Transcarinal needle aspiration biopsy in the staging of lung cancer

Lung cancer without distant metastasis often requires an invasive surgical procedure to document inoperability. In order to determine how often puncture biopsy was a valid substitute for a surgical procedure, we investigated the performance of endoscopic staging by means of transcarinal needle aspiration biopsy during rigid bronchoscopy. Eighty lung cancer patients with subcarinal lymph nodes visible on computed tomography (CT) scan were studied. Specimens were of histological quality (i.e. lymph node tissue) in 59 out of 80 (74%) patients, and showed malignant invasion of this lymph node tissue in 43 cases. Specimens of cytological quality (i.e. lymph node cells) were obtained in 13 out of 80 (16%) patients, and showed malignancy in 7 cases. Therefore, adequate evaluation of the subcarinal lymph nodes was possible in 72 out of 80 (90%) patients. In 50 of these 72, malignant mediastinal spread was proven, and further invasive surgical staging could be avoided. Subgroup analysis showed that this outcome tended to be more likely in patients with abnormal endoscopic appearance of the main carina, with locally extensive tumours, and with nonsquamous histology. These results indicate that transbronchial needle aspiration biopsy of subcarinal lymph nodes can be a valuable alternative to more invasive surgical staging in patients selected by CT scan.

Diagnostic tests of hyperventilation syndrome

In 90 patients referred to the pulmonary function laboratory for evaluation of hyperventilation syndrome (HVS) and in whom somatic causes of the complaints had been excluded, we investigated the degree of concordance between three widely applied diagnostic methods: 1) the standardized Nijmegen questionnaire on major daily complaints; 2) the reproduction of the same symptoms during the hyperventilation provocation test (HVPT); and 3) the responses of end-tidal CO2 fraction (FETCO2) during the HVPT. In 86% of the patients a concordance was found between Nijmegen questionnaire (i.e. score of 24/64 or more) and symptom reproduction during HVPT (i.e. recognition of at least 2 major daily complaints). Based on these combined data we made a definite diagnosis of HVS in 37 patients, of non-HVS in 40 patients, and we retained only a possible HVS in 13 patients. Each of the 16 complaints in the questionnaire contributed significantly to the distinction between HVS and non-HVS patients, and a striking similarity in rank order of daily complaints and reproduced symptoms was found. The responses in FETCO, during HVPT had little additional diagnostic value. A spontaneous fall of at least 0.25% FETCO2 during the 5 min adaptation period before the HVPT, was most reliably correlated with the aforementioned diagnostic criteria of HVS: specificity 83%, sensitivity 57%, and accuracy 70%. Neither the 3 min FETCO2 ratio nor the 5 min FETCO2 ratio during recovery after the HVPT showed a good correlation with the other diagnostic criteria. The response of FETCO2 during HVPT did especially not provide additional useful diagnostic information in the 13 patients with only possible HVS.

Diagnostic tests of hyperventilation syndrome

In 90 patients referred to the pulmonary function laboratory for evaluation of hyperventilation syndrome (HVS) and in whom somatic causes of the complaints had been excluded, we investigated the degree of concordance between three widely applied diagnostic methods: 1) the standardized Nijmegen questionnaire on major daily complaints; 2) the reproduction of the same symptoms during the hyperventilation provocation test (HVPT); and 3) the responses of end-tidal CO2 fraction (FETCO2) during the HVPT. In 86% of the patients a concordance was found between Nijmegen questionnaire (i.e. score of 24/64 or more) and symptom reproduction during HVPT (i.e. recognition of at least 2 major daily complaints). Based on these combined data we made a definite diagnosis of HVS in 37 patients, of non-HVS in 40 patients, and we retained only a possible HVS in 13 patients. Each of the 16 complaints in the questionnaire contributed significantly to the distinction between HVS and non-HVS patients, and a striking similarity in rank order of daily complaints and reproduced symptoms was found. The responses in FETCO, during HVPT had little additional diagnostic value. A spontaneous fall of at least 0.25% FETCO2 during the 5 min adaptation period before the HVPT, was most reliably correlated with the aforementioned diagnostic criteria of HVS: specificity 83%, sensitivity 57%, and accuracy 70%. Neither the 3 min FETCO2 ratio nor the 5 min FETCO2 ratio during recovery after the HVPT showed a good correlation with the other diagnostic criteria. The response of FETCO2 during HVPT did especially not provide additional useful diagnostic information in the 13 patients with only possible HVS.

Evaluation of the clinical usefulness of capnography curves during a hyperventilation provocation test in the diagnosis of hyperventilation syndrome

We evaluated the diagnostic usefulness of capnography curves during and following a hyperventilation provocation test (HVPT) in the hyperventilation syndrome (HVS). The diagnosis of HVS was based on the Nijmegen questionnaire and on the reproduction of symptoms during HVPT. Capnography curves of 40 HVS patients, 40 non-HVS patients with psycho-somatic complaints and 26 healthy controls were analyzed. There was no difference in baseline end-tidal CO2-level (FETCO2) between the 3 groups. The spontaneous fall of FETCO2 during the adaptation phase was clearly different in HVS patients versus non-HVS patients or controls: -0.12 mmol/l (95% confidence limits -0.18 to -0.06) versus +0.01 mmol/l (95% confidence limits -0.04 to +0.16) (p = 0.002). The 3 minutes FETCO2 recovery ratio and the 5 minutes ratio were not significantly different between the groups. In conclusion, in this study the spontaneous fall of FETCO2 during the adaptation phase of the HVPT was the only valuable part of the capnography test to discriminate between HVS and non-HVS patients.

Pulmonary metastases of a tibia adamantinoma. Case report and review of the literature

An adamantinoma is a rare primary tumour of bone. It is usually seen by stomatologists as a tumour of the jaws, although several cases of the long bones, especially the tibia, have been described. The tumour is considered as a low grade malignancy with unknown histogenesis. It has a high rate of local recurrence after resection and metastasizes in part of the cases. This report describes a 41-year-old woman with multiple pulmonary metastases occurring 27 years after the diagnosis of a tibia adamantinoma. The clinical, radiographic and fiber-bronchoscopic findings are presented. The literature of adamantinoma metastasis is reviewed. The need for an early locally aggressive treatment is stressed as the treatment of metastatic disease seems very disappointing.