The prediction of spread through air spaces with preoperative 18F-FDG PET/CT in cases with primary lung adenocarcinoma, its effect on the decision for an adjuvant treatment and its prognostic role.

PURPOSE: In lung adenocarcinoma cases, 'spread through air spaces' (STAS) is a new indicator of invasion and directly related to disease survival. The aim of our study is to establish whether a preoperatively performed 18F-Fluorodeoxyglucose (FDG) PET/computed tomography (CT) imaging data can predict the presence of STAS in cases with lung adenocarcinoma and thus predict the decision for the type of surgery and adjuvant chemotherapy. MATERIALS AND METHODS: Between 2000 and 2019, we retrospectively analyzed 63 patients with lung adenocarcinoma cases that had undergone lobectomy or pneumonectomy. Semiquantitative parameters were calculated and metabolic tumor volume (MTV)/CT volume (CTV) ratio was recorded from FDG PET/CT data. The pathological samples from these patients were evaluated for STAS. All these values were evaluated for their correlation with the alveolar spread. RESULTS: There was no statistically significant correlation to be found between CTV, MTV, total lesion glycolysis (TLG), standardized uptake value (SUV)max, SUVmean and STAS (P > 0.05). However, MTV/CTV ratio above 1 had statistically more alveolar spread. In the group with an MTV ratio above 1, STAS positivity was 27 (75%), and 9 (25%) did not have STAS, whereas these were 6 (22.2%) patients who had STAS, and 21 (77.8%) did not have STAS in the group with below 1 (P < 0.001). CONCLUSIONS: In the preoperative PET study inoperable lung adenocarcinoma cases, MTV/CTV ratio higher than 1 was found to predict STAS positivity. As a result, it was found that it provided significant clinical additional information regarding the need for a surgical approach (lobar resection instead of sublobar) and adjuvant chemotherapy.

Immune profiling after minimally invasive lobectomy.

OBJECTIVES: Whether acute phase and immune responses are minimally affected following minimally invasive lung surgery needs further investigation. We performed a pilot study to evaluate the immune profile of patients who underwent video-assisted thoracoscopic surgery or robot-assisted thoracic surgery lobectomies for the treatment of suspicious or known stage I non-small-cell lung cancer. METHODS: Blood samples were taken preoperatively and 3 and 24 h postoperatively were analysed for C-reactive protein, glucose, cortisol, tumour necrosis factor alpha (TNF-α), interleukin 8 (IL-8) and interleukin 10 (IL-10) levels. TNF-α, IL-8 and IL-10 were also measured in lung tissues. T (CD4, CD8), B (CD19) and natural killer (CD56, CD16) cell counts and natural killer cell functions were analysed using a flow cytometry-based assay before and after surgery. RESULTS: Minimally invasive surgery (robot-assisted thoracic surgery + video-assisted thoracoscopic surgery) significantly decreased IL-10 (P = 0.016) levels after surgery. No significant differences were detected in TNF-α (P = 0.48) and IL-8 (P = 0.15) levels before and after surgery. C-reactive protein (P < 0.001), cortisol (P < 0.001) and glucose levels (P < 0.001) increased significantly after surgery. Lymphocyte, total T cell, CD3+CD4+ and CD3+CD8+ CD16+CD56+ cell counts were significantly lower on postoperative day 1. CONCLUSION: There seems to be a dynamic balance between pro- and anti-inflammatory cytokines and immune cells following minimally invasive lobectomy.

Elevation in serum uric acid levels predicts favourable response to erlotinib treatment in patients with metastatic non-small-cell lung cancer.

WHAT IS KNOWN AND OBJECTIVE: Erlotinib is a small molecule tyrosine kinase inhibitor which blocks the activation of epidermal growth factor receptor (EGFR), a transmembrane receptor that is upregulated in many cancer types. Inhibition of angiogenesis with consequent impairments in intratumoral microcirculation is one of the mechanisms through which EGFR inhibition halts the progression of cancer. A consequence of impaired microcirculation is intratumoral hypoxia, which results in increases in serum uric acid levels. The goal of this study was to investigate the relationship between serum uric acid levels and response to erlotinib in metastatic non-small-cell lung cancer (NSCLC). METHODS: A total of 56 patients with metastatic non-small-cell lung cancer who received erlotinib for a duration of at least 3 months were included in this retrospective cohort study. Demographic characteristics, progression status, baseline serum uric levels and 3-month serum uric acid levels were recorded and analysed. RESULTS AND DISCUSSION: Of the study population, 21 (37.5%) were female and 35 (62.5%) were male patients. No significant difference in above demographic characteristics was observed among exitus, survivor with progression and survivor without progression groups. Patients who responded favourably to erlotinib with no progression of their disease had significantly increased uric acid levels at 3-month follow-up (P = .01). Such a correlation was not observed if the patient was exitus (P = .47) or had progressed on erlotinib therapy (P = .19). WHAT IS NEW AND CONCLUSION: In conclusion, this study is the first to demonstrate significant increases in serum uric acid levels in patients with metastatic NSCLC who responded favourably to erlotinib and had no progression under erlotinib therapy. Further studies are required to confirm and characterize serum uric acid as a novel biomarker in predicting the outcome in those with metastatic NSCLC.

Level of pleural invasion effects on prognosis in lung cancer.

OBJECTIVE: To analyze the extent of visceral pleural invasion (VPI) and its effect on survival along with its place in determining the T descriptor in TNM staging in our patients. METHODS: A total of 233 patients underwent lung resection. The data were retrospectively analyzed in terms of sex, age, histopathologic type, stage of the tumor, extent of VPI, and survival. Patients who had neoadjuvant chemotherapy or chemoradiotherapy, distant metastasis, parietal pleural invasion, and operative mortality were excluded. RESULTS: The median follow-up was 59 months (range 4-126). The extent of VPI was PL0 in 119 (65.7%) patients, PL1 in 47 (26%) patients, and PL2 in 15 (8%) patients. The median survival rates were 65 (range 43-96) months for PL0, 54 (range 37-72) months for PL1, and 39 (range 12-69) months for PL2. The 5-year overall survival rates were 74.7% for PL0, 77.8% for PL1, and 53.3% for PL2. There were statistically significant differences in overall survival among PL0, PL1, and PL2 ( p = 0.03). In subgroup analysis, the difference was insignificant in PL0 vs PL1 ( p = 0.81), but significant in PL0 vs PL2 ( p = 0.02) and PL1 vs PL2 ( p = 0.04) groups. CONCLUSIONS: This study emphasizes that the presence of VPI is related with poor prognosis independent of lymph node positivity, histologic subtypes, and tumor size. As the study shows, PL0 and PL1 have similar survival rates and these two groups may be considered as VPI (-) patients whereas PL2 disease affects survival outcomes.

Extensive chest wall resection, reconstruction and right pneumonectomy in a 24-week pregnant patient.

A 23-year-old pregnant patient was evaluated with a mass lesion located on the right sided chest wall. A MRI of the chest showed a lesion of approximately 18 × 16 × 17.5 cm originating from ribs. A tru-cut biopsy revealed the diagnosis of chondrosarcoma. The patient underwent an extended chest wall resection, reconstruction and right pneumonectomy operation in the 24th gestation week. After the recovery period, two cycles of chemotherapy were administrated. The patient delivered a healthy baby in 34th week of her pregnancy.

Results of videothoracoscopic thymectomy in children: an analysis of 40 patients†.

OBJECTIVES: Experience in video-assisted thoracoscopic (VATS) thymectomy is limited in paediatric patients with non-thymomatous myasthenia gravis (MG). The aim of this study is to evaluate the medical status and surgical results of paediatric patients who underwent a VATS thymectomy. METHODS: Of the 367 VATS thymectomies performed for MG patients in our Department of Thoracic Surgery between June 2002 and April 2013, 40 patients were in the paediatric age group. The data were evaluated retrospectively. Age, sex, duration of disease, body mass index, prescribed medication, duration of the operation, complications, chest tube duration, length of postoperative hospital stay and pain score using a visual analogue scale were analysed. RESULTS: The average age was 14.8 ± 2.2 years (range, 8-18 years), and 27 (68%) patients were female. The electromyography and acetylcholine receptor antibody tests were positive in 30 (75%) and 27 (67%) patients, respectively. The mean quantitative MG score was 11.5 ± 5.3. The mean prescribed preoperative pyridostigmine bromide dosage was 209 ± 112 mg. Eleven (27.5%) patients were on corticosteroid treatment and 22 (55%) received intravenous immunoglobulin treatment preoperatively. There were no open conversions or mortalities. The average duration of the operation was 48.9 ± 31.3 min. All patients were extubated on the table and only one (2.5%) required mechanic ventilation for 18 h postoperatively. Three (7.5%) patients experienced complications. The average duration of chest drainage and postoperative stay were 20.5 ± 12.1 h and 1.8 ± 1.0 days, respectively. The average pain score using a visual analogue scale was 2.3 ± 1.2. CONCLUSIONS: A right-sided VATS thymectomy is a safe procedure in paediatric patients with MG.

The comparison of complication, pain, quality of life and performance after lung resections with thoracoscopy and axillary thoracotomy.

OBJECTIVES: The aim of this prospective study was to compare the effects of axillary thoracotomy (AT) and video-assisted thoracoscopic surgery (VATS) on acute-phase responses, pain, performance status and quality of life in patients undergoing pulmonary resection. METHODS: Fifty-five patients with peripherally located lung lesions were enrolled into this study. Surgery was done by VATS or AT. Forced expiratory volume, smoking habits, complications, Charlson comorbidity index, sex, age, length of incision, length of operation, length of hospital stay, length of drainage, length of air leakage, preoperative and postoperative C-reactive protein (CRP) values, visual analogue scale, quality of life and performance status of the patients were measured and compared. RESULTS: Twenty-five patients had lung resection with VATS and 30 patients had lung resection with AT. The demographic variables were similar. The differences between the two groups' postoperative serum CRP levels were significantly lower for the VATS group. The length of postoperative stay was significantly shorter for the VATS group. There were no other statistical significance between the two groups in terms of operative variables, complications, pain, quality of life and performance status. CONCLUSIONS: AT is a technique equivalent to VATS in terms of early complications, pain, performance status and quality of life; VATS provided a shorter postoperative stay.

Factors associated with pulmonary recurrence after pulmonary metastasectomy for sarcomatous disease.

PURPOSE: To analyze the factors associated with survival and pulmonary recurrence after complete metastasectomy for patients with sarcomatous disease. METHODS: Among the 51 patients who underwent complete pulmonary metastasectomy at our hospital between January 2002 and November 2010, 30 (58.8 %) suffered pulmonary recurrence in an ipsilateral hemithorax. We analyzed the factors affecting survival and recurrence after complete metastasectomy. RESULTS: The 51 patients who underwent pulmonary metastasectomy comprised 33 male and 18 female patients, with a median age of 22 years (range 11-61 years). The median survival was 24 months. Multivariate analysis revealed recurrence (p = 0.016) and the type of tumor (p = 0.024) as independent predictors of survival. Recurrence developed in 30 (58.8 %) patients. The risk of recurrence was higher in patients with a DFI <12 months and >1 metastasis resected during the initial metastasectomy. CONCLUSIONS: Based on the findings of our analysis, patients with a DFI <12 months and >1 metastases resected during initial surgery have a higher risk of recurrence. We recommend postoperative follow-up at frequent intervals and reconsideration of oncological treatment after complete resection.