J. Vansteenkiste

Lymph node staging in non-small-cell lung cancer with FDG-PET scan: a prospective study on 690 lymph node stations from 68 patients.

PURPOSEnTo compare the accuracy of computed tomography-(CT) scan and the radiolabeled glucose analog 18F-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) visually correlated with CT (PET + CT) in the locoregional lymph node (LN) staging of non-small-cell lung cancer (NSCLC).nnnPATIENTS AND METHODSnSixty-eight patients with potentially operable NSCLC underwent thoracic CT, PET, and invasive surgical staging (ISS). Imaging studies were read prospectively and blinded to the surgical and pathologic data. A five-point visual scale was used for the interpretation of LNs on PET. Afterwards, with knowledge of the pathology, the relationship between standardized uptake values (SUVs) and the presence of metastasis in LNs was explored in a receiver operating characteristic (ROC) analysis, and the likelihood ratios (LRs) for SUVs of LNs were determined.nnnRESULTSnISS was available for 690 LN stations. CT correctly identified the nodal stage in 40 of 68 patients (59%), with understaging in 12 patients and overstaging in 16 patients. PET + CT was accurate in 59 patients (87%), with understaging in five patients and overstaging in four patients. In the detection of locally advanced disease (N2/N3), the sensitivity, specificity, and accuracy of CT were 75%, 63%, and 68%, respectively. For PET + CT, this was 93%, 95%, and 94% (P = .0004). In the ROC curve, the best SUV threshold to distinguish benign from malignant LNs was 4.40. The analysis with this SUV threshold was not superior to the use of a five-point visual scale. The LR of a SUV less than 3.5 in an LN was 0.152; for a SUV between 3.5 and 4.5, it was 3.157; and for a SUV greater than 4.5, it was 253.096.nnnCONCLUSIONnPET + CT is significantly more accurate than CT alone in LN staging of NSCLC. A five-point visual scale is as accurate as the use of an SUV threshold for LNs in the distinction between benign and malignant nodes. The very high negative predictive value of mediastinal PET could reduce the need for mediastinal ISS in NSCLC substantially.

Surgery for non-small cell lung cancer with unsuspected metastasis to ipsilateral mediastinal or subcarinal nodes (N2 disease)

OBJECTIVEnAlthough the results after surgery for N2 disease are disappointing, there seems to be a subgroup of patients which may benefit from primary resection. These patients have clinically unrecognized N2 involvement that is discovered only at the time of thoracotomy (unsuspected or unforeseen N2 disease). It was the aim of this retrospective study to analyze the survival after resection for unforeseen N2 disease and to evaluate different prognostic factors. We were interested to see whether our strategy of rigorous staging of the mediastinum with mediastinoscopy or anterior mediastinotomy had an effect on the resectability rate and survival of unsuspected N2 disease.nnnMETHODSnBetween 1985 and 1990, 859 patients with potentially operable non-small cell lung cancer were referred to our surgical department. Despite rigorous preoperative staging with computed tomography scan and cervical mediastinoscopy and/or anterior mediastinotomy, 103 patients (14.5%) had unsuspected N2 disease at thoracotomy. The tumor could be completely resected in 90 patients (87.5%).nnnRESULTSnThe 5-year survival after complete resection was 22%. Histology of the tumor, number of involved levels and extent of nodal disease had no effect on survival.nnnCONCLUSIONnWe conclude that resection is justified in patients with unforeseen N2 disease. Rigorous staging of the mediastinum by cervical mediastinoscopy or anterior mediastinotomy results in a high resectability rate and avoids unnecessary thoracotomies. Mediastinoscopy plays a central role in the staging of patients with carcinoma of the lung.

The TERT-CLPTM1L locus for lung cancer predisposes to bronchial obstruction and emphysema

Clinical studies suggest that bronchial obstruction and emphysema increase susceptibility to lung cancer. We assessed the possibility of a common genetic origin and investigated whether the lung cancer susceptibility locus on chromosome 5p15.33 increases the risk for bronchial obstruction and emphysema. Three variants in the 5p15.33 locus encompassing the TERT and CLPTM1L genes were genotyped in 777 heavy smokers and 212 lung cancer patients. Participants underwent pulmonary function tests and computed tomography of the chest, and completed questionnaires assessing smoking behaviour. The rs31489 C-allele correlated with reduced forced expiratory volume in 1 s (p=0.006). Homozygous carriers of the rs31489 C-allele exhibited increased susceptibility to bronchial obstruction (OR 1.82, 95% CI 1.24–2.69; p=0.002). A similar association was observed for diffusing capacity of the lung for carbon monoxide (p=0.004). Consistent with this, CC-carriers had an increased risk of emphysema (OR 2.04, 95% CI 1.41–2.94; p=1.73×10−4) and displayed greater alveolar destruction. Finally, CC-carriers also had an increased risk for lung cancer (OR 1.90, 95% CI 1.21–2.99; p=0.005), and were more susceptible to developing both lung cancer and bronchial obstruction than lung cancer alone (OR 2.11, 95% CI 1.04–4.26; p=0.038). The rs31489 variant on 5p15.33 is associated with bronchial obstruction, presence and severity of emphysema, and lung cancer.

Gefitinib monotherapy in advanced nonsmall cell lung cancer: a large Western community implementation study

Epidermal growth factor receptor tyrosine kinase inhibitors represent a new treatment option for patients with advanced nonsmall cell lung cancer (NSCLC). This retrospective study examined to what extent previous clinical trial experience matches large-scale Western community implementation of this treatment. In the Belgian expanded access programme, the data from 513 patients with advanced or metastatic NSCLC, not suitable for further chemotherapy and receiving oral gefitinib 250u2005mg·day-1 until disease progression, death or unacceptable toxicity, were analysed. The median (range) duration of gefitinib treatment was 2.3u2005months (0.0–32.7). Its use was predominantly in second- or third-line treatment. The overall response and disease control rates were 8.9 and 41.2%, respectively. In univariate analysis, response was more common in females and never-smokers. In multivariate analysis, female sex was the only significant predictive factor (odds ratio (OR) (95% confidence interval (CI)) 0.329 (0.129–0.839)). Symptom improvement was reported in 108 patients of whom 32 (29.6%) had an objective response, 66 (61.1%) experienced disease stabilisation and 10 (9.3%) progressed. Gefitinib was well tolerated; only 7.8% of the patients reported grade 3 or 4 toxicity. The overall median survival was 4.7u2005months, with a 1-yr survival rate of 21%. Survival was strongly influenced by a better performance status (PS) (good PS: hazard ratio (HR) (95%CI) 0.110 (0.077–0.157)) and adenocarcinoma with bronchioloalveolar carcinoma features histology (HR (95%CI) 0.483 (0.279–0.834)). In conclusion, the activity of gefitinib was confirmed in the present large Western community implementation study. Response, present in a small subgroup, led to a rewarding survival and could be predicted by sex only. Baseline performance status and adenocarcinoma with bronchioloalveolar carcinoma features histology were significant factors for survival.

Aandoeningen van ademhalingsstelsel, mediastinum en thoraxwand

Samenvatting Aet. Holtevorming in een ontstekingsproces dat met verettering gepaard gaat en dat o.a. ontstaat na bacteriële infecties (stafylokokken) eventueel in aansluiting op infecties met influenzavirus (grieppneumonie), bij patiënten met een geringe weerstand tegen infecties (klebsiellapneumonie), bij slechte mondhygiëne, na verslikken met aspiratie, bij verdrinking, verminderd bewustzijn, longinfarct en septische embolen, maar ook in een obstructiepneumonie achter een bronchusobstructie (bijv. bronchuscarcinoom of corpus alienum) of zonder bekende oorzaak. Geen voorkeurlokalisatie, behalve bij verslikken: dan in de dorsobasale segmenten, voornamelijk rechts.

Pulmonary Biopsies via Thoracoscopy

Diffuse or focal interstitial lung disease, peripheral nodular lesions of unknown etiology, and pulmonary infection do sometimes require invasive tissue sampling after an inconclusive bronchoscopy with bronchoalveolar lavage (BAL) and/or transbronchial lung biopsies (TBLB). The decision to perform a lung biopsy has to be based on the probability that the examination will yield a specific diagnosis leading to a specific and/or change in treatment.

MC13-0040 A novel HER3-V855A driver mutation homologous to EGFR-L858R in lung cancer

Results: Postoperative relapse was significantly correlated with overexpression of four genes including EVI2B (P=0.001, OR=4.622), ATP2A2 (P=0.006, OR=4.688), S100B (P=0.001, OR=11.521), TM4SF3 (P=0.001, OR=6.756), and OLFM4 (P=0.008, OR=3.545). Sensitivity, specificity, and accuracy of WENCA operation platform were 94.7%, 93.5%, and 97%, respectively. Conclusions: Detection of CTC-related multiple biomarkers by WEnCA operation platform can significantly improve the early prediction rate of postoperative CRC relapse.