Sublobar resection with I-125 brachytherapy for early-stage non-small cell lung cancer (NSCLC) using prefabricated mesh

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Background: Lobectomy is standard of care for stage I NSCLC, but it reduces pulmonary reserve. Patients with pulmonary dysfunction may tolerate curative wedge resection with a permanent I-125 mesh implant. We report results using this technique with and without a novel prefabricated mesh device. Methods: Between 7/06 and 5/08, 56 patients with clinical stage I NSCLC had wedge resection and brachytherapy. All had PET-CT staging and were ineligible for lobectomy. Median age was 72 (48–87) and median FEV-1 was 1.3 liters (0.6–3.4 liters). At surgery, a significant proportion were upstaged. Pathologic staging confirmed 60.7% to be stage IA and 23.2% stage IB. Others were IIA (3.6%), IIB (5.4%), IIIA (1.8%), IIIB (1.8%), and IV (3.6%). All implants consisted of absorbable polyglactin mesh containing a median of 40 (30–50) I-125 seeds with a median seed activity of 0.536 mCi (0.47 - 0.63 mCi). Half of the patients received mesh prepared intraoperatively, while the second half received patient-specific prefabricated mesh (BrachyMESH - Oncura). Results: The median hospital stay was 5 days. All were immediately extubated. Common toxicities included air leak delaying chest tube removal, leukocytosis, paroxysmal atrial fibrillation, and increased secretions. Two required repeat chest tube placement for subsequent pneumothorax. Two patients with severe pre-op pulmonary dysfunction (pre-op FEV-1 of 0.6 and 0.68 liters) experienced respiratory failure and expired following prolonged hospital stays. With a median follow-up of 7 months (0–23 months), overall survival is 87.5% and disease free survival is 89%. The local control was 96.4% with the intraoperative mesh and 100% with the prefabricated mesh. Conclusions: Wedge resection with permanent I-125 mesh implant is a generally well-tolerated procedure leading to acceptable early local control in patients ineligible for lobectomy. This technique may not be suitable for patients with pre-op FEV-1 < 0.7 liters; but, it provides accurate surgical staging conferring a diagnostic advantage over non-invasive treatment modalities. The prefabricated device offers similar results to manually prepared devices.

No significant financial relationships to disclose.

Detection of Toxoplasma gondii parasitemia in experimentally inoculated cats

Toxoplasma gondii B1 gene polymerase chain reaction (PCR) amplification utilizing a flanking and nesting reaction was compared to mouse bioassay on feline whole blood samples collected before and after experimental inoculation with T. gondii. Samples were collected from 5 cats prior to inoculation with T. gondii and on days 3, 7, 10, 14, 21, 28, 35, 42, 49, 56, 63, 70, 84, 112, 140, 143, 147, 150, 154, 161, 168, 175, and 182 after inoculation. Cats were challenged with T. gondii orally on day 140. Bioassay was found to be less effective for detection of parasitemia than B1 gene PCR. Parasitemia was detected in all 5 cats by PCR multiple times after primary and challenge inoculation. Detection of T. gondii parasitemia by PCR utilizing the flanking reaction described here may be useful in predicting the oocyst shedding period in individual cats. As none of the cats developed signs of systemic illness, yet were chronically parasitemic, T. gondii whole-blood PCR is not helpful as a diagnostic test for clinical feline toxoplasmosis.

Polymerase chain reaction for the detection of Toxoplasma gondii within aqueous humor of experimentally-inoculated cats

The purpose of this study was to determine the temporal appearance of T. gondii in aqueous humor of cats orally inoculated with T. gondii using polymerase chain reaction (PCR) for the detection of the B1 gene. Serum and aqueous humor were collected from five SPF cats prior to oral inoculation with T. gondii and days 7, 14, 21, 28, 42, 84, 140, 147, 154, 161, 168, and 182 after inoculation. Cats were inoculated orally with T. gondii tissue cysts on day 0 and day 140. T. gondii-specific IgM and IgG were measured in serum and aqueous humor from the cats at each sample data. T. gondii B1 gene PCR was performed on all the aqueous humor samples and the amplified DNA was detected by Southern blotting. Chorioretinitis developed in three out of the five cats, but anterior uveitis was not detected. All cats developed T. gondii-specific IgG titers in serum, and had T. gondii-specific IgG C-values > 1 in both eyes at varying times during the study. T. gondii was detected by PCR and Southern blotting in aqueous humor in both eyes of all cats at times varying from days 14-84 after primary inoculation and days 14-42 after challenge inoculation.

Polymerase chain reaction for the detection of Toxoplasma gondii in aqueous humor of cats

OBJECTIVES

To develop Toxoplasma gondii B1 gene polymerase chain reaction (PCR) for use with aqueous humor of cats, and to report PCR and antibody detection results in naturally exposed cats with and without uveitis.

SAMPLE POPULATION

Serum and aqueous humor samples from client-owned, healthy cats (n = 23) and client-owned cats with uveitis (n = 43).

PROCEDURE

T gondii-specific IgM and IgG were measured in serum and aqueous humor from all cats. The Goldman-Witmer coefficient for ocular antibody production was calculated for cats positive for T gondii-specific IgM or IgG in aqueous humor. Aqueous humor from all cats was assessed by the B1 gene PCR.

RESULTS

T gondii was detected in aqueous humor by PCR from 2 of 23 (8.7%) healthy cats and 8 of 43 (18.6%) cats with uveitis. T gondii-specific IgM in either serum or aqueous humor was detected in 5 of 8 (62.5%) cats with uveitis and T gondii in aqueous humor. All cats with uveitis and T gondii in aqueous humor had anterior segment disease. In 5 of 8 (62.5%) cats with uveitis and T gondii in aqueous humor, ocular production of T gondii antibodies was not detected. T gondii was not detected in aqueous humor from 14 of 17 (82.4%) cats with ocular production of T gondii-specific antibody.

CONCLUSIONS

The presence of T gondii in aqueous humor may correlate to clinical disease in some, but not all, cats.

CLINICAL RELEVANCE

T gondii-specific aqueous humor antibody tests and PCR should be used together to aid in the diagnosis of ocular toxoplasmosis in cats.

Use of streptokinase in four dogs with thrombosis

Four dogs with thrombosis were referred for diagnostic testing and were subsequently treated by the use of streptokinase. The range of duration of clinical signs associated with thrombosis was 6 to 120 days. Causes of thrombosis were heart disease (1 dog), protein-losing nephropathy and hyperadrenocorticism (1), hyperadrenocorticism (1), and idiopathic (1). Possible factors that predisposed dogs to hypercoagulability included hypertension (2 dogs) and diabetes mellitus (1). All dogs were treated for underlying disease by use of supportive care. The first dog was treated with a loading dose of 250,000 U of streptokinase, i.v., with a subsequent maintenance dosage of 100,000 U/h, i.v., and also was treated with anticoagulant. The subsequent 3 dogs were treated with a loading dose of 90,000 U of streptokinase, i.v., and maintenance dosage of 45,000 U/ h, i.v., at various intervals. These dogs also were treated with anticoagulant. Three dogs had minor hemorrhage as an adverse effect to streptokinase infusion, but they did not require treatment for the hemorrhage. Complete resolution of the thrombus was observed in 3 dogs, and partial resolution of the thrombus was observed in the other dog. In all dogs, partial or complete resolution of clinical signs associated with thrombosis was seen. Streptokinase may be an effective treatment for dogs with thrombosis.

Detection of Toxoplasma gondii-specific IgA in the aqueous humor of cats

Toxoplasma gondii-specific IgA, IgM, and IgG were measured by ELISA in the serum and aqueous humor of 29 client-owned cats with endogenous uveitis and 7 specific-pathogen-free cats tested sequentially for 20 weeks after inoculation with T gondii. Local antibody production in aqueous humor was estimated by multiplying the aqueous humor-to-serum T gondii-specific antibody ratio by the serum-to-aqueous humor total IgG (C value) or calicivirus-specific IgG (CTC value) ratio. Evidence for local production of antibody in aqueous humor was defined as C value greater than 8 or CTC value greater than 1. Toxoplasma gondii-specific IgM CTC values, IgG CTC values, or IgA CTC values greater than 1 were detected in the aqueous humor of 18 of 29 (62.1%) client-owned cats with endogenous uveitis; 2 cats had IgA CTC values greater than 1 without detectable IgM or IgG in aqueous humor. Toxoplasma gondii-specific IgM was not detected in the aqueous humor of experimentally inoculated cats before or after inoculation. Immunoglobulin G C values greater than 8 were detected in all 7 experimentally inoculated cats and ranged from 10.4 to 145.5. Immunoglobulin G C values greater than 8 were first detected 4 to 8 weeks after T gondii inoculation and were undetectable by week 16 after inoculation. Immunoglobulin A C values greater than 8 were detected in 4 of 7 cats and ranged from 12.7 to 264.3. Immunoglobulin A C values greater than 8 were first detected 4 to 8 weeks after inoculation, and were detected in 2 cats during week 20 after inoculation. It was concluded that some cats infected with T gondii develop detectable concentrations of T gondii-specific IgA in aqueous humor.

Detection of Toxoplasma gondii-specific IgA in the serum of cats

An ELISA for detection of Toxoplasma gondii-specific IgA in feline serum was developed. A group of cats (n = 7) was inoculated orally with T gondii bradyzoites. Toxoplasma gondii-specific serum IgM, IgG, and IgA responses were followed sequentially by use of the ELISA for 34 weeks. Serum IgA was detected later than IgM or IgG, and was detected in most cats on week 34 after inoculation. None of the cats was seropositive for IgA during the oocyst-shedding period. A group of client-owned cats with suspected clinical toxoplasmosis and a group of healthy cats were tested for T gondii-specific IgA in serum. A trend toward association of T gondii-specific IgA in serum of cats with ocular disease was observed.

Naturally occurring Tyzzer's disease in a puppy

A naturally occurring case of Tyzzer's disease due to infection with Bacillus piliformis in a wolf-dog hybrid resulted in widely disseminated lesions, including severe myocarditis, hepatitis, enterocolitis, intestinal leiomyositis, and adrenal cortical adenitis. Previously reported lesions for canine Tyzzer's disease have been limited to hepatic necrosis and a necrotizing enterocolitis.

Current trends in the diagnosis and treatment of hepatic artery aneurysms

Aneurysms of the hepatic artery are rare lesions that constitute 20% of all splanchnic artery aneurysms. Their well-documented natural history includes progressive enlargement and eventual rupture. Computerized tomography, abdominal ultrasonography, or MRI may be used for initial evaluation, but angiography is required to make the definitive diagnosis and for delineation of the vascular anatomy. The lesion should be corrected surgically after the diagnosis is confirmed. Lesions proximal to the gastroduodenal artery may be ligated if there is sufficient collateral flow to the liver. For lesions distal to this artery, surgical resection and reconstruction is required. Selective embolization of intrahepatic or subhepatic aneurysms may be an effective alternative in high-risk patients. We had two cases of aneurysm of the hepatic artery diagnosed at our institution over the course of 18 months. Excellent results were obtained from surgical revascularization of the liver in both cases.

Pulmonary, mediastinal, and cardiac presentations of histoplasmosis

Sixty-one patients with histoplasmosis were identified. They ranged from 14 months to 67 years old. There were 56 male and 5 female patients. Disease presentations were categorized into pulmonary (47), mediastinal (11), pericardial (2), and cardiac (1). Twenty of the patients with pulmonary involvement had histoplasmomas treated by wedge resection (18) or lobectomy (2). Twenty-two of the 27 cavitary lesions were treated by lobectomy and 4 by segmental resection, and 1 required pneumonectomy. The patients with mediastinal granulomas or fibrosis underwent exploration for diagnosis and curative or palliative procedures. Two patients with pericardial histoplasmosis required pericardial windows to relieve acute tamponade. One patient with disseminated histoplasmosis required aortic valve replacement for histoplasmosis valvulitis with severe regurgitation. The 1 operative death was a patient requiring pneumonectomy for mediastinal histoplasmosis. Indications for operative intervention in pulmonary histoplasmosis included resection of a new or enlarging pulmonary nodule to provide a definite pathological diagnosis and resection of persistent thick-walled pulmonary cavities. Mediastinal granuloma with or without fibrosis required exploration for diagnosis, palliation, or cure. Fungal endocarditis necessitated treatment with amphotericin B and valve replacement to stabilize the patient's hemodynamic status and prevent embolization of large fungal vegetations. Pericardial effusion, a rare manifestation of histoplasmosis, was seen as acute tamponade requiring emergency intervention.

Histoplasma capsulatum endocarditis requiring aortic valve replacement for aortic insufficiency

A patient with valvular heart disease was found to have disseminated histoplasmosis and Histoplasma endocarditis. Refractory congestive heart failure secondary to severe progressive aortic insufficiency and the presence of a large valvular vegetation necessitated aortic valve replacement, which was timed to coincide with the midpoint of a course of therapy with 4 gm of amphotericin B. The patient has done well since the completion of treatment.

Acquired benign bronchoesophageal fistulas in the adult

In a twenty-year period we have seen 7 patients with acquired nonmalignant bronchoesophageal fistulas at the Vanderbilt University Affiliated Hospitals. There were 5 men and 2 women ranging from 24 to 82 years old. Six patients were seen initially with a history of pulmonary inflammatory disease with cough and fever or with an abnormal chest roentgenogram. One patient had a traumatic fistula following blunt chest trauma. Six of the patients were treated surgically with no operative mortality. Five were repaired through a right-sided thoracotomy with division of the fistulous tract and closure of the bronchus and esophagus. One patient required esophageal resection and later reconstruction for permanent fistula closure. The remaining patient was diagnosed at bronchoscopy and was not treated surgically because of supervening complications following an extensive abdominal operation. Once the diagnosis was established, operative management resulted in complete closure of the fistulas, with no mortality and no late recurrences in these patients.

Rheumatoid pericarditis. Clinical significance and operative management

The incidence of subclinical pericarditis associated with rheumatoid pericarditis may be as high as 50 percent, but significant impairment of cardiac performance owing to this type of pericarditis rarely occurs. In the past 7 years, we have encountered eight men with congestive heart failure owing to rheumatoid pericarditis. Cardiac catheterization and echocardiography were useful in establishing the diagnosis of pericardial constriction. Pericardiocentesis was unsuccessful in relieving symptoms in the three patients in whom the procedure was performed. Seven patients underwent pericardiectomy; six had constrictive pericarditis and one patient had an acute pericarditis with the sudden onset of cardiac tamponade. The other patient died of cardiac tamponade prior to operation. All patients improved after operation and have remained free of cardiac symptoms 3 months to 4 1/2 years later. The frequent occurrence of adhesive and obliterative pericarditis with loculated effusions suggests the need for pericardiectomy rather than pericardiocentesis in the patient with rheumatoid arthritis and symptomatic pericardial involvement. Immediate and lasting relief of this unusual nonarticular manifestation of rheumatoid arthritis can be expected after pericardiectomy.

Proximal gastric vagotomy compared with vagotomy and antrectomy and selective gastric vagotomy and pyloroplasty

A prospective, randomized study of proximal gastric vagotomy without drainage (PGV) was done in 174 adult men with chronic duodenal ulcer intractable to medical therapy. PGV was randomized against truncal vagotomy with antrectomy (TV + A) and against selective gastric vagotomy with Finney pyloroplasty (SGV + P). Postgastrectomy sequelae (dumping, diarrhea and reflux gastritis) were less after PGV. One patient after PGV developed a recurrent ulcer as did one patient after SGV + P. Two patients developed gastric ulcers after PGV. Good to excellent results (Visick I and II) were obtained in 96% of patients with PGV, 94% with TV + A and 86% with SGV + P. Follow-up studies were from six months to four years.

Salmonella empyema: a review

A 35-year-old man developed salmonella pleural empyema during a three-month illness. Cultures of the empyema fluid yielded S enteritidis, serotype typhimurium. Cure was achieved by decortication and obliteration of the pleural empyema space, in combination with chloramphenicol therapy given parenterally. Review of the published reports revealed eight similar instances of salmonella empyema. Manifestations and treatment of this group are reviewed.