[show abstract][hide abstract] ABSTRACT: BACKGROUND: COPD is an independent risk factor for lung cancer, especially in patients with mild to moderate disease. OBJECTIVE: To determine if performing lung cancer screening in GOLD 1 and 2 COPD patients, results in reduced lung cancer mortality. METHODS: This study compared patients with mild to moderate COPD from 2 cohorts matched for age, gender, BMI, FEV1%, pack-yrs history and smoking status. The screening group (SG) had an annual low dose computed tomography (LDCT). The control group (CG) was prospectively followed with usual care. Lung cancer incidence and mortality densities were compared between groups. RESULTS: From an initial sample of 410 (SG) and 735 (CG) patients we were able to match 333 patients from each group. At the same follow-up time lung cancer incidence density was 1.79/100 person-years in the SG and 4.14/100 person-years in the CG (p = 0.004). The most frequent histological type was adenocarcinoma in both SG and CG (65% and 46%, respectively), followed by squamous cell carcinoma (25% and 37%, respectively). Eighty percent of lung cancers in the SG (16/20) were diagnosed in stage I, and all of CG cancers (35/35) were in stage III or IV. Mortality incidence density from lung cancer (0.08 vs. 2.48/100 person-years, p < 0.001) was lower in the SG. CONCLUSIONS: This pilot study in patients with mild to moderate COPD suggests that screening with LDCT detects lung cancer in early stages, and could decrease lung cancer mortality in that high risk group. Appropriately designed studies should confirm these important findings.
Respiratory medicine 02/2013; · 2.33 Impact Factor
[show abstract][hide abstract] ABSTRACT: Epicardial Adipose Tissue (EAT) volume as determined by chest computed tomography (CT) is an independent marker of cardiovascular events in the general population. COPD patients have an increased risk of cardiovascular disease, however nothing is known about the EAT volume in this population.
To assess EAT volume in COPD and explore its association with clinical and physiological variables of disease severity.
We measured EAT using low-dose CT in 171 stable COPD patients and 70 controls matched by age, smoking history and BMI. We determined blood pressure, cholesterol, glucose and HbA1c levels, microalbuminuria, lung function, BODE index, co-morbidity index and coronary artery calcium score (CAC). EAT volume were compared between groups. Uni and multivariate analyses explored the relationship between EAT volume and the COPD related variables.
COPD patients had a higher EAT volume [143.7 (P25-75, 108.3-196.6) vs 129.1 (P25-75, 91.3-170.8) cm(3), p = 0.02)] and the EAT volume was significantly associated with CAC (r = 0.38, p<0.001) and CRP (r = 0.32, p<0.001) but not with microalbuminuria (r = 0.12, p = 0.13). In COPD patients, EAT volume was associated with: age, pack-years, BMI, gender, FEV1%, 6 MWD, MMRC and HTN. Multivariate analysis showed that only pack-years (B = 0.6, 95% CI: 0.5-1.3), BMI (B = 7.8, 95% CI: 5.7-9.9) and 6 MWD (B = -0.2, 95% CI: -0.3--0.1), predicted EAT volume.
EAT volume is increased in COPD patients and is independently associated with smoking history, BMI and exercise capacity, all modifiable risk factors of future cardiovascular events. EAT volume could be a non-invasive marker of COPD patients at high risk for future cardiovascular events.
PLoS ONE 01/2013; 8(6):e65593. · 3.73 Impact Factor
[show abstract][hide abstract] ABSTRACT: Low-grade inflammation and emphysema have been shown to be associated with an increased risk of lung cancer. However, the systemic inflammatory response in patients with emphysema is still unknown.
TO COMPARE THE PLASMA CYTOKINE PROFILES IN TWO GROUPS OF CURRENT OR FORMER SMOKERS WITHOUT AIRWAY OBSTRUCTION: a control group of individuals without computed tomography (CT) detected emphysema vs. a study group of individuals with CT detected emphysema.
Subjects underwent a chest CT, spirometry, and determination of EGF, IL-15, IL-1ra, IL-8, MCP-1, MIP-1β, TGFα, TNFα, and VEGF levels in plasma. Cytokine levels in each group were compared adjusting for confounding factors.
160 current smokers and former smokers without airway obstruction participated in the study: 80 without emphysema and 80 subjects with emphysema. Adjusted group comparisons revealed significant reductions in EGF (-0.317, p = 0.01), IL-15 (-0.21, p = 0.01), IL-8 (-0.180, p = 0.02) and IL-1ra (-0.220, p = 0.03) in subjects with emphysema and normal spirometry.
Current or former smokers expressing a well-defined disease characteristic such as emphysema, has a specific plasma cytokine profile. This includes a decrease of cytokines mainly implicated in activation of apoptosis or decrease of immunosurveillance. This information should be taken into account when evaluated patients with tobacco respiratory diseases.
PLoS ONE 01/2013; 8(4):e60260. · 3.73 Impact Factor
[show abstract][hide abstract] ABSTRACT: The objective of our study was to investigate whether fluorodeoxyglucose (FDG) positron emission tomography scanning uptake impacts the yield of transbronchial needle aspiration (TBNA).
We carried out a retrospective analysis of data from 140 consecutive patients (178 lymph nodes) undergoing positron emission tomography-computed tomography scanning and subsequent TBNA with rapid onsite cytologic evaluation of the specimen. Patient and lymph node characteristics, including nodal station, size, FDG uptake, number of passes with the needle, sample adequacy, and the final diagnosis were recorded.
The diagnostic yield of TBNA was 75%. Themean short axis lymph node diameter was 18.7±9 mm and mean maximum standardized uptake value (SUVmax) was 7.7±4. The diagnostic yield depended on the lymph node size [odds ratio (OR)=1.07 (1.00-1.14); P=0.04], clinical suspicion of malignancy [OR=5.13 (1.95-13.52); P=0.001], malignant diagnosis [OR=4.91 (1.71-14.09); P=0.003], and FDG uptake [for SUVmax cutoff of 3.0: OR=33.8 (9.2-124); P<0.001]. Only clinical suspicion of cancer [OR=6.2 (2.2-17.2); P=0.001] and FDG uptake [for SUVmax cutoff of 3.0: OR=33.8 (9.2-123.8); P<0.001] remained significant on multivariate analysis. Receiver operating characteristic curves combining 3 key variables (lymph node size, clinical suspicion of malignancy, and SUVmax) showed an area of 0.83 under the curve for a 2.5 SUVmax cutoff and 0.84 for a 3.0 cutoff.
FDG uptake is the single most important variable impacting the TBNA yield. TBNA of lymph nodes with an SUVmax less than 3.0 is rarely diagnostic.
Journal of bronchology & interventional pulmonology. 01/2011; 18(1):7-14.
[show abstract][hide abstract] ABSTRACT: Phenotypic characterization of patients with COPD may have potential prognostic and therapeutic implications. Available information on the relationship between emphysema and the clinical presentation in patients with COPD is limited to advanced stages of the disease. The objective of this study was to describe emphysema presence, severity, and distribution and its impact on clinical presentation of patients with mild to moderate COPD.
One hundred fifteen patients with COPD underwent clinical and chest CT scan evaluation for the presence, severity, and distribution of emphysema. Patients with and without emphysema and with different forms of emphysema distribution (upper/lower/core/peel) were compared. The impact of emphysema severity and distribution on clinical presentation was determined.
Fifty percent of the patients had mild homogeneously distributed emphysema (1.84; 0.76%-4.77%). Upper and core zones had the more severe degree of emphysema. Patients with emphysema were older, more frequently men, and had lower FEV(1)%, higher total lung capacity percentage, and lower diffusing capacity of the lung for carbon monoxide. No differences were found between the clinical or physiologic parameters of the different emphysema distributions.
In patients with mild to moderate COPD, although the presence of emphysema has an impact on physiologic presentation, its severity and distribution seem to have little impact on clinical presentation.
[show abstract][hide abstract] ABSTRACT: Electromagnetic navigation bronchoscopy (ENB) has been developed as a novel ancillary tool for the bronchoscopic diagnosis of pulmonary nodules. Despite successful navigation in 90% of patients, ENB diagnostic yield does not generally exceed 70%. We sought to determine whether the presence of a bronchus sign on CT imaging conditions diagnostic yield of ENB and might account for the discrepancy between successful navigation and diagnostic yield.
We conducted a prospective, single-center study of ENB in 51 consecutive patients with pulmonary nodules. ENB was chosen as the least invasive diagnostic technique in patients with a high surgical risk, suspected metastatic disease, or advanced-stage disease, or in those who demanded a preoperative diagnosis prior to undergoing curative resection. We studied patient and technical variables that might condition diagnostic yield, including size, cause, location, distance to the pleural surface, and fluorodeoxyglucose uptake of a given nodule; the presence of a bronchus sign on CT imaging; registration point divergence; and the minimum distance from the tip of the locatable guide to the nodule measured during the procedure.
The diagnostic yield of ENB was 67% (34/51). The sensitivity and specificity of ENB for malignancy in this study were 71% and 100%, respectively. ENB was diagnostic in 79% (30/38) patients with a bronchus sign on CT imaging but only in 4/13 (31%) with no discernible bronchus sign. Univariate analysis identified the bronchus sign (P = .005) and nodule size (P = .04) as statistically significant variables conditioning yield, but on multivariate analysis, only the bronchus sign remained significant (OR, 7.6; 95% CI, 1.8-31.7). No procedure-related complications were observed.
ENB diagnostic yield is highly dependent on the presence of a bronchus sign on CT imaging.
[show abstract][hide abstract] ABSTRACT: High-resolution computed tomography (CT) is a validated method to quantify the extent of pulmonary emphysema. In this study, we assessed the reliability of low-dose volumetric CT (LDCT) for the quantification of emphysema and its correlation with spirometric indices of airway obstruction.
The study population consisted of 102 consecutive current and former smokers participating in a lung cancer screening trial. All subjects underwent spirometry testing and LDCT at entry and a LDCT after 12 months. The extent of emphysema was estimated by 2 techniques; by using the lung attenuation threshold analysis and by visual assessment of the 2 independent radiologists. The reproducibility of these determinations was assessed using test-retest reliability and kappa coefficient of agreement. The correlation of LDCT-based emphysema determinations with indices of airway obstruction on spirometry was also calculated.
Eighty percent of the participants were male, with a mean (standard deviation) age of 54.5 (7.5) years, and median pack-years (interquartile range) of 20 (24). Test-retest reliability of all LDCT-based emphysema determinations was very good (intraclass correlation coefficient of 0.92 for the volume of emphysema, and 0.93 for the emphysema index or emphysema volume/total lung volume). Similarly, there was an excellent interrater agreement for visual assessment of emphysema (kappa coefficient=0.91). Higher volumes of emphysema measured quantitatively or visually significantly correlated with spirometric markers of airway obstruction.
Volumetric LDCT is a reliable and valid technique for the quantification of emphysema in asymptomatic smokers.
Journal of thoracic imaging 09/2009; 24(3):206-11. · 1.42 Impact Factor
[show abstract][hide abstract] ABSTRACT: Identification of risk factors for lung cancer can help in selecting patients who may benefit the most from smoking cessation interventions, early detection, or chemoprevention.
To evaluate whether the presence of emphysema on low-radiation-dose CT (LDCT) of the chest is an independent risk factor for lung cancer.
The study used data from a prospective cohort of 1,166 former and current smokers participating in a lung cancer screening study. All individuals underwent a baseline LDCT and spirometry followed by yearly repeat LDCT studies. The incidence density of lung cancer among patients with and without emphysema on LDCT was estimated. Stratified and multiple regression analyses were used to assess whether emphysema is an independent risk factor for lung cancer after adjusting for age, gender, smoking history, and the presence of airway obstruction on spirometry.
On univariate analysis, the incidence density of lung cancer among individuals with and without emphysema on LDCT was 25.0 per 1,000 person-years and 7.5 per 1,000 person-years, respectively (risk ratio [RR], 3.33; 95% confidence interval [CI], 1.41 to 7.85). Emphysema was also associated with increased risk of lung cancer when the analysis was limited to individuals without airway obstruction on spirometry (RR, 4.33; 95% CI, 1.04 to 18.16). Multivariate analysis showed that the presence of emphysema (RR, 2.51; 95% CI, 1.01 to 6.23) on LDCT but not airway obstruction (RR, 2.10; 95% CI, 0.79 to 5.58) was associated with increased risk of lung cancer after adjusting for potential cofounders.
Results suggest that the presence of emphysema on LDCT is an independent risk factor for lung cancer.
[show abstract][hide abstract] ABSTRACT: Lung cancer screening using computed tomography (CT) is effective in detecting early stage disease. However, concerns regarding adherence have been raised. The current authors conducted a retrospective observational study of 641 asymptomatic smokers enrolled in a lung cancer screening programme between 2000 and 2003. Adherent subjects were compared with nonadherent subjects with regard to lung function, sex, age, motivation for enrollment, smoking status, distance to the referral centre, family history of lung cancer, asbestos exposure, education, the presence and type of nodule(s) seen on initial CT, and exposure to a nursing intervention designed to improve adherence. Overall, early adherence to the study protocol was 65%. Multivariate analysis confirmed the importance of sex, proximity to the referral centre, the presence of noncalcified nodules, and the nursing intervention as factors conditioning adherence to the study protocol. Patients encouraged to participate in the study were more adherent, as were former smokers. Sex interactions were observed in multivariate analysis. The nursing intervention was significant for females, while abnormal lung function improved male adherence. Adherence to lung cancer screening is particularly good among females and subjects living near the referral centre. The present study suggests the need to develop new strategies, especially those targeting males and subjects with low risk perception, in order to improve adherence.
European Respiratory Journal 10/2007; 30(3):532-7. · 6.36 Impact Factor
[show abstract][hide abstract] ABSTRACT: Leptin is a powerful stimulant of ventilation in rodents. In humans, resistance to leptin has been consistently associated with obesity. Raised leptin levels have been reported in subjects with sleep apnoea or obesity-hypoventilation syndrome. The aim of the present study was to assess, by multivariate analysis, the possible association between respiratory centre impairment and levels of serum leptin. In total, 364 obese subjects (body mass index >or=30 kg.m(-2)) underwent the following tests: sleep studies, respiratory function tests, baseline and hypercapnic response (mouth occlusion pressure (P(0.1)), minute ventilation), fasting leptin levels, body composition and anthropometric measures. Subjects with airways obstruction on spirometry were excluded. Out of the 346 subjects undergoing testing, 245 were included in the current analysis. Lung volumes, age, log leptin levels, end-tidal carbon dioxide tension, percentage body fat and minimal nocturnal saturation were predictors for baseline P(0.1). The hypercapnic response test was performed by 186 subjects; log leptin levels were predictors for hypercapnic response in males, but not in females. Hyperleptinaemia is associated with a reduction in respiratory drive and hypercapnic response, irrespective of the amount of body fat. These data suggest the extension of leptin resistance to the respiratory centre.
European Respiratory Journal 08/2007; 30(2):223-31. · 6.36 Impact Factor
[show abstract][hide abstract] ABSTRACT: Inpatient management of malignant pleural effusion includes the placement of a conventional thoracostomy tube for drainage and talc slurry pleurodesis and/or a surgical approach consisting of video-assisted thoracoscopic talc insufflation. Both techniques require prolonged hospital stays of up to 1 week. Unfortunately, life expectancy in patients with this disease does not usually exceed 6 months, and so the primary aim of any palliative intervention intended to improve quality of life should be to avoid hospital admissions and to relieve pain as far as possible. Of the few outpatient alternatives to hospital management the most frequently used is repeated thoracentesis. We describe the outpatient management of malignant pleural effusion by placement of a tunneled pleural catheter in a patient with stage IIIB lung adenocarcinoma. In our opinion, the use of this catheter offers a viable alternative to conventional therapy and is better tolerated.
Archivos de Bronconeumología 01/2007; 42(12):660-2. · 1.37 Impact Factor
[show abstract][hide abstract] ABSTRACT: Inpatient management of malignant pleural effusion includes the placement of a conventional thoracostomy tube for drainage and talc slurry pleurodesis and/or a surgical approach consisting of video-assisted thoracoscopic talc insufflation. Both techniques require prolonged hospital stays of up to 1 week. Unfortunately, life expectancy in patients with this disease does not usually exceed 6 months, and so the primary aim of any palliative intervention intended to improve quality of life should be to avoid hospital admissions and to relieve pain as far as possible.Of the few outpatient alternatives to hospital management the most frequently used is repeated thoracentesis. We describe the outpatient management of malignant pleural effusion by placement of a tunneled pleural catheter in a patient with stage IIIB lung adenocarcinoma. In our opinion, the use of this catheter offers a viable alternative to conventional therapy and is better tolerated.El manejo hospitalario del derrame pleural maligno in-cluye la colocación de un tubo de toracostomía convencio-nal, drenaje y esclerosis mediante talcaje, y/o el abordaje quirúrgico mediante videotoracoscopia. Ambas técnicas re-quieren ingresos prolongados, de hasta una semana de duración. Lamentablemente, la esperanza de vida en pacientes con esta enfermedad no suele superar los 6 meses, motivo por el que toda intervención paliativa destinada a mejorar la calidad de vida debe tener como objetivo primordial el evitar, en la medida de lo posible, el ingreso hospitalario y aliviar el dolor.Hay pocas alternativas ambulatorias al manejo hospitalario. De ellas, la toracocentesis de repetición es la más fre-cuentemente utilizada. Describimos el uso de un catéter tunelizado en el manejo ambulatorio del derrame pleural maligno de un paciente con adenocarcinoma de pulmón en estadio IIIB. Consideramos que este catéter ofrece una al-ternativa viable y mejor tolerada que el tratamiento convencional.
Archivos de Bronconeumología ((English Edition)). 12/2006;
[show abstract][hide abstract] ABSTRACT: Lung cancer screening using computed tomography (CT) is effective in detecting lung cancer in early stages. Concerns regarding false-positive rates and unnecessary invasive procedures have been raised.
To study the efficiency of a lung cancer protocol using spiral CT and F-18-fluorodeoxyglucose positron emission tomography (FDG-PET).
High-risk individuals underwent screening with annual spiral CTs. Follow-up CTs were done for noncalcified nodules of 5 mm or greater, and FDG-PET was done for nodules 10 mm or larger or smaller (> 7 mm), growing nodules.
A total of 911 individuals completed a baseline CT study and 424 had at least one annual follow-up study. Of the former, 14% had noncalcified nodules of 5 mm or larger, and 3.6% had nodules of 10 mm or larger. Eleven non-small cell lung cancers (NSCLC) and one small cell lung cancer (SCLC) were diagnosed in the baseline study (prevalence rate, 1.32%), and two NSCLCs in the annual study (incidence rate, 0.47%). All NSCLCs (92% of prevalence cancers) were diagnosed in stage I (12 stage IA, 1 stage IB). FDG-PET was helpful for the correct diagnosis in 19 of 25 indeterminate nodules. The sensitivity, specificity, positive predictive value, and negative predictive value of FDG-PET for the diagnosis of malignancy were 69, 91, 90, and 71%, respectively. However, the sensitivity and negative predictive value of the screening algorithm, which included a 3-month follow-up CT for nodules with a negative FDG-PET, was 100%.
A protocol for early lung cancer detection using spiral CT and FDG-PET is useful and may minimize unnecessary invasive procedures for benign lesions.
American Journal of Respiratory and Critical Care Medicine 06/2005; 171(12):1378-83. · 11.04 Impact Factor
[show abstract][hide abstract] ABSTRACT: Razionale: L'identificazione dei fattori di rischio del cancro al polmone può aiutare nella sele- zione dei pazienti che possono maggiormente trarre beneficio da interventi per la cessazione dell'abitudine al fumo, da una diagnosi precoce o dalla chemioprevenzione. Obiettivo: Valutare se la presenza di enfisema attraverso TC del torace a bassa dose di radia- zione (LDCT) è un fattore di rischio indipendente di cancro al polmone. Metodi: Lo studio ha utilizzato i dati di una coorte prospettica di 1.166 ex e attuali fumatori che partecipavano ad uno studio di screening per cancro al polmone. Tutti i soggetti sono stati sotto- posti a LDCT di base e spirometria seguite da studi LDCT ripetuti ogni anno. Le analisi di regressione stratificate e multiple sono state utilizzate per stabilire se l'enfisema è un fattore di rischio indipendente di cancro al polmone dopo un aggiustamento in base all'età, al sesso e alla storia di fumo, e la presenza di ostruzione delle vie aeree alla spirometria. Risultati: Secondo l'analisi univariata, la densità di incidenza di cancro al polmone tra individui con e senza enfisema attraverso LDCT era rispettivamente di 25,0 per 1.000 persone l'anno e 7,5 per 1.000 persone l'anno (rapporto di rischio (RR) 3,33; intervallo di confidenza (IC) da 1,41 a 7,85). L'enfisema era anche associato ad un aumento del rischio di cancro al polmone quando l'analisi era limitata a soggetti senza ostruzione delle vie aeree alla spirometria (RR, 4,33; IC al 95%, da 1,04 a 18,16). L'analisi multivariata mostrava che la presenza di enfisema (RR, 2,51; IC al 95%, da 1,01 a 6,23) all' LDCT ma non l'ostruzione delle vie aeree (RR, 2,10; IC al 95% da 0,79 a 5,58) era associata ad un aumento del rischio di cancro al polmone dopo aggiustamento per potenziali confondenti. Conclusioni: I risultati suggeriscono che la presenza di enfisema all'LDCT è un fattore di rischio indipendente per il cancro al polmone. (CHEST Edizione Italiana 2008; 1:26-32)