Objectives: As lung transplantation is not a realistic option for many of our chronic obstructive pulmonary disease (COPD) patients we have extended our selection criteria for lung volume reduction surgery. The iBODE index is a valid predictor of mortality in COPD. We wished to assess the risks and benefits of performing Lung volume reduction surgery (LVRS) in high risk patients who were potential transplant candidates as defined by their iBODE index. Methods: Our study population included 156 patients (age 60 [39-69] years, 88 males; 68 females) with an iBODE index of 5 or more who underwent VATS LVRS. Patients with pulmonary hypertension (Mean PAP >35 mmHg) or hypercapnia (pCO2 >7KPa) were excluded from surgery. The iBODE index was calculated from preoperative FEV1, body mass index (BMI), MRC dyspnoea score and shuttle walk test. In Group A, 109 (70%) patients had an iBODE index of 5 or 6. In Group B, 47 (30%) patients had an iBODE of 7 or above. Postoperative clinical assessment at 3, 6 and 12 months included record of FEV1, BMI and reassessment of quality of life with the Euroquol questionnaire. Results: Five-year survival was significantly higher in Group A than Group B. There was a significant improvement in all outcomes in both groups. The magnitude of perioperative improvement was similar in both groups. Conclusions: The risk of LVRS increases with the severity of the underlying COPD. However, the survival in those with the highest iBODE index is similar to that reported for lung transplantation. Even in those with the highest risk there is significant physiological, nutritional and subjective benefits from LVRS. Disclosure: No significant relationships.
The current staging system for malignant pleural mesothelioma (MPM) is controversial. To plan revisions of this system, the International Association for the Study of Lung Cancer Staging Committee developed an international database. Initial analyses focus on patients managed surgically.Participation was solicited from centers known to have MPM registries. Common data elements were analyzed by the International Association for the Study of Lung Cancer Staging Committee Statistical Center. Survival was analyzed by the Kaplan-Meier method, prognostic factors by log rank and Cox regression model. p Value less than 0.05 was significant.Data included 3101 patients (15 centers, 4 continents).median age 63 years, 79% men, 62.3% epithelioid tumor. Best tumor, node, metastasis (bTNM) stages were: I (11%), II, (21%), III (48%), and IV (20%). Curative-intent surgery was performed in 1494 patients (64.5%). Median survivals by clinical TNM and pathological TNM were similar: stage I, 21 months; stage II, 19 months; stage III, 16 months; and stage IV, 12 months. Median survival by histology: epithelioid 19 months, biphasic 13 months, and sarcomatoid 8 months. By multivariable analyses, significant differences in overall survival were seen for: T4 versus T3 and T3 versus T2 but not T2 versus T1; N0 versus N1 and N2 but not N1 versus N2; stages III and IV versus I but not II versus I; epithelioid histology versus other; age of female versus age of male; and palliative versus curative-intent surgery.This is the largest international database examining outcomes in surgically managed MPM patients. Survival differences reported from smaller databases are confirmed but suggest the need to revise tumor and node staging.
22132 Background: The role played by the innate immune system in determining survival from non-small cell lung cancer (NSCLC) is unclear. There is a survival advantage for patients with NSCLC expressing high numbers of macrophages in their tumour islets. The aim of this study was to investigate the immunological phenotype of islet and stromal macrophages in NSCLC. Methods: We used double-stain immunohistochemistry to identify CD68+ macrophages along with markers of either the non-cytotoxic M2 phenotype (CD163), or the cytotoxic M1 phenotype (HLA-DR,inducible nitric oxide synthase (iNOS), myeloid-related protein 8/14 dimerisation (MRP 8/14) and tumour necrosis factor-alpha (TNFα). This was performed on surgically resected tumours for 20 patients with good survival (median 92.7 months) compared to 20 patients with poor survival (median 7.7 months). Results: CD68+ macrophages were detected in both the tumour stroma and islets in all patients. There were significantly more double-stained CD68+ macrophages for all five phenotypes (11.5 cells/mm2 for CD163, 13.2 for HLA-DR, 21.6 for iNOS, 22.5 for MRP and 16.9 for TNFα) in islets of patients with > median survival compared with patients with < median survival (3.4, 3.9, 1.8, 2.9 and 3.7 cells/mm2 respectively) (p≤0.001). Conversely, there was no significant difference noted for the densities of these double-staining cells in the two survival groups in the stroma. Putative M1 macrophages were significantly increased compared to M2 macrophages in the islets of the good prognosis group (p≤0.05 for each marker). Conclusion: Macrophages in the tumour islets of patients with NSCLC express predominantly markers of the cytotoxic M1 macrophage population (HLA-DR, iNOS, MRP 8/14 & TNFα). This supports the view that the extended survival associated with islet macrophage infiltration is due to the cytotoxic anti-tumour activity of this macrophage population. No significant financial relationships to disclose.
Objectives: The aim of radical surgery for malignant pleural mesothelioma (MPM) is to achieve greater survival than from chemotherapy alone. Although adverse overall prognostic factors have already been determined, our aim was to identify the most important factors affecting long-term survival arbitrarily defined as greater than 24 months. Methods: We retrospectively reviewed the records of the 252 patients (35 female; 193 epithelioid and 59 biphasic; 112 extrapleural pneumonectomy [EPP], 140 extended pleurectomy decortication [RPD]) who survived for at least 90 postoperative days. We tested for factors affecting overall cancer-related mortality and specific clinical factors predicting 24-month survival. Results: Overall median survival was 18.2 (SE 1.2, 95% CI 15.8-20.7) months. There was no difference in survival between EPP and RPD (P = 0.91). One-hundred and twenty-eight patients received induction, adjuvant or palliative chemotherapy. Seventy-seven patients survived for >24 months. On univariate analysis, age older than 60 years (P = 0.044), pT4 stage (P = 0.041), any lymph node metastases (P = 0.002), biphasic cell type (P < 0.001) and no chemotherapy (P < 0.001) were associated with decreased survival. On multivariate analysis, age <60 years (P = 0.018, HR = 0.7), epithelioid disease (P = 0.001, HR = 0.56), negative nodes (P = 0.009, HR = 0.67) and any chemotherapy (P < 0.001, HR = 1.9) were associated with survival. Factors predicting survival over 24 months included age < 60 years (P = 0.014), epithelioid histology (P = 0.000), negative nodes (P = 0.001) and chemotherapy (P = 0.022). Conclusions: These results support a policy of accurate tissue diagnosis, nodal staging and induction chemotherapy prior to radical surgery for MPM. Trials investigating the additional role of surgery should be focused on confirming and refining these selection criteria.
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