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OBJECTIVES Resection of thymic tumours including the removal of both the tumour and the thymus gland (thymothymectomy; TT) is the procedure of choice and is recommended in most relevant articles in the literature. Nevertheless, in recent years, some authors have suggested that resection of the tumour (simple thymomectomy; ST) may suffice from an oncological standpoint in patients with early-stage thymoma who do not have myasthenia gravis (MG) (non-MG). The goal of our study was to compare the short- and long-term outcomes of ST versus TT in non-MG early-stage thymomas using the European Society of Thoracic Surgeons thymic database. METHODS A total of 498 non-MG patients with pathological stage I thymoma were included in the study. TT was performed in 466 (93.6%) of 498 patients who had surgery with curative intent; ST was done in 32 (6.4%). The completeness of resection, the rate of complications, the 30-day mortality, the overall recurrence and the freedom from recurrence were compared. We performed crude and propensity score-adjusted comparisons by surgical approach (ST vs TT). RESULTS TT showed the same rate of postoperative complications, 30-day mortality and postoperative length of stay as ST. The 5-year overall survival rate was 89% in the TT group and 55% in the ST group. The 5-year freedom from recurrence was 96% in the TT group and 79% in the ST group. CONCLUSION Patients with early-stage thymoma without MG who have a TT show significantly better freedom from recurrence than those who have an ST, without an increase in postoperative morbidity rate.

Korrektur zu 10.1093/ejcts/ezab224

Radiofrequency ablation is an effective treatment for atrial fibrillation. Pulmonary vein stenosis/occlusion is one of its rare complications. Herein, the case of a 50-year-old man with hemoptysis and migratory pulmonary infiltrations after transcatheter radiofrequency ablation for atrial fibrillation is presented. Initially, pneumonia, interstitial pulmonary disease, or lung cancer was suspected, but wedge resection revealed hemorrhagic infiltrations. Chest computed tomography pulmonary angiography detected no left superior pulmonary vein due to its total occlusion, and left upper lobectomy was performed. Post-ablation pulmonary vein occlusion must be strongly suspected in cases of migratory pulmonary infiltrations and/or hemoptysis.

Sampling, or systematic mediastinal lymph node dissection, is the standard-of-care surgical treatment for early stage non-small cell lung cancer, according to guidelines from the European Society of Thoracic Surgeons. Lymph node status defines disease status and patients' prognosis. In this video tutorial, a radical ipsilateral mediastinal lymph node dissection in a man suffering from a left, centrally located lung adenocarcinoma is presented. Systematic mediastinal lymph node dissection constitutes a high-quality metric for the efficacy of the surgical procedure and is essential to achieving adequate staging and treatment.

OBJECTIVES: Non-steroidal anti-inflammatory agents (NSAIDs) and paracetamol alter pleural permeability, hindering pleural fluid recycling. The aim of this study was to investigate the effect of different analgesic and anti-inflammatory agents on fluid recycling in an induced hydrothorax model in mice. METHODS: Hydrothorax was induced in C57BL/6 mice by injecting 500 μl phosphate-buffered saline–bovine serum albumin 1% isosmotic in the right hemithorax. Paracetamol (1 g/kg), ibuprofen (250 mg/kg) and parecoxib (2 mg/kg) were administered systematically by intraperitoneal injections. Each drug group included eight mice, which were sacrificed at 2 h and 4 h, respectively, after injections. The remaining hydrothorax volume and total cells contained were determined. RESULTS: Regarding the paracetamol and ibuprofen groups, the remaining hydrothorax volume was greater than in the control group (350 ± 61, 348 ± 62 and 270 ± 51 μl, respectively, P= 0.042) when mice were sacrificed within 2 h. Similar observations were made in groups sacrificed after 4 h (202 ± 45 and 198 ± 44 vs 107 ± 56 μl, respectively, P= 0.002). In the parecoxib group, the remaining hydrothorax volume was 122 ± 53 μ l( P= 0.038 versus paracetamol and ibuprofen, P> 0.05 versus control group). At the same time, the absorption rate in the paracetamol and ibuprofen groups was lower than in the parecoxib and control groups (P= 0.033). In the parecoxib group, the absorption rate was lower than that in the control group after 2 h (P= 0.042). In the paracetamol and ibuprofen groups, the total cell count and the macrophage and the neutrophils counts were increased, compared with the control and parecoxib groups (P= 0.025, 0.028 and 0.032, respectively). CONCLUSIONS: Paracetamol and ibuprofen acutely hinder pleural fluid recycling by lowering the fluid absorption rate (higher remaining hydrothorax volume), while they increased total white cell counts. COX-2s presented lower remaining hydrothorax volume without acutely increasing the absorption rate. These findings could present some relevance to the administration of painkillers in patients with pleural effusion after thoracotomy.

Aim The aim of this study is to investigate the need for admission of patients with isolated sternal fracture (ISF) by prospectively and randomly discharging or admitting them. Methods Patients with ISF after the completion of investigations were randomly discharged or admitted. Investigations performed included lateral chest x-ray; chest computed tomography; electrocardiogram; cardiac ultrasound; definition of C-reactive protein; and cardiac enzymes, such as creatine phosphokinase, myocardial branch of creatine phosphokinase, and troponin I (cardiac specific). These investigations were repeated after 6 hours in the admission and the next day in both groups. Results Forty-two patients were included in the study. Twenty-one were admitted, whereas 21 were discharged. Electrocardiogram and ultrasound were normal in both groups upon presentation and the next day. Creatine phosphokinase and myocardial branch of creatine phosphokinase, although elevated at presentation, were normal the next day and similar in both groups. There was no morbidity, need for surgery, or mortality in both groups during a 6-month follow-up. Conclusions Patients with ISF can be discharged safely as soon as investigations are completed. Extensive myocardial assessment is not needed on the posttraumatic period. Myocardial involvement seems unlikely in patients with ISF, who can be treated with oral analgesics.

Myasthenia gravis is present in a significant proportion of patients with thymoma. We investigated particular features of the clinical behavior of thymoma and its relationship to myasthenia in a retrospective study of 79 patients who underwent thymectomy for thymoma during the last 20 years. The presence of myasthenia gravis, Masaoka stage, World Health Organization histotype, myasthenia response, and survival were analyzed. The mean age of the patients was 56.1 ±12.4 years, and 39 had myasthenia gravis. A significantly higher proportion of patients with myasthenia was found in B2 and B3 histotypes compared to A, AB, and B1. Among myasthenic patients, 33.3% had no response, 50% had a partial response, and 16.7% achieved complete remission. During the follow-up period, 16 (21.1%) patients died. Mean survival was 4.8 ± 1.4 years for patients with no myasthenia response, whereas those with a partial or complete myasthenia response had significantly better survival.

Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) are used in clinical practice as analgesics or anti-inflammatory drugs. Studies have implicated them in participating in permeability throughout various tissues such as the kidneys and lungs. Objective: The effect of NSAIDs on the pleural permeability and the underlying mechanisms whereby this effect is mediated were investigated. Methods: Parietal pleural specimens were obtained from patients subjected to thoracic surgery and were mounted in Ussing chambers. Solutions containing paracetamol, acetylsalicylic acid, diclofenac, lornoxicam, parecoxib and ibuprofen were added in the chambers facing the pleural and the outer-pleural surface. Prostaglandin E2 was similarly used to investigate prostaglandin synthesis involvement at low and high doses. Amiloride- and ouabain-pretreated specimens were used in order to investigate ion transportation involvement. Transmesothelial resistance (RTM) was determined as a permeability indicator. Results: Paracetamol, acetylsalicylic acid, diclofenac, lornoxicam and ibuprofen increased RTM on the pleural and outer-pleural surface, inhibited by amiloride and ouabain. Parecoxib had no effect on the RTM. Prostaglandin decreased RTM on the pleural and outer-pleural surface inhibited by amiloride, ouabain and ibuprofen. Conclusion: NSAIDs, except parecoxib, induce a rapid decrease of the pleural permeability by inhibiting cellular transportation, an effect that is mediated by prostaglandin synthesis inhibition.

To the Editors: In recent years, the life expectancy of patients with Prader–Willi syndrome (PWS) has increased, unveiling several cases of early-onset cancer and raising the question whether the condition predisposes to tumourigenesis. We encountered a unique occurrence of pulmonary atypical carcinoid in a young never-smoker with PWS. A 28-yr-old, morbidly obese male with PWS was admitted as a candidate for gastric bypass. He was a lifetime nonsmoker, and his height, weight and body mass index were 1.78 m, 175 kg, and 55.2 kg·m−2, respectively. Polyphagia, obesity and a failure to achieve psychosocial milestones became apparent at the age of 5 yrs, when PWS was diagnosed based on clinical findings and a de novo deletion of the proximal region of chromosome 15 (del(15)(q11–q13)). Type II diabetes mellitus was diagnosed at the age of 17 yrs, and dietary control along with administration of sulfonylurea was initiated. The remainder of the anamnesis included low levels of testosterone, which were treated with monthly intramuscular depot injections of testosterone enanthate (250 mg). On admission, the patient reported mild shortness of breath, nonproductive cough and malaise of indeterminate origin. A physical exam revealed markedly increased subcutaneous fat, picking scars, hypoplastic external genitalia and a polyphonic wheeze over the right hemithorax. Pulse was regular and of normal rate, diastolic blood pressure was elevated (98 mmHg) and haemoglobin oxygen saturation was 96% in room air. Electrocardiography was normal. Laboratory data, including blood cell counts, routine serum biochemistry and coagulation times, were within normal limits, except for fasting plasma glucose (178 mg·dL−1) and lipids (total cholesterol 233 mg·dL−1; high-density lipoprotein cholesterol 32 mg·dL−1; triglycerides 322 mg·dL−1). A pre-operative chest radiograph, performed routinely but also prompted by the patient’s wheeze, showed a round, regular-shaped opacity of soft-tissue quality measuring …

Objective Bronchopleural fistula is a severe complication after pneumonectomy or lobectomy. Local application of silver nitrate to seal bronchopleural fistulae was reported once 25 years ago with considerable success but was never repeated. We aimed to develop and evaluate a concrete technique of applying silver nitrate through a flexible bronchoscope to treat bronchopleural fistulae in central airways. Methods Consecutive patients with small (≤5 mm) bronchopleural fistulae in proximal airways were included in the study. After measurement of bronchopleural fistula size through a flexible videobronchoscopy, a standard bronchoscopic cytology brush covered with silver nitrate was passed through the working channel of the scope and was rubbed against the fistula's orifice producing blanching and edema on the mucosa. This procedure was repeated until closure of the fistula's orifice (treatment success) or absence of any tissue response after 2 bronchoscopic sessions (treatment failure). Results Of 16 patients referred, 5 were excluded from treatment because of large (>5 mm) fistulae. Among the 11 treated patients (median fistula diameter 3 mm, range 2–5 mm), treatment failure was observed in 2 patients in whom treatment was attempted early (15 days postsurgery). In the remaining 9 patients, treatment success was achieved (81.8% success rate) after a median of 2.5 (range 1–10) applications of silver nitrate. After 11 (0.5–24) months of follow-up, no relapse was observed among successfully treated fistulae. Conclusion The local application of silver nitrate through a flexible bronchoscopic brush produced a burn and healing process on the mucosa of small bronchopleural fistulae of the central airways, leading to effective and lasting treatment in most cases.

A chest tube is a flexible plastic tube that is inserted through the chest wall and into the pleural space or mediastinum. It is used to remove air in the case of pneumothorax or fluid such as in the case of pleural effusion, blood, chyle, or pus when empyema occurs from the intrathoracic space. It is also known as a Bülau drain or an intercostal catheter. Insertion of chest tubes is widely performed by radiologists, pulmonary physicians and thoracic surgeons. Large catheters or small catheters are used based on each situation that the medical doctor encounters. In the current review we will focus on the chest drain systems that are in use.

Background. The prognostic factors in thymic epithelial tumors (TET) are investigated within a 27-year period in 104 patients submitted to surgical and pathologic complete resection of TET with a mean age of 53 14.6 years and a male to female ratio of 0.73. Methods. The medical records of all patients were reviewed and six variables that could affect the shortterm and long-term survival were entered into a Cox regression model. Follow-up was obtained from medical records and telephone contacts up to September 2004 or until the patient’s death. Results. Overall 5-year and 10-year survival was 83% and 78%, respectively. Univariate Cox regression analysis showed that long survival was affected by the age of the patient at the time of operation, the response of myasthenia gravis to the operation, the tumor recurrence, the histologic type according to the World Health Organization (WHO) classification, and the Masaoka stage. Multivariate analysis revealed that recurrence of the tumor (p 0.001), Masaoka stages II or III (p < 0.001), elder age of the patient at the time of operation (p 0.045), and presence of the WHO histologic types B2 or B3 (p 0.05) were bad prognostic factors. Conclusions. Recurrence of the tumor, the Masaoka staging, the WHO histologic type, and the age of the patient at the time of operation were the most important prognosticators for patients with TET submitted to complete resection of their tumor. (Ann Thorac Surg 2005;80:1056 – 62) © 2005 by The Society of Thoracic Surgeons

In this study, the expression of cyclins D1 and D3, as well as cyclin-dependent kinase inhibitor p27 in thymic epithelial tumors (thymomas) is examined. Histological specimens from 24 patients (11 males and 13 females) were submitted to classification according to WHO criteria. Staining for cyclins D1, D3 and p27 was applied and evaluation was performed for expression of D1, D3 and p27. Eighteen patients presented low-grade thymomas (nine B1, predominantly cortical; three B2, cortical; six B3, well-differentiated thymic carcinoma) and six patients benign thymomas (four A-medullary, two AB-mixed). The p27 expression in patients with benign thymomas was 42+/-26%, whereas in patients with low-grade thymoma, it was 11+/-13%. The expression of cyclins D1 and D3 was 2.8+/-2.7 and 10+/-6% for benign as well as 8.3+/-9.6 and 12+/-10% for low-grade thymomas, respectively. A statistically significant difference was revealed regarding the p27 expression through different grades (analysis of variance P-value 0.00076) and histopathological types of thymomas (P=0.0047). This finding of greater p27 expression in benign thymomas with progressive reduction in higher grades is compatible with observations on other soft tissue and solid tumors suggesting that p27 level decreases during tumor development and progression.

A 68-year-old man presented with a suppurating mass on his skull and a palpable mass on his right upper thoracic wall. Computed tomography revealed a round mass, 70 mm in diameter, invading the right pleural cavity, and a second tumor infiltrating the skull through the left parietal bone. Both masses were resected simultaneously. Histopathology showed that both tumors were hepatocellular carcinomas.

Background Foramen of Morgagni hernias have traditionally been repaired by laparotomy, lapascopy or even thoracoscopy. However, the trans-sternal approach should be used when these rare hernias coexist with other cardiac surgical diseases. Case presentation We present the case of a 74 year-old symptomatic male with severe aortic valve stenosis and global respiratory failure due to a giant Morgagni hernia causing additionally cardiac tamponade. The patient underwent simultaneous repair of the hernia defect and aortic valve replacement under cardiopulmonary bypass. The hernia was repaired through the sternotomy approach, without opening of its content and during cardiopulmonary reperfusion. Conclusions Morgagni hernia can rarely accompany cardiac surgical pathologies. The trans-sternal approach for its management is as effective as other popular reconstructive procedures, unless viscera strangulation and necrosis are suspected. If severe compressive effects to the heart dominate the patient's clinical presentation correction during the cardiopulmonary reperfusion period is mandatory.

Background Adrenal cortex oncocytic carcinoma (AOC) represents an exceptional pathological entity, since only 22 cases have been documented in the literature so far. Case presentation Our case concerns a 54-year-old man with past medical history of right adrenal excision with partial hepatectomy, due to an adrenocortical carcinoma. The patient was admitted in our hospital to undergo surgical resection of a left lung mass newly detected on chest Computed Tomography scan. The histological and immunohistochemical study revealed a metastatic AOC. Although the patient was given mitotane orally in adjuvant basis, he experienced relapse with multiple metastases in the thorax twice in the next year and was treated with consecutive resections. Two and a half years later, a right hip joint metastasis was found and concurrent chemoradiation was given. Finally, approximately five years post disease onset, the patient died due to massive metastatic disease. A thorough review of AOC and particularly all diagnostic difficulties are extensively stated. Conclusion Histological classification of adrenocortical oncocytic tumours has been so far a matter of debate. There is no officially established histological scoring system regarding these rare neoplasms and therefore many diagnostic difficulties occur for pathologists.

A 75-year-old man with bilateral carotid stenosis and severe coronary artery disease underwent successful simultaneous bilateral carotid endarterectomy under local anesthesia. A few days later, coronary artery bypass grafting was performed with no complications.

The internal mammary artery is the conduit of choice for cardiac revascularization. Atherosclerotic disease of the coronary arteries may simultaneously involve the subclavian artery. Proximal stenosis in the left subclavian artery may result in recurrent myocardial ischemia in patients with a patent left internal mammary artery (LIMA), due to coronary steal syndrome through the LIMA.

Objective: To examine retrospectively the patients of our department who had a self-expandable totally covered metal stent placed for oesophageal leak. Methods: Patients hospitalised in our department for oesophageal cancer and/or oesophageal perforation between 2004 and 2006. All medical records were retrospectively reviewed. Seventy-two patients underwent oesophageal resection for oesophageal cancer and 16 were managed for oesophageal perforations. Results: Eight out of 72 patients submitted to resection for oesophageal cancer had postoperative leaks, while one patient developed tracheo-oesophageal fistula (TEF) due to prolonged mechanical ventilation. Six of them had stent placement in first intention, whereas two received the procedure after an unsuccessful repeat operation. The mean stent placement time was 18.4 days (SD = 15.2 days), whereas the median was 14 days. The leak was managed efficiently by the stent in seven patients, whereas two patients needed repeat operations (one with TEF). The mean stent removal time was 56.8 days (SD = 30.5 days) and the median was 40 days. None developed anastomotic stricture. On the other hand, three out of 16 patients with perforation had a stent, two of them for Boerhaave syndrome and one for iatrogenic rupture after bariatric surgery. One of them required the stent 17 days after surgical repair with excellent results, while the other two patients had the stent placed immediately, but still needed thoracotomy to control the leak. Conclusions: Stent placement can prove very useful in the management of post-oesophagectomy anastomotic leaks, but its contribution needs to be evaluated with caution in cases of oesophageal perforations or TEF. Larger series and prospective comparative clinical trials could eventually clarify the role of stents in clinical practice of surgical patients. # 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Chest wall desmoid tumors (DT) are rare pathologic entities with microscopic features similar to, or undistinguishable from, fibromas or fibrosarcomas. From 1996 to 2001, four patients with DT were surgically managed in our department. Their ages ranged from 27 years to 43 years (mean 32.25 years, median 29.5 years). A resection of the lesion was performed with negative margins of 4 cm around the tumor (wide resection). A reconstruction of the chest wall was also performed with polytetrafluoroethylene (PTFE) in 2 patients and methylmethacrolate with Marlex mesh in 1 patient. One patient had a recurrence 15 months later, and was admitted for complementary resection, and remains disease-free for 5 years. The rest 3 patients are disease-free for 6 months to 5 years. Resection must include all adjacent, overlying and underlying musculature as well as soft tissues and any spare skin from the procedure should be used. Prognosis after a wide resection is good.

A 45-year-old man, with severe thoracic injury from a motor accident, is reported with traumatic aortic dissection type B and projection of the liver into the thoracic cavity due to a large rupture of the right hemidiaphragm. The patient was successfully managed with endoluminal stent placement in the descending thoracic aorta, and right thoracotomy for the repair of the diaphragmatic hernia. His postoperative course was uneventful. The co-existence of aortic traumatic dissection and right diaphragmatic rupture in trauma patients has never been reported in the literature previously, to our knowledge. Furthermore, the initial x-ray examination findings advocated injury of the right hemithorax and could be misleading. The diagnostic assessment must have a high index of suspicion, whereas the surgical manipulation needs to be fast and targeted to the major thoracic injuries of the patient.

Background Teratomas are manifested with a great variety of clinical and radiological features, while sometimes they simply represent incidental findings. Case presentation A rare case of benign teratoma of the dermoid cyst type, in an adult 40-year-old female patient, is reported. The patient had presented recurrent pulmonary infections for the previous 2 months, persistent cough, and progressively aggravating dyspnea. A chest X-ray showed total atelectasis of the left lung, and the thoracic CT-scan revealed a huge mass, containing multiple elements of heterogeneous density, probably originating from the mediastinum, occupying the whole left hemithorax. The mass compressed the vital structures of the mediastinum, great vessels and airways, and a chest MRI was performed to accurately detect the anatomical relations. The patient underwent left thoracotomy and the tumor was totally resected. The size of the tumor was extremely large although no invasion to the vessels or to the airway had occurred. Adherence to the adjacent left pulmonary artery and left main bronchus was present, but without erosion or fistulization. The postoperative course was uneventful, while the histological examination confirmed a teratoma. Conclusion A teratoma is a non-homogeneous pathological entity, clinically, radiologically or histologically. It is predominantly diagnosed between the second and fourth decade and the incidence is equal for both sexes. Symptoms are absent in one half of the patients. The case reported is noteworthy as the tumor appeared with total atelectasis of the left lung, and symptoms started 2 months prior to diagnosis. Total removal of the tumor is adequate treatment for this type of teratoma and the prognosis is excellent.

A 58-year-old man was admitted with severe dyspnea on mild exertion. Multiple masses in both lungs were revealed on thoracic X-ray (Fig. 1a) and were confirmed on CT-scan (Fig. 1b). From the history of the patient, a bilateral resection of pulmonary neurofibromas 15 years ago was reported. VonReclinghausen disease did not exist. Rethoracotomies were performed, first from the right side and 3 months later contralaterally. Five neurofibromas were removed from the right lung, all of them with enucleation (Fig. 2) and three from the left lung, two of them with enucleation, and the other one with segmentectomy of the lingula. Postoperative course was uneventful, dyspnea was totally recessed, and the patient is doing well out of recurrence 2 years after the left thoracotomy. European Journal of Cardio-thoracic Surgery 24 (2003) 826 www.elsevier.com/locate/ejcts

A case of idiopathic subglottic tracheal stenosis in a 50-year-old female is presented. A procedure of single-stage resection of the lesion and end-to-end anastomosis was performed with excellent results 1 year after the operation. The clinical, paraclinical, diagnostic, therapeutic and histopathological aspects of this rare pathologic condition are discussed and the literature on this topic is reviewed.

An 84-year-old male was admitted to our hospital with right common carotid artery rupture after an unsuccessful attempt at hemodialysis catheter placement in the right internal jugular vein. He was hemodynamically unstable (blood pressure 55/35 mmHg) and mechanically ventilated. His hematocrit had dropped from 38% to 23% in 3 hours. His computed tomogram (CT) of the chest showed extensive hemorrhagic infiltration around the right common carotid artery (Panel A, arrow), which expanded into the mediastinum. Leak of the artery with pseudoaneurysm formation, angiographically proven (Panel B), was successfully excluded with selfexpanding covered stent placement (Panel C). The patient was transferred to the intensive care unit where his hematocrit and hemoglobin stabilized. He had a complicated post-procedural course, and ultimately succumbed 5 days later to respiratory and metabolic complications. Emergent carotid artery stenting has been reported in cases of acute carotid dissection with or without associated pseudoaneurysm, as well as in blunt carotid injury, and once in perforation complicating an elective carotid

One of a variety of clinical disorders representing congenital developmental malformations of the lymphatic system, lymphangiomatosis describes the presence of multiple lymphangiomas. It is associated with other lymphatic abnormalities, and 75% of cases involve multiple organs. It most commonly presents in childhood, with predilection for thoracic and neck lesions, with up to 75% of patients having bony involvement. 1

I read with great interest the article entitled ‘Occlusion of the abdominal aorta in a patient with chronic atrial fibrillation’ by Ma et al. [1] that reports a case of intracardiac (left atrial) thrombus with infrarenal occlusion of the abdominal aorta. The legend of Fig. 2 states that the occlusion is of embolic origin. However, the development of such a bypassing collateral vascular network is rather associated with a chronic occlusion. Embolism is an acute event in a patent vessel, manifests as acute aortic occlusion, bypass does not exist, and surgical removal of the emboli is imperative. Acute aortic occlusion (AAO) most commonly results from aortic saddle embolus, in situ thrombosis of a previously atherosclerotic abdominal aorta, sudden thrombosis of small abdominal aortic aneurysms, traumatic elevation of a distal aortic intimal flap, and other rarer etiologies that embolize to the aortic bifurcation. AAO is a different entity than chronic obstruction, where a well-developed collateral circulation may minimize symptoms [2]. The patient probably suffered from aorto-iliac occlusive disease (Leriche syndrome) with significant collateralization [3] and the chronic atrial fibrillation is not associated with the infrarenal aortic occlusion; it simply coexists as concomitant disease and shares common predisposing factors.

Clinical summary. A 19-year-old woman from Albaniawas admitted for respiratory distress. One month previously,she had a normal uncomplicated delivery. Fifteen days later,leg edema, left-sided chest pain, and progressive dyspneadeveloped. On admission, physical examination revealed anill-looking woman with a respiratory rate of 40 breaths/min, apulse rate of 150 beats/min, an arterial blood pressure of80/40 mm Hg, and a temperature of 38.3°C. Ascites andpleural fluid were detected on percussion and auscultation,and veins in the neck were dilated. Computed tomographic(CT) scan of the thorax demonstrated an extended mass of theanterior and middle mediastinum, exerting pressure on theright subclavian vein and superior vena cava. An extrinsiccompression on the right superior lobar bronchus, atelectasisof the middle lobe, and right pleural effusion were revealed(Fig 1). CT scanning of the abdomen showed extensivehepatomegaly and prominent abdominal effusion. Echo-cardiography revealed an extracardiac mass encircling theposterior surface of the right and left atria and partly encir-cling the right and left ventricles. This mass resulted in com-pression of the superior vena cava and distention of the infe-rior vena cava. On diagnostic aspiration, the pleural fluidThoracic actinomycosis is a rare pathologic condition fre-quently masquerading as cancer of the lung. The mistakendiagnosis may result in thoracotomy and pulmonary resectionas treatment, given that the majority of the cases initiallyremain undiagnosed. Because of the high mortality of the dis-ease, if untreated, it is imperative to obtain the diagnosis assoon as possible. Appropriate treatment may ensure a goodprognosis.