- Email: [email protected]
Bronchial polyp secondary to foreign body
398
Ann Thorac Surg 1993;5639W2
CORRESPONDENCE
human internal thoracic artery. Ring segments (3 mm) of human internal thoracic artery were submaximally contracted with norepiphrine then relaxed with acetylcholine, an endotheliumdependent relaxant. In the presence of free hemoglobin in the organ bath, 0.1 pmol/L or 0.5 pmol/L, endothelium-dependent relaxation was reduced by 44% and 5576, respectively. The levels of free hemoglobin used in these experiments are within the range measured in patients' plasma (unpublished results). The increasing understanding of the endothelium as a regulatory organ of the circulatory system emphasizes the importance of its products and their inhibition. The generation of free plasma hemoglobin during CPB therefore should be noted because of the vasoactive effects it has on systemic blood pressure and blood flow through vascular conduits after CPB.
Anthony C . De Souza, FRCS Thoinas 1. Spyt, M D Dcparttnent of S u r y c y Leicester Royal fnfirniary PO Box 65, Leicestcr England LE2 7LX
References 1. Downing SW, Edmunds LH. Release of vasoactive substances during cardiopulmonary bypass. Ann Thorac Surg 1992;54: 1236-43. 2. De Souza AC, Samani N, Chambers K, West K, Spyt TJ. Free haemoglobin inhibition of EDRF-a mechanism of post cardiopulmonary bypass hypertension. Presented at the 12th Annual Cardiothoracic Surgery Symposium, Pathophysiology and Techniques of Cardiopulmonary Bypass, San Diego, CA, Feb 1992. 3. Tanaka K, Kanamori Y, Sato T, et al. Administration of haptoglobin during cardiopulmonary bypass surgery. ASAIO Trans 1991;37:M482-3. 4. Edwards DH, Griffith TM, Ryley HC, Henderson AH. Haptoglobin-haemoglobin complex in human plasma inhibits endothelium independent relaxation: evidence that endothelium derived factor acts as a local autocoid. Cardiovasc Res 1986; 20:549-56. 5. Hoar PF, Hickey RF, Ullyot DJ. Systemic hypertension following myocardial revascularization. J Thorac Cardiovasc Surg 1976;71:85944. 6. Sarrel I'M, Lindsay DC, Poole-Wilson PA, Collins P. Hypothesis: inhibition of endothelium-derived relaxing factor by haemoglobin in the pathogenesis of pre-eclampsia. Lancet 1990;336:103&2. 7. Martin W, Villani GM, Jothianandan D, Furchgott RF. Selective blockade of endothelium-dependent and glyceryl trinitrate induced relaxation by hemoglobin and by methylene blue in the rabbit aorta. J Pharmacol Exp Ther 1985;232:708-16.
Device-Supported Myocardial Revascularization To the Editor: I would like to congratulate Sweeney and Frazier on an excellent article [I]. Indeed, recent advances in anesthetics, cardiopulmonary bypass, myocardial protection, and intensive care have made coronary artery bypass grafting a safe procedure. This is particularly true if applied to elective low-risk cases 121; however, the results of coronary artery bypass grafting in high-risk patients, particularly those in cardiogenic shock, are less favorable 13, 41. Sweeney and Frazier have elegantly shown that by applying an old concept [5], the results of coronary artery bypass grafting in high-risk patients rival those of routine operation. The same technique has been used in the Silesian Heart Centre, Katowice,
Poland, for a number of years with similar results (A. Bohenic, personal communication, 1992). One of the main advantages of this technique seems to be the prevention of the global myocardial and pulmonary ischemia-reperfusion injury that occurs in conventional coronary operations [6]. The technique of device-supported myocardial revascularization would strengthen the argument for emergency coronary artery bypass grafting for patients in cardiogenic shock secondary to acute myocardial infarction, the prognosis of whom remained poor and unchanged over the last decade [7]. It is hard to say whether this technique would improve the results of operative treatment of acute ischemic mitral regurgitation and acute postinfarction ventricular septal defect [8]. The ventricular cannulation sites for ventricular assist devices are usually attended by a significantly higher complication rate, particularly if the site of cannulation included an area of infarction (91. Because direct ventricular cannulation decompresses the left ventricle significantly better than left atrial or aortic outflow cannulation, the implications of this cannulation site-related morbidity after this new technique need to be highlighted.
Reida M . E l Oaklcy, FRCS Department of Cardiothorucic S i q y y Wythenshurt1e Hospital Southnioor Rd Manchcster M23 9LT England
References 1. Sweeney MS, Frazier OH. Device-supported myocardial revascularization: safe help for sick hearts. Ann Thorac Surg 1992;54:1065-70. 2. Kirklin JW, Akins CW, Blackstone EH, et al. Guidelines and indications for coronary artery bypass graft surgery. A report of the American College of Cardiology/American Heart Association Task Force on Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee on Coronary Artery Bypass Surgery). J Am Coll Cardiol 1991;17:543439. 3. Naunheim KS, Fiore AC, Fagan DC, et al. Emergency coronary artery bypass grafting for failed angioplasty: risk factors and outcome. Ann Thorac Surg 1989;47:816-23. 4. Edwards FH, Bellamy RF, Burge JR, et al. True emergency coronary artery bypass surgery. Ann Thorac Surg 1990;49: 60S11. 5. Drew CE, Keen G, Benazen DB. Profound hypothermia. Lancet 1959;1:7457. 6. Kukreja RC, Hess ML. The oxygen free radical system: from equations through membrane-protein interactions to cardiovascular injury and protection. Cardiovasc Res 1992;26: 641-55. 7. Willersson JT, Frazier OH. Reducing mortality in patients with extensive myocardial infarction. N Engl J Med 1991;325: 1166-8. 8. Jones MT, Schofield I'M, Dark JF, et al. Surgical repair of acquired ventricular septal defect. J Thorac Cardiovasc Surg 1987;93:68M. 9. Pennock JL, Wiseman CB, Bull AP, Waldhausen JA. Survival and complication following ventricular assist pumping for cardiogenic shock. Ann Surg 1985;198:469-71.
Bronchial Polyp Secondary to Foreign Body To the Editor: We read with interest the review of tracheobronchial squamous papillomas by Naka and associates [I]. Benign inflammatory bronchial polyps are similar to squamous papillomas, and the two entities are easily confused [2]. Inflammatory polyps may
Ann I horac Surg 1993;56:39W2
occur in association with long-standing bronchial foreign bodies. To draw attention to this relationship and its implications for management of benign bronchial polypoid tumors, we report a case. A 70-year-old man complained of cough of 4 months’ duration and a single episode of hemoptysis. Right middle lobe collapse was seen on chest radiography. Flexible bronchoscopy showed a polypoid lesion arising from the membranous portion of the right main bronchus (Fig 1)and a foreign body in the right middle lobe bronchus. A spherical vegetable matter foreign body was extracted. Bronchial polyp was removed by rigid bronchoscopy. Microscopic examination showed a polypoid mass with a fibrous stalk covered by benign metaplastic squamous epithelium (Fig 2). Benign bronchial polyps are classified into three groups: multiple papillomas, solitary papillomas, and inflammatory polyps (31. Multiple papillomas, caused by human papilloma virus infection, are closely related to laryngeal papillomatosis. Solitary papillomas are benign tumors characterized by frondlike proliferation of metaplastic or dysplastic squamous epithelium [l, 21. Carcinoma in situ may develop [4]. Solitary bronchial papillomas are analogous to skin papillomas [3]. Inflammatory polyps are non-neoplastic proliferations of fibrous tissue and epithelium that develop in response to chronic infection, foreign bodies, asthma, or inhalation injury [2, 51. They are analogous to benign inflammatory nasal polyps [6]. It is difficult to differentiate solitary papillomas from inflammatory polyps on endoscopic examination. The possibility of bronchial foreign body should always be considered. Bronchoscopic removal is the treatment of choice for benign inflammatory bronchial polyps. It is both diagnostic and therapeutic. Surgical resection is unnecessarily radical [6].
john D . Urschel, M D William 1. Dickout, M D Glen D . Neuman, M D john M . Danyluk, M D Thoracic Diseases Unit Misericordia Hospital Edmonton, Alberta Canada T5R 4H5
References 1. Naka Y, Nakao K, Hamaji Y, Nakahara M, Tsujimoto M, Nakahara K. Solitary squamous cell papilloma of the trachea. Ann Thorac Surg 1993;55:189-93. 2. Freant LJ, Sawyers JL. Benign bronchial polyps and papillomas. Ann Thorac Surg 1971;11:46&7.
Fig I . Polyp in right main bronchus.
CORRESPONDENCE
399
Fig 2 Benign bronchial polyp. The fibrous stalk is lined by respiratory and metaplastic squamous epithelium. (Hematoxylin and eosrn, x 4 0 before 35% reduction.)
3. Drennan JM, Douglas AC. Solitary papilloma of a bronchus. J Clin Pathol 1965;18:401-2. 4. Spencer H, Dail DH, Arneaud J. Non-invasive bronchial epithelial papillary tumors. Cancer 1980;45.1486-97. 5. Barzo P, Molnar L, Minik K. Bronchial papillomas of vanous origins. Chest 1987;92:132-6 6. Saini VK, Wahi PL. Inflammatory polyp of the bronchus. Ann Thorac Surg 1968;5:141-5.
Reply To the Editor: I thank Dr Urschel and his colleagues for their comments I will discuss solitary papilloma and inflammatory polyp in this letter, although bronchial papillomas are divided into three groups: (1) multiple papillomas, (2) solitary papillomas, and (3) inflammatory polyps. As I stated in a previous review [l],I fundamentally agree with their opinion about the treatment of inflammatory bronchial polyps. However, I would like to contradict their statement that bronchoscopic removal is the treatment of choice for benign inflammatory polyps and surgical resection is unnecessarily radical. Bronchial inflammatory polyp and solitary squamous cell papilloma are very similar on endoscopic examination, but can be easily differentiated on histologic examination, as described in the letter by Urschel and associates and in the previous literature. In addihon, Spencer and colleagues [2] emphasized that solitary papillomas in individuals more than 40 years of age could ultimately develop carcinomatous change and should be searched carefully for foci of transformahon. Biopsy and histologic examinahon may be the first step in treating bronchial papillary polypoid lesion. In case of a wide-based tumor or a tumor that is poorly visualized on bronchoscopy, surgical resection should be recommended, even if the tumor is definitely diagnosed as an inflammatory polyp. The bronchial polyp in the patient reported by Urschel and his associates could be completely removed by endoscopy because the tumor was sited in the right middle lobe
Ann Thorac Surg 1993;5639W2
CORRESPONDENCE
human internal thoracic artery. Ring segments (3 mm) of human internal thoracic artery were submaximally contracted with norepiphrine then relaxed with acetylcholine, an endotheliumdependent relaxant. In the presence of free hemoglobin in the organ bath, 0.1 pmol/L or 0.5 pmol/L, endothelium-dependent relaxation was reduced by 44% and 5576, respectively. The levels of free hemoglobin used in these experiments are within the range measured in patients' plasma (unpublished results). The increasing understanding of the endothelium as a regulatory organ of the circulatory system emphasizes the importance of its products and their inhibition. The generation of free plasma hemoglobin during CPB therefore should be noted because of the vasoactive effects it has on systemic blood pressure and blood flow through vascular conduits after CPB.
Anthony C . De Souza, FRCS Thoinas 1. Spyt, M D Dcparttnent of S u r y c y Leicester Royal fnfirniary PO Box 65, Leicestcr England LE2 7LX
References 1. Downing SW, Edmunds LH. Release of vasoactive substances during cardiopulmonary bypass. Ann Thorac Surg 1992;54: 1236-43. 2. De Souza AC, Samani N, Chambers K, West K, Spyt TJ. Free haemoglobin inhibition of EDRF-a mechanism of post cardiopulmonary bypass hypertension. Presented at the 12th Annual Cardiothoracic Surgery Symposium, Pathophysiology and Techniques of Cardiopulmonary Bypass, San Diego, CA, Feb 1992. 3. Tanaka K, Kanamori Y, Sato T, et al. Administration of haptoglobin during cardiopulmonary bypass surgery. ASAIO Trans 1991;37:M482-3. 4. Edwards DH, Griffith TM, Ryley HC, Henderson AH. Haptoglobin-haemoglobin complex in human plasma inhibits endothelium independent relaxation: evidence that endothelium derived factor acts as a local autocoid. Cardiovasc Res 1986; 20:549-56. 5. Hoar PF, Hickey RF, Ullyot DJ. Systemic hypertension following myocardial revascularization. J Thorac Cardiovasc Surg 1976;71:85944. 6. Sarrel I'M, Lindsay DC, Poole-Wilson PA, Collins P. Hypothesis: inhibition of endothelium-derived relaxing factor by haemoglobin in the pathogenesis of pre-eclampsia. Lancet 1990;336:103&2. 7. Martin W, Villani GM, Jothianandan D, Furchgott RF. Selective blockade of endothelium-dependent and glyceryl trinitrate induced relaxation by hemoglobin and by methylene blue in the rabbit aorta. J Pharmacol Exp Ther 1985;232:708-16.
Device-Supported Myocardial Revascularization To the Editor: I would like to congratulate Sweeney and Frazier on an excellent article [I]. Indeed, recent advances in anesthetics, cardiopulmonary bypass, myocardial protection, and intensive care have made coronary artery bypass grafting a safe procedure. This is particularly true if applied to elective low-risk cases 121; however, the results of coronary artery bypass grafting in high-risk patients, particularly those in cardiogenic shock, are less favorable 13, 41. Sweeney and Frazier have elegantly shown that by applying an old concept [5], the results of coronary artery bypass grafting in high-risk patients rival those of routine operation. The same technique has been used in the Silesian Heart Centre, Katowice,
Poland, for a number of years with similar results (A. Bohenic, personal communication, 1992). One of the main advantages of this technique seems to be the prevention of the global myocardial and pulmonary ischemia-reperfusion injury that occurs in conventional coronary operations [6]. The technique of device-supported myocardial revascularization would strengthen the argument for emergency coronary artery bypass grafting for patients in cardiogenic shock secondary to acute myocardial infarction, the prognosis of whom remained poor and unchanged over the last decade [7]. It is hard to say whether this technique would improve the results of operative treatment of acute ischemic mitral regurgitation and acute postinfarction ventricular septal defect [8]. The ventricular cannulation sites for ventricular assist devices are usually attended by a significantly higher complication rate, particularly if the site of cannulation included an area of infarction (91. Because direct ventricular cannulation decompresses the left ventricle significantly better than left atrial or aortic outflow cannulation, the implications of this cannulation site-related morbidity after this new technique need to be highlighted.
Reida M . E l Oaklcy, FRCS Department of Cardiothorucic S i q y y Wythenshurt1e Hospital Southnioor Rd Manchcster M23 9LT England
References 1. Sweeney MS, Frazier OH. Device-supported myocardial revascularization: safe help for sick hearts. Ann Thorac Surg 1992;54:1065-70. 2. Kirklin JW, Akins CW, Blackstone EH, et al. Guidelines and indications for coronary artery bypass graft surgery. A report of the American College of Cardiology/American Heart Association Task Force on Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee on Coronary Artery Bypass Surgery). J Am Coll Cardiol 1991;17:543439. 3. Naunheim KS, Fiore AC, Fagan DC, et al. Emergency coronary artery bypass grafting for failed angioplasty: risk factors and outcome. Ann Thorac Surg 1989;47:816-23. 4. Edwards FH, Bellamy RF, Burge JR, et al. True emergency coronary artery bypass surgery. Ann Thorac Surg 1990;49: 60S11. 5. Drew CE, Keen G, Benazen DB. Profound hypothermia. Lancet 1959;1:7457. 6. Kukreja RC, Hess ML. The oxygen free radical system: from equations through membrane-protein interactions to cardiovascular injury and protection. Cardiovasc Res 1992;26: 641-55. 7. Willersson JT, Frazier OH. Reducing mortality in patients with extensive myocardial infarction. N Engl J Med 1991;325: 1166-8. 8. Jones MT, Schofield I'M, Dark JF, et al. Surgical repair of acquired ventricular septal defect. J Thorac Cardiovasc Surg 1987;93:68M. 9. Pennock JL, Wiseman CB, Bull AP, Waldhausen JA. Survival and complication following ventricular assist pumping for cardiogenic shock. Ann Surg 1985;198:469-71.
Bronchial Polyp Secondary to Foreign Body To the Editor: We read with interest the review of tracheobronchial squamous papillomas by Naka and associates [I]. Benign inflammatory bronchial polyps are similar to squamous papillomas, and the two entities are easily confused [2]. Inflammatory polyps may
Ann I horac Surg 1993;56:39W2
occur in association with long-standing bronchial foreign bodies. To draw attention to this relationship and its implications for management of benign bronchial polypoid tumors, we report a case. A 70-year-old man complained of cough of 4 months’ duration and a single episode of hemoptysis. Right middle lobe collapse was seen on chest radiography. Flexible bronchoscopy showed a polypoid lesion arising from the membranous portion of the right main bronchus (Fig 1)and a foreign body in the right middle lobe bronchus. A spherical vegetable matter foreign body was extracted. Bronchial polyp was removed by rigid bronchoscopy. Microscopic examination showed a polypoid mass with a fibrous stalk covered by benign metaplastic squamous epithelium (Fig 2). Benign bronchial polyps are classified into three groups: multiple papillomas, solitary papillomas, and inflammatory polyps (31. Multiple papillomas, caused by human papilloma virus infection, are closely related to laryngeal papillomatosis. Solitary papillomas are benign tumors characterized by frondlike proliferation of metaplastic or dysplastic squamous epithelium [l, 21. Carcinoma in situ may develop [4]. Solitary bronchial papillomas are analogous to skin papillomas [3]. Inflammatory polyps are non-neoplastic proliferations of fibrous tissue and epithelium that develop in response to chronic infection, foreign bodies, asthma, or inhalation injury [2, 51. They are analogous to benign inflammatory nasal polyps [6]. It is difficult to differentiate solitary papillomas from inflammatory polyps on endoscopic examination. The possibility of bronchial foreign body should always be considered. Bronchoscopic removal is the treatment of choice for benign inflammatory bronchial polyps. It is both diagnostic and therapeutic. Surgical resection is unnecessarily radical [6].
john D . Urschel, M D William 1. Dickout, M D Glen D . Neuman, M D john M . Danyluk, M D Thoracic Diseases Unit Misericordia Hospital Edmonton, Alberta Canada T5R 4H5
References 1. Naka Y, Nakao K, Hamaji Y, Nakahara M, Tsujimoto M, Nakahara K. Solitary squamous cell papilloma of the trachea. Ann Thorac Surg 1993;55:189-93. 2. Freant LJ, Sawyers JL. Benign bronchial polyps and papillomas. Ann Thorac Surg 1971;11:46&7.
Fig I . Polyp in right main bronchus.
CORRESPONDENCE
399
Fig 2 Benign bronchial polyp. The fibrous stalk is lined by respiratory and metaplastic squamous epithelium. (Hematoxylin and eosrn, x 4 0 before 35% reduction.)
3. Drennan JM, Douglas AC. Solitary papilloma of a bronchus. J Clin Pathol 1965;18:401-2. 4. Spencer H, Dail DH, Arneaud J. Non-invasive bronchial epithelial papillary tumors. Cancer 1980;45.1486-97. 5. Barzo P, Molnar L, Minik K. Bronchial papillomas of vanous origins. Chest 1987;92:132-6 6. Saini VK, Wahi PL. Inflammatory polyp of the bronchus. Ann Thorac Surg 1968;5:141-5.
Reply To the Editor: I thank Dr Urschel and his colleagues for their comments I will discuss solitary papilloma and inflammatory polyp in this letter, although bronchial papillomas are divided into three groups: (1) multiple papillomas, (2) solitary papillomas, and (3) inflammatory polyps. As I stated in a previous review [l],I fundamentally agree with their opinion about the treatment of inflammatory bronchial polyps. However, I would like to contradict their statement that bronchoscopic removal is the treatment of choice for benign inflammatory polyps and surgical resection is unnecessarily radical. Bronchial inflammatory polyp and solitary squamous cell papilloma are very similar on endoscopic examination, but can be easily differentiated on histologic examination, as described in the letter by Urschel and associates and in the previous literature. In addihon, Spencer and colleagues [2] emphasized that solitary papillomas in individuals more than 40 years of age could ultimately develop carcinomatous change and should be searched carefully for foci of transformahon. Biopsy and histologic examinahon may be the first step in treating bronchial papillary polypoid lesion. In case of a wide-based tumor or a tumor that is poorly visualized on bronchoscopy, surgical resection should be recommended, even if the tumor is definitely diagnosed as an inflammatory polyp. The bronchial polyp in the patient reported by Urschel and his associates could be completely removed by endoscopy because the tumor was sited in the right middle lobe