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Significance of the Presence of Microscopic Vascular Invasion After Complete Resection of Stage I-II pT1-T2N0 Non-small Cell Lung Cancer and Its Relation with T-Size Categories: Did the 2009 7th Edition of the TNM Staging System Miss Something?

Significance of the Presence of Microscopic Vascular Invasion After Complete Resection of Stage I-II pT1-T2N0 Non-small Cell Lung Cancer and Its Relation with T-Size Categories: Did the 2009 7th Edition of the TNM Staging System Miss Something?

J Thorac Oncol. 2010 Dec 15;

Authors: Ruffini E, Asioli S, Filosso PL, Buffoni L, Bruna MC, Mossetti C, Solidoro P, Oliaro A

INTRODUCTION:: The aim of this study was to assess the significance of microscopic vascular invasion (MVI) in a population of resected patients with early-stage non-small cell lung cancer (NSCLC), along with an analysis of the effect of the combination of MVI and tumor size for the T-size categories T1a-T2b according to the 2009 7th edition of the tumor, node, metastasis (TNM) classification. METHODS:: From January 1993 to August 2008, 746 patients with pT1-T2N0 NSCLC received resection at our institution. MVI was ascertained using histopathological and immunohistochemical techniques. RESULTS:: MVI was observed in 257 patients (34%). Prevalence was higher in adenocarcinoma (ADK) than in squamous cell carcinoma (p = 0.002). A significant correlation was found between MVI and ADK (p = 0.03), increased tumor dimension (p = 0.05), and the presence of tumor-infiltrating lymphocytes (p = 0.02). The presence of MVI was associated with a reduced 5-year survival overall (p = 0.003) and in ADK (p = 0.0002). In a multivariate survival analysis, MVI was an indicator of poor survival overall (p = 0.003) and in ADK (p = 0.0005). In each T category (T1a-T2b) of the 2009 TNM staging system, survival of MVI+ patients was significantly lower than the corresponding MVI- patients; T1a and T1b MVI+ patients had a survival similar to MVI- T2 patients. CONCLUSIONS:: The finding of MVI in pT1-T2N0 NSCLC is frequent. MVI correlates with adenocarcinoma histotype, increased tumor dimensions, and tumor-infiltrating lymphocytes. The presence of MVI is an independent negative prognostic factor. In our experience, MVI was a stronger prognostic indicator than T size in T1a-T2b categories according to the 2009 TNM staging system.

PMID: 21164365 [PubMed - as supplied by publisher]

Is Silver Nitrate Pleurodesis for Patients with Malignant Pleural Effusion Feasible and Safe When Performed in an Outpatient Setting?

Is Silver Nitrate Pleurodesis for Patients with Malignant Pleural Effusion Feasible and Safe When Performed in an Outpatient Setting?

Ann Surg Oncol. 2010 Dec 16;

Authors: Terra RM, Kim SY, Pego-Fernandes PM, Teixeira LR, Vargas FS, Jatene FB

BACKGROUND: The purpose of this study was to analyze the effectiveness and safety of silver nitrate pleurodesis (SNP) in patients with recurrent malignant pleural effusion (RMPE) when performed in an outpatient setting. MATERIALS AND METHODS: Prospective study including patients with RMPE recruited in a tertiary university-based hospital from February 2008 to June 2009. Elected patients underwent pleural catheter insertion (Day 1) followed by 0.5% SNP (Day 2), and on 7th day the drain was removed. All procedures were performed in an outpatient facility. Pleurodesis was considered successful when no additional pleural procedure was necessary by the 30th day. Complications were registered and graded according to the CTCAE3.0. Quality of life was evaluated before and 30 days after SNP. RESULTS: A total of 68 patients (54 female, 14 male, mean age: 57.3 years) were included. In addition, 7 had bilateral pleural effusions; therefore, 75 hemithoraces were drained. Also, 5 were excluded, and 70 hemithoraces (63 patients) underwent SNP. During the period of 30 days postpleurodesis, 8 deaths not related to the procedure occurred, and we lost contact with 10 patients who were followed elsewhere. At the 30th day, 48 hemithoraces (45 patients) were reevaluated, and 2 recurrences observed. The most frequent complication was pain-graded as 3 or more in 7 patients; infection occurred in 2 patients. Physical and environmental aspects of quality of life improved significantly after pleurodesis. CONCLUSIONS: In this study, SNP could be performed safely in an outpatient setting, with pain the most frequent complication. Recurrences occurred in 4% of the patients.

PMID: 21161728 [PubMed - as supplied by publisher]

Outcomes of Mediastinoscopy and Surgery with or without Neoadjuvant Therapy in Patients with Non-small Cell Lung Cancer Who are N2 Negative on Positron Emission Tomography and Computed Tomography.

The objectives of this study were (1) to assess the results of mediastinoscopy and mediastinal lymphadenectomy and (2) to compare outcomes of surgical treatment with or without neoadjuvant therapy in patients with non-small cell lung cancer who are N2 negative on integrated positron emission tomography and computed tomography (PET/CT).

METHODS : This was a retrospective, single-institution review of patients with non-small cell lung cancer who were N2 negative on CT and PET/CT. All patients underwent mediastinoscopy; if N2 positive, patients underwent neoadjuvant therapy followed by pulmonary resection, and if N2 negative, patients underwent pulmonary resection with mediastinal lymphadenectomy.

RESULTS : Between 2003 and 2007, there were 750 patients (547 men). Of these, 51 patients were N2 positive at mediastinoscopy and then underwent neoadjuvant therapy (mediastinoscopy N2 group), and 699 were N2 negative at mediastinoscopy and then underwent mediastinal lymphadenectomy. Mediastinal lymphadenectomy revealed that 635 had N0 or N1 disease (N2-negative group), and 64 had N2 disease (surgery N2 group). Overall 5-year survival was 73% for the N2-negative group, 44% for the surgery N2 group, and 47% for the mediastinoscopy N2 group. Disease-free 5-year survival was 59% for the N2-negative group, 27% for the surgery N2 group, and 29% for the mediastinoscopy N2 group.

CONCLUSIONS : We found that there were no significant differences in overall and disease-free survivals between the surgery N2 group and the mediastinoscopy N2 group. The benefit of neoadjuvant therapy in patients with PET/CT-negative but mediastinoscopy-positive N2 disease should be confirmed by randomized studies.

Diagnostic evaluation and management of chronic thromboembolic pulmonary hypertension: A clinical practice guideline.

Pulmonary embolism is a common condition. Some patients subsequently develop chronic thromboembolic pulmonary hypertension (CTEPH). Many care gaps exist in the diagnosis and management of CTEPH patients including lack of awareness, incomplete diagnostic assessment, and inconsistent use of surgical and medical therapies.

METHODS: A representative interdisciplinary panel of medical experts undertook a formal clinical practice guideline development process. A total of 20 key clinical issues were defined according to the patient population, intervention, comparator, outcome (PICO) approach. The panel performed an evidence-based, systematic, literature review, assessed and graded the relevant evidence, and made 26 recommendations.

RESULTS: Asymptomatic patients postpulmonary embolism should not be screened for CTEPH. In patients with pulmonary hypertension, the possibility of CTEPH should be routinely evaluated with initial ventilation⁄ perfusion lung scanning, not computed tomography angiography. Pulmonary endarterectomy surgery is the treatment of choice in patients with surgically accessible CTEPH, and may also be effective in CTEPH patients with disease in more 'distal' pulmonary arteries. The anatomical extent of CTEPH for surgical pulmonary endarterectomy is best assessed by contrast pulmonary angiography, although positive computed tomography angiography may be acceptable. Novel medications indicated for the treatment of pulmonary hypertension may be effective for selected CTEPH patients.

CONCLUSIONS: The present guideline requires formal dissemination to relevant target user groups, the development of tools for implementation into routine clinical practice and formal evaluation of the impact of the guideline on the quality of care of CTEPH patients. Moreover, the guideline will be updated periodically to reflect new evidence or clinical approaches.

Computed tomography (CT) predicts accurately the pathologic tumour size in stage I non-small-cell lung cancer (NSCLC).

In stage I non-small-cell lung cancer (NSCLC) tumour size has been the most consistent determinant of survival. The choice of therapy option is based on accurate definition of the stage. The aim of our study is to correlate tumour size by computed tomography scan (CT) with pathologic size and to determine possible prognostic factors in surgically resected pathologic stage IA and IB NSCLC patients.

Retrospective review of CT scans and medical history data from 89 pathologic stage I NSCLC patients. Clinical prognostic factors analysed were age, gender, smoking status, pulmonary function, performance status (PS), surgical procedure, histopathology, vessel invasion, pleural infi ltration, tumour size and number of lymph nodes resected. According to the new TNM classification for lung cancer, tumour size was divided into five groups (I: <2 cm, II: 2-3 cm, III: 3-5 cm, IV: 5-7 cm and V: >7 cm).

After a median surveillance of 55.2 months, 42 patients relapsed and 55 had died. The 5-year progressionfree survival was 55.7% and 5-year overall survival (OS) 49.9% (median 58.97 months). None of the clinical parameters analysed were predictors of OS. Significant correlation was found between tumour size in CT scan and pathologic stage (Pearson 0.75).

In our analysis with 89 surgically resected stage IA and IB NSCLC patients we found a good correlation between clinical and pathologic tumour size by CT scan. The prognoses factors analysed had no significant impact on survival.

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