Prognostic factors affecting survival in patients with non-small cell lung cancer treated with salvage surgery after drug therapy: a multi-institutional retrospective study.

BACKGROUND: The prevalence of salvage surgeries after drug therapy for non-small cell lung cancer (NSCLC) has risen, mainly due to recent progress in molecular-targeted drugs and immune checkpoint inhibitors for NSCLC. While the safety and effectiveness of salvage surgery after drug therapy for NSCLC have been studied, its indications remain unclear. We aimed to identify the prognostic factors affecting survival in patients with advanced-stage (stages III-IV) NSCLC treated with salvage surgery after drug therapy. METHODS: A retrospective investigation was conducted on patients who received salvage surgery after drug therapy at four hospitals between 2007 and 2020. Salvage surgery was defined as surgery after drug therapy for local progression, tumor conversion to resectable status, and discontinuation of prior drug therapy owing to serious complications. RESULTS: Thirty-two patients received cytotoxic agents alone (n = 12 [38%]), tyrosine kinase inhibitors (TKIs; n = 16 [50%]), or immune checkpoint inhibitors (n = 4 [13%]) as prior drug therapy. In 11 (34%) and 21 (66%) patients, the clinical stage before treatment was III or IV, respectively. The median initial and preoperative serum carcinoembryonic antigen (CEA) levels were 10.2 (range, 0.5-1024) ng/mL and 4.2 (range, 0.6-92.5) ng/mL, respectively. Among the patients, 28 (88%) underwent lobectomy, 2 (6%) underwent segmentectomy, and 2 (6%) underwent wedge resection. Complete resection of the primary lesion was accomplished in 28 (88%) patients. Postoperative complications were documented in six (19%) patients. Mortality rates were 0% at 30 days and 3% at 90 days post-operation. The 5-year overall survival rate stood at 66%, while the 5-year progression-free survival rate was 21%. Multivariate analyses showed that prior TKI therapy and preoperative serum CEA level < 5 ng/mL were prognostic factors influencing overall survival (hazard ratio [95% confidence interval]: 0.06 [0.006-0.68] and 0.03 [0.002-0.41], respectively). The 5-year overall survival in the 11 patients with both favorable prognosticators was 100%. CONCLUSIONS: In this study, prior TKI therapy and preoperative serum CEA level < 5 ng/mL were favorable prognostic factors for overall survival in patients with NSCLC treated with salvage surgery. Patients with these prognostic factors are considered good candidates for salvage surgery after drug therapy.

[Successful management of a patient with pain and dyspnea from bone metastasis and lymphangitis carcinomatosa after surgery for non-small cell lung cancer (NSCLC) in whom optimal dosages of transdermal fentanyl were determined by titration with fentanyl injection, and oxycodone hydrochloride].

With recent progress in disease-modifying treatments for cancer, patients who have recurrences during a period of several years before entering the terminal stage are encountered frequently. Despite improved life expectancy with cancer therapy, for patients this means prolongation of the period in which various symptoms such as cancer pain and adverse reactions are undergone. In these conditions, although the recognition is not yet sufficient, the importance of palliative care along with disease-modifying treatment is recognized in Japan. We treated a 50s female with pain and dyspnea from bone metastasis and lymphangitis carcinomatosa after surgery for NSCLC in whom the optimal dosages of transdermal fentanyl (Durotep Patch) were determined by titration with fentanyl injection, and oxycodone hydrochloride (OxyContin) in a short period. The dosages after titration were transdermal fentanyl 35 mg, oxycodone hydrochloride 60 mg, and betamethasone 4 mg. Before her death, she was able to stay at home with her family for 3 days without severe symptoms. In the present study we describe the clinical course of this case, the difference of characteristics in these opioids, and the titration method with fentanyl injection.

Experimental Study of Intraparenchymal Fibrinogen and Topical Thrombin to Seal Pleural Defects.

OBJECTIVE: Fibrin sealants are used to close surgical pleural defects, but may detach, causing a postoperative air-leak. We investigated a new means of applying fibrin glue for closing pleural defects. METHODS: Pleural defects (10-mm and 4-mm diameters, respectively) were created in swine and rats via thoracotomy. They were sealed by a) injection of a fibrinogen solution into the lung parenchyma after instillation of a thrombin solution onto the pleural defect (group A), b) fibrinogen and thrombin spray (group B), c) fibrinogen instillation and a thrombin-dipped polyglycolic acid sheet (group C), or d) fibrin glue-coated collagen fleece (group D). Resistance to airway pressure was compared and the sealed areas were histologically examined. RESULTS: In group A, the minimum seal-breaking airway pressure was consistently > 40 cmH2O, versus 37.2 ± 3.6 cmH2O in group B, 37.2 ± 4.0 cmH2O in group C, and 39.0 ± 1.7 cmH2O in group D, which was statistically significant. Histologically, the fibrin layer infiltrated the lung parenchyma and covered the defect in group A, but not in the other groups. CONCLUSIONS: The intraparenchymal injection of fibrinogen combined with instillation of thrombin created an effective fibrin layer associated with early pleural regeneration that reliably prevented pleural air leaks.