Abstract: A 71-year-old male patient was admitted with methicillin-resistant staphylococcus aureus mediastinitis two months after coronary artery bypass grafting. Treatment with immediate surgical debridement, removal of sternal wires and use of vacuum-assisted closure device was started. Spiral computerised tomography and aortography revealed a false aortic aneurysm at the cannulation site. Active mediastinitis and the patient's objection to further surgery led us to perform percutaneous coil embolisation. No postoperative complication was observed and one year later the patient is in excellent condition.
Abstract: Inflammatory myofibroblastic tumours are reported to occur in a variety of sites, including the head and neck, abdominal organs, central nervous system and urinary tract. They only rarely occur in the lung.We report a case of a 25-year-old male admitted with haemoptysis. His chest radiograph showed a peripheral right lung opacity and computed tomography revealed a right lower lobe soft tissue density mass. Bronchoscopy and fine needle aspiration were unhelpful. a diagnosis of pulmonary carcinoma was made, and the patient underwent a right lower lobectomy. On pathology, the tumor was found to be an inflammatory pseudotumor. These lesion are extremely rare, constituting less than 1% of pulmonary malignancies, but are known to occur in young patients. We believe clinicians need to retain an index of suspicion for the presence of this disease in young patients, which can masquerade as more common malignancies.
Abstract: BACKGROUND: Facial skin metastases from colorectal cancer are extremely rare and appear several years after resection of the primary tumour. They are an important finding, often being the first sign of metastasis from a previously treated colon cancer. CASE PRESENTATION: We describe a case of a 69 year old patient with cutaneous metastasis to the chin from a previously treated adenocarcinoma of the colon. The patient presented with dyspnoea, pleuritic pain and loss of weight. A chest x-ray revealed a right upper lobe mass of the lung which on subsequent surgical exploration proved to be metastatic from colorectal adenocarcinoma resected three years ago. During the postoperative course, a nodule was noted on the chin and excision biopsy revealed it was also a metastasis from the initial colorectal cancer. Palliative chemoradiotherapy was administered and the patient survived 8 months. CONCLUSION: High index of suspicion is necessary for the early detection of facial cutaneous metastases from colorectal cancer. The aim is to start treatment as soon as possible before widespread visceral metastases occur. Cutaneous metastases from colorectal cancer carry a better prognosis in comparison to those of other epithelial tumours.
Abstract: BACKGROUND: Hemangiopericytoma is a rare mesenchymal neoplasm, accounting for about 1% of vascular tumors The tumor occurs most commonly in the skin, subcutaneous soft tissues, muscles of the extremities, retroperitoneum but rarely in the lung, trachea or mediastinum. CASE PRESENTATION: A rare case of primary mediastinal hemangiopericytoma is presented. A 72-year-old woman was treated by complete surgical resection of the tumor. Details of the clinical and radiographic feature are presented. The patient's postoperative course was uneventful with no evidence of recurrence 9 months after the operation. CONCLUSION: Hemangiopericytoma is an uncommon, potentially malignant tumor originating from pericytes in the small vessels and surgical radical excision is the treatment of choice, although the criteria for determining the area of resection have not been established. International literature has demonstrated that recurrent disease usually occurs within 2 years and therefore a long-term careful follow-up is required.
Abstract: Chylothorax occurs in 0.25 to 0.50% of cardiac operations performed through thoracotomy incisions and is more unusual after median sternotomy. A case of chylothorax following coronary artery bypass grafting is presented. Combined treatment with pleural drainage, "nothing per os", total parenteral nutrition and subcutaneous injection of somatostatin was effective and led to rapid cessation of chyle production.
Abstract: Diaphragmatic hernia complicating pregnancy is rare and results in a high mortality rate, particularly if early surgical intervention is not undertaken. We report a case in which a woman presenting at 23 wk's gestation was admitted with symptoms of respiratory failure and bowel obstruction due to incarceration of viscera through a left posterolateral defect of the diaphragm (Bochdalek's hernia). Surgery (left thoracoabdominal incision) demonstrated compression atelectasis, mediastinal shift, strangulation and gangrene of the herniated viscera which led to segmental resection of the involved portion of large intestine with re-establishment of bowel continuity by end to end anastomosis. The greater omentum was partly necrotic necessitating resection. The diaphragmatic defect was closed with interrupted sutures. Postoperative period was uncomplicated. Pregnancy was allowed to continue until 39 wk's gestation at which time elective cesarean delivery was performed. It is concluded that symptomatic maternal diaphragmatic hernia during pregnancy is a surgical emergency and requires a high index of suspicion.
Abstract: BACKGROUND: Diaphragmatic hernia complicating pregnancy is rare and results in a high mortality rate, particularly if early surgical intervention is not undertaken. CASE PRESENTATION: A woman at 23 week gestation was admitted with symptoms of respiratory failure and bowel obstruction due to incarceration of viscera through a left posterolateral defect of the diaphragm (Bochdalek's hernia). Surgery (left thoracoabdominal incision) demonstrated compression atelectasis, mediastinal shift, strangulation and gangrene of the herniated viscera which led to segmental resection of the involved portion of large intestine with re-establishment of bowel continuity by end to end anastomosis. The greater omentum was partly necrotic necessitating resection. The diaphragmatic defect was closed with interrupted sutures. Postoperative period was uncomplicated. Pregnancy was allowed to continue until 39 weeks' gestation at which time elective cesarean delivery was performed. CONCLUSION: Symptomatic maternal diaphragmatic hernia during pregnancy is a surgical emergency and requires a high index of suspicion.
Abstract: INTRODUCTION: Patients with lung adenocarcinoma often suffer from metastatic pericardial effusion that may eventually cause cardiac tamponade. Recurrence of pericardial effusion is frequent after pericardial drainage and therapy for the prevention of fluid reaccumulation is still controversial. We evaluated the safety and effectiveness of the intrapericardial infusion of cisplatin, a substance with antineoplastic and sclerosing properties, after pericardiocentesis in patients with lung adenocarcinoma and malignant cardiac tamponade. METHODS: Twenty-five patients (19 males and 6 females, median age 55 years) with lung adenocarcinoma confirmed by cytological examination and cardiac tamponade were studied. All patients underwent subxiphoid pericardiocentesis through catheter insertion, under electrocardiographic, echocardiographic and haemodynamic guidance. After the malignant aetiology of the pericardial effusion had been confirmed by cytological examination, cisplatin was instilled (10 mg in 20 ml normal saline) into the pericardial cavity during three consecutive days. Clinical and echocardiographic evaluation was performed every month thereafter. RESULTS: Pericardial fluid of 350-1700 ml was removed (median 750 ml) and was haemorrhagic in 80% of the cases. Paroxysmal atrial fibrillation was detected in three patients (12%) and non-sustained ventricular tachycardia in two (8%). None of the patients had hypotension or retrosternal pain. One patient suffered from significant pericardial effusion reaccumulation (4%). Laboratory findings were not influenced by systemic drug absorption in any patient. Transthoracic echocardiographic study revealed pericardial thickening without physiology of constriction in 4 patients (16%). After pericardiocentesis, the mean survival period overall was 4.5 months (range 3-92 weeks), and mortality was attributed to widespread disease (respiratory failure). CONCLUSIONS: Intrapericardial administration of cisplatin is safe and effective in preventing the reaccumulation of malignant pericardial effusion in the majority of patients with lung adenocarcinoma.
Abstract: BACKGROUND: Bland-White-Garland syndrome (anomalous origin of the left coronary artery from the pulmonary artery) is a rare disease which may result in myocardial infarction, congestive heart failure and sometimes death during the early infantile period. CASE PRESENTATION: A successfully treated case of a 45-year-old mother of 2 children with Bland-White-Garland syndrome and concomitant severe mitral regurgitation is presented. Subsequent therapy consisted of ligation of the anomalous origin of the left coronary artery, anastomosis of the left internal mammary artery to the left anterior descending branch and mitral valve replacement. Continuous blood flow from the left coronary artery ostium during extracorporeal circulation and aorta clamping suggested systemic collateral supply. CONCLUSIONS: Recognition and diagnosis of Bland-White-Garland syndrome is important due to its potentially life-threatening complications.
Abstract: BACKGROUND: Supraventricular arrhythmias after thoracotomy for pulmonary resections are well documented. There has been considerable interest in their incidence, nature, predictability from preoperative assessment and treatment. The purpose of this study is to define prevalence, type, risk factors for post-thoracotomy supraventricular arrhythmias and to assess the efficacy of amiodarone as an antiarrhythmic drug. METHODS: The records of 250 patients undergoing pulmonary resection for lung cancer during last two years were followed up in this prospective study with particular attention to possible risk factors (gender, age, extent and side of resection, diabetes mellitus, hypertension, tobacco smoking, beta-blocker ingestion). Patients underwent biopsy only were excluded. Once onset of supraventricular arrhythmia was monitored or documented in the electrocardiogram, intravenous infusion of amiodarone was started with a loading dose of 5 mg/kg in 30 minutes and a maintenance dose of 15 mg/kg until remission of it. RESULTS: Forty-three episodes (21.6%) of supraventricular arrhythmias were documented with atrial fibrillation being the most common (88.3%). Rhythm disturbances were most likely to develop on the second postoperative day. Pneumonectomy, lobectomy and age >65 years were the statistically significant factors. The overall postoperative mortality was 3.2% and 2.3% for the patients with postoperative supraventricular arrhythmias. In none of the cases did supraventricular arrhythmia cause cardiac failure leading to death. Sinus rhythm was achieved with amiodarone in 37 out of 43 patients (86%). Electrical cardioversion was necessary for 6 patients who were hemodynamically unstable. The most common amiodarone-related complication was bradycardia (13.5%). CONCLUSIONS: Postoperative supraventricular arrhythmias are a common complication in elderly patients undergoing lung resection surgery (especially pneumonectomy or lobectomy). Amiodarone is both safe and effective in establishing sinus rhythm.
Abstract: BACKGROUND: Advanced ovarian cancer is the leading non-breast gynaecologic cause of malignant pleural effusion. Aim of this study was to assess the efficacy of mitoxantrone sclerotherapy as a palliative treatment of malignant pleural effusions due to ovarian cancer. METHODS: Sixty women with known ovarian cancer and malignant recurrent symptomatic pleural effusion were treated with chest tube drainage followed by intrapleural mitoxantrone sclerotherapy. Survival, complications and response to pleurodesis were recorded. The data are expressed as the mean +/- SEM and the median. RESULTS: The mean age of the entire group was 64 +/- 11,24 years. The mean interval between diagnosis of ovarian cancer and presentation of the effusion was 10 +/- 2,1 months. Eighteen patients (30%) had pleural effusion as the first evidence of recurrence. The mean volume of effusion drained was 1050 +/- 105 ml and chest tube was removed within 4 days in 75% of patients. There were no deaths related to the procedure. Side effects of chemical pleurodesis included fever (37-38,5 degrees C) chest pain, nausea and vomiting. At 30 days among 60 treated effusions, there was an 88% overall response rate, including 41 complete responses and 12 partial responses. At 60 days the overall response was 80% (38 complete responses and 10 partial responses). The mean survival of the entire population was 7,5 +/- 1,2 months. CONCLUSIONS: Mitoxantrone is effective in the treatment of malignant pleural effusion secondary to ovarian cancer without causing significant local or systemic toxicity.
Abstract: BACKGROUND: Carcinoma of the breast is the second leading cause of malignant pleural effusions. This study reports on the efficacy of mitoxantrone as a sclerosing agent in patients with breast cancer who had a pleural effusion as a direct consequence of metastatic disease. PATIENTS AND METHODS: Over a 5-year period, 114 patients with a known breast malignancy and having recurrent symptomatic pleural effusion referred for chest tube drainage and sclerotherapy were considered eligible. They had received no prior intrapleural therapy and had a predicted survival of >1 month. All of them underwent pleural drainage and chemical pleurodesis with mitoxantrone. Survival, complications and response to pleurodesis according to clinical and radiographic criteria were recorded. The data are expressed as the mean +/- standard error of the mean (SEM) and the median. The chi2 test was used for statistical analysis. To assess the prognostic value of Karnofsky's performance status score a Cox proportional hazards model was used. RESULTS: The mean age of the patients was 53.5 +/- 2.1 years. Effusion occurred after 38.2 +/- 6.2 months (range: 1-229 months) after the diagnosis. Ipsilateral effusion was seen in 73%, contralateral in 20% and bilateral in 7%. Forty patients (35%) had pleural effusion as the first evidence of recurrence. The mean volume of effusion drained was 1020 +/- 125 ml and the chest tube was removed within 5 days in 82% of patients. Side effects of chemical pleurodesis included mainly fever, chest pain, nausea and vomiting. At 30 days 64 patients (56.3%) had a complete response (CR) and 30 patients (26.3%) partial response (PR) to pleurodesis (overall response: 82.6%). At 60 days the overall response was 78.5% (CR:53.5%, PR: 25%). The mean survival was 15.6 +/- 2 months. Karnofsky's performance status score was found to be a statistically significant predictor. Patients with Karnofsky's performance status score >70 had a median survival of 513 days, as opposed to a median survival of only 63 days for patients with a Karnofsky's performance status score <30. CONCLUSIONS: Mitoxantrone is effective in the treatment of malignant pleural effusion due to breast carcinoma with relatively low local or systemic toxicity. Karnofsky's performance status score at the time of pleurodesis is predictive of survival.
Abstract: BACKGROUND: Metastatic involvement of pericardium producing cardiac tamponade is rare. When occurs it is mainly from the lung, breast and the neoplasms of the lymphoreticular system. Hematogenous spread of parotid adenocarcinoma to heart is extremely rare and only two cases have been reported in literature so far. CASE PRESENTATION: We report an unusual case of a patient with adenocarcinoma of the parotid gland, which presented with cardiac tamponade and was treated urgently with pericardial drainage and intrapericardial injection of cisplatin. CONCLUSIONS: Our case demonstrates the possibility of metastatic pericardial involvement and cardiac tamponade in patients with parotid adenocarcinoma. The patient was successfully treated with pericardial drainage and intrapericardial injection of chemotherapeutic agent to control recurrent pericardial effusion.
Abstract: Multiple myeloma presents with various clinical manifestations depending on the mode and the extent of organ involvement. Pericardial involvement by myeloma and subsequent cardiac tamponade is extremely rare. We report on the case of a patient with multiple myeloma who presented with cardiac tamponade and was evaluated surgically with thoracotomy and minimal debulking pericardiectomy (fenestration).
Abstract: Recurrent squamous cell carcinoma of the vulva advances locally, spreads via the regional lymphatics and hematogenous spread is late and unusual. This is a rare case of a patient with a solitary pulmonary tumor originating from squamous cell carcinoma of the vulva. According to the literature this form of pulmonary involvement has not previously been described in cases of vulvar carcinoma in the last 20 years.
Abstract: Seventy-two young males suffering from acute acoustic trauma with tinnitus due to gunshots were included prospectively in the study. Forty of the subjects had the left ear affected, four the right ear and the remaining 28 sustained bilateral acoustic traumas. The mean time of admission after onset of symptoms was 28 days (5-88 days). The subjects were randomly categorized into three groups: group A received trimetazidine, prednisolone and complex B vitamins; group B were treated only with trimetazidine; and group C received prednisolone and complex B vitamins. At 3-month follow up, tinnitus had been completely eradicated in only eight subjects and had in 17. No statistically significant difference was found between the three groups concerning improvement of tinnitus. However, it was found that early admission predisposed towards better prognosis. The degree of hearing improvement after medication did not seem to correlate with the relief of tinnitus.
