Overall survival with adjuvant atezolizumab after chemotherapy in resected stage II-IIIA non-small-cell lung cancer (IMpower010): a randomised, multicentre, open-label, phase III trial

BACKGROUND

IMpower010 (NCT02486718) demonstrated significantly improved disease-free survival (DFS) with adjuvant atezolizumab versus best supportive care (BSC) following platinum-based chemotherapy in the programmed death-ligand 1 (PD-L1)-positive and all stage II-IIIA non-small-cell lung cancer (NSCLC) populations, at the DFS interim analysis. Results of the first interim analysis of overall survival (OS) are reported here.

PATIENT AND METHODS

The design, participants, and primary-endpoint DFS outcomes have been reported for this phase III, open-label, 1 : 1 randomised study of atezolizumab (1200 mg q3w; 16 cycles) versus BSC after adjuvant platinum-based chemotherapy (1-4 cycles) in adults with completely resected stage IB (≥4 cm)-IIIA NSCLC (per the Union Internationale Contre le Cancer and American Joint Committee on Cancer staging system, 7th edition). Key secondary endpoints included OS in the stage IB-IIIA intent-to-treat (ITT) population and safety in randomised treated patients. The first pre-specified interim analysis of OS was conducted after 251 deaths in the ITT population. Exploratory analyses included OS by baseline PD-L1 expression level (SP263 assay).

RESULTS

At a median of 45.3 months' follow-up on 18 April 2022, 127 of 507 patients (25%) in the atezolizumab arm and 124 of 498 (24.9%) in the BSC arm had died. The median OS in the ITT population was not estimable; the stratified hazard ratio (HR) was 0.995 [95% confidence interval (CI) 0.78-1.28]. The stratified OS HRs (95% CI) were 0.95 (0.74-1.24) in the stage II-IIIA (n = 882), 0.71 (0.49-1.03) in the stage II-IIIA PD-L1 tumour cell (TC) ≥1% (n = 476), and 0.43 (95% CI 0.24-0.78) in the stage II-IIIA PD-L1 TC ≥50% (n = 229) populations. Atezolizumab-related adverse event incidences remained unchanged since the previous analysis [grade 3/4 in 53 (10.7%) and grade 5 in 4 (0.8%) of 495 patients, respectively].

CONCLUSIONS

Although OS remains immature for the ITT population, these data indicate a positive trend favouring atezolizumab in PD-L1 subgroup analyses, primarily driven by the PD-L1 TC ≥50% stage II-IIIA subgroup. No new safety signals were observed after 13 months' additional follow-up. Together, these findings support the positive benefit-risk profile of adjuvant atezolizumab in this setting.

[Antibiotic consumption and bacterial sensitivity in a teaching hospital: A 5-year study]

INTRODUCTION

To reduce risks of antibiotic resistance, governmental and learned societies decreed the optimal use of antibiotics. The relation between antibiotic consumption and bacterial resistance increase has been clearly demonstrated over the last several years. Antibiotic consumption data and bacterial sensitivity data are regularly published, but very few publications have searched for a correlation between these two variables. This study focused on antibiotic use and consumption as well as bacterial sensitivity to these antibiotics.

OBJECTIVES

The main objective was to describe the changes in antibiotic consumption and bacterial sensitivity in a mother-child teaching hospital. The secondary objectives were to explore whether antibiotic use and bacterial sensitivity were correlated and to comment on the usefulness of these data for clinicians.

METHODS

This was a 5-year retrospective, descriptive, cross-sectional study. All samples from usually sterile biologic liquids of hospitalized pediatric patients were included in the study. The samples from outpatient clinics were excluded. All types of bacteria identified in more than 30 isolates were included in the study. The antibiotics usually used to treat these bacteria were included. To assess antibiotic consumption, we calculated the number of days of therapy per 1000 patient-days for hospitalized pediatric patients and we calculated the Pearson correlation coefficient between antibiotic consumption and sensitivity rates to these antibiotics. Two scenarios were explored: one with correlation by year and one with the next year for bacterial sensitivity.

RESULTS

During the study period (2010-2011 to 2014-2015), overall antibiotics consumption remained relatively stable. Concerning bacterial sensitivity, we noted important changes (sensitivity rates increased for 12 antibiotic-bacteria pairs, remained stable for five, and decreased for 15). We found three significant correlations for the first scenario: Pseudomonas aeruginos-ceftazidime (P=0.01), P. aeruginosa-ciprofloxacin and fluoroquinolone consumption (P=0.02), Enterococcus sp-ampicillin and penicillin consumption (P=0.04). For the second scenario, we found only two significant correlations: coagulase-negative Staphylococcus-oxacilline and penicillin consumption (P=0.02), P. aeruginosa/piperacillin (P=0.04).

CONCLUSION

This exploratory study allowed us to describe antibiotic consumption and bacterial sensitivity progression. To our knowledge, this is the first study exploring the correlation between antibiotic consumption and the bacterial sensitivity rate in pediatrics in Canada. It remains very difficult to show this correlation between these two variables because of the multiple sources of bacterial resistance. These data are particularly useful for the antimicrobial stewardship programs and for clinicians.

Role of bronchoscopy in massive hemoptysis

Airway hemorrhage is a potentially rapidly fatal condition. Death may occur within minutes from asphyxiation before control can be achieved. The primary prognostic factors are the rate of bleeding and the underlying cardiopulmonary status of the patient. Bronchoscopy is central in management, but the goals differ, depending on circumstances. In stable patients who have minimal hemoptysis, bronchoscopy can diagnose the cause specifically and be used as the primary treatment modality. In the setting of massive or life-threatening bleeding, bronchoscopy primarily is performed to maintain ventilation and to direct endobronchial blockade. Although flexible bronchoscopy is an acceptable mode initially, there should be no delay in performing rigid bronchoscopy when it becomes apparent that bleeding is too vigorous to permit [figure: see text] successful airway exploration with the smaller flexible instrument. Once isolation of bleeding has been achieved, the choice must be made between embolization, surgical resection, or both of these procedures.

Endoscopic upper thoracic sympathectomy

Thoracoscopic sympathectomy provides a superb surgical option for the many patients with incapacitating essential hyperhidrosis. Whether one thoracoscopic approach to sympathectomy is ever likely to prevail is doubtful, as the results of the various reported techniques seem to be quite similar. There are definite advantages to the single-port approaches, which are faster and usually do not require repositioning of the patient to do both sides. In the rare instances where dense apical adhesions are encountered or when significant bleeding is encountered from one of the intercostal vessels, the two- or three-port approaches definitely provide better control (see commentary in article by Kohno and Takamoto). Surgeon preference probably dictates which approach is used at the different centers. Compensatory sweating remains a frequent and sometimes serious complication of the procedure, particularly in individuals living in hot climates. An understanding of its mechanisms needs improvement, with the hope of preventing its occurrence in the future. In the meantime, patients have to be informed of its frequency, and operations could probably be tailored to the patients' needs and their local climate.

Surgical management of lung gangrene

OBJECTIVE

To review the outcomes of five cases of pulmonary resection for lung gangrene.

DESIGN

A retrospective chart review.

SETTING

A tertiary referral centre.

POPULATION STUDIED

Five patients who underwent pulmonary resection for lung gangrene between April and December 1999.

MAIN RESULTS

Pathological confirmation of lung gangrene was obtained in all cases. Three patients were ventilator dependent. All five patients had ongoing sepsis despite antibiotic therapy. Additional indications for resection included bronchopleural fistula (two patients), empyema (three patients) and hemoptysis (one patient). In two cases, there was evidence of bilateral, diffuse necrotizing pneumonia, while in three cases the process was localized to one side. Computed tomography revealed cavitation in four cases and the absence of blood supply to the affected lung in one case. Surgical resection included wedge resection (one patient), lobectomy (two patients), bilobectomy (one patient) and pneumonectomy (one patient). In all cases, the bronchial stump was reinforced with an intercostal flap. Postoperative empyema occurred in two cases, one treated by thoracoscopic decortication, the other by percutaneous drainage. There were no instances of stump leak and no deaths. One patient remains ventilator dependent.

CONCLUSIONS

Resection for lung gangrene is possible even in the setting of diffuse parenchymal changes and ventilator dependency. A computed tomography scan of the chest is important to make the diagnosis of lung gangrene and to plan operative management. Reinforcement of the bronchial stump is critical.

Descending necrotizing mediastinitis: An analysis of the effects of serial surgical debridement on patient mortality

OBJECTIVES

Descending necrotizing mediastinitis is a polymicrobial infection originating in the oropharynx with previously reported mortality rates of 25% to 40%. This investigation reviews the effects of serial surgical drainage and debridement on the survival of patients with descending necrotizing mediastinitis.

METHODS

A retrospective review of patients from 1980 through 1998 with a diagnosis of descending necrotizing mediastinitis was performed. Their records were abstracted for personal demographics, hospital course, morbidity, and mortality. Also abstracted were all reports of patients with descending necrotizing mediastinitis published in English between 1970 and 1999.

RESULTS

We treated 10 patients in whom descending necrotizing mediastinitis was identified. The mean age of the patients was 38 years. They underwent a mean of 6 +/- 4 computed tomographic imaging studies, 4 +/- 1 transcervical drainage procedures, and 2 +/- 1 transthoracic drainage procedures. Three patients required abdominal exploration and 4 underwent tracheostomy. No deaths occurred. In contrast, 96 patients with descending necrotizing mediastinitis were identified from the literature with a mean age of 38 years. They underwent a mean of 2 +/- 1 computed tomographic imaging studies, 2 +/- 1 transcervical drainage procedures, and 0.7 + 0.3 transthoracic drainage procedures. Sixteen (17%) patients required abdominal exploration and 34 (35%) underwent tracheostomy. Twenty-eight (29%) patients from the literature cohort died during their treatment.

CONCLUSION

Descending necrotizing mediastinitis remains a life-threatening infection. On the basis of experience accrued in treating these patients, an algorithm incorporating computed tomographic imaging for diagnosis and surveillance and serial transcervical and transthoracic operative drainage is outlined in the hope of reducing the excessive mortality of descending necrotizing mediastinitis.

Early complications. Chylothorax

Postpneumonectomy chylothorax is a very common but serious complication. Drainage of the pneumonectomy space, metabolic and nutritional support with TPN, and absolute enteral rest may lead to control of the leak. Failure of these measures to obtain a rapid resolution of the chyle losses should be followed by early surgical intervention in most instances in an effort to alleviate the chronic metabolic, nutritional, and immunological consequences of prolonged chyle losses.

Percutaneous placement of tracheal T tube

Tracheal T tubes provide effective palliation of unresectable benign and malignant tracheal obstruction, but placement may be difficult when previous operation, radiation, or tumor limits surgical exposure of the cervical trachea. Percutaneous placement using commercially available percutaneous tracheostomy kits may provide an alternative approach in these cases.

Tracheobronchial resection and reconstruction

OBJECTIVE

To assess the indications and results of airway resection and how frequently airway reconstructive options changed proposed therapy.

DESIGN

A retrospective survey of patients undergoing major airway resection.

SETTING

University of Washington-affiliated hospitals, Seattle, May 1992 through December 1996.

PATIENTS

Fifty consecutive patients with resectable benign and malignant tracheal or main bronchial disease undergoing tracheobronchial resections.

INTERVENTIONS

Patients underwent major airway resection as follows: tracheal or laryngotracheal resection, 23 patients; carinal resection, 6; and bronchial sleeve resection with or without pulmonary resection, 21. Indications for surgery were non-small cell lung cancer in 19 patients, primary airway tumor in 12, thyroid carcinoma in 1, and tracheal or bronchial stenosis in 18.

MAIN OUTCOME MEASURES

Change in prereferral planned therapy from palliative to definitive or to pulmonary-sparing procedure, morbidity and mortality, relief of symptoms, and survival.

RESULTS

Mortality was 0%, and morbidity, 32% (15/50). Airway reconstruction changed the proposed therapy in 42 patients (84%). Functional results were good to excellent in 17 (94%) of 18 patients with benign disease. Patients with malignant disease had a 1-year survival of 93% (27/29) and a 2-year survival of 67% (12/18).

CONCLUSIONS

Airway resection and reconstruction provide reliable relief of benign and malignant tracheobronchial disease with minimal morbidity and mortality. Airway reconstruction frequently changed prereferral planned therapy and provided definitive and parenchymal-sparing procedures to patients with complex airway lesions.

Ex-vivo fine needle aspiration. A new method of xenografting non-small cell carcinoma of the lung

Ex-vivo needle aspiration (xvFNA) has been rarely used to obtain viable tumor cells. It has been occasionally employed for short-term cultures. Xenografting of lung carcinoma in athymic nude mice provides a good animal model for the study of this neoplasm. Successful engraftment using conventional methods has been disappointing) low (d 40%). Enzymatic digestion of the tumor fragments to obtain cell suspension lowers viability. We postulated that xvFNA might provide readily available tumor cell suspensions for xenografting lung carcinoma and that it would provide a higher success rate of engraftment than the conventional techniques. We aseptically performed xnFNA in 35 cases of freshly resected non-small cell carcinoma of the lung. These included 15 adenocarcinomas, 17 squamous carcinomas and 3 undifferentiated non-small cell carcinoma (UNSCC). Tumor cell suspensions were injected subcutaneously in athymic nude mice. Tumor necrosis in the aspirates ranged from 20-90% (median 60%). Gross evidence of engraftment was seen in 30 of 35 cases (85.7%) 1-19 weeks postimplantation (median 2 weeks). This was seen in UNSCC (3/3), squamous carcinomas (13/17) and adenocarcinomas (14/15). Xenograft sizes ranged from 5-34 mm (median 19 mm). They showed similar morphology to the primary tumors. Ex-vivo FNA used for harvesting lung carcinoma cells and their xenografting is an effective method for obtaining viable material for studying this neoplasm.

Combined microneurosurgical and thoracoscopic removal of neurogenic dumbbell tumors

The resection of posterior mediastinal dumbbell tumors has until now required laminectomy and some form of open access to the thoracic cavity. Over a 1-year period, a novel surgical approach combining posterior microneurosurgical and anterior video-assisted thoracoscopy techniques was used in 4 patients. In 3 patients, the tumor was removed successfully with minimal postoperative discomfort and rapid recovery. In the fourth patient, limited thoracotomy became necessary to control bleeding. This new approach, which combines modern-day neurosurgical and general thoracic surgical techniques, appears safe and could become the preferred method for removing most benign posterior mediastinal dumbbell tumors.

Carcinoid crisis after biopsy of a bronchial carcinoid

Pulmonary carcinoids are rarely associated with carcinoid syndromes and even less commonly with carcinoid crisis. Somatostatin analogues can control carcinoid syndrome or crisis with tumors of gastrointestinal origin. We report the successful use of a somatostatin analogue in preventing carcinoid crisis at the time of resection of an "active" bronchial carcinoid tumor.

Central neurogenic tumours of the thoracic region

Of special concern in the management of neurogenic tumours arising in the thorax is spinal-cord compression resulting from either intraspinal lesions or vertebral-body destruction and collapse. A review of 16 cases disclosed three dumbbell tumours, six intrathoracic tumours, one case of neurofibromatosis with multiple intraspinal neurogenic tumours, two malignant neurogenic tumours with vertebral-body destruction causing spinal-cord compression and four foraminal lesions with central intraspinal (extradural) extension. There were 3 men and 13 women, ranging in age at the time of operation from 37 to 79 years. Three patients, of the six with intrathoracic tumours, were asymptomatic; the remaining 13 had preoperative symptoms ranging in duration from 3 weeks to 12 months (average, 9 months). Back pain with intercostal neuralgia was present in eight patients and neurologic signs were present in six patients. A routine chest radiograph was abnormal in 10 patients, and x-rays of the thoracic spine were abnormal in 4 of the other 6 patients. The tumour was excised surgically in all patients. Complications developed postoperatively in two patients: one had Horner's syndrome, transient paraparesis and bleeding; the other had a small subarachnoid-cutaneous fistula. The authors conclude that dumbbell neurogenic tumours and those causing vertebral-body destruction and collapse demand a multidisciplinary one-stage surgical approach. If the lesion is malignant and resection is not complete, radiotherapy or chemotherapy is necessary.

Ambulatory mediastinoscopy and anterior mediastinotomy

Ambulatory facilities are being used more and more for various diagnostic and therapeutic procedures. We report 158 consecutive mediastinoscopies and anterior mediastinotomies performed in an ambulatory setting from July 1981 to February 1990. There were 120 patients with a malignancy: 114 bronchogenic carcinomas, 4 lymphomas, 1 teratocarcinoma, and 1 carcinoma of the stomach. Thirty-eight patients had a benign condition, including sarcoidosis in 27 and miscellaneous diagnosis in 11. Twenty-two patients (14%) were admitted the same day: 9 for elective operation in view of bed availability, 8 for medical observation, and 5 for overnight admission for nonmedical reasons. Six nonfatal complications were encountered: hemoptysis (2), atrial fibrillation (1), pneumonia (1), mediastinal self-contained bleed (1), and tear of a pulmonary artery (1). There was no operative mortality. Overall, ambulatory mediastinoscopy and anterior mediastinotomy permitted a diagnosis in 47 patients (20%) and confirmed unresectable malignant disease in 29 patients, thus sparing unnecessary admission to a surgical ward in 76 (48%) of the 158 patients. Mediastinoscopy and anterior mediastinotomy can be safely performed in an ambulatory setting and do alleviate the need for hospitalization in a substantial number of patients.

Incidence of mediastinal node involvement in clinical T1 bronchogenic carcinomas

The incidence of mediastinal node involvement of T1 non-small-cell bronchogenic carcinomas was determined in 262 patients for the period June 1981 to January 1986. All patients underwent mediastinoscopy as part of their evaluation. Thirty-five patients (13%) had clinical primary T1 lesions. There were 17 adenocarcinomas, 10 squamous cell carcinomas, 6 large-cell anaplastic carcinomas and 2 bronchoalveolar carcinomas. Five patients had node involvement at mediastinoscopy: two had large-cell anaplastic carcinomas and one was a squamous cell carcinoma. Thoracotomy in the remaining 30 patients revealed 2 with pleural metastases, 1 with left upper lobe adenocarcinoma with metastases to the subaortic nodal area (not assessed by cervical mediastinoscopy). The other patients underwent resection, for a resectability rate of 90%. Therefore the overall incidence of mediastinal node involvement in this series was 17% (6 of 35) and was found to be highest among patients with large-cell anaplastic carcinomas (2 of 6), followed by adenocarcinomas (3 of 19) and squamous cell carcinomas (1 of 10). The larger number of large-cell anaplastic carcinomas in this series probably accounts for the higher incidence of N2 disease found compared with that of previous studies in the literature. Accordingly, preoperative mediastinal staging is recommended for all T1 large-cell anaplastic carcinomas and adenocarcinomas and for suspicious lesions of undetermined histology.