Effect of a Rule-in Biomarker Test on Pulmonary Nodule Management: A Survey of Pulmonologists and Thoracic Surgeons.

INTRODUCTION: The field of biomarker development is evolving to assist in determining benign from malignant pulmonary nodules. Although a prospective clinical utility would best to show how a biomarker affects patient treatment and outcomes, we sought to begin to understand how the results might alter management by determining how physicians would use the results of a rule-in blood test to manage pulmonary nodules. MATERIALS AND METHODS: Pulmonologists and thoracic surgeons in the American College of Chest Physicians clinician database were invited to participate in an online survey. The participant demographic data were collected. Four hypothetical clinical vignettes were presented. The participants accessed the pretest probability (probability of cancer [pCA]) for malignancy and chose the management strategies as the case progressed. The management strategies chosen before and after the result of a rule-in biomarker test were compared and assessed for guideline concordance. RESULTS: Of the 455 eligible participants who had opened the survey, 416 (92%) completed it: 332 pulmonologists and 84 thoracic surgeons. Although 91% of the participants were very comfortable managing nodules, depending on the case, 30% to 62% incorrectly assessed the pCA, with 22% to 62% overestimating the risk and 8% to 51% underestimating the risk. After a rule-in blood test result, the clinician change in management moved in the right direction in some cases but, in others, the physicians used the results incorrectly. Pulmonologists and thoracic surgeons differed in the management strategies, with surgeons recommending surgery more often. CONCLUSIONS: Although the use of biomarker testing for pulmonary nodule evaluation is promising, without proper physician education, the potential for harm exists. Clinical utility studies are needed to appropriately inform the effect of biomarker use.

Screening Adherence in the Veterans Administration Lung Cancer Screening Demonstration Project.

BACKGROUND: Adherence to annual low-dose CT was 95% in the National Lung Screening Trial and must be replicated to achieve mortality benefit from screening. RESEARCH QUESTION: How do we determine adherence rates within the Veterans Affairs Lung Cancer Screening Demonstration Project and identify factors predictive of adherence? STUDY DESIGN AND METHODS: A secondary data analysis of the Lung Cancer Screening Demonstration Project that was conducted at eight Veterans Affairs medical centers was performed to determine adherence to follow up imaging and to determine factors predictive of adherence. RESULTS: A total of 2,103 patients were screened. The adherence to screening from baseline scan (T0) to first follow-up scan (T1) was 82.2% and 65.2% from T1 to second follow-up scan (T2). Logistic regression modeling showed that presence of a nodule and the site of lung cancer screening were predictive of adherence. After three rounds of screening, 1,343 patients (64%) who underwent baseline screening underwent both subsequent annual low-dose CT scans; 225 patients (11%) had only one subsequent low-dose CT; 0.4% did not have a T1 scan but did have a T2 scan; 70 patients (3%) died, and 36 patients (1.7%) were diagnosed with lung cancer. There was significant variation in screening adherence across the eight sites, which ranged from 63% to 94% at T1 and 52% to 82% at T2 (P < .05). INTERPRETATION: Despite a centralized program design with dedicated navigator and registry to assist with adherence to annual lung cancer screening, variations between sites suggest that active follow-up strategies are needed to optimize adherence. For the mortality benefit from lung cancer screening to be recognized, adherence to annual screening must achieve higher rates.

The Urinothorax: A Comprehensive Review With Case Series.

Urinothorax is an uncommon thoracic complication of genitourinary (GU) tract disease, which is most frequently caused by obstructive uropathy, but may also occur as a result of iatrogenic or traumatic GU injury. It is underrecognized because of a perceived notion as to the rarity of the diagnosis and the absence of established diagnostic criteria. Urinothorax is typically described as a paucicellular, transudative pleural effusion with a pleural fluid/serum creatinine ratio >1.0. It is the only transudate associated with pleural fluid acidosis (pH < 7.40). When the pleural fluid analysis demonstrates features of a transudate, pH <7.40 and a pleural fluid/serum creatinine ratio >1.0, a confident clinical diagnosis of urinothorax can be established. A technetium 99m renal scan can be considered a confirmatory test in patients who lack the typical pleural fluid analysis features or fail to demonstrate evidence of obstructive uropathy that can be identified via conventional radiographic modalities. Management of a urinothorax requires a multidisciplinary approach with an emphasis on the correction of the underlying GU tract pathology, and once corrected, this often leads to a rapid resolution of the pleural effusion.