Faculty Bibliography

OBJECTIVE: The treatment of non-small cell lung cancer depends on the stage, and this is clinically best determined by using fluorodeoxyglucose-positron emission tomography/computed tomography. We evaluated the effect smoking has on the accuracy of this test. METHODS: We performed a prospective cohort study evaluating the accuracy of clinical stage compared with pathologic stage between cigarette smokers and nonsmokers with non-small cell lung cancer. All patients were assigned a clinical TNM stage after fluorodeoxyglucose-positron emission tomographic/computed tomographic scanning and then underwent meticulously pathologic TNM staging. If N2, N3, or M1 negative, patients underwent thoracotomy with complete thoracic lymphadenectomy. The clinical and pathologic stages were compared. RESULTS: There were 246 patients: 52 never smoked (NS group), 112 quit at least 1 month before fluorodeoxyglucose-positron emission tomography/computed tomography (Q group), and 82 were still smokers (S group). The 3 groups were similar for stage and histology. The overall accuracy was 83%, 80%, and 64% for the NS, Q, and S groups, respectively (P = .03). The accuracy for the T status was 88%, 84%, and 86%; accuracy for the N2 lymph nodes was 96%, 75%, and 72%; and accuracy for the N1 lymph nodes was 92%, 78%, and 80%, respectively, favoring the NS group. The greater the pack-year history, the greater the N2 inaccuracy (P = .04). Multivariate analysis showed that status of smoking (P = .026) and maxSUV value (P = .014) were independent predictors of fluorodeoxyglucose-positron emission tomography/computed tomography accuracy. CONCLUSIONS: Patients with non-small cell lung cancer who continue to smoke at the time of their fluorodeoxyglucose-positron emission tomographic/computed tomographic scan have less accurate clinical staging compared with those who stopped 1 month before or who never smoked. As the pack-years increase, the accuracy for the N2 nodes decrease. Nonsmokers have the most accurate clinical staging.

BACKGROUND: Despite normal mediastinal (N2) lymph nodes shown on positron emission tomography (PET) and CT, some physicians routinely perform mediastinoscopy and/or endoscopic ultrasound fine-needle aspiration (EUS-FNA) in patients with non-small cell lung cancer (NSCLC). METHODS: A prospective trial on patients with NSCLC who were clinically staged N2 negative by both integrated PET/CT and CT scan. All underwent mediastinoscopy and EUS-FNA and if N2 negative underwent thoracotomy with thoracic lymphadenectomy. RESULTS: There were 153 patients (107 men). Of these, 136 patients were clinically staged N0 and 17 patients were clinically staged N1. Of the 136 patients who were staged as N0, 5 patients (3.7%) had positive EUS-FNA results (three in the subcarinal node), and 4 patients (2.9%) had positive mediastinoscopy results (all in the #4R node; one was N3). Six of the remaining 127 patients (4.7%) had N2 disease after resection. Seventeen patients were clinically staged as N1 by integrated PET/CT. Four patients (23.5%) had positive EUS-FNA results (two in the subcarinal node), 3 patients (17.6%) had positive mediastinoscopy results (all in #4R node; two were N2 and one was N3), and none of the remaining 10 patients had N2 disease after resection. Patients with unsuspected N2 disease were twice as likely (relative risk, 2.1; 95% confidence interval, 1.24 to 2.51; p = 0.02) to have a maximum standardized uptake value (maxSUV) > 10 and poorly differentiated cancer (relative risk, 2.1; 95% confidence interval, 1.14 to 2.38; p = 0.03). CONCLUSION: We do not recommend routine mediastinoscopy or EUS-FNA in patients who are clinically staged as N0 after both integrated PET/CT and CT. However, these procedures should both be considered in patients clinically staged as N1 after PET/CT, and/or in those with adenocarcinoma, upper-lobe tumors, or tumors with a maxSUV > or = 10.

OBJECTIVE: Bronchogenic malignancy is the number one cause of cancer deaths in both men and women worldwide. National registry-based studies have shown gender disparity in clinicopathologic characteristics and in survival. This study evaluates the risk factors and trends of lung cancer between genders. METHODS: A prospective cohort of consecutive patients with non-small cell lung cancer (NSCLC) who were carefully clinically (all underwent dedicated positron emission tomography scans) and pathologically staged with stage I, II, or III disease underwent homogenous treatment algorithms and were followed up over a period of 7 years. Primary outcomes were 5-year survival and response to neoadjuvant therapy. RESULTS: There were 1,085 patients (671 men and 414 women). Groups were similar for race, pulmonary function, smoking history, comorbidities, neoadjuvant therapy, histology, and resection rates. Women were younger (p = 0.014), had a higher incidence of adenocarcinoma (p = 0.01), and presented at an earlier pathologic stage (p = 0.01) than men. The overall age-adjusted and stage-adjusted 5-year survival rate favored women (60% vs 50%, respectively; p < 0.001). Women had better stage-specific 5-year survival rates (stage I disease, 69% vs 64%, respectively [p = 0.034]; stage II disease, 60% vs 50%, respectively [p = 0.042]; and stage III disease, 46% vs 37%, respectively [p = 0.024]). Women who received neoadjuvant chemotherapy alone (n = 76) were more likely to be a complete or partial responder than men (n = 142; p = 0.025). CONCLUSIONS: Despite uniform staging and treatment, the 5-year survival rate of women with stage I to III NSCLC was better than men overall and at each stage. Women are more likely to have adenocarcinoma, to present with earlier stage disease, and to be younger. Interestingly, women respond better to neoadjuvant chemotherapy.

BACKGROUND: Treatment of non-small cell lung cancer depends on stage. Patients with T4 lesions represent a heterogeneous group. METHODS: A case-control study of patients with pathologically proven, node-negative T4 lesions (T4 N0 M0) was conducted. Patients with T4 disease were stratified as T4 from a satellite nodule (T4-satellite) or T4 from local invasion (T4-invasion). T4-satellite patients were matched 1:4 for sex and histology with resected control patients with stage IA, IB, and IIA non-small cell lung cancer and matched 1:3 with stage II non-small cell lung cancer. Survival and the maximal standardized uptake value on F-18 fluorodeoxyglucose-positron emission tomography scans were compared. RESULTS: There were 337 patients, 26 patients with T4-satellite lesions, 25 with T4-invasion lesions, and 286 controls (104 patients with T1 N0 M0, 104 with T2 N0 M0, and 78 with T1 N1 M0 or T2 N1 M0 lesions). The two T4 groups were similar for age, race, sex, and neoadjuvant therapy rates. The 5-year survival was 80% for the T1 N0 M0 patients, 68% for T2 N0 M0, 57% for T4-satellite N0 M0, 45% for T1 N1 M0 or T2 N1 M0, and 30% for the T4-invasion N0 M0 patients (p = 0.016). Multivariate analysis showed that only the type of T4 impacted survival (p = 0.011). The median maximal standardized uptake values of the cancers were 4.2 for T1 N0 M0, 4.8 for T4-satellite, 5.4 for T2 N0 M0, 7.8 for T1 N1 M0 or T2 N1 M0, and 8.8 for the T4-invasion patients. CONCLUSIONS: Larger studies are needed; however, patients with T4-satellite non-small cell lung cancer who undergo complete resection have survival and maximal standardized uptake values similar to patients with stage IB and stage IIA lesions. Their survival is significantly better than those with T4-invasion. Patients with T4-satellite N0 M0 lesions should not be classified as stage IIIB and should not be grouped with patients with T4-invasion, and resection should be considered.

BACKGROUND: Positron emission tomography (PET) is often used for an indeterminate pulmonary nodule. METHODS: This is a prospective study on a consecutive series of patients who had an indeterminate pulmonary nodule that was 2.5 cm or less, underwent integrated positron emission tomography using fluorodeoxyglucose-PET/computed tomographic [FDG-PET/CT] scan with the maximum standardized uptake values (maxSUVs) reported, and who underwent complete resection. RESULTS: There were 585 patients (401 men). A total of 496 patients had a malignant nodule and the median maxSUV was 8.5 (range, 0 to 36). Eighty-nine patients had a benign nodule and the median maxSUV was 4.9 (range, 0 to 28, p < 0.001). If the maxSUV was between 0 and 2.5 there was a 24% chance the nodule was malignant, if between 2.6 and 4.0 it was 80%, and if 4.1 or greater it was 96%. False negative FDG-PET/CT was from bronchoalveolar carcinoma in 11 patients, carcinoid in 4, and renal cell in 2. False positives included fungal infections in 16 patients. Nodal involvement, whether malignant or infectious, was more likely with a pulmonary mass that had a higher maxSUV (8.4 vs 3.8 for nonmalignant lesions, 9.8 vs 4.5 for malignant lesions). CONCLUSIONS: Although integrated FDG-PET/CT is a valuable study for an indeterminate pulmonary nodule, one must be aware of causes of false positives and negatives. There is a 24% chance a suspicious nodule that has a maxSUV of 0 to 2.5 is cancer. The higher the maxSUV of the primary mass the more likely the nodes are to be involved with either malignancy or infection, and this may help direct nodal biopsy instead of pulmonary resection.

BACKGROUND: Patients with recurrent, refractory hepatic hydrothorax from porous diaphragm syndrome represent a therapeutic challenge with few options. METHODS: A retrospective review of an electronic prospective database of patients with cirrhosis and refractory hepatic hydrothorax. Patients underwent video-assisted thoracoscopic surgery (VATS) with talc pleurodesis insufflating 2.5 g of talc. Successful therapy was defined as relief of dyspnea and control of symptomatic hydrothorax for a minimum of 6 months after the procedure. RESULTS: There were 41 patients (21 men, median age 55 years), 25 with Child-Pugh class C and 14 with class B, and 2 liver transplant patients. The etiology of the cirrhosis was hepatitis B in 4, hepatitis C in 20, alcohol in 4, cryptogenic cirrhosis in 11, and other in 2. Definitive openings in the diaphragm were seen in only 2 patients. Seven patients (17%) required bedside talc slurry through the chest tube after the intraoperative talc. Overall success was achieved in 80% (33 of 41). Four patients experienced symptomatic fluid reaccumulation at 45, 61, 62, and 102 days and were treated with a repeat VATS, with success in 2. There was 1 operative death (coagulopathy). CONCLUSIONS: Patients with recurrent effusions from porous diaphragm syndrome have few options. Video-assisted thoracoscopic surgery with talc is safe and successful in about three fourths of patients, but repeat talc slurry through the chest tube or repeat VATS is often needed. Video-assisted thoracoscopic surgery provides an effective alternative to transjugular intrahepatic portosystemic shunt and is a bridge toward liver transplantation in patients with few other options.

BACKGROUND: We assessed the morbidity, mortality, and long-term survival of pulmonary resection for non-small cell lung cancer (NSCLC) in elderly patients in three subgroups: 70 years or greater, 75 years or greater, and 80 years or greater. METHODS: A nested case-control study over a 5-year period using an electronic prospective database (n = 6,450) of patients with NSCLC who underwent complete resection. Patients 70 years or older, 75 years or older, and 80 years or older were matched 1:1 to younger controls for stage, pulmonary function, performance status, and type of pulmonary resection. RESULTS: There were 726 patients: 363 were 70 years of age or older (191 patients were 70 to 74 years old, 121 were 75 to 79, and 51 patients were 80 or older). There were 363 patients younger than 70 years of age. There was no significant difference in length of stay, major morbidity, or operative mortality between any of the elderly groups and the younger controls. However, elderly patients who received neoadjuvant therapy had three times the risk of developing major morbidity (odds ratio [OR] 2.8, 95% confidence interval [CI] 1.14 to 7.41). There was a statistically significant better 5-year survival in elderly patients with stage I NSCLC (78% vs 69%, p = 0.01); however, survival was similar for all other stages. CONCLUSIONS: Elderly patients with NSCLC should not be denied pulmonary resection based on chronologic age. Their short-term risks and long-term survival are similar to younger patients. Additionally, there seems to be no increased risk in selected octogenarians. However, elderly patients had double the risk for developing major morbidity after resection if they underwent neoadjuvant therapy.