Video-assisted thoracoscopic resection of a small pulmonary nodule after computed tomography-guided localization with a hook-wire system. Experience in 45 consecutive patients.

BACKGROUND: This study is a single-institution validation of video-assisted thoracoscopic (VATS) resection of a small solitary pulmonary nodule (SPN) previously localized by a CT-guided hook-wire system in a consecutive series of 45 patients. METHODS: The records of all patients undergoing VATS resection for SPN preoperatively localized by CT-guided a hook-wire system from January 2002 to December 2004 were assessed with respect to failure to localize the lesion by the hook-wire system, conversion thoracotomy rate, duration of operation, postoperative complications, and histology of SPN. RESULTS: Forty-five patients underwent 49 VATS resections, with simultaneous bilateral SPN resection performed in 4. Preoperative CT-guided hook-wire localization failed in two patients (4%). Conversion thoracotomy was necessary in two patients (4%) because it was not possible to resect the lesion by a VATS approach. The average operative time was 50 min. Postoperative complications occurred in 3 patients (6%), one hemothorax and two pneumonia. The mean hospital stay was 5 days (range: 2-18 days). Histological assessment revealed inflammatory disease in 17 patients (38%), metastasis in 17 (38%), non-small-cell lung cancer (NSCLC) in 4 (9%), lymphoma in 3 (6%), interstitial fibrosis in 2 (4%), histiocytoma in one (2%), and hamartoma in one (2%). CONCLUSIONS: Histological analysis of resected SPN revealed unexpected malignant disease in more than 50% of the patients indicating that histological clarification of SPN seems warranted. Video-assisted thoracoscopic resection of SPN previously localized by a CT-guided hook-wire system is related to a low conversion thoracotomy rate, a short operation time, and few postoperative complications, and it is well suited for the clarification of SPN.

Axillary Sentinel Lymph Node Biopsy for Breast Cancer and Melanoma Patients after Previous Axillary Surgery: A Systematic Review

Objective: Sentinel lymph node biopsy (SLNB) is a validated staging technique for breast carcinoma. Some women are exposed to have a second SLNB due to breast cancer recurrence or a second neoplasia (breast or other). Due to modi- fied anatomy, it has been claimed that previous axillary surgery represents a contra-indication to SLNB. Our objective was to analyse the literature to assess if a second SLNB is to be recommended or not. Methods: For the present study, we performed a review of all published data during the last 10 years on patients with previous axilla surgery and second SLNB. Results: Our analysis shows that second SLNB is feasible in 70%. Extra-axillary SNs rate (31%) was higher after radical lymph node dissection (ALND) (60% - 84%) than after SLNB alone (14% - 65%). Follow-up and com- plementary ALND following negative and positive second SLNB shows that it is a reliable procedure. Conclusion: The review of literature confirms that SLNB is feasible after previous axillary dissection. Triple technique for SN mapping is the best examination to highlight modified lymphatic anatomy and shows definitively where SLNB must be per- formed. Surgery may be more demanding as patients may have more frequently extra-axillary SN only, like internal mammary nodes. ALND can be avoided when second SLNB harvests negative SNs. These conclusions should however be taken with caution because of the heterogeneity of publications regarding SLNB and surgical technique.

Intravitreal ranibizumab for age-related macular degeneration - optical coherence tomography guided retreatment intervals and their intra- and inter-individual variability

PURPOSE:To determine whether the need for retreatment after an initial loading phase of 3 monthly intravitreal injections of ranibizumab shows an intra-individual regular rhythm and to what degree it varies between different patients.SETTING:Prospective mono-centre cohort study.METHODS:Prospective study with 42 patients with exudative age-related macular degeneration (AMD), treatment na?ve, giving informed consent. Loading dose of 3 monthly doses of ranibizumab (0,5mg), followed by a 12 months pro re nata (PRN) regimen according to early exudative signs on spectral domain optical coherence tomography (HD-OCT Cirrus Zeiss?, cube 512x126). The follow-up visits were intensified (week 4, 5, 6, 7, 8, 10, 12, 14, 16, 20, 24, etc after each injection) in order to detect exudative recurrences early, and injection followed within 3 days in cases of subretinal fluid, or intraretinal cysts, or central thickness increase of >50?m. Intervals were calculated between injections and the following recurrence was calculated for the 12 month follow-up with PRN treatment. Variability was expressed as standard deviation (SD). RESULTS Visual acuity (VA) improved from a mean ETDRS letter score of 61.6 (SD 10.8) at baseline to 68.0 (SD 10.2, +6.4 letters) at month 3 and increased further to 74.7 (SD 9.0, +13.1 letters from baseline) at month 12. The 15 patients who have completed the study by October 2010 showed maintenance of the VA improvement. Retinal thickness of the central foveal subfield improved from a mean value of 366?m(baseline) to 253?m(month 3), well maintained thereafter. Mean number of injections was 8.8 (SD 3.5) per 12 months of follow-up (after 3 loading doses), ranging from 0 to 12, with mean individual treatment-recurrence intervals ranging from 28 to >365 days (mean 58 days). Intraindividual variability of treatment-recurrence intervals, measured as SD of the individual intervals, was 7.1days as a mean value(range 1.7 ? 22.6 days) for the 33 patients with more than 1 injection during follow-up. SD was higher for longer intervals of an individual patient. It ranged within 20% of the mean intra-individual interval for 30 patients(91%) and within 15% for 21 patients(64%). The first interval was within 1 week of the mean intra-individual interval in 64% of patients and within 2 weeks in 89% of patients.CONCLUSIONS:The majority of AMD patients showed a relatively stable rhythm for PRN injections of intravitreal ranibizumab after initial loading phase, associated with excellent functional and anatomical results. The initial interval between last loading dose and first recurrence may have a predictive value for further need of treatment, therefore potentially facilitating follow-up and patient care.

Ponction biopsie medullaire [Bone marrow aspiration and biopsy]

Le diagnostic final des pathologies impliquant le système hématopoïétique tel que les leucémies, pancytopénies inexpliquées ou autres désordres médullaires, requiert une ponction biopsie de moelle. Cette procédure relativement invasive doit être maîtrisée non seulement par l'hématologue, mais également par l'interniste. Il est crucial d'en connaître les indications et contre-indications et de pouvoir prévenir les complications par une bonne connaissance de celles-ci. Cet article revoit ces différents éléments et apporte les détails pratiques de la procédure ainsi que le matériel nécessaire. The definitive diagnosis of several hematological diseases, as for instance leukaemias, unexplained pancytopenias and other bone marrow disorders, requires a bone marrow aspiration and biopsy. Not only haematologists, but also internists, need to master this rather invasive procedure. The knowledge of indications, contra-indications, potential complications and their prevention of its complications is of utmost importance. This article reviews these topics about bone marrow biopsy, giving some practical advices on this procedure

Sentinel lymph node biopsy in nonmelanoma skin cancer patients.

The management of lymph nodes in nonmelanoma skin cancer patients is currently still debated. Merkel cell carcinoma (MCC), squamous cell carcinoma (SCC), pigmented epithelioid melanocytoma (PEM), and other rare skin neoplasms have a well-known risk to spread to regional lymph nodes. The use of sentinel lymph node biopsy (SLNB) could be a promising procedure to assess this risk in clinically N0 patients. Metastatic SNs have been observed in 4.5-28% SCC (according to risk factors), in 9-42% MCC, and in 14-57% PEM. We observed overall 30.8% positive SNs in 13 consecutive patients operated for high-risk nonmelanoma skin cancer between 2002 and 2011 in our institution. These high rates support recommendation to implement SLNB for nonmelanoma skin cancer especially for SCC patients. Completion lymph node dissection following positive SNs is also a matter of discussion especially in PEM. It must be remembered that a definitive survival benefit of SLNB in melanoma patients has not been proven yet. However, because of its low morbidity when compared to empiric elective lymph node dissection or radiation therapy of lymphatic basins, SLNB has allowed sparing a lot of morbidity and could therefore be used in nonmelanoma skin cancer patients, even though a significant impact on survival has not been demonstrated.

Goodpasture's disease presenting with acute renal failure

A 15-year-old boy was admitted for vomiting, diarrhea, fatigue, crampy abdominal pain and oliguria. A renal failure was diagnosed (creatinine 2523 μmol/, urea 53,1 mmol/l) with severe aregenerative anemia (80 g/l), metabolic acidosis, hyperkalemia, elevated inflammatory markers and normal platelet count. A nephrotic proteinuria was noticed (350 g/mol). Patient's creatinine was normal 4 months before. The diagnosis of rapidly progressive glomerulonephritis was suspected. C3 and C4 were normal, ANA and ANCA were negative; anti-glomerular basement membrane antibody (anti-GBM) was positive (1/320) which lead to the diagnosis of Goodpasture's disease. Chest X-ray showed bilateral hilar infiltration and CT-scan revealed multiple alveolar haemorrhages, confirmed by broncho-alveolar lavage. Renal ultrasound showed swollen and hyperechogenous kidneys with loss of corticomedullary differentiation. Renal biopsy revealed a global extracapillary necrotising glomerulonephritis, with IgG lining the membrane at immunofluorescence. The patient was treated with continuous venovenous hemodia- filtration, plasmapheresis and immunosuppressive therapy (cyclophosphamid and corticoids) which lead to normalisation of anti-GBM level and favourable respiratory evolution with no sequelae. The renal evolution was unfavourable and the patient developed end stage renal disease and was treated with haemodialysis. Goodpasture's disease is an autoimmune process in which anti-GBM are produced against collagen IV present in the kidneys and pulmonary alveolae, resulting in acute or rapidly progressive glomerulonephritis and altering the pulmonary alveolae. It is a rare disease concerning mostly infants and young adults. Clinical presentation consists in an acute renal failure with proteinuria. Pulmonary symptoms (60-70% of the total cases) are dyspnea, cough, and haemoptysis. Diagnosis is made with the dosage of immunological anti-GBM and with renal biopsy. Factors of poor prognosis are initial oliguria, alteration of >50% of the glomerulus, very high creatinine or need of dialysis. Anti-GBM dosage is used for follow up. Patients are treated with immunosuppressive therapy for 6 to 9 months and plasmapheresis. Few recurrences are seen. Goodpasture's disease should be evoqued whenever a young patient is seen with glomerulonephritis, especially if pulmonary abnormalities are present. The disease requires an aggressive treatment in order to prevent respiratory and kidney failure.

Intraoperative training on the techniques of sentinel node biopsy in breast cancer

Principles: Surgeon's experience is crucial for proper application of sentinel node biopsy (SNB) in patients with breast cancer. A 20-30 cases learning curve of sentinel node (SN) and axillary lymph node dissection (ALND) was widely practiced. In order to speed up this learning curve, surgeons may be trained intraoperative by an experienced surgeon. The purpose of this report is to evaluate the results of this procedure. Methods: Patients with one primary invasive breast cancer (cT1-T2[<3 cm]cN0) underwent SNB based on lymphoscintigraphy using technetium Tc 99m colloid, intraoperative gamma probe detection, with or without blue dye mapping. This was followed by completion ALND when SN was positive or not found. SNB was performed by one experienced surgeon (teacher) or by 10 junior surgeons trained by the experienced surgeon (trainees). Four groups were defined: (i) SNB with immediate ALND for the teacher's learning curve, (ii) SNB by the teacher, (iii) SNB by the trainees under the teacher's supervision, and (iv) SNB by the trainees alone. Results: Between May 1999 and December 2007, a total of 808 évaluable patients underwent SNB. The SN identification rate was 98% in the teacher's group, and 99% in the trainees' group (p = 0.196). SN were positive in respectively 28% and 29% of patients (p = 0.196). The distribution of isolated tumor cells, micrometastases and metastases was not statistically different between the teacher's and the trainees' groups (p = 0.163). Conclusion: These comparable results confirm the success with which the SNB was taught. This strategy avoided the 20-30 SNB followed by immediate ALND early required per surgeon.

Pulse pressure variation-guided fluid therapy after cardiac surgery: A pilot before-and-after trial.

PURPOSE: The aim of this study is to study the feasibility, safety, and physiological effects of pulse pressure variation (PPV)-guided fluid therapy in patients after cardiac surgery. MATERIALS AND METHODS: We conducted a pilot prospective before-and-after study during mandatory ventilation after cardiac surgery in a tertiary intensive care unit. We introduced a protocol to deliver a fluid bolus for a PPV ≥13% for at least >10 minutes during the intervention period. RESULTS: We studied 45 control patients and 53 intervention patients. During the intervention period, clinicians administered a fluid bolus on 79% of the defined PPV trigger episodes. Median total fluid intake was similar between 2 groups during mandatory ventilation (1297 mL [interquartile range 549-1968] vs 1481 mL [807-2563]; P = .17) and the first 24 hours (3046 mL [interquartile range 2317-3982] vs 3017 mL [2192-4028]; P = .73). After adjusting for several baseline factors, PPV-guided fluid management significantly increased fluid intake during mandatory ventilation (P = .004) but not during the first 24 hours (P = .47). Pulse pressure variation-guided fluid therapy, however, did not significantly affect hemodynamic, renal, and metabolic variables. No serious adverse events were noted. CONCLUSIONS: Pulse pressure variation-guided fluid management was feasible and safe during mandatory ventilation after cardiac surgery. However, its advantages may be clinically small.

Role of intra-operative duplex ultrasound in living renal donor transplantation

Objective: The treatment of choice in end-stage renal disease is¦transplantation.¦Hemodynamic disturbances can evoke graft loss, while early ultrasound¦identification of vascular problems improves outcome. The primary endpoint¦of this study was to identify differences in post-op complications with and¦without systematic, intraoperative Doppler ultrasound use. A secondary aim¦was to find a predictive resistance index limit which would show where surgical¦reintervention was necessary.¦Methods: Between Jan 2000 and Dec 2010, 108 renal transplants were¦performed from living donors at our institution. In group 1 (n = 67),¦intra-operative duplex ultrasound and intra-parenchymatous resistance index¦measurements assessed patients, while in group 2 (n = 41), no ultrasound was¦performed.¦Results. There were no inter-group differences in the overall post-op¦complication rate or in benefit to graft or patient survival with Doppler use,¦however, significantly more vascular complications (10% vs. 0%, p = 0·02) and¦more acute rejections (37% vs. 10%) occurred in group 2 than in group 1,¦respectively. When the resistance index was <0·5 intra-operatively, immediate¦surgical revision was undertaken to raise the index >0·6.¦Results: There were no inter-group differences in the overall post-op¦complication rate or in benefit to graft or patient survival with Doppler use,¦however, significantly more vascular complications (10% vs. 0%, p = 0·02) and¦more acute rejections (37% vs. 10%) occurred in group 2 than in group 1,¦respectively. When the resistance index was <0·5 intra-operatively, immediate¦surgical revision was undertaken to raise the index >0·6.¦Conclusion: This is the first report demonstrating benefits of systematic¦intraoperative Doppler ultrasound on post-operative complications in renal¦transplantation from living donors. Our results support surgical revision with a¦resistance index <0·5.

Renal tumor ablation using radiofrequency: results in 28 patient. Exposition scientifique: Radiologie interventionnelle

Objectifs: To describe the technique and results of radiofrequency ablation (RFA) of small renal tumors.Matériels et méthodes: 28 patients with median age 79 years were treated with RFA for small renal exophytic tumor (median size 20 mm). Most patients were poor operative candidatesbecause of associated morbidity. Four patients were treated for biopsy proven papillary tumor, 7 for clear cell carcinoma, 2 for oncocytoma and one for renalhepatocellular metastasis. No biopsy sample was obtained for the others because of a typical radiological aspect of RCC.Résultats: All patients but one were treated successfully in one session under combined ultrasound and CT guidance using either Radionics 2000 cool-tip or Bostonscientific expandable needles, one was treated in two sessions. One Splenic, 3 colic and 1 pancreatic displacement with CO2 injection and one injection of G5%solution in the costo-phrenic recessus were done in order to protect adjacent organs. Two complications were observed, one splenic iatrogenic lesion treated byembolization and one renal pelvis stenosis treated with JJ stent. After a mean follow-up of 20 months, no patient developped local recurrence on MRI follow-up.Conclusion: RFA is a simple and efficient technique pending on strict selected criteria (small size < 3 cm and exophytic lesion). Long local control is obtained with minimalmorbidity.

Lymphome surrénalien primaire bilatéral [Primary bilateral adrenal lymphoma]

When abdominal imaging reveals the existence of unsuspected adrenal masses, a diagnostic strategy is necessary. We report the case of a woman presenting with pulmonary embolism, in whom abdominal ultrasound revealed voluminous masses in both adrenals without clinical or biological signs of hormone hypersecretion, but with mild primary adrenal failure. From a CT scan-directed needle biopsy of the right adrenal mass and subsequent staging we were able to diagnose a primary bilateral adrenal lymphoma, diffuse large B-cell type (REAL/WHO). On CHOP chemotherapy both adrenal masses decreased dramatically and the patient is in remission 18 months later. Primary adrenal lymphoma is a rare condition, since 65 cases have been reported to date. Histological diagnosis is nevertheless important, in view of the excellent response to specific therapy observed in some cases.

A comparison of the accuracy of peritoneoscopy and liver biopsy in the diagnosis of cirrhosis

The accuracy of peritoneoscopy and liver biopsy in the diagnosis of hepatic cirrhosis was compared in 473 consecutive patients submitted to both procedures. One hundred and fifty-two of them had cirrhosis diagnosed by one or both methods. There was 73% agreement between the two procedures. `Apparent' false-negative results were 17·7% for peritoneoscopy and 9·3% for liver biopsy. The incidence of false-negative results in the diagnosis of cirrhosis can be reduced by combining both procedures.

Lymphocyte populations in liver biopsy specimens from patients with chronic liver disease

The characterisation of lymphocytes from liver biopsies indicates that 'activated' T lymphocytes are present in the liver in alcohol induced hepatitis, chronic active hepatitis (HBS+ve and -ve), and in primary biliary cirrhosis but not in inactive cirrhosis, chronic persistent hepatitis, extrahepatic and drug induced cholestasis. A greater percentage of lymphocytes bear Fc-receptors in chronic active hepatitis than in alcohol induced hepatitis or cholestatic liver disease. The concentration of 'activated' T cells in the peripheral blood in all groups studied was within the normal range, suggesting that the 'activated' T cells found in the liver were reacting to either native or foreign antigens within the liver. The data on Fc-receptor bearing cells are consistent with the involvement of antibody assisted K cell mediated cytotoxicity in chronic active hepatitis.

Clinical usefulness of temporal artery biopsy.

To assess the diagnostic usefulness of temporal artery biopsy in temporal arteritis (TA) and establish clinical features capable of predicting its positivity we have retrospectively studied the biopsy specimens and the clinical features of 103 patients who had undergone temporal artery biopsy. Temporal artery biopsy reached a positive predictive value of 90.2% with respect to the final diagnosis based on the criteria proposed by Ellis and Ralston and the clinical course. The simultaneous presence of recent onset headache, jaw claudication, and abnormalities of the temporal arteries on physical examination had a specificity of 94.8% with respect to the histological diagnosis and of 100% with respect to final diagnosis. The presence of any of these clinical features, though of little specificity (34.4%), had a sensitivity of 100% with respect to histological diagnosis, selecting a group of patients in whom temporal artery biopsy has more discriminative value.