[Management of choledocholithiasis]. / Prise en charge de la lithiase de la voie biliaire principale.

Choledocholithiasis is a not uncommon and potentially grave condition which requires a well-adapted approach. Echo endoscopy and biliary MRI have improved the ability to make the diagnosis non-invasively, but intraoperative cholangiography remains the most accurate study. A surgical approach permits simultaneous treatment of both choledocholithiasis and the associated cholecystolithiasis; laparoscopic common duct exploration has been more frequently performed through a laparoscopic approach in recent years, but this procedure requires specific equipment and surgical experience. In most circumstances, surgery should be preferred to endoscopic clearance of the common duct, but endoscopy may be preferred in the setting of severe cholangitis or pancreatitis. The importance of a systematic search for asymptomatic choledocholithiasis is once again emphasized.

Overexpression level of stromelysin 3 is related to the lymph node involvement in non-small cell lung cancer.

Proteases contribute to tumor invasion and metastasis via their potential to degrade basement membranes and extracellular matrix. Our aim was to compare the level of several proteases: urokinase-type plasminogen activator (u-PA), matrix metalloproteinase 2 (MMP-2; 72-kDa type IV collagenase, also known as gelatinase A), MMP-11 [also known as stromelysin 3 (STR3)], and cathepsins B and L in resected non-small cell lung cancer. Between June 1996 and March 1998, samples of lung tumor tissues were taken from 119 surgically treated patients. Thirty out of the 119 tumor samples were matched with corresponding adjacent normal tissue. u-PA was measured by a commercially available immunoluminometric assay. Metalloproteinases and cathepsins have been evaluated at the RNA level by Northern blot and quantified with a PhosphorImager. Expression of these proteases was compared to the following clinicopathological parameters: pathological diagnosis, tumor size, exposure to asbestos, radiotherapy, neo-adjuvant chemotherapy, tumor-node-metastasis stage, lymph node involvement, presence of metastasis. u-PA, MMP-2, MMP-11/STR3, and cathepsin B were significantly increased in tumor (the tumor:normal ratio was on average increased by 5.4-, 2.2-, 83.5-, and 2.2-fold, respectively). The tumor:normal ratio of MMP-11/ STR3 was found to be significantly linked to the lymph node involvement (P < 0.05). Our results suggest that several proteases are involved in the invasive potential of non-small cell lung cancer and that the quantification of MMP-11/ STR3 could represent an useful prognostic marker.

Pericardoscopy for primary management of pericardial effusion in cancer patients.

OBJECTIVE: To assess the usefulness of pericardoscopy via the subxyphoid route for the diagnosis and treatment of pericardial effusion in patients with a history of cancer. METHODS: All patients with a recent or remote history of cancer and a pericardial effusion of unknown origin requiring drainage for diagnostic and therapeutic purposes were included in the study. They underwent complete exploration and cleansing of the pericardial cavity. Abnormal structures or deposits were biopsied under direct visual control, with a 24 cm long rigid pericardoscope. RESULTS: Between 1985 and 1998, pericardoscopy was completed in 112 of the 114 patients included (feasibility 98%), resulting in the immediate relief of symptoms in all the cases. Peri-operative mortality was 3.5%, and post-operative morbidity, 6.1%. After pericardioscopy pericardial effusions were considered malignant in 43 cases. One more case (2.3%) due to a false negative result of pericardioscopy was diagnosed during follow-up. Overall, 44 of the 114 patients (38.6%) had a malignant effusion, and 70 (61.4%), a non-malignant effusion according the follow up. In 10 of the 44 patients with a malignant pericardial effusion (22.7%), pericardoscopy corrected the results of cytological pericardial fluid studies and pericardial window biopsy, both false negatives. The sensitivities of cytological studies of the pericardial fluid, pathological examinations of pericardial window biopsy and pericardioscopy were 75, 65 and 97%, respectively. One patient with a malignant effusion had a non-symptomatic recurrence 1 month after pericardioscopy (2.3%). CONCLUSION: We recommend pericardioscopy to ascertain the malignant nature of the effusion and to diminish the recurrence rate, this avoiding repeat procedures in patients with a short life expectancy.

Is computed tomography guided biopsy still necessary for the diagnosis of adrenal masses in patients with resectable non-small-cell lung cancer?

OBJECTIVES: This study was undertaken: (1) to evaluate the usefulness of unenhanced computed tomography (CT), magnetic resonance imaging (MRI) and CT guided biopsy for the characterization of adrenal masses in patients with operable non-small-cell lung cancer (NSCLC) and (2) to evaluate the situations in which CT guided biopsy is absolutely necessary before potentially curative resection of NSCLC. METHODS: Consecutive patients with operable NSCLC underwent unenhanced adrenal CT with density measurements of any adrenal mass over 1 cm in diameter. An adrenal mass was considered as an adenoma when its density was below 10 Hounsfield Units and a metastasis when its density exceeded 10 Hounsfield Units. Then patients underwent MRI, the signal on the T2 weighted images from the enlarged gland was classified adenoma or metastasis in comparison with that from the liver parenchyma. CT guided biopsy was performed after a pheochromocytoma was eliminated. Unenhanced CT attenuation values and signal intensity values on MRI were correlated with histopathologic results. RESULTS: Of the 443 patients, 32 had an adrenal mass consisting of adrenal metastases in 18 cases and adenomas in 14 cases. On CT, 3/14 (21%) of the adenomas were misdiagnosed as metastases (their densities exceeded 10 Hounsfield Units) and 2/18 (11%) of the metastases were misdiagnosed as adenomas (their densities were below 10 Hounsfield Units). On MRI, none of the metastases were misdiagnosed as an adenoma (100% sensitivity) but 7/14 (50%) of the adenomas were misdiagnosed as metastases (signal superior to that of liver). Overall, a diagnostic certainty of metastasis could not be obtained in 25/32 patients (78%). CT guided biopsy with 100% sensitivity and specificity corrected all the inaccurate results of CT and MRI without any morbidity. CONCLUSION: Despite extensive morphological evaluation with unenhanced CT and conventional MRI, CT guided biopsy is necessary for most patients referred to surgery for an operable NSCLC and an adrenal mass.

[Appendicitis and pregnancy. Seven case reports]. / Appendicite et grossesse. A propos de 7 observations.

OBJECTIVES: Determiner optimal diagnosis and therapeutic management of pregnant women with suspected appendicitis. METHOD: Among over 9,000 patients who delivered in our obstetrics ward over a 4-year period, 7 (1/1, 285) underwent appendectomy during their pregnancy. Based on these observations and a review of the literature, an attempt was made to determine the best diagnostic approach in this rare situation. RESULTS: The frequency observed here was in agreement with data reported in the literature (1/1,000 to 1/2,000). Premature delivery occurred eight days after appendectomy at 29 months gestation in one woman. There was no complication in the 6 other pregnancies. Positive diagnosis, difficult during pregnancy, was based on clinical, biological and echographic findings. Laparoscopy improved not only diagnosis but also treatment and prognosis before 20 weeks gestation. CONCLUSION: Clinical presentation of appendicitis is modified during pregnancy rendering diagnosis difficult. The gravity of the appendicitis as well early diagnosis and management influence the maternal and fetal prognosis more than its association with pregnancy.