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N. Girard

 

 

although only limited environmental data are available for rare pulmonary tumors.

In many cases with a localized lesion in the lung parenchyma, initial surgical resection provides both the correct diagnosis and the rst therapeutic step. However, preoperative diagnosis remains important for speci c subtypes, such as lymphoma, for which extensive resection is not warranted, and for sarcoma, which usually does not spread to the mediastinal lymph nodes and thus would not require nodal resection. Surgical biopsy may be required to obtain suf cient tissue material for extensive pathologic and molecular diagnoses, especially when clinical-radiologic presentation is not typical of neoplastic or non-neoplastic disease.

In the absence of evidence-based recommendations, expert consensus is mandatory for selection of a speci c therapeutic strategy, possibly based on strategies developed for lesions of similar histology arising in another anatomic location. As discussed, molecularly-tailored treatment may be useful, and systematic high-throughput genomic analyses, DNA/RNA sequencing, are then recommended. Also, these approaches highlight the need for multicenter collaboration to generate cohorts and to launch observational studies and clinical trials of rare lung tumors.

Ultimately, the management of patients requires continuous multidisciplinary expertise at each step of the disease. There has been a dramatic improvement in our knowledge in the last few years, through the development of large databases, translational research programs, and clinical trials. Access to innovative strategies represents a major challenge, because there is a lack of funding for clinical research in rare cancers as well as in orphan lung diseases and their rarity precludes the design of robust clinical trials that could lead to speci c approval of drugs. In this context, patient-centered initiatives, such as the establishment of dedicated networks, are warranted. International societies, as well as patient advocacy groups provide infrastructure for global collaboration, and there are many advantages to having strong regional groups working on the same issue. There may be regional differences in risk factors, susceptibility, management and outcomes. The ability to address questions both regionally as well as globally is ideal to develop a full understanding of rare pulmonary tumors.

For rare thoracic tumors, the recent establishment of the European Reference Network EURACAN provides an infrastructure of more than 70 healthcare providers with high level of multidisciplinary expertise for the diagnosis, the management and follow-up of patients with rare cancers, including rare thoracic tumors [57]. The objectives of EURACAN include the updating and the assessment of current guidelines, the development of educational programs, dissemination and communication with patients groups, and the establishment of research projects, from the diagnostic workup of the disease to therapeutic strategies. A multidisci-

plinary tumor board is hosted by a pan-European online platform called the Clinical Patient Management System. The European network also provides an infrastructure for collaboration with diagnosis and pharmaceutical companies. One example may be the opening of dedicated cohorts in basket trials, in which patients with different tumors but the same mutation or biomarker receive the same treatment. By using molecular characterization for assessing new drugs, the network allows a better identi cation of patients and facilitates the recruitment in the trials. Integration with European Reference Network-Lung dedicated to rare pulmonary disease is key to address the challenges of differential diagnoses. Achieving the highest quality of patient care is the main objective of EURACAN.

Ultimately, as in cancer management, multidisciplinary expertise and discussion is warranted for the management of orphan lung diseases, from diagnosis, to de nition of pretreatment workup, to therapeutic approach. Implementing multidisciplinary expert and reference networks is ongoing to ensure high level of quality and equality of care of patients.

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