Postoperative recurrence of primary lung cancer: anatomo-clinical and therapeutic study

BACKGROUND

Lung cancer is the leading cause of cancer mortality worldwide. Even after radical resection, the rate of recurrence of non-small cell lung cancer remains high.

AIM

To identify the profile of patients operated for lung cancer and to study the prognostic factors of tumor recurrence.

METHODS

We performed a retrospective study including 67 cases of lung cancer with curative surgery, hospitalized between 2010 and 2016.

RESULTS

The mean age was 61 years. The sex ratio was 21. The average time to diagnosis was 22 days. The average time to start treatment was 10 days. The most common histological type was adenocarcinoma (63%). Lobectomy was performed in 63% of the patients. Tumor recurrence was noted in 40% of the patients. The average time between recurrence and the surgical treatment was 12 months. The most common location of recurrence was the lung (70%). Recurrence was more common among adenocarcinoma and smokers older than 60 years. The majority of locally advanced and metastatic cancers have recurred. The average survival was 56 ± 4months. Better survival rates were observed in young patients, with less than 25 pack-years of early-stage, no lymph node involvement, and patients who received adjuvant chemotherapy. The probability of survival was 5 years for all tumor stages.

CONCLUSION

The prognostic factors for recurrence after radical resection for lung cancer were: the age of patients, smoking history, histological type, tumor stage, and surgical procedure.

Advanced Lung Cancer Inflammation index: a prognostic score in patients with metastatic non-small cell lung cancer

INTRODUCTION

Recent studies have identified that inflammation had a significant association with cancer development and progression.

AIM

To explore the relationship between ALI score and prognosis of metastatic non-small cell lung cancer (NSCLC).

METHODS

we conducted a retrospective study of 41 patients with metastatic NSCLC diagnosed between January2010 and January2012. ALI was calculated as body mass index x serum albumin/neutrophil to lymphocyte ratio. Patients were divided as low inflammation (ALI≥23.2) and high inflammation (ALI<23.2) groups.

RESULTS

Mean age was 56.3 years, 100% were male, and 49% had adenocarcinoma. The overall survival was 8.9months. Median ALI was 23.2. The median overall survival was 6.7 months and 11.3 months respectively in patients with ALI score<23.2 and ≥23.2 (p=0.043). On multivariate analysis, ALI score < 23.2 remained significantly associated with worse outcome.

CONCLUSION

Lower ALI (<23.2) was significantly associated with worse overall survival in metastatic NSCLC. The assessment of the ALI is inexpensive and widely available; it could help in identifying patients with poor prognosis in clinical routine practice.

Pulmonary Sarcomatoid carcinoma: a surgical diagnosis and prognostic factors

INTRODUCTION

Pulmonary Sarcomatoid Carcinoma (PSC) is a rare group of tumors accounting for about 0.4% of non-small cell lung carcinoma (NSCLC). Five subtypes were described: pleomorphic carcinoma, spindle cell carcinoma, carcinosarcoma, giant cell carcinoma and pulmonary blastoma. The diagnosis is pathological but requires a good quality sampling of the tumor.

METHODS

On a series of 1582 patients operated on for lung cancer from 1992 to 2016, 43 patients were retrospectively identified as having been treated surgically for pulmonary sarcomatoid carcinoma.

RESULTS

The population consisted of 33 males and 10 females with mean age of 55 years. Imaging findings showed a peripheral mass in the majority of cases (n=29). Careful investigation failed to discover a primitive lesion elsewhere. Six patients received induction therapy for wall involvement. Lobectomy or bilobectomy was performed in 30 patients and pneumonectomy in 11 patients. A wedge resection was performed in one patient and an exploratory thoracotomy in another. In macroscopy, the mean tumor's size was 5.2 cm (1-17.5cm). The histologic diagnoses were: pleomorphic carcinoma (n=30), carcinosarcoma (n=5), spindle cell carcinoma (n=1), giant cell carcinoma (n=3) and blastoma (n=4). Two patients died within 1 month of surgical complications and 5 died of disease within 17 months. Adjuvant therapy was performed in 6 patients. Recurrence happened in 4 patients within 12 months after operation. Median survival for all patients was 8months.

CONCLUSIONS

Resection of primary pulmonary sarcomatoid carcinoma is associated with an acceptable survival rate if the resection is complete. The size of the tumor is the most important prognosis factor. Nevertheless, a carefully follow-up is essential.

Brain metastases of non-small cell lung cancer: prognostic factors and management

BACKGROUND

The prognosis of patients with non-small cell lung cancer (NSCLC) with brain metastasis (BM) is dark. The aim of our study was to analyze the prognostic factors after the onset of BM and to evaluate the current management of BM.

METHODS

We conducted a retrospective study that included 100 patients diagnosed with primary NSCLC with BM. Survival was analysed using Kaplan Meier curve.Univariate survival analysis was performed to assess the prognostic value of sex, age, gender, performance status, histologic type, tumor size, BM features and treatment modality of primary lung tumor and BM.

RESULTS

The median age was 57 years; 94% of the patients were male. Most patients (85%) had a PS of (0-1). BM were unique in 54% of cases, symptomatic in 40% of cases and synchronous in 72% of cases. Chemotherapy was administered to 78% of patients; pulmonary tumor surgery was performed in 5% of patients. BM surgery and panencephalic irradiation were performed in 13% and 86% of patients, respectively. The median overall survival after NSCLC diagnosis was 13.33 months. The median overall survival after BM was 10.6 months. The Control of the primary tumor was the only factor associated with better overall survival (64.95 months Vs 10.6 months (p=0.02)).

CONCLUSION

Pulmonary tumor control with complete surgical excision is predictive of better overall survival in patients with NSCLC and BM.

Prognostic factors for second-line chemotherapy of metastatic non-small-cell lung cancer

BACKGROUND

Few studies have been conduct¬ed to determine prognostic factors of second-line chemotherapy. The aim of this study was to determine the prognostic factors for survival in patients receiving second-line treatment for advanced NSCLC.

METHODS

We retrospectively reviewed the records of 71 patients with metastatic NSCLC who received second-line chemotherapy from January 2006 to January 2013.

RESULTS

The mean age was 57 years. All patients were male. The performance status was 0 or 1 in 90.1% of cases. Sixty-four patients received a first line platinum-based chemotherapy. The second line chemotherapy regimen was docetaxel in 31 cases and pemetrexed in 18 cases. Fourteen patients (19.71%) had received third-line chemotherapy. The median overall survival was 13.5 months. Age older than 65 years (p=0.025), advanced T stage (T4 versus T3 and T2; p=0.01), advanced N stage (N3 versus N2 and N1; p=0.001), lower level hemoglobin (p=0.05) and non-responders who showed progression with first-line chemotherapy (p=0.04) were significant negative predictors in univariate analysis for overall survival (OS). The multivariate analysis showed that age≥ 65 years (HR=2.15; 95% CI[1.26-2.44]), advanced N stage (HR=2.273; 95% CI [1.26-2.44]) were independent prognostic factors for OS.

CONCLUSION

Age and advanced N stage were important factors in predicting the outcome of advanced NSCLC patients who were undergoing second-line chemotherapy.

[Paradoxical reaction following antituberculosis therapy in immunocompetent patient]

INTRODUCTION

The features of paradoxical reactions (PR) that occurred in non-HIV infected patients are rare and not well known.

CASE REPORT

The authors reported the case of a 21years old, non-immunocompromised, and HIV negative patient treated for disseminated tuberculosis. PR occurred after 8months after initiation of antituberculous treatment. PR presented as left cervical lymphadenopathy, pulmonary, pleural, costal and spinal location of the tuberculosis. The antituberculous drugs were prolonged. Patient's clinical symptoms improved initially. However, left inguinal lymphadenopathy appeared after 20months of antituberculous therapy. Inguinal lymph node biopsy revealed tuberculous lymphadenitis. The patient has a good compliance to the treatment. The patient was continued on same antituberculous treatment for a total of 28months. The cervical and inguinal lymphadenopathy disappeared and CT scan showed regression of thoracic, abdominal, costal and spinal lesions.

CONCLUSION

PR during antituberculous treatment must be considered after exclusion of other causes. No consensus on the therapeutic management of this entity has been developed to date.

Assessment of eating behavior after smoking cessation

Background Weight gain is very frequent after smoking cessation and constitutes an obstacle to the decision to quit smoking. Aim To assess the impact of smoking cessation on the weight and eating behaviour. Methods This was a prospective study that included thirty four smokers. A questionnaire allowing the assessment of the eating behaviour was given to all smokers at the first consultation and at one month of smoking cessation. Results The mean age was 40.32 years. Thirty two smokers were males. The mean weight had increased by 1.7 kg at 1 month of smoking cessation (p=0.00). The increase of weight was significativelly associated with the female gender, the age of smoking initiation and the consumption of cigarettes per day. The waist and hip circumferences had also increased (p=0.00). The calories intake had increased from 3875.70 Calories to 4168.85 Calories (p=0.03). Snacking had increased from de 73.5% to 82.4% (p= 0.263). The intake of lipids and carbohydrates had not changed. The intake of protein had decreased from 14.57% to 13.5% (p= 0.041). An increase of the intake of fiber (p= 0.033), zinc (p= 0.033), and vitB9 (p= 0.044) had been noted. Conclusion The weight gain is an unwanted effect of smoking cessation which justifies a global care.

[Impact of tobacco on bronchopulmonary affections: magnitude of the problem]

BACKGROUND

Tobacco smoking is frequent in the world affecting 20 à 50% of the population but with a decrease in occidental countries due to a huge effort based on sensiblisation and anti-tobacco decisions.

AIM

To review the impact of tobacco on bronchopulmonary affections.

METHODS

A narrative review of literature

RESULTS

In the next future, yearly tobacco-related deaths could increase from 4.2 millions in 2000 to 10 millions in 2025-2030 making smoking as the main evitable cause of deaths by respiratory diseases. Lung cancer is the leading killer cancer. Tobacco is the most frequent cause of respiratory diseases. It is responsible of 80 to 90% of deaths by chronic obstructive pneumobronchopathiy (COPD) and 80 to 85% deaths by bronchopulmonary cancer.

CONCLUSION

Tobacco is a « chronic disease » necessitating management with advices and medical treatment.

[Lung cancer with venous thrombo-embolism: clinical characteristics]

BACKGROUND

Lung cancer is the most common malignancy diagnosed in patients with venous thrombo-embolism (VTE).

AIM

To investigate clinical, biological, radiological features and survival of lung cancer patients with VTE.

METHODS

Retrospective case-control study investigating biologic, clinical course and survival of 25 patients lung cancers with VTE (Group M) and 50 lung cancers without VTE (group T).

RESULTS

The frequency of the VTE was 5.88% with 2.58% pulmonary embolism (PE). The mean age was 58 years ± 9.8 in group M and 57.9 years ± 9.6 in group T. No significant difference concerning medical or surgical history for both groups was found. The dyspnea and chest pain were at equal frequency (63.6%). Regarding the clinical probability of the PE, it was no significant differences between the two groups. A rate of D-dimer > 0.7μg/l was more frequent among group M (75% vs 20%; p = 0.054). The most common histological type was nonsmall cell lung cancer (88%). A stage IV was significantly more frequent in group M (86.4% vs. 52.3%; p = 0.007). The mean period of survival in Group M was 10.6 ± 1.2 month and 20.2 + 1.8 month in group T; p = 0.38.

CONCLUSION

The VTE associated to lung cancer is under diagnosed. Prospective studies are needed to establish more adapted scores.

[Palliative chemotherapy of non small lung cancer in Tunisia. Prospective study of the cost and impact on the quality of life]

BACKGROUND

Bronchopulmonary cancer is actually the first cancer in the world. In Tunisia, recent statistics are alarmous. The most bronchopulmonary cancer in tunisian series are diagnosis at metastatic states.

AIM

To evaluate the cost of the global treatment by chemotherapy in patients with metastatic non small lung cancer and its impact over the quality of life in Tunisia.

METHODS

It's a prospective study lead between January 2006 and Juin 2007 to evaluate the quality of life for patients hading metastatic non small lung cancer treated by palliative chemotherapy in Ibn Nafiss department in Abderrahmen Mami hospital.The evaluation of the quality of life is inspired by the questionnaire of EORTC: QLQC30 version 3 translated in en Arab language, filled before chemotherapy, after the le 3rd cycle, and at the end of the first ligne. The study of the cost is effected for the 2 protocols whose the most used in first ligne : Cisplatin-Vinorelbine (P-V) and Cisplatin- Gemcitabine (P-G) RESULTS: 30 patients had benefit from palliative chemotherapy based on P-V (18 cases) or P-G (12 cases). All patients had responded for the questionnaire in the opportunity moments. After 3 cycles of chemotherapy, we note an improve of the symptomatic, physical, activity, emotional and global health scales. In opposition, we note a deterioration of cognitive and social scales without any supplementary improvement(no significant difference) if we add other cycles in the twice protocols. At the same level of the benefit in term of quality of life and survival without supplementary toxicity, the choice is made by the less cost's protocol in other words P-V.

CONCLUSION

Our results confirm the benefit from chemotherapy in term of survival and quality of life in our context, however, the important cost of the chemotherapy necessitate to rationalize the indications and the le choice of the treatments in this palliative indication.

[Allergic bronchopulmonary aspergillosis. A review of 3 cases]

BACKGROUND

Allergic bronchopulmonary aspergillosis (ABPA) is a rare affection, initially described in 1952. Its pathophysiology incriminate several mechanisms in relation with the organism of the patient and the bronchial colonisation by the fongic agent.

AIM

To report three cases of ABPA.

CASES REPORT

Three patients had been treated for ABPA in Ibn Nafiss department in Abderrahmen Mami hospital in Ariana. ABPA had been discovered in the three cases by a cortico dependant asthma, refractory for different therapeutics. Positive diagnosis reposed in the 3 patients at 6 major and one minor criterion. Treatment was essentially based in corticotherapy.

CONCLUSION

Positive diagnosis of ABPA is actually well established, however, its treatment, although based on corticotherapy, remind not clearly codified. Association of antifongic treatment may improve the prognosis.

[Thoracic manifestations of systemic lupus erythematosus]

BACKGROUND

Systemic lupus erythematosus (SLE) is an autoimmune disease. The respiratory system is more commonly involved in SLE than in any other collagen vascular disease.

AIM

To study the pleuropulmonary manifestations of SLE.

METHODS

Retrospective study including 10 patients hospitalized between January 2000 and December 2008 for pleuro-pulmonary manifestation revealing or complicating the SLE.

RESULTS

Nine women and only one man aged between 21 and 67 years-old were included in this study. Two patients had already SLE and for the other patients the pleuro-pulmonary manifestations were revealing the SLE. Pleural effusion was the most common manifestation witch represents 50% of the patients. For the other patients we find one case of interstitial pneumonia, one case of pulmonary embolism, on case of pneumonia, on case of pulmonary haemorrhage and on case of pulmonary hypertension. All these patients were treated by corticoids and only one patient takes high doses of corticoids for managing a massive pulmonary haemorrhage. The evolution was favourable for 9 patients, one patient dead because of massive pulmonary haemorrhage complicated with acute respiratory failure.

CONCLUSION

Pleuro-pulmonary involvement in SLE is common and may be life threatening, in which case prompt and aggressive treatment is mandatory.

[Neoplasic vena cava syndrome]

BACKGROUND

Vena cava superior syndrome results of an obstruction of superior vein cava(SVC)and/or brachiocaphalic venous troncs by extrinsic compression and/or by tumoral or cruoric thrombosis. The bronchopulmonary cancer represents the most frequent aetiology.

AIM

The aim of this study is to establish clinical, radiological, evolutive profiles and modalities of treatment of neoplasic vena cava superior syndrome independently of its histological type.

METHODS

It is a retrospective study about 20 patients presenting vena cava superior syndrome complicating primary bronchopulmonary cancer, hospitalised between January 2000 and December 2007 in Ibn Nafiss department in Abderrahmen Mami hospital.

RESULTS

All patients were males with an average of 57,8 years. Vena cava superior syndrome had revealed cancer in 60% of cases. It was metachrone in 40% of the patients. The most frequent histological type was small cell lung cancer. Treatment was proceeded in 2 steps, symptomatic and etiologic for the bronchopulmonary cancer.

CONCLUSION

The bronchopulmonary cancer is the most frequent aetiology of vena cava superior syndrome. Its treatment is actually well codified.

[Tuberculosis in patients with asthma]

INTRODUCTION

The association of asthma and tuberculosis is rare but may raise particular issues around patient management. The aim of this study was to evaluate the clinical, therapeutic and progress of this association.

PATIENTS AND METHODS

We describe a retrospective study, which included seven asthmatic patients hospitalized for pulmonary tuberculosis during the period between June 2001 and June 2006.

RESULTS

Five men and two women were included. Mean age was 37 years. Two patients had mild asthma, four had moderate asthma and one had severe and corticosteroid-dependant asthma. Only four patients had controlled asthma when tuberculosis diagnosis was established. Asthma treatment was based on inhaled corticoids and long-acting beta-2-agonists. During antituberculosis treatment two patients developed near fatal asthma. Long-term stable asthma control was achieved over a time course of 3 to 8 years.

CONCLUSION

The association of asthma and tuberculosis can lead to potential therapeutic difficulties because of pharmacologic interactions between antituberculosis therapies and treatments for asthma treatment. In addition asthma following treatment for tuberculosis appears to be well controlled.

[Adjuvant chemotherapy in resected non small cell lung cancer: preliminary results about 8 cases]

AIM

Report the preliminary results of adjuvant chemotherapy in patients surgically treated for non small lung cancer.

METHODS

It's a prospective study about 12 patients surgically treated between January 2005 and December 2007.8 patients had benefit of adjuvant chemotherapy. The protocol had been based at 4 cycles of Cisplatine.

RESULTS

Our 8 men patients, aged for the mean of 59 years with a Performans Status at 1, had benefit of adjuvant chemotherapy after curative surgery. Six patients considered us II B stage, had benefit immediately for surgically treatment. Adjuvant chemotherapy protocol had been based of Cisplatin and Vinorelbine (5 patients) and Cisplatin and Gemcitabine (1 patient). The 4 cycles can be administered without any limiting toxicity only for one patient who's received 2 cycles of Cisplatin and Gemcitabine in front of the severity of digestive side effects. Two patients considered us IIIB stage, had been surgically treated after neo adjuvant chemotherapy based at Cisplatin and Vinorelbine. Histological response was complete for twice of them. The same chemotherapy was stopped after 2 cycles us adjuvant, in front of haematological side effects. Two patients did at 4 and 15 months of neoplasic progression. The six other patients had been still on life with a move back of 33 months.

CONCLUSION

Post operative adjuvant chemotherapy is the standard treatment for the II A and II B stages and probably for IB stage. For none immediately operative patients (IIIA and some III B), articulation of chemotherapy with surgery must be clarified.

[Solitary malignant fibrous tumors of the pleura]

Solitary fibrous tumours of the pleura are usually benign. However, malignancy is observed in 13% of the cases. The authors report two cases of 27 and 69 year-old patients, presenting chest pain and dyspnoea. The roentgenograms and computed tomography scanning revealed a pleural tumour in both cases. The patients underwent complete resections of these tumours. The immunohistochemical study confirmed the diagnosis of malignant solitary pleural fibroma. The patients succumbed to their disease secondary to local recurrences. Histopathology is very helpful in the diagnosis of malignant pleural fibroma. Surgery and long-term follow-up are mandatory.

[Rare localization of sarcoma in an adolescent: thoracic Ewing sarcoma]

BACKGROUND

Ewing Sarcoma is considered as primitive neuro ectodermic tumor. It's the most frequent osseous tumor in children and adolescent. It was localised frequently at long osseous and pelvis, however, it can be arising from the rib.

AIM

this article aimed to show that Ewing sarcome could arise twely from thorax.

CASE REPORT

We report the case of 15-year-old girl, admitted in our hospital because of left scapular pain with important weight loss. Chest X ray showed dense left latero tracheal opacity with mediastinal limits. Bronchofiberoscopy was performed and it showed no abnormalities. Thoracic CT scan and MRI noted left posteroir expansif mediastinal process infiltrating D2, D3 and homolateral conjugation's canal. This process was associated at vertebral metastasis in D1, D4 and D8.Rapid clinical aggravation, with installation for medullar compression was noted. The patient had benefit for three cures of decompress radiotherapy and treated by laminectomy of dorsal vertebras in neurosurgery department. Morphologic aspects and immunohistochimical study for the operator piece concluded at Ewing sarcoma of the children considered as primitive neuro ectodermic tumor. Six cures of chemotherapy had been prescribed with well recuperation of the motor failure. She still on life since 7 months.

CONCLUSION

Even rare, thoracic localisation of Ewing sarcoma in not exceptional, it is necessary to evocate it in front of mediastinal mass.

[Effect of tobacco smoking on pulmonary tuberculosis]

Tobacco increases the risk of pulmonary infection, especially tuberculosis. We try by this study to analyse this action. It's a comparative study between two groups of patients hospitalized in our department between January 2006 and June 2008. The first group was made of 30 smokers patients hospitalized because of confirmed pulmonary tuberculosis. The second group consists of 30 non smokers patients and also hospitalized because of confirmed pulmonary tuberculosis. Delay of diagnosis was longer in the group of smokers (3, 1 +/- 3 months versus 2 +/- 1 month with p = 0.039). The most frequent symptoms in both groups were cough and loss of weight. The biological investigations showed a high level of white blood cells with predominance of neutrophil cells especially in smokers (p = 0.024). Chest X ray showed essentially nodules in both groups. These nodules were bilateral in smokers (P = 0.045). Evolution after antituberculosis treatment was favourable for all patients. A delay of recovery (time between symptoms and recovery) was longer in smokers than in non smoker patients (p = 0.043). Pulmonary Sequels such as dyspnoea (p = 0.016) and fibrosis (p = 0.041) were most frequent in smokers. No patients had tuberculosis relapse. Tobacco may delay the recovery of pulmonary tuberculosis and may induce pulmonary sequels in spite of correctly antituberculosis treatment.

Pulmonary metastases revealing choriocarcinoma

BACKGROUND

Uterin choriocarcinoma is a trophoblastic tumour characterised by high metastasis potential. Pleuropulmonary metastasis can reveal rarely the neoplasm.

AIM

Repport a new case.

CASE REPORT

We report the case of a 31-years-old woman, with no pathological antecedent, admitted in our department for thoracic pain and haemoptysis occurring two months after delivery of a did in child-birth. Chest X ray and thoracic CT scan showed several bilateral opacities. A diagnosis of metastatic choriocarcinoma was confirmed by plasmatic level of beta human chorionic gonadotrophin (beta HCG) superior to 4000 UI/ml. Gynaecological exam revealed latero-uterine mass. Abdomino-pelvien ultra sound and CT scan showed tissular latero uterine and hepatic masses. Brain CT scan had been normal. Patient died after 3 cures of chemotherapy because of acute respiratory failure caused by massive pulmonary embolism.

CONCLUSION

Diagnosis of choriocarcinoma must be evocated in front of several pulmonary opacities occurring in genital activity women and necessities the dosage of level of BHCG.

Multiple myeloma presenting with multiple thoracic manifestations

Multiple myeloma is a malignant proliferation of plasma cells that affects mainly bone marrow but may also involve other organs as well. We report thoracic involvement in the form of left-sided pleural effusion, osseous lesions, bronchial infiltration, and mediastinal lymphadenopathy in a 61-year-old woman, non-smoker presented with chest pain, dyspnoea, cough and deterioration in general health over the preceding seven months. Immunoelectrophoresis and immunofixation showed raised kappa-light chain immunoglobulin G (IgG) in serum and pleural fluid. Bronchial and pleural biopsies documented myelomatous infiltration and bone marrow aspirate revealed extensive plasma cell infiltration. At eight months, following the fourth cycle of melphalan, endoxan and prednisone based chemotherapy, the patient died.

[Echinococcosis of the rib with epidural extension]

Osseous hydatidosis, especially when located in the rib, is a very rare disease. Less than 50 cases of costal echinococcosis have been reported in the literature to date. The authors report a case of echinococcosis of the rib with epidural extension in a 76-year-old patient presenting paraparesis. In addition, the patient presented a large posterior and thoracic soft tissue mass measuring about 30 centimetres in diameter. A chest x-ray, a CT thoracic scan and an MRI of the dorsal spine were performed. The imaging suggested echinococcosis of the rib with epidural extension. The cyst was completely resected. Histopathology of the resected specimen confirmed the diagnosis of echinococcosis. The patient died due to postoperative complications. Accurate presurgical diagnosis allows for appropriate management and helps eradicate the disease. This also prevents the dissemination of parasites and further complications.

Association deep veinous thrombosis with pulmonary tuberculosis

BACKGROUND

Pulmonary tuberculosis has been reported as a risk factor for deep venous thrombosis.

AIM

In the present study we reported, physiopathological, epidemiological, clinical and therapeutic features of the association of deep venous thrombosis and pulmonary tuberculosis.

METHODS

This is a retrospective study done in our department between January 2000 and December 2007. It is about 14 cases of confirmed pulmonary tuberculosis associated with deep venous thrombosis.

RESULTS

It is about 14 men. The mean age was 40 years old. Pulmonary tuberculosis was confirmed by the presence of acido-alcoolo-resistant bacillus on the sputum at direct exam in 12 cases (81, 8%) and in the bronchial aspiration in 2 cases (18%). Phlebitis occurred within a mean of 20 days after the diagnosis of tuberculosis. It was confirmed by doppler deep venous ultrasound of inferior members. All patients received anti-tuberculosis drugs in association with anticoagulant treatment. Etiologic investigations showed positive anti-phospholipids antibodies in one case, and decrease in C and S proteins for 2 patients in which phlebitis was complicated by arterial pulmonary embolism. We had difficulties for controlling prothrombin level in 4 cases and we must prescribe low molecular weight heparin for 6 months in one case.

CONCLUSION

A lot of attention should be done, in the follow up of pulmonary tuberculosis especially in severe presentation; because of the deep venous thrombosis's risk occurrence. Prophylactic anticoagulant treatment should be done in some cases, when the risk is higher.

[Left hemothorax caused by aortic dissection]

Hemothorax is generally secondary to trauma, invasive thoracic surgery or specific lung of pleural disease. Hemothorax secondary to aortic dissection is rare. We report a case in a 69-year-old man with a history of smoking and hypertension. The patient was referred for exploration of a left pleural opacity with mediastinal widening. Pleural puncture produced a hemorrhagic fluid. The thoracic scan led to the diagnosis of Stanford type B aortic dissection. The patient was given antihypertensive treatment and now has a sixteen month follow-up. Aortic dissection can give rise to hemothorax, especially in a hypertensive subject with an anomalous aortic arch or mediastinal widening on the chest X-ray. Computed tomography generally gives the diagnosis. Treatment may be medical or surgical, depending on the site of the lesion and the severity of the clinical presentation. Aortic dissection is a cause of hemothorax, particularly in patients with favorable conditions or a suggestive radiological anomaly.

[Broncholithiasis]

INTRODUCTION

Broncholithiasis is defined as the presence of calcified material in the bronchial lumen. The aim of our work was to study the clinical, radiological and therapeutic aspects of broncholithiasis.

OBSERVATIONS

We report the histories of 6 patients identified over 14 years (1990-2004). They included 4 men and 2 women with an average age of 50 years. A past history of pulmonary tuberculosis was found in 2 cases. The presenting symptom was haemoptysis in 4 patients. Fibreoptic bronchoscopy was performed in all patients and broncholiths were found in two. Thoracic CT scan was performed in 5 patients and in 3 showed hilar and parenchymal calcification, suggesting the diagnosis of broncholithiasis. The diagnosis was confirmed in 2 patients by bronchoscopy, in 2 others by surgical biopsy and in the remaining 2 by the CT appearances. Three patients were operated on: 2 for diagnosis and the third for haemostasis. Pulmonary tuberculosis was discovered in 2 patients, one by culture and the other by surgical biopsy. The outcome was satisfactory in all cases.

CONCLUSIONS

Broncholithiasis presents a problem of differential diagnosis from other pulmonary pathologies on account of misleading clinical, endoscopic and radiological features.

[Solitary plasmocytoma of the rib: a rare tumor not to miss]

Solitary plasmocytoma is a rare tumor accounting for 5% of all plasma cell neoplasias. The diagnosis is based on identification of the localized tumor composed of monoclonal plasma cells identical to those observed in multiple myeloma, and absence of the signs in favor of a disseminated form. We report the case of a52-year-old man who presented a growth of the chest wall in the left axillary region. Imaging disclosed a mass of tissue with a large zone of osteolysis of the 6th rib and infiltration of the chest wall. Surgical biopsy for pathology study and immunohistochemistry enabled the diagnosis of costal plasmocytoma. Blood protein immunoelectrophoresis revealed a monoclonal kappa type IgG. Bence-Jones proteinuria was positive. Search for other localizations was negative and the diagnosis of solitary plasmocytoma was retained. Radiotherapy was delivered and the patient has remained in remission at one year. Costal localization is rare for solitary plasmocytoma. The diagnosis is based on imaging findings and pathology. Radiotherapy is the treatment of choice but with the risk of progression with other bone lesions, the development of medullary plasmocytosis and multiple myeloma. Factors predictive of systemic recurrence have not been identified. Regular surveillance is required.

[Benign schwannoma: a case report about a uncommon localisation]

Schwannoma is a benign slow growing nerve sheath tumor which generally originates from cranial or spinal nerve roots. Peripheral nerve localisations are scarce. We report the case of a 76-year man who presented with a laterosternal chest wall mass located in the fourth intercostal space. Diagnosis of intercostal benign schwannoma was suggested by medical imaging and confirmed histologicolly upon surgical removal. Chest wall solitary schwannoma is exceptional. Our case is still more interesting by its peripheral localisation and late occurence following a chest trauma.

[Pseudo tumoral bronchial tuberculosis]

Bronchial lesion is a rare site for tuberculosis. It can mimic lung cancer especially when sputum- smear is negative, and this be a cause of a delay in diagnosis, that can be made later on by a culture of Koch bacillus or after a bronchial biopsy. Through these 4 cases reports, the authors recall the ethiopathogenic hypotheses of this lesion and review the radiologic, clinical and prognostic features of these unusual forms of TB.

[Pleural effusion revealing multiple myeloma]

Pleural effusion is rarely observed in multiple myeloma, its frequence is estimated at 6%, and its myelomatous origin occurs in only 1% of the cases. It is exceptionally the first sign of multiple myeloma. We report two cases of IgA and IgG multiple myeloma revealed by pleural effusion. The first case was a 61-year-old woman who developed pleural effusion with a bone endobronchial and pericardial location of multiple myeloma; the second case was a 65-year-old man who had isolated pleural effusion. These pleural effusions were found to be caused by myeloma and were verified by the presence of the same monoclonal immunoglobulin in both plasma and pleural liquid. Atypical plasma cells were found in the pleural fluid.

[Hydatid pulmonary embolisms. Seven cases]

Hydatid pulmonary embolism is a rare condition. Diagnosis is difficult and there is no consensus on treatment. Prognosis is generally poor. We conducted a retrospective analysis of patients hospitalized between 1994 and 2002 who had a diagnosis of hydatid pulmonary embolism. Seven cases were identified. All patients had a cyst which spontaneously ruptured into the bloodstream. All patients were symptomatic. Chest x-ray revealed images of metastatic pulmonary echinococciasis in all patients. Thoracic CT and/or angioscan provided the diagnosis in five patients. In one, the diagnosis was established with pulmonary angiography. For one other, the diagnosis was established at the pathology examination of the surgical specimen. Searching for the primary localization of the hydatid disease revealed hepatic cysts in all patients, associated in one with a cyst in the right atrium. The cardiac cyst was not operated and all hepatic cysts were removed. Embolectomy was performed in one patient. Medical treatment with albendazole was given in five patients. The clinical course was marked by death in two patients, due to abundant hemoptysia. The five other patients are followed regularly and were doing well at six months to five years. The diagnosis of hydatid pulmonary embolisms is basically obtained with imaging. Treatment is surgical resection of the embologenic focus then embolectomy. The role of medical treatment is not clearly defined. The short- and mid-term prognosis is generally poor.

[Diagnosis of non-severe pulmonary embolism by a decision analysis-based strategy in pulmonary hospital recruted-patients]

We have study prospectively cases of non severe pulmonary embolism in a pulmonary department by an analysis based strategy associating radio-clinical probability, venous ultra sonography, D-Dimers value followed, if no performed diagnosis, by pulmonary scintigraphy or angio-CT scan. 64 cases of pulmonary embolism suspicion have been hospitalised in our department between October 1998 and July 2001; 40 patients was included in our study and have been classified in 3 groups regarding pre test clinical probability. Anticoagulant treatment has been initialised only in the third group (probability >80%) Clinical probability associated with venous ultra sonography and D- Dimeres value allow or exclude pulmonary embolism diagnosis in 27 patients. In the others, scintigraphy and angio CT scan were necessary for establishing diagnosis. Application of this algorithm allow diagnosis of pulmonary embolism in 29 patients and exclude this pathology in the other 11. None of this patient complained from recurrent thrombo embolic accident during 17 to 42 months observance period.

[Bronchectasis in Horton's disease: fortuitous association?]

Respiratory manifestations in Horton's disease are uncommon. We report the case of 63 year-old man with Horton disease diagnosed 2 months before, who was hospitalised for fever, deterioration in general health, cough and hemoptysis. Chest X-ray showed an infiltrate in the right upper lobe and bilateral cystic opacities predominant on basal suggesting bronchectasis who was confirmed secondary in CT-scan. Even though cortico sensible clinical manifestations and radiologic infiltrate were previously described in Horton's disease, association with bronchectasis was never been reported in literature and her etio pathogenic mechanism must be clarified.

[Tuberculous thoracic parietal abcess. Report of 4 cases]

Cold abcess of the chest wall is a rare extra-pulmonary tuberculous location, usually described in cases of severe or disseminated form of tuberculous. His frequency is estimated for 1 to 5% of osteoarticular tuberculous. Four cases of cold abcess of the chest wall are reported. Three of the patients are more than 65- year- old and a 30-year-old woman. In three cases, abcess is developped in the posterior chest wall and it is sternal in the fourth case . Neither immunodepression nor previous tuberculous history or other location of the tuberculosis were noted. Diagnosis is based on demonstrating mycobacterium tuberculosis in pus culture in three cases and on histologic pattern in the last one. Classic anti-tuberculosis treatement was prolonged at 12 and 15 months in 2 patients because of respectively general and local prolonged evolution.

[Manifestations of rifampicin-induced hypersensitivity]

INTRODUCTION

The side effects of rifampicine due to an immunoallergic mechanism are rare and usually observed during discontinued treatment or administration of high doses.

OBSERVATIONS

An immediate hypersensitivity reaction with anaphylactic manifestations and increase in IgE occurred in a 39 year-old man suffering from resistant tuberculosis. The reaction occurred within the first hour following a low dose of rifampicin administered in a desensitisation attempt, the outcome of which was favourable after administration of corticosteroids and antihistamines. A type II hypersensitivity reaction occurred in a 76 year-old male patient in the form of thrombopenia on D76 of a twice weekly treatment, diagnosed because of hemoptysis with normalisation of platelet level on withdrawal of rifampicin. An immune complex hypersensitivity reaction was responsible for hepato-renal failure on D68 of twice weekly treatment and required permanent withdrawal of rifampicin and dialysis, which led to subsequent improvement.

COMMENTS

These clinical cases illustrate the variability of the hypersensitivity mechanisms observed with rifampicin, the difficulty in imputability tests and methods for immunological confirmation, the interest of continuous treatment which avoids a certain number of these accidents, and that of desensitisation during immediate hypersensitive reactions which permits the continuation this major anti-tuberculosis drug.

[Thymolipoma. A case report]

Thymolipoma is an uncommon benign tumor of the thymus. Asymptomatic, it is an incidental discovery. Pathogenesis remains controversial. We report a new case in a 36-year-old woman that was discovered on a chest x-ray ordered for pneumonia. The MRI findings suggested the diagnosis which was confirmed at the pathology examination of the surgical specimen.

[Pulmonary artery aneurysms in Behçet's disease: contribution of imaging in 5 cases]

Pulmonary involvement in Behçet's disease is an uncommon condition (12%). Thromboembolism of the superior vena cava and/or other mediastinal veins, aneurysms of the aorta and pulmonary arteries are the main vascular manifestations in addition to pulmonary infarct and intrathoracic hemorrhage. Despite their scarcity, respiratory symptoms may be life-threatening. The aim of this study was to assess the contribution of thoracic imaging for one of the most serious aspects of the disease: pulmonary artery aneurysm. We report five patients with pulmonary artery aneurysms (mean age: 39.5 years). Hemoptysia revealed Behçet's disease in three. Initially explored by conventional radiography, computed tomography and angiography, pulmonary artery aneurysms are currently investigated well with helicoidal computed tomography, digital angiography, magnetic resonance imaging (MRI) and angio-MRI. These imaging techniques provide helpful information for the diagnosis of Behçet's disease.

[Muscle metastasis of a primary bronchial carcinoma]

Intra muscular metastasis are rare. They usually occurs during the course of a cancer. The primary bronchial carcinoma is the most common. Clinical features include painful mass, frequently, they are symptomatic. Sonography CT scan and MR imaging shows a non specific abnormally, but they defined their seat and their extension. The authors report a case of metastases of epidermoid bronchial carcinoma to left adductor muscle and gives a review of the literature.

[A rare complication of antineoplastic BCG therapy: pulmonary tuberculosis]

Local treatment with intra vesical BCG for bladder carcinoma have few complications. Pulmonary side effects are rare, like interstitial pneumonitis. We report a case of a 77-year-old man, treated with BCG for bladder carcinoma who developed illness and tumoral chest-X-ray opacity. Mycobacterium tuberculosis bovis was isolated in culture and 2 years after in sputum. Physio pathologic mechanism of pulmonary features remains controversial, however this case suggest that lung lesions can be result of an infection process.

[Costal hydatid cyst (report of 2 cases)]

Hydatidosis is an endemic affection in our country. Hepatic and pulmonary localisation is the most frequent. The other localisation especially in the bone, are exceptional. We report 2 cases of costal hydatid diagnosed on 17 and 33 years old male patients admitted for parietal tumor respectively localized in cervix and thorax. The diagnosis, suspected on chest tomography is confirmed by histologic patterns of resected rib.