James Entwisle

Guidelines on the radical management of patients with lung cancer.

A joint initiative by the British Thoracic Society and the Society for Cardiothoracic Surgery in Great Britain and Ireland was undertaken to update the 2001 guidelines for the selection and assessment of patients with lung cancer who can potentially be managed by radical treatment.

Qualitative Analysis of High-Resolution CT Scans in Severe Asthma

BACKGROUND High-resolution CT (HRCT) scanning is part of the management of severe asthma, but its application varies between centers. We sought to describe the HRCT scan abnormalities of a large severe asthma cohort and to determine the utility of clinical features to direct the use of HRCT scanning in this group of patients. METHODS Subjects attending our Difficult Asthma Clinic (DAC) between February 2000 and November 2006 (n = 463) were extensively re-characterized and 185 underwent HRCT scan. The HRCT scans were analyzed qualitatively and the interobserver variability was assessed. Using logistic regression we defined clinical parameters that were associated with bronchiectasis (BE) and bronchial wall thickening (BWT) alone or in combination. RESULTS HRCT scan abnormalities were present in 80% of subjects and often coexisted with BWT (62%), BE (40%), and emphysema (8%). The interobserver agreement for BE (kappa = 0.76) and BWT (kappa = 0.63) was substantial. DAC patients who underwent HRCT scanning compared with those who did not were older, had longer disease duration, had poorer lung function, were receiving higher doses of corticosteroids, and had increased neutrophilic airway inflammation. The sensitivity and specificity of detecting BE clinically were 74% and 45%, respectively. FEV(1)/FVC ratio emerged as an important predictor for both BE and BWT but had poor discriminatory utility for subjects who did not have airway structural changes (FEV(1)/FVC ratio, >or= 75%; sensitivity, 67%; specificity, 65%). CONCLUSION HRCT scan abnormalities are common in patients with severe asthma. Nonradiologic assessments fail to reliably predict important bronchial wall changes; therefore, CT scan acquisition may be required in all patients with severe asthma.

The Mesothelioma and Radical surgery randomized controlled trial: the Mars feasibility study.

Hypothesis: The effectiveness of extrapleural pneumonectomy (EPP) to extend quality-adjusted survival in malignant pleural mesothelioma within multimodality treatment should be proven in a randomized controlled trial if this radical surgery is to be regarded as the standard of care. The question was whether randomization to surgery versus no surgery would be possible. Methods: The Mesothelioma and Radical Surgery trial was planned to randomize 50 patients to test feasibility. There was a two-stage consent process. At first consent, the patients who were possible candidates for radical surgery were registered into the trial for completion of assessment and staging. All received platinum-based chemotherapy. If still eligible, they completed a second consent to be randomized to have either EPP followed by radical hemithorax radiotherapy or to have continued best care. Results: Patients were recruited through 11 collaborating centers in the United Kingdom. One hundred twelve potentially eligible patients gave informed consent to enter the registration phase and undergo chemotherapy. One died, 27 progressed, five were inoperable, four were treated off trial, and 18 withdrew either during or after chemotherapy but before final review. Additionally six were deemed inoperable at review after completing chemotherapy and one more patient withdrew. The remaining 50 were randomized; 24 to EPP and 26 to continued best care. Conclusions: In this study, 50/112 (45%) of patients entering the evaluation and induction phase of the trial went on to be randomized. We have shown that this randomization between surgery and no surgery is feasible. This was the primary aim of the Mesothelioma and Radical Surgery trial.

Quantitative analysis of high-resolution computed tomography scans in severe asthma subphenotypes

Background Severe asthma is a heterogeneous condition. Airway remodelling is a feature of severe asthma and can be determined by the assessment of high-resolution computed tomography (HRCT) scans. The aim of this study was to assess whether airway remodelling is restricted to specific subphenotypes of severe asthma. Methods A retrospective analysis was performed of HRCT scans from subjects who had attended a single-centre severe asthma clinic between 2003 and 2008. The right upper lobe apical segmental bronchus (RB1) dimensions were measured and the clinical and sputum inflammatory characteristics associated with RB1 geometry were assessed by univariate and multivariate regression analyses. Longitudinal sputum data were available and were described as area under the time curve (AUC). Comparisons were made in RB1 geometry across subjects in four subphenotypes determined by cluster analysis, smokers and non-smokers, and subjects with and without persistent airflow obstruction. Results Ninety-nine subjects with severe asthma and 16 healthy controls were recruited. In the subjects with severe asthma the RB1 percentage wall area (%WA) was increased (p=0.009) and lumen area (LA)/body surface area (BSA) was decreased (p=0.008) compared with controls but was not different across the four subphenotypes. Airway geometry was not different between smokers and non-smokers and RB1 %WA was increased in those with persistent airflow obstruction. RB1 %WA in severe asthma was best associated with airflow limitation and persistent neutrophilic airway inflammation (model R2=0.27, p=0.001). Conclusions Airway remodelling of proximal airways occurs in severe asthma and is associated with impaired lung function and neutrophilic airway inflammation.

Expression of CXCR6 and its ligand CXCL16 in the lung in health and disease

Background Chemokine receptors (CR) play an important role in T cell migration, but their contribution to lung trafficking is unclear.

The Role of CT Scanning in Multidimensional Phenotyping of COPD

Background: COPD is a heterogeneous disease characterized by airflow obstruction and diagnosed by lung function. CT imaging is emerging as an important, noninvasive tool in phenotyping COPD. However, the use of CT imaging in defining the disease heterogeneity above lung function is not fully known. Methods: Seventy-five patients with COPD (58 men, 17 women) were studied with CT imaging and with measures of airway inflammation. Airway physiology and health status were also determined. Results: The presence of emphysema (EM), bronchiectasis (BE), and bronchial wall thickening (BWT) was found in 67%, 27%, and 27% of subjects, respectively. The presence of EM was associated with lower lung function (mean difference % FEV1, −20%; 95% CI, −28 to −11; P < .001). There was no difference in airway inflammation, exacerbation frequency, or bacterial load in patients with EM alone or with BE and/or BWT ± EM. The diffusing capacity of the lung for carbon monoxide/alveolar volume ratio was the most sensitive and specific parameter in identifying EM (area under the receiver operator characteristic curve, 0.87; 95% CI, 0.79-0.96). Physiologic cluster analysis identified three clusters, two of which were EM predominant and the third characterized by a heterogeneous combination of EM and BE. Conclusions: The application of CT imaging can be useful as a tool in the multidimensional approach to phenotyping patients with COPD.

Video-assisted versus open pulmonary metastasectomy: the surgeon's finger or the radiologist's eye? §

OBJECTIVE The use of VATS metastasectomy remains controversial because of doubt surrounding its ability to remove palpable but CT occult lesions. We aim to evaluate our policy of elective VATS and compare it with our results with open metastasectomy. METHODS Pulmonary metastasectomy was performed for metastatic colorectal adenocarcinoma in 52 patients: 27 open and 25 VATS over 8 years. The age and sex distribution was similar: median age was 66 for open and 69 years for VATS, p=0.48, 70% male in open and 64% male in VATS, p=0.31. Liver metastases were present in 37% in the open and 32% in the VATS group, p=0.46. The choice of surgical approach was dependent on the distance of the lesion from the surface of the lung. We examined the survival using the Kaplan-Meier method and we tested for differences in the incidence of missed lesions, pulmonary disease progression and repeat metastasectomy. RESULTS There was no in-hospital mortality. There was no difference in the incidence of missed lesions (1 in VATS, none in open, p=0.48), pulmonary disease progression (11 in open, 9 in VATS, p=0.47) or recurrence in the same lobe (4 in open, 3 in VATS, p=0.54). Median follow-up was 22 (1-70) months and there was no difference to the estimated actuarial survival. Mean survival for the open group was 47 months, SE 6 with 95% CI 36-59 months and mean survival for the VATS group 35.4 months, SE 3 with 95% CI 30-41.3 months. The estimated 1- and 2-year survival was 90% and 80% for open and 90% and 72% for VATS. CONCLUSIONS The selective use of VATS therapeutic metastasectomy in conjunction with multi-detector CT is justified in metastatic colorectal adenocarcinoma. The insertion of the surgical digit is not mandatory. Trust the radiologists eye.

Airway wall geometry in asthma and nonasthmatic eosinophilic bronchitis

Background:  Variable airflow obstruction and airway hyperresponsiveness (AHR) are features of asthma, which are absent in nonasthmatic eosinophilic bronchitis (EB). Airway remodelling is characteristic of both conditions suggesting that remodelling and airway dysfunction are disassociated, but whether the airway geometry differs between asthma and nonasthmatic EB is uncertain.

Ultrasound guided cytological aspiration of supraclavicular lymph nodes in patients with suspected lung cancer

Background: Lung cancer is the leading cause of death from cancer in the UK. Pathological diagnosis traditionally requires invasive procedures such as bronchoscopy, mediastinoscopy, or image guided biopsy. Ultrasound of the neck with fine needle aspiration cytology (FNAC) of enlarged but impalpable supraclavicular nodes has been used in patients with suspected lung cancer who have N2 or N3 disease on staging computed tomography (CT). If positive, this technique helps to both stage the patient and provide a cytological diagnosis. Methods: 101 patients were enrolled prospectively over a 1 year period. FNAC was performed on all supraclavicular nodes over 5 mm in size using the capillary aspiration technique. Results: Sixty one of the 101 patients had enlarged supraclavicular nodes and underwent FNAC. The overall malignant yield was 45.5% of patients scanned and 75.4% of patients sampled. As a result of FNAC, 43 patients (42.6%) avoided more invasive procedures. Conclusion: Ultrasound guided FNAC is a promising, relatively non-invasive technique for the staging and diagnosis of patients with lung cancer.

Thoracic ultrasound prior to medical thoracoscopy improves pleural access and predicts fibrous septation

Background and objective:  Medical thoracoscopy (MT) is indicated for the investigation of unexplained pleural exudates. Not all MT units create artificial pneumothoraces because of time. Difficult pleural space access and thick fibrous adhesions may prevent MT and pleurodesis, respectively. The potential role of thoracic ultrasound (TUS) pre‐MT has not been fully evaluated. We hypothesized TUS would reduce failure to access the pleural space and enable detection of thick fibrous adhesions.