Arnaud Patoir

Preliminary study of efficacy of dynamic compression system in the correction of typical pectus carinatum.

OBJECTIVES This preliminary study evaluates, by qualitative score, the efficacy of the dynamic compression system (DCS) with a pressure-measuring device in the treatment of pectus carinatum (PC) as an alternative to surgery. METHODS A total of 68 patients (infants, adolescents and young adults) presenting with typical PC (64 males and 4 females) were evaluated in our Chest Wall Deformities Unit, between October 2011 and February 2013. The criteria for including subjects were: patients with typical condrogladiolar PC and pressure for initial correction (PIC) ≤ 9 PSI (pound square inch). Seven patients were excluded in this study: three typical PC were treated by minimal invasive surgery (Abramson technique) due to highly elevated PIC and four atypical PC, hybrids forms (PE and PC) were treated by cup suction for pectus excavatum and by the DCS for the PC. The management protocol included: adjustment of the DCS, strengthening exercises and monthly clinical follow-up. The partial and final results were evaluated by the patients, by their parents or by both, using a qualitative scoring scale that was measured in a three-step grading system, where C is a low or very low result, B is acceptable and A is a very good or excellent result. RESULTS A total of 61 patients (59 males and 2 females) presenting with typical PC were treated by the DCS and included: symmetric PC in 43 cases and asymmetric PC in 18 cases. The mean age was 13.5 years (5-25). The mean PIC was 6.3 PSI (3-9 PSI). The mean utilization time was 19 h daily. The patients were divided into three groups. In Group I, consisting of 35 cases, all the patients have already completed the treatment with excellent aesthetic results (A). In 12 cases, Group II, the normal shape of the thorax has been obtained; all the patients in this group rated their results as excellent (A); however, these patients are still wearing the brace as a retainer for 3 additional months. Fourteen patients, Group III, are progressing and improving under active treatment, and surgeons and patients are very satisfied with the initial results. None of the 61 patients in this study abandoned the treatment and no complications were found. CONCLUSIONS This preliminary study demonstrated that the DCS with a pressure-measuring device is a minimal invasive system effective for treatment of PC in patients where the anterior chest wall is still compliant. The control of different pressure measurements could be used as the inclusion criterion as well as a predictive factor for aesthetic results and treatment duration.

Squamous cell carcinoma of middle rectum: Literature review

INTRODUCTION Squamous cell carcinoma SCC of the rectum is a distinct entity. We report a very rare case of squamous cell carcinoma of the middle rectum. PRESENTATION OF CASE The patient was a 62-year-old woman who presented with a history of rectal bleeding and discomfort. Colonoscopy revealed a polypoid tumour of the middle rectum. Biopsies of this mass revealed a poorly differentiated SCC of the rectum. CT scan of the chest, abdomen and pelvis was negative for distal metastases. The patient received combined chemo-radiation followed by surgical excision. The postoperative period was uncomplicated. DISCUSSION The pathogenesis of rectal SCC remains unclear and diagnosis is often delayed. Diagnostic criteria have been proposed. MRI of the rectum and trans-rectal endoscopic ultrasound R-EUS provide essential information to plan a therapeutic approach. The squamous cell carcinoma antigen level is not suitable for initial diagnosis of rectal SCC. Most authors conclude that the surgery is the gold standard treatment. Tumour stage is the most important prognostic predictor of SCC. CONCLUSION Squamous cell carcinoma of the rectum is a distinct entity. Before the final choice of treatment is made, digestive surgeons should bear in mind this rare tumour.

Preliminary study of efficacy of cup suction in the correction of typical pectus excavatum

OBJECTIVE This preliminary qualitative study evaluates the efficacy of cup suction in the correction of pectus excavatum (PE), and examines the place of this system as a strategic treatment and as an alternative to surgery. MATERIALS AND METHODS Between October 2011 and June 2014, a total of 84 patients (children and adult) presenting with PE were treated by cup suction, in our chest wall deformities unit. On first consultation, the patients with typical PE and with at least partial correction during the first application of cup suction and a maximal suction pressure for correction of less than 300 mbar (millibars) were included in this study. 11 patients were excluded from the present study as they presented with a complex carinatum/excavatum. The remaining 73 patients were divided into two groups: Group I, adult patients ≥ 18 year old, 17 patients. The mean age was 22.8 years old. Group II, pediatric patients <18 years old, 56 patients. The mean age was 11.5 years old. Medical photographic documentation was collected systematically. In addition, the depth of PE was measured. The management protocol involved: adjustment of cup suction, strengthening exercises, and clinical follow-up every two to three months. The evaluation criteria during, and on the completion of the trial were: depth of the PE, morbidity and treatment compliance. Partial and final results were evaluated by the patients, their parents, and doctor, using a qualitative scoring scale. RESULTS A total of 73 patients presenting typical PE (symmetric in 52 cases and asymmetric in 21 cases) were treated by cup suction. The mean depth of PE was 23 mm (9-44). Of the 73 patients, one adult abandoned treatment and three children abandoned follow-up. The mean time of use of the device was 4h daily. At six months of treatment, the mean depth of PE was 9 mm (0-30) across all patients. 23 patients completed the treatment and exhibited flattening of the sternum. These patients were considered to have an excellent aesthetic result. The mean treatment duration to normal reshape was achieved at 10 months (4-21). The remaining patients are improving under continuing active treatment. The mean depth of PE in this group was 12 mm (4-30), after a mean treatment duration of 9 months (2-22). CONCLUSIONS Treatment using cup suction is a promising useful alternative in selected cases of symmetric and asymmetric PE, providing that the thorax is flexible. Treatment duration is directly linked to age, severity and the frequency of use. It is becoming a well-recognized therapy, which improves the self-image of those patients whose anterior chest wall is still pliable. The cup suction can be used for pediatrics and young adults waiting for a treatment, possibly surgery, however, the long-term effect of this procedure remains unclear.

Frozen Sections in Pleural Pathology: A Valuable Tool

Background: Knowledge of pleural malignancy can lead to immediate pleurodesis during thoracoscopy. However, the accuracy of pleural frozen sections is largely unknown. Objectives: To investigate the accuracy of frozen sections in pleural tumor pathology. Methods: A total of 156 frozen pleural sections performed with the question of malignancy were retrospectively reviewed. The original frozen sections were compared to the permanent section slides which were considered as the gold standard. The influence of the following parameters on the frozen section response was evaluated: specimen size, clinical information, as well as the processing by a specialized pulmonary pathologist or not. The reasons of discrepancies were categorized as sampling errors or interpretation errors. Results: Frozen sections made up 16.4% of 951 pleural biopsies performed in the same time period. Accurate diagnosis was feasible in 92.3% of the cases. There were 7 (4.5%) deferred (inconclusive) cases and 5 (3.2%) discrepant cases. Sensitivity of the method was 96.26%, specificity 97.87%, the positive predictive value was 99.04%, and the negative predictive value was 92%. There was no association between the responses given during frozen section and specimen size, clinical information, or the evaluation by a specialized pulmonary pathologist. Four of the 12 cases were sampling errors, while 8 cases were interpretation errors mostly made in the absence of fat tissue invasion. Thus, paucicellular lesions without prominent invasion - fat invasion or haphazardly invading cellular proliferation - were those posing most of the difficulties during frozen section. Conclusions: Frozen sections are a highly accurate tool in pleural pathology. Thus, they can be used when an immediate pleurodesis is requested.

Mediastinal cyst of müllerian origin: evidence for developmental endosalpingiosis

Sir, Müllerianosis, the triad of endometriosis, endosalpingiosis and endocervicosis, has long been recognised but still is a challenging subject regarding its histogenesis. Several theories have been developed to explain the pathogenesis of endometriosis: there are those proposing that uterine endometrium is the site of origin, which either by retrograde menstruation or by lymphatic/haematogenous spread reaches distant sites; and those proposing that endometriotic foci arise from tissue other than uterine, such as müllerian rests, metaplasia of the mesothelium or from bone marrow progenitor cells. Endocervicosis, the presence of endocervical type glands into the bladder, colon or lymph nodes, probably derives from embryological rests, but when encountered deep in the uterine cervix, is mostly related to caesarian section as a form of diverticulosis (isthmocele). Finally, endosalpingiosis, the finding of glands lined by tubal-like epithelium in sites other than the fallopian tube, is mostly described in the peritoneum and retroperitoneal lymph nodes; the main theories proposed for its pathogenesis are the shedding and implanting of tubal cells or the origin from müllerian rests. Until now, the presence of endosalpingiosis has been rarely seen outside the abdomen, mostly in the form

PD-L1 expression in pleomorphic, spindle cell and giant cell carcinoma of the lung is related to TTF-1, p40 expression and might indicate a worse prognosis

Lung sarcomatoid carcinoma of the lung is a rare tumor with a poor prognosis. More than 90% of them are pleomorphic, spindle cell and giant cell carcinoma (PSCGCC). This rare subtype of lung cancer is thought to be more resistant to chemotherapy, and a small subset of them seems to exhibit targetable mutations. Immunotherapy against PD1/PDL-1 is a new emerging treatment, and might be of interest in PSGSCC because they frequently express PD-L1. The aim of our work is to evaluate PD1 and PDL-1 expression in a surgical series of lung PSCGCC and their relationship with morphological and immunohistochemical parameters and prognosis. Thirty-six patients who underwent surgical resection of a PSGSCC were included. PD-L1 (E1L3N) expression on tumor cells and PD1 (NAT105) expression by tumor infiltrating lymphocytes (TILs) were performed by immunohistochemistry. Results were compared to immunohistochemistry tests of TTF1, Napsin A, p40 and to molecular study of EGFR, KRAS, BRAF and HER2. Seventy-five % of PSCGCC were considered as positive for PD-L1.PD-L1 expression in PSGSCC is associated with TTF-1 and/or Napsin A expression (47.2%, p = 0.039). Few p40 positive PSCGCC expressed PD-L1 (8.3%, p = 0.013). PD1 expression was not related to TTF-1 and/or Napsin A expression (p = 0.47), p40 expression (p = 0.68) or survival (p = 0.14). PD-L1 or PD1 expression were not related to the age, gender, pT, pN, stage, visceral pleura invasion, histopathological subtype, the presence of giant cell component, the predominance of sarcomatoid component, and the presence of EGFR or BRAF or HER2 or PIK3CA mutation (p>0.05). PD-L1 expression was correlated with a worse overall survival in PSCGCC (p = 0.045). PD-L1 expression is frequent in PSCGCC and might be associated with the expression of adenocarcinoma markers (TTF-1, Napsin A) or the lack of expression of squamous cell carcinoma marker (p40).

Exercise Cardiac Output Limitation in Pectus Excavatum.

Indication of pectus excavatum (PE) surgical treatment is a much-debated subject, especially regarding functional impact of the deformation. The pulmonary consequences of PE have been found not to be the limiting factor in exercise for these patients. On the other hand, the hemodynamic consequences

Determinants of operative time in thyroid surgery: A prospective multicenter study of 3454 thyroidectomies

Objective To identify the determinants of operative time for thyroidectomy and quantify the relative influence of preoperative and intra-operative factors. Background Anticipation of operative time is key to avoid both waste of hospital resources and dissatisfaction of the surgical staff. Having an accurate and anticipated planning would allow a rationalized operating room use and may improve patient flow and staffing level. Methods We conducted a prospective, cross-sectional study between April 2008 and December 2009. The operative time of 3454 patients who underwent thyroidectomy performed by 28 surgeons in five academic hospitals was monitored. We used multilevel linear regression to model determinants of operative time while accounting for the interplay of characteristics specific to surgeons, patients, and surgical procedures. The relative impact of each variable on operative time was estimated. Results Overall, 86% (99% CI 83 to 89) of operative time variation was related to preoperative variables. Surgeon characteristics accounted for 32% (99% CI 29 to 35) of variation, center location for 29% (99% CI 25 to 33), and surgical procedure or patient variables for 24% (99% CI 20 to 27). Operative time was significantly lower among experienced surgeons having practiced from 5–19 years (-21.8 min, P<0.05), performing at least 300 thyroidectomies per year (-28.8 min, P<0.05), and with increasing number of thyroidectomies performed the same day (-11.7min, P<0.001). Conversely, operative time increased in cases of procedure supervision by a more experienced surgeon (+20.0 min, P<0.001). The remaining 13.0% of variability was attributable to unanticipated technical difficulties at the time of surgery. Conclusions Variation in thyroidectomy duration is largely explained by preoperative factors, suggesting that it can be accurately anticipated. Prediction tools allowing better regulation of patient flow in operating rooms appears feasible for both working conditions and cost management.

Postoperative lymphopenia: An independent risk factor for postoperative pneumonia after lung cancer surgery, results of a case-control study

Objective Postoperative lymphopenia has been proposed as a risk factor for postoperative infections but has never been identified as such in a multivariate analysis. Postoperative pneumonia (POP) is one of the most common complications after lung cancer surgery and is associated with a worse outcome. We aimed to evaluate the association between postoperative lymphopenia and POP after lung cancer surgery. Methods Patients admitted for lung cancer surgery (lobectomy, bilobectomy, or pneumonectomy) aged ≥ 18 years and with no history of an immunosuppressive state were eligible for inclusion. Lymphocyte counts were determined in blood drawn on the day before surgery and at postoperative days 1, 3 and 7. POP diagnosis was based on clinical, biological and radiological data. A logistic regression model adjusted on currently described risk factors for POP was used to explain the onset of this condition. Results Two hundred patients were included, of whom 43 (21.5%) developed POP. Preoperative lymphocyte count was 1.8±0.6x109 cells/L and 2.0±0.7x109 cells/L in patients with and without POP, respectively (P = .091). In both groups, the lymphocyte count nadir occurred at postoperative day 1. In multivariate analysis, lymphopenia at postoperative day 1 was significantly associated with increased risk of POP (odds ratio: 2.63, 95% CI [1.03–5.40]). POP rate at postoperative day 7 was higher in patients presenting low lymphocyte counts (≤1.19x109 cells/L) at postoperative day 1 (P = .003). Conclusions Our study showed that lymphopenia following lung cancer surgery was maximal at postoperative day 1 and was associated with POP.

B3 thymoma arising within thymolipoma

immunoprofile’ as benign giant cell tumours is a simplistic and inappropriate approach. Nevertheless, a diagnosis of giant cell tumour was adequately justified in our case, supported by accumulative clinicopathological and follow-up data. The tumour was mucosal based with no infiltrative growth, and despite extensive sampling and microscopic examination of the entire tumour, and comprehensive immunohistochemical studies on multiple blocks, no evidence of epithelial differentiation was affirmed. There was no radiological or clinical evidence of locoregional or metastatic disease at the time of diagnosis. Finally, on 20month follow-up to date, the patient is clinically well with no recurrence or metastasis. Spindle cell tumours rich in osteoclast-like giant cellswith low malignant potential are not limited to the gallbladder or biliary tree. The prototypical example is giant cell tumour of the bone and soft tissue, which is an indolent, locally recurrent neoplastic lesion with extremely low risk of metastasis. While giant cell tumours in the bone are generally considered neoplastic based on discovered genetic abnormalities and chromosomal aberrations, it has been argued that these lesions may represent an exuberant fibrohistiocytic reaction topersistent or recurrent haemorrhage in the bone owing to weak stromal support. This hypothetical reaction is mediated by plasma proteins and chemokines which result in activation and proliferation of stromal cells together with recruitment and conformation of monocytic cells into osteoclastic giant cells. Further gene expression modifications and enhanced telomerase activity in susceptible patients results in excessive neoplastic proliferation of mononuclear and multinucleated osteoclast-like giant cells. Synonymously in the ovary and peritoneum, rare occurrences of mucinous cystic tumours with spindle cell sarcoma-like mural nodules containing osteoclast-like giant cells have been reported. Although a subset of these nodules are actually confirmed to be sarcomas or anaplastic carcinomas on morphological, immunohistochemical and gene expression studies, benign spindle cell nodules of genuine reactive nature and indolent clinical behaviour have been reported. Exuberant proliferation of mesenchymal cells underlying the mucinous epithelium as a reactive response to haemorrhage or extruded mucin in the cyst wall, or alternatively a reaction to tumour related chemokines, have been suggested as the theoretical pathogenesis of these nodules. In contrast, the nodules of true sarcomatous or carcinomatous differentiation appear to be a clonal de-differentiation from the pre-existing mucinous tumour. In summary, we have described a rare case of giant cell tumour of the gallbladder, which appears to be a clinicopathologically distinct entity, analogous to the low-grade giant cell rich tumours of the other organs, in particular giant cell tumour of the bone. The exact pathogenesis and biological behaviour of this tumour is not clear due to its rarity. However analogous to giant cell rich lesions in the other organs, it may represent a local exuberant reactive response to persistent or recurrent local damage and haemorrhage in genetically predisposed individuals. Importantly, this tumour should be distinguished from undifferentiated carcinoma with osteoclast-like giant cells, which pursues a more aggressive clinical course. We believe this current case adds to the four previously reported cases of this unique entity.