Idiopathic Pulmonary Hypertension After Liver Transplantation.

Pulmonary hypertension is one of the problems that can be encountered before liver transplantation. It is not expected in cases with no additional disease in postoperative period. Herein, we report on a 43-year-old woman who developed idiopathic pulmonary hypertension in the early postoperative period. Further investigation both pathologically and clinically is needed in patients undergoing living donor liver transplantation that may help to solve the problems such as pulmonary arterial hypertension before it occurs and manage complex hemodynamic changes successfully in the future.

Advantages of Epidural Analgesia on Pulmonary Functions in Liver Transplant Donors.

OBJECTIVE: Epidural analgesia (EA) has positive effects on anesthetic requirement, blood loss, postoperative analgesia, and pulmonary function tests (PFTs). The purpose of the present study was to investigate the effect of EA on postoperative PFTs in liver transplant donors (LTDs). METHODS: In the present study, 66 LTDs were classified as total intravenous anesthesia (TIVA) and TIVA+EA groups. Patient's age, sex, body mass index, induction and maintenance dose of propofol (IDP and MDP), operation duration, forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, visual analog scale (VAS), atelectasis scores, and lengths of intensive care unit (ICU) and hospital stays were recorded. RESULTS: In the TIVA+EA group, IPD, MPD, delta-FEV1 delta-FVC, VAS for all time, atelectasis score and length of hospital stay were significantly lower than in the TIVA group (P < .001 for all). Whereas VAS at the end of the operation was negatively correlated with delta-FEV1 and delta-FVC (r2 = 0.26 P < .001; r2 = 0.41 P < .001; respectively), it was positively correlated with atelectasis score and length of ICU stay (r2 = 0.49, P < .001; and r2 = 0.41, P < .001; respectively). Atelectasis score was positively correlated with length of ICU stay (r2 = 0.86, P < .001). CONCLUSIONS: Reduced anesthetic requirement, better postoperative analgesia, reduced atelectasis score, and preserved PFTs can be provided with the use of EA in LTDs. Positive effects of EA on anesthesia requirement, pain management and pulmonary function are associated with outcomes.

Is an elevated neutrophil-to-lymphocyte ratio a predictor of metabolic syndrome in patients with chronic obstructive pulmonary disease?

OBJECTIVE: This study aimed to evaluate the diagnostic value of the neutrophil-to-lymphocyte ratio (NLR) in early detection of metabolic syndrome (MetS) in patients with chronic obstructive pulmonary disease (COPD). PATIENTS AND METHODS: We retrospectively enrolled hospital records of 140 COPD patients and 50 sex and age-matched healthy controls. The diagnostic values of NLR were estimated using the sensitivity, specificity, and area under the receiver operating characteristic curve (AUC). RESULTS: In total, 140 patients with COPD of which 63 patients had MetS and 50 healthy subjects were included in the study. We found that the NLR values of the stable COPD patients were significantly higher than those of the controls (p < 0.001). Among patients with COPD, the NLR was significantly higher in patients with than without MetS (p < 0.001). The AUC of the NLR was 0.898 in patients with MetS. The optimal NLR cut-off was 2.56 and was validated in the testing set. For evaluation of MetS, the sensitivity and specificity were 84.1% and 84.4% in patients with COPD under the suggested cut-offs. CONCLUSIONS: The NLR is a simple, effective, and practical predictor of MetS in patients with stable COPD. It has potential value in public health practice for management of patients with COPD.

The importance of COX-2 expression as prognostic factor in early breast cancer.

PURPOSE: A number of studies have been carried out, showing that the risk for breast carcinoma is decreased in those using non-steroidal anti-inflammatory drugs (NSAIDs). Increased cyclooxygenase-2 (COX-2) level is considered as a factor indicating poor prognosis and responsible for angiogenesis, increased cellular proliferation, apoptotic defect and aromatase enzyme induction. For this reason the level of COX-2 might have a prognostic and predictive value in breast cancer as well. This question has become the basis of the present study. METHODS: Eighty-eight female patients with early stage breast cancer being under adjuvant anthracycline based chemotherapy were prospectively recruited. The patient age, body weight, menopausal status, tumor size and grade as well as axillary lymph node involvement were recorded. Routine pathological examination was performed, and COX-2, CerbB2 (HER2), estrogen (ER) and progesterone receptors (PR) levels in breast cancer tissue were determined immunohistochemically. RESULTS: Multivariate analysis confirmed the independent predictive value of both menopausal status and ER expression for overall survival (OS) (p=0.009, HR=1.92, and p=0.014, HR=0.20, respectively). A negative correlation was observed between COX-2 levels and the levels of ER and PR (p=0.006, R= -0.303, and p=0.004, R=-0.312, respectively) whereas no significant correlation was observed concerning CerbB2. No statistically significant correlation was determined between COX-2 levels and the disease-free (DFS) and OS rates. CONCLUSION: Further studies investigating the role of COX- 2 levels in breast cancer progression are needed.

The role of VEGF and other parameters in tracking the clinical course in metronomic chemotherapy.

PURPOSE: The purpose of this study was to investigate the effect of metronomic chemotherapy on serum vascular endothelial growth factor (VEGF) levels in cancer patients. METHODS: The study included 11 metastatic cancer patients who received daily 50 mg cyclophosphamide and biweekly 5 mg methotrexate per os as metronomic chemotherapy. Bevacizumab together with FOLFIRI chemotherapy was administered as anti-angiogenic treatment in another group of 16 metastatic colorectal carcinoma patients. Furthermore, VEGF levels of 10 healthy individuals and 5 cord blood samples served for comparisons. VEGF levels of patients before therapy and 3 months after treatment were analyzed and compared. RESULTS: Serum VEGF levels prior to metronomic chemotherapy were higher compared with the healthy controls (p=0.0001). Similarly, serum VEGF levels prior to the bevacizumab-based chemoimmunotherapy were significantly higher compared with the healthy controls (p=0.005). In patients on metronomic chemotherapy VEGF levels showed non significant decrease (p=0.075). On the contary, VEGF levels decreased significantly (p=0.002) with bevacizumab treatment. CONCLUSION: Serum VEGF levels may be used for assessing of the efficacy of anti-angiogenic therapies.

Primary thyroid lymphoma: case series with literature review.

Non Hodgkin's lymphomas (NHL) of the thyroid are rare thyroid neoplasms. The majority of histopathologic types are extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) type and, diffuse large B-cell lymphoma (DLBCL). Most of them arise in a background of Hashimoto's thyroiditis and patients mostly present with a rapidly enlarging thyroid mass and with pressure symptoms. Treatment depends on the histological subtype and stage of the disease and includes radiotherapy and chemotherapy. The prognosis usually is favorable with proper treatment. Herein, we discuss the clinical diagnosis and treatment of thyroid lymphoma.

A patient with diffuse large B-cell non-Hodgkin's lymphoma and AA type amyloidosis.

AA-type amyloidosis is a consequence of a long-standing systemic inflammation and is not associated with a monoclonal protein or clonal bone marrow plasma cells. Proinflammatory cytokines such as interleukin (IL)1, IL-6, and tumor necrosis factor (TNF) stimulate the synthesis of serum amyloid A during inflammation. Although the association of non-Hodgkin's lymphoma (NHL) with AL-type amyloidosis is well known and patients with Hodgkin's lymphoma with AA amyloidosis have been described, AA-type amyloidosis with NHL is extremely infrequent. We report a case of amyloidosis associated with NHL that subsided during R-CHOP chemotherapy.

Bax, bcl-2 and c-kit expression in non-small-cell lung cancer and their effects on prognosis.

In non-small-cell lung cancer (NSCLC), stage of the disease is still the most important prognostic factor. Other than stage, many biological markers and many other prognostic factors are studied to define their effects on prognosis of lung cancer. In this study, we aimed to evaluate the expressions of Bax and bcl-2 genes which are important in apoptosis and c-kit, which is a tyrosine kinase transmembrane receptor, as well as searched their response to treatment modalities and effects on survival. Sixty-nine NSCLC cases' pathological samples were stained with specific Bax, bcl-2 and c-kit dyes by immunohistochemical (IHC) methods. IHC evaluation was done by the semichantitative method according to the distribution and intensity of the staining. Twelve of 69 cases (17.4%) were stage I, 28 (40.5%) were stage II, 17 were (24.6%) stage IIIA, nine cases were (13.1%) stage IIIB and three cases (4.4%) were stage IV patients. Their histological subtypes were as follows: of 69 cases, 36 (52.2%) were squamous cell carcinoma, 28 (40.6%) were adenocarcinoma, five (7.2%) were adenosquamous cell carcinoma (two patients) and large-cell carcinoma (three patients). The positive immunostaining rates for Bax and bcl-2 in whole group, squamous cell carcinoma and adenocarcinoma groups were 40.6%/36.2%, 55.6/69.4% and 25.0/0.0%, respectively. The positive immune staining rates for c-kit in whole group, squamous cell carcinoma and adenocarcinoma groups were 7.2, 5.6 and 7.1%, respectively. We didn't find any correlation with Bax, bcl-2 and c-kit expressions and clinicopathological parameters such as age, tumour size, lymph node involvement, smoking, stage of the disease, response to radiotherapy and chemotherapy. Results are interpreted according to survival; bax and bcl-2 expressions were not so effective both in whole group and histologically subgrouped patients. C-kit expression was also found not related with survival in whole group whereas found as a bad prognostic factor in patients with squamous cell carcinoma. These findings could indicate that the expression of apoptotic pathway markers and c-kit may have a role in the prognosis of early stage NSCLC, especially with squamous cell carcinoma subtype.

Technetium-99m hexamethylpropylene amine oxime lung scintigraphy findings in low-dose amiodarone therapy.

Amiodarone (AD)-induced pulmonary toxicity is one of the major complications of long-term AD therapy. Technetium-99m-labeled D: ,L: -hexamethylpropylene amine oxime (Tc-99m HMPAO) scintigraphy has been used to assess lung injury. We designed this study to clarify lung uptake changes of Tc-99m HMPAO using low doses of AD (5 mg/kg/day) during long-term therapy in a rabbit model. Group 1 consisted of 7 rabbits fed with AD by gavage for 6 months. To investigate the effect of ketamine on Tc-99m HMPAO uptake, 5 rabbits were included in Group 2 as a control group. Tc-99m HMPAO scintigraphy was performed in both Group 1 and Group 2 at baseline and after 2, 4, 6, 8, and 12 weeks of AD intake. After 16, 20, and 24 weeks of drug intake, Tc-99m HMPAO scintigraphy was repeated only in group 1. One-min anterior images were acquired 30 min after the injection of 37 MBq of Tc-99m HMPAO. For semiquantitative evaluation, the mean count values were obtained and lung/background and liver/background ratios were calculated. Histopathologic evaluation was performed. No increase in lung and liver uptake of Tc-99m HMPAO was found 2, 4, 6, 8, and 12 weeks after drug intake. There was no significant increase in L/B and H/B ratios of Tc-99m HMPAO in Group 1 compared with Group 2. Both scintigraphic studies and histopathologic examinations showed nonspecific changes. Longitudinal studies investigating Tc-99m HMPAO lung uptake may be planned in patients carrying risk factors for AD-induced lung toxicity.

Prognostic factors in limited-stage small cell lung cancer of patients treated with combined modality approach.

PURPOSE: To evaluate the combined modality treatment results of patients with limited-stage small cell lung cancer (SCLC), who were treated and followed by the DELCSG. PATIENTS AND METHODS: Sixty-three patients with limited-stage SCLC diagnosed between April 1991 and December 2002 were included. All patients were treated with combined chemotherapy and thoracic radiotherapy. Median age was 59 years (range 36-84), and all patients were male except 4. Surgery was performed for diagnosis in 3 patients. Four cycles of chemotherapy (median) were administered, composed of cisplatin-etoposide (CE) (26 patients), cyclophosphamide-vincristine-adriamycin (CAV) (10 patients) or alternated CE and CAV (18 patients). Nine patients received various chemotherapy regimes other than CE and/or CAV. A total dose of 5000 cGy with 180-200 cGy daily fractions was given to the primary tumor and mediastinum, excluding the spinal cord after 4500 cGy. Prophylactic cranial irradiation (PCI) was performed in 13 (20%) patients. Overall survival (OS) and progression-free survival (PFS) were calculated, beginning from the date of diagnosis and the end of radiotherapy, respectively. Kaplan-Meier method was used for obtaining survival rates. Log-rank test and Cox proportional hazards model were used for univariate and multivariate analyses, respectively. RESULTS: Median follow-up time was 17 months (range 3-131). Median PFS and OS were 12 (range 1-131) and 17 (range 3-131) months, respectively. Two-years PFS and OS rates were 27 % and 38 %, respectively. During follow-up, 27 (43%) patients developed brain metastasis; among them only 3 had received PCI. Univariate analysis showed that addition of PCI significantly improved PFS (p=0.025) and advanced age was a favorable prognostic factor for OS (p=0.039). In the multivariate analysis, advanced age (p=0.034) and addition of PCI (p=0.004) were independent factors increasing PFS, however no significant prognostic factor influencing OS was found. CONCLUSION: Our treatment results are in accordance with the relevant literature. It is also concluded that PCI should be given to all patients with complete response to chemotherapy. However, analysis of prognostic factors should be cautiously evaluated because of small number and heterogeneous distribution of patients in subgroups. Prospective studies are necessary for better determination of prognostic factors.

Aortic ruptured following lung resection in invasive aspergillosis.

Invasive pulmonary aspergillosis, although rare in the general population, can prove to be an important cause of morbidity and mortality in immunosuppressed patients. In this paper we represent a case of aortic rupture for a fungal invasion of the aorta after a pulmonary resection procedure. Although a few cases are documented in the literature, we report our experience to make our colleagues aware of this complication.

Reconstruction of the upper extremity with a compound rib-latissimus dorsi osteomusculocutaneous flap.

The reliability and versatility of the pedicled latissimus dorsi muscle or osteomusculocutaneous flap make it our first choice in the management of upper arm injuries and we have treated three such patients in this way. They had severe skeletonising, crushing injuries of an upper extremity with humeral defects that were treated with latissimus dorsi musculocutaneous flaps and segments taken from the ribs. All the flaps survived completely with no injury of the pleura at the donor site. The reconstructed humerus was strong enough for the patients to participate in all activities of daily living. We think that this technique is suitable for the upper arm defects with humeral loss because of its simplicity and minimal morbidity.

The role of autologous blood injection on postoperative air leak at lung resections.

BACKGROUND: The effects of autologous blood injection beneath the stapling lines on postoperative air leak after lung resections, especially in emphysematous lungs, were prospectively investigated. METHODS: The study was carried out on 16 randomized patients. The mean age of the study group was 58 and the mean forced expiratory volume at one second (FEV1) at the spirometry was 2.05 L. In the control group, the mean age was 60 and the mean FEV1 was 1.97 L. All 16 cases were males and had a history of smoking. In the study group, 10-20 ml of autologous venous blood was drawn by the anesthesist and transferred to the operation team. The blood was gently injected underneath the staple line and ultimately 1 cm thickened layer of the lung was obtained. In the control group only staplers were applied. RESULTS: There was no air leak at the end of the operation at the study group, whereas additional sutures which were pledgetted with Gore-tex patches were needed at four cases at the control group. There were minimal air leaks at three cases at the control group at the postoperative period, while there was no postoperative air leak problem at the study group. Thorax tubes were removed at the 3rd and the 3.9th days at the study and the control groups, respectively. CONCLUSIONS: We believe this simple and cheap method could be used at least in some instances where additional staple reinforcement would be necessary. It may also be remembered when air leaks are encountered at suture holes after suturing the lung.

[Evaluation of 572 cases of blunt and penetrating thoracic trauma]. / Künt ve penetre toraks travmali 572 olgunun degerlendirilmesi.

We retrospectively evaluated 572 patients with thoracic trauma from total of 2163 trauma patients who admitted to 2nd General Surgery Emergency Service of Kartal Education and Research Hospital from January 1997 to February 2000. 501 of the patients (87.5%) were male and 71 (12.5%) were female. The range of ages 2-84 and mean age was 32.2. 337 (59%) patients had blunt and 235 (41%) had penetrating thoracic trauma. While traffic accidents (72%) were determined as the most common ethiological factor for blunt thoracic trauma, penetrating and cutting instruments injuries (82%) were the most common factor for penetrating thoracic trauma. Accompanying trauma were observed in 37.5% of cases. 332 (58%) tube thoracostomy, 185 (32.5%) conservative treatment, 41 (7.1%) thoracotomy 14 (2.4%) mechanical ventilation were carried out. The rates of mortality were 6.8% and of morbidity 3.3%. Early diagnosis and immediate appropriate treatment in thoracic trauma increases the survival.

A case with some clinical findings overlapping to Rubinstein-Taybi, Rubinstein-Taybi-like syndrome or multiple pterygium syndrome: coincidental findings or a new entity?

We report a case with broad, deviated thumb and big, duplicated, deviated toes resembling Rubinstein-Taybi syndrome. But the patient did not have severe mental retardation as in Rubinstein-Taybi syndrome and had no microdeletions on chromosome 16 by FISH-based assay. This patient had mild webbing as seen in multiple pterygium syndrome, but broad-deviated thumb has not been reported in this syndrome. We discuss whether these are coincidental or overlapping findings or whether this is a possible new clinical entity.

Use of technetium-99m HMPAO scintigraphy for the detection of amiodarone lung toxicity in a rabbit model.

Amiodarone (AD) is a very effective anti-arrhythmic drug, but its use is often associated with serious pulmonary complications such as pneumonitis and interstitial pulmonary disease. The aim of this study was to investigate the relationship between the amount of amiodarone intake (and the related development of lung toxicity) and the lung uptake of technetium-99m labelled D,L-hexamethylpropylene amine oxime (HMPAO). Eighteen white female New Zealand rabbits were divided into three groups and fed AD by gavage at doses of 10 (group A), 50 (group B) or 150 (group C) mg/kg daily. 99mTc-HMPAO scintigraphy was performed at baseline and after 1, 2, 3 and 4 weeks of drug intake. Anterior images of 1 min duration were acquired at 30 min after the injection of 37 MBq 99mTc-HMPAO. Regions of interest (ROIs) were drawn on the lungs (L) and the upper limb (B) as the background. L/B ratios were calculated using the mean counts. In groups A and B histopathological evaluation of the lungs of all rabbits was performed at the end of the 4 weeks of AD intake, while in group C it was performed at 2 weeks because of increased mortality. At baseline, mean L/B ratios for groups A, B and C were 2.8 +/- 0.3, 2.8 +/- 0.3 and 2.8 +/- 0.4, respectively. After 3 weeks of AD intake, L/B ratios increased to 4.1 +/- 0.6 and 4.8 +/- 0.6 in groups A and B, respectively. The L/B ratio was 3.6 +/- 0.2 after 1 week of AD intake in group C. The correlation coefficients between the lung uptake of 99mTc-HMPAO and AD doses for groups A, B and C were r = 0.51 (P = 0.037), r = 0.74 (P = 0.0002) and r = 0.96 (P = 0.0001), respectively. Histopathological findings related to AD lung toxicity, such as interstitial pneumonitis and foamy alveolar macrophages, were observed more frequently in groups B and C than in group A. According to our findings, 99mTc-HMPAO lung uptake is correlated with AD dose. 99mTc-HMPAO lung imaging can demonstrate AD-induced lung injury.

A rare tumor of craniofacial bones in children: a pediatric chondroblastic osteosarcoma case with diagnostic and therapeutic problems.

Osteosarcoma of the cranial facial region is uncommon and only rarely involves the ethmoid or sphenoid bones. The authors report on an unusual case of a 17-year-old male presenting with chondroblastic osteosarcoma of the maxillary, ethmoid, and sphenoid sinuses who remains well and disease-free at 46 months. He was treated with anterior craniofacial resection followed by postoperative radiotherapy to the sight of the primary tumor. He did not receive chemotherapy because of emerging hepatitis-B infection and vasculitis. The literature on extragnathic craniofacial osteosarcomas is reviewed with particular emphasis on treatment options of this rare tumor.