Diagnostic of mediastinal lymphadenopathy in extrathoracic cancer: A place for EBUS-TBNA in real life practice?

INTRODUCTION: Mediastinal lymphadenopathy in patients with extrathoracic malignancy is common. To obtain tissue proof of metastatic spread, EBUS-TBNA is an alternative to mediastinoscopy or thoracoscopy, but there are limited data about its diagnostic performance. The aim of this study was to determine the diagnostic accuracy of EBUS-TBNA for the evaluation of mediastinal lymphadenopathy in patients with extrathoracic cancers. METHODS: We performed a multicenter retrospective study based on an online questionnaire to collect data from January 2011 to December 2012 in all patients with proven extrathoracic malignancy (current or past) and suspected mediastinal lymph node metastases who underwent EBUS-TBNA for diagnosis. RESULTS: Hundred and eighty-five patients were included. Extrathoracic malignancies observed were urological (43), breast (35), gastrointestinal (33), head and neck (30), melanoma (11), lymphoma (6), and others (27). EBUS-TBNA confirmed malignancy in 93 patients (50.3%): concordant metastases in 67 (36.2%); new lung cancer in 25 (13.5%); and 1 unidentified cancer. The diagnostic accuracy, sensitivity, specificity, negative predictive value, and positive predictive value were respectively 54.6%, 68.4%, 100%, 53.3%, and 100%. CONCLUSION: Mediastinoscopy remain the reference, but EBUS-TBNA may be considered as first line investigation in patients with suspected mediastinal lymph node metastases and extrathoracic malignancy. It prevented a surgical procedure in 50.3% of patients.

[Outcome in COPD patients treated with at-home, long-term, non-invasive ventilation]. / Devenir des patients BPCO traités par ventilation non invasive prolongée à domicile.

BACKGROUND: The use of domiciliary non-invasive positive pressure ventilation (NIPPV) is still controversial in stable hypercapnic COPD. METHODS: Records of COPD patients who received home NIPPV from 1990 to 2002 either following an acute exacerbation or because of stable hypercapnia were retrospectively reviewed. RESULTS: Thirty-seven patients receiving long term oxygen therapy for 50 +/- 47 months were included. At inclusion, their mean +/- SD: FEV1 was 27 +/- 9% predicted, inspiratory capacity was 45 +/- 14% predicted, PaO2 breathing room air was 50 +/- 10 mm Hg, PaCO2 breathing room air = 53 +/- 8 mm Hg, PaCO2 with oxygen was 60 +/- 9 mm Hg. Median survival with NIPPV was 41 months. The 1-year, 3-year and 5-year survival rates with NIPPV were 92%, 62% and 24% respectively. Twelve months after onset of home NIPPV, PaCO2 breathing room air and with oxygen were significantly lower (47 +/- 8 mm Hg, p = 0.028 and 53 +/- 8 mm Hg, p = 0.005, respectively), inspiratory capacity was significantly improved (54 +/- 18% predicted, p = 0.033). CONCLUSION: This study suggests that home NIPPV allows a lasting physiological stabilization in selected COPD patients, particularly those with an advanced disease, by reducing hypercapnia and improving inspiratory capacity.

[Which treatments should be proposed in resectable stage III cancers?]. / Quel traitement préopératoire pour les stades III résécables?

The results of surgery alone or associated with an adjuvant treatment, chemo- and/or radio-therapy, in the management of stage III resectable non-small cell lung cancer (NSCLC), are disappointing; with survival rates at 5 years generally lesser than 20% and many local and distant relapses. They justified the development of phase II trials that showed the feasibility of the chemotherapy and neo-adjuvant chemo-radiotherapy with high rates of response and acceptable toxicity. The three phase III studies with induction chemotherapy gave contradicting results; two of them were on small cohorts and presented methodological biases. Regarding pre-surgery chemo-radiotherapy, there is presently no published phase II trial and a recent phase II trial was in favour of a concomitant mode with bifractioned irradiation. The new targeted therapeutic agents do not yet have an indication in this field. In the particular case of resectable tumours of the apex invading the wall, so-called Pancoast, neo-adjuvant chemoradiotherapy followed by surgical resection has become the treatment of choice. The place of chemotherapy, radiotherapy and even surgery in the treatment of resectable stage III NSCLC remains to be defined and the inclusion of patients in randomised clinical trials is recommended.