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On review of 115 poorly or undifferentiated lung cancers from 671 lung tumors resected over a 7-year period, we have found 38 cases of basaloid carcinoma. The cardinal histopathologic features distinguishing this tumor from other non-small cell lung cancers are a lobular growth pattern of small cells with moderately hyperchromatic nuclei, with no prominent nucleoli, and with scant cytoplasm, a high mitotic rate, and peripheral palisading. Basaloid carcinoma was present in a pure form in 19 cases and the other 19 tumors were of a mixed, but prominent, basaloid type associated with squamous cell carcinoma, large cell carcinoma, or adenocarcinoma. The immunophenotype of basaloid cancers was close to that of basal bronchial epithelial cells, with a low level of expression of low molecular weight cytokeratins. Staining for neuroendocrine markers was infrequent and inconsistent. Ultrastructural study showed an absence of neurosecretory granules and the presence of some squamous and/or glandular differentiation. This morphologic and immunologic phenotype suggests that basaloid carcinoma is derived from a pluripotent reserve cell or a basal bronchial epithelial stem cell. This unique histologic form of lung tumor has a poor prognosis, with a median survival rate of 22 months for stage I and II disease. This justifies classification of basaloid carcinoma as a distinct form of lung cancer, separate from small cell lung carcinoma.

Right to left shunts in the adult in their usual location are either intraarticular or intrapulmonary, and are often congenital. The acquired intrapulmonary shunt of the cirrhotic is now well defined by the hepatopulmonary syndrome. The major complication of right to left shunts are paradoxical pulmonary emboli which are often more severe than haemoptysis or chronic hypoxia. The diagnosis of intracardiac shunts as well as intrapulmonary shunts is now easier, thanks to transoesophageal ultrasound associated with contrast. Pulmonary angiography enables the treatment of arteriovenous fistula to be carried out by embolisation, and also avoids any surgery.

Toxocariasis is a frequent disease in children, but the severe clinical manifestations are rare in the literature (diffuse interstitial pneumonia with hypoxaemia and acute severe asthma). The diagnosis is made thanks to the reliability of serological techniques (the ELISA test and using antigen excretion-secretion tests of the larvae of Toxocara canis). The authors report a case of acute severe eosinophilic pneumonia whose outcome was rapidly favourable following steroid therapy; the existence of positive Toxocara canis serology with a contamination risk of the patient in the domestic environment leads us to integrate the clinical picture into the larva migrans syndrome.

Formoterol aerosol, a long-acting new beta 2-mimetic was administered over a year at a dose of 12 micrograms twice daily, to 62 chronic obstructive bronchitics of mean age 66 +/- 6 years and of whom the basal VEMS was at 12,801 +/- 0.59. Clinical tolerance of the product was good with undesirable effects in 13 patients, the most frequent being shaking. No untoward effect was seen on systolic or diastolic arterial pressure, or the heart rate over successive visits at 1, 3, 6, 9 months and one year. Electrocardiographic surveillance found in only four patients electrical abnormalities that may be due to Formoterol, these were patients without previous cardiac problems but of advanced mean age. Functionally, a significant improvement of basal VEMS was noticed from the 6th month. The VEMS improved significantly after administration of 12 micrograms on successive visits, without tachyphylactic signs. Well tolerated, with functional benefits, Formoterol is a promising product amongst the long-acting beta 2-mimetics. Its usefulness and limitations in the basic treatment of these chronic bronchopathies remains to be defined.

Nine patients, 4 with chronic obstructive pulmonary disease (COPD) and 5 with obstructive sleep apnoea syndrome (OSAS) were monitored during sleep, rest and exercise. Left ventricular ejection fraction (LVEF) was investigated using gated equilibrium 99mtechnetium ventricular scintigraphy during rapid eye movement (REM) sleep, during exercise, and during wakeful rest. Control wakeful rest periods used for comparison with a study state (either REM sleep or exercise) were always selected during the same circadian segment as that state. Myocardial stress thallium-201 scintigraphy was performed during, and 4 h after, exercise, and results were compared to a daytime rest period. Several patients had myocardial hypoperfusion despite a normal electrocardiographic (ECG) treadmill test. During REM sleep, all patients exhibited a significant change in LVEF (greater than 5%) compared to wakefulness. During exercise, 5 subjects increased their LVEF normally (greater than 5%) and 4 (1 COPD, 3 OSAS) decreased it. All patients had a similar change (increase or decrease) during REM and at maximal exercise. Our results suggest that REM sleep in COPD and in OSAS can produce a myocardial stress as great as that produced by exercise. We conclude that REM sleep, like exercise, is a state in which morbidity may become higher and that it may account for mortality in COPD and OSAS patients with compromised myocardial circulation.

We have seen four cases of granular cell tumor (Abrikossoff's tumour) and it is recalled that these tumours are most often discovered fortuitously by bronchoscopy in the tracheo-bronchial region because they have a non specific clinical presentation. The cytological and histological characteristics enable an accurate diagnosis but there are problems posed as to the histogenesis of these tumours. With a tumour with a slow progression regular surveillance with regular biopsies seems preferable as in certain cases the tumour regresses spontaneously or disappears after ablation with the forceps. A good alternative approach is destruction of the tumours with a laser in certain complicated forms which enables one to avoid surgical excision.

We present an anatomical-clinical analysis of ten cases of benign pleural fibroma. This tumour was discovered in a systematic fashion in 8 of the 10 cases and fortuitously in one. Recent radiological examinations enabled the diagnosis to be suspected. Computerised tomography most often precisely identified the pleural topography and imagery by nuclear magnetic resonance in one case visualised fibrous tissue (with a zone of low signals on the scale in T2). The final diagnosis was achieved at the same time as the treatment when an exploratory thoracotomy was performed. In all the cases there was a tumour composed of fusiform cells covered by normal epithelium coming from the viscera pleura 8 times out of 10. The ultrastructure examination and immunohistochemistry of the fusiform cells (Vimentin plus, EMA-, KL1-) allowed for a differentiation of these tumours of connective tissue origin from tumours of mesothelial origin. These analyses constitute an argument in favour of the fibroblastic origin of pleural fibromas.

Twenty-six asthmatic patients who were hospitalised following an acute asthmatic attack and who had a peak expiratory flow of less than 50% predicted, without hypercapnia, received 5 mg. of salbutamol delivered by a micronebulizer LSA on admission (HO). At H1, 10 mg of additional salbutamol were nebulised in cases where there had been an increase of less than 20% of the PEF. At H2, all the subjects received steroid therapy. Group 1 in which success was defined by an increase of 20% of peak flow judged at H1 and H2, and group II where the increase in peak flow was less than 20%. Group II benefited at H2 by treatment with theophylline or salbutamol intravenously given in a randomised fashion. At H8 the 2 treatments were associated in group II in cases of failures. 15 men, and 11 women aged 40 +/- 17 suffering from severe asthma (65% of Charpin Stage IV) were included. The mean peak flow at HO was 32 +/- 9% of the predicted PEF. 21 subjects, or 81% improved their peak flow by more than 20% at H2. The toleration for salbutamol was very good from the cardiovascular point of view. At HO there was no clinical criteria nor peak flow assessment which would enable one to predict the failures from nebulized salbutamol for a given subject. Nevertheless a level of dyspnoea of greater than 5 on Borg's scale and a peak flow of less than 150 l/min made failure likely.(ABSTRACT TRUNCATED AT 250 WORDS)

Thirty patients with chronic obstructive pulmonary disease (COPD) and 15 healthy volunteers have been studied to assess the value of measuring right ventricular ejection fraction (RVEF) at rest with a perfusion of krypton-81m (81mKr). With this perfusion, equilibrium RVEF can be measured in a 30 degrees right anterior oblique projection, avoiding a superimposition of cardiac cavities. The average RVEF of the patients with COPD was significantly lower than that of the normal patients (36.3 +/- 9.3% vs 52.6 +/- 3.9%; p less than 0.001). An inverse linear relation was found between mean pulmonary artery pressure (Ppa) and RVEF (r = -0.543; p less than 0.01). The RVEF in a group of 15 patients with COPD and pulmonary hypertension (Ppa greater than 20 mmHg), averaged 30.4 +/- 7.26%, which was significantly lower than that of the other 15 COPD patients with normal Ppa, whose RVEF averaged 42.3 +/- 7.1% (p less than 0.01). Taking a RVEF value less than or equal to 35% as an indicator of pulmonary hypertension, the sensitivity was 80% and specificity was 75%, the predictive value for a positive test was 75%, and for a negative test was 80%. A positive but weak correlation was found between RVEF and PaO2 (r = 0.52; p less than 0.01), SaO2 (r = 0.41; p less than 0.05) and the forced expiratory volume in one second (FEV1) (r = 0.40; p less than 0.05). No correlation was found between RVEF and prior history of right cardiac insufficiency, PaCO2, pH, the ratio FEV1/vital capacity, ECG signs of cor pulmonale and left ventricular ejection fraction.(ABSTRACT TRUNCATED AT 250 WORDS)

Ninety-nine patients, who had never previously taken inhaled steroids were enrolled in a randomized, single-blind, parallel study, the aim of which was to compare the efficacy and safety of flunisolide inhalation, 500 meg twice daily, with beclomethasone dipropionate inhaler 100 meg four times daily for the treatment of chronic asthma. The treatment period was for 6 weeks. The patients were examined clinically at entry, week 3 and week 6 and both treatment groups showed a marked improvement in almost all parameters during the course of the study. Flunisolide was statistically significantly superior to beclomethasone dipropionate for wheezing at week 6, coughing at week 6 and chest tightness at weeks 3 and 6. The number of asthma attacks per day decreased significantly more with flunisolide treatment than with beclomethasone dipropionate. The over-all evaluation of efficacy by both doctors and patients also showed flunisolide to be superior to beclomethasone dipropionate. In several other parameters there was a trend shown favouring flunisolide, and beclomethasone dipropionate did not show a superiority over flunisolide in any efficacy parameter. Both drugs were well-tolerated, with unpleasant taste being the most frequent complaint in the flunisolide group. No patient in either group withdrew from the study because of adverse events. In this study, flunisolide inhaler was more effective than beclomethasone dipropionate inhaler for the treatment of chronic asthma exhibited by patients who had never been treated with inhaled steroids.

The authors report the results obtained with one single daily dose of 10 mg/kg of a long-acting theophylline preparation administered in the evening to asthmatic patients previously treated with the same dose twice a day. Twenty-seven patients presenting with airway obstruction reversible by beta-stimulants entered the study; their mean FEV1 value was 57% of the expected value, and diffuse sibilances were present; paroxysmal attacks occasionally occurred, particularly at night. No significant difference was found between the two dosage regimens with regard to symptomatic improvement, adjuvant drug consumption, and plasma theophylline levels 12 hours after the evening dose. The classical side-effects of theophylline therapy were not increased by the once-a-day regimen. It is concluded that one dose of theophylline per day is effective in the treatment of nocturnal asthma.

The authors report a case of Pancoast and Tobias syndrome due to a hydatic cyst on the apex of the left lung. This parasitosis is together with tuberculosis and least infrequent benign etiology of Pancoast and Tobias syndrome. In our observation it was a young cyst without complications as opposed to previously reported cases.

In patients with sleep apnoea syndrome abnormalities of the upper airways may play a major role in the genesis of apnoea. Three cases are presented which illustrate the part played by hypertrophy of the tonsils in a child and by stenosis of the pharynx in an adult and of the larynx in another adult. All three patients were cured by surgical correction of these abnormalities. The physiopathology of alveolar hypoventilation, present in one of the three patients, is discussed in relation to the effects of pure oxygen inhalation on the patient's ventilation.

22 patients with severe respiratory insufficiency were treated by definitive tracheostomy for intermittent ventilatory assistance. Early mortality is heavy (9/22 before three months). After three months, the respiratory condition of patients improved greatly and survival rate is good. Tracheostomy is too often delayed and realized at the bad time of a severe acute respiratory failure.

If diagnosis of chronic thromboses of pulmonary arteries is usually easy at the stage of confirmed chronic pulmonary heart, it is not so when dysponea is the only symptom of the disease. The authors report 30 cases of chronic thrombosis and remark that if respiratory alkalosis is very frequent, hipoxemia is often missing. On the other hand they observe 27 times out of 28 an increase of CO2 alveoloarterial difference; measuring the CO2 difference appears a safe and reliable test for detecting chronic thrombosis. It should take place in every systematic complete examination of unexplained dyspnoea.

A case of primary malignant fibrous histiocytoma of the lung is reported. The clinical course was divided into 2 periods: slow tumoral growth followed by rapid aggravation. The pathological aspects of the first localization and of the relapse are analyzed and discussed. Data from the literature are reviewed, with special attention to diagnostic and prognostic problems.

The authors report the case of a patient with severe alveolar hypoventilation, with a large emphysematous bulla in the upper part of the right pulmonary field. The drainage aspiration of the bulla as a life saving technique greatly improved the respiratory function. Blood gases reverted to normal and the bullae disappeared. Literature reviewing. Discussion of radiological and functional criteria of compressing the pulmonary parenchyma around the bulla.

Two anatomoclinical observations of lymphomatoid granulomatosis are reported. The first case concerns a patient presenting a cutaneous localisation and a severe pulmonary infection with acute febrile dyspnea and macronodular opacities seen in pulmonary radiographs. The treatment associating cortisone and chlorambucil led to a complete remission. Five years later a pulmonary recurrence was treated successfully with the same association. The second patient presents dyspnea upon progressive effort, a radiologic and functional syndrome of interstitial involvement. In the absence of precise diagnosis after pulmonary biopsy, the patient was treated with corticosteroids. Four months later, encephalitic damage led to death. In the 2 observations, the biopsies or autopsic samples from the lungs or brain showed necrotic nodular lesions. Bordering on the necrosis, the small arteries and veins are strictured or obstructured by an infiltrate of lymphocytes, plasmocytes, histiocytes, and large cells with atypical nucleus. The ultrastructural examination of the 2 pulmonary biopsies shows the reactional polymorphic nature of the lymphoid infiltrate, the generally imprecise nature of atypical large cells and the modifications of vascular elastic limitations. The blades of elastine are surrounded by microfibrillar material. These different data are compared with those in the literature.

In order to determine the frequency and the characteristics of neuropathies in chronic respiratory insufficiency, a systematic study of 43 patients affected by a chronic obstructive pulmonary disease was performed. In addition to neurological and electrophysiological examinations (including 6 nerve conduction studies on median, ulnar and peroneal nerves and EMG of 4 to 8 muscles), nerve and muscle biopsies (of the superficial peroneal nerve and lateral peroneus brevis muscle) were performed in 13 cases. Polyneuropathies were found in 74% patients: but mild in 39%, severe in 35%. Most were subclinical or poorly symptomatic. We determined the importance and distribution of abnormalities on the different nerves. From this we established that neuropathies are mixed but predominantly of the axonal type. Axonal degeneration and demyelination were confirmed by nerve biopsy; muscles presented neurogenic atrophy. Statistical analysis showed that the duration of hypoxemia was related to neuropathy. The pathogeny of these neuropathies is discussed.

Ten patients with chronic respiratory failure (PaO2 = 56,19 +/- 10,54; PaCO2 = 49,17 +/- 7,31 torr) were given intramuscular injections of tiapride, Changes in alveolar ventilation were assessed clinically and by monitoring blood gases. No adverse effects were recorded. PaO2 was similar before and one hour after tiapride. There was no hypoventilation but, on the contrary, a slight decrease in PaCO2 (49,17 +/- 7,3 and 47,10 +/- 7,3 torr) and a significant increase in pH (7,358 +/- 0,023 and 7,378 +/- 0,028; p less than 0,05). Tiapride was also given to ten patients before fiberoptic bronchoscopy. Endoscopy was well tolerated in eight patients, in six there was no anxiety, and in all normal vigilance was retained.

The aim of the study was: 1) to define the frequency of gastroesophageal reflux (GER) in asthmatics; 2) to study a possible relationship between episodes of GER and changes in airflow obstruction while maintaining as far as possible physiological conditions. Nineteen consecutive patients (aged 40.3 +/- 19 years) presenting with severe asthma requiring continuous treatment, were studied in a stable period. All treatments were stopped for 12 hours before the examination, except corticosteroids and sustained theophylline. Esophageal pH was measured continuously one hour before and three hours after a standardized meal. Respiratory function was measured every 30 minutes using a miniaturized spirometer which enabled the measurement of forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and FEV1-VC ratio: 1) the frequency of pathological GER was defined by a Kaye's score greater than 90 and was 32%; 2) there was no significant correlation between the individual changes in FEV1 and different variables for the pH measured in the 30 mn before the measurement of bronchial obstruction (number of GER episodes, duration of GER, duration of the last GER episode, time of the last GER); 3) we have found no significant difference between the variation of FEV1 above or below 10% of the best FEV1 of each patient in relation to the quality (intensity, duration, delay) of GER episodes recorded 10 minutes before the spirometry.in severe asthmatics these results: 1) confirm the high frequency of pathological GER; 2) do not allow the establishment of a direct causal relationship between GER episodes and occurrence of a bronchial obstruction.