were available. As mentioned in a previous issue of Chest,' we attempted such a study with this same group of patients. Once again, the severity of their lung disease differentiates them from Dr. Baum's patients and prevented such a sham study. Without oxygen therapy, patients with this severity of hypoxemic obstructive airway disease were unable to tolerate a month at home and the "control" period ended with an episode of acute respiratory insufficiency.
A. lay Block, M.D. Chief, Pulmonary Division Associate Professor of Medicine and Anesthesiology University of Florida, Gainesville
no myocardial depressant effects. It is just that Jawad-Kanber and Sherrod have not clearly demonstrated such an effect with their data. I am not aware of any study which does document the effect of this drug on left ventricular contractility in intact, conscious patients. Rex MacAlpin, M.D. UCLA School of Medicine Los Angeles
1 Stafford RW, Harris WS, Weissler AM, et al: Systolic time intervals as indexes of gravitational circulatory stress in man. Am J Cardiol 19: 152, 1967
To the Editor: 1 Krop HD, Block AJ, Cohen E: Neuropsychological effects of continuous oxygen therapy in chronic obstructive pulmonary disease. Chest 64:317, 1973
Intravenous Procaine Amide and Left Ventricular Performance
The only message that the study tried to relay was that procaine amide could be given intravenously with some margin of safety; since a loading dose produced measurable decrease in pump performance and ventricular mechanics (peak dpldt), but not to a level that was clinically significant in terms of untoward symptoms or signs in the patient evaluated.
G. Jawad-Kanber,M.D., F.C.C.P. Oak Park, Zllimis
To the Editor: In their report of the effects of intravenous procaine arnide on left ventricular function (Chest 66: 269-272, 1974), Drs. Jawad-Kanber and Sherrod concluded that the hemodynamic alterations which they observed are consistent with a myocardial depression or a negative inotropic effect of the drug. I presume they based this conclusion on the observation of decreases in cardiac index, arterial pressure, left ventricular stroke work, and peak positive left ventricular dpldt. Also noted was a rise in rate corrected pre-ejection ~ e r i o d .It seems to me, however, that they failed to appreciate that none of these hemodynamic variables are direct measures of left ventricular contractility; in fact, their data are equally or more consistent with a reduction in venous return and a decline in left ventricular end-diastolic volume and fiber length. The fall in left ventricular end-diastolic and pulmonary arterial pressures that was observed would be consistent with this alternate hypothesis. It is well established that a reduction in left ventricular "preload" will result in decreases in stroke volume, stroke work, and peak dpldt, and this also will cause an increase in rate corrected pre-ejection period1 without any intrinsic change in contractile state of the myocardium. I do not wish to imply that procaine amide has CHEST, 67: 6, JUNE, 1975
Comment on Lung Biopsy Techniques To the Editor: In reference to the report entitled "Percutaneous Needle Biopsy of the Lung: Report of Two Fatal Complications" ( Chest 66:216-218, 1974 ), we would like to comment on the conclusions reached by Drs. Norenberg, Claxton, and Takaro on the use of different lung biopsy techniques. In the past five years at the Washington University Medical Center, a p proximately 125 cutting needle biopsies of the lung have been performed by seven different individuals. In five instances the patient died during or immediately after the procedure. Four of these patients had immediate massive hemoptysis as described by Dr. Norenberg and his colleagues. Another young man with sarcoidosis developed a permanent hemiparalysis after the procedure, presumably from air embolus. Because of these results, we no longer use this biopsy technique. Our experience with aspiration needle biopsy has been quite different. In over 300 cases we have had no deaths, with significant morbidity limited to COMMUNICATIONS TO THE EDITOR 737
pneurnothorax requiring a chest tube in slightly less than 10 percent of the cases. With increasing practice our yield in the diagnosis of localized lung disease is now well over 90 percent. This is a safe simple procedure which can be accomplished in any hospital where image-intensification fluoroscopy and good cytologic services are available. In summary, we feel that the preferred method for obtaining tissue from undiagnosed localized lung lesions is fluoroscopically controlled needle aspiration biopsy. In diffuse lung disease a limited thoracotomy with open lung biopsy is used. We no longer perform cutting needle biopsies.
John V . Forrest, M.D., and Stuart S . Sagel, M.D. Co-Chiefs, Pulmonary Radiology Division Mallinckrodt Institute of Radiology, and Associate Professors, School of Medicine Washington University, St. Louis
Metastatic Bronchogenic Carcinoma: An Unusual Cause of Localized Arthritis To the Editor: Lung cancer is the most common fatal malignancy in the American male.' It is responsible for the deaths of 43 per 100,000 males in this country. All bronchogenic carcinomas tend to metastasize early, which accounts for the high mortality rates2 Bronchogenic carcinoma metastasizes beyond the thorax most commonly to lymph nodes, liver, adrenals, kidneys, bone and and bone metastases in bronchogenic carcinoma range from 10 to 20 p e r ~ e n t . ~ . ~ However, while metastases of bronchogenic carcinema to bone are common, metastatic neoplasms of the joint are a rare problem, with only one case having been described in which carcinomatous synovitis of one knee was the presenting feature of bronchogenic carcinoma.' We present a case of unilateral painful joint effusion in a patient with bronchogenic carcinoma. The malignant etiology of the effusion was established even in the absence of initial radiographic changes in the underlying bones, with routine cytologic examination of the aspirated fluid.
A 62-year-old white man was admitted on July 23, 1973 with chief complaints of hemoptysis of nine days' duration and progressive shortness of breath. The patient had been a pack-and-a-half per day smoker for 40 years. Past medical
738 COMMUNICATIONS TO THE EWTOR
history was noncontributory. Physical examination on admission revealed a fairly well built man in no distress with blood pressure 120/80 mm Hg, pulse 80 and regular, and respiratory rate 16 per minute; the rest of the exam was unremarkable. Chest x-ray film showed a density in the anterior segment of the left upper lobe. All the admitting laboratory values were entirely within normal limits. Following bronchoscopy and mediastinoscopy, which were inconclusive, the patient underwent thoracotomy on August 17, 1973 and was found to have intensive involvement of mediastinal nodes by undifferentiated carcinoma. Pneumonectomy was ruled out and the procedure terminated. A course of external radiation to left lung was subsequently administered. On September 5, 1973, the patient complained for the first time of a painful left knee, at which time the pain was localized to the medial aspect of the knee and there was no associated swelling. X-ray film of the left knee revealed minimal degenerative changes. Rheumatology consultation was obtained, and the possibility of calcific tendonitis or a medial ligament tear suggested. By September 19 a painful effusion was present in the left knee joint. This was tapped, a few milliliters of bloody fluid aspirated, and a routine cytologic examination showed poorly differentiated adenocarcinoma. Repeat x-ray films showed a lytic destructive lesion of the distal left humerus, a lytic metastatic lesion in the medial condyle of the left femur, and pathologic intertrochanteric fracture of the right hip. Total body bone scan was done on September 18 and markedly increased areas of uptake were seen in the left knee, the left elbow, and the greater trochanter of the right femur. Radiation therapy to the left knee and elbow was begun with symptomatic relief, but left knee effusion persisted. Repeat aspiration of the left knee again showed adenocarcinoma cells. The patient continued to deteriorate and expired on November 9, 1973. Autopsy showed undifferentiated carcinoma of left upper lobe with metastasis to mediastinal nodes, left adrenal cortex, both knees,left elbow and right femur.
Rheumatic symptoms in bronchogenic carcinoma are c o m r n ~ nusually ,~ resulting from skeletal metastases or hypertrophic osteoarthropathy; however, as we pointed out above, a painful joint effusion as a metastatic manifestation of bronchogenic carcinoma is very uncommon, with only one case having been described in the English literature.' The diagnostic value of cervical and sputum cytologic examinations is well establi~hed.~.~ This useful diagnostic tool is rarely, if ever, used in the evaluation of joint effusions. In a cytologic examination of 71 joint effusions there were no false positives and three positive aspirates for malignant cells, one of these being in a patient with a clinically unsuspected malignan~y.~ Thus, cytologic examination of joint effusions is very useful. In our patient the diagnosis of malignant joint effusion was established with cytologic examination even in the presence of an initially normal bone x-ray examination. This early diagnosis made it CHEST, 67: 6, JUNE, 1975
A. lay Block, M.D. Chief, Pulmonary Division Associate Professor of Medicine and Anesthesiology University of Florida, Gainesville
no myocardial depressant effects. It is just that Jawad-Kanber and Sherrod have not clearly demonstrated such an effect with their data. I am not aware of any study which does document the effect of this drug on left ventricular contractility in intact, conscious patients. Rex MacAlpin, M.D. UCLA School of Medicine Los Angeles
1 Stafford RW, Harris WS, Weissler AM, et al: Systolic time intervals as indexes of gravitational circulatory stress in man. Am J Cardiol 19: 152, 1967
To the Editor: 1 Krop HD, Block AJ, Cohen E: Neuropsychological effects of continuous oxygen therapy in chronic obstructive pulmonary disease. Chest 64:317, 1973
Intravenous Procaine Amide and Left Ventricular Performance
The only message that the study tried to relay was that procaine amide could be given intravenously with some margin of safety; since a loading dose produced measurable decrease in pump performance and ventricular mechanics (peak dpldt), but not to a level that was clinically significant in terms of untoward symptoms or signs in the patient evaluated.
G. Jawad-Kanber,M.D., F.C.C.P. Oak Park, Zllimis
To the Editor: In their report of the effects of intravenous procaine arnide on left ventricular function (Chest 66: 269-272, 1974), Drs. Jawad-Kanber and Sherrod concluded that the hemodynamic alterations which they observed are consistent with a myocardial depression or a negative inotropic effect of the drug. I presume they based this conclusion on the observation of decreases in cardiac index, arterial pressure, left ventricular stroke work, and peak positive left ventricular dpldt. Also noted was a rise in rate corrected pre-ejection ~ e r i o d .It seems to me, however, that they failed to appreciate that none of these hemodynamic variables are direct measures of left ventricular contractility; in fact, their data are equally or more consistent with a reduction in venous return and a decline in left ventricular end-diastolic volume and fiber length. The fall in left ventricular end-diastolic and pulmonary arterial pressures that was observed would be consistent with this alternate hypothesis. It is well established that a reduction in left ventricular "preload" will result in decreases in stroke volume, stroke work, and peak dpldt, and this also will cause an increase in rate corrected pre-ejection period1 without any intrinsic change in contractile state of the myocardium. I do not wish to imply that procaine amide has CHEST, 67: 6, JUNE, 1975
Comment on Lung Biopsy Techniques To the Editor: In reference to the report entitled "Percutaneous Needle Biopsy of the Lung: Report of Two Fatal Complications" ( Chest 66:216-218, 1974 ), we would like to comment on the conclusions reached by Drs. Norenberg, Claxton, and Takaro on the use of different lung biopsy techniques. In the past five years at the Washington University Medical Center, a p proximately 125 cutting needle biopsies of the lung have been performed by seven different individuals. In five instances the patient died during or immediately after the procedure. Four of these patients had immediate massive hemoptysis as described by Dr. Norenberg and his colleagues. Another young man with sarcoidosis developed a permanent hemiparalysis after the procedure, presumably from air embolus. Because of these results, we no longer use this biopsy technique. Our experience with aspiration needle biopsy has been quite different. In over 300 cases we have had no deaths, with significant morbidity limited to COMMUNICATIONS TO THE EDITOR 737
pneurnothorax requiring a chest tube in slightly less than 10 percent of the cases. With increasing practice our yield in the diagnosis of localized lung disease is now well over 90 percent. This is a safe simple procedure which can be accomplished in any hospital where image-intensification fluoroscopy and good cytologic services are available. In summary, we feel that the preferred method for obtaining tissue from undiagnosed localized lung lesions is fluoroscopically controlled needle aspiration biopsy. In diffuse lung disease a limited thoracotomy with open lung biopsy is used. We no longer perform cutting needle biopsies.
John V . Forrest, M.D., and Stuart S . Sagel, M.D. Co-Chiefs, Pulmonary Radiology Division Mallinckrodt Institute of Radiology, and Associate Professors, School of Medicine Washington University, St. Louis
Metastatic Bronchogenic Carcinoma: An Unusual Cause of Localized Arthritis To the Editor: Lung cancer is the most common fatal malignancy in the American male.' It is responsible for the deaths of 43 per 100,000 males in this country. All bronchogenic carcinomas tend to metastasize early, which accounts for the high mortality rates2 Bronchogenic carcinoma metastasizes beyond the thorax most commonly to lymph nodes, liver, adrenals, kidneys, bone and and bone metastases in bronchogenic carcinoma range from 10 to 20 p e r ~ e n t . ~ . ~ However, while metastases of bronchogenic carcinema to bone are common, metastatic neoplasms of the joint are a rare problem, with only one case having been described in which carcinomatous synovitis of one knee was the presenting feature of bronchogenic carcinoma.' We present a case of unilateral painful joint effusion in a patient with bronchogenic carcinoma. The malignant etiology of the effusion was established even in the absence of initial radiographic changes in the underlying bones, with routine cytologic examination of the aspirated fluid.
A 62-year-old white man was admitted on July 23, 1973 with chief complaints of hemoptysis of nine days' duration and progressive shortness of breath. The patient had been a pack-and-a-half per day smoker for 40 years. Past medical
738 COMMUNICATIONS TO THE EWTOR
history was noncontributory. Physical examination on admission revealed a fairly well built man in no distress with blood pressure 120/80 mm Hg, pulse 80 and regular, and respiratory rate 16 per minute; the rest of the exam was unremarkable. Chest x-ray film showed a density in the anterior segment of the left upper lobe. All the admitting laboratory values were entirely within normal limits. Following bronchoscopy and mediastinoscopy, which were inconclusive, the patient underwent thoracotomy on August 17, 1973 and was found to have intensive involvement of mediastinal nodes by undifferentiated carcinoma. Pneumonectomy was ruled out and the procedure terminated. A course of external radiation to left lung was subsequently administered. On September 5, 1973, the patient complained for the first time of a painful left knee, at which time the pain was localized to the medial aspect of the knee and there was no associated swelling. X-ray film of the left knee revealed minimal degenerative changes. Rheumatology consultation was obtained, and the possibility of calcific tendonitis or a medial ligament tear suggested. By September 19 a painful effusion was present in the left knee joint. This was tapped, a few milliliters of bloody fluid aspirated, and a routine cytologic examination showed poorly differentiated adenocarcinoma. Repeat x-ray films showed a lytic destructive lesion of the distal left humerus, a lytic metastatic lesion in the medial condyle of the left femur, and pathologic intertrochanteric fracture of the right hip. Total body bone scan was done on September 18 and markedly increased areas of uptake were seen in the left knee, the left elbow, and the greater trochanter of the right femur. Radiation therapy to the left knee and elbow was begun with symptomatic relief, but left knee effusion persisted. Repeat aspiration of the left knee again showed adenocarcinoma cells. The patient continued to deteriorate and expired on November 9, 1973. Autopsy showed undifferentiated carcinoma of left upper lobe with metastasis to mediastinal nodes, left adrenal cortex, both knees,left elbow and right femur.
Rheumatic symptoms in bronchogenic carcinoma are c o m r n ~ nusually ,~ resulting from skeletal metastases or hypertrophic osteoarthropathy; however, as we pointed out above, a painful joint effusion as a metastatic manifestation of bronchogenic carcinoma is very uncommon, with only one case having been described in the English literature.' The diagnostic value of cervical and sputum cytologic examinations is well establi~hed.~.~ This useful diagnostic tool is rarely, if ever, used in the evaluation of joint effusions. In a cytologic examination of 71 joint effusions there were no false positives and three positive aspirates for malignant cells, one of these being in a patient with a clinically unsuspected malignan~y.~ Thus, cytologic examination of joint effusions is very useful. In our patient the diagnosis of malignant joint effusion was established with cytologic examination even in the presence of an initially normal bone x-ray examination. This early diagnosis made it CHEST, 67: 6, JUNE, 1975
