Outpatient management of primary spontaneous pneumothorax: a prospective study.

We prospectively assessed the safety and cost saving of a small-bore drain based procedure for outpatient management of first episodes of primary spontaneous pneumothorax. Patients were managed by observation alone or insertion of an 8.5-F "pig-tail" drain connected to a one-way valve, according to size and clinical tolerance of the pneumothorax. All patients were reassessed after 4 h, on the first working day after discharge and on day 7. Patients still exhibiting air leak on day 4 underwent thoracoscopy. The primary end-point was complete lung re-expansion at day 7. 60 consecutive patients entered the study. 48 (80%) met the definition of large pneumothorax. The success rate was 83%. The 1-year recurrence rate was 17%. 36 (60%) patients were discharged after 4 h and 50% had full outpatient management. No severe complication was observed. The mean ± SD length of hospitalisation was 2.3 ± 3.1 days. This policy resulted in about a 40% reduction in hospital stay-related costs. The present study supports the use of a single system combined with a well-defined management algorithm including safe discharge criteria, as an alternative to manual aspiration or chest tube drainage. This approach participates in healthcare cost-savings.

Defect in recruiting effector memory CD8+ T-cells in malignant pleural effusions compared to normal pleural fluid.

BACKGROUND: Malignant pleural effusions (MPE) are a common and fatal complication in cancers including lung or breast cancers, or malignant pleural mesothelioma (MPM). MPE animal models and immunotherapy trials in MPM patients previously suggested defects of the cellular immunity in MPE. However only few observational studies of the immune response were done in MPM patients, using questionable control groups (transudate…). METHODS: We compared T cell populations evaluated by flow cytometry from blood and pleural effusion of untreated patients with MPM (n = 58), pleural metastasis of adenocarcinoma (n = 30) or with benign pleural lesions associated with asbestos exposure (n = 23). Blood and pleural fluid were also obtained from healthy subjects, providing normal values for T cell populations. RESULTS: Blood CD4+ or CD8+ T cells percentages were similar in all groups of patients or healthy subjects. Whereas pleural fluid from healthy controls contained mainly CD8+ T cells, benign or malignant pleural effusions included mainly CD4+ T cells. Effector memory T cells were the main T cell subpopulation in pleural fluid from healthy subjects. In contrast, there was a striking and selective recruitment of central memory CD4+ T cells in MPE, but not of effector cells CD8+ T cells or NK cells in the pleural fluid as one would expect in order to obtain an efficient immune response. CONCLUSIONS: Comparing for the first time MPE to pleural fluid from healthy subjects, we found a local defect in recruiting effector CD8+ T cells, which may be involved in the escape of tumor cells from immune response. Further studies are needed to characterize which subtypes of effector CD8+ T cells are involved, opening prospects for cell therapy in MPE and MPM.

[Antiangiogenic agents: current limits in thoracic oncology]. / Les antiangiogéniques : limites actuelles en oncologie thoracique.

Antiangiogenic agents appear as major therapeutic options in renal, colorectal and breast cancer. Their part in thoracic oncology is still limited today except for bevacizumab. We review the current limits of antiangiogenic agents in terms of efficacy, activity, tolerance and therapeutic strategies. Problems about predictive biomarkers and cost-effectiveness of antiangiogenic agents in thoracic oncology are also mentioned.

Serum mesothelin has a higher diagnostic utility than hyaluronic acid in malignant mesothelioma.

UNLABELLED: We assessed comparatively the diagnostic value of two potential malignant pleural mesothelioma (MPM) markers: hyaluronic acid (HA) and soluble mesothelin. MATERIALS AND METHOD: We measured serum and pleural fluid values of mesothelin and hyaluronic acid in 76 patients with MPM, 33 patients with pleural metastases of carcinomas (Mets group) and 27 patients with benign pleural effusion related to asbestos exposure (BPLAE). RESULTS: Using a serum HA cut-off of 100 microg/L, 8 patients/33 (24.2%) were positive in the Mets group versus 20/76 (26.3%) in the MPM group and only 1/27 BPLAE patients. The area under ROC curve for serum HA in MPM versus Mets or BPLAE groups was only 0.617 while it was 0.755 for mesothelin. In pleural fluid, both markers had similar diagnostic values. CONCLUSIONS: Serum mesothelin is more sensitive than hyaluronic acid in diagnosing MPM and there is no benefit in combining both markers.

Kinetics of soluble mesothelin in patients with malignant pleural mesothelioma during treatment.

RATIONALE: Previous data suggested that serum levels of soluble mesothelin (SM) are related to tumor size and may have prognostic significance in malignant pleural mesothelioma (MPM). OBJECTIVES: We tested the hypothesis that this marker could also be useful for monitoring response to treatment. METHODS: Serial measurements of SM were determined in 40 patients diagnosed with MPM and subjected to gene-transfer therapy using intrapleural infusion of an adenoviral vector expressing human IFN-beta or conventional treatment (mainly chemotherapy). MEASUREMENTS AND MAIN RESULTS: In patients with baseline SM levels greater than 1 nM/L and disease progression after therapy, SM levels increased by 2.1 nM/L at two, 5.2 nM/L at four and 1.3 nM/L at 6 months. Patients with initial SM below 1 nM/L had a similar but more moderate increase of SM over time. Patients who responded to treatment or were considered stable had an initial small decrease of SM followed by a return to baseline values after 6 months of follow-up. In patients with baseline SM levels greater than 1 nM/L, increasing levels were associated with a significantly shorter median survival than in patients with stable or decreasing SM levels (4.4 vs. 27.7 months; P = 0.012). CONCLUSIONS: Increasing serum levels of SM were associated with disease progression and worse outcome, whereas stable or decreasing values suggested response to treatment. If confirmed in larger series, SM could be used to monitor patients with malignant pleural mesothelioma under treatment.

[New diagnostic markers for malignant pleural mesothelioma]. / Nouveaux marqueurs diagnostiques du mésothéliome pleural malin.

The increasing number of malignant pleural mesothelioma (MPM) is a serious public health problem. The prognosis of this tumor is poor and most of the patients are diagnosed late in the disease's course when curative treatment is no more an option. It is therefore necessary to diagnose earlier MPM in these patients in order to obtain a potential significant improvement in survival. Some serum markers have been previously proposed for MPM diagnosis but none had sufficient sensitivity and specificity for being use in routine. Recently, soluble mesothelin and osteopontin have been proposed as diagnostic markers for mesothelioma. The authors reviewed recent data concerning the utility of these two molecules in the diagnosis and the treatment of MPM. Mesothelin seems to be a specific marker for the epithelioid subtype of mesothelioma. Despite a good sensitivity, osteopontin has a low specificity for mesothelioma diagnosis. However, there is not enough data yet to propose guidelines on the use of these markers in a day to day practice.

Pulmonary manifestations of Pyoderma gangrenosum.

INTRODUCTION: Pyoderma gangrenosum is an uncommon ulcerative cutaneous disorder. Extracutaneous localizations are rare. Respiratory system involvement has been described in a few cases, but the pulmonary features reported were highly variable. CASE: We report two cases of patients with Pyoderma gangrenosum combining cutaneous and pulmonary manifestations. One case presented multiple nodular lesions, some with cavitation. The underlying disease was varicella-zoster virus infection. The second presented pneumonitis with bronchiolar micronodules. DISCUSSION: Few cases have reported Pyoderma gangrenosum with pulmonary involvement, which appears to be manifested mainly as nodules or interstitial lung disease. The principal differential diagnosis is Wegener's granulomatosis.

Utility of osteopontin and serum mesothelin in malignant pleural mesothelioma diagnosis and prognosis assessment.

PURPOSE: Malignant mesothelioma is a highly aggressive tumor and is often diagnosed too late for a curative treatment. We compared diagnostic and prognostic values of mesothelin and osteopontin in 172 patients suspected of malignant pleural mesothelioma (MPM) and in a control group of 112 asymptomatic asbestos-exposed subjects. EXPERIMENTAL DESIGN: Osteopontin and mesothelin were assayed with commercial ELISA kits in a series of 43 patients with pleural metastases of various carcinomas, 33 patients with benign pleural lesions associated with asbestos exposure, 96 patients with MPMs, and 112 asbestos-exposed healthy subjects. Results were correlated with patient's diagnosis and survival. RESULTS: Serum osteopontin level was higher in MPM patients compared with healthy asbestos-exposed subjects and had a good capability to distinguish between these two populations. However, osteopontin was unable to distinguish between MPM and pleural metastatic carcinoma or benign pleural lesions associated with asbestos exposure. Neither plasma nor pleural fluid osteopontin were more powerful in this respect. Serum mesothelin had a good ability for diagnosing MPM but was unable to identify patients with nonepithelioid mesothelioma subtypes. Survival analysis identified tumor histologic subtype along with serum osteopontin and serum mesothelin as independent prognostic factors in mesothelioma patients. CONCLUSIONS: Osteopontin has a lower diagnostic accuracy than mesothelin in patients suspected of MPM. Insufficient specificity limits osteopontin utility as diagnostic marker. Both molecules have a potential value as prognostic markers.

Soluble mesothelin-related peptides in the diagnosis of malignant pleural mesothelioma.

BACKGROUND: Diagnosis of malignant pleural mesothelioma is a challenging issue. Potential markers in mesothelioma diagnosis include soluble mesothelin-related peptides (SMRPs) and osteopontin, but no subsequent validation has been published yet. METHODS: We prospectively evaluated SMRPs in serum and pleural effusion from patients with mesothelioma (n = 74), pleural metastasis of carcinomas (n = 35), or benign pleural lesions associated with asbestos exposure (n = 28), recruited when first suspected for mesothelioma. FINDINGS: Mean serum SMRP level was higher in patients with mesothelioma (2.05 +/- 2.57 nM/L [median +/- interquartile range]) than in patients with metastasis (1.02 +/- 1.79 nM/L) or benign lesions (0.55 +/- 0.59 nM/L). The area under the receiver operating characteristic curve (AUC) for serum SMRP was 0.872 for differentiating mesothelioma and benign lesions, cut-off = 0.93 nM/L (sensitivity = 80%, specificity = 82.6%). The AUC for serum SMRP differentiating metastasis and mesothelioma was 0.693, cut-off = 1.85 nM/L (sensitivity = 58.3%, specificity = 73.3%). SMRP values in pleural fluid were higher than in serum in all groups (mesothelioma: 46.1 +/- 83.2 nM/L; benign lesions: 6.4 +/- 11.1 nM/L; metastasis: 6.36 +/- 21.73 nM/L). The AUC for pleural SMRP-differentiating benign lesions and mesothelioma was 0.831, cut-off = 10.4 nM/L (sensitivity = 76.7%, specificity = 76.2%). The AUC for pleural SMRP-differentiating metastasis and mesothelioma was 0.793. INTERPRETATION: We show that SMRPs may be a promising marker for mesothelioma diagnosis when measured either in serum or pleural fluid. The diagnostic value of SMRPs was similar in both types of samples, but pleural fluid SMRPs may better discriminate mesothelioma from pleural metastasis.

[Value of hyperferritinemia and glycosylated ferritin in the diagnosis of adult-onset Still's disease. 3 case reports]. / Valeur diagnostique de l'hyperferritinémie et de la ferritine glycosylée dans la maladie de Still de l'adulte. 3 observations.

INTRODUCTION: The diagnosis of adult-onset Still's disease currently requires application of Yamaguchi's criteria and then exclusion of infectious, hematologic, autoimmune and neoplastic disorders. A recent article suggests that very high levels of serum ferritin together with an unusually low percentage of glycosylated ferritin may serve as diagnostic criteria or even as markers of disease progression. This new score has greater specificity than the other scores, including that of Yamaguchi. CASES: We describe 3 new cases with very high ferritin levels (exceeding 9000 microg/L) and glycosylated ferritin levels lower than 20%. DISCUSSION: The diagnosis of Still's disease was determined in all three cases by both Yamaguchi's score and the new criteria. One patient responded well to treatment with colchicine. CONCLUSION: Ferritin and glycosylated ferritin levels are interesting diagnostic markers. The new score suggested by Fautrel et al. is especially useful in that it does not require the exclusion of a list of differential diagnoses.