John Hinchion

Releasing pressure in tumors: what do we know so far and where do we go from here? A review.

Tumor interstitial pressure is a fundamental feature of cancer biology. Elevation in tumor pressure affects the efficacy of cancer treatment. It causes heterogenous intratumoral distribution of drugs and macromolecules. It also causes the development of hypoxia within tumor bulk, leading to reduced efficacy of therapeutic drugs and radiotherapy. Tumor pressure has been associated with increased metastatic potential and poor prognosis in some tumors. The formation of increased pressure in solid tumors is multifactorial. Factors known to affect tumor pressure include hyperpermeable tortuous tumor vasculatures, the lack of functional intratumoral lymphatic vessels, abnormal tumor microenvironment, and the solid stress exerted by proliferating tumor cells. Reducing this pressure is known to enhance the uptake and homogenous distribution of many therapies. Pharmacologic and biologic agents have been shown to reduce tumor pressure. These include antiangiogenic therapy, vasodilatory agents, antilymphogenic therapy, and proteolytic enzymes. Physical manipulation has been shown to cause reduction in tumor pressure. These include irradiation, hyperbaric oxygen therapy, hyper- or hypothermic therapy, and photodynamic therapy. This review explores the methods to reduce tumor pressure that may open up new avenues in cancer treatment.

Review of current thermal ablation treatment for lung cancer and the potential of electrochemotherapy as a means for treatment of lung tumours

Lung cancer remains the most common cancer diagnosed worldwide and has one of the lowest survival rates of all cancers. Surgery remains the only curative treatment option but because most patients are either diagnosed at advanced stages or are unfit for surgery, less than a third of all lung cancer patients will undergo a surgical resection. Thermal ablation has emerged as an alternative option in patients who are unfit to undergo surgery. Thermal ablative therapies used in clinical practice to date include Radiofrequency Ablation (RFA), Microwave Ablation (MWA) and Cryoablation This article will focus on the advantages and limitations of thermal ablative therapy and investigates the potential of a relatively new treatment modality, Electrochemotherapy (ECT), as a novel treatment for lung cancer.

Impact of pacing modality and biventricular pacing on cardiac output and coronary conduit flow in the post-cardiotomy patient.

We have previously demonstrated the role of univentricular pacing modalities in influencing coronary conduit flow in the immediate post-operative period in the cardiac surgery patient. We wanted to determine the mechanism of this improved coronary conduit and, in addition, to explore the possible benefits with biventricular pacing. Sixteen patients undergoing first time elective coronary artery bypass grafting who required pacing following surgery were recruited. Comparison of cardiac output and coronary conduit flow was performed between VVI and DDD pacing with a single right ventricular lead and biventricular pacing lead placement. Cardiac output was measured using arterial pulse waveform analysis while conduit flow was measured using ultrasonic transit time methodology. Cardiac output was greatest with DDD pacing using right ventricular lead placement only [DDD-univentricular 5.42 l (0.7), DDD-biventricular 5.33 l (0.8), VVI-univentricular 4.71 l (0.8), VVI-biventricular 4.68 l (0.6)]. DDD-univentricular pacing was significantly better than VVI-univentricular (P=0.023) and VVI-biventricular pacing (P=0.001) but there was no significant advantage to DDD-biventricular pacing (P=0.45). In relation to coronary conduit flow, DDD pacing again had the highest flow [DDD-univentricular 55 ml/min (24), DDD-biventricular 52 ml/min (25), VVI-univentricular 47 ml/min (23), VVI-biventricular 50 ml/min (26)]. DDD-univentricular pacing was significantly better than VVI-univentricular (P=0.006) pacing but not significantly different to VVI-biventricular pacing (P=0.109) or DDD-biventricular pacing (P=0.171). Pacing with a DDD modality offers the optimal coronary conduit flow by maximising cardiac output. Biventricular lead placement offered no significant benefit to coronary conduit flow or cardiac output.

Mucoepidermoid carcinoma of lung masquerading as urothelial carcinoma of bladder

BACKGROUND Mucoepidermoid carcinoma (MEC) of the lung is a rare subtype of non-small cell lung cancer. There is no consensus regarding optimal management for this disease. CASE REPORT We present a case of MEC of the lung in a 75 year-old female with a history of superficial urothelial carcinoma of the bladder. The patient was found to have an asymptomatic lung mass. Initial biopsy suggested metastatic recurrence of urothelial carcinoma and therefore, cisplatin and gemcitabine chemotherapy was administered prior to surgical resection. Pathological analysis of the resected specimen confirmed a diagnosis of stage IIIA MEC with focal high-grade features including transitional cell-like areas. Adjuvant radiotherapy was administered due to a positive microscopic resection margin. No chemotherapy was given due to lack of supporting data. The patient developed widespread metastatic disease 3 months following completion of radiotherapy and died 1 month later. CONCLUSION This case demonstrates the possibility of dual pathology in cases where metastatic disease is suspected. The use of small tissue samples may complicate diagnosis due to the heterogeneity of malignant tumours.

Diverticulum of the mitral valve, a rare cause of mitral regurgitation.

Non-infective mitral valve diverticulum is extremely rare. We present a case of intraoperatively diagnosed mitral valve diverticulum of a 69-year-old man presenting with mitral regurgitation who was successfully treated with mitral valve replacement.

If I had a hammer

Abstract We present the case of a 64-year-old man who was referred to our service after sustaining a self-inflicted nail-gun injury to his chest. He received three nails penetrated into his chest. Computer tomography revealed no massive haemorrhage or damage to major vessels. He underwent an emergency sternotomy, two nails caused pericardial perforation and myocardial injury were noted easily and removed easily via sternotomy. Myocardial injury showed a trajectory near the junction of the left anterior descending artery and the diagonal artery with no significant bleeding appreciated. The third nail was deep in the lung parenchyma at the hilum. A pacemaker magnet was used to locate the third nail, which was subsequently removed. Our case demonstrates the use of magnets in emergency surgery, to locate and remove metallic foreign bodies.

Infiltrating angiolipoma of the chest wall: a rare clinical entity

Angiolipoma is a rare variant of lipoma. Infiltrating chest wall angiolipoma usually presents as painful subcutaneous lesions. There are only a handful of cases reported in the literature. Malignancy is suspected in the differential diagnosis, and hence a tissue diagnosis is needed to rule out an underlying malignancy. Symptomatic infiltrating angiolipoma warrants surgical excision. We report a case of an infiltrating angiolipoma of the chest wall, which was successfully treated with surgical excision.

Successful Management of an Occult Cardiac Tamponade with Prompt Surgical Intervention and a Novel, Defined Pericardial Irrigation Protocol

Purulent pericarditis is a rare entity in the postantibiotic era. It usually occurs in patients who have underlying chronic and immunosuppressing conditions and its presentation in the healthy adult population is quite rare. Infection of the pericardial space can occur via direct extension from infectious endocarditis, pneumonia, or empyema, or from a more distant source such as meningitis. Purulent pericarditis carries a very high mortality because of delay in the diagnosis and early occurrence of fatal complications. We describe a case of purulent pericarditis with impending cardiac tamponade in a previously healthy 40-year-old female patient, which was successfully treated with a combination of prompt surgical drainage and a novel irrigation protocol.

Empyema thoracis from an inhaled peanut.

A 77-year-old man with a history of pulmonary sarcoidosis was referred with persistent cough and reduced air entry on auscultation of the right lung base. He was an ex-smoker with a 40-pack-year history and his general practitioner was concerned about the possibility of bronchogenic carcinoma. A chest radiograph showed a right-sided pleural effusion with right mid-zone airspace opacification. Bronchoscopy revealed a peanut covered in mucus lodged in the right lower lobe bronchus. CT of the thorax demonstrated a multiloculated right pleural effusion with associated compressive atelectasis, consistent with chronic empyema. A chest drain was inserted but failed to fully clear the collection and the patient proceeded to a thoracoscopic decortication of a pleural empyema secondary to the right lower lobe obstruction from an inhaled peanut. His postoperative recovery was uncomplicated.

Phrenic nerve block as a novel adjunct to the local treatment of bronchopleural fistula

Bronchopleural fistula (BPF) is a life threatening complication after pneumonectomy with an incidence of about 2-5% and a mortality rate of up to 50%. Topical treatment such as fibrin glue has been previously described with limited success. We present a novel case in which blocking the phrenic nerve assisted in a successful topical closure of the BPF.