Your browser doesn't support javascript.
loading
Show: 20 | 50 | 100
Results 1 - 20 de 26
Filter
1.
2.
Ann Thorac Surg ; 109(2): 337-342, 2020 02.
Article in English | MEDLINE | ID: mdl-31593659

ABSTRACT

BACKGROUND: There is a paucity of prognostic factors for patients with stage I non-small cell lung cancer (NSCLC) undergoing operations. We investigated the prognostic role of preoperative complete blood count values in patients with stage I NSCLC patients undergoing operations. METHODS: A retrospective medical record review was performed of patients who underwent operations for stage I NSCLC between 2000 and 2015. Patients who died within 30 days of the operations were excluded. The primary end point was recurrence. Preoperative complete blood count values were analyzed, and a median value was used as the cutoff. Statistical analysis used χ2 and t tests along with univariate and multivariate analyses by Cox regression modeling. RESULTS: The study included 103 patients. A high lymphocyte count was significantly associated with recurrence (5-year recurrence-free survival [RFS] of 69.8% for high vs 95.7% for low, P = .003), as well as high platelet (5-year RFS of 72.0% for high vs 91.8% for low, P = .02). Independent prognostic factors on multivariate analysis were high lymphocyte (hazard ratio [HR], 7.27; P = .005) and platelet counts (HR, 7.49; P = .003) as well as tumor (HR, 5.40; P = .008) and treatment characteristics (HR, 4.59; P = .01). Among patients with pT1 lesions, high lymphocyte (HR, 8.41; P = .03) and high platelet counts (HR, 19.78; P = .004) remained independent prognostic factors. Neither NLR nor PLR were significantly associated with recurrence. CONCLUSIONS: In patients with pathologic stage I NSCLC undergoing surgical resection, the preoperative blood count from peripheral blood may provide prognostic value. Of significance, in patients with pT1 N0 NSCLC, high lymphocyte count and high platelet count were associated with higher recurrence.


Subject(s)
Blood Platelets/pathology , Carcinoma, Non-Small-Cell Lung/blood , Carcinoma, Non-Small-Cell Lung/mortality , Lung Neoplasms/blood , Lung Neoplasms/mortality , Lymphocytes, Tumor-Infiltrating/pathology , Adult , Aged , Biomarkers, Tumor/blood , Carcinoma, Non-Small-Cell Lung/surgery , Databases, Factual , Disease-Free Survival , Female , Humans , Lung Neoplasms/surgery , Male , Middle Aged , Multivariate Analysis , Neoplasm Invasiveness/pathology , Neoplasm Staging , Platelet Count , Pneumonectomy/methods , Pneumonectomy/mortality , Prognosis , Proportional Hazards Models , Retrospective Studies , Survival Analysis , Treatment Outcome
3.
Tumori ; 105(4): 331-337, 2019 Aug.
Article in English | MEDLINE | ID: mdl-30905273

ABSTRACT

OBJECTIVE: To determine if induction chemotherapy with concurrent high-dose radiation followed by resection is associated with improved survival in patients with nonsuperior sulcus lung cancer with chest wall invasion. METHODS: We performed a retrospective review of clinical T3 (chest wall invasion) N0/N1 patients with non-small cell lung cancer who underwent surgical resection between January 1, 1992, and January 31, 2017. Exclusion criteria included superior sulcus tumors and resection performed for palliation/recurrence. Patients undergoing induction chemoradiation followed by surgical resection were compared to those undergoing resection first or those receiving induction radiation followed by resection. Overall survival was calculated using the Kaplan-Meier method. RESULTS: Thirty-four patients were included in the analysis, with 5-year overall survival (OS) of 30%. By clinical stage, 31 (91%) were IIB (T3N0) and 3 (9%) were IIIA (T3N1). Sixteen patients (47%) received induction chemoradiation before surgery. Of the remaining 18 patients, 5 (15%) received induction radiation followed by surgery, and 13 (38%) underwent surgery as the first treatment. Three patients belonging to the group not receiving induction chemoradiation died within 30 days after surgery and were excluded from survival analysis. In the remaining 31 patients, induction chemoradiation was associated with improved 5-year OS (53% for induction chemoradiation vs 7% for others; P<0.01). Disease recurrence was evident in 9 cases, 2 (12.5%) in the induction chemoradiation group and 7 (46.6%) in the others (median disease-free time 103.0 months for induction chemoradiation group vs 8.0 months for others; P<0.01). CONCLUSION: In patients with nonsuperior sulcus lung cancer with chest wall invasion, induction chemoradiation therapy followed by resection is associated with improved OS.


Subject(s)
Carcinoma, Non-Small-Cell Lung/drug therapy , Carcinoma, Non-Small-Cell Lung/radiotherapy , Lung Neoplasms/drug therapy , Lung Neoplasms/radiotherapy , Thoracic Wall/drug effects , Thoracic Wall/radiation effects , Adult , Aged , Aged, 80 and over , Carcinoma, Non-Small-Cell Lung/pathology , Chemoradiotherapy/methods , Combined Modality Therapy/methods , Female , Humans , Induction Chemotherapy/methods , Lung Neoplasms/pathology , Male , Middle Aged , Neoadjuvant Therapy/methods , Neoplasm Recurrence, Local/drug therapy , Neoplasm Recurrence, Local/radiotherapy , Neoplasm Staging/methods , Retrospective Studies , Survival Analysis , Thoracic Wall/pathology
4.
Innovations (Phila) ; 12(3): 180-185, 2017.
Article in English | MEDLINE | ID: mdl-28296655

ABSTRACT

OBJECTIVE: Transoral incisionless fundoplication (TIF) is a completely endoscopic approach to treat gastroesophageal reflux disease (GERD). We previously reported our initial results demonstrating safety and early effectiveness. We now present an updated experience describing outcomes with longer follow-up. METHODS: For a three-year period, TIF procedures were performed on 80 patients. Preoperative workup routinely consisted of contrast esophagram and manometry. PH testing was reserved for patients with either atypical symptoms or typical symptoms unresponsive to proton-pump inhibitors (PPIs). Heartburn severity was longitudinally assessed using the GERD health-related quality of life index. Safety analysis was performed on all 80 patients, and an effectiveness analysis was performed on patients with at least 6-month follow-up. RESULTS: Mean procedure time was 75 minutes. There were seven (8.75%) grade 2 complications and one (1.25%) grade 3 complication (aspiration pneumonia). The median length of stay was 1 day (mean, 1.4). Forty-one patients had a minimum of 6-month of follow-up (mean, 24 months; range, 6-68 months). The mean satisfaction scores at follow-up improved significantly from baseline (P < 0.001). Sixty-three percent of patients had completely stopped or reduced their PPI dose. Results were not impacted by impaired motility; however, the presence of a small hiatal hernia or a Hill grade 2/4 valve was associated with reduced GERD health-related quality of life scores postoperatively. CONCLUSIONS: At a mean follow-up of 24 months, TIF is effective. Although symptoms and satisfaction improved significantly, many patients continued to take PPIs. Future studies should focus on longer-term durability and comparisons with laparoscopic techniques.


Subject(s)
Esophagoscopy/methods , Fundoplication/methods , Gastroesophageal Reflux/surgery , Gastroscopy/methods , Adult , Aged , Female , Fundoplication/adverse effects , Gastroesophageal Reflux/epidemiology , Gastroesophageal Reflux/physiopathology , Humans , Male , Middle Aged , Postoperative Complications , Retrospective Studies , Young Adult
5.
J Thorac Cardiovasc Surg ; 149(3): 718-25; discussion 725-6, 2015 Mar.
Article in English | MEDLINE | ID: mdl-25500100

ABSTRACT

BACKGROUND: Prior studies have suggested that low baseline quality-of-life (QOL) scores predict worse survival in patients undergoing lung cancer surgery. However, these studies involved average-risk patients undergoing lobectomy. We report QOL results from a multicenter trial, American College of Surgeons Oncology Group Z4032, which randomized high-risk operable patients to sublobar resection (SR), or SR with brachytherapy, and included longitudinal QOL assessments. METHODS: Global QOL, using the 36-item Short-Form Health Survey (SF36), and the dyspnea score from the University of California, San Diego Shortness of Breath Questionnaire (SOBQ) scale, was measured at baseline, 3, 12, and 24 months. SF36 physical component summary (PCS) and mental component summary (MCS) scores were standardized and adjusted for age and gender normals, with scores <50 indicating below-average health status. SOBQ scores were transformed to a 0-100 (poor-excellent) scale. Aims were to: (1) determine the impact of baseline scores on recurrence-free survival, overall survival, and 30-day adverse events (AEs); and (2) identify subgroups (surgical approach, resection type. tumor location, tumor size, respiratory function) with a ≥ 10-point decline or improvement in QOL after SR. RESULTS: Two hundred twelve eligible patients were included. There were no significant differences in baseline QOL scores between arms. Median baseline PCS, MCS, and SOBQ scores were 42.7, 51.1, and 70.8, respectively. There were no differences in grade-3+ AEs, overall survival, or recurrence-free survival in patients with baseline scores ≤ median versus > median values, except for a significantly worse overall survival for patients with baseline SOBQ scores ≤ median value. There were no significant differences between the study arms in percentage change of QOL scores from baseline to 3, 12, or 24 months. Further comparison combining the 2 arms demonstrated a higher percentage of patients with a ≥ 10-point decline in SOBQ scores with segmentectomy compared with wedge resection (40.5% vs 21.9%, P = .03) at 12 months, with thoracotomy versus video-assisted thoracic surgery (VATS) (38.8% vs 20.4%, P = .03) at 12 months, and T1b versus T1a tumors (46.9% vs 23.5%, P = .020) at 24 months. A ≥ 10-point improvement in PCS score was seen at 3 months with VATS versus thoracotomy (16.5% vs 3.6%, P = .02). CONCLUSIONS: In high-risk operable patients, poor baseline QOL scores were not predictive for worse overall or recurrence-free survival, or for higher risk for AEs following SR. VATS was associated with improvement in physical function at 3 months, and improved dyspnea scores at 12 months, lending support for the preferential use of VATS when SR is undertaken.


Subject(s)
Lung Neoplasms/surgery , Pneumonectomy/psychology , Quality of Life , Aged , Aged, 80 and over , Brachytherapy , Disease Progression , Disease-Free Survival , Female , Health Status , Humans , Kaplan-Meier Estimate , Longitudinal Studies , Lung Neoplasms/mortality , Lung Neoplasms/pathology , Lung Neoplasms/psychology , Male , Middle Aged , Neoplasm Recurrence, Local , Neoplasm Staging , Pneumonectomy/adverse effects , Pneumonectomy/mortality , Prospective Studies , Radiotherapy, Adjuvant , Risk Assessment , Risk Factors , Surveys and Questionnaires , Time Factors , Treatment Outcome , United States
6.
J Clin Oncol ; 32(23): 2456-62, 2014 Aug 10.
Article in English | MEDLINE | ID: mdl-24982457

ABSTRACT

PURPOSE: A major concern with sublobar resection (SR) for non-small-cell lung cancer (NSCLC) is high local recurrence (LR). Adjuvant brachytherapy may reduce LR This multicenter randomized trial compares SR to SR with brachytherapy (SRB). PATIENTS AND METHODS: High-risk operable patients with NSCLC ≤ 3 cm were randomly assigned to SR or SRB. The primary end point was time to LR, where LR included recurrence at the staple line (local progression), in the primary tumor lobe away from the staple line, and in ipsilateral hilar nodes. The trial was designed to have a 90% power to detect a hazard ratio (HR) of 0.315 in favor of SRB, using a one-sided type I error rate of 0.05 with a sample size of 100 eligible patients in each arm. RESULTS: Two hundred twenty-four patients were randomly assigned; 222 patients were evaluable for intent-to-treat analysis. Median age was 71 years (range, 49 to 87 years). No differences were found in baseline characteristics. Median follow-up time was 4.38 years (range, 0.04 to 5.59 years). There was no difference in time to LR (HR, 1.01; 95% CI, 0.51 to 1.98; log-rank P = .98) or in the types of LR. Local progression occurred in only 17 (7.7%) of 222 patients. In patients with potentially compromised margins (margin < 1 cm, margin-to-tumor ratio < 1, positive staple line cytology, wedge resection, nodule size > 2.0 cm), SRB did not reduce LR, although trends favored the SRB arm. This was most marked in 14 patients with positive staple line cytology (HR, 0.22; P = .24). Three-year overall survival rates were similar for patients in the SR (71%) and SRB (71%) arms (P = .97). CONCLUSION: Brachytherapy did not reduce LR after SR. This finding may have been related to closer attention to parenchymal margins by surgeons participating in this study.


Subject(s)
Brachytherapy/methods , Carcinoma, Non-Small-Cell Lung/surgery , Lung Neoplasms/surgery , Aged , Aged, 80 and over , Carcinoma, Non-Small-Cell Lung/pathology , Cohort Studies , Female , Humans , Lung Neoplasms/pathology , Male , Middle Aged , Neoplasm Recurrence, Local/pathology
7.
AJR Am J Roentgenol ; 202(5): 1114-9, 2014 May.
Article in English | MEDLINE | ID: mdl-24758668

ABSTRACT

OBJECTIVE: The purpose of this study was to establish the correlation and reliability among the pathologic tumor volume and gradient and fixed threshold segmentations of (18)F-FDG PET metabolic tumor volume of human solid tumors. MATERIALS AND METHODS: There were 52 patients included in the study who had undergone baseline PET/CT with subsequent resection of head and neck, lung, and colorectal tumors. The pathologic volume was calculated from three dimensions of the gross tumor specimen as a reference standard. The primary tumor metabolic tumor volume was segmented using gradient and 30%, 40%, and 50% maximum standardized uptake value (SUVmax) threshold methods. Pearson correlation coefficient, intraclass correlation coefficient, and Bland-Altman analyses were performed to establish the correlation and reliability among the pathologic volume and segmented metabolic tumor volume. RESULTS: The mean pathologic volume; gradient-based metabolic tumor volume; and 30%, 40%, and 50% SUVmax threshold metabolic tumor volumes were 13.46, 13.75, 15.47, 10.63, and 7.57 mL, respectively. The intraclass correlation coefficients among the pathologic volume and the gradient-based and 30%, 40%, and 50% SUVmax threshold metabolic tumor volumes were 0.95, 0.85, 0.80, and 0.76, respectively. The Bland-Altman biases were -0.3, -2.0, 2.82, and 5.9 mL, respectively. Of the small tumors (< 10 mL), 23 of the 35 patients had PET segmented volume outside 50% of the pathologic volume, and among the large tumors (≥ 10 mL) three of the 17 patients had PET segmented volumes that were outside 50% of pathologic volume. CONCLUSION: FDG PET metabolic tumor volume estimated using gradient segmentation had superior correlation and reliability with the estimated ellipsoid pathologic volume of the tumors compared with threshold method segmentation.


Subject(s)
Fluorodeoxyglucose F18 , Neoplasms/metabolism , Neoplasms/pathology , Positron-Emission Tomography , Radiopharmaceuticals , Tumor Burden , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Multimodal Imaging , Reproducibility of Results , Retrospective Studies
8.
Ann Thorac Surg ; 96(5): 1747-54; discussion 1754-5, 2013 Nov.
Article in English | MEDLINE | ID: mdl-23998400

ABSTRACT

BACKGROUND: Patients with early-stage lung cancer and limited pulmonary reserve may not be appropriate candidates for lobectomy. In these situations, sublobar resection (wedge or segmentectomy) is generally performed. Many physicians believe that segmentectomy is superior because it allows for an improved parenchymal margin and nodal sampling. METHODS: We performed an analysis using operative and pathology reports collected as part of planned data collection for American College of Surgeons Surgical Oncology Group (ACOSG) Z4032. This was a prospective trial in which patients with clinical stage I lung cancer and limited pulmonary function were randomized to sublobar resection with or without brachytherapy. The operative approach (video-assisted thoracic surgery [VATS] vs thoracotomy), extent of resection, and degree of lymph node evaluation were at the discretion of the individual surgeon. The primary aim of this analysis was to compare the parenchymal margin achieved between segmentectomy and wedge resection. Secondary aims included the extent of nodal staging and whether the operative approach (VATS vs open) had an effect on margin status and nodal evaluation. RESULTS: Among 210 patients, 135 (64%) underwent a VATS approach and 75 (36%) a thoracotomy. A segmentectomy was performed in 57 patients (27%) and a wedge resection in 153 patients (73%). There were no significant differences in the degree of nodal upstaging, stations sampled, or parenchymal margin obtained between VATS and thoracotomy. However, significant differences were observed between patients who underwent a segmentectomy and those who underwent a wedge resection with regard to parenchymal margin (1.5 cm vs 0.8 cm, p = 0.0001), nodal upstaging (9% vs 1%, p = 0.006), and nodal stations sampled (3 vs 1, p < 0.0001) . Notably, 41% of patients treated by wedge resection had no nodes sampled at the time of operation compared with 2% of those who underwent segmentectomy (p < 0.0001). CONCLUSIONS: In ACOSG Z4032, wedge resection, regardless of the approach, was associated with a smaller parenchymal margin and a lower yield of lymph nodes and rate of nodal upstaging when compared with segmentectomy.


Subject(s)
Carcinoma, Non-Small-Cell Lung/surgery , Lung Neoplasms/surgery , Pneumonectomy/methods , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Prospective Studies , Risk Factors , Thoracic Surgery, Video-Assisted , Thoracotomy
9.
J Thorac Oncol ; 8(3): 279-86, 2013 Mar.
Article in English | MEDLINE | ID: mdl-23399959

ABSTRACT

INTRODUCTION: Homologous recombination repair (HRR) is a critical pathway for the repair of DNA damage caused by cisplatin or poly-ADP ribose polymerase (PARP) inhibitors. HRR may be impaired by multiple mechanisms in cancer, which complicates assessing the functional HRR status in cells. Here, we monitored the ability of non-small-cell lung cancer (NSCLC) cells to form subnuclear foci of DNA repair proteins as a surrogate of HRR proficiency. METHODS: We assessed clonogenic survival of 16 NSCLC cell lines in response to cisplatin, mitomycin C (MMC), and the PARP inhibitor olaparib. Thirteen tumor explants from patients with NSCLC were subjected to cisplatin ex vivo. Cells were assayed for foci of repair-associated proteins such as BRCA1, FANCD2, RAD51, and γ-H2AX. RESULTS: Four cell lines (25%) showed an impaired RAD51 foci-forming ability in response to cisplatin. Impaired foci formation correlated with cellular sensitivity to cisplatin, MMC and olaparib. Foci responses complemented or superseded genomic information suggesting alterations in the ATM/ATR and FA/BRCA pathways. Because baseline foci in untreated cells did not predict drug sensitivity, we adapted an ex vivo biomarker assay to monitor damage-induced RAD51 foci in NSCLC explants from patients. Ex vivo cisplatin treatment of explants identified two tumors (15%) exhibiting compromised RAD51 foci induction. CONCLUSIONS: A fraction of NSCLC harbors HRR defects that may sensitize the affected tumors to DNA-damaging agents including PARP inhibitors. We propose that foci-based functional biomarker assays represent a powerful tool for prospective determination of treatment sensitivity, but will require ex vivo techniques for induction of DNA damage to unmask the underlying HRR defect.


Subject(s)
Antineoplastic Agents/pharmacology , Carcinoma, Non-Small-Cell Lung/genetics , Lung Neoplasms/genetics , Poly(ADP-ribose) Polymerase Inhibitors , Recombination, Genetic/genetics , Recombinational DNA Repair/genetics , Antibiotics, Antineoplastic/pharmacology , BRCA1 Protein/metabolism , Carcinoma, Non-Small-Cell Lung/diagnosis , Carcinoma, Non-Small-Cell Lung/drug therapy , Cisplatin/pharmacology , DNA Damage/drug effects , DNA Damage/genetics , Fanconi Anemia Complementation Group D2 Protein/metabolism , Humans , Immunoenzyme Techniques , Lung Neoplasms/diagnosis , Lung Neoplasms/drug therapy , Microscopy, Fluorescence , Mitomycin/pharmacology , Phthalazines/pharmacology , Piperazines/pharmacology , Poly (ADP-Ribose) Polymerase-1 , Rad51 Recombinase/metabolism , Recombinational DNA Repair/drug effects , Tumor Cells, Cultured , Tumor Stem Cell Assay
10.
Innovations (Phila) ; 7(3): 187-90, 2012.
Article in English | MEDLINE | ID: mdl-22885459

ABSTRACT

OBJECTIVE: Electromagnetic (EM) navigation is increasingly used to assist with bronchoscopic interventions such as biopsy or fiducial placement. Electromagnetic navigation can also be a useful adjunct to computed tomography (CT)-guided thermal ablation and biopsy of lung tumors. This study compares procedures carried out using an EM navigation system (Veran Medical Technologies Inc, St Louis, MO) with procedures using CT fluoroscopy only. METHODS: Over a 23-month period, 17 patients scheduled for thermal ablation were prospectively enrolled in this study. The mean age was 72 years (range, 60-84 years). Seven patients were women. Patients were randomized to EM navigation (n = 7) or CT fluoroscopy alone (n = 10). In some cases, additional ablation or biopsies were performed with or without EM navigation depending on the randomization arm. All procedures were performed under general anesthesia either by a thoracic surgeon or a radiologist. RESULTS: A total of 23 procedures were performed in 17 patients: 20 were ablation procedures and 3 were biopsies. Fourteen were performed for non-small cell lung cancer, and 9 for pulmonary metastases from other organs. Despite randomization, patients receiving EM navigation had a trend for smaller tumors (mean diameter, 1.45 vs 2.90 cm; P = 0.06). For thermal ablation procedures, the time to complete intervention was significantly less when EM navigation was used (mean, 7.6 vs 19 minutes; P = 0.022). Although not statistically significant, there were fewer skin punctures (mean, 1 vs 1.25; P = 0.082), fewer adjustments (mean, 5.6 vs 11.8; P = 0.203), less CT fluoroscopy time (mean, 21.3 vs 34.3 seconds; P = 0.345), and fewer CT scans (mean, 7 vs 15; P = 0.204) whenever EM navigation was used. CONCLUSIONS: Electromagnetic navigation reduces the time to successfully place an ablation probe in a target tumor. Further study is required to determine whether EM navigation may also reduce the number of adjustments, skin punctures, and CT scans as well as decrease CT fluoroscopy time.


Subject(s)
Carcinoma, Non-Small-Cell Lung/surgery , Catheter Ablation/methods , Electromagnetic Fields , Lung Neoplasms/surgery , Radiography, Interventional/methods , Surgery, Computer-Assisted/methods , Tomography, X-Ray Computed/methods , Aged , Aged, 80 and over , Carcinoma, Non-Small-Cell Lung/diagnostic imaging , Female , Follow-Up Studies , Humans , Lung Neoplasms/diagnostic imaging , Male , Middle Aged , Prospective Studies , Treatment Outcome
11.
J Thorac Cardiovasc Surg ; 143(1): 228-34, 2012 Jan.
Article in English | MEDLINE | ID: mdl-22070927

ABSTRACT

OBJECTIVE: Transoral incisionless fundoplication (TIF) is a promising approach for gastroesophageal reflux disease (GERD) that may decrease morbidity compared with conventional antireflux procedures. We report our initial experience with this minimally invasive approach. METHODS: Over a 24-month period, 46 patients (mean age, 49 years; 50% female) underwent 48 TIF procedures. All procedures were performed under general anesthesia. Two surgeons participated in all cases; one served as the endoscopist, and the other performed the partial fundoplication. Heartburn severity was measured using the GERD health-related quality of life (GERD-HRQL) instrument (best score = 0, worst score = 45), which includes an additional question assessing overall satisfaction. RESULTS: Preoperatively, 33 (72%) of 46 patients had small (<3 cm) hiatal hernias, and none had undergone any previous antireflux procedures. Preoperative workup included manometry and barium esophagogram, with pH testing reserved for patients with atypical symptoms or typical symptoms and a lack of response to proton-pump inhibitors. The mean procedure time was 83 minutes (range, 36-180 minutes). The mean procedure time decreased after the first 5 cases from 122 to 78 minutes (P = .001). Mean length of stay was 1.3 days. One patient was readmitted with aspiration pneumonia. Three patients had minor complications (1 had minor bleeding from a suture site and 2 had urinary retention). There were no perioperative deaths. Mean follow-up was 140 days. The mean GERD-HRQL scores improved significantly (23 vs 7; P < .001). There were 22 patients with follow-up greater than 90 days (mean follow-up, 240 days). GERD-HRQL scores remained significantly improved for these patients (23 vs 8; P = .001). Four patients from the entire group (8.6%) had no improvement, in 3 instances due to breakdown of the wrap. Two patients were treated with repeat endoscopic fundoplication and 1 was treated with laparoscopic Nissen fundoplication, and all had a significant improvement in symptoms after reoperation. CONCLUSIONS: TIF is effective at short-term follow-up and safe for patients with GERD. However, long-term follow-up and randomized trials are required to assess the efficacy and durability of this approach compared with conventional surgical repair.


Subject(s)
Esophagoscopy , Fundoplication/methods , Gastroesophageal Reflux/surgery , Adult , Aged , Aged, 80 and over , Equipment Design , Esophagoscopes , Female , Humans , Male , Middle Aged , Retrospective Studies , Young Adult
12.
Surg Oncol Clin N Am ; 20(4): 721-32, 2011 Oct.
Article in English | MEDLINE | ID: mdl-21986268

ABSTRACT

Over the last 30 years neoadjuvant treatment of stage IIIA non-small cell lung cancer (NSCLC) followed by surgical resection for stage IIIB disease has significantly improved the overall results of treatment for patients with stage III NSCLC as well as for those with locally invasive tumors. Different chemotherapy regimens have been used, although in most studies some combination of drugs that include cisplatin is the standard. Radiation when given as part of the induction protocol appears to offer a higher rate of resection and complete resection, and higher doses of radiation are associated with better nodal downstaging. Resection in patients with persistent N2 disease and pneumonectomy following induction therapy remain controversial. Resection in patients with persistent N2 disease and pneumonectomy following induction therapy remain controversial.


Subject(s)
Antineoplastic Agents/therapeutic use , Carcinoma, Non-Small-Cell Lung/surgery , Lung Neoplasms/surgery , Carcinoma, Non-Small-Cell Lung/drug therapy , Combined Modality Therapy , Humans , Lung Neoplasms/drug therapy , Neoplasm Staging , Prognosis , Remission Induction
13.
J Thorac Cardiovasc Surg ; 142(5): 1143-51, 2011 Nov.
Article in English | MEDLINE | ID: mdl-21872277

ABSTRACT

OBJECTIVE: Sublobar resection (SR) is commonly used for patients considered high risk for lobectomy. Nonoperative therapies are increasingly being reported for patients with similar risk because of perceived lower morbidity. We report 30- and 90-day adverse events (AEs) from American College of Surgeons Oncology Group Z4032, a multicenter phase III study for high-risk patients with stage I non-small cell lung cancer. METHODS: Data from 222 evaluable patients randomized to SR (n = 114) or SR with brachytherapy (n = 108) are reported. AEs were recorded using the Common Terminology Criteria for Adverse Events, Version 3.0, at 30 and 90 days after surgery. Risk factors (age, percent baseline carbon monoxide diffusion in the lung [DLCO%], percent forced expiratory volume in 1 second [FEV1%], upper lobe vs lower lobe resections, performance status, surgery approach, video-assisted thoracic surgery vs open and extent, and wedge vs segmentectomy) were analyzed using a multivariable logistic model for their impact on the incidence of grade 3 or higher (G3+) AEs. Respiratory AEs were also specifically analyzed. RESULTS: Median age, FEV1%, and DLCO% were similar in the 2 treatment groups. There was no difference in the location of resection (upper vs lower lobe) or the use of segmental or wedge resections. There were no differences between the groups with respect to "respiratory" G3+ AEs (30 days: 14.9% vs 19.4%, P = .35; 0-90 days: 19.3% vs 25%, P = .31) and "any" G3+ AEs (30 days: 25.4% vs 30.6%, P = .37; 0-90 days: 29.8% vs 37%, P = .25). Further analysis combined the 2 groups. Mortality occurred in 3 patients (1.4%) by 30 days and in 6 patients (2.7%) by 90 days. Four of the 6 deaths were thought to be due to surgery. When considered as continuous variables, FEV1% was associated with "any" G3+ AE at days 0 to 30 (P = .03; odds ratio [OR] = 0.98) and days 0 to 90 (P = .05; OR = 0.98), and DLCO% was associated with "respiratory" G3+ AE at days 0 to 30 (P = .03; OR = 0.97) and days 0 to 90 (P = .05; OR = 0.98). Segmental resection was associated with a higher incidence of any G3+ AE compared with wedge resection at days 0 to 30 (40.3% vs 22.7%; OR = 2.56; P < .01) and days 0 to 90 (41.5% vs 29.7%; OR = 1.96; P = .04). The median FEV1% was 50%, and the median DLCO% was 46%. By using these median values as potential cutpoints, only a DLCO% of less than 46% was significantly associated with an increased risk of "respiratory" and "any" G3+ AE for days 0 to 30 and 0 to 90. CONCLUSIONS: In a multicenter setting, SR with brachytherapy was not associated with increased morbidity compared with SR alone. SR/SR with brachytherapy can be performed safely in high-risk patients with non-small cell lung cancer with low 30- and 90-day mortality and acceptable morbidity. Segmental resection was associated with increased "any" G3+ AE, and DLCO% less than 46% was associated with "any" G3+ AE and "respiratory" G3+ AE at both 30 and 90 days.


Subject(s)
Brachytherapy , Carcinoma, Non-Small-Cell Lung/radiotherapy , Carcinoma, Non-Small-Cell Lung/surgery , Lung Neoplasms/radiotherapy , Lung Neoplasms/surgery , Pulmonary Surgical Procedures , Thoracic Surgery, Video-Assisted , Aged , Aged, 80 and over , Brachytherapy/adverse effects , Brachytherapy/mortality , Carcinoma, Non-Small-Cell Lung/mortality , Carcinoma, Non-Small-Cell Lung/pathology , Chi-Square Distribution , Female , Humans , Logistic Models , Lung Neoplasms/mortality , Lung Neoplasms/pathology , Male , Middle Aged , Odds Ratio , Patient Selection , Postoperative Complications/etiology , Postoperative Complications/mortality , Prospective Studies , Pulmonary Surgical Procedures/adverse effects , Pulmonary Surgical Procedures/mortality , Radiotherapy, Adjuvant , Risk Assessment , Risk Factors , Thoracic Surgery, Video-Assisted/adverse effects , Thoracic Surgery, Video-Assisted/mortality , Time Factors , Treatment Outcome , United States
14.
J Thorac Cardiovasc Surg ; 142(3): 554-62, 2011 Sep.
Article in English | MEDLINE | ID: mdl-21724195

ABSTRACT

BACKGROUND: Z4032 was a randomized study conducted by the American College of Surgeons Oncology Group comparing sublobar resection alone versus sublobar resection with brachytherapy for high-risk operable patients with non-small cell lung cancer (NSCLC). This evaluates early impact of adjuvant brachytherapy on pulmonary function tests, dyspnea, and perioperative (30-day) respiratory complications in this impaired patient population. METHODS: Eligible patients with stage I NSCLC tumors 3 cm or smaller were randomly allocated to undergo sublobar resection with (SRB group) or without (SR group) brachytherapy. Outcomes measured included the percentage predicted forced expiratory volume in 1 second (FEV1%), percentage predicted carbon monoxide diffusion capacity (DLCO%), and dyspnea score per the University of California San Diego Shortness of Breath Questionnaire. Pulmonary morbidity was assessed per the Common Terminology Criteria for Adverse Events version 3.0. Outcomes were measured at baseline and 3 months. A 10% change in pulmonary function test or 10-point change in dyspnea score was deemed clinically meaningful. RESULTS: Z4032 permanently closed to patient accrual in January 2010 at 224 patients. At 3-month follow-up, pulmonary function data are currently available for 148 (74 SR and 74 SRB) patients described in this report. There were no differences in baseline characteristics between arms. In the SR arm, 9 patients (12%) reported grade 3 respiratory adverse events, compared with 12 (16%) in the SRB arm (P = .49). There was no significant change in percentage change in DLCO% or dyspnea score from baseline to 3 months within either arm. In the case of FEV1%, percentage change from baseline to 3 months was significant within the SR arm (P = .03), with patients reporting improvement in FEV1% at month 3. Multivariable regression analysis (adjusted for baseline values) showed no significant impact of treatment arm, tumor location (upper vs other lobe), or surgical approach (video-assisted thoracoscopic surgery vs thoracotomy) on 3-month FEV1%, DLCO%, and dyspnea score. There was no significant difference in incidence of clinically meaningful (10% pulmonary function or 10-point dyspnea score change) change between arms. Twenty-two percent of patients with lower-lobe tumors and 9% with upper-lobe tumors demonstrated 10% decline in FEV1% (odds ratio, 2.79; 95 confidence interval, 1.07-7.25; P = .04). CONCLUSIONS: Adjuvant intraoperative brachytherapy in conjunction with sublobar resection did not significantly worsen pulmonary function or dyspnea at 3 months in a high-risk population with NSCLC, nor was it associated with increased perioperative pulmonary adverse events. Lower-lobe resection was the only factor significantly associated with clinically meaningful decline in FEV1%.


Subject(s)
Brachytherapy , Carcinoma, Non-Small-Cell Lung/radiotherapy , Carcinoma, Non-Small-Cell Lung/surgery , Lung Neoplasms/radiotherapy , Lung Neoplasms/surgery , Aged , Aged, 80 and over , Carcinoma, Non-Small-Cell Lung/complications , Carcinoma, Non-Small-Cell Lung/physiopathology , Dyspnea/etiology , Female , Forced Expiratory Volume , Humans , Lung Neoplasms/complications , Lung Neoplasms/physiopathology , Male , Middle Aged , Prospective Studies , Pulmonary Diffusing Capacity , Radiotherapy, Adjuvant , Thoracic Surgery, Video-Assisted , Thoracotomy , Treatment Outcome
15.
J Thorac Cardiovasc Surg ; 141(6): 1392-7, 2011 Jun.
Article in English | MEDLINE | ID: mdl-21281948

ABSTRACT

OBJECTIVE: This study examined the impact of neoadjuvant chemotherapy and concurrent high-dose radiation therapy on survival in patients with node-negative T3 and T4 non-small cell lung cancer. METHODS: A total of 110 consecutive patients underwent surgical resection for invasive T3N0M0 (94 patients) and T4N0M0 (16 patients) non-small cell lung cancer between 1979 and 2008. Forty-seven patients received neoadjuvant chemotherapy and concurrent high-dose (5940 cGy) radiation therapy before resection (Chemo-RT group). Sixty-three patients underwent surgical resection without receiving induction chemoradiotherapy (Surg group), of whom 21 received neoadjuvant radiation, 19 received adjuvant radiation, 17 received surgery alone, 2 received adjuvant chemotherapy, 2 received adjuvant chemoradiotherapy, and 2 received brachytherapy. Survival of the Chemo-RT and Surg groups was compared using both crude and adjusted Cox proportional hazards models. RESULTS: The 5-year, 10-year, and median survivals were 61%, 50%, and 90 months, respectively, in the Chemo-RT group versus 22%, 14%, and 22 months, respectively, in the Surg group. Subjects in the Surg group had an increased risk of death (hazard ratio, 2.60; 95% confidence interval, 1.62-4.18; P = .0001) compared with the Chemo-RT group. After adjustment for potential confounding variables of age, sex, tumor size, tumor location, type of operation, and decade of care, subjects in the Surg group remained at increased risk of death (hazard ratio, 2.81; 95% confidence interval, 1.45-5.44, P = .002) compared with the Chemo-RT group. CONCLUSIONS: Aggressive treatment of node-negative invasive T3 and T4 NSCLC with induction chemoradiotherapy may significantly prolong survival. This approach should be evaluated in a prospective multicenter national trial.


Subject(s)
Carcinoma, Non-Small-Cell Lung/therapy , Lung Neoplasms/therapy , Pneumonectomy , Aged , Boston , Carcinoma, Non-Small-Cell Lung/mortality , Carcinoma, Non-Small-Cell Lung/pathology , Chemotherapy, Adjuvant , Chi-Square Distribution , Disease-Free Survival , Female , Humans , Kaplan-Meier Estimate , Lung Neoplasms/mortality , Lung Neoplasms/pathology , Male , Middle Aged , Neoadjuvant Therapy , Neoplasm Invasiveness , Neoplasm Staging , Proportional Hazards Models , Prospective Studies , Radiotherapy, Adjuvant , Risk Assessment , Risk Factors , Survival Rate , Time Factors , Treatment Outcome
16.
Ann Thorac Surg ; 90(4): 1116-9, 2010 Oct.
Article in English | MEDLINE | ID: mdl-20868798

ABSTRACT

BACKGROUND: Thermal ablation is increasingly used to treat pulmonary tumors in medically inoperable patients. Most procedures are performed with sedation in the radiology suite. Ideally, the ablation should encompass the entire tumor volume with a surrounding margin of necrosis; however, ablation may not be as effective in the normal aerated lung surrounding a denser tumor. Inducing atelectasis of the lung may potentially increase ablation volumes and increase local cancer control. This study examines the effect of single-lung ventilation on ablation size using a microwave system. METHODS: Twenty microwave ablation procedures were performed in the lungs of 10 swine. Bilateral thoracotomy using a clamshell approach was used. In one lung, ablation was performed with continuous ventilation. In the contralateral lung, single-lung ventilation was achieved by clamping the bronchus before ablation. The ablated lobes were resected and sent for pathologic analysis. Routine and supravital staining was performed. RESULTS: The ablation zone was clearly demarcated on gross examination, and in all cases 100% ablation occurred, without skip areas of viability. The ablation zones were elliptical with the long axis parallel to the axis of the ablation probes (active tip, 3.7 cm). Ablation diameters and volume were compared between the ventilated and nonventilated lungs. Ablation volume was superior in nonventilated lungs (10.74 cm(3) versus 7.35 cm(3); p = 0.039) primarily because of differences in the short axis of the ablation zone. CONCLUSIONS: Microwave energy can effectively ablate normal pulmonary parenchyma without skip areas of viable tissue within the gross ablation field. The volume of necrosis is increased in nonventilated lungs, suggesting that ablation results can be improved in patients by using general anesthesia with single-lung ventilation. Future studies will be required to confirm this hypothesis.


Subject(s)
Lung Neoplasms/surgery , Lung/surgery , Microwaves/therapeutic use , Animals , Hyperthermia, Induced , Lung/pathology , Models, Animal , Respiration, Artificial , Swine
17.
Ann Thorac Surg ; 89(6): S2123-7, 2010 Jun.
Article in English | MEDLINE | ID: mdl-20493995

ABSTRACT

Patients with clinical stage I lung cancer can be considered as arising from three treatment groups: (1) good-risk patients, who are usually treated with lobectomy; (2) high-risk patients, who are usually treated with sublobar (segmental or wedge) resection; and (3) medically inoperable patients, who have traditionally been treated with external beam radiation. Stereotactic body radiation therapy and radiofrequency ablation are two approaches that are gaining increasing popularity for medically inoperable patients. Some have even argued that stereotactic body radiation therapy may be equivalent to lobectomy because of equivalent local control. This assumption is incorrect, because the definitions of local control in the surgical, radiation oncology, and radiology literature are not the same. At best, stereotactic body radiation therapy and radiofrequency ablation can only approximate a wedge resection if it is assumed that 100% tumor destruction has occurred. Lymph node dissection and sampling can also be undertaken at the time of sublobar resection, potentially improving outcomes and allowing identification of unsuspected nodal disease. Despite this, stereotactic body radiation therapy and radiofrequency ablation may be clinically equivalent to sublobar resection for the high-risk patient because of lower procedural morbidity and more rapid return to normal function; however, this has not yet been determined in prospective studies. We review current data on oncologic and secondary outcomes such as morbidity and effect on pulmonary function to help define which therapy is best.


Subject(s)
Catheter Ablation , Lung Neoplasms/surgery , Pneumonectomy/methods , Radiosurgery , Humans , Neoplasm Recurrence, Local/epidemiology , Risk Factors
18.
Ann Thorac Surg ; 89(1): 265-8, 2010 Jan.
Article in English | MEDLINE | ID: mdl-20103250

ABSTRACT

PURPOSE: We evaluated an electromagnetic (EM) navigation system (Veran Medical Technologies Inc, St. Louis, MO) to determine its potential to reduce the number of skin punctures and instrument adjustments during computed tomographic-guided percutaneous ablation and biopsy of lung nodules. DESCRIPTION: Ten patients undergoing lung percutaneous ablation were prospectively enrolled. The mean age was 70 years. Positioning of the needle device was verified with computed tomographic fluoroscopy prior to the execution of any biopsy or ablation. Each EM navigation-guided procedure was defined as an EM-intervention. EVALUATION: Nineteen EM interventions were performed. When an EM-guided biopsy was performed, the intervention was done immediately prior to ablation. For all 19 EM interventions, only one skin-puncture was required. The mean number of instrument adjustments required was 1.2 (range, 0 to 2). The mean time for each EM intervention was 5.2 minutes (range, 1 to 20 minutes). Pneumothorax occurred in 5 patients (50%). Only the number of instrument adjustments was significantly related to the pneumothorax rate (p = 0.005). CONCLUSIONS: The EM navigation is feasible and seems to be a useful aid for image-guided procedures. Early experience suggests a low number of skin-puncture and instrument adjustments using the EM navigation system. Instrument adjustments were a key factor in pneumothorax development.


Subject(s)
Biopsy, Needle/methods , Catheter Ablation/methods , Electromagnetic Fields , Lung Neoplasms/surgery , Adult , Aged , Aged, 80 and over , Equipment Design , Female , Follow-Up Studies , Humans , Lung Neoplasms/diagnosis , Male , Middle Aged , Prospective Studies , Reproducibility of Results , Tomography, X-Ray Computed
19.
J Thorac Cardiovasc Surg ; 139(3): 713-6, 2010 Mar.
Article in English | MEDLINE | ID: mdl-20074750

ABSTRACT

OBJECTIVE: Radiofrequency ablation for Barrett's esophagus in combination with an antireflux procedure has not been widely documented. We report our initial experience with radiofrequency ablation in association with antireflux procedure for Barrett's metaplasia and low-grade dysplasia. METHODS: A total of 14 patients (10 male and 4 female patients) presented with Barrett's metaplasia (n=11) or low-grade dysplasia (n=3). Median age was 60 years (38-80 years). The severity of Barrett's esophagus was classified by length (in centimeters), appearance (circumferential/noncircumferential), and histology (1, normal; 2, Barrett's metaplasia; and 3, low-grade dysplasia). Radiofrequency ablation was performed with the HALO 360 degrees or 90 degrees systems (BARRX Medical, Sunnyvale, Calif). RESULTS: Median follow-up was 17 months. The mean number of ablative procedures undertaken was 2.6 (range, 1-6). There was no mortality, but there were 2 perioperative complications after the antireflux procedure (pneumonia, 1; atrial fibrillation, 1). One patient had mild dysphagia requiring a single dilation 2 months after ablation. The mean length of Barrett's esophagus decreased from 6.2 to 1.2 cm after treatment (P=.001). Barrett's grade decreased significantly (P=.003). Before therapy, circumferential Barrett's esophagus was present in 13 patients. At last endoscopy, only 1 patient had circumferential Barrett's esophagus present. The number of radiofrequency ablation treatments was significantly (P < .05) associated with success. All patients receiving 3 or more treatments had complete resolution of Barrett's metaplasia. CONCLUSIONS: Radiofrequency ablation performed either before or after an antireflux procedure is safe. This approach is effective for reducing or eliminating metaplasia and dysplasia. Long-term studies will be necessary to determine whether this approach can provide durable control of both reflux and Barrett's esophagus.


Subject(s)
Barrett Esophagus/surgery , Catheter Ablation , Gastroesophageal Reflux/surgery , Adult , Aged , Aged, 80 and over , Barrett Esophagus/complications , Barrett Esophagus/pathology , Combined Modality Therapy , Feasibility Studies , Female , Gastroesophageal Reflux/complications , Humans , Male , Middle Aged , Retrospective Studies
20.
Thorac Surg Clin ; 17(2): 273-8, 2007 May.
Article in English | MEDLINE | ID: mdl-17626405

ABSTRACT

There seems to be no role for adjuvant radiation in stage I NSCLC patients treated by lobectomy. Adjuvant brachytherapy in combination with sublobar resection is a promising approach that seems to decrease local recurrence rates similar to that reported following lobectomy. If the results of the current American College of Surgeons Oncology Group randomized trial are favorable, it may be possible in the future to define subgroups of patients with stage I NSCLC who are able to be treated with this approach in preference to lobectomy. Until further data are available, lobectomy should remain the standard of care. RFA is an alternative for the high-risk patient with NSCLC who is considered too high-risk even for sublobar resection. Although long-term results are not yet available, it does seem that local recurrence is a significant problem. In a similar fashion to the approach currently being investigated with sublobar resection, the addition of radiation may improve local control after RFA. In particular, adjuvant stereotactic radiation should be investigated as a potential method of decreasing local recurrence and preserving lung function in these high-risk patients.


Subject(s)
Carcinoma, Non-Small-Cell Lung/radiotherapy , Lung Neoplasms/radiotherapy , Radiotherapy, Adjuvant , Brachytherapy , Carcinoma, Non-Small-Cell Lung/pathology , Carcinoma, Non-Small-Cell Lung/surgery , Humans , Lung Neoplasms/pathology , Lung Neoplasms/surgery , Neoplasm Staging , Pneumonectomy , Radiotherapy, Adjuvant/adverse effects , Radiotherapy, Adjuvant/methods , Randomized Controlled Trials as Topic , Treatment Outcome
SELECTION OF CITATIONS
SEARCH DETAIL
...