The value of endoscopic ultrasound after bronchoscopy to diagnose thoracic sarcoidosis.

A clinicoradiological presentation of thoracic sarcoidosis requires histopathology in order to establish the diagnosis. Flexible bronchoscopy has a reasonable diagnostic yield and is the procedure of first choice for diagnosis. Endoscopic ultrasound (endoscopic ultrasound-guided fine needle aspiration/endobronchial ultrasound-guided transbronchial needle aspiration) can help in the diagnosis of sarcoidosis. An implementation strategy of endoscopic ultrasound for the diagnosis of sarcoidosis following negative flexible bronchoscopy results was examined prospectively in 15 clinics. A total of 137 patients (92 males; median age 43 yrs) were included, and sarcoidosis was found in 115 (84%). Alternative diagnoses were tuberculosis, lymphangitis carcinomatosa, pneumoconiosis and alveolitis. All patients were sent for flexible bronchoscopy, which was performed in 121 (88%), resulting in a definite diagnosis in 57 (42%). A total of 80 patients were sent for endoscopic ultrasound, which could be performed in 72 (90%), yielding a definite diagnosis in 47 (59%). Endoscopic ultrasound following negative flexible bronchoscopy avoided a surgical procedure in 47 out of 80 patients. The sensitivity of flexible bronchoscopy for sarcoidosis was 45% (95% confidence interval 35-54%), but 62% (50-72%) if biopsy specimens were taken. The sensitivity of endoscopic ultrasound following negative flexible bronchoscopy results was 71% (58-82%). With this strategy, 97 out of 115 (84% (76-90%)) of proven sarcoidosis was diagnosed using endoscopy. This large prospective implementation study (trial number NCT00888212; ClinicalTrials.gov) shows that endoscopic ultrasound is valuable for diagnosing sarcoidosis after negative flexible bronchoscopy results.

[Endobronchial ultrasound and PET positive mediastinal lymph nodes]. / Echographie endobronchique et ganglions TEP positifs dans le cancer broncho-pulmonaire.

INTRODUCTION: In bronchial carcinoma when positron emission tomography with 18-fluorodeoxyglucose (FDG-PET) shows increased emission in the mediastinal lymph nodes, confirmation by tissue biopsy is necessary. In this particular situation we have evaluated the use of real time lymph node aspiration under endobronchial ultrasound control. METHODS: Consecutive patients referred for staging and/or diagnosis of PET positive mediastinal nodes in the setting of suspected or confirmed bronchial carcinoma were included. The results of lymph node aspiration, performed under local anaesthesia in out-patients, were collected and if non-diagnostic surgical exploration was performed. RESULTS: 20 patients were studied between December 2004 and September 2005. The average number of ultrasound guided needle aspirations per patient was 4.8 +/- 1.2. Cytological or histological confirmation of malignancy was obtained by needle biopsy in 12 patients. The 8 negative cases were confirmed by surgical biopsy. In this preliminary series the sensitivity, specificity and negative predictive value of ultrasound guided aspiration of PET positive nodes was 100%. CONCLUSION: Endobronchial ultrasound with needle aspiration should be considered a primary method of investigation of PET positive mediastinal lymph nodes.

Endobronchial ultrasound and positron emission tomography positive mediastinal lymph nodes.

Positron emission tomography with 18F-fluoro-2-deoxy-d-glucose (FDG-PET) is more accurate than computed tomography for staging of mediastinal (hilar) lymph nodes. In the case of positive findings, tissue sampling of lymph nodes is required. The diagnostic/staging yield of transbronchial needle aspiration (TBNA) following endobronchial ultrasound (EBUS) localisation was assessed in this particular clinical setting. The number of avoided surgical procedures was evaluated. All consecutive patients referred for staging and/or diagnosis of mediastinal FDG-PET positive lesions were included. Data were prospectively collected. TBNA sampling of lymph nodes was performed after EBUS localisation. If no diagnosis was reached, further surgical sampling or adequate follow-up was performed. From January 2003 to June 2004, 33 patients were included. The average number of TBNA samples per patient was 4.2+/-1.5. Cytological or histological diagnoses were obtained in 27 (82%) of the patients, of which 78% were obtained after previous EBUS localisation. In 25 (76%) of the 33 patients, surgical staging procedures were suppressed. In conclusion, transbronchial needle aspiration after endobronchial ultrasound localisation should be considered as a primary method of evaluation of lymph nodes positive by positron emission tomography with 18F-fluoro-2-deoxy-d-glucose, and may replace the majority of surgical mediastinal staging/diagnostic procedures.

[Hemoptysis in a young man]. / Hémoptysies chez un jeune homme.

INTRODUCTION: We describe the development of severe and recurrent alveolar hemorrhage in a 30 year old man. The patient had presented with frank hemoptysis, that recurred after an interval of 4 weeks, associated with dyspnea and severe anemia requiring transfusion. The chest x-ray and CT scan showed bilateral diffuse ground glass shadows. Fibreoptic bronchoscopy confirmed bilateral diffuse bleeding. Investigations for the common causes of diffuse alveolar hemorrhage (immunological, infective) proved to be negative on two occasions. Toxicological examination of the urine during the relapse revealed a significant level of cannabis and a trace of cocaine. The patient repeatedly denied the use of illicit drugs. CASE REPORT: Because of the general condition of this young patient a lung biopsy was performed by video-thoracoscopy. This showed evidence of diffuse alveolar damage compatible with inhalation of cocaine. Faced with these results the patient admitted that he regularly smoked "improved joints". CONCLUSION: This clinical observation emphasises that the inhalation of cocaine is a cause of diffuse alveolar hemorrhage particularly in young adults.

[Pleural effusion]. / Epanchement pleural.

A Spanish man is diagnosed with a non-small cell lung cancer with pleural extension. A chemotherapy combining cisplatin and gemcitabine allows obtaining an excellent partial remission. A contralateral pleural effusion is noted in a context of weight loss and fever. The differential diagnosis of pleural effusion is discussed.

Synchronous roentgenographically occult lung carcinoma in patients with resectable primary lung cancer.

OBJECTIVE: To assess the prevalence of synchronous roentgenographically occult lung carcinoma (ROLC) in patients with resectable roentgenographically visible lung cancer (RVLC). METHODS: Patients undergoing surgery for RVLC in the same University Hospital were prospectively evaluated before surgery by fluorescence bronchoscopy under local anesthesia to detect synchronous ROLC. All abnormal areas, with the exception of the RVLC, had biopsies made. RESULTS: From June 1996 to January 1999, 43 patients (male/female ratio: 1.7/1.0) were evaluated before lobectomy (n = 34) or pneumonectomy (n = 10) for 44 primary RVLC. There were 10 T1N0, 19 T2N0, 1 T1N1, 9 T2N1, 1 T3N0, 3 T1N2, and 1 T3N1 lesions. The histologic type was mainly squamous carcinoma (n = 21) and adenocarcinoma (n = 14). All but two patients were smokers or ex-smokers (mean +/- SD, 48 +/- 28 pack-years). A total of 177 endobronchial biopsies were performed (4.1 +/- 2.5); 8 were too small to be informative, 43 showed non-preneoplastic alterations, and 50 were normal. There were 7 basal cell hyperplasias, 56 metaplasias, 9 dysplasias, and 4 carcinomas in situ (CIS). All the dysplasias and CIS lesions were observed in eight subjects. The synchronous CIS were treated by surgery (n = 1) or localized therapeutic modalities (n = 3). CONCLUSIONS: The high prevalence of synchronous early lung cancers (9.3%) as well as metaplasia and dysplasia in this series of patients with resectable RVLC suggests that fluorescence bronchoscopy may be a useful adjunct in the preoperative evaluation of lung cancer.

Detection of bronchial preneoplastic lesions and early lung cancer with fluorescence bronchoscopy: a study about its ambulatory feasibility under local anaesthesis.

BACKGROUND: Autofluorescence bronchoscopy (AB) enhances the bronchoscopist's ability to diagnose bronchial preneoplastic lesions and early cancer. We undertook a study to assess its feasibility and performance under local anaesthesia on a real ambulatory mode. METHODS: Thirty-four consecutive patients at very high risk for lung cancer were prospectively studied by AB under local anaesthesia, without any sedation. Lidocaine doses, time, oxygen saturation, peak expiratory flow (PEF) and the number of cough episodes were measured. Continuous assessment of the respiratory sensation was obtained with a visual analog scale. A total of 172 biopsies were performed in abnormal and normal areas. RESULTS: The procedure was long-lasting (mean +/- SD: 26.6 +/- 6.0 min), required high total doses of Lidocaine (660 +/- 107 mg) without any significant side effect, and was associated with significant decreases in O2 saturation from 98.5 +/- 1.4 to 96.1 +/- 2.5% and in PEF from 380 +/- 96 to 310 +/- 78 l/min. However, the cough counts were moderate and the majority of patients reported no respiratory discomfort. 62 hyperplasia, metaplasia, dysplasia and carcinoma in situ (CIS) were detected and the relative sensitivity of AB +/- white-light bronchoscopy (WLB) versus WLB alone was 3.75 for intraepithelial lesions corresponding to moderate dysplasia or worse. CONCLUSIONS: AB, a procedure that increases our ability to recognize preneoplastic lesions and early lung cancer, can be performed under local anaesthesia, without systemic sedation in patients at very high risk for lung cancer.

[Diagnosis and treatment of early-stage bronchial cancer: current status]. / Diagnostic et traitement du cancer bronchique au stade précoce: état de la question.

Lung cancer is the cancer with the largest mortality in Belgium. Nowadays, the most potent risk factor for lung cancer, tobacco smoking, is increasing, principally in teenagers. It is therefore necessary to intervene more efficiently in the natural history of the disease. This aim can be achieve by the early detection and the local treatment of small size lung cancer and in situ carcinoma. Interestingly, pulmonary preneoplastic lung lesions have been identified and characterized in the central airways as well as in the peripheral lung parenchyma. These preneoplastic lesions can evolve to invasive cancer or regress after tobacco smoking cessation or chemoprevention treatment. A new autofluorescence based endoscopy technique is described, that allows to detect preneoplastic pulmonary lesions and radio-occult lung cancer. These small sized lesions can be cured with endoscopic local treatment such as photodynamic therapy.

[Occupational asthma caused by isocyanates]. / Asthme professionnel aux isocyanates.

The aim of our study is to find whether the percentage of RAST positives to isocyanates within a company is a reflection of the exposure of the workers. Specific IgE was sought in 199 workers from ten companies where isocyanates were used. Twenty of them were followed for some time (june 87 to september 90). A non-exposed reference group was used for comparison. Measurements were made by the Pharmacia RAST-ELISA Method. In some cases, controls were made by RAST-RIA and CAPS ELISA/RIA. Results show that the proportion of positive RAST varies from one organisation to another and is probably a measure of the type and intensity of the exposure; the improvement of the working conditions to reduce the ambient concentration reduces, in time, the proportion of positive RAST; there were no positive RAST in the reference group; the conditions of taking and storage of blood samples before analysis influences the result. In conclusion, measurement of specific IgE may be an useful alternative to measurement of ambient concentration for following workers exposed to isocyanates.

[The role of serology in the diagnosis of Helicobacter (Campylobacter) pylori infection]. / Intérêts de la sérologie dans la détection de l'infection à Helicobacter (Campylobacter) pylori.

The purpose of the communication is to review the different aspects of the Helicobacter (Campylobacter) pylori infection. The first part of the communication is devoted to the description of the different gastric pathologies induced by the Helicobacter pylori infection and to the different methods used for the detection of this infection. Today a consensus assesses a causal role to Helicobacter pylori in the development of chronic active gastritis (or type B gastritis), in the pathogenesis of duodenal ulcer, and a major contributing factor in the development of peptic ulcer disease. The possible role played by this bacterium in the development of non-ulcer dyspepsia is still unclear. H. pylori infections can be detected using different methods including invasive methods--requiring an endoscopy (e.g.: culture of the micro-organism, urease test, microscopy) and non-invasive methods (e.g.: breath test, serology). Each of these methods has advantages but also some disadvantages, and none shows an absolute sensitivity and specificity. The second part of the presentation analyses the results obtained with a serologic method using a specific fractioned and purified antigenic complex extracted from Helicobacter pylori. This report demonstrates a good correlation with the other detection methods. Serology appears also as a useful tool for the therapeutical monitoring of infected patients. Serological results must however be interpreted in the light of the complete clinical examination of the patient.

[Asthma and isocyanates]. / Asthme et isocyanates.

1. After having reviewed all the 22 patients in Belgium who are indemnified for isocyanate occupational asthma, the authors cannot find any significant factor that would permit screening and previous eviction (atopy, smoking habits). Every patient suffers from a non-specific bronchial responsiveness even after the end of exposure. 2. The specific RAST HDI, MDI, TDI, performed on 26 exposed workers suggests an IgE-mediated sensitization, that does not appear to be a reliable diagnostic or prognostic factor of the disease.

[Effect of 300 mg of ranitidine, 800 mg of cimetidine and a placebo administered after the evening meal on 24-hour gastric pH in patients with duodenal ulcer]. / Effet de 300 mg de ranitidine, de 800 mg de cimétidine et d'un placebo administrés après le repas du soir sur le pH gastrique de 24 heures chez l'ulcéreux duodénal.

Twenty-four-hour intragastric pH monitoring was performed in 20 patients with duodenal ulcer in order to compare the results obtained with placebo, ranitidine 300 mg and cimetidine 800 mg administered one hour (7 PM) after evening meal (6 PM). During each 24 h period (8 AM-8 AM), gastric pH was continuously monitored in standardized dietary conditions. Treatment was started the evening (7 PM) before the test. Median acidity was calculated and percent of time of recording at or above any pH unit was graphically represented. Median acidity and areas under the curves were submitted to statistical comparison. The values were computed for the 24-h period, for the 8 AM-8 PM period, for the 8 PM-8 AM period. In these three periods studied gastric acidity decreased more with ranitidine than with cimetidine. No statistical difference was found between cimetidine and placebo for the 8 AM-8 PM period.

Mini-F E protein: the carboxy-terminal end is essential for E gene repression and mini-F copy number control.

Mini-F is a segment of the conjugative plasmid F consisting of two origins of replication flanked by regulatory regions, which ensure a normal control of replication and partitioning. Adjacent to the ori-2 origin is a complex coding region that consists of the E gene overlapped by three open reading frames with the coding potential for 9000 Mr polypeptides here designated 9 kd-1, 9 kd-2 and 9 kd-3. In this paper, we show that open reading frame 9 kd-3 is preceded by active promoter and Shine-Dalgarno sequences. The E coding region specifies: an initiator of replication, which acts at the ori-2 site; a function that negatively regulates the expression of the E gene; and a function involved in mini-F copy number control. To assign one of these functions to one of the overlapping coding sequence, we have isolated, characterized and sequenced mutations mapping in the E coding region. In this paper, we analyse two mutations (cop5 and pla25) that abolish the repression of the E gene. As these mutations affect the primary structure of protein E itself but not the 9 kd polypeptides, we conclude that protein E takes part in the negative regulation of its own synthesis. In addition, the localization of the cop5 and pla25 mutations indicates that the carboxy-terminal end of the E protein is involved in the autorepression function. The cop5 mutation causes an eightfold increase of the mini-F copy number. The pla25 mutation leads to the inability of the derived mini-F plasmid to give rise to plasmid-harbouring bacteria. The ways in which the cop5 and pla25 mutations may lead to such phenotypes are discussed in relation to the different functions mapping in the E coding sequence.