Carinal sleeve pneumonectomy for lung cancer.

BACKGROUND: Here, we present our experience of 12 lung cancer cases operated with carinal sleeve pneumonectomy (CSP) from 2001 to 2011. METHODS: 12 cases who had undergone CSP in our department from 2001 to 2011 were retrospectively evaluated and presented by taking into account their demographical and clinical features, the surgical technique that was used, the complications that developed and the latest conditions of these patients. RESULTS: Of the 12 cases, 11 were male and 1 was female with a mean age of 58.6 years (40-71 years). 11 cases had right and 1 had left CSP. The ethiology for resection was lung cancer in all cases. 10 cases had carinal invasion of the lung cancer, 1 had bronchopleural fistula developing after right pneumonectomy, 1 had distal tracheal rupture due to intubation tube placed during pneumonectomy; these all resulted in performing CSP. Five patients developed complications during the postoperative period. Three cases developed recurrences/metastases during the follow-up. Nine patients died, 3 patients were alive and were followed-up by our department. For all the cases, the median survival was 9 months, the estimated survival rate of 2-years was 33%, and 5-year survival rate was 22%. Survival for 2-4 years was 71%. CONCLUSIONS: We think that with increasing surgical experience better results are obtained in these technically demanding procedures.

Resection via median sternotomy in patients with lung cancer invading the main pulmonary artery.

BACKGROUND: Conventional pneumonectomy via posterolateral thoracotomy is not always possible in cases with T4 tumour with widespread pulmonary artery invasion. Our objective is to present our surgical experiments in cases with a hilar mass who were thought to have pulmonary artery invasion, in whom we performed intrapericardial pneumonectomy through median sternotomy. METHOD: Nine cases who had undergone intrapericardial pneumonectomy via median sternotomy were included in this study and evaluated retrospectively. These cases were thought to have right or left pulmonary artery invasion in preoperative evaluation. RESULTS: Two cases had right and seven cases left pneumonectomy. Based on TNM classification, two patients were Stage IIB, two Stage IIIA and five Stage IIIB in postoperative histopathological examination. Either right or left main pulmonary artery invasion was seen in IIIB cases while invasion was limited to the pericardium in the others. Lymph node involvement was detected in seven cases while six cases were N1, and one case was N2. There was no operative mortality. CONCLUSION: Standard posterolateral thoracotomy might not be possible in all cases, particularly in patients with hilar tumours invading the main pulmonary artery. In such patients an intrapericardial approach with median sternotomy provides an easier and safer alternative while making it possible to have wider lymph node dissection. Furthermore, if necessary, hemi-clamshell incision can easily be added to this approach.

Dilemma on the treatment of haemoptysis: an analysis of 249 patients.

BACKGROUND: Mild haemoptysis can change into massive haemoptysis and unfortunately one cannot predict whether it will change or not. For this reason, we investigated the records of patients who had been admitted due to haemoptysis retrospectively in order to find the trigger mechanisms of haemoptysis and the effects of conservative and aggressive treatment methods. METHODS: Hospital records of 249 patients with haemoptysis between 1997 and June 2005 were analysed retrospectively. Patients were classified into three groups according to the amount of blood expectorated in 24 hours. Group 1 included cases that had haemoptysis of less than 200 ml/24 h ; group 2 consisted of massive haemoptysis which was defined as expectoration of blood of 200-400 ml/24 h, and group 3 comprised patients who had 400 ml/24 h or more of haemoptysis defined as life-threatening haemoptysis. RESULTS: There were 169 male and 80 female patients. Mean age was 43.9 (4-78) in male patients and 33.8 (7-82) in female patients. The most frequent cause of haemoptysis was lung cancer in groups 1 and 2, and hydatid disease in group 3. Furthermore, we found that at least one trigger mechanism beyond primary disease caused haemoptysis in all groups. CONCLUSIONS: Haemoptysis is a life-threatening symptom that can alert patients to see a physician. Mild to moderate haemoptysis may change into massive and life-threatening forms. Unfortunately it is not predictable whether it will change or not. We deduced that a treatment strategy has to be planned according to trigger mechanism in patients with haemoptysis and that surgery is a definitive solution in these patients.

Congenital chest wall deformities: a modified surgical technique.

BACKGROUND: Congenital chest wall deformities are the most common disorders among the other congenital diseases in thoracic surgery. Standard surgical techniques seem to be sufficient, but to prevent recurrence and complications other surgical approaches have to be chosen, such as freeing the sternum from the second rib cartilage to the costal arch, completely and bilaterally, and external application of Kirschner wire for stabilization. PATIENTS AND METHODS: Between 1996 and 2005, 47 patients with congenital chest wall deformities were examined. The surgical method consists of resecting rib cartilages from the second rib up to the costal arch bilaterally and the application of Kirschner wire for the stabilization of the chest wall. RESULTS: No mortality occurred. Three patients had complications, such as wound infection and pneumothorax. Kirschner wire was removed on the 15th day (between 10-21 days). Mean hospital stay was 16.5 days (10-23 days). Patients were followed up between 2 months and 6 years. No recurrence was observed. CONCLUSION: To prevent recurrence and complications for cosmetic surgery is quite important. For this reason, the surgical technique has to be carried out carefully. Kirschner wire is useful for the stabilization of the chest wall with no risk of infection, foreign body reaction, or the need for a second operation for removal.

Peripheral intrapulmonary lipoma: a case report.

Lipomas are common benign neoplasms but they rarely occur in visceral organs. Pulmonary lipomas are rare, and most of them are seen in endobronchial localization. Peripherally located pulmonary lipomas are extremely uncommon. There are only eight cases reported in the literature and only one of the patients was female. Our case is the second peripheral pulmonary lipoma in a female patient. The patient is a 38-year old female, who has an incidentally found solitary pulmonary nodule, revealed by X-ray, during routine check-up procedure. A 1.5 cm diameter soft tissue mass was seen in the superior segment of the lower lobe of right lung in computerized thorax tomography. Wedge resection was performed with frozen section evaluation. Histopathologically the well-circumscribed lesion consisted of mature adipose tissue, containing areas of myxoid degeneration, organized as lobules surrounded by respiratory epithelium. The lesion was diagnosed as lipoma. Radiological imaging techniques have high sensitivity detecting the solitary pulmonary lesions but their ability to give information about their nature is limited. Although they are rare, intrapulmonary lipomas should be considered in the differential diagnosis of solitary pulmonary nodules. Wedge resection with frozen section evaluation seems to be the best choice for both diagnosis and treatment.

Superior vena cava syndrome caused by chemotherapy-induced fibrosis.

We report a case of a 51-year old man with small cell lung cancer who developed superior vena cava syndrome due to obstruction of the superior vena cava at the junction of the brachiocephalic vein by a fibrotic band, 2 months after completing six cycles of chemotherapy with cisplatin and etoposid. Superior vena cava syndrome caused by chemotherapy-induced pulmonary fibrosis should be kept in mind during follow-up.

Prognostic factors and c-erbB-2 expression in non-small-cell lung carcinoma (c-erbB-2 in non-small cell lung carcinoma).

The human proto-oncogene c-erbB-2/neu gene, which is structurally similar to the epidermal growth factor receptor gene, encodes a transmembrane protein of 185 kDa (p185) with tyrosine kinase activity. Paraffin-embedded sections from 42 cases with lung carcinoma were stained immunohistochemically using the Avidin-Biotin Horseradish Peroxidase method to search for c-erbB-2 reaction. Results were evaluated semiquantitatively. The c-erbB-2 expression from each case was compared according to tumor type, grade, mitotic activity, clinical stage and lymph node metastasis. Results were statistically analyzed by using chi-square tests. We were unable to detect a significant relation between c-erbB-2 expression and histological grade, nodal metastasis, number of mitotic figures or tumor type, but we did observe a statistically significant correlation between clinical stage and increased c-erbB-2 expression (p < 0.05). In our opinion, c-erbB-2 expression in human lung carcinomas may be useful for determining clinical outcome.

[Hemothorax and retroperitoneal bleeding caused by warfarin use in a polytraumatized patient]. / Politravmatize hastada warfarin kullanimina bagli hemotoraks ve retroperitoneal kanama.

If some medical problems are not noticed to in polytraumatized patients at the right time, they may be caused by serious complications. The haematological parameters, especially bleeding and coagulation factors, are very important for them. If they use warfarin, heparin or salicylates, they should be cared intensively. In this paper, a traffic accident case, a 48-year-old woman has been reported. She broke her iliac bone and made her hemothorax. In the first health centre the patient was admitted, Hemothorax was not recognized since chest graphics was not diagnosed at an earlier stage. When dyspnoea was began, pulmonary embolism diagnosis was made and warfarin was applied which caused retroperitoneal bleeding. In fact, it is not known whether hemothorax was caused by the first trauma or by the use of warfarin. In our hospital, with the teamwork of emergency room, thorax surgery, orthopaedics, internal medicine and chest department, correct diagnosis was made and correct treatment was applied, and the patient got out of the hospital in good health. In conclusion, patients with multiple traumas should be followed with a multidisciplinary approach. There are a lot of considerations in the follow-up and treatment of this class of patients. If the traumatized patients are used warfarin, they should be observed more carefully.

Intrapleural urokinase in the management of parapneumonic empyema: a randomised controlled trial.

We compared the effectiveness of intrapleural urokinase versus normal saline via a thoracostomy tube in the treatment of parapneumonic empyema in a randomised controlled study. Forty-nine patients with parapneumonic empyema were randomly assigned to receive either intrapleural urokinase or normal saline treatment. The daily volume instilled through a chest tube was 100 ml in both groups. Urokinase (100,000 IU/day) was diluted in normal saline before instillation. The mean duration for defervescence was shorter (7 +/- 3 vs 13 +/- 5 days, p<0.01) and the mean volume of drained fluid during the five-day treatment period was significantly greater in the urokinase group (1.8 +/- 1.5 vs 0.8 +/- 0.8 litres, p<0.001) than in the control group. The subsequent decortication rate was 60% and 29.1%, respectively (p<0.001). The duration of hospitalisation was also shorter in the urokinase group (14 +/- 4 vs 21 +/- 4 days, p<0.001) than in the saline group. We conclude that intrapleural instillation of urokinase in the management of parapneumonic empyema provides a better outcome and reduces the need for decortication.

Localized pleural malignant mesothelioma.

Pleural malignant mesothelioma (PMM) is a rare tumor and it is commonly seen in the form of multiple nodules or a diffuse tumor. A localized tumor mass in the pleura is extremely rare. Only seven cases have been reported. In this report, we present an additional case of localized PMM and describe the immunohistochemical and flow cytometric findings. A 61-year-old woman, without a history of smoking or asbestos exposure, presented with a severe pain in her right shoulder and arm. Chest radiography showed a solitary mass in the right upper lung field. Computed tomography showed a 5 cm right upper lung mass. Magnetic resonance imaging showed that the mass extended to the wall of the thorax. The patient underwent surgery for total removal of the tumor. Pathology revealed a localized malignant mesothelioma. Immunohistochemical analysis showed that the tumor was strongly and diffusely positive for cytokeratins with high and low molecular weight, and focally positive for vimentin and epithelial membrane antigen (EMA), but it was negative for carcinoembryonic antigen, Factor VIII, alpha-fetoprotein and Leu-M1. Flow cytometry showed an aneuploid DNA content in the tumor. The final diagnosis was localized malignant mesothelioma (epithelial type). The patient showed signs of local recurrence 5 months after surgery, and radiotherapy was given.

Inflammatory pseudotumor of the lung.

Inflammatory pseudotumors of the lung are uncommon in the thoracic surgical literature. These masses resemble carcinoma of the lung radiographically and are discovered only at time the of histologic review of the resected specimen. We report a case of inflammatory pseudotumor that was excised without pulmonary resection, although it completely filled the right hemithorax. We think it was the greatest inflammatory pseudotumor in the English literature.

Chest wall reconstruction with autologas rib grafts in dogs and report of a clinic case.

OBJECTIVE: Nowadays, in chest wall reconstruction prosthetic materials are generally used. However, the rejections of prosthetic materials and infections frequently occur in chest wall reconstruction, especially after radiotherapy or resection that is performed due to infections. METHODS: We used 10 mongrel dogs and performed resections of 8 cm diameter on their chest walls. In the reconstruction of these defects, in five of the subjects, we used two free rib grafts with periosteum to be resected from the contralateral side and in other five subjects, we used free rib grafts without periosteum. After this experimental study, sternal resection was performed in a 24-year-old man because of sternal osteomyelitis. First to obtain rib grafts with periosteum, partial resection was performed to 5th, 7th, and 9th ribs of the lateral left side. After, total sternal resection, end to end anastomosis was performed to the 2nd, 3rd, 4th and 5th anterior ends of the ribs. RESULTS: Autogeneous rib grafts were found to be enough to provide chest wall stabilization. CONCLUSIONS: The contralateral autogeneous free rib grafts can successfully be used in reconstruction of wide chest wall defects. This method is found to be effective and sufficient to prevent infection, rejection and to provide stabilization.