Bartłomiej Gałęcki

High costs as a slow down factor of thoracoscopic lobectomy development in Poland - an institutional experience.

Introduction Thoracoscopic (VATS) lobectomy after a decade of criticism is nowadays considered as a technically feasible, safe and oncologically proper operation. This approach has some advantages over conventional thoracotomy like: less postoperative pain, shorter hospitalization, fewer postoperative complications, better tolerance of adjuvant chemotherapy with comparable long-term survival rate. The VATS lobectomy is now generally accepted as an important alternative to open lobectomy in early-stage lung cancer. Aim In the study we analyzed all aspects of introducing video-assisted thoracoscopic surgery (VATS) lobectomy in our institution with special consideration of the costs of the procedure as a potential limiting factor of its widespread development. Material and methods The data of 212 consecutive patients with early stage lung cancer operated on during 2008-2011 were selected and analyzed. One hundred and eight patients underwent VATS lobectomy (VATS group) and 104 patients antero-lateral thoracotomy (thoracotomy group). Perioperative outcomes including operating time, blood loss during surgery, postoperative complication rate, length of hospital stay, and duration of chest tube drainage were assessed. The cost evaluation included: all direct theater costs, daily hospital costs, intensive care costs, pharmacy and disposable costs with special consideration of stapling device costs. Results The mean hospital stay after VATS lobectomy was significantly shorter than after thoracotomy, mean 7 days vs. 10 days (p < 0.0012). The complication rate and ICU admission rate were almost twice as high after thoracotomy than after VATS and were 46% vs. 23% (p < 0.0006) and 42% vs. 22% (p < 0.0027) respectively. Cost analysis showed significantly higher total costs of VATS lobectomy than after thoracotomy (median €2445 vs. €2047). Considerably higher theater costs for VATS compared to thoracotomy, median €1395 vs. €479, were caused mainly by endostapler costs, median €1069 vs. €161. Significantly higher hospital costs and ICU costs after thoracotomy did not compensate high theater costs of VATS lobectomy. Conclusions In Polish financial reality and potentially in other middle-income countries significantly higher costs of the procedure can limit widespread introduction of VATS lobectomy in clinical practice.

Completion pneumonectomy and chemoradiotherapy as treatment options in local recurrence of non-small-cell lung cancer

Introduction The selection of treatment for local recurrence in patients with non-small-cell lung cancer (NSCLC) depends on the possibility of performing a radical tumor resection, the patients performance status, and cardiopulmonary efficiency. Compared with chemoradiotherapy, surgical treatment offers a greater chance of long-term survival, but results in completion pneumonectomy and is associated with a relatively high rate of complications. Aim of the study Aim of the study was to evaluate early and long-term results of surgery and conservative treatment (chemoradiotherapy) in patients with local NSCLC recurrence. Material and methods Between 1998 and 2011, 1697 NSCLC patients underwent lobectomy or bilobectomy at the Department of Thoracic Surgery in Poznań. Among them, 137 patients (8.1%) were diagnosed with cancer recurrence; chemotherapy or chemoradiotherapy was provided to 116 patients; 21 patients (15.3%) were treated with completion pneumonectomy. The median time from primary surgery to recurrence was 13.4 months. No metastases to N2 lymph nodes were observed among the patients undergoing surgery; in 7 patients N1 lymph node metastases were confirmed. Results The rate of complications after surgery was significantly higher in comparison with conservative therapy (80.9% vs. 48.3%). Patients treated with surgery were most likely to suffer from complications associated with the circulatory system (80.9%), while hematologic complications were dominant in the group undergoing oncological treatment (41.4%). There were no perioperative deaths after completion pneumonectomy. The age of the patients was the only factor which significantly influenced the incidence of complications in both groups of patients. Analysis of the survival curves demonstrated statistically significant differences in survival between the groups treated with surgery, chemoradiotherapy, and chemotherapy (p = 0.00001). Five-year survival probability was significantly higher among patients treated surgically as compared to patients undergoing systemic therapy. Conclusions Despite the significant rate of postoperative complications (mostly circulatory), the long-term results of the surgical treatment of local NSCLC recurrence are more favorable than those achieved with chemoradiotherapy. The success of surgical treatment is conditioned on the exclusion of metastasis in N2 lymph nodes.

Decreased expression of cytochrome p450 1B1 in non-small cell lung cancer

Recent studies have associated oestrogen metabolism and cigarette smoking with their carcinogenic impact on the lungs. Compounds commonly found in tobacco smoke induce the activity of CYP1B1, the enzyme responsible for the synthesis of catecholic derivatives of oestrogens. During their redox transformations, these structures can release large amounts of reactive oxygen species or can form DNA adducts, which lead to the decomposition of genetic material. This process may illustrate the synergistic effect of oestrogenic activity and tobacco combustion on oestrogen-dependant lung cancer development. There is considerable evidence suggesting that the level of oestrogen in lung tumours is elevated. Therefore, by using reverse transcription, real-time PCR and Western Blot analysis, we evaluated the CYP1B1 status in tissues from 76 patients diagnosed with non-small cell lung cancer (NSCLC) to confirm whether potential overexpression of CYP1B1 may impact lung cancerogenesis induced by oestrogens. We found significantly lower levels of CYP1B1 transcripts (p=0.00001) and proteins (p=0.000085) in lung tumour material compared to corresponding, histopathologically unchanged tissues. We also analysed the association of CYP1B1 expression with gender, age and clinicopathological data of NSCLC patients. We observed lower amounts of CYP1B1 occurring in the middle stages of LC, regardless of gender, age or histological type of lung cancer.