Induction concurrent chemoradiotherapy using Paclitaxel and Carboplatin combination followed by surgery in locoregionally advanced non-small cell lung cancer--Asian experience.

INTRODUCTION: It has been established that combined chemoradiotherapy treatment benefits selected patients with stage III Non Small Cell Lung Cancer (NSCLC). However, locoregional recurrence still poses a problem. The addition of surgery as the third modality may provide a possible solution. We report our experience of using the triple-modality approach in this group of patients. MATERIALS AND METHODS: This is a retrospective review of 33 patients with stage III NSCLC treated between 1997 and 2005. Patients have good performance status and no significant weight loss. There were 26 males (79 %) with median age of 63 years (range, 43 to 74) and median follow-up of 49 months. Seventy-six percent had Stage IIIA disease. Chemotherapy consisted of paclitaxel at 175 mg/m2 over 3 hours followed by carboplatin at AUC of 5 over 1 hour. Thoracic radiotherapy was given concurrently with the second and third cycles of chemotherapy. All patients received 50 Gray in 25 fractions over 5 weeks. RESULTS: The main toxicities were grade 3/4 neutropenia (30%), grade 3 infection (15 %) and grade 3 oesophagitis (9%). Twenty-five patients (76%) underwent surgery. Of the 8 who did not undergo surgery, 1 was deemed medically unfit after induction chemoradiotherapy and 4 had progressive disease; 3 declined surgery. Nineteen patients (58 %) had lobectomy and 6 had pneumonectomy. The median overall survival was 29.9 months and 12 patients are still in remission. CONCLUSION: The use of the triplemodality approach is feasible, with an acceptable tolerability and resectability rate in this group of patients.

Survival of small-cell lung cancer and its determinants of outcome in Singapore.

INTRODUCTION: The survival and epidemiology of small-cell lung cancer (SCLC) in Singapore has not been described. We aim to present the characteristics as well as determine the survival outcome and important prognostic factors for SCLC patients. MATERIALS AND METHODS: A retrospective analysis of SCLC patients diagnosed from 1999 to 2002 was conducted at the Outram campus, Singapore. Clinical characteristics and treatment data were obtained from case records and survival data were checked with the registry of births and deaths on 30 May 2005. RESULTS: One hundred and eleven patients were analysed. There were 38 (34.2%) limited-disease (LD) patients and 73 (65.8%) extensive-disease (ED) patients. The majority were current or former smokers (94.7% among LD and 94.5% among ED). More patients with LD had good performance status (92% versus 63%, P = 0.0003) and were treated with combined chemotherapy and radiotherapy (82% versus 48%, P = 0.012). The median survival time of LD patients treated with curative chemoradiotherapy was 14.2 months (95% CI, 10.96 to 17.44). Those given prophylactic cranial irradiation had a median survival time of 16.9 months (95% CI, 11.83 to 21.97). For ED patients, the median survival time was 8.17 months (95%CI, 5.44 to 10.89). None of the factors analysed were significant prognostic factors for LD patients while performance status and type of treatment given were significant among ED patients. CONCLUSIONS: We found that the characteristics and survival of SCLC patients in Singapore are fairly similar to that of other countries.

Video-assisted thoracoscopic bronchoplasty.

Video-assisted thoracoscopic surgery (VATS) bronchoplasty is an advanced VATS technique requiring experience in endoscopic sewing, tying and suturing techniques reserved for cancers arising from central airways. There are three main types of bronchoplasty depending on the extent of cancer involvement of the bronchus. In this paper the author describes his experience with different types of bronchoplasty with case and video illustrations.

Beyond the limits, extreme minimally invasive surgery in invasive thymic tumours.

Generally accepted indications for minimally invasive surgery (MIS) approach to thymic tumours include small, well encapsulated non-invasive tumours. MIS for more advanced complicated thymic tumours remain controversial. This is due to concerns on whether an oncologically complete resection can be done. However with increased experience MIS can be used safely in a selected group of complex thymic tumours without oncological compromise.

VATS hand sewn intrathoracic esophagogastric anastomosis.

Totally endoscopic two stage (laparoscopic and VATS) esophagectomy for carcinoma of the esophagus is a well-established procedure. There are currently many methods to perform the intrathoracic esophagogastric anastomosis by VATS. This article describes a totally hand sewn VATS intrathoracic esophagogastric anastomosis technique in a 64-year-old female with a T2N0M0 adenocarcinoma of the lower third of the esophagus.

Left video-assisted thoracoscopic enucleation of a giant horseshoe oesophageal leiomyoma.

Oesophageal leiomyomas are rare neoplasms of the oesophagus, accounting for approximately 4% of all oesophageal tumours. Most oesophageal leiomyomas are small and well encapsulated. We report a rare case of a giant horseshoe oesophageal leiomyoma which was removed via video-assisted thoracoscopic enucleation and describe the management of an intra-operative complication of a mucosal breach.

Extralobar pulmonary sequestration simulates posterior neurogenic tumor.

We report a case of 19-year-old asymptomatic man with posterior mediastinal mass thought to be of neurogenic origin on computed tomography scan. During video-assisted thoracic surgery the mass appeared to be an extralobar pulmonary sequestration. Surgery was straightforward by division of vascular pedicle. Histopathology confirmed diagnosis.

Initial experience with video-assisted thoracoscopic bronchoplasty.

OBJECTIVES: Bronchial-origin involvement by endobronchial tumours or direct invasion by tumour or metastatic lymph nodes is a relative contraindication for video-assisted thoracoscopic (VATS) lobectomy. However, selected cases can be resected by VATS bronchoplasty. METHODS: Between 2006 and 2009, 21 of 231 (9.1%) VATS lobectomy cases underwent VATS bronchoplasty. Cases with endobronchial involvement and limited non-bulky invasion of bronchus by tumour or metastatic nodes without major vascular invasion were selected for bronchoplasty by preoperative bronchosocpy and CT scan thorax. Patients underwent a simple/wedge bronchoplasty (bronchus divided at origin and closed flush or transversely), sleeve bronchoplasty or others (bronchoplasty combined with other extended resections). All bronchoplasties were done totally endoscopically by directly watching a TV monitor. Bronchial margins were all subjected to intraoperative pathological analysis. Anastomosis was done with interrupted sutures. Integrity of anastomosis was checked by intraoperative bronchoscopy. The follow-up was done by 6-monthly CT scans and bronchoscopy. RESULTS: Eleven patients were females. Mean age was 64.9 years (range, 47-83 years). Indications were endobronchial tumours in 3, direct invasion in 6 and metastatic nodes in 12. In 4 cases, invasion was detected at the time of surgery. Mean hospital stay was 5.2 days (range, 3-8 days). Mean duration of surgery was 287 min (range, 135-540 min). Nine had simple/wedge bronchoplasty, 8, sleeve bronchoplasty and 4, extended bronchoplasties. Histology was non-small-cell carcinoma (NSCLC) in 19, carcinoid in 1 and colonic metastasis in 1. In the NSCLC, 5 patients were in stage IB, 5 in stage IIA, 2 in stage IIB and 7 were in IIIA. All bronchial margins were negative for malignancy. The mean follow-up was 26.2 months (range, 6-32 months). There was no operative mortality, but 1 patient developed bronchopleural fistula. To date, there have been no local tumour recurrences. CONCLUSIONS: Selected endobronchial and non bulky tumours with limited invasion at bronchial origin can be resected by VATS bronchoplasty.

Results of surgery for bronchiectasis and pulmonary abscesses.

Bronchiectasis and lung abscess are generally treated medically, reserving surgery for when medical treatment has failed. Current goals of surgical therapy for bronchiectasis are to offer possible cure and better quality of life after medical treatment has failed and to resolve and prevent complications, such as empyema, severe hemoptysis, and lung abscess. Whenever possible, complete resections of localized disease should be done, reserving palliative resections to selected diffuse bronchiectasis with localized severe disease. Most lung abscesses can be successfully treated medically provided early diagnosis and prompt treatment are instituted.

Can invasive thymomas be resected by video-assisted thoracoscopic surgery?

Although video-assisted thoracic surgery can be used for well-encapsulated thymomas, its role in invasive thymomas remains controversial. Between 1998 and 2009, 77 patients aged 22-76 years underwent thymomectomy by video-assisted thoracic surgery. Tumors <5 cm without major invasion on preoperative computed tomography were selected. There were 13 invasive thymomas (Masaoka stage III and IV). A modified dissection technique was employed to prevent breaching the tumor capsule and risking tumor seedling. Limited resection of the phrenic nerve, pericardium, perithymic fat, and a wedge of lung was performed en bloc with the tumor. The mean duration of surgery was 138 min. Hospital stay was 3.6 days. Eleven patients had associated myasthenia gravis. There was 1 case of wound infection and no operative mortality. The mean size of the thymomas was 34 mm (range, 23-55 mm). All patients had adjuvant radiotherapy. During follow-up of 4.9 years (range, 1-10 years), there was one local recurrence. With the modified video-assisted thoracic surgery technique, selected invasive thymomas detected during surgery can be removed safely without resorting to sternotomy.

Continuous absorbable suture technique for tracheobronchial sleeve resections.

From January 2000, we changed from the traditional interrupted suture technique for tracheobronchial sleeve resections to a continuous suture technique with absorbable suture. This retrospective study reviewed our experience in the first 50 consecutive patients operated on between January 2000 and August 2006. The median age was 61 years (range, 30 to 80 years). There were 35 men and 15 women, 49 had malignant disease, and 1 had a benign tumor. Two patients had tracheal resection without removal of lung parenchyma; all others underwent sleeve lobectomy. There was 1 (2%) operative death due to pneumonia, and 8 (16%) postoperative complications including atrial fibrillation, lobar atelectasis, prolonged parenchymal air leak, empyema, paralytic ileus, and chylothorax. There was no anastomotic dehiscence or bronchopleural fistula. None of the patients developed stricture at the anastomotic site when followed up for a mean duration of 18.6 months. The continuous suture technique is easy to perform and the results are comparable with those of the interrupted suture technique. The use of absorbable suture appears to reduce the incidence of stricture at the anastomotic site.

Genomic profiles specific to patient ethnicity in lung adenocarcinoma.

PURPOSE: East-Asian (EA) patients with non-small-cell lung cancer (NSCLC) are associated with a high proportion of nonsmoking women, epidermal growth factor receptor (EGFR)-activating somatic mutations, and clinical responses to tyrosine kinase inhibitors. We sought to identify novel molecular differences between NSCLCs from EA and Western European (WE) patients. EXPERIMENTAL DESIGN: A total of 226 lung adenocarcinoma samples from EA (n = 90) and WE (n = 136) patients were analyzed for copy number aberrations (CNA) by using a common high-resolution SNP (single nucleotide polymorphism) microarray platform. Univariate and multivariate analyses were carried out to identify CNAs specifically related to smoking history, EGFR mutation status, and ethnicity. RESULTS: The overall genomic profiles of adenocarcinomas from EA and WE patients were highly similar. Univariate analyses revealed several CNAs significantly associated with ethnicity, EGFR mutation, and smoking, but not to gender, and KRAS or p53 mutations. A multivariate model identified four ethnic-specific recurrent CNAs-significantly higher rates of copy number gain were observed on 16p13.13 and 16p13.11 in EA tumors, whereas higher rates of genomic loss on 19p13.3 and 19p13.11 were observed in tumors from WE patients. We identified several potential driver genes in these regions, showing a positive correlation between cis-localized copy number changes and transcriptomic changes. CONCLUSION: 16p copy number gains (EA) and 19p losses (WE) are ethnic-specific chromosomal aberrations in lung adenocarcinoma. Patient ethnicity should be considered when evaluating future NSCLC therapies targeting genes located on these areas.

Revisiting the prone position in video-assisted thoracoscopic surgery.

The fully prone position, once used in surgery for chronic inflammatory lung diseases, has become obsolete. In the last 2 years, a modified semiprone position was used for video-assisted thoracoscopic surgery in 358 patients undergoing lobectomy with mediastinal complete lymphadenectomy The ports were placed with the patient in the lateral decubitus position. The patient was rotated 45-60 degrees towards the surgeon, giving enhanced exposure of the posterior mediastinum, esophagus, subcarinal and paratracheal spaces, due to displacement of the lung under gravity away from the operative field. This position is safe, well-tolerated, and allows more ergonomic and anatomical placement of the ports.

Novel use of the internal thoracic artery retractor in transcervical thymectomy.

Transcervical thymectomy is a standard approach to the thymus and anterior mediastinum, but it is limited by poor exposure of the lower recesses of the anterior mediastinum. A novel technique using the widely available internal thoracic artery sternal retractor and a 30°-video camera allows enhanced exposure of the anterior mediastinum.

Clinical outcome of video-assisted thymectomy for myasthenia gravis and thymoma.

We reviewed our experience of video-assisted thoracoscopic thymectomy for myasthenia gravis and thymomas in 119 patients, aged 12-83 years, who were treated between 1998 and 2007. Disease severity was graded using the Osserman classification. To prevent rupture of the tumor capsule and tumor seeding, thymomas were resected using a modified no-touch technique. Thymoma diameters were 10-90 mm (mean, 50 mm). There were no operative deaths, 12 (10%) patients had complications, and 87 (73.1%) improved by 1 or more Osserman grades postoperatively. After follow-up of 1.9-10 years (mean, 4.9 years), 74 (62%) patients remained asymptomatic, with 21% in complete stable remission. Using multivariate regression analysis, there were no statistical differences in median pre- and postoperative Osserman grades with regards to age, sex, duration of symptoms, and presence of thymoma. Video-assisted thoracoscopic thymectomy for myasthenia gravis and selected thymomas can achieve long-term clinical outcomes comparable to those of standard approaches.

A unique case of spontaneous regression of metastatic papillary renal cell carcinoma: a case report.

Spontaneous regression of cancer is a rare, but well documented, phenomenon. We present a unique case of an 82 year old Chinese male who experienced spontaneous regression of histologically-verified metastatic type II papillary renal cell carcinoma in the absence of intervening systemic therapy or surgery. This is the first reported case of spontaneous regression of papillary renal cell carcinoma. The mechanism of spontaneous regression remains unknown, and represents a challenge for existing oncology paradigms.

Total tracheal resection for long-segment benign tracheal stenosis.

Tracheal resection for long benign tracheal stenosis is challenging because of the lack of a suitable replacement to facilitate tension-free anastomosis. We describe a patient with a 6-cm post-tuberculous tracheal stricture, severely debilitated post-recurrent bronchoscopic intervention. Staged resection facilitated near-total tracheal resection with primary anastomosis and complete symptom resolution.

Harmonic scalpel in video-assisted thoracoscopic thymic resections.

Video-assisted thoracoscopic thymectomy is safe, but the efficacy of this technique in thymomectomy is unproved. Data of 103 consecutive patients who had thoracoscopic thymectomy and thymomectomy between 1998 and 2006 were retrospectively reviewed. Conventional monopolar diathermy and endoscopic Liga clips were used in the first 50 patients, and the Harmonic Scalpel was employed in the next 53. Only mean tumor size differed between groups (56.6 +/- 18.2 vs 40.0 +/- 20.8 mm in Harmonic Scalpel group). A similar number of patients had myasthenia gravis in the first group (72%) and Harmonic Scalpel group (83%). There were 49 thymomas (22 in first group, 27 in Harmonic Scalpel group). Of the earlier patients, 2 were re-explored for excessive chest tube drainage, 1 had ipsilateral phrenic nerve injury, and 2 had left phrenic nerves sacrificed intraoperatively due to thymoma invasion, but there was no significant difference in complications between groups. At a mean follow-up of 3.40 +/- 2.38 years (range, 0.04-8.52 years), there was 1 thymoma recurrence in the first group. Use of the Harmonic Scalpel in video-assisted thoracoscopic thymic resection is safe and confers some advantages over conventional methods of dissection.