[Show abstract][Hide abstract] ABSTRACT: A previously healthy 57-year-old woman was admitted to the Emergency Department with hemothorax. She had continuously blood loss during the next 24 hours accordingly she went to the OR in order to achieve hemostasis.Intraoperative findings were multiple lesions in the lung parenchyma and diffuse bleeding from multiple small abnormal nodules on the surface of the visceral pleural and parietal pleura.Biopsies prompted the diagnosis of angiosarcoma and with the primary tumour burden in the lung parenchyma the pathologist diagnosed a primary pulmonary angiosarcoma.The disease was widespread at the time of diagnosis accordingly curative intended treatment was not an option and because of her general poor condition she died one day after discharge.
[Show abstract][Hide abstract] ABSTRACT: Background:
Video-assisted thoracic surgery (VATS) resection of pulmonary metastases has long been questioned because radiologically undetected parenchymal lesions may be missed when bimanual palpation is restricted to the portholes. Technology, however, has improved and advanced VATS resections are now performed routinely worldwide. This prompted us to conduct a prospective observer-blinded study on pulmonary metastasectomy.
Eligible patients with oligometastatic pulmonary disease on computed tomography (CT) underwent high-definition VATS, with digital palpation by 1 surgical team and subsequent immediate thoracotomy during the same anesthesia by a different surgical team, with bimanual palpation and resection of all palpable nodules. Preoperative CT evaluations and surgical results were blinded. Primary endpoints were number and histopathology of detected nodules.
During a 3-year period 89 consecutive patients, with newly developed nodules suspicious of lung metastases from previous cancers in colon-rectum (n=59), kidney (n=15), and other malignancies (n=15) were included, with a total of 140 suspicious nodules visible on CT. During VATS, 122 nodules were palpable (87%). All nodules were identified during thoracotomy, where 67 additional and unexpected nodules were also identified; 22 were metastases (33%), 43 (64%) were benign lesions, and 2 (3%) were primary lung cancers.
In patients operated for nodules suspicious of lung metastases, a substantial number of additional nodules were detected during thoracotomy despite advancements in CT imaging and VATS technology. Many of these nodules were malignant and would have been missed if VATS was used exclusively. Consequently, we considered VATS inadequate if the intention is to resect all pulmonary metastases during surgery.
The Annals of Thoracic Surgery 06/2014; 98(2). DOI:10.1016/j.athoracsur.2014.04.063 · 3.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We report a rare case of a primary schwanoma in trachea causing airway symptoms in a 78-year-old male. Benign tracheal tumours are often misdiagnosed as asthma or chronic lung disease and should be considered in patients who present with symptoms as upper airway obstruction and haemoptysis. In this case story the patient was treated with endoscopic resection of the tumour.
[Show abstract][Hide abstract] ABSTRACT: Boerhaave's syndrome or spontaneous esophageal perforation is a rare condition, with high mortality. We describe a case of Boerhaave's syndrome presenting with tension pneumothorax. The patient was infected with Norovirus and developed Boerhaave's syndrome, initially thought to be gastroenteritis but later developing with tension pneumothorax, and mediastinitis caused by esophageal perforation. The patient was treated with thoracotomy with primary suture and oesophageal stent placement. He had a long period of recovery and was discharged after 98 days. Boerhaaves syndrome is often delayed and must be considered in any patient with respiratory symptoms and a recent history of vomiting.
[Show abstract][Hide abstract] ABSTRACT: Benign tumours in the posterior mediastinum are often asymptomatic until they reach a considerable size. Technically it is easier to remove the tumour when it is small, but these patients are often asymptomatic and therefore the tumours are rarely found before the patients become symptomatic. During 2010 three patients underwent resection of large benign tumours in the posterior mediastinum with a diameter more than 10 centimetres. We discuss, when should large benign tumours in posterior mediastinum be resected. We conclude that symptomatic patients with large benign tumours should be referred directly for surgery independent of size while asymptomatic patients should be followed regularly and referred for surgical treatment if their tumour increases in size because surgery may be hazardous as size of the tumour increases and more likely to be associated with major postoperative morbidity.
[Show abstract][Hide abstract] ABSTRACT: Background:
Patients with limited metastatic disease in the lung may benefit from metastasectomy. Thoracotomy is considered the gold standard, and video-assisted thoracoscopic surgery (VATS) is controversial because nonimaged nodules may be missed when bimanual palpation is restricted. Against guideline recommendations, metastasectomy with therapeutic intent is now performed by VATS by 40% of thoracic surgeons surveyed. The evidence base for optimal surgical approach is limited to case series and registries, and no comparative surgical studies were observer blinded.
Patients considered eligible for pulmonary metastasectomy by VATS prospectively underwent high-definition VATS by one surgical team, followed by immediate thoracotomy with bimanual palpation and resection of all palpable nodules by a second surgical team during the same anesthesia. Both surgical teams were blinded during preoperative evaluation of CT scans and during surgery. Primary end points were number and histology of nodules detected.
During a 12-month period, 37 patients were included. Both surgical teams observed exactly 55 nodules suspicious of metastases on CT scans. Of these, 51 nodules were palpable during VATS (92%), and during subsequent thoracotomy 29 additional nodules were resected: Six (21%) were metastases, 19 (66%) were benign lesions, three (10%) were subpleural lymph nodes and one was a primary lung cancer.
Modern VATS technology is increasingly used for pulmonary metastasectomy with therapeutic intent, but several nonimaged, and therefore unexpected, nodules are frequently found during subsequent observer-blinded thoracotomy. A substantial proportion of these nodules are malignant, and, despite modern imaging and surgical technology, they would have been missed if VATS was used exclusively for metastasectomy with therapeutic intent.
[Show abstract][Hide abstract] ABSTRACT: Aggressive intravenous thrombolysis of pulmonary emboli after major thoracic surgery has rarely been reported and is controversial because of an assumed risk of fatal bleeding. We report a 62-year old female who underwent left upper lobectomy. Her postoperative course was complicated with symptomatic pulmonary embolism and on postoperative day 5 she was successfully treated with intravenous thrombolysis using alteplase (Actilyse(®)) without signs of bleeding. She was discharged from the hospital 12 days postoperatively.
Interactive Cardiovascular and Thoracic Surgery 02/2012; 14(5):660-1. DOI:10.1093/icvts/ivs002 · 1.16 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A 59-year-old man with previous anaplastic large cell T-cell lymphoma stage 3A was admitted with an isolated positron emission tomography(PET)-positive spot in a subcarinal lymph node. Diagnosis was achieved with endobronchial ultrasound-guided fine-needle aspiration demonstrating a well-differentiated squamous cell carcinoma but no primary tumor was visible on PET-computed tomography. Because of his previous lymphoma the patient was scheduled for mediastinoscopy where the diagnosis was confirmed. Subsequent gastroscopy was normal and a right-sided thoracotomy showed no evidence of cancer elsewhere, only an inoperable metastasis in a subcarinal lymph node which infiltrated the trachea, esophagus and aorta. Such isolated squamous cell carcinoma in a subcarinal lymph node without a primary tumor despite invasive work-up has not been reported before.
Thoracic Cancer 05/2011; 2(2). DOI:10.1111/j.1759-7714.2010.00039.x · 0.90 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A 71-year-old female was referred with three right-sided intrathoracic tumours. In 2003, she underwent radical left nephrectomy for renal cell cancer (RCC) clinical stage 1. She was since followed at her local hospital with annual computed tomography (CT)-scans during the first five years and did not present any symptoms until October 2009 when she was admitted with shortness of breath, cough and tiredness. The patient was scheduled for a diagnostic thoracoscopy when it was discovered that her lesions were not located in the lung parenchyma but were protruding nodules from the parietal pleura. Histology demonstrated metastases from RCC which apparently can reach the parietal pleura without lung metastases.
Interactive Cardiovascular and Thoracic Surgery 11/2010; 12(2):301-2. DOI:10.1510/icvts.2010.245340 · 1.16 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Lesions in mediastinum can represent malignancy and warrants further workup. Commonly a diagnosis is achieved by conventional bronchoscopy, transbronchial needle aspiration or CT guided fine needle aspiration, however a number of patients remain undiagnosed despite these common investigations
During a period of 36 months 601 patients underwent EBUS at our institution. Two hundred ninety three patients had an established diagnosis of lung cancer and were referred to us for mediastinal staging. The remaining patients had a radiologically suspicious intrathoracic lesion of which 107 had an undiagnosed lesion in mediastinum. All patients had been investigated by previous chest CT and bronchoscopy including brush cytology but remained undiagnosed.
Of the 107 patients with undiagnosed lesions in the mediastinum 89 enlarged lymph nodes and 18 mediastinal tumours. Forty-eight of the 89 patients (54%) with enlarged mediastinal lymph nodes were diagnosed by EBUS of the remaining 41 patients 11 went on to more invasive methods. In patients with undiagnosed tumours in mediastinum we achieved a final diagnosis by EBUS in 14 of the 18 patients (78%) and 3 went on to more invasive methods.
EBUS provides a final diagnosis in 78% of patients with tumour in mediastinum and in more than half of patients with enlarged lymph nodes despite previous workup.
[Show abstract][Hide abstract] ABSTRACT: Endobronchial ultrasound-guided transbronchial fine-needle aspiration (EBUS) is a minimally invasive method used routinely for mediastinal staging of patients with lung cancer. EBUS has also proved to be a valuable diagnostic tool for patients with different intrathoracic lesions who remain undiagnosed despite bronchoscopy and CT-guided fine-needle aspiration.
The present study focused on EBUS for diagnosing sarcoidosis.
During a 3-year period 308 of 601 patients who underwent EBUS at our institution were referred for further diagnostic of a radiologically suspicious lesion in the lung parenchyma (n = 195), enlarged lymph nodes in the mediastinum (n = 89), a suspicious tumor in the mediastinum or pleural disease (n = 24) but no one had a definite histological diagnosis. All charts were reviewed retrospectively.
Of the 308 patients 43 (14%) were eventually diagnosed with sarcoidosis. Thirty-three (77%) were diagnosed with EBUS. In the remaining 10 patients EBUS did not provide adequate tissue samples in 4 (9%) and in 6 patients (14%) EBUS provided adequate tissue but no definite diagnosis. EBUS was significantly better to establish the diagnosis in patients with enlarged mediastinal lymph nodes compared with isolated lung parenchymal involvement (85% vs 63%, p < 0.05).
EBUS is a valuable minimally invasive diagnostic modality to establish the diagnosis of sarcoidosis of unselected patients with undiagnosed intrathoracic lesions after conventional work up--particularly if patients have enlarged mediastinal lymph nodes. This minimally invasive procedure provides a final diagnosis without exposing the patient to the risk of complications from more invasive procedures.
Sarcoidosis, vasculitis, and diffuse lung diseases: official journal of WASOG / World Association of Sarcoidosis and Other Granulomatous Disorders 07/2010; 27(1):43-8. · 1.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A number of patients with radiologically suspicious chest tumors remain undiagnosed despite bronchoscopy or CT-guided fine-needle aspiration (CT-FNA). Such patients are often referred for mediastinoscopy, which is an invasive surgical procedure that poses a small but significant risk to the patient. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS) is a well-established method for mediastinal staging of lung cancer but may also be used as a diagnostic tool in patients with undiagnosed intrathoracic lesions.
During a 36-month period (January 2006 to December 2008), 601 patients underwent EBUS under general anesthesia. Two hundred ninety-three (293) patients had an established diagnosis of lung cancer and were referred to us for mediastinal staging. The remaining 308 patients had a radiologically suspicious lesion and had been investigated previously by CT and bronchoscopy, including brush cytology, but remained undiagnosed.
Overall, EBUS was able to diagnose 55% of the 308 patients. Diagnostic yield was significantly higher in central parenchymal lesions (72%) compared with enlarged lymph nodes (54%) or peripheral lesions (43%) (P < 0.05). All patients were examined as outpatients and there was not a single complication in any patient.
EBUS is a valuable tool to diagnose chest lesions and yield depends on the anatomical location. We believe that EBUS should be the first choice for further workup in patients who remain undiagnosed after conventional CT and bronchoscopy because it is very safe, fast, and minimally invasive.
World Journal of Surgery 04/2010; 34(8):1823-7. DOI:10.1007/s00268-010-0536-y · 2.64 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Endobronchial ultrasound-guided transbronchial fine-needle aspiration (EBUS-FNA) is a minimally invasive method used routinely for mediastinal staging of patients with lung cancer. We have used it in 135 consecutive patients with a radiologically suspicious intrathoracic lesion that remained undiagnosed despite bronchoscopy and CT-guided fine-needle aspiration (CT-FNA). There was no operative mortality or surgical complications. In 98 patients with a suspicious lesion in the lung parenchyma, adequate tissue was obtained in 83 patients (85%) and in 37 patients with enlarged lymph nodes or a mediastinal tumor adequate tissue was obtained in 35 cases (95%). However, a final diagnosis was only reached in 45% of the patients and further investigations led to malignancy in 13. We believe that EBUS-FNA represents a good alternative to more invasive diagnostic procedures when conventional methods fail, even though the diagnostic yield is lower compared with mediastinal staging in patients with known lung cancer. In almost half of the cases, EBUS-FNA provides the final diagnosis without exposing the patient to the risk of complications from more invasive procedures.
Interactive Cardiovascular and Thoracic Surgery 06/2009; 9(2):232-5. DOI:10.1510/icvts.2009.204263 · 1.16 Impact Factor