Localized Emphysema Research Articles

Clinical and experimental parallels in the assessment of microcirculatory dysfunctions of the lungs in thoracic radiology

Introduction. Chronic obstructive disease (COPD) and thromboembolism of the branches of the pulmonary artery or pulmonary embolism (PE) remain the most common and socially significant lung diseases. Circulatory disorders in these pathologies play a critical role in the development of the disease. Radiation techniques, such as computed tomography/angiography and single-photon emission computed tomography (SPECT), are the leading ones in recognizing changes in the lung parenchyma and vessels. Many questions can be successfully solved experimentally. The main radiation techniques used to study the vascular bed when modeling lung diseases in experimental animals are microangiography and perfusion scintigraphy. Purpose. To show the capabilities of radiation diagnostic methods for identifying vascular disorders in COPD and PE in experiments and clinical manifestations. Material and methods. A clinical and experimental comparison of pulmonary circulation changes during COPD and PE was carried out based on the results of perfusion scintigraphy/SPECT in 55 rats with simulated COPD- like condition and 622 patients with COPD of varying severity, as well as 58 rats with simulated PE and 180 patients with PE. Results. When modelling lung diseases (PE and COPD), the results similar to blood circulation and structural changes in the lung parenchyma in patients with these nosologies were obtained. In COPD, changes in the lung parenchyma correlated with disturbances in functional indicators (microcirculation, PaO2, PaCO2, DSLzd, DLco/VA, SDPA) and increased levels of endothelin-1 (r=0.72) and endothelial growth factor (VEGF-A) (r=0.79). Analysis of experimental and clinical data on PE showed the importance of identifying minor forms of thromboembolism. Conclusion. 1. Persistent microcirculatory dysfunctions in the pulmonary circulation play an important role in the pathogenesis of chronic broncho-obstructive pathology. After just 7 days, initial signs of emphysema can be detected in the ischemic area of the lung tissue, and by the 60th day typical bullous cavities can be detected. 2. In the chronic course of minor forms of thromboembolism of small branches of the pulmonary artery, local emphysema is formed. 3. At the early stages of COPD formation, regional zones of emphysematous restructuring of the lung tissue with a predominance of ventilation dysfunctions and zones of «compressive ischemia» with prevailing vascular disorders are formed. As the pathological process progresses, the ischemia factor acquires independent significance in the pathogenesis of the disease.

Topologic Parametric Response Mapping Identifies Tissue Subtypes Associated with Emphysema Progression

Small airways disease (SAD) and emphysema are significant components of chronic obstructive pulmonary disease (COPD), a heterogenous disease where predicting progression is difficult. SAD, a principal cause of airflow obstruction in mild COPD, has been identified as a precursor to emphysema. Parametric Response Mapping (PRM) of chest computed tomography (CT) can help distinguish SAD from emphysema. Specifically, topologic PRM can define local patterns of both diseases to characterize how and in whom COPD progresses. We aimed to determine if distribution of CT-based PRM of functional SAD (fSAD) is associated with emphysema progression. We analyzed paired inspiratory-expiratory chest CT scans at baseline and 5-year follow up in 1495 COPDGene subjects using topological analyses of PRM classifications. By spatially aligning temporal scans, we mapped local emphysema at year five to baseline lobar PRM-derived topological readouts. K-means clustering was applied to all observations. Subjects were subtyped based on predominant PRM cluster assignments and assessed using non-parametric statistical tests to determine differences in PRM values, pulmonary function metrics, and clinical measures. We identified distinct lobar imaging patterns and classified subjects into three radiologic subtypes: emphysema-dominant (ED), fSAD-dominant (FD), and fSAD-transition (FT: transition from healthy lung to fSAD). Relative to year five emphysema, FT showed rapid local emphysema progression (-57.5%±1.1) compared to FD (-49.9%±0.5) and ED (-33.1%±0.4). FT consisted primarily of at-risk subjects (roughly 60%) with normal spirometry. The FT subtype of COPD may allow earlier identification of individuals without spirometrically-defined COPD at-risk for developing emphysema.

A LUNG WITHIN A LUNG? A CASE REPORT OF MASSIVE HEMOPTYSIS SECONDARY TO PULMONARY SEQUESTRATION

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Bronchopulmonary sequestration (BPS), is defined as a non-functional mass of lung tissue with systemic arterial blood supply, but without normal tracheobronchial communication. BPS often presents in adulthood with recurrent pulmonary infections and even fatal hemoptysis. We present a case of a 53-year-old African American male with large volume hemoptysis while hiking in upstate New York, who was found to have right lower lobe intralobar pulmonary sequestration. CASE PRESENTATION: A 53-year-old African American male with a past medical history of hypertension, hyperlipidemia, and diabetes mellitus presented with a subacute cough for one month and one episode of large volume hemoptysis while hiking. Review of systems was negative for fever, chills, chest pain, pleurisy, history of tuberculosis, weight loss, and anticoagulation use. He admitted to recreational marajuana use, but denied smoking cigarettes. Initially he was tachypneic, saturating 91% on room air, but hemodynamically stable. Computed tomography angiography (CTA) revealed right lower lobe intralobar pulmonary sequestration with internal locules of air suggesting superimposed infection. Flexible bronchoscopy revealed fresh blood in the right mainstem and lower lobe. Thoracotomy was followed by a lower lobectomy, which confirmed the diagnosis as it demonstrated an aberrant arterial supply from the descending thoracic aorta. There was no envelopment of pleura around the lung fed by the large pulsatile artery. DISCUSSION: Pulmonary airway malformations are the most common type of congenital abnormalities of the lower respiratory tract, diagnosed 1 in 10,000 to 35,000 live births [1]. An intralobar sequestration (IS) is located in a normal lobe and an extralobar sequestration (ES) is outside, with both having their own visceral pleura. Hybrid lesions are most common and have features of both. ES presents early with associated congenital malformations, whereas IS presents later with hemoptysis and recurrent pulmonary infections [2]. BPS can appear as other pathologies on CT such as a mass lesion, cyst, cavity lesion and localized emphysema [3,4]. Lobectomy should be prompt to prevent complications, such as fatal hemoptysis [5]. Shorter recovery times have been noted with video-assisted thoracoscopic surgery (VATS) [6,7]. Postoperative complications include empyema, hemoptysis, prolonged air leak, and fistula formation. Berna et al described their surgical approach in 25 patients in 2011, and all patients were doing well at long-term follow-up [7]. CONCLUSIONS: BPS can be fatal despite its rarity and innocent presentation. Radiographic ambiguity and nonspecific symptoms may delay appropriate management. It is imperative to include BPS on the initial query when managing hemoptysis. In the era of COVID-19, where hemoptysis may herald a deadly disease, understanding the broad differential of hemoptysis expedites appropriate management. REFERENCE #1: [1] Durell J, Thakkar H, Gould S, Fowler D, Lakhoo K. Pathology of asymptomatic, prenatally diagnosed cystic lung malformations. J Pediatr Surg. 2016;51(2):231-235. doi:10.1016/j.jpedsurg.2015.10.061 REFERENCE #2: [2] Van Raemdonck D, De Boeck K, Devlieger H, et al. Pulmonary sequestration: a comparison between pediatric and adult patients. Eur J Cardiothorac Surg. 2001;19(4):388-395. doi:10.1016/s1010-7940(01)00603-0 REFERENCE #3: [3] Wei Y, Li F. Pulmonary sequestration: a retrospective analysis of 2625 cases in China. Eur J Cardiothorac Surg. 2011;40(1):e39-e42. doi:10.1016/j.ejcts.2011.01.080[4] Qi W, Zhao J, Shi G, Yang F. Intralobar pulmonary sequestration displayed as localized emphysema on computed tomography image. J Cardiothorac Surg. 2017;12(1):83. Published 2017 Sep 8. doi:10.1186/s13019-017-0646-9[5] Rubin EM, Garcia H, Horowitz MD, Guerra JJ Jr. Fatal massive hemoptysis secondary to intralobar sequestration. Chest. 1994 Sep;106(3):954-5. doi: 10.1378/chest.106.3.954. PMID: 8082388.[6] Sun X, Xiao Y. Pulmonary sequestration in adult patients: a retrospective study. Eur J Cardiothorac Surg. 2015;48(2):279-282. doi:10.1093/ejcts/ezu397[7] Polaczek, M., Baranska, I., Szolkowska, M., Zych, J., Rudzinski, P., Szopinski, J., Orlowski, T., & Roszkowski-Sliz, K. (2017). Clinical presentation and characteristics of 25 adult cases of pulmonary sequestration. Journal of thoracic disease, 9(3), 762–767. https://doi.org/10.21037/jtd.2017.03.107 DISCLOSURES: No relevant relationships by Christian Castaneda, source=Web Response no disclosure on file for Rammohan Gumpeni; No relevant relationships by Sophia Ji, source=Web Response No relevant relationships by Parmjyot Singh, source=Web Response No relevant relationships by Anthony Smith, source=Web Response

Bronchopulmonary dysplasia in extremely premature infant with congenital lobar emphysema: a case report

BackgroundCongenital lobar emphysema (CLE) is a congenital pulmonary cystic disease, characterized by overinflation of the pulmonary lobe and compression of the surrounding areas. Most patients with symptoms need an urgent surgical intervention. Caution and alertness for CLE is required in cases of local emphysema on chest X-ray images of extremely premature infants with bronchopulmonary dysplasia (BPD).Case presentationHere, we report a case of premature infant with 27 + 4 weeks of gestational age who suddenly presented with severe respiratory distress at 60 days after birth. Chest X-ray and computed tomography (CT) indicated emphysema in the middle lobe of the right lung. The diagnosis of CLE was confirmed by histopathological examinations.ConclusionsAlthough extremely premature infants have high-risk factors of bronchopulmonary dysplasia due to their small gestational age, alertness for CLE is necessary if local emphysema is present. Timely pulmonary CT scan and surgical interventions should be performed to avoid the delay of the diagnosis and treatment.

КОМПЬЮТЕРНАЯ ТОМОГРАФИЯ ОРГАНОВ ГРУДНОЙ КЛЕТКИ ПРИ ПНЕВМОНИИ, ОБУСЛОВЛЕННОЙ COVID-19, У ПАЦИЕНТОВ С ХРОНИЧЕСКОЙ ПОЧЕЧНОЙ НЕДОСТАТОЧНОСТЬЮ

The study aims to evaluate the signs and extent of lung damage in patients with pneumonia affected by COVID-19, associated with end-stage renal disease (ERSD) and without kidney disease, according to the data of computed tomography (CT) of the chest organs. Material and methods. The group of patients with pneumonia and ERSD had 53 people and the group without kidney disease consisted of 59 people. Despite the appropriate treatment, all patients died. The autopsy confirmed the presence of pneumonia caused by COVID-19. The average age of the patients was 68.40 ± 14.63 years. All 112 patients had chest CT 2.12 ± 0.94 days before death. Results. The lethal outcome in patients with pneumonia caused by COVID-19 and long-term ESRD occurred when the extent of the lung damage equaled 40.64 ± 18.50% with fluctuations from 3 to 69%. Among the patients without kidney disease, the extent of lung damage was 56.63 ± 19.17%, (p < 0.05) with fluctuations from 18 to 94%. According to CT data the ground-glass opacification, crazy-paving, and consolidation signs were observed in 100.0% of patients in both groups. These signs were referred to as the main ones for the purposes of the study. The frequency of other signs such as air bronchogram, pleural thickening, pleurisy, lymphadenopathy, atelectasis, local emphysema, nodules, reticulation, calcifications, fibrosis, bronchiectasis, and pulmonary edema ranged from 2 to 73%. There was no statistically significant difference in the frequency of the signs in both groups. The most frequent locations of pneumonia were the lower (94.4%) and posterior (98.2%) parts of the lungs, regardless of the group observed. The percentage of the severity of the main signs in the lungs was significantly lower among the patients with long-term ERSD.

PD-L1, FGFR1, PIK3CA, PTEN, and p16 expression in pulmonary emphysema and chronic obstructive pulmonary disease with resected lung squamous cell carcinoma

BackgroundEmphysema and chronic obstructive pulmonary disease (COPD) are well known independent risk factors for lung cancer. However, the developmental mechanisms between emphysema/COPD and lung cancer remain unknown. The purpose of this study was to evaluate PD-L1, FGFR1, PIK3CA, PTEN, and p16 expression in squamous cell carcinoma (SCC) associated with emphysema/COPD.MethodsA total of 59 patients with squamous cell lung carcinoma (SCC) resected between 2008 and 2012 were retrospectively reviewed. Emphysema was assessed according to the Goddard score. Total severity was divided into none-mild (0–7), moderate (8–15), and severe (≥ 16). Local severity around the existing tumor was divided into no emphysema (0) and presence of emphysema (1–4). COPD severity was based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria. PD-L1, FGFR1, PIK3CA, PTEN, and p16 expression were evaluated by immunohistochemistry (IHC). Expression level was classified as tumor cells (TC) 3 (≥ 50%), TC2 (5–49%), TC1 (1–4%), or TC0 (< 1%), and as tumor-infiltrating immune cells (IC) 3 (≥ 50%), IC2 (5–49%), IC1 (1–4%), or IC0 (< 1%) for PD-L1. Expression level was compared between none-mild/moderate-severe total emphysema, no/presence of local emphysema, no COPD/COPD, and GOLD 1/GOLD 2, 3.ResultsPD-L1 expression was significantly correlated with severity of emphysema in TC0, 1, 2 vs. TC3 (P = 0.012). PD-L1 was significantly higher inversely in none-mild emphysema compared to moderate-severe (95% CI, 0.061–5.852, P = 0.045). There were no other significant associations between PD-L1, FGFR1, PIK3CA, PTEN, and p16 expression and total/local severity of emphysema or presence of COPD/GOLD stage.ConclusionsPD-L1 expression in SCC was correlated with severity of emphysema in TC0, 1, 2 vs. TC3 and more frequent in none-mild emphysema than moderate-severe emphysema.

A comparison of ventilation perfusion combined with pulmonary perfusion fusion tomography imaging and CT pulmonary angiography for diagnosis of pulmonary embolism

Objective To compare the diagnostic value of ventilation/perfusion (V/Q) combined with pulmonary perfusion single photon emission computed tomography combined with CT (SPECT/CT) fusion tomography imaging and computed tomographic pulmonary angiography (CTPA) in evaluation of pulmonary embolism. Methods We retrospectively analyzed 60 patients with clinically suspected pulmonary embolism diagnosed in Shanxi Dayi Hospital from May 2015 to May 2017. All patients underwent pulmonary V/Q imaging and lung perfusion SPECT/CT fusion tomography, and CTPA inspections were completed within 3 days. The final clinical diagnosis and follow-up confirmed the presence or absence of pulmonary embolism. The diagnostic efficacy of two imaging methods for pulmonary embolism were calculated and compared. Results Of the 60 cases of patients, 33 cases were diagnosed with pulmonary embolism; the sensitivity, specificity, and accuracy of V/Q combined with pulmonary perfusion SPECT/CT fusion tomography were 96.97% (32/33), 92.59% (25/27) and 95% (57/60), respectively; the sensitivity, specificity, and accuracy of CTPA were 81.82% (27/33), 92.59% (25/27) and 86.67% (52/60), respectively; both have no diagnostic uncertainty, there was no significant difference in the qualitative diagnosis of pulmonary embolism between the two examination methods (P>0.05). V/Q combined with pulmonary perfusion SPECT/CT fusion tomography found 253 lung segment and 50 unmatched sub-pulmonary segments, including 15 V/Q mismatch lung segment and 5 sub-segment caused by lung lesions which were confirmed by lung perfusion SPECT/CT fusion image (5 interlobular or pleural effusion, 4 local emphysema and pulmonary bulla, 3 interlobular hypertrophy, 8 pulmonary parenchymal inflammation); CTPA found 3 sub-segmental pulmonary filling defects, 6 cases of false-negative cases were multiple sub-pulmonary segment pulmonary embolism. Conclusions V/Q combined with pulmonary perfusion SPECT/CT fusion tomography is similar to CTPA in diagnosing pulmonary embolism, and both of them have better diagnostic efficacy; the former has advantages in the diagnosis of sub-pulmonary segment pulmonary embolism, and can exclude false-positive diagnoses due to other lung lesions and provide additional diagnostic information for lung disease. Key words: Pulmonary embolism; Tomography, emission-computed, single-photon; Radionuclide imaging; Angiography; Tomography, spiral computed

Assessing lung function using contrast-enhanced dual-energy computed tomography for potential applications in radiation therapy.

There is an increasing interest in the evaluation of lung function from physiological images in radiation therapy treatment planning to reduce the extent of postradiation toxicities. The purpose of this work was to retrieve reliable functional information from contrast-enhanced dual-energy computed tomography (DECT) for new applications in radiation therapy. The functional information obtained by DECT is also compared with other methods using single-energy CT (SECT) and single-photon emission computed tomography (SPECT) with CT. The differential function between left and right lung, as well as between lobes is computed for all methods. Five lung cancer patients were retrospectively selected for this study; each underwent a SPECT/CT scan and a contrast-injected DECT scan, using 100 and 140 Sn kVp. The DECT images are postprocessed into iodine concentration maps, which are further used to determine the perfused blood volume. These maps are calculated in two steps: (a) a DECT stoichiometric calibration adapted to the presence of iodine and followed by (b) a two-material decomposition technique. The functional information from SECT is assumed proportional to the HU numbers from a mixed CT image. The functional data from SPECT/CT are considered proportional to the number of counts. A radiation oncologist segmented the entire lung volume into five lobes on both mixed CT images and low-dose CT images from SPECT/CT to allow a regional comparison. The differential function for each subvolume is computed relative to the entire lung volume. The differential function per lobe derived from SPECT/CT correlates strongly with DECT (Pearson's coefficient r = 0.91) and moderately with SECT (r = 0.46). The differential function for the left lung shows a mean difference of 7% between SPECT/CT and DECT; and 17% between SPECT/CT and SECT. The presence of nonfunctional areas, such as localized emphysema or a lung tumor, is reflected by an intensity drop in the iodine concentration maps. Functional dose volume histograms (fDVH) are also generated for two patients as a proof of concept. The extraction of iodine concentration maps from a contrast-enhanced DECT scan is achieved to compute the differential function for each lung subvolume and good agreement is found in respect to SPECT/CT. One promising avenue in radiation therapy is to include such functional information during treatment planning dose optimization to spare functional lung tissues.

Intralobar pulmonary sequestration displayed as localized emphysema on computed tomography image

BackgroundPulmonary sequestration is a relatively rare condition in which a systemic artery supplies blood to an abnormal lung tissue and the normal connection with the bronchial tree is absent. It can be displayed as various signs on the computed tomography image, but emphysema is extremely rare.Case presentationWe describe the case of a 35-year-old man with intralobar pulmonary sequestration that appeared as localized emphysema on the computed tomography image. The 3-D reconstruction revealed the presence of an anomalous feeding artery and the absence of normal connection with the bronchial tree.ConclusionWe presumed that it was a type between “anomalous systemic arterial supply to the normal lung” and the common type of pulmonary sequestration. Common pulmonary lobectomy was performed and the patient recovered well.

The influence of inspiratory effort and emphysema on pulmonary nodule volumetry reproducibility

To evaluate the impact of inspiratory effort and emphysema on reproducibility of pulmonary nodule volumetry. Eighty-eight nodules in 24 patients with emphysema were studied retrospectively. All patients had undergone volumetric inspiratory and end-expiratory thoracic computed tomography (CT) for consideration of bronchoscopic lung volume reduction. Inspiratory and expiratory nodule volumes were measured using commercially available software. Local emphysema extent was established by analysing a segmentation area extended circumferentially around each nodule (quantified as percent of lung with density of -950 HU or less). Lung volumes were established using the same software. Differences in inspiratory and expiratory nodule volumes were illustrated using the Bland-Altman test. The influences of percentage reduction in lung volume at expiration, local emphysema extent, and nodule size on nodule volume variability were tested with multiple linear regression. The majority of nodules (59/88 [67%]) showed an increased volume at expiration. Mean difference in nodule volume between expiration and inspiration was +7.5% (95% confidence interval: -24.1, 39.1%). No relationships were demonstrated between nodule volume variability and emphysema extent, degree of expiration, or nodule size. Expiration causes a modest increase in volumetry-derived nodule volumes; however, the effect is unpredictable. Local emphysema extent had no significant effect on volume variability in the present cohort.

Laryngeal Injury and Pneumomediastinum Due to Minor Blunt Neck Trauma: Case Report

BackgroundSerious isolated laryngeal injuries are uncommon in children. Case ReportWe describe the case of an 8-year-old boy with laryngeal injury and pneumomediastinum due to minor blunt neck trauma. He presented to the emergency department complaining of odynophagia and hoarseness, but without respiratory distress. Emphysema was seen between the trachea and vertebral body on initial cervical spine x-ray study, and flexible laryngoscopy revealed erythema and mild edema of both the right vocal cord and the arytenoid region. He recovered with conservative management only. Why Should an Emergency Physician Be Aware of This?We conclude that it is important to recognize subtle evidence of laryngeal injury secondary to blunt neck trauma to ensure early diagnosis. Initial cervical spine x-ray assessment should exclude both cervical spine fracture and local emphysema after blunt neck trauma. If patients with blunt neck trauma have evidence of a pneumomediastinum, the clinician should consider the possibility of aerodigestive injury.

Cystic Lung Disease in a Patient With Proteus Syndrome

Cystic Lung Disease in a Patient With Proteus Syndrome

Pulmonary kinematic analysis with non-rigid deformable registration for detecting localised emphysema

Emphysema is defined pathologically as destruction of alveolar walls and permanent enlargement of the airspaces. Detection of localised emphysema is difficult using conventional methods because the parameters evaluate macroscopic lung function. In this study, the pulmonary kinematics of control and emphysema model mice were evaluated to investigate whether pulmonary kinematic analysis is useful for diagnosing localised emphysema. Emphysema model mice were induced by porcine pancreatic elastase treatment, and 3D micro-CT images were obtained during stepwise inflation and deflation. The pulmonary vessels and pleura were segmented at each pressure, and pulmonary deformation and volumetric strain between consecutive different pressures were calculated by non-rigid deformable registration. In particular, during low lung pressure, craniocaudal deformation and volumetric strain were higher in the regions where the alveolar enlargement was observed in emphysema model mice. Furthermore, volumetric strain of emphysema model mice was larger at alveolar enlargement. On the other hand, there were no significant differences between control and emphysema model mice in conventional macroscopic lung pressures and volume relationships. The present results indicate that pulmonary kinematic analysis, examining craniocaudal deformation, and volumetric strain may become useful for the clinical assessment of localised emphysema.

Towards local progression estimation of pulmonary emphysema using CT

Whole lung densitometry on chest CT images is an accepted method for measuring tissue destruction in patients with pulmonary emphysema in clinical trials. Progression measurement is required for evaluation of change in health condition and the effect of drug treatment. Information about the location of emphysema progression within the lung may be important for the correct interpretation of drug efficacy, or for determining a treatment plan. The purpose of this study is therefore to develop and validate methods that enable the local measurement of lung density changes, which requires proper modeling of the effect of respiration on density. Four methods, all based on registration of baseline and follow-up chest CT scans, are compared. The first naïve method subtracts registered images. The second employs the so-called dry sponge model, where volume correction is performed using the determinant of the Jacobian of the transformation. The third and the fourth introduce a novel adaptation of the dry sponge model that circumvents its constant-mass assumption, which is shown to be invalid. The latter two methods require a third CT scan at a different inspiration level to estimate the patient-specific density-volume slope, where one method employs a global and the other a local slope. The methods were validated on CT scans of a phantom mimicking the lung, where mass and volume could be controlled. In addition, validation was performed on data of 21 patients with pulmonary emphysema. The image registration method was optimized leaving a registration error below half the slice increment (median 1.0 mm). The phantom study showed that the locally adapted slope model most accurately measured local progression. The systematic error in estimating progression, as measured on the phantom data, was below 2 gr/l for a 70 ml (6%) volume difference, and 5 gr/l for a 210 ml (19%) difference, if volume correction was applied. On the patient data an underlying linearity assumption relating lung volume change with density change was shown to hold (fitR(2) = 0.94), and globalized versions of the local models are consistent with global results (R(2) of 0.865 and 0.882 for the two adapted slope models, respectively). In conclusion, image matching and subsequent analysis of differences according to the proposed lung models (i) has good local registration accuracy on patient data, (ii) effectively eliminates a dependency on inspiration level at acquisition time, (iii) accurately predicts progression in phantom data, and (iv) is reasonably consistent with global results in patient data. It is therefore a potential future tool for assessing local emphysema progression in drug evaluation trials and in clinical practice.

Retromammary Approach for Endoscopic Resection of Benign Breast Lesions

One of the merits of endoscopic surgery is that it can be performed through small remote incisions made in inconspicuous areas. To improve cosmetic outcomes of surgical treatment of benign breast lesions, we performed endoscopic surgery through minimally sized axillary incisions with the goal of achieving scar-free breasts. From August 2007 to August 2008, 18 patients with 20 benign breast lesions underwent endoscopic breast excision in our institution. Endoscopic resection of benign breast lesions was performed via the retromammary route with video assistance. Cosmetic results were evaluated using the five-item, four-step ABNSW scoring system, assessing breast asymmetry, breast shape, nipple shape, skin condition, and wound scars. The median age of the patients was 27 years (IQR 23.0, 29.0). Median resected lesion size was 3.3 cm (IQR 2.9, 3.9). Median operative time was 85.0 min (IQR 70.0, 100.0). A marginally significant difference in operative times was noted between fibroadenoma and/or juvenile fibroadenoma cases and mastopathy or benign phyllodes cases (80.0 vs. 100.0; p < 0.06). Median total ABNSW score was 14 points. Postoperatively, 5 patients had mild local subcutaneous emphysema, and one had transient brachial palsy. No breast ecchymosis or deformity was noted. No major complications developed in any patient, and 89% of patients had good or excellent results. Video-assisted endoscopic breast surgery has changed routine breast surgery, manifesting cosmetic effects that cannot be achieved by previous routine surgical techniques. Patients with multiple or large benign tumors who desire excellent cosmetic results are good candidates for this approach.

Delayed localised subcutaneous emphysema following sternal repair

Delayed localised subcutaneous emphysema following sternal repair

Partial Liquid Ventilation (PLV) combined with Proportional Assist Ventilation (PAV) in Spontaneously Breathing Animals: Follow-up of Gas Exchange and Survival over a Four Week Period in a Rabbit Model 1673

This study tests the hypothesis that animals can be returned safely to gas ventilation after assisted ventilation with PLV combined with PAV.Methods: Nine anesthetized and intubated adult rabbits were ventilated using PAV with an FiO2 of 1.0 and a PEEP of 6 [4-6] cmH2O. The degree of unloading was adjusted to compensate approximately for the resistance of the endotracheal tube and to maintain a PaCO2 of 40-50 mmHg. An arterial femoral line was placed for blood gas measurements. Then a single dose of 30 ml/kg Perfluorocarbon (PFC), (Rimar 101) was instilled continuously into the endotracheal tube (rate 0.5ml/kg/min). The first two animals (early extubation group) were extubated after PaO2 had returned to baseline (approximately after 1 1/2 h); in subsequent animals(late extubation group; n=7) FiO2 was weaned after 3 h from 1.0 to 0.21 and animals were extubated after 5 h. Arterial blood gases were obtained in hourly intervals as well as 1 h, 12 h and 28 days after extubation. Weight gain was assessed in weekly intervals. Results: The two early extubated animals died within 48 h. Lung autopsy showed severe local emphysema in non-dependent regions, suggesting that evaporation had been incomplete, resulting in overdistension of non-dependent ventilated areas. 2/7 animals of the late extubation group died (one from a pneumothorax immediately after extubation and another for unknown reasons). Both did not show any evidence for pulmonary emphysema on autopsy. The other 5 animals were longterm survivors and showed progressive weight gain (106 ± 97 g/wk).Conclusion: Animals may be returned safely to gas ventilation after being supported with PLV combined with PAV if evaporation of PFC is complete. Table

History of Emphysema Surgery

Ever since the advent of modern chest surgery, surgical pioneers have attempted operations to alleviate, if not cure, patients with emphysema. From the physiologic standpoint illogical procedures such as costochondrectomy, phrenisectomy, or thoracoplasty lead to disastrous results, whereas the effect of operations on the autonomous nervous system was unpredictable. The only worthwhile procedure was bullectomy for localized bullous emphysema. The concept of volume reduction developed by Brantigan in the 1950s and rediscovered by Cooper is the only successful surgical approach to an essentially incurable pulmonary disease.

Intérêt et limites de l’obstruction bronchique sélective dans l’emphysème interstitiel unilatéral néonatal

Two methods of selective ventilation have been used for treating severe localized pulmonary emphysema in the neonates: controlateral selective intubation and selective bronchial obstruction. Three neonates with acute respiratory distress required respiratory support that was complicated by development of severe localized pulmonary interstitial emphysema of the right lobe (two cases) and the middle lobe (one case). Selective bronchial obstruction with a Swann Ganz catheter SF was tentatively made: in one case, improvement was moderate and transitory, requiring middle lobectomy. The localized emphysema disappeared within 3 days in the two other cases but a localized emphysema appeared in the controlateral lung in one of them, requiring left inferior lobectomy because the ineffectiveness of selective intubation or selective obstruction. Selective bronchial obstruction may fail but this easy and well tolerated method should be tried in severe localized emphysema, specially in those patients who cannot be ventilated with high-frequency oscillation.

Emphysema: definition, imaging, and quantification.

This review will discuss imaging of the chest in patients with pulmonary emphysema. Imaging findings must be related to the structure of the lung because emphysema is defined in anatomic terms. Accordingly, we first review the anatomic definitions of emphysema and its consequences and then review the imaging findings, with emphasis on CT, in patients with this disease. The more severe the morphologic emphysema, the more likely a radiographic diagnosis will be made, no matter what criteria are used. The criterion of arterial deficiency is specific but insensitive. The criteria used to assess overinflation are sensitive but not specific. CT can be used for both qualitative and quantitative assessment of emphysema. The presence and extent of emphysema can be determined by visual assessment of areas of abnormally low attenuation or by objective quantification based on the attenuation values. Statistically significant correlations between emphysema and CT findings have been shown in numerous studies, but mild morphologic emphysema may be missed by CT, and occasionally CT scans give false-positive findings. In patients with moderate to severe emphysema, the severity of emphysema is underestimated on the basis of CT findings by a factor of approximately three when compared directly with results of pathologic examination of lung specimens. In spite of these limitations, CT is the best way of recognizing emphysema in living patients and probably has a significant role in recognizing localized emphysema that is amenable to surgical treatment.