Frederic W. Grannis

Non-small cell lung cancer.

Most patients with non-small cell lung cancer (NSCLC) are diagnosed with advanced cancer. These guidelines only include information about stage IV NSCLC. Patients with widespread metastatic disease (stage IV) are candidates for systemic therapy, clinical trials, and/or palliative treatment. The goal is to identify patients with metastatic disease before initiating aggressive treatment, thus sparing these patients from unnecessary futile treatment. If metastatic disease is discovered during surgery, then extensive surgery is often aborted. Decisions about treatment should be based on multidisciplinary discussion.

Five-year lung cancer survival: which advanced stage nonsmall cell lung cancer patients attain long-term survival?

The core strategy of American College of Chest Physicians lung cancer guidelines is identification of the earliest symptoms of lung cancer and the immediate initiation of diagnosis and treatment. In the absence of screening, most symptomatic lung cancer is discovered at advanced stages, with the goal of long‐term survival entirely dependent on effective treatment of stage III and IV lung cancer.

Natural History of Typical Pulmonary Carcinoid Tumors: A Comparison of Nonsurgical and Surgical Treatment

BACKGROUND The natural history of typical pulmonary carcinoid tumors has not been described and has important implications for counseling elderly patients or patients with high operative-risk about surgical resection. METHODS Data from the Surveillance, Epidemiology, and End Results Program were used to identify 4,111 patients with biopsy specimen-proven lymph node-negative typical carcinoid tumor of the lung between 1988 and 2010; 306 had no resection, 929 underwent sublobar resection, and 2,876 underwent lobectomy. Overall survival and disease-specific survival (DSS) were analyzed using Kaplan-Meier plots. Multivariate analysis was used to determine predictors of survival. RESULTS Five-year overall survival in patients who underwent lobectomy, sublobar resection, or no surgery was 93%, 92%, and 69%, respectively (P < .0001); 5-year DSS was 97%, 98%, and 88%, respectively (P < .0001). Among T1 tumors, DSS was 98% for patients who underwent lobectomy and sublobar resection and 92% for no surgery; among T2 tumors, DSS was 97%, 100%, and 87%, respectively, and among T3 and T4 tumors, it was 96%, 100%, and 75%, respectively. On multivariate analysis, nonoperative management was associated with an increased risk for disease-specific mortality compared with lobectomy (hazard ratio, 2.14; 95% CI, 1.35-3.40; P = .0013). CONCLUSIONS In this population-based cohort, surgical resection of lymph node-negative carcinoid tumors is associated with a survival advantage over nonoperative treatment. However, the DSS at 5 years was still high without any treatment, suggesting that observation of asymptomatic peripheral typical carcinoid tumors or endoscopic management of symptomatic central carcinoid tumors may be considered in patients at high risk for surgical resection.

Recurrence of pulmonary mucinous cystic tumor of borderline malignancy

Cystic mucinous tumors of the lung are recently described neoplasms whose histology is different from most lung adenocarcinomas, and represent a spectrum of malignant potential. Little is known of the behavior of the more malignant subtype. We present a cystic mucinous tumor of borderline malignancy that recurred locally following initial limited resection, and was treated with lobectomy.

Original Research Lung CancerNatural History of Typical Pulmonary Carcinoid Tumors: A Comparison of Non surgical and Surgical Treatment

BACKGROUND The natural history of typical pulmonary carcinoid tumors has not been described and has important implications for counseling elderly patients or patients with high operative-risk about surgical resection. METHODS Data from the Surveillance, Epidemiology, and End Results Program were used to identify 4,111 patients with biopsy specimen-proven lymph node-negative typical carcinoid tumor of the lung between 1988 and 2010; 306 had no resection, 929 underwent sublobar resection, and 2,876 underwent lobectomy. Overall survival and disease-specific survival (DSS) were analyzed using Kaplan-Meier plots. Multivariate analysis was used to determine predictors of survival. RESULTS Five-year overall survival in patients who underwent lobectomy, sublobar resection, or no surgery was 93%, 92%, and 69%, respectively (P < .0001); 5-year DSS was 97%, 98%, and 88%, respectively (P < .0001). Among T1 tumors, DSS was 98% for patients who underwent lobectomy and sublobar resection and 92% for no surgery; among T2 tumors, DSS was 97%, 100%, and 87%, respectively, and among T3 and T4 tumors, it was 96%, 100%, and 75%, respectively. On multivariate analysis, nonoperative management was associated with an increased risk for disease-specific mortality compared with lobectomy (hazard ratio, 2.14; 95% CI, 1.35-3.40; P = .0013). CONCLUSIONS In this population-based cohort, surgical resection of lymph node-negative carcinoid tumors is associated with a survival advantage over nonoperative treatment. However, the DSS at 5 years was still high without any treatment, suggesting that observation of asymptomatic peripheral typical carcinoid tumors or endoscopic management of symptomatic central carcinoid tumors may be considered in patients at high risk for surgical resection.

Mediastinal germ cell tumor in a child with precocious puberty and Klinefelter syndrome

An 8-year-old boy presented with precocious puberty and a mediastinal mass. A computer search showed that this rare presentation is most common with germ cell tumor of the mediastinum in children with Klinefelter syndrome. The tumor was completely resected after preoperative chemotherapy, and the patient is well 2 years after the operation. In patients with Klinefelter syndrome, germ cell tumors are 50 times more common than in patients without Klinefelter syndrome, usually contain nonseminomatous elements, present at an earlier age, and are seldom testicular in location.

Minimizing over-diagnosis in lung cancer screening

Overestimation of the frequency and impact of over‐diagnosis bias in lung cancer screening has contributed to long delays in implementation of lung cancer screening programs. Literature review reveals little evidence of substantial numbers of over‐diagnosed non‐lethal lung cancer. There is now strong evidence that lung cancers that would not cause symptoms or kill during normal anticipated survival are uncommon and mostly limited to in situ adenocarcinomas, identifiable as CT non‐solid nodules. Prevention of overtreatment is possible within well‐constructed diagnostic algorithms. J. Surg. Oncol. 2013 108:289–293.

Survival following lung resection in immunocompromised patients with pulmonary invasive fungal infection.

OBJECTIVES Pulmonary invasive fungal infections (IFIs) are associated with high mortality in patients being treated for haematological malignancy. There is limited understanding of the role for surgical lung resection and outcomes in this patient population. METHODS This is a retrospective cohort of 50 immunocompromised patients who underwent lung resection for IFI. Patient charts were reviewed for details on primary malignancy and treatment course, presentation and work-up of IFI, reasons for surgery, type of resection and outcomes including postoperative complications, mortality, disease relapse and survival. Analysis was also performed on two subgroups based on year of surgery from 1990-2000 and 2001-2014. RESULTS The median age was 39 years (range: 5-64 years). Forty-seven patients (94%) had haematological malignancies and 38 (76%) underwent haematopoietic stem cell transplantation (HSCT). Surgical indications included haemoptysis, antifungal therapy failure and need for eradication before HSCT. The most common pathogen was Aspergillus in 34 patients (74%). Wedge resections were performed in 32 patients (64%), lobectomy in 9 (18%), segmentectomy in 2 (4%) and some combination of the 3 in 7 (14%) for locally extensive, multifocal disease. There were 9 (18%) minor and 14 (28%) major postoperative complications. Postoperative mortality at 30 days was 12% (n = 6). Acute respiratory distress syndrome was the most common cause of postoperative death. Overall 5-year survival was 19%. Patients who had surgery in the early period had a median survival of 24 months compared with 5 months for those who had surgery before 2001 (P = 0.046). At the time of death, 15 patients (30%) had probable or proven recurrent IFI. Causes of death were predominantly related to refractory malignancy, fungal lung disease or complications of graft versus host disease (GVHD). Patients who had positive preoperative bronchoscopy cultures had a trend towards worse survival compared with those with negative cultures (hazard ratio: 1.80, P = 0.087). CONCLUSIONS Surgical resection of IFI in immunocompromised patients is associated with high perioperative mortality. Long-term survival is limited by recurrent malignancy, persistent fungal infection and GVHD but has improved in recent years. Selection for surgical resection is difficult in this patient population, but should be carefully considered in those who are symptomatic, or have failed antifungal treatment.

Physical and Psychosocial Issues in Lung Cancer Survivors

Lung cancer emerged during the 20th century as an epidemic of enormous proportions.1 A rare disease at the beginning of the past century, lung cancer continues to be one of the most common cancers in the world, affecting 174,470 Americans (92,700 men and 81,770 women) in 2006.2 Mirroring changes in smoking patterns, the incidence of lung cancer among men continues to decline. Large-scale smoking among women occurred almost 20 years after men in the United States, with a subsequent delay in increased cases, peaking in the 1990s. Encouragingly, the most recent evidence demonstrates that lung cancer incidence among women is declining, as are death rates.3 In 2000, approximately 13% of men and 17% of women (age-adjusted, 15% overall) diagnosed with lung cancer were expected to survive at least 5 years (an estimated 26,065 Americans each year).2

Repair of a complex body wall defect using polytetrafluorethylene patches

Techniques for repair of chest wall, abdominal wall, and diaphragm have been well described, but simultaneous repair of defects involving each of these three areas after tumor ablation provides the surgeon with a difficult technical problem. Repair of a large defect with two polytetrafluorethylene patches after resection of an osteosarcoma invading the lower chest wall, abdominal wall, and diaphragm is described.