Jolanta Hauer

Non-small-cell lung cancer restaging with transcervical extended mediastinal lymphadenectomy

BACKGROUND To analyse a diagnostic yield of the transcervical extended mediastinal lymphadenectomy (TEMLA) in restaging of the mediastinal nodes after neoadjuvant chemo- or chemo-radiotherapy for non-small-cell lung cancer (NSCLC). METHODS From 1 January 2004 to 30 April 2009, 63 patients who underwent induction chemotherapy or chemo-radiotherapy for N2 and N2/3 metastatic nodes discovered preoperatively were restaged. There were 12 women and 51 men in the age group of 43-71 (mean 57.8) years. There were 45 squamous cell carcinomas, 13 adenocarcinomas, one pleomorphic carcinoma and four NSCLCs. A total of 54 patients underwent neoadjuvant chemotherapy and nine chemo-radiotherapy. Seven patients had mediastinoscopy before neoadjuvant therapy. As many as 34 patients underwent endobronchial ultrasound (EBUS), one patient underwent endo-oesophageal ultrasound (EUS) and 10 patients underwent combined EBUS/EUS. The diagnostic results of TEMLA were compared with the results of the largest published series of restaging patients. The results of subsequent thoracotomies after negative TEMLA were presented. RESULTS There were no serious complications or mortality after TEMLA. Metastatic nodes were discovered in 22 patients including three patients with N3 nodes and 19 patients with N2 nodes. Stations 7, 4R, 2R and 4L were the most prevalent. Of the 63 patients, 42 underwent subsequently thoracotomy. Resectability for negative TEMLA was 92.7%. There were 37 R0 resections and four R1 resections. There was no postoperative mortality, two bronchial fistulas were developed (after inferior bilobectomy and right pneumonectomy; the second one healed spontaneously) and there were no other serious complications. During thoracotomy with completion lymphadenectomy one false-negative result was found (single node in station 8). Sensitivity of TEMLA in the discovery of N2/3 nodes during restaging was 95.5%, specificity 100%, accuracy 98.3%, negative predictive value (NPV) 97.4% and positive predictive value (PPV) 100%. TEMLA was found to have significantly better sensitivity and NPV (p<0.05) than other series of restaging. During follow-up a local recurrence was noted in six of 37 (15.7%) patients after pulmonary resection. CONCLUSIONS (1) The results of TEMLA in restaging of NSCLC (N2/3) patients after induction chemotherapy or chemo-radiotherapy were significantly better than those achieved with remediastinoscopy, EBUS and positron emission tomography/computed tomography (PET/CT). (2) The results of future studies will show if TEMLA should be considered the gold standard of mediastinal nodal restaging after neoadjuvant therapy in patients with NSCLC.

Staging algorithm for diffuse malignant pleural mesothelioma

An algorithm of preoperative mediastinal nodal staging with endobronchial/endoesophageal ultrasonography (EBUS/EUS) and transcervical extended mediastinal lymphadenectomy (TEMLA) combined with laparoscopy/peritoneal lavage and cytology was analyzed to establish the realistic criteria for radical multimodality treatment of malignant pleural mesothelioma (MPM). The algorithm included computed tomography (CT), thoracoscopy with multiple pleural biopsies and talc pleurodesis, EBUS/EUS and one-stage TEMLA and laparoscopy/peritoneal lavage and cytology of the fluid. Forty-two patients were diagnosed from 1 January 2004 to 31 December 2008. There were 16 women and 26 men in ages ranging from 43 to 77 years (mean 57.8); 31 epithelioid, 2 sarcomatoid and 9 biphasic type MPM. 21/42 patients were considered possible candidates for multimodality treatment. Three patients who received neoadjuvant chemotherapy were excluded from this study. EBUS/EUS was performed to stage the mediastinal nodes. In 3/18 patients metastatic nodes were discovered. In the rest of the 15 patients simultaneous TEMLA and laparoscopy/peritoneal lavage and cytology of the fluid were performed. In three patients TEMLA was positive, in six patients laparoscopy was positive and in two patients both TEMLA and laparoscopy were positive. Finally, 4/42 (9.5%) patients underwent thoracotomy with one exploration (chest wall infiltration) and three pleuropneumonectomies with the subsequent chemo- and radiotherapy. The proposed algorithm of preoperative staging spared the majority of MPM patients from futile surgery.

Preoperative thrombocytosis in surgically treated patients with non-small cell lung cancer

Introduction Lung cancer is the most common cause of cancer‑related death. Accurate and easy‑to‑use prognostic factors are necessary. Increased platelet count might be a potential prognostic factor. Objectives We aimed to investigate the relationship between thrombocytosis and stage of lung cancer and to assess the frequency and clinical importance of thrombocytosis in this patient group. Patients and methods We retrospectively analyzed hospital records of consecutive patients with non-small cell lung cancer (NSCLC) who underwent curative‑intent pulmonary resections. Results Of 323 patients, 285 patients with NSCLC were selected (mean [SD] age, 66.55 [8.52] years; men, 63.86%). Squamous cell carcinoma was diagnosed in 130 patients (45.61%); adenocarcinoma, in 128 (44.91%); large cell carcinoma, in 16 (5.61%); and adenosquamous carcinoma, in 11 (3.86%). The prevalence of preoperative thrombocytosis in the whole sample was 10.18% (n = 29). Anemia was more common in patients with thrombocytosis compared with those without thrombocytosis (65.52% vs 30.08%; P <0.001). Thrombocytosis was found in 22.41% of patients with stage III+IV cancer and in 3.82% of those with stage I (P <0.001). Moreover, in patients with no metastases (N0, M0 according to the 7th edition of the TNM classification), thrombocytosis was more frequent in the group with stage II than in that with stage I cancer (3.85% vs 20.00%; P = 0.002). Thrombocytosis was also more frequent in patients with N2 than with N1 disease (9.76% vs 23.81%; P = 0.09). Conclusions Thrombocytosis is often observed in patients with NSCLC and is significantly associated with the higher stage of disease.