The Impact of a Multidisciplinary Team Conference on Non-Small Cell Lung Cancer Care: Time Barriers and Long-Term Outcomes.

Background/Objectives: The prolonged time to reach investigation and management decisions in non-small cell lung cancer (NSCLC) patients can negatively impact long-term outcomes. This retrospective cohort study aims to assess the impact of a multidisciplinary team conference (MDT) on NSCLC care quality and outcomes. Methods: This retrospective study included resectable NSCLC patients who underwent pulmonary resection at Chiang Mai University Hospital, Thailand, from 1 January 2009 to 31 December 2021. Patients were divided into two groups: non-MDT and MDT groups, based on the initiation of MDT on 1 March 2018. The study compared overall survival, disease-free survival, and waiting times for investigation and surgery between the two groups. The effect of MDT on these outcomes was analyzed using multivariable analysis with inverse-probability weighting propensity scores. Results: The study included 859 patients, with 583 in the non-MDT group and 276 in the MDT group. MDT groups had a higher proportion of stage I and II NSCLC patients undergoing pulmonary resection (78.6% vs. 59.69%, p < 0.001). In multivariable analysis, patients in the MDT group had a significantly higher likelihood of longer survival compared to the non-MDT group (adjusted HR 0.23, 95% CI 0.09-0.55). Median waiting times for bronchoscopy (3 days vs. 12 days, p = 0.012), pathologic report (7 days vs. 13 days, p < 0.001), and surgery scheduling (18 days vs. 25 days, p = 0.001) were significantly shorter in the MDT group. Conclusions: An MDT has a survival benefit in NSCLC care and improves waiting times for investigation and treatment steps. Further studies are needed to validate these results.

Frequency and predictive factors of nodal micro-metastasis (NMM) in resectable non-small cell lung cancer.

Background: The frequency of lymph nodal micrometastasis (NMM) in resectable non-small cell lung cancer (NSCLC) is frequently underestimated when relying solely on standard hematoxylin and eosin staining during pathological examination. Methods: This is a retrospective cross-sectional diagnostic research. Medical records of resectable pN0 NSCLC patients who underwent curative resection in Maharaj Nakorn Chiang Mai Hospital between January 2006 to December 2017 were retrospectively reviewed. Immunohistochemistry (IHC) staining using cytokeratin AE1/AE3, p53 and BerEP4 markers was employed to detect NMM. Primary objective of this study was to determine frequency of NMM in pN0 resectable NSCLC. Results: This study included 98 patients with pN0 NSCLC, of which 47 were male and 51 were female. NMM was detected in 21 of 98 patients (21.43%). Lymph node station 10 and 7 were the most common site of micrometastasis among patients with N1 and N2 micrometastasis, respectively. Cytokeratin AE1/AE3 was the most sensitive antibody in detecting micrometastasis in lymph nodes, identifying 25 out of 27 positive lymph nodes. Tumor size greater than 4 cm was a statistically significant predictive factor for NMM with risk ratio 6.69 [95% confidence interval (CI): 2.38-18.85, P<0.001]. Conclusions: NMM was identified in 21.43% of pN0 resectable NSCLC patients and tumor size greater than 4 cm is predictive factor for NMM.

Outcomes of pulmonary resection in pulmonary aspergilloma: A retrospective cohort study in a single tertiary-care hospital in Northern Thailand.

BACKGROUND: To date, surgery is the best approach to maximize a cure for symptomatic aspergilloma, but this is not without risk of both morbidity and mortality. The aim of this study is to present the characteristics and outcomes of 77 patients diagnosed with aspergilloma who underwent surgery at Chiang Mai University Hospital (CMUH), and to identify risk factors for composite major postoperative complications (CMPC). METHODS: This is an observational retrospective cohort study carried out at CMUH over a period of 11 years from January 1, 2010, to February 28, 2021. Patient characteristics and postoperative outcomes were studied. The primary outcomes were categorized into CMPC. Univariable and multivariable risk regression analysis were used to identify risk factors of CMPC, with risk ratio (RR) and 95% confidence intervals being calculated. RESULTS: There were 77 patients included in this study; 27 patients identified as having CMPC and 55 patients as a non-CMPC group. From the multivariable analysis, a factor associated with CMPC included perioperative FFP transfusion (risk ratio (RR) 1.01,95 % CI 1.01-1.02) and preoperative angiogram embolization (RR 8.42, 95 % CI 1.44-49.06) whereas immediate extubation (RR 0.22, 95% CI 0.06-0.81) was less likely to be associated with CMPC. There was a trend of increased risk of CMPC in patients received perioperative blood transfusion, but the data did not reach statistical significance. CONCLUSIONS: This study has identified a need for patient profiling before embarking on lung surgery for aspergilloma, to predict outcomes and allocate resources appropriately for safer surgery.

Small RNA Deep Sequencing of Circulating Small RNAs Discovers a Unique Panel of microRNAs as Feasible and Reliable Biomarkers of Non-Small Cell Lung Cancers in Northern Thailand.

OBJECTIVE: This study aimed to assess the practicality and reliability of utilizing microRNAs (miRNAs) as a potential screening and diagnosing tool for non-small cell lung cancers (NSCLCs) in Northern Thailand. METHODS: Small RNA sequencing and a literature review was performed to obtain a list of serum miRNA candidates. Serum levels of these selected miRNA candidates were measured in patients with NSCLC and healthy volunteers by real-time RT-PCR and receiver operating characteristic curve (ROC) were used to assess diagnostic performance. RESULTS: Sequencing data revealed 148 known miRNAs and 230 novel putative miRNAs in serum samples; 19 serum miRNAs were significantly downregulated and 242 were upregulated. Seven miRNAs selected according to sequencing data and 11 miRNAs according to previous reports were evaluated in training cohort (45 lung cancer patients, 26 controls) and 6 miRNAs were found differentially expressed (p < 0.05, Mann Whitney U test) and associated (p < 0.05, Chi-square test) with NSCLC development. Further analysis and verification identified an optimal combination of 4 miRNAs composed of hsa-miR23a, hsa-miR26b, hsa-miR4488 and novel-130 to provide the optimal AUC of 0.901±0.034. Detection of serum miRNA by real-time RT-PCR showed good reproducibility with the coefficient of variation (CV) ≤ 4%. The optimal screening miRNAs panel was primarily identified through sequencing data of local patient population, thus indicating that the etiology of NSCLCs may differ from one population to other and thus require a unique panel of miRNAs for their identification. CONCLUSION: Circulating miRNA is a feasible screening tool for NSCLCs. Nevertheless, populations with different lung cancer etiology may need to identify their own most suitable miRNA panel.

Phytochemical Profiles and Anticancer Effects of Calophyllum inophyllum L. Extract Relating to Reactive Oxygen Species Modulation on Patient-Derived Cells from Breast and Lung Cancers.

Reactive oxygen species (ROS) contribute to cancer growth and metastasis. Using antioxidants to modulate cellular ROS levels is a promisingstrategy for cancer prevention and treatment. Calophyllum inophyllum L., or tamanu, is a medicinal plant renowned for its anti-inflammatory, antioxidant, and anticancer properties in traditional medicine systems. However, the anticancer effects of C. inophyllum extract on cellular ROS remain unexplored. This study represents the first report on such effects and provides the potential mechanisms underlying the anticancer properties of C. inophyllum extract. The branches of C. inophyllum were extracted, and the extract was comprehensively analyzed for phytochemical constituents, antioxidant capacity, total phenolic content, and total flavonoid content. Subsequently, the extract's potential anticancer properties were evaluated using patient-derived cells from breast and lung cancer. The results revealed that the C. inophyllum extract possesses notable antioxidant activity and demonstrated no cytotoxicity within the initial 24 h of treatment. However, after 72 h, it exhibited significant antiproliferative effects. Moreover, the extract exhibited inhibitory properties against migration and invasion at concentrations below the IC50, which corresponded to the expression of related genes. Notably, these effects correlated with the reduction of intracellular ROS levels. Overall, our findings highlight the anticancer potential of C. inophyllum extract, emphasize its ability to modulate cellular ROS levels and target key molecular pathways involved in cancer progression. This study sheds light on the promising therapeutic implications of C. inophyllum extract as a novel agent for cancer treatment, which is safe for normal cells.

Effects of short-term bisoprolol on perioperative myocardial injury in patients undergoing non-cardiac surgery: a randomized control study.

The protective role of preoperative beta-blocker in patients undergoing non-cardiac surgery is unknown. We aimed to evaluate the effects of beta-blocker on perioperative myocardial injury in patients undergoing non-cardiac surgery. We consecutively enrolled 112 patients undergoing non-cardiac surgery. They were randomly allocated to receive bisoprolol or placebo given at least 2 days preoperatively and continued until 30 days after surgery. The primary outcome was incidence of perioperative myocardial injury defined by a rise of high-sensitive troponin-T (hs-TnT) more than 99th percentile of upper reference limit or a rise of hs-TnT more than 20% if baseline level is abnormal. Baseline characteristics were comparable between bisoprolol and placebo in randomized cohort Mean age was 62.5 ± 11.8 years and 76 (67.8%) of 112 patients were male. Among 112 patients, 49 (43.8%) underwent vascular surgery and 63 (56.2%) underwent thoracic surgery. The median duration of assigned treatment prior to surgery was 4 days (2-6 days). We did not demonstrate the significant difference in the incidence of perioperative myocardial injury [52.6% (30 of 57 patients) vs. 49.1% (27 of 55 patients), P = 0.706]. In addition, the incidence of intraoperative hypotension was higher in bisoprolol group than placebo group in patients undergoing non-cardiac surgery [70.2% (40 of 57 patients) vs. 47.3% (26 of 55 patients), P = 0.017]. We demonstrated that there was no statistically significant difference in perioperative myocardial injury observed between patients receiving bisoprolol and placebo who had undergone non-cardiac surgery.

Effect of Insurance Type on Stage at Presentation, Surgical Approach, Tumor Recurrence and Cancer-Specific Survival in Resectable Non-Small Lung Cancer Patients.

PURPOSE: The aim of this study was to identify the association between Thailand's insurance types and stage at presentation, surgical approach, tumor recurrence and cancer-specific survival in resectable non-small cell lung cancer (NSCLC) patients in northern Thailand. PATIENTS AND METHODS: Medical records of patients with NSCLC who underwent pulmonary resection at Chiang Mai University Hospital from January 2007 through December 2015 were retrospectively reviewed. Patients were divided into two groups: patients with the Universal Coverage Scheme (UCS) or Social Security Scheme (SSS) and patients with the Civil Servant Medical Benefit Scheme (CSMBS) or private insurance (PI). Patient characteristics were assessed. The primary outcome was cancer-specific survival while the secondary outcome was tumor recurrence. Cox's regression and matching propensity score analysis was used to analyze data. RESULTS: This study included 583 patients: 344 with UCS or SSS and 239 with CSMBS or PI. Patients with UCS or SSS were more likely to be active smokers, have a lower percent predicted FEV1, present with higher-stage tumors and worse differentiated tumors, present with tumor necrosis, and undergo an open surgical approach than those with CSMBS or PI. At multivariable analysis of all patients cohort, there were no significant differences in terms of early stage at presentation (adjusted odds ratio (ORadj) = 0.94, 95% confidence interval (CI) = 0.65-1.37), undergoing lobectomy (ORadj = 0.59, 95% CI = 0.24-1.46), and recurrent-free survival (adjusted hazard ratio (HRadj) =1.20, 95% CI = 0.88-1.65) between groups (UCS/SSS versus CSMBS/PI). However, patients with UCS or SSS had shorter cancer-specific survival (HRadj = 1.61, 95% CI = 1.22-2.15). The results from the propensity score matched patient cohort were not different from those analyses on the full patient cohort. CONCLUSION: Thai insurance types have an effect on cancer-specific survival. The Thai government should recognize the importance of these differences, and further multi-center studies with a larger sample size are warranted to confirm this result.

Potential of Thai Herbal Extracts on Lung Cancer Treatment by Inducing Apoptosis and Synergizing Chemotherapy.

The incidence of lung cancer has increased while the mortality rate has continued to remain high. Effective treatment of this disease is the key to survival. Therefore, this study is a necessity in continuing research into new effective treatments. In this study we determined the effects of three different Thai herbs on lung cancer. Bridelia ovata, Croton oblongifolius, and Erythrophleum succirubrum were extracted by ethyl acetate and 50% ethanol. The cytotoxicity was tested with A549 lung cancer cell line. We found four effective extracts that exhibited toxic effects on A549 cells. These extracts included ethyl acetate extracts of B. ovata (BEA), C. oblongifolius (CEA), and E. succirubrum (EEA), and an ethanolic extract of E. succirubrum (EE). Moreover, these effective extracts were tested in combination with chemotherapeutic drugs. An effective synergism of these treatments was found specifically through a combination of BEA with methotrexate, EE with methotrexate, and EE with etoposide. Apoptotic cell death was induced in A549 cells by these effective extracts via the mitochondria-mediated pathway. Additionally, we established primary lung cancer and normal epithelial cells from lung tissue of lung cancer patients. The cytotoxicity results showed that EE had significant potential to be used for lung cancer treatment. In conclusion, the four effective extracts possessed anticancer effects on lung cancer. The most effective extract was found to be E. succirubrum (EE).

Outcomes of pulmonary resection in non-small cell lung cancer patients older than 70 years old.

BACKGROUND: An appropriate treatment of older lung cancer patients has become an important issue. The aim of this study is to evaluate the short and long-term surgical outcomes in lung cancer patients using 70 years as a cut-point, and to identify prognostic factors of cancer-specific mortality in patients older than 70 years. METHODS: Medical records of non-small cell lung cancer (NSCLC) patients who underwent pulmonary resection at Chiang Mai University Hospital from January 2002 through December 2016 were retrospectively reviewed. Patients were divided into age less than 70 years (control group) and 70 years or more (study group). Primary outcomes were major post-operative complications and in-hospital death (POM); secondary outcome was long-term survival. Multivariable regression analysis was used. RESULTS: This study included 583 patients, 167 for study group, and 416 for control group. There were no differences in POM, both at univariable and multivariable analyses, however, for long-term cancer-specific mortality, the study group was more likely to die (HRadj = 1.40, 95%CI = 1.03-1.89). Adverse prognostic factors for long-term mortality in study group were having universal coverage scheme (HRadj = 1.70, 95%CI = 1.03-2.79), the presence of intratumoral lymphatic invasion (HRadj = 2.83, 95%CI = 1.28-6.29), perineural invasion (HRadj = 2.80, 95%CI = 1.13-6.94), underwent lymph node sampling (HRadj = 2.23, 95%CI = 1.16-4.30) and higher stage of disease (HRadj = 2.02, 95%CI = 1.06-3.85 for stage III, HRadj = 3.40, 95%CI = 1.29-8.94 for stage IV). CONCLUSIONS: In-hospital mortality and composite post-operative complications are acceptable in pulmonary resection for NSCLC patients older than 70 years. However, these patients had shorter long-term survival, especially who have some adverse prognostic factors. Further studies with larger sample size are warranted.

Comparative clinical outcomes after thymectomy for myasthenia gravis: Thoracoscopic versus trans-sternal approach.

BACKGROUND: Thymectomy is an effective treatment option for long-term remission of myasthenia gravis. The superiority of the trans-sternal and thoracoscopic surgical approaches is still being debated. The aims of this study are to compare postoperative outcomes and neurologic outcomes between the two approaches and to identify prognostic factors for complete stable remission (CSR). METHODS: Myasthenia gravis patients who underwent thymectomy with trans-sternal or thoracoscopic approach in MahaRaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand between January1, 2006 and December 31, 2013 were retrospectively reviewed. The endpoints were postoperative outcomes and cumulative incidence function for CSR. The analysis was performed using multilevel model, Cox's proportional hazard model, and propensity score. RESULTS: Ninety-eight patients were enrolled in this study: 53 in the thoracoscopic group and 45 in the trans-sternal group. There were no significant differences between groups in composite postoperative complications, surgical time, ventilator support days, and length of intensive care unit stay. Intraoperative blood loss and length of hospital stay were significant less in the thoracoscopic group. The CSR and median time to remission were not significantly different between the two approaches. Prognostic factors for CSR were nonthymoma (hazard ratio: 3.5, 95% confidence interval: 1.01-12.22) and presence of pharmacological remission (hazard ratio: 24.3, 95% confidence interval: 3.27-180.41). CONCLUSION: Thoracoscopic thymectomy is safe and provides good neurologic outcomes in comparison to the trans-sternal approach. Two predictive factors should be considered for CSR. Further prospective studies with a larger sample size and longer follow-up period are warranted to confirm these results.

Factors associated with recurrent bacterial empyema thoracis.

BACKGROUND: Empyema thoracis (ET) is one of the common thoracic diseases frequently found in developing countries. In the past, only a few studies have analyzed recurrent ET, and none had clearly identified the prognostic factors for recurrence. The aim of this study is to identify the prognostic factors of recurrent ET in Northern Thailand. METHODS: A retrospective cohort study was conducted. All patients diagnosed with Stage II and III ET at Maharaj Nakorn Chiang Mai Hospital (a tertiary-care hospital in northern Thailand) between January 1, 2007 and November 31, 2012 were enrolled in this study. All clinical data were extracted from the medical recording system. The primary outcome was recurrent disease. Multivariable Cox's proportion hazard model was used to identify the independent prognostic factors for recurrence. RESULTS: There were 382 patients enrolled in this study, and 34 patients (8.9%) had recurrent disease. The most common gram-positive and gram-negative pathogens found were Staphylococcus aureus and Acinetobacter baumannii, respectively. Three independent prognostic factors for recurrent disease were nonsepsis status prior to the surgery [hazard ratio (HR) = 12.3; 95% confidence interval (CI), 4.25-35.43], nonperforming decortication (HR = 5.4; 95% CI, 1.82-15.92), and persistent pleural spaces (HR = 4.1; 95% CI, 1.93-8.68). CONCLUSIONS: Clinical characteristics, surgical procedure, and persistent pleural spaces were independent prognostic factors for ET recurrence in this study. Decortication and early thoracoplasty in patients who had persistent pleural space should be considered. Large cohort studies are warranted to support these findings.

Impact of lymph node management on resectable non-small cell lung cancer patients.

BACKGROUND: A surgical lung resection with systematic mediastinal lymph node (LN) dissection is recommended by the National Comprehensive Cancer Network guideline. However, the effective number of dissected LNs, stations and positivity is still controversial. The aim of this study is to identify the impact of total numbers, LN stations and positivity of dissected LNs on tumor recurrence and overall death in resectable non-small cell lung cancer (NSCLC). METHODS: This prognostic study used a retrospective data collection design. Adult patients with clinical resectable NSCLC who underwent pulmonary resection and mediastinal lymphadenectomy at Chiang Mai University between June 2000 and June 2012 were enrolled in this study. A multilevel mixed-effects parametric survival model was used to identify the effect of numbers, LN stations and positivity of dissected LNs to tumor recurrence and mortality. RESULTS: The average number of dissected LNs was 22.7±12.8. Tumor recurrence was found in 51.3% and overall mortality was 43.3%. The number of dissected LNs was a prognostic factor for tumor recurrence [HR 0.98, 95% confidence interval (CI): 0.96-0.99]. There was a significant difference at the cut-pointed value of 11 dissected LNs for tumor recurrence (HR 2.22, 95% CI: 1.26-3.92). Dissection less than 11 nodes and less than 5 stations indicated a poor prognostic factor for tumor recurrence: for 3-4 stations (HR 3.01, 95% CI: 1.22-7.42) and for 1-2 stations (HR 1.96, 95% CI: 1.04-3.72). The positivity of dissected LNs was also a prognostic factor for tumor recurrence and overall mortality (HR 1.01, 95% CI: 1.01-1.02 and HR 1.01, 95% CI: 1.01-1.03, respectively). CONCLUSIONS: Eleven or more LN dissection with at least 5 stations influenced recurrent-free survival. Systematic LN dissection (SLND) should be performed not only to identify the positivity of dissected LNs but also to determine an accurate tumor nodal stage. A larger cohort should be further conducted to support these findings.

Retrospective study of ALK rearrangement and clinicopathological implications in completely resected non- small cell lung cancer patients in Northern Thailand: role of screening with D5F3 antibodies.

BACKGROUND: Anaplastic lymphoma kinase (ALK) gene rearrangement in non-small cell lung cancer (NSCLC) has been intensively studied. The gold standard for ALK detection is FISH, but this is not routinely conducted in clinical practice, so that the IHC method has a role. The aim of this study was to identify the incidence of ALK rearrangement and risk or prognostic factors for ALK positivity using both of IHC and FISH methods. MATERIALS AND METHODS: From January 2008 to December 2012, 267 completely resected NSCLC patients in Chiang Mai University Hospital were enrolled in this study. Clinical and pathological variables and outcomes of treatment were retrospectively reviewed. IHC and FISH were used to evaluate ALK rearrangement. Sensitivity and specificity of IHC were analyzed. Multivariable analysis was used to identify clinico-pathological correlations with positive results of IHC and clinical outcomes. RESULTS: Twenty-two (8.2%) of 267 specimens were IHC-positive for ALK with intense cytoplasmic staining, whereas only 10 (3.8%) were FISH-positive. Sensitivity, specificity and the positive likelihood ratio with IHC were 80.0%, 94.9%, and 15.8 respectively. Age less than 55 years (RR 4.4, 95%CI 1.78-10.73, p value=0.001) and presence of visceral pleural invasion (VPI) (RR 2.9, 95%CI 1.21-6.78, p value =0.017) were identified as risk factors for ALK rearrangement with FISH. There were no statistically significant differences in other clinical and pathological variables. ALK rearrangement was not a prognostic factor for tumor recurrence or overall survival. CONCLUSIONS: The incidences of ALK positivity in completely resected NSCLCs in northern Thailand were 8.2% by IHC and 3.8% by FISH. IHC with mouse monoclonal, Ventana D5F3 antibody can be used as a screening tool before FISH method because of high specificity and high positive likelihood ratio. Age less than 55 years and VPI are risk factors for ALK positivity.

Incidence and risk factors associated with ipsilateral shoulder pain after thoracic surgery.

OBJECTIVES: This study was designed to determine the incidence and risk factors associated with ipsilateral shoulder pain (ISP) after thoracic surgery and to investigate characteristics, locations, and severity of ISP. DESIGN: A prospective observational study. SETTING: University hospital. PARTICIPANTS: Two hundred five patients who underwent thoracic surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Pain at the incisional site and shoulder pain were assessed separately using the numeric rating scale (NRS) during the patients' stay in the postanesthesia care unit. The overall incidence of ISP was 47.3%. The incidence of ISP in thoracotomy patients (58.7%) was substantially higher than in video-assisted thoracoscopic surgery patients (20.9%). ISP was described most often as a dull aching pain (87%). In approximately half of the patients, ISP was located at the posterior side of the shoulder. The severity of ISP was classified as moderate to severe in 67% of patients. The potential risk factors associated with ISP were surgery using the thoracotomy approach (risk ratio: 2.12, 95% confidence interval: 1.16-3.86, p=0.014) and surgical duration>120 minutes (risk ratio: 1.61, 95% confidence interval: 1.07-2.44, p=0.023). CONCLUSIONS: The incidence of ISP after thoracic surgery was high and the severity of pain was significant. The thoracotomy approach and the long duration of surgery are potential risk factors for ISP.

Massive hemothorax due to intrathoracic extramedullary hematopoiesis in a patient with beta thalassemia hemoglobin E disease.

Case report of a 28-year-old man with beta thalassemia/hemoglobin E disease who developed a massive hemothorax due to bleeding from multiple large intrathoracic, paraspinal hematopoietic masses. Initially, a thoracotomy was required for the control of bleeding. Postoperatively, the patient received 2,000 ml of packed red cells but he continued bleeding after the blood chemistries and coagulopathy specimen were corrected. The decision was made to return to the operating room for a thoracotomy to control the bleeding. However, before re-operating, the patient underwent a collapse and failed resuscitation. This complication has never been previously reported in Thailand.

The prognostic value of ERCC1 and RRM1 gene expression in completely resected non-small cell lung cancer: tumor recurrence and overall survival.

BACKGROUND: The roles of excision repair cross-complementing group 1 gene (ERCC1) expression and ribonucleotide reductase subunit M1 gene (RRM1) expression in completely resected non-small cell lung cancer (NSCLC) are still debatable. Previous studies have shown that both genes affected the overall survival and outcomes of patients who received platinum-based chemotherapy; however, some studies did not show this correlation. The aim of this study was to evaluate the prognostic values of ERCC1 and RRM1 gene expression in predicting tumor recurrence and overall survival in patients with completely resected NSCLC who received adjuvant chemotherapy and in those who did not. PATIENTS AND METHODS: A retrospective cohort study was conducted in 247 patients with completely resected NSCLC. All patients had been treated with anatomic resection (lobectomy or pneumonectomy) with systematic mediastinal lymphadenectomy between January 2002 and December 2011 at Chiang Mai University Hospital, Chiang Mai, Thailand. They were divided into two groups: recurrence and no recurrence. Protein expression of ERCC1 and RRM1 was determined by immunohistochemistry. Correlations between clinicopathologic variables, including ERCC1 and RRM1 expression and tumor recurrence, were analyzed. Univariate and multivariate Cox proportional hazards regression analysis stratified by nodal involvement, tumor staging, intratumoral blood vessel invasion, intratumoral lymphatic invasion, and tumor necrosis was used to identify the prognostic roles of ERCC1 and RRM1. RESULTS: ERCC1 and RRM1 expression did not demonstrate prognostic value for tumor recurrence and overall survival in patients with completely resected NSCLC. In patients who did not receive adjuvant chemotherapy treatment, those with high ERCC1 and high RRM1 expression seemed to have greater potential for tumor recurrence and shorter overall survival than did those who had low ERCC1 and low RRM1 (hazard ratio [HR] =1.7, 95% confidence interval [CI] =0.6-4.3, P=0.292 and HR =1.6, 95% CI =0.5-4.5, P=0.411, respectively). In contrast, in patients who received adjuvant chemotherapy treatment, those with high ERCC1 and high RRM1 expression seemed to have benefited from adjuvant chemotherapy and showed good overall survival compared with those who had low ERCC1 and low RRM1 (HR =0.8, 95% CI = 0.4-1.8, P=0.612 and HR = 0.4, 95% CI = 0.1-2.4, P=0.325, respectively). Subgroup analysis in patients whose first-line metastatic chemotherapy failed demonstrated that ERCC1 expression and RRM1 expression were not prognostic factors for tumor recurrence and overall survival; however, patients who had high ERCC1 and high RRM1 expression seemed to have benefited from first-line chemotherapy treatment (HR =0.7, 95% CI =0.3-1.8, P=0.458). CONCLUSION: ERCC1 expression and RRM1 expression were not prognostic of tumor recurrence and overall survival in patients with completely resected NSCLC, either with or without adjuvant chemotherapy. Prospective studies that include a larger number of patients are needed for definite conclusions.

Completely resected n0 non-small cell lung cancer: prognostic factors affecting long-term survival.

Background. Although early stage non-small cell lung cancer (NSCLC) has an excellent outcome and correlated with good long-term survival, up to 15 percent of patients still relapse postoperatively and die. This study is conducted to identify prognostic factors that may affect the long-term survival in completely resected N0 NSCLC. Methods. Medical records of 124 patients with completely resected N0 NSCLC were retrospectively reviewed. Prognostic factors affecting long-term survival were analyzed by the Kaplan-Meier method and Cox proportional hazards analysis. Results. Overall five-year survival rate was 48 percent. Multivariable analysis revealed stage of disease, tumor necrosis, tumor recurrence, brain metastasis, adrenal metastases, and skin metastases as significant prognostic factors affecting long-term survival. The hazard ratio (HR) of tumor necrosis, tumor recurrence, brain metastasis, adrenal metastases, and skin metastases was 2.0, 2.3, 7.6, 4.1, and 8.3, respectively, and all P values were less than 0.001. Conclusions. Our study shows stage of disease, tumor necrosis, tumor recurrence, brain metastasis, adrenal metastasis, and skin metastasis as the independent prognostic factors of long-term survival in pathological N0 NSCLC. Early stage NSCLC patients without nodal involvement or presented with tumor necrosis should benefit from adjuvant chemotherapy, and sites of metastasis could predict the long-term survival as described.

Preoperative plasmapheresis for elective thymectomy in myasthenia patient: is it necessary?

Background. Role of plasmapheresis before thymectomy remains controversial. The aim of this study is to determine the peri-operative and post-operative outcome of a thymectomy between performing and not performing a pre-operative plasmaphreresis. Patients and Methods. A retrospective chart review study was conducted in Chiang Mai University Hospital between January 2006 and December 2011. There were 86 myasthenia patients divided into two groups; Preoperative plasmapheresis group (PPG) and no preoperative plasmapheresis group (NPPG). The primary outcome involved post-operative extubation and the secondary outcome included post-operative complications, 28 day mortality and length of hospital stay. Results. Eighty-six patients were enrolled in this study. The number of patients who had a history of myasthenic crisis at any time or within one month in the PPG was significantly more than those in the NPPG. Muscle power and forced expiratory vital capacity in the NPPG was higher than that in the PPG. The postoperative extubation rate was similar in both groups. After controlling for the propensity score, there were no statistically significant differences in both of primary and secondary outcomes. Conclusion. The results of this study shows no significant differences between both groups in all outcomes, therefore the pre-operative plasmaphresis is not necessary for elective thymectomy.

Prognostic factors of tumor recurrence in completely resected non-small cell lung cancer.

BACKGROUND: Patients with completely resected non-small cell lung cancer (NSCLC) have an excellent outcome; however tumor recurs in 30%-77% of patients. This study retrospectively analyzed the clinicopathologic features of patients with any operable stage of NSCLC to identify the prognostic factors that influence tumor recurrence, including intratumoral blood vessel invasion (IVI), tumor size, tumor necrosis, and intratumoral lymphatic invasion. METHODS: From January 2002 to December 2011, 227 consecutive patients were enrolled in this study. They were divided into two groups: the "no recurrence" group and the "recurrence" group. Recurrence-free survival was analyzed by multivariable Cox regression analysis, stratified by tumor staging, chemotherapy, and nodal involvement. RESULTS: IVI, tumor necrosis, tumor diameter more than 5 cm, and nodal involvement were identified as independent prognostic factors of tumor recurrence. The hazard ratio (HR) of patients with IVI was 2.1 times higher than that of patients without IVI (95% confident interval [CI]: 1.4-3.2) (P = 0.001).The HR of patients with tumor necrosis was 2.1 times higher than that of patients without tumor necrosis (95% CI: 1.3-3.4) (P = 0.001). Patients who had a maximum tumor diameter greater than 5 cm had significantly higher risk of recurrence than patients who had a maximum tumor diameter of less than 5 cm (HR 1.9, 95% CI: 1.0-3.5) (P = 0.033). CONCLUSION: IVI, tumor diameter more than 5 cm, and tumor necrosis are prognostic factors of tumor recurrence in completely resected NSCLC. Therefore, NSCLC patients, with or without nodal involvement, who have one or more prognostic factors of tumor recurrence may benefit from adjuvant chemotherapy for prevention of tumor recurrence.