Immune Checkpoint Inhibitor-Related Pulmonary Toxicity: A Comprehensive Review, Part II.

The development of immune checkpoint inhibitors (ICIs) has changed the treatment paradigm for cancer. The ICIs nivolumab, pembrolizumab, and cemiplimab target programmed cell death protein 1, and durvalumab, avelumab, and atezolizumab target programmed death ligand 1. Ipilimumab targets cytotoxic T lymphocyte-associated antigen-4. Used as monotherapy or in combination, they have shown remarkable efficacy in melanoma, lung cancer, and many other solid tumors, and indications continue to evolve. These checkpoint inhibitors are typically well tolerated; however, they may cause immune-mediated adverse effects, resulting in inflammation of any organ system. Pulmonary toxicity is vital to recognize, and it can be more challenging to diagnose in patients with lung cancer, given the nature of the disease course and treatment.

Immune Checkpoint Inhibitor-Related Pulmonary Toxicity: Focus on Nivolumab.

The development of checkpoint inhibitors has changed the treatment paradigm for cancer. Checkpoint inhibitors nivolumab, pembrolizumab, and cemiplimab target programmed death-1 (PD-1), whereas durvalumab, avelumab, and atezolizumab target PD-ligand 1. Ipilimumab targets cytotoxic T lymphocyte-associated antigen 4. Used as monotherapy or in combination, these inhibitors have shown remarkable efficacy in melanoma, lung cancer, urothelial cancer, and many other solid tumors, and indications are continuing to evolve. Checkpoint inhibitors are well tolerated when compared with traditional chemotherapy. The major adverse effect profiles are idiosyncratic immune-mediated toxicities resulting from the abnormal activation of autoreactive T cells, which can lead to inflammation in any organ system. The most commonly affected organs are bowel, lung, skin, and endocrine. Pulmonary toxicity is important to recognize, and it can be more challenging to diagnose in lung cancer patients, given the nature of the disease course and treatment. This review article focuses on all of the pulmonary adverse effects of a single PD-1 inhibitor (nivolumab) that have been described in the literature. These complications include dyspnea, pneumonitis, pleural effusion, pulmonary sarcoidosis, pulmonary tuberculosis, acute fibrinous organizing pneumonia, organizing pneumonia, eosinophilic pneumonia, adult respiratory distress syndrome, and lung cavitation. Clinicians must be aware of these toxicities and mindful when prescribing these medications in patients with known lung dysfunction due to chronic lung diseases or lung cancer.

Venovenous Extracorporeal Membrane Oxygenation Therapy in Adults.

Extracorporeal membrane oxygenation (ECMO) therapy is used as supportive therapy for patients with respiratory failure, cardiac failure, and cardiopulmonary failure. Venovenous extracorporeal membrane oxygenation (VV-ECMO) is one subtype used for respiratory failure as a supportive treatment for critically ill patients. The principle behind it is that the membrane lung (oxygenator) is placed sequentially with the normal lungs rather than in parallel like with cardiopulmonary bypass, therefore, the lungs do not have to work as hard to oxygenate the blood. Then using a drainage cannula, blood is drained from the right atrium (RA) and after going through the membrane lung, the newly oxygenated blood is returned back to the RA. Because of this, there is enough systemic oxygen delivery to manage metabolism and preserve the airway even at lower tidal volume ventilation settings. With ventilator settings placed at lower tidal volume, there is less risk of barotrauma. This is a review article discussing VV-ECMO therapy with adult patients. It will also go into detail regarding its indications, contraindications, configurations, patient assessment, vascular access, and complications.

Non-small Cell Lung Cancer with Squamous Features Metastatic to a Colonic Polyp: A Case Report of a Very Rare Presentation.

Among all malignant diseases, lung cancer is the most common on a worldwide basis. It is usually discovered incidentally on lung imaging studies or because of symptoms. The diagnosis is confirmed on biopsy material from the primary malignancy or from metastatic deposits. This is a report of metastatic lung cancer with squamous features discovered in an endoscopically removed colonic polyp. To our knowledge, there are only two prior reports of lung cancer being diagnosed in colonic polyps. We could not find any reports of lung cancer with squamous features metastatic to a colon polyp. In this case, the carcinoma was found in a polyp removed from a patient who presented with severe anemia and melena.

Massive hemoptysis due to recurrence of bronchial to pulmonary vascular malformation: A case report.

Bronchial dieulafoy lesions are quite rare with relatively few case reports in the literature. Symptoms may vary but the lesion is often associated with hemoptysis and may present as massive hemoptysis. We present a case of a 69-year-old male with a recurrent episode of hemoptysis three years after treatment for a bronchial dieulafoy lesion. The bronchoscopy done three years prior during an initial episode of hemoptysis showed a visible dieulafoy deep within a subsegmental branch of the right lower lobe. This case is unique because there are no other reports within the literature of a delayed recurrence several years after previous treatment of a bronchial dieulafoy lesion, which in our case was due to bronchial to pulmonary vascular malformation. Bronchial arteriography revealed a bronchial artery to pulmonary artery vascular malformation, which was successfully treated with coil embolization.

Case report: Steroid responsive mesothelioma-related pleural effusion.

Malignant pleural mesothelioma (MPM) is an asbestos-related tumor arising in the pleural cavity. Symptoms reflect extension of disease and include shortness of breath and chest pain. Unexplained pleural effusion and pleural pain in patients exposed to asbestos should raise the suspicion of MPM. The most common radiologic presentation is ipsilateral pleural effusion with or without pleural thickening or a mass. Thoracoscopic biopsy remains the most appropriate procedure for definitive diagnosis of mesothelioma. Despite advancement in diagnostic procedures and biomolecular research, this tumor nevertheless has poor prognosis. Mesothelioma remains a diagnostic and therapeutic challenge and is likely to remain one in the years to come. Here we present the first reported case of steroid treatment responsive pleural effusion in a 72 year-old-male that initially was misdiagnosed as rheumatoid related effusion. However, Pleuroscopy with biopsy revealed mesothelioma.

Urinothorax Caused by Xanthogranulomatous Pyelonephritis.

Xanthogranulomatous pyelonephritis is a rare form of chronic pyelonephritis that generally afflicts middle-aged women with a history of recurrent urinary tract infections. Its pathogenesis generally involves calculus obstructive uropathy and its histopathology is characterized by replacement of the renal parenchyma with lipid filled macrophages. This often manifests as an enlarged, nonfunctioning kidney that may be complicated by abscess or fistula. This case details the first reported case of xanthogranulomatous pyelonephritis complicated by urinothorax, which resolved on follow-up chest X-ray after robot-assisted nephrectomy.

The role and safety of endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis and management of infected bronchogenic mediastinal cysts in adults.

Bronchogenic and other duplication cysts are congenital abnormalities that can present at any age including adulthood years. They are usually asymptomatic and discovered incidentally on radiological imaging of the chest. They are commonly treated by surgical resection. Recently, endobronchial ultrasound has been used to assist in diagnosis when radiologic imaging is not definitive. Endobronchial ultrasound has been used rarely to drain infected cysts, a rare complication of the bronchogenic cyst. We present a unique case of an infected large bronchogenic cyst treated with endobronchial ultrasound drainage combined with conservative medical therapy. We also review the scarce available literature describing such an approach and its potential complications and add recommendations based on our experience in managing these anomalies.

Combined effects of climate change and bank stabilization on shallow water habitats of chinook salmon.

Significant challenges remain in the ability to estimate habitat change under the combined effects of natural variability, climate change, and human activity. We examined anticipated effects on shallow water over low-sloped beaches to these combined effects in the lower Willamette River, Oregon, an area highly altered by development. A proposal to stabilize some shoreline with large rocks (riprap) would alter shallow water areas, an important habitat for threatened Chinook salmon (Oncorhynchus tshawytscha), and would be subject to U.S. Endangered Species Act-mandated oversight. In the mainstem, subyearling Chinook salmon appear to preferentially occupy these areas, which fluctuate with river stages. We estimated effects with a geospatial model and projections of future river flows. Recent (1999-2009) median river stages during peak subyearling occupancy (April-June) maximized beach shallow water area in the lower mainstem. Upstream shallow water area was maximized at lower river stages than have occurred recently. Higher river stages in April-June, resulting from increased flows predicted for the 2080s, decreased beach shallow water area 17-32%. On the basis of projected 2080s flows, more than 15% of beach shallow water area was displaced by the riprap. Beach shallow water area lost to riprap represented up to 1.6% of the total from the mouth to 12.9 km upstream. Reductions in shallow water area could restrict salmon feeding, resting, and refuge from predators and potentially reduce opportunities for the expression of the full range of life-history strategies. Although climate change analyses provided useful information, detailed analyses are prohibitive at the project scale for the multitude of small projects reviewed annually. The benefits of our approach to resource managers include a wider geographic context for reviewing similar small projects in concert with climate change, an approach to analyze cumulative effects of similar actions, and estimation of the actions' long-term effects. Efectos Combinados del Cambio Climático y la Estabilización de Bordes de Ríos Hábitats de Aguas Poco Profundas del Salmón Chinook.

Mechanical ventilation management by pulmonologists and surgeons in patients with adult respiratory distress syndrome.

BACKGROUND: Treatment of patients with acute respiratory distress syndrome (ARDS) is complex, and management by a specialist with expertise in pulmonary mechanics may improve outcomes. We compared mechanical ventilation management of patients with ARDS by pulmonologists and surgeons. METHODS: We retrospectively reviewed 97 patients with an ICD-9 diagnosis of ARDS at 2 community hospitals. We collected information on demographics and all necessary parameters to calculate the acute physiology, age, and chronic health evaluation (APACHE II) score. Main outcomes included mortality and total days spent in the intensive care unit (ICU) and on mechanical ventilation. All outcomes were adjusted for APACHE II score using multiple logistic regression. RESULTS: Mechanical ventilation was managed by a pulmonologist in 62 patients and by a surgeon in 35 patients. Mortality rate was 35.5% (n = 22) in the patients treated by pulmonologists and 45.7% (n = 16) in patients treated by surgeons (P = 0.32). This result was unaffected by adjustment for APACHE II score. However, those surviving spent fewer days in the ICU (median of 10 vs 16 days; P = 0.07) and fewer days on mechanical ventilation (median of 7 vs 15 days; P = 0.003) when treated by pulmonologists. These results were unaffected by adjustment for APACHE II score. CONCLUSIONS: We found that patients who survived with ARDS spent fewer days on mechanical ventilation, and there was a trend for spending fewer days in the ICU when mechanical ventilation is managed by a pulmonologist compared with a surgeon. There was a lower mortality rate in the pulmonologist group, although this did not reach statistical significance. A small sample size and the retrospective design limit our findings. Further study using a multicenter design to determine if a disease specific specialist improves efficiency of care is needed because if our findings are confirmed, it would translate into significant cost savings.