Association Between Interstitial Lung Disease and Outcomes After Lung Cancer Resection

BACKGROUND

Prior studies have noted that patients with interstitial lung disease (ILD) possess an increased incidence of lung cancer and risk of postoperative respiratory failure and death. We sought to understand the impact of ILD on national-scale outcomes of lung resection.

METHODS

A retrospective cohort analysis using The Society of Thoracic Surgeons General Thoracic Surgery Database was conducted of patients who underwent a pulmonary resection for non-small cell lung cancer between 2009 and 2019. Baseline characteristics and postoperative outcomes were compared between patients with and without ILD (defined as interstitial fibrosis based on clinical, radiographic, or pathologic evidence). Multivariable logistic regression models identified risk factors associated with postoperative mortality, acute respiratory distress syndrome, and composite morbidity and mortality.

RESULTS

ILD was documented in 1.5% (1873 of 128,723) of patients who underwent a pulmonary resection for non-small cell lung cancer. Patients with ILD were more likely to smoke (90% vs 85%, P < .001), have pulmonary hypertension (6% vs 1.7%, P < .001), impaired diffusing capacity of lung for carbon monoxide (diffusing capacity of lung for carbon monoxide 40%-75%: 64% vs 51%; diffusing capacity of lung for carbon monoxide <40%: 11% vs 4%, P < .001), and undergo more sublobar resections (34% vs 23%, P < .001) compared with patients without ILD. Patients with ILD had increased postoperative mortality (5.1% vs 1.2%, P < .001), acute respiratory distress syndrome (1.9% vs 0.5%, P < .001), and composite morbidity and mortality (13.2% vs 7.4%, P < .001). ILD remained a strong predictor of mortality (odds ratio, 3.94; 95% CI, 3.09-5.01; P < .001), even when adjusted for patient comorbidities, pulmonary function, extent of resection, and center volume effects.

CONCLUSIONS

ILD is a risk factor for operative mortality and morbidity after lung cancer resection, even in patients with normal pulmonary function.

The Society of Thoracic Surgeons General Thoracic Surgery Database: 2022 Update on Outcomes and Research

The Society of Thoracic Surgeons General Thoracic Surgery Database (STS GTSD) remains the largest and most robust thoracic surgical database in the world. Participating sites receive risk-adjusted performance reports for benchmarking and quality improvement initiatives. The GTSD also provides several mechanisms for high-quality clinical research using data from 274 participant sites and 781,000 procedures since its inception in 2002. Participant sites are audited at random annually for completeness and accuracy. Over the last year and a half, the GTSD Task Force continued to refine the data collection process, implementing an updated data collection form in July 2021, ensuring high data fidelity while minimizing data entry burden. In addition, the STS Workforce on National Databases has supported a robust GTSD-based research program, which led to eight scholarly publications in 2021. This report provides an update on volume trends, outcomes, and database initiatives as well as a summary of research productivity resulting from the GTSD over the preceding year.

Tissue plasminogen activator with prolonged dwell time effectively evacuates pleural effusions

OBJECTIVES

Fibrinolytic therapy can be effective for management of complex pleural effusions. Tissue plasminogen activator (tPA, 10 mg) and deoxyribonuclease (DNAse) every 12 h with a dwell time of one hour is a common strategy based on published data. We used a simpler protocol of tPA (4 mg) without DNAse but with a longer dwell time of 12 h, repeated daily. We reviewed our results.

METHODS

Charts were reviewed and demographics, clinical data and treatment information were abstracted. Outcomes were assessed based on radiographic findings and need for surgery.

RESULTS

Two hundred and fifteen effusions in 207 patients (8 bilateral) were identified. 85% were either infectious or malignant. Two hundred and forty nine chest tubes were used: 84% were 10 Fr or 12 Fr and 7% were PleurX®. Five hundred and thirty one doses of tPA were given. The median number of doses per effusion was 2 (range 1-10), and 84% of effusions were treated with three or fewer doses. There were no significant bleeding complications. Median time to chest tube removal was 6 days (range 1 to 98, IQR 4 to 10). Drainage was considered complete for 78% of effusions, while 6% required decortication.

CONCLUSIONS

Low dose tPA daily with a 12 h dwell time may be as effective as the standard regimen of tPA and DNAse twice daily with one hour dwell. For most patients only three doses were required, and small pigtail catheters were sufficient. This regimen uses less medication and is logistically much easier than the current standard.

Risk of Each of the Five Lung Lobectomies: A Society of Thoracic Surgery Database Analysis

BACKGROUND

The perioperative risk of pulmonary lobectomy as a solitary procedure has been extensively studied, yet the differences in outcomes between each lobe, which have unique anatomy and a different amount of lung parenchyma, are entirely unknown. The purpose of this study is to define the risk of each of the five lobectomies.

METHODS

The Society of Thoracic Surgery Database was queried for patients undergoing lobectomy between 2008 and 2018. Patient and disease characteristics, operative variables, major morbidity and 30-day mortality were examined. A multivariable logistic regression model (using the same variables in the current STS lobectomy risk model) was developed to assess for the contribution to lobectomy site to adverse outcomes.

RESULTS

65,006 patients were analyzed. Adjusted perioperative mortality rate is lowest for RML (0.63%) intermediate for RUL, LUL and LLL (1.08-1.24%), and highest for RLL (1.63%). The adjusted major morbidity rate is lowest for RML (5.36%) intermediate for LLL and LUL (7.82-8.33%), and highest for RUL and RLL (8.94-9.32%). Adjusted intraoperative transfusion rate is lowest for RML (1.37%) intermediate for RLL and LLL (1.81-1.94%) and highest for RUL and LUL (2.47-2.72%).

CONCLUSIONS

There are clear differences in postoperative outcomes by lobectomy location. Mortality, major morbidity, and transfusion rate are lowest for RML, but vary across other lobectomies. These differences should be appreciated when evaluating risk of operation, deciding upon best therapy, counseling patients, and comparing outcomes.

The Society of Thoracic Surgeons General Thoracic Surgery Database: 2021 Update on Outcomes and Research

The Society of Thoracic Surgeons General Thoracic Surgery Database (STS GTSD) remains the largest and most robust thoracic surgical database in the world. Participating sites receive risk-adjusted performance reports for benchmarking and quality improvement initiatives. The GTSD also provides several mechanisms for high-quality clinical research using data from 271 participant sites and nearly 720,000 procedures since its inception in 2002. Participant sites are audited at random annually for completeness and accuracy. During the last year and a half, the GTSD Task Force continued to refine the data collection form, ensuring high-quality data while minimizing data entry burden. In addition, the STS Workforce on National Databases has supported robust GTSD-based research program, which led to 10 scholarly publications in 2020. This report provides an update on outcomes, volume trends, and database improvements as well as a summary of research productivity resulting from the GTSD over the preceding year.

Lobectomy Versus Stereotactic Body Radiotherapy in Healthy Octogenarians With Stage I Lung Cancer

BACKGROUND

Stereotactic body radiation therapy (SBRT) is increasingly being offered for early stage non-small cell lung cancer (NSCLC). We sought to evaluate long-term survival outcomes after lobectomy and SBRT in patients aged 80 years or more with stage I NSCLC.

METHODS

The National Cancer Database was queried for patients with clinical stage IA and IB (size 40 mm or smaller) NSCLC who underwent SBRT or lobectomy. Only patients with no comorbidities were selected. Number of lymph nodes (LN) examined was used to stratify lobectomy patients into 0 LN, 1 to 6 LN, and 7 or more LN. Propensity score analysis was used to adjust treatment groups. Kaplan-Meier and multivariate Cox regression analysis were used for survival analysis.

RESULTS

A total of 8964 patients with stage I NSCLC treated with lobectomy were compared with 286 patients who received SBRT. Using propensity matched pairs, lobectomy (7 LN or more) had significantly improved survival as compared with SBRT (median 74 vs 53.2 months, P < .05); however, no survival differences were observed when 0 LN were sampled (median 53.8 vs 52.3 months, P = .88). In multivariate analysis, lobectomy was associated with significantly improved survival (hazard ratio 0.726; 95% confidence interval; 0.580 to 0.910; P = .005). In addition, age, sex, high grade, and tumor size were independent predictors of survival.

CONCLUSIONS

Among healthy octogenarians with clinical stage I NSCLC who are good surgical candidates, lobectomy offers better survival than SBRT. Adequate LN dissection allows true nodal staging and opportunity for adjuvant treatment when unsuspected nodal metastases are found.

Comparison of Video-Assisted Thoracoscopic Surgery and Robotic Approaches for Clinical Stage I and Stage II Non-Small Cell Lung Cancer Using The Society of Thoracic Surgeons Database

BACKGROUND

Data from selected centers show that robotic lobectomy is safe and effective and has 30-day mortality comparable to that of video-assisted thoracoscopic surgery (VATS). However, widespread adoption of robotic lobectomy is controversial. We used The Society of Thoracic Surgeons General Thoracic Surgery (STS-GTS) Database to evaluate quality metrics for these 2 minimally invasive lobectomy techniques.

METHODS

A database query for primary clinical stage I or stage II non-small cell lung cancer (NSCLC) at high-volume centers from 2009 to 2013 identified 1,220 robotic lobectomies and 12,378 VATS procedures. Quality metrics evaluated included operative morbidity, 30-day mortality, and nodal upstaging, defined as cN0 to pN1. Multivariable logistic regression was used to evaluate nodal upstaging.

RESULTS

Patients undergoing robotic lobectomy were older, less active, and less likely to be an ever smoker and had higher body mass index (BMI) (all p < 0.05). They were also more likely to have coronary heart disease or hypertension (all p < 0.001) and to have had preoperative mediastinal staging (p < 0.0001). Robotic lobectomy operative times were longer (median 186 versus 173 minutes; p < 0.001); all other operative measurements were similar. All postoperative outcomes were similar, including complications and 30-day mortality (robotic lobectomy, 0.6% versus VATS, 0.8%; p = 0.4). Median length of stay was 4 days for both, but a higher proportion of patients undergoing robotic lobectomy had hospital stays less than 4 days (48% versus 39%; p < 0.001). Nodal upstaging overall was similar (p = 0.6) but with trends favoring VATS in the cT1b group and robotic lobectomy in the cT2a group.

CONCLUSIONS

Patients undergoing robotic lobectomy had more comorbidities and robotic lobectomy operative times were longer, but quality outcome measures, including complications, hospital stay, 30-day mortality, and nodal upstaging, suggest that robotic lobectomy and VATS are equivalent.

Invasive mediastinal staging: endobronchial ultrasound, endoscopic ultrasound, and mediastinoscopy

Accurate mediastinal staging is essential to determining the optimal therapeutic strategy for many patients with lung cancer. Computed tomography and positron emission tomography are first steps, but frequently tissue sampling is recommended to confirm the radiographic findings. Mediastinoscopy has been the gold standard for thirty years, but the new technologies of esophageal endoscopic ultrasound and endobronchial ultrasound provide a less invasive method for biopsy. These techniques enable needle aspiration sampling of nearly all mediastinal and hilar lymph nodes, and experience with them is now sufficiently mature to conclude that they can be equivalent if not preferable to mediastinoscopy. The keys to achieving accurate results are skillful execution combined with sound clinical judgment regarding when to use which techniques. Patients with lung cancer are best served by clinicians experienced with all three methods for invasive mediastinal staging.

Racial and ethnic disparities in presentation, treatment, and outcomes for minority populations with diagnosis of lung cancer

e17540

Background: There are differences in the presentation, treatment and outcome of lung cancer patients (pts), based on ethnicity, however there are not enough publications regarding these issues. Methods: Registry data on 2,255 pts with non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) treated during last 10 years (2002-2011) at Memorial Health Care System was obtained. The main objective of the study was to evaluate differences in lung cancer survival according to ethnicity. Chi-square was used to compare distribution of tumor stage. Survival curves were compared using log-rank test for each of the tumor stages. Adjusted hazard ratios (AHR) and 95% confidence intervals (95% CI) were reported based on the results of a multivariate Cox regression model for overall survival (OS) with adjustment for gender, age at diagnosis, race, stage and health insurance. Results: A total of 1940 pts (86%) had the diagnosis of NSCLC, the rest were SCLC. There were 1170 (52%) females. Non-Hispanic whites (NHW) were 1,791 pts (79%), Hispanics (H) 266 (12%) and African-American (AA) 149 (7%). Fifty eight percent of patients had stage III/IV at diagnosis. 2054 of the pts were insured (91%). There was a significant difference in age at diagnosis among H (66.5 y), AA (64.4y) and WNH (69.5y). The probability of being diagnosed at a late stage (IIIB/IV) was two times higher among AA compared to NHW (OR= 1.77, P<0.05) or H (OR = 1.67, p<0.05). There was no survival difference between NSCLC and SCLC (19m vs. 16m). Females with NSCLC lived significantly longer than males (Adjusted Hazard ratio (AHR= 1.14 p<0.01). The same was true for SCLC (AHR = 1.43 p < 0.01). Significant predictors for worse survival for patients with NSCLC were: older age at diagnosis (AHR = 1.01, p<0.001), male gender (AHR=1.12, p<0.05) and late stage at diagnosis (AHR=2.27, p<0.001). Insurance and ethnicity were not significant predictors of of survival. Conclusions: There are significant disparities in presentation and outcomes among minority patients with lung cancer. We will further evaluate if other social or genetic factors can explain these disparities.

Ethical process in human research published in thoracic surgery journals

BACKGROUND

Media reports of ethical transgressions in research with human subjects have increasingly focused attention on clinical investigators and have served to undermine public confidence in medical research. A series of editorials in The Annals of Thoracic Surgery and The Journal of Thoracic and Cardiovascular Surgery in 2002 and 2003 emphasized integrity in research publication. We investigated the extent to which the ethical process was mentioned in reports of thoracic surgical research with human subjects since 2002.

METHODS

We reviewed all reports of research involving human subjects published in these journals during the first 6 months of 2002, the first 6 months of 2003, and the last 6 months of 2004 (n = 273, 291 and 288 for each time period, respectively with a total of 852).

RESULTS

Ethical process was mentioned in 346 of 852 (41%) investigations. Comparing US and non-US studies, the rates of mentioning ethical process for prospective studies were 76 of 83 (92%) and 178 of 216 (82%), respectively, and for retrospective studies were 75 of 220 (34%) and 18 of 334 (5%), respectively. Between 2002 and 2004, the rates of mentioning ethical process for prospective studies increased from 79 of 101 (78%) to 80 of 89 (90%), and for retrospective studies it increased from 17 of 172 (10%) to 59 of 199 (30%).

CONCLUSIONS

There was a significant increase in mention of ethical process from early 2002 to late 2004; however, documentation of appropriate ethical process in human research published in cardiothoracic journals remains less than ideal. The main burden of ensuring ethical process in human investigations rests with researchers, their institutions, and institutional review boards; however, editors can help rectify this problem by requiring adherence to national and international standards in the human subjects' research studies they publish. In adhering to ethical standards, investigators respect the research subjects' right of self-determination and foster public confidence in human research.

Reversal of Laryngotracheal Separation: A Detailed Case Report with Long-term Followup

Chronic aspiration is a difficult and potentially lethal problem. Patients who have persistent soilage of the upper respiratory tract despite discontinuing oral intake may be offered surgical intervention to avoid life-threatening pulmonary infections. The Lindeman procedures (tracheoesophageal diversion and laryngotracheal separation) have gained popularity as surgical treatments for intractable aspiration because of their efficacy in preventing aspiration and their technical simplicity. A major downside of these procedures is the necessity for a tracheostoma and the loss of speech following surgery. Rarely, patients recover from the neurologic deficits which led to their intractable aspiration and desire reversal of their Lindeman procedure. While few "successful" reversals have been reported, detailed accounts of the long-term results of such patients are lacking. We describe a patient who underwent a laryngotracheal separation for intractable aspiration following a brainstem stroke. In the following six months he experienced significant neurologic recovery and, after careful evaluation, underwent surgical restoration of laryngotracheal continuity. Five years later he speaks fluently and has no dietary restrictions. Videofluooroscopic examination and quantitative voice analysis reveal near-normal laryngeal function.

Accurate Molecular Detection of Non-small Cell Lung Cancer Metastases in Mediastinal Lymph Nodes Sampled by Endoscopic Ultrasound-Guided Needle Aspiration

OBJECTIVES

The recurrence of disease after the complete resection of early stage non-small cell lung cancer (NSCLC) indicates that undetected metastases were present at the time of surgery. Quantitative real-time reverse transcriptase-polymerase chain reaction (RT-PCR) is a highly sensitive technique for detecting rare gene transcripts that may indicate the presence of cancer cells, and endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) is a minimally invasive technique for the nonoperative sampling of mediastinal lymph nodes. The aim of this study was to determine whether these two techniques could enhance the preoperative detection of occult metastases.

METHODS

Patients with NSCLC were evaluated with chest CT and positron emission tomography scans. Those patients without evidence of metastases (87 patients) underwent EUS-guided FNA. Lymph nodes from levels 2, 4, 5, 7, 8, and 9 were sampled and evaluated by standard cytopathology and real-time RT-PCR. Normal control FNA specimens were obtained from patients without cancer who were undergoing EUS for benign disease (17 control specimens). For each sample, messenger RNA was extracted and real-time RT-PCR was used to quantitate the expression of six lung cancer-associated genes (ie, CEA, CK19, KS1/4, lunx, muc1, and PDEF) relative to the expression of an internal control gene (beta(2)-microglobulin).

RESULTS

Clinical thresholds of marker positivity were set at 100% specificity, as determined by the receiver operating characteristic curve analysis. Of the cytology-positive lymph nodes (27 lymph nodes), the expression of the KS1/4 gene was above its respective clinical threshold in 25 of 27 samples (93%), making this the most sensitive marker for the detection of metastatic NSCLC. At least one of the six lung cancer-associated genes was overexpressed in 18 of 61 cytology-negative patients (30%), of which KS1/4 was overexpressed in 15 of 61 patients (25%).

CONCLUSIONS

Based on the high accuracy of EUS-guided FNA/RT-PCR, we predict that some of the patients in the cytology-negative/marker-positive category will have high NSCLC recurrence rates. Among the genes used in our marker panel, KS1/4 appears particularly useful for the detection of overt or occult metastatic disease.

Lunx is a superior molecular marker for detection of non-small cell lung cancer in peripheral blood [corrected]

The clinical management of non-small cell lung cancer (NSCLC) would benefit greatly by a test that was able to detect small amounts of NSCLC in the peripheral blood. In this report, we used a novel strategy to enrich tumor cells from the peripheral blood of 24 stage I to IV NSCLC patients and determined expression levels for six cancer-associated genes (lunx, muc1, KS1/4, CEA, CK19, and PSE). Using thresholds established at three standard deviations above the mean observed in 15 normal controls, we observed that lunx (10 of 24, 42%), muc1 (5 of 24, 21%), and CK19 (5 of 24, 21%) were overexpressed in 14 of 24 (58%) peripheral blood samples obtained from NSCLC patients. Patients who overexpressed either KS1/4 (n = 2) or PSE (n = 1) also overexpressed either lunx or muc1. Of patients with presumed curable and resectable stage I to II disease (n = 7), at least one marker was overexpressed in three (43%) patients. In advanced stage III to IV patients (n = 17), at least one marker was overexpressed in 11 patients (65%). These results provide evidence that circulating tumor cells can be detected in NSCLC patients by a high throughput molecular technique. Further studies are needed to determine the clinical relevance of gene overexpression.

Endoscopic ultrasound in lung cancer patients with a normal mediastinum on computed tomography

BACKGROUND

Computed tomography (CT) is the most common method of staging lung cancer. We have previously shown endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) to be highly accurate in staging patients with nonsmall cell lung cancer (NSCLC) who have enlarged mediastinal lymph nodes on CT scan. In this study we report the accuracy and yield of EUS-FNA in staging patients without enlarged mediastinal lymph nodes by CT.

METHODS

Patients with NSCLC and CT scan showing no enlarged mediastinal lymph nodes (> 1 cm for all nodes except > 1.2 cm for subcarinal) in the mediastinum underwent EUS. Fine needle aspiration was performed on at least one lymph node, if present, in the upper mediastinum, aortopulmonary window, subcarinal, and periesophagus regions. Each specimen was evaluated with on-site cytopathology and confirmed with complete cytopathologic examination.

RESULTS

Sixty-nine patients without enlarged mediastinal lymph nodes were evaluated. Endoscopic ultrasound detected malignant mediastinal lymph nodes in 14 of 69 patients as well as other advanced (American Joint Committee on Cancer [AJCC] stage III/IV) in 3 others (1 left adrenal, and 2 with mediastinal invasion of tumor) for a total of 17 of 69 (25%, 95% confidence interval: 16% to 34%) patients. Eleven additional patients were found to have advanced disease by bronchoscopy (2), mediastinoscopy (2), and thoracotomy with mediastinal lymph node dissection (7). The sensitivity of EUS for advanced mediastinal disease was 61% (49% to 75%), and the specificity was 98% (95% to 100%).

CONCLUSIONS

Endoscopic ultrasound guided fine needle aspiration can detect advanced mediastinal disease and avoid unnecessary surgical exploration in almost one of four patients who have no evidence of mediastinal disease on CT scan. In addition to previously reported results in patients with enlarged lymph nodes on CT, these data suggest that all potentially operable patients with nonmetastatic NSCLC may benefit from EUS staging.

Accuracy of EUS criteria and primary tumor site for identification of mediastinal lymph node metastasis from non-small-cell lung cancer

BACKGROUND

EUS with FNA is useful for staging non-small-cell lung cancer. However, benign mediastinal adenopathy is common. The aims of this study were to identify clinical factors, especially primary tumor location, and EUS lymph nodal characteristics predictive of aortopulmonary window and subcarinal lymph node metastases of non-small-cell lung cancer.

METHODS

Patients with known or suspected non-small-cell lung cancer underwent EUS staging at which EUS-FNA was performed for all identified mediastinal lymph nodes. Clinical characteristics, primary tumor data, EUS findings, and histopathology were reviewed. Exact tests were performed for both aortopulmonary window and subcarinal lymph nodes to identify factors predictive of malignant cytology.

RESULTS

Ninety-two patients with non-small-cell lung cancer were included. Fifty-one had aortopulmonary window, and 73 had subcarinal lymph nodes on EUS. The EUS with FNA specimens were interpreted as suspicious or diagnostic for malignancy for 9 aortopulmonary window and 9 subcarinal lymph nodes. When comparing benign vs. malignant EUS with FNA findings for aortopulmonary window and subcarinal lymph nodes, only lymph node size of 1 cm or greater and sharp lymph nodal edges were associated with malignancy in lymph nodes at both sites, whereas primary tumor site, lymph node shape, and echogenicity were associated with malignant subcarinal nodes. When 4 classic lymph nodal features of malignancy were evaluated, the presence of 3 or more typical features had positive and negative predictive values of, respectively, 41% and 96%.

CONCLUSIONS

Although tumor location and EUS lymph nodal characteristics are associated with malignant involvement of lymph nodes, the accuracy of these predictors does not obviate the need for cytologic evaluation. EUS with FNA should be performed for all lymph nodes when an abnormal finding will alter management.

Lunx is a superior molecular marker for detection of non-small cell lung cancer in peripheral blood [corrected]

The clinical management of non-small cell lung cancer (NSCLC) would benefit greatly by a test that was able to detect small amounts of NSCLC in the peripheral blood. In this report, we used a novel strategy to enrich tumor cells from the peripheral blood of 24 stage I to IV NSCLC patients and determined expression levels for six cancer-associated genes (lunx, muc1, KS1/4, CEA, CK19, and PSE). Using thresholds established at three standard deviations above the mean observed in 15 normal controls, we observed that lunx (10 of 24, 42%), muc1 (5 of 24, 21%), and CK19 (5 of 24, 21%) were overexpressed in 14 of 24 (58%) peripheral blood samples obtained from NSCLC patients. Patients who overexpressed either KS1/4 (n = 2) or PSE (n = 1) also overexpressed either lunx or muc1. Of patients with presumed curable and resectable stage I to II disease (n = 7), at least one marker was overexpressed in three (43%) patients. In advanced stage III to IV patients (n = 17), at least one marker was overexpressed in 11 patients (65%). These results provide evidence that circulating tumor cells can be detected in NSCLC patients by a high throughput molecular technique. Further studies are needed to determine the clinical relevance of gene overexpression.

"Drowned lung" following lobectomy and radiation therapy: a case report

Radiation therapy for locoregional control of NSCLC is controversial, and risk factors for developing radiation associated pneumopathies must be assessed before any patient undergoes adjuvant radiation therapy. Radiotherapy for patients with early stage NSCLC may be associated with increased morbidity and decreased survival. As evidenced by our case, adjuvant radiation therapy for a patient with significant risk factors and early stage disease generated morbidity from the treatment itself. It contributed to development of a bronchopleural fistula and chronic empyema, and led to distortion and obstructing of the airway causing irreversible pulmonary consolidation ("drowned lung"). Further, the final pathology report showed clear margins, suggesting that there was no clear indication for radiation therapy. Although NSCLC, the potential risks cannot be overlooked and patients should be carefully evaluated before recommending postoperative therapy.

Effect of preoperative delay on prognosis for patients with early stage non-small cell lung cancer

OBJECTIVE

Screening for lung cancer will discover many nodules of indeterminate pathology. Observation has the theoretic risk of permitting dissemination of a localized cancer and worsening prognosis, whereas immediate evaluation of benign conditions generates morbidity and cost. This study was conducted to assess the effect of delay in surgical intervention on survival for patients with early stage non-small cell lung cancer.

METHODS

Records for patients with resected pathologic stage I and II non-small cell lung cancer (1989-1999) were abstracted for patient age, race, sex, medical history, date of presentation, date and type of surgical treatment, pathologic stage, and date of death or last follow-up. Kaplan-Meier survival analysis was performed to test for the effect of delay (time from presentation to surgical intervention) on survival.

RESULTS

Eighty-four patients were identified. Median age was 66 years, median preoperative interval was 82 days (range, 1-641 days), and median follow-up was 3.3 years (range, 5 days-11.9 years). Median survival was 3.7 years. Overall 5-year survival was 40%; disease-specific 5-year survival was 63%. Log-rank analysis of the effect of delay on overall survival generated a P value of.54, with an estimated hazard ratio for a 90-day delay of 1.06 (95% confidence interval, 0.87-1.30).

CONCLUSIONS

For this population, we were unable to detect a significant effect of delay on prognosis. Although these results suggest that the risk of judicious observation of indeterminate pulmonary nodules might be low, the 95% confidence interval is broad. Larger sample sizes are needed to reach definitive conclusions.

Improvement in staging of esophageal cancer with the addition of positron emission tomography

BACKGROUND

Positron emission tomography with the glucose analogue 2-[18F]fluoro-2-deoxy-D-glucose (FDG) has been used to detect and stage a variety of malignancies. We hypothesized that FDG-positron emission tomography would improve staging of patients with esophageal cancer and thereby facilitate selection of candidates for resection.

METHODS

Fifty-eight patients (42 men and 16 women) with biopsy-proven esophageal cancer were evaluated with both FDG-positron emission tomography and computed tomography.

RESULTS

In all but 2 patients, increased FDG uptake was identified at the site of the primary tumor. Six patients were not operative candidates. Seventeen patients were not candidates for resection because of metastatic disease. Positron emission tomography identified the metastatic disease in all 17 (12 of whom underwent confirmatory biopsy), whereas computed tomography was positive for metastases in only 5. The remaining 35 patients underwent surgical exploration, were judged to have resectable disease and had esophagectomy. Pathologic examination of resected specimens identified lymph node metastases in 21 patients. These nodes were detected by positron emission tomography in 11 patients and by computed tomography in 6.

CONCLUSIONS

Positron emission tomography improved staging and facilitated selection of patients for operation by detecting distant disease not identified by computed tomography alone.

Coronary artery bypass grafting after a bilateral lung volume reduction operation

A 67-year-old man underwent coronary artery bypass grafting 31/2 months after a bilateral lung volume reduction operation for end-stage pulmonary emphysema. The principles of anesthetic management we have developed for use during volume reduction operations were applied with success in this individual and are described in detail. With the increasing application of this intervention as an alternative to lung transplantation, we anticipate further experience in the operative management of associated conditions after lung volume reduction operations.

Endogenous D-factor activity partially mediates the toxic but not the therapeutic effects of tumor necrosis factor

We have earlier shown that passive immunization against differentiation-inducing factor/leukemia-inhibitory factor (D factor) activity improves the survival of endotoxemic mice, suggesting that D factor may contribute to the systemic toxicity associated with tumor necrosis factor (TNF). In the current experiments, TNF induced D-factor gene expression in various tissues of non-tumor-bearing female C57BI/6 mice. Passive immunization against D-factor significantly improved survival after a lethal TNF challenge in both non-tumor-bearing (p2 < 0.02) and tumor-bearing mice (p2 < 0.01). In mice bearing 10-day s.c. MCA 105 sarcomas, D-factor antibody alone had no effect on tumor growth as compared with control IgG. Tumor regression and regrowth in mice treated i.v. with TNF was not affected by pre-treatment with D-factor antibody, as compared with pre-treatment with IgG. However, TNF-treatment-related mortality was abrogated by pre-treatment with D-factor antibody (0% vs. 36% for IgG-pre-treated controls). These results indicate that endogenous D-factor activity contributes to the toxicity but not to the anti-tumor effects of TNF therapy. With renewed interest in the use of TNF for the treatment of patients with cancer, improved understanding of the role of D factor in mediating the effects of TNF may have important clinical benefits.

Passive immunization of mice against D factor blocks lethality and cytokine release during endotoxemia

D factor, also known as leukemia inhibitory factor, is a pleiotropic cytokine whose role during acute injury and inflammation is not known. Intraperitoneal administration of Escherichia coli endotoxin induced D factor gene expression in mice, and passive immunization against D factor protected them from the lethal effects of endotoxin and blocked endotoxin-induced increases in serum levels of interleukin 1 and 6. Peak levels of tumor necrosis factor and interferon gamma were not affected. These results indicate that D factor is an essential early mediator of the inflammatory cytokine response and therefore may be important in the pathogenesis of the many inflammatory conditions, such as sepsis, arthritis, allograft rejection, and cancer immunotherapy.

Cholera toxin pretreatment protects against tumor necrosis factor lethality without compromising tumor response to therapy

Antitumor therapy with tumor necrosis factor is limited by systemic toxic effects. We studied whether cholera toxin, a bacterial exotoxin that adenosine diphosphate-ribosylates the alpha-subunit of Gs proteins, could separate the lethal from the antitumor effects of tumor necrosis factor. A single dose of intravenous cholera toxin protected non-tumor-bearing mice from a lethal dose of Escherichia coli endotoxin administered 6 or 24 hours later. On the basis of these results, tumor-bearing mice were randomized to receive either cholera toxin or saline, followed 6 hours later by either human tumor necrosis factor (400 micrograms/kg) or saline. Tumor-bearing mice pretreated with cholera toxin had (1) reduced treatment-related mortality (0/11 vs 5/11 for saline controls) and (2) tumor regression similar to that of controls. In a separate experiment in tumor-bearing mice, intravenous human tumor necrosis factor treatment induced an increase in serum levels of murine tumor necrosis factor to a peak of 500 pg/mL at 1 hour in saline-pretreated controls, while a similar increase could not be detected in those mice pretreated with cholera toxin. These results suggest that pretreatment with cholera toxin can reduce the endogenous tumor necrosis factor response to administered tumor necrosis factor and separate the lethal from the antitumor effects. Cholera toxin may prove to be a useful tool for investigating the mechanisms underlying the varied effects of tumor necrosis factor.

Single-dose tumor necrosis factor protection against endotoxin-induced shock and tissue injury in rats

Tumor necrosis factor (TNF), a macrophage product released in response to endotoxin and other stimuli, has been shown to be a central mediator of endotoxin or septic shock. However, its highly conserved and wide-ranging physiological effects suggest that it may also be an essential cytokine in the host defense against acute bacterial infection or sepsis. A single nontoxic dose of human recombinant TNF administered intravenously 24 h prior to a lethal infusion of Escherichia coli lipopolysaccharide (LPS) completely prevented acute LPS-induced hypotension, ameliorated tissue injury in the lungs and liver, and improved survival in male Fisher 344 rats. The protective effects of TNF were dose dependent and required a 24-h pretreatment interval. After the infusion of LPS, animals in both groups (TNF-treated animals and saline-pretreated controls) initially appeared acutely ill and had a similar severe metabolic acidosis, indicating that TNF did not inactivate or prevent the toxic effects of LPS. Twelve hours after the administration of TNF, the gene for manganous superoxide dismutase, a mitochondrial enzyme which scavenges toxic reactive oxygen species and is induced during conditions which generate a free radical stress, was expressed in liver tissue, suggesting that the induction of manganous superoxide dismutase may be an important in vivo protective mechanism against cellular injury during lethal endotoxemia.

Human recombinant interleukin-1 alpha protection against the lethality of endotoxin and experimental sepsis in mice

Human recombinant interleukin-1 alpha (IL-1) has a diverse range of physiological activities which may be beneficial or deleterious to the host. Pretreatment with doses of IL-1 has been shown to protect mice against a subsequent lethal bacterial injection; however, the protective effects of a single intravenous (iv) dose of IL-1 have not been well characterized. The current experiments were performed to determine the best dose, timing, and duration of action of a single iv dose of IL-1 against a subsequent lethal challenge with intraperitoneal endotoxin (LPS) or experimental sepsis induced by cecal ligation and puncture (CLP). Female C57B1/6 mice treated with iv IL-1 24 hr prior to 30 mg/kg LPS ip had improved survival compared to saline-treated controls (P less than 0.01). IL-1 was also protective when given 6 to 72 hr, but not 2 or 96 hr, prior to LPS. IL-1 protection against LPS lethality was similar to protection seen with an iv dose of tumor necrosis factor (TNF). After CLP, survival was improved with IL-1 versus saline pretreatment (P = 0.02). Unlike previous work with TNF, no toxicity or lethality was observed at any dose of IL-1 administered. A single iv dose of IL-1 protects against the lethality of LPS and CLP in mice. IL-1 may be a useful treatment strategy in patients at risk for the development of life-threatening sepsis.

Myocytolysis (vacuolar degeneration) of myocardium: immunohistochemical evidence of viability

Human myocardium with focal myocytolysis (vacuolar degeneration, colliquative myocytolysis) was examined by routine light microscopy and by immunoperoxidase staining techniques for creatine kinase (CK) M and B, myoglobin, lactate dehydrogenase (H4)(LDH-1), and aspartate aminotransferase (AST, GOT). Sections of myocardium were selected from autopsy and surgical specimens from patients with and without clinical morphologic evidence of ischemic heart disease. Areas of coagulation necrosis showed loss of enzyme staining, while both normal and myocytolytic cells stained darkly. These results indicate that fibers with myocytolysis retain enzymes and other proteins, indicating sarcolemmal integrity, which is not present in fibers with coagulation necrosis. The implication of these findings is that fibers with myocytolysis are viable; thus, myocytolysis may be a reversible form of myocardial alteration that does not necessarily lead to cell death and eventual myocardial fibrosis.

Myocardial myoglobin following coronary artery occlusion. An immunohistochemical study

To evaluate morphologic changes and myoglobin content in normal, ischemic and necrotic myocardium, the authors studied human (n = 13) and dog (n = 28) myocardium by triphenyltetrazolium chloride staining, light and electron microscopy, periodic acid-Schiff stain for glycogen loss, and by an immunoperoxidase technique. Myocardium from autopsied patients with infarction 10-24 hours old showed loss of myoglobin from necrotic fibers. Dogs with infarcts after 3 hours or more of coronary occlusion showed myoglobin loss in fibers shown to be necrotic. In 4 dogs with 50% reduction in left main coronary artery flow for 3 hours, which demonstrated ischemia without necrosis (glycogen loss with no triphenyl tetrazolium chloride evidence of necrosis), myoglobin staining in myocardial sections was similar to nonischemic and positive control tissues. By comparison of immunoperoxidase staining with concomitant study by light and electron microscopy and histochemistry, loss of myoglobin from necrotic myocardium was demonstrated, while ischemic but not necrotic fibers stained normally. These findings indicate that necrosis is necessary for myoglobin loss from myocardium to be detected by this immunoperoxidase technique.