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Adenoid Cystic Carcinoma Mimicking a Dermoid or Hydatid Cyst Oral Alpan and Selim Yalçin Chest 1993;103;983-984 DOI 10.1378/chest.103.3.983-b The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/103/3/983.2.citation

Chest is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright1993by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. (http://chestjournal.chestpubs.org/site/misc/reprints.xhtml) ISSN:0012-3692

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Table 1-Results of Spot U+inc&wa Sample

Subject

P, @ml

Cr, mdml

PICr, ng/mg/ml

1 2-12 13 14 15 16,17

HCW HCWs Patient Patient Patient Controls

2.62 0 30.2 84.7 30.7

1.62 0 1.17 2.94 5.2 0

1.625 0 25.8 28.8 5.97 0

0

P =pentamidine; Cr = creatinine; PICr =correction of pentamidine level for urinary creatinine concentration. were assayed by high-pressure liquid chromatography by Dr. G. Smaldone (Stony Brook, NY), who was blinded to the source of individual samples. Only in one sample from one of our HCWs was pentamidine detected at a level of 1.625 npjm@ml, approximately the same as the lower exposure levels in the study by O'Riordan and Smaldone. During the sampling day this HCW had been present during 35 individual treatments and had been present during some 790 treatments over the previous month. A subsequent sample on this HCW was negative later the same week. We consider administration of AP via the Fisoneb system, even in a high-volume clinic such as ours, to have negligible effects on individual HCWs. We agree that low-dose environmental exposure is inevitable, and that occasional higher levels due to environmental spillover should be expected, although they can be minimized. More important, we believe that breath-activated nebulizer systems, such as the Fisoneb system, are preferable because their very design significantly reduces environmental spillage, since they turn off after inspiration ceases or if coughing occurs.

R. Andrew Meloor, M.B., B.Ch., Leslie R. Lee hck, and Charks K. Chan, M.D.,F.C.C.E, lbronto Central Bntamidine Clinic, h t o , Ontario, C a d

a patient removes the device from his mouth in order to cough, he may neglect to switch it o@. Because of the design of the Fisoneb, such disconnected nebulization may be less likely to occur. 2. Another important difference between the studies is the design of the treatment rooms. We used a treatment room with an exhaust system that operated at 60 cu ftlmin. In contrast, McIvor et all had a specially designed treatment room that exhausted air at 450 cu ftl min during treatments. The frequency of air exchanges may be important. In our initial report of positive results in urine specimens from in HCWqP levels were higher at Stony Brook, where fewer treatments were administered but where the frequency of air exchanges was also less when compared with a Miami center, which had a more effective air exchange system but at which workers performed a much larger number of treatments. 3. In our study, HCWs supervised the treatments. In the Toronto study, the HCW was not in the room during treatments, which were self-administered by the patients. In general, because the possibility of disconnected nebulization is greatest during the absence of HCWs from the treatment room, it is usually recummended that HCWs not enter a room until two air exchanges have taken place following completion of an unsupervised treatment. This would take 20 min with our system. In Toronto, the more efficient exhaust system would markedly reduce the waiting time for two air exchanges. Thus, patient-administered treatments are likely to be much less hazardous to HCWs in Toronto than they wor~ldbe under our system. While the Toronto group should be congratulated on the effectiveness of their system in avoiding high exposures of HCWs to pentamidine, the conditions under which our HCWs administer pentamidine are, we believe, more typical of clinical practice than the conditions under which the Toronto group practices. Nevertheless, the simple precautions we advocated in our article can reduce the likelihood of high exposures with our system. We agree that chronic low-level exposure to pentamidine is inevitable and that the long-term consequences, if any, of this exposure are unclear at the present time.

? h m C . O'Riordan, M.B., and Gerald C . Smaldone, M . D.,Ph.D., RdnwnaylCritical Care Division, State Uniuersity of New York at Stony Brook, Stony Brook

REFERENCES 1 O'Riordan TG, Smaldone GC. Exposure of health care workers to aerosolized pentamidine. Chest 1992; 101:1494-99 2 Smaldone GC, Vinciguerra C, M o m L, Marchese L. Detection of inhaled pentamidine in health care workers. N Engl J Med 1991; 325891-92 3 Montaner J, Lawson L, Cervais A, Hyland RH,Chan CK, Falutz JM, et al. Aerosol pentamidine for secondary prophylaxis of AIDS-related Pneumocystis carinii pneumonia: a randomized, placebo-controlled study. Ann Intern Med 1991; 114:948-53 4 McIvor RA, Rachlis A, Berger P, Bonner M, Lee Pack L, Chan CK. Risk of second-hand exposure to aerosol pentamidine. J Aerosol Med 1992; 5:ll-7

REFERENCES 1 McIvor RA, Rachis A, Berger P, Bonner M, Lee Pack L, Chan CK. Risk of second hand exposure to aerosol pentamidine. J Aerosol Med 1992; 5:ll-7 2 Smaldone GC, Vinciguerra C, Morra L, Marchese J. Detection of inhaled pentamidine in health care workers. N Engl J Med 1991; 325:891-92

Adenoid Cystic Carcinoma Mimicking a Dermoid or Hydatid Cyst

lb the Editw: We thank Dr. McIvor and his coworkers for their interest in our study and for sharing their data. Analyzing random HCW urine specimens (assayed at our laboratory) from a large treatment center (up to 1,200 treatments per HCW per month), they found only one positive urine test for pentamidine in an HCW. There are three possible explanations for the differences in the two studies: 1.The Toronto group administered all treatments via the Fisoneb system, an ultrasonic nebulizer that only produces aerosol when a patient holds down a switch on the device. In our article we suggest that the most likely explanation for high-level intermittent exposure of HCWs to pentamidine is "disconnected nebulization" (ie, when

7b the Editor:

A 75-yearold nonsmoking male patient was admitted with the complaints of backache and clear, watery discharge on two occasions during coughing. Chest radiography revealed a mass lesion occupying almost all of the left hemithorax. A multiloculated cyst with solid components and calcified foci was observed on computed tomography of the thorax (Fig 1). Surgery was performed on the basis of the preliminary diagnosis of hydatid or dermoid cyst. Adenoid cystic carcinoma was found in the pathologic examination. Many cases of adenoid cystic carcinoma arising from the bronchial tree haie been reported.^; Few reports have described calcification. CHEST 1 103 1 3 1 MARCH. 1993

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983

of parented analgesics. The tube was clamped for 2 h, and the patient was repositioned frequently. Four of our 14 patients were men with an average age of 69 years and 10 were women with an average age of 70 years Ten patients had adenocarcinoma, and four had squamous cell carcinoma. AU patients reported pain: mild in ten cases, moderate in two cases, and severe in two cases In the 12 patients with fever, the temperature varied from 37.2% to 39.6OC during a period of 1to 3 days The pleural tube was retained for 1 to 4 days after the procedure. Follow-up data were available on ten patients In eight there was no relapse of effusion in a follow-up period of 7 to 180days (average, 43 days). We did not use preventive antibiotics, and we did not observe local or systemic infection in these ten cases. We think that the tetracycline powder can be used as a highly a c i e n t and lowcost alternative in these patients

Carlos Cunan, M.D.,and M.D.. Cesor Qui*. cunica Seroet. Sontiago. Chile

FIGURE 1. Computed tomo aphic scan shows a cystic mass, with calcification, closely resembfng a dermoid cyst. In most of the reported cases, solid components formed the bulk of the tumor. This case had some peculiarities Expectoration of clear, watery fluid was reported, and a large cystic mass with wall calcification was observed radiologically. It is concluded that adenoid cystic carcinoma may present with a cystic appearance mimicking a demoid or hydatid cyst on radiologic studies.

Oral Alpan. M.D., and Selim Y&n, M.D., Ataturk Chest Disease Center. Ankam, Arkey

REFERENCES 1 Enterline HT. Schoenberg HW. Carcinoma (cylindmmatoustype) of trachea and bronchi and bronchial adenoma. Cancer 1954; 7663-70 2 Gallagher CG, Stark R, Teskey J, Kryger M. Atypical manifestations of pulmonary adenoid cystic carcinoma. Br J Dis Chest l9M; 80:396-99

Tetracycline Pleurodesis Ib the Fditoc We read with interest the editorial by Heffier and Unruh.' which appeared in the January 1992 issue of Chest. The authors voiced their regret that injectable tetracycline hydrochloride has been discontinued by the sole manufacturer of the drug. This drug was used for patients with pneumothoraces and as the preferred method of chemical pleurodesis in patients with malignant pleural effusions.' Injectable tetracycline was not available to us for many years, but we replaced it with sterile tetracycline powder from D.S.A. Company (Hamburg, Germany). The vials are prepared as follows: (1)They remain at 120°C for 20 min. (2) They are cleaned externally with 4 percent chlorhexidine. (3) The rubber caps and aluminum seals are submitted to the same process. (4) The vials are transferred under ultraviolet light to a sterile area. where they are filled with the powder. Following the Sahn protom1,J we treated 14 patients with malignant a s i o n . We dissolved 1.5 to 2.0 g (20 to 30 m & g ) of tetracycline powder in 50 ml of saline, obtaining a solution with a pH of 2.2. The solution was instilled into the pleural cavity after intrapleuraladministration of 300 mg of lidocaine and administration

1 Heffner JE. Unruh LC. Tetracycline pleurodesis: adios, fueweu. adieu [editorial]. Chest 1992; 101:57 2 Kirby TJ, Ginsberg RJ. Management of pneumothom and barotrauma. Clin Chest Med 1992; 139'7-112 3 Sahn SA. Malignant pleural effusions. Clin Chest Med 1985; 6: 113-25

Adieu, Tetracycline Pleurodesis (But Not in Germany) Ib the Editor: I read with interest the editorial in the January 1992 issue of Chest in which Heffner and Unruh' bid a regretful h U to i n t r a p l e d tetracycline, since the injectable tetracychne hydrochloride used for pleurodesis has been discontinued by Lederle Laboratories, apparently the sole manufachver of the drug in the United States German chest physicians (and most likely colleagues from other European countries. too) do not need to share these h e U feelings since Gdnenthal still produces an intravenous tetracycline hydrochloride (Supramycin pro inhsione), which has always been used at our hospital for chemical pleurodesls It is the only injectable tetracycline left on the Germany market, bowever. Let us hope that Gr~nenthalwill continue production for the sake of patients requiring & c d o m and safe pleurodesis Ulrich Costabel. M.D.. EC.C.L.

Abteilung P n e u U e d o g i e . Ruhrlondklinik.

--w 1 HefFner JE.Unruh LC. Tetracycline pleurodesis: adios, h e l l . adieu [editorial]. Chest 1992; 101:5.7

Erratum The editors of Chart wish to apologize to N. Tony Eissa. M.D.. for misspelling his name in his article entitled "Effects of PEEP on Respiratory Mechanics after Open Heart Surgery" (Chart 1992; 102:227-33).

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Adenoid Cystic Carcinoma Mimicking a Dermoid or Hydatid Cyst Oral Alpan and Selim Yalçin Chest 1993;103; 983-984 DOI 10.1378/chest.103.3.983-b This information is current as of April 13, 2012 Updated Information & Services Updated Information and services can be found at: http://chestjournal.chestpubs.org/content/103/3/983.2.citation Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.chestpubs.org/site/misc/reprints.xhtml Reprints Information about ordering reprints can be found online: http://www.chestpubs.org/site/misc/reprints.xhtml Citation Alerts Receive free e-mail alerts when new articles cite this article. To sign up, select the "Services" link to the right of the online article. Images in PowerPoint format Figures that appear in CHEST articles can be downloaded for teaching purposes in PowerPoint slide format. See any online figure for directions.

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