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Optimizing management of chronic obstructive pulmonary disease in the upcoming decade (Free Fulltext)

Chronic obstructive pulmonary disease (COPD) is a leading cause of disability and mortality. Caring for patients with COPD, particularly those with advanced disease who experience frequent exacerbations, places a significant burden on health care budgets, and there is a global need to reduce the financial and personal burden of COPD. Evolving scientific evidence on the natural history and clinical course of COPD has fuelled a fundamental shift in our approach to the disease.

The emergence of data highlighting the heterogeneity in rate of lung function decline has altered our perception of disease progression in COPD and our understanding of appropriate strategies for the management of stable disease. These data have demonstrated that early, effective, and prolonged bronchodilation has the potential to slow the rate of decline in lung function and to reduce the frequency of exacerbations that contribute to functional decline. The goals of therapy for COPD are no longer confined to controlling symptoms, reducing exacerbations, and maintaining quality of life, and slowing disease progression is now becoming an achievable aim. A challenge for the future will be to capitalize on these observations by improving the identification and diagnosis of patients with COPD early in the course of their disease, so that effective interventions can be introduced before the more advanced, disabling, and costly stages of the disease.

Here we critically review emerging data that underpin the advances in our understanding of the clinical course and management of COPD, and evaluate both current and emerging pharmacologic options for effective maintenance treatment.

Vitamin D and responses to inhaled fluticasone in severe chronic obstructive pulmonary disease (Free Fulltext)

Patients with chronic obstructive pulmonary disease (COPD) demonstrate variable responses to inhaled corticosteroids (ICS). The factors contributing to this variability are not well understood. Data from patients with asthma have suggested that low 25-hydroxyvitamin D [25(OH)D] levels contribute to a lack of ICS response in asthma. The objective of this study was to determine whether serum levels of 25(OH)D were related to ICS responses in patients with COPD.

Methods: A total of 60 exsmokers with severe COPD (mean forced expiratory volume in one second [FEV1] 1.07 L, 36% of predicted) spent 4 weeks free of any ICS, followed by 4 weeks of ICS use (fluticasone propionate 500 µg twice daily). Spirometry was performed prior to and after 4 weeks of ICS use. Blood 25(OH)D levels were measured prior to ICS use and examined for relationships to changes in FEV1 following the 4 weeks of ICS use.

Results: The mean 25(OH)D level was 23.3 ± 9.3 ng/mL. There was a high prevalence of vitamin D insufficiency (35%) and deficiency (40%). There was no relationship between baseline 25(OH)D and changes in FEV1 following 4 weeks of ICS.

Conclusion: Baseline 25(OH)D does not contribute to the variation in short-term FEV1 responses to ICS in patients with severe COPD.

[Clinical characteristics and prognosis of large cell lung cancer.]

The aim of this study was to explore the clinical characteristics and analyze the prognostic factors of large cell lung cancer (LCLC).

METHODS: The clinical data of 111 LCLC cases were collected and retrospectively analyzed. The prognostic factors were evaluated by univariate and multivariate analyses.

RESULTS: Among the 111 cases, the lesions were in the right lung of 53 patients and 26 of them were located in the superior lobe. The lesions were in the left lung of 58 cases, and 35 of them were in the superior lobe. The lesions were presented as central in 36 cases and peripheral in 75 cases, with a mean diameter of 5.3 cm. All the 111 patients were diagnosed as stage I in 38 cases, stage II in 11 cases, stage III in 45 and stage IV in 17 cases. 60 patients had lymph node metastasis and 17 cases had distant metastasis. The overall 1-, 3- and 5-year survival rates of the LCLC were 54.7%, 30.9% and 20.6%, respectively. Cox univariate analysis revealed that TNM stage (P = 0.000), lymph node metastasis (P = 0.000) and M stage (P = 0.000) are prognostic factors. Cox multivariate analysis indicated that TNM stage (P = 0.000) is an independent prognostic factor.

CONCLUSION: The prognosis of LCLC is worse than other types of non-small cell lung cancer. Complete surgical resection remains the main therapeutic approach. TNM stage is an independent prognostic factor.

Impact of proposed IASLC/ATS/ERS classification of lung adenocarcinoma: prognostic subgroups and implications for further revision of staging based on analysis of 514 stage I cases.

A new lung adenocarcinoma classification is being proposed by the International Association for the Study of Lung Cancer, American Thoracic Society and European Respiratory Society (IASLC/ATS/ERS). This proposal has not yet been tested in clinical datasets to determine whether it defines prognostically significant subgroups of lung adenocarcinoma.

In all, 514 patients who had pathological stage I adenocarcinoma of the lung classified according to the Union for International Cancer Control/American Joint Committee on Cancer 7th Edition, and who had undergone a lobectomy with mediastinal lymph node dissection were retrospectively reviewed. Comprehensive histological subtyping was used to estimate the percentage of each histological subtype and to identify the predominant subtype. Tumors were classified according to the proposed new IASLC/ATS/ERS adenocarcinoma classification. Statistical analyses were made including Kaplan-Meier and Cox regression analyses. There were 323 females (63%) and 191 males (37%) with a median age of 69 years (33-89 years) and 298 stage IA and 216 stage IB patients. Three overall prognostic groups were identified: low grade: adenocarcinoma in situ (n=1) and minimally invasive adenocarcinoma (n=8) had 100% 5-year disease-free survival; intermediate grade: non-mucinous lepidic predominant (n=29), papillary predominant (n=143) and acinar predominant (n=232) with 90, 83 and 84% 5-year disease-free survival, respectively; and high grade: invasive mucinous adenocarcinoma (n=13), colloid predominant (n=9), solid predominant (n=67) and micropapillary predominant (n=12), with 75, 7170 and 67%, 5-year disease-free survival, respectively (P<0.001). Among the clinicopathological factors, stage 1B versus 1A (P<0.001), male sex (P<0.008), high histological grade (P<0.001), vascular invasion (P=0.002) and necrosis (P<0.001) were poorer prognostic factors on univariate analysis. Both gross tumor size (P=0.04) and invasive tumor size adjusted by the percentage of lepidic growth (P<0.001) were significantly associated with disease-free survival with a slightly stronger association for the latter. Multivariate analysis showed the prognostic groups of the IASLC/ATS/ERS histological classification (P=0.038), male gender (P=0.007), tumor invasive size (P=0.026) and necrosis (P=0.002) were significant poor prognostic factors.

In summary, the proposed IASLC/ATS/ERS classification of lung adenocarcinoma identifies histological categories with prognostic differences that may be helpful in identifying candidates for adjunctive therapy. The slightly stronger association with survival for invasive size versus gross size raises the need for further studies to determine whether this adjustment in measuring tumor size could impact TNM staging for small adenocarcinomas.

[Lung cancer staging.]

Lung cancer is the third most frequent new cancer diagnosis in Germany. An elaborate clinical diagnosis is essential for successful therapy planning. The necessary examinations are defined in the current S3 guideline on lung cancer diagnosis and therapy.

A compilation of diagnostic reports has led to the current 7th edition of the TNM system. According to this update staging is carried out in terms of tumor extent, lymph node status and distant metastases. The resultant tumor stage forms the basis for individual therapy planning. Current guidelines as well as the current TNM system are presented. The usefulness of modern cross-sectional imaging and the possible modalities in this system is reported.

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