[Drug-induced pneumonitis due to sirolimus: an interaction with atorvastatin?]

INTRODUCTION

Sirolimus is an immunosupressant used in renal transplantation because of its lack of nephrotoxicity. We report four cases of pneumonitis due to sirolimus, possibly revealing an interaction with atorvastatin.

CASE REPORT

Four patients (previously on long-term treatment with atorvastatin) presented with respiratory symptoms between 3 and 56 months after starting treatment with sirolimus following renal transplantation. Thoracic CT scans showed bilateral areas of peripheral alveolar consolidation. Bronchial lavage showed a lymphocytic alveolitis. Open-lung biopsy showed organizing pneumonia associated with diffuse alveolar damage and caseating granulomata. We attributed the pneumonitis to sirolimus on account of clinical and radiological resolution within 1 to 6 months of stopping treatment. We raise the possibility of an association between sirolimus and atorvastatin by competition for their hepatic degradation pathway via cytochrome P450 3A4.

CONCLUSION

Sirolimus causes drug-induced pneumonitis that is predominantly an organizing pneumonia. Atorvastatin may encourage its development by competition with sirolimus in the liver.

[Efficacy of rituximab in lymphomatoid granulomatosis]

INTRODUCTION

Lymphomatoid Granulomatosis is a rare and serious disease, now considered to be a B-cell lymphoma, which is frequently associated with Epstein-Barr virus infection. There is no consensus on treatment, which is usually based on steroid therapy, either alone or combined with cyclophosphamide and combination chemotherapy.

CASE REPORT

We report the case of an asymptomatic patient diagnosed after the incidental discovery of bilateral nodular opacities on their chest x-ray. Physical examination and bronchoscopy were normal. The diagnosis of Lymphomatoid Granulomatosis was made on the basis of surgical lung biopsy. Immunohistochemical studies confirmed the B phenotype of the lymphoma with the identification of atypical large CD 20 positive cells. In situ hybridisation confirmed the presence of EBV. In this case the course of the disease was slow. Treatment with anti CD 20 monoclonal antibodies (rituximab) led initially to a reduction in parenchymal abnormalities and mediastinal adenopathy.

CONCLUSION

This treatment, recently used in Lymphomatoid Granulomatosis with pulmonary involvement, has shown promising results. Rituximab can be used in combination chemotherapy as standard treatment for aggressive B-cell lymphoma.

Lung cancer among women in France

As the incidence of primary lung cancer in women seems to be increasing in parallel with that of smoking, we conducted an exhaustive epidemiological study in 137 hospitals in 2000. We identified 904 women with proven primary lung cancer (mean age 63.9 years), many of whom have never smoked (32.3%), particularly in cases of adenocarcinoma (43.4%). Small cell cancer accounted for 16.1% of cases. Adenocarcinomas were the most frequent (45.3%) of the non-small cell lung cancer (NSCLC), followed by squamous cell (23.4%), large cell (11.6%) and bronchoalveolar (1.9%) carcinomas. About one third (32.2%) of NSCLC were stage III and 48.1% were stage IV. Over half of all adenocarcinomas were stage IV. According to multivariate analysis, adenocarcinoma is related to less smoking and younger age. In conclusion, many women affected by lung cancer have never smoked. Adenocarcinoma appears to be the most frequent form and more often at a metastatic stage.

[Pneumopathies caused by inhalation of hydrocarbons: apropos of 3 cases]

We report three personal cases of hydrocarbide aspiration pneumonia. High-viscosity non-volatile hydrocarbides (paraffin oil, for instance) cause often pseudotumoral exogenous fat-aspiration lung disease. Low-viscosity volatile hydrocarbides (petroleum, gasoline, white spirit, for instance) cause acute pseudo-infectious lung disease with dyspnea and fever which usually resolves within a few weeks but which may also be life-threatening. Purely symptomatic treatment has greatly progressed with advances in intensive ventilatory assistance. Gastric emptying with emetic agents or lavage procedures is dangerous and must be avoided except for exceptional cases. When required, the airways must be protected with tracheal intubation. Volatile hydrocarbides should be stored in protected areas in containers with safety stoppers which children cannot open.

The addition of cisplatin to cyclophosphamide-doxorubicin-etoposide combination chemotherapy in the treatment of patients with small cell lung carcinoma: A randomized study of 457 patients. "Petites Cellules" Group

BACKGROUND

To assess whether the addition of cisplatin (100 mg/m(2) administered intravenously on Day 1) to CDE (cyclophosphamide [1000 mg/m(2) on Day 1], doxorubicin [45 mg/m(2) on Day 1], and etoposide [150 mg/m(2) on Days 1 and 2] combination is useful in the treatment of patients with small cell lung carcinoma (SCLC).

METHODS

In a multicenter clinical trial, 457 patients were randomized from May 1988 to March 1993 to receive either CDE (n = 228) or cisplatin-CDE (PCDE, n = 229) chemotherapy every 4 weeks for 6 cycles. As patients with limited SCLC were included in a concomitant trial assessing thoracic radiotherapy, the current study mainly included patients with extensive stage (79%) or limited stage disease and a contraindication for thoracic radiotherapy.

RESULTS

The objective response rate was higher in the cisplatin-CDE group (72%) than in the CDE group (53%) (P = 0.0001). The median overall survival was similar for the groups that received CDE (266 days) and PCDE (271 days) (P = 0.93, log rank test). A higher fatal neutropenia rate was observed in the PCDE group (n = 23) than in the CDE group (n = 4) (P < 0.001, log rank test), mainly for patients with extensive disease (n = 26; P = 0.015, log rank test).

CONCLUSIONS

The addition of cisplatin to a CDE regimen is toxic to patients with extensive SCLC and does not improve overall survival. The PCDE combination must be avoided for patients with extensive SCLC; CDE or cisplatin-etoposide combinations remain standard chemotherapy for these patients. The PCDE combination associated with granulocyte-colony stimulating factors could only be assessed in patients with good prognoses.

A randomized clinical trial comparing concurrent and alternating thoracic irradiation for patients with limited small cell lung carcinoma. "Petites Cellules" Group

BACKGROUND

Although thoracic radiotherapy is considered to be useful for the treatment of patients with small cell lung carcinoma (SCLC), its optimal administration schedule is still controversial.

METHODS

In a multicenter clinical trial, 164 patients with limited SCLC (of whom 156 were eligible for the study) were randomized to receive either concurrent thoracic irradiation, initiated immediately after the second cycle of chemotherapy (Days 30-64) at a dose of 50 grays in 20 fractions, or alternating thoracic irradiation, scheduled in 3 courses between the second, third, fourth, and fifth cycles of chemotherapy with a 7-day rest period after and before chemotherapy at a dose of 20 grays in 8 fractions (Days 36-47 and Days 64-75) and then 15 grays in 6 fractions (Days 92-101). The same chemotherapy regimen (cyclophosphamide-doxorubicin or vindesine-etoposide) was administered every 4 weeks in both groups.

RESULTS

Concurrent radiotherapy-induced lung toxicity led to early termination of this trial when a significant difference was observed (6 cases vs. 1, P = 0.05, 2-sided log rank test). Objective response rates were 89% in the 82 patients of the concurrent radiotherapy group and 95% in the 74 patients of the alternating radiotherapy group. Median survival periods were 13.5 and 14.0 months, respectively, with no significant difference between the two survival distributions (P = 0.15, 2-sided log rank test). Toxic deaths due to bone marrow hypoplasia were similar in both groups (3 vs. 2), but mortality due to lung toxicity (pulmonary fibrosis) was more frequent with concurrent radiotherapy (6 patients) than with alternating radiotherapy (1 patient) in long term analysis (P = 0.05, 2-sided log rank test).

CONCLUSIONS

Although no statistically significant overall survival difference was observed between the two radiation therapy schedules, the better tolerance of the alternating schedule justifies the choice of this schedule with this chemotherapy regimen, although it may not be applicable to other chemotherapy regimens.

[Pulmonary malacoplakia caused by Rhodococcus equi in AIDS: a case report]

We describe the observation of a right upper lobe consolidation with cavitation produced by Rhodococcus equi in a patient suffering from AIDS. The inefficacy of a prolonged antimicrobial therapy adapted against R. equi led to a right upper lobectomy. The histopathology showed a pseudotumoral mass, with dense infiltration of macrophages containing Michaelis-Gutmann bodies, which was positive for the culture of R. equi. Pulmonary malacoplakia with Rhodococcus equi was diagnosed. This pathology should be evoked when a R. equi pneumonia persists despite a right management of treatment for several months. The features of pneumonia with Rhodococcus equi and of pulmonary malacoplakia are taken from a literature review.

Fluticasone propionate 50 micrograms BID versus 100 micrograms BID in the treatment of children with persistent asthma. Fluticasone Propionate Study Group

The aim of this multicenter, double-masked study was to compare the efficacy and safety of two different doses of inhaled fluticasone propionate dry powder--50 micrograms and 100 micrograms--administered BID via a multidose powder inhaler with those of placebo in the treatment of children with persistent asthma. After a 2-week run-in period, 263 patients were randomized to treatment with twice-daily placebo (n = 92), fluticasone 50 micrograms (n = 85), or fluticasone 100 micrograms (n = 86) for 12 weeks. One hundred sixty-six (63%) patients were male, and 224 (85%) were white, with a mean age of 8 years. Two hundred twenty-one (84%) patients were atopic, and 167 (63%) had been asthmatic for 1 to 5 years. Baseline mean morning peak expiratory flow (PEF) values were 207 L/min, 199 L/min, and 194 L/min, and baseline percentages of predicted normal values were 86%, 80%, and 81% for the groups receiving placebo, fluticasone 50 micrograms, and fluticasone 100 micrograms, respectively. At the end of the first week of treatment, patients in both fluticasone groups had significantly greater improvements in morning PEF than did those receiving placebo. Patients experienced mean increases of 4 L/min, 22 L/min, and 26 L/min with placebo, fluticasone 50 micrograms, and fluticasone 100 micrograms, respectively. At the end point (the last evaluable visit), patients in both fluticasone groups continued to have significantly greater improvements in morning PEF than did patients receiving placebo. Patients experienced mean increases of 17 L/min, 50 L/min, and 57 L/min with placebo, fluticasone 50 micrograms, and fluticasone 100 micrograms, respectively. Changes in the percentage of predicted values by end point were 8%, 20%, and 26% with placebo, fluticasone 50 micrograms, and fluticasone 100 micrograms, respectively. The probability of remaining in the study, according to predefined withdrawal criteria, indicated a significant treatment difference in favor of fluticasone. Withdrawal criteria were met by 63%, 42%, and 29% of patients receiving placebo, fluticasone 50 micrograms, and fluticasone 100 micrograms, respectively. This study clearly demonstrates the superiority of fluticasone 50 and 100 micrograms BID over placebo in the treatment of persistent asthma in children.

Two cycles of cisplatin-vindesine and radiotherapy for localized nonsmall cell carcinoma of the lung (stage III). Results of a prospective trial with 149 patients

One hundred forty-nine patients with localized nonsmall cell carcinoma of the lung (Stage III A and B) were treated with two monthly cycles of initial chemotherapy that included vindesine-cisplatin followed by 6000 cGy of thoracic irradiation. Patients with complete, partial, and minor response after initial chemotherapy were randomized into groups to receive either maintenance chemotherapy (four cycles) after radiotherapy or radiotherapy alone. The objective response rate was 24% after chemotherapy and 41% after combined chemoradiotherapy (complete response, 7.5%). The overall median survival was 9 months and the 2-year survival was 14%. Survival was identical with or without maintenance chemotherapy. The 2-year survival of patients with complete response was 75% compared with 9% for patients with partial or minor response. These results suggest that only the few patients (ten) who achieve complete response have a strong probability of survival. It is therefore essential to search for other therapeutic modalities that result in an increase of the complete response rate.

[Allergic granulomatosis and angiitis (Churg-Strauss syndrome) or bronchial asthma with periarteritis nodosa (author's transl)]

The coexistence of hypereosinophilic asthma and periarteritis nodosa, though rare, has been recognised for a long time (Wilson and Alexander, 1945). Based on clinical (asthma, hypereosinophilia) and histological (extravascular granulomas) criteria, Churg and Strauss, in 1951, described a single entity which they considered to be distinct from PAN, and which they called allergic and granulomatous angiitis. The authors describe three such cases, compare their findings with those in the published literature, and discuss the classification of Churg and Strauss' syndrome in relation to PAN. Apart from the asthma and hypereosinophilia, symptomatology is comparable with that of PAN, and histological examination demonstrates very similar vascular lesions in both affections. Extravascular granulomas do not appear to be truly specific. It would seem that there is a lack of essential features that could separate PAN from Churg and Strauss' syndrome, the preexistence of an asthmatic state perhaps simply modifying the PAN disorder in certain particular ways.

[Primary bronchogenic and pharyngo-laryngeal carcinomas (author's transl)]

The study of 112 case histories of lung cancers, both primary and secondary, has allowed the authors to determine as being of 5% the incidence of primary bronchogenic carcinoma associated with treated pharyngo-laryngeal cancer. One out of three such primaries was a solitary lung opacity. Bronchogenic primaries appeared be almost as frequent as lung, pleura and mediastine secondarie. They can be diagnosed at any moment of the treatment or follow-up of pharyngo-laryngeal cancer, and appear to occur later than pulmonary metastases. Their symptoms are more "bronchopulmonary" in nature. They are more frequently associated with endolarynx and chorda carcinomas. They are possibly more frequent in cases of smaller primaries without lymph-node involvement. Solitary lung opacities should be considered as independent primaries and constitute the best candidates for efficient pulmonary treatment. Treated pharyngo-laryngeal patients should undergo regularly spaced lung roentgenograms and frequent tracheal sputum cytology.