[Thoracic ultrasound: the pneumologist's new stethoscope]

We now have access to a large library of publications validating transparietal thoracic echography in various clinical situations. Parietal lesions, including osteolysis, can be detected and biopsied during the thoracic ultrasound (TUS) examination. To evaluate the parietal extension of lung cancers, TUS has proved superior to tomodensitometry. Pleural effusions can be easily diagnosed and aspirated. Pneumothoraces can be detected using well defined lung artifacts with a high frequency probe. Pleural and peripheral lung nodules can be detected and biopsied with real time visualization; the procedure is safe and accurate. Lung consolidations with a pleural contact can be diagnosed; this is particularly useful for pregnant women. In conclusion, TUS is a precious diagnostic tool for chosen applications, and can help to guide interventional procedures. The portable devices are also very useful for bedridden patients or for out of hospital use.

Disturbed cytokine production at the systemic level in difficult-to-control atopic asthma: evidence for raised interleukin-4 and decreased interferon-γ release following lipopolysaccharide stimulation

BACKGROUND

Disturbed cytokine production is thought to govern inflammation in asthma, which, in its turn, may lead to uncontrolled disease. The aim of this study was to assess the relationship between cytokine production from blood leucocytes and the level of asthma control.

METHODS

We compared the production of interleukin (IL)-4, IL-6, IL-10, interferon (IFN)-γ and tumour necrosis factor-α from peripheral blood leucocytes in non-atopic healthy subjects (n = 22), atopic non-asthmatics (n = 10), well-controlled asthmatics [Juniper asthma control questionnaire (ACQ) score <1.5; n = 20] and patients with uncontrolled asthma despite inhaled or oral corticoids (ACQ score ≥1.5; n = 20). Fifty microlitres of peripheral blood was incubated for 24 h with RPMIc, lipopolysaccharide (LPS; 1 ng/ml) or phytohaemagglutinin (1 μg/ml), and cytokines were measured by immunotrapping (ELISA).

RESULTS

Both controlled and uncontrolled asthmatics as well as atopic non-asthmatics spontaneously produced more IL-4 than non-atopic healthy subjects (p < 0.001). IL-4 production induced by LPS was significantly greater (p < 0.05) in both asthma groups compared to atopic non-asthmatics and non-atopic healthy subjects. By contrast, IFN-γ release induced by LPS was lower in uncontrolled asthmatics than in non-atopic healthy subjects (p < 0.05) and controlled asthmatics (p < 0.05). IL-10 release after LPS was greater in uncontrolled asthmatics than in atopic non-asthmatics (p < 0.05). No difference was observed regarding other cytokines.

CONCLUSION

Blood cells from patients with difficult-to-control atopic asthma display highly skewed Th2 cytokine release following LPS stimulation.

[Clinical case of the month. A patient with advanced non-small-cell lung cancer presenting with an exceptional response to targeted therapies]

Advanced non-small-cell lung cancers are diseases of late diagnosis with bad prognosis. Conventional chemotherapies are not very efficient. Over the last years, many research works have been performed in this way to improve prognosis. Targeted therapies seem promising. They were notably developed against epithelial growth factor receptors and tumoral angiogenesis. We report here the clinical history of a patient with an advanced non-small-cell lung cancer presenting an exceptional response to small-molecule tyrosine kinase inhibitors.

Cytokine production from sputum cells and blood leukocytes in asthmatics according to disease severity

BACKGROUND

Although mild to moderate asthma is known to be Th2 driven, cytokines produced in refractory asthma might not fit the classical Th2 pattern.

METHODS

The aim of our study was to assess the cytokine production by sputum and blood cells from 15 refractory asthmatics (American Thoracic Society Criteria) compared to 15 mild untreated and 17 moderate treated asthmatics and 22 healthy subjects. Spontaneous production of interleukin (IL)-4, IL-6, IL-10, interferon-gamma, and tumor necrosis factor alpha was measured by immunotrapping after 24 h sputum or blood cell culture.

RESULTS

Moderate and refractory asthmatics were both characterized by a lower production of IL-6 from their airway cells compared to healthy subjects. However, the difference was no longer significant when expressing the results per gram of sputum. No significant difference between the three groups was found regarding other cytokines. As for cytokine production from blood, the three groups of asthmatics exhibited raised production of IL-4 when compared to healthy subjects, and this was true when results were expressed per blood volume or after normalization for total leukocyte cell count. Moderate asthmatics exhibited greater production of IL-10 when compared to refractory asthmatics and healthy subjects when results were normalized for total leukocyte cell count.

CONCLUSIONS

Sputum cells from moderate and refractory asthmatics release less IL-6. While the systemic overproduction of IL-4 was observed through the all spectrum of asthma severity, moderate asthmatics exhibited greater systemic IL-10 production compared to refractory asthmatics.

[Endobronchial ultrasonography: a novel technique for investigation of the mediastinum]

Mediastin pathology includes primary lesion and lymph node invasion. The exploration of this anatomical region remains difficult and even hazardous, particularly to obtain histological biopsies. No invasive diagnostic exploration (thorax tomodensitometry and positron emission tomography) allows a histological precision, so mediastinoscopy remains the gold standard in the mediastinum investigation. However, it is not deprived of risk. Recently, guided biopsies and real-time transbronchial needle aspiration by endobronchial ultrasonography (EBUS) have been shown to increase the diagnostic yield over conventional bronchoscopic techniques. Therefore, EBUS is a suitable alternative to mediastinoscopy in the diagnosis of pulmonary or extra-thoracic malignancy, in the staging of mediastinal lymphadenopathy, and in the evaluation of mediastinal response after induction therapy. In the present paper, we present this new diagnostic approach and clarify the current indications of EBUS.

[The UPLIFT study (Understanding Potential Long-term Impacts on Function with Tiotropium)]

The UPLIFT study (Understanding Potential Long-term Impacts on Function with Tiotropium) was a double-blind, randomised, international, multicentric, placebo-controlled clinical trial, investigating with tiotropium (Spiriva) the change in the annual rate of decline in FEV1 in chronic obstructive pulmonary disease (COPD). Secondary end points included COPD exacerbation rate with or without hospitalisation, lung function, quality of life and mortality. 5.993 patients were randomized. In this article, we briefly describe the most important results of the study. While tiotropium did not alter the annual rate of decline in FEV1 (pre and postbronchodilatation), it improved lung function and quality of life, and reduced exacerbations and hospitalisations by comparison with control for up to 4 years. Tiotropium also reduced respiratory and cardiac morbidity.

[Pulmonary rehabilitation in chronic obstructive pulmonary disease]

The current treatment of chronic obstructive pulmonary disease (COPD) patients must comprise, in addition to an optimal pharmacological treatment, a pulmonary rehabilitation, if possible multidisciplinary, and a program of post-rehabilitation in order to maintain the outcomes. Today pulmonary rehabilitation has proved to be effective in improving dyspnoea, exercise capacity and quality of life in COPD patients, and reducing the use of health services and thus the cost. In this article we want to present pulmonary rehabilitation, its indications and results, and the way by which it is held in the CHU of Liege.

[How do I explore...a pleural disease?]

Pleural involvements are common and various respiratory diseases including inflammatory, infectious, occupational, or neoplastic pathological entities...Pleural thickening and pleurisy are usual radiological presentation. Etiological diagnosis imposes a vast and sometimes difficult exploration and it, especially since the conventional imaging by radiology, ultrasound, scanning and nuclear magnetic resonance has no specific diagnostic criteria for pleural malignancy. The metabolic imaging by positron emission tomography (PET) has been gradually positioned in the decision-making algorithm exploration of the pleural disease due to its excellent sensitivity in the diagnosis of malignant pleurisy (88.8%-100%). The analysis of chemistry, bacteriology and cytology pleural fluid makes a significant contribution to the diagnostic approach. However, although inescapable, thoracocentesis has a diagnostic sensibility not exceeding 62%. Moreover, the sensibility of the pleural blind needle biopsies does not exceed 51%. So, thoracoscopy, more invasive, is often justified to precise pleural disease with a diagnostic sensitivity greater than 95%. Finally, despite the diagnostic arsenal available, over 10% of pleurisies remain unknown etiology.

[The place of the analysis of exhaled breath condensate in obstructive pulmonary diseases]

The number of publications on the analysis of the exhaled breath condensate (EBC) has increased considerably over the last five years. The EBC is a new, noninvasive and inexpensive technique which requires a minimum of cooperation on behalf of the patient. The condensate obtained consists of more than 99.99% of water vapour, to which are added various substances which reflect the inflammatory status of the airways. It is now especially used to characterize the inflammatory state of chronic respiratory diseases such as asthma and COPD. This article describes the technique and reviews the main data from the current literature.

[Mesothelioma: a still current occupational cancer]

Mesothelioma is a rare tumour, particularly aggressive, whose incidence increases because of the massive use of asbestos during the last century. Asbestos remains indeed the principal etiologic agent of this cancer. In the event of mesothelioma it is advisable to seek an exposure, even of short duration, often which dates back to several decades. In certain circumstances compensation can be obtained at the Occupational Diseases Found. The renewed interest with regard to this tumour is supported by the improvement of mesothelioma management, the new imaging techniques, the new treatments and the broad diffusion of information related to the risk of developing this tumour following asbestos inhalation.

[Therapeutic update in respiratory medicine]

We review what we think to be the major advances in the field of respiratory medicine over the last ten years. We concentrate here on four major diseases i.e. asthma, chronic obstructive pulmonary disease (COPD), lung cancer and chronic respiratory insufficiency due to restrictive disorders. Therapeutic advances are based either on new drugs or on new disease management concepts and, in some cases, on new medical devices. These advances have allowed a reduction in mortality and morbidity in aforementioned diseases.

[Clinical study of the month: the TORCH study (TOwards a Revolution in COPD Health)]

The TORCH study (Towards a Revolution in COPD Health) was a double-blind, randomised, placebo-controlled clinical trial, investigating the combination of salmeterol/fluticasone propionate for 3 years in COPD. The primary end point was on all-cause mortality. Secondary end points included COPD exacerbation rate, lung function and health status. More than 6000 patients were randomised. In this article, we briefly report the most significant results of the study. The efficacy on mortality (reduction of the risk of death of 17.5%) was near the predetermined level of statistical significance (p = 0.052); the combination had a significant effect on the three pillars of COPD management, that is: improvement of quality of life and respiratory function, and reduction of the rate of exacerbations. In addition to being effective, the combination salmeterol/fluticasone (50/500 microg 2x/day) is well tolerated in COPD and had a favourable benefit/risk ratio.

[Clinical case of the month. Compression of the right main bronchus by a mesothelioma]

We report the case of a patient treated by chemotherapy for a diagnosis of mesothelioma. A quickly progressive dyspnea developed which was due to compression of the right main bronchus by mediastinal extension of the tumor. This obstruction was treated by interventionnal bronchoscopy and stenting.

[Exacerbations in COPD: a burden to curtail]

Exacerbations of chronic obstructive pulmonary disease (COPD) play a very important role. Unfortunately they were neglected a long time in the therapeutic tests. However exacerbations influence the decline of the respiratory function over time, cause important deterioration of the quality of life of the patients, increase morbidity and mortality of COPD, and finally represent a burden for health care. Reducing the number of exacerbations could potentially slow down the progression of the disease. Thus the prevention of exacerbations should be the "corner stone" of the maintenance treatment of the COPD. In this review we propose to recall the importance of exacerbations in COPD and to present the treatment which have been shown to reduce exacerbation rate in COPD.

[Tiotropium: a new therapeutic option in chronic obstructive pulmonary disease]

Tiotropium is a long-acting anticholinergic bronchodilator, inhaled only once a day, which produces relaxation of airway smooth muscle through antagonism of acetylcholine at M3-muscarinic receptors. Its duration of action is at least 24 h with once daily administration of tiotropium. Several studies have shown its efficacy and its good tolerance in the treatment of patients who are suffering from moderate to very severe chronic obstructive pulmonary disease (COPD). Tiotropium improves spirometric measurements and quality of life, and reduces dyspnea and exacerbation rate in COPD patients.

Survival is better predicted with a new classification of stage III unresectable non-small cell lung carcinoma treated by chemotherapy and radiotherapy

The 1997 International staging system (ISS) classification separated stage III non-small cell lung cancer (NSCLC) into stages IIIA and IIIB. In a previous study including unresectable NSCLC initially treated with chemotherapy, we analysed survival according to tumour (T) and node (N) stages and derived a classification into stages IIIbeta (T3-4N3) and IIIalpha (other TN stage III) that had a better discrimination on survival distribution. The aim of this study was to validate these results in a further set of patients. Patients with unresectable stage III NSCLC included in a phase III trial assessing the role of increased dose chemotherapy (SuperMIP: mitomycin 6 mg/m2, ifosfamide 4.5 g/m2, cisplatin 60 mg/m2, carboplatin 200 mg/m2) in comparison to standard chemotherapy MIP (mitomycin 6 mg/m2, ifosfamide 3 g/m2, cisplatin 50 mg/m2), before thoracic irradiation (60 Gy in 30 fractions over 6 weeks) were the subject of this study. Survival distributions were assessed by the method of Kaplan-Meier. Survival comparisons were made by the log-rank test. Multivariate analyses using Cox regression models, included all potential prognostic factors for survival with a P-value <0.2 in univariate analysis. According to the 1997 International staging system classification, 328 eligible patients were included in the study. There was no imbalance between the two arms. Five parameters were significantly associated (P < or = 0.05) with survival in univariate analysis: European lung cancer working party (ELCWP) staging (IIIalpha[n = 294 pts] versus IIIbeta [n = 46]), Karnofsky index, weight loss, platelet count and haemoglobin level. These variables as well as the 1997 ISS staging, white blood cell (WBC) count, LDH and sodium levels were included in a multivariate analysis. Two models were constructed, including either the ELCWP or the 1997 ISS. In model 1 (ISS included), Karnofsky index (HR 0.69; 95% confidence interval (CI) 0.47-1.00; P = 0.05) and haemoglobin (HR 1.49; 95% CI 1.11-1.99; P = 0.007) were found significant. In model 2, including ELCWP staging, two variables were associated with survival: ELCWP staging (HR 1.68; 95% CI 1.20-2.35; P = 0.002) and haemoglobin (HR 1.54; 95% CI 1.15-2.07; P = 0.01).

CONCLUSION

In initially unresectable stage III NSCLC treated by chemotherapy and radiotherapy, we validated the results of our previous study. The classification into stages IIIbeta (T3-4N3M0) and IIIalpha (other TN stage III) better discriminates the patients in term of survival than the 1997 ISS classification.

[Tracheobronchial stents: Chu of Liège experience]

During recent years the endobronchial prostheses has become an essential part of the therapeutic bronchoscopy in order to remove obstructions from the proximal airways, in malignant diseases, (principally lung cancer) are in benign disorders. In this article we report our last ten year experience in stenting of the tracheo-bronchial tree. We will retrospectively review the indications of the stents, the type of prostheses and their modes of insertion, their complications, the clinical and functional results.

[Spiriva]

SPIRIVA (tiotropium) is a long-acting anticholinergic bronchodilatator, inhaled once a day, which produces relaxation of airway smooth muscle through antagonism of acetylcholine at M3-muscarinic receptors. Its duration of action is at least 24h with once daily administration of tiotropium. Several studies have shown its efficacy and its good tolerance in the treatment of patients who are suffering from moderate to very severe chronic obstructive pulmonary disease (COPD). SPIRIVA improves spirometric measurements and quality of life, and reduces dyspnea and exacerbation rate in COPD patients.

[Paroxysmal dyspnoea in a healthy individual: the spontaneous pneumothorax]

In a healthy individual, a dyspnoea of abrupt onset raises the suspicion of a spontaneous pneumothorax. The clinical examination and standard chest X-ray usually permit the correct diagnosis. The risk of reccurence can be assessed by the clinical history and examination. The functional consequences (which can be lethal) and the risk of recurrence will guide the short- and long-term therapy.

Increased IL-6 and TGF-beta1 concentrations in bronchoalveolar lavage fluid associated with thoracic radiotherapy

PURPOSE

To assess, in lung cancer patients, the effects of thoracic radiotherapy (RT) on the concentrations of transforming growth factor-beta(1) (TGF-beta(1)) and interleukin-6 (IL-6) in the bronchoalveolar lavage (BAL) fluid.

METHODS AND MATERIALS

Eleven patients with lung cancer requiring RT as part of their treatment were studied. BAL was performed bilaterally before, during, and 1, 3, and 6 months after RT. Before each BAL session, the patient's status was assessed clinically using pulmonary function tests and an adapted late effects on normal tissue-subjective, objective, management, analytic (LENT-SOMA) scale, including subjective and objective alterations. The National Cancer Institute Common Toxicity Criteria were used to grade pneumonitis. The TGF-beta(1) and IL-6 levels in the BAL fluid were determined using the Easia kit.

RESULTS

The TGF-beta(1) and IL-6 concentrations in the BAL fluid recovered from the irradiated areas were significantly increased by thoracic RT. The increase in TGF-beta(1) levels tended to be greater in the group of patients who developed severe pneumonitis. In the BAL fluid from the nonirradiated areas, the TGF-beta(1) and IL-6 concentrations remained unchanged.

CONCLUSION

The observed increase in TGF-beta(1) and IL-6 concentrations in the BAL fluid recovered from the irradiated lung areas demonstrated that these cytokines may contribute to the process leading to a radiation response in human lung tissue.

[Clinical case of the month. An unusual cause of bronchiectasis: primary ciliary dyskinesia]

We report a case of bronchiectasis due to primary ciliary dyskinesia.