James H. Harrell

Bronchoscopy and transbronchial biopsy in evaluation of patients with suspected active tuberculosis.

Abstract To assess the value of fiberoptic bronchoscopy and transbronchial biopsy for evaluating patients suspected of having tuberculosis, we reviewed the records of 56 patients (1974–1980). All patients (1) were clinically suspected of having active tuberculosis; (2) had an abnormality on chest roentgenogram consistent with tuberculosis; (3) had an absence of acid-fast bacilli on three sputum smears or an inability to produce sputum; (4) had undergone fiberoptic bronchoscopy and transbronchial biopsy. The evaluations included fiberoptic bronchoscopy with collection of bronchial washings and brushings, and transbronchial biopsy and postbronchoscopy sputum specimens. Thirteen patients subsequently underwent percutaneous needle aspiration and one underwent thoracotomy. Evaluations were diagnostic in 29 of the 56 patients (52 percent). Diagnoses were mycobacterial infection in 22 (39 percent) and other disease processes in seven (13 percent). Fiberoptic bronchoscopy and transbronchial biopsy provided a diagnosis when sputum cultures obtained before bronchoscopy were negative for Mycobacteria in 11 (20 percent) patients. Immediate diagnoses were made from microscopic specimens obtained from 11 of 23 (48 percent) fiberoptic bronchoscopy and transbronchial biopsy procedures on patients with previously undiagnosed mycobacterial infection. Transbronchial biopsy had the best yield for a microscopic diagnosis. On culture, bronchoscopy specimens had a lower yield (10 of 23 or 44 percent) than sputum specimens obtained before bronchoscopy (14 of 21 or 67 percent) probably due to the inhibition of mycobacterial growth by tetracaine. Of the patients in whom evaluation proved nondiagnostic, 17 of 27 were lost to follow-up; therefore, a definitive statement regarding the number of false negative evaluations is not possible. Fiberoptic bronchoscopy and transbronchial biopsy (FFB/TBB) is a useful procedure in evaluating patients with negative smears who are clinically suspected of having tuberculosis. It can improve the ability to document active tuberculosis, provide a sensitive means of making an immediate diagnosis, and uncover other disease processes presenting like tuberculosis.

Airway stenoses after lung transplantation: Incidence, management, and outcome

OBJECTIVE Airway stenoses have been a significant cause of morbidity and mortality after lung transplantation. We reviewed our 11-year experience with dilatation and silicone stent treatment of airway strictures after lung transplantation. We adopted this approach after managing the complications of nitinol/wire mesh stents, including stent fracture, granulation tissue overgrowth, and difficulty with removal. METHODS Between January of 1996 and December of 2007, 240 patients underwent lung transplantation (132 single lung, 108 double lung; 121 male, 119 female; mean age 49.4 +/- 12.9 years). Twenty patients (8.3%) developed >50% stenosis in 22 airways over 35 to 135 days following surgery. Short and long-segment strictures were managed with rigid bronchoscopy, mechanical/laser debridement, balloon dilatation, and silicone stent placement. Mean follow-up was 4.9 +/- 3.5 years after stent removal. RESULTS The mean time to diagnosis of airway stenosis was 81.5 +/- 26.9 days. Pulmonary aspergillosis and pseudomonal infection, age less than 45 years, and early rejection correlated with airway stenosis; however, ischemic time, side of transplant, and preoperative disease did not. Airway patency and symptom improvement were achieved in 18 of 20 patients. Sixteen patients were able to have their stents removed at a mean of 362.3 +/- 126.4 days with permanent resolution of airway stenosis. Overall survival was similar for patients with and without airway stenosis. CONCLUSION Airway stenosis after lung transplantation can be successfully managed with bronchoscopic dilatation and temporary silicone stent placement. With time, most short and long airway stenoses resolve with atraumatic stenting of the affected areas. Removal of stents with permanent airway patency is achievable in most lung transplant recipients with airway stenosis.

PERCUTANEOUS NEPHROSCOPY USING FIBEROPTIC BRONCHOSCOPE Removal of Renal Calculus

A method for percutaneous removal of renal calculus within the collecting system is presented. Thus utilized, a flexible fiberoptic bronchoscope with fluoroscopic guidance provides a safe and quick alternative treatment to reoperative surgery for retained renal calculi.

Surgical Management of Endobronchial Inflammatory Myofibroblastic Tumors

BACKGROUND Endobronchial myofibroblastic tumors are neoplasms composed of clonal populations of smooth muscle cells and a variable lymphocytic inflammatory component. They represent a challenge with respect to diagnosis, classification, and surgical resection due to their infrequent occurrence. METHODS We retrospectively reviewed our experience with patients who had myofibroblastic tumors in the major airways over a 15-year period, in order to understand the incidence, natural biology, treatment, and long-term outcome of individuals with this type of neoplasm in an endobronchial location. RESULTS Between 1995 and 2010, 11 patients (9 female, 2 male) underwent surgical resection of a myofibroblastic tumor arising within the tracheobronchial tree. The mean age was 39.6 years (range, 22.3 to 53.6 years). All patients were symptomatic, with cough and dyspnea as the most common presenting complaints. Rigid bronchoscopy with endobronchial biopsy was utilized to establish the diagnosis in 9 of 11 patients. Laser-mechanical debulking was performed to relieve airway obstruction prior to operation in 10 of 11 patients. Because of wide submucosal infiltration of the neoplasms, surgical resection for complete removal was required for all individuals. Tracheal resection was performed in 3 patients, carinal resection in 1 patient, mainstem bronchial resection in 2 patients, sleeve resection in 3 patients, bilobectomy in 1 patient, and right lower lobectomy in 1 patient. Resection with tumor-free margins was accomplished in all patients. Mean tumor size was 2.3 cm (range, 1.5 to 3.5 cm). There were no operative deaths, with all patients alive and disease-free at a mean of 6.1 ± 3.7 years. CONCLUSIONS Complete surgical resection of inflammatory myofibroblastic tumors presenting in a major airway is safe and leads to excellent survival for patients with this uncommon disease.

Granulocytic sarcoma of the tracheobronchial tree: Bronchoscopic and pathologic correlation

Granulocytic sarcoma (GS) is an extramedullary, solid tumor composed of immature granulocytic cells, which occurs in association with myeloproliferative or leukemic disorders. GS can precede, accompany, or complicate the presence of hematologic malignancy in the blood or bone marrow. The anatomic distribution commonly includes bone, nerve, lymph node, and skin, but may involve a variety of soft tissues. Pulmonary involvement is uncommon but may invade the parenchyma, pleura, mediastinum, and airways. We report a rare case of endobronchial granulocytic sarcoma with bronchoscopic and pathologic correlation.

Endotracheal Castleman Disease: A Case Report

Castleman disease (CD) is an uncommon benign lymphoid hyperplasia with several clinical and morphologic variants associated with distinct outcomes. Pulmonary CD has been reported as a rare extranodal manifestation in the literature. However, CD presenting as an obstructive mass in the airway has not been documented. We report a case of localized hyaline-vascular CD presenting as an endotracheal lesion. The patient was a 50-year-old woman with Marfan syndrome. The lesion caused near-complete airway obstruction with respiratory insufficiency. The patient underwent laser resection, and the diagnosis of CD was supported by comprehensive studies including histopathologic, immunohistochemical, and molecular methods.

Selected ReportsEndotracheal Castleman Disease: A Case Report

Castleman disease (CD) is an uncommon benign lymphoid hyperplasia with several clinical and morphologic variants associated with distinct outcomes. Pulmonary CD has been reported as a rare extranodal manifestation in the literature. However, CD presenting as an obstructive mass in the airway has not been documented. We report a case of localized hyaline-vascular CD presenting as an endotracheal lesion. The patient was a 50-year-old woman with Marfan syndrome. The lesion caused near-complete airway obstruction with respiratory insufficiency. The patient underwent laser resection, and the diagnosis of CD was supported by comprehensive studies including histopathologic, immunohistochemical, and molecular methods.

Clinical Considerations when Herpes Simplex Virus Is Isolated from Bronchoscopy Specimens

Abstract: The purpose of this pilot study was to define the clinical relevance of herpes simplex virus (HSV) isolated from bronchoscopy specimens. A retrospective review of clinical characteristics, bronchoscopic features and outcome for 40 patients (24 patients with Acquired Immunodeficiency Syndrome (AIDS), 16 without AIDS) was conducted during an 18 month period in a major university hospital. HSV was isolated from bronchoscopy specimens from all patients in the study. Procedures included flexible fiberoptic bronchoscopy with bronchoalveolar (BAL) washings, brushings and/or bronchoscopic lung biopsy. Hospital records, clinical studies, potential risk factors for HSV infection, and results of bronchoscopic examination were reviewed. 20 patients were hospitalized in the Intensive Care Unit (4 with AIDS, 16 without AIDS). Bronchoscopy revealed raised white plaques with surrounding erythema in the airways of 17 (42.5%) patients. Other potentially pathogenic organisms were present in 30 patients (75%). Cytology revealed inflammation in 2 (8.3%) patients with AIDS and in 9 (56.3%) patients without AIDS. HSV-like cellular changes, however, were seen in only 14 patients (5 with AIDS, 9 without AIDS). The isolation of HSV from bronchoscopy specimens may have different clinical relevance for patients, depending upon host immune status and other underlying illnesses. Regardless, the determination of the clinical relevance of HSV isolation in bronchoscopy specimens is complex. The full spectrum of HSV-related lower respiratory infections can only be addressed by well-designed, prospective studies that address histopathology, operating characteristics of bronchoscopic appearance, selective sampling of various parts of the respiratory tract, and specific antiviral therapy.

Multifocal Endobronchial Fibromas Presenting as Unilobar Emphysema

Tracheobronchial fibromas are very rare, locally-invasive tumors of the airways. Fewer than 30 cases have been reported within the English-speaking literature. Historically, these neoplasms have been diagnosed as isolated endobronchial masses, with affected patients presenting with wheezing, cough, stridor, hemoptysis, dyspnea, or pneumonia. We report the case of 39-year-old man with multiple, synchronous endobronchial fibromas causing unilobar emphysema. A computed tomographic scan and bronchoscopy with biopsy were performed preoperatively to diagnose these lesions in the orifices of the anterior segment and the lingula within the left upper lobe. The patient underwent successful video-assisted left upper lobectomy, without recurrence at 3 years. This is the first report of a synchronous presentation of multiple pulmonary endobronchial fibromas within the same patient and the first report of endobronchial fibroma presenting as unilobar air trapping. Recognition of the unusual presentation of this uncommon pathology can lead to timely intervention.