A Case of Pulmonary Blastomycosis Mimicking Pulmonary Tuberculosis / 결핵및호흡기질환

Blastomyces dermatitidis is a dimorphic fungus that causes the systemic pyogranulomatous disease known as blastomycosis. Blastomycosis most often involves the lungs, skin, and may involve nearly every organ in the body. It is difficult, however, to diagnose blastomycosis in the early stage of pulmonary disease because clinical manifestations are varied from subclinical infection to acute respiratory distress syndrome. Since blastomycosis is often accompanied by granulomatous inflammation in histopathologic findings, differentiation from other etiologic diseases is important. We report a case of a 45-year-old male with pulmonary blastomycosis who had been misdiagnosed with tuberculosis for 3 months.

Outcomes of the Initial Surgical Treatment without Neoadjuvant Therapy in Patients with Unexpected N2 Non-small Cell Lung Cancer / 대한흉부외과학회지

BACKGROUND: Preoperative chemotherapy has been adopted in our hospital as a standard treatment for non-small cell lung cancer patients with N2 disease. However, there have been cases of pathologic N2 disease that have been detected after curative-intent surgical resection. We retrospectively studied the outcomes of initial surgical treatment without neoadjuvant therapy in patients with unexpected N2 non-small cell lung cancer. MATERIAL AND METHOD: Between January 1995 and June 2007, 225 patients were diagnosed with pathologic N2 disease after they underwent initial pulmonary resection without neoadjuvant therapy. Among them, 170 patients were preoperatively diagnosed with lymph node stage N0 or N1. We retrospectively reviewed their medical record and analyzed the outcomes. RESULT: The overall 5-year survival rate was 35.4%. The prognostic factors that were significantly associated with survival were no adjuvant therapy, histologic cell types other than adenocarcinoma or squamous cell carcinoma, a pathologic T stage more than T1, old age (> or =70 years) and no mediastinoscopic biopsy. During the follow-up, 79 patients (46.5%) experienced tumor recurrence, including loco-regional recurrence in 20 patients (25.3%) and distant metastasis in 56 (70.9%). The 5-year recurrence-free survival rate was 33.7%. CONCLUSION: Based on our findings, the survival was good for patients with unexpected N2 non-small cell lung cancer and who underwent initial pulmonary resection without neoadjuvant therapy. A prospective comparative analysis is needed to obtain more conclusive and persuasive results.

Pulmonary Embolectomy for Treatment of Pulmonary Embolism / 대한흉부외과학회지

BACKGROUND: The treatment of acute pulmonary embolism is difficult, and it can be lethal when cardiogenic shock is involved with major pulmonary embolism. In the past, pulmonary embolectomy was considered as the last choice for patients with pulmonary embolism. Accordingly, we analyzed our experience with seven cases of pulmonary embolectomy as an alternative option for the early treatment of pulmonary embolism. MATERIAL AND METHOD: A retrospective analysis of medical charts of all patients who underwent pulmonary embolectomy at our hospital over the past eight years was performed. The patients were observed during their hospital stay and followed until their last visit to the outpatient department. RESULT: Among 7 patients (4 men and 3 women), 4 had massive pulmonary embolism, and 3 had submassive pulmonary embolism. An extracorporeal membrane oxygenator was inserted in 3 patients before surgery. There was no mortality, and postoperative echocardiography showed no pulmonary hypertension in 6 patients. CONCLUSION: Pulmonary embolectomy can be performed with minimal mortality. We think that the use of an extracorporeal membrane oxygenator in patients with cardiogenic shock before surgery improves survival.

Effect of the Neutrophil Elastase Inhibitor on Acute Lung Injury after Pulmonary Resection for Lung Cancer: A Preliminary Study / 대한구급학회지

BACKGROUND: Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are the leading causes of death after lungresection. Neutrophil elastase is thought to be an important mediator in the pathogenesis of ALI. Sivelestat is a new neutrophil elastase inhibitor which may improve the outcome in patients with ALI/ARDS after lung resection. The objective of this study was to determine whether or not sivelestat can reduce mortality in patients with ALI after pulmonary resection for lung cancer. METHODS: This study was a retrospective case-control study of twenty three patients who developed ALI/ARDS within seven days of lung resection for lung cancer. The control group (n = 12) received standard care, while the sivelestat group (n = 11) received a continuous infusion of sivelestat (0.2 mg/kg/hr) for seven days in addition to standard care. RESULTS: There was no significant difference in the baseline characteristics between the control and sivelestat groups, except for heart rate. Six of twelve patients (50%) in the control group survived, while seven of twelve patients (64%) survived in the sivelestat group (p = 0.34). There was also no significant difference between the two groups in the progression to ARDS. In the sivelelestat group, survivors had lower APACHE II and SOFA scores than the patients in the control group. CONCLUSIONS: There was no additional effect of a neutrophil elastase inhibitor in the treatment of ALI after pulmonary resection for lung cancer.

Pulmonary Resection for Metastases from Colorectal Cancer: Prognostic Factors and Survival

PURPOSE: Pulmonary metastases occur in up to 10% of all patients who undergo a curative resection for colorectal cancer. Surgical resection is an important part in the treatment of pulmonary metastasis from colorectal cancer. We analyzed the treatment outcome and the prognostic factors affecting survival in this subset of patients. METHODS: Between October 1994 and December 2004, 59 patients underwent a curative resection for pulmonary metastases from colorectal cancer. Uncontrollable synchronous liver and lung metastasis or synchronous colorectal cancers with isolated lung metastasis were excluded from this study. A retrospective review of the patients' characteristics and of factors influencing survival was performed. Survival was analyzed by using the Kaplan-Meier method. Comparisons between the groups were performed by using a log-rank analysis and the Cox proportional hazard model. RESULTS: The 5-year overall survival rate of all patients who received a pulmonary resection was 50.3%. The number of pulmonary metastases was significantly related with survival (P=0.032). A pre-thoracotomy CEA level exceeding 5 ng/ml was related with poor survival (P=0.001). A disease- free interval of greater than 2 years did not correlate with survival after a thoracotomy (P=0.3). CONCLUSIONS: The pre-thoracotomy CEA level and the number of metastases were independent prognostic factors. Resection of a pulmonary metastasis from colorectal cancer may result in improved survival or even cure in selected patients. A pulmonary resection of colorectal cancer is regarded as a safe and effective treatment with low morbidity and mortality rates.

Prognosis of Non-Small Cell Lung Cancer with Synchronous Brain Metastases Treated with Gamma Knife Radiosurgery

The clinical outcome and prognostic factors of patients with synchronous brain metastases from non-small cell lung cancer (NSCLC) who were treated with gamma knife radiosurgery (GKS) were analyzed. A total of 35 patients with NSCLC underwent GKS as an initial treatment for metastatic brain lesions of synchronous onset. The period of survival and various prognostic factors such as age, gender, performance status, multiplicity of the brain lesions, intracranial tumor volume, and extent of the primary tumor were analyzed. The overall median survival time for this series was 12 months (range 0.75 to 43 months) from the diagnosis. Of the 21 patients who were no longer alive at the conclusion of this study, only 7 (33.3%) died of neurological causes. Multivariate analysis of these data revealed that N stage, whole-brain radiotherapy (WBRT), and chemotherapy were significant predictors for survival (p<0.05). Survival of patients with NSCLC and synchronous brain metastases is mainly dependent upon the progression of the systemic disease, provided that the cerebral lesions are treated adequately with local treatment modalities including radiosurgery. Application of radiosurgery as an initial treatment option and aggressive local and systemic modalities to control extracranial disease may improve survival.

The Successful Application of Nuss Procedures with Modified Operative Technique / 대한흉부외과학회지

BACKGROUND: Nuss procedure is a minimally invasive technique for correcting the pectus excavatum. But there are some limitations of correcting the complex anomaly or grown-up patients. MATERIAL AND METHOD: we retrospectively reviewed 135 consecutive patients who underwent repair of pectus excavatum by the Nuss procedure and its modifications between November 1999 and December 2004. We analyzed the computed tomography, age on operation, operative technique, and complications. RESULT: We operated 135 patients of pectus excavatum during 62 months. Total number of operations about Nuss procedure is 216, including bar removal procedure of 64 cases, redo Nuss procedures of 17 cases. We modified the point of bar insertion to the hinge point, made a shoulder in the bar to prevent a displacement. And then we changed the fixation material from Vicryl to steel wire. If the patients are old, we retract the sternum during bar rotation and fixation. Until 2002, the number of redo Nuss operations were 17, complications were 23. but, after modifications, the number of redo Nuss operation were 0, complications were 2. CONCLUSION: This result indicates that our modifications of Nuss operation is effective, and could decrease the number of redo Nuss operation and complications.

Rounded Atelectasis: A Brief Case Report

Rounded atelectasis is a focal, pleural-based lesion that is the result of pleural and subpleural scarring and atelectasis of the adjacent lung tissue. We experienced a case of asbestosassociated rounded atelectasis that had developed in a 50-year-old male. When examined with routine chest radiography, the patient was shown to have an asymptomatic chest mass.Computed tomography showed a pleural-based mass with a curvilinear shape about 4.2 cmin greatest diameter in the medial basal segment of the right lower lobe. To exclude the possibilityof malignancy the mass was excised by video-assisted thoracotomy. The mass wasround and firm, and was gray and yellow in color. Microscopically, marked pleural fibrosisextended into the underlying lung parenchyme and then resulted in atelectasis. There areferruginous bodies in dense fibrous pleura.

Mediastinal Parathyroid Cyst

The mediastinal parathyroid cyst is a very rare cause of space occupying lesions in the mediastinum.We report a case of a non-functioning mediastinal parathyroid cyst that occurred ina 42 year-old male. He suffered from foreign body sensation of the throat whenever he wasin the supine position. A chest computed tomography showed a round cyst with a narrowbase attached to trachea. It was white and tan, thin-walled semi-transparent cyst containingyellow and tan serous fluid. Microscopically it was characterized by a thin fibrous wall linedwith a single or double layer of uniform cells with clear cytoplasm and small nuclei. The liningcells were immunopositive for chromogranin A.

A Case Report of a Bronchogenic Cyst Misconceived to Lung Cancer / 결핵

Bronchogenic cysts are generally presented as a well defined mass that have thin and smooth wall in the intrapulmonary or mediastinal area by simple chest radiographs. We present the case of a 20-year-old man with a ill-defined left upper lobe mass, found by chest radiographs. At the preoperative examinations, chest computed tomography showed ill-defined mass with Hounsfield Number 26, and nonspecific findings were shown by the bronchoscopy and percutaneous needle aspiration. The patient was undertaken the left upper lobectomy. The surgical specimen contained a ill-defined mass, measuring 2x3 cm. On the section of the mass, a cyst containing dark brown thick materials was noted. The cyst was unilocular, and the wall showed a trabeculation. Microscopically, the cystic mass was lined with ciliated pseudostratified columnar epitheliums and surrounded by smooth muscle and cartilage.

Postoperative Radiation Therapy for Chest Wall Invading pT3N0 Non-small Cell Lung Cancer: Elective Lymphatic Irradiation May Not Be Necessary / 대한방사선종양학회지

PURPOSE: No general consensus has been reached regarding the necessity of postoperative radiation therapy (PORT) and the optimal techniques of its application for patients with chest wall invasion (pT3cw) and node negative (N0) non-small cell lung cancer (NSCLC). We retrospectively analyzed the pT3cwN0 NSCLC patients who received PORT because of presumed inadequate resection margin on surgical findings. MATERIALS AND METHODS: From Aug. 1994 till June 2000, 21 pT3cwN0 NSCLC patients received PORT at Samsung Medical Center; all of whom underwent curative en-bloc resection of the primary tumor plus the chest wall and regional lymph node dissection. PORT was typically started 3 to 4 weeks after operation using 6 or 10 MV X-rays from a linear accelerator. The radiation target volume was confined to the tumor bed plus the immediate adjacent tissue, and no regional lymphatics were included. The planned radiation dose was 54 Gy by conventional fractionation schedule. The survival rates were calculated and the failure patterns analyzed. RESULTS: Overall survival, disease-free survival, loco-regional recurrence-free survival, and distant metastases-free survival rates at 5 years were 38.8%, 45.5%, 90.2%, and 48.1%, respectively. Eleven patients experienced treatment failure: six with distant metastases, three with intra-thoracic failures, and two with combined distant and intra-thoracic failures. Among the five patients with intra-thoracic failures, two had pleural seeding, two had in-field local failures, and only one had regional lymphatic failure in the mediastinum. No patients suffered from acute and late radiation side effects of RTOG grade 3 or higher. CONCLUSION: The strategy of adding PORT to surgery to improve the probability, not only of local control but also of survival, was justified, considering that local control was the most important component in the successful treatment of pT3cw NSCLC patients, especially when the resection margin was not adequate. The incidence and the severity of the acute and late side effects of PORT were markedly reduced, which contributed to improving the patients' quality of life both during and after PORT, without increasing the risk of regional failures by eliminating the regional lymphatics from the radiation target volume.

The Usefulness and Safety of Natural Stent in a Canine Model of Tracheal Stenosis / 결핵

BACKGROUND: In order to investigate the usefulness and safety of Natural Stent, we performed this study in a canine model of tracheal stenosis induced using Nd-YAG laser. METHODS: After tracheal stenosis was induced in 12 Mongrel dogs using Nd-YAG laser, either Dumon (n=6) or Natural (n=6) stent was inserted into the trachea. To assess the degree of stent migration and mucostasis, bronchoscopy was performed every week for 4 weeks, after which all stents were removed. One week after stent removal, tracheal stenosis was evaluated by bronchoscopy. RESULTS: The degree of stent migration was not different between the dogs with Dumon stent (3.0+/-0.8) and those with Natural (2.0+/-1.0), nor was the degree of mucostasis, at Dumon (1.7+/-0.5) and Natural Stent (1.5+/-0.6), respectively. One week after stent removal, the degree of tracheal stenosis was not different between the Dumon (1.5+/-0.5) and the Natural group (1.0+/-0.4). In addition, there was no death and the degree of tracheal stenosis remained always within the safe limit (less than 2.0) in all animals. CONCLUSION: In a canine model of tracheal stenosis induced using Nd-YAG laser, the usefulness and safety of Natural Stent were similar to those of Dumon Stent. A clinical trial is necessary to document the usefulness and safety of Natural Stent in patients with tracheal stenosis.

A Canine Model of Tracheal Stenosis Using Nd-YAG Laser / 결핵

BACKGROUND: Tracheal stenosis is an urgent but uncommon disease. Therefore, primary care clinicians have limited clinical experience. Animal models of a tracheal stenosis can be used conveniently for the learning, teaching, and developing new diagnostic and therapeutic modalities for tracheal stenosis. Recently, a canine model of a tracheal stenosis was developed using a Nd-YAG laser. To describe the methods and results of developed animal model, we performed this study. METHODS: Six Mongrel dogs were generally anesthetized and the anterior 180 degree of tracheal cartilage of the animal was photo-coagulated using a Nd-YAG laser. The animals were bronchoscopically evaluated every week for 4 weeks and a pathologic evaluation was also made. RESULTS: Two weeks after the laser coagulation, the trachea began to stenose and the stenosis progressed through 4 weeks. All animals suffered from shortness of breath, wheezing, and weight loss in the 3 weeks after the laser treatment, and two died of respiratory failure just before the fourth week. The gross pathologic findings showed the loss of cartilage and a dense fibrosis, which resulted in a fibrous stricture of the trachea. Microscopy also showed that the fibrous granulation tissue replaced destroyed cartilage. CONCLUSION: The canine model can assist in the understanding and development of new diagnostic and therapeutic modalities for tracheal stenosis.

Cavitating Adenocarcinoma and Squamous Cell Carcinoma in the Same Lobe of the Lung / 대한흉부외과학회지

Synchronous primary lung cancers in the same lobe are rare. Cavitating adenocarcinoma as single lung lesion is unusual. We experienced cavitating adenocarcinoma and squamous cell carcinoma in the same lobe of the lung. The patient was a 64-year-old male with chief complaints of hemoptysis. CT scan showd a central mass in right upper lobar bronchus, obstructive pneumonia, and lung abscess in the right upper lobe. Pathologically, the central mass was a 2.3x1x1 cm sized squamous cell carcinoma, and lung abscess was revealed as a 3x2x2 cm sized adenocarcinoma. The patient was discharged without any specific problem after right peumonectomy.

The Effect of Less Invasive Methods with VATS in the Management of Descending Necrotizing Mediastinitis / 대한흉부외과학회지

Although the incidence of descending necrotizing mediastinitis(DNM) is low, this is a serious disease because it"s mortality have been reported to be as high as 40~50%. Currently, many authors have emphasized aggressive surgical approaches rather than medical treatment alone. We report good results in 2 DNM patients treated by less invasive approach with video-assisted thoracoscopic surgery. Less invasive methods with video-assisted thoracoscopic surgery can reduce hospital stay and morbidity if effective drainage can be achieved in selected DNM patients.

Role of Flexible Fiberoptic Bronchoscopy in the Diagnosis of Childhood Endobronchial Tuberculosis / 소아알레르기및호흡기학회지

Endobrochial tuberculosis which may result in stenosis of the bronchus, is a rare complication of pulmonary tuberculosis in children. We recently treated three children with endobronchial tuberculosis which presented different clinical manifestations and different response to the treatments. Endoscopic examinations revealed bronchial masses, in which biopsy and polymerase chain reaction(PCR) were consistent with endobronchial tuberculosis. We reviewed the presentation and treatment of endobronchial tuberculosis in 3 children.

Resistance to Cisplatin Renders High Metastatic Potential in Human Non-Small Cell Lung Cancer Cell Line / 대한흉부외과학회지

BACKGROUND: Resistance to cytotoxic drugs such as cisplatin is an important cause of treatment failure in lung cancer. The mechanisms are omplex and have yet to be clearly elucidated, but the acquisition of drug resistance possibly has resulted in poor survival. The purpose of the study is to evaluate whether the resistant tumor cells would gain more potential for metastasis. MATERIAL AND METHOD: we examined the metastatic potential of a cisplatin-reisistant cell line, H460/CIS, which was established from the human lung cancer cell line H460 by in vitro selection with gradually increased concentration of cisplatin. The parental cisplatin-sensitive cell line(H460) was used as the control and analysis on the expression of angiogenesis or growth-related factors, gelatin zymographic analysis and in vivo spontaneous metastatic experiment in nude mice were done. RESULT: Increased levels of vascular endothelial growth factor(VEGF) and basic fibroblast growth factor (bFGF) were found in H460/CIS. Gelatin zymographic analyses showed that proteinase A in the culture medium of H460/CIS was processed from latent to activated form. The in vivo experiment showed that H460/CIS cells spontaneously metastasized to the lungs but parental cells did not. CONCLUSION: resistance to the chemotherapeutic agents may render the tumor aggressi-veness and metastatic potential. Therefore, the risk, rather than benefit, from inadvertent application of adj uvant or neoadj uvant chemotherapy to early-staged lung cancer should be considered.

Giant Thymic Hyperplasia in Children: 1 case report / 대한흉부외과학회지

Giant thymic Hyperplasia is a rare lesion in children. We report a case of giant thymic hyperplasia in the right anterior mediastinum in a 2 year-old male patient. Presenting symptom was frequent cough and sputum, plain chest X-ray and computed tomography showed huge mass in the right anterior mediastinum. The tumor resection was done through a median sternotomy for the prevention of progression to atelectasis caused by mass effect and tissue diagnosis. An open biopsy specimen showed normal thymic architecture. The patient recovered without any problem and is doing well untill now. We report this rare case of giant thymic hyperplasia with review of the literature.

Analysis of Risk and Benefit of Open Lung Biopsy in Severe Immunocompromised Patients with Pulmonary Complications / 대한흉부외과학회지

BACKGROUND: Pulmonary complications in immunocompromised patients are often fatal. Empirical treatment is usually applied based on the clinical and radiological findings because of the risk of the aggressive diagnostic procedures such as open lung biopsy. However, recent advancements in operative procedures and perioperative management has decreased the procedure-related risks. We have prospectively analyzed the risks and benefits of the early application of open lung biopsy in such patients. MATERIAL AND METHOD: Forty-two consecutive immunocompromised patients with critical pulmonary complications were included from June, 1996 to December, 1999. The definition of the immunocompromised is as those with chemotherapy and/or other modality for hematologic disorders, with usage of immunosuppressive drug after transplantation, with usage of steroid for more than 1 month, and with primary immunodeficiency disorders. The indication of open lung biopsy was those with no significant improvement after a week of aggressive application of empirical treatment or with rapidly aggressive process. The underlying disease included hematologic disorder(31 patients), post-transplantation(3 patients), chemotherapy for solid tumor(2 patients), and others(6 patients). Operations were done through thoracotomy(conventional or mini-) or VATS. RESULT: One patient died on the first postoperative day and seven patients died in the hospital after the operation but none was related to the operation. Preoperative usage of steroid and preoperative mechanical ventilator-dependency was significantly related to the in-hospital mortality but the other factors such as thrombocytopenia and neutropenia had no relation to the in-hospital mortality. There was no major or minor surgical complication except for prolonged air leak(1 patient). Postoperative diagnosis included infectious diseases (26 diagnoses; fungal, 20; pyogenic bacteria, 3; mycobacteria, 2; viral, 1), inflammatory disorders(6 diagnoses), malignancy(2 diagnoses), and nonspecifically-defined disorders(13 diagnoses). In 35 patients(81.4%) treatment plans were changed after open lung biopsy and 30 patients(69.8%) improved after change of treatment. CONCLUSION: Open lung biopsy in immunocompromised patients with pulmonary complications can be done with acceptable risk and significant benefit. For accurate diagnosis, adequate treatment, and better prognosis, the early application of open lung biopsy should be considered when the empirical treatment does not improve the patient's condition.

Congenital Cystic Adenomatoid Malformation of the Lung: Analysis of 17 Cases / 소아알레르기및호흡기학회지

PURPOSE: Congenital cystic adenomatoid malformation of the lung(CCAM) is characterized by an excessive overgrowth of terminal bronchiolar-type structures with a lack of mature alveoli. This study was performed to evaluate the manifestation among different pathologic classification. METHODS: Seventeen patients admitted to the Samsung Medical Center from January 1995 to June 2000, were investigated for their clinical characteristics, radiologic findings, timing of treatment and post-operative outcome in each type. RESULTS: 1) Seven patients have type 1, while 9 cases were type 2. One case was diagnosed as having mixed type. Mean ages at diagnosis are 7 years 4 months. 2) 4 cases had experienced respiratory diseases that are pneumonia(3 cases), empyema(2 cases) and lung abscess(2 cases). 3) The most common clinical manifestations are fever and cough, followed by chest pain, dyspnea, cyanosis, weak crying and moaning. 4) The left lung(10 cases), especially left lower lobe(8 cases) is involved more frequently than right lung. 5) Associated anomalies are pulmonary sequestration, pectus excavatum, diaphragmatic hernia. 6) All lesions were surgically removed and all of patients survived. In our cases, there was no difference in outcome by age at operation. CONCLUSION: In this study, CCAM show various clinical manifestations, and the outcome is good irrespective of their pathologic type and age at operation. Probably this is due to few associated anomalies in our cases, but it is not clear whether this is common finding in Korea. Our findings suggest that CCAM is treated successfully by surgical removal which can be delayed unless respiratory symptoms are evident.