Wall Necrosis Research Articles

Two subtypes of Churg–Strauss syndrome with neuropathy: the roles of eosinophils and ANCA

The aim of this study was to clarify the differences in the pathogenesis of neuropathy between myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA)-positive and -negative patients with Churg-Strauss syndrome (CSS). Eight MPO-ANCA-positive and 14 MPO-ANCA-negative patients were included. In addition to the standard histology, nerve biopsies were examined, employing immunohistochemistry for eosinophil major basic protein and electron microscopy. The groups did not differ significantly in clinical profiles, including the peak disability score and number of blood eosinophils. In nerve biopsies, necrotizing vasculitis was found in 63% (5/8) of the ANCA-positive and 21% (3/14) of the ANCA-negative patients. Fibrinoid necrosis of vessel walls was noted in 4 ANCA-positive patients (50%), and in one ANCA-negative patient (p = 0039). In contrast, a large number of eosinophilic infiltrations in the epineurium was shown in 36% (5/14) of the ANCA-negative patients, with no eosinophilic infiltrations shown in ANCA-positive patients. In 3 ANCA-negative patients, endoneurial eosinophils were seen where focal axonal loss and capillary dilatation were occasionally noted. There may be 2 pathogenetic mechanisms of neuropathy with CSS: ANCA-related vascular fibrinoid necrosis, and a toxic eosinophilic effect on nerve fibers which is independent of ANCA. Therapy targeting activated eosinophils may be a possible treatment for intractable neuropathy of CSS.

Abdominal Wall Necrosis After Harvest of Both Internal Thoracic and Inferior Epigastric Arteries

The internal thoracic artery (ITA) and inferior epigastric artery (IEA) may be used as conduits for myocardial revascularization. Harvesting the ITAs and IEAs can lead to clinically significant ischemia of the anterior abdominal wall. We created a registry with data from 108 patients receiving myocardial revascularization with 1 or greater ITA and (or) 1 or greater IEA. After revascularization, patients were followed to document their outcomes during hospitalization. We sought to identify risk factors for tissue necrosis in these patients. All patients had 1 (84%) or 2 (16%) IEAs harvested. Both ITAs were utilized in 81% of patients; 19% had only the left ITA harvested. All patients in whom 2 IEAs were harvested also had 2 ITAs harvested (17 of 108). Of these 17 patients, 2 (12%) developed abdominal wall necrosis. Only patients who had bilateral ITA and bilateral IEA harvest experienced this complication. Bilateral harvest of ITAs and IEAs results in a moderate risk of clinically significant abdominal wall necrosis. The extent of tissue loss may involve skin, muscle, and fascia, but the peritoneum and posterior rectus sheath remained intact in both affected patients in this series. These data may be most valuable to those who contemplate an abdominal operation in a patient who has had one or more of their ITAs or IEAs taken.

Medical management of pneumatosis intestinalis in patients undergoing allogeneic blood and marrow transplantation

Pneumatosis intestinalis (PI) occurs when gastrointestinal (GI) wall disruption, increased wall permeability or necrosis leads to wall infiltration by gas. It is associated with a spectrum of causal factors, including GI disease in allogeneic blood and marrow transplant patients. Traditionally, PI has been managed surgically with high morbidity and mortality. We describe our experience managing allogeneic blood and marrow transplant patients with PI. From January 1998 to May 2008, 320 patients underwent allogeneic blood and marrow transplant of whom 10 were identified with PI. PI diagnosis was established by computed tomography scan (n=7), plain film (n=2) or colonoscopy (n=1). A total of 9 of 10 patients had ongoing GI GvHD or received recent treatment for GI GvHD. Before April 2002, two patients underwent subtotal colectomy with ileostomy (n=1) and sigmoid colectomy with colostomy (n=1). One patient was managed with bowel rest and total parental nutrition (TPN) only. These three patients died 0.4, 1.1 and 3.9 years after PI diagnosis owing to GI GvHD (n=2) and surgical complications (n=1). Seven patients, diagnosed after September 2006, were treated with GI rest, TPN and antibiotics. PI treated with GI rest, TPN and antibiotics will resolve without surgical intervention. AlloBMT-associated PI is often a non-critical finding that does not represent true GI tract ischemia and/or GI tract perforation.

Endoscopic vacuum sponge therapy for esophageal defects

Anastomotic insufficiency in esophageal anastomosis and esophageal defects of other etiology are very severe complications. For anastomotic insufficiency in the rectum, endoscopic vacuum therapy has already been used successfully. The authors used vacuum therapy for anastomotic defects and other lesions of the esophagus. Between November 2006 and September 2009, 10 patients (5 men and 5 women, ages 46-82 years) were treated with endoscopic vacuum sponge therapy for anastomotic insufficiency secondary to esophagectomy or gastrectomy (n = 5), iatrogenic esophageal perforation (n = 2), esophageal wall necrosis (n = 1), Boerhaave's syndrome (n = 1), and perforation of esophageal cancer (n = 1). After one to seven changes of the sponge at intervals of 2-7 days and a mean therapy duration of 12 days, the defects were healed in all the surviving patients. During treatment, the patients were fed via an intestinal tube or percutaneous endoscopic gastrostomy (PEG), or enterally past the sponge. One patient died of intercurrent severe colitis. In three cases, a revision laparotomy was necessary at the beginning of treatment. No postinterventional stricture or functional relevant scar formation was observed during a follow-up period of 10-380 days after termination of the vacuum therapy. Esophageal anastomotic insufficiency and esophageal wall defects of other causes can be treated successfully with endoscopic vacuum sponge therapy.

Necrosis of the Anterior Abdominal Wall after Harvest of both Internal Thoracic Arteries and Inferior Epigastric Arteries

Introduction: The internal thoracic artery (ITA) and inferior epigastric artery (IEA) may be used as conduits for myocardial revascularization. ITA grafts are currently the gold standard for myocardial revascularization. The ITA provides a long conduit that resists atherosclerosis after implantation and offers long-term patency. Experience with IEA grafts remains limited due to their short length and greater variation in size and anatomy; IEAs are primarily used as Y-grafts from another arterial conduit. Therefore, harvesting bilateral ITAs and IEAs is rare. Harvesting the ITAs and IEAs potentially can lead to hypoperfusion of the adjacent abdominal wall. Clinical data were prospectively collected on our patients who had had ITA and IEA harvest for myocardial revascularization to determine the dimensions of the associated risk to the abdominal wall, particularly the incidence of clinically significant abdominal wall ischemia or necrosis and the extent of tissue loss. Methods: We created a prospective database from 1990 to 1992 with data from 108 patients receiving myocardial revascularization with at least 1 ITA and at least 1 IEA. Data recorded included age, sex, weight, height and body surface area. Pertinent history was taken, including prior revascularization and the presence of associated medical diseases. The harvesting procedure was similar in all patients. Myocardial revascularization was performed and patients were followed to document the outcomes of these procedures. The incidence of operative death, perioperative myocardial infarction, low cardiac output, and other significant complications were recorded. All tissue necrosis was noted during hospitalization. We defined clinically significant necrosis to be that which required surgical debridement with or without skin grafts. Results: All patients had 1 (84%) or 2 (16%) IEAs harvested. One ITA was harvested in 90% of patients and 82% had both ITAs utilized. All 17 patients in whom 2 IEAs were harvested also had 2 ITAs harvested (16%). Harvesting 2 ITAs and 2 IEAs was based on patient coronary anatomy and the resulting need for additional grafts. The most frequent postoperative complication was supraventricular tachycardia which occurred in 31 patients (28%). Other complications included low cardiac output, renal insufficiency, infections, and death. Only patients who had bilateral ITA and bilateral IEA harvest (N=17) developed abdominal wall tissue necrosis. Of these 17 patients, 2 (12%) had abdominal wall necrosis. The extent of necrosis was typically in an area of about 10 cm in maximum diameter, in the midline between the umbilicus and pubis. The extent of necrosis involved muscle and fascia, but the peritoneum and posterior rectus sheath remained intact in our patients and there was no instance of loss of full thickness of the abdominal wall. The 2 affected patients in our study had bulging of the abdominal wall but no medical intervention was indicated. Conclusions: A small but significant subset of patients have bilateral ITAs utilized for revascularization. While it is rarely necessary, bilateral harvesting of ITAs and IEAs results in about a 10-20% chance of tissue necrosis in the anterior abdominal wall due to ischemia. These data may be most valuable to those who contemplate an abdominal operation in a patient who, for one reason or another, has had one or more of their ITAs or IEAs taken.

An Emerging Pulmonary Haemorrhagic Syndrome in Dogs: Similar to the Human Leptospiral Pulmonary Haemorrhagic Syndrome?

Severe pulmonary haemorrhage is a rare necropsy finding in dogs but the leptospiral pulmonary haemorrhagic syndrome (LPHS) is a well recognized disease in humans. Here we report a pulmonary haemorrhagic syndrome in dogs that closely resembles the human disease. All 15 dogs had massive, pulmonary haemorrhage affecting all lung lobes while haemorrhage in other organs was minimal. Histologically, pulmonary lesions were characterized by acute, alveolar haemorrhage without identifiable vascular lesions. Seven dogs had mild alveolar wall necrosis with hyaline membranes and minimal intraalveolar fibrin. In addition, eight dogs had acute renal tubular necrosis. Six dogs had a clinical diagnosis of leptospirosis based on renal and hepatic failure, positive microscopic agglutination test (MAT) and/or positive blood/urine Leptospira-specific PCR. Leptospira could not be cultured post mortem from the lungs or kidneys. However, Leptospira-specific PCR was positive in lung, liver or kidneys of three dogs. In summary, a novel pulmonary haemorrhagic syndrome was identified in dogs but the mechanism of the massive pulmonary erythrocyte extravasation remains elusive. The lack of a consistent post mortem identification of Leptospira spp. in dogs with pulmonary haemorrhage raise questions as to whether additional factors besides Leptospira may cause this as yet unrecognized entity in dogs.

BK Virus in Solid Organ Transplant Recipients

The human polyomavirus BK (BKV) is linked to two ma-jor complications in transplant recipients, polyomavirus-associated nephropathy (PyVAN) (1–4) and polyomavirus-associated hemorrhagic cystitis (PyVHC) (5,6). PyVAN andPyVHC have been encountered in a variety of immunod-eficient patients (7,8), but most cases of PyVAN arise inkidney transplant patients at rates of 1–10%, while PyVHCpreferentially affects allogeneic hematopoietic stem celltransplant patients at rates of 5–15% (7,9). BKV hasbeen less frequently associated with other pathologies,such as ureteric stenosis, pneumonitis, hemophagocyticsyndrome, encephalitis, retinitis, multiorgan failure andpolyomavirus-associated multifocal leukoencephalopathy(PyVML) (10–12), a complication of the central nervoussystem mostly caused by the closely related polyomavirusJC (JCV) (13). The objective of this section is to updateprevious recommendations (14) regarding diagnosis andmanagement of BKV replication and PyVAN in solid organtransplantation (SOT) using the grading proposed by Grosset al. (15).BKV belongs to the family Polyomaviridaetogether withfive other polyomaviruses detected in human specimens,that is JCV, KI virus, WU virus, Merkel cell carcinoma virusand Simian virus 40 (16,17). The virions are nonenvelopedparticles of 42 nm diameter and fairly resistant to envi-ronmental inactivation (18). The circular double-strandedDNA genome of

Erratum to: Treatment and outcome of children with cerebral cavernomas: a survey on 32 patients

In two consecutive sentences of the ‘‘Discussion’’ section, due to a typing error, some numbers in square brackets do not correspond to the references listed in the ‘‘References’’ section. The correct sentences (i.e. reporting the correct numbers in square brackets corresponding to the references) are the following: ‘‘Several hypotheses have been put forward to explain their occurrence, including the effect of vessel wall necrosis and changes related to radiation therapy [39, 40], the ionizing effect of radiation energy generating vascular and connective tissue changes in the stroma [41], or the detection of a radiographically occult cavernoma only after radiotherapy [42]. Nimjee et al. [43] described 76 de novo CCs after radiation treatment’’.

Intraluminal Fibre-Tip Centring can Improve Endovenous Laser Ablation: A Histological Study

Objective In this histological study, the lateral saphenous vein of the goat was treated using a laser fibre to which a tulip-shaped, self-expandable catheter had been fixed to achieve endovenous laser ablation (EVLA). The catheter centres the laser fibre in the vein preventing direct contact with the vein wall. This study aims to establish whether prevention of direct contact between the fibre tip and the vein wall prevents ulceration and perforation of the vein wall and perivenous tissue destruction. Materials and Methods Ten lateral saphenous veins were treated, using the tulip catheter, in goats under general anaesthesia. Ten more veins were treated with a normal bare fibre. We used a 980 nm diode laser to provide the energy. Postoperatively the veins were removed immediately, at 10 days and after 3 weeks for histological examination. Destruction of the vessel wall was measured and perivenous tissue destruction was quantified using a graded scale. Results Ulceration and perforation were prevented when using the tulip catheter. It also achieved more even vein wall necrosis. Tulip-catheter-treated veins show a transmural vein wall necrosis in, on average, 80% of the total circumference compared to 64% in bare-fibre treated veins. Less perivenous tissue destruction was seen with the new catheter (perivenous tissue destruction scale: tulip catheter: 1.7 vs. bare fibre: 3.8). Three weeks after treatment, we found regression of the perivenous tissue destruction as the healing process continued. Conclusions EVLA using the tulip catheter avoids ulceration and perforation of the vein associated with treatment using a bare fibre. It also results in more even circumferential vein wall necrosis and less perivenous tissue destruction.

37. Prominent demyelination in vasculitic neuropathy

Introduction: The characteristic histopathological features of vasculitic neuropathy are axonal degeneration with vessel wall inflammation and necrosis. Other suggestive features include multifocal or segmental fibre loss, occluded or recanalised vessels, haemorrhage and vessel wall invasion without definite fibrinoid necrosis. Prominent demyelination is atypical however conduction block, the electrophysiological correlate of demyelination, has been reported in vasculitic neuropathy and demyelination is a prominent feature in some ischaemia/reperfusion nerve injury models.

Early Esophageal Perforation Due to a Large Impacted Food Bolus

Purpose: Esophageal perforation is a rare complication of food impaction in the esophagus and is seen less than 1% of the time. The risk of esophageal perforation increases significantly after the first 24 hours secondary to transmural ischemia. We present an unusual case in which an esophageal perforation, that was sealed by the large food bolus, developed within a relatively short amount of time (6-8 hours) after the food impaction occurred. Results: A 38-year-old male with no past medical history presented to the ER with ongoing chest pain approximately six hours after eating a hot dog at a baseball game. He was unable to tolerate any oral liquids or his own saliva. He had no crepitus of the neck or chest and routine CXR was negative for signs of an esophageal perforation. He was taken for an emergent EGD approximately 9 hours post-ingestion and the examination showed an esophageal mucosa rent. The underlying muscularis propria was visualized without any manipulation of the food bolus. The examination was immediately terminated. Following the brief procedure, the patient proceeded to regurgitate the food bolus, which was an intact piece of hot dog about 5 cm in length, at which time the chest pain worsened. There was now palpable crepitus over the neck and upper chest supporting the diagnosis of an esophageal perforation. The patient was taken emergently to surgery and upon exposure of the mediastinum, there was evidence of a small abscess at the perforation site now just 12 hours post-ingestion. Conclusion: There have been few reports of early esophageal perforation due to food impactions in the abcense of an underlying risk factor. With longstanding impactions, the obstructing bolus can cause transmural inflammation and pressure necrosis of the adjacent esophageal wall leading to mucosal breakdown and an increased risk of perforation. We report a case in which a patient had spontaneous focal perforation of the esophagus without underlying risk factors such as eosinophilic esophagitis or excessive manipulation during the endoscopy, that appeared to have been sealed by the large food bolus until it was spontaneously dislodged. We believe that the large size of the bolus intact was able to exert higher than normal pressures on the esophageal wall leading to an extremely rapid progression of ischemia leading to wall necrosis and early perforation.

Opposites attract: a case of magnet ingestion

Foreign-body ingestion is relatively common in the pediatric population and most objects pass through the gastrointestinal tract with minimal complications. Popular toy magnetic construction sets have resulted in numerous reports in the literature of serious complications including death following ingestion of multiple magnets. We report a case of a 5-year-old girl who presented to our emergency department with nonbilious vomiting and mild abdominal pain after accidentally ingesting 2 magnets 10 hours apart. Abdominal radiography showed the presence of 2 magnets, and a laparoscopy revealed multiple areas of bowel wall necrosis and perforation requiring subsequent laparotomy for repair of the bowel wall and retrieval of the magnets. This report aims to alert emergency care physicians of the necessity for early surgical referral with any multiple magnet ingestion to prevent severe complications.

Livedoid Vasculopathy With Underlying Subcutaneous Necrotizing Venulitis in an Asymptomatic Hepatitis B Virus Carrier: Is Livedoid Vasculopathy a True Nonvasculitic Disorder?

Livedoid vasculopathy has been accepted as a nonvasculitic disorder, but authentic vasculitis in the underlying subcutis can occur in cases of collagen disease and polyarteritis nodosa. We report a case of livedoid vasculopathy with underlying subcutaneous necrotizing venulitis in a 42-year-old carrier of hepatitis B virus. The patient also had a 15-year history of ankylosing spondylitis that was currently in remission. Skin lesions revealed superficial ulceration, purpura, atrophie blanche, and reticulate erythema on the lower extremities, and a skin biopsy showed a minimal dermal perivascular lymphocytic infiltrate with marked fibrin thrombi and fibrin deposits along luminal vessel walls, consistent with features of livedoid vasculopathy. However, necrotizing venulitis characterized by a predominant lymphocytic infiltrate in and around the vessel wall with marked fibrinoid vessel wall necrosis was found in the underlying subcutaneous tissue. A direct immunofluorescence study detected immunoglobulin M and C3 deposits in the papillary dermis. The patient responded well to oral aspirin and a prostaglandin analogue and was well controlled with a compression bandage. Vasculitic lesions in the underlying subcutis may have been overlooked in cases in which livedoid vasculopathy has been considered as a nonvasculitic disorder because our case demonstrates that livedoid vasculopathy can be accompanied by subcutaneous vasculitis.

Magnetic Compression Biliary–enteric Anastomosis for Palliation of Obstructive Jaundice: Initial Clinical Results

To report initial clinical experience with a nonsurgical method for sutureless biliary-enteric anastomosis with use of two magnetic elements that potentially overcomes the disadvantages of other palliative methods. The technique involves percutaneous transhepatic insertion of one magnet into the bile duct under fluoroscopic guidance and insertion of a second magnet endoscopically into the duodenum. The adherence of the two magnets creates ischemic necrosis of bile duct and duodenal walls. When these tissues slough, the resulting hole allows enteric passage of the magnets and creates a biliary-enteric fistula for decompression of an obstructed biliary system. A magnetic compression biliary-enteric anastomosis (MCBEA) was created in 34 patients (nine men; mean age, 64 years; age range, 46-82 y) with malignant obstructive jaundice at the level of the middle or distal common bile duct. There was no recurrent jaundice during the initial 30 postprocedural days. Total bilirubin levels decreased significantly in all patients 1 week after MCBEA formation (P < .0001), with normalization of bilirubin levels in eight of 34 patients. There was temporary occlusion caused by partial clogging of the bypass with coarse food in two cases, which was successfully revised endoscopically. Three patients required surgical revision as a result of tumor ingrowth. Median survival time was 10 months. The cause of death in all patients was progression of underlying malignancy. Creation of a biliary-enteric anastomosis with magnetic compression is a feasible alternative for palliative treatment of obstructive jaundice with satisfactory results.

Pelvic Cancer Recurrence

Local recurrence of pelvic cancer is a therapeutic challenge. Medical history retrieve frequently high dose radiotherapy and multiple pelvic surgery. Thus, surgical resection is complex and leads to hazardous postoperative courses. We report a case of radiofrequency thermoablation (RFTA) of an isolated pelvic recurrence. A 53-year-old woman presented in 2006 with a small (20 mm) pelvic recurrence of an anal canal cancer initially treated by radiochemotherapy and amputation of the rectum. The recurrence was localized in the left vaginal wall, involving the obturator internus muscle. Treatment consisted on primary chemotherapy followed by RFTA under real time endovaginal sonography with cooling of the bladder. Small vaginal wall necrosis occurred in postoperative courses and rapidly cicatrized. The patient was still alive without evolution 22 months after the treatment. RFTA is a feasible therapeutic option for some selected small isolated pelvic cancer recurrence. It allows good local control with survival improvement.

Neonatal bladder rupture

Neonatal bladder rupture is rare as a complication of bladder obstruction due to abnormal anatomy or iatrogenic cause such as umbilical catheterization. The present study describes the case of a 27-day old infant with ascites due to bladder perforation secondary to bladder wall necrosis as a result of severe urinary tract infection. The baby was treated aggressively with antibiotics and underwent successful surgical repair of the perforation.

Prevention and treatment of complications after surgical resection for esophageal and gastric cardiac cancers

To summarize the experience in surgical resection for esophageal and gastric cardiac cancers so as to put forward countermeasures to prevent the post-operative complications. From September 1952 to December 2005, 20,796 patients with esophageal and gastric cardiac cancers underwent surgical operation. The category and incidence of the complications in different decades were retrospectively analyzed. (1) 18,772 of the 20 796 patients with esophageal and gastric cardiac cancers underwent surgical resection. Operative complications occurred in 1741 patients (9.27%), death occurred in 433 of which (24.87%). (2) The complication rate was 39.77% in 1950s, and decreased to 4.10% in 2000s. The mortality rate of complication was 44.29% in 1950s, and decreased to 15.42% in 2000s. (3) The incidence and mortality rates of closely-surgery-related complications declined obviously over the period of study. The incidence and mortality rates of anastomotic leakage were 4.55% and 50.00% respectively in 1950s, and then decreased to 1.21% and 3.33% respectively in 2000s. The incidence and the mortality rates of empyema were 7.39% and 38.46% respectively in 1950s, and decreased to 0.36% and 5.56% respectively in 2000s. The incidence and the mortality rates of chylothorax was 0.16% and 0% recently. (4) The incidence of non-surgical-related complications declined slightly but the mortality rate was still very high over the period of study. The mortality rates of pulmonary and cardiovascular complication were 27.42% and 25.00% respectively recently. (1) One of the advantages of surgical treatment for esophagus and gastric cardiac cancers is the obvious decline of the incidence and the mortality rates of complications. (2) In order to reduce the incidence of systemic complication, especially pulmonary complication, active and corresponding preoperative preparation should be improved along with the expansion of the scope of surgical indication. (3) The key for prevention of post-operative complications is consummate surgery techniques. Prevention and treatment of anastomotic leakage, gastric wall necrosis, and intrathoracic and intraabdominal bleeding are still the focal points.

Medical Management of Pneumatosis Intestinalis in Patients Undergoing Allogeneic Blood and Marrow Transplantation

Pneumatosis intestinalis (PI) occurs when gastrointestinal (GI) wall disruption, increased GI wall permeability or necrosis leads to GI wall infiltration by gas. It is associated with a spectrum of causal factors including GI disease in allogeneic Blood and Marrow Transplant (alloBMT) patients (pts). Anaerobic bacteria likely produce gas which accumulates in the GI wall. Traditionally, PI has been managed with surgical exploration with high morbidity and mortality. We describe our institutional experience managing alloBMT pts with PI.

Cystic echinococcosis of the liver and lung treated by radiofrequency thermal ablation: An ex-vivo pilot experimental study in animal models

To evaluate radiofrequency thermal ablation (RTA) for treatment of cystic echinococcosis in animal models (explanted organs). Infected livers and lungs from slaughtered animals, 10 bovine and two ovine, were collected. Cysts were photographed, and their volume, cyst content, germinal layer adhesion status, wall calcification and presence of daughter or adjacent cysts were evaluated by ultrasound. Some cysts were treated with RTA at 150 W, 80 degrees C, 7 min. Temperature was monitored inside and outside the cyst. A second needle was placed inside the cyst for pressure stabilization. After treatment, all cysts were sectioned and examined by histology. Cysts were defined as alive if a preserved germinal layer at histology was evident, and as successfully treated if the germinal layer was necrotic. The subjects of the study were 17 cysts (nine hepatic and eight pulmonary), who were treated with RTA. Pathology showed 100% success rate in both hepatic (9/9) and lung cysts (8/8); immediate volume reduction of at least 65%; layer of host tissue necrosis outside the cyst, with average extension of 0.64 cm for liver and 1.57 cm for lung; and endocyst attached to the pericystium both in hepatic and lung cysts with small and focal de novo endocyst detachment in just 3/9 hepatic cysts. RTA appears to be very effective in killing hydatid cysts of explanted liver and lung. Bile duct and bronchial wall necrosis, persistence of endocyst attached to pericystium, should help avoid or greatly decrease in vivo post-treatment fistula occurrence and consequent overlapping complications that are common after surgery or percutaneous aspiration, injection and reaspiration. In vivo studies are required to confirm and validate this new therapeutic approach.

Hemoptysis in a Patient with Melanoma and Pulmonary Infiltrates

An 85-year-old white man with known history of melanoma was referred to the Interventional Pulmonary service for hemoptysis. Review of recent imaging revealed nodular infiltrates without significant volume loss. Bronchoscopy was performed revealing glistening polypoid endobronchial masses obstructing the apical-posterior segment (B 1 ) of the left upper lobe and anterior segment of the right upper lobe (B) (Figure 1). Bronchoscopic needle aspiration and biopsy were performed. Argon plasma coagulation was then undertaken with successful ablation and subsequent patency of the involved segments (Figure 2). Lung metastases from malignancy other than bronchogenic carcinoma are a common occurrence with the incidence ranging from 20 to 50%.1 Although the incidence for endobronchial metastasis has been reported to be from about 2 to 28%, a retrospective review of 1359 autopsies revealed only 2% of patients dying with solid tumors to have metastatic involvement of the central airways.2 Metastases from primary malignancy are traditionally described to spread via a hematogenous or lymphatic route, however, tracheal or bronchial obstruction due to endobronchial metastasis is rare, and must be differentiated from obstruction caused by an extrinsic mass. Although frequently asymptomatic (52%), endoluminal metastasis may commonly present with cough, wheezing, dyspnea, and hemoptysis as was present in our patient. Radiographic findings may include lobar or segmental atelectasis. Endoluminal metastasis may signal slow disease progression and have a median lag time of up to 5 years or more dependent upon the underlying primary malignancy.3 Renal cell carcinoma is thought to be the most frequent etiology of endobronchial metastasis with other tumors to include melanoma, lymphoma, breast, larynx, thyroid, and colon. Primary melanoma of the airway with tracheal obstruction and diffuse melanosis of the airways without associated skin or mucous membrane pigmentation has also been described. Rare patients with bronchial obstruction associated with malignant melanoma have been reported, as was true in our patient. Appropriate diagnosis should be performed to exclude the potential of a second primary. Endobronchial biopsies are easily obtained, however, as certain tumors are noted for a propensity toward significant bleeding, such as renal cell carcinoma and melanoma, initial sampling may easily be performed by means of endoluminal needle aspiration described by Wang et al.4 Management of bronchial metastases is symptom based. Historically, if the obstructing mass could be localized by imaging studies, external beam radiotherapy, or surgery was employed to palliate the obstruction. It is currently reasonable to attempt to relieve obstruction by laser endoscopy, argon coagulation, or photodynamic therapy. Endobronchial brachytherapy has sometimes been attempted with some success although late toxicity with bronchial wall necrosis has been attributed to contact between the catheter and bronchial wall mucosa. It should be