Surgical treatment of mediastinal cysts: report on 29 cases

AIM

Mediastinal cysts are rare, forming 12-18% of all primary mediastinal tumors. The purpose of this study is to evaluate type, clinical properties, treatment modalities, and results of mediastinal cystic neoplasm in the light of available literature.

PATIENTS AND METHODS

We retrospectively investigated 29 patients who were diagnosed and surgically treated for mediastinal cysts in our clinic between January 1996 and May 2011.

RESULTS

Sixteen (55.2%) patients were male and 13 (44.8%) were female. The average age of the patients was 36.5 +/- 22.1 (17-77 years old). The mediastinal cysts comprised 11 (37.9%) bronchogenic cysts; seven (24.1%) hydatid cysts; four (13.8%) benign cystic teratomas; three (10.3%) pericardial cysts; one (5.3%) thymic cyst; one (5.3%) cyst of the thoracic duct; one (5.3%) enteric cyst; and one (5.3%) lymphangioma. Approach methods were thoracotomy in 18 (62.1%) cases; video-assisted thoracoscopicsurgery (VATS) in seven (24.1%) cases; median sternotomy in three (10.3%) cases; and anterior mediastinotomy in one case. Postoperative observations during the follow-up period showed chylothorax in one patient; pleural effusion in one patient; and the recurrence of a bronchogenic cyst in one patient five years after the operation. Postoperative mortality did not occur in any case. The average postoperative hospitalization period was 7.3 days (2-14 days).

CONCLUSION

A surgical approach to mediastinal cysts offers histological analysis, pathological diagnosis, curative treatment, and prevention from complications.

A new risk factor in oesophageal cancer aetiology: hyperthyroidism

PURPOSE

In individuals with malignant disease, many qualitative and quantitative hormonal changes have been detected. Although there are many studies showing that there is a relationship between thyroid hormone disorders and certain tumours, no study investigating the association between oesophageal cancer and thyroid diseases has been reported. The present study was designed to evaluate whether there is a relationship between oesophageal cancer and thyroid hormones.

METHODS

In a prospective study conducted between December 2006 and February 2008, thyroid functions were studied in a group of 102 sequential patients with oesophageal cancer and a control group of 160 sequential patients without oesophageal cancer, presenting to the Thoracic Surgery Department of Ataturk University. Age, gender, tumour location and histological type in patients with oesophageal cancer were recorded.

RESULTS

Of 102 patients with oesophageal cancer, 21 (20.58%) had hyperthyroidism, 2 (1.96%) had hypothyroidism and 6 (5.88%) exhibited nodular/multinodular goitre on ultrasonography and computed tomography. In the control group, 8 patients (5.0%) had hyperthyroidism, 4 (2.5%) had hypothyroidism and 7 (4.38%) showed nodular/multinodular goitre. In patients with oesophageal cancer, the incidence of hyperthyroidism was found to be significantly higher compared to the control group (p < 0.001).

CONCLUSION

Data show that there may be an important relationship between oesophageal cancer and hyperthyroidism. We believe that thyroid hormone levels should be measured in all cases of oesophageal cancer. In further prospective and experimental studies, the physiopathology of this relationship can be fully explained.

The use of self-expandable metallic stents for palliative treatment of inoperable esophageal cancer

Most patients with esophageal carcinoma present in the advanced stage die from tumor invasion and widespread metastases. Because radical regimens are not appropriate for the majority of patients, and their expected survivals are as short as to be measured by months, the main aim of therapy is palliation with minimum morbidity and mortality. Among the palliative modalities are surgery, external radiotherapy or brachytherapy, dilatation, laser, photodynamic therapy, bipolar electrocoagulation tumor probe, and chemical ablation. The placement of self-expandable metallic stents is another method that improves dysphagia for these patients. In this study, the aim was to evaluate retrospectively the effectiveness of metallic stents deployed because of inoperable malignant esophageal stenosis and esophagotracheal fistulas. The results of 170 patients with 202 stents administered because of inoperable malignant esophageal stenosis and esophagorespiratory fistula between January 2000 and October 2008 at the Ataturk University, Department of Thoracic Surgery, were investigated. Despite epidemiological and clinical data, information regarding relief of dysphagia and quality of life were also examined. One hundred seventy patients with stents were between 28 and 91 years old (mean age 63.7 years+/-11.4 years). Ninety-seven were male and 73 were female. Stent indications were advanced tumors with distant metastasis (82 cases, 48.2%), unresectable tumors (51 cases, 30%), patients who cannot tolerate surgery or chemoradiotherapy (18 cases, 10.5%), local recurrence after primary therapy (1 case, 0.5%), esophagorespiratory fistulas from tumor or therapy (14 cases, 8.2%), and refusal of surgery (4 cases, 2.3%). Dysphagia scores evaluated by a modified Takita's grading system improved from 3.4 before the procedure to 2.6 afterward. The overall complication rate without chest pain was 31.7% (occurring in 64 cases). Mean survival was 177.7 days+/-59.3 days (2-993 days). Quality-of-life scores (The European Organization of Research and Treatment of Cancer QLQ C30) improved from 73+/-10.3 (57-85) to 112+/-12.6 (90-125). In therapy of malignant esophageal obstructions, metallic stents provide a significant improvement in dysphagia and require less frequent re-intervention according to other methods of dysphagia palliation such as dilatation, laser, and photodynamic therapy, nearly completely relieve esophagotracheal fistulas and improve quality of life to an important degree.

Total occlusion of the superior vena cava due to bronchogenic cyst

Bronchogenic cysts are the most common form of congenital cystic lesions in the mediastinum. Of all cases with bronchogenic cysts, 1/3 are symptomatic. The symptoms vary depending on the location and compression of the adjacent structures of the cyst. Some mediastinal bronchogenic cysts can cause severe respiratory distress due to airway and vascular compression. We herein present a case with a bronchogenic cyst that required venoplasty to the superior vena cava (SVC) due to total occlusion of the SVC.

Muco-epidermoid carcinoma of the oesophagus: a case report

Muco-epidermoid carcinomas (MECs) are typically located in the salivary, lacrimal and tracheobronchial glands. However, they can also be present in the oesophagus. Primary MECs of the oesophagus account for 0.05% to 2.2% of all cases of primary oesophageal cancer. Treatment for this tumour has primarily been surgical resection. In this report we present the surgical and pathological findings of a primary MEC of the oesophagus in an 82-year-old woman and review the management options for this tumour.

Current management of esophageal perforation: 20 years experience

Esophageal perforations are surgical emergencies associated with high morbidity and mortality rates. No single strategy has been sufficient to deal with the majority of situations. We aim to postulate a therapeutic algorithm for this complication based on 20 years of experience and also on data from published literature. We performed a retrospective clinical review of 44 patients treated for esophageal perforation at our hospital between January 1989 and May 2008. We reviewed the characteristics of these patients, including age, gender, accompanying diseases, etiology of perforation, diagnosis, location, time interval between perforation and diagnosis, treatment of the perforation, morbidity, hospital mortality, and duration of hospitalization. Perforation occurred in the cervical esophagus in 14 patients (31.8%), thoracic esophagus in 18 patients (40.9%), and abdominal esophagus in 12 patients (27.3%). Management of the esophageal perforation included primary closure in 23 patients (52.3%), resection in 7 patients (15.9%), and nonsurgical therapy in 14 patients (31.8%). In the surgically treated group, the mortality rate was 3 of 30 patients (10%), and 2 of 14 patients (14.3%) in the conservatively managed group. Four of the 14 nonsurgical patients were inserted with covered self-expandable stents. The specific treatment of an esophageal perforation should be selected according to each individual patient. To date, the most effective treatment would appear to be operative management. With improvements in endoscopic procedures, the morbidity and mortality rates of esophageal perforations are significantly decreased. We suggest that minimally invasive techniques for the repair of esophageal perforations will be very important in the future treatment of this condition.

Ethyl pyruvate protects colonic anastomosis from ischemia-reperfusion injury

Ethyl pyruvate is a simple derivative in Ca(+2)- and K(+)-containing balanced salt solution of pyruvate to avoid the problems associated with the instability of pyruvate in solution. It has been shown to ameliorate the effects of ischemia-reperfusion (I/R) injury in many organs. It has also been shown that I/R injury delays the healing of colonic anastomosis. In this study, the effect of ethyl pyruvate on the healing of colon anastomosis and anastomotic strength after I/R injury was investigated. Anastomosis of the colon was performed in 32 adult male Wistar albino rats divided into 4 groups of 8 individuals: (1) sham-operated control group (group 1); (2) 30 minutes of intestinal I/R by superior mesenteric artery occlusion (group 2); (3) I/R+ ethyl pyruvate (group 3), ethyl pyruvate was administered as a 50-mg/kg/d single dose; and (4) I/R+ ethyl pyruvate (group 4), ethyl pyruvate administration was repeatedly (every 6 hours) at the same dose (50 mg/kg). On the fifth postoperative day, animals were killed. Perianastomotic tissue hydroxyproline contents and anastomotic bursting pressures were measured in all groups. When the anastomotic bursting pressures and tissue hydroxyproline contents were compared, it was found that they were decreased in group 2 when compared with groups 1, 3, and 4 (P < .05). Both anastomotic bursting pressure (P = .005) and hydroxyproline content (P < .001) levels were found to be significantly increased with ethyl pyruvate administration when compared with group 2. When ethyl pyruvate administration doses were compared, a significant difference was not observed (P > .05). Ethyl pyruvate significantly prevents the delaying effect of I/R injury on anastomotic strength and healing independent from doses of administration.

The management of esophagogastric anastomotic leak after esophagectomy for esophageal carcinoma

Esophagogastric anastomotic leaks are the most feared surgical complications following resection of esophageal cancers. We aimed to develop a therapeutic algorithm for this complication characterized by high morbidity and mortality using our 20 years of experience and the published literature. A total of 354 patients who had undergone an esophagectomy and esophagogastric anastomosis due to esophageal carcinoma were evaluated retrospectively. The incidence for anastomotic leak was 15.5% (n = 90) in the cervical region and 4.2% (n = 264) in the thoracic region (mean: 7.1%). Cervical anastomotic leaks were detected after a mean period of 7.2 days following the procedure. Fourteen patients with cervical leaks were treated conservatively. Four out of 14 patients (28.6%) died due to sepsis and multi-organ failure related to fistula. Thoracic anastomotic leaks were detected after a mean period of 4.7 days following the procedure. Emergency reoperation, resection and reconstruction procedures were performed in one patient. Self-expanding metallic coated stents were placed at the anastomosis region in two patients. A more conservative approach was employed in other patients with thoracic anastomotic leaks. Six of them (46.2%) died due to fistula. General mortality rate was 37.0%, and the duration of hospitalization was 40.0 days for patients with anastomotic leaks. Cervical anastomotic leaks are more common than thoracic anastomotic leaks, but most of them are successfully treated with conservative approaches. Thoracic anastomotic leaks that in the past were related to high mortality rates despite conservative or surgical procedures might be successfully treated nowadays with the use of self-expanding metallic coated stents.

Factor V 1691 G-A (Leiden) polymorphism and cancer-related venous thromboembolism: a meta-analysis of published studies

PURPOSE

Although one of the most common genetic polymorphisms that predispose to venous thromboembolism (VTE) is factor V 1691 G-A (Factor V Leiden; FVL), the effect of this polymorphism on the development of VTE in cancer patients is unclear. We have therefore performed a meta-analysis to estimate the risk of VTE associated with FVL among cancer patients.

MATERIALS AND METHODS

Relevant studies published before May 2006 were retrieved from Pubmed/Medline. We selected studies comparing the prevalence of FVL in cancer patients with VTE with cancer patients without VTE. Both fixed and random effect models were used. P-values and odds ratios (ORs) with 95% confidence intervals (95% CI) were calculated by Fisher's exact test.

RESULTS

Pooled results from 9 studies, comprising 397 cancer patients with VTE and 678 cancer patients without VTE revealed that the prevalence of FVL was higher among cancer patients with VTE (7.3%) than those without VTE (4.6%) (chi(2) = 34.633 > chi(2) (18; 0.05) =28.869) (p=0.013). It was also found that mean effect size of FVL was 0.22 (95% CI 0.051-0.4892). Using the homogeneity test, there was evidence of statistical heterogeneity (Q(hom)= 46.334> chi(2) (8; 0.05) =15.507) (p=0.0000).

CONCLUSION

Although the published studies were small and the meta-analysis demonstrated an association of FVL with cancer-related thrombosis, testing for FVL can be routinely used as part of clinical thrombophilia assessment in cancer patients from the regions with high incidence of FVL.

Intramural esophageal bronchogenic cysts: a review of the literature

Bronchogenic cysts are rare congenital cystic lesions mostly located in the middle and superior mediastinum. Esophageal bronchogenic cysts are extremely rare. We review here 23 cases reported in English in the literature to date of intramural esophageal bronchogenic cyst and their features, including our patient. Although they are extremely rare, intramural esophageal bronchogenic cysts should be kept in mind in the differential diagnosis of benign esophageal lesions. With accurate diagnosis and treatment the prognosis is excellent and serious complications may be prevented.

Total intravenous anesthesia for evacuation of a hydatidiform mole and termination of pregnancy in a patient with thyrotoxicosis

Clinical hyperthyroidism is found in approximately 5% of women with a hydatidiform mole, as human chorionic gonadotropin secreted by molar tissue is structurally similar to thyroid-stimulating hormone. A hydatidiform mole occasionally presents with a co-existing viable fetus. Surgical evacuation may be indicated for significant hemorrhage or preeclampsia. Perioperative management in the presence of hyperthyroidism may be complicated by a thyroid storm. We report a case of total intravenous anesthesia with propofol and remifentanil, combined with an esmolol infusion, to control sympathetic hyperactivity during surgery.

Fibroadenoma in supernumerary breast

The presence of supernumerary breast (or polymastia) is not uncommon; however, reports of fibroadenoma in supernumerary breast tissue are rare. The present article reports a case of fibroadenoma developing in the supernumerary breast located below the normal left pectoral breast in a 26-year-old woman. Clinical and ultrasonographic examination of both pectoral breasts revealed no abnormalities but a mass was found in the third breast. The patient underwent resection of the supernumerary breast and the histopathological examination showed an intracanalicular type of fibroadenoma within the breast tissue.

Effect of piroxicam gel for pain control and inflammation in Nd:YAG 1064-nm laser hair removal

BACKGROUND

Laser-assisted hair removal is a variably uncomfortable and painful procedure.

OBJECTIVE

The aim of this study was to investigate the efficacy of piroxicam gel on pain control and subsequent inflammation in Nd:YAG 1064 nm laser hair removal in women volunteers.

METHODS

Fifty women volunteers were enrolled in this prospective, randomised, placebo-controlled study over a 6-month period. Subjects were randomly assigned to receive piroxicam gel as Group P or saline as a control group. Topical analgesic and saline were applied to the treatment sites for 45 minutes. The pain scores (VAS) and side effects were recorded before the hair removal, during the hair removal, at the end of the hair removal, and after 1 hour, 2 hours and 24 hours after the hair removal.

RESULTS

Subject characteristics and treatment settings in Nd:YAG 1064 nm laser were similar in both groups. The pain scores (VAS) were significantly lower in the Group P than those of the control group during the hair removal (p < 0.001). Inflammatory side effects such as erythema, edema, and folliculitis, were more frequent in the control group than those of Group P during the procedure (p < 0.001).

CONCLUSION

This study showed that piroxicam gel provided adequate pain relief after Nd:YAG 1064 nm laser hair removal in women volunteers. Piroxicam gel was associated with lesser inflammatory side effects when compared to placebo because of its anti-inflammatory effect after the procedure.

Serum levels of IGF-I and IGFBP-III and their relation with carcinoembryonic antigen and carbohydrate antigen 19-9 in cases of esophageal cancer

Tumour markers are used for diagnosis, staging, evaluation of response to treatment, prognosis and detection of recurrences in clinical oncology. In this study, we aim to investigate the levels of insulin-like growth factor (IGF)-I and IGF-binding protein (IGFBP)-III in cases with oesophageal carcinoma. We investigated their possible use as tumour markers and their relation to other tumour markers. Forty patients who were diagnosed as having oesophageal carcinoma by histopathological evaluation of endoscopic biopsies between January 2003 and July 2004 and 40 healthy people as the control group were included in the study. The serum levels of tumour markers including IGF-I, IGFBP-III, carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 were measured in both groups. Data were compared statistically, and the importance of IGF-I and IGFBP-III levels were investigated in cases with oesophageal carcinoma. IGF-I levels were significantly higher in patients with oesophageal carcinoma when compared with the control group (p < 0.05), whereas IGFBP-III levels were significantly lower (p < 0.05). The increase in CEA levels was not statistically significant when compared with the control group. The increase in CA 19-9 levels was statistically significant when compared with the control group (p < 0.05). No correlation was detected between levels of IGF-I and IGFBP-III and levels of CEA and CA 19-9. We suggest that the serum IGF-I level may be used as a tumour marker in oesophageal carcinoma. A low level of serum IGFBP-III is also significant in cases with oesophageal carcinoma. We believe that drugs which inhibit IGF-I function or which stimulate the function of IGFBP-III may open new horizons in extra-surgical modalities for the treatment of oesophageal cancer.

Follicular thyroid carcinoma: metastasis to the sternum, 13 years after total thyroidectomy

Primary and metastatic malignancies of the sternum are uncommon. Secondary lesions to the sternum occur more commonly in patients with lung and breast cancer, and only a few cases of sternal metastasis arising from a follicular thyroid carcinoma have been reported in the literature. Rarely, metastases to the sternum present in the guise of primary sternal tumours may be treated surgically with that diagnosis in mind. We describe a case of a sternal mass treated by radical surgery, which ultimately proved to be a solitary metastasis from a follicular carcinoma of the thyroid, appearing 13 years after total thyroidectomy and radioactive iodine therapy. Late metastatic thyroid carcinoma to the sternum should be kept in mind in the differential diagnosis of sternal lesions. For patients with thyroid carcinoma and sternal metastasis, we recommend surgical resection of the metastasis, not only as a curative or palliative measure but also to maximise the effect of subsequent radioiodine treatment.

Plasminogen activator inhibitor -1 gene 4G/5G polymorphism in patients with breast cancer

PURPOSE

The plasminogen activator inhibitor-1 (PAI-1) plays an important role in the development of tumor invasion and metastasis. The 4G allele of 4G/5G insertion / deletion polymorphism located in the promoter region 675 bp upstream from the transcription start sequence of PAI-1 gene is responsible for the higher plasma PAI-1 level. The aim of the present study was to evaluate the association between PAI-1 gene 4G / 5G polymorphism and breast cancer.

MATERIALS AND METHODS

Two groups were investigated: the first group(group 1)was composed of 34 patients with breast cancer, the second group (group 2) consisted of 90 unrelated healthy women without history of malignancy. Genomic DNA isolation was performed from peripheral venous blood by standard phenol-chloroform extraction and polymerase chain reaction of the PAI-1 4G/5G polymorphism was performed.

RESULTS

The prevalence of 4G/4G or 4G/5G genotype in group 1 and 2 was 97.1% and 78.8%, respectively. The distribution of the PAI-1 4G/5G genotypes was significantly different between the two groups (p<0.05).

CONCLUSIONS

We suggest that this polymorphism may contribute to an inherited predisposition to the development of breast cancer, however further studies with larger series from diverse ethnic populations are needed to confirm our results.

A comparison of patient-controlled subacromial and i.v. analgesia after open acromioplasty surgery

BACKGROUND

The aim of this study was to compare three patient-controlled analgesia (PCA) techniques for pain relief after acromioplasty. These techniques included use of subacromial ropivacaine, subacromial fentanyl or i.v. fentanyl.

METHODS

Forty-eight patients scheduled for open acromioplasty surgery were prospectively randomized to receive ropivacaine 0.2% (Group R) or fentanyl 4 microg ml(-1) (Group F) for subacromial analgesia, or fentanyl 4 microg ml(-1) (Group C) for i.v. analgesia. All patients received background infusion at a rate of 5 ml h(-1) plus a PCA bolus dose of 3 ml with a lockout time of 20 min. In addition, rescue analgesia with tramadol 50-100 mg i.v. was available on demand. Pain relief was regularly assessed using a visual analogue scale (0-10 cm) and side-effects were noted.

RESULTS

The postoperative pain scores at 2, 4, 6 and 12 h after the start of PCA were higher in Group F compared with Group R and Group C (P<0.001), However, the pain scores at the other time points were similar between the three groups. Pain scores, incremental dose requested and received, total volume of analgesic solution infused and rescue tramadol were similar between Group R and Group C. Specific side-effects were similar in the three groups.

CONCLUSION

The PCA techniques using subacromial ropivacaine or fentanyl i.v. provided similar and adequate pain relief and minimal side-effects after open acromioplasty surgery. The PCA using subacromial fentanyl was not as effective as either subacromial ropivacaine or i.v. fentanyl.