Is it possible to detect ulcerative colitis-related respiratory syndrome early?

OBJECTIVE: Obstructive airway disease, bronchiectasis, non-specific parenchymal infiltration and bronchiolitis obliterans organizing pneumonia are seen occasionally in patients with inflammatory bowel disease. In the present study, we evaluated ulcerative colitis (UC) patients for latent pulmonary involvement. METHODS: Fifteen patients (nine females, six males, mean age 44 years) were admitted into the study. All patients were free of respiratory symptoms. Ulcerative colitis was active in nine patients and all patients were using anti-inflammatory treatment. Pulmonary function tests (PFT), high resolution computed tomography of thorax (HRCT) and bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsy (TBLB) were carried out in all subjects. RESULTS: Mild airways obstruction was found in 1 of 13 patients. High resolution CT was abnormal in 4 of 15 patients. Ground glass appearance suggestive of an interstitial lung disease was present in three patients. Radiolucency and pneumocysts were present in the fourth patient suggesting obstructive small airway disease. High resolution CT findings correlated with disease activity (P < 0.05). Fiberoptic bronchoscopy was performed in 10 patients. A mixed type alveolitis was detected in BAL fluid in five patients. In eight patients, TBLB showed alveolar septal thickening by connective tissue, lymphocytic accumulation in the septal area and minimal septal fibrosis, suggesting subclinical pulmonary parenchymal involvement linked to UC. CONCLUSIONS: Our data suggest that latent interstitial pulmonary involvement may occur during the course of UC, despite an absence of symptoms of lung disease.

Occurrence of Riedel's thyroiditis in the course of sub-acute thyroiditis.

Riedel's Thyroiditis is an uncommon form of chronic thyroiditis characterized by an invasive fibrosclerosis of the gland, often involving surrounding tissue. The relationship of Riedel's Thyroiditis to other forms of thyroiditis is not clear. We presented a 47 year-old woman first diagnosed with sub-acute thyroiditis based on clinical findings and laboratory results. Eight months later, she had a thyroidectomy operation due to an enlargement of the thyroid gland and symptoms of compression. Histopathologic evaluation showed that she had Riedel's Thyroiditis, but there were some histopathologic findings of sub-acute thyroiditis as well. Until now, there has only been one case reported in which Riedel's Thyroiditis was diagnosed in a patient with a history of sub-acute thyroiditis in the literature. Although aetiology of Riedel's Thyroiditis is unknown, it may develop in the course of sub-acute thyroiditis.

Combining transbronchial aspiration with endobronchial and transbronchial biopsy in sarcoidosis.

This study was carried out to evaluate the diagnostic yield and safety of flexible transbronchial needle aspiration (TBNA), endobronchial biopsy (EBB) and transbronchial lung biopsy (TBLB) combinations in stages I-III sarcoidosis (SA). Between 1989 and 1997, 74 patients suspected of having SA underwent fibreoptic bronchoscopy along with TBNA + EBB + TBLB or EBB + TBLB. During the same fibreoptic bronchoscopy, TBNA (using a 19-gauge histological needle and contrast-enhanced computed tomography (CT) guidance), EBB (from abnormal or normal bronchial mucosa) and TBLB were performed in stages I (n = 33) and II (n = 25), and EBB and TBLB in stage III (n = 16). The diagnosis of SA required the presence of noncaseating granulomas and the absence of "allergic granulomatosis and angiitis with eosinophilic infiltration" or foreign body reaction, with negative Ziehl-Neelson and methenamine silver stains, as well as negative cultures for acid-fast bacilli, fungi and other organisms. TBNA was diagnostic in 20 (61%) and 10 (42%) cases of stages I and II, whereas EBB was diagnostic in 15 (45%), 12 (50%) and seven (58%) cases, of stages I, II and III, respectively, and TBLB in 17 (52%), 15 (63%) and 10 (83%). By means of TBNA, EBB and TBLB alone, the diagnostic yields were nine (27%), four (12%) and six (18%) cases in stage I, two (8%), four (17%) and seven (29%) in stage II, and two (17%) and five (42%) by EBB and TBLB in stage III, respectively. The diagnostic yield of TBNA + EBB + TBLB was 30 (91%) in stage I and 21 (88%) in stage II, and that of EBB + TBLB was 12 (100%) in stage III. Overall, 63 (91%) cases of SA were diagnosed by TBNA + EBB + TBLB and EBB + TBLB. In six of the eleven bronchoscopically-negative cases, mediastinoscopy (four) or thoracotomy (two) established the diagnosis of SA, whereas the remaining five were diagnosed along with non-sarcoidosis diseases (one case in stage II and four in stage III) by various tissue biopsies in the follow-up. The combination of TBNA + EBB + TBLB and EBB + TBLB provided an overall sensitivity and accuracy of 90% and a specificity of 100%. All six (9%) significant complications--pneumothorax (four) and 40-100 mL haemorrhage (two)--were attributable to TBLB. It is, therefore, inferred that the combination of transbronchial needle aspiration, endobronchial biopsy and transbronchial lung biopsy in stages I and II, and that of endobronchial biopsy and transbronchial lung biopsy in stage III, is safe and cost-effective as well as increasing the diagnostic yield, and should therefore be performed routinely in the diagnosis of sarcoidosis.

Chylothorax, chylopericardium and lymphoedema--the presenting features of signet-ring cell carcinoma.

This report describes a patient with chylous pleural and pericardial effusions in conjunction with severe lymphoedema resembling elephantiasis. The chylous effusions and generalized lymphoedema were associated with a signet-ring cell carcinoma.

Comparison of rigid and flexible transbronchial needle aspiration in the staging of bronchogenic carcinoma.

In staging bronchogenic carcinoma by transbronchial needle aspiration (TBNA), rigid histology needles are generally preferred to flexible cytology needles owing to the widespread opinion that rigid needles have higher diagnostic yield and less false-positive results. The objective of this study was to compare the efficacy and safety of the rigid and flexible TBNAs in staging bronchogenic carcinoma to establish whether a flexible cytology needle method can replace the rigid needle. A prospective study was conducted in 138 consecutive patients with extra- or endobronchial masses suggestive of bronchogenic carcinoma and amenable to surgical procedures. All 8 mm and larger paratracheal, carinal, hilar and/or main bronchial lymph nodes determined before bronchoscopy by computed tomography (CT) were sampled by successive 18-gauge rigid and 21-gauge flexible TBNAs in the same session. The anatomic landmarks were followed precisely during TBNAs, and a proper technique applied in sampling and specimen processing. Malignant lymph node involvement was specified in 97 (72%) cases of bronchogenic carcinoma by rigid, and in 89 (66%) by flexible TBNA. There were 4 (100%) benign cases (3 with tuberculosis and 1 with sarcoidosis) of 101 (73%) with positive rigid TBNAs (82 with histological and 19 with cytological specimens). TBNAs determined malignant lymph node involvement in a total of 104 (78%) patients. Of 30 TBNA-negative patients, 14 were proven to have false-negative TBNAs by mediastinoscopy/mediastinotomy/minithoracotomy, and 16 to have true-negative TBNAs by thoracotomy. Thoracotomy confirmed true positivity in 52 rigid and 49 flexible TBNAs, and false negativity in 4 rigid and 7 flexible TBNAs. Further staging was confirmed in these 7 cases. Four had proven false-negative results by both methods. The presence of small cell carcinoma (21) or N3 disease (27) presented a contraindication to thoracotomy in 48 TBNA-positive patients. Adequate-quality and malignant lymph node specimens were more frequently obtained by both techniques at advanced tumor and node stages. However, malignant lymph node invasion was significantly more frequent in rigid and flexible TBNA specimens only in the presence of advanced tumor status and abnormal endoscopic appearance. The sensitivities of rigid and flexible TBNAs were 74 and 70%, respectively (p > 0.05), but both had a specificity of 100%. Neither false-positive results nor serious complications other than hemorrhage of 30-100 ml (rigid: 5%, flexible: 2%) were encountered with either technique. These results indicate that in bronchogenic carcinoma, hilar and mediastinal lymph nodes can be staged by 21-gauge flexible TBNA (76%) as accurately as by 18-gauge rigid TBNA (79%) if a proper technique is applied and anatomic landmarks are followed precisely (p > 0.05).

CT bronchus sign-guided bronchoscopic multiple diagnostic procedures in carcinomatous solitary pulmonary nodules and masses.

CT bronchus sign (BS) designates a bronchus leading directly to a peripheral pulmonary lesion. The objective of this investigation is to determine the contribution of BS-guided bronchoscopic multiple diagnostic procedures (BMDPs) to the diagnostic yield of solitary nodules or masses (SPNMs) suspected of pulmonary carcinoma (PC). A prospective study was carried out in 92 patients with a 2-5 cm diameter SPNM at the level of third to fifth bronchial branching and without endobronchial tumors. Within 10 days after 2-mm CT scans were done, in each of 92, bronchial washing (BW), brushing (BR), transbronchial needle aspiration (TBNA) and transbronchial lung biopsy (TBB) were performed respectively, via fiberoptic bronchoscopy (FB) under fluoroscopic guidance. In 40 (82%) of 49 with BS and in 19 (44%) of 43 without BS, FB established the diagnosis (p < 0.01). In 84 cases of PC, BW, BR, TBNA and TBB provided the diagnostic yields of 4% (3), 26% (22), 57% (48) and 49% (41), respectively; the combined yield reached 68% (57). A metastasis and a tuberculoma were diagnosed exclusively by TBB, and TBNA, respectively. All differences of diagnostic yield except that between TBNA and TBB (p > 0.05) were determined to be significant (p < 0.05). Thoracotomy verified diagnosis in 48 of 59 cases diagnosed and 19 of 33 undiagnosed by FB, and various tissue biopsies or clinical follow-up in 11 diagnosed and 14 undiagnosed by FB. The above data suggest that in the diagnosis of PC as a SPNM at the level of third-fifth bronchial branching, combining the guidance of CT BS, and BMDPs under fluoroscopic guidance can increase the yield considerably.

Comparison of endobronchial needle aspiration with forceps and brush biopsies in the diagnosis of endobronchial lung cancer.

Endobronchial forceps biopsy (FB) specimens of lung carcinoma are not uncommonly interpreted as nondiagnostic owing to extensive crush artefact, necrosis, or insufficient tissue. FB cannot be performed in some endobronchial lung cancers (EBLCs) with massive bleeding tendency due to fragility and friability. Cytological studies from the brushings and washings may also be unproductive, increasing the bronchoscopist's frustration. The aim of this study was to compare the diagnostic yield and complications of endobronchial needle aspiration (EBNA) with those of FB and brush biopsy (BB) in EBLCs examined by fibreoptic bronchoscopy. A prospective sequential study was carried out on 151 in-patients with EBLC. Bronchial aspiration (BA), EBNA and BB were performed in the patients with respiratory distress and with accompanying tumours of high bleeding tendency, completely obstructing main bronchi (Group 1: 68 patients). BA, EBNA and FB were performed in those with either central or peripheral EBLCs but without respiratory distress and/or significant bleeding tendency (Group 2: 83 patients). In Group 1, the diagnostic yield of EBNA was found to be 90%, whereas that of BB was 66% (p < 0.05). In the same group, EBNA provided cell types in 95%, compared with 88% by BB (p > 0.05). EBNA was diagnostic in 92% of Group 2 patients, while FB established diagnosis in 78% of patients (p > 0.05). In determining cell type, no significant difference was found between EBNA (95%) and FB (97%) (p > 0.05). Regarding complications (only bleeding), there was no significant difference (p > 0.05) between EBNA (7%) and BB (13%), or between EBNA (4%) and FB (17%). We conclude that in endobronchial lung cancers: 1) the diagnostic yield of endobronchial needle aspiration is higher than brush biopsy; 2) endobronchial needle aspiration increases the yield of brush biopsy when forceps biopsy cannot be performed owing to significant bleeding; 3) endobronchial needle aspiration increases the diagnostic yield when a forceps biopsy specimen is inadequate because of crush artefact, necrosis, or tissue resistance; and 4) endobronchial needle aspiration is as safe as brush biopsy and forceps biopsy.