Lawrence Okiror

The Prognostic Significance of Maximum Standardized Uptake Value of Primary Tumor in Surgically Treated Non–Small-Cell Lung Cancer Patients: Analysis of 413 Cases

BACKGROUND Integrated PET/CT is widely used in the preoperative staging and prognostic assessment of non-small-cell lung cancer (NSCLC) patients. The aims of this study were to evaluate the prognostic significance of SUVmax of primary tumor in patients undergoing surgical treatment and, in order to minimize technical interferences, to verify whether SUVmax standardized by SUVmax liver or SUVmax blood pool provided additional prognostic information. PATIENTS AND METHODS A retrospective study of 413 consecutive NSCLC patients undergoing potentially curative surgical resection after PET/CT obtained in the same PET center over a 6-year period. The SUVmax was calculated drawing region of interest around the primitive tumor, the liver, and the aortic arch in PET images. The same procedure was performed for 2 adjacent planes and the average of these measures was considered. RESULTS Nine patients were considered 30-day postoperative deaths and were excluded from the analysis. At the end of the study, 312 (77.2%) of the 404 patients were alive (median follow-up, 26 months) and 92 had died (median survival, 17 months). At multivariate analysis tumor-node-metastasis stage, primary tumor grading and primary tumor SUVmax (T-SUVmax) were found to be independent prognostic factors, while T-SUVmax/SUVmax blood pool ratio, and T-SUVmax/SUVmax liver ratio were not. CONCLUSIONS T-SUVmax is an independent predictor for survival in NSCLC patients undergoing surgery and might be helpful in guiding adjuvant treatment strategies. SUVmax of primary tumor normalized by SUV blood pool or SUV liver does not provide additional prognostic information.

Patterns of disease progression on 18F-fluorodeoxyglucose positron emission tomography-computed tomography in patients with malignant pleural mesothelioma undergoing multimodality therapy with pleurectomy/ decortication

IntroductionThe aim of this study was to evaluate the patterns of disease progression in patients treated with pleurectomy/decortication (P/D), hyperthermic pleural lavage with povidone-iodine, prophylactic radiotherapy and adjuvant chemotherapy, using 18F-fluorodeoxyglucose (18F-FDG) PET/computed tomography (PET/CT). Materials and methodsThis was a retrospective study of 65 patients treated with a multimodality therapy including P/D between October 2004 and March 2012. Thirty-two patients underwent 18F-FDG PET/CT within 6 weeks of completion of adjuvant chemotherapy and 6-monthly thereafter at our institution. The first site of relapse on 18F-FDG PET/CT was recorded, and all scans were reviewed by an independent observer. ResultsThirty-two patients (27 male, median age 61 years, range 45–73) underwent their 18F-FDG PET/CT scans at our institution. Eighteen of the 32 patients were alive at last follow-up (median follow-up 42 months, range 16–76). Nine patients were alive with disease recurrence. Fourteen patients died of disease progression (median survival 24.7 months, range 15–38). The median maximum standardized uptake value (SUVmax) in relapsing mesothelioma was 10.9 (range 4.9–27.3). There was a statistically significant correlation between the SUVmax and tumour lesion glycolysis of recurrent mesothelioma and overall survival (P=0.05). The site of disease recurrence was the pleura in the majority of the alive patients and was extrapleural in the dead patients. There was a statistically significant correlation between disease-free survival and complete macroscopic resection (P=0.02). ConclusionAfter P/D with hyperthermic pleural lavage with povidone-iodine, prophylactic radiotherapy and adjuvant chemotherapy, the most frequent site of recurrence is the pleural cavity. Peritoneal seeding is rare. The tumour SUVmax and tumour lesion glycolysis correlate significantly with overall survival.

Predicting risk of intensive care unit admission after resection for non-small cell lung cancer: a validation study

A model for predicting the risk of emergency, unplanned intensive care unit (ICU) admission after lung resection for lung cancer has been reported. However, it has not been validated outside of the derivation cohort, and the aim of our study was to undertake external validation at our institution. We reviewed a series of consecutive patients who underwent major lung resection for non-small cell lung cancer over a 6-year period. Test performance was evaluated by area under the receiver operator characteristic (ROC) curve. Between 2003 and 2008, 425 patients underwent major lung resections for lung cancer. The mean age (SD) was 65 (10) years and 241 (57%) were men. A total of 77 (18%) patients were admitted to ICU, 47 for elective admission and 30 (7%) for treatment of post-procedure complications. Of the 30 patients admitted for complications, the median length of ICU (interquartile range) stay was 3 days (1-15 days). The mortality rate among these patients was 17%. The area under the ROC curve was 0.66 (95% CI 0.53-0.79). The Brunelli scoring system had moderate discriminating ability to predict the risk of ICU admission after lung resection in our institution.

Survival following Pulmonary Metastasectomy for Sarcoma.

OBJECTIVES The aim of this study is to report the overall survival after pulmonary metastasectomy in patients with metastatic sarcoma and prognostic factors for survival. METHODS This is a retrospective observational study of consecutive patients having pulmonary metastasectomy for sarcoma over a 5-year period. Survival was calculated by Kaplan-Meier method. RESULTS Between August 2007 and January 2014, a total of 80 pulmonary metastasectomies were performed on 66 patients with metastatic sarcoma. There were no postoperative in-hospital deaths. The median age was 51 years (range, 16-79) and 39 (59%) patients were male. Fourteen patients had bilateral lung operations and surgical access was by video-assisted thoracoscopic surgery in 48 (73%) cases. The median number of metastases resected was 3 (range, 1-9). The median disease-free interval was 25 months (range, 0-156). Median overall survival was 25.5 months (range, 1-60). At follow-up, 19 patients (29%) were dead with a median follow-up of 31 months (range, 1-60). Recurrence of metastases significantly affected survival: median of 25.5 months (95% confidence interval [CI], 17.7-33.4) versus 48.4 months (95% CI, 42.5-54.4) in patients with no recurrent metastases (p = 0.004). There was no significant difference in survival between patients with high-grade versus low-grade tumors (p = 0.13), histological type (osteosarcoma vs. other soft tissue sarcoma types, p = 0.14), unilateral versus bilateral lung metastases (p = 0.48), or lung metastases alone versus lung and other sites of metastases (p = 0.5). CONCLUSION In selected patients, pulmonary metastasectomy for sarcoma is safe and may confer a good medium-term survival. Recurrent metastasis after resection confers a poor prognosis.

Evaluation of integrated positron emission tomography and computed tomography accuracy in detecting lymph node metastasis in patients with adenocarcinoma vs squamous cell carcinoma

OBJECTIVES The aim of our study was to analyze the specificity and sensitivity of integrated positron emission tomography and computed tomography (PET/CT) in detecting nodal metastasis according to histology (adenocarcinoma vs squamous cell carcinoma), and to identify the factors related to false-negative findings. METHODS A retrospective, single-institution review of 353 consecutive patients with suspected or pathologically proven, potentially resectable non-small-cell lung cancer (NSCLC) who had integrated PET/CT scanning at the same centre. Lymph node staging was pathologically confirmed on tissue specimens obtained at mediastinoscopy and/or thoracotomy. Statistical evaluation of PET/CT results was performed on a per-patient and per-nodal-station basis. RESULTS A total of 2286 nodal stations (1643 mediastinal, 333 hilar and 310 intrapulmonary) were evaluated. Adenocarcinoma was the final diagnosis in 244 patients and squamous carcinoma in 109 patients. Nodes were positive for malignancy in 80 (32.8%) of 244 patients with adenocarcinoma (N1 = 31; N2 = 48 and N3 = 1) and in 32 (29.3%) of 109 with squamous carcinoma (N1 = 21 and N2 = 11). PET/CT in the adenocarcinoma group had a sensitivity, specificity and accuracy of 53.8, 91.5 and 79.1%, and in the squamous cell group, of 87.5, 81.8 and 83.5%, respectively in a per-patient analysis. In the analysis for N2 disease on a per-patient basis, the sensitivity, specificity and accuracy were 38.8, 97.4, and 85.7% for the adenocarcinoma group and 81.8, 91.8 and 90.8% in the squamous cell group. In the adenocarcinoma group, the mean diameter of false-negative lymph nodes was 7 mm (standard deviation [SD] ± 2.5 mm) compared with the diameter of true-positive lymph nodes of 12.5 (SD ± 4 mm; P < 0.00001). In the squamous cell group, the mean diameter of false-negative lymph nodes was 7.4 mm (SD ± 2.8 mm) compared with the diameter of true-positive lymph nodes of 14.7 (SD ± 6 mm; P < 0.005). In the adenocarcinoma group, false-negative lymph nodes were statistically correlated with the presence of vascular invasion and in the squamous cell group only with the maximum standardized uptake value (SUV(max)) < 5.4. CONCLUSIONS The sensitivity of PET/CT in detecting nodal metastasis in patients with adenocarcinoma is too low to avoid any further invasive staging procedure. Ultrasound-guided needle biopsy or mediastinoscopy is still necessary in staging patients undergoing lung resection for adenocarcinoma.

Bronchoscopic Management of Patients With Symptomatic Airway Stenosis and Prognostic Factors for Survival

BACKGROUND Interventional bronchoscopy is effective in the management of patients with symptomatic airway obstruction for both malignant and benign conditions. The main aim of this study is to report our experience with emergency interventional bronchoscopy in patients with symptomatic airway obstruction and identify prognostic factors for survival. METHODS This is a retrospective observational study of patients undergoing emergency interventional bronchoscopy over a 4-year period. Survival times were analyzed separately for patients with benign and malignant airway obstruction by the Kaplan-Meier method. RESULTS Between June 2009 and July 2013, 168 emergency interventional bronchoscopies were performed in 112 patients for airway obstruction. The median age was 63 years (range, 20 to 86), and 91 patients (54%) patients were female. Seventy-two cases (43%) had airway obstruction due to malignant disease. There were 3 in-hospital deaths (2.7%). Median survival of the study population was 5.6 months (range, 0 to 51) with a median follow-up of 7.3 months (range, 0 to 51). Median survival for patients with malignant airway obstruction was 3.5 months (range, 0 to 21), and 9.8 months (range, 0.1 to 51) for those with benign disease. Airway intervention facilitated palliative chemotherapy in 32 patients (44%) of those with malignant airway obstruction. At multivariate analysis in patients with malignant airway obstruction, presence of stridor (hazard ratio 1.919, 95% confidence interval: 1.082 to 3.404, p = 0.026) and not receiving postprocedure chemotherapy (hazard ratio 2.05, 95% confidence interval: 1.156 to 3.636, p = 0.014) were independent prognostic factors for death. CONCLUSIONS Emergency interventional bronchoscopy for airway obstruction is safe, relieved symptoms, and facilitated palliative chemotherapy, which improved survival.

Recurrent pleural effusion in yellow nail syndrome successfully treated with video-assisted thoracic surgery: comparison of two surgical strategies in two cases

Pleural effusions as part of the yellow nail syndrome (YNS) can often be recurrent, requiring multiple thoracocentesis. The optimal surgical treatment of such recurrent effusions remains unclear and various methods including thoracoscopic pleurodesis, pleuroperitioneal shunts and pleurectomy have been described. We report two cases of recurrent pleural effusions in YNS, the first case with bilateral effusions and the second with right-sided effusions treated 2 months apart from bilateral long-term tunnelled catheters and thoracoscopic pleurectomy and compare the results of the two treatment strategies.

What is the optimum strategy for thromboembolic prophylaxis following extrapleural pneumonectomy in patients with malignant pleural mesothelioma

Malignant pleural mesothelioma (MPM) increases the risk of venous thromboembolic (VTE) events. This risk is higher following extrapleural pneumonectomy (EPP) as part of trimodality therapy, where VTE can be catastrophic. In our series, the impact of warfarin in preventing a pulmonary embolus (PE) after neoadjuvant chemotherapy and EPP for MPM was analysed. A retrospective analysis of 21 consecutive patients undergoing EPP for MPM was conducted. The first 10 patients (Group A) had VTE prophylaxis by subcutaneous enoxaparin and compression stockings commenced a day prior to surgery, intraoperative pneumatic calf compression and early post-operative mobilization. Enoxaparin was continued for 30 days postoperatively. The following 11 patients (Group B) had the same VTE prophylaxis, together with warfarin, started prior to hospital discharge and continued for 6 months postoperatively. All patients had a computed tomography pulmonary angiogram within 8 weeks after surgery and a full examination at 1, 3, 6 and 12 months. Both groups were comparable for characteristics. Three patients in Group A suffered a PE at 4, 6 and 16 weeks postoperatively. One PE was fatal. No patient in Group B suffered VTE (P = 0.05, χ(2) test) or haemorrhagic complications. Warfarin anticoagulation following EPP is feasible and safe, and is associated with a significant reduction in VTE complications.

Does Previous Surgical Training Impact the Learning Curve in Video-Assisted Thoracic Surgery Lobectomy for Trainees?

Background To analyze if the number of open lung resections performed by trainees before starting video-assisted thoracic surgery (VATS) lobectomy training program has any impact on intraoperative and postoperative outcomes. Materials and Methods Retrospective analysis of 46 consecutive patients who underwent VATS lobectomies between December 2011 and September 2012 by two trainees (A.B. and L.O.). The previous surgical experience of the two trainees was evaluated to assess for any difference in terms of learning curve. Group A comprised 25 VATS lobectomies performed by one trainee (A.B.) and group B comprised 21 VATS lobectomies performed by the other trainee (L.O.). Results There was no statistical difference in terms of operating time and intraoperative bleeding between the two groups (p = 0.16 and p = 0.6). The conversion rate was 8% (2 out of 25 cases) in group A and 23.8% (5 out of 21 cases) in group B (p = 0.002). Evaluation of vascular injury showed no difference in the conversion rate (p = 0.56). The median length of the drainage and of hospital stay were 4 days and 7 days in group A and 4 days and 8 days in group B, respectively (p = 0.36 and p = 0.24). The complication rate was 44% in group A and 47.6% in group B (p = 0.52). A.B. had performed 139 and L.O. 70 operations as first operator before starting their VATS lobectomy training; the surgical experience had an impact only on the conversion rate. Conclusion Our study showed that a training program in VATS lobectomy is feasible, and previous surgical training has a minimal impact on intraoperative and postoperative outcomes.

Thoracotomy and decortication: impact of culture-positive empyema on the outcome of surgery

OBJECTIVES This study aimed to assess the efficacy of thoracotomy and decortication (T/D) in achieving lung re-expansion in patients with Stage III empyema and assess the impact of culture-positive empyema on the outcome of decortication. METHODS This is a retrospective observational study of consecutive patients treated with T/D over a 6-year period. RESULTS A total of 107 consecutive patients were identified. The median age was 55 (range 16-86) years; of which, 86% were male. The median length of hospital stay was 9 (range 2-45) days. Full lung re-expansion was achieved in 86% of cases. There were no postoperative deaths. Pleural cultures were positive in 56 (52%) cases. Patients with culture-positive empyema had a longer duration of pleural drainage (median of 11 days, range 3-112 versus median of 5 days, range 3-29 days for negative culture; P = 0.0004), longer length of hospital stay (median of 11 days, range 4-45 versus median of 7 days, range 2-34 days; P = 0.0002) and more complications (P = 0.0008), respectively. There was no statistically significant difference in the outcome of surgery, i.e. lung re-expansion versus trapped lung (P = 0.08) between the two groups. CONCLUSIONS T/D is safe and achieved lung re-expansion in the majority of patients. Culture-positive empyema was associated with worse outcomes.