Classification and staging of thymoma

The appropriate therapy and prognosis of patients with thymic malignancies is decisively influenced by the local extent and dissemination of the tumor. For this reason, a staging system that reflects these factors is essential. Mainly the Masaoka-Koga classification, which was introduced in 1994, has been applied for this purpose. The rarity of thymic malignancies makes it difficult not only to establish internationally standardized diagnostics and treatment, but also to progress staging. Besides, efforts were made to adapt the classification into a tumor-node-metastasis-based (TNM) system for standardization with the staging of other tumor entities. The 2017 published 8th edition of the TNM Classification of Malignant Tumors introduced several adjustments based on a proposal of the International Association for the Study of Lung Cancer (IASLC) and the International Thymic Malignancy Interest Group (ITMIG). Compared to the Masaoka-Koga classification, surgically good resectable tumor involvements like pericardium, mediastinal fat or mediastinal pleura have been shifted to lower stages. Thus, even more than in Masaoka-Koga classification, tumors are basically divided into completely resectable and thus surgically treatable tumors (stage I, II, IIIA) and advanced stages (stage IIIB, IVA and IVB) that require multimodal therapy.     

The role of postoperative radiotherapy for stage I/II/III thymic tumor—results of the ChART retrospective database

Background

Postoperative radiotherapy (PORT) for thymic tumor is still controversial. The object of the study is to evaluate the role of PORT for stage I to III thymic tumors.

Methods

The Chinese Alliance for Research in Thymomas (ChART) was searched for patients with stage I to III thymic tumors who underwent surgical resection without neoajuvant therapy between 1994 and 2012. Univariate and multivariate survival analyses were performed. Cox proportional hazard model was used to determine the hazard ratio for death.

Result

From the ChART database, 1,546 stage I to III patients were identified. Among these patients, 649 (41.98%) received PORT. PORT was associated with gender, histological type (World Health Organization, WHO), thymectomy extent, resection status, Masaoka-Koga stage and adjuvant chemotherapy. The 5-year and 10-year overall survival (OS) rates and disease-free survival (DFS) rates for patients underwent surgery followed by PORT were 90% and 80%, 81% and 63%, comparing with 96% and 95%, 92% and 90% for patients underwent surgery alone (P=0.001, P<0.001) respectively. In univariate analysis, age, histological type (WHO), Masaoka-Koga stage, completeness of resection, and PORT were associated with OS. Multivariable analysis showed that histological type (WHO) (P=0.001), Masaoka-Koga stage (P=0.029) and completeness of resection (P=0.003) were independently prognostic factors of OS. In univariate analysis, gender, myasthenia gravis, histological subtype, Masaoka-Koga stage, surgical approach, PORT and completeness of resection were associated with DFS. Multivariate analysis showed that histological subtype (P<0.001), Masaoka-Koga stage (P=0.005) and completeness of resection (P=0.006) were independent prognostic factors for DFS. Subgroup analysis showed that patients with incomplete resection underwent PORT achieved better OS and DFS (P=0.010, 0.017, respectively). However, patients with complete resection underwent PORT had the worse OS and DFS (P<0.001, P<0.001, respectively).

Conclusions

The current retrospective study indicates that PORT after incomplete resection could improve OS and DFS for patients with stage I to III thymic tumors. However for those after complete resection, PORT does not seem to have any survival benefit on the whole.     

CT staging and preoperative assessment of resectability for thymic epithelial tumors

Background

The aim of this study was to determine the computed tomography (CT) features potentially helpful for accurate staging and predicting resectability of thymic epithelial tumors (TET).

Methods

One hundred and thirty-eight consecutive TET patients undergoing surgical resection from April 2010 to November 2011 were prospectively entered into a database. All patients were staged according to the Masaoka-Koga staging system. The relationship between CT features with tumor staging and complete resection was reviewed after surgery.

Results

Surgico-pathological staging was stage I in 63, stage II in 32, stage III in 32, and stage IV in 11 patients. Preoperative CT staging was highly consistent with postoperative surgico-pathological staging (Kappa =0.525). Tumor shape, contour, enhancement, with or without invasion of the adjacent structures (mediastinal fat, mediastinal pleura, lung, pericardium, mediastinal vessels, phrenic nerve), and presence of pleural, pericardial effusionor intrapulmonary metastasis were correlated with Masaoka-Koga staging (P<0.05). However, tumor size, internal density or presence of calcification was not associated with staging (P>0.05). Tumor size, presence of calcification and mediastinal lymph node enlargement were not correlated with complete tumor resection (P>0.05). Tumor shape, contour, internal density, enhancement pattern, and invasion of adjacent structures were related to complete resection of the primary tumor in univariate analysis (P<0.05). However, upon multivariate logistic regression, only absence of artery systems invasion was predictive of complete resection (P<0.05).

Conclusions

Clinical staging of TET could be accurately evaluated with CT features including tumor shape, contour, enhancement pattern, with or without invasion of adjacent structures, and presence of pleural, pericardial effusion or intrapulmonary metastasis. Absence of arterial system invasion on CT was the only predictive feature for predicting complete resection of TET.     

Comparison of the prognostic accuracy of the sixth and seventh editions of the TNM classification for intrahepatic cholangiocarcinoma

Background

The seventh TNM edition introduced a new, specific staging structure for intrahepatic cholangiocarcinoma (IHC).

Objective

To compare the accuracy of the sixth and the new seventh edition to predict survival after hepatectomy for IHC.

Methods

In all, 434 consecutive patients who underwent hepatectomy at 16 tertiary-care centres (1990–2008) were identified. End points were overall (OS) and recurrence-free survival (RFS) for both T cohorts and stage strata.

Results

After a median follow-up of 32.4 months, 3- and 5-year OS and RFS estimates were 47.1% and 32.9%, and 26.5% and 19.1%, respectively. Overall, both the editions were statistically significant discriminators of OS and RFS (P < 0.05). However, the survival curves of the new T2a and T2b cohorts appear superimposed. Conversely, the old T2 and T3 cohorts accurately stratify patients into distinct prognostic groups (P < 0.01). The seventh edition does not show monotonicity of gradients (the T4 category demonstrates significantly better OS and RFS compared with T2 patients). The seventh edition stage I and II are significantly different whereas the old stage I and II were not.

Conclusions

The new seventh edition of the AJCC/UICC Staging System proved to be adequate although further studies are need to confirm its superiority compared with the previous edition.     

Thymectomy versus tumor resection for early-stage thymic malignancies: a Chinese Alliance for Research in Thymomas retrospective database analysis

Background

To evaluate the surgical outcomes of tumor resection with or without total thymectomy for thymic epithelial tumors (TETs) using the Chinese Alliance for Research in Thymomas (ChART) retrospective database.

Methods

Patients without preoperative therapy, who underwent surgery for early-stage (Masaoka-Koga stage I and II) tumors, were enrolled for the study. They were divided into thymectomy and thymomectomy groups according to the resection extent of the thymus. Demographic and surgical outcomes were compared between the two patients groups.

Results

A total of 1,047 patients were enrolled, with 796 cases in the thymectomy group and 251 cases in the thymomectomy group. Improvement rate of myasthenia gravis (MG) was higher after thymectomy than after thymomectomy (91.6% vs. 50.0%, P<0.001). Ten-year overall survival was similar between the two groups (90.9% after thymectomy and 89.4% after thymomectomy, P=0.732). Overall, recurrence rate was 3.1% after thymectomy and 5.4% after thymomectomy, with no significant difference between the two groups (P=0.149). Stratified analysis revealed no significant difference in recurrence rates in Masaoka–Koga stage I tumors (3.2% vs. 1.4%, P=0.259). However in patients with Masaoka-Koga stage II tumors, recurrence was significantly less after thymectomy group than after thymomectomy (2.9% vs. 14.5%, P=0.001).

Conclusions

Thymectomy, instead of tumor resection alone, should still be recommended as the surgical standard for thymic malignancies, especially for stage II tumors and those with concomitant MG.     

Perioperative outcomes and long-term survival in clinically early-stage thymic malignancies: video-assisted thoracoscopic thymectomy versus open approaches

Background

Video-assisted thoracoscopic surgery (VATS) theoretically offers advantages over open thymectomy for clinically early-stage (Masaoka-Koga stage I and II) thymic malignancies. However, long-term outcomes have not been well studied. We compared the postoperative outcomes and survival from a cohort study based on the database of the Chinese Alliance for Research in Thymomas (ChART).

Methods

Between 1994 and 2012, data of 1,117 patients having surgery for clinically early-stage (Masaoka-Koga stage I and II) tumors were enrolled for the study. Among them, 241 cases underwent VATS thymectomy (VATS group), while 876 cases underwent open thymectomy (Open group). Univariate analyses were used to compare the clinical character and perioperative outcomes between the two groups. And multivariate analysis was performed to determine the independent predictive factors for long-term survival.

Results

Compared with the Open group, the VATS group had higher percentage of total thymectomy (80.5% vs. 73.9%, P=0.028), resection rate (98.8% vs. 88.7%, P=0.000) and less recurrence (2.9% vs. 16.0%, P=0.000). Five-year overall survival was 92% after VATS and 92% after open thymectomy, with no significant difference between the two groups (P=0.15). However, 5-year disease free survival were 92% in VATS group and 83% in Open group (P=0.011). Cox proportional hazards model revealed that WHO classification, Masaoka-Koga stage and adjuvant therapy were independent predictive factors for overall survival, while surgical approach had no significant impact on long-term outcome.

Conclusions

This study suggests that VATS thymectomy is an effective approach for clinically early-stage thymic malignancies. And it may offer better perioperative outcomes, as well as equal oncological survival.     

Clinical characteristics of idiopathic pulmonary fibrosis patients with gender,age, and physiology staging at Okinawa Chubu Hospital

Background

Gender, age, and physiology (GAP) staging was recently advocated for idiopathic pulmonary fibrosis (IPF). However, clinical findings of GAP staging for IPF are limited. We aimed to investigate the clinical characteristics of IPF patients according to GAP staging in our hospital.

Methods

We retrospectively reviewed patient medical records and chest high-resolution computed tomography (HRCT) images from June 1, 2002, to December 31, 2012.

Results

We identified 54 IPF patients with [36 men; mean age: 71 years (range, 53-85 years)]. Mean fibrosis and ground glass opacity (GGO) scores were 1.9 (0-4) and 1.6 (1-3.3), respectively. Mean percent predicted forced vital capacity (% FVC), percent predicted diffusing capacity of the lung for carbon monoxide (% DLco) were 70.6 (6.4-114.3), 49.2 (15-105.9), respectively. Cox proportional hazards model showed that gender, percent predicted diffusing capacity of the lung for carbon monoxide (% DLco), and composite physiologic index (CPI) were strong predictors of mortality. Stage III patients had more pulmonary hypertension (50% vs. 23%, 0%) and progressive modified Medical Research Council (mMRC) changes at 1 year (1.3 vs. 0.6, 1.1; P=0.07) compared with other stages.

Conclusions

In our cohort, GAP staging was useful for evaluating IPF severity. Stage III patients might had more pulmonary hypertension and progressive dyspnea. Multicenter analyses are warranted to confirm these findings.

Keywords

Idiopathic pulmonary fibrosis (IPF); modified Medical Research Council (mMRC); mortality; pulmonary hypertension; staging     

Endobronchial ultrasound-guided transbronchial needle aspiration for lung cancer staging: early experience in Brazil

Objective:

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive, safe and accurate method for collecting samples from mediastinal and hilar lymph nodes. This study focused on the initial results obtained with EBUS-TBNA for lung cancer and lymph node staging at three teaching hospitals in Brazil.

Methods:

This was a retrospective analysis of patients diagnosed with lung cancer and submitted to EBUS-TBNA for mediastinal lymph node staging. The EBUS-TBNA procedures, which involved the use of an EBUS scope, an ultrasound processor, and a compatible, disposable 22 G needle, were performed while the patients were under general anesthesia.

Results:

Between January of 2011 and January of 2014, 149 patients underwent EBUS-TBNA for lymph node staging. The mean age was 66 ± 12 years, and 58% were male. A total of 407 lymph nodes were sampled by EBUS-TBNA. The most common types of lung neoplasm were adenocarcinoma (in 67%) and squamous cell carcinoma (in 24%). For lung cancer staging, EBUS-TBNA was found to have a sensitivity of 96%, a specificity of 100%, and a negative predictive value of 85%.

Conclusions:

We found EBUS-TBNA to be a safe and accurate method for lymph node staging in lung cancer patients.     

TBNA with and without EBUS: a comparative efficacy study for the diagnosis and staging of lung cancer

Introduction

Conventional transbronchial needle aspiration (TBNA) has been around for over 30 years with sensitivities approaching 70-90%. Recent development of endobronchial ultrasound (EBUS) TBNA demonstrated even higher sensitivities among experts. However EBUS-TBNA is more costly and less available worldwide than conventional TBNA. A comparison study to determine the efficacy of TBNA with and without EBUS in the diagnosis and staging of lung cancer is described.

Methods

A total of 287 patients with mediastinal and hilar lymphadenopathy presenting for diagnosis and/or staging of lung cancer at enrolling institutions were included. Equal numbers of punctures were performed at the target lymph node stations using conventional TBNA techniques followed by EBUS-TBNA at the same sites. Patients and puncture sites that were biopsied by both methods and were positive for lung cancer were compared to establish efficacy of each technique on the same patients.

Results

In 253 patients at least one pair of specimens were obtained by conventional TBNA and EBUS-TBNA. In 83 of these patients malignancy was diagnosed. Among the 83 patients with a diagnosis of a malignancy there was no significant difference in the diagnostic yield of conventional TBNA versus EBUS-TBNA. When comparing diagnosis of malignancy for each lymph node sampled, there were a significantly greater number of positive (diagnostic for malignancy) lymph nodes sampled by EBUS-TBNA.

Conclusions

Recommendations for current practice depend on individual centers and bronchoscopist comfort level with TBNA (with or without EBUS). In our study, no significant difference was seen between the techniques for the diagnosis and staging of individual patients.     

Comparative performances of staging systems for early hepatocellular carcinoma

Background:

Several staging systems for patients with hepatocellular carcinoma (HCC) have been proposed, but studies of their prognostic accuracy have yielded conflicting conclusions. Stratifying patients with early HCC is of particular interest because these patients may derive the greatest benefit from intervention, yet no studies have evaluated the comparative performances of staging systems in patients with early HCC.

Methods:

A retrospective cohort study was performed using data on 379 patients who underwent liver resection or liver transplantation for HCC at six major hepatobiliary centres in the USA and Europe. The staging systems evaluated were: the Okuda staging system, the International Hepato-Pancreato-Biliary Association (IHPBA) staging system, the Cancer of the Liver Italian Programme (CLIP) score, the Barcelona Clinic Liver Cancer (BCLC) staging system, the Japanese Integrated Staging (JIS) score and the American Joint Committee on Cancer/International Union Against Cancer (AJCC/UICC) staging system, 6th edition. A recently proposed early HCC prognostic score was also evaluated. The discriminative abilities of the staging systems were evaluated using Cox proportional hazards models and the bootstrap-corrected concordance index (c).

Results:

Overall survival of the cohort was 74% at 3 years and 52% at 5 years, with a median survival of 62 months. Most systems demonstrated poor discriminatory ability (P > 0.05 on Cox proportional hazards analysis, c≈ 0.5). However, the AJCC/UICC system clearly stratified patients (P < 0.001, c= 0.59), albeit only into two groups. The early HCC prognostic score also clearly stratified patients (P < 0.001, c= 0.60) and identified three distinct prognostic groups.

Discussion:

The early HCC prognostic score is superior to the AJCC/UICC staging system (6th edition) for predicting the survival of patients with early HCC after liver resection or liver transplantation. Other major HCC staging systems perform poorly in patients with early HCC.     

Indications for staging laparoscopy in pancreatic cancer

Background

To identify indications for staging laparoscopy (SL) in patients with resectable pancreatic cancer, and suggest a pre-operative algorithm for staging these patients.

Methods

Relevant articles were reviewed from the published literature using the Medline database. The search was performed using the keywords ‘pancreatic cancer’, ‘resectability’, ‘staging’, ‘laparoscopy’, and ‘Whipple''s procedure’.

Results

Twenty four studies were identified which fulfilled the inclusion criteria. Of the published data, the most reliable surrogate markers for selecting patients for SL to predict unresectability in patients with CT defined resectable pancreatic cancer were CA 19.9 and tumour size. Although there are studies suggesting a role for tumour location, CEA levels, and clinical findings such as weight loss and jaundice, there is currently not enough evidence for these variables to predict resectability. Based on the current data, patients with a CT suggestive of resectable disease and (1) CA 19.9 ≥150 U/mL; or (2) tumour size >3 cm should be considered for SL.

Conclusion

The role of laparoscopy in the staging of pancreatic cancer patients remains controversial. Potential predictors of unresectability to select patients for SL include CA 19.9 levels and tumour size.     

The application of postoperative chemotherapy in thymic tumors and its prognostic effect

Background

To study the role of postoperative chemotherapy and its prognostic effect in Masaoka-Koga stage III and IV thymic tumors.

Methods

Between 1994 and 2012, 1,700 patients with thymic tumors who underwent surgery without neoadjuvant therapy were enrolled for the study. Among them, 665 patients in Masaoka-Koga stage III and IV were further analyzed to evaluate the clinical value of postoperative chemotherapy. The Kaplan-Meier method was used to obtain the survival curve of the patients divided into different subgroups, and the Cox regression analysis was used to make multivariate analysis on the factors affecting prognosis. A Propensity-Matched Study was used to evaluate the clinical value of chemotherapy.

Results

Two-hundred and twenty-one patients were treated with postoperative chemotherapy, while the rest 444 cases were not. The two groups showed significant differences (P<0.05) regarding the incidence of myasthenia gravis, World Health Organization (WHO) histological subtypes, pathological staging, resection status and the use of postoperative radiotherapy. WHO type C tumors, incomplete resection, and postoperative radiotherapy were significantly related to increased recurrence and worse survival (P<0.05). Five-year and 10-year disease free survivals (DFS) and recurrence rates in patients who underwent surgery followed by postoperative chemotherapy were 51% and 30%, 46% and 68%, comparing with 73% and 58%, 26% and 40% in patients who had no adjuvant chemotherapy after surgery (P=0.001, P=0.001, respectively). In propensity-matched study, 158 pairs of patients with or without postoperative chemotherapy (316 patients in total) were selected and compared accordingly. Similar 5-year survival rates were detected between the two groups (P=0.332).

Conclusions

Pathologically higher grade histology, incomplete resection, and postoperative radiotherapy were found to be associated with worse outcomes in advanced stage thymic tumors. At present, there is no evidence to show that postoperative chemotherapy may help improve prognosis in patients with Masaoka-Koga stage III and IV thymic tumors.     

Diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration for mediastinal staging in lung cancer

OBJECTIVE:

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive diagnostic test with a high diagnostic yield for suspicious central pulmonary lesions and for mediastinal lymph node staging. The main objective of this study was to describe the diagnostic yield of EBUS-TBNA for mediastinal lymph node staging in patients with suspected lung cancer.

METHODS:

Prospective study of patients undergoing EBUS-TBNA for diagnosis. Patients ≥ 18 years of age were recruited between July of 2010 and August of 2013. We recorded demographic variables, radiological characteristics provided by axial CT of the chest, location of the lesion in the mediastinum as per the International Association for the Study of Lung Cancer classification, and definitive diagnostic result (EBUS with a diagnostic biopsy or a definitive diagnostic method).

RESULTS:

Our analysis included 354 biopsies, from 145 patients. Of those 145 patients, 54.48% were male. The mean age was 63.75 years. The mean lymph node size was 15.03 mm, and 90 lymph nodes were smaller than 10.0 mm. The EBUS-TBNA method showed a sensitivity of 91.17%, a specificity of 100.0%, and a negative predictive value of 92.9%. The most common histological diagnosis was adenocarcinoma.

CONCLUSIONS:

EBUS-TBNA is a diagnostic tool that yields satisfactory results in the staging of neoplastic mediastinal lesions.     

Incidental pT2-T3 gallbladder cancer after a cholecystectomy: outcome of staging at 3 months prior to a radical resection

Introduction

Patients with incidental pT2-T3 gallbladder cancer (IGC) after a cholecystectomy may benefit from a radical re-resection although their optimal treatment strategy is not well defined. In this Unit, such patients undergo delayed staging at 3 months after a cholecystectomy to assess the evidence of a residual tumour, extra hepatic spread and the biological behaviour of the tumour. The aim of this study was to evaluate the outcome of patients who had delayed staging at 3 months after a cholecystectomy.

Methods

From July 2003 to July 2011, 56 patients with T2-T3 gallbladder cancer were referred to this Unit of which 49 were diagnosed incidentally on histology after a cholecystectomy. All 49 patients underwent delayed pre-operative staging using multi-detector computed tomography (MDCT) followed selectively by laparoscopy at 3 months after a cholecystectomy. Data were collected from a prospectively held database. The peri-operative and long-term outcomes of patients were analysed. SPSS software was used for statistical analysis.

Results

There were 38 pT2 and 11 pT3 tumours. After delayed staging, 24/49 (49%) patients underwent a radical resection, 24/49 (49%) were found to be inoperable on pre-operative assessment and 1/49 (2%) patient underwent an exploratory laparotomy and were found to be unresectable. The overall median survival from referral was 20.7 months (54.8 months for the group who had a radical re-resection versus 9.7 months for the group who had unresectable disease, P < 0.001). These results compare favourably with the reported outcome of fast-track management for incidental pT2-T3 gallbladder cancer from other major series in the literature.

Conclusion

Delayed staging in patients with incidental T2-T3 gallbladder cancer after a cholecystectomy is a useful strategy to select patients who will benefit from a resection and avoid unnecessary major surgery.     

A new staging strategy for chronic obstructive pulmonary disease

Background:

The best method for expressing lung function impairment is undecided. We tested in a population of patients with chronic obstructive pulmonary disease (COPD) whether forced expiratory volume in 1 second (FEV₁) or FEV₁ divided by height squared (FEV₁/ht²) was better than FEV₁ percent predicted (FEV₁PP) for predicting survival.

Method:

FEV₁, FEV₁PP, and FEV₁/ht² recorded post bronchodilator were compared as predictors of survival in 1095 COPD patients followed for 15 years. A staging system for severity of COPD was defined from FEV₁/ht² and compared with the Global Initiative for Obstructive Lung Disease (GOLD) staging system.

Result:

FEV₁/ht² was a better univariate predictor of survival in COPD than FEV₁ and both were better than FEV₁PP. The best multivariate model for predicting survival included FEV₁/ht², age and sex. Comparing the GOLD stages with the FEV₁/ht² groups found that survival was more coherent within each FEV₁/ht group than it was within each GOLD stage. FEV₁/ht² had 60% more people in its most severe group than the severest GOLD stage with these extra subjects having equivalently poor survival and had 155% more in the least severe group with equivalent survival. GOLD staging misclassified 51% of subjects with regard to survival.

Conclusion:

We conclude that GOLD criteria using FEV₁PP do not optimally stage COPD with regard to survival. An alternative strategy using FEV₁/ht² improves the staging of this disease. Studies which stratify COPD patients to determine the effect of interventions such as drug trials, rehabilitation, or management guidelines should consider alternatives to the GOLD classification.     

FDG-positron emission tomography/computed tomography and standardized uptake value in the primary diagnosis and staging of hilar cholangiocarcinoma

Background

The diagnosis and staging of hilar cholangiocarcinoma (HCCA) remain challenging despite recent advances in imaging. Little is known about the use of positron emission tomography/computed tomography (PET/CT) in HCCA.

Objectives

This study aimed to evaluate the additional value of FDG-PET/CT and standardized uptake value (SUV) in patients with highly suspected HCCA.

Methods

Between February 2006 and August 2009, PET/CT was performed in 30 patients with highly suspected HCCA, all of whom were deemed resectable by conventional staging methods, including laparoscopy. The results of PET-CT and SUV were compared with intraoperative and histopathological findings.

Results

The primary tumour was ¹⁸F-FDG-positive in 88% of patients. Sensitivity and specificity for the detection of regional lymph node metastases and distant metastases were 67% and 68%, and 33% and 96%, respectively. The median SUV in the primary tumour was significantly (P < 0.05) higher in patients with (mean: 8.9) than without (mean: 6.1) distant metastases. The SUV in patients with benign disease (n = 4) showed a trend towards lower values than in patients with cholangiocarcinoma, although this was not significant.

Conclusions

After conventional staging including diagnostic laparoscopy, the additional value of PET/CT is limited. This somewhat disappointing finding may reflect the fact that extensive staging studies were carried out prior to PET/CT. The SUV potentially predicts patients with distant metastases and may differentiate between HCCA and benign lesions that mimic malignancies.     

Preoperative induction therapy for locally advanced thymic tumors: a retrospective analysis using the ChART database

Background

To evaluate the role of preoperative induction therapy on prognosis of locally advanced thymic malignancies.

Methods

Between 1994 and 2012, patients received preoperative induction therapies (IT group) in the Chinese Alliance for Research in Thymomas (ChART) database, were compared with those having surgery directly after preoperative evaluation (DS group). All tumors receiving induction therapies were locally advanced (clinically stage III–IV) before treatment and those turned out to be in pathological stage I and II were considered downstaged by induction. Clinical pathological characteristics were retrospectively analyzed. To more accurately study the effect of induction therapies, stage IV patients were then excluded. Only stage I-III tumors in the IT group and stage III cases in the DS group were selected for further comparison in a subgroup analysis.

Results

Only 68 (4%) out of 1,713 patients had induction therapies, with a R0 resection of 67.6%, 5-year recurrence of 44.9%, and 5- and 10-year overall survivals (OS) of 49.7% and 19.9%. Seventeen patients (25%) were downstaged after induction. Significantly more thymomas were downstaged than thymic carcinomas (38.7% vs. 13.9%, P=0.02). Tumors downstaged after induction had significantly higher 5-year OS than those not downstaged (93.8% vs. 35.6%, P=0.013). For the subgroup analysis when stage IV patients were excluded, 5-year OS was 85.2% in the DS group and 68.1% in the IT group (P=0.000), although R0 resection were similar (76.4% vs. 73.3%, P=0.63). However, 5-year OS in tumors downstaged after induction (93.8%) was similar to those in the DS group (85.2%, P=0.438), both significantly higher than those not downstaged after induction (35.6%, P=0.000).

Conclusions

Preoperative neoadjuvant therapy have been used only occasionally in locally advanced thymic malignances. Effective induction therapy leading to tumor downstaging may be beneficial for potentially unresectable diseases, especially in patients with thymomas. These findings would be helpful to related studies in the future.     

Lung cancer staging: the value of PET depends on the clinical setting

Background

Although positron emission tomography (PET) imaging is widely recommended in the evaluation of patients with lung cancer, randomized controlled trials (RCTs) assessing this have demonstrated inconsistent results. We asked whether differences in the clinical context and endpoints could explain these discrepancies.

Methods

We used realist synthesis methods to analyze how contextual differences among RCTs affected the results. We focused on RCTs to minimize confounding yet permit evaluation of differences by comparing across studies.

Results

This analysis suggests that the impact of PET depends on the clinical setting. PET is of greatest benefit in identifying M1 disease in patients with a high chance of such involvement and when little traditional imaging [e.g., abdominal/pelvis computed tomography (CT) and bone scan] is used. Identification of N2,3 involvement by PET prior to resection is seen primarily when there is at least a moderate probability of such and the rate of invasive staging is high. The rate of N2 disease not identified preoperatively appears to increase if PET is used to avoid invasive mediastinal staging in clinical settings in which the risk of N2,3 involvement is moderately high. There is both a potential benefit in avoiding stage-inappropriate resection as well as a risk of missed (stage-appropriate) resection if PET findings are not evaluated carefully.

Conclusions

A blanket recommendation for PET may be too simplistic without considering nuances of the clinical setting.     

Relevance of residual disease after liver resection for incidental gallbladder cancer

Objectives

In patients diagnosed with incidental gallbladder cancer (GC), the benefit and optimal extent of further surgery remain unclear. The aims of this study were to analyse outcomes in patients who underwent liver resection following a diagnosis of incidental GC and to determine factors associated with longterm survival.

Methods

A retrospective analysis of patients diagnosed with incidental GC between June 1999 and June 2010 was performed. Data covering demographics, clinical and surgical characteristics and local pathological stage were analysed.

Results

A total of 24 patients were identified. All patients underwent a resection of segments IVb and V and lymphadenectomy. Histological examination revealed residual disease in 10 patients, all of whom presented with recurrent disease at 3–12 months. Overall 5-year survival was 53%. Increasing T-stage (P < 0.001), tumour–node–metastasis (TNM) stage (P= 0.003), and the presence of residual tumour in the resected liver (P < 0.001) were all associated with worse survival.

Conclusions

Aggressive re-resection of incidental GC offers the only chance for cure, but its efficacy depends on the extent of disease found at the time of repeat surgery. The presence of residual disease correlated strongly with T-stage and was the most relevant prognostic factor for survival in patients treated with curative resection.