Differentiation between malignant and benign pleural effusion in patients with extra-pleural primary malignancies: assessment with positron emission tomography-computed tomography.

OBJECTIVES: We sought to define an accurate diagnostic approach for differentiating benign from malignant pleural effusion on positron emission tomography-computed tomography (PET-CT). MATERIAL AND METHODS: PET-CT studies of 31 patients with primary extrapleural malignancy and pleural effusion were reviewed retrospectively. CT parameters assessed were size and density (Hounsfield units, or HU) of the effusion and density (HU) and morphology of any solid pleural abnormality. Interpretation of PET data included review of the attenuation-corrected and nonattenuation-corrected images. RESULTS: PET-CT parameters that were found to be significant in identifying malignant pleural effusion included focal increased uptake of 18-fluorodeoxyglucose in the pleura (P<0.0001) and the presence of solid pleural abnormalities on CT (P<0.002): the sensitivity was 86% and 71%, respectively, and the specificity was 90% for each of the 2 parameters. A PET-CT pattern composed of pleural uptake and increased effusion activity on nonattenuation-corrected images was associated with sensitivity of 95%, specificity of 80%, positive predictive value of 91%, negative predictive value of 89%, and accuracy of 90%. CONCLUSIONS: On PET-CT, the presence of concomitant pleural abnormalities is the most accurate criterion in determining the malignant nature of pleural effusion.

Transcervical thymectomy for myasthenia gravis achieves results comparable to thymectomy by sternotomy.

BACKGROUND: It remains controversial whether transcervical thymectomy offers results equivalent to thymectomy by way of a median sternotomy in the treatment of myasthenia gravis. Furthermore, preoperative prognostic factors have not been clearly defined. METHODS: This study is a retrospective chart review and interview of 78 patients completing transcervical thymectomy for myasthenia gravis between 1992 and 1999. RESULTS: There were 24 men and 54 women. Mean age was 40 years (range, 13 to 78 years). Twelve patients were in Osserman class 1, 25 in class 2, 30 in class 3, and 11 in class 4 (mean, 2.5). There was no perioperative mortality and 6 (7.7%) morbidities. Mean length of stay was 1.5 days and mean follow-up, 54.6 months. The crude cumulative complete remission (asymptomatic off medications for 6 months) rate was 39.7% (n = 31). Only 8 patients (10.3%) failed to improve after transcervical thymectomy. Kaplan-Meier estimates of complete remission were 31% and 43% at 2 and 5 years, respectively. Eight patients with thymoma had a 5-year estimated complete remission rate of 75% in contrast to 43% in 38 patients with thymic hyperplasia and 36% in 32 patients with neither thymoma nor hyperplasia (p = 0.01). Twelve patients with ocular myasthenia had a 5-year estimated complete remission rate of 57%, whereas patients with mild-to-moderate (n = 55) or severe (n = 11) generalized symptoms had 5-year complete remission rates of 43% and 30%, respectively (p = 0.21). CONCLUSIONS: Overall, extended transcervical thymectomy offers results that are comparable to those published for the transsternal procedure. Patients with milder disease (including isolated ocular disease) and taking no preoperative immunosuppressive agents appear to experience higher remission rates. In contrast to previous studies, we also find that small thymomas predict better responses to thymectomy.

Incidental finding of myeloproliferative disorders during sternotomy.

We report 2 cases of myeloproliferative disorders discovered incidentally at the time of routine coronary bypass surgery. Suspicion of abnormal bone marrow tissue upon performing sternotomy and subsequent sampling for frozen section made the diagnosis. The surgical plan was changed, and partial revascularization without cardiopulmonary bypass was performed.

Suction vs water seal after pulmonary resection: a randomized prospective study.

STUDY OBJECTIVE: To evaluate whether suction or water seal is superior in the management of chest tubes after pulmonary resection. DESIGN: A prospective, randomized, controlled trial. After an initial, brief period of suction, patients were randomized to water seal or - 20 cm H(2)O suction. SETTING: University hospital. PATIENTS: Sixty-eight patients who underwent wedge resection, segmentectomy, or lobectomy were included in the study. Those patients who underwent reoperative surgery or lung volume reduction surgery were excluded. RESULTS: There were 34 patients in each group. The two groups were evenly matched for age, sex, operation performed, severity of lung disease, and nutritional status. Fifteen patients in each group (44%) had an air leak at the completion of surgery. The duration of the air leak was shorter in the water seal group than in the suction group (mean +/- SEM, 1.50 +/- 0.32 days vs 3.27 +/- 0.80 days, respectively; p = 0.05). The mean times to removal of chest tubes were 3.33 +/- 0.35 days in the water seal group and 5.47 +/- 0.98 days in the suction group (p = 0.06). The length of stapled parenchyma was measured for each patient and averaged 24.9 cm for the water seal group and 18.5 cm for the suction group (p = 0.18). When corrected for the length of staple lines, the duration of air leaks and days with chest tube were dramatically lower in the water seal group (p = 0.02 and p = 0.02, respectively). CONCLUSION: Placing chest tubes on water seal after a brief period of suction after pulmonary resection shortens the duration of the air leak and likely decreases the time that the chest tubes remain in place. Adoption of this practice may result in lower morbidity and lower hospital costs.