Single versus multiple video-assisted thoracocopic lung biopsy for suspected interstitial lung disease: a perspective on diagnostic efficacy and length of hospital stay.

Background: Nearly one-third of the patients with interstitial lung disease (ILD) require surgical biopsy for a definite diagnosis. Video-assisted thoracoscopic surgical (VATS) biopsy has replaced open lung biopsy, but the number of biopsy required to achieve an accurate diagnose is controversial. Objectives: Our study aims to show that a well-planned single VATS biopsy is as effective as multiple biopsies for the accurate diagnosis of ILD by reduced days of hospital stay. Methods: We included 111 patients with suspected ILD who underwent VATS biopsy in our study. Patients were separated into three groups according to the number of biopsies obtained. The differences between groups for diagnostic yield, mean time for chest tube removal, perioperative complications, and approximate volume per biopsy were analyzed statistically. Results: Eighteen single, 74 double, and 19 triple biopsies were made. Mean times of chest tube removal and hospital stay for single, double, and triple biopsy were 3.5, 4.8, and 6.1 days respectively. The number of biopsy and length of hospital stay was strongly related (p = 0.02), but there was no difference for diagnostic yield between single and multiple biopsy groups (p > 0.05). There was no intraoperative complication or perioperative mortality. In postoperative period, eight patients with multiple biopsies had prolonged air leak. Conclusion: Although classical knowledge suggests multiple biopsies from different locations of the lung are essential, recent reports have shown that the site and the number of biopsy are not as effective as previously thought in achieving the diagnosis for ILD. Our results show that a "single" biopsy, decided with multidisciplinary evaluation, is an effective and safe diagnostic tool, with lesser days of hospital stay. Main novel aspects: 1. The classical knowledge that multiple biopsies should be taken from different regions of the lung in the diagnosis of interstitial lung diseases has changed over time.2. Diagnostic concordance between multiple biopsy specimens is above 85%.3. A "single" biopsy, decided with multidisciplinary evaluation, is an effective and safe diagnostic tool with lower days of hospital stay.

The effectiveness of ARISCAT Risk Index, other scoring systems, and parameters in predicting pulmonary complications after thoracic surgery.

The Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) risk index, which is frequently used in nonthoracic surgery, may not be sufficient to predict postoperative pulmonary complications (PPCs). We aimed to evaluate the effectiveness of the ARISCAT risk index, ASA, preoperative albumin level, neutrophil/lymphocyte ratio (NLR), and other parameters in predicting PPCs after thoracic surgery. Patients undergoing elective thoracic surgery with 1-lung ventilation (OLV) were prospectively analyzed. Demographic data, ARISCAT score, ASA, Nutritional Risk Score-2002, NLR, white blood cell counts, albumin, hemoglobin levels, intraoperative complications, postoperative average visual analogue scale (VAS) score for pain at the 24th-hour, the length of stay in the postoperative intensive care unit, chest tube removal time, postoperative complications, and discharge time were recorded. Patients were assessed for morbidity and mortality on the 90th-day. 120 patients' data were analyzed. PPCs developed in 26 patients. The development of PPCs was statistically significant in patients with high ARISCAT scores (P = .002), high ARISCAT grades (P = .009), and ASA III (P = .002). The albumin level was statistically significantly lower in patients who had mortality within 3 months (P = .007). When scoring systems and laboratory parameters were evaluated together, patients with high ARISCAT grade, Albumin < 35g/L, and ASA III had significantly higher development of PPCs (P = .004). ARISCAT risk index and ASA were found to be significant in predicting PPCs after thoracic surgery. They were also valuable when evaluated in combination with preoperative albumin levels. Additionally; age, male gender, duration of surgery, and duration of OLV were also found to be associated with PPCs.

A rare case of pulmonary lymphomatoid granulomatosis complicated with venous thrombosis.

Lymphomatoid granulomatosis (LG) is Epstein-Barr virus associated and aggressive B cell lymphoproliferative disease. The most common sites of involvement are lungs, skin, kidneys, liver and central nervous system. The clinical presentation of pulmonary LG may mimic infectious diseases, malignancies or vasculitis. While treatment approach of low grade disease is watch and wait, patients with advanced stage require aggressive treatment with chemotherapy. Patients with hematological malignancy as well as solid tumors are at increased risk of venous thromboembolic events (VTE). We reported here in a case of pulmonary LG who was complicated with VTE during treatment with chemo-immunotherapy After 4 cycles of R-CHOP, she achieved complete remission for LG and was followed up without relapse for 2 years. She was anticoagulated with Low-Molecular-Weight Heparin (LMWH) during chemotherapy period, and the thrombus improved over the next several weeks. While on this paper written, patient completed her pregnancy successfully under anticoagulation prophylaxis.

Video-Assisted Thoracoscopic Treatment of Coelomic Cysts.

Background: Coelomic cysts are uncommon benign cyctic lesions of the mediastinum. Complete resection of the cyst with surgical treatment is indicated depending on whether the patient is symptomatic or whether the cyst grows during follow-up, or whether the diagnosis is uncertain. Surgical treatment prevents complications, relieves symptoms, and establishes diagnosis. Video-assisted thoracoscopic surgery (VATS) is the best method for excision of these cysts. This approach is safe and effective, has low morbidity, and shortens the length of hospital stay Objectives: We aimed to analyze our experience with coelomic cysts through VATS, reviewing clinical, radiological, and pathological features, early and long-term results of surgical management. Patients and Methods: Between January 2011 and December 2018, 20 patients with coelomic cysts who underwent VATS at our clinic were included in the study. Results: The study included 11 female and 9 male patients with a mean age of 45.6 years. Symptoms were present in 17 patients and 3 were asymptomatic. The average cyst diameter was 5.4 cm (range 2-8 cm). Fourteen of them were right sided, the others were left sided. There were no operative mortality and complications. Postoperatively there were no complications, in all cases course was uneventful, all of them were discharged after a mean of 3 days (range 2-6 days). Conclusions: Considering the low complication rate and hospital stay, excision of coelomic cysts through VATS is extremely safe and comfortable, so it should be considered the primary therapeutic procedure.

Lymphoepithelioma-like carcinoma of the lung: a rare case report and review of the literature.

Lymphoepithelioma-like carcinoma (LELC), is a rare type of cancer and typically occurs in pharyngeal and foregut-derivative organs, Including the salivary glands, thymus, stomach and liver (1). Pulmonary LELC typically affects the young and non-smoking population, and is associated with Ebstein-Barr virus (EBV) infection (1,2). We present an rare case with a pulmonary mass on CT scan of the thorax, which was subsequently proved as a LELC of the lung and a brief review of the relevant literature. The patient is a 51-year old man, presented with shorthness of breath and cough for 1 months. Chest x-ray was normal (Figure 1). Chest CT scan showed a 30-25 mm heterogeneously enhanced mass lesion with well defined margin, In the left lower lobe of the lung (Figure 2). Bronchoscopy showed no endobronchial lesion. After the PET-CT, the patient was staged as cT2aN1M0 (Stage 2B) (Figure 3). He received video-assisted thoracoscopic surgery of left lower lobe of lung and mediastinal lymph nodes dissection (Figure 4,5). His Ebv-Dna is Positive in blood tests. The pathology, immunohistochemical staining,and in situ hybridization results confirmed LELC of lung (Figure 6). Using in situ hybridization with exhibition of abundant EBV-encoded small nuclear RNA, in the majority of tumor cells is done. He received 4 cycles of induction chemotherapy with cysplatine and vinoralbine. The patient was discharged from hospital with close follow-up. No recurrence has been detected so far. Primary pulmonary LELC is a rare malignant tumor which accounts for only 0.9% of all primary lung cancer (1,2). Previous studies have demonstrated that pulmonary LELC is strongly associated with EBV infection (1,2). The majority of pulmonary LELC patients receive complete resection, as well as chemotherapy and radiotherapy based on their clinical stage (1,2). Comparing to other non-small cell cancer (NSCLC), pulmonary LELC is more sensitive to chemotherapy and radiotherapy (1,2). LELC of lung may be mistaken histopathologically for metastatic nasopharyngeal carcinoma or lymphoma. Its association with latent EBV infection have major implications for diagnosis and treatment. We present this case, because, its an unusual case with a pulmonary mass of the thorax, which was proved as a LELC of the lung.

Surgical treatment of bronchiectasis: Our 23 years of experience.

BACKGROUND: In this study, we aimed to evaluate the success of surgery and a complete resection for bronchiectasis treatment and to present our 23 years of surgical experience. METHODS: Between January 1991 and December 2013, a total of 1,357 patients (667 males, 690 females; mean age 30.5±14.3 years; range, 3 to 73 years) with the diagnosis of bronchiectasis who underwent pulmonary resection in our clinic were retrospectively analyzed. Demographic and clinical characteristics of the patients, etiologies, symptoms, localizations, surgical procedures, and long-term follow-up results were evaluated. RESULTS: There were 1,394 surgeries, as 37 (2.7%) patients had bilateral disease. The surgical procedures included lobectomy (n=702, 50.3%), pneumonectomy (n=183, 13.1%), segmental resections (n=114, 8.2%), bilobectomy (n=83, 6.0%), and lobectomy + segmentectomy (n=312, 22.4%). During the postoperative period, 1,269 (93.5%) patients were followed at a mean duration of 51.6 (range, 1 to 120) months. After surgery, 774 (61%) patients were asymptomatic, 456 (35.9%) showed an improvement, and 39 (3.1%) had no response or deterioration. CONCLUSION: The surgical treatment plays an important role in the clinical and symptomatic improvement of patients with bronchiectasis. Surgery reduces the morbidity and mortality rates with careful preoperative preparation and appropriately selected cases.

Primary pulmonary meningioma mimicking pulmonary metastasis: A rare case report.

Primary pulmonary meningiomas are rare and mostly benign tumors. They usually appear as a solid peripheral pulmonary nodule on chest radiography and computed tomography and are frequently diagnosed incidentally. Herein, we report a 55-year-old female case of primary pulmonary meningioma mimicking pulmonary metastasis.

Is the treatment for osteochondrolipomas and lipomas the same? Case report and review of the literature on osteochondrolipoma of chest wall.

Lipomas containing bony and chondroid areas are called osteochondrolipomas. Osteochondrolipomas are extremely rare and their treatment is not known exactly. In this article, we report a 41-year-old male patient who had a 45 mm long subcutaneous mass in the chest wall which was detected 15 years before. When the mass started to grow recently, the patient was admitted to our hospital. Total excision was performed to the mass of the chest wall. According to the histopathological examination of the material, the lesion was an osteochondrolipoma. It might be challenging to diagnose such rare osteochondrolipomas in the tru-cut or small biopsy specimens. Differential diagnosis may be challenging clinically, radiologically, and histopathologically. To our knowledge, this is the fifth case of a totally excised osteochondrolipoma of the chest wall which was reported in the literature.

First experiences and complications in video-assisted thoracoscopic surgery lobectomy at a thoracic surgery center.

BACKGROUND: This study aims to report the difficulties and complications we experienced in video-assisted thoracoscopic surgery lobectomies performed at our thoracic surgery center. METHODS: A total of 76 patients (54 males, 22 females; mean age 48.3 years; range 9 to 83 years) who underwent video-assisted thoracoscopic surgery lobectomy between January 2012 and June 2016 were retrospectively reviewed. Preoperative patient characteristics such as additional diseases or tuberculosis history, stage for malignant diseases, surgical characteristics such as port properties and amount of bleeding, postoperative characteristics such as amount, time and duration of drainage, air leakage, and discharge time, morbidity and mortality rates, and their causes were evaluated. RESULTS: Of the patients, 35 were evaluated due to benign pulmonary diseases and 41 due to malignant pulmonary diseases. Postoperative prolonged air leakage developed in 14 patients. Of these patients, one was administered thoracotomy and primary repair, three were administered pleurodesis, and three were administered secondary pleurocan catheter, while the air leakage ended spontaneously in seven patients. Due to bleeding, one patient was treated with revision video-assisted thoracoscopic surgery on the same day postoperatively. One patient developed chylothorax and one patient developed pneumonia, which caused respiratory failure. CONCLUSION: Video-assisted thoracoscopic surgery lobectomy is a safe thoracic procedure, which is used for both oncologic and non-oncologic diseases of the lung. Video-assisted thoracoscopic surgery may be performed by all thoracic surgeons experienced in open thoracic surgery. Thanks to the gained experiences, the rates of video-assisted thoracoscopic surgery lobectomy may improve in all centers.

Mediastinal epithelioid angiosarcoma arising in schwannoma: The first case in the literature.

Angiosarcoma arising in a long-standing schwannoma is extremely rare and only a few cases were reported in the English literature. Besides tumors arising from vagus, sciatic or adrenal nerves, tumors growing on neck, foot or kidney were also described. To the best of our knowledge, in this article, we report the first mediastinal case occurring in longstanding schwannoma in a 53-year-old female patient. The patient was admitted to our clinic with severe dyspnea and palpitation. Her medical history showed a progressive right-sided paramediastinal mass which was first diagnosed in 2002. Three transthoracic needle biopsies performed in 2002, 2015 and 2016 were all non-diagnostic. An operation was suggested since 2002, but the patient has not accepted. Thorax computed tomography and magnetic resonance imaging revealed a huge mediastinal mass nearly fulfilling the right hemithorax. A diagnosis of "malign spindle cell tumor" was established with the last transthoracic biopsy and total surgical resection via posterolateral throcatomy was performed. Microscopically, tumor was composed of two components: a benign schwannoma and an epithelioid angiosarcoma. Endothelial and neural cell differentiations were confirmed immunohistochemically.

Computed Tomography-Guided Methylene Blue Labeling Prior to Thoracoscopic Resection of Small Deeply Placed Pulmonary Nodules. Do We Really Need Palpation?

Background Video-assisted thoracic surgery (VATS) is widely used for thoracic surgery operations, and day by day it becomes routine for the excision of undetermined pulmonary nodules. However, it is sometimes hard to reach millimetric nodules through a VATS incision. Therefore, some additional techniques were developed to reach such nodules little in size and which are settled on a challenging localization. In the literature, coils, hook wires, methylene blue, lipidol, and barium staining, and also ultrasound guidance were described for this aim. Herein we discuss our experience with CT-guided methylene blue labeling of small, deeply located pulmonary nodules just before VATS excision. Method From April 2013 to October 2016, 11 patients with millimetric pulmonary nodules (average 8, 7 mm) were evaluated in our clinic. For all these patients who had strong predisposing factors for malignancy, an 18F-FDG PET-CT scan was also performed. The patients whose nodules were decided to be excised were consulted the radiology clinic. The favorable patients were taken to CT room 2 hours prior to the operation, and CT-guided methylene blue staining were performed under sterile conditions. Results Mean nodule size of 11 patients was 8.7 mm (6, 2-12). Mean distance from the visceral pleural surface was 12.7 mm (4-29.3). Four of the nodules were located on the left (2 upper lobes, 2 lower lobes), and seven of them were on the right (four lower lobes, two upper lobes, one middle lobe). The maximum standardized uptake values (SUV max) on 18F-FDG PET/CT scan ranged between 0 and 2, 79. Conclusion CT-guided methylene blue staining of millimetric deeply located pulmonary nodules is a safe and feasible technique that helps surgeon find these undetermined nodules by VATS technique without any need of digital palpation.

Surgical management of large-cell neuroendocrinelung carcinoma: an analysis of 25 cases.

BACKGROUND/AIM: Large-cell neuroendocrine carcinoma (LCNEC) of the lung is a relatively uncommon and aggressive subset of pulmonary neuroendocrine tumors, which include typical and atypical carcinoid, and small-cell lung cancer. LCNEC of the lung accounts for no more than 1% of all lung cancers. LCNECs show features of high-grade neuroendocrine tumors and patients with LCNEC have a very poor prognosis. MATERIALS AND METHODS: Twenty-five patients (22 males and 3 females; mean years 60.7; range 48 to 77 years) who underwent pulmonary resection for large-cell neuroendocrine carcinoma between January 2004 and December 2014 were investigated retrospectively. RESULTS: Type of surgery, pathologic TNM stage, adjuvant chemotherapy, time of recurrence, site of recurrence, response to treatment, and long-term results were evaluated. The longest patient follow-up period was 83 months. One-, two-, and three-year survival rates of these patients were, respectively, 80.95%, 76.47%, and 50%. CONCLUSION: Complete surgical resection is the treatment of choice for early-stage LCNEC and chemotherapy after radical surgical treatment improves survival. Follow-up periods after surgery adjuvant chemotherapy will prevent recurrence and patients may survive for many years if complete surgical resection and adjuvant chemotherapy are possible.

The role of FDG PET/CT in evaluation of mediastinal masses and neurogenic tumors of chest wall.

UNLABELLED: We evaluated the efficiency of FDG PET/CT for the differentiation of malignant from benign mediastinal masses and neurogenic tumors of chest-wall. METHODS: The 88 patients with chest wall-mediastinal masses who underwent examination before operation were retrospectively reviewed. Size, CT density (HU mean) and SUVmax of mediastinal and chest wall lesions were determined. Statistical differences of these parameters were compared between groups by Mann-Whitney U test. Receiver-operating characteristic curve (ROC) analysis with respect to SUVmax was performed to determine the best cutoff value for differentiating benign from malignant masses. RESULTS: The overall sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of PET/CT in detection of malignancy were 90%, 55.17%, 67%, 50.94% and 91.43%, respectively. The SUVmax, HU mean and size were higher in malignant cases (P < 0.05). To distinguish benign and malignant lesions, the cut off value of SUVmax was 4.67. The lesion SUVmax was significantly associated with the lesion size and lesion HU mean values (P < 0.05). The value of SUVmax and HU mean were higher in solid benign lesions than those of cystic benign lesions (P < 0.05). The lesion size was higher in cystic lesions (P = 0.000). The mean SUVmax was significantly higher in invasive thymomas than those of non-invasive forms (P = 0.029). CONCLUSION: FDG PET/CT may be complementary to conventional imaging methods for the evaluation of mediastinal and chest wall masses. PET/CT may reduce unnecessary invasive investigations for diagnosis in patients with nonavid or low avid FDG lesions. However confirmatory tissue sampling is required to confirm PET positive findings for the definite diagnosis.

Surgical management of pulmonary aspergilloma: clinical experience with 77 cases.

BACKGROUND/AIM: This retrospective study evaluated the clinical presentation, underlying lung disease, surgical indications, technique, treatment outcomes, and postoperative complications of pulmonary aspergilloma. MATERIALS AND METHODS: We evaluated 77 patients who underwent pulmonary resection of an aspergilloma at Atatürk Chest Diseases and Thoracic Surgery Research and Training Hospital between January 2000 and December 2013. The initial operations were 4 pneumonectomies, 24 lobectomies, 9 lobectomy plus myoplasties, 10 segmental resections, and 30 wedge resections. Six reoperations were carried out to deal with postoperative complications: 1 myoplasty, 2 completion lobectomies plus myoplasties, 2 myoplasties with rib resections, and 1 completion lobectomy. RESULTS: The subjects comprised 53 males (mean age: 44.26 (range: 10-73) years) and 24 females (mean age: 48.25 (range: 26-70) years). The most common indication for surgery was hemoptysis in 52 patients (67.53%). The most common underlying lung disease was tuberculosis in 37 patients (48.05%). Forty patients (51.94%) had a simple pulmonary aspergilloma and 37 (48.05%) had a complex pulmonary aspergilloma. Major complications occurred in 18 patients (23.37%). The postoperative mortality rate was 3.89%, with 3 patients dying. CONCLUSION: Surgical resection of pulmonary aspergilloma is the best way to prevent recurrent hemoptysis with low morbidity and mortality.

Video-assisted thoracic surgery for pulmonary sequestration.

Bronchopulmonary sequestration is a rare developmental abnormality. Most cases are asymptomatic and found incidentally. The definitive treatment for bronchopulmonary sequestration is surgical excision. An 18-year-old man was admitted to our clinic with longstanding cough, fever, and dense sputum. Chest computed tomography identified cystic bronchiectasis in common areas of the left lower lobe, and parenchymal destruction with air-fluid levels. A left lower lobectomy was performed via a video-thoracoscopic approach.

Diagnosis and Management of Parathyroid Cysts: Description with Two Cases.

Parathyroid cysts are unilocular, thin-walled cysts, and they are seen very rarely. Their formation mechanisms are not clear. They are usually localized in the cervical region, and mediastinal settlements are rare. They are usually asymptomatic, but cysts that have settled in the neck may be symptomatic, such as tracheal pressure symptoms. There are two types-namely, functional cysts and non-functional cysts-depending on their hormonal characteristics. There are still difficulties in the diagnosis, and they can be mistaken by thyroid pathology. Treatment is surgery. We discussed two cases of parathyroid cysts that we surgically excised.