abnormalities, althou~h it is lJuite likely that they are rarely dia~osed in this settin!!: due to clinician bias (which is as yet not supported by data). Given that the tme sensitivity and spedficity of arterial blood gas testing and VdlVt analysis ha~ not been determiued in a desi!!:n where all entered patients are evaluated until a dia!!:nostic study either confirms or excludes the dia!!:nosis, I do not believe that either can be used to exclude pulmonary embolism. Because of the prevalence of intrinsic lunl!: disease and resultant !!:as exchan!!:e abnormalities, and potentially the development of abnormal spirograms as a (.~msequence of vasoactive mediators of pulmonary embolism, I am unconvinced that the (.~)mbination of VdlVt and spirography will justify its expense in the routine clinical evaluation of pulmonary embolism. exchan~e
William M. Knfs, M.D .. San Francisco
Multiple Endobronchial Metastases due to Renal Carcinoma and Laser Therapy 7b the Editor:
1 found the report by Carlin et al (Chest 1989: 96: 1I 10) (.'Oncernin!!:
endobronchial metastases due to colorectal carcinoma and their Nd:Ya!!: laser debulking therapy very interesting. I also agree that Nd:Ya!!: laser debulkinl!:, in combination with external beam radiation therapy (XR1j and endobronchial radiation therapy, may afford an improved survival in selected patients with impendinl!: total airway obstmction. I recently enmuntered a 46-year-old Japanese man with right renal carcinoma associated with multiple endobronchial metastases (left B·' .. ri~t B" and basal bronchus). The patient underwent a riW1t radical nephrectomy with partial resection of the inferior vena cava plus lymphadenectomy in June, 198I. Fifty-seven months later, follow-up chest roentgenogram revealed an abnormal shadow at the left hilus and a mild obstructive pneumonia. Bronchoscopic examinations revealed obstruction of the lingular bronchus (B"') due to endobronchial metastases (Fig, upper left). TBLB specimens revealed metastatic lung cancer (clear cell renal carcinoma). The patient immediately underwent left upper lobectomy. Sixteen months later, follow-up bronchoscopic examination revealed a partial obstruction (85 percent) of the right B" bronchus due to endobronchial metastases (clear cell renal carcinoma) (Figure, upper right). After bronchoscopic Nd:Yag laser debulking therapy (total 4,500 J) and XRT (totalS,OOO cGy), obstruction of the B" bronchus was much improved but other endobronchial metastases in the right basal bronchus appeared (Fig, lower). Although further laser therapy
FIGURE. Bronchoscopic examination performed in February, 1986 revealed endobronchial metastases at the left linl!:Ular orifice (upper left). Bronchoscopic examination performed in September, 1987 revealed endobronchial metastases at the riW1t B" bronchial orifice (upper right). Bronchoscopic examination performed after Nd-Yag laser thempy and XRT revealed a marked reduction ofendobronchial metastases at the right B" hut other endobronchial metastases in the riW1t basal bronchial orifice (b, lower). T78
Communications to the Editor
(total 6,300 J) awunst the basal bronchial endobronchial metastases was continued, the patient died of respiratory failure 27 months after the appearance of endobronchial metastases at the ri~t Bfl bronchial orifice. These results suggest that Nd:Ya~ laser debulking therapy led to the relief of symptoms and a survival period of up to 27 months. Shigenobu Umeki, M.D., Ph.D., F.C.C.~, Division of Respiratory Diseases, Department of Medicine, Kawasaki Medical School, Okayama, Japan Reprint requests: Dr. Umeki, Division of Respiratory Disease/ Medicine, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama 701-01, japan
Treatment of Spontaneous Pneumothorax To the Editor: I disaJ.tree with the conclusions of O'Rourke and Yee in their article on the treatment of spontaneous pneumothorax. I I believe that observation is often appropriate and that immediate chest tube thorac.'Ostomy or thoracotomy unnecessarily prolon~s hospital stay and increases patient discomfort. An older paper-which is similar to O'Rourke and Yee's study in design, number and a~e of patients, and concurrent illness-supports the use of observation as initial treatment ofa spontaneous pneumothorax. 2 However, neither study was prospective or randomized, so conclusions can only reflect the authors' opinions. I suspect that the therapeutic modalities used in both studies reflected the training and bias ofthe attending physician rather than to the actual need for a chest tube or thoracotomy. Treatment of patients with pneumothorax should be individualized dependin~ on the clinical circumstances, but observation is still the appropriate c.'Ourse ofaction in many cases. In fact, O'Rourke and Yee state that 18 percent of patients in their observation ~roup eventually needed a chest tube. In other words, 82 percent of these patients did well without any intervention. I wonder ho\\' many of the patients in the other treatment groups would have done well with observation alone? More agwessive modes of therapy (such as aspiration, chest tube thoracostomy or aspiration) may be needed, hut should be reserved for patients with unresolved or recurrent pneumothorax, or in patients with poor pulmonary reserve in whom a pneumothorax would be dangerous. Howard Uss, A/.D., F.C.C.~, Wright State University School of Medicine, VA Medical Center, Dayton, Ohio
REFERENCES O'Rourke J~ Yee ES. Civilian spontaneous pneumothorax: treatment options and lon~-term results. Chest 1989; 96: 1302-30 2 Stradlin~ ~ Poole G. Conservative mana~ement of spontaneous pneumothorax. Thorax 1966; 21:145-49
To the Editor: I agree with Dr. Liss that, hecause our study was retrospective, physician bias win certainly effect the choice of therapeutic options offered f(>r the treatment of spontaneous pneumothorax. However, the great majority of patients in our study were admitted to and initially treated by n()nsur~eons. Surwcal consultation was ohtained when therapeutic intervention was requested.
Dr. Liss is in
William M. Knfs, M.D .. San Francisco
Multiple Endobronchial Metastases due to Renal Carcinoma and Laser Therapy 7b the Editor:
1 found the report by Carlin et al (Chest 1989: 96: 1I 10) (.'Oncernin!!:
endobronchial metastases due to colorectal carcinoma and their Nd:Ya!!: laser debulking therapy very interesting. I also agree that Nd:Ya!!: laser debulkinl!:, in combination with external beam radiation therapy (XR1j and endobronchial radiation therapy, may afford an improved survival in selected patients with impendinl!: total airway obstmction. I recently enmuntered a 46-year-old Japanese man with right renal carcinoma associated with multiple endobronchial metastases (left B·' .. ri~t B" and basal bronchus). The patient underwent a riW1t radical nephrectomy with partial resection of the inferior vena cava plus lymphadenectomy in June, 198I. Fifty-seven months later, follow-up chest roentgenogram revealed an abnormal shadow at the left hilus and a mild obstructive pneumonia. Bronchoscopic examinations revealed obstruction of the lingular bronchus (B"') due to endobronchial metastases (Fig, upper left). TBLB specimens revealed metastatic lung cancer (clear cell renal carcinoma). The patient immediately underwent left upper lobectomy. Sixteen months later, follow-up bronchoscopic examination revealed a partial obstruction (85 percent) of the right B" bronchus due to endobronchial metastases (clear cell renal carcinoma) (Figure, upper right). After bronchoscopic Nd:Yag laser debulking therapy (total 4,500 J) and XRT (totalS,OOO cGy), obstruction of the B" bronchus was much improved but other endobronchial metastases in the right basal bronchus appeared (Fig, lower). Although further laser therapy
FIGURE. Bronchoscopic examination performed in February, 1986 revealed endobronchial metastases at the left linl!:Ular orifice (upper left). Bronchoscopic examination performed in September, 1987 revealed endobronchial metastases at the riW1t B" bronchial orifice (upper right). Bronchoscopic examination performed after Nd-Yag laser thempy and XRT revealed a marked reduction ofendobronchial metastases at the right B" hut other endobronchial metastases in the riW1t basal bronchial orifice (b, lower). T78
Communications to the Editor
(total 6,300 J) awunst the basal bronchial endobronchial metastases was continued, the patient died of respiratory failure 27 months after the appearance of endobronchial metastases at the ri~t Bfl bronchial orifice. These results suggest that Nd:Ya~ laser debulking therapy led to the relief of symptoms and a survival period of up to 27 months. Shigenobu Umeki, M.D., Ph.D., F.C.C.~, Division of Respiratory Diseases, Department of Medicine, Kawasaki Medical School, Okayama, Japan Reprint requests: Dr. Umeki, Division of Respiratory Disease/ Medicine, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama 701-01, japan
Treatment of Spontaneous Pneumothorax To the Editor: I disaJ.tree with the conclusions of O'Rourke and Yee in their article on the treatment of spontaneous pneumothorax. I I believe that observation is often appropriate and that immediate chest tube thorac.'Ostomy or thoracotomy unnecessarily prolon~s hospital stay and increases patient discomfort. An older paper-which is similar to O'Rourke and Yee's study in design, number and a~e of patients, and concurrent illness-supports the use of observation as initial treatment ofa spontaneous pneumothorax. 2 However, neither study was prospective or randomized, so conclusions can only reflect the authors' opinions. I suspect that the therapeutic modalities used in both studies reflected the training and bias ofthe attending physician rather than to the actual need for a chest tube or thoracotomy. Treatment of patients with pneumothorax should be individualized dependin~ on the clinical circumstances, but observation is still the appropriate c.'Ourse ofaction in many cases. In fact, O'Rourke and Yee state that 18 percent of patients in their observation ~roup eventually needed a chest tube. In other words, 82 percent of these patients did well without any intervention. I wonder ho\\' many of the patients in the other treatment groups would have done well with observation alone? More agwessive modes of therapy (such as aspiration, chest tube thoracostomy or aspiration) may be needed, hut should be reserved for patients with unresolved or recurrent pneumothorax, or in patients with poor pulmonary reserve in whom a pneumothorax would be dangerous. Howard Uss, A/.D., F.C.C.~, Wright State University School of Medicine, VA Medical Center, Dayton, Ohio
REFERENCES O'Rourke J~ Yee ES. Civilian spontaneous pneumothorax: treatment options and lon~-term results. Chest 1989; 96: 1302-30 2 Stradlin~ ~ Poole G. Conservative mana~ement of spontaneous pneumothorax. Thorax 1966; 21:145-49
To the Editor: I agree with Dr. Liss that, hecause our study was retrospective, physician bias win certainly effect the choice of therapeutic options offered f(>r the treatment of spontaneous pneumothorax. However, the great majority of patients in our study were admitted to and initially treated by n()nsur~eons. Surwcal consultation was ohtained when therapeutic intervention was requested.
Dr. Liss is in
