Transbronchial needle aspiration in the diagnosis of sarcoidosis.

A total of 258 patients with suspected sarcoidosis underwent transbronchial needle aspiration lymph node biopsies and forceps bronchial biopsies during rigid bronchoscopy. Transbronchial needle aspiration biopsies revealed noncaseating granulomas in 66.3 percent of patients. When transbronchial needle aspiration biopsies were combined with forceps bronchial biopsies, the positive rate increased to 77.7 percent. No major complication occurred when using transbronchial needle aspiration. Rigid bronchoscopy with transbronchial needle aspiration biopsies appears to offer a sensitive and specific alternative to more invasive techniques used in the diagnosis of sarcoidosis.

[Is chemotherapy with cisplatin useful in non small cell bronchial cancer at staging IV? Results of a randomized study]. / La chimiothérapie comportant du cisplatine est-elle utile dans le cancer bronchique non microcellulaire au stade IV? Résultats d'une étude randomisée.

The benefit of chemotherapy for patients with disseminated non small cell lung cancer (NSCLC) is controversial. The introduction of cisplatinum in the combination chemotherapy for NSCLC gave rise to higher response rates. To study the question of the usefulness of cisplatinum-based chemotherapy in disseminated NSCLC we conducted a prospective randomized trial comparing best supportive care to vindesine + cisplatin. Between December 1985 and March 1988, 49 patients with stage IV NSCLC were enrolled. Of the 46 eligible patients 24 were in the chemotherapy group and 22 in the best supportive care group. The treatment groups were not significantly different in terms of age, performance status, histology. Toxicity on the chemotherapy arm grade 3 or more was observed in 17.5% for neutropenia, in 8.75% for vomiting. There was one death related to treatment. The overall response rate in the chemotherapy group was 41.7%. Patients of the chemotherapy group had a median survival time of 199 days and the patients of the best supportive care group had a median survival time of 73 days. The difference in survival is highly significant (p less than 0.001).

[Noninvasive diagnosis of pulmonary arterial hypertension in chronic respiratory insufficiency]. / Diagnostic non-invasif de l'hypertension artérielle pulmonaire dans l'insuffisance respiratoire chronique.

A precise assessment of pulmonary arterial hypertension (HTAP) in chronic lung disorders is not possible without right heart catheterisation. In spite of technological advances (floating catheters with or without balloons) the examination remains invasive, at least to a certain degree, in addition it is not currently practiced in respiratory function laboratories or in services specialising in thoracic medicine. The diagnosis of HTAP is important when considering both the prognosis and the therapeutic approach notably in chronic airflow obstruction (BPCO) and thus the interest in non-invasive diagnostic methods for HTAP. Do current methods offer such a diagnosis? It is this question that the authors endeavour to answer in analysing the possibilities of the principle methods available, from the most standard (eg ECG, chest radiographs) to the most recent (right heart echo-cardiography, myocardial scintigraphy, isotopic measurement of the right heart function). The reference factor is usually the mean pulmonary artery pressure at rest (PAP) supplied by right heart catheterisation. The ideas of sensibility and specificity of a method are defined and the importance of the correlation between the numerical results obtained by a given method and right heart catheterisation is emphasized: only a very strong correlation could assure the possibility of a correct prediction of the level of PAP. Individually no current methods allow such a prediction in a satisfactory manner. Right heart echo-cardiography is "a priori" the most tempting, but it is unfortunately difficult to accomplish in patients with BPCO. Bidimensional echo-cardiography and the Doppler have given very promising results, which need to be confirmed in patients with BPCO. By combining the results of several methods (eg. ECG, radiological measurements, echocardiography) to those of respiratory function (FEV1, PaO2, PaCO2) one can predict in a satisfactory manner the existence (or the absence) of HTAP but not the precise level of the PAP. An approach of this kind may help to limit the indications for right heart catheterisation which remains irreplaceable for the precise knowledge of pulmonary hemodynamic parameters.

[Invasive aspergillar pneumopathy during the treatment of microcellular bronchial cancer. Efficacy of early antifungal treatment]. / Pneumopathie aspergillaire invasive au cours du traitement d'un cancer bronchique microcellulaire. Efficacité du traitement antifungique précoce.

The invasive aspergillus pneumonias have been described particularly in chemotherapy for patients with haematological disorders. In respiratory disorders such cases are exceptional. The authors report a case of invasive aspergillus pneumonia, occurring during treatment of a small cell cancer; the rapid commencement of anti-fungal treatment by Amphotericin "B" and Flucytosine enabled an apparent cure of the tumour by radiotherapy and chemotherapy. The authors stress the difficulty of definitive diagnostic criteria at the beginning of the disorder and also the need to start anti-fungal treatment as soon as possible.

[Evaluation of the prognosis in sarcoidosis: remission as an issue of biological criteria and current cellular activities (ACE and alveolar lymphocytosis)]. / Evaluation du pronostic de la sarcoïdose: remise en question des critères biologiques et cellulaires usuels d'activité. (ECA et lymphocytose alvéolaire).

The spontaneous evolution of 60 patients suffering from recently diagnosed sarcoidosis was compared with their initial biological profile of "activity". 47% of this unselected group of patients belonged to an inactive group (ACE less than 35 nmol/ml/mn and the percentage of alveolar lymphocytes less than 30%). After a mean period of two years of follow up it turned out that the initial bioprofile of activity had no predicted value, even in the absence of any initial elevation of the markers (3 cases out of 28 grew worse). The repeated controls of criteria of activity did not objectively show any concordant change with the outcome in such cases. It is necessary to point out the unfavourable character of very raised ACE activity greater than 50 nmol/ml/mn (7 deteriorations out of 8 cases). It would appear that a systematic search for these criteria should be deferred principally in type 1 lymph node involvement or pulmonary and mediastinal type IIA, all the more so as in practice they have little influence on therapeutic decisions.

[Pleurisy in ovarian hyperstimulation syndrome. Apropos of a case]. / Les pleurésies du syndrome d'hyperstimulation ovarienne. A propos d'une observation.

The syndrome of ovarian hyperstimulation is a little known aetiology of pleural effusion. It should be thought of in young women who are under treatment to induce ovulation. Serous effusions which occur in these cases are a serious sign. The effusions are exudates and not transudates as occurs in Demons-Meigs syndrome. The treatment which will be undertaken ought to consider the possibility that a pregnancy is underway.

[Endobronchial aspergillosis associated with a carcinoid tumor]. / Aspergillose endobronchique greffée sur une tumeur carcinoïde.

We report a case of a 62 year old man who presented with effort dyspnoea accompanied by a cough and haemoptysis. The chest radiograph of the thorax showed atelectasis of the right upper lobe. Bronchoscopy showed evidence of a tumour like mass obstructing the right bronchus and this revealed itself to be a mass of organised fibrinous deposit in granulation tissue containing numerous colonies of Aspergillus. In fact it appeared to be an obstructive Aspergillus bronchitis, with a pseudo-tumour appearance attached to a carcinoid tumour which was obstructing the apical segment of the right upper lobe. Obstructive Aspergillus bronchitis makes up only a small percentage of overall respiratory disease caused by Aspergillus. They pose a problem of differential diagnosis with bronchopulmonary aspergillosis which is much more frequent.

[Multiple elemental organic components of the broncho-alveolar lavage fluid in normal subjects and in various lung pathologies (excluding silica and asbestos fibers)]. / Etude multi-élémentaire des composants inorganiques du liquide de lavage broncho-alvéolaire chez le sujet normal et dans diverses pathologies pulmonaires (silice et fibres d'amiante exclues).

Owing to a technical analysis enabling the detection of mineral elements present in trace amounts in small volumes, an analysis of the liquid obtained in 148 broncho-alveolar lavages could be studied. The elements consistently recovered were as follows: iron, copper, zinc, nickel, lead and titanium. Normal values were established. In the absence of exposure, there was no significant difference distinguishing the different pulmonary diseases studied. In occupational disease, the presence of iron in large quantities, tungsten, nickel and rare earths could be shown objectively, as well as the persistence of gold or iodine after medical absorption. However, this preliminary work does not allow one to establish a formal correlation between the alveolar concentrations obtained and the pulmonary disease observed.

[Clinical aspects of occupational asthma]. / Aspects cliniques de l'asthme professionnel.

Although on the increase overall, the actual prevalence of occupational asthma is difficult to assess because of variations seen according to periods, countries, jobs, and the agents responsible. In the authors' experience, this prevalence is slightly less than 10%. Three principal mechanisms, sometimes present together, not always elucidated: immunological, reflex and irritative, are responsible for such asthma. Whilst a positive diagnosis raises few problems, the aetiological diagnosis is difficult and involves two stages: recognition of the occupational characteristic of the asthma and attribution of this asthma to an allergen or substance in the occupational environment. Skin tests and in vitro tests, but above all exposure tests, make an important diagnostic contribution. Personal examples are used to illustrate the principal aetiological factors in occupational asthma of animal, vegetable or chemical origin.

[Diffuse interstitial pneumopathy related to tungsten carbide, confirmed by bronchoalveolar lavage, and responding to corticotherapy]. / Pneumopathie interstitielle diffuse liée au carbure de tungstène confirmée par lavage broncho-alvéolaire, régressive sous corticothérapie.

The authors report a case of severe diffuse interstitial hard metal lung disease responding to corticosteroid therapy. They point out that the course of this disease may be regressive and emphasise that analysis of broncho-alveolar washings showed no abnormality in the differential cell count. Mineralogical study of the same material confirmed exposure.

[Recurrent sarcoidosis in skin scars disclosing repeated thoracic sarcoidosis]. / Sarcoïdes récidivantes sur cicatrices cutanées révélatrices de sarcoïdose thoracique itérative.

Recurrence of thoracic sarcoidosis after spontaneous regression is extremely rare. Its existence is proven by two new cases associating sarcoidosis with L ofgren 's syndrome and sarcoid in skin scars, the latter facilitating the recognition of the presence of thoracic disease. Surveillance of the behaviour of scars forms part of routine examinations in the sarcoid patient. Even when there has been total spontaneous regression, subsequent clinical and radiological follow-up every two years must be continued.

[Home oxygen therapy of chronic bronchitis patients. Clinical, functional and pulmonary hemodynamic results. Apropos of 17 cases]. / L'oxygénothérapie à domicile des bronchitiques chroniques. Résultats cliniques, fonctionnels et hémodynamiques pulmonaires. A propos de 17 cas.

UNLABELLED: Seventeen subjects (16 male, 1 female) with a mean age of 60 +/- 7 years were studied. INCLUSION CRITERIA: severe chronic bronchitis (mean FEV1 = 960 ml with frank hypoxaemia (PaO2 less than 60 mmHg); past history of right heart failure or electrical signs of right ventricular hypertrophy or pulmonary hypertension (PAP greater than 20 mmHg); oxygen therapy at home for greater than 10/24 hours (most often greater than or equal to 12 hours) for more than a year; interval of more than 6 months between the first haemodynamic investigation (before the start of O2) and the last, this period being on average 23.9 +/- 18.6 months. From a clinical standpoint, there were 5 deaths occurring 11 to 30 months after the start of O2. Effort dyspnoea was stable or worsened but hospitalisations for cardiorespiratory decompensation were less frequent than before the start of O2. There were no significant changes in arterial blood gases: PaO2 rose from 51.9 +/- 8.1 to 52.5 +/- 7.0 mmHg. PAP improved in 12 cases out of 17, and for the group as a whole the difference was not statistically significant. However in the sub-group where the daily duration of administration was greater than 12/24 hours (n = 7), PAP improved in all the individual cases and fell on average from 26.4 +/- 6.8 to 19.9 +/- 3.4 mmHg (p less than 0.02) whilst in the 10-12 hours sub-group there was no mean change in PAP.(ABSTRACT TRUNCATED AT 250 WORDS)

[Practical value of the assay of serum angiotensin converting enzyme activity in sarcoidosis]. / Intérêt pratique du dosage de l'activité de l'enzyme de conversion de l'angiotensine sérique dans la sarcoïdose.

Serum levels of angiotensin conversion enzyme (A.C.E.) are increased in 60 to 80% of cases of sarcoidosis. A.C.E. levels were measured as part of the initial assessment of 70 patients with the disease, with repeated measurements in 18 of them. The subsequent course of sarcoidosis was evaluated over a minimum period of 7 months, in relation to initial serum A.C.E. levels. A high serum A.C.E. level is indicative of the secretion of the cells of the epithelioid and giant cell granuloma and reflects the activity of the disease at the particular time without providing any definite prognostic information. Study of 6 patients treated with corticosteroids showed that serum A.C.E. levels rose again when treatment was reduced or stopped in 4 of them, this renewed rise appearing to precede the radiological recurrence. Whilst the prognostic value of alveolar lymphocytosis is greater than that of serum A.C.E. levels in sarcoidosis, measurement of serum A.C.E. is easier in the context of therapeutic surveillance.

[Uninodular bronchiolo-alveolar cancer. Apropos of 5 cases with a prolonged course]. / Les cancers bronchiolo-alvéolaires uninodulaires. A propos de 5 cas d'évolution prolongée.

Five cases of uninodular bronchioloalveolar cell (BAC) carcinoma are reported. These 5 cases were characterized by the protracted course of the disease: 14.5 and 11.5 years respectively in the 2 patients who died; 7.5, 12 and 12.5 years respectively in the 3 patients who are still alive. Prior to being diagnosed at excision, the tumours had been followed up for an unusual 2 to 10 years period, with phases of radiological stability and phases of very slow growth. This very slow course is exceptional in lung cancer. It differs not only from the course of diffuse BAC carcinoma, but also from the habitual course of uninodular BAC carcinoma and from that of peripheral adenocarcinoma. Similar cases could be found in the literature, and a comparative study has been conducted between these slow-course carcinomas and normal-course carcinomas. Whatever their outcome, slow-course carcinomas are asymptomatic tumours which present at radiography of the chest as a peripheral round or oval opacity devoid of pathognomonic features. The post-operative prognosis of slow-course tumours seems to be more favourable than that of the other lung cancers. At histology, carcinomas with a protracted course usually show a pattern similar to that of lesions called by some authors "benign adenomatosis"; however, some of these tumours exhibit fairly distinct signs of malignancy, and electron microscopic images also are far from being uniform.

Long-term course of pulmonary arterial pressure in chronic obstructive pulmonary disease.

Ninety-three patients with severe chronic obstructive pulmonary disease (COPD) of the bronchitic (n = 74) or emphysematous type (n = 19), who all had arterial hypoxemia, underwent 2 right cardiac catheterizations in a clinical steady state, with a delay of 5 yr or more between the first and the last catheterization. No patients received long-term O2 therapy or pulmonary vasodilator drugs. Patients were divided into 2 groups according to the initial level of mean pulmonary artery pressure (Pap). Group 1 included 61 patients without initial pulmonary arterial hypertension (PAH), Pap being less than 20 mmHg; the average delay between the 2 catheterizations was 93.4 +/- 26.8 months. Group 2 included 32 patients with initial PAH (Pap greater than or equal to 20 mmHg), and the average delay was 85.0 +/- 26.0 months. The changes in Pap were small. They ranged from 15.5 +/- 2.4 to 19.6 +/- 7.0 mmHg in Group 1 (p less than 0.001) and from 25.8 +/- 5.6 to 27.8 +/- 9.5 mmHg in Group 2 (NS). The average increase in Pap was 0.65 mmHg/yr in Group 1 and 0.39 mmHg/yr in Group 2 (no statistical difference between the 2 groups). The other hemodynamic parameters (pulmonary capillary wedge pressure, right ventricle filling pressure, cardiac output) did not change. Hemodynamic "worsening," which was defined by an increase in Pap by greater than or equal to 5 mm Hg, was observed in 29% of the patients (n = 27). In these patients, there was a marked worsening of hypoxemia, which was not observed in the remaining 66 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

A study of the criteria used for clinical evaluation of prophylactic treatment in bronchial asthma.

In an attempt to find better criteria for the evaluation of prophylactic treatment of asthma, we have studied the significance and the correlations of the 3 parameters usually measured: symptoms, bronchodilator requirements, changes in Peak Expiratory Flow (PEF). We have collected these data daily over a 16 week period in 13 adult asthmatics allergic to Dermatophagoides pteronyssinus. For each patient, the 3 scores were compared graphically. Linear regression was used to analyze the individual relationship between 2 daily scores. Incomplete cards mostly revealed unexpected behaviour (e.g. normal lung function but many symptoms recorded) and cannot of course be taken into account in a trial protocol. We found a good correlation between PEF and symptom scores in 10 out of 13 patients and we could point out the poor correlation between medication score and the other scores. To our knowledge, it is the first time such an objective result has been shown in asthmatic adults. Our analysis provides data which should improve the studies of prophylactic treatment efficacy in asthma.

[Pulmonary aspergillosis. Apropos of 5 anatomo-clinical cases]. / Les aspergilloses pneumoniques. A propos de 5 observations anatomo-cliniques

The authors report five cases of invading and diffuse pulmonary aspergillosis. Clinically they are characterized by a development in a still clear pulmonary field in patients with a lessened organic resistance and under corticosteroid treatment. Necrotic phenomenons occurred very quickly and prognosis was poor. Anatomically, foci were spreading, rapidly necrosing and contained Aspergillus. Diagnosis was based, besides etiological circumstances, on the presence of Aspergillus in sputum and of anti-aspergillus precipitins in serum.

[Pulmonary hemodynamic effects of intravenous almitrine in patients with chronic bronchitis and respiratory insufficiency]. / Effets hémodynamiques pulmonaires de l'almitrine intraveineuse chez les bronchiteux chroniques insuffisants respiratoires.

The effects on ventilation, gas exchange and pulmonary haemodynamics of 1 h infusion of 0.5 mg X kg-1 almitrine (Vectarion) were studied in 14 patients with chronic bronchitis, with clear hypoxemia (PaO2 less than 65 mmHg) and hypercapnia (PaCO2 greater than or equal to 45 mmHg). The separate effects of the almitrine solvent and/or the solution were studied in six similar chronic bronchitics. In this latter group, blood gases and haemodynamic values were not significantly altered. In subjects treated with almitrine, PaO2 raised from 51.9 +/- 6.6 (control: T0) to 61.9 +/- 9.9 mmHg at the 60th min (t60) of infusion (p less than 0.001); PaCO2 decreased from 52.8 +/- 6.3 (t0) to 45.7 +/- 5.2 mmHg at t60 (p less than 0.001). The effects on blood gases were still marked 10 min after infusion (t70). The significant increase in PaO2 was faster (10th min) than that of PaCO2 (20th min). The mean pulmonary artery pressure (Ppa) rose appreciably, from 27.8 +/- 11.3 at t0 to 35.5 +/- 12.5 mmHg at t60 (p less than 0.001). This rise was significant from the 10th min (p less than 0.005) and was related to that of pulmonary vascular resistance since on average cardiac output and pulmonary wedge pressure did not change. Ppa came back to its initial value at t70. Thus pulmonary vasoactive effects were at the same time early and transitory. They seemed due to an arterial vasoconstriction (role of chemoreceptors?), which could also explain the perfusion redistribution to the best ventilated areas and the improvement of VA/Q inequalities.