2016 CHEST annual meeting
Electromagnetic navigation bronchoscopy
Published Online November 15, 2016 http://dx.doi.org/10.1016/ S2213-2600(16)30414-3 The 2016 annual meeting of the American College of Chest Physicians (CHEST) was held from Oct 22–26, 2016, in Los Angeles, CA, USA For more on the FLAME study see N Engl J Med 2016; 374: 2222–34 For more on the LANTERN study see Int J Chron Obstruct Pulmon Dis 2015; 10: 1015–26
Erik Folch (Massachussetts General Hospital, Boston, MA, USA) presented a prospective, multicentre, cohort study of electromagnetic navigation bronchoscopy (ENB). NAVIGATE is a 24-month ongoing study that aims to enrol up to 1500 patients in centres from the USA and western Europe. “Most previous studies [of ENB] were done in single centres by experts in the technology”, said Folch. Data presented at the meeting represented 30-day follow-up in 500 patients enrolled in 19 participating centres in the USA. Unlike traditional bronchoscopy, which has a yield of 30–40% in expert hands, ENB creates a magnetic field around the patient, enabling clinicians to better target lesions that have been identiﬁed on CT scan by acting a bit like a GPS navigation system. “We have to be careful not to talk about yield in the ﬁrst 30 days [of the study]”, Folch explained, “but the complication rate was exceedingly low and we were able to add value in some patients by undertaking other procedures during the same anaesthetic episode.” Continued follow-up for 24 months will enable the negative predictive value of ENB to be determined as well as the patient, lesion, and procedural characteristics that contribute to diagnostic yield. A second study is planned in Asia, where the presentation of lung nodules is very diﬀerent. “In the USA and Europe, 6% of patients have pure ground-glass nodules instead of solid nodules, but in Asia, 30% of lung nodules or more are ground-glass”, Folch explained.
Genetic and proteomic testing in newly diagnosed lung cancer Blood-based genomic and proteomic testing in patients with suspected lung cancer could provide valuable treatment information, according to a small study presented by Jennifer Mattingley and Kurt Oettel (Gundersen 12
Health System, La Cross, WI, USA). Blood samples from 20 patients at high risk of lung cancer were analysed using the genomic test, GeneStrat, and the proteomic test, VeriStrat. GeneStrat provides information on EGFR sensitising mutations, ALK fusions, and KRAS and BRAF mutations, whereas VeriStrat provides prognostic information for tyrosine kinase inhibitor (TKI) therapy by measuring chronic activation of complex proteomic pathways. Of the 20 patients in the study, 17 were diagnosed with non-small-cell lung cancer and three patients were diagnosed with small-cell lung cancer. GeneStrat testing identiﬁed a mutation in 6 (30%) of 20 patients and VeriStrat testing predicted TKI therapy response as poor in ﬁve (28%) of 18 patients tested. The authors concluded that “Blood-based genomic and proteomic testing can provide rapid results to aid in treatment decisions, decrease time to treatment and facilitate more informed prognostic conversations with patients”.
Inhaled ciproﬂoxacin in bronchiectasis Kevin Winthrop (Oregon Health and Science University, Portland, OR, USA) presented data from the RESPIRE I study. “This is one of two phase 3 randomised controlled trials looking at inhaled ciproﬂoxacin”, said Winthrop, “and it’s the first large randomised placebocontrolled trial of inhaled antibiotic to show efficacy in bronchiectasis”. 416 patients who had experienced two or more exacerbations in the preceding 12 months were randomly assigned to receive ciprofloxacin (32·5 mg twice a day) on a 14 days on/14 days off cyclical regimen, ciprofloxacin (same dose) on a 28 days on/28 days off cyclical regimen, or matched placebo. The 14-day treatment regimen resulted in significantly prolonged time to ﬁrst exacerbation
vs placebo (336 days vs 186 days, adjusted hazard ratio [HR] 0·53; 97·5% CI 0·36–0·80, p=0·0005) and a signiﬁcant reduction in exacerbation frequency (mean incidence rate 0·78 vs 1·42; adjusted incidence rate ratio [IRR] 0·61, 97·5% CI 0·40–0·91, p=0·0061). In the 28-day treatment regimen group, there was also a beneﬁt with regard to prolonging time to ﬁrst exacerbation, although these differences did not reach statistical signiﬁcance (time to ﬁrst exacerbation, HR 0·73; 97·5% CI 0·50–1·07, p=0·065; exacerbation frequency, IRR 0·98; 97·5% CI 0·64–1·48, p=0·89).
FLAME and LANTERN studies Combined treatment with indacaterol and glycopyrronium (IND/GLY) is superior to treatment with salmeterol and fluticasone (SFC) in reducing moderate to severe exacerbations in patients with COPD, according to a comparison of data from the FLAME and LANTERN studies. In the FLAME study, 3662 patients with one or more exacerbations in the previous 12 months were randomly assigned to receive either IND/GLY or SFC (inhaled indacaterol 110 μg/glycopyrronium 50 μg once per day, or inhaled salmeterol 50 μg/ ﬂuticasone 500 μg twice per day). The primary outcome was annual rate of all exacerbations. In the LANTERN study, 774 patients with one or no exacerbations in the previous 12 months were randomly assigned to either IND/GLY or SFC (same doses). Both studies showed a signiﬁcant reduction in exacerbation rate in the IND/GLY treatment group compared with the SFC group (FLAME: rate ratio 0·83; 95% CI 0·75–0·91, p<0·001; LANTERN: rate ratio 0·69; 95% CI 0·48–1·00, p=0·048). The authors concluded that, regardless of exacerbation history, IND/GLY is the preferred treatment option for patients with COPD.
Rebecca Akkermans www.thelancet.com/respiratory Vol 5 January 2017