Current role of computed tomography-guided transthoracic needle biopsy of metastatic lung lesions

AIM: As part of the Catania symposium on lung metastasectomy we reviewed our practice of computed tomography (CT)-guided percutaneous transthoracic needle biopsy of pulmonary metastatic lesions with particular emphasis on diagnostic accuracy and nature of complications lesions. MATERIALS & METHODS: 25 patients with metastatic lesions of the lung have been evaluated between May 2010 and February 2014. Inclusion criteria consisted of patients with histologically confirmed, metastatic disease of the lung, those receiving a CT-guided needle biopsy, were at least 18 years of age; and with adequate hepatic, renal and hematological function. We recorded also the size of the sampled lesions, their distance from the pleura, the complications encountered (pneumothorax and thoracostomy tube placement), the cytological diagnosis and the outcome in all the cases. RESULTS: CT-guided percutaneous transthoracic needle biopsy were performed on 23 of 25 patients with suspected lung metastases. 17 males and six females with a mean age of 71.4 years. The mean size of lesions was 4.2 cm (range: 1 to 17 cm). For CT-guided needle biopsy, an 18 gauge semi-automatic needle biopsy device was used. Of 23 biopsies, 20 (87%) yielded a correct diagnosis with specific histological typing for metastasis. Pneumothorax was the most common complication occurring in four cases (5.7%). CONCLUSION: CT-guided percutaneous transthoracic needle biopsy is a firm, useful and safe technique for the diagnosis of suspected pulmonary metastases as it avoids open biopsy in most cases

Surgical treatment of solitary sternal metastasis from breast cancer Case report

Bone metastasis is a frequent and early complication of breast cancer. This case report describes a technique for a partial exeresis of the sternum and the reconstruction of the pleura with autologous dermis from the lower abdomen and the loss of substance with a myocutaneous flap

ANATOMICAL VARIATIONS OF THE INTERNAL JUGULAR VEIN: THE ROLE OF ULTRASONOGRAPHY

Purpose: In many places, especially in emergency department, central venous catheter is still inserted using anatomical landmark guidance with a success rate up to 97.6% and complications up to 15%. This study was aimed to determine by the support of ultrasono-graphy (US) the anatomical variations of the internal jugular vein (IJV) in relation with other structures of the neck, such as the common carotid artery (CCA). Material and Methods: 830 patients requiring central vein catheterization (CVC) were in-cluded in the analysis. The position of the IJV in relation to the other structures of the neck was demonstrated by portable ultrasonography. Results: The mean diameter of IJV was 10.3 mm in right and 10.5 mm in left side of neck, in male (p > 0.05) and 9.1 mm in right and 10.5 mm in left side of neck, in female (p > 0.05). The mean distance between IJV and CCA was 1.9 mm in right and 1.7 mm in left side of neck in male, and 2.0 mm in right and 2.2 mm in left side of neck in female. The mean distance of IJV from the skin surface was 9.8 mm in right and 10.0 mm in left side of neck in male, and 12.1 mm in right and 12.5 mm in left side of neck in female. On 25.54 % we observed variations of internal jugular vein site. On 3.97 % we observed a small caliber of internal jugular vein that could complicate the catheterization of the vein. On 1.8 % was diagnosed a thrombus of internal jugular vein, that is considered as an ab-solute contraindication for a CVC. Conclusion: Different patients had anatomical variations that are important and should be knowed, in order to reduce the possibility of severe complication

A case of splenic rupture: a rare event after laparoscopic cholecystectomy

Background Laparoscopic cholecystectomy (LC) is generally safe and well-accepted. In rare cases, it is associated with complications (intra- e postoperative bleeding, visceral injury and surgical site infection). Splenic lesion has been reported only after direct trauma. We report an unusual case of splenic rupture presenting after “uncomplicated” LC. Case presentation A 77-year-old woman presented with distended abdomen, tenderness in the left upper quadrant and severe anemia 12 hours after LC. Clinical examination revealed hypovolemic shock. Abdominal computed tomography confirmed the diagnosis of splenic rupture, and the patient required an urgent splenectomy through midline incision. The post-operative course was uneventful and the patient was discharged on 7th postoperative day. Splenic injury rarely complicates LC. We postulate that congenital or post-traumatic adhesions of the parietal peritoneum to the spleen may have been stretched from the splenic capsule during pneumoperitoneum establishment, resulting in subcapsular hematoma and subsequent delayed rupture. Conclusions Splenic rupture is an unusual but life-threatening complication of LC. Direct visualization of the spleen at the end of LC might be a useful procedure to aid early recognition and management in such cases

A Strange Case of Left Bowel Ischemia after Right Hernioplasty

We report the first observed case of a young man who suffered of large and unsuspected left bowel ischemia following an elective right open hernioplasty. A 54-year-old man had a 2-year history of right inguinal reducible mass and was admitted to hospital for an elective day case open inguinal hernioplasty for a direct right inguinal hernia. Apart from mild hypertension controlled with ACE inhibitor, he was medically fit and well. The patient was submitted to open tension-free mesh repair with polypropylene preshaped mesh with local infiltration anesthesia and additive sedation with midazolam. The local anesthesia and surgery were uneventful and he was discharged home on the same day as per day case protocol. He was readmitted about 12 h after discharge with a history of central and left lower abdominal pain with palpable mass, and distension and fever (38°C). After imaging and laboratory studies the patient was submitted to explorative surgery with the suspicion of left colonic ischemia. After intraoperative confirmation we performed standard left hemicolectomy. The postoperative course was uneventful; the patient was discharged in good general condition on the 7th postoperative day. Actually, the patient is in follow-up, with normal coagulation and hemochromocytometric pattern, asymptomatic for hypercholesterolemia and atrial flutter/fibrillation. Complications relating to bowel during open techniques of hernia repair are limited to two situations: the freeing of an incarcerated or strangulated segment of bowel and inadvertent laceration of large bowel in the presence of a sliding hernia. Following this strange case of colonic ischemia, a boolean Medline search (terms: hernia, complication, repair, groin, herniorrhaphy, hernioplasty, all major MESH subjects without language restriction) revealed no previous similar cases reported. However, to our knowledge, there is another trouble hypothesis: not causality but casualty. In conclusion, to our knowledge this is the first reported case of large left bowel ischemia following right open hernioplasty. We can conclude that the presence of a dolichocolon is an added risk factor for this rare and uneventful complication, but further investigations and case reports are necessary to estabilish the real causality

Thoracoscopy in pleural effusion –two techniques: awake single-access video-assisted thoracic surgery versus 2-ports video-assisted thoracic surgery under general anesthesia

Awake single access video-assisted thoracic surgery with local anesthesia improves procedure tolerance, reduces postoperative stay and costs. MATERIALS & METHODS: Local anesthesia was made with lidocaine and ropivacaine. We realize one 20 mm incision for the 'single-access', and two incisions for the '2-trocars technique'. RESULTS: Mortality rate was 0% in both groups. Postoperative stay: 3dd ± 4 versus 4dd ± 5, mean operative time: 39 min versus 37 min (p < 0.05). Chest tube duration: 2dd ± 5 versus 3dd ± 6. COMPLICATIONS: 11/95 versus 10/79. CONCLUSION: Awake technique reduce postoperative hospital stay and chest drainage duration, similar complications and recurrence rate. The authors can say that 'awake single-access VATS' is an optimal diagnostic and therapeutic tool for the management of pleural effusions, but above extends surgical indication to high-risk patients

Nodular histiocytic/mesothelial hyperplasia as consequence of chronic mesothelium irritation by sub-phrenic abscess.

Nodular histiocytic/mesothelial hyperplasia (NHMH) is a benign localized alteration, first described in 1975 by Rosai in the hernia sac [1]. Few pulmonary cases have been reported in literature [2–6]. Sometimes it has been reported in the pericardium [7,8] or presenting as an inguinal mass [9]. The ‘mesothelial/monocytic incidental cardiac excrescence’, first described by Weinot et al. in 1994 [10] is now considered a similar lesion to NHMH [11]. It consists of a reactive proliferation of histiocytes and mesothelium secondary to chronic irritation and it has been observed in pleura-damaging processes, such as pneumothorax [5], or as consequence of cardiac catheterization, inflammation, mechanical or tumor stimulation [11]. The rarity of NHMH and the moderate cytological atypia often present, make this lesion difficult to diagnose. It can be easily confused with primary mesothelial lesions and neoplasms such as adenocarcinomas, granulosa cell tumors or Langerhans’ histiocytosis. We report a case of pleural NHMH in a patient with a subphrenic abscess, in which no pulmonary pathogenic noxa was evident. We hypothesize a transdiaphragmatic chronic irritation as a pathogenetic mechanism underlying NHMH

Utility of laser microdissection and pressure catapulting in the diagnosis of non small cell lung cancer: preliminary data.

Background: There are controversies about the adequacy of tumor tissue sample on which the sequencing of molecular diagnosis could be performed to achieve the targeted-therapy on lung cancer. The aim of this study is to demonstrate the role of the Laser Microdissection Pressure Catapulting (LMPC) technique to obtain adequate tumor tissue sample for the molecular analysis of gene mutations in the target therapy of lung cancer. Findings: From a consecutive series of 24 patients with a diagnosis of locally-advanced or metastatic Non Small Cell Lung Cancer (NSCLC), we performed 29 diagnostic procedures using the system of LMPC, to obtain an homogeneous samples where it was possible to run the sequencing of the 4 most frequently mutated exons of Epidermal Growth Factor Receptor (EGFR) (exon 18, 19, 20, 21). Results: There were 14 males (58.3%) and 10 females (41.7%), with a mean age of 61 years old. Twenty one patients were affected by adenocarcinomas, 2 by squamous cell carcinomas and 1 by large cell carcinoma. We were able to obtain the sequencing on 26 out 29 samples (89,6%) for EGFR mutation. EGFR mutation rate in our population was 7,7%. In 5 samples, we found a polymorphism in exon 20 and one of them carried a mutation on exon 18 as well. In another sample we found the deletion of exon 19. On the other 20 samples we did not find any mutation. Conclusions: Our preliminary data suggest that the LMPC technique permits to obtain the tumor cells sample more homogeneous facilitating the application of biological molecular analysis for EGFR-gene mutation in a larger number of patients with NSCLC

Wider implications of video-assisted thoracic surgery versus open approach for lung metastasectomy

Lung metastasectomy is considered a safe and potentially curative procedure despite there is not a strong evidence that metastasectomy prolongs long-term survival in patients with lung metastases. Moreover, the debate is open regarding the best approach for lung metastasectomy, video-assisted thoracic surgery versus open approach. A systematic review of literature to clarify what is the best approach to prolong survival in patients with lung metastases was performed. Our study confirms that overall survival is equivalent for video-assisted thoracic surgery and thoracotomy, therefore the ‘gold standard’ surgical treatment for lung metastases remains a point of debate. The choice of the surgical approach still depends more on the single center or surgeon practice than on strong scientific evidence. A prospective randomized trial could clarify the question

Ultrasonography-guided central venous catheterisation in haematological patients with severe thrombocytopenia

BACKGROUND: Cannulation of the internal jugular vein (CVC) is a blind surface landmark-guided technique that could be potentially dangerous in patients with very low platelet counts. In such patients, ultrasonography (US)-guided CVC may be a valid approach. There is a lack of published data on the efficacy and safety of urgent US-guided CVC performed in haematological patients with severe thrombocytopenia. MATERIALS AND METHODS: We retrospectively studied the safety of urgent CVC procedures in haematological patients including those with severe thrombocytopenia (platelet count <30×10(9)/L). From January 1999 to June 2009, 431 CVC insertional procedures in 431 consecutive patients were evaluated. Patients were included in the study if they had a haematological disorder and required urgent CVC insertion. Patients were placed in Trendelenburg's position, an 18-gauge needle and guide-wire were advanced under real-time US guidance into the last part of the internal jugular vein; central venous cannulation of the internal jugular vein was performed using the Seldinger technique in all the procedures. Major and minor procedure-related complications were recorded. RESULTS: All 431 patients studied had haematological disorders: 39 had severe thrombocytopenia, refractory to platelet transfusion (group 1), while 392 did not have severe thrombocytopenia (group 2). The general characteristics of the patients in the two groups differed only for platelet count. The average time taken to perform the procedure was 4 minutes. Success rates were 97.4% and 97.9% in group 1 and group 2, respectively. No major complications occurred in either group. DISCUSSION: US-guided CVC is a safe and effective approach in haematological patients with severe thrombocytopenia requiring urgent cannulation for life support, plasma-exchange, chemotherapy and transfusio