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Current Opinion in Pulmonary Medicine Jan 2024The purpose of this review is to elaborate on the role of medical thoracoscopy for various diagnostic and therapeutic parietal pleural interventions. The renewed... (Review)
Review
PURPOSE OF REVIEW
The purpose of this review is to elaborate on the role of medical thoracoscopy for various diagnostic and therapeutic parietal pleural interventions. The renewed interest in medical thoracoscopy has been boosted by the growth of the field of interventional pulmonology and, possibly, well tolerated and evolving anesthesia.
RECENT FINDINGS
Medical thoracoscopy to obtain pleural biopsies is established largely as a safe and effective diagnostic procedure. Recent data suggest how a pragmatic biopsy-first approach in specific cancer scenarios may be patient-centered. The current scope of medical thoracoscopy for therapeutic interventions other than pleurodesis and indwelling pleural catheter (IPC) placement is limited. In this review, we discuss the available evidence for therapeutic indications and why we must tread with caution in certain scenarios.
SUMMARY
This article reviews contemporary published data to highlight the best utility of medical thoracoscopy as a diagnostic procedure for undiagnosed exudative effusions or effusions suspected to be secondary to cancers or tuberculosis. The potentially therapeutic role of medical thoracoscopy in patients with pneumothorax or empyema warrants further research focusing on patient-centered outcomes and comparisons with video-assisted thoracoscopic surgery.
Topics: Humans; Neoplasms; Pleural Diseases; Pneumothorax; Thoracoscopy
PubMed: 37962206
DOI: 10.1097/MCP.0000000000001039 -
The Surgical Clinics of North America Apr 2024Common mechanisms of blunt thoracic injury include motor vehicle collisions and falls. Chest wall injuries include rib fractures and sternal fractures; treatment... (Review)
Review
Common mechanisms of blunt thoracic injury include motor vehicle collisions and falls. Chest wall injuries include rib fractures and sternal fractures; treatment involves supportive care, multimodal analgesia, and pulmonary toilet. Pneumothorax, hemothorax, and pulmonary contusions are also common and may be managed expectantly or with tube thoracostomy as indicated. Surgical treatment may be considered in select cases. Less common injury patterns include blunt trauma to the tracheobronchial tree, esophagus, diaphragm, heart, or aorta. Operative intervention is more often required to address these injuries.
Topics: Humans; Thoracic Injuries; Wounds, Nonpenetrating; Rib Fractures; Pneumothorax; Thoracotomy
PubMed: 38453306
DOI: 10.1016/j.suc.2023.09.007 -
Current Treatment Options in Oncology Dec 2023Malignant pleural mesothelioma (MPM) is an aggressive asbestos-associated thoracic malignancy that is usually incurable. As demonstrated in the landmark MARS2 trial,... (Review)
Review
Malignant pleural mesothelioma (MPM) is an aggressive asbestos-associated thoracic malignancy that is usually incurable. As demonstrated in the landmark MARS2 trial, surgical resection does not improve survival outcomes and its role in managing MPM is limited. Whilst platinum-pemetrexed chemotherapy in combination with bevacizumab was the standard first-line approach for unresectable disease, landmark phase 3 trials have now established the role of immune checkpoint inhibitors (CPIs) in the upfront management of unresectable disease: either nivolumab-ipilimumab or carboplatin-pemetrexed-pembrolizumab. Patient selection for optimal strategy remains an ongoing question. For relapsed disease novel genomic-based therapies targeting a range of aberrations including losses of the tumour suppressor genes BAP1, CDKN2A and NF2, are being evaluated. Nonetheless, the future of MPM therapeutics holds promise. Here we overview current treatment strategies in the management of MPM.
Topics: Humans; Mesothelioma, Malignant; Mesothelioma; Pemetrexed; Lung Neoplasms; Pleural Neoplasms; Antineoplastic Combined Chemotherapy Protocols
PubMed: 37975977
DOI: 10.1007/s11864-023-01148-2 -
Radiographics : a Review Publication of... Apr 2024The pleura is a thin, smooth, soft-tissue structure that lines the pleural cavity and separates the lungs from the chest wall, consisting of the visceral and parietal... (Review)
Review
The pleura is a thin, smooth, soft-tissue structure that lines the pleural cavity and separates the lungs from the chest wall, consisting of the visceral and parietal pleurae and physiologic pleural fluid. There is a broad spectrum of normal variations and abnormalities in the pleura, including pneumothorax, pleural effusion, and pleural thickening. Pneumothorax is associated with pulmonary diseases and is caused by iatrogenic or traumatic factors. Chest radiography and US help detect pneumothorax with various signs, and CT can also help assess the causes. Pleural effusion occurs in a wide spectrum of diseases, such as heart failure, cirrhosis, asbestos-related diseases, infections, chylothorax, and malignancies. Chest US allows detection of a small pleural effusion and evaluation of echogenicity or septa in pleural effusion. Pleural thickening may manifest as unilateral or bilateral and as focal, multifocal, or diffuse. Various diseases can demonstrate pleural thickening, such as asbestos-related diseases, neoplasms, and systemic diseases. CT, MRI, and fluorodeoxyglucose (FDG) PET/CT can help differentiate between benign and malignant lesions. Knowledge of these features can aid radiologists in suggesting diagnoses and recommending further examinations with other imaging modalities. The authors provide a comprehensive review of the clinical and multimodality imaging findings of pleural diseases and their differential diagnoses. RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.
Topics: Humans; Diagnosis, Differential; Pneumothorax; Positron Emission Tomography Computed Tomography; Pleural Diseases; Pleural Effusion; Asbestos; Pleural Neoplasms
PubMed: 38547031
DOI: 10.1148/rg.230079 -
Histopathology Jan 2024Mesothelioma is a rare disease with an historically poor prognosis. Over the past decade, a grading system has been developed that is a powerful prognostic tool in... (Review)
Review
Mesothelioma is a rare disease with an historically poor prognosis. Over the past decade, a grading system has been developed that is a powerful prognostic tool in epithelioid mesothelioma. Grading of epithelioid mesothelioma is now required or strongly recommended by expert consensus, the College of American Pathologists, the World Health Organization, and the International Mesothelioma Interest Group. The original nuclear grading system for epithelioid mesothelioma, developed in the United States, split epithelioid mesotheliomas into three prognostic groups with marked differences in survival. Now, this three-tiered nuclear grading system has been combined with the presence or absence of necrosis to form the currently recommended two-tiered grading system of low- and high-grade epithelioid mesothelioma. This review will focus on the development of this grading system in mesothelioma, the grading system's shortcomings, and the application of the grading system to cytology specimens and other extra-pleural sites. Lastly, this review will briefly discuss alternative grading systems and future considerations.
Topics: Humans; Pleural Neoplasms; Lung Neoplasms; Neoplasm Grading; Mesothelioma, Malignant; Mesothelioma; Prognosis; Biomarkers, Tumor
PubMed: 37872123
DOI: 10.1111/his.15065 -
Chest Sep 2023Pressure-dependent pneumothorax is a common clinical event, often occurring after pleural drainage in patients with visceral pleural restriction, partial lung resection,... (Review)
Review
Pressure-dependent pneumothorax is a common clinical event, often occurring after pleural drainage in patients with visceral pleural restriction, partial lung resection, or lobar atelectasis from bronchoscopic lung volume reduction or an endobronchial obstruction. This type of pneumothorax and air leak is clinically inconsequential. Failure to appreciate the benign nature of such air leaks may result in unnecessary pleural procedures or prolonged hospital stay. This review suggests that identification of pressure-dependent pneumothorax is clinically important because the air leak that results is not related to a lung injury that requires repair but rather to a physiological consequence of a pressure gradient. A pressure-dependent pneumothorax occurs during pleural drainage in patients with lung-thoracic cavity shape/size mismatch. It is caused by an air leak related to a pressure gradient between the subpleural lung parenchyma and the pleural space. Pressure-dependent pneumothorax and air leak do not need any further pleural interventions.
Topics: Humans; Pneumothorax; Pneumonectomy; Pleural Cavity; Thoracic Surgical Procedures; Pleura
PubMed: 37187435
DOI: 10.1016/j.chest.2023.04.049 -
Annals of Internal Medicine May 2024The field of pulmonology saw significant advances in 2023. The publications highlighted in this article address advances and changes in practice related to asthma,... (Review)
Review
The field of pulmonology saw significant advances in 2023. The publications highlighted in this article address advances and changes in practice related to asthma, chronic obstructive pulmonary disease (COPD), interstitial lung disease, pleural disorders, and sleep-disordered breathing. One article reviews data examining the efficacy of vaccination against respiratory syncytial virus, a respiratory viral illness that has had devastating effects globally. Four studies evaluate the role of various therapies in COPD, including dupilumab, ensifentrine, pulmonary rehabilitation programs, and lung volume reduction versus endobronchial valves. Another study explores the effect on vascular events of positive-pressure ventilation in patients with sleep-disordered breathing and recent stroke. The use of combination therapy with rituximab and mycophenolate mofetil on progression-free survival in patients with nonspecific interstitial pneumonia is the topic of another study. We also highlight an update of clinical recommendations for the evaluation of patients with pleural disorders and a systematic review analyzing the effectiveness of inhaled corticosteroids as a supplement to dual therapy for COPD.
Topics: Humans; Pulmonary Disease, Chronic Obstructive; Pulmonary Medicine; Lung Diseases, Interstitial; Asthma; Pleural Diseases; Sleep Apnea Syndromes
PubMed: 38621245
DOI: 10.7326/M24-0613 -
Minerva Surgery Apr 2024Infections in the pleural space have been a significant problem since ancient times and continue to be so today, with an incidence of 52% in patients with post-pneumonia... (Review)
Review
Infections in the pleural space have been a significant problem since ancient times and continue to be so today, with an incidence of 52% in patients with post-pneumonia syndrome. Typically, these effusions require a combination of medical treatment and surgical drainage, including debridement and decortication. Researchers have been studying the use of intrapleural fibrinolytics in managing complicated pleural effusions and empyema, but there is still ongoing debate and controversy among clinicians. Empyema has traditionally been considered a surgical disease, with antibiotics and chest tube drainage being the initial treatment modality. However, with advances in minimally invasive procedures such as video-assisted thoracoscopic surgery (VATS) and the use of intrapleural fibrinolytics, medical management is now preferred over surgery for many cases of empyema. Surgical options, such as open thoracotomy, are reserved for patients who fail conservative management and have complicated or chronic empyema. This comprehensive review aims to explore the evolution of various management strategies for pleural space infections from ancient times to the present day and how the shift from treating empyema as a surgical condition to a medical disease continues.
Topics: Humans; Empyema, Pleural; Thoracic Surgery, Video-Assisted; Drainage; Pleural Effusion; Thoracotomy
PubMed: 38264874
DOI: 10.23736/S2724-5691.23.09992-6 -
Seminars in Respiratory and Critical... Aug 2023In this review, we provide an update on the status of cancer biomarkers for the clinical management of pleural mesothelioma, an aggressive cancer associated with... (Review)
Review
In this review, we provide an update on the status of cancer biomarkers for the clinical management of pleural mesothelioma, an aggressive cancer associated with asbestos exposure. Mesothelioma can be difficult to diagnose, and response to treatment is transient, even with recently adopted immune checkpoint inhibitor (ICI) combinations. Identification of mesothelioma-specific biomarkers could facilitate early diagnosis and tailor treatment strategies. Mesothelioma is characterized by frequent loss or alteration of the tumor suppressor genes () and () Accumulating data show these genes and/or their related protein products will be valuable tissue-based biomarkers for mesothelioma. Loss of BAP1, CDKN2A, p16, or methylthioadenosine phosphorylase provide pathologists with a reliable means of differentiating between mesothelioma and reactive mesothelial cell proliferations. This can aid diagnosis in difficult cases and is requisite for the identification of the new pathological entity malignant mesothelioma in situ. However, limited progress in identifying clinically useful soluble biomarkers in this cancer type has been made, with mesothelin remaining the benchmark. To date, results from studies to identify predictive biomarkers for ICI response have been disappointing. A recent retrospective study demonstrated BAP1 loss was predictive of improved survival following combination pemetrexed- and platinum-based chemotherapy. Validation of this result could have important clinical implications. Clinical trials aimed at targeting therapy based on biomarker expression are generally in the early phase setting, with overall results being moderate. The identification of biomarkers for mesothelioma remains a key research question due to their potential to improve patient outcomes in this deadly cancer.
Topics: Humans; Mesothelioma, Malignant; Lung Neoplasms; Mesothelioma; Pleural Neoplasms; Biomarkers, Tumor
PubMed: 37253383
DOI: 10.1055/s-0043-1769097 -
Seminars in Respiratory and Critical... Aug 2023Malignant pleural diseases involves both primary pleural malignancies (e.g., mesothelioma) as well as metastatic disease involving the pleura. The management of primary... (Review)
Review
Malignant pleural diseases involves both primary pleural malignancies (e.g., mesothelioma) as well as metastatic disease involving the pleura. The management of primary pleural malignancies remains a challenge, given their limited response to conventional treatments such as surgery, systemic chemotherapy, and immunotherapy. In this article, we aimed to review the management of primary pleural malignancy as well as malignant pleural effusion and assess the current state of intrapleural anticancer therapies. We review the role intrapleural chemotherapy, immunotherapy, and immunogene therapy, as well as oncolytic viral, therapy and intrapleural drug device combination. We further discuss that while the pleural space offers a unique opportunity for local therapy as an adjuvant option to systemic therapy and may help decrease some of the systemic side effects, further patient outcome-oriented research is needed to determine the exact role of these treatments within the armamentarium of currently available options.
Topics: Humans; Mesothelioma, Malignant; Pleural Neoplasms; Pleural Effusion, Malignant; Mesothelioma; Pleura
PubMed: 37308112
DOI: 10.1055/s-0043-1769094