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Pneumonologia I Alergologia Polska 2015A 29-year old man was admitted to the intensive care unit after losing consciousness. On physical examination, a loud systolic murmur over the heart was found....
A 29-year old man was admitted to the intensive care unit after losing consciousness. On physical examination, a loud systolic murmur over the heart was found. Echocardiography revealed narrowing of pulmonary artery with high pressure gradient. Computed tomography of the chest revealed the presence of large tumour localised in the upper anterior mediastinum. Due to the risk of total closure of the pulmonary artery, interventional mediastinotomy was performed and diagnosis of carcinoma embryonale was established. Subsequent chemotherapy (BEP regimen) has brought regression of tumour and significant improvement in haemodynamic parameters (relief of pressure gradient in pulmonary artery). During the second surgery, the resection of all accessible tumour mass together with marginal resection of the right upper lobe was performed. No signs of cardiac or great vessels infiltration was found. Histopathologic examination revealed the necrotic masses and neoplastic foci diagnosed as teratoma immaturum. In a four-month follow-up the patient's condition remained good. The patient is still under the care of both oncological and cardiological specialists. Thus far he has not required further chemotherapy. Holter ECG monitoring revealed no arrhythmia, but the patient is still treated with mexiletine. The patient is planning to return to work.
Topics: Adult; Anti-Arrhythmia Agents; Carcinoma, Embryonal; Echocardiography; Heart Murmurs; Humans; Male; Mediastinal Neoplasms; Mediastinum; Mexiletine; Stenosis, Pulmonary Artery; Tomography, X-Ray Computed
PubMed: 25754058
DOI: 10.5603/PiAP.2015.0024 -
Pneumologie (Stuttgart, Germany) Mar 2015Proper staging of lung cancer represents the basis for any stage-adapted and optimized treatment. This is today implemented in specialized centers mainly through the use...
Proper staging of lung cancer represents the basis for any stage-adapted and optimized treatment. This is today implemented in specialized centers mainly through the use of modern imaging methods and minimally-invasive measures. However, general thoracic surgery has a role not only in the therapeutic management of lung cancer, but offers additional staging information whenever endoscopic or interventional methods fail to achieve representative tissue biopsies of mediastinal lymph nodes or suspect lesions for conclusive diagnosis. The thoracic surgical armentarium comprises of cervical or extended mediastinoscopy, video-assisted mediastinal lymphadenectomy (VAMLA), anterior mediastinotomy (Chamberlain procedure) and video-thoracoscopy (VATS). Indications for any invasive diagnostic methods always have to respect a therapeutic benefit for the patient.
Topics: Diagnostic Techniques, Surgical; Humans; Lung Neoplasms; Neoplasm Staging; Preoperative Care; Thoracic Surgery
PubMed: 25750096
DOI: 10.1055/s-0034-1391100 -
European Journal of Cardio-thoracic... Oct 2015
Topics: Female; Hernia; Herniorrhaphy; Humans; Lung Diseases; Mediastinum; Middle Aged; Rare Diseases; Surgical Mesh; Thoracotomy; Tomography, X-Ray Computed; Treatment Outcome
PubMed: 25681419
DOI: 10.1093/ejcts/ezv022 -
Annals of Thoracic Medicine Jul 2014Ligation and dissection of internal mammary vessels is the most under-estimated complication of anterior mediastinotomy. However, patients requiring anterior... (Review)
Review
Ligation and dissection of internal mammary vessels is the most under-estimated complication of anterior mediastinotomy. However, patients requiring anterior mediastinotomy may experience long survival that makes the development of ischemic heart disease throughout their life possible. Therefore, the un-judicial sacrifice of the internal mammary pedicle may deprive them from the benefit to have their internal mammary artery used as a graft in order to successfully bypass severe left anterior descending artery stenoses. We recommend the preservation of the internal mammary pedicle during anterior mediastinotomy, which should be a common message among our colleagues from the beginning of their training.
PubMed: 24987471
DOI: 10.4103/1817-1737.134067 -
F1000Research 2014Pericardial synovial sarcoma is an extremely rare tumor with poor prognosis. Timely diagnosis and aggressive multimodal management improves patient outcome. We present...
INTRODUCTION
Pericardial synovial sarcoma is an extremely rare tumor with poor prognosis. Timely diagnosis and aggressive multimodal management improves patient outcome. We present our experience of diagnosis and management of a young patient with monophasic synovial sarcoma arising from pericardium.
CASE
A 27-year-old man presented with dyspnea and cough of three weeks duration. Examination revealed sinus tachycardia, distant heart sounds and elevated jugular venous pressure. Chest X-ray showed widened mediastinum. Transthoracic echocardiogram (TTE) noted large pericardial effusion with tamponade physiology. Therapeutic pericardiocentesis yielded hemorrhagic fluid. Computed tomography (CT) of the chest showed persistent pericardial effusion and a left anterior mediastinal mass. Left anterior thoracotomy, pericardial window and left anterior mediastinotomy were done, revealing a well-encapsulated gelatinous tumor originating from the pericardium. Histology and immunohistochemical profile showed the tumor to be a monophasic synovial sarcoma. Fluorescent in-situ hybridization (FISH) was positive for SS18 (SYT) gene rearrangement on chromosome 18q11, substantiating the diagnosis. Work-up for metastases was negative. Neo-adjuvant chemotherapy with high dose ifosfamide led to substantial reduction in the size of the tumor. The patient underwent surgical resection and external beam radiation therapy (EBRT) post surgery. He had symptom-free survival for 8 months prior to local recurrence. This was managed with left lung upper lobectomy and follow-up chemotherapy with docetaxel. The patient is currently stable with an acceptable functional status.
CONCLUSION
In patients with pericardial effusions of unknown etiology, multiple modalities of cardiac imaging must be employed if there is suspicion of a pericardial mass. CT and magnetic resonance imaging (MRI) are useful to evaluate for pericardial thickening or masses in addition to TTE. Treatment of synovial sarcoma is not well established. Surgery is the cornerstone of treatment. In non-resectable tumors, aggressive neo-adjuvant chemotherapy with ifosfamide followed by surgical resection and EBRT may lead to improved outcome.
PubMed: 24715974
DOI: 10.12688/f1000research.3-15.v2 -
Surgical Infections Dec 2013Descending necrotizing mediastinitis (DNM) is a highly morbid infectious process. This uncommon disease process has carried historically a substantial burden of...
BACKGROUND
Descending necrotizing mediastinitis (DNM) is a highly morbid infectious process. This uncommon disease process has carried historically a substantial burden of morbidity and mortality. In this study we hypothesized that application of a prospective modified management algorithm would decrease the morbidity and mortality from this highly destructive process.
METHODS
We developed a systematic approach for managing DNM, focusing on serial debridement guided by imaging, in conjunction with the use of broad-spectrum antibiotics and modern principles of critical care. We reviewed all patients admitted with this disease process from 2007-2012. Data collected included demographic information, co-morbidities, laboratory data including culture results, operative details, imaging frequency and findings, complications, and survival. Continuous variables were reported as median values and ranges.
RESULTS
From 2007-2010, we treated eight patients with DNM. The median age of the patients was 33 y (range 28-63 y), and 63% were male. In accordance with our algorithm, the patients underwent serial imaging at regular intervals following operative debridement. The median number of imaging studies was 11 (range 4-19). The patients required a median of five operative debridements (range 1-15). In five patients, drainage was necessary through a cervical exploration. A thoracic approach was required in six patients (two thoracoscopic, four via thoracotomy). Additional procedures included thymectomy (n=2), anterior mediastinotomy, carotid sheath exploration and resections of the clavicle, first rib, manubrium, pectoralis major muscle, and sternocleidomastoid muscle. The most common etiologic agents were Peptostreptococcus spp. and Streptococcus anginosus. Study patients received a median of six different antibiotics (range 2-10) for a total of 42 d (range 34-55 d). These patients were hospitalized for a median of 29 days (range 16-56 d), with 15 d (range 7-48 d) spent in the intensive care unit. Remarkably, the rate of survival was 100% (median follow-up of 33 mo). The patients developed no major complications, required no re-admissions, and had no re-infections.
CONCLUSIONS
We applied an algorithmic approach to the treatment of DNM, consisting of aggressive operative debridement and enhanced by equally aggressive imaging. Our patients had excellent outcomes despite the widely known lethality of DNM. An aggressive approach may decrease complications and improve survival in this devastating disease process. Furthermore, our prospective experience with DNM suggests that this algorithm used in the present study should be the standard for managing patients with this challenging condition.
Topics: Adult; Anti-Bacterial Agents; Case Management; Critical Care; Debridement; Female; Humans; Male; Mediastinitis; Middle Aged; Optical Imaging; Standard of Care; Survival Analysis; Treatment Outcome
PubMed: 24351133
DOI: 10.1089/sur.2012.079 -
Ethiopian Medical Journal Apr 2013The mediastinum is the space that lies between the two pleural cavities containing many vital structures in it. When tumors or cysts arise in the mediastinum they can be...
BACKGROUND
The mediastinum is the space that lies between the two pleural cavities containing many vital structures in it. When tumors or cysts arise in the mediastinum they can be either asymptomatic or present as space occupying lesions causing symptoms and signs by their effect on the neighboring organs. Though mediastinal tumors are routinely treated at the study center, there are no studies in Ethiopia concerning the patterns, and modes of treatments of Mediastinal space occupying lesions.
OBJECTIVE
To review all the primary mediastinal tumors and cysts operated upon at the Tikur Anbessa Teaching Hospital, Addis Ababa University over a six year period, from August 2005-2011.
METHODOLOGY
Clinical retrospective review.
RESULTS
In the six years, 73 patients were operated, 49 (67.1%) were males, the and male to female ratio being 2.04:1. The mean age of patients was 35.9 +/- 10.5 years (range 14 to 74). Forty-five (61.6%) had lesions of the anterior mediastinum, 23 (31.5%) in the posterior mediastinum and 5 (6.8%) in the middle. The commonest anterior mediastinal tumors were thymic origin (24/45), and thymic lesions were found more common in females (17:7 ratio). From the 23 patients with posterior mediastinal tumors, 18 had benign neurogenic tumors (4 of which were dumbbell tumors). Chest pain and shortness of breath (dyspnea) were the two most common symptoms in 31 (42.4%) of the patients. Twenty three patients (31.5%) were asymptomatic, and all had benign lesions. None of the malignant lesions were asymptomatic. Eleven (15%) patients; eight with anterior and three with posterior mediastinal masses, had undergone pre-operative tissue diagnosis procedure by image guided FNAC. Fifty-nine (80.8%) patients were operated with intent of therapeutic surgical procedures. There were 28 (38.5%) midline sternotomies, 40 (54.7%) thoracotomies, four underwent a left sided mediastinotomies and one mediastinoscopy performed. The rate of malignancy in this study was 24 (32.8%), of which 19 (79.1%) were in the anterior compartment. A total of 13 (17.8%) patients had complications in the hospital and four (5.4%) of the patients died
CONCLUSION
Primary mediastinal tumors are not so rare in the setting. We would also like to recommend further large scale prospective studies which also included long-term outcome so that we can further understand the situation in the country.
Topics: Adolescent; Adult; Aged; Carcinoma; Chest Pain; Dyspnea; Ethiopia; Female; Humans; Lymphoma; Male; Mediastinal Neoplasms; Middle Aged; Neoplasms, Germ Cell and Embryonal; Nervous System Neoplasms; Retrospective Studies; Thymoma; Thymus Neoplasms; Young Adult
PubMed: 24079158
DOI: No ID Found -
Journal of Cardiothoracic and Vascular... Aug 2014
Topics: Adult; Anesthetics; Biopsy; Eosinophilic Granuloma; Female; Humans; Mediastinal Diseases; Nerve Block; Thoracic Vertebrae
PubMed: 24035063
DOI: 10.1053/j.jvca.2013.04.001 -
General Thoracic and Cardiovascular... May 2014Isolated mediastinal amyloidosis is a rare condition. We report an unusual case of amyloid presented as an isolated mass, entirely confined within anterior mediastinum...
Isolated mediastinal amyloidosis is a rare condition. We report an unusual case of amyloid presented as an isolated mass, entirely confined within anterior mediastinum and FDG-avid, mimicking a neoplastic lesion. Because the differential diagnosis included several diseases as lymphoma, a biopsy via mediastinotomy was attended to avoid unnecessary sternotomy. The pathological results diagnosed to be an amyloidosis. The patient was asymptomatic and biopsy allowed an exact diagnosis, thus we decided against the complete excision. No monoclonal gammopathy and/or amyloid deposition were found. Thus, other treatments as high-dose melphalan and/or autologous stem cell transplantation were not indicated.
Topics: Aged; Amyloidosis; Biopsy; Diagnosis, Differential; Humans; Male; Mediastinal Diseases; Mediastinal Neoplasms; Mediastinum; Radiography; Radionuclide Imaging
PubMed: 23585190
DOI: 10.1007/s11748-013-0251-3 -
Updates in Surgery Mar 2013Anterior mediastinotomy and VATS are today the most common surgical approaches to obtain tissue diagnosis or to remove mediastinal lesions. However, both methods lead to...
Anterior mediastinotomy and VATS are today the most common surgical approaches to obtain tissue diagnosis or to remove mediastinal lesions. However, both methods lead to inconveniences. This report demonstrates the advantages of a minimal access mediastinotomy to remove or diagnose mediastinal lesions.
Topics: Adult; Aged; Female; Humans; Male; Mediastinal Diseases; Mediastinoscopy; Mediastinum; Middle Aged
PubMed: 23179460
DOI: 10.1007/s13304-012-0187-7