Gluteal muscle metastases from malignant pleural mesothelioma: a case report.

Malignant pleural mesothelioma (MPM) is a rare malignancy arising from the mesothelial or subthelial layer of the pleura, and it has increased in recent decades, mainly associated with asbestos exposure. Sarcomatoid mesothelioma is the second-most common subtype of MPM. It is usually difficult to differentiate MPM from benign mesothelial pleural proliferations or other cancers. Because of its nonspecific symptoms, MPM is often diagnosed at a late stage with distal metastases. However, it is extremely rare to see a metastatic lesion within subcutaneous tissue and muscles, which is most likely caused by hematogenous spread. We present a case of sarcomatoid mesothelioma with a metastatic lesion of the right gluteal muscles.

Pleural effusion and Waldenström macroglobulinemia: if cytology and flow cytometric findings do not match. A case report.

Pleural effusion is a rare complication of lymphoplasmacytic lymphoma. When it occurs, traditional investigation techniques may not always be successful. The flow cytometry is a fast and precise diagnostic technique, which can be helpful in the diagnosis of pleural localization of hematological diseases. We present a case report of a pleural localization of Waldenström macroglobulinaemia detected by flow cytometry.

Synchronous lung cancer presenting with small cell carcinoma and squamous cell lung carcinoma: a case report.

Synchronous multiple primary lung cancers are separate tumors presenting at the same time with different histology. We present a rare case of a 64-year-old patient with a combination of small-cell lung carcinoma (SCLC) and squamous carcinoma in two different sites with metastasis of SCLC in the mediastinal lymph node. The SCLC diagnosis was performed via bronchoscopy, and the other diagnosis via CT-guided transthoracic biopsy. It is often difficult to distinguish a synchronous tumor from intrapulmonary metastases. To date, there are no guidelines for the treatment of these cases. The management of synchronous multiple primary lung cancer (SMPLC), mainly surgical with chemotherapy or radiotherapy, must be studied according to the histological type, staging and molecular testing of the tumors. These rare cases of SMPLC require individual treatment and a multidisciplinary approach.

Intracavitary fibrinolysis directly under vision during medical thoracoscopy: a case report.

Medical thoracoscopy is a minimally invasive single-port endoscopic technique that allows for direct visualization of the pleural surface as well as diagnostic and therapeutic procedures. When fibrous adhesions are extensive, its utility is limited. In patients with malignant pleural effusion and loculated effusion, fibrinolytics have been used through chest drainage to break down septations to relieve breathlessness and to improve pleurodesis success We described the use of intrapleural fibrinolytics during a medical thoracoscopy to break the septations and perform pleural biopsies in a patient with multiloculated pleural effusion. To the best of our knowledge, no studies on this subject have been published in the literature, only case reports. We believe that direct instillation of fibrinolytics during medical thoracoscopy is safe and has the potential to increase both the therapeutic and diagnostic capacity of medical thoracoscopy and fibrinolysis.

Unusual lymphadenopathy diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration.

Oxidized cellulose, used as hemostatic in thoracic surgery, may cause in some cases foreign body reactions, and simulate other diseases. We report the case of a 39-year-old man operated on a middle lobe lobectomy for atypical carcinoid. The follow up chest-CT showed enlarged mediastinal lymph nodes, so endobronchial ultrasound-guided transbronchial needle aspiration was performed suspecting recurrence of the tumor. The cytology results showed amorphous fragments such as foreign body reaction secondary to Pahacel®, used as hemostatic during the surgery. A few days later, the patient was re-operated on suspicion of mediastinitis induced by the endoscopic procedure. The aim of this case is to consider the foreign body reaction to Pahacel®, in patients with postoperative thoracic lymphadenopathy. It is also important to remember that in these patients the endoscopic procedures allow the diagnosis but may cause mediastinitis.

An unexpected diagnosis of a lung mass with endobronchial involvement.

Mantle cell lymphoma is a subtype of B-cell non-Hodgkin's lymphoma. Most cases of the disease have extranodal involvement at the time of the initial diagnosis; however, endobronchial involvement is rare. A 51-year-old woman was referred to our hospital because a chest CT showed pathological tissue in the right hilum englobing the pulmonary artery, the left main bronchus and their main lobar branches appearing to be small in caliber, multiple lymphadenopathies up to 4 cm in size in the subcarinal region. A bronchoscopy revealed stenotic lumen with infiltrated hyperemic mucosa of the left upper lobar bronchus and the left lower lobar bronchus. She was diagnosed as having mantle cell lymphoma based on an endobronchial biopsy and transbronchial needle aspiration. The diagnosis was confirmed using immunohistochemical staining.

Alpha1-antitrypsin deficiency and asthma.

α1-antitrypsin deficiency (AATD) is a genetically inherited autosomal-codominant disease with a variable clinical spectrum of lung-related diseases. Pulmonary involvement of α1-antitrypsin deficiency may also include emphysema with variable functional and radiological abnormalities, asthma, and bronchiectasis. Asthma and AATD are mutually exclusive disease entities, but the commonality of neutrophil inflammation across the diseases might suggest common underlying mechanisms of effect. The diseases share many clinical and functional features: patients with AATD commonly first present with asthma-like symptoms; functional alterations may be common to both, such as bronchial hyperresponsiveness or fixed obstruction after bronchial remodeling.  It has been recognized that allergy and asthma often coexist with AATD, but the relationship between allergy, asthma and AATD is not clear. Distinguishing AATD from asthma based on presentation and clinical evaluation is not possible. The clinician must assess each of the elements in the context of the whole patient, any patient with difficult-to-manage asthma should be screened for AATD. From the clinician's point of view, improving diagnosis in this population is fundamental to optimize clinical management. Genetic studies will probably be needed in the future to unequivocally establish the causal link between AATD and asthma.

Osimertinib induced cardiac failure and QT-prolongation in a patient with advanced pulmonary adenocarcinoma.

INTRODUCTION: Osimertinib is a third-generation tyrosine kinase inhibitor (TKI) of epidermal growth factor receptor (EGFR) used for the treatment of non-small cell lung cancer (NSCLC) presenting an EGFR mutation. Although Osimertinib has a better safety profile compared to older EGFR-TKIs and although adverse events (AEs) are described in literature, recently the relationship between Osimertinib therapy and cardiotoxicity is gaining attention. CASE REPORT: A 79-years old woman, with a history of lung adenocarcinoma on treatment with Osimertinib since 2019, was recovered in our department because of acute respiratory failure and acute heart failure with QT prolongation. The patient's history included hypertension, type 2 diabetes, breast carcinoma, Tuberculosis. MANAGEMENT AND OUTCOME: The patient discontinued Osimertinib therapy and we treated her with diuretics, ß-blocker, and oxygen. After an initial improvement, the heart failure worsened further, and the therapy had to be increased. We ruled out other respiratory causes of heart failure and cardiological causes of QT prolongation. After stable clinical improvement, the patient underwent coronary artery disease which was negative. Therefore, the most likely cause of acute heart disease was Osimertinib therapy. DISCUSSION: This is a rare case of concomitant QT prolongation and congestive heart failure induced by Osimertinib therapy. The cause of cardiotoxicity probably depends on factors related to the action of the drug and patient specific factors. The cardiotoxic risk in these patients seems underestimated and cardiotoxicity induced by new anticancer treatments is increasing in importance. Cardiac monitoring is recommended in neoplastic patients receiving Osimertinib therapy with cardiological risk factors.

The role of indacaterol for chronic obstructive pulmonary disease (COPD).

Indacaterol is the first long-acting ß2-agonist (LABAs) approved for the treatment of chronic obstructive pulmonary disease (COPD) that allows for once-daily (OD) administration. It is rapidly acting, with an onset of action in 5 minutes, like salbutamol and formoterol but with a sustained bronchodilator effect, that last for 24 hours, like tiotropium. In long-term clinical studies (12 weeks to 1 year) in patients with moderate to severe COPD, OD indacaterol 150 or 300 µg improved lung function (primary endpoint) significantly more than placebo, and improvements were significantly greater than twice-daily formoterol 12 µg or salmeterol 50 µg, and noninferior to OD tiotropium bromide 18 µg. Indacaterol was well tolerated at all doses and with a good overall safety profile. Cost-utility analyses show that indacaterol 150 µg has lower total costs and better outcomes than tiotropium and salmeterol. These findings suggest that indacaterol can be considered a first choice drug in the treatment of the patient with mild/moderate stable COPD. However, in people with COPD who remain symptomatic on treatment with indacaterol, adding a long-acting muscarinic antagonist (LAMA) is the preferable option. In any case, it is advisable to combine indacaterol with a OD inhaled corticosteroid (ICS), such as mometasone furoate or ciclesonide, in patients with low FEV1, and, in those patients who have many symptoms and a high risk of exacerbations, to combine it with a LAMA and a OD ICS.

Evaluation of the effects of the R- and S-enantiomers of salbutamol on equine isolated bronchi.

BACKGROUND: Equine obstructive pulmonary disease, also known as heaves or recurrent airway obstruction (RAO) is a common equine pulmonary disease with some similarities to human asthma and COPD, which represents a major cause of morbidity and loss of lung performance. Salbutamol has been widely used for the treatment of human airway diseases and has usually been prepared as the racemic form of the drug. However, recently the R-enantiomer of salbutamol has been introduced into clinical practice in the treatment of asthma in humans and this has been suggested to be an improvement on the racemic form of the drug; therefore thus the S-enantiomer has been demonstrated to have adverse effects in the lung and thus using the R-enantiomer may improve the therapeutic ratio. However, little is known about the properties of the R- and S-enantiomers of salbutamol in equine airways and the present study has evaluated the relaxant effects of racemic ß(2)-agonists in comparison with the R- and S-enantiomers in isolated equine isolated bronchi, as well as the bronchoprotective effects of these drugs on cholinergic and histaminergic pathway. METHODS: We have studied the effects of the R- and S-enantiomers of salbutamol on bronchi isolated from RAO-affected or unaffected horses. The first study assayed the relaxant effects of R- and S-salbutamol on isolated bronchial rings contracted with carbachol or histamine at a sub-maximal concentration (EC70). A second study evaluated the effects of R- and S-salbutamol on semi-logarithmic cumulative concentration-response curves induced by carbachol or histamine. Specific software was used to calculate statistical significance and the appropriate sigmoidal curve-fitting model. RESULTS: Neither enantiomers of salbutamol caused a relaxant effect on the sub-maximal plateau contractile effects of carbachol; in fact, both R- and S-salbutamol induced a slight, but significant contraction (P ≤ 0.05) compared to the controls. In contrast, R-salbutamol induced a significant relaxation of bronchi pre-contracted with histamine (RAO-unaffected: 92.06% ± 2.00; RAO-affected 100.20 ± 3.99; P ≤ 0.01). S-salbutamol induced a weak relaxation (RAO-unaffected: 15.81% ± 5.65; RAO-affected 12.36 ± 5.15) when compared to that induced by papaverine. The incubation with either R- or S-salbutamol shifted rightward (P ≤ 0.001) the carbachol contraction curve in RAO-unaffected bronchi, but not in RAO-affected bronchi, compared to control tissues. R-salbutamol induced a reduction in E(max) values (C: 9.07 gr ± 0.68; R-salb.: 6.36 gr ± 0.21; P ≤ 0.01) in normal bronchi. On the contrary it reduced the histamine potency in RAO-affected bronchi (EC50 7.10 µM ± 0.35, P < 0.001). The incubation with S-salbutamol shifted leftward the histamine concentration curve in both normal bronchi (C: 7.00 µM ± 0.29; S-salb.: 2.25 µM ± 0.19; P ≤ 0.001) and bronchi from RAO-affected horses (C: 2.80 µM ± 0.26; S-salb.: 1.50 µM ± 0.80; P ≤ 0.05). CONCLUSION: Our studies have demonstrated that S-salbutamol elicited a modest increase in contraction of equine airway smooth muscle induced by carbachol and induced a significant hyperresponsiveness to histamine. These results confirm the ability of the S-enantiomer of salbutamol to potentiate the contractile effect of certain spasmogens on airway smooth muscle. Such an adverse effect would be determined in the airways of horses with RAO and suggest that if salbutamol is to be used in the treatment of symptoms of RAO in horses, the R-enantiomer, rather than the racemic mixture should be considered.