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Zeng J, Liu Q, Chang R, Chen Y, Yu Z, Yi B, Gao Y. Effect of examining lymph nodes count on mortality risk in resected T1 non-small-cell lung cancer. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivad195. [PMID: 38039183 PMCID: PMC10873909 DOI: 10.1093/icvts/ivad195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 02/16/2024] [Accepted: 02/16/2024] [Indexed: 12/03/2023]
Abstract
OBJECTIVES This study aims to estimate the effect of the examined lymph node count (ELNC) on the cancer-related mortality risk and non-cancer-related mortality risk in patients with resected T1 non-small-cell lung cancer (NSCLC). METHODS Patients diagnosed as primary T1 NSCLC between 2000 and 2017 were extracted from the Surveillance, Epidemiology and End Results database. Patients were divided into 2 groups according to the ELNC cutoff value, which was calculated based on overall survival outcomes. Propensity score matching was used to equalize the differences in baseline characteristics between groups. RESULTS A total of 38 242 resected T1 NSCLC patients were extracted from the database with the ELNC cutoff value of 8. After propensity score matching, 27 676 patients were included in this study. Examining ≥8 ELNC was associated with a more accurate assessment of lymph node (LN) metastasis and significantly improving the prognosis. These trends remained consistent in subgroup analysis by histology type. In competing risk mode, examining ≥8 LNs could significantly reduce the risk of death from lung cancer, risk of death from chronic obstructive pulmonary disease, and risk of death from cardiac diseases. In the subgroup analysis, these trends were consistent. CONCLUSIONS Given the mortality risk associated with lung cancer, chronic obstructive pulmonary disease, and cardiac diseases, at least 8 LNs should be examined in surgery for T1 NSCLC.
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Affiliation(s)
- Jun Zeng
- Department of Thoracic Surgery, Xiangya Hospital, Central South University, Changsha, China
- Hunan Engineering Research Center for Pulmonary Nodules Precise Diagnosis & Treatment, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Changsha, China
- Xiangya Lung Cancer Center, Xiangya Hospital, Central South University, Changsha, China
| | - Qi Liu
- Department of Thoracic Surgery, Xiangya Hospital, Central South University, Changsha, China
- Hunan Engineering Research Center for Pulmonary Nodules Precise Diagnosis & Treatment, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Changsha, China
- Xiangya Lung Cancer Center, Xiangya Hospital, Central South University, Changsha, China
| | - Ruiming Chang
- Department of Thoracic Surgery, Xiangya Hospital, Central South University, Changsha, China
- Hunan Engineering Research Center for Pulmonary Nodules Precise Diagnosis & Treatment, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Changsha, China
- Xiangya Lung Cancer Center, Xiangya Hospital, Central South University, Changsha, China
| | - Yufan Chen
- Department of Thoracic Surgery, Xiangya Hospital, Central South University, Changsha, China
- Hunan Engineering Research Center for Pulmonary Nodules Precise Diagnosis & Treatment, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Changsha, China
- Xiangya Lung Cancer Center, Xiangya Hospital, Central South University, Changsha, China
| | - Zhongjie Yu
- Department of Thoracic Surgery, Xiangya Hospital, Central South University, Changsha, China
- Hunan Engineering Research Center for Pulmonary Nodules Precise Diagnosis & Treatment, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Changsha, China
- Xiangya Lung Cancer Center, Xiangya Hospital, Central South University, Changsha, China
| | - Bin Yi
- Department of Thoracic Surgery, Xiangya Hospital, Central South University, Changsha, China
- Hunan Engineering Research Center for Pulmonary Nodules Precise Diagnosis & Treatment, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Changsha, China
- Xiangya Lung Cancer Center, Xiangya Hospital, Central South University, Changsha, China
| | - Yang Gao
- Department of Thoracic Surgery, Xiangya Hospital, Central South University, Changsha, China
- Hunan Engineering Research Center for Pulmonary Nodules Precise Diagnosis & Treatment, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Changsha, China
- Xiangya Lung Cancer Center, Xiangya Hospital, Central South University, Changsha, China
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Jang S, Lee S, Chung JH, Lee KW, Lee KH. Radiologic Extranodal Extension of Metastatic Lymph Nodes in Patients With Non-Small Cell Lung Cancer: Prognostic Utility and Diagnostic Performance. AJR Am J Roentgenol 2023; 221:471-484. [PMID: 37255045 DOI: 10.2214/ajr.23.29285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND. Pathologic extranodal extension (ENE) in metastatic lymph nodes (LNs) has been associated with unfavorable prognosis in patients with non-small cell lung cancer (NSCLC). OBJECTIVE. The purpose of this article was to evaluate the prognostic utility of radiologic ENE and its diagnostic performance in predicting pathologic ENE in patients with NSCLC. METHODS. This retrospective study included 382 patients (mean age, 67 ± 10 [SD] years; 297 men, 85 women) diagnosed with NSCLC and clinical N1 or N2 disease between January 2010 and December 2016. Two thoracic radiologists reviewed staging chest CT examinations to record subjective overall impression for radiologic ENE (no ENE, possible/probable ENE, or unambiguous ENE), reviewing 30 examinations in consensus and the remaining examinations independently. Kaplan-Meier survival analysis and multivariable Cox proportional hazards model were used to evaluate the utility of radiologic ENE in predicting overall survival (OS). Prognostic utility of radiologic ENE was also assessed in patients with clinical N2a disease. In patients who underwent surgery, sensitivity and specificity were determined of radiologic unambiguous ENE in predicting pathologic ENE. RESULTS. The 5-year OS rates for no ENE, possible/probable ENE, and unambiguous ENE were 44.4%, 39.1%, and 20.9% for reader 1 and 45.7%, 36.6%, and 25.6% for reader 2, respectively. Unambiguous ENE was an independent prognostic factor for worse OS (reader 1: adjusted HR, 1.72, p = .008; reader 2: adjusted HR, 1.56, p = .03), whereas possible/probable ENE was not (reader 1: adjusted HR, 1.18, p = .33; reader 2: adjusted HR, 1.21, p = .25). In patients with clinical N2a disease, 5-year OS rate in patients with versus without unambiguous ENE for reader 1 was 22.2% versus 40.6% (p = .59) and for reader 2 was 27.6% versus 41.0% (p = .49). In 203 patients who underwent surgery (66 with pathologic ENE), sensitivity and specificity of radiologic unambiguous ENE for predicting pathologic ENE were 11% and 93% for reader 1 and 23% and 87% for reader 2. CONCLUSION. Radiologic unambiguous ENE was an independent predictor of worse OS in patients with NSCLC. The finding had low sensitivity but high specificity for pathologic ENE. CLINICAL IMPACT. Radiologic ENE may have a role in NSCLC staging workup and treatment selection.
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Affiliation(s)
- Sowon Jang
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Seungjae Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
- Institute of Health and Environment, Seoul National University, Seoul, Korea
| | - Jin-Haeng Chung
- Department of Pathology and Translational Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Kyung Won Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kyung Hee Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Korea
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Wang Z, Yang Z, Li S, Zhang J, Xia L, Zhou J, Chen N, Guo C, Liu L. A Comprehensive Comparison of Different Nodal Subclassification Methods in Surgically Resected Non-Small-Cell Lung Cancer Patients. Ann Surg Oncol 2022; 29:8144-8153. [PMID: 35980551 DOI: 10.1245/s10434-022-12363-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/11/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The revision of the N descriptor in non-small-cell lung cancer has been widely discussed in the past few years. Many different subclassification methods based on number or location of lymph nodes have been proposed for better distinguishing different N patients. This study aimed to systematically collect them and provide a comprehensive comparison among different subclassification methods in a large cohort. METHOD Pathological N1 or N2 non-small-cell lung cancer patients undergoing surgical resection between 2005 and 2016 in the Western China Lung Cancer Database were retrospectively reviewed. A literature review was conducted to collect previous subclassification methods. Kaplan-Meier and multivariable Cox analyses were used to examine the prognostic performance of subclassification methods. Decision curve analysis, Akaike's information criterion, and area under the receiver operating curve concordance were also performed to evaluate the standardized net benefit of the subclassification methods. RESULTS A total of 1625 patients were identified in our cohort. Eight subclassification methods were collected from previous articles and further grouped into subclassification based on number categories (node number or station number), location categories (lymph node zone or chain) or combination of number and location categories. Subclassification based on combination of lymph node location and number tended to have better discrimination ability in multivariable Cox analysis. No significant superiority among the different subclassification methods was observed in the three statistical models. CONCLUSION Subclassification based on the combination of location and number could be used to provide a more accurate prognostic stratification in surgically resected NSCLC and is worth further validation.
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Affiliation(s)
- Zihuai Wang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Zhenyu Yang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China.,West China School of Medicine, Sichuan University, Chengdu, China
| | - Sijia Li
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Junqi Zhang
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Liang Xia
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jian Zhou
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Nan Chen
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Chenglin Guo
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Lunxu Liu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China.
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Song H, Yoon SH, Kim J, Kim J, Lee KW, Lee W, Lee S, Kim K, Lee CT, Chung JH, Lee KH. Application of N Descriptors Proposed by the International Association for the Study of Lung Cancer in Clinical Staging. Radiology 2021; 300:450-457. [PMID: 34060941 DOI: 10.1148/radiol.2021204461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Patients with N1 or N2 non-small cell lung cancer exhibit prognostic heterogeneity. To refine the current N staging system, new N stages were proposed by the International Association for the Study of Lung Cancer. However, those proposed new N stages have not been validated. Purpose To evaluate the prognostic performance of the proposed N descriptors for clinical staging. Materials and Methods Participants with non-small cell lung cancer without distant metastasis from January 2010 to December 2014 were retrospectively included. Each patient's clinical N (cN) stage was assigned to one of seven categories (cN0, cN1a, cN1b, cN2a1, cN2a2, cN2b, cN3). The 5-year overall survival rates were estimated with the Kaplan-Meier method. The adjusted hazard ratios (HRs) and their 95% CIs were estimated by using a multivariable Cox proportional hazard model. Ad hoc analyses according to lymph node (LN) size were performed. Results A total of 1271 patients (median age, 66 years; interquartile range, 59-73 years; 812 men) were included. The 5-year overall survival rates were 77.3%, 53.7%, 36.0%, 29.2%, 34.4%, 18.0%, and 12.4% for stages cN0, cN1a, cN1b, cN2a1, cN2a2, cN2b, and cN3, respectively. Patients with cN2b disease had a worse prognosis than patients with cN2a disease (HR, 1.53; 95% CI: 1.06, 2.22; P = .02). There was no prognostic difference between cN1b and cN1a (HR, 1.13; 95% CI: 0.61, 2.09; P = .71); however, there was a difference between cN1 subgroups when stratified by LN size (≥2 cm; HR, 2.26; 95% CI: 1.16, 4.44; P = .02). Within cN2a disease, there were no differences between cN2a1 and cN2a2 (HR, 0.98; 95% CI: 0.61, 1.56; P = .93) or between subgroups according to LN size (HR, 0.74; 95% CI: 0.40, 1.37; P = .34). Conclusion A survival difference was observed between single- and multistation involvement among cN2 disease. The number of involved lymph node stations in patients with cN1 disease and the presence of skip metastasis in patients with cN2 disease were not associated with survival differences. © RSNA, 2021 Online supplemental material is available for this article.
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Affiliation(s)
- Hwayoung Song
- From the Department of Radiology (H.S., S.H.Y., Junghoon Kim, Jihang Kim, K.W.L., K.H.L.), Department of Thoracic and Cardiovascular Surgery (K.K.), Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine (C.T.L.), and Department of Pathology and Translational Medicine (J.H.C.), Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam 13620, Korea; and Departments of Public Health Science, Graduate School of Public Health (W.L.) and Applied Bioengineering, Graduate School of Convergence Science and Technology (S.L.), Seoul National University, Seoul, Korea
| | - Sung Hyun Yoon
- From the Department of Radiology (H.S., S.H.Y., Junghoon Kim, Jihang Kim, K.W.L., K.H.L.), Department of Thoracic and Cardiovascular Surgery (K.K.), Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine (C.T.L.), and Department of Pathology and Translational Medicine (J.H.C.), Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam 13620, Korea; and Departments of Public Health Science, Graduate School of Public Health (W.L.) and Applied Bioengineering, Graduate School of Convergence Science and Technology (S.L.), Seoul National University, Seoul, Korea
| | - Junghoon Kim
- From the Department of Radiology (H.S., S.H.Y., Junghoon Kim, Jihang Kim, K.W.L., K.H.L.), Department of Thoracic and Cardiovascular Surgery (K.K.), Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine (C.T.L.), and Department of Pathology and Translational Medicine (J.H.C.), Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam 13620, Korea; and Departments of Public Health Science, Graduate School of Public Health (W.L.) and Applied Bioengineering, Graduate School of Convergence Science and Technology (S.L.), Seoul National University, Seoul, Korea
| | - Jihang Kim
- From the Department of Radiology (H.S., S.H.Y., Junghoon Kim, Jihang Kim, K.W.L., K.H.L.), Department of Thoracic and Cardiovascular Surgery (K.K.), Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine (C.T.L.), and Department of Pathology and Translational Medicine (J.H.C.), Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam 13620, Korea; and Departments of Public Health Science, Graduate School of Public Health (W.L.) and Applied Bioengineering, Graduate School of Convergence Science and Technology (S.L.), Seoul National University, Seoul, Korea
| | - Kyoung Won Lee
- From the Department of Radiology (H.S., S.H.Y., Junghoon Kim, Jihang Kim, K.W.L., K.H.L.), Department of Thoracic and Cardiovascular Surgery (K.K.), Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine (C.T.L.), and Department of Pathology and Translational Medicine (J.H.C.), Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam 13620, Korea; and Departments of Public Health Science, Graduate School of Public Health (W.L.) and Applied Bioengineering, Graduate School of Convergence Science and Technology (S.L.), Seoul National University, Seoul, Korea
| | - Woojoo Lee
- From the Department of Radiology (H.S., S.H.Y., Junghoon Kim, Jihang Kim, K.W.L., K.H.L.), Department of Thoracic and Cardiovascular Surgery (K.K.), Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine (C.T.L.), and Department of Pathology and Translational Medicine (J.H.C.), Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam 13620, Korea; and Departments of Public Health Science, Graduate School of Public Health (W.L.) and Applied Bioengineering, Graduate School of Convergence Science and Technology (S.L.), Seoul National University, Seoul, Korea
| | - Seungjae Lee
- From the Department of Radiology (H.S., S.H.Y., Junghoon Kim, Jihang Kim, K.W.L., K.H.L.), Department of Thoracic and Cardiovascular Surgery (K.K.), Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine (C.T.L.), and Department of Pathology and Translational Medicine (J.H.C.), Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam 13620, Korea; and Departments of Public Health Science, Graduate School of Public Health (W.L.) and Applied Bioengineering, Graduate School of Convergence Science and Technology (S.L.), Seoul National University, Seoul, Korea
| | - Kwhanmien Kim
- From the Department of Radiology (H.S., S.H.Y., Junghoon Kim, Jihang Kim, K.W.L., K.H.L.), Department of Thoracic and Cardiovascular Surgery (K.K.), Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine (C.T.L.), and Department of Pathology and Translational Medicine (J.H.C.), Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam 13620, Korea; and Departments of Public Health Science, Graduate School of Public Health (W.L.) and Applied Bioengineering, Graduate School of Convergence Science and Technology (S.L.), Seoul National University, Seoul, Korea
| | - Choon-Taek Lee
- From the Department of Radiology (H.S., S.H.Y., Junghoon Kim, Jihang Kim, K.W.L., K.H.L.), Department of Thoracic and Cardiovascular Surgery (K.K.), Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine (C.T.L.), and Department of Pathology and Translational Medicine (J.H.C.), Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam 13620, Korea; and Departments of Public Health Science, Graduate School of Public Health (W.L.) and Applied Bioengineering, Graduate School of Convergence Science and Technology (S.L.), Seoul National University, Seoul, Korea
| | - Jin-Haeng Chung
- From the Department of Radiology (H.S., S.H.Y., Junghoon Kim, Jihang Kim, K.W.L., K.H.L.), Department of Thoracic and Cardiovascular Surgery (K.K.), Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine (C.T.L.), and Department of Pathology and Translational Medicine (J.H.C.), Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam 13620, Korea; and Departments of Public Health Science, Graduate School of Public Health (W.L.) and Applied Bioengineering, Graduate School of Convergence Science and Technology (S.L.), Seoul National University, Seoul, Korea
| | - Kyung Hee Lee
- From the Department of Radiology (H.S., S.H.Y., Junghoon Kim, Jihang Kim, K.W.L., K.H.L.), Department of Thoracic and Cardiovascular Surgery (K.K.), Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine (C.T.L.), and Department of Pathology and Translational Medicine (J.H.C.), Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam 13620, Korea; and Departments of Public Health Science, Graduate School of Public Health (W.L.) and Applied Bioengineering, Graduate School of Convergence Science and Technology (S.L.), Seoul National University, Seoul, Korea
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Aksoy Y, Çıtak N, Obuz Ç, Metin M, Sayar A. Does anatomical location-based metastatic lymph node density affect prognosis in lung cancer patients? Interact Cardiovasc Thorac Surg 2021; 33:541-549. [PMID: 34000035 DOI: 10.1093/icvts/ivab119] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/03/2021] [Accepted: 03/22/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The newly proposed N subclassification (new-N) was compared with the combined anatomical location and ratio of the number of metastatic lymph nodes to the total number of resected lymph nodes (anatomic-LNR) in terms of prognosis in resected lung cancer patients. METHODS Between 2005 and 2018, 961 patients who underwent lung cancer resection were catergorized into the pN1-single (N1a; n = 281), pN1-multiple (N1b; n = 182), pN2-single with skip metastasis (N2a1; n = 116), pN2-single with N1 metastasis (N2a2; n = 222) and pN2-multiple (N2b; n = 160) groups based on new-N. The optimal cut-off points for survival in pN1 and pN2 patients were determined using the best sensitivity and specificity scores, calculated using receiver operating characteristic analysis. RESULTS The difference in survival between N1a and N1b patients was statistically significant (P = 0.001), but there was no significant difference in the survival rates of N1b and N2a1 (P = 0.52). The survival curves for N2a1 and N2a2 patients almost overlapped (P = 0.143). N2a2 patients showed a better survival rate than N2b patients, with no significant difference (P = 0.132). The cut-off points for LNR were 0.10 and 0.25 for pN1 and pN2 patients, respectively, according to receiver operating characteristic analysis for survival. Based on receiver operating characteristic analysis, pN patients were categorized into the N1-lowLNR (n = 232), N1-highLNR (n = 231), N2-lowLNR (n = 266) and N2-highLNR (n = 232) groups. The 5-year survival rate was 62.9%, 49.8%, 41.1% and 27.1% for N1-lowLNR, N1-highLNR, N2-lowLNR and N2-highLNR, respectively (P < 0.001). CONCLUSIONS LowLNR is associated with better survival than highLNR in resected lung cancer patients. Anatomic-LNR shows a high discriminatory power for prognosis.
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Affiliation(s)
- Yunus Aksoy
- Thoracic Surgery, Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Necati Çıtak
- Thoracic Surgery, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Çiğdem Obuz
- Thoracic Surgery, Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Muzaffer Metin
- Thoracic Surgery, Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Adnan Sayar
- Thoracic Surgery, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
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