Mediastinal Teratoma Mimicking Neurofibroma in CT-Guided Biopsy in a Patient With Neurofibromatosis Type 1.

Teratomas are a type of germ cell tumor that may contain several different types of tissue. Neurofibroma is a benign peripheral nerve sheath tumor with the plexiform type being pathognomonic for neurofibromatosis type 1. We report a case of a 33-year-old woman with a background of Neurofibromatosis type 1 who presented with left-sided chest pain and shortness of breath. She was diagnosed with a large mediastinal mass which was confirmed from a CT-guided biopsy as neurofibroma. Following a multidisciplinary team discussion, she underwent mediastinal mass resection and the final histopathology report revealed mediastinal mature teratoma.

Establishing a Multidisciplinary Team-Based Pleural Service in the Era of Financial Austerity: The Role of the Thoracic Surgeon.

Medical thoracoscopy/pleuroscopy has become, after bronchoscopy, the second most commonly utilized endoscopic procedure in interventional pulmonology. Due to their common origin, medical thoracoscopy/pleuroscopy and video-assisted thoracic surgery (VATS) are quite similar procedures technically. In contrast to the prevailing attitude that it should predominantly be performed by interventional pulmonologists, we believe that, like all hybrid-in-nature techniques, it should be implemented as part of a combined specialist care service/team. Herewith, we describe our attempt to establish a multidisciplinary pleural disease program during a difficult economic period for our country, comprising thoracic surgeons, pulmonologists and anesthesiologists, all of whom brought in their experience, expertise and resources to establish and develop the service resulting in a hybridization of the technique, with, as reported, quite favorable results.

Basic Operative Tactics for Pulmonary Echinococcosis in the Era of Endostaplers and Energy Devices.

Human echinococcosis is a zoonotic infection caused by the larvae of the tapeworm species Echinococcus. The liver is the most common location for a primary echinococcosis. However, the parasite may bypass or spread from the liver to the lungs, causing primary or secondary pulmonary echinococcosis, respectively. Pulmonary echinococcosis is a clinically challenging condition in which anthelminthic regiments are important, but surgery has the central role in removing the cysts and preventing recurrences. Surgical treatment may involve cystotomy, enucleation, capitonnage, or atypical resections, which occasionally are in combination with hepatic procedures. The utilization of modern devices is greatly underdescribed in surgery for thoracic infections, even though these facilitate much of the work. Therefore, this article aims to describe pulmonary echinococcosis and the role of modern surgical devices in the treatment process. Furthermore, we report surgical treatment of three different cases of pulmonary echinococcosis. Surgeries of uncomplicated and ruptured hepatic or pulmonary cysts are described. Simple small pulmonary echinococcal lesions can be excised by endostaplers both for diagnostic and curative reasons. Larger cysts can be removed by energy devices unless large bronchial air leaks occur. Complicated cysts require treatment by more extensive techniques. Inexperienced surgeons should not abstain but should carefully decide preoperatively how to proceed.

The Impact of COVID-19 Pandemic on Surgical Treatment of Resectable Non-Small Cell Lung Cancer in Greece.

Background: The coronavirus disease (COVID-19) pandemic has posed an unprecedented challenge to health systems, and has significantly affected the healthcare of lung cancer patients. The aim of our study was to assess the impact of COVID-19 on early lung cancer patients' surgical treatment. Methods: All consecutive patients with early-stage non-small cell lung cancer eligible for surgical treatment stage I/II and resectable stage III, referred to our department during the first wave of COVID-19 between February to May 2020, were included and compared with those on the exact corresponding quarter in 2019, one year before the pandemic. Waiting time to surgical treatment, increase of tumor's size and increase on lung cancer stage were recorded and compared. All subjects were followed up for 12 months. Multiple linear and logistic regression models were applied to assess the differences in the management of the studied groups adjusting for potential confounders. Results: Sixty-one patients with early-stage lung cancer were included in the study; 28 (median age 67 years, SD: 7.1) during the pandemic and 33 (median age 67.1 years, SD: 7.5) one year earlier. A significantly longer period of waiting for treatment and an increase in tumor size were observed during the pandemic compared to before the pandemic [median time 47 days, interquartile rate (IQR): 23−100] vs. [median time 18 days, IQR: 11−23], p < 0.001. No significant differences were detected in the increase of the stage of lung cancer between the subgroups. Conclusion: The COVID-19 pandemic had a significant impact on surgical and oncological care, leading to significant delays on treatment and an increase in tumor size in early-stage lung cancer patients.

Synchronous Sternal Metastasectomy and Total Thyroidectomy for Differentiated Thyroid Cancer: A Rare Case Report.

Bone metastases from thyroid cancer are mainly rare, while sternal metastases are extremely uncommon. Bone metastases might be either synchronous or metachronous to primary thyroid cancer. A 60-year-old male patient presented to our department with a painful, fixed and firm sternal mass. Preoperative imaging studies, such as neck ultrasound (US) and computed tomography (CT) of the chest, revealed a 6.5 cm nodule of the right thyroid lobe with high-risk malignancy characteristics and a massive metastatic mass of the anterior mediastinal, which was extended from the sternal notch to the third intercostal space. The diagnosis of papillary thyroid carcinoma with sternal metastatic lesions was established. After meticulous discussion in the multidisciplinary board of our hospital, a total thyroidectomy plus en-bloc resection of this massive sternal metastasis and adjuvant radioiodine therapy were decided. Eight months postoperatively, no recurrence has occurred in this patient. R0 resection of isolated bone metastasis of thyroid origin is still an optimal therapeutic decision for these patients. In cases of sternal metastasis, radical surgical resection with negative margins, including both resection of the lesion and reconstruction of the chest wall, in order to successfully maintain the chest wall's stability, is recommended.

Platelet-Rich Plasma for Pleurodesis: An Experimental Study in Rabbits.

Background and Objectives: This study was designed to evaluate platelet-rich plasma (PRP) as a method of pleurodesis in a rabbit model. Pleurodesis with PRP was compared against the gold-standard use of talc. The secondary evaluation assessed the ideal time for achieving pleurodesis. Materials and Methods: 25 healthy New Zealand white rabbits were assigned to three groups, as follows: 12 animals in the first and second groups, as well as one animal with no intervention in the final group, which was used as a control. The talc pleurodesis group (baseline) underwent pleurodesis with sterile talc, which is the gold-standard sclerosing agent used for pleurodesis. The PRP group underwent pleurodesis using autologous PRP. The last group had one rabbit with no intervention. A total of 12 rabbits (n = 6 for the talc pleurodesis group and n = 6 for the PRP group) were sacrificed 3 days (72 h) after the intervention, and 12 rabbits (n = 6 for the talc pleurodesis group and n = 6 for the PRP group) were sacrificed 6 days (144 h) after the intervention. In both the talc and PRP group, FBC and CRP were measured before the intervention and in 3 or 6 days afterwards, respectively. The pleura and the lungs were evaluated histopathologically. Results: Macroscopically, there were no statistically significant differences between the two groups. In terms of microscopic findings, there were no statistically significant differences in inflammatory reactions provoked in the visceral and parietal pleura between the PRP and talc. In addition, with talc pleurodesis, a foreign-body reaction was observed in about 50% of the cases, which was not observed with PRP. In terms of inflammation between 3 and 6 days, there were no statistically significant differences with PRP, there was only a statistically significant difference between 3 and 6 days regarding the parietal pleura in the talc group. Conclusions: The instillation of autologous PRP in the pleural cavity shows promise in achieving pleurodesis. The efficacy of PRP as a pleurodesis agent should be examined further.

Large Intrathoracic Desmoid Tumor and Re-Expansion Pulmonary Edema: Case Report and Review of the Literature.

Re-expansion pulmonary edema is a potentially life-threatening situation following thoracic surgery of a compromised lung. We report the case of a 24-year-old female scheduled for a resection of a large intrathoracic desmoid tumor that presented with re-expansion pulmonary edema at the conclusion of her surgery and discuss the clinical presentation, mechanism and predictors of this entity and review similar cases reported in the literature.

Radiation-Induced Esophageal Cancer: Investigating the Pathogenesis, Management, and Prognosis.

One of the most serious late side effects of irradiation is the promotion of tumorigenesis. Radiation-induced esophageal cancer (RIEC) can arise in a previously irradiated field, mostly in patients previously irradiated for thoracic malignancies such as breast cancer, Hodgkin and non-Hodgkin lymphomas, head and neck cancers, lung cancer, or previous esophageal cancer. RIEC is rare and accounts for less than 1% of all carcinomas of the esophagus. There are little data available in the current literature regarding pathogenesis, diagnosis, treatment, and outcome of esophageal cancer developed in a previously irradiated field. RIEC seems to represent a biologically aggressive disease with a poor prognosis. Although it is difficult to perform radical surgery on a previously irradiated field, R0 resection remains the mainstay of treatment. The use of neoadjuvant and adjuvant chemoradiotherapy remains very helpful in RIEC, similarly to conventional esophageal cancer protocols. The aim of this article is to elucidate this rare but challenging entity.

Can the Ratio SUVmax of the Lesion/SUVmax of Mediastinal Tissues Guide the Choice of Surgical Access for the Resection of Thymic Epithelial Tumors?

Background: There are studies showing the utility of the 18-fluorodeoxyglucose positron emission tomography (18FDG PET) scan in the management of patients with thymic epithelial tumors. It seems to be a correlation between the standard uptake value (SUVmax) of thymic epithelial tumors and the histological type and the stage. This study aims to use the ratio of the SUVmax of the lesion to the SUVmax of the adjacent mediastinal tissues in order to guide the choice of the surgical access. Methods: All patients who presented an anterior mediastinal lesion with a high suspicion of being of thymic origin were included in a prospective database. A ratio inferior to 1 could predict a benign nature and less aggressive behavior, and a minimally invasive approach was performed. A ratio superior to 1 suggested a malignant and aggressive behavior, and a median sternotomy (or a thoracotomy) was performed. Results: There were 15 male (mean age 44.6 ± 16.26 years, range 25-73) and 15 female patients (mean age 50.1 ± 16.94 years, range 25-76). When the ratio is inferior to 1, it predicts benign disease in 80% of cases. When it is superior to 1, it predicts in half of cases advanced histological types (high risk thymomas and thymic carcinomas). On the contrary, it can quite accurately predict advanced Masaoka-Koga stages. Conclusions: The protocol of this study is in accordance with the current literature showing the utility of 18FDG PET scan in the treatment of thymic epithelial tumors. This study goes one step further since the choice of surgical access is based on the SUVmax values. The ratio SUVmax of the lesion/SUVmax of the mediastinal tissues could be a new marker, more pertinent than absolute SUVmax values.

Treatment of a chronic esophageal perforation after vertebral surgery with external vacuum therapy - a case report.

Esophageal perforations of any cause may escape early diagnosis and progress to lethal mediastinitis despite aggressive management. The treatment and outcome depends on the extent and chronicity of the injury. A CASE REPORT: We present a case of a late-diagnosed cervical esophageal rupture treated successfully with external vacuum therapy. A blunt trauma patient with cervical vertebral column fractures underwent fixation with a titanium bracket. A procedure-related esophageal perforation created an open fistulous communication to the skin. This was diagnosed with one month's delay. In diagnostic endoscopy the prosthesis was visible through a large esophageal defect. Evidence of mediastinitis was absent. The external wound was explored and a standard vacuum device was inserted. Nine weeks of continuous vacuum therapy achieved complete fistula closure and prevented infection. Mediastinitis was avoided and complete oral feeding was resumed. CONCLUSIONS: Different clinical presentations indicate surgical, endoscopic or conservative treatment. In this report, we provide the ground for discussion for the alternative application of the vacuum technology in a case where otherwise surgery would be the definite treatment.

Bochdalek hernias in the adult population: a systematic review of the literature.

BACKGROUND: Bochdalek hernia (BH) is characterized by the protrusion of viscera into thorax through the posterolateral section of the diaphragm. The aim of this study was to systematically review current literature concerning Bochdalek hernias in adults and elucidate their clinical characteristics and preferable treatment approach. METHODS: A search of PubMed and Cochrane bibliographical databases for studies regarding BHs was conducted (last search: 31st March 2021). RESULTS: Predefined inclusion criteria were met by 173 articles and concerned collectively 192 patients (50.5% males) with a mean age of 45.41 ± 20.26 years. Abdominal pain (62.0%) and pulmonary symptoms (41.1%) were the predominant symptomatology of included cases. BHs protruded mainly through the left side of the diaphragm (70.7%), with large intestine (42.7%) and stomach (37.1%) being the most commonly herniated abdominal organs. Most patients (53.8%) underwent an open surgical approach, while abdominal approach was preferred (64.8%). to the thoracic one. Thirty-day postoperative complication were encountered at 21.5% of patients, while 30-day mortality reached 4.4%. CONCLUSION: BH is an extremely rare type of congenital diaphragmatic hernia. It rarely concerns adults, and it manifests with vague gastrointestinal or pulmonary symptoms. Surgical approach is the preferred method for their management with open procedures being preferable at emergency cases, while minimal invasive approach necessitates experienced centers. Further research is needed in order to clarify their true incidence and optimal therapeutic strategy.

Gastrointestinal Stromal Tumor With Chondrosarcomatous Dedifferentiation Following Imatinib Therapy.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the digestive tract, followed by schwannomas, lipomas, leiomyomas, and vascular tumors. They arise more often in the stomach, followed by the small bowel, esophagus, and rectum. Imatinib mesylate, a tyrosine kinase inhibitor with activity against ABL, BCR-ABL, platelet-derived growth factor receptor-alpha (PDGFRA), and c-KIT (CD117), constitutes the cornerstone of treatment for inoperable or metastatic GIST. Cases showing disease progression or resistance to imatinib mesylate may retain their morphology or present unusual morphologic and immunohistochemical characteristics. We herein describe a case of a 67-year-old patient with a previous history of GIST of the stomach, with local recurrence, who was admitted with a workup of lung nodule on chest computed tomography as part of the routine follow-up. The nodule was resected which showed a malignant tumor composedof epithelioid cells, with an abrupt transition to chondrosarcoma. Epithelioid cells were immunostained for CD117, DOG1, and Vimentin, whereas chondrosarcomatous cells expressed only Vimentin. These findings were consistent with metachronous pulmonary metastasis of the previously diagnosed GIST with chondrosarcomatous dedifferentiation. No KIT or PDGFRA mutation was detected. A review of all accessible pertinent papers disclosed 26 similar cases with unusual morphological and immunohistochemical findings, either post-imatinib treatment or, less commonly, de novo, with heterogeneous differentiation. Awareness of the histological and immunohistochemical changes in GISTs post imatinib therapy is essential to avoid a severe diagnostic pitfall.

Monitored Anesthesia Care with Dexmedetomidine Supplemented by Midazolam/Fentanyl versus Midazolam/Fentanyl Alone in Patients Undergoing Pleuroscopy: Effect on Oxygenation and Respiratory Function.

Although pleuroscopy is considered a safe and well tolerated procedure with a low complication rate, it requires the administration of procedural sedation and analgesia. The purpose of this study was to assess the effects of dexmedetomidine administration on oxygenation and respiratory function in patients undergoing diagnostic or therapeutic pleuroscopy. Through a prospective, single center, cohort study, we studied 55 patients receiving either a dexmedetomidine intravenous infusion supplemented by midazolam/fentanyl (Group DEX + MZ/F) or a conventional sedation protocol with midazolam/fentanyl (Group MZ/F). Our primary outcome was the changes in lung gas exchange (PaO2/FiO2 ratio) obtained at baseline and at predetermined end points, while changes in respiratory mechanics (FEV1, FVC and the ratio FEV1/FVC) and PaCO2 levels, drug consumption, time to recover from sedation and adverse events were our secondary endpoints (NCT03597828). We found a lower postoperative decrease in FEV1 volumes in Group DEX + MZ/F compared to Group MZ/F (p = 0.039), while FVC, FEV1/FVC and gas exchange values did not differ between groups. We also found a significant reduction in midazolam (p < 0.001) and fentanyl consumption (p < 0.001), along with a more rapid recovery of alertness postprocedure in Group DEX + MZ/F compared to Group MZ/F (p = 0.003), while pain scores during the postoperative period, favored the Group DEX + MZ/F (p = 0.020). In conclusion, the use of intravenous dexmedetomidine during pleuroscopy is associated with a smaller decrease in FEV1, reduction of the consumption of supplementary sedatives and analgesics and quicker awakening of patients postoperatively, when compared to midazolam/fentanyl. Therefore, dexmedetomidine administration may provide clinically significant benefits in terms of lung mechanics and faster recovery of patients undergoing pleuroscopy.

Combining Minimally Invasive Techniques in Managing a Frail Patient with Postpneumonectomy Bronchopleural Fistula.

A postpneumonectomy bronchopleural fistula is a life-threatening complication requiring aggressive treatment and early repair. Reoperations are common due to initial treatment failure. Advanced bronchoscopic techniques are rapidly evolving, but permanent results are questionable. We report the minimally invasive management of a frail 79-year-old patient with postpneumonectomy fistula in respiratory failure due to repeated infections. Previous bronchoscopic closure attempts with fibrin failed. The multistep interdisciplinary management included airway surveillance by virtual bronchoscopy, percutaneous fibrin glue instillation under computed tomography, and awake thoracoscopic surgery to achieve temporary closure. This provided an acceptable long period of symptomatic and physical improvement. The bronchial stump failed again four months later, and the patient succumbed to pneumonia. Pneumonectomy has to be avoided unless strongly indicated. Complications are best managed with surgery for definite treatment. We emphasize our approach only when a patient declines surgery or is medically unfit as a temporary time-buying strategy in view of definite surgery in a high-volume center.

Metastatic Thyroid Osteosarcoma With Concomitant Multifocal Papillary Carcinoma Presenting as a Collision Tumor.

Metastatic involvement of the thyroid occurs rarely, by either hematogenous spread or direct extension from adjacent organs. The most frequent metastatic tumors are clear cell, renal cell, lung, breast, and squamous cell carcinoma. The occurrence of osteosarcoma and papillary thyroid carcinoma in the same patient is rare, with only a few reported cases in the literature. On the other hand, only one case of osteosarcoma thyroid metastasis has so far been reported. We herewith present another case with metastatic osteosarcoma and multifocal papillary thyroid carcinoma presenting as a collision tumor and review the relevant literature.

Multilocular Thymic Cyst in a Young, Otherwise Healthy Woman: A Case Report.

Thymic cysts are rare lesions, accounting approximately for 1% of all mediastinal masses. We report a case of a 36-year old woman who presented preoperatively with a calcified mass shadow found on a routine chest radiograph X-ray. After further investigation with chest computed tomography (CT), magnetic resonance imaging (MRI), and tests for Myasthenia gravis, a benign mediastinal cyst was diagnosed and the patient underwent median sternotomy and complete surgical excision of the lesion. The histological examination described a multilocular thymic cyst. Thymic cysts are usually associated with thymic epithelial tumors, such as thymomas, or multisystemic morbid conditions such as human immunodeficiency virus (HIV) infection, rheumatologic disease, and Myasthenia gravis. At all follow-up examinations to date, the patient remains healthy.