Towards individualised treatment in COPD
The heterogeneous nature of chronic obstructive pulmonary disease (COPD) was recognised long before the term was popularised by Briscoe and Nash,
The challenge in recent years has been to better characterise the different phenotypes that make up the syndrome of COPD and so develop a new classification and terminology for COPD. This is not an esoteric pursuit but a worthwhile endeavour which has the potential to shed light on the underlying pathophysiology, risk factors, natural history and treatment responses of the specific phenotypes. Ultimately, this has the potential to enable tailoring of treatment regimes to individual patients.
Currently this is not possible as the treatment guidelines for COPD do not differ according to phenotype, other than by severity. Furthermore, the randomised controlled trials on which the guidelines...
Pre- and intra-operative mediastinal staging in non-small-cell lung cancer.
Pre- and intra-operative mediastinal staging in non-small-cell lung cancer.
Swiss Med Wkly. 2011;141:w13168
Authors: Lardinois D
Primary mediastinal lymph node staging is important to select properly patients who can benefit from an induction treatment. The accuracy of CT scan in the evaluation of mediastinal lymph nodes is low. Further staging can be omitted in patients with negative mediastinal PET in most of the cases. PET positive findings should always be histologically or cytologically confirmed. Endoscopic techniques are accurate minimally invasive techniques mostly used to confirm a PET-positive finding but not for complete mediastinal staging. Mediastinoscopy is an invasive technique which provides a complete statging of the upper mediastinum. At least one ipsilateral, one contralateral and the subcarinal nodes should be routinely biopsied. Restaging of the mediastinum after induction treatment is necessary to select the patients who can benefit from surgery. There are no imaging techniques which can accurately determine the biological response of the tumour to the induction treatment. Neither CT, PET or PET-CT seem good enough to make further therapeutic decisions, based on their results. The accuracy of PET in mediastinal restaging is not optimal, mainly due to its low sensitivity. Fusion images with PET-CT seem to improve the results with a very favourable sensitivity, specificity and accuracy. An invasive technique providing cytohistological information is necessary. For restaging techniques, endoscopic techniques or surgical invasive techniques can be used. If they yield a positive result, definitive nonsurgical treatment seems to be indicated in most patients. Remediastinoscopy has proven to be feasible but due to adhesions and fibrosis, the intervention is technically challenging. The technique of lymph-node assessment during surgery for non-small-cell lung cancer (NSCLC) is not standardised to date. Accurate intra-operative staging is necessary to compare the results from different institutions and to conduct multi-institutional trials. Systematic mediastinal lymph-node dissection is recommended in all cases for complete resection of NSCLC and improves pathologic staging and the prospect for adjuvant therapy. The role of mediastinal lymphadenectomy regarding overall survival and local control remains controversial but systematic lymph-node dissection might be associated with a better outcome in stage I NSCLC. Lobe-specific systematic nodal dissection is acceptable for peripheral squamous T1 tumours, if hilar and interlobar nodes are negative on frozen section studies.
PMID: 21384283 [PubMed - indexed for MEDLINE]
The prognostic impact of sex on surgically resected non-small cell lung cancer depends on clinicopathologic characteristics.
The increasing incidence of lung cancer in women and their supposed survival advantage over men requires clarification of the significance of sex. Age, stage, histologic features, differentiation grade, and Ki-67 index were assessed in 405 surgically resected non-small cell lung cancers (NSCLCs) using a standardized tissue microarray platform.
Women were associated with well/moderate tumor differentiation, a Ki-67 index of 3% or less, and adenocarcinoma histologic features. Female sex predicted increased survival time only by univariate analysis. Stratified by sex, increased survival was noted for women older than 64 years, with a tumor at postsurgical International Union Against Cancer stage I, with adenocarcinoma histologic features, with well- or moderately differentiated tumors, or with a Ki-67 index of 3% or less. Sex is not an independent prognostic parameter for patients with surgically resected NSCLC. Sex-linked differences are associated with other factors, thus simulating a prognostic impact of sex.
This study elucidates sex-specific interactions between patient and tumor characteristics, which are pivotal toward improving prognostic accuracy, individualized therapies, and screening efforts.
Dual energy CT pulmonary blood volume assessment in acute pulmonary embolism - correlation with D-dimer level, right heart strain and clinical outcome.
OBJECTIVE: To investigate the role of perfusion defect (PD) size on dual energy CT pulmonary blood volume assessment as predictor of right heart strain and patient outcome and its correlation with d-dimer levels in acute pulmonary embolism (PE).
METHODS: 53 patients with acute PE who underwent DECT pulmonary angiography were retrospectively analyzed. Pulmonary PD size caused by PE was measured on DE iodine maps and quantified absolutely (VolPD) and relatively to the total lung volume (RelPD). Signs of right heart strain (RHS) on CT were determined. Information on d-dimer levels and readmission for recurrent onset of PE and death was collected.
RESULTS: D-dimer level was mildly (r = 0.43-0.47) correlated with PD size. Patients with RHS had significantly higher VolPD (215 vs. 73 ml) and RelPD (9.9 vs. 2.9%) than patients without RHS (p < 0.003). There were 2 deaths and 1 readmission due of PE in 18 patients with >5% RelPD, while no such events were found for patients with <5% RelPD.
CONCLUSION: Pulmonary blood volume on DECT in acute PE correlates with RHS and appears to be a predictor of patient outcome in this pilot study.
[Management of acute exacerbations of pulmonary fibrosis.]
INTRODUCTION: Acute exacerbation of idiopathic pulmonary fibrosis (IPF) is defined by an acute worsening of the respiratory status without any identified cause.
STATE OF THE ART: IPF is the most frequent type of chronic interstitial pneumonia. In general, its course is a progressive worsening with a median survival at 3years after diagnosis. Acute exacerbation is now recognized as a severe complication of IPF. It develops most often within less than 1 month and is characterized by a worsening of dyspnoea associated with the occurrence of new images on chest radiograph. Its diagnosis requires the exclusion of an identified cause for acute deterioration such as pulmonary embolism, bronchopulmonary infection, left heart failure or pneumothorax. The treatment of acute exacerbations of IPF is not well standardized and even though isolated cases of therapeutic success have been reported, its prognosis remains poor. In the most severe cases, mechanical ventilation is generally considered to be ineffective, thus leading most often to a conservative management strategy with no transfer to ICU. However, this attitude is now being questioned since it is now potentially possible to perform an urgent lung transplantation in some patients at least in several countries, including France.
CONCLUSION: Acute exacerbation of IPF is a severe complication of IPF, but its optimal management is not yet clearly defined.