Predictors in the treatment of malignant central airway obstruction with silicone stents

PURPOSE

To examine the role of the silicone stent in palliation of malignant central airway obstruction and identify potential preprocedural predictors for postprocedural outcome.

METHODS

Patients treated with endoscopic insertion of tracheobronchial silicone stents for malignant central airway obstruction at Aarhus University Hospital from 2012 to 2022 were identified from electronic medical records. Statistical analyses were carried out to identify factors affecting Days Alive and Out of Hospital, complications and overall survival.

RESULTS

81 patients underwent a total of 90 tracheobronchial stent insertions. Days Alive and Out of Hospital (DAOH) for the first 30 days were affected negatively by urgent intervention, p < 0.001, preprocedural non-invasive respiratory support, p < 0.001, and preprocedural intubation, p = 0.02. Post-procedural oncological treatment was associated with a significant improved DAOH, p = 0.04. Symptomatology and lesion characteristics were not significantly associated with any impact on DAOH. Overall survival was poor (mean survival was 158 days), and only significantly affected by severe degree of dyspnea, p = 0.02, and postprocedural oncological treatment, p < 0.001. Complication where registered in 25.6% of cases within the first 30 days was observed. Procedure-related mortality was 3.7%. Based on chart annotations by an ENT-surgeon, 95% of the patients experienced relief of symptoms following stent insertion.

CONCLUSIONS

Palliative tracheobronchial airway stenting with silicone stents is found to have a beneficial impact, more research is required for identification of predictors for postprocedural outcome based on preprocedural classifications.

The PERCIVAL detector: first user experiments

The PERCIVAL detector is a CMOS imager designed for the soft X-ray regime at photon sources. Although still in its final development phase, it has recently seen its first user experiments: ptychography at a free-electron laser, holographic imaging at a storage ring and preliminary tests on X-ray photon correlation spectroscopy. The detector performed remarkably well in terms of spatial resolution achievable in the sample plane, owing to its small pixel size, large active area and very large dynamic range; but also in terms of its frame rate, which is significantly faster than traditional CCDs. In particular, it is the combination of these features which makes PERCIVAL an attractive option for soft X-ray science.

Detector developments at DESY

With the increased brilliance of state-of-the-art synchrotron radiation sources and the advent of free-electron lasers (FELs) enabling revolutionary science with EUV to X-ray photons comes an urgent need for suitable photon imaging detectors. Requirements include high frame rates, very large dynamic range, single-photon sensitivity with low probability of false positives and (multi)-megapixels. At DESY, one ongoing development project - in collaboration with RAL/STFC, Elettra Sincrotrone Trieste, Diamond, and Pohang Accelerator Laboratory - is the CMOS-based soft X-ray imager PERCIVAL. PERCIVAL is a monolithic active-pixel sensor back-thinned to access its primary energy range of 250 eV to 1 keV with target efficiencies above 90%. According to preliminary specifications, the roughly 10 cm × 10 cm, 3.5k × 3.7k monolithic sensor will operate at frame rates up to 120 Hz (commensurate with most FELs) and use multiple gains within 27 µm pixels to measure 1 to ∼100000 (500 eV) simultaneously arriving photons. DESY is also leading the development of the AGIPD, a high-speed detector based on hybrid pixel technology intended for use at the European XFEL. This system is being developed in collaboration with PSI, University of Hamburg, and University of Bonn. The AGIPD allows single-pulse imaging at 4.5 MHz frame rate into a 352-frame buffer, with a dynamic range allowing single-photon detection and detection of more than 10000 photons at 12.4 keV in the same image. Modules of 65k pixels each are configured to make up (multi)megapixel cameras. This review describes the AGIPD and the PERCIVAL concepts and systems, including some recent results and a summary of their current status. It also gives a short overview over other FEL-relevant developments where the Photon Science Detector Group at DESY is involved.

I12: the Joint Engineering, Environment and Processing (JEEP) beamline at Diamond Light Source

I12 is the Joint Engineering, Environmental and Processing (JEEP) beamline, constructed during Phase II of the Diamond Light Source. I12 is located on a short (5 m) straight section of the Diamond storage ring and uses a 4.2 T superconducting wiggler to provide polychromatic and monochromatic X-rays in the energy range 50-150 keV. The beam energy enables good penetration through large or dense samples, combined with a large beam size (1 mrad horizontally × 0.3 mrad vertically). The beam characteristics permit the study of materials and processes inside environmental chambers without unacceptable attenuation of the beam and without the need to use sample sizes which are atypically small for the process under study. X-ray techniques available to users are radiography, tomography, energy-dispersive diffraction, monochromatic and white-beam two-dimensional diffraction/scattering and small-angle X-ray scattering. Since commencing operations in November 2009, I12 has established a broad user community in materials science and processing, chemical processing, biomedical engineering, civil engineering, environmental science, palaeontology and physics.

Limited value of ⁹⁹mTc depreotide single photon emission CT compared with CT for the evaluation of pulmonary lesions

OBJECTIVES

A contrast-enhanced multidetector CT (MDCT) scan is the first choice examination when evaluating patients with suspected lung cancer. However, while the clinical focus is on CT, research focus is on molecular biological methods whereby radiolabelled pharmaceuticals are injected into participants and target malignant lung tumours. We examined whether a contrast-enhanced MDCT scan supplied with an additional non-contrast enhanced high-resolution CT scan, or a newer but more expensive (99m)Tc depreotide single photon emission CT (SPECT) scan, was the better first-choice examination for the work-up of pulmonary lesions. Furthermore, we examined whether a (99m)Tc depreotide SPECT scan was an appropriate second-choice examination for patients with indeterminate lesions.

METHODS

140 participants were included in the analysis. CT images were given a malignancy potential rating of 1, 2 or 3 with higher rating being indicative of disease. (99m)Tc depreotide SPECT images were graded either positive or negative. Histopathology and CT follow-up were used as reference standard. Sensitivity, specificity and diagnostic accuracy were calculated.

RESULTS

Overall sensitivity, specificity and diagnostic accuracy of CT were 97%, 30% and 84%, respectively. Overall sensitivity, specificity and diagnostic accuracy of (99m)Tc depreotide SPECT were 94%, 58% and 76%, respectively. For indeterminate lesions sensitivity, specificity and diagnostic accuracy of (99m)Tc depreotide SPECT were 71%, 68% and 69%, respectively.

CONCLUSION

Both CT and (99m)Tc depreotide SPECT made valuable contributions to the evaluation of pulmonary lesions. (99m)Tc depreotide SPECT results were not superior to CT results and did not contribute further to the diagnostic work-up. Regarding indeterminate lesions,( 99m)Tc depreotide SPECT sensitivity was too low.

[Surgical treatment of tracheal stenosis]

INTRODUCTION

Surgical treatment of tracheal stenoses (TS) using tracheal resection (TR) is a treatment modality that should be considered in every case. We report the results from TR in a consecutive series of 17 patients in Western Denmark during the past five years.

MATERIAL AND METHODS

A total of 32 patients with TS were retrospectively evaluated, of whom 17 underwent TR with end-to-end anastomoses. Age, gender, aetiology, symptoms, findings, localisation and length of the stenoses were registered. In addition, other procedures than TR and patient satisfaction were registered.

RESULTS

Nine (53%) and three (18%) had post-tracheostomy and post-intubation stenoses, three (18%) had an intraluminal tumour, two (12%) had amyloidosis and sequelae after fracture of a tracheal ring, respectively. Prior to surgery, 29% underwent stent implantation, 41 and 47%, respectively, had had laser resection and/or dilation a number of times. The median stenosis length was 1.1 cm (0.4-2.0 cm), and they were primarily located 2-4 cm below the vocal cords. The length of resection ranged from 2.0 to 3.5 cm (median 2.3). Postoperatively, one (5.8%) patient died and one needed reoperation due to haematoma, none developed insufficient anastomosis and of those with preoperative permanent tracheal tube, all but one could do without the tube after surgery. The follow-up period was 3.0 years (0.0-5.5 yrs). 75% was - according to questionnaire answers - very satisfied with the result, 25% were moderately satisfied.

CONCLUSION

The results from surgical treatment of TS in Denmark are in line with international studies and TR is the treatment of choice in selected patients with TS.

Papillary microcarcinoma of the thyroid gland: is the immunohistochemical expression of cyclin D1 or galectin-3 in primary tumour an indicator of metastatic disease?

INTRODUCTION

Papillary microcarcinomas (PMC) of the thyroid gland are defined according to The WHO Committee as papillary carcinomas measuring 10 mm or less in diameter. A large proportion of these tumours are found coincidentally in the treatment of symptomatic goitre and most cases follow an indolent course with an excellent prognosis. However, a more aggressive behaviour with regional and distant metastases does occur. The aim of this study was to evaluate if the immunohistochemical markers cyclin D1 or galectin-3 might indicate the presence of metastatic disease in patients with PMC at the time of diagnosis.

MATERIAL AND METHODS

From the 1(st) of January 1996 to 31(st) of December 2002 a total of 169 PMC patients were diagnosed and registered in the national Danish thyroid cancer database DATHYRCA and 131 of these were eligible for the study. Forty-three (33%) had histologically verified regional or distant metastases. Slides were cut from the primary tumour and immunostaining and quantification was subsequently performed.

RESULTS

The percentage of positive cells was examined for patients with and without metastases. For cyclin D1 the median values were 31% (range: 0-59) and 21% (range: 0-75), respectively, showing a statistically significant difference (p=0.02). For galectin-3 the medians were 87% (range: 6-96) and 85% (range: 0-99) and no significant difference was found.

CONCLUSION

Cyclin D1 showed significantly higher median expression in patients with metastases compared to those without, indicating a correlation to tumour aggressiveness. However, both groups showed large variation in expression, which disqualify the marker as a discriminator for the detection of metastases. Galectin-3 was without any significant correlation to the presence of metastases from PMC.

Treatment outcome after laser excision of early glottic squamous cell carcinoma--a literature survey

Two treatment options are widely used for the cure of T1 glottic squamous cell carcinoma: radiotherapy and surgical removal. There is ongoing controversy about whether laser excision should be offered to patients with T1 glottic carcinoma. The purpose of this study is to present a review of studies dealing with treatment outcome after laser excision of T1 glottic carcinoma. Eighteen original papers on outcomes were identified. Recurrence rates ranged from 4% to 35%. The disease-specific survival rate at 5 years was found to be from 89% to 100% and crude survival from 74% to 100%. Of the six studies dealing with voice quality, radiation therapy was found to be more effective in preservation of the voice in three, while in the other three studies, no significant difference could be detected. With respect to costs of treatment, in three out of four studies laser surgery was found to be the more economical treatment option. Laser surgery seems to provide comparably low recurrence rates and high disease-specific survival as compared with radiotherapy. In T1 cancer, laser resection leaves the patient with a poorer voice quality than is the case with radiation therapy, but laser treatment seems to be the cheaper option.

Environmental indicators for long-range atmospheric transported heavy metals based on national moss surveys

Environmental indicators for long-range atmospheric transported heavy metals have been developed. The indicators are based on data for Pb and Cd from national moss surveys which are performed regularly in Norway. The interpolation programme 'kriging' has been used to transform the data from irregular grids to regular grids. Contour maps have been produced, and areas above estimated background levels for Pb and Cd in mosses have been calculated. The indicators are used to characterise the atmospheric deposition of long-range atmospheric transported heavy metals and monitor the changes with time.

Effect of epidural blockade and oxygen therapy on changes in subcutaneous oxygen tension after abdominal surgery

The effect of oxygen therapy (37% by face mask) and epidural local anesthetic blockade (9 ml 0.5% bupivacaine at Th9-11 level) on wound oxygenation was evaluated in eight otherwise healthy patients undergoing elective colorectal resection. The patients were monitored continuously for subcutaneous oxygen tension, arterial oxygen saturation, heart rate, and skin temperature on the day after operation, and arterial blood for gas analysis was drawn every 15 min during the study. A fluid challenge (10 ml saline/kg body wt) did not alter any of the measured values. The epidural blockade did not change any of the measured values. Oxygen therapy before epidural blockade increased median subcutaneous oxygen tension from 60 to 71 mmHg (P < 0.02) and, after epidural blockade, from 64 to 71 mmHg (P < 0.02) Time to reach steady state in subcutaneous oxygen tension with oxygen therapy was 30 (15-55) min without epidural blockade and 15 (10-20) min with blockade (P < 0.03). In conclusion, epidural local anesthetic blockade did not increase subcutaneous oxygen tension with or without oxygen therapy after elective uncomplicated major abdominal surgery.

[Malignant tracheal tumor--differential diagnosis in bronchial asthma]

Primary tumours of the trachea are rare and most of the symptoms relate to obstruction of the air passage leading to inspiratory and expiratory stridor. Unfortunately, the inclusion of malignant tracheal neoplasms in the differential diagnosis of onset of wheeze in adults is even more rare than the tumours themselves. We report a case where a tracheal adenoid cystic carcinoma presented symptoms suggestive of bronchial asthma. It is emphasized that delay by the physician in diagnosing tracheal tumours is the principal problem, and that adult patients who experience onset of stridor and dyspnoe and do not respond to accepted medical treatment deserve systematic radiographic and endoscopic evaluation of the entire air passage.

The diagnostic role of fiberoptic bronchoscopy in AIDS patients with suspected Pneumocystis carinii pneumonia

Fiberoptic bronchoscopy was carried out in 17 consecutive AIDS patients with suspected opportunistic infections. A total number of 23 bronchoscopies were performed and a comparison was made about the effectiveness of the available diagnostic techniques, which included bronchoalveolar lavage, transbronchial lung biopsy and bronchial brushings. The most common cause of pulmonary parenchymal disease was Pneumocystis carinii (7 patients). In 6 of these HIV-positive patients the detection of infection was decisive in making a diagnosis of AIDS. The most effective procedure for diagnosing P. carinii pneumonia was transbronchial lung biopsy (5 patients), while bronchoalveolar lavage and bronchial brushings showed P. carinii and 5 and 4 patients respectively. Complications were minor and occurred only in those patients subjected to transbronchial biopsy. Our findings showed that transbronchial biopsy has the highest yield in the diagnosis of P. carinii infection. When all diagnostic components of the bronchoscopic procedures are carried out, very few cases with these infections should be missed.

Fractures in polyvinyl chloride tracheostomy tubes

Fracture in polyvinyl chloride tracheostomy tubes in infants and children has not previously been described. On the basis of two events in the same infant a theory for the pathogenesis is outlined, and measures to prevent future cases are described.

Hearing improvement after stapedectomy: up to 19 years' follow-up period

The long-term results of 925 stapedectomies were analysed after a mean follow-up period of 15 years. Patients who had the operation before the age of 30 were analysed separately. The entire group deteriorated by an average of 0.91 dB/year at 500-2000 Hz, while the under-30 group deteriorated by 0.67 dB/year. There were but slight differences in the conductive component, considering frequencies and age. The perceptive loss/year was not far from that in a normal population.

Reduced strength of skin in osteogenesis imperfecta

The biochemical properties and ratio collagen type I/type III of skin biopsies from nine patients with osteogenesis imperfecta and nine age- and sex-matched controls were studied. Four of six patients with osteogenesis imperfecta Sillence type I had pronounced reductions in skin tensile strength, decreased ratios of collagen type I/type III, primarily accomplished by reduced amounts of collagen type I, moderate or no disability. The three patients with osteogenesis imperfecta Sillence type III had severe skeletal deformities, but normal skin tensile strength, and ratios of collagen type I/type III within the normal range. These observations may be explained as resulting from various structural defects in the type I collagen of patients with osteogenesis imperfecta.

Rheumatoid arthritis of the cricoarytenoid joints: a case of laryngeal obstruction due to acute and chronic joint changes

A 63-year-old female with severe rheumatoid arthritis and respiratory obstruction with stridor due to cricoarytenoid (c.a.) arthritis is described. Low voltage radiography of the neck revealed erosive changes in the c.a. joints. At laryngoscopy the arytenoids were fixed in adduction, and there were signs of active arthritis. Corticosteroid therapy was instituted with remarkable effect on the obstruction. After the active arthritis had subsided, there remained limited arytenoid mobility with a glottic chink of about 5 mm, but no laryngeal symptoms.

Lack of effects of human calcitonin in osteogenesis imperfecta

The effects of human calcitonin on bone mineral content and certain biochemical markers of bone metabolism were evaluated in a 2-12 month treatment period in seven patients with osteogenesis imperfecta. S-calcium, S-alkaline phosphatase, S-immuno-reactive parathyroid hormone and the urinary excretion of calcium were found to be within the normal range before and during the treatment period. After 4-5 months of therapy, a slight increase in the urinary excretion of hydroxyproline was observed, but the values were still within the normal range. The bone mineral content, measured in the forearm, remained unchanged during the treatment period. Side effects were common, in two cases resulting in discontinuation of the treatment. We concluded that, with the dose of human calcitonin used, it was impossible to detect any beneficial effect in patients with osteogenesis imperfecta.

Histopathology of the stapes in osteogenesis imperfecta

Conventional histological studies of stapes footplates from patients with osteogenesis imperfecta revealed, in nine out of 15 stapes examined, an otospongiotic-like lesion. Although the morphology of the stapedial lesion was comparable to the early otosclerotic focus, a greater structural disorganization and larger resorption spaces in osteogenesis imperfecta distinguished the two conditions. The histopathology of the stapes was related to the morphology of cortical and trabecular bone from the iliac crest. Various degrees of immature, osteogenic bony tissue were found in the iliac crest, showing no resemblance to the otospongiotic-like focus in the footplate. Even though the histologic appearance of the stapes footplates differed from the findings in peripheral bone, the present study indicates that the stapedial lesion in osteogenesis imperfecta is most likely a manifestation of the generalized bone and connective tissue disorder. The study further supports the view that osteogenesis imperfecta and otosclerosis are of different aetiology.

Histological investigation of skin biopsies in otosclerosis and osteogenesis imperfecta

Histological investigation of skin biopsies in four patients with osteogenesis imperfecta, nine patients with otosclerosis and 13 sex- and age-matched normal controls was carried out blindly. The dermal thickness was markedly reduced in osteogenesis imperfecta and slightly reduced in otosclerosis. Minor degenerative changes in the elastic fibres were seen in otosclerosis, while the elastic fibres were found to be more degenerated and more numerous in osteogenesis imperfecta. Our study does not support the hypothesis of otosclerosis being a localized form of osteogenesis imperfecta. The minor changes in the elastic fibres in otosclerosis indicate that further studies of the elastic fibres and of collagen will be necessary to determine whether otosclerosis is a localized disease or part of a general connective tissue disorder.

Rheumatoid arthritis of the crico-arytenoid and crico-thyroid joints: a radiological and clinical study

Low-voltage neck radiography and indirect laryngoscopy was performed in 22 randomly selected rheumatoid patients with the purpose of detecting intralaryngeal arthritis. Radiographic evidence of erosive arthritis of the crico-arytenoid (CA) joints was found in 45% of the patients. Clinical acute CA arthritis without erosive changes was present in two patients, the overall incidence of CA arthritis being 55%. The incidence was higher in females (65%) than in males (20%). The CA arthritis was asymptomatic in 58% of the patients. Radiography revealed osseous destruction at the crico-thyroid joint in four females.

Histomorphometric analysis of iliac trabecular bone in otosclerosis

With the aim of investigating whether patients with otosclerosis suffer from a generalized bone disorder, a histomorphometric analysis of trabecular bone from the iliac crest was performed. Iliac crest biopsies from 10 patients with otosclerosis and 20 normal controls were obtained after tetracycline double labelling and examined by histomorphometry. No significant differences were found in the estimates of density and remodeling of bone between patients and sex and age-matched normal controls. Qualitatively the bone specimens showed no signs of any generalized bone disorder.

Central corneal thickness in osteogenesis imperfecta and otosclerosis

The central corneal thickness was measured in 53 patients with osteogenesis imperfecta. The average thickness was found to be 0.443 +/- 0.003 (SEM) mm. This value was significantly lower than the central corneal thickness in 35 patients with otosclerosis (0.515 +/- 0.004 mm) and in 35 sex- and age-matched normal control subjects (0.522 +/- 0.004 mm). No difference in corneal thickness between otosclerosis and controls was observed. Measurements of the central corneal thickness may be of great value in the diagnosis of osteogenesis imperfecta.

Hearing loss in patients with osteogenesis imperfecta. A clinical and audiological study of 201 patients

Clinical otological features, hearing status and middle ear function in 201 patients with osteogenesis imperfecta are presented. The study covered 76% of the expected total number of patients with osteogenesis imperfecta in Denmark. 78% of the patients exhibited an autosomal dominant inheritance pattern with an almost 100% penetrance. In 39% of the ears examined, a conductive or mixed hearing loss was found. Sensorineural hearing loss or anacusis was seen in 11% of the ears. In most cases the onset of hearing impairment was noted in the second or third decade and progressing with increasing age, especially after the age of 60. Tympanometry and acoustic reflex measurements suggested that the cause of conductive or mixed hearing loss was stapedial fixation and in a few cases ossicular discontinuity due to aplasia or fracture of the stapedial crura. Findings during stapedectomy in 32 patients confirmed these assumptions.

HLA-A, -B, -C antigens in otosclerosis

One hundred unrelated, randomly chosen, consecutive patients with otosclerosis, verified by operation, were typed for HLA-A, -B, -C antigens. No significant association between HLA-A, -B, -C antigens and otosclerosis was found.

Stapedectomy in osteogenesis imperfecta

Operative findings and results of stapedectomy in 32 patients (43 ears) with osteogenesis imperfecta are presented. The stapes footplates were in many ears thick and of a very soft consistency. In all the operated ears we found the stapes footplates fixated in the oval window. Brittle and atrophic stapes crura were a common finding, but in only 5 ears fractures of the crura were observed. A thick and vascular middle ear mucosa was seen in several ears. Although the middle ear proved quite different from that of otosclerosis, no major difficulties and no serious complications occurred during stapedectomy. Both the immediate postoperative hearing gain and the long-term hearing results were, in general, satisfactory. Our study supports the statement of others, that stapedectomy in osteogenesis imperfecta is a safe and reasonable alternative to hearing aids.

The treatment of perennial rhinitis with a new, non-halogenated, topical, aerosol packed, steroid, Budesonide

The investigation of a recently synthesized non-halogenated steroid with a high local anti-inflammatory effect and low systemic glucocorticoid effect, on 36 patients with perennial rhinitis was carried out using a double-blind, cross-over technique, where the patients were treated with an aerosol spray containing a concentration corresponding to 200 micrograms/day and 400 micrograms/day of the active compound Budesonide, as well as placebo. There was a significantly better effect from the active compound than from placebo. A dosage-dependent effect was demonstrated for the symptoms nasal blockage and nasal discharge, while this was not so for sneezing bouts. No effect was observed on the function of the suprarenal glands. Local side effects were few and of no importance.

Diagnostic value of brush biopsy in suspected bronchial carcinoma with the use of the flexible fibre bronchoscope

In a 12-month period, brush biopsy through a fibreoptic bronchoscope was performed on 125 consecutive patients who were clinically or radiographically suspected of lung cancer. Of the patients, 62 appeared to have lung cancer. Cytological analysis of the brush-biopsy specimens was positive in 69%. A total of 58% had positive biopsy, and 58% had cancer cells in the bronchial secretion aspirated during the bronchoscopy. Thirty-five per cent had positive mediastinoscopy. When the methods of examination were combined, the diagnosis could be established in 90% of the patients. The study shows that brush biopsy and cytological analysis, in combination with the other methods of examination, increase the diagnostic sensitivity in bronchoscopically visible tumours. In bronchoscopically invisible tumours, brush cytological analysis, together with the study of bronchial secretion and fine-needle puncture, is the most effective diagnostic method. The diagnostic possibilities can presumably be further improved by the use of fluoroscopic control in two places during the bronchoscopy.