Recommendations for Post-Operative RadioTherapy After Complete Resection of Thymoma-a French DELPHI Consensus Initiative.

INTRODUCTION: Thymomas are rare intrathoracic malignancies that can relapse after surgery. Whether or not Post-Operative RadioTherapy (PORT) should be delivered after surgery remains a major issue. RADIORYTHMIC is an ongoing, multicenter, randomized phase 3 trial addressing this question in patients with completely R0 resected Masaoka-Koga stage IIb/III thymoma. Experts in the field met to develop recommendations for PORT. METHODS: A scientific committee from the RYTHMIC network identified key issues regarding the modalities of PORT in completely resected thymoma. A DELPHI method was used to question 24 national experts, with 115 questions regarding the following: (1) imaging techniques, (2) clinical target volume (CTV) and margins, (3) dose constraints to organs at risk, (4) dose and fractionation, and (5) follow-up and records. Consensus was defined when opinions reached more than or equal to 80% agreement. RESULTS: We established the following recommendations: preoperative contrast-enhanced computed tomography (CT) scan is recommended (94% agreement); optimization of radiation delivery includes either a four-dimensional CT-based planning (82% agreement), a breath-holding inspiration breath-hold-based planning, or daily control CT imaging (81% agreement); imaging fusion based on cardiovascular structures of preoperative and planning CT scan is recommended (82% agreement); right coronary and left anterior descending coronary arteries should be delineated as cardiac substructures (88% agreement); rotational RCMI/volumetric modulated arc therapy is recommended (88% agreement); total dose is 50 Gy (81% agreement) with 1.8 to 2 Gy per fraction (94% agreement); cardiac evaluation and follow-up for patients with history of cardiovascular disease are recommended (88% agreement) with electrocardiogram and evaluation of left ventricular ejection fraction at 5 years and 10 years. CONCLUSION: This is the first consensus for PORT in thymoma. Implementation will help to harmonize practices.

Anatomic lung resection after immune checkpoint inhibitors for initially unresectable advanced-staged non-small cell lung cancer: a retrospective cohort analysis.

Background: Patients with initially unresectable advanced non-small cell lung cancer (NSCLC) might experience prolonged responses under immune checkpoint inhibitors (ICIs). In this setting, Multidisciplinary Tumor Board (MTB) seldomly suggest surgical resection of the primary tumor with the ultimate goal to eradicate macroscopic residual disease. Our objective was to report the perioperative outcomes of patients who underwent anatomic lung resection in these infrequent circumstances. Methods: We set a retrospective multicentric single arm study, including all patients with advanced-staged initially unresectable NSCLC (stage IIIB to IVB) who received systemic therapy including ICIs and eventually anatomical resection of the primary tumor in 10 French thoracic surgery units from January 2016 to December 2020. Coprimary endpoints were in-hospital mortality and morbidity. Secondary endpoints were the rate of complete resection of the pulmonary disease, major pathologic response, risk factors associated with post-operative complications, and overall survival. Results: Twenty-one patients (median age 64, female 62%) were included. Eighteen patients (86%) progressed after first line chemotherapy and received second line ICI. The median time between diagnosis and surgery was 22 months [interquartile range (IQR) 18-35 months]. Minimally-invasive approach was used in 10 cases (48%), with half of these requiring conversion to open thoracotomy. Nine patients (43%) presented early post-operative complications, and one patient died from broncho-pleural fistula one month after surgery. Rates of complete resection of the pulmonary disease and major pathologic response were 100% and 43%, respectively. In univariable analysis, diffusing capacity for carbon monoxide (DLCO) was the only factor associated with the occurrence of postoperative complications (P=0.027). After a median follow-up of 16.0 months after surgery (IQR, 12.0-30.0 months), 19 patients (90%) were still alive. Conclusions: Anatomic lung resections appear to be a reasonable option for initially unresectable advanced NSCLC experiencing prolonged response under ICIs. Nonetheless, minimally invasive techniques have a low applicability and post-operative complications remains higher in patients who had lower DLCO values. The late timing of surgery may also contribute to complications.

Post-menopausal pulmonary leiomyoma metastasis: an unexpected finding.

Benign metastasizing leiomyoma (BML) is a rare entity characterized by proliferation of extra-uterine smooth muscle tumors. BML has both malignant behavior and benign characteristics. Here, we present a case of pulmonary BML occurring in a 70-year-old woman treated by surgery.

Postocclusion hyperemia provides a better estimate of coronary reserve than intracoronary adenosine in patients with coronary artery stenosis.

OBJECTIVE: The aim of this study was to compare the ability of intracoronary adenosine (ADE) and postocclusion hyperemia (PH) to cause maximal hyperemia in humans. BACKGROUND: The current clinical standard for induction of maximal coronary hyperemia is intracoronary ADE. However, animal studies have shown that maximal hyperemia was not achieved by ADE and that PH yielded a higher hyperemic response. METHODS: In 10 stable patients with coronary artery stenosis > or = 80%, basal and peak coronary blood flow velocity (intracoronary Doppler) were measured before and after coronary angioplasty (PTCA), both after an intracoronary bolus of 60 mcg ADE, and after 30-second occlusion of the coronary artery by a balloon angioplasty catheter. Coronary reserve was estimated through coronary flow reserve (CFR = peak-to-resting coronary blood flow velocity), and coronary resistance reserve (CRR = [resting aortic pressure/resting coronary flow velocity]/[aortic pressure at peak velocity/peak coronary flow velocity]). RESULTS: Before PTCA, ADE and PH result in comparable CFR (1.79 +/- 0.65 vs. 1.95 +/- 0.52, respectively; p = 0.0846), but CRR was higher with PH (1.75 +/- 0.52 vs. 2.14 +/- 0.81, respectively; p = 0.0125). After PTCA, CFR and CRR were significantly lower with ADE than with PH (CFR = 2.53 +/- 0.58 vs. 3.31 +/- 0.67, respectively; p = 0.0001, and CRR = 2.58 +/- 0.49 vs. 3.46 +/- 0.79; p = 0.0004, respectively). Lastly, the higher the coronary reserve, the greater the differences between ADE and PH values. CONCLUSIONS: Because intracoronary 60 mcg ADE elicits a lower hyperemic response than PH, intracoronary ADE represents a potential source of error in coronary reserve measurements, and may result in an underestimation of the physiological significance of a coronary artery stenosis.