Search

The authors present a new study on 789 cases of congenital thoracic malformations including 638 pectus excavatum and 151 Poland syndromes, according to a new classification which completes Chin's one. All these malformations were treated with silicone elastomer implants. The contribution of computer-aided design and manufacturing (CAD/CAM) since 2008 is essential. The one-stage surgical protocol is precisely described. The results are impressive, permanent, for life, and complications are rare. The authors evoke a common vascular etiopathogenesis theory at the embryonic stage and question the heavy techniques of invasive remodeling that are most often unjustified.

Most common congenital malformation of the thorax, Pectus Excavatum affects about one in 500 people. Several surgical or medical techniques have been proposed. Some are followed by complications or insufficient results even though their constant functional value is highly controversial. Secondary surgery with a deep customized 3D elastomer implant, may be an elegant effective and safe solution compared to others; it allows a good aesthetic result expected by patients in the absence of any respiratory or cardio-vascular functional context.

The presence of multiple synchronous lung tumors is not a rare event. Distinguishing intra-pulmonary metastases from multiple synchronous lung adenocarcinoma is a challenge for pathologists and physicians. We present observation of a patient with three lung tumors corresponding to three adenocarcinomas for which molecular analysis had a significant impact on tumor staging.Three suspect lesions were discovered in a 61-year-old patient, a smoker, in each lobe of the right lung. Right pneumonectomy with lymph node dissection was performed. Pathological examination showed that each tumor was in fact an adenocarcinoma. In order to more precisely indicate tumor staging, molecular analysis was performed with next generation sequencing showing a different point mutation in a driver gene on each tumor. The final diagnosis is that the three tumors are distinct synchronous tumors, which must be staged separately.In modern-day practice of thoracic oncology and of surgical pathology, molecular biology represents a complement for tumor staging in the event of multiple lung tumors.

Silicosis and sarcoidosis are two very distinct entities in the literature. All the additional non-invasive examinations, including the chest CT scan, often do not differentiate them. The history, including occupational exposure to identified silica particles, is a discriminating factor. However, due to the pathogenic power of silica, it would be possible to have the simultaneous development of these two pathologies in the same patient. To illustrate this situation, here is the case of a 62-year-old patient, who presented initially with a picture of dyspnea and productive cough. The chest CT showed micronodular peribronchovascular infiltrates and mediastinal lymphadenopathy. The other additional examinations did not find anything specific. In the diagnostic process, the patient had multiple endoscopic samples which did not make it possible to be conclusive on one or the other of these pathologies. He therefore underwent a surgical lung biopsy which revealed histological lesions compatible with the two pathologies. Recent studies suggest that inhaled particles, especially silica, could be responsible for the pattern of sarcoidosis. However, it is difficult to say whether, in this case, silica was responsible for the development of sarcoidosis.

Resume But de l’etude Decrire les principales caracteristiques techniques des protheses biologiques de renfort parietal et presenter l’etat de l’art sur leur rapport efficacite/tolerance. Methodes Nous avons procede a une analyse technique des dossiers des fabricants de protheses biologiques disponibles en France et realise une revue de la litterature en selectionnant les meta-analyses et revues systematiques, les essais randomises controles ainsi que les publications d’agences d’evaluation de technologies de sante. Resultats Les implants biologiques de renfort parietal sont majoritairement utilises en milieu contamine en cas de contre-indication des protheses synthetiques. Quatorze revues systematiques et meta-analyses ont ete identifiees ainsi qu’un essai randomise controle. Six essais cliniques en cours ont ete recenses. Deux interruptions d’essais cliniques ont ete repertoriees. En l’etat actuel des connaissances, il n’existe pas de donnees de haut niveau de preuve sur l’apport therapeutique des protheses biologiques ou qui permettent de prioriser l’utilisation des protheses biologiques en fonction de leurs caracteristiques ou de leurs differents procedes de fabrication. Conclusion En attendant les resultats d’essais randomises controles en cours qui permettront de valider les indications et eventuellement un remboursement specifique, l’utilisation des protheses biologiques de renfort parietal semble devoir etre limitee a de rares situations cliniques et apres discussion collegiale.

cited By 1; International audience; Study aim To describe the main technical characteristics of biologic prostheses used for parietal reinforcement and to present the state of the art on their risk/benefit ratio. Methods We conducted a technical analysis of manufacturer specifications of the biologic prostheses that are currently available in France accompanied by a literature review by selecting meta-analyses and systematic reviews, randomized controlled trials and publications of health technology rating agencies. Results Biological implants for parietal reinforcement are mainly intended for use in a contaminated environment where the use of synthetic prostheses is contra-indicated. We identified fourteen systematic reviews and meta-analyses and one randomized controlled trial. Six ongoing clinical trials were identified as well as two clinical trials that had been interrupted. In the current state of knowledge, there are no high-level evidence data on the therapeutic contribution of biologic prostheses that allow prioritization of the various biologic prostheses according to their characteristics or their different manufacturing processes. Conclusion Pending the results of current randomized controlled trials to validate the indications and an eventual specific reimbursement, indications for the use of biologic parietal reinforcement prostheses seems to be limited to rare clinical situations and only after collegial discussion. © 2016 Elsevier Masson SAS

Resume Introduction le syndrome de Mounier-Kuhn ou tracheobronchomegalie congenitale est une pathologie peu frequente, dont la prise en charge therapeutique est complexe. Nous rapportons ici le cas d’un patient traite par endoscopie interventionnelle. Observation Il s’agit d’un homme de 74 ans dont le diagnostic de tracheobronchomegalie a ete porte en 2003 dans un contexte de degradation de l’etat respiratoire et la survenue de syncopes posturales. Il a tout d’abord beneficie d’une prothese tracheobronchique en Y, en silicone, prolongee par des protheses metalliques au niveau tracheal et bronchique. Le montage est reste stable jusqu’en 2011. Il apparait alors des episodes d’asphyxie liee a la luxation posterieure de la prothese tracheobronchique, par rupture des mailles de la prothese metallique tracheale. Une nouvelle prothese tracheobronchique en Y est alors mise en place, faite « sur mesure », a partir d’une modelisation 3D des voies aeriennes, avec evolution clinique et fonctionnelle tout a fait satisfaisante. Discussion Ce cas clinique est un exemple de prise en charge d’un syndrome de Mounier-Kuhn, par bronchoscopie interventionnelle, avec un recul de 10 ans, et avec pour originalite l’adaptation du materiel prothetique, de maniere individualisee a l’anatomie des voies aeriennes du patient.

Introduction The management of metastatic cutaneous melanoma is changing, marked by innovative therapies. However, their respective use and place in the therapeutic strategy continue to be debated by healthcare professionals. Objective The French national cancer institute has led a national clinical practice guideline project since 2008. It has carried out a review of these modalities of treatment and established recommendations. Methods The clinical practice guidelines development process is based on systematic literature review and critical appraisal by experts. The recommendations are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines are reviewed by independent practitioners in cancer care delivery. Results This article presents the results of bibliographic search, the conclusions of the literature and the recommendations concerning locoregional treatments of brain metastases for patients with metastatic cutaneous melanoma.

Resume Introduction Ces dernieres annees ont ete marquees par l'emergence de nouvelles molecules pour le traitement des formes metastatiques du melanome cutane avec un benefice significatif sur la survie des patients apportant ainsi de nouvelles perspectives therapeutiques. Par ailleurs, de nombreuses techniques se developpent actuellement pour le traitement locoregional des sites metastatiques. La prise en charge du melanome metastatique est donc en pleine mutation, marquee par des approches therapeutiques innovantes. Neanmoins, la mise a disposition de ces nouveaux traitements souleve aupres des professionnels de sante des interrogations quant a leur utilisation et place dans la strategie therapeutique. Objectif L'Institut national du cancer (INCa), dont l'une des missions est de definir et de favoriser la diffusion de recommandations nationales de bonnes pratiques cliniques depuis 2008, a souhaite diffuser un etat des lieux des connaissances sur ces modalites de traitement et formuler des recommandations afin de permettre une diffusion au niveau national de l'innovation tout en favorisant son bon usage. Methode Le processus d'elaboration est base sur une revue systematique de la litterature et sur le jugement argumente d'experts cliniciens au sein d'un groupe de travail multidisciplinaire. Avant publication, les recommandations sont revues par des experts cliniciens independants du groupe de travail. Resultats Cet article presente les recommandations nationales relatives au traitement systemique de 1re et de 2e ligne et aux traitements locoregionaux des sites metastatiques des patients atteints d'un melanome cutane metastatique. ________________________________________ Summary Background Recent years have seen the emergence of new molecules for the treatment of patients with metastatic cutaneous melanoma, with significant benefits in terms of survival and the opening of new therapeutic perspectives. In addition, many techniques are currently being developed for locoregional treatment of metastatic sites. Management of metastatic melanoma is thus fast-changing and is marked by innovative therapeutic approaches. However, the availability of these new treatments has prompted debate among healthcare professionals concerning their use and their place in therapeutic strategy. Aims Since 2008, the French National Cancer Institute (INCa) has been leading a project to define and diffuse national clinical practice guidelines. It has performed a review of these treatment methods, which it aims to circulate, and it is seeking to develop recommendations in order to allow nationwide implementation of innovative approaches while promoting good use thereof. Methods The clinical practice guidelines development process is based on systematic literature review and critical appraisal by experts within a multidisciplinary working group, with feedback from specialists in cancer care delivery. The recommendations are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines are reviewed by independent practitioners in cancer care delivery. Results This article presents the national recommendations for first- and second-line systemic treatment and for locoregional treatment of metastatic sites in patients presenting metastatic cutaneous melanoma. Mots cles " Recommandations pour la pratique clinique; " Melanome cutane metastatique; " Traitement; " Therapies ciblees; " Chimiotherapie Keywords " Clinical practice guidelines; " Metastatic cutaneous melanoma; " Treatment; " Targeted therapies; " Chemotherapy ? Le rapport integral presentant les recommandations nationales de prise en charge des patients atteints d'un melanome cutane metastatique est disponible sur le site Internet de l'INCa : www.e-cancer.fr. ?? Le present article est publie par l'Institut national du cancer qui en detient les droits. Sa reutilisation est possible des lors qu'elle entre dans le champ d'application de la loi no 78-753 du 17 juillet 1978 et qu'elle en respecte les conditions (absence d'alteration, de denaturation de son sens et mention de la source et de la date de sa derniere mise a jour). ? The complete report of the clinical practice guidelines for the management of patients with metastatic cutaneous melanoma is available online at the French National Cancer Institute website: www.e-cancer.fr.

Introduction la mise a disposition recente de nouvelles molecules pour le traitement du melanome cutane metastatique avec un benefice significatif sur la survie des patients souleve aupres des professionnels de sante des interrogations quant a leur utilisation et place dans la strategie therapeutique.

Background The benefit of neoadjuvant chemotherapy (NCT) for early-stage oesophageal cancer is unknown. The aim of this study was to assess whether NCT improves the outcome of patients with stage I or II disease. Methods Data were collected from 30 European centres from 2000 to 2010. Patients who received NCT for stage I or II oesophageal cancer were compared with patients who underwent primary surgery with regard to postoperative morbidity, mortality, and overall and disease-free survival. Propensity score matching was used to adjust for differences in baseline characteristics. Results Of 1173 patients recruited (181 NCT, 992 primary surgery), 651 (55·5 per cent) had clinical stage I disease and 522 (44·5 per cent) had stage II disease. Comparisons of the NCT and primary surgery groups in the matched population (181 patients in each group) revealed in-hospital mortality rates of 4·4 and 5·5 per cent respectively (P = 0·660), R0 resection rates of 91·7 and 86·7 per cent (P = 0·338), 5-year overall survival rates of 47·7 and 38·6 per cent (hazard ratio (HR) 0·68, 95 per cent c.i. 0·49 to 0·93; P = 0·016), and 5-year disease-free survival rates of 44·9 and 36·1 per cent (HR 0·68, 0·50 to 0·93; P = 0·017). Conclusion NCT was associated with better overall and disease-free survival in patients with stage I or II oesophageal cancer, without increasing postoperative morbidity.

This study was designed as an external evaluation of the Steyerberg score in the prediction of different categories of postoperative mortality after esophagectomy on a large nationwide database of thoracic surgeons. Data collection was obtained from the Epithor national database encompassing the majority of thoracic procedures performed in France. We retrospectively compared the predicted to the observed postoperative 30-day (30DM), 90-day (90DM) and in-hospital mortality (IHM) rate in each decile of equal patient. Patients included in the study were operated for an esophageal cancer and Gastroesophageal junction (GEJ). Steyerberg score was determined according to its logarithmic formula obtained from a sum score including age, comorbidities, neoadjuvant treatment and hospital volume. Deviation of observed from theoretically expected number of deaths was investigated using the calibration test of Hosmer-Lemeshow. Discrimination of the score was determined using the measure of the area under the receiver operating characteristic curve (AUC) of each category of mortality. Over a 9-year period, 1039 consecutive patients underwent an esophagectomy over 42 centers. Among them, 18 centers were considered as intermediate or high-volume institutions, and 24 were low-volume institutions. There were 841 males (81%) with a mean age of 62.3 ± 10 years. Preoperative treatment was allocated to 420 patients (40%). Numbers of comorbidity was: 1 in 261 patients (25%), 2 in 264 patients (25%), 3 in 383 patients (36%) and 4 in 5 patients (1%). The 30DM, 90DM and IHM rate were, respectively, 5.6%, 9.2% and 9.6%. The main causes of postoperative deaths were related to pulmonary complications (44%), complications of the gastric interposition (28%), cardiologic and thromboembolism events (10%). For 30DM, there were significant differences between predicted/observed mortalities in four deciles, whereas there was no significant difference for 90DM and for IHM. In term of calibration, there was a fair agreement of the Steyerberg score with observed 30DM. Predictions were above 20% for seven deciles. Calibration seemed more adequate for 90DM and for IHM. Predictions were above 20% for only three deciles but deviations were not significant. In terms of discrimination, for the 30DM the Steyerberg score overpredicted, the observed mortality rate and AUC was 0.64 (CI 95%: 0.57-0.71). For the 90DM, AUC indicated 0.63 (CI 95%: 0.57-0.68). For the IHM, AUC indicated 0.63 (CI 95%: 0.58-0.68). Steyerberg scoring system seems to be a moderate risk score of the prediction of the IHM and 90DM. This score appears to have a fair discrimination for the 30DM. Nevertheless, because of its simplicity, we believe that this simple predictive score is relevant and transportable to others institution performing such surgery for benchmarking purposes. A reappraisal of the score adapted to current surgical cohort is required.

This study was designed as an external evaluation of the Steyerberg score in the prediction of different categories of postoperative mortality after esophagectomy on a large nationwide database of thoracic surgeons. Data collection was obtained from the Epithor national database encompassing the majority of thoracic procedures performed in France. We retrospectively compared the predicted to the observed postoperative 30-day (30DM), 90-day (90DM) and in-hospital mortality (IHM) rate in each decile of equal patient. Patients included in the study were operated for an esophageal cancer and Gastroesophageal junction (GEJ). Steyerberg score was determined according to its logarithmic formula obtained from a sum score including age, comorbidities, neoadjuvant treatment and hospital volume. Deviation of observed from theoretically expected number of deaths was investigated using the calibration test of Hosmer-Lemeshow. Discrimination of the score was determined using the measure of the area under the receiver operating characteristic curve (AUC) of each category of mortality. Over a 9-year period, 1039 consecutive patients underwent an esophagectomy over 42 centers. Among them, 18 centers were considered as intermediate or high-volume institutions, and 24 were low-volume institutions. There were 841 males (81%) with a mean age of 62.3 ± 10 years. Preoperative treatment was allocated to 420 patients (40%). Numbers of comorbidity was: 1 in 261 patients (25%), 2 in 264 patients (25%), 3 in 383 patients (36%) and 4 in 5 patients (1%). The 30DM, 90DM and IHM rate were, respectively, 5.6%, 9.2% and 9.6%. The main causes of postoperative deaths were related to pulmonary complications (44%), complications of the gastric interposition (28%), cardiologic and thromboembolism events (10%). For 30DM, there were significant differences between predicted/observed mortalities in four deciles, whereas there was no significant difference for 90DM and for IHM. In term of calibration, there was a fair agreement of the Steyerberg score with observed 30DM. Predictions were above 20% for seven deciles. Calibration seemed more adequate for 90DM and for IHM. Predictions were above 20% for only three deciles but deviations were not significant. In terms of discrimination, for the 30DM the Steyerberg score overpredicted, the observed mortality rate and AUC was 0.64 (CI 95%: 0.57-0.71). For the 90DM, AUC indicated 0.63 (CI 95%: 0.57-0.68). For the IHM, AUC indicated 0.63 (CI 95%: 0.58-0.68). Steyerberg scoring system seems to be a moderate risk score of the prediction of the IHM and 90DM. This score appears to have a fair discrimination for the 30DM. Nevertheless, because of its simplicity, we believe that this simple predictive score is relevant and transportable to others institution performing such surgery for benchmarking purposes. A reappraisal of the score adapted to current surgical cohort is required.

Resume Introduction Les pneumopathies organisees sont des pathologies pulmonaires inflammatoires et fibroproliferatives dont l’aspect radiologique le plus frequent est celui d’opacites migratrices bilaterales. Observation Le bilan radiologique d’un patient presentant une toux seche chronique a mis en evidence une lesion nodulaire unique peripherique du lobe inferieur gauche, hyperfixante en tomographie par emission de positrons (TEP), sans anomalie endobronchique. Une wedge-resection est realisee du fait de la constatation extemporanee d’un aspect de pneumopathie interstitielle avec lesions de bronchiolite obliterante. Le bilan etiologique n’a pas retrouve d’arguments en faveur d’une cause en particulier dysimmunitaire et le diagnostic final de pneumonie organisee cryptogenique (POC) a ete retenu. Conclusion Les POC peuvent parfois se presenter, sur le plan radiologique, sous la forme d’un nodule pulmonaire isole peripherique d’allure pseudotumorale, fixant en TEP. Le diagnostic est alors porte grâce a l’analyse anatomopathologique postoperatoire, sans que l’anamnese ou l’endoscopie n’aient pu faire evoquer le diagnostic. La gravite et la frequence du diagnostic alternatif rendent necessaire une investigation anatomopathologique.

BACKGROUND: Chest tube drainage is the standard treatment of a large spontaneous pneumothorax. Aspiration is an alternative technique that is simple and rapid to learn, and the success rate seems identical to chest tube drainage. Its widespread use justifies studies to define its place in the management strategy of spontaneous pneumothorax. METHODS: We propose a multicentre, prospective, randomized, open trial with two parallel groups. The main objective is to compare the therapeutic efficacy of a simple aspiration with chest tube drainage for a first large spontaneous pneumothorax. The hypothesis is that aspiration is not inferior to a chest drain in its immediate effect. The secondary objectives are to compare the therapeutic efficacy at 24h and at one-week, the relapse rate at one year, and the tolerance and complications. A comparison of both the medical and economic aspects will be made. With an α-risk of 0.05 and a β-risk of 0.10, a proportion of failures of 30% expected in both groups and a target of non-inferiority of δ=0.15, the number of subjects to be included is 200 per group, totalling 400 in all. EXPECTED RESULTS: In the case of equivalence, this study should help to better define the place of aspiration compared to chest tube drainage in the management of spontaneous pneumothorax.

Mounier-Kuhn syndrome or tracheobronchomegaly is a rare congenital condition, the management of which is complex. We report the case of a patient who was treated with interventional endoscopy.We describe the case of a 74-year-old man with a diagnosis of tracheobronchomegaly who was admitted in 2003 with a background of deteriorating respiratory status and the occurrence of postural syncope. He initially received a tracheobronchial silicone Y prosthesis, extended with metal prostheses at the tracheal and bronchial level. This arrangement remained stable until 2011. He then began to develop episodes of asphyxia related to posterior dislocation of the tracheobronchial prosthesis, after breakage of the metallic mesh tracheal prosthesis. A new tracheobronchial prosthesis Y was then placed, custom-made from a 3D model of the airways. This was clinically and functionally effective.This case describes the management of a patient with Mounier-Kuhn syndrome by interventional bronchoscopy, with the adaptation of prosthetic materials, on an individual basis, to the anatomy of the patient's airway.

The management of metastatic cutaneous melanoma is changing, marked by innovative therapies. However, their respective use and place in the therapeutic strategy continue to be debated by healthcare professionals.The French national cancer institute has led a national clinical practice guideline project since 2008. It has carried out a review of these modalities of treatment and established recommendations.The clinical practice guidelines development process is based on systematic literature review and critical appraisal by experts. The recommendations are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines are reviewed by independent practitioners in cancer care delivery.This article presents the results of bibliographic search, the conclusions of the literature and the recommendations concerning locoregional treatments of brain metastases for patients with metastatic cutaneous melanoma.

Resume But de l'etude Le but de ce travail retrospectif est de rapporter une serie de hernioplasties cœlioscopiques realisees dans deux centres hospitalo-universitaires et d'evaluer les resultats avec un recul moyen de 31 mois. Patients et methodes De janvier 1992 a janvier 1997, 318 patients ont ete operes par six chirurgiens seniors et six juniors. Il y avait 302 hommes et 16 femmes, âge moyen: 63 ans. Les techniques utilisees ont ete la voie extraperitoneale pour 298 hernies, la voie trans-abdominopreperitoneale pour 62 hernies, et la voie intra-abdominale pour 41 hernies. Resultats Le taux de conversion en chirurgie conventionnelle a ete de 7%. La mortalite a ete nulle. Le taux de com plications postoperatoires a ete de 10%, et le delai moyen d'hospitalisation de trois jours. Avec un suivi de un a cinq ans, quatre des 94% de patients ayant repondu a l'enquete ont presente une recidive: 3% de ceux operes par voie extraperitoneale; 4% de ceux operes par voie transabdomino-preperitoneale; 10 % de ceux operes par voie intra-abdominale. Conclusion Les hernioplasties laparoscopiques apparaissent aussi efficaces que celles realisees par voie traditionnelle, et beneficient des avantages d'une chirurgie mini-invasive. La voie extraperitoneale a notre preference et a ete la plus utilisee dans cette serie. La voie intraabdominale a ete abandonnee.

We report a case of spontaneous hepatic rupture secondary to HELLP syndrome. A favourable evolution was observed after massive transfusion and surgical management limited to hepatic packing. Subcapsular hepatic haematoma is a rare complication of preeclampsia occurring mainly in the context of HELLP syndrome. A high maternal and foetal mortality is observed. Different therapeutic options are presented including medical, surgical and radiological interventions. A unique strategy cannot be defined. Multidisciplinary approach seems mandatory. Surgery should remain as less aggressive as possible.

Esophageal perforation is associated with significant mortality, and this may markedly increase with advanced age. This multicenter study investigates this issue in patients older than 80 years. Data on 33 patients 80 years old who underwent conservative (10 patients), endoclip (one patient), stent grafting (11 patients), or surgical treatment (11 patients) for esophageal perforation were collected from nine centers. Surgical repair consisted of repair on drain in one patient, primary repair in seven patients, and esophagectomy in two patients. Among patients who underwent stent grafting, one required repeat stenting and another stent graft repositioning. One patient was converted to surgical repair after stent grafting. Thirteen patients (39.4%) died during the 30-day and/or in-hospital stay. Their mortality was significantly higher than in a series of patients80 years old (13.0%, 21/161 patients, P=0.001). Three patients (30.0%) died after conservative treatment, one (100%) after treatment with endoclips, five (45.5%) after stent grafting, and four (36.4%) after surgical repair (P=0.548). Early survival with salvaged esophagus was 42.4% (conservative treatment: 70.0% endoclips 0%, stent grafting: 54.5%, and surgical repair: 54.5%, respectively, P=0.558). Estimated glomerular filtration rate60 mL/minute/1.73 m2 (70.0% vs. 25.0%, P=0.043) and sepsis (100% vs. 32.1%, P=0.049) at presentation were associated with increased risk of early mortality in univariate analysis. Esophageal perforation in octogenarians is associated with very high early and intermediate high mortality irrespective of the treatment method used.

Recent years have seen the emergence of new molecules for the treatment of patients with metastatic cutaneous melanoma, with significant benefits in terms of survival and the opening of new therapeutic perspectives. In addition, many techniques are currently being developed for locoregional treatment of metastatic sites. Management of metastatic melanoma is thus fast-changing and is marked by innovative therapeutic approaches. However, the availability of these new treatments has prompted debate among healthcare professionals concerning their use and their place in therapeutic strategy.Since 2008, the French National Cancer Institute (INCa) has been leading a project to define and diffuse national clinical practice guidelines. It has performed a review of these treatment methods, which it aims to circulate, and it is seeking to develop recommendations in order to allow nationwide implementation of innovative approaches while promoting good use thereof.The clinical practice guidelines development process is based on systematic literature review and critical appraisal by experts within a multidisciplinary working group, with feedback from specialists in cancer care delivery. The recommendations are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines are reviewed by independent practitioners in cancer care delivery.This article presents the national recommendations for first- and second-line systemic treatment and for locoregional treatment of metastatic sites in patients presenting metastatic cutaneous melanoma.

International audience; BACKGROUND: Chest tube drainage is the standard treatment of a large spontaneous pneumothorax. Aspiration is an alternative technique that is simple and rapid to learn, and the success rate seems identical to chest tube drainage. Its widespread use justifies studies to define its place in the management strategy of spontaneous pneumothorax. METHODS: We propose a multicentre, prospective, randomized, open trial with two parallel groups. The main objective is to compare the therapeutic efficacy of a simple aspiration with chest tube drainage for a first large spontaneous pneumothorax. The hypothesis is that aspiration is not inferior to a chest drain in its immediate effect. The secondary objectives are to compare the therapeutic efficacy at 24h and at one-week, the relapse rate at one year, and the tolerance and complications. A comparison of both the medical and economic aspects will be made. With an α-risk of 0.05 and a β-risk of 0.10, a proportion of failures of 30% expected in both groups and a target of non-inferiority of δ=0.15, the number of subjects to be included is 200 per group, totalling 400 in all. EXPECTED RESULTS: In the case of equivalence, this study should help to better define the place of aspiration compared to chest tube drainage in the management of spontaneous pneumothorax.

a Pole pluridisciplinaire de medecine, clinique de dermatolo-venereologie, photobiologie et allergologie, hopital Michallon, 38043 Grenoble, France b Direction des recommandations et de la qualite de l’expertise, Institut national du cancer, 52, avenue Andre-Morizet, 92513 Boulogne-Billancourt, France c Departement de medecine interne et de pneumologie, hopital de la Cavale Blanche, boulevard Tanguy-Prigent, 29609 Brest, France d Unite onco-dermatologie, centre Leon-Berard, 28, rue Laennec, 69008 Lyon, France e Service de dermatologie, hopital Saint-Vincent-de-Paul, boulevard de Belfort, BP 387, 59020 Lille, France f Service de dermatologie, hopital Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges, France g Service d’oncologie medicale, ICM, institut du cancer de Montpellier Val-d’Aurelle, parc Euromedecine, 208, avenue des Apothicaires, 34298 Montpellier, France h Departement de neurochirurgie, hopital Charles-Nicolle, 1, rue de Germont, 76000 Rouen, France

Cryptogenic organizing pneumonia is inflammatory and proliferative pulmonary diseases whose specific radiologic feature are bilateral and migrant opacities.An isolated peripheral nodule of the left lower lobe was discovered on chest X-ray of a man who presented with isolated chronic cough. As this nodule has a positive FDG positron emission tomography uptake (PET) but with inconclusive fiberoptic bronchoscopy, the patient was sent to surgeon and a wedge-resection was processed because intraoperative analysis did not show any tumour. Histopathological study was in favour of organizing pneumonia. Search for potential cause remained negative and the diagnosis of cryptogenic organizing pneumonia was retained.Cryptogenic organizing pneumonia may mimic lung cancer, presenting as an isolated peripheral nodule with positive PET. Histopathological study remains absolutely necessary to retain the diagnosis because of dramatic differences in prognosis and therapy.

We report a case of spontaneous hepatic rupture secondary to HELLP syndrome. A favourable evolution was observed after massive transfusion and surgical management limited to hepatic packing. Subcapsular hepatic haematoma is a rare complication of preeclampsia occurring mainly in the context of HELLP syndrome. A high maternal and foetal mortality is observed. Different therapeutic options are presented including medical, surgical and radiological interventions. A unique strategy cannot be defined. Multidisciplinary approach seems mandatory. Surgery should remain as less aggressive as possible.

Anorectal melanoma is a rare condition and its surgical management is controversial. This article reports the case of a patient with anorectal melanoma who underwent abdominoperineal resection and Sentinel Lymph Node biopsy. Melanoma was classified pT4aN0. Fifty months after initial treatment, the patient is still alive disease free. SLN mapping allows better surgical excision of the presumed sites of the lymphatic dissemination in melanoma. SLN biopsy improve the accuracy of nodal staging. In case of sentinel node metastasis, it allows early therapeutic lymphadenectomy of the sentinel nodes's basin and could therefore reduce the high rate of regional recurrence in anorectal melanoma. Moreover, knowing the exact histological status of the regional nodes means that the relative merits of abdominoperineal resection and wild local excision could be compared in relation to tumor thickness.

Localised intrapulmonary plasmacytoma represents less than 5% of all extramedullary plasmacytomas. Their diagnosis is usually made difficult by a radiological presentation and non specific endoscopic findings as well as non contributory biochemical and cytological data. This often justifies the recourse to more invasive histological investigation aided by immunohistochemical techniques. We report the case of a patient who presented with an isolated plasmacytoma in the form of two parenchymatous pulmonary masses and who was treated by a combination of surgical resection and external radiotherapy. A search for multiple intraosseous myeloma remained negative. Unfortunately a relapse in the form of mediastinal invasion occurred 6 months after the completion of treatment and led to the death of the patient.

The study evaluated the contribution of serum PS100 assay to the detection of lymph node metastases during the follow-up of patients previously treated for a malignant melanoma, in addition to (99m)Tc sestamibi (MIBI) scintigraphy and investigation for gene MDR1, in order to detect chemoresistance phenomena. The study included 37 patients with a clinically questionable lymph node around basin lymphatic areas of the previously surgically-treated malignant melanoma. The sensitivity and specificity of PS100 assay were 91% and 86.5%, respectively. The sensitivity and specificity of MIBI scintigraphy were 95% and 85%, respectively. Overexpression of gene MDR1 was observed in six cases. In the event of negative scintigraphic findings, the concomitant analysis of PS100 levels and the scintigraphic result enabled the metastatic MDR+ patients to be distinguished from the non-metastatic patients. PS100 assay may therefore be proposed for the follow-up of malignant melanoma.

The aim of this study was to evaluate the detection of the first lymph node draining the primary tumour site, using a radioisotopic mapping alone and to determine whether a preoperative lymphoscintigraphy using technetium sulfur colloid and a hand-held gamma detecting probe could improve the detection of the sentinel lymph node (SLN) in melanoma.From January to December 1998, 36 patients with a cutaneous melanoma larger than 0.75 mm, stage I TNM were included in this prospective study. Mean Breslow was 1.85 mm. The distribution of melanoma was head and neck (n = 9), trunk (n = 7), upper extremities (n = 4), lower extremities (n = 16). Preoperative lymphoscintigram and intraoperative detection were used. The first hot lymph node was supposed to be the SLN.In all cases, a lymph node was found and nine patients had more than one SLN (average number of SLN per patient: 1.25). Aberrant drainages were found in seven patients (19.4%): 1 in-transit lymph node, three paradoxical bassins, three bypasses). Four out of 36 patients had lymph node metastases and underwent elective lymph node dissection.The radio-isotopic technique used alone for the identification of the SLN is efficient in melanoma with a 100% detection rate in this short series.

Bilateral adrenal haemorrhage of traumatic origin is rarely observed or possibly missed in severely multi-traumatised patients. It can lead to a potentially fatal adrenal shock. Its emergency diagnosis is made by imaging techniques, usually by CT-scan. Early substitution therapy has to be done. This complication emphasizes the importance of an immediate abdominal morphological exploration in multi-traumatized patients when this is feasible.

The aim of this retrospective study was to report a series of laparoscopic hernioplasty performed in two surgical centers, and to evaluate the results with a mean follow-up of 31 months.From January 1992 to January 1997, 318 patients with 401 inguinal hernias were operated on through laparoscopy by six senior surgeons and six junior surgeons. There were 302 men and 16 women (mean age: 53 years). The operation was performed through an extra-peritoneal approach (TEP) in 298 hernias, a trans-abdomino-preperitoneal approach (TAPP) in 62 hernias, and an intra-abdominal approach (IPOM) in 41 hernias.Conversion into open surgery was necessary in 7% of the patients. There was no postoperative death. The postoperative morbidity rate was 10%. The average hospital stay was three days. With a 1 to 5 year follow-up, 4% of the 94% of the patients who answered the questionnaire showed a recurrence (3% in the extra-peritoneal group; 4% in the trans abdomino-preperitoneal group; 10% in the intra-abdominal group).Laparoscopic hernioplasty seems as efficient as traditional hernoplasty with the advantages of mini-invasive surgery. The extra-peritoneal approach was preferred and performed in most cases of this series. The intra-peritoneal approach was abandoned.

A prospective study was undertaken in order to evaluate the effects of endoscopic sphincterotomy on the evolution of biliary and idiopathic acute pancreatitis.Among 320 patients with acute pancreatitis observed from 1986 to 1996, 118 were excluded from the study for etiological reasons and 137 were included for an endoscopic sphincterotomy within 72 hours from their admission. There were nine technical failures and 128 endoscopic sphincterotomies were performed. Sixty-five eligible patients were not included for logistic problems or patients' refusal; they can be considered as a "control group".The mortality rate of endoscopic sphincterotomy was 0 and the morbidity rate 2.1%. The mortality rate of acute pancreatitis was 3.1% in the sphincterotomy group vs 7.6% in the control group (P = 0.1) (NS) and the morbidity rate 25% versus 32% (Por = 0.1) (NS).These results suggest that endoscopic sphincterotomy could be beneficial in acute biliary or idiopathic pancreatitis but they are not statistically significant. Endoscopic sphincterotomy does not increase the severity of acute pancreatitis and can be considered particularly in cases of gallstone pancreatitis but it should be performed less than 48 hours after the onset of acute pancreatitis.

A case of intestinal pseudo-obstruction by amyloidosis, occurring after 20 years of dialysis in a 72-year-old woman is reported. Although acute intestinal complications of intestinal amyloidosis, such as ischemia, colonic obstruction or haemorrhage are well known, colonic pseudo-obstruction is more unusual. It gradually results in, it carries out an intestinal obstruction with colonic and gastric distension. The diffuse topography of amyloid deposits throughout the gastrointestinal tract carries a poor prognosis and surgery cannot be curative.

7530 Background: PN after induction CT for NSCLC is controversial due to excessive reported mortality. Methods: We conducted a multicenter, retrospective study including all patients treated by ind...