Predicting Incomplete Resection in Non-Small Cell Lung Cancer Preoperatively: A Validated Nomogram

Survival Analysis of Early-Stage NSCLC Patients Following Lobectomy: Impact of Surgical Techniques and Other Variables on Long-Term Outcomes

BACKGROUND

Surgical resection is a frontline management option for early-stage non-small cell lung cancer (NSCLC). Evolving techniques may be refining patient outcomes. This study compares the long-term survival of patients undergoing lobectomy for a primary NSCLC between video-assisted thoracoscopic surgery (VATS) and open thoracotomy (OT). The secondary aim of this study is to identify the variables that influence immediate and long-term patient outcomes.

METHOD

This is a single-centre retrospective cohort analysis spanning 20 years. The study reports on the outcomes of 743 patients who underwent lobectomy for primary NSCLC. There are 598 VATS cases and 145 OT cases. Variables likely to influence long-term survival were assessed with Kaplan-Meier survival analysis. The effect of VATS on long-term survival was assessed using a propensity-adjusted analysis.

RESULTS

Chronic obstructive pulmonary disease, history of other cancers, coronary artery disease, type 2 diabetes, and emphysema were the most common comorbidities reported in this cohort. The VATS technique showed shorter postoperative length of stay and fewer surgical complications compared with OT. There were no differences between VATS and OT in early mortality or completeness of the resection. Additionally, 32% of patients showed variable visceral pleural invasion (P1-P2), and their 5-year survival was significantly worse compared with P0 patients (18.75% and 36.85%, respectively). Major pulmonary complications were responsible for prolonging the length of hospital stay after index surgery and it was inversely related to the survival at 5 and 10 years (p<0.0004). Lymph node involvement was an important predictor for long-term survival (50% overall survival rate was 9.4 years, 4.5 years and 4.2 years for N0, N1, and N2, respectively). We observed longer median survival in the VATS group (10.04 years vs 8.99 years) and a lower risk of mortality after propensity analysis (odds ratio 0.86; 95% confidence interval 0.67-1.11), but neither observation was statistically significant.

CONCLUSIONS

Early surgical outcomes were significantly better in the VATS group, whereas long-term outcomes were not notably different between the groups. Regardless of the surgical techniques used, positive surgical margins, visceral pleural invasion, larger tumours, positive lymph nodes, age >70 years, and prolonged hospital stay were common variables responsible for the poor overall long-term survival.

Importance of driver gene mutation assessment and targeted therapy for patients with early‑stage non‑small cell lung cancer and non‑R0 resection

Patients with non-small cell lung cancer (NSCLC) and incomplete resection have poor clinical outcomes. The present study aimed to identify risk factors for disease progression and mortality. A total of 65 patients with early-stage NSCLC that underwent operation but had a non-R0 resection between August 2011 and December 2020 were included in the present study, and the clinicopathological features and driver gene mutation status were analyzed. The median follow-up time was 36.2 months; 39 patients (60.0%) experienced disease progression and 3 patients (4.6%) died. In total, 22 patients (33.8%) harbored mutations in driver genes. Multivariate analysis demonstrated that the presence of driver gene mutations was associated with an increased risk of disease progression [adjusted odds ratio, 24.08; 95% confidence interval (CI), 2.77-209.01; P=0.004]. Tumors classed as Eastern Cooperative Oncology Group performance status 2 [adjusted hazard ratio (HR), 3.49; 95% CI, 1.10-11.03; P=0.033], stage II-IIIB tumors (adjusted HR, 2.55; 95% CI, 1.06-6.17; P=0.037) and the presence of a driver gene mutation (adjusted HR, 3.28; 95% CI, 1.55-6.94; P=0.002) were associated with a significantly reduced progression-free survival (PFS). Driver gene-targeted therapy was associated with an increased post-progression survival for patients that were reported to have disease progression (adjusted HR, 0.38; 95% CI, 0.16-0.91; P=0.030). There was no significant impact of driver gene mutation status on the overall survival (OS) of patients. Although the presence of a driver gene mutation was associated with an increased risk of disease progression and a reduced PFS, it was demonstrated that patients with disease progression may benefit from driver gene-targeted therapy, as patients with driver gene-targeted therapy had a similar OS compared with that of patients with a driver gene-negative or unknown status. Therefore, early comprehensive analysis of driver gene mutation status may be recommended for early-stage NSCLC cancer patients experiencing non-R0 resection.

Ligand free FeSn2 alloy nanoparticles for safe T2-weighted MR imaging of in vivo lung tumors

Biosafety is a critical issue for the successful translocation of nanomaterial-based therapeutic/diagnostic agents from bench to bedside. For instance, after the withdrawal of clinically approved magnetic resonance (MR) imaging contrast agents (CAs) due to their biosafety issues, there is a massive demand for alternative, efficient, and biocompatible MR contrast agents for future MRI clinical applications. To this end, here we successfully demonstrate the in vivo MR contrast abilities and biocompatibilities of ligand-free FeSn₂ alloy NPs for tracking in vivo lung tumors. In vitro and in vivo results reveal the FeSn₂ alloy NPs acting as appreciable T₂ weighted MR contrast agents to locate tumors. The construction of iron (Fe) on biocompatible tin (Sn) greatly facilitates the reduction of the intrinsic toxicities of Fe in vivo resulting in no significant abnormalities in liver and kidney functions. Therefore, we envision that constructing ligand-free alloy NPs will be a promising candidate for tracking in vivo tumors in future clinical applications.

Non-Small-Cell Lung Cancer Patients with a High Predicted Risk of Irradical Resection: Can Chemoradiotherapy Offer Similar Survival?

Purpose

Irradical resection of non-small-cell lung cancer (NSCLC) is a detrimental prognostic factor. Recently, Rasing et al. presented an internationally validated risk score for pre-treatment prediction of irradical resection. We hypothesized that chemoradiation therapy (CRT) could serve as an alternative approach in patients with a high risk score and compared overall survival (OS) outcomes between surgery and CRT.

Methods

Patients from a population-based cohort with stage IIB–III NSCLC between 2015 and 2018 in The Netherlands were selected. Patients with a ‘Rasing score’ > 4 who underwent surgery were matched with patients who underwent CRT using 1:1 nearest-neighbor propensity score matching. The primary endpoint of OS was compared using a Kaplan–Meier analysis.

Results

In total, 2582 CRT and 638 surgery patients were eligible. After matching, 523 well-balanced pairs remained. Median OS in the CRT group was 27.5 months, compared with 45.6 months in the surgery group (HR 1.44, 95% CI 1.23–1.70, p < 0.001). The 114 surgical patients who underwent an R1–2 resection (21.8%) had a worse median OS than the CRT group (20.2 versus 27.5 months, HR 0.77, 95% CI 0.61–0.99, p = 0.039).

Conclusion

In NSCLC patients at high predicted risk of irradical resection, CRT appears to yield inferior survival compared with surgery. Therefore, choosing CRT instead of surgery cannot solely be based on the Rasing score. Since patients receiving an R1–2 resection do have detrimental outcomes compared with primary CRT, the treatment decision should be based on additional information, such as imaging features, comorbidities, patient preference, and the surgeon’s confidence in achieving an R0 resection.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-10982-3.

Adjuvant Treatment Following Irradical Resection of Stage I-III Non-small Cell Lung Cancer: A Population-based Study

Irradical (R1-2) resection for non-small cell lung cancer (NSCLC) is associated with a dismal prognosis. Adjuvant treatment attempts to improve survival outcomes, but evidence on the optimal strategy is limited. The purpose of this study was to compare overall survival (OS) between different adjuvant treatment strategies in these patients. Out of 8,528 patients with newly diagnosed NSCLC from 2015-2018, those with an R1-2 resection were identified from the Netherlands Cancer Registry. First, OS was compared between adjuvant treatment groups 'no therapy', 'radiotherapy (RT) only', 'chemotherapy only', and 'chemo- and radiotherapy (CRT)' using multinomial propensity score-weighted Cox regression analysis. Second, three 1:1 propensity score-matched sets were created for chemotherapy vs no chemotherapy, RT only vs no therapy, and CRT vs chemotherapy only. Kaplan-Meier and Cox regression analyses for OS were performed in each set. With a median follow-up of 23 months, 427 patients were selected. In the weighted regression analysis, compared to no adjuvant therapy, chemotherapy and CRT were associated with improved OS (HR 0.41, 95%CI: 0.22-0.76; and HR 0.55, 95%CI: 0.37-0.81, respectively), whereas RT was not (HR 1.04, 95%CI: 0.73-1.50). In the matched sets, OS was improved after chemotherapy (+/- RT) compared to no chemotherapy (HR 0.47, 95%CI: 0.32-0.69). No OS difference was observed between matched groups of RT only vs no adjuvant therapy (HR 1.13, 95%CI: 0.74-1.72), nor for CRT vs chemotherapy only (HR 1.37, 95%CI: 0.70-2.71). Adjuvant chemotherapy, but not radiotherapy, improves survival after an R1-2 resection in stage I-III NSCLC.