Glucose Uptake Values in Positron Emission Tomography Are Useful to Predict Survival after Sublobar Resection for Lung Cancer.

Background To assess the reliability of maximum standardized uptake values (SUVmax) at the primary lesion in 18-fluorodeoxyglucose positron emission tomography combined with computed tomography (18FDG-PET/CT) for identifying patients with lung cancer who were most likely to be cured by sublobar resection (SR). Methods We retrospectively reviewed the medical records of 120 patients who underwent SR for clinical (c)-stage IA + IB lung cancer after 18FDG-PET/CT. Various factors, including tumor size, SUVmax at the primary site, and microscopic tumor invasion, were examined to identify their association with postsurgical survival. Prognoses of patients undergoing SR were compared with those of 272 patients undergoing lobectomy and lymphadenectomy during the same period. Results The 5-year recurrence-free survival (RFS) and overall survival (OS) rates in all patients undergoing SR for c-stage IA + IB disease were 79.5% and 82.2%, respectively. In multivariate analysis, a lack of microscopic pleural invasion and SUVmax ≤ 3.0 significantly correlated with better RFS and OS in patients undergoing SR. Though there were no significant differences in RFS and OS following SR and lobectomy for c-stage IA + IB or IA disease, RFS was significantly inferior in nonintentional SR (NISR) than in lobectomy in c-stage IA disease (p < 0.01). However, in NISR identified based on SUVmax ≤ 2.0, RFS was comparable to those in lobectomy (p = 0.5371). Conclusion When certain subgroups of patients are accurately identified based on preoperative SUVmax, SR can be a highly curative surgical method for lung cancer.

[CURRENT STATUS AND FUTURE DIRECTION OF SURGICAL MANAGEMENT FOR ELDERLY PATIENTS WITH NON-SMALL CELL LUNG CANCER].

According to the 2012 annual report of the Japanese Association for Thoracic Surgery, the total number of surgical procedures performed for the treatment of lung cancer had reached 35,667. Patients over 70 years of age comprised 52% of those surgical cases, and those over 80 years 12%. This tendency has been increasing annually. Although hospital mortality rates in elderly patients over 80 years of age and others were almost the same, 30% of elderly patients died from other diseases, as reported by the Japanese Joint Committee of the Lung Cancer Registry in 1999. Therefore, current preoperative physiological and oncological risk evaluations of elderly patients do not appear to be sufficient. The Japanese Association for Chest Surgery planned and performed a multiinstitutional prospective cohort study of elderly patients with lung cancer who underwent thoracic surgery to answer clinical questions surrounding such risk evaluations.

Standardized Uptake Values in the Primary Lesions of Non-Small-Cell Lung Cancer in FDG-PET/CT Can Predict Regional Lymph Node Metastases.

PURPOSE: Maximum standardized uptake values (SUVmax) at the primary lesions of non-small-cell lung cancer in (18)F-fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG-PET/CT), and the microscopic local extension of tumors were examined to develop reliable criteria to determine candidates for sublobar resection. METHODS: We retrospectively analyzed 209 patients who underwent lobectomy, bilobectomy, or pneumonectomy with systematic lymph node dissection. Preoperative SUVmax at the primary lesion, microscopic lymphatic, venous, and pleural invasion in addition to lymph node metastases in the resected specimens were examined. Receiver operating characteristic analyses were used to predict an optimal cutoff for lymph node metastases. RESULTS: With receiver operating characteristic analysis, the areas under the curve for SUVmax and tumor size were 0.693 and 0.545, respectively, suggesting SUVmax superiority for prediction of lymph node metastases with a cutoff of 2.9. When a tumor was ≤2.0 cm (n = 41, 19.6 %), the percentages of microscopic lymphatic invasion, venous invasion, pleural invasion, and lymph node metastases were 12.2, 7.3, 4.9, and 17.1 %, respectively. When SUVmax was <3.0 (n = 91, 43.5 %), these percentages were 15.4, 3.3, 7.7, and 8.8 %, showing that SUVmax could efficiently exclude nodal metastases in more cases than tumor size. The postoperative 5-year survival rate was 86.6 % in patients with SUVmax < 3.0 and 58.1 % in patients with SUVmax ≥ 3.0 (p < 0.001). CONCLUSIONS: (18)F-FDG uptake value was more useful than tumor size for selecting patients with non-small-cell lung cancer suitable for intentional sublobar resection.

Automatic objective diagnosis of lymph nodal disease by B-mode images from convex-type echobronchoscopy.

BACKGROUND: We investigated whether artificial neural networks (ANNs) could diagnose pathology of lymph nodes by feeding B-mode images from convex-type echobronchoscopy to ANNs. METHODS: Subjects comprised 91 patients who had undergone endobronchial ultrasonography transbronchial needle aspiration at our hospital between April 2005 and March 2007. Diagnosis was lymph node metastasis from lung cancer in 66 patients, and sarcoidosis in 25 patients. Layered ANNs consisting of input, middle layers, and output layers were prepared. Back-propagation was chosen as a learning algorithm. For the malignant findings, images obtained from six patients with lymph node metastasis of lung cancer (ie, adenocarcinoma, two patients; squamous cell carcinoma, two patients; small cell carcinoma, two patients) were used. As benign findings, typical images obtained from three patients with sarcoidosis were used. For each image used for supervised training, 5, 10, or 15 regions of interest were randomly selected. Repeated learning comprised either 500,000 or 1,000,000 repetitions. A total of five thoracic surgeons were asked to diagnose the pathology base on the same images. Accuracies were compared between ANNs and thoracic surgeons. RESULTS: The diagnostic accuracy of the surgeon with 5 years of experience and that of the surgeon with 1 year of experience were 78% and 51%, respectively, compared to 91% for the ANNs. CONCLUSION: Assessment of B-mode images by ANNs may offer a useful basis for automatic diagnostic methods.

Impact of intraoperative blood loss on long-term survival after lung cancer resection.

PURPOSE: The purpose of this study was to clarify relationships between intraoperative blood loss (IBL) and long-term postsurgical survival in lung cancer patients. METHODS: We retrospectively analyzed 1336 patients undergoing surgery: lobectomy in 1016, sublobar resection in 174, pneumonectomy in 106, and combined resection with adjacent organs in 40. The lobectomy group was stratified further by pathologic stages; overall survival difference was examined according to amount of IBL. RESULTS: Volume of IBL differed significantly according to surgical procedure when all patients were included. Within the lobectomy group, IBL differed significantly between gender, pathologic stage, histologic type (adenocarcinoma vs. non-adenocarcinoma), and year of operation (1983 to 2002 vs. 2003 to 2012). After stratification by pathologic stage, survival differed with IBL for stages IB to IIIB. Multivariate analysis identified gender, patients age (<69 vs. ≥69), pathologic stage (IA to IIB vs. IIIA to IV), year of operation, histologic type, and IBL as significant predictors of survival. CONCLUSION: Since degree of IBL is an independent predictor of overall survival after lung cancer resection, IBL should be minimized carefully during surgery.

Association of IASLC/ATS/ERS Histologic Subtypes of Lung Adenocarcinoma With Epidermal Growth Factor Receptor Mutations in 320 Resected Cases.

BACKGROUND: The relationships between the subtypes defined by the new international histologic classification of lung adenocarcinoma (IASLC/ATS/ERS) and epidermal growth factor receptor (EGFR) mutations were studied. PATIENTS AND METHODS: We retrospectively reviewed 320 patients with lung adenocarcinoma (162 women, 158 men; mean age, 69 years) who had undergone complete resection, focusing on the new histologic subtypes and EGFR mutations. The clinical stage was IA in 196 patients, IB in 95, IIA in 10, IIB in 10, IIIA in 6, and IV in 3. RESULTS: The most prevalent subtype was papillary (35.0%), followed by acinar (29.4%), lepidic (13.1%), solid (7.2%), adenocarcinoma in situ (6.6%), minimally invasive adenocarcinoma (6.3%), micropapillary (1.6%), and invasive mucinous adenocarcinoma (1.0%). These subtypes were predictive for both postoperative disease-free and overall survival. EGFR mutations, detected in 40.6% of all cases, were most frequent in acinar (48.4%), followed by minimally invasive adenocarcinoma (45.0%) and papillary (43.8%). They were least frequent in the solid subtype (17.4%). EGFR mutation status did not affect postoperative disease-free or overall survival. CONCLUSION: The outcome after complete resection for lung adenocarcinoma was predicted by the proposed subtype classification. Because EGFR mutations were found in all subtypes, mutation analyses are essential to identify patients with postoperative relapse who would benefit from EGFR-tyrosine kinase inhibitor therapy.

Close association of IASLC/ATS/ERS lung adenocarcinoma subtypes with glucose-uptake in positron emission tomography.

OBJECTIVES: Correlations between maximum standardized uptake value (SUVmax) in fluorodeoxyglucose positron emission tomography (FDG-PET) and IASLC/ATS/ERS histopathologic subtypes of lung adenocarcinoma remain unclear. Therefore, the aim of this study was to retrospectively clarify associations between SUVmax and adenocarcinoma subtypes with postoperative outcomes. MATERIALS AND METHODS: Associations of SUVmax measured in preoperative FDG-PET/CT and histologic subtypes of lung adenocarcinoma resected in our hospital were analyzed retrospectively. Overall and disease-free survival rates after surgery were calculated by the Kaplan-Meier method, and survival differences between patient groups were tested by the log-rank test. Multivariate analysis for survival was performed using the Cox regression model. RESULTS: A total of 255 patients (130 men and 125 women; mean age, 69 years; range, 22-88 years) were included in the study. Clinical stages included IA in 151 patients, IB in 79, IIA in 9, IIB in 10, and IIIA in 6. SUVmax was closely associated with histologic subtype in resected specimens (p<0.0001). Values were highest in micropapillary predominant invasive adenocarcinoma (MPA) followed by solid predominant (SPA), invasive mucinous (IMA), acinar predominant (APA), papillary predominant (PPA), lepidic predominant (LPA), minimally invasive adenocarcinoma (MIA), and adenocarcinoma in situ (AIS). When the subtypes were classified into three subgroups [group A, AIS+MIA+LPA (low risk); group B, APA+PPA+IMA (intermediate risk); and group C, SPA+MPP (high risk)] by expected postoperative prognoses, there were significant differences in SUVmax among the subgroups corresponding to recurrence risk (p=0.0001). CONCLUSION: Preoperative SUVmax was closely associated with both adenocarcinoma subtype and aggregated subgroups, reflecting malignant grade of the tumor and prognosis.

Pleuroperitoneal shunt for chylothorax and chylopericardium in lung cancer: a case report.

A 70-year-old man with T1N3M1 stage IV squamous cell carcinoma in the right upper lobe of the lung developed chylothorax and chylopericardium as rare simultaneous complications. Intravenous hyperalimentation, repeated pleurodesis, and ligation of the thoracic duct were all ineffective. A pleuroperitoneal shunt was inserted into the right pleural cavity from the fifth intercostal space, and a peritoneal catheter was placed in the abdominal cavity. Chylothorax was markedly improved, and the quality of life of the patient increased. This case indicates that a pleuroperitoneal shunt can be used for lung cancer-related chylothorax, as well as for malignant pleural effusion.