Soluble CD163 is produced by monocyte-derived and alveolar macrophages, and is not associated with the severity of idiopathic pulmonary fibrosis

The soluble form of the membrane hemoglobin scavenger receptor CD163 (sCD163), released by shedding, is a strong marker for macrophage activation. Serum sCD163 levels rise in several acute inflammatory states and some fibrosing diseases. Monocyte-derived macrophages (MoDM) differentiated by macrophage colony-stimulating factor (M-MoDM) contribute to the pathophysiology of idiopathic pulmonary fibrosis (IPF), an irreversible and rapidly fatal interstitial lung disease. Since M-MoDM express high membrane CD163 levels, we thus postulated that sCD163 could be a relevant biomarker for macrophage activation in IPF. We found that M-MoDM constitutively released higher amounts of sCD163 (49.5 ± 24.5 ng/ml) than monocytes (0.45 ± 0.32 ng/ml) or MoDM differentiated with granulocyte macrophage-stimulating factor (2.24 ± 0.98 ng/ml). The basal production of sCD163 by M-MoDM was increased following stimulation with lipopolysaccharide (123.4 ± 54.9 ng/ml) or ATP (168.9 ± 41.8 ng/ml). The sCD163 release was controlled by metalloproteases but not through ADAM17 activation. Moreover, CD163-positive macrophages and sCD163 were detected in pulmonary tissues and alveolar fluids of Caucasian patients with IPF, respectively. IPF alveolar macrophages constitutively secreted sCD163 amounts (67.6 ± 44.6 ng/µg RNA) which were significantly higher than those released by alveolar macrophages isolated from controls (19.2 ± 7.6 ng/µg RNA) or patients with other interstitial lung disease (31.5 ± 16.6 ng/µg RNA). However, the concentrations of sCD163 in blood serum collected from 155 patients with IPF did not correlate with the severity of their disease. In conclusion, our results show that M-MoDM constituted a pertinent model to study the regulation of sCD163 production. Yet, serum sCD163 values could not provide a prognostic biomarker for IPF in our cohort.

Intrapleural use of urokinase and DNase in pleural infections managed with repeated thoracentesis: A comparative cohort study

Introduction

Evacuation of infected fluid in pleural infections is essential. To date, the use of an intrapleural fibrinolytic agent such as urokinase and DNase has not yet been assessed in infections managed by repeated therapeutic thoracentesis (RTT).

Methods

We performed a retrospective comparative study of two successive cohorts of consecutive patients with pleural infections from 2001 to 2018. Between 2001 and 2010, patients had RTT with intrapleural urokinase (RTT-U). After 2011, patients received intrapleural urokinase and DNase with RTT (RTT-UD). Data were collected through a standardized questionnaire.

Results

One hundred and thirty-three patients were included: 93 were men and the mean age was 59 years (standard deviation 17.2). Eighty-one patients were treated with a combination of intrapleural urokinase and DNase, and 52 were treated with intrapleural urokinase only. In the RTT-UD, RTT failure occurred in 14 patients (17%) compared to 10 (19%) in the RTT-U group (P = 0.82). There was no difference between the two groups in intensive care unit admission, surgical referrals or in-hospital mortality. RTT-UD was associated with faster time to apyrexia (aOR = 0.51, 95%CI [0.37–0.72]), a reduced length of hospital stay (aOR = 0.61, 95%CI [0.52–0.73]) and a higher volume of total pleural fluid retrieved (aOR = 1.38, 95%CI [1.02–1.88]). Complications were rare with only one hemothorax in the RTT-UD group and no pneumothorax requiring drainage in either group.

Conclusion

Compared to urokinase only, intrapleural use of urokinase and DNase in RTT was associated with quicker defervescence, shorter hospital stay and increased volumes of pleural fluid drained. Randomized controlled trials evaluating urokinase and DNase with RTT technique would be required to confirm these results.

TNF-α and IL-10 Control CXCL13 Expression in Human Macrophages

The chemokine CXCL13 controls the normal organization of secondary lymphoid tissues and the neogenesis of ectopic lymphoid structures in nonlymphoid organs, particularly the lungs. The progression and severity of idiopathic pulmonary fibrosis (IPF), a fatal and irreversible interstitial lung disease, is predicted by the circulating blood concentrations of CXCL13. Although CXCL13 is produced by pulmonary tissues, it has not been determined which cells are involved. This study examines CXCL13 production by lung tissue macrophages from patients with IPF and the signaling pathways controlling CXCL13 gene expression in human alveolar macrophages (AM) and monocyte-derived macrophages (MoDM). CXCL13 is found in CD68- and CD206-positive AM from patients with IPF, and the CXCL13 gene is induced in these macrophages and MoDM when they are stimulated with LPS. We found that TNF-α and IL-10 control optimal CXCL13 gene expression in MoDM and possibly in AM by activating the NF-κB and JAK/STAT pathways, respectively. We also found that blood TNF-α and CXCL13 concentrations are significantly correlated in patients with IPF, suggesting that TNF-α contributes to CXCL13 production in humans. In conclusion, the results of this study demonstrate that AM from patients with IPF produces CXCL13 and that the NF-κB and JAK/STAT pathways are required to induce the expression of this major chemokine.

Optimized radiotherapy to improve clinical outcomes for locally advanced lung cancer

Background

We aimed to evaluate the toxicity, loco-regional control (LRC) and overall survival (OS) associated with accelerated intensity-modulated radiotherapy (IMRT) for locally advanced lung cancer.

Methods

Seventy-three patients were consecutively treated with IMRT from November 2011 to August 2016. A total dose of 66 Gy was delivered using two different schedules of radiotherapy: simultaneous modulated accelerated radiotherapy (SMART) (30 × 2.2 Gy, across 6 weeks) with or without chemotherapy, or moderate hypofractionated radiotherapy (HRT) (24 × 2.75 Gy, across 4 weeks) in patients unfit to receive concomitant chemotherapy. Data on esophageal and pulmonary toxicities, LRC and OS were prospectively collected.

Results

The median follow-up duration was 44 months. Severe pneumonitis and esophagitis (grade 3–4) were observed in 7% and 1% of patients respectively, with only one case of grade 4 (pneumonitis). Overall, the 1-year and 2-year LRCs were 76% [95 confidence interval (CI)%: 66–87%] and 62% [95 CI%: 49–77%] respectively. The 1 and 2-year OS rates were 72% [95% CI: 63–83%] and 54% [95 CI%: 43–68%] respectively. None parameters were correlated with LRC or OS. In particular, no difference was observed between patients treated with SMART and H-RT (p = 0.26 and 0.6 respectively), with a 1-year LRC of 74% [95 CI%: 62–86%] for SMART and 91% [95 CI%: 74–100%] for H-RT. No significant differences were observed in the toxicity rates associated with each of the RT schedules.

Conclusions

Accelerated IMRT for locally advanced lung cancer is associated with low toxicities and high LRC. Moderate hypofractionated RT, by decreasing the total treatment time, may be promising in improving clinical outcomes.

Combined thoracic and hepatobiliary surgery for iatrogenic bronchobiliary fistula

Bronchobiliary fistula is a rare pathology mainly caused by hepatic tumors, bile duct obstruction, or hepatic hydatid disease. A 70-year-old man developed a bronchobiliary fistula after biliary stenting. After failure of conservative treatment including endoscopic retrograde biliary drainage, he underwent a combined operation with a two-level approach. Both a thoracotomy and laparotomy were performed, allowing pulmonary resection, diaphragmatic repair, and bile duct reconstruction during the same operation. Postoperative follow-up at one year showed optimal healing of the fistula.

Traumatic false aneurysms of the left ventricle after an attempt at video-thoracoscopic surgery

OBJECTIVES Video-thoracoscopic surgery (VTS) has been accepted as a safe and credible technique since 1990. Lung injury is one of the main perioperative complications. Few data are available about cardiac trauma and VTS-related false aneurysm of the left ventricular (LV) wall has not yet been reported. METHODS A 62-year old woman presented with a left thoracic empyema. Video-thoracoscopy was attempted for bacterial sampling and surgical drain of the pleura. A rapid conversion to open thoracotomy was necessary to control massive bleeding after the first thoracic port intrusion. An apical systolic murmur was found 2 weeks later during a systematic clinical examination. The patient was asymptomatic and had no personal history of cardiac disease. RESULTS Colour Doppler imaging showed two spurious aneurysms on the LV wall without any haemopericardium. Pericardial enhancement around the left ventricle was observed on the chest computerized tomography scan with the injection of contrast. After the careful excision of the two false aneurysms, a surgical repair was strengthened with a suture under a cardiopulmonary bypass. The postoperative course was uneventful and the patient was safe at 3 years. CONCLUSIONS This is the first report of LV traumatic false aneurysms secondary to an attempt of a video-thoracoscopic procedure. This is a rare but life-threatening complication because of the risk of spontaneous rupture. Left persistent thoracic empyemas associated with the ipsilateral mediastinum deviation carry a high risk of myocardial damage related to the trocar port intrusion.

Mid-Term Results of Endovascular Treatment for Descending Thoracic Aorta Diseases in High-Surgical Risk Patients

We report the initial experience of two cardiovascular surgery centers in the treatment of descending thoracic aorta lesions with covered stent grafts in high-surgical risk patients. From April 1999 to November 2004, 54 patients, mean age 64 years (range 16-83), were treated by stent graft for a lesion of the descending aorta (degenerative aneurysms n = 22, aortic dissections n = 12, chronic post traumatic aneurysms n = 5, anastomotic false aneurysms n = 2, penetrating ulcers n = 4, intramural hematomas n = 5, traumatic rupture n = 4), with 42.6% treated on an emergency basis. Three devices were used: Talent (n = 49), Excluder (n = 4), and Zenith (n = 1). In three patients, combined surgery of the proximal aorta was performed. Prior bypass of the left supra-aortic arteries was performed in four patients. The follow-up was clinical and radiological (plain chest film and computed tomographic scan) at 1, 3, 6, 12, 18, and 24 months and yearly thereafter. The stent graft was successfully deployed in all cases. Two early deaths related to the stent graft (one migration and aortic rupture and one stroke) and one related to adult respiratory distress syndrome occurred. Morbidity was 16.6% (iliac access damage n = 4, groin reintervention n = 3, transient ischemic attack n = 1, tamponade n = 1). The follow-up was 100% complete (mean 22.8 months, range 3-51). Fifteen primary endoleaks (type I n = 6, type II n = 8, type III n = 1) and one secondary endoleak were reported. They were treated by additional stent graft (n = 7) and elective surgical conversion (n = 1). Six endoleaks resolved spontaneously at 6 months, and two are being monitored. Twelve endoleaks (75%) occurred in patients treated for degenerative aneurysms. Freedom from secondary reintervention was 81.3% at 3 years. Two transient paraparesias were observed at 3 and 18 months. Of the 13 deaths observed during the follow-up, only one was related to the stent graft. Actuarial survival at 12 and 24 months was 90.0% and 75.4%, respectively. Mortality results are encouraging in this specific cohort of high-surgical risk patients. A new kind of morbidity is observed, related to endoleaks, whose necessary management could hinder the durability of the technique.

Surgery of the abdominal aorta and its branches in children: Late follow-up

BACKGROUND

The aim of this study was to evaluate the late results in adult patients who underwent surgery of the abdominal aorta as children.

METHODS

During a 17-year period, eight children underwent surgery for lesions of the abdominal aorta. There were 6 boys and 2 girls, with an average age of 10 years. The presenting symptom that led to diagnosis of abdominal aortic lesions was hypertension in five cases and lower-limb claudication in three. The underlying disease was middle aortic syndrome in three cases, infrarenal aortic hypoplasia in two, infrarenal aortic aneurysm in two, and Takayasu's disease in one. Five children had associated renal artery lesions, including four with bilateral lesions and one with a unilateral lesion. Aortic bypass was used in all cases. A straight tube graft was placed between the distal descending thoracic or supraceliac aorta and the infrarenal aorta in six cases, and a bifurcated bypass was placed between the infrarenal aorta and the iliac arteries in two. Renal artery revascularization procedures (n = 9) included ex vivo repair with renal autotransplantation in five cases, direct reimplantation on the arch of Riolan in two, and direct reimplantation of the renal artery onto the aortic graft in two.

RESULTS

One patient died on postoperative day 1. The remaining seven patients recovered uneventfully. Mean follow-up was 10.2 years. No patient was lost to follow-up. Further surgical intervention was required in three patients. The indications for additional surgery were fibrosis of a renal artery reimplanted onto the graft at 3 years, deterioration of the aortoaortic graft at 5 years, and false iliac aneurysm at 20 years. All seven patients had normal physical development. The average increase in height and weight were 28.5 cm and 26.2 kg, respectively. All patients had normal sexual function, and two are parents. All patients are currently asymptomatic. Short Form 36 scores for quality-of-life parameters were 78% to 83%.

CONCLUSIONS

Late results of abdominal aortic surgery in children, in our experience, are encouraging. Quality of life in adulthood was excellent. Insofar as possible, correction should be deferred until the child is 8 to 10 years old so that a prosthesis of sufficient diameter can be used.