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Role of imaging in diagnosis, staging and follow-up of lung cancer

imagePurpose of review : Primary lung cancer is still the number one cause of cancer death worldwide. Screening, detection and staging of lung cancer are important because the only potentially curative therapy today is surgical resection of early-stage lung cancer.

Recent findings : Different imaging techniques can be used in these different processes. Recent advances in computed tomography (CT) technology have allowed investigation of novel methods for the evaluation of lung cancer. Recent advances in magnetic resonance technology and administration of contrast media have further improved the image quality and diagnostic capability of magnetic resonance. Positron emission tomography (PET)/CT has been shown to be superior to stand-alone PET or CT in the evaluation of lymph nodes and in the detection of distant metastases.

Summary : The current recommended imaging required for lung cancer staging is CT of the thorax and PET/CT from skull base to mid-thigh. However, with the recent developments in the armamentarium of imaging techniques, the choice of one of these techniques can be directed by the presence of a technique in a local hospital and/or by the presence of an experienced person at that time.

Endobronchial valve placement for the treatment of bronchopleural fistula: a review of the current literature

imagePurpose of review : Bronchopleural fistula is a cause of increased morbidity and mortality. Patients who develop bronchopleural fistula after lung resection or spontaneous pneumothorax often have multiple co-morbidities making them poor candidates for repeated surgical intervention. Previous nonsurgical treatments for bronchopleural fistula have had limited success. Endobronchial valves, originally designed for bronchoscopic lung volume reduction, have been used under a humanitarian use exception for the treatment of bronchopleural fistula. Numerous case series and reports have been published; however, guidelines for the use of endobronchial valves specifically for bronchopleural fistula have yet to be developed.

Recent findings : A number of case series and reports have described the use of one-way endobronchial valves for the treatment of bronchopleural fistula, after spontaneous pneumothorax, lung resection and complication of suppurative lung disease. In the largest series reported (40 patients), 93% of patients experienced improvement in air leak, with 48% having complete resolution. Other series have shown similar success. Complications are rare and include pneumonia, expectoration or migration of valves, and bacterial colonization.

Summary : The use of endobronchial valves for the treatment of bronchopleural fistula is well tolerated and effective. Controlled clinical trials are needed to further evaluate their efficacy and identify ideal patient populations for their use.

Intrapleural minocycline pleurodesis for the treatment of primary spontaneous pneumothorax

imagePurpose of review : The role of chemical pleurodesis in the treatment of primary spontaneous pneumothorax remains unclear. According to current practice guidelines, chemical pleurodesis is reserved for patients who are unable or unwilling to have surgery. Some recent studies showed that intrapleural minocycline pleurodesis could decrease the rate of pneumothorax recurrence, when used either as the initial treatment for simple pneumothorax after successful aspiration and drainage or as an adjuvant treatment for complicated or recurrent pneumothorax following thoracoscopic surgery. The purpose of this review is to discuss the current available evidence on intrapleural minocycline pleurodesis for the treatment of primary spontaneous pneumothorax.

Recent findings : In a recently published prospective, randomized controlled trial, additional minocycline pleurodesis following simple aspiration and drainage was a well tolerated and more effective initial treatment for a first episode of primary spontaneous pneumothorax than simple aspiration and drainage alone. Other prospective, randomized controlled trials showed that additional minocycline pleurodesis after thoracoscopic treatment was a well tolerated and convenient procedure which can reduce the rate of ipsilateral recurrence of primary spontaneous pneumothorax.

Summary : Intrapleural minocycline pleurodesis can be considered an adjunct to standard treatment of primary spontaneous pneumothorax, after either simple aspiration and drainage or after thoracoscopic surgery. Video abstracthttp://links.lww.com/COPM/A12

Medical thoracoscopy: rigid thoracoscopy or flexi-rigid pleuroscopy?

Medical_thoracoscopyPurpose of review : In managing pleural diseases, medical thoracoscopy is often performed as a diagnostic and/or therapeutic procedure, particularly in undiagnosed pleural effusions. Flexi-rigid pleuroscopes are now widely available as an alternative to conventional rigid thoracoscopes. There is an ongoing debate on which is the better instrument.

This review analyses the current literature that compared rigid and flexi-rigid approaches, and outlines the medical advances that may influence the future role of thoracoscopy.

Recent findings : Both rigid and flexi-rigid thoracoscopies are well tolerated. Although biopsies are smaller with flexi-rigid biopsy forceps, two small randomized trials reported similar diagnostic yield using either instrument. No studies have specifically examined patient comfort or the outcome of talc poudrage using the two devices. New techniques (e.g. insulated-tip knife and cryobiopsy) have been used as adjuncts with flexi-rigid pleuroscopy to overcome the difficulties in sampling thickened pleura.

Summary : The rigid and flex-rigid instruments have different merits and limitations. Both approaches provide comparable diagnostic yields in the overall patient population undergoing diagnostic thoracoscopy, though their performances specifically in patients with fibrotic pleural thickening have not been examined. Operators using the flexi-rigid approach should have alternative strategies for sampling thickened pleura. Advances in cytopathology and imaging-guided biopsy will likely reduce the need of medical thoracoscopy in the future.

The health risk of chrysotile asbestos

chrysotilePurpose of review : The word asbestos is a poorly attributed term, as it refers to two very different minerals with very different characteristics. One is the serpentine mineral of which the white asbestos, chrysotile, is the most common. The other is the amphibole asbestos, which includes the blue asbestos crocidolite and the brown asbestos amosite. Although today chrysotile is the only type used commercially, the legacy of past use of amphibole asbestos remains.

This review clarifies the differences between the two mineral families referred to as asbestos and summarizes the scientific basis for understanding the important differences in the toxicology and epidemiology of these two minerals.

Recent findings : Biopersistence and sub-chronic inhalation toxicology studies have shown that exposure to chrysotile at up to 5000 times the current threshold limit value (0.1 fibers/cm3) produces no pathological response. These studies demonstrate as well that following short-term exposure the longer chrysotile fibers rapidly clear from the lung and are not observed in the pleural cavity. In contrast, short-term exposure to amphibole asbestos results quickly in the initiation of a pathological response in the lung and the pleural cavity.

Summary : Significant progress has been made in understanding the factors that influence inhalation toxicology studies of fibers and epidemiological studies of workers. Evaluation of the toxicology and epidemiology studies of chrysotile indicates that it can be used safely under controlled use. In contrast, even short-term exposure to amphibole asbestos can result in disease.

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