Introduction: There is a paucity of data evaluating whether a multidisciplinary conference coordinating surgery, chemotherapy and radiation therapy translates into better patient care. This article compares the experiences of patients with lung cancer before and after the formation of a prospective, multidisciplinary thoracic malignancy care conference (TMC). Methods: The records of patients with a non-small-cell lung cancer at a tertiary care hospital were reviewed for completeness of staging, multidisciplinary evaluation prior to the initiation of therapy, time from pathologic diagnosis to treatment, multimodality therapy and adherence to national treatment guidelines. The summary data of patients treated before and after the TMC were initiated, and then compared. Results: Between 2001 and 2007, 535 patients were treated prior to the initiation of the TMC and 687 patients within the TMC. The number of patients receiving a complete staging evaluation (79%/93%: p < 0.0001), multidisciplinary evaluation prior to therapy (62%/96%: p < 0.0001) and adherence to the National Comprehensive Cancer Network (NCCN) treatment guidelines (81%/97%: p < 0.0001) all increased significantly while mean days from diagnosis to treatment significantly decreased (29/17: p < 0.0001) following the initiation of a TMC. Conclusion: A multidisciplinary thoracic malignancy conference increased the percentage of patients receiving complete staging, a multidisciplinary evaluation and adherence to nationally accepted care guidelines while decreasing the interval from diagnosis to treatment significantly. While the ultimate goal of treatment is to improve patient survival, the surrogate variables examined in this review indicate that patients with non-small-cell lung cancer benefit from being evaluated in a prospective, multidisciplinary care conference.

Objective: Lung cancer resection in breathless patients with severe chronic obstructive pulmonary disease (COPD) remains controversial. Whilst open lobectomy remains the gold standard, alternative approaches have been described. We undertook a retrospective, observational study to compare the outcomes of a tailored strategy combining video-assisted thoracoscopic surgery (VATS) lobectomy and anatomical segmentectomy against open lobectomy in these patients. Method: Clinical outcomes were studied in 84 consecutive patients (male:female ratio was 56:28, mean age 69.0 years, median preoperative-forced expiratory volume in 1 s (FEV₁) 41%) with a predicted-postoperative FEV₁ ≤40% (median 32.8% and range 14–40%) who underwent anatomical lung resection for lung cancer. The control group consisted of 35 patients who underwent open lobectomy. The study group comprised 27 patients who underwent anatomical segmentectomy, 18 who underwent VATS lobectomy and four who underwent VATS segmentectomy. Results: There were no significant inter-group differences in age (p = 0.87), gender (p = 0.49), preoperative FEV₁ (p = 0.30) or cardiac co-morbidities (p = 0.78). There were more upper lobe resections in the control group (51% vs 94%, p < 0.0001). Tumour size tended to be smaller in the study group (p = 0.052). There were also more incidences of stage I cancers in the study group (90% vs 71%, p = 0.043). The median length of hospital stay was shorter in the study group (8 vs 12 days, p = 0.054). There was no significant difference in either in-hospital mortality (8% vs 14%, p = 0.48) or recurrence rate (26% vs 20%, p = 0.60). However, unadjusted survival was significantly longer in the study group (median survival 54 months vs 20 months, 5-year survival 42% vs 18%, p = 0.03). The survival benefit of this group remained significant in multivariate analyses (adjusted survival hazard ratio (HR) 2.39, 95% confidence interval (CI): 1.30–4.39, p = 0.005). A subgroup analysis on only uncomplicated stage I cancers found a similarly worse outcome in the control group (p = 0.002). After segregating surgical approach and the extent of resection, the VATS approach was identified as the critical factor conferring survival advantage to the study group (hazard ratio (HR) 2.78, 95% CI: 1.21–6.37, p = 0.016). Conclusions: Despite a tailored approach to patients with severe pulmonary dysfunction, there was still significant disparity in survival between groups. Patients who underwent open lobectomy have a worse outcome despite adjusting for confounders. This survival benefit was driven by thoracotomy avoidance through VATS resection. The use of operative techniques to reduce chest-wall dysfunction should be considered in the breathless patient.

Objective: Surgical resection is the treatment of choice to cure patients with non-small-cell lung cancer (NSCLC); nevertheless, the assessment of the lower limit of surgical tolerance remains difficult. Ventilatory inefficiency (measured as the ventilation to CO₂ production ratio (V'_E/V'_CO2 slope) is a survival predictor in pulmonary hypertension (PH) and chronic heart failure (CHF) and is considered a marker of PH in chronic obstructive pulmonary disease (COPD). The aim of this study was to investigate the role of V'_E/V'_CO2 slope as preoperative mortality and morbidity predictor in COPD patients submitted to lung resection for NSCLC and considered operable according to current standards. Patients and methods: A retrospective analysis was performed in 145 consecutive COPD patients with lung cancer (128 males and 17 females), with a mean age of 64 years (range: 41–82 years) who were referred for preoperatory evaluation. Because of bronchial obstruction or reduced pulmonary diffusion capacity for carbon monoxide (D_L,CO), all these patients were considered operable only after a cardiopulmonary exercise test showed a preserved cardiopulmonary function. Results: A total of 98 lobectomies, eight bilobectomies and 39 pneumonectomies (13 left and 26 right) were performed. Twenty-one patients (14.5%) suffered severe cardio-respiratory complications; 15/106 patients (14.2%) after lobectomy/bilobectomy and 6/39 (15.4%) after pneumonectomy. Five patients (3.4%) died within 30 days after surgery (3/106 after lobectomy/bilobectomy (2.8%) and 2/39 after pneumonectomy (5.1%)). Considering all functional parameters before surgery and the postoperative predicted values, a logistic regression analysis individuated the V'_E/V'_CO2 slope as the only independent mortality predictor (odds ratio (OR): 1.24 z = 2.77; p < 0.007). The V'_O2peak was instead the best predictor for the occurrence of severe cardiopulmonary postoperative complications (OR: 0.05, z = –2.39, p < 0.02). Conclusions: In COPD patients, a high V'_E/V'_CO2 slope before lung resection is an independent mortality predictor even in the presence of an acceptable cardiopulmonary performance. COPD patients with high V'_E/V'_CO2 slope before surgery must be carefully screened to exclude pulmonary hypertension, especially before surgical procedures with large parenchymal exeresis.

Objective: Survival after resections for non-small cell lung cancer remains poor. Recurrent lung cancer remains common. Due to the common risk factor of smoking, cardiovascular deaths occur in the absence of recurrent lung cancer in up to 15% of patients. Aspirin has been proven to reduce cardiovascular mortality as a secondary prophylactic agent, but not as a primary agent. Aspirin being a COX-2 inhibitor has been shown to reduce the chance of metastasis in adenocarcinoma but not squamous carcinoma. We sought to investigate the effect of long-term aspirin therapy on survival post potentially curative surgery. Methods: We analysed a prospective thoracic surgical database, from time period 2003 to date. Patients who were on aspirin pre-operatively, N = 412 were compared to non users, N = 1353. Patient long-term outcome was assessed utilising the national strategic tracking service that operates in the United Kingdom. Cox proportional hazards analysis was used to determine significant factors affecting survival. Results: 100% survival follow up was achieved. Regular users of aspirin had >5% increased survival, which was significant, p = 0.05, despite having a higher cardiovascular risk profile. Mode of death data was not available. Conclusions: Adjuvant aspirin post resection for potentially curative non-small cell lung cancer significantly increases survival. The mechanism of increased survival needs further investigation and is the basis for the trial: Adjuvant Aspirin for Non-Small cell Lung Cancer – The Big A Trial. www.TheBigATrial.co.uk.

Objectives: The increasing age of the population has raised the importance of determining the minimally required surgical treatment for elderly lung cancer patients. Despite a number of previous studies, the therapeutic impact of a radical mediastinal lymphadenectomy (RLA) associated with a pulmonary resection for lung cancer remains controversial. Herein, we investigated the impact of lymph node dissection on the overall survival for elderly lung cancer patients and assessed whether the non-performance of an RLA could be justified in the surgical treatment for these elderly patients. Methods: We analysed the data for 160 patients aged 70 years and older (113 males, 47 females) who underwent curative-intent surgery for non-small-cell lung cancer. They were divided into two groups, according to the method used for the intra-operative mediastinal lymph node dissection, the radical systematic lymphadenectomy (RLA, n = 76) and the non-radical lymphadenectomy (NLA, n = 94) groups. A Cox proportional hazards model and the Kaplan–Meier method were used for the survival analyses. Propensity-based analyses were also used to reduce the effect of non-randomisation and possible bias in indication of treatment between the two groups. Results: RLAs had no protective effect on mortality; the hazard ratio for the RLA group in comparison to the NLA group was 0.97 (95% confidence interval (CI): 0.32–2.89) in the multivariate analysis and 1.43 (95% CI: 0.42–4.91) in the propensity-based stratifying analysis. The 3-year survival probability was 81.3% (95% CI: 67.1–89.8) for the NLA group, which was marginally better than that of the RLA group (77.5% (95% CI: 63.3–86.8)). There was no significant difference in the overall survival between the two groups (p = 0.26). The 3-year survival probability of the NLA group at each quartile of the propensity score also tended to be better than that of the RLA group, which did not show any significant difference. Conclusions: There was no survival benefit shown for RLA associated with pulmonary resections in the present cohort, even in the propensity-based analyses. Although some reports recommend a systematic mediastinal lymphadenectomy for proper staging and better survival, a pulmonary resection with non-performance of radical lymphadenectomy could be an acceptable surgical treatment for the increasing number of elderly lung cancer patients.

Objectives: Epidermal growth factor receptor (EGFR)-targeted therapies are a valid therapeutic option for advanced non-small-cell lung cancer (NSCLC), but unequivocally recognised predictive factors for therapeutic response are lacking. However, intrinsic resistance might occur due to loss of EGFR expression during the course of the disease or its treatment. Methods: Paraffin-embedded tissue from cases with metastatic NSCLC obtained at autopsy was retrieved from our archive. Specimens of primary tumour (n = 39; 64% adenocarcinoma) and of all corresponding metastases (n = 70) were immunohistochemically stained for EGFR expression. Two observers independently scored staining intensity and evaluated the percentage of positively stained cells. Identical staining intensity and ≤10% difference in number of stained cells were defined as perfect concordance; and one-increment difference in staining intensity and less than 30% difference in number of stained cells were defined as good concordance. Results: Twenty-seven out of 39 primary tumours (69%) were EGFR-positive on immunohistochemistry (IHC), with 12/27 (44%) of positive tumours exhibiting intense or moderate EGFR expression. The median number of EGFR-expressing cells in primary tumours was 50% (range 0–100%). Overall Spearman's rank correlations for staining intensity and percentage of positively stained cells between primary tumours and paired metastases were 0.78 (p < 0.001) and 0.60 (p < 0.001), respectively. Perfect concordance was observed in 51% (20/39) and good concordance in 18% (7/39) of corresponding pairs, respectively, whereas 9/12 metastases showing discordant staining with their corresponding primary tumours had lacked EGFR expression. Conclusions: In most NSCLCs, EGFR status of primary tumours correlates with EGFR status of corresponding metastases. Hence, loss of EGFR expression is unlikely during disease progression, local or non-EGFR-targeting systemic treatment.

Objectives: We analysed our experience in primary malignant chest-wall tumours (PMCWTs) with an emphasis on a new reconstruction technique and on survival. Methods: From 1998 to 2008, 41 patients (23 (56%) male, mean age 48 years) with PMCWT were operated in our unit: chondrosarcoma n = 25; osteosarcoma n = 8; Ewing's sarcoma n = 2; other n = 6. We performed nine sternectomies and 32 lateral chest-wall resections (median number of ribs resected = 3.5). Resections were extended to the lung (n = 2), diaphragm (n = 3), vertebral body (n = 3), scapula (n = 1) and upper limb (n = 1). Stability was obtained by a prosthetic material, rigid and non-rigid and a muscular flap. As non-rigid material, we mostly used a polytetrafluoroethylene patch (n = 24). In the past 2 years, two patients (one total sternectomy and one wide anterior chest-wall resection) were reconstructed with a rigid system composed of mouldable titanium connecting bars and rib clips (Strasbourg Thoracic Osteosyntheses System – STRATOS, MedXpert GMbH, Heitersheim, Germany). A muscular flap was added in 12 patients (29.3%). Results: There was no perioperative mortality or significant morbidity and all patients were extubated within first 24 h. At a mean follow-up of 60.5 months (range 4–130 months), the overall 5- and 10-year survival was 61% and 47%, respectively. In the chondrosarcoma group, 5- and 10-year survival was 80%. Conclusions: Wide resection with tumour-free margins is necessary in PMCWT to minimise local recurrence and to contribute to long-term survival. The STRATOS system, developed for chest-wall replacement, allows a firm reconstruction, simple to handle and to fix, avoiding instability or paradoxical movement also in wide chest-wall resections.

Objective: Prolonged deep hypothermic circulatory arrest (DHCA) adversely affects outcome and quality of life in thoracic aortic surgery. Several techniques of antegrade cerebral perfusion are routinely used: bilateral selective antegrade cerebral protection (SACP) by introducing catheters in the innominate and left carotid artery, unilateral perfusion through the right axillary antegrade cerebral perfusion (RAACP) or a combination of right axillary perfusion with an additional catheter in the left carotid artery (RAACCP), resulting also in bilateral perfusion. The aim of the present study was to analyse the impact of the different approaches on the quality of life (QoL). Methods: The data of 292 patients who underwent surgery of the thoracic aorta using DHCA at our hospital between January 2004 and December 2007 have been analysed and a follow-up was performed focussing on QoL, assessed with the Short Form-36 Health Survey Questionnaire (SF-36). Results were analysed according to the type of cerebral perfusion and the duration of DHCA. Results: Patients’ characteristics were similar in all groups. Of the total, 3.4% patients underwent DHCA (average 8.3 ± 6.4 min) without ACP, 45.9% underwent SACP (average DHCA of 15.6 ± 7.1 min), 40.4% had RAACP (average DHCA of 28.1 ± 11.6 min) and 9.4% bilateral perfusion (RAACCP) (average DHCA of 43.1 ± 16.7 min). The average follow-up was 23.2 ± 15.1 months. QoL was preserved in all groups. For DHCA above 40 min, bilateral ACP provides superior midterm QoL than unilateral RAACP (average SF-36 95.1 ± 44.4 vs 87.6 ± 31.3; p = 0.072). Conclusions: When midterm QoL is assessed, bilateral SACP provides the best cerebral protection for prolonged DHCA (>40 min).