Stage III N2 non-small cell lung cancer treatment: decision-making among surgeons and radiation oncologists.

BACKGROUND: Stage III N2 non-small cell lung cancer (NSCLC) is a very heterogeneous disease associated with a poor prognosis. A number of therapeutic options are available for patients with Stage III N2 NSCLC, including surgery [with neoadjuvant or adjuvant chemotherapy (CTx)/neoadjuvant chemoradiotherapy (CRT)] or CRT potentially followed by adjuvant immunotherapy. We have no clear evidence demonstrating a significant survival benefit for either of these approaches, the selection between treatments is not always straightforward and can come down to physician and patient preference. The very heterogeneous definition of resectability of N2 disease makes the decision-making process even more complex. METHODS: We evaluated the treatment strategies for preoperatively diagnosed stage III cN2 NSCLC among Swiss thoracic surgeons and radiation oncologists. Treatment strategies were converted into decision trees and analysed for consensus and discrepancies. We analysed factors relevant to decision-making within these recommendations. RESULTS: For resectable "non-bulky" mediastinal lymph node involvement, there was a trend towards surgery. Numerous participants recommend a surgical approach outside existing guidelines as long as the disease was resectable, even in multilevel N2. With increasing extent of mediastinal nodal disease, multimodal treatment based on radiotherapy was more common. CONCLUSIONS: Both, surgery- or radiotherapy-based treatment regimens are feasible options in the management of Stage III N2 NSCLC. The different opinions reflected in the results of this manuscript reinforce the importance of a multidisciplinary setting and the importance of shared decision-making with the patient.

Prognostic factors of oligometastatic non-small-cell lung cancer following radical therapy: a multicentre analysis.

OBJECTIVES: Patients with oligometastatic non-small-cell lung cancer (NSCLC) may benefit from therapy with curative intent. Our goal was to identify prognostic factors related to better prognosis in a multicentre analysis of patients who underwent surgery of primary tumours in combination with radical treatment of all metastatic sites. METHODS: We retrospectively reviewed the records of oligometastatic patients who underwent resection of primary tumours at 4 centres (August 2001-February 2018). Oligometastasis was defined as ≤5 synchronous metastases in ≤2 organs. Radical metastatic treatment was surgery, radiotherapy or a combination. The Cox proportional hazards model was used for identification of prognostic factors on overall survival. RESULTS: We treated 124 patients; 72 (58%) were men, mean age 60 ± 9.8 years, with 87 (70%) adenocarcinoma. Sixty-seven (54%) patients had positive pathologic-N stage (pN). Brain metastases were most common (n = 76; 61%) followed by adrenal (n = 13; 10%) and bone (n = 12; 10%). Systemic therapy was administered in 101 (82%) patients. Median follow-up was 60 months [95% confidence interval (CI) 41-86]. Thirty- and 90-day mortality rates were 0 and 2.4%, respectively. One-, 2-, and 5-year overall survival were 80%, 58% and 36%, respectively. Cox regression analysis showed that patients ≤60 years [hazard ratio (HR) 0.41, 95% CI 0.24, 0.69; P = 0.001] and patients with pN0 (HR 0.38, 95% CI 0.21-0.69; P = 0.002) had a significant survival benefit. The presence of bone metastases negatively affected survival (HR 2.53, 95% CI 1.05-6.09; P = 0.04). CONCLUSIONS: Treatment with curative intent of selected oligometastatic NSCLC, including resection of the primary tumour, can be performed safely and with excellent 5-year survival rates, especially in younger patients with pN0 disease.

Effect of postoperative haemoglobin variation on major cardiopulmonary complications in high cardiac risk patients undergoing anatomical lung resections.

OBJECTIVES: Recent evidence shows that permissive anaemia strategies are safe in different surgical settings. However, effects of variations in haemoglobin (Hb) levels could have a negative impact in high-risk patients. We investigated the combined effect of postoperative Hb concentration and cardiac risk status on major cardiopulmonary complications after anatomical lung resections. METHODS: We retrospectively analysed the records, collected in a prospective clinical database, of 154 consecutive patients undergoing anatomical lung resections at our institution (February 2017-February 2019). Hb levels were displayed as preoperative concentration, nadir Hb level before onset of complications and delta Hb (ΔHb). Cardiac risk was stratified according to the Thoracic Revised Cardiac Risk Index (ThRCRI). Univariable and multivariable logistic regression analyses were used to test the associations between patients, surgical variables and cardiopulmonary complications according to the European Society of Thoracic Surgeons definitions. RESULTS: Cardiopulmonary complications occurred in 63 patients (17%). In the fully adjusted multivariable model, higher values of ΔHb were associated with increased risk of complications [odds ratio (OR) 1.07; P < 0.001], along with higher ThRCRI classes (classes A-B versus C-D: OR 0.09; P < 0.001). Interaction terms with transfusion were not statistically significant, indicating that the harmful effect of ΔHb was independent. According to receiver operating characteristic curve analysis, a ΔHb of 29 g/l was found to be the best cut-off value for predicting complications. CONCLUSIONS: In our series, ΔHb, rather than nadir Hb, was associated with an increased risk of complications, particularly in patients with higher cardiac risk. Restrictive transfusion strategies should be carefully applied in patients undergoing lung resections and balanced according to individual clinical status.

Spiral wire localization of lung nodules: procedure effectiveness and oncological usefulness.

BACKGROUND: In the last years, a large number of techniques and devices for localizing small pulmonary nodules prior to resection have been developed with the aim of facilitating minimally invasive surgery (VATS). However, each device presents pros and cons and there is no unanimous consensus. We report our experience with an uncommon wire system with spiral shape for percutaneous marking. METHODS: We recorded 102 consecutive CT-guided spiral wire localizations in our Institution, and we evaluated the efficacy of the method according to 4 success rates (SR): (I) successful targeting rate (SR-1): number of successful targeting procedures/number of all localizations; (II) successful localization in operative field (SR-2): (number of successful targeting procedures -number of dislodgements in operative field)/number of all localizations; (III) successful VATS rate (SR-3): number of successful VATS procedures/(number of localizations-number of thoracotomies not due to wire dislocation); (IV) successful curative rate (SR-4): number of neoplastic nodules resected with curative intent with free margins (R0) on definitive tissue diagnosis/number of neoplastic nodules resected with curative intent. Complications rate was recorded as well. RESULTS: SR-1: 100%, SR-2: 97.1%, SR-3: 100%, SR-4: 100%. Asymptomatic pneumothorax and minimal parenchymal hemorrhage were observed in 5 (4.9%) and 19 (18.6%) cases, respectively. CONCLUSIONS: Spiral wire localization showed very good results in terms of feasibility, stability in operative field and contributed to effective use of VATS during wedge resection performed for malignant nodules. In the era of widespread radiological investigations (as it is happening in lung cancer screening) and evolutions in cancer treatments, this appears to be clinically relevant.

Management of residual pleural space after lung resection: fully controllable paralysis of the diaphragm through continuous phrenic nerve block.

BACKGROUND: Residual pleural space after lung resection associated with air leak is a challenging issue, potentially causing serious complications. We report a new, postoperative technique to reduce the pleural space, inducing a controlled and reversible paralysis of the diaphragm. METHODS: Ten patients were enrolled (7 lobectomies, 2 bilobectomy, 1 wedge resection). Inclusion criteria were: digitally detected air flow >200 mL/min at post-op day 3, presence of empty pleural space at chest x-ray, absence of restrictive lung disease, absence of known arrhythmias. A 22G nerve-block catheter was place under ultrasound guidance in proximity to the phrenic nerve, between the sternocleidomastoid muscle and the anterior scalene muscle at the level of 6th cervical vertebra. Continuous infusion of ropivacaine 0.2% 3 mL/h was started. Fluoroscopy was used to confirm significant reduction in hemidiaphragm movements. Monitoring of vital signs and intense respiratory physiotherapy were enhanced. The infusion was stopped at air leak cessation and the catheter was removed along with the chest drain. RESULTS: No peri- and post-procedural complications occurred. In all patients, we observed an immediate reduction of the empty pleural space and resolution of the air leak within few days (3±1.16 days). After suspension of local anaesthetic, complete restoration of the hemidiaphragm function has been documented. CONCLUSIONS: This is an effective and minimally invasive method to reduce the residual pleural space after lung resections. Narrowing of the pleural space facilitates the contact between the lung and the chest wall promoting the resolution of the air leak. Diaphragm paralysis is controlled and temporary with no residual disabilities.

Chylothorax after endoscopic ultrasound with fine-needle aspiration causing migrating appearance of a solitary fibrous tumor of the pleura.

Trans-esophageal endoscopic ultrasound with fine-needle aspiration (EUS-FNA) is widely used to assess mediastinal masses. Common complications are self-limiting bleeding or pain, but occasionally, more serious accidents have been reported. A 54-year-old woman with a huge mass located in the left middle mediastinum presented 2 days after an EUS-FNA with dyspnea and chest pain. Computed tomography scan showed a massive left pleural effusion. A chest tube was inserted revealing a chylothorax (1800 ml). Over the following days, the pleural effusion did not diminish, requiring a left mini-thoracotomy. Intraoperative findings showed a pedunculated mass arising from the upper lobe. A wedge resection and a ligation of a large lymphatic vessel were performed. Postoperative course was regular. Histology showed a solitary fibrous tumor of the pleura. To our knowledge, the case we describe is the first reported chylothorax after EUS-FNA. Despite the demonstrated safety, particular care is mandatory in case of large, vascular, and heterogeneous masses.

Lung Ultrasound to Detect Residual Pneumothorax After Chest Drain Removal in Lung Resections.

BACKGROUND: Indication for postdrain removal imaging after lung resection is debated. Chest roentgenogram (CR) is widely used to confirm lung expansion but not evidence based. We propose to introduce lung ultrasound (LUS) as alternative to exclude significant pneumothorax (PTx) in this setting. METHODS: The study enrolled 50 patients undergoing lung resections. Inclusion criteria were complete expansion of the lung at postoperative CR, pleural effusion of less than 300 mL/24 h, air leak of 10 to 20 mL/min for 6 hours. Two hours after chest drain removal, LUS was performed at the second and third intercostal spaces to assess pleural sliding. Patients with no detected PTx or with apical PTx were considered for discharge. The same patients were blindly evaluated with CR by a second operator, and a comparison between the two methods was performed. Clinical decisions were taken based on CR results. RESULTS: LUS confirmed large PTxs in 7 patients, apical PTxs in 10 patients, and no PTx in 33 patients. CR confirmed 5 of 7 significant PTxs (1 chest drain reinserted, 4 patients observed), and 2 of 7 PTx were considered irrelevant. Apical PTxs were confirmed in 8 of 10 patients, and in 2 patients there was no PTx at CR. The 33 patients with no PTx at LUS had full lung expansion at CR. LUS has a negative predictive value of 100% in excluding large PTxs and a positive predictive value of 71%. CONCLUSIONS: In this subgroup of patients with air leak of 10 to 20 mL/min, performing an imaging study to verify the absence of PTx is desirable; however, when LUS confirms lung expansion or the presence of apical PTx, CR does not seem to be needed.