[Mediastinal opacities. Diagnostic orientation].
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Diagnosis, Differential↗
Biomedical subjects
P Levasseur
Publications and source records attributed to P Levasseur.
Primary lung cancer in young patients: a study of 82 surgically treated patients.
The aim of this study was to evaluate the prognosis for surgically treated young patients with primary lung cancer, a prognosis generally considered to be very poor. Eighty-two patients less than 40 years of age were operated on at Marie-Lannelongue Hospital between 1982 and 1990. There were 72 male and 10 female patients. Ten patients (12%) had never smoked, whereas 48 patients (59%) had smoked for more than 20 pack-years. The lung cancer was asymptomatic in 27 patients (33%) and symptomatic in the others. Adenocarcinoma was found in 42% of the patients, epidermoid carcinoma in 28%, mixed cell carcinoma in 16%, small cell carcinoma in 8.5%, and undifferentiated large cell carcinoma in 6%. Among the 69 resected tumors, 22 were stage I, ten were stage II, 32 were stage IIIa, and five were stage IIIb. The resection was considered complete and curative in 56 patients (68%) and noncurative in 26 (32%) either because of an incomplete resection (12 in stage IIIa; 1 in stage IIIb) or because of an exploratory thoracotomy only (13). The overall actuarial 5-year survival rate was 41%, and the actuarial 5-year survival for patients who had a complete resection was 56%. The actuarial 5-year survival rates were as follows: patients in stage I, 70%; stage II, 54%; stage IIIa, 28%; stage IIIb, 0%; and patients having exploratory thoracotomy only, 18%. These survival rates are similar to those of patients older than 40 years with similar stages of disease.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
The place for bilobectomy in bronchogenic carcinoma.
From 1978 to 1988, 148 bilobectomies (21 upper and middle and 127 lower and middle) were performed for bronchogenic carcinoma. A conservative procedure was mandatory in 29 patients in whom a pneumonectomy was not functionally feasible while bilobectomy was deliberately performed in 119 patients with near normal lung function. Overall mortality was 6% compared to 4% and 3%, respectively, following pneumonectomies and lobectomies. Preoperative functional status did not significantly influence mortality. The complication rate was 55%. The incidence of bronchopleural fistula electively observed after lower and middle lobe resection was significantly higher (11%) compared to 4% after pneumonectomy and 1.4% after lobectomy (P less than 0.01). The overall 5-year survival was 43% and was similar to that observed at comparable TNM stage after other pulmonary resections. Residual right pulmonary function demonstrated by perfusion isotopic scan was 24% +/- 10 in 21 long-term survivors. These results indicate that bilobectomy can reasonably be considered in patients requiring more than a lobectomy but in whom lung conservation is mandatory despite a significant increase in morbidity. The risk appears justifiable regarding late survival results and functional benefit of the remaining right lobe.
Aged↗
Cancer surgery on a single residual lung.
A series of nine patients with single lungs operated on for lung cancer is reported. This represents 10% of all the synchronous and metachronous lung cancers operated during the same period. There were three early postoperative deaths and a further three patients died subsequently at 15, 20 and 24 months, respectively, after operation; the remaining three are alive 6, 12 and 29 months, respectively, following their surgery. The analysis of the results of this small series indicates that wedge and segmental resection, when feasible, may be undertaken in patients with a single lung with reasonable life expectancy. The fact that lobectomy is not tolerated in such patients emphasizes the importance of early diagnosis when minimal local excision can be undertaken.
Cause of Death↗
Primary mediastinal germ cell tumors. Results of a French retrospective study.
Eighty-seven patients with primary mediastinal germ cell tumors treated between 1983 and 1990 were studied. Among the 23 patients classified as pure seminoma, eight (35 percent) underwent surgery followed by radiotherapy (n = 6), radiotherapy and/or chemotherapy (n = 2); two patients underwent radiotherapy; 13 patients (57 percent) underwent induction cisplatin-based chemotherapy (ten complete responses) followed by radiotherapy (n = 9), second line chemotherapy (n = 2) and surgical resection of residual tumor (n = 2). On completion of treatment, 22 patients (96 percent) with seminoma were free of disease. The two-year Kaplan-Meier survival rate of these patients was 86 percent. Among the 64 patients with nonseminomatous germ cell tumor, 19 patients (30 percent) underwent surgery as first treatment (ten complete resections) followed by chemotherapy (n = 17) and radiotherapy (n = 5). On completion of treatment, 12 of 19 patients were disease free. Forty-five patients (70 percent) underwent induction cisplatin-based chemotherapy (ten complete responses), and 22 of them underwent resection of residual tumor (19 complete resections). Twenty-three patients were treated with first line chemotherapy without postchemotherapy surgery (three complete responses). In summary, 33 patients (52 percent) with nonseminomatous germ cell tumors became free of disease, and seven patients (21 percent) relapsed after achieving a complete response. The two-year Kaplan-Meier survival rate of the nonseminomatous germ cell tumor patients was 53 percent (87 percent if a complete response), with a median survival of 28 months. Despite a worse prognosis than nonseminomaous tumors from other primary sites, this series of mediastinal germ cell tumors has confirmed the efficacy of therapy.
Adult↗
[How can intrathoracic lymphatic involvement be assessed using mediastinoscopy in primary bronchial cancer?].
In order to achieve mediastinal lymph node staging in bronchial cancer, axial mediastinoscopy (combined with left anterior mediastinoscopy for cancers of the left upper lobe) is by far the most efficient and the most reliable technique. Since mediastinoscopy has been part of the investigations that can be made before thoracotomy, the number of exploratory thoracotomies has considerably decreased in all teams, thus reducing at the same time intraoperative mortality. Thoracic CT, which arrived in the diagnostic weaponry for lung cancer a long time after mediastinoscopy, has a major asset in that it allows selecting the patients for whom mediastinoscopy seems to be useful, on the basis of criteria related to the size of mediastinal lymph nodes (10 mm generally being the threshold chosen to perform mediastinoscopy or not). For almost all authors, systematic mediastinoscopy is no longer useful. Similarly, a positive mediastinoscopy must not lead to systematically refuse patients, as the invasion or absence of invasion of a mediastinal lymph node is neither necessary nor sufficient to discuss a surgical indication. While some still automatically refuse all patients with positive mediastinoscopy, most authors still remain very interventionistic for N2 patients selected on very accurate criteria that are analyzed above. Surgery can then be performed at once or, for some authors, after a "neo-adjunctive" therapy, the long-term efficacy of which has unfortunately not been rigorously demonstrated as yet.
Carcinoma, Non-Small-Cell Lung↗
[Mediastinoscopy in the evaluation of the extension of primary bronchial cancer. Techniques, indications and therapeutic deductions].
In order to achieve mediastinal lymph node staging in bronchial cancer, axial mediastinoscopy (combined with left anterior mediastinoscopy for cancers of the left upper lobe) is by far the most efficient and the most reliable technique. Since mediastinoscopy has been part of the investigations that can be made before thoracotomy, the number of exploratory thoracotomies has considerably decreased in all teams, thus reducing intraoperative mortality at the same time. Thoracic CT, which arrived in the diagnostic weaponry against lung cancer a long time after mediastinoscopy, has a major asset in that it allows selecting the patients for whom mediastinoscopy seems to be useful, on the basis of criteria related to the size of mediastinal lymph nodes (10 mm generally being the threshold chosen to perform mediastinoscopy or not). For almost all authors, systematic mediastinoscopy is no longer useful at present. Similarly, positive mediastinoscopic findings must not lead to systematically refuse patients, as the invasion or absence of invasion of a mediastinal lymph node is neither necessary nor sufficient to discuss a surgical indication. While some still automatically refuse all patients with positive mediastinoscopy, most authors still remain very interventionistic for N2 patients selected on the basis of very accurate criteria that are analyzed above, and surgery can then be performed at once or, for some authors, after a "neo-adjunctive" therapy, the long-term efficacy of which has unfortunately not been rigorously demonstrated as yet.
Bronchial Neoplasms↗
Congenital respiratory-esophageal fistula in the adult. Report of nine cases and review of the literature.
Congenital tracheoesophageal or bronchoesophageal fistulas, if not associated with esophageal atresia, may not appear initially until adult life. Nine such cases (two tracheoesophageal and seven bronchoesophageal) are reported. The chief presenting symptoms were recurrent bouts of coughing, after drinking, and hemoptysis. In the majority of cases the duration of symptoms exceeded 15 years. The diagnosis was confirmed in seven patients by esophagography, in one patient by bronchoscopy, and in one patient the fistula was discovered incidentally during thoracotomy. The esophageal opening of the fistula was in the lower third in seven patients and in the middle third in two. Bronchoesophageal fistulas communicated with a segmental bronchus in four patients and with a main or lobar bronchus in three. Treatment involved excision of the fistula (five patients) or division and suturing (four patients). Postoperative follow-up revealed no long-term sequelae except persistent chronic respiratory failure in one patient. The respiratory failure had developed before treatment of the fistula. The analysis of this series and a review of the literature underline the high index of suspicion required in all cases of chronic cough and lung suppuration, to diagnose this benign condition before life-threatening complications occur.
Adult↗
[Primary malignant germinal tumors of the mediastinum. Results from a national retrospective survey].
The object of this enquiry was to group together a series of patients with a mediastinal germ cell tumour who were diagnosed and treated between 1983-1990 to specify their clinical characters and their prognostic factors and to evaluate the current therapeutic strategies. Out of a total of 87 cases that were analysed 23 had seminomas and 64 malignant dysembryomas. Amongst the 23 patients suffering from seminomas, 8 had first been treated by surgery, 13 by chemotherapy and 2 by radiotherapy. At the end of treatment 22 made a complete response and 4 patients relapsed after 4-13 months following a complete response. 3 patients had metastases at the outset and were alive and in complete response at 1,4 and 7 years respectively. The survival level at 2 years for seminomas was 84%. Of 64 patients suffering from a malignant dysembryoma, 19 were first treated with surgery (10 by complete resection) followed by chemotherapy in 17 cases. At the end of treatment 12 patients were in complete remission. Only one of these patients had a subsequent relapse. 45 patients were first treated by chemotherapy (10 complete responses, 26 partial responses) then secondary surgery was performed in 22 cases, allowing a complete remission in 21. Seven malignant dysembryomas relapsed after an initial complete remission. The patients treated for pure choriocarcinoma were 7 in number: 6 of these received primary chemotherapy. One patient underwent a secondary resection and was living at 26 months. The other 5 died rapidly. The 2 year survival for malignant dysembryomas was 52%. The median survival was 28 months. There was a significant difference in surviyal between dysembryomas in complete remission and those in partial remission.
Adolescent↗
[Lung resection for cancer in coronary patients. Immediate and medium-term results. Retrospective study in a series of 51 patients].
Patients with both resectable lung cancer and coronary artery disease require preoperative cardiac evaluation in order to determine and prevent the surgical risk and to discuss the desirability of preventive myocardial revascularization. The results of thoracic surgery in coronary disease patients have been studied in a series of 51 patients operated upon for lung cancer at the Marie Lannelongue hospital, Paris, between 1985 and 1988. Thirty-two patients underwent non invasive exploration prior to surgery (exertion ECG in 22, myocardial radioisotope scanning in 10); 35 patients had coronary arteriography at the last moment, and 9 asymptomatic patients with an old history of myocardial infarction had no specific exploration. Forty-nine patients had lung surgery alone, preceded in 5 cases by percutaneous coronary angioplasty; one patient had pulmonary surgery and coronary surgery simultaneously, and another patient had coronary surgery first, later followed by lung surgery. No perioperative death was due to cardiovascular causes. A 75-year old male patient died of respiratory failure 30 days after lobectomy. The postoperative period was totally uneventful in 39 patients. No perioperative myocardial infarction was recorded; 4 patients experienced an episode of thoracic pain with ECG signs of myocardial infarction but no rise in serum enzyme concentrations. One patient had a cerebral vascular accident responsible for hemiplegia. Two late sudden deaths, probably of cardiac origin, occurred 4 and 11 months respectively after surgery. The actuarial survival rate at 3 months was 48 percent. In all survivors, the coronary symptoms were controlled by medical treatment. It seems, therefore, that perioperative complications in this type of patient can be avoided by preoperative evaluation of the coronary disease and by preventive myocardial revascularization in case of critical coronary stenosis.
Adenocarcinoma↗
Results of resection for bronchogenic carcinoma with mediastinal lymph node metastases in selected patients.
Between 1982 and 1988, 254 consecutive patients underwent resection for bronchogenic carcinoma with mediastinal lymph node metastases at Marie Lannelongue Hospital. Selection of cases for surgery was carried out using CT and mediastinoscopy. The surgical procedure performed were pneumonectomy (169), lobectomy (65), or bilobectomy (20) associated with resection of ipsilateral mediastinal lymph nodes. Almost all diseased nodes appeared grossly enlarged at surgery and only a few were of normal size. Postoperative mortality was 5.6%. Resection was potentially curative in 191 cases (75%) and palliative in 63 cases (25%). Almost all patients received adjuvant treatment (mainly radiotherapy). Actuarial 5-year survival was 18% for the entire group, and 23% for those who underwent curative resection. No patient with palliative resection survived 5 years. The following factors proved to be significantly associated with a better prognosis: complete resection, independent lymph node metastases, involvement of only one level, lower paratracheal involvement. On the other hand, there was no difference between pathological types (squamous cell carcinomas, adenocarcinomas, oat cell carcinomas) with regard to prognosis. We advocate an aggressive approach in selected cases of N2 bronchogenic carcinoma. Neoadjuvant chemotherapy should be tested in these specific patients with a view to the possibility of improving results.
Aged↗
[Pseudotumoral lipid pneumopathies. Apropos of six cases].
In cases of localised pneumonia due to oil aspiration, the diagnosis may be difficult and is often assessed by thoracotomy. Six cases of lung paraffinoma are reported. The lesion, localised in the lower lobe in five patients out of six, was discovered on screening chest x-rays. In two cases, two lesions were observed in the same patient. All six patients underwent lung resection. Diagnosis was made on histologic examination showing foreign body reactions against oil. Oil aspiration was due to oily nose drops in one patient and to the use of paraffin oil on a tracheostomy in two others. The preoperative diagnosis may be suspected on bronchial lavage CT scan and MRI. When the diagnosis is strongly suspected, thoracotomy can be avoided as in some cases withdrawal of the medication can be followed by progressive resolution of the radiological signs.
Aged↗
[Pulmonary sequestration. Surgical aspects based on 61 cases].
Between 1955 and 1989, 61 patients (33 men, 28 women; mean age: 20 years) were operated upon for lung sequestration. Sequestration was intralobar in 49 cases and extralobar in 10 cases; both types were present in 2 cases. The abnormality was discovered by chance in 15 patients (24%). The most frequent clinical manifestations were those of recurrent bronchopneumonia (54%). X-ray films of the chest showed an apparently benign, posterobasal image in 88% of the cases. Arteriography was performed in 40 patients and revealed an abnormal systemic artery in 28. An abnormal artery was found by the surgeons and the pathologists in all cases. The intralobar type of sequestration was treated, by preference, by lobectomy, and the extralobar type by sequestrectomy. Problems were encountered in 5 cases: 2 wounds of an unrecognized artery and 3 difficult bleeding controls which required aortic clamping. The operative mortality was nil, and the morbidity rate was 5%. Computerized tomography and magnetic resonance imaging can confirm the diagnosis of pulmonary sequestration, but arteriography seems to be the best method to ascertain the diagnosis and guide the surgical procedure. Surgery is the rule in case of doubtful diagnosis or to treat symptomatic sequestration.
Adolescent↗
[Pulmonary arteriovenous aneurysms. Results of a survey conducted among members of the French-language Society of Thoracic and Cardiovascular Surgery. Study of 118 cases].
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Adolescent↗
Sarcoidosis and testicular germ cell tumor. Case report.
The authors describe the case of a patient with stage II non seminomatous germinal cell tumor of the testis with a generalized sarcoidosis. They review the existing literature and discuss the problem of diagnosis.
Adult↗
[Rupture of the diaphragm of late manifestation].
Twenty one cases of delayed diagnosis of ruptured diaphragm caused by closed trauma are reported: 14 on the left side and 7 on the right side. The clinical signs and the modes of presentation are non-specific. Although the history of thoraco-abdominal trauma and the chest x-ray are sufficient to establish the diagnosis of rupture of the left hemidiaphragm, they can only suggest the diagnosis in cases of righ-sided rupture. The mechanism of rupture is more often due to sudden reflex contraction of the diaphragm against a closed glottis than to excessive abdominal pressure caused by the trauma. Diaphragmatic rupture due to closed trauma causes large tears exposing the patient to a low risk of strangulation of intestinal structures in contrast with ruptures due to a penetrating injury, which causes small tears. The diaphragmatic domes must be systematically explored during laparotomy or thoracotomy performed for thoraco-abdominal trauma.
Adolescent↗
[Solitary plasmacytoma of the trachea. Apropos of a case].
A case of solitary plasmacytoma of the trachea is reported. Immunohistochemical study is mandatory to prove a monoclonal immunophenotyping. Research for signs of systemic disease and follow up over a long period of time are indicated. Surgery alone, sometimes followed by irradiation, seem to be the treatment of choice. In most cases, complete resolution is observed.
Aged↗
[Value of superior angiocardiography in the evaluation of the surgical excision of bronchial cancer. Respective role compared to thoracic x-ray computed tomography].
The place of angiography-superior vena cavography in the assessment of the resectability of a lung cancer must be defined in comparison with the data provided by thoracic computed tomography. Sixty-six patients with proximal lung cancers of doubtful resectability were studied by means of angiography and computed tomography and the results of these preoperative investigations were correlated with the operative findings. The sensitivity of these two examinations for the diagnosis of vascular invasion preventing pulmonary resection is poor (53% and 47% respectively). The specificity and positive predictive value of angiography appear to be slightly superior to those of computed tomography (Sp: 96% and 82%, PPV: 78% and 47%, respectively). The diagnostic performance of these two examinations remains poor. Magnetic resonance imaging may replace these two examinations in the future.
Carcinoma, Bronchogenic↗