Jorge Dionísio

Diagnostic flexible bronchoscopy and accessory techniques

We reviewed the most important diagnostic procedures implemented by means of flexible bronchoscopy, including bronchoalveolar lavage, bronchial brushing and biopsy, transbronchial lung biopsy and transbronchial needle aspiration. We reviewed the tools, techniques and potential complications of this examination.

Recurrent respiratory papillomatosis of the airway: The experience of an endoscopic unit

INTRODUCTION Recurrent respiratory papillomatosis (RPP) is a rare benign neoplasm caused by human papillomavirus (HPV). RPP is characterized by recurrent proliferation of the papillomata in the respiratory tract. OBJECTIVES AND METHODS Retrospective analysis of all adult patients with diagnosis of recurrent respiratory papillomatosis admitted to our endoscopic unit between 2000 and 2013 with histological proved papillomatosis. RESULTS Four patients were included (3 women) with an average age of 53±19 years (27-72). Before endoscopy unit admission, all the patients have been previously submitted to surgical removal of the papillomas with a median number of surgeries per patient of 6.5. These patients were submitted to therapeutic endoscopy and the most frequent endoscopic treatments were Laser YAG and local injection of cidofovir. All the patients treated with cidofovir presented complete remission of the disease. The median follow-up was 6 years: 2 presented malignant transformation to epidermoid carcinoma and 1 had severe dysplasia on the histological examination. We describe the four cases due to different forms of presentation. CONCLUSION Papillomatosis of the airway is a rare condition predisposing to malignant transformation. RRP tends to recur and repeated surgeries are needed to remove papillomatas. Endoscopic treatment is important for the removal of the papillomas that are not accessible via laryngoscopy (YAG Laser, cryotherapy, etc.) and for resistant moderate/severe cases of RPP because it allows intralesional administration of adjuvant therapy like cidofovir.

A Lymph Node Metastatic Lung Adenocarcinoma in a Previous Mediastinal Lymphoma

A 50-year-old female, smoker, with a past-history of a lymphocytic lymphoma in long last remission, presented with a tender large right lower neck mass, for which multiple fine needle aspiration cytology only disclosed necrotic material. Chest CT revealed a peripheral lung nodule, in right upper lobe (Fig. 1A), with multiple pathologic mediastinal lymph nodes (Fig. 1B). The EBUS allowed the identification and transbronchial needle aspiration (TBNA) of thoracic lymph nodes in station 4L, 4R, 7 and 11R (Fig. 1C). EBUS-TBNA in stations 4L, 4R, 7 and 11R was consistent with lymphocytic lymphoma confirmed by flow cytometry. However, in stations 4R and 11R lymph node infiltration, with metastatic TTF1+ lung adenocarcinoma, was also documented (Fig. 1D/E). Although carcinoma of multiple primary origins has been associated with previous or concomitant lymphoma, lymph node metastasis of adenocarcinoma in lymphomatous lymph nodes is a rare situation. Chronic immune suppression caused by lymphoma and/or cytostatic treatment seems a plausible predisposing factor for multiple primary tumors.1,2 This case highlights the need for a complete diagnostic work-up to elucidate the various clinical hypotheses, particularly in a nearby pathologic and draining territory.

Schwannoma endobronquial que involucra la carina

A 69-years-old male patient, non-smoker, with exertional dyspnea for the last 6 months, underwent a chest CT scan that revealed a large tumor mass under the carina with endobronchial involvement and obstruction of both main bronchi (Fig. 1a). Bronchoscopy showed two lobulated endobronchial masses protruding on each side of the main carina, with a bright, smooth, and highly vascularized surface. The masses extended 3 cm to the proximal segment of both main bronchi, producing a 90% bronchial lumen obstruction (Fig. 1b). The endobronchial component was treated with LASER photocoagulation and mechanical resection with significant desobstruction and symptom improvement. Histopathology revealed a benign schwannoma (fusiform cells with S100 expression). Definitive treatment consisted of carinal resection with reconstruction of a neocarina between the trachea and right and left main bronchi. Bronchoscopy 18 months after surgery showed a narrow right upper bronchus, straight intermediate bronchus, a S-shaped neocarina with a shifted left main bronchus (Fig. 1c and 1d). Endobronchial schwannoma is a rare entity, accounting for just 2% of benign tracheobronchial tumors. These tumors may affect any part of the tracheobronchial tree, with intra or extraluminal involvement.1 Clinical presentation depends on the tumor size and location. Treatment consists of surgical resection, especially in tumors with extraluminal extension.2

Doentes com neoplasia do pulmão de não pequenas células submetidos a tratamento com erlotinib – Casos clinicos

Resumo Apresentam-se quatro casos clinicos, da nossa expe-riencia do IPO, de doentes com neoplasia do pulmao nao pequenas celulas, tratados em segunda e terceira linhas com erlotinib. Sao doentes seleccionados em que se salienta a boa resposta ao tratamento instituido e a presenca de efeitos secundarios predo-minantemente cutâneos. Rev Port Pneumol 2008; XIV (Supl 3): S65-S69

Tuberculose das Cordas Vocais

Platelet derived serotonin (5HT) contributes to blood pressure elevation and the development of thromboembolic complications. Among the pathophysiological mechanisms involved in these vascular events, derangements in 5HT kinetics and exaggerated platelet response to 5HT may be part of the major triggering factors. An age-dependent attenuation platelet 5HT kinetics was revealed in normotensive control subjects but not in patients with essential hypertension. In older hypertensive patients, particularly in men, platelet 5HT uptake was decreased. In parallel, platelet reactivity was increased with advancing age as shown by a greater 5HT induced platelet aggregation and higher plasma concentration of beta-thromboglobulin. Antihypertensive treatment with the 5HT2-receptor antagonist ketanserin attenuated platelet 5HT turnover and inhibited 5HT induced platelet aggregation; the latter was more pronounced in older patients. The clinical efficacy and tolerability of ketanserin 20-40 mg twice daily given as mono- or combination therapy was evaluated in 188 patients with mild to moderate essential hypertension for a period of 12 weeks. A greater fraction of patients greater than or equal to 60 years achieved diastolic target pressure of less than or equal to 95 mgHg. Complaints related to the central nervous system or the peripheral circulation were greatly reduced in patients older than 60 years. In older patients, over and above the antihypertensive effect, 5HT2-receptor blockade may play an important role in the prevention of thromboembolic complications by inhibition of 5HT induced platelet activation.