Surgical management of massive hemoptysis. A ten-year experience.

Pulmonary bleeding was defined as massive when the collected blood was 600 ml or more in 24 hours. Hemoptysis of this magnitude carries more than 50% mortality when managed without surgical intervention, For this reason all patients admitted, bleeding massively, in the past ten years were considered candidates for surgical therapy. Localization of the bleeding was done by bronchoscopy. Pulmonary reserve was evaluated by clinical and radiological observation and, when feasible, by spirometry. Of the 75 patients seen with massive hemoptysis, 68 were operated. Seven patients were excluded for various reasons. Five of these patients died during the acute bleeding episode. Sixt-five resections were performed with 11 deaths (17%) and three cavernostomies with one death. Of 51 lobectomies, seven expired (14%). One segmentectomy survived. Other than the magnitude of the surgical resection, the mortality was related to the amount of bleeding in the 24 hours preceding the surgical procedure. Severe bleeding at the time of resection requiring one-lung ventilation also significantly influenced the mortality (33% against 7%). This experience shows that pulmonary resection is the treatment of choice in patients with massive hemoptysis.

Endodermal sinus tumor of the mediastinum. Ultrastructural study.

This is the eighth case report of an endodermal sinus tumor of the mediastinum (first case studied by electron microscopy). The ultrastructure of the tumor was found to mimic that of the normal yolk sac and was also similar to that of three previously reported cases of endodermal sinus tumor of the ovary, thus confirming the correctness of Teilum's original interpretation of the tumor as arising in germ cells and differentiating towards extraembryonic structures.

Granulomatous pulmonary angiitis in sarcoidosis.

The occurrence and morphologic aspects of granulomatous pulmonary angiitis were evaluated in open lung biopsy specimens from 128 patients with sarcoidosis. All of the specimens showed parenchymal granulomas characteristic of sarcoidosis, and in 88(69%), granulomatous angiitis was seen. In the speclimens that exhibited granulomatous angiitis, venous involvement was mos common, seen in 92% of the cases. In 61% of these biopsy specimens, only venous involvement was seen; in 31%, both venous and arterial involvement was present. Only 8% of the positive specimens showed arterial lesions exclusively. The extent of angiitis was quantitated. Focal segmental elastic tissue destruction, partial or complete, was a common finding. No instances of aneurysm formation, endothelial erosion, or thrombosis were observed. Occlusive narrowing of small vessels was frequent. Bronchial blood vessels were not involved.

Markedly elevated angiotensin converting enzyme in lymph nodes containing non-necrotizing granulomas in sarcoidosis.

Sarcoidosis is a disease of unknown etiology that is characterized by the generalized formation of granulomas and is accompanied by elevation in the serum in less than half the patients of angiotensin converting enzyme, a dipeptidyl carboxypeptidase that catalyzes the conversion of the decapeptide, angiotensin I, to the pressor octapeptide, angiotensin II, and L-histidyl-L-leucine. Mean activity of angiotensin converting enzyme was elevated generally more than 10-fold in granuloma-containing lymph nodes, but not in lung in which normally it is abundant, in 19 of 20 patients with sarcoidosis. Angiotensin converting enzyme in lymph nodes from subjects with sarcoidosis was similar to the enzyme from normal lung and lymph node with respect to activity as a function of pH, inhibition of activity by EDTA and o-phenanthroline, gel filtration on Sephadex G-200, and requirement for chloride for activity, but appeared to be more heat labile. The data suggest that the granulomas in sarcoidosis may be the source of the elevated serum enzyme and that cells of the granulomas, particularly the epitheloid cells which appear by electron microscopy to have active protein biosynthesis, may be actively synthesizing the enzyme.

Elevation of angiotensin-converting enzyme in granulomatous lymph nodes and serum in sarcoidosis: clinical and possible pathogenic significance.

A statistically highly significant elevation of serum ACE was found in a group of 58 patients with sarcoidosis (serum ACE was elevated in 34% of patients), as compared with normal controls and patients with tuberculosis and various other common diseases. The results suggest that serum ACE is a useful aid for the diagnosis of sarcoidosis when elevated, but that a normal value does not rule out the condition and may occur in more than one-half of monitored patients. There is a trend to diminution of serum ACE with increasing duration of disease with or without steroid therapy, perhaps correlating with the total body mass of active granulomas, as indirectly suggested in preliminary data by correlation of serum ACE with serum globulin in 16 sarcoidosis patients. It is not yet clear whether there is any significant steroid effect on serum ACE, but a significant number of patients on steroid therapy for more than 2-4 yr have elevated serum ACE values, which in some instances are extremely high. There was a 12-fold elevation in ACE to specific activities generally exceeding those of normal lung in granulomatous lymph nodes of 14 patients with sarcoidosis, suggesting that sarcoid granulomas may be actively synthesizing ACE and resulting in elevation of serum ACE. Extensively fibrotic sarcoid lymph nodes had normal or slightly elevated ACE, suggesting that obliteration of granulomas in sarcoid lymph nodes diminishes their ACE content and that this obliteration may be related to the tendency to diminution of serum ACE with time. ACE was not elevated in one tuberculous lymph node or in experimental granulomas, suggesting that elevation of ACE may have some specificity for the granuloma of sarcoidosis rather than being a characteristic of all granulomas. The catalytic and physical properties of ACE in serum and lymph nodes in sarcoidosis were generally similar to normal ACE with respect to pH activity, modulators, polyacrylamide-gel electrophoresis, and Sephadex G-200 gel filtration. However, sarcoid lymph node ACE appeared to be more heat labile than normal lung or lymph node ACE, suggesting the possibility that an abnormal ACE may be present in sarcoidosis. If an abnormal enzyme is indeed present, it might be coded for by a host gene that is not normally expressed or a nonhost gene or it might be a normal ACE that has been altered. No ACE activity was found in circulating white blood cells in sarcoidosis or in control subjects, suggesting that circulating white blood cells may not contain the epithelioid cell precursor or that ACE synthesis (or less likely, uptake) may be turned on at a later stage in the transformation. Lysozyme activity was also elevated in sarcoid lymph nodes. Serum ACE and serum lysozyme were significantly positively correlated in 16 sarcoidosis patients, suggesting a relationship between the two...

Control of hemorrhage in emergency pulmonary resection for massive hemoptysis.

Emergency pulmonary resection for hemoptysis during an episode of massive intrabronchial bleeding requires protection of the contraleteral lung from aspiration of blood. We describe a method of selective unilateral ventilation applied to 15 patients, without mortality attributable to this factor.