Diffuse Tenosynovial Giant Cell Tumor Encircling the First Metatarsal Bone Remodeling after Resection. A Case Report.

Introduction: The term tenosynovial giant cell tumor encompasses a group of rare soft-tissue tumors. A new classification divides the group in localized and diffuse type, depending on the involvement of the surrounding tissues. Due to the unclear origin and heterogeneity in extend of the diffuse-type giant cell tumors, there is only limited evidence on the tumor-specific treatment. Thus, every case report has an added value toward setting disease-specific guidelines. Case Report: Presentation of a diffuse type tenosynovial giant cell tumor encircling the first metatarsal. The tumor had mechanically eroded the plantar aspect of the distal metaphysis, with no signs of tumor spread. After an open biopsy, resection of the mass was performed without debriding or resecting the first metatarsal. Repeat imaging postoperatively showed no recurrence at 4-year follow-up and a bony remodeling of the lesion. Conclusion: Bone remodeling is possible after complete resection of diffuse tenosynovial giant cell tumor when the erosion is caused by mechanical pressure and no intraosseous expansion of the tumor is present.

Pancoast tumors: characteristics and preoperative assessment.

Superior sulcus tumors (SSTs), or as otherwise known Pancoast tumors, make up a clinically unique and challenging subset of non-small cell carcinoma of the lung (NSCLC). Although the outcome of patients with this disease has traditionally been poor, recent developments have contributed to a significant improvement in prognosis of SST patients. The combination of severe and unrelenting shoulder and arm pain along the distribution of the eighth cervical and first and second thoracic nerve trunks, Horner's syndrome (ptosis, miosis, and anhidrosis) and atrophy of the intrinsic hand muscles comprises a clinical entity named as "Pancoast-Tobias syndrome". Apart NSCLC, other lesions may, although less frequently, result in Pancoast syndrome. In the current review we will present the main characteristics of the disease and focus on the preoperative assessment.

Influence of apnoeic oxygenation in respiratory and circulatory system under general anaesthesia.

Apnoeic oxygenation is an alternative technique of oxygenation which is recommended in the consecutive oxygen administration with varying flows (2-10 lt/min) through a catheter which is positioned over the keel of the trachea. Apnoeic oxygenation maintains for a significant period of time the oxygenation of blood in breathless conditions. This technique was first applied in 1947 by Draper, Whitehead, and Spencer and it was studied sporadically by other inventors too. However, the international literature shows few studies that have examined closely apnoeic oxygenation and its effects on Hemodynamic image and the respiratory system of the human body. Recently they have begun to arise some studies which deal with the application of this technique in several conditions such as difficult tracheal intubation, ventilation of guinea pigs in campaign conditions where the oxygen supply is limited and calculable, the application of this technique in combination with the use of extracorporeal removal of carbon dioxide (CO2). All the above indicate, the clinical use of this technique.

Epithelial-myoepithelial carcinoma of the trachea-a rare entity case report.

Epithelial-myoepithelial tumors of the lung are rare neoplasms whose biological behavior and clinical course still remain to be defined. Epithelial-myoepithelial carcinoma (EMCa) is a low-grade malignant tumour. According to literature, most commonly occurs in salivary glands, particularly in parotic gland, but it can also occur in unusual locations such as breast, lachrymal gland, nose, paranasal sinus, lung, bronchus and, as in our case, trachea. There are no many documented case reports of a primary myoepithelial carcinoma in the trachea. We report a case of a 34-year-old man diagnosed with this unusual location of an epithelial-myoepithelial tumor. The tumour was removed by segmental tracheal resection and end-to-end anastomosis.

Effect of lornoxicam in lung inflammatory response syndrome after operations for cardiac surgery with cardiopulmonary bypass.

BACKGROUND: The establishment of Extracorporeal Circulation (EC) significantly contributed to improvement of cardiac surgery, but this is accompanied by harmful side-effects. The most important of them is systemic inflammatory response syndrome. Many efforts have been undertaken to minimize this problem but unfortunately without satisfied solution to date. MATERIALS AND METHODS: Lornoxicam is a non steroid anti-inflammatory drug which temporally inhibits the cycloxygenase. In this clinical trial we study the effect of lornoxicam in lung inflammatory response after operations for cardiac surgery with cardiopulmonary bypass. In our study we conclude 14 volunteers patients with ischemic coronary disease undergoing coronary artery bypass grafting with EC. In seven of them 16 mg lornoxicam was administered iv before the anesthesia induction and before the connection in heart-lung machine. In control group (7 patients) we administered the same amount of normal saline. RESULTS: Both groups are equal regarding pro-operative and intra-operative parameters. The inflammatory markers were calculated by Elisa method. We measured the levels of cytokines (IL-6, IL-8, TNF-a), adhesion molecules (ICAM-1, e-Selectin, p-Selectin) and matrix metaloproteinase-3 (MMP-3) just after anesthesia induction, before and after cardiopulmonary bypass, just after the patients administration in ICU and after 8 and 24 hrs. In all patients we estimated the lung's inflammatory reaction with lung biopsy taken at the begging and at the end of the operation. We calculated hemodynamics parameters: Cardiac Index (CI), Systemic Vascular Resistance Index (SVRI), Pulmonary Vascular Resistance Index (PVRI), Left Ventricular Stroke Work Index (LVSWI), Right Ventricular Stroke Work Index (RVSWI), and the Pulmonary arterial pressure, and respiratory parameters too: alveolo-arterial oxygen difference D (A-a), intrapulmonary shunt (Qs/Qt) and pulmonary Compliance. IL-6 levels of lornoxicam group were statistical significant lower at 1st postoperative day compared to them of control group (113±49 and 177±20 respectively, P=0.008). ICAM-1 levels were statistical significant lower at the patient admission in ICU, compared to them of control group (177±29 and 217±22 respectively, P=0.014), and the 1st postoperative day compared to them in control group (281±134 and 489±206 respectively, P=0.045). P-selectin levels were statistical significant lower, compared to them in control group in four measurements (97±23 and 119±7 respectively, P=0.030, 77±19 and 101±20 respectively, P=0.044, 86±4 and 105±13 respectively, P=0.06, 116±13 and 158±17 respectively, P=0.000). CONCLUSIONS: Hemodynamics and respiratory parameters were improved compared to control group, but these differences was not statistical significant. Eosinofil adhesion and sequestration in intermediate tissue of lung parenchyma were significantly lower compared to control group. Also, alveolar edema was not noted in lornoxicam's group. Lornoxicam reduce the inflammatory response in patients undergone coronary artery bypass grafting with extracorporeal circulation. This calculated from levels reduction of IL-6, ICAM-1 και p-Selectin, and from lung pathologoanatomic examination (absence of alveolar edema, reduce in eosinofil adhesion and sequestration in intermediate tissues). Despite the favorable effect of lornoxicam on the hemodinamics and respiratory parameters these improvement did not seem to be statistical significant.

Pneumothorax after transthoracic needle biopsy of lung lesions under CT guidance.

Transthoracic needle biopsy (TTNB) is done with imaging guidance and most frequently by a radiologist, for the aim is to diagnose a defined mass. It is integral in the diagnosis and treatment of many thoracic diseases, and is an important alternative to more invasive surgical procedures. FNAC is a method of aspiration cytopathology, which with transthoracic biopsy ("core biopsy") is a group of percutaneous minimally invasive diagnostic procedures for exploration of lung lesions. Needle choice depends mostly upon lesion characteristics and location. A recent innovation in biopsy needles has been the introduction of automatic core biopsy needle devices that yield large specimens and improve the diagnostic accuracy of needle biopsy. Both computed tomography and ultrasound may be used as imaging guidance for TTNB, with CT being more commonly utilized. Common complications of TTNB include pneumothorax and hemoptysis. The incidence of pneumothorax in patients undergoing TTNB has been reported to be from 9-54%, according to reports published in the past ten years, with an average of around 20%. Which factors statistically correlate with the frequency of pneumothorax remain controversial, but most reports have suggested that lesion size, depth and the presence of emphysema are the main factors influencing the incidence of pneumothorax after CT-guided needle biopsy. On the contrary, gender, age, and the number of pleural passes have not been shown to correlate with the incidence of pneumothorax. The problem most responsible for complicating outpatient management, after needle biopsy was performed, is not the presence of the pneumothorax per se, but an increase in the size of the pneumothorax that requires chest tube placement and patient hospitalization. Although it is a widely accepted procedure with relatively few complications, precise planning and detailed knowledge of various aspects of the biopsy procedure is mandatory to avert complications.

Advanced bronchoscopic techniques in diagnosis and staging of lung cancer.

The role of advanced brochoscopic diagnostic techniques in detection and staging of lung cancer has steeply increased in recent years. Bronchoscopic imaging techniques became widely available and easy to use. Technical improvement led to merging in technologies making autofluorescence or narrow band imaging incorporated into one bronchoscope. New tools, such as autofluorescence imagining (AFI), narrow band imaging (NBI) or fuji intelligent chromo endoscopy (FICE), found their place in respiratory endoscopy suites. Development of endobronchial ultrasound (EBUS) improved minimally invasive mediastinal staging and diagnosis of peripheral lung lesions. Linear EBUS proven to be complementary to mediastinoscopy. This technique is now available in almost all high volume centers performing bronchoscopy. Radial EBUS with mini-probes and guiding sheaths provides accurate diagnosis of peripheral pulmonary lesions. Combining EBUS guided procedures with rapid on site cytology (ROSE) increases diagnostic yield even more. Electromagnetic navigation technology (EMN) is also widely used for diagnosis of peripheral lesions. Future development will certainly lead to new improvements in technology and creation of new sophisticated tools for research in respiratory endoscopy. Broncho-microscopy, alveoloscopy, optical coherence tomography are some of the new research techniques emerging for rapid technological development.

Adjuvant chemotherapy and radiotherapy in the treatment of non-small cell lung cancer (NSCLC).

Lung cancer is one of the most common human malignancies and remains the leading cause of cancer related deaths worldwide. Many recent technological advances led to improved diagnostics and staging of lung cancer. With development of new treatment options such as targeted therapies there might be improvement in progression free survival of patients with advanced stage non-small cell lung cancer (NSCLC). Improvement in overall survival is still reserved for selected patients and selected treatments. One of the mostly investigated therapeutic options is adjuvant treatment. There are many open issues in selection of patients and administration of appropriate adjuvant treatment.

Surgical approaches of endobronchial neoplasms.

Endobronchial tumors are a rare entity that presents with different pathological findings. The interventional pulmonologist, but also the thoracic surgeon have at their disposal the same techniques for diagnosis, however; the two modalities differentiate in the treatment approach. Diagnosis evaluation should include lymph node evaluation. Minimal invasive techniques under local or general anesthesia are usually preferred by the interventional pulmonologists, whereas in the surgical approach of the thoracic surgeons the general anesthesia is necessary. A more extensive surgical approach either lobotomy or pneumonectomy should be performed in cases with positive intrapulmonary lymph nodes. Carinal reconstruction should be performed skillfully to get a negative proximal margin whenever needed. In the current manuscript we will present the methods of patient evaluation and surgical techniques for the management of these lesions.

The management of the advanced colorectal cancer: management of the pulmonary metastases.

Pulmonary metastases from colorectal cancer present as systemic manifestation of the disease. As a general principle, the presence of metastases predispose to a poor prognosis. However, the application of some criteria of "operability" permitted the surgical resection resulting in prolonged survival (reported 5-year survival up to 50%), in better quality of life and in the cure of some patients. When the primary tumor site is controlled, and the metastatic disease is limited in lungs without extrapulmonary location (except for resectable or resected hepatic lesion) surgical removal is indicated. As significant prognostic factors in metastasectomies have been reported the synchronous or metachronous caracter of the metastases, the disease free survival, the complete removal of the metastases, the thoracic lymph node invasion, the CEA level before metastasectomy and 1 month after, the solitary vs. multiple pulmonary metastatic locations, the induction chemotherapy, the histological type and differentiation grade, as well as the vascular emboli in histopathological examination. Thorough preoperative evaluation of the patient includes oncological assessment and respiratory functional tests. Alternatively, when the patient is not a good surgical candidate, radiofrequency ablation is an option. Many surgical accesses have been validated, as posterolateral or lateral or even posterior thoracotomy, sternotomy, clamshell incision, and thoracoscopic techniques that offer the advantages of less pain, fast recovery, and less morbidity. Though thoracoscopic metastasectomies have been questioned concerning to the completeness of metastatic removal, no statistical difference in survival has been revealed in many series comparing thoracotomy to thoracoscopic techniques. As a conclusion, there are many advances in the management of pulmonary metastases from colorectal cancer during last decade, the results have been essentially optimized, the role of surgery has been established, and the multimodality approach has been recognized as the cornerstone of a successful outcome.

Update on the use of aromatase inhibitors in early-stage breast cancer.

Aromatase inhibitors are currently included in the 'optimal' management of early-stage breast cancer. Uncertainty remains, however, as to the most appropriate treatment strategy, particularly for newly diagnosed women as they seek to trade off the cost, toxicities and efficacy of the treatment options. Recent publications provide conflicting advice on the role of aromatase inhibitors in the treatment of postmenopausal patients with early-stage hormone receptor-positive breast cancer. This review provides updates on the clinical trials of aromatase inhibitors in early breast cancer and tries to provide practical clinical guidance on their optimal use.

Angiogenesis inhibitors. Drug selectivity and target specificity.

The critical role of angiogenesis in tumor development and progression has long been appreciated. The elucidation of the mechanisms of tumor angiogenesis and the emergence of anticancer drugs targeting the tumor vasculature has been a breakthrough in the treatment of several tumors in the last few years. Several novel molecules are being developed that target different aspects of angiogenesis. This review outlines the principle of anti-angiogenic therapies, illustrates the main mechanisms and complexity of growth signals involved in tumor angiogenesis, its interactions with hypoxia, stroma and tumor microenvironment. It provides a comprehensive review of clinical results obtained with anti-angiogenic agents (VEGF/VEGFR signaling inhibitors, direct angiogenesis inhibitors, vascular disrupting agents) and finally discusses the differences of the several approaches and their limitations due to the emergence of resistance.