Retrospective review comparing intrapleural fibrinolytic therapy (alteplase) and surgical intervention in complex pleural effusion.

BACKGROUND: Intrapleural fibrinolytic therapy (IPFT) is one of the treatment options for complex pleural effusion. In this study, the IPFT agent used was alteplase, a tissue plasminogen activator (t-PA). This study aims to determine the difference in the outcome of patients with complex pleural effusion between IPFT and surgery in terms of radiological improvement, inflammatory parameters, length of stay, and post-intervention complications. METHODS: A retrospective review of patients with complex pleural effusion treated at Universiti Kebangsaan Malaysia Medical Center from January 2012 to August 2020 was performed. Patient demographics, chest imaging, drainage chart, inflammatory parameters, length of hospital stay, and post-intervention and outcome were analyzed. RESULTS: Fifty-eight patients were identified (surgical intervention, n = 18; 31% and IPFT, n = 40, 69%). The mean age was 51.7 ± 18.2 years. Indication for surgical intervention was pleural infection (n = 18; 100%), and MPE (n = 0). Indications for IPFT was pleural infection (n = 30; 75%) and MPE (n = 10; 25%). The dosages of t-PA were one to five doses of 2-50 mg. The baseline chest radiograph in the IPFT group was worse than in the surgical intervention group. (119.96 ± 56.05 vs. 78.19 ± 55.6; p = 0.029) At week 1, the radiological success rate for IPFT and surgical intervention were 27% and 20%, respectively, and at weeks 4-8, the success rate was 56% and 80% respectively. IPFT was associated with lesser complications; fever (17.5%), chest pain (10%), and non-life-threatening bleeding (5%). CONCLUSION: IPFT was comparable to surgery in radiological outcome, inflammatory parameters, and length of stay with lesser reported complications.

Recurrent and transformation of borderline to malignant phyllodes tumour with osteoid differentiation: a case report and literature review.

Phyllodes tumours or cystosarcoma phyllodes are fibroepithelial tumours of the breast and represent 1% of breast tumours. A 20-year-old nullipara presented with an enlarging left breast mass over 6 months. Although widely excised, it was reported to be a 12 × 10 × 5.5-cm borderline phyllodes tumour with involvement of the superior and inferior margins. Seven months later, she presented with a new ipsilateral breast lump measuring 8.5 × 7.5 × 4.6 cm. She underwent a left mastectomy, a three-rib resection with titanic rods for the thoracic cage reconstruction, and a latissimus dorsi flap wound closure. Histopathology revealed a high-grade malignant phyllodes tumour with features of osteoid differentiation with the nearest deep margin measuring 3 mm. She developed metastasis to the ipsilateral axillary lymph nodes and contralateral lung 2 months postoperatively. She was given palliative radiotherapy 60 Gy in 30 fractions to the left axilla. She developed sudden lower-limb weakness due to spinal metastases. The symptoms resolved with radiotherapy to the thoracic spine (T4-T8). As the lesion continued to grow rapidly from the anterior chest wall encircling towards the back, it was deemed unresectable. She was given palliative chemotherapy (doxorubicin six cycles, followed by ifosfamide one cycle) but had disease progression. She passed away 3 months later. The mainstay of treatment for phyllodes tumour is excision with a minimal margin of 1 cm. Although margins were involved after the first surgery, she was followed up as the pathology was a borderline phyllodes. When the lump recurred and had transformed, despite extensive surgery, it returned shortly and progressed. A borderline phyllodes should be excised to obtain a minimal margin of 1 cm, even if it means performing a mastectomy, to minimise recurrence. A recurrence may undergo malignant transformation which is largely chemotherapy and radiotherapy resistant. This will result in a poor outcome and decreased survival.

Successful Treatment of Sternal Osteomyelitis and Mediastinitis Caused by Rhizopus Following Cardiac Surgery.

Sternal osteomyelitis and mediastinitis are rare yet severe complications post-cardiac surgery, often associated with significant morbidity and mortality. Fungal etiologies, particularly those caused by Rhizopus spp., are infrequent but can lead to aggressive infections. Here, we present the case of a 68-year-old male who developed sternal osteomyelitis and mediastinitis caused by Rhizopus spp. two weeks following coronary artery bypass grafting surgery. Debridement and pectoralis flap reconstruction were performed following clinical identification and confirmation with microbiological examinations and a CT scan. Prompt recognition, aggressive surgical intervention, and targeted antifungal therapy were crucial for successful management. This case underscores the importance of considering fungal pathogens, such as Rhizopus, in the differential diagnosis of post-cardiac surgery infections, as well as aggressive treatment to improve outcomes for affected patients.

Sarcoma With Pulmonary Metastases: A Management Dilemma.

Pulmonary metastases in soft tissue, such as sarcoma and osteosarcoma, are associated with a poor prognosis. A complete surgical resection has been proven to prolong survival. We report four cases of sarcoma with pulmonary metastases, all with differing progressions, prognoses, and management. This highlights the challenging nature of managing sarcoma with pulmonary metastases. Surgical metastatectomy remains the mainstay treatment for sarcoma with pulmonary metastases. Studies have demonstrated a significant survival benefit with complete surgical resection. There is currently no consensus on the size of the metastasis or the number of lesions for considering a patient inoperable. Surgical metastatectomy provides improved survival for sarcoma patients with pulmonary metastases. Management strategy is rapidly evolving with the emergence of new treatment methods. A case-by-case assessment and MDT approach are paramount in deciding the best course of action.

Massive hemoptysis in pregnancy due to invasive pulmonary aspergillosis with pulmonary tuberculosis co-infection.

A 37-year-old woman, 25 weeks pregnant, experienced sudden massive hemoptysis. She had a background history of systemic lupus erythematosus (SLE) and past pulmonary tuberculosis (PTB). Emergency intubation was necessary, and bronchoscopy revealed blood pooling in both main bronchi, with active bleeding from the right upper lobe bronchus. Urgent computed tomography (CT) angiography of the bronchial artery identified a bleeding source and was successfully embolized. Antifungal and anti-tuberculous therapy was initiated based on bronchoalveolar lavage results. Despite initial improvement, hemoptysis recurred after the third week, leading to repeat embolization, followed by a caesarean section and right upper lobectomy. Both mother and baby survived, remaining well at a 6-week follow-up, emphasizing the complexities of managing recurrent hemoptysis during pregnancy and potential drug interactions.

Exploring the Potential of Saphenous Vein Grafts Ex Vivo: A Model for Intimal Hyperplasia and Re-Endothelialization.

Coronary artery bypass grafting (CABG) utilizing saphenous vein grafts (SVGs) stands as a fundamental approach to surgically treating coronary artery disease. However, the long-term success of CABG is often compromised by the development of intimal hyperplasia (IH) and subsequent graft failure. Understanding the mechanisms underlying this pathophysiology is crucial for improving graft patency and patient outcomes. Objectives: This study aims to explore the potential of an ex vivo model utilizing SVG to investigate IH and re-endothelialization. Methods: A thorough histological examination of 15 surplus SVG procured from CABG procedures at Hospital Canselor Tuanku Muhriz, Malaysia, was conducted to establish their baseline characteristics. Results: SVGs exhibited a mean diameter of 2.65 ± 0.93 mm with pre-existing IH averaging 0.42 ± 0.13 mm in thickness, alongside an observable lack of luminal endothelial cell lining. Analysis of extracellular matrix components, including collagen, elastin, and glycosaminoglycans, at baseline and after 7 days of ex vivo culture revealed no significant changes in collagen but demonstrated increased percentages of elastin and glycosaminoglycans. Despite unsuccessful attempts at re-endothelialization with blood outgrowth endothelial cells, the established ex vivo SVG IH model underscores the multifaceted nature of graft functionality and patency, characterized by IH presence, endothelial impairment, and extracellular matrix alterations post-CABG. Conclusions: The optimized ex vivo IH model provides a valuable platform for delving into the underlying mechanisms of IH formation and re-endothelialization of SVG. Further refinements are warranted, yet this model holds promise for future research aimed at enhancing graft durability and outcomes for CAD patients undergoing CABG.

Left Ventricular Outflow Tract Endocarditis as a Sequela of Pneumonia in a Patient without Valvular Abnormalities.

A 50-year-old woman with underlying end stage renal disease on hemodialysis developed large isolated staphylococcal infective endocarditis over the left ventricular outflow tract when she had pneumonia, without apparent valvular involvement. She subsequently had successful surgery for excision of vegetation.

Incidental finding of congenital pericardial defect during vats bullectomy. Tips and tricks to avoid blunder.

The absence of a small portion of the pericardium is termed pericardial defect. This rare entity can be either acquired or congenital. The prevalence of congenital pericardial defect is exceedingly rare, which is approximately 0.002-0.004% of surgical and pathologic series. The most common type is the absence of the entire left side of pericardium, seen in 67% of all patients with a congenital pericardial defect. Other varieties are incredibly uncommon. Congenital pericardial defect has a male preponderance with a male to female ratio of 3:1, and familial occurrence is uncommon. We report a case of left partial congenital pericardial defect detected incidentally in a 22-year-old man who presented with recurrent left spontaneous pneumothorax. He underwent video-assisted thoracoscopic bullectomy and intraoperatively, we discovered a left partial pericardial defect which exposed the left atrial appendage. Although generally asymptomatic, patients may present with non-specific cardiac symptoms such as atypical chest pain. Partial pericardial defects have an increased risk of herniation of the whole left atrium, the left atrial appendage or the ventricles. If this occurs, cardiac strangulation may occur, leading to necrosis and sudden death. Cardiac MRI is a sensitive tool and will demonstrate the absence of preaortic pericardial recess. In conclusion, no surgical intervention is required in cases of congenital pericardial defect, unless the patient is symptomatic due to complications. If detected incidentally during cardiac or thoracic surgery, the best may be to leave it alone.