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This article reports the case of a 4-year-old boy who suffered trauma to the thorax, with a fracture and late stenosis of the main left bronchus. The technique to enlarge the bronchial lumen used a free cartilage graft. The clinical and radiological results were very satisfactory.
A 1,100-g infant was found to have a right tension pneumothorax following multiple attempts at endotracheal intubation. Despite the use of high-frequency ventilation, adequate oxygenation was not possible. Bronchoscopy was hazardous, and bronchography of the right lung using propyliodone oil suspension confirmed perforation of the bronchus intermedius. At thoracotomy, while on high-frequency ventilation, the size of the perforation precluded suture repair, and right middle and lower lobectomies were performed. Follow-up at 1 year showed a small, though healthy infant. Review of the surgical literature has not documented successful operative management of bronchial perforation in a neonate. Selective bronchography was precise in identifying the site of perforation and was well tolerated.
Between 1980 and 1989, 8 wedge and 17 flap main bronchoplasties were done in 24 patients (4 carcinoid tumors, 4 benign lesions, 17 carcinomas). Bronchial anastomotic stenoses, pulmonary function, and survival were evaluated. Preoperative ventilation/perfusion scans with preoperative and postoperative spirometry were done in all patients except two who underwent a wedge bronchoplasty. Postoperative bronchoscopy was done in all patients. Follow-up was complete for the patients with carcinoma (N = 17). In the wedge group bronchial anastomotic stenoses occurred in three (38%) of eight patients. All three patients had serious postoperative complications (persistent atelectasis in one, prolonged ventilatory support in two); one patient died and the other two had impaired postoperative pulmonary function. Complete function recovery occurred in only three (38%) of eight patients who underwent wedge bronchoplasty. In the flap group, bronchostenosis occurred in 3 (18%) of 17 patients. The associated complications (mucus retention, minor atelectasis, partial lobar torsion) were mild. Complete pulmonary function recovery occurred in 13 (76%) of 17 patients who had flap bronchoplasty. Actuarial survival, for the patients with carcinoma, was 88%, 47%, and 41% after 1, 3, and 5 years, respectively. The local recurrence rate was 25% (4/16). In our series, flap main bronchoplasties were effective for the resection of bronchial tumors with local involvement of the adjacent main bronchus. Wedge main bronchoplasties, however, were associated with substantial postoperative complications.
A randomised trial comparing radiotherapy with a multiple chemotherapy regimen in 68 patients with small cell carcinoma of bronchus is reported. Although overall survival was poor, radiotherapy resulted in significantly longer survival, better amelioration of symptoms, and less side-effects than chemotherapy. Patients achieving complete or partial remission on radiotherapy relapsed mainly with extrathoracic disease, in contradistinction to those treated with chemotherapy whose thoracic disease recurred.
A randomised prospective trial comparing "no immediate treatment" with single and multiple agent chemotherapy in 188 patients with inoperable carcinoma of the bronchus is reported. No immediate treatment proved a significantly better policy both for patients' survival and for quality of remaining life.
The effect of corticotropin-releasing factor (CRF) on contractions of guinea pig isolated airways in response to electrical or chemical stimulation of tachykinergic nerve fibers was studied. CRF (1 microgram/ml) caused a 70% enhancement of the peak magnitude of the response to electrical field stimulation (EFS). CRF had a similar effect on contractions of the isolated bronchus evoked by capsaicin. CRF also potentiated contractions evoked by exogenously applied substance P. This effect was selective, as CRF has no effect on contractions evoked by neurokinin A or the substance P analog ASMSP. The potentiation of the substance P-induced contractions of airway smooth muscle was blocked by the CRF receptor antagonist alpha helical (9-41) CRF. These data support the hypothesis that CRF enhances the airway smooth muscle response to stimulation of tachykinin-containing nerve fibers and that this effect is due to a post-junctional mechanism of action.
The aim of the present report was to study in growing Wistar rats the development of immunocompetent cells in the bronchus-associated lymphoid tissue (BALT). We found at day 4 postpartum, a high number of TCRgamma/delta+ T cells and very few CD8alpha+, CD8beta+, CD5+, TCRalpha/beta+ T cells in BALT. The latter cells and CD4+ T cells increase with age. Even though T cells expressing TCRgamma/delta outnumber those expressing TCRalpha/beta early in development, until 45 days of age, alpha/beta+ predominate over gamma/delta+ T cells only in adult rats (60 days of age). Moreover, a predominance of suppressor/cytotoxic T cells over T-helper cells was found in 60 days old rats. Surprisingly, more CD8alpha+ than CD8beta+ T cells in BALT are observed. The number of IgA+ B and CD4+ T cells found in the BALT increases with age. The early appearance - 4 days of age - of all T-cell phenotypes in BALT especially of gamma/delta+ T cells may imply a benefit to respond to inhaled antigen soon after birth.
Tracheobronchial foreign bodies especially in infants and children is fraught with respiratory obstruction and even can lead to death if not intervened in time. The patients can present in variable forms but clinical suspicion and management for such cases is an art itself. We report a case of an unusual foreign body in a child of 1 year showing migratory movements from one main bronchus to other.
A 7-year-old boy with recurrent pneumonia of the right lower lobe is described. At bronchoscopy a small tumour almost totally obliterating the right lower lobe was detected. Surgical treatment was undertaken. Histopathologic studies showed findings consistent with those of a muco-epidermoid tumour. The case emphasizes bronchoscopy as an important investigation in children with recurrent pneumonia. It also shows the importance of performing the bronchoscopy during a prolonged course of antibiotic prophylaxis in order to ensure a minimum of infected mucus within the bronchi. This report is completed with a short review of the literature on muco-epidermoid tumours of the bronchus in children. Their favourable prognosis and very low malignant potential is underlined.
In 95 patients with inoperable squamous cell carcinoma of the bronchus, nine potential serum "markers" were analysed for their prognostic significance. Lactate dehydrogenase, alpha 1 HS-glycoprotein, ferritin, carcino-embryonic antigen and immunoglobulin E did not prove to be useful as prognostic indices. The erythrocyte sedimentation rate and the acute phase proteins alpha 1 acid glycoprotein, C-reactive protein and prealbumin were correlated with survival. After taking the performance status and tumour stage into account, C-reactive protein still proved to be a strong prognosticator. The clinical relevance of the acute phase proteins signifying a so-called "biochemical status" next to the "clinical status" is discussed.
In order to exploit the cytotoxic and radiosensitising actions of cis-platinum, we have treated 35 patients with locally advanced squamous cell carcinoma of the bronchus or head-and-neck. Each patient underwent radical irradiation (60 Gy/30 fractions over 6 weeks) with daily low-dose intravenous cisplatin (10 mg absolute dose per day) administered within 30 min of each daily radiation fraction. Total dose of cisplatin was 300 mg over 6 weeks. Although treatment was complicated by nausea in almost all patients and transient renal dysfunction in the majority, 27 patients completed treatment and renal function returned to normal or near normal in almost all cases. There was no obvious enhancement of pulmonary or skin toxicity, beyond what would have been expected from treatment with radical radiotherapy alone. There were two treatment-related deaths from renal failure. The response rate was high: all patients achieved at least a partial response, and in head-and-neck sites, there were nine complete responders and seven partial responders. Of the initial 35 patients, of whom all but two had advanced inoperable disease, 11 have died and 21 remain in continuous remission, 8-120 weeks from the start of treatment (median 55 weeks).
Silver staining of argyrophil nucleolar organizer regions (AgNORs) has become a valuable method to assess cell kinetics in paraffin sections and separate benign from malignant lesions. As a putative technique for the distinction between regenerative and preneoplastic alterations of the bronchial mucosa we employed the Ag-staining method, evaluating the number of dots/nucleus and shape of the dots. Dots/nucleus were counted by by standardized methods, and mean and standard deviation were calculated. Comparative investigations were performed in bioptically obtained specimens of normal bronchial epithelium (1.94 +/- 0.1 dots/nucleus, n = 12), basal cell hyperplasia (2.22 +/- 0.13 dots/nucleus, n = 15), goblet cell hyperplasia (2.38 +/- 0.16 dots/nucleus, n = 17), squamous cell metaplasia (2.58 +/- 0.17 dots/nucleus, n = 25), squamous cell metaplasia with mild and moderate dysplasia (2.50 +/- 0.5 dots/nucleus, n = 15), squamous cell metaplasia with severe dysplasia and carcinoma in situ (3.10 +/- 0.47 dots/nucleus, n = 17), micropapillomatosis (2.20 +/- 0.21 dots/nucleus, n = 13) and early squamous cell carcinoma of the bronchus (4.40 +/- 0.74, n = 13). In preneoplastic lesions a variability in form and size of the dots was found. Though showing an increase in the number of dots/nucleus coincidentally with the degree of proliferative activity, the AgNOR method cannot be considered as a statistically significant tool in the evaluation of regenerative and preneoplastic lesions in bioptically obtained specimens.
An extremely rare case of epithelial-myoepithelial carcinoma (EMC) of a lobar bronchus in a 47-year-old female is reported. Grossly, the tumor formed a polypoid mass obstructing the bronchial lumen. Microscopically, it was composed of two cellular types--epithelial cells with eosinophilic cytoplasm and clear myoepithelial cells. Numerous tubules formed by an inner epithelial and outer myoepithelial layer were found. Focally, the tumor showed solid growth of clear cells. Prominent hyalinization of the stroma was found. The nature of the cells was confirmed by positive expression of cytokeratins and epithelial membrane antigen in epithelial cells and vimentin and smooth muscle actin in myoepithelial cells. Differential diagnosis of EMC includes a broad spectrum of salivary gland-type tumors. Furthermore, metastases of clear cell carcinoma of the kidney or thyroid, clear cell ("sugar") tumor of the lung, glandular form of carcinoid, bronchioalveolar adenocarcinoma with myoepithelial cells and pulmonary adenosquamous carcinoma with amyloid-like stroma must be distinguished from EMC. The tumor has neither recurred nor metastasised, a fact supporting the current opinion, that EMC is a tumor of low grade malignancy.
A case is reported of bronchial rupture due to a Carlens double-lumen tube. A 73 year old male patient was to undergo a double right lower and middle lobectomy for carcinoma. All went well and as expected until 20 min after the start of left-sided unilateral ventilation by way of the double-lumen tube. A sudden increase in the inspiratory pressures led to the discovery, first, of a leak around the cuff, and then, air bubbles in the mediastinum. Surgical exploration showed up the 4 cm long rupture in the pars membrana of the left main bronchus through which the cuff was herniating. The patient was reintubated and the rupture surgically repaired. The right upper lobe had not been ventilated for 45 min and there were signs of micro-atelectasia. The immediate postoperative course was rather stormy, with severe cardiac failure, recurring right upper lobe atelectasia and bilateral pulmonary infection. The patient was only definitely weaned from the respirator 40 days after the surgical incident. Although such complications with double-lumen tubes are rare, they must be recognized and surgically repaired very rapidly. A few simple rules to prevent these complications are discussed.
Clinical experience during one-lung anesthesia using a new right-sided endobronchial tube (Portex Ltd, Hythe, Kent, UK) is reported in 148 patients with cancer of the left lung. The method allowed a reliable airtight separation of the lungs as well as right upper lobe ventilation in all cases. The new tube also allowed proper upper lobe ventilation in cases with anatomical variations of the length of the right main bronchus. The intubation technique was greatly simplified when compared with commercially available double-lumen tubes. Airway pressures and arterial blood gases were similar to those obtained with standard double-lumen tubes during one-lung ventilation. There were no complications due to the new tube system.
In the United Kingdom most patients with locally advanced non-small cell lung cancer are given treatment with palliative intent only, even when there is a good performance status and an absence of evidence for distant metastasis. It has, however, been shown that after radical radiotherapy prolonged survival can result, but only when complete regression of tumour is achieved. Research has, therefore, been directed toward an increase in primary tumour control. In pilot studies a combination of chemotherapy and radiotherapy has given improvement in tumour clearance and survival. Another approach has been to use a short intensive course of radiotherapy in which three treatments are given each day for 12 consecutive days--Continuous, Hyperfractionated, Accelerated Radiotherapy (CHART); an increase in local tumour control and survival has been shown in a comparison with the results achieved in previous cases. CHART and the combination of chemotherapy and radiotherapy are both the subject of multicentre randomized controlled trials in the United Kingdom. Patients with locally advanced non-small cell carcinoma of the bronchus should be considered for entry into these studies.
A retrospective study of 175 patients with T1-T3N0M0 carcinoma of the bronchus treated by radical radiotherapy at the Christie Hospital and Holt Radium Institute, Manchester between 1971 and 1980, is presented. Survival corrected for intercurrent death was 60.3% at 1 year and 19.6% at 5 years. Excluding T3 tumours which were all fatal by 5 years, corrected survival was 64.6% at 1 year and 26.0% at 5 years. A definition of the type of tumour suitable for radical radiotherapy is given.
The main objective was to analyse the transition of the bronchus to the parabronchus in birds and to describe its specific structure in an integrated light microscopic, transmission electron microscopic (TEM) and scanning electron microscopic (SEM) study. Lung tissue from immature and mature quail was subjected to standard processing for paraffin light microscopy, TEM and SEM after intratracheal inflation with fixative. In transverse paraffin and Durcupan semithin sections, the partition incompletely closing the broncho-parabronchial transition has the appearance of a crest-like fold delineating the entrance to the underlying parabronchial vestibulum. The core of the entrance fold is composed of loose connective tissue with free cells, and has a well-developed blood supply and innervation. Voluminous groups of smooth muscle cells are interconnected with those of neighbouring entrance folds and the interatrial septa. On the parabronchial surface and partly on the bronchial surface the entrance fold is invested with simple cuboid epithelium consisting exclusively of granular cells with lamellar inclusions. On the bronchial surface, they pass into ciliated columnar pseudostratified epithelium. At the root of the parabronchially orientated surface, they continue into the mixed population of granular and squamous atrial cells of the parabronchus. Among the granular cells of the entrance fold, scattered epithelial neuroendocrine cells are consistently present. The three-dimensional visualization demonstrated the oval form of the entrance window with a circular field of non-ciliated cells delineating the entrance to the parabronchial labyrinthine system. The general structural pattern of the entrance fold, together with the complex system of interatrial trabecles of the parabronchi underline the multifactorial function of a complex system submitted to the skeletal, regulatory and host defense of the gas exchange tissue.