Looking for Lepidic Component inside Invasive Adenocarcinomas Appearing as CT Solid Solitary Pulmonary Nodules (SPNs): CT Morpho-Densitometric Features and 18-FDG PET Findings.

OBJECTIVE: To investigate CT morphologic and densitometric features and 18-FDG PET findings of surgically excised lung adenocarcinomas "mixed subtype" with predominant lepidic component, appearing as solid solitary pulmonary nodules (SPNs) on CT scan. MATERIALS AND METHODS: Approval for this study was given from each local institutional review board according to its retrospective nature. Nodules pathologically classified as lung adenocarcinoma mixed subtype with bronchioloalveolar otherwise lepidic predominant component, in three different Italian institutions (Napoli; Varese; Parma), were retrospectively selected. RESULTS: 22 patients were identified. The number of SPNs with smooth margins was significantly lower with respect to the number of SPNs with spiculated margins (p: 0.033), radiating spiculations (p: 0.019), and notch sign (p: 0.011). Mean contrast enhancement (CE) was 53.34 HU (min 5.5 HU, max 112 HU); considering 15 HU as cut-off value, CE was positive in 20/22 cases. No significant correlation was found between size and CE. Mean SUVmax was 2.21, ranging from 0.2 up to 7.5 units; considering 2.5 units as cut-off, SUVmax was positive in 7/22 cases. The number of SPNs with positive CE was significantly higher than the number of SPNs with positive SUVmax (p: 0.0005). CONCLUSION: CT generally helps in identifying solid SPN suspicious for malignancy but 18-FDG PET may result in false-negative evaluation; when 18-FDG PET findings of a solid SPN are negative even though CT morphology and CE suggest malignancy, radiologist should consider that lepidic component may be present inside the invasive tumor, despite the absence of ground glass.

A surgical case of pyothorax-associated lymphoma of T-cell origin arising from the chest wall in chronic empyema.

We report a surgical a case of pyothorax-associated lymphoma of T-cell origin arising from the chest wall and developing on pleural sequelae of therapeutic pneumothorax for pulmonary tuberculosis. The tumor was removed with resection of the fifth to eighth ribs. The chest wall defect repaired with a Marlex (Phillips Sumika Polypropylene Co, Houston, TX) prothesis. The histologic, immunohistochemical, and genotypic features were conclusive for a diagnosis of T-cell non-Hodgkin lymphoma. The patient received postoperative chemotherapy and is doing well after 15 months.

Lung mast cells are a source of secreted phospholipases A2.

BACKGROUND: Secreted phospholipases A(2) (sPLA(2)s) are released in plasma and other biologic fluids of patients with inflammatory, autoimmune, and allergic diseases. OBJECTIVE: We sought to evaluate sPLA(2) activity in the bronchoalveolar lavage fluid (BALF) of asthmatic patients and to examine the expression and release of sPLA(2)s from primary human lung mast cells (HLMCs). METHODS: sPLA(2) activity was measured in BALF and supernatants of either unstimulated or anti-IgE-activated HLMCs as hydrolysis of oleic acid from radiolabeled Escherichia coli membranes. Expression of sPLA(2)s was examined by using RT-PCR. The release of cysteinyl leukotriene (LT) C(4) was measured by means of enzyme immunoassay. RESULTS: Phospholipase A(2) (PLA(2)) activity was higher in the BALF of asthmatic patients than in the control group. BALF PLA(2) activity was blocked by the sPLA(2) inhibitors dithiothreitol and Me-Indoxam but not by the cytosolic PLA(2) inhibitor AZ-1. HLMCs spontaneously released a PLA(2) activity that was increased on stimulation with anti-IgE. This PLA(2) activity was blocked by dithiothreitol and Me-Indoxam but not by AZ-1. HLMCs constitutively express mRNA for group IB, IIA, IID, IIE, IIF, III, V, X, XIIA, and XIIB sPLA(2)s. Anti-IgE did not modify the expression of sPLA(2)s. The cell-impermeable inhibitor Me-Indoxam significantly reduced (up to 40%) the production of LTC(4) from anti-IgE-stimulated HLMCs. CONCLUSIONS: sPLA(2) activity is increased in the airways of asthmatic patients. HLMCs express multiple sPLA(2)s and release 1 or more of them when activated by anti-IgE. The sPLA(2)s released by mast cells contribute to LTC(4) production by acting in an autocrine fashion. Mast cells can be a source of sPLA(2)s in the airways of asthmatic patients.

Pulmonary hernia secondary to limited access for mitral valve surgery and repaired by video thoracoscopic surgery.

Iatrogenic pulmonary hernia is a rare condition. Repair is performed due to persistent symptoms and it is usually carried out by open surgery. We report a case of a 59-year-old woman who developed a lung hernia after small anterior thoracotomy that was performed for mitral valve surgery. The herniated lung is reduced with success by video thoracoscopic surgery and the chest wall defect is repaired by a polypropylene mesh fitted to the thoracic wall. At six-month follow-up, she was asymptomatic and without recurrence of hernia. Our experience suggests that video thoracoscopic surgery is a feasible surgical technique even for lung hernia secondary to mini-thoracotomy. However, before performing video thoracoscopic surgery, several factors preclusive to using this strategy must be considered, including the extensiveness of pleural adhesions due to the time interval between the previous operation and lung hernia, the site and the size of the hernia, and the insufficient experience in video thoracoscopic surgery.

The role of technetium-99m hexakis-2-methoxyisobutyl isonitrile in the detection of neoplastic lung lesions.

OBJECTIVE: Our goal was to determine the role of technetium-99m hexakis-2-methoxyisobutyl isonitrile ((99m)Tc-MIBI) in the detection of neoplastic lung lesions. MATERIALS AND METHODS: We prospectively studied 79 consecutive patients with indeterminate lung lesion between January 2006 and September 2007. All patients were submitted to (99m)Tc-MIBI single-photon emission chest tomography (SPECT) before invasive diagnostic procedure. Qualitative analysis was performed to evaluate SPECT images in order to localize abnormal activity in the radiologically demonstrated lesion. In addition, semiquantitative analysis was made by calculating tumor/contralateral normal lung ratio (T/N). Finally, the scintigraphic findings were correlated to the histopathological diagnosis obtained by invasive procedure or confirmation of instrumental exams. RESULTS: Sixty patients had a malignant lesion: 44 squamous cell carcinoma, 7 adenocarcinomas, 4 large cell carcinoma, 1 small cell lung cancer, and 4 metastases. The mean size+/-standard deviation of malignant nodules was 3.9+/-1.61 cm (range 1.5-5.5 cm). Nineteen patients had a benign disease. The mean size+/-standard deviation of benign nodules was 3.3+/-1.71 cm (range 2-6 cm). (99m)Tc-MIBI SPECT delineated focal lesions with an increase in tracer accumulation in 55/60 malignant lesions; in 5/60 malignant lesions was negative. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 91%, 73%, 91%, and 73%, respectively. In patients with neoplastic lesion, the mean T/N ratio value+/-standard deviation was 1.72+/-0.35 whereas in patients with benign lesions was 1.14+/-0.25. Semiquantitative analysis showed that for a T/N value >1.23, the value of sensitivity, specificity, PPV, and PNV were 91%, 84%, 94%, and 76%, respectively (ROC curve). Metastatic mediastinal lymph nodes were found in 3/57 patients. (99m)Tc-MIBI SPECT showed a specificity and PPV of 100% in the detection of mediastinal lymph nodes with sensitivity, and PNV of 66% and 97%, respectively. Age, sex, histological type, and size of lesion did not affect the SPECT results. CONCLUSION: Our experiences seem to confirm that (99m)Tc-MIBI SPECT is a reliable diagnostic tool in the finding of lung cancer particularly cases in which radiological evaluation is indeterminate.

A home-made device for safe intraoperative aspiration of pulmonary hydatid cysts.

Surgical intervention is still the main modality for the treatment of hydatid disease. Different surgical procedure have been described; however, in the literature there is no collective agreement on the best surgical strategy. For intact pulmonary hydatid cysts, an enucleation or needle aspiration are possible strategies. Though, both methods need careful manipulation due to the serious complications after fluid rupture. Here, we present a novel technique that allows the aspiration of the cyst while reducing the risk of anaphylaxis and dissemination of disease. This is a home-made double suction device designed to aspirate hydatid cysts by creating a low pressure, wide mouth cylinder which holds the cyst wall against the base of the cylinder. A large thoracentesis needle is inserted across the low pressure chamber into the cyst to aspirate the fluid within. The complete evacuation of the cyst makes surgical treatment easier and facilitates its successive removal.

Electrothermal bipolar tissue sealing systems in lung surgery.

Various techniques have been proposed to reduce intraoperative blood loss in surgery. We report our experience with the use of LigaSure, a new electrothermal bipolar tissue sealing system, in lung surgery. This system has been already applied with good results in other surgical fields. However, the experience reported in the literature with the use of this technique in lung surgery is limited. Our clinical series with LigaSure (160 procedures in a 4-year period) is the largest reported to date. Technical aspects, clinical results and an overview of the literature are presented. We believe that LigaSure is an easy and safe technique, suitable for lung surgery. It could be a valid alternative or complement to staplers for several procedures, also in the thoracoscopic setting. Furthermore, it seems to allow functional lung tissue preservation and reduction of surgical supplies costs.

Intraoperative pleural lavage: is it a valid prognostic factor in lung cancer?

BACKGROUND: In patients undergoing lung resection for non-small cell lung cancer (NSCLC), the primary TNM (tumor-regional lymph node-distant metastasis) staging system is the best prognostic factor. However, it is necessary to investigate other factors that could more accurately predict a patient's prognosis. In this study we evaluated the significance of positive intraoperative pre-resectional lavage in patients with NSCLC. METHODS: We enrolled 84 patients (79 men, 5 women) aged between 36 and 81 years (mean age, 64.8 years) undergoing a major lung resection for NSCLC, with no preoperative evidence of pleural effusions. Intraoperatively, the patients were given a pre-resectional pleural lavage with physiologic saline solution. The fluid was aspirated and sent to cytology. RESULTS: Pre-resectional pleural lavage was positive in 19 patients (22.6%). The lavage was positive in 7.3% in patients with early stage I disease (3/41) and 37.2% in patients with stage II/III disease. In the group of 16 patients with chest wall neoplastic involvement (T3), 9 had a positive lavage (56.2%; p = 0.05). No significant correlation was found between positive lavage and nodal status, visceral pleural involvement, or histologic findings. Patients with malignant cells in the pre-resectional lavage had a significantly shorter survival than patients with a negative lavage (p = 0.025). CONCLUSIONS: A positive cytology finding of intraoperative pre-resectional pleural lavage could be an important prognostic factor in patients undergoing major lung resection for NSCLC. Patients with a positive lavage should be upstaged. However, larger series are needed to define accurately the role of this technique in early stage lung cancer.