Should we operate on microscopic N2 non-small cell lung cancer?

Traditionally non-small cell lung cancer (NSCLC) stage N2 is considered as a contraindication for curative resection. We investigated the outcome of patients with microscopic N2 disease, who underwent potentially curative resections. The independent effects of lobectomy vs. pneumonectomy, histology subtype, body mass index (BMI), sex, and PET-scanning were investigated. An N2 survival risk score was calculated and correlated with survival. Benchmarking revealed no discrepancies in our stage-specific survival data against the seventh edition of the International Association for the Study of Lung Cancer (IASLC) results. Of 1999 lung resections for primary lung cancer, 146 were pathologically staged as N2. Patients with resected microscopic N2 disease had a five-year survival equivalent to stage T3N1, P=0.39. Univariate analysis suggested pneumonectomy and T stage 3 as significant predictors of poor survival. Cox multivariate regression analysis revealed that age, BMI>30 kg/m(2), pneumonectomy, squamous type and positron emission tomography (PET)-scan all had a significant effect on survival, P<0.05. A low N2 survival risk score was associated with increased survival, P=0.001. Resecting microscopic N2 disease in NSCLC may be appropriate in some patients. An N2 survival scoring system may help select patients for surgery, and help evaluate adjuvant and neoadjuvant publications with regard to microscopic N2 disease.

Does positron emission tomography scanning improve survival in patients undergoing potentially curative lung resections for non-small-cell lung cancer?

OBJECTIVE: To determine if positron emission tomography (PET) scanning has resulted in an improvement in the short- and long-term survival of patients undergoing potentially curative resections for non-small-cell lung cancer. No publications exist to demonstrate an increased survival of patients with lung cancer due to the use of PET scanning. If PET scanning reduces unnecessary resections, the results from surgery should be improved with its introduction. METHODS: A prospective thoracic surgery database was retrospectively analysed. Patients (N=1999), who had undergone potentially curative resections for non-small-cell lung cancer, and those who had a PET scan pre operatively (N=934), were compared with patients who had not undergone PET scanning (N=1065), prior to surgical resection. PET scanning became routine for all patients 4 years ago in our unit. Staging was defined as pathological staging to eliminate bias by 'better' preoperative staging due multislice computed tomography (CT) and PET scanning. Propensity matching based on Cox regression analysis was performed for survival analysis at each stage. RESULTS: Propensity matching revealed that the introduction of routine PET scanning did not result in improved survival in the short or long term, for patients undergoing resections for stage Ia (N=271 in each matched group), p=0.74, stage Ib (N=321 in each matched group), p=0.43 and stage II (N=164 in each matched group), p=0.06. PET has however resulted in a significant increased survival for patients undergoing resections for stage III primary lung cancer (N=68 in each matched group), p=0.03. CONCLUSION: We concur with current guidelines for the use of PET scanning for stage III non-small-cell lung cancer. Our results need to be corroborated with other groups as potentially stage-Ia-, Ib-, and stage-II patients may not benefit from PET scanning.

Clinical upstaging of non-small cell lung cancer that extends across the fissure: implications for non-small cell lung cancer staging.

BACKGROUND: Little data exist as to the long-term outcome of non-small cell lung cancer that extends across the fissure into the adjacent lobe that requires either a bilobectomy or a lobectomy and wedge resection. METHODS: Lobectomy survival data was benchmarked with the International Association for the Study of Lung Cancer (IALSC) dataset. Matched analysis of a prospective thoracic surgery database of 1,020 patients who had undergone lobectomy during a 6-year period was analyzed to elucidate the effect on long-term survival of tumors that extend across the interlobar fissure. RESULTS: Benchmarking revealed our data are not significantly different from the IALSC dataset, allowing survival recommendations to be drawn. Histopathologic staging of matched patients was IA, 11.7%; IB, 51.1%; IIA, 1.7%; IIB, 21.1%; IIIA, 10.0%; IIIB, 2.8%; and IV, 1.7%. Stage I tumors crossing the interlobar fissure had a reduction in survival that is significant (10% to 15%) after 5 years (p = 0.037). The 5-year survival for stage I tumors extending across a lung fissure was 50%. This places the 5-year survival between stage I and II (60% and 40%, respectively). There was no difference in survival for tumors stage IIA and above with regard to importance of interlobar extension. The number of patients was too small to detect a significant difference between bilobectomy versus lobectomy and wedge. CONCLUSIONS: Non-small cell lung cancer that extends across the fissure into an adjacent lobe requiring a bilobectomy or a lobectomy and wedge resection has a 5-year survival between stages I and II.

Aspirin and non-small cell lung cancer resections: effect on long-term survival.

OBJECTIVE: Survival after resections for non-small cell lung cancer remains poor. Recurrent lung cancer remains common. Due to the common risk factor of smoking, cardiovascular deaths occur in the absence of recurrent lung cancer in up to 15% of patients. Aspirin has been proven to reduce cardiovascular mortality as a secondary prophylactic agent, but not as a primary agent. Aspirin being a COX-2 inhibitor has been shown to reduce the chance of metastasis in adenocarcinoma but not squamous carcinoma. We sought to investigate the effect of long-term aspirin therapy on survival post potentially curative surgery. METHODS: We analysed a prospective thoracic surgical database, from time period 2003 to date. Patients who were on aspirin pre-operatively, N=412 were compared to non users, N=1353. Patient long-term outcome was assessed utilising the national strategic tracking service that operates in the United Kingdom. Cox proportional hazards analysis was used to determine significant factors affecting survival. RESULTS: 100% survival follow up was achieved. Regular users of aspirin had >5% increased survival, which was significant, p=0.05, despite having a higher cardiovascular risk profile. Mode of death data was not available. CONCLUSIONS: Adjuvant aspirin post resection for potentially curative non-small cell lung cancer significantly increases survival. The mechanism of increased survival needs further investigation and is the basis for the trial: Adjuvant Aspirin for Non-Small cell Lung Cancer--The Big A Trial. www.TheBigATrial.co.uk.

Cardiac comorbidity is not a risk factor for mortality and morbidity following surgery for primary non-small cell lung cancer.

OBJECTIVE: We examined the effect of cardiac comorbidity on mortality and postoperative complications following surgery for primary non-small cell lung cancer. METHODS: Between October 2001 to December 2005, 1067 consecutive patients underwent lung resection for primary cancer within a single centre; patient data was collected prospectively. Two hundred and seventy-one patients had a history of cardiac comorbidity, which included 196 angina, 118 myocardial infarction, 36 revascularisation, 10 congestive cardiac failure and 19 rhythm disorders (numbers not mutually exclusive). To account for differences in case-mix we used logistic regression to develop a propensity score for cardiac comorbidity group membership and then performed a propensity-matched analysis. Kaplan-Meier curves were used to assess follow-up mortality. RESULTS: Patients with cardiac comorbidity were more likely to be hypertensive, have severe dyspnoea, diabetes, current or ex-smokers and were older. After performing propensity matching to account for these differences we successfully matched 199 patients with cardiac comorbidity to 398 patients with no cardiac history. There was no difference in in-hospital mortality (2.5% vs 3%, p=0.73), myocardial infarction (0.5% vs 0.3%, p>0.99), arrhythmia (15.6% vs 14.1%, p=0.62), renal failure (2% vs 1.5%, p=0.65), stroke (0.5% vs 0.3%, p>0.99), respiratory insufficiency (4% vs 3.3%, p=0.64), reintubation (1% vs 2.5%, p=0.35), tracheostomy (4% vs 7.8%, p=0.08), intensive care readmission (8.5% vs 6.5%, p=0.37) and length of stay (8 days vs 8 days, p=0.98). Three-year survival was similar (61.4% vs 56.2%, p=0.39). No differences in outcomes existed with different cardiac conditions. CONCLUSION: With careful assessment and patient selection, patients with cardiac comorbidity were not found to be at increased risk of mortality and morbidity following lung resection for primary non-small cell lung cancer in a propensity-matched population.

Pleural inflammatory myofibroblastoma: a locally aggressive intra-thoracic tumour.

A 41-year old non-smoking woman presented with persistent pleural effusion. Pleural fluid was hemorrhagic and fluid cytology was negative for malignant cells. A working diagnosis of chronic haemothorax was made and standard right thoracotomy was performed to identify the source of bleeding. A 10 x 10 cms poorly circumscribed mass containing blood clots, altered blood, fibrous tissue, and gelatinous debris was found and demonstrated features of inflammatory myofibroblastoma on immunohistochemistry. Thirteen months later, the patient developed a local recurrence, which was treated surgically. Semi-solid physical appearance of this tumour has not been reported previously. This case report further adds to the diagnostic dilemma related with this tumour.

Missing washer of the rib approximator? An easily overlooked foreign body.

Iatrogenic Foreign bodies especially Gauze swab following surgery are well reported. We report a very unusual case of a loose washer from SELLARS rib approximator, which came out loose in a thoracotomy wound. It was not recognised till reported missing by the central surgical supply department. The foreign body was identified and removed successfully. This case highlights the importance of checking the small connections of the instrument as a routine and especially if an instrument become loose.