Surgery for non-small cell lung cancer in younger patients: what are the differences?

Surgical outcomes for non-small cell lung cancer in younger adults: A population-based study

BACKGROUND

The surgical outcomes for younger patients with non-small cell lung cancer (NSCLC) remain uncertain. The aim of this study was to investigate the clinical features long-term survival outcomes in younger individuals with NSCLC following surgery.

METHODS

We queried the Surveillance, Epidemiology, and End Results database from 2010 to 2017, selecting all pathologically confirmed NSCLC cases that underwent cancer-directed surgery. Younger patients were defined as those aged 18-50 years, while older patients were 51-80 years. Propensity score matching (PSM) was implemented to mitigate selection bias. Overall survival (OS) and lung cancer-specific survival (LCSS) were compared using the Kaplan-Meier method.

RESULTS

Among the 33 586 treated surgically patients, 2223 (6.6%) were young. Compared to the older group, younger patients had a higher frequency of female gender, non-white ethnicity, carcinoid tumors, stage IV disease, pneumonectomy, and postoperative adjuvant therapies. The 5-year OS rates were significantly higher for younger patients (79.3% vs. 62.0%; p < 0.001), as were the 5-year LCSS rates (82.4% vs. 71.8%; p < 0.001). Post-PSM, younger patients consistently demonstrated significantly better OS and LCSS. Further stage-specific analysis revealed significantly improved 5-year OS rates at each stage and superior 5-year LCSS for stages I-II among younger patients. However, there was no statistically significant difference in LCSS for stages III-IV.

CONCLUSIONS

Overall, younger patients with NSCLC treated surgically exhibit superior OS and LCSS compared to their older counterparts, although no statistically significant difference in LCSS for stages III-IV was observed between the two age groups.

Efficacy of thoracoscopic segmentectomy versus lobectomy in the treatment of early invasive lung adenocarcinoma: a propensity score matching study

Objective

This study aimed to investigate and analyze the clinical application value of thoracoscopic segmentectomy and lobectomy in patients with invasive pulmonary adenocarcinoma.

Methods

286 patients with invasive pulmonary adenocarcinoma who underwent segmentectomy or lobectomy at the First Hospital of Jiaxing City from January 2018 to June 2020 were retrospectively analyzed. Patients were divided into a thoracoscopic segmentectomy group(n=97) and a lobectomy group (n=189). Patients were compared after obtaining 1:1 propensity score-matched cohorts. Outcome indicators included surgery-related indicators, immune-inflammation-related indicators, postoperative complications, recurrence, and metastasis.

Results

After 1:1 propensity score matching, 93 patients were included in each group. We found that the volume of intraoperative blood loss in the segmentectomy group was significantly less than in the lobectomy group (P=0.014). The duration of postoperative drainage (P = 0.005) and hospitalization (P=0.002) in the segmentectomy group were significantly shorter than in the lobectomy group. In terms of immunoinflammatory response, compared with the lobectomy group, white blood cells, neutrophils, SII, and NLR in the segmentectomy group were significantly lower than in the lobectomy group (P< 0.05). The recurrence-free survival (RFS) rates in the segmentectomy and lobectomy were 80.5% and 88.2% at 1 year and 35.1% and 52.6% at 3 years, respectively, and the difference was statistically significant (P<0.05). The segmentectomy group achieved similar outcomes to the lobectomy group at 1 year and 3 years (P > 0.05). Multivariate COX regression analysis showed that CAR was an independent risk factor for RFS in patients undergoing invasive adenocarcinoma surgery.

Conclusion

Compared with lobectomy, thoracoscopic segmentectomy can effectively reduce the postoperative inflammatory response in patients with early invasive lung adenocarcinoma and promote patient recovery. Although segmentectomy is associated with a higher recurrence rate in the short term for patients with early invasive lung adenocarcinoma, the associated survival rate is similar to the lobectomy group. Segmentectomy should be considered in the treatment of early invasive lung adenocarcinoma. Meanwhile, postoperative CAR represents an independent risk factor for early postoperative recurrence in patients with IAC.

Sex-specificity in Surgical Stages of Lung Cancer in Young Adults

Background

Young Patients with lung cancer represent a distinct subset of patients with this neoplasm. Young International studies show increased lung cancer rates in females, while the incidence in males continues to decline. There is evidence to suggest that this trend recurs in younger patients. We studied the effects of gender differences on the incidence of surgical stages of lung cancer in young adults and its mortality rate.

Methods

This study is a retrospective review (2010-2020) of young adults (aged under 45 years) with surgical-stage of lung cancer. We calculated female-to-male differences in incidence rate ratios, tumor characteristics, surgical management, and survival. Cumulative survival curves were generated by the Kaplan-Meier method.

Results

We examined 46 men and 24 women, under 45 years. Female patients were diagnosed at earlier stages. The proportion of stage IA disease was significantly higher in women than in men (46% versus 13%, respectively) (p=0.03). Women were more likely never smokers (42% versus 83%, p=0.02). A histologic subtype, females were more likely to have typical carcinoid tumors (13.54% versus 10.21% for males) (p>0.05). The largest histological type in men was adenocarcinoma (25.53% versus 4.16%, p>0.05). All the patients were operated. Three men had neoadjuvant chemotherapy and one was operated on for cerebral oligometastatic before his chest surgery. Adjuvant chemotherapy was given to 7 women and 21 men. Despite the small number of postoperative complications in our study (n= 8, 11.2%), the male sex was significant in predicting this complication (p<0.05). The mortality rate was 1.4%. The 5-year overall survival rates were 84% in men and 87% in women.

Conclusion

Our study identified sex differences in the incidence and mortality rates for surgical lung cancers in young adults, but the biological and endocrine mechanisms implicated in these disparities have not yet been determined.

Older age is not a negative factor for video-assisted thoracoscopic lobectomy for pathological stage I non-small cell lung cancer: a single-center, retrospective, propensity score-matching study

PURPOSE

Video-assisted thoracoscopic surgery (VATS) has changed the surgical approach to non-small cell lung cancer (NSCLC) dramatically. The current study compares the outcomes of older and younger patients who underwent VATS lobectomy for NSCLC.

METHODS

In total, 424 eligible patients with pathological stage I NSCLC underwent VATS lobectomy between 2007 and 2017. Patients were classified into two groups (< 75 and ≥ 75 years old), after which propensity score-matching was performed.

RESULTS

After matching, 143 patients were identified. No significant difference in postoperative complication rates was observed; however, the ≥ 75-year-old group had a longer postoperative hospital stay (p = 0.001). The 5-year overall survival, relapse-free survival, and lung cancer-specific survival rates of the < 75- and ≥ 75-year-old groups were 87.1% vs. 85.6% (p = 0.537), 82.1% vs. 79.0% (p = 0.531), and 93.5% vs. 92.7% (p = 0.832), respectively.

CONCLUSION

Despite the longer postoperative recovery following VATS lobectomy, the short- and long-term outcomes of older patients did not differ from those of younger patients. Thus, for early-stage NSCLC, older age alone was not a negative factor for lobectomy performed via minimally invasive surgery. Naturally, the systemic condition of this population must be evaluated carefully before surgery.

Older patients more likely to die from cancer-related diseases than younger with stage IA non-small cell lung cancer: a SEER database analysis

Background

Various reports showed some conflicting data on survival at different ages. This study aimed to investigate the main cause of death in older patients with lung cancer and to perform a comparison with younger patients in order to observe the differences between these two cohorts.

Methods

Outcomes of patients with stage IA non-small cell lung cancer (NSCLC) ≤3 cm who underwent lobectomy without induction therapy in the Surveillance, Epidemiology, and End Results-18 (SEER-18; January 2004 to December 2016) database were evaluated using multivariable Cox proportional hazards modeling and propensity score-matched analysis.

Results

A total of 16,672 eligible NSCLC cases were found in the SEER database. The number of patients aged ≤60, 61–70, and ≥71 years was 3,930, 6,391, and 6,351, respectively. Among these patient groups, 527 (13.4%), 1,018 (15.9%), and 1,235 (19.4%) died of lung cancer during follow-up, while 357 (9.1%), 964 (15.1%) and 1,579 (25.2%) died of non-lung cancer diseases, respectively. The overall survival (OS) and lung cancer-specific survival (LCSS) rates of younger patients showed a significant survival advantage over older patients. After propensity-score matching (PSM) of patients aged ≤60 and ≥71 years using a ratio of 1:1, we found that 403 (12.9%) and 584 (18.7%) patients in the ≤60 and ≥71 years age groups died of lung cancer, respectively. The OS and LCSS rates of younger patients still exhibited a significant survival advantage over older patients.

Conclusions

Older patients with stage IA NSCLC have a worse prognosis compared with younger patients. Also, cancer-related causes were more frequent in older patients than non-cancer-related causes.

Comprehensive Comparative Molecular Characterization of Young and Old Lung Cancer Patients

BACKGROUND

Young lung cancer as a small subgroup of lung cancer has not been fully studied. Most of the previous studies focused on the clinicopathological features, but studies of molecular characteristics are still few and limited. Here, we explore the characteristics of prognosis and variation in young lung cancer patients with NSCLC.

METHODS

A total of 5639 young lung cancer samples (NSCLC, age ≤40) were screened from the SEER and the same number of the old (NSCLC, age ≥60) were screened by propensity score matching to evaluate the prognosis of two groups. 165 treatment-naïve patients diagnosed with NSCLC were enrolled to explore the molecular feature difference between two age-varying groups. CCLE cell line expression data was used to verify the finding from the cohort of 165 patients.

RESULTS

The overall survival of the young lung cancer group was significantly better than the old. Germline analysis showed a trend that the young group contained a higher incidence of germline alterations. The TMB of the young group was lower. Meanwhile, the heterogeneity and evolutionary degrees of the young lung cancer group were also lower than the old. The mutation spectrums of two groups exhibited variance with LRP1B, SMARCA4, STK11, FAT2, RBM10, FANCM mutations, EGFR L858R more recurrent in the old group and EML4-ALK fusions, BCL2L11 deletion polymorphism, EGFR 19DEL, 20IN more recurrent in the young group. For the base substitution, the young showed a lower fraction of transversion. Further, we performed a pathway analysis and found the EGFR tyrosine kinase inhibitor resistance pathway enriched in the young lung cancer group, which was validated in gene expression data later.

CONCLUSIONS

There were significantly different molecular features of the young lung cancer group. The young lung cancer group had a more simple alteration structure. Alteration spectrums and base substitution types varied between two groups, implying the different pathogenesis. The young lung cancer group had more potential treatment choices. Although young lung patients had better outcomes, there were still adverse factors of them, suggesting that the young group still needs more caution for treatment choice and monitoring after the treatment to further improve the prognosis.

Comparison of operative and postoperative characteristics and outcomes between thoracoscopic segmentectomy and lobectomy for non-small-cell lung cancer: a propensity score matching study from the Italian VATS Group Registry

OBJECTIVES

Only few studies compared the surgical morbidity and mortality of thoracoscopic segmentectomy versus lobectomy for non-small-cell lung cancer, in particular, by relating the segmental resections with the corresponding anatomical lobes.

METHODS

We enrolled a total of 7487 patients who underwent VATS lobectomy (7269) or segmentectomy (218) from January 2014 to July 2019. A propensity score matching approach was used to account for potential confounding factors between the 2 groups. After matching, 349 lobectomies and 208 segmentectomies were included in the analysis. We analysed the operative and postoperative outcomes of video-assisted anatomical segmentectomy compared with video-assisted lobectomy and, in details, the results of segmentectomy with its corresponding lobectomy in a large cohort of patients from the Italian VATS Group Registry.

RESULTS

The overall conversion rate to thoracotomy was not statistically different between the groups (27 patients 8% vs 7 patients 3%, P = 0.1). The lobectomy group had a greater number of resected lymph nodes (median 11 vs 8, P = 0.006). No significant differences were detected in 30-day mortality (1.4%, 5 patients vs 0.9%, 2 patients), overall complications (18%, 62 patients vs 14%, 29 patients) and prolonged air leakage (31 patients, 9% vs 12 patients, 6%) between lobectomy and segmentectomy, respectively. No statistical differences were found regarding the median duration of drainage (3.2 days, P = 1) and the overall median length of hospital stay (6.4 days, P = 0.1) between the 2 groups. In the context of segmentectomy versus corresponding lobectomy, the right upper lobectomy compared with right upper segmentectomy showed a higher number of resected lymph nodes (P = 0.027). No statistical differences were reported in terms of conversion rate and postoperative complication and mortality.

CONCLUSIONS

Segmentectomy could be considered a safe procedure without significant differences compared to thoracoscopic lobectomy in terms of postoperative morbidity and mortality.

Non-Small Cell Lung Cancer in Young Patients: An Analysis of Clinical, Pathologic and TNM Stage Characteristics Compared to the Elderly

Purpose

To compare clinicopathologic factors including tumor-node-metastasis (TNM) stage between young and elderly patients with non-small cell lung cancer (NSCLC).

Methods

This retrospective study compared the following characteristics between 52 young patients with NSCLC (<50 years of age) and 67 elderly patients with NSCLC (>60 years): duration of symptoms before medical consultation, smoking index, family history of cancer, Ki-67 index, and pTNM stage. A binary logistic regression analysis was used to identify factors predictive of greater stage NSCLC (stage III/IV compared to stage I/II) within each age group.

Results

The incidence of adenocarcinoma was higher in the young than in the elderly (P=0.006). Smoking index (P=0.002) and Ki-67 index (P<0.001) were lower in the young than in the elderly. In young patients with NSCLC, delayed treatment (greater duration from symptoms to medical consultation, P=0.050) and active tumor proliferation (higher Ki-67 index, P=0.003) were predictive of more advanced cancer stage (III/IV), with only symptom duration being predictive of stage III/IV NSCLC among elderly patients. Among young patients, cough (P=0.021) and chest congestion (P=0.040) were the most significant warning symptoms of advanced-stage NSCLC.

Conclusion

High tumor proliferation and delayed treatment are predictive of advanced NSCLC on presentation among young individuals. Early diagnosis by imaging, such as with the use of low dose computed tomography (LDCT), for young individuals with coughing and chest congestion over 1 month might be effectiveto improve prognosis and outcomes.

Younger patients operated for lung cancer have a better prognosis

Background

The incidence of lung cancer in the population of patients younger than 50 years of age is relatively low. The aim of this study was to compare the clinical outcomes of patients with early lung cancer onset (ELCO, onset before the age of 50) and late lung cancer onset (LLCO, onset after the age of 50).

Methods

We have retrospectively analyzed the prospectively collected data of 1,518 patients with lung cancer treated in a Thoracic Surgery Department in the years 2007–2015. Including carcinoid tumors for the analysis may blur ELCO and LLCO population comparison; therefore we have made three analyses. We have compared overall survival (OS) in unmatched (86 patients with ELCO and 1,432 patients with LLCO) and matched the populations (with the use of propensity-score matched analysis).

Results

In comparison of unmatched patients, five-year survival in patients with ELCO was 71.9% compared to 58.7% in LLCO patients (P=0.008). In comparison of matched populations (comparing sex, pTNM, type of operation, pathological diagnosis and Charlson Comorbidity Index) five-year survival in patients with ELCO was 77.6% comparing to 61.5% in LLCO patients P<0.001). After exclusion of rare histological types of lung cancer and advanced stages no significant difference in survival rates was discovered comparing ELCO patients with LLCO patients, although there was still a trend towards better survival in ELCO patients (P=0.086).

Conclusions

Patients with ELCO have higher five-year survival after surgical treatment compared to patients with LLCO.

Development and validation of nomograms for predicting overall and cancer-specific survival in young patients with non-small cell lung cancer

Background

Young patients with non-small cell lung cancer (NSCLC) represent a distinct subgroup of patients with this disease. This study aimed to construct nomograms to predict the overall survival (OS) and cancer-specific survival (CSS) of young patients with NSCLC.

Methods

NSCLC patients under 50 years old diagnosed between 2010 and 2016 were selected from the Surveillance, Epidemiology, and End Results (SEER) database and randomly divided into training (n=1,357) and validation (n=678) cohorts at a ratio of 2:1. Independent prognostic factors for OS or CSS were identified through the log-rank test, Cox proportional hazards models or competing risk model and further integrated to construct nomograms. The predictive capability of the nomogram was assessed by Harrell's concordance index (C-index), the calibration curve and risk group stratification.

Results

A total of 2,035 patients were enrolled. In the training cohort, insurance, marital status, histological type, grade, T stage, N stage and surgery were identified as independent prognostic for OS and CSS. The C-index value were 0.759 [95% confidence interval (CI): 0.731-0.787] for OS and 0.810 (95% CI: 0.803-0.818) for BCSS in the training cohort and 0.751 (95% CI: 0.711-0.790) for OS and 0.807 (95% CI: 0.795-0.819) for CSS in the validation cohort. The calibration curves showed optimal agreement between the predicted and actual survival both in internal and external validation. In addition, patients in the validation cohort within different risk groups exhibited significantly different survival even in each TNM stage.

Conclusions

Nomograms were developed and validated to predict OS and CSS of young patients with NSCLC in our study. A prospective study with more potential prognostic factors and the latest TNM classification is required to ameliorate this model.

Lung cancer survivors and employment: A systematic review

BACKGROUND

The aim of this systematic review is to identify, in a comprehensive manner, the impact of lung cancer on the employment status of survivors.

METHODS

The Preferred Reported Items for Systematic Reviews and Meta-analyses (PRISMA) statement was used as a formal guideline. The systematic review includes scientific papers published between January 2000 and October 2018. The search strategy queried the database MEDLINE. Inclusion criteria comprised: (1) inclusion of patients diagnosed with lung cancer (LC) (2); assessment of employment status or employment outcomes or work adjustments or return to work (3); inclusion of scientific papers published in peer-reviewed journals (4); inclusion of articles written either in English or in French. Literature reviews were not included.

RESULTS

A total of 642 scientific papers were retrieved. Twenty-three articles were included in the systematic review: 5 longitudinal studies and 18 cross-sectional studies. LC survivors are 2-3 times more likely to be unemployed as compared with control groups. Previous studies highlight a median duration of sickness absence increased for LC survivors compared to control groups. The strongest decline in earnings was observed among LC survivors as compared to other cancer types.

CONCLUSIONS

LC is associated with a significant impact on employment of patients. The promising results of recent therapeutic strategies could lead to a better social and professional prognosis. A reduction of indirect costs is to be expected.

Young age increases risk for lymph node positivity but decreases risk for non-small cell lung cancer death

Non-small cell lung cancer (NSCLC) prognosis and risk of lymph node positivity (LN+) are reference points for reasonable treatments. The aim of the current study was to investigate the effect of age on LN+ and NSCLC death. Data from the Surveillance, Epidemiology, and End Results (SEER) registry were used to identify 82,253 patients with NSCLC diagnosed between 1988 and 2008. All the patients underwent standard lung cancer surgery with lymph node examination. Demographic and clinicopathological parameters were extracted and compared among each age group. Impact of age on LN+ and NSCLC death was evaluated by the Cochran-Armitage trend test and logistic univariate and multivariate analyses for all T stages. Overall, 22,711 (27.60%) patients of the entirety had lymph node metastasis and 28,968 (35.22%) patients died of NSCLC within 5 years. With the increase in age, LN+ rates decreased regardless of T stages (P<0.001), whereas NSCLC-specific mortality increased in stages T1-T3 (P<0.001). Controlling other covariates in multivariable logistic regression, age remained an independent risk factor for LN+ in all T stages (P<0.05) and in stages T1-T3 (P<0.05). Our SEER analysis demonstrated a higher rate of LN+ and lower mortality in younger patients with NSCLC, after accounting for other covariates.

Risk factors for bone metastasis in completely resected non-small-cell lung cancer

Aim: We assessed risk factors for bone metastasis in patients with completely resected non-small-cell lung cancer (NSCLC). Materials & methods: A total of 374 NSCLC patients who had undergone a complete resection from January 2008 to May 2012 were included in this retrospective study. The Kaplan–Meier method and multivariate Cox regression analysis were used to evaluate risk factors for bone metastasis. Results: A total of 47 (47/374; 12.6%) patients developed bone metastasis up until the last follow-up time. The patients with bone metastasis included 33 adenocarcinoma patients and 6 (4.9%) squamous cell carcinoma patients (p = 0.001). There were 17 (10.2%) patients with pathological stage (P-stage) I disease, 9 (9.5%) patients with P-stage II disease and 21 (18.8%) patients with P-stage III disease (p = 0.007) among all the bone metastasis patients. For patients without or with bone metastasis, the overall survival ratio at 3 years was 71.6% compared with 46.8% (p < 0.0001), respectively. Conclusion: Adenocarcinoma and P-stage III disease were related to a high risk of bone metastasis.

Non-small cell lung cancer in young adults: presentation and survival in the English National Lung Cancer Audit

BACKGROUND

Non-small cell lung cancer (NSCLC) in young adults is a rare but devastating illness with significant socioeconomic implications, and studies of this patient subgroup are limited.

AIM

This study employed the National Lung Cancer Audit to compare the clinical features and survival of young adults with NSCLC with the older age groups.

DESIGN

A retrospective cohort review using a validated national audit dataset.

METHODS

Data were analysed for the period between 1 January 2004 and 31 December 2011. Young adults were defined as between 18 and 39 years, and all others were divided into decade age groups, up to the 80 years and above group. We performed logistic and Cox regression analyses to assess clinical outcomes.

RESULTS

Of a total of 1 46 422 patients, 651 (0.5%) were young adults, of whom a higher proportion had adenocarcinoma (48%) than in any other age group. Stage distribution of NSCLC was similar across the age groups and 71% of young patients had stage IIIb/IV. Performance status (PS) was 0-1 for 85%. Young adults were more likely to have surgery and chemotherapy compared with the older age groups and had better overall and post-operative survival. The proportion with adenocarcinoma, better PS and that receiving surgery or chemotherapy diminished progressively with advancing decade age groups.

CONCLUSION

In our cohort of young adults with NSCLC, the majority had good PS despite the same late-stage disease as older patients. They were more likely to have treatment and survive longer than older patients.