Airway transplantation: a challenge for regenerative medicine

After more than 50 years of research, airway transplantation remains a major challenge in the fields of thoracic surgery and regenerative medicine. Five principal types of tracheobronchial substitutes, including synthetic prostheses, bioprostheses, allografts, autografts and bioengineered conduits have been evaluated experimentally in numerous studies. However, none of these works have provided a standardized technique for the replacement of the airways. More recently, few clinical attempts have offered encouraging results with ex vivo or stem cell-based engineered airways and tracheal allografts implanted after heterotopic revascularization. In 1997, we proposed a novel approach: the use of aortic grafts as a biological matrix for extensive airway reconstruction. In vivo regeneration of epithelium and cartilage were demonstrated in animal models. This led to the first human applications using cryopreserved aortic allografts that present key advantages because they are available in tissue banks and do not require immunosuppressive therapy. Favorable results obtained in pioneering cases have to be confirmed in larger series of patients with extensive tracheobronchial diseases.

18F-fluoro-2-deoxy-d-glucose positron emission tomography/computed tomography fused imaging in malignant mesothelioma patients: looking from outside is not enough

Malignant mesothelioma (MM) is an uncommon neoplasm with a poor prognosis usually associated with asbestos exposure. 18F-fluoro-2-deoxy-d-glucose (FDG) positron emission tomography (PET)/computed tomography (CT) has become an invaluable tool for the diagnosis, staging, and prognosis of this severe disease as it combines both anatomic and functional information in a single imaging procedure, allowing for improved management of this disease. For many authors, 18F-FDG-PET/CT is the cornerstone of the pre-therapeutic evaluation of mesothelioma patients, particularly when multimodal therapy (including extra-pleural pneumonectomy or omentectomy) is considered. However, while characteristic patterns have been reported as predictive of macroscopic pleural or peritoneal involvement, false negative findings are possible, both for pleural and peritoneal mesothelioma, during the initial diagnosis or during the patient's surveillance as illustrated by this report of three cases of suspected MM with negative PET/CT. This report highlights the limitations of PET/CT in the diagnostic evaluation of MM and the importance of histopathological confirmation by thoracoscopy and/or laparoscopy, which remain the most important diagnostic procedures in MM.

[Cost-effectiveness of lung volume reduction coil treatment in emphysema. STIC REVOLENS]

BACKGROUND

Medical therapeutic options for the treatment of emphysema remain limited. Lung volume reduction surgery is infrequently used because of its high morbi-mortality. Endobronchial lung volume reduction coil (LVRC(®), PneumRx, Mountain View, CA) treatment has been recently developed and has been shown to be feasible and associated with an acceptable safety profile, while resulting in improvements in dyspnea, exercise capacity and lung function. The objective of this study is to analyze the cost effectiveness of LVRC treatment in severe emphysema.

METHODS

This prospective, multicenter study, randomized with a 1:1 ratio (LVRC vs conventional treatment) will include 100 patients who will be followed up for 1year. The primary outcome measure is the 6-month improvement of the 6-minute walk test: the percentage of patients showing an improvement of at least 54m will be compared between groups. A cost-effectiveness study will estimate the cost of LVRC treatment, the global cost of this therapeutic option and will compare the cost between patients treated by LVRC and by medical treatment alone.

EXPECTED RESULTS

This study should allow validating the clinical efficacy of LVRC in severe emphysema. The cost-effectiveness study will assess the medical-economic impact of the LVRC therapeutic option.

Temporary endobronchial embolization with silicone spigots for moderate hemoptysis: a retrospective study

BACKGROUND

The management of airway bleeding is generally performed in an emergency to prevent hypoxemia and lung flooding. When the bleeding arises from peripheral lesions that are not visible endoscopically, bronchoscopic options have limited curative intents. Endobronchial embolization using silicone spigots (EESS) is a novel approach.

OBJECTIVES

We analyzed the efficacy and safety of EESS in a retrospective study.

METHODS

We retrospectively reviewed charts of patients referred to our center for moderate hemoptysis (MH) who underwent EESS. Successful management is defined as immediate bleeding cessation.

RESULTS

From December 2008 to January 2012, 9 patients were treated with EESS in our endoscopy unit. The MH originated from the left upper lobe in 4 cases, the right upper lobe in 3 cases and the right middle lobe and left lower lobe in 1 case each. Thirteen spigots were inserted. The success rate was 78%. Of the 9 patients, 7 were referred to interventional radiology for bronchial artery embolization, with a success rate of 86%, and 2 were referred for thoracic surgery. One patient had EESS as definitive treatment; the silicone spigots were bronchoscopically removed after a median of 4 days in 6 of the remaining 8 patients. Only 2 patients had hemoptysis recurrence after a median follow-up of 107 days (ranging from 13 to 1,017 days). None of the patients died from hemoptysis.

CONCLUSION

EESS is an original, temporary technique that requires only a flexible bronchoscope and biopsy forceps for placement and removal. EESS ensures airway protection while waiting for definitive management.

Lung cancer following bronchoscopic lung volume reduction for severe emphysema: a case and its management

Bronchoscopic lung volume reduction using endobronchial valves has been suggested as a potentially safer alternative to surgery in selected cases. Complications of this technique include pneumothoraces, pneumonia, COPD exacerbations, hemoptysis, and valve migrations. We report the case of a male patient who developed a parenchymal mass in the treated lobe after valve insertion. Due to severe emphysema, transthoracic needle aspiration was not feasible. Removal of the valves was mandatory to perform transbronchialbiopsies which revealed a non-small cell primary lung cancer. This first description illustrates the potential risk of lung cancer development following bronchoscopic lung volume reduction and highlights the different approach to diagnosis and management of indeterminate peripheral lung lesions needed in this context.

Endoscopic management of idiopathic tracheal stenosis

BACKGROUND

Idiopathic tracheal stenosis (ITS) is a rare condition representing a difficult therapeutic challenge. Endoscopic management is a therapeutic option but long-term results are not established. The aim of this retrospective multicenter study was to analyze long-term outcome after endoscopic management of ITS.

METHODS

Nine institutions involved in interventional bronchoscopy were contacted and asked to identify ITS endoscopically treated. A standard form was used to report the main characteristics and long-term outcome after endoscopic management.

RESULTS

Twenty-three patients, 96% women, aged 45±16 years, were endoscopically treated for ITS. Time between first symptoms and diagnosis was 19±18 months. Bronchoscopy showed a weblike (61%) or complex (39%) stenosis, located in the upper part of the trachea, mainly in the cricoid area. Endoscopic treatment included mechanical dilation only (52%) or associated with laser or electrocoagulation (30%) and stent placement (18%). All procedures were efficient. The follow-up after endoscopic management was 41±34 months. The ITS recurrence occurred in 30% at 6 months, 59% at 2 years, and 87% at 5 years, with a delay of 14±16 months. The treatment of recurrence (n=13) included endoscopic management in 12 cases.

CONCLUSIONS

Endoscopic management of ITS provides a safe and efficient therapeutic option but late recurrences are frequent and require long-term follow-up.

Thoracoscopic assessment of pleural tumor burden in patients with malignant pleural effusion: prognostic and therapeutic implications

BACKGROUND

Malignant pleural effusion (MPE) is encountered at an advanced stage of disease progression and often heralds a poor prognosis. The most reliable predictive factor of survival in such patients is the primary tumor. Thoracoscopy is often performed for accurate diagnosis and/or thoracoscopic talc insufflation as a therapeutic modality. It remains unknown whether pleural tumor burden, as visualized on thoracoscopy, has potential prognostic value. The objective of this study was to determine the prognostic accuracy of pleural tumor extent and localization (parietal, visceral, or diaphragmatic involvement), as assessed during medical thoracoscopy.

METHODS

Medical records of all patients who underwent thoracoscopy for suspicion of MPE between 2001 and 2008 at a tertiary care referral hospital were reviewed. Patients were included if pleural metastatic invasion was confirmed on tissue biopsy and survival status ascertained.

RESULTS

Four hundred twenty-one patients underwent diagnostic or therapeutic medical thoracoscopy at our referral center. Among them, 122 had confirmed metastatic pleural spread, but survival data were lacking in 15. Primary tumor consisted of non-mall cell lung cancer in 56, breast cancer in 23, melanoma in eight, and other malignancies in 20. Median survival of the entire population was 9.4 months. On univariate analysis, the following variables were significantly associated with reduced median overall survival: pleural metastatic melanoma, age less than 60 years, bloody MPE, extensive pleural adhesions, and widespread visceral pleural nodules (p < 0.05). On multivariate analysis, only melanoma as a primary tumor, pleural fluid appearance and extent of pleural adhesions remained independent and significant predictors of survival.

CONCLUSION

No significant association was found between the extent or localization of pleural tumor burden and overall survival.

Tracheal glomus tumor: a multidisciplinary approach to management

A 66-year-old man presented with acute respiratory distress due to a tracheal tumor involving the posterior wall of the upper trachea, with nearly complete airway obstruction. Partial debulking of the tumor's endoluminal component, via rigid bronchoscopy and yttrium-aluminum-perovskite laser, allowed timely and effective airway restoration. The diagnosis was benign tracheal glomus tumor. Two weeks later, elective tracheal sleeve resection with end-to-end anastomosis allowed complete resection of the lesion. No tumor recurrence was found at 21-month follow-up. We describe the multidisciplinary management of this extremely rare tracheal tumor, and review its features.

Use of a tunnelled pleural catheter for the management of refractory hepatic hydrothorax: a new therapeutic option

Refractory hepatic hydrothorax poses a challenging therapeutic dilemma, as treatment options are limited. Herein, we describe the case of a 48-year-old lady with advanced cirrhosis and recurrent transudative pleural effusion despite a sodium-restricted diet, optimal diuretic therapy and transjugular intrahepatic portosystemic shunt. Given the patient's platelet and coagulation disorders, thoracoscopic pleurodesis was deemed unsafe. Instead, a tunneled pleural catheter (PleurX®) was inserted under local anesthesia. Pleural drainage was achieved at the time of catheter placement and subsequently according to the patient's symptoms. Symptomatic improvement and gradual decrease of drainage volumes were noted. Six months following placement of PleurX, methicillin-resistant Staphylococcus aureus cellulitis at the insertion site prompted catheter removal. No pleural effusion was seen on chest X-ray at that time. Subsequent follow-up revealed spontaneous pleurodesis, as no recurrence of pleural effusion was seen over a 6-month follow-up period. Very few data are available with regard to the use of indwelling pleural catheters for benign transudative pleural effusion, and more specifically hepatic hydrothorax. Herein, we present this novel potential indication of the indwelling pleural catheter and illustrate the successful clinical outcome.

Could CT scan avoid unnecessary flexible bronchoscopy in children with active pulmonary tuberculosis? A retrospective study

BACKGROUND

Systematic flexible bronchoscopy is advocated in the initial management of childhood pulmonary tuberculosis.

METHODS

Our aim was to describe and to compare the systematic flexible bronchoscopy findings of 53 children (6.5 + or - 4.4 years; 52.8% boys) with active pulmonary tuberculosis to their initial clinical and radiological (chest x-ray, n=53; CT, n=45) features in an 11-year retrospective study.

RESULTS

Flexible bronchoscopy was normal in 51% of cases. A severe tracheobronchial involvement (extrinsic compression >50% or obstructive endoluminal mass >25% of the lumen) was found in 10 patients. Flexible bronchoscopy guided therapy in 13 cases (steroids n=12, bronchoscopic extraction of a granuloma n=1) and permitted isolation of Mycobacterium tuberculosis in three patients (5.7%). No useful information was obtained by flexible bronchoscopy in 73.5% of cases. No correlation was found between flexible bronchoscopy findings and clinical features or x-ray findings. Conversely, a strong correlation was found between severe bronchoscopic involvement and tracheobronchial luminal narrowing on CT. The CT negative predictive value was 100% (95% CI 91% to 100%). Based on CT results, flexible bronchoscopy could have been avoided in about 60% of our patients.

CONCLUSIONS

Flexible bronchoscopy remains a very relevant tool in the diagnostic and therapeutic management of childhood pulmonary tuberculosis but resulted in treatment modification or microbiological proof in a minority of our patients. We propose that flexible bronchoscopy in children with pulmonary tuberculosis be limited to those who show tracheobronchial luminal narrowing on an initial CT scan.

Massive hemoptysis: an update on the role of bronchoscopy in diagnosis and management

Hemoptysis is frequently encountered in clinical practice, and may be the presenting symptom of a number of diseases. Although massive hemoptysis accounts for only 5-15% of episodes, it should always be considered as a life-threatening condition that warrants effective assessment and management. In this article, we review the literature with regard to the definition, etiology, epidemiology, pathophysiology, diagnosis and treatment of massive hemoptysis, with special emphasis on the role of bronchoscopy as a diagnostic and therapeutic tool. We briefly present the circumstances under which the use of rigid bronchoscopy should be preferred for controlling massive bleeding. Moreover, we address the crucial importance of multidisciplinary collaboration by illustrating the roles of endovascular therapy and surgery in the optimal management of massive hemoptysis.

[A rare cause of stridor in a 59 year old woman in intensive care]

INTRODUCTION

Stridor in the post extubation period occurs frequently and is most commonly caused by laryngeal oedema. During this period, the trachea can also be obstructed by pseudomembranes.

CASE REPORT

We report the case of a 59 year old woman who required re-intubation, 15 days after extubation because of the acute onset of severe respiratory distress secondary to pseudomembranes in her trachea.

CONCLUSION

It is essential that physicians who care for patients during the post extubation period are aware of this severe and life threatening cause of stridor. Definitive treatment with the rigid bronchoscope allows for rapid recanalisation of the airway.

Distribution of breath sound images in patients with pneumothoraces compared to healthy subjects. Diagnostic yield of vibration response imaging technology

BACKGROUND

Vibration response imaging (VRI) is a new technology that provides a radiation-free dynamic lung image from the vibrations produced by airflow. The vibration energy from the respiratory cycle can be quantified for any lung region. This is obtained by integrating the energy profiles from 42 acoustic sensors placed on the patient's back.

OBJECTIVE

The aim of this study was to evaluate whether a physician trained in interpreting acoustic images can accurately distinguish between normal and abnormal breath sound distribution in patients with pneumothoraces compared to healthy controls.

METHODS

In total, 14 patients with spontaneous or iatrogenic pneumothoraces and 15 healthy volunteers were enrolled in the study. VRI recordings and physical examination were obtained in all cases. Chest radiographs (CXRs) were reviewed in patients with pneumothoraces. Dynamic images recorded during one complete respiratory cycle were analyzed for each subject.

RESULTS

The VRI images of patients with pneumothoraces demonstrated a reduction in the vibration response on the affected side which correlated with the CXR. Sensitivity was 100%, specificity was 87% and positive predictive value and negative predictive value were 86 and 100%, respectively.

CONCLUSIONS

This study demonstrates that VRI can be safely used to assess patients with pneumothoraces. Moreover, the analysis of breath sound distribution images obtained noninvasively can distinguish between patients with a normal chest examination from those with pneumothoraces.

[Specific emergencies in thoracic oncology: pleurisy, superior vena cava syndrome, and tracheobronchial obstruction]

In patients with lung cancer, the appearance of pleurisy, superior vena cava syndrome, or tracheobronchial obstruction are complications that require specialized care, often in an emergency context. Our objective is to present the different therapeutic options available in each of these three complications and to suggest recommendations on the care to provide in everyday clinical practice.

A multicenter retrospective study investigating the role of interventional bronchoscopic techniques in the management of endobronchial lipomas

BACKGROUND

Pulmonary lipomas are rare benign tumors that are usually found endobronchially. Undiagnosed, they can lead to the serious late sequelae associated with endobronchial obstruction. In the majority of cases, they are located in the first three subdivisions of the tracheobronchial tree, and therefore, they are amenable to endoscopic techniques for diagnostic and therapeutic purposes.

OBJECTIVES

It was our aim to retrospectively study the bronchoscopic management and follow-up of a large series of endobronchial lipomas, as well as defining the demographic and endoscopic characteristics of patients.

METHODS

A retrospective multicenter study was performed to identify all cases of lipomas that were treated endoscopically in 4 institutions in the period from 1981 to 2002. Demographic, radiological, endoscopic and histological data were collected.

RESULTS

Thirty-eight patients were included in the study; 81.6% of cases were males and the average age was 63.5 +/- 15.2 years. The majority of the patients were symptomatic (63.2%). Lipomas were located proximally in 18 cases (47.4%) and distally in 20 subjects (52.6%). Specimens obtained by rigid bronchoscopy were diagnostic in all cases. Thirty-six out of 38 patients underwent therapeutic rigid bronchoscopy. Laser and mechanical debulking was performed in 29 cases (76.3%), cryotherapy and mechanical debulking in 7 subjects (18.4%), and mechanical debulking alone in 2 cases (5.3%). No cases of recurrence occurred during the follow-up period.

CONCLUSIONS

This study demonstrates that endoscopic techniques are effective for the diagnosis and treatment of endobronchial lipomas when there is no evidence of severe distal bronchiectasis. This should be the treatment of choice after a full clinicoradiological evaluation.