Is palpation of the nonresected pulmonary lobe(s) required for patients with non-small cell lung cancer? A prospective study

Efficacy of Near-Infrared Fluorescence Video-Assisted Thoracoscopic Surgery for Small Pulmonary Nodule Resection with Indocyanine Green Inhalation: A Randomized Clinical Trial

BACKGROUND

Small pulmonary nodules (<3 cm) can sometimes be unrecognizable and nonpalpable in video-assisted thoracoscopic surgery (VATS). Near-infrared fluorescence (NIF) VATS after indocyanine green (ICG) inhalation may effectively guide surgeons to locate the nodules.

OBJECTIVE

This study aimed to investigate the safety, feasibility, and efficacy of ICG inhalation-based NIF imaging for guiding small pulmonary nodule resections.

METHODS

Between February and May 2021, the first-stage, non-randomized trial enrolled 21 patients with different nodule depth, ICG inhalation doses, post-inhalation surgery times, and nodule types at a tertiary referral hospital. Between May 2021 and May 2022, the second-stage randomized trial enrolled 56 patients, who were randomly assigned to the fluorescence VATS (FLVATS) or the white-light VATS (WLVATS) group. The ratio of effective guidance and the time consumption for nodule localization were compared.

RESULTS

The first-stage trial proved this new method is safe and feasible, and established a standardized protocol with optimized nodule depth (≤1 cm), ICG dose (0.20-0.25 mg/kg), and surgery window (50-90 min after ICG inhalation). In the second-stage trial, the FLVATS achieved 87.1% helpful nodule localization guidance, which was significantly higher than the WLVATS (59.1%, p < 0.05). The mean nodule locating time (standard deviation) was 1.8 [0.9] and 3.3 [2.3] min, respectively. Surgeons adopting FLVATS were significantly faster (p < 0.01), especially when locating small ground-glass opacities (1.3 [0.6] min vs. 7.0 [3.5] min, p < 0.05). Five of 31 nodules (16.1%) were only detectable by FLVATS, whereas both white light and palpation failed.

CONCLUSIONS

This new method is safe and feasible for small pulmonary nodule resection. It significantly improves nodule localization rates with less time consumption, and hence is highly worthy for clinical promotion. Clinical Trial Registration Chinese Clinical Trial Registry Identifier: ChiCTR2100047326.

Data-Driven Identification of Targets for Fluorescence-Guided Surgery in Non-Small Cell Lung Cancer

PURPOSE

Intraoperative identification of lung tumors can be challenging. Tumor-targeted fluorescence-guided surgery can provide surgeons with a tool for real-time intraoperative tumor detection. This study evaluated cell surface biomarkers, partially selected via data-driven selection software, as potential targets for fluorescence-guided surgery in non-small cell lung cancers: adenocarcinomas (ADC), adenocarcinomas in situ (AIS), and squamous cell carcinomas (SCC).

PROCEDURES

Formalin-fixed paraffin-embedded tissue slides of resection specimens from 15 patients with ADC and 15 patients with SCC were used and compared to healthy tissue. Molecular targets were selected based on two strategies: (1) a data-driven selection using > 275 multi-omics databases, literature, and experimental evidence; and (2) the availability of a fluorescent targeting ligand in advanced stages of clinical development. The selected targets were carbonic anhydrase 9 (CAIX), collagen type XVII alpha 1 chain (collagen XVII), glucose transporter 1 (GLUT1), G protein-coupled receptor 87 (GPR87), transmembrane protease serine 4 (TMPRSS4), carcinoembryonic antigen (CEA), epithelial cell adhesion molecule (EpCAM), folate receptor alpha (FRα), integrin αvβ6 (αvβ6), and urokinase-type plasminogen activator receptor (uPAR). Tumor expression of these targets was assessed by immunohistochemical staining. A total immunostaining score (TIS, range 0-12), combining the percentage and intensity of stained cells, was calculated. The most promising targets in ADC were explored in six AIS tissue slides to explore its potential in non-palpable lesions.

RESULTS

Statistically significant differences in TIS between healthy lung and tumor tissue for ADC samples were found for CEA, EpCAM, FRα, αvβ6, CAIX, collagen XVII, GLUT-1, and TMPRSS4, and of these, CEA, CAIX, and collagen XVII were also found in AIS. For SCC, EpCAM, uPAR, CAIX, collagen XVII, and GLUT-1 were found to be overexpressed.

CONCLUSIONS

EpCAM, CAIX, and Collagen XVII were identified using concomitant use of data-driven selection software and clinical evidence as promising targets for intraoperative fluorescence imaging for both major subtypes of non-small cell lung carcinomas.

Intraoperative Tumor Detection Using Pafolacianine

Cancer is a leading cause of death worldwide, with increasing numbers of new cases each year. For the vast majority of cancer patients, surgery is the most effective procedure for the complete removal of the malignant tissue. However, relapse due to the incomplete resection of the tumor occurs very often, as the surgeon must rely primarily on visual and tactile feedback. Intraoperative near-infrared imaging with pafolacianine is a newly developed technology designed for cancer detection during surgery, which has been proven to show excellent results in terms of safety and efficacy. Therefore, pafolacianine was approved by the U.S. Food and Drug Administration (FDA) on 29 November 2021, as an additional approach that can be used to identify malignant lesions and to ensure the total resection of the tumors in ovarian cancer patients. Currently, various studies have demonstrated the positive effects of pafolacianine’s use in a wide variety of other malignancies, with promising results expected in further research. This review focuses on the applications of the FDA-approved pafolacianine for the accurate intraoperative detection of malignant tissues. The cancer-targeting fluorescent ligands can shift the paradigm of surgical oncology by enabling the visualization of cancer lesions that are difficult to detect by inspection or palpation. The enhanced detection and removal of hard-to-detect cancer tissues during surgery will lead to remarkable outcomes for cancer patients and society, specifically by decreasing the cancer relapse rate, increasing the life expectancy and quality of life, and decreasing future rates of hospitalization, interventions, and costs.

Localization of subcentimeter pulmonary nodules using an indocyanine green near-infrared imaging system during uniportal video-assisted thoracoscopic surgery

BACKGROUND

To investigate the feasibility of indocyanine green (ICG) use in localizing subcentimeter pulmonary nodules during uniportal video-assisted thoracoscopic surgery.

METHODS

This study was a retrospective analysis of 32 patients who underwent surgery due to pulmonary nodules using ICG localization from September 2019 to March 2020 in the Department of Thoracic Surgery, The Fourth Affiliated Hospital of China Medical University. Laser positioning and large-aperture spiral CT simulation were performed preoperatively. ICG was injected into the lung (2.5 mg/ml). The clinical characteristics and postoperative indicators were recorded.

RESULTS

A total of 33 subcentimeter pulmonary nodules were successfully localized in 32 patients. Twenty-three patients underwent lobectomy, with an average surgical time of 45.3 min and an average tube retention time of 2 days. Non-small cell lung cancer was confirmed intraoperatively in 9 patients, among whom the longest surgical time was 120 min, and the shortest hospital stay was 7 days. No patient was converted to thoracotomy or developed serious complications.

CONCLUSIONS

ICG imaging is a safe and effective technique for localization of pulmonary nodules. Due to the widespread application of near-infrared devices, fluorescent localization and imaging technology will be more widely used in thoracic surgery.

Intraoperative fluorescence imaging in thoracic surgery

Intraoperative fluorescence imaging (IFI) can improve real-time identification of cancer cells during an operation. Phase I clinical trials in thoracic surgery have demonstrated that IFI with second window indocyanine green (TumorGlow^® ) can identify subcentimeter pulmonary nodules, anterior mediastinal masses, and mesothelioma, while the use of a folate receptor-targeted near-infrared agent, OTL38, can improve the specificity for diagnosing tumors with folate receptor expression. Here, we review the existing preclinical and clinical data on IFI in thoracic surgery.

The feasibility of electromagnetic navigational bronchoscopic localization with fluorescence and radiocontrast dyes for video-assisted thoracoscopic surgery resection

Recently, some groups have reported the utilization of electromagnetic navigational bronchoscopy (ENB) for localization of pulmonary lesion. Its application for intraoperative visual localization with dyes to determine the target area has been increasing. In this paper, we reviewed the feasibility of ENB utilization for video-assisted thoracoscopic surgery (VATS) or robotic sublobar resection as a localization tool, and its future application in minimally invasive thoracic surgery.

An open label trial of folate receptor-targeted intraoperative molecular imaging to localize pulmonary squamous cell carcinomas

BACKGROUND

Clinical applicability of folate receptor-targeted intraoperative molecular imaging (FR-IMI) has been established for surgically resectable pulmonary adenocarcinoma. A role for FR-IMI in other lung cancer histologies has not been studied. In this study, we evaluate feasibility of FR-IMI in patients undergoing pulmonary resection for squamous cell carcinomas (SCCs).

METHODS

In a human clinical trial (NCT02602119), twelve subjects with pulmonary SCCs underwent FR-IMI with a near-infrared contrast agent that targets the folate receptor-α (FRα), OTL38. Near-infrared signal from tumors and benign lung was quantified to calculate tumor-to-background ratios (TBR). Folate receptor-alpha expression was characterized, and histopathologic correlative analyses were performed to evaluate patterns of OTL38 accumulation. An exploratory analysis was performed to determine patient and histopathologic variables that predict tumor fluorescence.

RESULTS

9 of 13 SCCs (in 9 of 12 of subjects) displayed intraoperative fluorescence upon NIR evaluation (median TBR, 3.9). OTL38 accumulated within SCCs in a FRα-dependent manner. FR-IMI was reliable in localizing nodules as small as 1.1 cm, and prevented conversion to thoracotomy for nodule localization in three subjects. Upon evaluation of patient and histopathologic variables, in situ fluorescence was associated with distance from the pleural surface, and was independent of alternative variables including tumor size and metabolic activity.

CONCLUSIONS

This work demonstrates that FR-IMI is potentially feasible in 70% of SCC patients, and that molecular imaging can improve localization during minimally invasive pulmonary resection. These findings complement previous data demonstrating that ∼98% of pulmonary adenocarcinomas are localized during FR-IMI and suggest broad applicability for NSCLC patients undergoing resection.

A Phase I Clinical Trial of Targeted Intraoperative Molecular Imaging for Pulmonary Adenocarcinomas

BACKGROUND

Intraoperative identification of pulmonary nodules, particularly small lesions, can be challenging. We hypothesize that folate receptor-targeted intraoperative molecular imagining can be safe and improve localization of pulmonary nodules during resection.

METHODS

Twenty subjects with biopsy-proven pulmonary adenocarcinomas were enrolled in a phase I clinical trial to test the safety and feasibility of OTL38, a novel folate receptor-α (FRα) targeted optical contrast agent. During resection, tumors were imaged in situ and ex vivo and fluorescence was quantified. Resected specimens were analyzed to confirm diagnosis, and immunohistochemistry was utilized to quantify FRα expression. A multivariate analysis using clinical and tumor data was performed to determine variables impacting tumor fluorescence.

RESULTS

Of the 20 subjects, three grade I adverse events were observed: all transient nausea/abdominal pain. All symptoms resolved after completing the infusion. Sixteen of 20 subjects (80%) had tumors with in situ fluorescence with a mean tumor-to-background fluorescence level of 2.9 (interquartile range, 2.1 to 4.2). The remaining 4 subjects' tumors fluoresced ex vivo. In situ fluorescence was dependent on depth from the pleural surface. Four subcentimeter nodules not identified on preoperative imaging were detected with intraoperative imaging.

CONCLUSIONS

This phase I trial provides preliminary evidence suggesting that folate receptor-targeted molecular imaging with OTL38 is safe, with tolerable grade I toxicity. These data also suggest that OTL38 accumulates in known lung cancers and may improve identification of synchronous malignancies. Our group is initiating a five-center, phase II study to better understand the clinical implications of intraoperative molecular imaging using OTL38.

Identification of a Folate Receptor-Targeted Near-Infrared Molecular Contrast Agent to Localize Pulmonary Adenocarcinomas

Non-small cell lung cancer (NSCLC) is the number one cancer killer in the United States. Despite attempted curative surgical resection, nearly 40% of patients succumb to recurrent disease. High recurrence rates may be partially explained by data suggesting that 20% of NSCLC patients harbor synchronous disease that is missed during resection. In this report, we describe the use of a novel folate receptor-targeted near-infrared contrast agent (OTL38) to improve the intraoperative localization of NSCLC during pulmonary resection. Using optical phantoms, fluorescent imaging with OTL38 was associated with less autofluorescence and greater depth of detection compared to traditional optical contrast agents. Next, in in vitro and in vivo NSCLC models, OTL38 reliably localized NSCLC models in a folate receptor-dependent manner. Before testing intraoperative molecular imaging with OTL38 in humans, folate receptor-alpha expression was confirmed to be present in 86% of pulmonary adenocarcinomas upon histopathologic review of 100 human pulmonary resection specimens. Lastly, in a human feasibility study, intraoperative molecular imaging with OTL38 accurately identified 100% of pulmonary adenocarcinomas and allowed for identification of additional subcentimeter neoplastic processes in 30% of subjects. This technology may enhance the surgeon's ability to identify NSCLC during oncologic resection and potentially improve long-term outcomes.

Intraoperative molecular imaging to identify lung adenocarcinomas

Intraoperative molecular imaging is a promising new technology with numerous applications in lung cancer surgery. Accurate identification of small nodules and assessment of tumor margins are two challenges in pulmonary resections for cancer, particularly with increasing use of video-assisted thoracoscopic surgery (VATS). One potential solution to these problems is intraoperative use of a fluorescent contrast agent to improve detection of cancer cells. This technology requires both a targeted fluorescent dye that will selectively accumulate in cancer cells and a specialized imaging system to detect the cells. In several studies, we have shown that intraoperative imaging with indocyanine green (ICG) can be used to accurately identify indeterminate pulmonary nodules. The use of a folate-tagged fluorescent molecule targeted to the folate receptor-α (FRα) further improves the sensitivity and specificity of detecting lung adenocarcinomas. We have demonstrated this technology can be used as an "optical biopsy" to differentiate adenocarcinoma versus other histological subtypes of pulmonary nodules. This strategy has potential applications in assessing bronchial stump margins, identifying synchronous or metachronous lesions, and rapidly assessing lymph nodes for lung adenocarcinoma.

Evaluation of the diagnostic utility of endobronchial ultrasound-guided transbronchial needle aspiration for metastatic mediastinal tumors

Background and Objectives:

The mediastinum is a relatively uncommon site of distant metastases, which typically appear as peripheral lung nodules. We chose to assess the utility of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for the diagnosis of distant metastases to the mediastinum.

Materials and Methods:

Over the period 2008–2013, a total of 446 patients with concurrent or previously diagnosed and treated extrathoracic malignancies were evaluated.

Results:

Surgical treatment was carried out in 414 patients (156 women and 237 men aged 26–68 years, mean age of 56.5 years) presenting with distant metastases to the lungs: Thoracoscopic wedge resection was completed in 393 patients and lobectomy and segmentectomy were performed in 7 and 14 patients, respectively. The median time from primary tumor resection was 6.5 years (range: 4.5 months to 17 years). Thirty-two of these patients underwent EBUS-TBNA for mediastinal manifestation of the underlying disease. EBUS-TBNA specimens were aspirated from the subcarinal or right paratracheal lymph node stations in 26 (81%) patients and from the hilar lymph nodes in 6 (18.8%) patients only. Metastases to lymph nodes were confirmed in 14 of these patients (43.8%). Primary lung cancer was diagnosed in seven patients. Mediastinoscopy was performed in two patients to reveal either lymph node metastasis or sarcoidosis. Thoracotomy for pulmonary metastases resection and mediastinal lymph node biopsy was performed in nine patients. Lymph node metastasis was confirmed in five patients (15.6%). The diagnostic efficacy, sensitivity, specificity, and negative predictive value (NPV) of EBUS-TBNA were 78.8%, 93.3%, 100%, and 87.5%, respectively.

Conclusion:

EBUS-TBNA is a valuable diagnostic tool in a selected group of patients with secondary tumors in the mediastinum and lungs.

PET-CT for assessing mediastinal lymph node involvement in patients with suspected resectable non-small cell lung cancer

BACKGROUND

A major determinant of treatment offered to patients with non-small cell lung cancer (NSCLC) is their intrathoracic (mediastinal) nodal status. If the disease has not spread to the ipsilateral mediastinal nodes, subcarinal (N2) nodes, or both, and the patient is otherwise considered fit for surgery, resection is often the treatment of choice. Planning the optimal treatment is therefore critically dependent on accurate staging of the disease. PET-CT (positron emission tomography-computed tomography) is a non-invasive staging method of the mediastinum, which is increasingly available and used by lung cancer multidisciplinary teams. Although the non-invasive nature of PET-CT constitutes one of its major advantages, PET-CT may be suboptimal in detecting malignancy in normal-sized lymph nodes and in ruling out malignancy in patients with coexisting inflammatory or infectious diseases.

OBJECTIVES

To determine the diagnostic accuracy of integrated PET-CT for mediastinal staging of patients with suspected or confirmed NSCLC that is potentially suitable for treatment with curative intent.

SEARCH METHODS

We searched the following databases up to 30 April 2013: The Cochrane Library, MEDLINE via OvidSP (from 1946), Embase via OvidSP (from 1974), PreMEDLINE via OvidSP, OpenGrey, ProQuest Dissertations & Theses, and the trials register www.clinicaltrials.gov. There were no language or publication status restrictions on the search. We also contacted researchers in the field, checked reference lists, and conducted citation searches (with an end-date of 9 July 2013) of relevant studies.

SELECTION CRITERIA

Prospective or retrospective cross-sectional studies that assessed the diagnostic accuracy of integrated PET-CT for diagnosing N2 disease in patients with suspected resectable NSCLC. The studies must have used pathology as the reference standard and reported participants as the unit of analysis.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data pertaining to the study characteristics and the number of true and false positives and true and false negatives for the index test, and they independently assessed the quality of the included studies using QUADAS-2. We calculated sensitivity and specificity with 95% confidence intervals (CI) for each study and performed two main analyses based on the criteria for test positivity employed: Activity > background or SUVmax ≥ 2.5 (SUVmax = maximum standardised uptake value), where we fitted a summary receiver operating characteristic (ROC) curve using a hierarchical summary ROC (HSROC) model for each subset of studies. We identified the average operating point on the SROC curve and computed the average sensitivities and specificities. We checked for heterogeneity and examined the robustness of the meta-analyses through sensitivity analyses.

MAIN RESULTS

We included 45 studies, and based on the criteria for PET-CT positivity, we categorised the included studies into three groups: Activity > background (18 studies, N = 2823, prevalence of N2 and N3 nodes = 679/2328), SUVmax ≥ 2.5 (12 studies, N = 1656, prevalence of N2 and N3 nodes = 465/1656), and Other/mixed (15 studies, N = 1616, prevalence of N2 to N3 nodes = 400/1616). None of the studies reported (any) adverse events. Under-reporting generally hampered the quality assessment of the studies, and in 30/45 studies, the applicability of the study populations was of high or unclear concern.The summary sensitivity and specificity estimates for the 'Activity > background PET-CT positivity criterion were 77.4% (95% CI 65.3 to 86.1) and 90.1% (95% CI 85.3 to 93.5), respectively, but the accuracy estimates of these studies in ROC space showed a wide prediction region. This indicated high between-study heterogeneity and a relatively large 95% confidence region around the summary value of sensitivity and specificity, denoting a lack of precision. Sensitivity analyses suggested that the overall estimate of sensitivity was especially susceptible to selection bias; reference standard bias; clear definition of test positivity; and to a lesser extent, index test bias and commercial funding bias, with lower combined estimates of sensitivity observed for all the low 'Risk of bias' studies compared with the full analysis.The summary sensitivity and specificity estimates for the SUVmax ≥ 2.5 PET-CT positivity criterion were 81.3% (95% CI 70.2 to 88.9) and 79.4% (95% CI 70 to 86.5), respectively.In this group, the accuracy estimates of these studies in ROC space also showed a very wide prediction region. This indicated very high between-study heterogeneity, and there was a relatively large 95% confidence region around the summary value of sensitivity and specificity, denoting a clear lack of precision. Sensitivity analyses suggested that both overall accuracy estimates were marginally sensitive to flow and timing bias and commercial funding bias, which both lead to slightly lower estimates of sensitivity and specificity.Heterogeneity analyses showed that the accuracy estimates were significantly influenced by country of study origin, percentage of participants with adenocarcinoma, (¹⁸F)-2-fluoro-deoxy-D-glucose (FDG) dose, type of PET-CT scanner, and study size, but not by study design, consecutive recruitment, attenuation correction, year of publication, or tuberculosis incidence rate per 100,000 population.

AUTHORS' CONCLUSIONS

This review has shown that accuracy of PET-CT is insufficient to allow management based on PET-CT alone. The findings therefore support National Institute for Health and Care (formally 'clinical') Excellence (NICE) guidance on this topic, where PET-CT is used to guide clinicians in the next step: either a biopsy or where negative and nodes are small, directly to surgery. The apparent difference between the two main makes of PET-CT scanner is important and may influence the treatment decision in some circumstances. The differences in PET-CT accuracy estimates between scanner makes, NSCLC subtypes, FDG dose, and country of study origin, along with the general variability of results, suggest that all large centres should actively monitor their accuracy. This is so that they can make reliable decisions based on their own results and identify the populations in which PET-CT is of most use or potentially little value.

Intraoperative near-infrared imaging can identify pulmonary nodules

BACKGROUND

Over 80,000 people undergo pulmonary resection for a lung nodule in the United States each year. Small nodules are frequently missed or difficult to find despite preoperative imaging. We hypothesized that near-infrared (NIR) imaging technology could be used to identify and locate lung nodules during surgery.

METHODS

We enrolled 18 patients who were diagnosed with a pulmonary nodule that required resection. All patients had a fine-cut 1-mm computed tomography scan preoperatively. The patients were given systemic 5 mg/kg indocyanine green and then underwent an open thoracotomy 24 hours later. The NIR imaging was used to identify the primary nodule and search for additional nodules that were not found by visual inspection or manual palpation of the ipsilateral lung.

RESULTS

Manual palpation and visual inspection identified all 18 primary pulmonary nodules and no additional lesions. Intraoperative NIR imaging detected 16 out of the 18 primary nodules. The NIR imaging also identified 5 additional subcentimeter nodules; 3 metastatic adenocarcinomas and 2 metastatic sarcomas. This technology could identify nodules as small as 0.2 cm and as deep as 1.3 cm from the pleural surface. This approach discovered 3 nodules that were in different lobes than the primary tumor. Nodule fluorescence was independent of size, metabolic activity, histology, tumor grade and vascularity.

CONCLUSIONS

This is the first-in-human demonstration of identifying pulmonary nodules during thoracic surgery with NIR imaging without a priori knowledge of their location or existence. The NIR imaging can detect pulmonary nodules during lung resections that are poorly visualized on computed tomography and difficult to discriminate on finger palpation.

Complete video-assisted thoracoscopic surgery for lung cancer in 400 patients

BACKGROUND

We report the results of complete video-assisted thoracoscopic surgery for treatment of primary non-small cell lung cancer, which was performed completely through the monitor in 400 consecutive patients.

PATIENTS AND METHODS

Between September 25, 2002 and August 25, 2011, a retrospective database of 400 consecutive patients who underwent complete video-assisted thoracoscopic surgery for treatment of primary non-small cell lung cancer was reviewed. Demographic, histopathologic, preoperative, perioperative, postoperative, and outcome variables were assessed using standard descriptive statistics and Kaplan-Meier survival analyses.

RESULTS

Operating time was 258.13 ± 62.53 min, volume of blood loss was 253.21 ± 206.66 mL, duration of drainage was 3.6 ± 3.2 days, volume of drainage was 708.1 ± 522.8 mL, the postoperative respiratory complication rate was 14.8%, the reoperation rate was 1.3%, and operative mortality was 1.0%. The 5-year postsurgical survival rates for pathologic stages I, II, and III were 93.9%, 62.0%, and 61.6%, respectively; the 3-year postsurgical survival rate for pathologic stage IV was 40.0%

CONCLUSIONS

Complete video-assisted thoracoscopic surgery for treatment of primary non-small cell lung cancer is associated with safety and acceptable postoperative complication rates, operative mortality rates, and survival rates.

The stage classification of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

The current Lung Cancer Stage Classification system is the seventh edition, which took effect in January 2010. This article reviews the definitions for the TNM descriptors and the stage grouping in this system.

Special treatment issues in non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

This guideline updates the second edition and addresses patients with particular forms of non-small cell lung cancer that require special considerations, including Pancoast tumors, T4 N0,1 M0 tumors, additional nodules in the same lobe (T3), ipsilateral different lobe (T4) or contralateral lung (M1a), synchronous and metachronous second primary lung cancers, solitary brain and adrenal metastases, and chest wall involvement.

METHODS

The nature of these special clinical cases is such that in most cases, meta-analyses or large prospective studies of patients are not available. To ensure that these guidelines were supported by the most current data available, publications appropriate to the topics covered in this article were obtained by performing a literature search of the MEDLINE computerized database. Where possible, we also reference other consensus opinion statements. Recommendations were developed by the writing committee, graded by a standardized method, and reviewed by all members of the Lung Cancer Guidelines panel prior to approval by the Thoracic Oncology NetWork, Guidelines Oversight Committee, and the Board of Regents of the American College of Chest Physicians.

RESULTS

In patients with a Pancoast tumor, a multimodality approach appears to be optimal, involving chemoradiotherapy and surgical resection, provided that appropriate staging has been carried out. Carefully selected patients with central T4 tumors that do not have mediastinal node involvement are uncommon, but surgical resection appears to be beneficial as part of their treatment rather than definitive chemoradiotherapy alone. Patients with lung cancer and an additional malignant nodule are difficult to categorize, and the current stage classification rules are ambiguous. Such patients should be evaluated by an experienced multidisciplinary team to determine whether the additional lesion represents a second primary lung cancer or an additional tumor nodule corresponding to the dominant cancer. Highly selected patients with a solitary focus of metastatic disease in the brain or adrenal gland appear to benefit from resection or stereotactic radiosurgery. This is particularly true in patients with a long disease-free interval. Finally, in patients with chest wall involvement, provided that the tumor can be completely resected and N2 nodal disease is absent, primary surgical resection should be considered.

CONCLUSIONS

Carefully selected patients with more uncommon presentations of lung cancer may benefit from an aggressive surgical approach.

Video-assisted thoracic surgery for lung cancer

Video-assisted thoracic surgery (VATS) lobectomy is currently accepted as an appropriate procedure for selected patients with early-stage non-small-cell lung cancer (NSCLC). Evidence has demonstrated that VATS lobectomy is not only a safe and feasible technique, it provides better functional recovery and oncological efficacy similar to that achieved with conventional thoracotomy. However, there are still ongoing issues concerning VATS in terms of terminology, oncological efficacy, functional recovery, benefit of screening detected lung cancer, and its role in limited resection. As the number of VATS procedures are increasing and VATS is becoming a dominant procedural choice, it would be wise to collect evidence and come to a consensus to justify the expansion of surgical indications for VATS.

Patterns of recurrence and incidence of second primary tumors after lobectomy by means of video-assisted thoracoscopic surgery (VATS) versus thoracotomy for lung cancer

OBJECTIVE

Reports have questioned the oncologic efficacy of video-assisted thoracoscopic surgery when compared with thoracotomy despite similar survival results. In response, we investigated the pattern of recurrent disease and the incidence of second primary tumors after lobectomy by means of video-assisted thoracoscopic surgery and thoracotomy.

METHODS

All patients who underwent lobectomy for clinical stage IA lung cancer determined by means of computed tomographic and positron emission tomographic analysis were identified from a prospective database at a single institution. All patients were selected for video-assisted thoracoscopic surgery or thoracotomy by an individual surgeon. Patients' characteristics, perioperative results, recurrences, and second primary tumors were recorded. Variables were compared by using Student's t test, the Pearson χ(2) test, and Fisher's exact test. A logistic regression model was constructed to identify variables influencing the development of recurrent disease or metachronous tumors.

RESULTS

From 2002 to 2009, 520 patients underwent lobectomy by means of video-assisted thoracoscopic surgery, and 652 underwent lobectomy by means of thoracotomy. Final pathological stage was similar in the video-assisted thoracoscopic surgery and thoracotomy groups. Logistic regression demonstrated a lower risk (odds ratio, 0.65; P = .01) of recurrent disease in patients undergoing video-assisted thoracoscopic surgery after adjusting for age, stage, sex, histology, tumor location, and synchronous primary tumors.

CONCLUSIONS

Recurrence rates for video-assisted thoracoscopic surgery appear to be at least equivalent to those for thoracotomy. This study supports lobectomy by means of video-assisted thoracoscopic surgery as an oncologically sound technique.

Coping with the unexpected at surgery

In lung cancer surgery, it is best to avoid surprises; this requires knowledge of the reliability of preoperative assessment and careful planning. If this has been done, most of the more common situations should be manageable. If there is limited chest wall, mediastinal or N2 node involvement, one should proceed with resection. Unanticipated T4 tumors or bulky pN2 disease should not come as a surprise, and such patients should be sent to a more experienced center. One has to be careful to practice within the scope of one's knowledge and abilities as well as the sophistication of the institution. It only makes a mistake worse if an intraoperative surprise prompts one to embark on an operation that is beyond the means at hand. Collaborative organization via multidisciplinary tumor boards or inter-institutional interaction allows collective wisdom to promote better outcomes for all.

Surgical management of pulmonary metastases

Metastasectomy is the only curative option for some patients with secondary pulmonary malignancy. Many studies suggest a survival benefit in selected patients if complete resection of pulmonary metastases is accomplished. There are several operative approaches that may be used, with the goal of complete resection and with minimal parenchymal loss. Evaluation for resection must include ascertainment of control of the primary tumor and assessment of the ability to achieve complete resection. Minimally invasive approaches may offer advantages in quality of life outcomes, with equivalent oncologic outcomes.

Pulmonary metastasectomy from soft tissue sarcomas

INTRODUCTION

Isolated pulmonary metastases from soft tissue sarcomas occur in 20-50% of these(the issue is about metastases, not lung cancer )patients, and 70% of these patients will present disease limited only to the lungs. Surgical resection is well accepted as a standard approach to treat metastases from soft tissue sarcomas isolated in the lungs, and many studies investigating this technique have reported an overall 5-year survival ranging from 30-40%. The most consistent predictor of survival in these patients is complete resection. The aim of the present study was to determine the demographics and clinical treatment-related variables associated with long-term (90-month) overall survival in patients with lung metastases undergoing pulmonary metastasectomy from soft tissue sarcomas.

METHODS

We performed a retrospective review of patients admitted in the Thoracic Surgery Department with lung metastases who underwent thoracotomy for resection following treatment of the primary tumor. Data regarding primary tumor features, demographics, treatment, and outcome were collected.

RESULTS

One hundred twenty-two thoracotomies and 273 nodules were resected from 77 patients with previously treated soft tissue sarcomas. The median follow-up time of all patients was 36.7 months (range: 10-138 months). The postoperative complication rate was 9.1%, and the 30-day mortality rate was 0%. The 90-month overall survival rate for all patients was 34.7%. Multivariate analysis identified the following independent prognostic factors for overall survival: the number of metastases resected, the disease-free interval, and the number of complete resections.

CONCLUSION

These results confirm that lung metastasectomy is a safe and potentially curative procedure for patients with treated primary tumors. A select group of patients can achieve long-term survival after lung resection.

Clinical outcomes of video-assisted thoracoscopic lobectomy

OBJECTIVE

To review our experience with video-assisted thoracoscopic (VATS) lobectomy with respect to morbidity, mortality, and short-term outcome.

PATIENTS AND METHODS

VATS lobectomies were performed in 56 patients between July 6, 2006, and February 26, 2008. Two patients declined consent for research participation and were excluded. Clinical data for 54 patients were collected from medical records and analyzed retrospectively.

RESULTS

The studied cohort included 19 men (35%) and 35 women (65%) with a median age of 67.5 years (minimum-maximum, 21-87 years; interquartile range [IQR], 59-74 years). Median duration of operation for VATS lobectomy was 139 minutes (minimum-maximum, 78-275 minutes; IQR, 121-182 minutes). Two cases (4%) required conversion to open lobectomy. Median time to chest tube removal was 2 days (minimum-maximum, 1-12 days; IQR, 1.3-3.8 days). Median length of stay was 4 days (minimum-maximum, 1-12 days; IQR, 4-7 days). There was no operative mortality.

CONCLUSION

VATS lobectomy is safe and feasible for pulmonary resection. This minimally invasive approach may allow patients to benefit from lobectomy with shorter recovery times and hospital stays compared with conventional open thoracotomy.

Clinical outcomes of video-assisted thoracoscopic lobectomy

OBJECTIVE

To review our experience with video-assisted thoracoscopic (VATS) lobectomy with respect to morbidity, mortality, and short-term outcome.

PATIENTS AND METHODS

VATS lobectomies were performed in 56 patients between July 6, 2006, and February 26, 2008. Two patients declined consent for research participation and were excluded. Clinical data for 54 patients were collected from medical records and analyzed retrospectively.

RESULTS

The studied cohort included 19 men (35%) and 35 women (65%) with a median age of 67.5 years (minimum-maximum, 21-87 years; interquartile range [IQR], 59-74 years). Median duration of operation for VATS lobectomy was 139 minutes (minimum-maximum, 78-275 minutes; IQR, 121-182 minutes). Two cases (4%) required conversion to open lobectomy. Median time to chest tube removal was 2 days (minimum-maximum, 1-12 days; IQR, 1.3-3.8 days). Median length of stay was 4 days (minimum-maximum, 1-12 days; IQR, 4-7 days). There was no operative mortality.

CONCLUSION

VATS lobectomy is safe and feasible for pulmonary resection. This minimally invasive approach may allow patients to benefit from lobectomy with shorter recovery times and hospital stays compared with conventional open thoracotomy.

Surgical resection of lung metastases: results from 529 patients

OBJECTIVE

The aim of this study is to determine clinical, pathological, and treatment-relevant variables associated with long-term (90-month) overall survival in patients with lung metastases undergoing pulmonary metastasectomy.

METHODS

A retrospective review was performed of patients who were admitted with lung metastases, and who underwent thoracotomy for resection, after treatment of a primary tumor. Data were collected regarding demographics, tumor features, treatment, and outcome.

RESULTS

Patients (n = 529) were submitted to a total of 776 thoracotomies. Median follow-up time across all patients was 21.6 months (range: 0-192 months). The postoperative complication rate was 9.3%, and the 30-day mortality rate was 0.2%. The ninety-month overall survival rate for all patients was 30.4%. Multivariate analysis identified the number of pulmonary nodules detected on preoperative CT-scan, the number of malignant nodules resected, and complete resection as the independent prognostic factors for overall survival.

CONCLUSION

These results confirm that lung metastasectomy is a safe and potentially curative procedure for patients with treated primary tumors. A select group of patients can achieve long-term survival after resection.

Survival of patients with unsuspected N2 (stage IIIA) nonsmall-cell lung cancer

BACKGROUND

The objective of this study was to determine the survival of patients who have completely resected, nonsmall-cell, stage IIIA, lung cancer from unsuspected (nonimaged) N2 disease who received adjuvant chemotherapy.

METHODS

This is a retrospective cohort study using a prospective database. All patients underwent positron emission tomography scan and computed tomography scan with contrast, R0 resection with complete thoracic lymphadenectomy, and had unsuspected, pathologic N2 NSCLC.

RESULTS

Between June 1998 and December 2007, there were 148 patients (89 men). The most common pulmonary resection was right upper lobectomy in 67 patients (48%), and the most common lymph node station for unsuspected N2 diseased was 4R. One hundred and thirty-seven patients (93%) received adjuvant chemotherapy and 13% received postoperative radiation as well. The overall 2- and 5-year survivals were 58% and 35%, respectively. The 5-year survival for the 98 patients with single lymph node disease compared with patients with multiple nodal involvement was 40% versus 25%, respectively (p = 0.028). The number of lymph nodes involved (p = 0.032) was an independent predictors of survival on multivariate analysis. Median follow-up was 54 months.

CONCLUSIONS

The 5-year survival of patients with unsuspected N2 disease who undergo complete resection, followed by adjuvant therapy, is 35%. Patients with single station N2 disease fare better. The role for mediastinoscopy, endoscopic esophageal ultrasound with fine-needle aspirate, or endobronchial ultrasound in patients who are negative by positron emission tomography and computed tomography is unknown, since the benefit of neoadjuvant therapy in these patients is also unproven. A randomized study is needed.