Evaluation of prognostic factors for patients with eosinophilic granulomatosis with polyangiitis recruited at the pneumonological centre and mainly ANCA negativity: A retrospective analysis of a single cohort in Poland

OBJECTIVES

The aim was to investigate the risk factors for relapse and death in patients with eosinophilic granulomatosis with polyangiitis (EGPA) recruited at the pneumonological centre and mainly antineutrophil cytoplasmic antibody negativity.

METHODS

We retrospectively recruited 86 patients. Relapse was defined as the recurrence or appearance of new organ symptoms. The study end-point included the final examination.

RESULTS

Relapses occurred in 34.9% of the patients, while 9.3% died. Immunosuppressive therapy (P = 0.042), prolonged low-dose corticosteroid treatments (mainly for asthma) (P = 0.006), and longer follow-up duration (P = 0.004) were associated with a higher relapse risk, while advanced EGPA severity (P = 0.0015) and activity (P = 0.044), older age of onset (P = 0.030), symptomatic cardiac involvement (P = 0.007), and postinflammatory cardiac fibrosis (P = 0.038) were associated with a higher risk of death. Sinusitis (P = 0.028) and prolonged low-dose corticosteroid treatments (P = 0.025) correlated with a better prognosis. Relapses did not have an impact on the mortality (P = 0.693).

CONCLUSIONS

Relapses in EGPA remain frequent, although they do not impact mortality. Cardiac involvement is common, but clinically symptomatic cardiomyopathy is associated with a higher risk of death. Asthma requiring chronic corticosteroid treatments is associated with a lower risk of death, although the risk of EGPA recurrence is significantly higher.

Cardiac Involvement and Absence of Asthma – What is Phenotype Specificity of EGPA: A Case Report

Eosinophilic granulomatosis with polyangiitis (EGPA) typically is characterized by asthma, blood eosinophilia, and extrapulmonary manifestations. Asthma is a major EGPA symptom affecting almost all patients, but cardiac involvement is one of the most serious manifestations, responsible for 31% of deaths. Two recently defined phenotypes of EGPA, according to the patient’s antineutrophil cytoplasmic antibody (ANCA) status, differ significantly in clinical features and prognosis. We share a case of EGPA characterized by atypical manifestation without any evidence of asthma, in whom extensive cardiac involvement was the dominant manifestation of vasculitis. This case demonstrates the difficulties associated with phenotyping EGPA and highlights the importance of cardiac magnetic resonance imaging (CMRI) in definitive diagnosis.

The role of peripheral eosinophilia in diagnosing lung disorders: experience from a single pneumonological center

Background

Eosinophilia is rare but one of the important reasons to refer patients to pneumonological centers. Determining etiology of eosinophilia has practical implications for therapeutic intervention and disease prognosis. The study aimed to determine the role of peripheral eosinophilia in the diagnosis of lung disorders.

Methods

In this retrospective study were included 46 patients diagnosed with peripheral eosinophilia with coexisting respiratory symptoms and/or radiologically detected lung lesions. All patients underwent standard diagnostic procedures, including a detailed clinical history review, physical examination, routine laboratory tests with basal cardiological examinations, and serological tests to detect parasites and allergies. Other procedures carried out depended on the symptoms of each patient. The relation between eosinophil counts in the blood and patients’ clinical manifestation was investigated to identify the degree of eosinophilia requiring immediate diagnostic procedures and treatment. Statistical analyses were performed using scientific computation libraries in the Python programming language, SciPy, v. 1.3.1. Briefly, the following tests were used: parametric Kruskal-Wallis H test, an independent t-test, ANOVA, the Shapiro- Wilk test, Fisher’s and Chi-squared tests, and the Holm-Bonferroni method.

Results

Severe eosinophilia (≥5,000 cells/μl) was associated with extrapulmonary involvement and constitutional symptoms. Skin, heart, and pleural diseases were more frequent in these patients than in patients with mild or moderate eosinophilia (p=0.010, p=0.040, and p=0.007, respectively), and only these patients showed signs of kidney disease (p=0.006). Vasculitis was significantly more frequent in the severe eosinophilia group (p=0.048) than in the other two groups. In patients with moderate eosinophilia (1,500-5,000 cells/μl), extrapulmonary symptoms were less common, although signs of cardiac involvement were confirmed in 44% of subjects. In this group, vasculitis was the most commonly observed disease (42% of cases). Mild eosinophilia (<1,500 cells/μl) was mainly associated with airway disease. In this group, vasculitis and interstitial lung diseases were identified, but most were not typically connected with eosinophilia.

Conclusions

Identification of peripheral eosinophilia may essentially determine diagnostic procedures in patients with lung disorders and may be a useful indicator of disease etiology.

Antineutrophil cytoplasmic antibodies and their relationship with disease activity and presence of staphylococcal superantigens in nasal swabs in patients having granulomatosis with polyangiitis: results of a study involving 115 patients from a single center

OBJECTIVE

Antineutrophil cytoplasmic antibodies (ANCAs) are considered a risk factor for granulomatosis with polyangiitis (GPA) exacerbation, especially when staphylococcal superantigens (SAgs) are present in nasal swabs. Their role in monitoring disease activity remains controversial. This study determined the relationship of ANCAs with disease activity and presence of SAgs in GPA patients.

METHODS

Among a total of 115 GPA patients hospitalized in the period 2009-2016, we investigated the presence of SAgs and ANCA concentration. Blood samples and nasal swabs were taken at each visit (referred further to as episodes). Disease activity was assessed using the Birmingham Vasculitis Activity Score (BVAS).

RESULTS

We analyzed 362 episodes. ANCAs were detected in 215 (59.4%), while SAgs were detected in 126 (34.8%) episodes. We found a significant correlation between the presence of ANCAs and disease activity (p = 0.0032), as well as between their level and GPA severity (r = 0.25363, p = 0.000001). We also determined that an ANCA values ≥ 138 Ru/ml were an indicator of active disease with high specificity and low sensitivity (84.4% and 37.3%, respectively). The relationship between ANCA presence and the presence of SAgs was not confirmed; however, when SAgs were analyzed based on the different types, ANCA levels were found to be significantly higher in the group with SAg type B (p = 0.031).

CONCLUSIONS

There was no detectable evidence for the association between ANCA level and the presence of SAgs. Although monitoring ANCA levels as a marker of disease activity may be clinically relevant, GPA management cannot proceed on the basis of ANCA levels alone. Key Points • ANCA concentration usually correlates with GPA activity, although in half of patients, ANCAs persist despite effective treatment and clinical remission. • ANCA values of 138 Ru/ml seem to be an indicator of active disease with high specificity, but low sensitivity. • Although there is a relevance for ANCA monitoring as a marker of disease activity, GPA management cannot be based on ANCA levels alone. • The suspected clinical correlation between ANCA formation and SAg presence in nasal swabs is not obvious and requires further investigations.

Diffuse alveolar haemorrhage complicated by pulmonary embolism - problems with treatment

Diffuse alveolar haemorrhage (DAH) refers to a clinical syndrome resulting from injury of the alveolar capillaries, arterioles and venules leading to red blood cel accumulation in the distal air spaces. The conditions associated with DAH and underlying disease determine the prognosis and the treatment regimen. The coexistence of DAH with venous thromboembolism (VTE) is a seroius problem for clinicians and poses a challenge in the therapeutic management. We describe a young patient who developed massive DAH in the course of anti-glomerular basement membrane (anti-GBM) disease (formerly called Goodpasture's syndrome) complicated by pulmonary embolism (PE).

Clinical presentation and characteristics of 25 adult cases of pulmonary sequestration

BACKGROUND

Pulmonary sequestration (PS) is a rare congenital abnormality of lung tissue. Only few series of adult cases are reported. The aim was to describe clinical characteristics in adult cases of PS and to compare outcomes in different clinical situations.

METHODS

Using MSD engine we searched for cases of PS that have been diagnosed between Jan 1st, 2005 and Dec 31st, 2015. Clinical data was retrospectively gathered. Statistica v.12 (StatSoft, Inc.) was used for statistical analyses.

RESULTS

We found 25 cases (18 females, 7 males), which underwent surgery and were histologically proven. There were 22 cases of intralobar PS. 7 cases were asymptomatic, 12 had infectious history (including 3 cases of lung abscess and pleural empyema), 4 presented with hemoptysis, 2 with chest pain. The average age to undergo surgery was 38.24, in the asymptomatic group 34, in symptomatic 39.89. In the latter the symptoms preceded the surgery for 2.45-year. Great majority of sequestrations was located in lower lobes (96%), 52% on the left. Symptomatic cases were at higher than expected risk of surgical complications, comparing to asymptomatic (chi², P=0.04). In most cases there were surgical and histological signs of infection, only in 9 cases etiological factor was determined: in 5 cases it was A. fumigatus. A 0.53-day longer post-surgical hospital stay was observed in the symptomatic group, no statistical significance was found (U-test, P=0.45).

CONCLUSIONS

Surgical treatment of symptomatic cases of PS is characterized by slightly longer post-surgical hospital stay and higher risk of surgical complications. Fungal infections are the most likely to occur in PS.

Intratracheal Dilation-injection Technique in the Treatment of Granulomatosis with Polyangiitis Patients with Subglottic Stenosis

OBJECTIVE

An analysis of subglottic stenosis (SGS) occurrence frequency in patients with granulomatosis with polyangiitis (GPA) based on the time of appearance of clinical symptoms, and an assessment of treatment effectiveness, in particular with the intratracheal dilation-injection technique (IDIT).

METHODS

Review and treatment with IDIT of 34 patients with SGS associated with GPA.

RESULTS

SGS developed in 34 of 250 patients with GPA (13.6%) and was not reflective of disease activity in the organs in 15 of 34 patients (44%): 11 cases after and 4 cases during immunosuppressive therapy (IST) when patients did not have organ symptoms. All patients underwent IDIT and in total, the treatment resulted in immediate improvement. In addition, in 21 cases, IST was applied because of other organ involvement or of the lack of longterm efficacy of IDIT. The median time of response was 37 months and the median interval between sessions was 5 months. None of the patients required tracheostomy after beginning IDIT in our hospital.

CONCLUSION

SGS often occurs independently of other features of active GPA. IDIT is a safe and effective technique in the treatment of GPA-related SGS. It should be performed in all patients with GPA who develop significant SGS and in those with multiorgan disease concomitantly with IST. In patients with isolated SGS, IDIT also makes IST and tracheostomy unnecessary.

"The significance of cardiac magnetic resonance imaging in detection and monitoring of the treatment efficacy of heart involvement in eosinophilic granulomatosis with polyangiitis patients"

BACKGROUND

Cardiac magnetic resonance imaging (CMRI) has emerged as a sensitive and non-invasive technique in the evaluation of cardiac lesions in eosinophilic granulomatosis with polyangiitis (EGPA) patients.

OBJECTIVES

To evaluate the ability of CMRI to detection and monitoring of the treatment efficacy in EGPA patients with cardiac involvement.

METHODS

To the retrospective-prospective study were enrolled 33 cardiac involvement EGPA patients. In 19 of them CMRI at the moment of diagnosis was performed, in 14 - CMRI after treatment was made, when this method was available - in this group the cardiac involvement was based on the clinical findings. All patients were treated with corticosteroids (CSs) and/or cyclophosphamide (CY). In the first group the control CMRI after one year of treatment was performed, but in the second group the time from the end of the treatment to execution of CMRI was 2-5 years.

RESULTS

All patients had heart injury in CMRI. Myocardial edema was present in 87.8% cases, 54.5% of patients had perfusion defects and in all - late gadolinium enhancement was observed. Control CMRI was performed in 32 cases. Improvement was observed in 81% of patients - in 11% of them all lesions undergone completely remission and in 35% of them evolution to global fibrosis was found. In 7% of patients stabilization was achieved and in 12% - progression was observed.

CONCLUSIONS

CMRI is a sensitive method detecting cardiac lesions in EGPA patients. It helps to detect patients, who need combined therapy and helps evaluate the therapeutic effect.

Influence of delays in diagnosis and treatment on survival in small cell lung cancer patients

The purpose of this study was to evaluate the influence on survival of delays in the diagnosis and treatment in an unselected population of small cell lung (SCLC) patients. Demographic and disease data of 3,479 SCLC patients were registered in the National Tuberculosis and Lung Diseases Research Institute in Warsaw, Poland during 1995-1998. In 50 % of patients, treatment started within 78 days from the appearance of first symptom(s). The median delay was 30 days (mean 47 days) and the median referral delay to a specialist was 19 days (mean 36 days). Half of SCLC patients were diagnosed during 34 days (mean 55 days). The mean time elapse from the diagnosis to the onset of therapy was 30 days (median 6 days). The multivariate analysis revealed that male gender-HR (hazard ratio = 1.2), ECOG Performance Status of 2 (HR = 1.5) and 3 + 4 (HR = 2.4), and clinical stage III (HR = 1.3) and IV (HR = 1.9) of the disease were independent negative predictors of survival. The patients treated with surgery and combined modality treatment had a better prognosis than those treated with chemoradiotherapy (HR = 1.6), chemotherapy (HR = 2.5), symptomatically (HR = 4.0), or those who refused therapy (HR = 3.9). The delay in the diagnosis and treatment had no effect on survival. Interestingly, patients who were diagnosed faster (below 42 days) actually had a worse prognosis than those diagnosed later. We conclude that a prolonged workup of SCLC patients and an extended time for treatment onset have a positive influence on survival, which may likely have to do with the determination of disease stage and more targeted treatment.

Bronchial hyperreactivity in sarcoidosis patients: correlation with airflow limitation indices

Bronchial hyperreactivity (BHR) in sarcoidosis has been reported in 5 to 83% of patients, but the relationship between BHR and airway functional status being unclear. The aim of the study was to assess the prevalence and degree of BHR in a group of pulmonary sarcoidosis patients and how BHR does relate to the functional status of airways.

MATERIAL AND METHODS

56 consecutive sarcoidosis outpatients (26 f, 30 m) were included. There were 14 (25%) patients in stage I, 32 (57.1%) patients in stage II and 10 (17.9%) patients in stage III. In all patients the standard evaluation included a history, physical examination, chest radiogram, serum ACE activity and lung function assessment were done. The provocation challenge test with doubling concentrations of histamine was performed in all patients using the standardized protocol recommended by the ERS.

RESULTS

4 patients (7%) were restrictive, airway obstruction was detected in 7 (12.5%) cases. Up to 32% of patients had maximal expiratory flows at low lung volumes below the lower limit of normal (LLN). The histamine challenge test results: in 9 cases (16%) the fall in FEV1 was < 20% of the baseline; mean PC20H (n = 47) was 5.7 +/- 5.9 mg/mL, range: 0.56-26.7 mg/mL. The challenge test was regarded as positive (PC20H < or = 8 mg/mL) in 71.4% of the group. BHR expressed as ln(PC20H) correlated weakly but significantly with FEV1, FEV1%VC, MMEF and PEF.

CONCLUSION

BHR occurs frequently in sarcoidosis patients and should be considered especially in patients with airflow limitation.

Asymptomatic appearance of splenic infarction in Wegener's granulomatosis

Splenic involvements in Wegener's granulomatosis (WG) are rarely diagnosed ante-mortem, while an autopsy is able to reveal a high rate of spleen lesions (78-100%). To date, there have been a few reported cases of splenic abnormalities in WG, including: splenomegaly, capsular adhesion, dysfunction and infarction. We reported a case of biopsy-verified WG with radiological evidence of diffuse spleen infarction despite the lack of any clinical symptoms. We concluded that due to a potential risk of severe hemorrhagic complications when anticoagulant therapy is necessary, radiological assessment of spleen should be performed regularly in this group of patients, particularly because spleen involvement can be asymptomatic.

Neoadjuvant therapy affects tumor growth markers in early stage non-small-cell lung cancer

Introduction

While adjuvant therapy of early-stage non-small-cell lung cancer (NSCLC) is widely accepted, literature data concerning neoadjuvant treatment provide contradictory results with both improved and unaffected survival rates. Also, data concerning potential effects of neo-adjuvant therapy on cellular level are scarce.

Objective

The aim of present study was to analyze the effect of chemotherapy followed by surgical resection on several key biological markers of tumor growth (TGF-β, VEGF), apoptosis (sAPO-1/Fas/CD95) and invasiveness (TIMP-1) assessed in the sera of NSCLC early-stage patients (IB-IIIA).

Materials and methods

Measurements were performed by ELISA method in blood serum from 24 NSCLC patients (I-IIIA) collected prior therapy, one day before surgery and 3 days after.

Results

TGF-β serum concentrations were significantly lower after both chemotherapy (P < 0.05) and surgery (P < 0.01) in comparison to the baseline. VEGF levels decreased following NEO therapy with subsequent significant up-regulation after surgery (P < 0.001). Interestingly, post-surgery serum VEGF strongly correlated with TGF-β concentration (r = 0.52, P = 0.014). No significant differences were observed for serum sAPO-1/CD95/FAS as well as TIMP-1 concentrations at any of three evaluated time-points.

Conclusion

Neoadjuvant treatment of early-stage NSCLC affects mostly mechanisms responsible for tumor growth and vascularization. Its effect on cancer cells apoptotic activity needs further evaluation.

[Elevated serum NSE level in locally advanced and metastatic NSCLC predispose to better response to chemotherapy but worse survival]

The aim of the study was to evaluate the predictive and prognostic values of elevated serum levels of selected cancer markers (NSE, Cyfra 21-1, CEA, ferritin, free beta-hCG, LDH) in patients with inoperable non-small-cell lung cancer (NSCLC). We investigated a group of 79 patients (49 men and 30 women) with NSCLC. Multivariate regression analysis showed response in patients with NSE > 12.5 ng/ml (p = 0.002), good performance status (p = 0.007) and elderly patients (p = 0.005). However, elevated NSE adversely affected the prognosis. Median survival in patients with NSE < 12.5 ng/ml, 12.5-20.0 ng/ml and > 20.0 ng/ml was 13.3, 11.3 and 6.7 months, respectively (p = 0.004). The negative effect of elevated NSE was independent of the response category. Univariate regression analysis showed that the following factors had a significantly negative effect on the prognosis: performance status, stage IIIB or IV, weight loss of > 10%, NSE > 20 ng/ml, Cyfra 21-1 > 10 ng/ml, CEA > 3 ng/ml, ferritin ratio > 1 and LDH > 480 IU/l. Multivariate analysis showed an independent adverse prognostic effect of stage IIIB or IV and elevated ferritin.

Fibrosing mediastinitis as an untypical complication of tuberculosis: case report

Fibrosing mediastinitis (FM) is a rare benign disorder caused by proliferation of acellular collagen and fibrous tissue within the mediastinum. In the United States, most cases are thought to be caused by an abnormal immune response to Histoplasma capsulatum infection. Some cases of FM are related to tuberculosis. In most patients the cause of FM is unknown. The affected patients are typically young and present with signs and symptoms of obstruction or compression of the superior vena cava, pulmonary veins or arteries, central airways or esophagus. Computed tomography and magnetic resonance imaging are central to the diagnosis and management of this disorder. We present a rare case of FM as a sequela of tuberculosis.

[Common variable immunodeficiency in a patient with suspected sarcoidosis]

Common variable immunodeficiency is a primary immunodeficiency disease, characterized by hypogammaglobulinemia, low serum immunoglobulin concentrations, and recurrent bacterial infections of the respiratory and gastrointestinal tracts. We report on a 33-year-old patient with suspected sarcoidosis, diagnosed on the basis of an open lung biopsy, who was admitted to the National Tuberculosis and Lung Diseases Research Institute because of severe pneumonia and streptococcal sepsis. During diagnostics based on typical, clinical and laboratory features, CVID was diagnosed. The antibiotic treatment was successfully administered and the patient was directed to supplementary treatment.

[Comparison of Th1 and Th2 response in the blood of tuberculous patients and healthy contacts]

INTRODUCTION

Th1 response is known to play a dominant role in the resistance to tuberculosis. Nevertheless, IFN gamma levels are frequently increased in tuberculous patients, especially at the site of the disease. It is also possible that the shift toward Th2 response is responsible for the loss of resistance. The aim of this study was to compare the Th1 function of peripheral blood cells and the levels of antimycobacterial antibodies in the serum of culture positive tuberculosis patients and healthy tuberculosis (Tb) contacts. The correlation between the levels of antimycobacterial antibodies and Th1 function of blood cells was also evaluated.

MATERIAL AND METHODS

The material consisted of 51 tuberculous patients and 20 healthy persons, close contacts of tuberculosis patients. The ability of peripheral blood cells to secrete IFN gamma and IL-2 was estimated in whole blood cultures with PHA, PWM and tuberculin. The levels of IFN gamma and IL-2 in the supernatants of cultures was estimated via a commercial ELISA test. The levels of antimycobacterial antibodies was measured with commercial immunoenzymatic kits detecting IgG antibodies against 38 kDa + 16 kDa and IgG, IgA and IgM antibodies to 38 kDa + lipoarabinomannan (LAM).

RESULTS

No difference was found in the secretion of IFN gamma and IL-2 after stimulation with PHA and PWM between the patients and contacts. The secretion of IFN gamma after stimulation with tuberculin was even greater in tuberculous patients than in contacts. The levels of IgG and IgA (38 kDa + LAM) were higher in tuberculous patients than in contacts. There was a negative correlation between the level of IgG anti 38 kDa + LAM and the ability of peripheral blood cells to secrete IFN gamma after non-specific stimulation in patients with tuberculosis.

CONCLUSIONS

Our study confirms the hypothesis that it is not the diminished production of Th1 cytokines, but rather the parallel overproduction of Th2 cytokines, which are essential in the development of tuberculosis.

Interferon gamma production in the course of Mycobacterium tuberculosis infection

It is not clear why some individuals with unknown predisposition develop tuberculosis, while others remain healthy in spite of heavy exposure. Interferon gamma (IFNgamma) is considered to be the key cytokine responsible for resistance to M. tuberculosis infection, as confirmed by increased susceptibility to mycobacterial infections in rare inherited defects in IL-12-IFNgamma axis. The aim of this study was to assess the IFNgamma production by peripheral blood lymphocytes from immunocompetent tuberculosis (TB) patients. The study group included 51 TB patients. In all cases, TB was confirmed by culture. Twenty healthy TB contacts were considered as control group. Commercially available ELISA-based assays were used to measure IFNgamma in the supernatant of whole blood cell cultures after stimulation with PWM (Phytolacca Americana), PHA (phytohemagglutynin), and PPD (purified protein derivative). No difference in IFNgamma secretion between the patients and control group was found when blood cells were stimulated by PWM or PHA. PPD-induced IFNgamma formation was higher in TB patients than in controls. The secretion of IFNgamma after non-specific stimulation varied in different clinical and radiological presentation of tuberculosis and it was lower in most advanced and extensive forms of the disease. It is unclear whether the difference in formation and release of IFNgamma is a primary or secondary phenomenon in the course of the disease.

[Systemic treatment of non-small cell lung cancer--recommendations based on the results of reliable clinical trials]

Lung cancer is in Poland the most common malignancy. Non-small cell lung cancer (NSCLC) accounts for approximately 80% of all lung tumors. In the multidisciplinary treatment of non-small cell lung cancer patients the role of chemotherapy and, most recently, molecular targeted therapy is increasing. In 2005 we published recommendations for systemic treatment of non-small cell lung cancer and mesothelioma. As many new studies have been published since, it was necessary to update this document. We present here a consensus statement on this topic, prepared by a panel of experts in oncology, thoracic surgery, pathology and pneumonology.

[Chronic granulomatous disease recognised in 42-years-old patient]

Chronic granulomatous disease (CGD) comprises a heterogeneous group of diseases that are caused by defect in the superoxide-producing NADPH oxidase of neutrophils. This defect impairs the intracellular killing of microorganisms. Typical manifestations are recurrent bacterial or mycotic infections affecting the lungs, skin, lymph nodes and gastrointestinal tract (liver). Chronic granulomatous disease could be diagnosed on the basis of the anamnesis, clinical picture and results of granulocyte function tests showing impaired phagocytic activity (NBT tests, RDH test and a deficit of superoxide production). Typically symptoms of disease occur in the first years of live, leading often to death in the 2. or 3. decade. Below we present a patient, in whom diagnosis of the CGD was established at the age of 42.

[Lung cancer in Poland in 1970-2004]

INTRODUCTION

The aim of this paper was to evaluate time trends of incidence and mortality from lung cancer by sex and age in Poland since 1970 to 2004.

MATERIAL AND METHODS

Basing on the data from National Cancer Registry - incidence and mortality due to lung cancer in Poland 2004 and time trends in the period 1970-2004 were analyzed.

RESULTS

The were 20 359 cases of lung cancer in Poland in 2004: 15 741 cases in men (crude rate - 85,2/10(5)) and 4618 cases in women (crude rate - 23,8/10(5)). Sex ratio was 3,4. Since 1971 lung cancer is the most frequent cancer in males: in 2004 - 25,2% of total male cancers, in female there are less frequently - 7,8% total cancers and took third place after breast cancer - 20,5% and colorectal cancer - 10,4%. Incidence rate of lung cancer in males peaked in 1996 - 89,1/10(5) and then stabilized or event slightly decreased while corresponding rates in women steadily increased in whole period 1970-2004. The incidence of lung cancer for both men and women showed an increase with age and reached peak both in elderly men and women (age group 70-79) respectively - 516,9/105 in males and 81,2/10(5) in females. Median age of registered cases was as men as women in age group 60-69. In the reviewed period of time crude rate of incidence increased in men - 231,5% in women - 390% while standardized rates increased less - 172% in men and 282% in women. There were 16 565 deaths due lung cancer in men - crude rate 89,6/10(5) and 4641 deaths in women, crude rate - 23,6/10(5). Lung cancer is the leading cause of cancer-related mortality in men - 32,3% of all cancer deaths and took second position in women - 12,2% (after breast cancer - 12,9%) of total cancers deaths in women. In the analyzed periods of time - trend mortality was similar as times - trends incidence lung cancer. Both incidence and mortality lung cancer varies by regions: incidence in males from 73,2 to 109,9; in females from 14,5 to 33,8; mortality: in males from 73,9 to 99,8; in females from 13,0 to 30,9.

CONCLUSIONS

Lung cancer incidence and mortality rate in men has been on the stable level, even with the tendency to decline in last decade in Poland. Incidence and mortality rates among women have continued to increase, although the trend of increase has slowed in last years. Demographic distribution of lung cancer shows decline of the rates in young and middle age population and continuation of increase in old age people. Despite of some improvement of epidemiological situation in lung cancer in Poland it still remains the most common malignancy in men and is on the third position in most frequent cancers in woman. Lung cancer in Poland remains serious medical and social problem.

[Stroke as a predominant symptom at Churg-Strauss syndrome]

Intracerebral hemorrhage is a rare sequel of Churg-Strauss syndrome. We report a case of 55 years old man, who was admitted to the National Tuberculosis and Lung Diseases Research Institute because of paroxysmal dyspnea and persistent cough. 6 months prior to hospitalization the patient suffered from spontaneous intracerebral hemorrhage. The laboratory studies revealed: leukocytosis with 65% being eosinophils, elevated serum IgE (810 IU/ml) and pANCA titre (1:640). HRCT disclosed in both lungs several small ground glass attenuations and thickening of bronchial walls. In bronchoalveolar lavage numerous eosinophils were noted. During hospitalization episodes of dyspnea with bronchospasm improving after beta2-mimetics inhalation were repeatedly observed, the findings that could suggest asthma. Based on clinical criteria of French Vasculitis Study Group, Churg-Strauss syndrome was recognized. The patient was treated with prednisone 50 mg daily with rapid regression of the respiratory symptoms and gradual normalization of the laboratory results.

[A comparative evaluation of immunohistochemical markers for the differential diagnosis between malignant mesothelioma, non-small cell carcinoma involving the pleura, and benign reactive mesothelial cell proliferation]

INTRODUCTION

Histopathological diagnosis of malignant mesothelioma (MM) and differentiating it from tumors infiltrating the pleura is very difficult. Distinguishing benign reactive mesothelial cell proliferation from MM also presents problems. The objective of this study was to evaluate the significance of selected immunohistochemical stains in differentiating MM from non-small cell lung cancers infiltrating the pleura and from benign reactive mesothelial cell proliferation.

MATERIAL AND METHODS

The material encompassed 86 cases of MM, 54 cases of NSCLC infiltrating the pleura, and 43 cases of benign reactive mesothelial cell proliferation. The MM cases were reclassified according to the WHO criteria (2004): epithelioid, 61 cases (71%), including well-differentiated papillomatous, 3 cases; sarcomatous, 6 cases (6.8%); fibrous, 4 cases (4.7%); biphasic, 15 cases (17.5%). A panel of immunohistochemical stains was used in this study. It included broad-spectrum antibodies to cytokeratins (CKAE1/AE3, CKMNF116), vimentin, epithelial membrane antigen (EMA), mesothelial cells (HBME1, CK5/6, calretinin), adenocarcinoma cells (BerEp4, B72.3, CEA, TTF1), antibodies enabling the assessment of proliferation (Mib1) and cell-cycle regulating proteins (p53).

RESULTS

Coexpression of cytokeratins and vimentin was found in 63.9% of MM cases and cell-membrane reactions with EMA were seen in 58.9%. Positive staining for HBME1, CK5/6, calretinin, BerEp4, B72.3, CEA and p53 was obtained in 76.7%, 51.2%, 66.7%, 1.2%, 6.2%, 1.2% and 51% of the cases, respectively. None of the MM cases stained for TTF1. MM by WHO subgroups: Coexpression of cytokeratins and vimentin occurred in 55.7% cases of epithelioid MM, 93.3% of biphasic MM, 66.6% of sarcomatous MM, and in 100% of fibrous MM cases. Positive staining for HBME1, CK5/6, and calretinin was seen only in the epithelioid and mixed subtypes of MM; the respective percentages of positive reactions were: HBME1, 90.2% and 73.3%; CK5/6 58.2% and 53.3%; calretinin, 72% and 75%. Non-small cell lung cancers infiltrating the pleura: Coexpression of cytokeratin and vimentin was found in 17.6% of the cases, positive staining of membranes for EMA, in 13% cases. Positive staining for HBME1 was observed in 22.6% of the cases, for CK5/6, in 9.3%, for calretinin, in 2%, for BerEp4, in 72.2%, for B72.3, in 64.1%, for CEA, in 58.5%, and for TTF1, in 43.8%. Benign reactive mesothelial cell proliferation: Protein p53 was present in 9.3% of cases, whereas no positive staining for EMA was found. Differentiation of MM from non-small cell carcinomas: Among the antibodies used in the study, anti-HBME1 had the highest sensitivity (76.7%) but lowest specificity (77.4%). Staining for calretinin showed high specificity (99.8%), as did CEA and TTF1 (98.8% and 100%), with moderate sensitivity (66.7%, 58.5% and 43.8%, respectively). BerEp4 showed the highest sensitivity (72.2%) and specificity (98.8%).

CONCLUSION

In diagnosing mesothelioma it is necessary to use a panel of immunohistochemical stains, which should contain antibodies to markers for adenocarcinoma and mesothelioma. Due to the high costs of such a study, a two-stage method is advantageous. The best combination of sensitivity and specificity was found for BerEp4, CEA, and TTF1 and for calretinin and HBME1. In the diagnosis of spindle-cell pleural tumors and the fibrous form of MM and benign reactive mesothelial cell proliferation , markers of mesothelial cells are noncontributory. Immunohistochemical staining fails to identify a reactive process, but a diffuse, positive stain for EMA and the presence of protein p53 support the diagnosis of MM.

[Cardiac sarcoidosis -- own experiences]

Cardiac involvement in sarcoidosis may be incidentally discovered without any symptoms of the disease. When undiagnosed and untreated it is potentially fatal. Although there is no recommended strategy for the diagnosis, the introduction of newer technology is promising and may be useful for early diagnosis of sarcoid heart disease and for the evaluation of response to therapy. We present a case of 53-years old woman, with asymptomatic cardiac arrhythmias and x-ray chest picture changes without any respiratory symptoms. Further assessment and the use of cardiac magnetic resonance imaging allowed a diagnosis of cardiac sarcoidosis to be made.

[Pneumatocele during long-lasting observation of hyper IgE patient]

Hyper IgE syndrome (Job's syndrome) is a rare multiorgan disease characterized by the triad: elevated serum IgE level, recurrent sinopulmonary infections, most often staphylococcal, and cutaneous cold abscesses starting in infancy. We report 21 years old patient with hyper IgE syndrome, diagnosed at age of 6 years on the basis of hyperimmunoglobulinaemia E and recurrent pulmonary and cutaneous infections. Now he was admitted because of pneumonia complicating with pneumatocele, which could not be resolved despite intravenous antibiotics. Surgical intervention was necessary. The postoperative period was complicated by Staphyloccocus aureus sepsis.

Neuroendocrine phenotype of non-small cell lung carcinoma: immunohistological evaluation and biochemical study

AIMS AND METHODS

The prevalence and distribution of neuroendocrine differentiation in non-small cell lung cancer (NSCLC) was estimated by assays for synaptophysin (SYN), chromogranin A (CgA), Leu7 and neuron-specific enolase (NSE). Serum NSE and CgA were determined in parallel to find the values of these markers for distinguishing neuroendocrine differentiation in NSCLC. Fifty-eight resected NSCLC specimens and 34 sera of NSCLC patients entered the study. Neuroendocrine differentiation was graded according to the percentage of neuroendocrine tumor cells as NE0--0%, NE1-NE4--1%->76%. Serum NSE <12.5 ng/mL and serum CgA <46 U/L were taken as cutoff levels.

RESULTS

63.8% (37/58) of NSCLC were scored as NE1-NE4 according to the SYN, CgA and Leu7 levels; 34.5% as NE1; 29.3% as NE2-NE4. 56.8% of tumors were positive for SYN, 34.4% for CgA, 22.4% for Leu7, and 79.3% for NSE. A significant relationship was found between tumor SYN and tumor CgA expression, and between tumor SYN expression and tumor stage. Adenocarcinomas showed a significantly higher rate of neuroendocrine differentiation than squamous cell carcinomas. All normal serum CgA levels corresponded to a lack of CgA expression in the tumors. The increased serum NSE levels presented by 26% of NSCLC patients (mainly <16 ng/mL) did not correlate with tumor NSE expression.

CONCLUSIONS

The prevalence of neuroendocrine differentiation in NSCLC varies and depends on the immunohistochemical criteria used; this warrants standardization of the immunohistochemical criteria for neuroendocrine differentiation in NSCLC. NSE expression in the tumor and a mild increase in serum NSE are poor markers for distinguishing neuroendocrine differentiation in NSCLC.

[Invasive aspergillosis (IA) in patients treated in the Institute of Tuberculosis and Chest Diseases in the years 1993-2005--diagnostic problems]

The aim of this study was to present the diagnostic problems in pts treated for invasive aspergillosis (IA) in the IIIrd Clinic of the Institute of Tuberculosis in the years 1993-2005. The material consisted of clinical documentation of 18 pts. 15 out of 18 pts (83,4%) died. In all those cases autopsy examination was done. In 13 pts IA was the main and in another 2 only the accessory cause of death. All pts were treated with corticosteroids and/or cytostatic drugs because of lung cancer (13 pts), haematologic disorders (1 pts), Wegener's granulomatosis (3 pts) and idiopathic pulmonary fibrosis (1 pts). In 13 out of 18 pts granulocytopenia was revealed (on an average from 0,008 x 10(9)/L to 0,95 x 10(9)/L) one month before death. In 13 pts IA was limited to the lungs, in 5 others there were also fungal lesions in brain, kidneys, liver, spleen, pleura, pericardium and heart. Pts with disseminated form of IA had significantly lower granulocyte count and were treated with higher doses of corticosteroids than others. Immunosupressive drugs and granulocytopenia can be regarded as predisposing factors. IA was diagnosed before death only in 5 out of 18 pts. This was mainly caused by the lack of the symptoms of infection (4 pts) and negative results of mycological (6 pts) and serological examination (8 pts). We should underline that mycological examination was only done in 11 pts and serological examination of blood for fungal antigen only in 6 pts. We conclude that mycological infection ought to be searched in all pts treated with high doses of corticosteroids and those with prolonged granulocytopenia, especially if they have the symptoms of infection which does not respond to antibiotic therapy.

[Analysis of the treatment (neoadjuvant chemotherapy and surgery) in IIb and IIIa stages of non-small cell lung cancer]

THE AIMS

1) comparison of NSCLC stages according to bronchoscopic and radiological findings with pathological outcome (mediastinoscopy), 2) efficacy of the neoadjuvant ChT by means of nodal involvement and primary tumour (downstaging), 3) influence of ChT on the surgical procedures' extension and its morbidity

MATERIAL AND METHODS

100 consecutive patients with resectable NSCLC in stages IIB (13 pts) or IIIA (57 pts), who were qualified to neoadjuvant ChT, participated in this study (77 men and 23 women, aged 42-73). Tumour and lymph nodes (mediastinal and hilar) were measured in CT scan. Mediastinoscopy was performed in 70 pts (70%). Majority of patients (87%) received two cycles of neoadjuvant ChT (cisplatin 80 mg/m(2) iv on day 1 and vinorelbine 25 mg/m(2) on day 1 and 5) administered every 21 days. After ChT 85 patients were qualified to surgery.

THE RESULTS

The metastases in mediastinoscopy were excluded in 32 out of 45 patients (71%), whose lymph nodes were enlarged in CT scan (radiological false positive). Metastases were confirmed in 4 out of 25 patients (16%), whose lymph nodes were normal in CT scan (radiological false negative). After ChT the regression of the disease (PR+CR) was noted in 37% of patients. Pneumonectomy was performed in 23 (27%) pts, bilobectomy in 11 (13%) pts, lobectomy in 39 (46%) pts and "extended" (sleeve) lobectomy in 12 (14%) pts. Resected material was examined microscopically very exactly in patients, in whom mediastinoscopy was performed before treatment. Down-staging was confirmed in 6 out of 15 patients (40%).

CONCLUSIONS

Neoadjuvant ChT was effective in 37% of patients and allowed us to perform less extensive surgery in these patients. 22 (64,7%) out of 34 patients who responded to ChT underwent lobectomy. Only 17 (36%) out of 51 patients who did not respond to ChT had lobectomy performed. Generally, 85 pts were operated with postroperative complications in 22.3% patients and 2.3% mortality rate. Pneumonol. Alergol. Pol. 2006, 74, 171:178

[Is the microscopic morphology of thymoma of clinical significance?]

Thymomas are rare mediastinal tumors that have heterogeneous microscopic morphology and uncertain outcome.

AIM

The aim of the study was to evaluate the practical usefulness of WHO classification by correlation of histological subtype of thymoma with staging, symptoms and epidemiology.

MATERIAL AND METHODS

87 cases of thymomas was reclassified according to the WHO Histologic classification and Masaoka staging system. Clinical symptoms, age and sex of the patient were taken into consideration in each case.

RESULTS

The histological subtypes was diagnosed in order of frequency: AB (n = 21; 24%), B2 (n = 19; 22%), B1 (n = 14; 16%), A (n = 6; 7%), C (n = 4; 5%), B3 (n = 3; 3%). Combined types was observed in 17 (20%) cases. Tendency to invasion increased as follows: A < AB < B1 < B2 < B3 < C. The median value of patients' age was: type A--67,5 years, type AB--62 yrs., type B1--48 yrs., type B2--52 yrs., type B3--32 yrs. and type C (thymic carcinoma)--49,5 yrs. No correlation was found between histological type and sex of patient. The most often clinical symptom--myasthenia, accompanied predominantly B2 thymomas.

CONCLUSIONS

The WHO classification is useful in routine pathologic examination of thymomas, because it enables to distinguish histological subtypes with different clinical representation.

[The significance of the serum tumour markers as a prognostic and predictor factors in nonsmall cell lung cancer patients]

The aim of the study was to assess the role of serum tumour markers (NSE, Cyfra 21-1, CEA, LDH, ferritin) as a prognostic and predictive factors in 79 patients with advanced NSCLC treated with chemotherapy. Objective response to treatment was significantly more frequent in the patient with serum NSE > 12.5 ng/ml. Progression of disease was observed more often in patients with serum Cyfra 21-1 >10 ng/ml or LDH >480 U/L. CEA >3 ng/ml, LDH >480 U/L, for coefficient >1, NSE >20 ng/ml and Cyfra 21-1 >10 ng/ml had a negative impact on survival in univariate analysis. Independent negative prognostic significance of fer coefficient >1 was confirmed by multivariate analysis.

[Hypersensitivity pneumonitis recognised by open lung biopsy in patients at the Institute of Tuberculosis and Lung Diseases]

Diagnosis of hypersensitivity pneumonitis (HP) is made on the basis of a combination of clinical features connected with the exposition to organic dusts, radiographic abnormalities, lung function tests and immunological tests. Open lung biopsy (OLB) and histological examination is not necessary and is indicated mainly in chronic and subacute form of HP. In the chronic form of HP symptoms often do not show a temporal relationship with antigen exposure and errors occur especially if specific questions are not asked about exposure to antigen if HP. The aim of this paper was to analyse whether OLB was necessary in all patients in whom HP was recognised just after this procedure. Material included 21 patients in whom microscopic examination suggested HP among 258 pts in whom OLB was performed in the period of 1998-2003. There were 13 men and 8 women at the age of 18 to 65 years, mediana 42 years.

RESULTS

We found 3 groups of pts. Group "+" included 9 exposed pts. They were asked and confirmed contact with birds, hay and 7 of them observed correlation between exposition and symptoms. The second Group "-" included 7 pts who were asked about exposition and who answered in the negative. In all of them HRCT scans suggested HP. Restriction was below 70% of VC in 3 pts. The third Group "0" included 5 pts who were not asked about exposition and correlation with symptoms. Two from them lived in the rural area.

CONCLUSIONS

Open lung biopsy was not necessary for 6 patients in Group "+", because then had enough symptoms to recognise HP. In 3 patients of Group "+" and in 5 of Group "0" OLB could be not necessary because specific anamnesis and additional examinations were not collected. OLB was necessary method for 7 patients in Group "-".

[Pulmonary thromboembolism as a late complication of mitochondrial myopathy (Kearns-Sayer syndrome ]

A case of pulmonary thromboembolism with transient pulmonary hypertension of a rare cause is presented. In 24-year-old woman myasthenia was recognised on the ground of ptosis and fixation of eyes muscles from the 14th year of age. The treatment with mestinon was ineffective. Before planned thymectomy serious disturbances of heart rhythm and conduction were confirmed. Stimulator was implanted and thymectomy was done. No improvement of neurological state was observed despite the treatment with mestinone and prednisone. When she was 30 years old disease of lung appeared with fever, cough and parenchymal and pleural lesions of right lung. Antibiotic therapy was ineffective. CT scan and US examination revealed large thrombus inside the right auricle connected with stimulator electrodes. Embolisation of right pulmonary arteria was confirmed also. Treatment with heparin was ineffective and thrombectomy was performed. Exact neurological examination stated that the patient had no typical symptoms of myasthenia and that symptoms related with eyes and heart could be result of mitochondrial myopathy. Diagnosis was confirmed by EMG examination and muscle biopsy.

[Churg-Strauss syndrome--cardiac problem in lung disease department]

Eosinophilia and pleural effusion may suggest pulmonary eosinophilia. We present a case of 42 years old woman with hypereosinophilia history since 5 months and no evidence of parasitic infections. She had no history of heart disease. Laboratory tests revealed eosinophilia (13.0 x 10(9)/l) and elevated serum IgE (2050 IU/ml), ANCA was not detected. ECP was not elevated. Pleural effusion contained 37% of eosinophils. An ECG revealed low voltage of QRS in all leads and Q waves in leads Vi-V-3. An echocardiography showed enlargement of left auricle and left ventricle with ejection fraction = 35%. The only pulmonary manifestation in this case was eosinophilic pleural effusions associated with congestive heart failure. A women was treated with prednisone 1 mg/kg/d and cyclophosphamide 2 mg/kg/d with clinical improvement and normalisation of eosinophil number in peripheral blood. But echocardiographic picture of the heart was nor better during 2 months of observation.

[Prognosis in limited disease (LD) small cell lung cancer (SCLC) patients according to status performance, local extension of lesions, type of treatment and the completeness of staging]

The aim of this study was to assess the prognosis in LD SCLC pts according to their performance status, local extension of lesions, type of treatment and the completeness of staging. In the period 01.01.1986-31.12.1996 in the Institute of Tuberculosis and Chest Diseases 579 consecutive SCLC pts were treated. LD was diagnosed in 345 pts. In 193 out of them the staging was complete that is in addition to chest x-ray, abdomen USG/CT, brain CT/MRI and bilateral bone marrow trepanobiopsy was done. 152 pts were also regarded as limited but the staging was not complete. LD pts proved by complete staging survived significantly longer (median survival 15.7 months) than others (median survival 10.2 months). The pts in whom complete staging was done were however in better performance status and had smaller local extension of lesions and had more often radiotherapy than others. Status performance, local extension of lesions and radiotherapy but also completeness of staging were independent prognostic factors in multivariate analysis.

[Sepsis with staphylococcal vegetation on tricuspid valve. Differential diagnosis with Wegener's granulomatosis]

Acute, febrile disease in a young person with no previous medical history is most often caused by infection. If disease progresses despite antimicrobial treatment vascular and collagen diseases should be taken into account in differential diagnosis We present a case of a young man, with lung infiltrations and cavities in the course of febrile illness. He was referred to our hospital with a suspicion of Wegener's granulomatosis after few days of ineffective antimicrobial therapy. Positive blood culture for S. aureus and demonstration of tricuspid valve vegetation on echocardiographic examination enabled to make a final diagnosis of infective endocarditis with multiple lung abscessus.

[Wegener's granulomatosis overlapped with Takayasu arteritis complicated by thrombosis of the internal jugular vein]

A 30 year-old woman with Wegener's granulomatosis with typical lesions of nose, mouth, skin, lung and positive c-ANCA titre was admitted to our hospital because of ineffective treatment with corticosteroids and cyclophosphamide. Infiltration of the left side of chest wall and collateral circulation were seen during physical examination. Ultrasound examination revealed thrombus in the left internal jugular vein and in the left subclavicular vein. Angio CT revealed parenchymal infiltration in the lower right lobe, thrombi in segmental arteries in this area and enlarged mediastinum. MRI examination revealed thickened aorta wall to 25 mm with its contrast enhancement. It suggested inflammatory infiltration of aorta arcus and its branches. This picture was similar to early stages of Takayasu arteritis but our patient had no typical clinical symptoms related to narrowing or obliteration of large arteries. We recognised Wegener's granulomatosis with overlapped Takayasu arteritis with thrombosis of jugular vein and pulmonary thrombosis. In differential diagnosis: Wegener's granulomatosis with large arteries involvement is taken into account. Treatment with cyclophosphamide and prednisolone was effective.

Expression of vascular endothelial growth factor and basic fibroblast growth factor receptors in lung cancer

OBJECTIVE

To determine the expression of two angiogenic factors, vascular endothelial growth factor (VEGF) and fibroblast growth factor receptors (FGFR), in non-small cell lung carcinoma (NSCLC) in relation to tumor stage (TN0, TN1, TN2) and in association with the expression of p53 protein, a potential suppressor of tumor angiogenesis.

STUDY DESIGN

The immunohistochemical (IHC) expression of VEGF and FGFR was examined in paraffin sections of 56 NSCLC in relation to the presence of lymph node metastases and p53 expression. Nodal status of NSCLC determined: 27 tumors, N0; 16, N1; and 13, N2 stage. Semiquantitative analysis with a score corresponding to IHC staining intensity and percentage of positive cells was used. Statistical analysis was performed with the chi 2 test.

RESULTS

A significant association was noted between VEGF and FGFR expression in NSCLC. No relation was found between VEGF, FGFR expression and lymph node metastasis or p53 expression.

CONCLUSION

We assume that VEGF and FGFR act in a synergistic manner in NSCLC and that their expression is not related to lymph node metastases. Angiogenesis is a very complex phenomenon and heterogeneous within tumors. Also, it is affected by microenviromental factors.