Alfonso Fiorello

Lung mast cells are a source of secreted phospholipases A2

BACKGROUND Secreted phospholipases A(2) (sPLA(2)s) are released in plasma and other biologic fluids of patients with inflammatory, autoimmune, and allergic diseases. OBJECTIVE We sought to evaluate sPLA(2) activity in the bronchoalveolar lavage fluid (BALF) of asthmatic patients and to examine the expression and release of sPLA(2)s from primary human lung mast cells (HLMCs). METHODS sPLA(2) activity was measured in BALF and supernatants of either unstimulated or anti-IgE-activated HLMCs as hydrolysis of oleic acid from radiolabeled Escherichia coli membranes. Expression of sPLA(2)s was examined by using RT-PCR. The release of cysteinyl leukotriene (LT) C(4) was measured by means of enzyme immunoassay. RESULTS Phospholipase A(2) (PLA(2)) activity was higher in the BALF of asthmatic patients than in the control group. BALF PLA(2) activity was blocked by the sPLA(2) inhibitors dithiothreitol and Me-Indoxam but not by the cytosolic PLA(2) inhibitor AZ-1. HLMCs spontaneously released a PLA(2) activity that was increased on stimulation with anti-IgE. This PLA(2) activity was blocked by dithiothreitol and Me-Indoxam but not by AZ-1. HLMCs constitutively express mRNA for group IB, IIA, IID, IIE, IIF, III, V, X, XIIA, and XIIB sPLA(2)s. Anti-IgE did not modify the expression of sPLA(2)s. The cell-impermeable inhibitor Me-Indoxam significantly reduced (up to 40%) the production of LTC(4) from anti-IgE-stimulated HLMCs. CONCLUSIONS sPLA(2) activity is increased in the airways of asthmatic patients. HLMCs express multiple sPLA(2)s and release 1 or more of them when activated by anti-IgE. The sPLA(2)s released by mast cells contribute to LTC(4) production by acting in an autocrine fashion. Mast cells can be a source of sPLA(2)s in the airways of asthmatic patients.

The role of technetium-99m hexakis-2-methoxyisobutyl isonitrile in the detection of neoplastic lung lesions

OBJECTIVE Our goal was to determine the role of technetium-99m hexakis-2-methoxyisobutyl isonitrile ((99m)Tc-MIBI) in the detection of neoplastic lung lesions. MATERIALS AND METHODS We prospectively studied 79 consecutive patients with indeterminate lung lesion between January 2006 and September 2007. All patients were submitted to (99m)Tc-MIBI single-photon emission chest tomography (SPECT) before invasive diagnostic procedure. Qualitative analysis was performed to evaluate SPECT images in order to localize abnormal activity in the radiologically demonstrated lesion. In addition, semiquantitative analysis was made by calculating tumor/contralateral normal lung ratio (T/N). Finally, the scintigraphic findings were correlated to the histopathological diagnosis obtained by invasive procedure or confirmation of instrumental exams. RESULTS Sixty patients had a malignant lesion: 44 squamous cell carcinoma, 7 adenocarcinomas, 4 large cell carcinoma, 1 small cell lung cancer, and 4 metastases. The mean size+/-standard deviation of malignant nodules was 3.9+/-1.61 cm (range 1.5-5.5 cm). Nineteen patients had a benign disease. The mean size+/-standard deviation of benign nodules was 3.3+/-1.71 cm (range 2-6 cm). (99m)Tc-MIBI SPECT delineated focal lesions with an increase in tracer accumulation in 55/60 malignant lesions; in 5/60 malignant lesions was negative. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 91%, 73%, 91%, and 73%, respectively. In patients with neoplastic lesion, the mean T/N ratio value+/-standard deviation was 1.72+/-0.35 whereas in patients with benign lesions was 1.14+/-0.25. Semiquantitative analysis showed that for a T/N value >1.23, the value of sensitivity, specificity, PPV, and PNV were 91%, 84%, 94%, and 76%, respectively (ROC curve). Metastatic mediastinal lymph nodes were found in 3/57 patients. (99m)Tc-MIBI SPECT showed a specificity and PPV of 100% in the detection of mediastinal lymph nodes with sensitivity, and PNV of 66% and 97%, respectively. Age, sex, histological type, and size of lesion did not affect the SPECT results. CONCLUSION Our experiences seem to confirm that (99m)Tc-MIBI SPECT is a reliable diagnostic tool in the finding of lung cancer particularly cases in which radiological evaluation is indeterminate.

The use of LigaSure for preservation of a previous coronary artery bypass graft by using the left internal thoracic artery in a left upper lobectomy

We report an interesting clinical case concerning the use of an electrothermal bipolar tissue-sealing system (LigaSure, Valleylab, Inc, Boulder, Colo) 1 in a particularly challenging technical situation, such as the resection of the left upper pulmonary lobe in a patient with a previous coronary artery bypass graft (CABG) with the left internal thoracic artery (LITA). Clinical Summary In a 63-year-old man, an opacity localized in the left upper pulmonary lobe was incidentally discovered on chest radiographic analysis. He had undergone CABG 8 years before with the LITA on the left anterior descending coronary artery. Clinical and laboratory evaluation showed no abnormalities. Spirometric results were normal. Computed tomographic analysis demonstrated a peripheral mass in the left upper lobe, and there was no significant mediastinal adenopathy. Bronchoscopy did not demonstrate abnormalities of the left upper bronchus, and percutaneous needle biopsy showed a non‐small cell lung cancer (NSCLC). A standard posterolateral thoracotomy incision was performed through the fifth intercostal space. A 6-cm tumor was found in the left upper lobe (Figure 1). The dissection of the lobe from the pericardium was possible, but dense adhesions were identified between the LITA and the apex of the upper lobe. The challenge was to do an upper lobectomy while avoiding injury to the LITA. Therefore the part of parenchyma adjacent to the LITA was separated from the upper lobe by using LigaSure system (Figure 2). After this maneuver, we performed an anatomic upper lobectomy, leaving a small strip of parenchyma adjacent to the LITA; we tested the arterial graft manually, and a good pulsation was found. Anatomopathologic studies showed a 6‐cm stage IB squamous cell carcinoma, according to TNM classification. 2 The patient’s postoperative course was unremarkable, and he was discharged on the seventh postoperative day.

Electrothermal bipolar tissue sealing systems in lung surgery.

Various techniques have been proposed to reduce intraoperative blood loss in surgery. We report our experience with the use of LigaSure, a new electrothermal bipolar tissue sealing system, in lung surgery. This system has been already applied with good results in other surgical fields. However, the experience reported in the literature with the use of this technique in lung surgery is limited. Our clinical series with LigaSure (160 procedures in a 4-year period) is the largest reported to date. Technical aspects, clinical results and an overview of the literature are presented. We believe that LigaSure is an easy and safe technique, suitable for lung surgery. It could be a valid alternative or complement to staplers for several procedures, also in the thoracoscopic setting. Furthermore, it seems to allow functional lung tissue preservation and reduction of surgical supplies costs.

A Surgical Case of Pyothorax-Associated Lymphoma of T-Cell Origin Arising From the Chest Wall in Chronic Empyema

We report a surgical a case of pyothorax-associated lymphoma of T-cell origin arising from the chest wall and developing on pleural sequelae of therapeutic pneumothorax for pulmonary tuberculosis. The tumor was removed with resection of the fifth to eighth ribs. The chest wall defect repaired with a Marlex (Phillips Sumika Polypropylene Co, Houston, TX) prothesis. The histologic, immunohistochemical, and genotypic features were conclusive for a diagnosis of T-cell non-Hodgkin lymphoma. The patient received postoperative chemotherapy and is doing well after 15 months.

Pulmonary hernia secondary to limited access for mitral valve surgery and repaired by video thoracoscopic surgery

Iatrogenic pulmonary hernia is a rare condition. Repair is performed due to persistent symptoms and it is usually carried out by open surgery. We report a case of a 59-year-old woman who developed a lung hernia after small anterior thoracotomy that was performed for mitral valve surgery. The herniated lung is reduced with success by video thoracoscopic surgery and the chest wall defect is repaired by a polypropylene mesh fitted to the thoracic wall. At six-month follow-up, she was asymptomatic and without recurrence of hernia. Our experience suggests that video thoracoscopic surgery is a feasible surgical technique even for lung hernia secondary to mini-thoracotomy. However, before performing video thoracoscopic surgery, several factors preclusive to using this strategy must be considered, including the extensiveness of pleural adhesions due to the time interval between the previous operation and lung hernia, the site and the size of the hernia, and the insufficient experience in video thoracoscopic surgery.

A home-made device for safe intraoperative aspiration of pulmonary hydatid cysts

Surgical intervention is still the main modality for the treatment of hydatid disease. Different surgical procedure have been described; however, in the literature there is no collective agreement on the best surgical strategy. For intact pulmonary hydatid cysts, an enucleation or needle aspiration are possible strategies. Though, both methods need careful manipulation due to the serious complications after fluid rupture. Here, we present a novel technique that allows the aspiration of the cyst while reducing the risk of anaphylaxis and dissemination of disease. This is a home-made double suction device designed to aspirate hydatid cysts by creating a low pressure, wide mouth cylinder which holds the cyst wall against the base of the cylinder. A large thoracentesis needle is inserted across the low pressure chamber into the cyst to aspirate the fluid within. The complete evacuation of the cyst makes surgical treatment easier and facilitates its successive removal.