Glucocorticoid Treatment of Symptomatic Sarcoidosis in 2 Morbidly Obese Patients.

Corticosteroid management for patients with sarcoidosis requires the need for close monitoring to detect and manage any complications that may arise during treatment.

Bronchoscopic extraction of a chicken bone 5 years after aspiration.

A 58-year-old man with a remote history of choking on a chicken bone 5 years earlier presented with chronic cough but had no remarkable clinical examination findings. He was being followed for recurrent pneumonias complicated by a resistant empyema, for which he had undergone thoracotomy and decortication. Imaging studies initially missed a foreign body (the chicken bone), which was found on follow-up studies and was removed with a flexible bronchoscope despite the fact that 5 years had passed since the aspiration.

Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines.

BACKGROUND: Correctly staging lung cancer is important because the treatment options and prognosis differ significantly by stage. Several noninvasive imaging studies and invasive tests are available. Understanding the accuracy, advantages, and disadvantages of the available methods for staging non-small cell lung cancer is critical to decision-making. METHODS: Test accuracies for the available staging studies were updated from the second iteration of the American College of Chest Physicians Lung Cancer Guidelines. Systematic searches of the MEDLINE database were performed up to June 2012 with the inclusion of selected meta-analyses, practice guidelines, and reviews. Study designs and results are summarized in evidence tables. RESULTS: The sensitivity and specificity of CT scanning for identifying mediastinal lymph node metastasis were approximately 55% and 81%, respectively, confirming that CT scanning has limited ability either to rule in or exclude mediastinal metastasis. For PET scanning, estimates of sensitivity and specificity for identifying mediastinal metastasis were approximately 77% and 86%, respectively. These findings demonstrate that PET scanning is more accurate than CT scanning, but tissue biopsy is still required to confirm PET scan findings. The needle techniques endobronchial ultrasound-needle aspiration, endoscopic ultrasound-needle aspiration, and combined endobronchial ultrasound/endoscopic ultrasound-needle aspiration have sensitivities of approximately 89%, 89%, and 91%, respectively. In direct comparison with surgical staging, needle techniques have emerged as the best first diagnostic tools to obtain tissue. Based on randomized controlled trials, PET or PET-CT scanning is recommended for staging and to detect unsuspected metastatic disease and avoid noncurative resections. CONCLUSIONS: Since the last iteration of the staging guidelines, PET scanning has assumed a more prominent role both in its use prior to surgery and when evaluating for metastatic disease. Minimally invasive needle techniques to stage the mediastinum have become increasingly accepted and are the tests of first choice to confirm mediastinal disease in accessible lymph node stations. If negative, these needle techniques should be followed by surgical biopsy. All abnormal scans should be confirmed by tissue biopsy (by whatever method is available) to ensure accurate staging. Evidence suggests that more complete staging improves patient outcomes.

Race and lung cancer surgery--a qualitative analysis of relevant beliefs and management preferences.

PURPOSE/OBJECTIVES: To gain a better understanding of beliefs about the utility of lung cancer resection surgery and preferences for lung cancer management among African American and Caucasian adults. RESEARCH APPROACH: Qualitative. SETTING: The Philadelphia Veterans Affairs Medical Center. PARTICIPANTS: 21 participants (9 African Americans and 12 Caucasians; 11 with chronic obstructive pulmonary disease and 10 with lung cancer). METHODOLOGIC APPROACH: Three focus groups were conducted. Transcripts and field notes were coded, grouped into thematic categories, and explored in later focus groups. MAIN RESEARCH VARIABLES: Beliefs about lung cancer resection surgery and management preferences. FINDINGS: African Americans doubted that surgery was needed, questioned its efficacy, and preferred complementary and alternative medicine (CAM). African Americans and Caucasians believed that exposure to air during surgery could cause tumor spread and were skeptical that smoking caused lung cancer. Therefore, they had a sense of treatment futility. Conversely, Caucasians were impatient with forced waiting for surgery. Both groups believed that surgery would be better accepted if current patients met past surgical patients, obtained second opinions, and had trusting patient-provider relationships. CONCLUSIONS: Suspicion about surgeons' motives and perceived ineffectiveness of surgery, as well as support for CAM among African Americans, may contribute to key racial disparities in lung cancer care. INTERPRETATION: If providers understand more clearly the beliefs and preferences that impede acceptance of surgical resection, then they can formulate educational interventions directed at overcoming patient resistance. The clinical utility of such individualized interventions could be evaluated in future studies.

"The air got to it:" exploring a belief about surgery for lung cancer.

BACKGROUND: The belief that exposure of lung cancer to air during surgery causes tumor spread is prevalent but poorly understood. PURPOSE: The purpose of the study was to summarize the published literature on the potential historical origins of this belief, study the recurrence rates of surgically treated stage I nonsmall cell lung cancer, research the mechanisms by which surgery might promote tumor growth and metastasis, and examine the social and cultural implications of this belief. DATA SOURCES: Various databases, reference lists, and expert contacts were the sources of data. FINDINGS: Although the origin of this belief is obscure, its emergence may have been due to early debates within the medical community about the risks of lung biopsies, the significant surgical morbidity initially associated with thoracic surgery, and the difficulty early on of staging lung cancer patients before surgery. Approximately one-third of patients undergoing curative surgery for stage I lung cancer experience a recurrence of the tumor. Most recurrences are detected in the first 24 months after resection and likely reflect the presence of undetected, occult metastases at the time of surgery. Mechanisms by which surgery could promote tumor growth and worsen prognosis include direct seeding of tumor at local sites, tumor manipulation, stimulation of subclinical tumor by postsurgical inflammation, and accelerated metastatic tumor growth due to loss of inhibitory factors derived from the primary tumor. These beliefs are more likely to be prevalent, and resistant to change, in minority and disadvantaged groups. CONCLUSIONS: These findings provide the basis for an approach to patients who fear the spread of their cancer by surgery.

Noninvasive staging of non-small cell lung cancer: ACCP evidenced-based clinical practice guidelines (2nd edition).

BACKGROUND: Correctly staging lung cancer is important because the treatment options and the prognosis differ significantly by stage. Several noninvasive imaging studies including chest CT scanning and positron emission tomography (PET) scanning are available. Understanding the test characteristics of these noninvasive staging studies is critical to decision making. METHODS: Test characteristics for the noninvasive staging studies were updated from the first iteration of the lung cancer guidelines using systematic searches of the MEDLINE, HealthStar, and Cochrane Library databases up to May 2006, including selected metaanalyses, practice guidelines, and reviews. Study designs and results are summarized in evidence tables. RESULTS: The pooled sensitivity and specificity of CT scanning for identifying mediastinal lymph node metastasis were 51% (95% confidence interval [CI], 47 to 54%) and 85% (95% CI, 84 to 88%), respectively, confirming that CT scanning has limited ability either to rule in or exclude mediastinal metastasis. For PET scanning, the pooled estimates of sensitivity and specificity for identifying mediastinal metastasis were 74% (95% CI, 69 to 79%) and 85% (95% CI, 82 to 88%), respectively. These findings demonstrate that PET scanning is more accurate than CT scanning. If the clinical evaluation in search of metastatic disease is negative, the likelihood of finding metastasis is low. CONCLUSIONS: CT scanning of the chest is useful in providing anatomic detail, but the accuracy of chest CT scanning in differentiating benign from malignant lymph nodes in the mediastinum is poor. PET scanning has much better sensitivity and specificity than chest CT scanning for staging lung cancer in the mediastinum, and distant metastatic disease can be detected by PET scanning. With either test, abnormal findings must be confirmed by tissue biopsy to ensure accurate staging.

Change in forced expiratory time and spirometric performance during a single pulmonary function testing session.

BACKGROUND: Among patients with obstructive lung disease, the correlation between clinical improvement and bronchodilator response is poor. Forced expiratory time (FET) may explain some discrepancy, but FET has received little attention. METHODS: We analyzed change in FET during the 3 initial satisfactory flow-volume loops in 102 consecutive patients, 37 with normal spirometry and 65 with airflow obstruction referred to a Veterans Administration pulmonary function testing (PFT) laboratory over 5 months. Patients included both PFT-naïve and PFT-experienced individuals. We also evaluated the relationship between FET and spirometric performance (sum of forced expiratory volume in the first second and forced vital capacity) and the effect of inhaled bronchodilator on FET among patients with airflow obstruction. RESULTS: Normals and patients with airflow obstruction showed significant increments in FET and in spirometric performance during the 3 initial successive pre-bronchodilator attempts (p < 0.001 for both groups). This was true for PFT-naïve and PFT-experienced individuals. There were significant associations between increments in FET and improvements in spirometric performance in all subgroups. After inhaled bronchodilator there was a further FET increment among patients with airflow obstruction (p = 0.009), but there was no significant difference between bronchodilator responders and nonresponders. CONCLUSIONS: Patients with normal pulmonary function and those with obstruction develop longer FET during the initial phases of spirometric testing, regardless of previous PFT experience. Longer FET is associated with better spirometric performance. Bronchodilator administration is associated with modest prolongation of FET, but change in FET did not help identify bronchodilator responders.

Racial differences pertaining to a belief about lung cancer surgery: results of a multicenter survey.

BACKGROUND: Patients at the Philadelphia Veterans Affairs Medical Center frequently voice concern that air exposure during lung cancer surgery might cause tumor spread. Several African-American patients asserted that this belief was common in the African-American community. OBJECTIVE: To assess the prevalence of the belief that air exposure during lung cancer surgery might cause tumor spread and gauge the influence of this belief on the willingness of African-American and white patients to have lung cancer surgery. DESIGN: Prospective questionnaire survey. SETTING: Philadelphia Veterans Affairs Medical Center and University of Pennsylvania, Philadelphia, Pennsylvania; Los Angeles Veterans Affairs Medical Center, Los Angeles, California; and Medical University of South Carolina, Charleston, South Carolina. PATIENTS: 626 consecutive patients in pulmonary and lung cancer clinics. MEASUREMENTS: None. RESULTS: 38% of patients (61% of whom were African American and 29% of whom were white) stated that they believe air exposure at surgery causes tumor spread. The most significant predictor of belief was African-American race (odds ratio, 3.5 [95% CI, 1.9 to 6.5]), even after controlling for other relevant variables in a multivariable analysis. Nineteen percent of African Americans stated that this belief was a reason for opposing surgery, and 14% would not accept their physicians' assertion that the belief is false. These rates were also statistically significantly higher among African-American than white patients. CONCLUSIONS: Belief in accelerated tumor spread at surgery is prevalent among general pulmonary outpatients and lung cancer clinic patients facing lung surgery, particularly among African-American patients. Our findings may pertain to key racial disparities in lung cancer surgery and survival rates and suggest that culturally sensitive physician training or outreach programs directed at disparate beliefs and attitudes may help to address racial discrepancies in health care outcomes.

The noninvasive staging of non-small cell lung cancer: the guidelines.

Correctly staging lung cancer is extremely important because the treatment options and the prognosis differ significantly by stage. Several noninvasive imaging studies are available to aid in identifying disease both within and outside of the chest. Chest CT scanning is useful in providing anatomic detail that better identifies the location of the tumor, its proximity to local structures, and whether or not lymph nodes in the mediastinum are enlarged. Unfortunately, the accuracy of chest CT scanning in differentiating benign from malignant lymph nodes in the mediastinum is unacceptably low. Whole-body positron emission tomography (PET) scanning provides functional information on tissue activity and has much better sensitivity and specificity than chest CT scanning for staging lung cancer in the mediastinum. In addition, metastatic disease can be detected by PET scan. Still, positive findings of PET scans can occur from nonmalignant etiologies (eg, infections), so that tissue sampling to confirm the suspected malignancy must be performed. The clinical evaluation tool, which is composed of a thorough history and physical examination, remains the best predictor of metastatic disease. If the findings from the clinical evaluation are negative, then imaging studies such as a CT scan of the head, a bone scan, or an abdominal CT scan are unnecessary, and the search for metastatic disease is complete. If signs, symptoms, or findings from the physical examination suggest the presence of malignancy, then sequential imaging, starting with the most appropriate study based on the clues obtained by the clinical evaluation, should be performed. Abnormalities detected by all of the aforementioned imaging studies are not always cancer. Unless overwhelming evidence of metastatic disease is present on an imaging study, in situations in which it will make a difference in treatment, all abnormal scan findings require tissue confirmation of malignancy so that patients are not precluded from having potentially curative surgery.