2018年 · 第41卷第10期

This issue focuses on lung cancer.

At present, the overall incidence and mortality of lung cancer in the world are the highest among all malignant tumors^[1]。 According to data from China's Cancer Registration Center, there were 733,300 new lung cancer patients and 620,200 deaths in 2015^[2]。 Foreign smoking cessation campaigns have made the incidence of lung cancer gradually decrease, but the number of smokers in China is still rising, and the high incidence of lung cancer in China is difficult to control in the short term. In the past 10 years, although great progress has been made in the treatment of lung cancer, especially molecular targeted therapy and immunotherapy for advanced lung cancer, the 5-year overall survival rate of lung cancer is still not ideal. Data from the United States show that the 5-year overall survival rate of lung cancer is only 19.5%. The survival time of lung cancer patients with different clinical stages was significantly different: the tumor TNM stage was Ⅰ_A1The 5-year survival rate was 92%^[3]。 Unfortunately, most lung cancer patients are advanced at the initial visit, losing the chance of radical surgery and long-term survival. If it can be diagnosed early and treated in time, it can significantly improve the treatment effect and prolong the survival time of patients. Therefore, early diagnosis and treatment of lung cancer is one of the most important means to improve the prognosis of lung cancer patients at present.

Lung cancer is one of the most common malignant tumors, and its mortality rate ranks first in the world and China. non-small-cell lung cancer (NSCLC) accounts for about 70% to 80% of lung cancer patients^[1]Most of the patients were in advanced stage when they saw the doctor. The brain is a common metastatic site of advanced lung cancer. About 10% of newly diagnosed patients with advanced lung cancer have brain metastasis, and 30% ~50% of advanced lung cancer will eventually have brain metastasis^[2]。 Brain metastases include brain parenchymal metastases and meningeal metastases. The prognosis of NSCLC patients with brain metastases is extremely poor. The natural median survival time is only 1 to 2 months, and even after treatment, the median survival time is only about 7 months, while the survival time of patients with intracranial multiple site metastases is shortened to 3 months^[3]。 The results confirmed that patients with positive driver genes were more likely to develop brain metastases. 3% ~5% of NSCLC patients contain anaplastic lymphoma kinase (ALK) fusion gene^[4,5]The most common type of fusion gene is the fusion gene of echinoderm microtubule associated protein-like 4 (EML4) and ALK (EML4-ALK). The probability of brain metastasis in patients with positive ALK fusion gene at initial diagnosis is 20% ~50%^[6,7]。 Therefore, how to effectively diagnose and treat brain metastasis in patients with ALK fusion gene-positive NSCLC has attracted much attention.

epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKI) have become the first-line standard treatment for patients with mutation-positive non-small cell lung cancer (NSCLC). progress free survival (PFS) is significantly better than that of chemotherapy patients^[1,2,3,4]。 However, most patients will develop drug resistance after about one year of medication. Drug resistance has become a bottleneck limiting the clinical application of EGFR-TKI and is one of the problems to be solved urgently.

The first "Chinese Expert Consensus on Diagnosis and Treatment of Pulmonary Nodules" in 2015^[1]Since its publication, various countries and regions have successively updated the guidelines for the diagnosis and treatment of pulmonary nodules, and the updates of these guidelines and consensus have improved the diagnosis, treatment and management strategies of pulmonary nodules. In this context, in order to keep pace with the times and learn from others' strengths, we summarize the consensus on the diagnosis and treatment of the first pulmonary nodule in China^[1]Experience and problems encountered in the promotion process, and extensively listened to the opinions of multidisciplinary experts, with reference to "Pulmonary nodule assessment: Asian clinical practice guidelines"^[2]And other disciplinary consensus or guidelines^[3,4,5,6,7]Later, the original consensus was revised. The updated contents mainly include the following aspects: the classification of pulmonary nodules is refined, and the precise definition of pulmonary nodules and micronodules is made; The high-risk population of lung cancer in China is defined, and low-dose CT screening is recommended; The imaging diagnosis and differential diagnosis of pulmonary nodules were emphasized; Pay attention to punctual follow-up and observe the external structure and internal characteristics of pulmonary nodules, so as to improve the diagnosis and treatment level of pulmonary nodules by doctors at all levels of hospitals in China.

A 38-year-old male was admitted to the Department of Respiratory Medicine of Zhongshan Hospital affiliated to Fudan University on June 9, 2017 due to "fever, cough and expectoration for 18 days". The patient developed runny nose, fever, cough, and cough a small amount of white phlegm after fatigue on May 22, 2017. The symptomatic treatment did not improve. Chest CT examination at the local hospital (May 28, 2017) showed slight inflammation in both lungs (Figure 1), the blood routine showed that the white blood cells were 7.32×10⁹/L, neutrophils were 0.83, C-reactive protein was 74.2 mg/L, and procalcitonin was 40 ng/L. He was diagnosed as "community-acquired pneumonia". He was given anti-infective treatment with levofloxacin 0.5 g once/d and imipenem 1.0 g twice/d. The symptoms were still progressively aggravated, and the amount of sputum coughed up increased, about 200 ml/d, which was gray-white sputum, and the body temperature was as high as 40 ℃. G test, mycoplasma pneumoniae, sputum smear to find acid-fast bacilli (3 times), sputum culture, blood culture, autoantibodies, etc. were all negative. Re-examination of chest CT (7 Jun 2017) showed inflammatory changes in both pneumonies and multiple cavity formation (Figure 2）。 Since the onset of the disease, the patient has suffered from anorexia, high urine output, informable soft stools, and weight loss of about 2.5 kg.

Acute exacerbation of chronic obstructive pulmonary disease (COPD) is one of the key factors that determine the morbidity, mortality and medical cost of patients with COPD. As the course of COPD progresses, the number of acute exacerbations of patients gradually increases and the condition gradually deteriorates. Therefore, controlling the number of acute exacerbations of patients in stable phase is very critical for treatment^[1]。

Immunotherapy has become the most promising treatment in the field of advanced non-small-cell lung cancer (NSCLC) treatment after molecular targeted therapy. Among various immunotherapy methods, monoclonal antibodies (referred to as monoclonal antibodies for short) against immune checkpoint pathways, especially programmed death receptor-1 (PD-1) and programmed death ligand-1 (PD-L1) are one of the most effective immunotherapy drugs at present. Its mechanism is to release the inhibited state of T cells by blocking the binding of PD-1 and PD-L1, so that T cells can recover their activity, and then eliminate tumor cells. Although a large number of clinical studies have confirmed the significant efficacy of PD-1/PD-L1 monoclonal antibodies on a variety of tumors, the overall objective response rate of PD-1/PD-L1 monoclonal antibodies used alone in patients with advanced NSCLC is only about 20%. Therefore, exploring markers to predict the efficacy of PD-1/PD-L1 monoclonal antibody in the treatment of advanced NSCLC to screen out potential populations that benefit from PD-1/PD-L1 monoclonal antibody treatment is a key issue in lung cancer immunotherapy at present. The research progress of markers to predict the efficacy of PD-1/PD-L1 monoclonal antibodies in the treatment of advanced NSCLC is reviewed below.

Radiomics, also known as radiomics, refers to the extraction and analysis of a large number of quantitative imaging features using computed tomography (CT), positron emission tomography (PET) or magnetic resonance imaging (MRI) methods to obtain feature data of high-throughput imaging of medical images^{[1,2,3,4,5,6]}。 Genomics is a branch discipline that studies the structure and function of the whole genome from the molecular level. Its goal is to understand the structure, function and evolutionary law of genes, clarify all the information and interrelationship of the genetic material covered by the whole genome, and provide scientific basis for the prevention and treatment of human diseases^[7]。 Radiomics is related to genomics, proteomics and other related omics, and promotes each other and develops continuously. Radiogenomics uses imaging to show the changes of human tissue level, cellular and subcellular levels, and realizes the qualitative and quantitative study of its biological behavior on molecular images. Radiogenomics provides great help in disease prevention, diagnosis, treatment, prognosis and drug development, and shows a good prospect in gene function analysis and gene therapy research^[7]。

Lung cancer ranks first in the incidence and mortality of malignant tumors in China^[1]Platinum-based traditional chemotherapy is not effective, although epidermal growth factor receptor (EGFR) -tyrosine kinase inhibitors can significantly improve the prognosis of lung cancer patients with EGFR and other gene mutations^[2,3]But disease progression remains difficult to avoid^[4]。 programmed death receptor-1 (PD-1) and its ligand (PD-L1) inhibitor therapy is one of the promising treatment options for patients with advanced lung cancer^[5]。

Chronic obstructive pulmonary disease (COPD), bronchial asthma (asthma), and bronchopulmonary cancer are common airway diseases that seriously affect human health. At present, CT, extracorporeal high-frequency ultrasound and respiratory intervention techniques are the main diagnostic techniques for airway diseases. However, CT is not high in resolution, and has limited value in the diagnosis of pulmonary peripheral airway, and has a certain radiation dose^[1,2]； Extracorporeal high-frequency ultrasound is limited to low tissue resolution^[3]Moreover, only the cervical tracheal segment can be detected, and the airway located in the chest cavity cannot be clearly imaged; Bronchoscopy can only observe the airway cavity under direct vision, and biopsy by bronchoscopy can only reflect the local tissue morphology, while the resolution of radial ultrasound imaging for airway wall delamination is poor^[4,5,6]。 For chronic airway diseases, mainly small airway lesions, it is difficult to directly observe the morphological changes of small airway with commonly used clinical diagnostic techniques. It is still a big problem and challenge to evaluate the structural remodeling of small airway.

idiopathic pulmonary fibrosis (IPF) is a representative chronic fibrotic lung disease in clinic. The lesions are confined to the lungs and tend to occur in middle-aged and elderly men. The clinical manifestations are progressive aggravation of dyspnea, restrictive ventilation disorder with decreased diffusion volume, chest high-resolution CT (HRCT) and/or histopathological manifestations are usually interstitial pneumonia (UIP) type. IPF has occult onset and unknown etiology. Possible risk factors include smoking, exposure to occupational environment, infection, gastroesophageal reflux, aging and genetic factors. The median survival time is 3 to 5 years^[1,2,3]。 Recent studies have explored the risk prediction model of IPF, graded the severity of the disease, predicted the risk of death, facilitated the clinical selection of appropriate treatment, and conducted clinical research for patients at different disease stages. The research progress of IPF risk prediction model is summarized as follows.

A 78-year-old male, retired worker, was admitted to the hospital on October 6, 2017 due to "cough with runny nose for 15 days and shortness of breath for 5 days". The patient developed cough and runny nose after catching cold 15 days ago, which was paroxysmal cough without expectoration, fear of cold, fever, night sweats, chest pain and hemoptysis. After taking "Ganmaoling and amoxicillin" on his own, there was no improvement. 5 days ago, shortness of breath after activity began to appear, which was aggravated in the recumbent position, accompanied by chest tightness, palpitations, cough and runny nose, no fever, chest pain, lower limb edema, so he went to the emergency department of our hospital. Blood routine showed that white blood cells were 10.3×10⁹/L, neutrophils were 0.64, chest X-ray showed bilateral pleural effusion and slight inflammatory manifestations in the left lung. B-ultrasound-guided bilateral thoracic tubing drained yellow turbid liquid, which was admitted to the hospital for further diagnosis and treatment. There was no significant change in the patient's weight since the onset of the disease. He had a history of "type 2 diabetes" for 7 years in the past. He usually took "metformin and pioglitazone" regularly to control his blood sugar, and his fasting blood sugar was controlled at 6-7 mmol/L. He had no history of smoking and alcoholism. Those without hereditary diseases in their families.

BACKGROUND AND OBJECTIVE: There is no consensus on whether to perform routine transthoracic echocardiography (TTE) in patients with hemodynamically stable acute pulmonary embolism to evaluate the presence or absence of right ventricular injury. This study aims to investigate the correlation between early TTE and prognosis in these patients. Methods: A retrospective analysis of hemodynamically stable hospitalized cases of acute pulmonary embolism (≥18 years of age) in the US Premier Inc. database from 2008 to 2011 was performed. Results: A total of 64 037 inpatients with hemodynamically stable acute pulmonary embolism from 363 hospitals were included, with a mean age of 61.7 years, 54% of them female and 68% white, and 26 925 patients underwent TTE examination. TTE use varied greatly between hospitals (0% to 89%, median 41.4%). Hospital TTE use was associated with patient risk-adjusted mortality (ORValue is 0.88, 95%CI0.69~1.13), thrombolytic drug usage rate (ORValue is 1.28, 95%CI0.84 to 1.96) were not correlated. Hospitals with high TTE use, ICU hospitalization rates of patients (ORValue is 1.57, 95%CI1.18 to 2.07), length of hospital stay (RRValue is 1.08, 95%CI1.03 to 1.15) and the cost of treatment (RRValue is 1.15, 95%CI1.07 to 1.23) was higher. In patients undergoing TTE, thrombolytic therapy (ORValue is 5.58, 95%CI4.40 to 7.09) and the occurrence of serious bleeding events (ORValue is 1.37, 95%CI1.24 to 1.51) is higher. CONCLUSIONS: In the United States, the difference between hospitals regarding whether to perform TTE in patients with hemodynamically stable acute pulmonary embolism varies widely. Hospitals with high TTE use have failed to change the mortality rate of patients, but the medical cost has increased significantly, which further supports the 2016 ACCP pulmonary embolism guidelines that for patients with stable hemodynamics, selective, Rather than routine TTE examination.

Guidelines on evidence-based medicine for the provision of public Health services to Member States and other relevant institutions are one of the core responsibilities of the World Health Organization (WHO). WHO's latest evidence-based medicine guidelines on the treatment of multidrug-resistant tuberculosis (MDR-TB) or rifampicin-resistant tuberculosis (RR-TB) were released in October 2016. Subsequently, WHO collected emerging evidence and formally evaluated it to meet the needs. Cases from clinical trials, cohort studies, observational studies, and planned long-and short-course MDR-TB treatment regimens were anonymously included in the individual patient data base (IPD) of MDRTB and RR-TB established by McGill University in Canada for analysis. The internationally accepted Cochrane meta-analysis method was used to evaluate the relative contribution of single agent to patients' treatment outcome, and relevant information such as the design of MDR-TB and RR-TB treatment regimens, the effect of treatment course and drug resistance spectrum on treatment outcome was given.

Sponsored by Tuberculosis Branch of Chinese Medical Association, undertaken by the Fourth People's Hospital of Taiyuan City, Shanxi Province, and co-organized by Beijing Chest Hospital affiliated to Capital Medical University, Beijing Tuberculosis Diagnosis and Treatment Technology Innovation Alliance, Tuberculosis Prevention and Control Clinical Center of Chinese Center for Disease Control and Prevention, Tuberculosis Research and Training Cooperation Center of World Health Organization, and Beijing Tuberculosis Chest Tumor Research Institute, the 2018 National Tuberculosis Academic Annual Conference was held in Taiyuan City, Shanxi Province from June 13-15, 2018. This conference is one of the large-scale and high-quality academic conferences in the field of tuberculosis in China, with a total of 533 articles submitted and more than 2,300 participants. The theme of the conference is "New drugs help tuberculosis prevention and control". Deputy Secretary-General Wang Dafang of Chinese Medical Association, Deputy Director Xia Gang of Disease Control Bureau of National Health Commission, Academician Rao Zihe of Chinese Academy of Sciences, Vice Mayor Wang Aiqin of Taiyuan City, Shanxi Province, Vice President Chai Zhikai of Shanxi Medical Association, Deputy Director Yin Yanxiang of Shanxi Patriotic Health Association, and Editor-in-Chief Du Xian of People's Medical Publishing House were invited to attend the meeting.