Bronchial resection margin length and clinical outcome in non-small cell lung cancer. Eur J Cardiothorac Surg. 2011;40:1151-1156. [PMID: 21450488 DOI: 10.1016/j.ejcts.2011.02.042]

An antiquated contraindication for minimally invasive lung surgery: No place to staple the bronchus

Background

This study aims to evaluate the feasibility and outcomes of lobectomy operations without using a stapler for bronchial closure.

Methods

Between December 2014 and August 2018, a total of 108 patients (72 males, 36 females; mean age 62.1±9.8 years; range, 19 to 83 years) with primary lung cancer who underwent lobar resection with robot-assisted thoracoscopic surgery were included in this study. Primary bronchial closure (n=7) and sleeve anastomosis (n=9) were performed in some cases. These 16 patients were compared with other lobectomy cases (n=92) who had bronchial stapling for bronchial closure.

Results

There was no statistically significant difference in the mean duration of operation, amount of intraoperative bleeding, length of postoperative stay in the hospital, and morbidity and readmission rates between the two groups (p=0.3, p=0.5, p=0.06, p=0.4, and p=0.63, respectively). No bronchial fistula developed in any of the patients.

Conclusion

Primary bronchial closure and sleeve anastomosis can be safely performed with robot-assisted thoracoscopic surgery without conversion to thoracotomy, or a larger assistance incision with a similar success rate of the stapled bronchus.

The status of immunosuppression in patients with stage IIIB or IV non-small-cell lung cancer correlates with the clinical characteristics and response to chemotherapy

BACKGROUND

Indoleamine 2,3-dioxygenase (IDO) catalyzes the rate-limiting step of tryptophan (Trp) degradation via the kynurenine (Kyn) pathway, which inhibits the proliferation of T cells and induces the apoptosis of T cells, leading to immune tolerance. Therefore, IDO has been considered as the most important mechanism for tumor cells to escape from immune response. Previous studies suggested that IDO might be involved in the progression of tumor and resistance to chemotherapy. Several preclinical and clinical studies have proven that IDO inhibitors can regulate IDO-mediated tumor immune escape and potentiate the effect of chemotherapy. Thus, the present study investigated the correlation between the clinical parameters, responses to chemotherapy, and IDO activity to provide a theoretical basis for the clinical application of IDO inhibitors to improve the suppression status and poor prognosis in cancer patients.

METHODS

The serum concentrations of Trp and Kyn were measured by high-performance liquid chromatography in 252 patients with stage IIIB or IV non-small-cell lung cancer, and 55 healthy controls. The IDO activity was determined by calculating the serum Kyn-to-Trp (Kyn/Trp) ratio.

RESULTS

The IDO activity was significantly higher in the lung cancer patients than in the controls (median 0.0389 interquartile range [0.0178-0.0741] vs 0.0111 [0.0091-0.0133], respectively; P<0.0001). In addition, patients with adenocarcinoma had higher IDO activity than patients with nonadenocarcinoma (0.0449 [0.0189-0.0779] vs 0.0245 [0.0155-0.0563], respectively; P=0.006). Furthermore, patients with stage IIIB disease had higher IDO activity than patients with stage IV disease (0.0225 [0.0158-0.0595] vs 0.0445 [0.0190-0.0757], respectively; P=0.012). The most meaningful discovery was that there was a significant difference between the partial response (PR) patients and the stable disease (SD) and progressive disease (PD) patients (0.0240 [0.0155-0.0381] vs 0.0652 [0.0390-0.0831] vs 0.0868 [0.0209-0.0993], respectively, P<0.0001).

CONCLUSION

IDO activity was increased in lung cancer patients. Higher IDO activity correlated with histological types and disease stages of lung cancer patients, induced the cancer cells' resistance to chemotherapy, and decreased the efficacy of chemotherapy.

Relationship between EGFR gene mutation and local metastasis of resectable lung adenocarcinoma

Background

Resectable lung adenocarcinoma is dominated by peripheral distribution, and surgical resection is the main treatment protocol. However, high recurrence rate remains after surgery. Lung adenocarcinoma with epidermal growth factor receptor (EGFR) mutation has strong invasion ability, but the effects of this mutation on local invasion in early lung adenocarcinoma have been rarely studied. This study aimed to assess the effects of EGFR mutation on local invasion in resectable lung adenocarcinoma.

Methods

A retrospective analysis of 103 patients clinically diagnosed with peripheral lung adenocarcinoma was included. They underwent preoperative bronchoscopy, which indicated grades 2 or 3 bronchial involvement (lumen of the lobe or segment). The associations of EGFR mutation with pleural invasion, endobronchial metastasis, and lymph node metastasis were analyzed according to pathologies of pleural invasion and lymph node metastasis, as well as EGFR gene mutation detected by postoperative pathological specimens. Statistical analyses were performed by unpaired Chi-square test using the SPSS16.0 software.

Results

In patients with EGFR mutation, pleural invasion, endobronchial metastasis, and lymph node metastasis rates were 62.5, 39.1, and 34.4%, respectively, indicating statistically significant differences (p = 0.003). Meanwhile, the pleural invasion rate in patients with wild-type EGFR was 43.6%, significantly reduced compared with patients with mutated EGFR (62.5%; p = 0.018). In addition, the endobronchial metastasis rate in patients with wild-type EGFR was 17.9%, significantly lower than in patients with EGFR mutation (39.1%; p = 0.005). However, lymph node metastasis rates were similar between EGFR mutated and wild-type patients (34.4 vs 25.6%, respectively, p > 0.05).

Conclusions

Early resectable lung adenocarcinoma patients with EGFR mutation showed a higher rate of local invasion compared with those harboring wild-type EGFR. This finding provides a basis for improved therapy.

Trial registration

This study was supported by Project of Medical and Health Science Technology in Shandong Province (2015WS0376)

Surgical strategies in the therapy of non-small cell lung cancer

Lung cancer represents the leading cause of cancer mortality worldwide. Despite improvements in preoperative staging, surgical techniques, neoadjuvant/adjuvant options and postoperative care, there are still major difficulties in significantly improving survival, especially in locally advanced non-small cell lung cancer (NSCLC). To date, surgical resection is the primary mode of treatment for stage I and II NSCLC and has become an important component of the multimodality therapy of even more advanced disease with a curative intention. In fact, in NSCLC patients with solitary distant metastases, surgical interventions have been discussed in the last years. Accordingly, this review displays the recent surgical strategies implemented in the therapy of NSCLC patients.

Lung cancer surgery: an up to date

According to the International Agency for Research on Cancer (IARC) GLOBOCAN World Cancer Report, lung cancer affects more than 1 million people a year worldwide. In Greece according to the 2008 GLOBOCAN report, there were 6,667 cases recorded, 18% of the total incidence of all cancers in the population. Furthermore, there were 6,402 deaths due to lung cancer, 23.5% of all deaths due to cancer. Therefore, in our country, lung cancer is the most common and deadly form of cancer for the male population. The most important prognostic indicator in lung cancer is the extent of disease. The Union Internationale Contre le Cancer (UICC) and the American Joint Committee for Cancer Staging (AJCC) developed the tumour, node, and metastases (TNM) staging system which attempts to define those patients who might be suitable for radical surgery or radical radiotherapy, from the majority, who will only be suitable for palliative measures. Surgery has an important part for the therapy of patients with lung cancer. "Lobectomy is the gold standard treatment". This statement may be challenged in cases of stage Ia cancer or in patients with limited pulmonary function. In these cases an anatomical segmentectomy with lymph node dissection is an acceptable alternative. Chest wall invasion is not a contraindication to resection. En-bloc rib resection and reconstruction is the treatment of choice. N2 disease represents both a spectrum of disease and the interface between surgical and non-surgical treatment of lung cancer Evidence from trials suggests that multizone or unresectable N2 disease should be treated primarily by chemoradiotherapy. There may be a role for surgery if N2 is downstaged to N0 and lobectomy is possible, but pneumonectomy is avoidable. Small cell lung cancer (SCLC) is considered a systemic disease at diagnosis, because the potential for hematogenous and lymphogenic metastases is very high. The efficacy of surgical intervention for SCLC is not clear. Lung cancer resection can be performed using several surgical techniques. Video-assisted thoracoscopic surgery (VATS) lobectomy is a safe, efficient, well accepted and widespread technique among thoracic surgeons. The 5-year survival rate following complete resection of lung cancer is stage dependent. Incomplete resection rarely is useful and cures the patient.

Adjuvant chemotherapy and radiotherapy in the treatment of non-small cell lung cancer (NSCLC)

Lung cancer is one of the most common human malignancies and remains the leading cause of cancer related deaths worldwide. Many recent technological advances led to improved diagnostics and staging of lung cancer. With development of new treatment options such as targeted therapies there might be improvement in progression free survival of patients with advanced stage non-small cell lung cancer (NSCLC). Improvement in overall survival is still reserved for selected patients and selected treatments. One of the mostly investigated therapeutic options is adjuvant treatment. There are many open issues in selection of patients and administration of appropriate adjuvant treatment.

Serum kynurenic acid: possible association with invasiveness of non-small cell lung cancer

The lung adenocarcinoma is considered more aggressive than other types of non-small cell lung cancer. As metabolites of tryptophan degradation along the kynurenine pathway, including kynurenic acid, have been shown to induce immunosuppression and facilitate escape of tumor cells from immune surveillance, a hypothesis was set up that differences in biological behavior between types of lung cancer may be associated with altered activity of the kynurenine metabolic pathway. The aim of the study was to determine kynurenic acid levels in the serum of patients with bronchial adenocarcinoma for comparison with other types of non-small cell lung cancer. A total of 227 patients with non-small cell lung cancer were enrolled in the study, including 71 with adenocarcinoma and 96 with squamous cell carcinoma. Serum kynurenic acid concentration was determined with use of high performance liquid chromatography and fluorometry. The level of kynurenic acid in the serum of patients with adenocarcinoma was significantly higher than in those with squamous cell lung cancer (107.1 ± 62.8 pmol/ml; 95%CI: 92.4 to 132.3 pmol/ml versus 82.1 ± 47.6 pmol/ml; 95%CI: 78.5 to 91.2 pmol/ml, respectively; p = 0.027). Differences between other histological types of lung cancer were insignificant. We conclude that increased activity of kynurenine metabolic pathway manifested by elevated serum kynurenic acid level may be one of the factors associated with clinically distinct biological behavior of adenocarcinoma, in particular high invasiveness and rapid progression.

Surgical treatment of non-small-cell lung cancer in octogenarians

Reluctance to recommend lung cancer surgery for octogenarians is partly based on the expectation that the rate of complications and mortality is higher in this group of patients, and on the impression that the life expectancy of an octogenarian with lung cancer is limited by death from natural causes. Moreover, the belief that radiation therapy and observation yield similar results to surgery in early-stage disease have influenced low resection rates in this population. Nevertheless, advances in surgical techniques, anaesthesia and postoperative care have made surgical lung resection a safer procedure than it was in the past. Judging from the more recent findings, surgery should not be withheld because of postoperative mortality, but suboptimal or palliative treatment may be necessary in patients with poor physical or mental function. To enable informed decision-making, both patients and clinicians need information on the risks of surgical treatment. In this review, available information from the literature was collected in an effort to understand the real benefit of surgical treatment in octogenarians with non-small-cell lung cancer, and to determine what should be done or avoided during the selection course.

Postoperative radiation therapy for non-small cell lung cancer and thymic malignancies

For many thoracic malignancies, surgery, when feasible, is the preferred upfront modality for local control. However, adjuvant radiation plays an important role in minimizing the risk of locoregional recurrence. Tumors in the thoracic category include certain subgroups of non-small cell lung cancer (NSCLC) as well as thymic malignancies. The indications, radiation doses, and treatment fields vary amongst subtypes of thoracic tumors, as does the level of data supporting the use of radiation. For example, in the setting of NSCLC, postoperative radiation is typically reserved for close/positive margins or N2/N3 disease, although such diseases as superior sulcus tumors present unique cases in which the role of neoadjuvant vs. adjuvant treatment is still being elucidated. In contrast, for thymic malignancies, postoperative radiation therapy is often used for initially resected Masaoka stage III or higher disease, with its use for stage II disease remaining controversial. This review provides an overview of postoperative radiation therapy for thoracic tumors, with a separate focus on superior sulcus tumors and thymoma, including a discussion of acceptable radiation approaches and an assessment of the current controversies involved in its use.