C. Boutin

Thoracoscopy in pleural malignant mesothelioma: A prospective study of 188 consecutive patients. Part 2: Prognosis and staging

Background. Thoracoscopy appears to be essential in identifying tumors at the beginning of pleural disease.

Malignant pleural mesothelioma

The incidence of malignant pleural mesothelioma (MPM) has risen for some decades and is expected to peak between 2010 and 2020. Up to now, no single treatment has been proven to be effective and death usually occurs within about 12-17 months after diagnosis. Perhaps because of this poor prognosis, early screening has incited little interest. However, certain forms may have a better prognosis when diagnosed early and treated by multimodal therapy or intrapleural immunotherapy. Diagnosis depends foremost on histological analysis of samples obtained by thoracoscopy. This procedure allows the best staging of the pleural cavity with an attempt to detect visceral pleural involvement, which is one of the most important prognostic factors. Although radiotherapy seems necessary and is efficient in preventing the malignant seeding after diagnostic procedures in patients, there has been no randomized phase III study showing the superiority of any treatment compared with another. However, for the early-stage disease (stage I) a logical therapeutic approach seems to be neoadjuvant intrapleural treatment using cytokines. For more advanced disease (stages II and III) resectability should be discussed with the thoracic surgeons and a multimodal treatment combining surgery, radiotherapy and chemotherapy should be proposed for a randomized controlled study. Palliative treatment is indicated for stage IV. In any case, each patient should be enrolled in a clinical trial.

THE ROLE OF THORACOSCOPY IN THE EVALUATION AND MANAGEMENT OF PLEURAL EFFUSIONS

Diagnostic thoracoscopy is indicated in every patient where the usual investigations (including biochemistry, cytology, bacteriology, occasionally needle biopsy of the pleura) do not achieve a precise diagnosis. The percentage of so-called “idiopathic” effusions, amounting to approximately 20% in many published series, can be reduced to 4% after thoracoscopy. The sensibility of thoracoscopic biopsy reaches 93–97% of malignant or tuberculous pleural effusions. The procedure requires a short hospitalization of about 36 hr, and complications are rare.Therapeutic thoracoscopy is frequently performed in chronic, malignant, recurrent effusions in order to achieve a pleurodesis by means of a talc poudrage under visual control. The efficacy of the poudrage in the published randomized studies is better than tetracycline. About 90% of patients are cured, the effusion being totally suppressed. Side effects are rare if the quantity of talc does not exceed 10 ml.

Intrapleural immunotherapy with escalating doses of interleukin-2 in metastatic pleural effusions

Background. The authors assessed the tolerance and efficacy of intrapleural interleukin‐2 (IL‐2) in patients with malignant effusion.

Thoracoscopie diagnostique en hospitalisation courte

RésuméLe drainage thoracique de courte durée (moins d’une heure) allège considérablement le geste thoracoscopique en conservant un rendement élevé. La thoracoscopie diagnostique est sûre, fiable, et doit être un examen de premier plan dans le diagnostic des pleuresies.SummaryShort-term thoracic drainage (less than 1 hour) considerably simplifies a thoracoscopie exam while at the same time conserving a high rate of yield. Diagnostic thoracoscopy is sure, reliable, and should be in the forefront of exams for the diagnosis of pleurisies.ResumenEl drenaje torácico de duración corta (inferior a una hora) hace más llevadero el acto toracoscópico, manteniendo integro su rendimiento. La toracoscopia diagnostica es una exploración segura, fiable et debe ser tenida en cuenta como exploración prioritaria en el diagnostico de las pleuresias.

Endoprothèse trachéale en silicone: une nouvelle méthode de mise en place

ResuméLes auteurs décrivent une nouvelle méthode de mise en place d’une prothèse endotrachéale type « Endoxane » chez une patiente de 65 ans présentant une tumeur néoplasique du tiers inférieur de la trachée.SummaryThe authors describe a new endoscopic method for insertion of an « Endoxane » endotracheal prosthesis in a 65- year-old patient with an adenocarcinoma in the inferior part of the trachea.ResumenLos autores describen un nuevo método de colocación de una protesis endotraqueal tipo « Endoxane » en una paciente de 65 que tenía un tumor neoplásico del tercio inferior traqueal.

Intérêt des xérotomographies dans la surveillance des endoprothèses trachéo-bronchiques

RésuméLes auteurs, à propos de 7 patients porteurs de prothèses trachéo-bronchiques type « endoxane » donnent une première évaluation d’un schema de surveillance le moins traumatisant possible, surtout dans les lésions néoplasiques.SummaryIn a study of 7 patients with « endoxane » tracheobronchial prostheses, the authors set up a maintenance program which is as atraumatic as possible, especially in cases of neoplasic pathology.ResumenA partir de una experiencia inicial con 7 pacientes, los autores refieren una primera evaluación de la implantación de prótesis endobronquiales, estableciendose un esquema de seguimiento lo menos traumdtizante posible, en especial en los portadores de lesiones neoplásicas.

Intérêt des résections au Nd-YAG laser et des prothèses endobronchiques « type endoxane » dans le traitement palliatif des tumeurs malignes trachéo-bronchiques

RésuméLes auteurs rapportent leur expérience des resections laser et des endoprosthèses trachéobronchiques en matière de pathologie néoplasique. La période de l’etude s’etend de septembre 1988 à septembre 1989. Le confort des patients, le nombre de résections laser, le coût total du traitement palliatif, peuvent être améliorés par une mise en place très précoce, de la prothèse.SummaryThe authors report their experience with laser resections and tracheobronchial endoprostheses for the palliative treatment of neoplastic disease from September 1988 to September 1989. Patient comfort, the number of laser resections, and the total cost of palliative treatment can be improved if the prosthesis is inserted as early as possible.