Composite anatomical-clinical-molecular prognostic model in non-small cell lung cancer.

The objective of the present study was to elaborate a survival model that integrates anatomic factors, according to the 2010 seventh edition of the tumour, node and metastasis (TNM) staging system, with clinical and molecular factors. Pathologic TNM descriptors (group A), clinical variables (group B), laboratory parameters (group C) and molecular markers (tissue microarrays; group D) were collected from 512 early-stage nonsmall cell lung cancer (NSCLC) patients with complete resection. A multivariate analysis stepped supervised learning classification algorithm was used. The prognostic performance by groups was: areas under the receiver operating characteristic curve (C-index): 0.67 (group A), 0.65 (Group B), 0.57 (group C) and 0.65 (group D). Considering all variables together selected for each of the four groups (integrated group) the C-index was 0.74 (95% CI 0.70-0.79), with statistically significant differences compared with each isolated group (from p = 0.006 to p < 0.001). Variables with the greatest prognostic discrimination were the presence of another ipsilobar nodule and tumour size > 3 cm, followed by other anatomical and clinical factors, and molecular expressions of phosphorylated mammalian target of rapamycin (phospho-mTOR), Ki67cell proliferation index and phosphorylated acetyl-coenzyme A carboxylase. This study on early-stage NSCLC shows the benefit from integrating pathological TNM, clinical and molecular factors into a composite prognostic model. The model of the integrated group classified patients with significantly higher accuracy compared to the TNM 2010 staging.

Sublobar resection for lung cancer.

Sublobar resection for small lung cancers has been debated frequently and is still a controversial issue. The only randomised trial comparing lobectomy with sublobar resections found a significantly higher recurrence rate for the latter, but failed to show significant differences in survival, although survival was better for the lobectomy group. One meta-analysis and several nonrandomised comparisons have confirmed these results. In general, lobectomy and sublobar resections have similar 5-yr survival rates. Local recurrence after wedge resection is higher than after segmentectomy. However, for patients aged >71 yrs, lobectomy and wedge resection are associated with similar survival. For tumours of /=1 cm wide to avoid recurrence. For pure bronchioloalveolar carcinoma of

Surgical sealant for preventing air leaks after pulmonary resections in patients with lung cancer.

BACKGROUND: Postoperative air leak is a frequent complication after pulmonary resection for lung cancer. It may cause serious complications, such as empyema, or prolong the need for chest tube and hospitalisation. Surgical sealants of different types have been developed to prevent or to reduce postoperative air leaks. A systematic review was therefore undertaken to evaluate the evidence on their effectiveness. OBJECTIVES: To evaluate the effectiveness of surgical sealants in preventing or in reducing postoperative air leaks after pulmonary resection for lung cancer. SEARCH STRATEGY: The electronic databases MEDLINE (1966 to 2004), EMBASE (1974 to 2004), Cancerlit (1993 to 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3/2004) and listed references were searched, and handsearching of conference proceedings was conducted to identify published and unpublished trials. SELECTION CRITERIA: Randomised controlled clinical trials were included in which standard closure techniques plus a sealant were compared with the same intervention with no use of any sealant in patients undergoing elective pulmonary resection provided that a large proportion of the patients included in the studies had undergone pulmonary resection for lung cancer. DATA COLLECTION AND ANALYSIS: Three reviewers independently selected the trials to be included in the review, assessed methodological quality of each trial and extracted data using a standardised form. Because of several limitations, narrative synthesis was used at this stage. MAIN RESULTS: Twelve trials, with 1097 patients in total, were included. In eight trials there was a statistically significant difference between treatment and control patients in reducing postoperative air leaks. However this reduction only proved a significant reduction of hospital stay in one trial. Only in one trial reduction of time of chest drain removal and reduction of percentage of patient with persistent air leak were significantly smaller in the treatment group. AUTHORS' CONCLUSIONS: Although surgical sealants seem to reduce postoperative air leaks, length of hospitalisation is not affected and infectious complications may be increased. Therefore, systematic use of surgical sealants in clinical practice cannot be recommended at the moment. More randomised controlled clinical trials are needed.

Surgical treatment of lung cancer with adrenal metastasis.

Surgical treatment of adrenal metastasis from non-small cell lung cancer is controversial. Classically this group of patients has been considered incurable, therefore excision of the primary cancer and the adrenal gland has been avoided. However, recent reports show good results in their surgical management. Five selected patients with non-small cell lung cancer and adrenal metastases have been surgically treated. Two of them also presented with brain metastases that were excised, too. One patient with brain and adrenal metastases died 38 months after surgery. The other four patients are alive and with no sign of recurrent disease at 8, 16, 52 and 58 months of follow-up. In highly selected patients in whom both the primary and the metastatic tumors are resectable and in the absence of tumor spread to other organs, surgical treatment seems to be a good therapeutic option.

Critical factors for patient management.

The main critical factors for lung cancer patient management, apart from TNM staging, include expertise required to offer optimal management and conditions related to the patient, including performance status and weight loss and the presence of lung, cardiac or other comorbidities. Performance status and weight loss must be assessed for all patients. The minimal pulmonary functional evaluation should include spirometry. The minimal cardiac evaluation should consist of a clinical history and evaluation for cardiac risk factors and disease and at least preoperatively, and ECG. Age per se is not a contraindication for curative treatment.

Remediastinoscopy after induction chemotherapy in non-small cell lung cancer.

BACKGROUND: This study was undertaken to evaluate the technical feasibility and the sensitivity, specificity, and accuracy of remediastinoscopy in restaging N2 bronchogenic carcinoma treated with neoadjuvant chemotherapy. METHODS: Patients presenting mediastinal lymph node involvement at mediastinoscopy received three or four cycles of neoadjuvant chemotherapy with mitomycin, iphosphamide, and cisplatin or cisplatin and gemcitabine. If there was no disease progression, these patients underwent remediastinoscopy and, if no residual extracapsular involvement or N3 disease was found, a thoracotomy was then carried out. RESULTS: Twenty-four patients underwent remediastinoscopy. In 12 (50%) remediastinoscopy was positive. The 12 remaining patients were operated on and the tumors resected: 5 pneumonectomies and 7 lobectomies. Lymphadenectomy specimens showed residual disease in mediastinal lymph nodes in 5 patients (pN2) and hilar lymph nodes in 1 patient (pN1). The other 6 patients were free of nodal disease, and 4 of them presented no involvement at lung level either. The sensitivity, specificity, and accuracy of remediastinoscopy were 0.7, 1, and 0.8, respectively. CONCLUSIONS: Remediastinoscopy is a technically feasible staging tool with high diagnostic accuracy that is useful in the selection of patients who can be served best by complete resection after neoadjuvant chemotherapy.

Localized fibrous tumor of the pleura: immunohistochemical and flow-cytometric DNA study.

This report describes three cases of localized fibrous tumor of the pleura (LFTP) with clinical and pathological differences. Case 1 presented with symptoms; the tumor size was 6.5 cm and it was attached to the lung and chest wall; histologically it was composed of spindle cells with pleomorphism, mitoses, hemorrhage and necrosis. Cases 2 and 3 were casual findings and consisted of well-circumscribed tumors of 3 and 8.5 cm, respectively; histologically both showed hypocellularity. All cases exhibited positive stains for vimentin and negative for keratin. These results, added to histological features, suggested a mesenchymal origin. Flow cytometry quantitation of DNA disclosed a diploid pattern in all three cases with a small "near diploid" cell population additionally in Case 1; the S-phase fraction was low in all cases. These findings, that could be considered favourable prognostic signs, and the complete tumoral resection performed in the three tumors, could explain the absence of recurrences after 32, 27 and 19 months, respectively.

[Results of the surgical treatment of pathologic bronchogenic carcinoma N2 with negative mediastinoscopy]. / Resultados del tratamiento quirúrgico del carcinoma broncogénico N2 patológico con mediastinoscopia negativa.

OBJECTIVE: To analyze the survival of patients undergoing lung resection for N2 bronchogenic carcinoma with negative findings at mediastinoscopy. MATERIAL AND METHOD: Twenty-nine patients with N2 bronchogenic carcinoma were analyzed. The patients were taken from a series of 170 patients who underwent surgery between 1993 and 1997 and whose data were recorded by the Bronchogenic Carcinoma Cooperative Group of the Spanish Society of Pneumology and Thoracic Surgery (GCCB-S). In 26 patients, nodes were found in the upper mediastinum; in three patients nodes were paraesophageal or in the area of the pulmonary ligament. In 11 cases, extracapsular nodal disease was found. Three patients who died in the postoperative period were excluded from survival analysis. RESULTS: The five-year survival rate for the series of 170 patients was 39%. For the 26 patients with N2 carcinoma, five-year survival was 14% (median 12 months). Five-year survival for the remaining patients (excluding those with N2 carcinoma) was 46%. Although the median survival of patients with intracapsular nodal disease was more than twice (25 months) that of patients with extracapsular nodal disease (12 months), the difference was not significant. CONCLUSIONS: Lung resection in patients with N2 bronchogenic carcinoma with negative mediastinoscopy has little impact on survival. Surgical exploration of the mediastinum classifies such patients with greatest certainty, although the sensitivity of staging techniques warrants improvement to assure that thoracotomy is not used unnecessarily.

[Study of the personality of patients with spontaneous pneumothorax]. / Estudio de personalidad de los pacientes con neumotórax espontáneo.

INTRODUCTION: Medical psychology has contributed to a greater understanding of many diseases that are predominantly medical and has also helped to improve prognosis. This study explores a surgical entity, namely spontaneous pneumothorax. OBJECTIVES: The aim was to compare the personality, depression, anxiety and type-A behavior pattern in a group of 34 patients with spontaneous pneumothorax to a group of 33 control patients admitted for a variety of minor surgical procedures. MATERIAL AND METHODS: The following objective assessment instruments were used: Trait Anxiety Inventory, Beck Depression Inventory, Jenkins Activity Inventory, Eysenck Personality Questionnaire. The questionnaires were administered before the intervention of the surgeon and after an informative interview. RESULTS: The rate of type-A behavior was statistically different in the two groups. No differences were seen for personality, depression or anxiety. CONCLUSION: We conclude that type-A behavior patterns should be reduced in patients who suffer spontaneous pneumothorax in order to improve outcome.

[Survival after resection of lung metastasis from colorectal cancer]. / Supervivencia tras resección de metástasis pulmonares de cáncer colorrectal.

OBJECTIVE: To analyze the results of resection of lung metastases from colorectal adenocarcinoma in selected patients, evaluating type of resection, morbidity and mortality associated with the procedure, and overall actuarial survival rates after surgery. PATIENTS AND METHODS: Between 1988 and 1996, 811 patients were treated surgically for colorectal adenocarcinoma. Recurrent chronic lung metastases were resected, presumably with the intention to cure, in 15 patients in the series. One patient underwent surgery for pelvic recurrence and another seven for liver metastases, before resection of the lung metastases. RESULTS: Twenty-seven wedge resections were performed, two being non-malignant and one patient requiring re-resection of new lung metastases. Unsuspected locations of lung metastasis were found in three patients during surgery. Perioperative mortality was zero. Mean follow-up was 50 months (range 28 to 99). Seven patients presented new occurrences of metastasis or tumor recurrence and died as a result. The actuarial survival rate was 48% at 5 years. CONCLUSIONS: In selected patients, surgical resection of lung metastasis from colorectal cancer, with the assumed intention of cure, has yielded a good survival rate and zero perioperative mortality. It appears advisable to use an approach that permits exhaustive palpation of the pulmonary parenchyma, due to the risk of finding unsuspected metastases.

Surgical exploration of the mediastinum by mediastinoscopy, parasternal mediastinotomy and remediastinoscopy: indications, technique and complications.

Imaging diagnostics often fail to provide enough certainly to make therapeutic decisions, since radiological images do not always correlate well with the pathological condition of the lesions. Surgical exploration of the mediastinum by mediastinoscopy allows to obtain very accurate information from inspection, palpation and biopsies of lymph nodes or tumors directly affecting the mediastinum. Mediastinoscopy assesses the upper mediastinum, including nodal stations 1, 2R, 2L, 3, 4L, 7, 10R and 10L. It can also assess direct invasion of the mediastinum from adjacent tumors. Parasternal mediastinoscopy is a complementary technique to reach nodal stations 5 and 6, which cannot be reached with standard cervical mediastinoscopy. Remediastinoscopy has been performed to restage tumors after delayed treatment and to stage second primary and recurrent tumors. It has proved useful, too, to restage N2 lung cancer after induction chemotherapy. In all these indications, remediastinoscopy was technically possible. All these techniques are associated with very few complications (around 3%) and a low mortality rate of less than 1%.

Proposals for changes in the Mountain and Dresler mediastinal and pulmonary lymph node map.

Staging of the intrathoracic mediastinal and pulmonary lymph nodes is one of the most important problems in the treatment of non-small cell lung cancer. The map of the mediastinal and pulmonary lymph nodes proposed by Clifton F. Mountain and Carolyn M. Dresler gained wide acceptance and has become a standard of staging. However, it has some shortcomings of clarity in the description of localization of specific nodal stations. In our opinion, some modifications of this map are necessary. Based on our experience with extended mediastinoscopy and the new procedure, transcervical extended mediastinal lympadenectomy, the main changes we propose are: 1) the left innominate vein as the anatomic separation between nodal stations 1 and 2; 2) the merging of station 2 and 4 in a single right and left paratracheal station; 3) the shift of the midline to the left paratracheal margin; 4) the tracheobronchial angles as the landmark between stations 4 and 10 bilaterally; 5) the separation of three nodal groups in the subcarinal area: subcarinal (number 7), peribronchial (number 10R and 10L), and periesophageal (number 8); 6) the merging of station 5 and station 6 nodes in a single station with the following landmarks: medial border: the midline, lateral border, the descending aorta and upper border: the left innominate vein and lower border: the lower margin of the left pulmonary artery; and 7) the definition of station 3A nodes as those in front of the superior vena cava.