The International Association for the Study of Lung Cancer Lung Cancer Staging Project: Proposals for the Revision of the Clinical and Pathologic Staging of Small Cell Lung Cancer in the Forthcoming Eighth Edition of the TNM Classification for Lung Cancer

INTRODUCTION

Small cell lung cancer (SCLC) is commonly classified as either limited or extensive, but the Union for International Cancer Control TNM Classification of Malignant Tumours seventh edition (2009) recommended tumor, node, and metastasis (TNM) staging based on analysis of the International Association for the Study of Lung Cancer (IASLC) database.

METHODS

Survival analyses were performed for clinically and pathologically staged patients presenting with SCLC from 1999 through 2010. Prognosis was compared in relation to the TNM seventh edition staging to serve as validation and analyzed in relation to proposed changes to the T descriptors found in the eighth edition.

RESULTS

There were 5002 patients: 4848 patients with clinical and 582 with pathological stages. Among these, 428 had both. Survival differences were confirmed for T and N categories and maintained in relation to proposed revisions to T descriptors for seventh edition TNM categories and proposed changes in the eighth edition. There were also survival differences, notably at 12 months, in patients with brain-only single-site metastasis (SSM) compared to SSM at other sites, and SSM without a pleural effusion showed a better prognosis than other patients in the M1b category.

CONCLUSION

We confirm the prognostic value of clinical and pathological TNM staging in patients with SCLC, and recommend continued usage for SCLC in relation to proposed changes to T, N, and M descriptors for NSCLC in the eighth edition. However, for M descriptors, it remains uncertain whether survival differences in patients with SSM in the brain simply reflect better treatment options rather than better survival based on anatomic extent of disease.

2nd ESMO Consensus Conference on Lung Cancer: early-stage non-small-cell lung cancer consensus on diagnosis, treatment and follow-up

To complement the existing treatment guidelines for all tumour types, ESMO organises consensus conferences to focus on specific issues in each type of tumour. The 2nd ESMO Consensus Conference on Lung Cancer was held on 11-12 May 2013 in Lugano. A total of 35 experts met to address several questions on non-small-cell lung cancer (NSCLC) in each of four areas: pathology and molecular biomarkers, first-line/second and further lines in advanced disease, early-stage disease and locally advanced disease. For each question, recommendations were made including reference to the grade of recommendation and level of evidence. This consensus paper focuses on early-stage disease.

Intrathymic parathyroid adenoma presenting with seizures

A 59-year-old diabetic patient was admitted with loss of consciousness and convulsions. Hypercalcaemia and hypoglycaemia were discovered. Computed tomographic and technetium scans revealed a retrosternal paramedian nodule. Radical thymectomy was performed by median sternotomy. Diagnosis of intrathymic parathyroid adenoma was made. One year later the patient had good diabetes control without clinical symptoms.

Endarterectomy combined with retrograde stenting for tandem lesions of the carotid artery

OBJECTIVES

Due to its location in the chest wall, surgical treatment of lesions at the origin of the brachiocephalic trunk or common carotid artery (CCA) is unattractive. Complete endovascular treatment of lesions at the origin of the common carotid artery or brachiochephalic trunk combined with high-grade lesions at the carotid bifurcation carries a high risk for distal emboli before cerebral protection is installed. Therefore, the combination of open carotid endarterectomy with retrograde stenting of the proximal lesion through one stage is most attractive.

METHODS

Eleven patients were treated with a combined procedure for tandem lesions at the origin of the brachiocephalic trunk or common carotid artery (CCA) and the carotid bifurcation. Endpoint of this evaluation was the 30-day MACE (Major Adverse Cardiovascular Events).

RESULTS

All procedures were finished as planned and no conversion was necessary. Thirty-day mortality was 0%. One patient developed a restenosis after only 4 days for which he underwent a re-PTA procedure. The 30-day MACE was 0%. None of the patients needed additional treatment during follow-up (mean follow-up 33 months; range: 11 to 60) although one patient developed a non-significant stenosis during follow-up.

CONCLUSIONS

Combined treatment of tandem lesions of the carotid artery is safe and effective in the long-term.

Spontaneous pneumothorax: remaining controversies

Despite many guidelines issued by national and professional societies, a detailed literature survey between the late 1940s and 2010 clearly demonstrates that several aspects of pneumothorax pathogenesis and treatment still remain controversial. Related to pathogenesis of primary pneumothorax, the current manuscript highlights why further studies are needed to explain 1) mechanism of the oxygenation impairment in presence of a large pneumothorax; 2) oxygenation differences between age and sex-matched patients with a pneumothorax of the same size; and 3) sequence of events in tension pneumothorax. Concerning the overall therapeutic approach, video-assisted technology provides a minimally invasive operative treatment. For this reason methods of recurrence prevention are now shared between interventional pulmonologists and thoracic surgeons. Although a significantly higher recurrence rates was reported in patients with primary spontaneous pneumothorax after simple pleural drainage versus thoracoscopic talc poudrage, (34% and 5% respectively), such a policy is still not widely adopted. Certain concerns that relate to the use of talc in relapse prevention are also discussed, showing that they are mostly dependent on the type of the talc used. Concerning secondary pneumothorax, specificities of different forms related to diagnostics and therapeutic approach are also pointed out. Lung tuberculosis as the underlying cause is particularly addressed, due to the challenge of the timely recognition of specific lesions and prompt initiation of the antituberculous medical treatment . Similarly, lung cancer is mentioned as a possible underlying cause in patients with delayed lung expansion.

Surrogate markers predicting overall survival for lung cancer: ELCWP recommendations

The present systematic review was performed under the auspices of the European Lung Cancer Working Party (ELCWP) in order to determine the role of early intermediate criteria (surrogate markers), instead of survival, in determining treatment efficacy in patients with lung cancer. Initially, the level of evidence for the use of overall survival to evaluate treatment efficacy was reviewed. Nine questions were then formulated by the ELCWP. After reviewing the literature with experts on these questions, it can be concluded that overall survival is still the best criterion for predicting treatment efficacy in lung cancer. Some intermediate criteria can be early predictors, if not surrogates, for survival, despite limitations in their potential application: these include time to progression, progression-free survival, objective response, local control after radiotherapy, downstaging in locally advanced nonsmall cell lung cancer (NSCLC), complete resection and pathological TNM in resected NSCLC, and a few circulating markers. Other criteria assessed in these recommendations are not currently adequate surrogates of survival in lung cancer.

Restaging the mediastinum in non-small cell lung cancer after induction therapy: non-invasive versus invasive procedures

OBJECTIVE

Nodal status after induction therapy in patients with stage III non-small cell lung cancer (NSCLC) is an independent prognostic factor for survival. Prognosis is poor in patients with persisting mediastinal lymph node involvement.

METHODS

From February 2000 to September 2007, restaging for NSCLC was performed in 25 patients (23 men, 2 women) by computed tomography (CT), positron emission tomography (PET) as well as repeat mediastinoscopy. Initial proof of N2 or N3 disease was obtained by mediastinoscopy.

RESULTS

The non-invasive restaging modalities CT and PET had a rather low accuracy of 64% and 72%, respectively. Repeat mediastinoscopy performed better with an accuracy of 84%.

CONCLUSION

Histological proof of mediastinal involvement after induction therapy in NSCLC is necessary to select those patients who will benefit from surgical resection. When a first mediastinoscopy has been performed to obtain pathological proof of N2 or N3 disease, repeat mediastinoscopy proves to be more accurate than CT or PET scanning for mediastinal restaging.

Surgical resection of lung metastases including the role of locoregional therapy

Although no randomized trials are available, surgical resection is a widely accepted treatment for selected patients with pulmonary metastases. Specific criteria have been well defined and a macroscopic complete resection should be obtained. Important prognostic factors include histology, number of metastases and disease-free interval. However, even after complete resection, 5-year survival rates remain disappointingly low and many patients will have recurrent disease confined to the chest. For this reason, locoregional therapies are extensively investigated at the present time. These include biochemical and biophysical methods. Due to toxicity of high doses of intravenous chemotherapy, the main purpose is to deliver high-dose chemotherapy to the lung without systemic side-effects. Chemo-embolization, pulmonary artery infusion and isolated lung perfusion are most intensively studied. These techniques were found to be feasible and are able to deliver a high local concentration of chemotherapeutic drugs. The results of further phase II trials are awaited for to determine their effect on local recurrence and long-term survival.

Quality of life after lung cancer surgery: a review

The long-term goals of lung cancer surgery include cancer control, survival and quality of life (QoL). In a patient population with a high mortality rate, evaluation and preservation of QoL after treatment is imperative. Lung cancer patients already have a significant lower QoL compared to an age-matched healthy population with significant impairment in physical and emotional functioning. Lung cancer surgery causes further deterioration of QoL, especially in the first 3 to 6 months after surgery. While some studies suggest that QOL returns to baseline levels at 6 to 9 months postoperatively, others report that QOL is still significantly impaired at 6 and 12 months after surgery. Age, extent of surgery, preoperative lung function, access technique, and adjuvant treatment may all influence postoperative QoL. This review presents the basic concepts of QoL research, several commonly used QoL measurement instruments, and a summary of the available data on post-lung cancer surgery QoL.

Different indications for repeat mediastinoscopy: single institution experience of 79 cases

AIM

Different indications exist for repeat mediastinoscopy or remediastinoscopy (reMS). Presently, it is a valuable restaging tool in non-small cell lung cancer (NSCLC). Not only does it provide pathological evidence of mediastinal downstaging, it also selects those patients who will benefit from a subsequent surgical resection and determines prognosis. However, other indications for reMS exist. The authors reviewed their overall experience with reMS.

METHODS

From June 1994 until September 2007, 79 reMS were performed in 75 patients (65 men and 10 women). Mean age was 67.4 years (range 35 to 85 years).

RESULTS

ReMS was performed after induction therapy in 54 cases (68.4%), for recurrent lung cancer in 7 cases (8.9%), metachronous second primary lung cancer in 2 cases (2.5%), for lung cancer occurring after an unrelated disease such as sarcoidosis in 1 case (1.2%), for an inadequate first procedure in 8 cases (10.1%) and for a non-malignant disease such as sarcoidosis or lymphoma in 7 cases (8.9%). ReMS was technically feasible in all patients. There was no mortality. One hemorrhage was encountered from a bronchial artery during reMS which was controlled by packing and one tear in the bronchial wall which was treated conservatively. In patients with lung cancer (71 patients), reMS was positive in 29 cases (40.8%). ReMS provided a definitive diagnosis in 3 patients with sarcoidosis and in one patient with lymphoma .

CONCLUSIONS

Although mostly performed as a restaging procedure after induction therapy in non-small cell lung cancer, reMS can also safely be performed for other indications providing pathological evidence of mediastinal involvement.

Intralobar bronchopulmonary sequestration with mixed venous drainage in a 10-year-old girl

Bronchopulmonary sequestration consists of a mass of abnormal lung tissue that has no normal connection with the bronchial tree and is supplied with blood from an aberrant artery mostly originating in the thoracic aorta. Two forms are recognized: intralobar and extralobar sequestration. The first is localized within the normal visceral pleura and has a venous drainage into the pulmonary system; the latter is localized without the normal lung in its own pleura with venous drainage into the systemic venous system. Intralobar sequestration is the most common form accounting for 75% of the cases. Intralobar sequestration usually presents in adolescence or adulthood with signs of recurrent pneumonia. Extralobar sequestration presents early in life with respiratory distress or feeding difficulties and is frequently associated with other congenital malformations. The diagnosis is confirmed by CT scan of the lungs and magnetic resonance angiography as demonstration of the aberrant vascular supply is essential for the diagnosis. Therapy consists in surgical removal. We present a case of intralobar sequestration in a 10-year-old girl. The clinical symptomatology was typical. Arterial supply with two aberrant arteries and mixed venous drainage into the pulmonary and systemic systems were particular features.

Intrathoracic hibernoma: report of two cases

Hibernomas are uncommon benign soft tissue tumours mimicking brown fat. The most common anatomic locations include the neck, axilla, mediastinum, periaortic and perirenal zones. Intrathoracic and in particular pleural locations are exceptional. We report two cases of intrathoracic hibernoma with pleural involvement treated by surgical resection.

Intercostal lung herniation after repeat thoracotomy

Intercostal lung herniation is a rare condition caused by a defect in the thoracic wall, high intrathoracic pressure, or both. The authors report a case of intercostal lung herniation after repeat thoracotomy, which was repaired with a synthetic patch. Etiology, symptoms, diagnostic techniques and treatment of intercostal lung herniations are discussed.

Distinct angiogenic and non-angiogenic growth patterns of lung metastases from renal cell carcinoma

AIMS

We have recently evaluated a classification of non-small-cell lung cancer based upon the presence of an angiogenic or a non-angiogenic growth pattern. The aim of the present study was to test the hypothesis that lung metastases of clear cell renal cell carcinoma (RCC) can grow without eliciting angiogenesis and give rise to the same set of growth patterns.

METHODS AND RESULTS

Tissue sections of 24 patients with lung metastases from clear cell RCC were analysed. Haematoxylin and eosin and reticulin staining were performed to evaluate growth pattern. Double-labelling with antibodies to CD34 and proliferating cell nuclear antigen (PCNA) was performed to determine the endothelial cell proliferation fraction (ECPF) and the microvessel density (MVD). Three growth patterns were observed. In the destructive growth pattern (54%), the architecture of the lung was not preserved. In the alveolar (33%) and interstitial growth patterns (13%), the normal lung parenchyma was preserved within the metastases. MVD was higher in the destructive than in the alveolar growth pattern (P = 0.009). ECPF was higher in the destructive (mean 31.1 +/- 22.7%, median 30.0) than in the alveolar growth pattern (mean 3.6 +/- 2.8%, median 3.2; P = 0.005).

CONCLUSIONS

The present study demonstrates that highly angiogenic primary tumours can give rise to non-angiogenic metastases. This type of metastasis may be resistant to antiangiogenic therapy.

Mycotic aneurysm of the descending thoracic aorta. Review and case report

A 74-year-old male presented with bilateral invalidating claudication. A bilateral percutaneous transluminal angioplasty (PTA) with stenting of both superficial femoral arteries was performed but complicated by an urosepsis with Escherichia coli and a septic phlebitis at the site of an intravenous line. The phlebitis was complicated by a local abcedation for which incision and drainage were performed. One month after discharge he was readmitted at our hospital with septic fever and positive hemocultures for Escherichia coli. Positron emission tomography-computed tomographic scan (PET/CT-scan) showed a mycotic aneurysm of the thoracic aorta. Because no cryopreserved donor aorta was available and the aneurysm size rapidly increased, an open in situ repair was performed with a Dacron silver prosthesis soaked in rifampicin. His recovery was further complicated by a perforated toxic megacolon for which a subtotal colectomy was performed. Further recovery was uncomplicated and 10 months after the aortic repair patient is still free from infection.

Decision making about operability in non-small cell lung cancer

With the introduction of combined modality therapy and better staging techniques, the role of surgical resection for non-small cell lung cancer is continuously redefined. The final aim of surgical treatment for lung cancer is complete resection, also after neoadjuvant or induction therapy. Precise criteria for complete resection have recently been defined. Definite indications for surgery include clinical stages I, II and resectable IIIA. The precise role for surgical resection in stage IIIA-N2 lung cancer remains controversial but only downstaged patients should be considered. Stage IIIB is mostly treated by chemoradiotherapy. Accurate peroperative or surgical staging is necessary, as well regarding the tumour as nodal factor, to determine the extent of resection. A systematic nodal dissection should be performed including at least three hilar and three mediastinal lymph node stations. Post-induction surgical therapy often represents a greater technical challenge due to a pronounced hilar and mediastinal fibrosis. Downstaging is an important prognostic factor and persisting mediastinal lymph node involvement carries a poor prognosis. The optimal restaging method has not been established yet, but a pathological proof should be obtained. Remediastinoscopy is feasible with an acceptable accuracy but less invasive techniques are currently evaluated.

Spontaneous pseudo-aneurysm of the deep femoral artery treated by a covered stent

PURPOSE

To present the management of a spontaneous pseudo-aneurysm of the deep femoral artery by an endovascular technique.

CASE REPORT

An 82-year-old man presented with a painless pulsating mass at the level of the upper right thigh without any previous history of trauma, surgery or puncture of the femoral artery. The mass proved to be a pseudo-aneurysm of the deep femoral artery. Thrombin injection with simultaneous balloon inflation at the neck of the aneurysm did not result in a long-lasting thrombosis. Since both general and epidural anaesthesia were absolutely contra-indicated, and because of severe stenotic lesions of the femoro-popliteal axis, we chose to exclude this aneurysm under local anaesthesia with a balloon-expandable covered Jo-stent in order to maintain patency of the deep femoral artery. Twenty months postoperatively, the aneurysm is still thrombosed while the patency of both the superficial and deep femoral artery is preserved.

CONCLUSIONS

This case demonstrates that an endovascular approach can be an excellent treatment for aneurysms of the deep femoral artery, thereby avoiding an open surgical procedure while preserving the patency of the deep femoral artery.

Quality of life evolution after lung cancer surgery: A prospective study in 100 patients

OBJECTIVE

To evaluate quality of life (QoL) evolution after thoracic surgery for lung cancer with the European Organisation for Research and Treatment of Cancer (EORTC) QoL Questionnaire-C30 and the lung cancer specific module LC13.

METHODS

A prospective QoL registration started in 2002 for all patients undergoing major pulmonary surgery for malignant disease. Between January 2002 and November 2004, 100 patients were included. Questionnaires were administered pre-operatively and 1, 3, 6 and 12 months post-operatively (MPO) with response rates of 100%, 71%, 77%, 83% and 76%, respectively.

PROCEDURES

lobectomy 61%, pneumonectomy 17%, and wedge resection 22%. Approaches: anterolateral thoracotomy 79%, posterolateral thoracotomy 13% and video-assisted thoracic surgery (VATS) 8%.

RESULTS

Lobectomy and wedge resection are comparable in QoL evolution. Both resections are characterized by a 1 month temporary decrease in QoL functioning scores and an increase in pain symptoms. Lobectomy patients report an increase in dyspnea in the first month post-operatively, not seen after wedge resection. With exception of thoracic pain after lobectomy, QoL scores approximated baseline values 3MPO indicating good recovery. After pneumonectomy, there is no return to baseline in physical functioning, role functioning, pain, shoulder function and dyspnea in a 12 months follow-up period. Other QoL scores were comparable with baseline values. Pneumonectomy was significantly associated with a less favorable QoL score evolution when compared with lobectomy. Comparing antero- and posterolateral thoracotomy, significant differences in pain and dyspnea were seen in favor of the anterolateral technique. Comparing thoracotomy to VATS, significant differences were seen in physical functioning, QoL and thoracic pain in favor of VATS.

CONCLUSIONS

The present study documented QoL evolution profiles comparing pre-operative status with deficits and changes at 1, 3, 6 and 12 months after pulmonary surgery. Lung cancer surgery is well tolerated by the majority of patients. Lobectomy patients have a more favorable physical functioning and less thoracic pain, compared to pneumonectomy. Antero- and posterolateral thoracotomy are comparable for QoL evolution. After posterolateral thoracotomy more post-operative pain and dyspnea was seen. Post-operative physical functioning, pain and QoL are in favor of VATS.

European Trends in Preoperative and Intraoperative Nodal Staging: ESTS Guidelines

Preoperative and intraoperative lymph node (LN) staging is of paramount importance for patients with non-small cell lung cancer. The Council of the European Society of Thoracic Surgery took the initiative to organize workshops on intraoperative and preoperative mediastinal LN staging. This resulted in specific guidelines. Relevant peer-reviewed publications on these subjects, the experience of the participants, and the opinion of the European Society of Thoracic Surgery members contributing online were used to reach a consensus. For primary staging, mediastinoscopy remains the gold standard for the superior mediastinal LNs. Invasive procedures can be omitted in patients with peripheral tumors and negative mediastinal and hilar nodes on positron emission tomography scan. Positron emission tomography-positive mediastinal findings should always be cytohistologically confirmed. New minimally invasive techniques that provide cytohistological diagnosis became available. Their specificity is high, but the negative predictive value is low. If they yield negative results, an invasive surgical technique remains indicated. For restaging, invasive techniques providing cytohistological information are advisable. Systematic nodal dissection is recommended in all cases to ensure complete resection. Lobe-specific systematic nodal dissection is acceptable for peripheral squamous T1 tumors if hilar and interlobar nodes are negative on frozen section studies. The report from the pathologist should describe the number of LNs removed and studied, the overall number of metastatic LNs in each station, and the status of the LN capsule. We hope that the adherence to these guidelines will standardize and improve preoperative and intraoperative LN staging and pathologic evaluation of non-small cell lung cancer.