Endoluminal management of bronchogenic carcinoma in 2010: diagnosis, staging, and therapy

Endoluminal bronchogenic carcinoma, though a minority of lung cancer cases, presents a unique opportunity to utilize techniques for the diagnosis and therapy that are unavailable for more peripheral tumors. This review explores current techniques for the diagnosis, staging, and therapy of endoluminal central bronchogenic tumors and also introduces techniques currently under investigation as potential improvements or replacements for current techniques using recent literature. Additionally, the new staging criteria set forth in the 7th edition of the TMN staging system as a result of the American Joint Committee on Cancer (AJCC), International Union Against Cancer (IUCC), and the International Association for the Study of Lung Cancer (IASLC) are discussed with respect to endoluminal bronchogenic carcinoma.

Metastasectomy for melanoma in the VATS era

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Background: The role for metastasectomy in the setting of metastatic melanoma remains ill-defined. The aim of this study is to evaluate resection of limited metastases in the setting of melanoma comparing VATS and open approaches, specifically looking at perioperative morbidity and survival. Methods: All patients undergoing metastasectomy for melanoma with curative intent between January 1, 2001 and September 30, 2007 were included. Data was collected retrospectively from the UPMC tumor registry and chart review. Differences between groups were compared with the student's t-test. Results: Of 43 patients undergoing metastasectomy for melanoma, 31 patients were resected with intent to cure (16 VATS, 15 open). Complications were similar between the VATS (12%) and open (13%) groups. There were no perioperative deaths in either group. The median survival in the VATS group was 20.7 months, compared to 26.5 months in the open group (p = 0.17). Importantly, the VATS patients more frequently underwent resection of smaller, peripheral lesions via wedge resection (81%) and only 2 patients (13%) underwent lobectomy. Conversely, patients undergoing open procedures were more likely to have larger, more central lesions and undergo anatomic resections. There were 9 (60%) lobectomies, 3 (20%) segmentectomies 1 (7%) en bloc resection and only 2 (13%) wedge resections in the open group. Conclusions: Metastasectomy for metastatic melanoma in the thoracic cavity can be performed safely by a VATS or open approach. The two approaches have comparable morbidity, mortality and survival outcomes. Careful patient resection remains the hallmark of care in identifying appropriate candidates for metastasectomy. In the setting of patients with short life-expectancy, it may be advantageous to employ a VATS approach when possible to preserve quality of life while achieving similar oncologic outcomes to open procedures. Individuals with a radiographic indication of limited peripheral disease should be considered for a VATS approach to resection of melanoma metastases.

No significant financial relationships to disclose.

The impact of length of hospitalization following surgical resection of stage I non-small cell lung cancer on long-term survival

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Background: The aim of this study was to evaluate the impact of length of hospital stay (LOS) following surgical resection of stage I non-small cell lung cancer (NSCLC) on long-term survival. Methods: We reviewed the records of patients undergoing surgical resection for stage I NSCLC at our institution between 1990–2003. Patients not surviving hospitalization related to their surgery were excluded from analysis. Multivariate analysis was utilized to evaluate the impact of age, gender, tumor histology, tumor stage, LOS, and type of operation (lobar or sublobar) on long-term (>5 year) survival. As a secondary analysis, Kaplan-Meier survival curves of patients stratified according to LOS were compared using the log-rank test. Two-tailed p-values less than 0.05 were considered statistically significant. Results: A total of 730 patients underwent lobectomy (n=518) or sublobar resection during the study time period. There were 18 (2.5%) operative or in-hospital mortalities. Median LOS was 6 (range 1–81) and 7 (range 1–46) days in the lobar and sublobar cohorts, respectively. Patients with a longer hospital stay (≥14 days) had significantly worse 5- and 10-year overall survival rates as compared to those with a shorter hospitalization (lobectomy: 5-year- 60.3% vs 33.8%; 10-year-27.3% vs 8.4%; p<0.001; sublobar: 5-year-44.3% vs 11.7%; 10-year-9.9% vs 0%; p=0.006). There were 171 patients with extended clinical follow-up who had survived at least 5 years (mean follow-up = 88.1 ± 2.0 months). Multivariate analysis demonstrated that LOS predicted long-term survival independent of patient age, gender, tumor histology, tumor stage, and type of operation (p=0.013). Conclusions: LOS following surgical resection of stage I NSCLC is an independent predictor of long-term survival. These survival differences related to hospital stay may be related to underlying medical co-morbidities important to the decision making regarding therapy of patients with otherwise resectable stage I lung cancer. Prospective assessment of medical co-morbidities may be an important initiative for future treatment planning of early stage lung cancer patients.

No significant financial relationships to disclose.

Clinical impact of age on outcomes following anatomic lung resection for stage I non-small cell lung cancer

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Background: There is an increasing body of evidence that anatomic segmentectomy may represent an equivalent approach compared to lobectomy in the management of stage I NSCLC. Comorbidities associated with age may result in improved survival with sublobar resection for stage I cancer in the elderly. We report our single institution experience with segmentectomy vs. lobectomy for stage I non-small cell lung cancer stratified by age. Methods: A total of 232 consecutive anatomic segmentectomies were performed for stage IA (n=137) or IB (n=95) NSCLC from 2002–2007. Lobectomy was performed in 594 patients for stage IA (n=297) and IB (n=295) during the same period. Results of segmental resection were compared with lobectomy, stratified by the following age groups: <60, 60–69, 70–79 and = 80. Primary outcome variables included complications, mortality, recurrence patterns, and survival. Statistical analysis included t-test and Fisher's exact test. Results: Mean age (69.9 vs. 68.2), gender distribution and tumor histology were similar between the segmentectomy and lobectomy groups. There was no significant difference in complications, mortality, recurrence, and overall survival in the younger age groups (Table). Segmentectomy was associated with reduced mortality (7.8% vs. 2.8%) and improved overall 3-year survival (p=0.02) in patients >80 years old. Conclusions: Anatomic segmentectomy can be performed with similar morbidity, mortality, recurrence, and survival compared to lobectomy in stage I lung cancer. This approach may be particularly advantageous in the elderly age group, achieving comparable oncologic outcomes with less mortality and improved overall survival.

[Table: see text]

No significant financial relationships to disclose.

An increased proportion of inflammatory cells express tumor necrosis factor alpha in idiopathic achalasia of the esophagus

Achalasia is a motility disorder characterized by the absence of coordinated peristalsis and incomplete relaxation of the lower esophageal sphincter. The etiology remains unclear although dense inflammatory infiltrates within the myenteric plexus have been described. The nature of these infiltrating cells is unknown. The aim of this study was to evaluate the expression of proinflammatory cytokines - namely, tumor necrosis factor alpha and interleukin-2 - in the distal esophageal muscle in patients with achalasia. Lower esophageal sphincter muscle from eight patients undergoing myotomy or esophagectomy for achalasia of the esophagus were obtained at the time of surgery. Control specimens consisted of similar muscle taken from eight patients undergoing operation for cancer or Barrett's esophagus. The expression of tumor necrosis factor alpha and interleukin-2 were assessed by immunohistochemistry. The total number of inflammatory cells within the myenteric plexus were counted in five high power fields. The percentage of infiltrating cells expressing tumor necrosis factor alpha or interleukin-2 was calculated. Clinical data including demographics, preoperative lower esophageal sphincter pressure, duration of symptoms, and dysphagia score (1 = no dysphagia to 5 = dysphagia to saliva) were obtained through electronic medical records. Statistical comparisons between the groups were made using the unpaired t-test, Fisher's exact test, or Mann-Whitney U test, with a two-tailed P-value less than 0.05 being considered significant. The total number of inflammatory cells was found to be similar between the groups. A significantly higher proportion of inflammatory cells expressed tumor necrosis factor alpha in achalasia as compared with controls (22 vs. 11%; P= 0.02). A similar percentage of infiltrating cells expressed interleukin-2 (40 vs. 41%; P= 0.87). Age, gender, preoperative lower esophageal sphincter pressure, or dysphagia score were not correlated to expression of these cytokines. There was, however, a significant inverse correlation between duration of symptoms and the proportion of inflammatory cells expressing tumor necrosis factor alpha in achalasia (P= 0.007). In conclusion, a higher proportion of infiltrating inflammatory cells expressed tumor necrosis factor alpha in achalasia. Furthermore, this proportion appears to be highest early in the disease process. Further studies are required to more clearly delineate the role of tumor necrosis factor alpha in the pathogenesis of this idiopathic disease.

Anatomic segmentectomy for stage I non-small cell lung cancer: Comparison of outcomes with the VATS versus open approach

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Background: Anatomic segmentectomy for early-stage NSCLC has been proposed as a means of achieving a complete resection in high-risk patients with poor lung function, who might not otherwise tolerate conventional lobectomy. Historically, anatomic segmentectomy has been associated with increased recurrence rates and postoperative air leaks. In the current study, we present our experience with VATS versus open segmentectomy for stage I NSCLC. Methods: A total of 181 consecutive anatomic segmentectomies (114 Open, 67 VATS) were performed for Stage IA (n=110) or IB (n=71) NSCLC from 2002–2006. A VATS approach was employed in 67 patients, and an open approach in 114 patients. Outcome variables include hospital course, complications, mortality, recurrence patterns and survival. Results: The mean age was 70 years (range: 45–100). Average tumor size was 2.3 cm (2.0 cm VATS; 2.4 cm open, NS). Lymph node sampling or dissection was performed in 169 (93%) of patients with an average node harvest of 8.2 nodes (Open = 9.2; VATS = 6.2, p=0.006). There were two perioperative deaths (1.1%), both open. Complications occurred in 59 patients (33%). Median length of stay was 6 days (VATS=5, Open=7). Mean follow-up was 15.6 months. There were fewer major (7 vs. 31, p=0.005) and infectious (3 vs. 12%, p=0.026) complications in the VATS group, with no significant difference in pulmonary complications or air leaks. Twenty-nine recurrences (16%; VATS=7, Open=22) occurred at a mean of 12.7 months [11 locoregional (6%), 18 distant (10%)]. Overall mortality, complications, recurrence and two-year actuarial survival (78%) were similar between VATS and open segmentectomy. Conclusions: VATS segmentectomy can be performed safely with acceptable morbidity, mortality, recurrence and survival. The VATS approach affords a shorter length of stay and fewer postoperative complications (major and infectious) compared with open techniques. The potential benefits of segmentectomy will need to be further validated by prospective, randomized trials (ACOSOG Z4032). Sublobar resection techniques represent an important adjunct in treating compromised patients with early stage NSCLC.

No significant financial relationships to disclose.

A pilot study of botulinum toxin injection for the treatment of delayed gastric emptying following esophagectomy

OBJECTIVE

Esophagectomy may lead to impairment in gastric emptying, unless a pyloroplasty or pyloromyotomy is performed. These procedures may be technically challenging during minimally invasive esophagectomy, and they are associated with a small but definable morbidity, such as leakage and dumping syndrome. We sought to determine the results of our early experience with injecting the pylorus with botulinum toxin instead of conventional pyloric drainage.

METHODS

Fifteen patients who had undergone esophagectomy and injection of the pylorus with botulinum toxin were identified. Twelve patients had undergone botulinum toxin injection at the time of minimally invasive esophagectomy, and the remaining three had been treated endoscopically after surgery. The latter three patients had undergone esophagectomy with either no pyloric drainage (n = 2) or an inadequate pyloromyotomy (n = 1), and they presented in the postoperative period with delayed gastric emptying. The adequacy of emptying after injection was assessed by the patients' ability to tolerate a regular diet, a barium swallow, and a nuclear gastric emptying study.

RESULTS

No patient injected with botulinum toxin during esophagectomy developed delayed gastric emptying or aspiration pneumonia in the perioperative period. Eight of these patients underwent a nuclear emptying scan at a median of 4.2 months after surgery, which showed a mean emptying half-life of 100 min. With a median follow-up of 5.3 months, one patient (8%) required reintervention for symptoms of gastric stasis, presumably after the effect of the toxin subsided. All three patients injected postoperatively demonstrated an improvement in symptoms of gastric outlet obstruction and were able to resume a regular diet.

CONCLUSIONS

Injection of the pylorus with botulinum toxin can be performed safely in patients undergoing esophagectomy. Longer-term studies are needed to clarify the efficacy and durability of this technique compared to the accepted procedures of pyloromyotomy or pyloroplasty.

Nitric oxide induces angiogenesis and upregulates alpha(v)beta(3) integrin expression on endothelial cells

Nitric oxide (NO) has been implicated as a mediator of angiogenesis. However, its precise role in angiogenesis and its mechanism of action have not been established. We performed in vivo and in vitro angiogenesis assays using NO donor S-nitroso-N-acetylpenicillamine (SNAP) and NO synthase inhibitor N-iminoethyl-l-ornithine (L-NIO). SNAP significantly increased and L-NIO significantly suppressed capillary ingrowth into subcutaneously implanted Matrigel plugs in mice. For the in vitro angiogenesis assay, human umbilical vein endothelial cells (HUVECs) (4 x 10(4) cells/well) were treated with placebo, SNAP (100 microM), or L-NIO (100 microM) and cultured on Matrigel for 18 h. The typical capillary networks formed on Matrigel by HUVECs as a result of cell migration and differentiation were quantified by computer-assisted image analysis as a measure of angiogenesis. Treatment of HUVECs with SNAP significantly increased the capillary network area compared with control, 8701 +/- 693 vs 6258 +/- 622 area units (P < 0.05), whereas L-NIO significantly decreased the capillary area (4540 +/- 342, P < 0.05). Furthermore, we have shown with a blocking monoclonal antibody that formation of capillary networks on Matrigel is mediated by the functional expression of the alpha(v)beta(3) integrin, which plays a role in facilitating endothelial cell adhesion to basement membrane matrix and endothelial cell migration. After an 18-h culture, flow cytometry revealed that SNAP significantly upregulated and L-NIO significantly downregulated in a concentration-dependent manner alpha(v)beta(3) integrin expression on endothelial cells. In conclusion, NO induces angiogenesis in vivo and in vitro by promoting endothelial cell migration and differentiation into capillaries. One possible mechanism might involve the upregulation of alpha(v)beta(3) integrin on endothelial cells, a critical mediator of cell-matrix adhesion and migration.

Characterization of a newly discovered T-cell receptor beta-chain heterodimer expressed on a CD8+ bone marrow subpopulation that promotes allogeneic stem cell engraftment

The facilitating cell is a rare CD8+ bone marrow subpopulation that can enhance allogeneic hematopoietic stem cell engraftment across complete major histocompatibility complex barriers without inducing acute graft-versus-host disease. Here we describe a CD3epsilon-associated complex on the facilitating cell surface that consists of the T-cell receptor beta-chain disulfide-linked to a previously unknown 33-kilodalton glycoprotein. Provisionally called FCp33, this glycoprotein does not represent any of the known protein chains or surrogates associated with CD3-T-cell receptor beta. Expression of this CD3-T-cell receptor beta-FCp33 complex directly correlates with the facilitating cell's functional ability to enhance allogeneic stem cell engraftment in vivo.

The abrogation of allosensitization following the induction of mixed allogeneic chimerism

The association of preformed anti-donor Abs with the hyperacute rejection of bone marrow and solid organ allografts and the persistence of the anti-donor immune response secondary to immunologic memory make allosensitization an absolute contraindication to transplantation. Mixed allogeneic (A + B-->A) bone marrow chimerism has been demonstrated to confer donor-specific tolerance in nonsensitized recipients, but has not been evaluated in the setting of allosensitization. The current study documents that despite significant anti-donor sensitization, mixed allogeneic engraftment is possible and provides a marked advantage over fully allogeneic (B-->A) models. Moreover, the acceptance of donor skin grafts and loss of circulating anti-donor Abs suggest that allosensitization can be abrogated with the induction of stable mixed allogeneic chimerism.

A nonlethal conditioning approach to achieve durable multilineage mixed chimerism and tolerance across major, minor, and hematopoietic histocompatibility barriers

Reconstitution of lethally irradiated mice with a mixture of syngeneic and allogeneic (A+B-->A) bone marrow results in multilineage mixed allogeneic chimerism, donor-specific transplantation tolerance, superior immunocompetence and resistance to graft-vs-host disease. However, the morbidity and mortality associated with lethal irradiation would be a major limitation to the clinical application of chimerism to induce tolerance for solid organ grafts or treat other nonmalignant hematologic diseases. We report here that durable multilineage mixed allogeneic chimerism and donor-specific transplantation tolerance for skin and primarily vascularized allografts can be achieved across multiple histocompatibility barriers using a nonmyeloablative radiation-based approach. The percentage of B10 mouse recipients that engrafted directly correlated with the degree of disparity between donor and recipient and the dose of total body irradiation administered. Although the occurrence of engraftment following conditioning with doses of total body irradiation of > or = 600 cGy was similar for animals receiving bone marrow disparate at MHC or MHC, minor and hematopoietic (Hh-1) loci (67% vs 78%), the level of donor chimerism was significantly less when multiple histocompatibility barriers were present (94.6 +/- 3.8% vs 37.5 +/- 12.5%). Treatment of the recipient with cyclophosphamide 2 days following allogeneic bone marrow transplantation reduced the dose of radiation sufficient for reliable engraftment to only 500 cGy of total body irradiation, regardless of MHC and Hh-1 disparity. Donor chimerism was stable and present in all lineages, with production of lymphoid (T and B cell), NK, and myeloid (erythrocyte, platelet, granulocyte, and macrophage) cells. Mixed chimeras exhibited donor-specific tolerance in vitro, as assessed by mixed lymphocyte culture (MLR) and cytotoxicity (CML) assays, and in vivo to skin and primarily vascularized cardiac allografts. The observation that engraftment and tolerance can be achieved across multiple histocompatibility barriers using nonmyeloablative recipient conditioning may allow allogeneic bone marrow transplantation to be applied to nonmalignant disease states in which lethal conditioning cannot be justified, including the induction of donor-specific tolerance for solid organ transplantation and the treatment of hemoglobinopathies and enzyme deficiency states.

A nonlethal conditioning approach to achieve durable multilineage mixed chimerism and tolerance across major, minor, and hematopoietic histocompatibility barriers

Reconstitution of lethally irradiated mice with a mixture of syngeneic and allogeneic (A+B--&gt;A) bone marrow results in multilineage mixed allogeneic chimerism, donor-specific transplantation tolerance, superior immunocompetence and resistance to graft-vs-host disease. However, the morbidity and mortality associated with lethal irradiation would be a major limitation to the clinical application of chimerism to induce tolerance for solid organ grafts or treat other nonmalignant hematologic diseases. We report here that durable multilineage mixed allogeneic chimerism and donor-specific transplantation tolerance for skin and primarily vascularized allografts can be achieved across multiple histocompatibility barriers using a nonmyeloablative radiation-based approach. The percentage of B10 mouse recipients that engrafted directly correlated with the degree of disparity between donor and recipient and the dose of total body irradiation administered. Although the occurrence of engraftment following conditioning with doses of total body irradiation of &gt; or = 600 cGy was similar for animals receiving bone marrow disparate at MHC or MHC, minor and hematopoietic (Hh-1) loci (67% vs 78%), the level of donor chimerism was significantly less when multiple histocompatibility barriers were present (94.6 +/- 3.8% vs 37.5 +/- 12.5%). Treatment of the recipient with cyclophosphamide 2 days following allogeneic bone marrow transplantation reduced the dose of radiation sufficient for reliable engraftment to only 500 cGy of total body irradiation, regardless of MHC and Hh-1 disparity. Donor chimerism was stable and present in all lineages, with production of lymphoid (T and B cell), NK, and myeloid (erythrocyte, platelet, granulocyte, and macrophage) cells. Mixed chimeras exhibited donor-specific tolerance in vitro, as assessed by mixed lymphocyte culture (MLR) and cytotoxicity (CML) assays, and in vivo to skin and primarily vascularized cardiac allografts. The observation that engraftment and tolerance can be achieved across multiple histocompatibility barriers using nonmyeloablative recipient conditioning may allow allogeneic bone marrow transplantation to be applied to nonmalignant disease states in which lethal conditioning cannot be justified, including the induction of donor-specific tolerance for solid organ transplantation and the treatment of hemoglobinopathies and enzyme deficiency states.