Pleural metastasis of atypical meningioma: a novel therapeutic approach.

Meningiomas are the most common intracranial tumours in adults and they are infrequently associated with a metastasis clinical course. Pleural metastases are extremely rare and no guidelines on a specific treatment have been established. When localized, surgical resection is the mainstay of treatment, but there is a high risk of pleural recurrence. We aimed to describe a novel surgical approach in pleural metastasis of meningiomas. We report the case of a 41-year-old man with the medical history of surgically resected intracranial atypical meningioma. Nine years after diagnosis of atypical meningioma, a CT scan of the chest disclosed 10 pleural implants gathered in the fissure, in the paramediastinal pleura and at the base of the left hemithorax. Surgical resection was decided. Parietal and mediastinal pleura resection with visceral pleural lesions removal were performed. Cytoreductive surgery was associated with intrathoracic hyperthermic chemotherapy. Postoperative course was uneventful and no adjuvant therapy was undertaken. The patient is free of pleural recurrence 12 months post operatively. The present case report suggests that cytoreductive surgery with intrathoracic hyperthermic chemotherapy is feasible and safe in pleural metastasis from meningioma. Prolonged follow-up and prospective studies are mandatory to assess its oncological benefit.

Sarcoid-like granulomatosis and testicular germ cell tumor: the 'Great Imitator'.

OBJECTIVES: Only a few case reports and small case series of patients with sarcoidosis or sarcoid-like reaction and testicular germ cell tumors (GCT) have been reported in the literature. We performed a retrospective study of patients with testicular GCT managed at the Centre Léon-Bérard, who presented granulomatosis. METHODS: We performed a computerized search to identify all male patients with both a diagnosis of sarcoidosis or granuloma and testicular tumors seen at the Centre Léon-Bérard between 1992 and 2008. RESULTS: A total of 13 patients were identified among the 1,182 patients with testicular tumors. The median age at diagnosis of testicular GCT was 25.5 years. Six patients had stage I disease, 2 patients had stage IIb and 5 patients had stage III. Sarcoid-like granulomatosis was found in 9 patients at the time of initial diagnosis and in 4 patients during follow-up. Sarcoidosis presented mainly as pulmonary disease without severe organ involvement, with a benign evolution. CONCLUSION: We advise caution in the interpretation of clinical and histological findings in these patients. Sarcoid-like granulomatosis, a condition that can be combined with testicular cancer, should always be considered in the differential diagnosis of metastatic testicular tumors.

[Lung metastases of epithelioid sarcoma revealed by bilateral spontaneous pneumothorax: a pathological diagnosis]. / Métastases pulmonaires d'un sarcome épithélioïde révélées par un pneumothorax spontané bilatéral : un diagnostic anatomopathologique exclusif.

Spontaneous pneumothorax may be one of the presenting manifestation of metastatic epithelioid sarcoma even if imaging does not show evident metastatic nodules. We report the case of a 24-year-old man presenting a bilateral spontaneous pneumothorax in association with an epithelioid sarcoma developed in the right foot. CT-scan revealed bilateral microcystic lesions with no evidence of metastatic disease. A left thoracoscopy and a pleurodesis were performed. Persistent air leakage led to a thoracotomy during which lung biopsies were carried out. Histopathological examination of the pulmonary biopsies revealed rare millimetric nodules, composed of very atypical epithelioid cells, growing along alveolar walls reminiscent of a bronchiolo-alveolar carcinoma. However, these cells and primary neoplastic cells of the foot tumour were morphologically and immunohistochemically similar and the atypical pulmonary cells were TTF1 negative. All these constatations allowed a diagnosis of pulmonary metastases of the epithelioid sarcoma. This very unusual case underlines that sarcomatous metastases may be a clinical and pathological pitfall.

Is pneumonectomy after induction chemotherapy for non-small cell lung cancer a reasonable procedure? A multicenter retrospective study of 228 cases.

INTRODUCTION: Pneumonectomy (PN) after induction chemotherapy (CT) for non-small cell lung cancer is controversial because high-mortality rates are still reported. METHODS: This multicenter retrospective study included all patients treated by induction CT then PN between January 1993 and April 2006 in four General and Thoracic Surgery Departments. Postoperative mortality and morbidity and long-term outcomes were studied. RESULTS: The study considered 228 patients. Doublets with cisplatin and vinorelbine or gemcitabine were used in 66% of cases. pTNM stages (World Health Organization, 1997) were 0 (2%), I (16%), II (25%), IIIA (29%), IIIB (16%), and IV (12%). The postoperative morbidity rate was 37% (84 of 228 patients). The independent risk factors identified for postoperative morbidity were chronic obstructive pulmonary disease, more than four cycles of induction CT or an association of cisplatin, and an old cytotoxic molecule, extended PN, and extended anesthesia time. Postoperative mortality rates were 5.3% at 30 days (12 of 228 patients) and 9.2% at 90 days (21 of 228 patients). The independent risk factors identified for operative mortality were chronic obstructive pulmonary disease, manual suture of the stump, and pTNM stage higher than IIIA. The 90-day mortality rates were 10.3% (12 of 117) for right PN and 8.2% (9 of 111) for left PN (p = 0.65). The overall survival (OS) rates were 68% at 1 year, 39% at 3 years, and 32% at 5 years. CONCLUSIONS: Induction CT was not found to compromise short- or long-term outcomes after PN in non-small cell lung cancer. The right or left PN performed by experienced surgeons after induction CT seems to be a reasonable procedure in case of tumor local extension.

Multiple synchronous serous cystadenomas of the pancreas: uncommon CT and MRI findings.

Serous cystadenomas (SCAs) of the pancreas are benign cystic tumors. Although still controversial, asymptomatic SCAs, in contrast to their mucinous counterparts, can be treated conservatively. This attitude is mostly defendable for lesions of the pancreas head or multiple lesions distributed throughout the entire pancreas, as their surgical resection is still associated with significant morbidity. Thus, correct diagnosis is essential, and this relies on radiological and biological characteristics. Asymptomatic multiple SCAs are rare. Most cases described in the literature are either symptomatic, degenerated, or both. We present a case of huge (>10 cm), multiple asymptomatic SCAs, not associated with von Hippel-Lindau disease, involving the entire pancreas. The patient has been followed up for 3 years and remains asymptomatic. Tumor markers were within normal ranges. On abdominal computed tomography (CT) and magnetic resonance imaging (MRI), the lesions showed pathognomonic characteristics of SCAs, and their uncommon dimensions and number remained stable over time. 18-Fluorodeoxyglucose positron emission tomography (PET) scan performed at 3-year follow-up did not show hypermetabolic lesions.

Cystic involvement of the roof of the main biliary convergence in adult patients with congenital bile duct cysts: a difficult surgical challenge.

BACKGROUND: Complete cyst excision of the extrahepatic disease component with biliary reconstruction on proximal healthy bile ducts is considered to be the treatment of choice in patients with congenital bile duct cysts (BDC). Proximal cystic disease that extends to the roof of the main biliary convergence (MBC) might challenge this standard of surgical care. METHODS: A retrospective multicenter study was conducted in 4 European surgical centers concerning their experience with adult patients suffering from type I and IV BDC according to the Todani classification. Clinical presentation, operative management, and postoperative outcome were compared between patients with or without proximal extrahepatic cystic disease that involved at least the roof of the MBC (defined as being BDC with MBC involvement subgroup). RESULTS: From an overall series of 49 adult patients suffering from type I or IV BDC according to the Todani classification, 7 patients had BDC with MBC involvement (14%). Patient age, clinical presentation, duration of symptoms, associated major coexistent hepatobiliary and pancreatic diseases, and synchronous cancer were not significantly different in these patients compared with a control group of 42 adult patients with BDC without MBC involvement. Incomplete proximal cyst excision rate was 86% in the cases of BDC with MBC involvement. Early and late postoperative results were similar in BDC with MBC involvement and in the control group of adult patients, but the incidence of subsequent cancer was significantly higher in the BDC with MBC involvement group (29% vs 0%; P < .02). CONCLUSION: BDC that involves the roof of the MBC is a real surgical challenge to obtain complete proximal cystic disease excision. As suggested in this small study, primary incomplete excision of this particular form of BDC might expose the patient to the risk of subsequent cancer, a feature that must be confirmed in larger series.

[Benign salivary gland-type tumors of the bronchus: expression of high molecular weight cytokeratins]. / Adénomes bronchiques de type tumeurs des glandes salivaires: expression des cytokératines de haut poids moléculaire.

Primary lung tumors showing features of salivary gland-type neoplasms are extremely rare, and their immunohistochemical profile has been seldom studied. We report two cases of bronchial pleomorphic and mucous gland adenomas and study the expression of markers such as TTF-1 and high molecular weight keratins in these tumors. Both tumors were endobronchial. The pleomorphic adenoma also had a well-circumscribed parenchymal component, with a biphasic morphology composed of epithelial and myoepithelial cells in a background of myxoid and hyaline stroma. The mucous gland adenoma displayed papillary and dilated glandular structures. In both cases, epithelial cells showed strong and diffuse cytoplasmic staining with high molecular weight cytokeratins (cytokeratin 5/6 and keratin 903), and lacked TTF-1 expression. This immunoprofile provides useful clues for the histogenesis of pulmonary benign salivary gland-type adenomas and helps in distinguishing them from primary adenocarcinomas in small biopsy specimens.

Anatomical variations of the hepatic artery: study of 932 cases in liver transplantation.

The aim of this study was to identify and to classify anatomical hepatic artery (HA) variations concerning 932 HA dissections in liver transplantation (LT). Normal HA distribution was found in 68.1%. Variations of HA were detected in 31.9% and were divided into three groups describing 48 common hepatic artery (CHA) anomalies, 236 left or right hepatic artery (RHA) anomalies and 13 rare variations including one case of RHA stemmed from the inferior mesenteric artery and one case of normal CHA passed behind the portal vein. The authors propose a modified classification for HA anomalies which are based on the origin of the hepatic arterial supply (either by the CHA as the only source of the arterial vascularization or by additional or replaced right and left arteries) in order to improve management of liver disease thus as in LT.

Laparoscopic pancreatic resection: a preliminary experience of 15 patients.

BACKGROUND/AIMS: Worldwide experience with laparoscopic pancreatic resection remains limited. The aim of the study was to assess the feasibility, safety and outcome of laparoscopic pancreatic resection. METHODOLOGY: 15 consecutive patients suffering from benign cystic pancreatic (n=6), neuroendocrine tumors (n=8) or pancreatic metastasis from renal carcinoma (n=1) undergoing laparoscopic pancreatic resection were retrospectively collected from 5 academic hospitals. RESULTS: Laparoscopic procedure was completed in 10 patients, including 7 distal pancreatectomies (with 5 spleen preservation), 2 tumor enucleations and 1 partial cystic resection. Conversion was due to inappropriate operative finding for laparoscopic approach in 2 patients and for uncontrollable bleeding in 3 patients. Postoperative pancreatic-related complications included pancreatic fistula in 20% and peripancreatic collection in 13% of the patients. CONCLUSIONS: Laparoscopic pancreatic resection is feasible for distal pancreatic tumors. However, successful management of the pancreatic stump remains the challenge of this procedure, in order to achieve a clear benefit in the patient outcome.

[Excision of low rectal carcinomas with sphincter preservation. Multimodal strategy using neoadjuvant radiotherapy and "delayed" coloanal anastomosis without defunctioning stoma]. / Conservation sphinctérienne après exerèse des cancers du bas rectum. Stratégie multimodale combinant une radiothérapie pré-opératoire et une anastomose colo-anale "differée" sans stomie de protection.

Over the past 20 years there have been many advances in the management of rectal cancer. The medico-surgical school in Lyon, France, has a long tradition in managing this malignancy. The progression of ideas and practices requires a better knowledge of the patterns of tumor spread and local recurrence. Technical advances have greatly helped to facilitate sphincter preservation. Advances in radiotherapy have led to its routine use in the preoperative period. This approach has now emerged as the best therapeutic sequence. Our experience concerns 46 patients with low rectal carcinoma treated with this strategy. There were no post-operative deaths and no leakage. One patient (2%) had a pelvic abscess. Median follow-up was 50 months (1-151). At five years, the local recurrence rate was 8.5% and the actuarial survival rate was 72%, with a local control rate of 91%. Functional outcome, evaluated with a scoring system, was good in 60% of cases at one year and 78% at 5 years. Quality of life, evaluated with the American Society of Colon and Rectal Surgeons scale (A.S.C.R.S.), was 107 +/- 21 (range 33-140). The absence of defunctioning stoma (initial or late), good sexual and urinary well-being, and psychologic assessment are essential factors, requiring rigorous evaluation before the operation and specialized management after the operation. The proposed strategy based on this safe procedure and "French-type" neoadjuvant radiotherapy, permits sphincter preservation in patients with T2 and T3 tumors located near the dentate line, with good late oncological outcome. It is often amenable to the laparoscopic approach.

Impact of antireflux operation on columnar-lined esophagus.

BACKGROUND: The effect of antireflux operation on the natural history of columnar-lined esophagus (CLE) is not fully understood. The aim of this study was to assess a single center's experience and review the literature on the impact of antireflux operation on CLE without high-grade dysplasia. STUDY DESIGN: The medical records of 26 patients with CLE but without high-grade dysplasia who underwent antireflux operation in our unit were retrospectively analyzed at longterm followup with detailed endoscopic investigation. Thirteen patients presented with intestinal metaplasia (6 had short segments, and 1 had preoperative laser ablation) and 13 without intestinal metaplasia. For the group of 13 patients presenting with intestinal metaplasia, the mean endoscopic followup was 74.7 months (median 46 months). Three of six with short-segment lesion and two of seven with circumferential involvement had complete regression of intestinal metaplasia (one after laser therapy). None had progression to dysplasia or carcinoma. RESULTS: For the group of 13 patients without intestinal metaplasia, mean endoscopic followup was 43.9 months (median 28 months). One had complete regression of CLE, and none developed intestinal metaplasia during surveillance. CONCLUSIONS: Our study suggests that antireflux operation can alter the natural history of CLE, allowing disease stabilization in a substantial proportion of patients. After antireflux operation, total regression of CLE is possible, but in an unpredictable manner.

Percutaneous radiofrequency ablation of a lung metastasis: delayed cavitation with no infection.

A 64-year-old man presented with a lung metastasis of the lower left lobe. After partial response with chemotherapy, a thoracotomy was performed that did not allow a wedge resection, and lobectomy was contraindicated by the patient's ventilatory function. Radiofrequency ablation of this lung metastasis was thus performed, followed by a delayed cavitation with no infection, which, to our knowledge, has not yet been described.