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Early-Stage Non-small Cell Lung Cancer Recurrence

Objectives:

The purpose of this study was to evaluate risk factors for tumor recurrence in patients with completely resected early-stage non-small cell lung cancer (NSCLC).

 Methods:

Between July 1992 and December 2007, 1,967 consecutive patients with stage I and II NSCLC with diagnoses based on the seventh edition TNM classification underwent complete resection. All patients were divided into three groups according to the stage and presence of lymph node metastasis: stage I, patients with stage I, T1-T2aN0M0 disease; stage IIN0, patients with stage II, T2b-T3N0M0, node-negative disease; and stage IIN1, patients with stage II, T1-2N1M0, node-positive disease. Freedom from recurrence rate was estimated using the Kaplan-Meier method, and recurrence risk factors were identified by univariate and multivariate analyses.

 Results:

The 5-year freedom from recurrence rates for stage I, stage IIN0, and stage IIN1 patients were 84%, 61%, and 54%, respectively. By multivariate analyses, three variables (histologic differentiation, vessel invasion, and visceral pleural invasion) in stage I and two variables (adenocarcinoma histology and visceral pleural invasion) in stage IIN0 and stage IIN1 were shown to be independently significant risk factors for recurrence. According to subgroup analyses that combined these risk factors in each group, the 5-year freedom from recurrence rate was 63% for stage I with three risk factors, whereas those for stage IIN0 and stage IIN1 without risk factors were 83% and 78%, respectively.

 Conclusion:

In patients with stage I and II NSCLC, we identified risk factors for recurrence. When these factors are combined, high- and low-risk subgroups can be identified within each group.

Natriuretic Peptides and Central Sleep Apnea

Background:

Central sleep apnea (CSA) is frequent among patients with heart failure (HF) and associated with increased morbidity and mortality. Elevated cardiac filling pressures promote CSA and atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) secretion. We hypothesized that circulating natriuretic peptide concentrations predict CSA.

 Methods:

Consecutive patients with HF (n = 44) with left ventricular ejection fraction (LVEF) ≤ 35% underwent polysomnography for detection of CSA. CSA was defined as an apnea-hypopnea index ≥ 15 with ≥ 50% central apneic events. The relation of natriuretic peptide concentrations to CSA was evaluated by estimation of ORs and receiver operator characteristics (ROCs).

 Results:

Twenty-seven subjects (61%) had CSA, with men more frequently affected than women (73% vs 27%; OR, 7.1; P = .01); given that only three women had CSA, further analysis was restricted to men. Subjects with CSA had higher mean ANP (4,336 pg/mL vs 2,510 pg/mL, P = .03) and BNP concentrations (746 pg/mL vs 379 pg/mL, P = .05). ANP and BNP concentrations were significantly related to CSA (OR, 3.7 per 3,000 pg/mL, P = .03 and OR, 1.5 per 200 pg/mL, P = .04, respectively), whereas age, LVEF, and New York Heart Association functional class were not. Concentrations of ANP and BNP were predictive of CSA as ROC demonstrated areas under the curve of 0.75 and 0.73, respectively.

 Conclusions:

Risk of CSA is related to severity of HF. ANP and BNP concentrations performed similarly for detection of CSA; low concentrations appear associated with low risk for CSA in men.

Digital vs Film Radiographs for Pneumoconiosis

Background:

Digital radiography systems are replacing traditional film for chest radiographic monitoring in the recognition of pneumoconiosis.

 Methods:

To further investigate previous findings regarding the equivalence of film-screen radiographs (FSRs) and storage phosphor computed radiographs (CRs), FSRs and CRs from 172 underground coal miners were classified independently by seven National Institute for Occupational Safety and Health-approved B readers, using the International Labor Office (ILO) classification of radiographs of pneumoconiosis.

 Results:

More CRs were classified as "good" quality compared with FSRs (prevalence ratio [PR], 1.5; 95% CI, 1.4-1.6; P , .001). B readers showed good overall agreement on scoring small opacity profusion using CRs vs FSRs (weighted , 0.58; 95% CI, 0.54-0.62). Significantly more irregular opacities (compared with rounded) were classified using CR images compared with FSR (PR, 1.3; 95% CI, 1.1-1.6; P = .01). Similarly, the smallest sized opacities (width < 1.5 mm, p and s type) were reported more frequently using CR vs FSR images (PR, 1.3; 95% CI, 1.1-1.5; P < .001). Interreader and intrareader agreement was lower with respect to the classification of shape and size than for small opacity profusion. Overall, interreader and intrareader variability did not differ significantly using CR vs FSR.

 Conclusions:

Under optimal conditions, using standardized methods and equipment, reader visualization of small pneumoconiotic opacities does not appear to differ meaningfully, whether using CR or FSR. Variability in ILO classifications between imaging modalities appears to be considerably lower than variability among readers. The well-documented challenge of reader variability does not appear to be resolved through the use of digital imaging alone, and additional approaches must be evaluated.

Early Mobilization in the ICU

As ICU survival continues to improve, clinicians are faced with short- and long-term consequences of critical illness. Deconditioning and weakness have become common problems in survivors of critical illness requiring mechanical ventilation. Recent literature, mostly from a medical population of patients in the ICU, has challenged the patient care model of prolonged bed rest. Instead, the feasibility, safety, and benefits of early mobilization of mechanically ventilated ICU patients have been reported in recent publications. The benefits of early mobilization include reductions in length of stay in the ICU and hospital as well as improvements in strength and functional status. Such benefits can be accomplished with a remarkably acceptable patient safety profile. The importance of interactions between mind and body are highlighted by these studies, with improvements in patient awareness and reductions in ICU delirium being noted. Future research to address the benefits of early mobilization in other patient populations is needed. In addition, the potential for early mobilization to impact long-term outcomes in ICU survivors requires further study.

Cryoablation After Pneumonectomy

Lung cancers in the residual lungs of patients who have undergone pneumonectomies are often unresectable, primarily because of the risks of overt pulmonary function losses. Percutaneous cryoablation of lung tumors is a potentially minimally invasive technique that has recently been used in the treatment of lung cancers and metastatic lung tumors. Here, we present two patients who had previously undergone pneumonectomies, in whom lung cancers in the residual lungs were treated by cryoablation. In both patients, the procedures were performed safely without any complications, such as airway bleeding, hemothoraces, or pneumothoraces. The changes in pulmonary functions after the procedures were minimal: % vital capacity (–1% and –4%), and %FEV1 (–1% and +10%) in the first and second patients, respectively. The performance statuses were maintained at zero in both patients after cryoablation. In the first patient, local control has been maintained for 4 years. In the second patient, local control was maintained for 2 years until the patient died of distant metastases. This is, to our knowledge, the first reported case of lung cryoablation in residual lungs of patients who have previously undergone pneumonectomies. Application of percutaneous cryoablation may represent a new treatment option for lung tumors in patients who have previously undergone pneumonectomies.

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