Correlation between 18-FDG standardized uptake value and tumor grade in patients with resectable non-small cell lung cancer.

Background: Positron-emission tomography (PET) is widely used for staging lung cancer. Although a correlation between the fluorodeoxyglucose standardized uptake value (SUV) and the histologic grade of the tumor has been shown in several studies, little is known about the impact of different clinical variables on this correlation. This study aimed to evaluate the correlation between tumor SUV and tumor grade in a large cohort of patients and to analyse the impact of clinical factors on this correlation. Methods: This retrospective cohort study including patients with non-small cell lung cancer age 18-90 years, with clinical stage I-IVA, who underwent curative-intent lung resection. Results: Data from 726 patients was included in this study. There was a strong correlation between SUV and primary tumor grade in the whole cohort (P<0.001), which was significant in both sexes (P<0.001) and in all selected age groups (P<0.001-0.03). There was a significant SUV-grade correlation for the right upper and left lower lobes, as well as for the central location in the right lung (P<0.001, P=0.005 and P=0.04, respectively). Moreover, a significant SUV-grade correlation was found for squamous cell cancer and adenocarcinoma (P<0.001 and P=0.01, respectively), and for T1-T3 factors (P<0.001, P=0.006, P=0.005 respectively). Conclusions: In patients with resectable lung cancer, a significant correlation was observed between the SUV of the primary tumor and its grade. This correlation was maintained for both sexes, age groups, most common histological types and T factors T1-T3.

Preoperative thrombocytosis in surgically treated patients with non-small cell lung cancer.

Introduction Lung cancer is the most common cause of cancer­related death. Accurate and easy­to­use prognostic factors are necessary. Increased platelet count might be a potential prognostic factor. Objectives We aimed to investigate the relationship between thrombocytosis and stage of lung cancer and to assess the frequency and clinical importance of thrombocytosis in this patient group. Patients and methods We retrospectively analyzed hospital records of consecutive patients with non-small cell lung cancer (NSCLC) who underwent curative­intent pulmonary resections. Results Of 323 patients, 285 patients with NSCLC were selected (mean [SD] age, 66.55 [8.52] years; men, 63.86%). Squamous cell carcinoma was diagnosed in 130 patients (45.61%); adenocarcinoma, in 128 (44.91%); large cell carcinoma, in 16 (5.61%); and adenosquamous carcinoma, in 11 (3.86%). The prevalence of preoperative thrombocytosis in the whole sample was 10.18% (n = 29). Anemia was more common in patients with thrombocytosis compared with those without thrombocytosis (65.52% vs 30.08%; P <0.001). Thrombocytosis was found in 22.41% of patients with stage III+IV cancer and in 3.82% of those with stage I (P <0.001). Moreover, in patients with no metastases (N0, M0 according to the 7th edition of the TNM classification), thrombocytosis was more frequent in the group with stage II than in that with stage I cancer (3.85% vs 20.00%; P = 0.002). Thrombocytosis was also more frequent in patients with N2 than with N1 disease (9.76% vs 23.81%; P = 0.09). Conclusions Thrombocytosis is often observed in patients with NSCLC and is significantly associated with the higher stage of disease.

Minimally invasive strategy for mediastinal staging of patients with lung cancer.

INTRODUCTION: The exclusion of mediastinal involvement in patients with non-small cell lung cancer is essential for choosing an appropriate therapy. OBJECTIVES: The aim of the study was to analyze the ability of a new minimally invasive strategy combining positron emission tomography (PET), endobronchial ultrasound needle aspiration (EBUS-NA), and endoscopic ultrasound needle aspiration (EUS-NA) to exclude mediastinal nodal metastases of non-small cell lung cancer. PATIENTS AND METHODS: In a group of consecutive patients with primary non-small cell lung cancer, the preoperative assessment of medisastinal lymph nodes using PET, EBUS-NA, and EUS-NA. Patients in whom this minimally invasive staging protocol did not confirm mediastinal nodal metastases underwent pulmonary resection with systematic lymph node dissection. The negative predictive values of the combined EBUS-NA/EUS-NA as well as PET/EBUS -NA/EUS-NA were calculated. RESULTS: We analyzed data of 532 patients (367 men and 165 women; mean age, 65 years [range, 30-84 years]). Squamous carcinoma were diagnosed in 276 patients; adenocarcinoma, in 150; large cell carcinoma, in 22; adenosquamous carcinoma, in 40; small cell carcinoma, in 4; carcinoids, in 21; and other histological types, in 19. We performed 421 lobectomies, 55 pneumonectomies, 51 bilobectomies, and 5 sublobar resections. In all patients, systematic lymph node dissection was performed. The mean number of removed lymph nodes was 22. The negative predictive value of EBUS-NA/EUS-NA was 89.8% and of PET/EBUS-NA/EUS-NA-93.2%. CONCLUSIONS: Patients with lung cancer with negative results of PET, EBUS-NA, and EUS-NA are at low risk of mediastinal nodal metastasis. In these patients, invasive mediastinal staging may not be necessary.

[Transcervical Extended Mediastinal Lymphadenectomy (TEMLA) for staging of non-small-cell lung cancer (NSCLC)]. / TEMLA--rozszerzone wyciecie wezlów chlonnych sródpiersia w diagnostyce niedrobnokomórkowego raka pluca.

INTRODUCTION: The aim of the study is to analyze diagnostic yield of the new surgical technique--the Transcervical Extended Mediastinal Lymphadenectomy (TEMLA) in preoperative staging of Non-Small-Cell Lung Cancer (NSCLC). MATERIAL AND METHODS: Operative technique included 5-8 cm collar incision in the neck, elevation of the sternal manubrium with a special retractor, bilateral visualization of the laryngeal recurrent and vagus nerves and dissection of all mediastinal nodal stations except of the pulmonary ligament nodes (station 9). RESULTS: 698 patients (577 men, 121 women), of mean age 62.8 (41-79) were operated on from 1.1.2004 to 31.1.2010, including 501 squamous-cell carcinomas, 144 adenocarcinomas, 25 large cell carcinomas and 28 others. Mean operative time was 128 min. (45 to 330 min) and 106.5 min. in the last 100 patients. 30-day mortality was 0.7 % (unrelated causes) and morbidity 6.6%. The mean number of dissected nodes during TEMLA was 37.9 (15 to 85). Metastatic N2 and N3 nodes were found in 152/698 (21.8%) and 26/698 patients (3.7%), respectively. Subsequent thoracotomy was performed in 445/513 patients (86.7%) after negative result of TEMLA. During thoracotomy, omitted N2 was found in 7/445 (1.6%) patients. Sensitivity of TEMLA in discovery of metastatic N2-3 nodes was 96.2 %, specificity was 100%, accuracy was 99,0%, Negative Predictive Value (NPV) was 98.7 % and Positive Predictive Value (PPV) was 100%. CONCLUSIONS: TEMLA is a new minimally invasive surgical procedure providing unique possibility to perform very extensive, bilateral mediastinal lymphadenectomy with very high diagnostic yield in staging of NSCLC Pneumonol.

Comparison of complete remission rates after 5 year follow-up of three different techniques of thymectomy for myasthenia gravis.

OBJECTIVE: This study aims to analyse the effectiveness of treatment of myasthenia gravis with three different techniques of thymectomy. METHODS: Results of complete remission rates after 5-year follow-up of 60 patients who underwent basic transsternal thymectomies (group A) from 1 January 1996 to 31 December 1997, 75 patients who underwent extended transsternal thymectomies (group B) from 1 January 1998 to 30 June 2000 and 291 patients who underwent transcervical-subxiphoid-videothoracoscopic 'maximal' thymectomy (group C) from 1 September 2000 to 31 January 2009 were compared. RESULTS: There were no differences between groups according to patient's characteristics and postoperative complications' rate. Ectopic foci of the thymic tissue were discovered in the fat of the neck and the mediastinum in 53.9% of patients from the group B and in 65.9% patients from the group C. After 1, 2, 3, 4 and 5 years of follow-up, complete remission rates were 8.3%, 11.7%, 15.0%, 16.7% and 20.0%, respectively, in group A; 26.7%, 38.7%, 42.7%, 46.7% and 50.7%, respectively, in group B; and 31.5%, 39%, 45.8%, 46.3% and 53.1%, respectively, in group C. The differences between group A and the groups B and C after 1, 2, 3, 4 and 5 years were statistically significant. There were no significant differences between groups B and C. CONCLUSIONS: (1) The results of complete remission rates after 5-year follow-up were statistically better in patients with myasthenia gravis (MG), who were operated on with extended transsternal thymectomy and transcervical-subxiphoid-videothoracoscopic 'maximal' thymectomy than the patients who underwent basic transsternal thymectomy. (2) The difference can be explained by the removal of ectopic foci of the thymic tissue from the neck and the mediastinum in these patients.

Non-small-cell lung cancer restaging with transcervical extended mediastinal lymphadenectomy.

BACKGROUND: To analyse a diagnostic yield of the transcervical extended mediastinal lymphadenectomy (TEMLA) in restaging of the mediastinal nodes after neoadjuvant chemo- or chemo-radiotherapy for non-small-cell lung cancer (NSCLC). METHODS: From 1 January 2004 to 30 April 2009, 63 patients who underwent induction chemotherapy or chemo-radiotherapy for N2 and N2/3 metastatic nodes discovered preoperatively were restaged. There were 12 women and 51 men in the age group of 43-71 (mean 57.8) years. There were 45 squamous cell carcinomas, 13 adenocarcinomas, one pleomorphic carcinoma and four NSCLCs. A total of 54 patients underwent neoadjuvant chemotherapy and nine chemo-radiotherapy. Seven patients had mediastinoscopy before neoadjuvant therapy. As many as 34 patients underwent endobronchial ultrasound (EBUS), one patient underwent endo-oesophageal ultrasound (EUS) and 10 patients underwent combined EBUS/EUS. The diagnostic results of TEMLA were compared with the results of the largest published series of restaging patients. The results of subsequent thoracotomies after negative TEMLA were presented. RESULTS: There were no serious complications or mortality after TEMLA. Metastatic nodes were discovered in 22 patients including three patients with N3 nodes and 19 patients with N2 nodes. Stations 7, 4R, 2R and 4L were the most prevalent. Of the 63 patients, 42 underwent subsequently thoracotomy. Resectability for negative TEMLA was 92.7%. There were 37 R0 resections and four R1 resections. There was no postoperative mortality, two bronchial fistulas were developed (after inferior bilobectomy and right pneumonectomy; the second one healed spontaneously) and there were no other serious complications. During thoracotomy with completion lymphadenectomy one false-negative result was found (single node in station 8). Sensitivity of TEMLA in the discovery of N2/3 nodes during restaging was 95.5%, specificity 100%, accuracy 98.3%, negative predictive value (NPV) 97.4% and positive predictive value (PPV) 100%. TEMLA was found to have significantly better sensitivity and NPV (p<0.05) than other series of restaging. During follow-up a local recurrence was noted in six of 37 (15.7%) patients after pulmonary resection. CONCLUSIONS: (1) The results of TEMLA in restaging of NSCLC (N2/3) patients after induction chemotherapy or chemo-radiotherapy were significantly better than those achieved with remediastinoscopy, EBUS and positron emission tomography/computed tomography (PET/CT). (2) The results of future studies will show if TEMLA should be considered the gold standard of mediastinal nodal restaging after neoadjuvant therapy in patients with NSCLC.

Staging algorithm for diffuse malignant pleural mesothelioma.

An algorithm of preoperative mediastinal nodal staging with endobronchial/endoesophageal ultrasonography (EBUS/EUS) and transcervical extended mediastinal lymphadenectomy (TEMLA) combined with laparoscopy/peritoneal lavage and cytology was analyzed to establish the realistic criteria for radical multimodality treatment of malignant pleural mesothelioma (MPM). The algorithm included computed tomography (CT), thoracoscopy with multiple pleural biopsies and talc pleurodesis, EBUS/EUS and one-stage TEMLA and laparoscopy/peritoneal lavage and cytology of the fluid. Forty-two patients were diagnosed from 1 January 2004 to 31 December 2008. There were 16 women and 26 men in ages ranging from 43 to 77 years (mean 57.8); 31 epithelioid, 2 sarcomatoid and 9 biphasic type MPM. 21/42 patients were considered possible candidates for multimodality treatment. Three patients who received neoadjuvant chemotherapy were excluded from this study. EBUS/EUS was performed to stage the mediastinal nodes. In 3/18 patients metastatic nodes were discovered. In the rest of the 15 patients simultaneous TEMLA and laparoscopy/peritoneal lavage and cytology of the fluid were performed. In three patients TEMLA was positive, in six patients laparoscopy was positive and in two patients both TEMLA and laparoscopy were positive. Finally, 4/42 (9.5%) patients underwent thoracotomy with one exploration (chest wall infiltration) and three pleuropneumonectomies with the subsequent chemo- and radiotherapy. The proposed algorithm of preoperative staging spared the majority of MPM patients from futile surgery.

[Endoscopic ultrasound-guided needle aspiration in lung cancer]. / Przezprzelykowa biopsja wezlów chlonnych sródpiersia pod kontrola ultrasonografii wewnatrzprzelykowej w czasie rzeczywistym w diagnostyce raka pluca.

INTRODUCTION: The aim of the study was to assess the diagnostic yield of transoesophageal endoscopic ultrasound-guided needle aspiration (EUS-NA) in lung cancer (LC). MATERIAL AND METHODS: Real time EUS-NA was performed under local anaesthesia and sedation in consecutive LC patients. All negative EUS-NA results in NSCLC patients were verified by transcervical extended bilateral mediastinal lymphadenectomy (TEMLA). RESULTS: In 146 patients there were 206 biopsies performed in lymph node stations: subcarinal (7):124, left lower paratracheal (4L):70, paraoesophageal (8):9 and pulmonary ligament (9):3. A mean short axis of punctured node was 10+/-6.3 (95% CI) mm. Lymph node biopsy was technically successful in 95.6% and was diagnostic in 40.1% of LC patients. In NSCLC staging, the sensitivity of EUS-NA calculated on the per-patient basis was 85.5%, specificity 100%, accuracy 93.6% and negative predictive value (NPV) 89.7% in stations accessible for EUS-NA, but in all mediastinal stations it was 70.7%, 100%, 84.3% and 74.7, respectively (p=0.009). The sensitivity of EUS-NA in NSCLC staging patients, calculated on the per-biopsy basis was 88.6%, specificity 100%, accuracy 95.4% and NPV 91.4%. A diagnostic yield of EUS-NA on the per-biopsy basis was higher for station 4L than 7, but the difference was not significant (chi2 p=0.4). CONCLUSIONS: The diagnostic value of EUS-NA in LC is high. In NSCLC staging EUS-NA is insufficient and should be complemented by other invasive techniques, especially those that give access to the right paratracheal region.

[Ultrasound guided transbronchial needle aspiration as a diagnostic tool for lung cancer and sarcoidosis]. / Przezoskrzelowa biopsja wezlów chlonnych sródpiersia i wnek pluca pod kontrola ultrasonografii wewnatrzoskrzelowej w czasie rzeczywistym w diagnostyce raka pluca i sarkoidozy.

INTRODUCTION: The aim of the study was to assess the diagnostic yield of ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in mediastinal or hilar adenopathy in: 1) staging of non-small cell lung cancer (NSCLC) (97); 2) other malignant neoplasms including: small cell lung cancer (SCLC), metastatic neoplasms and Hodgkin's disease (16); 3) NSCLC recurrence (7); 4) sarcoidosis and other non-malignant diseases (29). MATERIAL AND METHODS: Real time EBUS-TBNA was performed under local anaesthesia and sedation in 149 consecutive patients - 237 biopsies in groups of lymph nodes: subcarinal (7) - 107, all paratracheal (2R, 2L, 4R, 4L) - 86, hilar (10R, 10L) - 41 and interlobar (11R, 11L) - 3. A mean axis of punctured node was 15 mm (range: 7-42 mm). All negative results were verified by transcervical extended bilateral mediastinal lymphadenectomy (TEMLA), mediastinoscopy or thoracotomy. RESULTS: Lymph node biopsy was technically successful in 92% and was diagnostic in 55% of lung cancer patients and in 85.7% of sarcoidosis patients. In NSCLC staging sensitivity of EBUS-TBNA was 88.7%, specificity 100%, accuracy 92.8% and NPV 83.3% (89.7%, 100%, 94.9% and 90.9% per biopsy), and in the whole group it was 91.5%, 98.7%, 94.6% and 87.3% respectively. In 7.2% of NSCLC staging patients with false negative results of EBUS-TBNA (mainly subcarinal) there was observed partial involvement of metastatic lymph nodes, mean 34.3% (range 10-50%), confirmed by TEMLA. CONCLUSION: The diagnostic value of EBUS-TBNA is very high in lung cancer, NSCLC staging and sarcoidosis.

[Transbronchial needle aspiration as a diagnostic method in lung cancer and non-malignant mediastinal adenopathy]. / Przezoskrzelowa biopsja iglowa wezlów chlonnych sródpiersia i wnek w rozpoznawaniu, ocenie stopnia zaawansowania i wznowy raka pluca oraz w rozpoznawaniu chorób nienowotworowych.

INTRODUCTION: The aim of the study was to assess the diagnostic yield of transbronchial needle aspiration (TBNA) in mediastinal or hilar adenopathy in: lung cancer, staging of NSCLC, sarcoidosis and other non-malignant diseases. MATERIAL AND METHODS: Transbronchial needle aspiration was performed in 347 consecutive patients - 402 biopsies in groups of lymph nodes: subcarinal (7) - 179, all paratracheal (2R, 2L, 4R, 4L) - 168 and hilar (10R, 10L) - 55, with no real-time imaging guidance, preceded by computed tomography (CT), using 22-gauge needles. All negative results in NSCLC patients were verified by transcervical extended bilateral mediastinal lymphadenectomy (TEMLA) and the remaining patients underwent mediastinoscopy or thoracotomy. RESULTS: TBNA technique was diagnostic in 67.1% of lung cancer patients and in 59.0% of patients with sarcoidosis. In the group of all lung cancer patients specificity was 100%, sensitivity 88.5%, accuracy 91.8% and negative predictive value 77.9% and in diagnosing of lymph nodes involvement in NSCLC was respectively 100%, 86.6%, 90.7% and 76.6%. The high diagnostic yield was comparable for all mediastinal groups. In 80% of NSCLC patients with false negative results of TBNA there was observed partial involvement of metastatic lymph nodes, confirmed by TEMLA. CONCLUSIONS: The diagnostic value of TBNA is very high in diagnostics of lung cancer, NSCLC staging and sarcoidosis but much lower in lymphomas, tuberculosis and other non-malignant diseases.