Table 3 - uploaded by David R Baldwin
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A joint initiative by the British Thoracic Society and the Society for Cardiothoracic Surgery in Great Britain and Ireland was undertaken to update the 2001 guidelines for the selection and assessment of patients with lung cancer who can potentially be managed by radical treatment.
Citations
... In-hospital mortality is statistically significantly increased from 1.5% to 7.2% in patients with PPCs. It has often been shown that mortality rates rise with the extent of lung parenchyma that is resected [20,21]. The volume of lung tissue removal is a known risk factor for PPCs after OTLR [22,23]. ...
Background: Postoperative pulmonary complications (PPCs) are the most common complications following lung surgery and can lead to increased postoperative mortality. In this study, we examined the incidence of PPCs, the in-hospital mortality rate, and the risk factors associated with PPCs in patients undergoing open thoracotomy lung resection (OTLR) for reasons other than primary lung cancer. Methods: Data from this multicenter, retrospective study involving 1.368 patients were extracted from the German Thorax Registry and analyzed using univariate and multivariable statistical methods. Results: In total, 278 patients showed at least one PPC. The presence of PPCs was associated with a significantly higher in-hospital mortality rate (7.2% vs. 1.5%; p = 0.000). Multivariable stepwise logistic regression analysis showed absolute age (OR 1.02) and BMI ≤ 19 (OR 2.6) as independent patient-specific risk factors. Significant preoperative risk factors included re-thoracotomy (OR 4.0) and FEV1 < 60% (OR 2.5). Procedure-related independent risk factors for PPCs included a surgical duration surpassing 195 min (OR 2.7), the continuation of invasive ventilation post-surgery (OR 3.8), and an intraoperative infusion of crystalloids greater than 6 mL/kg/h (OR 1.8). Conclusions: Optimizing intraoperative fluid therapy and on-table extubation when possible may reduce the incidence of PPCs and associated mortality.
... Treatment for NSCLC depends on the clinical stage at which it is diagnosed. For patients with stage I or II NSCLC, and for stage IIIA in patients without the N2 characteristic (with potentially resectable disease), the preferred treatment is radical pulmonary parenchyma resection with lobectomy as a method of choice [17]. In cases where surgical resection is contraindicated due to significant medical factors or patient refusal, radical radiotherapy (RT) or radiochemotherapy (RCHT) should be considered. ...
Introduction Lung cancer is a leading cause of cancer-related deaths worldwide, with rising cases and mortality. In 2022, there were 2.48 million new cases and 1.8 million deaths globally. The primary risk factor is tobacco smoking, though genetic factors, pollution, and other exposures also contribute. Lung cancer is divided into Non-Small Cell Lung Cancer (NSCLC), which includes adenocarcinoma, squamous cell carcinoma, large-cell carcinoma; and Small Cell Lung Cancer (SCLC), characterized by rapid growth, early metastatic spread and greater chemosensitivity in comparison to NSCLC. Treatment depends on the cancer type and stage, with surgery and radiotherapy being treatment of choice for NSCLC and chemoradiotherapy for SCLC. Materials and methods This article is the result of the review of the scientific literature available in PubMed database using keywords: “Lung Cancer”, “Radiotherapy”, “Non-Small Cell Lung Cancer”; “Small Cell Lung Cancer” Aim of study The aim of the study is to summarize available knowledge about various methods of treatment of lung cancer by means of radiation therapy and its diverse techniques. The epidemiology, etiology, staging and methods of treatment were summarized and described. Modern radiotherapy techniques for treating lung cancer have also been included. Conclusions For NSCLC, modern techniques like stereotactic radiotherapy (SBRT/SABR) provide surgical-level effectiveness in early stages with reduced toxicity, while concurrent chemoradiotherapy is optimal for inoperable stage III disease. Palliative radiotherapy remains vital for symptom relief in advanced stages. For SCLC, concurrent chemoradiotherapy is the standard for limited-stage disease, while prophylactic cranial irradiation (PCI) and thoracic radiotherapy improve survival in extensive-stage cases responding to chemotherapy.
... While the currently existing international guidelines, i.e., the ESMO (European Society for Medical Oncology), NCCN (National Comprehensive Cancer Network), NICE (National Institute for Health and Care Excellence), BTS (British Thoracic Society), and ACCP (American College of Chest Physicians) guidelines, concordantly recommend screening for stage III NSCLC patients, the recommendations vary for the indication of BI in early stages [20][21][22][23][24][25]. ...
... The sensitivity and specificity to detect distant metastases in NSCLC were 93% and 96%, respectively; however, the sensitivity for BMs was only 60% [21,55]. The problem with BMs in PET-CT arises firstly due to the small size of most BMs and the background brain F-fluoro-2-deoxy-D-glucose (FDG) uptake, which can cover the presence of BMs [20]. ...
... According to the ACCP guidelines, routine imaging with MRI or ce-CT (when MRI is not available) is recommended in stages III and IV [ 21] Moreover, neurologically symptomatic patients should undergo brain screening. Furthermore, the ACCP mentions that biannual follow-up MRI brain may detect early BMs, thereby providing opportunities for radio-surgery [62]. ...
Background: Lung cancer frequently metastasizes to the brain, liver, and adrenal glands with a significant negative prognostic impact on overall survival and quality of life (QoL). To optimize treatment and prognosis, adequate staging with the detection of distant metastases is crucial. The incidence of brain metastases in potentially resectable early-stage non-small cell lung cancer (NSCLC) is as low as 3%; hence, the need for preoperative brain imaging has been a constant matter of debate, especially in stage II. In stages III and IV NSCLC, neuroimaging is an essential part of staging. Methods: A systematic literature search was performed. Publications from 1999 to 2024, focusing on preoperative brain imaging (BI) in the staging of stages I–IV NSCLC, were included. Data extraction included study population characteristics, the modality of BI, the incidence of brain metastases (BMs), and the main outcomes of the studies. The final included studies were selected according to the PRISMA criteria. In the second step, guidelines on BI in NSCLC staging of major importance were identified and compared. Results: A total of 530 articles were identified, of which 25 articles were selected. Four prospective studies and 21 retrospective investigations were included. Most of the investigations focused on BI in the early stages. The main imaging modality for BI was magnetic resonance imaging (MRI), followed by computed tomography (CT). Besides the identified 25 studies, the most important internationally applied guidelines on brain imaging in the staging of NSCLC were reviewed. While some guidelines agree on preoperative BI in NSCLC stage III (Union for International Cancer Control—UICC eighth edition) patients, other guidelines recommend earlier BI starting from clinical stage II. All mentioned guidelines homogenously recommend BI in patients with symptoms suggestive of brain pathologies. Conclusions: BI in NSCLC staging is recommended in neurologically symptomatic patients suggestive of brain metastases as well as NSCLC patients with stage III disease. Neuroimaging in stage IA patients, as well as in pure GGO (Ground-Glass Opacity) lesions, was considered unnecessary. The predominantly applied imaging modality was ce-MRI (contrast-enhanced magnetic resonance imaging). Inconsistency exists concerning BI in stage II. The identification of prognostic factors for developing BM in patients with early-stage NSCLC could help to clarify which subgroup might benefit from preoperative BI.
... However, for nodules near the central region, ensuring safe and effective margins typically requires the removal of a substantial amount of lung tissue, which is unacceptable for patients with poor lung function. Additionally, for patients with poor cardiac function, coagulation disorders, or other conditions that render them unfit for surgery, ablation is a better option [5]. ...
Background
Pulmonary nodule ablation is an effective method for treating pulmonary nodules. This study is based on the traditional CT-guided percutaneous microwave ablation (MWA) of pulmonary nodules. By comparing laser guidance technology with freehand method, this study aims to explore the safety and efficacy and patients’ pain scores of these two approaches.
Methods
This study retrospectively analyzed 126 patients who underwent CT-guided percutaneous lung ablation at the First Affiliated Hospital of Soochow University from April 2020 to April 2024. Based on the guidance method, we divided those patients into the laser guidance group and the freehand group. The primary outcome such as operation time, the number of ablation needle adjustments, postoperative pain scores, postoperative hospital stay, and postoperative complications were analyzed.
Results
The laser guidance group had a significantly shorter mean operation time compared to the freehand group (39.3 ± 13.65 min vs. 43.82 ± 19.12 min, p < 0.01), and in the laser guidance group, fewer ablation needle adjustments were required than in the freehand group (3.3 ± 1.34 time vs. 4.37 ± 1.39 times, p < 0.001). As compared to the freehand group, the laser guidance group had fewer cases of mild pneumothorax (13.16% vs. 38.33%, p < 0.05). The postoperative pain score at 1 h and 1 day of the two groups showed no statistical difference.
Conclusion
Both methods are safe and effective. The laser guidance technology significantly reduces the number of puncture adjustments and the operation time compared to the freehand method. Laser guidance technology effectively reduces the incidence of mild pneumothorax.
... However, most of the studies have used direct measures such as VO 2 peak [23], and no previous studies have applied self-administered functional measures, which provide information about patient perception. In this sense, submaximal exercise capacity tests reflect the physical functioning and self-perceived effort of patients [24][25][26] through the dyspnea and fatigue expressed during the test. ...
Simple Summary
Lung-resected patients experience physical deterioration that limits their quality of life, but there are important gaps in the knowledge of the evolution of this deterioration. The aim of this study was to assess physical deterioration in lung cancer survivors in the short and medium term, using self-administered functional measures that would allow us to obtain information about patients’ perceptions. These results can facilitate the future management of lung cancer patients after resection, reducing the sequelae they suffer and improving their quality of life.
Abstract
Background. Lung resection represents the main curative treatment modality for lung cancer. These patients present with physical deterioration that has been studied previously using objective variables; however, no previous studies have evaluated the self-perceived physical fitness of these patients. For these reasons, to increase the current knowledge on lung cancer patients’ impairment, the aim of this study was to characterize the self-perceived physical deconditioning of lung cancer patients undergoing lung resection in the short and medium term after surgery. Methods. A longitudinal, observational, prospective cohort study was performed in the Thoracic Surgery Service of the Hospital Virgen de las Nieves (Granada). Symptoms (pain, fatigue, cough and dyspnea) and physical fitness (upper and lower limbs) were assessed before surgery, at discharge and at one month after discharge. Results. Among the total of 88 patients that we included in our study, significant differences were found at discharge in symptoms (p < 0.05) and physical fitness (p < 0.05). One month after surgery, higher levels of pain (p = 0,002) and dyspnea (p = 0.007) were observed, as well as poorer results in the upper (p = 0.023) and lower limbs’ physical fitness, with regard to the initial values. Conclusions. Patients undergoing lung resection present an increase in symptoms and physical fitness deterioration at discharge, which is maintained one month after surgery.
... Lung cancer has been reported to have the highest morbidity and mortality rates among all malignant tumors worldwide [1]. Surgery is the main treatment for resectable non-small cell lung cancer (NSCLC) [2]. With the development of surgical techniques, radical resection of lung cancer has evolved from open surgery to minimally invasive surgical approach. ...
Background
At present, research comparing the short-term postoperative outcomes of anatomical resection in lung cancer under different ports of da Vinci robot-assisted surgery is insufficient. This report aimed to compare the outcomes of three-port and four-port da Vinci robot-assisted thoracoscopic surgery for radical dissection of lung cancer.
Methods
171 consecutive patients who presented to our hospital from January 2020 to October 2021 with non-small cell lung cancer and treated with da Vinci robot-assisted thoracoscopic surgery for radical resection of lung cancer were retrospectively collected and divided into the three-port group (n = 97) and the four-port group (n = 74). The general clinical data, perioperative data and life quality were individually compared between the two groups.
Results
All the 171 patients successfully underwent surgeries. Compared to the four-port group, the three-port group had comparable baseline characteristics in terms of age, sex, tumor location, tumor size, history of chronic disease, pathological type, and pathological staging. The three-port group also had shorter operation time, less intraoperative blood loss, lower chest tube drainage volume, shorter postoperative hospitalization stay durations, but showed no statistically significant difference (P > 0.05). Postoperative 24, 48 and 72 h visual analogue scale pain scores were lower in the three-port group (p < 0.001). No significant difference was observed between the two groups in the hospitalization costs (P = 0.664), number or stations of total lymph node dissected (p > 0.05) and postoperative respiratory complications (P > 0.05).
Conclusions
The three-port robot-assisted thoracoscopic surgery is safe and effective and took better outcomes than the four-port robot-assisted thoracoscopic surgery in non-small cell lung cancer.
... One important question is whether it is necessary to evaluate the possible existence of brain metastases with brain MRI and/or bone metastases with BS. There is some controversy between existing guidelines, especially for early-stage NSCLC, as the detection rate of distant metastases is very low [3,4,[7][8][9][10][11]. In general, an initial routine brain MRI is unnecessary for patients with GGNs and subsolid nodules [2] because preoperative staging does not have prognostic benefit for survival [12,13]. ...
Background
Accurate clinical staging is crucial for selection of optimal oncological treatment strategies in non-small cell lung cancer (NSCLC). Although brain MRI, bone scintigraphy and whole-body PET/CT play important roles in detecting distant metastases, there is a lack of evidence regarding the indication for metastatic staging in early NSCLCs, especially ground-grass nodules (GGNs). Our aim was to determine whether checking for distant metastasis is required in cases of clinical T1N0 GGN.
Methods
This was a retrospective study of initial staging using imaging tests in patients who had undergone complete surgical R0 resection for clinical T1N0 Stage IA NSCLC.
Results
A total of 273 patients with cT1N0 GGNs ( n = 183) or cT1N0 solid tumors (STs, n = 90) were deemed eligible. No cases of distant metastasis were detected on initial routine imaging evaluations. Among all cT1N0M0 cases, there were 191 incidental findings on various modalities (128 in the GGN). Most frequently detected on brain MRI was cerebral leukoaraiosis, which was found in 98/273 (35.9%) patients, while cerebral infarction was detected in 12/273 (4.4%) patients. Treatable neoplasms, including brain meningioma and thyroid, gastric, renal and colon cancers were also detected on PET/CT (and/or MRI). Among those, 19 patients were diagnosed with a treatable disease, including other-site cancers curable with surgery.
Conclusions
Extensive staging (MRI, scintigraphy, PET/CT etc.) for distant metastasis is not required for patients diagnosed with clinical T1N0 GGNs, though various imaging modalities revealed the presence of adventitious diseases with the potential to increase surgical risks, lead to separate management, and worsen patient outcomes, especially in elderly patients. If clinically feasible, it could be considered to complement staging with whole-body procedures including PET/CT.
... Most patients had a single radiologically abnormal lymph node on CT and PET (88%, 105 of 115). In the majority, the reasons for missed N2 disease on staging EBUS were due to inaccessible (stations 5,6,8,9) N2 nodes at EBUS (34%, 13 of 38) and accessible lymph nodes not sampled during staging EBUS as not meeting sampling threshold (40%, 15 of 38) rather than false-negative sampling during EBUS (26%, 10 of 38). ...
... 1,2 International guidelines provide conflicting recommendations and often include multiple treatment options without preference. [3][4][5][6] This debate has become increasingly complex with a paradigm shift in the multimodality treatment of stage III NSCLC in the past five years, driven by practicechanging randomized controlled trials. These randomized controlled trials have revealed improved progression-free survival and overall survival (OS) from maintenance immunotherapy (IO) versus placebo after concurrent chemoradiotherapy in unresectable stage III NSCLC, 7 adjuvant third-generation tyrosine kinase inhibitor therapy versus placebo in EGFR mutationpositive NSCLC after surgical resection and adjuvant chemotherapy, 8 adjuvant chemotherapy and IO versus adjuvant chemotherapy alone after surgical resection of NSCLC 9,10 and neoadjuvant chemotherapy and IO versus neoadjuvant chemotherapy alone before surgical resection in resectable NSCLC. ...
... In the United Kingdom (UK), and beyond, the division between single-station N2 (ssN2) and multistation N2 (msN2) disease has been used to inform treatment decisions between surgical and non-surgical multimodality treatment. 6,12 Part of the reasoning behind this is an analysis of an international thoracic surgery database which revealed that patients who undergo surgical resection of NSCLC and have pathologic staging of ssN2 have a similar five-year OS to those with multi-station N1 disease at approximately 35%. 13 The same database revealed that five-year OS was worse for those with pathologic staging of msN2 disease at 20%. 13 This led some to conclude that ssN2 is an important surgical selection criterion for patients with N2 disease, given its similar long-term outcomes to resected N1 disease. An opposing view is that while the differentiation between ssN2 and msN2 is prognostic, it is not predictive of response to specific treatment modalities and given there was no comparator of non-surgical treatment within this international database it is not possible to say whether surgical multi-modality treatment would have provided better or worse outcomes in either ssN2 or msN2 compared with nonsurgical multimodality treatment. ...
Introduction
Single-station N2 (ssN2) versus multi-station N2 has been used as a selection criterion for treatment recommendations between surgical versus non-surgical multimodality treatment in stage III-N2 NSCLC. We hypothesized that clinical staging would be susceptible to upstaging on pathologic staging and, therefore, challenge this practice.
Methods
A retrospective study of prospectively collected routine clinical data for patients with stage III-N2 NSCLC that had completed computed tomography (CT), positron emission tomography (PET), and staging endobronchial ultrasound (EBUS) and had been confirmed clinical stage III-ssN2 at multidisciplinary team discussion and went on to complete surgical resection as the first treatment to provide pathologic staging. The study was completed in two cohorts (A) across a single cancer alliance in England (Greater Manchester) January 1, 2015 to December 31, 2018 and (B) across five United Kingdom centers to validate the findings in part A January 1, 2016 to December 31, 2020.
Results
A total of 115 patients met the inclusion criteria across cohort A (56 patients) and cohort B (59 patients) across 15 United Kingdom hospitals. The proportion of cases in which clinical stage III-ssN2 was upstaged to pathologic stage III-multi-station N2 was 34% (19 of 56) in cohort A, 32% in cohort B (19 of 59), and 33% across the combined study cohort (38 of 115). Most patients had a single radiologically abnormal lymph node on CT and PET (88%, 105 of 115). In the majority, the reasons for missed N2 disease on staging EBUS were due to inaccessible (stations 5, 6, 8, 9) N2 nodes at EBUS (34%, 13 of 38) and accessible lymph nodes not sampled during staging EBUS as not meeting sampling threshold (40%, 15 of 38) rather than false-negative sampling during EBUS (26%, 10 of 38).
Conclusions
During multidisciplinary team discussions, clinicians must be aware that one-third of patients with stage III-ssN2 on the basis of CT, PET, and staging EBUS do not truly have ssN2 and this questions the use of this criterion to define treatment recommendations.
... The British Thoracic Society 2010 guidelines (5) advocate that the International Association of the Study of Lung Cancer (IASLC) nodal map (6) should be used in the assessment and staging of lymph node disease. Intraoperatively, one should perform systematic nodal dissection in all patients undergoing resection for lung cancer and remove or sample a minimum of six lymph node stations. ...
Lung cancer, a leading cause of cancer-related death, often requires surgical resection for early-stage cases, with recent data supporting less invasive resections for tumors smaller than 2 cm. Central to resection is lymph node assessment, an area of controversy worldwide, compounded by advances in minimally invasive techniques. The review aims to assess current standards for lymph node assessment, recent data from the surgical era, and the immunobiological basis of how lymph node metastases impact patient outcomes. The British Thoracic Society guidelines recommend systematic nodal dissection during lung cancer resection, without specifying node removal or sampling. Historical data on mediastinal lymph node dissection (MLND) survival benefits are inconclusive, although proponents argue for lower recurrence rates. Recent trials such as ACOSOG Z0030 found no survival difference between MLND and nodal sampling, reinforcing the need for robust staging. While lobe-specific dissection strategies have been proposed, they currently lack consensus. JCOG1413 aims to compare the clinical benefits of lobe-specific and systematic dissection. TNM-9 staging revisions emphasize the prognostic significance of single-station N2 involvement. Robotic surgery shows promise, with trials such as RAVAL, which reported comparable outcomes to video-assisted thoracic surgery (VATS) and improved lymph node sampling. Immunobiological insights suggest preserving key immunological sites during lymphadenectomy, especially for patients receiving adjuvant immunotherapy. In conclusion, the standard lymph node resection strategy remains unsettled. The debate between systematic and selective dissection continues, with implications for staging accuracy and patient outcomes. As minimally invasive techniques evolve, robotic surgery emerges as an effective and low-risk approach to delivering optimal lymph node assessment.
... Low-dose computed tomography screening reduces lung cancer mortality by 20-24% through early detection and treatment (2,3), therefore, it is likely that national screening initiatives will be implemented in the future. Confirmatory histological diagnosis is recommended prior to commencing radical treatment (4). Recent advances in bronchoscopic techniques, such as navigation bronchoscopy (5) and robotic-assisted bronchoscopy (6,7), mean it is now possible to access the majority of peripherally-located pulmonary lesions. ...
Lung cancer is the most common cause of cancer-related deaths worldwide. Early detection improves outcomes, however, existing sampling techniques are associated with suboptimal diagnostic yield and procedure-related complications. Autofluorescence-based fluorescence-lifetime imaging microscopy (FLIM), a technique which measures endogenous fluorophore decay rates, may aid identification of optimal biopsy sites in suspected lung cancer. Our fibre-based fluorescence-lifetime imaging system, utilising 488 nm excitation, which is deliverable via existing diagnostic platforms, enables real-time visualisation and lifetime analysis of distal alveolar lung structure. We evaluated the diagnostic accuracy of the fibre-based fluorescence-lifetime imaging system to detect changes in fluorescence lifetime in freshly resected ex vivo lung cancer and adjacent healthy tissue as a first step towards future translation. The study compares paired non-small cell lung cancer (NSCLC) and non-cancerous tissues with gold standard diagnostic pathology to assess the performance of the technique. Paired NSCLC and non-cancerous lung tissues were obtained from thoracic resection patients (N=21). A clinically compatible 488 nm fluorescence-lifetime endomicroscopy platform was used to acquire simultaneous fluorescence intensity and lifetime images. Fluorescence lifetimes were calculated using a computationally-lightweight, rapid lifetime determination method. Fluorescence lifetime was significantly reduced in ex vivo lung cancer, compared with non-cancerous lung tissue [mean ± standard deviation (SD), 1.79±0.40 vs. 2.15±0.26 ns, P<0.0001], and fluorescence intensity images demonstrated distortion of alveolar elastin autofluorescence structure. Fibre-based fluorescence-lifetime imaging demonstrated good performance characteristics for distinguishing lung cancer, from adjacent non-cancerous tissue, with 81.0% sensitivity and 71.4% specificity. Our novel fibre-based fluorescence-lifetime imaging system, which enables label-free imaging and quantitative lifetime analysis, discriminates ex vivo lung cancer from adjacent healthy tissue. This minimally invasive technique has potential to be translated as a real-time biopsy guidance tool, capable of optimising diagnostic accuracy in lung cancer.
