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Objective: The aim of this study was to analyze overall survival (OS) of robotic-assisted lobectomy (RL), video-assisted thoracoscopic lobectomy (VATS), and open lobectomy (OL) performed by experienced thoracic surgeons across multiple institutions. Summary Background Data: Surgeons have increasingly adopted RL for resection of early-stage lung cancer. Comparative survival data following these approaches is largely from single-institution case series or administrative data sets. Methods: Retrospective data was collected from 21 institutions from 2013 to 2019. Consecutive cases performed for clinical stage IA–IIIA lung cancer were included. Induction therapy patients were excluded. The propensity-score method of inverse-probability of treatment weighting was used to balance baseline characteristics. OS was estimated using the Kaplan-Meier method. Multivariable Cox proportional hazard models were used to evaluate association among OS and relevant risk factors. Results: A total of 2789 RL, 2661 VATS, and 1196 OL cases were included. The unadjusted 5-year OS rate was highest for OL (84%) followed by RL (81%) and VATS (74%); P =0.008. Similar trends were also observed after inverse-probability of treatment weighting adjustment (RL 81%; VATS 73%, OL 85%, P =0.001). Multivariable Cox regression analyses revealed that OL and RL were associated with significantly higher OS compared with VATS (OL vs. VATS: hazard ratio=0.64, P <0.001 and RL vs. VATS: hazard ratio=0.79; P =0.007). Conclusions: Our finding from this large multicenter study suggests that patients undergoing RL and OL have statistically similar OS, while the VATS group was associated with shorter OS. Further studies with longer follow-up are necessary to help evaluate these observations. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to analyze outcomes of open lobectomy (OL), VATS, and robotic-assisted lobectomy (RL). Summary Background Data: Robotic-assisted lobectomy has seen increasing adoption for treatment of early-stage lung cancer. Comparative data regarding these approaches is largely from single-institution case series or administrative datasets. Methods: Retrospective data was collected from 21 institutions from 2013 to 2019. All consecutive cases performed for clinical stage IA-IIIA lung cancer were included. Neoadjuvant cases were excluded. Propensity-score matching (1:1) was based on age, sex, race, smoking-status, FEV1%, Zubrod score, American Society of Anesthesiologists score, tumor size, and clinical T and N stage. Results: A total of 2391 RL, 2174 VATS, and 1156 OL cases were included. After propensity-score matching there were 885 pairs of RL vs OL, 1,711 pairs of RL vs VATS, and 952 pairs of VATS vs OL. Operative time for RL was shorter than VATS (P < 0.0001) and OL (P = 0.0004). Compared to OL, RL and VATS had less overall postoperative complications, shorter hospital stay (LOS), and lower transfusion rates (all P <0.02). Compared to VATS, RL had lower conversion rate (P <0.0001), shorter hospital stay (P <0.0001) and a lower postoperative transfusion rate (P =0.01). RL and VATS cohorts had comparable postoperative complication rates. In-hospital mortality was comparable between all groups. Conclusions: RL and VATS approaches were associated with favorable perioperative outcomes compared to OL. Robotic-assisted lobectomy was also associated with a reduced length of stay and decreased conversion rate when compared to VATS. [ABSTRACT FROM AUTHOR]

OBJECTIVES Open in new tab Download slide Open in new tab Download slide The coronavirus disease 2019 (COVID-19) pandemic has resulted in patient reluctance to seek care due to fear of contracting the virus, especially in New York City which was the epicentre during the surge. The primary objectives of this study are to evaluate the safety of patients who have undergone pulmonary resection for lung cancer as well as provider safety, using COVID-19 testing, symptoms and early patient outcomes. METHODS Patients with confirmed or suspected pulmonary malignancy who underwent resection from 13 March to 4 May 2020 were retrospectively reviewed. RESULTS Between 13 March and 4 May 2020, 2087 COVID-19 patients were admitted, with a median daily census of 299, to one of our Manhattan campuses (80% of hospital capacity). During this time, 21 patients (median age 72 years) out of 45 eligible surgical candidates underwent pulmonary resection—13 lobectomies, 6 segmentectomies and 2 pneumonectomies were performed by the same providers who were caring for COVID-19 patients. None of the patients developed major complications, 5 had minor complications, and the median length of hospital stay was 2 days. No previously COVID-19-negative patient (n  = 20/21) or healthcare provider (n  = 9: 3 surgeons, 3 surgical assistants, 3 anaesthesiologists) developed symptoms of or tested positive for COVID-19. CONCLUSIONS Pulmonary resection for lung cancer is safe in selected patients, even when performed by providers who care for COVID-19 patients in a hospital with a large COVID-19 census. None of our patients or providers developed symptoms of COVID-19 and no patient experienced major morbidity or mortality. [ABSTRACT FROM AUTHOR]

OBJECTIVES Minimally invasive surgery is accepted for early-stage lung cancer, but its role in locally advanced disease is controversial, especially using a robotic platform. The aim of this retrospective study was to assess the safety and effectiveness of robot-assisted resection in patients with Stage IIIA non-small-cell lung cancer (NSCLC) or carcinoid tumours in the series as a whole and in different subgroups according to adjuvant treatment. METHODS This was a retrospective multicentre study of consecutive patients with clinically evident or occult N2 disease (210 NSCLC and 13 carcinoid) who, in 2007–2016, underwent robot-assisted resection at 7 high-volume centres. Perioperative outcomes, recurrences and overall survival were assessed. RESULTS N2 disease was diagnosed preoperatively in 72 (32%) patients and intraoperatively in 151 (68%) patients. Surgical margins were negative in 98.4% of cases with available data. Thirty-four (15.2%) patients received neoadjuvant treatment, 140 (63%) patients received postoperative treatment, and 49 (22%) patients underwent surgery only. There were 22 (9.9%) conversions to thoracotomy, 23 (10.3%) had serious (Grades III–IV) postoperative morbidity and the mean hospital stay was 5.3 days. Complications and outcomes did not differ significantly between treatment groups. Of the 34 patients who were given neoadjuvant chemotherapy, all had R0 resection, 5 (15%) patients required conversion but none required conversion because of bleeding and 4 (12%) patients had Grade III or IV postoperative complications. After a median of 18 (interquartile range 8–33) months, 3-year overall survival in NSCLC patients was 61.2% and 60.3% (P  = 0.6) of patients in the subgroup were given induction treatment. However, overall survival was significantly better (P  = 0.012) in NSCLC patients with ≤2 positive nodes (vs >2). Nineteen (8.5%) patients developed local recurrence. CONCLUSIONS Robot-assisted lobectomy is safe and effective in patients with Stage III NSCLC or carcinoid tumours with low conversions and complications. Among patients with NSCLC, including those who were given induction chemotherapy, survival was similar to that reported for open surgery. [ABSTRACT FROM AUTHOR]

Objective Our objective is to report the world's largest series with the longest follow-up of robotic lobectomy for non–small cell lung cancer (NSCLC). Methods This was a multi-institutional retrospective review of a consecutive series of patients from 4 institutions' prospective robotic databases. Results There were 1339 patients (men 55%, median age 68 years). The median operative time was 136 minutes, median number of lymph nodes was 13 (5 N2 stations and 1 N1), median blood loss was 50 cc, and 4 (0.005%) patients received intraoperative transfusions. Conversions occurred in 116 patients (9%) and for bleeding in 24 (2%). Median length of stay was 3 days. Major morbidity occurred in 8%. The 30-day and 90-day operative mortality was 0.2% and 0.5%, respectively. Follow-up was complete in 99% of patients with a median follow-up of 30 months (range 1-154 months). The 5-year stage-specific survival was: 83% for the 672 patients with stage IA NSCLC, 77% for the 281 patients with stage IB, 68% for the 118 patients with stage IIA, 70% for 99 patients with IIB, 62% for 143 patients with stage IIIA (122 had N2 disease, 73%), and 31% for 8 patients with stage IIIB (none had N3 disease). The cumulative incidence of metastatic NSCLC was 15% (128 patients, 95% confidence interval, 13%-18%). The cumulative incidence of local recurrence in the ipsilateral operated chest was 3% only (26 patients, 95% confidence interval, 2%-5%). Conclusions The oncologic results of robotic lobectomy for NSCLC are promising, especially for patients with pathologic N2 disease. However, further follow-up and studies are needed. [ABSTRACT FROM AUTHOR]

Our purpose is to identify the metrics used by the Society of Thoracic Surgeons (STS) to rank lobectomy and to show our process to improve. This is a review of our STS data for lobectomy and our results using the process of root cause analysis and lean methodology to improve our outcomes. The STS metrics are 30-day mortality, pneumonia, adult respiratory distress syndrome, bronchopleural fistula, pulmonary embolus, initial ventilator support greater than 48 hours, reintubation and respiratory failure, tracheostomy, myocardial infarction, or unexpected return to the operating room. Sixteen of 231 programs (7%) were ranked 3-star over a 3-year period from July 2011 to June 2014. The most common root cause analysis was failure to escalate care. The lean and process improvements we employed that seemed to improve the results were increasing exercise before surgery, adding a respiratory therapist, eliminating Foley catheters and arterial lines to reduce infection and to increase ambulation, offering stereotactic radiotherapy for marginal patients, favoring left upper segmentectomy over left upper lobectomy, and performing 91% of the last 493 lobectomies via a minimally invasive platform. Our major morbidity complications from August 2003 to December 2014 fell from 9.5% to 5.3% (P = 0.001) and mortality decreased from 3.3% to 0.54% (P < 0.0001). The metrics the STS used to rank lobectomy programs are 30-day mortality and predominantly respiratory complications. Root cause analysis, lean methodology, and process improvements allowed us to improve our lobectomy patient outcomes over time and to achieve a 3-star ranking over a 3-year time frame. These results may be obtainable by others. [ABSTRACT FROM AUTHOR]

Abstract: Background: We have used doses of 60Gy or higher for neoadjuvant chemoradiotherapy for select patients with advanced non-small cell lung cancer (NSCLC), including patients with N2 disease and those with Pancoast lesions, to avoid gaps in radiotherapy in case surgery is ultimately not offered. Methods: A retrospective cohort study using a prospective database. Patients underwent initial staging with CT, PET/CT and lymph node biopsy (mediastinoscopy, endoscopic esophageal ultrasound and endobronchial ultrasound) and then received neoadjuvant high dose radiotherapy and chemotherapy, followed by thoracotomy with intent to cure. Results: Between January 1998 and June 2008 there were 216 patients who were eligible for this study. The median dose of radiation was 60Gy (range 60–72Gy). Lobectomy was performed in 152 patients (70%) about 7 weeks after radiotherapy finished (mean 51 days, range 34–89 days).The bronchus was buttressed with an intercostal muscle flap in 97% patients. Median hospital stay was 4.5 days (range 2–57). Major morbidity occurred in 17%. There were five (2.3%) deaths. There were no bronchial-pleural fistulas after lobectomy, but two occurred after right pneumonectomy. Predictors of morbidity were FEV1 <50% (p <0.001), DLCO <60% (p <0.001) and age >75 years (p =0.008). The overall 5-year Kaplan–Meier survival was 34%. It was 42% for those who underwent R0 resection, 38% for those with initial N2 disease and 45% for the 71 complete responders. Conclusions: Pulmonary resection after high dose (≥60Gy) neoadjuvant chemoradiotherapy is safe. Lobectomy can be safely performed and bronchopleural fistula prevented. Sixty Gy allows for maximal medical therapy in case resection is not offered. Since complete response rates may be higher than when 45Gy is used and since surgery is safe, its use deserves further investigation. [Copyright &y& Elsevier]

A workshop of experts from France, Germany, Italy, and the United States took place at Humanitas Research Hospital Milan, Italy, on February 10 and 11, 2016, to examine techniques for and applications of robotic surgery to thoracic oncology. The main topics of presentation and discussion were robotic surgery for lung resection; robot-assisted thymectomy; minimally invasive surgery for esophageal cancer; new developments in computer-assisted surgery and medical applications of robots; the challenge of costs; and future clinical research in robotic thoracic surgery. The following article summarizes the main contributions to the workshop. The Workshop consensus was that since video-assisted thoracoscopic surgery (VATS) is becoming the mainstream approach to resectable lung cancer in North America and Europe, robotic surgery for thoracic oncology is likely to be embraced by an increasing numbers of thoracic surgeons, since it has technical advantages over VATS, including intuitive movements, tremor iltration, more degrees of manipulative freedom, motion scaling, and high-deinition stereoscopic vision. These advantages may make robotic surgery more accessible than VATS to trainees and experienced surgeons and also lead to expanded indications. However, the high costs of robotic surgery and absence of tactile feedback remain obstacles to widespread dissemination. A prospective multicentric randomized trial (NCT02804893) to compare robotic and VATS approaches to stages I and II lung cancer will start shortly. [ABSTRACT FROM AUTHOR]

The use of robotics for lung resection has increased significantly over the past several years. We favor a completely portal 4-arm approach. Left upper lobectomy, which many believe is the most complex of the 5 lobectomies, is well-suited for robotic assistance. Port placement and conduct of the operation are described. Robotic left upper lobectomy can be done with minimal morbidity and extremely low perioperative mortality, with similar postoperative and oncological results when compared with video-assisted thoracoscopic surgery lobectomy. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Even today, open lobectomy involves significant morbidity. Video-assisted thoracic surgery (VATS) lobectomy results in lesser blood loss, pain, and hospital stay compared to lobectomy by thoracotomy. Despite being an excellent procedure in expert hands, VATS lobectomy is associated with a longer learning curve because of its inherent basic limitations. The da Vinci surgical system was developed essentially to overcome these limitations. In this study, we report our initial experience with robotic pulmonary resections using the Completely Portal approach with four arms. To the best of our knowledge this is the first series of robotic lobectomy reported from India. MATERIAL AND METHODS: Data on patient characteristics, operative details, complications, and postoperative recovery were collected in a prospective manner for patients who underwent Robotic Lung resection at our institution between March 2012 and April 2014 for various indications including both benign and malignant cases. RESULTS: Between March 2012 to April 2014, a total of 13 patients were taken up for Robotic Lobectomy with a median age of 57 years. The median operative time was 210 min with a blood loss of 33 ml. R0 clearance was achieved in all patients with malignant disease. The median lymph node yield in nine patients with malignant disease was 19 (range 11-40). There was one intra-operative complication and two postoperative complications. The median hospital stay was 7 days with median duration to chest tube removal being 3 days. CONCLUSION: Robotic lobectomy is feasible and safe. It appears to be oncologically sound surgical treatment for earlystage lung cancer. Comparable benefits over VATS needs to be further evaluated by long-term studies. [ABSTRACT FROM AUTHOR]

Background Flattening filter-free (FFF) linear accelerators (linacs) are capable of delivering dose rates more than 4-times higher than conventional linacs during SBRT treatments, causing some to speculate whether the higher dose rate leads to increased toxicity owing to radiobiological dose rate effects. Despite wide clinical use of this emerging technology, clinical toxicity data for FFF SBRT are lacking. In this retrospective study, we report the acute and late toxicities observed in our lung radiosurgery experience using a FFF linac operating at 2400 MU/min. Methods We reviewed all flattening filter-free (FFF) lung SBRT cases treated at our institution from August 2010 through July 2012. Patients were eligible for inclusion if they had at least one clinical assessment at least 30 days following SBRT. Pulmonary, cardiac, dermatologic, neurologic, and gastrointestinal treatment related toxicities were scored according to CTCAE version 4.0. Toxicity observed within 90 days of SBRT was categorized as acute, whereas toxicity observed more than 90 days from SBRT was categorized as late. Factors thought to influence risk of toxicity were examined to assess relationship to grade > =2 toxicity. Results Sixty-four patients with >30 day follow up were eligible for inclusion. All patients were treated using 10 MV unflattened photons beams with intensity modulated radiation therapy (IMRT) inverse planning. Median SBRT dose was 48 Gy in 4 fractions (range: 30-60 Gy in 3-5 fractions). Six patients (9%) experienced > = grade 2 acute pulmonary toxicity; no nonpulmonary acute toxicities were observed. In a subset of 49 patients with greater than 90 day follow up (median 11.5 months), 11 pulmonary and three nerve related grade > =2 late toxicities were recorded. Pulmonary toxicities comprised six grade 2, three grade 3, and one each grade 4 and 5 events. Nerve related events were rare and included two cases of grade 2 chest wall pain and one grade 3 brachial plexopathy which spontaneously resolved. No grade > =2 late gastrointestinal, skin, or cardiac toxicities were observed. Tumor size, biologically effective dose (BED10, assuming α/β of 10), and tumor location (central vs peripheral) were not significantly associated with grade > =2 toxicity. Conclusions In this early clinical experience, lung SBRT using a FFF linac operating at 2400 MU/min yields minimal acute toxicity. Preliminary results of late treatment related toxicity suggest reasonable rates of grade > =2 toxicities. Further assessment of late effects and confirmation of the clinical efficacy of FFF SBRT is warranted. [ABSTRACT FROM AUTHOR]

Patients with non-small cell lung cancer (NSCLC) that invades the chest wall are often thought not to benefit from minimally invasive surgery. Frequently, open techniques involve cutting noninvolved extrathoracic muscles that lie over the cancer to gain access to resect the ribs that contain malignancy. We reviewed a new technique involving 21 patients that eliminates cutting of the extrathoracic (trapezius, rhomboids, serratus anterior) muscles. Ribs with invading cancer are resected from inside of the chest instead of cutting the uninvolved muscles over them. The approach used can be a thoracotomy, robotic, or video-assisted technique. [ABSTRACT FROM AUTHOR]

Objectives: Our objective was to determine the long-term survival of patients with resected synchronous multiple pulmonary malignant tumors. Methods: This is a multi-institutional retrospective study of patients who underwent surgical resection of synchronous (nonbronchioloalveolar) non–small cell lung cancer. Results: Between March 1996 and December 2009, 67 patients (30 men) underwent 121 operations. Forty-four patients had bilateral tumors. Positron emission tomographic scans were performed in 58 (87%) patients, computed tomographic scans and magnetic resonance imaging of the brain in 53 (79%), and mediastinoscopy in 56 (84%). N2 lymph nodes were benign in all patients before undergoing resection of bilateral tumors of the same histologic type. Types of resection were lobectomy in 62, sublobar in 73, and pneumonectomy in 1. Eleven patients (16%) had postoperative morbidities. Cancer-specific 3- and 5-year survivals were 73% and 69%, respectively, and overall 3- and 5-year survivals were 64% and 53%, respectively. Subgroup analysis demonstrated no difference in overall survival at 5 years between bilateral tumors of the same histologic type (M1a) (49%) versus different histologic types 42% (P = .88), or between bilateral tumors (50%) and ipsilateral tumors (54%) (P = .83). Conclusions: The 5-year survival of surgically resected, synchronous, N2-negative, nonbronchioloalveolar, non–small cell lung cancer is excellent, even in patients who have bilateral lung lesions that harbor the same histologic features. Although the new TNM classification system labels this disease as clinical stage IV M1a, survival acts more like a separate T1 lesion after surgical resection. Thus, surgical resection should be considered in appropriately selected patients who have multiple pulmonary malignant tumors that are N2 negative. [ABSTRACT FROM AUTHOR]

Background: Accurate false negative rates for endobronchial ultrasound (EBUS) and esophageal ultrasound (EUS) for mediastinal (N2) lymph nodes are unknown. Methods: A retrospective review of patients with non-small cell lung cancer (NSCLC) underwent integrated positron emission tomography and computed tomography (PET/CT) and CT scan. All suspicious N2 lymph nodes were biopsied before thoracotomy. The EBUS was performed for suspicious nodes in stations 2R, 4R, 4L, 5, and 7; the EUS was performed for 4L, 4R, 5, 7, 8, and 9. Mediastinoscopy was performed in selected patients if they were negative by EUS/EBUS; if N2 negative, all patients underwent thoracotomy with complete thoracic lymphadenectomy. Results: There were 425 patients over a 2-year period, and 234 had suspected N2 disease. Of these patients, 72 had an EBUS; 16 were positive for N2 disease and 12 were false negative (7 patients at station 4R/4L, 4 patients at station 7; patient sensitivity 57%, negative predictive value 79%, accuracy 83%). Seventy-nine patients had EUS; 20 patients were positive for N2 disease and 12 were false negative (4 patients at station 4R/4L, 4 patients at station 7; patient sensitivity 63%, negative predictive value 80%, accuracy 85%). One hundred and forty-six patients had mediastinoscopy, which revealed N2 or N3 disease in 42 patients, and 7 were false negative (patient sensitivity 88%, negative predictive value 93%, accuracy 95%). Conclusions: Both EBUS and EUS are useful initial tests to biopsy suspicious N2 mediastinal lymph nodes; however, as EBUS and EUS have high false negative rates, especially at stations 4R and 7, mediastinoscopy is still required for patients with suspicious nodal disease in these stations. [Copyright &y& Elsevier]

Background: Stage IIIA non-small cell lung (NSCLC) from N2 disease is common, but represents a heterogeneous group of patients. Predictors of who completes their neoadjuvant chemoradiotherapy and undergoes subsequent surgical resection are unknown. Methods: This retrospective cohort study used a prospective database. Patients who had biopsy-proven, nonbulky N2 disease underwent neoadjuvant chemoradiotherapy and were restaged or resected, or both. Results: There were 402 patients, and 326 (81%) completed their neoadjuvant therapy. Only 198 (50%) returned for definitive pathologic restaging, and 149 (37%) underwent thoracotomy for attempted resection. Predictors of who returned to the surgical arena were age (< 70), multiple node involvement, and response to neoadjuvant therapy. The 5-year survival was 8% for the 253 patients who did not return for restaging but was 47% for the 149 patients who underwent thoracotomy (p < 0.001). The 5-year survival for selected subgroups of patients who underwent complete resection was 42% for the 14 patients who had unsuspected recalcitrant N2 disease, 49% for the 65 patients who had a partial response, and 53% for the 34 patients who had a complete response. Conclusions: Only 37% of patients with favorable, nonbulky, biopsy-proven N2 disease actually complete their neoadjuvant therapy, undergo restaging, and then return for attempted resection. Only 28% undergo complete resection. However, in this highly selected subset of patients, the 5-year survival is 47% or better if partial or complete pathologic response is achieved. Therefore, surgical resection remains a viable treatment for selected patients with favorable N2 NSCLC. [Copyright &y& Elsevier]

Background: The objective of this study was to determine the survival of patients who have completely resected, nonsmall-cell, stage IIIA, lung cancer from unsuspected (nonimaged) N2 disease who received adjuvant chemotherapy. Methods: This is a retrospective cohort study using a prospective database. All patients underwent positron emission tomography scan and computed tomography scan with contrast, R0 resection with complete thoracic lymphadenectomy, and had unsuspected, pathologic N2 NSCLC. Results: Between June 1998 and December 2007, there were 148 patients (89 men). The most common pulmonary resection was right upper lobectomy in 67 patients (48%), and the most common lymph node station for unsuspected N2 diseased was 4R. One hundred and thirty-seven patients (93%) received adjuvant chemotherapy and 13% received postoperative radiation as well. The overall 2- and 5-year survivals were 58% and 35%, respectively. The 5-year survival for the 98 patients with single lymph node disease compared with patients with multiple nodal involvement was 40% versus 25%, respectively (p = 0.028). The number of lymph nodes involved (p = 0.032) was an independent predictors of survival on multivariate analysis. Median follow-up was 54 months. Conclusions: The 5-year survival of patients with unsuspected N2 disease who undergo complete resection, followed by adjuvant therapy, is 35%. Patients with single station N2 disease fare better. The role for mediastinoscopy, endoscopic esophageal ultrasound with fine-needle aspirate, or endobronchial ultrasound in patients who are negative by positron emission tomography and computed tomography is unknown, since the benefit of neoadjuvant therapy in these patients is also unproven. A randomized study is needed. [Copyright &y& Elsevier]

Background: The ideal time to repeat a 2-fluoro-2-deoxy-d-glucose (FDG) positron emission tomography (PET)/computed tomography (CT) scan to accurately restage a patient after neoadjuvant chemoradiotherapy for non-small cell lung cancer (NSCLC) is unknown. Methods: This retrospective cohort study used a prospective database of patients who underwent neoadjuvant chemoradiotherapy, an initial and repeat FDG-PET/CT scan, and pathologic staging. The accuracy of the clinical stage suggested by repeat FDG-PET/CT was compared with the actual pathologic stage. Receiver operating characteristic (ROC) curves were used to determine when it was most accurate to repeat the FDG-PET/CT after the completion of the last dose of chest radiation. Results: The study comprised 109 patients, 93 of whom patients received 60 Gy (or higher) of radiotherapy. The median time to restaging was 24 days (range, 2 to 88 days). ROC analysis showed the optimal time to restage patients was 26 days for overall staging (area under the curve [AUC], 0.88) and 29 days for N2 restaging (AUC, 0.82). The accuracy for overall stage was 3 (38%) of 8 for patients for less than 10 days, 28 (72%) of 39 for patients between 11 and 20 days, 42 (88%) of 49 between 21 and 30 days, and 8 (62%) of 13 for 31 days or more. The accuracy for these time intervals for the restaging of the N2 lymph node was 50% (1/2) 40% (2/5), 88% (7/8), and 100% (3/3), respectively. Conclusions: The optimal time to perform a repeat FDG-PET/CT scan after the completion of neoadjuvant chemotherapy and high-dose radiotherapy to maximize its accuracy for restaging patients with NSCLC is about 1 month after the last dose of radiation. [Copyright &y& Elsevier]

The stage of non-small cell lung cancer (NSCLC) determines that the treatment strategy and proper staging lead to improved survival. Integrated positron emission tomography/computerized tomography (CT) scan provides more accurate staging and better targets for biopsy than traditional methods such as CT scans of the chest and upper abdomen, bone scans, and magnetic resonance imaging scans. Integrated positron emission tomography/CT is the best initial test for an indeterminate pulmonary nodule that is 8 mm or greater; for the noninvasive staging of patients with NSCLC, it is the only test that produces a quantitative assessment of an NSCLC’s virulence or biologic aggressiveness in a particular patient and is the best tool for restaging patients after radiation and and/or chemotherapy. Finally, its use as a tool for postoperative surveillance is under study. [Copyright &y& Elsevier]

The article reports on the differences in histology, epidemiology, and survival between cigarette smokers and never-smokers who develop non-small cell lung cancer (NSCLC). It is forwarded that the impact of smoking cigarettes on the survival of patients with NSCLC is still in question. In this research, a retrospective cohort study using a prospective database patients with NSCLC over a 6-year period was employed.

Background: The maximum standardized uptake value (maxSUV) on F-18 fluorodeoxyglucose–positron emission tomography (FDG-PET) scan of mediastinal (N2) lymph nodes may predict pathology in patients with nonsmall-cell lung cancer. However, the maxSUV varies among PET scanners. Thus, we evaluated the ratio of the maxSUV of the lymph node to the primary tumor at different centers to determine whether it was a universal predictor of lymph node malignancy. Methods: This is a retrospective review of a prospective database. Patients with nonsmall-cell lung cancer, a dedicated FDG-PET with the maxSUV of the primary lung tumor and FDG-avid mediastinal (N2) nodes reported (before therapy), and who underwent lymph node removal were eligible. Results: There were 239 patients with 335 FDG-PET–positive N2 nodes at 14 different PET centers. The median ratio of the maxSUV of the lymph node to the maxSUV of the primary tumor of the pathologically proven malignant nodes was 0.58 (range, 0.32 to 1.61). Benign nodes had a median ratio of 0.40 (range, 0.21 to 1.10, p = 0.02). The median value was similar for all centers except one. Receiver operating characteristics analysis determined the optimal value of the ratio that maximized sensitivity to be 0.56 or greater (+LR 6.6, sensitivity 94%, specificity 72%). Conclusions: The ratio of the maxSUV of the mediastinal (N2) lymph node to the maxSUV of the primary tumor in patients with nonsmall-cell lung cancer predicts mediastinal nodal pathology across different PET centers. When the ratio is 0.56 or greater, there is a 94% chance that the node is malignant. The ratio may take into account the different techniques used at different centers. [Copyright &y& Elsevier]

The article focuses on the clinical study regarding the administration of routine mediastinoscopy and esophageal ultrasound fine-needle aspiration (EUS-FNA) in patients with non-small cell lung cancer (NSCLC) in the U.S. The researchers concluded that routine mediastinoscopy or EUS-FNA may not be helpful in patients with NSCLC after both positron emission tomography and computed tomography.

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. [Copyright &y& Elsevier]

Background: Clinical stage affects the care of patients with nonsmall cell lung cancer. Methods: This is a prospective trial on patients with suspected resectable nonsmall cell lung cancer. All patients underwent integrated positron emission tomographic scanning and computed tomographic scanning, and all suspicious metastatic sites were investigated. A, T, N, and M status was assigned. If N2, N3 and M1 were negative, patients underwent thoracotomy and complete thoracic lymphadenectomy. Results: There were 383 patients. The accuracy of clinical staging using positron emission tomographic scanning and computed tomographic scanning was 68% and 66% for stage I, 84% and 82% for stage II, 74% and 69% for stage III, and 93% and 92% for stage IV, respectively. N2 disease was discovered in 115 patients (30%) and was most common in the subcarinal lymph node (30%). Unsuspected N2 disease occurred in 28 patients (14%) and was most common in the posterior mediastinal lymph nodes (subcarinal, 38%; posterior aortopulmonary, 15%). It was found in 9% of patients who were clinically staged I (58% in the posterior mediastinal lymph nodes) and in 26% of patients clinically staged II (86% in posterior mediastinal lymph nodes). Conclusions: Despite integrated positron emission tomographic scanning and computed tomographic scanning, clinical staging remains relatively inaccurate for patients with nonsmall cell lung cancer. Recent studies suggest adjuvant therapy for stage Ib and II nonsmall cell lung cancer; thus the impact on preoperative care is to find unsuspected N2 disease. Unsuspected N2 disease is most common in posterior mediastinal lymph nodes inaccessible by mediastinoscopy. Thus one should consider endoscopic ultrasound fine-needle aspiration, especially for patients clinically staged as I and II, even if the nodes are negative on positron emission tomographic scanning and computed tomographic scanning. [Copyright &y& Elsevier]

Background: The treatment of patients with nonsmall cell lung cancer (NSCLC) is determined by the stage. We evaluated the accuracy of staging using integrated positron emission tomography (PET) and computed tomography (CT) and compared it with dedicated PET visually correlated with CT scan.Methods: A prospective blinded trial was performed on a consecutive series of patients with NSCLC. Patients underwent integrated PET-CT scanning with 2-[18F]-fluoro-2-deoxy-D-glucose (FDG-18). A radiologist assigned the T, N and M status. No sooner than 2 weeks the same radiologist read the dedicated PET alone, without the integrated CT images and a T, N and M status was assigned again. The most recent CT scan was available and visually correlated with both studies. All patients underwent biopsies of suspicious N2 or N3 lymph node or distant metastases and if negative, pulmonary resection with lymphadenectomy was performed.Results: There were 129 patients. Integrated PET-CT is a better predictor than PET for all stages of cancer and achieved statistical significance for stage I (52% versus 33%, p = 0.03) and for stage II (70% versus 36%, p = 0.04). It also is a better overall predictor for T status (70% versus 47%, p = 0.001) and the N status (78% versus 56%, p = 0.008). Nodal analysis shows that integrated PET-CT was more accurate for the total N2 nodes (96% versus 93%, p = 0.01) and for the total N1 nodes (90% versus 80%, p = 0.001). It was also more sensitive, specific, and had a higher positive predictive value for both N2 and N1 nodes (p < 0.05 for all). Integrated PET-CT is significantly more sensitive at the 4R, 5, 7, 10L and 11 stations and more accurate at the 7 and 11 lymph nodes stations than dedicated PET.Conclusions: Integrated PET-CT using FDG-18 better predicts stage I and II disease as well as the T and N status of patients with NSCLC when compared with dedicated PET alone. It is more accurate at some nodal stations but still only achieves an accuracy of 96% and 90% for the N2 and N1 nodes, respectively. [Copyright &y& Elsevier]

: BackgroundTo assess the role of flourodeoxyglucose–positron-emission tomography (FDG-PET) scan in staging patients with nonsmall cell lung cancer (NSCLC).: MethodsWe prospectively studied 400 patients with NSCLC. Each patient underwent a computed tomography (CT) scan of the chest and upper abdomen, other conventional staging studies and had a FDG-PET scan within 1 month before surgery. All suspicious N2 lymph nodes by either chest CT or by FDG-PET scan were biopsied. Patients that were N2 and M1 negative underwent pulmonary resection and complete thoracic lymphadenectomy.: ResultsThe FDG-PET had a higher sensitivity (71% vs 43%, p < 0.001), positive predictive value (44% vs 31%, p < 0.001), negative predictive value (91% vs 84%, p = 0.006), and accuracy (76% vs 68%, p = 0.037) than CT scan for N2 lymph nodes. Similarly, FDG-PET had a higher sensitivity (67% vs 41%, p < 0.001), but lower specificity (78% vs 88%, p = 0.009) than CT scan for N1 lymph nodes. FDG-PET led to unnecessary mediastinoscopy in 38 patients. FDG-PET was most commonly falsely negative in the subcarinal (#7) station and the aortopulmonary window lymph node (#5, #6) stations. It accurately upstaged 28 patients (7%) with unsuspected metastasis and it accurately downstaged 23 patients (6%).: ConclusionsThe FDG-PET scan allows for improved patient selection. It more accurately stages the mediastinum, however there are many false positives lymph nodes and it may be more likely to miss N2 disease in the #5, #6, and #7 stations. A positive FDG-PET scan means a tissue biopsy is indicated in that location. [Copyright &y& Elsevier]

The article focuses on the application of robotics in pulmonary resection. It outlines the advantages of robotic thoracic surgery over video-assisted thoracic surgery (VATS). Information is presented on the results of the study which investigated robotic pulmonary resection in patients with non-small cell lung cancer. It relates the disadvantages of robotics.

OBJECTIVES We evaluated factors that influenced morbidity and mortality in patients undergoing completion pneumonectomy (CP). METHODS A retrospective review of a consecutive series of patients who underwent CP at six international centres. RESULTS In total, 165 CP were performed between March 1990 and December 2009: 152 for malignant disease and 13 for benign disease. Forty-two patients (25.4%) underwent neoadjuvant therapy. Right CP was performed in 99 patients (60%) and left in 66 (40%). Thoracotomy was employed in 161 patients and median sternotomy in 4. Stapled closure of the bronchus was performed in 121 patients and hand closure in 44. The overall operative mortality was 10.3% (17 of 165). Operative mortality was 10.5% (16 of 152) in malignant diseases and 7.7% (1 of 13) in benign diseases. Complications occurred in 55.1% (91 of 165) of patients. Mean hospital stay was 16.02 ± 16.8 days (range: 3–151 days). Thirteen patients (7.9%) developed bronchopleural fistulas. No statistically significant relationship was found in mortality or morbidity according to side, gender, induction therapy and surgical approach. Stapled compared with hand closure for the bronchus did not affect the bronchopleural fistula rate (P = 0.4). The overall 5-year survival was 37.6%: 70.1% in benign disease (13 patients), 48.9% in squamous cell carcinoma of the lung (63 patients), 23.9% in primary lung adenocarcinoma (62 patients), 50% in grade 1 and grade 2 neuroendocrine carcinoma of the lung (4 patients), 54.7% in metastatic disease (14 patients) and 0% in primary lung sarcomas. A statistically significant better survival was observed in patients with squamous cell carcinoma versus adenocarcinoma (P = 0.04). CONCLUSIONS CP shows an acceptable operative mortality with a high morbidity rate. The overall 5-year survival is acceptable in properly selected patients (i.e. squamous cell carcinoma, metastatic disease). Side, gender, induction therapy and surgical approach did not influence mortality and morbidity. [ABSTRACT FROM AUTHOR]

Summary: Conventional treatments are not adequate for the majority of lung cancer patients. Conditionally replicating adenoviruses (CRAds) represent a promising new modality for the treatment of neoplastic diseases, including non-small cell lung cancer. Specifically, following cellular infection, the virus replicates selectively in the infected tumor cells and kills the cells by cytolysis. Next, the progeny virions infect a new population of surrounding target cells, replicate again and eradicate the infected tumor cells while leaving normal cells unaffected. However, to date, there have been two main limitations to successful clinical application of these CRAd agents; i.e. poor infectivity and poor tumor specificity. Here we report the construction of a CRAd agent, CRAd-CXCR4.RGD, in which the adenovirus E1 gene is driven by a tumor-specific CXCR4 promoter and the viral infectivity is enhanced by a capsid modification, RGD4C. This agent CRAd-CXCR4.RGD, as expected, improved both of the viral infectivity and tumor specificity as evaluated in an established lung tumor cell line and in primary tumor tissue from multiple patients. As an added benefit, the activity of the CXCR4 promoter was low in human liver as compared to three other promoters regularly used for targeting tumors. In addition, this agent has the potential of targeting multiple other tumor cell types. From these data, the CRAd-CXCR4.RGD appears to be a promising novel CRAd agent for lung cancer targeting with low host toxicity. [Copyright &y& Elsevier]