 pg versus 96 pg per mg protein (P<0.001 by Wilcoxon Rank test for paired data) and HSP-70 (median value: 525 ng versus 401 ng per mg protein (P=0.01 by Wilcoxon Rank test for paired data). Tumor and tumor-free tissues show similar levels of ubiquitin and HSP-27. Neither the survival rate nor the histologic type and extent of cancer are correlated with the observed differences in HSP-60 and HSP-70 expression (P>0.1 by one way analysis of variance for repeated measures with one between subject factor). Our data confirm, on a quantitative basis, the increased expression of HSP-60 and HSP-70 in non-small-cell lung carcinoma. However, no prognostic value was found to be associated with this over-expression. In contrast, LMW stress proteins such as ubiquitin and HSP-27, although implicated in cellular processes potentially related to malignant transformation, show no increased expression in lung carcinoma.

[Ludwig's angina]. / Angine de Ludwig.

Ludwig's angina is a rare infectious condition originating in the oropharyngeal region, most commonly from the teeth. The principal symptoms consist of cervical pain, dyspnea, dysphagia, symmetrical neck swelling and fever. Serious complications include respiratory collapses, mediastinitis, pleural empyema, pericarditis and pericardial tamponade, and may result in the death of the patient. The most useful investigations in patients with suspected Ludwig's angina are clinical assessment, a cervico-thoracic CT-scan to determine the extent of the lesions, microbiological examination and panoramic radiography to detect possible dental focuses of infection. Treatment consists of ensuring adequate ventilation by securing the upper airways, broad spectrum antibiotic therapy, eradication of the source of infection, and often early surgical decompression may be necessary. Rapid diagnosis and appropriate treatment can reduce the mortality rate to 10%.

Lung metastases from melanoma: when is surgical treatment warranted?

Surgical treatment of lung metastases from melanoma is highly controversial as the expected outcome is much poorer than for other primary tumours and a reliable system for selecting patients is lacking. This study evaluated the long-term results of lung metastasectomy for melanoma, with the aim of defining a subset of patients with better prognosis. By reviewing the data of the International Registry of Lung Metastases (IRLM), we identified 328 patients who underwent lung metastasectomy for melanoma in the period 1945-1995. Survival was calculated by Kaplan-Meier estimate, using log-rank test and Cox regression model for statistical analysis. After complete pulmonary metastasectomy (282 patients) the 5- and 10-year survival was 22% and 16%, respectively. In this group of patients, a time to pulmonary metastases (TPM) shorter than 36 months or the presence of multiple metastases were independent unfavourable prognostic factors. There were no long-term survivors after incomplete resection (46 patients, P< 0.01). Using the IRLM grouping system, patients without risk factors (TPM > 36 months and single lesion) experienced the best survival (29% at 5 years), followed by those with one risk factor only (20% at 5 years). On the other hand, those with two risk factors or incomplete resection showed a significantly poorer survival (7% and 0% at 5 years). Surgery plays an important role in carefully selected cases of pulmonary metastatic melanoma. The prognostic grouping system proposed by the International Registry of Lung Metastases provides a simple and effective method for improving the selection of surgical candidates.

Characterization of ligands for galectins, natural galactoside-binding immunoglobulin G subfractions and sarcolectin and also of the expression of calcyclin in thyroid lesions.

The purpose of this study was to characterize ligands for galectins, natural galactoside-binding immunoglobulin G subfractions and sarcolectin and also the expression of calcyclin in various benign and malignant thyroid lesions. The extent of the binding of eight glycochemical probes was quantitatively assessed using computer-assisted microscopy on 76 thyroid lesions including 10 not-otherwise-specified multinodular goiters (S_MNG), 11 multinodular goiters with adenomatous hyperplasia (AH_MNG), 8 normomacrovesicular (NM_ADE) and 12 microvesicular (MIC_ADE) adenomas, and 9 papillary (P_CAR), 10 follicular variants of papillary (FvarP_CAR), 7 follicular (F_CAR) and 9 anaplastic (A_CAR) carcinomas. The 8 histochemical probes included 5 animal lectins (including galectins and sarcolectin), 1 polyclonal antibody (raised against calcyclin) and 2 immunoglobulin G subfractions from human serum with selectivity to alpha- and beta-galactosyl residues. The results show that multinodular goiters with adenomatous hyperplasia exhibited histochemical characteristics intermediate to those of normal multinodular goiters and microvesicular adenomas. Normomacrovesicular adenomas behaved very distinctly from microvesicular ones. Microvesicular adenomas were more closely related to differentiated thyroid carcinomas than any other type of benign thyroid lesions of epithelial origin. Papillary and follicular carcinomas seemed to represent the two extremes of the same biological entity with the follicular variant of the papillary carcinoma serving as a biological link between these two extremes. Anaplastic carcinomas behaved in a significantly different manner when compared to the differentiated forms of thyroid carcinomas. The results suggest that the patterns of expression of the glycoconjugates investigated in the present study may constitute useful tools for characterizing lesions in the human thyroid.

Randomized trial of surgery versus radiotherapy in patients with stage IIIA (N2) non small-cell lung cancer after a response to induction chemotherapy. EORTC 08941.

Combined modality treatment of patients with stage III non small-cell lung cancer (NSCLC) has recently become widely accepted. Standard combinations are neoadjuvant chemotherapy followed by radiotherapy or concurrent chemotherapy and radiotherapy. The effect of combined modality treatment on survival is dependent on both the efficacy of chemotherapy to eradicate micrometastases and optimal local control. The European Organization for Research and Treatment of Cancer (EORTC) Lung Cancer Cooperative Group has chosen to investigate in a comparative way the side effects and the effect on survival of radiotherapy versus surgery in stage IIIA (N2) NSCLC.

A pilot study for identifying at risk thyroid lesions by means of a decision tree run on clinicocytological variables.

Fine-needle aspiration biopsy (FNAB) is safe, inexpensive, minimally invasive, and highly accurate in the diagnosis of nodular diseases of the thyroid. However, FNAB does not provide a reliable benign versus malignant diagnosis for 100% of the cases analysed. It is possible to increase the accuracy of the cytological diagnosis by means of information contributed by different clinical variables. In the present study we evaluate the diagnostic value of 10 variables in addition to FNAB on a series of 218 specimens for which we obtained histological diagnoses including 37 cancers (17%). The diagnostic information contributed by these variables was analyzed by means of the Decision Tree technique, an artificial intelligence-related method which forms part of the Supervised Learning algorithms. The results show that Decision Trees enable some subpopulations of patients with uncertain FNAB results to be characterized.

The influence of L-triiodothyronine, L-thyroxine, estradiol-17beta, the luteinizing-hormone-releasing hormone, the epidermal growth factor and gastrin on cell proliferation in organ cultures of 35 benign and 13 malignant human thyroid tumors.

PURPOSE: To characterize the influence of six factors on human thyroid tissues at the cell-proliferation level. These six factors were the epidermal growth factor (EGF), the luteinizing-hormone-releasing hormone (LHRH), triiodothyronine, thyroxine, estradiol and gastrin. METHODS: Forty-eight human thyroid specimens were obtained from surgical resection and maintained alive for 48 h ex vivo (in vitro) under organotypic culture conditions. These specimens comprised 35 benign cases (17 multinodular goiters and 18 adenomas) and 13 cancers. Cell proliferation in the control and treated conditions (at a 5 nM dose) was assessed by means of the thymidine labeling index, which enables the percentage of cells in the S phase of the cell cycle to be determined in accordance with autoradiographic procedures. RESULTS: The results show that, of the six factors tested here, EGF significantly (P < 0.05 to P < 0.001) increased cell proliferation in the greatest number of cancers as compared to what happened with the remaining five. Each of these six factors significantly increased or decreased proliferative cell activity in some 10%-30% of the cases under study. CONCLUSIONS: Triiodothyronine, thyroxine, LHRH and gastrin may increase or decrease cell proliferation in human thyroid tissues, whether benign or malignant, to the same extent as other hormones and/or growth factors such as thyrotropin, EGF, insulin-like growth factor 1, transforming growth factor beta1 and estradiol the effects of which on thyroid cell proliferation are already well documented in the literature.

[Limitations and perspectives of postoperative radiotherapy in bronchial cancer]. / Limites et perspectives de la radiothérapie postopératoire dans le cancer bronchique.

The role of postoperative irradiation for lung cancer remains a controversial issue. The available data suggest a reduction in local relapse in cases of positive mediastinal lymph node, but how this benefit translates into survival is not known. The current indications include tumors with positive mediastinal lymph node and incomplete resection with micro- or macroscopical residue. Nevertheless, postoperative irradiation requires a meticulous technique to avoid inducing life-threatening complications to vital organs such as the heart or the lung.

Ectopic Cushing's syndrome and pulmonary carcinoid tumour identified by [111In-DTPA-D-Phe1]octreotide.

The differential diagnosis and management of Cushing's syndrome remain difficult, particularly for ectopic adrenocorticotropin (ACTH) syndromes resulting from small bronchial carcinoids. We report the case of a 41-year-old man with ectopic ACTH-dependent Cushing's syndrome. Two computed tomography scans of the thorax were normal and magnetic resonance imaging of the chest showed a 6-mm hyperintense T1-weighted area close to the left pulmonary hilus, interpreted as probably vascular by the radiologists. An [111In-DTPA-D-Phe1]octreotide scintigraphy scan demonstrated a positive image for somatostatin receptors in exactly the same location and surgery confirmed the presence of a small ACTH-secreting carcinoid tumour in the upper left lung lobe which was resected. Surgery cured the hypercorticism of the patient. The differential diagnosis of Cushing's syndrome and the procedure for localisation of an ACTH source are discussed.

Respiratory mechanics and gas exchange during one-lung ventilation for thoracic surgery: the effects of end-inspiratory pause in stable COPD patients.

OBJECTIVE: To examine the effects of end-inspiratory pause (EIP) of different durations on pulmonary mechanics and gas exchange during one-lung ventilation (OLV) for thoracic surgery. DESIGN: A prospective clinical study. SETTING: A university hospital. PARTICIPANTS: Eleven patients undergoing elective pulmonary resection with pulmonary hyperinflation on their preoperative pulmonary function studies. INTERVENTIONS: Patients were anesthetized, paralyzed, and intubated with a double-lumen endotracheal tube. Their lungs were ventilated with a Siemens 900C ventilator (Siemens; Solna, Sweden), with constant inspiratory flow. Tidal volume, respiratory rate, and inspiratory time were kept constant during the study. MEASUREMENTS AND RESULTS: During one-lung ventilation in the lateral decubitus position, three levels of EIP (0%, 10%, and 30%) were applied to the dependent lung in random order. After 15 minutes on the given ventilatory pattern, end-inspiratory and end-expiratory occlusions of at least 5 seconds were performed to obtain respiratory mechanics data. Arterial blood gas samples were drawn to assess gas exchange. Altering the duration of end-inspiratory pause from 0% to 30% resulted in a significant increase in intrinsic positive end-expiratory pressure (PEEPi) from 4.1 cm H2O to 7.0 cm H2O. Arterial oxygenation was significantly decreased from 109.7 to 80.5 mmHg and there was a significant negative correlation between the value of partial pressure of arterial oxygen (PaO2) and PEEPi by altering the duration of end-inspiratory pause. From the preoperative pulmonary function studies, the value of functional residual capacity (FRC) (% predicted) showed a significant negative correlation with the PaO2 changes. Partial pressure of arterial carbon dioxide (PaCO2) was not altered significantly by increasing the duration of end-inspiratory pause. CONCLUSION: During the period of OLV in the lateral position of patients with preexisting pulmonary hyperinflation, the magnitude of PEEPi increased and oxygenation decreased significantly, whereas the efficacy of ventilation was not changed by the addition of an end-inspiratory pause to the ventilatory pattern. Because arterial oxygenation is affected by the presence of pulmonary hyperinflation, the method of ventilation should take into account the magnitude of preoperative pulmonary hyperinflation.