The Role of Resectional Surgery for the Treatment of Localized Multi-drug Resistant Pulmonary Tuberculosis / 결핵

BACKGROUND: Surgery may have a role when medical treatment alone is not successful in patients with multi-drug resistant (MDR) pulmonary tuberculosis (PTB). To document the role of resection in MDR PTB, we analyzed 4 years of our experience. METHODS: A retrospective review was performed on thirteen patients that underwent pulmonary resection for MDR PTB between May 1996 and February 2000. All patients had organisms resistant to many of the first-line drugs including isoniazid (INH) and rifampicin (RFP). RESULTS: The thirteen patients were 37.5±12.4 years old (mean±S.D.)(M:F=5:8), and their sputum was culture positive even with adequate medication for prolonged periods (109.7±132.0 months), resistant to 2-8 drugs including isoniazid and rifampin. All patients had localized lesion(s) and most (92.3%) had cavities. At least 3 sensitive anti-TB medications were started before surgery in all patients according to the drug sensitivity test. The preoperative FE1 was 2.37±0.83 L. Lobectomy was performed in 11 patients and pleuropneumonectomy in two. Postoperative mortality did not occur, but pneumonia occurred as a complication in one (7.7%). After 41.5±58.9 days (range 1~150 days) follow up, negative conversion of sputum culture was achieved in all patients within 5 months. Only one patient (7.7%) recurred 32 months after lung resection. CONCLUSION: When medical treatment alone is not successful, surgical resection can be a good treatment option in patients with localized MDR PTB.

Clinical Characteristics of Recurred Patients with Stage I ,II Non-Small Cell Lung Cancer / 결핵

BACKGROUND: Five year survival rate of postoperative stage I non-small lung cancer(NSCLC) reaches to 66%. In the remaining one third of patients, however, cancer recurs and overall survival of NSCLC remains dismal. To evaluate clinical and pathologic characteristics of recurred NSCLC, we studied patterns and factors for postoperative recurrence in patients with staged I, II NSCLC. METHOD: A retrospective analysis was performed in 234 patients who underwent radical resection for pathologic stage I, II NSCLC. All patients followed for at least one year were included in this study. RESULTS: 1) There were 177 men and 57 women. The median age was 63. The median duration of follow up was 732 days (range 365~1,695 days). The overall recurrence rate was 26.5% and the recurrence occurred at 358.8 +/- 239.8 days after operation. 2) The age of recurred NSCLC patients were higher (63.2 +/- 8.8 years) than that of non-recurred patients (60.3 +/- 9.8 years)(p=0.043). The recurrence rate was higher in stage II (46.9%) than in stage I (18.8%, p<0.001) NSCLC. The size of primary lung mass was larger in recurred (5.45 +/- 3.22 cm) than that of non-recurred NSCLC (3.74 +/- 1.75 cm, p<0.001). Interestingly, there were no recurrent cases when the resected primary tumors were less than 2cm. 3) Distant recurrence was more frequent than locoregional recurrence (66.1% vs. 33.9%). Distant recurrence rate was more frequent in female and adenocarcinoma. Brain metastasis was more frequent in patients with adenocarcinoma than squamous cell carcinoma (p=0.024). CONCLUSION: The tumor size and stage were two important factors for recurrence. Considering that distant brain metastasis was more frequent in patients with adenocarinoma, prospective study should follow to evaluate the effectiveness of preoperative brain imaging.

Clinical Features and Treatment Response in 18 Cases with Idiopathic Nonspecific Interstitial Pneumonia / 결핵

BACKGROUND: Nonspecific interstitial pneumonia (NSIP) has been reported recently to show much better response to medical treatment and better prognosis compared with idiopathic UIP. However, clinical characteristics of idiopathic NSIP discriminating from UIP have not been defined clearly. METHOD: Among 120 patients with biopsy-proven diffuse interstitial lung diseases between July 1996 and March 2000 at Samsung Medical Center, 18 patients with idiopathic NSIP were included in this study. Retrospective chart review and radiographic analysis were performed. RESULTS: 1) At diagnosis, 17 patients were female and average age was 55.2 +/-8.4 years (44~73 years). The average duration from development of respiratory symptom to surgical lung biopsy was 9.9+/-17.1 months. Increase in bronchoalveolar lavage fluid lymphocytes (23.0 +/-13.1%) was noted. On HRCT, ground glass and irregular linear opacity were seen but honeycombing was absent in all patients. 2) Corticosteroids were initially given to 13 patients of whom medication was stopped in 3 patients due to severe side effects. Further medical therapy was impossible in 1 patient who experienced streroid-induced psychosis. Herpes zoster (n=3), tuberculosis (n=1), avascu lar necrosis of hip (n=1), cataract (n=2) and diabetes mellitus (n=1) developed during prolonged corticosteroid administration. Of 7 patients receiving oral cyclophosphamide therapy, hemorrhagic cystitis hindered one patient from continuous medication. 3) After medical treatment, 14 of 17 patients improved and 3 patients remained stable (mean w-up ; 24.1+/-11.2 months). FVC increased by 20.2 +/-11.2% of predicted value and the extent of ground glass opacity on HRCT decreased significantly (15.7+/-14.7%). 4) Of 14 patients who had stopped medication, 5 showed recurrence of NSIP and 2 aggravated during steroid tapering. All patients with recurrence showed deterioration within one year after completion of initial treatment. CONCLUSION: Since idiopathic NSIP has unique clinical profiles and shows a good prognosis, differential diagnosis from UIP and aggressive medical treatment are needed.

Clinical differential diagnosis of usual interstitial pneumonia from nonspecific interstitial pneumonia / 결핵

BACKGROUND: Nonspecific interstitial pneumonitis (NSIP) is most likely to be confused with usual interstitial pneumonitis (UIP). Unlike patients with UIP, the majority of patients with NSIP have a good prognosis, with most patients improving after treatment with corticosteroids. Therefore it is clinically important to differentiate NSIP from UIP. UP to now, the only means of differentiating these two diseases was by means of surgical lung biopsy. American Thoracic Society (ATS) proposed a clinical diagnostic criterial for UIP to provide assistance to clinicians in its diagnosis without surgical lung biopsy. This study is aimed to investigate whether there were clinical and radiological differences between NSIP and UIP, and the usefulness of ATS clinical diagnostic criteria for UIP in Korea. METHODS: we studied 60 patients with UIP and NSIP confirmed by surgical lung biopsy. Clinical manifestations, pulmonary function test, arterial blood gas analysis, bronchoalveolar lavage (BAL), and high resolution computed tomography (HRCT) were evaluated and analyzed by Chi-square test or t-test. The clinical criteria for UIP proposed by ATS were applied to all patients with idiopathic interstitial pneumonia. RESULTS: Forty-two patients with UIP and 18 with NSIP were pathologically identified. Among the 18 patients with NSIP (M : F = 1 : 17), the mean age was 55.2± 8.4 (44~73)yr. Among the 42 patients with UIP (M : F = 33 : 9), the mean age was 59.5±7.1 (45~74) yr (p=0.0460. Fever was more frequent in NSIP (39%) (p=0.034), but clubbing was frequently observed in UIP (33%) (p=0.023). BAL lymphocytosis was more frequent (23%) (p=0.0001) and CD4/CD8 ratio was lower in NSIP (p=0.045). On HRCT, UIP frequently showed honeycomb appearance (36 of 42 patients) through not in NSIP (p=0.0001). Six of 42 UIP patients (14.3%) met the ATS clinical criteria for IPF, and 3 of 16 NSIP patients (18.8%) met the diagnostic criteria. CONCLUSION: Being a relatively young female and having short duration of illness, fever, BAL lymphocytosis, low CD4/CD8 ratio with the absence of clubbing and honeycomb appearance in HRCT increase the likelihood of the illness being NSIP. The usefulness of ATS clinical diagnostic criteria for UIP may be low in Korea.

Endobronchial Leiomyoma: A Case Report / 대한흉부외과학회지

Endobronchial leiomyoma is extremely rare and accounts for less than 2% of benign tumors of the lower respiratory tract. Leiomyomas are predominantly found in the young and the middle aged : of the average age being 35 years for bronchial and lung parenchymal lesions and 40.6 years for tracheal lesions. The symptom depends on the location of the tumor, its size, and changes in the lung distal to the lesion. A 37-year-old woman was admitted to our hospital complaining of coughing. Bronchoscopy revealed complete obstruction of the right main bonchus at the carina by an oval-shaped, nonulcerative, smooth, and pinkish-tan tumor with a broad margin and extended to the left main bronchus. A biopsy was performed and showed a benign spindle cell tumor. A right pneumonectomy was performed because of chronic infection, and the lung could not expanded during aeration. The histological diagnosis of the resected specimen was leiomyoma. The postoperative course was uneventful.

A Case with Severe Bone Disease Due to Primary Hyperparathyroidism Caused by Parathyroid Chief Cell Hyperplasia / 대한내과학회지

The routine screening of patients for hypercalcemia has increased the incidence of hyperpa-rathyroidism, But, Primary hyperparathyroidism is relatively rare disease in korea. Especially, primary hyperparathyroidism caused by parathyroid chief cell hyperplasia has not been reported. The numbers of patients with bone disease, renal stones, other severe complication has declined, but the numbers of patients with psychiatric and neuromuscular disturbance or with asymptomatic disease has increased. We experienced a case with severe bone diseases due to primary hyperparathyroidism caused by parathyroid chief cell hyprepiasia which was confirmed through the mearsurement of serum calcium and parathyroid hormone, neck CT scanning and surgical exploration and which was managed by total parathyroidectomy with autotransplantation.