Tracheobronchomalacia as a Rare Cause of Chronic Dyspnea in Adults.

OBJECTIVE: To emphasize the importance of a careful clinical evaluation to prevent unnecessary interventions and treatments. CLINICAL PRESENTATION AND INTERVENTION: A 76-year-old female patient had been diagnosed with asthma during previous admissions to different hospitals. She had also undergone fiberoptic bronchoscopy (FOB) on 2 occasions for evaluation of right middle lobe atelectasis observed on computed tomography. A repeated FOB revealed tracheobronchomalacia and nodular bronchial amyloidosis. A silicone Y stent was inserted, but the dyspnea increased. Excessive granulation tissue developed, and the patient died despite ventilatory support. CONCLUSION: The stenting technique used did not prevent the development of respiratory failure and death in this patient. Hence, a surgical procedure could be considered as an alternative to stenting in such cases.

Radiological findings and outcomes of bronchial artery embolization in cryptogenic hemoptysis.

Management of cryptogenic massive hemoptysis is difficult, and conservative treatment may be inadequate to stop the hemorrhage. Surgery is not a reasonable option because there is no underlying identifiable pathology. This study aimed to investigate the radiologic findings and bronchial artery embolization outcomes in cryptogenic hemoptysis, and to compare the results with non-cryptogenic hemoptysis. We evaluated 26 patients with cryptogenic hemoptysis and 152 patients with non-cryptogenic hemoptysis. A comparison of the bronchial artery abnormalities between the cryptogenic and non-cryptogenic hemoptysis groups showed that only extravasation was more statistically significant in the cryptogenic hemoptysis group than in the non-cryptogenic hemoptysis group, while the other bronchial artery abnormalities, such as bronchial artery dilatation, hypervascularity, and bronchial-to-pulmonary shunting, showed no significant difference between groups. Involvement of the non-bronchial systemic artery was significantly greater in the non-cryptogenic hemoptysis group than in the cryptogenic hemoptysis group. While 69.2% of patients with cryptogenic hemoptysis also had hypervascularity in the contralateral bronchial arteries and/or ipsilateral bronchial artery branches other than the bleeding lobar branches, this finding was not detected in non-cryptogenic hemoptysis. Embolization was performed on all patients using polyvinyl alcohol particles of 355-500 µm. Hemoptysis ceased in all patients immediately after embolization. While recurrence of hemoptysis showed no statistically significant difference between the cryptogenic and non-cryptogenic hemoptysis groups, it was mild in cryptogenic hemoptysis in contrast to mostly severe in non-cryptogenic hemoptysis. Transarterial embolization is a safe and effective technique to manage cryptogenic hemoptysis.

The relationship of metalloproteinase gene polymorphisms and lung cancer.

BACKGROUND: We analyzed the relationship between matrix metalloproteinase (MMP)-2, -7, and -13 gene expression and polymorphisms and disease susceptibility and prognosis in patients who had undergone surgery for non-small-cell lung cancers. MATERIALS AND METHODS: The study group consisted of 132 patients who had undergone radical surgery for non-small-cell lung cancers. The control group consisted of 80 healthy volunteers. We isolated deoxyribonuclease samples for use in analyzing gene polymorphisms from pathology blocks for the patient group and from blood samples for the control group. We identified MMP gene polymorphisms with polymerase chain reaction and restriction fragment length polymorphisms. Results were compared with those of the control group to evaluate disease susceptibility, correlation with other clinical parameters, and with survival and prognosis by using appropriate statistical methods. RESULTS: When we compared polymorphisms pertaining to MMP genes in healthy controls and lung tumor DNA, we observed a decrease in the MMP-2 (-735) polymorphism GG genotype and increases in the MMP-13 (A77G) polymorphism AG and GG genotypes (P = 0.008, P = 0.047, and P = 0.047, respectively). For the MMP-7 (-181) polymorphism, the genotype did not differ significantly for disease susceptibility. Median overall survival time was 25.5 mo in the MMP-13 AA/AG genotypes and 9.3 mo in the GG genotype. CONCLUSIONS: Decreases in the MMP-2 (-735) polymorphism GG genotype and increases in the MMP-13 (A77G) polymorphism AG and GG genotypes increase the risk for lung cancer. Furthermore, the presence of the MMP-13 (A77G) polymorphism GG genotype is an unfavorable prognostic factor.

[A rare complication of blunt trauma; diaphragm-pericardium rupture and cardiac herniation in a child case]. / Künt travmanin nadir komplikasyonu; Çocuk olguda diyafram-perikart rüptürü ve kardiyak herniasyon.

Diaphragma and pericardium rupture is rarely seen after blunt trauma. It's treatment is surgery. A 4-year-old male patient who was operated for diaphragm and pericardium rupture which developed after blunt trauma; rarity of this union, differences in the clinical and radiological features in children was examined.

Dexmedetomidine use in direct laryngoscopic biopsy under TIVA.

BACKGROUND: The purpose of this study is to investigate the suitability of dexmedetomidine as a helpful sedative agent in direct laryngoscopic biopsy (DLB), under total intravenous anesthesia (TIVA). METHODS: In this double blind randomised study, patients were allocated to receive dexmedetomidine 0.5 microg/kg (group D, n = 20) or saline placebo (group P, n = 20) intravenously. Forty ASA I-III patients were infused propofol and administered rocuronium bromur. They were intubated and performed biopsy. Aldrete scores, intraoperative propofol and postoperative analgesic requirements, satisfaction scores, recovery time, Ramsay sedation scale (RSS), haemodynamic changes and side effects were recorded. RESULTS: Postoperative analgesic requirement in group D was significantly lower and satisfaction scores and RSS were significantly higher than in group P. Additionally, MAP (mean arterial blood pressure) significantly decreased at post-extubation time in group D. CONCLUSION: The premedication with a single dose of dexmedetomidine decreases intraoperative propofol and postoperative analgesic requirements, increases the postoperative satisfaction and RSS considerably in patients undergoing DLB under TIVA.

[Treatment for esophageal perforations: analysis of 11 cases]. / Özofagus perforasyonlarinda tedavi: On bir olgunun analizi.

BACKGROUND: We present 11 cases with esophageal perforations who were treated in our department, with the intent of underlining the importance of surgical intervention. METHODS: We retrospectively analyzed 11 cases of esophageal perforation who were treated from 2005 to 2010. The cases diagnosed within the first 24 hours were regarded as early diagnoses; those diagnosed later than this period were regarded as late diagnoses. RESULTS: The mean age of the patients was 45.8 years. Following the perforation, 3 of the patients had early diagnoses and the others had late diagnoses. Of the 3 cases with early diagnosis, all had primary repair; of the late diagnosis cases, 4 had primary repair, 2 had colonic interposition, 1 had stent implantation, and 1 received medical treatment. All the cases with late diagnoses underwent drainage. The 3 cases who received early treatment recovered without complications. Of the other 8 cases, 1 had leakage from the anastomosis and 1 developed a fistula. Two (18.1%) of our patients died. CONCLUSION: Treatments performed before the development of mediastinitis are lifesaving in esophageal perforation patients. We think that surgical treatment performed within the first 72 hours that includes primary repair would yield favorable results.

Combined transbronchial needle aspiration and PET/CT for mediastinal staging of lung cancer.

In this study, we aimed to evaluate the performance of transbronchial needle aspiration (TBNA) combined with positron emission tomography/computed tomography (PET/CT) for the staging of lung cancer. Twenty-five patients having lymphadenopathies greater than 1 cm on thorax CT and maximum standardized uptake value (SUVmax) ≥ 2.5 on PET/CT were included in this prospective study performed between March 2006 and March 2008. Forty-three lymphnode stations were sampled by using TBNA. Surgical histology, as confirmed by mediastinoscopy, was accepted as the "gold standard". The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of combined TBNA and PET/CT for correct lymph node staging were 67%, 100%, 100%, 76% and 84%; respectively. The initial clinical staging was downstaged after TBNA in 13/19 (69%) patients with adequate TBNA samples, whereas staging was correct in 17/19 (89%) patients assessed by combined TBNA and PET/CT. Staging was completed by TBNA, without mediastinoscopy, in 6/25 (24%) patients. Among the clinical factors that were assessed, only the PET SUVmax was associated with positive TBNA results [odds ratio (OR) 1.27, 95% CI 1.004-1.61, p= 0.046]. A PET SUVmax ≥ 5 was eleven times more likely in patients with positive TBNA results [OR 10.68, 95% CI 1.91-59.62, p< 0.01]. In conclusion, the combination of TBNA with PET/CT increased the sensitivity of TBNA. Combined TBNA and PET/CT may also allow adequate mediastinal staging of lung cancer in most patients with enlarged lymph nodes, and reduce the need for mediastinoscopy. The SUVmax cut off point for a positive TBNA result was ≥ 5.

Surgical Treatment in Small-Cell Lung Cancer: Single-Center Experience and Survival.

OBJECTIVE: To evaluate the clinical outcomes of patients with different stages of small-cell lung cancer (SCLC) who underwent surgical treatment. MATERIAL AND METHODS: This retrospective study consisted of 13 patients with SCLC at a tertiary care health center. This study was conducted between 2011 and 2018 at Gaziantep University Faculty of Medicine, Thoracic Surgery Department. Patient follow-up data were collected from medical files. Patients were analyzed according to age, sex, site of resection, clinical stage, pathological stage, recurrence, operation type, chemotherapy, radiotherapy. RESULTS: The study group consisted of 3 females and 10 males (n = 13). The mean age of the patients was 65 ± 9.3 (52-85) years. The most common location of the primary tumor was the right upper lobe (6 patients, 46.2%). The mean tumor size was 4.36 ± 2.38 cm (1-8.5). In our study, 3 patients had already metastases (2 brain and 1 had metastases in more than 2 anatomic sites). Patients with solitary metastases, who underwent lung resection and metastasis excision had similar survival according to patients without metastases. CONCLUSION: Our results show that surgical treatment in SCLC could be contributed to the survival of patients. Therefore, patients must be given a chance for surgery, especially considering that the advances in diagnostic and surgical capabilities have increased the likelihood of early diagnosis and effective surgery.

The role of endothelial nitric oxide synthase gene polymorphisms in patients with lung cancer.

OBJECTIVES: Lung cancer is a disease characterized by uncontrolled cell growth in the lung tissues. The most common causes of lung cancer include smoking, exposure to radon gas, asbestos, environmental pollutants as well as genetic factors. Nitric oxide (NO) has potential mutagenic and carcinogenic activity and may play an important role in lung cancer. Endothelial NO, synthesized from L-arginine by endothelial NO synthase (eNOS), inhibits apoptosis and promotes angiogenesis and tumor cell proliferation. The aim of the present study was to examine the possible relationship between eNOS gene intron 4 variable number of tandem repeat (VNTR) and exon 7-G894T (Glu298Asp) polymorphisms and lung cancer risk. METHODS: DNA was extracted from peripheral blood leukocytes of 107 lung cancer patients and 100 control subjects. Designated polymorphisms were identified by polymerase chain reaction (PCR) and/or restriction fragment length polymorphism (RFLP). RESULTS: Our study showed that the frequencies of the b/b genotype and b allele of eNOS gene intron 4 VNTR polymorphism were significantly higher in lung cancer patients than in controls (P < 0.05). However, there was no significant association between eNOS gene G894T polymorphism and lung cancer risk (P > 0.05). CONCLUSION: These results suggest that the presence of the intron 4 VNTR* b allele and b/b genotype may be a genetic risk factor for development of lung cancer. Further larger-scale studies are needed to confirm these findings.

[Diagnosis that should be remembered during evaluation of trauma patients: diaphragmatic rupture]. / Travmali hastalarin degerlendirilmesinde akilda tutulmasi gereken tani: Diyafram yirtigi.

BACKGROUND: We aimed to emphasize the importance of delay in diagnosis of traumatic diaphragmatic ruptures and to investigate the results of treatment methods. METHODS: The records of 13 patients (11 males, 2 females; mean age 34.6; range 7 to 52 years) with traumatic diaphragmatic ruptures were evaluated with respect to demographic data, type and time of trauma, symptoms, diagnostic methods, localization, surgical therapy, morbidity and mortality. RESULTS: Blunt trauma was present in 8 cases (61.6%) and penetrating trauma in 5. Migration of abdominal organs into hemithorax was detected in 11 cases radiologically. The duration between diagnosis and the event was 2-20 years in 6 patients (46.1%). Three of them were penetrating and 3 were blunt trauma. In 3 cases, diagnosis had been overlooked despite exploratory thoracotomy and laparotomy in another center. Right hemi-diaphragm was injured in 1 patient and the left in 12 cases. Primary repair through posterolateral thoracotomy was performed in all cases. Morbidity occurred in 1 patient. No mortality was observed. CONCLUSION: Diaphragmatic ruptures should be remembered in trauma cases because of the probability of their being missed, and ruptures should be explored during thoracotomy or laparotomy performed for other organ injuries. Delayed diagnosis will increase morbidity and mortality.

Endobronchial lesions cases treated with interventional bronchoscopic techniques: Our single-center experiences.

BACKGROUND: In this study, we aimed to present our experience with interventional bronchoscopy in the treatment of endobronchial lesions in our clinic. METHODS: Between January 2010 and December 2018, a total of 18 patients (11 males, 7 females; mean age 55.1 years; range, 17 to 82 years) who were diagnosed with an endobronchial lesion using bronchoscopy in our clinic were retrospectively analyzed. Demographic characteristics, presenting symptoms, bronchoscopic procedure, location of the lesion, pathological diagnosis, treatment approaches, success of the bronchoscopic treatment, and follow-up outcomes of the patients were evaluated. RESULTS: Control bronchoscopy was performed in 14 patients and a second control bronchoscopy was performed in eight patients. The lesions were located in the right bronchial system in nine (50%), in the left bronchial system in six (33%), and in the trachea in three patients (17%). Except for one pregnant patient, all interventional procedures were performed with a rigid bronchoscope under general anesthesia. Distal areas which were unable to be reached with the rigid bronchoscope were evaluated by a flexible bronchoscope. There were no complications in any of the patients. At the end of the study, the final control biopsies of all patients were found to be normal. The success rate of interventional bronchoscopic methods was 100%. CONCLUSION: Interventional bronchoscopic methods are the most effective procedures in the diagnosis and treatment of bronchial lesions with a high success rate. Based on our study findings, we suggest that bronchoscopic methods should be preferred as the first-line treatment of benign and selected some malignant endobronchial lesions.

The reliability of mediastinoscopic frozen sections in deciding on oncological surgery in bronchogenic carcinoma.

INTRODUCTION: This study was carried out to determine the accuracy of mediastinoscopic frozen section examination, performed prior to major surgery-especially where mediastinal lymph node metastasis (N2 disease) was suspected. We aimed to find out whether or not mediastinoscopic frozen section analysis was (i) a reliable tool when deciding to continue resection in lung cancer patients and (ii) reliable in diagnosing mediastinal masses. METHODS: One-hundred and thirty-six patients undergoing mediastinoscopy were enrolled in this study. Resection was planned for each case, and biopsies were taken from at least two sites, including the subcarinal lymph node. Thoracotomy and resection were performed when the results of frozen section examination were negative for malignancy in patients with lung cancer. Results of frozen section examination during mediastinoscopy were compared to the results of definitive histological examination of the same specimens stained using haematoxylin-eosin. Additionally, the results of frozen section examination were compared to the results of definitive histological examination of the lymph nodes excised during resection. RESULTS: We determined total sensitivity, specificity, positive predictive and negative predictive values of 94.51%, 100%, 100% and 90%, respectively. In the 105 patients with malignant diseases, these values were 93.33%, 100%, 100% and 91.84%, respectively. In the 31 patients with benign diseases, values were 96.77%, 100%, 100% and 100%, respectively. CONCLUSIONS: It was confirmed that mediastinoscopy supported by frozen section examination plays an important role in establishing diagnosis and planning treatment both in benign and malignant diseases.

Surgical treatment of a giant primary cardiac angiosarcoma.

Primary cardiac angiosarcoma is a rare tumor, and surgical resection is often required to relieve its symptoms. A 54-year-old male with a large primary cardiac angiosarcoma is described in this case report. The tumor was located in the right atrium and right ventricle. The bulk was resected with the right coronary artery (RCA), and partial right atrium and partial right ventricle resections were performed during cardiopulmonary bypass. The resected tumor measured 15 x 10 x 8 cm, and the histopathological diagnosis was well differentiated primary cardiac angiosarcoma. In the postoperative period, the patient was followed up for 22 months, and radiotherapy and chemotherapy were performed for metastases. The optimal therapy for cardiac angiosarcoma is still controversial, but combined treatment including surgical resection should be considered.

A rare case of peripherally located non-bronchial pulmonary mucous gland adenoma.

Pulmonary mucous gland adenomas are rare benign tumors, which need to be differentiated from malign lung masses. The differential diagnosis is of particular importance for those arising from lung parenchyma in atypical locations. In this article, we report a 70-year-old male patient, who had complaints of cough and expectoration for almost two years. Chest computed tomography showed a 1 cm nodule at the left lower lobe of lung. The tumor was totally resected with mini-thoracotomy and wedge resection and sent to the pathology department for a frozen examination. The frozen result was reported as benign. The pathological diagnosis was mucous gland adenoma. The patient had no postoperative complication and made a complete recovery. Pulmonary mucous adenomas may rarely originate from lung parenchyma and be seen in patients with peripherally located lung lesions.

Surgical treatment of postintubation tracheal stenosis: A retrospective 22-patient series from a single center.

BACKGROUND/OBJECTIVE: We aimed to present cases of postintubation tracheal stenosis (PITS), all due to long-term intubation and treated surgically in a university hospital, and to discuss them in light of the literature. METHODS: In this retrospective study, 22 patients who were treated with tracheal resection and reconstruction due to PITS were included. Demographics, intubation characteristics, localization of stenosis, surgical technique and material, postoperative complications, and survival of patients were recorded. RESULTS: The mean intubation duration was 16.95 days with a median of 15.00 days. Collar incision was applied in 19 cases (86.4%); in two cases (9.1%) a median sternotomy incision was used; and in the remaining case (4.5%), a right thoracotomy incision was made. The mean tracheal stenosis length was 2.14 cm (mean excision length, 2.5 cm). In 17 cases (77.3%), the anterior walls were supported with vicryl (polyglactin) suture one by one. No postoperative complications were observed in 12 cases (54.5%). No recurrence developed during the long-term follow-up of 15 of the 22 patients (68.2%). Two patients (9.1%) died in the early stages after surgery, and five patients (22.7%) had a stent inserted due to restenosis. CONCLUSION: Tracheal resection and end-to-end anastomosis are the most efficient techniques in cases without medical contraindications, despite emerging stent or endoscopic procedures. Endoscopic interventions can be suggested as an alternative to surgery in patients for whom surgery cannot be performed or who develop recurrence.

Prognostic factors in operated T3 non-small cell lung cancer: A retrospective, single-center study of 129 patients.

BACKGROUND: This study aims to investigate the prognostic factors that affect survival rates and durations in patients with T3 non-small cell lung cancer who underwent surgery. METHODS: A total of 129 patients with T3 n on-small c ell l ung c ancer (125 males, 4 females; mean age 60±9.3 years; range 23 to 80 years) who were performed surgery in our clinic between January 1997 and December 2013 were evaluated retrospectively in terms of age, gender, type of resection, tumor histopathology, tumor, node and metastasis staging, lymph node invasion, chemotherapy and radiotherapy, and recurrence. RESULTS: During the evaluation, while 61 patients (47.3%) were alive, 68 (52.7%) had lost their lives. One-, two- and five-year survival rates of the study population were 79.8%, 56.9% and 23.2%, respectively. Mean duration of survival was 41.5±4.0 months (range 33.7-49.4 months). Patient's age or tumor histopathology did not affect the duration of survival. Overall duration of survival was significantly longer in patients of stage IIB, patients who had low stages of lymph node invasion, who were performed lobectomy, who received chemotherapy or radiotherapy or who were without recurrence (p<0.05 for each). Multivariate regression analysis revealed that lymph node invasion, presence of recurrence or pneumonectomy, or failure to have been administered chemotherapy increased mortality risk significantly (hazard ratios 0.217, 3.369, 2.791 and 2.254, respectively). CONCLUSION: Our findings revealed that lymph node invasion, presence of recurrence or pneumonectomy, or failure to have been administered chemotherapy are poor prognostic factors in T3 non-small cell lung cancer. Prognostic factors should be taken into consideration during treatment and follow-up periods of patients with T3 non-small cell lung cancer.

Outcomes after lobectomy and pneumonectomy in lungcancer patients aged 70 years or older.

BACKGROUND/AIM: For the early stage of nonsmall-cell lung cancer, surgical resection provides the best survival, but the surgical risk generally increases with age because of the increased prevalence of comorbidities, especially cardiovascular disorders. The aim of this study was to compare survival and mortality rates of two groups with different ages, younger and older than 70 years, who went curative resection for nonsmall-cell lung cancer. MATERIALS AND METHODS: We analyzed the patients who underwent curative lung cancer surgery in the Department of Thoracic Surgery of Gaziantep University Research Hospital between January 1997 and November 2014. Patients were divided into 2 groups according to their ages. RESULTS: A total of 497 patients were included in data analysis (381 were under 70 years old and 116 of them were ≥70 years old). The older group showed a 1.4-fold increased risk of mortality hazard ratio when the probability of survival was analyzed by histological type, lymph node involvement, disease stage, and age. CONCLUSION: There was no distinct increase in 30-day mortality rates of patients with nonsmall-cell lung cancer who were ≥70 years old, but the hazard rate for long-term survival was higher in the older group. Curative pulmonary resections due to lung cancer should be carefully performed in septuagenarians.

Dental technician pneumoconiosis mimicking lung cancer.

A 47-year-old man was referred for assessment of bilateral lymph node enlargement identified on a routine chest radiograph. Positron emission tomography showed high standardized uptake values (SUVmax: 20.5) in right supraclavicular, right intercostal, and multiple mediastinal lymph nodes. Biopsy samples obtained from the right upper and left lower paratracheal nodes by mediastinoscopy revealed granulomatous inflammation. Clinical and laboratory findings indicated a diagnosis of dental technician pneumoconiosis. The patient is alive and well 3 years after diagnosis. This case highlights the importance of obtaining an occupational history.

Intrapleural hyperthermic perfusion chemotherapy in subjects with metastatic pleural malignancies.

OBJECTIVES: Malignant pleural effusion (MPE) means poor prognosis in the majority of cases. Intrapleural Hyperthermic perfusion chemotherapy (HIPEC) looks promising approach for these patients. We aimed to investigate whether cytoreductive surgery followed by HIPEC provides any survival benefit in cases with metastatic MPEs. METHODS: Between January 2009 and December 2011, 19 patients with metastatic MPEs were treated with HIPEC following surgical interventions such as pleurectomy/decortication and/or lung resection (group 1). Comparison was done with historical control groups consisted of patients who received either talc pleurodesis or pleurectomy/decortication followed by systemic treatment for the management of metastatic MPEs between June 2007 and June 2008 (group 2 and 3). Statistical analyses including overall survival, disease free interval were done for the group comparisons. RESULTS: Median survival in group 1, 2 and 3 were 15.4, 6, 8 months, respectively. One year survival was 54.7% in group 1 where it was 0.6% and 0.8% in group 2 and 3, respectively. There was no operative mortality. Morbidity was occurred in 1 patient in group 1 (5.3%). CONCLUSIONS: HIPEC combined with cytoreductive surgery seems to be a promising treatment option for subjects with metastatic MPEs. Further studies are needed for the optimization of HIPEC method, drug of choice, and the best combination therapy for the multimodal treatment.