Carinal Compression from Primary Mediastinal Germ Cell Tumor.

Mediastinal masses can present as a medical emergency when there is central airway obstruction, superior vena cava (SVC) syndrome, direct mediastinal extension of tumor, or obstruction of the central pulmonary vasculature. Diagnostic evaluation may include the need for invasive tissue biopsy under anesthesia, which can pose several distinct risks for patients. Among the many etiologies of mediastinal tumors, primary mediastinal germ cell tumors are a rare form with a favorable prognosis.

Association between Tunneled Pleural Catheter Use and Infection in Patients Immunosuppressed from Antineoplastic Therapy. A Multicenter Study.

Rationale: Patients with malignant or paramalignant pleural effusions (MPEs or PMPEs) may have tunneled pleural catheter (TPC) management withheld because of infection concerns from immunosuppression associated with antineoplastic therapy.Objectives: To determine the rate of infections related to TPC use and to determine the relationship to antineoplastic therapy, immune system competency, and overall survival (OS).Methods: We performed an international, multiinstitutional study of patients with MPEs or PMPEs undergoing TPC management from 2008 to 2016. Patients were stratified by whether or not they underwent antineoplastic therapy and/or whether or not they were immunocompromised. Cumulative incidence functions and multivariable competing risk regression analyses were performed to identify independent predictors of TPC-related infection. Kaplan-Meier method and multivariable Cox proportional hazards modeling were performed to examine for independent effects on OS.Results: A total of 1,408 TPCs were placed in 1,318 patients. Patients had a high frequency of overlap between antineoplastic therapy and an immunocompromised state (75-83%). No difference in the overall (6-7%), deep pleural (3-5%), or superficial (3-4%) TPC-related infection rates between subsets of patients stratified by antineoplastic therapy or immune status was observed. The median time to infection was 41 (interquartile range, 19-87) days after TPC insertion. Multivariable competing risk analyses demonstrated that longer TPC duration was associated with a higher risk of TPC-related infection (subdistribution hazard ratio, 1.03; 95% confidence interval [CI], 1.00-1.06; P = 0.028). Cox proportional hazards analysis showed antineoplastic therapy was associated with better OS (hazard ratio, 0.84; 95% CI, 0.73-0.97; P = 0.015).Conclusions: The risk of TPC-related infection does not appear to be increased by antineoplastic therapy use or an immunocompromised state. The overall rates of infection are low and comparable with those of immunocompetent patients with no relevant antineoplastic therapy. These results support TPC palliation for MPE or PMPEs regardless of plans for antineoplastic therapy.

Bronchoalveolar lavage as a diagnostic procedure: a review of known cellular and molecular findings in various lung diseases.

Bronchoalveolar lavage (BAL) is a commonly used procedure in the evaluation of lung disease as it allows for sampling of the lower respiratory tract. In many circumstances, BAL differential cell counts have been reported to be typical of specific lung disorders. In addition, more specific diagnostic tests including molecular assays such as polymerase chain reaction (PCR) or enzyme-linked immunosorbent assay, special cytopathologic stains, or particular microscopic findings have been described as part of BAL fluid analysis. This review focuses on common cellular and molecular findings of BAL in a wide range of lung diseases. Since the performance of the first lung irrigation in 1927, BAL has become a common and important diagnostic tool. While some pulmonary disorders have a highly characteristic signature of BAL findings, BAL results alone often lack specificity and require interpretation along with other clinical and radiographic details. Development of new diagnostic assays is certain to reinforce the utility of BAL in the future. Our review of the BAL literature is intended to serve as a resource to assist clinicians in the care of patients with lung disorders.

The Link between Fusobacteria and Colon Cancer: a Fulminant Example and Review of the Evidence.

Systemic infections due to Fusobacterium may originate in the tonsillar/internal jugular veins or from the abdomen. We encountered a patient who presented with bacteremia, fulminant septic shock, and extensive soft tissue pyogenic infection due to Fusobacterium necrophorum. In addition, there was widespread metastatic colon cancer with the unique finding of pre-mortem co-localization of F. necrophorum and cancer cells at a site distant from the colon. We reviewed the literature of the association of F. necrophorum and colon cancer, and discuss the evidence of how each of these 2 distinct entities may mutually augment the development or progression of the other.

The Impact of Gravity vs Suction-driven Therapeutic Thoracentesis on Pressure-related Complications: The GRAVITAS Multicenter Randomized Controlled Trial.

BACKGROUND: Thoracentesis can be accomplished by active aspiration or drainage with gravity. This trial investigated whether gravity drainage could protect against negative pressure-related complications such as chest discomfort, re-expansion pulmonary edema, or pneumothorax compared with active aspiration. METHODS: This prospective, multicenter, single-blind, randomized controlled trial allocated patients with large free-flowing effusions estimated ≥ 500 mL 1:1 to undergo active aspiration or gravity drainage. Patients rated chest discomfort on 100-mm visual analog scales prior to, during, and following drainage. Thoracentesis was halted at complete evacuation or for persistent chest discomfort, intractable cough, or other complication. The primary outcome was overall procedural chest discomfort scored 5 min following the procedure. Secondary outcomes included measures of discomfort and breathlessness through 48 h postprocedure. RESULTS: A total of 142 patients were randomized to undergo treatment, with 140 in the final analysis. Groups did not differ for the primary outcome (mean visual analog scale score difference, 5.3 mm; 95% CI, -2.4 to 13.0; P = .17). Secondary outcomes of discomfort and dyspnea did not differ between groups. Comparable volumes were drained in both groups, but the procedure duration was significantly longer in the gravity arm (mean difference, 7.4 min; 95% CI, 10.2 to 4.6; P < .001). There were no serious complications. CONCLUSIONS: Thoracentesis via active aspiration and gravity drainage are both safe and result in comparable levels of procedural comfort and dyspnea improvement. Active aspiration requires less total procedural time. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT03591952; URL: www.clinicaltrials.gov.

Management of Lung Transplant Bronchial Stenosis With Mitomycin C.

BACKGROUND: Bronchial stenosis is a significant source of morbidity among lung transplant recipients, with etiologies including infection and ischemia of the airways. Current management with balloon bronchoplasty and stents is imperfect and a subset of patients requires multiple procedures to maintain airway patency. Mitomycin C (MMC) has been utilized for its antifibrotic properties in nonmalignant tracheobronchial stenosis but its application is not well studied in post-lung transplant stenosis. We performed this study to assess if MMC application decreases the need for repeated balloon bronchoplasty in lung transplant-related airway stenosis. METHODS: This is a retrospective cohort study of all lung transplant recipients who developed airway stenosis and who were treated with MMC over 4 years. MMC was injected submucosally into the stenotic airway. We compared the rate of bronchoscopic dilation at intervals of 3 and 6 months before and after MMC therapy. RESULTS: Eleven lung transplant recipients, with airway stenosis were included in our study, who required recurrent balloon dilation, despite airway stents in place in 73% of these patients. At 3 months after MMC treatment the median number of dilations decreased from 3 to 1 (P=0.023), and at 6 months from 3 to 2 dilations (P=0.004). There was a trend toward improvement in forced expiratory volume in one second and forced vital capacity, although it was not statistically significant. No adverse events related to MMC therapy was observed CONCLUSION:: Application of MMC is safe and is associated with a reduction in frequency of bronchoscopic balloon dilation in patients with post-lung transplant airway stenosis.