Catamenial pneumothorax--3 case reports and view of literature

INTRODUCTION

The unusual correlation between chronic recurring spontaneous pneumothorax and the menstrual cycle, was first presented by Maurer in 1958. In our clinic we had 3 cases in 5 years. The anamnesis shows that this syndrome is unknown to many of our colleagues. Not mentioned in several standard textbooks, warrants our attention.

METHODS

In 5 years we had 3 cases of C.P., all of them had already on admission, at least one recurrence; all of them had right sided thoracic pain and dyspnoea. They undergone video-assisted thoracoscopy, with histological examination of diaphragm specimen. Gynaecological consultations was followed by hormonal therapy and follow up.

RESULTS

In all 3 cases we found no signs of lung defects or bullae, instead, we identified diaphragm defects of different extension, even a liver prolapse in one of the cases. Endometriosis extra genitalis could be diagnosed in only one case which undergone a hysterectomy 8 years before.

CONCLUSION

A spontaneous pneumothorax which recurs in correlation with menses has a pathogenesis which concern only women, that is why is referred to as catamenial. Our experience supports the hypothesis, that air in the pleural cavity originates from the peritoneal one, arriving here via uterus and tuba. Beside the symptomatic therapy ther is an etiological one, by inhibition the menstrual cycle. Thoracosurgical intervention could help preventing recurrence, and contributes in clarifying the pathogenesis.

Pulmonary leiomyomatosis in women after hysterectomy for uterine myoma. Benign metastasizing leiomyoma?

INTRODUCTION

Leiomyomas, which usually occur multilocular in uterus, can develop even if rarely in other organs with smooth muscle cells. The tumour is considered benign; 2 case reports supports the hypothesis that uterus myoma could metastasize, and in the metastasis sites grow invasively.

METHODS

2 female patients 44 y. and 29 y. old were admitted to our clinic for MPL. Due to increasing tumor size respectively dypnea, they were operated on. Multiple nodules of the left lung in one case, and a mediastinal tumour in the other were resected; resected tumour was histologically examined.

RESULTS

In both cases it was a matter of well-differentiated leiomyosarcoma. The mediastinal tumour has already invade the N. phrenicus. Postoperatively there were no complications. Patients discharged in well-doing state, medical control one year later revealed no new growth.

CONCLUSION

Multiple pulmonary leiomyomas are rare, they occur in sexually mature women in coincidence with uterus myoma. Even though many authors assume that MPL is a lung metastasis of benign tumours, the pathogenesis is still hypothetical. Supporting this thesis is the hormone dependence of both the uterine and the pulmonary tumours; against it, is that extrapulmonary locations are too rarely observed. The still open pathogenetical question has no therapeutical consequence. Whenever technically possible, a radical, parenchyma-saving surgical therapy should be the first choice. Otherwise hormon-ablation is a good alternative.

Liposomal encapsulation of ganciclovir enhances the efficacy of herpes simplex virus type 1 thymidine kinase suicide gene therapy against hepatic tumors in rats

Suicide gene therapy based on ganciclovir (GCV) metabolism by transgene herpes simplex thymidine kinase (HSV-1 TK) has been used to selectively kill proliferating cells in clinical settings such as cancer, vascular restenosis, and immunological disorders. We investigated whether encapsulation of ganciclovir (GCV) into liposomes would improve its efficacy, especially against hepatic tumors. Large unilamellar liposomes containing GCV were prepared by reversed-phase evaporation. Pharmacokinetic studies in rats showed that, compared with free GCV, the intravenous injection of liposome-encapsulated GCV (lip-GCV) led to a faster decrease in GCV plasma concentrations, but higher liver-blood ratios. After treatment of syngeneic HSV-1 TK+ liver metastases in rats, histologically active tumors were found in 95% of the transplanted lesions when physiological saline had been given and in 50% when free GCV had been given at 90.2 microM/kg twice daily. This dose is known to be insufficient for the eradication of HSV-1 TK+ tumors. In contrast, only 5% viable tumors were found in rats receiving lip-GCV at this same concentration. Average tumor volumes were 19 +/- 15, 7 +/- 9, and <1 mm3 for the control, free GCV, and lip-GCV groups, respectively. GCV-related toxicity was no longer observed. The results demonstrate that liposomal encapsulation of GCV is feasible and significantly enhances its efficacy against HSV-1 TK+ hepatic tumors.

[Thoracic surgery relevant indications for adjuvant and/or palliative measures in breast carcinoma]

Metastatic lesions of breast cancer represent rare indications for operation in thoracic surgery. Only in case of persistent malignant pleural effusions or in case of tumour progress despite all other available therapy modalities thoracic surgery can be indicated. Over a period of 5 years between 1993 and 1997 53 patients with metastatic breast cancer were treated in our institution. 36 pts. suffered from persistent pleural effusions, 13 pts. had pulmonary metastases and 4 pts. had metastases involving the chest wall. In all these patients the disease could not be controlled by conservative measures. Our experiences are the following: Thoracoscopy is the diagnostic method of choice for pleural effusions in patients with malignant tumors. If a malignant pleural effusion is confirmed, a talc poudrage represents the most reliable treatment to palliate the dyspnea. The resection of a single solitary pulmonary metastasis can be indicated to confirm the histologic type of the nodule. Resections for centrally localized lesions causing hemoptysis or atelectasis represent rare occasions. Metastatic lesions of breast cancer involving the ribs or the sternum are resected in order to confirm the histologic diagnosis. According to the literature these procedures, with a 5-year survival rate of 50% and without perioperative mortality, can be beneficial.

[Surgical anatomy in lung resections]

When thoracic/lung surgery is performed autodidactically, intraoperative catastrophes and complications are to be expected. Atypical partial resections must be distinguished from typical resections of anatomical parechyma units (standard operations). More extensive operations which involve additional lung structures (lung lobes, trachea, bronchi) or attached organs (chest wall, heart, diaphragm etc.) are technically demanding. The larger the anatomical unit, the closer to the heart all vessels have to be arranged and, not seldom this means intrapericardially with clamping of the left atrium. All structures of the hilus are suitable for closing with staplers or suture. In the case of pneumonectomies, central lung structures can be cut most easily by cutting ligaments (Lig. anterior superius, Lig. pulmonale inferius). Pictures and photographs demonstrate specialties of topography of bilateral central lung structures in the context of extended resections.

Postoperative complications after bronchoplastic procedures in the treatment of bronchial malignancies

OBJECTIVE

The purpose of this study was to determine the frequency of postoperative complications after bronchoplastic procedures in the treatment of pulmonary malignant tumors and to analyze the factors influencing the complication rate.

METHODS

During a 5-year-period (1992-1996) 79 patients (68 male, 11 female, mean age 57 years) underwent reconstructive operations for bronchial malignancies. We performed 58 bronchoplastic procedures and 21 combined broncho- and angioplastic procedures. Among the bronchoplastic procedures the number of sleeve resections (n = 44) and wedge resections (n = 35) were comparable.

RESULTS

Fifty-nine patients (74,7%) showed a regular postoperative course; 12 patients (15,2%) had severe postoperative complications (death, re-operation). Concerning the primary operation the operative 30-day mortality was 5.1% (n = 4) and including the two deaths after re-operation it was 7.6% (n = 6). After subdividing the patients into three groups (severe, less severe and no complications) we tried to determine predictors for occurrence of postoperative complications. There was a higher rate of severe complications in the age group 61-70 years (6/25 = 24%) as compared with younger patients between 51 and 60 years (4/38 = 10,5%; P < 0,05). Concerning the location, the outcome was better after sleeve- or wedge lobectomies of the upper lobes (four complications/51 patients = 7.8%) compared with procedures of the lower lobes (3/14 = 21.4%). The data could not prove a lower frequency of severe postoperative complications or specific morbidity after pleural coverage following bronchial sleeve resection. The complication rate was higher when sleeve resection of the bronchus was performed (10/44 = 22.7%) as compared with wedge resections (2/35 = 5.7%; P = 0,011) and after resection of T3/T4 tumors (6/28 = 21,4%) compared with T1/T2 tumors (4/37 = 10.8%; P < 0,05).

CONCLUSIONS

Bronchoplastic procedures represent a fairly safe therapy opportunity in patients with centrally localized bronchial carcinoma and compromised or uncompromised pulmonary function. In this study the complication rate was higher after sleeve resection of the bronchus as compared with wedge resection. Pleural coverage of the anastomosis was not effective to prevent major complications due to dehiscence of the bronchial anastomosis. A pedicled muscle flap could be a valuable alternative.

[Delayed complications after extrapleural pneumonolysis for lung tuberculosis]

The epidemic spread of tuberculosis after World War II and the deficiency of appropriate antituberculotic drugs led to a renaissance of surgical procedure such as plombage thoracoplasty, initiated in 1891 by Tuffier. Especially in Germany the insertion of paraffin and polyethylene was used in order to achieve an extrapleural pneumothorax in order to collapse the tuberculous cavities in the upper lobes. Due to a high rate of early complications and the assumed cancerogenicity, in a considerable number of cases the material was removed soon after its deployment. In some cases with the filling remaining in place, 30-40 years later infections and/or neoplasms occurred. From 1985 to 1996 in two centers of thoracic surgery 13 patients underwent procedures for removal of filling material. The patients suffered from infections (n = 11), malignant lymphoma associated with infection of the plombage (n = 1) and bronchial carcinoma (n = 1). Technically, we performed the thoracoplasty described by Schede (n = 9). Schede's thoracoplasty in combination with a muscle flap repair (n = 1) or partial resection of the thoracic wall (n = 1), an empyemectomy (n = 1), and an en-bloc pleuropneumonectomy (n = 1). All patients suffered from multiple underlying diseases (COPD, coronary heart disease, diabetes mellitus). However, apart from beside two procedure related deaths (pulmonary embolism n = 1, pneumonia complicated by multi-organ failure n = 1) no other major complications were observed. The plombage material in the case of malignant lymphoma is probably carcinogenic in relation to the time of exposure and should be removed in all cases.

Influence of bilateral subnodular vagotomy and section of retrotracheal plexus on allergic bronchial constriction in guinea pigs

A bilateral subnodular vagotomy and a tracheal dissection with immediate readaptation (n = 18) or one of both (n = 8) was performed on ovalbumin sensitized guinea pigs. Control animals got a shame operation (n = 13). About one week later the animals were narcotized by ethylurethane 1.3 g per kg b.w. intraperitoneally and received a tracheotomy with insertion of a tracheal cannula and an additional insertion of a flexible catheter into the right jugular vein. Then the animals were artificially ventilated in a tank respirator by rhythmical exposure to a negative chest wall pressure, the ventilator settings were f = 20 per min, I: E = 1: 1, and rectangular pressure = -2 kPa. Breathing parameters were measured pneumotachographically. Flow, tidal volume, ECG and ventilation pressure were recorded with a 12-channel UV-light recorder. After the recording of initial parameters an intratracheal bolus-instillation of 0.5 mg/kg b.w. ovalbumin was given and 5 min later, a second ovalbumin bolus i.v. of 1 mg/kg b.w. Mean minimal tidal volumes reached after i.t. OA-provocation were: 17.6 +/- 19 in controls, 39.7 +/- 30 after vagotomy and tracheotomy, 40.5 +/- 20 after vagotomy alone, and 27.6 +/- 18 after tracheotomy alone. We found a significant inhibition of allergic bronchial constriction by bilateral vagotomy. The dissection of the retrotracheal plexus by tracheotomy was without significant effect on the allergic response. The investigation could demonstrate the significance of vagotomy on asthmatic reactions.(ABSTRACT TRUNCATED AT 250 WORDS)

[Diagnostic value of chest x-ray film in recognizing complications following homologous lung transplantation in the dog]

The postoperative controls of the course after unilateral homologous lung transplantation were interpreted by chest X-ray films of 86 dogs. Radiomorphologic findings in the transplanted lung had developed 69% of the surviving animals in the end of the 5th and 80% on the 9th postoperative day. The descriptive phenomena of the chest X-ray films were compared with the post-mortem findings concerning their etiology. Phenomena caused by rejection, by operation, and in a third group by rejection and operation could be separated statistically as to the temporal occurrence. - In that manner the partial or total shadow of the graft is a sign of rejection after the 5th postoperative day and the pneumothorax is a sign for a postoperative complication before the 5th day, on the other hand a phenomenon for the rejection after this time. - The radiologic findings are restricted by imperfect position of the animals during the radiograph and by overshadowing bony parts of the thorax. The diagnostic value of the chest X-ray film is reduced much, because the differential diagnosis to the radiomorphologic findings requires additional diagnostic methods for instance scintiscanning, angiography, bronchospirometry, and biopsy.

[Allogenic lung transplantations following pretreatment of recipients with donor-specific splenic antigens]

Lung transplantations were carried out in 20 not immunologically selected mongrel dogs which were pretreated with donor specific spleno-antigen mixture. The average survival time was double the size (12.3 days) as in a control group of untreated dogs after allogenic lung transplantation. A number of the receivers got Cyclophosphamid in addition to the spleno-antigen mixture. In this group the average survival time amounted to 17 days. A chronic course of the rejection was not to be achieved with this method. The autopsy showed thoracic infectious complications in nearly all receivers. A great number of central pulmonary vein thromboses in the transplant was discovered in this series in contrast to other lung transplantation series. Circumstances refer to a connection with hyperacute rejection courses. The receivers of this series survived the destruction of the transplant longer on an average as such in other experimental series.

[Results of studies on dogs after unilateral allogeneic lung transplantation without immunosuppression]

The observations and the results after allogenic lung transplantation in 24 receivers were reported. The animals were not treated immuno-suppressively. They survived 6.2 days on an average and died in consequence of the rejection. The transplant is progressively threatened of bacterial infections after the beginning of the rejection even in case of an operation under sterile conditions. The investigations confirmed a narrow correlation between the leucocyte count and the course of the rejection. However, the condition of the transplant can be estimated approximately certainly by means of complex clinical methods of examination.

[Tissue typing and donor-recipient selection in dogs for experimental organ transplants]

About first results of a tissue typing for donor recipient selection in dog is reported on obtaining an optimum degree of histocompatibility. The modified NIH-test according to Brand and coworker was carried out. The sera for typing were prepared by means of artificial or natural immunisation. Serologic and genetic problems are discussed. Possibilities on perfection are shown for donor recipient selection in dogs.

[Morphologic studies on in experimental lung transplantations. II. Light microscopic and histochemical findings in the transplanted homologous dog lung]

Morphologic Studies (light-microscopy, enzyme histochemistry, semi thin-layer preparation) on homografted canine lungs with and without immuno-suppressive therapy (Azathioprin, resp. anti-thymocyte serum) reveal different findings from untreated control animals and those after immuno-suppressive treatment. Under Azathioprin as well as anti-thymocyte serum the signs of rejection are attenuated, and regular pulmonary tissue is maintained in larger areas. Damages of certain cellular elements are better ascertained by means of determination of specific enzymes activities than by help of light-microscopic methods.

[Contributions of thoracic surgery in the Research Institute for Pulmonary Diseases and Tuberculosis since its founding and under the presence conditions in the treatment of specific and nonspecific lung diseases (author's transl)]

Thoracic surgery is done in the Research Institute for Pulmonary Diseases and Tuberculosis for about 25 years. 2463 lung resections on account of tuberculosis, 934 lung resections on account of intrathoracic tumors, among them 795 suffering from bronchial carcinoma, 422 operations because of nonspecific pulmonary diseases (bronchiectasis, lung abscess a.s.o.) and nearly the same number of operations because of spontaneous pneumothorax were performed in this time. Cystic lung disease, bullous emphysema, pulmonary mycosis and diseases of diaphragm and oesophagus were rarer indications for surgery. Since 1970 an increasing number of thoracic injuries by accidents were treated (70 patients). At the beginning collapse therapy (1953/54) was still in use (305 operations). In all the number of great thoracic operations 1978 was 5417. Besides, experimental investigations dealing with lung transplantation were done in dogs. These results are published in several papers. The technical experience gained by this research work could be utilized for clinical practice.

[Lung transplantations in the hospital (author's transl)]

Successful clinic lung transplantations are an urgent necessity. Till now published 37 transplantations were unsatisfactory in the result. They showed that today the lung transplantation is still an experimental method. This paper analyses the results with the mark to recognize emphasis of the experimental research.

[Differential diagnosis of mediastinal affections (author's transl)]

Differential diagnosis is necessary about chronic affections in the mediastinum. They are classified through appointed criterions in 3 groups. The technical methods of differential diagnosis and the degree of information are described. Operations of mediastinal tumours should be done as early and radically as possible.

[Coumarin necrosis in Klinefelter's syndrome]

A coumarin necrosis of the buttocks skin occurred in a patient with a Klinefelter's syndrome. In the acute stage of the complication the oestrogen activity was increased which is decreased in other persons with this arrangement of chromosomes. It is proposed to analyze the oestrogenes in urine of male patients or of females in the postclimacteric period with coumarine necroses before a treatment with sexual hormones.

[Drug-induced]

The rare clinical picture of the thrombocytopenia caused by drugs is described using own histories of diseases and data from literature. The questions of diagnostics and therapy are discussed. Despite the as a rule benign course it is referred to the fact to withold the noxa once diagnosed consequently from the patient for prevention of possible complications (cerebral haemorrhage).