Tag: stage IIIA

Global Connection: Dr. Michael Harden and chest wall resection

The short but informative Global Connection conference today delivered on two fronts; big and small..

Big for the multidisciplinary surgeries like large locally invasive tumor resections that offer hope to patients that might otherwise be turned away.. Small for the minimally invasive techniques and nonintubated techniques that improve the lives of our patients – faster recoveries, less post-operative pain and shorter hospital stays..

In a previous post, we talked about the John Wayne principle and large surgical resections. We’ve talked about multi-disciplinary surgeries before, but during today’s presentation by Dr. Michael Harden of Australia, he presented several cases that highlighted the critical importance of large scale surgical resections for stage IIB and IIIA lung cancers.

Dr. Michael Harden is a cardiothoracic surgeon at the Royal North Shore Private Hospital in a suburb of Sydney, Australia.

During his lecture, on chest wall reconstruction for lung cancer, Dr. Harden presented several cases illustrating successful large scale resections. While each of the procedures was technically challenging due to the presence of very large, invasive tumors, these cases were complex for multiple reasons such as pre-operative radiation, morbid obesity and other serious co-morbidities.

In each of these cases, he highlighted the importance of multi-disciplinary involvement, from plastic surgery for free flap harvesting and revascularization, to cardiac surgery (for ECMO/ CPR) for resection of tumors involving the great vessels or spinal surgery for a case requiring an enbloc removal of a vertebral body for a very large paraglioma involving the lung, vertebra and rib – which was encroaching on the the spinal cord.

One of his more notable cases is mentioned below. This case illustrates the importance of innovation and consideration for patient’s quality of living as this surgical technique allowed this patient to return to his job as a truck driver. (Many of the more commonly used techniques to repair the sternum such as muscle flaps are not as conducive to this type of occupation which requires more than sitting behind the wheel.)

  • We have reached out to Dr. Harden for more information about his work.

Intrathoracic Hyperthermic Chemotherapy (Hithoc) in advanced non-small lung cancer: the Nara Experience

As part of a continuing discussion of HITHOC (Hyperthermic IntraThoracic intraOperative Chemotherapy), today we are talking about the results of a small study conducted at the Nara Medical University, School of Medicine in Nara, Japan.

As part of a continuing discussion of HITHOC (Hyperthermic IntraThoracic intraOperative Chemotherapy), today we are talking about the results of a small study conducted at the Nara Medical University, School of Medicine in Nara, Japan.

While the study is small (just 19 patients in three groups), it’s important because the patients involved all had advanced lung cancer, with malignant pleural effusions or disseminated disease discovered at the time of surgery. This is important, as readers know, because lung cancers are often diagnosed late, (after patients develop malignant effusions), and that the prognosis for patients with malignant effusions is grim.

Population: 19 patients.

Notably, the treatment group C consisting of seven patients (which received no intrathoracic thermic treatment) who were treated during an earlier period (2001 – 2003). Group C had an average age of 64. Essentially a control group.

The remaining patients were treated during 2006 – 2008 and are divided into two groups;

Group A which received hyperthermic (hot) saline infusion with a 30 minute dwell time – consisted of seven patients.  This group was also older (average age 72).

Group B, consisting of five patients who received hyperthermic chemotherapy (cisplatin) infusion into the chest cavity with a 30 minute dwell time.

Note: Infusion in this post refers to instillation of fluid into the chest cavity, not an intravenous treatment.    All patients received post-operative adjuvant chemotherapy.

The grouping of A and B serves to distinguish whether the mechanism of treatment is related to the application of heat alone, or the application of heated chemotherapeutic agents.  Current theories about the effectiveness of HITHOC suggest that the heat of the chemotherapy allows the drugs to penetrate more deeply into the tissues compared to application of chemotherapy alone, but requires studies such as this to support this theory.

Interestingly, the pre-operative staging of these patients differed significantly from intra-operative findings with 8 patients diagnosed with early disease (stage I), five patients with stage II and only six patients as stage IIIA pre-operatively.  (Presence of a pleural effusion denotes stage IV).  Malignant effusions were not seen during pre-operative workup. (It is not uncommon to find more advanced cancer at the time of surgery.)

Surgery: All of the patients underwent a VATS procedure (video-assisted thoracoscopy).  The majority of patients of patients (16) underwent surgery to remove the primary lesion (cytoreductive surgery) with ten patients undergoing lobectomy and six patients undergoing wedge resection.

Intra-operative findings:  16 patients found to have malignant effusions, 10 patients with disseminated disease.

Results: No intra-operative/ post-operative deaths.

Group A (hot saline group): no deaths during follow-up period, with a median follow-up period of almost 20 months.  No recurrence of pleural effusions.

Group B (heated chemotherapy group): 4 deaths in follow-up period; median survival time was 41 months, one patient with recurrent pleural effusion 26 months after treatment.

Group C: (VATs alone): 5 deaths (during follow-up period) median survival 25 months, 4 patients with recurrent pleural effusions (average time to recurrent effusion: 3 months).

While this study is too small (with only five patients receiving intrathoracic chemotherapy) to generalize the results – it should prompt researchers into conducting more studies and trials into the use of hyperthermic intrathoracic chemotherapy in patients with late stage lung cancers.

The decreased incidence of pleural effusion in the treatment groups (A and B) is important also for quality of life issues.  However, these findings are also limited by the small study size.

I have written to Dr. Naito (corresponding author on this article) for further comment and information.

Reference:

1. Kimura, M., Tojo, T., Naito, H., Nagata, Y., Kawai, N., & Taniquichi, S. (2010). Effects of a simple intraoperative intrathoracic hyperthermotherapy for lung cancer with malignant pleural effusion or dissemination. Interactive Cardiovascular & Thoracic Surgery 2010, April, 10 (4); 568 -71.  (linked to pdf).