Occurrence of thymic pathology in two families. Is familial screening justified?

The familial occurrence of thymic pathology, even though rare, is widely reported in the literature and mainly concerns cases of familial autoimmune myasthenia gravis. Other less frequent cases of familial occurrence of thymoma, thymic carcinoid and thymic hyperplasia have been described. It seems that the familial occurrence is poorly recorded and thus its prevalence is underestimated. We report two families whose members presented different forms of thymic pathology and discuss the necessity of screening programs in family members of patients presenting a thymic lesion.

Clinical significance of positive Raoultella Ornithinolytica and Staphylococcus hominis cultures in a post lobectomy patient. A case report.

Raoultella Ornithinolytica (RO) is an encapsulated, Gram- negative, nonmotile aerobic rob which was reclassified from Klepsiella genus belonging in the family of Enterobacteriaceae. It is a rare human infection and few cases have been reported in post thoracotomy patients. Here we present a case of a left lower lobectomy patient that was complicated by pleural effusion and high fever with positive sputum cultures of Raoultella Ornithinolytica and positive pleural fluid cultures of Staphylococcus hominis. It is related with aquatic life poisoning. There are few cases reported and even fewer postoperatively. The infection is rare in human therefore the bacteria is still underreported.

Chilaiditi's sign or syndrome? Diagnostic question in two patients with concurrent cardiovascular diseases.

Chilaiditi's sign is the asymptomatic, usually incidental radiographic finding, in which a part of the intestine is located between the liver and the diaphragm. The term Chilaiditi syndrome is referred to cases with symptomatic hepatodiaphragmatic interposition. Chilaiditi's syndrome is usually associated with abdominal or lower thoracic symptoms. We present here the cases of two patients that were admitted with predominantly thoracic  atypical pain. During cardiac work up, it was found that there was a concurrent heart disease for which both patients were managed. Although both patients were treated for the heart disease, a full conservative treatment was implemented, having in mind that Chilaiditi's syndrome instead of sign could be responsible for the symptoms. Patients' course was uneventful and they are regularly followed up.

Two foreign bodies embedded in the intraventricular septum: A case report.

A 23-year old male was presented at the outpatient clinic of our department reporting that he had been subjected to insertion of foreign bodies in his chest. Physical examination was unremarkable. Imaging studies revealed the presence of two bodies in the subcutaneous tissue of the anterior chest wall and two needle-shaped intramyocardial bodies that were impacted in the intraventricular septum. Due to late appearance, the position, and because of the absence of symptoms, it was decided that the patient should be managed conservatively. Today, five years after the incident, the patient remains asymptomatic and he is followed-up regularly.

Unusual symptomatic late onset presentation of aberrant right subclavian artery: report of two cases and short literature review.

Aberrant subclavian arteries are congenital vascular anomalies that usually do not cause any symptoms. When symptomatic they are considered as a rare cause of dysphagia. This presentation is known as dysphagia lusoria. They are diagnosed by barium swallow or contrast-enhanced computed tomography, although it may be an incidental finding. Management varies from life modifications and drug therapy to surgical intervention. We report two cases of the unusual form of late onset symptomatic presentation because of the presence of aberrant right subclavian artery. Main symptom was chest pain without dysphagia. Due to age and medical comorbidities both patients where managed conservatively.

Aneurysmal rib cyst.

Thoracic cage is the site of development of various primary or metastatic tumors. An aneurysmal rib cyst is a benign tumor arising from the chest wall. Aneurysmal rib cyst is considered a rare surgical entity and its presence must be followed by removal for histology examination. We present here the case of an aneurysmal rib cyst to a young 33-year-old female. The tumor was presented as an expanding left anterior second rib mass during a self-breast examination. Chest x-ray showed a shadow on the left upper lung area and CT scan revealed a large multicystic mass in the anterolateral left 2nd rib protruding underneath the thoracic major muscle. We discuss the clinicopathological characteristics of this tumor and its surgical management along with a short literature review.

Mechanisms of oxidative stress and myocardial protection during open-heart surgery.

Cold heart protection via cardioplegia administration, limits the amount of oxygen demand. Systemic normothermia with warm cardioplegia was introduced due to the abundance of detrimental effects of hypothermia. A temperature of 32-33°C in combination with tepid blood cardioplegia of the same temperature appears to be protective enough for both; heart and brain. Reduction of nitric oxide (NO) concentration is in part responsible for myocardial injury after the cardioplegic cardiac arrest. Restoration of NO balance with exogenous NO supplementation has been shown useful to prevent inflammation and apoptosis. In this article, we discuss the "deleterious" effects of the oxidative stress of the extracorporeal circulation and the up-to-date theories of "ideal'' myocardial protection.

Surgical treatment for malignant pleural mesothelioma: extrapleural pneumonectomy, pleurectomy/decortication or extended pleurectomy?

Malignant pleural mesothelioma (MPM) is an asbestos-related disease with a dismal prognosis. Ethic, social, legal and economic parameters are implicated in its management. It is quite clear that multimodality therapy is necessary to improve long-term results but precise treatment schemes have not yet been equivocally accepted. The extent of surgery is questioned and radical operations are highly debatable. On the other hand, debulking or cyto-reductive surgery have been also proposed within a multimodality approach. However, the role and order of adjuvant or neoadjuvant use of chemotherapy, radiotherapy and surgery has not been established. The aim of this study was to analyze contemporary studies on the impact of different surgical approaches on outcome of patients with MPM.

S100A2 protein and non-small cell lung cancer. The dual role concept.

S100A2 is a member of the EF-hand motif family S100. Its role has been recently implicated in carcinogenesis and metastasis. Although its precise role in NSCLC patients is debated and conflicting results have been published, it has been associated with patient survival. S100A2 expression was downregulated in some studies while others disagree that S100A2 is strongly expressed in lung cancer. It has been recently published by Hountis et al. that there is a significant association between nuclear S100A2 positivity and better disease-free interval. Intensity of expression was the highest in the early and advanced stages, and equally distributed in the middle stages. This is indicative for a dual role of this protein in carcinogenesis. The expression of S100A2 in operable NSCLC varies widely, and this differential location and expression pattern (nuclear or cytoplasmic or both) seem to correlate with prognosis. The precise role for the movement of S100A2 protein between cytoplasm and nucleus is still unclear. We present here a literature review, and we propose the dual concept on its substantial role as a prognostic or predictive indicator in this unfavorable group of patients.

γ-H2AX expression detected by immunohistochemistry correlates with prognosis in early operable non-small cell lung cancer.

BACKGROUND: Phosphorylation of the H2AX histone is an early indicator of DNA double-strand breaks and of the resulting DNA damage response. In the present study, we assessed the expression and prognostic significance of γ-H2AX in a cohort of 96 patients with operable non-small cell lung carcinoma. METHODS: Ninety-six paraffin-embedded specimens of non-small cell lung cancer patients were examined. All patients underwent radical thoracic surgery of primary tumor (lobectomy or pneumonectomy) and regional lymph node dissection. γ-H2AX expression was assessed by standard immunohistochemistry. Follow-up was available for all patients; mean duration of follow-up was 27.50 ± 14.07 months (range 0.2-57 months, median 24 months). RESULTS: Sixty-three patients (65.2%) died during the follow-up period. The mean survival time was 32.2 ± 1.9 months (95% confidence interval [CI]: 28.5-35.8 months; median 30.0 months); 1-, 2- and 3-year survival rates were 86.5% ± 3.5%, 57.3% ± 5.1%, and 37.1% ± 5.4%, respectively. Low γ-H2AX expression was associated with a significantly better survival as compared with those having high γ-H2AX expression (35.3 months for low γ-H2AX expression versus 23.2 months for high γ-H2AX expression, P = 0.009; hazard ratio [HR] 1.95, 95% CI: 1.15-3.30). Further investigation with multivariate Cox proportional hazards regression analysis revealed that high expression of γ-H2AX remained an independent prognostic factor of shorter overall survival (HR 2.15, 95% CI: 1.22-3.79, P = 0.026). A combined p53/γ-H2AX analysis was performed, and we found that the p53 low/γ-H2AX low phenotype was associated with significantly better survival compared with all other phenotypes. CONCLUSION: Our study is the first to demonstrate that expression of γ-H2AX detected by immunohistochemistry may represent an independent prognostic indicator of overall survival in patients with non-small cell lung cancer. Further studies are needed to confirm our results.

Prognostic significance of different immunohistochemical S100A2 protein expression patterns in patients with operable nonsmall cell lung carcinoma.

S100 proteins are involved in carcinogenesis, metastasis, and survival. S100A2 is a member of the S100 family, and its expression and precise role in patients with non-small cell lung carcinoma (NSCLC) has been debated. Therefore, we examined the immunohistochemical expression patterns of S100A2 in NSCLC in relation to clinicopathological parameters, important molecular biomarkers, and patient outcome. Microarray data for 74 paraffin-embedded specimens from patients with NSCLC were immunostained for S100A2 and p53 proteins. Immunohistochemical staining patterns of S100A2 in the NSCLC tissue samples examined were either nuclear (nS100A2), cytoplasmic (cS100A2), or both. A significant association between nS100A2 positivity and better disease-free interval was observed (hazards ratio 0.47; 95% confidence interval 0.23-0.99; P = 0.047). Similarly, cS100A2 negativity was marginally associated with shorter overall survival (P = 0.07). Patients without lymphatic infiltration and an earlier disease stage had significantly better overall survival and disease-free interval. The S100A2 expression pattern in operable NSCLC varies widely, and this differential expression (nuclear, cytoplasmic or both) seems to correlate with prognosis. Intensity of expression was highest in the early and advanced stages, and equally distributed in the middle stages. This observation may be indicative of a dual role for this protein both during earlier and advanced disease stages, and may also explain the differential immunoexpression of S100A2. Analysis of the disease-free interval showed that nS100A2-negative and p53-positive expression was associated with a statistically significant (P = 0.003) shorter disease-free interval in comparison with nS100A2-positive and p53-negative expression (12 versus 30 months, respectively). Further studies are required to establish whether S100A2 protein may have a substantial role as a prognostic or predictive indicator in this unfavorable group of patients.

Intraoperative use of recombinant activated factor VII during complex aortic surgery.

OBJECTIVE: Postoperative bleeding is a major cause of morbidity and mortality after complex aortic surgery. Intraoperative coagulopathy is a well-known culprit in this process. Recombinant activated factor VII is increasingly used for the postoperative management of such bleeding. We report our experience with the intraoperative use of this agent. METHODS: We performed a propensity-matched analysis on 376 retrospectively identified patients who underwent aortic root, arch, or ascending aortic replacement surgeries from 1999 to 2010. We matched a total of 58 patients: recombinant activated factor VII-treated group (n = 29) and nonrecombinant activated factor VII-treated group (n = 29). We compared the matched patients on re-exploration, mortality, bleeding-related events, use of blood and blood products, length of intensive care unit stay, duration of hospitalization, and thrombotic complications. RESULTS: Propensity-matched patients had similar preoperative and intraoperative characteristics. The mean dose of recombinant activated factor VII group was 23 ± 12 µg/kg. We found significantly lower rates of surgical re-exploration (P = .004), fewer prolonged intubations (P = .004), less total chest tube output (P = .01), and fewer units of packed red blood cells (P = .01) and fresh-frozen plasma (P = .04) transfused postoperatively in the recombinant activated factor VII group. There was no significant difference in mortality (P = 1), duration of intensive care unit stay (P = .44) or hospital stay (P = .32), or thrombotic complications between the groups (P = .5). CONCLUSIONS: We recommend the intraoperative administration of low-dose recombinant activated factor VII but limited to the management of persistent, nonsurgical, mediastinal bleeding in aortic surgery. Further prospective randomized studies and larger cohorts are needed to verify these findings.

Isolated bilateral coronary artery ostial stenosis in aortitis syndrome.

Isolated bilateral coronary artery ostial stenosis is a rare condition that has been associated with various diseases. We present the case of a 47-year-old male with bilateral coronary ostial stenosis. The patient's history was not significant for systemic diseases. The aorta had prominent signs of aortitis of unknown etiology, possibly due to a chronic mycotic process. The patient underwent emergency surgery and had an uneventful course. The two-year follow up is excellent.

Superior vena cava syndrome in a patient with previous cardiac surgery: what else should we suspect?

BACKGROUND: Although mediastinal tumors compressing or invading the superior vena cava represent the major causes of the superior vena cava syndrome, benign processes may also be involved in the pathogenesis of this medical emergency. One of the rarest benign causes is a pseudoaneurysm developing in patients previously having heart surgery. CASE REPORT: We present the case of a large pseudoaneurysm of the ascending aorta, five years after primary surgery, with a significant compression of the right mediastinal venous system causing superior vena cava syndrome, detected at chest CT angiography. Perioperative findings showed two rush out points both coming from the distal aortic suture line which was performed five years ago. The patient underwent reoperation under circulatory arrest facilitating safe exploration and repair of the distal anastomotic leaks CONCLUSION: Enhanced chest CT should be always undertaken in all patients with superior vena cava syndrome, especially in those previously having cardiac or aortic surgery to correctly evaluate the presence of a pseudoaneurysm. Mass effect to the superior vena cava makes necessary an open surgical treatment of the pseudoaneurysm so as to concurrently resolve the right mediastinal venous system's compression. Surgery should be performed in terms of safe approach to avoid exsanguination and cerebral malperfusion.

Simultaneously performed off-pump coronary artery bypass grafting and colectomy: a case report.

This is written so as to report the case of a 71-year-old male with a diagnosis of sigmoid adenocarcinoma accompanied by severe coronary artery disease and unstable angina, which was subject to simultaneous surgical treatment. The patient initially underwent an off-pump coronary artery revascularization in order to avoid the complications of cardiopulmonary bypass, providing the opportunity of a colectomy at the same time with the use of safe surgical means. Our case suggests that performing an off-pump bypass procedure prior to cancer surgery can be an appropriate course of action in carefully selected cases.

Sarcomatoid lung carcinomas: a case series.

We report on three Caucasian Greeks 2 males and 1 female (67, 54 and 62 years old) that were operated with sarcomatoid carcinoma of the lung, an uncommon tumor that sometimes is referred as pleomorphic carcinoma (spindle and giant cell carcinomas). These tumors are encountered in the thorax far more often than true sarcomas. There are many erroneous reports of pulmonary sarcomas made before the advent of adjunctive pathologic screening, including immunohistochemical studies. Pulmonary Sarcomatoid Carcinomas represent 0.2-1% of all lung cancers in different series and they are considered that they are not significantly aggressive than ordinary lung carcinoma.

Low incidence of bronchopleural fistula after pneumonectomy for lung cancer.

Bronchopleural fistula (BPF) after pneumonectomy for NSCLC remains a highly morbid complication. We examined possible factors including the surgical techniques associated with BPF development. From 221 pneumonectomies for NSCLC, bronchial stump closure was mechanically performed in 192 patients and manually in the remaining 29. In all right-sided pneumonectomies mechanical closure was performed with associated stump coverage. In 114/130 left-sided procedures where mechanical closure was selected, bronchial stump remained uncovered. In the remaining 16 left-sided cases where manual stump closure was selectively performed, the stump was covered utilizing various tissues. Risk factors were classified into preoperative, intra-operative and postoperative. Five patients (2.3%) developed BPF. Univariate analysis revealed peri-operative transfusion, respiratory infection at the time of presentation, neoadjuvant therapy, right-sided pneumonectomy, manual type of bronchial closure, days of postoperative hospitalization and mechanical ventilation as significant risk factors for BPF development. Multivariate analysis followed revealing preoperative respiratory infection and right pneumonectomy as the only independent risk factors. In our series, a selected stump coverage policy showed a low incidence of BPF development. Mechanical stapling was superior to manual closure, although not as an independent factor. Early recognition of possible risk factors associated with fistula development is of paramount importance.

The role of omental transposition for the management of postoperative mediastinitis: a case series.

INTRODUCTION: The aim of our study is to present our experience from the management of six patients with deep sternal wood infection and mediastinitis after aortocoronary by pass grafting. CASE SERIES: Five Caucasian Greek male patients and a Caucasian Greek female were subjected to aortocoronary by pass grafting. Mean time of sternal dehiscence and mediastinitis was 9-17 (mean 11) days. We managed these patients with total sternectomy and transposition of the greater omentum in the thorax. All patients had an uneventful postoperative course. CONCLUSION: We believe that greater omentum is the ideal reconstruction tissue for deep sternal wound infections and mediastinitis. Timely diagnosis, aggressive sternal debridement and omental flap coverage represent the mainstay of therapy in this highly lethal complication.