Health-related quality of life and anxiety in the PAN-CAN lung cancer screening cohort.

OBJECTIVES: The impact of lung cancer screening with low-dose chest CT (LDCT) on participants' anxiety levels and health-related quality of life (HRQoL) is an important consideration in the implementation of such programmes. We aimed to describe changes in anxiety and HRQoL in a high-risk Canadian cohort undergoing LDCT lung cancer screening. METHODS: 2537 subjects who had 2% or greater lung cancer risk over 6 years using a risk prediction tool were recruited from eight centres across Canada in the Pan-Canadian Early Detection of Lung Cancer Study (2008-2010). We compared HRQoL and anxiety levels before and after screening of 1237 participants with LDCT (excluding a subset of 1300 participants who also underwent autofluorescence bronchoscopy screening), as well as after investigations performed because of a positive screening examination. The 12-item short-form Physical and Mental Component Scales (SF-12), EQ-5D-3L scores and State Trait Anxiety Inventory-State anxiety were used at each assessment. RESULTS: Overall, there were no clinically significant differences in HRQoL outcomes between baseline and each of the survey time points following initial screening. No mean change in anxiety in the overall cohort was noted following baseline LDCT, but more participants had clinically significant increase in anxiety versus decrease after baseline screening (increase >minimal clinically important difference (MCID) (n=180) vs decrease >MCID (n=50), p<0.001). This finding persisted but to a lesser degree at the 12 month time point (increase >MCID (n=146) vs decrease >MCID (n=87), p<0.001). CONCLUSIONS: CT screening for lung cancer has no major overall impact on HRQoL among participants, although a minority of participants (number-needed-to-harm=7 after baseline screening and 18 at 1 year) demonstrated clinically significant increased anxiety levels. TRIALREGISTRATION NUMBER: NCT00751660; Results.

Participant selection for lung cancer screening by risk modelling (the Pan-Canadian Early Detection of Lung Cancer [PanCan] study): a single-arm, prospective study.

BACKGROUND: Results from retrospective studies indicate that selecting individuals for low-dose CT lung cancer screening on the basis of a highly predictive risk model is superior to using criteria similar to those used in the National Lung Screening Trial (NLST; age, pack-year, and smoking quit-time). We designed the Pan-Canadian Early Detection of Lung Cancer (PanCan) study to assess the efficacy of a risk prediction model to select candidates for lung cancer screening, with the aim of determining whether this approach could better detect patients with early, potentially curable, lung cancer. METHODS: We did this single-arm, prospective study in eight centres across Canada. We recruited participants aged 50-75 years, who had smoked at some point in their life (ever-smokers), and who did not have a self-reported history of lung cancer. Participants had at least a 2% 6-year risk of lung cancer as estimated by the PanCan model, a precursor to the validated PLCOm2012 model. Risk variables in the model were age, smoking duration, pack-years, family history of lung cancer, education level, body-mass index, chest x-ray in the past 3 years, and history of chronic obstructive pulmonary disease. Individuals were screened with low-dose CT at baseline (T0), and at 1 (T1) and 4 (T4) years post-baseline. The primary outcome of the study was incidence of lung cancer. This study is registered with ClinicalTrials.gov, number NCT00751660. FINDINGS: 7059 queries came into the study coordinating centre and were screened for PanCan risk. 15 were duplicates, so 7044 participants were considered for enrolment. Between Sept 24, 2008, and Dec 17, 2010, we recruited and enrolled 2537 eligible ever-smokers. After a median follow-up of 5·5 years (IQR 3·2-6·1), 172 lung cancers were diagnosed in 164 individuals (cumulative incidence 0·065 [95% CI 0·055-0·075], incidence rate 138·1 per 10 000 person-years [117·8-160·9]). There were ten interval lung cancers (6% of lung cancers and 6% of individuals with cancer): one diagnosed between T0 and T1, and nine between T1 and T4. Cumulative incidence was significantly higher than that observed in NLST (4·0%; p<0·0001). Compared with 593 (57%) of 1040 lung cancers observed in NLST, 133 (77%) of 172 lung cancers in the PanCan Study were early stage (I or II; p<0·0001). INTERPRETATION: The PanCan model was effective in identifying individuals who were subsequently diagnosed with early, potentially curable, lung cancer. The incidence of cancers detected and the proportion of early stage cancers in the screened population was higher than observed in previous studies. This approach should be considered for adoption in lung cancer screening programmes. FUNDING: Terry Fox Research Institute and Canadian Partnership Against Cancer.

The Cost-Effectiveness of High-Risk Lung Cancer Screening and Drivers of Program Efficiency.

INTRODUCTION: Lung cancer risk prediction models have the potential to make programs more affordable; however, the economic evidence is limited. METHODS: Participants in the National Lung Cancer Screening Trial (NLST) were retrospectively identified with the risk prediction tool developed from the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial. The high-risk subgroup was assessed for lung cancer incidence and demographic characteristics compared with those in the low-risk subgroup and the Pan-Canadian Early Detection of Lung Cancer Study (PanCan), which is an observational study that was high-risk-selected in Canada. A comparison of high-risk screening versus standard care was made with a decision-analytic model using data from the NLST with Canadian cost data from screening and treatment in the PanCan study. Probabilistic and deterministic sensitivity analyses were undertaken to assess uncertainty and identify drivers of program efficiency. RESULTS: Use of the risk prediction tool developed from the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial with a threshold set at 2% over 6 years would have reduced the number of individuals who needed to be screened in the NLST by 81%. High-risk screening participants in the NLST had more adverse demographic characteristics than their counterparts in the PanCan study. High-risk screening would cost $20,724 (in 2015 Canadian dollars) per quality-adjusted life-year gained and would be considered cost-effective at a willingness-to-pay threshold of $100,000 in Canadian dollars per quality-adjusted life-year gained with a probability of 0.62. Cost-effectiveness was driven primarily by non-lung cancer outcomes. Higher noncurative drug costs or current costs for immunotherapy and targeted therapies in the United States would render lung cancer screening a cost-saving intervention. CONCLUSIONS: Non-lung cancer outcomes drive screening efficiency in diverse, tobacco-exposed populations. Use of risk selection can reduce the budget impact, and screening may even offer cost savings if noncurative treatment costs continue to rise.

Patient-Derived Xenograft Establishment from Human Malignant Pleural Mesothelioma.

Purpose: Malignant pleural mesothelioma (MPM) is a rare but aggressive disease with few therapeutic options. The tumor-stromal interface is important in MPM, but this is lost in cell lines, the main model used for preclinical studies. We sought to characterize MPM patient-derived xenografts (PDX) to determine their suitability as preclinical models and whether tumors that engraft reflect a more aggressive biological phenotype.Experimental Design: Fresh tumors were harvested from extrapleural pneumonectomy, decortication, or biopsy samples of 50 MPM patients and implanted subcutaneously into immunodeficient mice and serially passaged for up to five generations. We correlated selected mesothelioma biomarkers between PDX and patient tumors, and PDX establishment with the clinical pathologic features of the patients, including their survival. DNA of nine PDXs was profiled using the OncoScan FFPE Express platform. Ten PDXs were treated with cisplatin and pemetrexed.Results: A PDX was formed in 20 of 50 (40%) tumors implanted. Histologically, PDX models closely resembled the parent tumor. PDX models formed despite preoperative chemotherapy and radiotherapy. In multivariable analysis, patients whose tumors formed a PDX had significantly poorer survival when the model was adjusted for preoperative treatment (HR, 2.46; 95% confidence interval, 1.1-5.52; P = 0.028). Among 10 models treated with cisplatin, seven demonstrated growth inhibition. Genomic abnormalities seen in nine PDX models were similar to that previously reported.Conclusions: Patients whose tumors form PDX models have poorer clinical outcomes. MPM PDX tumors closely resemble the genotype and phenotype of parent tumors, making them valuable models for preclinical studies. Clin Cancer Res; 23(4); 1060-7. ©2016 AACR.

Plant Polyphenols as Chemopreventive Agents for Lung Cancer.

Lung cancer may be prevented by a diet rich in fruits and vegetables as they are enriched with dietary antioxidant polyphenols, such as flavonoids, proanthocyanidins, lignans, stilbenes, and phenolic acids. Dietary polyphenols exert a wide range of beneficial biological functions beyond their antioxidative properties and are involved in regulation of cell survival pathways leading to anticarcinogenic and antimutagenic functions. There are sufficient evidence from in vitro, in vivo, and epidemiological studies to suggest that the dietary intervention of polyphenols in cancer prevention, including the chemopreventive ability of dietary polyphenols, act against lung carcinogens. Cohort and epidemiological studies in selected risk populations have evaluated clinical effects of polyphenols. Polyphenols have demonstrated three major actions: antioxidative activity, regulation of phase I and II enzymes, and regulation of cell survival pathways against lung carcinogenesis. They have also shown an inverse association of lung cancer occurrences among high risk populations who consumed considerable amounts of fruits and vegetables in their daily diet. In in vitro cell culture experimental models, polyphenols bind with electrophilic metabolites from carcinogens, inactivate cellular oxygen radicals, prevent membrane lipid peroxidation and DNA oxidative damage, and adduct formation. Further, polyphenols enhance the detoxifying enzymes such as the phase II enzymes, glutathione transferases and glucuronosyl transferases.

Resource utilization and costs during the initial years of lung cancer screening with computed tomography in Canada.

BACKGROUND: It is estimated that millions of North Americans would qualify for lung cancer screening and that billions of dollars of national health expenditures would be required to support population-based computed tomography lung cancer screening programs. The decision to implement such programs should be informed by data on resource utilization and costs. METHODS: Resource utilization data were collected prospectively from 2059 participants in the Pan-Canadian Early Detection of Lung Cancer Study using low-dose computed tomography (LDCT). Participants who had 2% or greater lung cancer risk over 3 years using a risk prediction tool were recruited from seven major cities across Canada. A cost analysis was conducted from the Canadian public payer's perspective for resources that were used for the screening and treatment of lung cancer in the initial years of the study. RESULTS: The average per-person cost for screening individuals with LDCT was $453 (95% confidence interval [CI], $400-$505) for the initial 18-months of screening following a baseline scan. The screening costs were highly dependent on the detected lung nodule size, presence of cancer, screening intervention, and the screening center. The mean per-person cost of treating lung cancer with curative surgery was $33,344 (95% CI, $31,553-$34,935) over 2 years. This was lower than the cost of treating advanced-stage lung cancer with chemotherapy, radiotherapy, or supportive care alone, ($47,792; 95% CI, $43,254-$52,200; p = 0.061). CONCLUSION: In the Pan-Canadian study, the average cost to screen individuals with a high risk for developing lung cancer using LDCT and the average initial cost of curative intent treatment were lower than the average per-person cost of treating advanced stage lung cancer which infrequently results in a cure.

Probability of cancer in pulmonary nodules detected on first screening CT.

BACKGROUND: Major issues in the implementation of screening for lung cancer by means of low-dose computed tomography (CT) are the definition of a positive result and the management of lung nodules detected on the scans. We conducted a population-based prospective study to determine factors predicting the probability that lung nodules detected on the first screening low-dose CT scans are malignant or will be found to be malignant on follow-up. METHODS: We analyzed data from two cohorts of participants undergoing low-dose CT screening. The development data set included participants in the Pan-Canadian Early Detection of Lung Cancer Study (PanCan). The validation data set included participants involved in chemoprevention trials at the British Columbia Cancer Agency (BCCA), sponsored by the U.S. National Cancer Institute. The final outcomes of all nodules of any size that were detected on baseline low-dose CT scans were tracked. Parsimonious and fuller multivariable logistic-regression models were prepared to estimate the probability of lung cancer. RESULTS: In the PanCan data set, 1871 persons had 7008 nodules, of which 102 were malignant, and in the BCCA data set, 1090 persons had 5021 nodules, of which 42 were malignant. Among persons with nodules, the rates of cancer in the two data sets were 5.5% and 3.7%, respectively. Predictors of cancer in the model included older age, female sex, family history of lung cancer, emphysema, larger nodule size, location of the nodule in the upper lobe, part-solid nodule type, lower nodule count, and spiculation. Our final parsimonious and full models showed excellent discrimination and calibration, with areas under the receiver-operating-characteristic curve of more than 0.90, even for nodules that were 10 mm or smaller in the validation set. CONCLUSIONS: Predictive tools based on patient and nodule characteristics can be used to accurately estimate the probability that lung nodules detected on baseline screening low-dose CT scans are malignant. (Funded by the Terry Fox Research Institute and others; ClinicalTrials.gov number, NCT00751660.).

Randomized, double-blind, placebo-controlled, phase III chemoprevention trial of selenium supplementation in patients with resected stage I non-small-cell lung cancer: ECOG 5597.

PURPOSE: Selenium has been reported to have chemopreventive benefits in lung cancer. We conducted a double-blind, placebo-controlled trial to evaluate the incidence of second primary tumors (SPTs) in patients with resected non-small-cell lung cancer (NSCLC) receiving selenium supplementation. PATIENTS AND METHODS: Patients with completely resected stage I NSCLC were randomly assigned to take selenized yeast 200 µg versus placebo daily for 48 months. Participation was 6 to 36 months postoperatively and required a negative mediastinal node biopsy, no excessive vitamin intake, normal liver function, negative chest x-ray, and no other evidence of recurrence. RESULTS: The first interim analysis in October 2009, with 46% of the projected end points accumulated, showed a trend in favor of the placebo group with a low likelihood that the trial would become positive; thus, the study was stopped. One thousand seven hundred seventy-two participants were enrolled, with 1,561 patients randomly assigned. Analysis was updated in June 2011 with the maturation of 54% of the planned end points. Two hundred fifty-two SPTs (from 224 patients) developed, of which 98 (from 97 patients) were lung cancer (38.9%). Lung and overall SPT incidence were 1.62 and 3.54 per 100 person-years, respectively, for selenium versus 1.30 and 3.39 per 100 person-years, respectively, for placebo (P = .294). Five-year disease-free survival was 74.4% for selenium recipients versus 79.6% for placebo recipients. Grade 1 to 2 toxicity occurred in 31% of selenium recipients and 26% of placebo recipients, and grade ≥ 3 toxicity occurred in less than 2% of selenium recipients versus 3% of placebo recipients. Compliance was excellent. No increase in diabetes mellitus or skin cancer was detected. CONCLUSION: Selenium was safe but conferred no benefit over placebo in the prevention of SPT in patients with resected NSCLC.

Pathologic assessment of radiofrequency ablation of pulmonary metastases.

PURPOSE: To evaluate pathologically the effectiveness of radiofrequency (RF) ablation in the treatment of pulmonary metastases. MATERIALS AND METHODS: Patients with multiple pulmonary metastases scheduled for surgical resection were prospectively enrolled. Patients underwent RF ablation of one percutaneously accessible tumor and within 2-4 weeks underwent surgical resection of the ablated tumor and any additional lesions. Resected tumors all were assessed by routine light microscopy, and selected tumors were assessed by immunohistochemistry with MIB1 and proliferative cell nuclear antigen (PCNA). Relationship of ablation zone to the tumor and viability of the ablated tumors were assessed. RESULTS: Nine patients (four men and five women) 46-76 years of age were included in the study. Four patients had metastatic colorectal carcinoma, and five patients had metastases from soft tissue sarcomas. Ablated tumors ranged from 1.0-3.0 cm in diameter. Each target lesion was completely encompassed by the ablation zone. All tumor tissue within the ablation zone showed characteristic changes of coagulative necrosis with hematoxylin and eosin staining. Tumors showed preservation of MIB1 staining but loss of PCNA protein staining. RF ablation resulted in complete coagulative necrosis of all the pulmonary metastases treated in the study. CONCLUSIONS: Although this series is small, it provides histologic support for RF ablation as an effective treatment for selected pulmonary metastases.

Adoptive immunotherapy of cancer using ex vivo expanded human gammadelta T cells: A new approach.

gammadelta T cells can be an option for adoptive immunotherapy of cancer. The major obstacle to clinical application of gammadelta T cells is their low number and lack of a reliable method to expand them consistently and efficiently. We were able to expand gammadelta T cells with high purity in all donors regardless of their starting repertoire of gammadelta T cells. These ex vivo expanded gammadelta T cells are in early differentiation stage, can efficiently kill various tumors and inhibit growth of human lung cancer xenografts. This new approach for ex vivo expansion of human gammadelta T cells will open new horizons for clinical use of these cells.

Lung cancer risk in never-smokers: a population-based case-control study of epidemiologic risk factors.

BACKGROUND: We conducted a case-control study in the greater Toronto area to evaluate potential lung cancer risk factors including environmental tobacco smoke (ETS) exposure, family history of cancer, indoor air pollution, workplace exposures and history of previous respiratory diseases with special consideration given to never smokers. METHODS: 445 cases (35% of which were never smokers oversampled by design) between the ages of 20-84 were identified through four major tertiary care hospitals in metropolitan Toronto between 1997 and 2002 and were frequency matched on sex and ethnicity with 425 population controls and 523 hospital controls. Unconditional logistic regression models were used to estimate adjusted odds ratios (OR) and 95% confidence intervals (CI) for the associations between exposures and lung cancer risk. RESULTS: Any previous exposure to occupational exposures (OR total population 1.6, 95% CI 1.4-2.1, OR never smokers 2.1, 95% CI 1.3-3.3), a previous diagnosis of emphysema in the total population (OR 4.8, 95% CI 2.0-11.1) or a first degree family member with a previous cancer diagnosis before age 50 among never smokers (OR 1.8, 95% CI 1.0-3.2) were associated with increased lung cancer risk. CONCLUSIONS: Occupational exposures and family history of cancer with young onset were important risk factors among never smokers.

Synergistic antitumor effects of regulatory T cell blockade combined with pemetrexed in murine malignant mesothelioma.

CD4(+)CD25(+) regulatory T cells (Tregs) can promote the growth of some tumors, but it is unknown whether this is true for all tumors, including malignant pleural mesothelioma. We have previously shown that the existence of Tregs was associated with poor survival in patients with malignant pleural mesothelioma. In this study, using an intrathoracic murine model of malignant mesothelioma (MM), we provide evidence suggesting that Treg blockade could enhance survival when combined with pemetrexed in established tumor. AC29 murine MM cells were injected into the right pleural cavity of CBA mice for tumor development. Four days after the tumor injection, tumor-bearing mice were then treated with pemetrexed alone, Treg blockade alone, or a combination of pemetrexed and Treg blockade. We observed a synergistic antitumor effect of Treg blockade combined with pemetrexed resulting in prolonged survival. The combination of Treg blockade and pemetrexed was associated with decreased tumor-infiltrating Tregs, increased IL-2 production, dendritic cell maturation, and increased CD3(+)CD8(+)IFN-gamma(+) tumor-infiltrating T cells when compared with mice treated with pemetrexed alone or Treg blockade alone. The survival benefit was abrogated if anti-CD8 mAb was administered simultaneously. Likewise, the survival benefit resulting from the combined Treg blockade with pemetrexed was not observed when immunodeficient mice were used. Therefore, this study suggests that Treg blockade combined with pemetrexed can suppress mesothelioma growth in established tumor in vivo through an immune-mediated process. This study also validates a new intrathoracic tumor model of pleural effusion to explore the role of antitumor immunity in murine MM.

Initial treatment strategies and outcomes for multifocal bronchioloalveolar carcinoma.

BACKGROUND: Bronchioloalveolar carcinoma (BAC) commonly presents as multifocal disease. Management of multifocal BAC remains controversial and may include surgical resection, systemic therapy, surveillance, or a combination of these strategies. Knowledge of current practice patterns and outcomes could help to inform future research. MATERIALS AND METHODS: Medical records of patients with BAC were retrospectively reviewed, and regression analyses were conducted to correlate demographic parameters, disease characteristics, and treatment modality with clinical outcomes. RESULTS: Of the 109 cases identified, 85 patients were eligible for study, 26% with unifocal and 74% with multifocal BAC. Median age at diagnosis was 65 years; the majority of the patients were female (64%), were non-Asian (82%), and had a smoking history (66%). In the subset with multifocal BAC, 24% of the cases were confined to one lobe, 76% affected multiple lobes, and 40% involved both lungs. The primary treatment modality for multifocal disease included surgical resection (78%), systemic therapy (14%), and observation (8%). In multivariate analyses, extensive disease (> or = 3 lobes involved) and medical oncology assessment predicted treatment with systemic therapy (odds ratio [OR], 8.68; P = .03 and OR, 1.68; P < .01, respectively). The presence of extensive disease and the receipt of systemic therapy were associated with higher likelihood of disease progression (hazard ratio [HR], 8.62; P = .02 and HR, 8.46; P = .02, respectively). CONCLUSION: Initial treatment choices and referral patterns for multifocal BAC were diverse and influenced by clinical selection, whereby patients with extensive disease were more likely to discuss and receive systemic therapy. Surgery and surveillance were reasonable treatment options for selected patients. The precise roles of the various treatment strategies for multifocal BAC require further evaluation.

Screening for malignant pleural mesothelioma and lung cancer in individuals with a history of asbestos exposure.

PURPOSE: We established a screening program for prior asbestos workers using low-dose computed tomography (LDCT). METHODS: Between March 2005 and October 2007 we performed LDCT (50-60 mA, 120 kV, 1.25 mm) in 516 asbestos-exposed individuals. Parenchymal nodules were followed according to lung cancer screening recommendations, morphology and location of pleural plaques was noted in detail. RESULTS: We included 507 men and 9 women (median 60.0 years), 395 (76.6%) were smokers. Annual repeat has been performed in 356 participants. We found plaques in 357 subjects (69.2%), commonly calcified (79.6%), flat (86.6%), and symmetric (86.8%), and mostly involving the costal (96.4%) and diaphragmatic (81.8%) pleura. Uncommon plaques were lobulated (13.2%), right-dominant asymmetric (4.5%), or with effusions (0.1%).We found pulmonary nodules in 371 subjects (71.9%), 91 (17.6%) had at least one nodule > or =5 mm; 10 growing nodules were found on annual repeat LDCT. In 41 individuals, plaques were regarded as atypical; three had new pleural/peritoneal abnormalities on annual repeat LDCT. An interim limited computed tomography of the observed abnormality prompted 10 diagnostic biopsies, resulting in a diagnosis of six lung cancers, two pleural mesothelioma and two peritoneal mesothelioma; overall rate of screen-detected malignancies is 2.1%. There were four interval cancers, diagnosed after baseline (n = 1) or after the annual repeat (n = 3): two pleural and one peritoneal mesothelioma, and one mixed squamous/small cell carcinoma. CONCLUSION: Screening prior asbestos workers detects advanced malignant pleural mesothelioma and early as well as late stage lung cancer. We expect to learn more about the appearance of "early mesothelioma" with continued screening.

Implementation of real-time ultrasound in a thoracic surgery practice.

PURPOSE: The purpose of this study was to implement real-time transthoracic ultrasound in a thoracic surgery and lung transplant practice. DESCRIPTION: Ultrasound units that are light, small, robust, and portable are now available. Obstacles to use include demarcation issues between specialties, training, and a perception that basic ultrasound may be difficult to use. The experience of implementing this is described. EVALUATION: After a training period, 62 studies were performed in 4 months. Patients and clinicians gave positive feedback. The learning time was short, and with ultrasonic guidance, all interventional procedures were successful at the first attempt, without any complications. CONCLUSIONS: Basic transthoracic ultrasound was found to be easy to learn and use by thoracic surgeons, fellows, and specialist nurses. Patients were appreciative. Real-time use may have genuine advantages to patient care.

Induction chemoradiotherapy facilitates radical resection of T4 non-small cell lung cancer invading the spine.

OBJECTIVE: We evaluated the outcome, long-term results, and factors affecting outcome of induction chemoradiotherapy followed by surgical resection for T4 non-small cell lung cancer invading the spine. METHODS: Retrospective analysis of 23 consecutive patients undergoing radical vertebral resection for non-small cell lung cancer invading the spine between 1996 and 2007 was performed. In most cases, induction chemoradiotherapy consisted of cisplatin and etoposide followed by 45 Gy of radiation. Surgical resection with vertebrectomy was performed en bloc in either a 1-stage or 2-stage operation. Survival was estimated by Kaplan-Meier techniques. The log-rank comparison was used to compare groups. RESULTS: There were 13 men and 10 women with a median age of 61 years (range 32-75). Twenty-two patients had induction chemoradiotherapy and 1 had induction chemotherapy alone. Vertebral resections included 6 total vertebrectomies, 15 hemivertebrectomies, and 2 partial vertebrectomies. Complete resection was achieved in 19 (83%) patients. Two (8.7%) patients died postoperatively. Pathologic complete response was observed in 10 (43%) patients. The 3-year survival was 58% (median follow-up, 34 months). Patients who achieved pathologic complete response or near complete response (viable tumor cells < 1%) demonstrated significantly better survival than those who did not (3-year survival, 92% vs 20%; P = .006). CONCLUSION: Highly selected patients with lung cancer invading the spine can potentially be cured with induction chemoradiation therapy followed by radical en bloc resection of the tumor. A multidisciplinary operative strategy allows a significant chance of achieving complete resection in patients requiring multilevel hemivertebrectomy or total vertebrectomy and an appreciable cure rate.

Trimodality therapy with induction chemotherapy followed by extrapleural pneumonectomy and adjuvant high-dose hemithoracic radiation for malignant pleural mesothelioma.

PURPOSE: Malignant pleural mesothelioma (MPM) remains associated with poor outcome. We examined the results of trimodality therapy with cisplatin-based chemotherapy followed by extrapleural pneumonectomy (EPP) and adjuvant high-dose (50 to 60 Gy) hemithoracic radiation therapy for MPM. PATIENTS AND METHODS: We conducted a retrospective review of all patients prospectively evaluated for trimodality therapy protocol between January 2001 and December 2007 in our institution. RESULTS: A total of 60 patients were suitable candidates. Histology was epithelioid (n = 44) or biphasic (n = 16). Chemotherapy regimens included cisplatin/vinorelbine (n = 26), cisplatin/pemetrexed (n = 24), cisplatin/raltitrexed (n = 6), or cisplatin/gemcitabine (n = 4). EPP was performed in 45 patients, and hemithoracic radiation therapy to at least 50 Gy was administered postoperatively to 30 patients. Completion of the trimodality therapy in the absence of mediastinal node involvement was associated with the best survival (median survival of 59 months v

Translymphatic chemotherapy by intrapleural placement of gelatin sponge containing biodegradable Paclitaxel colloids controls lymphatic metastasis in lung cancer.

As a means of treating lymphatic metastasis from lung cancer, the pharmacokinetics and therapeutic effects of an intrapleural (ipl) implantable drug delivery system consisting of a gelatin sponge impregnated with polylactide-co-glycolide paclitaxel (PLGA-PTX) microspheres were studied. PLGA-PTX with 7% (w/w) drug loading were incorporated into gelatin matrix. The pharmacokinetics were studied in rats with one of the following regimens: (a) Taxol 8 mg/kg by i.v. injection; (b) Taxol 8 mg/kg ipl; (c) PLGA-PTX (100 mg/kg) ipl; (d) sponge containing PLGA-PTX (100 mg/kg) ipl. PTX concentrations in lymph node and plasma were determined by liquid chromatography mass spectrometry, and the area under the curve (AUC) was calculated. Therapeutic efficacy was assessed in an orthotopic lung cancer model with tumor resection 14 days following tumor implantation. Animals were randomized to ipl placement of PLGA-PTX sponge, placebo sponge, or no treatment. Lymph node metastases were examined at 32 d. The results show that the mediastinal lymph node AUC was significantly higher with ipl. placement of PLGA-PTX sponge compared with i.v. and ipl administration of Taxol. This represents 100- to 400-fold increase of lymphatic drug exposure compared with i.v. dosing. Peak plasma concentration was significantly reduced in the PLGA-PTX sponge group compared with i.v. dosing. PLGA-PTX particles were microscopically identified in lymphatic tissue and resulted in an 80% reduction of lymphatic metastasis compared with controls. Translymphatic-targeted drug delivery significantly decreases lymphatic metastasis in an orthotopic lung cancer model. This effect may be attributable to the improved distribution of PTX to the lymphatic system.

Impact of tumor-infiltrating T cells on survival in patients with malignant pleural mesothelioma.

OBJECTIVE: The aim of the study was to determine the impact of tumor-infiltrating lymphocytes on survival in patients with malignant pleural mesothelioma treated with induction chemotherapy followed by extrapleural pneumonectomy. METHODS: We performed an immunohistochemical analysis of 32 extrapleural pneumonectomy specimens to assess the distribution of T-cell subtypes (CD3(+), CD4(+), and CD8(+)), regulatory subtypes (CD25(+) and FOXP3(+)), and memory subtype (CD45RO(+)) within the tumor. RESULTS: Patients with high levels of CD8(+) tumor-infiltrating lymphocytes demonstrated better survival than those with low levels (3-year survival: 83% vs 28%; P = .06). Moreover, high levels of CD8(+) tumor-infiltrating lymphocytes were associated with a lower incidence of mediastinal node disease (P = .004) and longer progression-free survival (P = .05). Higher levels of CD8(+) tumor-infiltrating lymphocytes were observed in patients treated with cisplatin and pemetrexed than in those treated with cisplatin and vinorelbine (P = .02). Patients presenting high levels of CD4(+) or CD25(+) tumor-infiltrating lymphocytes or low levels of CD45RO(+) also demonstrated a trend toward shorter survival. However, the presence of FOXP3(+) tumor-infiltrating lymphocytes did not affect survival. After multivariate adjustment, high levels of CD8(+) tumor-infiltrating lymphocytes remained an independent prognostic factor associated with delayed recurrence (hazard ratio = 0.38; confidence interval = 0.09-0.87; P = .02) and better survival (hazard ratio = 0.39; confidence interval = 0.09-0.89; P = .02). CONCLUSION: The presence of high levels of CD8(+) tumor-infiltrating lymphocytes is associated with better prognosis in patients undergoing extrapleural pneumonectomy for malignant pleural mesothelioma. The stimulation of CD8(+) lymphocytes can be a potential therapeutic strategy to improve outcome.

Risk factors for major complications after extrapleural pneumonectomy for malignant pleural mesothelioma.

BACKGROUND: Factors associated with increased risk of major complications after extrapleural pneumonectomy (EPP) for malignant pleural mesothelioma are not well characterized; in particular, the risks of induction chemotherapy and red blood cell (RBC) transfusion have not been well defined. METHODS: We reviewed our experience with 62 consecutive EPP (28 right sided) performed in our institution for malignant pleural mesothelioma between January 1993 and May 2007. A total of 44 patients underwent induction chemotherapy with cisplatin-based therapy. RESULTS: The majority of patients (88%) received RBC transfusions (median, 4 units; range, 0 to 18 units). Patients undergoing induction chemotherapy had lower preoperative hemoglobin (122 +/- 16 g/L versus 134 +/- 15 g/L in the remaining patients, p = 0.02) and received more RBC transfusions (5.1 +/- 3.5 units versus 2.1 +/- 2.3 units in the remaining patients, p = 0.007). Twenty-two patients (35%) experienced major postoperative complications and 4 of them died (6.5%). Patients experiencing major complications were older (60 +/- 8 years versus 56 +/- 12 years, respectively; p = 0.2) and received more RBC transfusions (5.8 +/- 4.3 units versus 3.7 +/- 2.7 units, respectively; p = 0.02). Major complications occurred more frequently after right-sided EPP than after left-sided EPP (54% versus 21%, p = 0.007). Induction chemotherapy had no impact on the risk of major complications (p = 0.5). Transfusion of more than 4 units of RBC (p = 0.01) and right-sided EPP (p = 0.01) were associated with increased risk of major complications after EPP in multivariate analysis. CONCLUSIONS: Right EPP and more than 4 units of RBC transfusion are associated with increased risk of major complications. Although patients undergoing induction chemotherapy received more RBC transfusions, induction chemotherapy did not directly impact the risk of major complications.