Background. The aim of the study was to establish eventual progress in routine management of lung cancer patients over a ten-year period at University Clinic for Respiratory and Allergic Diseases Golnik, Slovenia, comparing the results of analysis of 345 patients, diagnosed in 1996 (with analysis performed in 2002), and 405 patients, diagnosed in 2006 (with analysis performed in 2008).Patients and methods. The patients of both analysed groups were of comparable age and number of patients in stage I and II, but there were relatively more females, patients with better performance status, more precise clinical staging and tumour histology in the 2006 group. The parameters used for assessing the progress of management were as follows: time period from admittance to diagnosis and to surgery; precision of staging; accordance of clinical and pathological staging in resected patients; percentage of exploratory thoracotomy; and use of new treatment modalities. The proportion of patients in selected/actual primary treatment modality and survival rate could also be used for assessing the progress.Results. Although unessential longer time from admittance to microscopic confirmed diagnosis increased from a mean 7.4 to 8.6 days in 2006 progress was established by the following: more precise clinical staging ( stage I and II also A and B stage, TNM staging also in small-cell lung cancer patients); improved accordance with clinical and pathological staging in resected patients (46% against 58%); decreased percentage of exploratory thoracotomy (13% against 4%); increased use of multimodality therapy as primary treatment modality (radiotherapy/chemotherapy, neoadjuvant chemotherapy); newly performed radio frequency tumour ablation. The proportion in selected/actual surgery increased from 76% to 93% and median survival rate of all patients from 6.2 to 10.6 months. One-year survival increased from 33.6% to 45.8% and two-year survival from 17.4% to 23%.Conclusions. Progress in routine lung cancer management was proved by better staging, lower percentage of exploratory thoracotomy, use of new treatment modalities, minor discordance between selected and actual therapy, and improved short-term survival rate.

Unusual results of surgical treatment in small-cell lung cancer (SCLC) patients were published by Lim et al.1Lim E Belcher E Yap YK Nicholson AG Goldstraw P The role of surgery in the treatment of limited disease small cell lung cancer: time to reevaluate.J Thorac Oncol. 2008; 3: 1267-1271Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar in the article “The role of surgery in he treatment of limited disease small cell lung cancer. Time to reevaluate” in the October issue of the Journal of Thoracic Oncology. In the group of 59 completely resected SCLC no patient had any documentation of preoperative chemotherapy, 13 patients had received adjuvant chemotherapy, two patients adjuvant radiotherapy, and one adjuvant chemo-radiotherapy. Despite this, the 5-year survival rate was 52%! This calculated (not observed) percentage of survival is quite comprehensible considering the median time to follow-up was only 2.8 years. Less acceptable is the paradoxical statement of survival by Union Internationale Contre le Cancer (UICC) clinical stage and clinical nodal status: patients with a more progressed stage had better survival. The results were similar when the pathologic stage was used for analysis. So, the authors state that “UICC classification had a poor discriminatory value for prognosis,” “the influence of nodal involvement was unclear; the best prognostic subgroup was in patients with N2 disease.” The prognostic value of UICC tumor node metastasis staging in SCLC has been established in many clinical studies. In the International Society of Chemotherapy-Lung Cancer Study Group, multinational, prospective, and randomized study of 183 SCLC patients treated surgically, which also included patients from Slovenia, the N0 patients had a significantly better survival rate than the N1 and N2 patients.2Karrer K Ulsperger E Surgery for cure followed by chemotherapy in small cell carcinoma of the lung. For the ISC-Lung Cancer Study Group.Acta Oncol. 1995; 34: 899-906Crossref PubMed Scopus (47) Google Scholar Lim et al. did not explain their unusual observations. Searching for a reason for such results, there is (beside accidental findings due to the small number of individual groups of patients) a reasonable possibility that patients in a higher stage more frequently received adjuvant therapy that could have led to better survival. From this point of view, the published study actually evaluated the role of adjuvant therapy in resected SCLC. A solitary limited pulmonary tumor without enlarged regional lymph nodes and without suspicion of distant metastases represents a challenge for the thoracic surgeon, even in the case of confirmed SCLC. In the literature, one finds data on successful surgical treatment of SCLC without chemotherapy, but the survival rate of such cases is low. This is substantiated by the survival rate in the period before routine use of chemotherapy. With the present knowledge of SCLC, the omission of adjuvant chemotherapy is too risky, whether the chemotherapy is adjuvant therapy to surgery or surgery adjuvant to chemotherapy. Based on our own experience in Slovenia,3Debevec M Orel J Treatment of small cell lung cancer by surgery, chemotherapy, and irradiation.Lung Cancer. 1991; 7: 339-344Abstract Full Text PDF Scopus (3) Google Scholar as in many thoracic centers world wide, surgery and chemotherapy are routinely performed in the case of selected small, solitary, preferably peripheral SCLC after consistently being carried through complete staging. Still, the percentage of such cases is very low.

In the December 2008 issue of Lung Cancer Lee et al. [ [1] Lee P. de Bree R. Brokx H.A.P. Leemans C.R. Postmus P.E. Sutedja T.G. Primary lung cancer after treatment of head and neck cancer without lymph node metastasis: is there a role for autofluorescence bronchoscopy?. Lung Cancer. 2008; 62: 309-315 Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar ] reported on second primary lung cancer (SPLC) in patients with curatively treated head and neck cancer (HNC) without lymph node metastases. In 51 patients, referred to the pulmonary department for radiological abnormalities and/or symptoms of lung cancer between 1995 and 2005, and prospectively followed until December 2006, the authors detected 42 cases of SPLC. Diagnosed SPLC at the same time or within 6 months of HNC was defined as synchronous and that developed after more than 6 months as metachronous cancer.

CT je danes rutinska slikovna preiskava za zamejitev pljučnega raka. Omogoča oceno razširjenosti in odstranljivosti raka v prsnem košu in zunaj njega. Vendar kljub bolj kakovostnim posnetkom CT ne omogoča zanesljive ocene vraščanja tumorja v interlobarno fisuro in mediastinum, pa tudi ne prizadetosti mediastinalnih bezgavk. Novejše CT naprave sicer omogočajo posnetke tudi v drugih ravninah, ne več samo v aksialni, kar je bila nekoč bistvena prednost MRI, ki je še vedno dražja in težje dostopna preiskava. Prednost MRI je v tem, da bolj zanesljivo pokaže prizadetost ožilja, vretenca in brahialnega pleteža, in da ni potrebno vbrizgati kontrastnega sredstva, ki lahko ogroža bolnike, ki so preobčutljivi na jod v njem. V prihodnosti naj bi MRI celotnega telesa omogočal tudi oceno M-stadija. Kot dopolnilne preiskave priporočajo endoskopski ultrazvok bronhijev (EBUZ) in požiralnika (EUZ) kakor tudi PET oz. PET-CT. Novejše raziskave kot tudi njihova metaanaliza so pokazale, da ima PET enako ali celo boljšo napovedno vrednost kot mediastinoskopija, 5 izboljša pa tudi zamejitev zunaj prsnega koša.6 Invazivne preiskave za zamejitev ne omogočajo samo dokončne diagnoze, ampak tudi analizo tumorskih označevalcev (markerjev), kar vpliva na nadaljnje, predvsem podporno zdravljenje. Poleg običajne vratne mediastinoskopije izvajajo tudi videomediastinoskopijo, v nekaterih centrih celo z odstranjenjem bezgavk – VEMLA (video-assisted mediastinal lymphadenectomy). Razdelitev drobnoceličnega raka samo na omejeni in razširjeni stadij ne zadostuje več; tudi pri rutinski obravnavi je priporočljiva klasifikacija TNM. Preživetje drobnoceličnega raka je v neposredni korelaciji s stadijema T in N. Bolniki s plevralnim izlivom pa imajo ne glede na to, ali gre za citološko pozitiven ali negativen izliv, napoved izida, ki je vmes med omejenim in razširjenim stadijem.8

Background: The aim of the study was to establish the comorbidity in the presented group of lung cancer patients and to examine the applicability of CI by determining the difference of survival rate according to CI.Methods: In 259 non-small cell lung cancer patients, median age 65, primarily treated nonsurgically (radiotherapy 187, radio- and chemotherapy 6, radiotherapy and interferon 3, chemotherapy 2, simptomatically 27, unknown 34), clinical stage IA in 9, IB in 51, IIA in 1, IIB in 61, IIIA in 116, IIIB in 14 and IV in 7 patients, the comorbidity and the survival rate according to CI were established.Results: No comorbidity was established in 66 (25.5 %) of patients, CI 1 in 121 (46.7 %), CI 2 in 54 (29.8 %), CI 3 in 14 (5.4 %), CI 4 in 3 (1.2 %), and CI 5 in 1 (0.4 %) patient. The majority (146 patients) had pulmonary disease, followed by cardiovascular disease (40 patients), other conditions were rarely observed. Median survival of CI 0 patients was 13.3 months, CI 1 patients 11.1 months, CI 2–5 patients 9.9 months. The survival difference was statistically significant (p = 0.0351). Conclusions: Most of the lung cancer patients had also other pulmonary and cardiovascular diseases. The survival rate was significantly different according to the established CI. This way the usefulness of CI for determining the comorbidity in non-small cell lung cancer patients was confirmed.

An interesting article by Balduyck et al. [ [1] Balduyck B. Hendrics J. Lauwers P. Van Schil P. Quality of life evolution after lung cancer surgery: a prospective study in 100 patients. Lung Cancer. 2007; 56: 423-431 Abstract Full Text Full Text PDF PubMed Scopus (108) Google Scholar ] was published in the June 2007 issue of Lung Cancer on quality of life (QoL) after lung cancer surgery, reporting on 100 patients included in a study of QoL, pre-operatively and 1, 3, 6 and 12 months post-operatively using questionnaire EORTC QLQ-C30 and its module QLQ LC13. Considering that there are not many articles published on the influence of thoracotomy on QoL in lung cancer patients, all new knowledge is important.

Background.The aim of the study was to assess the preoperative and postoperative quality of life (QoL) in lung cancer patients undergoing thoracotomy and to compare the impairment of QoL in resected and exploratory thoracotomized (ET) patients.Patients and methods.Forty-three patients age 31 to 82 (mean 61) thoracotomized (lobectomy 29, bilobectomy 1, pneumonectomy 8, ET 5) for non-small cell lung cancer were assessed using the EORTC QLQ-LC30 and QLQ-LC13 questionnaire preoperatively and a mean of 45±17 days after the thoracotomy and before eventual chemotherapy and radiation therapy.Results.After thoracotomy there were significantly impaired functional scales (physical functioning, role functioning, social functioning) and symptom scales (fatigue, constipation, appetite loss, dyspnoea, pain).The remaining symptoms (nausea/vomiting, insomnia, diarrhoea, coughing), global health status, functional scales (emotional functioning, cognitive functioning) and financial difficulties were impaired non-significantly.However, haemoptysis significantly improved and completely disappeared after thoracotomy.There were no significant differences between resected and ET patients.Conclusions.The study established significant impairment of QoL in the first two months after thoracotomy, but no significant differences between resected and ET patients.

An interesting article by Leo et al. on multidisciplinary management of lung cancer and testing its efficacy was published in the January 2007 issue of The Journal.1 We also performed a similar study.2,3 As mentioned by Leo et al., there is currently no information available in the literature regarding follow-up of these patients after multidisciplinary evaluation. Therefore, we are reporting our results to compare our study with theirs, although there is a time difference of 8 years between them.

Background.In a patient with suspicious synchronous multiple tumours, there are limited possibilities for effective therapy.Therefore, the decision for invasive diagnostics and precise staging of tumours is questionable, especially in elderly patients suitable only for symptomatic therapy.Case report.A 78-year-old man with hypertension and angina pectoris was admitted to the hospital due to syncope.Two primary lung tumours and a kidney tumour were detected by imaging investigation.The patient refused invasive diagnostics and left the hospital.After 19 months he was readmitted in an impaired clinical condition and subsequently died of bronchopneumonia.The autopsy revealed squamous cell carcinoma of the right upper lobe with metastases to regional lymph nodes and to the brain, small-cell carcinoma of the left upper lobe with metastases to regional lymph nodes and to the spleen, and clear-cell kidney carcinoma with multiple metastases to the lungs.All tumours were necrotizing, and therefore we assumed that any attempt at specific therapy would have been ineffective.Conclusions.In an elderly patient with advanced lung tumors and suspicious synchronous triple cancers, the "wait and see" option can be suitable.

Background: Resection yields the best survival rate in non-small cell lung cancer, and also as an adjuvant therapy to chemotherapy and radiation in small-cell lung cancer. Therefore it is suitable to search for patients with technically and medically operable tumours. Therefore it is necessary to perform the correct staging and estimation of a patient’s capacity for the intended surgery. Knowledge of the capability and reliability of singular investigations and their proper sequencing enables clinical staging of the tumour. The selection of the best treatment modality is based on the last factor. The diagnostic procedure should be rational and short, and the selected treatment useful for recovery, prolongation of survival or at least the relief of symptoms.Conclusions: Staging is based on TNM tumour classification. In the process and extent of staging it is necessary to carefully estimate and consider the patient’s capacity, particularly clinical condition, performance status, age, comorbidity and pulmonary function, and to assess tumour resectability by imaging (X-ray, CT, MRI, PET, US) and invasive investigations (bronchoscopy, cervical mediastinoscopy, parasternal mediastinotomy and [video]thoracoscopy). Before final selection of treatment, modality microscopic verification of the tumour is needed. Exploratory thoracotomy remains the ultimate possibility for verification and estimation of resectability. In addition to the imaging investigations mentioned, in searching for distant metastases the following are also useful: bone scanning, fine needle biopsy of palpable or reachable lesions of the lymph nodes, skin, bone marrow, body fluids and parenchymal organs. Laboratory tests of blood, urine and other bodily fluids may also indicate that the tumour has spread. It is necessary to take into account, that negative test results do not reliably exclude metastases.

PURPOSE:Pleurodesis can relieve dyspnea in patients with malignant pleural effusions. We retrospectively compared the success rate of talc slurry instillation pleurodesis with thoracoscopic talc powder insufflation pleurodesis. PATIENTS AND METHODS:From 2000 to 2005, two methods of talc pleurodesis were performed in 71 patients with symptomatic massive malignant pleural effusions: a) through the pleural drain (24F), 50 ml of a slurry containing 4-5 g of Luzenac talc in saline with 20 ml 1% lidocaine were instilled. The drain was clamped for 1 h; b) insufflation of 3-5 g of talc powder was performed via videothoracoscope using local anaesthesia. The drain was left in the pleural space until the daily secretion of pleural fluid was under 100 ml. Pleurodesis was considered successful when the patient was without dyspnea and did not need pleural fluid evacuation and the pleural fluid did not re-accumulate in the 1st month after pleurodesis. RESULTS:The success rate of talc slurry pleurodesis was 78%(38/49). Excluding 8 patients who died in the first month, the success rate increased to 93% (38/41). Thoracoscopic pleurodesis was successful in 77% (17/22) of patients. Excluding one patient who died in the first month, the success rate increased to 81%(17/21) (intergroup difference non significant). Complications were observed in 41% (20/49). vs. 73% (16/22) of patients in the talc slurry group and thoracoscopic group, respectively (p=0.013). CONCLUSION:Pleurodesis with instillation of talc slurry and with insufflation of talc during thoracoscopy were equally successful in patients with massive malignant pleural effusions. However, thoracoscopic pleurodesis is accompanied with considerably more complications, rather as a result of the thoracoscopy itself and not as a consequence of pleurodesis.

PURPOSE: To evaluate diagnostic procedures, reasons for exploratory thoracotomy (ET), causes of unresectability of lung cancer, possibility for reducing numbers of ETs, and the influence of ET on survival. PATIENTS AND METHODS: Between 1990 and 1999, 1808 patients with lung cancer were operated on. ET was performed in 165 (9.1%) of these cases. In total, 131 ET patients were evaluable for analysis. The clinical stages were: three patients in stage IA, 28 in IB, one in IIA, 35 in IIB, 50 in IIIA, 10 in IIIB (all due to invasion of the mediastinum), and four patients in IV (three with ipsilateral pulmonary and one with solitary suprarenal metastasis). The control group for calculating survival difference consisted of 130 consecutive non-operated patients with comparable characteristics (age, sex, clinical stage, performance status, histology and comorbidity) who were diagnosed during the period 1996–1998. RESULTS: The diagnostic procedure before ET comprised bronchoscopy in all patients, transthoracic needle biopsy in 13, cervical mediastinoscopy in nine, parasternal mediastinotomy in two and thoracoscopy in two, in all patients without proving unresectability. A CT scan was performed in 118 patients indicating resectability in 33%, doubtful resectability in 64% and unresectability in 3%. Clinical and surgical staging were equal in 3% of stage IIB patients, in 24% of stage IIIA, 100% of stage IIIB and 75% of patients in stage IV. The 30-day operative mortality was 4.6%. The reasons for ET were: diagnosis of preoperatively unverified tumor in one patient, necessity for pneumonectomy in the case of poor pulmonary function in 11 patients, and unresectability in 119 (due to invasion of the mediastinum in 98 patients, thoracic wall in three and vertebral body in one, and due to pleural metastases in 17 patients). ET could have been avoided in 15 (11%) patients. The median survival for both ET and control group patients was 11.1 months. The survival difference was not statistically significant (p = 0.420). CONCLUSION: ET could be partly avoided through a more accurate preoperative staging procedure. It does not appear possible to avoid ET in patients with limited pulmonary reserve precluding a resection larger than that predicted, nor to avoid ET as a consequence of intraoperative complications. Despite operative mortality, ET did not significantly influence the survival rate in the present study.

Background. The aim of the study was to establish characteristics of lung cancer patients diagnosed at the University Clinic of Respiratory and Allergic Diseases Golnik in 1996, their selected and realized therapy, and survival. Methods. The retrospective study comprises 345 patients aged from 37 to 90 years (mean 65), 285 males and 60 females. Performance status (Karnofsky): > 80 in 171 patients, 60-80 in 130 and <60 in 44 patients. Microscopically confirmed tumour in 97%: by bronchoscopy 281, transthoracic needle biopsy 23, peripheral lymph nodes biopsy 12, sputum cytology 7, pleural (effusion) cytology 4, distant metastases biopsy 2, mediastinoscopy 1, autopsy 4 patients. Histology and/or cytology: squamous 131, adenocarcinoma 86, large cell 63, small cell 51, non-small cell 1, unclassified 2. Clinical staging of non-small cell lung cancer (NSCLC): stage I 63, stage II 32, stage IIIA 48, stage IIIB 59, stage IV 77, undeterminable 2 patients. Staging in small cell lung cancer (SCLC): limited disease 24, extended disease 27 patients. Results. The selected primary oncological therapy was changed in 11%. Realized primary therapy: radiotherapy 102 (30%), surgery 77 (23%), chemotherapy 47 (14%), supportive treatment 111 (33%). In resected patients staging was correct in 46%, underestimated in 44%, overestimated in 10%. The overall five-year survival was 7.8% (median 6.2 months) and the five year survival of resected patients was 41.9% (median 33 months). The median survival of irradiated patients was 5.7 months, of supportively treated patients 2.5 months. The survival was significantly different according to the performance status and stage. Conclusions. The selected oncological therapy was actually realized in 89%. In our patients there was a low percentage of NSCLC treated by chemotherapy. Among five-year survivors there were 26 resected and one supportively treated patient, that confirms surgery as the most effective therapy in our lung cancer patients.

Background: IPF is lung disease of unfavorable prognosis. Earliest stages are responsive to treatment. Late diagnosis causes bad outcome.