Short-term safety of thoracoscopic talc pleurodesis for recurrent primary spontaneous pneumothorax: a prospective European multicentre study.

The safety of talc pleurodesis is under dispute following reports of talc-induced acute respiratory distress syndrome (ARDS) and death. We investigated the safety of large-particle talc for thoracoscopic pleurodesis to prevent recurrence of primary spontaneous pneumothorax (PSP). 418 patients with recurrent PSP were enrolled between 2002 and 2008 in nine centres in Europe and South Africa. The main exclusion criteria were infection, heart disease and coagulation disorders. Serious adverse events (ARDS, death or other) were recorded up to 30 days after the procedure. Oxygen saturation, supplemental oxygen use and temperature were recorded daily at baseline and after thoracoscopic pleurodesis (2 g graded talc). During the 30-day observation period following talc poudrage, no ARDS (95% CI 0.0-0.9%), intensive care unit admission or death were recorded. Seven patients presented with minor complications (1.7%, 95% CI 0.7-3.4%). After pleurodesis, mean body temperature increased by 0.41°C (95% CI 0.33-0.48°C; p<0.001) at day 1 and returned to baseline value at day 5. Pleural drains were removed after day 4 in 80% of patients. Serious adverse events, including ARDS or death, did not occur in this large, multicentre cohort. Thoracoscopic talc poudrage using larger particle talc to prevent recurrence of PSPS can be considered safe.

Videothoracoscopic appearance of first and recurrent pneumothorax.

STUDY OBJECTIVE: Comparison of the videothoracoscopic appearance of first and recurrent pneumothorax, and assessment of a relation between endoscopic appearance and recurrence rate. SETTING: University hospital. PATIENTS: Eighty-two patients, 64 men (mean age, 32.7 years) and 18 women (mean age, 31.5 years), were included. Patients with known underlying pulmonary disease at the time of hospital admission were excluded. There were 61 patients (74%) with first pneumothorax, and 21 patients (26%) with recurrent pneumothorax. INTERVENTIONS: All patients underwent videothoracoscopy under general anesthesia, with double-lumen intubation. RESULTS: Blebs or bullae were found in 47 patients (77%) with first pneumothorax, and in 14 patients (67%) with recurrent pneumothorax. Bullae > 2 cm were found in 34 patients (56%) with first pneumothorax and 10 patients (48%) with recurrent pneumothorax. Patients with blebs or bullae were significantly older than patients with normal videothoracoscopic appearance (mean age, 36.5 +/- 15.7 years vs 25.3 +/- 5.8 years, p < 0.05). Adhesions were significantly more frequently found in patients with blebs or bullae compared with patients with normal thoracoscopic appearance of the lung (p < 0.05). Seventeen of 21 patients (81%) with normal thoracoscopic appearance were smokers. Of nonsmoking patients (n = 22), 82% had blebs and bullae. CONCLUSIONS: No significant differences in videothoracoscopic appearance were found between first and recurrent pneumothorax. These results suggest that recurrence after the first event of spontaneous pneumothorax cannot be predicted by thoracoscopic findings. Smoking and blebs or bullae are independent risk factors for development of spontaneous pneumothorax.

Endoscopic management of bronchial stenosis after double lung transplantation.

Double lung transplantation with bilateral bronchial sutures is an increasingly popular therapeutic alternative for endstage, bilateral, septic pulmonary disease; however, surgical outcome has been hampered by mechanical complications at the level of the airway anastomoses. In our institution, therefore, the protocol for surveillance includes frequent flexible fiberoptic and rigid bronchoscopy under general anesthesia in all patients. Since 1988, there were 24 double lung transplantations (mean age, 19 yr) performed at the University of Marseille Hospitals using bilateral sutures without omental wrapping. Nineteen patients had cystic fibrosis; of the ten individuals (53 percent) with cystic fibrosis who ultimately developed bronchial stenosis, six required therapeutic endoscopic intervention including dilatation or Nd:YAG laser resection. Five patients required endobronchial silicone stents. Statistically significant risk factors for postsurgical airway narrowing included young age (mean, 14.3 yr vs 24.0 yr in patients without stenosis) and prolonged mechanical ventilation prior to transplant (all five patients ventilated before surgery developed stenosis). Results of interventional bronchoscopy were good, and an excellent level of physical activity was maintained in most patients. A team familiar with all aspects of therapeutic bronchoscopy is essential to ensure proper management of airway complications in patients after lung transplantation.

Primary sarcoma of the lung: a clinical study with long-term follow-up.

Primary pulmonary sarcoma is an extremely rare tumor. In more than 30 years, only 22 patients with PPS were seen in our hospital; 18 patients (82%) underwent operation. Radical resection is the only curative treatment in patients with primary pulmonary sarcoma. All 4 patients (18%) who did not undergo operation died within 17 months. All 7 patients (32%) in whom no radical resection could be performed died between 10 months and 16 years after operation. Total resection of the tumor could be performed in 11 patients (50%). Of these, 7 are still alive (64%), and 1 patient died of an unrelated cause after 25 years (mean follow-up, 13.5 years). Histologic diagnosis in these patients was leiomyosarcoma in 4, malignant schwannoma in 2, and fibrosarcoma and undifferentiated sarcoma in 1 each. Median survival for all patients was 24 months. Actuarial 5-year survival was 44% for all patients. Small tumor diameter and low-grade malignancy are statistically significant favorable prognostic factors. No patient with grade 1 tumor died; the median survival was 60 months for grade 2 sarcomas, and 17 months for grade 3 sarcomas. No patient with a completely resected small primary pulmonary sarcoma had recurrence or metastasis.

Pulmonary function of patients with spontaneous pneumothorax in relation to the extent of emphysema-like changes.

The aim of the present study was to analyse pulmonary function parameters of patients with spontaneous pneumothorax (SP) in relation to the extent of emphysema-like changes (ELCs). Pulmonary function tests were performed in 85 patients with unilateral SP, 6 weeks after video-assisted thoracoscopy (VAT). In 63 patients, thoracic computer tomography (CT) was obtained. An ELCs score, based on findings of CT and VAT, was used to quantify ELCs, ranging from 0 (expressing no ELCs) to 3 (expressing extensive ELCs). Emphysema-like changes were detected during VAT in 74% of patients, of which 70% were considered larger than 2 cm. An ELCs score > or = 2 was found in 27 patients. Clinical characteristics of the patients grouped according to thoracoscopical findings and ELCs score did not differ, except for age. Patients with large ELCs were significantly older than patients without ELCs or small ELCs (P = 0.0009). In patients with large ELCs and ELCs score > or = 2, increased mean percentages of predicted total lung capacity and decreased diffusing capacity (KCO) were found. None of the patients exhibited all pulmonary function criteria of emphysema, in contrast to 43% of the patients with an ELCs score > or = 2. KCO was the only pulmonary function parameter which was decreased in smokers, especially in patients with large ELCs or ELCs score > or = 2. Static lung compliance (Cstat) was the only pulmonary function parameter which was increased in patients with recurrent SP. The authors concluded that KCO is related to smoking behaviour and ELCs in patients with SP. Cstat is the only parameter which is increased in patients with recurrent SP. The discrepancy between pulmonary function and macroscopical parenchymal changes could be explained by the fact that not all patients with SP are old enough at presentation to show all signs of emphysema with pulmonary function testing. On the other hand, it might be possible that ELCs in SP cause different pulmonary function abnormalities than in centriacinar or panacinar emphysema.

Detection of areas with viable remnant tumor in postchemotherapy patients with Ewing's sarcoma by dynamic contrast-enhanced MRI using pharmacokinetic modeling.

An approach is presented for monitoring the effects of neoadjuvant chemotherapy in patients with Ewing's sarcoma using dynamic contrast-enhanced perfusion magnetic resonance (MR) images. For that purpose, we modify the three-compartment pharmacokinetic permeability model introduced by Tofts et al. (Magn Reson Med 1991;17:357-67) to a two-compartment model. Perfusion MR images acquired using an intravenous injection with Gadolinium (Gd-DTPA) are analyzed with this two-compartment pharmacokinetic model as well as the with an extended pharmacokinetic model that includes the (local) arrival time t(0) of the tracer as an endogenous (estimated) parameter. For each MR section, a wash-in parameter associated with each voxel is estimated twice by fitting each of the two pharmacokinetic models to the dynamic MR signal. A comparison of the two wash-in parametric images (global versus local arrival time) with matched histologic macroslices demonstrates a good correspondence between areas with viable remnant tumor and a high wash-in rate. This can be explained by the high number and permeability of the (leaking) capillaries in viable tumor tissue. The novel pharmacokinetic model based on a local arrival time of tracer results in the best fit of the wash-in rate, the most important factor discerning viable from nonviable tumor components. However, parameter estimates obtained with this model are also more sensitive to noise in the MR signal. The novel pharmacokinetic model resulted in a sensitivity between 0.22 and 0.60 and a specificity between 0.61 and 1. The model based on a global arrival time gave sensitivities between 0.33 and 0.77 and specificities between 0.58 and 0.99. Both statistics are computed as the fraction of correctly labeled voxels (viable or nonviable tumor) within a specified ROI, which delineates the tumor. We conclude that the added value of estimating the local arrival time of tracer first manifests itself for moderate noise levels in the MR signal. The novel pharmacokinetic model should moreover be preferred when pharmacokinetic modeling is applied on the average signal intensity within a ROI, where noise has less effect on the fitted parameters.

The value of parasternal mediastinoscopy in staging bronchial carcinoma.

Computed tomography (CT) is the non-invasive staging procedure of choice for assessment of metastasis to mediastinal lymph nodes in patients with bronchial carcinoma. Cervical mediastinoscopy can provide histologic evidence of mediastinal spread to the peritracheal, tracheobronchial and subcarinal lymph nodes. Sub-aortic and para-aortic nodes cannot be sampled via this route. The present study was performed to assess the staging value of the parasternal mediastinoscopy as a separate entity. Cervical and parasternal mediastinoscopy was performed in 37 patients with a proven diagnosis of non-small cell carcinoma of the left upper lobe. In 16 patients lymph node or tumor tissue could be biopsied via the parasternal route, in 21 patients no parasternal biopsy was taken. Of the 16 cases with biopsies, only one was positive (6%). Histologic examination of lymph node biopsy tissue was false negative in one other patient (6%). Of the 21 patients without biopsies taken during parasternal mediastinoscopy, three (14%) had proven lymphogenic spread to the subaortic and para-aortic nodes, detected at thoracotomy. The parasternal procedure changed treatment in only one patient (3%). Diagnostic sensitivity was 20%. It is concluded that parasternal mediastinoscopy should not be used as a routine staging procedure in patients with left upper lobe lung cancer.

Chylothorax.

Chylothorax is defined as an accumulation of chyle in the pleural space caused by disruption of the thoracic duct or one of its major divisions. Chyle has a high content of triglycerides. The odorless fluid is turbid and milky due to the presence of fat containing particles, the chylomicrons. The etiology of chylothorax can be divided into four major categories: tumor, trauma, idiopathic and miscellaneous. Although chylothorax is uncommon, it is a serious and potentially hazardous disorder. Loss of chyle leads to metabolic disturbances, malnutrition and immunodeficiency. Treatment consists of treatment of the underlying disease, conservative treatment (medium chain triglyceride diet, parenteral nutrition) or surgical intervention. Appropriate timing of surgical intervention is essential. Since the ligation of the thoracic duct can be performed during thoracoscopy, this minimal interventional technique is the procedure of choice when conservative treatment fails.

Thoracoscopy in the management of spontaneous pneumothorax.

For many years, treatment of spontaneous pneumothorax (SP) has been a matter of debate. Since the introduction of videothoracoscopy, videothoracoscopic procedures have replaced thoracotomy as the ultimate procedure for treatment of complicated cases of SP in many institutes. However, the place of (video) thoracoscopy in SP has not been fully established yet. Satisfactory results have been published about several different combinations of bullectomy (Stapler resection, endoloop ligation, electrocoagulation, Nd-YAG laser, CO2 laser, argon beam coagulation) and pleurodesis (mechanical, chemical, pleurectomy). Until today, it remains obscure if bullectomy as well as pleurodesis are always necessary to prevent recurrence.

Is thoracoscopic talc pleurodesis really safe?

Talc is a mineral defined as hydrated magnesium silicate in its pure form. It is mined in open pits throughout the world. For induction of chemical pleurodesis, talc has been shown to be superior to all other products. The safety of the use of talc for pleurodesis is subject to discussion in the literature. In early days, there was concern about asbestos contamination of talc, which could cause mesothelioma in patients who had undergone talc pleurodesis. The long-term safety of talc was proven in several studies, and today talc for pharmaceutical use is asbestos-free. Today the discussion is concentrated on the early complications of talc; Acute respiratory failure, sometimes with fatal outcome, has been attributed to the intrapleural use of talc particles. In recent animal studies, a relation was demonstrated between the size of talc particles and pulmonary injury as well as dissemination to other organs. Pulmonary injury and dissemination to other organs are related to a talc particle size of less than 10 micro. With certain precautions, talc can be used safely for pleurodesis; Simultaneous bilateral procedures, concomitant pulmonary biopsies and use of more than 5 grams of talc should be avoided. As long as the hypothesis about the influence of particle size on complications has not been confirmed by studies in humans, the use of talc with a large mean particle diameter is to be preferred.

[Treatment of spontaneous pneumothorax: survey among Dutch pneumonologists]. / Behandeling van spontane pneumothorax: enquête onder Nederlandse longartsen.

OBJECTIVE: To gain insight into the treatment of spontaneous pneumothorax in the Netherlands. DESIGN: Questionnaire. SETTING: Nationwide in the Netherlands. METHOD: A questionnaire was sent to all 286 practising pulmonologists in the Netherlands to inquire about the mode of treatment used for spontaneous pneumothorax. Answers were sorted by size of practice. University hospital, non-university hospitals qualified for residency training and offices with at least 4 pulmonologists were classified as large practices. Other practices were classified as small. RESULTS: 89% of all pulmonologists responded. In small practices, a first spontaneous pneumothorax was treated by chest tube drainage; in large practices, thoracoscopy was usually performed. In recurrent pneumothorax, thoracoscopy was the first choice in both small and large practices. The role of interventional thoracoscopy and surgery was not established. CONCLUSION: Worldwide, including in the Netherlands, there is no consensus about the treatment of spontaneous pneumothorax. Randomised studies with cost-effect analysis are necessary.

[localized fibrous tumors of the pleura]. / Gelokaliseerde fibreuze tumoren van de pleura.

The localized fibrous tumour of the pleura, also named localized fibrous mesothelioma or fibroma of the pleura, is a very rare tumour with a benign behaviour. Its origin, clinical behaviour and prognosis are very different from malign mesothelioma. In a 33-year period 22 patients with this diagnosis were surgically treated. The prognosis was excellent. In this article the clinical and radiological signs, as well as the diagnosis and therapy are discussed.

Quantitative analysis of vascular images, in particular of abdominal aorta aneurysms from 3D CTA data sets.

This article presents a combination of well known image processing techniques to automatically segment CTA images of the Abdominal Aortic Aneurysm. Current results are that about 80% of the contours need no manual corrections. The remaining 20% fail due to calcified plaque close to the lumen border. After correction a 3D surface model is created from the 2D contours which is used as input for flow simulations and for parameter extraction of the AAA by clinicians for selecting the proper size and shape endograft, and to plan the placement procedure of this endograft in the patient.

Why you do or do not need thoracoscopy.

Thoracoscopy is an old but still very valuable technique for the evaluation of pleural pathology and, especially for the further investigation of the aetiology of pleural fluid. It remains of great importance, since it is able to not only provide an exact diagnosis, but also can have therapeutic potential. In this review, the differential diagnostic aspects of transudate versus exudate are further elaborated, and the role of thoracoscopy is compared to closed pleural biopsy and image guided biopsy.

Autofluorescence videothoracoscopy in exudative pleural effusions: preliminary results.

Videothoracoscopy has been proven to be a safe tool to establish the diagnosis in >90% of patients with exudative pleural effusions of unknown origin. In the majority of patients with malignant pleural diseases, the endoscopic appearance of pleural lesions during white light thoracoscopy is suggestive of malignancy, but could be misleading in some cases. The aim of the present study was to estimate whether the combination of thoracoscopy with autofluorescence modalities would be useful to further improve the diagnostic accuracy of the conventional method. The present study displays early results of thoracoscopy performed consecutively with a normal light source and with autofluorescence light in 24 patients with exudative pleural effusion during 2003-2004. In all cases of malignant pleuritis (carcinoma or mesothelioma), the colour of the affected area of the pleura changed from white/pink to red (sensitivity 100%). However, in two cases of chronic pleuritis, a colour change from white/pink to orange/red was recorded (specificity 75%). In conclusion, the calculated positive predictive value of colour change for malignant pleuritis during autofluorescence thoracoscopy in this study was 92%. However, the clinical value of autofluorescence thoracoscopy in daily practice remains to be proven.