David Jonathan Heineman

The Quality of Staging Non-Small Cell Lung Cancer in the Netherlands: Data From the Dutch Lung Surgery Audit

BACKGROUND Clinical staging of non-small cell lung cancer (NSCLC) determines the initial treatment offered to a patient. The similarity between clinical and pathologic staging in some studies is as low as 50%, and others publish results as high as 91%. The Dutch Lung Surgery Audit is a clinical database that registers the clinical and pathologic TNM of almost all NSCLC patients who undergo operations in the Netherlands. The objective of this study was to determine the accuracy of clinical staging of NSCLC. METHODS Prospective data were derived from the Dutch Lung Surgery Audit in 2013 and 2014. Patients were included if they had undergone a surgical resection for stage IA to IIIB NSCLC without neoadjuvant treatment and had a positron emission tomography-computed tomography scan as part of the clinical workup. Clinical (c)TNM and pathologic (p)TNM were compared, and whether discrepancy was based on tumor or nodal staging was determined. RESULTS From 2,834 patients identified, 2,336 (82.4%) fulfilled the inclusion criteria and had complete data. Of these 2,336, 1,276 (54.6%) were staged accurately, 707 (30.3%) were clinically understaged, and 353 (15.1%) were clinically overstaged. In the understaged group, 346 patients had a higher pN stage (14.8%), of which 148 patients had unforeseen N2 disease (6.3%). In the overstaged group, 133 patients had a cN that was higher than the pN (5.7%). CONCLUSIONS Accuracy of NSCLC staging in the Netherlands is low (54.6%), even in the era of positron emission tomography-computed tomography. Especially accurate nodal staging remains challenging. Future efforts should include the identification of specific pitfalls in NSCLC staging.

Clinical staging of NSCLC: current evidence and implications for adjuvant chemotherapy

Survival of all non-small cell lung cancer (NSCLC) patients is disappointing, with a 5-year survival of 18%. Staging NSCLC patients is crucial because it determines the choice of treatment and prognosis. Clinical staging is a complex process that comes with many challenges and with low accuracy between the clinical and pathological stage. Treatment modalities for stage I–III NSCLC consist of surgical resection, radiotherapy and chemotherapy. This review describes the current evidence on staging and the implications on adjuvant chemotherapy. For stage I disease, staging is most accurate. Primary treatment consists of surgery or stereotactic ablative radiotherapy. When a patient has stage II disease, staging is less accurate because more diagnostic modalities are necessary to stage the mediastinal lymph nodes. Surgery remains the primary treatment modality and platinum-based adjuvant chemotherapy gives a 4% 5-year survival benefit. Staging patients with stage III disease is difficult because of the heterogeneity of the patients. It should be decided if a patient has potentially resectable disease with or without risk of incomplete resection. Induction therapy with chemo(radio)therapy followed by surgical resection or definitive chemoradiotherapy are the treatments of choice. The 5-year survival can reach 44% in selected patients. Decisions in staging and treating patients with NSCLC should be made by a multidisciplinary team with sufficient expertise in all aspects of staging and treatment.

A rare case of anomalous venous drainage of the right upper lobe

We present an unusual case of partial anomalous venous drainage in which the vein of the right upper lobe drains into the superior vena cava, together with the azygos vein. This was discovered during surgery for a lung tumor of the right upper lobe. We present the embryological background, functional consequences and literature on this rare anatomical anomaly.

Dutch Lung Surgery Audit: A National Audit Comprising Lung and Thoracic Surgery Patients

BACKGROUND The nationwide Dutch Lung Surgery Audit (DLSA) started in 2012 to monitor and evaluate the quality of lung operations in The Netherlands as an improvement tool. This outline describes the establishment, structure, and organization of the audit by the Dutch Society of Lung Surgeons (NVvL) and the Dutch Society of Cardiothoracic Surgeons (NVT), in collaboration with the Dutch Institute for Clinical Auditing. In addition, the first 4-year results are presented. METHODS The NVvL and NVT initiated a web-based registration, including weekly updated online feedback for participating hospitals. Data verification by external data managers is performed on regular basis. The audit is incorporated in national quality improvement programs, and participation in the DLSA is mandatory by health insurance organizations and the National Healthcare Inspectorate. RESULTS Between January 1, 2012, and December 31, 2015, all hospitals performing lung operations participated, and a total of 19,557 patients were registered from which almost half comprised lung cancer patients. Nationwide the guideline adherence increased over the years, and 96.5% of lung cancer patients were discussed in preoperative multidisciplinary teams. Overall postoperative complications and mortality after non-small cell lung cancer operations were 15.5% and 2.0%, respectively. CONCLUSIONS The audit provides reliable benchmarked information for caregivers and hospital management with potential to start local, regional, or national improvement initiatives. Currently, the audit is further completed with data from nonsurgical lung cancer patients, including treatment data from pulmonary oncologists and radiation oncologists. This will ultimately provide a comprehensive overview of lung cancer treatment in The Netherlands.

Invited letter to the editor on the editorial on “ Clinical staging of NSCLC: current evidence and implications for adjuvant chemotherapy ”

It is with great interest that we took notice of the expert knowledge on staging of non-small cell lung cancer (NSCLC) and the implications on adjuvant chemotherapy expressed in the two invited editorials on our previously published article entitled “ Clinical staging of NSCLC: current evidence and implications for adjuvant chemotherapy ” (1).