Ugur Gonlugur

Pancreatic involvement in small cell lung cancer

Abstract Background. Few data are available concerning incidence, clinical picture, and prognosis for pancreatic metastases of small cell lung carcinoma. In this paper we review the related literature available in English language. Conclusions. Although pancreatic metastases are generally asymptomatic, they can rarely produce clinical symptoms or functional abnormalities. The widespread use of multi-detector computerised tomography (CT) in contemporary medical practice has led to an increased detection of pancreatic metastases in oncology patients. Tissue diagnosis is imperative because radiological techniques alone are incapable of differentiating them from primary pancreatic tumours. Pancreatic metastases occur in the relative end stage of small cell lung cancer. The main complications of these lesions, although rare, are acute pancreatitis and obstructive jaundice. Early chemotherapy can provide a survival benefit even in patients with mild acute pancreatitis or extrahepatic biliary obstruction.

Prognostic factors for 100 patients with malignant pleural mesothelioma.

ABSTRACT The aim of this study was to investigate the effects of various clinical, laboratory characteristics, and therapeutic modalities on the survival of patients with malignant pleural mesothelioma. One hundred consecutive patients with a pathologically proven diagnosis of malignant pleural mesothelioma treated between 1993 and 2005 were included in the study. Using a Cox proportional hazard model, comorbidity, weight loss, breathlessness, and performance status were identified as independent prognostic factors. Comorbidity had interestingly favorable effect on the survival. Treated patients with chemotherapy had significantly longer survival than those treated with best supportive care. However, it was necessary to complete at least 6 cycles for a survival benefit. In conclusions, comorbidity information should be recorded in the recent prognostic studies. The drugs used for the comorbidity may improve survival.

Cervical necrotizing fasciitis associated with descending necrotizing mediastinitis

We report a case of potentially fatal cervical necrotizing fasciitis and descending necrotizing mediastinitis due to deep neck infection in a 66-year-old male patient with no history or evidence of immunocompromising disorders. On admission, he had painful neck movements and the skin over his neck was red, hot and tender. A computerized tomography (CT) scan of his neck and chest showed evidence of air collection in soft tissues. He was treated with broad-spectrum intravenous antibiotics and early massive cervical drainage. Prompt diagnosis by CT of the neck and chest enabled an early surgical treatment of cervical necrotizing fasciitis. Although acute mediastinitis is a fatal infection involving the connective tissues that fill the interpleural spaces and surround the median thoracic organs, an extensive cervicotomy combined with appropriate antibiotics can prevent the need for mediastinal drainage.RiassuntoDescriviamo il caso di una fascite cervicale necrotizzante potenzialmente fatale con mediastinite necrotizzante discendente causata da un’infezione profonda del collo in un maschio di 66 anni, in assenza di anamnesi o evidenza di patologie immunodepressive. All’ingresso presentava dolore al movimento del collo e la cute del collo era arrossata, calda e dolente. Una TAC di collo e torace mostrava enfisema nei tessuti molli. È stato trattato con antibiotici ad ampio spettro e.v. e drenaggio cervicale massivo precoce. Una diagnosi tempestiva con una TAC del collo e del torace ha consentito un trattamento chirurgico precoce della fascite necrotizzante cervicale. Nonostante la mediastinite acuta sia un’infezione fatale che interessa il tessuto connettivo interposto tra i foglietti pleurici e che circonda gli organi mesotoracici, una cervicotomia estensiva associata ad un’adeguata terapia antibiotica può prevenire la necessità di un drenaggio mediastinico.

Unilateral opaque or ‘white out’ hemithorax

Opaque lung is complete opacification of one hemithorax in chest X-ray. Aplasia or agenesis of the lung, diaphragmatic hernia, massive pleural effusion, diffuse pleural soft tissue lesions (fibrothorax, malignant mesothelioma), obstruction of the main bronchus (mucus plug, foreign body or endobronchial/ extrabronchial mass), bronchial rupture, large intrathoracic tumors/cysts (aortic aneurysm), pneumonia affecting all lobes in a hemithorax, unilateral pulmonary edema, and pneumonectomy are the most common cause of opaque lung (1). We present an interesting case with an opaque left hemithorax in this paper.

Solitary pancreatic metastases of small cell lung cancer.

Figure 1. Low attenuated mass on the pancreatic head. Many types of tumors have been reported to metastasize to the pancreas, including lung carcinoma, prostatic carcinoma, liver carcinoma, stomach carcinoma, colon carcinoma, breast carcinoma, thyroid carcinoma, renal cell carcinoma, Hodgkin disease, hepatoma, malignant melanoma, and meningioma. The most common histologic type of lung cancer that is related to pancreatic metastasis is small cell lung cancer [1,2]. Although pancreatic metastasis occurs toward the end stage of small cell lung cancer [2], we present multiple isolated pancreatic metastases of small cell carcinoma of the lung in this paper. A 58-year-old old man was admitted with complaints of chest pain and a cough that lasted for 1 month. He had a 40-pack per year smoking history. Clubbing was evident in the physical examination. The initial laboratory workup revealed a normal blood count and biochemistry, including alkaline phosphatase, total bilirubin, amylase, and lipase. A chest computed tomography (CT) scan showed a tumor with an irregular margin on the left hilar region. A bronchoscopic biopsy revealed small cell carcinoma. There were low attenuated masses on the pancreatic head (Fig. 1) and tail in CT of the abdomen. Following six cycles of first-line chemotherapy, consisting of etoposide and cisplatin, pancreatic masses showed partial regression. The pancreatic lesions disappeared after six cycles of second-line chemotherapy with topotecan. The pancreas is a relatively infrequent site of metastasis for small cell carcinoma of the lung. Although the main complications of these lesions are acute pancreatitis and obstructive jaundice, pancreatic metastases are usually asymptomatic or the symptoms are nonspecific, as was seen in our patient. The occurrence rates of acute pancreatitis, due to pancreatic metastasis of small cell lung carcinoma, vary between 3.3% and 7.5%. These results are lower than the 12e40% rate of small cell lung cancer metastases to the pancreas reported in autopsy findings [1]. It has been reported that most secondary tumors of the pancreas localize to the head of the gland [3]. The

A forgotten oat head aspiration in an adult patient.

Non-resolving or slowly resolving pneumonia in adults represents a diagnostic challenge for chest physicians. We present an interesting case with a forgotten foreign body as a rare cause of slowly resolving pneumonia. A 47-year-old woman was admitted for right-sided chest pain of three months’ duration. The patient had chronic cough for years, and was misdiagnosed as suffering from chronic bronchitis and asthma. She did not have a mental disease, neuromuscular disorders or use of sedative and hypnotic drugs. Chest computed tomography scan showed a tumor-like lesion (Figure 1), and a secondary lesion due to pneumonia or atelectasis. A foreign body was removed during diagnostic examination with a fibreoptic bronchoscope under local anesthesia (Figure 2). There was also granulation tissue at the posterior wall of the right lower lobe bronchus (Figure 3). Morphological examination of the foreign body was consistent with oat head. The patient reported that she had been farming oats 20 years ago. Figure 1 A chest-CT scan showing a smooth ovoid lesion in the right lower lobe Figure 2 Foreign body after removal Figure 3 Endoscopic aspect of foreign body and a mass suggestive of granulation tissue on the mucosa Occult tracheobronchial foreign body aspirations are infrequently seen in adults. It may be undetected for months to years [1], as in our case. In some cases with delayed diagnosis, pneumonitis [1] and granulation tissue appear surrounding the foreign body [2]. The oat head had probably been aspirated 20 years ago in our patient. Clinical and radiological features were consistent with pneumonitis and granulation tissue. The aspiration of a grass inflorescence can cause two different clinical pictures: obstructive type characterized by recurrent pneumonia and bronchiectasis; and migratory type, presenting with pleural or mediastinal complications [3]. An oat head moves unidirectionally, and it is impossible to expectorate once aspirated because of the nature of the structure. Although 5 cases of oat head aspiration have been reported in childhood [4], only 2 case reports [5, 6] in the adult population have been presented in the literature.