A case of Francisella tularensis meningitis in a 64-year-old man treated with quinolones.

We report a French case of tularemic meningitis - the second to be thoroughly described - and discuss the existing literature. The patient is a 64-year-old man with no medical history, who developed fever, cutaneous symptoms, and swollen lymph nodes within a week after a hunt. He was then diagnosed with meningitis caused by Francisella tularensis subsp. holarctica. Healing was quickly achieved ad integrum within 3 weeks with a course of ciprofloxacin. We discuss the existing literature about this specific issue, and try to shine a light on the superior efficacy and lesser toxicity of quinolones compared to the historical treatment.

[Second- or third-line treatment with erlotinib in EGFR wild-type non-small cell lung cancer: Real-life data]. / Erlotinib en 2e ou 3e ligne pour les cancers bronchiques non à petites cellules sans mutation de l'EGFR : données en vie réelle.

INTRODUCTION: The benefit of tyrosine kinase inhibitors for patients with an EGFR wild-type non-small cell lung cancer (NSCLC) remains controversial. METHODS: The survival of patients with an EGFR wild-type NSCLC who received second- or third-line erlotinib treatment was assessed using real-life data that had been collected in a prospective, national, multicenter, non-interventional cohort study. RESULTS: Data from 274 patients were analysed, 185 (68%) treated with erlotinib and 89 (32%) treated with supportive care only. The median overall survival was 4.2months (95% CI [3.5; 5.4]) with erlotinib, and 1.3months (95% CI [1.0; 1.8]) with supportive care. Survival rate at 3, 6, and 12months was 62%, 37%, and 17%, respectively, with erlotinib, versus 20%, 8%, et 3%, with exclusive supportive care. Significant predictive factors for longer overall survival were the presence of adenocarcinoma, and use of 1st line chemotherapy including either taxanes, pemetrexed or vinorelbine (P<0.05). CONCLUSION: Erlotinib remains a valuable therapeutic option to treat inoperable locally advanced or metastatic NSCLC after failure of at least one prior chemotherapy regimen in fragile patients who are not eligible for chemotherapy.

[IoNESCO trial: Immune neoajuvant therapy in early stage non-small cell lung cancer]. / Inhibiteurs du check-point immunitaire en néo-adjuvant dans les cancers bronchiques non à petites cellules localisés : essai IoNESCO.

BACKGROUND: Programmed cell death-ligand 1 (PD-L1) is a checkpoint receptor that facilitates immune evasion by tumor cells, through interaction with programmed cell death-1 (PD-1), a receptor expressed by T-cells. Durvalumab is an anti-PD-L1 monoclonal antibody that blocks PD-L1 interaction with PD-1 on T-cells, countering the tumor's immune-evading tactics. Phase I/II studies demonstrated durable responses and manageable tolerability in heavily pre-treated patients with non-small cell lung cancer (NSCLC). METHODS: This phase II study is designed to administrate three durvalumab IV infusions (10mg/kg at day 1, 15, 29) before surgery, to patients with pathologically confirmed NSCLC, clinical stage IB (>4cm) or stage II, ≥18 years of age, WHO performans status 0-1, without selection on PD-L1 expression. Preoperative chemotherapy and radiation therapy are not permitted. The primary objective is feasibility of complete surgical resection. Major pathological response on surgical tissue, defined as 10% or less remaining tumor cells, will be a secondary objective. Additional secondary objectives include tolerance, adverse effects, delay between start of treatment and surgery, response rate (RECIST 1.1), metabolic response rate, postoperative adverse events, disease-free survival and overall survival. A rate of complete resection<85% (P0) is considered unacceptable. P1 hypothesis is of 95%, and with a study power of 90% and an alpha risk of 5% (two-steps Fleming's procedure), 81 patients are required. EXPECTED RESULTS: To establish whether neoadjuvant immunotherapy is feasible and could improve the survival of patients with early-stage NSCLC.

[Endobronchial ultrasound with transbronchial needle aspiration: Evaluation of clinical practice]. / Échobronchoscopie avec ponction transbronchique à l'aiguille : évaluation des pratiques.

INTRODUCTION: Endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) has undergone a large increase in France since 2007. The aim is to study the evolution of the indications for EBUS-TBNA in our region during the period 2008-2013. MATERIAL AND METHODS: We conducted a retrospective observational study including all the patients who underwent an EBUS-TBNA procedure in Picardie from 2008 to 2013. The respective proportion for each indication was noted. RESULTS: During the study period, 1036 EBUS-TBNA procedures were performed with a continuous increase in number (86 in 2008 versus 275 in 2013). We observed an increase in the proportion of procedures performed for a suspected diagnosis of sarcoidosis (OR=1.31; IC 95% [1.09-1.58]; P=0.005) and for the simultaneous diagnosis and staging of lung cancer (OR=1.12; IC 95% [1.02-1.24]; P=0.022). For the diagnosis of sarcoidosis, we observed an improvement in the diagnostic yield between the periods [2008-2010] and [2011-2013] (42.9% versus 72.5%). CONCLUSION: A continuous increase in the number of EBUS-TBNA procedures was observed during the period 2008-2013. It was associated with a modification in practice with an increased proportion of procedures performed for the diagnosis of sarcoidosis.

[First treatment strategies in the 2 years following lung cancer diagnosis. ESCAP-2011-CPHG, a real-life study carried out in French general hospitals]. / Stratégies thérapeutiques les 2 premières années après un diagnostic de cancer du poumon. ESCAP-2011-CPHG, étude en situation réelle réalisée dans les hôpitaux généraux français.

INTRODUCTION: The objective of the ESCAP-2011-CPHG cohort study was to perform a real-life analysis of therapeutic strategies used during the first 2years of follow-up after a diagnosis of primary lung cancer. This paper presents the study and its first results in non-small-cell lung cancer (NSCLC). METHODS: Pulmonologists in the respiratory disease departments of 53 general hospitals consecutively included all patients aged 18years and over with lung cancer newly diagnosed in 2010. RESULTS: Of the 3943 patients included, 3418 (mean age: 65.4 years; male: 76%; never smokers: 12%) had NSCLC (adenocarcinoma: 53%; stages 0-II, IIIA, IIIB and IV: 18, 14, 9 and 59%, respectively). Mean follow-up was 13.2 (SD: 10.1) months; mean number of strategies implemented was 2 (SD: 1.3). Overall, 62% of patients had chemotherapy in the first strategy (74% in the second strategy); the rate of chemotherapy alone increased from 6 to 56% with cancer stage. CONCLUSIONS: ESCAP-2011-CPHG opens the way to many possible analyses of the therapeutic strategies currently implemented in French hospitals, comparing strategies, survival or patient characteristics.

[Effectiveness of erlotinib in Critical Care Unit in patients with non-small cell lung cancer with EGFR mutation]. / Efficacité de l'erlotinib en réanimation chez les patients présentant un cancer bronchique non à petites cellules avec une mutation de l'EGFR.

INTRODUCTION: The search for mutations epidermal growth factor receptor (EGFR) has changed the therapeutic approach and prognosis of non-small cell lung cancer (NSCLC). The effectiveness of tyrosine kinase inhibitors (TKI) has been demonstrated orally in patients with EGFR mutation. We report the case of a patient for whom treatment with TKI was started effectively in a Critical Care Unit. OBSERVATION: A patient of 59 years is followed for a stage IV lung adenocarcinoma with metastases in liver, brain, adrenal, lung and pleura. After a first course of chemotherapy (cisplatin-gemcitabine), the patient presents a multi-factorial acute respiratory distress. Due to an EGFR mutation, transfer to intensive care is decided then orotracheal intubation with mechanical ventilation. It is decided to initiate treatment with erlotinib via nasogastric tube. The evolution will be marked by a tumor response leading to a favorable issue. CONCLUSIONS: This case shows the value of initiate TKI despite hospitalization in Intensive Care Unit and highlights the question of the transfer in ICU patients with EGFR mutation.

[Relationship between primary lung cancer and tobacco consumption. Results of the KBP-2010-CPHG study by the French College of General Hospital Respiratory Physicians]. / Relation entre cancer bronchique primitif et consommation tabagique. Résultats de l'étude KBP-2010-CPHG du Collège des pneumologues des hôpitaux généraux.

INTRODUCTION: The Collège des Pneumologues des Hôpitaux Généraux has performed a prospective multicentre epidemiological study which aims to describe the baseline characteristics of all new cases of primary lung cancer histologically or cytologically diagnosed in 2010 and followed-up in the respiratory department of general hospitals. The present publication compares the characteristics of these presentations according to their smoking history. METHODS: Seven thousand and fifty-one adult patients were included from 104 respiratory departments. A standardized form was completed at diagnosis and a steering committee checked the completeness of inclusion. RESULTS: Only 10.9% of patients were never-smokers and 89.1% ever-smokers (i.e., current or former smokers). Respectively, 3.7%, 10.7% and 85.6% of ever-smokers consumed/had consumed 1-10, 11-20, and >20 pack-years. Mean smoking duration was 37.5 years. Former smokers had stopped smoking on average 14.8 years previously. Only 20.7% of never-smokers reported that they had been exposed to tobacco smoke passively. At diagnosis, statistically significant differences were found between never- and ever-smokers (P<0.0001) for sex (women: 60.8% vs 18.8%), age (mean: 70.7 years vs 64.9 years), stage (IV: 70.8% vs 58.7%), histology (adenocarcinoma: 68.5% vs 42.6%), EGFR mutation exploration (51.4% vs 28.0%) and positivity (37.0% vs 4.6%). Differences between never- and ever-smokers rose with increasing tobacco consumption. CONCLUSIONS: This study confirms that differences exist between never- and ever-smoker patients presenting with primary lung cancer and shows the impact of the level of tobacco consumption, in particular on histology.

Randomized phase II-III study of bevacizumab in combination with chemotherapy in previously untreated extensive small-cell lung cancer: results from the IFCT-0802 trial†.

BACKGROUND: This randomized phase II-III trial sought to evaluate the efficacy and safety of adding bevacizumab (Bev) following induction chemotherapy (CT) in extensive small-cell lung cancer (SCLC). PATIENTS AND METHODS: Enrolled SCLC patients received two induction cycles of CT. Responders were randomly assigned 1:1 to receive four additional cycles of CT alone or CT plus Bev (7.5 mg/kg), followed by single-agent Bev until progression or unacceptable toxicity. The primary end point was the percentage of patients for whom disease remained controlled (still in response) at the fourth cycle. RESULTS: In total, 147 patients were enrolled. Partial response was observed in 103 patients, 74 of whom were eligible for Bev and randomly assigned to the CT alone group (n = 37) or the CT plus Bev group (n = 37). Response assessment at the end of the fourth cycle showed that disease control did not differ between the two groups (89.2% versus 91.9% of patients remaining responders in CT alone versus CT plus Bev, respectively; Fisher's exact test: P = 1.00). Progression-free survival (PFS) since randomization did not significantly differ, with a median PFS of 5.5 months [95% confidence interval (CI) 4.9% to 6.0%] versus 5.3 months (95% CI 4.8% to 5.8%) in the CT alone and CT plus Bev groups, respectively [hazard ratio (HR) for CT alone: 1.1; 95% CI 0.7% to 1.7%; unadjusted P = 0.82]. Grade ≥2 hypertension and grade ≥3 thrombotic events were observed in 40% and 11% of patients, respectively, in the CT plus Bev group. Serum vascular endothelial growth factor (VEGF) and soluble VEGF receptor titrations failed to identify predictive biomarkers. CONCLUSION: Administering 7.5 mg/kg Bev after induction did not improve outcome in extensive SCLC patients.

[Severe hyponatremia during chemotherapy for small cell carcinoma]. / Hyponatrémie sévère sous chimiothérapie du carcinome à petites cellules.

INTRODUCTION: The small cell lung cancer (SCLC) is a rapidly progressive malignancy with a poor prognosis. Its chemosensitivity mandates prompt treatment. Hyponatremia occurs frequently in patients with small cell lung cancer due to the syndrome of inappropriate antidiuretic hormone (SIADH). We report a case of severe hyponatremia induced by chemotherapy that required management in intensive care. OBSERVATION: A 68-year-old patient was undergoing treatment for small cell cancer, invading the right lung. On the second day of the first cycle of treatment (cisplatine-vepeside), the patient became comatose and required transfer to an intensive care unit. The coma was due to severe hyponatremia (107 mmol/L) and improved with specific treatment. The patient had similar episodes on the second day of each chemotherapy treatment but with less and less severe clinical manifestations. Hyponatremia due to chemotherapy in SCLC is not commonly known; a relation between hyponatremia intensity and the tumor size is suspected. CONCLUSION: This clinical case highlights the possibility of severe hyponatremia during small cell lung cancer chemotherapy. Hyponatremia may be related to the reduction in tumor size. Monitoring of electrolytes on day 2 of chemotherapy is advised.

[Endobronchial ultrasound (EBUS): the state of the art]. / Échoendoscopie endobronchique (EBUS): le point de la question.

Endobronchial ultrasound (EBUS) is a technique which allows the endoscopist to sample mediastinal and/or hilar lymph nodes for complete staging of thoracic malignancy without recourse to surgery. Originally developed at the beginning of the 21st century, EBUS has become a well developed practice within France in recent years. As the technique requires high tech, expensive and fragile equipment, it has been important to develop an approach that is appropriate for the specific features and constraints of the French health system, including access to anaesthesia, imaging modalities and costing. The first centers to adopt EBUS had to adapt quickly and develop their own practices for its use. Training seminars were carried out in order to pass on this experience. After the passage of several years, it seems helpful to give a progress report on this technique through the stages of its development, taking account of the specificities of the French system and thus to transmit this accumulated experience. In this article, the authors review the literature concerning all the essential aspects needed to apply this technique under the best conditions in the French health system.

[Iatrogenic pulmonary necrosis due to hyperselective chemotherapy]. / Nécrose pulmonaire iatrogène due à une chimiothérapie hypersélective.

BACKGROUND: The management of cancer requires regular access to the central venous system. We report here, a case of a central venous access system causing pulmonary necrosis and abscess. CASE REPORT: A 48 year old woman with a past history of B-cell lymphoma presented with a relapse of her disease. A subcutaneous central venous access port was placed in the right brachiocephalic area with puncture of the subclavian vein. She received three doses of chemotherapy. Eight days later, she consulted the emergency department on account of right-sided chest pain. Examination revealed a right-sided pleural effusion. The chest x-ray showed the tip of the catheter at the right pulmonary hilum. A CT scan confirmed that the tip of the central venous catheter was located in a branch of the right lower lobe pulmonary artery and was surrounded by consolidation in the right middle and lower lobes. The progress was marked by the development of a lung abscess despite removal of the central venous access system. Subsequent surgery led to satisfactory resolution. CONCLUSION: We report a dramatic case that reminds us that placement of a central venous access system requires a sound technique and regular radiological surveillance.

[Study KBP-2010-CPHG: inclusion of new cases of primary lung cancer diagnosed in general hospital pneumology departments between 1st January and 31 December 2010]. / Étude KBP-2010-CPHG: recueil des nouveaux cas de cancer bronchopulmonaire primitif diagnostiqués dans les services de pneumologie des centres hospitaliers généraux du 1(er) janvier au 31 décembre 2010.

INTRODUCTION: The College of General Hospital Respiratory Physicians (CPHG) is following up the KBP-2000-CPHG study, performed ten years ago, with a new observational epidemiological study of primary lung cancer. PATIENTS AND METHODS: The study includes all new cases of primary lung cancer diagnosed on histology or cytology between 1 January and 31 December 2010 and managed by one of the general hospital pneumology departments participating in the study. The primary objective is to estimate five-year mortality and to analyze risk factors. Secondary objectives are to describe the characteristics of this patient population and their management, and to estimate one, four and five-year survival rates. These data will be compared to those of the KBP-2000-CPHG study. The four-year prognosis score developed in 2000 will also be assessed in the new study. Data are collected by standardized questionnaire with exhaustiveness control. EXPECTED RESULTS: One hundred and eight investigating centers have agreed to participate; 4000 to 5000 new cases of primary lung cancer should be collected and analyzed. CONCLUSION: The study will describe the characteristics of patients presenting with primary lung cancer in the participating pneumology departments during the year 2010, and their diagnostic and therapeutic management, and assess changes over the last ten years.

[Anaesthesia for bronchial echoendoscopy: experience with the laryngeal mask]. / Anesthésie en échoendoscopie bronchique : expérience du masque laryngé

INTRODUCTION: Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) has recently been shown to be an accurate modality in the diagnosis and staging of mediastinal lymph node metastases. This procedure takes significantly longer than a conventional bronchoscopy and may therefore cause more discomfort. Since its introduction into respiratory practice in France, several airway management strategies have been used. PATIENTS AND METHODS: Both anaesthesia care and procedural sedation services share the goals of providing the patient with comfort during a potentially distressing procedure while also ensuring that the operating physician has an acceptable working environment. Historically, anaesthesiologists have applied the expertise gained in managing anaesthesia for major surgery to sedation care for minor procedures. While the supply of anaesthesiologists and anaesthetists has shown only a modest increase, the growth in minimally invasive procedures has been exponential in recent years. To investigate this further, we performed a retrospective study of the use of general anaesthetic with ventilation by a laryngeal mask during EBUS, which we have adopted in our unit. RESULTS: Sixty-three patients were included in the study. In 41 a laryngeal mask was used and in 22 the examination was performed under local anaesthetic alone. Eighty-seven percent of procedures were informative with cells from lymph nodes obtained (89% from examinations using laryngeal mask with a mean of 3.8 passes and 86% with sedation alone with a mean of 2.9 passes). In 45 cases (78%) it was possible to avoid mediastinoscopy. CONCLUSION: It was possible to establish a secure airway and maintain oxygenation with the laryngeal mask during bronchoscopy without any reduction in the success of the procedure.

[Developping real time lymph node aspiration under endobronchial ultrasound control. One year's French experience in two different pulmonary departments]. / Mise en place de l'échoendoscopie bronchique avec ponction ganglionnaire en pneumologie: expérience française de deux centres.

INTRODUCTION: The histology and staging of bronchial carcinoma determines the treatment options for the condition. Endobronchial ultrasound allows the needle aspiration of mediastinal lymph nodes or pulmonary neoplasia where there is tracheo-bronchial contact under visual control. This procedure is aid for diagnosis and for mediastinal staging. French pulmonary departments have been slow to introduce this technique compared to other countries. METHODS: All Endobronchial ultrasound procedures performed during 2007 were retrospectively analysed in two pulmonary centres. The indications, practice management, complications, and diagnostic yield were reported. RESULTS: 103 Endobronchial ultrasound procedures were performed, in the majority under local anaesthesia in out-patients. Real time needle aspiration was performed only in 92 patients. Only 11 procedures were performed for mediastinal staging prior to thoracic surgery. 12.6% of patients had minor complications. 136 lymph node stations were sampled in 92 patients, but only 97 (70.3%) in 63 patients were judged to be 'satisfactory"(malignant cells and/or lymphocytes on cytology results). CONCLUSIONS: It is difficult to rapidly reach the diagnostic yield reported in literature. We think that appropriate training in the technique is of great importance.

[An unusual complication of thoracostomy]. / Une complication inhabituelle d'une thoracostomie.

INTRODUCTION: Post pneumonectomy infection is a well-described surgical complication. Treatment usually involves thoracostomy and requires local treatments. We report here an unusual complication of this situation. CASE REPORT: A 62 year old man had a pneumonectomy for non-small cell lung cancer. Following this he required a thoracostomy to treat a thoracic empyema and this was treated with local anti-septic agents. Subsequently he developed asthenia and a diagnosis of hyperthyroidism was made secondary to local disinfectant treatment with iodine agents. CONCLUSIONS: We describe an original case of thyroxicosis occurring in a patient following treatment for post-pneumonectomy empyema. We would recommend monitoring thyroid function in this context.

Noninvasive ventilation using a mouthpiece in patients with chronic obstructive pulmonary disease and acute respiratory failure.

BACKGROUND: Noninvasive positive pressure ventilation (NPPV) delivered via a mouthpiece (mNPPV) has been successfully used in stable chronic restrictive respiratory insufficiency, but not in patients with chronic obstructive pulmonary disease (COPD) and acute respiratory failure (ARF). OBJECTIVES: The purpose of this matched case-control study was to compare the usefulness of mNPPV to noninvasive ventilation using a nasal or oronasal mask (nNPPV) or standard medical treatment (SMT) in COPD patients with ARF. METHODS: Twenty-nine patients receiving mNPPV were matched with 29 patients receiving nNPPV and 29 patients receiving SMT regarding age, SAPSII, admission PaCO(2) and pH. RESULTS: In the mNPPV group, admission PaCO(2) and pH were 78.6 +/- 12 mm Hg and 7.30 +/- 0.04, respectively. mNPPV and nNPPV avoided the need for endotracheal intubation in 27 and 25 patients, respectively (nonsignificant) whereas SMT resulted in a higher mechanical ventilation rate (13 patients). At the end of the treatment protocol, PaCO(2) was lower in the mNPPV group (62.2 +/- 9.6 mm Hg) than in the SMT group (72.4 +/- 20.4 mm Hg, p < 0.018) leading to a significantly higher pH. No significant differences were observed between the mNPPV and nNPPV groups. CONCLUSIONS: In case of moderate respiratory acidosis, noninvasive ventilation using a mouthpiece significantly reduces the endotracheal intubation rate in comparison with SMT and therefore appears to be a second-line alternative to noninvasive ventilation delivered via a mask, especially when poorly tolerated.

[Spontaneous rupture of the esophagus or Boerhaave syndrome. Report of 3 cases and review of the literature]. / La rupture spontanée de l'oesophage ou syndrome de Boerhaave. A propos de trois cas et revue de la littérature.

A triad of signs constitutes Boerhaave syndrome: forceful vomiting, chest pain and subcutaneous emphysema. The syndrome results from spontaneous rupture of the oesophageal wall leading to an oeso-pleural or oeso-mediastinal fistula. Positive diagnosis is established with a water-soluble swallow, sometimes coupled with computed tomography of the thorax. Boerhaave syndrome is a surgical emergency. We report three cases of spontaneous rupture of the oesophagus and analyze the importance of emergency surgery as well as emergency treatment of the sepsis, an important prognosis factor.