Impact of the Video-Assisted Lobectomy Approach on Maximal Oxygen Consumption, Pulmonary Function and Quality of Life of Lung Cancer Patients

Nowadays video-assisted lobectomy could be considered an appropriate treatment option for early stage lung cancer patients, as obtaining similar or even better early outcomes when compared to open standard lobectomy. This study was aimed at verifying the long-term impact (three months after surgery) of VATS-lobectomy technique on physical and mental status of patients undergoing lung resection for lung cancer and to compare the physical variation to the one registered after open approach. We enrolled patients treated by VATS-lobectomy at our institution since June 2012 to June 2015, comparing the preoperative physical evaluation (in terms of FEV1, DLCO and VO2max) and perceived quality of life (measured using the EORTC questionnaire) to the postoperative values. Moreover we performed a propensity score matching analysis to verify if the physical variation registered after VATS-lobectomy differed from that after open resection. We found a three months postoperative reduction of the physical indicators in comparison to the preoperative values (FEV1-variation: -8.3%, DLCO-variation: -12.4%, VO2max-variation: -6.6%). A similar negative trend was found for the psychological indicators, but the only parameter with a significative worsening was the perceived physical functioning (variation: -6.2%). The propensity score procedure yielded 83 well-matched open and VATS-lobectomy patients. The reductions in FEV1, DLCO and VO2max were similar in both groups (open patients’ reduction: FEV1 -10%, DLCO -11.9%, VO2max -5.5%; VATS patients’ reduction: FEV1 -7.2%, DLCO -10.6%, VO2max -6.9%), with a Cohen effect size < 0.2 for all the comparisons. In conclusion, VATS-lobectomy influences a reduction of the preoperative functional status three months after the operation, without affecting the postoperative perceived quality of life. Moreover VATS-lobectomy doesn’t offer any advantage in terms of FEV1, DLCO and exercise capacity recovery in comparison to the open approach

Risk-adjusted econometric model to estimate postoperative costs: An additional instrument for monitoring performance after major lung resection

ObjectivesThe objectives of this study were to develop a risk-adjusted model to estimate individual postoperative costs after major lung resection and to use it for internal economic audit.MethodsVariable and fixed hospital costs were collected for 679 consecutive patients who underwent major lung resection from January 2000 through October 2006 at our unit. Several preoperative variables were used to develop a risk-adjusted econometric model from all patients operated on during the period 2000 through 2003 by a stepwise multiple regression analysis (validated by bootstrap). The model was then used to estimate the postoperative costs in the patients operated on during the 3 subsequent periods (years 2004, 2005, and 2006). Observed and predicted costs were then compared within each period by the Wilcoxon signed rank test.ResultsMultiple regression and bootstrap analysis yielded the following model predicting postoperative cost: 11,078 + 1340.3X (age > 70 years) + 1927.8X cardiac comorbidity − 95X ppoFEV1%. No differences between predicted and observed costs were noted in the first 2 periods analyzed (year 2004, $6188.40 vs$6241.40, P = .3; year 2005, $6308.60 vs$6483.60, P = .4), whereas in the most recent period (2006) observed costs were significantly lower than the predicted ones ($3457.30 vs$6162.70, P < .0001).ConclusionsGreater precision in predicting outcome and costs after therapy may assist clinicians in the optimization of clinical pathways and allocation of resources. Our economic model may be used as a methodologic template for economic audit in our specialty and complement more traditional outcome measures in the assessment of performance

Development of a patient-centered aggregate score to predict survival after lung resection for non–small cell lung cancer

ObjectiveThe objective of this analysis was to develop a survival aggregate score (SAS), including objective and subjective patient-based parameters, and assess its prognostic role after major anatomic resection for non–small cell lung cancer.MethodsA total of 245 patients underwent major lung resections for non–small cell lung cancer with preoperative evaluation of quality of life (Short-Form 36v2 survey) and complete follow-up. The Cox multivariable regression and bootstrap analyses were used to identify prognostic factors of overall servival, which were weighted to construct the scoring system and summed to generate the SAS.ResultsCox regression analysis showed that the factors negatively associated with overall survival and used to construct the score were 36-item short-form health survey physical component summary score less than 50 (hazard ratio [HR], 1.7; P = .008), aged older than 70 years (HR, 1.9; P = .002), and carbon monoxide lung diffusion capacity less than 70% (HR, 1.7; P = .01). Patients were grouped into 4 risk classes according to their SAS. The 5-year overall survival was 78% in class SAS0, 59% in class SAS1, 42% in class SAS2, and 14% in class SAS3 (log-rank test, P < .0001). SAS maintained its association with overall survival in patients with stages pT1 (log-rank test, P = .01), pT2 (log-rank test, P = .02), or pT3-4 (log-rank test, P = .001), and in those with stages pN0 (log-rank test, P = .0005) or pN1-2 (log-rank test, P = .02). The 5-year cancer-specific survival was 83% in class SAS0, 71% in class SAS1, 63% in class SAS2, and 17% in class SAS3 (log-rank test, P < .0001).ConclusionsThis system may be used to refine stratification of prognosis for clinical and research purposes

Outcome after video-assisted thoracoscopic surgery and open pulmonary lobectomy in patients with low VO_{2 max}: a case-matched analysis from the ESTS database

n/

Surgery or Locoregional Approaches for Hepatic Oligometastatic Pancreatic Cancer: Myth, Hope, or Reality?

Despite extensive research, pancreatic ductal adenocarcinoma (PDAC) remains a difficult-to-treat cancer associated with poor survival. Due to the known aggressive disease biology, palliative chemotherapy is the only routinely recommended treatment in the metastatic setting in patients with adequate performance status. However, in a subset of patients with oligometastatic disease, multimodality treatment with surgery and/or locoregional approaches may provide long-term disease control and prolong survival. In fact, in highly selected cases, median overall survival has been reported to extend to 56 months in patients treated with surgery. In particular, liver and extraregional nodal resections may provide long-term tumor control with acceptable morbidity. Current guidelines do not recommend surgery for patients with metastatic PDAC and, in the case of PDAC with oligometastases, there are no published randomized controlled trials regarding locoregional or surgical approaches. Here we review the literature on surgical and locoregional approaches including radiofrequency ablation, irreversible electroporation, and stereotactic body radiation, and focus on patients with hepatic oligometastatic pancreatic cancer. We provide a summary regarding survival outcomes, morbidity and mortality and discuss selection criteria that may be useful to predict the best outcomes for such strategies

Short-term perioperative treatment with ambroxol reduces pulmonary complications and hospital costs after pulmonary lobectomy: a randomized trial☆

n/

Inability to perform maximal stair climbing test before lung resection: a propensity score analysis on early outcome

Abstract Objective: The objective of the present study was to assess whether patients unable to perform a preoperative maximal stair climbing test had an increased incidence of morbidity and mortality after major lung resection compared to patients who were able to exercise. Methods: Three hundred and ninety one patients submitted to pulmonary lobectomy or pneumonectomy for lung cancer were analyzed. Forty-five of these patients were unable to perform a preoperative maximal stair climbing test for underlying comorbidities. Unadjusted and propensity score case matched comparisons were performed between patients who could and who could not perform a preoperative stair climbing test. Multivariable analyses were then performed to identify predictors of morbidity and mortality, and were validated by bootstrap bagging. Results: Patients who could not perform the stair climbing test had similar morbidity rates (31.1 vs. 35.6%, respectively, PZ0.7), but higher mortality rates (15.6 vs. 4.4%, respectively, PZ0.08) and deaths among complicated patients (50 vs. 12.5%, respectively, PZ0.025), compared to propensity score matched patients who could perform the stair climbing test. Logistic regression analyses showed that the inability to perform the stair climbing test was an independent and reliable predictor of mortality (PZ0.005) but not of morbidity (PZ0.2). Conclusions: Patients unable to perform a preoperative maximal exercise test had an increased risk of mortality after major lung resection. Half of these patients did not survive postoperative complications, due to their decreased aerobic reserve caused by physical inactivity which made them unable to cope with the increased oxygen demand.

Development and Multicenter Validation of a Novel Immune-Inflammation-Based Nomogram to Predict Survival in Western Resectable Gastric and Gastroesophageal Junction Adenocarcinoma (GEA): The NOMOGAST

Background. More than 50% of operable GEA relapse after curative-intent resection. We aimed at externally validating a nomogram to enable a more accurate estimate of individualized risk in resected GEA. Methods. Medical records of a training cohort (TC) and a validation cohort (VC) of patients undergoing radical surgery for c/uT2-T4 and/or node-positive GEA were retrieved, and potentially interesting variables were collected. Cox proportional hazards in univariate and multivariate regressions were used to assess the effects of the prognostic factors on OS. A graphical nomogram was constructed using R software’s package Regression Modeling Strategies (ver. 5.0-1). The performance of the prognostic model was evaluated and validated. Results. The TC and VC consisted of 185 and 151 patients. ECOG:PS > 0 (p < 0.001), angioinvasion (p < 0.001), log (Neutrophil/Lymphocyte ratio) (p < 0.001), and nodal status (p = 0.016) were independent prognostic values in the TC. They were used for the construction of a nomogram estimating 3- and 5-year OS. The discriminatory ability of the model was evaluated with the c-Harrell index. A 3-tier scoring system was developed through a linear predictor grouped by 25 and 75 percentiles, strengthening the model’s good discrimination (p < 0.001). A calibration plot demonstrated a concordance between the predicted and actual survival in the TC and VC. A decision curve analysis was plotted that depicted the nomogram’s clinical utility. Conclusions. We externally validated a prognostic nomogram to predict OS in a joint independent cohort of resectable GEA; the NOMOGAST could represent a valuable tool in assisting decision-making. This tool incorporates readily available and inexpensive patient and disease characteristics as well as immune-inflammatory determinants. It is accurate, generalizable, and clinically effectivex

European guidelines on structure and qualification of general thoracic surgery

OBJECTIVE To update the recommendations for the structural characteristics of general thoracic surgery (GTS) in Europe in order to provide a document that can be used as a guide for harmonizing the general thoracic surgical practice in Europe. METHODS A task force was created to set the structural, procedural and qualification characteristics of a European GTS unit. These criteria were endorsed by the Executive Committee of the European Society of Thoracic Surgeons and by the Thoracic Domain of the European Association for Cardio-Thoracic Surgery and were validated by the European Board of Thoracic Surgery at European Union of Medical Specialists. RESULTS Criteria regarding definition and scope of GTS, structure and qualification of GTS unit, training and education and recommendations for subjects of particular interest (lung transplant, oesophageal surgery, minimally invasive thoracic surgery, quality surveillance) were developed. CONCLUSIONS This document will hopefully represent the first step of a process of revision of the modern thoracic surgeons' curricula, which need to be qualitatively rethought in the setting of the qualification process. The structural criteria highlighted in the present document are meant to help and tackle the challenge of cultural and language barriers as well as of widely varying national training programme