The Role of Surgical Treatment in Second Primary Lung Cancer

Long-Term Survival and CANARY-Based Artificial Intelligence for Multifocal Lung Adenocarcinoma

Objective

To investigate whether an artificial intelligence (AI)-based model can predict tumor invasiveness in patients with multifocal lung adenocarcinoma (MFLA).

Patients and Methods

Patients with MFLA who underwent surgical resection were enrolled to a prospective registry trial (NCT01946100). Each identified nodule underwent retrospective computer-aided nodule assessment and risk yield (CANARY)-based AI to determine a quantitative degree of invasiveness. Data regarding age, sex, medical and surgical management, and survival were collected and analyzed. Pathologic review was performed by a pulmonary pathologist with comprehensive histologic subtyping.

Results

From January 1, 2013, through December 31, 2018, 68 patients with MFLA underwent at least 1 surgical resection. Five-year survival for the cohort was 91%, and 10-year survival was 73.6%. No significant differences in survival were observed when separated by sex, number, or size of the nodules. A 10-year survival trend was seen when comparing patients with unilateral (100% survival) vs bilateral disease (66%). Retrospective CANARY-based AI analysis demonstrated that the majority of the nodules present at the time of diagnosis (229/302; 75.8%) were classified good, with an average score of 0.19, suggesting indolent clinical behavior and noninvasive pathology. However, AI-CANARY scores of the surgically removed nodules were significantly higher compared with those of the nonresected nodules (P=.001).

Conclusion

The long-term survival for patients with N0, M0 MFLA who have undergone surgical resection may approach those of stage I non-small cell lung cancer. CANARY-based AI has the potential to stratify individual nodules to help guide surgical intervention versus observation of nodules.

Trial Registration

clinicaltrials.gov Identifier: NCT01946100.

Sublobar resection for metachronous stage I second primary non-small cell lung cancer: A single-centre experience

INTRODUCTION

More patients are developing second primary lung cancer (SPLC). This study aimed to evaluate the impact of the extent of SPLC resection on outcomes.

MATERIAL AND METHODS

We retrospectively investigated 1,895 patients with lung cancer who underwent pulmonary resection from 2011 to 2018. SPLC was diagnosed using the criteria of Martini and Melamed. Patients with pathological stage I SPLC who underwent lobectomy for first primary lung cancer (FPLC) were included in the study. Outcomes and clinical factors that could affect survival were evaluated.

RESULTS

Fifty-four patients were eligible for the study. Lobectomy, segmentectomy, or wedge resection was performed for 10, 32, and 12 patients, respectively. Neither overall nor relapse-free survival was significantly different based on the extent of resection for stage I SPLC. Multivariate analysis revealed that interval between FPLC and SPLC of less than 5 years was an independent risk factors for worse relapse-free survival after SPLC resection (interval: hazard ratio, 0.28; P = 0.048). The median interval from prior resection to secondary resection was 68 months.

CONCLUSIONS

Sublobar resection might be a realistic option for stage I SPLC. To realize early detection of SPLC that can undergo radical sublobar resection, the surveillance period after prior resection of FPLC is worth reconsidering.

Lobar or sublobar resection for early-stage second primary lung cancer ≤ 3 cm in size: a SEER population-based study

PURPOSE

Surgical strategy for second primary lung cancer (SPLC) may be more conservative due to influence of first primary lung cancer (FPLC). The optimal surgical method for SPLC warrants discussion. We aimed to explore a more suitable surgical approach for early-stage (T1-T2N0, ≤ 3 cm) SPLC and provide insights for clinical practice.

METHODS

A retrospective study was conducted using data from the Surveillance, Epidemiology and End Results database between 2004 and 2018, and data of patients with early-stage SPLC who underwent secondary surgery were collected. Propensity score matching (PSM) reduced potential bias between lobar and sublobar resection groups. The effect of lobar and sublobar resection on overall survival (OS) was assessed in all patients and subgroups.

RESULTS

A total of 714 patients who met the study entry criteria were enrolled, including 476 patients in the sublobar resection group (66.67%) and 238 patients in the lobar resection group (33.33%). There was no difference in OS between the lobar and sublobar resection groups before and after PSM (P = 0.289) and (P = 0.608), respectively. Subgroup analyses showed that lobar resection achieved a significantly better OS than sublobar resection only in patients with an SPLC tumor size of 2-3 cm (P < 0.05).

CONCLUSION

The OS of sublobar resection was not significantly different from that of lobar resection for early-stage SPLC. For SPLC with a 2-3 cm tumor size, lobar resection is more advantageous than sublobar resection.

Residual middle lobectomy after right upper or lower lobectomy: indications and outcome

OBJECTIVES

Residual middle lobectomy after upper lobectomy and lower lobectomy differs in their indications and perioperative outcomes. Therefore, we aimed to evaluate the indications and perioperative outcomes of residual middle lobectomy after upper and lower lobectomy.

METHODS

The data of 14 patients who underwent residual middle lobectomy after upper or lower lobectomy between January 1997 and December 2021 were extracted and analyzed.

RESULTS

Overall, six patients underwent residual middle lobectomy after upper lobectomy. The indication was second primary lung cancer in five patients and local recurrence in the hilar lymph node between the middle and lower lobar bronchi in one patient. However, one patient was treated with the R2 operation. The remaining eight patients underwent residual middle lobectomy after lower lobectomy. The indication was second primary lung cancer and bronchopleural fistula or stenosis in two and six patients, respectively. No postoperative 90-day mortality was observed.

CONCLUSIONS

Residual middle lobectomy for second lung cancer after upper lobectomy is difficult because of severe hilar adhesions. Simultaneous resection of hilar structures or pulmonary artery and parenchyma might be an option. Residual middle lobectomy could be a treatment option for bronchopleural fistula or stenosis after lower lobectomy.

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.

Development and validation of a competing risk model for second primary pancreatic ductal adenocarcinoma: A population-based study

Background

With advances in early diagnosis and treatment, the number of cancer survivors continues to grow, and more and more cancer survivors face the threat of second primary cancer (SPM). Second primary pancreatic ductal adenocarcinoma (spPDAC) is an important subclass of SPM, but its prognostic characteristics are poorly understood.

Methods

A total of 5,439 spPDAC samples and 67,262 primary pancreatic ductal adenocarcinoma (pPDAC) samples were extracted from the SEER database for this study. Survival differences between spPDAC and pPDAC samples were compared using Kaplan–Meier curves and log-rank tests. The Fine and Gray proportional subdistributed hazard method was used to analyze potential associations between clinical variables and pancreatic ductal adenocarcinoma-specific death (PDACSD) and death from other causes. After that, the clinical variables significantly related to PDACSD were screened out to construct a competing risk nomogram, which was used to evaluate the probability of the occurrence of PDACSD. The C-index was used to evaluate the discriminative ability of the model. The area under the curve (AUC) was used to verify the discrimination of the model. The calibration curve was used to verify the calibration of the model. Decision curve analysis (DCA) was used to validate the clinical utility of the model.

Results

Compared with patients with spPDAC, the pPDAC sample had a better prognosis (p = 0.0017). Across all spPDAC samples, the three most common sites of first-present cancer were the prostate, breast, and digestive system. Age (p < 0.001), race (p = 0.006), interval (p = 0.016), location (p < 0.001), T stage (p = 0.003), M stage (p < 0.001), chemotherapy (p < 0.001), and radiotherapy (p = 0.006) were the clinical variables associated with PDACSD screened by multivariate competing risks analysis. The concordance index values for the training and validation sets were 0.665 (95% CI, 0.655, 0.675) and 0.666 (95% CI, 0.650, 0.682), respectively. AUC, calibration curve, and DCA indicated that the model we constructed had good discrimination, calibration, and clinical utility.

Conclusions

In conclusion, we first analyzed the impact of previous cancer history on prognosis. We then constructed a competing risk model that can predict the probability of developing PDACSD in spPDAC. This model has good discriminative ability, calibration, and clinical practicability and has certain guiding value for clinical decision-making.

Multiple Primary Lung Cancers With ALK Rearrangement: A Case Report and Literature Review

Multiple primary lung cancers (MPLCs) are that patients with lung cancer may present with two primary tumors at the same time (synchronous multiple primary lung cancer, SMPLC) or may develop a second, metachronous primary lung cancer after treatment of the initial lesion. Currently, there are no definitive guidelines for the diagnosis and treatment of multiple primary lung cancers. Herein, we report a case of double primary lung cancers with ALK rearrangement. The patient was treated with chemotherapy, targeted therapy, and radiotherapy. After these treatments, the patient was free of locally recurrent or distant disease at 2 years.

Surgical strategies for patients with second primary non-small cell lung cancer lesions 2 cm or less in diameter

BACKGROUND AND PURPOSE

The wide application of low-dose computed tomography (CT) has led to an increase in the detection of small lung cancer lesions. Moreover, surgical recommendations for second primary non-small cell lung cancer (NSCLC) lesions ≤ 2 cm are obscure. This study compares the efficacy of wedge resection, lobectomy, and segmentectomy for small second primary NSCLC lesions.

METHODS

The cohort was established based on the SEER database. Univariate and multivariate cox regression analysis, least absolute shrinkage and selection operator (LASSO) regression, and restricted mean survival time (RMST) values were applied to identify prognostic factors. We used the Kaplan-Meier method to plot the survival curves of the different subgroups according to propensity score matching (PSM) analysis to then compare the therapeutic efficacy of the surgical procedures.

RESULTS

A total of 568 patients were enrolled in this study. Age, sex, grade, and lymph node ratio were selected as independent prognostic factors (p < 0.05). No significant differences were observed in survival probabilities among the groups of patients who underwent segmentectomy, wedge resection, or lobectomy (p > 0.05). We also established a nomogram model based on the four prognostic factors to guide clinical treatment.

CONCLUSIONS

Based on the findings of our study, segmentectomy was more appropriate than lobectomy for patients with a second primary NSCLC lesion ≤ 2 cm in diameter. The evidence to support other recommendations is insufficient.

Guiding Principles in the Management of Synchronous and Metachronous Primary Non-Small Cell Lung Cancer

Multiple lung cancers can be found simultaneously, with incidence ranging from 1% to 8%. Documentation of more than 1 pulmonary lesion can be challenging, because these solid, ground-glass, or mixed-density tumors may represent multicentric malignant disease or intrapulmonary metastases. If mediastinal nodal and distant deposits are excluded, surgery should be contemplated. After surgical treatment of lung cancer, patients should be followed closely for an undetermined period of time. Good clinical judgment is of outmost importance in deciding which individuals will benefit from those surgical interventions and which are candidates for alternate therapies. Every case should be discussed in a multidisciplinary meeting.

Completion Pneumonectomy for Second Primary/Primary Lung Cancer and Local Recurrence Lung Cancer

BACKGROUND

Completion pneumonectomy (CP) for second primary/primary lung cancer (SPLC) and local recurrence lung cancer (LRLC) is still controversial. Although several case series on such a practice exist, the oncological benefit is under debate. The purpose of this study was to review available literatures on CP for SPLC and LRLC and evaluate postoperative and long-term outcomes.

METHODS

MEDLINE, SCOPUS and Web of Science were reviewed for eligible studies in January 2021. Studies were included if they indicated outcomes of patients with lung cancer undergoing CP. Overall survival (OS) was defined as the primary end point; secondary end points included operative morbidity and 30-day mortality. Random-effects meta-analysis based on a binomial distribution was used to create pooled estimates.

RESULTS

Thirty-two eligible studies including 1,157 patients were identified. These studies were uniformly retrospective reports. Pooled estimates for 3- and 5-year OS were 50.6% [95% confidence interval (CI) 34.7-66.5] and 38.9% [95% CI 32.2-46.1] in SPLC patients. When the SPLC was a stage I tumor, pooled 5-year OS was favorable with 60.7% [95% CI 43.2-75.9]. In LRLC, pooled 3- and 5-year OS were 47.6% [95% CI 36.1-59.4] and 33.8% (95% CI 26.8-41.5). Pooled morbidity and 30-day mortality was reported in 38.2% (95% CI 32.0-44.9), and 10.0% (95% CI 8.1-12.3).

CONCLUSIONS

CP for SPLC and LRLC is a challenging procedure with significant perioperative morbimortality. However, published evidence indicates good long-term survival for selected patients. Further studies are needed to identify patient subgroups which benefit most from CP.

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.

Role of chemotherapy for survival in patients with second primary non-small cell lung cancer

Background

The therapeutic effect of chemotherapy is still unclear for clinical usage among second primary non‐small cell lung cancer (NSCLC) patients. The aim of this study was to verify the therapeutic effect of chemotherapy and identify the prognostic factors among patients who had received chemotherapy for second primary NSCLC.

Methods

A retrospective cohort was constructed based on the Surveillance, Epidemiology and End Results (SEER) database. Through least absolute shrinkage and selection operator regression, univariate Cox and multivariate Cox regression, we identified the prognostic factors among clinicopathological features. Propensity score matching analysis was used to verify the therapeutic effect of chemotherapy. Survival curves were plotted among the subgroups of the selected factors. We further selected clinicopathological features that would affect the prognosis among patients who had received chemotherapy through a similar process.

Results

A total of 769 patients were enrolled to verify the therapeutic value of chemotherapy for second primary lung cancer. Significant differences were observed between the chemotherapy and nonchemotherapy group for cancer‐specific survival. 215 patients who had received chemotherapy were analyzed to identify the factors that might influence outcome on the therapeutic effect of chemotherapy. Age, tumor size, histology and treatment were selected as significant factors.

Conclusions

The therapeutic effect of chemotherapy for second primary NSCLC was found to be significant. Age, tumor size and histology were significant prognostic factors among patients who had received chemotherapy for second primary NSCLC.

Key points

Significant findings of the study

A significant therapeutic effect of chemotherapy for second primary non‐small cell lung cancer was proven through univariate Cox regression and propensity score matching analysis.

Prognostic factors for second primary non‐small cell lung cancer patients who had received chemotherapy.

What this study adds

Chemotherapy could be applied in clinical practice as an additional therapeutic method for second primary non‐small cell lung cancer patients.

We selected prognostic factors for patients who had received chemotherapy to identify patients who were appropriate for chemotherapy.

Lymph Node Examination for Stage I Second Primary Lung Cancer Patients Who Received Second Surgical Treatment

PURPOSE

This study aims to investigate the effect of lymph node examination on overall survival (OS) and lung cancer-specific survival (LCSS) in stage I second primary lung cancer (SPLC) patients who underwent second pulmonary resection.

PATIENTS AND METHODS

We conducted a retrospective study with the Surveillance, Epidemiology, and End Results (SEER) database to identify stage I SPLC patients who received surgery from 1998 to 2015. The Kaplan-Meier method with landmark analysis and multivariable Cox regression analysis were performed to evaluate the prognostic value of lymph node examination.

RESULTS

A total of 842 patients from the SEER database with stage I SPLC who underwent a second surgical treatment were included. The 5-year survival rate was 54.8% for the whole cohort. Multivariable analysis revealed that the number of lymph nodes examined (LNE) was associated with better OS and LCSS in SPLC patients after 12 months postoperatively. Patients with contralateral SPLC had significantly more nodes removed than those with ipsilateral SPLC. For contralateral SPLC, more than 10 LNE was correlated with improved long-term survival outcomes. Ipsilateral SPLC patients benefited from 4 or more LNE. However, the current analysis did not show a significant survival benefit from lymph node examination within 12 months after surgery.

CONCLUSIONS

For stage I SPLC patients who received surgical treatment after initial resection, an adequate number of LNE would improve both OS and LCSS. We recommend more than 10 LNE for contralateral SPLC and at least 4 LNE for ipsilateral SPLC.

Perioperative Outcomes of Thoracoscopic Reoperations for Clinical Recurrence of Pulmonary Malignancy

The utility of thoracoscopic lung surgery is well established, however, reoperation for pulmonary resections has not been thoroughly studied. We sought to evaluate patient perioperative outcomes following redo thoracoscopic pulmonary resections for malignancy by comparing first and second ipsilateral operations. We included patients undergoing redo thoracoscopic pulmonary resections for clinically recurrent disease following prior lung resection for malignancy from January 1, 2011 to May 31, 2019. Nonmalignant indications were excluded. We analyzed type of procedure, diagnosis, rate of conversion to open, estimated blood loss, operating time, margin status, length of stay and complications. Forty-one patients met our inclusion criteria. The median age was 68 years (range 13-84) and 20 were women. Redo operations had longer lengths of stay with a trend toward higher rate of conversion to thoracotomy, but other perioperative outcomes were similar. No difference in outcomes was seen when patients were grouped by indication for reoperation (recurrence, multiple primaries, and metastasis) or approach of first operation (VATS vs open). However, patients undergoing an anatomic resection after a prior anatomic resection had more complications, higher blood loss, higher rate of conversions to thoracotomy, significantly longer length of stay and longer operative times than nonanatomic resections. Thoracoscopic reoperation for recurrent, metachronous, or metastatic cancer to the lung is a reasonable approach. However, the surgeon must recognize and counsel patients that in patients undergoing a redo anatomic resection, thoracoscopic reoperations are more difficult with more adverse outcomes.

Impact of postoperative complications on outcomes of second surgery for second primary lung cancer

PURPOSE

The best surgical approach for second primary lung cancer remains a subject of debate. The purpose of this study was to review the postoperative complications after second surgery for second primary lung cancer and to investigate the outcomes based on these complications.

METHODS

The clinical data of 105 consecutive patients who underwent pulmonary resection for multiple primary lung cancers between January, 1996 and December, 2017, were reviewed according to the Martini-Melamed criteria.

RESULTS

After the second surgery, low body mass index (BMI) (< 18.5 kg/m²) (P = 0.004) and high Charlson comorbidity index (CCI) (P = 0.002) were independent predictors of postoperative complications. Survival analysis revealed the 5-year overall survival rates of 74.5% and 61.4% for patients without postoperative complications and those with postoperative complications (P = 0.044), respectively, but the 5-year cancer-specific survival rates of 82.5% and 80.0% (P = 0.926), respectively. During this period, there were significantly more respiratory-related deaths of patients with complications than of those without complications (P = 0.011).

CONCLUSION

Surgical intervention is feasible and potentially effective for second primary lung cancer but may not achieve positive perioperative and long-term outcomes for patients with a low BMI or a high CCI. Treatment options should be considered carefully for these patients.

Extent of resection and lymph node evaluation in early stage metachronous second primary lung cancer: a population-based study

BACKGROUND

Evidence of the optimal surgery strategy for early stage metachronous second primary lung cancer (SPLC) has been limited and controversial. This study aims to compare the survival outcomes of different extents of resection and lymph node evaluation in these patients.

METHODS

Early stage metachronous SPLC patients, who had received lobectomy for initial primary lung cancer (IPLC) and developed SPLC more than 3 months later, were selected from the Surveillance, Epidemiology, and End Results (SEER) database according to the American College of Chest Physicians (ACCP) guideline. Overall survival (OS) and lung cancer-specific survival (CSS) of different extents of resection and lymph node evaluation were analyzed using Kaplan-Meier method and multivariate Cox regression model.

RESULTS

Overall, 1,784 SPLC patients without nodal or distant metastasis were identified. Lobectomy was associated with significantly longer OS (HR: 0.83, 95% CI: 0.71-0.97, 5-year survival: 59.2% vs. 53.3%, P=0.02) and CSS (HR: 0.72, 95% CI: 0.60-0.88, 5-year survival: 71.5% vs. 63.2%, P=0.001) compared with sublobar resection. In addition, examined lymph node number ≥10 demonstrated longer OS (HR: 0.63, 95% CI: 0.50-0.81, 5-year survival: 66.6% vs. 53.9%, P<0.001) and CSS (HR: 0.54, 95% CI: 0.40-0.74, 5-year survival: 77.4% vs. 64.7%, P<0.001) compared with an examined lymph node number <10. The survival benefits of lobectomy and examined lymph node number ≥10 were further validated in multivariate Cox regression and subgroup analysis stratified by tumor size.

CONCLUSIONS

Lobectomy and thorough lymph node evaluation provided significantly longer survival, and thus should be considered for early stage metachronous SPLC whenever possible.

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.

Multiple primary lung cancer: a rising challenge

With the use of high-resolution chest imaging system and lung cancer screening program, patients with multiple primary lung cancers (MPLCs) are becoming a growing population in clinical practice worldwide. The diagnostic criteria for MPLCs has been established and modified by three major lung cancer research institutes. However, due to the fact that the differential diagnosis between MPLCs and a recurrence, metastatic, or satellite lesion arising from the original lesion remains ambiguous and confusing, there is still insufficient evidence to support a uniform guideline. Newly developed molecular and genomic methods have the potential to better define the relationship among multiple lesions and bring the possibility of targeted therapy. Surgical resection remains the first choice for the treatment of MPLCs and detailed strategy should be carefully planned taking characteristics of the tumor and status of patients into consideration. For those who are intolerant to surgery, a new technology called stereotactic body radiation therapy (SBRT) is now an optional therapeutic strategy. Furthermore, multiple GGOs are unique MPLCs that need special attentions in the clinical practice.

Efficacy of repeated surgery is superior to that of non-surgery for recurrent/second primary lung cancer after initial operation for primary lung cancer

Background

The current study aimed to determine the oncological efficacy and surgical safety of multiple pulmonary resections (MPRs) after prior curative surgery for local regional recurrent or second primary lung cancers.

Methods

All cases of lung cancer included in our prospective database between January 2000 and July 2015 were retrospectively reviewed. The oncological efficacy endpoints for synchronous and metachronous MPR were five‐year overall survival (OS), disease‐free survival (DFS), and progression‐free survival (PFS) rates after the second surgery. The surgical safety endpoints were postoperative mortality and complications (Clavien‐Dindo classification) within 30 days.

Results

In total, 67 MPR cases were identified. There were no significant differences in the five‐year OS and DFS between the synchronous MPR group (n = 50) and the propensity score‐matched solitary major pulmonary resection group (n = 250) (5‐year OS 84.5% vs. 69.0%, log rank P = 0.112; DFS 64.4% vs. 58.0%, log rank P = 0.278). The five‐year OS and PFS of the metachronous MPR group (n = 17) were significantly better than those in the non‐surgical control group (n = 19) (5‐year OS 94.1% vs. 50.7%, log rank P = 0.005; 5‐year PFS 53.9% vs. 10.5%, log rank P = 0.020). No postoperative mortality or severe complications occurred in the MPR group.

Conclusion

The oncological efficacy of MPR is superior to the non‐surgical approach for the management of local regional recurrent or second primary lung cancer, with comparable postoperative mortality and complications.

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.

Predicting the Mortality Benefit of CT Screening for Second Lung Cancer in a High-Risk Population

Patients who survive an index lung cancer (ILC) after surgical resection continue to be at significant risk for a metachronous lung cancer (MLC). Indeed, this risk is much higher than the risk of developing an ILC in heavy smokers. There is currently little evidence upon which to base guidelines for screening at-risk patients for MLC, and the risk-reward tradeoffs for screening this patient population are unknown. The goal of this investigation was to estimate the maximum mortality benefit of CT screening for MLC. We developed a computational model to estimate the maximum rates of CT detection of MLC and surgical resection to be expected in a given population as a function of time after resection of an ILC. Applying the model to a hypothetical high-risk population suggests that screening for MLC within 5 years after resection of an ILC may identify only a very small number of treatable cancers. The risk of death from a potentially resectable MLC increases dramatically past this point, however, suggesting that screening after 5 years is imperative. The model also predicts a substantial detection gap for MLC that demonstrates the benefit to be gained as more sensitive screening methods are developed.

[Diagnosis and Treatment of Multiple Primary Lung Cancer]

Multiple primary lung cancer (MPLC) is an uncommon entity of the primary lung cancer. With the widespread use of early detection tools such as multislice spiral computed tomography (CT), positron emission tomography (PET), and the better survival results after resection of primary lung cancer, more and more MPLC have been detected. However, the current diagnostic and therapeutic methods cannot meet the needs of MPLC individualized demand of diagnosis and treatment. At present, diagnostic criteria of MPLC are based on histological types, genetic characteristics, image features, tumor locations and clinical manifestation. On the treatment of MPLC, Surgery-based multi-discipline comprehensive treatment is regarded as the treatment of choice. In this paper, we make a review through summarizing the latest literature progress on the epidemiology, etiology, diagnostic criteria, treatment options and prognosis of MPLC.

The dynamic pattern of recurrence in curatively resected non-small cell lung cancer patients: Experiences at a single institution

PURPOSE

To investigate the hazard function of tumor recurrence in patients with completely (R0) resected non-small cell lung cancer.

METHODS

A total of 1374 patients treated between 2003 and 2009 with complete resection and systematic lymph node dissection were studied. The risk of recurrence at a given time after operation was studied utilizing the cause-specific hazard function. Recurrence was categorized as local recurrence or distant recurrence. The risk distribution was assessed using clinical and pathological factors.

RESULTS

The hazard function for recurrence presented an early peak at approximately 10 months after surgery and maintained a tapered plateau-like tail extending up to 8 years. A similar risk pattern was detected for both local recurrence and distant recurrence, while the risk of distant recurrence was higher than that of local recurrence. The double-peaked pattern of hazard rate was present in several subgroups, such as p-stage IA patients. A comparison of histology and status of nodal involvement showed that pN1-2 adenocarcinoma patients demonstrated a high hazard rate of distant recurrence and that pN0 adenocarcinoma patients exhibited a small recurrent risk for a longer time. Squamous cell carcinoma patients showed only little difference in risk.

CONCLUSIONS

The data may be useful to select patients at high risk of recurrence and may provide information for each patient to decide how to manage the postoperative follow-up individually.

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.

Non-small cell lung cancer: when to offer sublobar resection

Sublobar resection for lung cancer--whether non-anatomic wedge resection or anatomic segmentectomy--has emerged as a credible alternative to lobectomy for the surgical treatment of selected patients with lung cancer. Sublobar resection promises to cause less pulmonary compromise in such patients. Emerging evidence suggests that sublobar resection may offer survival outcomes approaching that of lobectomy for lung cancer patients whose disease meets the following criteria: stage IA disease only; tumor up to 2-3 cm diameter; peripheral location of tumor in the lung; and predominantly ground-glass (non-solid) appearance on CT imaging. The best results are obtained with segmentectomy (as opposed to wedge resection) and complete lymph node dissection. Nevertheless, the evidence is currently still limited, and the above criteria are met only in a minority of patients. Large randomized trials are underway to define the clinical role of sublobar resections, and results are eagerly anticipated. Until that time, lobectomy should still be regarded as the mainstay of surgical therapy for patients with early stage lung cancer at present.

Second primary lung cancers: smokers versus nonsmokers after resection of stage I lung adenocarcinoma

BACKGROUND

Smokers have a higher risk of developing non-small cell lung cancer (NSCLC) than never-smokers, but the relative risk of developing second primary lung cancer (SPLC) is unclear. Determining the risk of SPLC in smokers versus never-smokers after treatment of an initial cancer may help guide recommendations for long-term surveillance.

METHODS

Patients who underwent resection for stage I adenocarcinoma were identified from a prospectively maintained institutional database. Patients with other histologies, synchronous lesions, or who received neoadjuvant or adjuvant therapy were excluded. The SPLCs were identified based on Martini criteria.

RESULTS

From 1995 to 2012, a total of 2,151 patients underwent resection for stage I adenocarcinoma (308 never-smokers [14%] and 1,843 ever-smokers [86%]). SPLC developed in 30 never-smokers (9.9%) and 145 ever-smokers (7.8%). The SPLC was detected by surveillance computed tomography scan in the majority of patients (161; 92%). In total, 87% of never-smokers and 83% of ever-smokers had stage I SPLC. There was no significant difference in the cumulative incidence of SPLC between never-smokers and ever-smokers (p = 0.18) in a competing-risks analysis. The cumulative incidence at 10 years was 20.3% for never-smokers and 18.2% for ever-smokers.

CONCLUSIONS

Although smokers have a greater risk of NSCLC, the risk of a second primary cancer developing after resection of stage I lung cancer is comparable between smokers and never-smokers. The majority of these second primary cancers are detectable at a curable stage. Ongoing postoperative surveillance should be recommended for all patients regardless of smoking status.

Clinical features of multiple lung cancers based on thin-section computed tomography: what are the appropriate surgical strategies for second lung cancers?

PURPOSE

We investigated the proper surgical strategies for second lung cancers based on the findings of thin-section CT.

METHODS

We classified 59 patients with second lung cancers into two categories based on the thin-section CT findings. In the ground glass nodule (GGN) group (n = 29), the first and/or the second lung cancers showed a GGN on thin-section CT. In the Solid group (n = 30), both the first and second lung cancers showed a solid appearance.

RESULTS

The overall 5-year survival rate after second surgery was 71.7 %. The univariate analyses revealed that the presence of more than three lung tumors was significantly more common in the GGN group. Regarding the surgical strategies, all the patients in the GGN group underwent limited resection for at least one of the operations, whereas 36 % of those in the Solid group underwent bilateral lobectomy. The 5-year survival in the GGN group (89.1 %) was significantly better than that in the Solid group (40.8 %) (p = 0.0305).

CONCLUSIONS

Limited resection should be performed for GGN patients as much as possible to preserve lung function, due to the possible presence of more than three lung cancers. Despite the higher likelihood of having more tumors, the GGN patients had a better survival. In contrast, lobectomy for second lesions should be aggressively considered for solid tumor patients whenever possible.

Tumor necrosis factor-alpha gene promoter -308 and -238 polymorphisms in patients with lung cancer as a second primary tumor

Background

Lung cancer is the most common second primary cancer. We investigated whether the TNF-α-308 and TNF-α-238 polymorphisms were associated with the susceptibility and severity of lung cancer as the second primary cancer (LC2).

Material/Methods

This study included 104 patients from the group LC2. The control subjects included 2 groups. The first control group (LC1) comprised 201 unrelated patients with lung cancer as a first primary cancer. The second control group (HC) comprised 230 healthy blood donors, matched for sex and age to the study group.

Results

The frequencies of the TNF-α-238 polymorphism GG genotype and the G allele were higher in the LC2 group than in the LC1 group, but the differences did not reach significance (p=0.054 and p=0.057, respectively). Similar differences were found in the TNF-α-238 polymorphism GG genotype and G allele between the LC2 group and the HC group (p=0.054 and p=0.057, respectively). In terms of the different types of lung cancer, patients with a second primary NSCLC (non-small cell lung cancer) more frequently had TNF-α-238 polymorphism GG genotypes and G alleles than patients with a first primary NSCLC (the differences approached statistical significance: p=0.060, p=0.064, respectively). All (100%) patients of group LC2 (n=104) had the GG genotype and the G allele. GG genotype was exclusive and no A allele was found in group LC2.

Conclusions

TNF-α-238 polymorphism GG genotype and the G allele could have a promotional effect on the development of NSCLC in the group of patients with LC2.

Is lobectomy really more effective than sublobar resection in the surgical treatment of second primary lung cancer?

OBJECTIVES

Sublobar resection for early-stage lung cancer is still a controversial issue. We sought to compare sublobar resection (segmentectomy or wedge resection) with lobectomy in the treatment of patients with a second primary lung cancer.

METHODS

From January 1995 to December 2010, 121 patients with second primary lung cancer, classified by the criteria proposed by Martini and Melamed, were treated at our Institution. We had 23 patients with a synchronous tumour and 98 with metachronous. As second treatment, we performed 61 lobectomies (17 of these were completion pneumonectomies), 38 atypical resections and 22 segmentectomies. Histology was adenocarcinoma in 49, squamous in 38, bronchoalveolar carcinomas in 14, adenosquamous in 8, large cells in 2, anaplastic in 5 and other histologies in 5.

RESULTS

Overall 5-year survival from second surgery was 42%; overall operative mortality was 2.5% (3 patients), while morbidity was 19% (22 patients). Morbidity was comparable between the lobectomy group, sublobar resection and completion pneumonectomies (12.8, 27.7 and 30.8%, respectively, P = 0.21). Regarding the type of surgery, the lobectomy group showed a better 5-year survival than sublobar resection (57.5 and 36%, respectively, P = 0.016). Compared with lobectomies, completion pneumonectomies showed a significantly less-favourable survival (57.5 and 20%, respectively, P = 0.001).

CONCLUSIONS

From our experience, lobectomy should still be considered as the treatment of choice in the management of second primary lung cancer, but sublobar resection remains a valid option in high-risk patients with limited pulmonary function. Completion pneumonectomy was a negative prognostic factor in long-term survival.

Metastasis dynamics for non-small-cell lung cancer: effect of patient and tumor-related factors

BACKGROUND

We studied event dynamics (probability of an event occurring over a specific time interval) in patients undergoing surgery for early-stage non-small-cell lung cancer (NSCLC) according to patient and tumor characteristics.

METHODS

By using a database of 1506 patients who underwent initial surgery for NSCLC, event dynamics, based on a time-specific hazard rate, were evaluated. The event of interest was the development of distant metastases, with or without a local recurrence. The effect of sex, tumor size, nodal involvement, histology, lymphovascular space invasion, pleural invasion, age, and race were studied.

RESULTS

The hazard rate for developing distant metastases was not constant over time but was characterized by specific peaks, the first being approximately 9 months after surgery and the second at 18 to 20 months for men and 24 to 26 months for women. For women, the hazard rate peaked considerably in the first year. For men, the hazard rate peaks were smaller but lasted for a longer duration. Pathologic factors associated with a higher risk of recurrence (eg, size, lymph node involvement, pleural invasion) all increased the sex-specific hazard rates.

CONCLUSIONS

The probability of developing distant metastases after surgery for NSCLC peaks at specific and consistent time intervals after surgery, with specific differences between men and women. A factor-specific modulation of peak heights that ranged from no impact (eg, race) to relevant effects for primary tumor size, nodal involvement, and pleural invasion, possibly related to sex, was also observed. The bimodal distant metastases dynamics may be an intrinsic feature of metastatic progression in NSCLC.