Effective radiation dose from cone beam CT guidance during bronchoscopic tumor ablation.

Introduction Endobronchial radiofrequency ablation (RFA) is a novel minimally invasive approach to management of peripheral non-small cell lung cancer (NSCLC) in medically inoperable patients. Minimally invasive ablative techniques are generally delivered withCone-beam computed tomography (CBCT) guidance. CBCT requires a significant number of two dimensional imaging projections to be acquired which is then reconstructed as a three dimensional cone beam image. The objective of this study was to determine the radiation dosimetry consequent to use of CBCT guidance for bronchoscopic RFA. Methods Post hoc analysis of data following bronchoscopic RFA of stage I biopsy-confirmed NSCLC performed with CBCT. Effective dose estimates for these patients were calculated using PCXMC2.0 software. Results Ten patients underwent bronchoscopic RFA, with a median 3 (range 2-4) CBCT spins per procedure. Mean dose area product (DAP) per procedure was 7,778 µGy.m2 (± 4743) with an effective dose of 11.6mSv (± 7.4). The DAP per spin for these 10 patients varied from 83.8 to 8,625.6 µGy.m2 (effective dose range 0.15 to 13.81 mSv.) Conclusion This is the first study to report radiation dosimetry consequent to CT guidance for bronchoscopic RFA procedures. Effective doses appear comparable to other CT-fluoroscopic procedures.

Long-term outcomes in surgically intervened empyema patients: a systematic review.

BACKGROUND: Pleural empyema is significant cause of morbidity and mortality. Debate in the literature exists regarding the best initial and definitive therapy, with recent research demonstrating superior short-term outcomes with initial surgical intervention. Despite this, the impact of surgical intervention on long-term outcomes has been incompletely described. A systematic review was undertaken to assess the current evidence evaluating the long-term impact of surgical intervention. METHODS: A systematic review was undertaken according to PRISMA guidelines utilizing three databases. Articles included all papers where patients received surgical intervention for empyema with outcomes evaluated beyond 90 days. Two reviewers extracted and reviewed the articles. Grey literature was included. RESULTS: Eleven studies and two abstracts were extracted. One study and two abstracts evaluated the quality of life outcomes, two studies evaluated dyspnoea outcomes, seven studies evaluated long-term lung function and two studies evaluated mortality and re-admissions. 60-65% of patients had no dyspnoea between 2 and 7 years follow-up. In six of seven studies, normal lung function was achieved in patients with chronic fibrothorax with FEV1% and FVC% improvements between 14-30% and 13-50%, respectively. The results from such biased cohorts could not be extrapolated to conclude that surgical intervention results in better outcomes than ICC drainage. Risk of bias was severe for all 11 studies. CONCLUSION: Surgical intervention potentially improves post-operative lung function, long-term dyspnoea, and mortality. The impact this has on quality of life remains unknown. Future prospective trials with homogenous comparative groups are required to better define the role of surgery and its impact on long-term outcomes.

Pleural abrasion versus apical pleurectomy for primary spontaneous pneumothorax: a systematic review and Meta-analysis.

BACKGROUND: Surgical approach is the most effective treatment for primary spontaneous pneumothorax. The two most widely adopted surgical methods are mechanical abrasion and apical pleurectomy, in addition to bullectomy. We performed a systematic review and meta-analysis to examine which technique is superior in treating primary spontaneous pneumothorax. METHODS: PubMed, MEDLINE and EMBASE databases were searched for studies published between January 2000 to September 2022 comparing mechanical abrasion and apical pleurectomy for treatment of primary spontaneous pneumothorax. The primary outcome was pneumothorax recurrence. Secondary outcomes included post-operative chest tube duration, hospital length of stay, operative time and intra-operative of blood loss. RESULTS: Eight studies were eligible for inclusion involving 1,613 patients. There was no difference in the rate of pneumothorax recurrence between pleural abrasion and pleurectomy (RR: 1.34; 95% CI: 0.94 to 1.92). However, pleural abrasion led to shorter hospital length of stay (MD: -0.25; 95% CI: -0.51 to 0.00), post-operative chest tube duration (MD: -0.30; 95% CI: -0.56 to -0.03), operative time (MD: -13.00; 95% CI -15.07 to 10.92) and less surgical blood loss (MD: -17.77; 95% CI: -24.36 to -11.18). CONCLUSION: Pleural abrasion leads to less perioperative patient burden and shorter hospital length of stay without compromising the rate of pneumothorax recurrence when compared to pleurectomy. Thus, pleural abrasion is a reasonable first choice surgical procedure for management of primary spontaneous pneumothorax.

Early immune pressure initiated by tissue-resident memory T cells sculpts tumor evolution in non-small cell lung cancer.

Tissue-resident memory T (TRM) cells provide immune defense against local infection and can inhibit cancer progression. However, it is unclear to what extent chronic inflammation impacts TRM activation and whether TRM cells existing in tissues before tumor onset influence cancer evolution in humans. We performed deep profiling of healthy lungs and lung cancers in never-smokers (NSs) and ever-smokers (ESs), finding evidence of enhanced immunosurveillance by cells with a TRM-like phenotype in ES lungs. In preclinical models, tumor-specific or bystander TRM-like cells present prior to tumor onset boosted immune cell recruitment, causing tumor immune evasion through loss of MHC class I protein expression and resistance to immune checkpoint inhibitors. In humans, only tumors arising in ES patients underwent clonal immune evasion, unrelated to tobacco-associated mutagenic signatures or oncogenic drivers. These data demonstrate that enhanced TRM-like activity prior to tumor development shapes the evolution of tumor immunogenicity and can impact immunotherapy outcomes.

Safety and Feasibility of a Novel Externally Cooled Bronchoscopic Radiofrequency Ablation Catheter for Ablation of Peripheral Lung Tumours: A First-In-Human Dose Escalation Study.

BACKGROUND: Radiofrequency ablation (RFA) is an established modality for percutaneous ablation of non-small cell lung cancer (NSCLC) in medically inoperable patients but is underutilized clinically due to side effects. We have developed a novel, completely endobronchial RFA catheter with an externally cooled electrode. OBJECTIVES: The objective of this study was to establish the safety and feasibility of bronchoscopic RFA using a novel, externally cooled catheter for ablation of peripheral NSCLC. METHODS: Patients with stage I biopsy-confirmed NSCLC underwent bronchoscopic RFA of tumour 7 days prior to lobectomy. The RFA catheter was delivered bronchoscopically to peripheral NSCLC lesions, guided by radial endobronchial ultrasound, with positioning confirmed using intra-procedural cone beam CT. Pre-operative CT chest and histologic examination of resected specimens were used to establish distribution/uniformity of ablation and efficacy of tumour ablation. RESULTS: RFA in the first patient was complicated by dispersal of heated saline due to cough, resulting in ICU admission. The patient recovered fully and underwent uncomplicated lobectomy. Subsequently, the protocol was altered to mandate neuromuscular blockade with a pre-determined dose escalation, with algorithm-restricted energy (kJ) and irrigated saline volume (mL) constraints. A further 10 patients consented and seven underwent successful bronchoscopic RFA of peripheral NSCLC. No significant adverse events were noted. Ablation zone included tumour in all cases (proportion of tumour ablated ranged 8-72%), with uniform necrosis of tissue within ablation zones observed at higher energy levels. Ablation zone diameter correlated with RFA energy delivered (R2 = 0.553), with maximum long axis diameter of ablation zone 3.1 cm (22.9 kJ). CONCLUSION: Bronchoscopic RFA using an externally cooled catheter is feasible, appears safe, and achieves uniform ablation within the treatment zone. Uncontrolled escape of heated saline poses a major safety risk but can be prevented procedurally through neuromuscular blockade and by limiting irrigation.

-8 cm H2 O, the new paradigm in chest drain management following thoracoscopic lung resection?

BACKGROUND: Chest drain suction of -20 cm H2 O has been used universally after lung resection. After introducing new guidelines,-8 cm H2 O was used routinely for all non-pneumonectomy, thoracoscopic lung resections. We conducted a review to determine outcomes and safety. METHODS: After introduction of the guidelines data were collected in the study institutions' thoracic surgical database and subsequently analysed. RESULTS: A total of 155 patients underwent thoracoscopic lung resection. Mean patient age was 61.5 ± 13.6 years. Video-assisted thoracoscopic surgery was performed in 92.2% (144/155) of patients and robotically-assisted thoracoscopic surgery was performed in 7.8% (12/155) of patients. Lobectomy was performed in 56.8% (88/155) of patients, segmentectomy was performed in 11.6% (18/155) of patients and wedge resection was performed in 31.6% (49/155) of patients. Median ICC duration time was 1 day (IQR 1-3). Median length of stay was 3 days (IQR 2-6). For patients undergoing lobectomy median ICC time was 2 days (IQR 1-4.5) and median length of stay was 3.5 days (IQR 2-7), for segmentectomy median ICC time was 1 day (IQR 1-5) and median length of stay was 2 days (IQR 1-5) and for wedge resection median ICC time was 1 day (IQR 1-1) and median admission time was 2 days (IQR 1-4). CONCLUSION: A suction level -8 cm H2 O is safe to use for thoracoscopic lung resections from day 0 post-operatively. A dedicated, prospective study comparing levels of suction should be performed.

Effect of a postoperative home-based exercise and self-management programme on physical function in people with lung cancer (CAPACITY): protocol for a randomised controlled trial.

INTRODUCTION: Exercise is important in the postoperative management of lung cancer, yet no strong evidence exists for delivery of home-based programmes. Our feasibility (phase I) study established feasibility of a home-based exercise and self-management programme (the programme) delivered postoperatively. This efficacy (phase II) study aims to determine whether the programme, compared with usual care, is effective in improving physical function (primary outcome) in patients after lung cancer surgery. METHODS AND ANALYSIS: This will be a prospective, multisite, two-arm parallel 1:1, randomised controlled superiority trial with assessors blinded to group allocation. 112 participants scheduled for surgery for lung cancer will be recruited and randomised to usual care (no exercise programme) or, usual care plus the 12-week programme. The primary outcome is physical function measured with the EORTC QLQ c30 questionnaire. Secondary outcomes include health-related quality of life (HRQoL); exercise capacity; muscle strength; physical activity levels and patient reported outcomes. HRQoL and patient-reported outcomes will be measured to 12 months, and survival to 5 years. In a substudy, patient experience interviews will be conducted in a subgroup of intervention participants. ETHICS AND DISSEMINATION: Ethics approval was gained from all sites. Results will be submitted for publications in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ACTRN12617001283369.

Increase in tumour PD-L1 expression in non-small cell lung cancer following bronchoscopic thermal vapour ablation.

Limited early evidence indicates thermal ablation of non-small cell lung cancer (NSCLC) may induce alterations to the immune response that could enhance the efficacy of immunotherapy with immune checkpoint inhibitor therapy. This study reports pilot data demonstrating increased programmed death-ligand 1 (PD-L1) expression on tumour cells in response to bronchoscopic thermal vapour ablation. Five patients underwent bronchoscopic thermal vapour ablation under a treat-and-resect protocol, as part of a clinical safety and feasibility study, with lobectomy performed five days after thermal vapour ablation. PD-L1 (clone SP263) immunohistochemistry (IHC) tumour proportion score (TPS) was assessed on both baseline diagnostic biopsy specimens, and post-ablation resection specimens in five patients with stage I NSCLC. Two areas of the resection sample defined as viable tumour and injured tumour were examined. All tumours demonstrated 0% PD-L1 TPS at baseline. Three of five (60%) patients demonstrated an increase in PD-L1 TPS in areas of injured tumour to 20%, 30% and 50%. One patient demonstrated an increase in PD-L1 expression in an area of viable tumour to 5%. Changes in PD-L1 expression did not correlate with measures of systemic inflammation. Our findings comprise the first evidence that thermal ablation of NSCLC may induce PD-L1 expression. Further investigation is required to determine the extent of an adaptive immune response, and confirm the potential for augmentation of clinical response to immune check point inhibitor therapy in NSCLC.

Thermal ablation in non-small cell lung cancer: a review of treatment modalities and the evidence for combination with immune checkpoint inhibitors.

Lung cancer is the leading cause of cancer death worldwide, with approximately 1.6 million cancer related deaths each year. Prognosis is best in patients with early stage disease, though even then five-year survival is only 55% in some groups. Median survival for advanced non-small cell lung cancer (NSCLC) is 8-12 months with conventional treatment. Immune checkpoint inhibitor (ICI) therapy has revolutionised the treatment of NSCLC with significant long-term improvements in survival demonstrated in some patients with advanced NSCLC. However, only a small proportion of patients respond to ICI, suggesting the need for further techniques to harness the potential of ICI therapy. Thermal ablation utilizes the extremes of temperature to cause tumour destruction. Commonly used modalities are radiofrequency ablation (RFA), cryoablation and microwave ablation (MWA). At present thermal ablation is reserved for curative-intent therapy in patients with localized NSCLC who are unable to undergo surgical resection or stereotactic ablative body radiotherapy (SABR). Limited evidence suggests that thermal ablative modalities can upregulate an anticancer immune response in NSCLC. It is postulated that thermal ablation can increase tumour antigen release, which would initiate and upregulated steps in the cancer immunity cycle required to elicit an anticancer immune response. This article will review the current thermal ablative techniques and their ability to modulate an anti-cancer immune response with a view of using thermal ablation in conjunction with ICI therapy.

Long-term outcomes of pulmonary metastasectomy: a multicentre analysis.

BACKGROUND: Many extrapulmonary neoplasms metastasize to the lungs. We conducted a retrospective review of all patients who underwent pulmonary metastasectomy for oligometastatic disease at two centres in order to determine long-term outcomes. METHODS: The study institutions' thoracic surgery databases were searched for all patients who underwent pulmonary metastasectomy from 2000 to 2017. RESULTS: There were a total of 476 patients who underwent pulmonary metastasectomy. Mean age at time of surgery was 57.2 ± 15.9 years. Mean number of pulmonary lesions was 1.9 ± 1.6. Mean disease-free interval (DFI) was 3.6 ± 4.3 years. The most common primary neoplasms were colorectal cancer (CRC) in 35.1% (167/476), sarcoma in 23.9% (114/476), melanoma in 16.2% (77/478), renal cell carcinoma (RCC) in 7.3% (35/476) and germ cell tumour (GCT) in 4.4% (21/476). Hospital mortality was 0.4% (2/476). Mean follow-up time was 3.8 ± 2.9 years. Survival was 88.9% (95% confidence interval 85.77-91.5) at 1 year and 49.6% (95% confidence interval 44.4-54.6) at 5 years. On multivariate Cox-regression analysis GCT (P = 0.004), CRC (P = 0.03), DFI of 36+ months (P = 0.007), R0 resection (P = 0.002) and non-anatomical, sub-lobar (wedge) resection (P = 0.002) were protective against mortality. CONCLUSION: Pulmonary metastasectomy is associated with survival of 50% at 5-year follow-up. DFI of over 36 months, R0 resections, lesions resectable by wedge resection rather than anatomic resection and GCT and CRC primary cancers were associated with improved survival.

Pulmonary carcinoid tumours: A multi-centre analysis of survival and predictors of outcome following sublobar, lobar, and extended pulmonary resections.

BACKGROUND: Pulmonary carcinoids are rare neoplasms, accounting for approximately 1%-2% of all lung malignancies. A retrospective analysis was undertaken of all patients who underwent surgical resection of pulmonary carcinoid tumours across multiple institutions in Melbourne, Australia. METHODS: From May 2000 through April 2020, 241 patients who underwent surgical resection of pulmonary carcinoid tumours were retrospectively reviewed. Patient demographics, pathologic data, and long-term outcomes were recorded. RESULTS: Median age was 57.7 years and the majority of patients were female (58.9% vs. 41.1%). Typical carcinoid was present in 77.1%. Histological subtype was associated with several factors. Atypical carcinoid was more likely to have larger tumour size and nodal involvement. Overall survival for typical carcinoid at 5, 10, and 15 years was 98%, 95%, and 84%, and for atypical carcinoid was 88%, 82%, and 62%, respectively. Histological subtype and age were found to be independent predictors of overall survival, with worse outcomes for atypical and those above 60 years of age. Disease-free survival was related to sublobar resection (p < 0.001, sub-hazard ratio (SHR): 6.89), lymph node involvement (p = 0.022, SHR: 3.18), and atypical histology (p < 0.001, SHR: 9.89). CONCLUSION: Excellent long-term outcomes can be achieved following surgical resection of pulmonary carcinoids. Atypical histology and lymph node involvement are significant prognostic factors, and sublobar resection should not be considered in patients with either of the above features. Typical carcinoid tumour without nodal involvement may be appropriate for sublobar resection. Typical and atypical carcinoid tumours should be considered distinct disease entities, and as such treated accordingly.

Bronchoscopic Thermal Vapour Ablation for Localized Cancer Lesions of the Lung: A Clinical Feasibility Treat-and-Resect Study.

BACKGROUND: Bronchoscopic thermal vapour ablation (BTVA) is an established and approved modality for minimally invasive lung volume reduction in severe emphysema. Preclinical data suggest potential for BTVA in minimally invasive ablation of lung cancer lesions. OBJECTIVES: The objective of this study is to establish the safety, feasibility, and ablative efficacy of BTVA for minimally invasive ablation of lung cancers. METHODS: Single arm treat-and-resect clinical feasibility study of patients with biopsy-confirmed lung cancer. A novel BTVA for lung cancer (BTVA-C) system for minimally invasive treatment of peripheral pulmonary tumours was used to deliver 330 Cal thermal vapour energy via bronchoscopy to target lesion. Patients underwent planned lobectomy to complete oncologic care. Pre-surgical CT chest and post-resection histologic analysis were performed to evaluate ablative efficacy. RESULTS: Six patients underwent BTVA-C, and 5 progressed to planned lobectomy. Median procedure duration was 12 min. No major procedure-related complications occurred. All 5 resected lesions were part-solid lung adenocarcinomas with median solid component size 1.32±0.36 cm. Large uniform ablation zones were seen in 4 patients where thermal dose exceeded 3 Cal/mL, with complete/near-complete necrosis of target lesions seen in 2 patients. Tumour positioned within ablation zones demonstrated necrosis in >99% of cross-sectional area examined. CONCLUSION: BTVA of lung tumours is feasible and well tolerated, with preliminary evidence suggesting high potential for effective ablation of tumours. Thermal injury is well demarcated, and uniform tissue necrosis is observed within ablation zones receiving sufficient thermal dose per volume of lung. Treatment of smaller volumes and ensuring adequate thermal dose may be important for ablative efficacy.

The role of 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (FDG PET/CT) in assessment of complex invasive fungal disease and opportunistic co-infections in patients with acute leukemia prior to allogeneic hematopoietic cell transplant.

INTRODUCTION: Individuals diagnosed with acute lymphoid and myeloid malignancies are at significant risk of invasive fungal and bacterial infections secondary to their marked immunocompromised states with a significant high risk of mortality. The role of metabolic imaging with 18F-Fluorodeoxyglucose (FDG) Positron Emission Tomography/Computed Tomography (PET/CT) has been increasingly recognized in optimizing the diagnosis of invasive infection, monitoring the response to therapy and guiding the duration of antimicrobial therapy or need to escalate to surgical intervention. METHODS: Two distinct cases of pulmonary co-infection of rare fungal and bacterial pathogens are explored in severely immunocompromised individuals where FDG PET/CT aided both patients to make a full recovery and transition to HCT. The first case explores mixed Scedosporium apiospermum and Rhizomucor pulmonary infection on a background of T cell/myeloid mixed phenotype acute leukemia ultimately warranting long-term antifungal therapy and lobectomy prior to HCT. The second case explores Fusarium and Nocardia pulmonary infection on a background of relapsed AML also warranting surgical resection with lobectomy and long-term antimicrobials prior to transition to HCT. DISCUSSION: The cases highlight the utility of FDG PET/CT to support the diagnosis of infections, including the presence or absence of disseminated infection, and to provide highly sensitive monitoring of the infection over time. FDG PET/CT played a key role in directing therapy duration decisions and prompted the necessity for surgical intervention. Ultimately, the use of FDG PET/CT allowed for a successful transition to HCT highlighting its value in this clinical setting. CONCLUSION: FDG PET/CT has an emerging role in the diagnostic and monitoring pathway for complex infections in high-risk immunocompromised patients.

Low recurrence of lung adenoid cystic carcinoma with radiotherapy and resection.

BACKGROUND: Adenoid cystic carcinoma is a rare cause of thoracic malignancy, and the prognosis may depend on the extent of surgical resection and adjuvant radiotherapy. Complete resection has low rates of local recurrence but is complicated by the involvement of central airways. Adjuvant radiotherapy is frequently recommended but unproven. METHODS: We describe the technicalities of radical resection and adjuvant radiotherapy using the primary endpoint of local recurrence and secondary endpoints of locoregional (mediastinal) recurrence and distant metastasis. Resections were classed as microscopically and macroscopically clear (R0) or only macroscopically clear (R1). RESULTS: Twelve patients (eight males) diagnosed between 1999 and 2016, with an average age of 44 ± 12 years, were included. Six of these were operable (operative group), and six had non-resectable lesions (radiotherapy group). In the operative group, three had tracheal disease and three had bronchial disease. Tracheal lesions underwent excision with tracheal anastomosis (all R1 resections). Main bronchial lesions underwent complete excision via pneumonectomy (two R0 and one R1 resections). All these patients received 50-60 Gray of adjuvant radiotherapy. At an average follow-up of 6.1 ± 4.3 years, no patient had local recurrence, two had locoregional recurrence and four had distant metastasis. The radiotherapy group received 60-70 Gray as definitive therapy, and at an average follow-up of 5.4 ± 4.2 years, three had locoregional recurrence and four had distant metastasis. CONCLUSION: Our case series consolidates evidence that early radical resection and radiotherapy is associated with a low risk of local recurrence in patients with thoracic adenoid cystic carcinoma.

Rare manifestation of Neurofibromatosis type 1: A plexiform neurofibroma involving the mediastinum and lungs with endobronchial neurofibromata.

Neurofibromatosis type 1 (NF1) is a multisystem phakomatosis. The intrathoracic manifestations of NF1 are protean. We describe a rare case of a plexiform neurofibroma infiltrating the mediastinum and lungs with multiple endobronchial neurofibromata. To our knowledge, a mediastinal plexiform neurofibroma extending into the lungs on CT has not been reported.

The Victorian Comprehensive Cancer Centre lung cancer clinical audit: collecting the UK National Lung Cancer Audit data from hospitals in Australia.

BACKGROUND: Clinical audit may improve practice in cancer service provision. The UK National Lung Cancer Audit (NLCA) collects data for all new cases of thoracic cancers. AIM: To collect similar data for our Victorian patients from six hospitals within the Victorian Comprehensive Cancer Centre and associated Western and Central Melbourne Integrated Cancer Service. METHODS: We conducted a retrospective audit of all newly diagnosed patients with lung cancer and mesothelioma in 2013 across the six Victorian Comprehensive Cancer Centre/Western and Central Melbourne Integrated Cancer Service hospitals. The objectives were to adapt the NLCA data set for use in the Australian context, to analyse the findings using descriptive statistics and to determine feasibility of implementing a routine, ongoing audit similar to that in the UK. Individual data items were adapted from the NLCA by an expert steering committee. Data were collated from the Victorian Cancer Registry, Victorian Admitted Episodes Dataset and individual hospital databases. Individual medical records were audited for missing data. RESULTS: Eight hundred and forty-five patients were diagnosed across the sites in 2013. Most were aged 65-80 (55%) and were male (62%). Most had non-small-cell lung cancer (81%) with 9% diagnosed with small cell lung cancer and 2% with mesothelioma. Data completeness varied significantly between fields. For those with higher levels of completeness, headline indicators of clinical care were comparable with NLCA data. The Victorian population seem to lack access to specialist lung cancer nurse services. CONCLUSION: Lung cancer care at participating hospitals appeared to be comparable with the UK in 2013. In future, prospective data collection should be harmonised across sites and correlated with survival outcomes. One area of concern was a lack of documented access to specialist nursing services.

Outcomes following resection of non-small cell lung cancer in octogenarians.

BACKGROUND: The treatment of choice for early stage non-small cell lung cancer (NSCLC) is surgical resection. Little is known about the short- and long-term outcomes among very elderly patients. We sought to determine predictors of short- and long-term survival among octogenarians undergoing curative-intent resection for NSCLC in Victoria, Australia. METHODS: We retrospectively reviewed data from all patients aged ≥80 years who underwent curative-intent resection for NSCLC over 12 years (January 2005-December 2016) across five tertiary centres. We examined effect of age, stage of disease, extent of surgery and lung function on short- and long-term survival. RESULTS: Two hundred patients aged ≥80 years underwent curative-intent resections. Mortality at 30 and 120 days was 2.9% and 5.9%, respectively. Increased early mortality was observed among those ≥83 years, at 30 days (6.8% versus 0.8%, P = 0.044) and 120 days (12.2% versus 2.3%, P = 0.0096). Early mortality was highest among patients ≥83 years requiring lobectomy, compared to sub-lobar resection at 120 days (17% versus 3.8%, P = 0.019). Long-term survival was predicted by age and stage of disease. Among patients with Stage I disease aged <83 years, lobectomy was associated with superior 5-year survival, compared to sub-lobar resection (83% versus 61%, P = 0.02). CONCLUSION: In carefully selected elderly patients undergoing curative-intent resection of early stage NSCLC, both short- and long-term outcomes appear consistent with younger historical cohorts. Early mortality was associated with lobectomy in those with advanced age. Older patients undergoing lobectomy appeared to be at highest risk for early mortality, while younger patients with Stage I disease undergoing at least lobectomy appear to have the best long-term survival.

CAPACITY: A physical activity self-management program for patients undergoing surgery for lung cancer, a phase I feasibility study.

OBJECTIVES: Physical activity is important in lung cancer, yet the majority of patients do not meet minimum weekly recommended activity levels. The objectives of this study were to determine the: 1) feasibility and 2) exploratory effectiveness of a physical activity self-management program aiming to increase physical activity levels of patients undergoing surgery for lung cancer. MATERIALS AND METHODS: Prospective case series including patients with operable lung cancer. The physical activity self-management program, based on international cancer physical activity guidelines, commenced pre-operative (if recruitment occurred ≥7 days before surgery) or post-operative if not, and continued until 8-weeks after surgery. The program included prescription of an unsupervised home aerobic exercise program, taught in an initial face-to-face consultation and followed-up with weekly telephone consultations. This was supplemented with patient education, behaviour change techniques and provision of an activity monitor. The primary endpoint was program feasibility including consent rate and number of consultations delivered. In addition, self-reported physical activity levels, self-efficacy for physical activity, health-related quality of life (HRQoL) and mood was assessed pre- and 8-weeks post-operative. RESULTS: The consent rate was 89%. Thirty-seven patients (54% male, mean age 66 ±â€¯10 years) were included. Only six participants commenced the program before surgery, with most (n = 31) commencing post-operatively. The median [IQR] number of consultations was 4 [3-6] per participant. There was no change in physical activity levels (total estimated mets/week pre-operative median [IQR] 1066 [0-2772], 8 weeks post-operative 924 [346-1752], p = 0.545) or sedentary time (television viewing hours/day pre-operative 4.5 [2.0-9.5], 8-weeks 4.0 [3.0-5.0], p = 0.527) after surgery. CONCLUSION: The physical activity program was feasible when implemented in the post-operative setting. Participants in this feasibility study demonstrated maintenance in physical activity levels 8-weeks after surgery, compared with published literature reporting decline after surgery. A randomised controlled trial is warranted to further investigate potential effectiveness of this intervention.