Alan M. Fein

Management strategies for the solitary pulmonary nodule

Purpose of review The challenge of diagnosis and management of solitary pulmonary nodules is among the most common yet most important areas of pulmonary medicine. Ideally, the goal of diagnosis and management is to promptly bring to surgery all patients with operable malignant nodules while avoiding unnecessary thoracotomy in patients with benign disease. Recent findings Effective management of the solitary pulmonary nodule depends upon an understanding of decision analysis principles so that diverse technologies can be integrated into a systematic approach. Summary In almost all patients computed tomography (CT) is the best first step. Three key questions can then help guide the workup of the SPN. These are what is the pretest probability of cancer, what is the risk of surgical complications, and does the appearance of the nodule on CT scan suggest a benign or malignant etiology. In patients with average surgical risk, positron emission tomography (PET) scan is warranted when there is discordance between pretest probability of cancer and the appearance of the nodule on CT scan. Thus, when either the patient has a low risk of cancer and the CT suggests a malignant origin, or when there is high risk of cancer and the CT appears benign, PET scan will be cost effective. In most other situations, PET scanning is only marginally more effective than CT and fine needle aspiration strategies but costs much more.

Hypercapnia complicating massive pulmonary embolism.

An elevated PaCO2 is distinctly unusual in pulmonary embolic disease. We report 2 patients with massive pulmonary emboli complicated by hypercapnia in the absence of underlying chronic obstructive lung disease. Profound alterations in ventilation/perfusion matching and reduced cardiac output are probable mechanisms of this gas-exchange problem.

Procainamide-induced lupus lung disease characterized by neutrophil alveolitis

Bronchoalveolar lavage demonstrated a flux of neutrophils into the lung of a patient with procainamide-induced lupus pulmonary disease. Serial lavage studies have shown persistent low-grade alveolitis despite the absence of clinical, serologic, and radiographic evidence of disease activity.

EFFECT OF PROSTAGLANDIN E1 INFUSION ON LEUKOCYTE TRAFFIC AND FIBROSIS IN ACUTE LUNG INJURY INDUCED BY BLEOMYCIN IN HAMSTERS

ObjectiveTo determine whether the iv infusion of prostaglandin E1 (PGE1) could modify the early influx of neutrophils into bleomycin-injured lungs and if that would affect subsequent development of inflammation and fibrosis. Background and MethodsIn vivo controlled animal study performed in a university hospital pulmonary research laboratory.Male Syrian golden hamsters (100− to 110-g body weight) were divided into four treatment groups: a) No treatment; b) intratracheal bleomycin plus PGE1 infusion; c) bleomycin plus saline infusion; d) PGE1 infusion only. PGE1 (180 ng/hr·100 g) or saline were infused iv 3 to 25 hr after intratracheal instillation of bleomycin sulfate (0.5 U/0.5 mL·100 g). Total and differential counts of cells recovered by lavage, lavage fluid protein, and lung total protein and hydroxyproline levels were measured from 6 hr to 30 days later. ResultsPGE1 infusion reduced the influx of neutrophils 6 hr after bleomycin injury by 53% compared with saline infusion (p < .0001), but increased inflammatory cell traffic after 24 hr for 15 days. At 4 days, protein recovered in lung lavage fluid was also decreased in PGE1-treated, bleomycin-injured animals, reflecting reduced injury to lung permeability barriers. Accumulation of lung collagen in the PGE1-treated, bleomycin-instilled hamsters tended to be lower than in the bleomycin-injured, saline-infused group at 15 and 30 days, although these differences did not achieve statistical significance. Despite this fact, >33% of the animals in the PGE1-treated group died, possibly indicating an increased risk of sepsis in these animals. ConclusionsPGE1 infusion can decrease early neutrophil traffic and reduce injury to the lung permeability barriers. However, this treatment augments late inflammatory events and does not significantly alter the development of fibrosis. (Crit Care Med 1991; 19:211)

Update in primary pulmonary lymphomas.

Purpose of review Despite the fact that primary pulmonary lymphoma (PPL) is a rare lung tumour, significant advances addressing clinical features, histological diagnosis, prognostic criteria and therapeutic management of this disease have been made within the past decade. Recent findings Monoclonality and phenotyping of alveolar lymphocytes are suggestive of mucosa-associated lymphoid tissue (MALT). Detection of MALT-1 gene rearrangements in bronchoalveolar fluid cells using fluorescence in-situ hybridization techniques helps to confirm the diagnosis of MALT PPL. Fine needle aspiration-computed tomography guided biopsies as well as transbronchial/cryobiopsies provide adequate tissue material for histological evaluation. Recent publications also provide a better appreciation of newer chemotherapeutic approaches, including fludarabine and mitoxantrone with or without ritubximab for the treatment of MALT, as well as complete surgical resection if local disease is present. Prognostic factors influencing survival and optimal therapy for MALT have not been well defined, but the use of tumour microvascular density appears promising. Summary This review outlines the implications of recent findings for clinical practice and research progress of PPL. Larger, multicentre and well designed studies are imperative to optimize the current diagnostic and therapeutic approach for this disease.

Malignant tracheal tumors: a review of current diagnostic and management strategies.

Purpose of review This article reviews the current literature for the purpose of developing a practical approach for the diagnosis and management of primary tracheal tumors. Recent findings Because of nonspecific symptoms, tracheal tumors remain a diagnostic challenge. Currently available management strategies are not being optimally utilized due to lack of physician awareness and knowledge. The use of newer diagnostic modalities has increased diagnostic accuracy resulting in earlier detection in recent years. This review describes currently available diagnostic modalities along with relatively newer ones such as virtual bronchoscopy, anatomic Optical Coherence Tomography, spectroscopic techniques, and endobronchial ultrasonography. We will review and discuss management strategies including surgical options, adjuvant therapies, and interventional pulmonary techniques including their role in palliation. Summary Early detection along with improved surgical and interventional pulmonology techniques has led to a decline in the death rates from tracheal cancer in recent years. However, further studies are required to define the role of chemotherapeutic agents, combination therapies, and novel techniques such as tracheal transplantation, in the management of primary tracheal tumors. More robust evidence-based studies are needed to provide evidence for clinical practice guidelines for the treatment of primary tracheal tumors.

Multiple pulmonary nodules in malignancy

Purpose of review Multiple pulmonary nodules are a common finding especially with the implementation of lung cancer screening. Available guidelines address the management of solitary pulmonary nodules. The management of the multiple pulmonary nodules would differ based on the characteristic of the nodules, their distribution, and the history of the patients as well. Recent findings Most of the recent publications on multiple pulmonary nodules consist of individual case reports or case series. Robust population studies are lacking. Summary In this article, we propose an approach for management of multiple pulmonary nodules which needs to be validated.