Current opinion in pulmonary medicine
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There is increasing awareness of minimally invasive endoscopic techniques for mediastinal staging in lung cancer. Traditionally, cervical mediastinoscopy has been utilized. Endobronchial ultrasound-guided fine needle aspiration (EBUS) has recently emerged as a potential alternative. ⋯ Currently, insufficient data are present to recommend replacing cervical mediastinoscopy with EBUS for lung cancer staging; the negative predictive value of EBUS requires validation. However, EBUS can be recommended for initial staging as a minimally invasive option provided negative results are followed by cervical mediastinoscopy. This would also allow cervical mediastinoscopy to be reserved for re-staging. Conventional transbronchial needle aspiration has a limited role only as a first-line staging procedure but may aid diagnosis. In the future, EBUS may have a role in presurgical staging of the radiologically normal mediastinum and re-staging if prior staging is done by cervical mediastinoscopy.
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Smoking is a major risk factor for lung cancer, which is the leading cause of cancer-related deaths both in the USA and worldwide. Chronic obstructive pulmonary disease and emphysema are comorbid conditions often found in lung cancer patients. The inflammatory pathways that link chronic obstructive pulmonary disease, emphysema, and lung cancer likely involve genetic and epigenetic modulations due to chronic tissue injury and abnormal tumor immunity in susceptible hosts. ⋯ The relationships between inflammation, airflow obstruction, and lung cancer are complex. Deregulated inflammation is complicit in the pathogenesis of chronic obstructive pulmonary disease and lung cancer, but the overlap of signaling events is not yet fully understood. Tobacco exposure is an important risk factor that confers long-term risk of lung disease. Diagnostic sensitivity of detecting lung cancer may improve with the utilization of genetic profiling in combination with pathologic evaluation of airway epithelium. Additional research is required to understand the role of epithelial-to-mesenchymal transition in chronic inflammatory lung diseases and lung carcinogenesis.
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Lung cancer is a health problem of global proportions. Despite intensive research over many years, the prognosis is still very poor. For the surgery to be effective, tumours need to be recognized early. Computed tomography (CT) is significantly more sensitive than chest radiograph for identifying small, asymptomatic lung cancers. Although low-dose CT screening observational trials have demonstrated that survival for all tumour types and sizes detected were extremely high, there is no clear evidence that low-dose CT screening reduces deaths from lung cancer. Only the results of ongoing randomized controlled trials can reveal a real benefit of screening in terms of mortality reduction. ⋯ Today, we cannot already prove the ultimate mortality benefit of lung cancer screening with low-dose CT nor we can confirm that this approach is not harmful. We are waiting the final analysis of randomized controlled trials for lung cancer mortality. Even if is widely accepted that pooling data of randomized controlled trials could be of help to get powerful results in terms of mortality reduction in shorter follow-up time, this opportunity is still under evaluation.
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Malignant mesothelioma is an asbestos-induced, aggressive tumour. In centres across the world, research has focused on evaluating biomarkers for malignant mesothelioma screening, diagnosis, prognostication and monitoring. With the incidence of malignant mesothelioma expected to increase, it is timely to review the current status of biomarkers in this field. ⋯ To date, soluble mesothelin remains the best available biomarker for malignant mesothelioma. However, a lack of sensitivity for early-stage disease and for all malignant mesothelioma histologies provides motivation for the search of novel malignant mesothelioma biomarkers with greater sensitivity, especially for very early disease.
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Ventilator-associated pneumonia (VAP) is the most serious and controversial of the infections of the critically ill patient. The accuracy of standard methods of diagnosis remains under constant scrutiny, and at the same time there is increasing debate about whether it is a preventable disease. This review focuses on the pathophysiology of respiratory tract infection in the ventilated patient, and how the latest advances have grown from our current understanding of its pathogenesis. ⋯ This review will focus on: the current understanding of the pathogenesis of VAT and VAP, modifiable risk factors and new approaches to treatment, and bacterial resistance challenges.