Image-Assısted Pleural Needle Biopsy or Medical Thoracoscopy: Which Method for Which Patient? - A Randomızed Controlled Trial

BACKGROUND

Image-guided or assisted needle biopsies and the increasing use of medical thoracoscopy (MT) have increased the diagnostic accuracy of pleural diseases significantly. However, no consensus exists regarding which patients with pleural effusion should undergo MT and which patients should undergo image-guided or assisted needle biopsy as the first procedure to ensure greater diagnostic accuracy.

RESEARCH QUESTION

Which biopsy method is more appropriate for which patient to provide the highest diagnostic accuracy in the diagnosis of pleural effusion?

STUDY DESIGN AND METHODS

This prospective, randomized, parallel study included 228 patients with undiagnosed exudative pleural effusion. Patients were divided into two groups based on CT scan findings. Group 1 included patients with pleural effusion only. Group 2 included patients with pleural thickening or lesion in addition to pleural effusion. Patients in each group were assigned randomly to an image-assisted Abrams needle biopsy (IA-ANPB) or MT arm. The diagnostic sensitivity, reliability, and safety were determined for both groups.

RESULTS

The false-negative rate was 30.3% for the IA-ANPB arm and 3.1% for the MT arm in group 1. The same rates were 11.9% for IA-ANPB and 4.7% for MT in group 2. In group 1, the sensitivity for the IA-ANPB arm was 69.7%, and the negative likelihood ratio was 0.30. The same rates for the MT arm were 96.9% and 0.03 (P = .009). In group 2, these values were 88.1% and 0.12 for the IA-ANPB arm and 95.4% and 0.05 for the MT arm (P = .207). The rate of complications between the two biopsy methods was not different (8.5% and 15.8%, respectively; P = .107).

INTERPRETATION

MT showed a high diagnostic success in all patients with pleural fluid. However, IA-ANPB showed similar diagnostic success as MT in patients with pleural effusion and associated pleural thickening or lesions. Therefore, in the latter case, IA-ANPB could be preferable to MT.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT05428891; URL: www.

CLINICALTRIALS

gov.

Correlation of Indeterminate Lesions of Covid-19 Pneumonia Detected on Computed Tomography with RT-PCR Results

BACKGROUND

The typical findings of COVID-19 pneumonia include multilobar ground-glass opacities and consolidation areas observed predominantly in the basal and peripheral parts of both lungs in computed tomography.

OBJECTIVE

The current study aimed to show the correlation of indeterminate lesions of COVID-19 pneumonia detected on computed tomography with the results of the reverse transcription-polymerase chain reaction (RT-PCR) test.

METHODS

Patients with high-resolution computed tomography images that were reported to contain indeterminate lesions in terms of COVID-19 pneumonia were included retrospectively in the study. The lesions were categorized and the patterns were classified. The RT-PCR-positive and the RT-PCR-negative patients were compared. P<0.05 was accepted as the statistical significance limit.

RESULTS

The RT-PCR-positive patients had a higher rate of the peripheral lesion. Limited consolidation areas were not detected in the RT-PCR-positive patients. In the RT-PCR-negative patients, the rates of acinar nodules and the tree-in-bud pattern were significantly higher. The RT-PCR-negative patients had higher nodular contour features and lesion coalescence. In the subgroup consisting of lesions with ground-glass opacities and/or ground-glass opacity around the nodule, the rate of nodular contour positivity was significantly higher in the RT-PCR- positive patients.

CONCLUSION

COVID-19 pneumonia can be suspected in peripheral indeterminate lesions. For indeterminate lesions, especially in the presence of the tree-in-bud pattern, acinar nodules, and limited consolidation areas, alternative diagnoses should be considered even these findings are accompanied by ground-glass opacities.

The effects of natural pollen exposure on inflammatory cytokines and their relationship with nonspecific bronchial hyperresponsiveness in seasonal allergic rhinitis

The exact mechanism of bronchial hyperresponsiveness (BHR) is not clear in allergic rhinitis (AR); an increase of BHR in pollen season suggests that natural pollen exposure causes airway inflammation in seasonal AR (SAR). This study was designed to investigate the effects of natural pollen exposure on inflammatory cytokines and their relationship with BHR. Sixty-six SAR patients with grass pollen sensitivity and 26 nonallergic rhinitis (NAR) patients were included. Peripheral blood samples for cytokine levels were taken and a nonspecific bronchial provocation test was performed during pollen season between May and August. The same measurements were repeated off-season between November and February. These measurements were done in NAR patients once. During the pollen season, SAR patients had significantly more increased levels of IL-13 than NAR patients (11.45 +/- 12.54 versus 5.19 +/- 4.02; p = 0.005). Blood eosinophil numbers were higher in those patients with BHR during pollen season than those without BHR (399.0 +/- 255.8 versus 278.9 +/- 193.2 mm(-3); p = 0.046). Blood eosinophil numbers during off-season were not different in those with and without BHR (respectively, 261.4 +/- 202.3 mm(-3) versus 205.9 +/- 116.9 mm(-3); p = 0.53). IL-10 levels were higher in the patients without BHR (n = 28) than those patients with BHR (n = 22) during off-season (8.12 +/- 13.1 versus 3.28 +/- 0.37; p = 0.04). Having higher levels of IL-10 than threshold value was more frequent in SAR patients without BHR than those patients with BHR during off-season (7/28 versus 1/22; chi(2) = 4.34; p = 0.04). IL-10 has a role in the continuation of BHR during off-season in SAR patients.

Medical thoracoscopy vs CT scan-guided Abrams pleural needle biopsy for diagnosis of patients with pleural effusions: a randomized, controlled trial

BACKGROUND

In cases of pleural effusion, tissue samples can be obtained through Abrams needle pleural biopsy (ANPB), thoracoscopy, or cutting-needle pleural biopsy under the guidance of CT scan (CT-CNPB) for histopathologic analysis. This study aimed to compare the diagnostic efficiency and reliability of ANPB under CT scan guidance (CT-ANPB) with that of medical thoracoscopy in patients with pleural effusion.

METHODS

Between January 2006 and January 2008, 124 patients with exudative pleural effusion that could not be diagnosed by cytologic analysis were included in the study. All patients were randomized after the CT scan was performed. Patients either underwent CT-ANPB or thoracoscopy. The two groups were compared in terms of diagnostic sensitivity and complications associated with the methods used.

RESULTS

Of the 124 patients, malignant mesothelioma was diagnosed in 33, metastatic pleural disease in 47, benign pleural disease in 42, and two were of indeterminate origin. In the CT-ANPB group, the diagnostic sensitivity was 87.5%, as compared with 94.1% in the thoracoscopy group; the difference was not statistically significant (P = .252). No difference was identified between the sensitivities of the two methods based on the cause, the CT scan findings, and the degree of pleural thickening. Complication rates were low and acceptable.

CONCLUSION

We recommend the use of CT-ANPB as the primary method of diagnosis in patients with pleural thickening or lesions observed by CT scan. In patients with only pleural fluid appearance on CT scan and in those who may have benign pleural pathologies other than TB, the primary method of diagnosis should be medical thoracoscopy.

TRIAL REGISTRATION

clinicaltrials.gov; Identifier: NCT00720954.

Pleurodesis in follow-up and treatment of malignant pleural mesothelioma patients

We analyzed the necessity of pleurodesis in the follow-up of the patients with malignant pleural mesothelioma (MPM), and how much it contributes to the survival period by determining the indications, efficiency, and reliability of the pleurodesis application. 191 patients were assessed retrospectively and 69 (36%) of them were established with a pleurodesis indication. In 42 patients accepting pleurodesis, the pleurodesis success was evaluated. Factors affecting the success of pleurodesis and the effect of pleurodesis on survival were assessed. Pleurodesis was a success in 26 (62%) of the 42 patients. In the group in which the pleurodesis process was a success, it was observed that KPS and pleural fluid pH were higher (p= 0.030, p= 0.032, respectively). In case of KPS > or = 80, the sensitivity was: 76.9%, specificity: 50.0%, PPV: 71.4%, and NPV was established as 57.1%. In case of pleural fluid pH > 7.27, the sensitivity was: 92.9%, specificity: 50.0%, PPV: 76.5%, and NPV was observed as 80.0%. In the group in which pleurodesis was a success, the median survival was longer (Log-rank: 11.2; p= 0.0008). Independently from chemotherapy, the chance of living longer for patients whose pleurodesis was a success was 2.6 times higher. A severe complication concerning the process was not observed. Pleurodesis is performed less frequently than it is assumed on patients with MPM. In patients with KPS > or = 80, pleural fluid pH > 7.27, and with indication, pleurodesis must be administered. In feasible patients, a successful pleurodesis with talc increases the survival of patients with MPM, and it can be safely administered.

Oropharyngeal candidiasis with dry-powdered fluticasone propionate: 500 microg/day versus 200 microg/day

We aimed to determine the frequency of oropharyngeal candidiasis and its clinical correlates in the asthmatic patients who use fluticasone propionate (FP) as a dry powdered inhaler. We selected four groups of patients: 62 asthmatic patients who were taking 200 microg/d FP, 122 asthmatics who were taking 500 microg/d FP, 50 asthmatic patients who had not been on inhaled corticosteroid (ICS) treatment and 40 normal non-asthmatic subjects. The frequency of positive swabs for Candida colonization was higher in 500 microg/d FP group than asthmatics without ICS use (chi2 = 6.8, p < 0.05) and normal controls (chi2 = 4.9, p < 0.05), whereas it wasn't different in the 200 microg/day FP group when compared to controls. When we considered patients who used ICS, the most effective variables affecting the occurrence of Candida colonization were washing of the throat by the patients (OR = 9.4, 95 % Confidence Interval [CI] = 3.9-22.7, p < 0.0001) and duration of ICS use more than 12 months (OR = 2.5, 95 % CI = 1.1-2.6, p < 0.05). The present study showed that in the patients who use ICS, the most important determinants on colonization were not washing the throat regularly and duration of ICS use for more than 12 months.

Characteristics of lung cancer patients with asbestos-related radiological findings

The purpose of the current study was to compare the characteristics of lung cancer patients who had exposure to asbestos and asbestos-related radiological findings (ARRF) to the characteristics of patients who had no exposure. Of the 766 lung cancer patients evaluated, 607 had no exposure to asbestos and no ARRF, 88 had ARRF and a history of exposure, remaining 71 patients had no exposure to asbestos occupationally and no ARRF, but we could not obtain environmental exposure history from them. So we excluded these 71 patients' data. The study patients were compared with respect to age, gender, smoking history, duration and nature of symptoms, findings on physical examination, tumor histological types, chest X-ray (CXR) findings, tumor site and stage, and survival. Lung cancer patients with ARRF were more often males, former smokers, and older than patients with no history of exposure to asbestos. There were no differences between the groups of patients in terms of the duration of symptoms, the distribution of symptoms, the findings on physical examination, tumor histological type, and the CXR findings. There was no difference between the two groups of patients in the distribution among tumor stages and median survival. The anatomic site of origin of the tumor in the group with ARRF was peripheral and in the lower zone of the lung. We suggest that specific attention should be given to the peripheral and lower zones of the lungs on CRX during the evaluation of the patients with ARRF for lung cancer.

Soft tissue sarcoma metastatic to pleura

Almost all cancers can cause distant pleural metastases. However, pleural metastases of soft tissue sarcoma that constitute less than 1% of adult solid malignancy are extremely rare. It is very difficult to distinguish them form sarcomatous malignant mesothelioma on histopathological features. We report a 57 year-old man who presented to us with left chest pain and progressive dyspnea and was diagnosed to have a pleural metastases of soft tissue sarcoma by thoracoscopic biopsy.

Detecting extrathoracic metastases in patients with non-small cell lung cancer: Is routine scanning necessary?

There is controversy over whether to scan extrathoracic sites for metastases in patients with non-small cell lung cancer (NSCLC). We tested the efficiency of clinical factors to determine whether metastasis has occurred, and whether routine scanning for NSCLC is required. Nine hundred and forty five patients scanned for extrathoracic metasates were included. Clinical factors indicating metastasis were determined using multivariate analysis. Of the 945 cases, 377 (39.9%) had metastasis. Bone metastases were determined by focal skeleton pains, elevated serum alkaline phosphatase levels, adenocarcinoma, KPS</=70, sensitivity of 90.6, specificity of 12.7, PPV of 16.3, NPV of 87.8, and silent metastases rate (SMR) of 9.4%. Brain metastases were determined by neurological symptoms, adenocarcinoma, hematocrite <40 for men and <35 for women, KPS</=70, sensitivity of 89.9, specificity of 7.9, PPV of 9.2, NPV of 88.3, and SMR of 10.1%. Abdominal metastases were determined by abdominal pain/tension, hepatomegaly, elevated GGT levels, serum LDH levels >500 IU, a N2 or N3 case, KPS</=70, sensitivity of 95.9, specificity of 7.1, PPV of 13.3, NPV of 92.1 and SMR of 4.1%. Of the 224 patients with stage I and II disease, 73 had metastasis with a rate of 10.9% silent metastasis. We concluded that routine scanning of NSCLC for staging is necessary.

Lung cancer in individuals less than 50 years of age

The aim of this study was to compare the epidemiologic, clinical, and laboratory characteristics and survival rates of younger and older patients with lung cancer. We studied 1340 patients who were histopathologically diagnosed as having lung cancer from 1990 to 2005. Based on prior reports, we defined "younger" as individuals less than 50 years old. The patients were classified into two groups: <50 years (the younger group) and >/=50 years (the older group). Of the 1340 patients, 179 (13.4%) were in the younger group and 1161 were in the older group. In the younger group, exposure to occupational risk factors was a risk factor for lung cancer, while in the older group, smoking was a risk factor. At the time of diagnosis, chest pain was more common in the younger group, while in the older group, cough, dyspnea, and hilar enlargement on chest X-ray were more frequent. The incidence of adenocarcinoma and small-cell carcinoma was greater in the younger group, while squamous cell carcinoma was more common in the older group. Metastasis rates were significantly different between the two age groups: 52.0% of the younger group presented with stage IV disease compared with 43.5% of the older group. Although fewer younger than older patients were not able to receive or rejected anticancer therapy, the overall survival was similar in both groups. These data indicate that lung cancer had different etiopathogenetic characteristics in younger patients, which may have clinical implications. By planning preventive measures based on these characteristics, more efficient use of resources can be achieved.

Predictors of hospital outcome and intubation in COPD patients admitted to the respiratory ICU for acute hypercapnic respiratory failure

BACKGROUND

Mortality rate, the possible factors affecting mortality and intubation in patients with acute exacerbation of chronic obstructive pulmonary diseases (COPD) and hypercapnic respiratory failure (RF) are yet unclear.

OBJECTIVE

To identify the possible factors affecting mortality and intubation in COPD patients.

DESIGN

A prospective study using data obtained over the first 24h of respiratory intensive care unit (RICU) admission. Consecutive admissions of 656 patients were monitored and 151 of them who had acute exacerbation of COPD and hypercapnic RF were enrolled.

SETTING

University hospital, Department of Chest Diseases, RICU.

RESULTS

Mean age was 65.1 years. The mean APACHE II score was 23.7. Eighty-seven patients (57.6%) received mechanical ventilation (MV) via an endotracheal tube for more than 24 h. Twenty-two patients received non-invasive ventilation (NIV). Fifty patients died (33.1%) in hospital during the study period. The mortality rate was 52.9% in patients in need of MV. In the multivariate analysis, the need for intubation, inadequate metabolic compensation for respiratory acidosis, and low (=bad) Glasgow Coma Score (GCS) were determined as independent factors associated with mortality. The low GCS (OR: 0.61; CI: 0.48-0.78) and high APACHE II score (OR: 1.24; CI: 1.11-1.38) were determined as factors associated with intubation.

CONCLUSION

The most important predictors related to hospital mortality were the need for invasive ventilation and complications to MV. Adequate metabolic compensation for respiratory acidosis at admittance is associated with better survival. A high APACHE II score and loss of consciousness (low GCS) were independent predictors of a need to intubate patients.

Peripheral intrapulmonary lipoma: a case report and review of the literature

Lipomas are common benign tumours, but intrathoracic lipomas are rare and peripheral lung lipomas are exceptionally rare. Eight cases have been described in the world literature. We report a case of lipoma arising in the periphery of the left lower lung in a 54-year old woman. Grossly, it was presented as a well- circumscribed, thinly encapsulated, rounded, pale yellow mass. A wedge resection was done of the left lung and the microscopic findings revealed lipoma of the lung. The present paper recapitulates the macroscopic and microscopic features, the treatment and the differential diagnosis of this rare neoplasm.

Nonmalignant pleural lesions due to environmental exposure to asbestos: a field-based, cross-sectional study

The aim of the present study was to investigate the frequencies of asbestos-related benign pleural diseases in villagers environmentally exposed to asbestos and the factors affecting these frequencies. A field-based, cross-sectional study was designed. In total, 991 villagers from 10 villages, randomly chosen from 67 villages with known use of asbestos-containing white soil in central Anatolia (Turkey), were investigated. The type of asbestos in the white soil was determined for each village, as well as air-borne fibre concentrations. The villagers were investigated with small-size chest roentgenograms and epidemiological features were recorded. The air-borne fibre levels were generally low. Despite this, pleural plaques were found in 14.4% of the villagers, 10.4% had diffuse pleural fibrosis and 0.4% asbestosis. The significant variables for plaques were age, sex, type of asbestos fibre, e.g. actinolite and tremolite, and exposure duration, while there was a negative relationship with cumulative exposure. The variables affecting diffuse pleural fibrosis were age, exposure duration and cumulative exposure. In conclusion, villagers exposed to environmental asbestos have high frequencies of pleural plaques and diffuse pleural fibrosis, similar to occupationally exposed asbestos cohorts. Different types of asbestos appear to result in different frequencies of pleural lesions.

High body mass index and long duration of intubation increase post-extubation stridor in patients with mechanical ventilation

Approximately 20% of mechanically ventilated patients experience post-extubation stridor (PES) and reintubation, which subsequently may lead to an increased risk of morbidity and mortality. The risk of PES development is significantly higher in obese patients. Low air leakage between the endotracheal tube and the trachea, following cuff deflation, may indicate a higher risk for the development of PES. The aim of this study is to identify the relationship between body mass index (BMI) and PES using the cuff-leak test in patients intubated in the respiratory intensive care unit. A total of 67 consecutive intubations on 56 different ventilated patients were included in this study. The mean age was 63.6 +/- 12.1 years and 84% of the patients were male. PES developed in seven patients (10.4%). The mean cuff-leak volume was 395 +/- 187 ml in non-PES patients and 240 +/- 93 ml in PES patients (p = 0.023). The mean BMI was 36 +/- 13 kg/m2 in PES patients and 24 +/- 7 kg/m2 in non-PES patients (p = 0.046). BMI > 26.5 kg/m2 (OR: 1.2), low cuff-leak volume (< 283 ml) and mechanical ventilation required for more than 5 days (OR: 0.9) were independent variables for PES occurrence. We therefore suggest that non-obese patients, short-term intubated patients and those having a high air leakage around the endotracheal tube could be extubated without much difficulty.

Primary lymphoepithelioma-like carcinoma of the lung

Lymphoepithelioma-like carcinoma (LELC), best known to occur in the nasopharynx, can arise in a variety of sites, such as the salivary gland, thymus, lung, stomach, and skin. Primary LELC of the lung is very rare, with only limited information in the literature. We presented a case of a 66-year-old white man with a T2N0M0 lymphoepithelioma-like carcinoma of the lung. Immunohistochemical analysis was negative for Epstein-Barr virus. Observation of the nasopharynx and a computerized tomography of the cavum were normal.

Vascular endothelial growth factor levels in active pulmonary tuberculosis

BACKGROUND

Vascular endothelial growth factor (VEGF) is a mediator with potent angiogenic, mitogenic, and vascular permeability-enhancing activities that are specific for endothelial cells. Intense angiogenesis has been found in active pulmonary tuberculosis lesions.

OBJECTIVES

To determine whether active pulmonary tuberculosis is associated with increased serum levels of VEGF compared with inactive tuberculosis and VEGF levels in healthy subjects, and to assess the changes in serum VEGF levels before and after therapy.

DESIGN

Prospective clinical study.

SETTING

Chest clinic of a university hospital, Eskisehir, Turkey.

PATIENTS AND MEASUREMENTS

Serum VEGF levels of 44 patients with active pulmonary tuberculosis, 24 patients with inactive pulmonary tuberculosis, and 20 healthy subjects were determined.

RESULTS

VEGF levels were increased in active pulmonary tuberculosis patients (mean [+/- SD] VEGF level, 598.03 +/- 298.25 pg/mL) compared to both inactive pulmonary tuberculosis patients (mean VEGF level, 296.98 +/- 115.31 pg/mL) and control subjects (mean VEGF level, 339.67 +/- 74.65 pg/mL). The increase in VEGF level observed in patients with active tuberculosis was statistically significant when compared with levels in two other groups (p < 0.001 for both). Serum VEGF levels were statistically different before treatment and after treatment in 10 patients who were observed from diagnosis to the end of treatment (p < 0.01).

CONCLUSIONS

Increased serum VEGF levels may be an indicator of active pulmonary tuberculosis, since levels were higher in patients with active pulmonary tuberculosis and were lower after successful treatment. The role of VEGF-mediated angiogenesis in the pathogenesis and progression of pulmonary tuberculosis lesions should be further elucidated.

Acute Phase Reactants and Cytokine Levels in Unilateral Community-Acquired Pneumonia

BACKGROUND

Bacterial infection of the lower respiratory tract initiates an acute inflammatory response. Regulation of the inflammatory response in bacterial pneumonia depends on a complex interaction between immune cells and inflammatory cytokines.

OBJECTIVES

We investigated the initial levels of proinflammatory cytokines and acute phase reactants (APR), e.g. C-reactive protein (CRP), upon presentation of community-acquired pneumonia (CAP) in relation to clinical and laboratory indices of infection.

METHODS

We prospectively studied 28 consecutive patients with unilateral CAP. Tumor necrosis factor-alpha (TNF-alpha), interleukin (IL)-1beta, IL-6 and IL-8 concentrations were measured by ELISA in both bronchoalveolar lavage (BAL) fluid and serum.

RESULTS

The concentrations of IL1-beta and IL-6 in BAL fluid were found to be significantly higher in the involved lung than those in either the uninvolved lung (p = 0.008 and p = 0.012, respectively) or serum (p = 0.002 and p = 0.025, respectively). Serum CRP concentrations were increased compared to those in the involved and uninvolved lung in BAL fluid (p = 0.000 and p = 0.000, respectively). In serum and BAL from involved lung, IL-6 concentrations were higher in the systemic inflammatory response syndrome (SIRS) group than in the non-SIRS group (p < 0.05), whereas CRP, TNF-alpha, IL-1beta and IL-8 concentrations showed no difference between SIRS and non-SIRS. There was no significant correlation between the acute physiology and chronic health evaluation II score and the cytokines.

CONCLUSIONS

Our results indicate that the CRP level is higher in the serum than in the BAL fluid in the lung, and that IL-6 is the most important cytokine for the determination of the severity of the disease.

[Epidemiological features of bronchial carcinoma cases with environmental asbestos exposure]

Due to environmental asbestos exposure, asbestos related lung diseases are common in Eskisehir district of Anatolia. In this study we aimed both to determine the epidemiological findings of the patients diagnosed as bronchial carcinoma and to discuss the features, which were probably related to asbestos exposure, presented by the patients. From May 1997 to December 2000, 301 cases were included in the study. Of the patients, 97 (32.2%) had epidermoid cell type, 84 (27.9%) had small cell, 39 (13%) had adenocarcinoma, 4 (1.3%) had large cell. Adenocarcinomas were more frequent in women. There were not significant differences among the cell types from the point of view of the age distributions. Adenocarcinomas were more frequently located in lower lobes of the lungs (36.9%) and more frequently showed peripheral locations (45.9%) than other cell types (20.6% for epidermoid and 14.6% for small cell). Pleural effusion was more detected in adenocarcinomas (48.7% to 17.3% in epidermoid, 18.3% in small cell). The duration of smoking was shortest in adenocarcinomas, mean 32.4 years; the same duration was 56.2 years for epidermoid carcinomas. Of the patients, 54% had asbestos exposure. Adenocarcinomas were more frequently detected in the patients who exposed to asbestos but did not smoke. Our findings support that asbestos exposure may increase adenocancer frequency. The epidemiological and clinical features of adenocancer cases exposed to asbestos environmentally were not different than those of adenocancer cases exposed to asbestos occupationally.

[Synchronous primary lung cancers: due to the four cases]

If two primary lung cancers are present in the same time, it diagnosed as synchronous lung cancer. It constitutes 0.1-1.6% of all lung cancers. In this report, we described four cases diagnosed synchronous multiple primary lung cancers (MPLC) in between June 1999 and May 2002. Mean age was 63, and all of those were male. All patients were heavy smoker (mean 58 packet/year). Histology of lung cancers was squamous-adeno in two cases, squamous-small cell lung cancer in one case, and squamous-squamous in two cases. All patients had bilateral mass lesions and no mediastinal and systemic spread. Lesion of second primary lung cancer was unable to seen in two patient's chest X-ray. Their lesions were seen by computerized tomography in one case, and by bronchoscope only in the other case. Lesion site was left lower lobe, right lower lobe, right middle lobe, and left upper lobe (25% for each). Diagnosis of lung cancer was made by transthoracic needle biopsy in three lesion, and made by bronchoscopic biopsy in other lesions. While it is recommended that, all of MPLC lesions were staged separately and treated surgically, due to the advanced age, presence of small cell lung cancer, and inadequate post-operative respiratory reserve, surgical treatment could not apply to these patients and they received chemotherapy. Three of them was died (mean survival was 11 months). Due to the this report, we emphasized that diagnostic procedures should be done separately for each lesions in patients who had more than one lesion, and treatment should plane according to these results.

Relapsing polychondritis

Relapsing polychondritis (RP) is a rare, inflammatory disease with multisystem involvement and it should be considered in the aetiology of sudden respiratory distress. A 49-year-old woman was admitted to the emergency service of Osmangazi Hospital in acute respiratory distress. She had a tracheostomy following a diagnosis of laryngeal stenosis 10 years earlier. She was managed thereafter at another hospital with a diagnosis of asthma. At admission she was in respiratory distress, had arthralgias, bilateral subconjunctival hyperaemia, periorbital oedema and skin lesions. A thoracic CT showed tracheal wall thickening. Calcification of the auricular regions were noted bilaterally. Bronchi, conjunctiva and skin lesions were biopsied with a provisional diagnosis of RP. The diagnosis of RP in this patient was based on clinical, pathological and radiological findings. Steroid therapy was begun and she was referred to a surgical centre for stenting. This case report emphasizes the need to consider the possibility of RP as a cause of sudden respiratory distress.

[Pleural effusion due to the ovarian hyperstimulation syndrome]

Ovulation induction is a treatment that aimed to increase the pregnancy probability by increasing the follicular grow up and maturation. The most frequent complication is ovarian hyperstimulation syndrome (OHSS). Pleural effusion and abdominal ascites accumulation is frequently accompany this syndrome. A young patient receiving ovulation induction therapy was admitted to our department with sudden chest pain and dyspnea. Exudative pleural effusion was determined in the right and we suggest that pleural effusion was accumulated due to OHSS because of the presence of abdominal ascites, hemoconcentration, recent application of ovulation induction therapy and elimination of other causative factors for pleural effusion. The disappearance of pleural effusion spontaneously in a week support our idea. We reviewed the literature about the pleural effusion due to ovarian hyperstimulation syndrome. In the differential diagnosis of pleural effusion in young female patients, the accumulation of pleural effusion due to the recent ovulation induction story should be kept in mind which is especially important in the differential diagnosis of pulmonary embolism.

[Wegener granulomatosis: three cases]

Wegener granulomatosis (WG) is characterized by granulomatous vasculitis that involves multisystem, including upper and lower airways and kidney. WG may be a mortal disease if the diagnosis is delayed. The aim of this study is to present three patients admitted with different prediagnosis but after the investigations were diagnosed as WG and followed in our clinic. The cases were discussed with the literature knowledge. All three patients were diagnosed as WG with clinical, radiological and pathological findings. c-ANCA was positive in two patients, and negative one. Complete remission was established with treatment in one case. The treatment of other patients going on, however, the third patient was lost to follow up.

[Serum adenosine deaminase activity in pulmonary tuberculosis]

Adenosine deaminase (ADA) activity has been helpful for the diagnosis of tuberculous pleurisy. However, there are few studies about the role of ADA in the diagnosis and follow-up of pulmonary tuberculosis. In our study, serum ADA activity was determined in order to investigate the role of the enzyme in the diagnosis of pulmonary tuberculosis and monitoring the efficiency of therapy. The ADA activity was (mean +/- SD) 21.77 +/- 8.51 U/L in pulmonary tuberculosis patients (n= 44), 6.24 +/- 3.25 U/L in old tuberculosis patients (n= 24), 8.58 +/- 4.38 U/L in healthy control subjects (n= 20), whereas the mean for the patients with bronchial cancer (n= 20) was 18.51 +/- 7.85 U/L. There was no statistical difference between the results of pulmonary tuberculosis patients and the patients with bronchial cancer. On the contrary, the result of these two group were significantly different from both old tuberculosis patients and healthy control subjects (p< 0.001 for both). In 10 pulmonary tuberculosis patients, ADA activities were determined both before and after treatment and a significant decrease was observed in ADA activities after treatment (p< 0.001). In conclusion, serum ADA activity is increased in pulmonary tuberculosis patients, therefore it may be a helpful parameter for monitoring therapy.

[The evaluation of pulmonary tuberculosis patients enrolled to Eskisehir Deliklitas Tuberculosis Control Dispensary]

Tuberculosis is an important public health problem in our country. Tuberculosis Control Dispensary has been important role in tuberculosis control programme. In this study we retrospectively evaluate 891 pulmonary tuberculosis patients who registered in Eskişehir Deliklitaş Tuberculosis Control Dispensary between January 1990 and June 2000. The mean age was 38.9 +/- 15.7 years, 159 (18.3%) patients were female, 710 (81.7%) patients were male. The most common symptom was cough (88.7%). 81 percent of patients have been found by examination of symptomatic people while 6.4 percent of them by examination of close contacts. 26.5 percent of patients had close contacts with tuberculosis patients. The scares of BCG vaccine has been recorded 63.6% of the patients and 80.3% percent of them had at least one scare, tuberculin skin test result has been recorded in 49.6% percent of patients. Cavitary pulmonary tuberculosis was a diagnosed of 27.7%. The sputum examination and culture for acid resistant basil has been performed 89.1% of the patients, 389 (50.2%) of patients had acid fast bacillus in sputum and 548 (70.8%) of patients had culture positivity. 80.3 percent of the patients has completed regularly their treatments (mean duration 10.4 +/- 2.6 months). The mortality rate was 5.8%.

[The evaluation of close contact case of pulmonary tuberculosis patients enrolled to Eskisehir Deliklitas Tuberculosis Control Dispensary]

Persons infected with Mycobacterium tuberculosis are at greatest risk for developing active tuberculosis especially in children, adolescents, young adults and persons who have selected risk factors. Persons who were contact with tuberculosis patients and who have positive tuberculin skin test reactions and had high risk for developing active tuberculosis should be use preventive chemotherapy. In this study, we aimed to evaluate retrospectively 1663 close contacts of 486 active tuberculosis patients who registered in Eskisehir Deliklitas Tuberculosis Control Dispensary. The mean age was 25.4 +/- 18.1 years, 961 (57.7%) cases were female and 702 (42.3%) cases were male. Diagnosis was performed 1114 (67%) of close contacts people's patients with microbiological study. The scatrix of BCG has been recorded 901 (54.2%) cases, tuberculin skin test results has been recorded 952 (57.2%) cases. Tuberculin skin test of 612 (64.5%) cases were above 15 mm. 37.8% of cases were used preventive chemotherapy and 2.6% of cases had active tuberculosis disease. The age group was 7-14 years and persons who had close contacts of bacile positive patients, 80.5% of them had used preventive chemotherapy. Persons who's tuberculin skin test positive and younger than 6 years, 98.5% of them had preventive chemotherapy. Only 372 (59.2%) of patients completed preventive chemotherapy. At the results; we established that the preventive chemotherapy programme which recommended to our country is using regularly, but most of the close contact patients didn't completed their therapy.

Usefulness of bone markers for detection of bone metastases in lung cancer patients

OBJECTIVES

Lung cancer commonly causes destructive bone metastases. The aim of this study was to compare efficiency of biochemical bone markers in the detection of bone metastases in lung cancer patients.

DESIGN AND METHODS

We measured serum calcium (Ca), alkaline phosphatase (ALP), bone isoenzyme of alkaline phosphatase (BALP), osteocalcin (OC) and urine deoxypyridinoline crosslinks (DPD) levels in 52 lung cancer patients; 27 patients with the evidence of bone metastases, 25 without metastases in bone when they were first diagnosed. BALP, OC and DPD were measured by specific immunoassays. ALP, Ca and urine creatinine levels were determined by colorimetric methods.

RESULTS

Ca, ALP, BALP, OC and DPD levels were significantly higher in the patients with bone metastases than those without bone metastases (p < 0.01 for BALP and OC, p < 0.001 for Ca, ALP and DPD). The sensitivity and specificities of all markers as follows: 89%-44% for BALP, 52%-88% for OC, 81%-76% for DPD, respectively. ROC curves were generated separately for BALP, OC and DPD to assess the diagnostic efficiency of markers in a different manner. DPD showed the best curve characteristics among the studied bone markers, followed by the BALP curve. OC curve showed poor characteristics.

CONCLUSIONS

Our results suggest that the measurement of DPD and BALP may be useful in detecting bone metastases in lung cancer patients. Also it could help in the follow-up of bone metastases from lung cancer since they can be repeated more often than roentgenography and bone scintigraphy, at less cost and with less discomfort to the patients.

Computed tomography features in malignant pleural mesothelioma and other commonly seen pleural diseases

OBJECTIVE

To investigate the computed tomography (CT) features of malignant pleural mesothelioma (MPM) cases, comparing them to those in other malignant and benign pleural diseases.

MATERIALS AND METHODS

We reviewed the CT findings of 215 patients; 99 with MPM, 39 with metastatic pleural disease (MPD), and 77 with benign pleural disease. The findings were evaluated in univariate and multivariate analysis for differentiation of pleural diseases.

RESULTS

In patients with MPM, the most common CT features were circumferential lung encasement by multiple nodules (28%); pleural thickening with irregular pleuropulmonary margins (26%); and pleural thickening with superimposed nodules (20%). In the majority (70%) of cases, there was rind-like extension of tumor on the pleural surfaces. In multivariate analysis, the CT findings of "rind-like pleural involvement", "mediastinal pleural involvement", and "pleural thickness more than 1 cm" were independent findings in differentiating MPM from MPD with the sensitivity/specificity values of 70/85, 85/67, and 59/82, respectively. "Rind-like pleural involvement", "mediastinal pleural involvement", "pleural nodularity" and "pleural thickness more than 1 cm" were independent findings for differentiation of malignant pleural diseases (MPM+MPD) from benign pleural disease with the sensitivity/specificity values of 54/95, 70/83, 38/96, and 47/64, respectively. Invasion of thoracic structures such as pericardium, chest wall, diaphragm, mediastinum, with pleural disease and nodular involvement of fissures, was detected infrequently; however, since these invasions were not seen in benign pleural diseases, it was concluded these invasions, if detected on a CT scan, directly suggested malignancy.

CONCLUSION

A patient has extremely high probability of malignant pleural disease if one or more of these CT findings are found and the possibility of MPM is high. These findings may be important for patients in bad state or patients who do not want any invasive biopsy procedures. It is also possible to identify cases with a low probability of malignant disease.

Prognostic factors in diffuse malignant pleural mesothelioma: effects of pretreatment clinical and laboratory characteristics

The aim of this study was to investigate the effects of various pretreatment clinical and laboratory characteristics on the survival of patients with diffuse malignant pleural mesothelioma (DMPM). One hundred histopathologically confirmed DMPM patients were evaluated. Fifty-nine were treated with chemoimmunotherapy while 41 who had refused chemoimmunotherapy received supportive therapy alone. The following pretreatment characteristics were evaluated in both univariate and multivariate Cox regression analyses: age, gender, Karnofsky performance score (KPS), histology asbestos exposure, presence of chest pain, dyspnoea, weight loss, symptom duration, smoking history, disease location, platelet count, haemoglobin, white blood cell (WBC) count, serum lactate dehydrogenase (LDH) and extent of disease (stage). Univariate analysis showed that patients with age > or = 75 years, male gender, smoking history advanced stages above stage I disease, KPS < 70, WBC count > or = 8450 and LDH level > or = 500 IU l(-1) have a worse prognosis. With multivariate Cox regression analyses, age > or = 75 years, advanced stages above stage I disease, KPS < 70 and LDH level > or = 500 IU l(-1) were found to be indicators of a poorer prognosis. In conclusion, in our study each of low performance status, older age, advanced stage disease, high LDH level and prognosis were found to be related.

An unusual case of esophageal tuberculosis in an adult

Tuberculous infection of the esophagus is a rare disease and usually occurs secondary to tuberculous mediastinal lymphadenopathy. We report a 74-year-old woman presenting with dysphagia and weight loss. The chest radiograph showed punctuated calcifications lining from the right hilar region to the paracardiac region. Upper gastrointestinal endoscopy revealed a 0.5 x 5 cm lesion localized in the 25th cm of the esophagus covered partly with normal mucosa, partly demonstrating ulcerous areas. Biopsy revealed granulomatous infiltrates being tuberculoid in type. Thorax CT showed a calcified lymph node at the right hilum. The patient did not give consent to therapy and died 1 month later.

Low prevalence of allergy to cockroach and latex in asthmatic patients in Eskisehir (Anatolia), Turkey

Allergy to cockroach and latex are said to be causes of asthma particularly in some groups. We studied allergy to cockroach and latex in asthmatic patients from Eskisehir (Anatolia), Turkey in order to determine whether these allergens play an important role in the Anatolian region. A total of 216 asthmatic patients (mean age 43.7+/-11.0 years) were skin tested with common aeroallergens, Blatella germanica and latex. Sixty-three patients were allergic (29.1%) and 153 were nonallergic (70.8%) according to skin test results. Sensitization to pollens (57%) and mites (55.5%) was most common among allergic patients. We found a low sensitization to cockroach (4.7%) and latex (1.4%). We suggested that cockroach sensitization plays a small role in sensitization in our geographic area and that latex sensitization is low in allergic asthmatic patients who were referred for reasons other than latex-related symptoms.

[Respiratory allergy to moulds among adults in Eskisehir Anatolia), Turkey]

Allergy to moulds has been known for several decades. But it is rarely isolated in contrast to the other pneumallergens. Prevalence of sensitization to moulds varies from one country to the another. We investigated the allergy to moulds using skin prick tests in adult patients with asthma and/or rhinitis in Eskisehir (Anatolia), Turkey. Cladosporium and Aspergillus were found to be the most common causes in the study population (115 patients). Isolated mould allergy was found as 4.3% with the exclusion of common non-fungal respiratory allergens, among them Cladosporium was the most common cause.

Prevalence of occupational asthma among automobile and furniture painters in the center of Eskisehir (Turkey): the effects of atopy and smoking habits on occupational asthma

BACKGROUND

Occupational asthma (OA) is a respiratory disorder characterized by airway hyperreactivity caused by agents present in the workplace. For determination of the prevalence of OA among car and furniture painters exposed to isocyanate in the center of Eskisehir, Turkey, a clinical and epidemiologic prospective study in three phases was done, incorporating 312 (89.4%) of the painters.

METHODS

Of these subjects, 190 (61%) were furniture painters and 122 (39%) automobile painters. In the first phase of the study, a modified questionnaire and pulmonary function test (PFT) were done. During the second phase, peak expiratory flow rate (PEFR) was monitored in 52 subjects whose complaints were confirmed and who agreed to a month of such monitoring. In the third phase, nonspecific bronchial provocation tests (NSBPT) with histamine were done on 23 of the PEFR-monitored workers.

RESULTS

Finally, through questionnaire, typical history, PFT, PEFR monitoring, and NSBPT, 30 workers (9.6%) were diagnosed as having OA. Smoking habits and atopy in the OA-diagnosed workers were found to be statistically significantly high in comparison to the other workers.

CONCLUSIONS

It was concluded that OA is a common disorder among automobile and furniture painters, and smoking habits and atopy were seen to have a significant effect on OA occurrence.

Comparative analysis of biochemical parameters for differentiation of pleural exudates from transudates Light's criteria, cholesterol, bilirubin, albumin gradient, alkaline phosphatase, creatine kinase, and uric acid

The differentiation of pleural effusions as being either transudate or exudate is the first step in the diagnosis of pleural effusions. The aim of this study was to compare the efficiency of the various biochemical parameters to the traditional criteria of Light et al., for differentiating exudates from transudates. Ninety-three pleural fluid and sera specimens were obtained and classified as transudates or exudates on the basis of their diagnosis. Of the 93 pleural fluids, 21 were transudates, 72 were exudates. The efficiencies of different parameters for detection of exudates were as follows: The criteria of Light 96%; effusion cholesterol concentration 77%; serum-fluid albumin gradient 67%, pleural/serum alkaline phosphatase ratio 83%; effusion creatine kinase levels 91%; pleural/serum creatine kinase ratio 83%, and effusion uric acid 71%. Pleural/serum uric acid ratio was insignificant for the purpose of this study.

Malignant localized fibrous tumor of the pleura occurring in a person environmentally exposed to tremolite asbestos

A case is presented of a malignant localized pleural fibroma occurring in a 60-year-old Turkish female who was environmentally exposed to tremolite. The tumor was excised but recurred 3 years later when it was again excised. It is possible that more radical surgery at initial presentation with chest wall resection would have been advantageous.

CT-guided pleural needle biopsy in the diagnosis of malignant mesothelioma

OBJECTIVE

Our goal was to determine the sensitivity of CT-guided closed pleural needle biopsy (CPNB) for the histopathologic diagnosis of diffuse malignant pleural mesothelioma (DMPM).

MATERIALS AND METHODS

Thirty patients with DMPM were studied with CT-guided CPNB. Tumor specimens were classified according to their cell types.

RESULTS

In 25 (83.3%) patients, the diagnosis was made by CT-guided CPNB. The remaining five patients were diagnosed by thoracoscopy, thoracotomy, or excisional biopsy of the chest wall mass. Pneumothorax was observed in 9.5% of patients and local seeding of tumor in 21.7% of patients who underwent CPNB.

CONCLUSION

Properly performed CPNB under CT guidance may yield an increased sensitivity for the diagnosis of diffuse malignant pleural mesothelioma.

Chromosome analysis in pleural effusions. Efficiency of this method in the differential diagnosis of pleural effusions

Various laboratory methods are being used to acquire diagnosis in pleural effusions. However, about 20% of the effusions cannot be diagnosed reliably. Cytogenetic analysis in pleural effusion is not used routinely, although many numerical and/or structural chromosome abnormalities have been observed in malignant pleural effusions. In this study, a total of the 61 pleural effusion samples, 34 malignant which included 19 diffuse pleural malignant mesothelioma, 15 metastatic malignant pleural effusions and 27 benign, were analyzed by direct chromosome analysis method. To the findings obtained in the study, 85.3% (29/34) of the 34 patients with malignant pleural effusion had numerical and/or structural abnormalities, and 3 of them had no mitosis. The patients who had benign pleural effusion indicated no numerical and/or structural abnormalities. We have concluded that if a pleural effusion cannot be reliably differentiated by the usual laboratory methods and especially malignancy is strongly suspected, cytogenetic analysis can be used to differentiate malignant effusions from benign effusions with a small rate of error, and also it can indicate that more invasive diagnostic procedures are necessary.