Yener Yoruk

Recurrent solitary fibrous tumor of the pleura: significant response to radiotherapy

Solitary fibrous tumor (SFT) of the pleura is an uncommon neoplasm with non-specific symptoms and non-pathognomonical radiological findings. Surgery allows establishment of a definitive diagnosis as well as a cure of the disease. The role of radiotherapy or chemotherapy in the management of the disease is unclear because of the rarity of the disease and the successful results of the surgical treatment. Long-term clinical follow-up may be useful for the patients with SFT because of the potential adverse biological behavior of this tumor, which may lead to repeated recurrences and/or malignant transformation. We reported a 66-year-old woman with recurrence of SFT in the right lung, which had significant response to external thoracic radiotherapy.

Multifocal mesenchymal hamartoma of the chest wall

Abstract:  Chest wall hamartomas are extremely rare. Frequently mesenchymal hamartomas are presented as a single mass and contain some primitive mesenchymal elements such as chondroid and trabecular bone structures. A 60‐year‐old man presented to hospital with chest pain. Thirteen years earlier, his CXR and thoracic CT showed three masses on the right and two masses on the left, but he had not received any treatment thereafter. His CT showed the same masses present 13 years earlier, but they were bigger and right thoracotomy was undertaken. At thoracotomy, two sections of the mass in the right posterior mediastinum and one section of the mass in the right apex were excised. They had an occasional bloody appearance and contained small cystic areas, and some areas were extremely hard. Microscopic examination showed that the lesions consisted of mature adipose tissue, a large number of veins of different diameters and collagen tissue. Besides, primitive mesenchymal elements, lymphoid cell accumulations and trabecular bone structures were seen focally. Bilateral chest wall hamartomas are extremely rare and may be confused with malignancy.

A patient with ankylosing spondylitis who presented with chronic necrotising aspergillosis : Report on one case and review of the literature

Upper lobe fibrobullous disease is a well-known finding in advanced stages of ankylosing spondylitis (AS). In this report, we present a 57-year-old male patient who was diagnosed with a right apical cavitary lesion after coming to us with the complaint of haemoptysis. The patient underwent upper lobe segmentectomy and an aspergilloma was detected. Histologic findings were in favour of necrotising Aspergillus pneumonia. It was interesting that the patient had not been diagnosed with AS before and presented initially with chronic necrotising Aspergillus pneumonia. In the literature, there are recently published series of pulmonary high-resolution computed tomography (HRCT) in AS which claim that parenchymal abnormalities are quite frequent. Although the clinical significance of these abnormalities is not known with certainty, it has been reported that they might be seen even in early-stage patients. It is suggested that the pulmonary involvement in AS might be affected by mechanical factors related to limitation of motion of the thoracic cage and also by parenchymal inflammation. Here, we review the series of pulmonary HRCT in AS patients.

Transaxillary Approach for Thoracic Outlet Syndrome: Results of Surgery

BACKGROUND Thoracic outlet syndrome (TOS) is one of the most complicated diseases in thoracic surgery with regard to both diagnosis and treatment. Surgical removal of the first rib and cervical rib, if present, has been suggested as the treatment of choice in patients who do not benefit from physiotherapy. In this retrospective study, our surgical experience with TOS and the management of surgical complications are presented. METHODS A total of 109 cases with the diagnosis of TOS were operated on between January 1995 and April 2010. Ninety-five of the cases were females (87.2 %) and 14 (12.8 %) were males with a mean age of 35.7 (16-58). RESULTS A total of 131 operations were performed, of which 21 were bilateral and one was a recurrent operation. The diagnosis was neurogenic TOS in 107 (98.2 %) and vascular TOS in two (1.8 %) patients. All neurogenic TOS operations were performed via the transaxillary route. A posterior thoracoplasty approach was used for recurrent TOS in one case. A total of 23 (21.1 %) cases had a cervical rib. Fibromuscular bands were observed in 68 (62.3 %) cases. The rates for favorable and poor surgical outcome were 125 (95.4 %) and 6 (4.6 %), respectively. The most common complication was apical pneumothorax in 32 (24.6 %) cases, followed by wound infection in four (3 %), lymphatic leak, axillary hematoma and mild brachial plexus traction palsy in one (0.8 %) case. Mortality was not observed. CONCLUSIONS In our experience the exposure provided by the transaxillary approach is safe and superior to that offered by other approaches as it allows a wide range of surgical applications such as first rib resection, cervical rib resection and resection of fibrotic bands.

Transabdominal subcostal approach in surgical management of Morgagni hernia

OBJECTIVE Morgagni hernia is an uncommon type of diaphragmatic hernias whose pathophysiology is not clear. We aimed to retrospectively evaluate morbidity, mortality, and treatment outcomes in 13 cases of Morgagni hernia treated with the subcostal approach. MATERIAL AND METHODS Between 1993 and 2009, 13 patients with Morgagni hernia were operated in our department. Of the 13 patients with a median age of 65 years (range: 13-78), 12 were female. Chest roentgenograms, thorax computed tomography (CT), and barium enema roentgenographic studies were used as diagnostic utilities. The contents of the hernia, as diagnosed with CT and confirmed at surgery, were omentum and colon in all patients. RESULTS All the patients were operated electively except one patient on ventilation treatment. Transabdominal repair with the subcostal approach was performed in all patients. There was no operative morbidity and mortality. The median hospital stay was 8 days (range: 6-14 days). There was no recurrence during the follow-up of 48.8 months (1-132 months). CONCLUSION We recommend the transabdominal subcostal approach in patients with Morgagni hernia for surgical exposure, easy repair of the hernia sac, and low morbidity.

A comparison of thoracic or lumbar patient-controlled epidural analgesia methods after thoracic surgery

BackgroundWe aimed to compare patient-controlled thoracic or lumbar epidural analgesia methods after thoracotomy operations.MethodsOne hundred and twenty patients were prospectively randomized to receive either thoracic epidural analgesia (TEA group) or lumbar epidural analgesia (LEA group). In both groups, epidural catheters were administered. Hemodynamic measurements, visual analog scale scores at rest (VAS-R) and after coughing (VAS-C), analgesic consumption, and side effects were compared at 0, 2, 4, 8, 16, and 24 hours postoperatively.ResultsThe VAS-R and VAS-C values were lower in the TEA group in comparison to the LEA group at 2, 4, 8, and 16 hours after surgery (for VAS-R, P = 0.001, P = 0.01, P = 0.008, and P = 0.029, respectively; and for VAS-C, P = 0.035, P = 0.023, P = 0.002, and P = 0.037, respectively). Total 24-hour analgesic consumption was different between groups (175 +/- 20 mL versus 185 +/- 31 mL; P = 0.034). The comparison of postoperative complications revealed that the incidence of hypotension (21/57, 36.8% versus 8/63, 12.7%; P = 0.002), bradycardia (9/57, 15.8% versus 2/63, 3.2%; P = 0.017), atelectasis (1/57, 1.8% versus 7/63, 11.1%; P = 0.04), and the need for intensive care unit (ICU) treatment (0/57, 0% versus 5/63, 7.9%; P = 0.03) were lower in the TEA group in comparison to the LEA group.ConclusionsTEA has beneficial hemostatic effects in comparison to LEA after thoracotomies along with more satisfactory pain relief profile.

Sentinel lymph node mapping in patients with operable non-small cell lung cancer

BACKGROUND The aim of this study was to determine the accuracy and the role of the sentinel lymph node (SLN) in patients with non-small cell lung cancer. MATERIAL AND METHOD This study was carried out on 25 consecutive patients [M/F=23(:)2, mean age 62.84 (47-81) years] with operable non-small cell lung cancer (NSCLC). At thoracotomy, 0.25 mCi of Technecium(99m) (99mTc) nanocolloid was injected into each quadrant of lung tissue surrounding the tumor. Before resection scintigraphic measurements of lymph nodes were obtained in vivo and ex vivo using a hand-held gamma probe counter and the findings were compared with histological examination. SLN was defined as the node with the highest count rate. RESULTS SLNs were identified in 23 of 25 patients (92%) with a total number of 52 SLNs. Seven of 52 (13%) of these SLNs were positive for metastatic involvement after histological and immunohistochemical examination. In two patients (8%), SLNs could not be found. The sensitivity and specificity were 55% and 86% respectively. CONCLUSIONS This technic is a good method for identifying the first site of potential nodal metastases of NSCLC. These preliminary results demonstrate this procedure is feasible, but the detection rate has to be improved.

Self-expandable esophageal stents placement for the palliation of dysphagia as a result of lung cancer.

We report our experience with self-expandable metallic stents for the palliation of malignant dysphagia and tracheoesophageal fistulae caused by lung cancer. Esophageal self-expandable metallic stents were deployed in 28 patients with malignant dysphagia as a result of lung cancer between August 2002 and January 2009. Mean age was 62.1 (42-77) with 26 male patients. Twenty-three patients received previous chemo-radiotherapy and two had pneumonectomy. Tracheoesophageal fistulae were coexisting in eight patients. Stents were inserted under fluoroscopic control over guide-wire with the patient under conscious sedation. One stent was used in all patients except one fistula patient with two stents. Immediate improvement after stent insertion was seen in all patients. Fistulae were sealed off in all. No complication was seen except transitional pain in 12 patients (42%). During the follow-up, all patients remained asymptomatic with no clinical appearance of dysphagia symptoms except one patient whom gastrostomy was applied. All patients with fistulae died with a mean survival of 15.4 weeks. Dysphagia patients without fistulae died with mean survival of 6 months except one patient with 1 month follow-up. Self-expandable esophageal metallic stent insertion can manage malignant dysphagia in lung cancer patients with significant survival period via nonsurgical approach.

THE CORRELATION BETWEEN TTF-1 IMMUNOREACTIVITY AND THE OCCURRENCE OF LYMPH NODE METASTASES IN PATIENTS WITH LUNG CANCER

Aims and background Thyroid transcription factor (TTF-1) is a tissue-specific transcription factor expressed in the epithelial cells of thyroid and lung. The aim of this study was to evaluate the relationship between the expression of TTF-1 and clinicopathological parameters in pulmonary adenocarcinoma and adenosquamous carcinoma. Methods Resection material of pneumonectomies and lobectomies of 39 patients was retrospectively examined. Twenty-eight patients were diagnosed with adenocarcinoma and 11 with adenosquamous carcinoma. Tumors were classified into 3 groups: a strongly positive group (++) with ‡50% tumor cells positive for TTF-1; a weakly positive group (+) with 1–49% positive tumor cells; and a negative group (-) with less than 1% or no positive tumor cells. Analysis was performed with Kaplan-Meier estimates and log-rank tests. Results Staining for TTF-1 was negative in 10 cases. There was focal staining in 9 cases, while there was diffuse staining in 20 (51%) cases out of 39, and 15 (75%) of these were adenocarcinomas. There was a statistically significant association between TTF-1 and lymph node metastases (P = 0.029). No relationship was found between TTF-1 positivity and disease-free and overall survival. Conclusions TTF-1 expression may be a predictor of lymph node metastases. Additional work in a larger group of patients is needed to better assess the utility of this marker.

Massive Bochdalek diaphragmatic hernia in adult with hypoplastic lung

Bochdalek diaphragmatic hernia is generally congenital and rarely diagnosed incidentally in adults. A 21-year-old man presented with a diaphragmatic hernia suspected during routine examination. Chest radiography showed the colon and small intestine herniating into the left hemithorax and the ileocecal appendix in the superior thoracic apertura. We performed a thoracoabdominal incision and the stomach, omentum, colon, and small intestine were retracted back into the abdomen. The diaphragm was repaired with Prolene mesh following adhesiolysis. Two months later, there was no recurrence but no lung expansion. The space was filled with effusion, but the patient had no complaints.