Nilgün Kanlıoğlu Kuman

Postresectional lung injury in thoracic surgery pre and intraoperative risk factors: a retrospective clinical study of a hundred forty-three cases.

IntroductionAcute respiratory dysfunction syndrome (ARDS), defined as acute hypoxemia accompanied by radiographic pulmonary infiltrates without a clearly identifiable cause, is a major cause of morbidity and mortality after pulmonary resection. The aim of the study was to determine the pre and intraoperative factors associated with ARDS after pulmonary resection retrospectively.MethodsPatients undergoing elective pulmonary resection at Adnan Menderes University Medical Faculty Thoracic Surgery Department from January 2005 to February 2010 were included in this retrospective study. The authors collected data on demographics, relevant co-morbidities, the American Society of Anesthesiologists (ASA) Physical Status classification score, pulmonary function tests, type of operation, duration of surgery and intraoperative fluid administration (fluid therapy and blood products). The primary outcome measure was postoperative ARDS, defined as the need for continuation of mechanical ventilation for greater than 48-hours postoperatively or the need for reinstitution of mechanical ventilation after extubation. Statistical analysis was performed with Fisher exact test for categorical variables and logistic regression analysis for continuous variables.ResultsOf one hundred forty-three pulmonary resection patients, 11 (7.5%) developed postoperative ARDS. Alcohol abuse (p = 0.01, OR = 39.6), ASA score (p = 0.001, OR: 1257.3), resection type (p = 0.032, OR = 28.6) and fresh frozen plasma (FFP)(p = 0.027, OR = 1.4) were the factors found to be statistically significant.ConclusionIn the light of the current study, lung injury after lung resection has a high mortality. Preoperative and postoperative risk factor were significant predictors of postoperative lung injury.

Osteopontin as a marker of weight loss in lung cancer

Abstract Although the role of osteopontin (OPN) in tumorigenesis and invasiveness is well-known, its role in systemic consequences of lung cancer has not been studied yet. The objective of the current study was to assess the value of osteopontin as a marker of weight loss in relation to systemic inflammation in non-small cell lung cancer (NSCLC) patients. A total of 63 male NSCLC patients (stage III and IV) and 25 age and sex-matched controls were included. The NSCLC patients were further divided into subgroups depending on whether they had > 5% weight loss in the last 6 months or not. Serum OPN and TNF-α concentrations were measured by ELISA using commercially available kits. Serum C-reactive protein (CRP) concentration was measured by the turbidimetric method. OPN (p = 0.001) and CRP (p < 0.001) concentrations were significantly higher in lung cancer patients compared to controls whereas TNF-α concentrations were similar in cancer and control groups (p = 0.063). There were 33 NSCLC patients (52.4%) with weight loss. Serum OPN concentration was found to be higher in this weight-losing group (p = 0.042). CRP concentration was also higher in the weight-losing group but the difference was not statistically significant (p = 0,246). TNF-α concentrations were similar in both subgroups (p = 0.094). In correlation tests, there was a positive correlation between OPN and CRP (r = 0.299, p = 0.044), but no correlation was detected between OPN and TNF-α (r = − 0.009, p = 0.930). A negative correlation was detected between OPN and BMI (r = − 0.246, p = 0.048). In addition to being an indicator of systemic inflammation in lung cancer patients, osteopontin may also be an indicator of weight loss.

PEComa (Clear Cell “Sugar” Tumor) of the Lung: A Benign Tumor That Presented With Trombocytosis

Perivascular epithelioid cell tumors of the lung are rare, benign neoplasms, usually presenting as a solitary pulmonary nodule on chest roentgenograms. Most lesions are solitary and asymptomatic, and are located within the peripheral lung. This is a case report of a 44-year-old woman who presented with thrombocytosis and solitary pulmonary nodule of the lung, which was removed by a thoracotomy.

A Hemiclamshell Incision for a Giant Solitary Fibrous Tumor of the Right Hemithorax

A 41-year-old female was admitted with respiratory distress. Chest radiographs showed opacity in the right hemithorax with mediastinal shift. Computed tomography (CT) scan showed a pleural mass with a 22 cm diameter occupying the whole right hemithorax and causing atelectasis. Magnetic resonance imaging (MRI) showed lower position of the right hemidiaphragm and the liver. Superior vena cava and heart were shifted to left. Presence of infiltration to the adjacent tissues could not be clearly evaluated because of pressure effect. Transthoracic needle biopsy specimen was reported to be benign. Because of the size and location of the mass, a hemiclamshell incision was chosen, which allowed excellent visualization and complete dissection of the giant tumor. The histopathology of the resected specimen confirmed solitary fibrous tumor. The patient was stabilized by careful observation and treatment. No complication except pneumonia in the postoperative first month occurred during the 22-month follow-up period.

Pulmonary Sequestration with Renal Aplasia and Elevated SUV Level in PET/CT

Extralobar sequestration with other bronchopulmonary malformations is commonly seen; however, the association of extralobar sequestration with renal aplasia is very rare. A 75-year-old female patient was admitted with back pain. Ultrasonography revealed aplasia of the left kidney and tomography showed 6 × 4.5 cm sized tumor in the left hemithorax at the posterobasal area. The lesion has focally increased glycolytic activity (SUVmax: 3.2) at the left upper pole on positron emission tomography scan (PET/CT). Sequestrectomy was performed after the confirmation by frozen section that the lesion was benign and of extrapulmonary sequestration. No complication occurred during postoperative and 50-month follow-up period.

Teratoma during Pregnancy with Positive Estrogen and Progesterone Receptors and Elevated Ca19-9 Antigen Levels

We present a 27-year-old female patient admitted with an anterior mediastinal mass. She complained of chest discomfort and hemoptysis which began seven months prior. She had given birth five months prior. Thoracic X-ray showed an anterior mediastinal mass. Thorax computed tomography (CT) confirmed a well-defined anterior mediastinal mass with 13 × 12 cm diameter, extending to the right hemithorax. It was composed of cystic spaces and discrete areas like soft tissue and fat. Serum Ca 19-9 level was elevated. CT features were consistent with a mature teratoma. During median sternotomy, the tumor revealed adhesions to the right lung and the right subclavian artery. Histologically, the tumor was diagnosed as a mature teratoma. Estrogen and progesterone receptors were detected to be positive in the resected tissue. We conclude that alterations in hormone levels during pregnancy might be the cause of rapid tumor growth which leads to hemoptysis.

An unusual bronchopulmonary malformation in adulthood: Bronchial atresia

Dear Editor, A 34-year-old female patient was admitted with chest pain, dyspnea, fever and sputum production for 1.5 years. On physical examination, the breath sounds were decreased in the right upper lung. Posteroanterior chest radiography revealed increased radiolucency along with overinflated lung parenchyma, spare vasculature and an irregular shaped opacity in the upper half of the right lung. Thoracic computed tomography showed a 2-cm tubular bilobulation of soft tissue density in the region of the superior segment of the right upper lobe. The anterior segment had emphysematous hyperaeration and the posterior segment had fibrotic changes. The orifice of the superior segmental bronchus could not be visualized by bronchoscopy. Routine laboratory and pulmonary tests were within normal limits. During the operation, there was a localized overinflated emphysematous change in the anterior segmental area of the right upper lobe. Proceeding over the posterior superior artery truncus to the lung, the upper lobe anterior and apical branches of the superior pulmonary vein passed posteriorly through the atretic bronchus of the superior segment and crossed the main bronchus, then joined the posterior lobe and middle lobe vein, thus forming the superior pulmonary vein (Fig. 1). Lobectomy was indicated because of a palpable lesion deep in the anterior segment and emphysematous appearance of that segment, fibronodular changes in the posterior segment, and complexity of the venous anatomy. Right upper lobectomy was performed. Pathological examination showed bronchial atresia, a lesion in the anterior segment, chronic active organized pneumonia, emphysematous changes in the anterior segment, and fibrotic changes in the posterior segment. No complications occurred postoperatively or during the 16-month follow-up period. Most congenital lung malformations are associated with occult atretic bronchus; however, the specific relationship between congenital bronchial atresia and other congenital lung masses has remained largely unexplored (Kunisaki et al. 2006). One explanation for bronchial stricture and obstruction development is that peripheral bronchi and alveolar structures in the obstructed area exert compression on the bronchus (Kameyama et al. 2006). In the present case, the superior segmental bronchus that was found to be obstructed also seemed to have an abnormality posterior and superior to the pulmonary vein. Thoracoscopy-assisted resection is considered to be an effective treatment for congenital bronchial atresia (Kameyama et al. 2006). However, performing thoracoscopic resection may be risky in cases in which chronic changes and pleural adhesions occur. We suggest that in our case, the abnormal localization of the pulmonary vein interfered with the developing bronchial tree, thus leading to bronchial atresia. The effect of chronic infection caused by atresia on the other lobes and subsequent chronic changes required wider resection.

Co-Occurrence Of Bronchıal Atresıa And Intrapulmonary Sequestration In Divergent Lobes

Bronchial atresia is a developmental anomaly characterized by focal obliteration of the proximal segment of a bronchus. As the atretic segment is ventilated collaterally it takes an emphysematous form. Congenital abnormalities like lobar emphysema, bronchogenic cyst and pectus excavatum are the most frequent pathologies accompanying the condition (Daltro et al. 2010). Also, foregut anomalies might be seen together (Riedlinger et al. 2006) A 21-year-old male patient was admitted to our hospital with a complaint of discomfort in his chest. He also had hemoptizia and exertional dyspnea. He had a medical history of drug use for hidatic cysts. His respiratory function tests were FVC (forced vital capacity): 3.30 L (68.8 %) FEV1 (forced expiration volume in1 s) 2.29 (56%) FEV1/FVC: 69.44. In his chest X-ray, hyperinflation at right lung mid-lobes and emphysema were detected. On further examination by thorax computerized tomography (CT), the bronchus of the lateral segment of the right lung mid-lobe was not visualized. At the same sequences of CT; images compatible with bronchocele and air trapping at the distal part of the lesion were demonstrated. Moreover, there was a 6 × 2 cm sized consolidation area at the mediobasal segment of right lung lower lobe (Fig. 1 A–D, Fig. S1–S4). By bronchoscopy we have seen that a rudimental bronchus existed at the lateral segment of mid-lobe and it was encapsulated by a pulsatile vessel. For the treatment of atresia and sequestration, we decided to undertake surgery. In the course of the operation, we saw that the mid-lobe lateral segment of the right lung and the artery of the mid-lobe were overexpanded and this artery compressed the atretic bronchus. We carried out segmentectomy for the mid-lobe lateral segment. We detected five pulsatile vascular constrictions along the inferior pulmonary ligament, which had originated from the mediastinum and penetrated the mediobasal segment. The mentioned segment was atelectatic and we performed mediobasal segmentectomy for this section. On pathological examination, the patient’s mediobasal segment had cystic bronchial formation, chronic inflammation areas, vessels connective tissue and smooth muscle tissue foci leading to the diagnoses of intrapulmonary sequestration, mid-lobe lateral segment having an emphysematous form and bronchial construction compatible with atresia. The patient had experienced no complications during the postoperative period, and was discharged at his fourth postoperative day. In the pathogenic pathway of bronchial atresia lies the interruption of the bronchial germ cells due to ischemia in the intrauterine period (Zylak et al. 2002). The distal part of the bronchus might go on developing with a central airway connection. Also, any compression may lead to atresia (Kameyama et al. 2006; Kanlıoglu Kuman et al. 2011). Radiological changes occur based on collateral air intake, air trapping in distal parts and overinflation. Dilated bronchus might be seen as a clear strip when filled with air. Magnetic resonance images might be useful in determining anatomic features (Mori et al. 1993). Bronchopulmonary sequestration in a nonfunctional dysplastic lung tissue having no connection with normal trachea bronchial and vascular tissue constitutes 7% of congenital lung anomalies and it is seen threefold more in males. Sequestrations originate from caudal diverticul of primitive foregut. Hence, it might be seen with some other foregut pathologies (Zylak et al. 2002; Daltro et al. 2010). The arterial vascularity of intralobar sequestration which forms 75% of all sequestrations is rooted in the aorta and drains to the pulmonary veins. It mostly takes place at the left lung lower lobe posterobasal segment and usually remains asymptomatic until adolescence. Large mass lesions might cause dyspnea due to compression and the only treatment is resection. To our knowledge, atretic bronchi are detected in sequestrated tissue in 82% of all resected intrapulmonary and extralober sequestrations (Riedlinger et al. 2006). This is the first case report in the literature documenting bronchial atresia and intrapulmonary sequestration in divergent and independent lobes. Obviously, two pathologies existing in different lobes each necessitating surgical attempt would eventuate in an apparent decrease of lung capacity postoperatively. In this case, by the concurrent mid-lobe lateral segmentectomy and lower lobe mediobasal segmentectomy performed for the first time in the literature, we have achieved the treatment aim, ultimately conserving lung capacity.

Bronchial sleeve resection for lung cancer preoperative empyema.

Surgical management of the cancer with empyema has rarely been reported in the literature because few of such cases are operable. Many patients might be misevaluated because of the incorrect staging associated with an acute or sub-acute infection. Even in the presence of an operable tumor mass; surgeons behave timid to these patients because of the possibility of infective postoperative complications. The balance between expected benefits and possible risk of surgical intervention is also important. If it is indicated, by the time pleural empyema is restored, procedures such as resection and even bronchoplasty should be performed. 59-years old patient with squamous cell carcinoma that completely obstructed left basal segments and caused to empyema. A thoracic catheter was inserted. Multiple pleural irrigations were done and proper antibiotherapy. Pathologic diagnosis of pleural fluid and pleural biopsy were benign. Pleural cultures were negative and amount of empyema fluid volume has decreased within two months. Positron emission tomography (PET) revealed a 2.5 cm sized left infrahilar tumor, right paratracheal, prevascular and subcarinal lymph nodes and non-homogeneous increased pleural activity. Mediastinal lymph nodes were evaluated as reactive with mediastinoscopy. Left lower lobectomy and lingulectomy were performed with bronchial resection and pathologic stage was 2A (T1bN1MO). Case Study Kuman et al.; BJMMR, 7(1): 82-85, 2015; Article no.BJMMR.2015.309 83

Bronchial cytokine changes following bronchial resection and reconstruction for carcinoid tumor.

As bronchial carcinoids are known to be notably rare, adequate histochemical investigations couldn’t have been carried out on these types of tumors hitherto. In this study, we investigated bronchial cytokines in a carcinoid tumor localized in the left main bronchus. Bronchial resection and reconstruction was performed without the lung resection. Bronchial lavage samples were obtained from both sides of main bronchial system preoperatively and postoperatively. TNF-α, IL-8 and IL6 levels were measured by ELISA. Preoperative TNF-α and IL-8 levels were found to be 2folds and 5-folds higher on the tumor side respectively (TNF-α; 14.184 pg/ml and IL-8; 3359.86 pg/ml) compared to tumor-free bronchial system (TNF-α; 6.886 pg/ml, IL-8; 615.072 pg/ml). Interestingly, both cytokine levels were found to be equal and within normal ranges on both sides subsequent to bronchial resection and reconstruction. There were no significant difference in IL-6 levels between two bronchial systems preoperatively (IL-6 levels of right bronchus, 16.44 pg/ml; levels of left bronchus, 19.11 pg/ml). However, there was more than four-fold increase in postoperative levels (IL-6 level; 89.41 pg/ml). In our study, we found that preoperative TNF-α and IL-8 levels were higher compared to the Case Study Kuman et al.; BJMMR, 7(5): 432-437, 2015; Article no.BJMMR.2015.350 433 postoperative ones; whereas IL-6 levels showed a significant increase, postoperatively. These findings led us through the idea that carcinoid tumors might be activating the inflammatory process among TNF-α and IL-8 and the surgical bronchoplastic procedure could be the cause of enhanced IL-6 response.