Beyond clinical trials: real-world impact of immunotherapy on NSCLC in Jordan.

Background: This study aims to evaluate real-world (rw) outcomes of immunotherapy (IO) for advanced stage NSCLC at King Hussein Cancer Center (KHCC) in Jordan. Methods: Advanced stage NSCLC patients who received IO at KHCC between 2017 and 2022 were included. The data were retrospectively collected. PFS and OS were estimated for patients with ECOG performance status (ECOG PS) 0-1. Cox regression analyzed predictors of OS in first-line (1L) IO, regardless of performance status. Results: The total number of patients included was 244. Out of those, 160 (65%), 67 (28%), and 17 (7%) patients received IO as 1L, second-line (2L), or third-line or beyond (3L or beyond), respectively. The median age for all patients was 59 years. Male were 88%, and 77% were smokers. The median follow-up time was 12.5 months. The median PFS and OS for 1L IO were 7 [95% CI 5.8 - 10.3] and 11.8 [95% CI 8.8 - 14.4], months, respectively. In the first 3 months after starting 1L IO, 34/160 (21%) patients had died. For those who survived beyond 3 months after starting 1L IO, the median PFS and OS were 11.3 [95% CI 8.3 - 16.5] and 15.4 [95% CI 13.2 - 21] months, respectively. In the Cox regression model of 1L IO patients with any performance status, ECOG PS 2 was predictive of worse OS compared to ECOG PS 0-1 (p= 0.005). Conclusion: This real-world study of advanced-stage NSCLC patients treated with immunotherapy at KHCC reveals outcomes that fall short of those anticipated from clinical trials. The inclusion of Middle Eastern patients in lung cancer trials is essential to ensure adequate representation of various ethnicities in clinical research.

Maintaining quality of life after major lung resection for carcinoid tumor.

BACKGROUND: Pulmonary carcinoid is a rare diagnosis with surgery remaining the standard treatment of choice. However, resection may impact patients' daily activities due to decreased lung volume reserve and postoperative pain. Our study aims to compare the impact of different types of surgical resection on the post-operative quality of life with the application of a strict peri-operative pulmonary care program. METHODS: Patients who underwent surgery for bronchopulmonary carcinoid tumors in a tertiary cancer center between August, 2017 and March, 2020 were identified and demographic data was collected. Patients were contacted via phone for the qualitative and quantitative assessment of pain and quality of life, utilizing the Arabic version of Short-form McGill Pain Questionnaire and Activity of Daily Living (ADL) instrument respectively. Lung reserve was assessed before and after surgery. Statistical analysis used Chi-Square for categorical variables and ANOVA for continuous variables. RESULTS: A total of 16 patients underwent different type of resection. The majority were male (n = 10; 63%) with a mean age of 44 years (19-81). Most common clinical stage was stage I (n = 12, 75%) with typical carcinoid features recorded in more than half of the cases (n = 11, 69%). Almost all patients underwent surgical excision (n = 15, 94%) with negative resection margin and no major post-operative complications. Bilobectomy was the most frequent procedure (n = 6, 40%) and video-assisted thoracoscopic surgery (VATS) was utilized in 8 patients (50%). Expected changes were recorded in pre- and postoperative pulmonary function test with an average drop of 10 in FEV1 and 14 mL/min/mmHg in DLCO. The majority of patients (n = 15, 94%) were totally independent doing daily activities. Mild intermittent pain was found in 7 patients (44%) who scored an average intensity of 1.6 out of 10. CONCLUSIONS: Excellent long-term outcomes can be achieved following surgical resection of pulmonary carcinoid tumors with little to no effect on patients' lung function and quality of life in regard to performance status and post-operative pain when a good peri-operative pulmonary, physical rehabilitation, and pain management programs are adopted and strictly implemented.

Locally advanced thymoma; does neoadjuvant chemotherapy make a difference?

BACKGROUND: Regardless of its rare occurrence, Thymoma remains the most frequently encountered primary tumor of the anterior mediastinum comprising about 50% of all masses in the region. Surgical resection, via thymectomy, remains the mainstay treatment modality. In locally advanced and borderline resectable tumors, neoadjuvant chemotherapy (NACT) may be utilized to increase the chance of R0 resection, raising the question of its efficacy and safety. METHODS: Demographic and clinical data from patients who presented to a tertiary cancer center between January 2015-October 2021 with a diagnosis of thymoma and underwent curative surgical resection was collected. Computed tomography scan was used to delineate clinical staging, tumor size and to detect post-therapeutic variations in tumor burden. The response evaluation criteria in solid tumors (RECIST) was used to classify the effect of NACT on tumor burden. The pathological response was determined by measuring the percentage of necrotic tissue. RESULTS: A total of 23 patients were diagnosed with thymoma. Most patients were male with a mean age 46 (± 15) years at diagnosis. The most common clinical stage was stage II with 5 patients (22%). A total of 12 patients had NACT as compared to 11 patients who had upfront surgery. The mean change in tumor volume was 165 cm3 (p = 0.079) and the change in and maximum diameter was 1.53 ± 1.49 cm (p < 0.01). The effect of NACT on tumor burden based on RECIST criteria was minimal as 8 patients had stable disease. Based on pathological findings, the average necrotic portion of the tumor was 39.5% (p = 0.152). The overall survival rate is 95.65%, mean survival was 115 months (4-125). Recurrence occurred in 5 patients. The NACT group had a higher risk for recurrence (4; 33.3%) with a mean survival of 43.8 months compared to 59.6 months in those who did not receive induction therapy. CONCLUSIONS: The exact role of induction chemotherapy in locally advanced thymoma patients remains controversial. NACT effect after utilizing radiological and pathological assessment tools was not found to significantly improve oncological outcomes compared to upfront surgery in locally advanced disease, with minimal radiologic and pathologic effect. To further demonstrate the impact of induction chemotherapy, we recommend multicentric collaborative studies.

Early surgical and oncological outcomes during adoption of a single port VATS lung resection in a tertiary cancer center: a retrospective analysis.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) is a safe and effective surgical approach for pulmonary resection. VATS can be accomplished with only a single incision, resulting in less postoperative pain and paresthesia, better cosmetic results, and greater patient satisfaction. Single-port VATS (spVATS) has become increasingly common for lung resection. We assess the early surgical and oncological outcomes after adopting this new technique at our tertiary cancer center as the first institution to do so in the country. METHOD: Medical records for 257 patients in a tertiary cancer center, with a diagnosis of non-small cell lung cancer, pulmonary metastasis, or other chest-confined pathology, were accessed to obtain perioperative outcomes, pathologic results, post-operative follow-up data, and early surgical and oncological outcomes. All patients underwent spVATS for limited or major lung resection. Simple descriptive analysis was utilized. RESULTS: spVATS was either performed with curative intent (79.8%, N = 205), or as a diagnostic procedure (20.2%, N = 52). Resection types were subcategorized for curative intent group as limited (73.6%, N = 151), lobectomy (16.6%, N = 34), and complex (9.7%, N = 20). Resection with a negative margin (R0) rate was 100% for the primary lung cancer (PLC) patients and 97% for the pulmonary metastasectomy (PM) group. The complication rate was 5%. Three-year disease-free survival was 87% and 68.5% for PLC and PM group, respectively. The 3-year overall-survival was 91.3% for the PLC and 82.8% for PM. Operation duration showed a downtrend over the study period in each curative subcategory with a borderline difference in the limited resection (P value = 0.05). CONCLUSION: All the spVATS procedures were successfully performed without perioperative severe complications or mortality, regardless of complexity. R0 resection was excellent. Middle- and long-term efficacies of spVATS for lung cancer require further follow-up. With proper training, appropriate indication and meticulous application, adopting spVATS is safe and feasible technique that does not compromise surgical and oncological outcomes.

Chest wall and diaphragm reconstruction; a technique not well established in literature - case report.

INTRODUCTION: Regardless of its rarity, and indolent clinical course, chest wall tumor places high morbidity and burden on patients especially when invasion to a neighboring structure is found. Once detected, surgery is the cornerstone for treatment of such etiology combined with chemo-radiotherapy. In order to maintain intact respiratory function, chest wall reconstruction must be performed whenever resection is done. Herein, we present a case of chest wall tumor that necessitated three ribs and part of hemidiaphragm resection and reconstruction with optimal post-operative results. CASE PRESENTATION: A 27-year-old male patient who had chest wall and diaphragm reconstruction for a chest wall Ewing sarcoma, using a single patch of expanded polytetrafluoroethylene (ePTFE) mesh with diaphragm implanted into the middle of the mesh. There were no immediate nor post-operative complications. The patient received post-operative radiotherapy with good functional and cosmetic results. CONCLUSION: We present a novel and safe technique for combined chest wall and diaphragmatic resection following excision of an invading tumor while ensuring cosmesis and functionality of the ribcage as well as the diaphragm.

Transdiaphragmatic single-port video-assisted thoracoscopic surgery; a novel approach for pulmonary metastasectomy through laparotomy incision - case series.

BACKGROUND: Pulmonary metastasectomy was performed in the early twentieth century and ever since, it has evolved to be one of the main treatment options for certain metastatic malignancies. The advancement of minimally invasive procedures enabled new techniques to minimize morbidity and improve patient quality of care and overall outcome. CASES PRESENTATION: Herein we present three patients, aged 53, 48, and 27 years, known to have sigmoid, rectal, and non-seminomatous germ cell tumors respectively. All patients were diagnosed to have metastatic lung nodules and underwent laparotomy to excise abdominal tumors followed by trans-diaphragmatic single-port video-assisted thoracoscopic pulmonary metastasectomy. All patients achieved complete surgical tumor excision, and none had pulmonary related complications on follow-up. CONCLUSION: Our prescribed novel trans-diaphragmatic single-port video-assisted thoracoscopic surgery (VATS) technique for synchronous pulmonary metastasectomy and intra-abdominal tumor resection is safe and can achieve complete resection with negative margins.

The impact of a perioperative pulmonary care bundle implementation on postoperative outcomes in 1,665 surgical cancer patients: experience from a tertiary referral cancer center in Jordan.

BACKGROUND: Postoperative pulmonary complications can be a major catastrophic consequence of major surgeries and can lead to increased morbidity, mortality, hospital stay, and cost. Many protocols have been tried to reduce serious adverse outcomes with effective strategies including a bundle of preoperative, intraoperative and postoperative techniques. Using these techniques maybe challenging in developing countries with limited resources even in specialized centers. METHODS: A before-and-after trial comparing our data from the national surgical quality improvement program (NSQIP) based on their reports. Data was collected prospectively for the patients who underwent major surgeries at King Hussein Cancer Center during the year 2017 when the use of the perioperative pulmonary care bundle was mandatory to all surgery teams and compared it with the data collected retrospectively for the patients who underwent the same type of surgeries in the year 2016 when the use of such a bundle was optional. The primary end point is the decrease in incidence of postoperative pulmonary complications. Simple descriptive statistical analysis was used to obtain results. RESULTS: The potential risk factors for postoperative pulmonary complications for 1665 patients divided into 2 groups (2016 vs. 2017); 764 (45.9%) vs. 901 (54.1%), respectively. There were no significant differences regarding gender (male 46.7% vs. 46.4%, P value = 0.891, female 53.3% vs. 53.6%, P value = 0.39), mean of age (53.5 year vs. 5.28 year, P value = 0.296), mean of body mass index (BMI) (28.6 vs. 6%, 28.6, P value = 0.95), smoking status; (69.6% vs. 65.1%, P value = 0.052), ventilator use (0.3% vs. 0.4% P value = 0.693) and chronic obstructive pulmonary disease (1.4% vs. 1.4 with, P value = 0.996).The data showed a significant reduction in postoperative pneumonia between the 2 groups (2016 vs. 2017) (2.7% vs. 0.9%, P value = 0.004) and showed a significant reduction in unplanned intubation, 1.4% in 2016 vs. 0.7% in 2017. CONCLUSIONS: The standardization of perioperative pulmonary care bundle, including smoking cessation, perioperative pulmonary interventions and early mobilization, significantly reduces the incidence of postoperative pulmonary complications in cancer patients. This technique's implementation was feasible easily even with limited resources in a developing country like Jordan.

The influence of pulmonary metastasectomy on survival in osteosarcoma and soft-tissue sarcomas: a retrospective analysis of survival outcomes, hospitalizations and requirements of home oxygen therapy.

OBJECTIVES: Pulmonary metastasectomy for sarcoma is a widely accepted practice. Nevertheless, no previous studies has been reported the outcomes following metastasectomy compared with chemotherapy for patients with resectable and isolated pulmonary metastases. Our aim is to compare these modalities for the subset of patients with resectable metastases. Furthermore, the outcomes for patients with unresectable lung metastases are reported. METHODS: Sarcoma patients with isolated lung metastases were identified and their computed axial tomography scans were reviewed by a thoracic surgeons' committee. Patients were divided into three groups: A: patients with resectable metastases treated with metastasectomy (n=29), B: patients with resectable metastases who received systemic therapy (n=17) and C: patients with unresectable metastases (n=25). Survival outcomes were plotted and compared through log-rank test for osteosarcoma and non-osteosarcoma patients. RESULTS: Seventy-one patients (32 with osteosarcoma and 39 with non-osteosarcoma) were eligible. Progression-free survival (PFS) was superior in patients who belonged to Group A compared with Groups B and C (8.0, 4.3 and 2.2 months, respectively, P=0.0002). Furthermore, overall survival (OS) was superior in patients who belonged to Group A compared with Groups B and C (39.6, 20.0 and 7.8 months, respectively, P<0.0001). A subanalysis for osteosarcoma patients showed superior PFS and OS for Group A vs B (median PFS 21.6 and 3.65 months, respectively, P=0.011 and median OS 34.0 and 12.4 months, respectively, P=0.0044). For non-osteosarcoma patients, there were no such significant survival differences between Groups A and B. Overall, patients who belonged to Group A had significantly lower mean percentage of their follow-up time spent admitted at hospital, and a trend towards lower requirements for home oxygen therapy. CONCLUSIONS: Pulmonary metastasectomy is associated with improved survival of osteosarcoma patients with resectable lung metastases. For non-osteosarcoma patients, the survival benefit of metastasectomy over chemotherapy is uncertain and warrants further evaluation. Patients with unresectable metastases have poor prognosis.