Ilkka Ilonen

Bronchial sleeve resection or pneumonectomy for non-small cell lung cancer: a propensity-matched analysis of long-term results, survival and quality of life

BACKGROUND No randomized studies exist comparing pneumonectomy (PN) and sleeve lobectomy (SL). We evaluated surgical results and long-term quality of life in patients operated on for central non-small cell lung cancer (NSCLC) using either SL or PN. METHODS A total of 641 NSCLC patients underwent surgery 2000-2010. SL was performed in 40 (6.2%) and PN in 67 (10.5%). In 2011, all surviving patients were sent a 15D Quality of Life Questionnaire which 83% replied. Propensity-score-matching analysis was utilized to compare the groups. RESULTS Thirty-two bronchial (18 right/14 left), seven vasculobronchial (3 right/4 left), one right wedge SL, and 18 right and 22 left PN were performed. Preoperatively, the Charlson Comorbidity Index (CCI) score, forced expiratory volume in 1 s (FEV1) and diffusion capacity did not differ between groups. The perioperative complication rate and pattern were similar, but SL group had less major complications (P<0.027). One perioperative death (2.5%) occurred in SL group and four (6%) in PN. The 90-day mortality rate was 5% (n=2) for SL and 7.5% (n=5) for PN. In the follow-up total cancer recurrence did not differ (P=0.187). Quality of life measured by 15D showed no significant difference in separate dimensions or total score, except tendency to favor SL in moving or breathing. The 5-year survival did not differ between groups (P=0.458), but no deaths were observed in SL group after 5 years. CONCLUSIONS Due to less major operative complications and better long-term survival, we would advocate using SL when feasible, but in patients tolerating PN it should be considered if SL seems not to be oncologically sufficiently radical.

Patient features predicting long-term survival and health-related quality of life after radical surgery for non-small cell lung cancer

This study presents a retrospective evaluation of patient, disease, and treatment features predicting long‐term survival and health‐related quality of life (HRQoL) among patients who underwent surgery for non‐small cell lung cancer (NSCLC).

Low skeletal muscle mass in stented esophageal cancer predicts poor survival: A retrospective observational study: Skeletal muscle mass and stented EC

In esophageal cancer, nutritional challenges are extremely common. Malignant obstruction resulting from esophageal cancer (EC) is often treated by the insertion of expandable stents, but little is known as to the role and evolution of sarcopenia in this patient population. The aim of this article was to determine the effects of body mass parameters on survival of advanced EC patients who received a stent for palliation of malignant obstruction.

Computed tomography in the evaluation of malignant pleural mesothelioma—Association of tumor size to a sarcomatoid histology, a more advanced TNM stage and poor survival

OBJECTIVES Appropriate clinical staging of malignant pleural mesothelioma (MPM) is critical for correct treatment decisions. Newly revised TNM staging protocol has been released for MPM. We investigated baseline computed tomography (CT) characteristics of MPM patients, the new staging system and a simple tumor size (TS) assessment in terms of survival. MATERIALS AND METHODS As part of our study that included all MPM patients diagnosed in Finland 2000-2012, we retrospectively reviewed 161 CT scans of MPM patients diagnosed between 2007 and 2012 in the Hospital District of Helsinki and Uusimaa. TS was estimated by using the maximal tumor thickness and grading tumor extension along the chest wall. Cox Regression models were used to identify relationships between survival, clinicopathological factors and CT-findings. RESULTS The median length of follow-up was 9.7 months and the median survival 9.1 months. The right sided tumors tended to be more advanced at baseline and had worse prognosis in the univariate analyses. In the multivariate survival model, TS, pleural effusion along with non-epithelioid histology were predictors of poor survival. Tumor size correlated significantly with a sarcomatoid histopathological finding and several parameters linked to a more advanced TNM stage. Most patients were diagnosed with locally advanced stage, while 12 (7%) had no sign of the tumor in CT. CONCLUSION In this study, we demonstrate a novel approach for MPM tumor size evaluation that has a strong relationship with mortality, sarcomatoid histology and TNM stage groups. TS could be used for prognostic purposes and it may be a useful method for assessing therapy responses.

European questionnaire on the clinical use of video-assisted thoracoscopic surgery

OBJECTIVES Video-assisted thoracoscopic surgery (VATS) has emerged as a safe and efficacious alternative approach to conventional thoracotomy for selected patients with non-small-cell lung cancer. The aim of the present study was to assess the current clinical practice of VATS among the European Society of Thoracic Surgeons (ESTS) members. METHODS A standardized questionnaire was sent to thoracic surgeons on the ESTS mailing list, with collection of data on demographics, use of multiportal or uniportal VATS, institutional experience with VATS procedures and proportion of operations performed by different approaches. Analysis was performed using SPSS statistical software. RESULTS Complete questionnaire results were collected from 100 unique institutions in 31 countries, representing data on the clinical practice of 461 board-certified thoracic surgeons. Three hundred and twenty-four of the 461 (70%) surgeons claimed to perform anatomical VATS resections, with a total estimated caseload of 9519 resections per year. Two hundred and thirty-one (50%) surgeons reported to have performed lobectomies primarily through the VATS approach. The case volume was significantly correlated to the number (P = 0.019) and proportion (P = 0.001) of surgeons who performed VATS anatomical resections. Overall, 47% of the centres performing anatomical VATS resections reported some use of uniportal approach. There was no association between the number of thoracic surgeons within an institution and the likelihood of performing uniportal VATS lobectomy. CONCLUSIONS Compared to previous surveys, results of the present European study suggested that there is a strong trend favouring VATS for a range of thoracic procedures in the current clinical setting. However, the use of uniportal VATS is still not yet widespread. The evolving adoption of VATS in Europe should be further assessed with regard to clinical outcomes in the form of large standardized registries.

Surgically Treated Unsuspected N2-Positive NSCLC: Role of Extent and Location of Lymph Node Metastasis

Micro‐Abstract: The role of positive lymph node location in non–small‐cell lung cancer (NSCLC) patients and effects on survival was assessed. A total of 88 operated patients with unsuspected N2 disease or station 10 lymph nodes were included. No difference was found in survival between inferior positive mediastinal N2 node patients compared to multilevel N2 disease patients. The survival of patients with positive hilar disease was similar to the inferior mediastinal positive N2 group. Background: The role of surgery in the treatment of non–small‐cell lung cancer that has spread to ipsilateral mediastinal or hilar lymph nodes (LNs) is controversial. We examined whether the location of LNs positive for non–small‐cell lung cancer in mediastinum or hilum influences the survival of these patients. Patients and Methods: We reviewed data from 881 patients and analyzed those with unsuspected N2 disease or hilar (station 10) LNs. The patients were stratified into the following groups: group A, positive hilar Naruke 10; group B, superior mediastinal and aortic nodes (Naruke 1, 2, 3, 4, 5, and 6); group C, inferior mediastinal nodes (Naruke 7, 8, and 9), and multilevel group D (2 or more positive N2 levels). Results: A total of 69 pN2 and 19 pN1 patients were included. Progression‐free survival (PFS) was statistically significant better in group B versus group C (P = .044) and group B versus group D (P = .0086). The overall survival (OS) of group A did not differ from that of group C. A statistically significant better OS was found between groups B and D (P = .051). Conclusion: Inferior positive mediastinal N2 node patients seem to have an OS and PFS as poor as multilevel N2 disease patients. The OS and PFS of patients with positive hilar disease are similar to those in the inferior mediastinal positive N2 group. Superior positive mediastinal N2 node patients have better OS and PFS than the inferior mediastinal positive N2 group.

A hamartoma presenting as an intramural upper oesophageal tumour

Oesophageal hamartomas are extremely rare conditions especially in upper oesophagus. We report on a 20-year-old woman who presented with dysphagia and was diagnosed with a retrosternal 4.9 cm × 9.0 cm heterogenic tumour located in her upper oesophagus. Preoperative examinations included computed tomography of the chest, bronchoscopy and esophagoscopy, and no signs of malignancy were noted. She underwent surgical resection of the mass and the final histopathological diagnosis was osteochondromatous hamartoma of the upper oesophagus. No acute or long-term complications or tumour recurrence were noted during a 6-year follow-up.

Preoperative stenting in oesophageal cancer has no effect on survival: a propensity-matched case-control study†

OBJECTIVES Previous studies have shown a link between oesophageal stenting before oesophagectomy and worse oncological outcomes. Our objective was to determine the effect of preoperative self-expanding covered metallic stent (SEMS) on survival, progression-free survival (PFS), operative time and complication rates in oesophageal cancer (EC). METHODS This study included EC patients undergoing surgery between January 2006 and January 2014 with a cT2 tumour or higher ( n  = 174; 135 adenocarcinomas and 39 squamous cell carcinomas). We propensity matched 1:1 a preoperative SEMS group ( n  = 30) to a control group. Despite the propensity matching, statistically non-significant residual covariate imbalances persisted. Median follow-up time was 33 months (range: 0-118 months). We performed Kaplan-Meier survival analysis for OS and PFS, the Students t -test for operative time and the chi-squared test for complication rates. RESULTS Median survival in the SEMS group was 28.5 months (range: 0-116 months) vs 34 months (4-118 months) in the control group and median PFS was 22 months (0-111 months) vs 27 (4-113 months) ( P  = 0.748 and P  = 0.764, respectively). Mean operative times between groups were 436 min vs 375 min ( P  = 0.017). No differences emerged in intraoperative (23.3% vs 10%, P  = 0.299), early (50.0% vs 46.7%, P  = 1) or late complication rates (53.3% vs 43.3%, P  = 0.606). CONCLUSIONS SEMS application has no significant effect on survival, PFS or complications. Mean operative time was significantly higher in the SEMS insertion group. We therefore conclude that preoperative SEMS insertion makes the operation more challenging by increasing operative time, but is otherwise a feasible and safe strategy in experienced centres as a bridge to surgery.

Conventional video-assisted thoracic surgery (VATS) vs . robotassisted lobectomy: where is the money?

The past 20 years have seen growing evidence for minimally invasive thoracic surgery, namely the widespread adoption of video-assisted thoracic surgery (VATS). The pinnacle of this procedure is the VATS lobectomy, which has thus far spawned multiple adaptations, such as robot-assisted, single-port and subxiphoidal approaches to mention only a few (1-3). Despite much higher adoption rate and more advanced technology, boundaries to conducting safe, efficient, reliably reproducible, minimally invasive surgery persist. Currently, the single-port approach offers no reported benefits over the conventional VATS lobectomy (4,5). Likewise, the robot-assisted VATS approach is reportedly non-inferior to that of conventional VATS (6). Debate about the rationality of the robot-assisted VATS approach is ongoing, as many surgeons feels the costs do not yet offset the benefits of this approach, as direct costs were significantly higher (robot-assisted surgery cost

The Effect of Albumin Dialysis on Cytokine Levels in Acute Liver Failure and Need for Liver Transplantation

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