Time-to-progression following conventional compared with drug-eluting-bead transcatheter arterial chemoembolisation in patients with large hepatocellular carcinoma.

AIMS: To identify the optimal transarterial chemoembolisation (TACE) approach in patients with large hepatocellular carcinoma (HCC; >5 cm) by comparing conventional TACE (cTACE) and drug-eluting-bead (DEB)-TACE. MATERIALS AND METHODS: This retrospective study included 63 consecutive HCC patients who received TACE at a single medical centre from September 2009 to October 2015. Primary endpoints were 3-year overall survival (OS) rate and time-to-progression (TTP). Hazard ratios (HRs) from Kaplan-Meier curves were calculated to compare survival estimates. RESULTS: The median OS was shorter in the cTACE group, but was not significantly different from the DEB-TACE group (33.9 versus 35.6 months, respectively; p=0.52). The mean TTP was shorter in the cTACE group than in the DEB-TACE group (13.9 versus 17.5 months, respectively; p=0.01). There was no difference in 3-year survival (HR=0.95, 95% confidence interval [CI]: 0.51-1.78; p=0.880) and TTP (HR=0.70, 95% CI: 0.42-1.16; p=0.147) between the groups; however, patients treated with DEB-TACE were more likely to have longer TTP in the first 2 years following treatment (HR=0.51, 95% CI: 0.29-0.88; p=0.009). CONCLUSION: Although DEB-TACE is not superior in terms of TTP or OS in patients with large HCC, it may have greater efficacy in the first 24 months following therapy.

Comparative study of percutaneous nephrostomy using catheters with and without locking strings.

BACKGROUND: Although it is generally felt that a catheter with a locking string can achieve better fixation and thus prevent catheter displacement, no formal study has ever substantiated this. METHODS: We retrospectively reviewed the charts from 80 patients (mean age of 64.6 ± 14.76 y) who underwent percutaneous nephrostomy (PCN) over a 1-year period. RESULTS: Most patients had catheters without locking strings and only 17 patients (21.3%) had catheters with locking strings. The median duration of catheter placement was 29 days (interquartile range 14 - 57 d). There were no significant differences in patients' characteristics or catheter outcomes between catheters with and catheters without locking strings (p > 0.05). In addition, no significant difference in the catheter 90-day survival between catheter types was found (log rank test, p = 0.638). On univariate analysis, tumor as an indication for PCN (p = 0.018), obstruction (p = 0.021) and displacement (p = 0.007) were associated with reduced catheter survival. The multivariate analysis indicated that tumor as an indication for PCN (HR: 0.28, 95% CI: 0.13 - 0.63, p = 0.002), obstruction (HR: 0.25, 95% CI: 0.08 - 0.77, p = 0.015) and catheter displacement (HR: 0.09, 95% CI: 0.03 - 0.31, p < 0.001) were independent hazard factors for reduced catheter 90-day survival. CONCLUSION: No significant difference in either complication rate or 90-day survival was found between catheters with or without locking strings. These findings may prove helpful to the clinician in deciding the type of catheter to use during PCN.

Ischemic bowel secondary to angiocentric T-cell lymphoma of intestine: a case report.

A case of intestinal angiocentric T-cell lymphoma is reported, occurring in a 72-year-old female who had suffered from poor appetite, body weight loss and abdominal pain for two months. Plain abdominal film revealed ileus, and she received laparotomy under the impression of ischemic bowel. Surprisingly, pathologic examination disclosed an angiocentric T-cell lymphoma of jejunum complicated with focal intestinal necrosis. This case emphasizes the angiocentric and angioinvasive character of some T-cell lymphomas. Angiocentric T-cell lymphoma must be considered as a possible cause of ischemic bowel.

Psoas abscess due to mucinous cystadenocarcinoma of the appendix: a case report.

Psoas muscle abscess is an uncommon and challenging entity. The present report describes a 64-year-old man presenting with right flank mass. Abdominal computerized tomography showed a right psoas abscess. Extraperitoneal drainage was performed, and pathology revealed metastatic mucinous adenocarcinoma. After further study, laparotomy and right hemicolectomy were performed under the impression of colon cancer. The final pathology showed mucinous cystadenocarcinoma of appendix. The literature about the etiology, diagnosis and treatment of psoas abscess are reviewed. Additionally, the treatment and prognosis for mucinous cystadenocarcinoma of the appendix are noted.

Evidence for accessory cell function by class II MHC antigen-expressing airway epithelial cells.

Expression of major histocompatibility complex (MHC) class II antigens is a requirement for accessory cell function in antigen presentation. Recent reports have demonstrated the presence of class II antigens on human bronchial epithelial cells. In the present study, immunohistochemical staining revealed HLA-DR on human airway epithelial cells obtained from two different mucosal sites (lobar bronchus and nasal turbinates). To determine whether airway epithelial cells bear functional class II molecules that allow for their cognate interaction with T lymphocytes, cells isolated from these sites were used in mixed lymphocyte cultures (MLR), as an in vitro model of accessory cell function. Freshly isolated cells (11 bronchi/3 turbinates) stimulated allogeneic T lymphocytes (stimulation index [S.I.] = 9.3 [mean]; P less than 0.001 compared to T cells alone). In order to assess the potential role of contaminating conventional accessory cells, bronchial epithelial cell isolates were first preincubated in a serum-free, growth factor-supplemented medium that functionally eliminates potential non-epithelial stimulators prior to MLR culture. Conventional accessory cell-depleted epithelial cells were still capable of stimulating allogenic T lymphocytes in 18 of 23 MLR cultures (S.I. = 5.5 [mean]; P less than 0.0005 compared to T cells alone). The addition of an anti-class II monoclonal antibody (VG2.2) at the onset of culture completely inhibited the MLR response (n = 10). No shift in the CD4+/CD8+ ratio was detected between lymphocytes harvested from airway epithelial cell MLR (1.42 +/- 1.29) and the ratio from T lymphocytes cultured alone (1.3 +/- 0.75), suggesting that both CD4+ and CD8+ T lymphocytes were proliferating in response to stimulation from alloepitopes recognized on airway epithelial cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Pulmonary infection with Mycobacterium avium-intracellulare: diagnosis, clinical patterns, treatment.

Most physicians fail to recognize Mycobacterium avium-intracellulare (MAI) as a major pathogen for pulmonary disease among patients admitted to hospitals throughout the United States. In a review of all records of positive MAI cultures during the 10 years beginning July 1, 1979, at The Mount Sinai Hospital, New York City, we have identified 244 patients who had pulmonary disease primarily or secondarily complicated by MAI. We also identified another 243 patients as false positive for MAI infection. We classed as false positives patients who had no subsequent positive culture and whose clinical picture was and remained incompatible with MAI infection. We identified four distinct clinical patterns in the 244 patients with true positive MAI infections: (a) pulmonary nodules ("tuberculomas") indistinguishable from pulmonary neoplasms (78 patients); (b) chronic bronchitis or bronchiectasis with sputum repeatedly positive for MAI or granulomas on biopsy (58 patients, virtually all older white women); (c) cavitary lung disease and scattered pulmonary nodules mimicking M. tuberculosis infection (12 patients); (d) diffuse pulmonary infiltrations in immunocompromised hosts, primarily patients with AIDS (96 patients). The diagnosis should be established either by surgical resection and culture of resected nodules, or by three repeated positive acid-fast bacillus cultures of sputum or fluid and tissue obtained by bronchoscopy, or by biopsy of other tissue which shows granulomas and one or more positive MAI cultures. Surgical resection is the best treatment for "solitary" MAI nodules. Multiple antituberculous drug therapy is indicated for patients with chronic infection that impairs function or causes hemoptysis. The presence of MAI in the sputum or lung aspirates of patients with AIDS usually heralds the presence of a preterminal disseminated infection.

Bronchoscopy in diffuse lung disease: evaluation by open lung biopsy in nondiagnostic transbronchial lung biopsy.

Transbronchial lung biopsy through the flexible bronchoscope is used widely for the diagnosis of diffuse lung disease; however, a significant number of specimens obtained by the bronchoscopic 2-mm biopsy forceps will reveal nonspecific findings, eg, interstitial fibrosis or nonspecific pneumonitis. Such a report may be an accurate reflection of the presence of idiopathic pulmonary fibrosis or nonspecific pneumonitis, but may merely indicate that the true diagnosis has been missed. We retrospectively studied 38 patients with diffuse lung disease whose transbronchial lung biopsies yielded nonspecific abnormalities. Subsequently, these patients were subjected to open lung biopsies. Nineteen of the 38 patients (50%) had a specific diagnosis made by open lung biopsy. The diagnoses included bronchiolitis obliterans, alveolar proteinosis, metastatic carcinoma, lymphoma, tuberculosis, and bronchioloalveolar cell carcinoma. Although transbronchial lung biopsy is useful in the diagnosis of many diffuse lung diseases, it is not a replacement for open lung biopsy. When nonspecific findings by transbronchial lung biopsy do not correlate with the clinical picture, open lung biopsy should be performed.

Flexible bronchoscopy in the diagnosis of Pneumocystis carinii pneumonia in patients with acquired immune deficiency syndrome.

Seventy-seven patients with acquired immune deficiency syndrome (AIDS) and suspected of having Pneumocystis carinii pneumonia (PCP) had flexible bronchoscopy. The diagnosis was established in 52 of the 54 patients (96%) who proved to have PCP. There was one false-positive result. The remaining 22 patients and the patient with the false-positive diagnosis had diseases other than PCP, or no diagnosis. Flexible bronchoscopy is a safe and sensitive diagnostic procedure in patients with PCP complicating AIDS, and is recommended as the first invasive diagnostic procedure when patients at risk for AIDS have acute pulmonary complications.

Transcutaneous oxygen monitoring during fiberoptic bronchoscopy.

A transcutaneous oxygen sensor was used to detect the development of hypoxemia in patients undergoing fiberoptic bronchoscopy. Measurements of transcutaneous PO2 (tcPO2) correlated well with arterial PO2 (PaO2), and correctly detected all instances when PaO2 was less than 65 mm Hg. The sensor was noninvasive and caused no adverse effects.

Diagnosis of pulmonary complications of the acquired immune deficiency syndrome.

Forty eight patients with the acquired immunedeficiency syndrome (AIDS) presented to the Mount Sinai Hospital in New York with persistent cough and dyspnoea or an abnormal chest radiograph, or both. Thirty two (67%) were found to have Pneumocystis carinii pneumonia, either alone or in combination with another pathogen. Of these patients, eight (25%) had a normal chest radiograph. Abnormalities in the single breath carbon monoxide diffusing capacity and alveolar-arterial oxygen gradient [A-a) DO2) suggested infection with Pneumocystis carinii. Fibreoptic bronchoscopy with transbronchial biopsy was 100% sensitive in the diagnosis of pneumocytis pneumonia. Fibreoptic bronchoscopy should be undertaken in patients suspected of having a pulmonary complication of AIDS, even if the chest radiograph is normal.

Diagnosis of lung cancer by fibreoptic bronchoscopy: problems in the histological classification of non-small cell carcinomas.

Specific cell typing in lung cancer has important implications for assessment of prognosis and the planning of treatment. Cell typing is, however, often difficult and the problem has been compounded by the universal use of the flexible fibreoptic bronchoscope, which yields specimens only 2 mm in diameter. We have reviewed the records of 107 patients who had a diagnosis of lung cancer established by fibreoptic bronchoscopy and who subsequently underwent staging biopsy or surgical resection. Examination of tissue obtained by surgical resection yielded a different cell type from that identified in specimens obtained at fibreoptic bronchoscopy in 11 of 32 patients with a bronchial biopsy specimen diagnostic of squamous cell, three of 44 patients with a diagnosis of adenocarcinoma, six of seven thought to have a poorly differentiated carcinoma, and 21 of 24 patients with a diagnosis of large cell carcinoma. In all, 41 of the 107 surgically removed specimens (38%) differed in cell type from their corresponding bronchoscopic specimens. Accurate cell typing by specimens obtained at fibreoptic bronchoscopy may be extremely difficult. If clearcut morphological criteria cannot be satisfied, the diagnosis of "lung cancer, non-small cell type" should be made.

Problems in the diagnosis of small cell carcinoma of the lungs by fiberoptic bronchoscopy.

Fiberoptic bronchoscopy (FOB) with the aid of endoscopic biopsies and brush cytology is recognized as a valuable approach in the diagnosis of lung cancer. However, histologic classification of lung cancer based on tiny specimens obtained from FOB can be difficult. Correct identification of small cell carcinoma of the lung is especially important because its recognition usually precludes surgery. In a review of 770 patients who underwent FOB biopsies at The Mount Sinai Hospital, New York, in individuals with proven lung cancer 150 instances of small cell carcinoma were encountered. In four of these instances subsequent surgery, such as scalene node biopsy, mediastinoscopy, or thoracotomy, was performed because clinically and radiologically the tumors did not behave as small cell carcinomas. Pathologic examination of larger tissue samples from these neoplasms provided the following final diagnoses: bronchial carcinoid, adenocarcinoma, squamous cell carcinoma, and small cell carcinomas-combined type. Analysis of the FOB biopsies and brush cytology usually permit diagnosis of small cell carcinoma of the lung. However, in instances where the biologic behavior of a tumor casts doubt on the diagnosis of small cell carcinoma, further studies should be performed, including radionuclide scans, and bone marrow and other biopsies before denying the patient a chance of surgical cure.

Flexible fiberoptic bronchoscopy in metastatic cancer to the lungs.

Seventy-eight patients with metastatic cancer to the lungs underwent flexible fiberoptic bronchoscopy for diagnosis. The patients were divided into two groups by presenting radiographic pattern as: (I) diffuse linear interstitial infiltrations (55 patients); and (II) localized or multiple nodular opacities (23 patients). The diagnosis of cancer was established by bronchoscopy in both groups of patients with approximately equal frequency. In Group I, bronchoscopic biopsy results were positive in 34 patients (62%), cytology results were positive in 30 patients (55%), and 42 patients (76%) had a positive biopsy and/or cytology result. In group II, biopsy results were positive in 14 patients (61%), cytology results were positive in 8 patients (35%), and 15 (65%) patients had a positive biopsy and/or cytology result. Patients whose chest radiograph showed atelectasis, suggesting the presence of endobronchial metastases, were excluded from the study. However, endobronchial examination unexpectedly revealed metastatic endobronchial carcinoma in 9 patients, 4 in Group I and 5 in Group II. Fiberoptic bronchoscopy is a relatively simple and direct technique for the histologic diagnosis of metastatic cancer to the lungs. Endobronchial metastases are common, even when not suspected by radiographic examination.

Adenocarcinoma arising in an intrathoracic duplication cyst of foregut origin: a case report with review of the literature.

A 41-year-old man presented with an asymptomatic superior mediastinal mass. At thoracotomy, a duplication cyst of the foregut was found. Microscopic examination of the cyst revealed mucosal alterations ranging from dysplasia and in situ carcinoma to infiltrating colonic carcinoma. Although malignant change has been reported in intra-abdominal foregut cysts, this is the first reported instance of carcinoma arising in a mediastinal duplication cyst.

Flexible fiberoptic bronchoscopy in the diagnosis of pulmonary complication of lymphoma.

Patients with known lymphoma frequently present with pulmonary abnormalities that require prompt diagnosis. The usual chest radiograph and bacteriologic studies often fail to be of diagnostic value. Since February 1973, we have performed flexible fiberoptic bronchoscopies on 76 patients with Hodgkin and non-Hodgkin lymphoma who presented with pulmonary abnormalities. Biopsy specimens revealed lymphoma in 21 of these 76 patients, pneumocystic carinii infection in six, aspergillus infection in three, and cryptococcus, herpes simplex, and squamous cell carcinoma, respectively, in the remaining three. In all, specific diagnosis was obtained in 33 patients (43%). One death from bleeding occurred in a patient with marked thrombocytopenia and respiratory failure. Flexible bronchoscopy is recommended as a valuable, relatively risk-free procedure in the diagnosis of the pulmonary manifestations, or complications, of lymphoma.

Fiberoptic bronchoscopy in patient with Hodgkin's and non-Hodgkin's lymphomas.

Sixty-four fiberoptic bronchoscopic examinations were performed for 58 patients with Hodgkin's and non-Hodgkin's lymphomas and radiographically evident pulmonary abnormalities. Diagnoses were obtained in 23 cases (36%). Examination of 12 lung biopsy specimens showed lymphoma and one, squamous cell carcinoma. Six patients had pneumocystis carinii; 2, aspergillosis; 1 cryptococcosis; and 1, herpes simplex infection. It is recommended that fiberoptic bronchoscopy be the first invasive procedure employed in the evaluation of pulmonary parenchymal abnormalities in patients with Hodgkin's and non-Hodgkin's lymphomas.

Rhizopus lung abscess in renal transplant patient successfully treated by lobectomy.

A 46-year-old man with diabetes mellitus and cadaveric kidney transplant, maintained on a regimen of prednisone and azathioprine, developed a necrotizing pneumonia. The abscess cavity became secondarily infected with Rhizopus and was cured by surgical resection. Secondary invasion of an abscess cavity by Rhizopus and the successful surgical treatment of pulmonary phycomycosis in an immunosuppressed patient have not previously been reported.