Bronchiectasis: Retrospective Analysis of Clinical and Pathological Findings in a Tertiary-Care Hospital.

Background: Bronchiectasis is still a challenging chronic lung disease in developing countries. Patients with bronchiectasis can also have pulmonary hypertension. There are sparse data on the prevalence of pulmonary hypertension in patients with bronchiectasis. Materials and methods. Archived H&E-stained slides of 141 patients histopathologically diagnosed with bronchiectasis were reevaluated. Cases were categorized into 4 subgroups based on histology: tubular, varicose, follicular, and cystic. In addition, concomitant histopathological changes were also reevaluated. For patients with available CT sections, main, right, and left pulmonary artery (PA) diameters and PA/aorta ratio were measured with regard to pulmonary hypertension. Results: Of the cases, 70% (n = 89) were female and 30% (n = 52) were male, with a mean age of 36.58 in females and 33.84 in males. Histopathologically, 43% (n = 68) of the cases showed follicular, 37% (n = 59) showed varicose, 35% (n = 56) showed tubular, and 28% (n = 45) showed cystic bronchiectasis morphology. All cases showed chronic inflammation, fibrosis, muscle destruction, and cartilage destruction. Aspergillus were present in 11% of the cases showing cystic morphology. Approximately 17% of the cases (n = 24) were found to have neuroendocrine cell proliferations. In cases with medial hypertrophy, a statistically significant increase in the left pulmonary artery diameter was radiologically determined. Conclusions: Medial hypertrophy was found to be significant with regard to indicating a radiological increase in left pulmonary artery diameter. Vascular changes observed in bronchiectasis cases and the presence of neuroendocrine cell proliferations should be specified in pathology reports, and aspergilloma should be carefully investigated in cases with predominant cystic morphology.

Management of spontaneous pneumothorax in patients with COVID-19.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pneumonia may cause cystic features of lung parenchyma which can resolve or progress to larger blebs. Pneumothorax was more likely in patients with neutrophilia, severe lung injury and a prolonged clinical course. The timely diagnosis and management will reduce COVID-19-associated morbidity and mortality. METHODS: We present 11 cases of spontaneous pneumothorax managed with chest tube thoracostomy or high-dose oxygen therapy. Isolated spontaneous pneumothorax was detected in all cases. RESULTS: Eight cases were male and 3 cases were female. There were bilateral ground-glass opacities or pulmonary infiltrates in the parenchyma of the 10 cases. We detected neutrophilia, lymphopaenia and increased C-reactive protein, Ferritin, lactate dehydrogenase, D-Dimer, interleukin-6 levels in almost all cases. Chest tube thoracostomy was sufficient to treat pneumothorax in our 9 of case. In 2 cases, pneumothorax healed with high-dose oxygen therapy. Favipiravir and antibiotic treatment were given to different 10 patients. In our institution, all patients with COVID-19 infection were placed on prophylactic or therapeutic anticoagulation, unless contraindicated. The treatments of patients diagnosed with secondary spontaneous pneumothorax during the pandemic period and those diagnosed with secondary spontaneous pneumothorax in the previous 3 years were compared with the durations of tube thoracostomy performed in both groups. CONCLUSIONS: The increased number of cases of pneumothorax suggests that pneumothorax may be a complication of COVID-19 infection. During medical treatment of COVID-19, pneumothorax may be the only reason for hospitalization. Although tube thoracostomy is a sufficient treatment option in most cases, clinicians should be aware of the difficulties that may arise in diagnosis and treatment.

Thymic Seminoma with Regressive Changes Obscured by Granulomatous Reaction.

Primary thymic seminoma is an exceedingly rare tumour. There are few case reports about mediastinal thymic seminoma accompanied by secondary changes. We report a case of a 29-year male admitted to our hospital because of chest pain and dyspnea for 8 months. Computed tomography of the thorax revealed hypodense, solid masses showing calcification and cystic degeneration in the anterior mediastinum. Histopathological examination of the resected specimen revealed a diagnosis of thymic seminoma with regressive and reactive changes. The present case was unique in its presentation as a primary seminoma showing combination of cystic degeneration, follicular hyperplasia, fibrosis, calcification and granulomatous reaction in one case. High level of suspicion is necessary to identify seminomas in a thymic lesion accompanied by secondary changes. Excluding the possibility of metastasis from testicular seminoma is very important before making this diagnosis. Key Words: Thymus, Seminoma, Granuloma, Calcification, Cyst.

Is it possible to achieve more accurate mediastinal nodal radiotherapy planning for NSCLC with PET/CT?

Objective: To assess whether more accurate mediastinal lymph nodes radiotherapy can be performed with fluorode oxyglu cosepositron emission tomogaphy/computed tomography. METHODS: The retrospective study was conducted at Inonu University Medical Faculty, Malatya, Turkey, and Afyon Kocatepe University Medical Faculty, Afyon, Turkey, and comprised record of patients histopathologically diagnosed with non-small cell lung carcinoma and who underwent fluorodeoxyglucose positron emission tomography / computed tomography between January 2013 and December 2016. Surgery and pathology reports of the patients were reviewed. Histopathologically proven malignant and benign lymph nodes were re-identified with fluorodeoxyglucose positron emission tomography / computed tomography imaging. Anatomical and metabolic parameters of lymph nodes were re-assessed by specialists and compared with histopathology reports. Maximum standardised uptake values were used to assess sensitivity, specificity, positive predictive value, and negative predictive values. SPSS 22 was used for data analysis. RESULTS: The study included 144 mediastinal lymph nodes related to 42 patients who had a mean age of 62.4±9.8 years (range: 41-79 years). In terms of subtypes of the primary squamous cell carcinoma was found in 24(57.2%) patients, adenocarcinoma in 12(27.5%), and other subtypes in 6(15.3%) patients. Of the 144 lymph nodes, 48(33.3%) were metastatic. Sensitivity, specificity, positive predictive value, and negative predictive value were 92.8%, 64.3%, 56.9%, and 94.7%, respectively when maximum standardised uptake value >2.5 was used as the malignancy criterion. When lymph node maximum standardised uptake value / liver standardised uptake value-mean>1.69 was used as the criterion, the sensitivity, specificity, positive predictive value, and negative predictive value were 95.83%, 91.67%, 85.2%, and 97.8%, respectively. When the same values with lymph node >8mm was used as the criterion, the four resultant values were 89.6%, 93.8%, 87.8%, and 94.7%, respectively. When lymph node was replaced with mean attenuation >35 as the criterion, the consequent values were 79.2%, 93.8%, 86.4%, and 90.0%, respectively. CONCLUSIONS: Lymph node maximum standardised uptake value / liver standardised uptake valuemean> 1.69 was associated with higher negative predictive value and more useful positive predictive value compared to maximum standardised uptake value >2.5. When this parameter was used along with short axis or mean attenuation value, there were no significant increase in positive predictive value, but there was a decrease in negative predictive value.

The Role of CD90 in the Differential Diagnosis of Pleural Malignant Mesothelioma, Pulmonary Carcinoma and Comparison with Calretinin.

Pleural Malignant Mesothelioma (MM) is a fatal disease that has been associated with asbestos exposure. Differential diagnosis between the pleural infiltration of pulmonary carcinomas and MM is rather difficult particularly for epitheloid type mesothelioma.We aimed to investigate the utility of CD90, a cancer stem cell marker, in the differential diagnosis of MM and lung carcinoma, its prognostic significance and compare its value with that of Calretinin. Ninety pathology specimens including MM (n:30), pulmonary adenocarcinoma (n:30) and pulmonary squamous cell carcinoma (n:30) were used in this study. Immunohistochemical comparision of CD 90 and Calretinin was made in all groups. Calretinin was positive in 20 cases with MM (64.5 %), and was negative in 10 (32.3 %). CD 90 was positive in 25 of these cases (80 %) and negative in 5 (16 %). On the other hand pulmonary adenocarcinomas and squamous cell carcinomas showed positivity with CD90, 63,6 % and 73 %, respectively. We think that CD 90 has no place in the differential diagnosis between mesothelioma and pulmonary carcinoma because of the low specificity in spite of the high sensitivity.

Hydatid cysts of the lung: lesion size in relation to clinical presentation and therapeutic approach.

PURPOSES: The aim of this study was to assess the relationship between the pulmonary hydatid cyst size and the clinical presentation, surgical approach, and postoperative outcome. We review the problems encountered in treating large pulmonary hydatid cysts and highlight the risks associated with the rupture of the cyst and a delay of the surgical treatment. METHODS: The medical records of 169 patients surgically treated for lung hydatid cysts were reviewed. Patients were divided into two groups based on cyst size: group 1 (n = 128) with small (<10 cm) cysts and group 2 (n = 41) with giant (≥10 cm) cysts. Data related to symptoms, preoperative complications, surgical procedures performed and postoperative morbidity were analyzed and compared. RESULTS: In both groups, the most common symptom was chest pain, followed by dyspnea and cough, respectively. There were no differences between the two groups with respect to cyst-associated parenchymal or pleural complications before surgery (p = 0.80). In the large majority of cases, the surgical treatment was cystotomy, removal of the cystic membrane and capitonnage. Wedge resection was performed in nine patients in total (seven in group 1, two in group 2) and one patient in group 2 required a lobectomy. Decortication was required significantly more frequently in group 2 than in group 1 (p = 0.001). Sixteen patients in group 1 and 10 patients in group 2 developed postoperative complications (p = 0.19). There was no peri or postoperative mortality. There was no difference between the groups with respect to the duration of hospitalization (p = 0.17). Two patients with complicated hydatid cysts in group 1 had recurrent lesions during follow-up, whereas there was no recurrence in group 2. CONCLUSION: All pulmonary hydatid cysts should be surgically treated as soon as possible after their diagnosis in order to avoid complications. Most of these lesions, regardless of size, can be surgically managed with procedures that preserve the maximal lung parenchyma and yield excellent outcomes.

Bilateral chylothorax after severe vomiting in a child.

In the etiology of chylothorax, traumas and malignancies are the first two leading causes. Today in pediatric patients, the most common cause of chylothorax includes the complications secondary to cardiothoracic operations. Bilateral chylothorax is rarely observed after severe vomiting leading to increase in intrathoracic pressure. In idiopathic chylothorax, bilateral localization is dominant. A 9-year-old girl who presented to our emergency department with the complaints of dyspnea and back pain following severe vomiting received a diagnosis of bilateral chylothorax. The patient was treated with the insertion of a bilateral chest tube, and pleurodesis was performed in left hemithorax. Examination did not reveal a pathology to this condition, except the vomiting observed 2 days previously after the meal.

Surgical management of upper- and lower-lobe bronchiectasis without middle lobe involvement: is middle lobectomy necessary?

Postoperative quality of life is a crucial factor in decisions regarding surgical management of bronchiectasis. The goal of surgical treatment in such cases is to eradicate diseased portions of lung while preserving as much healthy lung parenchyma as possible. The volume of remaining lung must be sufficient to fill the pleural space. In patients with bronchiectasis, it is extremely unusual to have upper- and lower-lobe involvement without middle lobe involvement. A normal-sized middle lobe alone is usually not adequate to fill the right hemithorax. When the disease involves both the upper and lower lung lobes, surgeons must assess whether pneumonectomy is required. Herein, we describe the case of a patient with bronchiectasis who was successfully treated with upper and lower lobectomy and preservation of the middle lobe.

Fibrinolytic therapy for parapneumonic empyema during pregnancy.

Pneumonia and parapneumonic complicated effusion during pregnancy is uncommon but poses potentially serious risks to both mother and fetus. Enzymatic debridement of the pleural cavity with fibrinolytic agents is a noninvasive option that can facilitate drainage and prevent the need for surgery. Herein, we describe the cases of two pregnant women with parapneumonic empyema who were successfully treated with intrapleural fibrinolytic therapy.

The use of the LigaSureTM in esophagectomy.

This study aimed to evaluate the efficacy of the LigaSure vessel sealing system (LVSS) when used for esophagectomy. We compared 56 consecutive patients (32 male and 24 female, mean age: 56.64+/-12.61 years), who had undergone Ivor-Lewis esophagectomy for esophageal carcinoma between January 2005 and May 2009. Among them, from January 2005 to April 2007, 27 patients (group 1) were operated on with the conventional clamp-and-tie technique, whereas from April 2007 to May 2009, 29 patients (group 2) underwent total esophagectomy for esophageal cancer with the LVSS. Both groups were compared for operation duration, amount of intraoperative bleeding, postoperative hospitalization time, and intraoperative complications. In the evaluation of the patients, the two groups had similar distributions of age and gender. The duration of operation (349.44+/-46.82 min vs. 288.27+/-60.09 min, P<0.05) and the amount of intraoperative bleeding (414.82+/-137.04 ml vs. 217.41+/-111.78 ml, P<0.05) were significantly lower in LVSS group than in the conventional method group. There were no differences for hospitalization time and intraoperative complications between the groups. LVSS significantly shortens operation duration and decreases the amount of intraoperative bleeding compared with the conventional methods, but does not provide advantages for hospitalization time and/or intraoperative complications. We believe LVSS is an effective and reliable method for esophagus surgery.

Optimal timing for surgical treatment to prevent recurrence of spontaneous pneumothorax.

PURPOSE: Persistent air leakage and recurrence are the most common indications for the surgical treatment of spontaneous pneumothorax; however, the optimal timing for surgery is still unclear. METHODS: The subjects of this study were 90 patients treated for either primary spontaneous pneumothorax (PSP; n = 58) or secondary spontaneous pneumothorax (SSP; n = 32). We compared the incidence of prolonged air leak, the rate of recurrence of pneumothorax, the time from the first episode of pneumothorax to recurrence, and the postoperative complications in the two groups. We also analyzed the recurrence rate after treatment with observation and tube drainage versus surgery. RESULTS: Seventy-three patients were treated with tube thoracostomy or oxygen therapy for the first episode of pneumothorax. Surgery was performed in 32 patients; for the first episode of pneumothorax in 17 and for the second or third episode in 15. Postoperative complications developed in six (18.7%) patients and 24 of 73 patients who did not undergo thoracotomy suffered recurrence. The incidence of a second episode was 32.9% and the incidence of a third episode in the 18 patients who suffered recurrence after conservative treatment was 61.1%. None of the patients who underwent surgery suffered recurrence. CONCLUSIONS: Tube thoracostomy is still the treatment of choice for first-time spontaneous pneumothorax. However, because the incidence of a third episode of pneumothorax after conservative treatment is high, surgical treatment should always be considered for patients with recurrence. In short, surgical intervention is safe and effective and minimizes the chance of recurrence of both PSP and SSP.

Tracheobronchial foreign body aspiration: a continuing challenge.

OBJECTIVE: The aim was to present the features and outcomes for 140 cases of foreign body aspiration and to discuss specific problems and new management recommendations. STUDY DESIGN AND SETTING: Records were retrospectively reviewed and the following data were recorded for each patient: age, sex, symptoms, duration of symptoms, findings on physical examination and chest radiography, location and type of foreign body, complications related to aspiration itself or to extraction, and outcome. RESULTS: Seventy-eight (55.7%) patients presented within 24 hours of aspiration. The most common symptoms and findings were cough, dyspnea-stridor, decreased breath sounds, radiopaque foreign body, air trapping, and atelectasis. All 140 patients underwent rigid bronchoscopy, and 110 had the foreign material extracted via the scope. No foreign body was detected bronchoscopically in 25 cases. In the other 5 cases, the material was visualized but could not be removed via the scope, and 3 of these patients required thoracotomy for removal. Eleven patients developed morbidity after bronchoscopy. CONCLUSIONS: History suggestive of foreign body aspiration is a definite indication for bronchoscopy, and bronchoscopic extraction should only be performed by experts. Each case tends to present different challenges, and endotracheal intubation and tracheotomy may be required.