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1.
CA Cancer J Clin ; 69(5): 402-429, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31283845

RESUMO

Mesothelioma affects mostly older individuals who have been occupationally exposed to asbestos. The global mesothelioma incidence and mortality rates are unknown, because data are not available from developing countries that continue to use large amounts of asbestos. The incidence rate of mesothelioma has decreased in Australia, the United States, and Western Europe, where the use of asbestos was banned or strictly regulated in the 1970s and 1980s, demonstrating the value of these preventive measures. However, in these same countries, the overall number of deaths from mesothelioma has not decreased as the size of the population and the percentage of old people have increased. Moreover, hotspots of mesothelioma may occur when carcinogenic fibers that are present in the environment are disturbed as rural areas are being developed. Novel immunohistochemical and molecular markers have improved the accuracy of diagnosis; however, about 14% (high-resource countries) to 50% (developing countries) of mesothelioma diagnoses are incorrect, resulting in inadequate treatment and complicating epidemiological studies. The discovery that germline BRCA1-asssociated protein 1 (BAP1) mutations cause mesothelioma and other cancers (BAP1 cancer syndrome) elucidated some of the key pathogenic mechanisms, and treatments targeting these molecular mechanisms and/or modulating the immune response are being tested. The role of surgery in pleural mesothelioma is controversial as it is difficult to predict who will benefit from aggressive management, even when local therapies are added to existing or novel systemic treatments. Treatment outcomes are improving, however, for peritoneal mesothelioma. Multidisciplinary international collaboration will be necessary to improve prevention, early detection, and treatment.


Assuntos
Antineoplásicos Imunológicos/uso terapêutico , Biomarcadores Tumorais/análise , Mesotelioma/terapia , Neoplasias Pleurais/terapia , Pneumonectomia/métodos , Amianto/efeitos adversos , Austrália/epidemiologia , Biomarcadores Tumorais/genética , Biomarcadores Tumorais/metabolismo , Carcinogênese/induzido quimicamente , Carcinogênese/genética , Carcinogênese/patologia , Terapia Combinada/métodos , Erros de Diagnóstico , Europa (Continente)/epidemiologia , Predisposição Genética para Doença , Mutação em Linhagem Germinativa , Carga Global da Doença , Humanos , Incidência , Exposição por Inalação/efeitos adversos , Cooperação Internacional , Mesotelioma/diagnóstico , Mesotelioma/epidemiologia , Mesotelioma/etiologia , Terapia de Alvo Molecular/métodos , Exposição Ocupacional/efeitos adversos , Pleura/efeitos dos fármacos , Pleura/patologia , Pleura/cirurgia , Neoplasias Pleurais/diagnóstico , Neoplasias Pleurais/epidemiologia , Neoplasias Pleurais/etiologia , Prognóstico , Proteínas Supressoras de Tumor/genética , Proteínas Supressoras de Tumor/metabolismo , Ubiquitina Tiolesterase/genética , Ubiquitina Tiolesterase/metabolismo , Estados Unidos/epidemiologia
2.
J Comput Assist Tomogr ; 48(2): 222-225, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-37832536

RESUMO

ABSTRACT: The coronavirus disease 2019 (COVID-19) pandemic disrupted health care systems, including implementation of lung cancer screening programs. The impact and recovery from this disruption on screening processes is not well appreciated. Herein, the radiology database of a Northeast tertiary health care network was reviewed before and during the pandemic (2013-2022). In the 3 months before the pandemic, an average of 77.3 lung cancer screening with computed tomography scans (LCS-CT) were performed per month. The average dropped to 23.3 between April and June of 2020, whereas COVID-19 hospitalizations peaked at 1604. By July, average hospitalizations dropped to 50, and LCS-CTs rose to >110 per month for the remaining year. LCS-CTs did not decline during COVID-19 surges in December of 2021 and 2022. The LCS-CT performance grew by 4.5% in 2020, 69.6% in 2021, and 27.0% in 2022, exceeding projected growth by 722 examinations. This resiliency indicates a potentially smaller impact of COVID-19 on lung cancer diagnoses than initially feared.


Assuntos
COVID-19 , Neoplasias Pulmonares , Humanos , Neoplasias Pulmonares/diagnóstico , Pandemias , Detecção Precoce de Câncer/métodos , Atenção à Saúde
3.
Ann Surg Oncol ; 28(9): 4953-4959, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33728541

RESUMO

BACKGROUND: Solitary fibrous tumors (SFTs) are rare mesenchymal tumors most commonly arising from the pleura in the thoracic cavity. The impact of tumor size on risk of recurrence in thoracic SFTs is not well understood. METHODS: A single institution review was performed on all resected thoracic SFTs (1992-2019) with giant SFT defined as ≥ 15 cm. Clinical information, pathologic characteristics, and long-term survival data were collected, and predictors of recurrence and survival were evaluated with regression and Kaplan-Meier analysis. RESULTS: There were 38 thoracic SFTs resected from patients, with the majority of tumors (n = 23, 60.5%) originating from visceral pleura. There were nine (23.7%) giant SFTs with a mean size 20.4 cm (range 17-30 cm). Mean follow-up time was 81.0 months (range 1-261 months), during which 4 of 38 (10.5%) patients experienced a recurrence within the thorax (range 51-178 months). The presence of tumor necrosis (p = 0.021) and ≥ 4 mitoses per high-powered field (p = 0.010) were associated with SFT recurrence on univariate regression. Overall 5-year, 10-year, and 20-year survival was 78.2%, 72.6%, and 42.4%, respectively, and SFT-related mortality occurred in three patients at 83, 180, and 208 months postoperatively. There were no recurrences or SFT-related mortality among patients with giant SFT. CONCLUSION: This study represents one of the largest contemporary single institution reviews of long-term outcomes of giant thoracic SFT. Our data suggest that size is not a risk factor for recurrence in thoracic SFTs and long-term survival is excellent for giant SFTs.


Assuntos
Tumores Fibrosos Solitários , Cavidade Torácica , Humanos , Recidiva Local de Neoplasia/cirurgia , Medição de Risco , Fatores de Risco , Tumores Fibrosos Solitários/cirurgia
4.
Exp Lung Res ; 47(1): 9-25, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33107354

RESUMO

PURPOSE: Malignant pleural mesothelioma (MPM) is a rare and deadly malignancy. Current MPM therapies remain inadequate, and outcomes are often disappointing. New meaningful therapeutic approaches are urgently needed. Accumulating evidence indicates that the cAbl pathway promotes various tumor-stimulating processes in MPM. In this study, we sought to determine ponatinib's potential utility, a clinically approved and potent cAbl inhibitor, in MPM treatment. MATERIAL AND METHODS: Four MPM lines (MSTO211H, H28, H2452, H2052) were treated with ponatinib in vitro, and their growth was assessed. Scratch wound assay was used to investigate the ponatinib effect on cell migration. The expression levels of pAbl and its downstream effectors pCrkL, pAKT, and pSTAT5 were characterized. The in vivo ponatinib effect was evaluated in human MPM cells derived tumor model. RESULTS: In all four MPM lines, significant expression levels of phosphorylated cAbl/Arg and pCrkl were observed. Differentially but strongly, ponatinib inhibited the in vitro cell growth and migration of all four MPM line. Western blot analysis showed that the activation of Abl signaling was blocked in the ponatinib-treated MMP lines. In keeping, the cellular levels of pAbl and its downstream effector pCrkL, pAKT, and pSTAT5 were markedly decrease following ponatinib treatment. Moreover, ponatinib treatment amplified the levels of γH2AX in cells denoting increased double-strand DNA breaks levels. Notably, ponatinib treatment reduced in vivo tumor growth and reduced pCrkl and pSTAT5 levels in tumor samples. CONCLUSION: Ponatinib may offer a new therapeutic strategy for MPM patients based on cAbl signaling pathway inhibition.


Assuntos
Neoplasias Pulmonares , Mesotelioma Maligno , Mesotelioma , Neoplasias Pleurais , Apoptose , Linhagem Celular Tumoral , Humanos , Imidazóis , Neoplasias Pulmonares/tratamento farmacológico , Mesotelioma/tratamento farmacológico , Neoplasias Pleurais/tratamento farmacológico , Piridazinas
5.
Future Oncol ; 17(34): 4785-4795, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-34435876

RESUMO

There remains a critical need for improved staging of non-small-cell lung cancer, as recurrence and mortality due to undetectable metastases at the time of surgery remain high even after complete resection of tumors currently categorized as 'early stage.' A 14-gene quantitative PCR-based expression profile has been extensively validated to better identify patients at high-risk of 5-year mortality after surgical resection than conventional staging - mortality that almost always results from previously undetectable metastases. Furthermore, prospective studies now suggest a predictive benefit in disease-free survival when the assay is used to guide adjuvant chemotherapy decisions in early-stage non-small-cell lung cancer patients.


Lay abstract There is a need for improvement in the way early-stage non-small-cell lung cancers are staged and treated because many patients with 'early-stage' disease suffer high rates of cancer recurrence after surgery. In recent years, a specialized test has been developed to allow better characterization of a tumor's risk of recurrence based on the genes being expressed by tumor cells. Use of this test, in conjunction with standard staging methods, is better able to identify patients at high risk of cancer recurrence after surgery. Evidence suggests that giving chemotherapy to patients at high risk of recurrence after surgery reduces recurrence rates and improves long-term patient survival.


Assuntos
Biomarcadores Tumorais/genética , Carcinoma Pulmonar de Células não Pequenas/mortalidade , Neoplasias Pulmonares/mortalidade , Técnicas de Diagnóstico Molecular/métodos , Recidiva Local de Neoplasia/epidemiologia , Carcinogênese/genética , Carcinoma Pulmonar de Células não Pequenas/diagnóstico , Carcinoma Pulmonar de Células não Pequenas/genética , Carcinoma Pulmonar de Células não Pequenas/terapia , Quimioterapia Adjuvante/estatística & dados numéricos , Tomada de Decisão Clínica , Conjuntos de Dados como Assunto , Intervalo Livre de Doença , Perfilação da Expressão Gênica , Regulação Neoplásica da Expressão Gênica , Humanos , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/genética , Neoplasias Pulmonares/terapia , Técnicas de Diagnóstico Molecular/estatística & dados numéricos , Recidiva Local de Neoplasia/genética , Recidiva Local de Neoplasia/prevenção & controle , Estadiamento de Neoplasias/métodos , Pneumonectomia/estatística & dados numéricos , Estudos Prospectivos , Reação em Cadeia da Polimerase em Tempo Real , Medição de Risco/métodos
9.
Cancer Treat Res ; 170: 47-75, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27535389

RESUMO

The seventh edition of the non-small cell lung cancer (NSCLC) TNM staging system was developed by the International Association for the Staging of Lung Cancer (IASLC) Lung Cancer Staging Project by a coordinated international effort to develop data-derived TNM classifications with significant survival differences. Based on these TNM groupings, current 5-year survival estimates in NSLCC range from 73 % in stage IA disease to 13 % in stage IV disease. TNM stage remains the most important prognostic factor in predicting recurrence rates and survival times, followed by tumor histologic grade, and patient sex, age, and performance status. Molecular prognostication in lung cancer is an exploding area of research where interest has moved beyond TNM stage and into individualized genetic tumor analysis with immunohistochemistry, microarray, and mutation profiles. However, despite intense research efforts and countless publications, no molecular prognostic marker has been adopted into clinical use since most fail in subsequent cross-validation with few exceptions. The recent interest in immunotherapy for NSCLC has identified new biomarkers with early evidence that suggests that PD-L1 is a predictive marker of a good response to new immunotherapy drugs but a poor prognostic indicator of overall survival. Future prognostication of outcomes in NSCLC will likely be based on a combination of TNM stage and molecular tumor profiling and yield more precise, individualized survival estimates and treatment algorithms.


Assuntos
Neoplasias Pulmonares/patologia , Estadiamento de Neoplasias/métodos , Biomarcadores Tumorais/análise , Humanos , Neoplasias Pulmonares/mortalidade , Prognóstico
10.
J Surg Oncol ; 114(7): 838-847, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27569043

RESUMO

BACKGROUND: There is a clear survival benefit to neoadjuvant chemoradiation prior to esophagectomy for patients with stages II-III esophageal cancer. A minimally invasive esophagectomy approach may decrease morbidity but is more challenging in a previously radiated field and therefore patients who undergo neoadjuvant chemoradiation may experience more postoperative complications. METHODS: A prospective database of all esophageal cancer patients who underwent attempted hybrid minimally invasive Ivor Lewis esophagectomy was maintained between 2006 and 2015. The clinical characteristics, neoadjuvant treatments, perioperative complications, and survival outcomes were reviewed. RESULTS: Overall 30- and 90-day mortality rates were 0.8% (1/131) and 2.3% (3/131), respectively. The majority of patients 58% (76/131) underwent induction treatment without significant adverse impact on mortality, major complications, or hospital stay. Overall survival at 1, 3, and 5 years was 85.9%, 65.3%, and 53.9%. Five-year survival by pathologic stage was stage I 68.9%, stage II 54.0%, and stage III 29.6%. CONCLUSIONS: The hybrid minimally invasive Ivor Lewis esophagectomy approach results in low perioperative morbidity and mortality and is well tolerated after neoadjuvant chemoradiation. Good long-term overall survival rates likely resulted from combined concurrent neoadjuvant chemoradiation in the majority of patients, which did not impact the ability to safely perform the operation or postoperative complications rates. J. Surg. Oncol. 2016;114:838-847. © 2016 2016 Wiley Periodicals, Inc.


Assuntos
Carcinoma/cirurgia , Quimiorradioterapia Adjuvante , Neoplasias Esofágicas/cirurgia , Esofagectomia/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Terapia Neoadjuvante , Tumores Neuroendócrinos/cirurgia , Adulto , Idoso , Carcinoma/mortalidade , Carcinoma/terapia , Neoplasias Esofágicas/mortalidade , Neoplasias Esofágicas/terapia , Feminino , Seguimentos , Humanos , Laparoscopia , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/epidemiologia , Tumores Neuroendócrinos/mortalidade , Tumores Neuroendócrinos/terapia , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Análise de Sobrevida , Toracotomia , Resultado do Tratamento
11.
Thorac Surg Clin ; 34(4): 405-414, 2024 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-39332865

RESUMO

Acquired tracheoesophageal fistulas (TEFs) are rare pathologic connections between the trachea and esophagus. Esophageal and tracheal stenting have been increasingly and safely utilized in management of TEFs, but surgical repair remains the most definitive treatment. Surgical approach to treating TEFs depends on its location, but principles include division and closure of the fistula tracts and insertion of a muscle flap in between the repairs to buttress and prevent recurrence. Advances in diagnostic tools, endoscopic and surgical methods, and intensive care have led to significantly improved outcomes in the management of acquired TEFs.


Assuntos
Fístula Traqueoesofágica , Humanos , Fístula Traqueoesofágica/cirurgia , Stents
12.
Clin Lung Cancer ; 25(3): e113-e123, 2024 May.
Artigo em Inglês | MEDLINE | ID: mdl-38310034

RESUMO

Lobectomy has been the standard treatment for stage I lung cancer in healthy patients, largely based on a randomized trial published in 1995. Nevertheless, research has continued regarding the role of sublobar resection. Three additional randomized trials addressing resection extent in healthy patients have recently been published. These 4 trials involve differences in design, eligibility, interventions, and intraoperative processes. Patients were ineligible if intraoperative assessment demonstrated stage > IA or inadequate resection margins. All trials consistently show no differences in perioperative morbidity, mortality, and postoperative changes in lung function between sublobar resection and lobectomy-consistent with other nonrandomized evidence. Long-term outcomes are generally encouraging of lesser resection, but some inconsistencies are apparent. The 2 larger recent trials demonstrated no overall survival difference while the others suggested better survival after lobectomy versus sublobar resection. Recurrence-free survival was found to be the same after lobectomy versus sublobar resection in 3 trials, despite higher locoregional recurrences after sublobar resection. The low 5-year recurrence-free survival (64%, regardless of resection extent) in 1 recent trial highlights the need for further optimization. Thus, there is high-level evidence that sublobar resection is a reasonable alternative to lobectomy in healthy patients. However, variability in long-term results suggests that aspects of patients, tumors and interventions need to be better understood. Therefore, we propose to apply sublobar resection cautiously; especially because there are no short-term benefits. Sublobar resection requires careful attention to intraoperative details (nodes, margins), and may be best suited for less aggressive (eg, ground glass, slow growing) tumors.


Assuntos
Neoplasias Pulmonares , Estadiamento de Neoplasias , Pneumonectomia , Humanos , Neoplasias Pulmonares/cirurgia , Neoplasias Pulmonares/patologia , Pneumonectomia/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto
13.
Chest ; 166(4): 882-895, 2024 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-38885896

RESUMO

A universal nomenclature of the anatomic extent of lung cancer has been critical for individual patient care as well as research advances. As progress occurs, new details emerge that need to be included in a refined system that aligns with contemporary clinical management issues. The ninth edition TNM classification of lung cancer, which is scheduled to take effect in January 2025, addresses this need. It is based on a large international database, multidisciplinary input, and extensive statistical analyses. Key features of the ninth edition include validation of the significant changes in the T component introduced in the eighth edition, subdivision of N2 after exploration of fundamentally different ways of categorizing the N component, and further subdivision of the M component. This has led to reordering of the TNM combinations included in stage groups, primarily involving stage groups IIA, IIB, IIIA, and IIIB. This article summarizes the analyses and revisions for the TNM classification of lung cancer to familiarize the broader medical community and facilitate implementation of the ninth edition system.


Assuntos
Neoplasias Pulmonares , Estadiamento de Neoplasias , Humanos , Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/classificação , Estadiamento de Neoplasias/métodos
14.
Artigo em Inglês | MEDLINE | ID: mdl-38944272

RESUMO

OBJECTIVE: We aimed to characterize chronologic trends of gender composition of the editorial boards of major cardiothoracic surgery journals in the current era. METHODS: A cross-sectional analysis was performed of gender representation in editorial board members of 2 North American cardiothoracic surgery journals from 2008 to 2023. Member names and roles were collected from available monthly issues. Validated software programming was used to classify gender. The annual proportion of women representation was compared to the thoracic surgery workforce. RESULTS: During the study period, 558 individuals (3641 names) were identified, 14.3% of whom were women. The total number of editorial board women increased for both journals. The proportion of women also increased from 2.5% (3 out of 118) in 2008 to 17.8% (71 out of 399) in 2023 (P < .001), exceeding the percentage of women in the thoracic surgery workforce, which increased from 3.8% in 2007 to 8.3% in 2021 (P < .001). The average duration of participation was longer for men than for women (53.8 vs 44.5 months; P = .01). Women in editorial board senior roles also increased from 3.3% (1 out of 30) in 2008 to 28.6% (42 out of 147) in 2023 (P < .001), almost triple the increase in nondesignated roles from 2.3% (2 out of 88) in 2008 to 11.5% (29 out of 252) in 2023 (P < .001). CONCLUSIONS: In recent years, the appointment of women to the editorial boards of high-impact cardiothoracic surgery journals and senior roles have proportionally exceeded the overall representation of women in cardiothoracic surgery. These findings indicate progress in inclusive efforts and offer insight toward reducing academic gender disparities.

15.
Hematol Oncol Clin North Am ; 37(3): 513-531, 2023 06.
Artigo em Inglês | MEDLINE | ID: mdl-37024389

RESUMO

During the last 2 decades, the understanding of non-small cell lung cancer (NSCLC) has evolved from a purely histologic classification system to a more complex model synthesizing clinical, histologic, and molecular data. Biomarker-driven targeted therapies have been approved by the United States Food and Drug Administration for patients with metastatic NSCLC harboring specific driver alterations in EGFR, HER2, KRAS, BRAF, MET, ALK, ROS1, RET, and NTRK. Novel immuno-oncology agents have contributed to improvements in NSCLC-related survival at the population-level. However, only in recent years has this nuanced understanding of NSCLC permeated into the systemic management of patients with resectable tumors.


Assuntos
Carcinoma Pulmonar de Células não Pequenas , Neoplasias Pulmonares , Humanos , Carcinoma Pulmonar de Células não Pequenas/tratamento farmacológico , Carcinoma Pulmonar de Células não Pequenas/genética , Carcinoma Pulmonar de Células não Pequenas/patologia , Neoplasias Pulmonares/tratamento farmacológico , Neoplasias Pulmonares/genética , Neoplasias Pulmonares/patologia , Proteínas Tirosina Quinases/genética , Proteínas Tirosina Quinases/uso terapêutico , Mutação , Proteínas Proto-Oncogênicas/genética , Proteínas Proto-Oncogênicas/uso terapêutico
16.
Lung Cancer ; 180: 107211, 2023 06.
Artigo em Inglês | MEDLINE | ID: mdl-37121213

RESUMO

BACKGROUND: Genetic changes that drive the transition from lepidic to invasive cancer development within a radiographic ground glass or semi-solid lung lesion (SSL) are not well understood. Biomarkers to predict the transition to solid, invasive cancer within SSL are needed. METHODS: Patients with surgically resected SSL were identified retrospectively from a surgical database. Clinical characteristics and survival were compared between stage I SSL (n = 65) and solid adenocarcinomas (n = 120) resected during the same time period. Areas of normal lung, in situ lepidic, and invasive solid tumor were microdissected from within the same SSL specimens and next generation sequencing (NGS) and Affymetrix microarray of gene expression were performed. RESULTS: There were more never smokers, Asian patients, and sub-lobar resections among SSL but no difference in 5-year survival between SSL and solid adenocarcinoma. Driver mutations found in both lepidic and solid invasive portion were EGFR (43%), KRAS (21%), and DNMT3A (5%). CEACAM5 was the most upregulated gene found in solid, invasive portions of SSL. Lepidic and invasive solid areas had many similarities in gene expression, however there were some significant differences with the gene SPP1 being a unique biomarker for the invasive component of a SSL. CONCLUSIONS: Common lung cancer driver mutations are present in in situ lepidic as well as invasive solid portions of a SSL, suggesting early development of driver mutations. CEACAM5 and SPP1 emerged as promising biomarkers of invasive potential in semi-solid lesions. Other studies have shown both genes to correlate with poor prognosis in lung cancer and their role in evolution of semi-solid lung lesions warrants further study.


Assuntos
Adenocarcinoma de Pulmão , Adenocarcinoma , Neoplasias Pulmonares , Humanos , Neoplasias Pulmonares/patologia , Estudos Retrospectivos , Adenocarcinoma de Pulmão/genética , Adenocarcinoma/patologia , Genômica
17.
JTO Clin Res Rep ; 4(12): 100583, 2023 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-38074773

RESUMO

Introduction: The increased use of cross-sectional imaging frequently identifies a growing number of lung nodules that require follow-up imaging studies and physician consultations. We report here the frequency of finding a ground-glass nodule (GGN) or semisolid lung lesion (SSL) in the past decade within a large academic health system. Methods: A radiology system database review was performed on all outpatient adult chest computed tomography (CT) scans between 2013 and 2022. Radiology reports were searched for the terms "ground-glass nodule," "subsolid," and "semisolid" to identify reports with findings potentially concerning for an adenocarcinoma spectrum lesion. Results: A total of 175,715 chest CT scans were performed between 2013 and 2022, with a steadily increasing number every year from 10,817 in 2013 to 21,916 performed in the year 2022. Identification of GGN or SSL on any outpatient CT increased from 5.9% in 2013 to 9.2% in 2022, representing a total of 2019 GGN or SSL reported on CT scans in 2022. The percentage of CT scans with a GGN or SSL finding increased during the study period in men and women and across all age groups above 50 years old. Conclusions: The total number of CT scans performed and the percentage of chest CT scans with GGN or SSL has more than doubled between 2013 and 2022; currently, 9% of all chest CT scans report a GGN or SSL. Although not all GGN or SSL radiographic findings represent true adenocarcinoma spectrum lesions, they are a growing burden to patients and health systems, and better methods to risk stratify radiographic lesions are needed.

18.
J Thorac Dis ; 14(6): 2340-2356, 2022 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-35813719

RESUMO

Background: Clinical decision-making for patients with stage I lung cancer is complex. It involves multiple options (lobectomy, segmentectomy, wedge, Stereotactic Body Radiotherapy, thermal ablation), weighing multiple outcomes (e.g., short-, intermediate-, long-term) and multiple aspects of each (e.g., magnitude of a difference, the degree of confidence in the evidence, and the applicability to the patient and setting at hand). A structure is needed to summarize the relevant evidence for an individual patient and to identify which outcomes have the greatest impact on the decision-making. Methods: Based on a systematic review from 2000-2021, evidence regarding relevant outcomes was assembled, with attention to aspects of applicability, uncertainty and effect modifiers. A framework was developed to present this information a format that enhances decision-making at the point of care for individual patients. Results: While patients often cross over several boundaries, the evidence fits into categories of healthy patients, compromised patients, and favorable tumors. In healthy patients with typical (i.e., solid spiculated) lung cancers, the impact on long-term outcomes is the major driver of treatment selection. This is only slightly ameliorated in older patients. In compromised patients increasing frailty accentuates short-term differences and diminishes long-term differences especially when considering non-surgical vs. surgical approaches; nuances of patient selection (technical treatment feasibility, anticipated risk of acute toxicity, delayed toxicity, and long-term outcomes) as well as patient values are increasingly influential. Favorable (less-aggressive) tumors generally have good long-term outcomes regardless of the treatment approach. Discussion: A framework is provided that organizes the evidence and identifies the major drivers of decision-making for an individual patient. This facilitates blending available evidence and clinical judgment in a flexible, nuanced manner that enhances individualized clinical care.

19.
J Thorac Dis ; 14(6): 2357-2386, 2022 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-35813747

RESUMO

Background: Clinical decision-making for patients with stage I lung cancer is complex. It involves multiple options (lobectomy, segmentectomy, wedge, stereotactic body radiotherapy, thermal ablation), weighing multiple outcomes (e.g., short-, intermediate-, long-term) and multiple aspects of each (e.g., magnitude of a difference, the degree of confidence in the evidence, and the applicability to the patient and setting at hand). A structure is needed to summarize the relevant evidence for an individual patient and to identify which outcomes have the greatest impact on the decision-making. Methods: A PubMed systematic review from 2000-2021 of outcomes after lobectomy, segmentectomy and wedge resection in generally healthy patients is the focus of this paper. Evidence was abstracted from randomized trials and non-randomized comparisons with at least some adjustment for confounders. The analysis involved careful assessment, including characteristics of patients, settings, residual confounding etc. to expose degrees of uncertainty and applicability to individual patients. Evidence is summarized that provides an at-a-glance overall impression as well as the ability to delve into layers of details of the patients, settings and treatments involved. Results: In healthy patients there is no short-term benefit to sublobar resection vs. lobectomy in randomized and non-randomized comparisons. A detriment in long-term outcomes is demonstrated by adjusted non-randomized comparisons, more marked for wedge than segmentectomy. Quality-of-life data is confounded by the use of video-assisted approaches; evidence suggests the approach has more impact than the resection extent. Differences in pulmonary function tests by resection extent are not clinically meaningful in healthy patients, especially for multi-segmentectomy vs. lobectomy. The margin distance is associated with the risk of recurrence. Conclusions: A systematic, comprehensive summary of evidence regarding resection extent in healthy patients with attention to aspects of applicability, uncertainty and effect modifiers provides a foundation on which to build a framework for individualized clinical decision-making.

20.
J Thorac Dis ; 14(6): 2387-2411, 2022 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-35813753

RESUMO

Background: Clinical decision-making for patients with stage I lung cancer is complex. It involves multiple options [lobectomy, segmentectomy, wedge, stereotactic body radiotherapy (SBRT), thermal ablation], weighing multiple outcomes (e.g., short-, intermediate-, long-term) and multiple aspects of each (e.g., magnitude of a difference, the degree of confidence in the evidence, and the applicability to the patient and setting at hand). A structure is needed to summarize the relevant evidence for an individual patient and to identify which outcomes have the greatest impact on the decision-making. Methods: A PubMed systematic review from 2000-2021 of outcomes after lobectomy, segmentectomy and wedge resection in older patients, patients with limited pulmonary reserve and favorable tumors is the focus of this paper. Evidence was abstracted from randomized trials and non-randomized comparisons (NRCs) with adjustment for confounders. The analysis involved careful assessment, including characteristics of patients, settings, residual confounding etc. to expose degrees of uncertainty and applicability to individual patients. Evidence is summarized that provides an at-a-glance overall impression as well as the ability to delve into layers of details of the patients, settings and treatments involved. Results: In older patients, perioperative mortality is minimally altered by resection extent and only slightly affected by increasing age; sublobar resection may slightly decrease morbidity. Long-term outcomes are worse after lesser resection; the difference is slightly attenuated with increasing age. Reported short-term outcomes are quite acceptable in (selected) patients with severely limited pulmonary reserve, not clearly altered by resection extent but substantially improved by a minimally invasive approach. Quality-of-life (QOL) and impact on pulmonary function hasn't been well studied, but there appears to be little difference by resection extent in older or compromised patients. Patient selection is paramount but not well defined. Ground-glass and screen-detected tumors exhibit favorable long-term outcomes regardless of resection extent; however solid tumors <1 cm are not a reliably favorable group. Conclusions: A systematic, comprehensive summary of evidence regarding resection extent in compromised patients and favorable tumors with attention to aspects of applicability, uncertainty and effect modifiers provides a foundation for a framework for individualized decision-making.

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