IIB Non-small Cell Lung Cancer Research Articles

Pre-operative clonal hematopoiesis is related to adverse outcome in lung cancer after adjuvant therapy

BackgroundClonal hematopoiesis (CH) frequently progresses after chemotherapy or radiotherapy. We evaluated the clinical impact of preoperative CH on the survival outcomes of patients with non-small cell lung cancer (NSCLC) who underwent surgical resection followed by adjuvant therapy.MethodsA total of 415 consecutive patients with NSCLC who underwent surgery followed by adjuvant therapy from 2011 to 2017 were analyzed. CH status was evaluated using targeted deep sequencing of blood samples collected before surgery. To minimize the possible selection bias between the two groups according to CH status, a propensity score matching (PSM) was adopted. Early-stage patients were further analyzed with additional matched cohort of patients who did not receive adjuvant therapy.ResultsCH was detected in 21% (86/415) of patients with NSCLC before adjuvant therapy. Patients with CH mutations had worse overall survival (OS) than those without (hazard ratio [95% confidence interval] = 1.56 [1.07–2.28], p = 0.020), which remained significant after the multivariable analysis (1.58 [1.08–2.32], p = 0.019). Of note, the presence of CH was associated with non–cancer mortality (p = 0.042) and mortality of unknown origin (p = 0.018). In patients with stage IIB NSCLC, there was a significant interaction on OS between CH and adjuvant therapy after the adjustment with several cofactors through the multivariable analysis (HR 1.19, 95% CI 1.00–1.1.41, p = 0.041).ConclusionsIn resected NSCLC, existence of preoperative CH might amplify CH-related adverse outcomes through adjuvant treatments, resulting in poor survival results.

Radiofrequency ablation for stage

Pulmonary carcinoma represents the second common cancer for human race while its mortality rate ranked the first all over the world. Surgery remains the primary option for early-stage non-small cell lung cancer (NSCLC) in some surgical traditions. Nevertheless, only less than half of patients are operable subjected to the limited lung function and multiple primary/metastatic lesions. Recent improvements in minimally invasive surgical techniques have made the procedure accessible to more patients, but this percentage still does not exceed half. In recent years, radiofrequency ablation (RFA), one of the thermal ablation procedures, has gradually advanced in the treatment of lung cancer in addition to being utilized to treat breast and liver cancer. Several guidelines, including the American College of Chest Physicians (ACCP), include RFA as an option for some patients with NSCLC although the level of evidence is mostly limited to retrospective studies. In this review, we emphasize the use of the RFA technique in patients with early-stage NSCLC and provide an overview of the RFA indication population, prognosis status, and complications. Meanwhile, the advantages and disadvantages of RFA proposed in existing studies are compared with surgical treatment and radiotherapy. Due to the high rate of gene mutation and immunocompetence in NSCLC, there are considerable challenges to clinical translation of combining targeted drugs or immunotherapy with RFA that the field has only recently begun to fully appreciate.

Clinicopathological and computed tomography features of patients with early-stage non-small-cell lung cancer harboring ALK rearrangement

BackgroundAlthough some studies have assessed the correlation between computed tomography (CT) features and anaplastic lymphoma kinase (ALK) rearrangement in patients with non-small-cell lung cancer (NSCLC), few have focused on early-stage patients. The results of some previous studies are inconsistent and contradictory. Therefore, this study aimed to analyze the clinicopathological and CT features of patients with early-stage NSCLC harboring ALK rearrangement.MethodsThis retrospective analysis included 65 patients with ALK rearrangement and 629 ALK-negative patients. All patients had surgically resected NSCLC and were diagnosed with stage IA or stage IIB NSCLC. Clinicopathological features and CT signs, including tumor size and density, consolidation tumor ratio (CTR), lesion location, round or irregular shape, lobulated or spiculated margins, air bronchograms, bubble-like lucency or cavities, and pleural retraction, were investigated according to different genotypes.ResultsThe prevalence of ALK rearrangement in patients with early-stage NSCLC was 9.3% (65/694). Patients with ALK rearrangement were significantly younger than those without ALK rearrangement (P = 0.033). The frequency of moderate cell differentiation was significantly lower in tumors with ALK rearrangement than in those without ALK rearrangement (46.2% vs. 59.8%, P = 0.034). The frequency of the mucinous subtype was significantly higher in the ALK-positive group than in the ALK-negative group (13.8% vs. 5.4%, P = 0.007). No significant differences were found in any CT signs between the ALK-positive and ALK-negative groups.ConclusionsPatients with ALK-positive lung cancer may have specific clinicopathological features, including younger age, lower frequency of moderate cell differentiation, and higher frequency of the mucinous type. CT features may not correlate with ALK rearrangement in early-stage lung cancer. Immunohistochemistry or next-generation sequencing is needed to further clarify the genomic mutation status.

Factors affecting survival after resection of stage iib non-small cell lung cancer

Factors affecting survival after resection of stage iib non-small cell lung cancer

Lymph Node Metastasis Location and Postoperative Adjuvant Chemotherapy in Patients With pN1 Stage IIB Non-small Cell Lung Cancer.

The benefit of adjuvant chemotherapy for patients with pN1 non-small cell lung cancer (NSCLC) according to the location of lymph node (LN) metastases remains unclear. In this study, we examined the location of LN metastasis and prognosis to identify the significance of adjuvant chemotherapy. Thirty-five patients with pathological T1a-2bN1M0 NSCLC who underwent curative resection between 2010 and 2016 were enrolled in the study. We defined patients with LN metastasis extending in stations 10-12 as the hilar group (n=22), and only in stations 13-14 as the intralobar group (n=13). There was a significant difference in the overall survival (OS) (p=0.042) and disease-free survival (DFS) rates (p=0.021) between the intralobar and hilar groups. In the intralobar group, there were no significant differences in the OS and DFS rates according to adjuvant chemotherapy. However, patients without adjuvant chemotherapy had a poorer OS (p<0.001) and DFS rates (p<0.001) in the hilar group. Prognosis significantly differed according to adjuvant chemotherapy in the hilar group.

Phase II Study of Neoadjuvant Concurrent Chemo-immuno-radiation Therapy Followed by Surgery and Adjuvant Immunotherapy for Resectable Stage IIIA-B (Discrete N2) Non–small-cell Lung Cancer: SQUAT trial (WJOG 12119L)

IntroductionWe describe our ongoing multicenter, prospective, single-arm, phase II trial of neoadjuvant concurrent chemo-immuno-radiation therapy followed by surgical resection and adjuvant immunotherapy for resectable stage IIIA-B (discrete N2) non–small-cell lung cancer (NSCLC) (registered at the Japan Pharmaceutical Information Center, Clinical Trials Information-195069). Patients and MethodsKey inclusion criteria include (1) clinical T1-3/T4 (tumor size) N2 stage IIIA-B NSCLC, and (2) pathologically confirmed N2 without extranodal invasion (based on diagnostic imaging). Patients will receive concurrent chemoradiotherapy (carboplatin [area under the curve = 2] and paclitaxel [40 mg/m2] on days 1, 8, 15, 22, and 29, with involved-field radiation therapy [RT] [dose 50 Gy] on days 1-25) and neoadjuvant immunotherapy (durvalumab [1500 mg] on days 1 and 29). Surgical resection with mediastinal lymph node dissection is performed within 2 to 6 weeks after RT. Consolidation therapy with durvalumab is administered for up to 1 year after surgery. The primary endpoint is major pathologic response (MPR) (≤10% residual viable tumor) according to the central pathological assessment. Secondary endpoints are progression-free survival, overall survival, and safety. The sample size is planned to be 31 patients based on the exact binomial distribution with a 1-sided significance level of 5% and a power of 80%, and assuming a threshold MPR rate of 40% and an expected MPR rate of 65%. ConclusionThis trial will help establish a novel treatment strategy for resectable N2-positive NSCLC.

Neoadjuvant PD-1 Inhibitors and Chemotherapy for Locally Advanced NSCLC: A Retrospective Study

BackgroundStage III non-small cell lung cancer (NSCLC) encompasses a variety of local invasion and nodal involvement and its management is still under debate. Immune checkpoint inhibitors (ICIs) have been shown to improve the survival in metastatic NSCLC, but are far from being accepted as an induction therapy. MethodsWe retrospectively collected data of all patients who received induction ICIs (nivolumab or pembrolizumab) and chemotherapy (carboplatin with paclitaxel) for stage IIIA-B NSCLC followed by surgery in our unit between January 2019 and March 2020. ResultsOf the 12 patients (9 men, 3 women) 6 had a squamous cell carcinoma, 4 had adenocarcinoma, 1 had an undifferentiated adenocarcinoma, and 1 had adeno-squamous carcinoma. Seven patients had stage IIIA disease and 5 had stage IIIB. After induction therapy, 6 patients had stable disease and 6 had a partial response. The median tumor reduction was 3.05 cm (range, 2.30-8.70 cm). All patients, but 1 due to the COVID-19 outbreak, had no delay in surgery. Two patients experienced myelosuppression after induction therapy, 2 had minor adverse effects. Three patients had postoperative complications not related to the induction therapy. All patients had a pathologic response: 5 complete, 4 major, and 3 partial. Eleven patients are alive (mean follow-up, 18.17 ± 4.97 months) and free of disease. ConclusionsInduction ICI chemotherapy may be a valid treatment in patients with locally advanced NSCLC, providing important tumor downstaging and rendering patients operable. In our experience patients had few side effects and a good pathologic response.

Impact of Multimodality Treatment Sequence on Survival in Stage IIB Non-Small Cell Lung Cancer

The value of neoadjuvant treatment in combination with resection as multimodality therapy (MMT) for stage IIB non-small cell lung cancer remains controversial. This was a national cohort study of patients with clinical stage IIB non-small cell lung cancer (2006 to 2015) that used the National Cancer Database. Cohorts were defined on the basis of the MMT sequence and were categorized as follows: surgery plus adjuvant chemotherapy (AC), surgery plus adjuvant chemoradiation (ACRT), neoadjuvant therapy plus surgery (NA), surgery-alone, and definitive chemotherapy or chemoradiation (nonsurgical). The primary comparison was between the NA and AC cohorts. Propensity matching methods were used to match cohorts who had AC vs NA. Multivariable Cox regression was used to analyze the difference in risk of death between the NA and AC groups. There were 10,841 patients with stage IIB lung cancer: 2476 in the AC, 854 with ACRT, 1195 with NA, 2019 with surgery alone, and 4297 with nonsurgical treatment. Of the 6544 patients who underwent surgery, 37.8% had AC, 13.1% had ACRT, 18.3% had NA, and 30.9% had surgery alone. Relative to those patients treated with AC, nonsurgical treatment (hazard ratio [HR], 2.92; 95% confidence interval [CI], 2.69 to 3.17) or surgery-alone (HR, 1.26; 95% CI, 1.14 to 1.38) was associated with a significantly higher risk of death. After propensity matching, there was no difference in the risk of death between the NA and AC cohorts (HR, 1.07; 95% CI, 0.88 to 1.31). MMT, including surgical resection, is associated with improved OS, regardless of treatment sequence, with no difference in survival on the basis of an NA or AC approach. The potential benefits of NA over AC to ensure that patients complete MMT warrant further prospective investigation.

Evaluation of a National Comprehensive Cancer Network Guidelines–Based Decision Support Tool in Patients With Non–Small Cell Lung Cancer

The association of guideline-based decision support with the quality of care in patients with non-small cell lung cancer (NSCLC) is not known. To evaluate the association of exposure to the National Comprehensive Cancer Center (NCCN) guidelines with guideline-concordant care and patients' decisional conflict. A nonrandomized clinical trial, conducted at a tertiary care academic institution, enrolled patients from February 23, 2015, to September 28, 2017. Data analysis was conducted from July 19, 2019, to April 22, 2020. A cohort of 76 patients with NSCLC seen at diagnosis or disease progression and a retrospective cohort of 157 patients treated before the trial were included. Adherence to 6 NCCN recommendations were evaluated: (1) smoking cessation counseling, (2) adjuvant chemotherapy for patients with stage IB to IIB NSCLC after surgery, (3) pathologic mediastinal staging in patients with stage III NSCLC before surgery, (4) pathologic mediastinal staging in patients with stage III NSCLC before nonsurgical treatment, (5) definitive chemoradiotherapy for patients with stage III NSCLC not having surgery, and (6) molecular testing for epidermal growth factor receptor and anaplastic lymphoma kinase alterations for patients with stage IV NSCLC. Subgroup analysis was conducted to compare the rates of guideline concordance between the prospective and retrospective cohorts. Secondary end points included decisional conflict and satisfaction. An online tool customizing the NCCN guidelines to patients' clinical and pathologic features was used during consultation, facilitated by a trained coordinator. Concordance of practice with 6 NCCN treatment recommendations on NSCLC and patients' decisional conflict. Of the 76 patients with NSCLC, 44 were men (57.9%), median age at diagnosis was 68 years (interquartile range [IQR], 41-87 years), and 59 patients (77.6%) had adenocarcinoma. In the retrospective cohort, 91 of 157 patients (58.0%) were men, median age at diagnosis was 66 years (IQR, 61-65 years), and 105 patients (66.9%) had adenocarcinoma. After the intervention, patients received more smoking cessation counseling (4 of 5 [80.0%] vs 1 of 24 [4.2%], P < .001) and less adjuvant chemotherapy (0 of 7 vs 7 of 11 [63.6%]; P = .012). There was no significant change in mutation testing of non-squamous cell stage IV disease (20 of 20 [100%] vs 48 of 57 [84.2%]; P = .10). There was no significant change in pathologic mediastinal staging or initial chemoradiotherapy for patients with stage III disease. After consultation with the tool, decisional conflict scores improved by a median of 20 points (IQR, 3-34; P < .001). The findings of this study suggest that exposure to the NCCN guidelines is associated with increased guideline-concordant care for 2 of 6 preselected recommendations and improvement in decisional conflict. ClinicalTrials.gov Identifier: NCT03982459.

Outcomes of Surgically Treated Patients with Stage IIB Non-small Cell Lung Cancer, a Single Center Experience

Stage IIB lung cancers according to TNM8 staging include T1-2N1M0 and T3N0M0 groups. It has been emphasized that the most important prognostic factor of lung cancer is of tumor in many studies. In this study, we investigated the prognostic effect of some variables including tumor diameter, visceral pleural invasion, lymph node invasion, type of surgery, etc. in same tumorstage. After the approval of the local ethics committee, a total of 139 patients who were surgically treated for non-small-cell lung cancer in our department and whose pathological staging was reported as stage IIB were included in the study. The 15 patients were female and 124 were male, and the mean age was 61.5 (Range, 39–81; SD, 7.9). The overall survival and disease-free survival of patients were analyzed according to N1 presence, tumor diameter, histopathological type, visceral pleural invasion, age, and gender. The 5-year survival rate was 50.4%, and the 5-year diseases free survival rate was 54.9%. The survival of N1 (+) group was worse than the T3 group. Pneumonectomy, big tumor diameter, and squamous cell carcinoma histopathology were negative prognostic factors for survival, whereas visceral pleural invasion and adenocarcinoma histopathology were found as statistically significant to negative effect disease-free survival. Furthermore the 5-year survival rate of T2bN1M0 group was found worst than others. According to the TNM system adopted in 2016, the stage IIB lung cancers are a heterogeneous group, and as the survival studies related to this group increase, a separate tumor stage formation or separation of T2bN1 group from stage IIB may be considered.

Definitive Radiotherapy for Inoperable Stage IIB Non–small-cell Lung Cancer: Patterns of Care and Comparative Effectiveness

BackgroundThe purpose of this study was to analyze practice patterns and perform comparative effectiveness of definitive radiotherapy techniques for inoperable stage IIB (American Joint Committee on Cancer eighth edition) non–small-cell lung cancer (NSCLC). Materials and MethodsAdults in the National Cancer Database diagnosed with T3N0M0 or T1-2N1M0 NCSLC between 2004 and 2015 who received definitive radiotherapy were identified. Cases were divided as stereotactic body radiotherapy (SBRT), hypofractionated radiotherapy (HFRT), or conventionally fractionated radiotherapy (CFRT) and stratified by systemic therapy (ST). Cox proportional hazards models evaluated the effect of covariates on overall survival (OS). Subgroup analysis by tumor size, chest wall invasion, multifocality, and ST use was performed with Kaplan-Meier estimates of OS. ResultsA total of 10,081 subjects met inclusion criteria: 4401 T3N0M0 (66.5% CFRT, 11.0% HFRT, and 22.5% SBRT) and 5680 T1-2N1M0 (92.5% CFRT and 7.5% HFRT). For T3N0M0 NSCLC, SBRT utilization increased from 3.7% in 2006% to 35.4% in 2015. Subjects treated with SBRT were more likely to have smaller tumors, multifocal tumors, or adenocarcinoma histology. SBRT resulted in similar or superior OS compared with CFRT for tumors > 5 cm, tumors invading the chest wall, or multifocal tumors. SBRT was significantly associated with improved OS on multivariate analysis (hazard ratio, 0.715; P < .001). For T1-2N1M0 NSCLC, patients treated with HFRT were significantly older and less likely to receive ST; nevertheless, there was no difference in OS between HFRT and CFRT on multivariate analysis. ConclusionCFRT + ST is utilized most frequently to treat stage IIB NSCLC in the United States when surgery is not performed, though it is decreasing. SBRT utilization for T3N0M0 NSCLC is increasing and was associated with improved OS.

Prognostic Factors in Stage IIB Non-Small Cell Lung Cancer according to the 8th Edition of TNM Staging System.

BackgroundThe purposes of this study were to evaluate the appropriateness of the stage migration of stage IIA non-small cell lung cancer (NSCLC) in the seventh edition of the tumor, node, and metastasis classification for lung cancer to stage IIB lung cancer in the eighth edition, and to identify prognostic factors in patients with eighth-edition stage IIB disease.MethodsPatients with eighth-edition stage IIB disease were subclassified into those with seventh-edition stage IIA disease and those with seventh-edition stage IIB disease, and their recurrence-free survival and disease-specific survival rates were compared. Risk factors for recurrence after curative resection were identified in all included patients.ResultsOf 122 patients with eighth-edition stage IIB NSCLC, 101 (82.8%) had seventh-edition stage IIA disease and 21 (17.2%) had seventh-edition stage IIB disease. Nonsignificant differences were observed in the 5-year recurrence-free survival rate and the 5-year disease-specific survival rate between the patients with seventh-edition stage IIA disease and those with seventh-edition stage IIB disease. Visceral pleural invasion was a significant risk factor for recurrence in patients with eighth-edition stage IIB NSCLC.ConclusionThe stage migration from seventh-edition stage IIA NSCLC to eighth-edition stage IIB NSCLC was appropriate in terms of oncological outcomes. Visceral pleural invasion was the only prognostic factor in patients with eighth-edition stage IIB NSCLC.

Contemporary patterns of racial/ethnic disparities in surgical treatment and overall survival for localized resectable non-small cell lung cancer in the United States.

e20057 Background: Racial disparities in the surgical treatment of early stage lung cancers are well documented for African-Americans relative to Whites. However, there is a paucity of contemporary data regarding lung cancer treatment disparities for other minority racial/ethnic groups. We sought to compare: i) contemporary rates of surgery, ii) and overall survival (OS) for resectable non-small cell lung cancer (NSCLC), across several minority populations in the United States (US). Methods: We identified new diagnoses of stages IA-IIIA NSCLC (AJCC7) from 2010-2015 among adults (20 years+) in the Surveillance, Epidemiology, and End Results (SEER) 18 registry. We compared rates of surgery +/- radiotherapy (RT) for stage IA NSCLC, and surgery +/- RT +/- chemotherapy for stages IB–IIIA NSCLC, among the following racial/ethnic groups: Non-Hispanic Whites (whites), Non-Hispanic Blacks (blacks), Hispanics, Asians or Pacific Islanders, and American Indians/Alaska Natives (native Americans). We also calculated and compared 5-year OS rates across these groups. Results: There were 339,912 cases of newly-diagnosed stages IA, IB, IIA, IIB, and IIIA NSCLC identified for analysis. Receipt of surgical treatment +/- RT for stage IA NSCLC was lower in blacks (63.5%), and native Americans (64.2%) than whites (69.4%), as well as for stage IIB NSCLC (whites 66.7%; blacks 56.7%; native Americans 55.6%). Blacks had lower rates of surgery relative to whites across the other NSCLC stages studied but no disparities were noted for Hispanics and Asians/Pacific Islanders. 5-year age-adjusted OS for stage IA-IIIA NSCLC were significantly lower for native Americans (62.3%, 95% CI 58.1%, 66.3%) and blacks (68.1%; 95% CI 67.4, 68.9%) relative to whites (69.2%; 95% CI 69.0%, 69.5%) with relative risks of 1.11 (95% CI 1.04, 1.19) and 1.02 (95% CI 1.01, 1.03), respectively. This inferior OS persisted for blacks even among those treated with cancer-directed surgery. Conclusions: Disparities in rates of surgical treatment and OS for resectable NSCLC persist for blacks and native Americans. Although it is unclear if inferior OS outcomes for blacks are solely attributable to lower rates of surgery, systems-based interventions are needed to help ensure equal and optimal receipt of surgery for resectable NSCLC across all racial/ethnic groups in the US.

Clinical outcomes following an initial experience with a novel powered vascular stapler in video-assisted thoracoscopic lobectomies: results of a Chinese multi-center study.

The development of minimally invasive surgical approaches has revolutionized surgical care and greatly improved surgical outcomes. This study aimed to evaluate the clinical effectiveness of a powered vascular stapler (PVS) during video-assisted thoracoscopic surgery (VATS) lobectomy. This prospective, multi-center, post-market clinical study in China enrolled 50 patients with either a suspected or formal diagnosis of clinical stage IA to IIB non-small cell lung cancer (NSCLC) scheduled for VATS lobectomy. The clinical effectiveness of the PVS for successful pulmonary artery (PA)/pulmonary vein (PV) transection was evaluated. In addition, the surgeon's stress, device usability, and surgeon satisfaction were measured using multiple questionnaires. A total of 167 PAs/PVs were transected with 3 (1.8%) requiring intra-operative intervention. Fourteen of the 50 patients (28.0%) experienced at least one adverse event (AE), among whom 5 (10.0%) suffered from serious AEs. There were no postoperative hemorrhagic complications related to transection of the PA/PV with PVS. Surgeon satisfaction was surveyed by questionnaire after each of the 50 procedures resulting in a 96% reported satisfaction with device usability, specifically related to a low stress load and an increase in work efficiency. For VATS lobectomy, the PVS demonstrated a positive surgical effectiveness and value in cognitive and physical distress reduction. Complications following VATS lobectomy to treat NSCLC were generally low and as expected. Intraoperative complications were few and there were no postoperative complications related to the transection of the PA and PV during VATS lobectomy. Favorable results were reported on the surgeon satisfaction questionnaire regarding usability and surgeon stress.

Definitive Radiotherapy for Inoperable Stage IIB Non-Small Cell Lung Cancer: Patterns of Care and Comparative Effectiveness Analyses Using the National Cancer Database

Definitive Radiotherapy for Inoperable Stage IIB Non-Small Cell Lung Cancer: Patterns of Care and Comparative Effectiveness Analyses Using the National Cancer Database

A Case of 1:1 Correlation Between PET/CT Scan and Endoscopic Findings of Diverticular Disease

Diverticulosis is the most common lesion found on routine colonoscopy and its complications impose a significant burden on US healthcare.It effects 70% of those 80y or older in the US and its incidence is expected to increase with the growing aging population.While diverticular disease may be identified on CT scan, colonoscopy is used to define extent of disease.In cases of brisk diverticular bleeding, nuclear medicine bleeding scans can aid in localizing bleeding source for further intervention, such as angiographic embolization or segmental colonic resection.We present an incidental case of subclinical diverticulitis found on PET/CT scan which was confirmed by endoscopic evaluation. A 55-year old African American male presented to the ED with dyspnea and right upper extremity swelling.CXR and CT demonstrated a pulmonary mass and pathology confirmed stage IIb non-small cell lung cancer. He underwent chemotherapeutic treatment and follow-up PET/CT scan was advised. In addition to confirming the presence lung malignancy, PET/CT scan revealed 3cm of intensely avid FDG uptake in the descending colon, concerning for diverticulitis v. neoplasm.The patient denied bleeding symptoms, weight loss, abdominal pain, change in bowel habits, previous colonoscopy or family history of colon cancer.Outpatient colonoscopy identified scattered diverticular disease in the descending colon, correlating exactly with the location of increased FDG activity on PET/CT scan. One month later, repeat PET/CT scan was performed for surveillance.The two foci of intense short segment activity in the descending colon remained unchanged in intense activity. The lesions demonstrated a perfect 1:1 correlation with the diverticular disease found on colonoscopy. We report the first case of 1:1 correlation between PET/CT and endoscopic findings of diverticular disease. The utility of PET/CT has been well described in the detection of malignant lesions, but our case demonstrates the ability of PET/CT to recognize non-cancerous inflammatory conditions. As PET/CT is twice as costly with radiation exposure comparable to CT, this modality should not be considered as a screening tool.PET/CT may have a role in select cases of pan-colonic diverticulosis to identify areas of severe inflammation amenable to segmental resection instead of total abdominal colectomy.Further studies should investigate whether this functional molecular imaging test may be implemented in this manner.

Results of a Single-Institution Experience With Dose-Escalated Chemoradiation for Locally Advanced Unresectable Non-Small Cell Lung Cancer

Abstract: Background: We determined factors associated with morbidity and outcomes of a series of non-small cell lung cancer (NSCLC) patients treated with dose escalated chemoradiotherapy at the University of Pittsburgh Lung Cancer Program. Methods and Materials: The records of 170 stage III NSCLC patients treated with definitive intent were retrospectively reviewed. All patients received 4D-CT simulation scan and had respiratory gating if tumor movement exceeded 5 mm. Overall survival (OS), locoregional control (LRC), and freedom from distant metastasis (FFDM) were calculated using log rank and Cox regression analysis. Results: For the present series of patients, median follow-up was 36.6 months, median survival 27.4 months, and the 2- and 4-year (OS) was 56.0 and 30.7%, respectively. The 4-year local regional control (LRC) and freedom from distant metastases (FFDM) were 43.9% and 40.7%, respectively. No benefit was associated with irradiation doses above 66 Gy in overall survival (OS) (p=0.586), LRC (p=0.440), or FFDM (p=0.230). On univariate analysis, variables associated with worse survival included: clinical stage IIIB (p=0.037), PTV over 450 cc (p 20% (43.8 vs. 21.3 months, p-0.01) were associated with lower survival. Grade 2 or higher acute lung toxicity and esophagitis were detected in 9.5% and 59.7%, respectively of patients. Grade 2 or higher acute lung toxicity was reduced if lung V5 was < 65 (7.4% vs. 23.8%, p=0.03). Grade 2 or higher acute esophagitis was reduced if V60 < 20% (62% vs. 81.3%, p=0.018). The use of Intensity Modulated Radiation Therapy (IMRT) was more frequent in stage IIIB compared to stage IIIA patients (56.5% vs. 39.5%, p=0.048), and was associated with a higher lung V5 and V10. Conclusions: The outcomes of a program of dose escalated chemoradiotherapy for unresectable stage IIIA and IIB NSCLC patients were consistent with other studies and showed no benefit to radiation doses above 66 Gy. Furthermore, maintaining low esophageal V60 and lung V5 were associated with lower morbidity and mortality.

A multicenter phase II study of concurrent chemoradiotherapy with cisplatin and oral S-1, followed by surgery for locally advanced non-small-cell lung cancer

Abstract Purpose This study was designed to evaluate the feasibility of concurrent induction chemoradiotherapy (CRT) using S-1, an oral fluoropyrimidine derivative, plus cisplatin followed by surgery in locally advanced non-small cell lung cancer (NSCLC). Patients and methods We defined locally advanced NSCLC as pathologically proven chest wall invasion or hilar and/or mediastinal lymph node metastases by endobronchial ultrasound-guided transbronchial needle aspiration. Twenty-three patients were enrolled in this study from May 2011 to April 2014. The patients received S-1 40mg/m 2 orally twice daily on days 1 through 14 and 29 through 42, and cisplatin 60mg/m 2 was injected intravenously on days 8 and 36. The patients also underwent radiotherapy and received a total dose of 40Gy in 20 fractions beginning on day 1. Surgical resection was performed from 4 to 6 weeks after completion of the induction treatment. Results Of the 23 eligible patients, 18 had stage IIIA and 5 had stage IIB NSCLC. Twenty patients (87.0%) completed induction CRT and underwent surgical resection. Representative grade 3 adverse reactions were neutropenia (21.7%) and leukocytopenia (8.7%); no grade 4 adverse reactions were observed. Radiologically, 7 (30.4%) of the 23 patients achieved partial response and were therefore radiologically downstaged. Twenty patients were curatively resected. Six (26.1%) complete responses were identified and 12 cases (52.2%) were histopathologically downstaged by induction CRT. Conclusion Concurrent induction CRT using S-1 plus cisplatin is a feasible and promising new treatment modality for locally advanced NSCLC. Evaluation of histopathological downstaging revealed sufficient anti-cancer effects for preoperative treatment. MicroAbstract Because chemoradiotherapy (CRT) using cisplatin and S-1, an oral fluoropyrimidine, is effective for unresectable non-small cell lung cancer, the feasibility of this therapy in a neoadjuvant setting was evaluated in a multicenter phase II study. Toxicities were very mild and 87.0% of the 23 patients completed induction CRT. This protocol seems feasible and is considered an option among preoperative therapies.

Surgical Treatment for Non-Small Cell Lung Cancer in Patients on Hemodialysis due to Chronic Kidney Disease: Clinical Outcome and Intermediate-Term Results.

BackgroundPatients on dialysis undergoing surgery belong to a high-risk group. Only a few studies have evaluated the outcome of major thoracic surgical procedures in dialysis patients. We evaluated the outcomes of pulmonary resection for non-small cell lung cancer (NSCLC) in patients on hemodialysis (HD).MethodsBetween 2008 and 2013, seven patients on HD underwent pulmonary resection for NSCLC at our institution. We retrospectively reviewed their surgical outcomes and prognoses.ResultsThe median duration of HD before surgery was 55.0 months. Five patients underwent lobectomy and two patients underwent wedge resection. Postoperative morbidity occurred in three patients, including pulmonary edema combined with pneumonia, cerebral infarction, and delirium. There were no instances of in-hospital mortality, although one patient died of intracranial bleeding 15 days after discharge. During follow-up, three patients (one patient with pathologic stage IIB NSCLC and two patients with pathologic stage IIIA NSCLC) experienced recurrence and died as a result of the progression of the cancer, while the remaining three patients (with pathologic stage I NSCLC) are alive with no evidence of disease.ConclusionSurgery for NSCLC in HD patients can be performed with acceptable perioperative morbidity. Good medium-term survival in patients with pathologic stage I NSCLC can also be expected. Pulmonary resection seems to be the proper treatment option for dialysis patients with stage I NSCLC.

Prognostic value of SPARC expression in unresectable NSCLC treated with concurrent chemoradiotherapy.

The aim of the present study was to determine the predictive/prognostic value of the secreted protein, acidic and rich in cysteine (SPARC) in cases of unresectable, locally advanced, non-small cell lung cancer. The study included 84 patients with Stage IIIA-B non-small cell lung cancer, undergoing simultaneous chemoradiotherapy including radiotherapy at a dose of 66 Gy and weekly docataxel (20 mg/m2) and cisplatin (20 mg/m2). SPARC expression was studied in biopsy material by immunohistochemical methods and correlations with treatment responses or survival were evaluated. Median overall survival was 16±2.73 (11.55-20.46) months for low expression vs 7±1.79 months (7.92-16.08) months for high expression (p=0.039), while median local control was 13±2.31 (8.48-17.5) months for low expression vs 6±0.85 (4.34-7.66) months for high expression (p=0.045) and median progression-free survival was 10±2.31 (5.48-14.5) months for low expression vs 6±1.10 (3.85-8.15) months for high expression (p=0.022). In both univariate and multivariate analyses, high SPARC expression was associated with significantly shorter overall survival (p=0.003, p=0.007, respectively), local control (p=0.008, p=0.036) and progression-free survival (p=0.004, p=0.029) when compared to low SPARC expression. No significant difference was detected between high and low SPARC expression groups regarding age, sex, T stage, N stage, histopathology and stage-related patient characteristics. High SPARC expression was identified as a poor prognostic factor in cases with locally advanced NSCLC treated with concurrent chemoradiotherapy.