Intrapleural administration of DNase alone for pleural empyema.

INTRODUCTION: Pleural empyema is a severe complication of various diseases. The essential is the inserting a drain into the pleural cavity and evacuation of the pus. Sometimes the pus is very thick and its evacuation and re-expansion of the lung is very difficult. METHODS: We report a group of 10 patients with intrapleural administration of Pulmozyme (dornase alpha) in dosages of either 2.5 mg once or on two separate occasions. All of the patients had a chest tube inserted into the pleural cavity. Measurement of viscosity was done before and after the instillation of the dornase alpha. RESULTS: In six patients dornase alfa was introduced into the pleural cavity once. Three of them received this on the 4th whilst the rest were treated with the agent on the 6th day. Four patients received the dornase alpha twice because of the small amount of drainage fluid after the previous instillation. Five patients were discharged from hospital with complete re-expansion of their lungs. Two patients were qualified for a surgical operation since the lung was trapped and did not re-expand. Three patients had to be discharged with a drain as a result of incomplete re-expansion of the lung. In all the patients the density of the pus after administering the dornase alpha decreased and the amount of the pus drainage increased. CONCLUSIONS: Dornase alpha may be used in some patients with pleural empyema with good results.

Stage IIIa cancer of the right lung ingrowing via right lower pulmonary vein to the left heart atrium.

Computed tomography is performed in every patient before lung tumour resection. The presented case realises how important it is to perform this study with contrast. In a 75-year-old male we detected a tumour ingrowing from the right lung through the right lower pulmonary vein into the left atrium of the heart. The patient was qualified for primary sternotomy with extracorporeal circulation and resection of the intracardiac part of the tumour. In the second stage, right-sided thoracotomy was performed, and right lower lung lobectomy was done. Mixed heterogeneous lung cancer was diagnosed (squamous cell and non-small cell endocrine) in stage IIIa. The perioperative period was uncomplicated. The patient, due to renal failure, was not eligible for adjuvant chemotherapy. If the patient were qualified for lobectomy based directly on computed tomography without contrast, there would have been a high risk of perioperative death due to embolic incidents and heart failure. Effective multidisciplinary collaboration allowed us to avoid this sort of complication.

Detection and cultivation of circulating tumor cells in malignant pleural mesothelioma.

UNLABELLED: Malignant pleural mesothelioma (MPM) is an aggressive disease with very poor prognosis which tends to affect older patients. Progress in the management of this group of patients has been limited by the rarity of the disease and hence, difficulty in conducting randomized trials. The vast majority of cancer deaths occur due to metastasis of the primary tumor to distant sites via circulating tumor cells (CTCs) in the circulation. CTCs are extremely rare and limits in technology used to capture these cells hamper our complete understanding over the metastatic process. In the present study we present a new method for detection and cultivation of CTCs isolated from peripheral blood of MPM patients. PATIENTS AND METHODS: Patients with diagnosed MPM were enrolled into this study. RESULTS: A size-based separation method for viable CTC enrichment from unclothed peripheral blood has been introduced; MetaCell. The size-based enrichment process was based on filtration of peripheral blood (PB) through porous polycarbonate membrane. The separated CTCs are cultured on the membrane in vitro under standard cancer cell culture conditions and observed by an inverted microscope. CONCLUSION: The reported methodology allows for quick and easy enrichment of CTCs and their cultivation. The cultivated cells can be used for next specification of gene expression and histological/biological specificity of concrete mesothelioma.

Immunomagnetic detection of cancer cells in pleural effusion of generalized cancer.

Malignant pleural effusions (MPE) are a common clinical problem in patients with neoplastic disease. Pleural fluid cytology is the simplest definitive method for obtaining a diagnosis of MPE. We describe a method that may increase the cancer cell detection rate using immunomagnetic separation in MPE. In comparison to standard MPE cytodiagnostic methods, we report a more streamlined method of isolation living cells that are able to proliferate. These captured cells can then be used for additional downstream analysis e.g. chemosensitivity testing. Several case studies of MPE diagnostics using immunomagnetic separation are presented in the following report. The immunomagnetic separation of cancer cells from MPE could be used for more accurate staging of patients with routine effusions.

New therapy of pleural empyema by deoxyribonuclease

Empyema is a severe complication of different diseases and traumas. Management of this complication is difficult and should comprise general and local procedures. The general procedure is mainly based on administering wide-spectrum antibiotics. Local management depends on patient general condition, but in all cases the essential procedure is to insert a drain into the pleural cavity and to evacuate the pus. Sometimes pus is very thick and its evacuation and following re-expansion of the lung is rather impossible. In these patients surgical intervention is needed. The use of intrapleural enzymes to support the drainage was first described in 1949 by Tillett and Sherry using a mixture of streptokinase and streptococcal deoxyribonuclease. Nowadays, purified streptokinase has come into widespread use, but recent studies reported no streptokinase effect on pus viscosity. On the other side, deoxyribonuclease reduces pus viscosity and may be more useful in treatment. We report two cases of intrapleural administration of Pulmozyme (alfa dornase - deoxyribonuclease (HOFFMANN-LA ROCHE AG) in dosage 2 × 2.5 mg with a significant improvement caused by changes in pus viscosity.

New therapy of pleural empyema by deoxyribonuclease.

Empyema is a severe complication of different diseases and traumas. Management of this complication is difficult and should comprise general and local procedures. The general procedure is mainly based on administering wide-spectrum antibiotics. Local management depends on patient general condition, but in all cases the essential procedure is to insert a drain into the pleural cavity and to evacuate the pus. Sometimes pus is very thick and its evacuation and following re-expansion of the lung is rather impossible. In these patients surgical intervention is needed. The use of intrapleural enzymes to support the drainage was first described in 1949 by Tillett and Sherry using a mixture of streptokinase and streptococcal deoxyribonuclease. Nowadays, purified streptokinase has come into widespread use, but recent studies reported no streptokinase effect on pus viscosity. On the other side, deoxyribonuclease reduces pus viscosity and may be more useful in treatment. We report two cases of intrapleural administration of Pulmozyme (alfa dornase - deoxyribonuclease (HOFFMANN-LA ROCHE AG) in dosage 2×2.5mg with a significant improvement caused by changes in pus viscosity.

Retrosternal goiter located in the mediastinum: surgical approach and operative difficulties.

Most retrosternal goiters are situated in the anterior mediastinal compartment, but according to the literature, 10-15% are located in the posterior mediastinum. Although most of the anterior mediastinal goiters can be removed by a transcervical approach, posterior mediastinal goiters may require additional extracervical incisions. We report the case of a huge posterior mediastinal goiter extending from the neck retrotracheally beyond the aortic arch and azygous vein with crossover from the left to the right side and ending at the level of the lower part of the left cardiac atrium, nearly reaching the diaphragm. Surgical removal is the treatment of choice in such cases. We performed an operation using a transcervical and right thoracotomy approach. Histopathological examination confirmed the diagnosis of the large goiter. The patient recovered well and was discharged in 1 week.

Cimetidine: an anticancer drug?

Cimetidine, H(2) receptor antagonists, is commonly prescribed for gastric and duodenal ulcer disease. Additionally, cimetidine has been shown to have anticancer effects. This review describes the mechanism of antitumor action of cimetidine including its ability to interfere with tumor cell adhesion, angiogenesis and proliferation; its effect on the immune system; as well as inhibition of postoperative immunosuppression. Its anticancer effect is also compared to that of the other H(2) receptor antagonists as well as outcomes of cimetidine in clinical studies in cancer patients.

A clinically relevant, syngeneic model of spontaneous, highly metastatic B16 mouse melanoma.

We report a syngeneic model of spontaneous metastatic B16-F10 mouse melanoma in C57/BL6 mice with a very high metastatic frequency that mimics clinical metastatic melanoma. The B16 melanoma cells were injected between the skin and cartilage on the dorsal side of the ear. The model generated lymphatic and visceral metastases in all of the tested animals. In mice with large primary tumors, tumor weight correlated with the tumor growth time and also with the number of metastases in lymph nodes and organs. The dorsal ear space between the skin and cartilage enables both lymphatic and hematogenous metastatic spread. The model should be useful to study the mechanism of melanoma metastasis and to develop therapy for this currently untreatable disease.

Causes and management of postpneumonectomy empyemas: our experience.

OBJECTIVE: Infection of the pleural cavity and development of empyema are potential dangers after pneumonectomy. In spite of decrease in frequency of postpneumonectomy empyemas (PPE) formation, this is still a serious complication. The aim of this study was: analysis the mechanisms of postpneumonectomy empyema formation and attempt the elaboration of the optimal management of these patients. METHODS: 1148 pneumonectomies were performed at the Thoracic Surgery Centre between 1984 and 2002. PPE occurred in 76 (6.6%) patients between the ages of 25-77. For statistical purposes the chi2 test was used. RESULTS: The causes of PPE showed that in 56/76 (73.7%) patients its formation was due to a postoperative complications. In 4/76 (5.3%) cases the cause of empyema was associated with intraoperative infection during the operation. In 3/76 (3.9%) patients a long period of treatment at the intensive care unit due to postoperative shock predisposed to the infection. In 13/76 (17.1%) patients the cause was not established. Statistically significant PPE was associated with postoperative complication (P=0). Postoperative complication caused by one factor was more frequent than those caused by 2 or 3 factors (P=0). PPE was the most often diagnosed in the second postoperative week (P=0.0001). 13 (17.1%) patients died during the 30 days after beginning of the treatment of PPE. The course of complication was more impetuous and more deaths were noted in patients diagnosed during the first week after operation. Only 8 patients from 34, who were selected for thoracentesis and lavage with deposition of antibiotics into the pleural cavity recovered. Jointly 68 (89.5%) patients underwent chest tube drainage. After 2-3 weeks the tube was removed in 16 patients. 17 (22.4%) patients were not qualified for operation. 35 (46.1%) patients underwent different operative procedures: 20 fenestrations, 12 fenestrations with myoplasty and 3 thoracoplastic operations with myoplasty. CONCLUSIONS: The most common causes of PPE were postoperative complications, mainly bronchopleural fistula. The scheme of therapeutic management in PPE was elaborated as a result of our experience.

[Post-pneumonectomy empyemas: causes, clinical course, management]. / Ropniaki komory poresekcyjnej: przyczyny, przebieg kliniczny, postepowanie.

Between 1984 and 2000 in the Thoracic Surgery Centre pneumonectomies were performed in 947 patients. Postpneumonectomy empyema (PE) occurred in 67 (7%) patients. The aim of this paper were: analysis the reasons of postpneumonectomy empyema appearance, defined bacterial flora, clinical course and optimal management. The causes of PE were: pleural cavity haematoma (20 patients-29.8%), wound suppuration (18 patients-26.8%), bronchial fistula (31 patients-46.2%). These complications appeared singly or together in 49 (73.1%) patients. In 2 (3.0%) patients a long treatment in the Intensive Care Unit because of postoperative shock was the cause of infection. In 3 (4.5%) cases the cause of empyema was associated with infection during the operation. In 13(19.4%) cases the cause of empyema was not established. In 55 patients infections of pleural cavities were diagnosed in the first 8 weeks after operations. In 12 patients empyemas were established later. 12 (17.9%) patients died during the analyzed 1 year period after operation. In 18 (26.9%) patients infections were caused by only one bacterial strain and in 49 (73.1%) by two or three bacterial strains. The different methods of treatment (thoracentesis, drainage, operation) depending on general condition of patient were done.