Does Every Necrotizing Granulomatous Inflammation Identified by NSCLC Resection Material Require Treatment?

BACKGROUND Lung cancer and tuberculosis (TB) are two major public health problems. They can coexist or appear sequentially. In patients with TB, lung cancer risk is increased. However, vice versa is not crystal clear. In this study, we aimed to determine the development of TB in patients with resectabled non-small cell lung cancer (NSCLC) in a 2-year postoperative follow-up period. MATERIAL AND METHODS We conducted a retrospective cohort study at three university hospitals. Patients who had NSCLC surgery between 2009 and 2013 were included and patient records were reviewed for the presence of necrotizing granulomatous inflammation (NGI) in resected specimens. Demographic properties, tumor type, stage, location, type of surgery, tuberculosis history, and thorax CT findings were recorded. We searched for the development of tuberculosis within a 2-year period after surgery. RESULTS A total of 1027 patient cases were reviewed, of which 48 patients had NGI. The median age was 63 years. The most common type of cancer was squamous carcinoma; and lobectomy was the preferred operation (70.8%). Cancer involvement most commonly included the right lung (61.8%) and upper lobes (47,9%). Only 11 patients had anti-TB treatment postoperatively, which was based on radiological findings. Prior tuberculosis or anti-TB history, type, stage or localization of cancer, and adjuvant/neoadjuvant therapy were not found to be related to TB treatment. None of the study population had TB during the two-year follow-up period. Treatment decisions appeared mostly related to physician experience. There was no difference in the risk of developing TB between patients with or without treatment. This finding may change the management of our patients. CONCLUSIONS Every NGI discovered in NSCLC resected material does not always require anti-TB treatment.

Cardiac Findings of Pulmonary Thromboembolism by Autopsy: A Review of 48 Cases.

BACKGROUND To identify the overall effects of pulmonary thromboembolism (PTE) on the heart, we evaluated the heart findings and clinical characteristics of deceased patients diagnosed with PTE. MATERIAL AND METHODS PTEs were classified into 2 categories: fatal and contributory. Cases with a history of cardiopulmonary disease or a finding of significant disease at autopsy, including valvular heart disease and coronary artery obstruction >50%, were excluded from the cardiac evaluation. We defined an LV wall ≥1.2 cm thick and an RV wall ≥0.8 cm thick as abnormal. RESULTS Forty-eight cases were included to the study (21 males and 27 females). The mean age was 41.42 ± 16.5 years. Of the 48 cases, 5 were excluded due to cardiopulmonary diseases for determining heart findings. The thicknesses of the LV and RV walls were not measured in some patients. In the 43 cases, cardiac hypertrophy was detected in 28 patients (65.1%). The mean heart weight was 387 ± 83.5 g. The mean thickness of the left ventricle (LV) wall was 1.40 ± 0.41 cm in 40 cases, and the mean thickness of the RV wall was 0.41 ± 0.135 cm in 41 cases. The LV walls of 35 (87.5%) cases and the RV walls of 2 cases met criteria for abnormal wall thickness. There were histopathological findings of heart in 24/43 cases (56%); these findings were necrosis, fibrosis, and hypertrophy. CONCLUSIONS The RV is affected by massive pulmonary embolism; however, the LV may also play a role in the pathogenesis of PTE.

Role of daytime polysomnography in the diagnosis of sleep apnea syndrome.

INTRODUCTION: Diagnosis of sleep apnea syndrome (SAS) depends on nocturnal polysomnography (nPSG), but waiting time for the test is long. Although, performing PSG in patients with excessive daytime sleepiness (EDS) at daytime (dPSG) was questioned, role and methods are not clear. The aim of the study was to assess the role of dPSG in the diagnosis of SAS, and the correlation between nPSG and dPSG. PATIENTS AND METHODS: Forty eight subjects, who were referred to our sleep laboratory with EDS were included to a cross-over study. Half of the patients underwent nPSG after dPSG, vice versa. Seven subjects excluded due to lack of participation. The rest (n= 41) had nPSG and dPSG. PSG recordings and analysis were performed according to AASM 2007 guideline. Results were analyzed for sleep efficiency, respiratory disturbance index (RDI), oxygen desaturation index (ODI), SAS severity and correlation between dPSG and nPSG. RESULTS: Total 41 subjects were analyzed. All patients had diagnosis of SAS. Sleep efficiency was higher at nPSG (86%), however also enough at dPSG (80%). Sleep stages of dPSG and nPSG were similar except stage 3 sleep, which was longer at nPSG. Undergoing dPSG or nPSG first did not correlate with sleep efficiency, respiratory disturbance (RDI) index, oxygen desaturation index (ODI) or severity of SAS. Despite BMI, neck circumference was closely related with RDI, ODI and severity. CONCLUSION: Daytime PSG, when performed appropriately, is an effective tool for diagnosing sleep disorders in patients with EDS. dPSG may decrease the amount of times that patients must wait to undergo PSG.

Endobronchial tuberculosis with lobar obstruction successfully treated by argon plasma coagulation.

Endobronchial tuberculosis (EBTB) is an infection of the tracheobronchial tree. A 17-year-old male patient with tuberculosis who developed middle lobe syndrome on antituberculous treatment is presented. The patient was admitted with complaints of fever, cough and weight loss. Right paracardiac and perihilar heterogeneous infiltrations were present. During fiberoptic bronchoscopy, the right middle lobe was found to be obstructed. Tuberculosis was diagnosed based on necrotizing granulomas in the bronchial biopsy and culture growth of M tuberculosis. After antituberculous and corticosteroid treatment, progression occurred. The endobronchial lesion was removed with argon plasma coagulation. After bronchoscopy, the patient's radiologic findings and clinical condition improved. In cases progressing despite steroid treatment, alternative treatments may be beneficial.

Use of PET-CT for the assessment of treatment results in patients with sarcoidosis.

BACKGROUND AND AIM: Sarcoidosis is a multisystem disease of unknown origin. Determining the involvement and the response to the treatment is important. The aim of this study was to identify the effects of methylprednisolone and indomethacine on metabolic activity and pulmonary function test parameters in patients with sarcoidosis. MATERIAL AND METHODS: A total of 24 pulmonary sarcoidosis patients were enrolled in the study. All the patients underwent spirometry and [(18)F]fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) scan before treatment and were divided into two groups according to the necessity of corticosteroid treatment or not. Patients who did not have corticosteroid indication were treated with indomethacine. Symptomatic patients and patients who did not respond to indomethacine treatment received methylprednisolone. Patients were followed up on a monthly basis to determine the response. FDG uptakes as the disease activity were re-evaluated before ending the treatment at the sixth month. RESULTS: Mean age of patients (16 male, 8 female) was 39.79 (9.3) years. Besides mediastinum and pulmonary parenchyma, extrapulmonary sites were also involved in patients with pulmonary sarcoidosis (distant lymph nodes (upper abdominal, supraclavicular, inguinal, and axillary), liver, and spleen). Although maximum standard uptake values of methylprednisolone group regressed significantly (p < 0.001) after treatment, indomethacine group did not have significant regression (p = 0.345). Despite metabolic regressions, spirometry values of patients did not significantly increase (p > 0.005). CONCLUSION: FDG PET-CT may be useful for determining activity and the efficacy of treatments. Methylprednisolone is effective in reducing metabolic activity but does not lead to improvement in functional parameters.

Isoniazid- and rifampicin-induced thrombocytopenia.

Treatment of tuberculosis has many side effects. Thrombocytopenia is a serious side effect of such treatment and occurs mostly due to rifampicin (RIF). There are very few reported cases of thrombocytopenia due to isoniazid (INH). An 18-year-old female patient was diagnosed with smear-positive pulmonary tuberculosis. A four-drug regimen [INH, RIF, ethambutol (EMB), and pyrazinamide (PZA)] was given. After the development of thrombocytopenia, the drug treatment was stopped, and a thrombocyte suspension was given until a normal thrombocyte count was obtained. After several start-stop trials, first INH and then RIF were identified as the possible causes of thrombocytopenia and were removed from the regimen. The patient was treated with EMB, streptomycin, PZA, and moxifloxacin with no further development of thrombocytopenia. The current case shows that antituberculosis drugs other than RIF and PZA may be responsible for the development of thrombocytopenia.

Evaluation of glutathione S-transferase P1 polymorphisms (Ile105Val and Ala114Val) in patients with small cell lung cancer.

AIMS: Glutathione S-transferase P1 (GSTP1) plays an important role in cellular protection against oxidative stress and toxic chemicals. Polymorphisms within GSTP1 are associated with alterations in enzyme activity, which may lead to development of lung disease and cancer. In this study, we aimed to investigate the GSTP1 Ile105Val and Ala114Val polymorphisms in patients with small cell lung cancer (SCLC). PATIENTS/METHODS: GSTP1 Ile105Val polymorphism in exon 5 and GSTP1 Ala114Val polymorphism in exon 6 were determined by using polymerase chain reaction-restriction fragment length polymorphism techniques in 89 patients with SCLC and 108 control patients with chronic obstructive pulmonary disease (COPD). Genotype frequencies and cigarette smoking intensities were compared among SCLC and COPD patients. RESULTS: There were significantly less SCLC patients with variant exon 6 genotypes than COPD patients (7.9% vs. 20.4%, p=0.007), while the number of patients with variant exon 5 genotypes were comparable among groups. SCLC and COPD patients with variant exon 6 genotype showed trends toward exhibiting reduced cigarette consumption. CONCLUSIONS: The variant GSTP1 exon 6 genotype might be conferring protection against SCLC development. Whether this effect is associated with exposure to cigarette smoking needs to be clarified.

Tracheopathia osteochondroplastica: two unusual cases.

We describe 2 unusual cases of tracheopathia osteochondroplastica (TPO), one of them presenting with lung carcinoma and the other at an uncommon age. A 74-year-old man presented with chronic bronchitis and a left lower lobe lesion as detected on chest computed tomography. Flexible bronchoscopy revealed multiple calcified nodular lesions involving the anterior-lateral walls of the trachea and main bronchi. Histologic analysis of the tracheal nodules confirmed the presence of TPO. Squamous cell carcinoma was diagnosed by transthoracic needle aspiration of the pulmonary nodule. The relevance of coexistence of these 2 conditions remains unknown. Our second case was in a young man who presented with persistent cough and a chest computed tomography scan revealing multiple tracheal nodules. Numerous hard tracheal nodules distributed around the lower trachea and main bronchi were observed at flexible bronchoscopy. When the cough and dyspnea persists despite conventional empiric treatment, uncommon tracheobronchial pathologies, such as TPO, should be considered.

Multifocal endobronchial carcinoid tumors: a rare case.

We present a case of multifocal endobronchial carcinoid tumor and review the literature on multifocal endobronchial carcinoid tumors. Our patient was admitted with complaints of paroxysmal cough and recurrent lower respiratory tract infections. Computed tomography of the chest showed tubular densities in the bilateral lower lobes and a 15-mm soft-tissue mass in the right lower lobe without any enlargement in the mediastinal lymph nodes. On positron emission tomography scan, there was no fluorodeoxyglucose uptake in any of these lesions. Bronchoscopy showed multiple endobronchial tumors with hypervascularity. The pathologic examination of biopsies showed neuroendocrine neoplasm and typical bronchial carcinoid tumor. Although the only effective treatment for a bronchial carcinoid is complete surgical excision of the tumor, surgical resection was not performed in our patient because of multiple, bilateral, biopsy-proven endobronchial tumors. Radiation and chemotherapy are generally reserved for symptomatic and metastatic disease, which was the treatment of choice for our patient.

Endobronchial Stenosis due to Wegener Granulomatosis.

Wegener granulomatosis (WG) is characterized by a necrotizing granulomatous vasculitis. Computed tomography of the chest is effective in detecting lung involvement with pulmonary nodules with or without cavitations and airspace consolidation. We report a case of endobronchial stenoses in the setting of WG. A 48-year-old man was admitted with complaints of dyspnea, cough, and sputum. A computed tomography scan revealed consolidation and small cavitating nodules, and stenoses were observed during bronchoscopy endobronchial. Narrowing improved after pulse cyclophosphamide and prednisolone therapy. Endobronchial stenoses are rare in the course of WG, and occur even more rarely than subglottic stenosis. Combined treatment with cytotoxic and corticosteroid agents has improved prognosis and long-term survival in patients with WG.

Radiofrequency ablation for inoperable lung cancer: a case report.

Lung cancer is among the most common malignancies in the world. Optimal treatments for unresectable primary lung cancer, local recurrence of lung cancer within a previous radiation field, pulmonary metastases, and small lung cancers (1 cm) have not been found. Radiofrequency ablation (RFA) has been increasingly performed as a local treatment for lung malignancies. Herein, we present a case of inoperable lung cancer that was successfully treated with a combination of RFA and radiotherapy. A 69-year-old man presented with exertion dyspnea of 3 weeks' duration. He had a remote history of larynx and lung cancer. The patient had remained in remission for 14 years until the current presentation. On physical examination, the patient was not in acute distress, and chest sounds were normal except for minimal prolongation of expiration. On a thorax computed tomography (CT) scan, a 2.3×1.7-cm, ill-defined, cystic lesion in the left upper lobe adjacent to major fissure was detected. CT-guided transthoracic fine needle aspiration biopsy revealed adenocarcinoma but the procedure was complicated by pneumothorax and hypercapnic respiratory failure. On account of the emerging medical inoperability, radiation therapy at 45 Gy in 3 fractions and RFA were performed successfully. After the ninth month of treatment, no fluorodeoxyglucose uptake was detected in the RFA application site in the control positron emission tomography-CT images (complete remission). RFA is a newer technique for lung cancer. Although the results of most studies were short and mid term, for patients with poor lung functions, RFA is an encouraging treatment modality, especially when combined with radiotherapy or chemotherapy in the presence of appropriate patient selection, adequate equipment, and experienced staff.