폐암의 진단에서 경기관지 침흡인술 ( TBNA ) 의 유용성에 대한 연구

이홍렬(Hong Lyeol Lee),김세규(Se Kyu Kim),장준(Joon Chang),김성규(Sung Kyu Kim),이원영(Won Young Lee) 대한내과학회 1995 대한내과학회지 Vol.48 No.2

N/A Objectives: Transbronchial needle aspiration (TBNA) is the newest technique to become available for use with the fiberoptic bronchoscope. But because it is associated with the technical difficulties and problems in the interpretation of cytologic examination, it carries the least application until now and its routine use just like forceps biopsy or washing is not recommended. Even though several indications have been suggested, the role of needle aspiration in the diagnosis of central lesion remains to be determined. The needle, however, would have the advantage of easy penetration through submucosal or peribronchial tissue layers that are difficult to access with biopsy forceps, it can have the unique diagnostic usefulness and it is a safe technique without any significant complications. The purpose of this study was to establish the diagnostic yield of TBNA, especially in patients with peribronchial or submucosal lesion or necrotic endobronchial lesion, to compare the yield to that of forcep biopsy. Methods: Sixty-seven patients who were found to have the lesions suggestive of peribronchial or submucosal tumor or necrotic endobronchial lesion during diagnostic fiberoptic bronchoscopy and fifty-two patients in whom primary or metastatic lung cancers were confirmed from January 1992 to December 1993 at Severance Hospital Yonsei University were included in this study. The TBNA always preceded all the other procedures in order to minimize the possibility of contamination of the aspirated specimen. Interpretation of TBNA result was done with four categories; ① carcinoma of definite cell type, ② carcinoma of uncertain cell type, ③ suspicious of malignancy, ④ negative or unsatisfactory, after correlating the biopsy result. Results: During this period, flexible fiberoptic bronchoscopic examination was done in 1,517 cases and TBNA in 4.4%. Of these patients of TBNA, 62.9% of lesions occurred in the right bronchi, 34.3% in the left bronchi, and 2.8% in the distal trachea. The difference of TRNA yield according to cell type or bronchoscopic appearance of lesion was not significant, but it showed the relatively better result in small cell carcinoma and metastatic lung cancer. The difference of the yield between TBNA and biopsy among any cell type or any bronchoscopic finding was not significant, but the difference between the yield of the biopsy alone and the biopsy combined with TBNA was statistically significant. The cases in which TBNA was the only diagnostic test that disclosed a malignant lesion were 15 (28.8%). For 5 patients in 10, repeated bronchoscopy could have been avoided if at initial bronchoscopy physicians had performed TBNA. Conclusion: Our findings suggest that TBNA is a safe technique that can significantly increase the diagnostic yield of fiberoptic bronchoscopy in the diagnosis of peribronchial or submucosal spread of bronchogenic carcinoma over that of forceps biopsy alone, and can be beneficial for suspected small cell carcinoma and pulmonary metastatic lesions. To obtain the maximal diagnostic yield, needle aspiration should be combined with the forceps biopsy.

제5우족지의 전이를 동반한 폐암

이홍렬 ( Hong Lyeol Lee ),김세규 ( Se Kyu Kim ),이환모 ( Hwan Mo Lee ),신동환 ( Dong Hwan Shin ),장중현 ( Jung Hyun Chang ),곽승민 ( Seung Min Kwak ),장준 ( Joon Chang ),김성규 ( Sung Kyu Kim ),이원영 ( Won Young Lee ) 대한결핵 및 호흡기학회 1993 Tuberculosis and Respiratory Diseases Vol.40 No.1

원발성 폐암에 동반된 과칼슘혈증에 대한 임상적 고찰

이홍렬(Hong Lyeol Lee),박규은(Kyu Eun Park),김세규(Se Kyu Kim),장준(Joon Chang),김성규(Sung Kyu Kim),이원영(Won Young Lee) 대한내과학회 1994 대한내과학회지 Vol.47 No.6

N/A Objectives: The humoral hypercalcemia of malignancy(HHM) describes a very specific clinical syndrome due to the production of a peptide or family of peptide hormones which share sequence homology and functional homology with parathyroid hormone. Patients with HHM account for up to 80 percent of malignancy-associated hypercalcemia. The hypercalcemia in lung cancer is mainly mediated by parathyroid hormone-related protein. Typical patients with HHM had little or no skeletal involvement. Hypercalcemia is predominantly associated with epidermoid and large cell anaplastic carcinoma. From a clinical standpoint, patients with hypercalcemia are usually in advanced stages with obviously bulky tumors and, therefore, carry a poor prognosis. Methods: Between January 1987 and November 1993, the patients those who fulfilled the following criteria were chosen as a subjects in this study: ① corrected serum calcium >10.5mg/dl; ② histologically proven primary lung cancer; ③ symptoms which could possibly be attributed to hypercalcemia. We investigated the various clinical features that could characterize the hypercalcemia in lung cancer. Results: Thirty-one patients with lung cancer were hypercalcemic and most of them had squamous cell carcinoma in histologic finding. The incidence between 50 and 69 years of age was higher significantly. The occurrence of hypercalcemia showed a strong positive correlation with the degree of histologic differentiation and the advancement of cancer stage. And the mean serum calcium level also showed a strong positive correlation with the mass size and the performance scale. Some symtoms such as general weakness, anorexia, constipation, consciousness change, and weight loss were more frequent in the patients of higher calcium level. There was no significant difference in effectiveness among the therapeutic regimens for hypercalcemia. Most of patients were hypercalcemic at the time that the diagnosis of lung cancer was made. Most of them died within 1 month after the development of hypercalcemia. Conclusion: The hypercalcemia in lung cancer was found more frequently in men whose ages were between 50 and 69 years old, and in the patients who had poorly differentiated squamous cell carcinoma or the carcinoma in advanced stage. Mean serum calcium level was higher in more symptomatic patients, and in the patients with worse performance scale or larger tumor mass. The prognosis of hypercalcemic patients with lung cancer was extremely poor.

폐외 악성 종양의 기관지내 전이

이홍렬(Hong Lyeol Lee),곽승민(Seung Min Kwak),장중현(Jung Hyun Chang),김세규(Se Kyu Kim),김성규(Sung Kyu Kim),이원영(Won Young Lee),신동환(Won Young Lee) 대한내과학회 1992 대한내과학회지 Vol.43 No.6

N/A Backgrounds: Endobronchial metastasis of extrapulmonary malignancies was defined as those cases in which metastatic foci were grossly evident in the main or lobar bronchi and occurs in less than 5% of all cases. The common extrapulmonary tumors associated with metastatic involvement of a central airway are carcinomas of the breast, kidney, colorectum and malignant melanoma. In the majority of cases, the primary tumor site is clinically apparent before symptoms of endobronchial metastasis. The clinical and roentgenographic features of endobronchial metastasis and primary bronchogenic carcinoma were found to be indistinguishable. Mostly, the histologic appearance of the bronchoscopic biopsy suggests the correct diagnosis but in some instances it may be impossible to differentiate metastatic involvement of the bronchus by an asymptomatic extrathoracic adenocarcinoma from a primary central adenocarcinoma of the lung. In addition to the treatment aspect of neoplasm spread, palliative surgical removal of endohronchial metastatic malignancies are strongly recommended to improve the patients qualify of life and to prevent resultant obstructive complications. Methods: We experienced 5cases of endobronchial metastasis during the recent 1½ years and reviewed the medical records of 12cases previously confirmed as endobronchial metastasis by bronchoscopic bioposies since 1985 to 1990. We investigated the clinical manifestations, primary sites, time intervals and bronchoscopic findings. Results: Breast carcinoma was the most common primary malignancy leading to the endobronchial metastasis. We also found the metastatic cases of hepatocellular carcinoma, sebacious gland adenocarcinoma and mouth floor carcinoma. Mostly patients complained of dyspnea and productive cough and chest X-ray revealed atelectasis. Endobronchial metastasis developed within 3 years in more than half of the cases and the mean time interval was 40,6months. In one prostate cancer and one thyroid cancer, metastasis was diagnosed prior to primary site presentation. On bronchoscopic examination, the right upper lobar bronchus was most commonly involved and subtotal obstruction was the most frequent finding. More than half of the patients expired within 2 years after the diagnosis of endobronchial metastasis. Conclusion: Endobronchial metastasis has unique clinical significance in that it requires differential diagnosis with primary bronchogenic carcinoma and aggressive palliative surgical management. If atypical clinical features are present or atypical cell type is discovered by biopsy of the lesion in lung ca, appropriate diagnostic studies should be undertaken to exlude the possibility of an asymptomatic extrapulmonary tumor before definite therapy is undertaken.

백서의 폐포 및 복강 대식세포의 세포독성에 대한 연구

이홍렬(Hong Lyeol Lee),김세규(Se Kyu Kim),장준(Joon Chang),김성규(Sung Kyu Kim),이원영(Won Young Lee),조철호(Chul Ho Cho) 대한내과학회 1992 대한내과학회지 Vol.43 No.4

N/A Background: Mechanisms involved in host resistance against malignant tumors have been found to be mediated mainly by cellular effectors. These effector mechanisms include activated macrophages, killer T-cells, natural killer cells and antibody-dependent cellmediated cytotoxicity. Activated macrophages can sup- press DNA synthesis of tumor cells and kill tumor cells in a selective but nonspecific fashiori in vitro. Lipopolysaccharides (LPS) can enhance the cytotoxicity of macrophages and the lipid A which is produced by mild acid hydrolysis of LPS, is responsible for the LPS effect on macrophages. The mechanism by which LPS modifies macrophage physiology is not known, but it is suggested that it acts at the level of the macrophage plasma membrane. LPS may make macrophages tumoricidal by altering the membrane composition or by transmitting a necessary signal from the membrane to the vacuolar system. Methods: We isolated alveolar and peritoneal macrophages by bronchoalveolar and peritoneal lavage in rats. Rat sarcoma cell line (XC) was used as the target cell. As recommended commonly we controlled the effector cell: target cell ratio at 10:1, Three groups were divided as folows; no LPS added group, LPS 5μg/ml added group and LPS 10μg/ml added group, We focused the assay of cytotoxicity on the cytolysis rather than cytostasis by measuring the [3H] thymidine released and calculated the percentage specific cytalysis, By this experiment, we examined the stimulation effect of LPS an the macrophage cytotoxicity and compared the cytotoxicity between alveolar and peritoneal macrophages. Results: The cytotoxicity of alveolar and peritoneal macrophages was significantly enhanced when stimulated both with 5μg/ml and 10μg/ml of LPS. There was no significant difference in macrophage cytotoxicity between two groups each stimulated with 5μg/ml and 10μg/ml of LPS. We could not observe the significant difference in cytotoxicity between the alveolar and peritoneal macrophages, Conclusion: Cytotoxicity was significantly enhanced by stimulation of LPS, in hoth alveolar and peritoneal macrophages but there was no significant difference in cytotoxicity enhancement between 5μg/ml and 10μg/ ml of LPS. Also there was no significant difference in cytotoxicity between alveolar and peritoneal macrophages.

기계호흡중인 환자에서 동맥혈 가스검사에 의한 예후의 조기평가에 대한 연구

이홍렬(Hong Lyeol Lee),김세규(Se Kyu Kim),장준(Joon Chang),김성규(Sung Kyu Kim),이원영(Won Young Lee) 대한내과학회 1992 대한내과학회지 Vol.43 No.3

N/A Background: Most clinicians caring for acutely ill patients in critical care units today agree that acute respiratory failure is one of the most common life- threatening processes encountered in children and adults. Whether acute respiratory failure presents as an acute exacerbation of advanced chronic obstructive lung disease or develops in patients with previous healthy lungs, it generally requires an intensive management including mechanical ventilation. Early prediction of outcome in such critically ill patients should be considered a high priority so that corrective measures or alternative support methods may be rapidly instituted. The most impotant clinical tool for the diagnosis and monitoring of acute respiratory failure is arterial blood gas measurement. Methods: We examined the arterial blood gas meaurement daily in patients with acute respiratory failure during the first 7days since the start of mechanical ventilation. We calculated each ratio of PaO2/FiO2 PAO2/FiO2 and PaO2/PAD2 from above and compared these values between each patient group. Results: When comparing these ratio parameters between the survival and expired groups in all patients, there was a significant difference from the second day since mechanical ventilation was initiated. When comparing these ratio parameters between the survival and expired groups in the nonpulmonary disease group, a significant difference was noted from the third day since mechanical ventilation was initiated. The values of PaO2/FiO2 and PaO2/PAO2 were higher in the survival group than in the expired group. These values had a tendency of gradual increase in the survival group and a slight decrease or almost no change in the expired group. The value of PAO2/FiO2 was lower in the survival group than in the expired group. This value had a tendency of continuous decrease in the survival group and a slight decrease or almost no change in the expired group. Conclusion: With the careful observation of changing patterns during the firs 7days since initiation of mechanical ventilation, these 3ratio parameters were thought to be helpful in the early prediction of outcome in mechanically ventilated patients due to acute respiratory failure by respiratory diseases and diseases other than the respiratory system.

기관지결석증에 대한 연구

이홍렬(Hong Lyeol Lee),김세규(Se Kyu Kim),장준(Joon Chang),김성규(Sung Kyu Kim),이원영(Won Young Lee),정경영(Kyong Young Chung) 대한내과학회 1995 대한내과학회지 Vol.48 No.3

N/A Objectives: Broncholithiasis is defined as a condition in which an concretion is present within a bronchus or a cavity in the lung communicating with a bronchus, It almost invariably represents the end stage of healing of granulomatous pulmonary diseases such as histioplasmosis or tuberculosis. Broncholiths are found with almost equal frequency in men and women, mostly in the fifth or sixth decade. Common symptoms are chronic cough, hemoptysis and sputum. Lithoptysis, which is pathognomic, is rare. The chest radiograph mostly shows calcified masses around the bronchi. In most cases, because of no significant symptoms or complication, observation may be the best course but bronchoscopic removal or surgical intervention are indicated in some instances. We report here the cases of broncholithiasis in which some clinical characteristics were observed. Methods: From January 1981 to December 1993, 13 patients with broncholithiasis had undergone the analysis for clinical manifestation, bronchoscopic fin- ding, treatment modality and follow-up status. Results : Broncholithiasis was distributed evenly from the fourth to the sixth decade and it developed in association with tuberculosis in 53.8%. Lithoptysis occurred in only 23.1% and calcification was found radiographically in 38.3%. Various positive findings, noted in all patients undergoing flexible bronchoscopy, included visualization of the broncholith, polypoid granulation tissue, stenotic or narrowed bronchi or blood clots. While 6 patients with conservative care only continued to have symptoms, an excellent result was evident in 3 of 7 patients in whom broncholith was removed after treatment or spontaneously. Conclusion: A clinical awareness of the manifestations of broncholithiasis will result in early diagnosis and treatment. As indicated, if the broncholith can be removed before irreversible distal bronchial and parenchymal damages occur, the long-term outlook for symptomatic relief is excellent.

반복적 굴곡성 기관지경검사(RFB)의 유용성에 대한 연구

이홍렬 ( Hong Lyeol Lee ),문태훈 ( Tae Hoon Moon ),조재화 ( Jae Hwa Cho ),류정선 ( Jeong Seon Ryu ),곽승민 ( Seung Min Kwak ),조철호 ( Chul Ho Cho ) 대한결핵 및 호흡기학회 2000 Tuberculosis and Respiratory Diseases Vol.48 No.3

정상인과 폐쇄성 및 제한성 폐질환 환자에서 구강폐쇄압에 대한 연구

이홍렬 ( Lee Hong Lyeol ),김성규 ( Kim Seong Gyu ),이원영 ( Lee Won Yeong ) 대한내과학회 1993 대한내과학회지 Vol.44 No.6

연구배경 : 구강폐쇄압(P_(0.1))의 기능성 잔기용량에서 흡기를 시작한 후 0.1초만에 측정한 구강의 폐쇄 압력으로, 호흡중추에 의한 신경근육계의 흡기욕구와 호흡근수축의 효용성을 평가하는 객관적인 지표이다. 검사가 화자의 협조여부에 크게 의존하지 않으며 방법이 간편할뿐만 아니라 폐쇄 자체가 호흡근에 전달되는 신경 방출에 변화를 초래하지 않고 P_(0.1)이 신경 방출과 일정한 연관성을 가지며 호흡근 수축의 효용성을 좌우하는 인자들의 영향을 거의 받지 않기 때문에 결과적으로 피검자의 의식이나 자발적인 반사 작용, 호흡기계의 기류-저항과 탄성 같은 폐역학, 폐용적에 대한 미주신경의 반사작용에 의해서도 영향을 받지 않는 유용한 지표가 된다. 방법 : 본 연구는 35세미만의 정상대조군, 50세이상의 정상대조군, 폐쇄성 폐질환 환자군, 제한성 폐질환 환자군들을 대상을 하여 동맥혈 가스검사, 기류-용량 곡선, 체용적변동기록검사, 폐확산능, 그리고 구강폐쇄압 측정의 순으로 진행하였다. P_(0.1)은 여러 가지 환기 척도들과 동시에 측정하였는데 먼저 대기호흡중에서 측정하였고 6% CO₂를 흡입시킨 후 다시 측정하였다. 환기 척도로는 MV/P_(0.1)(분당환기량/P_0.1), T_(i)/T_(t)(흡기시간/총호흡시산), V_(T)/T_(I)(상시호흡향/흡기시간), P_(0.1)/V_(T)/T_(I)(P_(0.1)/상시호흡량/흡기시간)등을 설정하였다. 결과 : 대기 호흡중에서 P_(0.1), MV/P_(0.1) 그리고 P_(0.1)/V_(T)/T_(I)가 정상군과 환자군간에 유의한 차이를 보였으며 폐쇄성 폐질환과 제한성 폐질환 환자군간에도 유의한 차이를 보였다. CO₂재호흡시에는 P_(0.1)과 P_(0.1)/V_(T)/T_(I)가 정상군에 비하여 환자군에서 유의하게 증가되었다. P_(0.1)과 환기 척도와의 관계에서는 대기호흡시 MV/P_(0.1), P_(0.1)/V_(T)/T_(I)와 유의한 상관과계를 보였고 CO₂ 재호흡시 P_(0.1)과 P_(0.1)/V_(T)/T_(I)간에만 유의한 상관관계가 있었다. 저산소혈증군과 정상산소혈증군간에는 유의한 차이를 보이지 않았으나 과탄산혈증을 보인 환자군에서 CO₂재호흡시 P_(0.1)의 절대치는 오히려 감소하면서 절대치와 변화치는 정상탄산혈증군에 비하여 유의하게 감소되었다. 결론 : 이상의 결과로 P_(0.1)과 P_(0.1)/V_(T)/T_(I)는 중추성 흡기 욕구 및 호흡근 수축의 효용성을 평가하기 위한 유용한 객관적 지표이며 CO₂축적을 동반한 진행된 만성 폐질환의 진단에 보조적인 수단으로 유용함을 알 수 있었다. Background : Mouth occlusion pressure (P_(0.1)) is the mouth pressure developed against a complete occlusion at 0.1 second after beginning of inspiration from functional residual capacity. It appears to be an objective index of central inspiratory neuromuscular drive and effectiveness of respiratory muscles contraction. It is simple to examine and doesn`t depend on the patients` cooperation. The occlusion itself does not produce a change in the neuronal discharge supplied to the respiratory muscles and it bears a constant relationship to the neuronal discharge. Furthermore, P_(0.1) is not affected by several factors which may have influence on the effectiveness of respiratory muscles contraction. Consequently, it is a valid index without being affected by patients` consciousness, autogenous reflexes, lung mechanics such as respiratory flow-resistance or compliance, and vagal reflex for lung volume. Methods : We did this study in sequence of arterial blood gas examination, flow-volume curve, body plethysmography, diffusion capacity and measurement of P_(0.1). The subjects were divided into 4 groups such as normal control group s below 35 years old and above 50 years old, and the patient groups of obstructive and restrictive pulmonary diseases. P_(0.1) was measured during breathing of the ambient air and, again during 6% CO₂-rebreathing with simultaneous measurement of ventilatory parameters. Here ventilatory parameters were MV/P_(0.1) (minute ventilatory volume/P_(0.1)), T_(i)/T_(t) (inspiratory time/total respiratory time), V_(T)/T_(I) (tidal volume/inspiratory time), and P_(0.1)/V_(T)/T_(I) (P_(0.1)/tidal volume/`inspiratory time). Results : P_(0.1), MV/P_(0.1) and P_(0.1)/V_(T)/T_(I) showed a significant difference between the control groups and patient groups, and also between the patient groups of obstructive and restrictives diseases during breathing of the ambient air. P_(0.1) and P_(0.1)/V_(T)/T_(I) showed a significant difference between the control groups and patient groups during CO₂-rebreathing. Significant correlations were found between P_(0.1) and MV/P_(0.1), and, between P_(0.1) and P_(0.1)/V_(T)/T_(I) during breating of the ambient air. During CO₂-rebreathing, P_(0.1) and P_(0.1)/V_(T)/T_(I) correlated significantly. We did not find a difference between the patients of normal PaO₂ and those with hypoxemia. But, there was a characteristic change of P_(0.1), in the hypercapnic patient group compared with the normocapnic patient group through CO₂-rebreathing. Conclusion : As a result of above study, we think P_(0.1) and P_(0.1)/V_(T)/V_(I) as valid indexes of central inspiratory muscles contraction. They are useful in the supportive measure for the diagnosis of far-advanced chronic lung disease which is accompanied by CO₂ retension.

급성 호흡부전증으로 기계 호흡중인 환자들에서 다발성 기관부전증에 대한 연구

이홍렬(Hong Lyeol Lee),김세규(Se Kyu Kim),장준(Joon Chang),김성규(Sung Kyu Kim),이원영(Won Young Lee) 대한내과학회 1995 대한내과학회지 Vol.48 No.4

N/A Objectives: The syndrome of multiple organ failure (MOF) is a dynamic process of progressive physiologic failure of several, independent organ systems with a complex interrelationship among individual organs. The MOF is frequently observed in the patients receiving the intensive care, especially with mechanical ventilation, and carries a high mortality. Even though nonpulmonary organs involvement such as kidney, liver, CNS and so forth, is an important factor for MOF, it correlates most strongly to the respiratory failure. Most of hypotheses as to how the lung failure and subsequent MOF process evolve after initial injury are based on a variant of an ischemia-reperfusion type injury. A number of humoral, inflammatory mediators have been reported to be involved in the initiation and perpetuation of this syndrome. We did a prospctive study of 58 patients with the syndrome to evaluate the contributions of these complications to outcome. Methods: The study population consisted of mechanically ventilated patients with one or more organs failed, in addition to the respiratory system, enrolled in a prospective study of MOF from May 1992 to February 1993. We made the simple and general criteria for the failure of each organ as possible as we can, A major effort was made to investigate the clinical features of failed organs, the significance of infection in this syndrome. And we compared the characteristics of MOF between the survivor and nonsurvivor groups or between the infected and noninfected groups. Results: There was no significant difference in the age between the survivor and nonsurvivor groups. Infection was the most frequently associated condition in both groups, The incidences of coagulopathy and cardiovascular failure were significantly higher in the nonsurvivor group. The lung was the most prevalent focus of infection and, Staphylococcus aureus and Pseudomonas aeruginosa were the most frequent organisms. Renal, cardiovascular, and neurologic dysfunctions were significantly higher in the infected group, and disseminated intravascular coagulation was found only in this group. There was no proportional increase of mortality with increased number of involved organs. Conclusion: Coagulation and cardiovascular system were thought to play a significant role in mortality. The incidences of MOF and mortality were significantly higher in the infected group. In this study, therefore, mortality was influenced by the fact which organ was involved rather than the number of failed organs. Infection was also an important factor in the development of MOF and prognosis.