Marc Meysman

Detecting upper airway obstruction in patients with tracheal stenosis

We propose a forced oscillation test modality for detecting upper airway obstruction (UAO) as an alternative to spirometric UAO indices in patients with tracheal stenosis. From oscillometry performed at different breathing flow rates, airway resistance at 5 Hz was determined at 0.5 l/s (R), and flow dependence of resistance was computed as the regression slope of resistance vs. flow up to 1 l/s (Delta R/Delta V). It was first verified by measurement in 10 normal subjects and 10 patients with chronic obstructive pulmonary disease that Delta R/Delta V was unaffected by the presence of peripheral airway obstruction and that external orifices (with lumen area down to 28 mm(2)) induced marked increases in R and Delta R/Delta V. Ten patients eligible for tracheal dilatation underwent spirometry and impulse oscillometry before and after intervention. Considering the lumen area of tracheal stenosis in the patients (42 +/- 28 mm(2), represented as the mean +/- SD), the R and Delta R/Delta V increases were of similar magnitude to those predicted by the external orifices. In addition, R (r = -0.68; P = 0.001) and Delta R/Delta V (r = -0.65; P = 0.001) showed better correlations with minimal tracheal lumen than any spirometric UAO index. Delta R/Delta V, but not R, showed a consistent return to normal after intervention in the stenosis patients. We conclude that the forced oscillation test at different breathing flow rates up to 1 l/s provides a measure of UAO, namely flow dependence of resistance Delta R/Delta V, which can signal a critical level of tracheal stenosis and is not confounded by the presence of concomitant peripheral airway obstruction.

Successful Removal of a Massive Endobronchial Blood Clot by Means of Cryotherapy

Abstract: Because of its freezing characteristics, cryotherapy can be used to remove water containing foreign bodies. We describe a patient with massive hemoptysis in whom a large endobronchial blood clot was successfully removed using cryotherapy. This technique is probably the treatment of choice for removal of large clot from the airways.

Final Overall Results of a Study with a Novel Triplet Induction Chemotherapy Regimen (PACCAGE) Followed by Consolidation Radiotherapy in Locally Advanced Inoperable Non-small Cell Lung Cancer (NSCLC)

Introduction: We report the long term and overall results of a triplet induction chemotherapy regimen followed by standard radiotherapy in patients with locally advanced inoperable stage III non-small cell lung cancer. Methods: Three cycles of paclitaxel, carboplatin, and gemcitabine were administered every 3 weeks before standard fractionated consolidation radiotherapy starting at least 4 weeks after the last chemotherapy administration. Toxicity and antitumor response was assessed in detail as well as the progression free and overall survival. Results: Sixty-four patients (25 stage IIIA and 39 stage IIIB) received a total of 179 cycles of chemotherapy. Fifty-six received the planned three cycles. Full-dose radiotherapy was administered in 47 patients (73%), a reduced dose in 11 (17%) and none in six (10%). A 55% objective response rate (OR) (one complete and 34 partial responses) was observed after induction chemotherapy. After completing the whole treatment including radiotherapy, the OR was 40 of 47 evaluable patients (85%). Median time to progression was 10.9 month and median overall survival was 17.2 month, with a significant difference between stage IIIA and stage IIIB patients (23.4 versus 10.5 month; p = 0.011). The strongest predictor for a favorable long-term outcome was a metabolic complete response after chemotherapy. Conclusion: Induction chemotherapy with the paclitaxel, carboplatin, and gemcitabine regimen preceding radiotherapy in patients with locally advanced inoperable stage III non-small cell lung cancer was feasible and active. Radiotherapy could be administered at a full dose in the majority of patients with acceptable toxicity. Long-term survival results of this sequential chemoradiotherapy regimen appear similar to those of concurrent treatment. Patients not achieving a metabolic complete response after induction chemotherapy should be the focus of studies aiming at improved local control.

Cough, fatigue and fever.

A 37‐yr‐old male complained of a dry cough, fever, nocturnal sudation and dyspnoea. On lung auscultation, his general practitioner noticed right-sided expiratory wheezing and the diagnosis of tracheitis was withheld. Clarithromycin and a cough syrup were given and a slight amelioration was noticed, except for the persistence of dry cough. Bronchial hyperreactivity was suspected and a combination of budesonide and formoterol was added to the treatment. During the following 2 months, symptomatology varied; cough and dyspnoea were intermittently present until the patient started complaining of right thoracic pain and important fatigue. Fever re-appeared reaching 39°C, and, after consulting his general practitioner, cefuroxime and paracetamol were prescribed. Once again the fever disappeared, but a very invalidating cough with mucopurulent sputum, fatigue and chest pain persisted. After the antibiotic was stopped, fever reappeared and the patient was hospitalised. In his past history the patient was treated at the age of 12 yrs by immunotherapy for an allergic rhinitis caused by dust allergy. There was no particular familial history. He had never smoked and worked in an office. On clinical examination, the patient was pale, sweaty and thin. His blood pressure was 125/65, pulse 100·min−1 and temperature 38.7°C. On lung auscultation, breath sounds were diminished at the right lung base. Otherwise, physical examination was normal. Laboratory studies demonstrated a white blood cell count of 16×109·L−1, with 83% neutrophils, haemoglobin 131 g·L−1 …

Broncho‐mediastinal fistula following perforation of the oesophagus

Abstract We present a 63‐year old female with mediastinitis following an esophageal perforation, possibly favoured by an oesophageal motility disorder and the use of non‐steroidal anti‐inflammatory drugs, who developed a broncho‐mediastinal fistula in the left main bronchus. She was successfully treated with intravenous antibiotics, a cervical oesophagostomy and secondary isoperistaltic coloplasty.

PRIMARY TRACHEOBRONCHIAL AMYLOIDOSIS: A SERIES OF 3 CASES

Abstract Primary tracheobronchial amyloidosis is a form of localized pulmonary amyloidosis, characterised by the deposition of AL-amyloid in trachea and bronchi. It is a rare and slowly progressive disease, usually requiring repeated endoscopic treatment. In this case series we describe symptoms, diagnostic and therapeutic procedures, radiological findings and pulmonary function testing in 3 cases of different presentation and severity. Two patients were treated by endoscopic debulking and stent placement during rigid bronchoscopy, both with excellent clinical and functional results. In one of these patients regular endoscopic and clinical control exams were performed in the 5 years following the initial treatment, showing stable disease, requiring no further therapeutic intervention until today.

Raltitrexed-related pulmonary toxicity.

Raltitrexed (Tomudex) has recently been registered for the treatment of metastatic colorectal cancer. This drug was shown to produce response, time to progression and survival rates identical to those with 5-fluorouracil-based regimens. The most frequent side effects relate to the hematopoetic and gastrointestinal systems (1). To the best of our knowledge, pulmonary toxicity has never been reported. Case report. A 68-year-old female patient without any significant previous medical history underwent a left hemicolectomy for: Dukes B adenocarcinoma of the sigmoid colon on March 1998. Surgery was uneventful and no adjuvant therapy was undertaken. During follow-up, a rise in serum CEA-level and detection of liver metastasis (CT scan) indicated recurrence. Ambulatory treatment with Raltitrexed 3 mg/m repeated every 3 weeks was initiated (October 15, 1998). Chest roentgenogram (Fig. 1a) and thoracic CT scan were completely normal at baseline. Owing to a significant increase in hepatic enzyme levels after course 2, the dosage of the drug was reduced by 20% as from course 3. A few days after each administration, the patient reported asthenia and dyspnoea on exercise, which resolved completely and spontaneously within days. A clinical examination of the heart (including ECG, cardiac enzymes and Doppler echography) and lungs after course 2 revealed no abnormalities. A partial remission (PR) was documented after 4 courses (January 6, 1999) and it was decided to continue the same chemotherapy, despite the unexplained and apparently increasing degree of dyspnoea and prolongation of time to recovery between the subsequent courses. A chest roentgenogram carried out at the time of the restaging investigations was normal. After 7 courses of therapy, stable disease (with respect to January 6, 1999, was documented on April 22nd. At that time, the chest roentgenogram showed a mild reticulonodular image in both lung bases (Fig. 1b). On May 18, 21 days after course 8, the patient was admitted to the hospital with progressive severe dyspnoea and fever. A few days after the 8th course the patient had again experienced the typical dyspnoea that accompanied each infusion. This time, however, no ‘spontaneous’ recovery occurred, but the symptoms progressively worsened and necessitated hospital admission. At admission, clinical examination showed a conscious, febrile (38°C) patient, extremely dyspnoeic at rest, with fine crackling bibasal lung rales. No signs of deep peripheral venous thrombosis were present. A chest roentgenogram revealed striking bilateral interstitial infiltrates, compatible with interstitial pneumonitis (Fig. 1c). Arterial hypoxemia was present in breathing room air (PaO2 56 mmHg; PaCO2 41 mmHg). The blood examination revealed only an accelerated sedimentation rate and a slightly elevated white blood cell count (10600 elements/mm) with normal differential count. A perfusion/ventilation scintigraphy of the lungs showed lacunar mismatched perfusion defects in the laterobasal and posterobasal segments of the right lower lobe, compatible with lung emboli. During the first few days of hospitalization the patient received supportive therapy (nasal oxygen supplementation, bed rest, IV hydration), large spectrum IV antibiotics and SC low molecular weight heparin. Hemocultures on admission and viral/bacterial serology failed to demonstrate infection. The results of thoracic CT scan suggested interstitial pneumonitis; no intravascular perfusion defects were observed in the right lower pulmonary artery. Two attempts to perform a transbronchial biopsy by bronchoendoscopy (to establish a histopathological diagnosis) failed because of severe hypoxemia. We were able to perform a bronchoalveolar lavage (BAL) on the second occasion but no abnormal cells were seen in the BAL fluid. Epithelial cells did not stain for CEA immunochemistry. Cytology showed a neutrophilic alveolitis with 9% neutrophilis. Total nucleated cell count was 210/mm (normal): Lymphocyte count was normal on BAL fluid and no eosinophils were present. The patient refused a transthoracic open-lung biopsy. Without a specific diagnosis and any clinical and laboratory amelioration while on empiric treatment, it was decided to start corticotherapy (methylprednisolone 32 mg/day). The response was strikingly favorable, with clinical recovery of respiratory function and a progressive increase in oxygen arterial blood saturation. Furthermore, the radiological lung parenchyma-image on the chest roentgenogram and CT scan improved significantly. The patient was discharged from the hospital in good general condition on June 21st. She was not rechallenged with Raltitrexed and modulated 5-fluorouracil (leucovorin/fluorouracil) chemotherapy was initiated on June 29th uneventfully. Discussion. We believe there are several reasons to suggest that the interstitial pneumonitis that occurred in this patient was caused by the administration of Raltitrexed. First, Raltitrexed was the only drug used in this patient, who had presented a non-lung related cancer and no concomitant lung comorbidity. Second, there was a

Respiratory failure with diffuse patchy lung infiltrates: an unusual presentation of squamous cell carcinoma

The case history is presented of a patient with squamous cell carcinoma of the lung with diffuse bilateral pulmonary shadowing mimicking bronchioloalveolar cell carcinoma which led to type I respiratory failure.