Gaetana Messina

Endobronchial treatment of giant emphysematous bullae with one-way valves: a new approach for surgically unfit patients

OBJECTIVE We aimed to evaluate the feasibility and short-term efficacy of endobronchial treatment with one-way valves for giant emphysematous bulla in surgically unfit patients. METHODS Nine consecutive patients with giant emphysematous bulla were enrolled in the last 3 years. Endobronchial valves were placed in the segmental bronchi to functionally isolate the airway that supplied the bulla, favouring the deflation of the bulla and its atelectasis. Mean value ± standard deviation of forced expiratory volume in 1s (FEV1), preoperative forced vital capacity (FVC) and residual volume (RV) were: 1.0 ± 0.2l (35 ± 9.9%), 1.5 ± 0.5l (42 ± 12%) and 5.5 ± 0.7 l (23 1 ± 32%), respectively; and the values for diffusion capacity for carbon monoxide was 31 ± 4.6% and for the 6-min walk test (6 MWT) was 156 ± 92 m); all patients required supplemental oxygen at rest. The St. Georges Respiratory Questionnaire (SGRQ) score was 85 ± 4.6. RESULTS At 24-48 h after the procedure, the mean value of FEV1 (from 35% to 47%, p < 0.01), FVC (from 42% to 52%, p < 0.01), diffusion lung capacity for carbon monoxide (DLCO) (from 31% to 33%, p < 0.05) and 6 MWT (from 156 m to 281 m, p < 0.01) significantly improved with respect to baseline value. Conversely, mean value of total lung capacity (TLC) (from 157% to 123%, p < 0.01) RV (from 231% to 158%, p < 0.01) and SGRQ score (from 85 to 37, p < 0.01) was significantly lower than baseline data; these changes were preserved during the entire follow-up. CONCLUSION Our preliminary data confirm the feasibility and the potential efficacy of this strategy with significantly immediate improvement of respiration and quality of life, which remains stable during 6 months of follow-up.

Vascular endothelial growth factor in pleural fluid for differential diagnosis of benign and malignant origin and its clinical applications

Our goal was to determine the role of vascular endothelial growth factor (VEGF) in diagnosing of pleural effusion (PE) in order to select patients deserving of more aggressive procedures. Seventy-nine consecutive patients with undiagnosed unilateral PE were enrolled. Pleural VEGF levels, measured using enzyme-linked immunosorbent assay (ELISA), were correlated to etiology of PEs and other markers (protein, lactic dehydrogenase, amylase, glucose). The median level of VEGF in exudates (n=65) was significantly higher than that in transudates (P=0.0001) and among exudates, it was significantly higher in malignant (n=49) than that in benign exudates (P=0.005). No significant differences were observed between malignant effusions due to lung cancer (n=11) and other malignant effusions [mesothelioma (n=13) and/or extra-thoracic cancer]. Among all variables evaluated, logistic regression found that only VEGF was significantly correlated with the presence of malignant disease (P=0.002). Analysis of the receiver operating characterists (ROC) curves showed that the areas under the curve of VEGF were significantly larger than that of amylase (P=0.02), glucose (P=0.01), lactic dehydrogenase (P=0.001) and protein (P=0.01). VEGF increased the diagnostic rate of cytological examination by 24%. VEGF may represent a helpful adjunct to conventional diagnostic tools in ruling out malignancy as a probable diagnosis, thus guiding the selection of patients who might benefit from further invasive procedures.

Pre-emptive local analgesia in video-assisted thoracic surgery sympathectomy.

OBJECTIVE Our goal is to determine whether infiltration with a short-acting local anaesthetic such as lidocaine before the surgical incision has a pre-emptive effect on postoperative pain intensity and on incidence of paraesthesia in patients undergoing standard thoracoscopic sympathectomy for palmar hyperhidrosis. MATERIAL AND METHODS This prospective study includes a consecutive series of 18 patients undergoing bilateral standard thoracoscopic sympathectomy for palmar hyperhidrosis during January 2005-December 2007. Each patient enrolled in the study was randomised to receive pre-incisional lidocaine with epinephrine infiltration of the wounds on the one side, and normal saline solution on the other. The identical surgery was performed on each side to allow patients to act as their own controls. Then, the side which received local analgesia was compared with the control side with regard to pain control and paraesthesia after 4, 24 and 168 h postoperatively. The patients and investigators were both blinded concerning the side randomised to receive pre-emptive local analgesia (PLA). RESULTS We found that patients reported significantly less pain on the side treated with pre-emptive local anaesthesia in contrast to the control side 4 and 24h after surgery (p=0.001 and p=0.004, respectively). However, that difference decreased with time and was no longer significant 168 h following surgery (p=0.156). Regarding the paraesthesia, the incidence was higher in the control side than the PLA side at 4, 24 and 168 h postoperatively, but the difference was not statistically significant. A total of 17 of 18 (94%) patients noted a change in palmar hyperhidrosis status after surgery. CONCLUSION Our study shows that the pre-injection of local anaesthetic before standard thoracoscopic sympathectomy suppresses the local pain mediators, hence resulting in significantly less pain in the first postoperative 24 h but not thereafter. The clinical impact of the procedure is the possibility of early discharge to home and early return to work with potential economical benefits. However, because of the small number of patients, further studies are needed to corroborate our results.

Does cannabis smoking predispose to lung bulla formation

Objective The data of a consecutive series of habitual marijuana smokers were retrospectively evaluated and compared with that of non-marijuana smokers to assess differences between the 2 groups. Methods 13 consecutive habitual marijuana smokers were referred for treatment of spontaneous pneumothorax. The demographic, clinical, radiological, and pathological findings of these patients were reviewed and compared with 140 non-marijuana smokers treated for the same pathology at the same time. Results Bullae were seen in 8/13 (62%) and 110/140 (78%) of marijuana smokers and non-marijuana smokers, respectively. However, when patients less than 35-years old were considered, the incidence of bulla was higher in marijuana smokers than non-marijuana smokers (7/10 vs. 3/10, p < 0.05). The pathological findings showed a greater presence of inflammatory cells in specimens from marijuana smokers than those of non-marijuana smokers (8/11 vs. 2/42, respectively, p < 0.05). No significant differences in hospital stay and clinical outcome were registered between the 2 groups. Conclusions Despite the fact that we were unable to demonstrate that marijuana had a causal role in the development of emphysema, our study showed that marijuana smokers had a higher incidence of inflammatory cells in pathological specimens, which may favor lung injury, thus predisposing to bulla formation.

The influence of body mass index and weight loss on outcome of elderly patients undergoing lung cancer resection.

BACKGROUND The aim of the study was to evaluate the influence of nutritional status on outcome of elderly patients resected for lung cancer. MATERIALS AND METHODS A total of 117 consecutive patients aged ≥ 70 years undergoing lung cancer resection were enrolled. In addition to routine preoperative evaluations, other variables such as body mass index, weight loss, serum albumin, lymphocytes, and transferrin were counted. According to the body mass index value, patients were divided into Group A (≤ 18.5, underweight) and Group B (> 18.5) and risk factors for morbidity and mortality were analyzed. RESULTS Group A and Group B counted 21 and 96 patients, respectively. The mean age was 74.9 ± 2.6; body mass index of Group A was significantly lower than that of Group B (16.7 ± 1.3 vs. 23.5 ± 1.7, respectively, p < 0.0001). On multivariate analysis, significant risk factors for complications were pneumonectomy (p = 0.001), stage (p = 0.006), predictive postoperative flow expiratory volume in 1 second (ppoFEV1%) (p = 0.003), and coronary disease (p = 0.04) and significant risk factors for early mortality were pneumonectomy (p = 0.0002), ppoFEV1% (p < 0.0001), BMI (0.02), and weight loss (0.007). The median survival time of Group A and Group B was 41 versus 54 months, respectively (p = 0.1). However, body mass index of less than 18.5 (p = 0.01) and weight loss of > 5% before operation (p = 0.01) were independent risk factors for 1 year mortality. CONCLUSIONS In elderly patients, malnutrition was a significant additional risk factor for early death. Nutritional assessment should be included in the routine preoperative selection. In malnourished patients, nutritional support before and after operation and a careful postdischarge care might be beneficial, but it should be corroborated by further prospective studies.

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.

Correlation between matrix metalloproteinase 9 and 18F-2-fluoro-2-deoxyglucose-positron emission tomography as diagnostic markers of lung cancer

OBJECTIVES This study was conducted to evaluate the diagnostic role of matrix metalloproteinase 9 (MMP9) measured in bronchoalveolar lavage (BAL), serum and tissue samples of patients with indeterminate lung lesions and its correlation with F-18-2-fluoro-2-deoxyglucose-positron emission tomography ((18)FDG-PET) findings in diagnostic work. METHODS MMP9 levels (ng/ml) in serum and BAL were analysed using enzyme-linked immunosorbent assay in 60 consecutive patients with lung mass. (18)FDG-PET was performed on all patients and a standard uptake value (SUV) threshold of 2.5 was used to differentiate benign from malignant lesions. In tissue samples of resectable patients, MMP9 expression was also revealed by immunohistochemical staining. RESULTS Twenty patients had benign disease and 40 patients had malignant lesions, of which 7 (17.5%) were classified as Stage I, 18 (45%) as Stage II, 7 (17.5%) as Stage III and 8 (20%) as Stage IV. MMP9 levels in serum were significantly higher in malignant than in benign lesions (673 ± 182 versus 309 ± 96, respectively, P < 0.0001), and were significantly higher in patients with metastatic disease than in patients of other stage groups; no significant difference was found between different histological types. MMP9 levels in BAL were higher in malignant than in benign lesions (502 ± 137 versus 325 ± 118, respectively, P = 0.001); no significant differences were found between different stages or histological groups. In patients with malignant lesions, MMP9 levels in BAL were inversely correlated with FEV(1) (volume that has been exhaled at the end of the first second of forced expiration) and FVC (forced vital capacity of maximally forced expiratory effort) values. In patients with SUV > 2.5, MMP9 levels in serum and BAL had a sensitivity, specificity, positive predictive value and negative predictive value of 73, 100, 100 and 81% (cut-off point of 601; area under the curve (AUC): 0.7) and 94, 100, 100 and 83% (cut-off point of 745; AUC: 0.9), respectively. In patients with SUV < 2.5, MMP9 levels in serum and BAL had a sensitivity, specificity, positive predictive value and negative predictive value of 94, 100, 100 and 75% (cut-off point of 240; AUC: 0.9) and 70, 100, 100 and 73% (cut-off point of 321; AUC: 0.7), respectively. Of the 26 tumour samples, 9 (34%) showed positive immunohistochemical staining for MMP9. CONCLUSIONS The measurement of MMP9 levels helps to differentiate benign from malignant lung mass. Its use in combination with PET study adds further information to the diagnosis work-up of lesions to select patients who may or may not benefit from additional invasive procedures.

Spontaneous expectoration of an obstructive fibrinous tracheal pseudomembrane after tracheal intubation.

We report a rare and potentially life-threatening complication related to tracheal intubation in the formation of obstructive tracheal pseudomembrane. In the present case, the pseudomembrane was spontaneously expectorated; this is very unusual and not been reported before. This condition was first misdiagnosed as edema subglottis. Then, computed tomography revealed a stenosis of the middle trachea, but subsequent flexible bronchoscopy was unable to provide additional information regarding its nature. Before attending a rigid bronchoscopy, planned to better define the cause of stenosis, a thick annular membrane was scraped away with a large amount of coughing. After that, the patients respiratory symptoms completely resolved. Control at 1 and again 3 months later showed no further tracheal stenosis. The diagnosis of obstructive tracheal pseudomembrane should be considered in cases of post-extubation stridor. Flexible bronchoscopic guidance after extubation may allow to diagnose such a complication earlier, but rigid bronchoscopy remains the treatment of choice.

Recurrent spontaneous pneumomediastinum: a rare but possible event!

A number of risk indices have been formulated in an attempt to predict risk of a major hemorrhage in an individual on warfarin therapy. No single index to date is able to reliably predict this risk in an individual patient. Although most warfarin related hemorrhages are gastrointestinal or intracranial in origin this case represents a particularly rare entity of a major hemorrhage presenting as an encysted empyema. To the best of our knowledge this has never before been described.

Metastasis from transitional cell carcinoma of urinary bladder as cystic pulmonary lesion.

Pulmonary metastases from transitional cell carcinoma usually present as multiple nodules, solitary mass, or interstitial micronodules but rarely manifested as cystic pulmonary lesions. We report an atypical case of multiple cavitating pulmonary metastases from transitional cell carcinoma of urinary bladder. Infectious disease is ruled out by sputum examination, laboratory exams and failure of response to antibiotic therapy. In closure, the need to exclude a second primary tumor led us to perform a fine-needle aspiration biopsy by which metastatic transitional cell carcinoma was diagnosed. Inadequacy of blood supply with necrosis may be advocated as possible mechanism of cavitations of the lesion.