[Diagnostic and therapeutic management of operable bronchopulmonary carcinoid tumours]. / Prise en charge diagnostique et thérapeutique des tumeurs carcinoïdes broncho-pulmonaires opérables.

INTRODUCTION: Bronchial carcinoid tumours (CT), divided into typical carcinoid (TC) or atypical carcinoid (AC), are rare tumours whose therapeutic management remains unspecified. METHODS: Retrospective study collecting cases of bronchial CT operated at the thoracic surgery department of Abderrahmane-Mami hospital of Ariana and recruited from the pneumology departments of Northern Tunisia, during a 12-year period. RESULTS: Ninety patients were collected (74 cases of TC and 16 cases of AC). The mean age was 45 years and the sex ratio H/F=0.5. The chest X-ray was normal in 11 cases, as well as flexible bronchoscopy in seven cases. The tumour was classified: stage IA (10 cases), IIA (28 cases), IIB (31 cases), IIIA (15 cases) and IIIB (six cases). Surgery resulted in a complete resection in 78 patients, an extensive resection in six patients, and a conservative resection in six patients. Adjuvant chemotherapy was given in 10 patients. The survival was 84% at five years and 42% at 10 years. CONCLUSION: The prognosis of CT depends directly on the histological subtype. It is excellent for TC after complete resection, unlike ACs that are similar to well-differentiated bronchial carcinomas.

A rare case of squamous inclusion cyst in cervical lymph node.

A 38-year-old man, with no history of malignancy, was found to have a 2 cm jugular lymph node, for which a lymph node tuberculosis was suspected. The specimen revealed a cystic structure lined by mature keratinizing squamous epithelium with a prominent granular cell layer consistent with a squamous inclusion cyst in a lymph node, but a metastatic squamous cell carcinoma could not be excluded. This is the first case report of a rapidly enlarging squamous inclusion cyst in a jugular lymph node. Our case demonstrates the diagnostic challenges related to a squamous inclusion cyst in cervical lymph node and serves to inform the readers to consider this lesion in the differential diagnosis for similar situations.

[Clinical and pathological profile of the pleural malignant mesothelioma: A retrospective study about 30 cases]. / Le profil anatomoclinique du mésothéliome pleural malin : une étude rétrospective à propos de 30 cas.

BACKGROUND: The malignant pleural mesothelioma (MPM) is a rare tumour usually associated to asbestos exposure. The delay between the exposure and the occurrence of the cancer can reach 40 years. This caused the pick of incidence described in many countries including Tunisia. The diagnosis is suspected based on clinical features but positive diagnosis is microscopic. Our aim was to describe the clinical and microscopic features of MPM through a single institution experience. PATIENTS AND METHODS: We conducted a retrospective study about 30 MPM diagnosed over a 20-year-period (1995-2015). We included only patients with complete records including clinical, radiologic and microscopic features. All the microscopic diagnoses were reviewed by 2 pathologists. A mean of 12 slides per case was reviewed. The diagnosis was based on the 2015 WHO classification. RESULTS: The mean age of the patients was 61 years, average 22 to 80 years. The sex ratio was 6,5. An asbetose exposition was reported in 21 cases. The most frequent symptoms was chest pain reported in 25 cases. Physical exam was normal in 9 cases. It revealed pleural syndorm in most patients (60 %). Imaging findings consisted mainly in diffuse pleural thickening in 17 cases. Twelve tumours were classified as stage I, 3 stage II, 14 stage III et 1 stage IV. Pleural biopsy was performed using needle in 18 cases, through thoracoscopy in 16 cases, thoracotomy in 3 cases and allowed the diagnosis in respectively 7 cases/18, 16 cases/16 and 3 cases/3. A lymph node biopsy was performed through mediastinoscopy in one case and yelded the diagnosis. The diagnosis was performed on surgical specimen in 2 patients: one bullectomy and one right upper lobectomy. The microscopic exam concluded to an EM in 17 cases, sarcomatoid mesothelioma (SM) in 4 cases and biphasic mesothelioma (BM) in 9 cases. Pan-cytokeratin antibody was used in all cases in association with 2 antibodies with positive diagnostic value and 2 antibodies with negative diagnostic value. It was repeated in 15 cases and the most used antibodies were the anti-calretinin and the TTF1. This was due to the lack of fixation in one case and in order to reach a quality criteria in the other cases. Surgical resection was possible in 2 patients. 15 patients were lost of view after a mean follow-up period of 3 months. Thirteen patients died before or during the follow-up. CONCLUSION: This work was about a Tunisian experience in the diagnosis and management of MPM. The major limits faced were the incomplete databases, the small number of patients included. Microsocpic positive diagnosis necessitates a degree of expertise and every laboratory has to determine the most valuable antibodies through its experience in order to optimize the diagnosis and to reduce the delay of diagnosis.

[Place of the microscopic examination in the diagnosis of costal fibrous dysplasia]. / Place de l'examen anatomopathologique dans le diagnostic de la dysplasie fibreuse costale.

BACKGROUND: Fibrous dysplasia of bone is a rare benign lesion characterized by the coexistence of a fibrous tissue and an immature osteogenesis. Costal localization is rare and may be monostotic or polyostotic. The diagnosis may be suspected based on clinical and radiological findings. Facing the development of radiological investigations, we tried to highlight the diagnostic role of the microscopic examination through the experience of our department. METHODS: We describe a retrospective study about 12 costal fibrous dysplasias diagnosed over a 17-year-period. Clinical records were retrieved from the department of thoracic surgery of the same hospital. RESULTS: Costal fibrous dysplasia is equally observed in men and women with predominance in the third and fourth decades. Clinical symptoms consist mainly in chest pain. Physical examination was normal in almost all cases. Based on the radiological findings, the diagnosis was suspected in 33% of the cases. Microscopic examination highlighted the diagnosis in all cases but it was challenging in one case and necessitated a multi-disciplinary approach. The difficulties encountered were due to artifact decalcification. CONCLUSION: Costal fibrous dysplasia is a benign lesion which diagnosis is based on microscopic features. Radiologic investigations show nonspecific features but allow to rule out a malignant tumor. The outcome of the patients is generally good except in rare cases with a malignant transformation.

The major prognostic factors of thymomas: about a Tunisian study of 100 cases.

AIM: Thymomas are characterised by their rarity, histologic variability and peculiar patterns of recurrence. Herein, we present the experience of a single institution and aim to highlight the major prognostic factors of these tumours. MATERIALS AND METHODS: We present a retrospective study on 100 thymomas diagnosed between 1994 and 2011. Statistical analyses were performed using version 18.0 SPSS. The Kaplan Meier method was used to estimate survival, and survival curves were compared using the Log-Rank test. A p < 0.05 was considered statistically significant. RESULTS: 50 men and 50 women underwent surgical resection for thymoma. Radiologic findings highlighted a diagnosis of thymoma in 51% of cases. The thymomas were classified as stage I in 25 cases, stage II in 47 cases, stage III in 25 cases and stage IV in 3 cases. According to the WHO classification, tumours were classified as type A in 14 cases, type AB in 24 cases, type B1 in 17 cases, type B2 in 20 cases, type B3 in 8 cases, B1/B2 in 8 cases and B2/B3 in 9 cases. The mean survival of patients was 136 months. Age, sex, tumour size, WHO classification and Masaoka stage were evaluated as prognostic factors. Univariate analysis showed that the major prognostic factors were WHO classification (p = 0.019) and Masaoka Stage (p = 0.0001). CONCLUSION: Our results place emphasis on the prognostic value of WHO classification and Masaoka stage in thymomas; in addition, the necessity of improving reproducibility of microscopic classification to avoid discrepancies among prognostic groups is highlighted.

[Bronchopulmonary carcinoid tumors: Tunisian experience with 115 surgically treated cases]. / Tumeurs carcinoïdes bronchopulmonaires : une série tunisienne de 115 cas opérés.

INTRODUCTION: Bronchial carcinoid tumors are rare well-differentiated, neuro-endocrine tumors, with low-grade malignancy. They are distinguished in two different groups: typical and atypical carcinoid. The purpose of this study was to review clinical, surgical and pathological characteristics in patients with primary bronchopulmonary carcinoid tumors. METHODS: This retrospective study included 115 bronchial carcinoid tumors surgically treated at a single institution during a twenty-one-year period, between 1992 and 2012. RESULTS: There were 56 men and 59 women, with a mean age of 43.73 years. Hundred patients had typical carcinoids and 15 atypical carcinoids. The majority of patients were symptomatic (96.52%). CT revealed a proximal mass in 51% which was obstructive leading to ventilator disorders in 80%. Bronchoscopy showed an endo-bronchial tumor in 83.48% of the cases. Anatomical resection had been achieved among 99 patients, and a conservative resection among 16 patients with typical carcinoid tumor. Lymph node metastases were present in 12.17% of the cases. Follow-up revealed recurrence in one patient and distant metastasis in 4 others. The 5-year survival rate was worse for atypical carcinoid with 45% than typical carcinoid with 95%. CONCLUSIONS: Carcinoids are rare malignant tumors, and their outcome is usually favorable after surgery. However, local recurrence and/or metastases can occur with both typical and atypical carcinoid tumors, justifying the need of prompt diagnosis and long-term follow-up. The factors influencing the survival included the pathological type, distant metastasis and mediastinal lymph node involvement.

In vitro antimicrobial activity of Pistacia lentiscus L. edible oil and phenolic extract.

Pistacia lentiscus L. is known in some Tunisian forest area by its fixed oil used in traditional medicine as an antiseptic product. This investigation is the first to study the antimicrobial activity of P.lentiscus edible oil and its phenolic extract. Oil was extracted from fruits harvested from six provenances located in Tunisia. The antimicrobial activity was tested using disc diffusion assay and the broth dilution method. Kbouch and Sidi Zid oils were most efficient (p < 0.003) against, respectively, Staphylococcus aureus and Aspergillus niger with an inhibition zone of 9.33 mm. The phenolic extract had the largest spectrum of sensitive microorganisms. The minimum inhibitory concentration and minimum bactericidal concentration results showed that all strains were inhibited by both oil and extract.

[Surgery for thoracic tuberculosis]. / La chirurgie dans la tuberculose thoracique.

Tuberculosis is mainly a medical disease. Surgery has been the unique therapeutic tool for a long time before the advent of specific antituberculous drugs, and the role of surgery was then confined to the treatment of the sequelae of tuberculosis and their complications. The resurgence of tuberculosis and the emergence of multidrug-resistant TB combined to immunosuppressed patients represent a new challenge for tuberculosis surgery. Surgery may be indicated for a diagnostic purpose in patients with pulmonary, pleural, mediastinal or thoracic wall involvement, or with a therapeutic purpose (drainage, resection, residual cavity obliteration). Modern imaging techniques and the advent of video-assisted thoracic surgery allowed a new approach of this pathology; the majority of diagnostic interventions and selected cases requiring lung resection can be performed through a mini-invasive approach. Patients proposed for aggressive surgery may be treated with the best results thanks to a good evaluation of the thoracic lesions, of the patients' nutritional, infectious and general status combined with a good coordination between the specialized medical team for an optimal preparation to surgery.

[Pulmonary zygomycosis in a diabetic child complicated with thrombus of the left atrial auricle]. / Mucormycose pulmonaire chez une enfant diabétique, compliquée d'un thrombus intra-auriculaire gauche.

Mucormycosis is a rare but fatal, opportunistic fungal infection caused by fungi of the order of mucorales in the class of Zygomycetes. Isolated pulmonary mucormycosis is rare and occurs principally in particular conditions, especially in patients with uncontrolled diabetes. The fungi invades the blood vessels and causes distal ischemic necrosis. We report a case in a 13-year-old girl with diabetes mellitus who developed pulmonary zygomycosis complicated with thrombus of the left atrial auricle. The diagnosis of mucormycosis was confirmed by histologic examination of endobronchial biopsies. Combined treatment with systemic amphotericin B and surgery resulted in a favorable outcome. This difficult diagnosis must be raised in diabetic patients with unresponsive lung infections in order to apply early aggressive therapy. Successful management continues to be early diagnosis, followed by systemic antifungal therapy and surgical resection combined with control of the underlying disease.

[Tracheal tumor treated as asthma]. / Une tumeur trachéale traitée comme un asthme.

Primary tumors of the trachea are very rare. In adults, the majority of them are malignant. Schwannomas are exceedingly rare benign tumors in the tracheobronchial tree. We report a case of a 37-year-old man who was hospitalized for increasing dyspnea. He had been treated for bronchial asthma for the last 4 years with no benefit. The CT scan of the chest and bronchoscopy identified a tracheal mass that was prolapsed in the left stem bronchus. The patient did not remain free of disease after endoscopic laser resection. So, surgical resection was made. The tumor was excised at its base. A segment of the left stem bronchus was removed and primary anastomosis was performed. The histopathologic diagnosis was of a benign schwannoma without malignant elements. There was no recurrence during the follow-up period. This case demonstrates that intratracheal masses should be considered in patients with dyspnea or in patients with asthma refractory to conventional therapy.

Fibroadenoma in an ectopic vulvar breast gland: a common neoplasm in an uncommon site.

Ectopic breast tissue is defined as glands located outside of the breast. It can be found anywhere along the milk line extending from the axilla to the groin, and can occur in the vulva. Ectopic breast tissue should be excised because it may develop benign or malignant pathologic processes. Less than 40 cases of fibroadenoma in the vulva have been reported in the literature. We report a case of a 37-year-old woman presenting a solitary vulvar mass. The mass was excised completely, and histology demonstrated an ectopic breast fibroadenoma. This is one of the few reports on the benign pathologies of vulvar mammary glands.

[Case report of pulmonary biphasic tumor with unusual follow-up]. / À propos d'une tumeur biphasique du poumon d'évolution inhabituelle.

BACKGROUND: Pulmonary blastoma, a rare primary lung malignancy is subdivided in 3 categories: well-differentiated fetal adenocarcinoma (WDFA), classic biphasic pulmonary blastoma (CBPB) and pleuropulmonary blastoma (PPB). Classic pulmonary blastoma is composed of a mixture of immature epithelial and mesenchymal tissue resembling fetal lung tissue. CASE REPORT: We described a case of a 48-year-old male, cigarette smoker, who presented with left thoracic pain and hemoptysis for 2 months. Chest radiography showed a well-delimited, homogeneous 4cm mass in the left lung periphery. Bronchoscopic examination revealed left endobronchial bleeding. Computed tomography of the chest revealed a tumor shadow measuring 7cm in the left upper lobe and bilateral nodules with no lymphadenopathy. A systemic evaluation demonstrated no metastatic lesion. Patient underwent a left upper lobectomy. The diagnosis of CBPB was affirmed on anatomopathology of the tumor resection. Immunohistochemical studies showed that tumor cells were positive for vimentin, desmin, actin, Pan Cytokeratin and TTF-1. The final diagnosis was BPB classified as pathological T3N0M0 and no adjuvant treatment was associated. The patient showed good objective response with no evidence of disease recurrence still in 5 years surgery resection. CONCLUSION: This case reiterates the importance of pathomorphological or immunohistochemical features in diagnosis of BPB.

Effect of growing area on tocopherols, carotenoids and fatty acid composition of Pistacia lentiscus edible oil.

In this investigation, we aim to study, for the first time, the effect of the growing area on tocopherols, carotenoids and fatty acid content of Pistacia lentiscus fixed oil. Fruits were harvested from eight different sites located in the north and the centre of Tunisia. Tocopherols, carotenoids and fatty acid content of the fixed oils were determined. The highest carotenoid content was exhibited by Feija oil (10.57 mg/kg of oil). Oueslatia and Tabarka oils displayed the highest α-tocopherol content (96.79 and 92.79 mg/kg of oil, respectively). Three major fatty acids were determined: oleic, palmitic and linoleic acids. Oleic acid was the main fatty acid presenting more than 50% of the total fatty acid content. Kebouche oil presented the highest oleic acid content (55.66%). All these results highlight the richness of carotenoids, tocopherols and unsaturated fatty acids in P. lentiscus seed oil and underscore the nutritional value of this natural product.

Primary mediastinal angiosarcoma: a rare observation in a patient with 8-year-survival.

BACKGROUND: Vascular tumours of the mediastinum are rare, accounting for 1-2% of all mediastinal tumours in this location. Angiosarcomas are most often encountered as sporadic lesions, typically in the scalp or face of elderly patients. However, they can occur in any anatomic site. Mediastinal angiosarcomas (MA) are very rare with less than 50 cases reported. CASE REPORT: The authors describe the case of a 38-year-old woman whose past medical history was consistent for a MA that was diagnosed in 2003. This tumour was treated by complete surgical resection followed by radiation therapy and chemotherapy. Diagnosis was based on histologic examination. In 2011, the patient presented a pleural localisation of the angiosarcoma and died one month after admission, 8 years after diagnosis of the MA. CONCLUSION: MA is a very rare tumour causing a diagnostic dilemma. Clinical and radiologic findings are non-specific, and final diagnosis is based on histologic examination. The case described is unusual considering the long period of survival, which may be explained by the treatment modalities associating complete surgical resection, chemotherapy and radiation therapy.

About a challenging tumour, elastofibroma dorsi: an eight-case study.

Elastofibroma dorsi is an uncommon benign soft tissue pseudotumour usually located at the lower pole of the scapula, deep to the serratus anterior and often attached to the periosteum of the ribs. This lesion is usually seen in patients over the age of 50 years and is commonly misdiagnosed as a malignant tumour because of its size and deep location. We describe 8 cases of elastofibroma dorsi diagnosed over a 10-year-period. Our study contained 5 females and 3 males with a mean age at diagnosis of 62.5 years (range 47-75 years). We aim to highlight the clinical and radiologic presentation of elastofibroma dorsi in order to increase awareness of its existence and management.

Diagnosis and clinical course of cardiac myxoma.

Cardiac myxomas are the most common benign tumours of the heart. In spite of their benign nature, these tumours may induce metastasis or recurrences. Their diagnosis is challenging because of the lack of specific signs, and positive diagnosis is based on microscopic findings. We report a case series of 6 patients documented by radiologic and microscopic findings. In addition, one case was unique due to its location in the right atrium. Tumours were detected by trans-oesophageal ultra-sound examination in all cases. They were located in the left atrium in five cases and in the right side in one case. All patients underwent a successful surgical excision with en-bloc removal of the tumour. The outcome was fatal in one patient because of atrial arrhythmia.

About the necessity of improving the current nodal classification of non-small cell lung carcinoma.

BACKGROUND: The current classification of lymph node status in non-small cell lung carcinoma has not been revised since 1997. This fact has prompted many authors to point out the limits of this classification. METHODS: We tried to explore the prognostic relevance of the current TNM classification in comparison with the nodal classification based on the ratio of metastatic lymph nodes (LNR) and the nodal classification based on the number of metastatic LNs (nLN). Additionally, we tried to explore the recommended number of resected LNs. This was done through a retrospective study of 39 cases. We compared the survival curves of patients using the current, RLN and nLN classifications. In the nLN classification, we grouped patients into three categories: nNO (no metastatic LNs), nN1 (1 to 2 metastatic LNs) and nN2 (> 2 metastatic LN). In the LNR classification, we grouped patients into three categories: rNO (0%), rN1 (< or = 12) and rN2 (> 12). Concerning the total number of the resected LNs, patients were categorized into two groups according to the number of LNs: < 10 versus > or = 10 and < 15 versus > or = 15. RESULTS: Our results showed that the LNR classification highlighted a difference in prognosis between the rN1 and rN2 groups. Moreover, survival of patients seemed to be better when the number of the resected LNs was higher. CONCLUSION: The ratio of metastatic LNs seems to be an important prognostic factor, but further studies are necessary to standardize this classification.

[A rare pulmonary lesion association]. / Une association lésionnelle pulmonaire rare.

INTRODUCTION: Pulmonary amyloidoma or nodular amyloidosis is a localized form of amyloidosis, which can mimic a bronchopulmonary carcinoma. This form of amyloidosis may be associated to an infectious, a systemic disease or a lymphoma. OBSERVATION: We describe the case of a 36-year-old patient whose past medical history was consistent for a diabetes mellitus and a hypothyroidism treated by medical treatment. The patient presented a Gougerot-Sjögren syndrome and was explored for non-specific respiratory symptoms. Physical examination was normal. Laboratory tests revealed a monoclonal pic of immunoglobulin. Radiologic findings showed bilateral pulmonary nodules associated to mediastinal lymph nodes. A pulmonary biopsy was performed. Histologic examination revealed a tumoral nodule containing an abundant eosinophilic material, which was acellular and surrounded by a dense lymphomatous infiltrate destroying the pulmonary parenchyma. Histochemical and immunohistochemical study revealed an association of a nodular pulmonary amyloidosis with a MAT pulmonary lymphoma complicating a Gougerot-Sjögren syndrome. CONCLUSION: The association of MALT pulmonary lymphoma and localized amyloidosis is rarely observed in case of Gougerot-Sjögren syndrome. The pathogenesis of this association remains unknown and the management non-consensual because of the rarity of the cases reported. Whereas, it appears that localized amyloidosis associated to a MALT lymphoma seems to have a better prognosis than a disseminated amyloidosis.