The use of PET/CT imaging in the work-up and management of patients with lung cancer has greatly increased in recent decades. The ability to combine functional and anatomical information has equipped PET/CT to look into various aspects of lung cancer, allowing more precise disease staging and providing useful data during the characterization of indeterminate pulmonary nodules. In addition, the accuracy of PET/CT has been shown to be greater than is that of conventional modalities in some scenarios, making PET/CT a valuable noninvasive method for the investigation of lung cancer. However, the interpretation of PET/CT findings presents numerous pitfalls and potential confounders. Therefore, it is imperative for pulmonologists and radiologists to familiarize themselves with the most relevant indications for and limitations of PET/CT, seeking to protect their patients from unnecessary radiation exposure and inappropriate treatment. This review article aimed to summarize the basic principles, indications, cancer staging considerations, and future applications related to the use of PET/CT in lung cancer.

Keywords: Carcinoma, non-small-cell lung; Small cell lung carcinoma; Positron-emission tomography; Tomography, X-ray computed; Neoplasm staging.

Objective: To determine the CT findings of multiple cavitary lung lesions that allow the differentiation between benign and malignant etiologies. Methods: We reviewed CT scans, including patients with two or more cavitary lung lesions. We evaluated the number of cavitary lesions, their location, cavity wall thickness, and additional findings, correlating the variables with the diagnosis of a benign or malignant lesion. Results: We reviewed the chest CT scans of 102 patients, 58 (56.9%) of whom were male. The average age was 50.5 ± 18.0 years. Benign and malignant lesions were diagnosed in 74 (72.6%) and 28 (27.4%) of the patients, respectively. On the CT scans, the mean number of cavities was 3, the mean wall thickness of the largest lesions was 6.0 mm, and the mean diameter of the largest lesions was 27.0 mm. The lesions were predominantly in the upper lobes, especially on the right (in 43.1%). In our comparison of the variables studied, a diagnosis of malignancy was not found to correlate significantly with the wall thickness of the largest cavity, lymph node enlargement, emphysema, consolidation, bronchiectasis, or bronchial obstruction. The presence of centrilobular nodules correlated significantly with the absence of malignant disease (p < 0.05). In contrast, a greater number of cavities correlated significantly with malignancy (p < 0.026). Conclusions: A larger number of cavitary lung lesions and the absence of centrilobular nodules may be characteristic of a malignant etiology. However, on the basis of our evaluation of the lesions in our sample, we cannot state that wall thickness is a good indicator of a benign or malignant etiology.

Keywords: Lung neoplasms/diagnosis; Lung diseases/diagnosis; Tomography, X-ray computed; Neoplasms.

Objective: To compile fiberoptic bronchoscopy findings in patients diagnosed with lung cancer and to correlate those with histopathological findings. Methods: This was a retrospective study involving 212 patients with a confirmed diagnosis of lung cancer by cytological evaluation of BAL specimens or by histopathological evaluation of endobronchial or transbronchial biopsy specimens. The data were collected at the Respiratory Endoscopy Section of Hospital São Salvador, located in the city of Goiânia, Brazil, between 2005 and 2010. The endoscopic findings were classified as endoscopically visible tumor, endoscopically invisible tumor, and mucosal injury, as well as being classified by the presence/type of secretion. The visible tumors were also classified according to their location in the tracheobronchial tree. Results: Endobronchial mass (64%) and mucosal infiltration (35%) were the main endoscopic findings. The histological type was determined in 199 cases, the most prevalent types being squamous carcinoma, in 78 (39%), adenocarcinoma, in 42 (21%), small cell carcinoma, in 24 (12%), and large cell carcinoma, in 2 (1%). More than 45% of the visible tumors were at the upper bronchi. Squamous carcinoma (n = 78) was most commonly visualized as an endobronchial mass (in 74%), mucosal infiltration (in 36%), luminal narrowing (in 10%), or external compression (in 6%). Conclusions: Our results show that an endobronchial mass is the most common bronchoscopic finding that is suggestive of malignancy. Proportionally, mucosal infiltration is the most common finding in small cell carcinoma. In adenocarcinoma, luminal narrowing, external compression, mucosal injury, and endobronchial secretion prevail.

Keywords: Lung neoplasms/diagnosis; Lung neoplasms/classification; Bronchoscopy.

Although lung cancer (LC) is one of the most common and lethal tumors, only 15% of patients are diagnosed at an early stage. Smoking is still responsible for more than 85% of cases. Lung cancer screening (LCS) with low-dose CT (LDCT) reduces LC-related mortality by 20%, and that reduction reaches 38% when LCS by LDCT is combined with smoking cessation. In the last decade, a number of countries have adopted population-based LCS as a public health recommendation. Albeit still incipient, discussion on this topic in Brazil is becoming increasingly broad and necessary. With the aim of increasing knowledge and stimulating debate on LCS, the Brazilian Society of Thoracic Surgery, the Brazilian Thoracic Association, and the Brazilian College of Radiology and Diagnostic Imaging convened a panel of experts to prepare recommendations for LCS in Brazil. The recommendations presented here were based on a narrative review of the literature, with an emphasis on large population-based studies, systematic reviews, and the recommendations of international guidelines, and were developed after extensive discussion by the panel of experts. The following topics were reviewed: reasons for screening; general considerations about smoking; epidemiology of LC; eligibility criteria; incidental findings; granulomatous lesions; probabilistic models; minimum requirements for LDCT; volumetric acquisition; risks of screening; minimum structure and role of the multidisciplinary team; practice according to the Lung CT Screening Reporting and Data System; costs versus benefits of screening; and future perspectives for LCS.

Keywords: Lung neoplasms; Early detection of cancer; Tomography, X-ray computed; Tobacco use disorder.

Recurrent pleural effusion, which is commonly seen in clinical practice, compromises patient quality of life, especially in patients with advanced malignant disease. The therapeutic approach to the pleural space involves a wide range of techniques, including aggressive procedures such as pleurectomy. Among such techniques, pleurodesis is the most frequently used. Pleurodesis can be induced through the insertion of pleural catheters, as well as through major surgical procedures (such as thoracotomy). There are various recommended sclerosing agents, including talc (which is the most widely used), silver nitrate and, recently, proliferative cytokines. This article summarizes the principal approaches to the treatment of recurrent pleural effusion, pleurodesis in particular, addressing the indications for, as well as the advantages and disadvantages of, their application in daily pulmonology practice.

Keywords: Pleural effusion, malignant/prevention & control; Pleural neoplasms; Pleura/surgery; Pleurodesis/methods; Silver nitrate; Talc; Recurrence

Lung cancer screening (LCS) programs are increasing worldwide. Incidental findings (IFs) on LCS are defined as low-dose CT findings unrelated to the primary purpose of identifying lung cancer. Most IFs on LCS are benign and clinically insignificant but are being increasingly recognized, and some require urgent referral for further diagnostic workup. Other findings are expected and are known as smoking-related comorbidities, including COPD, cardiovascular disease, emphysema, and interstitial lung disease, and their diagnosis can have a significant impact on patient prognosis. The purpose of this pictorial essay is to illustrate the most common IFs on LCS, organized by organ. We will discuss the current literature on IFs on LCS, focusing on their prevalence, appropriate communication, and triggering of clinical pathway systems.

Keywords: Diagnostic screening programs; Lung neoplasms; Incidental findings.

Objective: To investigate the applicability of ultrasound imaging of the diaphragm in interstitial lung disease (ILD). Methods: Using ultrasound, we compared ILD patients and healthy volunteers (controls) in terms of diaphragmatic mobility during quiet and deep breathing; diaphragm thickness at functional residual capacity (FRC) and at total lung capacity (TLC); and the thickening fraction (TF, proportional diaphragm thickening from FRC to TLC). We also evaluated correlations between diaphragmatic dysfunction and lung function variables. Results: Between the ILD patients (n = 40) and the controls (n = 16), mean diaphragmatic mobility was comparable during quiet breathing, although it was significantly lower in the patients during deep breathing (4.5 ± 1.7 cm vs. 7.6 ± 1.4 cm; p < 0.01). The patients showed greater diaphragm thickness at FRC (p = 0.05), although, due to lower diaphragm thickness at TLC, they also showed a lower TF (p < 0.01). The FVC as a percentage of the predicted value (FVC%) correlated with diaphragmatic mobility (r = 0.73; p < 0.01), and an FVC% cut-off value of < 60% presented high sensitivity (92%) and specificity (81%) for indentifying decreased diaphragmatic mobility. Conclusions: Using ultrasound, we were able to show that diaphragmatic mobility and the TF were lower in ILD patients than in healthy controls, despite the greater diaphragm thickness at FRC in the former. Diaphragmatic mobility correlated with ILD functional severity, and an FVC% cut-off value of < 60% was found to be highly accurate for indentifying diaphragmatic dysfunction on ultrasound.

Keywords: Diaphragm/ultrasonography; Lung diseases, interstitial; Respiratory muscles; Respiratory function tests.

Endometriosis is a benign gynecological disorder associated with pelvic pain and infertility, primarily affecting women of reproductive age. Thoracic endometriosis affects the pulmonary parenchyma or pleura. We report the cases of two patients with pleural endometriosis who presented with recurrent pneumothorax. In both cases, magnetic resonance imaging (MRI) of the chest showed right hydropneumothorax and well-defined, rounded nodules on the pleural surface in the right hemithorax. We conclude that MRI is a good option for the characterization of pleural endometriotic nodules and hemorrhagic pleural effusion.

Keywords: Endometriosis; Magnetic resonance imaging; Pneumothorax.

The relationship between cancer and coagulopathy was suggested by Trousseau nearly 150 years ago. Later, it became more evident that oncologic patients are at a higher risk of experiencing thromboembolic events. This can be due to activation of the coagulation system either by neoplastic cells or by prescribed therapies (chemotherapy or surgical procedures). In fact, these events can constitute the first manifestation of cancer, and their recurrence, despite efficient anticoagulation, has been described. The coagulation system is normally activated in order to provide healing. In the presence of neoplasms, this complex system is activated as a response to multiple stimuli and seems to contribute to cancer progression. Activation of the coagulation system has a greater effect on metastatic foci than on the primary tumor. However, most cancer victims die from complications caused by metastasis, which underscores the importance of this theme. In this area, various mechanisms have been described, creating promising perspectives for future treatments. The current success in using low-molecular-weight heparins against small cell lung cancer is encouraging. Although the knowledge of those mechanisms is relatively incipient, many basic research and clinical studies are underway.

Keywords: Lung neoplasms; Thrombophilia.

Objective: To describe the mortality trends for lung cancer, cancer of the trachea, and bronchial cancer in relation to gender and age brackets in Brazil. Methods: Data related to mortality between 1980 and 2003 were collected from the Brazilian Mortality Database. A trend analysis of mortality was carried out, nationwide and in selected states, using the LOWESS technique for rate smoothing and model adjustments. Results: In Brazil, the standardized mortality rate for lung cancer, cancer of the trachea, and bronchial cancer increased from 7.21/100,000 inhabitants in 1980 to 9.36/100,000 inhabitants in 2003. Specific mortality rates decreased in males in the 30-49 and 50-59 age brackets. In the 60-69 age bracket, the rates for males increased from 1980 to 1995 and declined thereafter. There was a trend toward higher mortality rates in males over 70, as well as in females over 30, throughout the period evaluated. Conclusions: The decrease in the mortality rates in younger males might have resulted from recent national interventions aimed at reducing the prevalence of smoking and reducing exposure in younger cohorts. High mortality rates in older populations remained constant due to prior tobacco use. Increased mortality rates in females are a worldwide trend and are attributable to the recent increase in smoking prevalence in females.

Keywords: Lung neoplasms/epidemiology; Mortality/trends; Brazil.

We report the case of a child with tetraplegia after cervical trauma, who subsequently underwent diaphragmatic pacemaker implantation. We reviewed the major indications for diaphragmatic pacing and the types of devices employed. We highlight the unequivocal benefit of diaphragmatic pacing in the social and educational reintegration of individuals with tetraplegia.

Keywords: Spinal cord injuries; Respiration, artificial; Pacemaker, artificial; Quadriplegia.

A review of the role of radiotherapy in lung cancer is presented, with the most recent innovations. Indications for postoperative irradiation and chemo-radiotherapy in non-small cell lung cancer are discussed. Recommendations are made for prophylactic cranium irradiation and perspectives of thoracic radiotherapy for small cell lung cancer. Recent techniques and results of the "Brazilian Consensus on Lung Cancer - Radiotherapy" are also presented.

Lung cancer is one of the most incident types of cancer and a leading cause of cancer mortality in Brazil. We reviewed the current status of lung cancer by searching relevant data on prevention, diagnosis, and treatment in the country. This review highlights several issues that need to be addressed, including smoking control, patient lack of awareness, late diagnosis, and disparities in the access to cancer health care facilities in Brazil. We propose strategies to help overcome these limitations and challenge health care providers, as well as the society and governmental representatives, to work together and to take a step forward in fighting lung cancer.

Keywords: Lung neoplasms/epidemiology; Lung neoplasms/therapy; Lung neoplasms/diagnosis; Biomarkers; Brazil.

Background: Lung cancer is the leading cause of cancer-related death worldwide. Objective: To determine the time spent diagnosing, staging and surgically treating lung cancer in a university hospital. Method: Between January 1990 and December 1998, 69 (53 male, 16 female) patients were diagnosed with lung cancer and underwent surgery. The hospital records of these patients were reviewed to evaluate clinical and histological data, dates of outpatient visits, hospital admission, tests and procedures, as well as to determine if the patients were examined as inpatients or as outpatients. Results: The 15 patients investigated as outpatients were designated as group I, the 28 examined as both inpatients and outpatients as group II, and the 26 investigated as inpatients as group III. Age ranged from 43 to 79 years (mean ± SD; 61 ± 10). Of the 69 patients, 43 were smokers and 23 were ex-smokers. The mean time from onset of symptoms to the first outpatient visit was 110 days and 33 days from the first outpatient visit until diagnosis. There was a lapse of 25 days between diagnosis and surgery. The mean total elapsed time between the first outpatient visit and surgery was 58 days. The mean total time was 72 days for group I, 72 days for group II, and 35 days for group III (p < 0.01). There was no significant difference regarding total time in relation to the different stages of the disease (p = 0.16). Conclusions: The results show that patients waited too long before seeking medical assistance and that medical treatment of lung cancer was further delayed when patients were examined in an outpatient setting.

Keywords: Lung neoplasm/surgery. Disease progression.

Carcinoma of the lung can present in a number of guises and a number of possible and often complementary diagnostic approaches are available. The choice of procedure should reflect the presentation of the tumor, local expertise, intended management and patient preference. There are different methods of investigation: sputum cytology, fiberbronchoscopy, transbronchial biopsy, transbronchial needle aspiration, transthoracic fine needle aspiration, etc. The association of all of these methods increases the power of diagnosis. Staging is the measurement of the anatomical extent of a tumor in any given patient. The staging of cancer began with Denoix's TNM classification system, and, although several modifications were developed, it remains the basis of lung cancer staging systems up to now. Assigning patients to a particular TNM stage allows choosing the most appropriate therapy and provides prognostic information. Also, the impact of new therapeutic methods can be evaluated for efficacy and a comparison of the expected survival rates can be predicted.

Objective: To analyze principal histological types of lung cancer, as well as the staging, treatment and survival of lung cancer patients. Methods: This was a retrospective study based on the analysis of medical charts of patients treated at the Botucatu School of Medicine Hospital das Clínicas over a six-year period. Results: From January of 2000 to January of 2006, 240 patients with lung cancer, most (64%) of whom were male, were treated. The most common histological type was squamous cell carcinoma (37.5%), followed by adenocarcinoma (30%), neuroendocrine carcinoma (19.6%) and large cell carcinoma (6.6%). Only 131 patients (54.6%) were treated. Of those, 52 patients (39.7%) received only chemotherapy, 32 (24.4%) were treated with chemotherapy combined with radiotherapy, and 47 (35.9%) were submitted to surgery alone or surgery accompanied by chemotherapy, with or without radiotherapy. Only 27 patients (20.6%) were submitted to surgery alone. Concerning staging, 34.4% presented stage IV at the time of diagnosis, 20.6% presented stage IIIB, 16.8% presented stage IIIA, and the remaining 28.2% were classified as stage I or II. Five-year survival was 65% for those in stage I and 25% for those in the remaining stages. Conclusions: Of the various histological types, the most common was squamous cell carcinoma and the least common was large cell carcinoma. Most cases presented advanced stages at the moment of diagnosis, and less than 30% of the cases presented early stages. This accounts for the low survival rate and the small number of patients submitted to surgical treatment alone, the majority being submitted to chemotherapy alone.

Keywords: Carcinoma, bronchogenic; Lung neoplasms/histology; Lung neoplasms/drug therapy; Lung neoplasms/radiotherapy; Surgery; Survival.

Lung cancer is the leading cause of cancer-related deaths worldwide. Promising new therapies have recently emerged from the development of molecular targeted drugs; particularly promising are those blocking the signal transduction machinery of cancer cells. One of the most widely studied cell signaling pathways is that of EGFR, which leads to uncontrolled cell proliferation, increased cell angiogenesis, and greater cell invasiveness. Activating mutations in the EGFR gene (deletions in exon 19 and mutation L858R in exon 21), first described in 2004, have been detected in approximately 10% of all non-squamous non-small cell lung cancer (NSCLC) patients in Western countries and are the most important predictors of a response to EGFR tyrosine-kinase inhibitors (EGFR-TKIs). Studies of the EGFR-TKIs gefitinib, erlotinib, and afatinib, in comparison with platinum-based regimens, as first-line treatments in chemotherapy-naïve patients have shown that the EGFR-TKIs produce gains in progression-free survival and overall response rates, although only in patients whose tumors harbor activating mutations in the EGFR gene. Clinical trials have also shown EGFR-TKIs to be effective as second- and third-line therapies in advanced NSCLC. Here, we review the main aspects of EGFR pathway activation in NSCLC, underscore the importance of correctly identifying activating mutations in the EGFR gene, and discuss the main outcomes of EGFR-TKI treatment in NSCLC.

Keywords: Molecular targeted therapy; Receptor, epidermal growth factor; Lung neoplasms/drug therapy; Mutation; Oncogenes.