Preoperative diagnosis with video-assisted thoracoscopy with miniaturized endoscopes in general thoracic surgery: a preliminary study

Video-assisted thoracoscopy using a miniaturized endoscope (mini-VAT) was applied for preoperative diagnosis in general thoracic surgery. Thirty-one patients, including 27 with indeterminate pulmonary nodule and 4 with suspected pleural involvement of lung cancer or metastatic pleural tumor, underwent mini-VAT. As a pilot study, 14 of the former 27 patients underwent mini-VAT while receiving general anesthesia. As a prospective study, all the remaining 17 patients underwent mini-VAT while receiving local anesthesia. Solid scopes of three different sizes, 0.9, 1.9, or 4.0 mm diameter, were used. An artificial pneumothorax for scope introduction was produced by needle thoracentesis under atmospheric pressure. Automatic cutting needle biopsy was used for tissue sampling. In the pilot study group, mini-VAT with a 4.0-mm scope provided excellent visibility and diagnostic sensitivity of 100%. This study group showed the diagnostic sensitivity of needle biopsy for pulmonary nodule to be 100%. Hemorrhages and air leaks at biopsy sites were sealed with blood coagulation in a short time. In the prospective study group, mini-VAT with a 4.0-mm scope with the patients receiving local anesthesia provided a diagnostic sensitivity of 91% for pulmonary nodule and a diagnostic accuracy of 100% for suspected pleural involvement. Causes of failure of mini-VAT with the use of local anesthesia were cough reflex during needle biopsy and incomplete lung collapse for deeply located target in two cases. The adverse effects of the mini-VAT were paradoxical respiration in two cases in which local anesthesia was used. The patients who received only local anesthesia required no chest tube drainage. Mini-VAT is a simple, minimally invasive procedure suitable as a preoperative examination technique for histologic diagnosis, evaluation of disease progression, and selection of strategy in thoracic surgery.     

Surgical treatment of lung abscesses

The authors analysed a group of patients with lung abscesses that received surgical treatment, as well as the characteristics of their evolution. Seventeen patients with lung abscesses which underwent surgical therapy from 1984 to 1995 were analysed. The group was composed of 12 male and 5 female. The age varied from 25 to 78 years (mean-50.1 years). The etiologies were: post-pneumonic, tuberculosis, foreign-body, empyema. Two types of surgical procedures were performed: pulmonary resection and transthoracic drainage. The indication of surgery was based on the failure of clinical treatment, massive hemoptysis, pleural empyema and residual cavity wider than 2 cm after 6 weeks of clinical treatment. The patients with poor clinical conditions were selected to transthoracic drainage, the less invasive procedure. Most patients had a satisfactory post-operative evolution (58.9%). Five patients had complications (29.4%) as empyema and air leak for more than three weeks and two patients died (11.9%). Regarding the surgical technics, the pulmonary resection (lobectomy and segmentectomy) showed no morbidity and mortality. The usage of external chest tube drainage of the abscess had a morbidity of 40% and mortality of 20%. In conclusion, the complicated lung abscess is still a surgical pathology and the best approach seems to be the resection of the pulmonary segment affected. The drainage has specific indication, mainly in patients with deteriorating condition, but this procedure has high mortality and morbidity rates.     

Blind pleural biopsy using a Tru-cut needle in moderate to large pleural effusion--an experience

BACKGROUND: Pleural biopsy is invaluable for the etiological diagnosis of pleural diseases in the presence of an exudative pleural effusion. Conventionally, pleural biopsy is either performed with the Cope's or the Abrams pleural biopsy needles. A few investigators have used the Tru-cut biopsy needle with or without ultrasound guidance. We report our experience in performing closed pleural biopsy using a Tru-cut needle without ultrasound guidance in moderate to large exudative pleural effusion. We used a perpendicular approach to biopsy the pleura instead of the tangential approach described earlier. METHODS: Closed Tru-cut biopsy was performed in 27 consecutive patients with exudative pleural effusion who volunteered to undergo the procedure. The biopsy specimen was sent for histopathology. Pleural fluid analysis and other relevant investigations required to obtain a specific diagnosis were carried out. RESULTS: A specific diagnosis of tuberculosis was obtained on histopathology of pleural tissue in 12 out of 16 patients (diagnostic yield 75%) and in 5 out of 7 patients with malignancy (diagnostic yield 71%). Among the other 4 patients, other causes of exudative pleural effusion were detected in 3 and in 1 patient, no specific diagnosis could be made, despite extensive investigation. CONCLUSION: Closed pleural biopsy using a Tru-cut needle is effective for the specific diagnosis of exudative pleural effusion. The use of a perpendicular approach to biopsy the pleura does not seem to increase the complication in moderate to large pleural effusion.     

The current aspects of seroepidemiological research in combined foci of leishmaniasis

The accuracies of ultrasonography (US) and computed tomography (CT) for determining tumor invasion of the chest wall in lung cancer were compared in a retrospective study of 120 patients. US findings were evaluated preoperatively according to the following criteria: disruption of pleura, extension through the chest wall, and fixation of tumor during breathing. CT findings were evaluated with the following criteria: obtuse angle of the mass to the pleural surface, more than 3 cm contact with the pleural surface, and visible pleural thickening associated with the mass. Chest wall invasion was judged as positive when at least two of the three findings were present with either technique. Nineteen of the 120 patients had chest wall invasion by tumor. The sensitivity of US was 100% and the specificity was 98%. The sensitivity of CT was 68% and the specificity was 66%. The accuracy of US and CT were 98% and 67%, respectively.     

The value of immediate cytologic evaluation for needle aspiration lung biopsy

RATIONALE AND OBJECTIVES: The authors evaluate the role of immediate cytologic evaluation (ICE) with fine-needle aspiration biopsy (FNAB) for lung lesions at highest risk for pneumothorax. METHODS: A prospective randomized study was conducted of 80 patients with lung lesions surrounded by aerated parenchyma undergoing FNAB with and without ICE (47 and 33 patients, respectively). An analysis of needle passes, procedure time, complications, specimen adequacy, diagnostic yield, and accuracy of procedure was made. RESULTS: There was an increased number of needle passes with ICE (> or = three passes: 23% [11 biopsies] versus 3% [1 biopsy]; P = 0.01). Fluoroscopic procedures took longer with ICE (median time: 15 versus 9 minutes; P = 0.002) with no difference in complication rates. Specimen adequacy was similar (74% and 64%) and the procedure was diagnostic in 79% (37 biopsies) with ICE and in 70% (33 biopsies) without ICE. There were no significant differences in the sensitivity, specificity, or accuracy of the biopsy. CONCLUSIONS: Immediate cytologic evaluation improved results marginally with increased procedure time and needle passes. Immediate cytologic evaluation may be most useful for lesions at lowest risk of complications to assure that a second procedure is not required.     

Selenocysteine inserting RNA elements modulate GTP hydrolysis of elongation factor SelB

Invasive pulmonary aspergillosis (IPA) is associated with a high mortality. In 27 consecutive neutropenic patients who underwent lung resection for suspected IPA, we analyzed preoperative diagnostic evaluation, operative procedure, perioperative management, histological findings, outcome concerning recurrence of aspergillosis, and survival to evaluate the morbidity and mortality of a surgical treatment of IPA. Seventeen patients with hematologic diseases had previously undergone high-dose chemotherapy and four stem cell transplantation. Six patients with aplastic anemia were treated with antilymphocyte globulin. IPA was suspected if localized infiltrates developed on thoracic CT scan, and fever persisted under antibiotic therapy in neutropenic patients. In only one case a diagnosis of IPA could be made preoperatively. Twenty patients underwent lobectomy and seven wedge resection. At day of surgery the neutrophil count was below 500 x 10(9)/L in 78% of patients, and the platelet count below in 50 x 10(9)/L in 58% of patients. Invasive fungal infection was confirmed histologically in 22 of 27 patients (81.5%); in five patients no fungal infection was documented. The median duration of surgery was 120 min. Postoperatively, patients stayed one night in the intensive care unit, and chest tubes were removed after 2 d. Within 7 d a median of four erythrocyte packs and two platelet packs per patient were replaced. Major surgical complications occurred in two patients (bronchial dehiscence; pleural aspergillosis). Minor surgical complications included prolonged chest tube drainage (recurrent pneumothorax, n = 2; air leakage, n = 1; hematothorax, n = 1), pleural effusion (n = 4), and seroma (n = 2). Postoperatively, two patients suffered from histologically proven disseminated aspergillosis (pleural aspergillosis, renal aspergilloma) and another patient from suspected orbital aspergillosis. At 30 d postoperative mortality was 11% and 3-mo survival was 77%. After lung resection, seven patients underwent stem cell transplantation without recurrence of IPA. In conclusion, we suggest lung resection is a therapeutic option for invasive pulmonary aspergillosis in neutropenic patients with hematologic diseases and is associated with a low surgery-related morbidity and mortality.     

Meta-analysis of the efficacy of extradural clonidine to relieve postoperative pain: an impossible task

PURPOSE: The diagnostic accuracy and rate of complications of CT-guided core biopsies (CB) from suspected tumors of the chest were compared to the accuracy a complications of fine-needle aspiration biopsies (FNAB). METHODS: The accuracy in the diagnosis of a benign or malignant lesion of 79 FNAB (19.5 G self-aspirating cutting needle) and of 83 CB (18 G automated core biopsy) and the rates of pneumothorax, pleural drainage and hemoptysis were retrospectively evaluated. RESULTS: With FNAB, the sensitivity for malignant lesions was 62.1% and the accuracy 68.4%. With CB the sensitivity amounted to 85.9% and accuracy to 86.7%. The rate of pneumothorax was 25.3% following FNAB, with a drainage rate of 5.1% compared to 19.3% and 6.0%, respectively, following CB. The rate of pneumothorax and drainage increased with increasing path length through aerated lung. In advanced emphysema, the pneumothorax rate did not increase; however, in pneumothoraces, pleural drainage was mandatory in 20% of FNAB and in 100% of CB. Hemoptysis without any therapeutic consequences occurred in 3.8% following FNAB and in 6.0% following CB. CONCLUSIONS: With CB diagnostic accuracy can be clearly increased without an obvious increase in the complication rate. However, in patients with obvious emphysema, the pleural drainage rate of pneumothorax may be higher following CB.     

Maternal smoking during pregnancy and psychiatric adjustment in late adolescence

Large-core (14g) needle biopsy (CNB) of the breast is a new diagnostic modality increasingly being used to evaluate patients with mammographic abnormalities. Two hundred twenty-four CNBs were performed on 198 patients. Surgical follow-up was available in 64 cases (28.6%). Overall concordance rate was 93.8% (60 of 64 cases). Of the four discordant cases, two were diagnosed as atypical ductal hyperplasia (ADH) on CNB; on excision, these cases showed cribriform ductal carcinoma in situ (DCIS); two remaining cases, diagnosed on CNB as ADH versus DCIS, showed invasive carcinoma (DCIS with invasive component and infiltrating cribriform carcinoma, respectively) on excisional biopsy. Malignancy, primary (52) or metastatic (5), was identified in 57 cases (25.4%); 47 of these patients underwent surgical excision, and the diagnosis was confirmed in all of these cases. Of 51 cases with radiographic evidence of microcalcifications, 48 (94%) had microcalcifications in the CNB: 30 (62.5%) were benign, 11 (22.9%) were malignant, and 7 (14.6%) were diagnosed as ADH. In the remaining three cases (1.3%), only benign breast tissue without microcalcifications was seen, and the lesion was considered to have been missed. Biopsy specimens were obtained from 173 lesions because of the presence of a mass: 125 (72.3%) were benign, 45 (26%) were malignant, and 3 (1.7%) were diagnosed as ADH. Follow-up was available in 118 patients with benign lesions: all were mammographically stable or decreased at 6 or 12 months; no follow-up was available for the remaining patients. CNB of the breast is a highly sensitive (96.9%) and specific (100%) technique for management of patients with mammographic abnormalities. The histologic findings should be correlated with the mammographic appearance, and an attempt should be made to achieve a specific diagnosis in all lesions, particularly masses. The diagnosis of ADH should always prompt excisional biopsy because of a high frequency of false-negative results caused by sampling errors or underestimation.     

Sonographic observation of pulmonary infarction and early infarctions by pulmonary embolism

Fifty-eight consecutive patients with clinical symptoms of pulmonary embolism/infarction were examined by ultrasound as the first imaging modality. The diagnosis was confirmed in 35 patients by ventilation-perfusion scintigraphy; 13 underwent pulmonary angiography for verification of clinical diagnosis. Seven patients died, necropsy was performed and the diagnosis of pulmonary embolism was confirmed in six cases; three patients were submitted to transthoracic lung biopsy. Intercostal space and an additional small pleural effusion in 48% of the examined patients served as a sonic window for the 5 MHz sector scanner. In 42 of the 54 cases with a final diagnosis of pulmonary embolism/infarction a total of 69, hypoechoic, lesions with a pleural basis were detected. These were conspicuous, predominantly triangular, of a mean size 4.6 x 3.7 cm (range 9 x 8 to 2 x 1.5). A hyperechoic structure with reverberation artefacts suggestive of air was frequently visible in the centre: a sign of segmental involvement. The ultrasound examination yielded a true positive result in 41 cases. The overall sensitivity was 98% and the specificity 66%. The prevalence of pulmonary embolism was 83% and the diagnostic accuracy 90%. This suggests that chest sonography can be an efficient technique in the detection of pulmonary infarction.     

The role of transthoracic needle biopsy for the diagnosis and staging of lung cancer

Percutaneous transthoracic needle biopsy (TNB) is a simple and safe procedure with high diagnostic accuracy for the diagnosis and staging of cancer in the lung, hilum, and mediastinum. The complication rate is low and consists primarily of pneumothorax, with only a small percentage of these requiring chest tube reexpansion. Major complications are rare. Computed tomographically guided biopsy is a powerful adjunct to fluoroscopic biopsy and expands the application of TNB to include most thoracic lesions. TNB is the initial diagnostic procedure of choice in peripheral lung lesions, suspected focal metastases, and most hilar and mediastinal masses. Its proper role in the diagnosis and staging of lung cancer requires the close collaboration of the radiologist, cytopathologist, and the patient's primary physician.     

Transthoracic needle biopsy of mediastinal lymph nodes for staging lung and other cancers

PURPOSE: To determine the usefulness of transthoracic needle biopsy of mediastinal lymphadenopathy for staging suspected lung and other cancers. MATERIALS AND METHODS: Transthoracic needle biopsy of the hilum or mediastinum was performed in 111 patients with suspected neoplasms. Most biopsy procedures were performed with computed tomographic guidance on an outpatient basis. Forty-eight adult patients had enlarged lymph nodes (defined as < or = 30 mm in the long axis and > or = 10 mm in the short axis). Sixty-three lesions larger than 30 mm were arbitrarily considered to be masses and were excluded. RESULTS: Carcinoma was diagnosed in 40 patients. Four patients had true-negative and one patient had false-negative results. Sensitivity for carcinoma was therefore 98% (40 of 41). One patient with a negative biopsy result did not have surgical confirmation and was excluded from analysis. Lymphoma was excluded from analysis. Lymphoma was diagnosed in two patients (positive in one and suspicious in one). Pneumothorax occurred in 19 (34%) of 56 biopsy procedures. Chest tube treatment was required in eight (14%). CONCLUSION: Transthoracic needle biopsy of mediastinal lymphadenopathy is a safe, accurate diagnostic staging procedure. It can frequently be used as an alternative to mediastinoscopy in patients with lymphadenopathy.     

Analysis of small lung nodules diagnosed by open lung or thoracoscopic biopsy

We examined clinicopathologic findings in 86 cases with peripheral lung nodules less than 30 mm in size diagnosed by open lung or video-assisted thoracoscopic surgery (VATS) biopsy. Biopsies were conducted because of the new appearance or enlargement of nodules as evidenced in a comparison with retrospective chest films in 47 patients, X-ray findings of malignancy suspicion without retrospective films in 13, enlargement of nodules after the administration of antituberculosis agents in 9, and a past history of malignancy in 17. Mean tumor size was 18.1 mm in primary lung cancer (n = 29), 16.2 mm in metastatic lung cancer (n = 13), 16.3 mm in tuberculosis (n = 18), 15.3 mm in nonspecific inflammation (n = 12), 16.7 mm in benign lung tumors (n = 7), 7.5 mm in intrapulmonary lymph node (n = 2), and 19.4 mm in others (n = 5). Among primary lung cancers with a clear N-factor, the percentage of T1N0M0 cancers was up to 72%. No significant difference was observed in either of the reasons for these biopsies and the size of nodules among diseases. To detect early lung cancer and increase the rate of cure, small pulmonary nodules that could be hardly diagnosed using bronchoscopic or needle aspiration biopsy should be diagnosed positively using VATS biopsy.     

Open lung biopsy--successful diagnostic tool with therapeutic implication in the critically ill paediatric population

Open lung biopsy (OLB) is an important diagnostic tool in children with immune deficiency and/or chronic lung disease with diffuse pulmonary compromise. These patients require a tailored therapeutic approach owing to their fragile status and the side effects of unnecessary or inadequate treatment. Twenty-six patients of mean age 5.6 y underwent 41 open lung biopsies in our centre between 1991 and 1995. Seventeen (65%) were immunocompromised (including 13 with malignancy) and 9 had other lung diseases. The biopsies were diagnostic in 25 patients (96%), and complete clinical-pathological correlation was found in 11 (42%). A specific infectious aetiology was detected in nine patients (35%), all of them immunocompromised. Therapeutic changes were instituted on the basis of the biopsy findings in 18 patients (69%). Two patients had postoperative complications (prolonged pleural leak). We conclude that OLB is a safe diagnostic procedure even in the critically ill child and should be employed without hesitation when conventional methods fail to provide a definitive diagnosis to help redirect therapy.     

Experience with closed needle biopsy and pleural fluid cytology in the diagnosis of malignant pleural effusions in Yaounde, Cameroon

To determine and compare the efficacy of pleural fluid cytology and closed needle biopsy of the pleura in establishing the diagnosis of malignant pleural effusions in Yaounde, we reviewed the medical records of all consecutive patients with a pleural effusion admitted in unit B of the Chest Clinic of the Jamot Hospital between January 1990 and December 1994. Fifty four cases of malignant pleural effusion were diagnosed over this period. Closed needle biopsy of the pleura alone permitted a diagnosis of malignancy involving the pleura in 32 instances while cytological studies of pleural fluid provided a diagnosis in thirty six cases. A combination of both techniques was diagnostic in 48 (88.9%) patients. We recommend that both pleural fluid cytology and closed needle biopsy of the pleura be used concomitantly in the evaluation of pleural effusion for which malignancy is suspected.     

Benign asbestos pleural effusion associated with pulmonary aspergilloma

A rare case of benign asbestos pleural effusion associated with aspergilloma is reported. A chest radiograph of a 75-year-old Japanese man who was admitted with right chest pain showed a right pleural effusion and nodular shadows in the right apex and left middle lung field. Thoracocentesis revealed an exudate with atypical mesothelial cells. An open lung biopsy showed aspergilloma in the right S2 area and no evidence of malignancy. Many reactive mesothelial cells were found in the pleura. A quantitative asbestos digestion study of the lung tissue biopsy showed high-grade asbestos exposure.     

Surgical management of pulmonary aspergilloma

Between 1983 and 1996., 79 patients'--operated on for pulmonary aspergilloma--clinical data has been analysed. The patients were comprised of 67 males and 12 females, with a mean age of 49 years (range, 24 to 69). Previous lung disorders were observed in about half of the cases (most frequently tuberculosis), while in the other half aspergilloma was developed on the basis of (sub)-acute infections. The most common symptom was haemoptysis (in 45% of cases). Aspergilloma was diagnosed preoperatively (especially by typical chest x-ray) in 62 patients. In the other cases tb, lung cancer, pyosclerosis were suspected. 67 patients underwent pulmonary resection (50 lobectomies, 12 wedge resections, 5 pneumonectomies), 12 cavities were opened by cavernostomy. The postoperative mortality rate was 10.1%. The most frequent complications were bleeding, prolonged air leak, pleural rest space, empyema, bronchial fistula and wound infection, which were occurred in cases with bigger cavities near chest wall. In most cases with pulmonary aspergilloma surgery remains the only effective treatment. Operation has a lower risk in asymptomatic patients, without chest wall involvement. In several cases cavernostomy might be applied successfully.     

Indwelling small pleural catheter needle thoracentesis in the management of large pleural effusions

STUDY OBJECTIVES: To evaluate the clinical safety, efficacy, and cost of a small indwelling pleural catheter (7F, Turkel Safety Thoracentesis System [Sherwood, Davis, and Geck; St. Louis]) vs repeated needle thoracentesis or closed tube thoracostomy as a means to drain a large-volume pleural effusion. SETTING: Inpatients in a tertiary care university teaching hospital in urban Chicago. DESIGN: Prospective, consecutive patient comparative study using historical controls. PATIENTS: Fifty-seven therapeutic aspirations in 23 patients with large pleural effusions as defined by opacification of at least one third of the hemithorax on chest radiography. Patients were excluded if they had a history of thoracic surgery, documented loculations, structural chest abnormalities, severe coagulopathy, or refused to give informed consent. MEASUREMENTS: Volume of each pleural aspiration, total fluid removed, pleural fluid lactate dehydrogenase, protein, glucose, cytologic analysis, microbiologic stains, and cultures based on clinical indications. RESULTS: We found that initial thoracentesis and repeated pleural drainage using the indwelling catheter system is a safe, efficacious, and cost-effective procedure that may aid the evacuation and management of a large-volume pleural effusion. There were fewer adverse effects and complications such as pneumothorax, splenic laceration, hemopneumothorax, local pain, dry tap, and hematomas, as compared with previous reports. The overall complication rate was 12% (7/57). There were two pneumothoraces detected (3.5%), one of which required closed tube thoracostomy for treatment (1.75%). A further benefit comes in the form of a significant cost savings at our institution ($80 vs $240) when this needle-catheter system is used in place of closed tube thoracostomy in the drainage of a large-volume pleural effusion. CONCLUSION: An indwelling pleural catheter with the Turkel safety needle-catheter (as described in the study) can be used to successfully drain the pleural space with reduced morbidity and a significant cost saving in comparison to repeated needle thoracenteses or closed tube thoracostomy.     

Video thoracoscopic lung biopsy in diffuse interstitial lung diseases

The present study examined the use of video thoracoscopic lung biopsy (VTLB) in diffuse interstitial lung disease, in comparison with open lung biopsy (OLB). Twenty and fifteen patients underwent VTLB and OLB, respectively, from 1987 to 1997 at the Central Chest Hospital, Thailand. Data in mean (SD). The mean age was 39 years in both groups. VTLB yielded equivalent size of lung tissues, 4.7 (2.32) cm3, and was as diagnostically useful as OLB. Estimated blood loss, 60 (37) mls, and length of pleural drainage, 2.8 (0.5) days, were comparable in either technique. As OLB had been in practice for decades, it took shorter operative time, 64 (11) mins, than VTLB, 105 (30) mins, (p = 0.005). Both VTLB and OLB approaches were safe and not associated with major postoperative complications.     

CT diagnosis of pleural dissemination without pleural effusion in primary lung cancer

We retrospectively reviewed the CT scans of 25 primary lung cancers with disseminated pleural nodules or minimal malignant pleural effusions that were not recognized preoperatively. Special attention was devoted to abutting interlobar fissures, thick major fissures, and disseminated nodules on the chest wall, the diaphragm, and in the interlobar fissures. Among 10 primary tumors abutting interlobar fissures, nine (90%) had at least one of these findings. Among 15 primary lung tumors which did not abut interlobar fissures, four (27%) had at least one of these findings. We conclude that CT is a useful modality for detecting the pleural dissemination of primary lung cancers when primary lung cancers abut interlobar fissures even if no pleural effusion is detectable on CT.     

Thoracoscopy. Results in pleural cancer (author's transl)

Macroscopic features and related problems of pleural cancer, as seen by thoracoscopy, are presented. A reference is made to its frequent localization in the pleural bases and to its ascending progression. In cases of lung cancer with pleural effusion, such a technique opens the possibility to treat those patients in whom the non-metastatic nature of the effusion is confirmed. The higher yield of this procedure, as compared to needle pleural biopsy, is discussed and the possibility of performing intraoperative pleurodesis is emphasized.