Thymic Hyperplasia with Lymphoepithelial Sialadenitis (LESA)-Like Features: Strong Association with Lymphomas and Non-Myasthenic Autoimmune Diseases.

Thymic hyperplasia (TH) with lymphoepithelial sialadenitis (LESA)-like features (LESA-like TH) has been described as a tumor-like, benign proliferation of thymic epithelial cells and lymphoid follicles. We aimed to determine the frequency of lymphoma and autoimmunity in LESA-like TH and performed retrospective analysis of cases with LESA-like TH and/or thymic MALT-lymphoma. Among 36 patients (21 males) with LESA-like TH (age 52 years, 32-80; lesion diameter 7.0 cm, 1-14.5; median, range), five (14%) showed associated lymphomas, including four (11%) thymic MALT lymphomas and one (3%) diffuse large B-cell lymphoma. One additional case showed a clonal B-cell-receptor rearrangement without evidence of lymphoma. Twelve (33%) patients (7 women) suffered from partially overlapping autoimmune diseases: systemic lupus erythematosus (n = 4, 11%), rheumatoid arthritis (n = 3, 8%), myasthenia gravis (n = 2, 6%), asthma (n = 2, 6%), scleroderma, Sjögren syndrome, pure red cell aplasia, Grave's disease and anti-IgLON5 syndrome (each n = 1, 3%). Among 11 primary thymic MALT lymphomas, remnants of LESA-like TH were found in two cases (18%). In summary, LESA-like TH shows a striking association with autoimmunity and predisposes to lymphomas. Thus, a hematologic and rheumatologic workup should become standard in patients diagnosed with LESA-like TH. Radiologists and clinicians should be aware of LESA-like TH as a differential diagnosis for mediastinal mass lesions in patients with autoimmune diseases.

From a sore throat to the intensive care unit: the Lemierre syndrome.

Lemierre syndrome is characterized by an acute oropharyngeal infection, suppurative thrombophlebitis of the internal jugular vein and metastatic infections. The infection is usually caused by Fusobacterium necrophorum. We report on a 19-year-old male patient who was admitted with a five-day history of fever, sore throat and progressive dyspnea. Computed tomography of the neck and chest revealed a parapharyngeal abscess, jugular vein thrombosis, descending necrotizing mediastinitis and multiple areas of bilateral consolidation and cavitations within the lungs. Fusobacterium necrophorum was identified in the blood culture. Early combined abscess drainage with neck and chest incisions, together with broad spectrum intravenous antibiotic treatment and medical management in an intensive care unit resulted in a good clinical outcome.

Video-assisted thoracic surgery for pleural empyema.

BACKGROUND: After we gained considerable experience with video-assisted thoracic surgery (VATS) and became familiar with its advantages, we started to use it for the treatment of thoracic empyema. METHODS: We treated 130 patients with pleural empyema in whom chest tube drainage and antibiotic therapy had failed to produce a satisfactory result. Six months after surgery they had clinical and radiologic assessment and spirometry. RESULTS: Video-assisted surgery was performed in all patients. Mean operative time was 93 minutes (range, from 55 to 180 minutes), mean duration of postoperative chest tube drainage was 10 days (range, from 5 to 32 days), and mean hospital stay was 16 days (range, from 3 to 56 days). The rate of conversion to open thoracotomy was 3.1%. Complications for which reoperation was necessary occurred in 9% of patients. At follow-up after six months, the mean forced expiratory volume in 1 second was 87.7% (range, from 69.5% to 105.9%), the mean postoperative vital capacity was 84.4%, (range, from 59.9% to 97.9%). There were no postoperative or procedure-related deaths. CONCLUSIONS: Video-assisted thoracic surgery is a safe and effective treatment option for fibropurulent empyema with low morbidity and mortality. Conversion to thoracotomy should be used if necessary to remove all of the fibropurulent material and achieve complete expansion of the lung to insure a good outcome.

Multidrug resistance markers P-glycoprotein, multidrug resistance protein 1, and lung resistance protein in non-small cell lung cancer: prognostic implications.

PURPOSE: The aim of this retrospective study was to comparatively investigate the expression of the three drug-resistance genes P-glycoprotein (P-gp), multidrug-resistance protein 1 (MRP1), and lung resistance protein (LRP), in non-small cell lung cancer (NSCLC) tissues, and to assess possible associations with clinicopathologic features. METHODS: Tumor specimens from 126 patients were analyzed by immunohistochemistry and, in selected cases, by reverse transcriptase polymerase chain reaction (RT-PCR), and data were statistically analyzed by SPSS. RESULTS: The mean expression levels of tumor tissues in the case of P-gp and LRP did not exceed the one of normal epithelia, while MRP1 was significantly enhanced in NSCLC. A weak association was observed between higher grading and P-glycoprotein expression (p <0.08) as well as lower grading and MRP1 expression in the case of adenocarcinoma (p <0.05). MRP1 levels were highest in TNM stage I and declined with advanced stage (p <0.03). A significant association was found between high MRP1 levels and longer overall survival (N =115, p <0.04), which was highly significant in the patient group never treated with chemotherapy (N =77; p <0.007). P-gp expression was enhanced in those patients who had received chemotherapy before surgery (p <0.05). CONCLUSIONS: Our data point towards a major role of MRP1 in the intrinsic treatment resistance of NSCLC and suggest, in addition, a significant activation of P-gp expression during chemotherapy.

The natural history of recurrence after bronchoplastic procedures for non-small cell lung cancer.

BACKGROUND: The natural course of recurrence after bronchoplastic procedures for non-small cell lung cancer (NSCLC) has not been described. METHODS: Sex, age, tnm-stage, histology, neoadjuvant chemotherapy, disease-free interval (months), exact localisation of tumour recurrence, time between first and second recurrence (months), survival after first and second recurrence (months), causes of death were retrospectively recorded in 83 patients operated between December 1993 and July 2001. RESULTS: One patient was lost to follow-up, five resections were nonradical. Survivors' follow-up lasted 5 to 100.7 months (mean 43.3). Fourteen patients (14.4%) died tumor free. Eleven (13.2%) distant recurrences were diagnosed 1 to 42 months (mean 10.6) postoperatively, eight (9.6%) died 0 to 17 months (mean 7.55) after diagnosis. Nine local recurrences (10.8%)-5 unifocal, 4 multifocal-occurred 2 to 35 months (mean 17.3) postoperatively, eight died 0 to 8 months (mean 2.13) after diagnosis. Nine mixed recurrences (10.8%)-1 synchronous, 8 metachronous-were found (14.8%) 2 to 21 months postoperatively (mean 8.3). All died 4 to 41 months (mean 17.83) after diagnosis. Fourteen mediastinal lymph node recurrences occurred, ten as a primary recurrence and four as secondary. Lymph nodes were involved in all multifocal recurrences. Intrabronchial recurrence was observed in five patients and was always a result of progressive regional lymph node recurrence. CONCLUSIONS: The pattern and natural history of recurrence cannot be sufficiently explained by stage and surgical radicality and suggest different genetic characteristics of the primary tumor. In case of reoperation due to intrabronchial recurrence adjuvant mediastinal irradiation should be considered.

Risk factors for the development of postoperative complications after bronchial sleeve resection for malignancy: a univariate and multivariate analysis.

BACKGROUND: This study was designed to identify risk factors responsible for postoperative complications after bronchoplastic procedures. METHODS: Excluding sleeve pneumonectomies between January 1994 and December 2001, 108 patients underwent bronchoplastic procedures for bronchial malignancy. Prospectively documented data were age, gender, side, type of bronchial reconstruction, extended resection, histology, TNM stage, diseased lobe, and bronchial tumour occlusion. Cardiovascular (CV) risk factors included heart disease, arterial hypertension, cerebro-occlusive disease, peripheral artery disease of the lower extremities, diabetes mellitus, and abdominal aortic aneurysm. Patients were grouped according to the presence/absence of any CV risk factor and the absolute number of CV risk factors present (zero to four). Non-CV risk factors included neoadjuvant chemotherapy, alcoholism, lung disease, sleep apnea, history of recent pneumococcal sepsis, and repeat thoracotomy. Groups were assembled according to the presence or absence of any non-CV risk factor, neoadjuvant chemotherapy, and alcoholism. Respiratory risk factors included lung function and blood gas analysis. Groups were assembled according to the absolute number of respiratory risk factors in each person (zero to three) and the combination of respiratory and CV risk factors. Complications were defined as septic (pneumonia, empyema, brochopleural fistula, colitis) and aseptic. For univariate statistical analysis, t test, cross-tabulation, and chi2 test were used. All factors with a significance of p < 0.1 were entered into a binary backwards-stepwise logistic regression model. RESULTS: The combination of respiratory and CV risk factors (p = 0.012, OR = 0.165) was predictive for overall complications. Coronary artery disease (p = 0.02, OR = 0.062) and the combination of two respiratory risk factors (p = 0.008, OR = 0.062) were predictive for septic complications. Peripheral artery disease (p = 0.024, OR = 0.28), moderate (p = 0.01, OR = 0.13) and severe chronic obstructive pulmonary disease (p = 0.018, OR = 0.11), and extended resections (p = 0.003, OR = 0.017.) were predictive for aseptic complications. CONCLUSIONS: Comorbidity significantly influences the postoperative complication rate and is therefore crucial for evaluation of patients for bronchoplastic procedures. Different risk factors are responsible for the occurrence of septic and aseptic complications after bronchoplastic procedures.

Preoperative attitudes, fears and expectations of non-small cell lung cancer patients.

Knowing preoperative fears in cancer patients should help us to overcome perioperative psychological problems. One hundred and three patients underwent a semistructured interview addressing the effect of preoperative information on disease and forthcoming operation, attitude towards operation, expectations for the postoperative time and family support. Evaluation was performed by three psychologists by qualitative structured content analysis according to Mayring. Interrater reliability was 85%. Only 42 patients (40.8%) were informed in detail about their diagnosis. Eighty-three patients (80.6%) considered the information given on their disease and the forthcoming operation as understandable, 57 patient (55.3%) experienced reduction of fear. Eighty-three patients (80.6%) showed a positive attitude to the operation, 21 (20.4%) expected an impairment of later life after operation although becoming healthy again. Diffuse fears were named in 47 cases (45.6%), 19 (18.4%) patients were afraid of metastases, 11 (10.7%) of postoperative death, 19 (18.4%) of pain, 11 (10.7%) of mutilation and 17 (16.5%) of surgical complications. Seventy-three patients (70.9%) had good family support, seven (6.8%) not. Of the support group 32 patients (31%) considered their relatives' empathy as onerous. Problems, that are self-evident to the attending staff may be insurmountable for the patients. If we succeed to overcome their most simple fears they can focus their energy on mastering the postoperative course.

Detection of the Epstein-Barr virus in primary adenocarcinoma of the lung with Signet-ring cells.

The Epstein-Barr virus (EBV) is directly implicated in the pathogenesis of a variety of undifferentiated carcinomas and has also been identified in conventional adenocarcinomas of the stomach. To date, the association of EBV with non-small cell lung carcinoma is restricted to Asian patients. To evaluate the presence of EBV in lung cancers from Europeans, we investigated primary lung adenocarcinomas with a similar morphological tumour pattern to those of the stomach, specifically rare tumours with components of signet-ring cells. Three tumours of signet-ring cell type were examined by means of polymerase chain reaction (PCR). To localise the virus to the neoplastic cells, in situ hybridisation (ISH) was performed using an antisense Epstein-Barr virus encoded RNA probe. Immunohistochemistry was performed to evaluate the expression of latent membrane protein-1 (LMP-1) and EBV nuclear antigen 2 (EBNA-2). PCR investigation confirmed the presence of EBV in one case. Positive signals confined to tumour cells were present on ISH. None of the tumours showed expression of LMP-1 and EBNA-2. To our knowledge, this is the first report on the presence of EBV in primary adenocarcinoma of the lung in a Caucasian patient. The present study indicates that EBV may infect some lung cancers with a specific tumour pattern.