Naveed Z. Alam

Video-assisted thoracic surgery lobectomy (VATS), open thoracotomy, and the robot for lung cancer.

Video-assisted thoracic surgery (VATS) lobectomy provides a minimally invasive approach for the management of early-stage lung cancer. Questions about the safety of VATS lobectomy and its adequacy as a cancer operation compared with open thoracotomy have hindered its universal acceptance among thoracic surgeons. Evidence suggests that VATS lobectomy can be safely performed and is an adequate cancer operation for early-stage non-small cell lung cancer. However, adequately powered well-balanced studies comparing VATS with open thoracotomy for lobectomy are lacking in the literature.

Imaging in the diagnosis and treatment of non‐small cell lung cancer

Abstract:  The available tools for diagnosing and staging lung cancer patients can be broadly categorized into non‐invasive, minimally invasive and invasive (surgical) modalities. Non‐invasive modalities include CT and PET. Minimally invasive modalities are endoscopic approaches, including endoscopic ultrasound, endobronchial ultrasound and transbronchial fine needle aspiration without ultrasound guidance. This review focuses on the non‐invasive and minimally invasive techniques involving imaging. Application of Bayesian principles indicates that tests with a high sensitivity and specificity for detection of both systemic metastases and mediastinal nodal involvement are required for treatment selection and planning in patients with non‐small cell lung cancer who would be considered for treatment with curative intent. Combined PET/CT using the glucose analogue fluorine‐18 fluorodeoxyglucose currently provides the best diagnostic performance for this purpose and should now be considered the standard of care for staging non‐small cell lung cancer. Endoscopic ultrasound and endobronchial ultrasound have important complementary roles to allow further evaluation of equivocal nodal abnormalities on PET or CT and to allow pathological samples to be obtained. Diagnostic CT has an important role in defining tumour relations for patients deemed suitable for surgical resection and as the initial investigation for patients with potential symptoms of lung cancer or proven lung cancer that would not be considered for curative treatment on medical grounds.

Prevalence, morphology, and natural history of FGFR1-amplified lung cancer, including squamous cell carcinoma, detected by FISH and SISH.

The aim of this study was to investigate the prevalence of fibroblast growth factor receptor 1 (FGFR1) amplification by fluorescence in situ hybridization (FISH) in a lung cancer patient cohort and to correlate results with morphology, silver in situ hybridization (SISH), and patient outcome. FGFR1 FISH and SISH were performed in 406 and 385 lung cancer cases, respectively, and the results were compared. High-level FGFR1 amplification was defined as the ratio of FGFR1/centromere 8 ≥2, or tumor cell percentage with ≥15 signals ≥10%, or average number of signals/tumor cell nucleus ≥6. Low-level amplification was defined as tumor cell percentage with ≥5 signals ≥50%. Of 406 tumors tested, there were 191 squamous cell carcinomas, 28 carcinomas with focal squamous morphology, 24 large cell carcinomas with squamous immunoprofile, 115 adenocarcinomas, 17 neuroendocrine tumors, and 31 carcinomas without squamous morphology or immunoprofile. FGFR1 FISH was assessable in 368 tumors, with FGFR1 amplification identified in 50, including 48 tumors with either squamous morphology or immunoprofile (48 of 225, 21.3%), and two ‘marker-null’ tumors without squamous or glandular morphology or immunoprofile (2 of 143, 1.4%; P<0.0001). FGFR1 SISH was assessable in 347 tumors. All 46 FGFR1 FISH-amplified tumors with tumor available for testing showed amplification with SISH, while all other tumors were negative. There was no relationship between FGFR1 amplification status and disease-free (P=0.88, HR=1.04, 95% confidence interval (CI)=0.67–1.60) or overall survival (P=0.97, HR=1.01, 95% CI=0.65–1.58) in surgically radically treated patients with tumors with any squamous morphology or immunoprofile. FGFR1 amplification is a common abnormality in tumors with any squamous morphology or immunoprofile, but it is also present in ‘marker-null’ tumors. The results of FGFR1 SISH showed 1:1 correlation with the results of FGFR1 FISH, indicating that SISH may be an alternative method to detect FGFR1 amplification. No relationship was detected between patient outcome and FGFR1 amplification.

Sex and SUVmax: sex-dependent prognostication in early non-small cell lung cancer.

The identification of robust prognostic factors for patients with early-stage non–small cell lung cancer (NSCLC) is clinically important. The International Association for the Study of Lung Cancer has identified both sex and the maximum standardized uptake value (SUVmax) of 18F-FDG in the primary tumor as measured by PET as potential prognostic variables. We examined the prognostic value of SUVmax in a surgical cohort of patients with NSCLC and disaggregated the findings by sex. Methods: Patients who had undergone a preoperative PET/CT scan and surgical resection with curative intent from 2001 to 2009 were identified from a prospective database. An SUVmax cutoff was calculated using receiver-operating-characteristic curves. Overall survival was correlated with SUVmax for the whole cohort and disaggregated by sex. Results: Inclusion criteria were met by 189 patients: 127 (67%) men and 62 (33%) women. Five-year survival was 54.6% for the whole cohort, 47.7% for men, and 68.2% for women. SUVmax correlated negatively with survival in a univariate analysis for the whole cohort (hazard ratio [HR], 2.51; 95% confidence interval [CI], 1.54–4.09; P < 0.001) and men (HR, 3.42; 95% CI, 1.94–6.05; P < 0.001) but not for women (HR, 1.61; 95% CI, 0.43–3.12; P = 0.77), using 8 as a cutoff. In multivariate analysis, SUVmax correlated with overall survival for the whole cohort (HR, 1.70; 95% CI, 1.05–2.99; P = 0.05) and men (HR, 2.40; 95% CI, 1.32–4.37; P = 0.004) but not for women (HR, 0.80; 95% CI, 0.15–4.47; P = 0.80). Conclusion: SUVmax independently predicted overall survival for men but not for women in this surgical cohort. Our results suggest that SUVmax is an independent prognostic variable in men with surgically treated early NSCLC.

Lung Resection in Patients with Marginal Pulmonary Function

The advent of MIS or VATS techniques, better perioperative anesthesia management, and better postoperative care enables thoracic surgeons to operate on marginal patients, with less risk than previously established. Careful preoperative decision making in a multidisciplinary setting should insure that all patients are given the best potential curative option.

Dieulafoy's disease of the bronchus: a rare cause of massive hemoptysis.

We present the case of a 30‐year‐old non‐smoker who presented with unexplained, massive hemoptysis and was diagnosed with a rare vascular malformation.

Decision Making and Algorithm for the Management of Pleural Effusions

Pleural effusions can be catagorised in to transudative effusions or exudative effusions. Causes include cardiovascular disease, infection and neoplasm. Diagnosis is the key to determining what management is required. History and examination can elicit the cause of the effusion and radiological investigations can be a useful adjunct. Thoracocentesis and laboratory testing of the pleural fluid is usually diagnostic and can direct further investigations or treatment. Management of the pleural effusion ultimately varies according to the diagnosis but can be either directed towards reversing the cause of the effusion or treating the symptoms that arise as a result of the effusion.

Impact of sex on prognostic host factors in surgical patients with lung cancer

Lung cancer has markedly poorer survival in men. Recognized important prognostic factors are divided into host, tumour and environmental factors. Traditional staging systems that use only tumour factors to predict prognosis are of limited accuracy. By examining sex‐based patterns of disease‐specific survival in non‐small cell lung cancer patients, we determined the effect of sex on the prognostic value of additional host factors.

Malignant Pleural Mesothelioma: Patient Selection for Pleurectomy

Although primary pleural tumors had been reported since the eighteenth century, the epidemiology of mesothelioma first came to light in 1960 with the report by Wagner and colleagues of 33 asbestos mine workers from South Africa who developed mesothelioma.1 Malignant pleural mesothelioma (MPM) is a rare tumor. Although the geographical distribution of the disease is diverse, taken as a whole the United States has an incidence just under 1 per 100,000.2 The incidence has been rising since the 1970s. The male to female ratio is 5:1 which is likely due to the occupational exposure of asbestos.

Pulmonary metastasectomy: analysis of survival and prognostic factors in 243 patients: Pulmonary metastasectomy

Pulmonary metastases are a sign of advanced malignant disease. Interdisciplinary management of metastatic cancer mandates the consideration of all treatment options, and in selected patients pulmonary metastasectomy can be performed with curative intent. This study aims to analyze the prognostic factors associated with survival and optimize the selection of surgical candidates. The sarcoma subset analysis aims to examine the role of multiple repeat resections for pulmonary metastatic recurrence.