The surgical management of stage I and stage II lung cancer

The effect of perioperative immunonutritional support on nutritional and inflammatory status in patients undergoing lung cancer surgery: a prospective, randomized controlled study

PURPOSE

Nutritional status is affected in patients who undergo lung cancer surgery (LCS). This study is aimed at investigating the effects of the use of immunonutritional support in the perioperative period on nutritional and inflammatory status in patients undergoing LCS.

METHODS

A single-center, prospective, randomized controlled clinical trial was conducted with seventy patients planning to have LCS and randomized into treatment (TG) and control groups (CG). Immunonutritional support was given orally twice a day for ten days before the operation and five days after the operation in the treatment group. The nutritional status of the patients was screened with the Patient-Generated Subjective Global Assessment (PG-SGA); the Prognostic Nutrition Index (PNI) and the Systemic Inflammation Index (SII) were calculated. The physical activity status was assessed with the Eastern Cooperative Oncology Group Performance Status (ECOG-PS).

RESULTS

Post-op nutritional status of the TG patients was better than the CG group (p = 0.009). Post-operative PG-SGA score was higher than preoperative PG-SGA score in both groups (p < 0.001). In the post-operative period, nutritional status (in terms of PG-SGA score category) in the patients in the TG was better than the CG (p = 0.046). In both groups, post-op ECOG score was higher than the pre-op ECOG score (p < 0.001). Post-op physical performance status was found to be better in the TG compared to the CG (p = 0.001). PNI level decreased statistically and significantly in the post-op period compared to the pre-op period, SII levels increased.

CONCLUSION

Patients who will undergo LCS should be supported in terms of immunonutrition starting from the preoperative period.

Numerical study on the effect of bifurcation vessel parameters on microwave ablation of lung tissue

Background: In order to study the effect of bifurcation vessels parameters on the temperature field and coagulation zone of microwave ablation on lung tissue. Methods: The finite element method was used to establish the simulation model. The angle of bifurcation vessel model was 60°. The position of the antenna and the main blood vessel are parallel, and the distance between them was 5, 10 and 15 mm, respectively. Temperature field distribution was obtained at 2450 MHz, 50 W and 300 s. The blood flow velocity was set to 0.1 and 0.2 m/s. Results: The results showed when the antenna was 5 mm away from the bifurcation vessel and the velocity was 0.1 m/s, the position of x = 8.4 mm achieved the complete necrosis at 220 s, while the fraction of necrotic tissue at the symmetry point x = 1.6 mm was 0.2 at 300 s. For the distance was 10 mm and the velocity was 0.1 m/s, the fraction of necrotic tissue at x = 3 mm that near the bifurcation vessel was 0.53 and was 0.69 at the symmetry point x = 17 mm. When the antenna is 15 mm away from the vessel, the fraction of necrotic tissue of symmetrical points on both sides of the antenna obtained after ablation were the same. Conclusions: The distance between the antenna and the bifurcation vessel over 15 mm, the blood flow has no effect on the coagulation zone. Besides, the distance between bifurcation vessel and antenna possesses a greater influence on the temperature distribution and coagulation zone than the blood flow velocity.

Radiofrequency ablation vs. stereotactic body radiotherapy for stage IA non-small cell lung cancer in nonsurgical patients

Background: Approximately 20% resectable non-small cell lung cancer (NSCLC) patients are treated non-surgically due to various reasons. The aim of the present study was to compare the effectiveness of radiofrequency ablation (RFA) and stereotactic body radiotherapy (SBRT) in patients with stage IA NSCLC who were ineligible for surgery using the surveillance, epidemiology and end-results (SEER) Database.

Methods: Using the SEER registry, we identified a total of 6,195 IA NSCLC patients who received SBRT or RFA between 2004 and 2015 because of ineligibility for surgical resection due to various reasons. Complete clinical information was available in all these patients. Overall survival (OS) and cancer-specific survival (CSS) were compared between RFA and SBRT groups by using propensity score matching (PSM), inverse probability of treatment weight (IPTW), and overlap weighting analysis. Additionally, an exploratory analysis was conducted to determine the effectiveness of RFA treatment based on the subsets of clinically relevant patients.

Results: Of the 6,195 nonsurgical IA NSCLC patients, 191 patients (3.1%) received RFA and the other 6,004 patients (96.9%) received SBRT. The one-, three- and five-year OS in the unmatched RFA and SBRT groups were 83.3%, 48.5%and 29.1% vs. 83.8%, 48.3% and 27.4%, respectively, there was similar results in the PSM, IPTW, overlap weighing analysis. Nonsurgical IA NSCLC patients receiving RFA seemed to have better five-year survival than those receiving SBRT, though the difference was not statistically significant (OS, HR; 0.986; 95% CI, 0.827-1.175, P=0.8738; CSS, HR; 0.965; 95% CI, 0.765-1.219, P=0.7663). We found that the odds of receiving RFA decreased with larger tumor size (>2, <3 cm, OR; 0.303; 95% CI, 0.191-0.479; >3 cm, OR; 0.153; 95% CI, 0.093-0.251) compared with tumor size <1 cm. In subgroup analysis, patients receiving RFA seemed to have better OS than those receiving SBRT, though the difference was not statistically significant. This specific trend was even more obvious in patients with tumors <1cm in diameter (P=0.1577).

Conclusion: In comparison with SBRT, RFA did not seem to adversely affect CSS and OS of IA NSCLC patients who were not suitable for surgical treatment. In addition, RFA seemed to offer better survival to IA NSCLC patients, especially those with tumors <1 cm.

Bronchoscopically delivered microwave ablation in an in vivo porcine lung model

Background

Percutaneous microwave ablation is clinically used for inoperable lung tumour treatment. Delivery of microwave ablation applicators to tumour sites within lung parenchyma under virtual bronchoscopy guidance may enable ablation with reduced risk of pneumothorax, providing a minimally invasive treatment of early-stage tumours, which are increasingly detected with computed tomography (CT) screening. The objective of this study was to integrate a custom microwave ablation platform, incorporating a flexible applicator, with a clinically established virtual bronchoscopy guidance system, and to assess technical feasibility for safely creating localised thermal ablations in porcine lungs in vivo.

Methods

Pre-ablation CTs of normal pigs were acquired to create a virtual model of the lungs, including airways and significant blood vessels. Virtual bronchoscopy-guided microwave ablation procedures were performed with 24–32 W power (at the applicator distal tip) delivered for 5–10 mins. A total of eight ablations were performed in three pigs. Post-treatment CT images were acquired to assess the extent of damage and ablation zones were further evaluated with viability stains and histopathologic analysis.

Results

The flexible microwave applicators were delivered to ablation sites within lung parenchyma 5–24 mm from the airway wall via a tunnel created under virtual bronchoscopy guidance. No pneumothorax or significant airway bleeding was observed. The ablation short axis observed on gross pathology ranged 16.5–23.5 mm and 14–26 mm on CT imaging.

Conclusion

We have demonstrated the technical feasibility for safely delivering microwave ablation in the lung parenchyma under virtual bronchoscopic guidance in an in vivo porcine lung model.

This paper demonstrates the technical feasibility of safely delivering microwave ablation in the lung parenchyma under virtual bronchoscopic guidance in an in vivo porcine lung modelhttps://bit.ly/32aruLf

A nomogram for the prediction of overall survival in patients with stage II and III non-small cell lung cancer using a population-based study

As a malignant tumor with poor prognosis, accurate and effective treatment of non-small cell lung cancer (NSCLC) is crucial. To predict overall survival in patients with stage II and III NSCLC, a nomogram was constructed using data from the Surveillance, Epidemiology and End Results database. Eligible patients with NSCLC with available clinical information diagnosed between January 1, 2010 and November 31, 2015 were selected from the database, and the data were randomly divided into a training set and a validation set. Univariate and multivariate Cox regression analyses were used to identify prognostic factors with a threshold of P<0.05, and a nomogram was constructed. Harrell's concordance indexes and calibration plots were used to verify the predictive power of the model. Risk group stratification by stage was also performed. A total of 15,344 patients with stage II and III NSCLC were included in the study. The 3- and 5-year survival rates were 0.382 and 0.278, respectively. The training and validation sets comprised 10,744 and 4,600 patients, respectively. Age, sex, race, marital status, histology, grade, Tumor-Node-Metastasis T and N stage, surgery type, extent of lymph node dissection, radiation therapy and chemotherapy were identified as prognostic factors for the construction of the nomogram. The nomogram exhibited a clinical predictive ability of 0.719 (95% CI, 0.718–0.719) in the training set and 0.721 (95% CI, 0.720–0.722) in the validation set. The predicted calibration curve was similar to the standard curve. In addition, the nomogram was able to divide the patients into groups according to stage IIA, IIB, IIIA, and IIIB NSCLC. Thus, the nomogram provided predictive results for stage II and III NSCLC patients and accurately determined the 3- and 5-year overall survival of patients.

Combined Coronary Artery Bypass Graft (CABG) Surgery and Lung Resection for Lung Cancer in Patients More than 50 Years-of-Age

Background

The co-existence of coronary heart disease (CHD) and lung cancer is increasing in an increasingly aging population. The aim of this study was to evaluate patient outcome from combined off-pump coronary artery bypass graft (CABG) surgery and lung resection in patients more than 50 years-of-age.

Material/Methods

A retrospective clinical study of 23 patients with a mean age of 70.2±8.4 years (range, 51–86 years) included 18 men and five women with CHD and lung cancer who underwent a single operation with combined off-pump CABG surgery and lung resection, for non-small cell lung cancer (NSCLC) (n=22) and small cell lung cancer (n=1). Surgical approaches included: median sternotomy in six patients; left lateral thoracotomy in nine patients; a median sternotomy in three patients; median sternotomy combined with thoracoscopic lobectomy in five patients.

Results

In the retrospective study of 23 patients, there were no deaths and no new cases of myocardial infarction (MI) in the immediate perioperative period. During the follow-up period, six patients died from lung cancer metastasis or recurrence; one patient died of acute renal failure; and one patient died from the effects of chemotherapy. The remaining 15 patients underwent postoperative follow-up for between 3–79 months with no deaths and no new cases of MI.

Conclusions

For patients who are more than 50 years-of-age and who have CHD and lung cancer, a single combined operation that includes off-pump CABG and lung resection can be safe and effective.

Pneumonectomy for Non-Small Cell Lung Cancer

Lung cancer is the leading cause of cancer deaths and its incidence continues to increase. Emerging therapies as part of a multimodal approach are making more patients eligible for surgical resection. As more surgeons are treating locally advanced non-small cell lung cancer they find themselves recommending pneumonectomy as the surgical component of the multidisciplinary plan. Performing a pneumonectomy is technically demanding and is associated with many potential perioperative comorbidities. With the proper preparation, experience, and attention to perioperative care, pneumonectomy can be carried out safely with excellent outcomes and a good quality of life.

Left sleeve lobectomy versus left pneumonectomy for the management of patients with non-small cell lung cancer

BACKGROUND

The study was conducted to compare the outcomes of sleeve lobectomy (SL) and pneumonectomy (PN) for management of the left lung in patients with non-small cell lung cancer (NSCLC).

METHODS

One hundred and thirty-five patients who underwent left SL (n = 87) or left PN (n = 48) for NSCLC from January 2006 to December 2011 were enrolled in this retrospective study. Left SL was performed when technically possible. The clinicopathological features and treatment outcomes in both groups were compared. Survival was evaluated using the Kaplan-Meier method, and significant differences were calculated using the log-rank test. Multivariate analysis was conducted using the Cox proportional hazards model to analyze significant variables associated with the outcomes of left SL.

RESULTS

There were no significant differences in general clinicopathological features (age, gender, lymph node metastasis, pathological stage, and complications of bronchial fistula) between patients who underwent left SL and left PN. The operation duration was markedly longer and the extent of bleeding was greater for left SL than left PN; however patients who underwent left SL achieved significantly longer overall survival than patients who underwent left PN. The outcomes of left SL were only associated with pathological stage.

CONCLUSIONS

Our results indicate that left SL may offer superior survival than left PN in selected patients. If anatomically feasible, left SL may be a preferred alternative to left PN for NSCLC patients. Pathological stage is an important factor to determine the outcome of SL.

Lung cancer resection with concurrent off-pump coronary artery bypasses: safety and efficiency

BACKGROUND

To assess the safety and efficacy of combined surgery for patients with concurrent lung cancer and severe coronary heart disease (CHD).

METHODS

Between 2003 and 2014, 34 patients with stage I or II lung cancer and simultaneous severe CHD underwent combined off-pump coronary artery bypass (OPCAB) grafting and lung resection. Surgically, myocardial revascularization was performed first and followed by lobectomies through the same or a second incision. Video-assisted thoracoscopes were used in some cases. Five patients also received chemotherapy before or after combined surgery in an effort to improve the long-term survival.

RESULTS

All patients survived the operation and no new myocardial infarctions (MIs) occurred in the perioperative period. The most frequent complications were cardiac arrhythmias (5 cases), atelectasis (4 cases), and pulmonary infections (2 cases). All patients were followed up for 5-60 months. Within this period, 6 patients (17.6%) died due to cancer recurrence. The 3- and 5-year survivals were 75% and 67% for these lung cancer patients, respectively.

CONCLUSIONS

Combined OPCAB and pulmonary resection for early stage lung cancer patients with concurrent severe CHD is a relatively safe and effective treatment with satisfactory long-term survival rates, especially for those patients with three-vessel disease who are not usually candidates for percutaneous coronary intervention (PCI) before open surgery.

The clonal evolution and therapeutic approaches of lung cancer

According to the World Cancer Research Foundation, the newly diagnosed annual lung cancer cases all over the world are alarmingly high at 12.5 %. It also shows the highest mortality rate among all the cancer types. Nearly 225,000 new lung cancer patients are reported annually in the USA. The lung cancer cells also have very fast growth rates. As a result of this rapid proliferation rate, the lung cancer cells are sensitive to the available therapeutics like the radiation, surgical, or chemo therapy. Notwithstanding all the advances in the field of tumor biology, the mortality rate with lung cancer has remained significantly high. Precise and early diagnosis of the disease can be an important step in the proper and successful setting up of the treatment modalities. There are no comprehensive reviews available that discusses all the basic and updated aspects of lung cancer. This review focuses on the basic aspects of lung cancer like the etiology, risk factors, and clonal evolution. Exposure to smoking comes up as a single major environmental cause of the disease. The classification of lung cancer has also been discussed in detail based on immunohistochemistry. The existing therapeutic approaches as well as the upcoming modern day interventions have been discussed with their pros and cons. Recent techniques like molecular profiling can prove to be highly beneficial if properly standardized. With such advancements in therapy in conjunction with the updated diagnostics, there is a real hope in the treatment of lung cancer.

Video-assisted thoracoscopic surgery and thoracotomy during lobectomy for clinical stage I non-small-cell lung cancer have equivalent oncological outcomes: A single-center experience of 212 consecutive resections

The aim of the present study was to compare the oncological outcomes following lobectomy using either video-assisted thoracoscopic surgery (VATS) or thoracotomy in clinical stage I non-small cell lung cancer (NSCLC) patients. Short- and long-term data from 212 consecutive patients who underwent lobectomy for clinical stage I NSCLC via VATS or thoracotomy between February 2003 and July 2013 were retrospectively reviewed. The primary endpoints were mediastinal lymph node staging, disease-free survival time and overall survival time. A total of 212 lobectomies for clinical stage I NSCLC were performed, 123 by VATS and 89 by thoracotomy. Patients’ demographic data, pathological stage and residual tumor were similar in the two groups. Reduced blood loss, less post-operative analgesia required and earlier hospital discharge were recorded for the VATS group, as compared with the thoracotomy group. The overall morbidity was similar in the two groups. However, the rate of major complications was higher following thoracotomy than following VATS. No 30-day mortality occurred subsequent to either thoracotomy or VATS lobectomy. The overall survival and disease-free survival times were comparable between the two groups. In the univariate analysis, the treatment approach was not associated with the overall five-year survival or the disease-free survival times. Multivariate Cox regression analysis of survival times revealed that significant predictors of shorter survival times were advanced pathological T3 stage, pathological N1 or N2 disease and poor cancer differentiation. In conclusion, it is reasonable to conclude from the present study that VATS lobectomy performed by specialist thoracic surgeons is safe and may achieve similar long-term survival times to the open surgery approach. However, further prospective randomized multi-center trials are warranted prior to incorporating VATS into clinical routine.

Establishing the role of tyrosine kinase 2 in cancer

Tyrosine kinase 2 (TYK2) is a member of the Janus family of non-receptor tyrosine kinases involved in cytokine signaling. TYK2 deficiency is associated with increased susceptibility to mycobacterial and viral infections, hyper IgE syndrome as well as with allergic asthma. However the precise role of TYK2 in oncogenesis and tumor progression is not clear yet. Tyk2-deficient mice are prone to develop tumors because they lack efficient cytotoxic CD8⁺ T-cell antitumor responses as a result of deficient Type I interferon signaling. However, as TYK2 functions downstream of growth factor receptors that are often hyperactivated in cancer, inhibiting TYK2 might also have beneficial effects for cancer treatment.

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.

Feasibility of transumbilical anatomic pulmonary lobectomy in a canine model

PURPOSE

Transthoracic thoracoscopic lobectomy is the preferred method of surgical treatment for early lung cancer. Current methods require a transthoracic approach and are associated with chronic postoperative pain in up to 25% of patients. Single-port transumbilical uniport surgery may offer advantages over multiport surgery with less postoperative pain and better cosmetic results. The aim of this study was to evaluate the feasibility of a transumbilical anatomic lobectomy of the lung (TUAL) in a canine model.

METHODS

TUAL was performed in 12 beagle dogs using a 3-cm umbilical incision combined with a 2.5-cm diaphragmatic incision. Variables evaluated for surgical outcomes were operating time, operative complications, body rectal temperature, respiratory rate, white blood cell count, and arterial blood gases.

RESULTS

TUAL was successfully completed in ten animals. There were six bleeding complications related to surgery. In four animals, an avulsion of pulmonary vessel causes intraoperative bleeding, requiring simultaneous pulmonary artery and bronchus resections. In one animal, slipping of endoclip after vessel clipping caused perioperative bleeding. The other animal encountered bleeding complication during dissection of inferior pulmonary vein. Both animals required conventional thoracotomy to complete the surgery.

CONCLUSIONS

TUAL in the canine model is feasible but associated with significant morbidity. With further development and refinement of instruments, comparative studies between the novel transumbilical lobectomy and the current video-assisted transthoracic lobectomy will clarify the role of transumbilical lobectomy in thoracic surgery.

The correlation between cell-free DNA and tumour burden was estimated by PET/CT in patients with advanced NSCLC

Background:

Cell-free DNA (cfDNA) circulating in the blood holds a possible prognostic value in malignant diseases. Under malignant conditions, the level of cfDNA increases but the biological mechanism remains to be fully understood. We aimed to examine the correlation between cfDNA and total tumour burden defined by positron emission tomography (PET) parameters.

Methods:

Patients with advanced non-small cell lung cancer (NSCLC) were enrolled into a prospective biomarker trial. Before treatment, plasma was extracted and the level of cfDNA was determined by qPCR. An ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) PET/computed tomography (CT) scan was performed and evaluated in terms of metabolic tumour volume (MTV) and total lesion glycolysis (TLG). Tumour contours were delineated semi-automatically by a threshold standardised uptake value (SUV) of 2.5. The primary end point was correlation among cfDNA, MTV and TLG. The secondary end point was overall survival (OS) according to cfDNA, MTV and TLG.

Results:

Fifty-three patients were included. There were no correlations between cfDNA and MTV (r=0.1) or TLG (r=0.1). cfDNA >75th percentile was correlated with shorter OS (P=0.02), confirmed in a multivariate analysis. MTV>the median was associated with a significantly shorter OS (P=0.02). There was no significant difference in OS according to TLG (P=0.08).

Conclusion:

Cell-free DNA may not be a simple measure of tumour burden, but seems to reflect more complex mechanisms of tumour biology, making it attractive as an independent prognostic marker.

Surgery in 2013 and beyond

Lung cancer is a leading cause of cancer related mortality. The role of surgery continues to evolve and in the last ten years there have been a number of significant changes in the surgical management of lung cancer. These changes extend across the entire surgical spectrum of lung cancer management including diagnosis, staging, treatment and pathology. Positron Emission Tomography (PET) scanning and ultrasound (EBUS) have redefined traditional staging paradigms, and surgical techniques, including video-assisted thoracoscopy (VATS), robotic surgery and uniportal surgery, are now accepted as standard of care in many centers. The changing pathology of lung cancer, with more peripheral tumours and an increase in adenocarcinomas has important implications for the Thoracic surgeon. Screening, using Low-Dose CT scanning, is having an impact, with not only a higher percentage of lower stage cancers detected, but also redefining the role of sublobar resection. The incidence of pneumonectomy has reduced as have the rates of "exploratory thoracotomy". In general, lung resection is considered for stage I and II patients with a selected role in more advanced stage disease as part of a multimodality approach. This paper will look at these issues and how they impact on Thoracic Surgical practice in 2013 and beyond.