Tracheobronchomalacia as a Rare Cause of Chronic Dyspnea in Adults.

OBJECTIVE: To emphasize the importance of a careful clinical evaluation to prevent unnecessary interventions and treatments. CLINICAL PRESENTATION AND INTERVENTION: A 76-year-old female patient had been diagnosed with asthma during previous admissions to different hospitals. She had also undergone fiberoptic bronchoscopy (FOB) on 2 occasions for evaluation of right middle lobe atelectasis observed on computed tomography. A repeated FOB revealed tracheobronchomalacia and nodular bronchial amyloidosis. A silicone Y stent was inserted, but the dyspnea increased. Excessive granulation tissue developed, and the patient died despite ventilatory support. CONCLUSION: The stenting technique used did not prevent the development of respiratory failure and death in this patient. Hence, a surgical procedure could be considered as an alternative to stenting in such cases.

The relationship of metalloproteinase gene polymorphisms and lung cancer.

BACKGROUND: We analyzed the relationship between matrix metalloproteinase (MMP)-2, -7, and -13 gene expression and polymorphisms and disease susceptibility and prognosis in patients who had undergone surgery for non-small-cell lung cancers. MATERIALS AND METHODS: The study group consisted of 132 patients who had undergone radical surgery for non-small-cell lung cancers. The control group consisted of 80 healthy volunteers. We isolated deoxyribonuclease samples for use in analyzing gene polymorphisms from pathology blocks for the patient group and from blood samples for the control group. We identified MMP gene polymorphisms with polymerase chain reaction and restriction fragment length polymorphisms. Results were compared with those of the control group to evaluate disease susceptibility, correlation with other clinical parameters, and with survival and prognosis by using appropriate statistical methods. RESULTS: When we compared polymorphisms pertaining to MMP genes in healthy controls and lung tumor DNA, we observed a decrease in the MMP-2 (-735) polymorphism GG genotype and increases in the MMP-13 (A77G) polymorphism AG and GG genotypes (P = 0.008, P = 0.047, and P = 0.047, respectively). For the MMP-7 (-181) polymorphism, the genotype did not differ significantly for disease susceptibility. Median overall survival time was 25.5 mo in the MMP-13 AA/AG genotypes and 9.3 mo in the GG genotype. CONCLUSIONS: Decreases in the MMP-2 (-735) polymorphism GG genotype and increases in the MMP-13 (A77G) polymorphism AG and GG genotypes increase the risk for lung cancer. Furthermore, the presence of the MMP-13 (A77G) polymorphism GG genotype is an unfavorable prognostic factor.

Management of upper aerodigestive tract amyloidosis.

OBJECTIVES: The aim of this study was to discuss the treatment options for upper aerodigestive tract amyloidosis. METHODS: Four patients with histologically confirmed amyloidosis were included in the study. All patients underwent surgical treatment. Three patients had laryngeal amyloidosis, and 1 patient had tonsillar amyloidosis. RESULTS: Two of the cases of laryngeal amyloidosis were successfully treated with a combination of surgery and radiation therapy. One case of laryngeal amyloidosis was treated with surgery alone. The tonsillar amyloidosis was removed by tonsillectomy. None of the cases showed systemic involvement. Long-term follow-up of the patients showed no recurrence or evidence of systemic disease. CONCLUSIONS: Surgical resection is the primary treatment for patients with upper aerodigestive tract amyloidosis. Radiation therapy is especially effective in cases of recurrent amyloidosis with submucosal involvement. Pedunculated polypoid lesions may be treated with surgery alone, and in cases of recurrence, irradiation following the surgical removal should be considered. Tonsillectomy is usually sufficient for treating tonsillar amyloidosis.

The effect of multiple outgrowths from bronchial tissue explants on progenitor/stem cell number in primary bronchial epithelial cell cultures from smokers and patients with COPD.

Background: Although studies suggest a deficiency in stem cell numbers in chronic airway diseases such as chronic obstructive pulmonary disease (COPD), the role of bronchial epithelial progenitor/stem (P/S) cells is not clear. The objectives of this study were to investigate expression of progenitor/stem (P/S) cell markers, cytokeratin (CK) 5, CK14 and p63 in bronchial epithelial explants and cell cultures obtained from smokers with and without COPD following multiple outgrowths, and to study this effect on bronchial epithelial cell (BEC) proliferation. Methods: Bronchial epithelial explants were dissected from lung explants and cultured on coverslips. Confluent cultures were obtained after 3-4 weeks' (transfer, Tr1), explants were then transferred and cultured for a second (Tr2) and third (Tr3) time, respectively. At each stage, expression of CK5, CK14 and p63 in explants and BEC were determined by immunostaining. In parallel experiments, outgrowing cells from explants were counted after 4wks, and explants subsequently transferred to obtain new cultures for a further 3 times. Results: As the transfer number advanced, CK5, CK14 and p63 expression was decreased in both explants and BEC from both smokers without COPD and patients with COPD, with a more pronounced decrease in BEC numbers in the COPD group. Total cell numbers cultured from explants were decreased with advancing outgrowth number in both groups. Smoking status and lung function parameters were correlated with reduced P/S marker expression and cell numbers. Conclusion: Our findings suggest that the number of P/S cells in airway epithelium may play a role in the pathogenesis of COPD, as well as a role in the proliferation of airway epithelial cells, in vitro.

Possible anti-metastatic effect of iloprost in a patient with systemic sclerosis with lung cancer: a case study.

Systemic sclerosis (SSc) is a chronic disease of unknown etiology which affects the vascular system and connective tissue. A wide series of studies showed an increased prevalence of cancer in patients with SSc than the normal population. Prostacyclin (PGI2) is an endogenously produced element that is basically synthesized by arachiodonic acid through prostacyclin synthesis in vascular system endothelial cells. Iloprost is a stable analogue of PGI2 which is used in the treatment of pulmonary arterial hypertension (PAH). In a limited number of animal models, the anti-metastatic activity of PGI2 is observed. Herein, we report iloprost treatment of a 60-year-old-woman with SSc, who lately developed PAH as a complication of her disease and lung adenocarcinoma as a co-incidence simultaneously. These two mortal complications were both treated successfully with inhaled iloprost until her death due to gastrointestinal complications of SSc.

Churg-Strauss syndrome related to montelukast.

A young male with complaints of cough, dyspnea and hemoptysis was admitted. He was using fluticasone propionate and salmeterol for two years for his asthma. Leukotriene receptor antagonist was prescribed two weeks prior to his admission and no reduction of his inhaled steroid therapy was performed. Eosinophil count was detected as 1460/mm³ (15%) and immunoglobulin E level was 547 IU/mL. Thorax computerized tomography revealed patchy infiltration. Increased eosinophilic inflammation were detected in bronchoalveolar lavage fluid and transbronchial biopsy. He received prednisolone treatment for Churg-Strauss syndrome. Improvement was observed on three months follow up period. He has no complaint in his follow up.

Combined transbronchial needle aspiration and PET/CT for mediastinal staging of lung cancer.

In this study, we aimed to evaluate the performance of transbronchial needle aspiration (TBNA) combined with positron emission tomography/computed tomography (PET/CT) for the staging of lung cancer. Twenty-five patients having lymphadenopathies greater than 1 cm on thorax CT and maximum standardized uptake value (SUVmax) ≥ 2.5 on PET/CT were included in this prospective study performed between March 2006 and March 2008. Forty-three lymphnode stations were sampled by using TBNA. Surgical histology, as confirmed by mediastinoscopy, was accepted as the "gold standard". The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of combined TBNA and PET/CT for correct lymph node staging were 67%, 100%, 100%, 76% and 84%; respectively. The initial clinical staging was downstaged after TBNA in 13/19 (69%) patients with adequate TBNA samples, whereas staging was correct in 17/19 (89%) patients assessed by combined TBNA and PET/CT. Staging was completed by TBNA, without mediastinoscopy, in 6/25 (24%) patients. Among the clinical factors that were assessed, only the PET SUVmax was associated with positive TBNA results [odds ratio (OR) 1.27, 95% CI 1.004-1.61, p= 0.046]. A PET SUVmax ≥ 5 was eleven times more likely in patients with positive TBNA results [OR 10.68, 95% CI 1.91-59.62, p< 0.01]. In conclusion, the combination of TBNA with PET/CT increased the sensitivity of TBNA. Combined TBNA and PET/CT may also allow adequate mediastinal staging of lung cancer in most patients with enlarged lymph nodes, and reduce the need for mediastinoscopy. The SUVmax cut off point for a positive TBNA result was ≥ 5.

Monoclonal Caveolin 1 Expression in the Differential Diagnosis of Malignant Pleural Mesothelioma and Pulmonary Adenocarcinoma: Is it Useful?

In this study we aim to demonstrate the value of monoclonal Caveolin 1 expression in distinguishing between malignant pleural mesothelioma and pulmonary adenocarcinoma. Total of 129 cases, consisting of 68 cases of malignant pleural mesothelioma (51 epitheloid, 12 biphasic, and 5 sarcomatoid type) and 61 cases of pulmonary adenocarcinoma were examined and stained with monoclonal Caveolin-1. Caveolin 1 expression with a membranous and /or cytoplasmic pattern was detected only in 32.35% (n:22/68) of malignant pleural mesothelioma and 6.5% (n:4/61) of pulmonary adenocarcinoma cases. This finding suggests that the choice of poly/monoclonal antibody for Caveolin 1 in the differential diagnosis of malignant pleural mesothelioma and pulmonary adenocarcinoma is important.

Correction to: Monoclonal Caveolin 1 Expression in the Differential Diagnosis of Malignant Pleural Mesothelioma and Pulmonary Adenocarcinoma: Is it Useful?

The original version of this article unfortunately contained an error in Fig. 1. Cav-1 expression in MPM and PA cases failed to show the histopathological details in Fig. 1 due to technical problem. The figure with the proper sharpness and clarity is shown in the next page.

Diffuse alveolar haemorrhage due to 5-nitroimidazole treatment.

Diffuse alveolar haemorrhage (DAH) is indicated by the presence of red blood cells, fibrin and haemosiderin deposits in the lung parenchyma. We present a case of DAH in a 25-year-old male following 5-nitroimidazole treatment. The first episode of haemoptysis occurred following metronidazole treatment 10 months previously. The second episode of haemoptysis occurred following ornidazole treatment 10 days before admission. During his first admission, the patients haemoglobin concentration decreased to 40 g/L. The CXR was normal, whereas high resolution CT of the lungs revealed a diffuse acinonodular pattern. Serological tests for connective tissue diseases were negative. The haemorrhagic appearance of the BAL fluid obtained during fibreoptic bronchoscopy was consistent with DAH. Microbiological analysis of the BAL fluid showed no evidence for bacterial or mycobacterial infection. Haemosiderin laden macrophages were detected in BAL fluid and lung biopsy specimens. DAH due to use of 5-nitroimidazole was diagnosed on the basis of the patient's previous history and complete recovery following treatment with corticosteroid. This is the first reported case of DAH due to use of 5-nitroimidazole. Physicians should be aware of this side-effect when prescribing this group of drugs to patients.

Randomized comparison of vasodilator effects of iloprost versus diltiazem on flow and pathologic changes in radial arteries: mid-term angiographic control study of the comparison of vasodilators on radial artery vasospasm.

BACKGROUND: The increasing prevalence of routine radial artery (RA) use in coronary artery bypass grafting (CABG) has rendered the pharmacologic prevention of spasm of this artery a critical consideration in the early postoperative period and in the long-term outcome. In this study, we compared the effects of iloprost and diltiazem on vasospasm. METHODS: Seventy patients who underwent CABG with the RA were randomized into 2 groups, and the vasodilator effects of iloprost and diltiazem were studied prospectively. RA flow was measured with Doppler ultrasonography. Following harvesting, a 5-mm piece was removed from the RA distally for pathologic examination. In group B, diltiazem was infused before removing the RA, whereas in group A, iloprost infusion was initiated 5 days before surgery. At the end of a 2-year follow-up, each patient underwent coronary angiography. RESULTS: Doppler flow measurements made during harvesting revealed a statistically significant reduction in flow, and a pathologic examination of the RAs revealed significant luminal narrowing in group B. A 2-year angiographic follow-up revealed all of the RA grafts in group A to be patent. CONCLUSIONS: Our evaluation of the results revealed the superior efficacy of iloprost over diltiazem in preventing RA spasm in the early period, and the 2-year angiographic findings showed that the use of iloprost produced superior mid-term patency.

Alveolar soft part sarcoma of the tongue.

Alveolar soft part sarcoma is a rare type of sarcoma that usually affects young adult women. It occurs mostly in the lower extremities, and nearly one quarter of the cases are found in the head and neck region. The most common site of origin in the head and neck region is the tongue followed by the orbit. Herein, we present an unusual case of alveolar soft part sarcoma of the tongue in an 18-year-old woman. The clinical, diagnostic, and therapeutic features of this quite rare entity were discussed.

A retrospective study on the coexistence of hydatid cyst and aspergillosis.

OBJECTIVES: Hydatid cyst is a zoonotic disease with an endemic regional distribution, and Aspergillus is a saprophytic fungus that may cause allergic pulmonary aspergillosis, aspergilloma, and semi-invasive and invasive aspergillosis. The coexistence of a saprophytic fungus and hydatid cyst is extremely rare. The aim of this retrospective study was to evaluate the coexistence of aspergillosis and echinococcosis in archival materials and to discuss its probable clinical significance. METHODS: Hematoxylin-eosin (HE)-stained sections of 100 archival cases with the diagnosis of hydatid cyst were reevaluated by four pathologists independently. Grocott's methenamine-silver (GMS) and periodic acid-Schiff (PAS) were applied to the slides that were suspected of having co-infection with Aspergillus to confirm the diagnosis. RESULTS: Two cases of aspergillosis and hydatid cyst coexistence were found out of the 100 reevaluated archival cases with a diagnosis of hydatid cyst. Both of the cases were located in the lung, in immunocompetent patients. CONCLUSIONS: Aspergillosis and hydatid cyst coexistence may be important in patients with immune deficiency and in cases with pre- or perioperatively ruptured cysts. There are no reliable data on the specificity and sensitivity of radiological imaging techniques in detecting the existence of Aspergillus in hydatid cysts. Histopathological evaluation is essential for diagnosis and for the planning of management.

The reliability of mediastinoscopic frozen sections in deciding on oncological surgery in bronchogenic carcinoma.

INTRODUCTION: This study was carried out to determine the accuracy of mediastinoscopic frozen section examination, performed prior to major surgery-especially where mediastinal lymph node metastasis (N2 disease) was suspected. We aimed to find out whether or not mediastinoscopic frozen section analysis was (i) a reliable tool when deciding to continue resection in lung cancer patients and (ii) reliable in diagnosing mediastinal masses. METHODS: One-hundred and thirty-six patients undergoing mediastinoscopy were enrolled in this study. Resection was planned for each case, and biopsies were taken from at least two sites, including the subcarinal lymph node. Thoracotomy and resection were performed when the results of frozen section examination were negative for malignancy in patients with lung cancer. Results of frozen section examination during mediastinoscopy were compared to the results of definitive histological examination of the same specimens stained using haematoxylin-eosin. Additionally, the results of frozen section examination were compared to the results of definitive histological examination of the lymph nodes excised during resection. RESULTS: We determined total sensitivity, specificity, positive predictive and negative predictive values of 94.51%, 100%, 100% and 90%, respectively. In the 105 patients with malignant diseases, these values were 93.33%, 100%, 100% and 91.84%, respectively. In the 31 patients with benign diseases, values were 96.77%, 100%, 100% and 100%, respectively. CONCLUSIONS: It was confirmed that mediastinoscopy supported by frozen section examination plays an important role in establishing diagnosis and planning treatment both in benign and malignant diseases.

Surgical treatment of a giant primary cardiac angiosarcoma.

Primary cardiac angiosarcoma is a rare tumor, and surgical resection is often required to relieve its symptoms. A 54-year-old male with a large primary cardiac angiosarcoma is described in this case report. The tumor was located in the right atrium and right ventricle. The bulk was resected with the right coronary artery (RCA), and partial right atrium and partial right ventricle resections were performed during cardiopulmonary bypass. The resected tumor measured 15 x 10 x 8 cm, and the histopathological diagnosis was well differentiated primary cardiac angiosarcoma. In the postoperative period, the patient was followed up for 22 months, and radiotherapy and chemotherapy were performed for metastases. The optimal therapy for cardiac angiosarcoma is still controversial, but combined treatment including surgical resection should be considered.

Catamenial hemoptysis.

Catamenial hemoptysis is a rare condition that is associated with the presence of intrapulmonary or endobronchial endometrial tissue. We describe a case of endobronchial endometriosis with catamenial hemoptysis. The patient was a 22 years-old girl presented with recurrent hemoptysis episodes for the last two years. Bronchoscopic examination was performed within first days of menses, and indicated multiple purplish-red submucosal patches in distal one third of trachea and bilateral bronchial trees that bled easily when touched. The cytological evaluation of the bronchial brushing specimens demonstrated clusters of small cuboidal cells consistent with an endometrial origin. Follow-up bronchoscopic examination at the end of the menstrual cycle revealed that the previous tracheobronchial lesions disappeared. The patient was treated with Gonadotropin-Releasing Hormone (GnRH) analogues and hormones including estrogen and progesterone therapy. Recurrent hemoptysis stopped following the medical treatment.

A rare case of peripherally located non-bronchial pulmonary mucous gland adenoma.

Pulmonary mucous gland adenomas are rare benign tumors, which need to be differentiated from malign lung masses. The differential diagnosis is of particular importance for those arising from lung parenchyma in atypical locations. In this article, we report a 70-year-old male patient, who had complaints of cough and expectoration for almost two years. Chest computed tomography showed a 1 cm nodule at the left lower lobe of lung. The tumor was totally resected with mini-thoracotomy and wedge resection and sent to the pathology department for a frozen examination. The frozen result was reported as benign. The pathological diagnosis was mucous gland adenoma. The patient had no postoperative complication and made a complete recovery. Pulmonary mucous adenomas may rarely originate from lung parenchyma and be seen in patients with peripherally located lung lesions.

Prognostic factors in operated T3 non-small cell lung cancer: A retrospective, single-center study of 129 patients.

BACKGROUND: This study aims to investigate the prognostic factors that affect survival rates and durations in patients with T3 non-small cell lung cancer who underwent surgery. METHODS: A total of 129 patients with T3 n on-small c ell l ung c ancer (125 males, 4 females; mean age 60±9.3 years; range 23 to 80 years) who were performed surgery in our clinic between January 1997 and December 2013 were evaluated retrospectively in terms of age, gender, type of resection, tumor histopathology, tumor, node and metastasis staging, lymph node invasion, chemotherapy and radiotherapy, and recurrence. RESULTS: During the evaluation, while 61 patients (47.3%) were alive, 68 (52.7%) had lost their lives. One-, two- and five-year survival rates of the study population were 79.8%, 56.9% and 23.2%, respectively. Mean duration of survival was 41.5±4.0 months (range 33.7-49.4 months). Patient's age or tumor histopathology did not affect the duration of survival. Overall duration of survival was significantly longer in patients of stage IIB, patients who had low stages of lymph node invasion, who were performed lobectomy, who received chemotherapy or radiotherapy or who were without recurrence (p<0.05 for each). Multivariate regression analysis revealed that lymph node invasion, presence of recurrence or pneumonectomy, or failure to have been administered chemotherapy increased mortality risk significantly (hazard ratios 0.217, 3.369, 2.791 and 2.254, respectively). CONCLUSION: Our findings revealed that lymph node invasion, presence of recurrence or pneumonectomy, or failure to have been administered chemotherapy are poor prognostic factors in T3 non-small cell lung cancer. Prognostic factors should be taken into consideration during treatment and follow-up periods of patients with T3 non-small cell lung cancer.

Medialization laryngoplasty with gore-tex: an animal study.

Vocal cord paralysis is a disease that can cause voice disability and aspiration problems. Expanded polytetrafluoroethylene (ePTFE; Gore-Tex) has been widely used in cardiovascular and plastic surgery; however, its biocompatibility and safety have not been established precisely in the larynx. In this study, the biocompatibility and safety of ePTFE used in vocal cord medialization in the rabbit larynx were assessed. Type 1 thyroplasty with Gore-Tex was performed on one side of the larynx in eight rabbits. A sham procedure was applied on the contralateral side of their larynx. The rabbits were sacrificed after 6 months, and macroscopic and microscopic evaluations and comparisons were performed. No significant inflammatory response to Gore-Tex or displacement of the implant was seen. There was only a tiny fibrotic capsule surrounding the material in each specimen. Intense eosinophilic cell infiltration was seen surrounding one rabbit specimen. Gore-Tex seems to be a biocompatible, stable, and reversible material that can be safely used in laryngeal framework surgery.

Outcomes after lobectomy and pneumonectomy in lungcancer patients aged 70 years or older.

BACKGROUND/AIM: For the early stage of nonsmall-cell lung cancer, surgical resection provides the best survival, but the surgical risk generally increases with age because of the increased prevalence of comorbidities, especially cardiovascular disorders. The aim of this study was to compare survival and mortality rates of two groups with different ages, younger and older than 70 years, who went curative resection for nonsmall-cell lung cancer. MATERIALS AND METHODS: We analyzed the patients who underwent curative lung cancer surgery in the Department of Thoracic Surgery of Gaziantep University Research Hospital between January 1997 and November 2014. Patients were divided into 2 groups according to their ages. RESULTS: A total of 497 patients were included in data analysis (381 were under 70 years old and 116 of them were ≥70 years old). The older group showed a 1.4-fold increased risk of mortality hazard ratio when the probability of survival was analyzed by histological type, lymph node involvement, disease stage, and age. CONCLUSION: There was no distinct increase in 30-day mortality rates of patients with nonsmall-cell lung cancer who were ≥70 years old, but the hazard rate for long-term survival was higher in the older group. Curative pulmonary resections due to lung cancer should be carefully performed in septuagenarians.