Intrapleural streptokinase in the management of empyema.

BACKGROUND: Significant morbidity and mortality result from the ineffective evacuation of empyema. Failure of conventional first line treatment with closed intercostal tube drainage and antibiotic therapy may result in fibrin deposition and loculated empyema. Enzymatic debridement using intrapleural instillation of streptokinase is a non-invasive therapeutic option which may obviate the need for surgical intervention. METHODS: Eleven adults with multiloculated post-pneumonic empyemas who had failed to respond satisfactorily to intercostal tube drainage and antibiotic therapy were treated with intrapleural streptokinase between November 1992 and January 1994. A small catheter was inserted under ultrasound guidance into a loculation within the pleural space. Aliquots of 250,000 units of streptokinase in 100 ml normal saline were instilled into the pleural cavity and the tube clamped for four hours. Response was assessed by clinical outcome, measurement of drain output after unclamping, and subsequent pleural ultrasound, chest radiography, or both. RESULTS: Streptokinase enhanced drainage in all patients. Complete resolution of the empyema with re-expansion of the underlying lung was effected in eight patients, all of whom remain well. Further resolution of minimal pleural thickening was shown on subsequent chest radiographs. Two patients with considerably thickened visceral pleura following empyema drainage underwent successful decortication. The other, with myocarditis and a pyopneumothorax, underwent surgery for non-resolution of the pneumothorax but died perioperatively from cardiac failure. The number of streptokinase instillations per patient ranged from two to six (median three), and the volume of empyema fluid drained per patient ranged from 100 ml to 4870 ml (median 900 ml). Streptokinase was well tolerated in all patients. CONCLUSIONS: Intrapleural streptokinase is an effective adjunct in the management of complicated empyema and may reduce the need for surgery.

High resolution computed tomographic assessment of asbestosis and cryptogenic fibrosing alveolitis: a comparative study.

BACKGROUND: The aim of this study was to compare the distribution and configuration of lung opacities in patients with cryptogenic fibrosing alveolitis and asbestosis by high resolution computed tomography. METHODS: Eighteen patients with cryptogenic fibrosing alveolitis and 24 with asbestosis were studied. Two independent observers assessed the type and distributions of opacities in the upper, middle, and lower zones of the computed tomogram. RESULTS: Upper zone fibrosis occurred in 10 of the 18 patients with cryptogenic fibrosing alveolitis and in six of the 24 patients with asbestosis. A specific pattern in which fibrosis was distributed posteriorly in the lower zones, laterally in the middle zones, and anteriorly in the upper zones was seen in 11 patients with cryptogenic fibrosing alveolitis and in four with asbestosis. Band like intrapulmonary opacities, often merging with the pleura, were seen in 19 patients with asbestosis but in only two with cryptogenic fibrosing alveolitis. Areas with a reticular pattern and a confluent or ground glass pattern were the commonest features of cryptogenic fibrosing alveolitis (15 and 14 patients respectively) but were uncommon in asbestosis (four and three patients). Pleural thickening or plaques were seen in 21 patients with asbestosis and in none with cryptogenic fibrosing alveolitis. CONCLUSION: Apart from showing pleural disease high resolution computed tomography showed that confluent (ground glass) opacities are common in cryptogenic fibrosing alveolitis and rare in asbestosis whereas thick, band like opacities are common in asbestosis and rare in cryptogenic fibrosing alveolitis.

Audit of bronchial artery embolisation in a specialist respiratory centre.

OBJECTIVE: To audit the use of bronchial arteriography and embolisation for controlling haemoptysis. DESIGN: Retrospective review of radiological and clinical data. SETTING: Brompton and National Heart Hospitals. PATIENTS: 35 patients with severe pulmonary disease in whom 58 bronchial arteriograms were obtained between 1 January 1984 and 31 December 1989 with the intention of bronchial artery embolisation for controlling haemoptysis. MAIN MEASURES: Rate of technical success and cessation of haemoptysis; detailed evaluation of patients, particularly those with major haemoptysis (> 100 ml expectorated blood); and retrospective assessment of the appropriateness of the procedure in each. RESULTS: 58 procedures were performed, nine of which were unsuitable for detailed analysis. Nine procedures were for minor haemoptysis, which subsequently recurred, and 40 for recent major haemoptysis in 26 patients with cystic fibrosis (16) aspergilloma (six), bronchiectasis (three), and an unknown diagnosis (one). The median total volume of haemoptysis in the episode before the procedure was 680 ml (range 270-2200 ml). Embolisation was technically successful in 33/40 procedures, in 17 of which, however, major haemoptysis recurred within 10 days of the procedure, leaving 16 clinically and technically successful procedures in 15 patients. Five patients (three with aspergilloma, two with cystic fibrosis) died of haemoptysis despite attempted embolisation. CONCLUSION: Success rate of bronchial artery embolisation was 40%(16/40). IMPLICATIONS: Bronchial artery embolisation is probably not justified for minor haemoptysis or when performed more than one week after a major haemoptysis. Repeat arteriograms during a single period of haemoptysis are seldom useful. With these criteria 43% fewer procedures would have been performed with no loss of clinical benefit.

A new high resolution computed tomography scoring system for pulmonary fibrosis, pleural disease, and emphysema in patients with asbestos related disease.

The aim of this study was to describe a scoring system for high resolution computed tomographic (HRCT) scans analogous to the International Labour Office (ILO) scoring system for plain chest radiographs in patients with asbestos related disease. Interstitial fibrosis, pleural disease, and emphysema were scored, the reproducibility and the interobserver agreement using this scoring system were examined, and the extent of the various types of disease was correlated with measurements of lung function. Sixty asbestos workers (five women and 55 men) mean age 59 (range 34-78) were studied. The lungs were divided into upper, middle, and lower thirds. An HRCT score for the extent of pleural disease and pulmonary disease in each third was recorded in a way analogous to the International Labour Office (ILO) method of scoring pleural and parenchymal disease on chest radiographs. A CT score for the extent of emphysema was also recorded. Pleural disease and interstitial fibrosis on the plain chest radiographs were assessed according to the ILO scoring system. A chest radiographic score for emphysema analogous to that used for HRCT was also recorded. Two independent readers assigned HRCT scores that differed by two categories or less in 96%, 92%, and 85% compared with 90%, 78%, and 79% of cases for chest radiographs for fibrosis, emphysema, and pleural disease respectively. There was better intraobserver repeatability for the HRCT scores than for the chest radiograph scores for all disorders. Multiple regression analysis showed that scores for interstitial fibrosis, emphysema, and pleural disease on chest radiographs and HRCT correlated to a similar degree with impairment of lung function.

Advanced multiple beam equalization radiography (AMBER) in the detection of diffuse lung disease.

To evaluate the effects of scanning equalization radiography (SER) on the detection of diffuse lung disease a clinical comparison between an Advanced Multiple Beam Equalization Radiography (AMBER) unit and conventional chest radiography was performed. Even though the overall detection of focal pulmonary lesions with the AMBER unit has been shown to be significantly higher than with conventional radiography because of the improved demonstration of the costophrenic and retrocardiac regions, the utility of AMBER in the demonstration of diffuse lung disease has not been established. Twenty-one patients with diffuse lung disease (fibrosing alveolitis or sarcoidosis) and six patients with no pulmonary disease had high kVp frontal and lateral chest radiographs on both an AMBER unit and a conventional chest stand. The pooled results of five observers using Receiver Operating Characteristic (ROC) analysis indicate that there is a slight improvement but no statistically significant difference in observer performance between AMBER (Area under the ROC curve AZ = 0.934) and conventional radiography (AZ = 0.868) in the task of detecting diffuse lung disease.

A randomised comparative trial of mitozantrone/methotrexate/mitomycin C (MMM) and cyclophosphamide/methotrexate/5 FU (CMF) in the treatment of advanced breast cancer.

Mitozantrone (Novantrone) has recently been incorporated into a new combination chemotherapy regimen with mitomycin-C and methotrexate (MMM) against advanced breast cancer. We have compared MMM (mitozantrone 8 mg m-2 i.v. q 3 weekly, methotrexate 35 mg m-2 i.v. q 3 weekly, mitomycin-C 8 mg m-2 i.v. q 6 weekly) with CMF (cyclophosphamide 100 mg orally, days 1-14, methotrexate 35 mg m-2 i.v., days 1 and 8, 5-FU 1,000 mg i.v., days 1 and 8, q 4 weekly), each regimen with folinic acid rescue, in a randomised trial, 29/57 evaluable patients treatment with MMM achieved an objective response (51%) compared with 33/55 treated with CMF (60%). Overall median survival was 16 months for MMM and 12 months for CMF. Subjective toxicity was low for both regimens and the only significant difference was in incidence of diarrhoea (50% for CMF vs 21% for MMM). Haematological toxicity was similar, leading to treatment delays and/or dose reductions in 35% patients with CMF vs 43% with MMM. Thrombocytopenia was significantly increased in MMM (34% vs 14%). No clinical cardiotoxicity was seen, but a significant reduction in left ventricular ejection fraction occurred in four patients on CMF vs 2 on MMM. MMM is an active, well tolerated new chemotherapy regimen for advanced/metastatic breast carcinoma with an efficacy and toxicity spectrum very similar to CMF.

Assessment of asbestos-induced pleural disease by computed tomography--correlation with chest radiograph and lung function.

We compared computed tomography (CT) scanning with chest radiography in the assessment of asbestos-induced pleural disease (AIPD) in 20 patients (17 men and 3 women, mean age 55 years, range 43-74 years). Involved pleura was scored on plain chest radiographs according to the International Labour Office (ILO) method of evaluating AIPD. A CT score was calculated from the measurement, using a digital length probe, of the circumference of the chest wall involved by pleural disease in each slice. The maximum width of pleural disease was taken into account in a way analogous to the ILO method for the chest radiograph. The CT score correlated with the chest radiograph score (r = +0.82, P less than 0.0006). CT demonstrated discrete plaques in 95% of patients but these were identified only in 59% patients on the radiograph. Diffuse pleural thickening was evident on the CT scan in all patients and in 70% on the radiograph. There was more inter-reader agreement about the type of pleural disease on the CT scans than on the chest radiographs. CT and chest radiograph scores inversely correlated with all lung function measurements except KCO. We conclude that increasingly extensive pleural disease is associated with increasingly severe impairment of lung function. CT scanning demonstrates the type of AIPD better than plain chest radiography.

Bronchography in the assessment of patients with lung collapse for endoscopic laser therapy.

In an attempt to improve selection of patients and the efficacy of endoscopic laser treatment, a bronchographic technique has been developed for patients with tumours causing complete endobronchial obstruction. This technique has shown patent distal airways in 16 out of 17 patients with a collapsed lung or lobe. These airways were abnormally dilated in each case, suggesting bronchiectasis. In one patient the appearances of bronchiectasis were sufficiently severe to decide against attempting treatment. Treatment was not attempted in another patient as a large cavity was seen within the collapsed lung and this was thought to carry a risk of postoperative infection and haemorrhage. Treatment with a neodymium YAG laser under general anaesthesia successfully recanalised the airway in 12 of the 15 remaining patients and was associated with a substantial reduction in breathlessness. The procedure was abandoned prematurely in one patient because of life threatening haemorrhage. In the remaining two patients in whom treatment was unsuccessful bronchography had suggested very extensive endobronchial obstruction. Spirometry and radionuclide lung scans were performed before and after treatment in eight patients treated successfully and showed significant improvements. Four patients were investigated within two weeks of lung re-expansion by repeat bronchography (three patients) or computed tomography (one patient); in each case the calibre of the airways had returned almost to normal. Thus the radiological demonstration of bronchial dilation in a collapsed lung does not necessarily imply a diagnosis of irreversible bronchiectasis and should not be regarded as a contraindication to treatment. It is concluded that preoperative bronchography provides reliable data on the extent of tumour, the patency of the distal airways, and presence of extensive cavitation. This information should facilitate successful laser treatment.

Technetium-99m-glucoheptonate lung imaging; has it a role in the diagnosis of bronchial carcinoma?

It has been shown by Vorne et al. and Passamonte et al. that technetium-99m-glucoheptonate (Tc-GH) concentrates in bronchial carcinomas. The two studies reported similar sensitivities (88 and 91%, respectively) but discordant specificities (88 and 10%, respectively). In order to assess the uptake of Tc-GH in bronchial carcinomas we performed lung imaging on patients with an abnormal chest radiograph who were undergoing routine investigations for bronchial carcinoma. 108 patients (85 carcinoma, 23 non-carcinoma) were given 555 MBq (15 mCi) Tc-GH intravenously and scanned 5 h later. Images were assessed by one investigator (J.A.L.) without knowledge of the patient's clinical details or other results. Localized uptake of Tc-GH was seen in 71 out of 85 patients who proved to have bronchial carcinoma. Uptake was also seen in 16 out of 23 patients with a variety of non-malignant lung conditions. Sensitivity for bronchial carcinoma was 84%, and specificity 30%. Uptake did not vary significantly with histology. Eleven out of 12 patients with proven tuberculosis had increased uptake of Tc-GH; two of those patients also had inactive lesions which did not concentrate the tracer. In conclusion, Tc-GH is of limited value in the diagnosis of bronchial carcinoma, because of its low specificity. A possible role in the diagnosis of active tuberculosis may exist, following further assessment.

Bronchoscopic and percutaneous aspiration biopsy in the diagnosis of bronchial carcinoma cell type.

The cell type of bronchial carcinoma predicted from the results of bronchial biopsy at fibreoptic or rigid bronchoscopy or of percutaneous aspiration lung biopsy was compared with the type determined by histological examination of specimens obtained by thoracotomy, biopsy of an extrapulmonary metastasis, or necropsy in 180 cases. The rates of agreement with the final diagnosis were 95.7% for bronchial biopsy through the fibreoptic bronchoscope and 86.5% through the rigid bronchoscope. For percutaneous biopsy, which was usually carried out on tumours inaccessible to the bronchoscope, the rate of agreement was 61%, significantly lower than by the other methods (p less than 0.001). The diagnosis of oat-cell carcinoma by any technique was very reliable. Bronchial biopsy was more reliable than was percutaneous biopsy in diagnosing squamous-cell carcinoma. With any technique the commonest error was the incorrect diagnosis of squamous-cell carcinoma or adenocarcinoma as large-cell undifferentiated carcinoma.

Echocardiographic diagnosis of primitive ventricle with two atrioventricular valves.

Anatomical studies have shown that the pathognomonic feature of primitive ventricle is absence of that portion of the interventricular septum which interposes between the atrioventricular valves. The relation of this posterior septum to the atrioventricular valves is such that echocardiography should be a particularly suitable technique for showing its presence or absence. When a posterior septum is present, it is seen on an echocardiogram as a double echo between the two atrioventricular valves. It presence limits posterior movement of the septal cusp of the anterior atrioventricular valve. Absence of the posterior septum should, therefore, be seen echocardiographically as more than mere absence of the double septal echo. It should be possible to show unusual posterior excursion of the "septal" cusp of the anterior atrioventricular valve and apposition of the "septal" cusps of the atrioventricular valves during diastole. In most instances it should also be possible to demonstrate that the posterior great artery is in continuity with both atrioventricular valves. We have shown these echocardiographic features in 26 patients. The diagnosis of primitive ventricle has been confirmed at necropsy or at operation in 4 patients. In the other 22 patients in angiographic data are compatible with a diagnosis of primitive ventricle. Demonstration of these positive features at echocardiography is, therefore, of considerable value in the initial diagnosis of primitive ventricle and in particular its differentiation from other congenital malformations.

A unique pulmonary venous abnormality: with associated pulmonary arterial anomaly and arteriovenous malformation.

A man aged 29 was first seen at the age of 11, when he was found to have a congenital anomaly of the pulmonary veins which follow an abnormal course to the hilum. On the left side, two large veins descend peripherally before turning medially towards the left atrium; on the right, several smaller veins follow a similar circuitous route from the periphery, before uniting into two main veins which enter the left atrium. The proximal pulmonary arteries are normal in their pattern of branching and distribution but are dilated and tortous and taper abruptly: the left lower lobe artery is abnormally large almost down to the diaphragm. There is also a systemic arterio/pulmonary venous fistula. There is no haemodynamic disturbance, but gas transfer is slightly impaired, and there is slight arterial desaturation. The congenital anomaly is unique. Reported cases described as having pulmonary venous varices are a heterogeneous group, but one patient described as such shows resemblances to our case.