Chronic obstructive lung diseases and risk of non-small cell lung cancer in women

INTRODUCTION

The link between lung cancer and chronic obstructive lung diseases (COPD) has not been well studied in women even though lung cancer and COPD account for significant and growing morbidity and mortality among women.

METHODS

We evaluated the relationship between COPD and non-small cell lung cancer in a population-based case-control study of women and constructed a time course of chronic lung diseases in relation to onset of lung cancer. Five hundred sixty-two women aged 18 to 74, diagnosed with non-small cell lung cancer and 564 population-based controls matched on race and age participated. Multivariable unconditional logistic regression models were used to estimate risk associated with a history of COPD, chronic bronchitis, or emphysema.

RESULTS

Lung cancer risk increased significantly for white women with a history of COPD (odds ratios [OR] = 1.85; 95% confidence intervals [CI]: 1.21-2.81), but this was not seen in African American women. Risk associated with a history of chronic bronchitis was strongest when diagnosed at age 25 or earlier (OR = 2.35, 95% CI: 1.17-4.72); emphysema diagnosed within 9 years of lung cancer was also associated with substantial risk (OR = 6.36, 95% CI: 2.36-17.13). Race, pack-years of smoking, exposure to environmental tobacco smoke as an adult, childhood asthma, and exposure to asbestos were associated with a history of COPD among lung cancer cases.

CONCLUSIONS

In women, COPD is associated with risk of lung cancer differentially by race. Untangling whether COPD is in the causal pathway or simply shares risk factors will require future studies to focus on specific COPD features, while exploring underlying genetic susceptibility to these diseases.

Diagnostic approach of pulmonary disease in the HIV negative immunocompromised host

The advances in medicine have resulted in increasing number of immunocompromised patients with complications related to their underlying disease or the treatment of these conditions. Pulmonary infectious and non-infectious conditions are a major cause of morbidity and mortality in these patients, and represent a diagnostic challenge. This article reviews the major conditions causing pulmonary symptoms in the HIV negative immunocompromised host. It also discusses the role of the different diagnostic methods, including the recent advances in non-invasive studies, in reaching a diagnosis of pulmonary disease in this patient population.

Nuclear, compared with combined nuclear and cytoplasmic expression of maspin, is linked in lung adenocarcinoma to reduced VEGF-A levels and in Stage I, improved survival

AIMS

To evaluate whether there is a correlation between the subcellular localization of maspin and the histological, molecular and biological features of pulmonary adenocarcinoma, particularly addressing the hypothesis that the tumour inhibitor properties of maspin may be linked to a nuclear, compared with a combined nuclear and cytoplasmic expression pattern.

METHODS AND RESULTS

The subcellular expression of maspin was determined in 80 resected pulmonary adenocarcinomas (Stage I, 46; Stage II, 10; Stage III, 20; Stage IV, 4) and correlated with histological grade, proliferative rate, p53 expression, vascular endothelial growth factor (VEGF)-A levels, and prognosis (mean follow-up of 41.5 months). Cases with nuclear (N) maspin (n = 47), compared with the [N + cytoplasmic (C)] group (n = 28), showed lower (P <or= 0.05): histological grade, proliferative rate, p53 expression and VEGF-A levels. Cox multivariate analysis revealed in stage I adenocarcinomas (N) maspin as the only predictor of improved survival.

CONCLUSIONS

(N) maspin selects lung adenocarcinomas with distinct molecular and clinical features, supporting the hypothesis that its tumour inhibitor properties may be linked to its nuclear localization.

Quantification of tryptophan transport and metabolism in lung tumors using PET

Abnormal tryptophan metabolism catalyzed by indoleamine 2,3-dioxygenase may play a prominent role in tumor immunoresistance in many tumor types, including lung tumors. The goal of this study was to evaluate the in vivo kinetics of alpha-(11)C-methyl-l-tryptophan (AMT), a PET tracer for tryptophan metabolism, in human lung tumors.

METHODS

Tracer transport and metabolic rates were evaluated in 18 lesions of 10 patients using dynamic PET/CT with AMT. The kinetic values were compared between tumors and unaffected lung tissue, tested against a simplified analytic approach requiring no arterial blood sampling, and correlated with standardized uptake values (SUVs) obtained from (18)F-FDG PET/CT scans.

RESULTS

Most non-small cell lung cancers (NSCLCs) showed prolonged retention of AMT, but 3 other lesions (2 benign lesions and a rectal cancer metastasis) and unaffected lung tissue showed no such retention. Transport and metabolic rates of AMT were substantially higher in NSCLCs than in the other tumors and unaffected lung tissue. A simplified analytic approach provided an excellent estimate of transport rates but only suboptimal approximation of tryptophan metabolic rates. (18)F-FDG SUVs showed a positive correlation with AMT uptake, suggesting higher tryptophan transport and metabolism in tumors with higher proliferation rates.

CONCLUSION

Prolonged retention of AMT in NSCLCs suggests high metabolic rates of tryptophan in these tumors. AMT PET/CT may be a clinically useful molecular imaging method for personalized cancer treatment by identifying and monitoring patients who have increased tumor tryptophan metabolism and are potentially sensitive to immunopharmacotherapy with indoleamine 2,3-dioxygenase inhibitors.

The evaluation and management of the solitary pulmonary nodule

Solitary pulmonary nodules (SPNs) are increasingly detected with the widespread use of chest computed tomography (CT) scans. The primary goal of the evaluation of these nodules is to determine whether they are malignant or benign. Clinical factors such as older age, tobacco smoking and current or remote history of malignancy increase the pre-test likelihood of malignancy. Radiological features of the SPN based on chest CT with high resolution cuts are critical in differentiating between benign or malignant lesions. These features include size, change in size, the presence and pattern of calcification, edge characteristics, attenuation, and contrast enhancement. SPNs that are stable in size for >2 years and those with benign pattern of calcification do not need further studies. Lesions with clear change in size are malignant until proven otherwise and require tissue diagnosis. Frequently, the aetiology of the SPN following chest CT scan remains indeterminate and requires further evaluation. The approach to the management of indeterminate SPN ranges between observation with repeat chest CT scan, further diagnostic studies such as positron emission tomography (PET) scan, or invasive procedures to obtain tissue diagnosis. These procedures include bronchoscopy, transthoracic needle aspirate, and resection by video assisted thoracoscopy or thoracotomy. Determination of which approach to follow depends on the pre-test probability of malignancy, whether the patient is a surgical candidate, and the patient's informed preferences. This article reviews the radiological features of the SPN and their value in differentiating between benign and malignant lesions. This is followed by discussion of the different approaches to the management of the SPN after initial characterisation by chest CT scan, including the benefits and limitations of the different diagnostic studies.

The clinical and radiologic features of nodular pulmonary sarcoidosis

STUDY OBJECTIVES

Nodular sarcoidosis is an uncommon presentation of sarcoidosis. Our objective was to describe the clinical characteristics of a large cohort of patients with nodular sarcoidosis.

METHODS

We performed a retrospective study of patients with nodular sarcoidosis diagnosed at an urban teaching hospital over a 10-year period.

RESULTS

Thirty-three patients with nodular sarcoidosis were identified. All patients were African-American. The mean age was 35 and the female-to-male ratio was 5:1. Twenty-six patients were current or former smokers. All patients had chest CT scan and/or chest radiograph evidence of pulmonary masses. Twenty-seven patients had multiple pulmonary masses/nodules and six had solitary pulmonary nodules/masses. The upper lobes were involved in 27 patients. Mediastinal lymphadenopathy and pleural-based masses were present in 30 and 20 patients, respectively. Extrapulmonary manifestations were present in 14 patients. All patients had tissue diagnosis of noncaseating granulomas with negative culture. Twenty-two patients underwent bronchoscopy with transbronchial biopsies, which were diagnostic in 19. Follow-up data were available on 27 patients: complete or nearly complete resolution of the pulmonary masses--either spontaneously or with systemic treatment--was documented for 19 patients, no change in the radiologic findings for 7 patients, and progression to pulmonary fibrosis for 1 patient.

CONCLUSIONS

Nodular sarcoidosis is a rare presentation of pulmonary sarcoidosis. It usually presents with multiple pulmonary masses that tend to be peripheral and are associated with mediastinal lymphadenopathy. Bronchoscopy with transbronchial biopsies has high diagnostic yield. Despite its ominous presentation, nodular sarcoidosis has favorable prognosis.

Invasive pulmonary aspergillosis in patients with COPD: a report of five cases and systematic review of the literature

BACKGROUND

There are increasing reports describing invasive pulmonary aspergillosis (IPA) in patients with chronic obstructive pulmonary disease (COPD) without the classic risk factors for this severe infection. The available literature on this association is based on case reports or small case series. The aim of this review is to systematically review these cases and describe the clinical features, diagnostic studies and outcome.

METHODS

We identified all the cases of IPA and COPD reported in the literature and had enough clinical information. We also included five cases of IPA in patients with COPD identified by the authors. These cases were systematically reviewed for clinical features, diagnostic studies and outcome.

RESULTS

There were 60 cases of IPA in patients with COPD identified from the literature. The total number of cases reviewed was 65. The mean age was 65.1 years, the mean FEV1 was 39% of predicted (n = 17, range 19-56%). Forty-nine patients were documented to be on systemic corticosteroids. The mean dose was 24 mg/day (range 15-65 mg/day). Five patients were only on inhaled corticosteroids and in 11 patients there was no documentation of corticosteroid therapy. The clinical and radiological findings were nonspecific. Thirteen patients had documented evidence of disseminated IPA. Sputum examination was positive for Aspergillus in 76% and bronchoscopy with bronchoalveolar lavage that was positive in 70%. The diagnosis of IPA was definite in 43 patients and probable in 22 patients. Forty-six patients were treated with anti-fungal therapy. Fifty-nine patients (91%) died with IPA.

CONCLUSION

Invasive pulmonary aspergillosis is an emerging serious infection in patients with COPD. The majority of these patients have advanced COPD and/or on corticosteroid therapy. The clinical and radiological presentation is nonspecific. High index of suspicion is necessary for the timely treatment of these patients.

The yield and safety of thoracentesis in hematopoietic stem cell transplantation recipients

The aim of this study was to assess the diagnostic value and safety of thoracentesis in hematopoietic stem cell transplantation (HSCT) recipients. We identified all hospitalized HSCT recipients who underwent thoracentesis from 1998 to 2006. We collected patients' clinical characteristics, indications for thoracenstesis, the complications of the procedure, and the etiology of the pleural effusion. A total of 50 thoracentesis findings were analyzed. Twenty-six patients underwent allogeneic HSCT, while 24 patients underwent autologous HSCT. The main indications for performing thoracentesis were to rule out infection and document or diagnose malignancy. Pleural effusions were characterized as exudate in 33 patients (66%). A specific diagnosis based on the thoracentesis was made in 13 patients (26%). These were malignancy in nine patients, parapneumonic in three patients, and empyema in one patient. The only documented complication was pneumothorax in five patients. The presence of exudative effusion and underlying solid malignancy were associated with specific diagnosis by thoracentesis (p = 0.0001 and 0.013, respectively). In spite of the tendency of HSCT recipients to develop pulmonary infections, complex parapneumonic effusions are rarely diagnosed by thoracentesis. The rate of complications is comparable to other patient populations.

Outcome and prognostic factors of lung cancer patients admitted to the medical intensive care unit

The aim of the present study was to assess the outcome of lung cancer patients who were admitted to a medical intensive care unit (MICU) and to identify the measurable predictors of their MICU outcome. The retrospective study took place at the MICUs of a university-affiliated medical centre and involved adult lung cancer patients admitted to the MICU between January 1998 and October 2005. A total of 139 lung cancer patients were included during the study period. The mean age+/-sd at MICU admission was 64.2+/-10.2 yrs (48% males, 52% females). In total, 96 (69%) patients had nonsmall cell lung cancer, 18 (13%) patients had small cell lung cancer, and one patient had mesothelioma. The MICU mortality was 22% (31 patients), while the in-hospital mortality was 40% (56 patients). Sixty-eight (49%) patients required mechanical ventilation (MV), with MICU mortality of 38% and in-hospital mortality of 53%. The independent predictors of poor MICU outcome were: the need for MV; Acute Physiology And Chronic Health Evaluation III and Simplified Acute Physiology Score III scores; the use of vasopressors; positive blood cultures; high serum lactate; two or more organ system failures; and the need for adult cardiac life support. On multivariate analysis, only the need for vasopressors and the presence of two or more organ system failures predicted poor MICU outcome. The present study shows that the medical intensive care unit outcome of lung cancer patients is better than previously reported. Intensive care and mechanical ventilation should not be considered futile care in this patient population. While there were no absolute predictors of mortality, the need for vasopressors and the presence of two or more organ system failures predicted poor medical intensive care unit care.

Pulmonary aspergillosis: a clinical update

Aspergillus spp may cause a variety of pulmonary diseases, depending on immune status and the presence of underlying lung disease. These manifestations range from invasive pulmonary aspergillosis in severely immunocompromised patients, to chronic necrotizing aspergillosis in patients with chronic lung disease and/or mildly compromised immune systems. Aspergilloma is mainly seen in patients with cavitary lung disease, while allergic bronchopulmonary aspergillosis is described in patients with hypersensitivity to Aspergillus antigens. Recent major advances in the diagnosis and management of pulmonary aspergillosis include the introduction of non-invasive tests, and the development of new antifungal agents, such as azoles and echinocandins, that significantly affect the management and outcome of patients with pulmonary aspergillosis. This review provides a clinical update on the epidemiology, risk factors, clinical presentation, diagnosis and management of the major syndromes associated with pulmonary aspergillosis.

Bronchiolitis obliterans following haematopoietic stem cell transplantation

The aim of the present article is to review the available clinical data on bronchiolitis obliterans following haematopoietic stem cell transplantation (HSCT). The data sources used were the Medline database and references from the identified articles related to bronchiolitis obliterans, noninfectious pulmonary complications and HSCT. HSCT is an important treatment for a variety of malignant and nonmalignant conditions. However, the procedure is limited by significant complications that may involve every organ of the body. Pulmonary complications are seen in 40-60% of HSCT recipients. The recent advances in prophylaxis and treatment of infectious complications have increased the significance of late noninfectious pulmonary conditions. Currently, bronchiolitis obliterans is one of the most challenging pulmonary complications facing clinicians who are taking care of haematopoietic stem cell transplantation recipients. This article reviews the clinical and pathological features of this condition, sheds some light on potential mechanisms of pathogenesis, and discusses the available management options.

Fine needle aspiration cytology of lung lesions: a clinicopathological and cytopathological review of 150 cases with emphasis on the relation between the number of passes and the incidence of pneumothorax

OBJECTIVE

The aim of this study was to review the lung fine needle aspirations (FNA) that were done in our hospital between January 1998 and April 2004. Interobserver agreement, sample adequacy and the relation between the number of passes and the occurrence of pneumothorax are presented.

STUDY DESIGN

One hundred fifty cases of lung FNA from the department of pathology files were identified and the available specimens and patient charts were reviewed. The interobserver agreement was calculated. The relation between the number of passes and the subsequent development of pneumothorax was tested using Mann-Whitney U-test.

RESULTS

The material of 132 patients (88%) out of 150 were retrieved and reviewed. There were 85 cases of non-small cell lung cancer (NSCLC) (64.4%), nine cases of small cell lung cancer (6.8%), five cases of metastatic cancer (3.8%) and 33 cases were reported negative for cancer (25%). The NSCLC included 36 cases of adenocarcinoma (27.3%), 32 cases of squamous cell carcinoma (24.2%), and 17 cases of large cell undifferentiated carcinoma (12.9%). The interobserver agreement k was 0.93, (95% CI 0.87-0.98). The majority of cases (95.5%) were considered adequate for interpretation. The charts of 138 patients (92%) were reviewed for postprocedure radiologically confirmed pneumothorax. Sixteen patients (11.6%) developed pneumothorax only three of whom (2%) required a chest tube for treatment. The number of passes was identified in 118 patients (85.5%). The number of passes did not have a statistically significant association with the development of a pneumothorax (P = 0.747).

CONCLUSION

Fine needle aspirations to diagnose lung lesions is a safe procedure with a low incidence of pneumothorax. Its findings are reproducible with high interobserver agreement. Immediate adequacy evaluation and triage by a pathologist guarantees adequate sample in most instances. The number of passes was not associated with an increased incidence of pneumothorax.

The major autopsy findings in adult patients after hematopoietic stem cell transplantation

BACKGROUND

Hematopoietic stem cell transplantation (HSCT) is a curative treatment option for hematological malignancies, but this treatment can be associated with a mortality risk.

MATERIAL/METHODS

A ten-year retrospective review of all autopsies was performed where those who underwent HSCT were studied. The major autopsy findings and the cause of death were characterized and compared between those seen in allogeneic and those in autologous HSCT recipients. The study period preceded the use of prophylactic antifungal agents.

RESULTS

A total of 66 autopsies were identified; 52 (79%) received allogeneic and 14 (21%) autologous transplantation. Death occurred at a median of 85 days post transplantation (range 2-1825 days); 36 (55%) died within the first 100 days post stem cells infusion. The major complications for HSCT patients were pulmonary, including diffuse alveolar damage (DAD), acute pneumonia and invasive pulmonary aspergillosis. The most common cause of death in the allogeneic HSCT group was DAD (13/52; 25%), followed by invasive pulmonary aspergillosis (10/52; 19%), acute pneumonia (10/52; 19%) and massive gastrointestinal bleeding (6/52; 12%); in the autologous group causes were disease relapse/progression of the underlying malignancy (4/14; 29%), acute pneumonia (3/14; 21%) and DAD (2/14; 14%).

CONCLUSIONS

We conclude that the spectrum of disease entities, commonly diagnosed at autopsy in HSCT recipients may provide insight to clinicians for anticipating complications and consequently help in the management of these high risk patients. The increased infectious complications observed in the allogeneic transplant cases may be explained by immunosuppression and that the study period preceded the use of prophylactic antifungal agents. However, relapse/progression of the disease is the predominant cause of mortality after autologous transplant.

Isolation of Aspergillus in critically ill patients: a potential marker of poor outcome

OBJECTIVE

Recent reports have suggested a rising incidence of pulmonary aspergillosis in intensive care unit (ICU) patients. The aim of this study was to determine the clinical significance of isolating Aspergillus from respiratory samples of critically ill patients.

DESIGN

Retrospective review of medical records.

SETTING

Tertiary medical center that has a large cancer center.

PATIENTS

All patients admitted to the ICU between January 1998 and August 2004, in whom Aspergillus was isolated from respiratory samples or lung tissue.

INTERVENTION

None.

RESULTS

The charts of 104 patients were reviewed. Aspergillus was isolated for a mean of 6.6 days after ICU admission. Thirty-three percent of patients had hematological malignancy, 10% had absolute neutropenia, 14% had bone marrow transplant, 11% had HIV infection, and 22% had chronic obstructive pulmonary disease. Upon admission to ICU, 79%, 43%, and 19% were on antibiotics, corticosteroids, or immunosuppressive therapy, respectively. Ninety percent of patients required mechanical ventilation. The mean Acute Physiologic and Chronic Health Evaluation II score on ICU admission was 20.6, with predicted mortality of 35.5%. However, the actual ICU mortality rate for the cohort was 50%. Twenty-eight percent of patients were diagnosed with probable or definite invasive pulmonary aspergillosis, and 72% had Aspergillus colonization. On univariate analysis, the significant clinical differences between the 2 groups were the presence of neutropenia (P < .05), immunosuppressants (P < .05), antibiotics (P < .05), or bone marrow transplant (P < .05). The differences in Acute Physiologic and Chronic Health Evaluation II score, the need for mechanical ventilation, ICU length of stay, and ICU mortality were not statistically significant. On multivariate analysis, the following factors were independently associated with invasive diseases, bone marrow transplantation (P < .01), hematological malignancy (P = .02), and broad-spectrum antibiotics (P = .02).

CONCLUSION

Isolation of Aspergillus in critically ill patients is a poor prognostic marker and is associated with high mortality irrespective of invasion or colonization. Those who are neutropenic, on immunosuppressive therapy, on broad-spectrum antibiotics, or had bone marrow transplantation are more likely to have invasive pulmonary aspergillosis.

Critical care considerations of hematopoietic stem cell transplantation

OBJECTIVE

To review the available clinical data on the critical care complications of hematopoietic stem cell transplantation (HSCT).

DATA SOURCE

The MEDLINE database and references from the identified articles related to the critical care in HSCT.

CONCLUSION

HSCT is an important treatment for a variety of malignant and nonmalignant conditions. The procedure is, however, limited by significant complications that may involve every organ of the body. Up to 40% of HSCT recipients are admitted to the intensive care unit as a result of severe complications related to the transplantation. The outcome of those critically ill patients has been traditionally poor. However, recent advances in the transplantation procedure, diagnostic studies, antimicrobial prophylaxis and therapy, and intensive care unit care have improved the outcome of these patients. The increasing number of HSCTs performed annually, the unique complications that develop in these patients, and the improvement in the intensive care unit outcome make knowledge about the critical care aspect of HSCT an essential part of the current practice of critical care medicine.

The high-resolution chest CT findings in an adult with Melnick–Needles syndrome

Melnick-Needles syndrome is an X-linked dominant skeletal dysplasia in which patients often succumb at an early age to chronic pulmonary disease. Radiographic findings of Melnick-Needles syndrome consist of characteristic bony abnormalities and interstitial lung disease. We present the high-resolution computed tomographic (CT) findings in a 39-year-old survivor of Melnick-Needles syndrome. The clinical and physical exam findings also demonstrate an association between Melnick-Needles syndrome and obstructive sleep apnea.

The findings of surgical lung biopsy in HIV patients in the era of highly active antiretroviral therapy

BACKGROUND

Surgical lung biopsy (SLB) is rarely necessary in the evaluation of pulmonary infiltrates in patients with human immunodeficiency virus (HIV). The aim of this study is to describe the findings of SLB in a recent cohort of HIV-infected patients with unexplained pulmonary infiltrates, and determine the impact of this procedure on management and outcome of these patients.

METHODS

We used a retrospective review of medical records for this study.

RESULTS

Twenty-six patients who underwent SLB where evaluated. The procedure was performed either by video-assisted thoracoscopy, in 42% of the cases, or by thoracotomy in 58%. Eleven patients (42%) had focal infiltrates, and 15 (58%) had diffuse infiltrates. There were 31 diagnoses in the 26 patients; 26 (84%) were specific and 5(16%) were nonspecific. The most common specific diagnoses were infection (58%), malignancy (16%), and inflammatory conditions (10%). Pneumocystis carinii, alone or in combination with other conditions, was the most common diagnosis of all biopsies (34%). Surgical lung biopsy led to a change in management in 17 patients (65%), and was associated with complications in 4 patients (15%). The in-hospital mortality rate was 27%.

CONCLUSIONS

Surgical lung biopsy is a relatively safe procedure, and provides a specific diagnosis in the majority of patients with HIV infection and unexplained pulmonary infiltrates. Pneumocystis carinii alone or in combination with other conditions is the most common finding.