M. Kerjouan

Ambulatory Management of Large Spontaneous Pneumothorax With Pigtail Catheters

STUDY OBJECTIVE There is no consensus about the management of large spontaneous pneumothoraces. Guidelines recommend either needle aspiration or chest tube drainage and most patients are hospitalized. We assess the efficiency of ambulatory management of large spontaneous pneumothoraces with pigtail catheters. METHODS From February 2007 to January 2011, all primary and secondary large spontaneous pneumothoraces from Lorients hospital (France) were managed with pigtail catheters with a 1-way valve. The patients were discharged immediately and then evaluated every 2 days according to a specific algorithm. RESULTS Of the 132 consecutive patients (110 primary, 22 secondary), 103 were exclusively managed as outpatients, with full resolution of the pneumothorax by day 2 or 4, which represents an ambulatory success rate of 78%. Mean time (SD) of drainage was 3.4 days (1.8). Seven patients were initially hospitalized but quickly discharged and had full resolution by day 2 or 4, leading to a total success rate of 83%. The use of analgesics was low. The 1-year recurrence rate was 26%. If successful, this outpatient management is potentially cost saving, with a mean cost of

La protéinose alvéolaire pulmonaire

926, assuming up to 2 outpatient visits and 1 chest radiograph, compared with

Trends in Prevalence and Prognosis in Subjects With Acute Chronic Respiratory Failure Treated With Noninvasive and/or Invasive Ventilation

4,276 if a chest tube was placed and the patient was admitted to the hospital for 4 days. CONCLUSION Ambulatory management with pigtail catheters with 1-way valves could be a reasonable first-line of treatment for large spontaneous pneumothoraces. Compared with that of other studies, our protocol does not require hospitalization and is cost saving.

Sarcoïdose pulmonaire apparue sous étanercept

Alveolar proteinosis (AP) is a rare disease characterized by alveolar accumulation of surfactant components, which impairs gas exchange. AP is classified into three groups: auto-immune AP defined by the presence of plasma autoantibodies anti-GM-CSF, the most frequent form (90% of all AP); secondary AP, mainly occurring as a consequence of haematological diseases, or following on from toxic inhalation or infections, and genetic AP, which affects almost exclusively children. AP diagnosis is suspected where chest CT-scan demonstrates interstitial lung disease with a crazy paving aspect; and confirmed by bronchoalveolar lavage, which has a milky appearance and contains periodic acid Schiff positive proteinaceous alveolar deposits. The use of surgical lung biopsy to confirm AP is less frequent nowadays. In this context, positive antibodies against GM-CSF indicates an auto-immune etiology of the AP. Concerning management, whole lung lavage is the gold standard therapy. In refractory AP, new treatments are available such as subcutaneous or inhaled GM-CSF supplementation, or rituximab infusions. The clinical course is unpredictable. Spontaneous improvement or even cure can occur, and the 5-year actuarial survival is 95%. The most frequent complications are infectious etiology.

Iterative Thoracentesis as First-Line Treatment of Complicated Parapneumonic Effusion

BACKGROUND: The pattern and outcome of noninvasive ventilation (NIV) use in patients with acute or chronic respiratory disease other than COPD is not well known. The aims of this study were to investigate trends over time in underlying respiratory diseases, use of NIV, and outcomes in COPD and non-COPD patients with acute respiratory failure. METHODS: We made a retrospective analysis of data recorded prospectively from 1,113 subjects admitted between 1998 and 2012. RESULTS: Subject diagnoses were distributed as follows: COPD, n = 568 (51%); bilateral bronchiectasis, n = 113 (10%); obesity, n = 166 (15%); chronic diffuse interstitial lung disease, n = 131 (12%); restrictive pulmonary disease, n = 113 (10%); and asthma, n = 22 (2%). The proportion of subjects with bilateral bronchiectasis significantly decreased (OR 0.91, 95% CI 0.865–0.951, P < .001), whereas the proportion of subjects with obesity increased (OR 1.03, 95% CI 1.001–1.063, P = .049) over time. The use of NIV (OR 1.05, 95% CI 1.010–1.090, P = .01) and the proportion of subjects initially treated with NIV (OR 1.05, 95% CI 1.013–1.094, P = .009) increased significantly in COPD subjects only. Time trend of mortality was not significant (OR 0.98, 95% CI 0.95–1.01, P = .23), whereas the severity of illness in subjects significantly increased. Transition from NIV to invasive mechanical ventilation (IMV) (OR 2.05, 95% CI 1.36–3.11, P = < .001), IMV (OR 10.49, 95% CI 4.88–10.56, P < .001) and diffuse interstitial lung disease (OR 10.63, 95% CI 5.43–20.83, P < .001) were independently associated with death in the ICU. CONCLUSIONS: Over time, respiratory diseases have changed in non-COPD subjects and trends in the use and efficacy of NIV differ between COPD and non-COPD subjects. Mortality remained stable while the severity of illness in subjects increased. In COPD and non-COPD subjects, transition from NIV to IMV was associated with a poorer prognosis.

Haemodynamically proven pulmonary hypertension in a patient with GATA2 deficiency-associated pulmonary alveolar proteinosis and fibrosis

INTRODUCTION TNF blockers are widely used to treat inflammatory rheumatic diseases and also in the treatment of extrapulmonary sarcoidosis. TNFα plays a major role in the development and persistence of sarcoid granulomata. However, recent studies have reported the involvement of anti-TNF therapies in the development of granulomatosis associated with the clinical and radiological features of sarcoidosis. CASE REPORT A 54-years-old man with ankylosing spondylitis was treated with etanercept for two years. He was admitted with symptoms of bronchitis associated with radiological evidence of bilateral pulmonary nodules and a right upper lobe infiltrate. Anti-TNF therapy was stopped even though the patient had received 3 months of prophylactic treatment with rifampicin and isoniazid before starting etanercept. Bronchoalveolar lavage excluded infection, particularly tuberculosis. The chest CT-scan showed bilateral pulmonary nodules with peribronchovascular micronodules and enlarged mediastinal lymph nodes. Surgical lung biopsy was performed and revealed non-caseating granulomata. All the data were consistent with a diagnosis of pulmonary sarcoidosis. The patient remained symptomatic despite discontinuation of etanercept for ten months. Corticosteroids were then introduced, leading to a clinical, functional and radiological improvement. CONCLUSION This case report underlines the importance of studying the pulmonary complications of TNF blockers. The first priority is to exclude tuberculosis but a diagnosis of sarcoid-like granulomatosis has to be considered. Twenty-three cases have been described in the literature to date.

Mutational Landscape of DDR2 Gene in Lung Squamous Cell Carcinoma Using Next-generation Sequencing

Rationale Optimal management of complicated parapneumonic effusions (CPPE) remains controversial. Objectives to assess safety and efficacy of iterative therapeutic thoracentesis (ITTC), the first-line treatment of CPPE in Rennes University Hospital. Methods Patients with CPPE were identified through our computerized database. We retrospectively studied all cases of CPPE initially managed with ITTC in our institution between 2001 and 2010. ITTC failure was defined by the need for additional treatment (i.e. surgery or percutaneous drainage), or death. Results Seventy-nine consecutive patients were included. The success rate was 81% (n = 64). Only 3 patients (4%) were referred to thoracic surgery. The one-year survival rate was 88%. On multivariate analysis, microorganisms observed in pleural fluid after Gram staining and first thoracentesis volume ≥450 mL were associated with ITTC failure with adjusted odds-ratios of 7.65 [95% CI, 1.44–40.67] and 6.97 [95% CI, 1.86–26.07], respectively. The main complications of ITTC were iatrogenic pneumothorax (n = 5, 6%) and vasovagal reactions (n = 3, 4%). None of the pneumothoraces required chest tube drainage, and no hemothorax or re-expansion pulmonary edema was observed. Conclusions Although not indicated in international recommendations, ITTC is safe and effective as first-line treatment of CPPE, with limited invasiveness.

EFGR-mutant lung adenocarcinoma and Li-Fraumeni syndrome: Report of two cases and review of the literature

Over the past few years, genetics has significantly improved the understanding of interstitial lung diseases (ILD). For example, in idiopathic pulmonary fibrosis, telomerase complex mutations have been shown to drive a specific phenotype including haematological, liver and cutaneous abnormalities [1]. Recently, GATA2 deficiency has been associated with a broad phenotype including haematological, vascular, infectious and pulmonary diseases [2–4]. GATA2 is a zinc finger transcription factor essential for differentiation of immature haematopoietic cells. Among many other functions, GATA2 regulates the phagocytosis of alveolar macrophages. Therefore, alveolar macrophage dysfunction is thought to be the pathophysiological basis for the occurrence of pulmonary alveolar proteinosis, the main lung condition in GATA2 deficiency [4]. However, pulmonary alveolar proteinosis associated with GATA2 deficiency does not share the same clinical, biological or radiological features as autoimmune pulmonary alveolar proteinosis. In all cases of GATA2 deficiency-associated pulmonary alveolar proteinosis reported in the literature, granulocyte–macrophage colony-stimulating factor (GM-CSF) antibodies were absent [2, 4]. Moreover, other pulmonary diseases such as fibrosis or pulmonary hypertension (PH) have been reported to occur in GATA2 deficiency [4], suggesting that the precise pathophysiological mechanisms are not fully understood. Pulmonary fibrosis may be more prevalent in adults with GATA2 deficiency due to a longer duration of the disease http://ow.ly/WHnu30aCZ4S

Simultaneously modulated accelerated radiation therapy reduces severe oesophageal toxicity in concomitant chemoradiotherapy of locally advanced non-small-cell lung cancer

Micro‐Abstract Discoidin domain receptor 2 (DDR2) alterations were identified as a promising therapeutic target in lung squamous cell carcinoma. Using a large cohort, DDR2 genetic landscape was assessed by next‐generation sequencing. DDR2 mutations are present in 4% of squamous cell carcinoma, are not exclusive with driver genes alterations, and have no prognosis impact. This study emphasizes the need for a better knowledge of DDR2 biology before developing dedicated targeted therapies. Background: Lung cancer represents the leading cause of cancer‐related death worldwide. Despite great advances in lung cancer management with the recent emergence of molecular targeted therapies for non‐squamous non–small‐cell lung cancer, no dramatic improvements have been achieved in lung squamous cell carcinoma (SCC). Mutations in discoidin domain receptor 2 (DDR2) gene were recently identified as promising molecular targets in this histology. The aim of this study is to describe the DDR2 mutational landscape of lung SCC and investigate the associated clinical factors. Methods: Next‐generation sequencing of the DDR2 gene was performed on 271 samples of lung SCC. Patients followed in our institution from January 2011 to August 2014 were retrospectively selected for data collection. Other driver gene alterations (EGFR, KRAS, BRAF, HER2, and PI3KCA) were analyzed using pyrosequencing. Results: A total of 11 patients harboring a DDR2 mutation was detected among the 271 sequenced lung SCC samples (4%). We describe 10 unreported mutations, comprising a novel DDR2 exon 7 splice mutant. DDR2 mutations were not mutually exclusive with other driver gene alterations. One hundred thirty‐six patients were included for clinical comparison and logistic regression analysis. No difference was detected between DDR2‐mutant and DDR2 wild‐type lung SCC regarding clinical characteristics or survival. Conclusion: DDR2 mutations were observed in 4% of cases of lung SCC of European descent. DDR2‐mutated tumors can exhibit other driver gene alterations. No clinical characteristics were significantly associated with DDR2 mutation.

Impaired efferocytosis and neutrophil extracellular traps clearance by macrophages in ARDS

We report two cases of non-smoker patients diagnosed with EGFR-mutated lung adenocarcinoma and bearing germinal TP53 gene mutation, also known as Li-Fraumeni syndrome (LFS). We describe for the first time an EGFR-TKI resistance mutation in this population. Finally, we provide an analysis of discerning epidemiological data obtained from the IARC database and from all the published cases of EGFR-mutated lung cancer in TP53 germline mutation carriers.