Multimodality treatment and long-term follow-up of the primary pulmonary lymphoepithelioma-like carcinoma.

INTRODUCTION: Primary pulmonary lymphoepithelioma-like carcinoma (LELC) is a very rare subtype of non-small-cell lung cancer. Most cases are reported in Southeast Asia and are associated with Epstein-Barr virus infections. Because of its rare incidence, the optimal treatment and the results of long-term follow-up are not well understood. This study is an attempt to discover the multimodality treatment results of the primary pulmonary LELC. METHODS: This retrospective study enrolled 21 patients with primary pulmonary LELC treated at 2 hospitals with a multimodality approach, including surgery, chemotherapy, radiotherapy, and targeted therapy. RESULTS: The median follow-up time is 5.9 years and the median survival is 6.4 years. The median overall survival for patients with stage III and with stage IV disease is 3.4 years. In early-stage primary pulmonary LELC, surgery and adjuvant chemotherapy provided good treatment outcome. Advanced primary pulmonary LELC is relatively more chemosensitive and radiosensitive. CONCLUSION: Patients with primary pulmonary LELC showed better prognosis than those with other types of non-small-cell lung cancer and achieved longer survival under multimodality treatment. This disease character is similar to that of nasopharyngeal carcinoma. Accurate pathologic diagnosis is recommended before the treatment. For advanced diseases, platinum-based doublet chemotherapy can be considered the first-line treatment. Radiation dose should consider tumor location, and 5000 to 7000 cGy is frequently applied for pulmonary LELC.

Characteristics of integrated 18F-FDG PET/CT in Pulmonary Cryptococcosis.

BACKGROUND: Pulmonary cryptococcosis is an uncommon cause of pulmonary nodules found by (18)F-fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) scans. It is rarely reported but may mislead interpretation. PURPOSE: To describe the (18)F-FDG PET/CT findings of pulmonary cryptococcosis. MATERIAL AND METHODS: The (18)F-FDG PET/CT images of seven patients with pulmonary cryptococcosis were evaluated. RESULTS: The (18)F-FDG PET/CT exams showed single or multiple nodular lesions. The standardized uptake values (SUV) in early images varied significantly for the seven patients (ranging from 2.2 to 11.6). Delayed SUVs showed significant increases in four patients. CONCLUSION: Pulmonary cryptococcosis mimics primary or metastatic lung cancer on (18)F-FDG PET/CT scan. Tissue confirmation should be considered for any suspicious pulmonary nodules found on (18)F-FDG PET/CT scan with an SUV score higher than 2.5, in order to avoid overdiagnosis or overstaging.

Thoracic chordoma: an unusual presentation of the spinal tumor.

Chordoma is an uncommon malignant bone tumor that originates from the remnants of the embryonic notochord. In most of the reported cases, chordomas occur at the skull base or in the sacrococcygeal spine but rarely in the thoracic spine. In this report, we describe a case of a large thoracic chordoma with posterior mediastinal extension in a 25-year-old woman who presented with left-hand anhydrosis. The imaging studies, pathology findings, and recent advances in treatment are discussed.

Computed tomography characteristics of primary pulmonary lymphoepithelioma-like carcinoma.

Primary pulmonary lymphoepithelioma-like carcinoma is a very rare subtype of lung cancer. This report documents the CT features of 16 Chinese patients diagnosed with primary pulmonary lymphoepithelioma-like carcinoma from January 1999 to December 2005. A pre-treatment CT was used to assess the tumour site, size, borders, pleural and vascular involvement, and the presence of lymph node involvement. The majority of the patients were female non-smokers with centrally located tumours. Lymph node involvement and bronchial and vascular encasement were frequent. In an Epstein-Barr virus endemic area, primary pulmonary lymphoepithelioma-like carcinoma is an important differential diagnosis to consider.

Association between adrenal insufficiency and ventilator weaning.

RATIONALE: Adrenal insufficiency is a common disorder in critically ill patients with mechanical ventilation and is usually associated with higher mortality and poor clinical outcome. OBJECTIVES: To determine whether stress dose corticosteroid supplementation can improve ventilator weaning and clinical outcome in patients with adrenal insufficiency. METHODS: A prospective, randomized, placebo controlled, double-blinded study was conducted in the intensive care unit of a tertiary teaching hospital. A total of 93 mechanically ventilated patients were enrolled in the ventilator weaning trial. Adrenal function was assessed in all patients. Patients with adrenal insufficiency were randomized to the treatment group (50 mg intravenous hydrocortisone every 6 h) and the placebo group. MEASUREMENTS AND MAIN RESULTS: The successful ventilator weaning percentage was significantly higher in the adequate adrenal reserve group (88.4%) and in the stress dose hydrocortisone treatment group (91.4%) than in the placebo group (68.6%). The weaning period was shorter in the hydrocortisone treatment group than in the placebo group. No significant adverse effects were observed in the corticosteroid treatment group. CONCLUSIONS: For patients with respiratory failure, early identification of adrenal insufficiency and appropriate supplementation with stress dose hydrocortisone increase the success of ventilator weaning and shortens the weaning period.

Subacute pulmonary manifestation in a survivor of severe paraquat intoxication.

Paraquat has been widely used as a nonselective contact herbicide since 1962. It is highly toxic for humans, and many cases of acute poisoning, especially intentional self-poisoning, have been reported over the past few decades in developing countries. Ingestion of a threshold volume results in multiple organ failure and death after a longer period of time, but aggressive clinical studies are rarely done when the diagnosis is clear. We report the case of a patient who survived severe paraquat intoxication; he presented with subacute pulmonary manifestations including physiologic dysfunction and abnormalities on radiographs.

Stabilization of hypoxia-inducible factor-1{alpha} by prostacyclin under prolonged hypoxia via reducing reactive oxygen species level in endothelial cells.

Hypoxia-inducible factor-1 (HIF-1) takes part in the transcriptional activation of hypoxia-responsive genes. HIF-1alpha, a subunit of HIF-1, is rapidly degraded under normoxic conditions by the ubiquitin-proteosome system. Hypoxia up-regulates HIF-1alpha by inhibiting its degradation, thereby allowing it to accumulate to high levels with 3-6 h of hypoxia treatment and decreasing thereafter. In vascular tissues, prostacyclin (prostaglandin I(2) (PGI(2))) is a potent vasodilator and inhibitor of platelet aggregation and is known as a vasoprotective molecule. However, the role of PGI(2) in HIF-1 activation has not been studied. In the present study, we investigated the effect of PGI(2) on HIF-1 regulation in human umbilical vein endothelial cells under prolonged hypoxia (12 h). Augmentation of PGI(2) via adenovirus-mediated gene transfer of both cyclooxygenase-1 and PGI(2) synthase activated HIF-1 by stabilizing HIF-1alpha in cells under prolonged hypoxia or the hypoxia-normoxia transition but not under normoxia. Exogenous H(2)O(2) abolished PGI(2)- and catalase-induced HIF-1alpha up-regulation, which suggests that degradation of HIF-1alpha under prolonged hypoxia is through a reactive oxygen species-dependent pathway. Moreover, PGI(2) attenuated NADPH oxidase activity by suppressing Rac1 and p47(phox) expression under hypoxia. These data demonstrate a novel function of PGI(2) in down-regulating reactive oxygen species production by attenuating NADPH oxidase activity, which stabilizes HIF-1alpha in human umbilical vein endothelial cells exposed to prolonged hypoxia.

Large cryptococcoma mimicking lung cancer in an HIV-negative, type 2 diabetic patient.

Pulmonary cryptococcoma is an unusual disease in immunocompetent patients. The typical radiologic findings are single or multiple small nodules. We describe a case of a large pulmonary cryptococcoma in a 69-year-old patient, who presented with generalized weakness and poor appetite. Computed tomography of the chest showed a large mass that was strongly suggestive of lung cancer. Pulmonary cryptococcal infection was diagnosed by transthoracic needle biopsy. Human immunodeficiency virus testing was negative. The mass resolved with 200 mg daily of oral fluconazole over the course of 6 months.

Massive subcutaneous emphysema following bronchoscopy-guided percutaneous dilatational tracheostomy.

Although percutaneous dilatational tracheostomy (PDT) has become a safe procedure for airway management in critically ill patients, this operation can be associated with serious life-threatening complications. Massive subcutaneous emphysema is an unusual and sometimes lethal complication which may extend the length of stay in the intensive care unit (ICU). We report 2 cases, including 1 fatality, of massive subcutaneous emphysema without tracheal wall laceration that occurred in the ICU after elective bronchoscopy-guided Ciaglia Blue Rhino (Cook Critical Care, Bloomington, IL, USA) PDT. Our analysis of these cases suggested that PDT-related barotraumas and imperfect positioning of the fenestrated tracheostomy tube could be the possible mechanisms for the observed complications. In case 1, we reduced the ventilator pressure and prescribed bronchodilator to decrease the airway pressure and keep the airway patent. In case 2, the suggested approach was to check if the fenestration of tracheostomy tube was extraluminal or change to non-fenestrating cannulas. For diminishing the impact of PDT on respiratory mechanics, especially in patients with underlying lung diseases, we recommend introducing the bronchoscope only when needed, instead of keeping the bronchoscope in the airway throughout the PDT procedure and using forceps to create a larger stoma if the dilation procedure is not smooth.

Zafirlukast improves pulmonary function in patients with moderate persistent asthma receiving regular inhaled steroids: a prospective randomized control study.

BACKGROUND: Zafirlukast is a leukotriene receptor antagonist that was invented to treat patients with chronic asthma. METHODS: To evaluate whether the zafirlukast improved the peak expiratory flow rate (PEFR) and clinical symptoms, 31 asthmatic patients with moderate persistent asthma who received regular inhaled corticosteroid were randomly divided into the study group (N = 17). They received the zafirlukast 20 mg bid for 4 weeks, and the control group (N = 14) received a placebo. Daily morning and evening PEFR and St. George's Respiratory Questionnaire (SGRQ) scoring were recorded respectively. The levels of serum IgE and urine leukotriene E4 before and after treatment were measured using enzyme linked immunosorbent assay and enzyme immunoassay kits. RESULTS: In the zafirlukast treated group, the morning PEFR was significantly improved from 314.4 +/- 20.6 to 340.6 +/- 18.3 L/min (N = 17, p < 0.05) after 4 weeks of treatment, while the control group did not show any significant changes. The zafirlukast group had significant improvement in their symptom scores of SGRQ from 48.6 +/- 4.6 to 33.8 +/- 4.7 (N = 17, p < 0.05). However, the placebo did not improve the symptom scores. CONCLUSION: Leukotriene receptor antagonists effectively improved symptoms and benefited lung function for moderate persistent asthmatic patients who had received regular treatments with inhaled steroids.