Seminars in respiratory and critical care medicine
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Solitary pulmonary nodules (SPNs) are commonly encountered in pulmonary practice. Their management is complex, and multiple clinical factors must be considered. The three common management strategies applied to solitary pulmonary nodules are careful observation, diagnostic testing, and surgery. ⋯ Patients who have a high pretest probability of cancer merit surgical diagnosis. Patients with an intermediate pretest probability of cancer go on to further diagnostic testing, primarily with CT-guided fine needle aspiration or positron-emission tomography. Patient preferences are considered throughout the process because the absolute difference in outcome between some strategies may be small.
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The number of solitary pulmonary nodules (SPNs) detected each year is expected to increase dramatically with the implementation of lung cancer screening. Although some will have radiographic features highly specific for benignity, the rest are considered indeterminate and require further investigation. The management options include continued surveillance or immediate diagnostic sampling. ⋯ Surgical methods are preferred in SPNs with high probability of malignancy because they provide both a definitive diagnosis and treatment in a single procedure. In contrast, when the probability of malignancy is low to moderate nonsurgical sampling is preferred. The following is a review of the diagnostic management options available when approaching an SPN.
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Semin Respir Crit Care Med · Dec 2013
ReviewSalvage Therapy beyond Targeted Therapy in Lung Adenocarcinoma.
Targeted therapy in lung adenocarcinoma has evolved rapidly over the last few years, especially in the application of epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors (TKIs). Although many patients with advanced EGFR-mutated or ALK-rearranged lung adenocarcinoma do benefit from treatment with a specific TKI, the duration of disease control is notoriously short. Different patterns of disease progression have been recognized that may require distinct treatment approaches. ⋯ It is now known that EGFR TKI-acquired resistance is mostly (50-60%) due to a single resistance mutation in exon 20 (T790M) and occasionally (5-10%) due to c-MET amplification. On the contrary, the acquired resistance mechanisms to ALK TKI appear more diverse. Specific therapeutic strategies are being developed to overcome various acquired resistance mechanisms and may further improve the overall prognosis of advanced lung adenocarcinoma with actionable driver mutations.
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Semin Respir Crit Care Med · Dec 2013
ReviewPersonalizing therapy in advanced non-small cell lung cancer.
The recognition that non-small cell lung cancer (NSCLC) is not a single disease entity, but rather a collection of distinct molecularly driven neoplasms, has permanently shifted the therapeutic landscape of NSCLC to a personalized approach. This personalization of NSCLC therapy is typified by the dramatic response rates seen in EGFR mutant NSCLC when treated with targeted tyrosine kinase inhibitor therapy and in ALK translocation-driven NSCLC when treated with ALK inhibitors. ⋯ The identification of these oncogenic drivers and the triage of patients to clinical trials evaluating novel targeted therapeutic approaches will increasingly mold a landscape of personalized lung cancer therapy where each genotype has an associated targeted therapy. This review outlines the state of personalized lung cancer therapy as it pertains to individual NSCLC genotypes.
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The National Lung Screening Trial demonstrated that lung cancer screening with three annual low-dose computed tomographic scans has the potential to reduce lung cancer-specific mortality by 20% in an older population of heavy smokers. This was a great achievement by the National Lung Screening Trial (NLST) investigators, but this should be viewed as an important first step in an unfinished process. ⋯ Screening for lung cancer will be most effective if it is accompanied by continued research into risk modeling, patient communication strategies, and biomarkers. For clinicians establishing a program of lung cancer screening, we encourage this to be done in a responsible fashion, adhering to practices specified in the design of the NLST, and with careful attention given to proper management of screen-detected abnormalities and maintenance of screening registries.