Intraoperative diagnosis of retroaortic left innominate vein in a patient with congenital heart disease

Diagnosis of retroaortic left innominate vein is usually made by echocardiography, computed tomography, and magnetic resonance imaging, but in several cases, diagnosis is made in the theater.

Giant malignant Triton tumour of the posterior mediastinum

Outsized tumours of the mediastinum are always present a challenge for the thoracic surgeon. This is a case report of a giant malignant Triton tumour occupying almost the entire right hemithorax. The patient presented in the accident and emergency (A&E) with severe dyspnoea. He referred a history of surgically excised fibromyxomatous sarcoma of the left lower limb with 2 local recurrences. The imaging studies revealed apart the giant neoplasm, total right lung atelectasis and pleural effusion. After diagnostic evacuation of the pleural effusion and bronchoscopy, the patient operated through a right postero-lateral thoracotomy; a giant well-encapsulated tumour not invading any anatomic structures or lymph nodes originated from the posterior mediastinum was excised radically. The patient recovered well and received radiotherapy after the operation for preventing local recurrence.

Acute dyspnoea due to an unusual giant thymic cyst

Does a percutaneous needle aspiration of thymic cyst should be considered? In case when a surgical excision is contradicted, the percutaneous needle aspiration should be performed. Surgical resection can be performed with a thoracotomy or a videothoracoscopic procedure, but sometimes, a median sternotomy is unavoidable.

Expression of γ-tubulin in non-small cell lung cancer and effect on patient survival

INTRODUCTION

It has been reported that overexpression and altered compartmentalization of γ-tubulin may contribute to tumorigenesis and tumor aggressiveness in a variety of human malignancies. We have shown that γ-tubulin expression and cellular distribution pattern is also altered in non-small cell lung cancer (NSCLC) (Histol. Histopathol. 2012; 27: 1183-1194). In the present study we examined the relationship between γ-tubulin expression and patient overall survival (OS).

MATERIAL AND METHODS

Immunohistochemistry was performed, with well-characterized anti-γ-tubulin antibodies, on 109 formalin-fixed, paraffin-embedded NSCLC specimens (p-TNM stage I-III). γ-Tubulin labeling indexes (LIs) were determined, and the association of γ-tubulin expression with clinicopathological parameters was evaluated. To analyze OS rates according to γ-tubulin LIs, patients were categorized into three groups: those with low (0-30%), intermediate (31-69%) or high (70-100%) γ-tubulin LI. Association of clinicopathological parameters and γ-tubulin with survival were examined using univariate and multivariate Cox regression analysis.

RESULTS

No statistically significant association was seen between γ-tubulin overexpression and histological type, tumor differentiation, p-TNM stage and adenocarcinoma subtyping. Longer survival was observed in the high γ-tubulin LI group of patients with p-TNM stages II+III when compared to intermediate or low γ-tubulin LI groups, but the difference was not statistically significant (p=0.066). On the other hand, when combined low and intermediate γ-tubulin LI groups (p-TNM stages II+III) where compared to high γ-tubulin LI group, statistically significant longer survival was observed in high γ-tubulin group (p=0.021).

CONCLUSION

Our findings suggest that level of γ-tubulin expression may have an impact on patient survival at more advanced NSCLC stages.

Unilateral pulmonary hypoplasia in an adult patient

Pulmonary hypoplasia (PH) is a developmental anomaly of the lung parenchyma, characterized by a decrease in the number and size of airways, alveoli and vessels. We present a case of a 31-year-old patient with a history of chronic productive cough and frequent respiratory infections, who was referred for investigation of abnormal chest x-ray. The combination of chest computed tomography (CT) and bronchoscopy set the diagnosis of left pulmonary hypoplasia and the patient was treated surgically with a left pneumonectomy. PH is usually diagnosed immediately after birth, causing severe respiratory failure with high mortality. The less severe, unilateral forms can possibly survive by causing compensatory hyperinflation of the other lung and remain undiagnosed until adulthood, presenting either asymptomatic or with symptoms of chronic bronchitis and recurrent respiratory infections. Chest CT is considered the imaging technique of choice for the diagnosis and for the differential diagnosis from other congenital or acquired conditions. The treatment is usually conservative, although surgical resection is indicated in cases of severe cystic changes and intense symptomatology.

Changes in Simple Spirometric Parameters After Lobectomy for Bronchial Carcinoma

Introduction: The purpose of this study was to describe the postoperative changes in lung function after pure open lobectomy for lung carcinoma.

Methods: 30 patients (mean age 64 ± 7 years old, 16 men and 14 women) underwent a left or right lobectomy. They underwent spirometric pulmonary tests preoperatively, and at 1 and 6 months after the operation.

Results: The average preoperative forced expiratory volume in 1 second (FEV1) was 2.55±0.62lt and the mean postoperative FEV1 at 1 and 6 months was 1.97 ± 0.59 L and 2.15±0.66 L respectively. The percentage losses for FEV1 were 22.7% and 15.4% after 1 and 6 months respectively. An average percentage increase of 9.4% for FEV1 was estimated at the time of 6 months in comparison with this of 1 month after the operation. The average preoperative forced vital capacity (FVC) was 3.17 ± 0.81 L and the mean postoperative FVC at 1 and 6 months after the operation was 2.50 ± 0.63 L and 2.72 ± 0.67 L respectively. The percentage losses for FVC were 21.1% and 14.2% after 1 and 6 months respectively. An average percentage increase of 8.7% was observed at the time period of 6 months in comparison with this of 1 month after the operation.

Conclusion: Although, we observed a significant decrease in FEV1 and FVC after the operation, all patients were in excellent clinical status. FEV1 and FVC of 6 months were increased in comparison with the respective values of 1 month after the operation, but did not reach the preoperative values in any patient.

Left thoracotomy utilizing splenectomy in blunt thoracic injury: An alternative surgical approach

INTRODUCTION

Posterolateral thoracotomy could be an alternative surgical approach in selected cases coexistence of abdominal injuries with ipsilateral thoracic injury.

PRESENTATION OF CASE

A 65-year-old male with left sided chest injury was initially admitted to a regional health center after a crawler overthrow accident. He underwent chest tube drainage of left hemithorax and he was transferred immediately to our hospital. A CT scan showed a large spleen which was injured by a wedged splint of the 10th rib into its parenchyma. Lung parenchyma was also lacerated by chest tube misplacement with associated hemothorax. He underwent a lower left lateral thoracotomy. Splenectomy was performed via a phrenotomy and subsequently the injured lung was repaired. His postoperative course was uneventful.

DISCUSSION

Incisions in the diaphragm are commonly made to provide adequate exposure during a variety of thoracic and abdominal operations. Thoracic approach could potentially be advantageous for thoracic and abdominal injuries.

CONCLUSION

Thoracic approach is a safe alternative, providing excellent exposure of upper abdominal organs, and should be considered in selected cases of abdominal trauma, especially when an ipsilateral thoracic injury coexists.

Acute histological changes of the lung after experimental Fontan circulation in a swine model

Background

Histological changes of the lungs were studied after the establishment of a modified total cavopulmonary connection (TCPC) without the use of cardiopulmonary bypass (CPB) or other means of temporary bypass on a swine model.

Material/Methods

8 open chest-anesthetized pigs Landrace × Large White pigs (mean weight 43kg, mean age 4.5 months) underwent TCPC by the use of an appropriate size Y-shaped conduit connecting the superior and inferior caval veins (end-to-end anastomosis) to the pulmonary trunk (end-to-side anastomosis). After sternotomy, a wedge resection of the lung parenchyma was performed at baseline. Hemodynamic stability was sustained after TCPC establishment and 2 hours later another wedge resection of the lung was performed (from the same anatomic area). Histological studies were conducted by hematoxylin and eosin staining.

Results

All samples (n=8) at baseline were consistent with normal lung parenchyma. After the establishment of TCPC, all samples (n=8) revealed moderate mononuclear infiltration adjacent to pulmonary alveoli and bronchioles, findings compatible with bronchiolitis.

Conclusions

In a normal swine model, 2 hours after the establishment of Fontan circulation without the use of CPB, pathologic examination of the lungs revealed bronchiolitis. Further research is needed to clarify these findings and the potential implications to the Fontan circulation, either immediate or long-term.

Severe haemoptysis due to subclavian arteritis

Severe haemoptysis due to infective subclavian arteritis has, to our knowledge, never been documented. We report a case of subclavian arterial vasculitis that eroded into the left lung apex, causing a large intraparenchymal mycotic pseudoaneurysm. The patient presented with high fever and blood expectoration. An emergent left lateral thoracotomy was performed. The inflamed segment of the subclavian artery was resected and continuity was restored with a reversed saphenous vein graft. The postoperative course was uneventful and the patient was discharged on the 10th postoperative day.

Papillary fibroelastoma of the aortic valve in a β-thalassemia patient

Papillary fibroelastomas are uncommon benign tumors with frond-like growths usually arising from the heart valves. The identification of their presence is of major clinical importance owing to the fact that although rarely symptomatic they can cause coronary occlusion, stroke, and even sudden cardiac death. We present an asymptomatic 38-year-old woman with homozygous β-thalassemia in whom transthoracic echocardiography incidentally discovered an aortic mass. Two-dimensional echocardiography and magnetic resonance imaging confirmed the diagnosis of papillary fibroelastoma. Valvesparing tumor resection, even in asymptomatic patients, is recommended as the standard therapy procedure.

Cor triatriatum presenting as heart failure with reduced ejection fraction: a case report

Cor triatriatum is a rare congenital cardiac malformation and it usually refers to the left atrium. We report an unusual case of cor triatriatum in a 33 - year old woman presented with congestive heart failure caused by left ventricular systolic dysfunction.

Experimentally modified Fontan circulation in an adolescent pig model without the use of cardiopulmonary bypass

Background

The feasibility and the hemodynamic outcome of Fontan circulation, without the use of cardiopulmonary bypass, were studied on a beating heart of an adolescent pig model, using a modified total cavopulmonary connection.

Material/Methods

Eight open-chest anesthetized pigs underwent a successful total cavopulmonary connection with the use of an appropriate Y-shaped Dacron-type conduit. Through a median sternotomy, the distal part of the superior vena cava was anastomosed end-to-end to one side of the conduit. The other side of the graft was anastomosed end-to-side to the main pulmonary artery. The conduit was tailored to an appropriate length and anastomosed end-to-end to the inferior vena cava. The hemodynamic status of the animals was recorded before and after the establishment of the total cavopulmonary connection.

Results

Forty-five minutes after completion of total cavopulmonary connection, and for a total of 1 hour, hemodynamic measurements showed a decrease in mean arterial and mean pulmonary artery pressures, heart rate and cardiac output. The inferior vena caval pressure and total pulmonary vascular resistance were increased.

Conclusions

A total cavopulmonary connection, performed on a beating heart, without extracorporeal circulation or other means of temporary bypass, although it is technically demanding, is feasible.

Paroxysmal atrial fibrillation due to left atrial appendage herniation and review of the literature

The incidence of the isolated form of partial absence of the pericardium is a rare finding. The authors present a case of an isolated left sided pericardial defect with intrathoracic protrusion of the left atrial appendage found during a left upper lobectomy for lung cancer, unrecognized after serial echocardiographs and computed tomography scan of the thorax. The patient suffered from episodes of atrial fibrillation which disappeared after pericardial defect repair without antiarrhythmic medication.

The significance of one-station N2 disease in the prognosis of patients with nonsmall-cell lung cancer

BACKGROUND

A retrospective study was conducted to define the characteristics and the prognosis of N2 disease subgroups according to their patterns of spread.

METHODS

From January 1993 to December 2004, 1,329 patients underwent lung resection for bronchogenic carcinoma The records of all patients with positive mediastinal lymph nodes at the surgical specimen (pIIIA/N2) after radical resection were analyzed, and the pattern of mediastinal lymphatic spread was classified according to regional spread, to skip metastasis, and to one or two or more lymph node stations, in relation to primary tumor location. Age, sex, type of resection, right or left lesion, T status, primary tumor location, tumor size, tumor central or peripheral location, histology, and survival were recorded and analyzed. Survival was analyzed according to regional spread or not, number of mediastinal lymph node stations involved, and skip metastasis status.

RESULTS

Among 302 cases (22.7%) with positive mediastinal lymph nodes pIIIA/N2, 66 (22%) were skip metastases, 72 (24%) had a nonregional mode of spread, and 199 (66%) included two or more stations of mediastinal lymph node invasion. Cox regression analysis of all cases disclosed malignant invasion in only one mediastinal lymph node station as the only favorable factor of survival (p < 0.001, odds ratio 0.57, 95% confidence interval: 0.42 to 0.78).

CONCLUSIONS

The presence of one-station mediastinal lymph node metastasis in patients with nonsmall-cell lung cancer who underwent major lung resection with complete mediastinal lymph node dissection proved to be a good prognostic factor that should be taken into account in the future.

Prognosis of stage pIIIA non small cell lung cancer after mediastinal lymph node dissection or sampling

PURPOSE

The aim of this study was to define the impact of systematic mediastinal lymph node dissection (MLD) and mediastinal lymph node sampling (MLS) on the long-term results of patients suffering from non-small cell lung cancer (NSCLC) with N2 disease (pIIIA/N2).

PATIENTS AND METHODS

From 1999 to 2002, patients with NSCLC in stage pIIIA/N2 were retrospectively classified according to MLD or MLS procedure. Several clinical and pathological factors such as overall survival, disease-free interval, and complications were recorded and analyzed.

RESULTS

Ninety-seven (64%) patients were subjected to MLD and 54 (35%) to MLS. Comparison between the two studied groups disclosed more frequent detection of one station pN2 nodes in MLS specimens (p <0.001), while skip metastasis was more often encountered after MLD (p=0.05). Duration of the operation, amount of postoperative bleeding and incidence of prolonged air leak were not significantly different between MLD and MLS groups. Cox regression analysis of all cases disclosed squamous histology as the only favorable factor of survival. The disease-free interval was significantly longer after MLD (p <0.001).

CONCLUSION

Although radical lymphadenectomy did not offer significant prolongation of survival, the disease-free interval was significantly longer after MLD compared with MLS.

Primary myofibrosarcoma of the lung. A rare case with challenging diagnosis

Primary myofibrosarcoma (MFS), or myofibroblastic sarcoma of the lung, is a rare tumor. A 47-year-old man with a history of melanoma presented with a central tumor of the left lung. The initial diagnosis was inflammatory myofibroblastic tumor but after extensive pathologic analysis MFS of the lung was confirmed. He underwent left pneumonectomy and died on the 6th postoperative month. This is the second case of primary pulmonary MFS to be reported.

The hybrid stent-graft technique: a solution to complex aortic problems and lessons learned

OBJECTIVE

The frozen elephant trunk technique has been recently presented in the literature and has been considered as a novel surgical option for single-stage repair of complex aortic pathology such as combined arch and descending thoracic aortic aneurysms.

PATIENTS AND METHODS

The first patient, a 74-year-old male, was admitted severely symptomatic (interscapular pain), with aortic distal arch and proximal descending thoracic aortic aneurysm with a diameter of 6 cm. The second patient, a 72-year-old male, underwent descending aortic aneurysm stent grafting one year ago and was admitted gravely symptomatic (interscapular pain), with aortic arch aneurysm (diameter of 5.7 cm) and type I endoleak at the proximal end of the stent.

RESULTS

The first patient developed paraplegia after the operation and died three months after the operation due to pneumonia while he was on a rehabilitation program. The second patient's recovery was uneventful and was discharged on postoperative day nine.

CONCLUSION

This report summarizes our preliminary experience with this technique emphasizing two points: first, it offers the opportunity to manage efficiently complex aortic problems, and second, there is a potential risk of serious complications related to the limited stent sizes available of the device to match the patient's anatomical characteristics and pathology.

Surgical management of lung cancer invading the aorta or the superior vena cava

OBJECTIVE

Invasion of mediastinal structures (T4) is considered as an absolute contraindication to surgical management of non-small cell lung cancer (NSCLC). The authors studied the role of surgical treatment in case of direct aortic and superior venous caval involvement.

PATIENTS

From 1995 to 2000, 13 patients with left lung NSCLC invading descending aorta and 9 patients with right upper lobe NSCLC and superior vena cava (SVC) invasion were subjected to thoracotomy for lung resection. Surgery was indicated in case of absence of intraluminal extension. All patients were cN2 negative. The pathology results and 5-year survival were recorded and analyzed.

RESULTS

In three cases (23%) the tumor was adhered to the parietal pleura overlying descending aorta, which was resected en block with tumor-associated lung parenchyma. Aortic adventitia invasion by tumor led to local resection of adventitia (<1cm(2)) in nine patients (69%). Invasion deeper than adventitia was encountered in one case (8%), which was managed with aortic partial occlusion, resection of aortic wall and repair of the defect with Gore graft patch. In three patients (33%) the SVC wall was involved by the tumor 1-3cm in length and 2-4mm of the circumference. The defect was repaired with direct suturing. In five patients (56%) the area of SVC wall that was invaded was 3cmx2cm. The defect was repaired with Dacron patch. In 1 patient (11%) an arterial 14 graft was end-to-end interposed. All resections were radical (R0). Neither associated postoperative complications nor operative mortality was recorded. Five-year survival was 30.7% for the cases with aortic invasion and 11% for the ones with SVC involvement.

CONCLUSIONS

Radical surgical resection of lung tumors with localized aortic invasion can be considered after exclusion of N2 involvement.

Intravenous adenosine for surgical management of penetrating heart wounds

Accurate suturing of penetrating cardiac injuries is difficult. Heart motion, ongoing blood loss, arrhythmias due to heart manipulation, and the near-death condition of the patient can all affect the outcome. Rapid intravenous injection of adenosine induces temporary asystole that enables placement of sutures in a motionless surgical field. Use of this technique improves surgical conditions, and it is faster than other methods. Herein, we describe our experience with the use of intravenous adenosine to successfully treat 3 patients who had penetrating heart wounds.

Early Detection of Occult Bronchopleural Fistula After Routine Standard Pneumonectomy

OBJECTIVE

The aim of this study was to define symptoms and signs for early diagnosis of occult bronchopleural fistula (OBPF) after routine pneumonectomy.

PATIENTS AND METHOD

From 1999 to 2003, 301 pneumonectomies for malignancy were performed. The records of these patients were retrospectively analyzed for several clinicopathologic factors. All patients (group A) that presented postoperatively with one or more suspicious symptoms and signs were recorded. These cases were grouped according to bronchopleural fistula documentation (group A1) or not (group A2). Both groups were subjected to multivariate analysis.

RESULTS

In 10 cases (3.3%) bronchopleural communication was confirmed (group A1). The most frequent signs included the lack of contracture or even enlargement of postpneumonectomy space (52.7%), subcutaneous emphysema (33.3%), fever (27.7%), respiratory insufficiency (27.7%), and cough (22.2%). Multivariate analysis disclosed failure of the postpneumonectomy space to contract as an independent prodromal sign for bronchopleural communication (P=0.03, odds ratio 58.3, 95% CI: 1.45-2335.9).

CONCLUSION

Chest radiology proved to be the diagnostic modality of choice for early detection of bronchopleural fistula.

Are the perioperative changes of serum magnesium in lung surgery arrhythmiogenic?

PURPOSE

To prospectively study the perioperative changes in serum magnesium (sMg) after major lung resections and their effect to the generation of cardiac dysrhythmias, and to present a brief review of the literature surrounding this phenomenon.

PATIENTS AND METHODS

We studied 33 patients with non small cell lung cancer (NSCLC), scheduled for major pulmonary resection. Three patients were excluded from the study due to preoperative medication with beta-blocker and calcium (Ca) antagonists. Pneumonectomy was performed in 10 patients and lobectomy in 20. Heparinized arterial blood samples for the assessment of sMg, potassium (K) and Ca concentration were obtained before surgery, on arrival to the High Dependency Unit (HDU), and on the morning of the first and the second postoperative day. No patient had evidence of cardiac disease.

RESULTS

Atrial fibrillation occurred in 3 (10%) patients. There was no statistically significant association between sMg and dysrhythmias. A statistically significant difference after adjusting for age was found between sMg concentration, just after the operation and the first post-operative day and the baseline measurement (before the operation). The type of surgical procedure was not found to be associated with the sMg concentration or the appearance of dysrhythmia. The serum K and Ca concentration for all samples was within normal range.

CONCLUSION

Serum concentration of Mg decreases significantly within the first 24 hours of major lung resection. Although our study didn't demonstrate a relationship between decreases in sMg and the generation of arrhythmias, this link is well established in other fields and thus we support the prophylactic MgSO(4) administration in their prevention in such cases whilst we await further larger studies.

Diagnostic mini-video assisted thoracic surgery. Effectiveness and accuracy of new generation 2.0 mm instruments

OBJECTIVE

Recently 2.0 mm mini-VATS has aroused much interest among surgeons involved with endoscopic surgery. We report our initial experience with the first first 54 patients who underwent this procedure. The aim of this study is to evaluate the effectiveness and accuracy of mini-VATS.

METHODS

54 patients were undertaken to mini-VATS for diagnostic purposes. Patients were randomly selected and the indication for operation was set by the classic VATS criteria. 35 (65%) patients were treated under general anesthesia, while 19 (35%) patients were treated under local anesthesia.

RESULTS

The average length of hospital stay was 1.8 +/- 0.9 days. The days of requirement for narcotic analgesia were 1.9 +/- 1.0. Diagnostic accuracy was 100%; morbidity and mortality rates were 0%.

CONCLUSIONS

The high diagnostic accuracy and low operative danger, combined with less postoperative pain, due to minor surgical trauma and faster patient recovery, has established mini-VATS as a dynamic competitor to the classic VATS procedure. Since high technology is a strong partner in endoscopic surgery, a strong potentiality for evolution exists.

The use of pedicled pleural flaps for the repair of pericardial defects, resulting after intrapericardial pneumonectomy

We report our technique for the repair of large pericardial defects resulting after intrapericardial pneumonectomy for locally advanced non-small cell lung carcinoma, using pedicled pleural flaps. Creation of a pedicled pleural flap, large enough to cover the pericardial defect, performing blunt dissection of parietal pleura from the inferior edge of the thoracotomy incision and suturing it in the defect margins, is an easy, safe and effective technique for the prevention of cardiac herniation. Pedicled pleural flaps are an excellent material, not very popular nowadays, for the repair of pericardial defects resulting after intrapericardial pneumonectomy, when it is possible to create a pleural flap.

Wedge resection of the bronchus: an alternative bronchoplastic technique for preservation of lung tissue

OBJECTIVES

We present a modified wedge resection of the bronchus, as an alternative bronchoplastic technique for lung resection, in cases of patients with or without adequate pulmonary reserve to undergo a pneumonectomy, in order to preserve lung tissue.

METHODS

Seventeen patients underwent a major lung resection with wedge resection of the bronchus for non-small cell lung cancer (NSCLC) in our department, from March 1995 to October 1999. A right-sided NSCLC were diagnosed in 17 males, with a mean age 62.5+/-6.6 (range 51-72) years. Further workup was free of metastatic disease. All patients underwent a right posterolateral thoracotomy, under general anesthesia with a double lumen endotracheal tube. Twelve right upper lobectomies, four right upper and middle lobectomies and one carinal resection were performed. The wedge resection of the bronchus carried out longitudinally, along the bronchial tree, and the bronchial defect was reapproximated transversely, in a single-layer, with interrupted non-absorbable suture. The frozen section of the distal margin of the resected bronchus was negative for malignancy in all patients. Extended mediastinal lymph node dissection followed each lung resection.

RESULTS

The pathology report showed 12 squamous-cell carcinomas, three adenocarcinomas, one adenosquamous carcinoma and one neuroendocrine carcinoma. The differentiation of the carcinomas was well in two cases, moderate in ten and poor in five. The pTNM stage was IB in four patients (23.5%), IIA in one (5.9%), IIB in eight (47.1%) and IIIA in four (23.5%). The median disease-free distal margin of the bronchus was 5 mm (range 2-15 mm). The average postoperative hospital stay was 15 days (range 12-28 days). The morbidity and mortality rate was 11.8 and 5.9%, respectively. Postoperative follow-up was every 6 months. The average survival is 20.0+/-15.2 months (range 1-54 months). There are 12 patients alive, and their follow-up is negative for locoregional recurrence or distant metastasis. The survival study showed no significantly statistic relation to the histologic type, cancer differentiation, pTNM stage, and disease-free distal margin of resection larger or less than 0.5 cm (Kaplan-Meier study log rank method).

CONCLUSIONS

The wedge resection of the bronchus as a bronchoplastic procedure is an easy, fast and safe technique of reparation of the bronchial tree. It presents not only a low rate of morbidity and mortality, but also a satisfactory survival.

Prognostic significance of pleural lavage cytology after resection for non-small cell lung cancer

OBJECTIVE

In the staging of lung cancer, pleural effusion that is malignant on cytologic examination is regarded as T4 disease, and curative resection cannot be performed. We conducted this study to determine whether cancer cells can be present in the pleural cavity with no pleural effusion, to investigate the factors contributing to that occurrence, and to evaluate its prognostic significance.

METHODS

Eighty-five patients (77 males, eight females) with a median age 60.1-+/--7.9 years (31--74 years) underwent a major lung resection, due to lung cancer in our department. From January 1998 to December 1999, 30 pneumonectomies, seven bilobectomies, 46 lobectomies and two wedge-resections were performed. Chest wall resection was performed in four patients. After performing a posterolateral thoracotomy and lung resection with extended mediastinal lymph node dissection, the pleural cavity was filled with 1 l physiologic saline solution (PSS) and the fluid was shaken. The lavage fluid was suctioned off (S1). Immediately after the lavage, the pleural cavity was refilled with 3 l PSS. The surgeon washed out the pleural cavity by hand for 1 min and the fluid was suctioned off. Finally, the pleural cavity was refilled with 1 l PSS and a new lavage fluid was suctioned off (S2). A cytologic examination was carried out for each sample.

RESULTS

The pathology report showed 39 adenocarcinomas, 33 squamous-cell, two adenosquamous, four large-cell, two neuroendocrine and five undifferentiated carcinomas. S1 was positive in eight patients (9.4%), while S2 was positive in four patients (4.7%). The correlation of positive pleural lavage and infiltrated lymph nodes demonstrated a statistically significant relation between presence of N2 disease and positive S2 sample (P = 0.049). No significant correlation existed between positive lavage sample (S1 or S2) and TNM stage, level of T, extent of tumor invasion, kind of operation, histological type or differentiation of the cancer (Chi square test). The mean follow-up is 11.3 +/- 6.2 months (4--22 months). There are 78 patients alive. A significance difference in survival was identified in-patients with positive S1 (P = 0.0081), and positive S2 (P = 0.0251) (Kaplan--Meier).

CONCLUSION

The cytologic results of lavage were positive for malignant cells in eight of 85 patients (9.4%). The existence of cancer cells in the pleural cavity can be the result of their exfoliation or surgical manipulations. The mechanical irrigation subdivides the percentage of positive samples. Our study supports that the positive findings on pleural lavage cytology is an essential prognostic factor.

Acute pulmonary embolism due to multiple hydatid cysts

A case of acute pulmonary embolism due to multiple hydatid cysts is reported. Chest X-ray, echocardiography, spiral CT scan and MR-angiography were performed for the diagnostic evaluation. The patient underwent a left anterior thoracotomy and a left pulmonary arteriotomy in order to remove the hydatid cysts, without using extracorporeal circulation. The post-operative recovery was uneventful and the patient, 42 months later, has a normal life.

Congenital bronchoesophageal fistula in the adult

Congenital bronchoesophageal fistulas, when not associated with esophageal atresia, are compatible with life and may persist until adulthood before diagnosis has been established. We report such a rare case of a 55-year-old Caucasian female with a history of repeated pulmonary infections, suffering from cough during the last 12 months due to a mass in the right lung. A bronchoesophageal fistula (type III according to Braimbridge and Keith classification) was incidentally discovered during thoracotomy which was resected and end-sutured. Following that, a right lower lobectomy was performed. The patient had an uneventful recovery. The final diagnosis of congenital bronchoesophageal fistula was established excluding all the reasons that lead to the acquired disease. The diagnostic and therapeutic procedures are analyzed and the relevant literature is reviewed.