[Transbronchial lung cryobiopsy in interstitial lung diseases]. / Les cryobiopsies pulmonaires transbronchiques dans les pneumopathies infiltrantes diffuses.

In some cases of interstitial lung disease (ILD), clinical and biological findings associated with CT scan pattern during multidisciplinary discussion (MDD) fail to yield a confident diagnosis. In these cases, histology may be necessary. Transbronchial lung cryobiopsy (TBLC) is a bronchoscopic procedure that has been developed in recent years and currently contributes to diagnostic work-up in patients with ILD. TBLC provides tissue samples for histological analysis with an acceptable risk of complications, consisting mainly in pneumothorax or bleeding. In addition to higher diagnostic yield than conventional forceps biopsies, the procedure shows a better safety profile than surgical biopsies. The indication to perform TBLC is decided during a 1st MDD and during a 2nd MDD, results can provide a diagnostic yield approximating 80%. TBLC appears to be an attractive, minimally invasive technique to be proposed as a first-line procedure in selected patients in experienced centers, while surgical lung biopsy may be considered as a second-line solution.

Total unilateral pulmonary collapse secondary to allergic bronchopulmonary aspergillosis: a case series of an unusual cause of complete atelectasis.

BACKGROUND: Allergic bronchopulmonary aspergillosis (ABPA) is a bronchopulmonary disease caused by a complex hypersensitivity to Aspergillus and is usually associated with underlying respiratory diseases such as asthma or cystic fibrosis. Mucus plugging can lead to segmental or lobar atelectasis, but complete lung atelectasis has been exceptionally reported in the literature, making it difficult to diagnose. The diagnosis of ABPA may however be suggested in patients without known predisposing respiratory disorder, even in the absence of other relevant radiographic findings. CASE PRESENTATION: We report five cases of total unilateral lung collapse secondary to ABPA in 70-81-year-old women. Two of them had a past history of ABPA, while total unilateral lung collapse was the first sign of the disease in the other three patients, contributing to the initial misdiagnosis. Flexible bronchoscopy was initially performed to remove mucus plugs from the obstructed airways but was inefficient in four cases. Corticosteroid and/or antifungal treatment was needed. CONCLUSION: ABPA can cause total unilateral lung collapse even in patients without known underlying chronic respiratory disease, making the diagnosis difficult. Flexible bronchoscopy should be considered when lung collapse is associated with respiratory distress but corticosteroids are the mainstay treatment for ABPA.

Percutaneous CT-guided lung biopsy for the diagnosis of persistent pulmonary consolidation.

PURPOSE: The primary objective of this study was to determine the diagnostic accuracy of percutaneous computed tomography (CT)-guided biopsy of persistent pulmonary consolidations. The secondary objective was to determine the complication rate and identify factors affecting diagnostic yield. MATERIALS AND METHODS: Two radiologists retrospectively reviewed 98 percutaneous CT-guided biopsies performed in 93 patients (60 men, 33 women; mean age, 62±14.0 (SD) years; range: 18-88 years) with persistent pulmonary consolidations. Final diagnoses were based on surgical outcomes or 12 months clinical follow-up findings. Biopsy results were compared to the final diagnosis to estimate diagnostic yield. RESULTS: A final diagnosis was obtained for all patients: 51/93 (54.8%) had malignant lesions, 12/93 (12.9%) specific definite benign lesions (including 9 infections, two pneumoconiosis and one lipoid pneumonia) and 30/93 (32.3%) non-specific benign lesions. CT-guided biopsy had an overall diagnostic yield of 60% (59/98) with a correct diagnosis for 50/51 malignant lesions (diagnostic yield of 98% for malignancy) and for 9/47 benign lesions (diagnostic yield of 19% for benign conditions). Major complications occurred in 4/98 (4%) of lung biopsies (four pneumothoraxes requiring chest tube placement). CONCLUSION: Percutaneous CT-guided biopsy is an alternative to endoscopic or surgical biopsy for the diagnosis of persistent consolidation with a low risk of severe complication.

[Malignant pleural effusion as the presenting site of cancer: comparison with metastatic pleural effusions from known cancers]. / Pleurésies malignes révélatrices d'un cancer: comparaison des étiologies avec les pleurésies métastatiques d'un cancer connu.

INTRODUCTION: Few studies have focused on malignant pleural effusions as the presenting site of cancer. The aim of our study is to evaluate their proportion in the total number of malignant pleural effusions, to identify their causes and determine their prognosis. PATIENTS AND METHODS: Patients were selected retrospectively from the database of the Pathology Department of the University Hospital of Nantes (France), which contained only the patients in whom a diagnosis of malignant effusion was made as the result of cytology of pleural fluid or pleural biopsy, between January 1999 and December 2001. Pleural effusions as the presenting site of cancer (R group) and those metastatic from known cancer (C group) were identified by study of the clinical data. RESULTS: Of 209 cases, the malignant effusion was presenting site of cancer in 85 patients. In this group (R), a male predominance was identified (sex-ratio 1.36 vs. 0.42 in group C, p<0.01). In order of frequency the causes were: lung cancer (31 cases), mesothelioma (18 cases), primary cancer unknown (15 cases), ovarian carcinoma (10 cases), lymphoma (5 cases) and other carcinoma (2 cases). In men lung cancer was the leading cause (42.8%); and in women its frequency was the same as ovarian carcinoma (27.7%). The median survival of these patients was 6.5 months. CONCLUSION: Pleural effusions as the presenting site of cancer account for 41% of all malignant pleural effusions. Their causes are mainly lung cancer in men and lung and ovarian cancers in women.

[Anti-inflammatory effects of macrolides: applications in lung disease]. / Effets anti-inflammatoires des macrolides: applications en pneumologie.

Besides their antibiotic effect, C14 and C15 macrolides exhibit immunomodulatory properties which can have therapeutic applications for chronic inflammation of the airways. In vitro studies have demonstrated the anti-inflammatory effects of macrolides: decreased productions of IL-6, IL-8, TNF alpha, chemotactism of polymorphonuclear neutrophils. Cell activity is modified with reduced production of elastase and oxidizing agents. These immunomodulator effects appear to result from an interaction with transcription factors which regulate the expression of cell gens. In addition, they lead to a modified bronchial mucosal secretion and have an action on the biofilm and the pseudomonas pilis. Their clinical activity has been demonstrated in panbronchiolitis and is in favor of use in cystic fibrosis. Use of macrolides should be carefully monitored in the event of bronchectasia, COPD, asthma, or chronic rhinosinusitis.

[Recent progress in treatment of malignant pleural mesothelioma]. / Progrès thérapeutiques récents dans le mésothéliome malin primitif de la plèvre.

Incidence of malignant pleural mesothelioma will rise until 2030-2040 because the elapsed time between exposure and diagnostic is up to several decades. Prognosis remains very poor with median survival less than one year and five-year survival not exceeding 5%. As compared to 1999, standart treatment adds chemotherapy with cisplatin and pemetrexed to local radiotherapy for prevention of local seeding after invasive diagnostic procedures. Despite various growth factors and their receptors are involved in malignant mesothelioma, first clinical trials of targeted therapies reported poor results. Multimodality therapy with extrapleural pneumonectomy and radiation therapy (+/-chemotherapy) can be of benefit in subgroups of patients but it cannot be recommended in a routine approach. As compared to bronchial carcinoma, inclusion of patients in clinical trials (using intensity-modulated radiation therapy) is the only way to somewhat improve results.

[Malignant pleural mesothelioma: radiotherapy for the prevention of seeding nodules]. / Mésothéliome malin pleural: radiothérapie préventive des nodules de perméation.

INTRODUCTION: Radiotherapy for the prevention of skin nodules appearing at the sites of aspiration, needle biopsies, chest drains or surgical incisions is the only treatment currently recommended for malignant mesothelioma. METHODS: 59 patients suffering from this condition were identified from the database of the Nantes Regional Cancer Centre. 33 received prophylactic irradiation, 25 did not and 1 was excluded. RESULTS: The treated group showed typical demographic and histological features. The delay in initiating radiotherapy ranged from 10 to 123 days and several different treatment regimes were used. In the treated group 7 out of 32 patients developed nodules following radiotherapy with 4 recurrences in the treated and 3 in the untreated areas. The mean interval before recurrence was 9 months (range 3 to 17 months). The recurrence rate was lower in the treated (21%) than in the untreated group (48%;12 out of 25). CONCLUSIONS: The poor results compared with the reference series may be explained by a longer follow-up (mean 12 months), less thorough treatment of all puncture sites and a very long delay before treatment (mean 37 days).

[Complex respiratory aspergillosis: diagnostic and therapeuthic difficulties]. / Aspergilloses respiratoires complexes: difficultés diagnostiques et thérapeutiques.

INTRODUCTION: Respiratory aspergillosis with different physiopathologic mechanisms can be associated in one patient in rare occasions. CASE REPORT: We review three cases associating an allergic bronchopulmonary aspergillosis (ABPA) and an other form of aspergillosis: aspergilloma, chronic necrotizing pulmonary aspergillosis and we present a review of literature. CONCLUSION: Such associations result in diagnostic and therapeutic difficulties. Corticosteroid treatment used for ABPA can increase the risk of severe infections. Such cases are a good indication of systemic antifungal therapy.

[Unusual bronchial tumor...]. / Une tumeur bronchique inhabituelle....

We report a case of atelectasis of the upper right lobe which did not respond to antibiotics. A third bronchial endoscopy with bronchoalveolar lavage was required to make the diagnosis of endobronchial nocardiasis. Search for extension revealed a brain localization. Search for immune deficiency only revealed calcification of the bronchial mucosa in the area of the nocardiasis.

[Acute eosinophilic pneumopathy induced by minocycline]. / Pneumopathie aiguë à éosinophiles induite par la minocycline.

A 22-year-old patient was hospitalized for severe acute eosinophil pneumonia imputable to treatment with minocyclin chlorhydrate (Mynocine). Clinical manifestations began one week after onset of drug intake. The clinical picture included fever at 38 degrees C, polypnoea at 44/min, pulmonary crepitation and severe hypoxia at 4.5 kPa. Eosinophil blood counts were high (3.02 x 10(9)/l) Standard chest X-ray led to the diagnosis of eosinophil pneumonia. Approximately 50% of the polynuclears were eosinophils. The clinical course was rapidly favourable after withdrawal of minocyclin and administration of corticosteroids. This case was analysed and compared with other reports of minocylin induced pneumonia.

[Prognostic factors in the survival of patients with neuromuscular diseases after an episode of acute respiratory insufficiency]. / Facteurs pronostiques de la survie de patients atteints de maladies neuromusculaires après une insuffisance respiratoire aiguë.

We have studied the survival of 49 patients suffering from neuromuscular disease, who were hospitalised in the Respiratory Intensive Care Unit between 1981 and 1990 (29 males and 20 females with a mean age of 49.3 +/- 17 years with a range of 15 to 79). The neuromuscular diseases consisted of 8 with multiple sclerosis, 9 with amyotrophic lateral sclerosis, 8 with Steinert's disease, 11 myopathies, and 10 suffering from miscellaneous neurological diseases. Initially 27 of the 49 patients had been intubated and ventilated. During the hospital stay long-term ventilation was undertaken in 27 patients (21 by tracheotomy and 6 by nasal mask). The principal prognostic factor was the aetiology. Three groups of varying degrees of severity could be individualized: progressive neuromuscular disease (amyotrophic lateral sclerosis and multiple sclerosis), primary muscle disorders (myopathies and Steinert's disease), and neuromuscular disease with little or no evolution (survival at two years was 15%, 45% and 71% respectively for three groups. p = 0.001 by log-rank testing). The other factors which influence survival are age (p < 0.01), the presence of false route (p < 0.01), and the reason for hospitalisation (acute as opposed to chronic progressive deterioration, p < 0.05). In a multivariate analysis the most significant factors associated with the diagnosis were age, the reason for hospitalisation, and the existence of false routes. The initial treatment (intubation) and the prescription of long-term ventilation did not bring with it any significant further information as to prognosis, compared to the model which included these four factors.