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A.WHAT MATTERS IN THE SURGICAL ONCOLOGY
General Background

B. UPPER LESION
Surgical Oncology of the Early Bronchial Lesion. The Contribution of CBC

C. LOWER LESION
Surgical Oncology of the Early Lesion of the Pulmonary Tissue. The Contribution of CBC

D. THESIS
Concept B CZ

E.
ACHIEVING OPTIMAL RESULTS THROUGH EARLY MULTIDISCIPLINARY CARE IN PULMONARY ONCOLOGY

 



A.
 WHAT MATTERS IN THE SURGICAL ONCOLOGY


T. Horvath

Introduction

Surgical oncologist is a peculiar element of the varied community of the vigorously engaging specialists in the struggle with the lethal disease. As the surgery is a teamwork par excellence, he knows, that a chain is as strong as its weakest link: in the spheres in which a pessimist is crying, which is a situation than I am willing not to take into account; where an optimist ingenuously bumps against a new challenge of disease, he ought as a realist to recall the success in a way “one for all and all for one” arranging matters in compliance with that and the chain becomes suddenly not to be broken.

Particular components of surgical oncology exist themselves alone – simultaneously, independently, with the same level of significance – without superiority or inferiority without merging or separating – creating a sole integral entirety characterized with a high difference and a profound equality of their parts. Although each of them represents specific issue, all of them belong to the specialty.

Surgical oncology would be ranked among the most comprehensive proficiencies supporting a view of legitimacy of the knowledge unity concept. That is not a case of golden hands. It is much more attractive. It includes the delicate handling with tissue and organs as well the whole patient’s human being. They are harmonized there the information of multilayered variety of oncogenous processes categorized by medical and other sciences, natural as well as human, with an important participation of technologies, with non-negligible roles of intuition and empiricism – including manual labour. It is influenced by feedbacks proper to surgery and medicine, in the widest sense of the words, by statistics, economics, psychology, sociology and obviously also by politics. Surgical oncology is created by four parts.
 Let’s define the chapters in singles :

I. Surgery of premalignancy
II. Treatment of “surgical stage” of oncological disease
III. Surgery of locally advanced disease:
Palliation, sanitation, devitalization, metaintervention
IV. Surgical treatment of metastatic disease:
IV. a – surgery of solitary metastasis by means of the strategy identical with the second chapter.
IV. b – surgery of general spreading of the disease, solving a local problem of the general extent by means of strategy similar to the saving treatments of the third chapter.


I. Surgery of premalignancy
a) The advanced premalignant changes are signalling a risk of cancer development in the tissue. Biopsy proof of the severe dysplasia leads to think about the presence of malignancy in the concerned focus with the whole appropriate surgical routine of work. b) Another scenario is represented by mild or moderate dysplasia, at a given moment clinically insignificant. Their biological development in the subsequent phase is used to be difficult to guess, especially at the earlier detections. The context faced dilemma of overdiagnosis /overtreatment versus underdiagnosis/undertreatment:
- the overdiagnosis represents clinically an irrelevant/insignificant diagnosis, not requiring any treatment, because it would be superfluous – overtreatment, as express commonly used terms.
- the underdiagnosis includes all varieties of diagnosis underestimation, usually in connection with an insufficient treatment – undertreatment with all consequences. Decision making is not easy but the surgical empiricism knows a rule of thumb: it is better to perform surgery unnecessarily than late. An example might be a diagnosis so “simple” as appendicitis; and a special example then a pulmonary coin lesion.

II. Treatment of “surgical stage” of oncological disease
Preoperative counselling in the widest sense signifies offering and getting of all appropriate information, before an informed consent of the patient: a) to communicate with the patient, having respect for all her/his personal (physical, psychical and spiritual), familiar, professional and social peculiarities. b) to cultivate permanent relationships with specialists of imaging, medical and radiation oncology, cytology and histopathology, medicine, clinical psychology etc., to find an optimal, generally valid and acceptable solution. That should precede the following steps: c) determination of one’s own chirurgical strategy d) explanation of general organisation of the surgical concept and special details referring to the particular patient e) all of that in accordance with up-to-date progress in the field of knowledge.
It doesn’t remain as to say, that the strategy of the contemporary surgical oncology usually recommend to consider radical surgery with sufficient safety border of healthy tissue by the smallest biologically acceptable anatomical resection in connection with regional lymphadenectomy en block – expressed by the term curative resection.

III. Surgery of locally advanced disease: Palliation, sanitation, devitalization, metaintervention
Heterogenous surgical interventions there are involved in the third chapter, all with a common denominator: locally considerably advanced, radically predominantly insoluble disease. Procedures used in this category represent prospect for survival of incurable patient with amelioration of the quality of life. Exceptionally, they can become to a qualified effort for its radical solution, even if close to the extreme.
They are represented mainly by non-radical procedures:
1) Palliation – classical examples: the avoidance of inoperable obstacle of GIT passage by entero-enteroanastomosis, laser recanalisation of bronchus obstructed with tumour mass, or artificial reinforcement by stenting of ureter compressed by tumour.
2) Sanitation – the ablation of necrotic tumour mass even in spite of general spreading of disease, on account of massive secretion, of pungent odour, threatening to bleed to death
3) Devitalization – trying to dissolve the extensive inoperable tumours by interruption
of their vascular supply. Even if the argumentation of devitalization followers is from the point of view of general oncology in some respects incomplete, its supremely surgical ethos can’t be neglected. As there is also the case of metaintervention, below mentioned. Surely under condition of nil nocere. While the indications of palliation and sanitation are more or less obvious, devitalization can be always considered an enfant terrible.
4) Radical intervention in the chosen cases of locally extremely advanced disease with excluded distant metastases represents a relative novelty. It requires transanatomical access often with utilization of (auto)transplantation and of artificial materials for replacement of infiltrated vascular structures. These procedures are issued from seasoned surgeons in well coordinated teams of top centres. They have their proponents and also opponents. The indications are individual. In the essential argumentation compete technical realizability with biological authority. The internal strain of this type of conduct, could be perhaps expressed by the term metaintervention. The fundamental and global motive of this chapter too, is the life prolongation and improvement of its quality with an attitude, not at all just formal (!), and of great importance at any stage of disease: the help is possible. The most tragic expression of misunderstanding our profession, and under no circumstances unflagging work at full stretch of the surgical oncology, is as follows: The surgeon did not know what to do.


IV. Surgical treatment of metastatic disease
Surgery of the metastatic disease is very specific branch of oncology:
1) More than at the synchronous metastases the treatment of distant solitary metachronous metastases evokes the access of the second chapter of surgical oncology. It should represent a complete resection with a curative intent. The others conclude about suitability of a simple excision of the lesion in the case of metachronous lesion, too. Valid data are lacking. A way downwards cannot be excused automatically. Each case has to be judged individually in all given correlations.
2) Surgery of general spreading disease, e.g. a wedge excision of ten metastases of sarcoma to the lung, or the radiofrequency ablation of five metastatic focuses in the liver in terms of tumour mass reduction, for instance before perfusion chemotherapy, remains open. There are both their advocates and opponents.
3) Another category of the management of distant metastatic disease includes also palliative abdominocentesis for a tumour ascites, or talc poudrage of the interpleural space for a metastatic pleural effusion. The same procedures would be used in the part a/ of the previous third chapter within the bounds of surgical palliation of the manifestation of locally advanced cancer of relevant organs.

Conclusion
No collective authority of a specialized indicating commission can remove from any individual surgeon the personal responsibility for the actual treatment sewed to the patient to measure – it is said today personalized. Definitive decision is sometimes done at the most dramatic moment of the surgical procedure. In that sense and in accordance with the above mentioned, a surgeon is not only a meek part of a deciding chain, but as an executive agent, he is autonomous. That does not weaken him; it strengthens him. The more he is well-educated and skilled, the more he is independent and free to make correct decisions. Surgery never means a defensive. The surgery, cheir ergein , means, apart from other things, the well informed, consequently reserved, nevertheless a strong fortitude to act.

©C11_DUSOth


 

B.
 SURGICAL ONCOLOGY OF THE EARLY PULMONARY LESION
UPPER LESION The contribution of CBC to the issue

Summary


Background: Description of the morphological features of bronchial carcinogenesis (Scheme 1)
in vivo by use of autofluorescence bronchoscopy.

Patients and methods:
Yearly repeated bronchoscopy in persons (n=361) with high risk of lung cancer by Autofluorescence endoscopy SAFE-1000 Pentax during dozen years (1999-2010). Both white light bronchoscopy (WLB) and autofluorescence (AFB) mode are feasible at the same investigation. Hematoxylin-and-eosin histopathology and immunohistochemistry p21 and ki67 were used.
Results:
Eleven morphological units of bronchial premalignancy are defined. They are divided into two classes: Superficial Spreading Lesion – 1/ invisible islet and 2/ spot, 3/ redness islet and 4/ spot, 5/ spider, 6/ swollen and thickened mucosal fold, 7/ granular, 8/ mixed lesion; and Protruding Lesion – 9/ nodular, 10/ wart-like 11/ polypoid. Superficial spreading lesions are of high variability. Roughening in WLB and arenaceous depiction at AFB mode of the surface of the lesion represent evolving risk of malignant transformation. Irregular margin of the lesion (star shaped; spider) is important sign of advanced lesion. Superficial spreading lesions with distinct limitation (border) represent by histopathology early premalignant processes. Protruding lesion with smooth surface in WLB and low decreased autofluorescence signal output is not risky; Protruding lesion with smooth surface and deep decreased autofluorescence characteristic is at risk of malignant development or it is malignant. Wart-like surface of the protruding lesion represents advanced lesion at risk.
The cogency of overdiagnosis and underdiagnosis issue of every particular lesion in the course of time were studied (Scheme 2). There are defined three classes of the lesions regardless of their superficial spreading or protruding nature in general: 1/ Quiet – oncologically unimportant, in the course of time disappearing lesion 2/ Ambiguous – representing biologically uncertain unit inviting follow-up endeavour, and 3/ Persistent – proliferative lesion at risk needed particular attention from the clinical point of view.
Conclusion:
To detect early bronchial premalignancy low output ilumination intensity and mild autofluorescence signal amplification are needed. A part of advanced premalignant bronchial lesions at risk is recognizable by naked eye.
 

KEY WORDS: Autofluorescence; Bronchoscopy; Carcinogenesis; Morphology.



Scheme 1. Principle of Bronchial Dysplasia Detection

© Ján Otradovec

 

Scheme 2 Overdiagnosis and Underdiagnosis

N – normal epithelium IEN – dysplasia CIS – carcinoma in situ

T1a – superficial cancer t – time E – epithelial stage of the disease

I – intersticial spreading of the disease

Lesion:
 P – proliferative 

A – ambiguous 

Q – quiescent 

 

PP – persistent proliferative lesion at risk D – disappearing lesion

 


 

C.
 SURGICAL ONCOLOGY OF THE EARLY PULMONARY LESION
LOWER LESION The contribution of CBC to the issue

Summary


Background: Czech pioneering of pulmonary segmentectomy for cancer.

Patients and methods: Pulmonary opacity suspect of lung cancer without enlargement of lymphnodes on CT imaging was detected in twenty persons from high risk group (n=305) by follow up through 5127 examinations during the period of 1999-2008 yrs. Proven non small cell lung cancer and tumours of uncertain histopathology with diameter up to 20mm were indicated to segmentectomy (Figure 1). Borderline diameter for segmentectomy of a metastatis was 30 mm. They were implemented twenty one Overholts procedures. The histopathology was stated under hematoxylin-and-eosin staining and immunohistochemistry examination.
Results: Nine non - small cell lung cancers, six metastases, and six benign lesions were found histopathologically. No local recurrence and no involvement of regional lymphnodes were recorded postoperatively in both cancer series with median age of 63 yrs (range 45-79) and median duration of follow up 35 months. No perioperative 30-days mortality was registered. Six distant recurrences appeared, 3 in NSCLC and 3 in extrapulmonary cancer patients. Five cancer-patients died, three of them through the general progression of the disease, two deaths were non-cancer related. Patients with NSCLC represent 1‰ among all operated Czech pacients with lung cancer of the period.
Conclusion: Lung segmentectomy seems to accomplish local control of early stage NSCLC and pulmonary metastasis of extrapulmonary cancer. Broad multidisciplinary collaboration focused on early stage disease is needed.

KEYWORDS: Early Lung Cancer; Segmentectomy; Lymphadenectomy.


Figure 1 Scheme of the Surgical Lung Segment

© Marek Malik

Legend:

1  intersegmental pulmonary vein

2  intrasegmental pulmonary vein

3  subpleural pulmonary vein

4  pulmonary artery segmental branch

5  segmental lymphnodes

6  subsegmental lymphatics

7  segmental bronchus

8  intersegmental space

9  visceral pleura

 

Figure 2 IASLC Scheme of Thoracic Lymphatics

 

© Marek Malik

Legend:

1 Lower Cervical, Supraclavicular and Jugular

2 2L Upper Paratracheal Left 2R Upper Paratracheal Right

3 3a Prevascular 3p Retrotracheal

4 4R Lower Paratracheal Right 4L Lower Paratracheal Left

5 Subaortal (Aortopulmonal Window)

6 Paraaortal (Ascending Aorta, or Phrenic )

7 Subcarinal

8 Paraesofageal

9 Pulmonary Ligament

10 Hilar

11 Interlobar

12 Lobar

13 Segmental

14 Subsegmental

 

Figure 3 Anatomical Scheme of the Lung and Mediastinal Lymphatics
Lymphatic Stream

© Marek Malik

Legend:

1 deep lymphytics

2 ubpleural lymphatics

3 pulmonary lymphatic nodes

4 bronchopulmonary lymphatic nodes

5 hilar lymphytic nodes

6 tracheobronchial lymphatic nodes

7 lower paratracheal lymphytic nodes

8 upper paratracheal lymphytic nodes

9 right bronchomediastinal lymphatic trunk

10 left bronchomediastinal lymphytic trunk

11 thoracic duct

12 left venous angle

13 right venous angle

 


 

D.
THESIS
Lung cancer – preventable disease. A surgical view.

Concept B CZ Horvath T. & Horvathova M.


I. Introduction

Lung tumours are located in two anatomically distinct regions – in the central airways (upper lesion) and in the pulmonary parenchyma (lower lesion). They demand different diagnostic and therapeutic tools. Diagnostic modality of upper lesion is bronchoscopy. Lower lesion is detected by imaging, especially computer tomography (CT). Key note of the prevention and early diagnosis fall within of authority of epidemiology and public medicine. The most efficient method of the treatment is surgery. Treatment methodology of proximal lesion is partly represented by therapeutic bronchoscopy, greater part of it is dominating by surgery. The treatment of distal lesion is surgical. Being efficient surgery needs effective diagnostics by imaging, endoscopy, and histopathology. The more are they integrated into surgical oncology (it goes without saying the more is a surgical oncologist involved into the professions most close to her/his profession) the closer to the entirety of goal seeking. Respect to the category of the lesion is neded to reach a solution adequacy in: A. premalignant B. primary pulmonary malignancy C. pulmonary metastasis.
A.
Endoscopically detectable premalignancy has a suite of morphological features, but three biological variantions only: 1/ persistent proliferative lesion at risk 2/ ambiguous intraepithelial lesion in a part progressing in the course of time to the risky dysplasia or regressing back to normal mucosa 3/ transient quiet lesion, disappearing in the course of time. Long term monitoring of the finding discloses the biological character of the tissue differentiating clinically important and unimportant lesion (over/under-diagnosis issue). To diversify clinically important and inconsequential finding is assisted by accumulation of certain measure of experience. That precedes an undervaluation of the manifested initial asymptomatic weighty development – underdiagnosis – or its overestimation i.e. overdiagnosis. They might lead at the same time to the undertreatment – meaning insufficient therapy; or to the overtreatment – i.e. superfluous therapy.
Endoscopically detected malignancy is treated mainly surgically.
B.
Technically and biologically operable primary pulmonary tumours detected by imaging and endoscopy represent the field for radical surgery of the lung (classic, videoassisted, robotic) in the “surgical“ stage of the disease: i.e. anatomical resection, sufficient margin of healthy tissue, adequate lymphadenectomy. Sooner the better, but extreme cases tackle a question of overdiagnosis and led-time bias.
Surgery of the peripheral nodules argues with relevance or irrelevance of the diagnosis (under/overdiagnosis) lead time bias including, and with the justification of surgical intervention. These are discussed with the context of less agressive properties of a part of detected peripheral pulmonary lesions and with the role of the lymphatics in the spreading of more agressive tumours.
C.
Solitary metastatic pulmonary tumour is an object for radical resection with identical technical premises mentioned above (being aware of permanent dilemma of overtreatment enthroned).
Radical anatomical procedure with regional lymphadenectomy alternating wedge resection without lymphadenectomy are used. There are no EBM arguments to the recommendation of regional lymphadenectomy in the case of metastasis. Some background warn against its overall refusal .
Lobe specific lymphadenectomy is according contemporary ESTS guideline and IASLC recommendation inseparable part of the curative pulmonary resection of NSCLC. The premise of the united proceeding is represented by the IASLC map of pulmonary and mediastinal lymphatics.

II. Upper Lesion

Individuals from a mixed cohort of persons with high risk of lung cancer were more years investigated periodically. In vivo manifestation of varied optical and morphological features of bronchial intraepithelial neoplasia (dysplasia) using System Autofluorescence Endoscopy SAFE-1000 Pentax was studied.
They are descibed twelve morphological units classified into six groups. They represent three manner of biological behaviour mentioned above. As a result of the endeavour was found a surprisingly simple fact that persistent lesion shows the signs of proliferation by ki67 and p21 immunohistochemical investigation. It is at risk. Because it is relevant and necessary take it out.

III. Lower Lesion

Starting to cultivate Czech clinical culture of pulmonary segmentectomy for tumour up to 20 millimeters in diameter in junction with regional lymphadenectomy since its scientific confirmation years ago we are advocating it to date still as unique subject in the state. That accounts for the part of 1 per mille of the lung cancer surgical procedures in the Czech Republic in the monitored ten years time period 1999-2008.
Facultative indication of pulmonary segmentectomy for primary non-small cell lung cancer represent small peripheral tumour up 2 cm in the diameter with a margin of healthy tissue wider than 1 cm providing normal preoperative finding on the thorax CT scan on the pulmonary and mediastinal lymphatics and negative histopathology of the lymphatic nodes. We are detected the tumours in the risk group by ourselves. There are not registered local recurrence with folloow-up median of 35 months.The metastatic tumours are indicated up to 30mm in the diameter for resection. Pulmonary and mediastinal lymphatics were classified by Naruke. It is used IASLC lymphatic map a common scheme of general acceptance recently. There are in the IASLC scheme described 14 stations of thoracic lymphatics divided into 5 categories and 7 zones:
Supraclaviclar zone # 1 SUPRACLAVICULAR NODES; Upper zone # 2,3,4; SUPERIOR MEDIASTINAL NODES AP zone AORTIC NODES # 5,6; INFERIOR MEDIASTINAL NODES Subcarinal zone # 7; Lower zone # 8,9; N1 NODES Hilar / Interlobar zone # 10,11; Peripheral zone 12,13,14;

IV. Thesis Resource

The optimal access to lung cancer is represented by primary, secondary and tertiary prevention focused onto risk groups. It is connected with early diagnosis and treatment, the entirety of a longstanding follow-up including. In a carefull follow-up examination is founded high potential to the detection of synchronous or metachronous extrapulmonary tumour duplicities and lung involvement with metastatic disease too. Disclosing and solving of non-oncological problems of surgical and medical nature made easier.
A complicated and very interesting issue is concerned: on the very horizon of full endeavour emerges a catch of sight of lung cancer curability paradigm.


V. THESIS

FOCUSING EARLY DETECTION ON ADEQUATE CATEGORIES OF PERSONS AT RISK OF LUNG CANCER CONNECTED WITH EARLY THERAPY OF THE FINDINGS FACILIATES PROLONGED SURVIVAL, IMPROVEMENT OF THE QUALITY OF LIFE, FINANCIAL SAVINGS IN THE SYSTEM OF MEDICAL INSURANCE AND MANY-SIDED PERSONAL, FAMILIAR, PROFESSIONAL AND SOCIAL ADVANTAGE.


 

E.
ACHIEVING OPTIMAL RESULTS THROUGH EARLY MULTIDISCIPLINARY CARE IN PULMONARY ONCOLOGY

Teodor Horvath


BACKGROUND DEFINITION

Early management of lung cancer continues to be one of cardinal questions of pulmonary oncology. Scientific knowledge of relatively self-contained space of early diagnosis and therapy are searched, checked up and classified in cooperative field of histopathology, pneumonology, radiology and surgical oncology. Basic information is acquired by the research in the risk groups. Comparing the results sourced by different methods and/or with the situation in non-risk population is defined the difference. Verrified data represent rational basis to advance suggestion for modification of the standard algorithms

HISTOPATHOLOGY OF THE PULMONARY ONCOLOGY

Multistep process originating pulmonary adenocarcinoma (ADL) – adenocarcinogenesis – is illustrated through mapping of allelic imbalance of 25 selected genes by Masayuki Nogutchi. The progress of adenocarcinoma in situ (AIS) to early invasive adenocarcinoma (EIA) is considerably supported by participation of abnormal demethylation of stratifin (SFN).
Peripheral ADL is on the CT imaging presented by ground glass opacity (GGO). Cavita Garg analyses the controversies of the clinical management of GGO by correlating histopathology of ADL with HRCT imaging of three GGO essentials – pure GGO, GGO with solid part(s), and solid lesion. They are presented in numerous variable forms. She emphasizes the need of multidisciplinary teamwork on their classification with the aim of desirable general guide. Similar appeals are heard from many sites. They might not be disregarded as accidental. Further examples referred to necessary multidisciplinary cooperation are strict differentiation of the biological behaviour of particular forms of non-small cell lung cancer (NSCLC) i.e. among squamous cell lung cancer (SQL), ADL, and their mixed forms, pulmonary carcinoid (CAT) and other kinds of pulmonary neuroendocrine tumours (PNET), exact definition of less and high agressive forms of small cell lung cancer (SCLC) and giant cell PNET, clear correlation of their incidence with smoking and additional risk factors. That all seen in real efficiency of the bronchology, radiology, aspiration cytology, small or greater biopsy samples, and surgery with final diagnosis of the resecate by immunohistochemistry.
Horizontal integration is not limited on sparse institutions only, but it represents a general tendency. Despite of the fact that high level resolution cannot be achieved by those which have other problems than complicated cases.
Signalized by the finding of severe dysplasia (SD) or carcinoma in situ (CIS) pertinent SQL should be anticipated anywhere in the lung location. With a probability of 80% SQL will evolves in the detected lesion in a time period of 2-3 years. It happens on the basis of numerous abnormalities counted minimally twenty genetic and epigenetic alterations of various chronology and kinetics according conclusions of Sylvie Lantéjoul. The survey continues about the development of ADL: from preinvasive atypical alveolar hyperplasia (AAH) in the typical CT appearance as pure GGO with need of follow up only, up to the adenocarcinoma in situ (AIS) in fact ex-bronchioloalveolar cancer (BAC) finally up to microinvasive forms of peripheral ADL, most frequently seen as a non-solid peripheral pulmonary opacity. Its character is variable. Onto the biological make out of the lesion take part both West (Keith M. Kerr, Wiliam D. Trawis), and East (M. Noguchi). Recent information declared that mucinous adenocancer of the lung is probably separate nosologic unit.
Wide histopathological engangement does not interfere with simple direction for surgical handling. It is enabled by this, in contrary. The indication for surgery is in principle represented by any long lasting GGO with a development to a non-solid appearance.
Diffuse interstitial proliferative neuroendocrine cells hyperplasia (DIPNECH) is an autonomous chapter of histopathology of the preinvasive pulmonary lesion, a precursos of carcinoid. Even experienced histopathologists studying signs of the lesion face temptation to assume that DIPNECH might be a precursos of SCLC, perhaps only some its forms. If is it the case of the less of most agressive form according clinical observation? Nobody knows. The issue is an item of sharp disputes (regarded desirable) and of deep study (regarded needful).

BRONCHOLOGY

In the clinical field of early lung cancer is bronchology represented by autofluorescence bronchoscopy (AFB) . Is it an important diagnostic tool or not ? Is the clinical benefit of the method predominated over the time, economic and technic limitations ? No, they are not predominated over. The AFB is a specific tool established to detailed identification of detected lesion(s), and areas estimated for minimally invasive therapy, in patients with lesions multiplicity (synchronous and metachronous) and the follow up care in the risk group. Is there a need of technical enhancement ? Yes, of course. It undergoes a development similar to any other method, concludes Eric Edell.

CLINICAL SYNTHESIS THROUGH IMAGING

Notable information based on the recent released results from the National Lung Screening Trial (NSLC) sponsored by the National Cancer Institute of the United States is pointed out by John K. Field: Claudia Henschke with coworkers showed, that lung cancer deaths was reduced by 20% and all-causes mortality reduced by 7% when smokers defined as former and current smokers with 30 or greater pack-years of smoking were screened regularly using low-dose spiral CT compared with standard X-ray.
The commentary to NLST of Giulia Veronesi “Hypothesis of overdiagnosis is undermined“ speaks eloquently to the supporter, irresolute or opponent of the method.
See www.nejm.org/doi/full/10.1056/NEJMoa110283 (1) or http://iaslc.technetrics.com/policies/statement-on-ct-screening

SURGERY

The surgical statement for the management of early lesion is theoretically and technically clear. Curative surgery is represented by anatomical resection with regional lymphadenectomy. One can reflect segmentectomy for small tumours up to 20 mm in diameter onto the basic practical level. Greater tumours are indicated to lobectomy. In the surgical pool are offered classical open and videoassisted procedures. The replenishing of the arsenal is continual by the development of both its parts. The value belongs to the lymphadenectomy is accented. The finding should be staged as accurately as possible. The classical procedures are refilled with TEMLA ( transcervical mediastinal lymphadenectomy) by Marcin Zielinski a method prerequisite for cervical pulmonary lobectomy. Videoassisted mediastinal lymphadenectomy (VAMLA) cultivated by Martin Hürtgen and coworkers represents good tested stil attractive novelty of the miniinvasive line.
The surgery is reliable, effective and economical therapeutic instrument. Its fundamental advantage is represented with radical solution. The surgeon might lose the way in the abundance of molecular biological data by forgetting one of the best rules of the art … to operate rather uncesessarily than late.
There is everytime something for doing better in the organization chart. The importance of team work demonstrates concrete example from United Kingdom by Kevin Wing Lan. Surprisingly 58% of British hospitals performing thoracic surgery deal with only one thoracic surgeon. No surprise that regions with carefully worked-out level hierarchy starting basic through extension personal and technical equipment up to top centres with skilled teams and wide technology background show better perioperative and long-term results.
The progress move along to robotic pulmonary surgery in the actual western (Bernard Park, Kemp Kerstine) or eastern (Hyun-Sung Lee) presentation. One cannot neglect importance of stereotactic body radiation therapy (SBRT) in the comprehensive declamation of Dirk De Ruysscher especially in functionally or medically inoperable patients, despite of an imperfection in the reasoning with sets without complete histopathology.

EPIDEMIOLOGY

Little data exist regarding causation of lung cancer in non-smokers (approximately 25% of the incidence). It is caused in contrast to smokers by other biological mechanisms. Preferred population are women of younger age. It originates probably endemically too, e.g. in some areas of China. Lung cancer of non-smokers is conditional on genetic determinants and enviromental components. There are examined only partially or non-examined. Beside radon and asbestos figure among the causes hormones, viruses, coal smoke, and kitchen exhalation. There is accepted the clonal theory of the origination from one cell but the non-clonal possibility too. Closer elucidation of the matter will need further united endeavour with great application.
(2)

CONCLUSION

Through the standard wrestling of neophilia with neophobia one can observe in the pulmonary oncology that checking old estimation from new angle of view benefits the knowledge. The opportunity for effective solution so far seemingly non-soluble problem finally emerged. Are we ready?

REFERENCE
1)
Reduced Lung-Cancer Mortality with Low-Dose Computed Tomographic ScreeningThe National Lung Screening Trial Research Team N Engl J Med 2011; 365:395-409
2)
Supplement to Journal of Thoracic Oncology 2011;6 Book 1,2.

ABBREVIATIONS

AAH atypical alveolar hyperplasia
ADL adenocarcinoma of the lung
AFB autofluorescence bronchoscopy
AIS adenocarcinoma of the lung in situ
BAC bronchioloalveolar carcinoma (=AIS)
CAT carcinoid tumor / typical carcinoid
CIS carcinoma in situ
CT computer tomography
DIPNECH diffuse intersticial proliferative hyperplasia fo neuroendocrine cells
GGO ground glass opacity
HRCT high resolution computer tomography
EIA early invasive adenocarcinoma of the lung
LDsCT low dose spiral computed tomography
NLST National Lung Screening Trial
NSCLC non small cell lung cancer
PNET pulmonary neuroendocrine tumour
SBRT stereotactic body radiation therapy
SCLC small cell lung cancer
SFN stratifin
SD severe dysplasia
SQL squamous cell lung cancer
TEMLA transcervical mediastinal lymphadenectromy
VAMLA videoassisted mediastinal lymphadenectomy
 

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