Yair Lieberman

Review of smooth muscle tumours of the lower respiratory tract

A case of leiomyoma of the lung was described by our department 17 years ago. We now report three new cases of smooth muscle tumours of the lower respiratory tract: a leiomyoma of the lung, a leiomyosarcoma of the right main bronchus, and a leiomyoma of the trachea. Whereas in the previous case the tumour was bronchoscopically removed, all the recent tumours were surgically resected. All the patients have done well, including the one with the leiomyosarcoma who underwent surgery 7.5 years ago. One hundred and eighty cases of leiomyoma and leiomyosarcoma of the lung and trachea have been reported to date. Pulmonary leiomyoma most commonly presents as an asymptomatic solitary lung nodule. The endobronchial variety may cause cough, haemoptysis, or shortness of breath. Most of these tumours were dealt with by major pulmonary resection, although a lesser resection would have sufficed in many cases if a histological diagnosis had been established prior to surgery. Pulmonary leiomyosarcoma may occur at any age, and is much more common in females. The majority of the patients have thoracic symptoms. These neoplasms seem resistant to chemotherapy or radiotherapy and should be treated by radical resection whenever possible, which results in a 45% 5-year survival rate. Only seven cases of leiomyosarcoma and 12 cases of leiomyoma of the trachea have been reported. These usually cause respiratory obstruction and/or haemoptysis. The malignant as well as the benign tumour is probably best treated by complete surgical resection.

Percutaneous Tube Drainage: The Treatment of Choice for Refractory Lung Abscess

During the years 1978 to 1982, 48 patients with primary lung abscess were seen in the Sheba Medical Center in Israel. Seven of them (14%) did not respond to conservative treatment and were candidates for operation. All were successfully treated by percutaneous tube drainage initiated under local anesthesia, and all recovered completely. There were no relapses after a follow-up period of 2 to 5 years. During this period, we did not perform pulmonary resection for primary lung abscess. Three patients with malignant abscesses were also treated initially by transthoracic drainage but eventually required surgical intervention. We conclude that percutaneous transthoracic drainage is an efficient and safe mode of treatment, and we recommend transthoracic drainage as the treatment of choice for long-standing, refractory primary lung abscesses.

The human coronary microcirculation: An electron microscopic study

The ultrastructure of the terminal vascular bed of human coronary arteries was studied in the myocardial tissue obtained at surgery from different locations in the heart in five patients. The following vessels were identified: (1) Arterioles; slender and prolonged endothelial cells, flat nuclei and two to three layers of smooth muscle cells. (2) Precapillary sphincters: short endothelial cells, large nuclei bulging into the lumen, close myoendothelial junctions and a single layer of circular smooth muscle. (3) Capillaries: composed of one or more slender endothelial cells. (4) Venules: flat endothelial cells and nuclei, no muscular layer, rich collagen tissue. The function of these structures is believed to be as follows: the arterioles are the smallest blood-distributing arteries in the heart. The precapillary sphincters control blood flow to the capillaries; pressor substances present in the blood are picked up by endothelial cells, pass rapidly through the myoendothelial junctions and cause contractions of the smooth circular muscle layer; the bulging nuclei of endothelial cells then passively obstruct the lumen almost completely. The main exchange of gases and nourishing substances takes place in the capillaries. We postulate that in some pathologic conditions, abnormal constriction of the sphincters may cause diminished flow and be the basis for some well defined or unclear ischemic events.

Segmental study of the terminal coronary vessels in coarctation of the aorta: A natural model for study of the effect of coronary hypertension on human coronary circulation

An electron microscopic study of the coronary terminal circulation (starting with the small coronary arteries) was carried out on small pieces of myocardium operatively resected from the left ventricle on 11 patients with coarctation of the aorta. The patients were 4 to 20 years of age. Structural modifications were found in the small coronary arteries and arterioles. Two patterns of morphologic alterations were noted in these small resistance vessels. In the first pattern, seen in most of the children, the components of the arterial wall were still distinguishable, and well represented portions of smooth muscle layers were visualized together with muscle cells showing signs of degeneration and more or less widespread collagenous islets. The second pattern, seen in young adults, was characterized by a total collagenous transformation of the arterial wall. In contrast, the smaller microvessels (precapillary sphincter, metarterioles and capillaries) appeared free of pathologic change. It is postulated that the precapillary sphincters play a special protecting and regulating role in the coronary microcirculation in such cases with elevated coronary pressure. It is suggested that surgery should be performed at an early age to prevent further development of structural changes in the microvessels. The microcirculatory damage may contribute to the increased surgical mortality in patients with coarctation of the aorta operated on at a later age. These findings should trigger further research on the small coronary vessels in systemic hypertension.

Chondrosarcoma of the bronchus.

A primary chondrosarcoma of the right main bronchus was removed by pneumonectomy in a 74-year-old woman. The presenting symptoms were dyspnea and cough with a lung mass evident for 18 months. She is well and free of tumor 16 months later. Only eight established cases of primary chondrosarcoma arising from the lung, and four originating from the tracheobronchial tree have been previously described. The long preoperative history and the outcome so far confirm the relatively less aggressive character of the tracheobronchial as compared to the lung subdivision of primary pulmonary chondrosarcoma.

Fibrothorax associated with a ventriculopleural shunt in a hydrocephalic child

Ventriculopleural (VPL) shunts are considered a safe alternative to peritoneal shunts in the management of hydrocephalus. Occasionally, however, they are associated with persistent pleural effusion. We report a child, aged 3 1/2 years, who developed severe fibrothorax following the use of a VPL shunt. The shunt was removed and decortication had to be performed to alleviate his respiratory symptoms. This serious complication, never reported previously, should be borne in mind when the pleural cavity is chosen for deviation of the cerebrospinal fluid in hydrocephalic children.

Modified urinary collecting bags for prolonged underwater chest drainage

We describe a method by which a modified urinary collecting bag is used as part of a chest drainage system. This system is especially suitable for patients who require prolonged periods of drainage.

Prognosis of patients with adenocarcinoma of the lung and mediastinal lymph node metastases undergoing pulmonary resection

Of 57 patients who were operated on for adenocarcinoma of the lung during the period 1966-1970, 18 with mediastinal lymph node metastases successfully underwent potentially curative pulmonary resection combined with complete mediastinal lymph node dissection. The 5-year survival rate was nil. In light of this poor outlook, we do not recommend surgery as the primary treatment of choice in patients with adenocarcinoma of the lung and known mediastinal lymph node metastases.

Diffuse Lymphangioma with Intrathoracic Involvement

A case of a young girl with oligosymptomatic multiple cystic lesions of the chest is presented. The chest lesions were found on routine chest X-ray when she was admitted because of meningococcal meningitis. As the lesions increased in size, surgery was performed; the operative specimens were identified as lymphangioma. This is a rare disorder, which presents difficulties in diagnosis and treatment. Its benign nature is challenged by its tendency to recur and the need for repeated operations.