Current opinion in pulmonary medicine
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Therapeutic thoracentesis is one of the most commonly performed medical procedures. The availability of handheld ultrasound machines has greatly enhanced the evaluation and management of patients with pleural effusions, with advantages including the absence of radiation, ease of use, portability and real-time/dynamic imaging. Pleural manometry refers to the measurement of pleural pressure during thoracentesis. Though described more than 122 years ago, most physicians do not measure pleural pressure, or even consider the role pleural pressures plays in the development of pleural effusions. This review summarizes the relevant data behind the use of ultrasound and manometry and explores their use during therapeutic thoracentesis ⋯ The use of ultrasound and pleural manometry enhances the understanding of pleural disease and is associated with clinical benefit that will lead to improved patient care.
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Lung cancer is the most common cause of cancer related mortality in the United States. The fastest growing segment of the population has been the elderly, who frequently have other significant co-morbidities. In the medically inoperable, high-risk patient, new treatment options including minimally invasive surgery, computed tomography-guided ablative therapy and sterotactic radiosurgery are encouraging. The purpose of this article is to review some of these advances and emerging technologies in the management of early stage lung cancer, particularly in the high-risk patient. ⋯ Lobectomy remains the standard for early stage lung cancer. In compromised patients, minimally invasive surgical approaches via thoracoscopy allow sublobar resection (wedge resection or segmentectomy) with or without adjunct brachytherapy mesh to offer results that approach that of lobectomy in some cases. Radiofrequency ablation and stereotactic radiosurgery are emerging technologies for the treatment of lung neoplasm, which are particularly applicable in high-risk patients who are not fit for even minimally invasive surgery. Prospective studies are underway in our center and others to further define the role of these new technologies in the treatment of lung neoplasm.
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Cisplatin-based chemotherapy remains the treatment of choice in advanced nonsmall-cell lung cancer. The development of predictive biomarkers able to identify lung-cancer patients who are most likely to benefit from cisplatin-based chemotherapy would be a powerful tool. Many reports have explored the role of ERCC1 expression in the repair mechanism of cisplatin-induced DNA adducts in cancer cells. ⋯ High ERCC1 expression is predictive of resistance to platinum-based therapy. Thus, there is solid evidence to support ERCC1 as a useful marker of clinical resistance to platinum-based chemotherapy in the adjuvant setting of nonsmall-cell lung cancer. Meanwhile, optimization of methodology and standardization of technical procedures seem necessary before larger prospective studies can address the same question.
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Malignant pleural effusion is a common complication in advanced malignancy that causes debilitating symptoms which result in impaired quality of life. The primary therapeutic goal in malignant pleural effusion management is effective palliation of the associated respiratory symptoms. Pleurodesis by chest tube or thoracoscopy is widely accepted as the gold standard treatment, although these treatments are not without problems. Tunneled pleural catheters represent a new safe and effective outpatient treatment option for these patients, with no reported mortality and minimal morbidity. ⋯ The optimal method for palliative management of malignant pleural effusion remains controversial. The high success rates, low complication rates and efficacy in patients with a wide range of performance status support the use of tunneled pleural catheters as a first-line treatment for symptomatic malignant pleural effusion.