per cutaneous treatment of pulmonary hydatis

8/8/2019 Per Cutaneous Treatment of Pulmonary Hydatis

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Cardiovasc Intervent Radiol (1994) 17:271-275 CardioVascularand IntervenfionalRadiology9 Springer-Verlag N ew York Inc. 1994

Percutaneous Treatment o f Pulmonary Hydat id CystsO k a n A k h a n , ~ M u s t a f a N . 0 z m e n , ~ A l p D i n n e r, 1 A y h a n G 6 ~ m e n , 2 F u a t K a l y o n c u 3~Department of Rad iology, Hacettepe Un iversitesi, Tip Fakiiltesi, TR-06 100 Ankara, Tu rkey2Departmen t of Pediatric Chest Diseases, Hacettepe Universitesi, Tip F akiiltesi, TR-06 100 Ank ara, Turkey3Departmen t of Ch est Diseases, Hacettepe Universitesi, Tip Fakiiltesi, TR-06 100 Ank ara, Turkey

A b s t r a c tPurpose: T o e v a l u a t e t h e s a f e t y a n d e f f i c a c y o f p e r-c u t a n e o u s d r a i n a g e o f p u l m o n a r y h y d a t i d c y s ts .Methods: E l e v e n p u l m o n a r y h y d a t i d c y s ts i n e i g h t p a -t i en t s w e r e d r a i n e d p e r c u t a n e o u s l y a f te r 1 - 2 y e a r s o ft r e at m e n t w i t h m e b e n d a z o l e ( 5 0 m g / k g / d a y ) . P e r c u t a-n e o u s n e e d l e a s p i r a t i o n w a s c a r r i e d o u t u n d e r u l t ra -s o u n d ( U S ) i n s i x p at ie n t s an d c o m p u t e d t o m o g r a p h y( C T ) i n tw o p a t i en t s . N i n e c y s t s w e r e c l o s e t o , a n d t w oc y s t s w e r e d i s t a n t f r o m t h e t h o r a c i c w a l l. A f t e r a s p i -r a t io n , h y p e r t o n i c ( 1 5 % ) s a l in e s o l u t i o n w a s i n s t i l l e df o r u p t o 3 5 % o f t h e e s ti m a t e d v o l u m e o f t h e c y s t a n da s p i r a t e d 5 - 1 0 m i n l a te r . F o l l o w - u p r a n g e d f r o m 8 to3 1 m o n t h s ( m e a n 1 6 .3 m o n t h s ) .Results: N e i t h e r a n a p h y l a c t i c s h o c k n o r d e a t h o c c u r r e di n a n y o f t h e e i g h t p a t ie n t s . O n e p a t i e n t d e v e l o p e d f e v e r ,i p s i la t e r a l h y d r o p n e u m o t h o r a x , a n d c o n t r a la t e ra l p l e u r ale f fu s i o n . O n e p a t i en t s u f f e re d f r o m f e v er , p n e u m o t h o -r a x , a n d a b s c e s s a n d w a s t r e a t e d s u r g i c a l ly ; o n e d e v e l -o p e d f e v e r a n d d y s p n e a . T h e v o l u m e r e d u c t i o n d u ri n gf o l l o w - u p w a s 4 7 % - 9 3 % . T h e c y s t ic c o n t e n t s t u r n e di n to a p s e u d o t u m o r a p p e a r a n c e w i t h a th i c k i rr e g u l a rc o n t o u r o n C T a n d h i g h e r H o u n s f i e l d u n it s. O n U S , t h ec y s t s s h o w e d a h e t e r o g e n e o u s c o n t e n t w i t h i n t er n a l ec h -o e s r e p r e s e n t i n g d e t a c h e d a n d d e g e n e r a t e d m e m b r a n e s ,a n d t h e f lu i d c o n t en t a l m o s t c o m p l e t e l y d i s a p p e a r ed .Conclusion: W e b e l i e v e th a t p e rc u t a n e o u s t h e r a p y o fp u l m o n a r y h y d a t i d d i s e a s e i s a n e f f e c t iv e a l t e r n a ti v e tos u r g i c a l t r e a t m e n t i n p a t ie n t s w h o h a v e f a i l e d m e d i c a lt h e r a p y .K e y w o r d s : H y d a t i d c y s t, p u l m o n a r y , t r e a t m e n t - - P e r -c u t a n e o u s a s p i r a ti o n , n e e d l e

H y d a t i d d i s ea s e , ca u s e d b y Eccinoccocus granulosus,i s e n d e m i c i n s o m e c o u n t r i e s e s p e c i a l l y t h e M i d d l e

Correspondence to:Dr. O. Akhan

E a s t , t h e M e d i t e r r a n e a n c o u n t r i e s , S o u t h A m e r i c a ,N e w Z e a l a n d , a n d A u s tr a l i a . T h e m o s t c o m m o n l y i n -v o l v e d o r g a n s a r e l iv e r a n d l u n g s [ 1] .

T h e t r a d i t i o n a l t r e a t m e n t o f p u l m o n a r y e c c i n o c o c -c a l c y s t s i s s u r g i c a l , a s i n a b d o m i n a l h y d a t i d d i s e a s e[ 2, 3 ]. A l t h o u g h l o n g - t e r m m e d i c a l t r e a tm e n t w i t h m e -b e n d a z o l e o r a l b e n d a z o l e h a v e b e e n u s e d i n t h e la s t 15y e a r s , t h e r e s u l t s a re s t il l c o n t r o v e r s i a l [ 4 - 8 ] .

I n t h e r e c e n t l i t e r a t u r e , th e r e a r e s e v e r a l r e p o r t s o np e r c u t an e o u s t r e a t m e n t o f a b d o m i n a l h y d a t i d c y s ts a n du n i n t e n d e d p e r c u t a n e o u s a s p i r a ti o n o f p u l m o n a r y h y -d a t i d c y s ts [ 9 - 1 9 ] . T h e a i m o f t h is s t u d y w a s t o a s s e s st h e e f f e c t iv e n e s s o f t h e p e r c u t a n e o u s t r e a t m e n t o f p u l -m o n a r y h y d a t i d d i s e a s e a s an a l t e r n a t i v e t o s u r g i c a lt r e a t m e n t i n s e l e c t e d p a t i e n t s in w h o m m e d i c a l t re a t -m e n t h a d f a i l e d .

M a t e r i a l a n d M e t h o d sFrom Nov ember 1990 to June 1993, e ight pat ients (aged 7-5 5 years,three female, five male) with 11 pulmonary hydatid cysts were re-ferred for percutaneous treatment. Mebendazole (50 mg/kg/day) hadbeen g iven as medical treatment in six patients for 1 year and in twopatients for 2 years. One of the patients (patient 8) had undergonesurgery 3 years earlier. On e yea r thereafter, when two recurrent cystswere diagnosed, she was given mebendazole for 1 year. Medicaltreatment was con sidered ineffective so these patients were referredfor percutaneous treatment. Possible comp lications and results of sur-gical and percutaneous treatments were explained in detail to thepatients, and informed consent was obtained. Prior to the percuta-neous procedure, every patient had a PA chest radiograph, thoracicultrasound (US), and computed tomography (CT) for the diagnosisof hydatid cyst. One of the cysts was in the right lung, and 10 wereleft sided. All cysts were type I (pure anechoic cyst w ith well-definedborders) according to the classifications of Niron and Ozer or Gh arbiet al. [20, 21]. Nine cysts were close to, and two cysts were distantfrom the thoracic wall. One week before and after the percutaneousprocedure, the patients were given mebendazole orally (50 mg/kg/day) to prevent dissemination from leakage of cyst fluid [22]. Beforethe procedure, premedication with diazepam (5 mg) and atropine(0.25 mg) and a single dose of first-generation cephalosporine (2 g)were given intravenously. All the patients were monitored by an an-esthesiologist ready for intervention in case o f anaphylaxis.


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272 O. Akhan et al.: Percutaneous Treatment of Pulmonary HydatosisTable 1. Characteristics and procedural information for 11 percutaneously aspirated echinococcal cysts in eight patients

Preprocedure cyst Complication Cough Postprocedure cyst VolumePatient during Follow-up reduction# Type Size (ram) Vol. (cc) Minor Major procedure (months) Type Size (mm) Vol. (cc) rate (%)1 I 3 0 x 3 0 x 32 14 - - + 31 IV 14 x 16 x 11 1 932 I 31 x 30 x 33 15 - - - 23 IV 27 x 27 X 22 8 473 I 85 z 63 x 75 198 Feve r RP effu sion + 20 IV 47 X 26 29 17 91

! 54 X 54 X 50 71 LHP T IV 31 x 29 X 25 11 854 I 59 X 47 x 50 68 - - - 18 IV 44 x 19 X 20 8 88

I 5 0 X 3 3 x 35 28 IV 52 X 24 X 20 12 575 I 97 X 81 X 100 385 Feve r Pneu motho rax - Opera tedAbscess6 I 37 x 28 X 25 13 - - - 10 IV 28 X 22 X 20 6 547 I 100 X 90 X 95 419 Fe ver - - 8 IV 60 X 40 50 59 86Dyspnea8 I 40 x 33 X 35 23 - - - 8 IV 30 X 27 30 12 48

I 3 7 X 3 2 X 35 20 IV 29 X 25 25 9 55RP: right pleural effusion; LHPT: left hydropneumothora x; Vol.: estimated volume = A x B X C x 0.49 10 3 (A, B, C in mm and volumein cubic cm)Postprocedural measurements are obtained at the last follow-up time indicated in the table

Percutaneous needle aspiration was carried out under US guid-ance in six patients and CT guidance in two patients. Under standardsterile conditions, 2% lidocaine was used for local anesthesia at theselected puncture point. PAIR (puncture--aspiration of cyst con-tents--injection of hypertonic saline solution--reaspiration) tech-nique, described in previous reports [23], was used for theprocedures. An 18-gauge (g) Seldinger needle was used for punctur-ing the cysts close to the thoracic wall whereas a 22-g Chiba needlewas preferred for the cysts located deeply. After the needle was inthe correct position, hydatid fluid was aspirated as much as possibleand this was followed by instillation of hypertonic saline solution(15% NaC1) for up to 35% of the estimated cyst volume. The salinesolution was aspirated after 5-10 rain. After evacuating the cysticcontent, the needle was withdrawn.The follow-up was carded out by clinical and radiological eval-uation. PA chest radiograms, US, and CT were performed every 3months for the first year after the procedure and twice annually inthe following years. The follow- up ranged from 8 to 31 months ( mean16.3 months). During the follow-up, changes in size, content, andwall of the cysts were assessed.

Fig. 1. A CT scan of a 32-year-old woman prior to the procedureshows a round, left pleural based hyperdense mass (14 HU). B CTscan 16 months after aspiration shows the same mass (63 HU) withsignificant size and volume reduction.

Results

The r esu l t s a r e summar ized in Tab le 1 . Nei ther ana-phy lac t ic shock nor death o ccur red in any o f the e igh tpatients . Dyspnea, as a minor al lergic reaction, wasseen in one pat ien t (pa t ien t 7 ). Fe ver was no ted in th reepatients (up to 38.5~ and subsided withou t treatment.Two pat ien ts s tar ted coughing and expe cto ra ted cys tcon ten ts ( f lu id and membra~es) af ter hydat id f lu id as-pirat ion or hyper tonic sal ine inject ion, as air enteredinto the cyst ic cavity. One patient (patient 3) had one


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O. Akhan et al.: Percutaneous Treatme nt of Pulmona ry Hydatosis 273

Fig. 2. Tho racic US (A) and CT (B) of a 10-year-old boy show around cystic mass (12 HU) on the left side prior to treatment. C Ninemonths after the percutaneou s aspiration, US show s a sm all hypo-echoic lesion with irregular contour and internal echoes representingdegenerated laminated and ge rminative mem branes. D C T sho ws asmall hyperdense lesion with 85 HU absorption value. Volume re-duction rate is 88%.

small cys t in the r ight lung and two cysts in the left .We per formed percutaneous t rea tment of the l e f t cys t swhere only one was in contac t wi th the thorac ic wa l l .Af te r the procedure , p leura l e f fus ion occur red on ther ight s ide and hydropneumothorax on the l e f t . The hy-dropneumothorax was t rea ted by a ches t tube (22 F r )which was removed 24 h l a t e r . No recur rence was en-counte red dur ing a fo l low-up per iod of 20 months (F ig.1) . In another pa t i en t (pa t i en t 5) , pos tprocedure pneu-moth orax oc cur red on the ips il a t e ra l side. A ches t tubewas inse r t ed for 2 days . Whi le the pneumothorax wast rea ted , an absces s deve loped in the cys t cavi ty . Al -though percu taneous d ra inage of the absces s was of -fered, the pat ient went to surgery 10 days la ter . Noviable pro toscol i ces were found in the cavi ty f lu id. Ex-cept for pa t i en t 5 , hospi t a l i za t ion was l imi ted to 1-2days .

The s i ze of 10 cys t s was reduced cons iderably . Thi sreduct ion was found to be s ignif icant on a t - tes t andWi lco xon t es t (p < 0 .05) . The volu me reduc t ion rangedbe twee n 47% and 93% (mean 70 .4%) . Four of the 10cys t s conta ined var i ab le amou nts o f a ir up to 18 monthsafter the procedure. Later , a l l 10 cys ts turned into asmal l mass (pseudotumor appearance) wi th a th ick i r -regula r contour on C T and had h igher Houns f ie ld uni t s.

Cys t s in contac t wi th p leura had a he te rogeneous so l idappearance represent ing de tached and degenera tedm e m b r a n e s , a n d t h e f l u i d c o m p o n e n t a l m o s t c o m -ple te ly d i sappeared on US ( type IV , according to Ghar -b i ' s c l as s if i ca tion) (F ig. 2) . Th e w al l th icknesses of thecys t s were inc reased on fo l low-up US and CT.

Discussion

Pulmonary hyda t id cys t s ra re ly hea l by spontaneousevacua t ion in to the bronchus . However , in t rabronchia lrupture , anaphylac t i c reac t ion , rupture in to the p leura lcavi ty wi th hydropneumothorax , rupture in to the me-dias t inum wi th sudden occ lus ion of bronchus or t ra -chea , infec t ion , lung absces s , and bronchiec tases a rese r ious and poss ib ly fata l compl ica t ions of pulmon aryhydat id cys ts [3] .

The t rad i t ional the rapy for pulmon ary hyda t id cys t si s surg ica l , a s i t i s for abdomina l hyda t id cys t s . How-ever , pos topera t ive compl ica t ions a re s een in 3 .5% o fpa t i en t s and the repor ted 30-d ay m or ta l i ty ra te i s 1 .7%and 2% in two se r i es [3] . Though l a rge se r i es of sur -g ica l ly t rea ted pulmonary hyda t id cys t s have been re -


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274 o. Akhan et al.: Percutaneous Treatmentof Pulmonary Hydatosisp o r t e d , t h e r e i s a l a c k o f e x t e n d e d f o l l o w - u p d a t ai n c l u d i n g r e c u r r e n c e r a t e s.

M e d i c a l t r e a t m e n t ( m e b e n d a z o l e a n d a l b e n d a z o le )i s th e t r e a t m e n t o f c h o i c e i n p u l m o n a r y h y d a t i d d i s e a s e .T h e r e s u l t s o f th i s t r e a t m e n t a r e a l so v a r i a b l e [ 4 - 8 ] .T o d o r o v e t a l . [4 ] r e p o r t e d th a t 3 7 o f 5 6 p u l m o n a r yc y s t s ( 6 6 % ) d i s a p p e a r e d a f t e r m e d i c a l t h e r a p y w i th m e -b e n d a z o l e , w h e r e a s n o c h a n g e w a s s e e n i n 1 7 ( 3 0 % ) .W i t h a l b e n d a zo l e , t h e y o b s e r v e d d i s a p p e a r a n c e o f 2 0o u t o f 2 4 c y s t s ( 8 3 % ) . T h e s u c c e s s o f t r e a t m e n t w i t hb e n z e m i d a z o l e - c a r b a m a t e s d e p e n d s h i g h l y o n t h e l o -c a l i z a t i o n o f t h e c y s t s : I n p a t i e n t s t r e a t e d w i t hm e b e n d a z o l e , s u c c e s s f u l r e s u l t s w e r e o b s e r v e d i n 2 1 %o f p u l m o n a r y , b u t o n l y 7 % o f l i v e r e c h i n o c o c c o s is . A 1-b e n d a z o l e w a s s u c c e s s f u l i n t h r e e o f f o u r ( 7 5 % ) l u n g ,a n d i n 2 1 % o f l i v e r e c h i n o c o c c o s i s [ 6] . G r q m e n e t al .[ 7 ] r e p o r t e d t h a t 3 0 c h i l d r e n w i t h p u l m o n a r y h y d a t i dc y s t s w e r e g i v e n m e b e n d a z o l e ( 5 0 m g / k g / d a y ) w i t h am e a n t r e a t m e n t t im e o f 1 1 . 7 m o n t h s . A l l b u t o n e o f t h ep a t i e n t s h a d n e a r l y c l e a r c h e s t r a d i o g r a p h s w i t h a s m a l lf i b r o t ic b a n d . A l t h o u g h p u l m o n a r y h y d a t i d c y s t s a r em o r e r e s p o n s i v e t o m e d i c a l t r e a t m e n t w i t h m e b e n d a -z o l e o r a l b e n d a z o l e , t h e r e a r e s t i l l m o r e p u l m o n a r yc y s t s t h a t a r e n o t a f f e c t e d b y m e d i c a l t r e a tm e n t .

P e r c u t a n e o u s a s p i r a t i o n o f a h y d a t i d c y s t i s g e n e r -a l ly n o t r e c o m m e n d e d b e c a u s e o f t h e r is k o f a n a l l e r g icr e a c t i o n , w h i c h c a n b e s e r i o u s , a n d b e c a u s e o f t h e d a n -g e r o f s p r e a d i n g t h e d i s e a s e b y s p i l l i n g c y s t c o n t e n t s .H o w e v e r , t h e r e h a v e b e e n s e v e ra l r e p o rt s o f p e r c u t a -n e o u s t h e r a p y o f l i v e r h y d a t i d c y s t s w h i c h w e r e n o tc o m p l i c a t e d b y a l l e r g i c r e a c t i o n o r s p i ll a g e o f t h e c y s tc o n t e n t s [ 9 - 1 3 ] . I n a n e x p e r i m e n t a l s t u d y o n s h e e p ,d i s s e m i n a t i o n a n d a n a p h y l a c t i c r e a c t i o n s w e r e n o ts e en , a n d p e r c u t a n e o u s t r e a tm e n t o f a b d o m i n a l h y d a t i dc y s t s w a s f o u n d s a f e a n d e f f e c t i v e [ 1 4 ] . L e w a l l a n dM c C o r k e l l [ 1 8 ] s t a te d t h a t 4 o f t h e i r 2 4 p a t i e n t s( 1 6 . 7% ) w i t h r u p t u r e d h y d a t i d cy s t s h ad s y m p t o m s o rh i s t o r y o f a n a l l e r g i c e p i s o d e f o l l o w i n g c y s t r u p t u r e ,b u t n o n e h a d f a t a l a n a p h y l a x i s . I t c o u l d b e c o n c l u d e dt h a t p e r c u t a n e o u s a s p i r a t i o n o f a h y d a t i d c y s t i s n o tn e c e s s a r i l y f o l l o w e d b y a n a n a p h y l a c t i c r e a c ti o n . U n -f o r t u n a t e l y , s e r o l o g i c a l o r i m m u n o l o g i c a l t e s ts p l a y n or o l e i n p r e d i c t i n g a n a n a p h y l a c t i c r e a c t i o n [ 1 6 , 1 7] .

T r a n s b r o n c h i a l a s p i r a t i o n o f p u l m o n a r y h y d a t i dc y s t s w a s r e p o r t e d b y 6 ~ e r e t a l . [1 5 ] in 1 9 7 7 . F i f t e e no f t h e 1 7 c y s t s w e r e s u p e r i n f e c t e d w i t h o u t v i a b l e p a r-a s i te s , w h e r e a s t h e r e m a i n i n g 2 h a d i n t a c t g e r m i n a t i v em e m b r a n e s . S i x o f 1 7 c a s e s e x p e c t o r a t e d a l l o f t h e c y s tc o n t e n t i m m e d i a t e l y a f t e r t r a n s b r o n c h i a l a s p i r a t i o n o ra c o u p l e o f d a y s l a t e r. N o m e n t i o n o f a l le r g i c r e a c t i o nw a s m a d e i n t h i s r e p o r t .

T r a n s t h o r a c i c a s p i r a t i o n o f a p u l m o n a r y h y d a t i dcys t was f i r s t r epo r t ed in 1982 [16 ] . In a l a t e r r epo r t ,t h r e e v i a b l e , n o n i n f e c t e d e c h i n o c o c c a l c y s t s o f t h e l u n gw e r e u n i n t e n t i o n a l l y p u n c t u r e d b y t r a n s t h o r a c i c a s p i -r a t i o n . T h e r e w a s n o a l l e r g i c r e a c t i o n d u r i n g o r a f t e r

t h e p r o c e d u r e . C y s t o b r o n c h i a l c o m m u n i c a t i o n w a ss e e n i n a l l t h r e e c a s e s . T h e f o l l o w - u p o f t h e p a t i e n t sr a n g e d f r o m 2 m o n t h s t o 3 y e a r s . T h e r e w a s n o e v i -d e n c e o f d i s e a s e s p r e a d d u r i n g f o l l o w - u p [ 1 7 ] . U n i n -t e n t i o n a l p e r c u t a n e o u s a s p i r a t i o n o f a p l e u r a l h y d a t i dc y s t w a s r e p o r t e d b y K a r a w i e t a l . [1 9 ] w h o p e r f o r m e dr e p e a t e d a s p i r a t i o n o f p l e u r a l e f f u s i o n c a u s e d b y h y -d a t i d d i s e as e . W h e n t h e y p r o v e d t h e e x i s t e n c e o f p le u -r a l h y d a t i d d i s e a s e , s u r g i c a l t r e a t m e n t w a s p e r f o r m e d .T h e r e w a s n o p l e u r a l r e c u r r e n c e d u r i n g 4 2 m o n t h s o ff o l l o w - u p .

L e w a l l a n d M c C o r k e l l [ 1 8] r e p o r t e d t h a t c o m m u n i -c a t i o n b e t w e e n t h e c y s t a n d t h e b r o n c h i a l t r e e m a yb e e s t a b l i s h e d b y b r o n c h i o l e s i n c o r p o r a t e d i n t h ep e r i c y s t . C o m m u n i c a t i n g r u p t u r e i n t o t h e l u n g w i l ll e a d t o e x p e c t o r a t i o n o f f lu i d a n d m e m b r a n e s , a n dm a y r e s u l t in e v a c u a t i o n a n d c u r e o f t h e c y s t. T h e r ew a s n o e v i d e n c e t h a t tr a n s b i l i a r y o r tr a n s b r o n c h i a ld i s p e r s i o n o f s c o l e c e s c a u s e s d i s s e m i n a t i o n o f e c h i n -o c o c c a l d i s e a s e .

I n o u r s t u d y , w e p e r f o r m e d p e r c u t a n e o u s t re a t m e n to f 1 1 p u l m o n a r y h y d a t i d c y s t s in e i g h t p a t i e n t s. O n e o ft h e m , w i t h a p r e v i o u s h i s t o r y o f s u r g e r y , h a d r e c u r r e n td i s ea s e , a n d s e v e n o f t h em , w h o h a d b e e n g i v e n m e -b e n d a z o l e f o r m o r e t h a n 1 y e a r , h a d n o s i g n o f i m -p r o v e m e n t . B e f o r e a sp i r a t io n , p a t i e n ts w e r e g i v e nm e b e n d a z o l e ( 5 0 m g / k g / d a y ) f o r 1 w e e k i n o r d e rt o d e c r e a s e t h e p o s s i b i l i t y o f s p r e a d i n g e c h i n o c o c c a lcys t s [23 ] .

D u r i n g t h e p r o c e d u r e a n d f o l l o w - u p , w e e n c o u n -t e r e d n e i t h e r a n a p h y l a c t i c r e a c t i o n n o r r e c u r r e n c e o fd i s e a s e. M i n o r c o m p l i c a t i o n s , s u c h as f e v e r a n d d y s p -n e a , o c c u r r e d i n th r e e o f e i g h t p a t i en t s . A s m a j o rc o m p l i c a t i o n s , w e e n c o u n t e r e d a n i p s i l a t e r a l h y d r o -p n e u m o t h o r a x a n d a c o n t r a l a t e r a l p l e u r a l e f f u s i o n i no n e p a t i e n t ( p a t i e n t 3 ) a n d a p n e u m o t h o r a x o n t h e i p -s i l a t e ra l s ide in ano the r (pa t i en t 5 ) .

B a c t e r i a l i n f e c t i o n is t h e m o s t s e r i o u s c o m p l i c a t i o no f r u p t u r e ( s p o n t a n e o u s o r i a t r o g e n i c ) o f t h e h y d a t i dcys t s [18 ] . In th i s s e r i e s , we on ly gave a s ing le dos e o fp r o p h y l a c t i c a n t i b i o t i c ( f i r s t g e n e r a t i o n c e p h a l o s p o -r i n e ) . B u t a s d e m o n s t r a t e d i n o n e p a t i e n t ( p a t i e n t 5) , as i n g l e d o s e c o u l d n o t p r e v e n t a b s c e s s f o r m a t i o n . A l -t h o u g h i n s o m e c a s e s a l l t h e f l u id c o n t e n t o f t h e c y s tw a s a s p i r a t e d , e a r l y a f t e r t h e p e r c u t a n e o u s p r o c e d u r e ,s e r o u s f l u i d w i t h o u t m i c r o o r g a n i s m s a n d h y d a t i d sr e f il l ed a l m o s t 3 0 % - 4 0 % o f t h e c a v it y . T h i s f l u idg r a d u a l l y r e s o l v e s s p o n t a n e o u s l y d u r i n g f o l l o w - u p ( u n -p u b l i s h e d d a t a ) . I n p a t i e n t 5, t h e a s p i r a t e d c y s t w a s o n eo f t h e t w o l a r g e s t in o u r s e r ie s . W e t h i n k t h a t t h e l a r g e rt h e a m o u n t o f s e r o u s f l u i d r e a c c u m u l a t i o n t h e g r e a t e rt h e r i s k o f i n f e c t i o n . I f w e h a d g i v e n t h e p a t i e n t a n t i -b i o t i c s f o r a l o n g e r p e r i o d , t h e a b s c e s s m a y h a v e b e e na v o i d e d .

F o u r o f t h e 1 0 c y s t s c o n t a i n e d v a r i a b l e a m o u n t s o fa i r u p t o 1 8 m o n t h s a f t e r th e p r o c e d u r e . B e c a u s e i n t r a -


5/5

O . A k h an e t a l. : Pe rcu t an eo u s Trea t men t o f Pu l mo n a ry H y d a t o s i s 2 7 5

c a v i t a r y p r e s s u r e , w h i c h c a n b e a s h i g h a s 1 0 0 c m H 2 0 ,i s r e d u c e d b y r e m o v i n g s o m e c y s t f l u id , a ir m a y e n t e rt h e c y s t i c c a v i t y f r o m a b r o n c h u s o f t h e p e r i c y s t , w h i c hw a s c o m p r e s s e d b e f o r e t h e p r o c e d u r e . A c c o r d i n g t oo u r o b s e r v a t i o n , a i r m a y e n t e r t h e c y s t i c c a v i t y e i t h e rd u r i n g ( t w o p a t i e n t s ) o r a f t e r ( t w o p a t i e n t s ) t h e p r o c e -d u r e .

D u r i n g t h e f o l l o w - u p , a l l 1 0 c y s t s s h o w e d n o s i g no f v i a b l e s c o l i c e s o n U S a n d C T . I t h a s b e e n s h o w nt h a t s i g n i f i c a n t s i z e a n d v o l u m e r e d u c t i o n , s o l i d i f i c a -t i o n , a b s e n c e o f f l u id c o m p o n e n t , a n d a t h i c k , i r r e g u l a rc o n t o u r a r e s i g n s o f h e a l i n g [ 1 4 ] . U n d e r t h e s e c r i t e r ia ,w e h a d a r e m a r k a b l e c u r e r a t e o f 9 1 % ( 1 0 o f 1 1 c y s t s) .

T o o u r k n o w l e d g e , t h i s i s t h e f ir s t s y s t e m a t i c s t u d yo n p e r c u t a n e o u s t r e a t m e n t o f p u l m o n a r y h y d a t i d c y s ts .W e b e l i e v e th a t p e r c u t an e o u s t r e a t m e n t o f p u l m o n a r yh y d a t i d c y s t s i s t h e t r e a t m e n t o f c h o i c e i n c a s e s w h e r et h e c y s t i s r e s i s t a n t t o m e d i c a l t r e a t m e n t . T h e f e a r o fs e r i o u s a n a p h y l a c t i c r e a c t i o n s a s s o c i a t e d w i t h t h e p e r -c u t a n e o u s t r e a t m e n t a p p e a r s u n f o u n d e d u n d e r t h e t r e at -m e n t r e g i m e n w e a p p l i e d . A s t h i s s t u d y c o n t a i n s o n l ya l i m i t e d n u m b e r o f p a t i e n t s , f u r t h e r i n v e s t i g a t i o n i sn e e d e d .

Re fe r enc e s1 . M a t o ss i o n RM, R i ck a rd MD , Sm y t h JD (1 9 7 7 ) H y d a t id o s i s : Ag l o b a l p ro b l em o f i n c rea s i n g i mp o r t an ce . W H O C h ro n 5 5 : 4 9 9 -5 072. D o,a n R, Yt iksel M, ~e t in G, Sfizer K, Alp M, Kay a S, Onl t iM, Mo l d i b i B (1 9 8 9 ) Su rg i ca l t re a t men t o f h y d a t i d cy st s o f t h e

l u n g : Rep o r t o n 1 0 55 ca se s . Th o rax 4 4 : 1 9 2 - 1 9 93 . A y t aq A , Y u rd ak u l Y , i k i z l e r C , O l g a R , Say l am A (1 9 7 7 ) Pu l -mo n a ry h y d a t i d d i sea se : Rep o r t o f 1 0 0 p a t i en t s . A n n Th o racS u r g 2 3 : 1 4 5 - 1 5 14 . To d o ro v T , V u t o v a K , Mech k o v G , Pe t k o v D , N ed e l k o v G ,To rch ev Z (1 9 9 0 ) Ev a l u a t i o n o f re sp o n se t o ch emo t h e rap y o fh u ma n cy s t i c ech in o co cco s i s . B r J Rad i o l 6 3 : 5 2 3 -5 3 15 . D e Ro sa F , T eg g i A (1 9 8 5 ) F i r s t ex p e r i en ce i n t h e t rea t men t o fh u ma n h y d a t i d d i sease w i t h meb en d azo l e . D ru g s Ex p t l C l i n Res1 2 : 8 7 5 - 8 7 86 . D av i s A , Paw l o w sk i ZS, D i x o n H (1 9 8 6 ) Mu l t i cen t re c l i n i ca lt r ia l s o f b en z i mi d azo l eca rb ama t e s i n h u m an ech i n o co cco s i s .B u l l W o r l d H e a l th O r g 6 4 : 3 8 3 - 3 8 8

7 . G t q m en A , To p p a re MF, K i p e r N (1 9 9 3 ) Trea t men t o f h y d a t i dd i sea se in ch i l d h o o d w i t h meb en d azo l e . Eu r Res J 6 : 2 5 3 -2 5 78 . Sah i n A A , Se l g u k ZT, K a l y o n cu A F, ~ t p l t i L , Em ri S , Baf i~ Y I(1 9 9 3 ) Trea t men t o f Ech i n o co ccu s g ran u l o su s cy s t s ( l e t t e r ) .Scan d J In fec t D i s 2 5 : 2 6 99 . Mu e l l e r PR , D aw so n SL , Fe r ru c i JT , N a rd i G L (1 9 8 5 ) H ep a t i cech i n o co cca l cy s t : Su ccess fu l p e rcu t an eo u s d ra i n ag e . Rad i o l o g y1 5 5 : 6 2 7 - 6 2 81 0 . Bre t PM, Fo n d A , Bre t ag n o l l e M, V a l e t t a PS , Th i e sse P , Lamb er tR , Lab ad i e M (1 9 8 8 ) Pe rcu t an eo u s a sp i ra t i o n an d d ra i n ag e o fh y d a t i d cy s ts i n l i v er . Rad i o l o g y 1 6 8 : 6 1 7 - 6 2 011. Fi l ice C, Pi ro la F, Brunet t i E, Dughet t i S, St rosel l i M, Fogl ieriCS (1 9 9 0 ) A n ew t h e rap eu t ic ap p ro ach fo r h y d a t i d l i v e r cy s ts .G as t ro en t e ro l o g y 9 8 : 1 3 6 6 -1 3 6 81 2 . A k h an O , D i n q e r B , O zmen M, S ay ek l , G t q me n A , ~ ek i rg e S ,K i p e r N , Bes i m A (1 9 9 2 ) Pe rcu t an eo u s t rea tmen t o f ab d o mi n a lcyst ic hydat id d isease . Cardiovasc In tervent Radio l (abst ract )15(suppl ):S301 3 . A cu n a~ B , Ro zan es I , ~ e l i k L , M i n a rec i O , A cu n a~ G , A l p e r A ,A r i o ~ u l O , G t k men E (1 9 9 2 ) Pu re l y cy s t i c h y d a t i d d i sea se o ft h e l i v e r : T rea t men t w i t h p e rcu t an eo u s a sp i ra t i o n an d i n j ec t i o no f h y p e r t o n i c sa li n e . Rad i o l o g y 1 8 2 : 5 4 1 -5 4 31 4 . A k h an O , D i n q e r A , G t k t z A , Say ek I , H av l i o ~ l u S , A b b aso ~ l uO , Ery i l maz M , Bes i m A , Ba r i~ J (1 9 9 3 ) Pe rcu t an eo u s t rea t men to f ab d o mi n a l h y d a t i d cy s t w i t h h y p e r t o n i c sa l i n e an d a l co h o l :A n ex p e r i m en t a l s tu d y i n sh eep . In v es t Rad i o l 2 8 : 1 2 1 -1 2 71 5 . O ~ e r O (1 9 7 6 ) Lu n g en ech i n o k o k k u s : d i ag n o s t i sch e u n d t h e ra -p eu t i sch e Mo eg l i ch k e i t en m i t t e ls p e f i p h e re r K a t h e t e rau g b i o p s i e[A sp i ra t i o n b i o p sy i n t h e d i ag n o s i s an d t rea t men t o f l u n g ech i -n o co ccu s d i sea se ] . Prax Pn eu mo l 3 0 : 2 9 2 -3 0 01 6 . S t amp fe l G (1 9 8 2 ) A n ap h y l ak t o i d e Reak t i o n a l s se lt en e K o m-p l i k a t i o n d e r Lu n g en - fe i n n ad e l p u n k t i o n [A n ap h y l ac t o i d reac -t i o n : A ra re co mp l i ca t i o n a f t e r f in e n eed l e b i o p sy o f t h e l u n g ] .R a d i ol o g e 2 2 : 3 2 9 - 3 3 01 7 . McCo rk e l l SJ (1 9 8 4 ) U n i n t en d ed p e rcu t an eo u s a sp ira t i o n o f p u l -mo n a ry ech i n o co cca l cy s t s. A JR 1 4 3 : 1 2 3 -1 2 61 8 . Lew a l l D B, M cCo rk e l l SJ (1 9 8 5 ) Ru p t u re o f e ch i n o co cca l cy s t s:Diagnosis , c lassi f ica t ion , an d c l in ical impl icat ions. A JR1 4 6 : 3 9 1 - 3 9 41 9 . K a raw i MA , E l Sh i eh h Mo h amm ed A R, E1 Tay eb BO , Y asaw yMI (1 99 1 ) U n i n t en t i o n a l p e rcu tan eo u s a sp i ra t i o n o f a p l eu ra l h y -d a t i d cy s t s . Th o rax 4 6 : 8 5 9 -8 6 02 0 . N i ro n EA , O ze r H (1 9 8 1 ) U l t ra so u n d ap p ea ran ce o f l i v e r h y d a t i dd i sease . B r J Rad i o l 5 4 : 3 3 5 -3 3 82 1 . G h a rb i H A , H u ss i n e W , Brau n e r MW , D u p u ch K (1 9 8 1 ) U l t ra -so u n d ex ami n a t i o n o f t h e h y d a t ic l i v er . Rad i o l o g y 1 3 9 : 4 5 9 -4 6 322. Sayek I , (~akmak~i M (1 986) The effect of prophy lact ic meben-d azo l e i n ex p e r i men t a l p e r i t o n ea l h y d a ti d o s i s . Su rg G y n eco l O b -s t e t 1 6 3 : 3 5 1 -3 5 32 3 . Ben A m o r N , G a rg o u r i M, G h a rb i H A , G h a rb e l A , G o l v an Y I ,H amm u -Jed d i H , K i l an i M, Lah mar S (1 9 8 6 ) Tra i t men t d u k y s t eh y d a t i q u e d u fo i e d u mo u t o n p a r p o n c t i o n so u s 6 ch o g rap h i e. LaTu n i s i e Med i ca l e 6 4 : 3 2 5 -3 3 1

per cutaneous treatment of pulmonary hydatis

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