RESUMO
Background: Lung cancers with air lucency are poorly understood, often recognized only after substantial progression. Methods: From a systematic review (PubMed and EMBASE, 2000-2022, terms related to cystic, cavitary, bulla, pseudocavitary, bubble-like, date 10-30-2022) 49 studies were selected using broad inclusion criteria (case series of ≥10 cases up to trials and reviews). There was no source of funding. Primary evidence relevant to clinical management issues was assembled. Because data was available only from heterogeneous retrospective case series, meta-analysis and formal risk-of-bias assessment was omitted. A framework was developed to guide clinical management based on the available data. Results: Demographic, smoking and histologic differences suggest that cystic, cavitary and bullous lung cancers with air lucency may be distinct entities; insufficient data leaves it unclear whether this also applies to pseudocavitary (solid) or bubble-like (ground glass) cancers. Annual observation of irregular thin-walled cysts is warranted; a surgical diagnosis (and resection) is justified once a solid component appears because subsequent progression is often rapid with markedly worse outcomes. Bubble-like ground glass lesions should be managed similarly. Cavitary lesions must be distinguished from infection or vasculitis, but generally require needle or surgical biopsy. Pseudocavitary lesions are less well studied; positron emission tomography may be useful in this setting to differentiate scar from malignancy. Further research is needed because these conclusions are based on interpretation of retrospective case series. Conclusions: The aggregate of available evidence suggests a framework for management of suspected lung cancers with air lucency. Greater awareness, earlier detection, and aggressive management once a solid component appears are needed. This review and framework should facilitate further research; questions include whether the suggested entities and proposed management are borne out and should involve clearly defined terms and outcomes related to progression and treatment. In summary, a conceptual understanding is emerging from interpretation of available data about a previously poorly understood topic; this should improve patient outcomes.
RESUMO
The preoperative impairment of renal function is associated with the need for postoperative renal replacement therapy (RRT) in patients undergoing liver transplantation. The principal goal of this investigation was to identify other factors apparent before or during transplant that were independently associated with the need for RRT in the early posttransplant period. A total of 260 consecutive adult patients who received a primary liver transplant were studied. Twenty-eight patients required early RRT (RRT initiated within 1 wk of transplant); 23 for control of volume overload. Preoperative blood urea nitrogen (odds ratio [95% CI], 1.52 [1.15 to 2.01] per 10 mg/dl), serum creatinine (1.91 [1.06 to 3.44] per 1 mg/dl), and urine output (0.12 [0.03 to 0.44] L/d) were independently predictive of the need for early RRT and in combination formed a parsimonious model that discriminated well (area under the receiver operating characteristic curve, 0.877) and had excellent fit (P = 0.699 to reject model fit). No other potential predictors meaningfully improved predictions of which patients would require early RRT. Patients requiring early RRT consumed more healthcare resources than patients who did not require early RRT, spending more time in intensive care (15 +/- 13 d versus 7 +/- 11 d; P < 0.001) and in the hospital (34 +/- 27 d versus 19 +/- 20 d; P < 0.001). The need for early RRT was strongly associated with death before hospital discharge (29% mortality versus 4% mortality among all others; P < 0.001). The data demonstrate that dependency on RRT in the first week after orthotopic liver transplantation stems almost entirely from preoperative renal dysfunction.
