Surgical outcome of wide wedge resection in poor-risk patients with clinical-N0 non-small cell lung cancer

Prognostic value of consolidation-to-tumor ratio on computed tomography in NSCLC: a meta-analysis

BACKGROUND

Although several studies have confirmed the prognostic value of the consolidation to tumor ratio (CTR) in non-small cell lung cancer (NSCLC), there still remains controversial about it.

METHODS

We systematically searched the PubMed, Embase, and Web of Science databases from inception to April, 2022 for eligible studies that reported the correlation between CTR and prognosis in NSCLC. Hazard ratios (HRs) with 95% confidence intervals (95% CIs) were extracted and pooled to assess the overall effects. Heterogeneity was estimated by I² statistics. Subgroup analysis based on the cut-off value of CTR, country, source of HR and histology type was conducted to detect the sources of heterogeneity. Statistical analyses were performed using STATA version 12.0.

RESULTS

A total of 29 studies published between 2001 and 2022 with 10,347 patients were enrolled. The pooled results demonstrated that elevated CTR was associated with poorer overall survival (HR = 1.88, 95% CI 1.42-2.50, P < 0.01) and disease-free survival (DFS)/recurrence-free survival (RFS)/progression-free survival (PFS) (HR = 1.42, 95% CI 1.27-1.59, P < 0.01) in NSCLC. According to subgroup analysis by the cut-off value of CTR and histology type, both lung adenocarcinoma and NSCLC patients who had a higher CTR showed worse survival. Subgroup analysis stratified by country revealed that CTR was a prognostic factor for OS and DFS/RFS/PFS in Chinese, Japanese, and Turkish patients.

CONCLUSIONS

In NSCLC patients with high CTR, the prognosis was worse than that with low CTR, indicating that CTR may be a prognostic factor.

Measuring the margin distance in pulmonary wedge resection

BACKGROUND

Margin distance contributes to survival and recurrence during wedge resections for early-stage non-small cell lung cancer. The Initiative for Early Lung Cancer Research on Treatment sought to standardize a surgeon-measured margin intraoperatively.

METHODS

Lung cancer patients who underwent wedge resection were reviewed. Margins were measured by the surgeon twice as per a standardized protocol. Intraobserver variability as well as surgeon-pathologist variability were compared.

RESULTS

Forty-five patients underwent wedge resection. Same-surgeon measurement analysis indicated good reliability with a small mean difference and narrow limit of agreement for the two measures. The median surgeon-measured margin was 18.0 mm, median pathologist-measured margin was 16.0 mm and the median difference between the surgeon-pathologist margin was -1.0 mm, ranging from -18.0 to 12.0 mm. Bland-Altman analysis for margin measurements demonstrated a mean difference of 0.65 mm. The limit of agreement for the two approaches were wide, with the difference lying between -16.25 and 14.96 mm.

CONCLUSIONS

A novel protocol of surgeon-measured margin was evaluated and compared with pathologist-measured margin. High intraobserver agreement for repeat surgeon measurements yet low-to-moderate correlation or directionality between surgeon and pathologic measurements were found.

DISCUSSION

A standardized protocol may reduce variability in pathologic assessment. These findings have critical implications considering the impact of margin distance on outcomes.

The surgical management of early-stage lung adenocarcinoma: is wedge resection effective?

Background

The aim of the study was to explore the outcomes of wedge resection on patients with early-stage lung adenocarcinoma (LUAD) and further identify potential prognostic factors for these patients.

Methods

A retrospective cohort of 190 patients (99 solitary LUAD and 91 multifocal LUAD) undergone wedge resection from October 2014 to September 2015 was established. Cox proportional-hazards model was used to evaluate the significant clinical prognostic factors. Further, data on patients with multifocal adenocarcinoma after segmentectomy were retrieved and propensity score matching was used to compare the outcomes of patients with multiple pulmonary nodules (MPNs) after wedge resection and segmentectomy.

Results

The 5-year overall survival (OS), progression-free survival (PFS), and lung cancer specific survival of the 190 patients after wedge resection were 95.5%, 87.9%, and 97.7%, respectively. Multivariable analysis showed that MPN [hazard ratio (HR) 3.07; 95% confidence interval (CI), 1.05–8.98] and solid-dominant lesions (HR 15.87; 95% CI, 2.38–105.84) were independently associated with worse PFS. Further, propensity score matching analysis showed that MPN patients had better PFS after segmentectomy compared with wedge resection (94% vs. 80.9%, P=0.008). MPN patients were more likely to perform systematic mediastinal nodal sampling (95.6% vs. 59.3%, P<0.001) after segmentectomy compared to patients who underwent wedge resection.

Conclusions

Wedge resection is a practical option for appropriately selected early-stage LUAD where tumor size is less than 2 cm and has a consolidation-to-tumor ratio ≤0.5. However, for MPNs, wedge resection may be not reliable and alternative procedures such as segmentectomy should be used.

Lobectomy versus sublobar resection in patients with non-small cell lung cancer: a systematic review

Surgery is the gold standard treatment of lung cancer. The minimally invasive technique does not only concern access to the chest but also the limits of parenchymal resection. The study debates on the safety and oncological adequacy of sublobar resections in bronchogenic carcinoma patients. A systematic analysis of the data in the literature was carried out, comparing the outcomes of patients with resectable non-small lung cancer (NSCLC) who underwent lobectomy or sublobar resection. These last interventions include both segmentectomies and wedge resections taking into consideration the following parameters: complications, relapse rate and overall survival. The complication rate is higher in patients underwent lobectomy compared to sublobar resection, especially in presence of high comorbidity index or octogenarian patients (overall values respectively between 0 and 48% and 0 and 46.6%). Contrarily, the relapse rate (6.2% to 32% vs. 3.6% to 53.4%) and overall survival (50.2% to 93.8% vs. 38.6% to 100%) are more favorable in patients undergoing lobectomy. Sublobar resections are particularly indicated in elderly patients and in patients with high comorbidity index or reduced respiratory functional reserve. However, pulmonary lobectomy still remains the safest and oncologically correct method in patients with good performance status or higher risk of recurrence.

Prediction models for the viability of pulmonary metastatic lesions after chemotherapy in nonseminomatous germ cell tumors

OBJECTIVES

To analyze predictors associated with viable cells in pulmonary residual lesions after chemotherapy for metastatic testicular nonseminomatous germ cell tumors and to develop models to prioritize pulmonary resection.

METHODS

Between 2008 and 2017, 40 patients underwent pulmonary metastasectomy after chemotherapy for nonseminomatous germ cell tumors. We evaluated these patients, and 326 pulmonary residual lesions were confirmed using computed tomography and pathological evaluations. Relationships with outcomes were analyzed using logistic regression analyses. Risk prediction models were developed, and predictive probabilities for the risk of viable cells were estimated.

RESULTS

Histological examinations showed that 73 (22%) pulmonary residual lesions contained viable cells: teratomas, 46 (14%); and cancer cells, 37 (11%). Multivariate analyses showed that the predictors associated with cancer cells in the residual lesions were elevated tumor marker levels, multiregimen chemotherapy, increased tumor size 6 months before surgery and the histological composition of the primary lesion, including yolk sac tumors. Additional predictors associated with teratomas were aspect ratio and histological composition of the primary lesion, including teratomas.

CONCLUSIONS

Intratumoral heterogeneity contributes to nonseminomatous germ cell tumor chemoresistance, and primary lesion site yolk sac tumors and teratomas are associated with greater risks of viable cells. Increased residual lesion size during chemotherapy could also be a predictor. Our simple model can predict the presence of viable cells in residual lesions after chemotherapy, and it might assist in decision-making and prioritizing pulmonary residual lesion resection.