571133
research-article2015
SCVXXX10.1177/1089253215571133Seminars in Cardiothoracic and Vascular AnesthesiaWeyant
The Perioperative Year in Review 2014
The Year in Thoracic Surgery: Highlights From 2014
Seminars in Cardiothoracic and Vascular Anesthesia 2015, Vol. 19(1) 24–28 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1089253215571133 scv.sagepub.com
Michael J. Weyant, MD1
Abstract The year 2014 produced several noteworthy articles that have advanced the care of thoracic surgery patients. Further knowledge has been gained regarding screening and treatment of early stage lung cancer. The use of neoadjuvant therapy for subsets of patients with esophageal cancer continues to evolve. Endobronchial therapy for emphysema is reported in a multicenter trial. The purpose of this review is to highlight the major advances in thoracic surgical disease in the year 2014. Keywords thoracic surgery, lung cancer screening, emphysema, lung cancer, stereotactic radiotherapy (SBRT), neoadjuvant therapy, esophageal cancer, smoking cessation
Introduction The field of thoracic surgery continues to evolve, with several innovative articles published each year that modify and improve our daily practice in thoracic surgery. The year 2014 continued this trend with many new contributions to the literature. These articles were contributed not only by surgeons but also by investigators in non–surgically related fields. The number of articles published exceeds the ability of practitioners to address them all and remain current in the field. The purpose of this article is to highlight some of the pertinent articles published in 2014 that pertain to thoracic surgery and that may be of interest to cardiothoracic anesthesiologists and thoracic surgeons alike. As with other articles in this series of Seminars in Cardiothoracic and Vascular Anesthesia, this article is not meant to be a comprehensive review of all the literature published in 2014 but more a discussion of selected, quality articles addressing current issues and innovations in the field of thoracic surgery. The year 2013 was monumental in the demonstration of the viability of computed tomographic screening of patients at high risk of developing lung cancer. Given this major advancement, it is no surprise that some of the pertinent literature published in 2014 pertains to lung cancer screening. The identification of more and smaller lung cancers continues to challenge our way of thinking regarding the management of these small lesions. The use of nonsurgical modalities such as stereotactic radiotherapy to treat these lesions is often discussed. Critical review of the literature published in this area is valuable to determine the most beneficial therapy for these patients. The publication of a definitive article demonstrating the benefits of neoadjuvant therapy for locally advanced
esophageal cancer in 2011 has transformed how we treat patients with esophageal cancer. The additions to the literature in 2014 regarding esophageal cancer focus now on identifying subsets of patients with esophageal cancer that may or may not benefit from this aggressive approach. One such article is discussed here. Last it is often overlooked that advances can be made in areas of thoracic surgery that do not address cancer-related issues. One such article is discussed here. It has been many years since pertinent articles have been published regarding the procedural management of emphysema. A multicenter trial regarding the endobronchial treatment of emphysema is discussed here as well. The following review summarizes important findings from these articles published over the past year as well as a discussion of the associated strengths and weaknesses. The reader is encouraged to reference these articles for more details on the important updates in thoracic surgery during 2014.
Wedge Resection Versus Stereotactic Body Radiotherapy (SBRT) for Early Stage Lung Cancer Thoracic surgeons are routinely faced with the decision of how to manage early stage lung cancer in patients who are marginal candidates for lobar resection that is considered 1
University of Colorado School of Medicine, Aurora, CO, USA
Corresponding Author: Michael J. Weyant, University of Colorado School of Medicine, 12631 East 17th Avenue, MS C310, Aurora, CO 80045, USA. Email: [email protected]
Downloaded from scv.sagepub.com at NANYANG TECH UNIV LIBRARY on April 26, 2015
25
Weyant the gold standard of care. In the past the main alternative was to consider sublobar or wedge resection in these patients. The introduction of SBRT as treatment for these lesions has expanded our options for treatment of these compromised patients. The published experience in the treatment of these patients has demonstrated SBRT to potentially reduce the risks of surgery in this high-risk group. These findings have led some practitioners to suggest that SBRT could be a viable treatment option in uncompromised patients. Port and colleagues1 performed a review of a large prospectively collected database from a single institution and selected patients with clinical stage IA lung cancer. Patients undergoing SBRT or brachytherapy were also included in this database. Using propensity analysis, patients undergoing wedge resection and SBRT who were operable according to spirometry criteria and had adequate cardiopulmonary reserve were selected. Statistical analysis was used to measure cancer recurrence and mortality. The authors were able to identify 38 patients undergoing a wedge resection and 23 undergoing SBRT over an 11-year period that had comparable but adequate physical function. The small sample size is due to the small number of SBRT patients who were treated and had operable physiologic criteria. Median follow-up was 35 months. Overall recurrence was significantly higher after SBRT (wedge 9.5%; SBRT 30%; P = .16). Additionally, recurrence-free 3-year survival was significantly better in the surgery group compared with SBRT (88% vs 72%; P = .001). These findings suggest that wedge resection is superior to SBRT in operable patients. Analysis of this study would suggest that it is difficult to generate meaningful results given the small sample size of each group. However, there are very few studies evaluating the results of SBRT in operable patients, and this analysis is a valuable tool to help guide future studies. Using the proposed propensity analysis outlined by the authors, similar groups of patients were studied, which lends strength to their analysis. The main point that should be disseminated from this article is that the standard of care for the treatment of early stage lung cancer continues to be surgical resection.
Increased Smoking Cessation in Lung Cancer Screening Patients The United States Lung Screening Trial (NLST) demonstrated that annual low-dose computed tomography screening reduces lung cancer mortality by 20% compared with chest x-ray screening. Multiple subsequent publications from the NLST database have addressed other issues such as a cost analysis of screening the group of patients at high risk for lung cancer. Tammemägi and colleagues2 examine the effect lung cancer screening has on smoking cessation.
The authors used the database of 53 452 patients enrolled in the NLST trial and examined a subset of 16 265 who were baseline smokers. The authors evaluated whether annual self-reported smoking behavior was associated with preceding results. The primary predictor of interest was screening result, which was classified as normal, negative but minor abnormalities, negative but significant new abnormalities, or positive for lung cancer. The authors used statistical analysis to correlate the effect of the results of screening regarding the severity of the results with the rate of smoking decline in the study population. It was demonstrated that the highest proportion of smoking occurred in those with a normal screen. The second highest proportion occurred in those that had a screen with a minor abnormality followed by an even lower proportion in those with major noncancerous findings on the screening computed tomography. The cumulative impact of screening results on smoking prevalence appeared to be durable with a statistically significant observed difference 5 years after the last screening. The authors also performed a multiple regression model to evaluate predictors of continued smoking in those known to be baseline smokers. Increased risk of continued smoking was associated with younger age, lower education, being spousless, lower body mass index, history of heavier smoking intensity, and exposure to secondhand smoke. This study illustrates yet another potential beneficial aspect of screening for lung cancer. The study is aided by an extremely large data set and only suffers from being retrospective in nature. It is likely that more publications like this will arise in the years to come demonstrating more tangible benefits of using lung cancer screening.
Lung Cancer Screening Supported by the Centers for Medicare and Medicaid Services (CMS) The results of the NLST were evaluated by CMS and was viewed favorably in regard to coverage for screening in high-risk patients.3 The CMS proposed that the evidence is sufficient to add a lung cancer screening counseling and shared decision making visit, and for appropriate beneficiaries, screening for lung cancer with low-dose computed tomography (LDCT), once per year, as an additional preventive service benefit under the Medicare program. The highlights of the beneficiary eligibility criteria are as follows: •• Age 55-74 years •• Asymptomatic (no signs or symptoms of lung disease) •• Tobacco smoking history of at least 30 pack-years (1 pack-year smoking 1 pack per day for 1 year; 1 pack = 20 cigarettes)
Downloaded from scv.sagepub.com at NANYANG TECH UNIV LIBRARY on April 26, 2015
26
Seminars in Cardiothoracic and Vascular Anesthesia 19(1)
•• Current smoker or one who has quit smoking within the last 15 years •• A written order for LDCT lung cancer screening that meets CMS criteria included in an initial established visit •• Documentation of tobacco cessation counseling The radiologists who will be reimbursed for interpreting screening studies must meet the following eligibility criteria: •• Current certification with the American Board of Radiology or equivalent organization
Data Type Facility Radiologist (reading) Patient Ordering practitioner Demographics Indication Smoking history CT scanner Effective radiation dose Screening exam results Diagnostic follow-up of abnormal findings within 1 year Lung cancer incidence within 1 year Health outcomes
•• Documented training in diagnostic radiology and radiation safety •• Involvement in the supervision and interpretation of at least 300 chest computed tomography acquisitions in the past 3 years •• Documented participation in continuing medical education in accordance with current American College of Radiology standards The data from screening visits must be collected in a registry and submitted to a CMS-approved national registry. The data submitted must include, at minimum, all of the following elements:
Minimum Required Data Elements Identifier National Provider Identifier (NPI) Identifier National Provider Identifier (NPI) Date of birth, gender, race/ethnicity Lung cancer LDCT screening—absence of signs or symptoms (yes/no) Current status (current, former, never) If former smoker, years since quitting Pack-years as reported by the ordering practitioner Manufacturer, model CT dose index, tube current-time, tube voltage, scanning time, scanning volume, pitch, slice thickness (collimation) Baseline or repeat screen Screen date Clinically significant non–lung cancer findings (yes/no); if yes, list Nodule (yes/no), if yes: number, type (calcified or noncalcified; solid or semisolid), size, and location of each nodule Low-dose chest CT Diagnostic chest CT Bronchoscopy Nonsurgical biopsy Resection (with dates) Other (please specify) Incident cancers Date of diagnosis Stage Histology Period of follow-up for incidence All-cause mortality Lung cancer mortality Death within 60 days after most invasive diagnostic procedure
Abbreviations: CT, computed tomography; LDCT, low-dose computed tomography.
Although this is not a peer-reviewed publication, the impact of this legislation could have significant impact on thoracic surgeons. Given the integral involvement of
thoracic surgeons in lung cancer screening, we will need to be integrally involved in the decision-making process regarding resection and management of screening detected lesions.
Downloaded from scv.sagepub.com at NANYANG TECH UNIV LIBRARY on April 26, 2015
27
Weyant
Endobronchial Coil Treatment of Advanced Heterogeneous Chronic Obstructive Pulmonary Disease (COPD) Patients with advanced lung disease secondary to chronic obstructive pulmonary disease have few options for definitive treatment of their disease. Lung volume reduction surgery (LVRS) and lung transplantation can be used in highly selected patients. However, the morbidity is high in LVRS patients, and in the case of transplantation, significant donor shortage hinders widespread usage. Endobronchial valves have proven to be useful in some patients but only a small percentage of patients experience success with this modality due to collateral ventilation between lobes.4 Lung volume reduction coils have been developed that are thought to be useful in patients with collateral ventilation.4 Deslee and colleagues report on a multicenter feasibility trial based in Europe. The study is a prospective open-label multicenter trial involving 11 hospitals in France, Germany, and the Netherlands. Patients with upper lobe predominant disease were included. The primary endpoint studied was improvement in the St. George’s Respiratory Questionnaire (SGRQ). Secondary endpoints studied included improvements in spirometry values and 6-minute walk distance (6MWD). Sixty patients were enrolled over the 2-year period of the study from December 2009 to October 2011. Serious adverse events included COPD exacerbations (6.1%), pneumonia (5.2%), pneumothorax (3.5%), and hemoptysis (0.9%), with no deaths being reported. Patients in the study showed significant improvements in the SGRQ, 6MWD, and FEV1, which was durable at least up to 1 year. These results are significant as it demonstrates benefits in patients with COPD using newer technology. The device is also demonstrated to be safe with comparable side effects to standard treatment. Clearly these data set the stage for a prospective randomized trial. The study has the potential for bias due to its cohort nature, but this is understandable given that this is mainly a feasibility study.
Management of T2N0 Esophageal Cancer Recent data published regarding the management of locally advanced esophageal carcinoma for the first time definitively established a positive role for neoadjuvant chemoradiotherapy for these patients. Additionally data supporting only local therapy for early staged esophageal cancer exists to guide surgeons in the decision to manage early staged localized disease. These studies do not provide clear recommendations on how to manage T2N0 esophageal cancer. There are several reasons for this as it is in a watershed area of our knowledge. Early staged tumors are much less likely
to be node positive, thus making the logical decision to avoid systemic therapy logical. T2N0 tumors are in a group of tumors that is somewhat rare and also challenging to accurately diagnose. The main determinant of stage is a pretreatment endoscopic ultrasound. Diagnosing T2 lesions has a lower accuracy rate than either T3 or T1 tumors. Speicher et al5 report on a large series of T2N0 lesions obtained from the national cancer database. This is one of the largest series evaluating this tumor stage. The authors identify 4799 patients from this database as having T2N0 lesions. Interestingly, only 2057 (42.9%) of patients had esophagectomy as part of their treatment. The authors identified education level and treatment at an academic medical center as predictors of being offered esophagectomy in patients with T2N0 disease. When comparing surgical to nonsurgically managed patients, the survival was significantly higher for those patients who had esophagectomy. The 2057 patients who had esophagectomy were then divided according to surgery alone versus induction therapy followed by surgery. A total of 871 patients had surgery alone versus 688 patients who has induction therapy followed by surgery. The authors conclude that there was no survival difference in patients who had induction therapy with T2N0 disease. One of the arguments regarding using induction therapy is that there are a significant number of patients who are upstaged after resection and found to be node positive. In this study, there was no survival benefit even in those patients who have been upstaged to positive nodal status.
Conclusion The management of thoracic surgical disease continues to evolve. The care of thoracic surgical patients continues to improve through clinical research in areas both directly and indirectly related to thoracic surgery. The summary presented here illustrates the continued need for dedicated clinical trials and dedicated research personnel in these areas. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Port JL, Parashar B, Osakwe N, et al. A propensity-matched analysis of wedge resection and stereotactic body radiotherapy for early stage lung cancer. Ann Thorac Surg. 2014;98: 1152-1159.
Downloaded from scv.sagepub.com at NANYANG TECH UNIV LIBRARY on April 26, 2015
28
Seminars in Cardiothoracic and Vascular Anesthesia 19(1)
2. Tammemägi MC, Berg CD, Riley TL, Cunningham CR, Taylor KL. Impact of lung cancer screening results on smoking cessation. J Natl Cancer Inst. 2014;106(6):dju081. doi:10.1093/jnci/dju084. 3. Proposed Decision Memo for Screening for Lung Cancer with Low Dose Computed Tomography. Centers for Medicare & Medicaid Services. http://www.cms.gov/medicare-cover age-database/details/nca-proposed-decision-memo. Accessed January 23, 2015.
4. Deslee G, Klooster K, Hetzel M, et al. Lung volume reduction coil treatment for patients with severe emphysema: a European multicentre trial. Thorax. 2014;69: 980-986. 5. Speicher PJ, Ganapathi AM, Englum BR, et al. Induction therapy does not improve survival for clinical stage T2N0 esophageal cancer. J Thorac Oncol. 2014;9:1195-1201.
Downloaded from scv.sagepub.com at NANYANG TECH UNIV LIBRARY on April 26, 2015
research-article2015
SCVXXX10.1177/1089253215571133Seminars in Cardiothoracic and Vascular AnesthesiaWeyant
The Perioperative Year in Review 2014
The Year in Thoracic Surgery: Highlights From 2014
Seminars in Cardiothoracic and Vascular Anesthesia 2015, Vol. 19(1) 24–28 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1089253215571133 scv.sagepub.com
Michael J. Weyant, MD1
Abstract The year 2014 produced several noteworthy articles that have advanced the care of thoracic surgery patients. Further knowledge has been gained regarding screening and treatment of early stage lung cancer. The use of neoadjuvant therapy for subsets of patients with esophageal cancer continues to evolve. Endobronchial therapy for emphysema is reported in a multicenter trial. The purpose of this review is to highlight the major advances in thoracic surgical disease in the year 2014. Keywords thoracic surgery, lung cancer screening, emphysema, lung cancer, stereotactic radiotherapy (SBRT), neoadjuvant therapy, esophageal cancer, smoking cessation
Introduction The field of thoracic surgery continues to evolve, with several innovative articles published each year that modify and improve our daily practice in thoracic surgery. The year 2014 continued this trend with many new contributions to the literature. These articles were contributed not only by surgeons but also by investigators in non–surgically related fields. The number of articles published exceeds the ability of practitioners to address them all and remain current in the field. The purpose of this article is to highlight some of the pertinent articles published in 2014 that pertain to thoracic surgery and that may be of interest to cardiothoracic anesthesiologists and thoracic surgeons alike. As with other articles in this series of Seminars in Cardiothoracic and Vascular Anesthesia, this article is not meant to be a comprehensive review of all the literature published in 2014 but more a discussion of selected, quality articles addressing current issues and innovations in the field of thoracic surgery. The year 2013 was monumental in the demonstration of the viability of computed tomographic screening of patients at high risk of developing lung cancer. Given this major advancement, it is no surprise that some of the pertinent literature published in 2014 pertains to lung cancer screening. The identification of more and smaller lung cancers continues to challenge our way of thinking regarding the management of these small lesions. The use of nonsurgical modalities such as stereotactic radiotherapy to treat these lesions is often discussed. Critical review of the literature published in this area is valuable to determine the most beneficial therapy for these patients. The publication of a definitive article demonstrating the benefits of neoadjuvant therapy for locally advanced
esophageal cancer in 2011 has transformed how we treat patients with esophageal cancer. The additions to the literature in 2014 regarding esophageal cancer focus now on identifying subsets of patients with esophageal cancer that may or may not benefit from this aggressive approach. One such article is discussed here. Last it is often overlooked that advances can be made in areas of thoracic surgery that do not address cancer-related issues. One such article is discussed here. It has been many years since pertinent articles have been published regarding the procedural management of emphysema. A multicenter trial regarding the endobronchial treatment of emphysema is discussed here as well. The following review summarizes important findings from these articles published over the past year as well as a discussion of the associated strengths and weaknesses. The reader is encouraged to reference these articles for more details on the important updates in thoracic surgery during 2014.
Wedge Resection Versus Stereotactic Body Radiotherapy (SBRT) for Early Stage Lung Cancer Thoracic surgeons are routinely faced with the decision of how to manage early stage lung cancer in patients who are marginal candidates for lobar resection that is considered 1
University of Colorado School of Medicine, Aurora, CO, USA
Corresponding Author: Michael J. Weyant, University of Colorado School of Medicine, 12631 East 17th Avenue, MS C310, Aurora, CO 80045, USA. Email: [email protected]
Downloaded from scv.sagepub.com at NANYANG TECH UNIV LIBRARY on April 26, 2015
25
Weyant the gold standard of care. In the past the main alternative was to consider sublobar or wedge resection in these patients. The introduction of SBRT as treatment for these lesions has expanded our options for treatment of these compromised patients. The published experience in the treatment of these patients has demonstrated SBRT to potentially reduce the risks of surgery in this high-risk group. These findings have led some practitioners to suggest that SBRT could be a viable treatment option in uncompromised patients. Port and colleagues1 performed a review of a large prospectively collected database from a single institution and selected patients with clinical stage IA lung cancer. Patients undergoing SBRT or brachytherapy were also included in this database. Using propensity analysis, patients undergoing wedge resection and SBRT who were operable according to spirometry criteria and had adequate cardiopulmonary reserve were selected. Statistical analysis was used to measure cancer recurrence and mortality. The authors were able to identify 38 patients undergoing a wedge resection and 23 undergoing SBRT over an 11-year period that had comparable but adequate physical function. The small sample size is due to the small number of SBRT patients who were treated and had operable physiologic criteria. Median follow-up was 35 months. Overall recurrence was significantly higher after SBRT (wedge 9.5%; SBRT 30%; P = .16). Additionally, recurrence-free 3-year survival was significantly better in the surgery group compared with SBRT (88% vs 72%; P = .001). These findings suggest that wedge resection is superior to SBRT in operable patients. Analysis of this study would suggest that it is difficult to generate meaningful results given the small sample size of each group. However, there are very few studies evaluating the results of SBRT in operable patients, and this analysis is a valuable tool to help guide future studies. Using the proposed propensity analysis outlined by the authors, similar groups of patients were studied, which lends strength to their analysis. The main point that should be disseminated from this article is that the standard of care for the treatment of early stage lung cancer continues to be surgical resection.
Increased Smoking Cessation in Lung Cancer Screening Patients The United States Lung Screening Trial (NLST) demonstrated that annual low-dose computed tomography screening reduces lung cancer mortality by 20% compared with chest x-ray screening. Multiple subsequent publications from the NLST database have addressed other issues such as a cost analysis of screening the group of patients at high risk for lung cancer. Tammemägi and colleagues2 examine the effect lung cancer screening has on smoking cessation.
The authors used the database of 53 452 patients enrolled in the NLST trial and examined a subset of 16 265 who were baseline smokers. The authors evaluated whether annual self-reported smoking behavior was associated with preceding results. The primary predictor of interest was screening result, which was classified as normal, negative but minor abnormalities, negative but significant new abnormalities, or positive for lung cancer. The authors used statistical analysis to correlate the effect of the results of screening regarding the severity of the results with the rate of smoking decline in the study population. It was demonstrated that the highest proportion of smoking occurred in those with a normal screen. The second highest proportion occurred in those that had a screen with a minor abnormality followed by an even lower proportion in those with major noncancerous findings on the screening computed tomography. The cumulative impact of screening results on smoking prevalence appeared to be durable with a statistically significant observed difference 5 years after the last screening. The authors also performed a multiple regression model to evaluate predictors of continued smoking in those known to be baseline smokers. Increased risk of continued smoking was associated with younger age, lower education, being spousless, lower body mass index, history of heavier smoking intensity, and exposure to secondhand smoke. This study illustrates yet another potential beneficial aspect of screening for lung cancer. The study is aided by an extremely large data set and only suffers from being retrospective in nature. It is likely that more publications like this will arise in the years to come demonstrating more tangible benefits of using lung cancer screening.
Lung Cancer Screening Supported by the Centers for Medicare and Medicaid Services (CMS) The results of the NLST were evaluated by CMS and was viewed favorably in regard to coverage for screening in high-risk patients.3 The CMS proposed that the evidence is sufficient to add a lung cancer screening counseling and shared decision making visit, and for appropriate beneficiaries, screening for lung cancer with low-dose computed tomography (LDCT), once per year, as an additional preventive service benefit under the Medicare program. The highlights of the beneficiary eligibility criteria are as follows: •• Age 55-74 years •• Asymptomatic (no signs or symptoms of lung disease) •• Tobacco smoking history of at least 30 pack-years (1 pack-year smoking 1 pack per day for 1 year; 1 pack = 20 cigarettes)
Downloaded from scv.sagepub.com at NANYANG TECH UNIV LIBRARY on April 26, 2015
26
Seminars in Cardiothoracic and Vascular Anesthesia 19(1)
•• Current smoker or one who has quit smoking within the last 15 years •• A written order for LDCT lung cancer screening that meets CMS criteria included in an initial established visit •• Documentation of tobacco cessation counseling The radiologists who will be reimbursed for interpreting screening studies must meet the following eligibility criteria: •• Current certification with the American Board of Radiology or equivalent organization
Data Type Facility Radiologist (reading) Patient Ordering practitioner Demographics Indication Smoking history CT scanner Effective radiation dose Screening exam results Diagnostic follow-up of abnormal findings within 1 year Lung cancer incidence within 1 year Health outcomes
•• Documented training in diagnostic radiology and radiation safety •• Involvement in the supervision and interpretation of at least 300 chest computed tomography acquisitions in the past 3 years •• Documented participation in continuing medical education in accordance with current American College of Radiology standards The data from screening visits must be collected in a registry and submitted to a CMS-approved national registry. The data submitted must include, at minimum, all of the following elements:
Minimum Required Data Elements Identifier National Provider Identifier (NPI) Identifier National Provider Identifier (NPI) Date of birth, gender, race/ethnicity Lung cancer LDCT screening—absence of signs or symptoms (yes/no) Current status (current, former, never) If former smoker, years since quitting Pack-years as reported by the ordering practitioner Manufacturer, model CT dose index, tube current-time, tube voltage, scanning time, scanning volume, pitch, slice thickness (collimation) Baseline or repeat screen Screen date Clinically significant non–lung cancer findings (yes/no); if yes, list Nodule (yes/no), if yes: number, type (calcified or noncalcified; solid or semisolid), size, and location of each nodule Low-dose chest CT Diagnostic chest CT Bronchoscopy Nonsurgical biopsy Resection (with dates) Other (please specify) Incident cancers Date of diagnosis Stage Histology Period of follow-up for incidence All-cause mortality Lung cancer mortality Death within 60 days after most invasive diagnostic procedure
Abbreviations: CT, computed tomography; LDCT, low-dose computed tomography.
Although this is not a peer-reviewed publication, the impact of this legislation could have significant impact on thoracic surgeons. Given the integral involvement of
thoracic surgeons in lung cancer screening, we will need to be integrally involved in the decision-making process regarding resection and management of screening detected lesions.
Downloaded from scv.sagepub.com at NANYANG TECH UNIV LIBRARY on April 26, 2015
27
Weyant
Endobronchial Coil Treatment of Advanced Heterogeneous Chronic Obstructive Pulmonary Disease (COPD) Patients with advanced lung disease secondary to chronic obstructive pulmonary disease have few options for definitive treatment of their disease. Lung volume reduction surgery (LVRS) and lung transplantation can be used in highly selected patients. However, the morbidity is high in LVRS patients, and in the case of transplantation, significant donor shortage hinders widespread usage. Endobronchial valves have proven to be useful in some patients but only a small percentage of patients experience success with this modality due to collateral ventilation between lobes.4 Lung volume reduction coils have been developed that are thought to be useful in patients with collateral ventilation.4 Deslee and colleagues report on a multicenter feasibility trial based in Europe. The study is a prospective open-label multicenter trial involving 11 hospitals in France, Germany, and the Netherlands. Patients with upper lobe predominant disease were included. The primary endpoint studied was improvement in the St. George’s Respiratory Questionnaire (SGRQ). Secondary endpoints studied included improvements in spirometry values and 6-minute walk distance (6MWD). Sixty patients were enrolled over the 2-year period of the study from December 2009 to October 2011. Serious adverse events included COPD exacerbations (6.1%), pneumonia (5.2%), pneumothorax (3.5%), and hemoptysis (0.9%), with no deaths being reported. Patients in the study showed significant improvements in the SGRQ, 6MWD, and FEV1, which was durable at least up to 1 year. These results are significant as it demonstrates benefits in patients with COPD using newer technology. The device is also demonstrated to be safe with comparable side effects to standard treatment. Clearly these data set the stage for a prospective randomized trial. The study has the potential for bias due to its cohort nature, but this is understandable given that this is mainly a feasibility study.
Management of T2N0 Esophageal Cancer Recent data published regarding the management of locally advanced esophageal carcinoma for the first time definitively established a positive role for neoadjuvant chemoradiotherapy for these patients. Additionally data supporting only local therapy for early staged esophageal cancer exists to guide surgeons in the decision to manage early staged localized disease. These studies do not provide clear recommendations on how to manage T2N0 esophageal cancer. There are several reasons for this as it is in a watershed area of our knowledge. Early staged tumors are much less likely
to be node positive, thus making the logical decision to avoid systemic therapy logical. T2N0 tumors are in a group of tumors that is somewhat rare and also challenging to accurately diagnose. The main determinant of stage is a pretreatment endoscopic ultrasound. Diagnosing T2 lesions has a lower accuracy rate than either T3 or T1 tumors. Speicher et al5 report on a large series of T2N0 lesions obtained from the national cancer database. This is one of the largest series evaluating this tumor stage. The authors identify 4799 patients from this database as having T2N0 lesions. Interestingly, only 2057 (42.9%) of patients had esophagectomy as part of their treatment. The authors identified education level and treatment at an academic medical center as predictors of being offered esophagectomy in patients with T2N0 disease. When comparing surgical to nonsurgically managed patients, the survival was significantly higher for those patients who had esophagectomy. The 2057 patients who had esophagectomy were then divided according to surgery alone versus induction therapy followed by surgery. A total of 871 patients had surgery alone versus 688 patients who has induction therapy followed by surgery. The authors conclude that there was no survival difference in patients who had induction therapy with T2N0 disease. One of the arguments regarding using induction therapy is that there are a significant number of patients who are upstaged after resection and found to be node positive. In this study, there was no survival benefit even in those patients who have been upstaged to positive nodal status.
Conclusion The management of thoracic surgical disease continues to evolve. The care of thoracic surgical patients continues to improve through clinical research in areas both directly and indirectly related to thoracic surgery. The summary presented here illustrates the continued need for dedicated clinical trials and dedicated research personnel in these areas. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Port JL, Parashar B, Osakwe N, et al. A propensity-matched analysis of wedge resection and stereotactic body radiotherapy for early stage lung cancer. Ann Thorac Surg. 2014;98: 1152-1159.
Downloaded from scv.sagepub.com at NANYANG TECH UNIV LIBRARY on April 26, 2015
28
Seminars in Cardiothoracic and Vascular Anesthesia 19(1)
2. Tammemägi MC, Berg CD, Riley TL, Cunningham CR, Taylor KL. Impact of lung cancer screening results on smoking cessation. J Natl Cancer Inst. 2014;106(6):dju081. doi:10.1093/jnci/dju084. 3. Proposed Decision Memo for Screening for Lung Cancer with Low Dose Computed Tomography. Centers for Medicare & Medicaid Services. http://www.cms.gov/medicare-cover age-database/details/nca-proposed-decision-memo. Accessed January 23, 2015.
4. Deslee G, Klooster K, Hetzel M, et al. Lung volume reduction coil treatment for patients with severe emphysema: a European multicentre trial. Thorax. 2014;69: 980-986. 5. Speicher PJ, Ganapathi AM, Englum BR, et al. Induction therapy does not improve survival for clinical stage T2N0 esophageal cancer. J Thorac Oncol. 2014;9:1195-1201.
Downloaded from scv.sagepub.com at NANYANG TECH UNIV LIBRARY on April 26, 2015
