[Transbronchial lung cryobiopsy in interstitial lung diseases]

In some cases of interstitial lung disease (ILD), clinical and biological findings associated with CT scan pattern during multidisciplinary discussion (MDD) fail to yield a confident diagnosis. In these cases, histology may be necessary. Transbronchial lung cryobiopsy (TBLC) is a bronchoscopic procedure that has been developed in recent years and currently contributes to diagnostic work-up in patients with ILD. TBLC provides tissue samples for histological analysis with an acceptable risk of complications, consisting mainly in pneumothorax or bleeding. In addition to higher diagnostic yield than conventional forceps biopsies, the procedure shows a better safety profile than surgical biopsies. The indication to perform TBLC is decided during a 1st MDD and during a 2nd MDD, results can provide a diagnostic yield approximating 80%. TBLC appears to be an attractive, minimally invasive technique to be proposed as a first-line procedure in selected patients in experienced centers, while surgical lung biopsy may be considered as a second-line solution.

Percutaneous CT-guided lung biopsy for the diagnosis of persistent pulmonary consolidation

PURPOSE

The primary objective of this study was to determine the diagnostic accuracy of percutaneous computed tomography (CT)-guided biopsy of persistent pulmonary consolidations. The secondary objective was to determine the complication rate and identify factors affecting diagnostic yield.

MATERIALS AND METHODS

Two radiologists retrospectively reviewed 98 percutaneous CT-guided biopsies performed in 93 patients (60 men, 33 women; mean age, 62±14.0 (SD) years; range: 18-88 years) with persistent pulmonary consolidations. Final diagnoses were based on surgical outcomes or 12 months clinical follow-up findings. Biopsy results were compared to the final diagnosis to estimate diagnostic yield.

RESULTS

A final diagnosis was obtained for all patients: 51/93 (54.8%) had malignant lesions, 12/93 (12.9%) specific definite benign lesions (including 9 infections, two pneumoconiosis and one lipoid pneumonia) and 30/93 (32.3%) non-specific benign lesions. CT-guided biopsy had an overall diagnostic yield of 60% (59/98) with a correct diagnosis for 50/51 malignant lesions (diagnostic yield of 98% for malignancy) and for 9/47 benign lesions (diagnostic yield of 19% for benign conditions). Major complications occurred in 4/98 (4%) of lung biopsies (four pneumothoraxes requiring chest tube placement).

CONCLUSION

Percutaneous CT-guided biopsy is an alternative to endoscopic or surgical biopsy for the diagnosis of persistent consolidation with a low risk of severe complication.

Phase II trial of extrapleural pneumonectomy followed by adjuvant radiotherapy in malignant pleural mesothelioma

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Background: This phase II clinical study was conducted to evaluate the effectiveness of the association of extrapleural pneumonectomy followed by radiation therapy in patients with potentially resectable malignant pleural mesothelioma (MPM). Methods: Eligible patients had histologically proven epithelial or mixed MPM with clinical stage T1–3, N0–2, M0 disease considered to be completely resectable and a WHO performance status of 0 or 1. Surgery had to consist of a complete extrapleural pneumonectomy including resection of pericardium and diaphragm. Postoperative radiotherapy (40 Gy) was delivered through anterior and posterior fields, with a 10 to 20 Gy boost dose if necessary. Results: Thirty seven patients were included in this study. Extrapleural pneumonectomy was completed in 35 patients. Overall hospital mortality was 5,7 %. Major post operative complications were: 3 acute lung injury, 1 bronchopleural fistula, 1 stroke, 1 chylothorax and one diaphragmatic patch dehiscence. IMIG post-operative staging was: stage II = 5 patients; stage III = 25 patients; stage IV = 5 patients. Adjuvant radiation was administered to 29 patients. Survival for the 35 patients with complete resection was 47 ± 8 % at 2 years. Median overall survival time was 22 months. Survival without recurrence was 37 ± 8 % at 2 years. Median time to progression was 15 months. Locoregional recurrence is the most common form of relapse. Conclusions: In the era of surgical neoadjuvant therapy in MPM treatment, extrapleural pneumonectomy followed by radiation therapy in patients with resectable epithelial or mixed MPM can achieve acceptable results.

No significant financial relationships to disclose.

[Anti-inflammatory effects of macrolides: applications in lung disease]

Besides their antibiotic effect, C14 and C15 macrolides exhibit immunomodulatory properties which can have therapeutic applications for chronic inflammation of the airways. In vitro studies have demonstrated the anti-inflammatory effects of macrolides: decreased productions of IL-6, IL-8, TNF alpha, chemotactism of polymorphonuclear neutrophils. Cell activity is modified with reduced production of elastase and oxidizing agents. These immunomodulator effects appear to result from an interaction with transcription factors which regulate the expression of cell gens. In addition, they lead to a modified bronchial mucosal secretion and have an action on the biofilm and the pseudomonas pilis. Their clinical activity has been demonstrated in panbronchiolitis and is in favor of use in cystic fibrosis. Use of macrolides should be carefully monitored in the event of bronchectasia, COPD, asthma, or chronic rhinosinusitis.

[Recent progress in treatment of malignant pleural mesothelioma]

Incidence of malignant pleural mesothelioma will rise until 2030-2040 because the elapsed time between exposure and diagnostic is up to several decades. Prognosis remains very poor with median survival less than one year and five-year survival not exceeding 5%. As compared to 1999, standart treatment adds chemotherapy with cisplatin and pemetrexed to local radiotherapy for prevention of local seeding after invasive diagnostic procedures. Despite various growth factors and their receptors are involved in malignant mesothelioma, first clinical trials of targeted therapies reported poor results. Multimodality therapy with extrapleural pneumonectomy and radiation therapy (+/-chemotherapy) can be of benefit in subgroups of patients but it cannot be recommended in a routine approach. As compared to bronchial carcinoma, inclusion of patients in clinical trials (using intensity-modulated radiation therapy) is the only way to somewhat improve results.

Aspergilloses respiratoires complexes : difficultés diagnostiques et thérapeutiques

INTRODUCTION

Respiratory aspergillosis with different physiopathologic mechanisms can be associated in one patient in rare occasions.

CASE REPORT

We review three cases associating an allergic bronchopulmonary aspergillosis (ABPA) and an other form of aspergillosis: aspergilloma, chronic necrotizing pulmonary aspergillosis and we present a review of literature.

CONCLUSION

Such associations result in diagnostic and therapeutic difficulties. Corticosteroid treatment used for ABPA can increase the risk of severe infections. Such cases are a good indication of systemic antifungal therapy.

Mésothéliome malin pleural : radiothérapie préventive des nodules de perméation

INTRODUCTION

Radiotherapy for the prevention of skin nodules appearing at the sites of aspiration, needle biopsies, chest drains or surgical incisions is the only treatment currently recommended for malignant mesothelioma.

METHODS

59 patients suffering from this condition were identified from the database of the Nantes Regional Cancer Centre. 33 received prophylactic irradiation, 25 did not and 1 was excluded.

RESULTS

The treated group showed typical demographic and histological features. The delay in initiating radiotherapy ranged from 10 to 123 days and several different treatment regimes were used. In the treated group 7 out of 32 patients developed nodules following radiotherapy with 4 recurrences in the treated and 3 in the untreated areas. The mean interval before recurrence was 9 months (range 3 to 17 months). The recurrence rate was lower in the treated (21%) than in the untreated group (48%;12 out of 25).

CONCLUSIONS

The poor results compared with the reference series may be explained by a longer follow-up (mean 12 months), less thorough treatment of all puncture sites and a very long delay before treatment (mean 37 days).

[Unusual bronchial tumor...]

We report a case of atelectasis of the upper right lobe which did not respond to antibiotics. A third bronchial endoscopy with bronchoalveolar lavage was required to make the diagnosis of endobronchial nocardiasis. Search for extension revealed a brain localization. Search for immune deficiency only revealed calcification of the bronchial mucosa in the area of the nocardiasis.

[Acute eosinophilic pneumopathy induced by minocycline]

A 22-year-old patient was hospitalized for severe acute eosinophil pneumonia imputable to treatment with minocyclin chlorhydrate (Mynocine). Clinical manifestations began one week after onset of drug intake. The clinical picture included fever at 38 degrees C, polypnoea at 44/min, pulmonary crepitation and severe hypoxia at 4.5 kPa. Eosinophil blood counts were high (3.02 x 10(9)/l) Standard chest X-ray led to the diagnosis of eosinophil pneumonia. Approximately 50% of the polynuclears were eosinophils. The clinical course was rapidly favourable after withdrawal of minocyclin and administration of corticosteroids. This case was analysed and compared with other reports of minocylin induced pneumonia.