Mark E. Lund

A Comprehensive Review of Spontaneous Pneumothorax Complicating Sarcoma

BACKGROUND Spontaneous pneumothorax (SPTX) is an uncommon phenomenon in the general population and is most commonly associated with prior bulbous emphysema, cystic parenchymal lung disease, and tuberculous lung disease. A rare cause of SPTX is malignant disease, either in the form of primary lung or pleural cancers, or in metastatic disease to the lungs. The purpose of this investigation was to compile patient characteristics, treatments received, and outcomes of patients with SPTX complicating sarcomatous cancer. METHODS Case reports and series published in the medical literature were identified through a MEDLINE search and compiled to determine similarities among patient characteristics, treatments received, and outcomes. RESULTS One hundred fifty-three cases representing 20 different sarcoma cell types were included; 126 (82.3%) had received some form of treatment prior to the development of pneumothorax, and 70 (45.7%) experienced recurrence of pneumothorax at an average of 61 (+/- 112) days. Patients had poor survival, with only seven of 81 subjects remaining alive 2 years after the initial diagnosis of SPTX. CONCLUSIONS SPTX complicating sarcoma is associated with most cell types and is associated with increased mortality compared with patients without this complication.

Association of cetuximab with adverse pulmonary events in cancer patients: a comprehensive review

Compounds derived from biologic sources, or biologicals, are increasingly utilized as therapeutic agents in malignancy. Development of anti-cancer targeted therapies from biologics is increasingly being utilized. Cetuximab, a chimeric monoclonal antibody, is one such anti-cancer targeted therapeutic that has shown efficacy in quelling the rate of patient decline in colorectal, head/neck, and non-small cell lung cancer. However, due to the relatively recent addition of biologic compounds to the therapeutic arsenal, information related to adverse reactions is less well known than those seen in traditional chemotherapeutics. Dermatologic reactions have been demonstrated as the most frequent side effect cited during cetuximab therapy for malignancy; however, other effects may lead to greater morbidity. In general, pulmonary complications of therapeutics can lead to significant morbidity and mortality. The purpose of this review is to compile the various pulmonary side effects seen in patients treated with cetuximab for various malignancies, and to compare the incidence of these adverse reactions to standard therapies.

Transbronchial Needle Injection: A Systematic Review of a New Diagnostic and Therapeutic Paradigm

Background and Objective: Transbronchial needle catheters are commonly used during flexible and rigid bronchoscopy for needle aspiration. The use of these catheters can be expanded by employing the technique of transbronchial needle injection. Methods and Results: By injecting lesions in the airways, peribronchial structures, mediastinum, or lung parenchyma, transbronchial needle injection has been applied to the treatment of lung cancer, inflammatory disorders of the airways, recurrent respiratory papillomatosis, as well as bronchopleural fistulas. Diagnostic applications have included the localization of peripheral lung nodules as well as sentinel lymph nodes. Conclusions: Our review defines this bronchoscopic technique and summarizes its various reported applications.

The microbiology of postobstructive pneumonia in lung cancer patients.

Recurrent pneumonias often occur in the setting of an airway obstruction and can be the presenting symptom of an undiagnosed malignancy. Little is known regarding the microbiology of these pneumonias making antibiotic therapy difficult to direct; however, the few studies available show these pneumonias to be polymicrobial. Examining the colonization patterns of at-risk populations such as patients with chronic obstructive pulmonary disease and using techniques such as ultrasound and computed tomography-guided biopsies may help in the treatment of these pneumonias. The following review is presented to highlight the current medical knowledge as well as suggest areas for future evaluation.

Intraoperative Radiation Therapy for Breast Cancer Not Associated with Pulmonary Complications

Radiation pneumonitis and radiation-induced cryptogenic organizing pneumonia are common complications after external beam radiation therapy following breast conserving surgery for patients with early stage breast cancer. Intraoperative radiation therapy (IORT) is designed to decrease radiation exposure to the lung, skin, soft tissue, and contralateral breast. A single-center, retrospective cohort of all patients receiving IORT between 2009 and 2013 was analyzed, and 122 cases of IORT were found. There were no instances of pulmonary complication in patients receiving IORT without whole breast irradiation. The only instance of radiation pneumonitis identified was in a patient who received subsequent external beam radiation after boost IORT. As there are no previous systemic evaluations of pulmonary complications of IORT, this study supports its reported safety.

Pulmonary Manifestations of Amyloidosis

Amyloidosis is a disease characterized by the deposition of abnormal proteins in extracellular tissue. The deposits originate from serum derived or locally produced proteins. (Sipe et al., 2010) The term “amyloid” was first used by Rudolph Virchow in 1854. (Saleiro et al., 2008) According to the Nomenclature Committee of the International Society of Amyloidosis 2010 recommendations, an amyloid fibril protein must occur in tissue deposits and exhibit affinity for Congo red and green birefringence when viewed by polarization microscopy. Furthermore, the protein must have been unambiguously characterized by protein sequence analysis (DNA sequencing in the case of familial diseases). In this chapter, we will focus on the pulmonary manifestations of amyloid. We will discuss the classification, presentation, symptoms, diagnostic testing and therapeutic options with regards to amyloid in the respiratory tract. Amyloidosis had been classified over the years based on the site of deposition and presence or absence of other diseases. (Thompson & Citron, 1983) The term “Generalized” or “Systemic” had been used to describe deposition in multiple anatomic sites and “localized” used to describe deposition in one anatomic site. The term “secondary” used to describe patients with coexistent disease like multiple myeloma and “primary” for patients with no such coexistent disease. (Utz et al., 1996)

Practice patterns for maintaining airway stents deployed for malignant central airway obstruction.

Although significant experience exists in placing airway stents, and knowledge of stent-related complications is widespread, information is lacking regarding methods of surveillance and maintaining patency of these stents. The purpose of this investigation was to determine the actual practice patterns used by interventional pulmonologists for airway stent maintenance. We prospectively surveyed members of the American Association of Bronchology and Interventional Pulmonology or attendees at their annual meeting during Chest 2008. Sixty-two respondents returned the completed surveys and were included in the analysis. Practice settings included university (50%), single specialty (27%), community academic (11%), and multispecialty (11%) settings. Annual placement of stents was ≤10 (31%); 11 to 30 (45%); and >30 (24%). Considerable variability existed in both medications used for maintenance and surveillance schedules, and less than 50% protocolized postplacement management. Although stent placement is common among experienced interventional pulmonologists, half have no protocol for surveillance or maintenance. Similarly, there is no discernable consistency or standard practice pattern to monitor for or prevent stent failure. Further study is required to determine the best practices for postdeployment surveillance and maintenance of airway stents.

Bronchoscopy in Bronchiectasis and Cystic Fibrosis

Bronchiectasis is a constellation of diseases characterized by abnormally dilated bronchi with thickened bronchial walls due to repeated infection and inflammation. Bronchiectasis causes impairment of mucociliary clearance, airflow limitation, bronchorrhea, and predisposes to recurrent respiratory infections. It has a number of potential underlying causes. Laennec first described bronchiectasis as a distinct clinical entity in 1819 (Barker 2002, O’Donnell 1998). The diagnosis, investigation and particularly management of bronchiectasis has been largely empirical and unfortunately, the subject of relatively few controlled clinical trials. Cystic fibrosis causes about a third of all bronchiectasis in United States (O’Donnell 1998), and is common worldwide. Cystic fibrosis (CF) is a recessive genetic disease characterized by dehydration of the airway surface liquid and impaired mucociliary clearance caused by altered functioning of a chloride channel called the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR). Impaired chloride conductance through the apical portion of airway cells leads to dehydration of airway secretions causing lung destruction through obstruction of the airways with thickened secretions. The resultant endobronchial infection and exaggerated inflammatory response leads to the development of bronchiectasis (destruction and widening of airways) and progressive obstructive airway disease. This chapter provides insight into the specific diagnostic and therapeutic roles of bronchoscopy in patients with bronchiectasis and Cystic Fibrosis.