Diagnostic efficacy of computed tomography-guided transthoracic needle aspiration and biopsy in patients with pulmonary disease.

BACKGROUND: Computed tomography-guided transthoracic needle aspiration (TTNA) and biopsy (TTNB) is a well established, safe, and rapid method of reaching a definitive diagnosis for most thoracic lesions. The present study aimed to determine the roles of TTNA and TTNB in the diagnosis of pulmonary diseases and to compare the results using these two techniques. METHODS: TTNB and TTNA were performed in 105 patients admitted to our clinic due to peripheral pulmonary lesions between May 2005 and November 2007. Needle biopsies were performed using 18-gauge Tru-Cut® biopsy needles and aspirations was performed using 18-20-22-gauge Chiba needles. RESULTS: Malignant lesions diagnosed by TTNB were non-small cell lung carcinoma (51 patients, 73%), small cell lung carcinoma (nine patients, 13%), malignant tissue (three patients, 5%), lymphoma (two patients, 3%), thymoma (two patients, 3%), plasmacytoma (one patient, 1%), rhabdomyosarcoma (one patient, 1%), and metastasis (one patient, 1%). The malignant lesions diagnosed by TTNA were non-small cell lung carcinoma in eleven patients (92%) and malignant tissue in one patient (8%). Three (100%) of the benign lesions diagnosed by TTNB were granulomas and two (100%) benign lesions diagnosed by TTNA were infarctions. When the diagnostic value of TTNB and TTNA was compared, TTNB was significantly superior. Malignant lesions were identified in 70 (84%) and benign lesions were identified in three (4%) of the 83 patients in the TTNB group. Ten (12%) patients in the TTNB group could not be diagnosed. Malignant lesions were found in 12 (55%) and benign lesions were found in two (9%) of the 22 patients in the TTNA group. Negative results were obtained in eight (36%) patients. The diagnostic sensitivity, specificity, and accuracy of TTNB was calculated to be 92%, 100%, and 93%, respectively (Table 5). The diagnostic sensitivity, specificity, and accuracy of TTNA was 78%, 100%, and 82%, respectively. TTNB had a sensitivity of 92% (70/76) in malignant cases and 100% (3/3) in benign cases, while the sensitivity of TTNA in malignant and benign cases was 75% (3/4) and 67% (2/3), respectively. CONCLUSION: TTNB is a safe and easy procedure which provides a highly accurate diagnosis of benign and malignant lung lesions without causing a significant increase in complication rates.

Percutaneous cavitary lavage in the diagnosis of pulmonary cavities.

OBJECTIVE: To investigate diagnostic significance of percutaneous cavitary lavage (PCL) in differential diagnosis of benign and malignant pulmonary cavitary lesions. METHODS: An alternative diagnostic method called PCL was performed on 16 patients having peripherally located pulmonary cavitary lesions with thin walls which were not suitable for tissue biopsy and whose diagnosis could not be made by sputum examination and bronchoscopic procedures. A 22-gauge needle was inserted into the cavity under computed tomography (CT) guidance. Saline was injected through the needle and then aspirated. The specimen was examined cytologically and microbiologically. RESULTS: PCL could make a correct diagnosis in 12 of 16 patients (75%). In three patients (18.7%) appropriate specimen could not be taken. Diagnostic sensitivity and specificity of PCL for malignant-benign differentiation was 80% and 100%, respectively. The accuracy of PCL for this differentiation was 92.3%. There was only one complication, a small pneumothorax resolved without any intervention. CONCLUSIONS: PCL is an alternative method in the differential diagnosis of thin walled pulmonary cavitary lesions especially for patients whose diagnosis could not be made by sputum and bronchoscopic procedures and who are not suitable for cutting needle biopsy.

A very rare cause of pleuritic chest pain: bilateral pleuritis as a first sign of familial mediterranean Fever.

The familial Mediterranean fever (FMF), also called recurrent polyserositis, is characterized by reccurrent episodes of serositis at pleura, peritoneum, and synovial membrane and fever. We present a patient with recurrent bilateral pleural effusion due to serositis attacks as a first sign of FMF. A 59-year-old Turkish man suffered from recurrent pleuritic chest pain due to pleural effusion and atelectasis. The etiology was not found, and his symptoms were spontaneously recovered during several weeks. The pleuritic chest pain was associated with abdominal pain in the last attack. The gene mutation analysis revealed the homozygosity of FMF (F479L) gene mutation in both our patient and his grandchild. After the colchicine treatment, the attack has not developed. In conclusion, recurrent pleural effusion and pleuritic chest pain may be the first signs of the FMF.

An unusual cause of precordial chest pain.

Extraskeletal chondrosarcoma in anterior mediastinum is very rare. A 45-year-old male patient was admitted to the hospital with precordial chest pain. A large and well-shaped mass in the anterior mediastinum was seen radiologically, and there was a clearly compression of the heart by the mass. The lesion was totally resected, and extraskeletal mediastinal chondrosarcoma was histopathologically diagnosed. We aimed to present and discuss the radiologic, clinic, and histopathologic features of unusual presentation of extraskeletal chondrosarcoma in a case.

Long-term survival rates of patients with stage IIIB and IV non-small cell lung cancer treated with cisplatin plus vinorelbine or gemcitabine.

Limited data exist concerning the long-term (≥5 year) survival rates of patients with stage IIIB and IV non-small cell lung carcinoma (NSCLC) receiving chemotherapy. We aimed to determine the long-term results of cisplatin plus third-generation (vinorelbine or gemcitabine) cytotoxic chemotherapy in patients with locally advanced and advanced NSCLC. The study included 141 patients, and all patients were followed up from the time of diagnosis until death. The median age of the patients was 59.1±9.9 years. The male-to-female ratio was 124/17; 62.4% of the patients had stage IIIB and 37.6% had stage IV NSCLC. Squamous cell carcinoma, adenocarcinoma and undifferentiated NSCLC subtypes accounted for 69.5, 17.7 and 12.7% of the cases, respectively. The overall response rate was 32.6% and the median survival time was 12.3 months (95% CI, 10.2-14.5). The median survival times for stages IIIB and IV were 12.6±1.4 and 11.9±1.7 months, respectively. The 1-, 2-, 3- and 5-year survival rates were 33, 7.5, 4.3 and 2.8%, respectively. In conclusion, cisplatin-based new-generation cytotoxic agents for combined modality therapy offer an increased hope of long-term survival for patients with locally advanced and advanced NSCLC.

Right sided arcus aorta as a cause of dyspnea and chronic cough.

BACKGROUND: Right sided arcus aorta (RSAA) is a rare condition that is usually asymptomatic. Patients may present with exertional dyspnea and chronic cough. A recent article suggested that RSAA should be included in the differential diagnosis of asthma, especially in patients with intractable exertional dyspnea. We aimed to present the clinical, radiologic and spirometric features of thirteen patients with RSAA observed in four years at the Rize Education and Research Hospital and Samsun Chest Diseases and Thoracic Surgery Hospital. METHODS: The characteristics of patients with RSAA, including age, gender, symptoms, radiologic and spirometric findings, were retrospectively evaluated. RESULTS: A total of thirteen patients were diagnosed with RSAA. Their ages ranged from 17 to 86 years and the male to female ratio was 11:2. Seven of the patients (54%) were symptomatic. The most common symptoms were exertional dyspnea, dysphagia and chronic cough. Five patients had received treatment for asthma with bronchodilators. Spirometry showed intrathoracic tracheal obstruction in five patients. CONCLUSIONS: The RSAA anomaly occurs more frequently than might be estimated from the number of patients who are detected. Patients with intractable exertional dyspnea and chronic cough should be evaluated for the RSAA anomaly by thoracic CT.

Endobronchial tuberculosis: histopathological subsets and microbiological results.

BACKGROUND: Endobronchial tuberculosis (EBTB) is defined as a tuberculous infection of the tracheobronchial tree with microbial and histopathological evidence, with or without parenchymal involvement. Bronchoscopic appearances of EBTB have been divided into seven subtypes: actively caseating, edematous-hyperemic, fibrostenotic, tumorous, granular, ulcerative, and nonspecific bronchitic. However, information for establishing a definite microbiological diagnosis in each of these categories is lacking.We aimed to present bronchoscopic appearances and percentages for the EBTB subtypes and to compare bronchoscopic appearances with microbiological positivity in bronchial lavage fluid. METHODS: From 2003 to 2009, 23 biopsy-proven EBTB patients were enrolled in the study. Diagnosis of EBTB was histopathologically confirmed in all patients. RESULTS: The commonest subtype was the edematous-hyperemic type (34.7%); other subtypes in order of occurrence were: tumorous (21.7%), granular (17.3%), actively caseating (17.3%), fibrostenotic (4.3%), and nonspecific bronchitic (4.3%). Although all patients were sputum-smear-negative for acid-fast bacilli (AFB), 26% of patients were smear-positive for AFB in the bronchial lavage fluid. The bronchial lavage fluid grew Mycobacterium tuberculosis in 39.1% of all patients.The bronchial lavage smear positivity for AFB in the bronchial lavage fluid was 75%, 25%, 20%, 12.5%, 0%, and 0% for the granular, actively caseating, tumorous, edematous-hyperemic, fibrostenotic, and nonspecific bronchitic subtypes of EBTB, respectively. Culture positivity for Mycobacterium tuberculosis in bronchial lavage fluid was 75%, 50%, 40%, 25%, 0%, and 0%, respectively. CONCLUSION: The commonest subtype of EBTB was the edematous-hyperemic subtype. The granular type had the highest smear positivity and culture positivity for Mycobacterium tuberculosis in bronchial lavage fluid. Bronchoscopy should be performed in all patients suspected to have EBTB.

Pleural effusion in pulmonary embolism.

PURPOSE OF REVIEW: Pulmonary embolism is a common and potentially lethal disease that recurs frequently and is associated with long-term impairment and suffering. Patients with pulmonary embolism are at risk of death, recurrence of embolism, or chronic morbidity. Appropriate therapy can reduce the incidence of all. Pulmonary embolism is the most commonly overlooked disorder in patients with pleural effusion. Recent findings of pleural effusions due to pulmonary embolism are discussed in this review. RECENT FINDINGS: The presence of pleuritic chest pain in a patient with a pleural effusion is highly suggestive of pulmonary embolism. Nearly all pleural effusions due to pulmonary embolism are exudates, frequently hemorrhagic, and with a marked mesothelial hyperplasia. Patients with a pleural effusion are likely to have an embolus in the central, lobar, segmental, or subsegmental pulmonary arteries and these are the regions in which spiral computed tomography pulmonary angiography (CTPA) can detect an embolus. No specific treatment is required for pleural effusion. The presence of bloody pleural fluid is not a contraindication for the administration of anticoagulant therapy. SUMMARY: Pulmonary embolism is probably responsible for a significant percentage of undiagnosed exudative pleural effusions. Spiral CTPA is the best way to evaluate the possibility of pulmonary embolism in a patient with a pleural effusion. The treatment protocol of the patient with pleural effusion secondary to pulmonary embolism is the same as that for any patient with pulmonary embolism.

The costs of hospitalization in patients with acute exacerbation of chronic obstructive pulmonary disease.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is a major public health problem. It imparts a substantial economic burden on individuals and society. Acute exacerbations are the main cause of hospital admissions and hospitalizations in patients with COPD in Turkey. OBJECTIVES: We aimed to determine the costs of hospitalization in patients with acute exacerbations of COPD (AECOPD). RESULTS: A total of 7832 (1556 women, 6276 men) patients were hospitalized due to acute exacerbations of COPD between 2005-2009 in the Samsun Chest Diseases and Thoracic Surgery Hospital, northern Turkey. The mean age was 64.6 ± 19.8 years old and median length of hospital stay was 14.8 ± 9.5 days. The mean cost per admission was US$718 ± 364. Drug costs accounted for the largest portion (53.5%) of the mean cost, followed by bed cost (19.6%). One hundred seventy-four (2.2%) of the total hospitalized patients with AECOPD died in hospital. CONCLUSION: AECOPD continues to have both significant economic burden and high mortality rate.

Sarcoidosis and Gullain-Barré syndrome.

A 35-year-old female presented with three days' history of aching discomfort in her back, chest, and ankles. She had also noticed increasing weakness of her legs and a week before admission had shown flu-like symptoms. Chest X-ray showed bilateral hilar and right paratracheal lymphadenopathy. Bronchoscopic biopsies revealed non-caseating granuloma. She was diagnosed with sarcoidosis and was given prednisolone. The patient developed facial palsy and rapidly progressive ascending paralysis beginning from the lower extremities on the third and fourth days after initial presentation, respectively. Analysis of lumbar puncture showed acellular fluid with a high protein content. EMG was consistent with diffuse sensorimotor demyelinating polyneuropathy. Thus, the diagnosis was Guillain-Barré syndrome (GBS) presenting with sarcoidosis. Intravenous immune globulin was given and prednisolone stopped. One month after initial presentation the patient was completely recovered and discharged on prednisolone therapy. If neurologic symptoms such as aching discomfort and weakness are the main complaints in patients with suspected or biopsy proven sarcoidosis, GBS should be suspected.

Tracheal bronchus in the adult population.

BACKGROUND: Tracheal bronchus is an abnormal bronchus that comes directly off the lateral wall of the trachea (ie, above the main carina) and supplies ventilation to the upper lobe. A new nomenclature and classification system has been developed for tracheal bronchus. The purpose of this study was to evaluate the anatomic and bronchoscopic features of tracheal bronchus subtypes on the basis of the new nomenclature and classification system. METHODS: A retrospective study was performed using data from eight patients with tracheal bronchus. RESULTS: The incidence of tracheal bronchus was found to be 0.06% (8 of 12,648 patients) and the distribution of the subtypes was as follows: displaced type (7 patients, 87.5%) and supernumerary type (1 patient, 12.5%). Among the patients with displaced tracheal bronchus, 6 had displaced preeparterial (75%), 1 had displaced preeparterial and posteparterial tracheal bronchus (12.5%), and 1 patient had supernumerary eparterial tracheal bronchus (12.5%). In all cases, the tracheal bronchi were located on the right side of the trachea. The mean distance between the origin of the tracheal bronchus and main carina was 16.25 mm (range, 5 to 40 mm). In 1 case, posteparterial bronchus was detected with its orifice on the lateral side of the intermediate bronchus. CONCLUSIONS: Displaced preeparterial tracheal bronchus was the most common subtype of tracheal bronchus. Furthermore, in all cases, tracheal bronchus was located on the right side of the trachea. Both flexible bronchoscopy and computed tomography of the chest were crucial for its diagnosis.

An unusual cause of dyspnea.

BACKGROUND: Right-sided arcus aorta (RSAA) is a rare condition and usually asymptomatic. However, it may be symptomatic if it causes tracheal or esophageal compression. METHODS: The authors evaluated clinical and radiological features of seven patients with RSAA who had the diagnosis between May 2006 and May 2009. RESULTS: The authors found that the incidence of RSAA was 0.16% in patients who had applied to their clinic. The age of patients ranged from 17 to 55 years. The male to female ratio was 6/1. Four patients were symptomatic due to RSAA. Most common symptoms were dyspnea during exercise, which is similar to exercise-induced asthma and dysphagia. Two patients were misdiagnosed as asthma. The flow-volume curves on spirometry of the patients showed intrathoracic upper airway obstruction. Thorax magnetic resonance imaging (MRI) revealed marked narrowing of the tracheal air column due to external compression of RSAA in three patients. CONCLUSIONS: RSAA should be included in the differential diagnosis of asthma. Spirometry may help to suspect RSAA. Thorax computed tomography (CT) and/or MRI are the best imaging methods for the diagnosis of RSAA.

A prospective evaluation of hemoptysis cases in a tertiary referral hospital.

BACKGROUND AND AIMS: Hemoptysis is symptomatic of a potentially serious and life-threatening thoracic disease. The purpose of this study was to evaluate the relative frequency of the different causes of hemoptysis, the change of the frequency of diseases, the value of the evaluation process and the outcome in a tertiary referral hospital. METHODS: A prospective study was carried out on consecutive patients presented with hemoptysis. RESULTS: A total of 178 patients (136 male, 42 female) were included to the study. Lung cancer (51), pulmonary embolism (23) and bronchiectasis (23) constituted most of the diagnosis. The most frequent cause of hemoptysis in males was by far lung carcinoma (50). Twelve cases of bronchiectasis and 11 cases of pulmonary embolism were observed in females. While lung cancer and pulmonary embolism were associated with mild to moderate amounts of bleeding (84% and 100%, respectively), patients with active tuberculosis and pulmonary vasculitis had severe to massive hemoptysis (50% and 44%, respectively). Transthoracic and other organ biopsies, spiral computed tomography (CT) angiography (X pres/GX model TSX-002a, Toshiba, Tochigi Ken, Japan) and aortography yielded high diagnostic results in our group (100%, 67%, 59% and 100%, respectively). The most frequent final diagnosis in patients with normal chest radiograph was pulmonary embolism (seven cases). CONCLUSIONS: Lung cancer, pulmonary embolism and bronchiectasis were the main causes of hemoptysis in this prospective cohort; however, this is the first report showing pulmonary embolism as a leading cause of hemoptysis. CT angiography with high-resolution CT should be the primary diagnostic modality if the initial investigation is inconclusive in hemoptysis cases.

Vena caval thromboses.

BACKGROUND: Patients with vena caval (VC) thrombosis have been reported with a variety of clinical presentations, which may create a diagnostic challenge for physicians. OBJECTIVE: The objective of the study was to evaluate the clinical characteristics of patients with VC thrombosis. PATIENTS AND METHODS: Files and all imaging methods of consecutive patients with superior or inferior VC thrombosis with or without pulmonary embolism (PE) between January 26, 2001, and May 12, 2006, were retrospectively studied in detail. RESULTS: In our series, VC thromboses within the inferior and superior VC were detected in 28 patients, mostly by combined computed tomographic venography and spiral computed tomographic pulmonary angiography. Nine of these 28 patients (32.1%) had VC thromboses without PE (7 patients with isolated and 2 patients with nonisolated VC thrombosis). Key symptoms and findings in the 9 patients without PE were unexplained dyspnea and tachypnea, respectively. CONCLUSIONS: Many patients with VC thrombosis do not have peripheral vein thrombosis. Moreover, nearly one third of patients with VC thrombosis have negative pulmonary angiograms but do have dyspnea and tachypnea.

Asymptomatic double aortic arch.

A 51-year-old male patient with a past history of lung tuberculosis was referred to our clinic for routine control. The patient reported no complaints and chest X-ray was normal. Three-dimensional thoracic computed tomography revealed a balanced-type double aortic arch with no compression of trachea or esophagus.

[The evaluation of 92 interstitial lung disease patients]. / Klinigimizde interstisyel akciger hastaligi tanisi alan 92 hastanin incelenmesi.

Interstitial lung diseases (ILD) include many acute and chronic pulmonary disorders. We aimed to evaluate the patients diagnosed as ILD in our clinic. Between January 2000 and August 2004, 92 patients were included in the study. Fifty eight (63%) of our patients were female, 34 (37%) were male and the median age was 50.2 + or - 14.2 (19-80) years. The most frequent diagnoses were sarcoidosis in females, and IPF in males. The diagnostic methods used were as follows; clinically and radiologically in 36 (39.1%) patients, bronchoscopy in 33 (34.8%) patients, mediastinoscopy in 10 (10.9%) patients, open lung biopsy in 8 (8.7%) patients, skin biopsy in 2 (2.2%), oral mucosal biopsy in 1 (1.1%), lymph node biopsy in 1 (1.1%), renal biopsy in 1 (1.1%) and pleural fluid examination in 1 (1.1%). Bronchoscopic biopsies were diagnostic in 60.9% of sarcoid patients. Twelve (48%) IPF patients had an occupational toxic exposure history. Medical treatment were given to 80 patients. There were good clinical and radiological response in patients with sarcoidosis (96.9%) and cryptogenic organizing pneumonia (COP) (85.7%), however disease was stable in CTD patients and only three of idiopathic pulmonary fibrosis (IPF) patients (15.7%) responded to treatment. In IPF patients, diagnosis was established medially 35.7 months later after the first symptom appeared. Two of the IPF patients had also lung cancer. Treatment related complications occurred in six patients. Fourteen patients died during the follow-up period and eight were IPF. ILD is frequently encountered in general practice of pulmonary physicians and should be considered in differential diagnosis during routine pulmonology clinic. Sarcoidosis and IPF were the most commonly seen diseases. Although ILD is a difficult challenge to diagnose in clinical practice, it may be diagnosed by means of clinical features, radiologic techniques and several biopsy procedures.

A case of endobronchial lipoma mimicking bronchial asthma.

Endobronchial lipoma is a rare neoplasm of the tracheobronchial tree and it may cause irreversible pulmonary damage due to recurrent pneumonia. Rarely, it may mimic bronchial asthma. We present a 53-year-old woman with an endobronchial lipoma, which had been treated as a bronchial asthma for four years. She also had developed recurrent pneumonia three times.

Penile metastasis as a first sign of lung cancer.

Lung cancer does not generally produce any symptoms at the early stages and it rapidly metastasizes. Although lung cancer has a potential of metastasis to all organs and tissues, metastasis to the penis from lung cancer is very rare. We present a case with a penile lesion as the first sign of lung cancer.

Polyostotic fibrous dysplasia of the ribs: An unusual cause of chest pain and dyspnea.

Fibrous dysplasia is a benign bony abnormality that may be monostotic or polyostotic and is not included in the differential diagnosis of chest pain and dyspnea, since it is typically asymptomatic. A 36-year-old man presented with left-sided chest pain and dsypnea for three months. Chest X-ray and chest computed tomography scan revealed a large solid mass arising from the anterior parts of the left fourth, fifth, and sixth ribs and compressing the adjacent lung parenchyma. The tumor was completely removed surgically and histopathologic examination was consistent with fibrous dysplasia without malignant transformation. This report demonstrates that polyostotic dysplasia of the ribs may cause chest pain and dyspnea and present radiographically as a large mass.

Role of bacteria in acute exacerbations of chronic obstructive pulmonary disease.

BACKGROUND AND STUDY OBJECTIVE: Infections are major causes of acute exacerbations of chronic obstructive pulmonary disease (COPD) which result in significant mortality and morbidity. The primary aim of the study was to determine the microbiological spectrum including atypical agents in acute exacerbations. The secondary aim was to evaluate resistance patterns in the microorganisms. METHODS: The sputum culture of 75 patients admitted to our clinic from January 1, 1999 to December 31, 2002 was evaluated prospectively, for aerobic Gram-positive and Gram-negative bacteria, and serologically for Chlamydophila pneumoniae and Mycoplasma pneumoniae. Sensitivity patterns in potentially pathogenic microorganisms (PPMs) were also investigated. RESULTS: An infectious agent was identified in 46 patients, either serologically or with sputum culture. Pathogens most commonly demonstrated were: Haemophilus influenzae (30%), Chlamydophila pneumoniae (17%), and Mycoplasma pneumoniae (9%). Mixed infections were diagnosed in 9 patients. PPMs showed a high resistance rate to commonly used antibiotics. CONCLUSION: We have shown that microorganisms causing acute exacerbations of COPD are not only typical bacteria (46%) but also atypical pathogens (26%), with unpredictable high rates. Typical agents showed a high resistance to commonly used antibiotics.