Maria Elena Cufari

Increasing frequency of non-smoking lung cancer: Presentation of patients with early disease to a tertiary institution in the UK

BACKGROUND Never-smokers with lung cancer often present late as there are no established aetiological risk factors. The aim of the study is to define the frequency over time and characterise clinical features of never-smokers presenting sufficiently early to determine if it is possible to identify patients at risk. METHODS We retrospectively analysed data from a prospectively collected database of patients who underwent surgery. The frequency was defined as number of never-smokers versus current and ex-smokers by year. Clinical features at presentation were collated as frequency. RESULTS A total of 2170 patients underwent resection for lung cancer from March 2008 to November 2014. The annual frequency of developing lung cancer in never-smokers increased from 13% to 28%, attributable to an absolute increase in numbers and not simply a change in the ratio of never-smokers to current and ex-smokers. A total of 436 (20%) patients were never-smokers. The mean age was 60 (16 SD) years and 67% were female. Presenting features were non-specific consisting of cough in 34%, chest infections in 18% and haemoptysis in 11%. A total of 14% were detected on incidental chest film, 30% on computed tomography, 7% on positron-emission tomography/computed tomography and 1% on MRI. CONCLUSIONS We observed more than a double of the annual frequency of never-smokers in the last 7 years. Patients present with non-specific symptoms and majority were detected on incidental imaging, a modality that is likely to play an increasingly important role for early detection in this cohort that does not have any observable clinical risk factors.

Beware of arteria lusoria during lymph node dissection of the right paratracheal fossa for lung cancer surgery

An asymptomatic elderly woman presented with a solitary right upper lobe mass revealed to be non-small cell lung cancer following routine surveillance post mastectomy. Upon review of CT with contrast in preparation for rigid bronchoscopy and right upper lobectomy, we noticed that the patient had a rare case of arteria lusoria. This is the presence of an aberrant right subclavian artery extending from the left side of the aortic arch, crossing posteriorly across the midline to supply the upper limb. We suggest that with a documented 100% diagnostic sensitivity on 64 multislice computed tomography, the presence of arteria lusoria within the posterior paratracheal fossa may cause life-threatening complications in the unaware during systematic lymph node dissection for non-small cell lung cancer (NSCLC).

Selection for adjuvant chemotherapy in completely resected stage I non-small cell lung cancer: external validation of a Chinese prognostic risk model

BACKGROUND The ability to sub-stratify survival within stage I is an important consideration as it is assumed that survival is heterogeneous within this sub-group. Liang et al. recently published a nomogram to predict post-operative survival in patients undergoing lung cancer surgery. The aim of our study is external validation of their published nomogram in a British cohort focusing on stages IA and IB to determine applicability in selection of adjuvant chemotherapy within stage I. METHODS Patient variables were extracted and the score individually calculated. Receiver operative characteristics curve (ROC) was calculated and compared with the original derivation cohort and the discriminatory ability was further quantified using survival plots by splitting our (external) validation cohort into three tertiles and Kaplan Meier plots were constructed and individual curves tested using Cox regression analysis on Stata 13 and R 3.1.2 respectively. RESULTS A total of 1,238 patients were included for analysis. For all patients from stage IA to IIB the mean (SD) score was 9.95 (4.2). The ROC score comparing patients who died versus those that remained alive was 0.62 (95% CI: 0.58 to 0.67). When divided into prognostic score tertiles, survival discrimination remained evident for the entire cohort, as well as those for stage IA and IB alone. The P value comparing survival between the middle and highest score with baseline (low score) was P=0.031 and P=0.034 respectively. CONCLUSIONS Our results of external validation suggested lower survival discrimination than reported by the original group; however discrimination between survival remained evident for stage I.

eComment. The ways to increase the effectivity of pleurodesis

lower recurrence rate in comparison with TT talc pleurodesis. Aihara et al. [3] studied the efficacy and safety of blood and TT talc pleurodesis for SSP in 34 patients with interstitial lung disease. Air leakage ceased in 16 of 22 (72.7%) episodes after blood pleurodesis and in 11 of 14 (78.6%) episodes after talc pleurodesis. No harmful events were associated with either procedures, but the median survival after an attack of pneumothorax was 9 months; hence, no long-term follow-up period was available. Ng et al. [4] conducted a retrospective analysis on SSP patients who underwent minocycline pleurodesis (n = 121) versus talc slurry (n = 64). Both groups had a comparable sclerosing efficacy in SSP, with immediate success rates of 71.9 and 78.1%, respectively (P = 0.31). Pain was experienced in 44.6 and 37.5%, respectively, with more common in patients receiving high doses of talc (≥5 g; P = 0.03). Respiratory distress was found in 1.7 and 1.6%, respectively. There was no long-term follow-up recorded. The authors concluded that both agents appeared to be effective and safe for chemical pleurodesis in SSP, but were associated with a slightly high failure rate. Adewole et al. [5] treated 20 SSP out of 41 spontaneous pneumothorax patients by VATS talc pleurodesis over a 2-year period. Immediate success was observed in 18 of 20 patients (90%). The mean postoperative hospital stay was 3 ± 3.2 days. There was no associated significant morbidity or in-hospital mortality. Follow-up period was 24 months. Pneumothorax recurred in 3/20 (15%) of patients during the follow-up period and all were treated successfully by repeated VATS talcage. The authors concluded that the study confirms the short-term andmedium-term effectiveness of VATS talc pleurodesis. Pletinckx et al. [6] reported 5 SSP patients out of 20 pneumothorax patients who underwent VATS talc pleurodesis over a 5-year period. Immediate success of talcage was 100%. There were no major complications or in-hospital mortality. The mean follow-up period was 22.7 months. No cases of recurrence were recorded during this follow-up period. The authors concluded that thoracoscopic talc pleurodesis was safe and efficient in their experience. Noppen et al. [7] studied 20 patients with SSP who had a VATS talc pleurodesis over a 25-month period. Prolonged air leak was observed in 26% of patients, but all air leaks ceased during the hospital stay period. The median hospital stay was 4.7 (±2) days. No major postoperative complications or in-hospital mortality was recorded. The recurrence rate was 8.7% during a mean follow-up period of 18 months. The authors concluded that thoracoscopic talcage is efficient and safe in achieving pleurodesis in persistent spontaneous pneumothorax. The BTS guidelines in 2010 [8] for the management of spontaneous pneumothorax suggest that chemical pleurodesis via TT for recurrent spontaneous pneumothorax should be reserved for frail patients as it is associated with a higher recurrence rate when compared with VATS pleurodesis although there are no available comparative studies.