DOI: 10.3897/folmed.68.e172308

Authors: Vladimir Aleksiev, Daniel Markov, Kristian Bechev, Boyko Yavorov, Filip Shterev

Abstract: Introduction: Malignant pleural effusions (MPEs) are a frequent complication of cancer, causing significant morbidity and representing a major diagnostic challenge. Tumor markers in pleural fluid have been studied, but their interrelationships remain poorly understood. Aim: To investigate the correlations among commonly used tumor markers in pleural effusions and to assess their potential role in differentiating malignant from benign cases. Materials and methods: A cross-sectional case-control study was conducted on 151 Bulgarian patients with hydrothorax. The control group consisted of 72 patients with benign pleural effusions (38 inflammatory, 34 non-inflammatory), while 79 patients had malignant pleural involvement. Correlation analysis was applied to evaluate the relationships between carcinoembryonic antigen (CEA), CA19-9, CA72-4, CA125, CA15-3, and PIVKA-II. Results: Significant moderate positive correlations were found between CEA, CA19-9, CA72-4, and CA125, indicating overlapping tumor biology. CA125 also correlated with CA15-3, consistent with their role in epithelial malignancies. In contrast, PIVKA-II showed no significant correlation with other markers, suggesting limited utility in pleural malignancy diagnosis. These findings point to both redundancy and complementarity among tumor markers. Conclusions: Tumor markers in pleural fluid, particularly CEA, CA125, CA19-9, and CA72-4, may provide valuable diagnostic information when assessed together. Their interrelationships support the rational selection of marker panels to improve diagnostic accuracy for MPEs. PIVKA-II appears less informative in this setting. Understanding these correlations may enhance minimally invasive diagnostic strategies and contribute to more personalized management of pleural malignancy.

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DOI: 10.3897/folmed.68.e146872

Authors: Dimcho Argirov, Vladimir Aleksiev, Boyko Yavorov

Abstract: Hydatid disease is a parasitic infection in humans caused by Echinococcus granulosus and can lead to tissue cyst formation anywhere in the body. The most common sites for the development of parasitic cysts are the liver (75%) and lungs (15%). Skeletal involvement in echinococcal infection is relatively rare, occurring in only 1%–4% of cases. Few reports in the available medical literature describe rib hydatidosis, which clinically mimics benign or malignant cystic tumors. We present the case of a 73-year-old female patient who underwent multiple surgeries for pulmonary and hepatic echinococcosis. She was treated with albendazole (800 mg daily) and underwent computed tomography, which revealed cystic formations in the chest wall, including lysis of a thoracic vertebra and adjacent rib arches, interpreted in the differential diagnosis as pulmonary carcinoma or pleural mesothelioma. Surgery facilitated both diagnosis and treatment. Six months postoperatively, no recurrence in the chest wall was observed. Hydatid cysts occurring in the chest wall are rare and should be included in the differential diagnosis of chest wall formations, particularly in endemic areas and in patients with a history of hydatid disease.

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DOI: 10.3897/folmed.67.e139306

Authors: Ivoslav Ivanov, Dimo Mitev

Abstract: Small cell carcinoma is a disease mainly of pulmonary origin, but in extremely rare cases it can also be observed as a primary mediastinal mass. Here, we present the case of a 48-year-old male patient with a clinical manifestation of superior vena cava syndrome and a CT scan showing a tumor mass in the upper mediastinum compressing the major vessels. A surgical intervention was performed – videomedistinoscopy with partial excision of the tumor from which primary small cell neuroendocrine carcinoma of the mediastinum was detected during histological and immunohistochemical analysis. Multimodal treatment was administered, and after the surgical intervention, the patient was treated with chemotherapy and radiotherapy. The patient was actively monitored, and 8 months after diagnosis, there was a lack of persistent symptoms. From the monitoring PET/CT scan, a minimal single focus with metabolic activity in the mediastinum was observed with significant reduction in tumor size and lack of compression on the mediastinal vessels.

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DOI: 10.3897/folmed.67.e145825

Authors: Vladimir Aleksiev, Daniel Markov, Boyko Yavorov, Kristian Bechev, Galabin Markov, Filip Shterev, Dimcho Argirov

Abstract: Introduction: Malignant pleural effusions are a common and debilitating complication of advanced malignancies, affecting approximately one million patients annually. This condition leads to significant morbidity and a decline in quality of life. Accurate diagnosis and effective management are critical yet challenging due to the overlap in biochemical markers between malignant and benign pleural effusions. Aim: This study evaluates an extended panel of biochemical parameters, including albumin gradient, total protein, cholesterol, pH, glucose, specific gravity, and lactate dehydrogenase (LDH), to enhance diagnostic precision. Materials and methods: In order to achieve this, we conducted a cross-sectional, observational case-control study in order to analyze pleural fluid samples from 151 Bulgarian patients, including 79 with malignant effusions and 72 with benign effusions. Biochemical markers, such as albumin gradient, total protein, cholesterol, lactate dehydrogenase (LDH), pH, glucose, and specific gravity, were measured using advanced clinical chemistry analyzers. Statistical analyses, including Mann-Whitney U tests, t-tests, and Spearman’s rank correlations, were used to identify diagnostic markers. Results: The key findings highlighted the diagnostic value of albumin gradient, total protein, and cholesterol levels, which are strongly associated with malignant effusions. LDH and specific gravity also demonstrated potential as supplementary markers, while pH and glucose measurements showed limited utility in differentiating malignancy. Conclusion: Combining these biochemical parameters enhances the precision of pleural effusion analysis, offering a more robust framework for diagnosing and managing malignant pleural effusions effectively.

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DOI: 10.3897/folmed.67.e131189

Authors: Ivoslav Ivanov, Dimo Mitev

Abstract: Perforation of the hypopharynx is an extremely rare condition of various etiologies. In even rarer cases, it can lead to mediastinitis, a serious complication with a high mortality rate of up to 35%. We present a case of a 52-year-old male patient with a purulent descending mediastinitis caused by a rare condition of rupture of the hypopharynx after the ingestion of solid food. Mediastinal gas and fluid as well as pleural empyema were observed on CT scan. The case is unique because of the cervical surgical approach used to treat it, as well as a number of techniques that appear to control the infection and treat the source of mediastinitis. The patient recovered completely 20 days postoperatively and was followed up clinically and by computed tomography without persistent symptoms or late complications.

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DOI: 10.3897/folmed.66.e134503

Authors: Petar Uchikov, Nedzhat Ali, Milena Sandeva, Krasimir Kraev, Krasimira Eneva, Bozhidar Hristov, Mariya Kraeva, Elizabet Dzhambazova, Daniela Taneva, Tihomir Tenchev, Angel Uchikov

Abstract: Introduction: Hydatidosis is one of the most critical parasitic zoonotic diseases worldwide. Lungs are the second most common site of the disease. Aim: This study aimed to evaluate the clinical presentation, diagnosis, radiological findings, surgical treatment and post-operative complications of pulmonary hydatid cyst in patients referred to the Second Surgery Clinic at St George University Hospital in Plovdiv, Bulgaria. Materials and methods: From January 2014 to December 2022, 69 patients were operated on due to pulmonary hydatidosis in the Clinic of Thoracic and Abdominal Surgery at St George University Hospital in Plovdiv, Bulgaria. Demographic data of the patients were collected including clinical symptoms, laboratory studies, radiological findings, location of the lung involvement, and surgical procedures and post-operative complications were recorded. Results: Pulmonary hydatidosis was confirmed for 69 (46 male and 23 female) patients. The average age of the study group was 31.59±19.49 years. In 29 of the tested patients, specific antibodies of the IgG class to Echinococcus granulosus were positive, and 23 patients showed negative results. The leading symptom was non-productive cough followed by shortness of breath, chest pain, fever, productive cough; rash was reported in one patient. 91.3% of the cases presented with a typical X-ray image and in 8.7% it was atypical. It turned out that 66.7% of patients with an atypical X-ray findings developed complications in the postoperative period. Right lung was affected in 50.7% of the cases. The average size of the echinococcal cyst was 7.43±3.23 cm. Statistical analysis revealed a correlation between the size of the hydatid cyst and the length of the postoperative period. Dissemination in other organs was found in 16 of the patients. No statistically significant differences were reported in the patients with dissemination, regarding the size of the primary hydatid cyst, complications and duration of the postoperative period. The preferred methods of approach were thoracotomy and VATS. The most commonly performed surgical technique was echinococcectomy and capitonnage a modo Delbet followed by two lobectomies and one wedge resection. The mean postoperative period was 7.00±2.81 days. In 12 of the analyzed patients, complications occurred in the postoperative period, and mortality was reported in one patient. Conclusion: Pulmonary echinococcosis remains a significant health issue in many countries worldwide including Bulgaria. With a prolonged silent period, it is usually diagnosed when clinical symptoms as cough, dyspnea, chest pain and fever start manifesting. Plain chest radiography remains the basic imaging method for initial diagnosis while ELISA test has limited diagnostic accuracy in cases of pulmonary hydatidosis. Irrelevant to surgical approach, Delbet’s capitonnage procedure is associated with good postoperative results and low complication rates.

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DOI: 10.3897/folmed.66.e104433

Authors: Georgi Yankov, Magdalena Alexieva, Silvia Ivanova, Stefka Yankova, Evgeni Mekov

Abstract: Primary pulmonary synovial sarcoma is an extremely rare and aggressive neoplasm that primarily affects young people and has a poor prognosis. Establishing this diagnosis requires the exclusion of a wide number of other neoplasms with multimodal clinical, imaging, histological, immunohistochemical, and cytogenetic assessment. We present a case of synovial sarcoma of the left lung in a 44-year-old man, diagnosed immunohistochemically after left lower lobectomy with atypical resection of the 5th segment. Imaging, diagnostic workup, histological and immunohistochemical characteristics, surgical treatment, and prognosis are discussed.

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DOI: 10.3897/folmed.66.e121799

Authors: Anastas Chapkanov, Miroslava Todorova, Antoaneta Chirlova, Blagoi Marinov

Abstract: Introduction: Despite significant development in systemic therapy and radiotherapy, surgery is still the cornerstone for curative lung cancer treatment. Although predicted postoperative function (ppo) somewhat exactly correlates with actual postoperative function bigger differences may be a cause of serious clinical outcome. Aim: The aim of our study was to identify clinical factors affecting prediction accuracy of postoperative lung function for more careful selection of operable lung cancer patients. Patients and methods: Seventy patients were studied prospectively. The preoperative lung function tests (FEV1 and DL,CO) were performed within a week before surgery, and the follow-up tests were performed 4 to 6 weeks after surgery. Calculation of predicted postoperative values were calculated by three methods: two segment formulas and vibration response imaging (VRI). The correlation between each clinical parameter and accuracy of prediction was screened on univariate analysis of Pearson’s correlation coefficient, and significant factors were confirmed by multivariate linear regression analysis applying backward stepwise elimination approach. Results: Univariate linear regression analysis between the predicted and the actual postoperative values of FEV1% and DL,CO showed the highest prediction accuracy with acoustic mapping (VRI). Multivariate regression analysis showed that prediction accuracy of postoperative lung function is significantly affected by COPD (p<0.001) and volume of resection (p<0.001). Conclusion: Vibration response imaging (VRI) is a more accurate method for predicting postoperative lung function than segment method formulas. Anatomical calculation significantly underestimates the postoperative values of FEV1% in patients with COPD. Prediction of FEV1% and DL,CO with segment counting is significantly influenced by the volume of resection.

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DOI: 10.3897/folmed.66.e102981

Authors: Georgi Yankov, Magdalena Alexieva, Evgeni Mekov, Rosen Petkov

Abstract: Resection and reconstruction of the superior vena cava (SVC) are required in a selected group of patients with anterior mediastinal tumors and lung neoplasms. We present the case of a 63-year-old woman who underwent invasive type B2 thymoma resection and a rare type of reconstruction of the superior vena cava using a patch of the left brachiocephalic vein (LBV). The various types of reconstruction of the superior vena cava are discussed.

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DOI: 10.3897/folmed.65.e91076

Authors: Georgi Yankov, Magdalena Alexieva, Dinko Valev, Evgeni Mekov

Abstract: Foreign body (FB) aspiration is a rare incident in adults. Many patients cannot recall the episode of aspiration and are hospitalized with complications of an endobronchial FB. We present a case with right-sided chronic pleural empyema, ineffectively treated in another hospital with chest drainage, uniportal VATS, and insertion of five chest drains as a result of occult foreign body aspiration. Endoscopic extirpation of a foreign body in the right lower lobar bronchus was performed. Right posterolateral thoracotomy, decortication, and pleurectomy were performed because of a trapped right lung. Preoperative bronchoscopy is recommended in all patients with pleural empyema before surgery. When chest drainage and VATS are unsuccessful in expanding the lung in chronic empyema then thoracotomy, debridement, pleurectomy, and decortication are indicated.

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DOI: 10.3897/folmed.65.e93864

Authors: Georgi Yankov, Magdalena Alexieva, Silvia Ivanova, Nikolay Yanev

Abstract: Paraganglioma is a neuroendocrine tumor that originates from extraadrenal chromaffin cells. Primary thyroid paraganglioma is an extremely rare neoplasm. In this study, an exceptionally uncommon case of recurrent mediastinal malignant paraganglioma with primary origin from thyroid gland is presented. Median resternotomy, resection of left brachiocephalic vein, and extirpation of the mediastinal tumor were performed successfully. Commonly, it is preoperatively misdiagnosed and has unpredictable biological behavior. Incorrect diagnosis results in disastrous consequences for the patient, and consequently, correct pre- and postoperative diagnoses promise an optimal treatment plan and good prognosis. Long-term follow-up is indicated in all patients due to the risk of recurrence and distant metastases.

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DOI: 10.3897/folmed.65.e78431

Authors: Ivoslav Ivanov, Dimo Mitev, Rumen Filipov, Plamen Parvanov

Abstract: Cardiac luxation is a rare condition in cases of blunt thoracic trauma, yet it is quite fatal. We present a case of a 28-year-old man, admitted to the emergency room after a motorcycle accident in a hemodynamically unstable condition and radiographic presentation of multiple rib fractures, bilateral pneumothorax, pneumomediastinum, and significant dislocation of the heart to the right. After performing emergency bilateral tube thoracostomy and achieving hemodynamic stability, a CT scan was performed and the patient was diagnosed with pericardial rupture with right-sided luxation of the heart. An emergency sternotomy was performed with repositioning of the heart and pericardial reconstruction. In the postoperative period, suspicion of myocardial infarction was ruled out and the patient was discharged with persistent traumatic monoplegia of the left upper limb and Claude Bernard-Horner syndrome. An analysis of this very rare type of chest trauma has been made and the probable mechanism for its occurrence has been discussed.

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DOI: 10.3897/folmed.65.e76658

Authors: Ivoslav A. Ivanov, Dimo B. Mitev, Rumen A. Filipov

Abstract: Introduction: Tension pneumomediastinum is an increasingly common condition since the COVID-19 pandemic’s onset. It is a life-threatening complication with severe hemodynamic instability that is refractory to catecholamines. Surgical decompression with drainage is the key point of treatment. Various surgical procedures are reported in the literature, but no cohesive approach has yet been developed. Aim: The aim was to present the available options for surgical treatment of tension pneumomediastinum, as well as the post-interventional results. Materials and methods: Nine cervical mediastinotomies were performed on intensive-care unit (ICU) patients who developed a tension pneumomediastinum during mechanical ventilation. The age and sex of patients, surgical complications, pre- and post-intervention basic hemodynamic parameters, as well as oxygen saturation levels, were recorded and analyzed. Results: The mean age of patients was 62±16 years (6 males and 3 females). No postoperative surgical complications were recorded. The average preoperative systolic blood pressure was 91±12 mmHg, the heart rate was 104±8 bpm, and the oxygen saturation level was 89±6%, while the short-term postoperative values changed to 105±6 mmHg, 101±4 bpm, and 94±5%, respectively. There was no long-term survival benefit, with a mortality rate of 100%. Conclusions: Cervical mediastinotomy is the operative method of choice in the presence of tension pneumomediastinum allowing an effective decompression of the mediastinal structures and improving the condition of the affected patients without improving the survival rate.

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DOI: 10.3897/folmed.63.e54539

Authors: Serghei Covantev, Varvara Afanaseva, Alexandru Corlateanu

Abstract: Thymic cysts are a rare abnormality accounting for 1%–3% of all mediastinal masses. In most cases, they are asymptomatic and localized in the anterior mediastinum. Despite their benign nature, the presence of a mass is an indication for surgery to obtain a histological conclusion and reliably exclude an oncological process. Epidermoid cysts are rare and only a few cases are described in the literature. In our case report, we present a rare case of examination and treatment of a patient with a large anterior mediastinum mass, which, according to the results of histology, was an epidermoid cyst of the thymus.

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