Non-Small Cell Lung Cancer, Version 4.2024, NCCN Clinical Practice Guidelines in Oncology

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Non-Small Cell Lung Cancer (NSCLC) provide recommendations for the treatment of patients with NSCLC, including diagnosis, primary disease management, surveillance for relapse, and subsequent treatment. The panel has updated the list of recommended targeted therapies based on recent FDA approvals and clinical data. This selection from the NCCN Guidelines for NSCLC focuses on treatment recommendations for advanced or metastatic NSCLC with actionable molecular biomarkers.

NCCN Guidelines® Insights: Mesothelioma: Pleural, Version 1.2024.

Mesothelioma is a rare cancer that originates from the mesothelial surfaces of the pleura and other sites, and is estimated to occur in approximately 3,500 people in the United States annually. Pleural mesothelioma is the most common type and represents approximately 85% of these cases. The NCCN Guidelines for Mesothelioma: Pleural provide recommendations for the diagnosis, evaluation, treatment, and follow-up for patients with pleural mesothelioma. These NCCN Guidelines Insights highlight significant updates to the NCCN Guidelines for Mesothelioma: Pleural, including revised guidance on disease classification and systemic therapy options.

Mesothelioma: Peritoneal, Version 2.2023, NCCN Clinical Practice Guidelines in Oncology.

Mesothelioma is a rare cancer originating in mesothelial surfaces of the peritoneum, pleura, and other sites. These NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) focus on peritoneal mesothelioma (PeM). The NCCN Guidelines for PeM provide recommendations for workup, diagnosis, and treatment of primary as well as previously treated PeM. The diagnosis of PeM may be delayed because PeM mimics other diseases and conditions and because the disease is so rare. The pathology section was recently updated to include new information about markers used to identify mesothelioma, which is difficult to diagnose. The term "malignant" is no longer used to classify mesotheliomas, because all mesotheliomas are now defined as malignant.

One hundred cases of primary spontaneous pneumomediastinum: leukocytosis is common, pleural effusions and age over 40 are rare.

Background: Primary spontaneous pneumomediastinum (PSPM) is a benign condition, but it can be difficult to discriminate from Boerhaave syndrome. The diagnostic difficulty is attributable to a shared constellation of history, signs, and symptoms combined with a poor understanding of the basic vital signs, labs, and diagnostic findings characterizing PSPM. These challenges likely contribute to high resource utilization for diagnosis and management of a benign process. Methods: Patients aged 18 years or older with PSPM were identified from our radiology department's database. A retrospective chart review was performed. Results: Exactly 100 patients with PSPM were identified between March 2001 and November 2019. Demographics and histories correlated well with prior studies: mean age (25 years); male predominance (70%); association with cough (34%), asthma (27%), retching or emesis (24%), tobacco abuse (11%), and physical activity (11%); acute chest pain (75%), and dyspnea (57%) as the first and second most frequent symptoms and subcutaneous emphysema (33%) as the most common sign. We provide the first robust data on presenting vital signs and laboratory values of PSPM, showing that tachycardia (31%) and leukocytosis (30%) were common. No pleural effusion was found in the 66 patients who underwent computed tomography (CT) of the chest. We provide the first data on inter-hospital transfer rates (27%). 79% of transfers were due to concern for esophageal perforation. Most patients were admitted (57%), with an average length of stay (LOS) of 2.3 days, and 25% received antibiotics. Conclusions: PSPM patients frequently present in their twenties with chest pain, subcutaneous emphysema, tachycardia, and leukocytosis. Approximately 25% have a history of retching or emesis and it is this population that must be discriminated from those with Boerhaave syndrome. An esophagram is rarely indicated and observation alone is appropriate in patients under age 40 with a known precipitating event or risk factors for PSPM (e.g., asthma, smoking) if they have no history of retching or emesis. Fever, pleural effusion, and age over 40 are rare in PSPM and should raise concern for esophageal perforation in a patient with a history of retching, emesis, or both.

NCCN Guidelines® Insights: Non-Small Cell Lung Cancer, Version 2.2023.

The NCCN Guidelines for Non-Small Cell Lung Cancer (NSCLC) provide recommendations for management of disease in patients with NSCLC. These NCCN Guidelines Insights focus on neoadjuvant and adjuvant (also known as perioperative) systemic therapy options for eligible patients with resectable NSCLC.

Systems of Care Factors Should Be Considered in Regionalization of Congenital Cardiac Surgery.

BACKGROUND: Regionalization of care has been proposed to optimize outcomes in congenital cardiac surgery (CCS). We hypothesized that hospital infrastructure and systems of care factors could also be considered in regionalization efforts. METHODS: Observed-to-expected (O/E) mortality ratio and hospital volumes were obtained between 2015 and 2018 from public reporting data. Using a resource dependence framework, we examined factors obtained from American Hospital Association, Children's Hospital Association, and hospital websites. Linear regression models were estimated with volume only, then with hospital factors, stratified by procedural complexity. Robust regression models were reestimated to assess the impact of outliers. RESULTS: We found wide variation in the volume of congenital cardiac surgeries performed (89-3920) and in the surgical outcomes (O/E ratio range, 0.3-3.1). Six outlier hospitals performed few high-complexity cases with high mortality. Univariate analysis including all cases indicated that higher volume predicted lower O/E ratio (ß = -0.02; SE = 0.008; P = .011). However, this effect was driven by the most complex cases. Models stratified by The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category show that volume is a significant predictor only in category 5 cases (ß = -1.707; SE = 0.663; P = .012). Robust univariate regression accounting for outliers found no effect of volume on O/E ratio (ß = 0.005; SE = 0.002; P = .975). Elimination of outliers through robust multivariate regression decreased the volume-outcome relationship and found a modest relationship between health plan ownership and outcomes. CONCLUSIONS: Systems of care factors should be considered in addition to volume in designing regionalization in CCS. Patient-level data sets will better define these factors.

Body mass Index does not impact long-term survival of patients with idiopathic pulmonary fibrosis undergoing lung transplantation.

Objective: We investigated the impact of body mass index (BMI) on post-operative outcomes and survival of patients with interstitial pulmonary fibrosis (IPF) undergoing lung transplantation. Methods: We retrospectively reviewed 222 patients with IPF that underwent lung transplant (LT) at our institution from 2005 to 2019. Recipients were divided in 4 groups: group-1 consisted of underweight patients (BMI ≤18.5 kg/m2), group-2 of normal weight patients (BMI 18.5-25 kg/m2), group-3 of over-weight patients (BMI 25-29.9 kg/m2) and group-4 of obese patients (BMI ≥30 kg/m2). Results: Group-1 consisted of 13 (6%) patients, group-2 of 67 (30%) patients, group-3 of 79 (36%) patients, group-4 consisted of 63 (28%) patients. Median BMI for group-1 was 17 [interquartile range (IQR): 17, 18], for group-2 was 23 (22, 24), for group-3 was 29 (28, 29.5) and group-4 was 32 (31, 33). Patients in group-1 were significantly younger (p < 0.01). Single LT comprised the majority of operation type in group-2 to group-4 and it was significantly higher than group 1 (p < 0.01). Median follow-up time was 39 months (13-76). A total of 79 (35.5%) patients died by the end of study. Overall, five deaths occurred in group-1, 17 in group-2, 33 in group-3, and 24 in group-4. Kaplan-Meier analysis showed that mortality was not statistically significant between the groups (p = 0.24). Cox-regression analysis was used to assess other possible risk factors that could influence the effect of BMI on mortality, including transplant type (single, double), lung allocation score, and age, diabetes and creatinine levels at surgery. None of these factors were shown to affect patient mortality (p > 0.05). Overall reasons for death included graft failure (24%), infection (23%), respiratory failure (14%), and malignancy (13%). Conclusions: Body mass index does not impact long-term survival of patients with IPF undergoing lung transplantation.

Non-Small Cell Lung Cancer, Version 3.2022, NCCN Clinical Practice Guidelines in Oncology.

NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Non-Small Cell Lung Cancer (NSCLC) provide recommended management for patients with NSCLC, including diagnosis, primary treatment, surveillance for relapse, and subsequent treatment. Patients with metastatic lung cancer who are eligible for targeted therapies or immunotherapies are now surviving longer. This selection from the NCCN Guidelines for NSCLC focuses on targeted therapies for patients with metastatic NSCLC and actionable mutations.

Consensus for Thoracoscopic Lower Lobectomy: Essential Components and Targets for Simulation.

BACKGROUND: Despite demonstration of its clear benefits relative to open approaches, a video-assisted thoracic surgery technique for pulmonary lobectomy has not been universally adopted. This study aims to overcome potential barriers by establishing the essential components of the operation and determining which steps are most useful for simulation training. METHODS: After randomly selecting experienced thoracic surgeons to participate, an initial list of components to a lower lobectomy was distributed. Feedback was provided by the participants, and modifications were made based on anonymous responses in a Delphi process. Components were declared essential once at least 80% of participants came to an agreement. The steps were then rated based on cognitive and technical difficulty followed by listing the components most appropriate for simulation. RESULTS: After 3 rounds of voting 18 components were identified as essential to performance of a video-assisted thoracic surgery for lower lobectomy. The components deemed the most difficult were isolation and division of the basilar and superior segmental branches of the pulmonary artery, isolation and division of the lower lobe bronchus, and dissection of lymphovascular tissue to expose the target bronchus. The steps determined to be most amenable for simulation were isolation and division of the branches of the pulmonary artery, the lower lobe bronchus, and the inferior pulmonary vein. CONCLUSIONS: Using a Delphi process a list of essential components for a video-assisted thoracic surgery for lower lobectomy was established. Furthermore 3 components were identified as most appropriate for simulation-based training, providing insights for future simulation development.

Successful Lung Transplantation for Severe Post-COVID-19 Pulmonary Fibrosis.

Lung transplantation has been well described for patients with coronavirus disease 2019 (COVID-19) in the acute setting, but less so for the resulting pulmonary sequelae. This report describes a case of lung transplantation for post-COVID-19 pulmonary fibrosis. A 52-year-old woman contracted COVID-19 in July 2020 and mounted a partial recovery, but she went on to have declining function over the ensuing 3 months, with development of fibrocystic lung changes. She underwent bilateral lung transplantation and recovered rapidly, was discharged home on postoperative day 14, and has done well in follow-up. This case report demonstrates that lung transplantation is an acceptable therapy for post-COVID-19 pulmonary fibrosis.

A narrative review of primary spontaneous pneumomediastinum: a poorly understood and resource-intensive problem.

Primary spontaneous pneumomediastinum (PSPM) is a benign self-limited condition that can be difficult to discriminate from esophageal perforation. This may trigger costly work-up, transfers and hospital admissions. To better understand this diagnostic dilemma and current management, we undertook the most comprehensive and up to date review of PSPM. The PubMed database was searched using the MeSH term "Mediastinal Emphysema"[Mesh], to identify randomized controlled trials, meta-analyses and case series (including 10 or more patients) relevant to the clinical presentation and management of patients with PSPM. There were no relevant randomized controlled trials or meta-analyses. Nineteen case series met our criteria, including a total of 535 patients. The average mean age was 23 years with a 3:1 male predominance. Chest pain was the most common symptom, found in 70.9% of the patients. Dyspnea and neck pain were the second and third most common symptoms, found in 43.4% and 32% of the patients, respectively. Subcutaneous emphysema was the most common sign (54.2%). Common histories included smoking (29.6%), cough (27.7%), asthma (25.9%), physical exertion (21.1%) and recent retching or emesis (13%). Nearly all patients (96.9%) underwent chest X-ray (CXR). Other diagnostic studies included computed tomography (65%) and esophagram (35.6%). Invasive studies were common, with 13% of patients undergoing esophagogastroduodenoscopy and 14.6% undergoing bronchoscopy. The rate of hospital admission was 86.5%, with an average length of stay of 4.4 days. No deaths were reported. Notably, we identified a dearth of information regarding the vitals, laboratory values and imaging findings specific to patients presenting with PSPM. We conclude that PSPM is a benign clinical entity that continues to present a resource-intensive diagnostic challenge and that data on the vitals, labs, and imaging findings specific to PSPM patients is scant. An improved understanding of these factors may lead to more efficient diagnosis and management of these patients.

Analysis of Recent Literature on Lung Volume Reduction Surgery.

Publication of the National Emphysema Treatment Trial (NETT) in 2003 established lung volume reduction surgery (LVRS) as a viable treatment of select patients with moderate to severe emphysema, and the only intervention since the availability of ambulatory supplemental oxygen to improve survival. Despite these findings, surgical treatment has been underused in part because of concern for high morbidity and mortality. This article reviews recent literature generated since the original NETT publication, focusing on physiologic implications of LVRS, recent data regarding the safety and durability of LVRS, and patient selection and extension of NETT criteria to other patient populations.

Impact of distance from implant center on mechanical circulatory device patient outcomes.

OBJECTIVES: Patients on left ventricular assist device (LVAD) support receive extensive care and education before discharge home. We investigated the impact of patient's residential distance from LVAD implantation center on outcomes and survival. METHODS: A total of 214 patients received a LVAD between 2006 and 2018 at our institution. Patient's residential distance from the LVAD implantation center, LVAD complications, hospitalization, and death were recorded. Patients were divided into two groups: patients living less than or equal to 100 miles (Group 1), patients living more than 100 (Group 2). RESULTS: A total of 106 patients were assigned to Group 1 and 108 patients were assigned to Group 2. Destination therapy was intended in 20% of patients in Group 1 and 34% in Group 2 (p = .023). Mean length of stay was 13 ± 9 days for Group 1 and 21 ± 12 for Group 2 (p < .001). Major postoperative complications were unplanned readmissions due to infections (9% and 12%), gastrointenstinal bleeding (15% and 14%), cerebrovascular accidents (6% and 7.4%), and acute kidney injury (5% and 2%), respectively for Group 1 and Group 2. There was no difference in major complications (all p > .05) and survival between patients in both groups (p > .05). CONCLUSIONS: Distance from implanting center had no impact on adverse outcomes after LVAD implantation. There was a significant increase in hospital stay for patients who live far from the implanting center, suggesting that distance should not be a contraindication when considering patients for LVAD therapy, but plans should be made for prolonged hospital stay or extended local stay near the hospital for close follow-up.

The Society of Thoracic Surgeons Composite Score Rating for Pulmonary Resection for Lung Cancer.

BACKGROUND: The Society of Thoracic Surgeons (STS) General Thoracic Surgery Database (GTSD) has developed composite quality measures for lobectomy and esophagectomy. This study sought to develop a composite measure including all resections for lung cancer. METHODS: The STS lung cancer composite score is based on 2 outcomes: risk-adjusted mortality and morbidity. GTSD data were included from January 2015 to December 2017. "Star ratings" were created for centers with 30 or more cases by using 95% Bayesian credible intervals. The Bayesian model was performed with and without inclusion of the minimally invasive approach to assess the impact of approach on the composite measure. RESULTS: The study population included 38,461 patients from 256 centers. Overall operative mortality was 1.3% (495 of 38,461). The major complication rate was 7.9% (3045 of 38,461). The median number of nodes examined was 10 (interquartile range, 5 to 16); the median number of nodal stations sampled was 4 (interquartile range, 3 to 5). Positive resection margins were identified in 3.7% (1420 of 38,461). A total of 214 centers with 30 or more cases were assigned star ratings. There were 7 1-star, 194 2-star, and 13 3-star programs; 70.6% of resections were performed through a minimally invasive approach. Inclusion of minimally invasive approach, which was adjusted for in previous models, altered the star ratings for 3% (6 of 214) of the programs. CONCLUSIONS: Participants in the STS GTSD perform lung cancer resection with low morbidity and mortality. Lymph node data suggest that participants are meeting contemporary staging standards. There is wide variability among participants in application of minimally invasive approaches. The study found that risk adjustment for approach altered ratings in 3% of participants.

Survival after adjuvant radiation therapy in localized small cell lung cancer treated with complete resection.

OBJECTIVES: To determine whether there is an overall survival (OS) benefit to the addition of thoracic radiation therapy (RT) following R0 resection of pathologic (p) T1 or pT2 N0 M0 small cell lung cancer. METHODS: Using the National Cancer Database, we performed a retrospective cohort analysis. Patients who underwent R0 resection for pT1 or p2 N0 M0 small cell lung cancer, stratified by receipt of adjuvant thoracic RT, were compared on the basis of OS using hierarchical Cox Proportional hazards models. RESULTS: Of 4969 patients diagnosed with pT1or pT2 N0 M0 SCLC from 2004 to 2014, 1617 (33%) underwent R0 resection of their primary tumor; of these resected patients, 146 (9.0%) had adjuvant thoracic RT. In unadjusted analysis, there was no significant difference in OS between groups (median survival: surgery alone, 62.2 months vs surgery+RT, 43.8 months; P = .1436). In multivariable analysis, RT was not associated with improved survival (P = .099). There was no significant difference in unadjusted or adjusted survival associated with receipt of RT in both a young and healthy cohort (P = .647 for unadjusted and P = .858 for adjusted) and a matched cohort (P = .867 and P = .954). In the matched cohort, improved OS was associated with younger patient age (adjusted hazard ratio, 1.07; 95% confidence interval, 1.04-1.10; P < .001), female sex (adjusted hazard ratio, 0.68, 95% confidence interval, 0.47-0.97; P = .035), and smaller tumors (adjusted hazard ratio, 1.02; 95% confidence interval, 1.01-1.03; P = .005). Having 2 or more comorbidities was associated with worse OS (adjusted hazard ratio, 2.16; 95% confidence interval, 1.21-3.86; P = .009). CONCLUSIONS: Although complete resection was accomplished in a minority of patients, for these patients, survival was good. The addition of thoracic RT to complete resection does not appear to confer additional survival benefit.

Evaluation of adherence to the Commission on Cancer lung cancer quality measures.

OBJECTIVE: In this study we present historic data on adherence to and survival outcomes associated with recently introduced quality measures for the management of non-small-cell lung cancer. METHODS: The National Cancer Data Base was queried to identify all patients with non-small-cell lung cancer from 1998 to 2011. Adherence to guidelines was assessed for each of 3 Commission on Cancer-defined quality measures: (1) sampling 10 regional lymph nodes at surgery; (2a) surgery within 120 days of neoadjuvant chemotherapy or, (2b) 180 days of adjuvant chemotherapy; and (3) nonsurgical primary therapy in cN2 disease. The likelihood of measure adherence and the association of measure adherence with all-cause mortality were analyzed controlling for patient, hospital, and time period characteristics. RESULTS: Regional lymph node sampling was inadequate in 72.7% of cases. Only 28.7% began adjuvant chemotherapy within 180 days of surgery. However, 96.5% of patients who received neoadjuvant chemotherapy proceeded to surgery within 120 days and surgery was first-line treatment for cN2 disease in only 3.7% of patients. Uninsured or Medicaid status was an independent risk factor for a prolonged delay between neoadjuvant chemotherapy and surgery (odds ratio, 1.36; 95% confidence interval, 1.08-1.72) and surgery and adjuvant treatment (odds ratio, 1.92; 95% confidence interval, 1.69-2.19). Overall survival was significantly better in patients whose care conformed to quality standards for nodal sampling (measure 1), and timing of chemotherapy. CONCLUSIONS: Adherence rates for nodal sampling at the time of surgery and receipt of adjuvant chemotherapy were low. These findings highlight opportunities for improvement efforts, but more measures are needed to more broadly assess the quality of lung cancer care.