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The five commandments of efficient and effective care in the initial evaluation of lung cancer

imagePurpose of review: Multiple recent studies have found an astounding lack of concordance with national guidelines in the workup of lung cancer in both community and academic settings. The resultant increase in complications and delays may potentially contribute to the overall dismal outcomes, as well as cost. This article aims to increase awareness among clinicians about the scope of this problem, and provides a simplified primer on the core concepts of how to perform an efficient and effective workup that is in-line with national guidelines.
Recent findings: Although the basic principles underlying lung cancer evaluation have not changed in the last decade, there are new areas of debate which are outlined and discussed in this article. These include: the value of brain and bone imaging in asymptomatic patients, the best initial site to biopsy in the era of genomics, and the use of biomarkers with low-dose chest tomography screening.

Summary: Given the huge stakes in lung cancer, the current national quality gap in initial evaluation is unacceptable. However, physician re-education can change this. This article provides a quick review of how to properly evaluate a patient with potential lung cancer, as well as an update on new and continuing controversies in the field.

Pleural effusions as markers of mortality and disease severity: a state-of-the-art review

imagePurpose of review: Pleural effusions are common and are the result of various etiologies. Malignant pleural effusion (MPE) has a known high mortality, but there is also increasing evidence that patients with benign pleural effusions also have a poor prognosis. This review will discuss the most recent literature on mortality and prognostication in patients with pleural effusion.
Recent findings: Survival in patients with MPE is influenced by many factors, the most significant of which are underlying tumor type, performance score, and markers of systemic inflammation. Prognostic models have been developed for patients with both MPE and those with pleural infection to aid with treatment decision-making and patient counseling. Patients with benign pleural effusions may benefit from more definitive treatment of their pleural effusion as opposed to repeated thoracentesis.

Summary: Both benign and MPEs are associated with high mortality. Prognostic models and studies comparing treatment modality effect on survival will continue to guide management of these complex problems.

Advanced bronchoscopic techniques for the diagnosis of peripheral pulmonary lesions

imagePurpose of review: The review describes recent advances in bronchoscopic modalities used to diagnose peripheral pulmonary lesions. Recent findings: The pooled diagnostic yield and sensitivity of radial probe endobronchial ultrasound (r-EBUS) has been reported to be 56% for lesions less than 2 cm and 78% for lesions more than 2 cm and 73%, respectively. The pooled diagnostic yield and sensitivity of electromagnetic navigational bronchoscopy (ENB) has been reported to be 65 and 71%, respectively. However, significant heterogeneity between studies was evident for both r-EBUS and ENB (sensitivity of r-EBUS: I2 = 75%; sensitivity of ENB: I2 = 57% and diagnostic yield of ENB: I2 = 66%). Recent studies show that these technologies do not perform in the clinical setting as well as reported in the literature. Conceptually, the domains of advanced bronchoscopic modalities that affect performance are navigation, maneuverability, and location verification. Combining technologies that deal with different domains, such as ENB (navigation) and r-EBUS (location verification), has led to synergistic effects with improved outcomes.

Summary: The performance characteristics of the different advanced bronchoscopic modalities reported in the literature may not be representative of performance in clinical practice because of clinical and statistical heterogeneity in the published literature. However, evidence is accumulating that synergistic combinations of technologies may ultimately lead to better performance.

Malignant pleural effusions because of lung cancer

imagePurpose of review: The discovery of a pleural effusion in the setting of lung cancer has diagnostic, prognostic, and therapeutic challenges, some of which are addressed in this review. Recent findings: Around 20% of patients with lung cancer have minimal pleural effusions, which are not amenable to a diagnostic thoracentesis. These patients have a poorer overall survival (∼7.5 months) than those without effusions (∼12–18 months), although slightly better than those with proven malignant fluids (∼5.5 months). Tumor genotype techniques are feasible on pleural fluid specimens and clinically helpful in identifying patients who may benefit from targeted therapies. If limited pleural involvement is detected during lung cancer surgery despite the presurgical imaging studies, macroscopic complete resection of the lung tumor is still a treatment option. Cytological examination for cancer cells in pleural cavity washings at the time of thoracotomy (pleural lavage cytology) is recommended to uncover pleural dissemination. Patients with non-small cell lung cancer with visceral pleural invasion might be considered candidates for postsurgical adjuvant therapy.
Summary: Some predictors of adverse survival in patients with lung cancer include the presence of a minimal pleural effusion, positive pleural lavage cytology, visceral pleural invasion on pathologic examination, and unexpected pleural involvement during surgery.

WHO Strategies for the programmatic management of drug-resistant tuberculosis.

Related Articles

WHO Strategies for the programmatic management of drug-resistant tuberculosis.

Expert Rev Respir Med. 2016 Jun 8;

Authors: Matteelli A, Centis R, D'Ambrosio L, Sotgiu G, Tadolini M, Pontali E, Spanevello A, Migliori GB

Abstract
Adequate management of drug-resistant tuberculosis (TB), including multidrug- (MDR-) and extensively drug-resistant (XDR-)TB are within the priorities of the newly launched World Health Organization's End TB and Elimination Strategies. This manuscript aims to present the evidence on the MDR- /XDR-TB epidemiology and to discuss how the five recommended priority actions can be applied at the programmatic level to tackle the epidemic: 1) Prevent development of MDR-TB thorough high quality treatment of drug- susceptible TB; 2) Expand rapid testing and detection of drug-resistant TB; 3) Provide immediate access to effective treatment and proper care; 4) Prevent transmission through infection control; 5) Increase political commitment and financing. A non-systematic review of the available literature was performed to provide the reader with a comprehensive view on the topic.

PMID: 27276361 [PubMed - as supplied by publisher]

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