Compensatory hyperhidrosis: a consequence of truncal sympathectomy treated by video assisted application of botulinum toxin and reoperation.

Hyperhidrosis is a debilitating condition characterised by sweating that exceeds the need of normal thermoregulation. Surgical management of primary hyperhidrosis by upper dorsal sympathectomy is the treatment of choice for intractable hyperhidrosis, however, paradoxically it may be followed by troublesome compensatory hyperhidrosis in a significant number of patients. The frequency of compensatory hyperhidrosis often reflects the extensiveness of the denervation. We report for the first time the successful treatment of a patient who developed compensatory hyperhidrosis following sympathectomy using video assisted extension of the sympathectomy by application of botulinum toxin (BTX-A). In addition, this case highlights the use of botulinum toxin as a guide for the potential successful management of compensatory hyperhidrosis prior to definitive extension of a sympathectomy.

The value of video-assisted mediastinoscopy in pulmonary metastasectomy.

OBJECTIVE: To assess the role of video-assisted mediastinoscopy (VAM) in identifying involved mediastinal lymph nodes in patients undergoing pulmonary metastasectomy. METHODS: Over a 4-year period (2002-2005) a retrospective study was carried out in 57 patients (44 men, 13 women, mean age 59 years) undergoing isolated, unilateral or bilateral metastasectomy. Following staging CT scan, VAM was performed prior to open thoracotomy, median sternotomy or VATS resection of the metastasis. Follow-up was complete in all patients. RESULTS: Fifty-seven patients underwent 62 operations for metastatic disease. The majority had colorectal cancer (39) followed by renal (11), sarcoma (9), liver (2) and miscellaneous (8). Six patients (10.5%) had positive mediastinal nodes on VAM. There was no perioperative morbidity or mortality. At a median follow-up of 25 months, 63 patients (68.5%) were still alive. CONCLUSIONS: Mediastinal lymph node involvement has been reported to occur in up to 14% of patients with pulmonary metastasis. In our study, 10% of patients treated for pulmonary metastasis had positive nodal disease at metastasectomy. We believe our results confirm that VAM can be safely performed and may have a role in more accurate staging of metastatic disease and influence the decision for post-resection adjuvant therapy.

Castleman's disease - a diagnostic dilemma.

Castleman's disease is a benign lymphoproliferative disease characterised by hyperplasia of lymphoid follicles. It can affect any lymph nodes in the body. Here we describe a caucasian patient who presented with six months history of shortness of breath with CT scan confirming an 8 cm segment of consolidated lung in left hilum. PET scan revealed a mass measuring 68x80x55 mm extending from the left hilum out into the left upper lobe containing area of calcification with SUV max 4.8. The differential diagnosis included atypical sequestration, hamartoma and primary lung malignancy. The patient underwent left video assisted enucleation of the lesion. The histology confirmed the diagnosis of Castleman's disease.

Thymic cyst presenting as tachy-brady syndrome.

Tachy-brady syndrome or sick-sinus syndrome as it is also known is a cardiac rhythm disturbance resulting in alternating episodes of bradycardia and tachycardia. Diagnosis can be difficult because of its nonspecific symptoms and elusive findings on electrocardiogram or 24h tape. Thymic cysts are relatively uncommon tumours that are predominantly asymptomatic and located in the anterior mediastinum. We present the first known report of tachy-brady syndrome associated with a large thymic cyst. Treatment consisted of dual-chamber pacemaker implantation prior to video-assisted removal of the thymic cyst.

Malignant pleural effusion in the presence of trapped lung. Five-year experience of PleurX tunnelled catheters.

Malignant pleural effusions in the presence of trapped lung remain notoriously difficult to treat. Various methods exist ranging from minimally invasive procedures including repeated needle thoracocentesis to the need for a formal surgical procedure such as placement of a pleuroperitoneal shunt and even thoracotomy and decortication. Controversy exists as to what is the optimum treatment for this condition. Any planned treatment should balance the therapeutic benefit provided against convalesce for a disease with a limited life expectancy. Patients should not spend a significant proportion of their remaining life span recovering from palliative procedures. In a series of patients with malignant pleural effusion the medial survival time was 20 weeks, with 30 days and 1 year mortality rates of 12.8% and 83.6%, respectively. We describe our five-year experience with the use of indwelling PleurX catheters in patients with malignant pleural effusions in the presence of confirmed trapped lung on radiological or VATS investigation. Patient health related quality of life was investigated by telephone questionnaire. The parameters analysed were symptomatic relief, mobility and ease of management following insertion. One hundred and sixteen patients underwent PleurX catheter insertion by a single operator, 48 questionnaires were completed. Of the 48 cases analysed, improvement in all three quality of life indices was recorded following catheter insertion. Ease of mobility was recorded as moderately satisfied and very satisfied in 50% and 15% of patients, respectively. Symptomatic improvement was found to have been increased with 42% and 6% of patients responding to moderately satisfied and very satisfied, respectively. Ease of management was recorded as 'slightly satisfied' and moderately satisfied in 50% and 33% of patients, respectively, demonstrating a high satisfaction index in patients with chronic progressively debilitating malignancies. Complications were either transient or readily correctable. Pain was the predominant complication occurring in 35% of patients lasting <3 days. No patient required catheter removal for resolution of discomfort. Our findings support the use of PleurX catheters for palliative patients with malignant pleural effusions in the presence of trapped lung. The catheters are not only easy to insert and discrete but they can be managed effectively by patients and community nurse practitioners and prevent repeated admissions to hospital in palliative patients with compromised life expectancy.

Massive bronchogenic cyst mimicking ischaemic chest pain.

The presentation of the bronchogenic cyst is variable making preoperative diagnosis difficult. The majority are either asymptomatic or discovered incidentally. The most common presenting symptoms are cough, fever and dyspnoea. We discuss the case of a large bronchogenic cyst in the posterior mediastinum mimicking ischaemic cardiac pain in a patient with known heart disease. This case demonstrates the need for detailed investigations prior to the treatment of an assumed acute coronary syndrome as a bronchogenic cyst may be the rare cause of such symptoms.

Photodynamic therapy (PDT) in early central lung cancer: a treatment option for patients ineligible for surgical resection.

OBJECTIVES: To review the Yorkshire Laser Centre experience with bronchoscopic photodynamic therapy (PDT) in early central lung cancer in subjects not eligible for surgery and to discuss diagnostic problems and the indications for PDT in such cases. METHODS: Of 200 patients undergoing bronchoscopic PDT, 21 had early central lung cancer and were entered into a prospective study. Patients underwent standard investigations including white light bronchoscopy in all and autofluorescence bronchoscopy in 12 of the most recent cases. Indications for bronchoscopic PDT were recurrence/metachronous endobronchial lesions following previous treatment with curative intent in 10 patients (11 lesions), ineligibility for surgery because of poor cardiorespiratory function in 8 patients (9 lesions) and declined consent to operation in 3 patients. PDT consisted of intravenous administration of Photofrin 2 mg/kg followed by bronchoscopic illumination 24-48 h later. RESULTS: 29 treatments were performed in 21 patients (23 lesions). There was no procedure-related or 30 day mortality. One patient developed mild skin photosensitivity. All patients expressed satisfaction with the treatment and had a complete response of variable duration. Six patients died at 3-103 months (mean 39.3), three of which were not as a result of cancer. Fifteen patients were alive at 12-82 months. CONCLUSION: Bronchoscopic PDT in early central lung cancer can achieve long disease-free survival and should be considered as a treatment option in those ineligible for resection. Autofluorescence bronchoscopy is a valuable complementary investigation for identification of synchronous lesions and accurate illumination in bronchoscopic PDT.