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Use of Nd:YAG Laser in Endobronchial Kaposi's Sarcoma
Use of Nd:YAG Laser in Endobronchial Kaposi's Sarcoma* Steven Nathan, M.D.; Rati Vaghaiwalla, M.D.; and Zab Mohsenifar, M.D., FC.C.P
An unusual case of endobronchial Kaposi's sarcoma causing right middle and lower lobe atelectasis is reported. The lesion was successfully removed with Nd-YAG laser photoresection. (Chest 1990; 98:1299-1300)
ulmonary Kaposi's sarcoma is commonly associated with cutaneous lesions in patients with AIDS. We report an unusual presentation of this entity in a presumptively HIVpositive patient without cutaneous involvement.
P
CASE REPORT
The patient was a 40-year-old hIack homosexual man who was in his usual state of health until two weeks prior to admission, when he developed symptoms of chills, fevers, and myal~as. He was seen by his private physician and was treated with ciproRoxacin (500 mg orally twice daily) for ten days, with improvement in his symptoms; however, two days prior to his admission, the patient developed increasing shortness of breath and a cough productive of purulent sputum. He was seen once again by his private physician who admitted him for further evaluation. Upon admission the patient was febrile to 39.4°C (103°F) but had otherwise normal vital signs. The findings from physical examination were remarkable for shotty cervical lymphadenopathy and diminished breath sounds at the right base. The laboratory tests upon admission were significant for a white blood cell <."Ount of 8,600/cu mm, with 56 percent polymorphonuclear leukocytes, 3 percent band forms, 31 percent lymphocytes, 6 percent monocytes, 3 percent eosinophils, and 1 percent basophils. His arterial blood gas levels on rlKlm air were as follows: pH 7.47; PaCO., 34 mm Hg; PaO., 65 mm Hg; bicarbonate, 24 mEqlL; and oxyhemoglobin saturation, 93 percent. The patient refused an HIV test, but his Thelper to T-suppressor ratio was 0.3. His chest roentgenogram upon admission revealed evidence of right middle lobe and right lower lobe atelectasis (Fig 1). A Rexible fiberoptic bronchoscopy was performed, and an exophytic gmy lesion was noted to be occluding the hronchus intermedius (Fig 2). Biopsy of this mass was performed and was found to be consistent with Kaposi's sarcoma. The patient was taken to the opemting room for removal of the lesion with Nd-YAG laser photoresection. At the time of the procedure, the lesion was noted to be exophytic and based on a wide pedicle which was easily photoresected with the laser beam; however, the procedure was mmplicated by bleeding in excess of 400 ml from the severed stalk. This was (.'Ontrolled with aggressive suctioning and the hemostatic effect of the YAG laser beam. After surgery the patient did quite well, with reexpansion of his atelectatic lohes (Fig 3) and complete resolution of his dyspnea.
FIGURE 1. Posteroanterior chest roentgenogram showing evidence of right middle and lower lobe atelectasis.
reported to occur in between 21 percent and 52 percent of the AIDS patients with Kaposi's san:oma'" who develop respiratory symptoms. Pulmonary Kaposi's sarcoma occurs in association with cutaneous or visceral lesions in approximately 92 percent of the cases; however, most of those patients without initial cutaneous involvement subsequently develop the characteristic cutaneous lesions.2.3s.. Radiographic features of pulmonary Kaposi's sarcoma may include interstitial infiltrates, alveolar infiltrates, or nodular densities. '.3.5,. Patients may also have pulmonary involvement with a clear chest roentgenogram. Pleural effusions can occur in association with parenchymal disease and have been re-
DISCUSSION
Kaposi's sarcoma occurs in approximately 35 percent of the patients with AIDS.' Pulmonary involvement has been *From the Division of Pulmonary Medicine, Department of Medicine, Cedars-Sinai Medical Center, UCLA School of Medicine, Los Angeles. Reprint requests: Dr. Nathan, Cedars-Sinai Medical Center, PIlInwnary Division, 8700 Beverly Blvd, ws Angeles 90048
FIGllRE 2. Endohronchial lesion occluding hronchus intermedius, as seen by Rexihle liheroptic hronchoscope. CHEST I 98 I 5 I NOVEMBER, 1990
1299
manifestations of Kaposi's sarmma. Chest 1987; 91:39-43 3 Meduri GU. Stover DE. Lee M. Myskowski PL. Camvelli JF. Zaman MB. Pulmonary Kaposi~s sarmma in the acquired immune deficiency syndrome. Am J Med 1986; 81:11-8 4 Niedt GW. Schinella RA. Acquired immune deficiency syndrome: a clinicopatholo¢cal study of 56 autopsies. Arch Pat hoi Lah Med 1985; 109:727-34 5 Sivit CJ. Schwartz AM. RockoH'SD. Kaposi~s sarcoma of the lung in AIDS. AJR 1987; 148:25-8 6 Fouret pJ. Touboul JL. Mayaud CM. Roland J. Pulmonary Kaposi's sarcoma in patients with acquired immune deficiency syndrome: a c1inicopatholo¢cal study. Thorax 1987; 42:262-68
The Malignancy-sarcoidosis Syndrome* john S. Suen, M.D.; Monique S. Forse. M.D.; Robert H. Hyland. M.D .• F.C.C.P.; and Charles K. Chan. M.D .• F.C.C.P.
FIGURE 3. Posteroanterior chest roentgenogram demonstrating complete resolution of right middle and lower lobe atelectasis. after successful removal of endobronchial lesion with Nd-YAG laser.
ported to occur in anywhere from 15 percent to 54 percent of the patients with pulmonary Kaposi's sarcoma. 2.3 Pleural effusions are usually exudative and serosanguineous with a negative cytologic examination. 2 Hilar or mediastinal lymphadenopathy or both have also been noted to occur (0 to 55 percent).2.3 Endobronchial Kaposi's sarcoma in association with parenchymal disease is a relatively common finding. occurring in anywhere from 32 percent to 89 percent of the patients with pulmonary Kaposi's sarcoma. 2.• The characteristic lesions are discrete, raised cherry-red to violaceous nodules which are multiple and tend to occur at segmental orifices. 2• Endobronchial biopsies have been reported to have a low sensitivity,'·3.• and the diagnosis of endobronchial Kaposi's sarcoma is based on the characteristic endoscopic appearance. Despite the vascular nature of the lesions, excessive bleeding on biopsy appears to be relatively rare. Therefore. when the diagnosis is in doubt, biopsy of the lesions is not contraindicated. 2.3 Our case was unusual in that there were no associated cutaneous lesions. Furthermore. the pedunculated nature of the lesion, its solitary occurrence, and the resultant atelectasis are all most unusual and previously undescribed manifestations of endobronchial Kaposi's sarcoma. Lastly. the successful. albeit sanguineous. removal of the lesion with Nd:YAG laser serves to underscore the vascular nature of these lesions and warrants caution. REFERENCES
O!!:nibene Fp, Steis RG. Macher AM. Kaposi's sarmma causin!!: pulmonary infiltrates and respiratory failure in the acquired immunodeficiencv svndrome. Ann Intern Med 1985: 102:471-75 2 Gamy SM. Bel~nk;l M. Fazzini E. Schinella R. Pulmonary
1300
In a retrospective review of six patients with malignancy preceding sarcoidosis, we found four cases of malignant Iymphoproliferative disease (LD) and one case each of ovarian cancer and breast cancer. The median interval from onset or relapse of malignancy to sarcoidosis was nine months. Of the four patients with LD, sarcoidosis appeared within six months of termination of chemotherapy for three of the patients and 15 months after allogeneic bone marrow transplantation for the fourth patient. At the time of diagnosis of sarcoidosis, there was no clinical or pathologic evidence of malignancy in the chest. We conclude that in contradistinction to the previously described syndrome of sarcoidosis preceding LD, there exists a syndrome of sarcoidosis following malignancy with or without chemo(Chest 1990; 98:1300-02) therapy.
I LD =Iymphoproliferative disease I ver the past two decades, there has heen increasing recognition of the coexistence of sarcoidosis and malignancy. Brincker and Wilbek' found that of 2.544 cases of sarcoidosis in a Danish registry, 48 patients had malignancy concurrent with or after the diagnosis of sarcoidosis. The observed occurrence rate was substantially more than the expected malignancy rate of 33.8 in an age- and sexmatched Danish general population. I They found that the difference was accounted for entirely hy increased numbers of mali/-,'Ilant lymphomas and lung cancers. with no significant differences between expected and observed rates of occurrence in other cancers. More recently, Brincker reviewed 46 cases of coexisting sarcoidosis and malignant
O
*From the Division of Respiratory and Critical Care Medicine. The Wellesley and Princess Margaret Hospitals. University of1hronto. limmto. Canada. Dr. Chan was supported in part by the Connaught Funds. Presented as an ahstract at the 55th Annual Scientific Assemhly. American Colle!!:e of Chest Physicians. Boston. Octoher 30Novemher 3. 1989. Rellrint requl'stS: Dr. Chan. Wellesley Hospital, 160 \\Hlesley Street, East. Ttmmto. Ontario, Canada MolY 1]3 Malignancy-Sarcoidosis
Syndrome (Suan at a/)
An unusual case of endobronchial Kaposi's sarcoma causing right middle and lower lobe atelectasis is reported. The lesion was successfully removed with Nd-YAG laser photoresection. (Chest 1990; 98:1299-1300)
ulmonary Kaposi's sarcoma is commonly associated with cutaneous lesions in patients with AIDS. We report an unusual presentation of this entity in a presumptively HIVpositive patient without cutaneous involvement.
P
CASE REPORT
The patient was a 40-year-old hIack homosexual man who was in his usual state of health until two weeks prior to admission, when he developed symptoms of chills, fevers, and myal~as. He was seen by his private physician and was treated with ciproRoxacin (500 mg orally twice daily) for ten days, with improvement in his symptoms; however, two days prior to his admission, the patient developed increasing shortness of breath and a cough productive of purulent sputum. He was seen once again by his private physician who admitted him for further evaluation. Upon admission the patient was febrile to 39.4°C (103°F) but had otherwise normal vital signs. The findings from physical examination were remarkable for shotty cervical lymphadenopathy and diminished breath sounds at the right base. The laboratory tests upon admission were significant for a white blood cell <."Ount of 8,600/cu mm, with 56 percent polymorphonuclear leukocytes, 3 percent band forms, 31 percent lymphocytes, 6 percent monocytes, 3 percent eosinophils, and 1 percent basophils. His arterial blood gas levels on rlKlm air were as follows: pH 7.47; PaCO., 34 mm Hg; PaO., 65 mm Hg; bicarbonate, 24 mEqlL; and oxyhemoglobin saturation, 93 percent. The patient refused an HIV test, but his Thelper to T-suppressor ratio was 0.3. His chest roentgenogram upon admission revealed evidence of right middle lobe and right lower lobe atelectasis (Fig 1). A Rexible fiberoptic bronchoscopy was performed, and an exophytic gmy lesion was noted to be occluding the hronchus intermedius (Fig 2). Biopsy of this mass was performed and was found to be consistent with Kaposi's sarcoma. The patient was taken to the opemting room for removal of the lesion with Nd-YAG laser photoresection. At the time of the procedure, the lesion was noted to be exophytic and based on a wide pedicle which was easily photoresected with the laser beam; however, the procedure was mmplicated by bleeding in excess of 400 ml from the severed stalk. This was (.'Ontrolled with aggressive suctioning and the hemostatic effect of the YAG laser beam. After surgery the patient did quite well, with reexpansion of his atelectatic lohes (Fig 3) and complete resolution of his dyspnea.
FIGURE 1. Posteroanterior chest roentgenogram showing evidence of right middle and lower lobe atelectasis.
reported to occur in between 21 percent and 52 percent of the AIDS patients with Kaposi's san:oma'" who develop respiratory symptoms. Pulmonary Kaposi's sarcoma occurs in association with cutaneous or visceral lesions in approximately 92 percent of the cases; however, most of those patients without initial cutaneous involvement subsequently develop the characteristic cutaneous lesions.2.3s.. Radiographic features of pulmonary Kaposi's sarcoma may include interstitial infiltrates, alveolar infiltrates, or nodular densities. '.3.5,. Patients may also have pulmonary involvement with a clear chest roentgenogram. Pleural effusions can occur in association with parenchymal disease and have been re-
DISCUSSION
Kaposi's sarcoma occurs in approximately 35 percent of the patients with AIDS.' Pulmonary involvement has been *From the Division of Pulmonary Medicine, Department of Medicine, Cedars-Sinai Medical Center, UCLA School of Medicine, Los Angeles. Reprint requests: Dr. Nathan, Cedars-Sinai Medical Center, PIlInwnary Division, 8700 Beverly Blvd, ws Angeles 90048
FIGllRE 2. Endohronchial lesion occluding hronchus intermedius, as seen by Rexihle liheroptic hronchoscope. CHEST I 98 I 5 I NOVEMBER, 1990
1299
manifestations of Kaposi's sarmma. Chest 1987; 91:39-43 3 Meduri GU. Stover DE. Lee M. Myskowski PL. Camvelli JF. Zaman MB. Pulmonary Kaposi~s sarmma in the acquired immune deficiency syndrome. Am J Med 1986; 81:11-8 4 Niedt GW. Schinella RA. Acquired immune deficiency syndrome: a clinicopatholo¢cal study of 56 autopsies. Arch Pat hoi Lah Med 1985; 109:727-34 5 Sivit CJ. Schwartz AM. RockoH'SD. Kaposi~s sarcoma of the lung in AIDS. AJR 1987; 148:25-8 6 Fouret pJ. Touboul JL. Mayaud CM. Roland J. Pulmonary Kaposi's sarcoma in patients with acquired immune deficiency syndrome: a c1inicopatholo¢cal study. Thorax 1987; 42:262-68
The Malignancy-sarcoidosis Syndrome* john S. Suen, M.D.; Monique S. Forse. M.D.; Robert H. Hyland. M.D .• F.C.C.P.; and Charles K. Chan. M.D .• F.C.C.P.
FIGURE 3. Posteroanterior chest roentgenogram demonstrating complete resolution of right middle and lower lobe atelectasis. after successful removal of endobronchial lesion with Nd-YAG laser.
ported to occur in anywhere from 15 percent to 54 percent of the patients with pulmonary Kaposi's sarcoma. 2.3 Pleural effusions are usually exudative and serosanguineous with a negative cytologic examination. 2 Hilar or mediastinal lymphadenopathy or both have also been noted to occur (0 to 55 percent).2.3 Endobronchial Kaposi's sarcoma in association with parenchymal disease is a relatively common finding. occurring in anywhere from 32 percent to 89 percent of the patients with pulmonary Kaposi's sarcoma. 2.• The characteristic lesions are discrete, raised cherry-red to violaceous nodules which are multiple and tend to occur at segmental orifices. 2• Endobronchial biopsies have been reported to have a low sensitivity,'·3.• and the diagnosis of endobronchial Kaposi's sarcoma is based on the characteristic endoscopic appearance. Despite the vascular nature of the lesions, excessive bleeding on biopsy appears to be relatively rare. Therefore. when the diagnosis is in doubt, biopsy of the lesions is not contraindicated. 2.3 Our case was unusual in that there were no associated cutaneous lesions. Furthermore. the pedunculated nature of the lesion, its solitary occurrence, and the resultant atelectasis are all most unusual and previously undescribed manifestations of endobronchial Kaposi's sarcoma. Lastly. the successful. albeit sanguineous. removal of the lesion with Nd:YAG laser serves to underscore the vascular nature of these lesions and warrants caution. REFERENCES
O!!:nibene Fp, Steis RG. Macher AM. Kaposi's sarmma causin!!: pulmonary infiltrates and respiratory failure in the acquired immunodeficiencv svndrome. Ann Intern Med 1985: 102:471-75 2 Gamy SM. Bel~nk;l M. Fazzini E. Schinella R. Pulmonary
1300
In a retrospective review of six patients with malignancy preceding sarcoidosis, we found four cases of malignant Iymphoproliferative disease (LD) and one case each of ovarian cancer and breast cancer. The median interval from onset or relapse of malignancy to sarcoidosis was nine months. Of the four patients with LD, sarcoidosis appeared within six months of termination of chemotherapy for three of the patients and 15 months after allogeneic bone marrow transplantation for the fourth patient. At the time of diagnosis of sarcoidosis, there was no clinical or pathologic evidence of malignancy in the chest. We conclude that in contradistinction to the previously described syndrome of sarcoidosis preceding LD, there exists a syndrome of sarcoidosis following malignancy with or without chemo(Chest 1990; 98:1300-02) therapy.
I LD =Iymphoproliferative disease I ver the past two decades, there has heen increasing recognition of the coexistence of sarcoidosis and malignancy. Brincker and Wilbek' found that of 2.544 cases of sarcoidosis in a Danish registry, 48 patients had malignancy concurrent with or after the diagnosis of sarcoidosis. The observed occurrence rate was substantially more than the expected malignancy rate of 33.8 in an age- and sexmatched Danish general population. I They found that the difference was accounted for entirely hy increased numbers of mali/-,'Ilant lymphomas and lung cancers. with no significant differences between expected and observed rates of occurrence in other cancers. More recently, Brincker reviewed 46 cases of coexisting sarcoidosis and malignant
O
*From the Division of Respiratory and Critical Care Medicine. The Wellesley and Princess Margaret Hospitals. University of1hronto. limmto. Canada. Dr. Chan was supported in part by the Connaught Funds. Presented as an ahstract at the 55th Annual Scientific Assemhly. American Colle!!:e of Chest Physicians. Boston. Octoher 30Novemher 3. 1989. Rellrint requl'stS: Dr. Chan. Wellesley Hospital, 160 \\Hlesley Street, East. Ttmmto. Ontario, Canada MolY 1]3 Malignancy-Sarcoidosis
Syndrome (Suan at a/)