Diagnosis of lung cancer: a bronchoscopist's perspective.

BACKGROUND: Guidelines recommend multiple types of cytologic and tissue samplings in the diagnosis of lung cancer by bronchoscopy, but differences of opinion exist as to the relative value of bronchial brushings and endobronchial or transbronchial biopsies. Our objective was to determine concordance of these procedures by a test of symmetry in a historical cohort referred to the pulmonary diagnostic laboratory. METHODS: From 1988 to 2001, patients with pathologic confirmation of primary lung cancer were examined by standard bronchoscopic techniques of that period. An electronic medical record system was used, with statistical analysis of symmetry between brushings and biopsies establishing the diagnosis. RESULTS: Of 968 patients, 98% had bronchoscopy for 624 central and 322 peripheral suspect lesions. Bronchial brushings from 915 patients confirmed pulmonary malignancy in 811 (89%) patients. Endobronchial or transbronchial biopsies from 739 patients showed lung cancer in 603 (82%) cases. Bronchial washings in 16 patients and transthoracic needle biopsies in 30 patients established diagnosis. Transbronchial needle aspiration of mediastinal nodes identified metastases in 94 patients. Only 14 patients required a surgical procedure for diagnosis, but 188 received surgical excision as primary treatment. Statistical evaluation used only patients with both bronchial brushings and endobronchial or transbronchial biopsies. Analysis by a test of symmetry showed a significant difference (P<0.0001). CONCLUSIONS: Positive, suspicious, and negative specimens were consistent, with bronchial brushings being more sensitive with a lower false-negative rate than endobronchial or transbronchial biopsies. Multiple techniques are recommended for bronchoscopic confirmation of lung cancer, but bronchial brushings should be collected initially, as technical or patient limitations might preclude diagnostic tissue biopsies.

Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: ACCP evidenced-based clinical practice guidelines (2nd edition).

BACKGROUND: This section of the guidelines is intended to provide an evidence-based approach to the preoperative physiologic assessment of a patient being considered for surgical resection of lung cancer. METHODS: Current guidelines and medical literature applicable to this issue were identified by computerized search and evaluated using standardized methods. Recommendations were framed using the approach described by the Health and Science Policy Committee. RESULTS: The preoperative physiologic assessment should begin with a cardiovascular evaluation and spirometry to measure the FEV(1). If diffuse parenchymal lung disease is evident on radiographic studies or if there is dyspnea on exertion that is clinically out of proportion to the FEV(1), the diffusing capacity of the lung for carbon monoxide (Dlco) should also be measured. In patients with either an FEV(1) or Dlco < 80% predicted, the likely postoperative pulmonary reserve should be estimated by either the perfusion scan method for pneumonectomy or the anatomic method, based on counting the number of segments to be removed, for lobectomy. An estimated postoperative FEV(1) or Dlco < 40% predicted indicates an increased risk for perioperative complications, including death, from a standard lung cancer resection (lobectomy or greater removal of lung tissue). Cardiopulmonary exercise testing (CPET) to measure maximal oxygen consumption (Vo(2)max) should be performed to further define the perioperative risk of surgery; a Vo(2)max of < 15 mL/kg/min indicates an increased risk of perioperative complications. Alternative types of exercise testing, such as stair climbing, the shuttle walk, and the 6-min walk, should be considered if CPET is not available. Although often not performed in a standardized manner, patients who cannot climb one flight of stairs are expected to have a Vo(2)max of < 10 mL/kg/min. Data on the shuttle walk and 6-min walk are limited, but patients who cannot complete 25 shuttles on two occasions will likely have a Vo(2)max of < 10 mL/kg/min. Desaturation during an exercise test has not clearly been associated with an increased risk for perioperative complications. Lung volume reduction surgery (LVRS) improves survival in selected patients with severe emphysema. Accumulating experience suggests that patients with extremely poor lung function who are deemed inoperable by conventional criteria might tolerate combined LVRS and curative-intent resection of lung cancer with an acceptable mortality rate and good postoperative outcomes. Combining LVRS and lung cancer resection should be considered in patients with a cancer in an area of upper lobe emphysema, an FEV(1) of > 20% predicted, and a Dlco of > 20% predicted. CONCLUSIONS: A careful preoperative physiologic assessment will be useful to identify those patients who are at increased risk with standard lung cancer resection and to enable an informed decision by the patient about the appropriate therapeutic approach to treating their lung cancer. This preoperative risk assessment must be placed in the context that surgery for early-stage lung cancer is the most effective currently available treatment for this disease.

Palliative care consultation, quality-of-life measurements, and bereavement for end-of-life care in patients with lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition).

OBJECTIVE: To develop clinical practice guidelines for application of palliative care consultation, quality-of-life measurements, and appropriate bereavement activities for patients with lung cancer. METHODS: To review the pertinent medical literature on palliative care consultation, quality-of-life measurements, and bereavement for patients with lung cancer, developing multidisciplinary discussions with authorities in these areas, and evolving written guidelines for end-of-life care of these patients. RESULTS: Palliative care consultation has developed into a new specialty with credentialing of experts in this field based on extensive experience with patients in end-of-life circumstances including those with lung cancer. Bereavement studies of the physical and emotional morbidity of family members and caregivers before, during, and after the death of a cancer patient have supported truthful communication, consideration of psychological problems, effective palliative care, understanding of the patient's spiritual and cultural background, and sufficient forewarning of impending death. CONCLUSION: Multidisciplinary investigations and experiences, with emphasis on consultation and delivery of palliative care, timely use of quality-of-life measurements for morbidities of treatment modalities and prognosis, and an understanding of the multifaceted complexities of the bereavement process, have clarified additional responsibilities of the attending physician.

Wedge resection for non-small cell lung cancer in patients with pulmonary insufficiency: prospective ten-year survival.

BACKGROUND: Possibility of curative resection by lobectomy for non-small cell lung cancer is often denied patients with compromised pulmonary reserve. Analysis of survival of such patients treated by wedge resection was compared with that of patients treated by standard resection, with both groups followed for 10 years. DESIGN: A prospective 5-year cohort study. METHODS: From 1988 to 1992, an observational cohort of 127 consecutive resected patients at Memphis VA Medical Center was divided into those receiving lobectomy in 81 cases and pneumonectomy in 15 cases (group I) versus 31 patients with compromised pulmonary reserve (group II), who had complete tumor excision by wedge resection. Preoperative clinical staging was corrected to surgical-pathological staging after demonstration of its superiority. Survival estimates were obtained by Kaplan-Meier method with curves compared by log rank tests, with all-cause mortality calculated from date of surgery. RESULTS: Extent of disease in group I was 58% stage I, 19% stage II, and 23% stage III. In group II, extent of disease was 84% stage I, 3% stage II, and 14% stage III. Group I median survival was 26 months with 30% 5-year survival; for group II, median survival was 30 months and 32%. Kaplan-Meier survival plots showed similar curves in groups I and II. Realizing less extent of disease in group II, another Kaplan-Meier plot restricted to stage I and II patients showed overlapping survival curves for groups I and II. CONCLUSION: Survival during 10-year observation was similar for patients with pulmonary insufficiency treated by wedge resection to that of patients receiving standard resection in this single-institution consecutive cohort.

End-of-life care in patients with lung cancer.

Evidence-based practice guidelines for end-of-life care for patients with lung cancer have been previously available only from the British health-care system. Currently in this setting, there has been increasing concern in attaining control of the physical, psychological, social, and spiritual distress of the patient and family. This American College of Chest Physicians'-sponsored multidisciplinary panel has generated recommendations for improving quality of life after examining the English-language literature for answers to some of the most important questions in end-of-life care. Communication between the doctor, patient, and family is central to the active total care of patients with disease that is not responsive to curative treatment. The advance care directive, which has been slowly evolving and is presently limited in application and often circumstantially ineffective, better protects patient autonomy. The problem-solving capability of the hospital ethics committee has been poorly utilized, often due to a lack of understanding of its composition and function. Cost considerations and a sense of futility have confused caregivers as to the potentially important role of the critical care specialist in this scenario. Symptomatic and supportive care provided in a timely and consistent fashion in the hospice environment, which treats the patient and family at home, has been increasingly used, and at this time is the best model for end-of-life care in the United States.

The Leper Hospital of St Mary Magdalene at Baldock, Hertfordshire.

The remains of the old Leper Hospital in Baldock have been identified. In the parish church of St Mary's in Clothall, medieval glass roundels show Mary Magdalene with left sided facial palsy. This is the oldest visual art depiction of this condition.

The leper Hospital of St Mary Magdalene at Baldock, Hertfordshire

The remains of the old Leper Hospital in Baldock have been identified. In the parish church of St Mary's in Clothall, medieval glass roundels show Mary Magdalene with left sided facial palsy. This is the oldest visual art depiction of this condition.