Symptomatic giant thymolipoma in a child.

Thymolipomas are slow-growing benign tumors arising from the thymus. They are rare in children, are usually asymptomatic, and can attain enormous size at diagnosis. Contrast-enhanced computerized tomography (CECT) scan characterizes the thymolipomas as a fat-attenuating lesions in the anterior mediastinum. Surgical excision provides relief from symptoms and is the definitive management. We report a case of a symptomatic giant thymolipoma in a 5-year child to highlight issues in diagnosis and management.

Unilobar re-expansion pulmonary oedema following removal of a large intra-thoracic mass.

Re-expansion pulmonary oedema (RPE) is not so rare complication associated with sudden expansion of a collapsed lung. RPE has been most frequently reported following rapid drainage of a large pneumothorax or chronic pleural effusion. Development of RPE following removal of a large intrathoracic mass is not commonly recognised, though sporadic reports exist in the literature. RPE can be fatal, but early diagnosis with appropriate management usually leads to satisfactory outcomes. We report a case of RPE, which occurred following removal of a giant intra-thoracic mass and its subsequent management and outcome with a brief review of relevant literature.

Primary endobronchial myxoid leiomyoma in a child: An unusual case report and review of literature.

Primary leiomyomas are rare benign tumors of the lung and only 25 cases have been documented in children, most of which are endobronchial. Leiomyomas are benign smooth muscle neoplasms, usually diagnosed on morphological characteristics. However, immunohistochemistry plays a crucial role in the lineage differentiation when these are encountered at unusual sites or with unexpected morphological features. We report a case of endobronchial tumor of a 13-year-old male child who presented with a dry cough and hemoptysis. A mass lesion in the right main bronchus was detected by bronchoscopy and contrast-enhanced computed tomography. On histopathological examination of the resected specimen, a diagnosis of myxoid leiomyoma was made. To the best of our knowledge, this is the first case of myxoid leiomyoma to be reported in the respiratory tract. This case also demonstrates the need for a high index of suspicion and the role of immunomarkers in the diagnosis of such challenging cases.

Management of a patient with unstable angina, left main coronary artery disease, and respiratory insufficiency due to eventration of the diaphragm.

The incidence of eventration of diaphragm before cardiac surgery is rare. We describe the management of a patient with eventration of the diaphragm who underwent a coronary artery bypass grafting (CABG) for left main coronary artery disease followed by left diaphragm plication with video-assisted thoracic surgery (VATS) for the postoperative respiratory insufficiency.

End-of-life decisions in an Indian intensive care unit.

BACKGROUND: There is a paucity of data on end-of-life decisions (EOLD) for patients in Indian intensive care units (ICUs). OBJECTIVE: To document the end-of-life and full-support (FS) decisions among patients dying in an ICU, to compare the respective patient characteristics and to describe the process of decision-making. DESIGN: Retrospective, observational. PATIENTS: Consecutive patients admitted to a 12-bed closed medical-surgical ICU. EXCLUSIONS: Patients with EOLD discharged home or transferred to another hospital. MEASUREMENTS AND RESULTS: Demographic profile, APACHE IV at 24 h, ICU outcome, type of limitation, disease category, pre-admission functional status, reasons for EOLD, interventions and therapies within 3 days of death, time to EOLD, time to death after EOLD and ICU length of stay. Out of 88 deaths among 830 admissions, 49% were preceded by EOLD. Of these 58% had withholding of treatment, 35% had do-not-resuscitate orders (DNR) and 7% had a withdrawal decision. Mean age and APACHE IV scores were similar between EOLD and FS groups. Functional dependence before hospitalization favored EOLD. Patients receiving EOLD as opposed to FS had longer stays. Fifty-three percent of limitations were decided during the first week of ICU stay well before the time of death. Escalation of therapy within 3 days of death was less frequent in the EOLD group. CONCLUSIONS: Despite societal and legal barriers, half the patients dying in the ICU received a decision to limit therapy mostly as withholding or DNR orders. These decisions evolved early in the course of stay and resulted in significant reduction of therapeutic burdens.

Molecular profiling of genes in squamous cell lung carcinoma in Asian Indians.

Early metastasis and a poor five-year survival make lung cancer the leading cause of cancer related deaths worldwide. The clinical profile of lung cancer patients in India differs from the West as they present earlier, with squamous cell carcinoma being the commonest histological type. We compared gene expression profiles in primary lung squamous cell carcinoma (LSCC) and matched normal lung tissues in Asian Indians. Using suppression subtractive hybridization, two subtracted cDNA libraries containing differentially expressed genes in the tumors were constructed. Differential expression was confirmed by reverse Northern blot analysis. DNA of confirmed clones was sequenced and subjected to GenBank Blast searches. RNA expression levels were then analyzed by Northern blotting and validated by semiquantitative RT-PCR (in 10 cases of NSCLC). Seventeen differentially expressed gene cDNA fragments of LSCC were analyzed. The differentially expressed genes included those associated with cellular metabolism, cell-cycle, -structure, -adhesion, transcription, proliferation, apoptosis and signal transduction. The study provided first evidence that KIAA0767, a Death Inducing Protein, a novel p53 independent target of E2F1, and Geminin, an inhibitor of DNA replication are differentially expressed in LSCC. Identification of the differentially expressed genes in lung cancer in this study may serve as better molecular markers for early diagnosis and identifying novel intervention sites for anticancer therapy.

A randomized comparison of the early outcome of stapled and unstapled techniques of laparoscopic total extraperitoneal inguinal hernia repair.

OBJECTIVE: The need for stapling is a relative drawback of laparoscopic hernia repairs because it adds to the complications and costs. The safety of unstapled repairs as a viable alternative lacks validation, due to the dearth of analogous comparative trials. METHODS: Patients were randomized to undergo either stapled or unstapled total extraperitoneal hernia repairs. The groups were matched for age and the type of hernia repaired. Pain scores, intraoperative complications, postoperative complications, postoperative recovery, and long-term outcomes (ie, groin pain, paraesthesias, testicular atrophy, and recurrence) were studied. RESULTS: The incidence of complications, pain scores, pain trends, hospital stay, return to activity, and long-term outcomes were comparable. No recurrence has been noted at a median follow-up of 23 months in 63 hernias repaired in 49 patients. CONCLUSION: Unstapled laparoscopic hernia repair scores are equivalent to their stapled counterparts with respect to recurrence and complications.

Chemotherapy alone vs. chemotherapy plus high dose multiple antioxidants in patients with advanced non small cell lung cancer.

OBJECTIVE: In vitro and animal studies suggest that antitumor effect of chemotherapeutic agents may be enhanced by antioxidants. Therefore, we initiated a clinical study to test the efficacy of high-dose multiple antioxidants (vitamins C, E and beta carotene) as an adjunct to chemotherapy (paclitaxel and carboplatin) in non-small-cell lung cancer. METHODS: 136 patients of stage IIIb and stage IV NSCLC were randomized to receive chemotherapy (paclitaxel and carboplatin) alone (chemotherapy arm, n = 72) or chemotherapy in combination with ascorbic acid 6100 mg/day, dl-alpha-tocopherol (vitamin E) 1050 mg/day and beta-carotene 60 mg/day (combination arm, n = 64). Survival were calculated by the Kaplan-Meier method and compared using the log-rank test. RESULTS: An overall response rate (RR) of 33% was observed in chemotherapy arm with 24 patients showing a partial response (PR) and none showing a complete response (CR). In combination arm the overall RR was 37% with 24 patients showing PR and two showing CR. The median survival times in chemotherapy arm and combination arm were nine and 11 months respectively. The overall survival (OS) rates in chemotherapy arm and combination arm at one year were 32.9% and 39.1%, and at two years, 11.1% and 15.6% respectively. None of these differences were statistically significant (p = 0.20). Toxicity profiles were similar in both arms. CONCLUSIONS: These results do not support the concern that antioxidants might protect cancer cells from the free radical damage induced by chemotherapy. Larger trials are needed to demonstrate whether high-dose multiple antioxidants in conjunction with chemotherapy increase the response rates and/or survival time in advanced lung cancer.

The increase in body mass index observed after lung volume reduction may act as surrogate marker of improved health status.

OBJECTIVE: To assess the effects of lung volume reduction surgery (LVRS) on body mass index (BMI). METHODS: Prospective data was collected on a series of 63 patients undergoing LVRS (bilateral in 22 patients, unilateral in 41 patients). Median age was 58 (41-70) years. The peri-operative effects of LVRS on BMI, lung function and health status (assessed by SF 36 questionnaire) were recorded at 3, 6, 12 and 24 months. RESULTS: We found an overall increase in BMI after LVRS, which was significant up to 2 years. These changes correlated with the changes in FEV1 (R = 0.3, P < 0.01 6 months after LVRS) and diffusing capacity for carbon monoxide (DLCO) (R = 0.5, P < 0.01 6 months after LVRS). At 6 months, when the best results in health status were found, the patients were divided in a responders group (improved SF 36 score) and a non-responders group (same or worse SF 36 score) for each of the 8 domains of the SF 36. In 6 domains the non-responders showed no increase in BMI. In 6 domains the responders showed a significant increase in BMI. CONCLUSION: LVRS significantly improves postoperative BMI, which correlates with improvements in DLCO and reflects changes in health status.

Characterization of apoptosis-related molecular changes in a desmoid tumor of the chest wall: report of a case.

Desmoid tumors are uncommon benign tumors composed of fibrous tissue, which originate from aponeuroses. Little is known about their molecular pathogenesis and the reason that they recur. We report the case of a 20-year-old man with a recurrent desmoid tumor of the chest wall, focusing on our analysis of the apoptosis and its related molecular events. Immunohistochemical examination showed higher expression of antiapoptotic Bcl-2, Bcl-XL, survivin, and the transcription factor, NF-kappaB, in the recurrent tumor than in the adjoining normal tissue. Proapoptotic Bax was not detected in the tumor. Similar findings were obtained in the original primary tumor. Both tumors had a low apoptotic index according to the terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling assay. These changes occurred in the absence of cell proliferation, shown by the absence of both Ki-67 staining and increased telomerase activity. This derangement of apoptosis gives the aggressive desmoid tumor cells a proliferative advantage, and presumably, forms the basis of its high recurrence rate. Therefore, inhibitors of apoptosis proteins (IAPs) may be useful for predicting recurrence. The regulation of apoptosis by antisense therapy against these inhibitors could prove beneficial for overcoming repeated recurrence, even after surgery.