Complications of Outpatient Chest Tube Management for Prolonged Air Leaks After Pulmonary Surgery.

PURPOSE: Air leaks are common after pulmonary surgery. Prolonged air leaks (PALs) may persist through discharge and often are managed with one-way valve devices (OWD). We sought to determine the course and complications of patients discharged with OWDs, risk factors for complications, and to evaluate the utility of clamp trials before chest tube (CT) removal. METHODS: Single-institution, retrospective review of patients discharged with a OWD after pulmonary surgery between 2008 and 2022. Charts were examined for the presence of complications and CT duration. Differences in CT duration were compared by using the Wilcoxon rank-sum test. RESULT: Sixty-four of 1917 (3.3%) pulmonary surgeries resulted in OWD use. Twelve of 64 (19%) patients discharged with a OWD suffered a complication. Nine of 64 (14%) had a CT-related readmission, and seven of 64 (11%) required PAL intervention. Patients sustaining a complication demonstrated longer CT durations before complication compared with duration in patients without complications, with median days of 13 [IQR 6-21] vs. 7 [IQR 6-12], p = 0.04). Five (7.8%) OWD patients developed an empyema; only one (20%) occurred before a CT duration of 14 days. Sixteen of 64 (25%) patients underwent a clamp trial before CT removal. One of ten (10%) failed even with no air leak present, whereas one of six (17%) failed with a present/questionable air leak. CONCLUSIONS: One-way valve device use has a substantial complication rate, and chest tube duration is a risk factor. In-hospital interventions might benefit patients with larger leaks that likely require prolonged OWD use. Because clamp trials occasionally fail, we contend that a clamp trial is the safest course before CT removal.

“Obesity paradox” has not an impact on minimally invasive anatomical lung resection

IntroductionThe paradoxical benefit of obesity, the ‘obesity paradox’, has been analyzed in lung surgical populations with contradictory results. Our goal was assessing the relationship of body mass index (BMI) to acute outcomes after minimally invasive major pulmonary resections.MethodsRetrospective review of consecutive patients who underwent pulmonary anatomical resection through a minimally invasive approach for the period 2014–2019. Patients were grouped as underweight, normal, overweight and obese type I, II and III. Adjusted odds ratios regarding postoperative complications (overall, respiratory, cardiovascular and surgical morbidity) were produced with their exact 95% confidence intervals. All tests were considered statistically significant at p<0.05.ResultsAmong 722 patients included in the study, 37.7% had a normal BMI and 61.8% were overweight or obese patients. When compared with that of normal BMI patients, adjusted pulmonary complications were significantly higher in obese type I patients (2.6% vs 10.6%, OR: 4.53 [95%CI: 1.86–12.11]) and obese type II–III (2.6% vs 10%, OR: 6.09 [95%CI: 1.38–26.89]). No significant differences were found regarding overall, cardiovascular or surgical complications among groups.ConclusionsObesity has not favourable effects on early outcomes in patients undergoing minimally invasive anatomical lung resections, since the risk of respiratory complications in patients with BMI≥30kg/m2 and BMI≥35kg/m2 is 4.5 and 6 times higher than that of patients with normal BMI (AU)

IntroducciónEl beneficio paradójico de la obesidad, la «paradoja de la obesidad», ha sido analizado en distintas series de cirugía de resección pulmonar con conclusiones contradictorias. El objetivo del estudio es evaluar la influencia del índice de masa corporal (IMC) en los resultados postoperatorios de resecciones pulmonares anatómicas por vía mínimamente invasiva.MétodosRevisión retrospectiva de pacientes consecutivos sometidos a resección pulmonar anatómica a través de un abordaje mínimamente invasivo durante el período comprendido entre 2014 y 2019. Los pacientes se agruparon en: bajo peso, normopeso, sobrepeso y obesidad tipo I, II y III. Se calcularon las odds ratio ajustadas con respecto a las distintas complicaciones (globales, respiratorias, cardiovasculares y quirúrgicas) con sus intervalos de confianza al 95% (IC 95%). Todas las pruebas se consideraron estadísticamente significativas con p<0,05.ResultadosEntre 722 pacientes incluidos en el estudio, el 37,7% tenían un IMC normal y el 61,8% eran pacientes con sobrepeso u obesidad. En comparación con los pacientes con IMC normal, las complicaciones pulmonares ajustadas fueron significativamente mayores en los pacientes obesos tipo I (2,6 vs. 10,6%; OR: 4,53 [IC 95%: 1,72-11,92]) y obesos tipo II-III (2,6 vs. 10%; OR: 6,09 [IC 95%: 1,38-26,89]). No se encontraron diferencias significativas con respecto a las complicaciones globales, cardiovasculares o quirúrgicas entre los distintos grupos.ConclusionesLa obesidad no tiene efectos favorables en los resultados postoperatorios en pacientes sometidos a resecciones pulmonares anatómicas mínimamente invasivas. El riesgo de complicaciones respiratorias en pacientes con IMC≥30kg/m2 e IMC≥35kg/m2 es 4,5 y 6 veces mayor que el de pacientes con IMC normal (AU)

Clinicopathological and prognostic implications of ALK rearrangement in patients with completely surgically resected lung adenocarcinoma.

BACKGROUND: The prognostic significance of ALK rearrangement is still contradictory. Here, we aimed to investigate the clinical characteristics and outcomes of lung adenocarcinoma patients with ALK rearrangement, and analyze whether these patients benefited from targeted therapy. METHODS: This was a retrospective cohort study of 80 ALK-rearranged lung adenocarcinoma patients who had undergone radical surgery and another 3031 ALK mutation-negative patients were retrospectively reviewed for inclusion in this case-controlled analyses. Overall survival (OS) was evaluated using the Kaplan--Meier method. Univariate analysis (UVA) and multivariate analysis (MVA) by the Cox proportional hazards regression identified risk factors that predicted OS. RESULTS: Compared to ALK-negative patients, the ALK rearranged patients were younger, with more non-smokers, more females, a larger primary tumor was demonstrated, and were a higher pathological stage. In particular, the risk of lymph node metastasis was higher. For patients with surgically-resected tumors, the prognosis was better for ALK rearranged patients (HR = 0.503; 95% CI: 0.259-0.974, p = 0.041). In addition, for stage II-III patients, targeted therapy was an independent prognostic factor of better OS (HR = 0.159; 95% CI: 0.032-0.801, p = 0.026). CONCLUSIONS: ALK rearranged lung adenocarcinoma patients who have undergone radical surgery have distinct clinical features. Patients with ALK rearrangement may have a favorable prognosis, and stage II-III patients may benefit from targeted treatment.

Outcomes of salvage lung resections in advanced EGFR-mutant lung adenocarcinomas under EGFR TKIs.

BACKGROUND: Studies regarding the outcomes of salvage lung resections of epidermal growth factor receptor (EGFR)-mutant advanced lung adenocarcinomas (ALAs) following treatment with EGFR tyrosine kinase inhibitors (TKIs) are limited, hence the objective of this study was to investigate such outcomes. METHODS: A total of 29 patients with EGFR-mutant ALA who underwent salvage surgery after EGFR-TKI treatment from October 2013 through January 2019 were enrolled. The patients were divided into two groups according to the surgical indications. Their perioperative parameters and surgical outcomes, including progression-free survival (PFS) and overall survival (OS), were then analyzed. RESULTS: The initial stages of the patients were stage IIIB (seven patients), IVA (17 patients), and IVB (five patients). Their surgical indications included residual tumor (25 patients) and progressive disease (PD) (four patients). They all underwent surgery via minimally invasive approaches and the median follow-up was 33.9 months. Within that follow-up duration, the median PFS after surgery was 36.4 months, and the median OS was still not reached. There were no significant differences in PFS or OS according to the different EGFR-TKIs used, the different durations of EGFR-TKI treatment before surgery, or the different surgical indications. However, the patients presenting with pleural seeding before EGFR-TKI treatment had significantly poorer PFS and OS than the other patients (P < 0.001). CONCLUSIONS: Salvage surgery following EGFR-TKI treatment of ALAs is a safe procedure with acceptable intra- and postoperative results. However, studies involving more cases and longer follow-up periods are needed to clarify its benefits. KEY POINTS: Salvage surgery following EGFR-TKI treatment of ALAs is a safe procedure with acceptable intra- and postoperative results. Our results support the use of surgery following treatment with EGFR-TKIs such as afatinib in advanced lung cancer.

The influence of positive end-expiratory pressure (PEEP) in predicting fluid responsiveness in patients undergoing one-lung ventilation.

Background: Dynamic preload parameters such as pulse pressure variation (PPV) and stroke volume variation (SVV) have widely been used as accurate predictors for fluid responsiveness in patients under mechanical ventilation. To circumvent the limitation of decreased cyclic change of intrathoracic pressure, we performed an intermittent PEEP challenge test to evaluate whether PPV or SVV can predict fluid responsiveness during one-lung ventilation (OLV). Methods: Forty patients undergoing OLV were analyzed. Baseline hemodynamic variables including PPV and SVV and respiratory variables were recorded after chest opening in lateral position under OLV (T1). Five minutes after application of PEEP 10 cmH2O, the parameters were recorded (T2). Thereafter, PEEP was withdrawn to 0 cmH2O for 5 minutes (T3), and fluid loading was performed with balanced crystalloid solution 6 mL/kg of ideal body weight for 5 minutes. Five minutes after completion of fluid loading, all variables were recorded (T4). The patient was classified as fluid responder if SV increased ≥10% after fluid loading and as non-responder if SV increased <10%. Results: Prediction of fluid responsiveness was evaluated with area under the receiver operating characteristic (ROC) curve (AUC). Change in stroke volume variation (ΔSVV) showed AUC of 0.9 (P < 0.001), 95% CI = 0.82-0.99, sensitivity = 88%, specificity = 82% for discrimination of fluid responsiveness. Change in pulse pressure variation (ΔPPV) showed AUC of 0.88 (P < 0.001), 95% CI = 0.78-0.97, sensitivity = 83%, specificity = 72% in predictability of fluid responsiveness. Cardiac index and stroke volume were well maintained after PEEP challenge in non-responders while they increased in responders. Conclusions: ΔPPV and ΔSVV induced by PEEP challenge are reliable parameters to predict fluid responsiveness as well as very good predictors of fluid unresponsiveness during OLV.

Pulmonary resection for tissue harvest in adoptive tumor-infiltrating lymphocyte therapy: Safety and feasibility.

BACKGROUND AND OBJECTIVES: Adoptive T-cell therapies (ACTs) using expansion of tumor-infiltrating lymphocyte (TIL) populations are of great interest for advanced malignancies, with promising response rates in trial settings. However, postoperative outcomes following pulmonary TIL harvest have not been widely documented, and surgeons may be hesitant to operate in the setting of widespread disease. METHODS: Patients who underwent pulmonary TIL harvest were identified, and postoperative outcomes were studied, including pulmonary, cardiovascular, infectious, and wound complications. RESULTS: 83 patients met inclusion criteria. Pulmonary TIL harvest was undertaken primarily via a thoracoscopy with a median operative blood loss and duration of 30 ml and 65 min, respectively. The median length of stay was 2 days. Postoperative events were rare, occurring in only five (6%) patients, including two discharged with a chest tube, one discharged with oxygen, one episode of urinary retention, and one blood transfusion. No reoperations occurred. The median time from TIL harvest to ACT infusion was 37 days. CONCLUSIONS: Pulmonary TIL harvest is safe and feasible, without major postoperative events in our cohort. All patients were able to receive intended ACT infusion without delays. Therefore, thoracic surgeons should actively participate in ongoing ACT trials and aggressively seek to enroll patients on these protocols.

Perioperative Lung Resection Outcomes After Implementation of a Multidisciplinary, Evidence-based Thoracic ERAS Program.

OBJECTIVE: This prospective study evaluated perioperative lung resection outcomes after implementation of a multidisciplinary, evidence-based Thoracic Enhanced Recovery After Surgery (ERAS) Program in an academic, quaternary-care center. BACKGROUND: ERAS programs have the potential to improve outcomes, but have not been widely utilized in thoracic surgery. METHODS: In all, 295 patients underwent elective lung resection for pulmonary malignancy from 2015 to 2019 PRE (n = 169) and POST (n = 126) implementation of an ERAS program containing all major ERAS Society guidelines. Propensity score-matched analysis, based upon patient, tumor, and surgical characteristics, was utilized to evaluate outcomes. RESULTS: After ERAS implementation, there was increased minimally invasive surgery (PRE 39.6%→POST 62.7%), reduced intensive care unit utilization (PRE 70.4%→POST 21.4%), improved chest tube (PRE 24.3%→POST 54.8%) and urinary catheter (PRE 20.1%→POST 65.1%) removal by postoperative day 1, and increased ambulation ≥3× on postoperative day 1 (PRE 46.8%→POST 54.8%). Propensity score-matched analysis that accounted for minimally invasive surgery demonstrated that program implementation reduced length of stay by 1.2 days [95% confidence interval (CI) 0.3-2.0; PRE 4.4→POST 3.2), morbidity by 12.0% (95% CI 1.6%-22.5%; PRE 32.0%→POST 20.0%), opioid use by 19 oral morphine equivalents daily (95% CI 1-36; PRE 101→POST 82), and the direct costs of surgery and hospitalization by $3500 (95% CI $1100-5900; PRE $23,000→POST $19,500). Despite expedited discharge, readmission remained unchanged (PRE 6.3%→POST 6.6%; P = 0.94). CONCLUSIONS: The Thoracic ERAS Program for lung resection reduced length of stay, morbidity, opioid use, and direct costs without change in readmission. This is the first external validation of the ERAS Society thoracic guidelines; adoption by other centers may show similar benefit.

Vicryl Mesh Coverage Reduced Recurrence After Bullectomy for Primary Spontaneous Pneumothorax.

BACKGROUND: Although thoracoscopic stapled bullectomy is a standard procedure for primary spontaneous pneumothorax (PSP), the postoperative recurrence rate is high. We investigated whether using a Vicryl (Ethicon, Somerville, NJ) mesh to cover the staple line after bullectomy reduces the postoperative recurrence rate. METHODS: Our single-blind, parallel-group, prospective, randomized controlled trial at 2 medical centers in Taiwan studied patients with PSP who were aged 15 to 50 years and required thoracoscopic bullectomy. On the day of operation, patients were randomly assigned (1:1) to receive Vicryl mesh (mesh group) or not (control group) after thoracoscopic bullectomy with linear stapling and mechanical apical pleural abrasion. Randomization was achieved using computer-generated random numbers in sealed envelopes. Our primary end point was the pneumothorax recurrence rate within 1 year after the operation (clinicaltrials.gov number, NCT01848860.) RESULTS: Between June 2013 and March 2016, 102 patients were assigned to the mesh group and 102 to the control group. Within 1 year after operation, recurrent pneumothorax was diagnosed in 3 patients (2.9%) in the mesh group compared with 16 (15.7%) in the control group (P = .005). The short-term postoperative results and hospitalization duration were comparable between the groups. CONCLUSIONS: For thoracoscopic bullectomy with linear stapling and mechanical apical pleural abrasion, the use of a Vicryl mesh to cover the staple line is effective for reducing the postoperative recurrence of pneumothorax. Vicryl mesh coverage can be considered an optimal adjunct to the standard surgical procedure for PSP.

Patients' views of routine quality of life assessment following a diagnosis of early-stage non-small cell lung cancer.

OBJECTIVES: There is an increasing interest in the quality of life (QoL) evaluation following video-assisted thoracoscopic anatomical lung resection or stereotactic ablative body radiotherapy for early-stage non-small-cell lung cancer (NSCLC). A qualitative interview study was conducted to gain insight into the optimal methods of assessing and discussing QoL in clinical practice. METHODS: A prospective observational longitudinal study of patients with early-stage NSCLC was conducted where repeated QoL measures were administered either online or on paper. A subset of participants was invited for qualitative interviews after the 6-month assessment or at the end of the study. The semi-structured interviews were transcribed verbatim and thematically analysed. RESULTS: Twenty-three patients were interviewed. Generally, patients were content with recruitment and data collection procedures. Most opted to complete the assessments on paper instead of online; this choice was influenced by the level of technology literacy. Some found the questionnaires too generic to reflect their experiences. Barriers to questionnaire completion were mostly practical, and many acknowledged benefits of QoL assessment including allowing them to express problems and health issues, and following changes over time. Generally, participants would like to discuss QoL results during clinical consultations, but reported this rarely happened. CONCLUSIONS: Lung cancer patient interviews confirm the acceptability of repeated QoL assessments, but online data capture is limited. Patients highlight the importance of discussing QoL aspects with their clinical team. Future strategies are needed to optimize the routine collection of patient-reported outcomes in clinical practice.

Lung Resection for Trauma: A Propensity Score Adjusted Analysis Comparing Wedge Resection, Lobectomy, and Pneumonectomy.

The resection of lung parenchyma for thoracic trauma is uncommon. Different surgical procedures with a wide range of complexities have been described depending on the severity of trauma and the presence of associated injuries. The aim of this study was to analyze outcomes of wedge resection, lobectomy, and pneumonectomy. Data for this study were obtained from an eight-year retrospective National Trauma Data Bank study (2007-2015). Adult patients who sustained severe chest trauma (Abbreviated Injury Scale > 3) that required any type of lung resection were included. Propensity score (PS) analysis was adopted. Overall, 3107 patients were included. Wedge resection was performed in 54.3 per cent, lobectomy in 38.2 per cent, and pneumonectomy in 7.5 per cent of patients. Longer in-hospital length of stay (P = 0.01), ICU length of stay (P = 0.002), and mechanical ventilation days (P = 0.038) were found in case of major resections. The overall morbidity and mortality were 32 per cent and 27.5 per cent, respectively. A stepwise increase in mortality occurred when comparing wedge (20.3%), lobectomy (30.8%), and pneumonectomy (63.4%) (P < 0.001). After PS analysis, lobectomy and pneumonectomy were associated with higher mortality compared with wedge resection (odds ratio [OR] 1.42; 95% confidence interval 1.26-1.71 and OR 4.16; 95% confidence interval 2.84-6.07, respectively). Similarly, after PS analysis, lobectomy and pneumonectomy were associated with higher overall complications compared with wedge resection (OR 1.21 and OR 1.56, respectively). Comparable results were found in the subgroup analysis of patients with isolated lung injury. After PS matching, lobectomy and pneumonectomy were associated with significantly higher morbidity and mortality compared with nonanatomical wedge resection.

A nurse-driven enhanced recovery after surgery (ERAS) nursing program for geriatric patients following lung surgery.

Enhanced recovery after surgery (ERAS) is a multiprofessional, multidisciplinary and evidence-based program that aims to reduce complications, improve overall prognosis, shorten hospital stays, and promote fast recovery following major surgery. Nurses play a crucial role in the successful implementation of the ERAS program. Therefore, this research focuses on the trajectory optimized and acquired by nurses in the enhanced recovery of elderly patients undergoing radical surgery for lung cancer. This study concludes that the implementation of the proposed ERAS preoperative point-of-care trajectory is highly beneficial for improved outcomes and enhanced recovery of geriatric patients following lung surgery.

Role of Adjuvant Chemotherapy in Pulmonary Carcinoids: An NCDB Analysis.

BACKGROUND/AIM: Typical carcinoids (TC) and atypical carcinoids (AC) are rare diseases. A paucity of randomized studies and disagreements among various guidelines makes the management challenging. PATIENTS AND METHODS: Using codes for TC (8240) and AC (8249) in the National Cancer Database (NCDB), all surgically resected cases from 2004-2014 were included to evaluate the need for adjuvant chemotherapy. RESULTS: A total of 6,673 cases were included, 88% were TCs and 12% were ACs. From 2004 to 2014, the proportion of TCs went up from 1.3% to 1.8% and ACs from 0.1% to 0.3% of all lung malignancies. TC patients did well with surgery alone in all stages. AC patients with stage I [5-year overall survival (OS) - 84% vs. 52%; S vs. S+CT] and stage II disease (5-year OS - 81% vs. 55%; S vs. S+CT) showed better OS trend with surgery alone, while stage III patients showed some benefit with the use of adjuvant chemotherapy (5-year OS - 46% vs. 54%; S vs. S+CT). These results supported the National Comprehensive Cancer Network (NCCN) guidelines. CONCLUSION: No benefit was seen from adjuvant chemotherapy in TCs. While the adjuvant therapy may add benefit in stage III AC, the numbers are small and did not reach statistical significance.

Supraglottic airway versus endotracheal tube during interventional pulmonary procedures - a retrospective study.

BACKGROUND: As the field of interventional pulmonology (IP) expands, anesthesia services are increasingly being utilized when complex procedures of longer duration are performed on sicker patients with high risk co-morbidities and lung pathology. Yet, evidence on the optimal anesthetic management for these patients remains lacking. Our aim was to characterize the airway management and, secondarily anesthetic maintenance patterns used for IP procedures at our institution. METHODS: From 2894 identified encounters, charts of 783 patients undergoing an IP procedure with general anesthesia over a 5-year period, employing an endotracheal tube (ETT) or a supraglottic airway (SGA) for airway maintenance, were identified and reviewed after exclusions. Patients posted for a concurrent thoracic surgical procedure and those already intubated at presentation were excluded. Baseline patient demographics, procedure, proceduralist type, anesthesia maintenance modality, neuromuscular blocking drug (NMBD) use, and airway management characteristics were extracted and analyzed. RESULTS: Inhaled general anesthesia with an ETT for airway maintenance was most commonly employed; however, SGAs were used in one-third of patients with a very low conversion rate (0.4%), and their use was associated with a significant reduction in NMBD use. CONCLUSIONS: In this large series of patients receiving general anesthesia for IP procedures, inhaled anesthetic agents and ETTs were favored. However, in appropriately selected patients, SGA use was effective for airway maintenance and allowed for a reduction in NMBD use, which may have implications in this patient population who may have an increased risk for pulmonary complications and warrants further investigation.

Anaesthetic considerations for whole lung lavage for pulmonary alveolar proteinosis.

Pulmonary alveolar proteinosis (PAP) is an uncommon lung disease characterized by excessive accumulation of pulmonary surfactant that usually requires treatment with whole-lung lavage. A 47-year-old female presented with history of dry cough and breathlessness for past 6months. Chest radiograph demonstrated bilateral alveolar shadows and high resolution computerized tomography thorax showed crazy paving pattern. Broncho-alveolar lavage (BAL) and transbronchial lung biopsy confirmed a diagnosis of PAP. Due to worsening hypoxemia and respiratory failure, wholelung lavage was planned and performed. Anaesthetic management involved integrated use of pre-oxygenation, complete lung isolation, one-lung ventilation with optimal positive end-expiratory pressure, vigilant use of positional manoeuvres, and use of recruitment manoeuvres for the lavaged lung. We have discussed valuable strategies for the anaesthetic management of patients undergoing this multifaceted procedure in a case of severe PAP. FUNDING: None declared.

What have we learned in interventional pulmonology in the past decade?

Background/aim: The increasing number of lung diseases and particularly pulmonary malignancies has intensified the need for diverse interventions in the field of interventional pulmonology. In recent years we have seen many new developments and expanding applications in the field of interventional pulmonology. This has resulted in an increased number and variety of performed procedures and differing approaches. The purpose of the present study is to provide information on patient characteristics, range of interventions, complication rates, and the evolving approach of an experienced center for interventional pulmonology. Materials and methods: We retrospectively examined the records of 1307 patients who underwent a total of 2029 interventional procedures in our interventional pulmonology department between January 2008 and December 2017. Results: About half of the interventional procedures (47.2%) were performed on patients with airway stenosis due to malignant disease. Among patients with benign airway stenosis, the most frequent reason for intervention was postintubation tracheal stenosis. The number of patients who developed complications was 81 (6.2%), and the most common complication was hemorrhage (n = 31, 2.99%); 94.9% (n = 1240) of interventional procedures were performed under general anesthesia, without complications or deaths associated with anesthesia. Only one death (0.076%) occurred in the perioperative period. A total of 18 patients (1.38%) died in the 30-day perioperative and postoperative period. None of the patients with benign airway stenosis died. Conclusion: Interventional bronchoscopy is an invasive but considerably safe and efficient procedure for selected cases and effective treatment modality for airway obstructions, massive hemoptysis, and foreign body aspiration. Interventional pulmonology is a field of pulmonary medicine that needs effort to progress and provide an opportunity to witness relevant developments, and increase the number of competent physicians and centers.

Consolidation-to-tumor ratio and tumor disappearance ratio are not independent prognostic factors for the patients with resected lung adenocarcinomas.

OBJECTIVES: Our study aimed to investigate the independent prognostic values of consolidation-to-tumor ratio (CTR) and tumor disappearance ratio (TDR) after adjustment for the conventional prognostic factors and the eighth edition clinical T category for patients with resected lung adenocarcinomas. MATERIALS AND METHODS: This retrospective study included 691 patients (281 men and 410 women; median age, 63 years) with resected lung adenocarcinomas (clinical T1N0M0). The prognostic implications for disease-free survival (DFS) of CTR and TDR in continuous and categorical forms were analyzed using multivariable-adjusted Cox regression analysis, including multiple clinico-radiological prognostic factors and the clinical T category based on the solid portion measurement. Analysis was performed for the total study population and for two part-solid nodule subgroups (cT1mi/cT1a to cT1c and cT1mi/cT1a to cT1b, respectively). RESULTS: For the total study population, CTR and TDR were not selected in the multivariable Cox regression models, which indicated that these are not independent prognostic factors. Age (adjusted HR: 1.026; P = 0.022) and clinical T category (adjusted HR for cT1b: 3.475; P = 0.019; adjusted HR for cT1c: 9.938; P < 0.001) were independently associated with DFS. For the part-solid nodule subgroups, multivariable-adjusted HRs for CTR and TDR were not statistically significant (all P > 0.05). CONCLUSION: CTR and TDR were not independent prognostic factors. Preoperative prognostication based on clinical T category would be sufficient without further stratification according to CTR or TDR.

Impact of health care organization on surgical lung cancer care.

OBJECTIVES: Organization and governance of national healthcare might play an important role in decision-making and outcomes in patients with lung cancer. Both Denmark and the Netherlands have a high level of healthcare but a different financial coverage, governance and level of centralization. By using both national databases we analyzed the consequences of these differences on patterns of care and outcomes with a focus on morbidity, mortality and clinical staging. MATERIALS AND METHODS: General numbers on both healthcare systems were requested. All patients who had surgery for lung cancer from 2013 to 2016 were included. Mortality, morbidity and clinical staging were analyzed for patients with NSCLC without metastases, only one operation and no neo-adjuvant therapy. RESULTS: In 2016 annual budget as share of gross national product was 10.4% for both countries. In Denmark 4 hospitals performed lung surgery in 2016, compared to 43 hospitals in the Netherlands. We included 4030 Danish and 8286 Dutch patients. In the subgroup 30-day mortality was 1.5% in Denmark compared to 1.9% in the Netherlands. The percentage of patients with a complicated course was 24.4% and 34.8% respectively (p < 0.05). Accuracy between cTNM and pTNM was 53.0% in Denmark and 52.9% in the Netherlands. CONCLUSION: Surgery for lung cancer is at a high level in both countries, reflected by low mortality-rates. Centralization has been implemented successfully in Denmark, which might explain the lower rate of patients with a complicated post-operative course, although different definitions preclude firm conclusions. In both countries correct clinical staging of lung cancer remains a challenge.

Lung cancer photothermal ablation by low-power near-infrared laser and topical injection of indocyanine green.

OBJECTIVES: Surgical treatment is the gold standard for the treatment of early-stage non-small-cell lung cancer. However, minimally invasive tumour ablation can be an alternative treatment for patients not eligible for surgery due to comorbidities. The aim of this study was to evaluate the efficacy of photothermal ablation therapy using low-power near-infrared laser and topical injection of indocyanine green (ICG), a photosensitizer, in a preclinical study using a rabbit VX2 lung cancer model. METHODS: Six New Zealand white rabbits were used. Five hundred microlitres of a suspension containing 0.5 × 107 VX2 cancer cells with growth factor-reduced Matrigel was inoculated into the right lung using an ultrathin bronchoscope. Three rabbits were treated with laser ablation therapy with topical injection of ICG, whereas another 3 rabbits were treated with laser ablation alone. All tumours were irradiated with a laser with 500-mW output at 808 nm for 15 min. The tumours were examined histopathologically to assess the state of ablation. RESULTS: The maximum tumour surface temperatures in rabbits treated using ICG/laser and laser alone were higher than 58°C and lower than 40°C, respectively. The ablated areas in the rabbits treated with ICG/laser were significantly larger than those in the rabbits treated with laser alone (0.49 ± 0.27 vs 0.02 ± 0.002 cm2, respectively) (P < 0.05). CONCLUSIONS: The photothermal treatment using the combination of low-power near-infrared laser and topical injection of ICG can ablate a larger tumour area than laser treatment alone.