Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Dec 2013
ReviewAdvances in surgical techniques in non-small cell lung cancer.
Thoracic surgery is a dynamic field, and many scientific, technological, technical, and organizational changes are occurring. A prominent example is the use of less invasive approaches to major resection of non-small cell lung cancer (NSCLC), both thoracoscopic and robotic. Sophisticated technology corroborated by clinical data has led to these approaches becoming accepted additions to the armamentarium. ⋯ Lung cancer is being detected more often at an early stage. At the same time, advances in techniques, patient care, clinical science, and multidisciplinary treatment support an increased role for aggressive resection in the face of larger locally advanced tumors or for those with limited metastatic disease. These advances, conducted in the setting of multidisciplinary decision making, have resulted in real and palpable advancements for patients with lung cancer.
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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
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.