TNM Stage Is the Most Important Determinant of Survival in Metachronous Lung Cancer

Favourable surgical outcomes for either second primary lung cancer or intrapulmonary metastasis after resection of non-small-cell lung cancer

OBJECTIVES

Metachronous lung cancer arising after resection of non-small-cell lung cancer is either a second primary lung cancer (SPLC) or intrapulmonary metastasis (IPM) of the initial lung cancer; however, differential diagnosis is difficult. We evaluated the surgical outcomes of metachronous lung cancer in a combined population of patients with SPLC and IPM.

METHODS

A retrospective study of 3534 consecutive patients with resected non-small-cell lung cancer between 1992 and 2016 was conducted at 4 institutions.

RESULTS

A total of 105 patients (66 males; median age, 70 years) who underwent a second pulmonary resection for metachronous lung cancer were included. Most patients (81%) underwent sublobar resection, and there was no 30-day mortality. All metachronous lung cancers were cN0, 5 were pN1-2. The postoperative comprehensive histologic assessment revealed SPLC (n = 77) and IPM (n = 28). The 5-year overall survival rate after the second resection was 70.6% (median follow-up: 69.7 months). A multivariable analysis showed that age >70 years at the second resection (P = 0.013), male sex (P = 0.003), lymph node involvement in metachronous cancer (P < 0.001), pathological invasive size of metachronous cancer >15 mm (P < 0.001) and overlapping squamous cell carcinoma histology of the initial and metachronous cancers (P = 0.003) were significant prognostic factors for poor survival after the second resection, whereas histological IPM was not (P = 0.065).

CONCLUSIONS

Surgery for cN0 metachronous lung cancer is safe and shows good outcomes. There were no statistically significant differences in the SPLC and IPM results. Caution should be exercised when operating on patients with overlapping squamous cell carcinoma.

Survival and quality-of-life outcomes in early-stage NSCLC patients: a literature review of real-world evidence

Aim

Assess the long-term survival and quality-of-life outcomes in early-stage NSCLC (eNSCLC) patients.

Methods

Review of long-term survival and quality-of-life after curative treatment in eNSCLC patients in observational studies.

Results

Disease-free proportion decreased in stage III vs stage I patients. Recurrence-free proportion decreased with age and disease stage. Advanced stage and vascular invasion increased risk of late recurrence. Conditional 5-year relative survival rates did not exceed 87%, indicating higher mortality in eNSCLC survivors. Lower conditional survival rates and relative survival rates were associated with older age and advanced disease. Survivors of eNSCLC had poorer physical quality-of-life.

Conclusion

Despite curative-intent therapy, survivors of eNSCLC still face significant risks of recurrence, excess mortality, and diminished quality-of-life.

Restrictive Ventilatory Impairment as a Poor Prognostic Factor in Patients Who Undergo Surgical Resection for Metachronous Second Primary Lung Cancer

PURPOSE

To evaluate the prognostic impact of restrictive ventilatory impairment in patients who undergo pulmonary resection of metachronous second primary lung cancer.

METHODS

The clinical characteristics and surgical outcomes of 70 patients with metachronous second primary lung cancer were analyzed.

RESULTS

The surgical procedures consisted of wedge resection in 40 patients, segmentectomy in 17, lobectomy in 12, and completion pneumonectomy in one. Patients who underwent ipsilateral pulmonary resection developed more perioperative complications (p = 0.0339). Three-year and 5-year overall survival rates were 78.2% and 69.2%, respectively. In univariate analysis, sex, restrictive ventilatory impairment, and histology of second primary lung cancer were significantly poor prognostic factors (all p <0.05). Multivariate analysis identified restrictive ventilatory impairment to be an independent predictor of a poor prognosis (p = 0.0193). In the 22 patients who died, the cause of death was lung cancer in 11 and other diseases, including pneumonia and respiratory failure, in 11. Death from another disease was significantly more common in patients with restrictive ventilatory impairment (p = 0.0216).

CONCLUSION

Restrictive ventilatory impairment was an independent predictor of a poor prognosis in patients with a second primary lung cancer. Restrictive ventilatory impairment as a result of repeated thoracic surgery may increase the likelihood of death from another disease.

Evaluation of surgical outcomes and prognostic factors of second primary lung cancer based on a systematic review and meta-analysis

BACKGROUND

Although surgery has been widely applied for SPLC therapy, there is still no uniform treatment approach. Whether SPLC and primary lung cancer have similar prognostic characteristics remains controversial. Herein, based on a systematic review and meta-analysis, we aimed to enucleate the influences of diverse surgical strategies and underlying prognostic factors on the prognosis of patients with both the first primary lung cancer and SPLC underwent surgical resection.

METHODS

A comprehensive and systematic literature search was implemented in three databases (MEDLINE, EMBASE, and Cochrane), and eligible studies were screened following inclusion and exclusion criteria. Meanwhile, we extracted the hazard ratios (HR) together with 95% confidence intervals (CI) for each prognostic factor, either directly or indirectly, from the enrolled literature.

RESULTS

Eleven studies (published between 2000 and 2022) were included in this study, including 1,131 SPLC patients. The overall survival (OS) exhibited no difference between patients with lobectomy and sublobar resection after SPLC (HR: 0.87, 95%CI: 0.62-1.21, P = 0.41). The patients after completion pneumonectomy had a poor prognosis (HR: 1.85, 95% CI: 1.34-2.55, P < 0.01). Poor prognostic factors after SPLC surgery included synchronous SPLC (HR: 3.38, 95%CI: 1.53-7.46, P < 0.01), tumor diameter > 2 cm (HR: 2.44, 95%CI: 1.73-3.44, P < 0.01), solid predominant in CT morphology (HR: 3.08, 95% CI: 1.14-8.33, P = 0.03), lymph node metastasis (HR: 2.79, 95%CI: 1.40-5.56), and smoking (HR: 2.37, 95%CI: 1.08-26.82, P < 0.01). Tumor disease-free interval (DFI), tumor histological type, and gender had no impact on the prognosis of patients received SPLC surgery.

CONCLUSIONS

Patients with SPLC, especially those with poor cardiopulmonary function reserve, should be prioritized for sublobar resection for treatment. These patients should also try to avoid completion pneumonectomy. Patients with synchronous SPLC, tumor diameter > 2 cm, solid predominant in CT morphology, lymph node metastasis, and smoking had a poor prognosis. Meanwhile, SPLC has similar prognostic characteristics with single primary lung cancer. However, the study has some limitations and more evidence is warranted to verify the findings.

Prognostic Nomogram and Therapeutic Option of Cancer-Specific Death in the Patients with Metachronous Second Primary Lung Cancer

With the increase of long-term primary lung cancer survivors, studies focused on metachronous second primary lung cancer (SPLC) have become very urgent. This study aimed to develop a prognostic nomogram and determine therapeutic options of cancer-specific death for patients with metachronous SPLC with and without the competing risk of other-specific death. Study population came from the SEER-18 database between 2006 and 2016. According to the clinical practice guideline of SPLC, the interval time of IPLC and metachronous SPLC was set to 4 years. We constructed nomograms with Lasso + Cox regression model and competing risk model to predict the prognosis and identify therapeutic options of metachronous SPLC patients with the assessment of model performance by the C-index, calibration plot, and decision curve analysis. In addition, two subgroup analyses stratified by histology and tumor size were used to better select therapeutic options for a certain population. 1300 patients with metachronous SPLC were incorporated in this study with 50.1% of the 5-year cumulative incidence in cancer-specific death. Compared with Lasso + Cox regression analysis, competing risk analysis harbored a higher C-index (0.811 vs. 0.76) and better net benefit in predicting cancer-specific death of metachronous SPLC. Two statistical analyses suggested that surgery alone was a preferentially therapeutic option of metachronous SPLC, whereas the effect of surgery + radiation in treating metachronous SPLC was similar to radiation alone. Subgroup analyses indicated that patients with metachronous SPLC were considered receiving different therapeutic options in different histology and tumor size but preferred to receive surgical treatment as the first choice. For primary lung cancer survivors, aggressive surgical treatment was the first-line selection of metachronous SPLC, followed by radiation alone, surgery + radiation, and no surgery + radiation.

Multiomics analysis reveals a distinct response mechanism in multiple primary lung adenocarcinoma after neoadjuvant immunotherapy

Multiple primary lung cancer (MPLC) remains a tough challenge to diagnose and treat. Although neoadjuvant immunotherapy has shown promising results in early stage non-small cell lung cancer, whether such modality can benefit all primary lesions remains unclear. Herein, we performed integrated multiomics analysis in one patient with early stage MPLC with remarkable tumor shrinkage in a solid nodule and no response in two subsolid nodules after treatment with three cycles of neoadjuvant pembrolizumab. Genomic heterogeneity was observed among responding nodules with high levels of infiltrating CD8⁺ and CD68⁺ immune cells. Substantially downregulated human leukocyte antigen (HLA)-related genes and impaired T lymphocyte function were observed in non-responding nodules. A larger proportion of infiltrating tissue resident memory T cells (Trm) along with high T cell receptor repertoire clonality in responding nodules were validated as predictive and prognostic biomarkers in multiple cancer types using external public datasets. These results suggested that neoadjuvant programmed death 1 (PD-1)/programmed death ligand 1 inhibitors alone may not be an optimal therapeutic strategy for MPLC due to disparities in genomic alterations and immune microenvironment among different lesions. Additionally, we postulate that increased infiltration of Trm may be a unique marker of early immune responses to PD-1 blockade.

Surgical outcomes of ipsilateral metachronous second primary lung cancer

OBJECTIVES

The optimal surgical approach for metachronous second primary lung cancer (MSPLC), especially ipsilateral MSPLC, remains unclear. This study aimed to review postoperative complications and examine surgical outcomes based on the extent of resection after surgery for ipsilateral MSPLC.

METHODS

Clinical data from 61 consecutive patients who underwent pulmonary resection for ipsilateral MSPLC according to the Martini-Melamed criteria between January 2005 and December 2017 in 3 institutes were retrospectively reviewed.

RESULTS

Postoperative complications were identified in 12 patients (19.7%). Regarding the combination of initial and second surgery, intraoperative bleeding was significantly greater in patients with anatomic-anatomic resection than in others (P < 0.001). Operation time was significantly longer in patients with anatomic-anatomic resection than in others (P < 0.001). However, postoperative complications showed no significant differences based on the combination of surgeries. Five-year overall survival rates in patients with anatomic resection and wedge resection after second surgery were 75.8% and 75.8%, respectively (P = 0.738), and 5-year recurrence-free survival rates were 54.2% and 67.6%, respectively (P = 0.368). Cox multivariate analysis identified ever-smoker status (P = 0.029), poor performance status (P = 0.011) and tumour size >20 mm (P = 0.001) as independent predictors of poor overall survival, while ever-smoker status (P = 0.040) and tumour size >20 mm (P = 0.007) were considered independent predictors of poor recurrence-free survival.

CONCLUSIONS

Regarding postoperative and long-term outcomes for patients with ipsilateral MSPLC, surgical intervention is safe and offers good long-term survival. Wedge resection is an acceptable provided tumours ≤2 cm and ground-glass opacity-predominant as a second surgery for early-stage ipsilateral MSPLC.

Enolase 1 Correlated With Cancer Progression and Immune-Infiltrating in Multiple Cancer Types: A Pan-Cancer Analysis

Enolase 1 (ENO1) is an oxidative stress protein expressed in endothelial cells. This study aimed to investigate the correlation of ENO1 with prognosis, tumor stage, and levels of tumor-infiltrating immune cells in multiple cancers. ENO1 expression and its influence on tumor stage and clinical prognosis were analyzed by UCSC Xena browser, Gene Expression Profiling Interactive Analysis (GEPIA), The Cancer Genome Atlas (TCGA), and GTEx Portal. The ENO1 mutation analysis was performed by cBio Portal, and demonstrated ENO1 mutation (1.8%) did not impact on tumor prognosis. The relationship between ENO1 expression and tumor immunity was analyzed by Tumor Immune Estimation Resource (TIMER) and GEPIA. The potential functions of ENO1 in pathways were investigated by Gene Set Enrichment Analysis. ENO1 expression was significantly different in tumor and corresponding normal tissues. ENO1 expression in multiple tumor tissues correlated with prognosis and stage. ENO1 showed correlation with immune infiltrates including B cells, CD8⁺ and CD4⁺ T cells, macrophages, neutrophils, and dendritic cells, and tumor purity. ENO1 was proved to be involved in DNA replication, cell cycle, apoptosis, glycolysis process, and other processes. These findings indicate that ENO1 is a potential prognostic biomarker that correlates with cancer progression immune infiltration.

Prior Treatment for Non-small Cell Lung Cancer Is Associated With Improved Survival in Patients who Undergo Definitive Stereotactic Body Radiation Therapy for a Subsequent Lung Malignancy: A Retrospective Multivariate and Matched Pair Analysis

BACKGROUND

Despite occurring commonly, the prognoses of second early-stage non-small cell lung cancers (NSCLC) are not well known.

METHODS

The authors retrospectively reviewed the charts of inoperable patients who underwent thoracic stereotactic body radiation therapy (SBRT) from February 2007 to April 2019. Those with previous small cell lung cancers or SBRT treatments for tumors other than NSCLC were excluded. Multivariate Cox regression and a matched pair cohort analyses evaluated the prognoses of patients undergoing definitive SBRT for a new second primary.

RESULTS

Of 438 patients who underwent definitive SBRT for NSCLC, 84 had previously treated NSCLC. Univariate log-rank tests identified gender, Karnofksy performance status (KPS), prior lung cancer, anticoagulation use, and history of heart disease to correlate with overall survival (OS) (P<0.05). These factors were incorporated into a multivariate Cox regression model that demonstrated female sex (P=0.004, hazard ratio [HR]=0.68), KPS (P<0.001, HR=2.0), and prior lung cancer (P=0.049, HR=0.7) to be significantly associated with OS. A similar approach found only gender (P=0.017, HR=0.64) and tumor stage (P=0.02, HR=1.7) to correlate with relapse-free survival. To support the Cox regression analysis, propensity score matching was performed using gender, age, KPS, tumor stage, history of heart disease, and anticoagulation use. Kaplan-Meier survival analysis within the matched pairs found prior lung cancer to be associated with improved OS (P=0.011), but not relapse-free survival (P=0.44).

CONCLUSIONS

Compared with initial lung cancer SBRT inoperable cases, ablative radiotherapy for new primaries was associated with improved OS. Physicians should not be dissuaded from offering SBRT to such patients.

MED15, transforming growth factor beta 1 (TGF-β1), FcγRIII (CD16), and HNK-1 (CD57) are prognostic biomarkers of oral squamous cell carcinoma

Owing to the high incidence and mortality of oral squamous cell carcinoma (OSCC), knowledge of its diagnostic and prognostic factors is of significant value. The biomarkers 'CD16, CD57, transforming growth factor beta 1 (TGF-β1), and MED15' can play crucial roles in tumorigenesis, and hence might contribute to diagnosis, prognosis, and treatment. Since there was no previous study on MED15 in almost all cancers, and since the studies on diagnostic/prognostic values of the other three biomarkers were a few in OSCC (if any) and highly controversial, this study was conducted. Biomarker expressions in all OSCC tissues and their adjacent normal tissues available at the National Tumor Bank (n = 4 biomarkers × [48 cancers + 48 controls]) were estimated thrice using qRT-PCR. Diagnostic values of tumors were assessed using receiver-operator characteristic (ROC) curves. Factors contributing to patients' survival over 10 years were assessed using multiple Cox regressions. ROC curves were used to estimate cut-off points for significant prognostic variables (α = 0.05). Areas under the curve pertaining to diagnostic values of all markers were non-significant (P > 0.15). Survival was associated positively with tumoral upregulation of TGF-β1 and downregulation of CD16, CD57, and MED15. It was also associated positively with younger ages, lower histological grades, milder Jacobson clinical TNM stages (and lower pathological Ns), smaller and thinner tumors, and surgery cases not treated with incisional biopsy (Cox regression, P < 0.05). The cut-off point for clinical stage -as the only variable with a significant area under the curve- was between the stages 2 and 3. Increased TGF-β1 and reduced CD16, CD57, and MED15 expressions in the tumor might independently favor the prognosis. Clinical TNM staging might be one of the most reliable prognostic factors, and stages above 2 can predict a considerably poorer prognosis.

Surgical treatment to multiple primary lung cancer patients: a systematic review and meta-analysis

BACKGROUND

As there is no consensus on the optimal surgery strategy for multiple primary lung cancer (MPLC), we conducted this study to address this issue by comparing the prognosis of MPLC patients underwent different surgical strategies including sublobar resection and the standard resection through a systemic review and meta-analysis.

METHODS

Relevant literature was obtained from three databases including PubMed, Embase and Web of Science. Inclusion and exclusion criteria were set for the screening of articles to be selected for further conduction of systemic review and meta-analysis. The HRs of OS of the sublobar group compared with standard resection group were extracted directly or calculated indirectly from included researches.

RESULTS

Ten researches published from 2000 to 2017 were included in this study, with 468 and 445 MPLC cases for the standard resection group and sublobar resection group respectively. The result suggested that OS of MPLC patients underwent sublobar resection (segmentectomy or wedge resection for at least one lesion) was comparable with those underwent standard resection approach (lobectomy or pneumonectomy for all lesions), with HR 1.07, 95% CI 0.67-1.71, p = 0.784. Further analysis found no difference in subgroups of synchronous and metachronous (from second metachronous lesion), different population region and dominant sex type.

CONCLUSIONS

This study may reveal that sublobar resection is acceptable for patients with MPLC at an early stage, because of the equivalent prognosis to the standard resection and better pulmonary function preservation. Further research is needed to validate these findings.

Prognostic Impact of Tumor Doubling Time in Patients with Metachronous Lung Cancer

BACKGROUND

Good prognosis following surgery for metachronous lung cancer has been reported. However, prognostic factors have not been fully investigated. The purpose of this study was to identify the preoperative predictor of survival in metachronous lung cancer.

METHODS

Patients who underwent a second pulmonary resection for metachronous lung cancer at our institution between 2000 and 2014 were analyzed.

RESULTS

A retrospective chart review identified 86 eligible patients (of 6213; 1.4%). The 5-year overall survival was 77%. All 86 cancers met Martini and Melamed's criteria for second primary cancer. However, on pathological examination based on morphological concordance between the initial and metachronous cancer, 73 (85%) cases were diagnosed as second primary cancer and 13 (15%) as a possible recurrent tumor. The 5-year overall survivals were 82% for second primary cancers and 52% for possible recurrent tumors. Tumor doubling time > 180 days (p < 0.001), pathological diagnosis of second primary cancer (p = 0.013), pathological stage IA (p = 0.016), interval between resections > 2 years (p = 0.040), and consolidation/tumor diameter ratio ≤ 0.5 (p = 0.045) were associated with superior overall survival. Multivariate Cox regression analysis identified tumor doubling time > 180 days as the only independent predictor of overall survival (hazard ratio 3.600, 95% confidence interval 1.226-10.338; p = 0.0196).

CONCLUSIONS

Surgical resection for metachronous lung cancer is effective and feasible. Particularly, a tumor doubling time > 180 days is associated with superior survival in patients with metachronous lung cancer.

The Prognostic and Clinicopathologic Characteristics of OCT4 and Lung Cancer: A Meta-Analysis

Objective:

The relationship between OCT4 and clinicopathological features in lung cancer is shown to be controversial in recent publications. Therefore, we conducted this meta-analysis to quantitatively investigate the prognostic and clinicopathological characteristics of OCT4 in lung cancer.

Methods:

A comprehensive literature search of the PubMed, EMBASE, Cochrane Library, WOS, CNKI and Wanfang databases was performed to identify studies. Correlations between OCT4 expression and survival outcomes or clinicopathological features were analyzed using meta-analysis methods.

Results:

Twenty-one studies with 2523 patients were included. High OCT4 expression showed a poorer overall survival (OS) (univariate: HR= 2.00, 95% CI = (1.68, 2.39), p<0.0001; multivariate: HR= 2.43, 95% CI = (1.67, 3.55), p<0.0001) and median overall survival (MSR = 0.51, 95% CI = (0.44, 0.58), p < 0.0001), disease-free survival (DFS) (HR= 2.18, 95% CI = (1.30, 3.67), p = 0.003) and poorer disease-specific survival (DSS) (HR= 2.23, 95% CI = (1.21, 4.11), p = 0.010). Furthermore, high OCT4 expression was found to be related with lower 5 year disease-specific survival rate (OR= 0.24, 95% CI = (0.14, 0.41), p<0.0001) and 10 year overall survival rate (OR= 0.22, 95% CI = (0.12, 0.40), p=0.0001). Additionally, OCT4-high expression was also strongly associated with higher clinical TNM stage, lymph node metastasis, tumor distant metastasis, higher histopathologic grade, but not related with gender, smoking status, tumor size and histologic type of lung cancer.

Conclusion:

OCT4 over-expression in lung cancer was strongly related to poorer clinicopathological features and worse survival outcomes, which suggests that OCT4 could be a valuable prognostic marker in lung cancer.

Triple synchronous primary lung cancer: a case report and review of the literature

Background

Multiple primary lung cancer may present in synchronous or metachronous form. Synchronous multiple primary lung cancer is defined as multiple lung lesions that develop at the same time, whereas metachronous multiple primary lung cancer describes multiple lung lesions that develop at different times, typically following treatment of the primary lung cancer. Patients with previously treated lung cancer are at risk for developing metachronous lung cancer, but with the success of computed tomography and positron emission tomography, the ability to detect both synchronous and metachronous lung cancer has increased.

Case presentation

We present a case of a 63-year-old Hispanic man who came to our hospital for evaluation of chest pain, dry cough, and weight loss. He had recently been diagnosed with adenocarcinoma in the right upper lobe, with a poorly differentiated carcinoma favoring squamous cell cancer based on bronchoalveolar lavage of the right lower lobe for which treatment was started. Later, bronchoscopy incidentally revealed the patient to have an endobronchial lesion that turned out to be mixed small and large cell neuroendocrine lung cancer. Our patient had triple synchronous primary lung cancers that histologically were variant primary cancers.

Conclusions

Triple synchronous primary lung cancer management continues to be a challenge. Our patient’s case suggests that multiple primary lung cancers may still occur at a greater rate than can be detected by high-resolution computed tomography.

Clinical outcomes of patients with metachronous second primary lung adenocarcinomas

BACKGROUND

The incidence of adenocarcinomas as multiple primary lung cancers (MPLCs) is increasing. How to determine the treatment strategies of MPLCs, especially second primary lung adenocarcinomas (SPLACs), and the prognostic factors associated with it are unclear.

METHODS

The clinical records of patients undergoing surgery for second adenocarcinomas based on Martini-Melamed criteria between 2001 and 2014 were retrospectively reviewed. Survival rates were calculated by the Kaplan-Meier method and compared using the log-rank test. Multivariate analysis was conducted using the Cox proportional hazards model.

RESULTS

A total of 115 patients with SPLACs were identified based on Martini-Melamed criteria. With respect to the second resections, three subgroups with low- (adenocarcinoma in situ, n=6; minimally invasive adenocarcinoma, n=19), intermediate- (lepidic, n=9; acinar, n=40; papillary, n=23), and high-grades (solid, n=9; micropapillary, n=2; invasive mucinous, n=7) were assigned. The 5-year overall survival (OS) rates from the time of the first and the second resections were 86.5% and 69.5%, respectively. Cox multivariate analysis identified computed tomography (CT) morphology of SPLACs (ground glass opacity predominant versus solid predominant; hazard ratio [HR]=0.42; P=0.036), histologic classification (same/similar vs different; HR=0.06; P<0.001), pathologic stage of the primary (stage I vs II; HR=0.20; P=0.015) and second tumors (stage I vs IIIa; HR=0.21; P=0.002), and histologic grade of SPLACs (low- vs high-grade, HR=0.05, P=0.016; intermediate- vs high-grade, HR=0.37, P=0.027) as significantly favorable prognostic factors for OS.

CONCLUSION

In addition to pathologic stage of the initial tumors and histologic classification, pathologic stage and CT morphology of SPLACs were identified as predictors of survival. The histologic grade of SPLACs based on the new adenocarcinoma classification could provide additional prognostic information.

Pulmonary Metastases from NSCLC and MPLC (Multiple Primary Lung Cancers): Management and Outcome in a Single Centre Experience

BACKGROUND

This is an institutional review of surgical management of second pulmonary tumours in patients with history of Non-small Cell Lung Cancer (NSCLC) resection according to The American College of Chest Physicians' (ACCP) revision to the Martini and Melamed's criteria for the classification of multiple primary lung cancers (MPLC).

METHODS

All patients who underwent iterative pulmonary resections for pulmonary metastasis (Group A) or MPLC (Group B) between 2006 and 2012 were reviewed and their survivals compared accordingly. The main criteria of insertion in Group B were different histology and the same histology with disease-free interval ≤ 4 years; we excluded loco-regional recurrence in nodes and/or on bronchial stump.

RESULTS

Group A: Twenty patients; Disease free time (DFT) after first operation was 15.2 months (range 2-44). One, two and three years overall survival after second resection was 74%, 29%, 14% respectively. Group B: Thirty-six patients. One, two and three years overall survival was 94%, 81%, and 69% respectively. No statistical differences on outcome were found between the two groups in spite of the apparent worse survival rate for Group A (p=.197).

CONCLUSIONS

A further resection for additional nodules, whether designated as intrapulmonary metastases or second primary NSCLC, can be an appropriate curative strategy in selected patients with unimpaired respiratory function and no evidence of distant metastatic disease. The site, the extent of the second resection, the histology and even the stage are unlikely to be related to survival.

TGF-β1 induces erlotinib resistance in non-small cell lung cancer by down-regulating PTEN

BACKGROUND

TKI-acquired resistance is a tough obstacle for effectively treating NSCLC patients with EGFR mutant characteristics. T790M mutations and MET amplifications account for 70% of the acquired resistance, but the causes for the remaining 30% need elucidation.

METHODS

We detected TGF-β1and PTEN expression levels in 51 NSCLC patients undergoing EGFR-TKI treatment using Immunohistochemistry (IHC) assay. We examined erlotinib sensitivity, apoptosis rate, and invasion ability in PC-9 cells and PC-9/TGF-β1 cells with CCK-8, flow cytometry, and trans-well assays. We examined and analyzed the AKT and ERK pathways' expression levels using western blot.

RESULTS

High TGF-β1 and low PTEN expression levels were correlated with poor EGFR-TKI sensitivity and overall survival in 51 NSCLC samples. In vitro analysis revealed that TGF-β1 could reduce erlotinib sensitivity, increase anti-apoptosis ability and invasive characteristic in TKI-sensitive PC-9 cell lines by down-regulating PTEN and activating the Akt and ERK pathways.

CONCLUSIONS

The results suggest that TGF-β1 demonstrated another acquired erlotinib resistance by down-regulating PTEN expression.

Surgical Therapy for Bilateral Multiple Primary Lung Cancer

BACKGROUND

With the development of diagnostic techniques, the incidence of multiple pulmonary nodules has increased. The management of multiple primary lung cancer patients based on currently established criteria, however, remains controversial.

METHODS

Patients who underwent curative operations for bilateral multiple primary lung cancer (BMPLC) based on the Martini-Melamed criterion between January 2001 and June 2014 were reviewed retrospectively.

RESULTS

Bilateral lobectomies and lobectomies with contralateral sublobar resections were performed in 39 and 49 patients, respectively. Bilateral sublobar resections were performed in the remaining 13 cases. Overall survival at 3 and 5 years was 84.5% and 75.0%, respectively. The use of a limited resection procedure for the contralateral second nodule in cases with stage I BMPLC did not have a negative effect on the 5-year overall survival (p = 0.752). Postoperative pathologic diagnosis classified by the most advanced TNM stage appeared to present a good correlation with prognosis in patients with BMPLC. Cox multivariate analysis identified the most advanced TNM stage (p = 0.018) and the number of lesions (p = 0.001) as significant predictors of overall survival.

CONCLUSIONS

The prognosis of patients after bilateral surgical treatment with curative intent for BMPLC was shown to be promising. The use of a limited resection procedure for the contralateral second nodule in cases with stage I BMPLC did not have a negative effect on the 5-year overall survival. Postoperative pathologic diagnosis classified by the most advanced TNM had a good correlation with prognosis in patients with BMPLC.

Metachronous second primary lung cancer surgically treated five years or more after the initial surgery

Surgical treatment for metachronous second primary lung cancer following curative resection of primary lung cancer may be challenging. Standard surgical strategies for metachronous second primary lung cancer have not yet been established. The purpose of this study was to evaluate the outcomes of patients who underwent surgical resection for metachronous second primary lung cancer. A total of 12 patients surgically treated for metachronous second primary lung cancer ≥5 years after the initial surgery were retrospectively analyzed. The overall 5-year survival after the second surgery was 56.5%. There was no operative mortality. Patients with T1aN0M0 metachronous second primary lung cancer experienced a significantly higher 5-year overall survival rate compared with other patients (100 vs. 26.7%, respectively; P=0.0336). Among patients who underwent sublobar resection, all 3 patients with T1aN0M0 disease remained alive at the last follow-up, while 4 of the 5 patients (80%) with non-T1aN0M0 disease had developed recurrence. Surgery for metachronous second primary lung cancer may be safely performed. Early-stage metachronous second primary lung cancer was associated with a good prognosis, even among patients who underwent sublobar resection. Early detection of metachronous second primary lung cancer with close long-term follow-up following initial surgery may improve surgical outcomes.

A meta-analysis of resected metachronous second non-small cell lung cancer

This meta-analysis was designed to determine the effect of surgical treatment on overall survival of patients treated surgically for a second non-small cell lung cancer (NSCLC) that occurred after resection of an initial NSCLC. PubMed and Scopus databases were queried. Nine studies were identified. Meta-analyses revealed pooled operative mortality of 7% for the second resection, pooled 5-year overall survival of 46% after resection of the second NSCLC, and 79% after resection of the first NSCLC. These results suggest that surgical resection can be considered for patients who have a second primary NSCLC after resection of an initial lung cancer.

[Lung cancer surgery in a single-lung]

INTRODUCTION

The diagnosis of a second lung cancer in a patient with a previous medical history of lung cancer is no longer a rarity. Also, it is possible to observe a new location in a patient who underwent pneumonectomy in the past. Surgery remains the best treatment. Our objective was to overview this subject.

PATIENTS AND METHODS

Among 5611 patients operated in our institution, 186 (3.3%) had metachronous cancer and 17 had previous pneumonectomy (0.7% of pneumonectomies and 0.2% of NSCLC treated in our department). The procedure was diagnostic and therapeutic in 88% of cases (n=15).

RESULTS

There were 16 males and 1 female, mean age was 62.5-years. All were smokers (11 were former smokers) and 6 had other medical history. Mean FEV was 52% (range 35-95%). Types of resection were 2 lobectomies, 4 segmentectomies, and 11 wedge resections. There were no postoperative deaths, but two complications. Histological subtype of the first and second cancer was the same in 11 patients. All patients were pN0 after second surgery. The long-term survival (median 33 months) was 35.3% at 5-years and 14.1% at 10-years. Two patients treated with pneumonectomy for their first cancer were pN2. Patients who underwent upper right lobectomy for treatment of their second cancer survived longer than 5-years.

CONCLUSION

Surgical resection for lung cancer on single-lung is associated with acceptable morbidity and mortality. Prolonged survival can be achieved in selected patients.

Prognosis of synchronous and metachronous multiple primary lung cancers: systematic review and meta-analysis

BACKGROUND

With the development of imaging technology, an increasing number of multiple primary lung cancers (MPLC) are diagnosed in recent years. However, there is still ambiguity in the stage classification rules for patients with MPLC. Our purpose was to access the prognosis of synchronous and metachronous MPLC.

METHODS

A systematic literature search was performed on four databases (EBSCO, Pubmed, OVID and Springer) to obtain relevant articles. We used published hazard ratios (HRs) of overall survival (OS) if available or estimates from the published survival data.

RESULTS

There were 1796 patients with MPLC in 22 relevant studies, who were eligible for analysis. We found that the OS of patients with synchronous MPLC was inferior to the one of metachronous MPLC patients when starting from the diagnosis of the first metachronous tumor (HR 3.36, 95% CI 2.39-4.74; p<0.001). However, there was no difference when starting from the diagnosis of the second metachronous tumor (HR 1.19, 95% CI 0.86-1.66; p=0.29). From further analysis we found the OS of patients with MPLC was superior to that of patients with intrapulmonary metastasis (HR 2.66, 95% CI 1.30-5.44; p=0.007). Besides, we found no difference in OS between synchronous (HR 1.39, 95% CI 0.98-1.96; p=0.06) and metachronous (HR 1.05, 95% CI 0.75-1.47; p=0.77) patients, in spite of the histology. In terms of unilateral and bilateral MPLC patients, the OS had no difference either (HR 1.30, 95% CI 1.00-1.69; p=0.05).

CONCLUSION

We found that MPLC had better OS than the lung cancer patients with intrapulmonary metastasis. And despite the tumor-free interval, the OS for metachronous MPLC was as good as that for synchronous MPLC. Furthermore, there was no difference of OS in different subgroups, including histology and position.

Characteristics and outcomes of secondary nodules identified on initial computed tomography scan for patients undergoing resection for primary non-small cell lung cancer

OBJECTIVE

We sought to define the prevalence, malignancy rate, and outcome of secondary nodules (SNs) detected on computed tomography (CT) scan for patients undergoing resection for primary non-small cell lung cancer (NSCLC).

METHODS

In consecutive patients with NSCLC, we reviewed all CT scan reports obtained at diagnosis of the dominant tumor for description of SNs. When resected, pathology was reviewed. Serial CT reports for 2 years postoperatively were evaluated to follow SNs not resected.

RESULTS

Among 155 patients, 88 (57%) were found to have SNs. A total of 137 SNs were evaluated (median size, 0.5 cm). Thirty-two nodules were resected at primary resection. Nineteen (61%) resected nodules were benign, whereas 13 (39%) were malignant (8 synchronous primary tumors and 5 lobar metastases). A total of 105 unresected nodules were followed by CT. Of these, 32 (30%) resolved completely, 20 (19%) shrunk, and 28 (27%) were stable, whereas 11 (11%) were lost to follow-up. Fourteen SNs (13%) grew, of which 5 were found to be malignant, each a new primary. Overall 5-year survival was not different between patients with or without SNs (67% vs 64%; P = .88).

DISCUSSION

The prevalence of SNs on CT scan in patients undergoing resection for primary NSCLC is high. Only a low proportion of SNs are ever found to be malignant, predominantly those on the ipsilateral side as the dominant tumor. The presence of SNs has no effect on survival. Patients with SNs, if otherwise appropriately staged, should not be denied surgical therapy.

The stage classification of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

The current Lung Cancer Stage Classification system is the seventh edition, which took effect in January 2010. This article reviews the definitions for the TNM descriptors and the stage grouping in this system.

Special treatment issues in non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

This guideline updates the second edition and addresses patients with particular forms of non-small cell lung cancer that require special considerations, including Pancoast tumors, T4 N0,1 M0 tumors, additional nodules in the same lobe (T3), ipsilateral different lobe (T4) or contralateral lung (M1a), synchronous and metachronous second primary lung cancers, solitary brain and adrenal metastases, and chest wall involvement.

METHODS

The nature of these special clinical cases is such that in most cases, meta-analyses or large prospective studies of patients are not available. To ensure that these guidelines were supported by the most current data available, publications appropriate to the topics covered in this article were obtained by performing a literature search of the MEDLINE computerized database. Where possible, we also reference other consensus opinion statements. Recommendations were developed by the writing committee, graded by a standardized method, and reviewed by all members of the Lung Cancer Guidelines panel prior to approval by the Thoracic Oncology NetWork, Guidelines Oversight Committee, and the Board of Regents of the American College of Chest Physicians.

RESULTS

In patients with a Pancoast tumor, a multimodality approach appears to be optimal, involving chemoradiotherapy and surgical resection, provided that appropriate staging has been carried out. Carefully selected patients with central T4 tumors that do not have mediastinal node involvement are uncommon, but surgical resection appears to be beneficial as part of their treatment rather than definitive chemoradiotherapy alone. Patients with lung cancer and an additional malignant nodule are difficult to categorize, and the current stage classification rules are ambiguous. Such patients should be evaluated by an experienced multidisciplinary team to determine whether the additional lesion represents a second primary lung cancer or an additional tumor nodule corresponding to the dominant cancer. Highly selected patients with a solitary focus of metastatic disease in the brain or adrenal gland appear to benefit from resection or stereotactic radiosurgery. This is particularly true in patients with a long disease-free interval. Finally, in patients with chest wall involvement, provided that the tumor can be completely resected and N2 nodal disease is absent, primary surgical resection should be considered.

CONCLUSIONS

Carefully selected patients with more uncommon presentations of lung cancer may benefit from an aggressive surgical approach.

Multiplex PCR-based detection of circulating tumor cells in lung cancer patients using CK19, PTHrP, and LUNX specific primers

INTRODUCTION

The aim of this study was to develop a multiplex polymerase chain reaction (PCR)-based method for detection of circulating tumor cells in peripheral blood of lung cancer (LC) patients.

PATIENTS AND METHODS

Peripheral blood was collected from 71 healthy donors and 125 LC patients at different pathological stages. Samples were analyzed using multiplex PCR, and specific primers for CK19, PTHrP, and LUNX mRNA. The sensitivity of our method was set at 10 LC cells (A549 cells) in 3 mL of peripheral blood of healthy donors using spiking experiments.

RESULTS

The detection rates in LC patients for CK19, PTHrP, and LUNX were 45.6%, 64.8%, and 28%, and in healthy individuals were 7%, 7%, and 5.6%, respectively. Overall, our method produced 77.8% positive detections for at least 1 molecular marker. Twenty-eight (22.2%) were negative for expression of all markers, 39 (31.2%) were positive for expression of 1 marker, 42 (33.6%) were positive for expression of 2 markers, and 17 (13.6%) were positive for expression of all 3 markers. Detection of CK19 mRNA expression positively correlated with LC stage and distant metastases. PTHrP mRNA detection correlated positively with LC stage, presence of bone metastasis, and squamous cell carcinoma, and LUNX mRNA detection correlated with lymph node involvement. Combined detection of 2 or 3 markers was significantly correlated with metastatic disease, and negative detection of all 3 molecular markers was correlated with early stage nonmetastatic disease.

CONCLUSION

Multiple PCR-based detection of CK19, PTHrP, and LUNX mRNA expression provides useful information for disease stage and dissemination in LC patients.

Postoperative surveillance for non-small cell lung cancer resected with curative intent: developing a patient-centered approach

Local recurrence or the development of metachronous cancer after surgical therapy for early-stage non-small cell lung cancer (NSCLC) is not uncommon, and these conditions are often amenable to curative therapy. Predictors of recurrence based on surgical, patient, and pathologic factors are well known. A literature search was performed for articles regarding identification or treatment with curative intent of early local recurrence or metachronous cancer after resection of NSCLC. A patient-centered algorithm for surveillance after resection can be developed based on both risk of recurrence and potential benefit from further treatment to optimize individual follow-up algorithms.