Surgical management of a simultaneous aortic valve replacement and pneumonectomy.

Combined heart surgery and lung resection remains a controversial issue. The treatment of two major conditions in the same operative time may be attempted in certain cases. We report the case of a 68-year-old man who presented for dyspnea on exertion. The chest computerized tomography scan showed an infiltrating tumor which involved the right interlobar artery. A pneumonectomy was indicated and the preoperative echocardiography detected a calcified aortic valve with severe stenosis and significant pressure gradient. The patient had combined pneumonectomy and aortic valve replacement through median sternotomy and was discharged 18 days after surgery. Cardiac valve replacement is feasible in conjunction with pulmonary resection. However morbidity is increased in case of associated pneumonectomy.

Synchronous mantle cell lymph node lymphoma and pulmonary adenocarcinoma: a case report with literature review.

BACKGROUND AND AIMS: Coexistence of mantle cell lymphoma and lung adenocarcinoma is extremely rare. The aim of this study is to present the first case of incidental discovery of primary lung adenocarcinoma associated to lymph node mantle cell lymphoma. METHODS: A 45 year-old man, admitted for inguinal mass appeared since three months. Physical examination showed a 1 cm axillary and 3 cm inguinal adenopathies which were hard and fixed. A biopsy of inguinal mass revealed mantle cell lymphoma. Assessment of disease extension found a right superior lobe tumor with mediastinal lymphadenopathies. Fibreoptic bronchoscopy was normal. A fine needle biopsy of lung tumor was performed to determinate the nature of the pulmonary lesion. Histopathological findings were consistent with primary poor differentiated pulmonary adenocarcinoma with TTF-1 expression. A first mediastinoscopy was realized to verify mediastinal lymphadenopathies; frozen section showed a mantle cell lymphoma. A right lobectomy was then performed confirming the diagnosis of lung adenocarcinoma. Then, the patient was treated for the mantle cell lymphoma by 6 cures of alternating RCHOP and RDHAP (dexamethasone, high-dose Ara-Cytarabine and cisplatin) regimens followed by autologous stem cell transplantation. RESULTS: The patient died because of treatment complications 3 years after diagnosis. CONCLUSION: Progresses are necessary to understand the pathogenesis of of synchronous occurrence of both diseases.

The emergent use of Cardiopulmonary bypass and extracorporeal membrane oxygenator in a child with sickle cell disease.

The use of Cardiopulmonary bypass (CPB) and extracorporeal membrane oxygenator (ECMO) in patients suffering from Sickle cell disease (SCD) needs specific precautions. Whereas, no consensual protocols have been established to clarify therapeutic management. CASE REPORT A 7-year-old boy was admitted to the hospital for surgery of advanced endocarditis.  Major dyspnea, hemodynamic distress and fever were noted on physical examination. Biological tests exploring anaemia revealed Haemoglobin (Hb) S levels of 39.1%. Echocardiography showed important right heart cavities dilation with multiple aortic vegetations. The child was accepted for emergent surgery. Ten minutes after anesthetic induction, serious hemodynamic distress was established. The patient was put on normothermic CPB when he received four packed red-blood-cell. After surgery, he was placed on ECMO support for 2 days than he succumbed. CONCLUSION Urgent cardiac surgery in patients suffering from SCD poses a major therapeutic dilemma. Multiplying case reports and encouraging prospective studies are necessary to define the right place of cardio-pulmonary assistance in treatment protocols for better management.

Clinicopathologic and prognostic factors of thymoma in Tunisia.

BACKGROUND: although rare, thymomas are the most common tumors of the thymus in adults. They represent about 20% of all mediastinal tumors. AIM: the aim of this study is to present clinicopathological features of thymomas in Tunisia and analyse the prognostic factors. METHODS: From 1993 to 2004, clinical data of 40 cases of thymomas were compiled retrospectively. Microscopic slides were reviewed and reclassified according to the WHO classification of thymic tumors 2004. Clinical staging adopted was Masaoka system. Analysis of survival was determined by Kaplan-Meier method and log-rank test was used to compare survival curves. These statistical analyses were performed by SPSS. RESULTS: they were 23 women and 17 males of ages ranging from 14 to 76 years (mean age 51 years). The distribution of histological WHO types was: 1 type A, 7 type AB, 6 type B1, 17 type B2, 6 type B3, 2 cases of micronodular thymoma with lymphoid stroma and 1 case of metaplastic thymoma. According to Masaoka stage, 10 patients were in stage I, 11 stage II, 9 stage IIIa, 4 stage IIIb, 5 stage Iva and 1 stage IVb. The average overall survival was 56 months. Univariate analyses showed that Masaoka stage, completeness surgical resection and age were prognostic factors whereas in multivariate analysis, age was the only prognostic factor. Neither myasthenia gravis nor histological WHO subtypes had effect in survival. CONCLUSION: masaoka stage, completeness surgical resection and age are the prognostic factors predicting survival in our series.

Pulmonary carcinosarcoma with heterologous component: report of two cases with literature review.

Carcinosarcoma is an uncommon malignant biphasic tumor that accounts for less than 1% of all lung cancers. It is defined by coexisting histologic elements of carcinomatous and sarcomatous components. We report two cases of carcinosarcoma in a 68-year-old patient and a 78-year-old patient explored for lung masses. Macroscopically, the resected tumors were 7 and 10 cm in diameter. Histologically, they consisted in adenosquamous carcinoma with osteosarcoma in one case and adenocarcinoma with chondrosarcoma in the other case.

[Sarcomatoid carcinoma of the lung: retrospective study of 28 cases]. / Carcinomes sarcomatoïdes du poumon: étude rétrospective de 28 cas.

INTRODUCTION: Sarcomatoid carcinoma (SC) of the lung is defined by the World Health Organization as poorly differentiated non-small cell carcinoma that contains a component of sarcoma or sarcoma-like elements. It represents an overall continuum of epithelial and mesenchymal differentiation. Five subtypes are recognized: pleomorphic carcinoma, spindle cell carcinoma, giant cell carcinoma, carcinosarcoma, and pulmonary blastoma. The diagnosis is pathological and requires a good sampling of the tumor. PATIENTS AND METHODS: Twenty-eight cases of primary sarcomatoid carcinoma, diagnosed between 1993 and 2010, were reviewed retrospectively, noting the clinicopathological characteristics. RESULTS: The patient population consisted of 25 males and 3 females with mean age of 62.9 years (48-75 years). The symptomatology was dominated by respiratory symptoms. Imaging features showed a pulmonary mass invading pleura or thoracic wall in 5 cases. The diagnosis was made in all cases on histological examination. These 28 tumors were divided as below: into 19 pleomorphic carcinomas, 4 giant cell carcinomas, 1 spindle cell carcinoma and 4 carcinosarcomas. Twenty-seven tumors were treated surgically. Associated treatments were neoadjuvant (3 cases) or adjuvant chemotherapy (1 case) and preoperative radiotherapy (5 cases). Deaths occurred in 7 patients. Twenty-two patients were lost to follow up. CONCLUSION: These tumors are frequently symptomatic, are locally advanced, and have higher rates of recurrence. Its prognosis is worse than that of other non-small cell lung cancer.

Brief original scientific report: a new surgical approach for the treatment of left pulmonary and hepatic hydatid disease.

BACKGROUND: The combination of pulmonary and hepatic hydatid cysts is frequently encountered, and poses a challenge in terms of surgical accessibility. The surgical treatment of the two locations by the same incision (thoracotomy with phrenotomy) has been proposed, but always from the right side. However, applying this technique to the left side seems to be more difficult and unusual. We herein describe a new left-sided technique that was used to treat two patients with pulmonary and hepatic hydatid cysts. METHODS: The first patient was 14-year-old; he had bilateral pulmonary hydatid cysts and one type I cyst of the left lobe of the liver. The second patient was a 10-year-old female who had a hydatid cyst of the upper left lobe with one type III cyst of hepatic segments 2 and 3. RESULTS: Both patients were operated on via a left lateral thoracotomy through the sixth intercostal space. They underwent cystectomy for the left pulmonary hydatid cysts, followed by padding, and then the hepatic cyst was treated by Lagrot's method via a radial phrenotomy. The postoperative course was uneventful in both cases, with postoperative hospital stays of 3 and 5 days, respectively. CONCLUSION: This combined treatment of pulmonary and hepatic hydatid cysts by the left-sided thoracic approach is feasible and provides a good outcome. It should be indicated under the same conditions of accessibility and feasibility applied for the right thoracic side.

Major pulmonary resections by exclusive VTS. a first in Tunisia.

Although thoracoscopic surgery had been introduced in Tunisia since 1993, there were no anatomical resections performed that way. We report herein the first 3 cases of lobectomy performed by exclusive video-thoracoscopic surgery (VTS). Three female patients presenting with bronchiectasis (2 cases) and cystic adenomatoid malformation (1 case) have underwent a thoracoscopic lobectomy with different outcomes.

Conservative management of postoperative bronchopleural fistulas.

OBJECTIVE: A bronchopleural fistula (BPF) is a serious complication after pulmonary resection and carries a high mortality rate. It remains a therapeutic challenge. The lack of a consensus suggests that no optimal therapy is available; however, endoscopic closure of a fistula may avoid extensive and potentially risky surgery. METHODS: Seventeen patients (15 men and 2 women) with a BPF after a pneumonectomy (n = 2) or a lobectomy (n = 15), seen between 1995 and 2010, were reviewed. Their median age was 50 years (range, 14-75 years). Underlying diseases were malignant (n = 4) and nonmalignant (n = 13). RESULTS: The mean interval between surgery and fistula development was 20 days (range, 5-270 days). Clinical symptoms leading to a diagnosis of BPF were a persistent air leak (n = 2), a persistent air leak associated with pleural empyema (n = 3), pleural empyema alone (n = 11), and dyspnea (n = 1). Mean fistula size was 3.3 mm (range, 2-9 mm). Treatment consisted of oriented pleural drainage, adequate antibiotic therapy, and endoscopic closure of the fistula with local application of silver nitrate through a flexible bronchoscope (3-15 sessions, 3 times per week). Fistula closure was successful in 16 patients, but failed in 1 patient, who died from acute respiratory distress. CONCLUSIONS: BPF is a severe complication in thoracic surgery. The combination of pleural drainage, adequate antibiotic treatment, and mucosal application of silver nitrate, through a flexible bronchoscope, is an efficient alternative and avoids extensive surgical intervention.

[Beating heart coronary artery bypass: 100 cases]. / Pontage coronaire à coeur battant : A propos de 100 cas.

BACKGROUND: Coronary artery revascularization with cardiopulmonary bypass has been reported to carry several risks. AIM: Off-pump coronary artery bypass grafting has been proposed to result in a better outcome. The aim of this study is to assess the effect of off-pump cardiopulmonary bypass. METHODS: In a 7-year period, a total of 100 patients undergoing isolated first-time off-pump coronary artery bypass graft were studied. The mean ejection fractions was 48% and the EUROSCORE mean was 4.9. RESULTS: The average number of grafts was 1.55 per patient. The postoperative outcomes were simple for most patients with little use of inotropes after 24 hours (42%), few cases of atrial fibrillation (9.4%), and transfusion (27.3%). Time to extubation was less than 48 hours in most cases (94.7%) and hospital mortality rate was 10.5%. CONCLUSION: The beating heart bypass surgery allows good immediate results including multi-vessel disease and in patients at high risk.

What outcome after the prescription of neoadjuvant chemotherapy in lung cancer?

BACKGROUND: The treatment of patients with locally advanced non-small-cell lung cancer is controversial. Surgery remains the gold standard, even in this group. Neoadjuvant chemotherapy could allow surgical resection in patients initially judged inoperable. METHODS: From January 2009 to May 2010, neoadjuvant chemotherapy was indicated in 27 patients with NSCLC (25 men, 2 women). Their mean age was 65 years. The stages were: IIB in 5, IIIA in 17 (6 in stage IIIAN2), IIIB in 2, and IV in 3. RESULTS: 23 patients received neoadjuvant chemotherapy, 2 refused induction treatment, and 2 had impaired status. The neoadjuvant chemotherapy regimen was gemcitabine-cisplatin in 17 patients and vinorelbine-cisplatin in 6. Only 5 patients underwent complete surgical treatment after induction: 1 in stage IIB, 1 in stage IIIAN0, 1 in IIIB, and 2 in stage IV (1 operated brain metastasis, and 1 operated adrenal metastasis). Surgical treatment was not achieved after neoadjuvant chemotherapy in 18 patients because of progressive disease. CONCLUSION: Neoadjuvant chemotherapy offers several potential benefits, but it may delay surgery or eliminate eligibility as a surgical candidate. Rigorous patient selection for this type of multimodal treatment is essential.

Synovial sarcoma of the chest wall: a case report and literature review.

Synovial sarcoma is a malignant soft-tissue tumor that most commonly occurs in the extremities of young adults. Synovial sarcoma arising from the chest wall is rare and only some cases had been reported in the literature. We present a 57-year-old woman who presented with chest pain. Radiologic evaluation revealed a right parietal tumor destructing the mid-portion of the 8(th) rib, with heterogeneous enhancement and invasion of the pectoral muscle and extra pleural fat. A surgical resection consisting in parietectomy was achieved. The histological and immunohistochemical findings were consistent with synovial sarcoma. An adjuvant chemotherapy was prescribed but the patient was lost of view. She presented 6 months later with a recurrent huge parietal mass.

A rare and particular form of goiter to recognize.

Dyshormonogenetic goiter is a rare cause of congenital hypothyroidism occurring due to a lack of enzymes necessary for the synthesis of thyroid hormones. It is morphologically characterized by architectural and cellular pleomorphism that may mimic thyroid malignancy and cause difficulties in differential diagnosis. We report a new case occurring in a 37-year-old male with history of hypothyroidism since the age of 6 years treated by L-thyroxin. He developed a progressively slow growing multinodular goiter and consulted for recent dyspnea. Computed tomography scan showed a multinodular plunging goiter with compression of the trachea and vessels in the left side. A total thyroidectomy was performed. Gross examination revealed an enlarged and multinodular thyroid gland, presenting hemorrhagic changes in the larger nodules. Histologically, the features were consistent with dyshormonogenetic goiter. The literature on the histopathology of dyshormonogenetic goiter is reviewed and clues to avoid inappropriate overdiagnosis of malignancy are given.

Elastofibroma of scapula: a case report and literature review.

Elastofibromas are benign soft tissue tumors. They occur mostly in the infrascapular region between the thoracic wall, the serratus anterior and the latissimus dorsi muscle, with a prevalence of up to 24% in the elderly. The etiology of this lesion remains uncertain and is a source of ongoing debate. We herein report a 54-year-old female patient, manual worker who presented with bilateral subscapular slow growing tumors for 7 months. Physical examination showed two masses of 4 cm in diameter on the right, and 8 cm on the left, both located inferior to the inferior margin of the scapula. They were more or less firm and mobile on palpation. Computed tomography scan showed large fusiform subscapular soft tissue heterogeneous solid masses with linear areas of low density secondary to fat. The lesions measured 5 cm × 4 cm on the right side and 8 cm × 8 cm on the left. Resection of the largest left tumor was achieved. Macroscopic and histological findings were consistent with elastofibroma.

[Primary malignant tumors of the sternum]. / Tumeurs malignes primitives du sternum.

BACKGROUND: Primary tumors of the sternum are rare and account only 0.5% of all primary bone tumors. They are often malignant, osteolytic and aggressive. They often present difficulties in management. AIM: to determine clinical, pathological and therapeutic characteristics for primary malignant tumors of the sternum. PATIENTS AND METHODS: We report a series of six cases of primary malignant tumors of the sternum, collected in our institution between 1993 and 2009. RESULTS: There were 4 men and 2 women with a mean age of 69, 5 years. Parietal swelling was the most frequent symptom. Imaging showed a sternal lytic lesion. Three tumors were treated surgically. Associated treatments were neoadjuvant chemotherapy (1 case) and postoperative radiotherapy (1 case). A medical treatment (radiotherapy alone or chemotherapy) was performed in 3 cases. These tumors were divided as below: 3 plasmacytoma, 1 chondrosarcoma, 1 osteosarcoma and 1 large B cell lymphoma. CONCLUSION: The management of primary malignant tumors of the sternum is multidisciplinary. It depends on the histological type, the possibility of surgical treatment and the distant and local aggressiveness.