Leiomyosarcoma of the pulmonary vein.

OBJECTIVE: We report a case of leiomyosarcoma (LMS) of the pulmonary vein and comment on the natural history and determinants for survival for this rare condition. EXPERIMENTAL DESIGN: Our retrospective review is only the fourth such case reported in the world's literature. SETTING: A teaching hospital with an active surgical residency program. PATIENT OR PARTICIPANT: A 61-year-old female who presented with a central pulmonary mass. INTERVENTIONS: Complete resection without pneumonectomy of cardiopulmonary bypass. Pathology showed low grade LMS. MEASURES: Determinants for survival include complete surgical resection and a low mitotic activity of the tumor. RESULTS: The patient remains no evidence of disease three years following initial treatment. CONCLUSIONS: One reported case of LMS of the pulmonary vein had favorable determinants for survival; complete surgical resection and low mitotic activity of the tumor. These factors may have contributed to the successful outcome. The natural history of LMS of the pulmonary vein appears similar to the more widely studied LMS of the inferior vena cava.

Techniques in the composite reconstruction of extensive thoracoabdominal tumor resections.

BACKGROUND: This report illustrates the unique problems of reconstructing thoracoabdominal wall defects coexisting with diaphragmatic defects. STUDY DESIGN: Two patients with extensive primary chest wall tumors (chondrosarcoma and desmoid tumor) underwent aggressive resection of the hemithorax, hemidiaphragm, and anterior chest wall for cure. The combined chest and abdominal wall defect was greater than 625 cm2 in both cases. RESULTS: Functional restoration of these massive thoracoabdominal defects was accomplished by use of polypropylene-methyl methacrylate prostheses and vascularized tissue coverage. The requirements for rigidity, protection, and esthetic contouring of the chest wall are satisfied by this reconstruction. This technique also offers the flexibility and durability that the abdominal wall requires. Repair of the diaphragm using this technique is secure and simple. CONCLUSIONS: Our report confirms the principle that, with modern thoracic and plastic operative techniques, the extent of tumor resection should not be compromised because of concern over the ability to reconstruct the defect.

Pulmonary artery and noninvasive hemodynamics during lung lavage in primary alveolar proteinosis.

Noninvasive hemodynamic monitoring by bioimpedance has been compared to cardiac output measured by thermodilution. The technology of bioimpedance does allow for monitoring of static thoracic impedance, a measurement thought to be affected by extravascular lung water. No contemporary studies (in the last 20 years) have examined the effectiveness of that parameter in measuring changes in lung water. This case report notes hemodynamics and examines thoracic impedance in a patient undergoing unilateral lung lavage. The hemodynamic data measured by bioimpedance and thermodilution correlated well (r = 0.97 for cardiac output). The changes in static impedance were compared to thoracic compliance during infusion of saline solution and evacuation. The changes in both parameters followed each other closely. Further work is required in patients with pulmonary edema or effusions before bioimpedance can be used to monitor such clinical events.

Acquired immunodeficiency syndrome-related lymphoma of the lung presenting as empyema thoracis.

B-cell lymphoma in patients infected with the human immunodeficiency virus is usually a disseminated process that occasionally involves the lungs. Surgical diagnosis is often necessary to distinguish this from other neoplasms or opportunistic infections of the lung. We report a case of pulmonary B-cell lymphoma in a patient infected with human immunodeficiency virus who presented with a left empyema thoracis and an associated left lower lobe abscess secondary to bronchial obstruction. Resection was performed and the patient subsequently recovered from the acute process and survived an additional 6 months. This report demonstrates that surgical intervention may be necessary for both the diagnosis of pulmonary lymphoma and the definitive management of infectious complications that may arise as a result of pulmonary neoplastic disease in patients with acquired immunodeficiency syndrome.

Benign cartilaginous tumor (chondroma) of the liver.

A 44-year-old woman with a large benign cartilaginous tumor (chondroma) of the liver is presented. After being followed up by computed tomography for 6 years and with imagining evidence for a recent increase in its size, this asymptomatic tumor was successfully removed at surgery. The resected tumor proved to be chondroma, a benign cartilaginous tumor. A review of the literature showed no previous reports of this type of hepatic neoplasm.

Monoclonal immunoglobulin deposition disease in a renal allograft: probable recurrent disease in a patient without myeloma.

A case in which monoclonal IgG-kappa deposition in the glomeruli of a renal allograft apparently resulted in graft failure is described. Review of biopsy material obtained from the patient's native kidney biopsy indicates a high probability that this glomerulopathy represents recurrent disease in the allograft. The reported transplantation experience with this entity (monoclonal immunoglobulin deposition disease; light-chain nephropathy) is limited; this case indicates the potential for disease recurrence even in the absence of a systemic lymphoplasmacytic disorder.

Cloning and sequence of cDNA coding for alpha 1-antitrypsin.

Recombinant plasmids containing human and baboon cDNA have been screened for alpha 1-antitrypsin, a major serine protease inhibitor present in blood. One plasmid, designated pBa alpha 1a2, was found to contain a cDNA insert of 1352 base pairs coding for the baboon inhibitor. It included 45 nucleotides that code for 15 amino acids present in the amino-terminal signal sequence of the protein, 1182 nucleotides that code for 394 amino acids in the mature protein, a stop codon, and a noncoding region of 76 nucleotides. Comparison of the amino acid sequences of baboon alpha 1-antitrypsin, human antithrombin III, and chicken ovalbumin indicated that these three proteins are about 230% homologous. A second plasmid, designated pH alpha 1a1, was found to contain a human cDNA insert of 306 base pairs. This plasmid coded for 69 amino acids present in the carboxyl-terminal region of human alpha 1-antitrypsin. The human and baboon cDNAs and their amino acid sequences are greater than 96% homologous.

The use of self-retained ureteral stents in the management of urologic complications in renal transplant recipients.

Nineteen self-retaining ureteral stents were used to manage postoperative ureteral obstruction and fistulas in 12 renal transplant recipients. In 3 patients with ureteral obstruction and 2 with a fistula placement of the self-retaining stents for 4 to 6 weeks allowed the complication to resolve. In 3 patients with ureteral obstruction placement of the self-retaining stents allowed for stabilization of the condition and reduction of immunosuppression therapy before an open surgical repair. In 6 patients self-retaining ureteral stents were used to protect the high risk anastomosis done at an open surgical repair of a complication. Placement of a self-retaining ureteral stent may be the best choice in the early management of ureteral obstruction and fistulas in transplant recipients.

Colon perforation in renal transplant patients.

Seven patients had perforated colonic diverticula 1 to 17 months after transplantation. Operation was performed immediately in four patients and from 4 days to 3 months later in three patients. Three patients are alive 9 to 36 months later. Two died of sepsis and two of myocardial infarction. Immediate operation with exclusion carries the best prognosis.

Gibbons ureteral stent in renal transplant recipients.

The Gibbons indwelling ureteral stent was used in 5 renal recipients. Early post-operative obstructions at the ureterovesical junction in 2 cases and 1 at the ureteroplevic junction were treated by placing the stent through an open cystostomy. Late strictures were treated in 2 patients by inserting the stent endoscopically. It was also used to stent a ureteroureterostomy. After removal of the stent in 2 of 3 patients, no further treatment of the obstriction was required. In the third case it provided time to allow the steroid dose to be lowered so definitive repair could be undertaken. One stent has remained patent for fourteen months. The Gibbons stent appears to be a valuable new tool in the treatment of post-transplant ureteral obstruction.

The adverse effect of high-dose steroids on renal autografts and homografts.

We observed that canine renal homografts preserved for 5 hours with hypothermic pulsatile perfusion to which large doses of methylprednisolone were added showed obliteration of glomerular capillary loops by eosinophilic proteinaceous material immediately after revascularization. The lesion progressed to focal necrosis at 24 hours and diffuse necrosis by 5 days. Urine formation was present 7.8 (+/- 3.2 S.D.) days in eight control kidneys not exposed to methylprednisolone, 5.8 (+/- 3.8 S.D.) in 11 organs perfused with 1.0 Gm. of methylprednisolone added, and 3.0 (+/- 2.9 S.D.) in eight with 2.0 Gm. of the drug in the standard cryoprecipitated canine plasma perfusate. Autografts treated with the larger dose also showed a similar but temporally more variable lesion. Two kidneys ceased functioning at 4 and 7 days, and six still were functioning at 14 days. Ninety-four percent of human renal homografts from living related donors were functioning at one month and 82 percent at one year in 88 patients who had rejection crises treated with one gram of methylprednisolone or less intravenously. In 32 human recipients of living related donor grafts receiving 40 mg. per kilogram of methylprednisolone intravenously from days one to 3 postoperatively and for rejection crises, 69 and 59 percent were functioning at one month and one year, respectively. From this data we conclude that exercise doses of methylprednisolone are inadvisable in renal transplantation.