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This study was designed as an external evaluation of the Steyerberg score in the prediction of different categories of postoperative mortality after esophagectomy on a large nationwide database of thoracic surgeons. Data collection was obtained from the Epithor national database encompassing the majority of thoracic procedures performed in France. We retrospectively compared the predicted to the observed postoperative 30-day (30DM), 90-day (90DM) and in-hospital mortality (IHM) rate in each decile of equal patient. Patients included in the study were operated for an esophageal cancer and Gastroesophageal junction (GEJ). Steyerberg score was determined according to its logarithmic formula obtained from a sum score including age, comorbidities, neoadjuvant treatment and hospital volume. Deviation of observed from theoretically expected number of deaths was investigated using the calibration test of Hosmer-Lemeshow. Discrimination of the score was determined using the measure of the area under the receiver operating characteristic curve (AUC) of each category of mortality. Over a 9-year period, 1039 consecutive patients underwent an esophagectomy over 42 centers. Among them, 18 centers were considered as intermediate or high-volume institutions, and 24 were low-volume institutions. There were 841 males (81%) with a mean age of 62.3 ± 10 years. Preoperative treatment was allocated to 420 patients (40%). Numbers of comorbidity was: 1 in 261 patients (25%), 2 in 264 patients (25%), 3 in 383 patients (36%) and 4 in 5 patients (1%). The 30DM, 90DM and IHM rate were, respectively, 5.6%, 9.2% and 9.6%. The main causes of postoperative deaths were related to pulmonary complications (44%), complications of the gastric interposition (28%), cardiologic and thromboembolism events (10%). For 30DM, there were significant differences between predicted/observed mortalities in four deciles, whereas there was no significant difference for 90DM and for IHM. In term of calibration, there was a fair agreement of the Steyerberg score with observed 30DM. Predictions were above 20% for seven deciles. Calibration seemed more adequate for 90DM and for IHM. Predictions were above 20% for only three deciles but deviations were not significant. In terms of discrimination, for the 30DM the Steyerberg score overpredicted, the observed mortality rate and AUC was 0.64 (CI 95%: 0.57-0.71). For the 90DM, AUC indicated 0.63 (CI 95%: 0.57-0.68). For the IHM, AUC indicated 0.63 (CI 95%: 0.58-0.68). Steyerberg scoring system seems to be a moderate risk score of the prediction of the IHM and 90DM. This score appears to have a fair discrimination for the 30DM. Nevertheless, because of its simplicity, we believe that this simple predictive score is relevant and transportable to others institution performing such surgery for benchmarking purposes. A reappraisal of the score adapted to current surgical cohort is required., (© 2015 International Society for Diseases of the Esophagus.)

Objective: To study endobronchial cancers occurring in a population at high risk of bronchial cancer (history of surgically treated bronchial or ENT cancer in complete remission, and symptoms due to smoking) detected by annual volume CT scans and biannual fibroscopy., Material and Methods: Two hundred and sixty-six patients were included in this single centre prospective study; 27 bronchopulmonary cancers were detected. Ten endobronchial cancers (37%) were identified by fibroscopy (nine invasive cancers and one carcinoma in situ) in 10 patients (nine men) (51-78 years old) nine of whom were smokers (dark tobacco: seven). The screening CTs were reappraised by two radiologists., Results: Three cancers out of 10 were detected by CT during the initial reading. The sensitivity of the reappraised CT was 80% with seven false positives. In five cases, the mean period between the first CT scan where the lesion was visible retrospectively, but not described, and the diagnostic fibroscopy was 463 days (213-808 days); two cancers were not visible in the CT scan. Seven curative treatments were undertaken., Conclusion: In this population, the sensitivity of the initial reading of the CT scan for detecting endobronchial tumours was 30%, while 80% of the tumours were visible retrospectively, underlining the importance of careful analysis of the proximal bronchial tree., (Copyright © 2012 Éditions françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved.)

Bronchopleural fistula (BPF) is a feared postoperative complication of pneumonectomy that carries significant morbidity and mortality. BPF can be treated by various surgical and medical techniques. Endobronchial techniques have been used for the delivery of biological glue, sealants, coils, and covered stents with variable degrees of success, depending on the size of the fistula. A recent case report described the endobronchial closure of a BPF through the implantation of an Amplatzer ASD device, commonly used for transcatheter closure of atrial septal defects. In this case report, we describe closure of a BFP using the Amplatzer PFO device., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

The incidence of adenocarcinoma is increasing, particularly among females. We sought to assess the role of tobacco consumption in clinical presentation according to sex. In this retrospective study, 848 patients diagnosed between 1997 and 2006 at Grenoble University Hospital (Grenoble, France) were stratified into four groups according to smoking habits. Differences between sexes and two contrasting female profiles emerged. Female current smokers were younger than female never-smokers (median 51 versus 69 yrs; p < 0.001), more often had surgery (62.7% versus 39%; p = 0.01) and had a median (95% CI) estimated survival of 26.2 (18.1-49.2) versus 15.1 (12.8-22.2) months (p = 0.002). Both groups had similar survival when taking treatment into account. Among males, smoking did not influence presentation. Male current smokers were older than female current smokers (median 59 yrs; p < 0.001) and fewer had surgery (48.8%; p = 0.015), although the percentage of stage IIIb-IV disease was similar (53% and 46%; nonsignificant) and they had a poorer estimated survival of 14.3 (13.0-18.5) months (p = 0.0024). Males smoked more than females (median 41 versus 30 pack-yrs; p < 0.001). Quitting smoking delayed age at diagnosis by 11 yrs for females (p = 0.0035) and 8 yrs for males (p < 0.001). Our results support the hypothesis that carcinogenesis differs between males and females, and between female smokers and never-smokers.

Background: Cervical necrotizing fasciitis (CNF) associated with descending necrotizing mediastinitis (DNM) is a rapidly evolving and life-threatening condition. The aim of this retrospective study was to describe a treatment strategy for CNF with DNM and present a management algorithm for mediastinal extensions of CNF., Methods: Patients diagnosed and treated for CNF with DNM over 14 years in a tertiary referral centre were included., Results: Seventeen adult patients were included. The origin of infection was mainly oropharyngeal. The diagnosis of CNF/DNM was based on clinical and computed tomography findings. All patients underwent cervicotomy for CNF. In ten patients, DNM was located above the carina and could be accessed by a cervical approach. In seven patients, DNM was below the carina, and necessitated sternotomy for anteroinferior mediastinal involvement and posterolateral thoracotomy for posteroinferior mediastinal involvement. All patients received broad-spectrum antibiotics. One patient died 3 days after surgery. The median hospital stay was 30 days. There was no recurrence during long-term follow-up., Conclusion: Prompt diagnosis and early surgical treatment are essential for reducing mortality in CNF/DNM. All patients should undergo extensive cervicotomy. The surgical approach to the mediastinum depends on the supracarinal or infracarinal location of the disease., (Copyright (c) 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Postoperative complications after pneumonectomy, lobectomy, or wedge resection are relatively frequent and potentially significant. Chest radiographs and CT have a crucial role in the early detection and prompt management of these complications. The purpose of this paper is to illustrate the most frequent or severe complications, based on the timing of occurrence. Early complications include bronchopleural fistula, empyema, atelectasis, pneumonia, hemothorax, chylothorax, pulmonary edema, lobar torsion, cardiac hernia, gossypiboma and esophagopleural fistula. Late complications include bronchopleural fistula, esophagopleural fistula, postpneumonectomy syndrome, chest wall arteriovenous fistula and local tumor recurrence.

Lung transplantation (LT) is a recognized procedure for selected patients with end-stage respiratory failure. We performed 123 LT, including 32 single lung, 84 double lung, and 7 heart-lung transplantations in 48 patients with chronic obstructive pulmonary disease (COPD), 13 patients with pulmonary hypertension (PH), 33 with cystic fibrosis (CF), and 29 with interstitial lung disease (ILD) between July 1990 and January 2008. Survival was compared for periods before and after December 2001. The mean age of patients was 44.4 years (range 16-66.5 years); 84 (69%) were men. Before LT, 1 second forced expiratory volume was 28.7% +/- 18.1% and PaCO(2) = 6.3 kPa. Fifty-five patients were on noninvasive ventilation. Cold ischemia time was 320 +/- 91 minutes. Cardiopulmonary bypass (CPB) was used in 77 patients (64%). There were 18 early surgical reinterventions, 8 extracorporeal membrane oxygenations, and 38 bronchial stent insertions among 206 at-risk bronchial sutures. Crude survivals were 69%, 58%, 41%, and 18% at 1, 2, 5, and 10 years, respectively. Comparing before (n = 70 with 15 CF) vs after December 2001 (n = 53 with 17 CF), survivals were 63% vs 78%, 51% vs 71%, and 33% vs 60% at 1, 2, and 5 years, respectively (P = .01) and for CF patients, 52% vs 100%, 52% vs 94%, and 25% vs 94% at 1, 2, and 5 years, respectively (P = .005). There was significant improvement in survival before and after 2001 in 123 LT and particularly among CF patients. Improvement in survival after LT may be related to the sum of numerous changes in our practice since December 2001, including the use of pulmonary rehabilitation pre-LT, extracellular pneumoplegia, statins, macrolides for chronic rejection, monitoring of Epstein-Barr blood load, changes in maintenance immunosuppressants, as well as position movement up the coordinator nurse and learning curve.

Pleuro-pulmonary solitary fibrous tumor (SFT) is a relatively uncommon mesenchymal neoplasm of uncertain histogenesis, unknown molecular features, and unpredictable clinical behavior. Although complete resection is universally accepted as the most important single prognostic factor, some clinicopathologic characteristics (gross appearance, tumor size, mitotic index, tumor necrosis, hypercellularity, and pleomorphism) are related to patient outcome, and a staging system based on these parameters with practical therapeutical implications has been recently proposed by de Perrot et al. Here, 88 pleuro-pulmonary SFTs were collected and clinicopathologic characteristics including de Perrot classification, patients' follow-up, p53 expression, and several "targetable" kinases [c-kit, v-raf murine sarcoma viral oncogene homolog B1, platelet-derived growth factor receptor (PDGFR)-alpha/beta, c-met, epidermal growth factor receptor (EGFR)] were retrospectively analyzed. Fifty-two cases (59%) had at least 1 clinicopathologic feature related to malignancy, whereas mortality and recurrences occurred in 10.2% and 18.2% of the cases, respectively. de Perrot staging and high p53 expression were significantly related to the conventional clinicopathologic prognostic features as well as to overall survival (OS) and disease-free survival (DFS) (P<0.001). At multivariate analysis, high p53 expression and tumor necrosis were the only parameters significantly associated with OS and DFS (P=0.017 and P=0.012, respectively). Immunohistochemical expression was frequently detected for PDGFR-alpha (97.7%), PDGFR-beta (86.5%), and hepatocyte growth factor receptor (96.6%), whereas missense mutations were only identified in 2 cases both involving PDGFR-beta (exons 18 and 20). We conclude that de Perrot stratification of SFT is a reliable prognostic indicator and merits consideration in view of its suggestions for the management of these tumors in daily practice. p53 expression may represent a valid and easy-to-test prognostic factor significantly related to OS and DFS. Although mutations of the corresponding genes are rare events in SFT, PDGFR-alpha/beta, and hepatocyte growth factor receptor tyrosine kinases should be further investigated given the availability of specific inhibitory molecules which might provide useful and novel therapeutical approaches for SFT patients.

Lung carcinoma with a basaloid pattern (BC) is classified as either a basaloid variant of squamous cell carcinoma (SCC) or as variant of large cell carcinoma (LCC) depending on the presence of a squamous component. In a previous study of 37 cases, the present authors showed that BC presented with a shorter median and overall survival. In order to confirm its clinical significance in a larger series, 90 BC, including 46 basaloid variants of LCC and 44 basaloid variants of SCC, were compared with 1,328 other nonsmall cell lung carcinoma (NSCLC) with regard to clinical features and survival. The survival of basaloid variants of LCC and SCC was comparable. Median and overall survival were significantly lower for BC than for NSCLC in stage I-II patients, with a median survival of 29 and 49 months, respectively, and 5-yr survival rates of 27 and 44% for BC and NSCLC. When disease-specific survival was considered, BC had a shorter survival than both NSCLC and SCC. Basaloid pattern confers a poor prognosis in nonsmall cell lung carcinoma, especially in stage I-II patients, suggesting that lung carcinoma with a basaloid pattern is not only a variant of squamous cell carcinoma or large cell carcinoma, but is a unique entity with a significantly poor prognosis.

Introduction: The entities of non-solid and part-solid pulmonary nodules on CT scan have been recently described., State of Art: Nonsolid and part-solid pulmonary nodules account for between 2.9 and 19% of all pulmonary nodules detected in high-risk patients included in CT screening series for lung cancer. Radio-pathological correlations have shown that the aetiology could be either benign (chronic pneumonia, atypical adenomatous hyperplasia, localized fibrosis) or malignant (broncholoalveolar cell carcinoma, adenocarcinoma, more rarely metastasis). Part-solid or non-solid nodules are more likely to be malignant than solid ones. The doubling time of non-solid nodules can be longer than part-solid ones and even longer than the doubling time of solid nodules. Patient prognosis is related to the proportion of the ground glass component., Perspective: The management of these nodules requires prolonged surveillance of nodules less than 10mm in diameter and surgical excision of nodules greater than 10mm persisting on scans between 1 to 3 months after they have been discovered and anti-inflammatory and anti-infectious therapy has been administered., Conclusions: Nonsolid and part-solid pulmonary nodules found on CT scan warrant a specific diagnostic workup.

The case reported herein consists of nodular pulmonary amyloidosis presenting with unusual cystic radiological features which reveal a pulmonary localisation of an extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma). The present case is the first to report a radiological presentation of nodular pulmonary amyloidosis in the absence of Sjögren's syndrome. Although transthoracic fine-needle biopsy was helpful for the diagnostic of amyloidosis, final diagnosis of associated MALT-type lymphoma required an open lung biopsy. This emphasises the importance of performing surgical investigations in pulmonary nodular amyloidosis in order to depict the presence of underlying lung tumours or lymphoproliferative disorders.

Primary tumors are relatively rare in the pleura. Histological types include mesothelioma, epitheliod, biphasic or sarcomatoid tumors as well as primary lymphoma and mesenchymatous tumors which include solitary fibrous tumor, epithelioid hemangioendothelioma and angiosarcoma and synovialosarcoma. We detail here the new WHO classification 2004 explaining the different entities, excluding metastatic tumors which are the most frequent tumors of the pleura.

Five percent of pleural tumors are benign. Solitary fibrous tumors are the most frequent. We recall the clinical and pathological features and present the radiographic, computed tomographic and magenetic resonance imaging results obtained for the main types of benign tumors of the pleura.

Patients with nonsmall cell lung cancer (NSCLC) have been shown to have a higher prevalence of comorbidity associated with age and tobacco consumption. The objective of the present study was to determine the impact of comorbidity on survival after surgery of stage I NSCLC. In total, 588 consecutive patients operated on for a pathological stage I NSCLC between January 1, 1979 and December 31, 2003 were studied. Comorbidities were analysed individually. Overall comorbidity was assessed using the Charlson index of comorbidity (CCI). Survival data were collected for each patient from the date of operation, with a median duration of follow-up of 104 months. Survival analyses and Cox proportional hazards model analyses were used. The mean age of patients was 62.7 yrs, and 529 (89%) patients were male. The distribution of overall comorbidity severity was as follows. CCI grade 0: 47.1%; grade 1-2: 43.7%; grade 3-4: 8.3%; and grade > or =5: 0.8%. The 2, 3 and 5 yrs survival were 69, 62 and 50%, respectively. Multivariable analysis showed that T stage, age, a concomitant history of moderate-to-severe liver disease, a past history of cured cancer, cerebrovascular disease and CCI were independent predictors of survival (Hazard Ratio for CCI grade >2: 1.81; 95% confidence interval 1.25-2.63). In conclusion, comorbidity has a significant impact on survival after surgical resection of patients with stage I nonsmall cell lung cancer. The use of a validated index of comorbidity in prognostic analyses of resected nonsmall cell lung cancer is recommended.

Purpose: To describe the imaging features of bronchial carcinoids and to define the role of CT as a diagnostic and pretherapeutic tool., Materials and Methods: We performed a retrospective study including 54 carcinoids. We evaluated and compared the clinical, radiographic, CT, fiberoptic, and pathologic data., Results: At presentation, the mean age was 48.5 years (14-81) and patients mainly complained of signs related to bronchial obstruction (55.7%). 72% of bronchial carcinoids were located in the proximal airway. CT showed calcifications in 26% of 54 cases and contrast enhancement in 60%. Typical carcinoids differed from atypical carcinoids in their size and lymph node extension. As compared to fiberoptic bronchoscopy, CT identified proximal carcinoids with exo-bronchial extension (7.4%), peripheral tumors (20.4%), and parenchymal complications. The sensitivity and predictive positive-value of CT for lymph node extension was 28% and 20%, respectively., Conclusion: CT is a useful technique for diagnosing and localizing bronchial carcinoids. The results of CT in determining lymph node extension is disappointing, and should raise caution in case of localized treatment using fiberoptic bronchoscopy.

Pulmonary adenocarcinoma of the lung and its variants are well-defined entities, since the recent WHO classification of lung tumours. However, scant descriptions have been allocated to associated stromal changes, such as prominent inflammation and fibrosis, which can overshadow a tumoral proliferation and masquerade as a benign reactive process and this has not been recognised as a histopathological variant. The case of a 72-yr-old farmer who presented a multifocal well-differentiated adenocarcinoma that mimicked honeycomb lung with bronchiolectasis radiologically, on computed tomography scan and histologically at open lung biopsy, is reported. Histological pitfalls in the biopsy were represented by mild atypical cuboidal or columnar epithelial cells lining bronchiolar structures resembling florid bronchiolar metaplasia in a background of extensive fibrosis and inflammation, features that mimicked inflammatory honeycombing. However, histological analysis of the surgical resection of the main lesion, performed because of a clinical alteration of the patient, confirmed the diagnosis of multifocal adenocarcinoma of mixed subtype. A monomorphic proliferation of clear cells, lack of associated ciliated or squamous cells and presence of significant cytologic atypia gave a diagnosis of malignancy. This case illustrates how inflammatory and fibrotic changes may conceal a correct diagnosis of carcinoma and emphasises the importance of adequate sampling in such cases.

In a previous anatomical study of the oblique sinus of pericardium, we reported on the morphological variations of this recess. We noted a previously undescribed variation of its top in 32.7% of our cases. Here we detail this variation using microscopic and macroscopic mediastinal dissections of 107 adult fresh cadavers. It seems a top fold of the oblique sinus contains a permeable esophago-atrial vein or a fibrous cord. These unique variations of the oblique sinus modify the classical anatomical and embryological descriptions. Abnormal esophago-atrial veins have not been described previously but they are predictable according to embryological knowledge. From a clinical point of view, such a vein, permeable or not, may facilitate extension of esophageal carcinoma to the pericardium and may represent a porto-systemic bypass in cases of portal hypertension.

Human telomerase reverse transcriptase is a ribonucleoprotein that synthesises telomeric sequences, which decrease at each cell division. In cancer cells, its activity is linked to telomere maintenance leading to unlimited cellular proliferation and immortality. To evaluate the prognostic value of the catalytic subunit telomerase reverse transcriptase (hTERT), we analysed its expression by immunohistochemistry in 122 formalin-fixed lung tumours including 42 squamous cell carcinoma (SCC), 43 adenocarcinoma (ADC), 19 basaloid carcinoma (BC) and 18 small-cell lung carcinoma (SCLC) in comparison with detection of hTERT mRNA by in situ hybridisation and relative telomerase activity by TRAP assay in a subset of tumours. We observed a high concordance between hTERT protein expression and detection of hTERT mRNA and telomerase activity. Telomerase expression varied according to histology (P=0.0002) being significantly lower in ADC than in SCC, BC and SCLC (P<0.0001). Adenocarcinoma and SCC exhibited either a nuclear or a nucleolar staining in contrast with a diffuse nuclear staining observed in most BC and all SCLC (P=0.01). In stage I NSCLC telomerase expression was lower than in other stages (P=0.04), and a nucleolar staining was correlated with a short survival (P=0.03). We concluded that telomerase expression and pattern are distinctive among histopathological classes of lung cancer and convey prognostic influence.

Authors report on a case of one intramuscular metastasis from a non-medullary differentiated thyroid carcinoma. Muscular metastasis are rare in this pathology. Moreover, body-scanning scintigraphic interpretation is difficult for the pelvic area. False-positive are numerous and a very precise topographical diagnosis is required to choose the best surgical approach. Authors propose a specific management of different imaging methods for such a metastatic site. They associate a CT scan and a multiplanar iodine and technetium scintigraphy.

Aims: Monoclonal antibody 34betaE12 (Ck34betaE12) recognizes a set of cytokeratins (1, 5, 10, 14) expressed in normal stratified squamous epithelium. We have recently reported its expression in squamous cell carcinoma and basaloid carcinoma, in contrast to large cell neuroendocrine carcinoma, an entity with overlapping morphological features with basaloid carcinoma. We have now examined the role of Ck34betaE12 in discriminating between neuroendocrine and non-neuroendocrine proliferations., Methods and Results: We performed an immunohistochemical study of 228 cases, comprising the whole spectrum of lung neuroendocrine proliferations and tumours. All cases of neuroendocrine cell hyperplasia (n = 15), tumorlet (n = 23), typical carcinoid (n = 27) and atypical carcinoid (n = 23) were completely negative for Ck34betaE12. Although the neuroendocrine cells of small cell lung carcinoma and large cell neuroendocrine carcinoma were consistently negative, a strong and diffuse positive staining was found in the non-neuroendocrine components of combined small cell carcinoma (three of eight cases) and combined large cell neuroendocrine carcinoma (11 of 12 cases). In addition, scattered Ck34betaE12+ cells were noted in 11 of 64 (17%) large cell neuroendocrine carcinoma and in seven of 56 (12.5%) small cell carcinoma, which were not obviously histologically combined. This heterogeneity of high-grade neuroendocrine tumours was not observed in carcinoids which lack Ck34betaE12 clusters of reactive cells. There was mutual exclusion between expression of neuroendocrine markers and that of Ck34betaE12., Conclusion: We conclude that 34betaE12 expression excludes the neuroendocrine nature of tumour cells and uncovers the real frequency of combined forms in high-grade neuroendocrine tumours.

Early detection of lung cancer requires none or few invasive techniques. Distal lung cancer (40% of the cases in most European countries) can be sensitively detected by spiral computed tomography. Theoretically, in 60% of cases, the proximal lesions (main to segmental bronchi, accessible by bronchoscopy) should be able to be detected by sputum cytology. Unfortunately, this very specific technique has a low sensitivity and is time consuming. Fluorescent bronchoscopy increases the detection rate of early or micro-invasive lesions and may be proposed in highly selected populations, but not as a screening test. Biomarkers in blood and sputum have not yet been clinically validated. However, the amount of data generated from studies first on resected tumours, then on early bronchial lesions and more recently on blood and sputum offer a wide field for investigation. Lung carcinogenesis is a multistep process characterised by the accumulation of successive molecular genetic and epigenetic abnormalities, resulting in selection of clonal cells with uncontrolled growth capacities throughout the whole respiratory tract (field cancerisation). Molecular lesions far precede morphological transformation of preneoplastic bronchial lesions (dysplasia) or alveolar lesions (atypical alveolar hyperplasia). Genetic and epigenetic abnormalities in the genes involved in cell cycle, senescence, apoptosis, repair, differentiation and cell migration control may be detected on bronchial biopsies, on respiratory cells from the sputum and even in the circulating deoxyribonucleic acid (DNA). The key genes involved include those in the P53-retinoblastoma (Rb) pathways. The balance between cyclin-dependent kinases and their inhibitors regulates the level of Rb phosphorylation and its function at G1-S transition; P53 plays at least two functions (cell cycle and apoptosis control). The balance of bax-bcl2 is important in the control of apoptosis as well as loss of fragile histidine triad expression. O(6)-methylguanine-DNA methyltransferase seems to be important in DNA repair control, the RARbeta receptor in differentiation, and cadherin H and E and different metalloproteases genes in cell migration. The demonstration of hyperexpression or silencing of these genes needs different validated techniques: immunohistochemistry on biopsies or cytological preparations, molecular biology techniques for mutations, loss of heterozygosity and aberrant methylation abnormalities. Automation and miniaturisation of these techniques will allow early detection and may be widely applied once clinically validated.

Basaloid carcinoma (BC) and large-cell neuroendocrine carcinoma (LCNEC) are 2 recently recognized variants of large-cell lung carcinomas that may overlap in their morphology, and are discriminated by expression of neuroendocrine markers in LCNEC. Because thyroid transcription factor 1 (TTF-1) is expressed in lung adenocarcinomas but not in squamous cell carcinomas (SCC), and 34betaE12 recognizes a set of high-molecular-weight cytokeratins characteristic of basal stem cells, we hypothesized that these 2 markers could help in distinguishing BC from LCNEC. Immunostaining for TTF-1 was detected in 40.9% of pure LCNEC but in no BC or basaloid variant of SCC. In contrast, immunoreactivity for 34betaE12 was shown in all BC and basaloid variant of SCC but in only 1 LCNEC. Bouin fixation was less efficient than formalin in the immunodetection of both markers for its well-known deleterious effect on antigen preservation. Specificity of TTF-1 for LCNEC (100%) and that of 34betaE12 for BC (98.3%) exceeded that of NE markers for distinction of these 2 entities. These data show that TTF-1 and 34betaE12, in association with specific neuroendocrine markers, represent a useful panel of antibodies in differentiating carcinomas presenting with a solid pattern, palisading, or pseudorosettes, the expression of TTF-1 excluding the diagnosis of BC, and staining with 34betaE12 excluding pure LCNEC., (Copyright 2001 by W.B. Saunders Company)

Gorham's disease is a rare disorder characterized by a proliferation of thin-walled lymphatic vessels (lymphangiectasia) resulting in an osteolysis. A chylothorax is present in about one-fifth of the patients and carries a poor prognosis. In this circumstance, surgery including thoracic duct ligation, pleurodesis, and excision of involved tissue is probably the treatment of choice. It is facilitated by a precise radiological assessment using a computed tomographic scanning coupled with a lymphography. We report such a case.

Study Aim: Burkitt's lymphomas are rarely revealed by acute intestinal intussusception in children. The study aim was to report eight cases., Patients and Methods: Between 1988 and 1999, eight children, seven boys and one girl (mean age: 6 years) were hospitalized for an acute abdominal syndrome. Abdominal ultrasonography showed intestinal intussusception (n = 8) primitive tumor (n = 2), mesentivic lymph nodes (n = 2) and liver nodes (n = 1). Enema (n = 6) confirmed presence and irreductibility of the intestinal intussusception. A laparotomy was performed on emergency in seven patients and found the primitive tumor in 6. The procedure consisted in disinvagination (n = 4) and intestinal resection for ischaemia (n = 2). One patient was not operated on and the diagnosis was performed through ultrasonography guided tumoral puncture., Results: According to the Murphy classification, there were 2 stage II, 3 stage III and 3 stage IV patients. With LMB protocol chemotherapy, a complete remission was observed following the first cure. All the children were alive at the time of this study with a follow-up longer than one year after the complete remission., Conclusion: Abdominal sonography is the most efficient examination for the diagnosis of intestinal intussusception and sometimes of the primitive lesion. In the absence of sonographic intestinal impair, thanks to ultrasonography guided tumoral puncture, diagnosis may be made and chemotherapy started. If the lymphoma is not visualized with ultrasonography, an emergency laparotomy is necessary for the diagnosis of the lymphoma and the intestinal resection in case of necessity. Burkitt's lymphoma is very sensible to chemotherapy.

Background: Although it induces a relevant reduction in the risk of both visceral metastases and locoregional recurrences, the combination of chemotherapy and surgery only marginally improves the survival of patients with Stage IIIA(N2) (International Union Against Cancer staging and classification system) nonsmall-cell lung carcinoma (NSCLC). The purpose of the current study was to analyze the patterns of relapse in these patients., Methods: In this study, the authors compared the patterns of relapse in 81 patients with clinically detectable N2 NSCLC who had been treated with preoperative chemotherapy with the relapse patterns of 186 comparable patients who had been treated with primary surgery. Clinically detectable N2 (cN2) denotes mediastinal lymph node enlargement on computed tomography scan, which then is confirmed by mediastinoscopy., Results: Overall 20% of patients developed a locoregional recurrence. Chemotherapy decreased the risk of visceral metastasis as 28% of the patients preoperatively treated and 38%of those not treated with preoperative chemotherapy presented a visceral metastasis (P < 0.05). Preoperative chemotherapy and adenocarcinoma subtypes were associated with a higher rate of brain metastasis (P < 0.05). Thirty-two percent of the patients treated preoperatively and 18% of those not treated with preoperative chemotherapy presented a brain metastasis (P < 0.05), which was isolated in 22% and 11% of the patients, respectively (P < 0.05)., Conclusion: The current study found that preoperative chemotherapy for cN2 decreases the risk of visceral metastasis but is associated with a high rate of isolated brain metastases. Prophylactic cranial irradiation may need to be reinvestigated in clinical trials, especially in patients who present with an adenocarcinoma., (Copyright 2001 American Cancer Society.)

The aim of this study was to report two cases of symptomatic and non-functional parathyroid cyst, diagnosed with ultrasonography and percutaneous punction and treated by surgical resection of the cystic gland.

Objectives: Published series on the synchronous combined resection of brain metastases and primary non-small cell lung cancer are small and scarce. We therefore undertook a multicenter retrospective study to determine long-term survival and identify potential prognostic factors., Design: Our series includes 103 patients who were operated on between 1985 and 1998 for the following tumors: adenocarcinomas (74); squamous cell carcinomas (20); and large cell carcinomas (9). Three patients had two brain metastases, and one patient had three metastases; the remaining patients had a single metastasis. Ninety-three patients presented with neurologic signs that regressed completely after resection in 60 patients and partially, in 26 patients. Neurosurgical resection was incomplete in six patients. Seventy-five patients received postoperative brain radiotherapy. The time interval between the brain operation and the lung resection was < 4 months. Pulmonary resection was incomplete in eight patients., Results: The survival calculated from the date of the first operation was 56% at 1 year, 28% at 2 years, and 11% at 5 years. Univariate analysis showed a better prognosis for adenocarcinomas (p = 0.019) and a trend toward a better prognosis for patients with small pulmonary tumors (T1 vs T3, p = 0.068), N0 stage disease (N0 vs N+, p = 0.069), and complete pulmonary resection (p = 0.057). In a multivariate analysis, adenocarcinoma histology also affected the survival rate (p = 0.03)., Conclusions: It seems legitimate to proceed with lung resection after complete resection of a single brain metastasis, at least in patients with an adenocarcinoma and a small lung tumor and without abnormal mediastinal lymph nodes seen on the CT scan or during mediastinoscopy.

Nutritional status was studied in lung transplant (LT) candidates. The hypotheses were that nutritional depletion was highly prevalent and lean body mass depletion was a risk factor for a higher mortality both before and after LT. Of 78 consecutive patients listed for LT, 16 (21%) died while on the waiting list, eight (10%) were alive awaiting LT, and 54 (69%) received a graft. Mean age was 42.3+/-4.4 (mean+/-SD). Thirty-eight per cent had a diagnosis of bronchiectasis or cystic fibrosis (BRO/CF), 33% of emphysema, 20% of idiopathic pulmonary fibrosis (IPF) and 8% of primary pulmonary hypertension. Body mass index (BMI) was 20.4+/-4.3 kg.m2, weight was 87.9+/-16.6% of ideal body weight (IBW). Patients were classed into four nutritional groups according to IBW and creatinine height index (CHI): 1: weight <90% IBW and CHI <60% of predicted (28% of cases); II: weight <90% IBW and CHI > or =60% (27%); III: weight > or =90% IBW and CHI <60% (17%); IV: weight > or =90% IBW and CHI > or =60% (28%). Overall, 72% were depleted corresponding to groups 1, II and III. Lean body mass depletion occurred despite normal weight in 17% of the cases (group III). Subjects with BRO/CF were mostly in groups 1, II, III whereas IPF were concentrated in group II. Lean body mass depletion was associated with more severe hypoxaemia, reduced 6-minute walking distance and a higher mortality while awaiting. After LT, duration of mechanical ventilation, time spent in intensive care unit (ICU) was related to initial body composition. Survival after LT was lowest in group III. To conclude, nutritional depletion in lung transplant candidates is highly prevalent and should be more precisely assessed with a special reference to lean body mass since it has specific consequences both while awaiting and after lung transplant. Attempts should be made to increase lean body mass before lung transplant.

Purpose: Patients who suffer from non-small-cell lung cancer (NSCLC) with ipsilateral mediastinal lymph node involvement (N2) belong to a heterogeneous subgroup of patients. We analyzed the prognosis of patients with resected N2 NSCLC to propose homogeneous patient subgroups., Patients and Methods: The present study comprised 702 consecutive patients from six French centers who underwent surgical resection of N2 NSCLC. Initially, two groups of patients were defined: patients with clinical N2 (cN2) and those with minimal N2 (mN2) disease were patients in whom N2 disease was and was not detected preoperatively at computed tomographic scan, respectively., Results: The median duration of follow-up was 52 months (range, 18 to 120 months). A multivariate analysis using Cox regression identified four negative prognostic factors, namely, cN2 status (P <. 0001), involvement of multiple lymph node levels (L2+; P <.0001), pT3 to T4 stage (P <.0001), and no preoperative chemotherapy (P <. 01). For patients treated with primary surgery, 5-year survival rates were as follows: mN2, one level involved (mN2L1, n = 244): 34%; mN2, multiple level involvement (mN2L2+, n = 78): 11%; cN2L1 (n = 118): 8%; and cN2L2+ (n = 122): 3%. When only patients with mN2L1 disease were considered, the site of lymph node involvement according to the American Thoracic Society numbering system had no prognostic significance (P =.14). Preoperative chemotherapy was associated with a better prognosis for those with cN2 (P <.0001). Five-year survival rates were 18% and 5% for cN2 patients treated with and without preoperative chemotherapy, respectively., Conclusion: This study has identified homogeneous N2 NSCLC prognostic subgroups and suggests different therapeutic approaches according to the subgroup profile.

The thymic cysts are benign tumours of the thymo-pharyngeal canal, usually located in the cervico-mediastinal region. The authors report the case of a large thymic cyst with an ectopic right paracardiac location compressing the right heart chambers. It was a chance finding on chest X-ray of an asymptomatic 21 year old man. Though suggestive of a pericardial cyst in view of its position, curative surgical ablation allowed confirmation of the diagnosis at anatomo-pathological examination.

We report a case of mediastinal liposarcoma resected by thoracoscopy. Despite the precautionary measures, chest wall implantations occurred rapidly at the port's sites in the chest wall and led to death within 24 months. We conclude that thoracoscopy is not a good approach for resection of anterior mediastinal masses in view of their possible malignant character.

Objective: To propose a simple and minimally invasive approach for parathyroid surgery., Summary Background Data: Minimally invasive approaches to the parathyroid glands may involve preoperative morphologic explorations, perioperative biologic controls, or videocervicoscopy, a new method., Methods: The authors describe 597 patients who underwent parathyroidectomy through an original bilateral oblique approach between 1976 and 1997. None underwent morphologic exploration or biologic perioperative monitoring. In primary hyperparathyroidism, the four glands are controlled and it is possible to check their abnormalities of location or number. In secondary hyperparathyroidism and multiple endocrine neoplasia (MEN), a total or subtotal parathyroidectomy is performed., Results: The results and vocal morbidity are the same as that from authors using transverse cervicotomy, but this approach is more comfortable for the patient and allows total exploration of the location through short incisions without bleeding, visceral contusions, or muscle lesion., Conclusions: This cervicotomy is easy and secure even if the surgeon is not trained in this approach because it uses and respects the anatomy of the cervical fasciae. It can be used without preoperative localization, intraoperative monitoring, or specialized material. But this approach could be also proposed for unilateral exploration guided by these methods and for surgical treatment of recurrent hyperparathyroidism after a transverse cervicotomy.

A 42-year-old patient with emphysema was hospitalized in the intensive care unit for an episode of acute respiratory failure. The patient became dependent on invasive mechanical ventilation and surgical lung volume reduction was performed. The indication of lung volume reduction in this pathological situation but was followed by rapid weaning 48 hours postoperatively. The patient was discharged without ventilatory assistance and has not required further ventilatory assistance after more than 2 years follow-up.

Background: Basaloid cancer of the esophagus is exceptional. The tumor probably develops from epithelial basal cells. This histological type is generally observed in ENT or bronchial localizations., Case Report: A 62-year-old man underwent total pharyngo-laryngo-esophagectomy for a double tumor localization of a basaloid carcinoma of the esophagus and a hypophyayngeal squamous cell carcinoma., Discussion: Basaloid carcinoma has specific histological features difficult to recognize at the pathology examination. Because of the high risk of metastasis, it may be important to propose radiotherapy and/or chemotherapy after surgical excision.

Background: In 9 out of 10 cases, lymphangiomas are observed during the first years of life, generally located in the neck. Rare lymphangiomas have been reported in adults, usually in an intrathoracic localization, raising the hypothesis of an acquired origin., Patients and Methods: A retrospective analysis of patients undergoing surgery for lymphanioma of the neck or mediastinum was conducted. Pathology reports, clinical data and medical imaging (CT) were reviewed and operative and post-operative findings were analyzed in order to determine whether the cases could be divided into congenital and non-congenital forms., Results: Data were obtained on 37 patients (23 men and 14 women, mean age 45 years, range 8-77). Four lesions (11%) were located in the neck: 3 in children and one in an elderly subject (77 yrs). Thirty-three tumors (89%) were located in the mediastinum. In 5 cases, the tumor was located in the phrenic nodes of the anterior mediastinum. These lymphangiomas occurred in young adults, had a CT density less than liquid with enhancement after contrast injection, and had a malformative vascular component proven anatomically and histologically (hemolymphangioma). These elements favored a congenital orgin. In 28 cases (76.6%) the tumor involved nodes in the posterior or middle mediastinum. They occurred in older adults and were purely liquid with no vascular component. These lymphangiomas were undoubtedly acquired., Conclusion: In children, adolescents and young adults, lymphagiomas are found in the neck or anterior mediastinum and have a tissular component. These tumors should be considered as congenital lymphangiomas. In older adults, lymphangiomas are found in the posterior or middle mediastinum and are purely liquid cysts suggesting an acquired origin.

Alloreactivity is caused by T cell recognition of foreign histocompatibility antigens according to two models: (i) indirect recognition, in which processed allogeneic antigens are presented by self-major histocompatibility complexes like any other foreign antigen, and (ii) direct recognition, where the foreign MHC itself is recognized breaking the T cell recognition rule of self-restriction. This paper uses these two cases of alloantigen presentation as illustrative examples to investigate (i) the capacity of Epstein-Barr virus-transformed B cells (EBV-B cells) to process alloantigens, and (ii) in vitro assays with EBV-B cell lysate as a source of alloantigen, in order to characterize alloreactive T cell populations. A microculture system was established using donor EBV-B cell lysate as a source of the allogeneic antigen and donor or recipient EBV-B cells as antigen presenting cells to investigate whether alloantigen is recognized by effector T cells from the recipient. T lymphocytes produced after expansion in the presence of interleukin-2 from four samples of liver biopsies (three patients) and four samples of bronchoalveolar lavages (four patients) were used as effector cells. Upon human leucocyte antigen class II typing, these expressed the patient phenotype. When the T lymphocytes were from liver grafts, the recognition involved donor antigens presented by donor EBV-B cells (direct recognition). On the other hand, when the T lymphocytes were cultured from lung grafts, they mainly recognized antigens of donor EBV-B cell lysates in a self-restricted context (indirect recognition). These data suggest that EBV-B cells can provide allogeneic determinants recognized by T cells in donor or self-contexts, i.e. through either direct or indirect recognition.

We report the results of a prospective series of 60 consecutive splenectomies for hematologic disorders performed between February 1995 and May 1996. The portal venous flow of all the patients (34 men and 26 women with a mean age of 54.1 years) was systematically studied before and after intervention with Doppler color imaging (on the day before the intervention and on the 7th and 30th postoperative days). The objective of this study were to determine the real frequency of asymptomatic portal or splenic venous thrombosis (PSVT) after hematologic splenectomy. The intervention began with exteriorization of the spleen and the tail of the pancreas; ligation of the splenic vein was performed close to its junction with the inferior mesenteric vein. Twenty-three complications (38.3%) were noted with three deaths (5%). One symptomatic PSVT (1.6%) and three asymptomatic PSVTs (6.7%) were diagnosed and treated with no deaths. Three risk factors of PSVT, recognized by all the authors, were present in these four cases: large splenomegaly, thrombocytosis, or myeloproliferative disorder. The systematic ultrasonographic (US) examinations increased the frequency of diagnosis of PSVT sevenfold during the perioperative period. Patients with marked splenomegaly associated with lymphoma, chronic lymphocytic leukemia, or myeloid metaplasia probably require systematic US monitoring during follow-up, but this must be determined by further study.

The case of a 46 years old man presenting a chronic history of right upper lobe pneumonia is reported. The clinical presentation associated with nodular pulmonary computed tomographic scan lesions, highly suggested a malignant bronchopulmonary process. A lobectomy was performed. Histological analysis revealed an inflammatory pseudotumor. This inflammatory process may be a particular end stage disease of pulmonary infectious disease.

Unlabelled: Immunoscintigraphy (IS) using anti-CEA F(ab')2 monoclonal antibody (MAb) is useful for improving mediastinal staging of nonsmall cell lung cancer (NSCLC), but the technique was limited because of an insufficient contrast between tumor and normal tissues. The aim of this study was to determine if the method could be improved by a two-step method which uses a bispecific anti-CEA/anti-di-DTPA antibody (Bs-MAb) and 111In-labeled di-DTPA-tyrosyl-lysine bivalent hapten., Methods: Twelve patients were intravenously given a 30 min Bs-MAb infusion (0.1 mg/kg). Four days later, they were injected intravenously with 0.1 microgram/kg hapten labeled with 185 MBq 111In (5 mCi). Images were recorded immediately and 6 and 24 hr after hapten injection. A pharmacokinetic analysis was performed. Surgery was performed 3 days after 111In-hapten injection, and samples of tumor and normal tissues were collected for immunohistochemical and biodistribution studies. IS results were classified as true-positive (TP), false-positive (FP), true-negative (TN) or false-negative (FN) according to the surgical data., Results: Primary tumors were visualized in nine patients. The contrast was excellent, generally higher than that obtained with direct labeling of anti-CEA. In the mediastinum, IS results were (after surgery) five TN, two TP and one FP. One case remains undetermined. The FP result was due to a Bs-MAb uptake in intrapulmonary lymph nodes. IS was in agreement with preoperative staging in six of these nine patients and discordant in three., Conclusion: Our study confirmed that the two-step method with a bispecific antibody could greatly improve the performances of IS for lung cancer staging.

Two thousand lung cancer patients were registered as Grenoble's university hospital joint oncology clinic from 1/1/1982 to 12/31/1991. These cases consisted of 449 small cell lung cancers (SCLC) and 1,551 non-small cell lung cancers (NSCLC). SCLC patients had a 4.6% and 2.9% survival rate at 5 and 10 years and only 7.2% of patients had a survival longer than 30 months. The main prognostic factors for survival were age, sex, TNM stage and WHO performance status. There was no increase in survival during the 2 periods of the study. NSCLC patients had a 14% and 7% survival rate at 5 and 10 years. Among 727 stage III or IV patients not treated with surgery, 2% were alive at 30 months. The main prognostic factors for survival were age, histology, TNM stage and WHO performance status. There was no increase in survival during the 2 periods of the study.

Nine patients with mediastinal lymph node metastasis in differentiated thyroid carcinoma (7 papillary carcinomas, 1 Hürtle's cells carcinoma, 1 insular carcinoma) have been treated by systematic mediastinal dissection, 2 cases arose 6 and 10 years after the initial surgery, 2 cases after 18 and 20 months, but 5 revealed their metastases at the moment of the diagnosis or 3 months later. Investigations caused by a rise in thyroglobuline level (4 cases) necessarily involve a mediastinal CT scan, which always proved conclusive. All the patients underwent a median total sternotomy associated with a cervicotomy either for total thyroidectomy with conservative bilateral neck dissection, or for revision of the initial dissection. We describe the technique of mediastinal dissection allowing the resection of all the mediastinal lymph nodes. Mortality was zero and morbidity remained reasonable. 3 patients had recurrences: 2 died from multiple diffused metastases 18 months later, the third has pulmonary and mediastinal metastases well controlled by radio-iodine and external radiotherapy with a 5 years follow-up 6 are under total remission without sequel with a follow up ranging from 6 months to 8 years. Rather uncommon, total mediastinal dissection gives a long lasting remission with good living conditions to patients unresponsive to other therapies.

The authors have studied the pericardial recesses of the venous aspect of the heart. They report 107 anatomical dissections on fresh cadavers with the cardiac cavities artificially filled. Variations in the number of the pulmonary vv., in their diameters and their pericardial segments are reported. The characteristics of the oblique sinus, of the postcaval and pulmonary recesses are also reported. These variations define five types of pericardial morphology. A classification is proposed. These results differ from those in the literature, possibly because the pericardial reflection is delineated in diastolic filling of the cavities. These morphometric data are useful in anatomic instruction, imaging of the mediastinum, and the surgery of malignant tumors and pulmonary transplantation.

A 70 year old patient with a past history of a left ventricular cardiomyopathy with concentric hypertrophy presented with an exacerbation of cardiac failure; radiology revealed bilateral lung infiltrations, predominantly on the right and a restrictive ventilatory disorder. The broncho-alveolar lavage revealed a lymphocytosis with CD4 prominence. Microbiological examination was negative. With a worsening radiological picture despite increased anti-failure treatment a video-assisted surgical biopsy was performed. The histological examination revealed diffuse interstitial pulmonary amyloidosis. This observation underlined the value of looking for this rare cause of cardiac failure and pulmonary infiltration in a situation where the pulmonary images did not improve on diuretics.