[Endobronchial ultrasound transbronchial needle aspiration initiation into the Lyon Sud hospital center: Experience of the first three years]. / Initiation de la technique d'écho-endoscopie bronchique au centre hospitalier Lyon-Sud : expérience des trois premières années.

INTRODUCTION: Endobronchial ultrasound is a recent technique for the diagnosis and the lymph node staging in lung cancer. It also showed interest in non tumoral mediastinal lymph nodes diagnosis. This work relates the CHLS first three years' experience in terms of EEB practical use as a new diagnostic tool in this field. METHODS: Retrospective study of consecutive cases patients having undergone endobronchial ultrasound from November 2008 till June 2011 in the CHLS. RESULTS: On 65 endobronchial ultrasound, general anesthesia was practiced in 89 % of the cases, with a good tolerance in 81 % of the cases. In 77 % cases, EEB allowed diagnosis and avoided mediastinoscopy in 60.5 % of the cases. The respective sensibility, specificity, positive and negative predictive values were 74 %, 100 %, 100 % and 48 %. CONCLUSION: These data, reflect of a novice team experience, illustrate the results obtained in the current practice in terms of etiologic diagnosis. Endobronchial ultrasound seems destined to a bright future but requires the development of dedicated centers allowing pulmonologists training and specialized pathologists in this field.

[Patient's beliefs about oral targeted therapies and impact on drug adherence in lung cancer: A pilot prospective study]. / Croyances des patients envers les thérapies ciblées orales et leur influence sur l'observance dans le cancer broncho-pulmonaire : une étude pilote prospective.

INTRODUCTION: Oral targeted therapies are a new option for lung cancer treatment. However, patient's belief about these drugs - which may interact with adherence - is poorly known in this setting. METHOD: Our study is a pilot prospective unicentric study. Inclusion criteria were: to have been diagnosed with a lung cancer; and to be prescribed with an oral targeted therapy in second line or more. The main objective was to assess patient's specific (SB) and general beliefs (GB) about these drugs according to the Beliefs about Medicines Questionnaire (BMQ). The declared adherence was assessed with the Morisky's test. All included patients underwent a semi-structured interview with a psychologist. RESULTS: Fifthteen patients were included: 12 underwent erlotinib treatment and 3 a crizotinib treatment. The mean score (±standard deviation) at BMQ was 54/85 (±6) overall; 34/50 (±5) for specific belief and 19/35 (±3) for general belief about drugs. During interview, 47% believed in efficacy of targeted oral therapy; 93% reported concerns about their drug; 80% considered that the information given by the physician about the drug was comprehensive; but 40% still required additional information about it. The mean score at Morisky's test was 3/4 (±2) and 53% reported to have forgotten at least once their antineoplastic drug. No correlation was found between belief and adherence. CONCLUSION: Belief about t anti-cancer targeted oral therapy is relatively fair but adherence is moderate in this pilot study. Interview shows the need for additional information about the prescribed drug.

[How practical guidelines can be applied in poor countries? Example of the introduction of a bronchoscopy unit in Cambodia]. / Comment appliquer les recommandations de bonnes pratiques dans les pays pauvres ? L'exemple de la mise en place d'une unité d'endoscopie bronchique au Cambodge.

According to UN, Cambodia is one of the poorest countries in the World. Respiratory diseases are current public health priorities. In this context, a new bronchoscopy unit (BSU) was created in the respiratory medicine department of Preah Kossamak hospital (PKH) thanks to a tight cooperation between a French and a Cambodian team. Aim of this study was to describe conditions of introduction of this equipment. Two guidelines for practice are available. They are respectively edited by the French and British societies of pulmonology. These guidelines were reviewed and compared to the conditions in which BS was introduced in PKH. Each item from guidelines was combined to a categorical value: "applied", "adapted" or "not applied". In 2009, 54 bronchoscopies were performed in PKH, mainly for suspicion of infectious or tumour disease. In total, 52% and 46% of the French and British guideline items respectively were followed in this Cambodian unit. Patient safety items are those highly followed. By contrast "staff safety" items were those weakly applied. Implementation of EBS in developing countries seems feasible in good conditions of quality and safety for patients. However, some recommendations cannot be applied due to local conditions.

[Chronic necrotizing pulmonary aspergillosis following an infection by Mycobacterium malmoense]. / Aspergillose pulmonaire chronique nécrosante compliquant une pneumopathie à Mycobacterium malmoense.

Pneumonia due to Mycobacterium malmoense is rare and usually occurs in damaged lung as is the case with Aspergillus infections. We report the case of a patient who developed chronic necrotizing pulmonary aspergillosis following an infection by atypical mycobacteria. A 53-year-old woman was hospitalized because of weight loss and fever. Direct examination of sputum smear was positive for acid fast bacilli and PCR and culture led to the diagnosis of infection with M. malmoense. Treatment was begun with clarithromycin, rifampicin and ethambutol. Despite initial improvement and excellent adherence to treatment, fever and weight loss recurred 6 months later. Relapse of the mycobacterial infection was excluded and the final diagnosis was necrotizing pulmonary aspergillosis. Infection with A. fumigatus complicating the treatment of M. malmoense is unusual. The management is challenging because of strong interactions between voriconazole and rifampicin, and thus requires a multidisciplinary and specialized approach.

[Single French centre retrospective analysis of local control after high dose radiotherapy with or without chemotherapy and local control for Pancoast tumours]. / Analyse rétrospective monocentrique française du contrôle local des cancers bronchiques non à petites cellules de l'apex après radiothérapie de haute dose avec ou sans chimiothérapie.

PURPOSE: Superior sulcus non-small cell lung cancer represents less than 5% of all lung cancers and is a challenge for the physicians because of clinical presentation, treatments related toxicities and poor prognosis. The aim of this preliminary retrospective report is to present outcomes of patients affected by a superior sulcus non-small cell lung cancer, treated by high dose radiotherapy (>60 Gy) with or with our chemotherapy. PATIENTS AND METHODS: All adult inoperable or unresectable patients (≥18 years) with a clinical and radiological diagnosis of superior sulcus non-small cell lung cancer treated in our department by radiotherapy with or without chemotherapy were retrospectively analysed. Primary endpoint was the local control. Overall survival, metastasis free survival and toxicity rates were also analysed and reported. RESULTS: From January 1999 to June 2009, 12 patients were treated by exclusive high-dose radiochemotherapy. Median age was 53 years (range: 33-64 years); mean follow-up time was 20 months (range: 2-75 months). Mean local control, overall survival and metastasis free survival were 20.2, 22 and 20 months, respectively. At the time of this analysis, seven patients died of cancer and three of them presented only a metastatic disease progression. One patient died of acute cardiac failure 36 months after the end of radiochemotherapy and was disease free. Treatment was well tolerated and any acute and/or late G3-4 toxicity was recorded (NCI-CTC v 3.0 score). CONCLUSION: This analysis confirms the interest of exclusive high-dose radiochemotherapy in treating inoperable superior sulcus non-small cell lung cancer patients, in achieving good local control and overall survival rates.

[Exsudative pleurisy revealing an infected aneurysm of the abdominal aorta]. / Pleurésie exsudative révélant un anévrisme infectieux de l'aorte abdominale.

INTRODUCTION: The development of a sero-sanguinous pleural effusion is a rare, often overlooked, manifestation of a ruptured infected aneurysm of the abdominal aorta. CASE REPORT: A man of 84years was referred for management of a left-sided pleural effusion associated with symptoms of infection. He had presented two months previously with methicillin resistant staphylococcal septicaemia, the origin of which was a plantar ulcer. The patient was apyrexial and had no abdominal pain. A thoraco-abdominal CT scan without contrast showed a peri-aortic abdominal mass suggesting a tumour. A contrast enhanced scan and peri-aneurysmal aspiration showed that it was an infected aneurysm of the abdominal aorta that had ruptured into the left pleural cavity. The progress was unfavourable despite double antibiotic therapy. CONCLUSION: In the face of a sero-sanguinous pleurisy, particularly if associated with unexplained symptoms of infection, a search should be made for an abdominal aortic aneurysm. Surgical treatment of the aneurysm should be undertaken if the general condition of the patient and the localisation and morphology of the aneurysm permit.

[Thymic tumours, autoimmune neutropaenia and autoimmune haemolytic anaemia]. / Tumeurs épithéliales thymiques, neutropénie et anémie hémolytique auto-immunes.

INTRODUCTION: Although an association between thymic tumour and autoimmune disease (including autoimmune cytopenia) has been established, the association between thymic tumour and autoimmune neutropenia has rarely been reported, with only 13 cases described in the literature. OBSERVATION: We report on a 30 year old man diagnosed with autoimmune neutropenia who had been treated for invasive thymic tumour one year previously. He successfully responded to cyclosporin and steroids therapy. A few months later, the patient presented with autoimmune haemolytic anaemia after prematurely halting his own immunosuppressive treatment. CONCLUSION: This observation brings additional insights about the clinical features, biology and treatment of autoimmune neutropenia associated with thymic tumours and underlines the potential severity of such an association. Furthermore, the association of a thymic tumour with both autoimmune neutropaenia and autoimmune haemolytic anaemia has not been reported previously.

[IFCT-0302 trial: randomised study comparing two follow-up schedules in completely resected non-small cell lung cancer]. / Protocole IFCT-0302: essai randomisé de deux schémas de surveillance dans les cancers bronchiques non à petites cellules complètement réséqués.

BACKGROUND: The authorities advocate a minimalist attitude towards the follow-up of resected bronchial carcinoma (clinical examination and chest x-ray). A survey showed that 70% of French respiratory physicians have chosen to use the CT scanner and often endoscopy. The published data are equivocal and are often based on retrospective studies. Lung cancer is a good model for a study of post-operative surveillance. Recurrences often occur in easily observed areas, they may be detected while still asymptomatic and are sometimes potentially curable. Second primary tumours may develop at the same site. METHODS: The Intergroupe Francophone de Cancerologie Thoracique (IFCT) has initiated a trial comparing simple follow-up (clinical examination, chest x-ray) with a more intensive follow-up (CT scan, fibreoptic bronchoscopy). The surveillance will take place every 6 months for 2 years and then annually until 5 years. EXPECTED RESULTS: The main aim is to determine whether intensive follow-up improves patient survival. The opposite question is equally important. If an expensive and demanding follow-up does not affect the chances of cure these results will influence our practice.

Phase II trial of temozolomide and cisplatin followed by whole brain radiotherapy in non-small-cell lung cancer patients with brain metastases: a GLOT-GFPC study.

BACKGROUND: Brain metastases (BM) considerably worsen the prognosis of non-small-cell lung cancer (NSCLC) patients. The usefulness and choice of chemotherapy remain uncertain in this indication since these patients are excluded from most clinical trials. We conducted a phase II study to determine the efficacy and tolerability of up-front chemotherapy with association of temozolomide and cisplatin in NSCLC patients with BM. PATIENTS AND METHODS: Fifty NSCLC patients with BM received temozolomide (200 mg/m(2)/day for 5 days every 28 days) and cisplatin (75 mg/m(2) at day 1 of each cycle), up to six cycles, followed by whole brain radiotherapy (WBRT). An evaluation was carried out every two cycles and after WBRT. WBRT was performed earlier in case of progressive disease at any time or stable disease after cycle 4. RESULTS: Eight objective responses were achieved (16%). Overall median survival was 5 months. Median time to progression was 2.3 months. Ten patients (20%) presented a grade 3/4 neutropenia and 11 patients (22%) presented a grade 3/4 thrombopenia. CONCLUSION: This study demonstrates a lack of efficacy of up-front chemotherapy with association of temozolomide and cisplatin in these patients. Nevertheless, it supports the feasibility of chemotherapy before brain radiotherapy in NSCLC patients with BM.

[Gastropleural fistula presenting with a pyopneumothorax in pregnancy]. / Pyopneumothorax révélant une fistule gastropleurale.

INTRODUCTION: Gastropleural fistula has only rarely been described in the literature, typically presenting with evidence of left-sided pleural infection. CASE REPORT: The diagnosis may be suggested by the occurrence of chest pain and repeated vomiting with the diagnosis confirmed by microbiological examination of the pleural fluid and appropriate radiological investigations. The fistula occurs most frequently after abdominal or anterior thoracic surgery. Generally, surgical repair should be performed urgently but in the case that we describe occurring during pregnancy, surgery was delayed for 10 weeks until a caesarean section could be performed. CONCLUSION: In the presence of left-sided basal pleuritic chest pain in the context of a possible gap in the diaphragm the diagnosis of gastropleural fistula should be considered. Treatment is usually a medico-surgical emergency.

[Evaluation criteria for bronchial carcinoma. How to assess quality of life in lung cancer?]. / Les critères d'évaluation des cancers broncho-pulmonaires. Comment apprécier la qualité de vie en cancérologie pulmonaire?

The aim of medical treatment in lung cancer is often to a large extent palliative, due to advanced stage at the time of diagnosis. Evaluation of such treatment has usually been based on objective responses, global survival, survival at 1 or 2 years and the occurrence of toxicities, but also more recently on assessment of quality of life. Two Quality of Life questionnaires have been validated (FACT and QLQ C30). The different criteria of 'quality of life' are presented and also their difficulties in application and interpretation, due to potential problems of bias. In routine clinical practice, only the visual symptom scales are of use, in association with the wishes and understanding of patients which must remain at the centre of medical care allowing the patient being a partner in therapeutic decisions.

[French experience of gefitinib in non-small cell bronchial carcinoma]. / Expérience française du géfitinib dans le cancer bronchique non à petites cellules.

INTRODUCTION: Gefitinib (Iressa, ZD 1839; AstraZeneca) is a selective Epidermal Growth Factor receptor tyrosine kinase inhibitor. In two randomized phase II trials (IDEAL 1 and IDEAL 2), it has demonstrated an activity against NSCLC, showing partial response and symptoms improvement rates respectively in about 20% and 40% of patients. Multivariate analyses revealed that being a woman, a non-smoker and having an adenocarcinoma was associated with response rate. METHODS: We describe a retrospective study of patients receiving Gefitinib as a third line compassionate treatment of NSCLC. RESULTS: We enrolled 37 patients (29 men, 8 women). Tumors included 25 adenocarcinoma, 4 squamous cell carcinoma, 7 large cell carcinoma, and 1 neuroendocrine carcinoma. Partial response rate was 8.1%, and stable disease rate 27.0%. The 3 responders were all non-smoker women, with an histological type of adenocarcinoma. Symptoms improvement was observed in 59.5% of patients. Main toxicities were diarrhoea and skin reactions. We observed that responding patients had more adverse drugs-related reactions than stable or non-responding patients. CONCLUSIONS: Gefitinib is a meaningful active therapy in NSCLC with a favorable toxicity profile. We suggest that being a woman, a never-smoker and having an adenocarcinoma may be clinical predictive factors of response to Gefitinib.

[Treatment of lung cancer in the elderly]. / Traitement du cancer bronchique du sujet âgé.

Elderly patients form an increasing proportion of the lung cancer population. However, they are poorly represented in clinical trials. The published studies are generally phase II trials on highly selected small numbers of patients. Applying these trials to clinical practice is therefore difficult and this is compounded by the fear of increased treatment toxicity in elderly patients. In the event of organ failure (respiratory, cardiac or other organ failure), where conventional therapy is not possible, there are a number of alternative options: radiotherapy for inoperable limited non-small-cell-lung cancer, chemotherapy without platinum for those with more extensive disease or with analogues of platinum for small-cell-lung-cancer. Finally, adjunctive therapy with haematopoietic-cell growth factors or cytoprotectors may allow full doses of treatment to be delivered whilst limiting toxicity. More studies in elderly patients, with larger numbers, are needed to develop more rational therapeutic strategies. We present here some studies of reference and the most recent publications on this subject.

[Treatment of bronchial carcinoma in the elderly]. / Traitement du cancer bronchique du sujet âgé

Elderly patients form an increasing proportion of the lung cancer population. However, they are poorly represented in clinical trials. The published studies are generally phase II trials on highly selected small numbers of patients. Applying these trials to clinical practice is therefore difficult and this is compounded by the fear of increased treatment toxicity in elderly patients. In the event of organ failure (respiratory, cardiac or other organ failure), where conventional therapy is not possible, there are a number of alternative options: radiotherapy for inoperable limited non-small-cell-lung cancer, chemotherapy without platinum for those with more extensive disease or with analogues of platinum for small-cell-lung-cancer. Finally, adjunctive therapy with haematopoietic-cell growth factors or cytoprotectors may allow full doses of treatment to be delivered whilst limiting toxicity. More studies in elderly patients, with larger numbers, are needed to develop more rational therapeutic strategies. We present here some studies of reference and the most recent publications on this subject.

[Isolated pleurisy revealing ovarian hyperstimulation syndrome]. / Pleurésie isolée révélant un syndrome d'hyperstimulation ovarienne.

Ovarian hyperstimulation is a rare but serious iatrogenic complication following induction of ovulation cycles. Release of vasoactive substances by the stimulated ovaries leads to leakage of intravascular fluid into the extracellular and serous spaces due to enhanced capillary permeability. Pleural effusion is a classical finding in the most severe forms, often associated with ascitis and signs of hemoconcentration. We report the case of a women who presented pleural effusion as the sole inaugural sign of ovarian hyperstimulation.

Rhabdomyosarcoma arising in mediastinal teratoma in an adult man: a case report.

We report a case of rhabdomyosarcoma which occurred in a mediastinal teratoma in a 44-year-old man. Presentation symptoms were chest pain, hoarseness and a cough. Diagnosis was fortuitous, performed by the histological and immunohistochemical study of a mediastinal tumour biopsy specimen that showed embryonal carcinoma and yolk sac tumour components associated with the rhabdomyosarcoma. After cisplatin-based chemotherapy (bleomycin-etoposide-cisplatin), surgical resection of the residual mediastinal tumour was performed. Histological and immunohistochemical study of this tumour confirmed the presence of mature teratoma and embryonal rhabdomyosarcoma. Evolution was marked by a local extension of the mediastinal tumour, occurrence of multiple metastases and bone marrow involvement. The patient died 8 months after diagnosis despite chemotherapy and radiotherapy. A review of the literature reveals that the development of rhabdomyosarcoma in primary mediastinal teratomas is unusual in adults. The diagnostic, therapeutic and prognostic implications of such an association are reviewed.

The role of chemotherapy in early stage of non-small cell lung cancer.

Despite surgery, resectable NSCLC (stage I, II, and IIIA N2) has a quite poor prognosis: about 50% of patients will die during the first 2 years by metastatic disease and only 36% are alive at 5 years after diagnosis. Postoperative radiotherapy is not effective in case of complete resection (PORT meta-analysis). The role of perioperative chemotherapy is still questionnable. Cambridge meta-analysis has shown a little benefit of cisplatin based postoperative chemotherapy. Several randomised trials are completed like Alpi Trial or ANITA or still in progress. Results would be available in 2 or 3 years. Several phase II trials of preoperative chemotherapy have demonstrated that preoperative chemotherapy is feasible, with high response rate, very few progression (mainly metastatic progression without local progression) and no increase of mortality and morbidity. Two small phase III trials have demonstrated that preoperative chemotherapy can dramatically increase survival compared with surgery alone, in case of N2 disease. The MIP trial of Depierre has studied two or four cycles of MIP regimen in perioperative setting in stage IB, II or IIIA, compared to surgery alone (TRT in case of N2 disease). After 3 years of survey there is a trend in favor of MIP in case of stage IB and II (23% increase of 3 years survival) but not in case of N2. The toxicity of MIP is a possible explanation of such poor results in N2 patients despite a high response rate (64%). Some other trials are in progress in the world. Surgery is also questionnable in case of resectable N2 disease. Several trials comparing chemo radiotherapy to chemo (+/- radiotherapy)+surgery are in progress in U.S. and Europe.

[Chemotherapy of stage IV non-small-cell lung cancer: contribution of gemcitabine]. / Chimiothérapie des cancers du poumon non à petites cellules de stade IV. Apport de la gemcitabine.

Several drugs active against non-small-cell lung cancer currently available. The efficacy of the cicplatin-gemcitabine combination was recently demonstrated in three randomized trials published over the last twelve months in the Journal of Clinical Oncology. This association compares favorably with cisplatin alone, cisplatin-etoposide and mitomycin-ifosfamide-cisplatin combinations. The cisplatin-gemcitabine combination can now be considered as a new "classical" activ regimen in stage IV NSCLC patients and could be used in patients with more favorable prognosis (i.e. in the periopertive seeting). Nevertheless, the benefit of such treatment in stage IV NSCLC seems to be limited to patients with a good performance status (PS 0 and 1).