Video assisted thoracic surgery for treatment of pneumothorax and lung resections: systematic review of randomised clinical trials

<b>Objectives</b> To determine if video assisted thoracic surgery is associated with better clinical outcomes than thoracotomy for three common procedures: surgery for pneumothorax, minor resections, and lobectomy. <b>Design</b> Systematic review of randomised clinical trials. <b>Data sources</b> Medline, Embase, Cochrane database of systematic reviews, Cochrane controlled trials register. Reference lists of relevant articles and reviews. <b>Methods</b> Criteria for inclusion were random allocation of patients and no concurrent use of another experimental medication or device. At least two authors performed and confirmed data abstraction and analyses. Information on quality of trials, demographics, frequency of the events, and numbers randomised were collected. <b>Results</b> 12 trials randomised 670 patients. Video assisted thoracic surgery was associated with shorter length of stay (reduction ranged from 1.0 to 4.2 days) and less pain or use of pain medication than thoracotomy in the five out of seven trials in which the technique was used for pneumothorax or minor lung resection. In the treatment of pneumothorax, video assisted thoracic surgery was associated with substantially fewer recurrences than pleural drainage in two trials (from 20 to 53 events prevented per 100 treated patients). No substantial advantages were observed for video assisted thoracic surgery in lobectomies. <b>Conclusions</b> Video assisted thoracic surgery is associated with better outcomes and seems to have a complication profile comparable with that of thoracotomy for the treatment of pneumothorax and minor resections. As for lobectomy, further studies are needed to determine how it compares with thoracotomy

Einfluss der Art der Materialgewinnung auf die Diagnosefindung in der Lungenpathologie

Das Ziel der Arbeit ist die Darstellung der Möglichkeiten der Kryobiopsien für die Diagnostik von Lungenerkrankungen und Pleuraerkrankungen. Es wurde zunächst gezeigt, dass die transbronchialen Kryobiopsien einen deutlichen morphologischen Unterschied gegenüber den konventionellen transbronchialen Biopsien zeigen, indem sie größer sind und häufiger alveoläres Gewebe enthalten. Entnahmebedingte Artefakte des alveolären Gewebes zeigten sich nicht. Untersucht wurden Patientenkollektive mit Krebserkrankungen sowie mit interstitiellen Lungenerkrankungen. In beiden Gruppen zeigt sich eine deutliche Steigerung der diagnostischen Ausbeute. Bei den pleuralen Läsionen konnte mindestens eine Gleichwertigkeit der Methode der Kryobiopsie der Pleura mit einer flexiblen Zangenbiopsie gezeigt werden. Die letzte vorgelegte Arbeit zeigt die erste Beschreibung einer durch Kryobiopsie gesicherten diffusen idiopathischen Hyperplasie der neuroendokrinen Zellen (DIPNECH). Insgesamt zeigt sich eine gute Einsetzbarkeit der Methode bei allen Lungen- und Pleuraerkrankungen.The aim of this work is to present a variety of cryobiopsies for the diagnosis of pulmonary and pleural diseases. The first paper describes a distinct morphologic difference between cryobiopsies and traditional transbronchial biopsies. Cryobiopsies reveal to be larger, contain more common alveolar tissue, which does not show any artefacts. The following analyses included patient groups with cancer and interstitial lung diseases. Both groups show a higher diagnostic yield concerning the specific disease. For the pleural lesions it could be demonstrated that there is at least a diagnostic equivalence between cryobiopsy and flexible thoracosopy. Finally, the last paper is a first case report of a cryobiopsy-diagnosed diffuse idiopathic neuroendocrine cell hyperplasia (DIPNECH). Altogether, the method presents itself suitable for application in all groups of lung and pleural diseases

Variability in the reported management of pulmonary metastases in osteosarcoma.

Nearly 20% of patients with newly diagnosed osteosarcoma have detectable metastases at diagnosis; the majority of which occur in the lungs. There are no established recommendations for the timing and modality of metastasectomy. Members of the Connective Tissue Oncology Society (CTOS) were emailed an anonymous 10-min survey assessing their management practices for pulmonary findings at the time of an osteosarcoma diagnosis. The questionnaire presented three scenarios and discussed the choice to perform surgery, the timing of resection, and the choice of surgical procedure. Analyses were stratified by medical profession. One hundred and eighty-three physicians responded to our questionnaire. Respondents were comprised of orthopedic surgeons (37%), medical oncologists (31%), pediatric oncologists (22%), and other medical subspecialties (10%). There was variability among the respondents in the management of the pulmonary nodules. The majority of physicians chose to resect the pulmonary nodules following neoadjuvant chemotherapy (46-63%). Thoracotomy was the preferred technique for surgical resection. When only unilateral findings were present, the majority of physicians did not explore the contralateral lung. The majority of respondents did not recommend resection if the pulmonary nodule disappeared following chemotherapy. The survey demonstrated heterogeneity in the management of pulmonary metastases in osteosarcoma. Prospective trials need to evaluate whether these differences in management have implications for outcomes for patients with metastatic osteosarcoma

Small particle-size talc is associated with poor outcome and increased inflammation in thoracoscopic pleurodesis

Rationale: Talc is very effective for pleurodesis, but there is concern about complications, especially acute respiratory distress syndrome. Objectives: It was the aim of this study to investigate if talc with a high concentration of small particles induces greater production of cytokines, and if pleural tumor burden has any influence on the local production and spillover of cytokines to the systemic circulation and eventual complications. Methods: We investigated 227 consecutive patients with malignant effusion submitted to talc pleurodesis. One hundred and three patients received 'small-particle talc' (ST; containing about 50% particles <10 ¿m) and 124 received 'large-particle talc' (with <20% particles <10 ¿m). Serial samples of both pleural fluid and blood were taken before and 3, 24, 48 and 72 h after thoracoscopy. Also, mesothelial cells were stimulated with both types of talc in vitro. Measurements and Results: Interleukin-8, tumor necrosis factor-¿, vascular endothelial growth factor, basic fibroblast growth factor and thrombin-antithrombin complex were measured in all samples. Early death (<7 days after talc) occurred in 8 of 103 patients in the ST and in 1 of 124 in the 'large-particle talc' group (p = 0.007). Patients who received ST had significantly higher proinflammatory cytokines in pleural fluid and serum after talc application, and also in supernatants of the in vitro study. Pleural tumor burden correlated positively with proinflammatory cytokines in serum, suggesting that advanced tumor states induce stronger systemic reactions after talc application. Conclusions: ST provokes a strong inflammatory reaction in both pleural space and serum, which is associated with a higher rate of early deaths observed in patients receiving it.Instituto de Salud Carlos III FIS 04/028

Early Contrast Enhancement: a novel Magnetic Resonance Imaging biomarker of pleural malignancy

Introduction: Pleural Malignancy (PM) is often occult on subjective radiological assessment. We sought to define a novel, semi-objective Magnetic Resonance Imaging (MRI) biomarker of PM, targeted to increased tumour microvessel density (MVD) and applicable to minimal pleural thickening. Materials and methods: 60 consecutive patients with suspected PM underwent contrast-enhanced 3-T MRI then pleural biopsy. In 58/60, parietal pleura signal intensity (SI) was measured in multiple regions of interest (ROI) at multiple time-points, generating ROI SI/time curves and Mean SI gradient (MSIG: SI increment/time). The diagnostic performance of Early Contrast Enhancement (ECE; which was defined as a SI peak in at least one ROI at or before 4.5 min) was compared with subjective MRI and Computed Tomography (CT) morphology results. MSIG was correlated against tumour MVD (based on Factor VIII immunostain) in 31 patients with Mesothelioma. Results: 71% (41/58) patients had PM. Pleural thickening was &#60;10 mm in 49/58 (84%). ECE sensitivity was 83% (95% CI 61–94%), specificity 83% (95% CI 68–91%), positive predictive value 68% (95% CI 47–84%), negative predictive value 92% (78–97%). ECE performance was similar or superior to subjective CT and MRI. MSIG correlated with MVD (r = 0.4258, p = .02). Discussion: ECE is a semi-objective, perfusion-based biomarker of PM, measurable in minimal pleural thickening. Further studies are warranted

Chest pain caused by multiple exostoses of the ribs: A case report and a review of literature

Abstract The aim of this paper is to report an exceptional case of multiple internal exostoses of the ribs in a young patient affected by multiple hereditary exostoses (MHE) coming to our observation for chest pain as the only symptom of an intra-thoracic localization. A 16 years old patient with familiar history of MHE came to our observation complaining a left-sided chest pain. This pain had increased in the last months with no correlation to a traumatic event. The computed tomography (CT) scan revealed the presence of three exostoses located on the left third, fourth and sixth ribs, all protruding into the thoracic cavity, directly in contact with visceral pleura. Moreover, the apex of the one located on the sixth rib revealed to be only 12 mm away from pericardium. Patient underwent video-assisted thoracoscopy with an additional 4-cm mini toracotomy approach. At the last 1-year followup, patient was very satisfied and no signs of recurrence or major complication had occured. In conclusion, chest pain could be the only symptom of an intra-thoracic exostoses localization, possibly leading to serious complications. Thoracic localization in MHE must be suspected when patients complain chest pain. A chest CT scan is indicated to confirm exostoses and to clarify relationship with surrounding structures. Video-assisted thoracoscopic surgery can be considered a valuable option for exostoses removal, alone or in addiction to a mini-thoracotomy approach, in order to reduce thoracotomy morbidity

Lymphangiography to treat postoperative lymphatic leakage: a technical review.

In addition to imaging the lymphatics and detecting various types of lymphatic leakage, lymphangiography is a therapeutic option for patients with chylothorax, chylous ascites, and lymphatic fistula. Percutaneous thoracic duct embolization, transabdominal catheterization of the cisterna chyli or thoracic duct, and subsequent embolization of the thoracic duct is an alternative to surgical ligation of the thoracic duct. In this pictorial review, we present the detailed technique, clinical applications, and complications of lymphangiography and thoracic duct embolization

Estimating past inhalation exposure to asbestos: a tool for risk attribution and disease screening

Introduction: Late presentation is common in mesothelioma. Reliable assessment of past exposure to asbestos is a necessary first step for risk attribution and for the development of a future screening programme. Such a programme could maximise access to trials of novel therapies and would pave the way for development of novel chemoprophylaxis strategies. This paper describes a method for individual exposure reconstruction along with data from a validation study. Methods: The exposure assessment method uses only descriptive information about the circumstances of the work that could be obtained from questioning the worker. The assessment is based on the tasks carried out and includes parameters for substance emission potential, activity emission potential, the effectiveness of any local control measures, passive emission, the fractional time the asbestos source is active and the efficiency of any respiratory protection worn. Results: There was a good association between the estimated and measured exposure levels. Pearson’s correlation coefficient between the log-transformed measurements and estimates from the model was 0.86, and 95% of the estimated individual values were within about a factor of ten of the associated measured value. The method described would be suitable for pre-selecting individuals at high risk of malignant pleural mesothelioma for screening using appropriate tools and/or enrolment in clinical trials of chemo-prophylaxis. Discussion: This method is of potential clinical value in developing novel treatment approaches for mesothelioma. Pilot studies to test this approach are urgently needed

Can malignant and inflammatory pleural effusions in dogs be distinguished using computed tomography

Computed tomography (CT) is the primary imaging modality used to investigate human patients with suspected malignant or inflammatory pleural effusion, but there is a lack of information about the clinical use of this test in dogs. To identify CT signs that could be used to distinguish pleural malignant neoplasia from pleuritis, a retrospective case‐control study was done based on dogs that had pleural effusion, pre‐ and postcontrast thoracic CT images, and cytological or histopathological diagnosis of malignant or inflammatory pleural effusion. There were 20 dogs with malignant pleural effusion (13 mesothelioma, 6 carcinoma; 1 lymphoma), and 32 dogs with pleuritis (18 pyothorax; 14 chylothorax). Compared to dogs with pleuritis, dogs with malignant pleural effusions were significantly older (median 8.5 years vs. 4.9 years, P = 0.001), more frequently had CT signs of pleural thickening (65% vs.34%, P = 0.05), tended to have thickening of the parietal pleura only (45% vs. 3%, P = 0.002) and had more marked pleural thickening (median 3 mm vs. 0 mm, P = 0.03). Computed tomography signs of thoracic wall invasion were observed only in dogs with malignant pleural effusions (P = 0.05). There were no significant differences in pleural fluid volume, distribution or attenuation, degree of pleural contrast accumulation, amount of pannus, or prevalence of mediastinal adenopathy. Although there was considerable overlap in findings in dogs with malignant pleural effusion and pleuritis, marked thickening affecting the parietal pleural alone and signs of thoracic wall invasion on CT support diagnosis of pleural malignant neoplasia, and may help prioritize further diagnostic testing