Urban-Rural Disparities in the Lung Cancer Surgical Treatment Pathway: The Paradox of a Rich, Small Region

Introduction: Rural populations in large countries often receive delayed or less effective diagnosis and treatment for lung cancer. Differences are related to population-based factors such as lower pro capita income or increased risk factors or to differences in access to facilities. Switzerland is a small, rich country with peculiar geographic and urban characteristics.We explored the relationship between lung cancer diagnostic-surgical pathway and urban-rural residency in our region. Methods: We retrospectively analyzed the medical records of 280 consecutive patients treated for primary non-small cell lung cancer at our institution (2017-2021). This is a regional tertiary center for diagnosis and treatment, and data were extracted from a prospectively collected clinical database. We included anatomical lung resection. Collected variables included patients and surgical characteristics, risk factors, comorbidities, histology and staging, symptoms (vs. incidental diagnosis), general practitioner (GP) involvement, health insurance, and suspected test-treatment interval. The exposure was rurality, defined by the 2009 rural-urban residency classification from the Department of Land. Results: A total of 150 patients (54%) lived in rural areas. Rural patients had a higher rate of smoking history (93% vs. 82%; p = 0.007). Symptomatic vs. incidental diagnosis did not differ as well as previous cancer rate, insurance, and pathological staging. In rural patients, there was a greater burden of comorbidities (mean Charlson Comorbidity Index Age-Adjusted 5.3 in rural population vs. 4.8 in urban population, p = 0.05), and GP was more involved in the diagnostic pathway (51% vs. 39%, p = 0.04). The interval between the first suspected test and treatment was significantly shorter (56 vs. 66.5 days, p = 0.03). Multiple linear regression with backward elimination was run. These variables statistically predicted the time from the first suspected test and surgical treatment [F(3, 270), p < .05, R 2 = 0.24]: rurality (p = 0.04), GP involvement (p = 0.04), and presence of lung cancer-related symptoms (p = 0.02). Conclusions: In our territory with inhomogeneous population distribution and geographic barriers, residency has an impact on the lung cancer pathway. It seems paradoxical that rural patients had a shorter route. The more constant involvement of GP might explain this finding, having suggested more tests for high-risk patients in the absence of symptoms or follow-ups. This did not change the staging of surgical patients, but it might be essential for the organization of an effective lung cancer screening program. Keywords: lung cancer; rurality; screening; surgical treatment; treatment disparitie

Spiral wire localization of lung nodules: procedure effectiveness and oncological usefulness

Background: In the last years, a large number of techniques and devices for localizing small pulmonary nodules prior to resection have been developed with the aim of facilitating minimally invasive surgery (VATS). However, each device presents pros and cons and there is no unanimous consensus. We report our experience with an uncommon wire system with spiral shape for percutaneous marking. Methods: We recorded 102 consecutive CT-guided spiral wire localizations in our Institution, and we evaluated the efficacy of the method according to 4 success rates (SR): (I) successful targeting rate (SR-1): number of successful targeting procedures/number of all localizations; (II) successful localization in operative field (SR-2): (number of successful targeting procedures -number of dislodgements in operative field)/number of all localizations; (III) successful VATS rate (SR-3): number of successful VATS procedures/(number of localizations-number of thoracotomies not due to wire dislocation); (IV) successful curative rate (SR-4): number of neoplastic nodules resected with curative intent with free margins (R0) on definitive tissue diagnosis/number of neoplastic nodules resected with curative intent. Complications rate was recorded as well. Results: SR-1: 100%, SR-2: 97.1%, SR-3: 100%, SR-4: 100%. Asymptomatic pneumothorax and minimal parenchymal hemorrhage were observed in 5 (4.9%) and 19 (18.6%) cases, respectively. Conclusions: Spiral wire localization showed very good results in terms of feasibility, stability in operative field and contributed to effective use of VATS during wedge resection performed for malignant nodules. In the era of widespread radiological investigations (as it is happening in lung cancer screening) and evolutions in cancer treatments, this appears to be clinically relevant

Tracking the outcomes of surgical treatment of Stage 2 and 3 empyema: introduction and consolidation of minimally invasive approach

BACKGROUND We described the results of surgical treatment of empyema, tracing outcomes throughout the passage from the open thoracotomy (OT) approach to video-assisted thoracoscopic surgery (VATS) in a single institute. METHODS We retrospectively analyzed the records of 88 consecutive patients treated for Stage 2 and 3 empyema (2010-2019). We divided the study period into three groups: OT period (2010-2013), early VATS (2014-2017, from the introduction of VATS program, until acme of learning curve), and late VATS (2018-2019). Groups were compared to investigate the outcomes evolution. RESULTS Most relevant findings of the study were significant variation in postoperative length of stay (median [interquartile range]: 9 days [7.5-10], 10 [7.5-17.5], and 7 [5-10] for OT period, early VATS, and late VATS, respectively, p = 0.005), hospital admission referral to thoracic surgery interval (7.5 days [4.5-11], 6.5 [3-9], and 2.5 [1.5-5.5], p = 0.003), chest tube duration (5.5 days [5-7.5], 6 [4-6], 4 [3-5], p = 0.003), and proportion of operation performed by residents (3 [15%], 6 [16.7%], 14 [43.6%], p = 0.01). CONCLUSIONS Our findings pictured the trajectory evolution of outcomes during introduction and consolidation of VATS treatment of empyema. During the early phase, we observed a decline in some indicators that improved significantly in the late VATS period. After a learning curve, all outcomes showed better results and we entered into a teaching phase

Surgical treatment of pleural empyema in Coronavirus disease 19 patients: the Southern Switzerland experience

We report the first surgical series of patients developing pleural empyema after severe bilateral interstitial lung disease in confirmed severe acute respiratory syndrome coronavirus 2 infection. The empyema results in a complex medical challenge that requires combination of medical therapies, mechanical ventilation and surgery. The chest drainage approach was not successful to relieve the symptomatology and to drain the excess fluid. After multidisciplinary discussion, a surgical approach was recommended. Even though decortication and pleurectomy are high-risk procedures, they must be considered as an option for pleural effusion in Coronavirus disease-positive patients. This is a life-treating condition, which can worsen the coronavirus disease manifestation and should be treated immediately to improve patient's status and chance of recovery

Effect of postoperative haemoglobin variation on major cardiopulmonary complications in high cardiac risk patients undergoing anatomical lung resections

OBJECTIVES: Recent evidence shows that permissive anaemia strategies are safe in different surgical settings. However, effects of variations in haemoglobin (Hb) levels could have a negative impact in high-risk patients. We investigated the combined effect of postoperative Hb concentration and cardiac risk status on major cardiopulmonary complications after anatomical lung resections. METHODS: We retrospectively analysed the records, collected in a prospective clinical database, of 154 consecutive patients undergoing anatomical lung resections at our institution (February 2017-February 2019). Hb levels were displayed as preoperative concentration, nadir Hb level before onset of complications and delta Hb (ΔHb). Cardiac risk was stratified according to the Thoracic Revised Cardiac Risk Index (ThRCRI). Univariable and multivariable logistic regression analyses were used to test the associations between patients, surgical variables and cardiopulmonary complications according to the European Society of Thoracic Surgeons definitions. RESULTS: Cardiopulmonary complications occurred in 63 patients (17%). In the fully adjusted multivariable model, higher values of ΔHb were associated with increased risk of complications [odds ratio (OR) 1.07; P < 0.001], along with higher ThRCRI classes (classes A-B versus C-D: OR 0.09; P < 0.001). Interaction terms with transfusion were not statistically significant, indicating that the harmful effect of ΔHb was independent. According to receiver operating characteristic curve analysis, a ΔHb of 29 g/l was found to be the best cut-off value for predicting complications. CONCLUSIONS: In our series, ΔHb, rather than nadir Hb, was associated with an increased risk of complications, particularly in patients with higher cardiac risk. Restrictive transfusion strategies should be carefully applied in patients undergoing lung resections and balanced according to individual clinical status