Maruti Kumaran

Ultrasound guided cytological aspiration of supraclavicular lymph nodes in patients with suspected lung cancer

Background: Lung cancer is the leading cause of death from cancer in the UK. Pathological diagnosis traditionally requires invasive procedures such as bronchoscopy, mediastinoscopy, or image guided biopsy. Ultrasound of the neck with fine needle aspiration cytology (FNAC) of enlarged but impalpable supraclavicular nodes has been used in patients with suspected lung cancer who have N2 or N3 disease on staging computed tomography (CT). If positive, this technique helps to both stage the patient and provide a cytological diagnosis. Methods: 101 patients were enrolled prospectively over a 1 year period. FNAC was performed on all supraclavicular nodes over 5 mm in size using the capillary aspiration technique. Results: Sixty one of the 101 patients had enlarged supraclavicular nodes and underwent FNAC. The overall malignant yield was 45.5% of patients scanned and 75.4% of patients sampled. As a result of FNAC, 43 patients (42.6%) avoided more invasive procedures. Conclusion: Ultrasound guided FNAC is a promising, relatively non-invasive technique for the staging and diagnosis of patients with lung cancer.

A 2-year randomised placebo-controlled trial of doxycycline for lymphangioleiomyomatosis

Lymphangioleiomyomatosis (LAM) is characterised by lung cysts and airflow obstruction. Matrix metalloproteinases have been implicated in lung destruction in LAM. We performed a randomised, double-blind trial, comparing the matrix metalloproteinases inhibitor doxycycline with placebo on the progression of LAM. 23 females with LAM were randomised to doxycycline 100 mg daily for 3 months followed by 200 mg daily for 21 months, or matched placebo. Lung function, exercise capacity, quality of life and matrix metalloproteinases levels were measured. 21 patients completed 6 months of treatment, 17 completed 1 year of treatment and 15 completed 2 years of treatment. Eight withdrew from the trial due, four due to a pneumothorax and four because of other reasons. The mean±sd decline in FEV1, the primary endpoint, did not differ between the groups being -90±154 mL·year−1 in the placebo group and -123±246 mL·year−1 in the doxycycline group (difference -32.5, 95% CI -213–148; p=0.35). Doxycycline had no effect upon vital capacity, gas transfer, shuttle walk distance or quality of life. Urine matrix metalloproteinases-9 measurements were lower with doxycycline treatment (p=0.03). Although with limited numbers we cannot completely exclude an effect of doxycycline, the lack of effect on any outcome makes it unlikely that doxycycline has a useful effect in LAM. Doxycycline does not prevent progression of lung disease in LAM http://ow.ly/tiMqo

Presence of a prothrombotic state in people with idiopathic pulmonary fibrosis: a population-based case–control study

Background Laboratory studies suggest that the clotting cascade is activated in fibrotic lungs. Since humans vary in their tendency to clot due to a variety of inherited or acquired defects, we investigated whether a prothrombotic state increases the chance of developing idiopathic pulmonary fibrosis (IPF) and/or worsens the prognosis of IPF. Methods We recruited 211 incident cases of IPF and 256 age- and sex-matched general population controls and collected data on medical history, medication, smoking habit, blood samples as well as lung function and high-resolution CT scans done as part of routine clinical care. A prothrombotic state was defined as the presence of at least one inherited or acquired clotting defect or marker of fibrinolytic dysfunction. We used logistic regression to quantify the association between a prothrombotic state and IPF adjusted for age, sex, smoking habit and highly sensitive C reactive protein. Cox regression was used to determine the influence of a prothrombotic state on survival. Results Cases were more than four times more likely than controls to have a prothrombotic state (OR 4.78, 95% CI 2.93 to 7.80; p<0.0001). Cases with a prothrombotic state were also likely to have more severe disease (forced vital capacity <70% predicted) at presentation (OR 10.79, 95% CI 2.43 to 47.91) and had a threefold increased risk of death (HR 3.26, 95% CI 1.09 to 9.75). Conclusions People with IPF are more likely to have a prothrombotic state than general population controls and the presence of a prothrombotic state has an adverse impact on survival.

Clinical utility of diagnostic guidelines and putative biomarkers in lymphangioleiomyomatosis.

BackgroundLymphangioleiomyomatosis is a rare disease occurring almost exclusively in women. Diagnosis often requires surgical biopsy and the clinical course varies between patients with no predictors of progression. We evaluated recent diagnostic guidelines, clinical features and serum biomarkers as diagnostic and prognostic tools.MethodsSerum vascular endothelial growth factor-D (VEGF-D), angiotensin converting enzyme (ACE), matrix metalloproteinases (MMP) -2 and -9, clinical phenotype, thoracic and abdominal computerised tomography, lung function and quality of life were examined in a cohort of 58 patients. 32 healthy female controls had serum biomarkers measured.ResultsSerum VEGF-D, ACE and total MMP-2 levels were elevated in patients. VEGF-D was the strongest discriminator between patients and controls (median = 1174 vs. 332 pg/ml p < 0.0001 with an area under the receiver operating characteristic curve of 0.967, 95% CI 0.93-1.01). Application of European Respiratory Society criteria allowed a definite diagnosis without biopsy in 69%. Adding VEGF-D measurement to ERS criteria further reduced the need for biopsy by 10%. VEGF-D was associated with lymphatic involvement (p = 0.017) but not the presence of angiomyolipomas.ConclusionsCombining ERS criteria and serum VEGF-D reduces the need for lung biopsy in LAM. VEGF-D was associated with lymphatic disease but not lung function.

Brain metastases following radical surgical treatment of non-small cell lung cancer: Is preoperative brain imaging important?

OBJECTIVES There is a lack of good quality evidence or a clear consensus of opinion internationally regarding who should receive preoperative imaging of the brain prior to radical treatment for non-small cell lung cancer (NSCLC). We aimed to establish the proportion of patients who developed brain metastases following curative surgery and to estimate how many could have been detected by preoperative magnetic resonance imaging (MR). METHODS We performed a retrospective analysis of 646 patients who underwent surgery for lung cancer with curative intent at a regional thoracic surgical centre in the United Kingdom. We identified those who developed brain metastases in the postoperative period and, by using volume doubling times, estimated the size of the metastasis at the time of surgery. We then determined the proportion of metastases that would have been seen on preoperative MR brain at detection thresholds of 2 and 5mm diameter. RESULTS There was a 6.3% incidence of postoperative brain metastases, with the majority occurring within 12 months of surgery. Those who developed metastases were more likely to have adenocarcinoma and the majority had early stage malignancy (73% stage I or stage II). We estimate that 71% of those who developed cerebral metastases might have been detected had they undergone MR brain as part of their staging (4.4% of all patients). CONCLUSION Based on our findings we suggest that, in addition to standard staging investigations, patients have brain imaging (MR or equivalent) prior to curative surgery in NSCLC regardless of preoperative stage.

The surgical management of intercostal lung herniation using bioprosthesis.

Lung hernia is a rare occurrence. Consequently there is little literature providing guidance to effective management. Classified as congenital or acquired, there are fewer than 300 cases described in current literature (1). We describe a unique method for the management of spontaneous rib fractures and, resulting posterior lung herniation in a 65 year old man following a bout of coughing.

Lymphangitis carcinomatosa as an unusual presentation of renal cell carcinoma: a case report

IntroductionRenal cell carcinoma is a common adult malignancy that can present incidentally or with a multitude of clinical symptoms and signs. Metastatic spread is frequent, occurring via haematogenous and lymphatic routes, although it does not typically present with lymphangitis carcinomatosa.Case presentationWe describe a patient who presented with cough and increasing dyspnoea. Initial chest x-ray and computed tomography were consistent with lymphangitis carcinomatosa that proved secondary to underlying renal cell carcinoma.ConclusionLymphangitis carcinomatosa occurs with many different primary tumours and can rarely be the presenting feature of renal cell carcinoma. Underlying renal cell carcinoma should be considered in the differential diagnosis of lymphangitis carcinomatosa and excluded with subsequent investigations.

Intercostal lung hernia: Radiographic and MDCT findings

Lung hernia, defined as protrusion of pulmonary tissue beyond the normal confines of the thoracic cage, is an unusual clinical entity. We describe radiographic and MDCT findings in a series of six cases. The diagnostic sign of intercostal lung hernia apparent on a chest radiograph and cross-sectional imaging is the detection of lung parenchyma or intra-thoracic contents beyond the rib cage. Multidetector computed tomography (MDCT) allows a detailed study of the underlying anatomy and is helpful in planning further management.

S97 Is an Increased Tendency to Clot a Risk Factor For Developing Idiopathic Pulmonary Fibrosis

Background The aetiology of idiopathic pulmonary fibrosis (IPF) remains poorly understood. Recent animal studies and epidemiological data have suggested that activation of the coagulation cascade in the lung may have an important role in the pathogenesis of IPF. Methods We recruited incident cases of physician diagnosed IPF from five teaching hospitals and eight district general hospitals in England and Wales. Age and sex matched general population controls were recruited from the same region. Participants were asked for details of lifetime occupational history, current or previous illnesses, medication and smoking. Each case and control then had a venous blood sample taken for a thrombophilia screen, including inherited and acquired clotting defects. We also collected high resolution computed tomography (HRCT) scans for all cases, which were reviewed by two experienced thoracic radiologists to confirm the diagnosis of IPF. After excluding individuals on warfarin, logistic regression was used to estimate odds ratios for the association between a prothrombotic state and IPF, adjusting for age, sex and highly sensitive C Reactive Protein (hsCRP). Individuals were defined as being prothrombotic if they had at least one clotting defect present. The analysis was then repeated, stratifying cases by radiological diagnosis. Results Our study included 306 incident cases of IPF(mean age at diagnosis 72.6 years, 70.6% male) and 256 controls (see Table 1). We found an increased tendency to clot among our cases (Odds Ratio [OR] 4.67; 95% Confidence Interval [CI] 3.00 to 7.23) compared to controls. After stratifying by radiological diagnosis, this association was stronger in those with definite usual interstitial pneumonia (UIP) (OR 5.86; 95% CI 3.08 to 11.15) compared to probable UIP (OR 3.47; 95% CI: 1.92 to 6.29). There was no effect modification by age, sex or hsCRP. Abstract S97 Table 1 Conclusion An increased tendency to clot appears to be an independent risk factor for developing IPF. A clinical trial using one of the new, safer anticoagulants may be warranted.

Giant colonic pseudo-diverticula importance of, and aids to radiological diagnosis: a case series.

IntroductionThis case series illustrates the clinical presentation and radiological findings of two patients in whom the diagnosis of a Giant Colonic Diverticulum (GCD) was histologically confirmed. We also discuss the pathogenesis and differential diagnosis.Case presentationIn one case, the patient had no previous large bowel symptoms and intra operatively no other colonic diverticula were found. Both were treated with surgical resection.ConclusionThe preoperative diagnosis of GCD is made radiographically, and the importance of the early recognition of radiological findings, especially in asymptomatic disease, is emphasised.