Ganglioneuroma presenting as subpulmonic effusion-a differential to consider?

Ganglioneuroma is a benign, slow-growing neurogenic tumor arising from neural crest cells. It is extremely rare (1/1,000,000) and is located most commonly in the posterior mediastinum (41.5%), retroperitoneum (37.5%), and adrenal glands (21%). We present a case of a 62-year-old lady who had complaints of shortness of breath on exertion and dyspnea for the past 3 months. She had no other significant history. Computerised tomography (CT) scan of the thorax suggested left-sided loculated subpulmonic pleural effusion, 14 × 12 cm in dimension. She underwent assisted video-assisted thoracoscopic surgery (VATS) exploration of the thorax with debridement and drainage of subpulmonic collection that was abutting the diaphragm, along with release of trapped lung. Histopathological examination showed multiple ruptured cystic masses with nodules; microscopical evidences of Schwann cells, ganglion cells, and spindle cells-all these along with immunohistochemistry-revealed features consistent with ganglioneuroma. Postoperative recovery was uneventful, and the patient did not have any complaints or other limitations to daily life activities at 6 months' follow-up. Ganglioneuroma is essentially benign in nature, asymptomatic, and rare. A systematic review of the literature has shown that giant-sized ganglioneuromas (size more than 10 cm) have rarely been reported. Surgical excision and clearance is the treatment modality of choice. In our case, due to large size and difficulty in access and mobilisation of the mass adherent to the diaphragm, assisted VATS had to be performed. We increased the size of the utility port from 5 to 10 cm and used a rib retractor for better surgical negotiation. This could have been more challenging, as there have been incidences where ganglioneuromas have extended both into the thoracic and abdominal cavities and even involved vital organs and vessels. Regular follow-up is essential, as late recurrence and slow progression potential is a known complication.

Understanding the practice of thoracic surgery during the COVID-19 pandemic.

The COVID-19 pandemic has affected the entire medical community including the thoracic surgical practice. The guidelines, consensus statements, and preliminary recommendations published by the thoracic surgeons so far have appreciated the importance of triage of patients with thoracic surgical diseases and multidisciplinary team (MDT) meeting. Delaying surgery or planning alternative treatment in patient care should be done by taking input from experts in thoracic specialties. The procedures that can be carried out in a hospital are based on the prevalence of COVID-19 patients within the hospital and availability of hospital resources. As a result, proper triaging, ensuring safety of patient and health care personnel, and optimal utilization of the available resources remain the cornerstone while fighting the COVID-19 pandemic. In this manuscript, we highlight these issues with respect to practice of thoracic surgery.

Malignant perivascular epitheloid cell tumour (PEComa) of the lung - a rare entity.

Malignant Perivascular Epitheloid Cell Tumour (PEComa) of the lung is very rare, with only six cases reported in literature. This case presented with a large mass originating from right upper lobe of the lung with dilemma in its histopathological diagnosis and management. Postoperative histopathology after a right upper and middle lobectomy describes a tumour with an alveolar/nested pattern of growth and epitheloid morphology with expression of TFE-3 and diagnosed as PEComa. After 6 months the patient had a local recurrence inside the thorax & chest wall.This case qualifies it as a rare type of malignant PEComa with younger age of presentation, aggressive clinical behaviour & malignant histological features along with TFE3 positivity on immunohistochemistry. This case is probably the first of its kind with the largest reported size involving two lobes of the lung.

Angiography for management of perioperative myocardial ischemia: does it have any role?

OBJECTIVE: Perioperative myocardial ischemia (PMI) is a relatively rare but potentially fatal complication after coronary artery bypass grafting and is due to graft-related problems in a significant proportion of cases. The usual indicators of MI in the postoperative setting are unreliable and therefore have uncertain diagnostic value. Angiography, the criterion standard for preoperative angina, remains underused for evaluation of PMI. The aim of this study was to evaluate the role of angiography in the management of PMI. METHODS: Between January 2011 and September 2012, a total of 2312 isolated primary consecutive coronary artery bypass graft surgeries were performed, of which 2057 (89%) were carried out on the beating heart. Twenty-six (1.12%) of these patients needed perioperative angiography. The patients needing angiography were selected on the basis of a number of clinical, biochemical, and other diagnostic parameters RESULTS: Twenty-six patients with PMI required angiography, of which 18 (69 %) were found to have graft-related issues. The mean (SD) time between operation and angiography was 24.58 (6.71) hours. Of the 18 patients, 17 (94.44%) required surgical intervention and 1 patient was treated with angioplasty. There were 2 deaths (11.1%) in the group undergoing intervention. Angiographic findings included occluded vein graft (n = 7), narrowing of the left internal mammary artery (n = 3), and kinking or stretching of grafts (n = 8). CONCLUSIONS: Angiography is useful in diagnosing graft-related problems in the perioperative period. In presence of signs of graft compromise, we suggest that having a low threshold for angiographic graft evaluation may be beneficial in a carefully selected subset of patients after coronary artery bypass.