Spontaneous pneumothorax and tuberculosis: long-term follow-up.

Though spontaneous pneumothorax (SP) is a well-known complication of pulmonary tuberculosis (TB), there are very few reports addressing this topic. For this reason, we retrospectively analysed the experience of SP in patients diagnosed with TB in our hospital between 1989 and 2010. Out of 872 patients treated for SP during this period, 47 (5.4%) had TB antecedents, 21 with active TB (0.95% of the 2,089 TB cases diagnosed during this period) and 26 with residual inactive TB. 46 cases were treated with pleural drainage (PD): 40 (85%) with only one PD, two with two, and four with three. The mean ± SD length of PD treatment was 12.9 ± 11.3 days. In 11 (23%) cases, a relapse of SP occurred, with no statistical relationship between the different studied variables. In 13 (28%) cases, it became necessary to carry out a resection (atypical segmentectomy in all cases) for persistent air leaks with PD. Survival statistics were unfavourable only in elderly patients and those infected with HIV. We conclude that the treatment of SP secondary to TB with PD is usually a sound response, with a good general prognosis and a low percentage of cases that require another PD and surgical treatment.

Composite anatomical-clinical-molecular prognostic model in non-small cell lung cancer.

The objective of the present study was to elaborate a survival model that integrates anatomic factors, according to the 2010 seventh edition of the tumour, node and metastasis (TNM) staging system, with clinical and molecular factors. Pathologic TNM descriptors (group A), clinical variables (group B), laboratory parameters (group C) and molecular markers (tissue microarrays; group D) were collected from 512 early-stage nonsmall cell lung cancer (NSCLC) patients with complete resection. A multivariate analysis stepped supervised learning classification algorithm was used. The prognostic performance by groups was: areas under the receiver operating characteristic curve (C-index): 0.67 (group A), 0.65 (Group B), 0.57 (group C) and 0.65 (group D). Considering all variables together selected for each of the four groups (integrated group) the C-index was 0.74 (95% CI 0.70-0.79), with statistically significant differences compared with each isolated group (from p = 0.006 to p < 0.001). Variables with the greatest prognostic discrimination were the presence of another ipsilobar nodule and tumour size > 3 cm, followed by other anatomical and clinical factors, and molecular expressions of phosphorylated mammalian target of rapamycin (phospho-mTOR), Ki67cell proliferation index and phosphorylated acetyl-coenzyme A carboxylase. This study on early-stage NSCLC shows the benefit from integrating pathological TNM, clinical and molecular factors into a composite prognostic model. The model of the integrated group classified patients with significantly higher accuracy compared to the TNM 2010 staging.

[Giant thymolipoma]. / Timolipoma gigante.

Thymolipoma is an uncommon benign tumor (accounting for 2% to 9% of thymus tumors). We present the case of a 26-year-old man who sought medical attention for left-sided pleural pain of 3 months duration. Computed tomography showed a mass in the left side of the chest occupying both the anterior mediastinum and the left pleural cavity. This mass caused lung collapse and mediastinal shift. Magnetic resonance imaging revealed a large fatty tumor and transthoracic biopsy with radiological guidance confirmed the diagnosis. The tumor was resected through a left thoracotomy. No postsurgical complications occurred and the histopathological diagnosis was thymolipoma.

[Mediastinoscopy in the diagnosis of mediastinal disease. An analysis of 181 explorations]. / La mediastinoscopia para el diagnóstico de la enfermedad mediastínica: análisis de 181 exploraciones.

To validate our experience with standard cervical mediastinoscopy (SCM) and extended cervical mediastinoscopy (ECM) to diagnose mediastinal nodes and masses, we studied 181 patients between January 1992 and February 2001. SCM and ECM were indicated for diagnostic staging of nodes related to bronchogenic carcinoma (Group I) or of mediastinal masses (Group II). An SCM was performed in all cases to explore the paratracheal region (2R, 2L, 4R, 4L, 7, 10R and 10L); in 21 additional cases, an ECM was performed to explore the aortopulmonary window or the subaortic region (area 5) and the para-aortic region (area 6). In Group I, the sensitivity of SCM was 93.6% and specificity was 100%; the positive predictive value (PPV) was 100%, the negative predictive value (NPV) was 82.8%, and the diagnostic yield was 95.1%. The sensitivity of ECM was 91% and specificity was 100%; PPV was 100%, NPV 93.3% and yield was 96%. In Group II, the sensitivity was 93.3%, specificity 100%, PPV 100%, NPV 81.2% and diagnostic yield 94.8%. The sensitivity of ECM in this group was 80%, specificity was 100%, PPV 100%, NPV 66.7% and yield 85.7%. A 2.7% complication rate was observed, with one case of bleeding after injury to the superior vena cava, one tracheal lesion, one recurring paralysis and two cases of surgical wound infection. The mean postoperative stay was 36 hours and mortality was zero. We conclude that SCM is highly specific for the evaluation of mediastinal node involvement in bronchogenic carcinoma and it is the approach of choice when a diagnosis of lesions located in the mid-mediastinal region has not been reached. ECM is a valid, safe alternative to anterior mediastinotomy for staging nodes and masses occupying para-aortic zones or the aortopulmonary window, with good diagnostic yield, low morbidity and absence of mortality.

[Recurring invasive thymoma of the diaphragm]. / Timoma invasor recidivante en el diafragma.

Diaphragmatic recurrence of a thymoma is rare. We report the case of a 70-year-old woman who underwent transternal thymectomy and adjuvant radiation therapy, and who was admitted four years later with recurrence of the thymoma in the left hemidiaphragm with infiltration of the inferior ipsilateral pulmonary lobe. The thymoma was excised along with the left hemidiaphragm, chest wall and three ribs and an atypical segmentectomy of the left lower lobe was performed. The hemidiaphragm was reconstructed and the chest wall was repaired with synthetic mesh. Surgery was complemented with radiotherapy.

[Transthoracic approach to the spinal column]. / Abordaje transtorácico de la columna vertebral.

Thoracotomy is used to approach and treat anterior spinal lesions arising from various causes. Between 1990 and 1997, we treated 56 patients (40 men and 16 women) between 14 and 67 years old (mean 38.4). All had spinal lesions that were impossible or difficult to reach by a posterior approach. Thirty-one (55.3%) had suffered spinal damage, 8 (14.3%) had spinal deformities, 7 (12.5%) had metastatic tumors, 5 (8.9%) had herniated discs, 4 (7.1%) had Pott's disease and 1 (1.8%) had osteolysis at D6. Thoracotomy was left-sided in 35 cases (62.5%) and right-sided in 19 (33.9%). Video-assisted thoracoscopy was used twice (3.6%). The level of incision was based on the site of the lesion, and the pleural cavity was opened in all cases except one. The posterolateral pleuro-diaphragmatic fold was dissected and the diaphragm opened for retroperitoneal access in 37 cases (66.1%) of thoracolumbar disease. Orthopedic treatment consisted of autologous bone grafts in all cases and placement of a Kaneda splint in 32 cases (57.1%). One patient had to undergo surgery a second time due to inappropriate placement of the vertebral splint. Pneumothorax occurred in one patient after removal of pleural drains. The incision became infected in one patient, and one case of ileal paralysis was observed. Overall, morbidity was 7.1%. We conclude that thoracotomy offers a good alternative approach to spinal lesions. Results are good and morbidity low.

Surgical indications for treatment of pulmonary tuberculosis.

Surgery for pulmonary tuberculosis (PTB) has passed through various stages throughout history, having been the treatment of choice in the past. It has now been relegated to second place for treatment of this disease. One of the most strongly debated surgical indications has been clinical picture of multidrug resistance with the focus of pulmonary tuberculous activity located in a segment, lobe, or lung. In these cases some authors have described good results with surgical excision. Another important indication is the complications of PTB, among which bronchiectases (provoking pictures of suppuration, superinfections, or hemoptysis) are found, along with known destructive pulmonary sequelae such as destroyed lung, massive hemoptysis, and the presence of a bronchopleural fistula that cannot be resolved with pleural drainage. The presence of a neoplasm in a patient affected by PTB is a surgical indication if the lesion is resectable. The existence of an unidentifiable pulmonary mass or node is a surgical criterion because it might signal bronchogenic carcinoma. A frequent indication for surgery is pulmonary aspergilloma, which in a large percentage of cases is a destructive PTB sequela and generates serious complications, hemoptysis being the most frequent. Mediastinal tuberculous lymphadenitis that produces compressive symptoms and pulmonary complications, especially in children, is another surgical indication for decompressing the bronchial tree. The surgery in these cases consists in excision and curettage of adenopathies. Surgery therefore now constitutes a valid option for the treatment of certain clinical pictures of PTB that do not respond to medical treatment, are serious, and are potentially fatal.

Surgical treatment of primary spontaneous pneumothorax with video-assisted thoracic surgery.

We report the results of our experience using video-assisted thoracoscopic surgery (VATS) to treat primary spontaneous pneumothorax (PSP) from January 1992 until December 1994 in a multicentered co-operative study. A total of 132 patients (110 males and 22 females, aged 13-38 yrs, mean age 26 yrs) were treated by VATS to deal with the PSP that they presented with. A standard VATS technique was used. Apical bullae were always removed, and mechanical pleural abrasion was performed, leaving a pleural drainage tube. In two cases (1.5%), a switch to thoracotomy was necessary. In eight cases (6%), air leakage persisted for 5 days after surgery, which resolved with pleural drainage. There were eight postoperative relapses (6%), which were treated with pleural drainage (n = 4), VATS (n = 3) or axillar thoracotomy (n = 1). The average postoperative stay was 5.6 days (range 2-15 days). We conclude that video-assisted thoracoscopic surgery is a viable alternative for the treatment of primary spontaneous pneumothorax. There is, however, a high relapse rate, and in a number of cases air leakage persists in the postoperative period.

Comparison of bronchoscopic diagnostic techniques with histological findings in brain dead organ donors without suspected pneumonia.

BACKGROUND: The techniques for recognising pneumonia in mechanically ventilated patients were evaluated as no "gold standard" is available to establish the diagnosis in these patients. METHODS: A prospective study was performed on nine brain dead organ donors not suspected of having pneumonia to assess the specificity of bacteriological results from different samples by comparing them with the histological findings from an open pulmonary biopsy specimen taken immediately after death through a mini-thoracotomy. RESULTS: Seven of the nine organ donors without clinical evidence of pulmonary infection and not on antibiotic therapy showed histological features of bronchopneumonia. There was no association between the histological findings and quantitative cultures of the lung biopsy specimen. CONCLUSIONS: Histological evidence of pneumonia was common in this group of ventilated patients who had no clinical signs of the disease.

Massive hemoptysis as a manifestation of fistulized thoracic aortic aneurysms into the bronchial tree.

Aortobronchial fistulas are an uncommon and serious cause of hemoptysis. We present three cases of aortobronchial fistulas that were diagnosed and treated at our hospital. They were presented as massive hemoptysis. The clinical suspicion of a leaking thoracic aortic aneurysm into the bronchial tree should prompt the correct diagnostic procedures since early surgery is the only way to manage this condition.