Ben J. Venmans

Radiographically occult lung cancer treated with fibreoptic bronchoscopic electrocautery: a pilot study of a simple and inexpensive technique

The curative potential of bronchoscopic intervention, e.g. photodynamic therapy (PDT) and brachytherapy, for resectable radiographically occult lung cancer has been reported previously. Bronchoscopic electrocautery is currently feasible using an insulated flexible bronchoscope to coagulate and vaporize tumour tissue. Since the lesions are usually small, noninvasive bronchoscopic electrocautery may be able to eradicate radiographically occult lung cancer completely. In a prospective study, 13 patients with 15 radiographically occult lung cancer lesions were treated with bronchoscopic electrocautery. The duration of follow-up was > or = 16 months. The median age of the patients was 69 yrs (range 48-79 yrs). Fibreoptic bronchoscopy under local anaesthesia was used to coagulate the occult lung cancer. Approximately 30 W of energy was applied until visible necrosis of the tumour area became apparent. There were no immediate complications. In 10 patients with 12 lesions, a complete response (CR) was obtained (CR rate 80%; 95% confidence interval (95% CI) 52-96%). Median duration of follow-up was 21 months (range 16-43 months). Bronchoscopic electrocautery did not obtain a CR in the remaining three patients, but PDT also failed to achieve CR. Two patients underwent radical resection, and the tumours were histologically confirmed to be more invasive. One patient received external radiotherapy. Three patients with a CR died during follow-up, two as a result of myocardial infarction and apoplexy, and one because of metastasis from his previously resected T3N1 primary large cell cancer. Current data show bronchoscopic electrocautery to be equally effective and potentially as curative as photodynamic therapy for treating patients with radiographically occult lung cancer. Obvious advantages are that it is an inexpensive and simple procedure, which does not cause photosensitivity.

Bronchoscopic treatment of intraluminal typical carcinoid: A pilot study☆☆☆★

OBJECTIVE The curative potential of various bronchoscopic treatments such as Nd:YAG laser, photodynamic therapy, and brachytherapy for the treatment of intraluminal tumor has been reported previously. Bronchoscopic treatment can be used to treat small intraluminal tumor with curative intent, such as in patients with roentgenologically occult squamous cell cancer. In a retrospective study, we showed that bronchoscopic treatment provided excellent local control with surgical proof of cure in 6 of 11 patients with intraluminal typical bronchial carcinoid. METHODS In a prospective study, 19 patients (8 women and 11 men) with resectable intraluminal typical bronchial carcinoid have undergone bronchoscopic treatment under general anesthesia. Median age was 44 years (range, 20-74 years). If tumor persisted after 2 bronchoscopic treatment sessions, surgery was performed within 4 months after the treatment. RESULTS Bronchoscopic treatment was able to completely eradicate tumor in 14 of the 19 patients (complete response rate 73%, 95% CI: 49%-91%). Median follow-up of these patients is 29 months (range, 8-62 months). One patient had severe cicatricial stenosis after bronchoscopic treatment, and sleeve lobectomy was necessary. No residual carcinoid was found in the resected specimen. In the remaining 5 patients, bronchoscopic treatment did not result in a complete response and radical surgical resection was performed afterward with confirmation of residual carcinoid in the resected specimen. Median follow-up of the surgical group is 34 months (range, 12-62 months). CONCLUSIONS Current data suggest that bronchoscopic treatment may be an effective alternative to surgical resection in a subgroup of patients with resectable intraluminal typical bronchial carcinoid. It alleviated the necessity of surgical resection in 68% (95% CI: 43%-87%) of the patients.

Fluorescence bronchoscopy for early detection of lung cancer: A clinical perspective

The conventional method of bronchoscopy has only a 30% sensitivity to detect early stage cancer in the central airways. For patients with positive sputum cytology who clearly harbor early cancers, repeat and lengthy sessions of bronchoscopies are required for accurate localization of these lesions. This leads to a significant delay in obtaining the diagnosis, postponing an appropriate treatment and reduces the chance for cure. There are valid reasons for improving the detection rate of early stage lung cancers. The number of individuals at risk forms a large population, the outcome of patients treated with early stage cancer has been shown to be better and bronchoscopic treatments, e.g. photodynamic therapy and electrocautery, are currently alternatives for surgical resection. Finding more early stage cancers by screening the population at risk and accurate staging to enable treatment at the earliest stage feasible, may improve the dismal prognosis of many patients. This article deals with the clinical background and current problems in early detection of lung cancer and discusses our expectations regarding new developments in bronchoscopy for early detection, accurate staging and treatment of lung cancer.

Photodynamic therapy, Nd-YAG laser and electrocautery for treating early-stage intraluminal cancer: which to choose?

The degree of healing and damage of the bronchial wall after photodynamic therapy, Nd-YAG laser and electrocautery for intraluminal early-stage cancer have been analysed. Review of the bronchoscopy reports and follow-up histology specimens of twenty-nine patients treated bronchoscopically with curative intent for their intraluminal tumor have been performed. Seventeen patients had been treated with bronchoscopic electrocautery (BE) only, six with photodynamic therapy (PDT) and six with Nd-YAG laser. Bronchial wall scarring seen during follow-up bronchoscopy was scored and subepithelial fibrosis were histologically evaluated using Alcian blue staining, Azan staining and polarised light. After BE, prominent airway scarring was seen in five patients (29%), with significant stenosis (>50% lumen) in one of these cases. Prominent scarring and significant stenosis were found in four (67%), after PDT. In five (83%) after Nd-YAG laser prominent scarring was found, one patient had significant stenosis. In three cases, two after BE and one after PDT, subepithelial tissue in the follow-up biopsies was insufficient for proper histologic examination. In the remaining biopsy specimen only one (7%) showed a moderate or excessive amount of fibroblasts after BE, whereas for PDT and Nd-YAG this was found in three (60%) and four patients (67%), respectively. Excessive matrix was found in none of the biopsies after BE, in two (40%) after PDT and in three (50%) after Nd-YAG laser. Compact collagen formations were seen in two (12%) biopsies after BE, in two (40 and 33%) after PDT and Nd-YAG, respectively. Compared to electrocautery, more airway scarring and more subepithelial fibrosis were seen after treatment with PDT and Nd-YAG laser. These findings, especially regarding PDT, is in contrast to the assumption that PDT is selective and may be important in the choice of treatment for patients with early stage cancer.

Results of two years expenience with fluorescence bronchoscopy in detection of preinvasive bronchial neoplasia.

The aim of the study was to determine whether use of fluorescence bronchoscopy improves the detection of preinvasive neoplastic bronchial lesions. The data of all patients who underwent fluorescence bronchoscopy and in whom bronchial biopsies were taken, were analyzed. Most patients were at risk for preinvasive lesions. A total of 174 bronchoscopies were performed in 95 patients. Of the 681 representative biopsies, 31 were found to be moderate dysplastic, 39 were found to be severe dysplastic and 9 exhibited carcinoma in situ. These 79 preinvasive lesions were found in 34 patients. The respective results of fluorescence bronchoscopy in addition to conventional bronchoscopy and of conventional bronchoscopy alone for detection of preinvasive lesions were: sensitivity 85% (67/79) and 59% (47/79); specificity 60% (351/581) and 85% (493/581); positive predictive values of 23% (67/297) and 35% (47/135); negative predictive values of 97% (351/363) and 94% (493/525). A separate analysis of only the first bronchoscopy of each patient showed similar results. Results of fluoresence bronchoscopy were better in the second part of the patient group. We conclude that after a learning period fluorescence bronchoscopy can increase the yield of finding preinvasive neoplastic lesions when used in addition to conventional bronchoscopy.

Sleep complaints in postpolio syndrome

OBJECTIVE This study evaluated the prevalence of sleep-related and sleep-disordered-breathing (SDB)-related complaints in a group of postpolio patients compared with healthy controls. DESIGN A questionnaire, consisting of the validated Sleep Wake Experience List (SWEL), and a list of questions pertaining to sleep-disordered breathing (SDB), was mailed to a group of 43 postpolio patients. PARTICIPANTS The patient group consisted of 43 former polio patients who had been evaluated at a neuromuscular disease clinic in a tertiary referral center for new complaints of progressive muscle weakness. The patients were requested to select two healthy controls from their neighborhood who also filled out a questionnaire. RESULTS In the group of postpolio patients the frequency of tiredness on waking up and during the day, headache on waking up, daytime sleepiness, and restless legs was significantly higher compared with the control group. Complaints specifically related to SDB, such as apneas and snoring, were not mentioned significantly more often by the postpolio patients. CONCLUSION Up to half of postpolio patients report complaints of disordered sleep, which is likely to influence daytime functioning. Further studies, including sleep studies into SDB and restless legs, are necessary to elucidate the causes for these complaints.

Observer Variability in Histopathologic Reporting of Bronchial Biopsy Specimens: Influence on the Results of Autofluorescence Bronchoscopy in Detection of Preinvasive Bronchial Neoplasia

Abstract:To determine the influence of interobserver variability in histopathologic reporting of bronchial biopsy specimens on the results of autofluorescence bronchoscopy in detection of preinvasive bronchial neoplasia, we compared original histopathologic reports with reports of a review panel. Fo

Sleep complaints and sleep disordered breathing in hemodialysis patients

BACKGROUND The objective of the study was to determine the prevalence of sleep complaints and of sleep disordered breathing (SDB) in hemodialysis patients not selected for sleep complaints and to determine the effect of hemodialysis on SDB. The feasibility of home recording of sleep related respiration in these patients was also studied. METHODS The patients completed a questionnaire and parameters of SDB were examined in the home setting on nights following dialysis and nights following no dialysis with the Edentrace II Recording System. RESULTS Six (46%) of 13 patients had sleep complaints. Symptoms suggestive for sleep apnea syndrome were found in four (31%) of these 13 patients. In three (75%) of these four patients SDB was found. Sleep related respiration was monitored in 15 patients. Registrations satisfactory for interpretation were obtained in all patients. SDB was observed in five (33%) of these 15 patients. There were no significant differences in parameters of SDB between nights following dialysis and nights following no dialysis. CONCLUSIONS Home recording of sleep related respiration in hemodialysis patients is feasible. Sleep complaints and SDB are common in these patients. No clinically significant differences in SDB were found between nights following dialysis and nights following no dialysis.

Assessment of Sleep Complaints and Sleep-Disordered Breathing in a Consecutive Series of Obese Patients

Background/Objective: The prevalence of sleep-related complaints (SRC) and the frequency of sleep-disordered breathing (SDB) in obese patients has not been studied extensively. We investigated SRC and SDB in a group of obese persons as part of a preoperative workup for weight reduction (bariatric) surgery. Methods: All consecutive patients attending a weight-loss clinic for evaluation for bariatric surgery were asked to complete a questionnaire. The questionnaire consisted of a section on SRC and a validated general sleep questionnaire (Sleep Wake Experience List). The patients underwent sleep studies in which an Edentrace recorder registered heart rate, chest wall movements by impedance, airflow and oxygen saturation. Results: Fifty-one patients (14 men, 37 women) were evaluated. Mean body mass index (BMI) was 45 kg/m2 (range 33–61). Eighteen patients (35%) demonstrated SDB, defined as (a) an apnea/hypopnea index ≥5, and/or (b) more than 2% of registration time with an oxygen saturation below 90%. There was no difference between these 18 patients and patients who did not exhibit SDB in age, sex, BMI or SRC. Seven patients had SDB of a severity warranting closer investigation and perioperative monitoring. Conclusion: Both SRC and SDB are common in obese patients. Limited nocturnal respiratory monitoring is indicated as part of the preoperative workup for weight reduction surgery.