Küçük hücreli dýþý akciðer kanserinde ana prensip; tümörün çevre dokudan güvenli bir sýnýrla tam rezeksiyonudur. Bronþ güdüðünde tümör mikroinvazyonu olmasýnýn prognoza negatif etkisi henüz tam olarak kanýtlanmamýþ olsa da, komplet rezeksiyon vazgeçilmez bir öneme sahiptir. Ocak 1993 ve Kasým 1998 tarihleri arasýnda opere edilen 400 olgudan; bronþ güdüðünde tümör bulunduðu için inkomplet rezeksiyon kabul edilen onbeþ olgu, retrospektif olarak incelendi. Hastalar ortalama 20.3 ay takip edildi. Operasyondan sonra ampiyem vakalarýnýn yedisinde bronkoplevral fistül (BPF) geliþti. BPF oraný inkomplet rezeksiyon yapýlanlarda, komplet rezeksiyon yapýlanlara göre daha yüksekti (%26.6 ve %3.7). T faktörü inkomplet rezeksiyon yapýlan grupta daha yüksekti. Prognoz komplet rezeksiyon yapýlan grupta daha iyi bulundu. Ýnkomplet rezeksiyon oraný 60 yaþ üzerinde daha fazlaydý. Bronþ güdüðünde tümör bulunmasý nedeni ile inkomplet rezeksiyonun prognoza etkisi kötüdür ve ampiyem veya BPF riskini artýrýr. Daha iyi sonuçlar elde etmek için komplet rezeksiyon zorlanmalýdýr.

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Çalýþmada ileri evre akciðer kanserinin immun sistem üzerine etkisini incelemeyi amaçladýk. 4'ü KHAK, 20'si KHDAK toplam 24 akciðer kanserli erkek hasta ile 11 saðlýklý erkek, kontrol grubu çalýþmaya alýndý. Kanserli olgularda ve kontrol grubunda periferik kanda þowsitometrik yöntemle CD3, CD4, CD8, CD16, CD19 lenfosit alt gruplarýna ve IgA, IgG ve IgM yüzdelerine bakýldý. Akciðer kanserli olgularda periferik kan CD4, CD19 ve CD4/CD8 düzeyleri kontrol grubuna göre anlamlý olarak düþük bulundu (p<0,05). T evresi arttýkça (T1-4) periferik kan CD3 düzeyinin çok anlamlý olarak azaldýðý (p<0,001), radyolojik N (lenf nodu tutulumu) arttýkça CD4 düzeyinin azaldýðý bulundu (p<0,05). Akciðer kanserli olgularda yaþla beraber periferik kan CD16+'liðinin anlamlý olarak arttýðý tespit edildi (p=0,022). Performansý ve kan albümin düzeyi düþük olan akciðer kanserli hastalarda periferik kan CD16+'lik düzeyi yüksek bulundu (p<0,05). Sonuç olarak akciðer kanserinde ilerleyen hastalýk ve buna karþý immun yanýtýn göstergesi olarak bazý lenfosit alt gruplarýnda (CD4, CD19, CD4/CD8 oraný) deðiþiklikler olur. Ýleri evre akciðer kanserinde matür T ve B-lenfositler (CD3, CD4 ve CD19) anti-tümör immunitede temel rol oynuyor olabilir.

We investigated the effect of advanced lung cancer on the immune system. Histopathologically confirmed and staged 24 male patients (4 patients with SCLC and 20 patients with NSCLC) and 11 healthy male subjects were recruited in the study. Using flowcytometry, CD3, CD4, CD8, CD16, CD19 lymphocyte subgroups and IgA, IgG and IgM percentages were measured in the peripheral blood samples of both groups. In patients with lung cancer CD4, CD9 and CD4 / CD8 levels in the peripheral blood were low compared to the control group, the difference being statistically significant (p<0,05). With progression from stage T1 to T4, peripheral blood CD3 level decreased significantly (p<0,001). Likely as radiological N (lymph node involvement) increased, CD4 level diminished (p<0,05). Among patients with lung cancer, with age increased peripheral blood CD16 positivity was detected (p<0,05). CD16 (+) level was high in peripheral blood of lung cancer patients with poor performance and low albumin levels. As a result, various changes occur in some lymphocyte subgroups (CD4, CD19, CD4/CD8) in lung cancer, as a marker of progressive disease and immune response. In advanced lung cancer, matur T and B-lymphocytes (CD3, CD4 and CD19) may play a major role in anti-tumour immunity.

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Çalýþmada ileri evre akciðer kanserinde kemoterapinin immun sistem üzerine etkisini, kemoterapi yanýtý ve en önemli kemoterapi komplikasyonu olan nötropenik enfeksiyonlar ile immun sistem iliþkisini incelemeyi amaçladýk. 4'ü KHAK, 20'si KHDAK toplam 24 akciðer kanserli erkek hasta çalýþmaya alýndý. Periferik kanda þowsitometrik yöntemle CD3, CD4, CD8, CD16, CD19 lenfosit alt gruplarýna ve IgA, IgG ve IgM yüzdelerine bakýldý. Olgulara 21 gün ara ile 2 kür sistemik kemoterapi uygulandýktan sonra ayný immunolojik parametrelere tekrar bakýldý. Kanserli olgularda KT ile CD16 yüzdesinin azaldýðý ve CD19 yüzdesinin ise arttýðý tespit edildi (p<0,05). Kemoterapiye yanýt veren olgularda (n=13) CD8+'liði kemoterapiye yanýtsýz olan olgulara (n=11) göre anlamlý olarak yüksek bulundu (p<0,05). Kemoterapi ile nötropenik enfeksiyon komplikasyonu geliþen olgularýn, KT öncesi CD4 ve CD19 düzeyleri diðer hastalardan anlamlý olarak düþük bulundu (p<0,05). Sonuç olarak akciðer kanserinde uygulanan sistemik kemoterapi bazý lenfosit alt gruplarýný etkilemektedir. Lenfosit alt gruplarýna bakýlarak kemoterapiye yanýt ve kemoterapiye baðlý nötropeni geliþme olasýlýðý önceden tahmin edilebilir.

We investigated the effect of chemotherapy on the immune system by the advanced lung cancer. The relationship between the immune system and the response to chemotherapy, as well as the incidence of the neutropenic infections occurring as the most important complication of chemotherapy was evaluated. 4 male patients with SCLC and 20 male patients with NSCLC (total 24 male patients) were recruited in the study. Using flowcytometry, CD3, CD4, CD8, CD16, CD19 lymphocyte subgroups and IgA, IgG and IgM percentages were measured in the peripheral blood samples of patients. The patients with lung cancer had 2 courses of chemotherapy within 21 days interval. Then, the same immunological parameters were remeasured. After the 2nd course of chemotherapy, a decrease in CD16% and an increase in CD19% were detected when compared to the initial levels (p<0,05). CD8 (+) level was higher in chemotherapy responsive cancer patients (n=12) compared to unresponsive ones (n=11) and the difference was statistically significant (p<0,05). Initial CD4 and CD19 levels of patients who developed neutropenic infections were significantly less than the patients with not having this complication. As a result, systemic chemotherapy effects some lymphocyte subgroups. Therefore, lymphocyte subgroups analysis may be guiding in predicting the neutropenic infection complication which is the leading cause of mortality of chemotherapy and the response to chemotherapy.

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Ýleri dönem amfizem olgularýnda, akciðerin hacim azaltýcý cerrahisi, solunum fonksiyonlarýnda ve akciðerdeki gaz alýþveriþinde iyileþmeler saðlayabilen palyatif bir cerrahi iþlemdir. Merkezimizde, ileri evre amfizem teþhisi ile gördüðü maksimal tedaviye karþýn, ileri derecede dispnesi bulunan ve ameliyat kriterlerimize uygunluk gösteren ve yaþlarý 43 ile 55 arasý (ortalama:47) olan 4 olguya, bilateral 'akciðer hacim azaltýcý cerrahi' (AVAC) uygulandý. Olgularýn üçüne sternotomi ile ayný anda bilateral, diðerine ise, anterior torakotomi ile sýralý olarak hacim azaltýcý ameliyat uygulandý. Olgularýn baþvurudaki FEV1 deðerleri 0.44 ile 0.71 lt arasýnda deðiþmekte, ortalama 0.61 lt (%26) idi. Postoperatif PaO2, preop ortalama 62 mmHg düzeyinden 74 mmHg'ya çýktý (p=0.02). Olgularýn ortalama PaCO2 düzeyleri anlamlý ölçüde deðiþmedi (ortalama 48 mmHg'dan postop 46 mmHg'ya). Ameliyat ile oluþan solunum fonksiyon testi deðiþimleri FEV1 de 0.61 lt'den 0.90 lt'ye (%47.5 artýþ) (p=0.01), TLC'de, 7.23 lt'den 4.73lt'ye (%34.5 düþme), (p=0.03), RV'de 5.70 lt'den 3.34 lt'ye (% 41.4 düþme) (p=0.009) olarak gerçekleþti. Olgularýn tümünün dispne derecelerinde iyileþme oldu. 6 dk yürüme mesafeleri 260 m'den 340 m'ye çýktý (%30 artýþ). Olgular, biri 40 ay olmak üzere median 29 aydýr izlenmektedir. Bu süre içinde olgularýn tümü halen preop. günlük aktivitelerinden daha iyi aktivitelere sahip bulunduðu, ancak FEV1 deðerlerinde izlenebilir düþüþler olduðu saptandý. Buna karþýlýk, halen ortalama FEV1 deðerleri, 0.8 lt ile preop. ortalamadan daha yüksektir. AVAC, palyatif etkileri 2 yýla kadar sürebilen ve seçilmiþ ileri amfizemli olgularda uygulanabilecek bir cerrahidir. Ancak, tam olarak etkilerinin ve bu etkilerin mekanizmalarýnýn aydýnlatýlabilmesi için ileri çalýþmalar gereklidir.

Lung volume reduction surgery (LVRS) of the lung has been accepted as a paliative procedure which may achieve improvement in lung function tests and gas exchange in patients with adanced emphysema. Four patients with severe dyspnea despite a maximum bronchodilatator therapy aged between 43 and 55 (mean ; 47) underwent bilateral lung volume reduction. Three out of four patients were operated through sternotomy, while the another patient had bilateral volume reduction surgery through sequential anterior thoracotomies. The mean baseline FEV1 was 0.61 lt (26%),(ranging 0.44 to 0.71). The postoperative mean PaO2 increased to 74 mmHg from mean preoperative 62 mmHg (p=0.03). Although, the mean PaCO2 level did not changed significantly (From 48 mmHg to 46 mmHg postoperatively). LVRS induced a significant increase in mean FEV1. (i.e., from 0.61 to 0.9 l;p=0.01), reduction in total lung capacity (i.e., from 7.23 l to 4.73 l; p=0.03) and residual volume (from 5.70 to 3.34 l;p<0.009). All patients had better dyspnea scores. The 6-minute walk distance increased from 260m (mean) to 340 m (i.e., 30% increase). All patients were followed up for up to 40 months (mean 29 months). In this period, all patients were found to have better daily activities than those of preoperative ones. Although the mean FEV1 decreased 30% during the 2-year follow-up period, the last assessed mean FEV1 was 800 mL which is higher than preoperative mean value. LVRS has been proven to be an appropriate surgical procedure for the selected patients with end-stage emphysema and improvement in pulmonary functions lasted for at least 2-years and wane eventually. However, further studies are warranted to clarify its mechanism of action.

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Plevral sývýda homojenizasyon ve kültür yöntemiyle asidorezistan basil (ARB) aranmasý ve plevral biyopsi örneðinin histopatolojik incelenmesi sonrasýnda bile yaklaþýk % 10 tüberküloz (Tb) plörezi olgusuna taný konamamaktadýr. Tüberküloz plörezide T lenfositlerin fazla miktarda -IFN ürettikleri bilinmektedir. Bu çalýþmanýn amacý farklý etyolojilere baðlý oluþmuþ plevral sývýlarda -IFN düzeyini ölçerek Tb plörezi için tanýsal duyarlýlýk ve özgüllüðünü belirlemektir. Seksen dokuz olgunun 32'sinde Tb plörezi, 17'sinde malign, 15'inde transüdatif, 12'sinde etyolojisi belirlenemeyen eksudatif, yedisinde paramalign ve altýsýnda parapnömonik plörezi saptandý. Tüberküloz plörezi tanýsýnda plevral sývý -IFN düzeyi ölçümünün duyarlýlýðý % 100, özgüllüðü % 94.7 olarak bulundu. Plevral sývý miktarýyla -IFN düzeyi arasýnda iliþki bulunamadý. Pulmoner tutulumu da olan Tb plörezi olgularýnda -IFN düzeyi daha yüksek bulundu (604±183 ve 392±232 pg/ml). Tüberküloz plörezili olgularda eritrosit sedimentasyon hýzýyla plevral sývý -IFN düzeyi arasýnda orta derecede doðrusal iliþki bulundu (r=0.5827, p=0.0005). Sonuç olarak Tb plörezi tanýsýnda plevral sývýda -IFN düzeyi ölçümü oldukça etkin, yüksek duyarlýlýk ve özgüllükte güvenilir bir yöntemdir.

Despite histopathologic evaluation of pleural biopsy, acid-fast staining and culture of pleural fluid, at least 10% of pleural tuberculosis (PT) remain undiagnosed. T-lymphocytes are known to produce huge amounts of interferon- (IFN- ) in tuberculosis (TB). Therefore the purpose of the present study was to determine IFN- levels in pleural fluids of different etiology and the diagnostic sensitivity and specificity of pleural fluid IFN- levels for the diagnosis of PT. Relationship between presence of pulmonary TB and IFN- levels in pleural fluid was also evaluated. Of 89 patients studied, 32 had pleural tuberculosis. 17 had malignant, 15 had transudative, 12 had etiologically undiagnosed exudative, 7 had paramalign, and 6 had parapneumonic effusions. Pleural fluid IFN- level was found to have a sensitivity of 100% and a specificity of 94.7% in the diagnosis of PT. There was no relation between the level of pleural fluid and IFN- level. Patients with pulmonary TB had higher levels of IFN- in their pleural fluids comparing with those without parenchymal involvement (604±183 and 392±232 pg/ml respectively). A moderate linear relation was found between eritrocyte sedimentation rate and IFNlevels of patients with TB (r=0.5827, p=0.0005). In conclusion, determination of IFN- level in pleural fluid was very effective, reliable method with high sensitivity and specificity for the diagnosis of PT.

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Çalýþmamýz Mart ve Nisan 1998'de Bilecik jandarma er eðitim merkezinde gözlenen kýzamýk epidemisi sonrasýnda kliniðimize sevk edilen 6 adet pnömoni olgusunu içermektedir. Vakalarýn hepsi 20 yaþýndaki erkek hastalardý. En önemli baþvuru þikayetleri öksürük, üþüme titreme, ateþ ve nefes darlýðý idi. Radyolojik olarak 4 hastada lober, 2 hastada da bilateral akciðer tutulumu vardý. Bilateral tutulumu olan hastalarýn 1'i mortal seyretti, diðeri ise yaygýn nekrotizan pnömoni nedeniyle lobektomi operasyonuna verildi. Hastalarýn C-reaktif protein (CRP) deðerleri yüksekti (137mg/L), tedavi sonrasýndaki deðerlerinde ise düþme gözlendi (36.5mg/L), bu düþme tedaviye cevap vermeyen 2 vaka çýkarýldýðýnda daha belirgindi (11.25mg/L). Mikrobiyolojik incelemelerinde 3 vakada Pseudomonas aeruginosa, 1 vakada Haemophilus influenzae üredi. Vakalarýn hepsinde hipoksemi vardý, 2'sinde mekanik ventilatör desteðine ihtiyaç duyuldu. Kýzamýk sonrasýnda özellikle eriþkinlerde ventilatör tedavisi gerektirecek kadar solunum yetmezliði yapan aðýr Pseudomonas aeruginosa pnömonileri geliþebilir.

In this study consist of 6 patients with measles and pneumonia who came from an epidemic of measles occured in the Bilecik army between March 1998 and April 1998. The mean age of the patients was 20 years. Cough, fewer, chills and dyspnea were the most commonly reported respiratory symptoms. Pulmonary infiltrates were present radiographically in all patients, 4 of them had lober and 2 of them had multilober infiltration. One patient with measles associated pneumonia died and one patient had lobectomy because of necrotizan pneumonia. At the initial, the levels of CRP were high (137mg/L) and at the end of therapy levels of CRP were decreased (36.5mg/L). Infection with bacteria was recognized in 4 patients: Pseudomonas aeruginosa in 3 patients and Haemophilus influenzae in 1 patient. All of the patients had hypoxemia and 2 of them were severe enough to require mechanical ventilation. One patient with measles associated pneumonia died. At a result Pseudomonas aeruginosa pneomonia might be seen a suprainfection in young adult with measles and associated with respiratory failure which require mechanical ventilation.

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Antifosfolipid sendromu (AFS); tekrarlayan arteriyel-venöz emboliler, rekürren spontan abortus, trombositopeni ve demans, psikiatrik deðiþiklikler, migren, epilepsi ve korea gibi nöropsikiatrik belirtiler ile karakterizedir. Ayrýca tekrarlayan emboliler ve buna baðlý olarak geliþen pulmoner hipertansiyon en sýk akciðer komplikasyonlarýdýr. Bu olgu sunumunda akciðer grafisinde yaygýn iki taraflý akciðer infiltrasyonu gösteren ve sistemik lupus eritematosusa (SLE) eþlik eden antifosfolipid sendromlu iki genç kadýn olguyu sunuyoruz. Hastalarýmýzdan ilki 19 yaþýnda ve hiç doðum yapmamýþ, ikincisi ise primipar ancak ilk gebeliðinin 30. haftasýnda ölü doðum yapmýþtý. Her iki olguda istirahatte ve minimal egzersizle gelen nefes darlýðý, ateþ, akciðer grafisinde bilateral yaygýn akciðer infiltrasyonu vardý. Yapýlan laboratuar incelemede antikardiolipin antikorlarý pozitif bulundu. Ýkinci olgumuz solunum yetmezliði sonucu kaybedildi. Birinci olgumuz ise diüretik ve antikoagülan tedavisi ile düzeldi. Sonuç olarak her iki olgumuzun klinik ve radyolojik özellikleri; genç kadýnlarda antifosfolipid antikor araþtýrýlmasýnýn erken tedaviye baþlanmasý açýsýndan mortalite ve morbiditeyi azaltmada faydalý olacaðýný hatýrtlatýyor.

Antiphospholipid syndrome (APS) is characterized by recurrent arterial, venous thromboses, recurrent spontaneous abortions, thrombocytopenia and neuropsychiatric manifestations such as dementia, psychiatric features, migraine, epilepsy and chorea . The most common pulmonary manifestations are pulmonary embolism, and pulmonary hypertension secondary to recurrent pulmonary emboli. In this case report, we present 19 and 25 years-old females who have diffuse bilateral infiltrates on chest radiography with systemic lupus erythematosus and antiphospholipid syndrome. The first case had never been pregnant. The second case was admitted to the hospital because of abortus at 30 weeks’gestation in the first pregnancy. Both cases had fever with shortness of breath at rest and minimal exercise. Chest radiography of each patients revealed diffuse bilateral pulmonary infiltrates. Antiphospholipid antibodies were positive in two patients. The second case died because of respiratory failure. The first case improved with diuretic and anticuagulan treatment. As a conclusion, the identification of the APS is clinically important because of the risk of recurrent thrombosis and the need for antithrombotic therapy in young females with diffuse bilateral pulmonary infiltrates.

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Dev lenf nodu hiperplazisi, anjiofoliküler lenfoid hiperplazi, lenf nodu hamartomu olarak da bilinen Castleman Hastalýðý, etyolojisi tam olarak aydýnlatýlamayan, tüm vücutta bulunabilmekle beraber sýklýkla toraksta yerleþen reaktif aktif lenf nodu hiperplazisidir. Genellikle genç eriþkinlerde görülür ve asemptomatik seyreder; lenf nodu büyük düzgün sýnýrlý, sýklýkla ön ve orta mediastende lokalizedir. Lokalize olan tipin tedavisi cerrahidir. Bu özellikleri taþýyan olgumuzun nadir olmasý nedeniyle yayýnlýyoruz.

The Castleman Disease, which is etiologically unknown, is also defined as lymph node hamartoma or angiofollicular lymphoid hyperplasia. This hyperplasia of reactive lymph node is frequently placed in the thorax, however it may also be found at the whole lymphoid tissue. Castleman Disease is mostly observed at young adults. The disease is asymptomatic; the lymph node is in giant size, with smooth borders and often localized at the anterior and middle mediastinum and treatment is surgical.

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Altmýþbir yaþýnda bayan hasta, 9 yýldýr ön mediastinal kitle ve myastenia gravis nedeniyle izlenmekte iken, kitlede geliþen progresyon ve plevral lezyonlarý nedeniyle tetkik edildi. Radyolojik olarak ön mediastende 7 cm çapýnda kitle lezyonu ve sol hemitoraksta plevral kalýnlaþma, yer yer noduler lezyonlar ve plevral sývý izlendi. Yapýlan kesici iðne biopsileri sonucu Evre IV invaziv timoma ve plevra metastazý olarak taný aldý. Dokuz yýl non-invaziv olarak gidip kýsa sürede ilerleme göstermesi ve malign mezotelyoma ile radyolojik ve patolojik benzerlik gösteren plevra tutulumu nedeniyle ilginç bulunarak sunuldu.

61 years old female patient, being followed with anterior mediastinal mass and myastenia gravis, was investigated because of the progression of the primary mass and recent pleural lesions. Thoracal computed tomography showed an anterior mediastinal mass lesion 7cm in diameter and pleural thickening with some nodularities and pleural effusion. The histopathological examination of tru-cut biopsy specimens of both mass and pleura revealed Stage IV invasive thymoma. Progression of the tumor following its non-invasive course of 9 years and the similarities of pleural involvement histopathologically and radiologically mimicking malignant mesothelioma made this case interesting to present.

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