neumologia: update 2016 (cosecha del 15-‐16)

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NEUMOLOGIA :UPDATE 2016 (COSECHA DEL 15-‐16)

Josep Morera BARCELONA 3 Junio 2016

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CONTENIDO -‐  Tabaquismo -‐  Tos crónica -‐  EPOC -‐  Asma Bronquial -‐  Bronquiectasias -‐  Neumonía -‐  Tuberculosis -‐  Cáncer de Pulmón -‐  Fibrosis Pulmonar -‐  SLEEP –APNEA -‐ Conclusiones

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Tabaquismo The art of medicine The cigarePe catastrophe conQnues

The lancet Vol 385 March14,2015 Robert N Proctor

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Tabaquismo

To the Editor: In their nice editorial in the March issue of the Journal, Kiley and colleagues (1) list the strategic prioriRes and procedures of the NaRonal Heart, Lung, and Blood InsRtute (NHLBI) to streamline human health research up to 2025. From a historical perspecRve, we all recognize the significant achievements of the U.S. NaRonal InsRtutes of Health and the NHLBI, with decades of success, that have facilitated breakthroughs in promoRng health and fighRng disease by funding key research both internally and extramurally, including internaRonally. However, we were surprised that the (magical) keyword “tobacco” was not menQoned at all within this short document, so anyone might wonder, what if . . . the NHLBI considers tobacco? Likely, beyond your pages, some readers in the sister, simultaneous publicaRons in the American Journal of Public Health, Blood, CirculaRon, or the Journal of the American College of Cardiology might consider that tobacco affects paRents in most (all?) respiratory and nonrespiratory condiRons. We must keep reminding ourselves that tobacco is the first and foremost causal, avoidable risk factor for human disease. Perhaps it has been neglected too oaen in the past in many medical venues (2, 3). Therefore, the NHLBI should welcome iniRaRves on key tobacco-‐related translaRonal issues as well as on the efficacy and the effecRveness of any smoking reducRon and/or avoidance intervenRons, in addiRon to iniRaRves on any other risk factors to help define smoking issues at the populaRon and individual levels. Well past the so-‐called cigarede century (4), tobacco is sRll causally linked to an increasing number of diseases (5). Although there have been some recent successes in the West, there are more smokers nowadays than ever before in human history, causing far too many premature deaths and disabiliRes (6). We strongly believe that research drives all health advocacy and that the final soluRon to the tobacco problem will be through legislaRon (7). Rephrasing the introductory paragraphs of the editorial, “Imagine a world with no tobacco, and later, perhaps only one generaRon aaer, a no-‐tobacco-‐related-‐disease world.” Wouldn’t it be nice? We can set this objecRve within our lifeRme, and certainly we will parRcipate in this process (8). Volume 191, Issue 1(June 15, 2015) Soriano and Morera

What if . . . the NaQonal Heart, Lung, and Blood InsQtute Considers Tobacco? Joan B. Soriano M.D. and Josep Morera M.D.

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Tabaquismo

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Tabaquismo

Smoking and Mortality — Beyond Established Causes Brian D. Carter, ChrisRan C. Abnet, Diane Feskanich, Neal D. Freedman., Patricia Hartge, Sc.D., Cora E. Lewis, M.D., Judith K. Ockene, Ross L. PrenRce., Frank E. Speizer,, Michael J. Thun, and Eric J. Jacobs. N Engl J Med 2015; 372: February 12,

In conclusion, this comprehensive examinaRon of cause-‐specific mortality in a large contemporary populaRon idenRfied associaRons between smoking and increased mortality from several diseases that are not currently established as caused by smoking. Although these associaRons should be invesRgated further, our results suggest that the number of persons in the United States who die each year as a result of smoking cigaredes may be substanRally greater than currently esRmated.

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Tabaquismo

The impact of smoking on gender differences in life expectancy: more heterogeneous than ofen stated Marc Luy and ChrisRan Wegner-‐Siegmundt

Eur J Public Health. 2015 Aug

Smoking and survival afer breast cancer diagnosis in Japanese women: A prospecQve cohort study Yoichiro Kakugawa, Masaaki Kawai, Yoshikazu Nishino Kayoko Fukamachi, Takanori Ishida, Noriaki Ohuchi, and Yuko Minami Cancer Sci. 2015 Aug; 106(8): 1066–1074.

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Tos crónica

Pregabalin and Speech Pathology CombinaQon Therapy for Refractory Chronic Cough: A Randomized Controlled Trial. VerRgan AE1, Kapela SL2, Ryan NM3, Birring SS4, McElduff P5, Gibson PG6. Chest. 2016 Mar

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EPOC

Lung-‐FuncQon Trajectories Leading to Chronic ObstrucQve Pulmonary Disease. Lange P1, Celli B, Agusr A, Boje Jensen G, Divo M, Faner R, Guerra S, Marod JL, MarRnez FD, MarRnez-‐Camblor P, Meek P, Owen CA, Petersen H, Pinto-‐Plata V, Schnohr P, Sood A, Soriano JB, Tesfaigzi Y, Vestbo J.

N Engl J Med. 2015 Jul

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EPOC

FluQcasone furoate and vilanterol and survival in chronic obstrucQve pulmonary disease with heightened cardiovascular risk (SUMMIT): a double-‐blind randomised controlled trial Jorgen Vestbo, Julie A Anderson, Robert D Brook,Peter M A Calverley, B.Celli, Courtney Crim, Fernando MarRnez, Julie Yates, David E Newby, on behalf of the SUMMIT InvesRgators.

The lancet. April 2016

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EPOC

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EPOC

Indacaterol-‐Glycopyrronium versus Salmeterol-‐FluQcasone for COPD. Wedzicha JA1, Banerji D1, Chapman KR1, Vestbo J1, Roche N1, Ayers RT1, Thach C1, Fogel R1, Patalano F1, Vogelmeier CF1; FLAME InvesRgators. N Engl J Med. 2016 May 15

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EPOC

A SystemaQc Review With Meta-‐Analysis of Dual BronchodilaQon With LAMA/LABA for the Treatment of Stable COPD. Calzeda L, Rogliani P, Matera MG, Cazzola M. Chest. 2016 May

CONCLUSIONS: The gradient of effecRveness emerging from this meta-‐analysis is merely a weak indicator of possible differences between the various LAMA/LABA FDCs. Only direct comparisons will document if a specific LAMA/LABA FDC is beder than the other. In the meanwhile, we believe it is only proper to consider that dual bronchodilaRon is beder than a LAMA or a LABA alone, regardless of the drugs used.

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EPOC

The Asthma–COPD Overlap Syndrome Postma DS, Rabe KF. N Engl J Med 2015;373:1241-‐1249.

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EPOC

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Asma bronquial

Risk factors for asthma: is prevenQon possible? Beasley R, Semprini A, Mitchell EA. Lancet. 2015 Sep

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Asma bronquial

A systemaQc review of socioeconomic posiQon in relaQon to asthma and allergic diseases.Uphoff, Cabieses, Pinart, Valdés, Antó, Wright. Eur Respir J. 2015 Aug.

Seung of research conducted on asthma/allergies and socioeconomic posiRon. ISAAC: InternaRonal Study of Asthma and Allergies in Childhood.

Evidence from this systemaQc review suggests that asthma is associated with lower SEP, whereas the prevalence of allergies is associated with higher SEP.

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Asma bronquial

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Asma bronquial

Reduced AnQviral Interferon ProducQon in Poorly Controlled Asthma Is Associated With Neutrophilic InflammaQon and High-‐Dose Inhaled CorQcosteroids. Simpson JL, Carroll M, Yang IA, Reynolds PN, Hodge S, James AL, Gibson PG, Upham JW. Chest. 2016 Mar;

CONCLUSIONS: AnRviral type I IFN producRon is impaired in those with neutrophilic airway inflammaRon and in those prescribed high doses of inhaled corRcosteroids. Our study is an important step toward idenRfying those with poorly controlled asthma who might respond best to inhaled IFN therapy during exacerbaRons.

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Asma bronquial

PaPerns of Growth and Decline in Lung FuncQon in Persistent Childhood Asthma. McGeachie MJ, Yates KP, Zhou X, Guo F, Sternberg AL, Van Nada ML, Wise RA, Szefler SJ, Sharma S, Kho AT, Cho MH, Croteau-‐Chonka DC, Castaldi PJ, Jain G, Sanyal A, Zhan Y, Lajoie BR, Dekker J, Stamatoyannopoulos J, Covar RA, Zeiger RS, Adkinson NF, Williams PV, Kelly HW, Grasemann H, Vonk JM, Koppelman GH, Postma DS, Raby BA, Houston I, Lu Q, Fuhlbrigge AL, TanRsira KG, Silverman EK, Tonascia J, Weiss ST, Strunk RC; CAMP Research Group.

N Engl J Med. 2016 May 12

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Bronquiectasias

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Bronquiectasias

Expert Opin. Emerging Drugs (2015) 20(2)

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Neumonía

Community-‐acquired pneumonia. Prina E, Ranzani OT, Torres A Lancet. 2015 Sep 12;

Community-‐Acquired Pneumonia Requiring HospitalizaQon among U.S. Adults. Jain S1, Self WH, Wunderink RG, Fakhran S, Balk R, Bramley AM, Reed C, Grijalva CG, Anderson EJ, Courtney DM, Chappell JD, Qi C, Hart EM, Carroll F, Trabue C, Donnelly HK, Williams DJ, Zhu Y, Arnold SR, Ampofo K, Waterer GW, Levine M, Lindstrom S, Winchell JM, Katz JM, Erdman D, Schneider E, Hicks LA, McCullers JA, Pavia AT, Edwards KM, Finelli L; CDC EPIC Study Team. N Engl J Med. 2015 Jul 30;373(5):415-‐27.

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Tuberculosis

Treatment of Tuberculosis. Horsburgh CR Jr, Barry CE, Lange C. N Engl J Med. 2015 Nov 26;373(22):2149-‐60.

Tuberculosis. Dheda K, Barry CE, Maartens G. Lancet. 2016 Mar 19;387(10024):1211-‐26.

Adenocarcinoma

•  Mixed subtype •  Acinar •  Papillary •  Bronchioloalveolar •  Solid

•  Lepidic •  Acinar •  Papillary •  Micropapillary •  Solid •  Invasive •  Colloid •  Fetal •  Enteric •  Minimally invasive - MIA

–  Non-mucinous –  Mucinous

•  Preinvasive lesions –  Atypical adenomatous hyperplasia –  Adenocarcinoma in situ

•  Non mucinous •  Mucinous

2004 2015

International Agency for Research on Cancer 4th Edition

Cáncer de pulmón

Stage groups and subgroups according to TNM

Detterbeck et al. CHEST 2013; 143(5)(Suppl):e191S–e210S

Lung carcinoma stages (I and II)


Cáncer de pulmón

Lung carcinoma stages (III)


Cáncer de pulmón

Lung carcinoma stages (IV)


Cáncer de pulmón

IASLC lymph node map

Detterbeck et al. CHEST 2013;

Cáncer de pulmón

J Pathol 2014; 232: 121–133

Immuno-regulatory antibodies for the treatment of cancer. Honeychurch et al. Expert Opin Biol Ther. 2015 Jun;15(6):787-801.

PD-‐1-‐pathway blockers

Cáncer de pulmón

Cáncer de pulmón

A Bronchial Genomic Classifier for the DiagnosQc EvaluaQon of Lung Cancer. Silvestri GA, Vachani A, Whitney D, Elashoff M, Porta Smith K, Ferguson JS, Parsons E, Mitra N, Brody J, Lenburg ME, Spira A; AEGIS Study Team. N Engl J Med. 2015 Jul 16;373(3):

Conclusions: The gene-‐expression classifier improved the diagnosRc performance of bronchoscopy for the detecRon of lung cancer. In intermediate-‐risk paRents with a nondiagnosRc bronchoscopic examinaRon, a negaRve classifier score provides support for a more conservaRve diagnosRc approach.

Herth FJF, et al. Thorax 2015;70:326–332.

Cáncer de pulmón

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Cáncer de pulmón

Pembrolizumab versus docetaxel for previously treated, PD-‐L1-‐posiQve, advanced non-‐small-‐cell lung cancer (KEYNOTE-‐010): a randomised controlled trial. Herbst R, Baas P, Kim DW, Felip E, Pérez-‐Gracia JL, Han JY, Molina J, Kim JH, Arvis CD, Ahn MJ, Majem M, Fidler MJ, de Castro G Jr, Garrido M, Lubiniecki GM Shentu Y, Im E, Dolled-‐Filhart M, Garon EB Lancet. 2016 Apr

Nanotechnology in respiratory medicine Omlor et al. Respiratory Research (2015)

Cáncer de pulmón

Fibrosis pulmonar

CT staging and monitoring of fibroQc intersQQal lung diseases in clinical pracQce and treatment trials: a posiQon paper from the Fleischner Society. Hansell DM, Goldin JG, King TE Jr, Lynch DA, Richeldi L, Wells AU. Lancet Respir Med. 2015 Jun;3(6):483-‐96.

Fibrosis pulmonar

CT Imaging Phenotypes of Pulmonary Fibrosis in the MUC5B Promoter Site Polymorphism. Chung JH, Peljto AL, Chawla A, Talbert JL, McKean DF, Rho BH, Fingerlin TE, Schwarz MI, Schwartz DA, Lynch DA. Chest. 2016 May;149(5):1215-‐22.

ClassificaQon of usual intersQQal pneumonia in paQents with intersQQal lung disease: assessment of a machine learning approach using high-‐dimensional transcripQonal data. Kim SY, Diggans J, Pankratz D, Huang J, Pagan M, Sindy N, Tom E, Anderson J, Choi Y, Lynch DA, Steele MP, Flaherty KR, Brown KK, Farah H, Bukstein MJ, Pardo A, Selman M, Wolters PJ, Nathan SD, Colby TV, Myers JL, Katzenstein AL, Raghu G, Kennedy GC. Lancet Respir Med. 2015 Jun;3(6):473-‐82.

Fibrosis pulmonar

Drug Treatment of Idiopathic Pulmonary Fibrosis: SystemaQc Review and Network Meta-‐Analysis. Canestaro WJ, Forrester SH, Raghu G, Ho L, Devine BE

Chest. 2016 Mar;149(3):756-‐66.

CONCLUSIONS: Although two treatments have been approved for IPF on the basis of reduced decline in pulmonary funcRon, neither one has a clear advantage on mortality outcomes.

Sleep -‐Apnea

AdapQve Servo-‐VenQlaQon for Central Sleep Apnea in Systolic Heart Failure. Cowie MR, Woehrle H, Wegscheider K, Angermann C, d'Ortho MP, Erdmann E, Levy P, Simonds AK, Somers VK, Zannad F, Teschler H. N Engl J Med. 2015 Sep 17;373(12):1095-‐105.

CONCLUSIONES 1.-‐ Los neumólogos debemos de ser implacables contra el tabaco. 2.-‐ La prevalencia de la mayoría de las enfermedades respiratorias Qende a incrementarse. 3.-‐ De entre todos los retos, el diagnosQco precoz y el tratamiento del cáncer de pulmón es probablemente el mas importante.

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MUCHAS GRACIAS !!

neumologia: update 2016 (cosecha del 15-‐16)

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