Update on Novel Targeted Therapy for Pleural Organization and Fibrosis.

Pleural injury and subsequent loculation is characterized by acute injury, sustained inflammation and, when severe, pathologic tissue reorganization. While fibrin deposition is a normal part of the injury response, disordered fibrin turnover can promote pleural loculation and, when unresolved, fibrosis of the affected area. Within this review, we present a brief discussion of the current IPFT therapies, including scuPA, for the treatment of pathologic fibrin deposition and empyema. We also discuss endogenously expressed PAI-1 and how it may affect the efficacy of IPFT therapies. We further delineate the role of pleural mesothelial cells in the progression of pleural injury and subsequent pleural remodeling resulting from matrix deposition. We also describe how pleural mesothelial cells promote pleural fibrosis as myofibroblasts via mesomesenchymal transition. Finally, we discuss novel therapeutic targets which focus on blocking and/or reversing the myofibroblast differentiation of pleural mesothelial cells for the treatment of pleural fibrosis.

New haemostat in thoracic surgery.

INTRODUCTION: The authors present the results of a promising method to reduce peroperative bleeding in thoracic surgery within large thoracic surgical interventions. Usage of a resorbable haemostat on the basis of oxidized cellulose in the form of cotton wool may minimize the cause of bleeding, mainly in patients with post-inflammatory thoracic complications. The strong point of this material is its easy application and malleability. Another advantage is the long-term antibacterial effect caused by lowering pH during its biodegradation. AIM: Retrospective evaluation of post-operative blood losses, time of thoracic drainage, length of hospitalisation, and development of inflammatory indicators between groups using and not using haemostats. METHODOLOGY: A group consisted of 48 patients (group A), who underwent operation for post-inflammatory thoracic complications and where haemostat was used. Using the pair selection method, 48 patients were selected to the control group B, where no haemostats were applied during operation. The selection depended on a similar demographic profile, identical diagnosis, and a type of operations. Post-operational blood loss, dynamics of haematological profile, time of thoracic drainage, blood parameters value, inflammatory response of the organism, and length of hospitalisation. RESULTS: A key differentiation of dynamics in development was found between the groups in the concentration of haemoglobin and haematocrit in the post-operative period, in the time of thoracic drainage, and in total length of hospitalisation. A sudden rise of CRP serum values in the group A after 12 hours after application of haemostat was recorded, most probably as manifestation of the aseptic pleuritic (Tab. 4, Fig. 1, Ref. 16).

A Case of Bilateral Hemorrhagic Pleural Effusion Due to Dual Antiplatelet Therapy in a Dialysis Patient.

Etiologies of hemorrhagic pleural effusions (hemithoraces) are multifactorial. They can be traumatic, non-traumatic, or idiopathic in nature. In this report, we present a rare case of a 64-year-old male with end-stage renal disease (ESRD) on chronic hemodialysis and dual antiplatelet therapy (DAPT), due to a recent history of coronary arterial stent placement, who presented with progressive shortness of breath for one month. The CT of the chest revealed bilateral large pleural effusions (left > right) with a complete collapse of the left lung and partial collapse of the right lung. Ultrasound-guided left-sided thoracentesis revealed hemorrhagic pleural effusions. After the discontinuation of DAPT, drainage from the right-sided pleural effusion via a pigtail catheter showed continued drainage of pleural fluid without hemorrhage. The effusion on the left side was also noted to have resolved on the repeat chest X-ray. Prompt recognition of this rare cause of any hemorrhagic pleural effusion is essential for patients on dialysis to avoid complications. This report focuses on the possible etiology and potential complications of a hemorrhagic pleural effusion, followed by a brief discussion on the rare but significant association involving the incidence of a hemorrhagic pleural effusion in a dialysis patient receiving DAPT.

Lung Decortication With Argon Plasma Energy for the Treatment of Chronic Pleural Empyema.

Lung decortication for the treatment of chronic pleural empyema remains a technically challenging procedure that is associated with bleeding and air leak. The recent advent of pure argon plasma has provided thoracic surgeons with an electrically neutral energy source for dissection and coagulation of pulmonary tissue with minimal depth of necrosis. In this article, we describe the technique of lung decortication with argon plasma energy (PlasmaJet, Plasma Surgical, Roswell, GA, USA) for the treatment of chronic pleural empyema. With appropriate application, the PlasmaJet can facilitate the removal of fibrous cortex with satisfactory hemostasis and aerostasis. Argon plasma energy can potentially be a useful adjunct in lung decortication. Controlled trials are needed to determine its role in the surgical management of advanced pleural empyema.

The use of lobectomy for management of clinically significant pulmonary vein stenosis and occlusion refractory to percutaneous intervention.

Pulmonary vein stenosis (PVS) is a serious complication of radiofrequency ablation (RFA) for the treatment of atrial fibrillation. The prevalence of this complication was reported to be as high as 42% in 1999 when RFA was first implemented [1]. However, with improvements in operator technique including wide area circumferential ablation, antral isolation, and the use of intracardiac ultrasound, the incidence of symptomatic severe PVS following RFA ranges from 0% to 2.1% while the incidence of symptomatic pulmonary vein occlusion (PVO) following RFA was found to be 0.67% [2-8]. Despite a decrease in the incidence of clinically significant PVS following RFA, there have been increased reports of complications associated with PVS to include hemoptysis, scarring, lung infarction, and intraparenchymal hemorrhage [9]. Studies have shown that PVS is often misdiagnosed as pneumonia, pulmonary embolism, and lung cancer and as a result, patients are often subjected to unnecessary diagnostic procedures [2,10]. The current first line treatment for this condition is percutaneous balloon angioplasty with stenting; however, there are studies that have shown that there is a relatively high rate of restenosis despite optimal medical therapy [2-3,10,11]. Three case reports have described the use of lobectomy to treat patients with persistent respiratory symptoms in the setting of severe PVO with good outcomes [12-14]. We present a case of iatrogenic PVO and ipsilateral severe PVS following RFA who underwent attempted lobectomy for persistent exertional dyspnea and persistent hypoperfusion of the left upper lung lobe despite percutaneous intervention and six months of optimal medical therapy. The lobectomy was aborted due to the presence of a significant fibrothorax, and the patient continues to have significant exercise limitation despite participation in pulmonary rehabilitation.

Trapped lung secondary to cardiomegaly in a 78 year-old male with congestive heart failure.

Although the etiologies of both trapped lung and cardiomegaly are well-established, co-presentation of the two conditions, and possible interactions between them, are much rarer. Here we describe the case of 78 year-old male found to have both cardiomegaly and trapped lung, with a cause of death of congestive heart failure and subsequent cardiac arrest. This case prompted consideration of possible interactions between the two conditions. Issues related to decision-making for imaging and clinical interventions are also discussed.

Flex-rigid pleuroscopic biopsy with the SB knife Jr is a novel technique for diagnosis of malignant or benign fibrothorax.

Diagnosing pleural effusion is challenging, especially in patients with malignant or benign fibrothorax, which is difficult to sample using standard flexible forceps (SFF) via flex-rigid pleuroscopy. An adequate sample is crucial for the differential diagnosis of malignant fibrothorax (malignant pleural mesothelioma, metastatic lung carcinoma, etc.) from benign fibrothorax (benign asbestos pleural disease, tuberculous pleuritis, etc.). Novel biopsy techniques are required in flex-rigid pleuroscopy to improve the sample size and quality. The SB knife Jr, which is a scissor forceps that uses a mono-pole high frequency, was developed to allow convenient and accurate resection of larger lesions during endoscopic dissection (ESD). Herein, we report two patients with fibrothorax who underwent a pleural biopsy using an SB knife Jr to investigate the potential use of this tool in flex-rigid pleuroscopy when pleural lesions are difficult to biopsy via SFF. The biopsies were successful, with sufficient size and quality for definitive diagnosis. We also successfully performed adhesiolysis with the SB knife Jr in one case, and adequate biopsies were conducted. No complications were observed. Electrosurgical biopsy with the SB knife Jr during flex-rigid pleuroscopy allowed us to obtain adequate samples for the diagnosis of malignant versus benign fibrothorax, which is usually not possible with SFF. The SB knife Jr also demonstrated a potential use for pleuropulmonary adhesions.

Refractory Pleural Effusion in Systemic Lupus Erythematosus Treated by Pleurectomy

Pleural effusion is a common pulmonary manifestation of systemic lupus erythematosus (SLE) and often occurs as bilateral exudative pleural effusion. The condition usually responds quickly to corticosteroid therapy. However, massive pleural effusion refractory to immunosuppressive drugs has rarely been reported; thus, the proper therapeutic modality is largely decided on a case-by-case basis. In this case, we describe successful treatment with surgical pleurectomy for massive refractory pleural effusion in a patient with SLE.

Clinical Reviews of Spontaneous Hemopneumothorax / 대한흉부외과학회지

BACKGROUND: Spontaneous hemopneumothorax is a rare disease and can be life threatening; it occurs in 1~12% of patients with spontaneous pneumothorax. We analyzed clinical reviews and treatments, as well as complications of spontaneous hemopneumothorax patients that were treated to aid in the optimal management. MATERIAL AND METHOD: We studied retrospectively 30 cases with spontaneous hemopneumothorax for 11 years, from 1995 to 2006, at our hospital. RESULT: All the patients were male and most of the patients were under 30 years. The sides with the disorder were as follows: right in 15 cases and left in 15 cases. Patients showed mostly initial symptoms of chest pain, dyspnea and hypovolemic shock. All patients underwent a closed thoracostomy and 27 patients underwent surgery. Chemical pleurodesis was performed because of postoperative persistent air leakage and one case was treated in the ICU due to re-expansion pulmonary edema. There were no other complications such as fibrothorax seen during the follow-up periods. CONCLUSION: The most important finding is proper initial management, as the spontaneous hemopneumothorax can potentially lead to a life-threatening condition. Recently, video assisted thoracoscopic surgery (VATS) is common procedure for general thoracic surgery and overcomes the weak points of performing a thoracotomy. The results of VATS are encouraging.

Failure to wean caused by cryptogenic fibrosing pleuritis and bilateral lung trapping: case report

BACKGROUND AND OBJECTIVES: Cryptogenic fibrosing pleuritis is an extremely rare disease, which can affect both lungs from a very young age. The most common finding is severe lung restriction resulting in both hypoxemic and ventilatory failure. CASE REPORT: Male patient, 26 year old with acute deterioration of chronic respiratory failure. Following admission prolonged mechanical ventilation was necessary. An atypical clinical presentation made the diagnosis difficult, but eventually cryptogenic fibrosing pleuritis and lung fibrosis were established. CONCLUSIONS: The prognostic outcome of patients with the final diagnosis of cryptogenic fibrosing pleuritis is extremely poor, especially in an advanced phase of this disease. We recommend early treatment with corticosteroids or surgical pleural decortication.

JUSTIFICATIVA E OBJETIVOS: Fibrose pleural idiopática é uma doença rara e pode afetar ambos pulmões já desde uma idade precoce. O achado mais comum na fibrose pleural idiopática é uma restrição pulmonar grave que pode levar a um quadro de falência respiratória e hipoxemia. RELATO DO CASO: Paciente do sexo masculino, 26 anos, internado com reagudização de insuficiência respiratória crônica e submetido à ventilação mecânica prolongada. Após intensa investigação e uma apresentação clínica atípica, foi estabelecido o diagnóstico de fibrose pleural idiopática associado à fibrose pulmonar. CONCLUSÕES: O prognóstico de pacientes com fibrose pleural idiopática é extremamente ruim, particularmente em fase avançada da doença. Recomenda-se o tratamento precoce com corticosteróides ou decorticação pleural cirúrgica.