Elisabeth Cassagnau

Safety concern between autologous fat graft, mesenchymal stem cell and osteosarcoma recurrence.

Background Osteosarcoma is the most common malignant primary bone tumour in young adult treated by neo adjuvant chemotherapy, surgical tumor removal and adjuvant multidrug chemotherapy. For correction of soft tissue defect consecutive to surgery and/or tumor treatment, autologous fat graft has been proposed in plastic and reconstructive surgery. Principal Findings We report here a case of a late local recurrence of osteosarcoma which occurred 13 years after the initial pathology and 18 months after a lipofilling procedure. Because such recurrence was highly unexpected, we investigated the possible relationship of tumor growth with fat injections and with mesenchymal stem/stromal cell like cells which are largely found in fatty tissue. Results obtained in osteosarcoma pre-clinical models show that fat grafts or progenitor cells promoted tumor growth. Significance These observations and results raise the question of whether autologous fat grafting is a safe reconstructive procedure in a known post neoplasic context.

Life-Threatening Hemorrhaging in Neonatal Ulcerated Congenital Hemangioma: Two Case Reports

IMPORTANCE Congenital hemangiomas (CHs) are rare benign vascular tumors that differ from common infantile hemangiomas in that they grow in utero and are fully developed at birth. While ulceration is a common, predominantly benign complication in infantile hemangioma, little is known about the prognosis of ulcerated CH. However, it has been observed that ulcerated CH may be complicated by life-threatening bleeding episodes. OBSERVATIONS We report 2 cases of ulcerated rapidly involuting congenital hemangiomas (RICH) that were complicated by life-threatening bleeding episodes in the neonatal period. In both cases, the CHs were fed by high-flow vessels and the ensuing massive bleeding was due to superficial vessel wall erosion induced by the ulceration. Both patients were successfully treated with intravascular embolization; one patient underwent additional hemostatic surgery. CONCLUSIONS AND RELEVANCE These 2 cases highlight the importance of closely monitoring children with ulcerated CH because of the risk of severe bleeding. Embolization is the treatment of choice in the case of severe bleeding, as the natural history of RICH is to spontaneously regress.

25 Prévalence et facteurs de risque de résection inadéquate dans la chirurgie des sarcomes des tissus mous

Introduction La planification des marges de resection dans la chirurgie des sarcomes des tissus mous resulte d’un compromis entre sacrifice fonctionnel et securite therapeutique. En pratique, l’analyse histologique des marges de resection montre souvent que l’objectif preoperatoire n’est pas obtenu. Nous avons defini ceci comme une « discordance anatomo-chirurgicale » et en avons etudie la prevalence et les facteurs de risque. Materiel et methode Il s’agit d’une serie prospective monocentrique de 133 patients. Les objectifs de resection, les resultats de l’examen anatomopathologique, ainsi qu’une fiche de transmission peroperatoire ont ete colliges. Les marges ont ete classees selon l’UICC (R0, R1, R2). Les donnees ont ete incluses dans une grille regroupant egalement les informations preoperatoires caracterisant les patients et les tumeurs. Les cas de discordance definis comme R0 planifie pour R1 ou R2 obtenu, ont ete identifies et etudies a l’aide d’un logiciel statistique (Statview 5.0). Resultats La prevalence des discordances anatomo-chirurgicales etait de 25,2 %. Parmi les facteurs analyses, l’aspect des limites etait significativement lie au mauvais resultat chirurgical (Odds Ratio = 2,85 [1,47-5,52] (p = 0,0031)). L’etude des differentes variables n’a pas permis la mise en evidence d’autres facteurs de risque significatif. Au-dela de 2 mm de marge, la chirurgie etait consideree comme adequate dans 100 % des cas. Discussion Notre etude n’a pas permis d’identifier de facteur predictif preoperatoire de marges de resection inadequates. En postoperatoire, l’aspect microscopique des limites de la proliferation lors de l’examen anatomopathologique final est pour nous significativement associe aux cas de resection inadequate. Or, la classification actuelle des marges (entre R0 et R1) reste peu precise dans les cas de resection marginale (dans notre etude, inferieurs a 2 mm), particulierement pour les tumeurs mal limitees. Cela semble etre la source de difficultes d’interpretation pour le pathologiste et pose des problemes de prise en charge pour le chirurgien. Seul le recul permettant d’evaluer le devenir de ces patients nous permettra d’eclaircir ce point. Conclusion Nous n’avons pas mis en evidence de facteur predictif de resection inadequate accessible en preoperatoire. Un aspect microscopique mal limite de la tumeur est significativement associe aux resections inadequates. Cependant, la classification actuelle pose des problemes d’interpretation pour les exereses avec marges inferieures a 2 mm. Concernant ces cas, il reste necessaire de clarifier la definition des marges afin d’optimiser la prise en charge des patients.

MémoireÉtude anatomique de l’innervation de l’articulation trapézo-métacarpienne: À propos de 15 dissectionsAnatomical study of the nerve supply of the trapeziometacarpal joint

Resume Dans certaines rhizarthroses, la denervation articulaire selective de l’articulation trapezo-metacarpienne (ATM) peut etre proposee. Les resultats observes etant inconstants, le but de notre travail a ete d’etudier l’innervation de l’ATM, afin de determiner la faisabilite technique d’une denervation selective et efficace. Notre etude anatomique a ete realisee par la dissection sous loupes (4,5-x350) de 15 membres superieurs de cadavres frais, sectionnes au niveau du tiers distal de l’avant-bras. Les nerfs disseques etaient le nerf median, avec ses branches thenarienne et cutanee palmaire, ainsi que les rameaux de terminaison de la branche sensitive du nerf radial. Les rameaux articulaires destines a l’ATM ont ete soigneusement identifies, et des prelevements a visee histologique realises afin d’authentifier la nature nerveuse des elements disseques. Toutes les dissections ont retrouve une participation des nerfs radial et median a l’innervation de l’ATM, avec une preponderance pour les rameaux issus du nerf median, de nombre et de calibre relatif plus importants. L’analyse histologique a confirme la nature nerveuse des prelevements. Malgre les constatations de Cozzi en 1960, la branche sensitive dorsale du nerf radial n’a ainsi pas un role exclusif ni preponderant dans l’innervation de l’ATM. La participation du nerf median a l’innervation de l’ATM est plus « importante », notamment par ses branches cutanee palmaire et surtout thenarienne. Realiser une denervation articulaire selective de l’ATM qui soit « totale » semble difficile. En effet, un tel geste comporterait un abord large, et une dissection etendue, source de complications genantes.PURPOSE OF THE STUDY When the radiological signs are minimal in patients with a painful carpal syndrome involving the trapeziometacarpal joint (TMCJ), selective articular denervation can be proposed as an alternative after failure of conservative treatment. Results have been variable, sometimes disappointing, suggesting the anatomic basis of denervation should be revisited. The purpose of this work was to study the nerve supply to the TMCJ in order to acquire the indispensable elements necessary for performing effective selective articular denervation. MATERIAL AND METHODS This anatomical study was performed by dissection under magnification (4.5-x350) of 15 upper limb cadaver specimens. The median nerve, its thenar and volar cutaneous branches and the terminal sensorial branches of the radial nerve were dissected. Articular branches to the TMCJ were carefully identified. Histological samples were taken to verify the neurological nature of the elements dissected. RESULTS All TMCJs dissected exhibited radial and median nerve supply. Branches of the median nerve predominated in number and caliber. The volar cutaneous branch gave rise to articular branches in eleven dissections and the thenar branch gave rise to articular branches via a retrograde arciform trajectory between the short abductor and the opponens digiti pollicis in thirteen. For five dissections, the TMCJ branches arose directly from the median nerve within the carpal tunnel. At histological analysis the dissected elements were identified as nerves. DISCUSSION There have been few anatomic studies concerning the nerve supply of the TMCJ. Unlike the findings reported by Cozzi in 1960, we did not find the dorsal sensorial branch of the radial nerve to play an exclusive or preponderant role in the innervation of the TMCJ. The median nerve supply to the TMCJ appeared to be more significant, particularly for the volar cutaneous and especially thenar branches. CONCLUSION Total and definitive selective denervation of the TMCJ appears to be a most difficult procedure which would require a very wide access and extensive dissection, including the thenar branch which would raise the risk of significant complications.Purpose of the study When the radiological signs are minimal in patients with a painful carpal syndrome involving the trapeziometacarpal joint (TMCJ), selective articular denervation can be proposed as an alternative after failure of conservative treatment. Results have been variable, sometimes disappointing, suggesting the anatomic basis of denervation should be revisited. The purpose of this work was to study the nerve supply to the TMCJ in order to acquire the indispensable elements necessary for performing effective selective articular denervation.

Étude anatomique de l’innervation de l’articulation trapézo-métacarpienne

Resume Dans certaines rhizarthroses, la denervation articulaire selective de l’articulation trapezo-metacarpienne (ATM) peut etre proposee. Les resultats observes etant inconstants, le but de notre travail a ete d’etudier l’innervation de l’ATM, afin de determiner la faisabilite technique d’une denervation selective et efficace. Notre etude anatomique a ete realisee par la dissection sous loupes (4,5-x350) de 15 membres superieurs de cadavres frais, sectionnes au niveau du tiers distal de l’avant-bras. Les nerfs disseques etaient le nerf median, avec ses branches thenarienne et cutanee palmaire, ainsi que les rameaux de terminaison de la branche sensitive du nerf radial. Les rameaux articulaires destines a l’ATM ont ete soigneusement identifies, et des prelevements a visee histologique realises afin d’authentifier la nature nerveuse des elements disseques. Toutes les dissections ont retrouve une participation des nerfs radial et median a l’innervation de l’ATM, avec une preponderance pour les rameaux issus du nerf median, de nombre et de calibre relatif plus importants. L’analyse histologique a confirme la nature nerveuse des prelevements. Malgre les constatations de Cozzi en 1960, la branche sensitive dorsale du nerf radial n’a ainsi pas un role exclusif ni preponderant dans l’innervation de l’ATM. La participation du nerf median a l’innervation de l’ATM est plus « importante », notamment par ses branches cutanee palmaire et surtout thenarienne. Realiser une denervation articulaire selective de l’ATM qui soit « totale » semble difficile. En effet, un tel geste comporterait un abord large, et une dissection etendue, source de complications genantes.PURPOSE OF THE STUDY When the radiological signs are minimal in patients with a painful carpal syndrome involving the trapeziometacarpal joint (TMCJ), selective articular denervation can be proposed as an alternative after failure of conservative treatment. Results have been variable, sometimes disappointing, suggesting the anatomic basis of denervation should be revisited. The purpose of this work was to study the nerve supply to the TMCJ in order to acquire the indispensable elements necessary for performing effective selective articular denervation. MATERIAL AND METHODS This anatomical study was performed by dissection under magnification (4.5-x350) of 15 upper limb cadaver specimens. The median nerve, its thenar and volar cutaneous branches and the terminal sensorial branches of the radial nerve were dissected. Articular branches to the TMCJ were carefully identified. Histological samples were taken to verify the neurological nature of the elements dissected. RESULTS All TMCJs dissected exhibited radial and median nerve supply. Branches of the median nerve predominated in number and caliber. The volar cutaneous branch gave rise to articular branches in eleven dissections and the thenar branch gave rise to articular branches via a retrograde arciform trajectory between the short abductor and the opponens digiti pollicis in thirteen. For five dissections, the TMCJ branches arose directly from the median nerve within the carpal tunnel. At histological analysis the dissected elements were identified as nerves. DISCUSSION There have been few anatomic studies concerning the nerve supply of the TMCJ. Unlike the findings reported by Cozzi in 1960, we did not find the dorsal sensorial branch of the radial nerve to play an exclusive or preponderant role in the innervation of the TMCJ. The median nerve supply to the TMCJ appeared to be more significant, particularly for the volar cutaneous and especially thenar branches. CONCLUSION Total and definitive selective denervation of the TMCJ appears to be a most difficult procedure which would require a very wide access and extensive dissection, including the thenar branch which would raise the risk of significant complications.Purpose of the study When the radiological signs are minimal in patients with a painful carpal syndrome involving the trapeziometacarpal joint (TMCJ), selective articular denervation can be proposed as an alternative after failure of conservative treatment. Results have been variable, sometimes disappointing, suggesting the anatomic basis of denervation should be revisited. The purpose of this work was to study the nerve supply to the TMCJ in order to acquire the indispensable elements necessary for performing effective selective articular denervation.

Étude anatomique de l'innervation de l'articulation trapézo-métacarpienne : À propos de 15 dissections

Resume Dans certaines rhizarthroses, la denervation articulaire selective de l’articulation trapezo-metacarpienne (ATM) peut etre proposee. Les resultats observes etant inconstants, le but de notre travail a ete d’etudier l’innervation de l’ATM, afin de determiner la faisabilite technique d’une denervation selective et efficace. Notre etude anatomique a ete realisee par la dissection sous loupes (4,5-x350) de 15 membres superieurs de cadavres frais, sectionnes au niveau du tiers distal de l’avant-bras. Les nerfs disseques etaient le nerf median, avec ses branches thenarienne et cutanee palmaire, ainsi que les rameaux de terminaison de la branche sensitive du nerf radial. Les rameaux articulaires destines a l’ATM ont ete soigneusement identifies, et des prelevements a visee histologique realises afin d’authentifier la nature nerveuse des elements disseques. Toutes les dissections ont retrouve une participation des nerfs radial et median a l’innervation de l’ATM, avec une preponderance pour les rameaux issus du nerf median, de nombre et de calibre relatif plus importants. L’analyse histologique a confirme la nature nerveuse des prelevements. Malgre les constatations de Cozzi en 1960, la branche sensitive dorsale du nerf radial n’a ainsi pas un role exclusif ni preponderant dans l’innervation de l’ATM. La participation du nerf median a l’innervation de l’ATM est plus « importante », notamment par ses branches cutanee palmaire et surtout thenarienne. Realiser une denervation articulaire selective de l’ATM qui soit « totale » semble difficile. En effet, un tel geste comporterait un abord large, et une dissection etendue, source de complications genantes.PURPOSE OF THE STUDY When the radiological signs are minimal in patients with a painful carpal syndrome involving the trapeziometacarpal joint (TMCJ), selective articular denervation can be proposed as an alternative after failure of conservative treatment. Results have been variable, sometimes disappointing, suggesting the anatomic basis of denervation should be revisited. The purpose of this work was to study the nerve supply to the TMCJ in order to acquire the indispensable elements necessary for performing effective selective articular denervation. MATERIAL AND METHODS This anatomical study was performed by dissection under magnification (4.5-x350) of 15 upper limb cadaver specimens. The median nerve, its thenar and volar cutaneous branches and the terminal sensorial branches of the radial nerve were dissected. Articular branches to the TMCJ were carefully identified. Histological samples were taken to verify the neurological nature of the elements dissected. RESULTS All TMCJs dissected exhibited radial and median nerve supply. Branches of the median nerve predominated in number and caliber. The volar cutaneous branch gave rise to articular branches in eleven dissections and the thenar branch gave rise to articular branches via a retrograde arciform trajectory between the short abductor and the opponens digiti pollicis in thirteen. For five dissections, the TMCJ branches arose directly from the median nerve within the carpal tunnel. At histological analysis the dissected elements were identified as nerves. DISCUSSION There have been few anatomic studies concerning the nerve supply of the TMCJ. Unlike the findings reported by Cozzi in 1960, we did not find the dorsal sensorial branch of the radial nerve to play an exclusive or preponderant role in the innervation of the TMCJ. The median nerve supply to the TMCJ appeared to be more significant, particularly for the volar cutaneous and especially thenar branches. CONCLUSION Total and definitive selective denervation of the TMCJ appears to be a most difficult procedure which would require a very wide access and extensive dissection, including the thenar branch which would raise the risk of significant complications.Purpose of the study When the radiological signs are minimal in patients with a painful carpal syndrome involving the trapeziometacarpal joint (TMCJ), selective articular denervation can be proposed as an alternative after failure of conservative treatment. Results have been variable, sometimes disappointing, suggesting the anatomic basis of denervation should be revisited. The purpose of this work was to study the nerve supply to the TMCJ in order to acquire the indispensable elements necessary for performing effective selective articular denervation.