Ton J. van Boxem

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.

Prevalence and severity of sleep disordered breathing in a group of morbidly obese patients.

Abstract Background: Obesity may be complicated by sleep disordered breathing (SDB). The presence of SDB is associated with increased morbidity and mortality. Patient characteristics, pulmonary function tests and daytime arterial blood gas analyses may help to identify patients with SDB. These variables and the prevalence and severity of sleep disordered breathing were studied in a group morbidly obese patients. Methods: Forty-eight patients, 19 men and 29 women who were referred to our clinic of internal medicine because of their obesity were included. Characteristics, pulmonary function tests and daytime arterial blood gas analyses of groups with different grades of SDB were compared. Results: Male subjects had significantly more apnoeas/hypopnoeas per hour (AHI) (18.4±20.9 versus 4.8±9.4) with more desaturation, a lower mean saturation (92.6±4.1 versus 96.1±1.6) and a lower saturation nadir (73,8±12,0 versus 83,1±6,7). Five (26%) of the male subjects and none of the female subjects had severe SDB (AHI ≥25). Subjects were divided into three groups according to the severity of their SDB: twenty-nine subjects (23 women and 6 men) with AHI Conclusion: Our study confirms the finding that morbidly obese men have SDB more frequently and more severely than obese women. Patient characteristics other than gender, pulmonary function tests and daytime blood gas analyses have no predictive value. (See Editorials p. 184, 188 and Original article p. 207)

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.

Endobronchial Electrocautery is an Excellent Alternative for Nd: Yag Laser to Treat Airway Tumors

Abstract The Nd:YAG laser is the most popular instrument to treat patients with intraluminal tumor in the major airways. It is usually performed under general anesthesia. Fiberoptic bronchoscopic electrocautery (FBE) under local anesthesia was shown to be effective in providing rapid palliation. We have studied prospectively the effectiveness of FBE for clearing intraluminal tumor. Patients with visible intraluminal tumor in the large airways were treated with FBE. ND:YAG laser equipment was kept ready for use during FBE sessions. A treatment session was terminated when significant tumor clearance had been achieved, or in cases with extraluminal tumor compression. Fifty-six patients, median age 64 years (range 20–90), were treated, and 82 FBE sessions were completed. Thirty-seven patients (66%) had intraluminal non-small-cell cancer, ten had typical carcinoid and the rest had miscellaneous tumors. Significant tumor clearance was documented in 39 patients (70%). The remaining patients proved to have extraluminal tumor. Ten sessions (12%) were completed under general anesthesia, in nine cases for the treatment of carcinoid. No conversion to Nd:YAG laser treatment was necessary, but additional Nd:YAG treatment was given to obtain more in-depth necrosis in one patient. A switch to rigid bronchoscopy was necessary to control bleeding in one patient. In this phase II prospective study, FBE achieved sufficient clearance of intraluminal tumor in the majority of patients who were considered to be Nd:YAG laser candidates. Our findings indicate that FBE may be competitive with Nd:YAG laser treatment for this category of patients. A randomized phase III study is underway.

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

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.

Bronchial Intraepithelial Neoplastic Lesions in Head and Neck Cancer Patients: Results of Autofluorescence Bronchoscopy:

To determine the efficacy of autofluorescence bronchoscopy for detection of bronchial intraepithelial neoplastic lesions in head and neck cancer patients, we analyzed data from head and neck cancer patients who underwent both white light bronchoscopy and autofluorescence bronchoscopy for the rates of detection of intraepithelial neoplastic lesions. The results of the histopathologic examination were compared with the bronchoscopic findings. The sensitivity for detection of intraepithelial neoplastic lesions was calculated. Eleven moderate dysplasias and 3 severe dysplasias were detected during 8 of the 42 bronchoscopic examinations (19%) in 6 of the 24 patients (25%). The sensitivities for white light bronchoscopy alone and for white light bronchoscopy combined with autofluorescence bronchoscopy for detection of intraepithelial neoplastic lesions were, respectively, 21% (3 of 14) and 57% (8 of 14). In short, bronchial intraepithelial neoplastic lesions were found in a considerable percentage of head and neck cancer patients. Use of autofluorescence bronchoscopy improved the detection of these lesions.

Exercise-induced spontaneous hemothorax insinuates trauma; yet unmasks a lament disorder

The investigation for a plausible explanation of the development of massive spontaneous hemothorax during exercise in two patients led to the disclosure of two different malignancies. The first patient (pleural fibrosarcoma) passed away shortly after diagnosis. The second patient is alive without signs of disease (peripheral neuro-ectodermal tumor, PNET) since the diagnosis was made 3 years before. Spontaneous hemothorax (SH) arising during exercise does not exclusively designate trauma and full search for anatomical abnormality is warranted.