[Use of pedicled dorsal muscle flap combined with negative pressure therapy in the management of postpneumonectomy septic complications]. / Utilisation du lambeau de muscle grand dorsal pédiculé combiné à la thérapie à pression négative dans la prise en charge des complications septiques post-pneumonectomie.

SUBJECT: The objective of this study is to report our experience in the management of septic complications arising from pulmonary resection surgery by placing a pedicled upper back muscle flap associated with dressings by therapy. Negative pressure in all patients supported in our center from November 2015 to March 2018. MATERIAL AND METHODS: Characteristics of fourteen patients with a pedicled dorsal muscle flap in the context of chronic empyema associated with bronchopulmonary fistula were identified. Flap placement time, complications, and success rate were assessed. RESULTS: The median flap placement after completion of the open window thoracostomy was 19days [3-65]. The median healing time was 3months. Healing was definitively achieved in 12 patients, a success rate of 86%. CONCLUSION: Through this series we have shown that our coverage by pneumonectomy cavity coverage with an early dorsal muscle flap associated with negative pressure therapy, has a similar mortality rate and success rate to those found in the literature.

[Prophylactic radiotherapy in a single fraction of 10Gy at intervention pleural site in patient with malignant pleural mesothelioma: A retrospective monocentric cohort study]. / Irradiation préventive en une séance de 10Gy des sites d'intervention pleurale des patients atteints de mésothéliome pleural malin : étude de cohorte rétrospective monocentrique.

PURPOSE: Prophylactic radiotherapy to prevent procedure-tracts metastases from malignant pleural mesothelioma remains controversial and clinical practice varies. The purpose was to assess the efficacy of local radiotherapy in a single fraction of 10Gy in preventing malignant seeding at intervention pleural site in patients with malignant pleural mesothelioma. MATERIAL AND METHODS: This is a retrospective cohort study, including patients with histological confirmed malignant pleural mesothelioma treated by prophylactic irradiation to prevent interventional site metastases with a unique fraction of 10Gy with 6 to 18MeV, from January 1990 to December 2013 in the institut de cancérologie de Lorraine (Nancy, France). RESULTS: Ninety-one patients were treated by irradiation in intervention site, involving 120 intervention pleural sites, 91 thoracoscopies, 17 thoracotomies with chest drain and 12 CT or ultrasound guided needle biopsies. The median follow-up was 7 months (interquartile between 3 and 15 months). The overall survival was 43.5% at 12 months. The local progression free survival was 43.7% at 12 month. The incidence of local recurrence was 8% at 12 months. The median interval from radiotherapy to local recurrence was 4 months (2; 32). No grade II or higher toxicity was observed. CONCLUSION: Irradiation of pleural intervention sites with a single fraction of 10Gy is effective, well tolerated, simple, fast and cost effective.

[Paraneoplastic hypoglycemia: The hopes of pathophysiological documentation]. / Hypoglycémie paranéoplasique : les espoirs d'une documentation physiopathologique.

Doege-Potter syndrome is a paraneoplastic syndrome characterized by non-islet cell tumor hypoglycemia secondary to a solitary fibrous tumor. These tumors are rare and usually asymptomatic. The syndrome of hypoglycemia is seen in less than 5% of the cases, and the associated tumors are large with a high mitotic rate. The cause of hypoglycemia is related to insulin-like growth factors produced by these tumors called "big" IGF-2. Several biological tests can demonstrate the increase of "big" IGF-2 plasma levels confirming the diagnosis of non-islet cell tumor induced hypoglycemia. The diagnosis is suggested by imaging but diagnostic confirmation is provided by the surgery, which remains the treatment of choice. Resection in many cases is the cure leading to hypoglycemia resolution. Recurrences and malignant transformations are possible which imposes a long-term monitoring. We report a case with relapsed malignant pleural fibrous tumor for which the pathophysiological mechanism of hypoglycemia could be documented as a paraneoplastic syndrome.

[Treatment of bilateral spontaneous pneumothorax during pazopanib therapy for pulmonary soft tissue sarcoma metastases. What to do when there is so few evidence?] / Traitement d'un pneumothorax spontané bilatéral au cours d'un traitement par pazopanib pour la prise en charge de métastases pulmonaires d'un sarcome. Quelle conduite à tenir ?

Soft tissue sarcomas are rare malignant tumors with a great variety of histological types and different response to multimodality treatment. Pazopanib has been recently introduced for the treatment of non-adipocytic metastatic soft tissue sarcomas which are resistant to conventional chemotherapy. Spontaneous pneumothorax is a rare but well recognized complication of this molecule and its treatment is quite challenging. The case reported herein describes the surgical management of a simultaneous bilateral spontaneous pneumothorax in a patient with pulmonary metastases treated with pazopanib. It underlines the fact that the main objective should be the maintenance of the treatment in patients who benefit from it. Close oncologic and surgical collaboration is crucial in order to deal with adverse effects due to the anti-angiogenic action of pazopanib.

[Staple line presenting as a suspicious pulmonary nodule]. / Une ligne d'agrafage imitant un nodule pulmonaire suspect.

The case reported herein concerns a 47-year-old female patient with a right apical pulmonary nodule, which was hypermetabolic on positron emission tomography scan. Eighteen years ago, she underwent a right axillary thoracotomy with apical blebectomy and pleurectomy for a recurrent primary spontaneous pneumothorax. Percutaneous transthoracic needle biopsy was unsuccessful. Surgical exploration revealed that the lesion was in fact the reinforcement material of the staple line that was used in the previous operation. Even though it is a rare presentation, previous use of surgical staples should alert the care team, especially when a new nodule is located near the ancient staple line, in order to avoid unnecessary invasive procedures.

[Intra-thoracic fracture-dislocation of the humeral head: a case report and review of the literature]. / Fracture-luxation intrathoracique de la tête humérale: à propos d'un cas et revue de la littérature.

A 50-year-old male traffic accident victim sustained high-energy trauma leading to intra-thoracic fracture-dislocation of the humeral head. Dislocation of the humeral head into the thoracic cavity is a very rare injury. Only twelve cases have been reported in the literature. Treatment modalities vary and no guidelines have been proposed. The mechanism of the injury and the treatment options are discussed together with a review of the literature.

Resection of adrenal metastases from non-small cell lung cancer: a multicenter study.

BACKGROUND: In recent case reports and limited series, adrenalectomy was recommended for an isolated adrenal metastasis from non-small cell lung cancer (NSCLC). METHODS: We retrospectively studied patients with a solitary adrenal metastasis from NSCLC who had undergone potentially curative resection in eight centers. RESULTS: Forty-three patients were included. Their adrenal gland metastasis was discovered synchronously with NSCLC in 32 patients, and metachronously in 11. It was homolateral to the NSCLC in 31 patients and contralateral in 12 (p < 0.01). Median survival was 11 months, and 3 patients survived more than 5 years. There was no difference between the synchronous and metachronous groups regarding recurrence rate or survival. Survival was not affected by the homolateral location of the metastasis, the histology of the NSCLC, TNM stage, any adjuvant and neoadjuvant treatment, or, in the metachronous group, a disease-free interval exceeding 6 months. CONCLUSIONS: We confirm the possibility of long-term survival after resection of isolated adrenal metastasis from NSCLC, but no clinical or pathologic criteria were detected to identify patients amenable to potential cure.

Retinoic acid receptor and retinoid X receptor alterations in lung cancer precursor lesions.

Smoking prevention will decrease lung cancer incidence in time. However, early detection would improve lung cancer prognosis in subjects at risk provided that specific markers could be identified. We previously reported that retinoic acid receptor (RAR) and retinoid X receptor (RXR) expression was altered in lung tumors. RAR-beta gene status could be derived from corresponding allelotyping and immunohistochemistry data. We now report the continued study on lung cancer precursor lesions. Fluorescence PCR-based assays were used for allelotyping at the RAR/RXR loci of: (a) 66 lung precursor lesions found at the free resection margins of 41 patients undergoing surgery for lung cancer (+ 31 paired tumors); and (b) bronchial cells also found at the free resection margins from 16 current and 8 never smokers operated on for noncancerous diseases. Three microsatellites located at 3p14-21 and 9p21 were also used for interwork comparison. Immunohistochemistry was additionally performed to evaluate P53 and RAR-beta expression in precursor lesions. Chi2 tests showed significant differences (P < 0.05) when comparing the results obtained from never smokers, smokers, squamous metaplasia, dysplasia + in situ carcinoma, and tumors. Microsatellite changes occurred frequently in all samples, but without specificity for any group (P < 0.08-0.52). They were globally correlated with tobacco exposure (P < 0.04), for which the RAR-gamma marker appeared as a preferential target (P < 0.004). Few reparation error phenotypes were observed, mostly at the RXR-alpha and RXR-gamma markers for which combined changes were also linearly increasing from never smokers to dysplasia + in situ carcinoma (P < 0.05 and P < 0.03). RAR-beta marker losses also increased from the first to the last group studied (P < 0.01), with a concomitant decrease in RAR-beta protein expression and correlated p53 increased immunoreactivity (P < 0.02). Losses at 3p14, 3p21, and P16 were frequent, but no significant differences between groups could be found. Unexpectedly, high constitutive homozygosity was observed near the RAR-alpha locus in squamous cell lung cancer cases. RARs/RXRs form homodimers or heterodimers involved in ligand binding. Their added alterations could result in a state of functional vitamin A deficiency in the affected bronchial cells. Further deletion events drawn from a limited repertoire of specific regions such as 3p14-21 and 9p21 could subsequently drive the deficient cells to invasive carcinoma.

Predictive survival markers in patients with surgically resected non-small cell lung carcinoma.

Among patients with resected non-small cell lung carcinoma, about 50% will present a tumor recurrence. Thus, it would be of major importance to be able to predict and try to prevent these relapses by an active chemotherapy and/or radiotherapy. In an attempt to answer this question, the tumors of 227 patients with a surgically resected non-small cell lung carcinoma were evaluated as follows: tumors were classified as squamous cell carcinoma (n = 132) or adenocarcinoma (n = 95), and tumor differentiation was evaluated for each type. Then, all tumors were classified in respect to their pathological TNM staging (WHO) and screened by immunohistochemistry for the detection of the expression of the following antigens: Bcl-2, A+B+H blood group antigens, c-erb-b2, p53, and Pan-Ras antigens. Furthermore, adenocarcinomas were screened for the presence of point mutations in Ki-Ras codons 1-31. Finally, the patient blood group was defined, and patient survival was analyzed using nonparametric tests and proportional hazard Cox models. Using Kaplan-Meier survival curves, disease pathological TNM staging was shown to be a strong predictive factor of survival for both squamous cell carcinoma and adenocarcinoma. Patients with squamous cell carcinoma experienced fewer relapses than those with adenocarcinoma (42% versus 63%; P = 0.0002) and had a significantly better survival. All evaluated antigens were more often present in squamous cell carcinoma than in adenocarcinoma except for Pan-Ras (three times more frequent in adenocarcinoma). In patients with squamous cell carcinoma, only tumor staging had a significant prognosis value (P = 0.01). In patients with lung adenocarcinoma, a well-differentiated tumor (P = 0.009) as well as a positive Bcl-2 staining (P = 0.009) and an A+B+H antigen tumor staining (P = 0.024) were associated with a better survival. In contrast, patients with a stage I or II disease and a p53-positive tumor staining and patients with the O blood group (P = 0.01) had a shorter survival. Interestingly, no relation with patient survival was related to c-erb-b2 and Pan-Ras staining. Finally, 12 point mutations were found out of 81 tumors (15%) evaluated for Ki-Ras codons 1-31; they involved codon 12 but also 8, 14, and 15 without any relationship to survival. In respect to lung adenocarcinoma, using Cox proportional hazard models stratified on tumor staging, the following markers were shown to be related to survival: (a) Independent markers of longer survival (ie., high histological degree of tumor differentiation and positive Bcl-2 and A+B+H blood group antigen expression by tumor cells); and (b) Independent markers of shorter survival (i.e., O blood group for all patients and p53 tumor staining in patients with stage I and II diseases). This study suggests that, in patients who undergo surgery for lung adenocarcinoma, the presence or absence of these criteria could be used to define a subset of patients who may benefit from a more specific follow-up.

[Lung transplantation: indications, techniques and results]. / La transplantation pulmonaire: indications, techniques et résultats.

Lung transplantation is proposed for young patients with a severe disease that can be expected to be fatal within less than two or three years. The main indications are chronic respiratory failure induced by chronic obstructive lung disease, cystic fibrosis or pulmonary fibrosis, and severe primary or secondary (Eisenmenger syndrome) pulmonary hypertension. The type of transplantation, determined after an exhaustive work-up ruling out all contraindications, is generally a single lung transplantation if there is no bronchial infection or two-lung transplantation or heart-lung transplantation in case of bronchiectasis or pulmonary artery hypertension. Survival at 1, 3 and 5 years is 72, 57 and 43% respectively. Transplantation improves exercise capacity, quality of life and lung function. It normalizes hematosis in case of chronic respiratory failure and pulmonary hemodynamics in case of pulmonary hypertension. The risk of complications, dominated by infections and rejections, requires careful clinical, functional and endoscopic follow-up. Bacterial infections are frequent during the first weeks. The frequency of opportunistic infections can be reduced by anti-infectious prophylaxis strategies. The rejection can occur as an acute episode, frequent during the first 100 days, or is sometimes asymptomatic. Chronic rejection or obliterating bronchiolitis is the main mid-term complication after lung transplantation and is responsible for the low long-term survival rate with recurrent secondary infections due to frequent bronchial colonization with Pseudomonas aeruginosa. Improved prognosis of lung transplantation requires the development of new immunosuppressive agents with lower risk of infection and chronic rejection observed with current treatments.

Expression of retinoid receptor genes and proteins in non-small-cell lung cancer.

BACKGROUND: Retinoids can suppress carcinogenesis in high-risk non-neoplastic bronchial lesions and can reduce the risk of second primary non-small-cell lung cancer (NSCLC). The effects of retinoids are mediated by nuclear receptors, i.e., the retinoic acid receptors (RARalpha, RARbeta, and RARgamma) and the retinoid X receptors (RXRalpha, RXRbeta, and RXRgamma). We investigated whether abnormalities in the in vivo expression of retinoid receptors are observed in NSCLC. METHODS: Expression of retinoid receptors in paired specimens of normal and cancerous tissues from the lungs of 76 patients with NSCLC was studied by use of antiretinoid receptor antibodies (except those against RXRgamma) and immunohistochemistry. RAR messenger RNAs were analyzed by use of in situ hybridization and by reverse transcription-polymerase chain reaction (RT-PCR). Samples were also studied for loss of heterozygosity (LOH) at chromosome 3p24. All P values are two-sided. RESULTS: All studied receptors were expressed in normal lung cells and in high- risk non-neoplastic lesions. In tumor cells, overexpression of RXRalpha and RARalpha was frequently observed. In contrast, RXRbeta expression decreased in 18% of the tumor specimens. Furthermore, there was a marked decrease in the expression of RARbeta in 63% of the tumors (P<.0001). Decreased expression of RARgamma was observed by RT-PCR in 41% of the tumors (P<.0001). LOH at 3p24 was observed in 41% of the tumor specimens from informative patients and in 20% of the non-neoplastic lesions. CONCLUSIONS: Expression of RARalpha and RXRalpha is either normal or elevated in NSCLC. In contrast, a large percentage of tumors show a marked decrease in the expression of RARbeta, RARgamma, and RXRbeta as well as a high frequency of LOH at 3p24, which was also observed in non-neoplastic lesions. These data suggest that altered retinoid receptor expression may play a role in lung carcinogenesis.

Effect of the H1 blocker d-chlorpheniramine on cerebral blood flow in the conscious dog during normocapnic hypoxia.

The mechanism causing cerebral vasodilatation during hypoxia remains unclear. A role for histamine is suspected because H2 receptor-blocking drugs blunt the hypoxia-induced increase in cerebral blood flow (CBF). Moreover, in vitro blockade of H1 receptors by chlorpheniramine decreases the vasodilatation of cerebral arteries that is induced by histamine. The present study tested the hypothesis that an H1 receptor blocker (d-chlorpheniramine) would have a similar effect in vivo during hypoxia. Isocapnic hypoxia (inspired oxygen fraction, FIO2 = 0.10; inspired carbon dioxide fraction, FICO2 = 0.035) was induced in 16 conscious dogs randomly divided into two groups: eight dogs received saline intravenously (controls) at time 0 (normoxia) and after 2 h and 4 h hypoxia, and the other eight dogs received d-chlorpheniramine intravenously (0.5 mg kg-1) to block the H1 receptors. Regional CBF was measured by the radioactive microspheres technique 15 min after each injection of d-chlorpheniramine or saline. In the control group, CBF increased during hypoxia in all regions of the brain. In the d-chlorpheniramine group, total CBF increased similarly after 2 h of hypoxia. After 4 h of hypoxia, the increase was limited, especially in the pons, cerebral peduncles, hippocampus, hypothalamus, thalamus, and occipital lobes (six out of 12 studied regions). It is concluded that the H1 blocker d-chlorpheniramine did not strongly inhibit the increase in CBF during hypoxia. After cumulative doses, however, as in the fourth hour of hypoxia, the increase in total CBF was limited.

Human immunodeficiency virus type 1 in an unusual cystic lymphoepithelial lesion of the lung.

AIMS: We present the clinical and histopathological findings of an unusual pulmonary cystic lymphoepithelial lesion in an HIV sero-positive patient. METHODS AND RESULTS: The 32-year-old female patient developed two nodules in the vicinity of the right and left hila. Left upper lobectomy showed a 40-mm wide cystic lesion. The cyst wall was lined by a squamous epithelium and lymphoid tissue with a marked follicular hyperplasia and a prominent follicular cell dendritic network expressing HIV major core protein p24. CONCLUSIONS: The absence of an Epstein-Barr virus infected lymphoid population and monoclonal immunoglobulin gene rearrangement supported the benign nature of the lesion.

[Exposed infra-inguinal bypass: conservative treatment or in situ replacement]. / Pontages sous-inguinaux exposés: traitement conservateur ou remplacement in situ.

Infection or exposure of a infra-inguinal bypass is a severe complication which can lead to death or amputation. With conservative treatments, the bypass is left in situ or replaced with an autologous vein or an allograft. Results in a series of 393 consecutive conservative treatments for infra-inguinal revascularizations were analyzed retrospectively. Sixteen patients were studied and divided into 2 groups: Group 1 included 8 patients who had no bleeding or signs of infection and who were treated locally. Group II included 8 patients with bleeding or signs of infection in whom the bypass was replaced by an in situ autologous vein (n = 4) or an arterial allograft (n = 4). Mortality was 12.5% and the rate of amputation was 12.5%. These percentages are in agreement with reports from other authors who also propose this therapeutic option. Local treatment should be reserved for infection free of complications due to thrombosis, hemorrhage or signs of a septic syndrome. Other cases should benefit from in situ replacement with a vein or an arterial allograft. In some unsuccessful cases there are a few indications for extra-anatomic prosthetic bypasses.

Effect of the inhibitor of nitric oxide synthase, NG-nitro-L-arginine methyl ester, on cerebral and myocardial blood flows during hypoxia in the awake dog.

The increase in cerebral blood flow (CBF) elicited by moderate hypoxia in anesthetized animals is little attenuated by nitric oxide (NO) synthase inhibitors. However, in previous studies, the effects of NO synthase inhibitors may have been altered by anesthetics. Consequently, we studied the effects of the NO synthase inhibitor, NG-nitro-L-arginine methyl ester (L-NAME), on cerebral and myocardial blood flows during hypoxia in the awake dog. Regional CBF and myocardial blood flows (MBF) were measured under normoxia and hypoxia in 16 beagle dogs after an intravenous (IV) injection of either saline (control, n = 8) or L-NAME 20 mg/kg (n = 8). One week after thoracotomy for catheter insertion, awake dogs were studied during three periods: normoxia and after 2 and 4 h of normocapanic hypoxia in an environmental chamber (FIO2 = 0.10, FICO2 = 0.035, balance N2). At each stage, a bolus injection of L-NAME or saline was followed 15 min later by left atrial injection of radiolabeled microspheres (141Ce, 103Ru, 46Sc) for regional CBF and MBF. After the dogs were killed, the brain and the heart were fixed in 10% formaldehyde, dissected by region and weighed, and radioactivity was measured in a gamma counter. During hypoxia, Pao2 was approximately 45 mm Hg with normal Paco2. In the control group, CBF increased by 45% after 2 h and 48% after 4 h of hypoxia; MBF increased by 69% and 60%, respectively. L-NAME prevented the CBF increase during hypoxia and the MBF increase after 2 h of hypoxia; after 4 h of hypoxia the measurement of MBF was confounded by cardiac dysfunction. These results suggest that NO plays a role in cerebral vasodilation during hypoxia in the awake animal.

[Popliteal vascular trauma: therapeutic management]. / Les traumatismes vasculaires poplités: attitude thérapeutique.

The functional severity of popliteal artery injury is intimately related to the direct consequences of tissue ischaemia increased by the associated traumatic attrition. The conservation of a functional limb requires: limitation of the duration and repercussions of ischaemia, by the use of a rigorous therapeutic protocol; "functional" surgical or even microsurgical reconstruction whose limits are still confused with the degree of traumatic myolysis and the potential of nervous recovery. Therefore, it seems obvious that the major difficulty lies in the definition of the limits for limb preservation.