False positive PET scan deserves attention.

PURPOSE: Pulmonary focal lesions are frequently identified incidentally. Furthermore, a final diagnosis is really a considerable problem for patients having risk factors for malignancy or particularly for a newly detected nodule during the postoperative period after any kind of lung surgery. For treatment decisions, the nature of the lesions needs to be clarified. Relatively recently positron emission tomography (PET) scan has been introduced as a non-invasive imaging method for the diagnosis of lesions on the basis of metabolic activity. METHODS: In this study 19 cases with false-positive nodules on PET scan are presented. Chest x-rays and thoracic computed tomographies (CT) were performed to all patients. Due to abnormal/suspicious lesions on radiologic imagies, PET scan was performed to these patients and high standard uptake values (SUV) above the cut-off value of 2.5 were suggestive of malignancy. Invasive procedures were performed to the patients with high suspicion of malignancy. RESULTS: Histology of the resected lesions showed that all of them were benign and therefore the PET results were false-positive. The final diagnoses were tuberculosis, aspergilloma, bronchiolitis obliterans organizing pneumonia (BOOP), sarcoidosis, sequestration, anthracosis and hamartoma. CONCLUSION: Patients living especially in countries with a high incidence of granulomatous diseases like tuberculosis, or patients in postoperative periods with high SUV should be studied thoroughly for false-positive PET results.

Is a small-bore catheter efficient for most pleural pathologies?

PURPOSE: Chest tubes are used for drainage of the pleural cavity. Traditionally, large-bore catheters are inserted for all indications, but there has been a recent tendency to use small-bore catheters. We share the results of our experience of using small-bore catheters for almost all indications routinely in our clinic. METHODS: A collective total of 309 small-bore chest catheters (10 F) were inserted via the Seldinger technique in 287 patients during a 5-year-period. Malignant pleural effusion and pneumothorax were the most common indications for chest tube insertion. RESULTS: The mean catheter duration was 5.6 days, being 5 days for pneumothorax and 6 days for malignant pleural effusion. Pleurodesis was performed effectively for malignant pleural effusions. In this series, the failure rate of small-bore catheters was 7.2 %. CONCLUSION: Based on our clinical experience of using small-bore catheters, we believe that they are potentially effective for almost all pleural pathologies. Our results concur with those in the literature, but this series also includes different pleural diseases requiring chest tube insertion.

Excision of ectopic mediastinal parathyroid adenoma via parasternal videomediastinoscopy.

Mediastinum is one of the place in which ectopic parathyroid adenomas can be located.Here, an ectopic mediastinal parathyroid adenoma, which was excised via parasternal videomediastinoscopy was presented. The patient with chronic renal insufficiency had increased calcium levels persistence after the surgery for cervical parathyroid adenoma.Radiologic and scintigraphic examinations revealed a focal intense nodule in anterior mediastinum. Parasternal videomediastinoscopy was performed via parasternal incision through the second intercostal space. Ex-vivo specimen radioactivity measurements and frozen examination confirmed parathyroid adenoma. Calcium levels were decreased dramatically after the operation. Parasternal videomediastinoscopy could be an alternative surgical way in anterior mediastinal small masses such as ectopic parathyroid adenoma. It is the first case in which parasternal videomediastinoscopy was used for excision of mediastinal parathyroid adenoma.

Characterization of malignant thrombus in an invasive thymoma with intravascular growth.

We report an unusual case of an invasive thymoma with a thrombus in the right atrium and describe the radiological findings consistent with the malignant nature of the thrombus. The thrombus showed significant enhancement on computerized tomography images similar to the tumoral mass. On magnetic resonance imaging, both the tumor and the thrombus have heterogeneously high signal intensities on T2-weighted images. On diffusion-weighted images they both exhibit high signal intensity and low apparent diffusion coefficient (ADC) values which support the malignant nature of the thrombus and the mass.

Value of autofluorescence in video-assisted thoracoscopic surgery in pleural diseases.

BACKGROUND: Autofluorescence (AF) examination in thoracoscopy has not been used frequently. Here, our aim was to determine whether AF examination contributes additional information to white-light (WL) examination when attempting to detect malignant pleural lesions. We also liked to know whether the effectiveness of WL and AF-mode combination would be different for various pathologies or lesions of the pleura. METHODS: It is a retrospective study. Thirty-three patients with unexplained exudative pleural effusions underwent AF-assisted video-assisted thoracic surgery (VATS). Patients' data from the files were evaluated. In each case, the pleural cavity was thoroughly examined under WL alone and then in AF mode. RESULTS: The sensitivity and specificity of AF-assisted VATS for detecting malignant pleural lesions were 78.7 and 85%, respectively, and there were 21.3% false negatives. In the group with metastatic pleural disease, AF VATS correctly identified all lesions as AF positive, whereas sensitivity was lower for the group with malignant mesothelioma. Seven lesions, which were not diagnosed under WL, were detected in AF mode. CONCLUSION: The overall sensitivity of AF-assisted VATS for detecting pleural malignancies was not satisfactory because of diagnostic errors in malignant mesothelioma. But it would be useful in detecting small malignant pleural lesions, which are not diagnosed under WL.

Aspiration of a cigarette filter from a bronchodilator inhaler.

The majority of foreign-body aspirations are seen in children. In adults, neurological dysfunction, trauma, alcohol abuse, or psychological disorders can lead to aspiration, but normal adults can also suffer foreign body aspiration. The symptoms include acute asphyxiation, with or without complete airway obstruction, cough, dyspnea, choking, and fever, which also occur in many other medical conditions. Bronchoscopic removal of the foreign body is necessary, and flexible bronchoscopy is effective in the diagnosis and removal. We saw a patient with COPD who aspirated a plastic cigarette filter while using his bronchodilator inhaler.

Necessity for additional incisions with the cervical collar incision to remove retrosternal goiters.

PURPOSE: Retrosternal goiters (RSGs) can be removed transcervically, but additional incisions are sometimes necessary. We examined the factors determining the need for additional incisions to remove an RSG goiter, based on our experience and on an algorithm. METHODS: Among 499 patients who underwent surgery for a goiter, 52 (10.4%) had an RSG removed via a collar incision. Additional incisions were necessary in 11 patients (21% of those with an RSG and 2.2% overall): a partial sternotomy in 4, total sternotomy in 5, and right thoracotomy in 2. RESULTS: Recurrent nerve paralysis developed in two patients and one patient had a tracheal laceration. There was no mortality. A diagnosis of adenomatous goiter was confirmed in all patients. CONCLUSIONS: Additional incisions can be made if thyroidectomy cannot be done transcervically and if the goiter extends to the level of the aortic arch. If the thyroid gland extends below the aortic arch and the lateral diameter of the goiter is greater than 10 cm, a partial sternotomy may be required. Total sternotomy is needed when an RSG extends caudally to the azygos vein, if it is located in the retrotracheal or retroesophageal space, or if it is recurrent or ectopic. Coexisting lung disorders and goiters extending to the left atrium also require thoracotomy.

Spontaneous rupture of a giant diaphragmatic hydatid cyst into the intrapleural space.

OBJECTIVE: We report a case of giant diaphragmatic hydatid cyst which ruptured spontaneously into the intrapleural space in a patient with coexistent giant hepatic hydatid cyst. CLINICAL PRESENTATION AND INTERVENTION: A 62-year-old female was admitted for dyspnea, nausea, vomiting, and right thoracic pain. Clinical findings, laboratory and radiological examinations including multislice computed tomography scan were consistent with the diagnosis of a giant diaphragmatic hydatid cyst which ruptured into the intrapleural space. Surgical intervention was performed through thoracotomy and phrenotomy in a one-stage operation for both cysts. CONCLUSION: This case shows that hydatid cysts of the diaphragm can rupture into the intrapleural space spontaneously. One-stage operation through thoracotomy may be successful for the surgical intervention for diaphragmatic hydatid cysts with coexistent hepatic cyst.

Mycobacterial infection of intraparenchymal bronchogenic cysts.

Bronchogenic cysts (BCs) may rarely cause some interesting and unusual complications. Although infection is a common complication of BCs, there are only two patients with BC infected with mycobacterium in English literature. Two intraparenchymal BCs infected with mycobacterium are presented here as unusual complications. Cystectomy was performed for the cysts. They were given antituberculosis treatment. No complication or recurrences were detected in follow up period.

Survival of biphasic pulmonary blastoma.

Pulmonary blastoma is a rare malignant lung tumor with a poor prognosis. It is composed of immature mesenchymal and epithelial components that resemble fetal lung tissue. We aimed to share our treatment results in biphasic pulmonary blastoma. In Ataturk Chest Disease and Thoracic Surgery Center, five patients with biphasic pulmonary blastoma (four men, one woman, aged between 27 and 61-mean 39.4) were treated between 1987 and 2000 (0.3% of operated NSCC). Hemoptysis, cough, chest pain and dyspnea were the symptoms. Anemia and high erythrocyte sedimentation rate were determined in two patients. Radiological examinations revealed a mass in four patients and massive pleural effusion in one. None of the patients were diagnosed preoperatively and hence all patients underwent exploratory thoracotomy. Three lobectomy, one pneumonectomy and one wedge resection were performed. Histopathological examinations revealed biphasic pulmonary blastoma in all the patients. Pathological stagings were as follows: 1 patient in T1N0M0 and 1 patient in T2N0M0 (198 and 112 months survival, respectively), three patients in T2N1M0 (9,10,17 months survival). In follow up period, prostate carcinoma and rectum carcinoma were detected as second primary tumors in the patient in stage T2N0M0. In patients who have small size tumors without nodal involvement, long-term survival can be obtained with radical surgery; even in biphasic pulmonary blastomas. According to our limited experiences, N1 nodal involvement shows very poor prognosis.

The effects of estradiol and progesterone on the synthesis of collagen in tracheal surgery.

OBJECTIVE: Estrogen and progesterone have the decreasing effect on massive collagen synthesis in wound healing. Here, it is aimed to determine their decreasing effect on collagen accumulation and fibroblast proliferation in trachea histologically and to understand if they would be protective for tracheal stenosis. METHODS: Thirteen male Winstar rats were divided randomly into two groups: estrogen-progesterone group (group 1, eight rats) and control group (group 2, five rats). Under general anesthesia, tracheas were incised vertically extending from second to fifth tracheal ring. Incision was closed with absorbable sutures. Estrodiol benzoat and progesterone was given intramuscularly to estrogen progesterone group, saline solution to control group. After 4 weeks they were sacrificed and tracheas were excised. Horizontal cross section of the narrowest part of the incised trachea was examined histologically. Epithelial regeneration, inflammatory cell infiltration, angiogenesis, fibroblast proliferation and collagen deposition were evaluated by histological grading. RESULTS: Statistically significant difference was found between the groups in collagen deposition and fibroblast proliferation (p=0.011, <0.05). For epithelial regeneration, inflammatory cell infiltration, and angiogenesis there was no difference. CONCLUSION: As a result, it was proved that sex hormones inhibit massive collagen deposition and fibroblast proliferation in wound healing of tracheal surgery. Hence, they may prevent tracheal stenosis.

Horner's syndrome as a complication in thoracic surgical practice.

OBJECTIVE: To determine the incidence, reasons and prognosis about Horner's syndrome in thoracic surgical patients. METHODS: In this prospective clinical study, 933 adult patients were assessed between the years of 1998 and 2002. All patients who underwent chest tube insertion (n: 662 patients) or thoracotomy (n: 342 patients), or who had thoracic trauma (n: 268 patients) were routinely examined to detect of Horner's syndrome. The patients with Horner's syndrome due to the invasion of malignant tumour to sympathetic chain were not included in the study. RESULTS: Horner's syndrome was detected in twelve patients from these 933 patients (1.3%). The considered etiologic factors were chest tube pressure in five patients, operative complication in two patients and trauma in five patients. In patients with chest tube pressure were fully recovered from Horner's syndrome but the remaining did not. CONCLUSIONS: Malposition of the chest tube is an important aetiological factor of Horner's syndrome, and it is reversible if the tube position is corrected urgently.

Chest injury due to blunt trauma.

OBJECTIVE: Given its importance in trauma practice, we aimed to determine the pathologies associated with blunt chest injuries and to analyze the accurate identification of patients at high risk for major chest trauma. METHODS: We reviewed our experience with 1490 patients with blunt chest injuries who were admitted over a 2-year period. Patients were divided into three groups based on the presence of rib fractures. The groups were evaluated to demonstrate the relationship between the number of rib fractures and associated injuries. The possible effects of age and Injury Severity Score (ISS) on mortality were analyzed. RESULTS: Mean hospitalization time was 4.5 days. Mortality rate was 1% for the patients with blunt chest trauma, 4.7% in patients with more than two rib fractures and 17% for those with flail chest. There was significant association between the mortality rate and number of rib fractures, the patient's age and ISS. The rate of development of pneumothorax and/or hemothorax was 6.7% in patients with no rib fracture, 24.9% in patients with one or two rib fractures and 81.4% in patients with more than two rib fractures. The number of rib fractures was significantly related with the presence of hemothorax or pneumothorax. CONCLUSION: Achieving better results in the treatment of patients with chest wall injury depend on a variety of factors. The risk of mortality was associated with the presence of more than two rib fractures, with patients over the age of 60 years and with an ISS greater than or equal to 16 in chest trauma. Those patients at high risk for morbidity and mortality and the suitable approach methods for them should be acknowledged.