[Conservative surgery in pulmonary aspergilloma]. / Place de la chirurgie conservatrice dans l'aspergillome pulmonaire.

INTRODUCTION: Pulmonary aspergilloma is a mycotic infection due to the deposit of mycelial fibres, usually in a pre-existing cavity within the lung. Surgical resection is the treatment of choice, with anatomical resection the most practiced technique. Simple aspergillomas are becoming more and more frequent urging this review of the place of conservative surgery. AIM: The aim of this study was to establish the characteristics of aspergillomas which may benefit from a conservative surgery. METHODS: We undertook a retrospective study of 64 cases that were operated on in the thoracic surgery unit in Abderrahmen-Mami Ariana's hospital between 1984 and 2008. RESULTS: Fourteen patients had conservative surgical treatment, with an atypical resection to remove the aspergilloma. The other 50 patients had undergone anatomical resection; segmental resection, lobectomy or pneumonectomy. The perioperative mortality rate was 5%. One case of aspergilloma recurrence had been recorded in a patient who had had conservative surgery for a complex aspergilloma. CONCLUSION: Surgery is the only effective treatment of aspergilloma. Conservative surgery may be an alternative in simple-peripheral forms, which have a diameter less than 4cm.

[Primary heterotopic pleural hydatid cyst presenting as a pneumothorax]. / Un pneumothorax révélateur d'une hydatidose pleurale primitive hétérotopique.

INTRODUCTION: Hydatid cyst is a parasitic disease that is endemic in many countries. Pneumothorax may be a presentation of this disease that presents urgent problems of diagnosis and treatment. CASE REPORT: We report the case of a 23-year-old woman, amenorrheic for 22 weeks, who presented with chest pain and dyspnoea. Chest x-ray revealed a right-sided tension pneumothorax. A check x-ray after drainage showed a homogeneous opacity of water density occupying the lower 2/3 of the right hemithorax. Thoracic ultrasound suggested an uncomplicated hydatid cyst at the right base. Surgical exploration revealed a hydatid cyst 14cm in diameter in the pleural space, and a cavity in the right lower lobe with two bronchial fistulae. Treatment consisted of removal of the cyst intact, closure of the bronchial fistulae and capitonnage of the residual cavity. The postoperative course was uncomplicated. CONCLUSION: Primary heterotopic pleural hydatid cyst is an exceptional cause of pneumothorax that should considered in countries where hydatid disease is endemic. Treatment is surgical following drainage of the pneumothorax.

Benign metastasizing leiomyoma: report of 2 cases and review of the literature.

Benign metastasizing leiomyoma (BML) is a benign spindle cell lesion affecting women who have undergone hysterectomy for uterine leiomyomas in young adulthood, and subsequently present pulmonary metastases during the peri-menopausal period. We present 2 cases of BML in women with prior medical history of hysterectomy for multiple myomas. Both patients presented pulmonary metastases at 17 and 12 years after hysterectomy. The pulmonary nodules were totally excised in the both cases, and neither patient experienced complications or recurrences after 1 and 2 years of follow up, respectively. BML is a rare benign entity with a debated pathogenesis. We have developed different hypotheses about its pathogenesis, mechanisms of spread, histological characteristics and commonly employed treatment modalities.

[Primary thymic carcinomas. Three cases and a review of the literature]. / Carcinomes thymiques primitifs : à propos de trois cas avec revue de la littérature.

Thymic carcinoma is a very rare malignancy. In 1999, a World Health Organization committee published histologic criteria for distinct thymoma entities (labelled as type A, AB, B1, B2, B3 thymomas) and for the heterogeneous group of thymic carcinomas, collectively called type C tumour. Thymic carcinoma differs from thymoma in that it displays cytologically malignant features, extensive local invasion, and a substantial potential for metastasis. It constitutes a heterogeneous group of tumours that display different biological behaviours and prognoses. The majority of thymic carcinomas are either squamous carcinomas or lymphoepithelioma-like carcinomas. This study included three male patients aged 20, 46 and 19years respectively with histologically proven thymic carcinoma diagnosed at the author's institution. All of the patients presented a large mass of the anterior mediastinum. Histological examination of the different tumours revealed three distinct variants of thymic carcinoma, namely: epidermoid carcinoma, clear cell carcinoma and lymphoepithelioma-like carcinoma.

A pulmonary mucinous cystic tumour of borderline malignancy.

We report a well-documented case of pulmonary mucinous cystic tumour of borderline malignancy involving the left lower lobe. The lesion was found incidentally by chest radiograph and CT scan with a provisional diagnosis of bronchioloalveolar carcinoma. The tumour was 4 cm in its greatest dimension, cystic and filled with gelatinous mucus. Microscopically, the neoplastic mucinous epithelium was composed of cuboidal cells with focally nuclear stratification and mild to moderate nuclear atypia. The patient has remained free from recurrence or metastases for 6 years. Pulmonary mucinous cystic tumour of borderline malignancy is a rare, recently described neoplasm, which spans a spectrum of tumours with malignant potential. The recent World Health Organization classification of lung tumours does not recognize this entity, which has a very good prognosis, and as such should be distinguished from classic pulmonary adenocarcinoma. Histological diagnosis can be difficult to distinguish from cystic bronchioloalveolar carcinoma or metastatic mucinous adenocarcinoma.

[Benign mature teratomas of the mediastinum]. / Tératomes matures bénins du médiastin.

INTRODUCTION: Mature teratomas of the mediastinum are rare. However, they represent the most common mediastinal germ cell tumours. The aim of this study is to describe their clinical and pathological characteristics. PATIENTS AND METHODS: Fourteen cases of mediastinal mature teratoma, diagnosed between January 1992 and December 2006, were reviewed retrospectively, noting the clinical, radiological, surgical, and pathological findings. RESULTS: The patient population consisted of 10 females and 4 males with mean age of 29 years (5-56 years). Chest pain was the main symptom. Imaging features comprised a heterogeneous anterior mediastinal mass containing soft-tissue, fluid, fat, or calcium attenuation, or any combination of the four. Macroscopically all the tumours were cystic, or predominantly cystic, containing mostly grumous material. The mean size was 9 cm (5-12 cm). Histological examination constantly revealed skin with or without appendages. Other components identified were bronchial mucosa (12 cases), fat (12 cases), muscle (10 cases), cartilage (8 cases), bone (7 cases), gastrointestinal mucosa (7 cases), pancreas (5 cases), urothelial epithelium (3 cases), nervous and prostatic tissues (one case each). All the teratomas were mature, and 7 of them were intrathymic. CONCLUSION: Every form of teratoma occurs in the mediastinum (mature, immature and with malignant transformation) but, in our study, they were exclusively mature. The histology is essentially similar to that of teratomas of gonads. However, pancreatic tissue occurs frequently in mediastinum (54% in literature, 25% in our study) but not in the gonads. On the other hand, thyroid follicles have not yet been seen in mediastinal teratomas.

[Desmoid fibromatosis of the posterior mediastinum]. / Fibromatose de type desmoïde du médiastin postérieur.

Fibromatosis are uncommon connective tissue tumours arising from musculo-aponeurotic tissue and characterised by spindle cell fibroblastic and myofibroblastic proliferation. The exact aetiology is unknown but several factors are considered to be positively correlated with their development and growth (genetic and hormonal factors and trauma). Although they are considered histologically benign they behave aggressively locally and relapse repeatedly after surgical excision. Mediastinal localisation is very rare. We describe a case of de novo fibromatosis of the posterior mediastinum in a 61 year old man with no history of thoracotomy or trauma. Although mediastinal fibromatosis is very uncommon physicians should be aware of this disease in order to ensure appropriate surgical treatment.

[Hydatid disease of the first rib treated surgically by the Roos approach]. / Hydatidose de la première côte opérée par voie de Roos.

Hydatid disease is a parasitic infection due to Echinococcus granulosus. Since involvement of the ribs and in particular the first rib is rare, diagnosis and treatment in these locations can pose special problems. The purpose of this report is to describe the case of a 27-year-old man in whom an apical left opacity was discovered by chance. Clinical examination was normal. Thoracic ultrasound demonstrated multilocular cyst in the left apical region of the thorax. Thoracic computed tomography (CT) demonstrated a hydatid cyst originating from the first rib. The patient was operated using the technique known as the Roos approach. The procedure consisted of cystectomy with resection of the first rib. The multiloculated appearance of the lesion and erosion at the first rib was consistent with hydatid cyst. The Roos approach is the technique of choice for the treatment of the first rib.

A prospective, randomised comparison of continuous paravertebral block and continuous intercostal nerve block for post-thoracotomy pain

ABSTRACTBackground: This study aimed to compare paravertebral block and continuous intercostal nerve block after thoracotomy.Methods: Forty-six adult patients undergoing elective posterolateral thoracotomy were randomised to receive either acontinuous intercostal nerve blockade or a paravertebral block. Opioid consumption and postoperative pain were assessedfor 48 hours .Pulmonary function was assessed by forced expiratory volume in 1 s (FEV1) recorded at 4 hours intervals.Results: With respect to the objective visual assessment (VAS), both techniques were effective for post thoracotomy pain.The average VAS score at rest was 29±10mm for paravertebral block and 31.5±11mm for continuous intercostal nerve block.The average VAS score on coughing was 36±14mm for the first one and 4 ±14mm for the second group.Pain at rest was similar in both groups. Pain scores on coughing were lower in paravertebral block group at 42 and 48hours. Post-thoracotomy function was better preserved with paravertebral block. No difference was found among the twogroups for side effects related to technique, major morbidity or duration of hospitalisation.Conclusion: We found that continuous intercostal nerve block and paravertebral block were effective and safe methods forpost-thoracotomy pain

[Management of postoperative chylothorax]. / Prise en charge des chylothorax post opératoires.

INTRODUCTION: A chylothorax can occur following any intrathoracic procedure. It is generally straightforward to make the diagnosis but optimal management can be problematic. METHODS: Between 1995 and 2002, three women and one man aged from 13 to 58 years were treated for chylothorax after thoracic surgery. Their initial illnesses were a right pulmonary hydatid cyst associated with hepatic disease, a tumour of the posterior mediastinum, an oesophageal carcinoma and metastases in the left lung. RESULTS: These patients had: a pulmonary and hepatic cystectomies, a resection of the mediastinal tumor, an Akyama oesophagectomy and a resection of four left pulmonary metastases. Chylothorax became apparent post operatively between the 1st and the 4th day. All patients were treated with a medium-chain triglyceride diet. Two patients were re-explored with ligation of lymphatic vessels. One woman who did not have further surgery was treated with etilefrine. In the patient who had had an oesophagectomy, chylothorax persisted after re-operation. He was successfully treated by talc pleurodesis via a chest drain, which prevented further recurrence. CONCLUSIONS: In the management of postoperative chylothorax, medical treatment must be started early but surgery should not be delayed as operative risk is increased by the development of malnutrition and immune deficiency.

[Clinical aspects and diagnosis of pleural fibromas]. / Aspects cliniques et approche diagnostique des fibromes pleuraux.

Pleural fibromas are rare malignant or benign tumors requiring pathology study for certain diagnosis. From January 1985 to January 2001, 7 patients underwent surgery in our unit for pleural fibroma: 4 females and 3 males, mean age 60 years. The inaugural symptoms were chest pain (3 patients), dyspnea (2 patients), joint pain in a patient with Pierre-Marie pneumonic hypertrophic osteo-arthropathy, and acute hypoglycemia. Radiological investigations were decisive in orienting the diagnosis (chest X-ray, ultrasound, computed tomography and MRI). Surgical resection and pathological study of the surgical specimen is required to confirm the diagnosis. Patients should be carefully followed due to the risk of malignant recurrence.

[Huge benign lung tumor in a female smoker]. / Tumeur de 5 cm chez une femme fumeuse.

UNLABELLED: Pulmonary sclerosing hemangioma is a rare, slow-growing, benign tumor. Its potential for progression and its histiogenesis remains controversial. CASE REPORT: A routine chest X-ray revealed a right abdominal mass in 41-year-old woman. Search for a cause was negative. The patient underwent posterolateral thoracotomy for tumorectomy. Intraoperative pathology analysis revealed the benign nature of the tumor. No complication was observed postoperatively. The final pathological conclusion was sclerosing hemangioma of the lung. Pulmonary sclerosing hemangioma is a parenchymal tumor of the lung. The latest immunohistochemical studies of this lesion suggest a pneumocyte origin. Prognosis is good, but extension to lymph nodes may occur. Surgery is always required for cure, and must be associated with lymph node dissection for large tumors.

[Lung carcinosarcoma. A case report]. / Le carcinosarcome du poumon. A propos d'un cas.

Carcinosarcoma of the lung is a rare highly malignant tumor of unknown histogenesis. There is an epithelial carcinomatous component and a malignant mesenchmatous component with heterologous tissue. Survival at two years after surgical resection is not greater than 10%. We report a case observed in a 71-year-old man who developed chest pain. Outcome was fatal at three months. Pathology examination of a transparietal biopsy provided the diagnosis which was confirmed by immunohistochemistry on the surgical resection specimen.

[Benign myoepithelioma of the lung]. / Myoépithéliome bénin du poumon.

Benign myoepithelioma of the lung is a benign tumor caused by proliferating myoepithelial cells with no ductal component. These tumors are exceptional: only three cases have been reported in the literature. We report a fourth case in a 37-year-old woman at 8 months gestation. Pathological proof of diagnosis was obtained.

[Immediate postoperative arrhythmias follwing pneumonectomy for lung cancer]. / Les troubles du rythme cardiaque dans les suites de pneumonectomie pour cancer broncho-pulmonaire.

UNLABELLED: Immediate postoperative arrhythmias after pneumonectomy for non small cell lung cancer is a serious complication. Frequency is estimated 10 to 28% of all patients. The goal of this study is to evaluate the incidence of this complication in our experience, preoperative risk factors, therapeutic implications and short outcome. 132 consecutive patients underwent pneumonectomy for lung cancer. We retrospectively studied this series of which 29 patients developed arrhythmias postoperatively. Mean age was 58 years (48 to 79), 16 patients were older than 65 years. Seven patients had medical history of either myocardial infarction or hypertension. Arrhythmias appeared post-operatively on days 1 and 2 six times, days 3 ans 4 ten times, days 5 to 6 six times and days 7 to 10 twice. The trouble consisted in atrial fibrillation in 18 patients, atrial associated with ventricular premature beats in 11 patients. Antiarrhythmic medication (amiodarone) was started as soon as the trouble was confirmed by EKG in all cases. Normalization was obtained in 27 patients (95%). One patient remained dysrrhythmic in spite of treatment. One death occurred on day 4 postoperatively. The mean hospitalisation stay was 10 days. CONCLUSION: Cardiac arrhythmia in the immediate postoperative course is not rare. Early diagnosis in patients at risk followed by adequat treatment is necessary to avoid haemodynamic storm in these quite fragile patients. Amiodarone is the treatment of choice.

[Acute arterial ischemia due to tumor embolism after pulmonary resection: report of two cases and review of the literature]. / Ischemie arterielle aigue par embolie tumorale apres resection pulmonaire: a propos de deux cas et revue de la littérature.

From january 1984 to december 1999 we operate in our institution, 465 patients affected by lung cancer. In the early post-operative period we observe two arterial peripheral embolic events. Treatment consist in surgical embolectomy by Fogarty probe under femoral way. We don't observe post-operative complications or any functional sequelae. For the two patients tumoral character of the embolism was confirmed this work confirm the need of pre-operative precautions to avoid this complication that way be severe when in diagnosed or treated lately.