Adrian Marchbank

Test performance of PET-CT for mediastinal lymph node staging of pulmonary carcinoid tumours

Positron emission tomography-CT (PET-CT) is one of the initial mediastinal staging modality for non-small cell lung cancer; however, the clinical utility in carcinoid tumours is uncertain. We sought to determine the test performance of PET-CT for mediastinal lymph node staging of pulmonary carcinoid tumours. We collated data from seven institutions, performing a retrospective search on pathological databases for a consecutive series of patients who underwent thoracic surgery (with lymph nodal dissection) for carcinoid tumours with preoperative PET-CT staging. PET-CT results were compared with the reference standard of pathologic results obtained from lymph node dissection and test performance reported using sensitivity and specificity. From November 1999 to January 2013, 247 patients from seven institutions underwent surgery for carcinoid tumours with a corresponding preoperative PET-CT scan. The mean age of the patients was 61 (SD 15, range 73) and 84 were male patients (34%). The pathologic subtype was typical carcinoid in 217 patients (88%) and atypical carcinoid in 30 patients (12%). Results from lymph node dissection were obtained in 207 patients. The calculated sensitivity and specificity of PET-CT to identify mediastinal lymph node disease was 33% (95% CI 4% to 78%) and 94% (95% CI 89% to 97%), respectively. Our results indicate that PET-CT has a poor sensitivity but good specificity to detect the presence of mediastinal lymph node metastases in pulmonary carcinoid tumours. Mediastinal lymph node metastases cannot be ruled out with negative PET-CT uptake, and if the absence of mediastinal lymph node disease is a prerequisite for directing management, tissue sampling should be undertaken.

Thrombotic Occlusion of Giant Circumflex Artery Aneurysm After Ligation of Arteriovenous Fistula

A 39-year-old man with no significant past medical history and no conventional coronary risk factors presented with a history of gradually progressive exertional dyspnea and a systolic heart murmur. Chest x-ray showed an enlarged cardiac silhouette with pulmonary plethora. Initial assessment by transthoracic echocardiography demonstrated mild mitral regurgitation but also revealed an enlarged coronary sinus with abnormal Doppler flow patterns in the right atrium. A subsequent transesophageal echocardiogram demonstrated a large, serpiginous coronary artery fistula from the dominant left circumflex artery to the coronary sinus causing aneurysmal dilatation of the left circumflex artery extending back to the left main stem (maximum cross-sectional diameter, 17 mm). No other congenital heart defects were identified. A 64-slice multidetector computed tomography (GE Lightspeed VCT, Chalfront St Giles, Buckinghamshire, UK) coronary angiogram confirmed the transesophageal echocardiographic findings and demonstrated that the left anterior descending …

Left lower lobe torsion following upper lobectomy-prompt recognition and treatment improve survival.

Lobar torsion is a rare but life-threatening complication after lung resection. We report a case of left lower lobe torsion in 57-year-old women after upper lobectomy for underlying lung cancer. Definitive diagnosis of lung torsion was made at exploratory thoracotomy following abnormal chest radiography and bronchoscopy on the first post-operative day. An emergency completion pneumonectomy was performed and left lower lobe was resected. The post-operative course was uncomplicated and patient was discharged home on the seventh post-operative day. Early recognition and prompt treatment of lobar torsion is essential for preventing potentially catastrophic complications including fatal gangrene of the pulmonary lobe.

Cardiopulmonary Bypass Without Ischemic Arrest: A Myocardial Protection Strategy for High‐Risk Patients Requiring Urgent CABG

Abstract  For patients requiring emergency coronary artery revascularization, mortality remains high. One of the primary reasons is poor functional and metabolic recovery of the myocardium after ischemic arrest. We describe a hybrid of the off‐pump and on‐pump techniques to avoid ischemic arrest during coronary revascularization for this high‐risk group.

Gauze-based negative pressure wound therapy to infected deep sternotomy wound complicated by cardiac tamponade: a case report.

Negative pressure wound therapy is the standard of care for infections after median sternotomy. Foam‐based systems are commonly used even in scenarios when the myocardium is exposed. Gauze‐based systems have recently gained popularity. We describe a case of deep sternal dehiscence that lead to a life‐threatening complication secondary to wound filler choice.