Clinical Outcomes Beyond 1L EGFR-TKI Progression in mNSCLC: Final Results of the Real-World Study 'LUNGFUL'

BACKGROUND/AIM

Real-world data on the EGFR mutational profile upon progression after first/second-generation EGFR-TKI treatment in patients with advanced non-small-cell lung cancer (NSCLC) and treatment strategies employed thereon are needed.

PATIENTS AND METHODS

This observational study was conducted in 23 hospital-based lung cancer Centers in Greece (protocol code: D133FR00126). Ninety-six eligible patients were consecutively enrolled between July-2017 and September-2019. Re-biopsy was performed in 18 of 79 patients who tested T790M-negative in liquid biopsy after progression in the first-line (1L) setting.

RESULTS

Of the study population, 21.9% tested T790M-positive, while 72.9% proceeded to 2L treatment, mainly comprising of a third-generation EGFR-TKI (48.6%), a switch to chemotherapy (30.0%), or chemo-immunotherapy (17.1%). The objective response rate (ORR) in 2L was 27.9% in T790M-negative and 50.0% in T790M-positive patients. Of evaluable patients, 67.2% experienced disease progression; median progression-free survival (PFS) was 5.7 and 10.0 months among T790M-negative and positive patients, respectively. Among T790M-negative patients, longer median PFS and post-progression survival were observed with third-generation EGFR-TKI treatment.

CONCLUSION

Mutational status and treatment strategy were identified as critical determinants of clinical outcomes in the 2L-setting of EGFR-mutated NSCLC patients in real-world settings in Greece, with early diagnosis, appropriate molecular testing and high-efficacy treatments at first lines positively affecting ORR and PFS.

Effect of compliance to continuous positive airway pressure on exacerbations, lung function and symptoms in patients with chronic obstructive pulmonary disease and obstructive sleep apnea (overlap syndrome)

INTRODUCTION

Patients with overlap syndrome (OS), that is obstructive sleep apnea (OSA) and chronic obstructive pulmonary disease (COPD), are at increased risk of acute exacerbations related to COPD (AECOPD). We assessed the effect of CPAP compliance on AECOPD, symptoms and pulmonary function in OS patients.

METHODS

Consecutive OS patients underwent assessment at baseline and at 12 months under treatment with CPAP of: AECOPD and hospitalizations, COPD Assessment Test (CAT) and modified British Medical Research Council (mMRC) questionnaires, pulmonary function testing and 6-min walking test (6MWT).

RESULTS

In total, 59 patients (54 males) with OS were followed for 12 months and divided post hoc according to CPAP compliance into: group A with good (≥4 h CPAP use/night, n = 29) and group B with poor (<4 h CPAP use/night, n = 30) CPAP compliance. At 12 months, group A showed improvements in FEV₁ (p = 0.024), total lung capacity (p = 0.024), RV/TLC (p = 0.003), 6MWT (p < 0.001) and CAT (p < 0.001). COPD exacerbations decreased in patients with good CPAP compliance from baseline to 12 months (17 before vs. 5 after, p = 0.001), but not in those with poor compliance (15 before vs. 15 after, p = 1). At multivariate regression analysis, COPD exacerbations were associated with poor CPAP compliance (β = 0.362, 95% CI: 0.075-0.649, p = 0.015).

CONCLUSIONS

When compared to poorly compliant patients, OS patients with good CPAP compliance had a lower number of AECOPD and showed improved lung function and COPD related symptoms.

Chest ultrasound findings in usual interstitial pneumonia patterns: a pilot study

It is unknown what role chest ultrasound plays in distinguishing the various usual interstitial pneumonia (UIP) patterns of high-resolution chest tomography (HRCT). The purpose of this study was to see if there was a link between the results of chest ultrasound (u/s) and HRCT in patients with idiopathic pulmonary fibrosis (IPF). We performed chest u/s in 16 patients with UIP and probable UIP patterns to indeterminate UIP and alternative diagnosis patterns in this single center prospective study to determine any possible relationship with the HRCT findings. A chest radiologist reviewed each HRCT to determine the pattern in accordance with the American Thoracic Society (ATS) / European Respiratory Society (ERS) Guidelines. The local multidisciplinary committee validated the patients' diagnoses before they were included. When compared to the indeterminate for UIP or alternative diagnosis pattern group, there was a trend (p=0.07) toward the presence of more B lines in UIP or probable UIP patterns. There was no statistically significant difference in the presence of small, large, white lung, or pleural line thickening >5mm. Subgroup analysis revealed that patients with honeycombing were more likely to have a fragmented pleural line (p=0.04). To summarize, in our pilot study, chest u/s appears unable to differentiate UIP and probable UIP patterns from indeterminate UIP and alternative diagnosis patterns. However, it appears that this technique can be used to recognize the honeycombing pattern.

Two years progression-free survival under vinorelbine metronomic therapy of a patient with metastatic epithelioid hemangioendothelioma

Epithelioid hemangioendothelioma (EHE) is a very rare vascular tumor, originating from endothelial cells. The etiology of EHE is unknown, yet at the molecular level, different angiogenic stimulators may act as promoters of endothelial cell proliferation. The tumor affects more commonly the lung, the liver and the bones but it can affect any other organ. Due to its heterogeneous presentation and its rarity it is often misdiagnosed. No treatment is proved to be efficient in metastatic EHE and the median survival of patients with metastatic pleural disease is generally poor, less than one year. we report a case of a 57-year-old female with multiple metastatic EHE including pleural, diagnosed by medical thoracoscopy, with a progression-free survival of 24 months with oral vinorelbine as maintenance therapy after combination of cisplatin-vinorelbine. We believe that this therapy might be of value to test in this patient population as it has never been tested before.

Pulmonary calcinosis associated with Alport syndrome

We report the case of a 48-year-old woman under dialysis from chronic renal failure (CRF) since the age of 27, due to Alport syndrome. The patient underwent routine chest X-ray on which diffuse micronodules were shown. Chest computed tomography showed partially calcified micronodules with centrilobular distribution respecting the subpleural spaces and predominant in the upper lobar regions. Metastatic pulmonary calcinosis was confirmed by the bone scan with an overall course of 29 years. This is the first reported case of pulmonary calcinosis from CRF due to Alport syndrome.

Review of the Physiology and Anesthetic Considerations for Pleuroscopy/Medical Thoracoscopy

Pleuroscopy or medical thoracoscopy is the second most common utilized procedure after bronchoscopy in the promising field of interventional pulmonology. Its main application is for the diagnosis and management of benign or malignant pleural effusions. Entry into the hemithorax is associated with pain and patient discomfort, whereas concurrently, notable pathophysiologic alterations occur. Therefore, frequently procedural sedation and analgesia is needed, not only to alleviate the patient's emotional stress and discomfort by mitigating the anxiety and minimizing the pain but also for yielding better procedural conditions for the operator. The scope of this review is to present the physiologic derangements occurring in pleuroscopy and compare the various anesthetic techniques and sedative agents that are currently being used in this context.

The Immune Microenvironment of Malignant Pleural Mesothelioma: A Literature Review

Malignant pleural mesothelioma (MPM) is a rare and aggressive tumour with a poor prognosis, associated with asbestos exposure. Nowadays, treatment is based on chemotherapy with a median overall survival of less than two years. This review highlights the main characteristics of the immune microenvironment in MPM with special emphasis on recent biological advances. The MPM microenvironment is highly infiltrated by tumour-associated macrophages, mainly M2-macrophages. In line with infiltration by M2-macrophages, which contribute to immune suppression, other effectors of innate immune response are deficient in MPM, such as dendritic cells or natural killer cells. On the other hand, tumour infiltrating lymphocytes (TILs) are also found in MPM, but CD4+ and CD8+ TILs might have decreased cytotoxic effects through T-regulators and high expression of immune checkpoints. Taken together, the immune microenvironment is particularly heterogeneous and can be considered as mainly immunotolerant or immunosuppressive. Therefore, identifying molecular vulnerabilities is particularly relevant to the improvement of patient outcomes and the assessment of promising treatment approaches.

A Real-World, Observational, Prospective Study to Assess the Molecular Epidemiology of Epidermal Growth Factor Receptor (EGFR) Mutations upon Progression on or after First-Line Therapy with a First- or Second-Generation EGFR Tyrosine Kinase Inhibitor in EGFR Mutation-Positive Locally Advanced or Metastatic Non-Small Cell Lung Cancer: The 'LUNGFUL' Study

Simple Summary

Non-small cell lung cancer (NSCLC) accounts for approximately 85% of lung cancer cases, with few patients carrying driver mutations in the gene encoding for epidermal growth factor receptor (EGFR). Advances in translational research have established EGFR tyrosine kinase inhibitors (TKIs) as the standard first-line therapy for NSCLC patients with activating EGFR mutations. The aim of our observational study was to assess the frequency of T790M acquired resistance and predictors of its presence, in patients with EGFR-mutated locally advanced or metastatic NSCLC who have progressed in the first-line EGFR-TKI treatment setting with first- or second-generation TKIs and have undergone molecular testing in tissue and/or plasma biopsy. The study highlights the challenges of performing tissue re-biopsy in routine care settings, which can lead to patients considered non-eligible for certain therapies from which they can benefit, and merits further actions from the healthcare community, in order to establish re-biopsy as a standard procedure.

Abstract

Background: Real-world data on the molecular epidemiology of EGFR resistance mutations at or after progression with first- or second-generation EGFR-TKIs in patients with advanced NSCLC are lacking. Methods: This ongoing observational study was carried out by 23 hospital-based physicians in Greece. The decision to perform cobas^®EGFR Mutation Test v2 in tissue and/or plasma at disease progression was made before enrollment. For patients with negative/inconclusive T790M plasma-based results, tissue re-biopsy could be performed. Results: Ninety-six (96) eligible patients were consecutively enrolled (median age: 67.8 years) between July-2017 and September-2019. Of the patients, 98% were tested upon progression using plasma and 2% using tissue/cytology biopsy. The T790M mutation was detected in 16.0% of liquid biopsies. Tissue re-biopsy was performed in 22.8% of patients with a T790M-negative plasma result. In total, the T790M positivity rate was 21.9%, not differing between patients on first- or second-generation EGFR-TKI. Higher (≥2) ECOG performance status and longer (≥10 months) time to disease progression following EGFR-TKI treatment initiation were associated with T790M positivity. Conclusions: Results from plasma/tissue-cytology samples in a real-world setting, yielded a T790M positivity rate lower than previous reports. Fewer than one in four patients with negative plasma-based testing underwent tissue re-biopsy, indicating the challenges in routine care settings.

Medical Thoracoscopy Implementation after a European Respiratory Society Course Held from 2003 to 2016: A Survey

BACKGROUND

Medical thoracoscopy (MT) is an important procedure in the management of patients with pleural diseases.

OBJECTIVES

We designed a survey to explore whether the participants of our courses implement MT at their hospital after attending the course as no real-life data exist.

METHODS

We distributed by e-mail a questionnaire to the participants of the courses. The questionnaire included general information about the participants, the precourse experience on MT, the postcourse implementation of the technique, and the reasons for failure.

RESULTS

Responses were obtained from 104 of 324 (32.3%) identified emails. Responders were males (76%), seniors (59.7%), respiratory physicians (91.3%), working in a public/university hospital (78.8%), and mostly beginners (65.3%) from 41 countries. Following the course, 58.6% of responders either created or modified a MT program in their workplace. The reasons for not performing MT before the course were as follows: patients' referral to a thoracic surgeon, not enough training, lack of funding, department understaffed, and refusal by the hospital/department. Overall, these reasons were significantly decreased (p = 0.002) after the course.

CONCLUSIONS

Real-life data of our survey suggest that more than half of the responders have implemented the technique or modified their practice according to the skills they got from the course.

Local Anesthesia Thoracoscopy with versus without Midazolam: A Randomized Controlled Trial

BACKGROUND

Medical thoracoscopy is the gold standard for the diagnosis of pleural diseases. To date, no consensus exists regarding the choice of sedative and analgesic agents in patients undergoing local anesthetic thoracoscopy (LAT), and questions are raised as to whether sedatives may add to respiratory side effects.

OBJECTIVE

The aim of the study was to test the hypothesis that administration of midazolam associated with lidocaine versus lidocaine alone in patients with LAT adds to respiratory side effects.

METHODS

We randomly assigned 80 patients to a 1:1 study to 2 groups: local anesthesia by lidocaine (n = 40) versus lidocaine and midazolam (n = 40), with the primary end point being the mean lowest oxygen saturation. The secondary end points were cardiovascular parameters, complications, days of drainage, hospital stay, and patients' quality of life (QoL) as assessed by a visual analog scale (VAS).

RESULTS

The mean age of all patients was 66.6 ± 13.1 years. The study comprised 50 males (62.5%). No difference was observed in the demographics between the 2 groups. No significant difference was observed between the 2 groups in oxygen saturation (primary end point). A significant difference was observed in favor of the midazolam group regarding the QoL assessed by VAS.

CONCLUSION

Midazolam does not add to respiratory side effects when it is used with lidocaine for LAT, while patients' QoL is actually improved in this group. Therefore, in our department, we changed our startegy in favor of the association of lidocaine and midazolam.

Lungful: An observational prospective study to assess the molecular epidemiology of EGFR mutations upon progression on or after first line EGFR-TKI therapy, in real-life clinical settings in Greece

e21641

Background: Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) are the gold standard 1st line strategy for non-small-cell lung cancer (NSCLC) patients with activating EGFR mutations (EGFRm), associated with improved survival outcomes and quality of life compared to chemotherapy. Despite the high response rate with first- and second- generation TKIs, most patients develop resistance to treatment and progress. The acquisition of T790M mutation in exon 20 is considered the most common resistance mechanism. This study aims to investigate the molecular epidemiology of EGFR resistance mutations, focusing on T790M in EGFRm NSCLC patients treated with TKIs. Methods: The study included patients with locally advanced/metastatic EGFRm NSCLC who have progressed on or after 1st line treatment with first- or second- generation TKI. Samples either from plasma-based liquid biopsy and/or tissue re-biopsy were analysed using the Cobas EGFR Mutation Test v2. All patients signed informed consent and were enrolled between July 2017 and September 2019. Statistical analyses were performed using SAS software, Version 9.4. Results: Ninety-six eligible patients were enrolled. At the time of progression, T790M mutation was detected in 16.7%of the patients using plasma-based liquid biopsies. Among patients with negative T790M result, in plasma, tissue re-biopsy was performed in 22,7% with evaluable/valid results in 72.2% of them. T790M mutation was identified in 38.5% of re-biopsy samples. According to Cobas EGFR Mutation test results (combined plasma and tissue), T790M mutation was identified in 21.9% of the patients. Of T790M-positive patients 42.9% had previously received first and 57.1% second generation EGFR-TKI. Conclusions: Results from this study in real world clinical setting in Greece, show that EGFR-T790M acquired resistance positivity rate in plasma is lower compared to previous reports. Moreover, these data underline the challenges of implementing precision medicine using tissue re-biopsy in advanced/metastatic NSCLC. Clinical trial information: D133FR00126. [Table: see text]

Metabolic Syndrome in Patients with Coexistent Obstructive Sleep Apnea Syndrome and Chronic Obstructive Pulmonary Disease (Overlap Syndrome)

Background: Evidence suggests that metabolic syndrome (MetS) is highly prevalent in patients with obstructive sleep apnea syndrome (OSAS) and chronic obstructive pulmonary disease (COPD). However, data on the prevalence of MetS in patients having both OSAS and COPD, or overlap syndrome (OS), are scarce. The aim of this study was to evaluate the prevalence and identify predictors of MetS in patients with OS. Methods: MetS was evaluated in consecutive patients who were diagnosed with OS by polysomnography and pulmonary function testing. Results: A total of 163 subjects (138 males and 25 females) were included. MetS was present in 38% of OS patients. Patients were divided into group A (OS without MetS group: 101 patients) and group B (OS with MetS group: 62 patients). Groups were similar in terms of pulmonary function and sleep parameters. In group B, abdominal obesity was the most prevalent component of MetS (100%), followed by hypertension (82.3%), hypertriglyceridemia (72.6%), and hyperglycemia (51.6%). Age (P = 0.009) and body mass index (P = 0.029) were independent predictors of MetS in patients with OS. Conclusions: An increased prevalence of MetS was observed in a group of patients with OS. Early identification and treatment of MetS may play a significant role in prevention of complications related to OS.

Clinical long-term outcome of non-specific pleuritis (NSP) after surgical or medical thoracoscopy

Background

Thoracoscopy, either “medical” or “surgical”, is the gold standard to reveal the cause of pleural effusion by taking large biopsies. However, in some cases, the histology of pleural biopsies is inconclusive for a specific cause, describing a variable process of inflammation, encompassing for non-specific pleuritis (NSP). Questions are raised whether the surgical (or video-assisted thoracoscopic surgery, VATS) is doing better than the medical thoracoscopy (MT or pleuroscopy), but no direct comparison between the two techniques exist in the current bibliography. The aim of our retrospective study was to compare these two techniques to find whether there is any difference in the false negative cases of NSP.

Methods

We included in our study 295 patients with NSP, 179 patients who underwent VATS comparing to 116 patients who underwent MT for pleural effusion of initially undetermined cause, having a follow-up of at least one year. Analysis of patients’ files, history, clinical examinations, further tests, and follow-up were recorded.

Results

The mean age of our patients was 58.5±19.1 and M/F gender was 216/79; no difference was observed between the two groups. The mean follow-up period was 47.3±20.7 months. After VATS, only one patient (0.55%) was finally diagnosed with pleural malignancy (false negative) while after MT 2 patients (1.7%). Negative predictive value for pleura-related malignancy for VATS was 0.994 and for MT 0.982.

Conclusions

In patients with histological diagnosis of NSP both VATS and MT showed similar and excellent results of false negative cases and negative predictive value in excluding malignant pleural disease.

Increased risk for cardiovascular disease in patients with obstructive sleep apnoea syndrome-chronic obstructive pulmonary disease (overlap syndrome)

INTRODUCTION

Accumulating evidence suggests that cardiovascular disease (CVD) is highly prevalent among patients with concurrent obstructive sleep apnoea syndrome (OSAS) and chronic obstructive pulmonary disease, otherwise known as overlap syndrome (OS).

OBJECTIVES

The aim of this study was to investigate the 10-year risk for CVD in OS patients compared with OSAS patients and controls.

METHODS

Consecutive patients, referred for symptoms suggestive of OSAS, were evaluated with polysomnography and pulmonary function testing. Cardiovascular risk was assessed using the Framingham risk score (FRS) and systematic coronary risk evaluation (SCORE).

RESULTS

Overall, 244 participants (184 males) without CVD and diabetes were divided into 3 groups: controls (n = 63), OSAS (n = 139) and OS (n = 42). Both FRS and SCORE were found to be elevated in the OS group compared with the OSAS and control groups (P < .001 for all). In multivariate analysis, age (β = .461, P < .001), forced expiratory volume in first second (β = -.285, P = .036) and oxygen desaturation index (ODI) (β = .234, P = .007) were major determinants for the SCORE, whereas age (β = .308, P < .001) and apnoea-hypopnoea index (β = .252, P = .010) for the FRS.

CONCLUSION

In our study, an increased risk for CVD was observed in a group of patients with OS at the time of their initial evaluation. Further studies are needed in the field of OS in order to investigate, prevent and manage early CVD in this population.

Reduced Serum Vitamin D Levels Are Associated with Insulin Resistance in Patients with Obstructive Sleep Apnea Syndrome

Background and objectives: Obstructive sleep apnea syndrome (OSAS) is associated with cardiovascular and metabolic risk factors, such as insulin resistance. Furthermore, OSAS has been associated with decreased levels of vitamin D (Vit D). The aim of the study was to assess the association between Vit D levels (expressed as 25(OH)D serum levels) and insulin resistance in patients with OSAS. Materials and Methods: Serum 25(OH)D levels were measured in consecutive subjects who had undergone polysomnography and pulmonary function testing. OSAS patients were divided into those with (homeostatic model assessment [HOMA-IR] ≥ 2) and without insulin resistance (HOMA-IR < 2). Results: Overall, 92 patients (81 males) were included in the study. OSAS patients with insulin resistance significantly differed from those without insulin resistance in terms of the body-mass index (BMI) (36.3 ± 5.8 compared to 32 ± 5.6 kg/m², respectively, p = 0.001), apnoea-hypopnoea index (AHI) (57.4 ± 28.9 compared to 40.9 ± 27.9 events/h, respectively, p = 0.009) and indices of hypoxia during sleep. Patients with OSAS and insulin resistance had lower levels of serum 25 (OH) D compared with OSAS but without insulin resistance (19.3 ± 11.5 vs 26.7 ± 12.2 ng/mL, respectively, p = 0.005). Regression analysis demonstrated a negative association of 25(OH)D levels (β = −0.048, odds ratio [OR]: 0.953, 95% confidence interval [CI]: 0.913–0.995, p = 0.030) and a positive association of BMI (β = 0.110, OR: 1.116, 95% CI: 1.007–1.237, p = 0.036) with insulin resistance. Conclusions: Vit D insufficiency was significantly more frequent among OSAS patients with insulin resistance. Both low 25(OH)D levels and high BMI were associated with the risk of insulin resistance in this population.

Comparison of cytology, chest computed and positron emission tomography findings in malignant pleural effusion from lung cancer

Background

Malignant pleural effusion (MPE) is a common medical problem in lung cancer (LC). Pleural fluid cytology (PFC), chest computed tomography (CCT) and positron emission tomography (PET) findings are helpful as first line approach. The objectives of this study were to evaluate whether there is a correlation between PFC, CCT and PET in patients with MPE due to LC.

Methods

We selected patients from our electronic files. Data of PFC, pleural biopsy (PB), CCT and PET have been recorded and analyzed.

Results

A total of 101 consecutive patients (66 males, 65.3%) with a mean age of 66.2±31 years were selected. Types of LC were adenocarcinoma in 71 patients (70.2%), squamous in 13 (12.8%), small-cell in 12 (11.8%) and large cell in 5 (4.9%). CCT showed nodules in 6 (5.9%), pleural thickening in 8 (7.9%) and both in 17 (16.8%) patients. PFC was positive in 55/91 thoracentesis (60.4%) and 32/52 thoracoscopy (61.5%), while PB in 38/40 performed (95%). PET fixation was found in 32/47 (68%) patients who had MPE at diagnosis. When we associate PFC to CCT and PET findings, the yield in our study becomes 90%. No correlation was observed between CCT findings and PFC (P=0.62) between PFC and PET fixation (P=0.63) or between CCT and PET (P=0.06).

Conclusions

In our cohort of LC patients with MPE, we observed a high sensitivity for PFC, while in most of the cases no findings were observed in CCT. PET had a relative low sensitivity. However, when all 3 methods were combined the yield was 90%.

Lung function changes after chemoradiation therapy in patients with lung cancer treated by three usual platinum combinations

Background

Reports point out lung toxicity of chemotherapeutic agents and radiation therapy in cancer patients. The aim of our study was to assess lung function after sequential chemoradiation therapy in patients with lung cancer.

Methods

Fifteen lung cancer patients participated the study and underwent lung function assessment before and after sequential treatment of chemotherapy with the 3 most applied platinum-based combinations: of vinorelbine (VN) 6 patients, gemcitabine (GEM) 4 patients and etoposide (EP) 5 patients and radiation therapy. Lung function tests were forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), total lung capacity (TLC), diffusing capacity for carbon monoxide (DL_CO) and carbon monoxide transfer coefficient (Kco).

Results

Mean patients' age was 58±9.4 years (42-75 years). Male patients were 14 (93.3%), all smokers. Overall, after chemoradiation treatment significant changes were noted in FEV1 (P=0.012), FVC (P=0.046), TLC (P=0.04) from baseline. The drop from baseline was more significant after chemoradiation therapy in DLCO (P=0.002) and KCO (P=0.008).

Conclusions

According to our results, sequential chemoradiation causes significant changes in lung function parameters in patients with lung cancer.

Longitudinal outcomes of patients enrolled in a phase Ib clinical trial of the adipose-derived stromal cells-stromal vascular fraction in idiopathic pulmonary fibrosis

BACKGROUND AND OBJECTIVE

Cell-based therapies have been used for the management of several diseases, holding promising results. Few studies have evaluated their use in chronic lung diseases. Idiopathic pulmonary fibrosis (IPF) remains a lethal disease although new therapies have emerged the recent years. We have recently published a phase I study of 14 patients receiving endobronchially adipose-derived stem cells (ADSCs). The aim of this report is to assess the outcome for our patients' population.

PATIENTS AND METHODS

Patients who originally participated in this phase I study were followed up until the time of death. Pulmonary function tests as well as disease progression and survival time points were recorded.

RESULTS

After first administration, a significant functional decline was observed as assessed by the changes (delta-Δ) of diffusion capacity for carbon monoxide (DLco) (mean ΔDLco = 6.2%, P = .04) and forced vital capacity (FVC) (mean ΔFVC = 6%, P = .029) at 18 and at 24 months, respectively. Median overall progression-free survival was 26 months and median overall survival was 32 months. All patients were alive for at least 2 years (survival rate, 100%) after first administration. Twelve patients (85.7%) died owing to disease progression. None of the patients experienced tumor development.

CONCLUSIONS

Significant functional decline occurred at 24 months after first administration. The median survival and time to progression are in line with the published epidemiologic data. Further clinical trials complemented by mechanistic studies are sorely needed to delineate the role of ADSCs in IPF pathogenesis and treatment.

Necrotizing sarcoid granulomatosis: A distinctive form of pulmonary granulomatous disease

OBJECTIVES

To define the characteristics of necrotizing sarcoid granulomatosis (NGS) a very rare pulmonary disease hardly recognised by pulmonologists and pathologists.

DATA SOURCE

PubMed was searched for the term necrotising or necrotizing sarcoid granulomatosis.

STUDY SELECTION

All cases reported in the English literature were included.

RESULTS

NGS is presented at all ages (range 8-68 years) with a median age of 42 years old. It shows female (62%) and Caucasian (80%) predominance. The most frequent symptoms are cough, fever, dyspnoea and chest pain. Extra-pulmonary involvement is found in one third of the cases, with ocular being the most common (12.5%). At imaging, multiple nodules (64.75%) or a solitary mass (20.49%) are found accompanied by mediastinal lymphadenopathy at one third of the cases. It can be clinically mistaken for malignancy as it is tumour-like, increases rapidly in size and it is hyperfixating in PET-SCAN. Histologically, NGS is defined by large areas of necrosis, well-formed granulomas and vascularitis.

CONCLUSION

NGS is a disease often confounded clinically with malignancy or with sarcoidosis even histologically when all criteria are not strictly applied. This review provides NGS' characteristics and discusses its differential diagnosis form sarcoidosis, Wegener granulomatosis and tuberculosis.

Bilateral empyema treated by sequential pleuroscopy

Bilateral empyema associated to infectious pericarditis is an extremely rare, yet life-threatening condition. Pleuroscopy-medical thoracoscopy has proved its efficacy in series of patients with empyema. Yet, all reported cases treated by this technique, concerned patients with pleural infection located to a single hemithorax. We present the case of a 71-year-old man with bilateral empyema treated successfully by sequential pleuroscopy, associated to infectious pericarditis.

Endobronchial metastases from melanoma: a survival analysis

BACKGROUND

Metastatic spread to the tracheobronchial tree from other than bronchopulmonary tumors is a common clinical problem. However, malignant melanoma, a highly metastatic potential tumor, is rarely metastasing in the airways. Therefore little is known about survival of patients with endobronchial metastasis from melanoma.

OBJECTIVES

The aim of our study was to assess survival of patients with endobronchial metastasis of melanomas according to clinical and radiological features, to determine any possible factor affecting survival.

METHODS

This retrospective study included 19 patients who underwent a bronchoscopy from 11 different hospitals. Data about patients' demographics, symptoms, radiographic, endoscopic findings and treatment were investigated to evaluate any possible impact on survival.

RESULTS

Endobronchial metastases occurred at a median of 48 months (range 0-120) following the diagnosis of the primary tumor. About 73.7% of patients had other proven metastases when the endobronchial involvement was diagnosed. Symptoms are not specific as well as radiological features. Median overall survival of the studied population was 6 months (range 1-46). Factors of poor survival were multiple metastatic sites (P = 0.019), pleural (P = 0.0014) and soft tissue metastasis (P = 0.024). Different treatment modalities applied in our patients showed no effect on survival.

CONCLUSION

Patients with endobronchial metastasis have overall poor survival, affected by multiple organ involvement, the presence of pleural and soft tissue disease, while no impact on survival has been shown by any treatment applied.

41 years into the bronchial tree: a very obstructive cap

Inhaled foreign body, which remains unknown from the childhood until the mid-age is extremely rare. We report the case of a 58-year-old man who was addressed to our department to remove a pen cap, inhaled forty-one years earlier. It was discovered during a routine pre-op check-up for bronchiectasis, caused by the long period of retention into the bronchial tree. The successful removal of the cap changed completely the therapeutic strategy, as there was no indication for surgical resection any more.

Mean Platelet Volume as a Surrogate Marker for Platelet Activation in Patients With Idiopathic Pulmonary Fibrosis

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is associated with a prothrombotic state.

AIM

To study mean platelet volume (MPV) and Platelet Distribution Width (PDW) as markers of platelet activation and their potential association with lung function in patients with recently diagnosed IPF.

MATERIALS AND METHODS

This study included 56 patients with IPF (age 64.9±7.4 years) and 79 controls (age 64.2 ± 5.9 years).

RESULTS

An inverse relation was demonstrated between platelet count and MPV in the control group but not among patients with IPF. Platelet count was significantly lower in patients with IPF compared with controls (230 ± 60 vs 256 ± 75 × 10(3)/μL, P = .038). Conversely, MPV was higher in patients versus controls (10.3 ± 1.2 vs 9.8 ± 1.2 fl, P = .024), while there was no difference between the groups in PDW. Respiratory function was, as expected, significantly impaired in patients with IPF versus controls in terms of forced expiratory volume in first second (FEV1; 67.2 ± 23.1 vs 102.6 ± 15.9% of predicted value, P < .001), forced vital capacity (FVC; 65.3 ± 21 vs 95.2 ± 16.1% of predicted value, P < .001), FEV1/FVC (83.1 ± 15 vs 87.5 ± 6.4%, P = .041) and partial pressure of oxygen in arterial blood (PaO2; 67.1 ± 10.3 vs 81.5 ± 15.2 mm Hg, P < .001). No significant correlation was seen between MPV and FVC (r = -.1497, P = .275), MPV and lung diffusion capacity for carbon monoxide (r = .035, P = .798) and total lung capacity (r = .032, P = .820).

CONCLUSIONS

Patients with IPF exhibit higher MPV values and lower platelet count. Further studies are needed to assess the clinical implications of these findings.

Pleuroscopy in 'Idiopathic' eosinophilic pleural effusions

BACKGROUND

Idiopathic eosinophilic pleural effusions (IEPEs) comprise the eosinophilic pleural effusions for which a specific aetiology cannot be established. There are no reports investigating IEPE on the basis of a systematically applied pleuroscopy approach and entailing an appropriate patient follow-up till the final outcome is established; existing series rather combine clinical and thoracocentesis criteria to establish the idiopathic character of the diagnosis.

OBJECTIVES

The aim of our study was to assess the clinical outcome of patients with IEPE, who underwent a systematic diagnostic approach by pleuroscopy.

METHODS

We studied 10 patients with IEPE among 175 consecutive patients who underwent pleuroscopy for undiagnosed pleural effusion. Pleural biopsies were obtained from observed lesions. All patients were followed up by means of clinical examination and imaging.

RESULTS

The diagnosis of IEPE was established in 10 patients (median age was 50.5 years, range 35-91). Macroscopic examination of the pleura showed diffuse thickening with pleural plaques in eight patients, consistent with diffuse pleural eosinophilic inflammation histologically proven. In two patients, macroscopic examination showed scattered nodules associated with non-caseating granulomas histologically. In all 10 patients, a specific aetiology could not be established. Follow-up was available for all patients ranging from 24-102 months (median 60 months). No patient received a specific treatment during the follow-up period. No relapse of a pleural effusion was documented during this period.

CONCLUSION

Pleuroscopy is mandatory in diagnosing IEPE. Negative histology and a long follow-up showed a benign course. These findings suggest that we should call these effusions 'indeterminate'.

Histological changes after radiation therapy in patients with lung cancer: a prospective study

BACKGROUND

Radiotherapy for lung cancer may induce pneumonitis. However, histological effects of radiotherapy on normal lung tissue are unknown. Transbronchial biopsy (TBB) is safe and accurate in monitoring parenchymal lesions in lung-transplanted patients. The aim of this prospective study was to evaluate whether histological changes of the healthy lung parenchyma after radiotherapy are present on TBB biopsies.

PATIENTS AND METHODS

Twelve patients with lung cancer necessitating radiation therapy participated in the study. Serial TBBs were obtained from lung parenchyma contra-lateral to the tumor before, just after radiotherapy, and at six months post-irradiation. Evaluation of each specimen was based on the presence of congestion, inflammation, hemorrhage and fibrosis.

RESULTS

A significant increase of interstitial fibrosis (thickness) and congestion was observed between the point prior to radiotherapy and after completion of radiotherapy (p=0.047), as well as between the pre-radiotherapy point and at six months after radiotherapy (p=0.014). Six patients (50%) showed intra-alveolar fibroblastic growth after radiotherapy. No patient showed clinical or radiographic findings of radiation pneumonitis.

CONCLUSION

Even in the absence of clinical or radiographic findings, the lung parenchyma contra-lateral to the tumor suffers early histological lesions after radiation therapy, as monitored by serial TBBs.

Prognostic factors in patients presenting with pleural effusion revealing malignancy

BACKGROUND

The survival of patients with malignant pleural effusion is considered generally poor. Most of the studies reporting results of prognostic factors are retrospective, using pleural thoracentesis for diagnosis. The objectives of our study were to reveal possible prognostic factors in patients initially presenting with undiagnosed pleural effusion proven to be malignant by diagnostic thoracoscopy.

METHODS

Ninety consecutive patients, 48 of whom were male (53%), with a median age of 69 years (range 37-93) and a performance status (PS) of 0/1 (63%) and with initially undiagnosed pleural effusion that was proven to be malignant by thoracoscopy were evaluated. Survival time was defined as the time from thoracoscopic diagnosis to death or the last follow-up. A regression analysis was used to determine significant clinical and biological prognostic factors.

RESULTS

Lung carcinoma (44.4%), breast carcinoma (24.4%), and mesothelioma (12.2%) were the most frequent tumors diagnosed. The median overall survival was 11 months (range 0.5-55). The survival of the patients was related to the following factors: histology of the primary tumor (p = 0.008), PS (p < 0.001), white blood cells (p = 0.018), and the blood neutrophil-to-lymphocyte (N/L) ratio (p = 0.002). Multiple regression showed PS, histology, and the N/L ratio.

CONCLUSION

The factors affecting survival in our patients were PS, primary tumor histology, and the N/L ratio. These factors may help physicians select patients for treatment and/or interventional procedures.

A rare case of "switch on and off" multi-system Langerhans cell histiocytosis in an adult patient

INTRODUCTION

We report the case of a 24-year-old Greek woman with histologically proven osseous and pulmonary Langerhans cell histiocytosis whose lesions had progressively regressed with a "switch on and off" mode. This is the first report in the literature of this mode of presentation of Langerhans cell histiocytosis.

CASE PRESENTATION

The patient had first presented at the age of 20 years with a solitary lesion of the humerus which spontaneously regressed. At that time, no therapy or smoking cessation was indicated. Four years later she presented with bilateral pneumothorax and pulmonary lesions of Langerhans cell histiocytosis. She had pleurodesis for this disease-related complication, and no further systemic treatment was applied, except with regard to smoking cessation. During the follow-up period, her pulmonary lesions regressed without recurrence six years after the initial lung involvement.

CONCLUSION

This uncommon case of remission of multi-system Langerhans cell histiocytosis indicates the unpredictable evolution of the disease, raising the question of conservative management in such a patient.

Light-chain 3A autophagic activity and prognostic significance in non-small cell lung carcinomas

BACKGROUND

Lung carcinoma has a poor prognosis that is mainly predicted by the stage of the disease. Despite evaluation of various prognostic factors, the role of autophagy, a self-degradative process involved in the turnover of cytoplasmic material, remains unexplored in lung malignancy.

METHODS

Autophagic activity was investigated in 115 patients with non-small cell lung carcinoma treated with surgery (64 squamous cell carcinomas, 24 adenocarcinomas of mixed subtype, 18 large cell carcinomas, 9 uncommon types). The median overall survival was 32 months (range, 2-102 months). We used the MAP1LC3A antibody and a standard immunohistochemical technique. Autophagic activity was correlated with clinical and pathologic parameters.

RESULTS

Immunohistochemical examination revealed three patterns of autophagic activity: diffuse cytoplasmic, cytoplasmic perinuclear, and "stone-like" structures (SLSs), which are dense, rounded cytosolic structures typically enclosed within light-chain 3 (LC3) A-positive vacuoles. A high SLS count was associated with a reduction of the overall median survival from 88 to 15 months and constituted the strongest independent variable in multivariate analysis. Interestingly, a high presence of SLS defined significantly poor prognosis within stage I and II, whereas a similar trend was noted within stage III. The other two patterns of LC3A reactivity were not correlated with prognosis.

CONCLUSIONS

Exaggerated autophagy, as indicated by the intense presence of SLSs, is strongly correlated with a poor outcome in non-small cell lung carcinoma, suggesting possibly that autophagy functions as a survival tool in cancer cells.

Intrapleural r-tPA in association with low-molecular heparin may cause massive hemothorax resulting in hypovolemia

The use of intrapleural instillation of recombinant tissue plasminogen activator (r-tPA) in the treatment of pleural infection may increase pleural fluid drainage associated with a clinical and imaging improvement, leading to a faster resolution. The use of r-tPA is generally well tolerated. Here we report 2 cases of massive pleural hemorrhage resulting in life-threatening hypovolemia, in 2 patients treated with intrapleural r-tPA for a pleural infection, who were simultaneously receiving systemic anticoagulation (1 therapeutic, the second prophylactic) with low-molecular weight heparin. It appears that the decision of treating pleural infection with r-tPA in patients receiving therapeutic or prophylactic systemic anticoagulation must be well balanced and in case of association of these compounds, close monitoring is necessary.

Intrapleural administration of lipoplatin in an animal model

BACKGROUND

Lipoplatin is a new liposomal cisplatin already tested in solid tumors with encouraging results. Little is known about the activity of lipoplatin administered intrapleurally (IP).

AIM

The aim of this study was to assess in an animal model the pharmacokinetics, and potentially induced histopathological lesions of lung and kidney after IP vs. IV injection of lipoplatin.

METHODS

15 male Wistar rats were assigned to an IV group at dose 10mg/kg of lipoplatin (group 1) and to IP groups at 10 (group 2) or 20mg/kg (group 3) equal to 60 and 120 mg/m(2) in humans respectively. After lipoplatin administration, serial plasma samples were analyzed by atomic absorption spectrometry for the maximum plasma concentration (C(max)), the area under the plasma concentration-time curve (AUC), and the total body clearance (CL). Pleura, lungs and kidneys of the rats were histologically examined for possible lesions.

RESULTS

The C(max) was significantly higher in groups 1 vs. 2 (p = 0.02) and vs. 3 (p = 0.01). The AUC of groups 3 vs. 1 was significantly higher (p = 0.028) but the AUC of groups 2 vs. 1 was significantly lower (p = 0.02). CL in IP rats did not differ considerably compared to the IV. Inflammatory changes were noted in the pleura of IP rats and mild kidneys lesions in IV group.

CONCLUSION

Compared to the IV route, IP20 administration of lipoplatin yielded higher AUC, equal CL, but a significantly lower C(max). As C(max) is a determinant of lipoplatin toxicity, IP administration might offer a more effective therapeutic index while improving tolerability. We noted fibrotic changes in the pleura of IP rats, and mild kidneys changes in IV rats, as expected.

Reduction in cotton dust concentration does not totally eliminate respiratory health hazards: the Greek study

A number of epidemiological studies have shown that byssinosis is associated with exposure to high levels of cotton dust. In this first survey, the prevalence of respiratory symptoms in cotton workers under low concentration of cotton dust was investigated. A respiratory questionnaire consisting of 47 questions was given to 443 cotton workers. Their lung function was measured with spirometry. Breathing zone cotton dust concentration was measured by personal samplers and static sampling was used to define the level of the work area concentration. Workers with abnormalities in the pulmonary function parameters, including forced expiratory volume in 1 second (FEV₁), forced vital capacity (FVC) and peak expiratory flow rate (PEFR), were 5.9%. In this group of operatives 7.7% had symptoms compatible with byssinosis, 65.4% of them were smokers, 69.2% of them had symptoms of allergic rhinitis, while 72.2% of them were smokers. Asthma, which appeared after the age of 30, was reported by 57.7%, while 60% of them were smokers. Mean breathing zone cotton dust concentration was 0.16 mg/m³ and the mean work area cotton dust concentration 0.14 mg/m³. Despite the reduction in cotton dust concentration, byssinosis symptoms, allergic rhinitis, asthma and impaired pulmonary function are the most common findings in our cotton workers depending on the duration of exposure, whether they are smokers or not and the nature of the cotton dust.