Detection of circulating tumor cells in patients with non-small cell lung cancer undergoing lobectomy by video-assisted thoracic surgery: a potential hazard for intraoperative hematogenous tumor cell dissemination

A Cadaveric Study of Variations in Lung Fissures and Drainage Patterns of Pulmonary Veins at the Hilum With Its Clinical Implications

Introduction The human lungs are located in the pleural cavity, divided by fissures into lobes, facilitating respiration movements. It acts as a barrier to prevent the spread of infection to adjacent lobes. The pulmonary hilum in each lung contains pulmonary vessels, bronchial vessels, and the bronchus. Pulmonary venous drainage variations are expected to be significant in diagnostic and therapeutic procedures. The present study aims to study the variant pattern of the lung fissures and the drainage pattern of the right and left pulmonary veins at the pulmonary hilum. Methodology The descriptive study was conducted on 75 lungs in the Department of Anatomy after obtaining ethical approval from Vinayaka Mission's Medical College and Hospital, Karaikal, India. A few lung specimens were procured from the government hospital, Karaikal. All the lung specimens belonging to adults of unknown age and gender collected over three years were included in our study. Lungs with evident pathological conditions, damage, surgical resections, and metastatic disease were excluded from the study. The pattern of oblique and horizontal fissures and accessory fissures was studied on both the right and left lungs. These fissures were categorized based on the Craig and Walker classification, a widely accepted system in pulmonary anatomy. The hilar structures were dissected on both the right and left lungs, the pulmonary veins were picked up, the different drainage patterns of pulmonary veins at the hilum were studied, and the results were expressed in percentage. In addition, the presence of an accessory vein and anomalous unilateral single pulmonary vein was documented. Results Out of 35 right lungs, incomplete and absent oblique fissures were observed in 10 (28.57%) and four (11.43%), and incomplete and absent horizontal fissures were observed in 12 (34.29%) and seven (20%) of the specimens. Out of 40 left lungs, incomplete and absent oblique fissures were observed in 13 (32.5%) and three (7.5%) of the specimens. Superior and inferior accessory fissures were present in five (14.29%) and four (11.4%) of the right lungs, and the left minor fissures were seen in 15 (37.5%) of the specimens. Different patterns of pulmonary venous drainage were reported in our study, and variations were observed in 52% of the specimens. A single unilateral pulmonary vein was documented in two (5.71%) and 14 (35%), and the accessory vein was noted in seven (20%) and two (5%) of the right and left lungs, respectively. These findings underscore the importance of understanding the variant patterns of pulmonary veins and the presence of accessory veins in the context of cardio-thoracic surgeries. Conclusions As revealed by our study, the variations in the pulmonary veins and fissures are paramount in the surgical field. These findings will reassure and instill confidence in surgeons and radiologists, enabling them to diagnose and perform cardio-thoracic surgeries with a strong foundation of anatomical knowledge.

Contemporaneous Perioperative Inflammatory and Angiogenic Cytokine Profiles of Surgical Breast, Colorectal, and Prostate Cancer Patients: Clinical Implications

Surgery-induced tumor growth acceleration and synchronous metastatic growth promotion have been observed for decades. Surgery-induced wound healing, orchestrated through growth factors, chemokines, and cytokines, can negatively impact patients harboring residual or metastatic disease. We provide detailed clinical evidence of this process in surgical breast, prostate, and colorectal cancer patients. Plasma samples were analyzed from 68 cancer patients who had not received treatment before surgery or adjuvant therapy until at least four weeks post-surgery. The levels of plasma cytokines, chemokines, and growth factors were simultaneously quantified and profiled using multiplexed immunoassays for eight time points sampled per patient. The immunologic processes are induced immediately after surgery in patients, characterized by a drastic short-term shift in the expression levels of pro-inflammatory and angiogenic molecules and cytokines. A rapid and significant spike in circulating plasma levels of hepatocyte growth factor (HGF), interleukin-6 (IL-6), placental growth factor (PLGF), and matrix metalloproteinase-9 (MMP-9) after surgery was noted. The rise in these molecules was concomitant with a significant drop in transforming growth factor-β1 (TGF-β1), platelet-derived growth factor (PDGF-AB/BB), insulin-like growth factor-1 (IGF-1), and monocyte chemoattractant protein-2 (MCP-2). If not earlier, each plasma analyte was normalized to baseline levels within 1-2 weeks after surgery, suggesting that surgical intervention alone was responsible for these effects. The effects of surgical tumor removal on disrupting the pro-inflammatory and angiogenic plasma profiles of cancer patients provide evidence for potentiating malignant progression. Our findings indicate a narrow therapeutic window of opportunity after surgery to prevent disease recurrence.

Perioperative change of circulating tumor cells in cytoreductive radical prostatectomy for oligometastatic hormone-sensitive prostate cancer: the preliminary safety evidence from long-term oncologic outcomes

Surgical manipulation has a risk of triggering the shedding of circulating tumor cells (CTCs) in patients with malignancies, However, perioperative change of circulating tumor cells in cytoreductive radical prostatectomy (CRP) for patients with oligometastatic hormone-sensitive prostate cancer (omHSPC) has not yet been well documented. This study aimed to assess whether CRP is a safe procedure for patients with omHSPC by monitoring the perioperative change of CTCs and investigating its impact on long-term oncologic outcomes. We have observed a significant decrease between the median CTC counts before and after surgery (6 vs. 4, p = 0.026). Comparing preoperative and postoperative CTC levels, seven patients increased (CTC increase group), one did not change and nineteen decreased (CTC non-increase group). PSA response rates in CTC increase group were lower than those in CTC non-increase group (73.0% vs 99.8%, p = 0.162), and nadir PSA was higher in CTC increase group (0.043 vs 0.003, p = 0.072). The CTC increase was positively correlated with the nadir PSA (r = 0.386, p = 0.047). The median follow-up period was 71.6 months, we found that there was no significant difference in clinical-pathological, operative variables or long-term oncologic outcomes between perioperative CTC increase and non-increase groups. In the entire cohort, the CTC level significantly decreased after surgery. There was no significant differences in long-term oncologic outcomes between the CTC increase and non-increase groups, implying that CRP potentially represents a safe procedure for the treatment of patients with omHSPC. The results need to be confirmed in a prospective large-scale clinical trial.

Circulating Tumor Cells as a Predictive Biomarker in Resectable Lung Cancer: A Systematic Review and Meta-Analysis

Background: In breast, prostate, and other epithelial tumors, circulating tumor cells (CTC) in peripheral blood may predict survival. Our study evaluated the prognostic significance of baseline and postoperative CTC in patients with early non-small cell lung cancer (NSCLC) through a meta-analytic approach. Methods: Prospective studies comparing survival outcomes between positive (CTC+) and negative CTC (CTC−) patients were systematically searched. Primary outcomes were overall (OS) and disease-free survival (DFS) with hazard ratio (HR) and 95% confidence interval (CI) as the effect measure. Pooled HR determined the prognostic role under a fixed-effect or random-effect model depending on heterogeneity. Results: Eighteen studies with 1321 patients were eligible. CTC+ patients were associated with an increased risk of death (HR 3.53, 95% CI 2.51−4.95; p < 0.00001) and relapse (HR 2.97, 95% CI 2.08−4.22; p < 0.00001). Subgroup analysis results were consistent in different subsets, including time points (baseline and postoperative) and sources (peripheral and pulmonary vein) of blood collection, detection methods (label-free, label-dependent, and RT-PCR), and follow-up duration. Conclusion: Our meta-analysis revealed that CTC is a promising predictive biomarker for stratifying survival outcomes in patients with early-stage NSCLC. However, future studies are required to validate these findings and standardize detection methods.

Local anesthetic lidocaine induces growth suppression of HeLa cells by decreasing and changing the cellular localization of the proliferation marker Ki-67

Although surgery is a basic therapy for cancer, it causes inflammation and immunosuppression, often resulting in recurrence and metastasis. Previous studies have suggested that anesthetic management influences the prognosis of cancer surgery patients. Administration of local anesthetics, such as lidocaine, for pain control reportedly improves their clinical outcomes; however, the precise underlying mechanism has not been fully elucidated. The growth of human embryonic kidney (HEK) 293T and cervical cancer HeLa cells was inhibited by lidocaine treatment and these cell lines showed different sensitivities for lidocaine. Ki-67 is a significant prognostic marker of cancer because it is expressed in the nucleus of actively proliferating cells. In lidocaine-treated HeLa cells, Ki-67 was detected not only in the nucleus but also in the cytoplasm. In addition, lidocaine-induced cytoplasmic Ki-67 partly colocalized with the increased ER chaperone, glucose-regulated protein 78, which is crucial for protein folding and maintenance of cellular homeostasis. Furthermore, lidocaine decreased Ki-67 levels and increased the population of HeLa cells in the G0/G1 phase. These results indicate that lidocaine plays a significant role in growth suppression by regulating the expression and distribution of Ki-67. This article is protected by copyright. All rights reserved.

Circulating Tumor Cells and the Non-Touch Isolation Technique in Surgery for Non-Small-Cell Lung Cancer

Circulating tumor cells (CTCs) are dislodged from the primary tumor into the bloodstream, travel within the bloodstream to distant organs, and finally extravasate and proliferate as epithelial metastatic deposits. The relationship between the existence of CTCs and tumor prognosis has been demonstrated by many researchers. In surgery for malignancies, the surgical manipulation of tumors and tissues around the tumor may lead to the release of CTCs into the bloodstream. The non-touch isolation technique (NTIT) has been advocated to prevent the release of CTCs during surgery. The concept of NTIT is the prevention of intraoperative increment of CTCs from the primary tumor by the early blockade of outflow vessels, and ‘pulmonary vein (PV)-first lobectomy’ during surgery for non-small-cell lung cancer (NSCLC) corresponds to this technique. The concept of PV-first lobectomy is well known among thoracic surgeons, but evidence of its efficacy for preventing the increase of intra- and postoperative CTCs and for improving postoperative prognosis is still uncertain. Our study summarizes evidence regarding the relationship between NTIT and CTCs in NSCLC and suggests the need for further research on CTCs and CTC-detecting modalities.

Uniportal video-assisted thoracic surgery for major lung resection is associated with less immunochemokine disturbances than multiportal approach

Multiportal video-assisted thoracic surgery (VATS) for major lung resection causes less immunochemokine production compared to thoracotomy. Whether uniportal VATS is similarly associated with lower early postoperative circulating levels of immunochemokines compared to multiportal VATS have not been studied. Selected patients who received uniportal or multiportal VATS major lung resection were recruited. Blood samples were collected preoperatively and on postoperative days 1 and 3 for enzyme linked immunosorbent assay of serum levels of Tissue Inhibitor of Metalloproteinase (TIMP)-1, Insulin Growth Factor Binding Protein (IGFBP)-3, and Matrix Metalloproteinase (MMP)-9. A linear mixed-effects models were used to analyze the effects of uniportal VATS on the postoperative circulating chemokine levels. From March 2014 to April 2017, 68 consecutive patients consented for the prospective study and received major lung resection by either uniportal VATS (N = 29) or multiportal VATS (N = 39) were identified. Uniportal VATS major lung resection was associated with lower post-operative levels of TIMP-1 and MMP-9 compared to multiportal VATS after controlling for the effects of the corresponding baseline level and the time of follow-up measurement. No difference was observed for the level of IGFBP-3. Less immunochemokine disturbances was observed after uniportal VATS major lung resection compared to multiportal VATS.

Circulating tumor cells detected only after surgery for non-small cell lung cancer: is it a predictor of recurrence?

Background

Surgical manipulation of a tumor can lead to shedding of tumor cells that can enter the circulation and lead to metastasis. The present study evaluated the clinical relevance of circulating tumor cells (CTCs) that were identified immediately after non-small cell lung cancer resection in patients without preoperative CTCs, and whether postoperative CTC detection was associated with recurrence.

Methods

Immediate preoperative testing for CTCs was performed for 147 patients with pulmonary nodules. This study included 81 lung cancer patients (55.1%) with negative preoperative results for CTCs and who completed postoperative testing for CTCs. The clinical relevance of postoperative CTC detection was evaluated based on the clinicopathological characteristics and recurrence patterns.

Results

Among the eligible patients, the postoperative CTC results were none detected in 58 patients (71.6%, “Group N”), only a single CTC detected in 6 patients (7.4%, “Group S”), and CTC clusters detected in 17 patients (21.0%, “Group C”). The presence of postoperative CTCs was associated with tumor vessel invasion, lymph duct invasion, and pleural invasion. Distant metastasis was very common in cases with postoperatively detected CTC clusters. The 2-year recurrence-free survival rates were 94.6% for Group N, 62.5% for Group S, and 52.9% for Group C (P<0.01). Multivariate analysis revealed that recurrence was independently related to the postoperative detection of single CTCs and CTC clusters.

Conclusions

In cases without preoperative CTCs, we postoperatively detected CTCs and the postoperative CTC results were an independent predictor of recurrence.

Video-assisted thoracoscopic surgery as the gold standard for lung cancer surgery

Surgical resection remains the only effective means of cure in the vast majority of patients with early-stage lung cancer. It can be performed via a traditional open approach (particularly thoracotomy) or a minimally invasive approach. VATS is 'keyhole' surgery in the chest, and was first used for lung cancer resection in the early 1990s. Since then, a large volume of evolving clinical evidence has confirmed that VATS lung cancer resection offered proven safety and feasibility, better patient-reported post-operative outcomes, less surgical trauma as quantified by objective outcome measures and equivalent or better survival than open surgery. This has firmly established VATS as the surgical approach of choice for early-stage lung cancer today. Although impressive new non-surgical lung cancer therapies have emerged in recent years, VATS is also being constantly rejuvenated by the development of 'next generation' VATS techniques, the refinement of VATS sublobar resection for selected patients, the utilization of bespoke post-operative recovery programmes for VATS and the synthesis of VATS into multi-modality lung cancer therapy. There is little doubt that VATS will remain as the gold standard for lung cancer surgery for the foreseeable future.

Possible role of circulating tumor cells in early detection of lung cancer

The prognosis of lung cancer varies highly depending on the disease stage at diagnosis, from a 5-year survival rate close to 90% in stage I, to 10% or less in stage IV disease. The enhancement of early diagnosis of this malignancy is mandatory to improve prognosis, because lung cancer patients stay long asymptomatic or few symptomatic after disease onset. Nowadays, liquid biopsy has emerged as a minimally-invasive tool to address the urgent need for real time monitoring, stratification, and personalized treatment of malignancies, including lung cancer. Liquid biopsy refers to a class of biomarkers, including circulating tumor cells (CTCs), cell-free circulating tumor DNA (ctDNA) and tumor-derived extracellular vesicles (tdEV). Since CTCs represent a crucial step in disease progression and metastasis, we reviewed here the scientific literature about the use of CTCs in early diagnosis of lung cancer; different techniques, and different strategies (e.g., source of analysis sample or high-risk groups of patients) were discussed showing the potential of implementing liquid biopsy in the clinical routine of non-metastatic lung cancer.

Comprehensive study of pulmonary hilam with its clinical correlation

INTRODUCTION

Awareness of pulmonary hilar variations is essential for lobectomy of lung.

MATERIALS AND METHODS

We studied 54 left and 49 right hilum of formalin fixed adult cadaveric lungs. Morphologic and mophometric details were recorded and variations were noted.

RESULTS

Classical picture of hilum was found in 35.19% left lung and 40.82% right lung. Morphological variations were more on left side (64.81%) than right side (59.18%) in terms of numbers of structures. On the left side, highest percentage of variable structure was bronchus (46.3%) followed by pulmonary artery (37.31%) and lowest by pulmonary vein (31.48%) whereas on right side, percentage for variable pulmonary artery and vein were same (36.73%) followed by bronchi (20.41%). Maximum number of pulmonary veins was five, pulmonary artery was three and accessory bronchus was two on both side hila. In morphometric measurement, mean vertical length of hilum was more on right side whereas anteroposterior length was more on left side. Right hilum is slightly lower and anteriorly placed than left hilum in the mediastinal surface of lung. Significant correlations between vertical length of lung and hilum and antero-postero length of lung and hilum of left and right sides were found.

CONCLUSIONS

By analysis and comparison with previous studies, present study concludes that morphology of pulmonary hila is extremely variable which contributes significant consequences in the field of pulmonary resection.

Clinical updates of approaches for biopsy of pulmonary lesions based on systematic review

BACKGROUND

Convenient approaches for accurate biopsy are extremely important to the diagnosis of lung cancer. We aimed to systematically review the clinical updates and development trends of approaches for biopsy, i.e., CT-guided PTNB (Percutaneous Transthoracic Needle Biopsy), ENB (Electromagnetic Navigation Bronchoscopy), EBUS-TBNA (Endobroncheal Ultrasonography-Transbronchial Needle Aspiration), mediastinoscopy and CTC (Circulating Tumor Cell).

METHODS

Medline and manual searches were performed. We identified the relevant studies, assessed study eligibility, evaluated methodological quality, and summarized diagnostic yields and complications regarding CT-guided PTNB (22 citations), ENB(31 citations), EBUS-TBNA(66 citations), Mediastinoscopy(15 citations) and CTC (19 citations), respectively.

RESULTS

The overall sensitivity and specificity of CT-guided PTNB were reported to be 92.52% ± 3.14% and 97.98% ± 3.28%, respectively. The top two complications of CT-guided PTNB was pneumothorax (946/4170:22.69%) and hemorrhage (138/1949:7.08%). The detection rate of lung cancer by ENB increased gradually to 79.79% ± 15.34% with pneumothorax as the top one complication (86/1648:5.2%). Detection rate of EBUS-TBNA was 86.06% ± 9.70% with the top three complications, i.e., hemorrhage (53/8662:0.61%), pneumothorax (46/12432:0.37%) and infection (34/11250:0.30%). The detection rate of mediastinoscopy gradually increased to 92.77% ± 3.99% with .hoarseness as the refractory complication (4/2137:0.19%). Sensitivity and specificity of CTCs detection by using PCR (Polymerase Chain Reaction) were reported to be 78.81% ± 14.72% and 90.88% ± 0.53%, respectively.

CONCLUSION

The biopsy approaches should be chosen considering a variety of location and situation of lesions. CT-guided PTNB is effective to reach lung parenchyma, however, diagnostic accuracy and incidence of complications may be impacted by lesion size or needle path length. ENB has an advantage for biopsy of smaller and deeper lesions in lung parenchyma. ENB plus EBUS imaging can further improve the detection rate of lesion in lung parenchyma. EBUS-TBNA is relatively safer and mediastinoscopy provides more tissue acquisition and better diagnostic yield of 4R and 7th lymph node. CTC detection can be considered for adjuvant diagnosis.

Metabolic Hallmarks of Metastasis Formation

Metastasis to distant organs is a predictor of poor prognosis. Therefore, it is of paramount importance to understand the mechanisms that impinge on the different steps of the metastatic cascade. Recent work has revealed that particular metabolic pathways are rewired in cancer cells to support their transition through the metastatic cascade, resulting in the formation of secondary tumors in distant organs. Indeed, metabolic rewiring induces signaling pathways during initial cancer invasion, circulating cancer cells depend on enhanced antioxidant defenses, and cancer cells colonizing a distant organ require increased ATP production. Moreover, the local environment of the metastatic niche dictates the metabolic pathways secondary tumors rely on. Here we describe mechanisms of metabolic rewiring associated with distinct steps of metastasis formation.

Clinical indications for, and the future of, circulating tumor cells

Circulating tumor cells (CTCs) are cells that have detached from the primary tumor and entered circulation with potential to initiate a site of metastasis. Currently, CTC detection using CellSearch is cleared by the Food and Drug Administration for monitoring metastatic breast, prostate, and colorectal cancers as a prognostic biomarker for progression-free and overall survival. Accumulating evidence suggests CTCs have similar prognostic value in other metastatic and non-metastatic settings. Current research efforts are focused on extending the utility of CTCs beyond a prognostic biomarker to help guide clinical decision-making. These include using CTCs as a screening tool for diagnosis, liquid biopsy for molecular profiling, predictive biomarker to specific therapies, and monitoring tool to assess response and guide changes to treatment. CTCs have unique advantages vs circulating tumor DNA in this endeavor. Indications for CTCs in daily practice will expand as isolation techniques improve and clinical studies validating their utility continue to grow.

Molecular characterization of circulating tumor cells in lung cancer: moving beyond enumeration

Molecular characterization of tumor cells is a key step in the diagnosis and optimal treatment of lung cancer. However, analysis of tumor samples, often corresponding to small biopsies, can be difficult and does not accurately reflect tumor heterogeneity. Recent studies have shown that isolation of circulating tumor cells (CTCs) is feasible in non-small cell lung cancer patients, even at early disease stages. The amount of CTCs corresponds to the metastatic potential of the tumor and to patient prognosis. Moreover, molecular analyses, even at the single-cell level, can be performed on CTCs. This review describes the technologies currently available for detecting and capturing CTCs, the potential for downstream molecular diagnostics, and the clinical applications of CTCs isolated from lung cancer patients as screening, prognostic, and predictive tools. Main limitations of CTCs are also discussed.

Detection of circulating tumor cells in pulmonary venous blood for resectable non-small cell lung cancer

Intraoperative manipulation causes circulating tumor cell (CTC) shedding into the blood and accelerates metastasis in non-small cell lung cancer (NSCLC). The present study was conducted to assess the degree of dissemination resulting from surgery and to explore the biological features of CTCs. In patients with NSCLC who underwent complete resection, the pulmonary vein (PV) was isolated and stapled following thoracotomy. The number of CTCs retained per 7.5 ml PV blood (CTC-PV) and peripheral blood were detected. Following hematopoietic cell depletion, a xenograft assay was performed using the CTC-PV. A total of 32 consecutive patients were enrolled in the study, the majority of whom had CTCs in their PV blood (n=29, 90.6%). Circulating tumor microemboli (CTM) were identified in 12 patients (37.5%). The CTC-PV and CTM-PV counts were positively correlated with tumor size (P=0.012 and P=0.028, respectively). Patients with small tumors (<3.0 cm) also had considerable CTC-PV and CTM-PV. A total of 8 patients received platinum-based chemotherapy prior to surgery. The CTC-PV and CTM-PV counts in patients with partial response were significantly lower than those in patients with stable disease or who did not receive induction therapy (P=0.025 and P=0.044, respectively). The enriched CTC-PV from 3 patients were injected into 3 immunodeficient mice, and 1 mouse developed a xenograft tumor. To conclude, the present study indicates that intraoperative manipulation contributes to the hematogenous dissemination of tumorigenic CTCs and CTM. Lobectomy is recommended for lung cancer of any tumor size and stage according to oncological principles, in addition to ligating the PV, if possible, prior to any other treatment.

[Research Progresses of Circulating Tumor Cells in Diagnosis and Treatment of Early Lung Cancer]

循环肿瘤细胞（circulating tumor cells, CTCs）作为液体活检的一种重要类型，在肺癌的筛查诊断、疗效评估、术后监测与预后判断等方面显示出越来越丰富的临床价值。随着对肺癌高危人群筛查工作的进展，大量肺小结节患者被检出，但是肺小结节不等于肺癌，而且据统计良性比例达90%-95%，这使得该部分患者在首次就诊时的良恶性鉴别诊断成为临床医生面临着的新的机遇与挑战。CTCs检测技术的不断进步与完善，是否可以在早期肺癌的鉴别诊断中发挥更大的作用，此外，它是否对早期肺癌手术治疗时的操作具有指导意义，这还需要进一步科研探索，以期将来实现临床转化。

Association Among Blood Transfusion, Sepsis, and Decreased Long-term Survival After Colon Cancer Resection

OBJECTIVE

To investigate the potential additive effects of blood transfusion and sepsis on colon cancer disease-specific survival, cardiovascular disease-specific survival, and overall survival after colon cancer surgery.

BACKGROUND

Perioperative blood transfusions are associated with infectious complications and increased risk of cancer recurrence through systemic inflammatory effects. Furthermore, recent studies have suggested an association among sepsis, subsequent systemic inflammation, and adverse cardiovascular outcomes. However, no study has investigated the association among transfusion, sepsis, and disease-specific survival in postoperative patients.

METHODS

The New York State Cancer Registry and Statewide Planning and Research Cooperative System were queried for stage I to III colon cancer resections from 2004 to 2011. Propensity-adjusted survival analyses assessed the association of perioperative allogeneic blood transfusion, sepsis, and 5-year colon cancer disease-specific survival, cardiovascular disease-specific survival, and overall survival.

RESULTS

Among 24,230 patients, 29% received a transfusion and 4% developed sepsis. After risk adjustment, transfusion and sepsis were associated with worse colon cancer disease-specific survival [(+)transfusion: hazard ratio (HR) 1.19, 95% confidence interval (CI) 1.09-1.30; (+)sepsis: HR 1.84, 95% CI 1.44-2.35; (+)transfusion/(+)sepsis: HR 2.27, 95% CI 1.87-2.76], cardiovascular disease-specific survival [(+)transfusion: HR 1.18, 95% CI 1.04-1.33; (+)sepsis: HR 1.63, 95% CI 1.14-2.31; (+)transfusion/(+)sepsis: HR 2.04, 95% CI 1.58-2.63], and overall survival [(+)transfusion: HR 1.21, 95% CI 1.14-1.29; (+)sepsis: HR 1.76, 95% CI 1.48-2.09; (+)transfusion/(+)sepsis: HR 2.36, 95% CI 2.07-2.68] relative to (-)transfusion/(-)sepsis. Additional analyses suggested an additive effect with those who both received a blood transfusion and developed sepsis having even worse survival.

CONCLUSIONS

Perioperative blood transfusions are associated with shorter survival, independent of sepsis, after colon cancer resection. However, receiving a transfusion and developing sepsis has an additive effect and is associated with even worse survival. Restrictive perioperative transfusion practices are a possible strategy to reduce sepsis rates and improve survival after colon cancer surgery.

Clinical utility of circulating tumor cells in patients with non-small-cell lung cancer

Several different studies have addressed the role of the circulating tumor cells (CTC) in non-small-cell lung cancer (NSCLC). In particular, the potential of CTC analysis in the early diagnosis of NSCLC and in the prediction of the outcome of patients with early and advanced NSCLC have been explored. A major limit of these studies is that they used different techniques for CTC isolation and enumeration, they employed different thresholds to discriminate between high- and low-risk patients, and they enrolled heterogeneous and often small cohort of patients. Nevertheless, the results of many studies are concordant in indicating a correlation between high CTC count and poor prognosis in both early and advanced NSCLC. The reduction of CTC number following treatment might also represent an important indicator of sensitivity to therapy in patients with metastatic disease. Preliminary data also suggest the potential for CTC analysis in the early diagnosis of NSCLC in high-risk individuals. However, these findings need to be confirmed in large prospective trials in order to be transferred to the clinical practice. The molecular profiling of single CTC in NSCLC might provide important information on tumor biology and on the mechanisms involved in tumor dissemination and in acquired resistance to targeted therapies. In this respect, xenografts derived from CTC might represent a valuable tool to investigate these phenomena and to develop novel therapeutic strategies.

Different dissecting orders of the pulmonary bronchus and vessels during right upper lobectomy are associated with surgical feasibility and postoperative recovery for lung cancer patients

Background

Right upper lobectomy (RUL) for lung cancer with different dissecting orders involves the most variable anatomical structures, but no studies have analyzed its effects on postoperative recovery. This study compared the conventional surgical approach, VAB (dissecting pulmonary vessels first, followed by the bronchus), and the alternative surgical approach, aBVA (dissecting the posterior ascending arterial branch first, followed by the bronchus and vessels) on improving surgical feasibility and postoperative recovery for lung cancer patients.

Methods

According to the surgical approach, consecutive lung cancer patients undergoing RUL were grouped into aBVA and VAB cohorts. Their clinical, pathologic, and perioperative characteristics were collected to compare perioperative outcomes.

Results

Three hundred one patients were selected (109 in the aBVA cohort and 192 in the VAB cohort). The mean operation time was shorter in the aBVA cohort than in the VAB cohort (164 vs. 221 min, P < 0.001), and less blood loss occurred in the aBVA cohort (92 vs. 141 mL, P < 0.001). The rate of conversion to thoracotomy was lower in the aBVA cohort than in the VAB cohort (0% vs. 11.5%, P < 0.001). The mean duration of postoperative chest drainage was shorter in the aBVA cohort than in the VAB cohort (3.6 vs. 4.5 days, P = 0.001). The rates of postoperative complications were comparable (P = 0.629). The median overall survival was not arrived in both cohorts (P > 0.05). The median disease-free survival was comparable for all patients in the two cohorts (not arrived vs. 41.97 months) and for patients with disease recurrences (13.25 vs. 9.44 months) (both P > 0.05). The recurrence models in two cohorts were also comparable for patients with local recurrences (6.4% vs. 7.8%), distant metastases (10.1% vs. 8.3%), and both (1.8% vs. 1.6%) (all P > 0.05).

Conclusions

Dissecting the right upper bronchus before turning over the lobe repeatedly and dissecting veins via the aBVA approach during RUL would promote surgical feasibility and achieve comparable postoperative recovery for lung cancer patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s40880-017-0220-9) contains supplementary material, which is available to authorized users.

Enumeration and molecular characterization of circulating tumor cell using an in vivo capture system in squamous cell carcinoma of head and neck

Objective

Detection rate and isolation yield of circulating tumor cell (CTC) are low in squamous cell carcinoma of head and neck (SCCHN) with in vitro approaches due to limited sample volumes. In this study, we applied the CellCollector to capture CTC in vivo from peripheral blood.

Methods

In total, the study included 22 cases with 37 times of detection. All of the patients were newly diagnosed with locally advanced or metastatic SCCHN, including laryngocarcinoma (40.9%, 9/22) and hypopharyngeal carcinoma (59.1%, 13/22). All patients received CTC analysis before treatment. Three patients received induction chemotherapy. Sixteen patients received surgical therapy, of which 13 patients received postoperative detection. Two patients received both induction chemotherapy and surgery treatment. Patients underwent two successive CellCollector applications 24 h before and 7 d after surgical therapy. Nine healthy volunteers were enrolled as the control group. Epidermal growth factor receptor variant type III (EGFRVIII) expression was analyzed with fluorescent dye labeled antibody.

Results

With CellCollector isolation, 72.7% (16/22) of the patients were positive for ≥1 CTC (CTC; range, 1–17 cells) before treatments and 46.7% (7/15) of patients were CTC positive for ≥1 CTC (CTC; range, 1–29 cells) after surgical therapy. Moreover, the detection rate of CellCollector (82.4%, 14/17; CTC count range, 0–17) in advanced SCCHN (stage III–IV) was much higher than that in early stages (stage I–II, 40.0%, 2/5; CTC count range, 0–2) (P<0.05). EGFRVIII expression of CTC was also analyzed with fluorescence staining. One CTC^EGFRVIII-positive patient was detected from six CTC-positive patients, and the positive expression of EGFRVIII was also found in the tumor tissue of this patient.

Conclusions

In vivo detection of CTCs had high sensitivity in SCCHN, which might improve CTC application in clinic.

Sevoflurane attenuates platelets activation of patients undergoing lung cancer surgery and suppresses platelets-induced invasion of lung cancer cells

STUDY OBJECTIVE

Platelets play a pivotal role in metastasis of tumor cells. The aim of this study is to explore the effects of sevoflurane and isoflurane on platelets activation of patients undergoing lung cancer surgery, and the effects of sevoflurane and isoflurane on platelets-induced invasion of lung cancer cells.

DESIGN

Prospective and randomized study, and in vitro experiment.

SETTING

University-affiliated teaching hospital and laboratory.

PATIENTS

Forty-six patients scheduled for lung cancer radical surgery.

INTERVENTIONS

Patients were randomized to two groups of 23 patients each and were received sevoflurane (group SEV) or isoflurane (group ISO) during surgery, respectively. In vitro, lung cancer cells were treated with platelets in the presence or absence anesthetics.

MEASUREMENTS

Platelets activation were determined by detecting glycoproteinIIb/IIIa (GPIIb/IIIa), CD62P, and platelets aggregation rate (PAR) pre-, intra-, and postoperatively. Invasion ability of lung cancer cells were evaluated by Transwell assay.

RESULTS

The levels of GPIIb/IIIa, CD62P, and PAR were reduced markedly in group SEV during perioperative period compared with group ISO. In vitro, activated platelets contributed profoundly to the invasive ability of lung cancer cells. Sevoflurane, but not isoflurane, inhibited platelets-induced invasion of lung cancer cells. Furthermore, sevoflurane suppressed the platelets activity in vitro.

CONCLUSION

Sevoflurane attenuates platelets activation of patients undergoing lung cancer surgery. In vitro, sevoflurane suppresses platelets-induced invasion of lung cancer cells via decreasing platelets activity.

Does the mobilization of circulating tumour cells during cancer therapy cause metastasis?

Despite progressive improvements in the management of patients with locoregionally confined, advanced-stage solid tumours, distant metastasis remains a very common - and usually fatal - mode of failure after attempted curative treatment. Surgery and radiotherapy are the primary curative modalities for these patients, often combined with each other and/or with chemotherapy. Distant metastasis occurring after treatment can arise from previously undetected micrometastases or, alternatively, from persistent locoregional disease. Another possibility is that treatment itself might sometimes cause or promote metastasis. Surgical interventions in patients with cancer, including biopsies, are commonly associated with increased concentrations of circulating tumour cells (CTCs). High CTC numbers are associated with an unfavourable prognosis in many cancers. Radiotherapy and systemic antitumour therapies might also mobilize CTCs. We review the preclinical and clinical data concerning cancer treatments, CTC mobilization and other factors that might promote metastasis. Contemporary treatment regimens represent the best available curative options for patients who might otherwise die from locally confined, advanced-stage cancers; however, if such treatments can promote metastasis, this process must be understood and addressed therapeutically to improve patient survival.

Lack of Impact of Robotic Assisted Laparoscopic Radical Prostatectomy on Intraoperative Levels of Prostate Cancer Circulating Tumor Cells

PURPOSE

While the significance of circulating tumor cells in clinically localized cancer remains controversial, it has been reported that surgical tumor manipulation can increase circulating tumor cells, including during open prostatectomy. To our knowledge it is unknown whether this cell shedding also occurs during minimally invasive prostatectomy, which minimizes tumor palpation and uses earlier vascular control. We tested the impact of robotic assisted laparoscopic radical prostatectomy on intraoperative circulating tumor cell levels.

MATERIALS AND METHODS

Circulating tumor cell counts were compared in peripheral blood specimens from 25 patients treated with robotic assisted laparoscopic radical prostatectomy preoperatively vs intraoperatively after prostate excision, in addition to 11 healthy blood donors. Circulating tumor cell detection was performed using EpCAM immunomagnetic enrichment and multiparametric flow cytometry quantification of viable EpCAM positive/prostate specific membrane antigen positive/CD45 negative cells. Intraoperative cell counts and increases were tested in univariable analyses for associations with perioperative variables, histopathology and postoperative progression.

RESULTS

Circulating tumor cells were detected in 0% of healthy controls compared to 48% and 52% of prostatectomy cases preoperatively and intraoperatively, respectively (range 1 to 8 cells). There was no difference in the incidence or mean number of circulating tumor cells preoperatively vs intraoperatively. Of the patients 60% had no intraoperative change from preoperative levels. Intraoperative cell increases vs decreases were equally infrequent (each 20%) with no intraoperative increase greater than 1 circulating tumor cell. Intraoperative circulating tumor cell detection was not significantly associated with prostatectomy operative characteristics, histopathology or early postoperative progression at a median 21-month followup.

CONCLUSIONS

Robotic assisted laparoscopic radical prostatectomy does not cause significant intraoperative increases in circulating tumor cells in contrast to historical reports of open prostatectomy. These findings may aid urologists in counseling candidates for robotic assisted laparoscopic radical prostatectomy regarding the possibility of intraoperative tumor cell shedding.

Curative Effects of Different Sequences of Vessel Interruption During the Completely Thoracoscopic Lobectomy on Early Stage Non-Small Cell Lung Cancer

OBJECTIVE

To study the correlation between prognosis and different sequences of pulmonary artery and vein interruption during completely thoracoscopic lobectomy for early stage non-small cell lung cancer.

METHODS

Retrospective analysis of 334 cases underwent completely thoracoscopic lobectomy, which were identified as stage I~II non-small cell lung cancer by pathology. They were divided into three groups according to the order of vessel interruption: pulmonary vein first (Group V, n = 174), pulmonary artery first (Group A, n = 93), and artery-vein-artery group (Group M, n = 67). Their preoperative and operative conditions, and the postoperative survival, recurrence were compared.

RESULTS

Group A had less cases with history of smoking but more with history of pulmonary infection. The average bleeding amount during the operation in Group A is significantly less Group V, and Group M fell in between them. The duration of operation and postoperative complications were similar among the three groups. The types of tumor recurrence were also similar, which were mostly distant metastasis. There was no statistically significant difference in tumor-free survival and overall survival among the three groups.

CONCLUSIONS

For the treatment of stage I~II non-small cell lung cancer using completely thoracoscopic lobectomy, pulmonary artery interruption first can reduce the bleeding amount without affecting the operative difficulty and postoperative complications. The sequence of vessel interruption during lobectomy by thoracoscopic surgery would not affect tumor recurrence, metastasis and survival.

Circulating tumor cells in lung cancer: detection methods and clinical applications

Circulating tumor cells (CTCs) are tumor cells that have disseminated from primary and metastatic sites, and circulate in the bloodstream. Advanced immunological and molecular-based methods can be used to detect and analyze the cells with the characteristics of tumor cells, and can be detected and analyzed in the blood of cancer patients. The most commonly used methods in lung cancer combine the processes of immunomagnetic enrichment and immunocytochemical detection, morphology-based enrichment coupled with reverse transcriptase polymerase chain reaction (RT-PCR), and RT-PCR alone. CTC analysis is considered a liquid biopsy approach for early diagnosis, risk stratification, evaluation of curative efficacy, and early detection of lung cancer relapse. In this review, we discuss the present techniques for analyzing CTCs, and the restrictions of using these methods in lung cancer. We also review the clinical studies in lung cancer and discuss the underlying associations between these studies and their future applications to this disease.

Anaesthetic techniques for risk of malignant tumour recurrence

BACKGROUND

Surgery remains a mainstay of treatment for malignant tumours; however, surgical manipulation leads to a significant systemic release of tumour cells. Whether these cells lead to metastases is largely dependent on the balance between aggressiveness of the tumour cells and resilience of the body. Surgical stress per se, anaesthetic agents and administration of opioid analgesics perioperatively can compromise immune function and might shift the balance towards progression of minimal residual disease. Regional anaesthesia techniques provide perioperative pain relief; they therefore reduce the quantity of systemic opioids and of anaesthetic agents used. Additionally, regional anaesthesia techniques are known to prevent or attenuate the surgical stress response. In recent years, the potential benefit of regional anaesthesia techniques for tumour recurrence has received major attention and has been discussed many times in the literature. In preparing this review, we aimed to summarize the current evidence systematically and comprehensively.

OBJECTIVES

To establish whether anaesthetic technique (general anaesthesia versus regional anaesthesia or a combination of the two techniques) influences the long-term prognosis for individuals with malignant tumours.

SEARCH METHODS

We searched The Cochrane Library (2013, Issue 12), PubMed (1950 to 15 December 2013), EMBASE (1974 to 15 December 2013), BIOSIS (1926 to 15 December 2013) and Web of Science (1965 to 15 December 2013). We handsearched relevant websites and conference proceedings and reference lists of cited articles. We applied no language restrictions.

SELECTION CRITERIA

We included all randomized controlled trials or controlled clinical trials that investigated the effects of general versus regional anaesthesia on the risk of malignant tumour recurrence in patients undergoing resection of primary malignant tumours. Comparisons of interventions consisted of (1) general anaesthesia alone versus general anaesthesia combined with one or more regional anaesthetic techniques; (2) general anaesthesia combined with one or more regional anaesthetic techniques versus one or more regional anaesthetic techniques; and (3) general anaesthesia alone versus one or more regional anaesthetic techniques. Primary outcomes included (1) overall survival, (2) progression-free survival and (3) time to tumour progression.

DATA COLLECTION AND ANALYSIS

Two review authors independently scanned the titles and abstracts of identified reports and extracted study data.All primary outcome variables are time-to-event data. If the individual trial report provided summary statistics with odds ratios, relative risks or Kaplan-Meier curves, extracted data enabled us to calculate the hazard ratio using the hazard ratio calculating spreadsheet. To assess risk of bias, we used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included four studies with a total of 746 participants. All studies included adult patients undergoing surgery for primary tumour resection. Two studies enrolled male and female participants undergoing major abdominal surgery for cancer. One study enrolled male participants undergoing surgery for prostate cancer, and one study male participants undergoing surgery for colon cancer. Follow-up time ranged from nine to 17 years. All four studies compared general anaesthesia alone versus general anaesthesia combined with epidural anaesthesia and analgesia. All four studies are secondary data analyses of previously conducted prospective randomized controlled trials.Of the four included studies, only three contributed to the outcome of overall survival, and two each to the outcomes of progression-free survival and time to tumour progression. In our meta-analysis, we could not find an advantage for either study group for the outcomes of overall survival (hazard ratio (HR) 1.03, 95% confidence interval (CI) 0.86 to 1.24) and progression-free survival (HR 0.88, 95% CI 0.56 to 1.38). For progression-free survival, the level of inconsistency was high. Pooled data for time to tumour progression showed a slightly favourable outcome for the control group (general anaesthesia alone) compared with the intervention group (epidural and general anaesthesia) (HR 1.50, 95% CI 1.00 to 2.25).Quality of evidence was graded low for overall survival and very low for progression-free survival and time to tumour progression. The outcome of overall survival was downgraded for serious imprecision and serious indirectness. The outcomes of progression-free survival and time to tumour progression were also downgraded for serious inconsistency and serious risk of bias, respectively.Reporting of adverse events was sparse, and data could not be analysed.

AUTHORS' CONCLUSIONS

Currently, evidence for the benefit of regional anaesthesia techniques on tumour recurrence is inadequate. An encouraging number of prospective randomized controlled trials are ongoing, and it is hoped that their results, when reported, will add evidence for this topic in the near future.

Predictive and prognostic value of circulating tumor cell detection in lung cancer: a clinician's perspective

There is increasing evidence for the use of circulating tumor cells (CTCs) as a "liquid biopsy" for early detection of lung cancer recurrence, prognosticating disease and monitoring treatment response. Further, CTC molecular analysis and interrogation of single cells hold significant potential in providing insights into tumor biology and the metastatic process. Ongoing research will likely see the translation of CTCs as a prognostic and predictive biomarker in both small cell, and non-small cell, lung cancer to routine clinical practice.

[Major pulmonary resections for lung cancer and thoracoscopic approach: some reflections on published data]

Video-assisted thoracic surgery has a renewed topicality in treating early stage non-small cell lung cancer. Numerous publications show the benefits of this surgical technique in comparison with conventional thoracotomy. However, some surgeons are still apprehensive for its validity in lung cancer. Few works were dedicated to the critical aspect of this new technique which generates silent controversy and is far from having the general approval of all surgical teams. A critical review of several papers disclosed some concerns related to this approach, notably the risk of intra-operative technical problems and the possibility of questionable results concerning cancer dissection and clearance. A randomized clinical trial is now mandatory to confirm the safety and usefulness of this technique.

Anesthetic techniques and cancer recurrence after surgery

Many of the most common anesthetics are used in surgical oncology, yet effects on cancer cells are still not known. Anesthesia technique could differentially affect cancer recurrence in oncologic patients undergoing surgery, due to immunosuppression, stimulation of angiogenesis, and dissemination of residual cancer cells. Data support the use of intravenous anesthetics, such as propofol anesthesia, thanks to antitumoral protective effects inhibiting cyclooxygenase 2 and prostaglandins E2 in cancer cells, and stimulation of immunity response; a restriction in the use of volatile anesthetics; restriction in the use of opioids as they suppress humoral and cellular immunity, and their chronic use favors angiogenesis and development of metastases; use of locoregional anesthesia compared with general anesthesia, as locoregional appears to reduce cancer recurrence after surgery. However, these findings must be interpreted cautiously as there is no evidence that simple changes in the practice of anesthesia can have a positive impact on postsurgical survival of cancer patients.

Quantification of B16 melanoma cells in lungs using triplex Q-PCR--a new approach to evaluate melanoma cell metastasis and tumor control

Skin cancer is the most common type of all cancers. However, it comprises several different types of cancers, one of which is malignant melanoma. Even though melanomas only make up about 5% of skin cancers, they are responsible for the majority of skin cancer deaths due to the poor chance of survival once the tumor has metastasized. In the present study, we have developed a new assay for quantitative analysis of B16 melanoma metastasis in the lungs. We have used a triplex Q-PCR to determine the expression of the melanoma genes GP100/Pmel and tyrosinase-related protein 2 (TRP-2), and found that B16.F10gp cells were detectable in the lungs as early as 2 hours after intravenous challenge with ≥10⁴ tumor cells. When investigating the gene expression as a function of time, we observed a gradual decrease from 2–24 hours post tumor challenge followed by an increase of approximately 2 log₁₀ on day 11. The early decrease was accelerated in the presence of activated NK cells. To further evaluate our assay, we also investigated the level of metastasis in the context of vaccination with replication defective adenoviral vectors, Ad-Ii-GP and Ad-GP, previously found to significantly delay the outgrowth of subcutaneous melanomas. Results obtained using Q-PCR were compared to conventional counting of metastatic foci under a dissection microscope. A marked reduction in gene expression was observed in the lungs after vaccination with both vectors; however, Ad-Ii-GP showed the highest protection, and matching results were obtained by enumeration of visible tumor nodules on the lung surfaces. Finally, we could show that inhibition of tumor metastasis required antigen-specific CD8 T cells and IFNγ, but not perforin. In conclusion, the presented results validate triplex Q-PCR as a fast, objective, and quantitative method for analysis of melanoma metastasis in the lungs.

Surgical trauma and immune functional changes following major lung resection

Video-assisted thoracic surgery (VATS) has evolved greatly over the last two decades. VATS major lung resection for early stage non-small cell lung carcinoma (NSCLC) has been shown to result in less postoperative pain, less pulmonary dysfunction postoperatively, shorter hospital stay, and better patient tolerance to adjuvant chemotherapy compared with patients who underwent thoracotomy. Several recent studies have even reported improved long-term survival in those who underwent VATS major lung resection for early stage NSCLC when compared with open technique. Interestingly, the immune status and autologous tumor killing ability of lung cancer patients have previously been associated with long-term survival. VATS major lung resection can result in an attenuated postoperative inflammatory response. Furthermore, the minimal invasive approach better preserve patients' postoperative immune function, leading to higher circulating natural killer and T cells numbers, T cell oxidative activity, and levels of immunochemokines such as insulin growth factor binding protein 3 following VATS compared with thoracotomy. Apart from host immunity, the angiogenic environment following surgery may also have a role in determining cancer recurrence and possibly survival. Whether differences in immunological and biochemical mediators contribute significantly towards improved clinical outcomes following VATS major lung resection for lung cancer remains to be further investigated. Future studies will also need to address whether the reduced access trauma from advanced thoracic surgical techniques, such as single-port VATS, can further attenuate the postoperative inflammatory response.

The feasibility of a Two-incision video-assisted thoracoscopic lobectomy

Background

This study is to evaluate the feasibility and safety of video-assisted thoracoscopic (VATS) lobectomy with two incisions.

Methods

A total of 73 patients (male 47, female 26; mean age 61.2 ± 12.00 years old) who underwent major pulmonary resection, through VATS, using two incisions were included in this study. The thoracoscopy port was placed at the 7th or the 8th intercostal space in the mid-axillary line, and the working port, 3~5 cm long, at the 5th intercostal space, on the operator’s side.

Results

The preoperative diagnosis was benign lung disease in 8 patients (11.0%) and malignant lung disease in 65 (89.0%). Two patients (3.1%) needed a third port during surgery due to severe pleural adhesion, and conversion to thoracotomy was needed in 5 (6.8%), due to bleeding at pulmonary arterial branch (n = 3), anthracofibrotic lymph nodes around pulmonary artery (n = 1), and severe pleural adhesion (n = 1). The mean duration of the operation in the 66 patients, completed by a two-incision VATS lobectomy, was 163.4 ± 30.40 minutes. In 56 cases, which were completed by a two-incision VATS lobectomy for primary lung cancer, a total number of dissected lymph nodes per patient were 20.2 ± 11.2. The chest tube was removed on postoperative day 5.4 ± 2.8, and there was no occurrence of major perioperative morbidity and mortality.

Conclusions

Two-incision VATS lobectomy is applicable in the selected cases, and may obtain similar results with the conventional VATS lobectomy, through a certain period of learning curve.

Meta-analysis of circulating tumor cells as a prognostic marker in lung cancer

INTRODUCTION

Recent studies have shown that circulating tumor cells (CTCs) play potential roles as diagnostic and prognostic biomarkers with various cancer types. The aim of this study was to comprehensively and quantitatively summarize the evidence for the use of CTCs to predict the survival outcome of lung cancer patients.

MATERIALS AND METHODS

Relevant literature was identified using Medline and EMBASE. Patients' clinical characteristics, overall survival (OS) and progression-free survival (PFS) together with CTC positive rates at different time points (before, during and after treatment) were extracted. A meta-analysis was performed to clarify the prognostic role of CTCs and the correlation between the CTC appearance and clinical characteristics.

RESULTS

A total of 12 articles containing survival outcomes and clinical characteristics and 15 articles containing only clinical characteristics were included for the global meta-analysis. The hazard ratio (HR) for OS predicted by pro-treatment CTCs was 2.61 [1.82, 3.74], while the HR for PFS was 2.37 [1.41, 3.99]. The HR for OS predicted by post-treatment CTCs was 4.19 [2.92, 6.00], while the HR for PFS was 4.97 [3.05, 8.11]. Subgroup analyses were conducted according to histological classification and detection method. Odds ratio (OR) showed the appearance of pro-treatment CTCs correlated with the lymph node status, distant metastasis, and TNM staging, while post-treatment CTCs correlated with TNM staging only.

CONCLUSION

Detection of CTCs in the peripheral blood indicates a poor prognosis in patients with lung cancer.

Fluid biopsy for solid tumors: a patient's companion for lifelong characterization of their disease

Cancer is currently diagnosed and treated based on the results of a tissue biopsy of the primary tumor or a metastasis using invasive techniques such as surgical resection or needle biopsy. New technology for retrieving cancer cells from the circulation, developed in the last 5 years, has made it possible to obtain a 'fluid biopsy' from the bloodstream without the need for an invasive procedure. This technological development makes it possible to diagnose and manage cancer from a blood test rather than from a traditional biopsy. It also allows the repeated sampling of cancer cells from a patient, making it possible, in a practical manner, to interrogate the disease repeatedly in order to understand the mechanisms by which cancer cells evolve within a given individual. The ability to obtain cancer cells repeatedly also has the potential to substantially advance drug development by enabling early ex vivo validation of both targets and early-stage compounds, as well as creating new efficiencies in the drug development process during clinical trials.

Effects of different sequences of pulmonary artery and vein ligations during pulmonary lobectomy on blood micrometastasis of non-small cell lung cancer

The aim of this study was to investigate the effects of different sequences of pulmonary artery and vein ligations during lobectomy on blood micrometastasis of non-small cell lung cancer (NSCLC). Cytokeratin 19 (CK19)/adhesion molecule CD44v6 mRNA were used as markers. A total of 30 NSCLC patients undergoing pulmonary lobectomy were randomly divided into pulmonary artery (PA)-first and pulmonary vein (PV)-first groups according to the order of artery or vein ligation (15 cases in each). Fluorescent quantitative-RT-PCR (FQ-RT-PCR) was used to detect the mRNA expression of CK19 and CD44v6 in pulmonary venous blood at the early and late periods during surgery, and ΔCt values were calculated. Meanwhile, the peripheral blood samples from 10 healthy volunteers were selected as the control. ΔCt values of CD44v6 and CK19 of NSCLC groups at the early period during surgery were 7.83±1.70 and 10.76±2.74, while those of the control group were 9.17±1.04 and 12.76±2.36. The expression of CD44v6 and CK19 genes in venous blood of NSCLC groups was significantly higher than that of the control group (P<0.05). In addition, the ΔCt values of CD44v6 and CK19 in the early and late periods during surgery in the PA-first group were 7.92±1.97 vs. 5.67±2.11 (P= 0.008) and 11.21±3.14 vs. 8.60±4.02 (P= 0.05), respectively. The expression of CD44v6 and CK19 in the late period were both significantly higher than those in the early period, while neither the ΔCt value of CD44v6 nor that of CK19 in the early vs. late periods in the PV-first group exhibited statistically significant differences (7.95±1.91 vs. 7.74±2.10 and 10.60±3.15 vs. 10.30±2.98) (P<0.05). Surgical manipulation itself may stimulate the occurrence of blood micrometastasis and the ligation of the PV first during surgery may help prevent blood micrometastasis.

Angiogenic response to major lung resection for non-small cell lung cancer with video-assisted thoracic surgical and open access

Background. Angiogenic factors following oncological surgery is important in tumor recurrence. Vascular endothelial growth factor (VEGF), angiopoietin 1 (Ang-1), Ang-2, soluble VEGF-receptor 1 (sVEGFR1) and sVEGFR2 may influence angiogenesis. This prospective study examined the influence of open and video-assisted thoracic surgery (VATS) lung resections for early stage non-small cell lung cancer (NSCLC) on postoperative circulating angiogenic factors. Methods. Forty-three consecutive patients underwent major lung resection through either VATS (n = 23) or Open thoracotomy (n = 20) over an 8-month period. Blood samples were collected preoperatively and postoperatively on days (POD) 1 and 3 for enzyme linked immunosorbent assay determination of angiogenic factors. Results. Patient demographics were comparable. For all patients undergoing major lung resection, postoperative Ang-1 and sVEGFR2 levels were significantly decreased, while Ang-2 and sVEGFR1 levels markedly increased. No significant peri-operative changes in VEGF levels were observed. Compared with open group, VATS had significantly lower plasma levels of VEGF (VATS 170 ± 93 pg/mL; Open 486 ± 641 pg/mL; P = 0.04) and Ang-2 (VATS 2484 ± 1119 pg/mL; Open 3379 ± 1287 pg/mL; P = 0.026) on POD3. Conclusions. Major lung resection for early stage NSCLC leads to a pro-angiogenic status, with increased Ang-2 and decreased Ang-1 productions. VATS is associated with an attenuated angiogenic response with lower circulating VEGF and Ang-2 levels compared with open. Such differences in angiogenic factors may be important in lung cancer biology and recurrence following surgery.

[Influence of anesthesia procedure on malignant tumor outcome]

Malignant tumors are the second major cause of death in Germany. The essential therapy of operable cancer is surgical removal of primary tumors combined with adjuvant therapy. However, several consequences of surgery may promote metastasis, such as shedding of tumor cells into the circulation, decrease in tumor-induced antiangiogenesis factors, excessive release of growth factors for wound healing and suppression of immunity induced by surgical stress. In the last decade it has become clear that cell-mediated immunity controls the development of metastasis. Various perioperative factors, such as surgical stress, certain anesthetic and analgesic drugs and pain can suppress the patients' immune system perioperatively. On the other hand, by modifications of the anesthesia technique (e.g. regional anesthesia) and perioperative management to minimize immunosuppression, anesthesiologists can play a considerable role for a better outcome in patients having malignant tumors. Sufficient clinical evidence is not yet available to prove or disprove the hypothesis that anesthesia practice can improve cancer prognosis. Despite difficulties in study design, several prospective randomized trials are currently running and the results are awaited to elucidate this topic.

CXCL12-binding receptors expression in non-small cell lung cancer relates to tumoral microvascular density and CXCR4 positive circulating tumoral cells in lung draining venous blood

OBJECTIVES

Lung cancer is the main cause of cancer-related death in Western countries. Despite early diagnosis, approximately 40% of patients have undergone surgical resection for localized non-small cell lung cancer relapse within 24 months after surgery. Current prognostic criteria for patients with non-small cell lung cancer are gradually enriched by the discovery of critical biological markers in surgical samples to better stratify patients with high risk for recurrent and metastatic disease after surgical manipulation. In fact, specific biological features are needed to drive metastasis development and, among these chemokine receptors, when activated, seem to play a relevant role, promoting both neovessels formation and tumoral cell migration.

METHODS

To this purpose, blood samples from the closed stumps of the pulmonary veins were drawn immediately after major pulmonary surgery in 45 patients with resectable non-small cell lung cancer to evaluate the expression of chemokine CXCL12 receptor, CXCR4, in circulating tumor cells. In addition, primary tumor sections have been used to assess microvascular density (MVD) and vessels invasion and build prognostic tissue micro-array to investigate the expression of CXCL12 receptors CXCR4 and CXCR7.

RESULTS

Cells positive for cytokeratins from tumor draining pulmonary venous blood were detectable in 11 cases (23.9%). In 8 out of 11 cases, CK positive cells coexpressed CXCR4. Moreover, in tumoral tissue high CXCR4 expression was significantly associated to high mMVD (p = 0.046), high CXCR7 expression (p = 0.001), adenocarcinoma histotype (p = 0.023), and to the presence of circulating tumoral cells in pulmonary veins (p = 0.001). Finally, vessel invasions relate to high MVD.

CONCLUSION

In conclusion, the results of our study underline the significant potential role of CXCL12 receptors in determining both vessel formation and tumoral cell migration to blood stream, favoring metastasis development.

Economics and practice management issues associated with acute pain management

The use of regional anesthesia (RA) improves cost benefit (hospital-centered) and cost utility (patient-centered) over general anesthesia with volatile agents (GAVA), based upon research in outpatient populations. To make the cost savings a reality, the authors recommend: (1) avoidance of GAVA or at least volatile agents, (2) adopting published postanesthesia care unit (PACU)-bypass criteria conducive to RA, (3) maximizing PACU-bypass rates, and (4) utilizing a block induction area. Inpatient-based acute pain services are not uniform, which makes cost analyses and comparison between practices unreliable. Additional review and commentary address surgical site infections, cancer recurrence, blood transfusions, and chronic postsurgical pain.

Analysis of 1,067 cases of video-assisted thoracic surgery lobectomy

Background

Video-assisted thoracic surgery (VATS) lobectomy has been performed with increasing frequency over the last decade. However, there is still controversy as to its indications, safety, and feasibility. Especially regarding lung cancer surgery, it is not certain whether it can reduce local recurrences and improve overall survival.

Materials and Methods

We retrospectively reviewed 1,067 cases of VATS lobectomy performed between 2003 and 2009, including the indications, postoperative morbidity, mortality, recurrence, and survival rate.

Results

One thousand and sixty seven patients underwent VATS lobectomy for the following indications: non-small cell lung cancer (NSCLC) (n=832), carcinoid tumors (n=12), metastatic lung cancer (n=48), and benign or other diseases (n=175). There were 63 cases (5.9%) of conversion to open thoracotomy during VATS lobectomy. One hundred thirty one (15.7%) of the 832 NSCLC patients experienced pathologic upstaging postoperatively. The hospital mortality rate was 0.84% (9 patients), and all of them died of acute respiratory distress syndrome. One hundred forty-nine patients (14.0%) experienced postoperative complications. The median follow-up was 22.9 months for patients with NSCLC. During follow-up, 120 patients had a recurrence and 55 patients died. For patients with pathologic stage I, the overall survival rate and disease-free survival rate at 3 years was 92.2±1.5% and 86.2±1.9%, respectively. For patients with pathologic stage II disease, the overall survival rate and disease-free survival rate at 3 years was 79.2±6.5% and 61.9±6.6%, respectively.

Conclusion

Our results suggest that VATS lobectomy is a technically feasible and safe operation, which can be applied to various lung diseases. In patients with early-stage lung cancer, excellent survival can be also achieved.

Video-Assisted Thoracic Surgery (VATS) Lobectomy for Pathologic Stage I Non-Small Cell Lung Cancer: A Comparative Study with Thoracotomy Lobectomy

BACKGROUND

Surgical treatment of stage I non-small cell lung cancer (NSCLC) can be performed either by thoracotomy or by employing video-assisted thoracic surgery (VATS). The aim of this study was to evaluate the feasibility of VATS lobectomy for pathologic stage I NSCLC.

MATERIAL AND METHODS

Between December 2003 and December 2007, 529 patients with pathologic stage I NSCLC underwent lobectomies (373 thoracotomy, 156 VATS). Patients in both groups were selected after being matched by age, gender and pathologic stage using propensity score method, to create two comparable groups: thoracotomy and VATS groups, and the overall survival, recurrence-free survival, complication and length of hospitalization were compared between these two groups.

RESULTS

After the patients were matched by age, gender and pathologic stage, 272 patients remained eligible for analysis, 136 in each group (mean age of 59.5 years; 70 men, 66 women; 80 stage IA, 56 stage IB). There was no statistical difference in other preoperative clinical characteristics between the two groups. No hospital mortality was observed in both groups. Overall 3-year survival rate was 97.4% in thoracotomy group and 96.6% in VATS groups (p=0.76). During the follow-up, 20 patients (14.7%) developed recurrence in thoracotomy group, including loco- regional recurrence in 7, distant metastasis in 13. In VATS group, 13 patients (9.6%) developed recurrence, including loco-regional recurrence in 4, distant metastasis in 9. Three-year recurrence-free survival rate was 81.8% in thoracotomy group and 85.3% in VATS groups (p=0.43). There was no significant difference in postoperative complications between thoracotomy and VATS groups (30 cases in 22 patients vs. 19 cases in 17 patients, p=0.65, odds ratio=1.19). The mean hospital stay of VATS group was 2 days shorter than that of thoracotomy group (8.8±6.5 days vs. 6.3±3.3 days, p<0.05).

CONCLUSION

VATS lobectomy for pathologic stage I lung cancer is a feasible operation with shorter hospitalization, while surgical outcome is comparable to thoracotomy lobectomy.

Review article: the role of the perioperative period in recurrence after cancer surgery

A wealth of basic science data supports the hypothesis that the surgical stress response increases the likelihood of cancer dissemination and metastasis during and after cancer surgery. Anesthetic management of the cancer patient, therefore, could potentially influence long-term outcome. Preclinical data suggest that beneficial approaches might include selection of induction drugs such as propofol, minimizing the use of volatile anesthetics, and coadministration of cyclooxygenase antagonists with systemic opioids. Retrospective clinical trials suggest that the addition of regional anesthesia might decrease recurrence after cancer surgery. Other factors such as blood transfusion, temperature regulation, and statin administration may also affect long-term outcome.