Juergen Hetzel

Lung volume reduction coil treatment for patients with severe emphysema: a European multicentre trial

Background The lung volume reduction (LVR) coil is a minimally invasive bronchoscopic nitinol device designed to reduce hyperinflation and improve elastic recoil in severe emphysema. We investigated the feasibility, safety and efficacy of LVR coil treatment in a prospective multicentre cohort trial in patients with severe emphysema. Methods Patients were treated in 11 centres. Safety was evaluated by recording all adverse events, efficacy by the St Georges Respiratory Questionnaire (SGRQ) as primary endpoint, and pulmonary function testing, modified Medical Research Council dyspnoea score (mMRC) and 6-min walk distance (6MWD) up to 12 months after the final treatment. Results Sixty patients (60.9 ± 7.5 years, forced expiratory volume in 1 s (FEV1) 30.2 ± 6.3% pred) were bronchoscopically treated with coils (55 bilateral, 5 unilateral), with a median of 10 (range 5–15) coils per lobe. Within 30 days post-treatment, seven chronic obstructive pulmonary disease exacerbations (6.1%), six pneumonias (5.2%), four pneumothoraces (3.5%) and one haemoptysis (0.9%) occurred as serious adverse events. At 6 and 12 months, respectively, ΔSGRQ was −12.1±12.9 and −11.1±13.3 points, Δ6MWD was +29.7±74.1 m and +51.4±76 m, ΔFEV1 was +0.11±0.20 L and +0.11±0.30 L, and ΔRV (residual volume) was −0.65±0.90 L and −0.71±0.81 L (all p<0.01). Post hoc analyses showed significant responses for SGRQ, 6MWD and RV in patients with both heterogeneous and homogeneous emphysema. Conclusions LVR coil treatment results in significant clinical improvements in patients with severe emphysema, with a good safety profile and sustained results for up to 1 year. Trial registration number: NCT01328899.

The use of positron emission tomography/CT in the diagnosis of tuberculosis-associated uveitis

Background Detection of tuberculosis as the underlying disease in uveitis can be problematic because of the limited sensitivity of conventional diagnostic methods, especially in the case of latent infection. The aim of our study was to evaluate the clinical usefulness of 18F-fluorodeoxyglucose positron emission tomography/CT (18F-FDG-PET/CT) in patients with uveitis and positive interferon-γ release assay. Methods We screened 95 patients with different uveitis forms by QuantiFERON TB-Gold test. Positive results were found in 24 cases. 18F-FDG-PET/CT was performed in 20 QuantiFERON-positive patients. PET/CT images were evaluated for the presence, size and metabolic activity of hilar and mediastinal lymph nodes and pulmonary lesions. Results In nine patients (45%) PET/CT detected increased FDG uptake in mediastinal or hilar lymph nodes. In two patients Mycobacterium tuberculosis was detected in culture after PET/CT-guided lymph node biopsy. In seven patients (35%) with serpiginous choroiditis partly calcified lymph nodes without FDG-uptake were found. Remission of uveitis was achieved in nine of 11 (82%) anti-tuberculosis-treated patients with progressive course of uveitis. Conclusion In QuantiFERON-positive patients with severe uveitis forms, such as serpiginous choroiditis and occlusive retinal vasculitis, 18F-FDG-PET/CT is useful to identify lesions appropriate for biopsy and helps to establish the diagnosis and appropriate therapy for presumed tuberculosis-induced intraocular inflammation.

Reliability of symptoms to determine use of bone scans to identify bone metastases in lung cancer: prospective study

Based on the hypotheses that most skeletal metastases in lung cancer are clinically symptomatic, that the incidence of bony metastases in early stages is low, and that bone scintigraphy has a sensitivity of nearly 100%, leading professional societies recommend diagnostic skeletal imaging depending on clinical symptoms.1 2 No study has assessed the significance of skeletal symptoms as a criterion for skeletal imaging in patients with lung cancer since 1991.3 But in the intervening period gamma camera technology has been considerably refined and more sensitive methods such as magnetic resonance imaging have become available for skeletal imaging. We redetermine the role of symptoms and serum concentrations in detecting bony metastases in lung cancer and reassess the accuracy of bone scans for screening. From September 1999 to September 2001 we recruited 153 consecutive patients at University Hospital Ulm. We included patients based on cytological or histological evidence of lung cancer returned no more than …

Bronchoscopic Coil Treatment for Patients with Severe Emphysema: A Meta-Analysis.

Background: Bronchoscopic coil treatment has been shown to improve pulmonary function, exercise capacity, and quality of life in patients with severe emphysema. Objectives: To perform a meta-analysis of the results of four independent European clinical trials investigating this coil therapy for emphysema. Methods: Data on all patients included in the four European clinical trials were analyzed for efficacy and safety outcomes. Results: A total of 2,536 coils were placed during 259 procedures in 140 patients. A total of 37 chronic obstructive pulmonary disease exacerbations and 27 pneumonias were recorded as serious adverse events up to 1 year after treatment. The pneumothorax rate was 6.4%. Both 6 and 12 months after treatment, significant (all p < 0.001) improvements were observed for: forced expiratory volume in 1 s [+0.08 liters (±0.19) and +0.08 liters (±0.21)], residual volume [RV; -510 ml (±850) and -430 ml (±720)], 6-min walking distance [6MWD; +44.1 m (±69.8) and +38.1 m (±71.9)], and St. Georges Respiratory Questionnaire score [SGRQ; -9.5 points (±14.3) and -7.7 points (±14.2)]. No differences in any outcome measures were observed between heterogeneous and homogeneous emphysema patients. Only a high baseline RV was found to be an independent predictor of successful treatment. Conclusions: Bronchoscopic coil treatment improves pulmonary function, 6MWD, and quality of life in patients with severe emphysema up to 1 year after treatment, independent of the distribution of the disease.

Intraobserver and interobserver agreement of volume perfusion CT (VPCT) measurements in patients with lung lesions

OBJECTIVES To evaluate intraobserver and interobserver agreement of manually encompassed lung lesions for perfusion measurements using volume-perfusion computed tomography (VPCT). MATERIALS AND METHODS Institutional review board approval and informed consent were obtained. HIPAA guidelines were followed. A 65-s dynamic study was acquired with scan parameters 80 kV, 60 mAs (80 mAs for patients ≥ 70 kg), 128 × 0.6mm collimation. Blood flow (BF), blood volume (BV) and K(trans) parameters were determined by syngo volume perfusion CT body with 88 lesions analyzed retrospectively. RESULTS Within-subject coefficients of variation for intraobserver agreement (range 6.59-12.82%) were superior to those for interobserver agreement (range 21.75-38.30%). Size-dependent analysis revealed lower agreements for lesions <4 cm as compared to larger lesions. Additionally, agreements of the upper, middle and lower lung zones were different. CONCLUSIONS Intraobserver agreement was substantial for VPCT lung cancer perfusion measurements encouraging the use for tumor characterization and therapy response monitoring. Interobserver agreement is limited and unexperienced readers should be trained before using this new method.

Presumed Tuberculosis-induced Retinal Vasculitis, Diagnosed with Positron Emission Tomography (18F-FDG-PET/CT), Aspiration Biopsy, and Culture

Purpose: The diagnosis of tuberculosis as an etiological factor in patients with uveitis is difficult because of lack of specific diagnostic tests. The authors report 2 cases of occlusive retinal vasculitis, in which 18F-FDG-PET/CT was helpful for the diagnosis of tuberculosis as a presumptive cause of intraocular inflammation. Methods: In 2 patients with severe occlusive retinal vasculitis and positive QuantiFERON TB-Gold test, 18F-FDG-PET/CT, transbronchial needle-aspiration biopsy, and microbiological investigation were performed. Results: 18F-FDG-PET/CT showed increased fluorodeoxyglucose uptake in some mediastinal and hilar lymph nodes. After needle-aspiration biopsy of PET-positive lymph nodes, M. tuberculosis was recovered in culture in both cases. Remission of uveitis was achieved only after a combination therapy with 3 anti-tubercular agents and systemic steroids. Conclusion: The authors favor the use of 18F-FDG-PET/CT in patients with sight-threatening intraocular inflammation and positive interferon-gamma release assay. Anti-tubercular therapy, together with anti-inflammatory treatment, may lead to a remission in such patients.

Controlled Pressure: The Solution for a High-Pressure Situation - Aetiology and Techniques for Control of Airway Haemorrhage

Before the widespread use of effective chemotherapy, artificial pneumothoraces were created by clinicians treating tuberculosis in an attempt to collapse and “rest” the affected lung and heal cavitating disease [4] . This strategy of collapsing part of the lung was thought to reduce aerobic conditions and hinder mycobacterial progress. In 1882, the Italian physician Carlo Forlanini performed detailed theoretical and animal studies and developed specialised instruments enabling the injection of air into the pleural cavity. Artificial pneumothoraces created by the instillation of larger volumes (<3 L of nitrogen) by surgical incision and with X-ray guidance followed [5] . By 1912, it received recognition and became the primary therapy for pulmonary tuberculosis until the 1950s, when streptomycin and rifampicin became the frontline of clinical practice. Cessation of recurrent haemoptysis in pulmonary tuberculosis by repeated unilateral and bilateral pleural insufflation of air/oxygen or nitrogen was also established in the late 19th century [6] . The use of endobronchial techniques or devices for the control of haemoptysis is established. Bronchoscopy is performed to identify the source of bleeding, isolate the remaining lung, and create tamponade until there is control of the bleeding. Haemorrhage management involves suction above the point of bleeding, administration of cold saline, diluted adrenaline (1 in 100,000 to 1 in 200,000 Massive haemoptysis is a medical emergency with variably successful outcomes depending on the source, cause, and institution of effective control measures. Haemoptysis as a complication of fibrocavitatory lung disease, tuberculosis being the exemplar, is well described and variously innocuous or catastrophic. In the early 19 th century, during his detailed correlations of clinical presentations with morbid anatomy, Laennec [1] suggested a pathological distinction between the common and often self-resolving “slight haemoptysis” and the universally catastrophic massive haemoptysis for which he developed the term pulmonary apoplexy. In these cases, he observed that the rupture of the aneurysmal pulmonary vessels (i.e., Rasmussen or intercostal artery) or rupture of often tortuous blood vessels with a weakened adventitia and media) traversing the tuberculous cavities were the main aetiological factor. It is suggested that budding capillaries in the granulation tissue increase the capillary bed supplied by the bronchial arteries, leading to increased load and hypertrophy [2] . Aspergillomas also lead to an extensive network of small vessels but usually from the pulmonary circulation. Several abnormal connections may exist in a single patient. In lung abscess, the pathogenesis of haemoptysis is not entirely clear but may be due to progression of local inflammatory processes causing necrosis of branches of the pulmonary artery [3] . Published online: April 20, 2017

Endobronchial Coils Versus Lung Volume Reduction Surgery or Medical Therapy for Treatment of Advanced Homogenous Emphysema

Rationale: Bronchoscopic lung volume reduction utilizing shape-memory nitinol endobronchial coils (EBC) may be safer and more effective in severely hyperinflated homogeneous emphysema compared to medical therapy or lung volume reduction surgery (LVRS). Methods: The effect of bilateral EBC in patients with homogeneous emphysema on spirometry, lung volumes and survival was compared to patients with homogeneous emphysema randomized in the National Emphysema Treatment Trial (NETT) to LVRS or medical therapy. NETT participants were selected to match EBC participants in age, baseline spirometry, and gender. Outcomes were compared from baseline, at 6 and 12 months. Results: There were no significant baseline differences in gender in the EBC, NETT-LVRS or medical treatment patients. At baseline no differences existed between EBC and NETT-LVRS patients in forced expiratory volume in 1 second ( FEV1) or total lung capacity (TLC) %-predicted; residual volume (RV) and diffusing capacity of the lung for carbon monoxide (DLco) %-predicted were higher in the EBC group compared to NETT-LVRS (p < 0.001). Compared to the medical treatment group, EBC produced greater improvements in FEV1 and RV but not TLC at 6 months. FEV1 and RV in the EBC group remained significantly improved at 12-months compared to the medical treatment group. While all 3 therapies improved quality of life, survival at 12 months with EBC or medical therapy was greater than NETT-LVRS. Conclusion: EBC may be a potential therapeutic option in patients with severe homogeneous emphysema and hyperinflation who are already receiving optimal medical treatment.

A new functional method to choose the target lobe for lung volume reduction in emphysema – comparison with the conventional densitometric method

Background Lung volume reduction (LVR) improves breathing mechanics by reducing hyperinflation. Lobar selection usually focuses on choosing the most destroyed emphysematous lobes as seen on an inspiratory CT scan. However, it has never been shown to what extent these densitometric CT parameters predict the least deflation of an individual lobe during expiration. The addition of expiratory CT analysis allows measurement of the extent of lobar air trapping and could therefore provide additional functional information for choice of potential treatment targets. Objectives To determine lobar vital capacity/lobar total capacity (LVC/LTC) as a functional parameter for lobar air trapping using on an inspiratory and expiratory CT scan. To compare lobar selection by LVC/LTC with the established morphological CT density parameters. Methods 36 patients referred for endoscopic LVR were studied. LVC/LTC, defined as delta volume over maximum volume of a lobe, was calculated using inspiratory and expiratory CT scans. The CT morphological parameters of mean lung density (MLD), low attenuation volume (LAV), and 15th percentile of Hounsfield units (15%P) were determined on an inspiratory CT scan for each lobe. We compared and correlated LVC/LTC with MLD, LAV, and 15%P. Results There was a weak correlation between the functional parameter LVC/LTC and all inspiratory densitometric parameters. Target lobe selection using lowest lobar deflation (lowest LVC/LTC) correlated with target lobe selection based on lowest MLD in 18 patients (50.0%), with the highest LAV in 13 patients (36.1%), and with the lowest 15%P in 12 patients (33.3%). Conclusion CT-based measurement of deflation (LVC/LTC) as a functional parameter correlates weakly with all densitometric CT parameters on a lobar level. Therefore, morphological criteria based on inspiratory CT densitometry partially reflect the deflation of particular lung lobes, and may be of limited value as a sole predictor for target lobe selection in LVR.