Mantle cell lymphoma with endobronchial involvement: A case report

BACKGROUND

Mantle cell lymphoma (MCL) is a subtype of Non-Hodgkin's lymphoma (NHL). MCL frequently affects extranodal sites while endobronchial involvement is uncommon. Only 5 cases of MCL with endobronchial involvement have been previously reported.

CASE SUMMARY

A 56-year-old male patient arrived at the hospital complaining of a dry cough. A mass in the right upper lobe of the lung was revealed in Chest computed tomography (CT). Right lung hilar and mediastinal lymphadenopathies were also found by CT scan. The patient was diagnosed with central-type lung cancer with multiple lymph node metastases after positron emission tomography (PET) CT scan examination. The fiber optic bronchoscope examination revealed diffuse neoplasm infiltration in the inlet of the right up lobar bronchus. The patient was finally diagnosed with MCL based on the bronchoscopy and mediastinoscopy biopsy results.

CONCLUSION

MCL could masquerade as central type lung cancer. An endobronchial biopsy examination is necessary for the early diagnosis of MCL.

Bronchial eosinophils, neutrophils, and CD8 + T cells influence asthma control and lung function in schoolchildren and adolescents with severe treatment-resistant asthma

BACKGROUND

Studies in adult severe treatment-resistant asthma (STRA) have demonstrated heterogeneous pathophysiology. Studies in the pediatric age group are still scarce, and few include bronchial tissue analysis.

OBJECTIVE

We investigated 6-18-year-old patients diagnosed with STRA in Sao Paulo, Brazil, by characterizing the different lung compartments and their correlations with asthma control and lung function.

METHODS

Inflammatory profiles of 13 patients with a confirmed diagnosis of STRA were analyzed using blood, induced sputum, bronchoalveolar lavage, viral and bacterial screens and endobronchial biopsy. Inflammatory cells, cytokines, and basement membrane thickening were tested for correlations with the asthma control test (ACT) and spirometry and plethysmography parameters.

RESULTS

Endobronchial biopsy specimens from 11 patients were viable for analysis. All biopsies showed eosinophilic infiltration. Submucosal (SM) eosinophils and neutrophils were correlated with worse lung function (pre-BD FEV1), and SM neutrophils were correlated with fixed obstruction (post-BD FEV1). Intraepithelial (IE) neutrophils were positively correlated with lung function (pre-BD sGaw). CD8 + T cells had the highest density in the IE and SM layers and were positively correlated with ACT and negatively correlated with the cytokines IL1β, IL2, IL5, IL7, IL10, IL12, IL17, GCSF, MCP-1, INF-δ, and TNFα in sputum supernatant. The ASM chymase + mast cell density correlated positively with quality-of-life score (pAQLQ) and ACT.

CONCLUSION

Eosinophils and SM neutrophils correlated with worse lung function, while IE neutrophils correlated with better lung function. Most importantly, CD8 + T cells were abundant in bronchial biopsies of STRA patients and showed protective associations, as did chymase + mast cells.

Airway smooth muscle as an underutilised biomarker: a case report

Background

Severe asthma and chronic obstructive pulmonary disease (COPD) can be challenging to manage, particularly when the clinical features may be similar. With the increased availability of advanced therapies for both entities, it is more important than ever to diagnose and phenotype accurately to inform appropriate treatment decisions. This case highlights the use of endobronchial biopsies to allow for histological evaluation of airways disease, and in particular the role of airway smooth muscle mass as an additional biomarker that could facilitate the diagnostic process.

Case presentation

A 65 year old woman presented with a diagnosis of severe COPD on the background of previous smoking and mild childhood asthma. Despite taking maximal inhaled pharmacotherapy, she had frequent exacerbations requiring corticosteroids and remained dyspnoeic on mild exertion. Lung function tests showed severe obstruction on spirometry (forced expiratory ratio 43%, forced expiratory volume in 1 s 47% predicted), and single breath Diffusing Capacity for Carbon Monoxide was moderately reduced at 45% predicted. Computed tomography revealed hyperinflation without marked emphysema. Quantitative CT for emphysema distribution demonstrated a relatively small lung fraction of 9.35% with <− 950 Hounsfield units. Bronchoscopy with endobronchial biopsy was undertaken to further determine the underlying pathology, and airway mucosa histology was consistent with typical findings of asthma. The patient was treated with bronchial thermoplasty as she did not meet prescribing criteria for monoclonal antibodies. Six months post treatment, she had a significant improvement in symptom control and medication usage, without any exacerbations.

Conclusions

Airway smooth muscle histology is an underutilised biomarker that has a valuable role in phenotyping airways disease in the era of individualised medicine.

Non-linear association of plasma level of high-density lipoprotein cholesterol with endobronchial biopsy bleeding in patients with lung cancer

Background

Despite a large body of studies have demonstrated the multifaceted behavior of high-density lipoproteins (HDLs) in several physiological and pathological processes, the levels of plasma HDL-cholesterol (HDL-C) that may be associated with endobronchial biopsy (EBB)-related bleeding have never been examined.

Methods

We conducted a single-center retrospective cohort study of 628 consecutive patients with primary lung cancer who had undergone EBB at a large tertiary hospital between January 2014 and February 2018. Patients were divided into the bleeding group and the non-bleeding group according to the bronchoscopy report. The association between HDL-C levels and EBB-induced bleeding was evaluated using the LASSO regression analysis, multiple regression analysis and smooth curve fitting adjusted for potential confounders.

Results

There was an inverse association of plasma HDL-C concentration with the incidence of EBB-induced bleeding as assessed by univariate analysis (P < 0.05). However, in piecewise linear regression analysis, a non-linear relationship with threshold saturation effects was observed between plasma HDL-C concentrations and EBB-induced bleeding. The incidence of EBB-induced bleeding decreased with HDL-C concentrations from 1.5 mmol/L up to 2.0 mmol/L (adjusted OR, 0.39; 95% CI, 0.20–0.74), but increased with HDL-C levels above the inflection point (HDL-C = 2.0 mmol/L).

Conclusions

There was a non-linear association between plasma HDL-C concentrations and the risk of EBB-induced bleeding in patients with lung cancer. The plasma level of HDL-C above 2.0 mmol/L or below 1.5 mmol/L may increase the risk of EBB-induced bleeding.

Plasma apolipoprotein E level is associated with the risk of endobronchial biopsy-induced bleeding in patients with lung cancer

Background

Factors affecting the risk of bleeding by bronchoscopic biopsy in patients with lung cancer remain unclear. The levels of plasma apolipoprotein E (ApoE) that may be associated with endobronchial biopsy (EBB)-induced bleeding have never been examined.

Methods

This was a retrospective study using data collected from 615 consecutive patients who had undergone EBB and been diagnosed with primary lung cancer from January 2014 through February 2018. Patients were either classified as the bleeding group (n = 214) or the non-bleeding group (n = 391) based on the bronchoscopy report. Multiple regression analysis was done to estimate the independent relationship between ApoE levels and EBB-induced bleeding, with an adjustment for potential confounders.

Results

The mean plasma ApoE concentration was higher in the non-bleeding group compared to that in the bleeding group (P < 0.05). However, a non-linear relationship with threshold effects was observed between plasma ApoE levels and EBB-induced bleeding in a piecewise linear regression analysis. The risk of EBB-induced bleeding decreased with ApoE concentrations from 3.5 mg/dL up to 5.9 mg/dL (adjusted odds ratio, 0.64; 95% confidence interval, 0.43–0.94); however, the incidence of EBB-induced bleeding increased with ApoE levels above the turning point (ApoE = 5.9 mg/dL).

Conclusions

There was a non-linear association between plasma ApoE levels and the risk of EBB-induced bleeding. Higher plasma ApoE concentrations (> 5.9 mg/dL) are the independent risk factor for hemorrhage during EBB in patients with lung cancer.

Endobronchial involvement of mantle cell lymphoma: A case report

Mantle cell lymphoma (MCL) is a subtype of B-cell non-Hodgkin's lymphoma. Most cases of MCL have extranodal involvement at the time of the initial diagnosis; however, endobronchial involvement is rare. An 87-year-old man was referred to our hospital because of dyspnea on exertion. A chest CT revealed diffuse irregular wall thickening of the trachea and bilateral bronchi. A bronchoscopy revealed a diffuse irregular surface of the tracheal and bilateral bronchial mucosa and polyposis-like lesions. He was diagnosed as having MCL based on an endobronchial biopsy, and the diagnosis was confirmed using immunohistochemical staining.

Endobronchial biopsies on aspirin and prasugrel

Patients are generally required to stop antiplatelet therapy prior to elective invasive procedures. Some patients receive dual antiplatelet therapy for recent vascular procedures such as drug-eluting coronary stenting, and early discontinuation of antiplatelet agents could lead to a significant risk of stent thrombosis. Most bronchoscopic procedures are performed on patients using Aspirin but not on those using Clopidogrel or Prasugrel. In this report, we describe a unique case of a patient with a recent placement of drug-eluting stents, who required endobronchial biopsies for evaluation of lung cancer recurrence. The procedure was performed successfully and safely with no complications.

IL-33 promotes airway remodeling in pediatric patients with severe steroid-resistant asthma

BACKGROUND

TH2 cytokines are not responsible for the ongoing symptoms and pathology in children with severe therapy-resistant asthma (STRA). IL-33 induces airway hyperresponsiveness, but its role in airway remodeling and steroid resistance is unknown.

OBJECTIVE

We sought to investigate the relationship between IL-33 and airway remodeling in pediatric patients with STRA.

METHODS

IL-33 levels were quantified in neonatal mice given inhaled house dust mite (HDM), and the effect of blocking IL-13 on remodeling and IL-33 levels was assessed. HDM-induced allergic airways disease (AAD) in neonatal ST2(-/-) mice lacking the IL-33 receptor was assessed, together with collagen production after IL-33 administration. The effect of steroid therapy on IL-33 levels in patients with neonatal AAD was explored. IL-33 expression was quantified in endobronchial biopsy (EB) specimens from children with STRA and related to remodeling, and collagen production by airway fibroblasts from pediatric patients stimulated with IL-33 and budesonide was quantified.

RESULTS

Blocking IL-13 after AAD was established in neonatal mice and did not reduce remodeling or IL-33 levels; airway hyperresponsiveness was only partially reduced. IL-33 promoted collagen synthesis both from asthmatic fibroblasts from pediatric patients and after intranasal administration in mice. Increased cellular expression of IL-33, but not IL-13, was associated with increased reticular basement membrane thickness in EB specimens from children with STRA, whereas remodeling was absent in HDM-exposed ST2(-/-) mice. IL-33 levels were maintained, whereas IL-13 levels were abrogated by steroid treatment in neonatal HDM-exposed mice and in EB specimens from children with STRA.

CONCLUSION

IL-33 is a relatively steroid-resistant mediator that promotes airway remodeling in patients with STRA and is an important therapeutic target.