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Background SBRT is standard therapy for early stage lung cancer. Toxicity in central tumors has been a concern. RTOG 0813 showed that central SBRT is safe and effective. We report our experience with central SBRT. Methods We reviewed the records of patients treated with SBRT for central lung tumors (

Nevi and melanocytic proliferations are known to appear in multiple extracutaneous sites, including lymph nodes and meninges. We report a case of an anterior mediastinal mass in a patient with a giant congenital nevus and neurofibromatosis type I. Histologically, the tumor was found to be a malignant melanoma in the thymus arising in association with a nevus that involved most of the thymic tissue. There was no sign of cutaneous melanoma on skin examination. We suggest that the tumor originated from the benign nevus in the thymus, a rare extracutaneous location for nevi and malignant melanoma.

Advanced non-small cell lung cancer (NSCLC) is still a therapeutic challenge as the 5-year survival is under 30%. The optimal treatment regimen is still under debate.Neo adjuvant (NA) treatment given pre-pneumonectomy does not increase surgical complexity or peri-OP mortality while it has a potential to increase long term survival.We have conducted a retrospective study of 169 patients who underwent a pneumonectomy for NSCLC between January 2005 to December 2015 and focused on stage IIIa patients; a cohort of 51 patients, 30 which received neo adjuvant chemo-radiation (NA group) prior to pneumonectomy and 21 patients who had undergone pneumonectomy followed by adjuvant treatment (Adjuvant group). Surgical complexity and short- and long-term survival were evaluated. Surgical complexity was assessed by surrogates as surgery duration, hospitalization length and interdepartmental transfer.While no statistically significant differences were found in surgery duration, hospitalization length, morbidity in the 1st year post-OP and the peri-OP mortality; The long term beneficiary effect among the neo adjuvant patients was clear; while 30% of the NA patients were alive 8 years post-OP, there were no survivors in the adjuvant group 5.5 years post-OP.We conclude that while NA treatment has no effect on operation complexity, peri-OP mortality or post-OP morbidity; its impact on long term survival is protuberant, therefore, we believe that NA treatment should be considered as the treatment of choice in advanced NSCLC in need for pneumonectomy.

Introduction Pneumonectomy results in impairments of pulmonary function and exercise intolerance associated with respiratory limitations. However, exercise capacity and functional capacity are less known at long-term followup. The aims of this study were to assess exercise tolerance and functional capacity among long-term postpneumonectomy patients and to identify the limiting factors in exercise related to comorbidities and which lung was involved. Methods Seventeen postpneumonectomy patients aged 59 ± 13 years and 5.5 ± 4.2 years postoperation were prospectively studied. Pulmonary function tests (PFTs), cardiopulmonary exercise test (CPET), Doppler-echocardiography, 6-minute walk test (6MWT) distance, and "senior fitness tests" (SFTs) were conducted with all patients. Results Exercise capacity and PFT were diminished ((Equation is included in full-text article.)O2 peak; 11.5 ± 3.3 mL·kg·min, 48 ± 17% predicted, forced vital capacity % predicted; 55 ± 13, FEV1% predicted; 46 ± 14, respectively). Most patients presented with low exercise cardiovascular parameters and normal breathing reserve (17 ± 12 L) during CPET. No significant differences were shown between right and left pneumonectomy and comorbidities related to exercise limitations (χ= 1.96, P = .376). Functional capacity in walking and SFTs were near normal (6MWT distance; 490 ± 15 m, 89 ± 25% predicted). Echocardiography showed normal left ventricle systolic function (ejection fraction, 60 ± 4%) with mildly elevated systolic pulmonary arterial pressure (38 ± 12 mm Hg). Conclusions Long-term postpneumonectomy patients demonstrated decreased exercise capacity, limited primarily by the cardiovascular system regardless of lung resection side or comorbidities, although tests of functional capacity were near normal. Most patients can maintain near normal life in activities of daily living, but the long-term cardiopulmonary exercise function should be considered for meticulous evaluation and clinical care to preserve physiological reserves.

Background: Trimodality therapy (chemoradiation followed by surgery) provides a benefit in progression-free survival but not overall survival. We sought to determine if a high dose of radiation could be delivered safely and provide a clinical benefit. Methods: Consecutive patients with stage IIIA or IIIB non-small-cell lung cancer (NSCLC) treated with concurrent chemoradiotherapy followed by surgery were reviewed with IRB approval. Results: A total of 48 patients were treated from November 2007 to May 2014. Of these, 64% had stage IIIA disease while 36% had stage IIIB; 46% had adenocarcinoma, 34% squamous, and 23% NSCLC not otherwise specified. The median dose of chemoradiotherapy was 72 Gy (60–72). Overall, 86% of patients received cisplatin (50 mg/m2) and etoposide (50 mg/m2) concurrently with radiotherapy; 72% of patients underwent lobectomy following chemoradiotherapy and 28% underwent pneumonectomy. The 30- and 90-day mortality rates were 0%. The nodal downstaging rate was 82% and there was a 64% rate of pathologic complete response. The overall survival was 29.9 months (95% CI, 19–86 months). The median time to locoregional progression was 35.1 months and the median time to distant progression was 39.3 months. Locoregional failure was 8% and distant failure was 44%. Conclusion: High-dose preoperative chemoradiotherapy was safe and effective. This combination should be further considered.

Objectives To assess the characteristics that correlate with better outcomes after lung transplantation for patients with cystic fibrosis (CF). Methods We retrospectively reviewed the charts of all patients with CF who underwent lung transplantation between 1996-2014 at Rabin Medical Center, Israel. Results Fifty patients with CF underwent 55 lung transplantations. Eighteen patients (36%) died during the study period. Actuarial survival was 83%, 68%, 62% and 39% at 1, 3, 5 and 10 years, respectively. Better survival correlated with: BMI at 6-months and 1-year after transplantation (p=0.002 and p=0.003, respectively), ischemic time of less than 300 minutes (p=0.023), absence of liver disease (p=0.012) and Jewish compared to Arab ethnicity (p=0.007). Freedom from bronchiolitis obliterans syndrome (BOS) was 87%, 75% and 72% at 1, 3 and 5 years, respectively. BOS was more common and appeared earlier in the Arab than in the Jewish population (p=0.012, p=0.007). Additionally, prolonged time free of BOS correlated with male gender (p=0.039), older age (p

Objectives Bronchial stenosis is still a significant source of morbidity and mortality following lung transplantation (LTX) and often mandating placement of a bronchial stent. It has been suggested that although self-expanding metal stents offer excellent early palliation, their long-term complication rates are unacceptably high, and hence, their usage in many transplantation centres has been nearly abandoned. The aim of the study was to assess short- and long-term complication rates and survival in LTX patients with bronchial stenosis treated with insertion of self-expanding metal stents. Methods From January 1997 to March 2013, 435 patients underwent LTX (325 single-LTX and 110 bilateral LTX). Of 503 actual anastomoses at risk (derived by subtracting the number of anastomoses in 30 patients who died within 30 days of LTX), 60 airway complications (11.9%) in 47 patients required self-expanding metal stent insertion. We assessed the early results and long-term outcomes and survival compared with LTX patients in whom stents were not required. Results The median follow-up period ranged from 1 to 132 (median 54) months. Immediate relief of symptoms was achieved in the vast majority of patients (95%). One-, three- and five-year survival in patients who required self-expanding metal stent placement were 77.7, 66.6 and 55.5%, respectively. The corresponding survival rates in LTX patients without stents were 69, 64.9 and 61.1% (P > 0.05). Conclusions Self-expanding metal stents are safe and effective tools in the management of airway complications post-LTX and provide immediate improvement in symptoms and pulmonary function tests in the vast majority of cases. The long-term complication rate is low, and mortality is similar to that in LTX patients who did not require stent insertion.

Silicosis is a progressive lung disease resulting from the inhalation of respirable crystalline silica. Lung transplantation is the only treatment for end-stage silicosis. The aim of this study was to analyze the survival experience following lung transplantation among patients with silicosis.We reviewed data for all patients who underwent lung transplantation for silicosis and a matched group undergoing lung transplantation for idiopathic pulmonary fibrosis (IPF) at a single medical center between March 2006 and the end of December 2013. Survival was followed through 2015.A total of 17 lung transplantations were performed for silicosis among 342 lung transplantations (4.9%) during the study period. We observed non-statistically significant survival advantage (hazard ratio 0.6; 95%CI 0.24-1.55) for those undergoing lung transplantation for silicosis relative to IPF patients undergoing lung transplantation during the same period.Within the limits of a small sample, survival in silicosis patients following lung transplantation was not reduced compared to IPF. Am. J. Ind. Med. 60:248-254, 2017. © 2017 Wiley Periodicals, Inc.

Background RET (rearranged during transfection) fusions have been reported in 1% to 2% of lung adenocarcinoma (LADC) cases. In contrast, KIF5B-RET and CCDC6-RET fusion genes have been identified in 70% to 90% and 10% to 25% of tumors, respectively. The natural history and management of RET-rearranged LADC are still being delineated. Materials and Methods We present a series of 14 patients with RET-rearranged LADC. The response to therapy was assessed by the clinical response and an avatar model in 2 cases. Patients underwent chemotherapy, targeted therapy, and immunotherapy. Results A total of 14 patients (8 women; 10 never smokers; 4 light smokers; mean age, 57 years) were included. KIF5B-RET and CCDC6-RET variants were diagnosed in 10 and 4 cases, respectively. Eight patients had an early disseminated manifestation, seven with KIF5B-RET rearranged tumor. The features of this subset included bilateral miliary lung metastases, bone metastases, and unusual early visceral abdominal involvement. One such patient demonstrated an early and durable complete response to cabozantinib for 7 months. Another 2 patients treated with cabozantinib experienced a partial response, with rapid significant clinical improvement. Four patients with tumors harboring CCDC6-RET and KIF5B-RET fusions showed pronounced and durable responses to platinum-based chemotherapy that lasted for 8 to 15 months. Two patients' tumors showed programmed cell death ligand 1-positive staining but did not respond to pembrolizumab. The median overall survival was 22.8 months. Conclusion RET-rearranged LADC in our series tended to occur as bilateral disease with early visceral involvement, especially with KIF5B fusion. Treatment with cabozantinib achieved responses, including 1 complete response. However, further studies are required in this group of patients.

Local recurrence after complete resection (R(0)) occur in approximately 20% of patients with stage I disease and in up to 50% with stage III. This study focuses on early detection of stump recurrence by a routine bronchoscopy.Prospective analysis 1 year after surgery between April 2006 and April 2008.104 NSCLC patients (age 69.1+/-9.6 years) participated in the study; 97 underwent lobectomy and 7 pneumonectomy. 61% were stage I, 25% stage II, 10% IIIA, 5% IIIB and 1% stage IV. 66% had N0, 21% had N1 disease, 9% N2 disease and 4% had N3. Bronchoscopy was performed 12.9+/-3.8 months after surgery. Nine percents had stump polyp, 5 (5%) had a suspicious mucosa. Four of the nine polyps were malignant. Nine other patients had squamous metaplasia and two had squamous dysplasia. Malignant stump recurrence was observed in four cases, all had a stump polyp. All had R(0), but two had short (1.0 cm) tumor-free bronchial margin, two had N1 disease and two N2 disease. Fisher exact analysis showed short bronchus (p=0.003), N2 vs. N0-1 (p=0.012), and N1 vs. N0 (p=0.011) as significant risk factor for stump recurrence. For stump recurrence, one patient underwent completion pneumonectomy and has no evidence for disease (32.2 months), two patients were treated by chemotherapy and one patient died from pneumonia before therapy.Routine bronchoscopy 1 year after thoracic resection for NSCLC is justified in patients who are at high risk for local recurrence, i.e. short free bronchial margins and N2/N1 disease.

Lung transplantation in patients with scleroderma: case series, review of the literature, and criteria for transplantation. Clin Transplant 2009: 23: 178-183. a 2009 John Wiley & Sons A/S. Abstract: Backgrounds: The use of lung transplantation (LTX) to treat respiratory failure because of scleroderma is controversial. We present our experience, review the current literature, and suggest specific criteria for LTX in scleroderma. Of the 174 patients who underwent LTX at our center, seven (4%) had scleroderma-associated respiratory failure. Patients and methods: A MEDLINE search of the English literature was performed for studies of LTX in patients with scleroderma between 1986 and 2006. A Kaplan-Meier survival curve was calculated over the time of the studies. Results: The MEDLINE search yielded one large review and four small case series. The small case series were included in the review. The review and our series yield a total of 54 patients. Mean patient age was 47.1 yr; 59.3% were female. Pre-operative lung data were available for 24 patients: 22 (92%) had pulmonary fibrosis and 17 (71%) had pulmonary hypertension. Most patients (69%) underwent single-lung transplantation. Mean forced expiratory volume at one s after LTX was 67% (range 56-87%). There was no difference in infection and rejection rates between the patients with scleroderma and other LTX recipients. The two- and five-yr survival rates were 72% and 55%, respectively. Conclusions: LTX is a valid option in well-selected patients with sclero- derma and pulmonary fibrosis, yielding good pulmonary function and acceptable morbidity and mortality.

Background. Lung transplantation impairs surfactant activity, which may contribute to primary graft dysfunction (PGD). Prompted by studies in animals and a few reports in humans, this study sought to determine if the administration of surfactant during transplantation serves as an effective preventive measure. Methods. An open, randomized, controlled prospective design was used. Forty-two patients scheduled for single (n= 38) or double (n=4) lung transplantation at a major tertiary medical center were randomly assigned to receive, or not, intraoperative surfactant treatment. In the treated group, bovine surfactant was administered at a dose of 20 mg phospholipids/kg through bronchoscope after the establishment of bronchial anastomosis. The groups were compared for oxygenation (PaO 2 /FiO 2 ), chest X-ray findings, PGD grade, and outcome. Results. Compared with the untreated group, the patients who received surfactant were characterized by better postoperative oxygenation mean PaO 2 /FiO 2 (418.8 ± 123.8 vs. 277.9 ± 165 mm Hg, P=0.004), better chest radiograph score, a lower PGD grade (0.66 vs. 1.86, P=0.005), fewer cases of severe PGD (1 patient vs. 12, P

Pulmonary involvement is not an infrequent complication of systemic amyloidosis, although affected patients rarely have significant pulmonary symptoms. In contrast, localized (primary) pulmonary amyloidosis is rare. We report a case of pulmonary low-grade B cell lymphoma with amyloid production, causing localized pulmonary amyloidosis.

Pulmonary veno-occlusive disease, a rare cause of pulmonary hypertension, is characterized by extensive and diffuse occlusion of pulmonary veins by fibrous tissue. Although the diagnosis can be suspected by the presence of the classic clinical triad of severe pulmonary arterial hypertension, radiographic evidence of pulmonary hypertension and edema, and normal pulmonary artery occlusion pressure, the definitive diagnosis is histopathologic. The prognosis of pulmonary veno-occlusive disease is poor with most described patients dying within 2 years of diagnosis. Although anti-coagulation, oxygen, and vasodilator therapies are effective temporarily, the definitive treatment is lung transplantation. We describe the recurrence of pulmonary veno-occlusive disease at 3 months after heart-lung transplantation in a 26-year-old man. Recurrence after transplantation for this disease has not been reported previously, and lung transplantation was thought to be definitive treatment. With this 1st report of early recurrence of pulmonary veno-occlusive disease after heart-lung transplantation, we believe that extrapulmonary factors may play a role in the pathogenesis of this rare disease.

Background: The development of a bronchopleural fistula (BPF) is associated with high rates of morbidity and mortality. We have developed a minimally invasive method of bronchoscopic BPF closure using Amplatzer devices (AD) and Amplatzer vascular plugs (AVP), with excellent short-term results. Objectives: The aim of the present report was to explore the long-term outcome of patients treated by Amplatzer occluders and the durability of this novel modality of BPF treatment. Methods: A total of 31 central BPF in 31 patients (mean age 66.8 years, range 19-91) were sealed under moderate sedation bronchoscopically by either AD (n = 19) or AVP (n = 12). The average follow-up period was 17.6 months (range 1-68 months). Results: The main etiology for BPF was surgery (n = 24), pneumonectomy (n = 14) or lobectomy/segmentectomy (n = 10). The underlying disease was either primary (n = 19) or metastatic (n = 2) lung cancer. The immediate success rate was 96% as symptoms related to BPF disappeared in 30 of the 31 patients. Short-term (Conclusion: Endobronchial closure of BPF using both types of Amplatzer occluders (AD and AVP) is a minimally invasive effective modality of treatment with high safety profile and satisfactory long-term outcome considering the poor prognosis in this particular group of patients.

Pulmonary arteriovenous malformation (PAVM) may occur primarily or in association with hereditary hemorrhagic telangiectasia. We present a case of PAVM in the central lower lobe of the left lung of a 75-year-old woman, which was successfully treated by lobectomy. Contrast echocardiography is an excellent tool for evaluation of this uncommon lesion. Advances in interventional radiology have led to the introduction of obliterative techniques for the treatment of PAVM. However, in the presence of a large solitary malformation centrally located, as in our case, and in high-risk patients, surgery is still a safe and effective first option.

Bronchopulmonary fistulae (BPFs) are a severe complication of lobectomy and pneumonectomy and are associated with high rates of morbidity and mortality. We have developed a novel, minimally invasive method of central BPF closure using Amplatzer devices (ADs) that were originally designed for the transcatheter closure of cardiac defects. Ten patients with 11 BPFs (eight men and two women, aged 66.3±10.1 years [mean±SD]) were treated under conscious sedation with bronchoscopic closure of the BPFs using ADs. A nitinol double-disk occluder device was delivered under direct bronchoscopic guidance over a guidewire into the fistula. By extruding a disk on either side of the BPF, the fistula was occluded. Bronchography was performed by injecting contrast medium through the delivery sheath following the procedure to ensure correct device positioning. In nine patients, the procedure was successful and symptoms related to the BPF disappeared following closure by the AD. The results were maintained over a median follow-up period of 9 months. Therefore, we state that endobronchial closure using an AD is a safe and effective method for treatment of a postoperative BPF.

OBJECTIVE: Bronchopulmonary fistula (BPF) is a severe complication following lobectomy or pneumonectomy and is associated with a high rate of morbidity and mortality. We have developed a novel minimally invasive method of central BPF closure using Amplatzer vascular plug (AVP) device that was originally designed for the transcatheter closure of vascular structures in patients with small BPF. METHODS: Patients with BPFs were treated under conscious sedation by bronchoscopic closure of BPFs using AVP. After locating the fistula using bronchography, the self-expanding nitinol made AVP occluder to be delivered under direct bronchoscopic guidance over a loader wire into the fistula followed by bronchography to assure correct device positioning and sealing of the BPF. RESULTS: Six AVPs were placed in five patients, four males and one female, with a mean age of 62.3 years (range: 51–82 years). The underlying disorders and etiologies for BPF development were lobectomy (two patients), pneumonectomy for lung cancer (one patient), lobectomy due to necrotizing pneumonia (one patient), and post-tracheostomy tracheo-pleural fistula (one patient). In all the patients, the bronchoscopic procedure was successful and symptoms related to BPF disappeared following closure by the AVP. The results were maintained over a median follow-up of 9 months (range: 5–34 months). CONCLUSIONS: Endobronchial closure using the AVP is a safe and effective method for treatment of small postoperative BPF. The ease of their implantation by bronchoscopy under conscious sedation adds this novel technique to the armatorium of minimally invasive modalities for the treatment of small BPF.

Delayed-onset pericardial effusion following cardiac surgery can give rise to significant morbidity due to its presentation as well as management by traditional surgical techniques. An institutional experience of a video-assisted thoracoscopic technique to create a pericardial window, with the advantages of a minimally invasive approach combined with excellent visualization in such patients, was reviewed. A retrospective analysis was conducted on all patients undergoing video-assisted thoracoscopic for delayed pericardial effusion after cardiac surgery from January 2001 to January 2006 at our center. Seven patients with echocardiographically diagnosed delayed tamponade underwent video-assisted thoracoscopy; 5 were receiving anticoagulants after valve replacement, and 2 had undergone heart transplantation. Pericardial windows were created under general anesthesia and single-lung ventilation using 2 to 3 trocars. Mean operative time was 45 min. There were no complications of the thoracoscopic technique. Video-assisted thoracoscopic creation of a pericardial window is safe and effective treatment for loculated pericardial effusions secondary to cardiac surgery.

Introduction: Long-distance transportation of a patient in an unstable condition is a challenging operation. When circumstances require using a commercial flight it is even more so. Case Report: A 57-yr-old man in Israel underwent extrapleural pneumonectomy for mesothelioma, following which he developed a massive chylothorax of more than 6 L·d -1 . Due to the failure of medical treatment and the high operative risk under such conditions, it was decided to transfer him to the United States by commercial flight for a percutaneous, fluoroscopy-guided closure of the thoracic duct. The patient was accompanied by a physician and a non-medical assistant and occupied a first-class seat enclosed by curtains. He arrived at the departure airport in a hypovolemic state with low cardiac output and blood pressure of 78/60 Torr. During the flight he was treated with intravenous fluids, chest physiotherapy, and oxygen. In addition, fibrin clots blocked the drainage system on two occasions, requiring corrective action. On arrival in the United States the patient's condition had improved: his blood pressure was 123/91 Torr with a capillary oxygen saturation of 95% without supplementary oxygen. During the 18 h in transit (11 h in flight) he had lost more than 5 L of lymph. Conclusion: Under carefully controlled circumstances it is possible to use commercial flights to transport patients whose condition is unstable and complicated. Safety can be increased by focusing on the specific problems associated with the clinical condition and anticipating possible adverse events during the flight.

Bronchopulmonary fistula (BPF) is associated with high morbidity and mortality. It occurs as an uncommon but often severe complication of pneumonectomy. BPF may be treated by a range of surgical and medical techniques, including chest drain, Eloesser muscle flap, omental flap, transsternal bronchial closure, thoracoplasty, and prolonged therapy with antibiotic regimens. The use of bronchoscopy has been reported for the delivery of biological glue, coils, covered stents, and sealants. In this work, we describe a novel method of BPF closure using the Amplatzer device, which is commonly used for transcatheter closure of atrial septal defects.

Upper mediastinum involvement in diseases of the head and neck may require a sternal split. This study describes our adaptation of the upper median or “minimal” sternotomy technique for the treatment of head and neck pathologies. Between April 2002 and October 2005, 17 patients aged 4 to 82 years underwent minimal sternotomy in our institution for a variety of head and neck pathologies. The 17 patients included 11 adults with metastatic thyroid disease (six metastatic papillary thyroid carcinoma, two medullary carcinoma, and one Hürthle cell carcinoma) and huge retrosternal goiter (n = 2), four adults with parathyroid disease (two primary parathyroid adenoma, one secondary hyperplasia, and one parathyroid carcinoma), and two children with lymphangioma and huge thymic cyst (one each). Average hospitalization was 8 days. Four patients needed a thoracic drain for 2 days, one had recurrent laryngeal nerve palsy, and one had phrenic nerve paresis. There were no postoperative deaths. Minimal sternotomy appears to be an excellent alternative for surgical exploration of the mediastinum and may be used in head and neck surgery for a range of indications.

Objective: Patients with end-stage lung disease very frequently die while awaiting lung transplantation. The aim of this study was to identify factors associated with mortality in patients referred for lung transplant assessment. Methods:The files of all consecutive patients listed for lung transplantation in Israel between 1997 and 2006 were reviewed and the data were compared statistically between those who survived to transplantation. Results: A total of 229 patients were listed for lung transplantation, of whom 42 (18.3%) died while awaiting transplantation. Comparison of the patients who survived to transplantation with those who did not using univariate analysis revealed that the died-waiting group was significantly older, used steroids to a greater extent, had more IPF patients and less emphysematous, and lower mean oxygen saturation at rest (p = 0.005). There were no between-group differences in comorbid diseases or pulmonary function measurements. The 6 min walk distance was strongly and inversely correlated with risk of death before transplantation (p = 0.005). On multivariate analysis, only oxygen saturation at rest was a significant independent risk factor for death while awaiting transplantation (OR 0.886; C.I. 0.805—0.974). Conclusions: There are several risk factors for death in the Israeli population listed for LTX, including age, steroid use, emphysematous patients and lower saturation at rest.

Objective: Post-transplant diabetes mellitus (PTDM) is a common and potentially serious complication after solid organ transplantation. There are only a few data, however, about the incidence of DM in patients undergoinglung transplantation. Patients and methods:The medical records of 119 consecutive patients who underwent lung transplantation from 1998 to September 2004 were reviewed. Patients were divided in three groups according to their diabetes status, including pre-transplant DM, the PTDM group and those without DM. Patient records and all laboratory data were reviewed and the clinical course of diabetes was monitored. All recipients were treated with tacrolimus based regimen. Results: Mean follow-up for all patients was 25 10. Twenty-three patients had DM in the pre-lung transplantation (LTX) DM group. PTDM developed in 34 of the remaining 96 patients (35.4%) with an incidence of 20%, 23% after 6 months and 12 months post-transplant. No significant difference was noted between 12 and 24 months post-LTX. The patients who developed DM were older (57 15 vs 53 13 years, p = 0.009), had increased BMI (26 5 vs 24 4, p = 0.0001), shorter time from diagnosis to LTX (21 13 vs 28 18 months, p = 0.007) more cytomegalovirus infection and more acute rejection and hyperglycemia in the first month after LTX. Four patients died in the PTDM group compared to nine patients in the no-DMgroup (12% vs 14%; p = 0.72). Conclusions: Post-transplant diabetes is a common complication in lung transplant patients receiving tacrolimus-based immunosuppression. The risk for developing PTDM is greatest among older recipients, those obese, and among recipients with more rejections episodes.

Lung transplantation is a well-established therapeutic option for end-stage lung disease in cystic fibrosis. Although it confers a clear survival advantage, outcome differs among centers according to local experience, patient selection, transplantation procedure, and postoperative care.To evaluate the national Israeli experience with lung transplantation in patients with CF.We reviewed the medical charts of all CF patients who underwent lung transplantation between January 1996 and June 2005 at the two Israeli centers that perform this procedure.Eighteen transplantations were performed in 17 patients. Mean patient age at transplantation was 25.3 +/- 9.1 years, and mean duration of follow-up in survivors (n=14) was 37.2 months (range 1-113 months). The actuarial survival rate was 88% at 1 year and 74% at 5 years. Pulmonary function, expressed as percent of predicted normal forced expiratory volume in 1 sec, improved from 22.4 +/- 8.1% to 76 +/- 16.8% at one year after transplantation. Bronchiolitis obliterans syndrome was diagnosed in 5 patients (29%), of whom 2 died and 2 are currently candidates for retransplantation. Median time to onset of BOS was 34.2 months (range 17-64 months).In Israel, the early and intermediate-term results of lung transplantation for cystic fibrosis are encouraging. BOS remains a major complication that threatens long-term outcome.

Purpose: Paraplegia is an uncommon yet devastating complication following thoracotomy, usually caused by compression or ischemia of the spinal cord. Ischemia without compression may be a result of global ischemia, vascular injury and other causes. Epidural anesthesia has been implicated as a major cause. This report highlights the fact that perioperative cord ischemia and paraplegia may be unrelated to epidural intervention. Clinical features: A 71-yr-old woman was admitted for a left upper lobectomy for resection of a non-small cell carcinoma of the lung. The patient refused epidural catheter placement and underwent a left T5–6 thoracotomy under general anesthesia. During surgery, she was hemodynamically stable and good oxygen saturation was maintained. Several hours following surgery the patient complained of loss of sensation in her legs. Neurological examination disclosed a complete motor and sensory block at the T5–6 level. Magnetic resonance imaging (MRI) revealed spinal cord ischemia. The patient received iv steroid treatment, but remained paraplegic. Five months following the surgery there was only partial improvement in her motor symptoms. A follow-up MRI study was consistent with a diagnosis of spinal cord ischemia. Conclusion: In this case of paraplegia following thoracic surgery for lung resection, epidural anesthesia/analgesia was not used. The MRI demonstrated evidence of spinal cord ischemia, and no evidence of cord compression. This case highlights that etiologies other than epidural intervention, such as injury to the spinal segmental arteries during thoracotomy, should be considered as potential causes of cord ischemia and resultant paraplegia in this surgical population.

We describe a case of takotsubo cardiomyopathy in a 69-year-old woman after right upper lobectomy, without cardiac antecedents. The immediate course of recovery was uneventful. On the first postoperative day, clinical symptoms of acute coronary syndrome developed in association with ischemic electrocardiographic changes and a mild elevation in creatinine phosphokinase levels. Echocardiography showed moderate left ventricular dysfunction, with a typical takotsubo pattern. Coronary angiography revealed no abnormalities. After 2 days of supportive treatment, the patient recovered completely. The clinical presentation, instrumental findings, additional cardiac and noncardiac diseases, and the potential pathomechanism of takotsubo cardiomyopathy are described according to the current medical literature.

Lymphoproliferative disorder is a well-recognized complication of lung transplantation. Risk factors include Epstein-Barr virus infection and immuno-suppression. The gastrointestinal manifestations of posttransplant lymphoproliferative disorder in lung transplant recipients have not been fully characterized. Case presentation and 16 previously reported cases of posttransplant lymphoproliferative disorder with gastrointestinal involvement are reviewed. Patient ages ranged from 25 to 65 (median, 52) years. Median time from lung transplantation to onset of posttransplant lymphoproliferative disorder was 36 (range, 1–109) months; 35 percent of cases (6/17) occurred within 18 months; Eighty-eight percent of patients (15/17) had positive Epstein-Barr virus serology before transplantation. In five patients (29 percent), the posttransplant lymphoproliferative disorder also involved sites other than the gastrointestinal tract. The most common gastrointestinal site of posttransplant lymphoproliferative disorder was the colon, followed by the small intestine and stomach. Clinical features included abdominal pain, nausea, and bloody diarrhea. Diagnosis was based on typical pathologic changes on gastrointestinal tract biopsy obtained mainly by colonoscopy. Treatment included a reduction in the immunosuppressive regimen in 15 of 17 cases (88 percent) and surgical resection in 10 (59 percent). One patient was untreated. Seven of 16 patients (44 percent) responded to treatment and 9 patients died. Median time from onset of posttransplant lymphoproliferative disorder to death was 70 (range, 10–85) days. Posttransplant lymphoproliferative disorder with gastrointestinal involvement is a unique entity that should be considered in all Epstein-Barr-Virus-positive lung transplant recipients who present with abdominal symptoms. Although immunosuppressive modulation and resection can lead to remission, the risk of death is 50 percent.

Itraconazole is often given for fungal prophylaxis to lung transplant recipients after transplantation. The aim of this study was to determine the extent of interaction between tacrolimus and itraconazole in lung transplant recipients and the efficacy of itraconazole prophylaxis.The study group included 40 lung transplant recipients followed for at least 12 months. All received prophylactic itraconazole, 200 mg twice a day, for the first 6 months after transplantation. Tacrolimus levels and dosage requirements were compared during and after itraconazole therapy. Rejection rate, fungal infection rate, and renal function were assessed. The mean cost per daily treatment of the itraconazole/tacrolimus combination and tacrolimus alone was calculated.The mean tacrolimus dose during itraconazole treatment was 3.26 +/- 2.1 mg/day compared with 5.74 +/- 2.9 mg/day after itraconazole was stopped (p0.0001) for a mean total daily dose elevation of tacrolimus of 76%. When the cost of itraconazole was taken into account, the average total daily cost of the combined treatment was US5.86 dollars less than the treatment with tacrolimus alone. No differences in the rejection or fungal infection rate, or in renal toxicity, were observed between the periods with and without itraconazole treatment, although less positive fungal isolates were identified during itraconazole therapy.Prophylaxis therapy with itraconazole is highly effective. Itraconazole reduces the dose of tacrolimus and therefore lowers the cost of therapy without causing an increase in rejection rate and with renal function preservation.

Localized pulmonary amyloidosis is a rare condition whose pathogenesis is insufficiently understood. In the present study, we report a case of localized pulmonary amyloidosis associated with lung-restricted lymphoplasmacytoid lymphoma, monoclonal for immunoglobulin (Ig) G lambda (lambda). Biochemical microtechniques have been applied for extraction, purification, and characterization of amyloid proteins. Surprisingly, chemical analysis of these proteins revealed a not-previously-described case of combined deposits containing Ig fragments of gamma heavy chain (variable domain) and lambda light chain (constant domain). In view of the absence of circulating monoclonal Ig, this case supports the hypothesis that localized amyloid is formed by local plasmacytoid cells.

Background Video-assisted thoracoscopy with the creation of a pericardial window is a noninvasive method of pericardial drainage. It also allows an excellent view of both the pleural cavity and pericardium and the precise selection of biopsy sites. We review our 3-year experience with this technique. Methods Between January 2001 and February 2004, 18 patients (10 men, 8 women; mean age 57 years) with echocardiographically diagnosed pericardial effusion underwent video-assisted thoracoscopy at our center. Pericardial windows were created under general anesthesia and single-lung ventilation using 2 to 3 trocars. Mean operating time was 46 minutes. A right thoracic approach was used in 16 patients and a left thoracic approach in 2. Results Microbiology and virology cultures of the pericardial fluid were negative. Histologic findings were compatible with tuberculosis in 2 cases and granulocytic sarcoma, infiltrating breast carcinoma, and infiltrating nonsmall cell carcinoma in 1 case each. In the remaining patients, the histologic diagnosis was chronic or subacute nonspecific pericarditis. Talc pleurodesis was performed in 3 patients for concomitant malignant pleural effusion. In 4 patients, the pericardial effusion occurred secondary to cardiac surgery; 3 were receiving anticoagulants after valve replacement, and 1 had a heart transplant. There were no complications of the thoracoscopy technique. Conclusions Video-assisted thoracoscopic fenestration is an effective technique for pericardial drainage and biopsy. Apart from its diagnostic value, it allows the physician to fashion a pleuropericardial window for effective drainage while avoiding the complications of classic surgical procedures. Concomitant pleural and pulmonary disorders may be managed simultaneously.

Short-term improvement in lung function was observed in 5 of 6 lung transplant recipients with bronchiolitis obliterans syndrome (BOS) who were treated with oral azithromycin. We assessed the long-term effect (mean duration 10 months) of treatment with oral azithromycin in 11 lung transplant recipients with BOS. Mean forced expiratory volume in 1 second (FEV1) was 40 +/- 9% at initiation of azithromycin treatment, 39 +/- 10% after 1 month, 39 +/- 12% after 4 months, 38 +/- 10% after 7 months and 38 +/- 10% after 10 months, respectively (statistically non-significant for all data). We conclude that long-term administration with oral azithromycin does not reverse BOS in lung transplant recipients, but may slow progression of the disease.

Lung transplantation is a relatively new field in solid organ transplantation. We present our early experience with the first 70 cases at the Rabin Medical Center during the years 1997-2003. Forty seven patients underwent single lung, eight double lung and eight heart-lung transplantations. The patients treated included 49 men and 21 women aged 5-66 years. There were 26 cases with emphysema COPD. 30 patients with pulmonary fibrosis. 5 patients with pulmonary hypertension/Eisenmenger and 9 patients with cystic fibrosis and bronchiectasis. Although early results (1997-1999) showed 1 and 3 year survival of only 50%, in the last 3 years (2000-2003), survival reached 84% and 82% at 1 and 3 years respectively. Improvement in the success rate is due to better patient selection, new immunosuppressive regimen and, most importantly, excellent teamwork. We conclude that lung transplantation is a viable option for selected patients with end-stage lung disease.

Inflammatory myofibroblastic tumor is a rare solid tumor that most often affects children and young adults. Although benign, the tumor may be very aggressive locally. We describe a 9-year-old boy with primary inflammatory myofibroblastic tumor of the left upper lobe involving the left atrium.

Objective: Pleural effusions are extremely common in the early postoperative period after lung transplantation (LTX). It occurs in all transplant recipients, and like pleural fluid following other cardiothoracic surgery is bloody, exudative and neutrophil predominant. There was no information, however, on the characteristics of the late (14 ‐45 days) postoperative pleural fluid after LTX. The purpose of this study was to describe the characteristics and the clinical implications of late postoperative pleural effusion after LTX. Methods: Thirty-five patients underwent TX between May 1997 and May 2001. Seven patients (20%) developed late postoperative pleural effusion. Thoracentesis were performed in these patients and the white blood cell counts, cell differential as well as biochemical parameters were determined. Results: The median time for late pleural effusion appearance was 23 days (range, 14‐ 34 days) after TX. The pleural effusions were medium in size (700 ml, range, 100‐ 1300), exudative in all the patients and had lymphocyte predominance. No evidence of fluid recurrence or clinical deterioration was noted in these patients. Conclusion: Late-onset exudative lymphocytic pleural effusion after LTX is not uncommon. When there is no evidence of rejection or infection, it usually has a benign, favorable outcome. q 2003 Elsevier Science B.V. All rights reserved.

OSTTRANSPLANT diabetes mellitus (PTDM) has gained widespread attention due to the micro- and macrovascular complications that increase the morbidity and mortality rates of patients receiving solid organs. A higher incidence of PTDM has been associated with immunosuppressive therapy. This study compares glucose metabolism in heart transplant recipients receiving either FK506 or cyclosporine. METHODS Two groups of heart transplant recipients, differing in their immunosuppressive regimen—FK506 or cyclosporin—were followed for periods up to 6 years. Blood levels of glucose and of the respective immunosuppressive agent were measured regularly, and, if needed, anti-hyperglycemic treatment prescribed. The concomitant therapy with low-dose steroids and azathioprine was the same for both cohorts. T-test were performed to compare with the mean values of the two groups. RESULTS

Historically, donor age above 55 years has been considered to be a relative contraindication for organ transplantation. The shortage of organs for transplantation has led to the expansion of the donor pool by accepling older donors.To compare the 1 year follow-up in patients after lung transplantation from older donors (50 years old) and in patients after transplantation from younger donors (or = 50 years).The study group comprised all adult patients who underwent lung transplantation at the Rabin Medical Center between May 1997 and August 2001. Donors were classified into two groups according to their age:or = 50 years (n = 20) and50 years (n = 9). Survival, number and total days of hospitalization, development of bronchiolitis obliterans syndrome, and pulmonary function tests, were examined 1 year after transplantation.We performed 29 lung transplantations in our center during the observed period. Donor age had no statistically significant impact on 1 year survival after lung transplantation. There was no statistically significant effect on lung function parameters, the incidence of hospitalization or the incidence of bronchiolitis obliterans between both donor age groups at 1 year after transplantation.Donor age did not influence survival or important secondary end-points 1 year after lung transplantation By liberalizing donor criteria of age up to 65 years, we can expand the donor pool, while assessing other possible mechanisms to increase donor availability.

Video-assisted thoracic surgery (VATS) is widely used for many thoracic surgical procedures. Post-operative pain is less after VATS than after conventional thoracic surgery, but is still significant. The objective of this study was to assess the efficacy of thoracoscopic, internal intercostal nerve block in alleviating immediate postoperative pain.Thirty-two patients underwent VATS bilateral sympathectomy for the treatment of hyperhidrosis. The patients were randomly divided into two groups with similar demographic and preoperative physiologic parameters. Group A (n = 16) was submitted to thoracoscopic, internal intercostal nerve blocks performed at T2, T3, and T4 intercostal levels using 3 cc of 0.5% bupivacain in each intercostal space. The injections were performed bilaterally, immediately after the sympathectomy, through the same port. Group B (n = 16) underwent bilateral thoracic sympathectomy without the block. During the immediate postoperative period, heart rate, blood pressure, respiratory rate, pain score, and analgesic requirements were monitored every 30 minutes.No morbidity was recorded in association with the thoracoscopic, internal intercostal nerve block. The mean heart rates (77 +/- 6 vs 89 +/- 12 beats per minute, p0.001), respiratory rates (15 +/- 2 vs 18 +/- 3 respirations per minute, p0.01), pain score (1.9 +/- 0.6 vs 2.7 +/- 0.5, p0.01), and postoperative analgesic requirements (20 +/- 18 vs 50 +/- 21 mg pethidine HCL, p0.001) were significantly lower in group A. There was no significant difference in blood pressures.Thoracoscopic, internal intercostal nerve block with bupivacain 0.5% during VATS is safe and effectively reduced the immediate postoperative pain and analgesic requirements.

Background . Open lung biopsy (OLB) has long been considered the gold standard for the diagnosis of parenchymal lung disease. With recent advances in computed tomographic imaging and diagnostic techniques (eg, bronchoscopy), we thought it necessary to reevaluate the role of OLB in the management of patients with interstitial lung disease. Methods . We carried out a retrospective analysis of 103 OLBs performed at Hadassah University Hospital, Jerusalem, and Carmel Medical Center, Haifa, between 1980 and 1994. Data gathered included demographic information, underlying condition, indications for biopsy, diagnosis before biopsy, final diagnosis, change in therapy, and mortality. "Benefit" was defined as a change in therapy resulting in survival. Results . There were 45 immunocompetent patients (group 1), 39 immunocompromised patients (group 2), and 26 children (group 3), 7 of whom were included in group 2 for analysis. Overall, a diagnosis was reached after OLB in 85% of patients. An unexpected diagnosis was reached in 52%, and a change in therapy was instituted in 46%. The overall mortality rate was 20%. In group 1, the mortality rate was 13%, and "benefit" from OLB was reached in only 18%. In group 2, the mortality rate was 39%, and "benefit" was achieved in 46%, and in group 3, the mortality rate was 12% and "benefit", 50%. Conclusions . Open lung biopsy is an excellent diagnostic technique. In immunocompetent patients, the "benefit" is relatively low, as therapy (corticosteroids) is frequently used after biopsy. In immunocompromised patients, therapy changes substantially after OLB, but mortality is high. Therefore, OLB should be reserved for patients in whom the diagnosis is likely to lead to a change in therapy and in patients in whom the underlying condition has a reasonable prognosis according to the clinical impression by the attending physician.

The shortage of organs for lung transplantation has led to the growing use of "marginal" donors. Although patients on hemodialysis are still excluded as lung transplant donors because of the possible effects of renal failure on the lungs, recent data suggest that they may be suitable in selected cases. This article describes the successful transplantation of two lungs from a single donor who had been receiving long-term hemodialysis treatment. In the absence of other causes of pulmonary diseases, such as smoking or lung infection, lungs from dialysis-dependent patients may be acceptable for lung transplantation.

Background Students report that their operating room experience during specialty clerkships has been less than satisfactory. To deal with this and other, roblems in a 1-week cardiothoracic clerkship, a video conference system was introduced. Methods Three teaching strategies were used: a seminar dealing with the disease process and a description of the operative procedure; bedside pre-operative assessment of the patient, with a tutor; and a live video conference of the operation. The tutor observed the live video presentation with the students, initiating interaction with the operating surgeon and facilitating questions and discussion. Video quality was maintained by one camera connected to the headlight of the surgeon and another placed above the operative field. Results Both students and staff expressed a high degree of satisfaction in debriefing sessions and on a standard faculty evaluation form. Conclusions This innovation in surgery specialty teaching contributes to the acquisition of educational objectives in the operating room and in a cardiothoracic clerkship.

Purpose : We carried out a Phase II trial in an attempt to improve resectability and survivability of inoperable Stage III A and III B nonsmall cell lung cancer (NSCLC) patients by implementing a neoadjuvant chemoradiotherapy treatment program. Methods and Materials : Thirty-six patients with locally advanced Stage III NSCLC received neoadjuvant therapy consisting of 50.4 Gy in 5.5 weeks concurrent with two cycles of chemotherapy, using cisplatin and etoposide. No postsurgical consolidation therapy was given. Results : Assessment at 3 to 6 weeks after treatment suggested that 26 (72%) ) patients had been rendered resectable. Toxicities were common but usually tolerable ; however, one toxic death occurred. Of 24 patients who proceeded to thoracotomy, complete resection was achieved in 20 (56%). There were two surgically related deaths. Surgical-pathological staging showed downstaging in 18 patients, including complete sterilization of the tumor in 3 (8%). The median survival for all 36 patients is 15 months, but at the time of analysis, median survival of resectable patients had not been reached. The actuarial 2-year survival is 39% for all study groups, 57% for resectable patients, and 16% for the remaining (p < 0.005). Conclusions : While this preoperative neoadjuvant appears to improve survival of patients with Stage III NSCLC, comparison with previous reports of other similar trials indicate a superior survival advantage in association with higher doses of radiotherapy.

Resection of a mediastinal tumor (Fig. 1) in a 57-year-old woman who presented with progressively aggravated dyspnea at rest, productive cough, and a referred vague left chest pain, established the diagnosis of schwannoma (Fig. 2a,b), a benign, slow-growing neoplasm that frequently arises from a spinal nerve root but may involve any thoracic nerve. European Journal of Cardio-thoracic Surgery 24 (2003) 1030 www.elsevier.com/locate/ejcts