Purpose: Pleural nodular histiocytic/mesothelial hyperplasia is a nodular histiocytic/ mesothelial proliferation, often delimiting cystic cavities, due to irritation by a pulmonary noxa. Case report results: The patient had right pleural parietal and diaphragmatic thickness, with pleural effusion, without lung alterations. He previously underwent left hemicolectomy and liver resection, due to a diverticulitis and a liver histiocytes-rich abscess. Video-assisted thoracoscopy biopsy showed a double population of reactive mesothelial cells and histiocytes. Conclusion: Nodular histiocytic/mesothelial hyperplasia represents a potential pitfall for pathologists. Immunohistochemistry is crucial for the differential diagnosis with some malignancies. We suggest that in our patient, a chronic mesothelium inflammation happened by transdiaphragmatic involvement as a consequence of the liver abscess. Some pathogenetic mechanisms are hypothesized. KEYWORDS• mesothelial hyperplasia • pleural effusion • VATS 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][3][4][5][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. Case reportA 57-year-old man presented to our department in June 2014, due to the presence of a right pleural effusion with undefined diagnosis. At admission he had no fever, infections or history of exposure to asbestos and other dust. Shortness of breath after moderate exertion was noted, blood pressure was 130/85 mmHg and heart rate 77 bpm with normal sinus rhythm. Physical examination showed abolition of breath sounds and fremitus on all fields on the right side and dullness plexus. The patients drug history was negative. Due to the onset of pleural effusion and dyspnea, the patient For reprint orders, please contact: reprints@futuremedicine.com
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. KEYWORDS• awake VATS • pleural effusion • single port • VATSThe history of video-assisted thoracic surgery (VATS) utilizing the local anesthesia and sedation is almost one century old with Jacobeus and Bethune [1].The authors started an 'awake single port VATS' program because they hypothesized that the use of just one access associated with local anesthesia might be feasible and could result in a better procedure acceptance, in a more rapid recovery, in a reduced procedure-related cost and in a more less invasive procedure.A single access associated with local anesthesia aims to improve procedure tolerance, shorten recovery and reduce costs. Materials & methodsThe authors retrospectively analyzed 174 patients with pleural effusion treated by awake technique or general anaesthesia. At admission, patients underwent complete laboratory assay, blood gases, chest roentgenograms, ectrocardiogram and eventually chest computed tomography (CT) scan and cardiological evaluation. An informed consent was obtained from all patients, including possibility of endotracheal intubation and thoracotomy. Premedication consisted in atropine 0.01 mg/kg and ondansetron 8 mg. Pain control and sedation were obtained by remifentanile (0.05-0.1 μg/kg/min) and midazolam (0.02-0.04 mg/kg). In the operating room, the patient was turned to a full lateral decubitus position and the table was flexed to widen the rib spaces on the operation side. A small antidecubitus mattress was placed below the dependent hemitorax to obtain a slight splitting of intercostal spaces without patient's discomforts. The position of the lonely trocar was usually defined with the help of utrasound (US). The using of US to choose the site of access was a rapid and safe method that helped to visualize the pleural effusion and that guided the operator to define the site of access, keeping away from some 'hazardous areas.' A line which included the plan of incision was drawn and the standard antiseptic procedure was performed. Local anesthesia was obtained with For reprint orders, please contact: reprints@futuremedicine.com
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. Keywords• CT-guided biopsy • lung metastasis • transthoracic needle biopsy It is known that the lungs are a common site for metastases from other primary cancers, such as breast, colon and sarcomas. Although in the patients with high-risk of lung metastasis the increasing utility of computed tomography (CT) low-dose screening has grown dramatically the sensitivity of identifying small lung nodules [1], CT-guided needle biopsy (CTgNB) of lung metastases (LM) with automatic or semi-automatic biopsy gun have proven to bring in diagnostic label with few complications and is widely accepted as accurate and safe procedure for characterizing pulmonary nodules. [2] Percutaneous transthoracic needle biopsy guided by CT is considered as a relatively well and safe method for diagnosing LM [3]. The rates of diagnostic accuracy have been documented between 72 and 100% for pulmonary metastatic lesions. However, the diagnostic accuracy decrease for smaller lesions between 10 and 20 mm; several studies have reported the diagnostic accuracy range of 52 and 96.5% [4,5].The purpose of our study was to review our experience with CT-guided biopsy of suspected LM with a view to providing a critical assessment of the efficacy and safety of the procedure.For reprint orders, please contact: reprints@futuremedicine.com
INTRODUCTION AND OBJECTIVES: Elderly patients are a vulnerable population at increased risk for treatment-related toxicity. Almost 25% of the urological population is older than 75 years. Methods to reduce the morbidity from surgery are eagerly awaited. ASA classification is a system for assessing the fitness of patients before surgery worldwide adopted. A frailty index predicting adverse outcomes in urologic oncological major surgeries was validated by Lascano (1) and simplified by Chappidi (2) for radical cystectomy. The aim of our prospective study was to compare the modified frailty index (mFI) and the ASA score in consecutive patients undergoing urological procedures for oncological and non-oncological diseases.METHODS: Consecutive patients undergoing urological procedures were prospectively entered. The surgical intervention were classified as follows: 1. Major open/laparoscopic; 2. Lower urinary tract endoscopy; 3. Upper urinary tract procedures; 4 Minor surgery. For all patients age, ASA score, BMI, serum albumin, smoking history and routine hematological exams were preoperatively recorded. mFI was calculated. Operative time, hospital length of stay and post-operative complications according to Clavien-Dindo classification were recorded.RESULTS: 247 consecutive patients, 203 men and 44 women underwent urological surgery. Age was over 75 years in 53 (21%) patients. Patients' characteristics are given in table 1. While 239 (97%) were assigned in ASA 2 and 3 categories, they resulted more widely distributed among the 5 MFI levels.Particularly of the 165 patients classified as ASA 3-4, 37 (22.4%) only were allocated in 3-5 mFI index and on the contrary of the 82 patients in ASA 1-2 classes, 79 (96.3%) were allocated in 0-2 mFI categories.At univariate analysis both ASA and mFI were not associated with any complications (p[0.76 and p[0.67), serious complications (p[0.06 and p[0.49), and late complications rates (p[0.46 and p[0.28). mFI was associated with age (p<0.05) only, while ASA index only with age (p<0.05), readmission rate (p[0.03) and length of hospital stay (p[0.004).CONCLUSIONS: A correspondence between ASA and mFI emerges only for low risk classes, since 22% only of the patients classified as ASA 3-4 resulted allocated in the corresponding high risk classes of mFI. In Both mFI and ASA were not associated with complication incidence when oncological and non oncological urologic surgery is considered.
BackgroundPlasmoblastic lymphoma is a rare and aggressive subtype of diffuse large B cell lymphoma, which occurs usually in the jaw of immunocompromised subjects.Case presentationWe describe the occurrence of plasmoblastic lymphoma in the mediastinum and chest wall skin of an human immunodeficiency virus-negative 63-year-old Caucasian man who had had polycytemia vera 7 years before. At admission, the patient showed a superior vena cava syndrome, with persistent dyspnoea, cough, and distension of the jugular veins. Imaging findings showed a 9.7 × 8 × 5.7 cm mediastinal mass. A chest wall neoformation biopsy and ultrasound-guided fine-needle aspiration biopsy of the mediastinal mass allowed diagnosis of plasmoblastic lymphoma and establishment of an immediate chemotherapeutic regimen, with rapid remission of compression symptoms.ConclusionsPlasmoblastic lymphoma is a very uncommon, difficult to diagnose, and aggressive disease. The presented case represents the first rare mediastinal plasmoblastic lymphoma in a human immunodeficiency virus-/human herpesvirus-8-negative patient. Pathologists should be aware that this tumor does appear in sites other than the oral cavity. Fine-needle aspiration biopsy is a low-cost, repeatable, easy-to-perform technique, with a high diagnostic accuracy and with very low complication and mortality rates. Fine-needle aspiration biopsy could represent the right alternative to surgery in those patients affected by plasmoblastic lymphoma, being rapid and minimally invasive. It allowed establishment of prompt medical treatment with subsequent considerable reduction of the neoplastic tissue and resolution of the mediastinal syndrome.
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