Challenges in diagnosis and management of giant solitary fibrous tumour of pleura: a case report.

BACKGROUND: Majority of patients with solitary fibrous tumours of the pleura (SFTP) are asymptomatic. Acute presentation with symptoms resulting from mass effect due to rapid expansion of tumour size has not been reported before. CASE PRESENTATION: This report chronicles the case of a giant SFTP in a 76-year-old lady who presented with acute onset of haemoptysis, left-sided pleuritic chest pain and hoarseness of voice. Her chest radiograph showed a large left upper hemithorax mass with an ipsilateral effusion. Computed tomography (CT) scan of the thorax confirmed the presence of a pleural-based mass lesion in the left apex measuring 9.7 cm with close apposition to the aortic arch. The mass demonstrated neovascularization and there was also presence of a moderate-sized heterogeneous-appearing left pleural effusion. Thoracocentesis yielded deeply haemoserous pleural fluid with a pleural aspirate hematocrit closely approaching that of peripheral blood hematocrit and alongside a 2 unit decrease in haemoglobin, was indicative of a haemothorax. Repeat CT 10 days from initial presentation showed reduction in size of the left apical mass as well as resolution of the left effusion. This was consistent with the occurrence of an intra-tumoural bleed resulting in rapid increase in the size of the SFTP, causing rupture of superficial blood vessels on the tumour surface (haemothorax) and consequential compression of the lung parenchyma (haemoptysis) and left recurrent laryngeal nerve (hoarseness of voice). The patient eventually underwent an uneventful surgical resection. CONCLUSION: A benign SFTP can present acutely with compressive symptoms as a result of spontaneous intra-tumoural bleed causing sudden increase in its size. It is important to allow temporal regression of these acute changes before deciding on surgical resectability.

Differences between small-cell lung cancer and non-small-cell lung cancer among tobacco smokers.

It is known that smoking increases the risk for all histological subtypes of lung cancer. To date, the factors that determine why some patients develop small-cell lung cancer (SCLC) while others develop non-small-cell lung cancer (NSCLC) remain unknown. We compared the characteristics of 774 smokers with SCLC and NSCLC diagnosed during the period January 1999 till December 2002. Multivariate logistic regression was used to estimate the odds ratio (OR) with 95% CI. Testing of linear trend across categories of pack-years was also conducted. Six hundred and sixty-five NSCLC were compared to 109 SCLC. Among SCLC, there were significantly more females (20.2% versus 12.8%), current-smokers (81.7% versus 71.9%) as well as smokers who had smoked more than 40 pack-years (75.6% versus 50.3%). Comparing SCLC with NSCLC among the men only, having smoked more than 40 pack-years was associated with a significantly elevated odds ratio (OR) of 3.71 of developing SCLC (95% CI, 1.05-13.1; p=0.041). There was a decreasing trend in OR with increasing smoking cessation period. When comparing SCLC with adenocarcinoma, the women had a higher OR of 2.37 of developing SCLC (95% CI, 1.05-5.31; p=0.037) compared to the men. Our findings suggest that cumulative smoking exposure in terms of pack-years smoked is an important determining factor for the preferred development of SCLC among smokers.

Survival of small-cell lung cancer and its determinants of outcome in Singapore.

INTRODUCTION: The survival and epidemiology of small-cell lung cancer (SCLC) in Singapore has not been described. We aim to present the characteristics as well as determine the survival outcome and important prognostic factors for SCLC patients. MATERIALS AND METHODS: A retrospective analysis of SCLC patients diagnosed from 1999 to 2002 was conducted at the Outram campus, Singapore. Clinical characteristics and treatment data were obtained from case records and survival data were checked with the registry of births and deaths on 30 May 2005. RESULTS: One hundred and eleven patients were analysed. There were 38 (34.2%) limited-disease (LD) patients and 73 (65.8%) extensive-disease (ED) patients. The majority were current or former smokers (94.7% among LD and 94.5% among ED). More patients with LD had good performance status (92% versus 63%, P = 0.0003) and were treated with combined chemotherapy and radiotherapy (82% versus 48%, P = 0.012). The median survival time of LD patients treated with curative chemoradiotherapy was 14.2 months (95% CI, 10.96 to 17.44). Those given prophylactic cranial irradiation had a median survival time of 16.9 months (95% CI, 11.83 to 21.97). For ED patients, the median survival time was 8.17 months (95%CI, 5.44 to 10.89). None of the factors analysed were significant prognostic factors for LD patients while performance status and type of treatment given were significant among ED patients. CONCLUSIONS: We found that the characteristics and survival of SCLC patients in Singapore are fairly similar to that of other countries.

Rigid bronchoscopy and stenting for esophageal cancer causing airway obstruction.

BACKGROUND: Thirty percent of patients with esophageal cancer have malignant involvement of the major airways, leading to respiratory distress and life-threatening major airway obstruction. Tracheobronchial stenting has been reported to be effective in providing sustained relief from obstruction. METHODS: We conducted a chart review of all patients with advanced inoperable esophageal cancer who had malignant tracheobronchial obstruction requiring rigid bronchoscopy and airway stenting at our institution between June 1998 and July 2001. Outcome measures, which included survival, efficacy, and complications, were recorded. RESULTS: There were 11 patients (4 women) with a mean age of 61 years. Five patients had distant metastases at the time they underwent rigid bronchoscopy. Four patients who required mechanical ventilation for respiratory failure were successfully weaned off mechanical ventilation after the stenting procedure. All patients with dyspnea had immediate relief of respiratory symptoms, which was sustained for seven patients (64%). The mean duration of survival was 61 days. Two patients required repeat procedures, one for stent dislodgment on extubation and the other for stent migration. CONCLUSION: Stenting in patients with malignant tracheobronchial obstructions due to advanced esophageal cancer achieves immediate, dramatic, and sustainable relief in respiratory symptoms, conferring a survival benefit in patients whose conditions are otherwise deemed to be terminal.

Never-smokers with lung cancer: epidemiologic evidence of a distinct disease entity.

PURPOSE: Tobacco smoke is a definite causative agent for lung cancer. It is increasingly being recognized that never-smokers can be afflicted with non-small-cell lung cancer (NSCLC). We aim to assess survival differences between smokers and never-smokers with NSCLC. PATIENTS AND METHODS: We analyzed 975 NSCLC patients who presented from January 1999 to December 2002. Clinical characteristics among current-, former- and never-smokers were tested using chi2 or Kruskal-Wallis test. The hazard ratio (HR) for death and its 95% CI were calculated by Cox regression. RESULTS: Of 975 patients, 59 had no smoking history and 33 had no quit time recorded. Of 883 patients analyzed, 286 patients (32.4%) were never-smokers. One hundred ninety-six never-smokers (68.5%) were females compared with 12% among current- and 13% among former-smokers (P < .001). There was a significant difference in histologic subtype between never-smokers and smokers: 69.9% with adenocarcinoma versus 39.9% (current-smokers) versus 47.3% (former-smokers); 5.9% with squamous cell carcinoma versus 35.7% (current-smokers) versus 28% (former-smokers; P < .001). Smokers had significantly poorer performance status (P = .002) and higher median age at diagnosis (P < .001) while more never-smokers presented with advanced disease (P = .002). Eight hundred and five patients (82.6%) died by May 30, 2005. The HR for smokers was significantly higher on both univariate and multivariate analysis (HR, 1.297; 95% CI, 1.040 to 1.619). CONCLUSION: Never-smokers comprised a high proportion of NSCLC patients in Singapore. Definite epidemiologic differences exist between never-smokers and smokers. Differences in survival outcome further suggest that the biology underlying the pathogenesis and behavior of the disease may be different for never-smokers.

Thoracic embolotherapy for life-threatening haemoptysis: a pulmonologist's perspective.

Haemoptysis is the expectoration of blood from the respiratory tract and is life-threatening when blood obstructs the major airway causing asphyxiation. This may occur in the presence or absence of pre-existing compromised pulmonary reserve and medical comorbidities. Life-threatening haemoptysis is a relatively common clinical situation encountered by pulmonologists and thoracic embolotherapy is a key therapeutic option. Although thoracic embolotherapy primarily involves bronchial arterial embolization, it also encompasses embolization of non-bronchial systemic arteries and the pulmonary arterial supply. A pulmonologist's perspective on this topic is presented. Pertinent areas related to this theme, namely surgery and the role of bronchoscopy in life-threatening haemoptysis are discussed briefly.

Continuous positive airway pressure therapy in sleep apnoea.

Sleep apnoea is associated with increased mortality and morbidity. The treatment goal is to reduce the neurocognitive and cardiovascular sequelae. CPAP therapy in sleep apnoea is discussed in two parts in the article. The first part will consider CPAP therapy in the more common form of sleep apnoea (i.e. obstructive or mixed sleep apnoea) and the second part will consider CPAP therapy in central sleep apnoea. Alternative positive airway pressure modalities are discussed. CPAP therapy has been extensively studied and it remains the mainstay of treatment in obstructive sleep apnoea, as it is still the most consistently efficacious and safe option. However, its major disadvantage is that it does not confer a cure to this disorder and hence therapy is generally life long with its usual treatment compliance problems. As such, there are continuous improvement strategies. The role of CPAP therapy in central sleep apnoea is more limited. There has been increasing data on the beneficial effect of CPAP on central sleep apnoea/Cheyne-Stokes respiration in congestive heart failure. Evidence for CPAP therapy in sleep apnoea has evolved significantly over the last decade. However, more research and publication of large-scale long-term randomized trials of treatment in sleep apnoea to assess patient-orientated outcomes and preferences are necessary.