Preoperative Evaluation of Patients Undergoing Lung Resection Surgery: Defining the Role of the Anesthesiologist on a Multidisciplinary Team

IN THE FIELD of thoracic surgery, one of the key problems in lung resection is the management and function of the residual lung, which has the potential to interfere with both the pulmonary and cardiovascular systems, and, therefore, influence surgical outcome in terms of morbidity and mortality. Between 2007 and 2013, 5 papers addressing preoperative evaluation and risk stratification were published.1-5 However, the members of the task forces responsible for these documents did not include all the professionals involved in the preoperative surgical evaluation, and the documents mainly addressed the stratification of respiratory risk

Survival analysis in single N2 station lung adenocarcinoma: The prognostic role of involved lymph nodes and adjuvant therapy

Background: Prognostic factors in patients with single mediastinal station (sN2) involvement continues to be a debated issue. Methods: Data on 213 adenocarcinoma patients with sN2 involvement and who had undergone complete anatomical lung resection and lymphadenectomy, were retrospectively reviewed. Clinical and pathological characteristics together with adjuvant therapy (AD) and node (N) status classifications (number of resected nodes (#RN), number of metastatic nodes (#MN), and node ratio (#MN/#RN = NR) were analyzed. Results: Univariable analysis confirmed that age (0.009), #MN (0.009), NR (0.003), #N1 involved stations (p = 0.003), and skip metastases (p = 0.005) were related to overall survival (OS). Multivariable analysis confirmed, as independent prognostic factors, age <66 years and NR with a three-year OS (3YOS) of 78.7% in NR < 10% vs. 46.6% in NR > 10%. In skip metastases, NR (HR 2.734, 95% CI 1.417–5.277, p = 0.003) and pT stage (HR2.136, 95% CI 1.001–4.557, p = 0.050) were confirmed as independent prognostic factors. AD did not influence the OS of patients with singular positive lymph nodes (p = 0.41), while in patients with multiple lymph nodes and AD, a significantly better 3YOS was demonstrated, i.e., 49.1% vs. 30% (p = 0.004). In patients with N2 + N1 involvement, age (p = 0.002) and AD (p = 0.022) were favorable prognostic factors. Conclusions: Adenocarcinoma patients with single N2 station involvement had a favorable outcome in the case of skip metastases and low NR. Adjuvant therapy improves survival with multiple nodal involvement, while its role in single node involvement should be clarified

Correlation between tumor necrosis factor-alpha and D-dimer levels in non-small cell lung cancer patients

The present study was designed to investigate whether a correlation exists between IL-6, TNF-alpha and coagulation (Thrombin-antithrombin, TATc) or fibrinolysis (D-dimer) activation in non-small cell lung cancer (NSCLC) patients. One hundred thirty patients with NSCLC (n=65, 53 males, mean age 65 +/- 8, adenocarcinoma n=32, squamous cancer n=33) or chronic obstructive pulmonary disease (COPD) (n=65, 51 males, mean age 67 +/- 9) were studied. As control group 65 healthy donors (51 males, mean age 61 +/- 14) were also evaluated. The results obtained showed that median D-dimer levels were higher in NSCLC patients (3.0 microg/ml) compared either to COPD patients (1.1 microg/ml, P<0.05) or controls (0.3 microg/ml, P<0.0001). Positive TNF-alpha levels (>10 pg/ml) were found in 26% of NSCLC compared to 3% of COPD (P<0.002) and 5% of controls (P<0.0005). On the other hand, positive (>8.5 pg/ml) IL-6 levels were found in 53% of NSCLC and 21% of COPD patients, compared to 5% of control subjects (P<0.001). Median TATc levels were elevated in either NSCLC (6.9 microg/l) or COPD (5.7 microg/l) patients compared to controls (1.8 microg/l, P<0.0001). Elevated D-dimer levels were significantly associated to positive TNF-alpha levels in patients without distant metastasis (F=4.3, P<0.05). Moreover, TNF-alpha levels (P<0.01) were independently related to the presence of positive D-dimer levels in patients with non-metastatic NSCLC. These results suggest that increased levels of TNF-alpha might be responsible for an activation of fibrinolysis in patients with NSCLC

Pneumonectomy with en bloc chest wall resection : Is it worthwhile? Report on 34 patients from two institutions

OBJECTIVES: Pneumonectomy with en bloc chest wall resection is often denied because of the procedure-related high risk. We evaluated the short- and long-term outcome of this procedure. METHODS: From January 1995 to October 2011, 34 patients (30 males and 4 females; mean age: 61.8 years) underwent pneumonectomy with en bloc chest wall resection for 33 non-small-cell lung cancer and 1 metastatic osteosarcoma in two institutions. Data were retrospectively reviewed. RESULTS: Operative (30-day) mortality was 2.9% (1 of 34), and morbidity was 38.2% (13 of 34). There were 14 (41.1%) right-side procedures and 20 (58.8%) left-side procedures. Three (8.8%) patients developed bronchopleural fistulas. The mean number of resected ribs per patient was 2.7 \ub1 1.1. In 13 (38.2%) patients, a prosthetic reconstruction of the chest wall was needed. In 3 (8.8%) cases, the bronchial step was buttressed. Preoperative pain was statistically significantly related to the depth of chest wall invasion (P = 0.026). The N status was N0 in 18 (52.9%) cases, N1 in 9 (26.4%), N2 in 6 (17.6%) and Nx in 1 (metastatic osteosarcoma). Patients were followed-up for a total of 979 months. The median survival was 40 months. The overall 5-year survival was 46.8% (\ub1 95% confidence interval [CI]: 0.2-0.6): 45.2 (\ub1 95% CI: 0.03-0.8) for right-side and 48.4% (\ub1 95% CI: 0.2-0.7) for left-side procedures, respectively. According to the N status, the 5-year survival was 59.7 (\ub1 95% CI: 0.3-0.8) in N0, 55.5 (\ub1 95% CI: 0.06-1) in N1 and 16.6% (\ub1 95% CI: 0-0.4) in N2. The subgroup N0 plus N1 (27 patients) showed a 58.08% (\ub1 95% CI: 0.3-0.8) 5-year survival compared with 16.6% (\ub1 95% CI: 0-0.4) in N2 (\u3c7(2): 3.7; P = 0.053). CONCLUSIONS: Pneumonectomy with en bloc chest wall reconstruction can be safely offered to selected patients. The addition of en bloc chest wall resection to pneumonectomy does not affect operative mortality and morbidity compared with standard pneumonectomy. The pivotal additional effect of the chest wall resection should not be considered a contraindication for such procedures. Survival showed a clinically relevant difference by comparing N0 plus N1 with N2 (58.1 vs 16.6%), not confirmed by the statistical analysis (P = 0.053)

Prognostic impact of alternative splicing-derived hMENA isoforms in resected, node-negative, non-small-cell lung cancer

Risk assessment and treatment choice remain a challenge in early non-small-cell lung cancer (NSCLC). Alternative splicing is an emerging source for diagnostic, prognostic and therapeutic tools. Here, we investigated the prognostic value of the actin cytoskeleton regulator hMENA and its isoforms, hMENA(11a) and hMENA Delta v6, in early NSCLC. The epithelial hMENA(11a) isoform was expressed in NSCLC lines expressing E-CADHERIN and was alternatively expressed with hMENA Delta v6. Enforced expression of hMENA Delta v6 or hMENA(11a) increased or decreased the invasive ability of A549 cells, respectively. hMENA isoform expression was evaluated in 248 node-negative NSCLC. High pan-hMENA and low hMENA(11a) were the only independent predictors of shorter disease-free and cancer-specific survival, and low hMENA(11a) was an independent predictor of shorter overall survival, at multivariate analysis. Patients with low pan-hMENA/high hMENA(11a) expression fared significantly better (P &lt;= 0.0015) than any other subgroup. Such hybrid variable was incorporated with T-size and number of resected lymph nodes into a 3-class-risk stratification model, which strikingly discriminated between different risks of relapse, cancer-related death, and death. The model was externally validated in an independent dataset of 133 patients. Relative expression of hMENA splice isoforms is a powerful prognostic factor in early NSCLC, complementing clinical parameters to accurately predict individual patient risk