Luca Paoletti

The Utility of Nodule Volume in the Context of Malignancy Prediction for Small Pulmonary Nodules

BACKGROUND An estimated 150,000 pulmonary nodules are identified each year, and the number is likely to increase given the results of the National Lung Screening Trial. Decision tools are needed to help with the management of such pulmonary nodules. We examined whether adding any of three novel functions of nodule volume improves the accuracy of an existing malignancy prediction model of CT scan-detected nodules. METHODS Swensens 1997 prediction model was used to estimate the probability of malignancy in CT scan-detected nodules identified from a sample of 221 patients at the Medical University of South Carolina between 2006 and 2010. Three multivariate logistic models that included a novel function of nodule volume were used to investigate the added predictive value. Several measures were used to evaluate model classification performance. RESULTS With use of a 0.5 cutoff associated with predicted probability, the Swensen model correctly classified 67% of nodules. The three novel models suggested that the addition of nodule volume enhances the ability to correctly predict malignancy; 83%, 88%, and 88% of subjects were correctly classified as having malignant or benign nodules, with significant net improved reclassification for each (P<.0001). All three models also performed well based on Nagelkerke R2, discrimination slope, area under the receiver operating characteristic curve, and Hosmer-Lemeshow calibration test. CONCLUSIONS The findings demonstrate that the addition of nodule volume to existing malignancy prediction models increases the proportion of nodules correctly classified. This enhanced tool will help clinicians to risk stratify pulmonary nodules more effectively.

A Decade of Advances in Treatment of Early-Stage Lung Cancer

Emerging from the past decade, there has been a diversification of options for the treatment of early-stage lung cancer. Video-assisted thoracoscopic surgery is now more widely performed, with oncologic outcomes equivalent to those with open thoracotomy. Although lobectomy remains the standard approach to surgical resection, lesser resections, such as segmentectomy and wedge resection, are considerations for some patients. Advances in surgical, radiation, and medical therapies continue to evolve. Future research questions will focus on comparing long-term outcomes with these modalities, including survival, as well as patient-centered endpoints, such as quality of life.

Current Status of Tobacco Policy and Control

Behaviors pertaining to tobacco use have changed significantly over the past century. Compared with 1964, smoking prevalence rates have halved from 40% to 20%, and as a result there has been a slow but steady decline in the rates of tobacco-induced diseases such as heart disease and cancer. Growing awareness of the health risks of smoking was aided by the US Surgeon Reports that were issued on a nearly annual basis starting from 1964. Concerns about the hazards of breathing in second-hand smoke further contributed to the declining social acceptance of smoking, which evolved into regulatory actions restricting smoking on buses, planes, retail outlets, restaurants, and bars. Today, 23 states and 493 localities have comprehensive laws restricting indoor smoking. This paper examines public policies that have made a significant impact on smoking and lung cancer rates and discusses potential future research directions to further reduce the diseases caused by smoking.

Lung transplantation for interstitial lung disease

There have been over 120 diffuse parenchymal lung diseases (DPLD) identified, and these diseases have similar clinical and pathological findings. These diseases are associated with autoimmune disorders, environmental or drug exposures, or are idiopathic in nature. Unfortunately, many of these diseases have limited effective therapies and may require lung transplantation for ongoing survival. Because of changes that have been made in lung allocation, lung transplantation in patients with DPLD is becoming more common. For successful lung transplantation, the DPLD patient requires optimized global medical management. Once transplanted, patients typically have a change in their lifestyle that requires multiple medications, dedication to lifelong exercise, and chronic medical management; however, they also garner a survival benefit and significant improvement in quality of life. Part of the transplant process is to inform patients fully of the risks, costs, and benefits associated with the procedure. It is imperative that patients are evaluated early so that a relationship between transplant centers and patients can be established.

Oropharyngeal swallow physiology and swallowing-related quality of life in underweight patients with concomitant advanced chronic obstructive pulmonary disease

Background Swallowing impairment (dysphagia) has been associated with COPD and may contribute to exacerbations of this chronic and progressive disease. Further, risk of mortality increases with concomitant presence of cachexia in the COPD population. The purpose of this prospective study was to depict oropharyngeal swallowing physiology in underweight patients with stable but advanced-stage COPD. Patients and methods Ten underweight patients with stable but advanced COPD underwent a modified barium swallow study. Analysis of oropharyngeal swallowing function was completed using the standardized Modified Barium Swallow Impairment Profile and the Penetration–Aspiration Scale. Scores from the Dysphagia Handicap Index and 10-item Eating Assessment Tool were collected to assess patient perception of swallowing difficulty. Findings were compared to age- and sex-matched healthy controls. Results Significantly higher MBSImP oral total scores (P=0.007) were observed in COPD patients compared to matched controls, but no difference was observed in pharyngeal total scores (P=0.105). Patients with COPD had significantly higher maximum PAS scores compared with controls (P=0.030). There was no significant difference in EAT-10 or DHI scores between patients with COPD and controls (P=0.41 and P=0.08, respectively). Conclusion Underweight patients with severe but stable COPD present with dysphagia that may not be recognized by the patient. Further investigation is needed to elucidate the interaction between the respiratory–swallowing systems, how muscular weakness may contribute to swallowing impairment, and responsiveness to swallowing treatment.

Lung Donation After Death Resulting From a Stanford Type A Aortic Dissection

The number of lung transplantations performed in the United States has increased at a modest pace over the past decades and reached an all-time high of 2,052 in 2015. However, the transplant wait list mortality remains unacceptably high with approximately one in five patients removed from the list because of death or being too sick for transplantation. The greatest limitation to performing lung transplantations is the relative lack of acceptable lung donors. Here we report the use of lungs from a donor who died as the result of adverse events related to a Stanford type A aortic dissection.