Assist.Prof.Apichat Tantraworasin M.D., Ph.D., FRCS(T ... · •Thoracenthesis •Ultrasound or CT scan •Needle-guided aspiration •Culture negative : 25-60%* •Concurrent ABO

Assist.Prof.Apichat Tantraworasin M.D., Ph.D., FRCS(T)

General Surgery Unit, Department of Surgery

Faculty of Medicine, Chiang Mai University

วัตถุประสงค์การเรียนรู้

1. นักศึกษาทราบถงึ anatomy และ physiology ของ pleura

2. นักศึกษาทราบลักษณะอาการและอาการแสดง การตรวจร่างกาย การส่งตรวจทางหอ้งปฏิบัติการ รวมถึงการรักษาอย่างเหมาะสม ในโรคทาง pleura ที่พบบ่อยในเวชปฏิบัติ

Contents• Anatomy

• Pleural effusion

• Empyema thoracis

• Chylothorax

• Pneumothorax

• Tumor of pleura

Anatomy of Pleura

• Parietal pleura

• Visceral pleura

• Mesothelial lining of each hemithorax

• Potential pleural space : a thin layer of lubricating pleural fluid

Anatomy of Pleura

• Parietal pleura

• A network of somatic, sympathetic, and parasympathetic fibers

• Irritation of the parietal surface by inflammation, tumor invasion, trauma, and other processes can lead to a sensation of chest wall pain

• Visceral pleura

• No somatic innervation

Anatomy of Pleura

• 15-20 mL

• Microvessels supplying the parietal pleura• The net balance of pressures in capillaries leads

to fluid flow from the parietal pleural surface into the pleural space

• The net balance of forces in the pulmonary circulation leads to absorption through the visceral pleura

Pleural Effusion

Cause Annual Incidence Transudate Exudate

Congestive heart failure 500,000 Yes No

Pneumonia 300,000 No Yes

Cancer 200,000 No Yes

Pulmonary embolus 150,000 Sometimes Sometimes

Viral disease 100,000 No Yes

Coronary artery bypass surgery 60,000 No Yes

Cirrhosis with ascites 50,000 Yes No

Leading Causes of Pleural Effusion in the United States, Based on Data from Patients Undergoing Thoracentesis

Pleural Effusion

Diagnostic Work-Up

• Patient's history and physical examination

• Thoracenthesis

http://www.vanderbilthealth.com/includes/healthtopics/article.php?ContentTypeId=3&ContentId=40149&Category=Pulmonary&SubtopicId=19049&lang=en&section=19030

Pleural Effusion

Light’s criteria

Exudate versus Transudate

• Pleural fluid protein/serum protein > 0.5

• Pleural fluid LDH/serum LDH > 0.6

• Pleural LDH level > 2/3 of UNL for serum

Pleural EffusionAlternative diagnostic criteria for Exudative pleural effusion ( at least 1 criteria)❖ Two-test rule

• Pleural fluid cholesteral > 45 mg/dL• Pleural fluid LDH > 0.45 times the upper limit of serum LDH

❖ Three-test rule • Pleural fluid protein > 2.9 g/dL (29 g/L)• Pleural fluid cholesteral > 45 mg/dL• Pleural fluid LDH > 0.45 times the upper limit of serum LDH

Pleural EffusionDifferential Diagnosis of Pleural Effusions

Transxudative pleural effusionsA. Congestive heart failure H. Glomerulonephritis

B. Cirrhosis I. Myxedema

C. Nephrotic syndrome J. Cerebrospinal fluid leaks to pleura

D. Superior vena caval obstruction K. Hypoalbuminemia

E. Fontan procedure L. Pulmonary emboli

F. Urinothorax M. Sarcoidosis

G. Peritoneal dialysis


Chemical analysis Differential diagnosis

Triglyceride > 110 mg/dL Chylothorax

Glucose < 60 mg/dL [3.33 mmol/liter] Rheumatoid pleurisyComplicated parapneumonic effusion or empyemaMalignant effusionTuberculous pleurisyLupus pleuriticEsophageal rupture

Amylase > upper normal limit of serum amylase

Acute pancreatitisChronic pancreatic pleural effusionEsophageal ruptureMalignancy



Adenosine deaminase (ADA) > 35-50 U/L

Tuberculous pleurisy(ADA > 50 U/L and L/N > 0.75)

N-terminal pro-BNP Heart failure

Nucleated cells

> 50,000 / microL Complicated parapneumonic effusion/empyema thoracis

> 10,000 /microL Exudative effusion

< 5000 /microL Chronic exudates (TB or malignancy)



Lymphocytes

85-95 % of total nucleated cells Tuberculous pleurisy, lymphoma, sarcoidosis,, chronic rheumatoid pleurisy, yellow nail syndrome, chylothorax

50-70 % of total nucleated cells Malignancy



Eosinophilia

( > 10 % of total nucleated cells)

• Benign, self-limited disease• Pneumothorax• Hemothorax• Pulmonary infarction• Benign asbestos pleural effusion• Parasitic disease

• Fungal infection (coccidioidomycosis, cryptococcosis, histoplasmosis)

• Drugs

• Catamenial pneumothorax with pleural effusion

• Malignancy (carcinoma, lymphoma, myeloma


Exudative pleural effusionsA. Neoplastic diseases B. Infectious diseases

1. Metastatic disease 1. Tuberculosis

2. Mesothelioma 2. Other bacterial infections

3. Body cavity lymphoma 3. Fungal infections

4. Pyothorax-associated lymphoma 4. Parasitic infections

5. Viral infections

C. Hemothorax

D. Chylothorax


Exudative pleural effusionsE. Pulmonary embolization

F. Gastrointestinal disease

1. Pancreatic disease 6. After abdominal surgery

2. Subphrenic abscess 7. Diaphragmatic hernia

3. Intrahepatic abscess 8. Endoscopic variceal sclerosis

4. Intrasplenic abscess 9. After liver transplantation

5. Esophageal perforation


Exudative pleural effusionsG. Heart diseases H. Obstetric and gynecologic diseases

1. After CABG surgery 1. Ovarian hyperstimulation syndrome

2. Post–cardiac injury (Dressler's) syndrome

2. Fetal pleural effusion

3. Pericardial disease 3. Postpartum pleural effusion

4. Megis' syndrome

5. Endometriosis


Exudative pleural effusionsI. Collagen vascular diseases J. Drug-induced pleural disease

1. Rheumatoid pleuritis 1. Nitrofurantoin

2. Systemic lupus erythematosus 2. Dantrolene

3. Drug-induced lupus 3. Methysergide

4. Immunoblastic lymphadenopathy 4. Ergot alkaloids

5. Sjögren's syndrome 5. Amiodarone

6. Familial Mediterranean fever 6. Interleukin-2

7. Churg-Strauss syndrome 7. Procarbazine

8. Wegeners granulomatosis 8. Methotrexate

9. Clozapine


Exudative pleural effusionsK. Miscellaneous diseases and conditions

1. Asbestos exposure 10. Amyloidosis

2. After lung transplantation 11. Milk of calcium pleural effusion

3. After bone marrow transplantation 12. Electrical burns

4. Yellow nail syndrome 13. Extramedullary hematopoiesis

5. Sarcoidosis 14. Rupture of mediastinal cyst

6. Uremia 15. Acute respiratory distress syndrome

7. Trapped lung 16. Whipple's disease

8. Therapeutic radiation exposure 17. Iatrogenic pleural effusions

9. Drowning

Malignant Pleural EffusionPrimary Organ Site or Neoplasm Type in Male Patients with Malignant Pleural Effusions

Primary Site or Tumor Type No. of Male Patients Percentage of Male Patients

Lung 140 49.1

Lymphoma/leukemia 60 21.1

Gastrointestinal tract 20 7.0

Genitourinary tract 17 6.0

Melanoma 4 1.4

Miscellaneous less common tumors 10 3.5

Primary site unknown 31 10.9

Total 285 100

Malignant Pleural EffusionPrimary Organ Site or Neoplasm Type in Female Patients with Malignant Pleural Effusions

Primary Site or Tumor Type No. of Female Patients Percentage of Female Patients

Breast 70 37.4

Female genital tract 38 20.3

Lung 28 15.0

Lymphoma 14 8.0

Gastrointestinal tract 8 4.3

Melanoma 6 3.2

Urinary tract 2 1.1

Miscellaneous less common tumors 3 1.6

Primary site unknown 17 9.1

Total 187 100.0

Malignant Pleural Effusion

• Exudate and often tinged with blood

• Advanced stage of disease : unresectable tumor

• Mean survival : 3-11 months

• Bronchogenic NSCLC

• Benign pleural effusion : Cytologic test negative

• Resectable tumor ??


Treatment • Asymptomatic patients

• Wait and see ??

• Symptomatic or moderate to larger effusions

• Drained by chest tube, pigtail catheter, or VATS

• Pleurodesis with sclerosing agent if lung was fully expanded

• Talc, bleomycin, doxycycline, or iodoprovidine

• 60-90 % of success rate


Garrido et al. Arch Bronconeumol 2014;50:235-49

Malignant Pleural EffusionSclerosing agent

Clinical efficacya Advantages Disadvantages

Talc poudrage 80%–95%- Inexpensive- Very effective- Easy availability

- Extrapleural dissemination of particles if

<15μm, with risk of respiratory distress- Requires thoracoscopy

Talc in suspension (“Slurry”)

70%–85%- Inexpensive- Easy availability- Easy to apply

- Extrapleural dissemination of particles if

<15μm, with risk of respiratory distress- Less effective and with more loculations

than poudrage

Doxycycline 70%–85%- Easy availability- Easy to apply

- Very painful- It usually requires several doses- Risk of acute respiratory failure

Iodine povidone 65%–95%- Inexpensive- Easy availability- Easy to apply

- Risk of anaphylaxis by Iodine- Possible thyroid uptake- Very painful- Hypotension

http://www.archbronconeumol.org/en/recommendations-diagnosis-treatment-pleural-effusion-/articulo/S1579212914001293/#tblfn0010

Malignant Pleural EffusionSclerosing agent

Clinical efficacya Advantages Disadvantages

Bleomycin 60%–85%- Similar efficacy to talc slurry

- Very expensive- Painful- Potential toxicity from systemic

absorption

Silver nitrate 75%–90%- Easy availability- Similar efficacy to talc

slurry

- Very painful- (Transient) alveolar inflammation in

underlying lung- May induce systemic inflammation

Corynebacterium parvum

75%–85%- Easy to apply- Good efficacy

- Not available in most countries

Quinacrine 70%–90%- Very painful- Occasional psychotic symptoms- It usually requires several doses

Oxytetracycline 60%–80% - Easy to apply- Not available in most institutions- Late recurrences

http://www.archbronconeumol.org/en/recommendations-diagnosis-treatment-pleural-effusion-/articulo/S1579212914001293/#tblfn0010

Date of download: 7/8/2014

Copyright © American College of Chest Physicians. All rights reserved.

From: Counterpoint: Should Thoracoscopic Talc Pleurodesis Be the First Choice Management for Malignant Pleural Effusion? NoThoracoscopic Talc Pleurodesis? No

Chest. 2012;142(1):17-19. doi:10.1378/chest.12-1087


Decision algorithm for the management of malignant pleural

effusion :

BTS guideline 2010

Symptomatic MPE

Empyema Thoracis• Accumulation of pus in the pleural space

• Pus : thick, viscous fluid ….purulent

Empyema ThoracisEtiologies• Parapneumonic effusion : 40-60%

• Post-thoracotomy : 20%

• Post-traumatic : 4-10%

• Idiopathic : 9%

• Other : 5-10% • Esophageal rupture

• Infection in chest wall, spine, or mediastinal LN

• Transdiaphragmatic extension of subphrenic abscess

Empyema ThoracisMicrobiology

Anaerobic Aerobic

Fusobacterium sppPrevotella spp (previously B. Melaninogenicus)Peptostreptococcus sppB. gragilisLactobacillus sppClostridium

S. viridansGroup D non-streptococcusCoagulase-negative staphylococcusP. aeruginosaE. coliK. pneumoniae

Empyema ThoracisClinical presentations

• Not specific

• Depends on..• Causative organism (responsible of organism)

• Volume of pus in the pleural space

• Quantity of bacteria and fluid in pleural space

• Stage of disease

• Underlying pulmonary process

• Host defense mechanisms

Empyema ThoracisClinical presentations• Aerobic organism

• Acutely cough, fever, chills, pleuritic chest pain, dyspnea.

• Anaerobic infection

• Weight loss, fever, anemia, and chronic productive cough

• Aspiration • Alcoholism

• Unconsciousness

• Periodontal disease

Empyema ThoracisClinical presentations• Erode into bronchus… BPF

• Chronic cough with foul-smelling sputum and sudden expectoration of a large amount of purulent sputum or hemoptysis

• Silent empyema

• Chronic debilitation

• Treated with corticosteroids


• PE

– ↓ respiratory excursion

– Pain on percussion

– Friction rub

– Distant to absent breath sounds

– Erode chest wall … spontaneously draining subcutaneous abscess

• Empyema necessitatis


Pleural fluid characteristics in the different stages of empyemaStage Pleural

fluidWBC

cells/mm3

LDH (IU) pH Glucose (mg/dL)

Bacteriagram stain

Pleural peel

Exudative Thin exudates

< 1000 < 500 > 7.3 40-60 Absent Thin; elastic

Fibrinopurulent(complicated parapneumoniceffusion )

Turbid; purulent

>5000 >1000 < 7.1 < 40 Present Thin; inelastic

organizing Turbid ; difficult to obtain

Variable Variable < 7.1 < 40 +/- Thick ; rigid

A. De Hoyos, S. Sundaresan/Surg Clin N Am 82 (2002) p646.

Empyema ThoracisDiagnosis• CXR

• Thoracenthesis

• Ultrasound or CT scan • Needle-guided aspiration

• Culture negative : 25-60%*• Concurrent ABO

• Repeatedly sterile and fails to improve • Secondary to TB or fungal infection

*Bergeron MG. International trends in general thoracic surgery. St. Louis: Mosby-Year Book; 1990,Vol 6.p. 197-207.

Empyema ThoracisDiagnosis

• CT scan and bronchoscopy

• Distinguish between lung consolidation or atelectasis and pleural fluid

• R/O pneumonic process secondary to bronchial obstruction due to bronchogenic carcinonoma

Empyema ThoracisManagement

1. Control of infection and sepsis

• Appropriate antibiotic therapy

2. Adequate drainage

• Evacuation of pus from the pleural space

3. Reexpansion of the underlying lung

4. Convert infected space to sterile space

5. Obliteration of the empyema cavity

Empyema ThoracisManagementAcute emypema :Adequate drainage

▪ Exudative phase

▪ Tube thoracostomy or ICD

▪ Early fibrinopurulent phase

▪ Intrapleural instillation of fibrinolytics

▪ Late fibrinopurulent or organizing phase

▪ Open surgical drainage : rib resection

▪ VATs or thoracotomy for breakdown of adhesions or decortication

Empyema ThoracisManagement

Chronic emypema

1. Rib resection drainage

2. Open thoracic window

• Open-flap Eloesser flap procedure

3. Thoracoplasty

Rib resection

Rib resection

Decortication

Decortication

Decortication

Chronic empyema

Open-window thoracostomy• Eloesser flap

– Long-term drainage

– Easily irrigated and cleaned

– Space fill with granulation tissue or by complete

reepithelialization from the skin flaps.

• Too large space

– Left open permanently

– Pedicle muscle interposition flap

– Modified Eloesser flap procedure**

*Eloesser L. et al . Surg Gunecol Obstet 1935;60:1096.**Thourani VH et al. Ann Thorac Surg 2003;76:401.

Open-flap Eloesser flap precedure

Chronic empyema

Space sterilization

Clagett procedure*

• Open pleural drainage

• Serial operative debridement

• Chest closure after filling with antibiotic

• Gentamicin, neomycin, and polymyxin B

Zaheer S et al. Ann Thorac Surg 2006;82:279.

Chronic empyema

• Original Dape solution

• Polymicin + gentamicin + neomycin

• Modify Dape solution

• Fosfomycin 2 gm + NSS 200-1000 ml เช้า

• Netilmycin 300 mg +NSS 200-1000 ml เย็น

Chronic empyema

• Space-Filling prodedures

• Decortication

• Removal of a constricting peel over the lung

• Empyemectomy

• Complete excision of parietal and visceral peel.

• Avoiding contamination of either the thoracotomy incision or the free pleural space.

Pre-operative CXR

Immediate post-operative CXR

5th day after surgery

1 wks after surgery

30th day after surgery

Chylothorax

ChylothoraxComposition of Chyle

Component Amount (per 100 mL)

Total fat 0.4–5 g

Total cholesterol 65–220 mg

Total protein 2.21–5.9 g

Albumin 1.1–4.1 g

Globulin 1.1–3.1 g

Fibrinogen 16–24 g

Sugars 48–200 g

Electrolytes Similar to levels in plasma

ChylothoraxComposition of Chyle

Component Amount (per 100 mL)

Cellular elements

Lymphocytes 400–6800/mm3

Erythrocytes 50–600/mm3

Antithrombin globulin >25% of plasma concentration

Prothrombin >25% of plasma concentration

Fibrinogen >25% of plasma concentration

ChylothoraxCauses • Congenital : birth trauma

• Traumatic and/or iatrogenic• Esophagectomy, neck dissection (Left), central line dissection

• Neoplasms • Infections

• Tuberculous lymphadenitis, Filariasis

• Miscellaneous• Venous thrombosis

Chylothorax

• Main function : transport fat absorbed from the digestive system

• Significant injuries : leaks in excess of 2 L/d

• Untreated : loss protein, volume, and lymphocyte

• Diagnosis

• Gross : milky and non-purulent fluid

• Lab : triglyceride > 110 mg/dL (1.24 mmol/L) or present with chylomicron

• TG < 110 mg/dL: 15 %, 50 mg/100 mL : 3 %

Chylothorax

Garrido et al. Arch Bronconeumol 2014;50:235-49

Pneumothorax Spontaneous : Primary

▪ No immediately apparent lung disease

▪ Subpleural bleb rupture

▪ Risk factors

• Smoking : related to the amount of cigarette smoking

•Male > Female


▪Risk factors

Smoking status Male Female

Non-smoker Reference Reference

Light smoker (1-12 cigarettes/day) 7 times 4 times

Moderate smoker (13-22 cigarettes/day) 21 times 14 times

Heavy smoker (>22 cigarettes/day) 102 times 68 times


▪ Risk factors

• Family history

▪Autosomal dominant: Birt-Hogg-Dube syndrome (benign skin tumors and renal cancer)

• Anorexia nervosa : malnutrition


▪ Causes : rupture of apical subpleural bleb

• Mechanism

1. Degradation of elastic fibers

สัมพันธ์กับการสูบบุหรี่ ท าให้เกดิ influx ของ neutrophils และ macrophages

เป็นผลให้เกดิการเสียสมดุลของ protease-antiprotease และ oxidant-

antioxidant systems.

2. เกิดจากความแตกต่าง alveolar pressure ระหว่าง base และ apex ของปอดในท่า upright


▪ Causes : rupture of apical subpleural bleb

• Mechanism

3. ชว่งอกมกีารขยายตัวอย่างรวดเร็วในแนว vertical ในขณะที่อยู่ใน early

childhood และ adolescence ซึ่งมีผลต่อ intrathoracic pressure และ

ท าให้เกิด subpleural cyst formation (Emphysematous-liked

change (ELC) formation)

4. Familial patterns of inheritance (AD, X-linxed recessive, FBN1

gene mutation , HLA haplotypes, and AR)

Subpleural bleb

Pneumothorax

Spontaneous Acquired

Primary Secondary Neonatal

Pneumothorax

Spontaneous• Secondary

▪ Complication of clinically apparent lung disease ▪ Airway disease ▪ COPD

• Bullous disease• Cystic fibrosis • Asthma

▪ Infectious lung disease • Tuberculosis• HIV and Pneumocystis jiroveci pneumonia • Necrotizing pneumonia

Pneumothorax

Spontaneous• Secondary

▪ Interstitial lung disease• Cryptogenic fibrosing

alveolitis• Sarcoidosis• Histiocytosis• Lymphangioleiomyomatosis

▪ Connective tissue disease (CTD) • Wegener’s granulomatosis • Rheumatoid lung • Mixed CTD• Marfan's syndrome

▪ Cancer

• Metastatic sarcomas to the lung

• Mesothelioma

• Lung cancer

▪ Thoracic endometriosis

Catamenial pneumothorax

Pneumothorax

Spontaneous Acquired

Primary Secondary Neonatal

Pneumothorax

Acquired

▪ Iatrogenic

▪ Transthoracic needle biopsy

▪ Subclavian (percutaneous) catheterization

▪Central lines

▪Pacemaker insertion

▪ Transbronchial lung biopsy

▪ Thoracocentesis

PneumothoraxAcquired

▪ Iatrogenic ▪ Chest tube malfunction ▪ After laparoscopic surgery

▪ Barotrauma ▪ Traumatic

▪ Blunt trauma ▪ Motor vehicle accidents ▪ Falls ▪ Sports-related

▪ Penetrating trauma ▪ Gunshot wounds ▪ Stab wounds

Differences between primary and secondary pneumothorax

Primary Secondary

Presentation Age Usually < 35 yrs Usually > 45 yrs

Chest pain Usual, may be severe Occasional

Dyspnea Usually mild/moderate Often severe

Chest radiograph Degree of collapse Any size, often small

Pleural reaction Common, may suggest diagnosis Usually small or moderate

Other findings Often mediastinal shift in complete collapse

Changes of underlying disease

Resolution on medical management

Observation alone Often possible, outpatient Usually inappropriate, requires admission

Preferred initial intervention

Simple aspiration or CASP Simple aspiration or CASP

Persistent air leak Occasional, surgery indicated Common, but 20% eventually resolve

Prevention recurrence

Medical pleurodesis Not appropriate If high surgical risk

Surgical approach VATS is best option VATS, but mini-thoracotomy may be needed.

Investigations

• Chest X-ray

• CT-scan

–Abnormalities in CXR

–Suspected underlying lung disease

• Ultrasound : loss of pleural sliding sign

Investigation : CXR PA upright

Visceral pleural line

Investigation : CT chest

Subpleural blebs

Treatment options

Primary Spontaneous Pneumothorax (PSP)

❖Depend on patient characteristics and clinical circumstances

❖Clinically stable and first PSP

❖Small pneumothorax (≤2-3 cm between the lung and chest wall)

❖Observation, supplemental O2

Treatment options Primary Spontaneous Pneumothorax (PSP)


❖Clinically stable and first PSP

❖Large pneumothorax (> 3 cm rim of air)

❖Needle aspiration or Catheter drainage of pneumothorax (CASP)

❖Tube thoracostomy : chest pain or dyspnea

❖ Thoracoscopy (VATS: video-assisted thoracoscopic surgery)

Treatment options Primary Spontaneous Pneumothorax (PSP)


❖Clinically unstable and first PSP

❖ initial : a 14 gauge IV catheter

❖at 2nd or 3rd ICS midclavicular line

❖At 5th ICS in anterior axillary line or anterior to midaxillary line

❖ Followed by Chest tube insertion

Size Estimation of the Pneumothorax

Light index

% pneumothorax = 100- (average diameter of the lung3 / average diameter of hemithorax3) x 100

**Diameter ให้วัดท่ีระดับ hilar


Rhea method

• (A + B + C) / 3 • Nomogram


Collin formula

• Size % = 4.2 + 4.7 x (A+B+C)


ACCP guideline

• Small pneumothorax A < 3 cm


BTS guideline

• Small pneumothorax

▪ Distance from chest wall to visceral pleural line < 2 cm (30 %)

Diagram showing range of points positioned on chest.

E P Ferrie et al. Emerg Med J 2005;22:788-789

http://www.nataliescasebook.com/img/Case-

http://www.nataliescasebook.com/img/Case-

Treatment options


❖Indication for surgery1. Ipsilateral recurrence

2. First contralateral pnuemothorax

3. Contralateral pneumonectomy

4. Bilateral pneumothorax

5. Continuous air leak > 3-4 days ( > 5 days for SSP)

6. Hemopneumothorax

7. Occupation related to high pressure gradient environment: pilot, diver etc.

8. Living in distant area which is difficult to access hospital

Treatment options


Surgical intervention

▪ VATS for Blebectomy and pleurodesis

▪ Pleurodesis >> recurrence prevention by induced pleural symphysis

• Mechanical pleurodesis: pleural abrasion, pleurectomy

• Chemical pleurodesis: Talc, tetracycline derivatives(doxyclycline or minocycline), bleomycin, iodopovidine etc.

Treatment options Secondary Spontaneous Pneumothorax (SSP)

Catamenial pneumothorax

• Part of the thoracic endometriosis syndrome (TES)

▪ Catamenial pneumothorax, catamenial hemothorax, catamenial hemoptysis, and lung nodules.

• Recurrent pneumothorax

• Occuring within 72 hrs of the onset of menstruation

▪ Immediate premenstrual period

▪ Ovulatory phase

Catamenial pneumonthorax • Growth of endometrial glands and stroma in the lungs,

pleural surfaces, diaphragm, and rarely the

tracheobronchial tree

– Pulmonary : bilateral.

– Pleura or diaphragm : unilateral , right-sided.

• Mean age : 35 yrs ( 15-54 yrs)

• Diaphragmatic abnormality

– Fenestrations and endometrial implants

– Most common at tendinous portion

Catamenial pneumonthorax

Blue-brown implants or “chocolate cysts”



Treatment • Initial surgical procedures

▪ Aspiration, Thoracostomy, Chemical sclerosis/pleurodesis : high failure rate if treated alone**

• Secondary non-surgical procedures

▪ Progestin therapy (non-bioidentical) : Oral contraceptives (birth control pills)

• Low success rate if treated alone

▪ GnRH therapy (non-bioidentical): Gonadotropin releasing hormone agonist

• Suppress menstruation, induced artificial menopause

• Better success rate than OCP

▪ Bioidentical hormone therapy : bioidentical progesterone

Catamenial pneumonthoraxTreatment

• Major surgical procedures

▪ VATS : endometrial implants or holes in the diaphragm or bleb

▪ Mechanical pleurodesis: prevention

▪ Diaphragmatic repair using polymesh (Vicryl type mesh)

▪ Hysterectomy / bilateral salpingo-oophorectomy: last choice

• Combine : VATS followed by GnRH therapy**

Tumors of the Pleura

• Malignant Mesothelioma

• Most common type of tumor of pleura

• 20% : arises from the peritoneum

• Benign and malignant fibrous tumors of the pleura

• Lipomas

• Cysts

Malignant Mesothelioma

Male : female (2:1), most common after 40 years old

Risk factors

• Asbestos : latency period at least 20 years

• Dust from clothing or the work environment

• Fibers : amphibole, serpentine (large), crocidolite (narrow,

straight amphibole)

• Radiation


• Multiple pleura-based nodules >>> sheets of tumor

• Parietal pleura >> visceral surfaces

• Most patients have distant metastases

http://segal-law.com/practice-areas/mesothelioma/


Clinical Presentation

• Dyspnea and chest pain

• Over 90% have a pleural effusion

Diagnosis

• Thoracentesis : <10%

• Thoracoscopy or open pleural biopsy with special staining

• Required to differentiate mesotheliomas from adenocarcinomas


Differentiation of Mesothelioma from AdenocarcinomaImmunohistochemical results Mesothelioma Adenocarcinoma

Carcinoembryonic antigen Negative Positive

Vimentin Positive Negative

Low molecular weight cytokeratins Positive Negative

Electron microscopic features Long, sinuous villi Short, straight villi with fuzzy glycocalyx


Pathology

• Epithelial type

• More faverable prognosis

• Some patients achieve long-term survival with no treatment

• Sarcomatous and mixed types : More aggressive course


Management

• Controversial

• Prognosis : Staging

• Many patients present with advanced local or distant disease beyond curative potential



NCCN guidelines version 2.2018

Management


NCCN guidelines version 2.2018

Management


Management

• Options

• Supportive care only

• Surgical resection

• Multimodality approaches (using a combination of surgery, chemotherapy, and radiation therapy)

Malignant Mesothelioma ManagementSurgical options• Early-stage tumors with good pulmonary function

• Complete gross cytoreduction of the tumor • Macroscopic complete resection • Remove of all visible or palpable tumors

• Surgical choice• Pleurectomy/decortication (P/D) with mediastinal LN sampling (complete removal of

the pleura and all gross tumor +/- en-bloc resection of pericardium and/or diaphragm with reconstruction

• Extrapleural pneumonectomy (EPP) (en-bloc resection of the pleura, lung , ipsilateral diaphragm, and often pericardium

• Mediastinal LN sampling : at least 3 nodal stations


Management

Surgical options

• Advance-stage tumors or poor functional status• N2 disease

• Palliative approaches • Local control

• Improvement in short-term survival

• Pleurectomy or talc pleurodesis

Malignant Mesothelioma ManagementIntrapleural therapy : Locoregional control • Cisplatin + mitomycin C

• After pleurectomy and decortication• Both systemic and intrapleural therapy • Recurrence rate of 80%

• Hyperthermic cisplatinHigher ratio of local tissue platinum concentration comparing with normothermic perfusion

Fibrous Tumors of the Pleura

• Unrelated to asbestos exposure or malignant mesotheliomas

• Single pedunculated mass arising from the visceral pleura

• Incidental finding without pleural effusion

• Benign or Malignant


• Symptoms • 30-40 % : cough, chest pain, and dyspnea

• Less common : fever, hypertrophic pulmonary osteoarthropathy, hemoptysis, and hypoglycemia (4%)

• Treatment • Complete surgical resection : curative treatment

• Imcomplete resection in malignant tumors • Recurrence or metastasis : death within 2-5 years



Documents

Assist.Prof.Apichat Tantraworasin M.D., Ph.D., FRCS(T ... · •Thoracenthesis •Ultrasound or CT scan •Needle-guided aspiration •Culture negative : 25-60%* •Concurrent ABO