Transesophageal endoscopic ultrasound-guided fine-needle aspiration for the mediastinal staging of extrathoracic tumors: a new perspective.

BACKGROUND: Several extrathoracic tumors metastasize to the mediastinum. Mediastinoscopy is the standard method to obtain tissue proof of mediastinal spread, but drawbacks are its invasiveness, requirement for general anesthesia and costs. Transesophageal endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is indicated in lung cancer staging guidelines as a minimally invasive alternative for surgical staging. The diagnostic values in patients with suspected mediastinal metastases and various (previous) extrathoracic malignancies were assessed. PATIENTS AND METHODS: Consecutive patients with suspected mediastinal metastases (on computed tomography or positron emission tomography) and an (previous) extrathoracic malignancy underwent EUS-FNA. RESULTS: Seventy-five patients with current (n = 14) or previously diagnosed (n = 61) extrathoracic malignancies were evaluated. EUS-FNA detected mediastinal malignancies in 43 patients (57%) [metastases of extrathoracic tumors, n = 36 (48%); second malignancy (lung cancer), n = 7 (9%)]. Mediastinal metastases were found at subsequent surgical staging in seven patients or during follow-up (one patient). In seven patients, an alternative diagnosis was established. Sensitivity, specificity, accuracy and negative predictive value of EUS-FNA for mediastinal staging were 86%, 100%, 91% and 72%, respectively. CONCLUSION: EUS-FNA is a minimally invasive mediastinal staging method for patients with extrathoracic malignancies to confirm nodal metastatic spread and therefore may qualify as an alternative for surgical staging.

[Tiotropium, a long-acting bronchodilating agent for the treatment of COPD]. / Tiotropium, een lang werkende bronchusverwijder voor de behandeling van COPD.

The goals of COPD management according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline are: prevention of disease progression, relief of symptoms, improvement of exercise tolerance and the quality of life, prevention and treatment of exacerbations and complications, and reduction of mortality and adverse effects. These correspond to the goals formulated in the Dutch 'National transmural agreements on COPD'. Bronchodilators play a key role in the pharmacological treatment and with the availability of tiotropium, a long-acting anticholinergic bronchodilator, it has become important to decide at what moment this is indicated in COPD management. In comparative studies, tiotropium was an effective long-acting bronchodilator that had a favourable effect not only on lung function but also on the other parameters indicated in the GOLD guideline. When maintenance treatment with bronchodilators is needed, one should consider a long-acting bronchodilator. In view of the additive positive effects, tiotropium is the bronchodilator of choice. In case of severe symptoms, a combination of tiotropium with a long-acting beta2-sympathicomimetic agent is recommended.

A critical appraisal of prognostic and predictive factors for common lung cancers.

The outlook for patients with lung cancer remains poor despite advances in the understanding of the pathology and biology of this disease. To optimize treatment protocols prognostic data are essential. The current era with molecular research on mRNA expression analysis and proteomics will lead to a plethora of new molecular markers, which are likely to be correlated, at least in part, with each other and with disease activity, progression and survival. However, although the number of prognostic factors analysed in published systematic reviews on lung cancer is large, the scope of these factors in individual studies is often narrow. In daily practice prognostic factors other than general TNM staging are not implemented. To assess the efficacy of new prognostic factors for the management of individual patients with non-small cell lung cancer, studies with clinically relevant modelling are required. In this review arguments are provided to use a model combining radiological and histopathological growth rate, histopathological diagnosis and molecular characteristics as markers for metastatic capacity, tumour volume doubling time and expected response to targeted therapy. This may reveal time-related predictive information useful for treatment guidance of the individual patient.