Patient-related independent clinical risk factors for early complications following Nd: YAG laser resection of lung cancer

INTRODUCTION

Neodymium:yttrium aluminum garnet (Nd:YAG) laser resection is one of the most established interventional pulmonology techniques for immediate debulking of malignant central airway obstruction (CAO). The major aim of this study was to investigate the complication rate and identify clinical risk factors for complications in patients with advanced lung cancer.

METHODS

In the period from January 2006 to January 2011, data sufficient for analysis were identified in 464 patients. Nd:YAG laser resection due to malignant CAO was performed in all patients. The procedure was carried out in general anesthesia. Complications after laser resection were defined as severe hypoxemia, global respiratory failure, arrhythmia requiring treatment, hemoptysis, pneumothorax, pneumomediastinum, pulmonary edema, tracheoesophageal fistulae, and death. Risk factors were defined as acute myocardial infarction within 6 months before treatment, hypertension, chronic arrhythmia, chronic obstructive pulmonary disease (COPD), stabilized cardiomyopathy, previous external beam radiotherapy, previous chemotherapy, and previous interventional pulmonology treatment.

RESULTS

There was 76.1% male and 23.9% female patients in the study, 76.5% were current smokers, 17.2% former smokers, and 6.3% of nonsmokers. The majority of patients had squamous cell lung cancer (70%), small cell lung cancer was identified in 18.3%, adenocarcinoma in 3.4%, and metastases from lung primary in 8.2%. The overall complication rate was 8.4%. Statistically significant risk factors were age (P = 0.001), current smoking status (P = 0.012), arterial hypertension (P < 0.0001), chronic arrhythmia (P = 0.034), COPD (P < 0.0001), and stabilized cardiomyopathy (P < 0.0001). Independent clinical risk factors were age over 60 years (P = 0.026), arterial hypertension (P < 0.0001), and COPD (P < 0.0001).

CONCLUSION

Closer monitoring of patients with identified risk factors is advisable prior and immediately after laser resection. In order to avoid or minimize complications, special attention should be directed toward patients who are current smokers, over 60 years of age, with arterial hypertension or COPD.

The sarcoid granuloma: ‘epithelioid’ or ‘lymphocytic-epithelioid’ granuloma?

Background: This study aims to analyze the structure and quantities of cellular elements in sarcoid granulomas. Methods: We investigated 34 transbronchial lung biopsy samples obtained from 34 sarcoid patients. The quantity and composition of the cellular elements inside a granuloma were determined by the quantitative stereometry method, employing the numerical density as a stereological method. Results: A total of 102 sarcoid granulomas were analyzed. The central part of all granulomas was occupied by epithelioid cells. Besides these, giant cells, lymphocytes, macrophages and plasma cells were also seen. The mean numerical density of all the cells in the central part of a sarcoid granuloma was 111,751 mm-3. Lymphocytes prevailed in number, exceeding the total count of all other cells. With a mean numerical density of 74,321 mm-3, lymphocytes were twice as numerous as both epithelioid cells and macrophages with a mean numerical density of 37,193 mm-3. Conclusions: Lymphocytes are the predominant cell type in the central part of a sarcoid granuloma, significantly exceeding both epithelioid cells and macrophages in number, raising the question if the term “epithelioid granuloma”, routinely used to designate sarcoid granulomas, is correct, or if it would be more logical to call them “lymphocytic-epithelioid granulomas” instead. Trial registration: This study was supported by the Serbian Ministry of Science and Environmental Protection Grant Number 175006/2011.

The sarcoid granuloma: 'epithelioid' or 'lymphocytic-epithelioid' granuloma?

Background

This study aims to analyze the structure and quantities of cellular elements in sarcoid granulomas.

Methods

We investigated 34 transbronchial lung biopsy samples obtained from 34 sarcoid patients. The quantity and composition of the cellular elements inside a granuloma were determined by the quantitative stereometry method, employing the numerical density as a stereological method.

Results

A total of 102 sarcoid granulomas were analyzed. The central part of all granulomas was occupied by epithelioid cells. Besides these, giant cells, lymphocytes, macrophages and plasma cells were also seen. The mean numerical density of all the cells in the central part of a sarcoid granuloma was 111,751 mm^-3. Lymphocytes prevailed in number, exceeding the total count of all other cells. With a mean numerical density of 74,321 mm^-3, lymphocytes were twice as numerous as both epithelioid cells and macrophages with a mean numerical density of 37,193 mm^-3.

Conclusions

Lymphocytes are the predominant cell type in the central part of a sarcoid granuloma, significantly exceeding both epithelioid cells and macrophages in number, raising the question if the term “epithelioid granuloma”, routinely used to designate sarcoid granulomas, is correct, or if it would be more logical to call them “lymphocytic-epithelioid granulomas” instead.

Trial registration

This study was supported by the Serbian Ministry of Science and Environmental Protection Grant Number 175006/2011.

Autofluorescence imaging videobronchoscopy in the detection of lung cancer: from research tool to everyday procedure

Autofluorescence imaging videobronchoscopy (AFI) is one of the new systems of autofluorescence bronchoscopy designed for thorough examination of bronchial mucosa. The integration of autofluorescence and videobronchoscopy provides clear images of normal and pathologically altered bronchial mucosa. Major indications for AFI include evaluation of early-stage lung cancer and detection of precancerous lesions. However, in recent years, the indications for AFI are widening, and this tool might find its place in routine daily bronchoscopic practice. With new indications for AFI, such as evaluation of tumor extension or follow-up after surgical resection, this tool might be more often used by bronchoscopists. A sharp learning curve and clear distinction between healthy and pathologically altered mucosa make this technology acceptable for young and inexperienced bronchoscopists. One of the major disadvantages of AFI is low specificity in the detection of premalignant lesions and early-stage lung cancer. This disadvantage could be overcome with the appearance of new and improved technologies in autofluorescence, such as the addition of backscattered light analysis, ultraviolet spectra, fluorescence-reflectance or dual digital systems. Quantitative image analysis is also one of the ways to improve objectivity and minimize observer errors. However, one of the most appropriate solutions would be the addition of AFI to narrow band imaging, and merging the two technologies into one videobronchoscope.

Clinical trials in advanced stage lung cancer: a survey of patients' opinion about their treatment

BACKGROUND

The major aim of this study was to investigate what patients with advanced stage lung cancer, enrolled in a clinical trial, thought about their treatment. We also wanted to investigate if there exist any characteristics that could influence patients' opinion about the clinical trial.

PATIENTS AND METHODS

Over the period from June 2008 to June 2009, 59 eligible patients were enrolled in this study. The major inclusion criteria were: participation in a clinical trial, previously treated advanced stage lung cancer, and good performance status (ECOG 0-2). All patients were asked to answer a questionnaire designed to investigate their impressions about participation in a clinical trial. The questionnaire was deposited in a sealed box which was opened at the end of the study.We investigated a possible influence of age, gender, education, lung cancer stage, chemotherapy line and tumor type on the patients' opinion about some aspects of the clinical trial.

RESULTS

The majority of the patients were aware they were participating in the clinical trial and a significant number of them were very satisfied with the treatment. Of the investigated factors, only the level of education had a statistically significant influence on some of the questions raised in the questionnaire.

CONCLUSIONS

Patients participating in clinical trials are satisfied with their treatment, ready to proceed with it and would recommend it to other patients. It depends mainly on health professionals to maintain this level of confidence and justify their trust.

Clinical trials in advanced stage lung cancer: a survey of patients’ opinion about their treatment

Background: The major aim of this study was to investigate what patients with advanced stage lung cancer, enrolled in a clinical trial, thought about their treatment. We also wanted to investigate if there exist any characteristics that could influence patients’ opinion about the clinical trial. Patients and methods: Over the period from June 2008 to June 2009, 59 eligible patients were enrolled in this study. The major inclusion criteria were: participation in a clinical trial, previously treated advanced stage lung cancer, and good per- formance status (ECOG 0-2). All patients were asked to answer a questionnaire designed to investigate their impres- sions about participation in a clinical trial. The questionnaire was deposited in a sealed box which was opened at the end of the study. We investigated a possible influence of age, gender, education, lung cancer stage, chemotherapy line and tumor type on the patients' opinion about some aspects of the clinical trial. Results: The majority of the patients were aware they were participating in the clinical trial and a significant number of them were very satisfied with the treatment. Of the investi- gated factors, only the level of education had a statistically significant influence on some of the questions raised in the questionnaire. Conclusions: Patients participating in clinical trials are satis- fied with their treatment, ready to proceed with it and would recommend it to other patients. It depends mainly on health professionals to maintain this level of confidence and justify their trust.

Clinical prognostic factors and outcome of surgical treatment in patients with early-stage bronchial carcinoid tumors

PURPOSE

Surgical resection is the treatment of choice for bronchial carcinoids (BC). The primary endpoint of this study was to look at the survival of patients with BC after the surgical treatment and to identify some clinicopathological prognostic factors influencing survival.

METHODS

The analysis included 57 patients with early- stage BC submitted to surgical treatment in the period 2000-2008. Major inclusion criteria were: pathologically confirmed BC, ECOG performance status 0-2, and surgical resection of the tumor.

RESULTS

No significant difference in survival in relation to gender was registered. N0, N1 and N2 status was registered in 39, 9 and 2 patients, respectively. There were statistically significant differences in survival according to N status (p=0.032). Twenty-two patients had T1N0 stage, 21 T2N0, and 4 T1N1. There was a trend for significant differences in survival according to TN stage (p=0.063). Also, analysis revealed significant differences in survival depending on tumor size (p=0.000), as well as on the type of the tumor (typical vs. atypical) (p=0.010).

CONCLUSION

Nodal status and TN stage affect patients' survival. Tumor size and typical/atypical tumor are also significant prognostic factors for survival of surgically treated patients.

Narrow band imaging videobronchoscopy improves assessment of lung cancer extension and influences therapeutic strategy

OBJECTIVE

Narrow band imaging (NBI) videobronchoscopy is a new technique aimed at lung cancer detection. This study investigated its sensitivity and specificity for evaluation of lung cancer extension and its possible influence on therapeutic decision, compared with white light videobronchoscopy.

METHODS

In this prospective study, we evaluated 106 patients with suspected lung cancer. All patients were examined using EVIS LUCERA videoendoscopy system. In every patient, at least three biopsies were taken from places visualized as pathologic, surrounding primary tumor, and three biopsies from places that appeared normal. The overall number of biopsies performed in 106 patients was 636.

RESULTS

The specificity and sensitivity of NBI in revealing greater lung cancer extension were 85.6% and 95%, respectively; positive and negative predictive values were 84% and 95.6%, respectively. Specificity and sensitivity were significantly better when compared with white light bronchoscopy alone (P < 0.01). NBI led to the change in therapeutic decision in 14 patients. There was statistically significant correlation between NBI assessment of tumor extension and change in therapeutic decision (P < 0.000).

CONCLUSIONS

NBI showed significantly better specificity and sensitivity in the assessment of lung cancer extension. NBI proved that it might have potential influence on therapeutic decision, making it more accurate. The procedure is safe and easily deployed in everyday practice.

Autofluorescence videobronchoscopy (AFI) for the assessment of tumor extension in lung cancer

The major objective of our study was to determine the specificity and sensitivity of AFI videobronchoscopy vs. white light videobronchoscopy, in the assessment of lung cancer extent. Secondary objective was to investigate whether or not AFI can reveal greater extension of the tumor, and can it influence therapy making decision. Autofluorescence videobronchoscopy systems are new technology for visualization of bronchial mucosa, and the proper indications for such systems will be determined in the near future. In this prospective trial we have enrolled 27 patients with suspected lung cancer in whom we performed 108 diagnostic biopsies and 54 control biopsies. All patients underwent WL videobronchoscopy followed by Auto Fluorescence Imaging (AFI) examination of tracheobronchial tree. We were using videobronchoscope BF-F260 and EVIS LUCERA SPECTRUM processor unit. Overall specificity for AFI in the diagnostics of lung cancer was found to be 85%, sensitivity was 90%, positive predictive value (PPV) 78%, and negative predictive value (NPV) 94%. Specificity, sensitivity, PPV, and NPV for WL videobronchoscopy in lung cancer diagnostics were 54%, 64%, 51%, and 69%, respectively. Relative sensitivity ratio of AFI over WL videobronchoscopy, which is calculated to be 1.41, confirmed superiority of AFI in lung cancer diagnostics. We confirmed significant correlation between the greater extension of the tumor (assessed with AFI) and the therapeutical decision in lung cancer treatment (p = 0.01). Influence of AFI on therapeutical decision was significant (p = 0.034). AFI videobronchoscopy system yields significantly higher sensitivity and specificity for the assessment of lung cancer extent than WLB videobronchoscopy alone. It had shown to be able to influence therapeutic option for lung cancer treatment. Further studies are needed to evaluate and validate these results.

Aprepitant--where do we stand in the control of chemotherapy-induced nausea and vomiting?

Despite progress in the area of supportive care in oncology in the last two decades, nausea and vomiting continue to be significant side effects of cancer therapy. These symptoms can escalate over time and can result in patients' refusal to continue with chemotherapy. Introduction of serotonin (5-HT3) receptor antagonists was a major therapeutic advance in the treatment of chemotherapy-induced nausea and vomiting with enhanced efficacy when corticosteroids were added. However, these agents have limited protection in the acute phase of chemotherapy-induced nausea and vomiting with little or no effect over the delayed phase. The aim of this review was to introduce a new class of antiemetics, a selective high-affinity antagonist at human substance P neurokinin 1 (NK(1)) receptors-aprepitant. Its pharmacological characteristics as well as its efficacy are reviewed. Aprepitant appears to be well tolerated but, due to its inhibitory effect on cytochrome P450 isoenzyme 3A4, it can lead to significant drug interactions, resulting in need for dose modification of concomitant therapy. The addition of aprepitant to 5-HT(3) receptor antagonists and corticosteroids was found to be superior to the combination of 5-HT(3) receptor antagonists and corticosteroids alone in patients treated with highly and moderately emetogenic chemotherapy. Clinical trials with aprepitant and other antiemetic agents are warranted to determine a regimen that will ensure complete protection from both acute and delayed chemotherapy-induced nausea and vomiting, thus contributing to improved supportive care and patients' quality of life (QoL).

The effect of Nd:YAG laser resection on symptom control, time to progression and survival in lung cancer patients

PURPOSE

The aim of this study was to determine the effect of Nd:YAG laser resection of centrally located tumors on the control of various symptoms and signs, time to progression and survival in lung cancer patients.

PATIENTS AND METHODS

We evaluated the effects of Nd: YAG laser resection in combination with high-dose rate (HDR) brachytherapy and external beam radiotherapy (EBRT) vs. combination of HDR brachytherapy and EBRT alone on lung cancer symptoms and signs, ECOG performance status, time to progression and overall survival in lung cancer patients. Patients in group I (n=81) were treated with combination of HDR brachytherapy and EBRT, while patients in group II (n=97) were treated with Nd:YAG laser in combination with HDR brachytherapy and EBRT. Patients were evaluated before and after treatment, and were followed-up regularly every 3 months until the end of life. After RT +/- laser treatment all patients received standard chemotherapy (cisplatin plus etoposide) during the course of disease.

RESULTS

After treatment in both groups significant improvement in all investigated parameters was seen. Improvement in dyspnoea, thoracic pain, body weight loss and ECOG performance status was significantly better in group II (p <0.05), as were time to progression and overall survival (p <0.05).

CONCLUSION

Laser resection improves symptom control in lung cancer patients with central airway obstruction (CAO). Longer time to progression and survival of lung cancer patients could be the result of imminent airway desobstruction accomplished with Nd:YAG laser.

Clinical presentation, treatment options and outcome in patients with bronchioloalveolar carcinoma

PURPOSE

To determine the characteristics of bronchioloalveolar carcinoma (BAC) as a special clinical and pathological entity and to evaluate the effects of treatment options on survival of BAC patients.

PATIENTS AND METHODS

The study was partially retrospective and partially prospective, non randomized. We evaluated the clinical presentation, smoking habits, radiographic findings, treatment and survival of 21 patients with BAC treated at our Institute from 2000-2004.

RESULTS

Registered were 16 (76.2%) male and 5 (23.8%) female patients, most of them in the 6th and 7th decade of life. Among younger patients females prevailed. Most common symptoms were dyspnoea 15 (71.4%), cough 14 (66.6%) and bronchial hypersecretion 9 (42.8%). There were 5 (23.8%) smokers, 6 (28.6%) ex-smokers and 10 (47.6%) nonsmokers. Main radiographic findings were lung consolidation (9; 42.8%), diffuse interstitial infiltrates (6; 28.6%), solitary (4; 19.0%) and multiple pulmonary lesions (2; 9.5%). Surgery was performed in 8 (38.0%) patients and 5 of them received adjuvant radio- and chemotherapy, while the remaining received chemotherapy alone (9; 42.8%) and symptomatic treatment (4; 19.0%). The median survival was 25 months and 1-year survival 70%, regardless of stage. In the group of patients treated surgically 1- and 2-year survival rate was 100% and the median survival 33 months. In non-operated patients the median survival was 18 months and 1- and 2-year survival 55% and 25%, respectively.

CONCLUSION

BAC is a special clinical and pathological form of adenocarcinoma of the lung. Surgical treatment is the best option for selected BAC patients. Survival is associated with the treatment modality. Larger scale studies are necessary to confirm these findings.

The influence of dexamethasone in the decrease of chemotherapy-induced nausea and vomiting

PURPOSE

The aim of this study was to determine the influence of dexamethasone in the decrease of cisplatin and etoposide-induced nausea and vomiting in patients treated for lung cancer during and after 2 chemotherapy cycles.

PATIENTS AND METHODS

The analysis included 60 patients with histologically proven lung cancer, who were divided in two groups. Group A consisted of 30 patients who received cisplatin and etoposide with standard antiemetic drugs: ondansetron [serotonin receptor antagonist (5-HT(3) antagonist)] and metoclopramide (dopamine receptor antagonist). Group B consisted of 30 patients who received the same chemotherapy regimen with the previous antiemetic therapy plus dexamethasone 8 mg intravenously (i.v.) per day during the 3 days of chemotherapy. During and after the 3-day therapy, patients filled in a questionnaire issuing adverse effects of chemotherapy concerning many symptoms including nausea and vomiting. The results were statistically processed.

RESULTS

There was a significant decrease in the frequency and toxicity of nausea, acute and delayed vomiting in the group of patients who received antiemetic treatment with ondansetron, metoclopramide plus dexamethasone.

CONCLUSION

Dexamethasone administered with 5-HT(3) antagonists and dopamine receptor antagonists significantly decreases the chemotherapy-induced nausea and vomiting.