Thoracic Oncology

There have been significant advances in the understanding of the biology and treatment of non-small-cell lung cancer (NSCLC) during the past few years. A number of molecularly targeted agents are in the clinic or in development for patients with advanced NSCLC. We are beginning to understand the mechanisms of acquired resistance after exposure to tyrosine kinase inhibitors in patients with oncogene addicted NSCLC. The advent of next-generation sequencing has enabled to study comprehensively genomic alterations in lung cancer. Finally, early results from immune checkpoint inhibitors are very encouraging. This review summarizes recent advances in the area of cancer genomics, targeted therapies, and immunotherapy.

Thymectomy, the surgical removal of the thymic gland, is essential in cases of thymoma. The majority of cases of a myasthenia gravis (MG) represent a relative indication for thymectomy which requires cooperation with specialized neurologists. Patients with MG may present with a tumor of the thymic gland. In case of suspicious thymoma, the resectability of the tumor has to be evaluated in the preoperative diagnostic. The clinical condition of patients with MG has to be stabilized preoperatively. The aim of thymectomy is the radical removal of thymoma and/or maximal improvement of MG symptoms. This requires the complete extirpation of the thymic gland including all ectopic thymic tissue in the anterior mediastinum. There is a variety of surgical techniques for performing a complete thymectomy. In addition to the conventional techniques with sternotomy, the significance of minimally-invasive approaches is increasing rapidly. Despite the ongoing scarcity of data of higher evidence concerning the procedure of thymectomy an increasing number of equivalent results with minimally-invasive operation techniques for MG and for thymoma are available. The successful surgical performance of a thymectomy is part of an interdisciplinary cooperation in the perioperative treatment of MG as well as the postoperative long-term care for patients with MG and/or thymoma. Georg Thieme Verlag KG Stuttgart · New York.

Patients affected with early stage (IA–IB) non-small cell lung cancer (NSCLC), deemed medically inoperable, are usually treated by conventional 3D-CRT, with poor results in terms of local tumour control and survival. Hypofractionated stereotactic body radiation therapy (SBRT) appears to be a valid alternative option, with high rates of local control and promising survival rates according to recent reported series. We herein report the final results of a prospective phase II trial of SBRT in 62 stage I NSCLC patients, homogeneously treated with three fractions of 15 Gy each, given every other day during a 1 week time, up to a total dose of 45 Gy; dose was prescribed to the 80%-isodose encompassing planning target volume. Patients were immobilized in a dedicated stereotactic body frame; margins around gross tumour volume were 5 mm in the axial plane and 10 mm in the longitudinal direction. Median age was 73.7 years. A pathologic confirmation of NSCLC was obtained in 64.5% of patients. Forty-three patients had stage IA and 19 stage IB disease. The majority of patients did not experience any toxicity; mild skin reactions, fatigue, dyspnea/cough or transient thoracic pain were recorded in approximately 10% of patients. With a median follow-up time of 28 months, 2 patients experienced an isolated local relapse, 4 an isolated nodal relapse and 15 a systemic failure. At 3 years, local control rate was 87.8%, cancer-specific survival 72.5%, overall survival 57.1%, with 8 out of 20 non-cancer related deaths. In multivariate analysis, tumour volume was associated with a better outcome. In our series, SBRT was well tolerated and confirmed its efficacy, with local control and survival rates globally superior to those reported using conventional radiotherapy. A longer follow-up is needed in order to establish a correct comparison with surgical series, and to fully ascertain a potential negative impact of SBRT on comorbidities of such a fragile patients population.

Activated Leukocyte Cell Adhesion Molecule (ALCAM/CD166), is expressed on osteoblasts (OB) and hematopoietic stem cells (HSC) residing in the hematopoietic niche, and may have important regulatory roles in bone formation. Because HSC numbers are reduced 77% in CD166(-/-) mice, we hypothesized that changes in bone phenotype and consequently the endosteal niche may partially be responsible for this alteration. Therefore, we investigated bone phenotype and OB function in CD166(-/-) mice. Although osteoclastic measures were not affected by loss of CD166, CD166(-/-) mice exhibited a modest increase in trabecular bone fraction (42%), and increases in osteoid deposition (72%), OB number (60%), and bone formation rate (152%). Cortical bone geometry was altered in CD166(-/-) mice resulting in up to 81% and 49% increases in stiffness and ultimate force, respectively. CD166(-/-) OB displayed elevated alkaline phosphatase (ALP) activity and mineralization, and increased mRNA expression of Fra 1...

Solitary fibrous tumors (SFT) are rare mesenchymal neoplasms. Most follow a benign course, but a subset will recur or metastasize. Various risk stratification schemes have been proposed for SFT, but none have been universally endorsed and few have focused on pleuropulmonary SFT. Histologic sections were examined from surgically resected pleuropulmonary SFT, with confirmatory immunohistochemistry. Patients were risk stratified using 4 prediction models as proposed by de Perrot, Demicco (original and modified), and Tapias. Kaplan-Meier analysis estimated overall survival (OS) and progression-free survival (PFS). The 147 study patients included 78 females (53.1%), with a median age of 61.5 years (range 25-87). Median follow up was 5.5 years (range 0-33). Recurrence or metastasis occurred in 15 patients (10.2%), with 5 deaths from disease. Significant predictors of worse OS included male gender, age ≥ 55, size≥10 cm, non-pedunculated growth, severe atypia, necrosis, and mitoses ≥ 4/10 h...

Lung cancer care is rapidly changing with advances in genomic testing, the development of next-generation targeted kinase inhibitors, and the continued broad study of immunotherapy in new settings and potential combinations. The IASLC and the Journal of Thoracic Oncology publish this annual update to help readers keep pace with these important developments. Experts in thoracic cancer and care provide focused updates across multiple areas including prevention and early detection, molecular diagnostics, pathology and staging, surgery, adjuvant therapy, radiotherapy, molecular targeted therapy, and immunotherapy for non-small cell lung cancer, small cell lung cancer, and mesothelioma. Quality and value of care and perspectives on the future of lung cancer research and treatment have also been included in this concise review.

Isolated nodal failure (INF) without synchronous local or distant failure is an uncommon occurrence after stereotactic body radiation therapy (SBRT) for lung cancer. Here we review the natural history and patterns of failure after post-SBRT INF with or without salvage mediastinal radiotherapy (SvRT). Patients treated with SBRT for non-small cell lung cancer with definitive intent were identified. Patients who experienced hilar or mediastinal INF without synchronous distant, lobar, or local failure were included and grouped according to the use of SvRT. The rates of subsequent locoregional control, distant metastases, progression-free survival (PFS), and overall survival were assessed. Of 797 patients treated with definitive SBRT, 24 (3%) experienced INF and 15 (63%) received SvRT. The most common SvRT regimen (53%) was 45 Gy in 15 fractions. The median follow-up after INF was 11.3 months for survivors. There were no grade 3 or higher toxicities after SvRT. The 1-year Kaplan-Meier PF...

To maximize the benefits of CT screening for lung cancer, optimal treatment is for small, early lung cancers is needed. Limiting the extent of surgery spares lung tissue, preserves pulmonary function, and decreases operative time, complications, and morbidities. It also increases the likelihood of resecting future new primary lung cancers. The goal is to assess alternative treatments in a timely manner. The focus sessions with patients and physicians separately highlighted the need to consider their perceptions. Literature reviews and analyses of treatment results using large databases were performed to formulate critical questions about long-term treatment outcomes, recurrence, and quality of life (QoL) of alternative treatments. Based on these analyses, the investigators developed a prospective multi-institutional cohort study, the Initiative for Early Lung Cancer Research for Treatment (IELCART), to compare treatments for Stage I non-small-cell lung cancer (NSCLC). HIPAA complian...