Surgery for non-small cell lung cancer in younger patients: what are the differences?

BACKGROUND: Non-small cell lung cancer (NSCLC) in young adults is uncommon. The objective of this study was to evaluate the clinicopathological characteristics, outcomes and prognosis of people younger than 50 years old treated surgically for NSCLC. METHODS: A retrospective study was conducted using the institutional database of four thoracic surgery units to collect patients with NSCLC younger than 50 years who had undergone surgery. These patients were compared with older patients (>75-years) operated in the same institutions and in the same period. RESULTS: We identified 113 young patients and 347 older patients. Younger patients were more likely to be female, non-smokers, with fewer comorbidities. Younger patients were more likely to be symptomatic at the time of diagnosis. Risk factors for poor prognosis in younger patients were T-stage, and disease-free-interval less than 548 days. Kaplan-Meier analysis showed a lower five-year survival in older patients compared with the younger ones (66% vs 38%, p=0.001). CONCLUSIONS: In conclusion NSCLC in younger patients has some distinct clinicopathological characteristics. The overall-survival of young patients is better than in older patients. Young patients receive more complete and aggressive treatment that could explain better survival. Further prospective studies with larger patient populations are required, to clarify the biological and genetic variance of NSCLC in younger patients.

Operating room data management: improving efficiency and safety in a surgical block.

BACKGROUND: European Healthcare Systems are facing a difficult period characterized by increasing costs and spending cuts due to economic problems. There is the urgent need for new tools which sustain Hospitals decision makers work. This project aimed to develop a data recording system of the surgical process of every patient within the operating theatre. The primary goal was to create a practical and easy data processing tool to give hospital managers, anesthesiologists and surgeons the information basis to increase operating theaters efficiency and patient safety. METHODS: The developed data analysis tool is embedded in an Oracle Business Intelligence Environment, which processes data to simple and understandable performance tachometers and tables. The underlying data analysis is based on scientific literature and the projects teams experience with tracked data. The system login is layered and different users have access to different data outputs depending on their professional needs. The system is divided in the tree profile types Manager, Anesthesiologist and Surgeon. Every profile includes subcategories where operators can access more detailed data analyses. The first data output screen shows general information and guides the user towards more detailed data analysis. The data recording system enabled the registration of 14.675 surgical operations performed from 2009 to 2011. RESULTS: Raw utilization increased from 44% in 2009 to 52% in 2011. The number of high complexity surgical procedures (≥120 minutes) has increased in certain units while decreased in others. The number of unscheduled procedures performed has been reduced (from 25% in 2009 to 14% in 2011) while maintaining the same percentage of surgical procedures. The number of overtime events decreased in 2010 (23%) and in 2011 (21%) compared to 2009 (28%) and the delays expressed in minutes are almost the same (mean 78 min). The direct link found between the complexity of surgical procedures, the number of unscheduled procedures and overtime show a positive impact of the project on OR management. Despite a consistency in the complexity of procedures (19% in 2009 and 21% in 2011), surgical groups have been successful in reducing the number of unscheduled procedures (from 25% in 2009 to 14% in 2011) and overtime (from 28% in 2009 to 21% in 2011). CONCLUSIONS: The developed project gives healthcare managers, anesthesiologists and surgeons useful information to increase surgical theaters efficiency and patient safety. In difficult economic times is possible to develop something that is of some value to the patient and healthcare system too.

Sequential chemotherapy with cisplatin/gemcitabine (CG) followed by mitoxantrone/methotrexate/mitomycin (MMM) in patients with malignant pleural mesothelioma. A multicenter Italian Phase II Study (SITMP1).

PURPOSE: We performed a multicenter phase II trial to evaluate the impact on the activity, efficacy, symptom control and safety of using two active regimens in a sequential schedule (cisplatin/gemcitabine followed by mitoxantrone/methotrexate/mitomycin) as first-line chemotherapy for unresectable malignant pleural mesothelioma (MPM). PATIENTS AND METHODS: A total of 54 patients received cisplatin 75 mg/m(2) on day 1 and gemcitabine 1,200 mg/m(2) on days 1 and 8, every 3 weeks for four courses (CG regimen) followed by mitoxantrone 10 mg/m(2) on day 1, methotrexate 35 mg/m(2) on day 1 and mitomycin 7 mg/m(2) on day 1, every 3 weeks with mitomycin in alternate cycles for four courses (MMM regimen). RESULTS: We observed 3 complete responses (CRs) (5.6%) and 13 partial responses (PRs) (24.0%), with an overall response rate (ORR) of 29.6% (95% confidence interval, 17-42%), 33 stable disease (SD) (61.1%) and 5 progressive disease (PD) (9.2%). Median time to progression (TTP) was 9.5 months (range, 2-23). Median overall survival (OS) was 13 months (range, 3-33); 1-year survival rate was 63%. The treatment produced a good symptom control, with an improvement during chemotherapy in dyspnea and pain in 52.9 and 48.3% of patients, respectively. The major toxicity observed was hematological. Grades 3-4 NCI-CTC v 2.0 toxicity with the CG regimen included: neutropenia (11.1%), anemia (1.9%), thrombocytopenia (7.4%), vomiting (11.1%) and with the MMM regimen: neutropenia (35.2%), anemia (5.5%), thrombocytopenia (7.4%) and stomatitis (1.9%). CONCLUSION: This phase II study with the sequential approach of two active regimens showed a good disease control in MPM, with symptom improvement and only mild toxicity.

[Esophageal perforation: analysis of seven cases treated by early surgical treatment with good functional results]. / Le perforazioni esofagee: analisi di 7 recenti casi risoltisi favorevolmente con trattamento chirurgico precoce.

INTRODUCTION: Esophageal perforation has been considered a catastrophic and often life-threatening event, with very high mortality rates. Most of the cases are due to a complication in endoscopic manouvers and the best treatment, conservative rather than aggressive, remains a controversial topic. MATERIAL AND METHODS: In 1995-2005 period we observed 7 cases of esophageal perforation, 5 women and 2 men mean age 73.2 y (range 60-87). Three cases are due to foreign body ingestion, 2 cases to endoscopic manoeuvres, 2 cases were spontaneous. In 3 cases the lesion was in the cervical tract of the esophagus, in the thoracic tract the others. All the patients were admitted very early to our Unit and presented disphagia, vomiting and dyspnoea, 2 out of them also a pleural effusion. In iatrogenic perforation we performed a cervicotomy and a drainage of mediastinic abscess, while in spontaneous lesions mono (one case) or bipolar esophageal exclusion (one case) with primary suture, jujunostomy and drainage of pleural effusion were the treatment. In foreign body perforation we performed thoracotomic and cervicotomic esophagotomy, extraction of the foreign body, direct suture with pleural or muscle protection. We didn't observe any intra or post-operative mortality. About the complications, we observed a bilateral pleural empyema, a chylous fistula, a digestive bleeding due to gastric ulcer, a laparotomic infection, a parossistic FA and a persistent esophageal fistula. Mean hospital stay was 24.3 days (range 10-43). All the patients were discharged to the hospital in good conditions. CONCLUSIONS: In conclusion in most of the cases of esophageal perforation the surgical treatment is the treatment of choice for its lower morbidity and mortality and good functional results.

Lobar and sub-lobar lung resection in octogenarians with early stage non-small cell lung cancer: factors affecting surgical outcomes and long-term results.

OBJECTIVES: Consensus exists as to the concept that surgical therapy should not be denied based on older age alone. Elderly lung cancer patients with multiple morbidities are increasingly referred for surgical care. The aim of this study was to evaluate the surgical outcomes and the long-term survival in octogenarians with early-stage non-small cell lung cancer. METHODS: Between January 2000 and December 2010, we identified 73 octogenarians who underwent intended curative lung resection for lung cancer in three different thoracic surgery departments. Two surgical groups were defined: patients who underwent lobar resection (group A) and patients who underwent sub-lobar resection (group B). RESULTS: The in-hospital mortality was 2.7% without difference between groups. Group B had a lower incidence of post-operative complications, in particular respiratory complications. Chronic renal failure, multi pre-operative comorbidities and type of resection were risk factors for post-operative morbidity. After a mean follow-up time of 63.8 months, the overall survival at 1, 3 and 5 years was 96, 83 and 60%, respectively. The low-respiratory reserve was associated with worse long-term survival. The intra-operative and post-operative factors able to influence survival were: the cN status, recurrence of disease and local versus systemic recurrence. The type of operation did not influence survival. CONCLUSIONS: In our experience, surgery is a safe and justifiable option for octogenarian patients with early stage NSCLC. Sublobar resection provides an equivalent in-hospital mortality and long-term survival in comparison with open lobectomy but with less postoperative morbidity. Further large-scale randomized studies are necessary to confirm our results.

Early and long-term results of pulmonary resection for non-small-cell lung cancer in patients over 75 years of age: a multi-institutional study.

OBJECTIVES: Older lung cancer patients with multiple morbidities are increasingly referred to thoracic surgery departments. The aim of this multicenter study was to analyse the prognostic factors for in-hospital morbidity and mortality and to elucidate the predictors of long-term survival and oncological outcomes. METHODS: We identified 319 patients aged ≥ 75 years who underwent intended curative lung resection for lung cancer in three different thoracic surgery departments between January 2000 and December 2010. RESULTS: Seventy-one patients underwent limited resection, 202 had lobectomy, 16 had bilobectomy and 30 had pneumonectomy. The in-hospital mortality was 6.6%. Chronic renal failure, low respiratory reserve and pneumonectomy were predictors of in-hospital mortality. The mean follow-up time was 3.9 years, ranging from 1 month to 10.4 years. The disease-free survivals at 1, 3 and 5 years were 82, 60 and 47%, respectively. The overall survivals at 1, 3 and 5 years were 86, 59 and 38%, respectively. The long-term overall survival was negatively influenced by pneumonectomy, extended resection, N(1-2) subgroups and pathological TNM stage. CONCLUSIONS: Nowadays, we can consider surgery a safe and justifiable option for elderly patients. Careful preoperative work-up and selection are mandatory to gain satisfactory results. Good long-term results were achieved in elderly patients with early stage who underwent lobar or sublobar lung resection. The role of surgery or other alternative therapies, in patients with advanced stages, extensive nodal involvement and/or requiring extensive surgical resection for curative intent, is still unclear and further studies are certainly needed.

Disseminated basidiobolomycosis in an immunocompetent woman.

Basidiobolomycosis is a chronic subcutaneous infection of the trunk and limbs due to Basidiobolus ranarum. The disease is well known in tropical areas, although recent cases of gastrointestinal basidiobolomycosis have also been reported in Arizona. We describe a young immunocompetent women who had presented with eosinophilia and lung infiltrates. She subsequently died, and diagnosis of disseminated basidiobolomycosis was made on the basis of histological features at autopsy.