Importance of tumour volume and histology in trimodality treatment of patients with Stage IIIA non-small cell lung cancer-results from a retrospective analysis.

OBJECTIVES: Chemoradiotherapy (CRT) has been the backbone of guideline-recommended treatment for Stage IIIA non-small cell lung cancer (NSCLC). However, in selected operable patients with a resectable tumour, good results have been achieved with trimodality treatment (TT). The objective of this bi-institutional analysis of outcomes in patients treated for Stage IIIA NSCLC was to identify particular factors supporting the role of surgery after CRT. METHODS: In a 2-centre retrospective cohort study, patients with Stage III NSCLC (seventh edition TNM) were identified and those patients with Stage IIIA who were treated with CRT or TT between January 2007 and December 2013 were selected. Patient characteristics as well as tumour parameters were evaluated in relation to outcome and whether or not these variables were predictive for the influence of treatment (TT or CRT) on outcome [overall survival (OS) or progression-free survival (PFS)]. Estimation of treatment effect on PFS and OS was performed using propensity-weighted cox regression analysis based on inverse probability weighting. RESULTS: From a database of 725 Stage III NSCLC patients, 257 Stage IIIA NSCLC patients, treated with curative intent, were analysed; 186 (72%) with cIIIA-N2 and 71 (28%) with cT3N1/cT4N0 disease. One hundred and ninety-six (76.3%) patients were treated by CRT alone (high-dose radiation with daily low-dose cisplatin) and 61 (23.7%) by TT. The unweighted data showed that TT resulted in better PFS and OS. After weighting for factors predictive of treatment assignment, patients with a large gross tumour volume (>120 cc) had better PFS when treated with TT, and patients with an adenocarcinoma treated with TT had better OS, regardless of tumour volume. CONCLUSIONS: Patients with Stage IIIA NSCLC and large tumour volume, as well as patients with adenocarcinoma, who were selected for TT, had favourable outcome compared to patients receiving CRT. This information can be used to assist multidisciplinary team decision-making and for stratifying patients in studies comparing TT and definitive CRT.

Trends in the Treatment of Pectus Excavatum in the Netherlands.

INTRODUCTION: Pectus excavatum (PE) is the most common deformity of the anterior chest wall and can be corrected surgically with different techniques. In the past years, medical literature suggests that the minimal invasive surgical correction of PE (MIRPE) has currently become the operation technique of choice in Europe, and the number of PE patients undergoing surgery has increased. The aim of this study was to evaluate trends in the number of patients operated on and the surgical techniques generally used in patients with PE in the Netherlands. MATERIALS AND METHODS: From the registration by Statistics Netherlands, the numbers of live births and gender were obtained for the period 1980 to 2017. Furthermore, from the Dutch hospital registration performed by Kiwa Prismant systems, the number of total surgical procedures of PE patients from the period 1998 to 2017, and the numbers of open and MIRPE surgery were obtained over the period 2005 to 2013. RESULTS: The birth rate in Netherlands has stayed more or less stable in the last two decades. The number of PE patients asking for correction, however, has increased. In addition, the percentage of thoracoscopic assisted correction has increased. CONCLUSION: The increase in correction of PE is not due to an increased incidence but to an increase of patient wishes. The use of MIRPE is gaining popularity over time.

The Quality of Web Sites' Health Information on Minimal Invasive Repair of Pectus Excavatum Using the DISCERN Instrument.

INTRODUCTION: The Internet is a frequently used tool for patients with pectus excavatum (PE) to get information about symptoms and treatment options. In addition, it is used by both health care providers as a marketing tool and support group systems. The Internet health information varies in precision, quality, and reliability. The study purpose was to determine the quality of information on the PE Web sites using the DISCERN instrument, including information about operation and potential complications after a Nuss bar procedure. MATERIALS AND METHODS: Four search engines, Google, Yahoo, Ask, and Bing, were used to explore seven key terms concerning PE. Search language was English. The DISCERN quality instrument was used to evaluate the Web sites. Also, information on possible complications was scored per Web site. RESULTS: A total of 560 Web sites were assessed in March 2019. Excluded were 139 Web sites. There were 333 duplicates, leaving 88 unique Web sites. Of these, 58.1% were hospital-related information Web sites, 28.4% medical information Web sites, and 3.4% patient forum sites. Interactive multimedia was used on 21.6% of the sites. Pain postoperatively was mentioned on 64.8% of the sites, while only 9.1% mentioned the mortality risk of the surgical correction of PE for Nuss bar placement. The quality of the unique Web sites showed a mean DISCERN score of 42.5 (standard deviation 12.2). Medical information Web sites, encyclopedia, and government-sponsored sites had higher DISCERN scores. Hospital-related information sites, medical companies, and lay persons' sites, had lower total scores. CONCLUSION: The overall quality of PE Web sites is low to moderate, with serious shortcomings.

The Outcome of the Single Step Questionnaire in Pectus Excavatum Patients is Phase Dependent.

INTRODUCTION: Pectus excavatum (PE) is the most common chest wall deformity. Patients with PE may have cosmetic complaints, restricted physical capabilities, or both and may seek surgical correction. One method to assess satisfaction after surgery is the single step questionnaire (SSQ). Although the developers state that the SSQ produces a stabile score and only needs to be used once, we hypothesized that the score may depend on point in time after surgery. MATERIALS AND METHODS: One hundred and eight patients from a longitudinal cohort of patients undergoing a Nuss bar placement for PE were selected. Mean age was 16.0 years (range: 12-29). SSQ was completed at 6 weeks, 6 months, 1 year, and 2 years postoperatively. Mean and median scores per question and total scores were calculated on each measurement moment. Overall scores were tested using the Friedman test. RESULTS: There were significant differences in overall SSQ scores (p < 0.009) throughout the postoperative period, especially between 6 weeks and 6 months (p = 0.006). Scores on general health, exercise capacity, impact on social life, pain during hospital stay, and after discharge changed also significant in the first 2 years after Nuss bar placement. CONCLUSION: There were significant differences in total SSQ score depending on the time of application postoperatively. However, the most clinical relevant difference was between 6 weeks and 6 months. Assessment of the overall satisfaction postoperative with the SSQ questionnaire should not be done with a single measurement but rather at different postoperative time intervals before and after 6 months postoperatively.

Early cost-utility estimation of the surgical correction of pectus excavatum with the Nuss bar.

OBJECTIVES: The surgical correction of pectus excavatum (PE) with a Nuss bar provides satisfactory outcomes, but its cost-effectiveness is yet unproven. We prospectively analysed early outcomes and costs for Nuss bar placement. METHODS: Fifty-four patients aged 16 years or older (6 females and 48 males; mean age, 17.9 years; range 16.0-29.4 years) with a PE filled out a Short Form-36 Health Survey (SF-6D) preoperatively and 1 year after a Nuss procedure. Costs included professional fees and fees for the operating room, materials and hospital care. Changes in the responses to the SF-36 or its domains were compared using the Wilcoxon signed rank test and the utility test results were calculated preoperatively and postoperatively from the SF-6D. The quality-adjusted life years (QALYs) were calculated from the results of these tests. RESULTS: Significant improvements in physical functioning, social functioning, mental health and health transition (all P < 0.05) were noted. The other SF-36 subgroups showed improvement; however, the improvement was not significant. The SF-6D utility showed improvement from 0.76 preoperatively to 0.79 at the 1-year follow-up (P = 0.096). The mean direct costs were €8805. The 1-year discounted QALY gain was 0.03. The estimated cost-utility ratio was €293 500 per QALY gained. CONCLUSIONS: Despite a significant improvement in many domains of the SF-36, the results of the SF-6D cost-utility analysis showed only a small improvement in cost-effectiveness (> €80 000/QALY) for patients with PE 1 year after Nuss bar placement. Based on this discrepancy, general health outcome measurements as the basis for cost-utility analysis in patients with PE may not be the best way forward.

Sports activity in adolescents in the Netherlands with a pectus excavatum; the impact of surgery.

PURPOSE: Pectus excavatum (PE) is the most common chest wall deformity in adolescents. The main complaint is cosmetic, but many patients also complain about exertional dyspnea. This may lead to the patient seeking surgery of the thoracic wall deformity (TWD). The assumption is that both, appearance and physical complaints will have a negative effect on being able or wanting to engage in sport activity. METHODS: In December 2011 a prospective registration of sport activity in pectus excavatum patients started. Sport activity was assessed using questionnaires (CHQ, SF-36 and PEEQ). Measurements were taken before corrective surgery (preoperatively) and 12 months postoperatively. RESULTS: 127 patients have been included. The number of patients who were active in sports preoperatively and after 12 months remained steady. The type of sport activity, individual sport or team sport showed no significant change. The CHQ showed that physical activity caused fewer complaints (p < 0.001). The PEEQ showed a decrease in difficulties with sports activity performance after 12 months (p < 0.001). CONCLUSIONS: Twelve months after surgical correction of PE there was no significant increase in the number of patients performing sport activities. However there was a significant decrease of complaints or difficulties during sport compared to preoperatively. LEVEL OF EVIDENCE: Level IV.

Bronchial colonization and complications after lung cancer surgery.

PURPOSE: Infectious complications occur following pulmonary resections preceded or not by induction chemoradiotherapy. We aimed to investigate whether bacterial colonization of the bronchial tree at the time of surgery was associated with postoperative complications. PATIENTS AND METHODS: A retrospective analysis of all patients who underwent open anatomical pulmonary resections for malignancies at a single center was performed. Demographical data of the included patients, intraoperative data, and data on the postoperative course of patients were collected. Outcome of patients with a positive intraoperative bronchial culture was compared to patients with a negative bronchial culture. Relations between the presence of potential bacterial pathogens in the bronchial tree and other possible risk factors for the development of postoperative infectious and non-infectious complications, were analyzed using uni- and multivariate analysis. RESULTS: Between January 2010 and January 2012, a total of 121 consecutive patients underwent open anatomical pulmonary resections for malignancy, of whom 45 were preceded by induction chemoradiotherapy and 5 by induction chemotherapy. Intraoperative bronchial cultures were taken from 58 patients (48 %). Patients with a positive bronchial culture developed significantly more infectious (88 % vs. 20 %, p < 0.001) and non-infectious complications (63 % vs. 12 %, p = 0.001). Positive intraoperative bronchial cultures showed the strongest association with the development of infectious and non-infectious postoperative complications (OR 24.8 and 12.2, respectively). After multivariate analysis, only BMI less than 20 kg/m(2) and the presence of a positive intraoperative bronchial culture were found to be independent risk factors for the development of infectious complications. Chemoradiotherapy was not associated with postoperative complications in the present study. CONCLUSIONS: Bacterial colonization of the bronchial tree assessed intraoperatively, appears to be associated with higher rates of infectious and non-infectious complications after pulmonary resection. Whether early starting of appropriate antibiotics based on intraoperative-taken culture findings will reduce the infectious complication rate in a subcategory of patients needs to be investigated.

Severe kyphosis with spinal cord compression after resection of a superior sulcus tumor.

Vertebral involvement is no longer a contraindication for resection of superior sulcus tumors. We describe a patient who developed a kyphoscoliosis with spinal cord compression after resection of a superior sulcus tumor that invaded the vertebral column. Risk factors for spinal instability and indications for stabilization are discussed.

Negative pressure dressing for radiation-associated wound dehiscence after posterolateral thoracotomy.

Wound complications following surgical resection in patients treated with neoadjuvant chemoradiation therapy are common and can be a difficult problem to manage. Negative pressure dressing technology appears to be safe and effective in the treatment of radiation-associated wound complications and can be used in the outpatients clinic setting. The presented case demonstrates that negative pressure dressing also manages the hydropneumothorax as a result of the dehiscence of the thoracic wall.

A nonresponding small cell lung carcinoma.

We present a case with limited disease small cell lung carcinoma with persisting disease and a troublesome syndrome of inappropriate antidiuretic hormone, despite concurrent chemoradiotherapy and second-line chemotherapy. To gain local control, a lobectomy was performed.