Selective Bronchography following Fiberoptic Bronchoscopy

oid-appearing fibrous connective tissue. These areas were highly vascularized and contained spindle and stellate cells with prominent eosinophilic cytoplasm. Cross-striations were

TO TH© eDITOR

lacking. The nuclei did not exhibit hyperchromatism, coarse chromatin, or abnormal mitoses. Denser regions had fewer

Communications

for this section

and priorities

permit.

The

comments

words

in length,

figure

or table can be printed.

particular

with a maximum

circumstances.

of unique

to publish a

should

space

Exceptions

may occur may

character.

cially in the myxoid areas. The spicules of bone showed

one

evidence of osteoblastic and osteoclastic activity. This patho-

under

logic description is much like the descriptions of the tissue

com-

reclaimed from the heart and brain of this patient. Detailed

include

should be cited in a covering

or they may

Specific

spindle cells. Deposits of hemosiderin were abundant, espe-

500

not exceed

in this periodical,

educational

as

of five references;

Contributions

ments on articles published reports

will be published

be

permission

letter or appended

as

ultrastructural examinations of the scapular tissue and the tissue from the brain is presently being done. The intracranial lesion arose in an area previously subjected to embolism. The patient's bone scan is consistent with

postscript.

metastatic disease. The specimens of tissue removed from her heart, brain, and bone are similar in appearance. Thus, we are

The Nature of Cardiac Myxomas To the

comfortable in attributing the extracardiac lesions in this patient to the primary cardiac tumor, rather than to three

Editor:

separate

A controversy exists as to the nature of cardiac myxomas.

unrelated

attributable to local mechanics

as suggested by Page Laura I. Rankin,

W h e t h e r they are neoplasms or organized thrombi with a distinctive morphology

processes,

and

Hutchins. Indiana

at

University

Medical Center,

M.D.

Indianapolis

their site of origin has not been determined. In view of this unresolved question, the recent report b y Rankin and DeSousa

must be considered unfortunate. F r o m the limited

1

information given, it seems very likely that the patient had the

following

three

unrelated

conditions:

(1)

an

atrial

myxoma; ( 2 ) a chondroid neoplasm; and ( 3 ) a myxopapillary ependymoma. T h e implication that the multiple lesions of the bones and the neoplasm

arising from the

choroid

plexus were metastases from a left atrial myxoma removed eight years before is unlikely and unsubstantiated. T h e uncommon "malignant" behavior of atrial myxomas may

be

accounted for by explanations that do not require the lesions to be neoplasms. malignant

2

It is, therefore, important that claims for

behavior

of

cardiac

pathologic documentation,

myxomas

have

adequate

a feature lacking in this

case

report. David L. Page, M.D., Department Vanderhilt and Grover M. Hutchins, Johns Hopkins

University,

Pathology;

Nashville,

M.D., Department Medical

of

Tenn;

of

Pathology,

Institutions,

Baltimore

Reprint requests: Dr. Rankin, Indiana University Center, 1100 West Michigan, Indianapolis 45223

Medical

Selective Bronchography following Fiberoptic Bronchoscopy To the

Editor:

Bronchography has been performed by three major techniques,

ie,

transcricothyroid

puncture,

transnasolaryngeal

passage, and passage through an endotracheal tube. The technique of transcricothyroid puncture has associated problems of infection, bleeding, and subcutaneous emphysema. The transnasolaryngeal passage is limited at times by the difficulty in blindly passing the catheter, and the technique of passage

through

an endotracheal

tube requires an anes-

thesiologist in attendance, with the concomitant expense. The procedures are limited by ( 1 ) the loss of anesthesia resulting in coughing and alveolarization and ( 2 ) the expense. W e describe a technique of selective bronchography fol-

REFERENCES 1 Rankin L I , DeSousa A L : Metastatic atrial myxoma presenting as intracranial mass. Chest 7 4 : 4 5 1 - 4 5 2 , 1 9 7 8 2 Salyer W R , P a g e D L , Hutchins G M : T h e development of cardiac myxomas and papillary endocardial lesions from mural thrombus. Am Heart J 8 9 : 4 - 1 7 , 1 9 7 5 To the

Editor:

P a g e and Hutchins point out the controversy that exists as to the nature of cardiac myxomas. W e were unable to supply detailed information because of limitations on space. Tissue removed from the brain was compared microscopically to that removed from the heart. Since the specimens were identical in appearance, we believed we were justified in preparing our report. In addition, in December 1 9 7 8 , the patient underwent excision of a painful scapular lesion (illustrated in our case report; Chest 7 4 : 4 5 1 - 4 5 2 , 1 9 7 8 ) . T h e tissue removed from the acromion and scapula had rubbery yellowish areas intermixed with translucent gelatinous areas. Intertwined through these areas were firm, whitish, partially calcified cartilaginous bands. Histologic sections revealed focal collections of myx-

240

COMMUNICATIONS TO THE EDITOR

lowing fiberoptic bronchoscopy which can be performed in an additional five minutes with little additional expense and no increase in morbidity. TECHNIQUE T h e nasal passageway and pharynx are anesthetized with a 1 percent solution of lidocaine ( X y l o c a i n e ) . The bronchoscope is advanced through the nasal passageway, and the epiglottis and vocal cords are visualized and anesthetized. T h e bronchoscope is then passed into the trachea, and the trachea and bronchial tree are anesthetized. Bronchoscopic examination of all of the segments is then performed. T h e segment in question is then localized, and additional anesthesia is administered until the cough reflex is totally suppressed. A 1 4 5 - c m 0.035-inch guide wire is advanced through the suctioning channel of the bronchoscope into the selected segment ( F i g 1 ) . The bronchoscope is withdrawn over the wire. A No. 10 French blunt-tipped soft rubber catheter is advanced over the guide wire. The guide wire is removed, and 3 to 5 ml of warm propyliodone (Dionosil) is instilled under fluoroscopic control, after decantation of the supernatant peanut oil. Chest x-ray films are obtained in the anteroposterior, lateral, and oblique projections. This completes the procedure.

CHEST, 76: 2, AUGUST, 1979

intrapleural therapy with tetracycline to be effective in 8 3 to 100 percent of the patients with malignant pleural effusions; our rate of successful treatment approaches 9 0 percent.

4

In

addition, studies in animals have confirmed the effectiveness of tetracycline

in producing pleural symphysis and

have

suggested that there is a dose-related response. Perhaps one 5

explanation for the lower rate of successful

tetracycline-

induced pleural symphysis reported by Lees and Hoy was more

extensive

pleural

involvement with

tumor

in

their

patients. W e have noted that patients who have a malignant effusion with a low level of glucose and a low p H have a poor rate of successful pleurodesis, when compared to those who have effusions with a normal p H and a normal level of glucose.

We

think

that this is due

infiltration by the tumor,

to extensive

pleural

which makes the likelihood of

pleurodesis low, and the development of a "trapped lung" due to visceral pleural carcinomatosis more likely. If successful reexpansion of the lung cannot be accomplished, it is impossible to obliterate the space with instillation of the sclerosing agent, and this should probably not be attempted. W e think that properly selected patients with malignant pleural effusions should have a high rate ( > 8 0 percent) of successful pleural symphysis following drainage via a chest FIGURE 1. Guide wire advanced through suctioning channel of bronchoscope into selected segment.

tube and intrapleural instillation of 15 to 2 0 mg of tetracycline per kilogram of body weight. James and Steven

DISCUSSION The use of this technique following the

University

procedure allows us to obtain a diagnostic bronchogram in an additional five minutes of time. This technique saves the patient from an additional procedure, with its accompanying morbidity and expense.

Hospital

Meals,

D.O.;

Burton

D.O.; and William

of Philadelphia

College

Marks,

Dickerson,

of Osteopathic

D.O.; D.O.,

Medicine, Philadelphia

Reprint requests: Mawr, Pennsylvania

Dr. Simelaro, 19010

624

Heather

Lane,

Bryn

Management of Pleural Effusions in Cancer of the Breast To the

requests:

of Pulmonary

Sciences,

of Colorado

Dr. Good,

M.D.

Medical

Center,

Denver

4200 East Ninth

Avenue,

Denver

REFERENCES

John P. Simelaro, Robert

Reprint 80262

Jr.,

F.C.C.P.,

Division

bronchoscopic

T. Good,

A. Sahn, M.D.,

Editor:

In the article entitled "Management of Pleural Effusions in Breast C a n c e r " (Chest 7 5 : 5 1 - 5 3 , 1 9 7 9 ) , Lees and Hoy report their experience in treating pleural effusions associated with carcinoma of the breast. While their study is a retrospective analysis, the numbers are large, and their technique for instillation of sclerosing agents into the pleural space following drainage via a chest tube appears a d e q u a t e . Since it is recognized that carcinoma of the breast is a malignant neoplasm producing malignant effusions in which the prognosis is not so ominous, successful management of these effusions is extremely important. 1

W e were surprised by the results of Lees and Hoy showing no significant difference between the four groups of therapeutic manipulations, which included ( 1 ) thoracocentesis alone, ( 2 ) thoracocentesis plus instillation of an alkalating agent, ( 3 ) drainage via a chest tube plus instillation of an alkalating agent, and ( 4 ) drainage via a chest tube plus instillation of tetracycline. Their report rate of successful obliteration of the pleural space with tetracycline is much lower (approaching 5 0 percent) than has been reported previously. Both W a l l a c h and Rubinson and Bolooki report 2

CHEST, 76: 2, AUGUST, 1979

3

1 Good J T Jr, Sahn SA: Intrapleural therapy with tetracycline in malignant pleural effusions: The importance of proper technique (letter to e d i t o r ) . Chest 7 4 : 6 0 2 , 1 9 7 8 2 Wallach H W : Intrapleural tetracycline for malignant pleural effusions. Chest 6 8 : 5 1 0 - 5 1 2 , 1 9 7 5 3 Rubinson RM, Bolooki H : Intrapleural tetracycline for control of malignant pleural effusions. South Med J 6 5 : 8 4 7 8 4 9 , 1972 4 Sahn SA, Good J T Jr, Potts D E : T h e p H of sclerosing agents: A determinant of pleural symphysis. Chest, to be published 5 Sahn SA, Potts D E : The effect of tetracycline on the pleural membrane of rabbits. Am Rev Respir Dis 1 1 7 : 4 9 3 499, 1978 To the

Editor:

The comparison of results of the management of pleural effusion in cancer of the breast is difficult unless the criteria for judging the rate of response are the s a m e . from Edmonton, Alberta (Chest

1

Our results

7 5 : 5 1 - 5 3 , 1 9 7 9 ) , apply only

to cancer of the breast, were calculated by actuarial methods, and refer to greater numbers and longer periods of follow-up than those of W a l l a c h

2

and of Rubinson and Bolooki

3

and,

therefore, cannot be directly compared. The report by Sahn et a l

of 9 0 percent obliteration is impressive, but as the

4

report is in press a t the time of this writing, there is no indication as to whether tiris refers only to cancer of the breast and whether this result was calculated on an actuarial basis. An effect related to dosage of tetracycline was sought but not found in our study. There is no way of telling whether our patients had more extensive pleural involvement than those in the other rep o r t s . " T h e collaborating thoracic surgeons have suggested 1

4

COMMUNICATIONS TO THE EDITOR 241