Gaetane Michaud

Treatment of stage III non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines.

OBJECTIVES Stage III non-small cell lung cancer (NSCLC) describes a heterogeneous population with disease presentation ranging from apparently resectable tumors with occult microscopic nodal metastases to unresectable, bulky nodal disease. This review updates the published clinical trials since the last American College of Chest Physicians guidelines to make treatment recommendations for this controversial subset of patients. METHODS Systematic searches were conducted through MEDLINE, Embase, and the Cochrane Database for Systematic Review up to December 2011, focusing primarily on randomized trials, selected meta-analyses, practice guidelines, and reviews. RESULTS For individuals with stage IIIA or IIIB disease, good performance scores, and minimal weight loss, treatment with combined chemoradiotherapy results in better survival than radiotherapy alone. Consolidation chemotherapy or targeted therapy following definitive chemoradiation for stage IIIA is not supported. Neoadjuvant therapy followed by surgery is neither clearly better nor clearly worse than definitive chemoradiation. Most of the arguments made regarding patient selection for neoadjuvant therapy and surgical resection provide evidence for better prognosis but not for a beneficial impact of this treatment strategy; however, weak comparative data suggest a possible role if only lobectomy is needed in a center with a low perioperative mortality rate. The evidence supports routine platinum-based adjuvant chemotherapy following complete resection of stage IIIA lung cancer encountered unexpectedly at surgery. Postoperative radiotherapy improves local control without improving survival. CONCLUSIONS Multimodality therapy is preferable in most subsets of patients with stage III lung cancer. Variability in the patients included in randomized trials limits the ability to combine results across studies and thus limits the strength of recommendations in many scenarios. Future trials are needed to investigate the roles of individualized chemotherapy, surgery in particular cohorts or settings, prophylactic cranial radiation, and adaptive radiation.

Complications, Consequences, and Practice Patterns of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: Results of the AQuIRE Registry

BACKGROUND Few studies of endobronchial ultrasound-guided transbronchial needle aspiration(EBUS-TBNA) have been large enough to identify risk factors for complications. The primary objective of this study was to quantify the incidence of and risk factors for complications in patients undergoing EBUS-TBNA. METHODS Data on prospectively enrolled patients undergoing EBUS-TBNA in the American College of Chest Physicians Quality Improvement Registry, Evaluation, and Education (AQuIRE)database were extracted and analyzed for the incidence, consequences, and predictors of complications. RESULTS We enrolled 1,317 patients at six hospitals. Complications occurred in 19 patients (1.44%;95% CI, 0.87%-2.24%). Transbronchial lung biopsy (TBBx) was the only risk factor for complications,which occurred in 3.21% of patients who underwent the procedure and in 1.15% of those who did not (OR, 2.85; 95% CI, 1.07-7.59; P 5 .04). Pneumothorax occurred in seven patients(0.53%; 95% CI, 0.21%-1.09%). Escalations in level of care occurred in 14 patients (1.06%;95% CI, 0.58%-1.78%); its risk factors were age . 70 years (OR, 4.06; 95% CI, 1.36-12.12; P 5 .012),inpatient status (OR, 4.93; 95% CI, 1.30-18.74; P 5 .019), and undergoing deep sedation or general anesthesia (OR, 4.68; 95% CI, 1.02-21.61; P 5 .048). TBBx was performed in only 12.6% of patients when rapid on site cytologic evaluation (ROSE ) was used and in 19.1% when it was not used ( P 5 .006).Interhospital variation in TBBx use when ROSE was used was significant ( P , .001). CONCLUSIONS TBBx was the only risk factor for complications during EBUS-TBNA procedures.ROSE significantly reduced the use of TBBx.

Relapsing Polychondritis and Airway Involvement

OBJECTIVE To assess the prevalence and characteristics of airway involvement in relapsing polychondritis (RP). METHODS Retrospective chart review and data analysis of RP patients seen in the Rheumatology Clinic and the Complex Airway Center at Beth Israel Deaconess Medical Center from January 2004 through February 2008. RESULTS RP was diagnosed in 145 patients. Thirty-one patients had airway involvement, a prevalence of 21%. Twenty-two patients were women (70%), and they were between 11 and 61 years of age (median age, 42 years) at the time of first symptoms. Airway symptoms were the first manifestation of disease in 17 patients (54%). Dyspnea was the most common symptom in 20 patients (64%), followed by cough, stridor, and hoarseness. Airway problems included the following: subglottic stenosis (n = 8; 26%); focal and diffuse malacia (n = 15; 48%); and focal stenosis in different areas of the bronchial tree in the rest of the patients. Twelve patients (40%) required and underwent intervention including balloon dilatation, stent placement, tracheotomy, or a combination of the above with good success. The majority of patients experienced improvement in airway symptoms after intervention. One patient died during the follow-up period from the progression of airway disease. The rest of the patients continue to undergo periodic evaluation and intervention. CONCLUSION In this largest cohort described in the English language literature, we found symptomatic airway involvement in RP to be common and at times severe. The nature of airway problems is diverse, with tracheomalacia being the most common. Airway intervention is frequently required and in experienced hands results in symptom improvement.

Use of tunnelled catheters for malignant pleural effusions in patients fit for pleurodesis

The aim of the present study was to examine the effectiveness of tunnelled pleural catheters (TPC) in patients with malignant pleural effusions who would otherwise be candidates for pleurodesis. Patients were selected from a previously reported database of 250 TPC insertions. The study group was selected based on lung re-expansion and survival as a surrogate maker of eligibility for pleurodesis procedure, as defined by survival of ≥90 days and lung re-expansion ≥80% post-drainage on a standard chest radiograph 2 weeks post TPC placement. There were 109 procedures in 97 patients that met the entry criteria. Spontaneous pleurodesis (SP) was achieved following 70% of procedures and correlated with symptom control. The mean time to SP was 90 days. There was no need for a repeat procedure in 87% of cases overall and in 92% of patients experiencing SP. There were few complications and no procedure-related deaths. Tunnelled pleural catheters are an effective way of controlling malignant pleural effusions when used as first-line treatment in patients who appear to be candidates for pleurodesis procedures.

Diagnostic Yield and Complications of Bronchoscopy for Peripheral Lung Lesions. Results of the AQuIRE Registry.

RATIONALE Advanced bronchoscopy techniques such as electromagnetic navigation (EMN) have been studied in clinical trials, but there are no randomized studies comparing EMN with standard bronchoscopy. OBJECTIVES To measure and identify the determinants of diagnostic yield for bronchoscopy in patients with peripheral lung lesions. Secondary outcomes included diagnostic yield of different sampling techniques, complications, and practice pattern variations. METHODS We used the AQuIRE (ACCP Quality Improvement Registry, Evaluation, and Education) registry to conduct a multicenter study of consecutive patients who underwent transbronchial biopsy (TBBx) for evaluation of peripheral lesions. MEASUREMENTS AND MAIN RESULTS Fifteen centers with 22 physicians enrolled 581 patients. Of the 581 patients, 312 (53.7%) had a diagnostic bronchoscopy. Unadjusted for other factors, the diagnostic yield was 63.7% when no radial endobronchial ultrasound (r-EBUS) and no EMN were used, 57.0% with r-EBUS alone, 38.5% with EMN alone, and 47.1% with EMN combined with r-EBUS. In multivariate analysis, peripheral transbronchial needle aspiration (TBNA), larger lesion size, nonupper lobe location, and tobacco use were associated with increased diagnostic yield, whereas EMN was associated with lower diagnostic yield. Peripheral TBNA was used in 16.4% of cases. TBNA was diagnostic, whereas TBBx was nondiagnostic in 9.5% of cases in which both were performed. Complications occurred in 13 (2.2%) patients, and pneumothorax occurred in 10 (1.7%) patients. There were significant differences between centers and physicians in terms of case selection, sampling methods, and anesthesia. Medical center diagnostic yields ranged from 33 to 73% (P = 0.16). CONCLUSIONS Peripheral TBNA improved diagnostic yield for peripheral lesions but was underused. The diagnostic yields of EMN and r-EBUS were lower than expected, even after adjustment.

Effect of Endobronchial Coils vs Usual Care on Exercise Tolerance in Patients With Severe Emphysema: The RENEW Randomized Clinical Trial

IMPORTANCE Preliminary clinical trials have demonstrated that endobronchial coils compress emphysematous lung tissue and may improve lung function, exercise tolerance, and symptoms in patients with emphysema and severe lung hyperinflation. OBJECTIVE To determine the effectiveness and safety of endobronchial coil treatment. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial conducted among 315 patients with emphysema and severe air trapping recruited from 21 North American and 5 European sites from December 2012 through November 2015. INTERVENTIONS Participants were randomly assigned to continue usual care alone (guideline based, including pulmonary rehabilitation and bronchodilators; n = 157) vs usual care plus bilateral coil treatment (n = 158) involving 2 sequential procedures 4 months apart in which 10 to 14 coils were bronchoscopically placed in a single lobe of each lung. MAIN OUTCOMES AND MEASURES The primary effectiveness outcome was difference in absolute change in 6-minute-walk distance between baseline and 12 months (minimal clinically important difference [MCID], 25 m). Secondary end points included the difference between groups in 6-minute walk distance responder rate, absolute change in quality of life using the St Georges Respiratory Questionnaire (MCID, 4) and change in forced expiratory volume in the first second (FEV1; MCID, 10%). The primary safety analysis compared the proportion of participants experiencing at least 1 of 7 prespecified major complications. RESULTS Among 315 participants (mean age, 64 years; 52% women), 90% completed the 12-month follow-up. Median change in 6-minute walk distance at 12 months was 10.3 m with coil treatment vs -7.6 m with usual care, with a between-group difference of 14.6 m (Hodges-Lehmann 97.5% CI, 0.4 m to ∞; 1-sided P = .02). Improvement of at least 25 m occurred in 40.0% of patients in the coil group vs 26.9% with usual care (odds ratio, 1.8 [97.5% CI, 1.1 to ∞]; unadjusted between-group difference, 11.8% [97.5% CI, 1.0% to ∞]; 1-sided P = .01). The between-group difference in median change in FEV1 was 7.0% (97.5% CI, 3.4% to ∞; 1-sided P < .001), and the between-group St Georges Respiratory Questionnaire score improved -8.9 points (97.5% CI, -∞ to -6.3 points; 1-sided P < .001), each favoring the coil group. Major complications (including pneumonia requiring hospitalization and other potentially life-threatening or fatal events) occurred in 34.8% of coil participants vs 19.1% of usual care (P = .002). Other serious adverse events including pneumonia (20% coil vs 4.5% usual care) and pneumothorax (9.7% vs 0.6%, respectively) occurred more frequently in the coil group. CONCLUSIONS AND RELEVANCE Among patients with emphysema and severe hyperinflation treated for 12 months, the use of endobronchial coils compared with usual care resulted in an improvement in median exercise tolerance that was modest and of uncertain clinical importance, with a higher likelihood of major complications. Further follow-up is needed to assess long-term effects on health outcomes. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01608490.

Whole-Lung Lavage for Pulmonary Alveolar Proteinosis

Pulmonary alveolar proteinosis (PAP) is a disease characterized by the deposition of amorphous lipoproteinaceous material in the alveoli secondary to abnormal processing of surfactant by macrophages. Whole-lung lavage often is performed as the first line of treatment for this disease because it is a means to wash out the proteinaceous material from the alveoli and reestablish effective oxygenation and ventilation. Whole-lung lavage is a large-volume BAL that is performed mainly in the treatment of PAP. In brief, it involves the induction of general anesthesia followed by isolation of the two lungs with a double-lumen endotracheal tube and performance of single-lung ventilation while large-volume lavages are performed on the nonventilated lung. Warmed normal saline solution in 1-L aliquots (total volumes up to 20 L) is instilled into the lung, chest physiotherapy is performed, then the proteinaceous effluent is drained with the aid of postural positioning. The sequence of events is repeated until such time as the effluent, which is initially milky and opaque, becomes clear. This procedure results in significant clinical and radiographic improvement secondary to the washing out of the proteinaceous material from the alveoli. The whole-lung lavage video details all aspects of the procedure, including case selection, patient preparation and equipment, a step-by-step review of the procedure, and postoperative considerations.

Predicting Atelectasis by Assessment of Collateral Ventilation prior to Endobronchial Lung Volume Reduction: A Feasibility Study

Background: The advent of endoscopic lung volume reduction (ELVR), especially relying on valve technology to achieve atelectasis, has aroused new interest in the assessment of collateral ventilation, which has been implicated in ELVR failures. We are reporting on the use of a catheter-based device that measures airway pressures and flows, and calculates airway resistance in vivo. Objectives: To assess the safety of this catheter-based system and the feasibility of obtaining measurements predictive of atelectasis after ELVR. Methods: Patients undergoing ELVR were prospectively included in this double-blind cohort study. Each lobe targeted for ELVR was blocked with a catheter system (Chartis® System; Pulmonx, Inc., Redwood, Calif., USA); pressures and flows were assessed continuously. The primary endpoints were to evaluate the safety and feasibility; the secondary endpoint was to assess whether there was a relationship between the measurements and the incidence of atelectasis following ELVR. Results: From June 2008 to November 2008, 25 patients were included in the study. All procedures could be performed without any complications. Due to pneumothorax in 1 case and inability to assess the catheter-based measurements in 4 cases, the final analysis included 20 patients. Atelectasis occurred in 8 out of 20 cases following implantation. In 18 patients (90%), the resistance measurements correlated with the postimplantation atelectasis visualized on a chest X-ray; in 2 patients (10%), a mismatch was detected. Conclusions: Resistance measurements were safely and successfully achieved. In 90% of the analyzable cases, the resistance measurements correlated with the occurrence of atelectasis after ELVR. The clinical impact of these findings will need to be evaluated in subsequent trials.

Tracheobronchoplasty for Severe Tracheobronchomalacia: A Prospective Outcome Analysis

RATIONALE Central airway stabilization with silicone stents can improve respiratory symptoms in patients with severe symptomatic tracheobronchomalacia (TBM) but is associated with a relatively high rate of complications. Surgery with posterior tracheobronchial splinting using a polypropylene mesh has also been used for this condition but to date has not been evaluated prospectively and objectively for patient outcomes. OBJECTIVES To evaluate the effect of surgical tracheobronchoplasty on symptoms, functional status, quality of life, lung function, and exercise capacity in patients with severe and symptomatic TBM. METHODS A prospective observational study in which baseline measurements were compared to those obtained 3 months after surgical tracheobronchoplasty. MEASUREMENTS AND MAIN RESULTS Of 104 referred patients to our complex airway center for severe TBM, 77 had baseline measurements. Of this group, 57 patients had severe malacia and underwent stent placement for central airway stabilization. Of those, 37 patients reported improvement in respiratory symptoms and 35 were considered for surgical tracheobronchoplasty. Two patients were excluded from surgery for medical reasons. Median age was 61 years (range, 39 to 83 years), 20 patients were men, 11 patients (31%) had COPD, 9 patients (26%) had asthma, and 4 patients (11%) had Mounier-Kuhn syndrome. Thirty-three patients (94%) presented with severe dyspnea, 26 patients (74%) with uncontrollable cough, and 18 patients (51%) reported recurrent pulmonary infections. Two patients (3%) presented with respiratory failure requiring mechanical ventilation. After surgery, quality of life scores improved in 25 of 31 patients (p < 0.0001), dyspnea scores improved in 19 of 26 patients (p = 0.007), functional status scores improved in 20 of 31 patients (p = 0.003), and mean exercise capacity improved in 10 patients (p = 0.012). CONCLUSIONS In experienced hands, surgical central airway stabilization with posterior tracheobronchial splinting using a polypropylene mesh improves respiratory symptoms, health-related quality of life, and functional status in highly selected patients with severe symptomatic TBM.

Symptom Management in Patients With Lung Cancer : Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

BACKGROUND Many patients with lung cancer will develop symptoms related to their disease process or the treatment they are receiving. These symptoms can be as debilitating as the disease progression itself. To many physicians these problems can be the most difficult to manage. METHODS A detailed review of the literature using strict methodologic review of article quality was used in the development of this article. MEDLINE literature reviews, in addition to Cochrane reviews and other databases, were used for this review. The resulting article lists were then reviewed by experts in each area for quality and finally interpreted for content. RESULTS We have developed recommendations for the management of many of the symptom complexes that patients with lung cancer may experience: pain, dyspnea, airway obstruction, cough, bone metastasis, brain metastasis, spinal cord metastasis, superior vena cava syndrome, hemoptysis, tracheoesophageal fistula, pleural effusions, venous thromboembolic disease, depression, fatigue, anorexia, and insomnia. Some areas, such as dyspnea, are covered in considerable detail in previously created high-quality evidence-based guidelines and are identified as excellent sources of reference. The goal of this guideline is to provide the reader recommendations based on evidence supported by scientific study. CONCLUSIONS Improved understanding and recognition of cancer-related symptoms can improve management strategies, patient compliance, and quality of life for all patients with lung cancer.