Bronchopulmonary Neuroendocrine Neoplasms and Their Precursor Lesions in Multiple Endocrine Neoplasia Type 1.

OBJECTIVE: The prevalence and clinical behavior of bronchopulmonary neuroendocrine tumors (bNET) associated with multiple endocrine neoplasia type 1 (MEN1) are not well defined. This study aimed to determine the prevalence, potential precursor lesions and prognosis of bNET in patients with MEN1. METHODS: A database of 75 prospectively collected MEN1 cases was retrospectively analyzed for bNET. Patient characteristics, imaging and treatment were evaluated. Resection specimens of operated patients were reassessed by two specialized pathologists. Available CT scans of the whole cohort were reviewed to determine the prevalence of bronchopulmonary nodules. RESULTS: Five of the 75 MEN1 patients (6.6%; 2 male, 3 female) developed histologically confirmed bNET after a median follow-up of 134 months. The median age at diagnosis of bNET was 47 years (range 31-67), and all patients were asymptomatic. Four patients underwent anatomic lung resections with lymphadenectomy; the remaining patient with multiple lesions had only a wedge resection of the largest bNET. Tumor sizes ranged from 7 to 32 mm in diameter, and all bNET were well differentiated. Two patients had lymph node metastases. Two of 4 reevaluated resection specimens revealed multifocal bNET, and 3 specimens showed tumorlets (up to 3) associated with multifocal areas of a neuroendocrine cell hyperplasia within the subsegmental bronchi. One bNET-related death (1.3%) occurred during long-term follow-up. Review of the available CT scans of the patients without proven bNET revealed small bronchopulmonary lesions (≥3 mm) in 16 of 53 cases (30.2%). CONCLUSIONS: bNET in MEN1 might be more common than previously recognized. Their natural course seems to be rather benign. Multifocal tumorlets and multifocal neuroendocrine cell hyperplasia might represent their precursor lesions.

Gardening can induce pulmonary failure: Aspergillus ARDS in an immunocompetent patient, a case report.

BACKGROUND: Acute Aspergillus fumigatus infection in immunocompetent patients is rare. This is the first known case of a patient who survived Aspergillus sepsis after being treated early with veno-venous extracorporeal membrane (ECMO) and antifungal therapy. CASE PRESENTATION: An immunocompetent 54-year-old woman was exposed to plant mulch during gardening and subsequently developed pulmonary failure that progressed to sepsis with multiorgan failure. Owing to her severe clinical condition, she was treated for acute respiratory distress syndrome (ARDS) with veno-venous ECMO. Empiric antifungal therapy comprising voriconazole was also initiated owing to her history and a previous case report of aspergillosis after plant mulch exposure, though there was no microbiological proof at the time. A. fumigatus was later cultured and detected on antibody testing. The patient recovered, and ECMO was discontinued 1 week later. After 7 days of antifungal treatment, Aspergillus antibodies were undetectable. CONCLUSIONS: In cases of sepsis that occur after gardening, clinicians should consider Aspergillus inhalation as an aetiology, and early antimycotic therapy is recommended.

Simultaneous adrenalectomy during radical nephrectomy for renal cell carcinoma will not cure patients with adrenal metastasis.

OBJECTIVES: To present data from all patients with adrenal involvement after prolonged follow-up and to revise our advice given in 1999. In 1999, we published our results for a large series of patients with adrenal metastasis from renal cell carcinoma. METHODS: The charts of 617 patients who had undergone radical nephrectomy with simultaneous adrenalectomy for renal cell carcinoma at the Department of Urology, Philipps-University Medical School, Marburg from 1985 to 1999 were retrospectively reviewed. In 1999, 23 of 617 patients (3.7%) were found to have adrenal metastasis. The 23 patients included 16 with unilateral ipsilateral adrenal metastasis only, 1 with unilateral contralateral metastasis, and 6 with bilateral adrenal involvement. The postoperative course of the 23 patients has been updated regarding progression and survival after surgery. RESULTS: After a mean follow-up of 59.1 months (range 1.1-156.7), only 5 patients were still alive, all with progressive disease. With a mean interval to death of 41.7 months (range 1.1-126.0), 18 patients had died, 17 of whom had cancer progression. One patient died without signs of disease recurrence 49.1 months after radical nephrectomy and simultaneous ipsilateral adrenalectomy. The mean time to progression was 34.2 months (range 0-91.5). CONCLUSIONS: With these data available, we are now aware that we cannot cure patients with adrenal metastasis by incorporating simultaneous ipsilateral adrenalectomy into routine radical nephrectomy for renal cell carcinoma. The routine incorporation of ipsilateral adrenalectomy should, therefore, be abandoned.

Guidance of percutaneous pulmonary biopsies with real-time CT fluoroscopy.

OBJECTIVE: Clinical evaluation of computed tomography (CT) fluoroscopy and comparison with conventional CT guidance for monitoring of percutaneous pulmonary biopsy procedures. METHODS: Twenty CT-guided pulmonary biopsy procedures were conducted. The interventions have prospectively been performed either with CT fluoroscopy or with conventional CT guidance. About 120 kV and 50 mA with a frame-rate of eight images per second were used for CT fluoroscopy. Number of pleural needle passages, procedure times, radiation doses and histologic results were analyzed separately for both methods. RESULTS: Compared with conventional CT guidance, CT fluoroscopy was associated with less pleural needle passages (1.8+/-0.6 vs. 1.1+/-0.3; P=0.003, t-test) and procedure times were shorter than for conventional CT guidance (12.7+/-2.2 min vs. 26.7+/-16.4 min; P=0.02). Analysis of estimated patient related radiation exposure and histologic outcome showed no significant difference between conventional and fluoroscopic CT-guided procedures (P>0.05). CONCLUSION: CT fluoroscopy facilitates guidance of percutaneous pulmonary biopsy procedures. Compared with conventional CT assistance, procedure times are decreased and less pleural needle passages are required. While patient-related radiation exposure is similar, operator-related radiation exposure remains a disadvantage associated with CT fluoroscopy.