[Diagnostic and therapeutic management of operable bronchopulmonary carcinoid tumours]

INTRODUCTION

Bronchial carcinoid tumours (CT), divided into typical carcinoid (TC) or atypical carcinoid (AC), are rare tumours whose therapeutic management remains unspecified.

METHODS

Retrospective study collecting cases of bronchial CT operated at the thoracic surgery department of Abderrahmane-Mami hospital of Ariana and recruited from the pneumology departments of Northern Tunisia, during a 12-year period.

RESULTS

Ninety patients were collected (74 cases of TC and 16 cases of AC). The mean age was 45 years and the sex ratio H/F=0.5. The chest X-ray was normal in 11 cases, as well as flexible bronchoscopy in seven cases. The tumour was classified: stage IA (10 cases), IIA (28 cases), IIB (31 cases), IIIA (15 cases) and IIIB (six cases). Surgery resulted in a complete resection in 78 patients, an extensive resection in six patients, and a conservative resection in six patients. Adjuvant chemotherapy was given in 10 patients. The survival was 84% at five years and 42% at 10 years.

CONCLUSION

The prognosis of CT depends directly on the histological subtype. It is excellent for TC after complete resection, unlike ACs that are similar to well-differentiated bronchial carcinomas.

A rare case of squamous inclusion cyst in cervical lymph node

A 38-year-old man, with no history of malignancy, was found to have a 2 cm jugular lymph node, for which a lymph node tuberculosis was suspected. The specimen revealed a cystic structure lined by mature keratinizing squamous epithelium with a prominent granular cell layer consistent with a squamous inclusion cyst in a lymph node, but a metastatic squamous cell carcinoma could not be excluded. This is the first case report of a rapidly enlarging squamous inclusion cyst in a jugular lymph node. Our case demonstrates the diagnostic challenges related to a squamous inclusion cyst in cervical lymph node and serves to inform the readers to consider this lesion in the differential diagnosis for similar situations.

[Clinical and pathological profile of the pleural malignant mesothelioma: A retrospective study about 30 cases]

BACKGROUND

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.

PATIENTS AND METHODS

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.

RESULTS

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.

CONCLUSION

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.

[Place of the microscopic examination in the diagnosis of costal fibrous dysplasia]

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

[Surgery for thoracic tuberculosis]

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.

In vitro antimicrobial activity of Pistacia lentiscus L. edible oil and phenolic extract

Pistacia lentiscus L. is known in some Tunisian forest area by its fixed oil used in traditional medicine as an antiseptic product. This investigation is the first to study the antimicrobial activity of P.lentiscus edible oil and its phenolic extract. Oil was extracted from fruits harvested from six provenances located in Tunisia. The antimicrobial activity was tested using disc diffusion assay and the broth dilution method. Kbouch and Sidi Zid oils were most efficient (p < 0.003) against, respectively, Staphylococcus aureus and Aspergillus niger with an inhibition zone of 9.33 mm. The phenolic extract had the largest spectrum of sensitive microorganisms. The minimum inhibitory concentration and minimum bactericidal concentration results showed that all strains were inhibited by both oil and extract.

Effect of growing area on tocopherols, carotenoids and fatty acid composition of Pistacia lentiscus edible oil

In this investigation, we aim to study, for the first time, the effect of the growing area on tocopherols, carotenoids and fatty acid content of Pistacia lentiscus fixed oil. Fruits were harvested from eight different sites located in the north and the centre of Tunisia. Tocopherols, carotenoids and fatty acid content of the fixed oils were determined. The highest carotenoid content was exhibited by Feija oil (10.57 mg/kg of oil). Oueslatia and Tabarka oils displayed the highest α-tocopherol content (96.79 and 92.79 mg/kg of oil, respectively). Three major fatty acids were determined: oleic, palmitic and linoleic acids. Oleic acid was the main fatty acid presenting more than 50% of the total fatty acid content. Kebouche oil presented the highest oleic acid content (55.66%). All these results highlight the richness of carotenoids, tocopherols and unsaturated fatty acids in P. lentiscus seed oil and underscore the nutritional value of this natural product.

About the necessity of improving the current nodal classification of non-small cell lung carcinoma

BACKGROUND

The current classification of lymph node status in non-small cell lung carcinoma has not been revised since 1997. This fact has prompted many authors to point out the limits of this classification.

METHODS

We tried to explore the prognostic relevance of the current TNM classification in comparison with the nodal classification based on the ratio of metastatic lymph nodes (LNR) and the nodal classification based on the number of metastatic LNs (nLN). Additionally, we tried to explore the recommended number of resected LNs. This was done through a retrospective study of 39 cases. We compared the survival curves of patients using the current, RLN and nLN classifications. In the nLN classification, we grouped patients into three categories: nNO (no metastatic LNs), nN1 (1 to 2 metastatic LNs) and nN2 (> 2 metastatic LN). In the LNR classification, we grouped patients into three categories: rNO (0%), rN1 (< or = 12) and rN2 (> 12). Concerning the total number of the resected LNs, patients were categorized into two groups according to the number of LNs: < 10 versus > or = 10 and < 15 versus > or = 15.

RESULTS

Our results showed that the LNR classification highlighted a difference in prognosis between the rN1 and rN2 groups. Moreover, survival of patients seemed to be better when the number of the resected LNs was higher.

CONCLUSION

The ratio of metastatic LNs seems to be an important prognostic factor, but further studies are necessary to standardize this classification.

About a challenging tumour, elastofibroma dorsi: an eight-case study

Elastofibroma dorsi is an uncommon benign soft tissue pseudotumour usually located at the lower pole of the scapula, deep to the serratus anterior and often attached to the periosteum of the ribs. This lesion is usually seen in patients over the age of 50 years and is commonly misdiagnosed as a malignant tumour because of its size and deep location. We describe 8 cases of elastofibroma dorsi diagnosed over a 10-year-period. Our study contained 5 females and 3 males with a mean age at diagnosis of 62.5 years (range 47-75 years). We aim to highlight the clinical and radiologic presentation of elastofibroma dorsi in order to increase awareness of its existence and management.

The efficacy of bronchial washings in diagnosis of lung carcinoma

BACKGROUND

The accurate diagnosis of lung carcinoma has become compulsory, especially after the introduction of new targeted therapies. The majority of these patients are non-operable, highlighting the importance of the cytology specimen. Our aim was to assess the diagnostic efficacy of bronchial washings in low income countries where this low cost technique is widely performed.

MATERIAL AND METHODS

We conducted a study of 118 bronchial washings collected in the Department of Pathology. Bronchial washings were smeared on 5-6 clean slides. These were fixed in 95% ethyl alcohol for haematoxylin and eosin staining. Cases were retrospectively reviewed by two pathologists (FM and MM) together with the corresponding biopsies. False negative cases were reviewed twice, and the diagnosis was reassessed in one case. We calculated the sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV) and Yoden index.

CONCLUSIONS

Our study showed a sensitivity of 56%, specificity of 90%, PPV of 55%, NPV of 76% and a Yoden index of 0.45. These results emphasise the diagnostic efficacy of bronchial washings and the possibility of performing molecular tests on cytology specimens.

[Primary breast lymphoma: a case report]

BACKGROUND

Non-hodgkinian's lymphoma (NHL) represents 0.04 to 0.53% of all breast cancers. The clinical aspects and therapeutic models of the disease are a subject of debate.

AIM

The purpose of this paper is to report the clinical, imaging (sonographic, mammographic and MRI) and pathological features of breast lymphoma, a rare but aggressive tumor, based on a case report review.

CASE REPORT

We report a case of primary non-hodgkinian's lymphoma of the breast in one patient aged of 52 years. The patient went to a systematic screening of breast cancer. Physical examen was normal. Mammography showed breast with transitional density, BIRADS type 2, micro-calcifications behind the.... but sometimes it had linear...., neither not distorsion were identified. Ultrasonography did not show a tumor. The disease was revealed by breast MRI. The additional value of MRI in diagnosis is validated in our patient. In fact, when cancer is occult, size evaluation is difficult at standard imaging (7 mm). The diagnosis of non-hodgkinian's lymphoma was confirmed on histological examination of tumor biopsies. It was a B-cell non-Hodgkins-type lymphoma. The clinical features have been reviewed and the tumor have been evaluated both on a morphologic and an immunohistochemical basis. With chemotherapy, the course was favourable.

CONCLUSION

The breast is an uncommon site of development of malignant lymphomas. Secondary disease is more common than the primitive form. Primary breast lymphoma is a difficult diagnosis because it is very rare. The diagnosis is mainly histological. Chemotherapy is the principal therapeutic mean. Treatment combines radiotherapy and chemotherapy. Prognosis is generally bad.

[Clinical aspects and diagnosis of pleural fibromas]

Pleural fibromas are rare malignant or benign tumors requiring pathology study for certain diagnosis. From January 1985 to January 2001, 7 patients underwent surgery in our unit for pleural fibroma: 4 females and 3 males, mean age 60 years. The inaugural symptoms were chest pain (3 patients), dyspnea (2 patients), joint pain in a patient with Pierre-Marie pneumonic hypertrophic osteo-arthropathy, and acute hypoglycemia. Radiological investigations were decisive in orienting the diagnosis (chest X-ray, ultrasound, computed tomography and MRI). Surgical resection and pathological study of the surgical specimen is required to confirm the diagnosis. Patients should be carefully followed due to the risk of malignant recurrence.

[Unusual presentation of pulmonary alveolar proteinosis]

Pulmonary alveolar proteinosis is a rare disease characterized by the accumulation of granular lipoproteinaceous material within the alveoli; the interstitium is preserved. We report the case of a 27-year-old patient hospitalized for exploration of asymptomatic bilateral interstitial syndrome. Neither the radiographic signs nor the aspect of bronchoalveolar lavage was typical. The diagnosis was confirmed by pathology examination of surgical lung biopsy specimen which revealed lesions of interstitial fibrosis and cholesterol granulomas in association with pulmonary alveolar proteinosis. Since there was no functional deterioration, therapeutic abstention was decided.

[Antineutrophil cytoplasmic antibodies positivity in a case of idiopathic pulmonary haemosiderosis]

Idiopathic pulmonary haemosiderosis is a rare disease of unknown etiopathogeny which is characterized by hemoptysis due to alveolar haemorrhage. We report the case of a 16 years-old girl with idiopathic pulmonary haemosiderosis, diagnosed through clinical, radiological, cytological and histopathological data. The finding of myeloperoxydase-anti-neutrophil cytoplasmic antibodies (ANCA) positivity led us to suspect an associated vasculitis which was not further demonstrated.

[Molar pregnancy. Retrospective study of 60 cases in Tunisia]

To identify the epidemiologic, clinical end therapeutic particularities of molar pregnancies in Tunisia. A retrospective study of 60 cases of molar pregnancy Diagnosis of MP was base on elevated urine HCG level and/or histologic examination of uterine revision done for all patients. The incidence of MP is 1/793(60/47624) pregnancies. The mean age of patients was 31.7 years and 16 patients had more than 35 years. The metrorragia is the main symptom (91.6%). Excessive uterine enlargement and lutein ovarian cysts were observed respectively in 57 and 6.6% of cases. Human chorionic gonadotropin level was upper than 50,000 UI/l in 91.4% of cases. Ultrasonography contributed to diagnosis in 82.8% of cases. Histological findings were complete molar in 33 cases and partial molar in 27 cases. 6 of 33 patients having complete molar developed persistent gestational trophoblastic tumor. Actinomycin D induced complete remission in all cases. Molar pregnancy is a relatively common disease in Tunisia. Careful and reliable human chorionic gonadotropin monitoring is essential for the early detection of post molar persistent gestational trophoblastic tumor.

[Ovarian fibrothecal tumors. Apropos of 12 cases]

OBJECTIVE

To identify diagnosis, therapeutic and histological particularities of ovarian fibro-thecomas.

STUDY DESIGN

A retrospective study of 12 patients who underwent surgical treatment for ovarian fibro-thecoma between January 1994 and December 1999 was reported. Clinical, ultRasonographic, tumour marker, therapeutic and histologic data were analysed.

RESULTS

Mean age of patients was 46.83 years. Three patients were in perimenopausal period and six were menopausal. Ultrasonographic findings were: ovarian echogenic tumor in six cases, hypoechogenic tumor in three cases, mixed tumor in three cases and anechogenic tumour in one case. CA 125 level measured in 11 cases was normal. Nine patients underwent laparotomy. Three patients underwent laparoscopy, however, one was converted to laparotomy due to a suspected tumour. A conservative treatment was performed for three patients and radical treatment for nine patients. Histological findings were eight fibromas and five fibro-thecomas.

CONCLUSION

Ovarian fibro-thecoma is uncommon. These lesions occur often in perimenopausal and menopausal patients. Clinical, ultrasonographic and tumour marker data remains the best preoperative approach currently available for ovarian tumours. However, the diagnosis remains histological. Tumorectomy is well indicated for young patients, however radical treatment is indicated for perimenopausal and menopausal patients.

[Leiomyosarcoma of the bladder: apropos of 2 cases]

The authors report two cases of bladder leiomyosarcoma, an extremely rare invasive bladder tumour, with a very poor prognosis due to very early local invasion. The definitive diagnosis can only be established by histological examination. The treatment modalities for this histological type of bladder tumour have not been standardized and remain controversial. However, the treatment of choice appears to be radical prostatocystectomy preceded by neoadjuvant chemotherapy when compatible with the patient's general state.

[Recessive osteopetrosis. Identification of a form of medium severity]

BACKGROUND

Several distinct forms of osteopetrosis have been identified. Some of the autosomally recessive inherited forms are benign, much like the autosomal dominant form. Others are more malignant.

PATIENTS

The clinical data, skeletal radiographs, histological features and histories of 32 children with osteopetrosis were analyzed retrospectively.

RESULTS

The 32 patients, belonging to 20 sibships were divided into two groups. The first group included 24 patients, aged 1 day-11 months (mean 4.5 months), suffering from hepatosplenomegaly, anemia, thrombocytopenia and optic atrophy in early infancy. They also had a generalized increase in bone density, abnormal bone remodeling, rachitic lesions and a "bone-within-bone" appearance. Biopsies showed severe bone resorption and myelofibrosis. 19 of the 20 patients whose outcomes were known died during the first year of life. The second group included 8 patients, aged 40 days-3 years (mean: 11 months). Hepatosplenomegaly appeared later, anemia was less severe and thrombocytopenia occurred in only 1 patient. However, all 8 patients suffered from optic atrophy and 3 were deaf. Radiographs showed bone growth without rachitic lesions. Biopsies from 2 patients showed bone resorption, but no myelofibrosis. The outcome was less severe: 6 patients, now aged 8 months to 8 years, have survived, 3 of them for over 5 years. Genetic investigation showed patterns compatible with autosomal recessive inheritance in both groups, with similar sets of features within each sibship.

CONCLUSION

This study reveals a new type of recessively inherited osteopetrosis. It can be classified as an intermediate form, distinct from both the malignant and the benign forms, and also distinct from osteopetrosis with carbonic anhydrase II deficiency.

[Lymphoid hyperplasia of the intestine in children. 15 cases]

Fifteen cases of nodular lymphoid hyperplasia (NLH) of the bowel in patients aged 17 months to 15 years are reported. Fourteen patients had NLH confined to the small bowel and one had involvement of both the small bowel and colon. Mean age at diagnosis was 10 years. The most common presenting symptoms were intestinal manifestations (86%). Diagnosis was suspected upon roentgenographic studies in one case and digestive endoscopy in ten cases. Histologic confirmation was obtained in all fifteen patients. Immunohistochemical studies, done in 8 patients, demonstrated a paucity of IgA plasmocytes in one patient with an immune deficiency and a polyclonal plasmocyte population with mainly IgA plasmocytes in the seven other patients. Five patients had a deficiency in humoral immunity, with variable expression hypogammaglobulinemia in three patients and IgA deficiency in two; intestinal giardiasis was found in eight patients. Histologic outcome was documented in five cases; evidence of NLH disappeared in only one patient. Metronidazole improved clinical symptoms in most instances.

[Carcinosarcoma of the uterus. Clinical case and review of the literature]

The authors report a case of carcinosarcoma which occurred in the uterus of a 69 year old woman. The survey of literature shows that it is a scarce tumor (1-3% of the uterine cancers). Its definition and its classification are still debated. Its final diagnosis is anatomopathological. Its treatment is generally radio-chirurgical and its prognosis is bad.

[Abdominal actinomycosis: a rare complication of gastric surgery? Apropos of a case]

One case of abdominal actinomycosis is reported which was detected in a diabetic patient three years after surgery for duodenal peptic ulcer. Gastric actinomycosis is very rare and is usually discovered during surgery for gastric mass. The role of surgery as a predisposing condition to infection is discussed. The diagnosis rely on the characterization of the bacteria in cultures from a discharging wall fistula and on histopathologic examination which reveals the characteristic actinomycotic granules.