Biomedical subjects
Publications and source records attributed to P C Hawley.
Two cases are reported of tracheobronchial repair in which a posteriorly based intercostal muscle flap was incorporated into the membranous portion of the airway to increase the diameter of the reconstruction or to relieve tension in the suture lines. This technique permits repair of a small left main bronchus without compromise to the lumen and tension-free repair of the membranous trachea.
BACKGROUND AND OBJECTIVE: Photodynamic therapy (PDT) was used to stop life-threatening hemoptysis from bleeding hereditary telangiectasia in bronchi in a 42-year-old man with a 4-year history of repeated embolotherapies, tracheostomies, and ventilator dependence. At the time of his first PDT, he was 10 days past his third embolotherapy, was being ventilated through a tracheostomy and bringing up 100-200 cc of blood daily, necessitating multiple transfusions of blood and platelets. STUDY DESIGN/MATERIAL AND METHODS: Four hours after intravenous injection (60 mg/m2 body surface) of the photosensitizer dihematoporphyrin ether (DHE), bronchoscopy through his tracheostomy showed continuous oozing of non-clotting blood from bronchial vessels in both lung fields, requiring continuous suction. We performed PDT to seven bronchial sites. The 630 nm wavelength light energy to activate the photosensitizer was generated by a tunable dye argon laser system and delivered to the endobronchus through a quartz fiber modified with a 2.5 cm diffusing tip passed through the biopsy channel of the bronchoscope. The light power was 500 mW per cm of diffuser and the light dose was 200 J per cm of diffuser. At the end of the treatments, the bleeding had decreased so as not to require suctioning. The following day we treated three other sites with the same light dose. At this time the only bleeding was from the LUL, which oozed briskly after passing the bronchoscope through it. At the end of the treatment bronchoscopy there was minimal bleeding. RESULTS: One week after PDT he was discharged with a tracheosotomy and mechanical ventilator. Four months later his tracheostomy was removed. He remained free of hemoptysis for 26 months when life-threatening hemoptysis recurred. Twenty-two hours after his second injection of DHE, we treated four different endobronchial sites with PDT for bleeding from both the right and left bronchial tree. Sixteen months after his second PDT he remains free of hemoptysis. Three other patients treated for uncontrollable life-threatening hemoptysis for bronchitis have remained free of hemoptysis for 9, 17, and 23 months. CONCLUSIONS: Photodynamic therapy causes thromobosis and can control bleeding from small vessels regardless of their location or etiology.
The effects of various light power densities (milliwatts per centimeter of diffusing fiber [mW/cf]) and light doses (joules per centimeter of diffusing fiber [J/cf]) on the effectiveness of photodynamic therapy to endobronchial and tracheal tumors were evaluated at 46 different sites. All patients had squamous cell carcinoma or adenocarcinoma. They received 2 mg/kg body weight dihematoporphyrin ether intravenously 2 days before treatment bronchoscopy. Only one light treatment was delivered to the site. Patients were treated with diffusing cylinder light tips and underwent toilet bronchoscopy 2 days after photodynamic therapy. The percentage of obstruction was estimated before and after treatment and before and after toilet bronchoscopy. There was no difference between the effects resulting from power densities of 400 and 500 mW/cf, nor were there differences in the reactions between squamous cell carcinoma and adenocarcinoma. The amount of tumor that could be removed at the end of the treatment bronchoscopy, the amount of reobstruction by secretions and exudate seen at toilet bronchoscopy, and the final percent decrease in obstruction at the end of toilet bronchoscopy were proportional to the light dose. Because the final percentage decrease in obstruction plateaued at light doses of 400 to 500 J/cf and there was no statistically significant difference between 400 and 500 J/cf, we recommend using a power density of 500 mW/cf and a light dose of 400 J/cf during photodynamic therapy.
Between September 1982 and July 1987 we treated 102 patients with endobronchial or endotracheal disease with one or a combination of the following modalities: CO2 laser, Nd:YAG laser, and photodynamic therapy (PDT). Many patients had multiple treatments and treatment sites. In all, 259 Nd:YAG treatments were performed on 154 sites in 80 patients, 118 PDT treatments were performed on 87 sites in 45 patients, and nine CO2 treatments were performed on nine sites in nine patients. Of the 71 patients who died, 19 lived longer than 6 months, and seven lived longer than 1 year. A total of 11 patients have survived for more than 1 year, including four who are still alive 18, 22, 33, and 54 months after treatment. Five patients achieved a status of "no evidence of disease," and at autopsy, two others had no evidence of disease to the treated site. All seven of these patients were treated with PDT only. There were no intraoperative deaths or cases of intraoperative bleeding or smoke with PDT. Eight patients died from pulmonary hemorrhage 2 to 9 weeks after treatment. Four had been treated with Nd:YAG therapy alone and four with PDT alone. Evaluation of the survival rate in this study must consider that this therapy involves severely ill patients with a high potential for intraoperative or perioperative fatality. Some patients who were near death before treatment have enjoyed quality survival for over 1 year.
Forty-nine tumor sites in 31 consecutive patients with tracheobronchial malignant neoplasms were treated with photodynamic therapy (PDT). After sensitization with the intravenous hematoporphyrin derivative (HpD) or its more purified form of dihematoporphyrin ether (DHE), 630 nm of light from a tunable sensitizer argon light system was delivered to the tumor site through the biopsy channel of a flexible bronchoscope. All patients had received, refused, or were ineligible for conventional surgery, ionizing radiation therapy, or chemotherapy. Before or at 1 month after each treatment, tumor response was evaluated according to the following categories: (1) complete response (CR) (no visible abnormality, and negative biopsy specimen and cytology); (2) partial response (PR) (degree of obstruction or size of tumor reduced more than 50%); (3) some response (SR) (degree of obstruction or size of tumor reduced 20% to 50%); and (4) progression (PROG) (degree of obstruction or size of tumor reduced by less than 20%). Results were as follows: (1) 37% of the tumors treated achieved CR; (2) 55% achieved PR; (3) 4% achieved SR; and (4) 4% were categorized as PROG. Complete follow-up was achieved in all patients. Clinical effect was evaluated 1 month after treatment by comparing the Karnofsky performance status (KPS), dyspnea level, oxygen requirement, and presence of symptoms. Sixty-eight percent had clinical improvement in at least one variable and 48% in two or more variables. The results of this study suggest that PDT can play a useful role in the treatment of endobronchial malignancies.
Amyloidosis is a generalized metabolic disorder characterized by deposition of insoluble protein in the extracellular space of various organs. We have treated a woman presenting with menorrhagia and anemia, who was subsequently diagnosed as having systemic amyloidosis. This represents the first known documentation of amyloid involvement of the female reproductive tract.
We have described a case of isopropyl alcohol intoxication with the confusing picture of normoglycemia and ketonuria, without evidence of metabolic acidosis. The patient also had a spurious elevation of serum creatinine caused by the high acetone level. The positive ketone test was secondary to high levels of acetone, the main metabolic product of isopropyl alcohol. This is the first case of isopropyl alcohol ingestion in which "pseudo" renal failure has been described.
Clinical, roentgenologic, and physiologic manifestations of three adult patients with biopsy-proved bronchiolitis fibrosa obliterans illustrate the varied clinical features of the different stages of this disease and emphasize the rapidly progressive nature of the disorder in some patients. Although the chronic stage of bronchiolitis fibrosa obliterans has not been shown previously to respond to corticosteroid therapy, both of our patients with this stage of the disease had a dramatic response to high-dose prednisone. Furthermore, our one patient with the acute stage of the disease had complete resolution of his disease with treatment. Our experience suggests that early diagnosis and treatment are important in determining the clinical course of the disease.
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