Mohit Chawla

Symptom Management in Patients With Lung Cancer : Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

BACKGROUND Many patients with lung cancer will develop symptoms related to their disease process or the treatment they are receiving. These symptoms can be as debilitating as the disease progression itself. To many physicians these problems can be the most difficult to manage. METHODS A detailed review of the literature using strict methodologic review of article quality was used in the development of this article. MEDLINE literature reviews, in addition to Cochrane reviews and other databases, were used for this review. The resulting article lists were then reviewed by experts in each area for quality and finally interpreted for content. RESULTS We have developed recommendations for the management of many of the symptom complexes that patients with lung cancer may experience: pain, dyspnea, airway obstruction, cough, bone metastasis, brain metastasis, spinal cord metastasis, superior vena cava syndrome, hemoptysis, tracheoesophageal fistula, pleural effusions, venous thromboembolic disease, depression, fatigue, anorexia, and insomnia. Some areas, such as dyspnea, are covered in considerable detail in previously created high-quality evidence-based guidelines and are identified as excellent sources of reference. The goal of this guideline is to provide the reader recommendations based on evidence supported by scientific study. CONCLUSIONS Improved understanding and recognition of cancer-related symptoms can improve management strategies, patient compliance, and quality of life for all patients with lung cancer.

Technical aspects of endobronchial ultrasound-guided transbronchial needle aspiration CHEST guideline and expert panel report

BACKGROUND Endobronchial ultrasound (EBUS) was introduced in the last decade, enabling real-time guidance of transbronchial needle aspiration (TBNA) of mediastinal and hilar structures and parabronchial lung masses. The many publications produced about EBUS-TBNA have led to a better understanding of the performance characteristics of this procedure. The goal of this document was to examine the current literature on the technical aspects of EBUS-TBNA as they relate to patient, technology, and proceduralist factors to provide evidence-based and expert guidance to clinicians. METHODS Rigorous methodology has been applied to provide a trustworthy evidence-based guideline and expert panel report. A group of approved panelists developed key clinical questions by using the PICO (population, intervention, comparator, and outcome) format that addressed specific topics on the technical aspects of EBUS-TBNA. MEDLINE (via PubMed) and the Cochrane Library were systematically searched for relevant literature, which was supplemented by manual searches. References were screened for inclusion, and well-recognized document evaluation tools were used to assess the quality of included studies, to extract meaningful data, and to grade the level of evidence to support each recommendation or suggestion. RESULTS Our systematic review and critical analysis of the literature on 15 PICO questions related to the technical aspects of EBUS-TBNA resulted in 12 statements: 7 evidence-based graded recommendations and 5 ungraded consensus-based statements. Three questions did not have sufficient evidence to generate a statement. CONCLUSIONS Evidence on the technical aspects of EBUS-TBNA varies in strength but is satisfactory in certain areas to guide clinicians on the best conditions to perform EBUS-guided tissue sampling. Additional research is needed to enhance our knowledge regarding the optimal performance of this effective procedure.

Validation of an Interventional Pulmonary Examination

BACKGROUND Interventional pulmonology (IP) is an emerging subspecialty with a dedicated 12 months of additional training after traditional pulmonary and critical care fellowships with fellowships across the country. A multiple-choice question (MCQ) examination was developed to measure didactic knowledge acquired in IP fellowships. METHODS Interventional pulmonologists from 10 academic centers developed a MCQ-based examination on a proposed curriculum for IP fellowships. The 75 multiple-choice question examination was proctored, time limited (120 min), and computer-based. The examination was administered to IP faculty, IP fellows in their last month of fellowship, graduating pulmonary and critical care fellows in their last month of training, and incoming first-year pulmonary and critical care fellows. RESULTS The mean score for IP faculty was 87% (range, 83%-94%), 74% for IP fellows (range, 61%-81%, SD 5.09, median 76%), 62% for graduating pulmonary and critical care fellows (range 52% to 73%), and 50% for incoming pulmonary/critical care fellows (range, 35%-65%). There was a graduated increase in mean scores with level of IP training. Scores differed significantly across the four groups (P = .001). CONCLUSION A validated MCQ examination can measure IP knowledge. There is a difference in IP knowledge based on IP training exposure.

Pleural epithelioid hemangioendothelioma.

A 51-year-old female presented to the emergency department complaining of left-sided, nonpleuritic chest pain and a 10-lb. weight loss over the previous 2 months. She was a current smoker with a 20 pack-year history. A PA/lateral chest radiograph and chest computed tomogram (CT) demonstrated a large loculated effusion with pleural thickening (Fig. 1). There were no lung nodules or pathologic mediastinal or hilar lymphadenopathy. A diagnostic thoracentesis was performed, and serosanguineous pleural fluid was obtained. Cytology was negative. For further diagnostic sampling, she underwent a thoracotomy with pleural fluid drainage and pleural biopsy, which demonstrated sheets of atypical epithelioid cells displaying prominent intra-alveolar growth (Fig. 2). The cells stained positive for CD31 and CD34. Stains for pan-cytokeratin, CK5-6, p63, calretinin, S-100, Melan-A, TTF-1, CD68, and EMA were negative. She was given a diagnosis of pleural epithelioid hemangioendothelioma. In the multidisciplinary oncology conference, it was felt she was not a candidate for surgical resection given the extensive nature of the tumor. She was offered chemotherapy with doxorubicin. Less than 4 months after her initial presentation, the patient was admitted to the hospital with a bowel obstruction. Repeat imaging demonstrated further extension of tumor in the left hemithorax with associated volume loss, an enlarging right-sided pleural effusion, evidence of liver and spleen metastasis, and new-onset ascites. Her condition continued to deteriorate with the onset of respiratory failure and she died several days later.