Successful endoscopic Nd-YAG laser treatment of endobronchial endometriosis

Catamenial hemoptysis is a rare condition that is associated with the presence of intrapulmonary or endobronchial endometrial tissue. Diagnosis of and therapy for this condition are still a matter of debate. We describe a case of endobronchial endometriosis with catamenial hemoptysis. An endobronchial lesion was diagnosed by spiral CT scan, taken at the onset of the menses, and confirmed with flexible bronchoscopy. The patient was successfully treated with endoscopic Nd-YAG laser therapy with a 1-day in-hospital procedure. We suggest that endoscopic laser treatment should be the first line of therapy for central airway endometriosis, provided that the source of bleeding has been conclusively located and all of the lesions can be reached with the bronchoscope.     

Endobronchial gene therapy

Gene therapy for pulmonary disease, a field still in the experimental stage, has nonetheless progressed considerably in the past decade. There have been significant advances in pre-clinical studies, as well as important developments resulting from multiple early-phase human clinical trials for a variety of respiratory disorders. Although there are several ways of delivering therapeutic genes to the lungs, the primary delivery modality remains flexible bronchoscopy. The flexible bronchoscope, because of its unique access to both large and small airways, serves as an ideal instrument to deliver therapeutic genes to the tracheobronchial tree, even to small airways and alveoli that are beyond the reach of the bronchoscope. In addition, bronchoscopic gene delivery has the capacity to treat pulmonary vascular disorders because delivery of marker and therapeutic genes via the airways has been demonstrated to successfully transduce the pulmonary vascular endothelium. This article describes the various methods and disease targets of bronchoscopically mediated gene therapy, focusing in particular on the results of clinical studies and providing a glimpse into the future of the field.     

Endobronchial laser therapy

We have sought to briefly outline the history and current role of laser therapy in airway obstruction. A primary goal in the use of laser therapy is the safe, effective, and rapid palliation of symptoms owing to tracheal or bronchial obstruction. This seems clearly supported in the literature despite some variation in definitions as to measurement of success. Objective criteria for improvement has also been studied, with authors noting improvement in walk tests, spirometric studies, and caliber of airways after treatment in significant percentages of patients. Patient survival, as noted by Ramser and Beamis, may not be the proper endpoint when discussing therapy, which for malignant causes, is meant to be palliative. Noting this, there are many benign conditions that may be effectively treated with laser therapy with a possible "cure" for some lesions defined as "carcinoma in situ." We believe laser therapy in the treatment of airway obstruction is an important tool that has proven beneficial in the therapy of benign and malignant lesions of the airway. Although future studies should prospectively examine survival characteristics, the current evidence firmly supports the use of laser as a useful modality of therapy in our endeavors to provide palliative and potentially curative care to our patients with lung disease.     

Endobronchial resection with the Nd-YAG laser – Two years experience in an Australian unit

Abstract In a two year period 44 endobronchial resections using the Neodymium-YAG laser have been performed in 28 patients. The majority of cases had either bronchogenic carcinoma (57%) or metastatic carcinoma (18%) involving the bronchial tree. Adenoid cystic carcinoma, benign tumours, lymphoma, tracheal papillomatosis, Wegener's granulomatosis and benign stricture comprised the other cases. Rigid bronchoscopy and general anaesthesia were used in the majority. Symptomatic improvement of dyspnoea when relief of bronchial obstruction occurred was marked in ten of 17 cases, moderate in four and absent in three. Haemoptysis was markedly improved in two of three cases and obstructive pneumonias resolved in one of two cases. Significant respiratory function improvement was observed in R_aw (most sensitive), FEV₁, FVC and TLC. Laser treatment restored the lumen to normal calibre in 52% (including all patients with tracheal lesions), to greater than half normal in 28% and to less than half normal in 20% of cases. Re-expansion of a collapsed lung or lobe occurred in seven of eight patients. In six of these patients laser treatment was the initial therapy resulting in immediate re-expansion and symptomatic relief prior to further therapy. In patients with bronchogenic carcinoma the mean time to retreatment or death was 72 days. For metastatic carcinoma this was 60 days. Two early deaths (3 hours, 36 hours) due to respiratory failure occurred in patients with very severe bilateral bronchial obstruction too advanced for effective clearance. Other complications included laryngeal oedema requiring prolonged intubation (1), bronchospasm (1), atrial fibrillation (1), and acute pulmonary oedema (1). Laser treatment provides effective palliation for bronchial obstruction and haemoptysis in selected proximal endobronchial cancers.     

支气管结核介入诊治的认识和思考

支气管结核（EBTB）的介入诊断和治疗有了长足的进展,但也面临着诸多的问题,有必要加深认识和思考。EBTB的支气管镜下目前分为5型,即炎症浸润型（Ⅰ型）、溃疡坏死型（Ⅱ型）、肉芽增殖型（Ⅲ型）、瘢痕狭窄型（Ⅳ型）和管壁软化型（Ⅴ型）,建议在原来EBTB＂五型＂的基础上将结核性支气管瘘从第Ⅱ型中分离出来成为单独的类型,即Ⅵ型。在支气管结核的治疗中,应根据不同的类型,采用包括高频电刀、冷冻、氩气刀、激光、支架置入、球囊扩张以及黏膜下穿刺注射抗结核药物等综合介入技术进行治疗。     

Antiangiogenesis therapy for endometriosis

It is known that angiogenesis is of pivotal importance for the development of endometriosis. However, in the treatment of endometriosis patients, prevention of endometriosis lesion development only will not be sufficient as a therapy. Treatment options, aimed at interfering with established lesions, have to be developed. In this study we evaluated whether inhibition of angiogenesis by angiostatic therapy is also effective in antagonizing the sustentation of endometriosis. We evaluated the effect of the angiostatic compounds antihuman vascular endothelial growth factor, TNP-470, endostatin, and anginex on the growth of established endometriosis lesions in the nude mouse model. We show that human endometrium in the proliferative endometrium is highly angiogenic and that vascular endothelial growth factor-A is the most important angiogenesis promotory factor. The angiostatic compounds significantly decreased microvessel densities and the number of established endometriosis lesions. In the remaining lesions, the number of pericyte-protected vessels is not different in control and treated mice; however, the number of unprotected vessels was significantly reduced in the groups treated with the angiostatic agents. Our data demonstrate that inhibitors of angiogenesis effectively interfere with the maintenance and growth of endometriosis by inhibiting angiogenesis. This suggests that the use of angiostatic agents may be promising as a therapy for endometriosis.     

Catheter ablation vs antiarrhythmic drug therapy for atrial fibrillation: a systematic review

BACKGROUND: Circumferential pulmonary vein ablation (CPVA) has become common therapy for atrial fibrillation (AF), but results of large randomized controlled trials comparing this procedure with antiarrhythmic drug therapy (ADT) have not been published to date. We conducted a systematic literature review to assess whether CPVA is superior to ADT for the management of AF. METHODS: We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials for relevant randomized controlled trials. Data were abstracted to construct a 2 x 2 table for each trial. Recurrence of any atrial tachyarrhythmia (AT) was considered the primary end point of the trials. The estimate and confidence interval for the pooled risk ratio of AT recurrence-free survival in the CPVA group vs the ADT group were obtained using the random-effects model. RESULTS: Four trials qualified for the meta-analysis. In total, 162 of 214 patients (75.7%) in the CPVA group had AT recurrence-free survival vs 41 of 218 patients (18.8%) in the ADT group. The random-effects pooled risk ratio for AT recurrence-free survival was 3.73 (95% confidence interval, 2.47-5.63). In addition, fewer adverse events were reported in the CPVA group compared with that in the ADT group. CONCLUSIONS: We observed statistically significantly better AT recurrence-free survival with CPVA than with ADT. These results highlight the need for larger trials to determine the appropriate role for CPVA in the management of AF. Ongoing clinical trials may provide further guidance on these treatment options for AF.     

Endobronchial laser therapy of post-tuberculosis bronchial fibrous stenosis]

The results of endobronchial treatment of 9 patients with post-tuberculous fibrous stenoses of large bronchi by using neodymium-YAG laser are presented. After recanalization of fibrous stenoses the patients were given antioxidants (7.5% sodium thiosulfate solution, 0.5 ml, as endobronchial infusions in combination with oral or intramuscular alpha-tocopherol, 600 mg, for a month) in combination with endobronchial phototherapy with helium-neon laser radiation. This therapy improved the patients' general condition, pulmonary functional parameters, normalized lipid peroxidation and enhanced epithelial regeneration in the bronchial mucosa, thus providing a steady-state dilatation of the airways lumen by more than twice than that in stenosis.     

Angiogenesis and antiangiogenic therapy in endometriosis

Endometriosis, the presence of endometrium-like tissue outside of the uterine cavity, is a common disease among women of reproductive age. Typical symptoms include abdominal pain and painful menstruation. In addition, endometriosis is associated with reduced fertility. Current treatment modalities, the surgical removal of endometriotic lesions and the hormonal suppression of estrogen are associated with significant morbidity, side-effects and recurrence rates. Despite uncertainties about the pathophysiology of the disease it has recently become apparent that angiogenesis plays a pivotal role in endometriosis. This review focuses on a multitude of factors involved in the angiogenic phenotype of endometriosis demonstrating that many biological systems such as the immune system and steroid hormones are closely connected to angiogenic pathways in this disease. In addition, experimental and clinical data are discussed that concentrate on the inhibition of angiogenesis as a novel therapeutic approach for endometriosis.     

Endoscopic Nd-YAG laser therapy as palliative treatment for esophageal and cardial cancer

The aim of this study was to report long-term results of endoscopic Nd-YAG laser therapy in the palliative treatment of 144 esophageal and cardial carcinomas and to define parameters that could predict the long-term outcome in order to better define the indications and limitations of Nd-YAG laser therapy for esophagocardial cancer. One hundred nineteen men and 25 women were treated. The mean age was 67 +/- 12 years. Histology showed 94 patients with squamous cell carcinoma and 50 with cardial or esophageal adenocarcinoma. Improvement of dysphagia was achieved in 119 of the 144 patients (83%) after a median of 2.9 sessions. For the 105 patients initially symptomatically improved by the first laser course, the cumulative probability of remaining symptomatically improved at three and six months was respectively 38.5 +/- 5% and 22 +/- 4%. Four perforations and nine esophagotracheal fistulas occurred. In the stepwise regression analysis (Cox model), among 11 variables, three variables had an independent prognostic value at six months. The importance of improvement after the initial laser treatment (P less than 0.005) and the presence of an adenocarcinoma (P less than 0.05) were positively correlated with the symptom improvement duration. The initial tumor length (P less than 0.01) was negatively correlated with the symptomatic improvement duration. Therefore, in inoperable patients, we think that laser therapy should be proposed first for adenocarcinoma and for squamous cell carcinoma less than 6 cm in length.(ABSTRACT TRUNCATED AT 250 WORDS)     

Nd-YAG laser vs bronchoscopic electrocautery for palliation of symptomatic airway obstruction: a cost-effectiveness study.

STUDY OBJECTIVE: To evaluate the cost effectiveness of the Nd-YAG laser and bronchoscopic electrocautery for palliation in patients with symptomatic tumor obstruction. DESIGN: A retrospective study. SETTING: Bronchoscopy unit of a university hospital. PATIENTS AND INTERVENTION: Thirty-one consecutive patients with inoperable non-small cell lung cancer and symptomatic intraluminal tumor underwent bronchoscopic treatment. Dyspnea relief was the primary goal of treatment. Fourteen patients were treated with the Nd-YAG laser and 17 patients with electrocautery. MEASUREMENTS AND RESULTS: Improvement of symptoms was achieved in 70% of patients treated by either Nd-YAG laser or electrocautery. Mean +/- SD survival was 8.0 +/- 2.5 months after Nd-YAG laser treatment and 11.5 +/- 3.5 months after electrocautery. The number of treatment sessions per patient was comparable: Nd-YAG laser, 1.1; electrocautery, 1.2. Duration of hospital stay was longer in patients treated with the Nd-YAG laser (8.4 vs 6.7 days). Average treatment costs, including admission charges, were $5,321 for the Nd-YAG laser and $4,290 for electrocautery. Higher costs in the group treated with the Nd-YAG laser were caused by a longer hospital stay before bronchoscopic treatment. Costs of equipment (electrocautery $6,701 and Nd-YAG laser $208,333), write-offs, maintenance, and repair were not included in this calculation. CONCLUSION: Bronchoscopic electrocautery is equally effective but is a less expensive and, in our hospital, a more accessible modality than the Nd-YAG laser for symptomatic palliation of patients with intraluminal airway obstruction.     

Endobronchial and parenchymal juvenile laryngotracheobronchial papillomatosis. Effect of photodynamic therapy

Juvenile laryngotracheobronchial papillomatosis (JLTBP) is a recurrent, prolonged disease usually confined to the upper airway. Rarely, tracheobronchial tree or lung parenchymal involvement occurs. The various therapeutic interventions are often unsuccessful once extralaryngeal involvement becomes apparent. Photodynamic therapy (PDT) has been successful in eradicating JLTBP in a few case reports. We present a case of extensive JLTBP with parenchymal involvement treated with multiple courses of PDT. We demonstrated temporary regression of endobronchial papillomas, but no change in parenchymal lesions. Recurrent endobronchial disease was most likely related to reinfection from parenchymal lesions inaccessible to PDT.     

Endobronchial tuberculosis

Endobronchial tuberculosis (EBTB) is defined as tuberculous infection of the tracheobronchial tree with microbial and histopathological evidence. It is seen in 10-40% of patients with active pulmonary tuberculosis. More than 90% of the patients with EBTB have some degree of bronchial stenosis. Ten to 20 percent have normal chest radiograph. Therefore, a clear chest radiograph does not exclude the diagnosis of EBTB. Bronchoscopic sampling has been the key to the diagnosis producing more than 90% yield on smear as well as on culture. Bronchoscopy and computed tomography are the methods of choice for accurate diagnosis of bronchial involvement and assessment for the surgical interventions. Characteristic HRCT findings of FBTB are patchy asymmetric centrilobular nodules and branching lines (tree-in-bud appearance). Early supervised antituberculosis therapy results in minimal structural and functional residua. Corticosteroid therapy may not influence the outcome of endobronchial tuberculosis. Early diagnosis and prompt treatment, before the development of fibrosis is important to prevent complications of endobronchial tuberculosis, such as bronchostenosis.     

Endobronchial hamartoma

OBJECTIVES: To describe clinical, endoscopic, radiographic, and follow-up characteristics of a series of patients in whom endobronchial hamartoma (EH) had been diagnosed. METHODS: Retrospective study of all cases of hamartoma diagnosed by bronchial biopsy between 1974 and 1997 in a tertiary referral hospital in Madrid, Spain. RESULTS: EH was diagnosed 47 patients during the study period. Four patients were excluded from the study because no clinical history was available. We analyzed the cases of 43 patients (37 men and 6 women), with a mean (+/- SD) age of 62 +/- 12 years. Seven patients had a concurrent lung neoplasm, and the EH was an incidental endoscopic finding. Among the other 36 patients, 31 had a new onset of respiratory symptoms, most commonly, recurrent respiratory infections in 16 patients (44%) and hemoptysis in a further 12 patients (33.4%). Chest radiograph findings were abnormal in 38 of 43 patients. At bronchoscopy, the lesions were equally distributed throughout the right and left lungs with no clear lobar predilection. Endobronchial obstruction was evident in 26 patients (72.2%) without concurrent neoplasm, 17 of whom underwent resection with a rigid bronchoscope and laser, with total resolution in 13 patients. Partial resolution was achieved in four patients, two of whom needed a second endoscopic procedure. Five patients were treated with open lung surgery. Clinical and endoscopic follow-up was performed in 23 patients at 1 to 73 months (mean, 17 months), and recurrence was found in 4 patients. CONCLUSION: EH frequently produces respiratory complaints and radiographic abnormalities. Patients with endobronchial obstructions had satisfactory responses to endoscopic therapy.     

Endobronchial hamartoma

Two cases of endobronchial hamartoma are reported, making a total of forty-two noted in the British and American literature. Although uncommon, hamartoma should be given consideration in any case manifesting bronchial obstruction.