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Langston and Sampson point out that the sine qua non of empyema management is early, adequate, and dependent drainage. Diagnostic thoracentesis followed by closed tube thoracostomy and conversion to open drainage, either by a large-bore tube or a rib-resection with a pleurocutaneous fistula, are initial procedures that may be continued for an extended period to control infection, obliterate loculations, and heal co-apted pleural surfaces secondarily. Clagett and Geraci have noted that postpneumonectomy empyema spaces can be "sterilized" and the initial drainage site can be closed after antibiotic instillation. Miller, however, reports success rates for this procedure only in the range of 25% to 33%. Our results are somewhat higher. Obliteration of the persistent space after control of infection by drainage can be accomplished by interposition of muscle flaps with closure of any bronchopleural fistulas and/or by thoracoplasty. As stated previously, myoplastic techniques to obliterate empyemas and close bronchial fistulas in tuberculous disease have a success rate of approximately 75%. Such techniques, however, not only assist in limiting the extent of thoracoplasty, but also may avoid the procedure entirely in some cases. Virkkula has emphasized that use of pedicled myoplasty does not necessarily obviate the need for thoracoplasty. Pairolero and colleagues reported that the use of selected thoracoplasty combined with muscle transposition afforded a 73% success rate for postpneumonectomy empyema and a 64% success rate for closure of persistent bronchopleural fistulas and precludes protracted drainage and/or extended thoracoplasty. Young and Ungerleider concluded that (1) thoracoplasty is more successful if it is applied for patients with parapneumonic rather than postresectional empyemas; (2) concomitant tailoring thoracoplasty has a higher rate of failure; (3) preliminary drainage followed by thoracoplasty has a higher success rate in eliminating the empyema than thoracoplasty alone; (4) first rib resection is indicated for apical collapse only; (5) preoperative preparation is important to control and manage underlying suppurative processes; and (6) thoracoplasty of any type should not be used as a desperation modality of therapy in which uncontrolled sepsis and inadequate drainage are present or in which cancer or unidentified sites of hemorrhage exist. Sequential management of the residual infected space can proceed along several pathways. Many patients with empyema are well-controlled with simple open drainage and with underlying lung reexpansion, either spontaneously or in association with decortication, and may never need thoracoplasty. Drainage and thoracoplasty alone may be effective not only in obliterating an empyema space but also in sealing a bronchopleural fistula.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:Thoracoplasty. 795 86

Complete opacification on chest radiographs may be due to collapse of the lung, consolidation, massive pleural effusion, empyema, hemothorax, chylothorax, fibrothorax, and other causes. We report a case of complete opacification of the hemithorax produced by large cell lymphoma, a previously unreported cause of this finding. Diagnosis was complicated by the CT finding of replacement of the lung parenchyma by a soft-tissue mass with an associated small pleural effusion, while bronchoscopy failed to reveal any major airway obstruction. Large cell lymphoma should therefore be added to the differential diagnosis when considering causes of complete opacification of the hemithorax. Both the patient and his brother had the combination of Lowe's syndrome and cancer.
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PMID:Diffuse large cell lymphoma of the lung: an unusual cause of complete opacification of the hemithorax. 797 13

Tuberculous spondylitis is a well-recognized cause of back pain and vertebral collapse due to infection and with must not be overlooked even if it is not the most likely diagnosis. If a patient, particularly one of Asian origin, were to present with a solitary destructive bone lesion, without evidence of myeloma or other malignancy, a trial of anti-tuberculous chemotherapy would be one therapeutic approach, even if there was no evidence of tuberculosis elsewhere. However, failure to biopsy the bone lesion and undertake the appropriate microbiology could lead to other important diagnoses being missed. This is illustrated by the case which we report below.
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PMID:Cryptococcal spondylitis: solitary infective bone lesions are not always tuberculous. 798 98

Thoracoscopic mobilization was performed in nine patients with oesophageal cancer. Five principles emerged as essential for successful dissection: (1) the selection of patients with mobile oesophageal tumours without evidence of local invasion; (2) double-lumen anaesthesia and complete collapse of the right lung during surgery; (3) simultaneous use of a flexible gastroscope; (4) high-quality illumination; and (5) minimal blood loss during dissection. The surgeon should have adequate training in thoracic operations. Further experience should permit mediastinal lymph node dissection. Postoperative pulmonary complications were common, requiring prolonged intensive care management. Widespread adoption of the technique cannot be recommended.
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PMID:Right thoracoscopically assisted oesophagectomy for cancer. 815 45

We report a 14 year old Indian-Muslim girl who developed a fulminant, disseminated and fatal varicella infection while receiving steroids for nephrotic syndrome. The terminal phase of her illness was complicated by a bleeding dyscrasia and circulatory collapse. Varicella infection in healthy children is a benign disease. However in neonates and immunosuppressed patients it may be severe and often fatal. There are many reports of fatalities occurring in cancer patients receiving chemotherapy, patients on immunosuppressives for asthma, haemolytic anaemia, rheumatic fever, and renal and bone marrow transplantation. Patients with nephrotic syndrome receiving cyclophosphamide treatment are at particular risk of developing severe chickenpox infection. To our knowledge, there has been only one report of fatal chickenpox infection in a child who received steroids for nephrotic syndrome. We report here a case of fatal haemorrhagic chickenpox complicating nephrotic syndrome.
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PMID:Fatal haemorrhagic chickenpox complicating nephrotic syndrome. 818 71

Cavitation (volume oscillations and collapse of gas bubbles), as generated by a co-administration of shockwaves (SW) and microbubbles (SWB), induces cytotoxicity in vitro. Moreover, cavitation potentiates the effects of Fluorouracil (FUra) on colon cancer cells. We aimed at reproducing such effects in vivo. A peritoneal carcinomatosis was induced in BDIX rats by intraperitoneal (IP) injection of DHDK12PROb cells. Cavitation was produced by various SW regimens (250 to 750SW) combined with bubbles (air/gelatin emulsion) infused through an IP catheter. In two consecutive experiments, microtumours (day 3 after cell injection) were submitted to various combinations of cavitation and/or Fluorouracil (FUra) and Cisplatinum (CDDP) at either high or low doses. After 30 days, 100% of control animals were dead or presented carcinomatosis with ascites, vs 60% after FUra 5 mg kg dy, day 4 through 8, and 0% after 250 SWB, day 4 and 6 + FUra 5 mg kg dy, day 4 through 8 (P < 0.001); similar differences were found with CDDP. Survival after low dose FUra + SWB was comparable to high dose FUra (25 mg kg dy day through 8) and was improved as compared to low-dose FUra alone. Only a high dose FUra + SWB schedule induced 40% long term (> 150 days) disease-free survival, but also a higher undesirable toxicity (40% toxic deaths within 1 month). It is concluded that cavitation is cytotoxic in vivo and that it potentiates the effects of FUra and CDDP in this animal model.
Br J Cancer 1993 Jul
PMID:In vivo effects of cavitation alone or in combination with chemotherapy in a peritoneal carcinomatosis in the rat. 831 2

A 24-year-old man had a mediastinal embryonal carcinoma containing yolk sac foci. Combination chemotherapy with cisplatin, bleomycin, etoposide, and vinblastine was given, and the residual mass was then resected. Histology showed only necrotic cells. No other treatment was given. Two years later the patient presented with episodes of flushing and syncopes related to a systemicmastocytosis. Bone marrow examination showed a diffuse infiltration with large, atypical mast cells often with multilobulated nuclei. The patient suffered several episodes of cardiovascular collapse and died during one of these episodes, 8 months after the diagnosis of systemic mastocytosis and 40 months after the diagnosis of mediastinal tumor. Autopsy findings included the absence of mediastinal tumor and a diffuse liver and spleen mast cell infiltration. This was the second case with the similar clinicopathologic picture of two rare diseases being associated. This fact supports the hypothesis of a distinct entity, part of the mediastinal germ cell tumor/hematologic malignancy syndrome. The hypothesis of a cytokine secretion induced by mediastinal germ cell tumor supporting mast cell proliferation may be considered.
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PMID:Systemic mastocytosis following mediastinal germ cell tumor: an association confirmed. 838 Feb 74

The effect of angiotensin II-induced hypertension on tumor interstitial fluid pressure (TIFP) and tumor blood flow (TBF) was investigated to examine blood flow and pressure regulation in solid tumors. TIFP measurements were made before and after administration of angiotensin II using the wick-in-needle method in s.c. tumor implants. Relative TBF was continuously monitored by laser doppler velocimetry. The effect of host strain on TIFP was evaluated in MCA-IV mammary carcinoma, transplanted in C3H and SCID mice, and showed no significant difference. The effects of tumor types were evaluated by comparing two murine tumors, MCA-IV mammary carcinoma and FSaII fibrosarcoma, and a human tumor xenograft, LS174T adenocarcinoma, transplanted in SCID mice. Baseline TIFP was elevated in all three tumor lines to significantly different pressures. AII-induced hypertension (approximately 150 mm Hg) had a variable but tumor line-specific effect on TIFP and TBF. The increase in TIFP was correlated with the baseline TIFP (r2 = 0.853) (increasing from 6.9 to 8.7 mm Hg, 10.5 to 15.8 mm Hg, and 21.7 to 29.4 mm Hg in FSaII, MCA-IV, and LS174T, respectively). These data suggest that in addition to blood flow redistribution due to the steal phenomenon, arterial control of TBF and TIFP exists within these solid tumors; however, the extent of control is tumor line dependent and less than that in normal tissues. Moreover, parallel increases in TIFP and TBF do not support the hypothesis that elevated TIFP causes vascular collapse and thus decreases TBF.
Cancer Res 1993 Jun 01
PMID:Effect of angiotensin II induced hypertension on tumor blood flow and interstitial fluid pressure. 849 5

Osteoporotic vertebral crush fractures with neurologic complications are rarely reported in the literature. We report six new cases particularly severe in which death occurred in two cases. The study group included four women and two men with a mean age of 75 years (range: 72-79). Vertebral collapse causing neurological deficit was T5, T9, T11 in two cases, L1 and L3. The mean number of vertebral collapses was three per patient (range: 1-9). Back pain appeared without traumatism 6 weeks before admission (range: 1-24). Neurological complications appeared 2.5 weeks after back pain (range: 1-8). One patient suffered from a paraplegia, three from a paraparesia with bladder dysfunction (n = 1). In one case there was a severe weakness of the levator muscles of the foot and in another a L3 femoral neuralgia with severe bowel and bladder dysfunction. X-rays demonstrated backwards displacement of the posterior cortex in three cases, an intravertebral vacuum phenomenon in two cases and a heterogeneous appearance suggesting a malignancy in two cases. Computed tomography, performed in four patients and tomography in one patient, demonstrated fragmentation of the vertebral body in all the cases and vacuum phenomenon in four cases. Magnetic resonance imaging performed in four cases has confirmed the absence of epiduritis and a compression due to bony structures in two cases. A vertebral biopsy was performed in three cases. Osteoporosis was observed in all the cases and in two cases there was also an osteonecrosis. Surgical treatment was performed in three cases and conservative medical treatment in the other cases. After surgical treatment we have observed an absence of improvement of neurological complications in one case, an improvement in another and finally a full recovery in the last case. After conservative treatment we have noted in two cases an absence of improvement of neurological complications and in one case an improvement of neurological deficit. Two patients died (one after medical treatment and another after surgical treatment).
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PMID:[Osteoporotic vertebral crush fractures with severe neurologic manifestations. Apropos of 6 cases]. 857 Sep 51

Various vasoactive agents have been used to modify tumor blood flow with the ultimate goal of improving cancer detection and treatment, with widely disparate results. Furthermore, the lack of mechanistic interpretations has hindered understanding of how these agents affect the different physiological parameters involved in perfusion. Thus, there is a need to develop a unified framework for understanding the interrelated physiological effects of pharmacological and physical agents. The goals of this study were (1) to develop a mathematical model which helps determine the location and magnitude of changes in the vascular resistance of tumor and normal tissues and (2) to test the model with our experimental studies and by comparison with results from the literature. The systemic and interstitial pressures and relative tumor blood flow were measured before and after administration of angiotensin II, epinephrine, norepinephrine, nitroglycerin, and hydralazine in SCID mice bearing LS174T human colon adenocarcinoma xenografts. A mathematical model was developed in analogy to electrical circuits which examined the pressure, flow, and resistance relationships for arterial and venous segments of the vasculature of a tumor and surrounding normal tissue. Vasoconstrictor-induced increases in the mean arterial blood pressure led to increases in tumor blood flow and interstitial pressure with the magnitude of change dependent on the agent (percentage change in blood flow: angiotensin > epinephrine > norepinephrine). The vasodilating agents induced decreases in tumor blood flow in parallel to the induced decreases in the systemic pressure, but only the long-acting arterial vasodilator hydralazine was capable of effecting a decrease in tumor interstitial pressure. The model was also found to be consistent with other data available in the literature on norepinephrine, pentoxifylline, nicotinamide, and hemodilution, and was useful in providing input as to the location and degree of the physiological effects of these agents. The results of the data and model show that the steal phenomenon is the dominant mechanism for redistribution of host blood flow to the tumor. However, some degree of arterial control was found to be present in the tumors. Moreover, the parallel increases in tumor interstitial pressure and blood flow contradict any hypothesis suggesting that elevated interstitial fluid pressure precipitates chronic vascular collapse, thus decreasing blood flow.
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PMID:Pharmacologic modification of tumor blood flow and interstitial fluid pressure in a human tumor xenograft: network analysis and mechanistic interpretation. 899 38


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