Dun-Bing Chang

Carcinoid tumours of the thymus.

BACKGROUND--Carcinoid tumours of the thymus are rare. The clinical manifestations, radiographic findings, and cytological features of eight histopathologically verified thymic carcinoid tumours have been assessed. METHODS--One hundred and sixty two patients of mean age 52 (range 31-68) years with malignant mediastinal tumours were reviewed retrospectively and eight cases of thymic carcinoid were identified. Four of the eight patients were diagnosed by percutaneous ultrasound guided fine needle aspiration biopsy via a parasternal approach. RESULTS--Two patients had Cushings syndrome at presentation and four had symptoms and signs secondary to mediastinal compression. Two were asymptomatic. Local extension of the tumour to pleura, pericardium, great vessels, phrenic nerve or regional lymph nodes, or both, were found in seven patients. Only one had the tumour confined to the thymus at diagnosis. Distant metastases were found in two patients, one to both lungs and the other in the iliac bone. Local recurrence or distant metastases developed 15-60 months after surgery in four of the five patients who underwent radical resection of the thymic tumour. Three patients died at 17 months, 34 months, and 10 years after diagnosis. The other five patients are alive at 9-51 months. CONCLUSION--Thymic carcinoid is a slow growing tumour with a poor prognosis because of its tendency to local and distant spread. Cytological examination of samples obtained by ultrasound guided fine needle aspiration may provide a useful method for diagnosis in selected patients.

Comparison of OK‐432 and mitomycin C pleurodesis for malignant pleural effusion caused by lung cancer. A Randomized Trial

A prospective randomized study to compare the effectiveness of pleurodesis by two new sclerosing agents: OK‐432 and mitomycin C were conducted in S3 patients with malignant pleural effusion caused by lung cancer. None of the patients received concomitant systemic chemotherapy or radiation therapy during the study. After complete drainage of pleural fluid, the patients were allocated randomly to receive 10 Klinische Einheit units of OK‐432 or 8 mg of mitomycin C by intrapleural injection at weekly intervals. The treatment was terminated if the pleural effusion disappeared or the patients had received four consecutive procedures. There were 26 patients who received pleurodesis with OK‐432 and 27, with mitomycin C. Patient characteristics in the two treatment groups (age, sex, histologic type, performance status, and prior treatment before pleurodesis) were compatible. These results showed that pleurodesis with OK‐432 achieved a higher complete response rate (73%) than that of mitomycin C (41%). The rates of objective treatment response (complete response plus partial response) were comparable in both groups (88% for OK‐432 and 67% for mitomycin C). The average number of intrapleural injections needed to achieve complete response was fewer in the OK‐432 group (1.9 +M 0.9) than in mitomycin C group (2.8 +M 0.9). There was no significant difference in the median survival of the patients who received pleurodesis with OK‐432 (5.8 months) or mitomycin C (5.1 months). However, the effusion‐free period in the OK‐432 group was significantly longer than that in the mitomycin C group (7.0 months versus 1.5 months). Patients who underwent OK‐432 pleurodesis had a higher complication rate (80%) than did those in the mitomycin C group (30%). Transient febrile reaction was the most common reaction encountered. The immunologic study in OK‐432 group showed an increase in peripheral leukocyte count and decrease in the OKT4/OKT8 ratio. The mitomycin C group had a mild reduction in peripheral blood leukocyte count and no significant change in the OKT4/OKT8 ratio. It was concluded that pleurodesis with OK‐432 is an effective alternative treatment for malignant effusion in patients with lung cancer.

Ultrasonographically guided biopsy of thoracic tumors. A comparison of large-bore cutting biopsy with fine-needle aspiration

A prospective study to compare the safety and diagnostic accuracy of ultrasonographically guided transthoracic large‐bore cutting biopsy histologic examination with fine‐needle aspiration cytologic examination was conducted in 149 patients with thoracic tumors (29 mediastinal tumors and 120 pulmonary masses). The authors found that large‐bore cutting biopsy under ultrasonogra phic guidance could be as safe as fine‐needle aspiration, whereas diagnostic accuracy was significantly higher (97% versus 59% in malignant tumors, respectively, P <0.5; 85% versus 33% in benign lesions, respectively, P < 0.05). The size, depth, and location of lesions did not influence the results of transthoracic needle aspiration or cutting biopsy. In 77 patients with primary lung cancer, fine‐needle aspiration cytologic examination, although achieving 88% positive cytologic results, identi fied the histologic cell type accurately in only 70%, whereas Tru‐Cut (Top Surgical, Tokyo, Japan) biopsy was 97% accurate in confirmative histologic diagnosis. Fourteen patients had discordant cytologic and histologic diagnoses, and the cases of 3 (3.9%) were between small cell lung cancer and non‐small cell lung cancer. The diagnostic accuracy of Tru‐Cut biopsy also was signifi cantly higher than that of fine‐needle aspiration in meta static cancers (90% versus 33%, respectively) and mediastinal tumors (100% versus 46%, respectively). The authors conclude that transthoracic cutting biopsy under ultrasonographic guidance is safe and has a higher diagnostic accuracy as compared with fine‐needle aspiration. This technique is particularly useful for benign lesions or tumors with pleomorphic morphologic characteristics, such as lymphomas and thymomas. Cancer 1992; 69:2553‐2560.

Clinical spectrum of tuberculosis in older patients

Clinical Spectrum of Tuberculosis in Older Patients

Mediastinal malignancy: ultrasound guided biopsy through the supraclavicular approach.

BACKGROUND: Malignancies located in the upper middle mediastinum usually do not have a sufficiently large acoustic window to permit a conventional ultrasound guided parasternal biopsy. This study was concerned with an alternative approach whereby ultrasound is applied through the supraclavicular paratracheal window to allow percutaneous biopsy of middle mediastinal malignancies. METHODS: Fifteen patients who had upper mediastinal malignancies not in contact with the chest wall underwent real time and Doppler ultrasonographic studies by the supraclavicular approach. None of these tumours could be reached by conventional ultrasound guided parasternal biopsy. The ultrasound was scanned downwards through the supraclavicular fossa, along the acoustic window of the paratracheal soft tissue space. Percutaneous aspiration biopsy was performed with a 22 gauge needle under ultrasound guidance. If fine needle aspiration could not obtain an adequate tissue smear an 18 gauge Trucut biopsy was performed to obtain a histological diagnosis. RESULTS: Twelve of 15 mediastinal malignancies were detected by ultrasound through the supraclavicular approach. These 12 patients underwent percutaneous needle aspiration biopsy under ultrasound guidance. Four of the patients also had a Trucut biopsy because the needle aspirates from the tumours were inadequate. The needle had to pass through the jugular veins in four patients who received fine needle aspiration but in none of the patients who required a Trucut biopsy. Definite histological diagnoses were obtained in all 12 of these patients. Ten of the tumours were malignant and two benign. None of the patients developed any complication. CONCLUSIONS: Ultrasound and ultrasound guided biopsy through the supraclavicular paratracheal window provides a new approach for malignancy located in the upper middle mediastinum, which cannot be reached by conventional ultrasound guided parasternal biopsy. The diagnostic yield of this technique is high and the procedure is relatively safe.

Transthoracic needle biopsy of thoracic tumours by a colour Doppler ultrasound puncture guiding device.

BACKGROUND--Ultrasound guided transthoracic needle aspiration biopsy has recently been used to obtain specimens for histological diagnosis of pulmonary and mediastinal tumours. Conventional real time, grey scale puncture guiding devices cannot differentiate vascular structures, and clear visualisation of the needle shaft or tip within a desired target is not always possible. This study describes a new built-in colour Doppler ultrasound puncture guiding device and assesses the relative safety of transthoracic needle aspiration biopsy of thoracic tumours by grey scale or colour Doppler ultrasound guidance. METHODS--Thirty patients with radiographic evidence of pulmonary (22 patients) or mediastinal tumours (eight patients) underwent ultrasonographic evaluation and transthoracic needle aspiration biopsy by using the colour Doppler ultrasound puncture guiding device (Aloka UST 5045P-3.5). These tumours were initially examined by grey scale ultrasound, and colour Doppler imaging was then used to evaluate the number of blood vessels surrounding and within the target tumour and the possibility of visualisation of the needle shaft or needle tip during the aspiration biopsy procedure. RESULTS--The colour Doppler ultrasound guiding device was far superior to the grey scale device for identification of the number of vessels surrounding or within the target tumour (83% v 20%) and for visualisation of the needle shaft or needle tip (80% v 17%). CONCLUSIONS--By using the colour Doppler ultrasound puncture device, vascular structures surrounding or within the target tumour can be verified. Visualisation of the needle shaft or tip is also better. Biopsy routes can be selected to avoid puncturing vessels. This approach should be particularly helpful for guiding biopsies of mediastinal tumours, where puncturing the heart or great vessels is a potential complication.

Diagnosis of pulmonary cryptococcosis by ultrasound guided percutaneous aspiration.

BACKGROUND: Ultrasound is useful for locating thoracic lesions and guiding biopsy procedures. The use of sonographic appearances and ultrasound guided needle aspiration has led to the diagnosis of pulmonary cryptococcosis at this hospital. METHODS: Six hundred and eight patients who had ultrasound guided lung aspirations were reviewed retrospectively and nine with documented pulmonary cryptococcosis were collected. All patients had nodules or infiltrates on the chest radiograph. The needle aspirates obtained under ultrasound guidance were stained by Rius or Papanicolaous method or with India ink, and six were sent for culture. Five patients also underwent bronchoscopy and biopsy. RESULTS: The nine patients had 18 pulmonary lesions, of which 15 were nodules and three infiltrates. Fifteen lesions were detectable by ultrasound, which showed the nodules to be hypoechoic with eccentrically located air echoes. In eight of the nine cases cryptococci were detected after the lung aspirates had been stained with Rius or Papanicolaou stain or with India ink. In five of the six aspirates sent for fungal culture Cryptococcus neoformans was isolated. The diagnostic yield was higher than that of bronchoscopy. None developed post-aspiration pneumothorax or any evidence of late dissemination. CONCLUSIONS: Because they tend to be subpleural pulmonary cryptococcal lesions seem to be identifiable by ultrasound. Ultrasound guided lung aspiration is an effective, rapid, and safe method for diagnosis.

Ultrasound guided aspiration biopsy for pulmonary tuberculosis with unusual radiographic appearances.

BACKGROUND: Pulmonary tuberculosis can produce unusual radiographic appearances and negative results of sputum and bronchoscopic examinations are common. This study assessed the value of ultrasound guided aspiration biopsy in the diagnosis of pulmonary tuberculosis with unusual radiographic appearances. METHODS: Thirteen patients, ultimately diagnosed as having tuberculosis, underwent a chest ultrasonographic examination between June 1984 and August 1991. All had sputum available for examination and nine were also examined by bronchoscopy. Ten patients who had a negative sputum smear and negative bronchoscopic brushing smears underwent ultrasound guided aspiration or biopsy. Percutaneous aspiration was performed with a 22 gauge needle. If the smear did not reveal acid fast bacilli, a biopsy sample was taken with a 16 gauge Tru-cut needle to obtain a histological diagnosis. RESULTS: The ultrasonographic examination delineated the more complex nature of the lesions better than the chest radiograph. Ultrasound guided aspiration biopsy provided the diagnosis in nine of 10 patients, while the sputum smear and culture provided diagnosis in five of 13, and bronchoscopy in four of nine. In terms of rapid diagnosis, ultrasound guided aspiration biopsy gave the diagnosis in eight of 10 cases. No patient developed a major complication. CONCLUSION: Ultrasonography can direct the needle to the most suitable part of a lesion to obtain the relevant specimens. The diagnostic yield is high and the procedure is relatively safe. It is especially helpful in patients with negative results of sputum and bronchoscopic examinations.

Tumour‐infiltrating lymphocytes in non‐small cell lung cancer are activated T lymphocytes

This study was carried out in order to investigate the local immune reaction of tumour‐infiltrating lymphocytes (TILs) in the primary tumours of non‐small cell lung carcinomas. Thirty non‐small cell lung cancer (NSCLC) patients were included. The tumour tissue was taken at thoracotomy and monocellular suspension of the tumour was obtained by mechanical disaggregation. Dual‐coloured flow cytometric analysis of TILs and their corresponding peripheral blood lymphocytes (PBLs) was performed. Tumour‐infiltrating lymphocytes contained significantly higher proportions of CD3(+) T lymphocytes and CD8(+) T lymphocytes than the corresponding PBLs (82.0%±13.9%vs 66.3%±10.6% for CD3, P<0.001; 39.0%±18.4%vs 26.4%±5.2% for CD8, P<0.001). Tumour‐infiltrating lymphocytes contained significantly higher proportions of activated memory lymphocytes than PBLs did (9.8%±8.6%vs 1.3%±1.5% for CD25, P<0.001; 40.5%±30.2%vs 10.2%±14.8% for CD71, P<0.001; 75.5%±11.9%vs 28.6%±9.8% for HLA‐DR, P<0.001). These findings were also found in both CD4(+) TILs and CD8(+) TILs. The TILs of NSCLC contained higher proportions of T lymphocytes and CD8(+) lymphocytes than their corresponding peripheral bloods. The proportions of activated memory lymphocytes were also significantly higher in the TILs, both in CD4(+) TILs and CD8(+) TILs, than the corresponding PBLs.