An epidermal growth factor receptor compound mutation of L858R with S768I in advanced non-small-cell lung cancer: a case report.

BACKGROUND: In the current treatment landscape for non-small cell lung cancers, epidermal growth factor receptor-tyrosine kinase inhibitors have emerged as a well-established treatment option for patients with advanced or metastatic disease. This is particularly true for those with commonly occurring epidermal growth factor receptor mutations. However, the therapeutic efficacy of these agents for so-called rare epidermal growth factor receptor mutations, and in particular those characterized by a high degree of complexity, such as double mutations, remains a subject of clinical uncertainty. CASE PRESENTATION: In this context, we present the case of a 64-year-old man of Moroccan descent, a lifelong non-smoker, diagnosed with metastatic non-small cell lung cancer characterized by a complex epidermal growth factor receptor mutation encompassing L858R and S768I. The patient subsequently underwent afatinib-based treatment, showing notable clinical results. These included a remarkable overall survival of 51 months, with a median progression-free survival of more than 39 months. CONCLUSIONS: This case report is a compelling testimony to the evolving therapeutic landscape of non-small cell lung cancers, providing valuable insight into the potential therapeutic efficacy of epidermal growth factor receptor-tyrosine kinase inhibitors in the realm of rare and complex epidermal growth factor receptor mutations.

How can I treat calcified chronic pleural empyema in African context: A case report.

INTRODUCTION AND IMPORTANCE: Despite the chance of a complete cure that surgery offers for patients seen early, the management of some complicated forms of chronic pyothorax with calcified pleural pockets of tuberculosis origin is risky, if not impossible. In these conditions, thoracomyoplasty with complete effacement of the pleural pocket is an effective alternative in the surgical management of these pockets. CASE PRESENTATION: We report the case of a 37-year-old male African Arab who was treated for a chronic, calcified pleural pocket of tuberculous origin and in whom low thoracomyoplasty was performed because of the impossibility of performing a left pleuropneumonectomy. The operating courses were uneventful with full pocket closures. REVIEW: 1 year later, the patient reported having resumed his active professional life. CLINICAL DISCUSSION: Pleural decortication associated or not with a pulmonary resection is the main surgical procedure used to manage chronic pyothorax. However, this procedure remains difficult with the risk of death, if not impossible, in cases of long-term chronicity with calcification of the pleural poche wall. In these cases, thoracomyoplasty constitutes a viable alternative in the surgical management of these pleural pockets. CONCLUSION: In the context of tuberculosis and chronic pleural empyema, thoracomyoplasty can be an alternative with satisfactory results when performed by an experienced team using this technique.

Heterogeneous distribution of EGFR mutation in NSCLC: Case report.

Background: We herein report the case of a patient with advanced lung adenocarcinoma who presented a heterogeneous distribution of EGFR mutation. Case report: A 74-year-old Moroccan male former smoker was diagnosed with advanced lung adenocarcinoma, harboring S768I exon 20 substitution mutation confirmed by Real Time PCR and Pyrosequencing, but not detected by direct sequencing despite 70% of tumor cells. The present report describes a case of minor histologic intratumoral heterogeneity with heterogeneous distribution of EGFR mutation. Conclusion: Both sensitivity and specificity of molecular methods can provide evidence of intratumoral heterogeneity, which may explain the mismatch between the validation of oncology biomarkers and predicting therapeutic response to targeted therapy.

Which Role for Muscle-Sparing Posterolateral Thoracotomy in the Treatment of Spontaneous Pneumothorax?

Objective This study aims to show the place of muscle-sparing posterolateral thoracotomy in the treatment of spontaneous pneumothorax. Methods It was a single-center study performed in the Department of Thoracic Surgery of Teaching hospital Hassan II of Fez for 8 years. We adopted the nosological definition, which classifies spontaneous pneumothorax into three categories. We included patients over 15 years of age with primary or secondary spontaneous pneumothorax operated by posterolateral thoracotomy without muscle section, and we analyzed the specific indications of this approach. It included 49 patients with primary or secondary spontaneous pneumothorax, operated by muscle-sparing posterolateral thoracotomy. Data were collected from regularly updated computer files of patients, entered by Excel 2013, and analyzed using SPSS.20 software. These data are: epidemiological, clinical, radiological, surgical exploration, surgical procedure, the result of the surgery and the evolution. Results The average age was 42 years. Smoking was found in 61% of cases and pulmonary tuberculosis in 10% of cases. Thoracic computed tomography (CT) showed bullae and blebs in 31% of cases, pleural adhesions and pachypleuritis in 50% of cases, and hydropneumothorax with pachypleuritis in 37% of cases. There is a statistical correlation between pleuropulmonary decortication and pachypleuritis ( p = 0.002) or hydropneumothorax ( p = 0.001) on CT. Bullae and blebs resection was performed in 53% of cases and pleuropulmonary decortication in 63% of cases. A right pleuropneumonectomy was performed in one case. The follow-up was uneventful in 82% of cases. Conclusion Muscle-sparing posterolateral thoracotomy remains the best approach and leads to good results.

Outcomes after Thymectomy in Patients with Thymomatous Myasthenia Gravis.

Objectives This article describes the clinical outcomes after thymectomy in patients with thymomatous myasthenia gravis (T-MG) managed in the department of thoracic surgery of Hassan II University Hospital of Fez, Fez, Morocco. Materials and Methods We performed a retrospective analysis of medical records of 16 patients with T-MG between January 2009 and January 2017. Results There were 11 women and 5 men with a median age of 40 years at the thymectomy time and a median time of onset of symptoms to thymectomy of 12 months. At the preoperative evaluation (Myasthenia Gravis Foundation of America [MGFA] clinical classification), 7 patients were class II, 7 class III, and 2 class IV. Nine patients were in Masaoka stage I, and the remaining 7 patients stage II. We recorded one case of postoperative myasthenic crisis. At 3 years of follow-up after thymectomy, 6 patients had complete stable remission and the other 10 patients improved. Of these patients with clinical improvement, 6 patients were in MGFA class I and the remaining 4 patients class II. Conclusion The present study shows the beneficial effect of thymectomy in patients with T-MG. Postoperative clinical outcomes seem to be better when the preoperative severity of myasthenic symptoms is mild (MGFA class II).

Correlation of Epidermal Growth Factor Receptor Mutation With Major Histologic Subtype of Lung Adenocarcinoma According to IASLC/ATS/ERS Classification.

OBJECTIVE: Our prospective study aims to define the correlation of EGFR(epidermal growth factor receptor) mutations with major histological subtypes of lung adenocarcinoma from resected and non-resected specimens, according to the WHO 2015 classification, in Moroccan North East Population. METHODS: Epidermal growth factor receptor mutations of 150 primary lung adenocarcinoma were performed using Real-Time PCR or SANGER sequencing. SPSS 21 was used to assess the relationship between histological subtypes of lung adenocarcinoma and EGFR mutation status. RESULTS: 25 mutations were detected in the series of 150 lung adenocarcinomas, most of which were found in cases with papillary, acinar, patterns than without these patterns and more frequently occurred in the cases without solid pattern than with this pattern. A significant correlation was observed between EGFR mutation and acinar (P = 0,024), papillary pattern (P = 0,003) and, negative association with a solid pattern (P < 0,001). In females, EGFR mutations were significantly correlated with the acinar pattern (P = 0,02), whereas in males with the papillary pattern (P = 0,01). Association between the histologic component and exon 19 deletions and exon 21 mutations were also evaluated and, we found a significant correlation between the papillary major pattern with exon 19 mutations (P = 0,004) and, ex21 with the acinar component (P = 0,03). CONCLUSION: An analysis of resected and non-resected lung ADC specimens in 150 Moroccan Northeast patients, revealed that acinar and papillary patterns may predict the presence of a mutation in the EGFR gene. While the solid major pattern may indicate a low mutation rate of the EGFR gene.

Cardiac hydatid cyst interposed between the right atrium and right ventricle on the tricuspid valve.

Hydatidosis disease is commonly localized in the lungs and liver and the radical treatment remains surgery. Cardiac hydatid cyst is a rare and particular location disease that can be associated with serious complications. The most common site in the heart according to the is the left ventricle. We describe a case of cardiac hydatid cyst localized between the right atrium and right ventricle on the tricuspid valve in a 15-year-old patient.

Unusual imaging findings of SARS-CoV-2 in HIV-positive patient : A case report.

Considering SARS-CoV-2 as a major differential diagnosis of pneumocystis in HIV-positive patients even if the lesions are typical.

Intratracheal migration of two Kirschner wires after surgery for a clavicle fracture.

Kirschner wire is frequently used in orthopedic surgery, and migration is not exceptional. Intrathoracic migration is well-known, especially after surgery on the shoulder girdle, however, intratracheal migration is extremely rare. We describe a case of intratracheal migration of two Kirschner wires in a 41-year-old man who had them placed two years previously for a right clavicle fracture. He experienced chest pain followed by hemoptysis. Thoracic computed tomography revealed intratracheal migration. Remove of the Kirschner wires was performed by a cervical-sternotomy approach. Prompt removal of migrated Kirschner wires must be carried out urgently to avoid fatal complications.

How thoracic surgeon manage tracheal tumors in African country? (Case series).

INTRODUCTION: Tracheal tumors are a rare pathological entity whose diagnosis is usually delayed by clinical latency. Surgery, which consists of a tracheal resection-anastomosis with or without reconstructive reconstruction, remains the treatment that ensures the best long-term survival. METHODS: This is a retrospective study about 8 patients admitted in the department of thoracic surgery of Hassan II's university hospital of Fes for tracheal tumors management during 7 years time (December 2010 to December 2017). RESULTS: There were 6 men and 2 women with an average age of 44.4 years ranged from 17 to 65 years, 4 were smokers. Dyspnea was the main trigger sign. Seven (7) have undergone bronchial fibroscopy diagnostic with a finding of budding process in 5 patients, the middle of the trachea is often concerned in 3 patients, obstructing the lumen of the trachea in almost all patients. The treatment in all patients was surgical with an intubation via the operative field, 4 trachea resection-anastomosis, 4 plasty (Lateral resection with V plasty, Kergin's plasty, Mattey's tracheobronchial anastomosis and widened V-resection to the carina). The most common histological type in our series was Adenoid Cystic Carcinoma in 2 of our patients. For the other patients we have found squamous cell carcinoma (1 case), adenocarcinoma (1 case), atypical carcinoid tumor (1 case), low grade mucoepidermoid carcinoma (1 case), an adenoma pleomorph (1 case) and endotracheal goiter (1 case). The operative follow-up was simple in 7 of our patients, all of whom underwent post-operative fibroscopy within an average of 9 days. Two cases of post-operative recurrent palsy had been observed, all of which had progressed well under treatment. We have noted 2 deaths, including one at day 4 post-operative, and the other died from complications of post-radiation tracheal stenosis. Back to 32 months' average follow-up, we have enregistered a case of a distant relapse by cervical lymph node metastasis in one patient, 5 years after surgery. CONCLUSION: Primary tumors of the trachea remain of reserved prognosis with 5-year survival of 57% of all histological types combined. Computed tomodensitometry and tracheobronchial fibroscopy remain the means of reference exploration in the diagnosis and assessment of surgical resectability.

The value of intraoperative parathyroid hormone assay in the surgery of mediastinal ectopic parathyroid adenoma (A case series).

BACKGROUND AND AIMS: Ectopic parathyroid adenoma is a rare entity. Its clinical management is challenging due to varying locations in the mediastinum. The aim of our study is to report our experience about the preoperative localization of the ectopic parathyroid adenoma and to emphasize the major role of the intraoperative parathyroid hormone assay in such circumstances. METHODS: It is a monocentric, retrospective study about patients diagnosed with EPA (ectopic parathyroid adenoma) from January 2015 to December 2016. Clinical aspects, preoperative management as well as the surgical procedures have been analyzed. RESULTS: There were 7 women, with an average age of 59.14 years. Six patients presented with biological disorders of the phosphocalcic metabolism such as spontaneous bone fracture and recurrent renal lithiasis. In one case, EPA was discovered in the setting of malignant hypercalcemia. The topographic preoperative assessment with a cervicothoracic CT (computed tomography) showed spontaneously hyperdense tissular masses of variable localizations in the mediastinum. A Tc-99 m (99mTc - MIBI) scintigraphy was performed in 5 patients and showed uptake in all cases. We performed cervicotomy in 1 case, manubriotomy in 2 patients, neck manubriotomy in 2 cases, total vertical sternotomy in 1 case, and posterolateral thoracotomy in 1 patient. The lesion was localized in the mediastinum in 1 patient in the perithymic fat in 1 case; EPA was laterotracheal in 1 case, retro tracheal in 1 case, intra-thymic in 2 cases, inter-jugulo-carotidian with contact with the left subclavial artery in 1 case, and anterior mediastinal in 1 patient. The 1-h after-parathormonemia following removal of the surgical specimens showed a decrease value of 45 and 80% of the baseline value. No surgical morbidity was noted after an average follow-up of 7.9 months (range of 5-18 months). CONCLUSION: The preoperative topographic diagnosis of ectopic parathyroid adenoma is challenging for the surgeon despite progress in the morphological assessment. The intraoperative parathyroid hormone assay is a valuable tool for an appropriate surgical management.

Pneumonectomy for non-tumoral diseases: etiologies and follow-up in 38 cases.

INTRODUCTION: Pneumonectomy is a surgical procedure associated with high rates of morbidity and mortality. Chronic inflammatory pathologies increase these rates, depending on the degree of pleural symphysis and the underlying pulmonary pathology. The occurrence of a bronchopleural fistula after pneumonectomy remains of great concern to the thoracic surgeon, because it leads to empyema in the pneumonectomy cavity, which requires protracted and difficult management. METHODS: A retrospective single-center study was carried out on 38 patients who underwent pneumonectomy for non-tumoral pathologies between 2010 and 2017. Of the 38 patients, 22 (57.8%) men and 16 (42.2%) women, the average age was 40.3 years, and 30 (79%) patients were treated for tuberculosis. RESULTS: The symptoms were predominantly hemoptysis with bronchorrhea in 22 (57.9%) cases. Chest computed tomography showed right-sided involvement in 15 (39.5%) patients, with destroyed lung in 31 (81.5%). Early postoperative complications included bleeding in 11 (28.9%) patients, postpneumonectomy empyema in 4 (10.5%), and death in 2 (5.2%). The average duration of follow-up was 2 years, without any recurrence. CONCLUSION: The endemicity of tuberculosis in our context, and the absence of screening for lung cancer, explain the frequency of pneumonectomy for chronic inflammatory diseases, and the rate of complications after this surgical procedure.

An Unusual Mass of Posterior Mediastinum: A Case of Retrotracheal Parathyroid Adenoma Presenting With Primary Hyperparathyroidism.

Although parathyroid ectopy in the mediastinum has been the subject of several publications, its location in the posterior mediastinum is very rarely reported. We report a case of a 69-year-old patient who presented with clinical symptoms of malignant hypercalcemia due to a retrotracheal mediastinal parathyroid adenoma. The surgical excision leads to a quick normalisation of the phosphocalcic balance with improvement of the clinical symptoms. Ectopic hypersecreting parathyroid adenoma with life-threatening hypercalcemia should prompt radiological assessment and appropriate surgical management to prevent further clinical complications.

Primitive necrotizing fasciitis of the thoracic wall: Fatal complication of diabetic patient.

INTRODUCTION: necrotizing fasciitis of the chest wall is a rare condition in subcutaneous tissues and deep fascia. Primary thoracic involvement is exceptional and is a diagnostic and therapeutic emergency. AIM: To report our experience in the management of this rare pathology of which clinical picture is unknown by most practitioners. METHODS: This is a retrospective study carried out over a period of 07 years, compiling 07 cases of primitive necrotizing fasciitis of the thoracic wall at the department of thoracic surgery at the CHU Hassan II in Fez. RESULTS: Patients were five men and two women, with an average age of 58 years. All our patients were known to have poorly balanced diabetes. The reason for consultation was a swelling of the chest wall with fever in all patients. On the results of thoracic computed tomography (CT), the presence of a deep collection of soft tissue was found   in all patients. The treatment was a large necrosectomy, taking away the skin as well as the adjacent muscle. Postoperative follow-up was favorable in five patients. We noted two deceased patients due to postoperaive septic shock. CONCLUSION: Necrotizing chest wall fasciitis is a medical and surgical emergency, requiring early diagnosis and rapid and appropriate management which will determine the prognosis.

Surgical management of hydatid Bilio-bronchial fistula by exclusive thoracotomy.

In the industrialized countries, most of Bilio-bronchial fistula are secondary to hepatobiliary trauma, hepatic resection surgery or in the case of congenital malformation of the biliary tract, Bilio-bronchial fistula is recognized as the complication of a number of infectious pathologies such as hydatidosis and hepatic amoebiasis. Among the causes, the Bilio-bronchial fistula of hydatic origin is by far the most frequent especially in the zones of hydatid endemic as Morocco. It is a serious complication of liver hydatid cysts. The surgical management has long been believed to be difficult, and often associated with a very pejorative prognosis due to the simultaneous attack of the thoracic and abdominal stage through the diaphragm. This tripartite involvement reflects the difficulty of choosing the first approach between the thoracic, abdominal or a combination of both approaches. However, progress, especially in the possibility of carrying out adequate preoperative preparation with the increasing introduction of retrograde endoscopic cholangiography with sphincterotomy, has made possible this exclusive thoracotomy surgery with acceptable outcomes.

Unusual mode of presentation of intrathoracic bronchogenic cyst: A double location.

A 63 year old woman presenting chronic back pain and neuralgia had abnormal shadow on chest radiograph. She has a history of pulmonary tuberculosis treated in 1977. The chest-CT scan showed a soft tissue mass in the lower lobe of the right lung and a cystic mass in the paravertebral region. The patient had right lower lobectomy and complete excision of a paraoesophageal cyst. Both masses were bronchogenic cysts at histology. The patient had an uneventful discharge the seventh postoperative day. After 4 years and 7 months of follow-up with CT-scann, the patient was free of symptoms with no evidence of recurrent disease.