The choice of invasive diagnostic techniques in advanced lung cancer.

BACKGROUND: We retrospectively evaluated the invasive diagnostic techniques that were not suitable for transthoracic biopsy or bronchoscopy and the results of these techniques for advanced lung cancer cases. METHODS: The files of patients operated at the Department of Thoracic Surgery, Faculty of Medicine, Pamukkale University for advanced lung cancer (stages III and IV) between 2006 and 2010 were retrospectively reviewed for the analysis of definite diagnostic methods. RESULTS: The mean age of 59 patients who underwent invasive diagnostic techniques was 56.55 ± 9.42 years (32 to 75) and the female to male ratio was 1:4 (11 female:48 male). Mediastinoscopy was the most commonly used invasive technique with 20 patients (34%) while the second most common technique was video-assisted thoracoscopic surgery with 10 patients (17%). Thoracotomy was the most invasive diagnostic technique with four patients (6.5%). CONCLUSIONS: Although it would be desirable to use noninvasive and minimally invasive diagnostic techniques in the diagnosis of lung cancers, we should not try to avoid using invasive diagnostic techniques in surgical practice in advanced lung cancers where other techniques may be inadequate.

A single-center large-volume experience in the surgical management of hydatid disease of the lung with and without extrapulmonary involvement.

BACKGROUND: We compared the number of incisions, surgical procedures, hospital duration, and complications in hydatid cyst patients with unilateral or bilateral thoracic involvement and concomitant involvement of the extrathoracic organs. METHODS: A total of 76 hydatid cyst cases surgically treated between the years 2007 and 2012 were divided into three groups according to radiological evidence of other organ involvement and surgical procedures: group 1 had only unilateral thoracic involvement and a single incision; group 2 had additional involvement of the contralateral thoracic side or extrathoracic organs and at most two incisions were performed at the same session; and group 3 had two or more incisions performed at separate sessions in addition to the involvement features of group 2. RESULTS: We had 46 (60.5 %) cases with only thoracic involvement and 30 others (39.5 %) with extrathoracic organ involvement. Complications were seen in only one patient each in the first and second groups, and in 6 patients in the third group. Duration of hospital stay was 7.04 ± 0.86 (5-9) days in group 1.8.33 ± 1.87 (7-13) days in group 2, and 13.95 ± 2.03 (9-18) days in group 3. CONCLUSIONS: Although multiple session surgery is used to decrease the risk of complications, contamination, and infection in multiple or bilateral pulmonary hydatid cyst cases, or in patients with other organ involvement, single-session surgery can be used in selected cases taking into account the operative trauma, financial consequences, and psychological profile.

The comparison of tracheostomy and translaryngeal intubation regarding free radical formation and pulmonary effects.

BACKGROUND: Our aim in this study was to compare the blood gas changes, the malondialdehyde (MDA) and endogenous antioxidant glutathione (GSH) levels in blood and lung tissues after ischemia/reperfusion, the histopathological damage in lung tissue in rats provided respiratory support with mechanical ventilation after translaryngeal intubation and tracheostomy. METHODS: Group 1 rats were provided mechanical ventilator support after translaryngeal intubation, Group 2 mechanical ventilator support after tracheostomy, and Group 3 was the control group where rats were only anesthetized. Three groups were compared for blood gas changes, MDA, GSH, and histopathological changes. RESULTS: Blood gas evaluation showed a more marked increase in pO2 values and decline in pCO2 values in Group 2 than Group 1 (p<0.05), and higher serum MDA levels in Group 1 than Group 2 (p<0.05). Tissue GSH levels in Groups 1 and 2 were higher than the control group, but this difference was not statistically significant (p>0.05). In terms of histopathological scoring, the damage score in Group 1 was higher than in Group 2 (p<0.05). CONCLUSION: This is the first study to show tracheostomy to be more advantageous than translaryngeal intubation in terms of blood gases, ischemia/reperfusion damage, and structural changes in the lung tissue.

Postoperative respiratory muscle training in addition to chest physiotherapy after pulmonary resection: A randomized controlled study.

Purpose: The effects of preoperative respiratory muscle training (RMT) on postoperative complications in patients with pulmonary resection have recently attracted the attention of researchers. More studies are obviously needed to clarify the effects of RMT after pulmonary resection. The aim of this study was to evaluate the effectiveness of intense RMT in addition to chest physiotherapy after pulmonary resection in terms of respiratory muscle strength, exercise capacity, and length of hospital stay rather than postoperative complications. Methods: Forty subjects undergoing pulmonary resection were included in the study. Subjects were divided into two groups using a simple randomization method. The subjects in the study group (SG; n = 20) received RMT in addition to regular chest physiotherapy in the postoperative period. The subjects in the control group (CG; n = 20) received only regular chest physiotherapy. Respiratory muscle strength (maximal inspiratory and expiratory pressure [PImax and PEmax]) was measured pre-postoperatively and before discharge, and exercise capacity, which was measured by the 6-min walk test (6MWT), was assessed preoperatively and before discharge. The length of hospital stay was also recorded. Results: There were no differences between groups in terms of demographic and surgical characteristics. The nonsignificant change of PImax from the preoperative to the discharge value was 65.1 ± 15.5 to 68.2 ± 19.2 cmH2O in SG and 59.2 ± 13.7 to 44.3 ± 14.8 cmH2O in CG (p > 0.05, p > 0.05, respectively). The change of PEmax from the preoperative to the discharge value was 80.4 ± 24.9 to 81.5 ± 24.9 cmH2O in SG (nonsignificant) and 85.4 ± 38.2 to 61.3 ± 25.4 cmH2O in CG (p > 0.05, p = 0.002, respectively). There was a significant difference between SG and CG in terms of RMT effect (PImax: 11.05 [21.84; 0.25] cmH2O p = 0.045; PEmax: 25.23 [42.83; 7.62] cmH2O p = 0.006). A significant difference was found in the 6MWT when the mean differences were compared between the groups (85.72 [166.15; 5.28] m p = 0.037). The length of hospital stay was significantly shorter in the SG (number of days for SG 9.1 ± 3 and for CG 12.9 ± 4.2 [p = 0.002]). Conclusion: The addition of RMT to chest physiotherapy after pulmonary resection can have positive effects on respiratory muscle strength, exercise capacity, and length of hospital stay.

Sinus cut-off sign: a helpful sign in the CT diagnosis of diaphragmatic rupture associated with pleural effusion.

The objective of our study was to describe the "sinus cut-off" sign at CT in the diagnosis of diaphragmatic rupture in patients with blunt abdominal trauma complicated with pleural effusion, and evaluate its utility in an experimental model. Between January 2004 and March 2005, we observed an unusual interruption of costophrenic sinus at CT in three patients with blunt abdominal trauma accompanied with pleural effusion. This observation prompted us to evaluate the utility of this sign in an experimental model. Laparotomically, we created 2 cm diapragmatic lacerations at each hemidiaphragm in two rabbits and pushed up the abdominal viscera with omentum through the defect. To simulate hemothorax, we also injected 5-10 mL of diluted contrast material into the pleural space. Using a dual-slice helical CT scanner, limited thoracoabdominal CT examination was performed before and after injection of intrapleural contrast material. The images were analyzed for the presence of CT signs for diaphragmatic injury. The left posterior costophrenic sulcus was interrupted in all of the three patients with left pleural effusion. While it was associated with other findings of diaphragmatic injury, the "sinus cut-off sign" was the sole finding in one patient. The sinus cut-off sign was observed on the CT scans of 100% of the rabbits with a left and right sided diaphragmatic rupture. The "sinus cut-off sign" is useful and can increase the CT detection of acute diaphragmatic injury associated with pleural effusion.

A Case of Idiopathic Subglottic and Bilateral Bronchial Stenosis.

Subglottic stenosis is rarely idiopathic. In this case report, a 40-year-old female patient presented with subglottic stenosis with an unidentified etiology along with bilateral bronchial stenosis. Hoarseness arose in the last 4 years in this patient, who was undergoing treatment because of asthma for 13 years. Her physical examination revealed the presence of bilateral rhonci. Her tomography analysis revealed tracheal stenosis in a 2-cm segment at the C6-7 level. Her bronchoscopy analysis revealed subglottic stenosis. White plaques were observed in the entire tracheobronchial tree; biopsy was performed and lavage was taken. Samples were sent for pathological and microbiological examinations. Stenosis in the bronchial system was clear in the left main bronchus entry and at the right intermediate bronchus level. Dilatation was performed. Chronic active inflammation and squamous hyperplasia were observed in the pathology of the biopsies. Growth did not occur in tuberculosis and nonspecific cultures. Reflux was not present in the gastrointestinal system examination. All serological and rheumatologic examinations performed were normal. Idiopathic subglottic stenosis is exceedingly rare. Bronchial system stenosis accompanying idiopathic tracheal stenosis is even rarer, and its treatment is difficult.

The Right Inferior Pulmonary Vein Related Inflammatory Myofibroblastic Tumor in an Adult Case.

Inflammatory myofibroblastic tumor (IMT) is a rare neoplasm, which is derived of mesenchymal origin. Here we present an adult case with IMT, the origin of which was considered to be right inferior pulmonary vein. A male patient who was 52 years old, admitted to our outpatient clinic with the complaint of shortness of breath. He had cigarette smoking history for 30 years. On direct posterior - anterior X-Ray of the chest, a well-circumscribed mass with calcification in right hilum of the lung was observed. There was a mass which was extending to the inferior inferior pulmonary vein from right hilum of the lung, was measured 70 × 60 mm on computed tomography of the chest. Hamartoma, teratoma and Castleman Disease were among the possible diagnoses. On diagnostic bronchoscopy, signs of pressure from outside to the bronchi of the right middle and lower lobe was observed. Surgical excision is decided and the mass was totally excised through a muscle-sparing thoracotomy. The mass thought to arise from the inferior pulmonary vein on intraoperative inspection and right inferior lobe excision is undertaken by intrapericardial approach. No postoperative complication is encountered. Histological examination of the mass indicated inflammatory myofibroblastic tumor. Main treatment of IMT is surgical excision with negative surgical margin. Here in we present an IMT which is encountered at an unexpected location is excised completely with right lower lobe excision by an intrapericardial approach.

Effectiveness of Palatal Mucosa Graft in Surgical Treatment of Sub-Glottic Stenosis.

OBJECTIVES: Mucosal free grafts may be successfully applied in many surgical interventions. This study aims at investigating the feasibility of palatal mucosa graft in sub-glottic field in an animal model. METHODS: This randomized prospective controlled study was conducted with an animal model. Sub-glottic inflammation was created in 15 adult rabbits in each group and sub-glottic stenosis surgery was applied thereafter. The rabbits in group 1 (control group) underwent segmental resection, partial cricoidectomy, and trachea-thyroid cartilage anastomosis; the rabbits in group 2 underwent segmental resection, cricoplasty, and crico-tracheal anastomosis using free buccal mucosa graft; and the rabbits in group 3 underwent segmental resection, cricoplasty, and crico-tracheal anastomosis using free palatal mucosa graft. Re-stenosis was evaluated after 42 days. RESULTS: The percentages of stenosis were 27%±20%, 40%±20%, and 34%±23% for group 1, 2, and 3, respectively and the difference was not statistically significant (P=0.29). Intensive and tight fibrosis was observed in 2 rabbits (13%) in group 1, in 5 rabbits (33%) in group 2, and in 3 rabbits (20%) in group 3. There was not a statistically significant difference between groups (P=0.41). Excessive inflammation was observed in 3 rabbits (20%) in group 1, in 7 rabbits (47%) in group 2, and 3 rabbits (20%) in group 3. There was no a statistically significant difference between groups although inflammation rate was higher in the rabbits which underwent buccal mucosa graft (P=0.18). CONCLUSION: The surgical treatments applied with free mucosa graft reduced anastomosis tension through enabling anastomosis to the distal of cricoid instead of thyroid cartilage. Free palatal mucosa grafts may be used in sub-glottic field, one of the most challenging fields of trachea surgery, due to ease of application and rapid vascularization.

[Evaluation of IHA, ELISA and Western Blot tests in diagnosis of pulmonary cystic hidatidosis]. / Akciger hidatidozunun tanisinda IHA, ELISA ve Western Blot testlerinin degerlendirilmesi.

Pulmonary cystic hidatidosis caused by the larval stages of Echinococcus granulosus is a common parasitic disease in Turkey and throughout the world. In this study IHA, ELISA and Western Blot (WB) tests were performed with a panel of 59 sera from 31 surgically confirmed pulmonary cystic hidatidosis patients, 18 patients with pulmonary disease other than cystic hidatidosis and 10 healthy individual. The overall sensitivity of the IHA, ELISA and WB tests used for the serodiagnosis of pulmonary cystic hidatidosis were found as 96.7%, 87.1%, 100% and the specificities were 82.2%, 89.2% and %85.7, respectively. Using the WB test 8-12 kDa, 24 kDa and 124 kDa bands were detected as valuable for surgically confirmed patients' sera. One or more of these bands were also detected in sera of four patients with other pulmonary diseases false-positively. In conclusion conventional serologic test like IHA and ELISA is valuable in diagnosis of pulmonary cystic hidatidosis, also evaluation of some specific bands in WB would contribute to the diagnosis.

Patient and physician delay in the diagnosis and treatment of non-small cell lung cancer in Turkey.

AIM: The early diagnosis and treatment of lung cancer are important for the prognosis of patients with lung cancer. This study was undertaken to investigate patient and doctor delays in the diagnosis and treatment of NSCLC and the factors affecting these delays. MATERIALS AND METHODS: A total of 1016 patients, including 926 (91.1%) males and 90 (8.9%) females with a mean age of 61.5±10.1 years, were enrolled prospectively in this study between May 2010 and May 2011 from 17 sites in various Turkish provinces. RESULTS: The patient delay was found to be 49.9±96.9 days, doctor delay was found to be 87.7±99.6 days, and total delay was found to be 131.3±135.2 days. The referral delay was found to be 61.6±127.2 days, diagnostic delay was found to be 20.4±44.5 days, and treatment delay was found to be 24.4±54.9 days. When the major factors responsible for these delays were examined, patient delay was found to be more frequent in workers, while referral delay was found to be more frequent in patients living in villages (p<0.05). We determined that referral delay, doctor delay, and total delay increased as the number of doctors who were consulted by patients increased (p<0.05). Additionally, we determined that diagnostic and treatment delays were more frequent at the early tumour stages in NSCLC patients (p<0.05). DISCUSSION: The extended length of patient delay underscores the necessity of educating people about lung cancer. To decrease doctor delay, education is a crucial first step. Additionally, to further reduce the diagnostic and treatment delays of chest specialists, multidisciplinary management and algorithms must be used regularly.

Horner's syndrome as a complication in thoracic surgical practice.

OBJECTIVE: To determine the incidence, reasons and prognosis about Horner's syndrome in thoracic surgical patients. METHODS: In this prospective clinical study, 933 adult patients were assessed between the years of 1998 and 2002. All patients who underwent chest tube insertion (n: 662 patients) or thoracotomy (n: 342 patients), or who had thoracic trauma (n: 268 patients) were routinely examined to detect of Horner's syndrome. The patients with Horner's syndrome due to the invasion of malignant tumour to sympathetic chain were not included in the study. RESULTS: Horner's syndrome was detected in twelve patients from these 933 patients (1.3%). The considered etiologic factors were chest tube pressure in five patients, operative complication in two patients and trauma in five patients. In patients with chest tube pressure were fully recovered from Horner's syndrome but the remaining did not. CONCLUSIONS: Malposition of the chest tube is an important aetiological factor of Horner's syndrome, and it is reversible if the tube position is corrected urgently.

Large mediastinal teratoma originating from the aortic adventitia.

Many mediastinal tumors do not cause local symptoms, so they are discovered incidentally upon thoracic imaging. We present the case of a patient who had a large, mature, cystic, mediastinal teratoma. The primary tumor arose from the ascending aortic adventitia and was in a highly unusual location-the medial mediastinum. The teratoma, which was diagnosed in our patient on thoracic computed tomography for follow-up evaluation of empyema, was resected completely. To our knowledge, such a teratoma, arising from the adventitia of the ascending aorta in the medial mediastinum, has not previously been reported in the English medical literature. We review diagnostic methods and therapeutic approaches to such mediastinal tumors. We conclude that surgical resection is the method of choice for treating these tumors, because it enables radical therapy and tissue diagnosis after extirpation.

Comparison of only T3 and T3-T4 sympathectomy for axillary hyperhidrosis regarding treatment effect and compensatory sweating.

OBJECTIVES: Patients diagnosed with axillary hyperhidrosis can face psychosocial issues that can ultimately hinder their quality of life both privately and socially. The routine treatment for axillary hyperhidrosis is T3-T4 sympathectomy, but compensatory sweating is a serious side effect that is commonly seen with this approach. This study was designed to evaluate whether a T3 sympathectomy was effective for the treatment of axillary hyperhidrosis and whether this treatment led to less compensatory sweating than T3-T4 sympathectomies among our 60-patient population. METHODS: One hundred and twenty endoscopic thoracic sympathectomies were performed on 60 patients who had axillary hyperhidrosis. The sympathectomies were accomplished by means of a single-lumen endotracheal tube and a single port. The axillary hyperhidrosis patients were randomly divided into two groups with 17 patients in Group 1 undergoing T3-T4 sympathectomies and 43 in Group 2 undergoing only T3 sympathectomies. We analysed the data associated with the resolution of axillary hyperhidrosis, the degree of patient satisfaction with the surgical outcome and the quality of life in parallel with compensatory sweating after the procedure as reported by the patient and confirmed by the examiner. Moreover, the results were compared statistically. RESULTS: No statistically significant difference was observed between the groups based on age (P=0.56), gender (P=0.81), duration of the surgery (P=0.35) or postoperative satisfaction levels (P=0.45). However, the incidence and degree of compensatory sweating were lower in the T3 group than the T3-T4 group at the 1-year follow-up (P=0.008). CONCLUSIONS: T3 sympathectomy was as effective as T3-T4 sympathectomy for the treatment of axillary hyperhidrosis based on the patients' reported postoperative satisfaction, and the T3 group demonstrated lower compensatory sweating at the 1-year follow-up.

Total situs inversus found coincidentally following a firearm injury.

Situs inversus totalis is very rare and usually diagnosed coincidentally as it does not affect the patient's life. Being unaware of the patient's condition can lead to undesirable results from the surgeon and patient's point of view when an emergency and forensic surgical intervention is required. We present a case who was operated on urgently for a firearm injury after receiving a preoperative diagnosis of situs inversus totalis. In conclusion, situs inversus totalis can cause difficulties for surgeons in case of emergency surgery and is usually diagnosed coincidentally. There are a few cases of situs inversus with lung cancer in the literature but this is the first time a case with a firearm injury has been reported.

Squamotous-type sarcomatoid carcinoma of the lung with rhabdomyosarcomatous components.

Lung carcinosarcoma is an infrequently biphasic tumor composed of carcinomatous and sarcomatous components. It is divided into endobronchial (squamous-type) and peripheral (glandular type) categories. The carcinomatous component is usually a squamous carcinoma, and the sarcomatous component usually resembles a fibrosarcoma or a malignant fibrous histiocytoma. The presence of rhabdomyoblastic differentiation in such neoplasms is exceedingly rare. There are strong associations with smoking and asbestosis. In this study, we describe a unique case of a 43-year-old man with a 75 packet/year smoking history in whom a rare mixed malignant tumor of the lung was diagnosed and treated by left pneumonectomy. Histological examination of the resected specimen showed squamous cell carcinoma and rhabdomyosarcoma components. Although rare, the association of a sarcomatoid carcinoma of the lung with squamous cell carcinoma and rhabdomyosarcomatous component is possible and should be kept in mind when dealing with these unusual tumors.

Hydatid cyst, an unusual cause of spontaneous hemothorax and diagnostic thoracoscopy: case report.

Hydatid disease is a common parasitic disease in areas where sheep and cattle are raised and is currently endemic in the eastern and southwestern parts of Turkey. Patients with hydatid cysts typically present with cough, chest pain, dyspnea, hemoptysis, or allergic reactions. When ruptured, these cysts may cause hemoptysis, dyspnea, and hydatid thorax. Previously published series of cyst hydatid have reported cyst hydatid rupture and hemothorax secondary to trauma, but nontraumatic hemothorax due to spontaneous rupture of hydatid cyst has not been defined. We discuss the clinical features of a patient with no history of trauma who presented to the emergency department with hemoptysis and dyspnea and was found to have hemothorax due to spontaneous rupture of the hydatid cyst on videothoracoscopic investigation and underwent thoracotomy for hydatid disease treatment.

Endobronchial lipomatous hamartoma: an unusual cause of bronchial obstruction (2007: 7b).

Imaging findings were reported in an unusual case of endobronchial lipomatous hamartoma obstructing the left mainstem bronchus. Computed tomography readily demonstrated the presence of fat density within the lesion narrowing the differential diagnosis to endobronchial lipoma or lipomatous hamartoma.

Hydatid cyst presenting as an eosinophilic pleural effusion.

A 61-year-old woman presented with an eosinophilic pleural effusion, secondary to transdiaphragmatic intrapleural spread of an hepatic hydatid cyst. Right posterolateral thoracotomy and frenotomy revealed a loculated pleural effusion associated with a 10 x 8 cm hydatid cyst in the posterior segment of the liver. Hydatid disease should be included in the differential diagnosis of eosinophilic pleural effusions in endemic regions.

Giant benign fibrous tumor of the pleura in a pregnant woman: report of a case.

While most pleural neoplasms are malignant and associated with asbestos exposure, benign tumors may also occur. Benign fibrous tumors of the pleura are rare and, unless diagnosed and resected early, they may reach an enormous size and cause severe symptoms. We report the case of a pregnant woman with a giant benign fibrous tumor localized in the pleura.