[Severe complications of systemic treatment in thoracic oncology]

Primary thoracic cancers affect a large number of patients, mainly those with lung cancer and to a lesser extent those with pleural mesothelioma and thymic tumours. Given their frequency and associated comorbidities, in patients whose mean age is high, these diseases are associated with multiple complications. This article, the last of a series dedicated to emergencies in onco-haematological patients, aims to present a clinical picture of the severe complications (side effects, immune-related adverse events) associated with systemic treatments, excluding infections and respiratory emergencies, with which general practitioners and specialists can be confronted. New toxicities are to be expected with the implementation of innovative therapeutic approaches, such as CAR-T cells, along with immunomodulators and antibody-drug conjugates.

[The role of the intensive care unit after thoracic surgery]

Lung (bronchial) cancer is the leading cause of cancer-related death in Western countries today. Thoracic surgery represents a major therapeutic strategy and the various advances made in recent years have made it possible to develop less and less invasive techniques. That said, the postoperative period may be lengthy, post-surgical approaches need to be more precisely codified, and it matters that the different interventions involved be supported by sound scientific evidence. To date, however, there exists no evidence that preventive postoperative admission to intensive care is beneficial for patients having undergone lung resection surgery without immediate complications. A stratification of the risk of complications taking into consideration the patient's general state of health (e.g., nutritional status, degree of autonomy, etc.), comorbidities and type of surgery could be a useful predictive tool regarding the need for postoperative intensive care. However, serious post-operative complications remain relatively frequent and post-operative management of these intensive care patients is liable to become complex and long-lasting. In the aftermath of the validation of "enhanced recovery after surgery" (ERAS) in thoracic surgery, new protocols are needed to optimize management of patients having undergone pulmonary resection. This article focuses on the main postoperative complications and more broadly on intensive care patient management following thoracic surgery.

[The role of prophylactic cranial irradiation in small cell lung cancer]

INTRODUCTION

Prophylactic cranial irradiation (PCI) is considered standard therapeutic management in small cell lung cancer (SCLC). This is based on old randomised trials with methodological limitations, namely the absence of magnetic resonance imaging (MRI) of the brain. The aim of this study is to assess the risk not administering PCI when systematic brain imaging is applied.

METHODS

Retrospective study including untreated SCLC, without PCI and receiving brain imaging at the time of diagnosis. Kaplan-Meier and log-rank statistics were used for survival analyses.

RESULTS

Among 150 patients, 75 were possibly eligible for PCI. Thirteen patients presented with an isolated brain recurrence as the first site of progression with no other metastatic sites apparent, and in 6 patients, the brain was the only recurrent site during the whole follow-up. In the group of patients eligible for PCI, there was no statistically significant survival difference according to the brain progression status (P=0.11).

CONCLUSIONS

The expected impact of PCI seems limited in terms of overall survival and prevention of isolated brain metastases in patients having systematic brain imaging during SCLC work-up.

[Lung cancer: Prognosis in intensive care depends mainly on the acute complication]

INTRODUCTION

It has been demonstrated in unselected populations of cancer patients that prognosis in intensive care is essentially dependent on the extent of the acute physiological disturbance caused by the complication precipitating the admission. By contrast, the prognosis after hospital discharge remains dependent on the characteristics of the underlying neoplasm. The aim of our study was to confirm whether this general finding was the case in a specific population of lung cancer patients, since there are no data on this patient group in the literature.

PATIENTS AND METHODS

We conducted a retrospective study including all patients with lung cancer admitted to our ICU between September 1, 2008 and December 31, 2013.

RESULTS

During this period, 180 different patients with lung cancer were admitted into ICU. The simplified acute physiology score II (SAPS II) (OR 1.07 ; 95% CI 1.04-1.11), respiratory failure (OR 4.00; 95% CI 1.76-9.07) and the presence of therapeutic limitations were the 3 factors independently affecting hospital mortality in multivariate analysis. Considering only patients discharged alive from the hospital, the presence of metastases (HR 2.30; 95% CI 1.44-3.65) and limitations on therapy (HR 5,89; IC 95% 3,11-11,14) were the two statistically independent prognostic factors for overall survival.

CONCLUSION

In this population of lung cancer patients admitted into ICU, independent predictors of hospital mortality are determined by the physiological perturbations induced by the acute presenting complication. After recovery from this, prognosis is again determined by the characteristics of the underlying cancer.

Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA

Purpose

Whether the quality of the ethical climate in the intensive care unit (ICU) improves the identification of patients receiving excessive care and affects patient outcomes is unknown.

Methods

In this prospective observational study, perceptions of excessive care (PECs) by clinicians working in 68 ICUs in Europe and the USA were collected daily during a 28-day period. The quality of the ethical climate in the ICUs was assessed via a validated questionnaire. We compared the combined endpoint (death, not at home or poor quality of life at 1 year) of patients with PECs and the time from PECs until written treatment-limitation decisions (TLDs) and death across the four climates defined via cluster analysis.

Results

Of the 4747 eligible clinicians, 2992 (63%) evaluated the ethical climate in their ICU. Of the 321 and 623 patients not admitted for monitoring only in ICUs with a good (n = 12, 18%) and poor (n = 24, 35%) climate, 36 (11%) and 74 (12%), respectively were identified with PECs by at least two clinicians. Of the 35 and 71 identified patients with an available combined endpoint, 100% (95% CI 90.0–1.00) and 85.9% (75.4–92.0) (P = 0.02) attained that endpoint. The risk of death (HR 1.88, 95% CI 1.20–2.92) or receiving a written TLD (HR 2.32, CI 1.11–4.85) in patients with PECs by at least two clinicians was higher in ICUs with a good climate than in those with a poor one. The differences between ICUs with an average climate, with (n = 12, 18%) or without (n = 20, 29%) nursing involvement at the end of life, and ICUs with a poor climate were less obvious but still in favour of the former.

Conclusion

Enhancing the quality of the ethical climate in the ICU may improve both the identification of patients receiving excessive care and the decision-making process at the end of life.

Electronic supplementary material

The online version of this article (10.1007/s00134-018-5231-8) contains supplementary material, which is available to authorized users.

[Impact of routine brain imaging in the initial management of lung cancer]

INTRODUCTION

Brain metastases are a common complication of bronchial carcinoma (BC). There is no consensus as to the need to undertake a systematic search for these lesions during the initial assessment. The aim of this study was to evaluate the contribution of brain imaging in the initial evaluation of patients with CB.

METHODS

We undertook a retrospective analysis of patients treated in the Thoracic Oncology Clinic at the Institute Jules-Bordet between 01/09/2008 and 31/08/2013, who were treatment-naïve and were having a full diagnostic work-up including brain imaging.

RESULTS

Four hundred and sixty-three patients consecutively diagnosed with BC were included. Brain magnetic resonance imaging and/or CT-scan showed brain metastases in 101 patients (21.8%), of whom 67 had no symptoms suggestive of brain metastatic disease. The addition of a brain imaging into the work-up procedure resulted in a stage migration for 30 patients (6.5%), mainly otherwise staged IIIA (n=10) or IIIB (n=14) without brain imaging.

CONCLUSION

The addition of brain imaging in the initial assessment of bronchial carcinoma allows the identification of brain metastases in one case among 5, of which 2/3 are asymptomatic. This leads to a change in staging, primarily for disease otherwise considered to be stage III.

[Immunotherapy and non-small cell lung cancer : a (r)evolution]

Immunotherapy renews in non-small cell lung cancer. Antibodies directed against PD1 and PD-L1, blocking the relationship between the cancer cells and the immune system, allowed in randomised trials to significantly improve cancer control with an interesting survival impact of treated patients. However, it remains to determine the most benefiting populations from this expensive and potentially toxic therapy.

[Dyspnea and cardia cancer, an unusual etiology]

CASE REPORT

a 63-year old man, followed for a metastatic cardia cancer, develop a pericardial effusion with sign of pre-tamponade. A CT scanner suggests the presence of a gastro- esophageal-pericardial fistula. A surgical drainage brings a purulent fluid, infected by a polymicrobial flora. Despite early antibiotics with vancomycin and piperacillin-tazobactam, the patient dies five days after the drainage.

DISCUSSION

purulent pericarditis associated with gastrointestinal neoplasia may be due to sepsis or a proximity invasion . The diagnosis is based on ultrasound and pericardiocentesis. The most commonly involved organism is Streptococcus pneumoniae. The treatment involves intravenous antibiotics, pericardial drainage and intrapericardial instillation of antibiotics. The mortality rate remains high, especially in cases associated with gastrointestinal neoplasia.

Noninvasive ventilation during acute respiratory distress syndrome in patients with cancer: Trends in use and outcome

PURPOSE

The objectives of our study were to describe the outcome of patients with malignancies treated for acute respiratory distress syndrome (ARDS) with noninvasive ventilation (NIV) and to evaluate factors associated with NIV failure.

METHODS

Post hoc analysis of a multicenter database within 20 years was performed. All patients with malignancies and Berlin ARDS definition were included. Noninvasive ventilation use was defined as NIV lasting more than 1 hour, whereas failure was defined as a subsequent requirement of invasive ventilation. Conditional backward logistic regression analyses were conducted.

RESULTS

A total of 1004 met the Berlin definition of ARDS. Noninvasive ventilation was used in 387 patients (38.6%) and NIV failure occurred in 71%, with an in-hospital mortality of 62.7%. Severity of ARDS defined by the partial pressure arterial oxygen and fraction of inspired oxygen ratio (odds ratio [OR], 2.20; 95% confidence interval [CI], 1.15-4.19), pulmonary infection (OR, 1.81; 95% CI, 1.08-3.03), and modified Sequential Organ Failure Assessment (SOFA) score (OR, 1.13; 95% CI, 1.06-1.21) were associated with NIV failure. Factors associated with hospital mortality were NIV failure (OR, 2.52; 95% CI, 1.56-4.07), severe ARDS as compared with mild ARDS (OR, 1.89; 95% CI, 1.05-1.19), and modified SOFA score (OR, 1.12; 95% CI, 1.05-1.19).

CONCLUSION

Noninvasive ventilation failure in ARDS patients with malignancies is frequent and related to ARDS severity, SOFA score, and pulmonary infection-related ARDS. Noninvasive ventilation failure is associated with in-hospital mortality.

[A 38 years old female with inflammatory myofibroblastic tumor and lactic acidosis]

Inflammatory myofibroblastic tumors (IMT) are rare tumors. They were originally described in the lung, but they have been now observed in many others locations, mainly abdominal and pelvic. These tumors are usually benign but their recurrent nature and the presence of an abnormality of chromosome band 2p23 in some of them, suggest that some lesions form a true tumor entity. Surgical excision as complete as possible is the gold standard treatment. We report the case of a 38 years old female, who presented a recurrent metastasizing inflammatory myofibroblastic tumor causing lactic acidosis and other biological abnormalities such as hypercalcemia, hypoalbuminemia, hypoglycemia, disseminated intravascular coagulation and inflammatory syndrome.

[Difficulties and limitations in conducting translational research in thoracic oncology. A practical example]

INTRODUCTION

In a first study, we identified signatures of 3 mRNAs (semaphorin 3D [SEMA3D], cytokeratin 16 [KRT16] and UL16 binding protein 2 [ULBP2]) associated to response to a cisplatin-vinorelbin chemotherapy and to survival of advanced non-small cell lung cancers (NSCLC).

MATERIAL AND METHODS

The aim of this study was to develop immunohistochemistry tests for KRT16, ULBP2 and SEMA3D and to test proteins expression for prediction of response and survival in biopsies of the same patients.

RESULTS

We were not able to reproduce by the protein expression study the signature predicting response to chemotherapy in advanced NSCLC.

CONCLUSION

We highlight the difficulties of translational research in thoracic oncology emphasizing the complexity in obtaining adequate tissue samples and the difficulties in conduction and transposing in routine practice high throughput technique for transcriptomic analyses.

[Oncological intensive care: 2013 and 2014 years'review]

The objective of this paper is to review the literature published in 2013 and 2014 in the field of intensive care and emergency related to oncology. Are discussed because of new original publications: prognosis, life-supporting techniques, septic shock and infectious complications, anticancer treatment in intensive care, tumoral lysis syndrome, respiratory, thromboembolic and vascular, digestive and hepatic, and neurologic complications, oncologic emergencies, therapeutic limitations.

[Implementation of an oncological care program in a multidisciplinary clinic]

INTRODUCTION

A working group has highlighted guidelines in thoracic oncology in Europe without study of their implementation, due to a lack of data.

METHODS

The records of 354 untreated lung cancer patients seen between January 2009 and December 2012 were reviewed. Any new treatment should have been proposed by a multidisciplinary consultation (MDC) in accordance with an oncology care program (OCP) based on the European Lung Cancer Working Party guidelines.

RESULTS

For the 354 patients, there were 636 MDC (332, 176, 81 and 47 in 1st, 2nd, 3rd and subsequent lines). For the first line, the MDC rate was 88%, in accordance with the OCP, and 75% of treatments were in agreement with the guidelines. For the 2nd and 3rd lines, the rates were 93% and 92% respectively (MDC), 90 and 89% (OCP), 55 and 63% (guidelines). In the first line, the main causes of non-compliance with the OCP were patient's refusal or doctor's choice and with guidelines a lack of adequate recommendations for specific situations such as comorbidities or the appearance of new treatments.

CONCLUSION

The vast majority of patients are the subject of a MDC with a high rate of application of OCP. Guidelines should be updated regularly to incorporate new treatments.

[Renal cysts - A novel complication of crizotinib treatment for lung cancer]

We report the case of a woman with an ALK positive lung adenocarcinoma, who developed bilateral complex renal cysts 17 months after the introduction of treatment with crizotinib. Clinical investigation led to the conclusion that the cysts were due to anticancer drug. Regression of the renal cysts was observed one month after cessation of the crizotinib. This case illustrates that specific and little known toxicities can occur with these novel molecules which have entered use for the management of lung cancer.

Rate and patterns of ICU admission among colorectal cancer patients: a single-center experience

PURPOSE

The purposes of this study were to evaluate, in colorectal cancer patients, the cause of ICU admission and to find predictors of death during and after hospitalization.

METHODS

This is a retrospective study including all patients with colorectal cancer admitted in the ICU of a cancer hospital from January 1st 2003 to December 31 2012.

RESULTS

Among 3721 ICU admissions occurring during the study period, 119 (3.2 %) admissions dealt with colorectal cancer, of whom 89 were eligible and assessable. The main reasons for admission were of metabolic (24 %), hemodynamic (19 %), cardiovascular (18 %), gastrointestinal (16 %), respiratory (13 %), or neurologic (6 %) origin. These complications were due to cancer in 43 %, to the antineoplastic treatment in 25 %, or were unrelated to the cancer or its treatment in 33 %. A quarter of the patients died during hospitalization. Independent predictors of death were the Sequential Organ Failure Assessment (SOFA) score (with risk of dying increasing by 42 % per unit of SOFA score), fever (with risk of dying multiplied by three per °C), and high values of GOT (with risk of dying multiplied by 1 % per unit increase), while cancer control (i.e., stage progression or not), compliance to the initial cancer treatment plan, and LDH ≤ median levels had prognostic significance for further longer survival after hospital discharge.

CONCLUSION

This is the first study looking at specific causes for unplanned ICU admission of patients with colorectal cancer. Hospital mortality was influenced by the characteristics of the complication that entailed the ICU admission while cancer characteristics retained their prognostic influence on survival after hospital discharge.

[The patient with lung cancer in intensive care]

In Western countries, lung cancer (LC) is the most common cause of cancer death. It is present in 15-20% of patients admitted to the ICU with a neoplastic condition. The purpose of this article is to review the causes of admission to ICU of patients with LC, their prognosis and the results of different life-support techniques. Most studies include mixed populations of non-small cell (NSCLC) and small-cell lung cancers (SCLC). However, there is preponderance of NSCLC (70%) and LC of advanced or metastatic stages, reflecting the distribution in the general population of LC. The cause of admission of LC patients to ICU is most often of respiratory origin. The ICU mortality rate currently ranges from 13 to 47% and the hospital mortality rate from 24 to 65%. The predictors of in-hospital mortality are mainly severity scores, organ dysfunction, general condition (performance status), respiratory distress and the need for mechanical ventilation or vasopressor drugs. When considering the long-term mortality, it is the features of the cancer (presence of metastases, cancer progression) that are important predictive factors.

[Management of extensive disease small cell lung cancer. Guidelines of clinical practice made by the European Lung Cancer Working Party]

The present updated guidelines on the management of extensive disease small cell lung cancer (SCLC) formulated by the ELCWP are designed to answer the following questions : 1) What is the definition of extensive disease? 2) What are the active drugs? 3) What is the best induction regimen? 4) Is there a role for maintenance chemotherapy? 5) Is there a role for dose-intensive chemotherapy (without administration of hematopoietic growth factors)-? 6) Is there a role for the use of haematopoietic growth factors and stem cells support? 7) Is there a role for alternating or sequential chemotherapy? 8) Is there a role for biological treatments? 9) Is there a place for second-line chemotherapy? 10) Is there a role for preventive brain irradiation (PCI)?

[Oncological intensive care: review of 2012 literature]

The objective of this paper is to review the literature published in 2012 in the field of intensive care and emergency related to oncology. Are discussed because of new original publications: prognosis, resuscitation techniques, oncologic emergencies, haemodynamic, respiratory and metabolic complications, microangiopathic anemia, serious toxicities of anticancer treatment and limitations to life-support techniques.

[Identification of occupational exposure in thoracic oncology: a Belgian experience]

INTRODUCTION

In Belgium in 2008, the body responsible for compensating and indemnifying victims of occupational diseases recognized 62 cases of lung cancer, although 702 cases were expected. There is an "underreporting" of occupational lung cancer. This study aimed to assess the number of cases of occupational lung cancer in a Belgian hospital specialized in oncology.

PATIENT AND METHOD

From September 1st, 2009 to January 31st, 2011, each new patient with lung cancer has been directed to a consultation identifying occupational exposure to lung carcinogens.

RESULTS

Among 81 occupational histories, 28 patients (35%) were found to have been definitely or probably exposed to one or more lung carcinogens (known or suspected). These patients were all male, mostly blue collar workers. Thirteen compensation claims for occupational disease have been introduced: nine recognized, one rejected and three pending.

CONCLUSION

This study demonstrates the importance of a physician trained in occupational diseases within a thoracic oncology unit in reducing the "underreporting" of occupational lung cancer and thus providing the victims with the compensation to which they are legitimately due.

Identification of microRNA-based signatures for response and survival for non-small cell lung cancer treated with cisplatin-vinorelbine A ELCWP prospective study

Clinical variables, like stage and performance status (PS), have predictive and prognostic values in advanced non-small cell lung cancer (NSCLC) patients treated with chemotherapy, not allowing adequate individual prediction. MicroRNA (miRNA) are non-coding RNAs regulating gene expression. In a prospective study, we assessed the predictive value for response and survival of tumour miRNA in NSCLC patients treated by 1st line cisplatin and vinorelbine. miRNA expression was analysed on a biopsy obtained during the diagnostic bronchoscopy, using TaqMan Low Density Arrays. The signature for response was derived using logistic regression with stepwise variable selection. The associations between overall survival and miRNA expression levels were estimated by using the Kaplan-Meier method, log-rank test, and Cox proportional hazard regression models to estimate the hazard ratios. In total, 38 patients with adequate tumour biopsies, treated with cisplatin-vinorelbine were included: male (n = 27), 80-100 Karnofsky PS (n = 27), adenocarcinoma (n = 20), stage IV (n = 30). One patient was considered not assessable for response but remained included in the survival analyses. Out of the 37 patients assessable for response, 16 partial responses (43%) were observed. A two miRNA signature (miR-149 and miR-375) was found predictive for response and was also associated to progression-free survival (p = 0.05). Using a linear combination of the miR CT values with Cox's regression coefficients as weights, we constructed a prognostic score for overall survival including four miRNA (miR-200c, miR-424, miR-29c and miR-124). The signature distinguished patients with good (n = 18) and poor (n = 20) prognosis with respective median survival times of 47.3 months (95% CI 29.8-52.4) and 15.5 months (95% CI 9.1-22.8) (p < 0.001; hazard ratio 21.1, 95% CI 4.7-94.9).

CONCLUSIONS

miRNA signature allows predicting response and is of prognostic value for survival in patients with NSCLC treated with first line cisplatin and vinorelbine.

[An atypical presentation of bronchial adenocarcinoma]

Currently, adenocarcinoma represents 41 % of primary lung cancers in women and 34 % in men. Thyroid metastases of lung cancer are rare and usually asymptomatic. We report the case of a patient presenting with stridor secondary to an enlarged multiple nodular thyroid accompanied by cervical lymphadenopathies accompanied by an enlarged and multiple nodular thyroid and by stridor. The final diagnosis was thyroid metastases of primary lung adenocarcinoma.

[Thoracic oncology: annual review]

The objective of this paper is to review the literature published in 2011-12 in the field of thoracic oncology. Are discussed because of new original publications: epidemiology, screening, pulmonary nodule, diagnosis and assessment, treatment of lung cancer non-small cell, small cell lung cancer, prognosis, palliative care and end of life, organization of care, mesothelioma.

The lung cancer patient at the emergency department: a three-year retrospective study

INTRODUCTION

Currently, there are limited data on the lung cancer patient at the emergency department. Our objective is to review the medical charts of those patients to determine the frequency and main causes of emergency consultations and the predicting factors for hospital admissions and deaths.

METHODS

We conducted a retrospective study including all patients with lung cancer consulting at the emergency department of a cancer hospital.

RESULTS

From January 1, 2008 to December 31, 2010, 269 patients with lung cancer presented at the emergency, corresponding to 548 consultations (8.3% of all 6575 visits). During the same period, 626 patients for lung cancer were treated in our institution meaning that 43% of them are consulting at least once the emergency department during the course of their disease. The main reasons for consultation were respiratory symptoms (22.3%) and fever (19.9%). Emergency visit leads to hospital admission in 63% of the cases. In multivariate analysis, the main independent predictor factor of hospitalisation is arrival by ambulance (odd ratio 12), which is also the principal predictor of death during hospitalisation (odd ratio 9.5). The presence of signs at physical examination is also an important factor.

CONCLUSION

Our study shows that emergency visit is a frequent event for lung cancer patients and has identified simple factors predicting hospitalisation and deaths.

[Oncological intensive care: 2011 year's review]

The objective of this paper is to review the literature published in 2011 in the field of intensive care and emergency related to oncology. Are discussed because of new original publications: prognosis, resuscitation techniques, oncologic emergencies, serious toxicities of cytotoxic chemotherapy and targeted therapies, complicated aplastic anemia, toxicity of bisphosphonates, respiratory complications, pulmonary embolism and neurological complications.

[Pemetrexed salvage chemotherapy for NSCLC: implementation study]

BACKGROUND

Registration trials demonstrated the activity of pemetrexed in non small cell lung carcinoma (NSCLC) either in combination with first-line agents or in monotherapy for salvage treatment. The aim of our implementation study was to verify, in an unselected population, the results obtained with pemetrexed salvage chemotherapy in clinical practice.

PATIENTS AND METHODS

The charts of all patients diagnosed with NSCLC, receiving pemetrexed for progressive disease after at least one previous course of chemotherapy, were retrospectively reviewed in two academic institutions. Response was assessed according to WHO and toxicity using the CTCAE and WHO criteria.

RESULTS

Between November 2004 and September 2009, 84 patients were given pemetrexed as second, third or greater than third line therapy (n=18/14/52). Intent-to-treat response rate was 11.9% (95% CI, 5%-18.8%). Median progression-free survival was 2.2 months and median survival time was 6.4 months. The most frequent grade 3-5 toxicity was neutropenia (23.9%).

CONCLUSION

Salvage chemotherapy with pemetrexed for progressing NSCLC confirmed, in an unselected population, who had been extensively treated previously, the level of activity observed in registration trials although a significant toxicity was noted.

[A rare cause of superior vena cava syndrome]

A 85-year old patient with an history of low grade follicular lymphoma was admitted in the hospital with a superior vena cava (SVC) syndrome. The computed tomography scan of the thorax and the trans-esophageal echocardiography revealed a voluminous mass in the right atrium, extending to the origin of the SVC. A transvenous biopsy was done under echocardiographic control. The immunohistology showed a diffuse large B cell lymphoma. He received chemotherapy associating rituximab, doxorubicine, cyclophosphamide, vincristine and prednisone. The clinical response after the second cycle was remarkable with a near complete regression of the SVC syndrome. The tumor was no longer visible in imaging after four cycles of treatment.

Surrogate markers predicting overall survival for lung cancer: ELCWP recommendations

The present systematic review was performed under the auspices of the European Lung Cancer Working Party (ELCWP) in order to determine the role of early intermediate criteria (surrogate markers), instead of survival, in determining treatment efficacy in patients with lung cancer. Initially, the level of evidence for the use of overall survival to evaluate treatment efficacy was reviewed. Nine questions were then formulated by the ELCWP. After reviewing the literature with experts on these questions, it can be concluded that overall survival is still the best criterion for predicting treatment efficacy in lung cancer. Some intermediate criteria can be early predictors, if not surrogates, for survival, despite limitations in their potential application: these include time to progression, progression-free survival, objective response, local control after radiotherapy, downstaging in locally advanced nonsmall cell lung cancer (NSCLC), complete resection and pathological TNM in resected NSCLC, and a few circulating markers. Other criteria assessed in these recommendations are not currently adequate surrogates of survival in lung cancer.

Validation and comparison of several published prognostic systems for patients with small cell lung cancer

The aim of the present study was to validate and compare published prognostic classifications for predicting the survival of patients with small cell lung cancer. We pooled data from phase III randomised clinical trials, and used Cox models for validation purposes and concordance probability estimates for assessing predictive ability. We included 693 patients. All the classifications impacted significantly on survival, with hazard ratios (HRs) in the range 1.57-1.68 (all p<0.0001). Median survival times were 16-19 months for the best predicted groups, while they were 6-7 months for the most poorly predicted groups. Most of the paired comparisons were statistically significant. We obtained similar results when restricting the analysis to patients with extensive disease. Multivariate Cox models for fitting survival data were also performed. The HRs for a single covariate were 8.23 (95% CI 5.88-11.69), and 9.46 (6.67-13.50), and for extensive disease were 5.60 (3.13-9.93), 12.49 (5.57-28.01) and 8.83 (4.66-16.64). Concordance probability estimates ranged 0.55-0.65 (overlapping confidence intervals). Published classifications were validated and suitable for use at a population level. As expected, prediction at an individual level remains problematic. A specific model designed for extensive-disease patients did not appear to perform better.

[Febrile neutropenia at the emergency department of a cancer hospital]

Febrile neutropenia is an important cause of fever in the cancer patient. When he/she is undergoing chemotherapy, the priority is to exclude that complication because it requires rapid administration of empiric broad-spectrum antibiotics. We have studied the rate and characteristics of febrile neutropenia in cancer patients consulting in a emergency department. We have conducted a retrospective study in the emergency department of a cancer hospital over the year 2008. Every patient with cancer and fever > or = 38 degrees C was included. Over 2.130 consultations, 408 were selected (313 patients) including 21.6% (88) for febrile neutropenia. A focal symptom or physical sign was present in the majority of the cases. 88% were assessed as low risk for severe complications and about half of them received oral antibiotics. There were only a few patients with a nude fever for which it was difficult to make a hypothetical diagnosis in order to administer a probabilistic treatment. The majority of the consultations lead to hospital admission. Over the 80 hospitalisations, 6 deaths occurred. There was no death among the patients who remained ambulatory. In conclusion, our study shows that febrile neutropenia is frequent in ambulatory cancer patients presenting with fever and that in the majority of the cases, it is associated with a low risk. In such a situation, ambulatory management is more and more often considered or, at least, a rapid discharge after a short admission in case of low risk febrile neutropenia. In that context, the role of the general practioner has to be emphasised and to facilitate the outpatient management, we propose an algorithm that requires validation.

Invasive mechanical ventilation in cancer patients. Prior non invasive ventilation is a poor prognostic factor

PURPOSE

Prior non invasive ventilation (NIV) is associated with an increased mortality in patients with haematological malignancies and acute respiratory failure treated by invasive mechanical ventilation (IMV). We have assessed whether NIV failure is an independent prognostic factor for hospital discharge in a general cancer population treated by IMV.

METHODS

106 patients with solid tumors and 58 patients with haematological malignancies were eligible for this retrospective study; 41 were treated by NIV before IMV.

RESULTS

The main indications for mechanical ventilation were sepsis/shock (35%), acute respiratory failure (33%), cardiopulmonary resuscitation (16%) and neurologic disease (10%). Respectively, 35%, 28% and 24% of the patients were extubated, discharged from the intensive care unit (ICU) and from the hospital. For patients treated with NIV prior to IMV, the rates were 22%, 17% and 10%, respectively. In multivariate analysis, 3 variables were independently associated with a decreased probability of being discharged from the hospital: NIV use before IMV (odds ratio/OR=0.30, 95% confidence interval/CI: 0.09-0.95; p=0.04); leukopenia (OR=0.21, 95% CI: 0.06-0.77; p=0.02) and serum bilirubin >1.1 mg/dl (OR=0.38, 95% CI: 0.16-0.94; p=0.04).

CONCLUSION

NIV failure before IMV is an independent poor prognostic factor in cancer patients treated by IMV.

[Pulmonary nodule: a bayesian approach]

A solitary pulmonary nodule is a common clinical problem. It is usually detected incidentally. The prevalence of solitary pulmonary nodule (SPN) in the lung cancer screening study varies from 8 to 50% (with a prevalence of malignant nodule from 1 to 13%). The bayesian approach can help us to identify promptly malignant nodule in order to treat them surgically and to avoid surgery for benign nodules. Therefore, it is needed to estimate the probability of cancer (Pca) in the SPN. Likelihood ratio (LR) for overall prevalence of malignancy and for different clinical and radiological information (age, smoking exposure, symptoms, cancer history, nodule size, spiculation, calcification, location, growth...) can be obtained from the literature. The odds of cancer-malignancy (odds ca) can be calculated by multiplying all of these LRs together. The Pca = odds ca/1+odds ca. Using this bayeasian approach, the probability of cancer based on an abnormal or normal fluoro-2-deoxy-D-glucose-positron emission tomography (FDG-PET) scan has been estimated. Sensitivity, specificity, positive predictive value and negative predictive value of PET scan are respectively about 90%, 83%, 92% and 90%. Moreover, the LR for malignancy are higher with an abnormal PET scan when compared to most clinical and radiological LRs. Today, the Bayesian approach of SPN must include PET scan.

[Stage IV NSCLC. Place of chemotherapy]

Cisplatin based chemotherapy for stage IV non small cell lung cancer patients with good performance status is associated with improved survival and better symptom control. Chemotherapeutic regimens should include cisplatin with at least one other active drugs as ifosfamide, mitomycin C, vindesine, vinblastine (second generation drugs) or gemcitabine, paclitaxel, docetaxel, irinotecan and/or vinorelbine (third generation drugs). If the other drug is a new one, there is no evidence for the addition of a third agent. Four to six cycles is proposed in responding patients. Non-platinum-based regimens may be used in cases where platinum-based chemotherapy is contra-indicated. Single agent chemotherapy may be considered in patients with poor performance status.

EGFR, TTF-1 and Mdm2 expression in stage III non-small cell lung cancer: a positive association

New biological factors have not been extensively studied in stage III NSCLC as yet. The aim of this retrospective study was to assess the association between the expression and the prognostic role on survival of four biological markers in stage III NSCLC. Clinical characteristics were retrieved from the patients charts. EGF-R, Mdm2, p53 and TTF-1 expressions were evaluated by immunohistochemistry by three independent observers. Cox multivariate model was used to assess the impact of clinical and biological factors on patients' survival. A total of 84 stage III NSCLC patients, treated between 03/1987 and 08/2003, were included in the study. There was a statistically significant association between the expression of TTF-1 and EGFR (p=0.01) or TTF-1 and Mdm2 (p=0.04). Positive expressions for EGFR or TTF-1 were almost mutually exclusive. The status EGFR+/TTF-1--was mainly found in squamous cell carcinoma (18 among 19tumours). In multivariate analysis, only treatment with curative intent was independently associated with better survival (p=0.0004). In stage III NSCLC, there was a significant association between TTF-1 and EGFR or TTF-1 and Mdm2. The status EGFR+/TTF-1--was associated with squamous cell carcinoma.

[Indications and results of intensive care in patients with lung cancer]

Based on experience acquired in the intensive care unit of a cancer hospital, the prognosis and the results of different life-supporting techniques (cardiopulmonary resuscitation, invasive mechanical ventilation, non-invasive ventilation and renal replacement therapy) are discussed. The main message is that the prognosis of cancer patients admitted to the ICU is not determined by the characteristics of their underlying neoplastic disease but by those of the condition requiring critical care; following discharge and resolution of the complication, the prognosis is again influenced by the characteristics of the underlying malignancy. This would appear to justify the application of life-supporting techniques in patients where there is the potential for ongoing anti-cancer treatment.

Chemotherapy improves low performance status lung cancer patients

The aim of the present study was to determine the potential benefit of conventional cisplatin-based chemotherapy on patients with advanced nonsmall cell lung cancer (NSCLC) and poor performance status (PS), defined as 60-70 on the Karnofsky scale. Retrospective analysis was carried out of a randomised trial performed in advanced NSCLC where 485 patients received three courses of gemcitabine+ifosfamide+cisplatin induction chemotherapy. Of the patients, 80% had good PS (Karnofsky 80-100) and 20% poor PS. Response rates were 38 and 28%, respectively. Clinical improvement, defined as achieving a good PS during chemotherapy, was observed overall in 25% of the poor PS patients, with rates of 38, 20 and 14%, respectively, in case of response, no change and progression. PS improved more quickly in the responders. Survival of patients with poor PS was significantly worse, but survival of responders was similar, irrespective of the initial poor or good PS. Although nonfatal toxicity was almost similar, there were more toxic deaths (including vascular and cardiac fatalities) in the poor PS patients (9.2 versus 2.1%). In conclusion, combination chemotherapy is associated with clinical improvement in a substantial number of patients with advanced nonsmall cell lung cancer of poor performance status.

A phase III randomised trial comparing sequential chemotherapy using cisplatin-based regimen and paclitaxel to cisplatin-based chemotherapy alone in advanced non-small-cell lung cancer

BACKGROUND

The purpose of this study is to determine whether in advanced non-small-cell lung cancer (NSCLC), the sequential administration of cisplatin-based chemotherapy and paclitaxel (Taxol) is superior to a cisplatin-based chemotherapy, followed by paclitaxel as salvage treatment.

PATIENTS AND METHODS

A total of 485 chemotherapy naive patients with advanced NSCLC were treated with three courses of GIP (gemcitibine + ifosfamide + cisplatin), consisting of cisplatin 50 mg/m(2) on day 1, ifosfamide 3 g/m(2) on day 1 and gemcitabine 1 g/m(2) on days 1 and 8. Patients with nonprogressive disease were then randomised to further similar courses of GIP or courses of paclitaxel (225 mg/m(2) over 3 h every 3 weeks).

RESULTS

Objective response or nonprogression after induction GIP occurred in 174 and 115 patients, respectively. After randomisation, there were 140 patients in the GIP arm and 141 in the paclitaxel arm. In terms of postrandomisation survival, there was no statistically significant difference (P = 0.17) between the two arms. Median times were 9.7 [95% confidence interval (CI) 7.8-11.6] and 11.9 (95% CI 9.4-14.3) months for paclitaxel and GIP, respectively. Multivariate analysis demonstrated that sex and haemoglobin were independent prognostic factors. After adjustment for these factors, the observed hazard ratio was 0.81 (95% CI 0.63-1.04) in favour of GIP (P = 0.10). Toxicity was tolerable; there was a significantly higher rate of grades III/IV thrombocytopenia with GIP and more alopecia with paclitaxel.

CONCLUSION

Sequential chemotherapy using cisplatin-based regimen followed by paclitaxel does not result in better outcome than cisplatin-based chemotherapy using taxane as salvage treatment.

Second-line paclitaxel in non-small cell lung cancer initially treated with cisplatin: a study by the European Lung Cancer Working Party

In the context of a phase III trial comparing in advanced non-small cell lung cancer (NSCLC) sequential to conventional administration of cisplatin-based chemotherapy and paclitaxel, we evaluated the activity of paclitaxel as second-line chemotherapy and investigated any relation of its efficacy with the type of failure after cisplatin. Patients received three courses of induction GIP (gemcitabine, ifosfamide, cisplatin). Non-progressing patients were randomised between three further courses of GIP or three courses of paclitaxel. Second-line paclitaxel was given to patients with primary failure (PF) to GIP and to those progressing after randomisation to further GIP (secondary failure or SF). One hundred sixty patients received second-line paclitaxel. Response rates were 7.7% for PF and 11.6% for SF (P=0.42). Median survival times (calculated from paclitaxel start) were 4.1 and 7.1 months for PF and SF (P=0.002). In multivariate analysis, three variables were independently associated with better survival: SF (hazard ratio (HR)=1.55, 95% confidence interval (CI) 1.08–2.22; P=0.02), normal haemoglobin level (HR=1.56, 95% CI 1.08–2.26; P=0.02) and minimal weight loss (HR=1.79, 95% CI 1.26–2.55; P=0.001). Paclitaxel in NSCLC patients, whether given for primary or for SF after cisplatin-based chemotherapy, demonstrates activity similar to other drugs considered active as second-line therapy.

Angiogenesis in preinvasive, early invasive bronchial lesions and micropapillomatosis and correlation with EGFR expression

AIMS

To study the association between morphological changes of the bronchial epithelium and its angiogenic status evaluated by microvessel count (MVC), in order to gain a better understanding of bronchial carcinogenesis. Also, to correlate MVC with epidermal growth factor receptor (EGFR) expression.

METHODS AND RESULTS

Eighty-three biopsy specimens were assessed for MVC: four normal bronchial epithelia, 23 hyperplasias, 26 metaplasias, two mild dysplasias, five moderate dysplasias, nine severe dysplasias, three carcinomas in situ, six early invasive squamous cell carcinomas (EIC) and five cases of micropapillomatosis. We observed a statistically significant difference in terms of MVC between EIC and all other subgroups and between micropapillomatosis and all other subgroups. There was also a statistically significant difference between micropapillomatosis and EIC. We did not observe any difference in MVC between normal mucosa, metaplasias, hyperplasias, dysplasias or carcinoma in situ. EGFR expression was higher in severe dysplasia, carcinoma in situ and EIC, whereas it was very low in micropapillomatosis. A statistically significant difference was observed in the expression profile of EGFR vs. MVC. EGFR expression was increased in severe dysplasia, whereas an increase in MVC occurred only in EIC.

CONCLUSION

During bronchial carcinogenesis, except for micropapillomatosis, EGFR expression appears to be a prerequisite for neoangiogenesis in bronchial carcinogenesis.

Gefitinib monotherapy in advanced nonsmall cell lung cancer: a large Western community implementation study

Epidermal growth factor receptor tyrosine kinase inhibitors represent a new treatment option for patients with advanced nonsmall cell lung cancer (NSCLC). This retrospective study examined to what extent previous clinical trial experience matches large-scale Western community implementation of this treatment. In the Belgian expanded access programme, the data from 513 patients with advanced or metastatic NSCLC, not suitable for further chemotherapy and receiving oral gefitinib 250 mg.day(-1) until disease progression, death or unacceptable toxicity, were analysed. The median (range) duration of gefitinib treatment was 2.3 months (0.0-32.7). Its use was predominantly in second- or third-line treatment. The overall response and disease control rates were 8.9 and 41.2%, respectively. In univariate analysis, response was more common in females and never-smokers. In multivariate analysis, female sex was the only significant predictive factor (odds ratio (OR) (95% confidence interval (CI)) 0.329 (0.129-0.839)). Symptom improvement was reported in 108 patients of whom 32 (29.6%) had an objective response, 66 (61.1%) experienced disease stabilisation and 10 (9.3%) progressed. Gefitinib was well tolerated; only 7.8% of the patients reported grade 3 or 4 toxicity. The overall median survival was 4.7 months, with a 1-yr survival rate of 21%. Survival was strongly influenced by a better performance status (PS) (good PS: hazard ratio (HR) (95%CI) 0.110 (0.077-0.157)) and adenocarcinoma with bronchioloalveolar carcinoma features histology (HR (95%CI) 0.483 (0.279-0.834)). In conclusion, the activity of gefitinib was confirmed in the present large Western community implementation study. Response, present in a small subgroup, led to a rewarding survival and could be predicted by sex only. Baseline performance status and adenocarcinoma with bronchioloalveolar carcinoma features histology were significant factors for survival.

Thyroid transcription factor 1--a new prognostic factor in lung cancer: a meta-analysis

BACKGROUND

The aim of this study was to determine the prognostic role for survival of thyroid transcription factor 1 (TTF-1) in lung cancer.

METHODS

Studies evaluating survival and TTF-1 in lung cancer patients, published until August 2005, were assessed with a methodological scoring system. The required data for estimation of individual hazard ratios (HRs) for survival were extracted from the publications and a combined HR was calculated.

RESULTS

We identified 10 eligible papers, all dealing with non-small-cell lung cancer (NSCLC). Eight were meta-analysed (evaluable studies). Seven studies included patients with local and/or locoregional diseases and three dealt only with adenocarcinoma. Median methodological quality score was 65.9% (range = 31.8%-70.5%). TTF-1 positivity was associated with statistically significant reduced or improved survival in one and four studies, respectively. Combined HR for the eight evaluable studies was 0.64 [95% confidence interval (CI) = 0.41-1.00]. In the subgroup of adenocarcinoma, the combined HR was 0.53 (95% CI = 0.29-0.95).

CONCLUSION

TTF-1 is a good prognostic factor for survival in NSCLC. Its effect appears also significant when the analysis is restricted to patients with adenocarcinoma. This study supports the fact that TTF-1 could be included in further prospective trials studying prognostic factors in NSCLC.

Hypothermia and Hodgkin's disease: case report and review of the literature

We reported the case of a patient with stage IV Hodgkin's disease (involving the nodes and Liver) presenting with paraneoplastic fever and who subsequently developed hypothermia during chemotherapy administration. We also reviewed the 12 other cases of hypothermia in Hodgkin's disease reported in the literature and discussed the most probable physiopathologic aetiologies.

Has Cox-2 a prognostic role in non-small-cell lung cancer? A systematic review of the literature with meta-analysis of the survival results

Cyclooxygenase-2 (COX-2) is overexpressed in lung cancer, especially in adenocarcinoma (ADC). Our aim was to determine the prognostic value of COX-2 on survival in patients with lung cancer. Studies evaluating the survival impact of COX-2 in lung cancer, published until December 2005, were selected. Data for estimation of individual hazard ratios (HR) for survival were extracted from the publications and combined in a pooled HR. Among 14 eligible papers, all dealing with non-small-cell lung cancer, 10 provided results for meta-analysis of survival data (evaluable studies). Cyclooxygenase-2 positivity was associated with reduced survival, improved survival or no statistically significant impact in six, one and seven studies, respectively. Combined HR for the 10 evaluable studies (1236 patients) was 1.39 (95% confidence intervals (CI): 0.97-1.99). In stage I lung cancer (six evaluable studies, 554 patients), it was 1.64 (95% CI: 1.21-2.24). No significant impact was shown in ADC. A slight detrimental effect on survival in patients with lung cancer is associated with COX-2 expression, but the statistical significance is not reached. This effect is statistically significant in stage I, suggesting that COX-2 expression could be useful at early stages to distinguish those with a worse prognosis.

Mitomycin, ifosfamide, cisplatin for non-small cell lung cancer: an implementation study

BACKGROUND

The MIP regimen (mitomycin, ifosfamide, cisplatin) demonstrated its effectiveness as first-line chemotherapy in phase II and III trials in NSCLC. We aimed to determine whether these results could be confirmed in a hospital population.

METHODS

Between 1987 and 2004, 204 patients with NSCLC received MIP in our institution. Patients treated in and off trials received the same combination of cisplatin (50 mg/m2), ifosfamide (3 g/m2) and mitomycin C (6 mg/m2) every three weeks and were staged and followed in a similar way.

RESULTS

Response rates for patients treated in or outside trials were 36.8% and 40.7%, respectively. After multiple logistic regressions, the only statistically significant factor predicting objective response was stage. The median survival time was 54.6 and 43.7 weeks respectively for patients treated in and outside trials. In multivariate analysis, four factors were statistically significantly associated with better survival: good performance status (p = 0.003), normal LDH value (p < 0.001), early stage (p = 0.01) and active smoking (p = 0.03).

CONCLUSION

Participation in a clinical trial was not associated with a significant difference in efficacy. This implementation study thus confirms the activity of the MIP regimen when used in the routine management of patients with NSCLC.

EGFR, c-erbB-2 and ki-67 in NSCLC and preneoplastic bronchial lesions

BACKGROUND

The relationships between EGF-R and c-erbB-2 with other factors involved in tumour regulation are not well understood. The aim of this study was to correlate the expression of these markers with tumour proliferation.

MATERIALS AND METHODS

The presence of EGF-R, c-erbB-2 and Ki-67 was evaluated by immunohistochemistry in non-small cell lung cancer (NSCLC) and preneoplastic lesions.

RESULTS

Forty-two percent of the tumours were positive for EGF-R, 22% for c-erbB-2 and 97% for Ki-67. No statistically significant correlation was found between EGF-R and Ki-67, EGF-R and c-erbB-2 or between c-erbB-2 and Ki-67. With regards to Ki-67, a significant difference in survival was noted in favour of patients who did not express the marker. In preneoplastic lesions, most of the low-grade lesions showed neither EGF-R nor Ki-67 staining. In contrast, most of the high-grade lesions stained positively for these proteins.

CONCLUSION

EGF-R and c-erbB-2 do not seem to be correlated with Ki-67 in NSCLC.

Survival improvement in resectable non-small cell lung cancer with (neo)adjuvant chemotherapy: Results of a meta-analysis of the literature

The recent publication of many randomised trials about (neo)adjuvant chemotherapy in resectable non-small cell lung cancer (NSCLC) has prompted our group to update a prior meta-analysis of the literature. Randomised studies published in French and English between 1965 and June 2004 were included in this analysis. A qualitative assessment of each trial was first performed using the European lung cancer working party (ELCWP) and the Chalmers' scales. In absence of statistically significant quality difference between positive and negative trials, a quantitative aggregation (meta-analysis) of the individual results was performed. Two trials for which data were available on ASCO virtual meeting website were also included in the meta-analysis. Twenty-five studies eligible for this analysis assessed chemotherapy as induction (n = 6) or adjuvant to surgery (n = 19). No quality difference was detected between positive and negative trials according to the two scores, whatever all trials were combined or only adjuvant chemotherapy studies were considered. The overall meta-analysis showed that the hazard ratio (HR) of the combined results was 0.66 (95% CI 0.48-0.93) in favour of the addition of induction chemotherapy to a standard surgical procedure and 0.84 (95% CI 0.78-0.89) in favour of adjuvant chemotherapy. The effect was significant for adjuvant chemotherapy in stages I and II with a HR of 0.88 (95% CI 0.83-0.94). It was not statistically significant in stage III although the trend was in favour of chemotherapy whatever adjuvant (HR = 0.85; 95% CI 0.69-1.04) or (neo)adjuvant (HR = 0.65; 95% CI 0.41-1.04) chemotherapy was tested. In conclusion, our meta-analysis shows the efficacy of adjuvant chemotherapy in stages I and II resected NSCLC. More data are needed to confirm such a role for induction chemotherapy. Further trials should separate stage III disease from earlier stages.