[Pulmonary neuroendocrine neoplasms]

The pulmonary neuroendocrine neoplasms originate from the enterochromaffin cells which are diffusely distributed in the body. The incidence of these tumors has increased significantly in recent decades due to the available diagnostics. They make up about 1-2% of all lung tumors and 20-30% of all neuroendocrine neoplasms. The current WHO classification from 2004 divides them into typical carcinoids (TC), atypical carcinoids (AC), large cell neuroendocrine carcinomas (LCNEC) and small cell carcinomas (SCLC). The major neuroendocrine biomarkers are chromogranin A, synaptophysin and CD56. TC have a low mitotic rate of <2 mitoses/2mm(2) (10 HPF), whereas the mitotic rate of the AC is 2-10 mitoses/2 mm(2) (10 HPF). The Ki-67 staining is helpful to distinguish typical and atypical carcinoids from the highly malignant LCNEC and SCLC. Clinically, the patient presents usually with cough, hemoptysis or bronchial obstruction. The occurrence of a carcinoid or Cushing's syndrome and a tumor-associated acromegaly are rare. Surgical resection with radical lymph node dissection is the treatment of choice for achieving long-term survival. Endoscopic resection of the endobronchial tumor growth is a good alternative for inoperable endobronchially localized tumors. Peptide receptor radionuclide therapy (PRRT) is a promising treatment option for patients with metastatic or unresectable pulmonary neuroendocrine tumors. New targeted therapies using angiogenesis inhibitors, mTOR inhibitors, and tyrosine kinase inhibitors are being tested for their effectiveness in many previous studies. Typical carcinoid tumors metastasize less frequently than AC, the 5-year survival rate of patients with TC being over 90%. Patients with AC have a 5-year survival rate between 35% and 87%. The highly malignant LCNEC and SCLC, on the other hand, have a 5-year survival rate between 15% and 57%, and <5% respectively. The increasing number of therapeutic options and diagnostic procedures requires a multidisciplinary approach and decision-making in multidisciplinary tumor conferences to ensure a personalized treatment approach. Therefore patients with a neuroendocrine neoplasm of the lung should be treated in specialized centers.

[Expectoration of embolization coils 15 years after embolization of pulmonary arteriovenous malformations in a patient with hereditary hemorrhagic telangiectasia]

Hereditary hemorrhagic telangiectasia can manifest itself with pulmonary arteriovenous malformations (pavm). A transcatheter coil embolization should be made to avoid complications and to close off relevant arteriovenous shunts. We report on a patient with expectoration of embolization coils 15 years after embolotherapy. In case of hemoptysis following embolotherapy with coils, even years after their placement one should consider coil migration into the pulmonary system, besides newly formed pavms, in the differential diagnosis and initiate contrast-CT of the thorax and bronchoscopy.

[The respiratory therapist]

Because of the expected significant growth in the elderly population and respiratory diseases, the topic of "delegation of physician's duties" is of increasing importance to the German health-care system. In 2004 the German Respiratory Society (Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin e. V. (DGP)) established the new profession: respiratory therapist. A curriculum was defined which offers training for certified nurses and physiotherapists. Respiratory therapists evaluate, treat, document and care for patients with pulmonary disorders. Under appropriate supervision a licensed respiratory therapist performs some of the work previously done by physicians at the same quality of care. The first respiratory therapists have finished their professional training in Germany. Most of these respiratory therapists are now employed in hospital-based positions requiring their specific skills. Generally, the increased medical responsibility and the increased degree of decision-making possibilities associated with the new profession contribute to a better job satisfaction. However, this is not yet true for all the newly employed respiratory therapists. Only few of the new graduate respiratory therapists were awarded higher salaries. It is a strongly recommendation to the heads of medical departments and the human resources managers of hospitals that they should recognise the increased qualifications of nurses and physiotherapists who become respiratory therapists by appropriate remuneration.

[Respiratory therapist: introduction of a new profession]

Respiratory therapists are healthcare professionals taking care of patients with pulmonary disorders. They are an allied health specialty, practicing under medical direction. The professionalism of nurses and therapists must grow up to act successfully in new fields of medicine, where evidence-based independent action is necessary. Specialized therapists can help us coordinate separated processes (diagnoses, therapy and nursing). The profession "Respiratory Therapist" was created in the United States 50 years ago. We intend to introduce this profession also in Germany. We follow many other countries who have already taken this step. We hope that we can reach yet a higher quality of patient care.

[How are interstitial lung diseases diagnosed in Germany? Results of the scientific registry for the exploration of interstitial lung diseases ("Fibrosis registry") of the WATL]

From 1995 to 1999 we evaluated questionnaires sent by pulmonologists and departments of pulmonology in order to register interstitial lung diseases. On the whole 1142 patients (579 males, 563 females, mean age 51.1 +/- 15.3 years, sarcoidosis, n = 511, extrinsic allergic alveolitis, n = 145, idiopathic pulmonary fibrosis, n = 308, bronchiolitis obliterans organizing pneumonia (BOOP), n = 93, others, n = 85) were recorded in the registry. With reference to the mean age sarcoidosis occurred most frequently in the fourth decade and idiopathic pulmonary fibrosis in the sixth decade. In all these diseases bronchoscopy with bronchoalveolar lavage and transbronchial biopsy was predominantly used for further diagnosis. It was striking that high-resolution computed tomography of the thorax was still rarely used when diagnosing these diseases. Apart from the group with BOOP the number of non-smokers in men and women was decisively higher than the average of the population of Germany.

[CT-assisted transthoracic puncture of pulmonary lesions and mediastinal infiltrations. A retrospective study of 300 patients]

With this retrospective study we evaluated the results and the complications of our 343 CT-guided transthoracic biopsies, which we performed in 300 patients with localised and infiltrative lesions of the lung and the mediastinum during 4 years, using the VacuCut-needle in 96% of our cases. In 256 pts. bronchoscopy without final diagnosis was performed before transthoracic biopsy. In 219 pts. (73.0%) we had positive results. In 209 pts. with malignancies the positive rate was 73.7%. In patients with benign processes the positive rate was less (67.8%). Out of 32 pts, suffering from mediastinal lesions 29 had malignancies. In 79.3% positive results were obtained. The rate of complications was low (9%) in 311 biopsies of pulmonary lesions, most were pneumothoraces (7.7%). Haemorrhages occurred in 4 pts. (1.3%) 5 pts. (1.6%) required drainage because of pneumothorax. On the base of our good results and the low complication rate we recommend CT-guided transthoracic aspiration biopsy with the VacuCut-needle as a useful and accurate diagnostic technique.

[Tracheobronchomegaly--Mounier-Kuhn syndrome--case report and review of the literature]

Tracheobronchomegaly is a rare disorder. A marked dilatation of the trachea and the main stem bronchi is the characteristic sign measured as an enlarged transverse diameter (mean +/- 3 SD). Bronchiectasis is usual. In about one third of the published cases a diverticulosis was described as demonstrated in one our cases. For diagnostic modern radiological methods (CT including 3 D reconstruction, MRT) and bronchoscopy are recommended. The number and seize of the diverticula are documented by tracheography or by bronchography. In a part of all cases of tracheobronchomegaly the cause of the disorder is known. Therefore a division into congenital and acquired tracheobronchomegaly is useful.

[Incidence of collagenoses in patients with lung fibrosis]

In 63 out of 887 patients with alveolitis and pulmonary fibroses was causally found a so-called "collagenosis". A participation of the lung in such diseases is prognostically unfavourable. The changes in the framework of the lungs radiographically, functionally and morphologically cannot be separated from fibroses of other origin. The diagnosis is to be made after exclusion of other noxae and taking into consideration the appearances of the primary disease (clinic, spectrum of organs, special laboratory parameters etc.).