Objective: EBUS-TBNA cytological sampling is routinely performed for pathological diagnosis, mediastinal staging, and molecular testing in lung cancer patients. EBUS-TBNA samples are not formally accepted for testing programmed death-ligand 1 (PD-L1) expression. The objective of the study was to compare the feasibility, reproducibility, and accuracy of PD-L1 expression assessment in cytological specimens and histological samples. Methods: We prospectively collected histological (transbronchial forceps biopsy) and cytological (EBUS-TBNA) samples from peribronchial neoplastic lesions during an endoscopic procedure at the same target lesion for the pathological diagnosis and molecular assessment of stage IV non-small cell lung cancer (NSCLC). Results: Fifteen patients underwent the procedure. Adequate cytological samples (at least 100 neoplastic cells) were obtained in 12 cases (92.3%). Assessment of PD-L1 expression was similar between histological and cytological samples (agreement rate = 92%). Sensitivity and diagnostic accuracy of EBUS-TBNA cytological specimens were 88.9% and 100%, respectively. Conclusions: The evaluation of PD-L1 expression in EBUS-TBNA cytological specimens is feasible and presents good reproducibility when compared with routine histological samples. EBUS-TBNA cytological samples could be used for the assessment of PD-L1 expression in patients with NSCLC as a minimally invasive approach in stage IV NSCLC cancer patients.

Keywords: Ultrasonography; Biopsy, needle; Lung neoplasms; Molecular targeted therapy.

In this era of immunosuppression and transplantation, it is imperative that laboratory scientists remain in close communication with physicians. In patients receiving immunosuppressive therapy, the diagnosis of mycoses must be rapid, which is complicated, requiring the cooperation and collaboration of a number of professionals from various fields of expertise. In this paper, the laboratory diagnosis of pulmonary fungal infection is reviewed. The following topics are included: host factors such as immunological response and predisposing anatomical features; collection, transport and storage of specimens; laboratory processing of samples; direct microscopy; staining techniques, culture and identification of fungi; laboratory biosafety; tissue tropism and reactions; serology; and antigen detection.

Keywords: Mycology; Laboratories, hospital; Diagnostic techniques and procedures; Lung diseases, fungal.

The main objectives of tuberculosis therapy are to cure the patients and to minimize the possibility of transmission of the bacillus to healthy subjects. Adverse effects of antituberculosis drugs or drug interactions (among antituberculosis drugs or between antituberculosis drugs and other drugs) can make it necessary to modify or discontinue treatment. We briefly review the new guidelines for the pharmacological treatment of tuberculosis, introduced by the Brazilian National Ministry of Health in 2009, and describe the general mechanism of action, absorption, metabolization, and excretion of the first-line drugs used in the basic regimen. We describe adverse drug reactions and interactions (with other drugs, food, and antacids), as well as the most appropriate approach to special situations, such as pregnancy, breastfeeding, liver failure, and kidney failure. We also describe the mechanisms by which the interactions among the antituberculosis drugs used in the basic regimen can cause drug-induced hepatitis, and we discuss the alternatives in this situation.

Keywords: Tuberculosis; Drug interactions; Antibiotics, antitubercular; Pharmacologic actions; Drug toxicity; Drug-induced liver injury.

The evaluation of patients with lung cancer involves not only the detection of enlarged mediastinal lymph nodes and the delineation of the relationship between the primary lesion with the mediastinal structures but also the determination of extra thoracic metastases. This article reviews the major imaging techniques that are currently used to stage bronchogenic carcinoma. Radiologic studies have made an important impact on the evaluation of the solitary pulmonary nodule. Mediastinal staging coupled with imaging methods is not accurate. CT and MR imaging of the chest and abdomen are often used to stage a known or suspected lung carcinoma. Despite their limitations, CT and MR prevent unnecessary thoracotomies and invasive procedures. MR can be helpful in the evaluation of parts of the chest not well shown on CT. PET-FDG imaging complements chest CT in the noninvasive evaluation of lung cancer and strategies for its use merit further investigation.

Keywords: Radiology. Bronchogenic carcinoma. Lung neoplasms. Diagnostic imaging. Emission-computed tomography. Nuclear magnetic resonance.

Once a rare disease, lung cancer has become the most common type of lethal cancer throughout the world. This change has occurred since the 1920s , when it was observed both in Europe and in North America that the number of the cases began to increase. Although mentioned sporadically in the medical literature in the first half of the century, it was in 1950 that several well-performed case-controlled studies first suggested tobacco smoking as the overwhelming cause of lung cancer. It took even more years before results of large prospective studies, like the pioneering work of Doll and Hill, convinced both the public and the governments that smoking is the most important cause of the disease. Histologically, lung cancer is divided into four major subgroups: squamous-, adeno-, small cell, and large cell carcinomas. In a substantial number of cases, however, accurate histological diagnosis may be difficult, due to both intrinsic tumor heterogeneity and to inter-observer variability. Kreyberg suggested that only squamous and small cell carcinomas were caused by tobacco smoking, but most of the more recent studies indicate that the majority of adenocarcinomas is also caused by tobacco smoking. In all studies the proportion of adenocarcinoma is much higher in females than in males and secular trends during 1980s and 1990s have shown an increase in the occurrence of adenocarcinoma. Most occupational carcinogens, with the exception of chloromethyl ethers and radiation (radon), which have a higher tendency to promote small cell lung cancer, give rise to tumors with a histological distribution that is similar to tumors caused by tobacco smoke.

Keywords: Lung cancer. Epidemiology.

Lung cancer is a multifactorial disease. Hereditary, genetic, and environmental factors interact in its genesis. The principal risk factor for lung cancer is smoking. However, the workplace provides an environment in which there is a risk of exposure to carcinogens. The International Agency for Research on Cancer currently lists 19 substances/work situations/occupations that have been proven to be associated with lung cancer (group 1). Thorough occupational history taking is not widely practiced in patients with lung cancer, which has a negative impact on the investigation of causality and, consequently, on the identification of cases of occupational cancer. The objectives of this review were to list the agents that are recognized as causes of lung cancer, to discuss the contribution of occupation to the development of the disease, to cite national studies on the subject, and to propose a list of procedures that are essential to the appropriate investigation of causality between lung cancer and occupation.

Keywords: Lung neoplasms; Occupational diseases; Occupations; Carcinogens.

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.

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.

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.

Objective: To analyze the association between paracoccidioidomycosis (Pcm) and cancer in a series of 25 cases and to review the literature on this topic. Methods: A retrospective review of 25 cases diagnosed with Pcm and cancer, retrieved from a series of 808 consecutive adult patients diagnosed with Pcm based on tests conducted in the Mycology Laboratory of the Santa Casa Complexo Hospitalar, in the city of Porto Alegre, Brazil, between 1972 and 2007. The diagnosis of Pcm was confirmed by means of direct microscopic examination, histopathological examination or immunodiffusion test. All cancer cases were confirmed by histopathological or cytopathological examination. Results: Respiratory symptoms were the principal complaints of the patients evaluated. Pulmonary involvement predominated, followed by skin and lymph node involvement. The most prevalent tumor was bronchial carcinoma, in 15 patients, followed by other types of carcinoma, and 1 patient had Hodgkin's lymphoma. In 16 patients (64%), the site of the Pcm was the same as that of the tumor. In most cases, Pcm treatment consisted of the isolated administration of sulfanilamide, sulfamethoxazole-trimethoprim, ketoconazole, itraconazole or amphotericin B. The most common treatment for cancer was surgery, followed by radiotherapy and chemotherapy. Of the 25 patients, 12 were cured of Pcm, and 4 died. In 9 patients, the final outcome was unknown. In the general population of the area under study, the prevalence of lung cancer was significantly higher in smokers with Pcm than in smokers without Pcm (p < 0.001). Conclusions: A diagnosis of Pcm appears to increase the risk of lung cancer.

Keywords: Paracoccidioides; Paracoccidioidomycosis; Neoplasms.

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.

A 79 year-old man sought treatment in the emergency room complaining of persistent fever, chest pain, and general fatigue. A chest X-ray showed a giant infectious bulla (24 cm in diameter) in the left lung. The patient had no history of abnormalities on X-rays, and his latest medical check-up, conducted in the preceding year, had produced no abnormal findings. Diagnostic procedures, including bronchoscopy, revealed lung cancer (large cell carcinoma) in the left lower bronchus. The tumor obstructed the airway. Although there have been various reports of giant bullae, their etiology remains unknown. We suggest that an obstruction, such as that caused by the tumor in this case, can lead to air trapping, resulting in the formation of a bulla. In the case of a giant bulla that rapidly increases in size, lung cancer should be included in the differential diagnosis.

Keywords: Lung neoplasms/complications; Infection; Drainage.

The presence of mediastinal lymph node metastasis in lung cancer has a great influence on treatment selection and prognosis, and the diagnosis of lymphatic metastasis must be accurate. CT chest scans and mediastinoscopy are the diagnostic tools available to detect mediastinal lymph node metastases and to establish preoperative staging. Lymph node size evaluated by CT scans is not an acceptable criterion in the patients studied here. The aim of this study was to find out a representative pattern of size to indicate the possibility of neoplastic invasion in the population studied. Fifty consecutive patients were operated on and were submitted to pulmonary resection and mediastinal dissection to treat lung cancer. Seventy-four percent of the lymph nodes with transverse section of more than 3 cm had no neoplastic invasion. CT scans and mediastinoscopy have similar sensitivity (close to 65%), but mediastinoscopy has higher specificity (100%). This means that the authors must have histologic confirmation of any suspected lymph node to achieve a correct staging.

Keywords: Carcinoma, non-small cell. Lung neoplasias. Lymph nodes. Lymphatic metastasis. Mediatinoscopy. Neoplasm, staging. CT scanning.

The authors analyze the nutritional status of patients with lung cancer. 131 patients, 96 (73.3%) male and 35 (26.7%) female, were classified into three groups: I - malnourished patients; II - eutrophic patients and III - obese patients. Most of the malnourished had anorexia (59.7%), which was not seen in the eutrophic (25%) and obese patients (26.1%). More than 70% of patients reported some degree of previous weight loss at the initial evaluation, weight loss being higher among malnourished patients. Weight loss was observed in more than 60% of the patients during the follow-up period of 3 months after the first evaluation. Patients with squamous carcinoma neoplasms prevailed in the malnourished group whereas adenocarcinoma was more prevalent in the other two groups. Most patients had advanced stages of the disease.

Keywords: Lung cancer. Nutritional status.

Silica is one of the main occupational agents associated with lung cancer. It is classified by the International Agency for Research on Cancer (IARC) as a Group 1 substance, i.e., carcinogenic for humans, since 1996. The objective of this paper is to report two cases of workers previously exposed to silica who developed lung cancer, seen in an out-patient clinic, focusing on important points of the current literature on the subject.