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Johnson SR, Shaw DE, Avoseh M, Soomro I, Pointon KS, Kokosi M, Nicholson AG, Desai SR, George PM. Diagnosis of cystic lung diseases: a position statement from the UK Cystic Lung Disease Rare Disease Collaborative Network. Thorax 2024; 79:366-377. [PMID: 38182428 DOI: 10.1136/thorax-2022-219738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/15/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Rare cystic lung diseases are increasingly recognised due the wider application of CT scanning making cystic lung disease management a growing part of respiratory care. Cystic lung diseases tend to have extrapulmonary features that can both be diagnostic but also require surveillance and treatment in their own right. As some of these diseases now have specific treatments, making a precise diagnosis is crucial. While Langerhans cell histiocytosis, Birt-Hogg-Dubé syndrome, lymphoid interstitial pneumonia and lymphangioleiomyomatosis are becoming relatively well-known diseases to respiratory physicians, a targeted and thorough workup improves diagnostic accuracy and may suggest other ultrarare diseases such as light chain deposition disease, cystic pulmonary amyloidosis, low-grade metastatic neoplasms or infections. In many cases, diagnostic information is overlooked leaving uncertainty over the disease course and treatments. AIMS This position statement from the Rare Disease Collaborative Network for cystic lung diseases will review how clinical, radiological and physiological features can be used to differentiate between these diseases. NARRATIVE We highlight that in many cases a multidisciplinary diagnosis can be made without the need for lung biopsy and discuss where tissue sampling is necessary when non-invasive methods leave diagnostic doubt. We suggest an initial workup focusing on points in the history which identify key disease features, underlying systemic and familial diseases and a clinical examination to search for connective tissue disease and features of genetic causes of lung cysts. All patients should have a CT of the thorax and abdomen to characterise the pattern and burden of lung cysts and extrapulmonary features and also spirometry, gas transfer and a 6 min walk test. Discussion with a rare cystic lung disease centre is suggested before a surgical biopsy is undertaken. CONCLUSIONS We suggest that this focused workup should be performed in all people with multiple lung cysts and would streamline referral pathways, help guide early treatment, management decisions, improve patient experience and reduce overall care costs. It could also potentially catalyse a national research database to describe these less well-understood and unidentified diseases, categorise disease phenotypes and outcomes, potentially leading to better prognostic data and generating a stronger platform to understand specific disease biology.
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Affiliation(s)
- Simon R Johnson
- Respiratory Medicine, University of Nottingham, Nottingham, UK
| | - Dominick E Shaw
- Respiratory Medicine, University of Nottingham, Nottingham, UK
| | - Michael Avoseh
- Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Irshad Soomro
- Department of Cellular Pathology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Kate S Pointon
- Department of Radiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Maria Kokosi
- Interstitial Lung Disease Unit, Department of Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | | | - Sujal R Desai
- Radiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Peter M George
- Interstitial Lung Disease Unit, Royal Brompton and Harefield NHS Foundation Trust, London, UK
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Rossi RL, Elia D, Torre O, Cassandro R, Caminati A, Bulgheroni E, Carelli E, Vasco C, Abrignani S, Geginat J, Harari S. Identification of Lymphangioleiomyomatosis-associated Serum MicroRNAs. Am J Respir Cell Mol Biol 2024; 70:146-148. [PMID: 38299793 DOI: 10.1165/rcmb.2023-0243le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024] Open
Affiliation(s)
| | | | | | | | | | | | - Elena Carelli
- Istituto Nazionale di Genetica Molecolare Milan, Italy
| | - Chiara Vasco
- Istituto Nazionale di Genetica Molecolare Milan, Italy
| | - Sergio Abrignani
- Istituto Nazionale di Genetica Molecolare Milan, Italy
- Department of Clinical Sciences and Community Health (DISCCO) Università degli Studi di Milano Milan, Italy
| | - Jens Geginat
- Istituto Nazionale di Genetica Molecolare Milan, Italy
- Department of Clinical Sciences and Community Health (DISCCO) Università degli Studi di Milano Milan, Italy
| | - Sergio Harari
- MultiMedica IRCCS Milan, Italy
- Department of Clinical Sciences and Community Health (DISCCO) Università degli Studi di Milano Milan, Italy
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Mine K, Sakamoto N, Ozasa M, Tsutsui S, Miyashita R, Tokito T, Okuno D, Yura H, Kido T, Ishimoto H, Takemoto S, Takazono T, Obase Y, Ishimatsu Y, Fukuoka J, Mukae H. Pulmonary Langerhans cell histiocytosis diagnosed using transbronchial lung cryobiopsy: A case report. Respir Med Case Rep 2023; 46:101928. [PMID: 37869608 PMCID: PMC10585380 DOI: 10.1016/j.rmcr.2023.101928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 09/12/2023] [Accepted: 10/07/2023] [Indexed: 10/24/2023] Open
Abstract
A 63-year-old Japanese woman with multiple cysts in both lungs on chest computed tomography (CT) was referred to our hospital after a thorough examination, including a transbronchial lung biopsy (TBLB), failed to provide a diagnosis. Based on the findings on chest CT and pathological examination of the bronchoalveolar lavage fluid and transbronchial lung cryobiopsy (TBLC) specimen, the patient was diagnosed with pulmonary Langerhans cell histiocytosis (PLCH). TBLC may replace TBLB as the main diagnostic technique for PLCH, although further studies are required to determine the usefulness of TBLC for the diagnosis of PLCH.
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Affiliation(s)
- Keisuke Mine
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Noriho Sakamoto
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Mutsumi Ozasa
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Shin Tsutsui
- Department of Radiology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Ritsuko Miyashita
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Takatomo Tokito
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Daisuke Okuno
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Hirokazu Yura
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Takashi Kido
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Hiroshi Ishimoto
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Shinnosuke Takemoto
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Takahiro Takazono
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Yasushi Obase
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Yuji Ishimatsu
- Department of Nursing, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8520, Japan
| | - Junya Fukuoka
- Department of Pathology Informatics, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8523, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
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Abstract
Lymphangioleiomyomatosis (LAM) is an ultra-rare, slowly progressive neoplastic cystic disease, belonging to the group of PEComas. It can occur sporadically or associated to tuberous sclerosis complex disease and affects mainly women in child-birth age. Dyspnoea is the most frequent symptom referred to the time of diagnosis, however spontaneous pneumothorax may be a typical presentation associated to extrathoracic manifestations, such as renal angiomyolipomas. In the last decade, important advances in understanding molecular mechanisms underlying the LAM pathogenesis have been reached. It has allowed to obtain improvements in the research of novel biomarkers, treatment and a better management of the disease.
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Affiliation(s)
- Davide Elia
- UO di Pneumologia e Terapia Semi-Intensiva Respiratoria - Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, MultiMedica IRCCS, Via San Vittore 12, 20123 Milan, Italy
| | - Roberto Cassandro
- UO di Pneumologia e Terapia Semi-Intensiva Respiratoria - Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, MultiMedica IRCCS, Via San Vittore 12, 20123 Milan, Italy
| | - Antonella Caminati
- UO di Pneumologia e Terapia Semi-Intensiva Respiratoria - Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, MultiMedica IRCCS, Via San Vittore 12, 20123 Milan, Italy
| | - Francesca Luisi
- UO di Pneumologia e Terapia Semi-Intensiva Respiratoria - Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, MultiMedica IRCCS, Via San Vittore 12, 20123 Milan, Italy
| | - Sergio Harari
- UO di Pneumologia e Terapia Semi-Intensiva Respiratoria - Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, MultiMedica IRCCS, Via San Vittore 12, 20123 Milan, Italy; Department of Clinical Sciences and Community Health, - Università degli Studi di Milano, 20123 Milan, Italy.
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Cottin V, Blanchard E, Kerjouan M, Lazor R, Reynaud-Gaubert M, Taille C, Uzunhan Y, Wemeau L, Andrejak C, Baud D, Bonniaud P, Brillet PY, Calender A, Chalabreysse L, Court-Fortune I, Desbaillets NP, Ferretti G, Guillemot A, Hardelin L, Kambouchner M, Leclerc V, Lederlin M, Malinge MC, Mancel A, Marchand-Adam S, Maury JM, Naccache JM, Nasser M, Nunes H, Pagnoux G, Prévot G, Rousset-Jablonski C, Rouviere O, Si-Mohamed S, Touraine R, Traclet J, Turquier S, Vagnarelli S, Ahmad K. French recommendations for the diagnosis and management of lymphangioleiomyomatosis. Respir Med Res 2023; 83:101010. [PMID: 37087906 DOI: 10.1016/j.resmer.2023.101010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/12/2023] [Accepted: 03/13/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND The present article is an English-language version of the French National Diagnostic and Care Protocol, a pragmatic tool to optimize and harmonize the diagnosis, care pathway, management and follow-up of lymphangioleiomyomatosis in France. METHODS Practical recommendations were developed in accordance with the method for developing a National Diagnosis and Care Protocol for rare diseases of the Haute Autorité de Santé and following international guidelines and literature on lymphangioleiomyomatosis. It was developed by a multidisciplinary group, with the help of patient representatives and of RespiFIL, the rare disease network on respiratory diseases. RESULTS Lymphangioleiomyomatosis is a rare lung disease characterised by a proliferation of smooth muscle cells that leads to the formation of multiple lung cysts. It occurs sporadically or as part of a genetic disease called tuberous sclerosis complex (TSC). The document addresses multiple aspects of the disease, to guide the clinicians regarding when to suspect a diagnosis of lymphangioleiomyomatosis, what to do in case of recurrent pneumothorax or angiomyolipomas, what investigations are needed to make the diagnosis of lymphangioleiomyomatosis, what the diagnostic criteria are for lymphangioleiomyomatosis, what the principles of management are, and how follow-up can be organised. Recommendations are made regarding the use of pharmaceutical specialties and treatment other than medications. CONCLUSION These recommendations are intended to guide the diagnosis and practical management of pulmonary lymphangioleiomyomatosis.
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Affiliation(s)
- Vincent Cottin
- Centre de Référence Coordinateur des maladies pulmonaires rares (OrphaLung), Hôpital Louis Pradel, Hospices Civils de Lyon, 28 avenue Doyen Lepine, ERN-LUNG, 69677 Lyon, France; UMR 754, INRAE, Université Claude Bernard Lyon 1, 8 avenue Rockefeller, 69008 Lyon, France.
| | - Elodie Blanchard
- Centre de Compétence des maladies pulmonaires rares (OrphaLung), GH Sud Haut-Lévêque, Avenue Magellan, 33600 Pessac, France
| | - Mallorie Kerjouan
- Centre de Compétence des maladies pulmonaires rares (OrphaLung), CHU Pontchailloux, 2 rue Henri le Guilloux, 35000 Rennes, France
| | - Romain Lazor
- Service de Pneumologie, Centre Hospitalier Universitaire Vaudois, BU44/07.2137, Rue du Bugnon 46, 1011 Lausanne, Suisse
| | - Martine Reynaud-Gaubert
- Centre de Compétence des maladies pulmonaires rares (OrphaLung), Hôpital Nord, Chemin Bourrely, 13015 Marseille, France; URMITE-CNRS-IRD UMR 6236, Aix-Marseille Université, 51 boulevard Pierre Dramard, 13344 Marseille cedex 15, France
| | - Camille Taille
- Centre de Référence Constitutif des maladies pulmonaires rares (OrphaLung), Hôpital Bichat, 46 rue Henri Huchard, 75018 Paris, France; Université Paris-Diderot, 17 rue Jean Antoine de Baïf, 75013 Paris, France
| | - Yurdagül Uzunhan
- Centre de Référence constitutif des maladies pulmonaires rares (OrphaLung), Hôpital Avicenne, 125 rue Stalingrad, 93000 Bobigny, France; Université Sorbonne Paris Nord, INSERM UMR 1272 "Hypoxie et Poumon", 1 rue Chablis, 93000 Bobigny, Paris, France
| | - Lidwine Wemeau
- Centre de Référence constitutif des maladies pulmonaires rares, CHRU, 5 rue Oscar Lambret, 59000 Lille, France
| | - Claire Andrejak
- Service de pneumologie, CHU Amiens, 1 Place Victor Pauchet, 80054 Amiens, France; UFR de médecine, 3 rue Louvels, 80000 Amiens, France
| | - Dany Baud
- Hôpital Suisse de Paris, 10 rue Minard, 92130 Issy les Moulineaux, France
| | - Philippe Bonniaud
- Centre de Référence constitutif des maladies pulmonaires rares, CHU de Dijon, BP 77908, 21079, Dijon, France; INSERM, LNC UMR1231, LipSTIC LabEx Team, 21000 Dijon, France
| | - Pierre-Yves Brillet
- Université Sorbonne Paris Nord, INSERM UMR 1272 "Hypoxie et Poumon", 1 rue Chablis, 93000 Bobigny, Paris, France; Service de radiologie, hôpital Avicenne, 125 rue Stalingrad, 93000 Bobigny, France
| | - Alain Calender
- Département de génétique, Hospices Civils de Lyon, 28 avenue Doyen Lepine, 69677 Lyon, France; IBCP, Université Claude Bernard Lyon 1, 8 avenue Rockefeller, 69008 Lyon, France
| | - Lara Chalabreysse
- Service de pathologie, Groupe hospitalier est, Hospices Civils de Lyon, 28 avenue Doyen Lepine, 69677 Lyon, France; Université Claude Bernard Lyon 1, 8 avenue Rockefeller, 69008 Lyon, France
| | | | | | - Gilbert Ferretti
- Pole imagerie, CHU Grenoble Alpes, Boulevard Chantourne, 38700 La Tronche, France
| | - Anne Guillemot
- Centre de Référence Coordinateur des maladies pulmonaires rares (OrphaLung), Hôpital Louis Pradel, Hospices Civils de Lyon, 28 avenue Doyen Lepine, ERN-LUNG, 69677 Lyon, France
| | - Laurane Hardelin
- Centre de Référence Coordinateur des maladies pulmonaires rares (OrphaLung), Hôpital Louis Pradel, Hospices Civils de Lyon, 28 avenue Doyen Lepine, ERN-LUNG, 69677 Lyon, France
| | - Marianne Kambouchner
- Service d'anatomopatholologie, Hôpital Avicenne, 125 rue Stalingrad, 93000 Bobigny, France
| | - Violette Leclerc
- Association France Lymphangioléiomyomatose, 4, Rue des Vieux-Moulins, 56 680 Plouhinec, France
| | - Mathieu Lederlin
- Service de radiologie, CHU Pontchailloux, 2 rue Henri le Guilloux, 35000 Rennes, France
| | | | - Alain Mancel
- Association France Lymphangioléiomyomatose, 4, Rue des Vieux-Moulins, 56 680 Plouhinec, France
| | - Sylvain Marchand-Adam
- Centre de Compétence des maladies pulmonaires rares (OrphaLung), Hôpital Bretonneau, CHRU Tours, 2 Boulevard Tonnellé, 37000 Tours, France; Université de Tours, CEPR INSERMU1100, 10 Boulevard Tonnellé, 37000 Tours, France
| | - Jean-Michel Maury
- Service de chirurgie thoracique, Hôpital Louis Pradel, Hospices Civils de Lyon, 28 avenue Doyen Lepine, 69677 Lyon, France
| | - Jean-Marc Naccache
- Service de pneumologie, Hôpital Saint Joseph, 185 rue Raymond Losserand, 75014 Paris, France
| | - Mouhamad Nasser
- Centre de Référence Coordinateur des maladies pulmonaires rares (OrphaLung), Hôpital Louis Pradel, Hospices Civils de Lyon, 28 avenue Doyen Lepine, ERN-LUNG, 69677 Lyon, France
| | - Hilario Nunes
- Centre de Référence constitutif des maladies pulmonaires rares (OrphaLung), Hôpital Avicenne, 125 rue Stalingrad, 93000 Bobigny, France; Université Sorbonne Paris Nord, INSERM UMR 1272 "Hypoxie et Poumon", 1 rue Chablis, 93000 Bobigny, Paris, France
| | - Gaële Pagnoux
- Service de radiologie, Hôpital Edouard Herriot, 5 place d'Arsonval, 69008 Lyon, France
| | - Grégoire Prévot
- Centre de Compétence des maladies pulmonaires rares (OrphaLung), service de pneumologie, hôpital Larrey, 24 chemin de Pouvourville, 31059 Toulouse cedex 9, France
| | | | - Olivier Rouviere
- Université Claude Bernard Lyon 1, 8 avenue Rockefeller, 69008 Lyon, France; Service de radiologie, Hôpital Edouard Herriot, 5 place d'Arsonval, 69008 Lyon, France
| | - Salim Si-Mohamed
- Université Claude Bernard Lyon 1, 8 avenue Rockefeller, 69008 Lyon, France; Service d'imagerie, Hôpital Louis Pradel, Hospices Civils de Lyon, 28 avenue Doyen Lepine, 69677 Lyon, France
| | - Renaud Touraine
- Laboratoire de Génétique Chromosomique et Moléculaire, CHU-Hôpital Nord, Laboratoire AURAGEN (Plan France Médecine Génomique 2025), 42270 Saint Priest en Jarest, France
| | - Julie Traclet
- Centre de Référence Coordinateur des maladies pulmonaires rares (OrphaLung), Hôpital Louis Pradel, Hospices Civils de Lyon, 28 avenue Doyen Lepine, ERN-LUNG, 69677 Lyon, France
| | - Ségolène Turquier
- Service d'exploration fonctionnelle respiratoire, Hôpital Louis Pradel, Hospices Civils de Lyon, 28 avenue Doyen Lepine, 69677 Lyon, France
| | - Stéphane Vagnarelli
- Centre de Référence constitutif des maladies pulmonaires rares (OrphaLung), Hôpital Avicenne, 125 rue Stalingrad, 93000 Bobigny, France
| | - Kaïs Ahmad
- Centre de Référence Coordinateur des maladies pulmonaires rares (OrphaLung), Hôpital Louis Pradel, Hospices Civils de Lyon, 28 avenue Doyen Lepine, ERN-LUNG, 69677 Lyon, France
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Panjwani A, Salman MR. Multiple cystic lung disease in a smoker. Egypt J Intern Med 2022. [DOI: 10.1186/s43162-022-00184-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Pulmonary cyst is a rounded lung parenchymal lucency, usually containing air or fluid. Approach to establishing the etiology of lung cyst includes determining their location, number, distribution, and presence or absence of associated computed tomography findings (associated with nodules or ground-glass attenuation). Multiple cysts may be seen in various diseases, and radiological imaging is the usual starting point in detecting lung cysts. Importance of adequate clinical examination accompanied with relevant investigations in securing the etiology of lung cysts cannot be overemphasized. We present a first case of a rare multiple cystic lung disease from the Kingdom of Bahrain that was successfully managed with oral corticosteroids.
Case presentation
A 42-year-old male, chronic smoker presented with progressive dyspnea and productive cough of 1 year duration. He was evaluated and found to have multiple variable sized thin and thick-walled cysts with bizarre shapes in both lungs. A diagnosis of pulmonary Langerhans’ cell histiocytosis was made, and the patient was treated with smoking cessation and oral corticosteroids for 9 months.
Conclusion
Patients with characteristic clinical and radiological features can be diagnosed as pulmonary Langerhans’ cell histiocytosis, without a tissue biopsy. A good response may be seen with smoking cessation and oral corticosteroids in selected group of patients.
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Xuan S, Li Y, Wu Y, Adcock IM, Zeng X, Yao X. Langerin-expressing dendritic cells in pulmonary immune-related diseases. Front Med (Lausanne) 2022; 9:909057. [PMID: 36160158 PMCID: PMC9490018 DOI: 10.3389/fmed.2022.909057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 08/12/2022] [Indexed: 11/30/2022] Open
Abstract
Dendritic cells (DCs) are “frontline” immune cells dedicated to antigen presentation. They serve as an important bridge connecting innate and adaptive immunity, and express various receptors for antigen capture. DCs are divided into various subclasses according to their differential expression of cell surface receptors and different subclasses of DCs exhibit specific immunological characteristics. Exploring the common features of each sub-category has became the focus of many studies. There are certain amounts of DCs expressing langerin in airways and peripheral lungs while the precise mechanism by which langerin+ DCs drive pulmonary disease is unclear. Langerin-expressing DCs can be further subdivided into numerous subtypes based on the co-expressed receptors, but here, we identify commonalities across these subtypes that point to the major role of langerin. Better understanding is required to clarify key disease pathways and determine potential new therapeutic approaches.
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Affiliation(s)
- Shurui Xuan
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yuebei Li
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yunhui Wu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ian M. Adcock
- Airway Disease Section, National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Xiaoning Zeng
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xin Yao
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- *Correspondence: Xin Yao
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Vehar SJ, Ribeiro Neto ML, Culver DA, Mehta AC. CD1a Staining in Bronchoalveolar Lavage in Pulmonary Langerhans Cell Histiocytosis: "Barking Up the Wrong Tree!". J Bronchology Interv Pulmonol 2022; 29:e33-e35. [PMID: 35730782 DOI: 10.1097/lbr.0000000000000772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Susan J Vehar
- Cleveland Clinic Respiratory Institute Cleveland, OH
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9
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Rama Esendagli D, Ntiamoah P, Kupeli E, Bhardwaj A, Ghosh S, Mukhopadhyay S, Mehta AC. Recurrence of primary disease following lung transplantation. ERJ Open Res 2022; 8:00038-2022. [PMID: 35651363 PMCID: PMC9149385 DOI: 10.1183/23120541.00038-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/12/2022] [Indexed: 11/17/2022] Open
Abstract
Lung transplant has become definitive treatment for patients with several end-stage lung diseases. Since the first attempted lung transplantation in 1963, survival has significantly improved due to advancement in immunosuppression, organ procurement, ex vivo lung perfusion, surgical techniques, prevention of chronic lung allograft dysfunction and bridging to transplant using extracorporeal membrane oxygenation. Despite a steady increase in number of lung transplantations each year, there is still a huge gap between demand and supply of organs available, and work continues to select recipients with potential for best outcomes. According to review of the literature, there are some rare primary diseases that may recur following transplantation. As the number of lung transplants increase, we continue to identify disease processes at highest risk for recurrence, thus shaping our future approaches. While the aim of lung transplantation is improving survival and quality of life, choosing the best recipients is crucial due to a shortage of donated organs. Here we discuss the common disease processes that recur and highlight its impact on overall outcome following lung transplantation. This article reviews the underlying conditions leading to lung transplant with potential for recurrence and the impact of such recurrences on the overall outcome following transplanthttps://bit.ly/3v3gSvJ
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Goyal G, Tazi A, Go RS, Rech KL, Picarsic JL, Vassallo R, Young JR, Cox CW, Van Laar J, Hermiston ML, Cao XX, Makras P, Kaltsas G, Haroche J, Collin M, McClain KL, Diamond EL, Girschikofsky M. International expert consensus recommendations for the diagnosis and treatment of Langerhans cell histiocytosis in adults. Blood 2022; 139:2601-2621. [PMID: 35271698 PMCID: PMC11022927 DOI: 10.1182/blood.2021014343] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 02/24/2022] [Indexed: 11/20/2022] Open
Abstract
Langerhans cell histiocytosis (LCH) can affect children and adults with a wide variety of clinical manifestations, including unifocal, single-system multifocal, single-system pulmonary (smoking-associated), or multisystem disease. The existing paradigms in the management of LCH in adults are mostly derived from the pediatric literature. Over the last decade, the discovery of clonality and MAPK-ERK pathway mutations in most cases led to the recognition of LCH as a hematopoietic neoplasm, opening the doors for treatment with targeted therapies. These advances have necessitated an update of the existing recommendations for the diagnosis and treatment of LCH in adults. This document presents consensus recommendations that resulted from the discussions at the annual Histiocyte Society meeting in 2019, encompassing clinical features, classification, diagnostic criteria, treatment algorithm, and response assessment for adults with LCH. The recommendations favor the use of 18F-Fluorodeoxyglucose positron emission tomography-based imaging for staging and response assessment in the majority of cases. Most adults with unifocal disease may be cured by local therapies, while the first-line treatment for single-system pulmonary LCH remains smoking cessation. Among patients not amenable or unresponsive to these treatments and/or have multifocal and multisystem disease, systemic treatments are recommended. Preferred systemic treatments in adults with LCH include cladribine or cytarabine, with the emerging role of targeted (BRAF and MEK inhibitor) therapies. Despite documented responses to treatments, many patients struggle with a high symptom burden from pain, fatigue, and mood disorders that should be acknowledged and managed appropriately.
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Affiliation(s)
- Gaurav Goyal
- Division of Hematology-Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Abdellatif Tazi
- Université de Paris, INSERM UMR 976, Saint Louis Research Institute, Paris, France
- French National Reference Center for Histiocytoses, Department of Pulmonology, Saint-Louis Teaching Hospital, Assistance Publique-Hôpiaux de Paris, Paris, France
| | | | - Karen L. Rech
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Jennifer L. Picarsic
- Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | | | | | - Jan Van Laar
- Department of Internal Medicine
- Department of Immunology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Michelle L. Hermiston
- Division of Pediatric Hematology-Oncology, University of California, San Francisco, San Francisco, CA
| | - Xin-Xin Cao
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Polyzois Makras
- LCH Adult Clinic
- Department of Endocrinology and Diabetes, 251 Hellenic Air Force and VA General Hospital, Athens, Greece
| | - Gregory Kaltsas
- 1st Propaedeutic Department of Internal Medicine, National and Kapodistrian University of Athens, Greece
| | - Julien Haroche
- Service de médecine interne 2, Centre de Référence des Histiocytoses, Hôpital Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris (APHP), Sorbonne Université, Paris, France
| | - Matthew Collin
- Newcastle University and Newcastle Upon Tyne Hospitals, Newcastle Upon Tyne, United Kingdom
| | - Kenneth L. McClain
- Texas Children's Cancer and Hematology Centers, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Eli L. Diamond
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Michael Girschikofsky
- Internal Medicine I (Hemostasis, Hematology and Stem, Cell Transplantation and Medical Oncology), Ordensklinikum Linz Elisabethinen, Linz, Austria
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11
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Zhang L, Ouyang R. Clinical analysis for 15 patients with pulmonary Langerhans cell histiocytosis and literature review. Zhong Nan Da Xue Xue Bao Yi Xue Ban 2022; 47:334-343. [PMID: 35545326 PMCID: PMC10930052 DOI: 10.11817/j.issn.1672-7347.2022.210581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Pulmonary Langerhans cell histiocytosis (PLCH) is a clonal disease, characterized by proliferation of Langerhans cells that derived from bone marrow infiltrating the lungs and other organs. Due to the rarity of the disease, the current understanding of the disease is insufficient, often misdiagnosed or missed diagnosis. This study aims to raise clinicians' awareness for this disease via summarizing the clinical characteristics, imaging features, and treatment of PLCH. METHODS We retrospectively analyzed clinical and follow-up data of 15 hospitalized cases of PLCH from September 2012 to June 2021 in the Second Xiangya Hospital of Central South University. RESULTS The age of 15 patients (9 men and 6 women, with a sex ratio of 3 to 2) was 21-52 (median 33) years. Among them, 8 had a history of smoking and 5 suffered spontaneous pneumothorax during disease course. There were 3 patients with single system PLCH and 12 patients with multi-system PLCH, including 7 patients with pituitary involvement, 7 patients with lymph node involvement, 6 patients with bone involvement, 5 patients with liver involvement, 2 patients with skin involvement, 2 patients with thyroid involvement, and 1 patients with thymus involvement. The clinical manifestations were varied but non-specific. Respiratory symptoms mainly included dry cough, sputum expectoration, chest pain, etc. Constitutional symptoms included fever and weight loss. Patients with multi-system involvement experienced symptoms such as polyuria-polydipsia, bone pain, and skin rash. All patients were confirmed by pathology, including 6 by lung biopsy, 3 by bone biopsy, 2 by lymph node biopsy, and 4 by liver, skin, suprasternal fossa tumor, or pituitary stalk biopsy. The most common CT findings from this cohort of patients were nodules and/or cysts and nodular and cystic shadows were found in 7 patients. Three patients presented simple multiple cystic shadows, 3 patients presented multiple nodules, and 2 patients presented with single nodules and mass shadows. Pulmonary function tests were performed in 4 patients, ventilation dysfunction was showed in 2 patients at the first visit. Pulmonary diffusion function tests were performed in 4 patients and showed a decrease in 3 patients. Smoking cessation was recommended to PLCH patients with smoking history. Ten patients received chemotherapy while 2 patients received oral glucocorticoid therapy. Among the 11 patients with the long-term follow-up, 9 were in stable condition. CONCLUSIONS PLCH is a neoplastic disease closely related to smoking. The clinical manifestations and laboratory examination are not specific. Pneumothorax could be the first symptom which is very suggestive of the disease. Definitive diagnosis relies on histology. There is no unified treatment plan for PLCH, and individualized treatment should be carried out according to organ involvement. Early smoking cessation is essential. Chemotherapy is the main treatment for rapidly progressing PLCH involved multiple organs. All diagnosed patients can be considered for the detection of BRAFV600E gene and relevant targeted therapies have been implemented recently.
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Affiliation(s)
- Lianhua Zhang
- Department of Respiratory and Critical Care Medicine, Second Xiangya Hospital, Central South University, Changsha 410011, China.
| | - Ruoyun Ouyang
- Department of Respiratory and Critical Care Medicine, Second Xiangya Hospital, Central South University, Changsha 410011, China.
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12
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Xu W, Cui H, Liu H, Feng R, Tian X, Yang Y, Xu KF. The value of transbronchial lung biopsy in the diagnosis of lymphangioleiomyomatosis. BMC Pulm Med 2021; 21:146. [PMID: 33941134 PMCID: PMC8091759 DOI: 10.1186/s12890-021-01518-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 04/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Transbronchial lung biopsy (TBLB) in the diagnosis of lymphangioleiomyomatosis (LAM) is not a common approach, although TBLB is often performed in diffuse lung diseases. We aimed to examine the diagnostic value and safety of TBLB in LAM patients based on the data collected in our center. METHODS We reviewed LAM patients registered in our LAM Clinic from December 8, 2006, to December 31, 2019. All patients with definite or probable diagnosis of LAM who had been examined using TBLB were included. All available pathology slides were reviewed by an experienced LAM pathologist. All complications were reviewed by the medical records and confirmed using telephone interviews. RESULTS The pathology results of 86 patients (including 74 definite LAM and 12 probable LAM) were available. The positive rate of TBLB in LAM patients was 49/86 (57.0%). The positive rates of SMA, HMB-45, ER, and PR in LAM patients were 97.6%, 93%, 84.6%, and 78.4% respectively. The positive rate of TBLB was 40%, 60% and 60.8% in patients with CT Grade I, Grade II, and Grade III respectively, and the difference was not significant. Patients who had 3-4 or 5-6 biopsied specimens had a higher rate of diagnosis than those with 1-2 biopsied specimens. Four patients (5.6%) reported pneumothorax. No major hemoptysis was reported. CONCLUSIONS TBLB is a feasible and safe procedure for obtaining a pathological diagnosis of LAM. Taking more than 2 samples during the biopsy procedure increased the rate of diagnosis.
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Affiliation(s)
- Wenshuai Xu
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100730, China
| | - Han Cui
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100730, China.,Department of Pathophysiology, State Key Laboratory of Medical Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Hongrui Liu
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Ruie Feng
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Xinlun Tian
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100730, China
| | - Yanli Yang
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100730, China.
| | - Kai-Feng Xu
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100730, China.
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13
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Duquenne JB, Duysinx B, Radermecker M, Nchimi A, Louis R, Guiot J. [Cystic lung diseases]. Rev Mal Respir 2021; 38:257-268. [PMID: 33707116 DOI: 10.1016/j.rmr.2021.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 01/02/2021] [Indexed: 11/29/2022]
Abstract
Cystic lung diseases present uncommonly and have an undetermined incidence. Cysts result from a broad spectrum of causative mechanisms and diseases leading to variable clinical presentations. The pathogenic mechanisms that can lead to lung cyst formation include infection, neoplastic, systemic, traumatic, genetic and congenital processes. A rigorous, systemic and multidisciplinary approach is advised in the diagnostic workup of these conditions. In this article, we review cystic lung diseases including their presentation and management.
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Affiliation(s)
- J-B Duquenne
- Service de pneumologie, CHU Liège, Liège, Belgique.
| | - B Duysinx
- Service de pneumologie, CHU Liège, Liège, Belgique
| | - M Radermecker
- Service de chirurgie thoracique, CHU Liège, Liège, Belgique
| | - A Nchimi
- Service de radiologie, CH de Luxembourg ville, Luxembourg, Luxembourg
| | - R Louis
- Service de pneumologie, CHU Liège, Liège, Belgique
| | - J Guiot
- Service de pneumologie, CHU Liège, Liège, Belgique
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14
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Abstract
Pulmonary Langerhans cell (LC) histiocytosis (PLCH) has unknown cause and is a rare neoplastic disorder characterized by the infiltration of lungs and various organs by bone marrow-derived Langerhans cells with an accompanying strong inflammatory response. These cells carry somatic mutations of BRAF gene and/or NRAS, KRAS, and MAP2K1 genes, which cause activation of the mitogen-activated protein kinase (MAPK)/extracellular signal-regulated kinase (ERK) signaling pathway. PLCH occurs predominantly in young smokers, without gender predominance. Lungs might be involved as an isolated organ or as part of a multiorgan disease. High-resolution computed chest tomography plays an outstanding role in PLCH diagnosis. The typical radiological picture of PLCH is the presence of small intralobular nodules, “tree in bud” opacities, cavitated nodules, and thin- and thick-walled cysts, frequently confluent. Histological examination of the lesion and demonstration of characteristic eosinophilic granulomas with the presence of LCs that display antigen CD1a or CD207 in immunohistochemistry are required for definite diagnosis. Smoking cessation is the most important recommendation for PLCH patients, but treatment of progressive PLCH and multisystem disease is based on chemotherapy. Recently, new targeted therapies have been implemented.
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Affiliation(s)
- Elzbieta Radzikowska
- III Department of Lung Diseases and Oncology, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland
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15
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Keane RJ, Subramaniam A, Varghese C, Jeffers M, Donnelly SC. Initial presentation of Pulmonary Langerhans cell histiocytosis as recurrent spontaneous pneumothoraces. Respir Med Case Rep 2020; 31:101280. [PMID: 33209579 DOI: 10.1016/j.rmcr.2020.101280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/19/2020] [Accepted: 11/02/2020] [Indexed: 11/22/2022] Open
Abstract
Pulmonary Langerhans cell histiocytosis (PLCH) is a rare cystic lung disease. The natural history is often unpredictable making it difficult to diagnose. We report a 63-year-old male with dyspnoea, chronic cough and recurrent respiratory tract infections, who developed progressive multifocal cystic lesions on pulmonary nodule surveillance over 4 years. He was a heavy smoker with a history of multiple spontaneous pneumothoraces in his teens. Extensive investigations culminated in a thoracoscopic wedge resection, which identified histiocytic nodules staining positive for CD1a and thus confirming the diagnosis of PLCH. It is now apparent that PLCH was the likely cause of his pneumothoraces. PLCH is difficult to diagnose due to its heterogeneous presentation and insidious natural history. PLCH is a cause of recurrent pneumothoraces, and almost exclusively in smokers. PLCH usually has innumerable cystic lesions that progress in a nodulocystic pattern. CD1 antigen is characteristic of PLCH as it is uniquely expressed in Langerhans-like dendritic cells. Smoking cessation is an effective first line monotherapy for PLCH.
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16
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Abstract
Diffuse cystic lung diseases include a group of heterogeneous disorders characterised by the presence of cysts within the lung parenchyma, sometimes showing a characteristic computed tomography scan pattern that allows diagnosis. The pathogenetic mechanisms underlying cyst formation in the lung are still not clear and a number of hypotheses have been postulated according to the different aetiologies: ball-valve effect, ischaemic dilatation of small airways and alveoli related to infiltration and obstruction of small vessels and capillaries that supply the terminal bronchioles and connective tissue degradation by matrix metalloproteases. A wide number of lung cyst diseases have been classified into six diagnostic groups according to the aetiology: neoplastic, congenital/genetic, lymphoproliferative, infective, associated with interstitial lung diseases, and other causes. This article focuses on lymphangioleiomyomatosis, pulmonary Langerhans cell histiocytosis and Erdheim–Chester disease, Birt–Hogg–Dubé, follicular bronchiolitis and lymphocytic interstitial pneumonia, light-chain deposition disease and amyloidosis, congenital lung disease associated with aberrant lung development and growth, and cystic lung disease associated with neoplastic lesion. These cystic diseases are epidemiologically considered as ultra-rare conditions as they affect fewer than one individual per 50 000 or fewer than 20 individuals per million. Despite the rarity of this group of disorders, the increasing use of high-resolution computed tomography has improved the diagnostic yield, even in asymptomatic patients allowing prompt and correct therapy and management without the need for a biopsy. Diffuse cystic lung diseases show a characteristic CT scan pattern that often allows for diagnosis, even in asymptomatic patients, allowing prompt correct therapy and management without the needing of a biopsyhttps://bit.ly/2wIUKet
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17
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Zaidi A, Kaur H, Gupta P, Gupta N, Srinivasan R, Dey P, Rohilla M, Rajwanshi A, Bal A, Agarwal R. Role of bronchoalveolar lavage in diagnosing pulmonary infections and malignancies: Experience from a tertiary care center. Diagn Cytopathol 2020; 48:1290-1299. [PMID: 32770787 DOI: 10.1002/dc.24574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 06/29/2020] [Accepted: 07/20/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND Bronchoalveolar lavage (BAL), is a safe, minimally invasive procedure to sample the terminal airways and the lung parenchyma. Although frequently used, there is lack of contemporary literature regarding the diagnostic utility of BAL for various pulmonary diseases. This study was conducted to evaluate the utility of BAL in diagnosis of various pulmonary pathologies, both infectious and neoplastic. METHODS This was a retrospective study performed over a period of 2 years. All the BAL samples reported on cytology were studied, their clinical details were retrieved, and the corresponding smears were reviewed. Cyto-histopathologic correlation was done, wherever possible. RESULTS There were a total of 1835 cases (1153 men, 682 women; age, 8 months to 78 years). Of these, 19 (1%) cases were assessed as inadequate for opinion. In 348 (19%) cases, specific infective cause could be identified on BAL cytology alone. Tuberculosis and fungal infections could be diagnosed in 165 (9%) and 178 (9.7%) cases respectively. There were 46 (2.5%) neoplasms, including adenocarcinoma (n = 20), squamous cell carcinoma (n = 5), small cell carcinoma (n = 2), Langerhans cell histiocytosis (n = 1), suspicious for malignancy (n = 15) and metastatic carcinoma (n = 3). Some rare diagnoses were also reported on BAL cytology, including sarcoidosis, actinomycosis, leishmaniasis, pulmonary alveolar proteinosis and metastatic papillary carcinoma of the thyroid. CONCLUSION BAL is a safe and useful procedure for primary diagnosis of infections such as tuberculosis and fungal infections, which has special significance in developing nations where prevalence of such infections is high. In addition, BAL has the potential to diagnose both primary as well as secondary malignant lung lesions.
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Affiliation(s)
- Ariba Zaidi
- Department of Pathology, PGIMER, Chandigarh, India
| | | | - Parikshaa Gupta
- Department of Cytology and Gynecologic Pathology, PGIMER, Chandigarh, India
| | - Nalini Gupta
- Department of Cytology and Gynecologic Pathology, PGIMER, Chandigarh, India
| | - Radhika Srinivasan
- Department of Cytology and Gynecologic Pathology, PGIMER, Chandigarh, India
| | - Pranab Dey
- Department of Cytology and Gynecologic Pathology, PGIMER, Chandigarh, India
| | - Manish Rohilla
- Department of Cytology and Gynecologic Pathology, PGIMER, Chandigarh, India
| | - Arvind Rajwanshi
- Department of Cytology and Gynecologic Pathology, PGIMER, Chandigarh, India
| | - Amanjit Bal
- Department of Pathology, PGIMER, Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, PGIMER, Chandigarh, India
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18
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Abstract
Paediatric pulmonary Langerhans cell histiocytosis (pPLCH) is a rare diffuse cystic lung disease. Unlike pulmonary Langerhans cell histiocytosis (LCH) in adults, which is often seen as an isolated condition with smoking being a major risk factor, isolated pPLCH is vanishingly rare in children and it is most often a component of multisystem LCH. Diagnosis should be based on histological and immunophenotypic examination of affected tissue in addition to clinical and radiological features. It should be considered an important differential for diffuse cystic lung disease in paediatric patients. Recent progress in the biological understanding of the disease supports the classification of LCH as an inflammatory myeloid neoplasia. Chemotherapy and specific management of respiratory complications are the mainstays of treatment. The lungs are no longer considered a "risk organ" in LCH as pulmonary involvement is not associated with a worse prognosis than the involvement of other organs. Multidisciplinary treatment approaches are needed. Prognosis can be good but is adversely influenced by multisystem involvement, and complications such as pneumothoraces and respiratory failure can be life threatening. This review aims to give an overview of this condition, with a focus on the diagnosis, monitoring and management of complications such as pneumothoraces and respiratory failure, which can be challenging for the paediatric respiratory specialist. EDUCATIONAL AIMS To give an overview of paediatric pulmonary LCH.To discuss the differential diagnosis of paediatric cystic lung disease.
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Affiliation(s)
- Mhairi Barclay
- Paediatric Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Rebecca Devaney
- Paediatric Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jayesh. M. Bhatt
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
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19
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Okamoto S, Suzuki K, Hayashi T, Muraki K, Nagaoka T, Nishino K, Sekimoto Y, Sasaki S, Takahashi K, Seyama K. Transbronchial lung biopsy for the diagnosis of lymphangioleiomyomatosis: the severity of cystic lung destruction assessed by the modified Goddard scoring system as a predictor for establishing the diagnosis. Orphanet J Rare Dis 2020; 15:125. [PMID: 32456649 PMCID: PMC7249378 DOI: 10.1186/s13023-020-01409-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 05/14/2020] [Indexed: 11/25/2022] Open
Abstract
Background A guide of patient selection for establishing the diagnosis of lymphangioleiomyomatosis (LAM) by transbronchial lung biopsy (TBLB) has not been established, although the pathological confirmation of LAM by lung biopsy is desirable, particularly when patients have no additional test results except typical findings of computed tomography (CT) of the chest. Methods We retrospectively reviewed the medical records of LAM patients who visited at our hospital from January 2010 to September 2018. We found 19 patients who underwent TBLB and collected the following data to investigate which parameters could predict the TBLB diagnostic positivity for LAM: age, degree of exertional dyspnea, pulmonary function test, cystic lung destruction visually assessed by the modified Goddard scoring system (MGS), serum level of vascular endothelial growth factor-D, and TBLB-related data. Results The diagnosis of LAM was established by TBLB in 15 of 19 patients (78.9%) and no serious complications occurred. MGS was significantly higher in the TBLB-positive group than the TBLB-negative group. In LAM patients without pulmonary lymphatic congestion on CT (N = 16), multivariable logistic regression analysis revealed that MGS and FEV1/FVC were independent contributing parameters for TBLB diagnostic positivity. However, the analysis of Bayesian inference demonstrated that MGS is a better predictor than FEV1/FVC; the probability of establishing diagnosis exceeds 80% if MGS is > 2 (i.e., area of cystic destruction occupies > 25% of lung parenchyma on CT). Conclusions MGS may be a helpful and convenient tool to select candidates for TBLB to establish the diagnosis of LAM pathologically.
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Affiliation(s)
- Shouichi Okamoto
- Division of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, Japan. .,The Study Group for Pneumothorax and Cystic Lung Diseases, 4-8-1 Seta, Setagaya-ku, Tokyo, Japan.
| | - Kazuhiro Suzuki
- The Study Group for Pneumothorax and Cystic Lung Diseases, 4-8-1 Seta, Setagaya-ku, Tokyo, Japan.,Division of Radiology, Juntendo University Faculty of Medicine and Graduate School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Takuo Hayashi
- The Study Group for Pneumothorax and Cystic Lung Diseases, 4-8-1 Seta, Setagaya-ku, Tokyo, Japan.,Division of Human Pathology, Juntendo University Faculty of Medicine and Graduate School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Keiko Muraki
- Division of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Tetsutaro Nagaoka
- Division of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Koichi Nishino
- Division of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, Japan.,The Study Group for Pneumothorax and Cystic Lung Diseases, 4-8-1 Seta, Setagaya-ku, Tokyo, Japan
| | - Yasuhito Sekimoto
- Division of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, Japan.,The Study Group for Pneumothorax and Cystic Lung Diseases, 4-8-1 Seta, Setagaya-ku, Tokyo, Japan
| | - Shinichi Sasaki
- Division of Respiratory Medicine, Juntendo Urayasu Hospital, 2-1-1 Tomioka Urayasu-shi, Chiba, Japan
| | - Kazuhisa Takahashi
- Division of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Kuniaki Seyama
- Division of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, Japan.,The Study Group for Pneumothorax and Cystic Lung Diseases, 4-8-1 Seta, Setagaya-ku, Tokyo, Japan
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20
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Abstract
A 25-year-old male is admitted with complaints of dry cough for the past 5 years, and increased thirst, urinary frequency and output for the past 18 months. He also complains of shortness of breath on climbing a flight of stairs, and itchy lesions on the scalp and back for the past 2–3 months. There is no history of bone pain or abdominal pain. He has history of bilateral recurrent pneumothoraxes, twice on the right and once on the left side, in the past month. Pleurodesis with povidone iodine is performed on left side and the patient is transferred to your hospital with persistent right pneumothorax with air leak, with an intercostal drainage tube in situ. The patient is a never-smoker with no family history of pneumothorax. On general examination, he has small papules, 1–2 mm in diameter, with scaling over scalp and back. Onycholysis, onychoschisis and subungual splinter haemorrhages are present (figure 1). The causes of cystic lung diseases are varied. Proper evaluation is required for appropriate management.http://bit.ly/37J7dvE
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Affiliation(s)
- Kunal Deokar
- Dept of Pulmonary Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Ram Niwas
- Dept of Pulmonary Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Nishant Chauhan
- Dept of Pulmonary Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Naveen Dutt
- Dept of Pulmonary Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Priyank Jain
- Dept of Pulmonary Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Shahir Asfahan
- Dept of Pulmonary Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Rajani Kumawat
- Dept of Biochemistry, All India Institute of Medical Sciences, Jodhpur, India
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21
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Khaliq MF, Noorani MM, Tariq SM, Koirala A, Mohamed H. Pulmonary Langerhans Cell Histiocytosis Associated with Bronchogenic Carcinoma. Cureus 2020; 12:e6634. [PMID: 32064207 PMCID: PMC7011584 DOI: 10.7759/cureus.6634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Pulmonary Langerhans cell histiocytosis (PLCH, pulmonary eosinophilic granuloma) is a rare disease of clonal dendritic cells that primarily affects adults who smoke cigarettes. PLCH association with other malignancies is rarely reported. Herein, an unusual case of PLCH is presented with synchronous lung adenocarcinoma. A 76-year-old woman and chronic smoker was admitted for persistent dyspnea and productive cough, and had a left lower lung mass detected by computed tomography. She underwent bronchoscopy with biopsies. Histopathological analysis was negative, but cultures grew Mycobacterium avium complex. She subsequently underwent lobectomy and was found to have papillary adenocarcinoma with PLCH in the surrounding lung nodules.
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Affiliation(s)
- Muhammad F Khaliq
- Internal Medicine, Charleston Area Medical Center, West Virginia University-Charleston Division, Charleston, USA
| | | | - Syed Maaz Tariq
- Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | - Ashish Koirala
- Internal Medicine: Pulmonology/Critical Care, West Virginia University School of Medicine, Morgantown, USA
| | - Hesham Mohamed
- Internal Medicine: Pulmonology/Critical Care, Charleston Area Medical Center, Charleston, USA
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Sousa C, Rodrigues M, Carvalho A, Viamonte B, Cunha R, Guimarães S, de Moura CS, Morais A, Pereira JM. Diffuse smoking-related lung diseases: insights from a radiologic-pathologic correlation. Insights Imaging 2019; 10:73. [PMID: 31312909 DOI: 10.1186/s13244-019-0765-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 07/02/2019] [Indexed: 01/12/2023] Open
Abstract
Cigarettes are well-recognized risk factors responsible for the emergence of a variety of pathologic conditions affecting both the airways and the lungs. Smoking-related lung diseases can be classified as chronic obstructive pulmonary disease (COPD) and several types of interstitial diseases, such as pulmonary Langerhans cell histiocytosis, bronchiolitis, desquamative interstitial pneumonitis, acute eosinophilic pneumonia, and interstitial fibrosing lung diseases. The evidence of combined lower lung fibrosis and predominant upper lung emphysema is renowned as a distinct clinical entity, named combined pulmonary fibrosis and emphysema. Although computerized tomography permits an adequate classification and distinction of these diseases, the clinical, imaging, and histological features often overlap and coexist in a single patient. Therefore, a combined radiologic and pathologic approach, in the appropriate clinical setting, is useful for best comprehension and distinction of these entities. Our goals are to describe the imaging features in smoking-related lung diseases and how the pathological manifestations translate on high-resolution computerized tomography.
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Abstract
PURPOSE OF REVIEW Diffuse cystic lung diseases (DCLDs) are a heterogeneous group of disorders with varying pathophysiologic mechanisms that are characterized by the presence of air-filled lung cysts. These cysts are prone to rupture, leading to the development of recurrent spontaneous pneumothoraces. In this article, we review the epidemiology, clinical features, and management DCLD-associated spontaneous pneumothorax, with a focus on lymphangioleiomyomatosis, Birt-Hogg-Dubé syndrome, and pulmonary Langerhans cell histiocytosis. RECENT FINDINGS DCLDs are responsible for approximately 10% of apparent primary spontaneous pneumothoraces. Computed tomography screening for DCLDs (Birt-Hogg-Dubé syndrome, lymphangioleiomyomatosis, and pulmonary Langerhans cell histiocytosis) following the first spontaneous pneumothorax has recently been shown to be cost-effective and can help facilitate early diagnosis of the underlying disorders. Patients with DCLD-associated spontaneous pneumothorax have a very high rate of recurrence, and thus pleurodesis should be considered following the first episode of spontaneous pneumothorax in these patients, rather than waiting for a recurrent episode. Prior pleurodesis is not a contraindication to future lung transplant. SUMMARY Although DCLDs are uncommon, spontaneous pneumothorax is often the sentinel event that provides an opportunity for diagnosis. By understanding the burden and implications of pneumothoraces in DCLDs, clinicians can facilitate early diagnosis and appropriate management of the underlying disorders.
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Kumar A, Cherian SV, Vassallo R, Yi ES, Ryu JH. Current Concepts in Pathogenesis, Diagnosis, and Management of Smoking-Related Interstitial Lung Diseases. Chest 2018; 154:394-408. [PMID: 29222007 DOI: 10.1016/j.chest.2017.11.023] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 11/01/2017] [Accepted: 11/26/2017] [Indexed: 11/21/2022] Open
Abstract
Tobacco exposure results in various changes to the airways and lung parenchyma. Although emphysema represents the more common injury pattern, in some individuals, cigarette smoke injures alveolar epithelial cells and other lung cells, resulting in diffuse infiltrates and parenchymal fibrosis. Smoking can trigger interstitial injury patterns mediated via recruitment and inappropriate persistence of myeloid and other immune cells, including eosinophils. As our understanding of the role of cigarette smoke constituents in triggering lung injury continues to evolve, so does our recognition of the spectrum of smoking-related interstitial lung changes. Although respiratory bronchiolitis-interstitial lung disease, desquamative interstitial pneumonia, pulmonary Langerhans cell histiocytosis, and acute eosinophilic pneumonia have a well-established association with tobacco use, its role and impact on idiopathic pulmonary fibrosis, combined pulmonary fibrosis and emphysema, and connective tissue disease-related interstitial lung diseases is still ambiguous. Smoking-related interstitial fibrosis is a relatively newly appreciated entity with distinct histopathologic features but with unclear clinical ramifications. Increased implementation of lung cancer screening programs and utilization of CT scans in thoracic imaging have also resulted in increased identification of "incidental" or "subclinical" interstitial lung changes in smokers, the ensuing impact of which remains to be studied.
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25
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Gupta N, Finlay GA, Kotloff RM, Strange C, Wilson KC, Young LR, Taveira-DaSilva AM, Johnson SR, Cottin V, Sahn SA, Ryu JH, Seyama K, Inoue Y, Downey GP, Han MK, Colby TV, Wikenheiser-Brokamp KA, Meyer CA, Smith K, Moss J, McCormack FX. Lymphangioleiomyomatosis Diagnosis and Management: High-Resolution Chest Computed Tomography, Transbronchial Lung Biopsy, and Pleural Disease Management. An Official American Thoracic Society/Japanese Respiratory Society Clinical Practice Guideline. Am J Respir Crit Care Med 2017; 196:1337-1348. [PMID: 29140122 DOI: 10.1164/rccm.201709-1965st] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Recommendations regarding key aspects related to the diagnosis and pharmacological treatment of lymphangioleiomyomatosis (LAM) were recently published. We now provide additional recommendations regarding four specific questions related to the diagnosis of LAM and management of pneumothoraces in patients with LAM. METHODS Systematic reviews were performed and then discussed by a multidisciplinary panel. For each intervention, the panel considered its confidence in the estimated effects, the balance of desirable (i.e., benefits) and undesirable (i.e., harms and burdens) consequences, patient values and preferences, cost, and feasibility. Evidence-based recommendations were then formulated, written, and graded using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. RESULTS For women who have cystic changes on high-resolution computed tomography of the chest characteristic of LAM, but who have no additional confirmatory features of LAM (i.e., clinical, radiologic, or serologic), the guideline panel made conditional recommendations against making a clinical diagnosis of LAM on the basis of the high-resolution computed tomography findings alone and for considering transbronchial lung biopsy as a diagnostic tool. The guideline panel also made conditional recommendations for offering pleurodesis after an initial pneumothorax rather than postponing the procedure until the first recurrence and against pleurodesis being used as a reason to exclude patients from lung transplantation. CONCLUSIONS Evidence-based recommendations for the diagnosis and treatment of patients with LAM are provided. Frequent reassessment and updating will be needed.
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Daccord C, Nicod L, Lazor R. Cystic Lung Disease in Genetic Syndromes with Deficient Tumor Suppressor Gene Function. Respiration 2017; 94:467-485. [DOI: 10.1159/000485106] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 11/09/2017] [Indexed: 12/28/2022] Open
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Mittal S, Jain A, Arava S, Hadda V, Mohan A, Guleria R, Madan K. A 26-year-old man with dyspnea and chest pain. Lung India 2017; 34:562-566. [PMID: 29099006 PMCID: PMC5684818 DOI: 10.4103/lungindia.lungindia_111_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
A 26-year-old smoker male presented with a history of sudden onset dyspnea and right-sided chest pain. Chest radiograph revealed large right-sided pneumothorax which was managed with tube thoracostomy. High-resolution computed tomography thorax revealed multiple lung cysts, and for a definite diagnosis, a video-assisted thoracoscopic surgery-guided lung biopsy was performed followed by pleurodesis. This clinicopathologic conference discusses the clinical and radiological differential diagnoses, utility of lung biopsy, and management options for patients with such a clinical presentation.
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Affiliation(s)
- Saurabh Mittal
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Akanksha Jain
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Sudheer Arava
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Vijay Hadda
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Anant Mohan
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Randeep Guleria
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Karan Madan
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
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Torre O, Elia D, Caminati A, Harari S. New insights in lymphangioleiomyomatosis and pulmonary Langerhans cell histiocytosis. Eur Respir Rev 2017; 26:26/145/170042. [PMID: 28954765 PMCID: PMC9488980 DOI: 10.1183/16000617.0042-2017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 07/26/2017] [Indexed: 12/15/2022] Open
Abstract
Lymphangioleiomyomatosis (LAM) and pulmonary Langerhans cell histiocytosis (PLCH) are rare diseases that lead to progressive cystic destruction of the lungs. Despite their distinctive characteristics, these diseases share several features. Patients affected by LAM or PLCH have similar radiological cystic patterns, a similar age of onset, and the possibility of extrapulmonary involvement. In this review, the recent advances in the understanding of the molecular pathogenesis, as well as the current and most promising biomarkers and therapeutic approaches, are described. Understanding of LAM/PLCH pathogenesis has improved over the past years, leading to new therapeutic approacheshttp://ow.ly/7wjR30erSJY
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Affiliation(s)
- Olga Torre
- U.O. di Pneumologia e Terapia Semi-Intensiva Respiratoria, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, Ospedale San Giuseppe, MultiMedica IRCCS, Milan, Italy
| | - Davide Elia
- U.O. di Pneumologia e Terapia Semi-Intensiva Respiratoria, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, Ospedale San Giuseppe, MultiMedica IRCCS, Milan, Italy
| | - Antonella Caminati
- U.O. di Pneumologia e Terapia Semi-Intensiva Respiratoria, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, Ospedale San Giuseppe, MultiMedica IRCCS, Milan, Italy
| | - Sergio Harari
- U.O. di Pneumologia e Terapia Semi-Intensiva Respiratoria, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, Ospedale San Giuseppe, MultiMedica IRCCS, Milan, Italy
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Abstract
Pulmonary Langerhans cell histiocytosis (PLCH) is a rare sporadic cystic lung disease of unknown aetiology that is characterised by the infiltration and destruction of the wall of distal bronchioles by CD1a+ Langerhans-like cells. In adults, PLCH is frequently isolated and affects young smokers of both sexes. Recent multicentre studies have led to the more standardised management of patients in clinical practice. Smoking cessation is essential and is occasionally the only suitable intervention. Serial lung function testing is important because a significant proportion of patients may experience an early decline in forced expiratory volume in 1 s and develop airflow obstruction. Cladribine was reported to dramatically improve progressive PLCH in some patients. Its efficacy and tolerance are currently being evaluated. Patients who complain of unexplained dyspnoea with decreased diffusing capacity of the lung for carbon monoxide should be screened for pulmonary hypertension by Doppler echocardiography, which must be confirmed by right heart catheterisation. Lung transplantation is a therapeutic option for patients with advanced PLCH.The identification of the BRAFV600E mutation in approximately half of Langerhans cell histiocytosis lesions, including PLCH, and other mutations of the mitogen-activated protein kinase (MAPK) pathway in a subset of lesions has led to targeted treatments (BRAF and MEK (MAPK kinase) inhibitors). These treatments need to be rigorously evaluated because of their potentially severe side-effects.
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Affiliation(s)
- Gwenaël Lorillon
- National Reference Centre for Histiocytoses, Pulmonary Dept, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris, France
| | - Abdellatif Tazi
- National Reference Centre for Histiocytoses, Pulmonary Dept, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Paris, France .,University Paris Diderot, Sorbonne, Paris Cité, Inserm UMR-1153 (CRESS), Biostatistics and Clinical Epidemiology Research Team (ECSTRA), Paris, France
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30
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McCormack FX, Gupta N, Finlay GR, Young LR, Taveira-DaSilva AM, Glasgow CG, Steagall WK, Johnson SR, Sahn SA, Ryu JH, Strange C, Seyama K, Sullivan EJ, Kotloff RM, Downey GP, Chapman JT, Han MK, D'Armiento JM, Inoue Y, Henske EP, Bissler JJ, Colby TV, Kinder BW, Wikenheiser-Brokamp KA, Brown KK, Cordier JF, Meyer C, Cottin V, Brozek JL, Smith K, Wilson KC, Moss J. Official American Thoracic Society/Japanese Respiratory Society Clinical Practice Guidelines: Lymphangioleiomyomatosis Diagnosis and Management. Am J Respir Crit Care Med 2017; 194:748-61. [PMID: 27628078 DOI: 10.1164/rccm.201607-1384st] [Citation(s) in RCA: 189] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Lymphangioleiomyomatosis (LAM) is a rare cystic lung disease that primarily affects women. The purpose of these guidelines is to provide recommendations for the diagnosis and treatment of LAM. METHODS Systematic reviews were performed to summarize evidence pertinent to our questions. The evidence was summarized and discussed by a multidisciplinary panel. Evidence-based recommendations were then formulated, written, and graded using the Grading of Recommendations, Assessment, Development, and Evaluation approach. RESULTS After considering the panel's confidence in the estimated effects, the balance of desirable (i.e., benefits) and undesirable (i.e., harms and burdens) consequences of treatment, patient values and preferences, cost, and feasibility, recommendations were formulated for or against specific interventions. These included recommendations for sirolimus treatment and vascular endothelial growth factor D testing and recommendations against doxycycline and hormonal therapy. CONCLUSIONS Evidence-based recommendations for the diagnosis and treatment of patients with LAM are provided. Frequent reassessment and updating will be needed.
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31
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Vassallo R, Harari S, Tazi A. Current understanding and management of pulmonary Langerhans cell histiocytosis. Thorax 2017; 72:937-945. [PMID: 28689173 DOI: 10.1136/thoraxjnl-2017-210125] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 05/10/2017] [Accepted: 05/15/2017] [Indexed: 12/13/2022]
Abstract
Pulmonary Langerhans cell histiocytosis (PLCH) is a diffuse lung disease that usually affects young adult smokers. PLCH affects different lung compartments; bronchiolar, interstitial and pulmonary vascular dysfunction may coexist to varying extents, resulting in diverse phenotypes. Analyses of PLCH tissues have identified activating mutations of specific mitogen-activated protein kinases (BRAFV600E and others). The current consensus is that PLCH represents a myeloid neoplasm with inflammatory properties: the myeloid tumour cells exhibit surface CD1a expression and up to 50% of the cells harbour activating BRAF or other MAPK mutations. PLCH may be associated with multisystem disease. The detection of disease outside of the thorax is facilitated by whole body positron emission tomography. The natural history of PLCH is unpredictable. In some patients, disease may remit or stabilise following smoking cessation. Others develop progressive lung disease, often associated with evidence of airflow limitation and pulmonary vascular dysfunction. Due to the inability to accurately predict the natural history, it is important that all patients undergo longitudinal follow-up at least twice a year for the first few years following diagnosis. The treatment of PLCH is challenging and should be individualised. While there is no general consensus regarding the role of immunosuppression or chemotherapy in management, selected patients may experience improvement in lung function with therapy. Determination of BRAFV600E or other mutations may assist with the development of an individualised approach to therapy. Patients with progressive disease should be referred to specialised centres and considered for a trial of pharmacotherapy or evaluated for transplantation.
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Affiliation(s)
- Robert Vassallo
- Departments of Medicine, Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
| | - Sergio Harari
- U.O. di Pneumologia e Terapia Semi-Intensiva Respiratoria "Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, Ospedale San Giuseppe" Multimedica IRCCS, Milano, Italy
| | - Abdellatif Tazi
- Department of Pulmonary Medicine, Saint-Louis Hospital, National Reference Center for Langerhans Cell Histiocytosis, University Paris Diderot, Sorbonne Paris Cite, Inserm UMR-1153 (CRESS), Biostatistics and Clinical Epidemiology Research Team (ECSTRA), Paris, Ile-de-France, France
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33
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Abstract
CONTEXT Pulmonary Langerhans cell histiocytosis (PLCH) is a rare histiocytic disorder that almost exclusively affects the lungs of smokers. PLCH is characterized by bronchiolocentric nodules and/or cysts in an upper and mid lung distribution with sparing of the costophrenic angles. The diagnosis can be challenging and often requires transbronchial biopsy or surgical lung biopsy. Pulmonary hypertension is a relatively common and sometimes severe complication of PLCH. The pathogenesis of PLCH is still debated. Recently, BRAF V600E mutation and BRAF expression have been identified in some patients with PLCH, suggesting that at least a subset of PLCH has a clonal proliferation. While smoking cessation is the first-line treatment of PLCH, some patients might require additional treatment and eventually transplant. Given that the lesional cells of PLCH express BRAF in some patients, MAPKinase pathway-targeted treatment might be useful for therapy-resistant patients. OBJECTIVE To present the more recently recognized clinical and pathologic aspects of PLCH, including pulmonary hypertension in PLCH, pathogenesis, and treatment, as well as the basic diagnostic approach to PLCH. DATA SOURCES Authors' own research, and search of literature database (PubMed) and UpToDate. CONCLUSIONS Despite the recent progress, more studies are needed to elucidate the biology of PLCH for identification of prognostic factors and appropriate treatment options, especially for therapy-refractory PLCH cases.
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Affiliation(s)
- Anja C Roden
- From the Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, Rochester, Minnesota
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Abstract
INTRODUCTION Lymphangioleiomyomatosis (LAM) is a disease of women characterized by cystic lung destruction, lymphatic involvement, and renal angiomyolipomas. AREAS COVERED LAM is caused by proliferation of abnormal smooth muscle-like LAM cells containing mutations and perhaps epigenetic modifications of the TSC1 or TSC2 genes, which encode, respectively, hamartin and tuberin, two proteins controlling the mechanistic target of rapamycin (mTOR) signaling pathway. LAM occurs sporadically or in association with tuberous sclerosis complex. LAM may present with dyspnea, recurrent pneumothorax or chylothorax. Pulmonary function tests show reduced flow rates and lung diffusion capacity. Exercise testing may reveal hypoxemia and ventilatory limitation. The severity and progression of disease may be assessed by computer tomography, and pulmonary function and exercise testing. mTOR inhibitors, (e.g., sirolimus) are effective in stabilizing lung function, and reducing the size of chylous effusions, lymphangioleiomyomas, and angiomyolipomas. EXPERT OPINION Different clinical phenotypes including variable rates of disease progression and variable responses to therapy are seen in LAM patients. No one test is available that predicts the course of disease at the time of diagnosis. Further research regarding the molecular biology of LAM clinical phenotypes is warranted. Recent advances in the characterization of the pathogenesis of LAM are leading to the development of new therapies.
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Affiliation(s)
- Angelo M. Taveira-DaSilva
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10, Room 6D03, MSC 1590, Bethesda, Maryland 20892-1590, USA
| | - Joel Moss
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10, Room 6D03, MSC 1590, Bethesda, Maryland 20892-1590, USA
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35
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Chebib N, Khouatra C, Lazor R, Archer F, Leroux C, Gamondes D, Thivolet-Bejui F, Cordier JF, Cottin V. [Pulmonary lymphangioleiomyomatosis: From pathogenesis to management]. Rev Mal Respir 2015; 33:718-734. [PMID: 26604019 DOI: 10.1016/j.rmr.2015.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 10/06/2015] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Pulmonary lymphangioleiomyomatosis (LAM) is a rare disease affecting mainly young women. BACKGROUND The respiratory manifestations are characterized by a progressive cystic destruction of the lung parenchyma. Extrapulmonary involvement includes benign renal tumours called angiomyolipomas and abdominal lymphatic masses called lymphangioleiomyomas. At the pathological level, the cellular proliferation found in LAM is in part due to the presence of mutations in the tumour suppressor genes TSC1 and TSC2 (Tuberous Sclerosis Complex). These mutations lead to the activation of the mTOR pathway, which is currently the main therapeutic target. mTOR inhibitors such as sirolimus or everolimus have shown a beneficial effect on the decline in pulmonary function and a reduction of angiomyolipoma size, but are necessary in only some patients. PERSPECTIVES LAM cells have migratory properties mediated by the formation of new lymphatic vessels. They are also able to secrete metalloproteases, which enhance their invasiveness. Moreover, the expression of estrogen and progesterone receptors by LAM cells suggests a possible role for sex hormones in the pathogenesis of the disease. CONCLUSION A better understanding of mTOR-independent mechanisms would allow the development of novel therapeutic approaches.
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Affiliation(s)
- N Chebib
- Service de pneumologie, centre de référence des maladies pulmonaires rares, hôpital Louis-Pradel, hospices civils de Lyon, 8, avenue du Doyen-Lépine, 69677 Lyon cedex, France; UMR 754 Inra, université de Lyon, université Claude-Bernard Lyon 1, 69366 Lyon cedex, France
| | - C Khouatra
- Service de pneumologie, centre de référence des maladies pulmonaires rares, hôpital Louis-Pradel, hospices civils de Lyon, 8, avenue du Doyen-Lépine, 69677 Lyon cedex, France
| | - R Lazor
- Service de pneumologie, centre de référence des maladies pulmonaires rares, hôpital Louis-Pradel, hospices civils de Lyon, 8, avenue du Doyen-Lépine, 69677 Lyon cedex, France; Unité des pneumopathies interstitielles et maladies pulmonaires rares, service de pneumologie, centre hospitalier universitaire vaudois, 1011 Lausanne, Suisse
| | - F Archer
- UMR 754 Inra, université de Lyon, université Claude-Bernard Lyon 1, 69366 Lyon cedex, France
| | - C Leroux
- UMR 754 Inra, université de Lyon, université Claude-Bernard Lyon 1, 69366 Lyon cedex, France
| | - D Gamondes
- Service de radiologie, hôpital Louis-Pradel, hospices civils de Lyon, 69677 Lyon cedex, France
| | - F Thivolet-Bejui
- Centre de pathologie Est, groupement hospitalier Est, hospices civils de Lyon, 69677 Lyon cedex, France
| | - J F Cordier
- Service de pneumologie, centre de référence des maladies pulmonaires rares, hôpital Louis-Pradel, hospices civils de Lyon, 8, avenue du Doyen-Lépine, 69677 Lyon cedex, France; UMR 754 Inra, université de Lyon, université Claude-Bernard Lyon 1, 69366 Lyon cedex, France
| | - V Cottin
- Service de pneumologie, centre de référence des maladies pulmonaires rares, hôpital Louis-Pradel, hospices civils de Lyon, 8, avenue du Doyen-Lépine, 69677 Lyon cedex, France; UMR 754 Inra, université de Lyon, université Claude-Bernard Lyon 1, 69366 Lyon cedex, France.
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Abstract
The diffuse cystic lung diseases have a broad differential diagnosis. A wide variety of pathophysiological processes spanning the spectrum from airway obstruction to lung remodeling can lead to multifocal cyst development in the lung. Although lymphangioleiomyomatosis and pulmonary Langerhans cell histiocytosis are perhaps more frequently seen in the clinic, disorders such as Birt-Hogg-Dubé syndrome, lymphocytic interstitial pneumonia, follicular bronchiolitis, and light-chain deposition disease are increasingly being recognized. Obtaining an accurate diagnosis can be challenging, and management approaches are highly disease dependent. Unique imaging features, genetic tests, serum studies, and clinical features provide invaluable clues that help clinicians distinguish among the various etiologies, but biopsy is often required for definitive diagnosis. In part II of this review, we present an overview of the diffuse cystic lung diseases caused by lymphoproliferative disorders, genetic mutations, or aberrant lung development and provide an approach to aid in their diagnosis and management.
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Affiliation(s)
- Nishant Gupta
- 1 Division of Pulmonary, Critical Care, and Sleep Medicine and.,2 Veterans Affairs Medical Center, Department of Veterans Affairs, Cincinnati, Ohio
| | - Robert Vassallo
- 3 Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota; and
| | - Kathryn A Wikenheiser-Brokamp
- 4 Department of Pathology and Laboratory Medicine, University of Cincinnati, Cincinnati, Ohio.,5 Division of Pathology and Laboratory Medicine and.,6 Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Francis X McCormack
- 1 Division of Pulmonary, Critical Care, and Sleep Medicine and.,2 Veterans Affairs Medical Center, Department of Veterans Affairs, Cincinnati, Ohio
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Abstract
The diffuse cystic lung diseases (DCLDs) are a group of pathophysiologically heterogenous processes that are characterized by the presence of multiple spherical or irregularly shaped, thin-walled, air-filled spaces within the pulmonary parenchyma. Although the mechanisms of cyst formation remain incompletely defined for all DCLDs, in most cases lung remodeling associated with inflammatory or infiltrative processes results in displacement, destruction, or replacement of alveolar septa, distal airways, and small vessels within the secondary lobules of the lung. The DCLDs can be broadly classified according to underlying etiology as those caused by low-grade or high-grade metastasizing neoplasms, polyclonal or monoclonal lymphoproliferative disorders, infections, interstitial lung diseases, smoking, and congenital or developmental defects. In the first of a two-part series, we present an overview of the cystic lung diseases caused by neoplasms, infections, smoking-related diseases, and interstitial lung diseases, with a focus on lymphangioleiomyomatosis and pulmonary Langerhans cell histiocytosis.
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Affiliation(s)
- Nishant Gupta
- 1 Division of Pulmonary, Critical Care, and Sleep Medicine and.,2 Veterans Affairs Medical Center, Department of Veterans Affairs, Cincinnati, Ohio
| | - Robert Vassallo
- 3 Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota; and
| | - Kathryn A Wikenheiser-Brokamp
- 4 Department of Pathology and Laboratory Medicine, University of Cincinnati, Cincinnati, Ohio.,5 Division of Pathology and Laboratory Medicine and.,6 Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Francis X McCormack
- 1 Division of Pulmonary, Critical Care, and Sleep Medicine and.,2 Veterans Affairs Medical Center, Department of Veterans Affairs, Cincinnati, Ohio
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Margaritopoulos GA, Harari S, Caminati A, Antoniou KM. Smoking-related idiopathic interstitial pneumonia: A review. Respirology 2015; 21:57-64. [PMID: 26138798 DOI: 10.1111/resp.12576] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 12/09/2014] [Accepted: 05/06/2015] [Indexed: 01/02/2023]
Abstract
For many years, cigarette smoking has been considered as the leading cause of chronic obstructive pulmonary disease and lung cancer. Recently, however, it has also been associated with the development of diffuse interstitial lung diseases. In the latest classification of the major idiopathic interstitial pneumonias (IIP), the term smoking-related IIP has been introduced, including two entities, namely desquamative interstitial pneumonia (DIP) and respiratory bronchiolitis-interstitial lung disease (RB-ILD). Other entities in which smoking has a definite or suggested role include pulmonary Langerhan's cell histiocytosis, smoking-related interstitial fibrosis, combined pulmonary fibrosis and emphysema syndrome and idiopathic pulmonary fibrosis. In this review, we will focus on the mechanisms of smoking-related lung damage and on the clinical aspects of these disorders with the exception of idiopathic pulmonary fibrosis, which will be reviewed elsewhere in this review series.
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Affiliation(s)
- George A Margaritopoulos
- Department of Thoracic Medicine and Laboratory of Molecular and Cellular Pneumonology, Interstitial Lung Disease Unit, University Hospital of Heraklion, Heraklion, Greece.,Department of Respiratory Medicine, General Hospital of Kavala, Kavala, Greece
| | - Sergio Harari
- Respiratory Medicine and Semi-Intensive Therapy Unit, Respiratory Physiopathology and Pulmonary haemodynamics Services, San Giuseppe Hospital-Multimedica, Milan, Italy
| | - Antonella Caminati
- Respiratory Medicine and Semi-Intensive Therapy Unit, Respiratory Physiopathology and Pulmonary haemodynamics Services, San Giuseppe Hospital-Multimedica, Milan, Italy
| | - Katerina M Antoniou
- Department of Thoracic Medicine and Laboratory of Molecular and Cellular Pneumonology, Interstitial Lung Disease Unit, University Hospital of Heraklion, Heraklion, Greece
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Elia D, Torre O, Cassandro R, Caminati A, Harari S. Pulmonary Langerhans cell histiocytosis: a comprehensive analysis of 40 patients and literature review. Eur J Intern Med 2015; 26:351-6. [PMID: 25899682 DOI: 10.1016/j.ejim.2015.04.001] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 03/30/2015] [Accepted: 04/01/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pulmonary Langerhans cell histiocytosis (PLCH) is a rare interstitial disease affecting primarily young adult smokers. In order to highlight the clinical features of the disease, we conducted a retrospective analysis on clinical data of PLCH patients followed at our center; moreover, we reviewed the current literature on PLCH. METHOD AND RESULTS Between January 2004 and July 2014, 40 patients with PLCH were evaluated at our Division. The average patients' age was 40 (± 14) years, and 22 of them were females. Diagnosis was based on search of CD1a+ cells in the bronchoalveolar lavage (10 patients), lung biopsy (8 patients), or cystic bone lesion's biopsy (2 patients); in 12 patients, diagnosis was achieved on the basis of the clinical-radiological data. The principal manifestation of PLCH was the presence of cysts involving upper lung zones with costophrenic sparing on chest CT scan (in 25 patients); micronodular pattern in the middle-upper zone and combination of the two radiological patterns were less frequently observed (in 9 and 6 patients, respectively). Pulmonary hypertension was found in 4 patients. Extra pulmonary manifestations were diabetes insipidus, bone lesions, and skin involvement (in 5, 7, and 1 patient, respectively). For 25 patients, smoking cessation was the only required therapy. Treatments with low dose of prednisolone, vinblastine and prednisolone, or 6-mercaptopurin were reserved for patients with major pulmonary or extra-pulmonary involvement (for 11, 4, and 5 patients, respectively). In conclusion, PLCH is a rare, multi-systemic disease; early diagnosis, accurate staging and smoking cessation are considered critical in PLCH management.
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Affiliation(s)
- Davide Elia
- U.O. di Pneumologia e Terapia Semi-Intensiva, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare Ospedale San Giuseppe MultiMedica, via San Vittore 12, 20123 Milano, Italy
| | - Olga Torre
- U.O. di Pneumologia e Terapia Semi-Intensiva, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare Ospedale San Giuseppe MultiMedica, via San Vittore 12, 20123 Milano, Italy
| | - Roberto Cassandro
- U.O. di Pneumologia e Terapia Semi-Intensiva, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare Ospedale San Giuseppe MultiMedica, via San Vittore 12, 20123 Milano, Italy
| | - Antonella Caminati
- U.O. di Pneumologia e Terapia Semi-Intensiva, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare Ospedale San Giuseppe MultiMedica, via San Vittore 12, 20123 Milano, Italy
| | - Sergio Harari
- U.O. di Pneumologia e Terapia Semi-Intensiva, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare Ospedale San Giuseppe MultiMedica, via San Vittore 12, 20123 Milano, Italy.
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Abstract
Pulmonary Langerhans cell histiocytosis is a rare diffuse cystic interstitial pneumonia of unknown etiology that occurs selectively in young smokers of both genders. The multicenter studies conducted by the reference center have better defined the short and medium terms natural history of the disease and the clinical management of patients. A substantial proportion of patients experience a dramatic decline in their lung function soon after diagnosis. Importantly, smoking cessation is associated with a decreased risk of subsequent deterioration. Cladribine, a purine analogue, chemotherapy may dramatically improve lung function in patients with progressive pulmonary Langerhans cell histiocytosis, but this treatment should be used only in the setting of clinical research. Specific pulmonary hypertension therapies (anti-endothelin receptors, inhibitors of phosphodiesterases) may be used with caution in specialized centres for patients with severe pulmonary hypertension, and seem to be well tolerated. The recent identification of the V600E mutation of the BRAF oncogene in approximately half of the Langerhans cell histiocytosis lesions, including pulmonary granulomas, represents an important step forward in the understanding of the pathogenesis of Langerhans cell histiocytosis. Potentially it opens the way to targeted therapies.
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Affiliation(s)
- J Obert
- Service de pneumologie, Centre national de référence de l'histiocytose langerhansienne, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris, 1, avenue Claude-Vellefaux, 75475 Paris cedex 10, France
| | - A Tazi
- Service de pneumologie, Centre national de référence de l'histiocytose langerhansienne, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris, 1, avenue Claude-Vellefaux, 75475 Paris cedex 10, France; U1153 CRESS, équipe de recherche en biostatistiques et épidémiologie clinique, université Paris Diderot, Sorbonne Paris Cité, 75013 Paris, France.
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Abstract
Lymphangioleiomyomatosis (LAM) is a multisystem disease of women, characterized by proliferation of abnormal smooth muscle-like LAM cells, leading to the formation of lung cysts, fluid-filled cystic structures in the axial lymphatics (eg, lymphangioleiomyomas), and renal angiomyolipomas. LAM is caused by mutations of the TSC1 or TSC2 genes, which encode, respectively, hamartin and tuberin, two proteins with a major role in control of the mammalian target of rapamycin (mTOR) signaling pathway. LAM occurs sporadically or in association with tuberous sclerosis complex, an autosomal-dominant syndrome characterized by widespread hamartomatous lesions. LAM may present with progressive dyspnea, recurrent pneumothorax, or chylothorax. Pulmonary function tests show reduced flow rates (forced expiratory volume in the first second) and diffusion capacity. Exercise testing may reveal gas exchange abnormalities, ventilatory limitation, and hypoxemia. The severity and progression of disease may be assessed by lung histology scores, quantification of computed tomography, pulmonary function testing, 6-minute walk tests, cardiopulmonary exercise testing, and measurement of serum vascular endothelial growth factor D levels. Sirolimus and everolimus, two mTOR inhibitors, are effective in stabilizing lung function and reducing the size of chylous effusions, lymphangioleiomyo-mas, and angiomyolipomas. However, inhibition of mTOR complex 1 increases autophagy, possibly enhancing LAM cell survival. Inhibition of autophagy with hydroxychloroquine, in combination with sirolimus, has been proposed as a possible treatment for LAM. Deficiency of tuberin results in increased RhoA GTPase activity and cell survival, an effect that is mediated through mTOR complex 2 signaling. Because sirolimus and everolimus only affect the activity of mTOR complex 1, therapies targeting RhoA GTPases with simvastatin, which inhibits Rho GTPases and promotes apoptosis, are being investigated. As in the case of cancer, LAM may be best treated with multiple drugs targeting signaling pathways considered important in the pathogenesis of disease.
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Affiliation(s)
- Angelo M Taveira-DaSilva
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Joel Moss
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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Aburto M, Capelastegui A. [Pulmonary Langerhans' cell histiocytosis in adults: an unknown old disease]. Med Clin (Barc) 2014; 143:444-5. [PMID: 24747024 DOI: 10.1016/j.medcli.2014.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 02/06/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Myriam Aburto
- Servicio de Neumología, Hospital de Galdakao-Usansolo, Galdakao, Bizkaia, España
| | - Alberto Capelastegui
- Servicio de Neumología, Hospital de Galdakao-Usansolo, Galdakao, Bizkaia, España.
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Abstract
Lymphangioleiomyomatosis (LAM) is an uncommon disease presented as diffuse thin-walled cystic changes in the lung. The main differential diagnoses include pulmonary Langerhans’ histiocytosis (PLCH), Birt-Hogg-Dubé syndrome (BHD), lymphoid interstitial pneumonia (LIP), and amyloidosis. A combination of clinical, radiological, and pathological approaches as well as genetic testing will clarify the diagnosis in most cases. LAM is a disease almost exclusively in women. Dyspnea, pneumothorax, and hemoptysis are common presentations in LAM patients. LAM is also a lymphatic disorder affecting lymphatic vessels and lymph nodes. Chylothorax, chylous ascites, and lymphangiomyomas are frequently seen. LAM can present sporadically as a single entity or as part of tuberous sclerosis complex (TSC). Angiomyolipoma (AML) is a characteristic extra-pulmonary lesion, either found in association with sporadic or TSC-related LAM. High-risk populations should be screened for LAM, including adult women with TSC and female patients with spontaneous pneumothorax, AMLs in the kidney, and diffuse cystic lung diseases. Definitive diagnosis of LAM is based on a high level of clinical suspicion on presentation supported by pathological findings or by a distinct feature, such as a history of TSC, AMLs in the kidney, chylothorax, or chylous ascites. Vascular endothelial growth factor-D (VEGF-D) in serum is a noninvasive and reliable diagnostic biomarker. In experienced centers, trans-bronchial lung biopsy (TBLB) provides a convenient and safe way to obtain lung specimens for diagnostic purposes. An effective treatment for LAM is now available, namely using a mechanistic target of rapamycin (mTOR) inhibitor such as sirolimus. Efficacy of sirolimus has been confirmed in clinical trials. Research in other molecular-targeted therapies is under investigation. A previously little-known rare disease with no cure is now better understood with regards to its pathogenesis, diagnosis, and management. In this review, current knowledge in diagnosis and differential diagnosis of LAM will be discussed, followed by the discussion of therapy with mTOR inhibitors.
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Affiliation(s)
- Kai-Feng Xu
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Beijing, People's Republic of China
| | - Bee Hong Lo
- Developmental Pediatrician, PECAT, Children's Hospital Westmead, Sydney, NSW, Australia
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