[An unusual cause of chylothorax: primary amyloidosis]. / Une cause exceptionnelle de chylothorax: l'amylose primitive.

BACKGROUND: Amyloidosis is a large family of diseases defined by the presence of extra cellular protein deposits which can remain localised but are generally diffuse. Pleural involvement with effusion is rare (6% only), and difficult to diagnose because the clinical signs are non-specific. OBSERVATION: We report the case of a 77 year old man, hospitalized for anasarca, with recurring pleural effusions despite two drainages and talcage. Pleural aspiration revealed a chylothorax. ProBNP was high: 24000 ng/l. Echocardiography revealed a restrictive cardiomyopathy and suggested the diagnosis of a systemic disease. Negative peripheral biopsies led us to perform an endomyocardial biopsy, which confirmed the diagnosis of amyloidosis AL. CONCLUSION: We report an original case of primary amyloidosis presenting as a chylothorax and confirmed by an endomyocardial biopsy. We highlight the multi factorial character of pleural effusions associated with amyloidosis. This explains the delay in treatment and the disease's critical nature (median survival 2 months). The prognostic value of proBNP is also emphasised.

Gemcitabine-docetaxel versus cisplatin-vinorelbine in advanced or metastatic non-small-cell lung cancer: a phase III study addressing the case for cisplatin.

BACKGROUND: This multicenter, randomized, phase III study compared the efficacy, including progression-free survival (PFS), and safety of gemcitabine-docetaxel (GD) combination versus cisplatin-vinorelbine (CV) in the treatment of advanced non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS: Chemonaive patients with stage IIIB or IV NSCLC were treated with GD (gemcitabine 1000 mg/m(2) days 1 and 8 plus docetaxel 85 mg/m(2) day 8, every 3 weeks for eight cycles) or CV (cisplatin 100 mg/m(2) day 1 plus vinorelbine 30 mg/m(2), days 1, 8, 15 and 22, every 4 weeks for six cycles). RESULTS: A total of 311 patients were enrolled (155 GD and 156 CV). Neither PFS nor overall survival differed significantly between the two arms (median PFS 4.2 and 4 months; median survival 11.1 and 9.6 months; 1-year survival 46% and 42%, for GD and CV, respectively). For the GD arm compared with the CV arm, the hazard ratio for PFS was 1.04 [95% confidence interval (CI) 0.83-1.32], and for overall survival, it was 0.90 (95% CI 0.70-1.16). Objective response rates did not differ significantly (31% for GD, 35.9% for CV). Myelosupression, emesis and frequency of febrile neutropenia were less pronounced on the GD arm, whereas fluid retention and pulmonary events were more pronounced. The CV arm experienced a higher number of serious adverse events and a lower compliance with the protocol. There was no quality of life (QoL) difference between arms. Median time to definite impairment of health-related QoL was 153 and 168 days in GD and CV arms, respectively. CONCLUSIONS: There was no advantage in PFS with GD compared with CV; however, the CV regimen had higher rate of toxic events, mainly myelosuppression. The herein, non-platinum-containing regimen could be considered as a rational alternative to the cisplatin-based doublet.

Early CYFRA 21-1 variation predicts tumor response to chemotherapy and survival in locally advanced non-small cell lung cancer patients.

We have evaluated CYFRA 21-1 serum level variations as an indicator of tumor response and survival in 44 consecutive patients with locally advanced non-small cell lung cancer (NSCLC) treated with induction chemotherapy (IC). Irrespective of the initial CYFRA 21-1 serum concentration, a more than 65% decrease in the serum level after the first chemotherapy course was significantly predictive of an objective tumor response (p = 0.0022). In addition, a more than 80% decrease in this level significantly predicted a better disease-free survival (p = 0.039). In patients with initial CYFRA 21-1 serum levels > 3.3 ng/mL (n = 29), a more than 80% decrease after the first IC course was the most significant predictor of overall survival (p = 0.025) in a Cox analysis including initial staging, tumor response and surgery. We conclude that early monitoring of CYFRA 21-1 serum levels may be a useful prognostic tool for tumor response and survival in stage III NSCLC patients treated by induction chemotherapy.

[Features of tomodensitometry in the development of pleuropulmonary lesions related to Wegener's granulomatosis]. / Apport de la tomodensitométrie dans le suivi évolutif des lésions pleuropulmonaires de la granulomatose de Wegener.

PURPOSE: The aim of this study was to determine CT scan value for the follow-up of patients with pleuropulmonary lesions related to Wegener's granulomatosis. METHODS: Retrospective study of ten patients who were diagnosed with diffuse Wegener's granulomatosis including lung involvement and for whom mean follow-up was 23 months (range 4-61). RESULTS: During early stages of the disease, the most common finding was the existence of either nodules (90% of the patients) or consolidations (100% of the patients). CT scan controls showed that nodules disappeared within 6 months in 60% of patients and had completely resolved after 12 months. Linear opacities relating to traction developed, replacing subpleural nodules. A pneumothorax occurred in two patients who had excavated subpleural nodules. Consolidations disappeared in 44% of the patients, most frequently within 4 months. When consolidations persisted, they were replaced by alveolar infiltrates accompanied by bronchiolectasies and linear opacities. Regarding either nodules or consolidations, CT features related to relapse were similar to those of initial lesions in 40% of the cases. CONCLUSION: The main features of pleuropulmonary lesions relating to Wegener's granulomatosis were subpleural nodules that either disappeared with, however, subsequent linear opacities sequelae, or were complicated by the occurrence of pneumothorax.

Interaction between cold and hypoxia on pulmonary circulation in COPD.

This study was designed to investigate the interaction of mild and localized cold exposure and hypoxia on pulmonary hemodynamics in chronic obstructive pulmonary disease (COPD). Nineteen patients with COPD were studied at sea level and seven at an altitude of 2,640 m. For all patients, pulmonary hemodynamic measurements were performed 10 min after insertion of a catheter in a femoral vein and following 10 min of cold exposure. Cold exposure was restricted to the forehead, and subjects breathed air at ambient temperature. Flow and temperature of air (1.5 L.s(-1), 5 degrees C) to the forehead were chosen to cool down the forehead skin to approximately 20 degrees C without discomfort for the subject. For the seven patients studied at high altitude, the same measurements were also performed after 5 min of oxygen supplementation with and without cold exposure. At sea level, an increase in pulmonary vascular resistance (PVR) during cold exposure was inversely related to the initial PaO2. In six severe hypoxic subjects (PaO2 < 50 mm Hg), PVR increased by 24%. At high altitude, PVR was significantly increased by 15%. After O2 supplementation, cold exposure did not induce an increase in PVR. We concluded that mild and localized cold exposure to the forehead only induced an increase in PVR in COPD patients with severe hypoxia. Moreover, in cold exposure responders, O2 supplementation negated the effect of cold exposure on pulmonary hemodynamics.

An ongoing randomized study of neoadjuvant chemotherapy in resectable non-small cell lung cancer.

The purpose of this trial is to assess the possible benefit of neoadjuvant chemotherapy before surgery in patients with operable non-small cell lung cancer. Patients with operable stages I (except T 1N0), II, or IIIA disease are eligible for this ongoing trial. Patients are randomized into two arms. Surgery is performed first in group I; patients found to have T3 tumors or N2 lymph nodes are given postoperative radiotherapy. Group 2 patients start with two cycles of chemotherapy; following surgery, two more cycles are administered in responder patients and, as in group I, patients with T3 tumors or N2 lymph nodes are given radiotherapy. Chemotherapy is the MIP protocol: mitomycin 6 mg/m2 day I, ifosfamide 1.5 g/m2 days 1 to 3, cisplatin 30 mg/m2 days I to 3, and mesna 1,200 mg/m2 days 1 to 3. One hundred fifty patients were enrolled between June 1991 and September 1993. By the time this report was prepared, 117 patients had completed all assigned treatment, 63 in group I and 54 in group 2. There were two ineligible patients, one in each group. Forty-nine patients underwent thoracotomy in the chemotherapy-surgery group and 62 in the surgery-only group. There was only one progression after two cycles of chemotherapy. Rates of exploratory and incomplete surgery were 17% in group I and 12% in group 2. The trial is ongoing.