Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Oct 2016
ReviewSurgical Treatment of Early l Stage Lung Cancer: What has Changed and What will Change in the Future.
Recent advances in the surgical treatment of early stage non-small cell lung cancer (NSCLC) have focused heavily on making procedures less invasive, less radical, and better tolerated. Advances in accuracy and increased utilization of cross-sectional imaging allows for diagnosis of smaller and more indolent tumors and preinvasive lesions. ⋯ Minimally invasive approaches either by video-assisted thoracoscopic surgery (VATS) or robotic-assisted thoracic surgery are becoming the procedures of choice for anatomic NSCLC resections and provide decreased perioperative complications and increased tolerability, especially in the elderly and medically high-risk patients. Reports of even less invasive techniques including uniportal VATS and nonintubated lobar resections are now appearing in the literature.
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In the past 5 years, there has arguably been a shift in the pathologic diagnosis of lung cancer, especially adenocarcinoma, moving toward a more patient-centered approach to reporting that works to incorporate information that may be clinically meaningful to prognosis and impactful to clinical management strategy. As the demand for specialty team care surges, the need for effective communication between specialties continues to increase, particularly to ensure that we are all speaking the same language with regard to diagnostic certainty and the implementation of new terminology. This review of lung cancer pathology is not all-inclusive; but rather, in addition to providing salient histologic and immunohistochemical features of selected topics in adenocarcinoma, squamous cell carcinoma, neuroendocrine tumors, and large cell carcinoma, it also attempts to highlight problems in cancer diagnosis from the pathologist's perspective, including addressing variations in interobserver agreement and limitations to the diagnostic process with regard to immunohistochemistry. In the end, many times, problematic cases might reach resolution not through the narrow-sighted ocular of pathology, but rather through employment of a multidisciplinary approach.
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Semin Respir Crit Care Med · Oct 2016
ReviewPredictive and Prognostic Biomarkers in Non-Small Cell Lung Cancer.
Therapy of non-small cell lung cancer (NSCLC) patients has evolved over the past few years with the incorporation of targeted therapy and immune therapy. These changes have increased the importance of prognostic and predictive biomarkers to enable practicing physicians in making the most appropriate treatment decisions for NSCLC patients. A variety of prognostic factors based on clinical and pathologic features determine the overall outcome of the patient and these factors do influence decisions regarding initiation of therapy. ⋯ In addition, there is increasing use of immune-modulating drugs, specifically anti-PD-1 drugs, in advanced NSCLC patients. Several studies have shown that the probability of clinical benefit from these agents is greater in patients with NSCLCs that express PD-L1. The totality of these data suggests that determination of predictive markers prior to initiation of therapy is critical.
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Lung cancer patients are at high risk of suffering due to severe and refractory symptoms, concomitant respiratory comorbidity, frequent disease progression, and treatment that can worsen and compromise quality of life. Palliative care (PC) has shown multiple benefits to cancer patients such as better quality of life, higher patient and family satisfaction, improved disease understanding, less symptom burden, fewer depressive symptoms, less aggressive end of life care, and even improved survival with early implementation. ⋯ Misconceptions about PC often underlie delayed referral to PC. This review summarizes the literature for utilization of PC in lung cancer and focuses on patient benefits, misconceptions, barriers, and implementation.
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Semin Respir Crit Care Med · Oct 2016
Radiation Therapy for Stage I Nonoperable or Medically Inoperable Lung Cancer.
Non-small cell lung cancer (NSCLC) is the second most common solid malignancy in the United States of America, and the leading cause of cancer-related mortality. Nearly 15% of patients present with early-stage disease, for which the standard of care is lobectomy. However, the median age at diagnosis ranges from 65 to 74 years, and many patients have significant comorbidities that preclude surgical treatment. ⋯ Here, we review the historical context of RT for NSCLC, provide a brief of overview of the radiobiological rationale for and the medical physics aspects of SBRT, and review the clinical evidence for its efficacy. We then briefly discuss future directions, including identifying the optimal dose/fractionation regimen and exploring the treatment of centrally-located tumors. Finally, we discuss the available data regarding the use of SBRT for medically operable patients.