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Resume Introduction Le mesotheliome pleural malin (MPM) est une tumeur rare souvent associee a l’exposition a l’amiante. Le temps de latence entre l’exposition et l’apparition du cancer peut atteindre 40 ans. Ce delai est a l’origine du pic d’incidence recent observe dans de nombreux pays notamment la Tunisie. Les donnees cliniques font suspecter le diagnostic qui ne peut etre retenu qu’au terme de l’examen anatomopathologique. Notre objectif etait de decrire les caracteristiques cliniques et anatomopathologiques du MPM en nous basant sur une experience uni-institutionnelle. Patients et methodes Nous avons collige une etude retrospective a propos de 30 MPM diagnostiques sur une periode de 20 ans (1995–2015). N’ont ete inclus que les patients pour lesquels tous les renseignements cliniques, radiologiques et anatomopathologiques etaient disponibles. Tous les diagnostics etablis ont ete relus par 2 pathologistes. Une moyenne de 12 lames/cas a ete relue. La classification des differents types de mesotheliomes a ete faite selon la classification de l’OMS 2015. Resultats L’âge moyen des patients etait de 61 ans [22–80 ans]. Le sex-ratio H/F etait de 6,5. La notion d’exposition a l’amiante a ete mentionnee dans 21 cas. Le signe clinique le plus frequent etait la douleur thoracique qui etait rapportee dans 25 cas. L’examen physique a objective un syndrome pleuretique dans 18 cas (60 %). Les moyens d’imagerie ont objective une tumeur unilaterale dans tous les cas realisant un epaississement pleural diffus dans 17 cas. Au terme du bilan d’extension, 12 patients etaient classes en stade I, 3 en stade II, 14 en stade III et 1 patient en stade IV. Une biopsie pleurale a ete realisee a l’aiguille dans 18 cas, sous thoracoscopie dans 16 cas, sous thoracotomie dans 3 cas et a permis de confirmer le diagnostic dans respectivement 7 cas/18, 16 cas/16 et 3 cas/3. Une biopsie ganglionnaire par mediastinoscopie a ete realisee dans un cas et a permis de poser le diagnostic. Le diagnostic de MPM a ete fait sur une piece operatoire chez 2 patients qui ont eu respectivement une resection tumorale de proprete avec lobectomie superieure droite et une bullectomie. L’examen microscopique a conclu a 17 ME, 4 mesotheliomes sarcomatoides (MS) et 9 mesotheliomes biphasiques (MB). En immunohistochimie, la pan-cytokeratine a ete utilisee dans tous les cas en association a 2 anticorps a valeur diagnostique positive et 2 anticorps a valeur diagnostique negative. Les etudes immunohistochimiques ont ete repetees dans 15 cas et les anticorps le plus souvent redemandes etaient la calretinine et le TTF1. Ceci etait justifie par la mauvaise fixation des prelevements dans un cas et afin de satisfaire un critere qualite a savoir l’obtention d’un marquage intense et diffus dans les autres cas. Une resection chirurgicale a ete realisee chez 2 patients. 15 malades ont ete perdus de vue apres un suivi moyen de 3 mois. Treize malades sont decedes avant ou pendant le traitement. Conclusion Ce travail a permis de mettre en evidence une experience Tunisienne dans le diagnostic et la prise en charge du MPM en Tunisie. Parmi les principaux ecueils rencontres, on peut citer le faible effectif de notre serie et les donnees incompletes dans les dossiers medicaux qui ont conduit a l’exclusion de nombreux cas. Le diagnostic positif anatomopathologique necessite un certain degre d’expertise et chaque laboratoire doit determiner les valeurs diagnostiques des differents anticorps disponibles afin d’optimiser leur utilisation et diminuer les delais diagnostiques.

Resume Problematique La dysplasie fibreuse des os est une lesion benigne rare ou l’os normal est remplace par un tissu pseudo-fibreux renfermant une osteogenese immature. La localisation costale est rare. Elle peut etre monostotique ou polyostotique. Le diagnostic est suspecte sur des elements cliniques et radiologiques. But du travail Face aux progres techniques en imagerie, on s’est interroge sur le role de l’examen anatomopathologique et ce a travers l’experience de notre service. Methodes Nous decrivons une etude retrospective a propos de 12 dysplasies fibreuses costales diagnostiquees sur une periode de 17 ans (1996–2013). Les dossiers des patients ont ete retires des services de chirurgie thoracique du meme hopital. Resultats La dysplasie fibreuse costale etait observee de facon presque egale dans les deux sexes avec une predominance pour la 3 e et 4 e decade de la vie. La symptomatologie fonctionnelle etait marquee par les douleurs thoraciques. L’examen etait sans particularite dans la majorite des cas. Le diagnostic a ete suspecte dans 33 % des cas. L’examen anatomopathologique a permis d’etablir le diagnostic dans tous les cas et a ete delicat dans un cas necessitant une concertation pluridisciplinaire. Les difficultes diagnostiques etaient imputees aux artefacts de decalcification. Conclusion La dysplasie fibreuse costale est une lesion benigne dont le diagnostic de certitude est anatomopathologique. Les moyens d’imagerie montrent des signes non specifiques mais orientent vers la benignite. L’evolution est generalement favorable bien que des transformations malignes exceptionnelles aient ete rapportees.

The malignant pleural mesothelioma (MPM) is a rare tumour usually associated to asbestos exposure. The delay between the exposure and the occurrence of the cancer can reach 40 years. This caused the pick of incidence described in many countries including Tunisia. The diagnosis is suspected based on clinical features but positive diagnosis is microscopic. Our aim was to describe the clinical and microscopic features of MPM through a single institution experience.We conducted a retrospective study about 30 MPM diagnosed over a 20-year-period (1995-2015). We included only patients with complete records including clinical, radiologic and microscopic features. All the microscopic diagnoses were reviewed by 2 pathologists. A mean of 12 slides per case was reviewed. The diagnosis was based on the 2015 WHO classification.The mean age of the patients was 61 years, average 22 to 80 years. The sex ratio was 6,5. An asbetose exposition was reported in 21 cases. The most frequent symptoms was chest pain reported in 25 cases. Physical exam was normal in 9 cases. It revealed pleural syndorm in most patients (60 %). Imaging findings consisted mainly in diffuse pleural thickening in 17 cases. Twelve tumours were classified as stage I, 3 stage II, 14 stage III et 1 stage IV. Pleural biopsy was performed using needle in 18 cases, through thoracoscopy in 16 cases, thoracotomy in 3 cases and allowed the diagnosis in respectively 7 cases/18, 16 cases/16 and 3 cases/3. A lymph node biopsy was performed through mediastinoscopy in one case and yelded the diagnosis. The diagnosis was performed on surgical specimen in 2 patients: one bullectomy and one right upper lobectomy. The microscopic exam concluded to an EM in 17 cases, sarcomatoid mesothelioma (SM) in 4 cases and biphasic mesothelioma (BM) in 9 cases. Pan-cytokeratin antibody was used in all cases in association with 2 antibodies with positive diagnostic value and 2 antibodies with negative diagnostic value. It was repeated in 15 cases and the most used antibodies were the anti-calretinin and the TTF1. This was due to the lack of fixation in one case and in order to reach a quality criteria in the other cases. Surgical resection was possible in 2 patients. 15 patients were lost of view after a mean follow-up period of 3 months. Thirteen patients died before or during the follow-up.This work was about a Tunisian experience in the diagnosis and management of MPM. The major limits faced were the incomplete databases, the small number of patients included. Microsocpic positive diagnosis necessitates a degree of expertise and every laboratory has to determine the most valuable antibodies through its experience in order to optimize the diagnosis and to reduce the delay of diagnosis.

Resume Introduction Les tumeurs carcinoides bronchiques sont des tumeurs neuro-endocrines bien differenciees, rares, a malignite attenuee. Elles sont distinguees en 2 groupes differents : les carcinoides typiques et les carcinoides atypiques. Le but de ce travail est d’etudier les particularites cliniques, chirurgicales et histologiques de ces tumeurs. Methodes Etude retrospective de 115 tumeurs carcinoides bronchiques operees sur une periode de 21 ans (1992–2012). Resultats Il s’agissait de 56 hommes et 59 femmes avec un âge moyen de 43,73 ans. Cent patients avaient un carcinoide typique et les 15 autres, un carcinoide atypique. La majorite des patients etaient symptomatiques (96,52 %). La tomodensitometrie a objective, dans 51 % des cas, une masse proximale, qui etait obstructive avec trouble ventilatoire d’aval dans 80 % des cas. La fibroscopie a objective un bourgeon endo-bronchique dans 83,48 % des cas. Une exerese carcinologique reglee a ete realisee chez 99 patients, et une resection conservatrice dans 16 cas de carcinoide typique. Un envahissement ganglionnaire etait present dans 12,17 % des cas. Au cours du suivi, un patient a presente une recidive locale et 4 autres des metastases a distance. La survie a 5 ans etait plus defavorable pour les carcinoides atypiques avec 45 % versus 95 % pour les carcinoides typiques. Conclusions Malgre une evolution favorable apres traitement chirurgical, les tumeurs carcinoides presentent, quelle que soit leur forme typique ou atypique, un risque de recurrence et/ou de metastase justifiant l’interet d’un diagnostic precoce et d’un suivi prolonge. Les facteurs influencant la survie sont le type histologique, les metastases a distance et l’envahissement des ganglions mediastinaux.

Tuberculosis is mainly a medical disease. Surgery has been the unique therapeutic tool for a long time before the advent of specific antituberculous drugs, and the role of surgery was then confined to the treatment of the sequelae of tuberculosis and their complications. The resurgence of tuberculosis and the emergence of multidrug-resistant TB combined to immunosuppressed patients represent a new challenge for tuberculosis surgery. Surgery may be indicated for a diagnostic purpose in patients with pulmonary, pleural, mediastinal or thoracic wall involvement, or with a therapeutic purpose (drainage, resection, residual cavity obliteration). Modern imaging techniques and the advent of video-assisted thoracic surgery allowed a new approach of this pathology; the majority of diagnostic interventions and selected cases requiring lung resection can be performed through a mini-invasive approach. Patients proposed for aggressive surgery may be treated with the best results thanks to a good evaluation of the thoracic lesions, of the patients' nutritional, infectious and general status combined with a good coordination between the specialized medical team for an optimal preparation to surgery.

Resume Les tumeurs primitives de la trachee sont tres rares. Chez l’adulte, la majorite d’entre elles sont malignes. Les schwannomes sont des tumeurs benignes, exceptionnelles dans leur localisation tracheobronchique. Nous rapportons le cas d’un patient âge de 37 ans, traite pour asthme depuis 4 ans, hospitalise pour dyspnee d’aggravation progressive resistante au traitement. La tomodensitometrie thoracique et la fibroscopie bronchique mettaient en evidence une image intratracheale se prolabant au niveau de la bronche souche gauche. Une resection chirurgicale a ete indiquee apres echec d’une tentative de desobstruction au laser. Une excision de la base d’implantation de la tumeur a ete realisee, emportant les 2 premiers anneaux de la bronche souche gauche avec retablissement de la continuite. L’analyse histologique de la tumeur affirmait le diagnostic de schwannome sans caractere suspect de malignite. La surveillance ne constatait pas de recidive. Nous concluons a partir de ce cas qu’il faut penser a une masse intratracheale chez les patients presentant une dyspnee ou souffrant d’un asthme refractaire au traitement habituel.

Resume Introduction L’amyloidome pulmonaire ou amylose nodulaire est une forme localisee d’amylose pouvant mimer un cancer bronchopulmonaire et pouvant etre observee en association avec une pathologie infectieuse, une maladie de systeme ou un lymphome. Observation Nous decrivons le cas d’une patiente âgee de 36 ans ayant pour antecedent un diabete insulinodependant et une hypothyroidie sous traitement medical. Cette patiente presentait un syndrome de Gougerot-Sjogren et etait hospitalisee pour une symptomatologie respiratoire. L’examen physique etait sans particularite. Le bilan biologique revelait un pic monoclonal d’immunoglobulines. A l’imagerie, des nodules pulmonaires bilateraux associes a des adenopathies mediastinales etaient objectives. Une biopsie pulmonaire chirurgicale a ete effectuee. L’examen histologique montrait un nodule tumoral centre par un abondant materiel eosinophile, acellulaire et craquele cerne par un infiltrat lymphomateux dense, diffus et monomorphe detruisant le parenchyme pulmonaire. Les etudes histochimiques et immuno-histochimiques ont permis de conclure a une association d’une amylose nodulaire pulmonaire et d’un lymphome primitif du MALT, compliquant un syndrome de Gougerot-Sjogren. Conclusion L’association lymphome MALT pulmonaire primitif et depots amyloides localises est rarement observee dans le cadre du syndrome de Gougerot-Sjogren. La pathogenie de cette association demeure discutee et sa prise en charge ainsi que son pronostic demeurent sujets a debat vu la rarete des cas rapportes dans la litterature. Cependant, il apparaitrait que l’amylose localisee associee au lymphome MALT aurait un meilleur pronostic que l’amylose disseminee.

Resume Les tumeurs primitives costales sont des tumeurs rares dominees par les tumeurs malignes. L’hemangiome osseux ne represente que 1 % des tumeurs osseuses. La localisation costale ne represente que 1 % des cas avec uniquement une cinquantaine de cas decrits dans la litterature. But Les auteurs ont pour objectif de rapporter une tumeur costale rare, de decrire ses aspects histologiques et de rapporter les principaux diagnostics differentiels. Observation Les auteurs decrivent le cas d’une patiente âgee de 46 ans qui consultait pour des douleurs thoraciques. Les donnees radiologiques n’ont pas permis d’eliminer une tumeur maligne et le traitement a consiste en une resection de l’arc posterieur de la sixieme cote emportant toute la tumeur. L’examen microscopique a conclu a un hemangiome costal et la patiente n’a pas presente de recidive apres un recul de six ans. Conclusion L’hemangiome costal est une tumeur tres rare d’etiologie controversee. Certains aspects radiologiques sont specifiques comme l’aspect de bulles de savon ou de nids d’abeilles. Cependant, le diagnostic de certitude demeure microscopique. Ces tumeurs sont de bon pronostic et aucun cas de recidive n’a ete decrit apres resection complete.

Fibrous dysplasia of bone is a rare benign lesion characterized by the coexistence of a fibrous tissue and an immature osteogenesis. Costal localization is rare and may be monostotic or polyostotic. The diagnosis may be suspected based on clinical and radiological findings. Facing the development of radiological investigations, we tried to highlight the diagnostic role of the microscopic examination through the experience of our department.We describe a retrospective study about 12 costal fibrous dysplasias diagnosed over a 17-year-period. Clinical records were retrieved from the department of thoracic surgery of the same hospital.Costal fibrous dysplasia is equally observed in men and women with predominance in the third and fourth decades. Clinical symptoms consist mainly in chest pain. Physical examination was normal in almost all cases. Based on the radiological findings, the diagnosis was suspected in 33% of the cases. Microscopic examination highlighted the diagnosis in all cases but it was challenging in one case and necessitated a multi-disciplinary approach. The difficulties encountered were due to artifact decalcification.Costal fibrous dysplasia is a benign lesion which diagnosis is based on microscopic features. Radiologic investigations show nonspecific features but allow to rule out a malignant tumor. The outcome of the patients is generally good except in rare cases with a malignant transformation.

Bronchial carcinoid tumors are rare well-differentiated, neuro-endocrine tumors, with low-grade malignancy. They are distinguished in two different groups: typical and atypical carcinoid. The purpose of this study was to review clinical, surgical and pathological characteristics in patients with primary bronchopulmonary carcinoid tumors.This retrospective study included 115 bronchial carcinoid tumors surgically treated at a single institution during a twenty-one-year period, between 1992 and 2012.There were 56 men and 59 women, with a mean age of 43.73 years. Hundred patients had typical carcinoids and 15 atypical carcinoids. The majority of patients were symptomatic (96.52%). CT revealed a proximal mass in 51% which was obstructive leading to ventilator disorders in 80%. Bronchoscopy showed an endo-bronchial tumor in 83.48% of the cases. Anatomical resection had been achieved among 99 patients, and a conservative resection among 16 patients with typical carcinoid tumor. Lymph node metastases were present in 12.17% of the cases. Follow-up revealed recurrence in one patient and distant metastasis in 4 others. The 5-year survival rate was worse for atypical carcinoid with 45% than typical carcinoid with 95%.Carcinoids are rare malignant tumors, and their outcome is usually favorable after surgery. However, local recurrence and/or metastases can occur with both typical and atypical carcinoid tumors, justifying the need of prompt diagnosis and long-term follow-up. The factors influencing the survival included the pathological type, distant metastasis and mediastinal lymph node involvement.

Primary tumors of the trachea are very rare. In adults, the majority of them are malignant. Schwannomas are exceedingly rare benign tumors in the tracheobronchial tree. We report a case of a 37-year-old man who was hospitalized for increasing dyspnea. He had been treated for bronchial asthma for the last 4 years with no benefit. The CT scan of the chest and bronchoscopy identified a tracheal mass that was prolapsed in the left stem bronchus. The patient did not remain free of disease after endoscopic laser resection. So, surgical resection was made. The tumor was excised at its base. A segment of the left stem bronchus was removed and primary anastomosis was performed. The histopathologic diagnosis was of a benign schwannoma without malignant elements. There was no recurrence during the follow-up period. This case demonstrates that intratracheal masses should be considered in patients with dyspnea or in patients with asthma refractory to conventional therapy.

Tuberculosis is mainly a medical disease. Surgery has been the unique therapeutic tool for a long time before the advent of specific antituberculous drugs, and the role of surgery was then confined to the treatment of the sequelae of tuberculosis and their complications. The resurgence of tuberculosis and the emergence of multidrug-resistant TB combined to immunosuppressed patients represent a new challenge for tuberculosis surgery. Surgery may be indicated for a diagnostic purpose in patients with pulmonary, pleural, mediastinal or thoracic wall involvement, or with a therapeutic purpose (drainage, resection, residual cavity obliteration). Modern imaging techniques and the advent of video-assisted thoracic surgery allowed a new approach of this pathology; the majority of diagnostic interventions and selected cases requiring lung resection can be performed through a mini-invasive approach. Patients proposed for aggressive surgery may be treated with the best results thanks to a good evaluation of the thoracic lesions, of the patients' nutritional, infectious and general status combined with a good coordination between the specialized medical team for an optimal preparation to surgery.

Pulmonary amyloidoma or nodular amyloidosis is a localized form of amyloidosis, which can mimic a bronchopulmonary carcinoma. This form of amyloidosis may be associated to an infectious, a systemic disease or a lymphoma.We describe the case of a 36-year-old patient whose past medical history was consistent for a diabetes mellitus and a hypothyroidism treated by medical treatment. The patient presented a Gougerot-Sjögren syndrome and was explored for non-specific respiratory symptoms. Physical examination was normal. Laboratory tests revealed a monoclonal pic of immunoglobulin. Radiologic findings showed bilateral pulmonary nodules associated to mediastinal lymph nodes. A pulmonary biopsy was performed. Histologic examination revealed a tumoral nodule containing an abundant eosinophilic material, which was acellular and surrounded by a dense lymphomatous infiltrate destroying the pulmonary parenchyma. Histochemical and immunohistochemical study revealed an association of a nodular pulmonary amyloidosis with a MAT pulmonary lymphoma complicating a Gougerot-Sjögren syndrome.The association of MALT pulmonary lymphoma and localized amyloidosis is rarely observed in case of Gougerot-Sjögren syndrome. The pathogenesis of this association remains unknown and the management non-consensual because of the rarity of the cases reported. Whereas, it appears that localized amyloidosis associated to a MALT lymphoma seems to have a better prognosis than a disseminated amyloidosis.

Costal primary tumors are rare and dominated by malignant tumors. Haemangioma of the bone represents only 1% of bone tumors. Costal localization accounts only for 1% of the cases and only about fifty cases have been reported in the literature.The authors aim to describe a rare costal tumor, its histological features and the main differential diagnoses.The authors describe the case of a 46-year-old woman who presented with chest pain. Radiological findings did not permit a malignant tumor to be ruled out and the treatment consisted of a resection of the posterior arch of the rib. Microscopic examination concluded that the patient had a costal haemangioma and the patient didn't present any recurrence after a six-year follow-up.The costal haemangioma is a very rare tumor with a debated etiology. Some radiological features are specific such as the "soap bubble" or "honeycomb" aspect. However, the basis for diagnosis remains microscopic examination. These tumors have a good prognosis and no cases of recurrence have been reported following complete resection.