Pathologies

Metastases are secondary tumours that spread from the primary tumour to other organs. The spread of cancers to the lungs is very common and can originate from any cancer such as bowel, breast, skin or sarcoma. Cancer cells spread via the bloodstream to the lungs and other organs.

How are lung metastases treated?

Chemotherapy is the most commonly proposed treatment, although lung metastases can sometimes be treated by surgical resection. Surgery is recommended for operable patients with good control of the primary tumour, with the aim of cure.

On the other hand, surgery can play a role in diagnosing a lung nodule discovered in a patient with cancer of another organ (in order to determine whether it is really a metastasis, a primary lung tumour or a lesion of another origin).

What operations are possible?

• Thoracoscopy
• Segmentectomy
• Wedge resection 

Pleural effusion is the accumulation of fluid in the pleural space. Two types of effusion can occur:

• Transsudat : It refers to an accumulation of water or extracellular fluid. The causes are often extra thoracic, such as congestive heart failure, cirrhosis or renal failure.

• Exudate : It may be composed of blood, pus or digestive fluid. The causes are often intra-thoracic, such as metastatic cancer to the pleura (lung cancer, breast cancer, lymphoma, mesothelioma, etc.), pulmonary embolism, infection (pneumonia, tuberculosis, etc.), accumulation of lymph (chylothorax) or trauma.

What are the symptoms of pleural effusion?

Pleural effusion causes lung compression, resulting in breathlessness or difficulty in breathing (dyspnoea), coughing, pain or a feeling of heaviness in the chest.

How is pleural effusion treated?

Determining the composition of the fluid is essential for diagnosis and treatment. The first step is to remove the fluid, either by puncture or by draining, in order to analyze it. If this does not make the diagnosis, a thoracoscopy to inspect the pleural cavity and take biopsies may be performed.

Treatment of an effusion depends on its cause.

• If the effusion is caused by heart, kidney, liver or other disease, it is treated by treating the underlying condition.
• If it is a metastatic pleural effusion, the treatment may be chemotherapy to treat the tumour responsible. The other possibility is to perform a procedure to "glue" the lung to the chest wall (chemical pleurodesis) to obliterate the pleural space and prevent the effusion from re-accumulating. If the patient cannot be operated on, a permanent drainage system (PleurX) may be used.
• In the case of chylothorax, a fat-free diet is often sufficient, but rarely surgical treatment to close the thoracic duct (a conduit that carries lymph from the abdomen to the left subclavian vein) is necessary.
• In the case of effusion due to pneumonia, antibiotic therapy and pleural drainage are the first step, but sometimes surgery (decortication) is necessary.

What operations are possible?

• Thoracoscopy
• Chemical pleurodesis
• Pleural biopsy by thoracoscopy
• Pleur-x

Chylothorax is a lactescent pleural effusion caused by damage to the thoracic duct, which transports lymph from the abdomen to the left subclavian vein, causing chyle to leak into the pleural space. The most common causes of chylothorax are traumatic, mainly following surgery. Tumours, particularly lymphomas, can also cause chylothorax.

How is a chylothorax diagnosed?

Diagnosis is based primarily on the determination of triglycerides in pleural fluid.

What are the symptoms of a chylothorax?

It often manifests itself as breathlessness or difficulty in breathing (dyspnoea), coughing or pain or a feeling of heaviness in the chest.

How is a chylothorax treated?

Conservative treatment is based on pleural drainage with a low-fat diet (either by mouth or exclusively by vein). If this fails, closure of the thoracic lymphatic duct by surgery or interventional radiology (injection of a form of glue under CT scan) should be considered.

What operations are possible?

• Thoracoscopy
• Thoracic duct ligation

Pleural mesothelioma is a rare type of tumour that affects the layer that surrounds the lung and chest wall (the pleura). It is generally caused by exposure to asbestos, a mineral found in insulation materials such as asbestos.

What are the symptoms of mesothelioma?

Chest pain and/or difficulty in breathing (dyspnoea) are the most common symptoms.

How is mesothelioma diagnosed?

Chest CT scans and PET scans are the most useful imaging tests. A biopsy (removal of a fragment of tissue for analysis under a microscope) is necessary to confirm the diagnosis.

How is mesothelioma treated?

Treatment depends on the extent of the tumour and its histological type. Surgery plays a role in cases where the disease is limited, the type of cancer less aggressive and the patient operable. In other cases, chemotherapy, chemoimmunotherapy or immunotherapy is the proposed treatment, sometimes combined with surgery.

What operations are possible?

• Thoracoscopy
• Thoracotomy
• Pleurectomy/decortication
• Open pleural biopsy

Chest wall tumours are tumours that originate in the bone or soft tissues that make up the chest wall. The chest wall can also be directly infiltrated by breast cancer or lung cancer.

How are chest wall tumours treated?

When they are benign, complete surgical removal is curative. When they are malignant, the tumours may be, for example, sarcomas, which require multidisciplinary management including thoracic and sometimes plastic surgery, radiotherapy and chemotherapy.

What operations are possible?

• Thoracotomy
• Chest wall resection

The germ cell tumours are cancers developed from cells of embryonic origin. Mediastinal location accounts for 1 to 3% of germ cell tumours. There are several types:

• Teratomas (mature or immature)  : They are the benign variety of germ cell tumours and rarely become malignant. Teratomas are often large, with solid and cystic areas, sometimes containing hair, teeth or sebum.

• Seminomas : They occur almost exclusively in men. They are malignant tumours, presenting as a solid mass, and the prognosis is often favourable.

• Non-seminomatous germ cell tumours : They are classified as embryonal carcinoma, yolk sac tumour and choriocarcinoma. These are malignant tumours with a more or less favourable prognosis, depending above all on their extent.

What are the symptoms of germ cell tumours?

Germ cell tumours are often discovered incidentally.

How are germ cell tumours diagnosed?

Diagnosis is based on a chest CT scan and the expression of various markers in the blood (β-hCG, AFP).

How are germ cell tumours treated?

Treatment depends on the type of tumour. For teratomas, treatment is purely surgical and complete resection is curative. Malignant germ cell tumours are treated immediately with chemotherapy. A small operation to obtain a sample of the mass is often necessary before starting treatment. If a residual mass remains after chemotherapy, surgery may be indicated to resect the mass.

What operations are possible?

• Thoracoscopy
• Médiastinoscopy
• Chamberlain anterior mediastinotomy

Lymphoma is a cancer of the lymphatic system, the main component of the body's immune system. When a patient has lymphoma, the lymphocytes become abnormal and grow out of control. These cells can move to different parts of the body and sometimes congregate in the mediastinum.

There are different types of lymphoma, some of which develop very slowly while others grow more rapidly.

What are the symptoms of lymphoma?

Lymphoma can manifest itself with weight loss and fatigue, fever, sweating and pruritus. In the event of airway compression, coughing, difficulty breathing (dyspnoea) and/or facial oedema may occur.

How is lymphoma treated?

Treatment is based on chemotherapy. Surgery only plays a role in diagnosis by obtaining tumour fragments (biopsy).

What operations are possible ? 

• Thoracoscopy
• Médiastinoscopy
• Chamberlain anterior mediastinotomy

Mediastinal adenopathy is an increase in the size of one or more lymph nodes located in the mediastinum.

This anomaly may be of infectious (e.g. tuberculosis), caused by autoimmune diseases (e.g. sarcoidosis) or tumour (e.g. lymphoma or lung cancer).

How are adenopathies treated?

Treatment depends on the cause of the adenopathy and may include long-term antibiotic therapy, medical treatment or chemotherapy. Surgery may be required to obtain a sufficient tissue sample to make an accurate diagnosis.

What operations are possible ? 

• Thoracoscopy
• Médiastinoscopy
• Chamberlain anterior mediastinotomy

Neurogenic tumours (schwannomas, para-gangliomas, neurofibromas, ganglioneuromas, ganglioneuroblastomas and neuroblastomas) are tumours that originate in intra-thoracic nerve structures.

What are the symptoms of neurogenic tumours?

The majority of these tumours are benign and asymptomatic, but sometimes the symptoms are due to the effect of compression on the nerve itself, causing pain, paresthesia or even paralysis, depending on the location.

How are neurogenic tumours treated?

Most of these tumours are treated by complete surgical resection. These resections may require the collaboration of the thoracic surgeon and the neurosurgeon when there is an intrarachid component (inside the spinal column).

Malignant variants require multidisciplinary management coordinated by surgeons, medical oncologists and radio-oncologists.

What operations are possible ?

• Thoracoscopy
• Thoracotomy

A lung abscess is a pus-filled cavity inside the lung. It often occurs in patients weakened by another illness, or after pneumonia or bronchoaspiration.

How is lung abscess treated?

When abscesses are small, they generally respond to a well-managed course of antibiotics, which often continues for several weeks.

When they are larger, antibiotic treatment is usually combined with percutaneous drainage (using a catheter which is introduced into the abscess cavity through the skin, usually by a radiologist under CT scan control).

Some very large, chronic abscesses cannot subside and heal with such treatment. In these cases, formal resection is required, as well as in cases of haemorrhage (haemoptysis).

What operations are possible ?

• Thoracoscopy 
• Thoracotomy
• Lobectomy
• Segmentectomy
• Wedge resection

Emphysema is a disease lung disease of the distal airways characterised by the destruction of the alveolar walls (septa) and the consequent formation of large bubbles in the lung parenchyma. The two main causes of pulmonary emphysema are smoking and alpha 1-antitrypsindeficiency, a genetic disease very rare. The classic symptoms are dyspnoea and cough.

How is emphysema treated?

Emphysema is a permanent lesion of the lung parenchyma. There is no cure. The aim of treatment is to alleviate respiratory symptoms and prevent worsening of the disease. Endoscopic treatment by bronchoscopy may be possible.

Patients can slow the progression of emphysema by stopping smoking. Rarely, surgery may be proposed, in the form of:

• Lung volume reduction : this surgery is based on the principle that resection of a non-functional part of the lung parenchyma allows the chest wall to recover its position and regain a mobile capacity that partially restores its breathing function. It applies only to emphysema with a heterogeneous distribution, where changes in the parenchyma predominate in one lobe or segments of the lung. This operation should be considered palliative, i.e. it improves the patient's quality of life but does not lead to a cure.

• Bullectomy : if the emphysema is in the form of one or more very localised bullae, it is possible to resect only that part of the parenchyma to allow the crushed lung to return to its original position.

• Lung transplantation

What operations are possible ?

• Thoracoscopy
• Pulmonary volume reduction
• Bullectomy

Whatever the cause of the injury, whether open (penetrating wounds) or closed (no communication with the outside), the trauma may result in injury to several organs or structures at once: heart, great vessels, lung, oesophagus, trachea, etc. In the case of thoracic trauma, priority is given to treating life-threatening injuries.

How is chest trauma with internal injuries diagnosed?

On arrival at ER, a chest X-ray is almost always performed. An emergency ultrasound may also be useful to identify a pneumothorax, haemothorax or cardiac lesion. If the patient is sufficiently stable, a chest CT scan is often added to the work-up.

How is thoracic trauma with internal injuries treated?

Treatment depends on the organ affected.

• Lung : It may be torn or bruised more or less deeply. This can lead to pneumothorax, haemothorax or a combination of the two. Treatment may be as simple as placing a drain in the pleural cavity, with spontaneous repair of the lesions, or it may require an operation to repair the injured lung or to resect it. The lung can also suffer pulmonary contusion, with a suffusion of blood inside the lung. If the phenomenon is very limited, the contusion has very few consequences and resolves itself. Depending on the severity, it can lead to more or less serious respiratory failure, which may require the patient's breathing to be ensured by a machine (artificial ventilation).

• Heart and large vessels : They can be injured both by penetrating wounds and by closed trauma to the thorax. Surgery may be required to treat these injuries. Certain vascular lesions can sometimes be treated by placing a stent (tubular prosthesis) inside the vessel.

• Trachea and main bronchi : They may be severed in penetrating trauma or torn in closed trauma. In principle, these injuries require surgical repair.

• Oesophagus : Although the oesophagus is rarely affected by penetrating wounds because of its deep position in the thorax, when there is an injury it usually requires surgical repair or the insertion of a stent (tubular prosthesis), combined with antibiotic treatment.

What operations are possible ?

• Thoracoscopy
• Thoracotomy
• Lobectomy
• Wedge resection

The pectus carinatum is a type of deformity in which the sternum is projected forward by the hypertrophied costal cartilages.

What is the treatment for pectus carinatum?

The principle of sternochondroplasty is the removal of excess cartilage between the ribs and the sternum, combined with partial transverse sectioning of the sternum to reposition it backwards.

What operations are possible?

• Correction of the pectus carinatum or excavatum (sternochondroplasty)

Hyperhidrosis is characterised by sweating and affects around 1-3% of the population. It usually affects the hands (palmar hyperhidrosis), feet (plantar hyperhidrosis), armpits (axillary hyperhidrosis) and face.

It may also be associated with pathological erythrophobia (facial blushing). It may be primary (idiopathic), linked to hyperactivity of the sympathetic nervous system. It can also be secondary to medication or various medical conditions, such as diabetes, hyperthyroidism, Parkinson's disease, etc.

How is hyperhidrosis treated?

Treatment of secondary hyperhidrosis obviously depends on the underlying cause. Several treatments are available for primary hyperhidrosis:

• Topical products : Topical antiperspirants containing alcohol or aluminium salts are generally recommended as first-line treatment.

• Ionophoresis : Iontophoresis involves passing an electric current through the skin by bathing the hands or feet in basins filled with water through which a continuous electric current flows.

• Botulinum toxin (Botox) : Botulinum toxin injections induce a blockage in the endings innervating the sweat glands. This phenomenon is only temporary.

• Surgical treatment : Surgery is reserved for extreme forms of hyperhidrosis of the hands and armpits that are resistant to medical treatment. This operation involves cutting the sympathetic chain that stimulates the sweat glands. The operation is effective, but there is a relatively frequent complication known as compensatory sweating: perspiration can move elsewhere on the body, such as the torso, back or buttocks.

What operations are possible ? 

• Thoracoscopy
• Sympathectomy

Diaphragmatic paralysis corresponds to a permanent lifting of one or both domes of the diaphragm and can lead to breathing difficulties at rest, during exercise or when lying down. It can follow trauma, heart or lung surgery or infection, but can also be associated with neuromuscular or autoimmune disease, or toxic damage. It is most often discovered during an X-ray or CT scan.

What are the symptoms of diaphragm paralysis?

Symptoms vary depending on whether the paralysis involves one or both diaphragmatic coupoles. Unilateral paralysis is sometimes asymptomatic, it means that the patient has no symptoms, or only a few breathing difficulties characterised by accelerated breathing and paradoxical movements of the abdomen on inspiration. Bilateral paralysis leads to significant respiratory difficulty with reduced expiratory force, a broken airway and a weak, toneless cough.

What is the treatment for diaphragm paralysis?

Treatment depends on the cause of the diaphragm paralysis. Drug treatment may be prescribed if the cause is an autoimmune disease. Surgical treatment consists of folding the diaphragm (diaphragm plication) so that it can be lowered into its original position, allowing the lung to fill with air more easily.

What operations are possible ? 

• Thoracoscopy
• Thoracotomy
• Diaphragm plication

Rupture of the diaphragm is a tear in this muscle caused by high-energy trauma. It is often associated with a migration of abdominal organs (liver, stomach, intestine, spleen, kidneys) into the thorax (diaphragmatic hernia). Diagnosis can easily be missed during initial treatment and is only made early in half of cases. Sometimes the trauma has only caused a small diaphragmatic lesion, and it is only later that the abdominal organs migrate.

What are the symptoms of a ruptured diaphragm?

Symptoms depend on the severity of the diaphragmatic rupture and the abdominal organs that have migrated. There may be chest pain, abdominal pain, difficulty breathing (dyspnoea), coughing and symptoms of gastro-oesophageal reflux.

How is a ruptured diaphragm treated?

If diagnosed early, treatment is usually surgical, involving suturing the ruptured tissue. In emergency situations, this is done by laparotomy (open abdominal cavity operation) or thoracotomy (open chest cavity operation). If the patient is stable, surgery is performed one or two days after the trauma, using minimally invasive techniques.

If the diagnosis is made late, treatment depends on the severity of the symptoms.

What operations are possible ? 

• Thoracoscopy 
• Thoracotomy
• Diaphragm repair