Swiss pilot low-dose computed tomography lung cancer screening study

Objective

Low-dose computed tomography (LDCT) lung cancer screening is endorsed by US guidelines and has recently been shown effective in a large European randomized controlled trial. Nevertheless, actual realization of a lung cancer screening program is challenging and depends on country-specific factors. This pilot study aimed to evaluate implementation, execution, and performance of LDCT lung cancer screening in Switzerland.

Methods

Since October 2018, asymptomatic participants aged 55–74 years with more than 30 pack-years smoking history were enrolled at a tertiary hospital in Switzerland. Participants with history of lung cancer, major (palliative) health problems or those that had a thorax CT scan 18 months prior to enrollment were excluded. First, we evaluated lung cancer risk according to NLST guidelines. Second, we estimated lung cancer risk using the PLCOm2012 model risk calculator with threshold of 5%. Lung nodules were assessed according to Lung-RADS (Version 1.1. 2019). Participants were recruited through flyers, a newspaper article and pulmonary specialists. Screening consisted of one LDCT-scan, follow-up was recommended for suspicious nodules only. LDCT assessment was performed by two radiologists, one of them a board certified chest radiologist. Enrollment and follow-up are currently ongoing.

Results

To date, 75 participants (25 (33%) females) with a median age of 62 years (interquartile range [IQR] 56–67 years) were included. Median number of pack years smoked was 49 (IQR 41–58 pack years). Median PLCOm2012 6-year lung cancer probability was 2.7% (IQR 2.6–2.9%), 19 (26%) participants had stopped smoking before enrollment. 6 participants required follow up imaging of suspect nodules, resulting in a recall rate of 8%. At baseline, lung cancer was found in 2 (2.7%, one squamous cell (stage IIIA) and one adenocarcinoma (stage IV)) participants.

Conclusion

In this Swiss LDCT lung cancer screening pilot study using modified inclusion criteria, 2.7% were diagnosed with lung cancer to date.

Extra-anatomical VATS lung resection: the outpatient experience with the aid of a digital chest drain device

OBJECTIVE

The aim of the present study was to evaluate of the feasibility of video-assisted thoracic surgery (VATS) wedge resections in an outpatient setting using a digital air leak detection device.

PATIENTS AND METHODS

Data from all patients who underwent outpatient VATS wedge resections from November 2010 to November 2013 was analyzed. The thoracoscopic approach was done in all cases under general anesthesia, with double lumen intubation, three port sites and one or two wedge resections without the reinforcement of the suture line. The chest-drain with continuous suction (-20 cm/H2O) placed after surgery was removed when no air leak (0-10 ml/min) was detected digitally within two hours after surgery. Patients were discharged after exclusion of pneumothorax by chest x-ray. Patient distribution according to gender, smoking habit, indication for resection, number of wedge resections, and histological findings was compared.

RESULTS

In the study period, 66 VATS patients (44.3%) of al VATS procedures were eligible for the outpatient procedure. Fifty-five of them (83.3%) were discharged on the same day, while 11 were admitted due to patients preference, presence of an air leak or for other medical reasons. In the outpatient group (OG) the indications for surgery were lung nodules in 90.9% (50 cases) and interstitial disease in the remaining 9.1%. In the OG, 18 patients (32.7%) received two wedge resections. All patients had no leak detected by digital device prior to drainage removal. The overall re-admission rate was 7.3% (4/55). Statistical analysis did not show any difference regarding sex, smoking habits, indications for surgery, number of parenchymal resection, disease localization, and malignant histology. All patients who had an outpatient procedure confirmed that they would repeat the procedure.

CONCLUSIONS

Outpatient thoracoscopic non-anatomic resections managed with a digital chest drain device have both low complication rates as well as lead to fewer re-admissions. Because of the growing number of VATS Wedge Resections due to pre-identified lung nodules, this could have important implications. Further research should identify the most suitable subgroup of patients for this approach.

[Minimal-invasive surgery for lung cancer - strategies and limits]

Minimal invasive surgical procedures, also known as keyhole surgery, have gained in importance in the last years and have become the standard of care in experienced hands for most surgical procedures. Despite initial concerns with respect to the radicalness of the approach it is nowadays also established in oncologic surgery. Minimal invasive procedures aim at minimizing the operative trauma and associated inflammatory reactions to achieve faster convalescence after surgery. In addition to obvious cosmetic advantages minimal invasive surgery has been shown to be associated with fewer postoperative pain and shorter postoperative rehabilitation and faster reintegration into everyday as well as working life. With 15% of all cancer diagnoses and 29% of all cancer-associated causes of death, lung cancer is the most frequent malignancy in the general public and hence the treatment of lung cancer is a main focus of thoracic surgery. Within the scope of modern multimodal treatment concepts radical surgical resection of lung cancer is essential and the main pillar of curative treatment. In early stage lung cancer the current standard of care is a thoracoscopic lobectomy with mediastinal lymphadenectomy. The expertise of specialized centers allows for curative minimal-invasive treatment in a large number of patients, particularly of patients of advanced age or with limited pulmonary function.

Surgery for non-localized bronchiectasis

Background

Resection for localized bronchiectasis is a well established therapy. However, there is little information on the role of surgery in non-localized bronchiectasis.

Methods

Between January 1992 and April 2001, 55 patients without cystic fibrosis underwent resection. Forty-eight patients (mean age 45 (range 23–74) years; 32 women) were available for long-term follow-up. Twenty-five patients underwent resection for localized disease (group 1) and 23 had bronchiectasis in at least two different lobes (group 2).

Results

Thirty-one of the 48 patients were treated by Video Assisted Thoracoscopic Surgery (VATS) resection. There was no 30-day mortality. Mean duration of hospital stay was 10·9 (range 6–31) days in group 1 and 11·1 (range 5–19) days in group 2. Three of 25 patients in group 1 required reoperation. Only minor complications occurred in group 2 (three patients). Mean follow-up for both groups was 37 (range 6–97) months. Twenty-three of 25 patients in group 1 and 16 of 23 in group 2 reported satisfaction at 6 months after the operation. Recurrent infection was noted in three patients in each group. Haemoptysis recurred in only one patient in group 2.

Conclusion

The surgical treatment of selected patients with non-localized bronchiectasis was safe and most patients were satisfied with the outcome.

Bronchoscopic radioisotope injection for sentinel lymph-node mapping in potentially resectable non-small-cell lung cancer

OBJECTIVE

Prospective study to evaluate the feasibility of a preoperative bronchoscopic radioisotope application, followed by conventional sentinel lymph-node (SLN) identification and to investigate the occurrence and distribution of micrometastases in relation to SLN activity.

METHODS

Twenty patients with a mean age of 63 years and proven clinical stage T1-3 N0-1 non-small-cell lung cancer (NSCLC) were included. A dosage of 80MBq radiolabeled technetium-99m nanocolloid was endoscopically administrated on intubated patients in the operation theatre. At thoracotomy, scintigraphic readings of both the primary tumor and hilar and mediastinal lymph-node stations were obtained with a hand-held gamma-counter. Patients underwent lung resection and mediastinal lymphadenectomy. Radiolabeled nodes were also examined separately on back-table. SLNs were defined as the hottest nodes or nodes with at least one-tenth of the radioactivity of the hottest nodes. SLNs pathologic assessment included standard examination using hematoxylin and eosin staining on step sections and immunohistochemistry (ICH) for cytokeratins.

RESULTS

Identification of SLNs was possible in 19/20 (95%) patients after bronchoscopic radioisotope application. In 7/19 (37%) patients, a unique SLN was identified, whereas in 12/19 (63%) patients, nodes from two different stations could be classified as SLNs. Metastatic nodal disease was found in 9/19 (47%) patients. ICH revealed micrometastases in 2/12 (17%) patients, initially classified nodal negative. Pathologic negative SLNs were a predictor for absence of metastatic nodal disease after mediastinal lymphadenectomy. No complication related to the procedure was observed.

CONCLUSION

Our preliminary results suggest that preoperative bronchoscopic radioisotope injection for SLN identification is a safe and simple method, improving accuracy of SLN detection in comparison to intraoperative technique. The absence of metastases in the SLNs seems to predict a negative nodal status accurately.

[Effect of climatic changes on the phenology of plants and the presence of pollen in the air in Switzerland]

The phenologic observations carried out in Switzerland since 1951 show a clear tendency to the earlier appearance of the spring phases of development of the vegetation during last decades. As these phases are strongly influenced by the temperature, these results reinforce the hypothesis according to which the climatic reheating in progress strongly influences the development of the vegetation. The flowering and the release of the pollen of the plants allergens are significant phenologic phases for human health. Modifications in their dates of manifestation lead to a displacement of the periods of allergic risk. The analysis of the aerobiologic data of the Swiss stations over one duration of more than 20 years showed that the species which flower in winter and in spring were subject to the influence of the soft winters of the years 1990 to 2000. In certain areas the pollen of birch, for example, is nowadays waited on average 3 weeks earlier than 20 years ago, whereas the pollen of ash appears with one month in advance. The phenologic and aeropalynologic studies thus prove sensitive witnesses of the climatic change in progress. This last intervenes like an indirect but significant component of human health, in particular when the field of the allergies is considered.

[Ambrosia pollen in Switzerland--produced locally or transported?]

The ambrosia (Ambrosia artemisiifolia L.) has been announced in Switzerland for more than 100 years. During the last decade, signs of an increased presence of the ambrosia and its pollen appear in the south-west of Switzerland, in particular in Geneva. Aerobiologic measurements make it possible to highlight the importance of the transport of pollen by the winds since the area of Lyon, where the ambrosia is abundant. It also bring elements making it possible to detect a local production of pollen in the Geneva area, where several invaded fields were discovered with the autumn 2001. A multidisciplinary group was created in Geneva and it attempts to prevent as far as possible probable invasion of the ambrosia.

Accelerated treatment for early and late postpneumonectomy empyema

BACKGROUND

Postpneumonectomy empyema is a rare but serious complication of pneumonectomy. Despite use of various therapeutic approaches and techniques during the last five decades, successful therapy remains difficult and is often associated with high morbidity and prolonged hospitalization.

METHODS

We evaluated a concept for accelerated treatment, which consists of radical debridement of the pleural cavity and packing with wet dressings of povidoneiodine. This was repeated in the operating theater every second day, until the chest cavity was macroscopically clean. If present, bronchial stump insufficiency was closed and secured by omentopexy. Finally, the pleural space was obliterated with antibiotic solution.

RESULTS

Twenty patients, 13 with early postpneumonectomy empyema (10 to 89 days; mean, 37 days) and 7 with late postpneumonectomy empyema (124 to 7,200 days; mean, 1,126 days) were treated. Fifteen patients presented with bronchopleural fistula (11 right, 4 left), which developed after chemotherapy (n = 6) or after radiotherapy (n = 3) (unknown cause in 4 patients). Six patients were referred after previously unsuccessful surgical attempts. Pleural cultures were positive in 17 cases for one or several bacteria including fungoides (n = 2). The average number of interventions was 3.5 (3 to 5). The chest was definitively closed in all patients within 8 days. Mean hospitalization time was 17 days (7 to 35 days). During the same hospitalization, 2 patients needed reoperation because of an undetected bronchopleural fistula. Postpneumonectomy empyema was successfully treated in all patients. There was no in-hospital or 3-month postoperative mortality.

CONCLUSIONS

Repeated surgical debridement combined with closure of bronchopleural fistula and antimicrobial therapy enables successful treatment of early and late postpneumonectomy empyema within a short period and is a well-tolerated concept.

8-Br-cGMP is superior to prostaglandin E1 for lung preservation

BACKGROUND

Substitution of the nitric oxide (NO) pathway reduces ischemia/reperfusion injury after lung transplantation. 8-Br-cGMP is a membrane-permeable analogue of cGMP, the second messenger of NO. In this study, we evaluated the effect of administration of 8-Br-cGMP in the flush solution on early graft function.

METHODS

Unilateral left lung transplantation was performed in 10 weight-matched pairs of outbred pigs (24 to 31 kg). Donor lungs were flushed with 1.5 L cold (1 degree C) low potassium dextrane (LPD) solution and preserved for 20 hours. In group I (n = 5), 8-Br-cGMP (1 mg/kg) was added to the flush solution. In group II (n = 5), 8 microg/kg prostaglandin E1 (PGE1) was injected into the pulmonary artery (PA) before flush. One hour after reperfusion, the recipients' contralateral right PA and bronchus were ligated to assess graft function only. cGMP levels in the PA and pulmonary vein were measured. Extravascular lung water index (EVLWI), pulmonary vascular resistance, mean PA pressure, and gas exchange (PaO2) were assessed during a 5-hour observation period. Lipid peroxidation (thiobarbituric acid-reactive substance) and neutrophil migration to the allograft (myeloperoxidase activity) were measured at the end of the assessment.

RESULTS

In group I, a significant reduction of EVLWI (group I, 6.7 +/- 1.0 mL/kg vs group II, 10.1 +/- 0.6 ml/kg after 2 hours of reperfusion; p = 0.022), TBARS (group I, 65.6 +/- 10.0 pmol/g vs group II, 120.8 +/- 7.2 pmol/g, p = 0.0039), and MPO activity (group I, 0.8 +/- 0.1 change in optical density, (deltaOD)/mg/min vs group II, 1.7 +/- 0.3 deltaOD/mg/min, p = 0.036) was noted in comparison with group II. PaO2 levels tended to be higher in cGMP-treated animals, but the changes were not significant. Hemodynamic parameters did not differ between groups.

CONCLUSIONS

In this large animal model of lung allograft ischemia/reperfusion injury, 8-Br-cGMP as additive to the flush solution improves posttransplant lung edema, lipid peroxidation, and neutrophil migration to the allograft. This effect is not attributable to improved flush by vasodilation, as we compared 8-Br-cGMP with PGE1 given before flush in control animals.

Combined treatment with endothelin- and PAF-antagonists reduces posttransplant lung ischemia/reperfusion injury

BACKGROUND

Pathophysiologic changes of posttransplant lung ischemia/reperfusion injury are mediated by redundant cellular and humoral mechanisms. We investigated the protective effect of combined administration of platelet activating factor (PAF) and endothelin (ET) antagonists after prolonged ischemia in a small animal lung transplantation model.

METHODS

Orthotopic left lung transplantation was performed after 20 hours cold ischemia in male Fischer (F344) rats weighing 200-250 g. Group I served as control. In Group II, donors received 1 mg/kg body weight of the endothelin antagonist TAK-044, and recipients 2 mg/kg. Group III was treated with the PAF antagonist TCV-309 (donor: 50 microg/kg; recipient: 100 microg/kg) (Takeda Chemicals Ltd.). Group IV received a combined treatment with both substances at the same dosage. Twenty-four hours after reperfusion, the native contralateral lung was occluded to assess gas exchange of the graft only, and 5 minutes later the thoracic aorta was punctured for arterial blood gas analysis (n = 5). In other animals (n = 5), lung tissue was frozen 24 hours after reperfusion and assessed for myeloperoxidase activity (MPO) and thiobarbituric acid reactive substances.

RESULTS

Combined inhibition of PAF and ET-1 at the receptor level resulted in significantly improved graft function as compared to controls (Group I), and to groups treated with either TAK-044 or TCV-309. This was determined by a higher arterial oxygen content (112 +/- 9 mmHg, p = .00061 vs control, 48 +/- 5 mmHg), reduced MPO activity (0.35 +/- 0.02 deltaOD/mg/min, p = .000002 vs control, 1.1 +/- 0.1 deltaOD/mg/min) and reduced lipid peroxidation (59.5 +/- 2.5 pmol/g, p = .011 vs control, 78.5 +/- 4.1 pmol/g). The improvement of arterial oxygen (Group II 77 +/- 10 mmHg, p = .027 vs control; Group III 84 +/- 8 mmHg, p = .0081 vs control) and reduction of MPO activity (Group II 0.85 +/- 0.061 deltaOD/mg/min, p = .017; Group III 0.92 +/- 0.079 deltaOD/mg/min, p = .058) in groups treated with either a PAF antagonist or an ET antagonist was significantly less than in Group IV.

CONCLUSIONS

Combined donor and recipient treatment with an ET antagonist and a PAF antagonist results in superior posttransplant graft function 24 hours after reperfusion, suggesting a synergistic role of ET-1 and PAF in the mediation of reperfusion injury in this model. Single treatment with either of the antagonists revealed only a slight improvement compared to untreated controls.