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Gredic M, Karnati S, Ruppert C, Guenther A, Avdeev SN, Kosanovic D. Combined Pulmonary Fibrosis and Emphysema: When Scylla and Charybdis Ally. Cells 2023; 12:1278. [PMID: 37174678 PMCID: PMC10177208 DOI: 10.3390/cells12091278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/17/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
Combined pulmonary fibrosis and emphysema (CPFE) is a recently recognized syndrome that, as its name indicates, involves the existence of both interstitial lung fibrosis and emphysema in one individual, and is often accompanied by pulmonary hypertension. This debilitating, progressive condition is most often encountered in males with an extensive smoking history, and is presented by dyspnea, preserved lung volumes, and contrastingly impaired gas exchange capacity. The diagnosis of the disease is based on computed tomography imaging, demonstrating the coexistence of emphysema and interstitial fibrosis in the lungs, which might be of various types and extents, in different areas of the lung and several relative positions to each other. CPFE bears high mortality and to date, specific and efficient treatment options do not exist. In this review, we will summarize current knowledge about the clinical attributes and manifestations of CPFE. Moreover, we will focus on pathophysiological and pathohistological lung phenomena and suspected etiological factors of this disease. Finally, since there is a paucity of preclinical research performed for this particular lung pathology, we will review existing animal studies and provide suggestions for the development of additional in vivo models of CPFE syndrome.
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Affiliation(s)
- Marija Gredic
- Cardio-Pulmonary Institute (CPI), Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus Liebig University, 35392 Giessen, Germany
| | - Srikanth Karnati
- Institute for Anatomy and Cell Biology, Julius-Maximilians-University Würzburg, 97070 Würzburg, Germany
| | - Clemens Ruppert
- Cardio-Pulmonary Institute (CPI), Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus Liebig University, 35392 Giessen, Germany
- UGMLC Giessen Biobank & European IPF Registry/Biobank, 35392 Giessen, Germany
| | - Andreas Guenther
- Cardio-Pulmonary Institute (CPI), Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research (DZL), Justus Liebig University, 35392 Giessen, Germany
- UGMLC Giessen Biobank & European IPF Registry/Biobank, 35392 Giessen, Germany
- Institute for Lung Health (ILH), 35392 Giessen, Germany
- Lung Clinic, Evangelisches Krankenhaus Mittelhessen, 35398 Giessen, Germany
| | - Sergey N. Avdeev
- Department of Pulmonology, I.M. Sechenov First Moscow State Medical University (Sechenov University), 119991 Moscow, Russia
| | - Djuro Kosanovic
- Department of Pulmonology, I.M. Sechenov First Moscow State Medical University (Sechenov University), 119991 Moscow, Russia
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Serrano Gotarredona MP, Navarro Herrero S, Gómez Izquierdo L, Rodríguez Portal JA. Smoking-related interstitial lung disease. RADIOLOGIA 2022; 64 Suppl 3:277-289. [PMID: 36737166 DOI: 10.1016/j.rxeng.2022.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 10/22/2022] [Indexed: 02/05/2023]
Abstract
Exposure to smoke is associated with the development of diseases of the airways and lung parenchyma. Apart from chronic obstructive pulmonary disease (COPD), in some individuals, tobacco smoke can also trigger mechanisms of interstitial damage that result in various pathological changes and pulmonary fibrosis. A causal relation has been established between tobacco smoke and a group of entities that includes respiratory bronchiolitis-associated interstitial lung disease (RB-ILD), desquamative interstitial pneumonia (DIP), Langerhans cell histiocytosis (LCH), and acute eosinophilic pneumonia (AEP). Smoking is considered a risk factor for idiopathic pulmonary fibrosis (IPF); however, the role and impact of smoking in the development of this differentiated clinical entity, which has also been called combined pulmonary fibrosis and emphysema (CPFE) as well as nonspecific interstitial pneumonia (NIP), remains to be determined. The definition of smoking-related interstitial fibrosis (SRIF) is relatively recent, with differentiated histological characteristics. The likely interconnection between the mechanisms involved in inflammation and pulmonary fibrosis in all these processes often results in an overlapping of clinical, radiological, and histological features in the same patient that can sometimes lead to radiological patterns of interstitial lung disease that are impossible to classify. For this reason, a combined approach to diagnosis is recommendable. This combined approach should be based on the joint interpretation of the histological and radiological findings while taking the clinical context into consideration. This paper aims to describe the high-resolution computed tomography (HRCT) findings in this group of disease entities in correlation with the clinical manifestations and histological changes underlying the radiological pattern.
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Affiliation(s)
- M P Serrano Gotarredona
- Unidad de Imagen Cardiotorácica, Servicio de Radiodiagnóstico, Hospital Universitario Virgen del Rocío, Sevilla, Spain.
| | - S Navarro Herrero
- Unidad de Imagen Cardiotorácica, Servicio de Radiodiagnóstico, Hospital Universitario Virgen del Rocío, Sevilla, Spain.
| | - L Gómez Izquierdo
- Servicio de Anatomía Patológica, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - J A Rodríguez Portal
- Unidad de Patología Intersticial, Servicio de Neumología, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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Wang L, Shao M, Jiang W, Huang Y. Resveratrol alleviates bleomycin-induced pulmonary fibrosis by inhibiting epithelial-mesenchymal transition and down-regulating TLR4/NF-κB and TGF-β1/smad3 signalling pathways in rats. Tissue Cell 2022; 79:101953. [DOI: 10.1016/j.tice.2022.101953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/22/2022] [Accepted: 10/04/2022] [Indexed: 11/17/2022]
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Serrano Gotarredona M, Navarro Herrero S, Gómez Izquierdo L, Rodríguez Portal J. Enfermedades pulmonares intersticiales relacionadas con el tabaco. RADIOLOGIA 2022. [DOI: 10.1016/j.rx.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Raucherassoziierte interstitielle Lungenerkrankungen. DIE RADIOLOGIE 2022; 62:738-746. [PMID: 35736996 PMCID: PMC9433357 DOI: 10.1007/s00117-022-01025-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/25/2022] [Indexed: 11/07/2022]
Abstract
Klinisches Problem Raucherassoziierte interstitielle Lungenerkrankungen umfassen heterogene pulmonale Pathologien, deren korrekte Diagnostik prognostische und therapeutische Konsequenzen hat. In diesem Artikel werden die gängigsten raucherassoziierten interstitiellen Lungenerkrankungen beschrieben sowie eine strukturierte Herangehensweise präsentiert, welche den diagnostischen Arbeitsprozess erleichtern kann. Empfehlungen für die Praxis Die Computertomographie (CT) besitzt einen hohen Stellenwert in der Diagnose der raucherassoziierten interstitiellen Lungenerkrankungen und kann dazu beitragen, Lungenbiopsien zu verhindern. Um eine hohe diagnostische Genauigkeit zu erreichen, sollten standardisierte Untersuchungsprotokolle sowie eine strukturierte Herangehensweise in der Befundung zur Anwendung kommen. In den entzündlich dominierten Stadien der respiratorischen Bronchiolitis (RB), der respiratorischen Bronchiolitis mit interstitieller Lungenerkrankung (RB-ILD) sowie der desquamativen interstitiellen Pneumonie (DIP) haben die Beendigung des Rauchens sowie Steroide den größten therapeutischen Effekt. Bei fibrotischen Veränderungen (z. B. im Rahmen einer idiopathischen pulmonalen Fibrose [IPF]) können antifibrotische Therapien mit Pirfenidon und Nintedanib zum Einsatz kommen. Patienten mit dem Verdacht auf raucherassoziierte interstitielle Lungenerkrankung sollten in multidisziplinären Boards abgeklärt und behandelt werden.
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Guzmán-Vargas J, Ambrocio-Ortiz E, Pérez-Rubio G, Ponce-Gallegos MA, Hernández-Zenteno RDJ, Mejía M, Ramírez-Venegas A, Buendia-Roldan I, Falfán-Valencia R. Differential Genomic Profile in TERT, DSP, and FAM13A Between COPD Patients With Emphysema, IPF, and CPFE Syndrome. Front Med (Lausanne) 2021; 8:725144. [PMID: 34490311 PMCID: PMC8416604 DOI: 10.3389/fmed.2021.725144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 07/22/2021] [Indexed: 12/31/2022] Open
Abstract
Background: Genetic association studies have identified single nucleotide polymorphisms (SNPs) associated with lasting lung diseases such as Chronic Obstructive Pulmonary Disease (COPD) and Idiopathic Pulmonary Fibrosis (IPF), as well as the simultaneous presentation, known as Combined Pulmonary Fibrosis and Emphysema (CPFE) Syndrome. It is unknown if these diseases share genetic variants previously described in an independent way. This study aims to identify common or differential variants between COPD, IPF, and CPFE. Materials and methods: The association analysis was carried out through a case-control design in a Mexican mestizo population (n = 828); three patients' groups were included: COPD smokers (COPD-S, n = 178), IPF patients (n = 93), and CPFE patients (n = 16). Also, two comparison groups were analyzed: smokers without COPD (SWOC, n = 367) and healthy subjects belonging to the Mexican Pulmonary Aging Cohort (PAC, n = 174). Five SNPs in four genes previously associated to interstitial and obstructive diseases were selected: rs2609255 (FAM13A), rs2736100 (TERT), rs2076295 (DSP) rs5743890, and rs111521887 (TOLLIP). Genotyping was performed by qPCR using predesigned Taqman probes. Results: In comparing IPF vs. PAC, significant differences were found in the frequency of the rs260955 G allele associated with the IPF risk (OR = 1.68, p = 0.01). Also, the genotypes, GG of rs260955 (OR = 2.86, p = 0.01) and TT of rs2076295 (OR = 1.79, p = 0.03) were associated with an increased risk of IPF; after adjusting by covariables, only the rs260955 G allele remain significant (p = 0.01). For the CPFE vs. PAC comparison, an increased CPFE risk was identified since there is a difference in the rs2736100 C allele (OR = 4.02, p < 0.01; adjusted p < 0.01). For COPD-S, the rs2609255 TG genotype was associated with increased COPD risk after adjusting by covariables. Conclusion: The rs2736100 C allele is associated with decreased IPF risk and confers an increased risk for CPFE. Also, the rs2076295 TT genotype is associated with increased IPF risk, while the GG genotype is associated with CFPE susceptibility. The rs2609255 G allele and GG genotype are associated with IPF susceptibility, while the TG genotype is present in patients with emphysema.
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Affiliation(s)
- Javier Guzmán-Vargas
- HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Enrique Ambrocio-Ortiz
- HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Gloria Pérez-Rubio
- HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | | | | | - Mayra Mejía
- Interstitial Pulmonary Diseases and Rheumatology Unit, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Alejandra Ramírez-Venegas
- Tobacco Smoking and COPD Research Department, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Ivette Buendia-Roldan
- Translational Research Laboratory on Aging and Pulmonary Fibrosis, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Ramcés Falfán-Valencia
- HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
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Hage R, Gautschi F, Steinack C, Schuurmans MM. Combined Pulmonary Fibrosis and Emphysema (CPFE) Clinical Features and Management. Int J Chron Obstruct Pulmon Dis 2021; 16:167-177. [PMID: 33536752 PMCID: PMC7850450 DOI: 10.2147/copd.s286360] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/30/2020] [Indexed: 01/14/2023] Open
Abstract
Background Combined pulmonary fibrosis and emphysema (CPFE) is an underrecognized syndrome characterized by chronic, progressive disease with a dismal prognosis. Frequent co-morbidities with a higher incidence than in idiopathic pulmonary fibrosis or emphysema alone are pulmonary hypertension (WHO group 3) in 47–90% of the patients and lung cancer in 46.8% of the patients. Objective Review current evidence and knowledge concerning diagnosis, risk factors, disease evolution and treatment options of CPFE. Methods We searched studies reporting CPFE in original papers, observational studies, case reports, and meta-analyses published between 1990 and August 2020, in the PubMed, Embase, Cochrane Library, Wiley Online Library databases and Google Scholar using the search terms [CPFE], [pulmonary fibrosis] OR [IPF] AND [emphysema]. Bibliographies of retrieved articles were searched as well. Further inclusion criteria were publications in English, French, German and Italian, with reference to humans. In vitro data and animal data were not considered unless they were mentioned in studies reporting predominantly human data. Results Between May 1, 1990, and September 1, 2020, we found 16 studies on CPFE from the online sources and bibliographies. A total of 890 patients are described in the literature. Although male/female ratio was not reported in all studies, the large majority of patients were male (at least 78%), most of them were current or former heavy smokers. Conclusion CPFE is a syndrome presenting with dyspnea on exertion followed by disruptive cough and recurrent exacerbations. The disease may progress rapidly, be aggravated by pulmonary hypertension WHO group 3 and is associated with an increased risk of lung cancer. Smoking and male sex are important risk factors. There is a need for more research on CPFE especially relating to etiology, influence of genetics, treatment and prevention options. Antifibrotic therapy might be an interesting treatment option for these patients.
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Affiliation(s)
- René Hage
- University Hospital Zurich, Division of Pulmonology, Zurich, Switzerland.,University of Zurich, Faculty of Medicine, Zurich, Switzerland
| | - Fiorenza Gautschi
- University Hospital Zurich, Division of Pulmonology, Zurich, Switzerland.,University of Zurich, Faculty of Medicine, Zurich, Switzerland
| | - Carolin Steinack
- University Hospital Zurich, Division of Pulmonology, Zurich, Switzerland.,University of Zurich, Faculty of Medicine, Zurich, Switzerland
| | - Macé M Schuurmans
- University Hospital Zurich, Division of Pulmonology, Zurich, Switzerland.,University of Zurich, Faculty of Medicine, Zurich, Switzerland
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Kulshrestha R, Singh H, Pandey A, Soundarya D, Jaggi AS, Ravi K. Differential expression of caveolin-1 during pathogenesis of combined pulmonary fibrosis and emphysema: Effect of phosphodiesterase-5 inhibitor. Biochim Biophys Acta Mol Basis Dis 2020; 1866:165802. [PMID: 32311453 DOI: 10.1016/j.bbadis.2020.165802] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 03/20/2020] [Accepted: 04/13/2020] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Combined pulmonary fibrosis and emphysema (CPFE) is a relatively new entity within the spectrum of cigarette smoke induced lung disorders. Currently there is no consensus about its treatment. We hypothesized that caveolin-1 critically determines the parenchymal and vascular remodeling leading to the development of CPFE. We assessed the effect of therapeutic targeting of caveolin-1 in mesenchymal and endothelial cells by the phosphodiesterase-5 inhibitor, sildenafil. METHODS Male Wistar rats (n = 168) were exposed to; room air (control); bleomycin (7 U/kg), bleomycin+sildenafil (50 mg/kg/day P.O.), cigarette smoke (CS) (4 Gold Flake 69 mm/day), CS + sildenafil, CS + bleomycin, CS + bleomycin+sildenafil. Animals were euthanized at 8, 9, 11, 12 weeks and lung histopathological changes, collagen deposition, ROS, Xanthine oxidase, caveolin-1 determined. RESULTS Cigarette smoke causes progressive ROS accumulation, caveolin-1 up-regulation in alveolar epithelial cells, alveolar macrophages, peribronchiolar fibroblasts, endothelial and vascular smooth muscle cells, interstitial inflammation and emphysema. Sildenafil reduces oxidative stress, parenchymal caveolin-1 and attenuates emphysema caused by CS. Bleomycin increases lung ROS and downregulates caveolin-1 leading to fibroblast proliferation and fibrosis. Combined cigarette smoke and bleomycin exposure, results in differential caveolin-1 expression and heterogeneous parenchymal remodeling with alternating areas of emphysema and fibrosis. Increased caveolin-1 induces premature senescence of lung fibroblasts and emphysema. Decreased caveolin-1 is associated with propagation of EMT and fibrosis. Sildenafil attenuates the parenchymal remodeling however it is not effective in reducing VSMC hypertrophy in combined group. CONCLUSION CPFE is characterized by heterogenous parenchymal remodeling and differential caveolin-1 expression. Sildenafil therapy attenuates parenchymal pathologies in CPFE. Additional therapy is however needed for attenuating VSMC remodeling.
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Affiliation(s)
- R Kulshrestha
- Department of Pathology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India.
| | - H Singh
- Department of Pathology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - A Pandey
- Department of Pathology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - D Soundarya
- Department of Pathology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - A S Jaggi
- Dept of Pharmaceutical Sciences and Drug Research, Punjabi University, Patiala, India
| | - K Ravi
- Department of Physiology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
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Malli F, Papakosta D, Antoniou K, Dimadi M, Polychronopoulos V, Malagari K, Oikonomou A, Bouros DE, Daniil Z. Combined pulmonary fibrosis and emphysema characteristics in a Greek cohort. ERJ Open Res 2019; 5:00014-2018. [PMID: 30895186 PMCID: PMC6421361 DOI: 10.1183/23120541.00014-2018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 01/25/2019] [Indexed: 01/26/2023] Open
Abstract
Background Combined pulmonary fibrosis and emphysema (CPFE) has recently received great attention, with studies suggesting that it presents a distinct clinical entity while others have challenged this hypothesis. This nationwide study aimed to describe a large cohort of Greek CPFE patients and to examine potential prognostic factors for survival. Methods This retrospective study included 97 patients with CPFE. Demographic and clinical data, pulmonary function tests, echocardiography results and bronchoalveolar lavage analysis were recorded. Results Most patients were male (94.8%) and 92% were current or ex-smokers. Spirometry results were abnormal (forced vital capacity (FVC) 72.9±19.9% pred and forced expiratory volume in 1 s/FVC 82.9±9.7%) with reduced diffusing capacity of the lung for carbon monoxide (DLCO) (42.3±17.4% pred). Mean systolic pulmonary arterial pressure was 41.9±19.7 mmHg and pulmonary hypertension was present in 58.8% of patients. Mean 6-min walk distance was 335.4±159.4 m. Mean emphysema score was 14.23±8.69% and mean interstitial lung disease (ILD) extent was 39.58±19.82%. Mean survival was 84 months (95% CI 72–96 months). Patients with DLCO ≥39% pred had better survival than patients with DLCO <39% pred (p=0.031). Patients with ILD extent ≥30% had worse survival than patients with ILD extent <30% (p=0.037). Conclusions Our results indicate that CPFE patients have preserved lung volumes associated with disproportionately reduced DLCO, while reduced DLCO and increased ILD extent was associated with worse prognosis. Prognosis of CPFE is associated with pulmonary function status and ILD extenthttp://ow.ly/izvd30nHFgh
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Affiliation(s)
- Foteini Malli
- Respiratory Medicine Dept, University of Thessaly, School of Medicine, Larissa, Greece
| | - Despoina Papakosta
- University of Thessaloniki, G. Papanikolaou Hospital, Dept of Pneumonology Thessaloniki, Thessaloniki, Greece
| | - Katerina Antoniou
- Dept of Thoracic Medicine and Laboratory of Molecular and Cellular Pneumonology, Interstitial Lung Disease Unit, University Hospital of Heraklion, Heraklion, Greece
| | - Maria Dimadi
- "SOTIRIA" Athens Chest Hospital, 1st Dept of Pneumonology, Athens, Greece
| | | | - Katerina Malagari
- Evgenidion University Hospital, Imaging and Research Unit, Athens, Greece
| | | | - Demosthenes E Bouros
- Interstitial Lung Diseases Unit, Hospital for Diseases of the Chest Sotiria, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Zoe Daniil
- Respiratory Medicine Dept, University of Thessaly, School of Medicine, Larissa, Greece
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Improvement of pulmonary arterial compliance by pulmonary vasodilator in pulmonary hypertension from combined pulmonary fibrosis and emphysema. Respir Med Case Rep 2019; 28:100940. [PMID: 31667076 PMCID: PMC6812224 DOI: 10.1016/j.rmcr.2019.100940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 09/25/2019] [Accepted: 09/26/2019] [Indexed: 12/03/2022] Open
Abstract
Combined pulmonary fibrosis and emphysema (CPFE) is a common but under-recognized syndrome characterized with distinct profiles of both pulmonary fibrosis and emphysema. Pulmonary hypertension (PH) is particularly prone to develop as a common complication, leading to exercise limitation and worse prognosis of CPFE. Although the therapy of patients with PH from CPFE cannot be endorsed, an individual treatment may be considerable when accompanying severe PH. We report a case of a 71-year-old male with PH from CPFE, who improved pulmonary arterial compliance (PAC) and exercise capacity in response to pulmonary vasodilator.
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Peiffer G, Underner M, Perriot J. [The respiratory effects of smoking]. REVUE DE PNEUMOLOGIE CLINIQUE 2018; 74:133-144. [PMID: 29793770 DOI: 10.1016/j.pneumo.2018.04.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 04/26/2018] [Accepted: 04/26/2018] [Indexed: 02/05/2023]
Abstract
A marked increase in the morbidity and mortality of a large number of broncho-pulmonary diseases has been documented in relation to smoking. The influence of tobacco smoking on various respiratory conditions. is discussed: incidence, severity or natural history modification of some respiratory illnesses: obstructive lung diseases (COPD, asthma), lung cancer, bacterial, viral respiratory infections, with the impact of smoking on tuberculosis. Finally, the relationship of tobacco with diffuse interstitial lung disease: protective role of smoking (controversial in sarcoidosis, real in hypersensitivity pneumonitis). The benefits of smoking cessation are described.
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Affiliation(s)
- G Peiffer
- Service de pneumologie, CHR Metz-Thionville, hôpital de Mercy, 1, allée du Château 57085 Metz cedex 3, France.
| | - M Underner
- Unité de recherche clinique, centre hospitalier Henri-Laborit, 86000 Poitiers, France.
| | - J Perriot
- CLAT 63, dispensaire Emile-Roux, 11, rue Vaucanson, 63100 Clermont-Ferrand, France.
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Current Concepts in Pathogenesis, Diagnosis, and Management of Smoking-Related Interstitial Lung Diseases. Chest 2017; 154:394-408. [PMID: 29222007 DOI: 10.1016/j.chest.2017.11.023] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 11/01/2017] [Accepted: 11/26/2017] [Indexed: 11/21/2022] Open
Abstract
Tobacco exposure results in various changes to the airways and lung parenchyma. Although emphysema represents the more common injury pattern, in some individuals, cigarette smoke injures alveolar epithelial cells and other lung cells, resulting in diffuse infiltrates and parenchymal fibrosis. Smoking can trigger interstitial injury patterns mediated via recruitment and inappropriate persistence of myeloid and other immune cells, including eosinophils. As our understanding of the role of cigarette smoke constituents in triggering lung injury continues to evolve, so does our recognition of the spectrum of smoking-related interstitial lung changes. Although respiratory bronchiolitis-interstitial lung disease, desquamative interstitial pneumonia, pulmonary Langerhans cell histiocytosis, and acute eosinophilic pneumonia have a well-established association with tobacco use, its role and impact on idiopathic pulmonary fibrosis, combined pulmonary fibrosis and emphysema, and connective tissue disease-related interstitial lung diseases is still ambiguous. Smoking-related interstitial fibrosis is a relatively newly appreciated entity with distinct histopathologic features but with unclear clinical ramifications. Increased implementation of lung cancer screening programs and utilization of CT scans in thoracic imaging have also resulted in increased identification of "incidental" or "subclinical" interstitial lung changes in smokers, the ensuing impact of which remains to be studied.
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Li C, Wu W, Chen N, Song H, Lu T, Yang Z, Wang Z, Zhou J, Liu L. Clinical characteristics and outcomes of lung cancer patients with combined pulmonary fibrosis and emphysema: a systematic review and meta-analysis of 13 studies. J Thorac Dis 2017; 9:5322-5334. [PMID: 29312742 DOI: 10.21037/jtd.2017.12.72] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background The characteristic and outcomes of lung cancer patients with combined pulmonary fibrosis and emphysema (CPFE) have long been assessed, but results were controversial. Therefore, we performed a meta-analysis to assess the clinical features and prognosis of lung cancer patients with CPFE. Methods The databases PubMed, Embase, and Web of Science (updated to October 1, 2017) were searched for eligible studies. Pooled odds ratios (ORs), weighted mean differences (WMD) or hazard ratios (HRs) with 95% confidence intervals (95% CIs) were used to evaluate the clinicopathological characteristics, the short-term outcome after operation and long-term survival of lung cancer patients with CPFE compared with lung cancer patients without CPFE (fibrosis, emphysema, and normal). Results Thirty original studies with 8,050 patients were included in this meta-analysis. The pooled results indicated that lung cancer patients with CPFE were associated with higher age (MD =3.39; 95% CI: 2.12-4.67, P<0.001), male (OR =8.46; 95% CI: 6.36-11.26, P<0.001), ex- or current smoker (OR =39.65; 95% CI: 15.64-100.5, P<0.001), longer smoking history (MD =15.56; 95% CI: 3.73-27.39, P=0.01), lower DLCO% (MD =-13.82; 95% CI: -21.4 to -6.24, P<0.001), squamous cell carcinoma histology (OR =3.55; 95% CI: 2.49-5.05, P<0.001), the lower lobes (OR =1.92; 95% CI: 1.52-2.43, P<0.001), advanced pathological stage (OR =1.55; 95% CI: 1.22-1.96, P<0.001). Lung cancer patients with CPFE had higher 30-day mortality (OR =4.72, 95% CI: 2.06-10.85, P<0.001), 90-day mortality (OR =5.33; 95% CI: 1.39-20.42, P=0.01), and incidence of postoperative complications (OR =5.25, 95% CI: 2.38-11.57, P<0.001). In addition, the lung cancer patients with CPFE had a poorer OS (HR =2.006, 95% CI: 1.347-2.986, P=0.001) than lung cancer patients without CPFE. Conclusions This meta-analysis demonstrated that lung cancer patients with CPFE have more aggressive clinical characteristic and a poor prognosis, suggesting that lung cancer patients with CPFE should be early detected, treated reasonably and be taken good care of.
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Affiliation(s)
- Chuan Li
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China.,West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Wenwen Wu
- West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Nan Chen
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China.,West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Huizi Song
- West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Tianjian Lu
- West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Zhenyu Yang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China.,West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Zihuai Wang
- West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Jian Zhou
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China.,West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Lunxu Liu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
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Comparative study of two models of combined pulmonary fibrosis and emphysema in mice. Acta Histochem 2017; 119:244-251. [PMID: 28233574 DOI: 10.1016/j.acthis.2017.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 12/31/2016] [Accepted: 01/23/2017] [Indexed: 11/20/2022]
Abstract
Combined pulmonary fibrosis and emphysema (CPFE) is an "umbrella term" encompassing emphysema and pulmonary fibrosis, but its pathogenesis is not known. We established two models of CPFE in mice using tracheal instillation with bleomycin (BLM) or murine gammaherpesvirus 68 (MHV-68). Experimental mice were divided randomly into four groups: A (normal control, n=6), B (emphysema, n=6), C (emphysema+MHV-68, n=24), D (emphysema+BLM, n=6). Group C was subdivided into four groups: C1 (sacrificed on day 367, 7 days after tracheal instillation of MHV-68); C2 (day 374; 14days); C3 (day 381; 21days); C4 (day 388; 28days). Conspicuous emphysema and interstitial fibrosis were observed in BLM and MHV-68 CPFE mouse models. However, BLM induced diffuse pulmonary interstitial fibrosis with severely diffuse pulmonary inflammation; MHV-68 induced relatively modest inflammation and fibrosis, and the inflammation and fibrosis were not diffuse, but instead around bronchioles. Inflammation and fibrosis were detectable in the day-7 subgroup and reached a peak in the day-28 subgroup in the emphysema + MHV-68 group. Levels of macrophage chemoattractant protein-1, macrophage inflammatory protein-1α, interleukin-13, and transforming growth factor-β1 in bronchoalveolar lavage fluid were increased significantly in both models. Percentage of apoptotic type-2 lung epithelial cells was significantly higher; however, all four types of cytokine and number of macrophages were significantly lower in the emphysema+MHV-68 group compared with the emphysema +BLM group. The different changes in pathology between BLM and MHV-68 mice models demonstrated different pathology subtypes of CPFE: macrophage infiltration and apoptosis of type-II lung epithelial cells increased with increasing pathology score for pulmonary fibrosis.
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15
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Koo HJ, Do KH, Lee JB, Alblushi S, Lee SM. Lung Cancer in Combined Pulmonary Fibrosis and Emphysema: A Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0161437. [PMID: 27618692 PMCID: PMC5019377 DOI: 10.1371/journal.pone.0161437] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 08/07/2016] [Indexed: 11/18/2022] Open
Abstract
Purpose Patients with combined pulmonary fibrosis and emphysema (CPFE) have been suggested to have an increased risk of lung cancer. We conducted a systematic review of all published data and performed a meta-analysis to define the characteristics of lung cancer that develops in CPFE. Method We searched Pubmed, Embase, and Cochrane to find original articles about lung cancer and CPFE published prior to September 2015. All titles/abstracts were reviewed by two radiologists to identify articles that used predefined selection criteria. Summary estimates were generated using a random-effect model and odds ratios (ORs) to develop squamous cell carcinoma (SqCC) were calculated. Kaplan–Meier survival curves were obtained for the survival of patients with CPFE and non-CPFE. Results Nine original articles that assessed 620 patients were included in this review. In the pooled data, patients were older age (70.4 years), almost all were heavy smokers (53.5 pack years), and males were predominant (92.6%). SqCC was the most common type (42.3%), followed by adenocarcinoma (34.4%). Compared with lung cancer population with an otherwise normal lung, the OR to develop SqCC in CPFE was 9.06 (95% CI, 6.08–13.5). The ORs in CPFE compared with lung cancers that developed in lungs with fibrosis or emphysema were also higher. The median survival for CPFE patients with lung cancer (19.5 months) was significantly shorter than in non-CPFE (53.1 months). Conclusions Lung cancer in CPFE, most commonly SqCC, presents in elderly heavy smokers with a male predominance. The median survival for CPFE patients with lung cancer is 19.5 months.
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Affiliation(s)
- Hyun Jung Koo
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Kyung-Hyun Do
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
- * E-mail:
| | - Jung Bok Lee
- Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | | | - Sang Min Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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16
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Bahig H, Filion E, Vu T, Chalaoui J, Lambert L, Roberge D, Gagnon M, Fortin B, Béliveau-Nadeau D, Mathieu D, Campeau MP. Severe radiation pneumonitis after lung stereotactic ablative radiation therapy in patients with interstitial lung disease. Pract Radiat Oncol 2016; 6:367-374. [DOI: 10.1016/j.prro.2016.01.009] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Revised: 01/18/2016] [Accepted: 01/21/2016] [Indexed: 12/16/2022]
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17
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Ciccarese F, Attinà D, Zompatori M. Combined pulmonary fibrosis and emphysema (CPFE): what radiologist should know. Radiol Med 2016; 121:564-72. [PMID: 26892068 DOI: 10.1007/s11547-016-0627-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 01/27/2016] [Indexed: 12/11/2022]
Abstract
Combined pulmonary fibrosis and emphysema is a relatively newly defined entity, which has been deeply studied in the recent years. Despite the wide numbers of papers on this topic, there are still several open questions about pathogenesis, epidemiology, natural history and prognosis. The diagnosis could be assessed only after HRCT scan as functional tests often result in an underestimation of this syndrome. What radiologists need to know about this syndrome consists in the heterogeneity of appearances: emphysema is mainly paraseptal and fibrotic pattern could be variable, including the variant of airspace enlargement with fibrosis which needs to be differentiated from honeycombing. A special attention must be paid on complications which could worsen the prognosis, such as pulmonary hypertension and lung cancer. Further studies are needed to address if the type of fibrotic pattern as well as fibrosis CT index could be considered as prognostic factors. Thus, the role of radiologists in the management of these patients is crucial as it involves diagnosis, detection of complications and could possible concerns the identification of patients at higher risk.
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Affiliation(s)
- Federica Ciccarese
- Radiology Unit, Cardio-Thoracic-Vascular Department, S.Orsola Malpighi University Hospital, Via Massarenti 9, 40100, Bologna, Italy.
| | - Domenico Attinà
- Radiology Unit, Cardio-Thoracic-Vascular Department, S.Orsola Malpighi University Hospital, Via Massarenti 9, 40100, Bologna, Italy
| | - Maurizio Zompatori
- Radiology Unit, Cardio-Thoracic-Vascular Department, S.Orsola Malpighi University Hospital, Via Massarenti 9, 40100, Bologna, Italy
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Pappas RS, Halstead MM, Watson CH. Electron Microscopic Analysis of Silicate and Calcium Particles in Cigarette Smoke Tar. INTERNATIONAL JOURNAL OF RESPIRATORY AND PULMONARY MEDICINE 2016; 3:3:039. [PMID: 27158665 PMCID: PMC4858188 DOI: 10.23937/2378-3516/1410039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Scanning electron microscopy with energy dispersive x-ray spectroscopy (SEM-EDS) supplies information that is complementary to those data traditionally obtained using inductively coupled plasma-mass spectrometry for analysis of inorganic tobacco and tobacco smoke constituents. The SEM-EDS approach was used to identify select inorganic constituents of mainstream cigarette smoke "tar." The nature of SEM-EDS instrumentation makes it an ideal choice for microstructural analyses as it provides information relevant to inorganic constituents that could result from exposure to combusted tobacco products. Our analyses show that aluminum silicates, silica, and calcium compounds were common constituents of cigarette mainstream smoke "tar." Identifying inorganic tobacco smoke constituents is important because inhalation of fine inorganic particles could lead to inflammatory responses in the lung and systemic inflammatory responses. As cigarette smoking causes chronic inflammation in the respiratory tract, information on inorganic particulate in mainstream smoke informs efforts to determine causative agents associated with increased morbidity and mortality from tobacco use.
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Affiliation(s)
- R Steven Pappas
- Centers for Disease Control and Prevention, Atlanta, GA, USA
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19
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Sanchez MEV, Steiner R. Images in COPD: Combined Pulmonary Fibrosis and Emphysema. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2015; 2:367-369. [PMID: 28848856 DOI: 10.15326/jcopdf.2.4.2015.0162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Maria Elena Vega Sanchez
- Department of Thoracic Medicine and Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Robert Steiner
- Department of Radiology, Temple University School of Medicine, Philadelphia, Pennsylvania
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20
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The evolving role of MDCT in the assessment of patients with chronic obstructive pulmonary disease. Clin Radiol 2015; 70:752-9. [PMID: 25861874 DOI: 10.1016/j.crad.2015.02.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 01/05/2015] [Accepted: 02/20/2015] [Indexed: 12/21/2022]
Abstract
The purpose of this article is to educate the reader in the value a radiologist can offer in the multidetector (MD) CT assessment of patients with chronic obstructive pulmonary disease (COPD). MDCT can identify patients in whom treatments such as lung volume reduction surgery or newer endobronchial therapies may be of benefit. We will also discuss important and under-recognised associated cardiorespiratory disease, which may be incidentally identified.
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21
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Prevalence and progression of combined pulmonary fibrosis and emphysema in asymptomatic smokers: A case-control study. Eur Radiol 2015; 25:2326-34. [DOI: 10.1007/s00330-015-3617-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 01/05/2015] [Accepted: 01/20/2015] [Indexed: 01/06/2023]
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22
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Ahmadi A, Ohira H, Mielniczuk LM. FDG PET Imaging for Identifying Pulmonary Hypertension and Right Heart Failure. Curr Cardiol Rep 2014; 17:555. [DOI: 10.1007/s11886-014-0555-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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23
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Lung Cancer in Combined Pulmonary Fibrosis and Emphysema: A Series of 47 Western Patients. J Thorac Oncol 2014; 9:1162-70. [DOI: 10.1097/jto.0000000000000209] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Flaherty KR, Fell C, Aubry MC, Brown K, Colby T, Costabel U, Franks TJ, Gross BH, Hansell DM, Kazerooni E, Kim DS, King TE, Kitachi M, Lynch D, Myers J, Nagai S, Nicholson AG, Poletti V, Raghu G, Selman M, Toews G, Travis W, Wells AU, Vassallo R, Martinez FJ. Smoking-related idiopathic interstitial pneumonia. Eur Respir J 2014; 44:594-602. [PMID: 25063244 DOI: 10.1183/09031936.00166813] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cigarette smoking is a key factor in the development of numerous pulmonary diseases. An international group of clinicians, radiologists and pathologists evaluated patients with previously identified idiopathic interstitial pneumonia (IIP) to determine unique features of cigarette smoking. Phase 1 (derivation group) identified smoking-related features in patients with a history of smoking (n=41). Phase 2 (validation group) determined if these features correctly predicted the smoking status of IIP patients (n=100) to participants blinded to smoking history. Finally, the investigators sought to determine if a new smoking-related interstitial lung disease phenotype could be defined. Phase 1 suggested that preserved forced vital capacity with disproportionately reduced diffusing capacity of the lung for carbon monoxide, and various radiographic and histopathological findings were smoking-related features. In phase 2, the kappa coefficient among clinicians was 0.16 (95% CI 0.11-0.21), among the pathologists 0.36 (95% CI 0.32-0.40) and among the radiologists 0.43 (95% CI 0.35-0.52) for smoking-related features. Eight of the 100 cases were felt to represent a potential smoking-related interstitial lung disease. Smoking-related features of interstitial lung disease were identified in a minority of smokers and were not specific for smoking. This study is limited by its retrospective design, the potential for recall bias in smoking history and lack of information on second-hand smoke exposure. Further research is needed to understand the relationship between smoking and interstitial lung disease.
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Affiliation(s)
- Kevin R Flaherty
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA Both authors contributed equally
| | - Charlene Fell
- Division of Respiratory Medicine, University of Calgary, Calgary, AB, Canada Both authors contributed equally
| | | | - Kevin Brown
- Division of Pulmonary Medicine, National Jewish Medical and Research Center, Denver, CO, USA
| | - Thomas Colby
- Dept of Pathology, Mayo Clinic, Scottsdale, AZ, USA
| | - Ulrich Costabel
- Dept of Pneumology/Allergy, Ruhrlandklinik, University Hospital, Essen, Germany
| | - Teri J Franks
- Dept of Pulmonary and Mediastinal Pathology, The Joint Pathology Center, Silver Spring, MD, USA
| | - Barry H Gross
- Dept of Radiology, University of Michigan, Ann Arbor, MI, USA
| | | | - Ella Kazerooni
- Dept of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Dong Soon Kim
- Dept of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Talmadge E King
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, CA, USA
| | | | - David Lynch
- Dept of Radiology, National Jewish Medical and Research Center, Denver, CO, USA
| | - Jeff Myers
- Dept of Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Sonoko Nagai
- Respiratory Medicine, Kyoto University, Kyoto, Japan
| | | | - Venerino Poletti
- Dipartimento di Malattie del Torace, Universita di Parma, Forli, Italy
| | - Ganesh Raghu
- Division of Pulmonary Medicine, University of Washington, Seattle, WA, USA
| | - Moises Selman
- Instituto Nacional de Enfermedades Respiratorias, Mexico DF, Mexico
| | - Galen Toews
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
| | - William Travis
- Dept of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Athol U Wells
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK
| | - Robert Vassallo
- Division of Pulmonary, Allergy and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Fernando J Martinez
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA Dept of Medicine, Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical Center, New York, NY, USA
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Idiopathic pulmonary fibrosis as a prognostic factor in non-small cell lung cancer. Int J Clin Oncol 2013; 19:266-73. [DOI: 10.1007/s10147-013-0566-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 04/24/2013] [Indexed: 10/26/2022]
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