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Bensenane R, Helfre S, Cao K, Carton M, Champion L, Girard N, Glorion M, Vieira T, Waissi W, Crehange G, Beddok A. Optimizing lung cancer radiation therapy: A systematic review of multifactorial risk assessment for radiation-induced lung toxicity. Cancer Treat Rev 2024; 124:102684. [PMID: 38278078 DOI: 10.1016/j.ctrv.2024.102684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 12/27/2023] [Accepted: 01/11/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND Radiation therapy (RT) is essential in treating advanced lung cancer, but may lead to radiation pneumonitis (RP). This systematic review investigates the use of pulmonary function tests (PFT) and other parameters to predict and mitigate RP, thereby improving RT planning. METHODS A systematic review sifted through PubMed and on BioMed Central, targeting articles from September 2005 to December 2022 containing the keywords: Lung Cancer, Radiotherapy, and pulmonary function test. RESULTS From 1153 articles, 80 were included. RP was assessed using CTCAEv.4 in 30 % of these. Six studies evaluated post-RT quality of life in lung cancer patients, reporting no decline. Patients with RP and chronic obstructive pulmonary disease (COPD) generally exhibited poorer overall survival. Notably, forced expiratory volume in one second (FEV1) and diffusing capacity of the lung for carbon monoxide (DLCO) declined 24 months post-RT, while forced vital capacity (FVC) stayed stable. In the majority of studies, age over 60, tumors located in the lower part of the lung, and low FEV1 before RT were associated with a higher risk of RP. Dosimetric factors (V5, V20, MLD) and metabolic imaging emerged as significant predictors of RP risk. A clinical checklist blending patient and tumor characteristics, PFT results, and dosimetric criteria was proposed for assessing RP risk before RT. CONCLUSION The review reveals the multifactorial nature of RP development following RT in lung cancer. This approach should guide individualized management and calls for a prospective study to validate these findings and enhance RP prevention strategies.
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Affiliation(s)
- Rayan Bensenane
- Institut Curie, PSL Research University, Radiation Oncology Department, Paris/Saint-Cloud/Orsay, France
| | - Sylvie Helfre
- Institut Curie, PSL Research University, Radiation Oncology Department, Paris/Saint-Cloud/Orsay, France
| | - Kim Cao
- Institut Curie, PSL Research University, Radiation Oncology Department, Paris/Saint-Cloud/Orsay, France
| | | | | | - Nicolas Girard
- Institut Curie, Department of Thoracic Oncology, Paris, France
| | | | - Thibaut Vieira
- Institut Mutualist Montsouris, Department of Pneumology, Paris, France
| | - Waisse Waissi
- Centre Léon Bérard, Department of Radiation Oncology, Lyon, France
| | - Gilles Crehange
- Institut Curie, PSL Research University, Radiation Oncology Department, Paris/Saint-Cloud/Orsay, France
| | - Arnaud Beddok
- Institut Curie, PSL Research University, Radiation Oncology Department, Paris/Saint-Cloud/Orsay, France; Institut Curie, PSL Research University, University Paris Saclay, Inserm LITO, 91898 Orsay, France.
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Isaka T, Nagashima T, Adachi H, Narimatsu H, Murakami K, Shigefuku S, Kikunishi N, Shigeta N, Watabe K, Kudo Y, Miyata Y, Okada M, Ikeda N, Ito H. Wedge resection vs. segmentectomy for lung cancer measuring ≤ 2 cm with consolidation tumor ratio > 0.25. Front Oncol 2023; 13:1253414. [PMID: 37700837 PMCID: PMC10493869 DOI: 10.3389/fonc.2023.1253414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/15/2023] [Indexed: 09/14/2023] Open
Abstract
Objectives We aimed to clarify the differences in prognosis between wedge resection and segmentectomy performed for cN0 non-small cell lung cancer (NSCLC) measuring ≤ 2 cm, with consolidation tumor ratio (CTR) > 0.25. Methods This multicenter study included 570 patients with cN0 NSCLC (tumor size ≤ 2 cm, CTR > 0.25) who underwent wedge resection (n = 244) and segmentectomy (n = 326) between January 2010 and December 2018. After propensity score matching (PSM, 1:1 method), 182 patients were matched for clinical characteristics (age, sex, laterality, smoking index, tumor size, CTR, carcinoembryonic antigen value, positron-emission tomography-documented maximum standardized uptake value, clinical stage, and tumor disappearance rate) and intergroup comparison of disease-free survival (DFS) and overall survival (OS). Using Gray's test, an intergroup comparison of the cumulative incidence of lung cancer-specific mortality was performed. Results After PSM, similar DFS (5-year DFS, 79.9% vs. 87.1%, p = 0.103) and OS (5-year OS, 88.7% vs. 88.9%, p = 0.719) rates were observed in the wedge resection and segmentectomy groups. We observed no significant intergroup differences in lung cancer-specific mortality (5-year cumulative incidence: 4.6% vs. 3.5%; p = 0.235). Subgroup analysis revealed no specific subgroup demonstrating improved DFS or OS after undergoing wedge resection or segmentectomy. Conclusion DFS, OS, and lung cancer-specific mortality were comparable between wedge resection and segmentectomy of cN0 NSCLC-tumor size ≤ 2 cm and CTR > 0.25. Large-scale prospective clinical trials are warranted to compare the prognoses of wedge resection and segmentectomy for these tumors.
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Affiliation(s)
- Tetsuya Isaka
- Department of Thoracic Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Takuya Nagashima
- Department of Thoracic Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Hiroyuki Adachi
- Department of Thoracic Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Hiroto Narimatsu
- Department of Genetic Medicine, Kanagawa Cancer Center, Yokohama, Japan
- Cancer Prevention and Cancer Control Division, Kanagawa Cancer Center Research Institute, Yokohama, Japan
| | - Kotaro Murakami
- Department of Thoracic Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | | | | | - Naoko Shigeta
- Department of Thoracic Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Kozue Watabe
- Department of Thoracic Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Yujin Kudo
- Department of Surgery, Tokyo Medical University, Tokyo, Japan
| | - Yoshihiro Miyata
- Department of Surgical Oncology, Hiroshima University, Hiroshima, Japan
| | - Morihito Okada
- Department of Surgical Oncology, Hiroshima University, Hiroshima, Japan
| | - Norihiko Ikeda
- Department of Surgery, Tokyo Medical University, Tokyo, Japan
| | - Hiroyuki Ito
- Department of Thoracic Surgery, Kanagawa Cancer Center, Yokohama, Japan
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Isaka T, Ito H, Yokose T, Saito H, Adachi H, Miura J, Murakami K, Rino Y. Impact of segmentectomy and lobectomy on non-lung cancer death in early-stage lung cancer patients. EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2022; 63:6705233. [PMID: 36124963 DOI: 10.1093/ejcts/ezac458] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/23/2022] [Accepted: 09/16/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVES This study aimed to analyse the risk of death from non-lung cancer after segmentectomy or lobectomy for early-stage lung cancer. METHODS A total of 1385 patients underwent lobectomy or segmentectomy for clinical stage 0-I primary lung cancer, with no evidence of recurrence after surgery, between January 2008 and December 2018. Risk factors for non-lung cancer deaths (NLCD) were analysed using multivariable logistic regression analysis. The overall survival (OS) of patients with low and high comorbidities who underwent lobectomy and segmentectomy was compared using a log-rank test. RESULTS Patients with NLCD (n = 126) were more likely to have undergone lobectomy than patients with non-recurrence survival (n = 1259). Multivariable analysis revealed that age (≥65 years), smoking index (≥600), body mass index (≤18.5 kg/m2), interstitial pneumonia, values for percentage of predicted vital capacity (≤9.4%) and lobectomy were risk factors for NLCD. Patients who underwent segmentectomy had significantly better 5-year OS than those who underwent lobectomy, after propensity score matching (94.6% vs 90.4%, P = 0.027). Patients with high comorbidities (patients with ≥2 of the following risks: age ≥65 years, smoking index ≥600, body mass index ≤18.5 kg/m2, Charlson Comorbidity Index ≥1, values for percentage of predicted vital capacity ≤96.4%) who underwent segmentectomy had a better 5-year OS than those who underwent lobectomy (92.8% vs 87.8%, P = 0.016). However, there was no difference in 5-year OS between segmentectomy and lobectomy in patients with low comorbidities (98.5% vs 97.4%, P = 0.867). CONCLUSIONS The impact of lobectomy and segmentectomy on NLCD depends on the extent of the patients' comorbidities.
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Affiliation(s)
- Tetsuya Isaka
- Department of Thoracic Surgery, Kanagawa Cancer Center, Yokohama, Japan.,Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Hiroyuki Ito
- Department of Thoracic Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Tomoyuki Yokose
- Department of Pathology, Kanagawa Cancer Center, Yokohama, Japan
| | - Haruhiro Saito
- Department of Thoracic Oncology, Kanagawa Cancer Center, Yokohama, Japan
| | - Hiroyuki Adachi
- Department of Thoracic Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Jun Miura
- Department of Thoracic Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Kotaro Murakami
- Department of Thoracic Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Yasushi Rino
- Department of Surgery, Yokohama City University, Yokohama, Japan
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Bade BC, Blasberg JD, Mase VJ, Kumbasar U, Li AX, Park HS, Decker RH, Madoff DC, Brandt WS, Woodard GA, Detterbeck FC. A guide for managing patients with stage I NSCLC: deciding between lobectomy, segmentectomy, wedge, SBRT and ablation-part 3: systematic review of evidence regarding surgery in compromised patients or specific tumors. J Thorac Dis 2022; 14:2387-2411. [PMID: 35813753 PMCID: PMC9264070 DOI: 10.21037/jtd-21-1825] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 05/09/2022] [Indexed: 11/06/2022]
Abstract
Background Clinical decision-making for patients with stage I lung cancer is complex. It involves multiple options [lobectomy, segmentectomy, wedge, stereotactic body radiotherapy (SBRT), thermal ablation], weighing multiple outcomes (e.g., short-, intermediate-, long-term) and multiple aspects of each (e.g., magnitude of a difference, the degree of confidence in the evidence, and the applicability to the patient and setting at hand). A structure is needed to summarize the relevant evidence for an individual patient and to identify which outcomes have the greatest impact on the decision-making. Methods A PubMed systematic review from 2000-2021 of outcomes after lobectomy, segmentectomy and wedge resection in older patients, patients with limited pulmonary reserve and favorable tumors is the focus of this paper. Evidence was abstracted from randomized trials and non-randomized comparisons (NRCs) with adjustment for confounders. The analysis involved careful assessment, including characteristics of patients, settings, residual confounding etc. to expose degrees of uncertainty and applicability to individual patients. Evidence is summarized that provides an at-a-glance overall impression as well as the ability to delve into layers of details of the patients, settings and treatments involved. Results In older patients, perioperative mortality is minimally altered by resection extent and only slightly affected by increasing age; sublobar resection may slightly decrease morbidity. Long-term outcomes are worse after lesser resection; the difference is slightly attenuated with increasing age. Reported short-term outcomes are quite acceptable in (selected) patients with severely limited pulmonary reserve, not clearly altered by resection extent but substantially improved by a minimally invasive approach. Quality-of-life (QOL) and impact on pulmonary function hasn't been well studied, but there appears to be little difference by resection extent in older or compromised patients. Patient selection is paramount but not well defined. Ground-glass and screen-detected tumors exhibit favorable long-term outcomes regardless of resection extent; however solid tumors <1 cm are not a reliably favorable group. Conclusions A systematic, comprehensive summary of evidence regarding resection extent in compromised patients and favorable tumors with attention to aspects of applicability, uncertainty and effect modifiers provides a foundation for a framework for individualized decision-making.
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Affiliation(s)
- Brett C. Bade
- Department of Pulmonary Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Justin D. Blasberg
- Department of Thoracic Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Vincent J. Mase
- Department of Thoracic Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Ulas Kumbasar
- Department of Thoracic Surgery, Hacettepe University School of Medicine, Ankara, Turkey
| | - Andrew X. Li
- Department of General Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Henry S. Park
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Roy H. Decker
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - David C. Madoff
- Department of Radiology & Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Whitney S. Brandt
- Department of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Gavitt A. Woodard
- Department of Thoracic Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Frank C. Detterbeck
- Department of Thoracic Surgery, Yale University School of Medicine, New Haven, CT, USA
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Syed YA, Stokes W, Rupji M, Liu Y, Khullar O, Sebastian N, Higgins K, Bradley JD, Curran WJ, Ramalingam S, Taylor J, Sancheti M, Fernandez F, Moghanaki D. Surgical Outcomes for Early Stage Non-small Cell Lung Cancer at Facilities With Stereotactic Body Radiation Therapy Programs. Chest 2022; 161:833-844. [PMID: 34785235 PMCID: PMC8941602 DOI: 10.1016/j.chest.2021.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/26/2021] [Accepted: 11/07/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Patients undergoing surgery for early stage non-small cell lung cancer (NSCLC) may be at high risk for postoperative mortality. Access to stereotactic body radiation therapy (SBRT) may facilitate more appropriate patient selection for surgery. RESEARCH QUESTION Is postoperative mortality associated with early stage NSCLC lower at facilities with higher use of SBRT? STUDY DESIGN AND METHODS Patients with early stage NSCLC reported to the National Cancer Database between 2004 and 2015 were included. Use of SBRT was defined by each facility's SBRT experience (in years) and SBRT to surgery volume ratios. Multivariate logistic regression was used to test for the associations between SBRT use and postoperative mortality. RESULTS The study cohort consisted of 202,542 patients who underwent surgical resection of cT1-T2N0M0 NSCLC tumors. The 90-day postoperative mortality rate declined during the study period from 4.6% to 2.6% (P < .001), the proportion of facilities that used SBRT increased from 4.6% to 77.5% (P < .001), and the proportion of patients treated with SBRT increased from 0.7% to 15.4% (P < .001). On multivariate analysis, lower 90-day postoperative mortality rates were observed at facilities with > 6 years of SBRT experience (OR, 0.84; 95% CI, 0.76-0.94; P = .003) and SBRT to surgery volume ratios of more than 17% (OR, 0.85; 95% CI, 0.79-0.92; P < .001). Ninety-day mortality also was associated with surgical volume, region, year, age, sex, and race, among other covariates. Interaction testing between these covariates showed negative results. INTERPRETATION Patients who underwent resection for early stage NSCLC at facilities with higher SBRT use showed lower rates of postoperative mortality. These findings suggest that the availability and use of SBRT may improve the selection of patients for surgery who are predicted to be at high risk of postoperative mortality.
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Affiliation(s)
- Yusef A. Syed
- Department of Radiation Oncology, Emory University Winship Cancer Institute, Atlanta, GA
| | - William Stokes
- Department of Radiation Oncology, Emory University Winship Cancer Institute, Atlanta, GA
| | - Manali Rupji
- Biostatistics Shared Resource, Emory University Winship Cancer Institute, Atlanta, GA
| | - Yuan Liu
- Biostatistics Shared Resource, Emory University Winship Cancer Institute, Atlanta, GA
| | - Onkar Khullar
- Department of Surgery, Emory University, Atlanta, GA
| | - Nikhil Sebastian
- Department of Radiation Oncology, Emory University Winship Cancer Institute, Atlanta, GA
| | - Kristin Higgins
- Department of Radiation Oncology, Emory University Winship Cancer Institute, Atlanta, GA
| | - Jeffrey D. Bradley
- Department of Radiation Oncology, Emory University Winship Cancer Institute, Atlanta, GA
| | - Walter J. Curran
- Department of Radiation Oncology, Emory University Winship Cancer Institute, Atlanta, GA
| | - Suresh Ramalingam
- Department of Hematology and Medical Oncology, Emory University, Atlanta, GA
| | - James Taylor
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA
| | - Manu Sancheti
- Department of Surgery, Emory University, Atlanta, GA
| | | | - Drew Moghanaki
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA.
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Connolly JG, Fiasconaro M, Tan KS, Cirelli MA, Jones GD, Caso R, Mansour DE, Dycoco J, No JS, Molena D, Isbell JM, Park BJ, Bott MJ, Jones DR, Rocco G. Postinduction therapy pulmonary function retesting is necessary before surgical resection for non–small cell lung cancer. J Thorac Cardiovasc Surg 2021; 164:389-397.e7. [PMID: 35086669 PMCID: PMC9218003 DOI: 10.1016/j.jtcvs.2021.12.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/09/2021] [Accepted: 12/15/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Pretreatment-predicted postoperative diffusing capacity of the lung for carbon monoxide (DLCO) has been associated with operative mortality in patients who receive induction therapy for resectable non-small cell lung cancer (NSCLC). It is unknown whether a reduction in pulmonary function after induction therapy and before surgery affects the risk of morbidity or mortality. We sought to determine the relationship between induction therapy and perioperative outcomes as a function of postinduction pulmonary status in patients who underwent surgical resection for NSCLC. METHODS We retrospectively reviewed data for 1001 patients with pathologic stage I, II, or III NSCLC who received induction therapy before lung resection. Pulmonary function was defined according to American College of Surgeons Oncology Group major criteria: DLCO ≥50% = normal; DLCO <50% = impaired. Patients were categorized into 5 subgroups according to combined pre- and postinduction DLCO status: normal-normal, normal-impaired, impaired-normal, impaired-impaired, and preinduction only (without postinduction pulmonary function test measurements). Multivariable logistic regression was used to quantify the relationship between DLCO categories and dichotomous end points. RESULTS In multivariable analysis, normal-impaired DLCO status was associated with an increased risk of respiratory complications (odds ratio, 2.29 [95% CI, 1.12-4.49]; P = .02) and in-hospital complications (odds ratio, 2.83 [95% CI, 1.55-5.26]; P < .001). Type of neoadjuvant therapy was not associated with an increased risk of complications, compared with conventional chemotherapy. CONCLUSIONS Reduced postinduction DLCO might predict perioperative outcomes. The use of repeat pulmonary function testing might identify patients at higher risk of morbidity or mortality.
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Outcome of thoracoscopic anatomical sublobar resection under 3-dimensional computed tomography simulation. Surg Endosc 2021; 36:2312-2320. [PMID: 33881626 DOI: 10.1007/s00464-021-08506-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 04/07/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Previous studies have reported the feasibility and efficacy of thoracoscopic anatomical sublobar resection under three-dimensional computed tomography (3DCT) simulation; however, its long-term outcomes have not been clearly established in primary lung cancer. This study aimed to evaluate the long-term outcomes of this technique. METHODS We retrospectively reviewed data from 112 consecutive patients with selected clinical stage IA non-small cell lung cancer (NSCLC) who underwent thoracoscopic anatomical sublobar resection from 2004 to 2014. This procedure was planned using preoperative 3DCT simulation to ensure sufficient surgical margins and enabled tailor-made surgery for each patient. Patients who had predominantly ground glass opacity lung cancers underwent anatomical sublobar resection as a curative-intent resection. Other patients who were high-risk candidates for lobectomy underwent anatomical sublobar resection as a compromised limited resection. RESULTS Of the 112 cases, 82 had a curative-intent resection, while 30 had a compromised limited resection. Recurrence occurred in only 2 cases (1.8%), both of which were in the compromised limited group. A second primary lung cancer was observed in 5 cases (4.5%). Of the 5 patients, 4 underwent surgery for a second cancer and had no recurrence. The 5-year overall survival, lung cancer-specific overall survival, and recurrence-free survival rates were 92.5%, 100%, and 98.2%, respectively, for all cases; 97.6%, 100%, and 100%, respectively, in the curative-intent group; and 75.8%, 100% and 92.6%, respectively, in the compromised limited group. CONCLUSIONS Thoracoscopic anatomical sublobar resection under 3DCT simulation may be an acceptable alternative treatment in selected patients with NSCLC. TRIAL AND CLINICAL REGISTRY Clinical registration number: IRB No. 2020-98 (Dated: 2020.6.30).
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Prognostic significance of tumor spread through air spaces in patients with stage IA part-solid lung adenocarcinoma after sublobar resection. Lung Cancer 2020; 152:21-26. [PMID: 33338924 DOI: 10.1016/j.lungcan.2020.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/22/2020] [Accepted: 12/01/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The purpose of this study was to assess the clinicopathologic implications of tumor spread through air spaces (STAS) in patients with stage IA part-solid lung adenocarcinoma after sublobar resection. MATERIALS AND METHODS Medical records of patients with stage IA part-solid adenocarcinoma who underwent curative pulmonary resection between February 2009 and December 2016 were retrospectively reviewed. The clinicopathological features of STAS and its influence on postoperative recurrence and survival were investigated. RESULTS Among the 115 patients with stage IA part-solid adenocarcinoma who underwent wedge resection, 20 (17.4 %) had STAS. The multivariable analysis showed presence of STAS [HR (hazard ratio), 9.447; p = 0.002) and a larger invasive component size (HR, 1.097; p = 0.034) were independent risk factors for recurrence. The 5-year freedom from recurrence rates were 62.4 % and 97.9 % in cases with and without STAS, respectively (p < 0.001), and the 5-year disease-free survival rates were 58.5 % and 97.9 % in cases with and without STAS, respectively (p < 0.001). The presence of STAS was associated with old age (p = 0.030), male gender (p = 0.023), acinar predominant histologic pattern (p = 0.004), presence of micropapillary pattern (p < 0.001), lymphovascular invasion (p < 0.001) and larger invasive component (p < 0.001). CONCLUSION STAS could be an important prognostic factor in patients with stage IA part-solid lung adenocarcinoma after sublobar resection. Effective preoperative evaluation and postoperative surveillance may help improve the outcome of patients with small part-solid nodules, particularly when accompanied by STAS.
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Tsutani Y, Handa Y, Shimada Y, Ito H, Ikeda N, Nakayama H, Yoshimura K, Okada M. Comparison of cancer control between segmentectomy and wedge resection in patients with clinical stage IA non-small cell lung cancer. J Thorac Cardiovasc Surg 2020; 162:1244-1252.e1. [PMID: 33213872 DOI: 10.1016/j.jtcvs.2020.10.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 10/06/2020] [Accepted: 10/08/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The study objective was to compare cancer control between segmentectomy and wedge resection in patients with clinical stage IA non-small cell lung cancer. METHODS Between 2010 and 2015, 457 patients with clinical stage IA (8th edition) non-small cell lung cancer undergoing wedge resection or segmentectomy were identified at 3 institutions. Propensity scores were calculated on the basis of the extent of resection (wedge resection or segmentectomy) and included adjustment for confounding variables, such as age, sex, smoking status, pulmonary functions, laterality, tumor size, maximum standardized uptake value on 18F-fluorodeoxyglucose positron emission tomography, presence of ground-glass opacity on high-resolution computed tomography, histology, and visceral pleural invasion for multivariable analysis and matching. The primary end point was cumulative incidence of recurrence. RESULTS In all cohorts, postoperative recurrence occurred in 36 of 195 patients (18.5%) undergoing wedge resection and 14 of 262 patients (5.3%) undergoing segmentectomy. Cumulative incidence of recurrence was significantly lower in patients undergoing segmentectomy (5-year cumulative incidence of recurrence, 5.3%) than in those undergoing wedge resection (5-year cumulative incidence of recurrence, 19.1%; P < .001). In propensity score-adjusted multivariable analysis, segmentectomy was identified as an independent favorable prognostic factor for cumulative incidence of recurrence (hazard ratio, 0.47; 95% confidence interval, 0.24-0.90; P = .022). In propensity score matching of 163 pairs, cumulative incidence of recurrence was significantly lower in patients undergoing segmentectomy (5-year cumulative incidence of recurrence, 6.6%) than in those undergoing wedge resection (5-year cumulative incidence of recurrence, 13.2%; P = .041). CONCLUSIONS Cancer control was better in segmentectomy than in wedge resection. Segmentectomy is the preferred oncologic procedure as sublobar resection to treat clinical stage IA non-small cell lung cancer.
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Affiliation(s)
- Yasuhiro Tsutani
- Department of Surgical Oncology, Hiroshima University, Hiroshima, Japan.
| | - Yoshinori Handa
- Department of Surgical Oncology, Hiroshima University, Hiroshima, Japan
| | - Yoshihisa Shimada
- Department of Thoracic Surgery, Tokyo Medical University, Tokyo, Japan
| | - Hiroyuki Ito
- Department of Thoracic Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Norihiko Ikeda
- Department of Thoracic Surgery, Tokyo Medical University, Tokyo, Japan
| | - Haruhiko Nakayama
- Department of Thoracic Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Kenichi Yoshimura
- Medical Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan
| | - Morihito Okada
- Department of Surgical Oncology, Hiroshima University, Hiroshima, Japan.
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Ijsseldijk MA, Shoni M, Siegert C, Wiering B, van Engelenburg AKC, Tsai TC, Ten Broek RPG, Lebenthal A. Oncologic Outcomes of Surgery Versus SBRT for Non-Small-Cell Lung Carcinoma: A Systematic Review and Meta-analysis. Clin Lung Cancer 2020; 22:e235-e292. [PMID: 32912754 DOI: 10.1016/j.cllc.2020.04.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/21/2020] [Accepted: 04/25/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The optimal treatment of stage I non-small-cell lung carcinoma is subject to debate. The aim of this study was to compare overall survival and oncologic outcomes of lobar resection (LR), sublobar resection (SR), and stereotactic body radiotherapy (SBRT). METHODS A systematic review and meta-analysis of oncologic outcomes of propensity matched comparative and noncomparative cohort studies was performed. Outcomes of interest were overall survival and disease-free survival. The inverse variance method and the random-effects method for meta-analysis were utilized to assess the pooled estimates. RESULTS A total of 100 studies with patients treated for clinical stage I non-small-cell lung carcinoma were included. Long-term overall and disease-free survival after LR was superior over SBRT in all comparisons, and for most comparisons, SR was superior to SBRT. Noncomparative studies showed superior long-term overall and disease-free survival for both LR and SR over SBRT. Although the papers were heterogeneous and of low quality, results remained essentially the same throughout a large number of stratifications and sensitivity analyses. CONCLUSION Results of this systematic review and meta-analysis showed that LR has superior outcomes compared to SBRT for cI non-small-cell lung carcinoma. New trials are underway evaluating long-term results of SBRT in potentially operable patients.
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Affiliation(s)
- Michiel A Ijsseldijk
- Division of Surgery, Slingeland Ziekenhuis, Doetinchem, The Netherlands; Division of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Melina Shoni
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Charles Siegert
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA; Division of Thoracic Surgery, West Roxbury Veterans Administration, West Roxbury, MA
| | - Bastiaan Wiering
- Division of Surgery, Slingeland Ziekenhuis, Doetinchem, The Netherlands
| | | | - Thomas C Tsai
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Richard P G Ten Broek
- Division of Surgery, Slingeland Ziekenhuis, Doetinchem, The Netherlands; Division of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Abraham Lebenthal
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA; Division of Thoracic Surgery, West Roxbury Veterans Administration, West Roxbury, MA; Harvard Medical School, Boston, MA
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11
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Shiono S, Endo M, Suzuki K, Yanagawa N. Spread through air spaces affects survival and recurrence of patients with clinical stage IA non-small cell lung cancer after wedge resection. J Thorac Dis 2020; 12:2247-2260. [PMID: 32642130 PMCID: PMC7330349 DOI: 10.21037/jtd.2020.04.47] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Spread through air spaces (STAS) is reportedly a significant risk factor for recurrence and a prognostic factor in patients with non-small cell lung cancer (NSCLC), especially after sublobar resection. Because wedge resection (WR) is associated with insufficient margins, we hypothesized that STAS has a greater prognostic impact in patients who undergo WR compared with segmentectomy. We aimed to clarify the value of STAS as a prognostic factor in patients with NSCLC after WR. Methods We evaluated 217 patients with clinical stage IA NSCLC who underwent sublobar resection. The prognostic impact of STAS in these patients was compared between the WR (n=100) and segmentectomy (n=117) cases. Results STAS was present in 15.7% of the 217 patients. STAS was a significant prognostic factor for overall survival in univariate (P<0.001) and multivariate (P=0.003) analyses for the WR cases, but not the segmentectomy cases (P=0.399). STAS was also a significant prognostic factor for freedom from recurrence in univariate (P=0.010) and multivariate (P=0.024) analyses for the WR cases, but was only marginally significant for the segmentectomy cases (P=0.050, univariate analysis). The solid tumor size on chest computed tomography was significantly related to STAS. A cut-off solid tumor size of 1.7 cm for predicting the presence of STAS was determined by receiver operating characteristic analysis. Conclusions STAS was a significant prognostic factor for patients with clinical stage IA NSCLC who underwent WR, but not those who underwent segmentectomy.
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Affiliation(s)
- Satoshi Shiono
- Department of Thoracic Surgery, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Makoto Endo
- Department of Thoracic Surgery, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Katsuyuki Suzuki
- Department of Thoracic Surgery, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Naoki Yanagawa
- Department of Pathology, Yamagata Prefectural Central Hospital, Yamagata, Japan
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12
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Broderick SR, Grau-Sepulveda M, Kosinski AS, Kurlansky PA, Shahian DM, Jacobs JP, Becker S, DeCamp MM, Seder CW, Grogan EL, Brown LM, Burfeind W, Magee M, Raymond DP, Puri V, Chang AC, Kozower BD. The Society of Thoracic Surgeons Composite Score Rating for Pulmonary Resection for Lung Cancer. Ann Thorac Surg 2020; 109:848-855. [DOI: 10.1016/j.athoracsur.2019.08.114] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 08/19/2019] [Indexed: 12/01/2022]
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13
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Tsutani Y, Kagimoto A, Handa Y, Mimae T, Miyata Y, Okada M. Wedge resection versus segmentectomy in patients with stage I non–small-cell lung cancer unfit for lobectomy. Jpn J Clin Oncol 2019; 49:1134-1142. [DOI: 10.1093/jjco/hyz122] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 07/12/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
Objective
The present study aimed to compare the outcomes of wedge resection and segmentectomy in patients with clinical stage I non–small-cell lung cancer (NSCLC) who were unfit for lobectomy.
Methods
Between April 2007 and December 2015, 99 patients with stage I NSCLC who were considered unfit for lobectomy and had undergone sublobar resection were identified. Propensity scores were estimated for multivariable analyses, and surgical outcomes were compared between patients who underwent wedge resection and those who underwent segmentectomy.
Results
Sixty patients underwent wedge resection and 39 underwent segmentectomy. Severe postoperative complications (>Grade IIIa) were more frequent in segmentectomy (15.4%) than in wedge resection (3.3%, P = 0.054). Propensity score-adjusted multivariable analysis revealed that operative procedure was an independent predictive factor for severe postoperative complication (segmentectomy, odds ratio = 8.18; P = 0.021). Overall survival (OS) and recurrence-free survival (RFS) were not significantly different between wedge resection (5-year OS, 61.3%, 5-year RFS, 49.4%) and segmentectomy (5-year OS, 68.2%, 5-year RFS, 56.8 %, P = 0.95, P = 0.93, respectively). Propensity score-adjusted multivariable Cox analysis revealed that operative procedure was not an independent factor for OS (segmentectomy, hazard ratio = 1.21, P = 0.62) or RFS (segmentectomy, hazard ratio = 1.07, P = 0.84).
Conclusion
Segmentectomy was more toxic but failed to show the superiority of survival compared with wedge resection. Wedge resection may be the optimal procedure for patients with clinical stage I NSCLC who are considered to be unfit for lobectomy.
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Affiliation(s)
- Yasuhiro Tsutani
- Department of Surgical Oncology, Hiroshima University, Hiroshima 734-8551, Japan
| | - Atsushi Kagimoto
- Department of Surgical Oncology, Hiroshima University, Hiroshima 734-8551, Japan
| | - Yoshinori Handa
- Department of Surgical Oncology, Hiroshima University, Hiroshima 734-8551, Japan
| | - Takahiro Mimae
- Department of Surgical Oncology, Hiroshima University, Hiroshima 734-8551, Japan
| | - Yoshihiro Miyata
- Department of Surgical Oncology, Hiroshima University, Hiroshima 734-8551, Japan
| | - Morihito Okada
- Department of Surgical Oncology, Hiroshima University, Hiroshima 734-8551, Japan
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14
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Perioperative mortality and morbidity after sublobar versus lobar resection for early-stage non-small-cell lung cancer: post-hoc analysis of an international, randomised, phase 3 trial (CALGB/Alliance 140503). THE LANCET RESPIRATORY MEDICINE 2018; 6:915-924. [PMID: 30442588 DOI: 10.1016/s2213-2600(18)30411-9] [Citation(s) in RCA: 243] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/11/2018] [Accepted: 09/27/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Increased detection of small-sized, peripheral, non-small-cell lung cancer has renewed interest in sublobar resection instead of lobectomy, the traditional standard of care for early-stage lung cancer. We aimed to assess morbidity and mortality associated with lobar and sublobar resection for early-stage lung cancer. METHODS CALGB/Alliance 140503 is a multicentre, international, non-inferiority, phase 3 trial in patients with peripheral non-small-cell lung cancer clinically staged as T1aN0. Patients were recruited from 69 academic and community-based institutions in Australia, Canada, and the USA. Patients were randomly assigned intraoperatively to either lobar or sublobar resection. The random assignment was based on permuted block randomisation without concealment and was stratified according to radiographic tumour size, histology, and smoking status. The primary endpoint of the trial is disease-free survival; here, we report a post-hoc, exploratory, comparative analysis of perioperative mortality and morbidity associated with lobar and sublobar resection. Perioperative mortality was defined as death from any cause within 30 days and 90 days of surgical intervention and was calculated for all randomised patients. Morbidity was graded using Common Terminology Criteria for Adverse Events version 4.0. All analyses were done on an intention-to-treat basis for randomised patients with data available. This trial is registered with ClinicalTrials.gov, number NCT00499330. FINDINGS Between June 15, 2007, and March 13, 2017, 697 patients were randomly allocated to either lobar resection (n=357) or sublobar resection (n=340; 59% wedge resection). Six (0·9%) patients died by 30 days, four (1·1%) after lobar resection and two (0·6%) after sublobar resection; by 90 days, ten (1·4%) patients had died, six (1·7%) after lobar resection and four (1·2%) after sublobar resection (difference at 30 days, 0·5%, 95% CI -1·1 to 2·3; difference at 90 days, 0·5%, 95% CI -1·5 to 2·6). An adverse event of any grade occurred in 193 (54%) of 355 patients after lobar resection and 172 (51%) of 337 patients after sublobar resection. Adverse events of grade 3 or worse occurred in 54 (15%) patients assigned lobar resection and in 48 (14%) patients assigned sublobar resection. No differences between surgical approaches were noted in cardiac or pulmonary complications. Grade 3 haemorrhage (requiring transfusion) occurred in six (2%) patients assigned lobar resection and eight (2%) patients assigned sublobar resection. Prolonged air leak occurred in nine (3%) patients after lobar resection and two (1%) patients after sublobar resection. INTERPRETATION Our post-hoc analysis showed that perioperative mortality and morbidity did not seem to differ between lobar and sublobar resection in physically and functionally fit patients with clinical T1aN0 non-small-cell lung cancer. These data may affect the daily choices made by patients and their doctors in establishing the best treatment approach for stage I lung cancer. FUNDING National Cancer Institute.
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15
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Taylor LJ, Julliard WA, Maloney JD. Predictive value of pulmonary function measures for short-term outcomes following lung resection: analysis of a single high-volume institution. J Thorac Dis 2018; 10:1072-1076. [PMID: 29607183 DOI: 10.21037/jtd.2018.01.100] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Despite the importance of preoperative risk-stratification, there is a lack of consensus on how to identify high-risk patients for pulmonary resection. Enrollment criteria for national trials propose one definition based on preoperative pulmonary function tests. We sought to examine the value of preoperative forced expiratory volume in 1 second (FEV1) and diffusion capacity for carbon monoxide (DLCO) to predict short-term outcomes following pulmonary resection. Using our institutional Society of Thoracic Surgeons (STS) database we identified 419 consecutive lung cancer patients who presented to our institution for pulmonary resection between 2012 and 2016. We identified patients as "high risk" based on the national trial criteria of FEV1 or DLCO ≤50%. Our primary outcome was any postoperative complication within 30 days of surgery. Secondary outcomes included cardiac and pulmonary complications, 30-day readmission, and discharge disposition. DLCO ≤50% was associated with any postoperative complication (P=0.03), but not predictive of cardiac events, pulmonary complications, or 30-day readmission. There were no significant differences in any of these short-term outcomes for patients with FEV1 ≤50%. On multivariable analysis, neither FEV1 nor DLCO ≤50% were significantly associated with occurrence of postoperative complication (OR =1.67, 95% CI: 0.60-4.63; OR =1.66, 95% CI: 0.96-2.86, respectively). Notably, DLCO ≤50%-but not FEV1-was associated with discharge to a skilled facility on univariate (P=0.01) and multivariable analysis (OR =2.54; 95% CI: 1.08-5.99; P=0.03). This association between DLCO and discharge to a skilled facility persisted when DLCO was used as a continuous variable. For all-comers presenting to our institution for lung cancer resection, classification based on FEV1 or DLCO ≤50% may not reliably identify those at highest risk for short-term postoperative complications. While our findings suggest caution when using pulmonary parameters in isolation, the potential value of DLCO as a proxy for underlying comorbidity warrants further investigation.
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Affiliation(s)
- Lauren J Taylor
- Department of Surgery, Division of Cardiothoracic Surgery, University of Wisconsin, Madison, WI, USA
| | - Walker A Julliard
- Department of Surgery, Division of Cardiothoracic Surgery, University of Wisconsin, Madison, WI, USA
| | - James D Maloney
- Department of Surgery, William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
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16
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Hattori A, Matsunaga T, Takamochi K, Oh S, Suzuki K. Surgical resection for clinical-Stage I radiological pure-solid lung cancer that met the current high risk criteria. Jpn J Clin Oncol 2017; 47:630-638. [PMID: 28419333 DOI: 10.1093/jjco/hyx054] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Accepted: 04/03/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Aritoshi Hattori
- Department of General Thoracic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Takeshi Matsunaga
- Department of General Thoracic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Kazuya Takamochi
- Department of General Thoracic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Shiaki Oh
- Department of General Thoracic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Kenji Suzuki
- Department of General Thoracic Surgery, Juntendo University School of Medicine, Tokyo, Japan
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17
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Palma DA, Nguyen TK, Kwan K, Gaede S, Landis M, Malthaner R, Fortin D, Louie AV, Frechette E, Rodrigues GB, Yaremko B, Yu E, Dar AR, Lee TY, Gratton A, Warner A, Ward A, Inculet R. Short report: interim safety results for a phase II trial measuring the integration of stereotactic ablative radiotherapy (SABR) plus surgery for early stage non-small cell lung cancer (MISSILE-NSCLC). Radiat Oncol 2017; 12:30. [PMID: 28129789 PMCID: PMC5270342 DOI: 10.1186/s13014-017-0770-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 01/18/2017] [Indexed: 02/11/2023] Open
Abstract
Abstract A phase II trial was launched to evaluate if neoadjuvant stereotactic ablative radiotherapy (SABR) before surgery improves oncologic outcomes in patients with stage I non-small cell lung cancer (NSCLC). We report a mandated interim safety analysis for the first 10 patients who completed protocol treatment. Operable patients with biopsy-proven T1-2 N0 NSCLC were eligible. SABR was delivered using a risk-adapted fractionation (54Gy/3 fractions, 55/5 or 60/8). Surgical resection was planned 10 weeks later at a high-volume center (>200 lung cancer resections annually). Patients were imaged with dynamic positron emission tomography-computed tomography scans using 18F-fludeoxyglucose (18F-FDG-PET CT) and dynamic contrast-enhanced CT before SABR and again before surgery. Toxicity was recorded using CTCAE version 4.0. Twelve patients were enrolled between 09/2014 and 09/2015. Two did not undergo surgery, due to patient or surgeon preference; neither patient has developed toxicity or recurrence. For the 10 patients completing both treatments, median age was 70 (range: 54–76), 60% had T1 disease, and 60% had adenocarcinoma. Median FEV1 was 73% predicted (range: 54–87%). Median time to surgery post-SABR was 10.1 weeks (range: 9.3–15.6 weeks). Surgery consisted of lobectomy (n = 8) or wedge resection (n = 2). Median follow-up post-SABR was 6.3 months. After combined treatment, the rate of acute grade 3–4 toxicity was 10%. There was no post-operative mortality at 90 days. The small sample size included herein precludes any definitive conclusions regarding overall toxicity rates until larger datasets are available. However, these data may inform others who are designing or conducting similar trials. Trial registration NCT02136355. Registered 8 May 2014.
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Affiliation(s)
- David A Palma
- Department of Radiation Oncology, London Health Sciences Centre, London, Canada. .,Department of Oncology, Western University, London, Canada.
| | - Timothy K Nguyen
- Department of Radiation Oncology, London Health Sciences Centre, London, Canada
| | - Keith Kwan
- Department of Pathology, Western University, London, Canada
| | - Stewart Gaede
- Department of Oncology, Western University, London, Canada.,Department of Medical Biophysics, Western University, London, Canada.,Department of Physics and Engineering, London Health Sciences Centre, London, Canada
| | - Mark Landis
- Department of Radiology, Western University, London, Canada
| | - Richard Malthaner
- Department of Surgery, Division of Thoracic Surgery, Western University, London, Canada
| | - Dalilah Fortin
- Department of Surgery, Division of Thoracic Surgery, Western University, London, Canada
| | - Alexander V Louie
- Department of Radiation Oncology, London Health Sciences Centre, London, Canada.,Department of Oncology, Western University, London, Canada
| | - Eric Frechette
- Department of Surgery, Division of Thoracic Surgery, Western University, London, Canada
| | - George B Rodrigues
- Department of Radiation Oncology, London Health Sciences Centre, London, Canada.,Department of Oncology, Western University, London, Canada
| | - Brian Yaremko
- Department of Radiation Oncology, London Health Sciences Centre, London, Canada.,Department of Oncology, Western University, London, Canada
| | - Edward Yu
- Department of Radiation Oncology, London Health Sciences Centre, London, Canada.,Department of Oncology, Western University, London, Canada
| | - A Rashid Dar
- Department of Radiation Oncology, London Health Sciences Centre, London, Canada.,Department of Oncology, Western University, London, Canada
| | - Ting-Yim Lee
- Department of Medical Biophysics, Western University, London, Canada.,Imaging Program, Lawson Health Research Institute, London, Canada
| | - Al Gratton
- Department of Radiation Oncology, London Health Sciences Centre, London, Canada
| | - Andrew Warner
- Department of Radiation Oncology, London Health Sciences Centre, London, Canada
| | - Aaron Ward
- Department of Oncology, Western University, London, Canada.,Department of Medical Biophysics, Western University, London, Canada
| | - Richard Inculet
- Department of Surgery, Division of Thoracic Surgery, Western University, London, Canada
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18
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Treatment Outcomes in Stage I Lung Cancer: A Comparison of Surgery and Stereotactic Body Radiation Therapy. J Thorac Oncol 2016; 10:1776-84. [PMID: 26334753 DOI: 10.1097/jto.0000000000000680] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION The relative roles of surgery and stereotactic body radiation therapy in stage I non-small-cell lung cancer (NSCLC) are evolving particularly for marginally operable patients. Because there is limited prospective comparative data for these treatment modalities, we evaluated their relative use and outcomes at the population level using a national database. METHODS Patient variables and treatment-related outcomes were abstracted for patients with clinical stage I NSCLC from the National Cancer Database. Patients receiving surgery were compared with those undergoing stereotactic body radiation therapy (SBRT) in exploratory unmatched and subsequent propensity matched analyses. RESULTS Between 1998 and 2010, 117,618 patients underwent surgery or SBRT for clinical stage I NSCLC. Of these, 111,731 (95%) received surgery, whereas 5887 (5%) underwent SBRT. Patients in the surgery group were younger, more likely to be males, and had higher Charlson comorbidity scores. SBRT patients were more likely to have T1 (versus T2) tumors and receive treatment at academic centers. Thirty-day surgical mortality was 2596 of 109,485 (2.4%). Median overall survival favored the surgery group in both unmatched (68.4 versus 33.3 months, p < 0.001) and matched analysis based on patient characteristics (62.3 versus 33.1 months, p < 0.001). Disease-specific survival was unavailable from the data set. CONCLUSION In a propensity matched comparison, patients selected for surgery have improved survival compared with SBRT. In the absence of information on cause of death and with limited variables to characterize comorbidity, it is not possible to assess the relative contribution of patient selection or better cancer control toward the improved survival. Rigorous prospective studies are needed to optimize patient selection for SBRT in the high-risk surgical population.
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19
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Hou B, Deng XF, Zhou D, Liu QX, Dai JG. Segmentectomy versus wedge resection for the treatment of high-risk operable patients with stage I non-small cell lung cancer: a meta-analysis. Ther Adv Respir Dis 2016; 10:435-43. [PMID: 27585599 PMCID: PMC5933623 DOI: 10.1177/1753465816667121] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Although lobectomy is still the preferred treatment for patients with stage I non-small cell lung cancer (NSCLC), segmentectomy or wedge resection is frequently performed on patients who cannot withstand the physiological rigors of lobectomy. The objective of this study was to compare the overall survival (OS), cancer-specific survival (CSS), and disease-free survival outcomes among patients with stage I NSCLC who have undergone these procedures. METHODS A systematic electronic search in three online databases was conducted from their earliest publication dates to June 2015. The studies were evaluated according to rigorous, predefined inclusion criteria. The hazard ratio (HR) was used as the outcome measure for data combining. RESULTS There were nine eligible studies. These studies included 1181 patients who underwent segmentectomy and 2003 patients who underwent wedge resection. Stage I NSCLC patients who underwent segmentectomy had significantly better OS (HR 0.80; 95% confidence interval [CI], 0.68-0.93; p = 0.004) and CSS (HR 0.42; 95% CI, 0.20-0.88; p = 0.02) rates than those who underwent wedge resection. However, there were no significant differences in OS (HR 0.39; 95% CI, 0.15-1.02; p = 0.06) and CSS (HR 1.87; 95% CI, 0.29-12.06; p = 0.51) rates between segmentectomy and wedge resection in patients with stage Ia NSCLC with tumor size ⩽ 2 cm. CONCLUSIONS For patients with stage I NSCLC, segmentectomy results in higher survival rates than wedge resection, whereas the outcomes of wedge resection are comparable to those of segmentectomy for patients with stage Ia NSCLC with tumor size ⩽ 2 cm. Considering the limitations and heterogeneity of the included studies, this conclusion should be further confirmed by rigorous randomized clinical trials.
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Affiliation(s)
- Bing Hou
- Department of Thoracic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing China
| | - Xu-Feng Deng
- Department of Thoracic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing China
| | - Dong Zhou
- Department of Thoracic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing China
| | - Quan-Xing Liu
- Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Ji-Gang Dai
- Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
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20
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SABR vs. Limited Resection for Non-small Cell Lung Cancer: Are We Closer to an Answer? Curr Treat Options Oncol 2016; 17:27. [DOI: 10.1007/s11864-016-0407-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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21
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A Nomogram to Predict Recurrence and Survival of High-Risk Patients Undergoing Sublobar Resection for Lung Cancer: An Analysis of a Multicenter Prospective Study (ACOSOG Z4032). Ann Thorac Surg 2016; 102:239-46. [PMID: 27101729 DOI: 10.1016/j.athoracsur.2016.01.063] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 01/12/2016] [Accepted: 01/13/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND Individualized prediction of outcomes may help with therapy decisions for patients with non-small cell lung cancer. We developed a nomogram by analyzing 17 clinical factors and outcomes from a randomized study of sublobar resection for non-small cell lung cancer in high-risk operable patients. The study compared sublobar resection alone with sublobar resection with brachytherapy. There were no differences in primary and secondary outcomes between the study arms, and they were therefore combined for this analysis. METHODS The clinical factors of interest (considered as continuous variables) were assessed in a univariate Cox proportional hazards model for significance at the 0.10 level for their impact on overall survival (OS), local recurrence-free survival (LRFS), and any recurrence-free survival (RFS). The final multivariable model was developed using a stepwise model selection. RESULTS Of 212 patients, 173 had complete data on all 17 risk factors. Median follow-up was 4.94 years (range, 0.04 to 6.22). The 5-year OS, LRFS, and RFS were 58.4%, 53.2%, and 47.4%, respectively. Age, baseline percent diffusing capacity of lung for carbon monoxide, and maximum tumor diameter were significant predictors for OS, LRFS, and RFS in the multivariable model. Nomograms were subsequently developed for predicting 5-year OS, LRFS, and RFS. CONCLUSIONS Age, baseline percent diffusing capacity of lung for carbon monoxide, and maximum tumor diameter significantly predicted outcomes after sublobar resection. Such nomograms may be helpful for treatment planning in early stage non-small cell lung cancer and to guide future studies.
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22
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Kent MS, Mandrekar SJ, Landreneau R, Nichols F, DiPetrillo TA, Meyers B, Heron DE, Jones DR, Tan AD, Starnes S, Putnam JB, Fernando HC. Impact of Sublobar Resection on Pulmonary Function: Long-Term Results from American College of Surgeons Oncology Group Z4032 (Alliance). Ann Thorac Surg 2016; 102:230-8. [PMID: 27101728 DOI: 10.1016/j.athoracsur.2016.01.069] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 01/04/2016] [Accepted: 01/06/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Sublobar resection (SR) in high-risk operable patients may result in a long-term decrease in pulmonary function. We previously reported 3-month pulmonary function outcomes from a randomized phase III study of SR alone compared with SR with brachytherapy in patients with non-small cell lung cancer. We now report long-term pulmonary function after SR. METHODS Pulmonary function was measured at baseline and at 3, 12, and 24 months. A decline of 10% or more from baseline in the percentage predicted forced expiratory volume of 1 percentage or in the diffusion capacity of the lung for carbon monoxide was considered clinically meaningful. The effect of study arm, tumor location, size, approach (video-assisted thoracoscopic surgery vs thoracotomy), and SR type (wedge vs segmentectomy) on pulmonary function was assessed using a Wilcoxon rank sum test. A generalized estimating equation model was used to assess the effect of each factor on longitudinal data, including all four time points. RESULTS Complete pulmonary function data at all time points was available in 69 patients. No significant differences were observed in pulmonary function between SR and SR with brachytherapy, thus the study arms were combined for all analyses. A decline of 10% or more (p = 0.02) in the percentage predicted forced expiratory volume in 1 second was demonstrated for lower-lobe resections at 3 months but was not at 12 or 24 months. A decline of 10% or more (p = 0.05) in the percentage predicted diffusion capacity of the lung for carbon monoxide was seen for thoracotomy at 3 months but was not at 12 or 24 months. CONCLUSIONS Clinically meaningful declines in pulmonary function occurred after lower lobe resection and after thoracotomy at 3 months but subsequently recovered. This study suggests that SR does not result in sustained decreased pulmonary function in high-risk operable patients.
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Affiliation(s)
- Michael S Kent
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
| | - Sumithra J Mandrekar
- Department of Health Sciences Research, Alliance Statistics and Data Center, Mayo Clinic, Rochester, Minnesota
| | - Rodney Landreneau
- Department of Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | | | - Thomas A DiPetrillo
- Department of Radiation Oncology, Rhode Island Hospital, Providence, Rhode Island
| | - Bryan Meyers
- Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Dwight E Heron
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - David R Jones
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Angelina D Tan
- Department of Health Sciences Research, Alliance Statistics and Data Center, Mayo Clinic, Rochester, Minnesota
| | - Sandra Starnes
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Joe B Putnam
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hiran C Fernando
- Department of Surgery, Boston Medical Center, Boston, Massachusetts
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23
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Fleming C, Rimner A, Cohen GN, Woo KM, Zhang Z, Rosenzweig KE, Alektiar KM, Zelefsky MJ, Bains MS, Wu AJ. High- and low-dose-rate intraoperative radiotherapy for thoracic malignancies resected with close or positive margins. Brachytherapy 2016; 15:208-15. [PMID: 26825857 DOI: 10.1016/j.brachy.2015.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 10/31/2015] [Accepted: 11/25/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE Local recurrence is a significant problem after surgical resection of thoracic tumors. As intraoperative radiotherapy (IORT) can deliver radiation directly to the threatened margin, we have used this therapy in an attempt to reduce local recurrence, using high-dose-rate (HDR) as well as low-dose-rate (LDR) techniques. METHODS AND MATERIALS We performed a retrospective review of patients undergoing LDR ((125)I) mesh placement or HDR ((192)Ir) afterloading therapy during lung tumor resection between 2001 and 2013 at our institution. Competing risks methods were used to estimate the cumulative incidence of local failure. We also assessed possible predictive factors of local failure. RESULTS Fifty-nine procedures (41 LDR and 18 HDR) were performed on 58 patients. Median follow-up was 55.1 months. Cumulative incidence of local failure at 1, 2, and 3 years was 28.5%, 34.2%, and 34.2%, respectively. Median overall survival was 39.9 months. There was no significant difference in local failure according to margin status, HDR vs. LDR, use of adjuvant external beam radiotherapy, or metastatic vs. primary tumor. Two patients (3.4%) experienced Grade 3+ toxicities likely related to brachytherapy. Additionally, 7 patients experienced Grade 3+ postsurgical complications unlikely related to brachytherapy. CONCLUSIONS IORT is associated with good local control after resection of thoracic tumors otherwise at very high risk for local recurrence. There is a low incidence of severe toxicity attributable to brachytherapy. HDR-IORT appears to have equivalent outcomes to LDR-IORT. HDR or LDR-IORT can, therefore, be considered in situations where the oncologic completeness of thoracic tumor resection is in doubt.
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Affiliation(s)
- Christopher Fleming
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Gil'ad N Cohen
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kaitlin M Woo
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Kaled M Alektiar
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Michael J Zelefsky
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Manjit S Bains
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY.
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Sancheti MS, Melvan JN, Medbery RL, Fernandez FG, Gillespie TW, Li Q, Binongo JN, Pickens A, Force SD. Outcomes After Surgery in High-Risk Patients With Early Stage Lung Cancer. Ann Thorac Surg 2015; 101:1043-50; Discussion 1051. [PMID: 26572255 DOI: 10.1016/j.athoracsur.2015.08.088] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Revised: 07/27/2015] [Accepted: 08/21/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND Patients with early stage lung cancer considered high risk for surgery are increasingly being treated with nonsurgical therapies. However, consensus on the classification of high risk does not exist. We compared clinical outcomes of patients considered to be high risk with those of standard-risk patients, after lung cancer surgery. METHODS A total of 490 patients from our institutional Society of Thoracic Surgeons data from 2009 to 2013 underwent resection for clinical stage I lung cancer. High-risk patients were identified by ACOSOG z4032/z4099 criteria: major: forced expiratory volume in 1 second (FEV1) 50% or less or diffusing capacity of lung for carbon monoxide (Dlco) 50% or less; and minor: (two of the following), age 75 years or more, FEV1 51% to 60%, or Dlco 51% to 60%. Demographics, perioperative outcomes, and survival between high-risk and standard-risk patients undergoing lobectomy and sublobar resection were compared. Univariate analysis was performed using the χ(2) test/Fisher's exact test and the t test/Mann-Whitney U test. Survival was studied using a Cox regression model to calculate hazard ratios, and Kaplan-Meier survival curves were drawn. RESULTS In all, 180 patients (37%) were classified as high risk. These patients were older than standard-risk patients (70 years versus 65 years, respectively; p < 0.0001) and had worse FEV1 (57% versus 85%, p < 0.0001), and Dlco (47% versus 77%, p < 0.0001). High-risk patients also had more smoking pack-years than standard-risk patients (46 versus 30, p < 0.0001) and a greater incidence of chronic obstructive pulmonary disease (72% versus 32%, p < 0.0001), and were more likely to undergo sublobar resection (32% versus 20%, p = 0.001). Length of stay was longer in the high-risk group (5 versus 4 days, p < 0.0001), but there was no difference in postoperative mortality (2% versus 1%, p = 0.53). Nodal upstaging occurred in 20% of high-risk patients and 21% of standard-risk patients (p = 0.79). Three-year survival was 59% for high-risk patients and 76% for standard-risk patients (p < 0.0001). CONCLUSIONS Good clinical outcomes after surgery for early stage lung cancer can be achieved in patients classified as high risk. In our study, surgery led to upstaging in 20% of patients and acceptable 1-, 2-, and 3-year survival as compared with historical rates for nonsurgical therapies. This study suggests that empiric selection criteria may deny patients optimal oncologic therapy.
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Affiliation(s)
- Manu S Sancheti
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia.
| | - John N Melvan
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Rachel L Medbery
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Felix G Fernandez
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Theresa W Gillespie
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia; Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Qunna Li
- Rollins School of Public Health, Emory University School of Medicine, Atlanta, Georgia
| | - Jose N Binongo
- Rollins School of Public Health, Emory University School of Medicine, Atlanta, Georgia
| | - Allan Pickens
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Seth D Force
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
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Hattori A, Takamochi K, Matsunaga T, Oh S, Suzuki K. Oncological outcomes of sublobar resection for clinical-stage IA high-risk non-small cell lung cancer patients with a radiologically solid appearance on computed tomography. Gen Thorac Cardiovasc Surg 2015; 64:18-24. [DOI: 10.1007/s11748-015-0598-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 10/14/2015] [Indexed: 12/25/2022]
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Makey I, Berger RL, Cabral HJ, Celli B, Folch E, Whyte RI. Maximal Oxygen Uptake--Risk Predictor of NSCLC Resection in Patients With Comorbid Emphysema: Lessons From NETT. Semin Thorac Cardiovasc Surg 2015; 27:225-31. [PMID: 26686452 DOI: 10.1053/j.semtcvs.2015.07.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2015] [Indexed: 12/25/2022]
Abstract
We compared VO2 max values from ACCP Guidelines and from NETT's homogenous NULPD surrogate for predicting operative mortalities. Estimated mid and long-term non-cancer related survival in NETT's subset was also obtained. NETT and ACCP Guideline VO2 max values were similar in the "low" and "mid" risk operative mortality categories but NETT's "high" risk subset showed lower mortality (14% vs. 26%). Estimated non-cancer related survival in NETT "low", "mid" and "high" risk VO2 max categories at two and eight years were 100%, 74%, 59% and 48%, 26%, 14%, respectively. The lower predicted risk in NETT's "high- risk" subset raises the possibility of extending indications for potential curative resection in selected patients. The NETT surrogate also provides hitherto unavailable estimate on long-term non-cancer related survival after potential curative resection of NSCLC and suggests that the operation does not shorten eight-year longevity.
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Affiliation(s)
- Ian Makey
- Division of Cardiothoracic Surgery, University of Texas San Antonio Health Sciences Center, San Antonio, Texas
| | - Robert L Berger
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
| | - Howard J Cabral
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Bartolome Celli
- Department of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Erik Folch
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Richard I Whyte
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Meyers BF, Puri V, Broderick SR, Samson P, Keogan K, Crabtree TD. Lobectomy versus stereotactic body radiotherapy for stage I non-small cell lung cancer: Post hoc analysis dressed up as level-1 evidence? J Thorac Cardiovasc Surg 2015; 150:468-71. [PMID: 26259993 DOI: 10.1016/j.jtcvs.2015.06.086] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 06/23/2015] [Indexed: 11/15/2022]
Affiliation(s)
- Bryan F Meyers
- Division of Cardiothoracic Surgery, Washington University in St Louis, St Louis, Mo.
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University in St Louis, St Louis, Mo
| | - Stephen R Broderick
- Division of Cardiothoracic Surgery, Washington University in St Louis, St Louis, Mo
| | - Pamela Samson
- Division of Cardiothoracic Surgery, Washington University in St Louis, St Louis, Mo
| | - Kathleen Keogan
- Division of Cardiothoracic Surgery, Washington University in St Louis, St Louis, Mo
| | - Traves D Crabtree
- Division of Cardiothoracic Surgery, Washington University in St Louis, St Louis, Mo
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Fernando HC, Landreneau RJ, Mandrekar SJ, Nichols FC, DiPetrillo TA, Meyers BF, Heron DE, Hillman SL, Jones DR, Starnes SL, Tan AD, Daly BDT, Putnam JB. Analysis of longitudinal quality-of-life data in high-risk operable patients with lung cancer: results from the ACOSOG Z4032 (Alliance) multicenter randomized trial. J Thorac Cardiovasc Surg 2014; 149:718-25; discussion 725-6. [PMID: 25500100 DOI: 10.1016/j.jtcvs.2014.11.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 09/10/2014] [Accepted: 11/04/2014] [Indexed: 01/01/2023]
Abstract
BACKGROUND Prior studies have suggested that low baseline quality-of-life (QOL) scores predict worse survival in patients undergoing lung cancer surgery. However, these studies involved average-risk patients undergoing lobectomy. We report QOL results from a multicenter trial, American College of Surgeons Oncology Group Z4032, which randomized high-risk operable patients to sublobar resection (SR), or SR with brachytherapy, and included longitudinal QOL assessments. METHODS Global QOL, using the 36-item Short-Form Health Survey (SF36), and the dyspnea score from the University of California, San Diego Shortness of Breath Questionnaire (SOBQ) scale, was measured at baseline, 3, 12, and 24 months. SF36 physical component summary (PCS) and mental component summary (MCS) scores were standardized and adjusted for age and gender normals, with scores <50 indicating below-average health status. SOBQ scores were transformed to a 0-100 (poor-excellent) scale. Aims were to: (1) determine the impact of baseline scores on recurrence-free survival, overall survival, and 30-day adverse events (AEs); and (2) identify subgroups (surgical approach, resection type. tumor location, tumor size, respiratory function) with a ≥ 10-point decline or improvement in QOL after SR. RESULTS Two hundred twelve eligible patients were included. There were no significant differences in baseline QOL scores between arms. Median baseline PCS, MCS, and SOBQ scores were 42.7, 51.1, and 70.8, respectively. There were no differences in grade-3+ AEs, overall survival, or recurrence-free survival in patients with baseline scores ≤ median versus > median values, except for a significantly worse overall survival for patients with baseline SOBQ scores ≤ median value. There were no significant differences between the study arms in percentage change of QOL scores from baseline to 3, 12, or 24 months. Further comparison combining the 2 arms demonstrated a higher percentage of patients with a ≥ 10-point decline in SOBQ scores with segmentectomy compared with wedge resection (40.5% vs 21.9%, P = .03) at 12 months, with thoracotomy versus video-assisted thoracic surgery (VATS) (38.8% vs 20.4%, P = .03) at 12 months, and T1b versus T1a tumors (46.9% vs 23.5%, P = .020) at 24 months. A ≥ 10-point improvement in PCS score was seen at 3 months with VATS versus thoracotomy (16.5% vs 3.6%, P = .02). CONCLUSIONS In high-risk operable patients, poor baseline QOL scores were not predictive for worse overall or recurrence-free survival, or for higher risk for AEs following SR. VATS was associated with improvement in physical function at 3 months, and improved dyspnea scores at 12 months, lending support for the preferential use of VATS when SR is undertaken.
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Affiliation(s)
| | | | | | | | | | | | | | - Shauna L Hillman
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, Minn
| | | | | | - Angelina D Tan
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, Minn
| | | | - Joe B Putnam
- Vanderbilt University Medical Center, Nashville, Tenn
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Fairweather M, Wang J, Devlin PM, Hansen J, Baldini EH, Ready JE, Sugarbaker DJ, Bertagnolli MM, Raut CP. Safety and efficacy of radiation dose delivered via iodine-125 brachytherapy mesh implantation for deep cavity sarcomas. Ann Surg Oncol 2014; 22:1455-63. [PMID: 25341749 DOI: 10.1245/s10434-014-4171-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Radiation delivered as brachytherapy (BRT) via catheters placed during extremity soft tissue sarcoma (STS) resection results in acceptable local control rates; however, there are limitations in deep cavities. (125)I seeds embedded in mesh provide a flexible BRT platform that may be contoured to irregular deep cavities surfaces, but the risks and benefits are unknown. METHODS Patients with thoracic, abdominal, pelvic, retroperitoneal, and deep truncal STS undergoing resection and implantation of permanent (125)I mesh BRT at our institution were reviewed. Local recurrence rates within the tumor bed covered by mesh (in field) and postoperative complications were analyzed. RESULTS Between 2000 and 2010, a total of 46 patients were treated for primary (n = 8, 17 %) or recurrent (n = 38, 83 %) deep cavity STS (median follow-up 34.8 months); 74 % received external-beam radiotherapy for this or a prior presentation. In-field recurrences were observed in 9 patients (19.5 %). Crude cumulative incidences of in-field, regional, and distant recurrences at 5 years were 26.3, 54.2, and 54.1 %, respectively. 5-year overall survival rate was 47.2 %; median survival was 44.0 months. Twenty-two patients (48 %) experienced complications, half of whom (24 %) developed grade III/IV complications requiring percutaneous intervention (n = 6) or reoperation (n = 5) at a median of 35.5 days. There were no postoperative deaths. CONCLUSIONS To our knowledge, this is the first study to report safety and efficacy for permanent (125)I mesh BRT implantation after resection of deep cavity STS. Local in-field recurrence rates were relatively low in this high-risk population. However, 24 % developed complications requiring intervention. (125)I mesh BRT appears effective, but it should be used with caution.
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Affiliation(s)
- Mark Fairweather
- Division of Surgical Oncology, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA,
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Non-small cell lung cancer: when to offer sublobar resection. Lung Cancer 2014; 86:115-20. [PMID: 25249427 DOI: 10.1016/j.lungcan.2014.09.004] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 09/07/2014] [Indexed: 11/20/2022]
Abstract
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.
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Fernando HC, Landreneau RJ, Mandrekar SJ, Nichols FC, Hillman SL, Heron DE, Meyers BF, DiPetrillo TA, Jones DR, Starnes SL, Tan AD, Daly BDT, Putnam JB. Impact of brachytherapy on local recurrence rates after sublobar resection: results from ACOSOG Z4032 (Alliance), a phase III randomized trial for high-risk operable non-small-cell lung cancer. J Clin Oncol 2014; 32:2456-62. [PMID: 24982457 DOI: 10.1200/jco.2013.53.4115] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE A major concern with sublobar resection (SR) for non-small-cell lung cancer (NSCLC) is high local recurrence (LR). Adjuvant brachytherapy may reduce LR This multicenter randomized trial compares SR to SR with brachytherapy (SRB). PATIENTS AND METHODS High-risk operable patients with NSCLC ≤ 3 cm were randomly assigned to SR or SRB. The primary end point was time to LR, where LR included recurrence at the staple line (local progression), in the primary tumor lobe away from the staple line, and in ipsilateral hilar nodes. The trial was designed to have a 90% power to detect a hazard ratio (HR) of 0.315 in favor of SRB, using a one-sided type I error rate of 0.05 with a sample size of 100 eligible patients in each arm. RESULTS Two hundred twenty-four patients were randomly assigned; 222 patients were evaluable for intent-to-treat analysis. Median age was 71 years (range, 49 to 87 years). No differences were found in baseline characteristics. Median follow-up time was 4.38 years (range, 0.04 to 5.59 years). There was no difference in time to LR (HR, 1.01; 95% CI, 0.51 to 1.98; log-rank P = .98) or in the types of LR. Local progression occurred in only 17 (7.7%) of 222 patients. In patients with potentially compromised margins (margin < 1 cm, margin-to-tumor ratio < 1, positive staple line cytology, wedge resection, nodule size > 2.0 cm), SRB did not reduce LR, although trends favored the SRB arm. This was most marked in 14 patients with positive staple line cytology (HR, 0.22; P = .24). Three-year overall survival rates were similar for patients in the SR (71%) and SRB (71%) arms (P = .97). CONCLUSION Brachytherapy did not reduce LR after SR. This finding may have been related to closer attention to parenchymal margins by surgeons participating in this study.
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Affiliation(s)
- Hiran C Fernando
- Hiran C. Fernando, Boston Medical Center, Boston, MA; Rodney J. Landreneau, Dwight E. Heron, and Benedict D.T. Daly, University of Pittsburgh, Pittsburgh, PA; Sumithra J. Mandrekar, Francis C. Nichols, Shauna L. Hillman, and Angelina D. Tan, Mayo Clinic, Rochester, MN; Bryan F. Meyers, Washington University of St Louis, St Louis, MO; Thomas A. DiPetrillo, Rhode Island Hospital, Providence, RI; David R. Jones, University of Virginia, Charlottesville, VA; Sandra L. Starnes, University of Cincinnati, Cincinnati, OH; and Joe B. Putnam Jr, Vanderbilt University Medical Center, Nashville, TN.
| | - Rodney J Landreneau
- Hiran C. Fernando, Boston Medical Center, Boston, MA; Rodney J. Landreneau, Dwight E. Heron, and Benedict D.T. Daly, University of Pittsburgh, Pittsburgh, PA; Sumithra J. Mandrekar, Francis C. Nichols, Shauna L. Hillman, and Angelina D. Tan, Mayo Clinic, Rochester, MN; Bryan F. Meyers, Washington University of St Louis, St Louis, MO; Thomas A. DiPetrillo, Rhode Island Hospital, Providence, RI; David R. Jones, University of Virginia, Charlottesville, VA; Sandra L. Starnes, University of Cincinnati, Cincinnati, OH; and Joe B. Putnam Jr, Vanderbilt University Medical Center, Nashville, TN
| | - Sumithra J Mandrekar
- Hiran C. Fernando, Boston Medical Center, Boston, MA; Rodney J. Landreneau, Dwight E. Heron, and Benedict D.T. Daly, University of Pittsburgh, Pittsburgh, PA; Sumithra J. Mandrekar, Francis C. Nichols, Shauna L. Hillman, and Angelina D. Tan, Mayo Clinic, Rochester, MN; Bryan F. Meyers, Washington University of St Louis, St Louis, MO; Thomas A. DiPetrillo, Rhode Island Hospital, Providence, RI; David R. Jones, University of Virginia, Charlottesville, VA; Sandra L. Starnes, University of Cincinnati, Cincinnati, OH; and Joe B. Putnam Jr, Vanderbilt University Medical Center, Nashville, TN
| | - Francis C Nichols
- Hiran C. Fernando, Boston Medical Center, Boston, MA; Rodney J. Landreneau, Dwight E. Heron, and Benedict D.T. Daly, University of Pittsburgh, Pittsburgh, PA; Sumithra J. Mandrekar, Francis C. Nichols, Shauna L. Hillman, and Angelina D. Tan, Mayo Clinic, Rochester, MN; Bryan F. Meyers, Washington University of St Louis, St Louis, MO; Thomas A. DiPetrillo, Rhode Island Hospital, Providence, RI; David R. Jones, University of Virginia, Charlottesville, VA; Sandra L. Starnes, University of Cincinnati, Cincinnati, OH; and Joe B. Putnam Jr, Vanderbilt University Medical Center, Nashville, TN
| | - Shauna L Hillman
- Hiran C. Fernando, Boston Medical Center, Boston, MA; Rodney J. Landreneau, Dwight E. Heron, and Benedict D.T. Daly, University of Pittsburgh, Pittsburgh, PA; Sumithra J. Mandrekar, Francis C. Nichols, Shauna L. Hillman, and Angelina D. Tan, Mayo Clinic, Rochester, MN; Bryan F. Meyers, Washington University of St Louis, St Louis, MO; Thomas A. DiPetrillo, Rhode Island Hospital, Providence, RI; David R. Jones, University of Virginia, Charlottesville, VA; Sandra L. Starnes, University of Cincinnati, Cincinnati, OH; and Joe B. Putnam Jr, Vanderbilt University Medical Center, Nashville, TN
| | - Dwight E Heron
- Hiran C. Fernando, Boston Medical Center, Boston, MA; Rodney J. Landreneau, Dwight E. Heron, and Benedict D.T. Daly, University of Pittsburgh, Pittsburgh, PA; Sumithra J. Mandrekar, Francis C. Nichols, Shauna L. Hillman, and Angelina D. Tan, Mayo Clinic, Rochester, MN; Bryan F. Meyers, Washington University of St Louis, St Louis, MO; Thomas A. DiPetrillo, Rhode Island Hospital, Providence, RI; David R. Jones, University of Virginia, Charlottesville, VA; Sandra L. Starnes, University of Cincinnati, Cincinnati, OH; and Joe B. Putnam Jr, Vanderbilt University Medical Center, Nashville, TN
| | - Bryan F Meyers
- Hiran C. Fernando, Boston Medical Center, Boston, MA; Rodney J. Landreneau, Dwight E. Heron, and Benedict D.T. Daly, University of Pittsburgh, Pittsburgh, PA; Sumithra J. Mandrekar, Francis C. Nichols, Shauna L. Hillman, and Angelina D. Tan, Mayo Clinic, Rochester, MN; Bryan F. Meyers, Washington University of St Louis, St Louis, MO; Thomas A. DiPetrillo, Rhode Island Hospital, Providence, RI; David R. Jones, University of Virginia, Charlottesville, VA; Sandra L. Starnes, University of Cincinnati, Cincinnati, OH; and Joe B. Putnam Jr, Vanderbilt University Medical Center, Nashville, TN
| | - Thomas A DiPetrillo
- Hiran C. Fernando, Boston Medical Center, Boston, MA; Rodney J. Landreneau, Dwight E. Heron, and Benedict D.T. Daly, University of Pittsburgh, Pittsburgh, PA; Sumithra J. Mandrekar, Francis C. Nichols, Shauna L. Hillman, and Angelina D. Tan, Mayo Clinic, Rochester, MN; Bryan F. Meyers, Washington University of St Louis, St Louis, MO; Thomas A. DiPetrillo, Rhode Island Hospital, Providence, RI; David R. Jones, University of Virginia, Charlottesville, VA; Sandra L. Starnes, University of Cincinnati, Cincinnati, OH; and Joe B. Putnam Jr, Vanderbilt University Medical Center, Nashville, TN
| | - David R Jones
- Hiran C. Fernando, Boston Medical Center, Boston, MA; Rodney J. Landreneau, Dwight E. Heron, and Benedict D.T. Daly, University of Pittsburgh, Pittsburgh, PA; Sumithra J. Mandrekar, Francis C. Nichols, Shauna L. Hillman, and Angelina D. Tan, Mayo Clinic, Rochester, MN; Bryan F. Meyers, Washington University of St Louis, St Louis, MO; Thomas A. DiPetrillo, Rhode Island Hospital, Providence, RI; David R. Jones, University of Virginia, Charlottesville, VA; Sandra L. Starnes, University of Cincinnati, Cincinnati, OH; and Joe B. Putnam Jr, Vanderbilt University Medical Center, Nashville, TN
| | - Sandra L Starnes
- Hiran C. Fernando, Boston Medical Center, Boston, MA; Rodney J. Landreneau, Dwight E. Heron, and Benedict D.T. Daly, University of Pittsburgh, Pittsburgh, PA; Sumithra J. Mandrekar, Francis C. Nichols, Shauna L. Hillman, and Angelina D. Tan, Mayo Clinic, Rochester, MN; Bryan F. Meyers, Washington University of St Louis, St Louis, MO; Thomas A. DiPetrillo, Rhode Island Hospital, Providence, RI; David R. Jones, University of Virginia, Charlottesville, VA; Sandra L. Starnes, University of Cincinnati, Cincinnati, OH; and Joe B. Putnam Jr, Vanderbilt University Medical Center, Nashville, TN
| | - Angelina D Tan
- Hiran C. Fernando, Boston Medical Center, Boston, MA; Rodney J. Landreneau, Dwight E. Heron, and Benedict D.T. Daly, University of Pittsburgh, Pittsburgh, PA; Sumithra J. Mandrekar, Francis C. Nichols, Shauna L. Hillman, and Angelina D. Tan, Mayo Clinic, Rochester, MN; Bryan F. Meyers, Washington University of St Louis, St Louis, MO; Thomas A. DiPetrillo, Rhode Island Hospital, Providence, RI; David R. Jones, University of Virginia, Charlottesville, VA; Sandra L. Starnes, University of Cincinnati, Cincinnati, OH; and Joe B. Putnam Jr, Vanderbilt University Medical Center, Nashville, TN
| | - Benedict D T Daly
- Hiran C. Fernando, Boston Medical Center, Boston, MA; Rodney J. Landreneau, Dwight E. Heron, and Benedict D.T. Daly, University of Pittsburgh, Pittsburgh, PA; Sumithra J. Mandrekar, Francis C. Nichols, Shauna L. Hillman, and Angelina D. Tan, Mayo Clinic, Rochester, MN; Bryan F. Meyers, Washington University of St Louis, St Louis, MO; Thomas A. DiPetrillo, Rhode Island Hospital, Providence, RI; David R. Jones, University of Virginia, Charlottesville, VA; Sandra L. Starnes, University of Cincinnati, Cincinnati, OH; and Joe B. Putnam Jr, Vanderbilt University Medical Center, Nashville, TN
| | - Joe B Putnam
- Hiran C. Fernando, Boston Medical Center, Boston, MA; Rodney J. Landreneau, Dwight E. Heron, and Benedict D.T. Daly, University of Pittsburgh, Pittsburgh, PA; Sumithra J. Mandrekar, Francis C. Nichols, Shauna L. Hillman, and Angelina D. Tan, Mayo Clinic, Rochester, MN; Bryan F. Meyers, Washington University of St Louis, St Louis, MO; Thomas A. DiPetrillo, Rhode Island Hospital, Providence, RI; David R. Jones, University of Virginia, Charlottesville, VA; Sandra L. Starnes, University of Cincinnati, Cincinnati, OH; and Joe B. Putnam Jr, Vanderbilt University Medical Center, Nashville, TN
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Bott MJ, Crabtree T. Treatment of stage I lung cancer in high-risk and inoperable patients: SBRT vs. RFA vs. sublobar resection. Ann Cardiothorac Surg 2014; 3:167-9. [PMID: 24790840 DOI: 10.3978/j.issn.2225-319x.2014.03.04] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Accepted: 02/27/2014] [Indexed: 11/14/2022]
Affiliation(s)
- Matthew J Bott
- Division of Thoracic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Traves Crabtree
- Division of Thoracic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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Hu Y, McMurry TL, Isbell JM, Stukenborg GJ, Kozower BD. Readmission after lung cancer resection is associated with a 6-fold increase in 90-day postoperative mortality. J Thorac Cardiovasc Surg 2014; 148:2261-2267.e1. [PMID: 24823283 DOI: 10.1016/j.jtcvs.2014.04.026] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 03/25/2014] [Accepted: 04/11/2014] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Postoperative readmission affects patient care and healthcare costs. There is a paucity of nationwide data describing the clinical significance of readmission after thoracic operations. The purpose of this study was to evaluate the relationship between postoperative readmission and mortality after lung cancer resection. METHODS Data were extracted for patients undergoing lung cancer resection from the linked Surveillance Epidemiology and End Results-Medicare registry (2006-2011), including demographics, comorbidities, socioeconomic factors, readmission within 30 days from discharge, and 90-day mortality. Readmitting facility and diagnoses were identified. A hierarchical regression model clustered at the hospital level identified predictors of readmission. RESULTS We identified 11,432 patients undergoing lung cancer resection discharged alive from 677 hospitals. The median age was 74.5 years, and 52% of patients received an open lobectomy. Thirty-day readmission rate was 12.8%, and 28.3% of readmissions were to facilities that did not perform the original operation. Readmission was associated with a 6-fold increase in 90-day mortality (14.4% vs 2.5%, P<.001). The most common readmitting diagnoses were respiratory insufficiency, pneumonia, pneumothorax, and cardiac complications. Patient factors associated with readmission included resection type; age; prior induction chemoradiation; preoperative comorbidities, including congestive heart failure and chronic obstructive pulmonary disease; and low regional population density. CONCLUSIONS Factors associated with early readmission after lung cancer resection include patient comorbidities, type of operation, and socioeconomic factors. Metrics that only report readmissions to the operative provider miss one-fourth of all cases. Readmitted patients have an increased risk of death and demand maximum attention and optimal care.
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Affiliation(s)
- Yinin Hu
- Division of Thoracic Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Va
| | - Timothy L McMurry
- Department of Public Health Sciences, University of Virginia Health System, Charlottesville, Va
| | - James M Isbell
- Division of Thoracic Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Va
| | - George J Stukenborg
- Department of Public Health Sciences, University of Virginia Health System, Charlottesville, Va
| | - Benjamin D Kozower
- Division of Thoracic Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Va; Department of Public Health Sciences, University of Virginia Health System, Charlottesville, Va.
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Donington JS. Current readings: sublobar resection for non-small-cell lung cancer. Semin Thorac Cardiovasc Surg 2014; 25:22-9. [PMID: 23800526 DOI: 10.1053/j.semtcvs.2013.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2013] [Indexed: 11/11/2022]
Abstract
The Lung Cancer Study Group consensus recommending lobectomy for stage I non-small-cell lung cancer (NSCLC) to reduce local recurrence associated with sublobar resections has directed NSCLC care since its 1995 publication. However, enhancements in imaging technology and in our understanding of the molecular biology of NSCLC over the past 2 decades have produced large cohorts of patients with smaller, better staged, and more indolent tumors than evaluated by the Lung Cancer Study Group. Numerous single-institution trials have demonstrated that in well-selected patients, sublobar resection can afford comparable survival and recurrence rates with lobectomy with a more favorable risk profile. This review of recent literature will focus on 2 separate issues with regard to the use of sublobar resections for stage I NSCLC: (1) a comparison to nonoperative ablative therapies in medically unfit patients, and (2) identifying in which subset of the noncompromised standard-risk population, sublobar resections provide equivalent outcome to lobectomy.
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Affiliation(s)
- Jessica S Donington
- Department of Cardiothoracic Surgery, NYU School of Medicine, New York, New York 10016, USA.
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Puri V, Crabtree TD, Bell JM, Kreisel D, Krupnick AS, Broderick S, Patterson GA, Meyers BF. National cooperative group trials of "high-risk" patients with lung cancer: are they truly "high-risk"? Ann Thorac Surg 2014; 97:1678-83; discussion 1683-5. [PMID: 24534644 DOI: 10.1016/j.athoracsur.2013.12.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 12/02/2013] [Accepted: 12/09/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND The American College of Surgery Oncology Group (ACOSOG) trials z4032 and z4033 prospectively characterized lung cancer patients as "high-risk" for surgical intervention, and these results have appeared frequently in the literature. We hypothesized that many patients who meet the objective enrollment criteria for these trials ("high-risk") have similar perioperative outcomes as "normal-risk" patients. METHODS We reviewed a prospective institutional database and classified patients undergoing resection for clinical stage I lung cancer as "high-risk" and "normal-risk" by ACOSOG major criteria. RESULTS From 2000 to 2010, 1,066 patients underwent resection for clinical stage I lung cancer. Of these, 194 (18%) met ACOSOG major criteria for risk (preoperative forced expiratory volume in 1 second or diffusion capacity of the lung for carbon monoxide≤50% predicted). "High-risk" patients were older (66.4 vs 64.6 years, p=0.02) but similar to controls in sex, prevalence of hypertension, diabetes, and coronary artery disease. "High-risk" patients were less likely than "normal-risk" patients to undergo a lobectomy (117 of 194 [60%] vs 665 of 872 [76%], p<0.001). "High-risk" and control patients experienced similar morbidity (any complication: 55 of 194 [28%] vs 230 of 872 [26%], p=0.59) and 30-day mortality (2 of 194 [1%] vs 14 of 872 [ 2%], p=0.75). A regression analysis showed age (hazard risk, 1.04; 95% confidence interval, 1.02 to 1.06) and coronary artery disease (hazard risk, 1.58; 95% confidence interval, 1.05 to 2.40) were associated with an elevated risk of complications in those undergoing lobectomy, whereas female sex (hazard ratio, 0.63; 95% confidence interval, 0.44 to 0.91) was protective. ACOSOG "high-risk" status was not associated with perioperative morbidity. CONCLUSIONS There are no important differences in early postsurgical outcomes between lung cancer patients characterized as "high-risk" and "normal-risk" by ACOSOG trial enrollment criteria, despite a significant proportion of "high-risk" patients undergoing lobectomy.
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Affiliation(s)
- Varun Puri
- Department of Surgery, Washington University, St. Louis, St. Louis, Missouri.
| | - Traves D Crabtree
- Department of Surgery, Washington University, St. Louis, St. Louis, Missouri
| | - Jennifer M Bell
- Department of Surgery, Washington University, St. Louis, St. Louis, Missouri
| | - Daniel Kreisel
- Department of Surgery, Washington University, St. Louis, St. Louis, Missouri
| | | | - Stephen Broderick
- Department of Surgery, Washington University, St. Louis, St. Louis, Missouri
| | | | - Bryan F Meyers
- Department of Surgery, Washington University, St. Louis, St. Louis, Missouri
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Hennon MW, Yendamuri S. [Advance in lung cancer surgery]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2014; 16:C5-8. [PMID: 23677002 PMCID: PMC6123567 DOI: 10.3779/j.issn.1009-3419.2013.03.11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
近年来微创技术在各期肺癌的检测、诊断和治疗中的应用出现爆发。这些技术的应用提高了手术的风险-收益比,并且使考虑肺癌手术治疗的患者更易接受手术。同时它们为晚期肺癌患者综合治疗的实施提供了便利。该综述总结了代表肺癌胸外科手术前沿的现有外科技术。
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Affiliation(s)
- Mark W Hennon
- Department of Thoracic Surgery, Roswell Park Cancer Institute, State University of New York, Buffalo, NY, USA
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Analysis of first recurrence and survival in patients with stage I non-small cell lung cancer treated with surgical resection or stereotactic radiation therapy. J Thorac Cardiovasc Surg 2014; 147:1183-1191; discussion 1191-2. [PMID: 24507980 DOI: 10.1016/j.jtcvs.2013.11.057] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 11/21/2013] [Accepted: 11/29/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Comparative studies of survival between stereotactic body radiation therapy (SBRT) and surgery have been limited by lack of comparisons of recurrence patterns between matched cohorts in non-small cell lung cancer (NSCLC). METHODS All patients undergoing treatment with surgery or SBRT for clinical stage I NSCLC between June 2004 and December 2010 were reviewed. Age, tumor characteristics, comorbidity score, pulmonary function, overall survival (OS), disease-free survival (DFS), and recurrence data were collected and propensity matching performed. RESULTS The mean age for surgery (n = 458) was 65.8 ± 10.5 versus 74.4 ± 9.4 for SBRT (n = 151) (P < .0001). For the entire surgical cohort, 3-year OS was 78% and DFS was 72%. For the entire SBRT cohort, 3-year OS was 47% and DFS was 42%. The overall local recurrence rate for surgery was 2.6%. The overall local recurrence rate for SBRT was 10.7%. A propensity-matched comparison based on age, tumor size, Adult Comorbidity Evaluation comorbidity score, forced expiratory volume in the first second of expiration, and tumor location resulted in 56 matched pairs. The 3-year OS was 52% versus 68% for SBRT and surgery (P = .05); DFS was 47% versus 65% (P = .01). At 3 years, local recurrence-free survival was 90% versus 92% for SBRT and surgery (P = .07). CONCLUSIONS Although surgical resection seems to result in better OS and DFS versus SBRT, matching these disparate cohorts of patients remains challenging. Participation in clinical trials is essential to define the indications and relative efficacy of surgery and radiation therapy in a high-risk population with stage I NSCLC.
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Kent M, Landreneau R, Mandrekar S, Hillman S, Nichols F, Jones D, Starnes S, Tan A, Putnam J, Meyers B, Daly B, Fernando HC. Segmentectomy Versus Wedge Resection for Non-Small Cell Lung Cancer in High-Risk Operable Patients. Ann Thorac Surg 2013; 96:1747-54; discussion 1754-5. [DOI: 10.1016/j.athoracsur.2013.05.104] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 05/22/2013] [Accepted: 05/24/2013] [Indexed: 10/26/2022]
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Mahmood S, Bilal H, Faivre-Finn C, Shah R. Is stereotactic ablative radiotherapy equivalent to sublobar resection in high-risk surgical patients with stage I non-small-cell lung cancer? Interact Cardiovasc Thorac Surg 2013; 17:845-53. [PMID: 23900381 DOI: 10.1093/icvts/ivt262] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'Is stereotactic ablative radiotherapy equivalent to sublobar resection in high-risk surgical patients with Stage I non-small cell lung cancer?'. Altogether over 318 papers were found, of which 18 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Stereotactic ablative radiotherapy (SABR) and sublobar resection (SLR) offer clear survival benefit in the treatment of early-stage non-small-cell lung cancer (NSCLC) in high-risk patients unsuitable for lobectomy and SABR has shown good results in medically operable patients. No randomized data are available comparing SLR and SABR, and therefore, data from prospective studies were compared. Overall survival at 1 year was similar between patients treated with SABR and SLR (81-85.7 vs 92%); however, overall 3-year survival was higher following SLR (87.1 vs 45.1-57.1%). There was no statistically significant difference in local recurrence in patients treated with SABR compared with SLR (3.5-14.5 vs 4.8-20%). Both treatment modalities are associated with complications. Fatigue (31-32.6%), pneumonitis (2.1-12.5%) and chest wall pain (3.1-12%) were common following SABR; however, serious grade 3 and 4 toxicity were rare. Morbidity following SLR was reported between 7.3 and 33.7%. Thirty-day mortality following SABR was 0%, while predicted 30-day mortality following a lung resection, using the thoracoscore predictive model ranges between 1 and 2.6%. Treatment for early-stage NSCLC should be tailored to individual patients. SABR is an acceptable alternative to SLR in high-risk patients but comparative data are required.
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[Treatment of non-small cell lung carcinoma in early stages]. Cir Esp 2013; 91:625-32. [PMID: 23829961 DOI: 10.1016/j.ciresp.2013.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 01/31/2013] [Indexed: 11/23/2022]
Abstract
Treatment of lung carcinoma is multidisciplinary. There are different therapeutic strategies available, although surgery shows the best results in those patients with lung carcinoma in early stages. Other options such as stereotactic radiation therapy are relegated to patients with small tumors and poor cardiopulmonary reserve or to those who reject surgery. Adjuvant chemotherapy is not justified in patients with stage i of the disease and so double adjuvant chemotherapy should be considered. This adjuvant chemotherapy should be based on cisplatin after surgery in those patients with stages ii and IIIA.
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Shah A, Hahn SM, Stetson RL, Friedberg JS, Pechet TTV, Sher DJ. Cost-effectiveness of stereotactic body radiation therapy versus surgical resection for stage I non-small cell lung cancer. Cancer 2013; 119:3123-32. [DOI: 10.1002/cncr.28131] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Revised: 03/06/2013] [Accepted: 03/14/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Anand Shah
- Department of Radiation Oncology; Perelman School of Medicine, University of Pennsylvania; Philadelphia Pennsylvania
- Department of Radiation Oncology; Columbia University Medical Center; New York New York
| | - Stephen M. Hahn
- Department of Radiation Oncology; Perelman School of Medicine, University of Pennsylvania; Philadelphia Pennsylvania
| | - Robert L. Stetson
- Office of Strategic Decision Support, University of Pennsylvania Health System; Philadelphia Pennsylvania
| | - Joseph S. Friedberg
- Department of Surgery; Perelman School of Medicine, University of Pennsylvania; Philadelphia Pennsylvania
| | - Taine T. V. Pechet
- Department of Surgery; Perelman School of Medicine, University of Pennsylvania; Philadelphia Pennsylvania
| | - David J. Sher
- Department of Radiation Oncology; Rush University Medical Center; Chicago Illinois
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Abstract
Sublobar resection is a compromise for patients with insufficient lung function. Recently small lung cancers are usually detected at the early stage, but sublobar resection in patients who can tolerate lobectomy is not yet standard treatment. Although a few old studies showed higher rates of local recurrence and a poorer prognosis after sublobar resection compared with lobectomy, most have indicated promising outcomes after sublobar resection. Large-scale, randomized, controlled multicenter trials are ongoing in the United States and Japan, the results of which could create revolutionary changes in general thoracic surgery. This article reviews the literature on surgical outcomes of radical sublobar resection.
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Senthi S, Haasbeek CJA, Lagerwaard FJ, Verbakel WF, de Haan PF, Slotman BJ, Senan S. Radiotherapy for a second primary lung cancer arising post-pneumonectomy: planning considerations and clinical outcomes. J Thorac Dis 2013; 5:116-22. [PMID: 23585935 DOI: 10.3978/j.issn.2072-1439.2013.02.07] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Accepted: 02/27/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Second primary non-small cell lung cancer (SPLC) is a significant cause of death amongst lung cancer survivors. As subsequent surgery is seldom feasible post-pneumonectomy, we studied the long-term clinical outcomes achieved with curative radiotherapy using modern delivery techniques. METHODS Retrospective review of an institutional database between 2003-2011 identified 27 patients who had received curative radiotherapy for SPLC arising post-pneumonectomy. Treatments included; stereotactic ablative radiotherapy (SABR, n=20, dose 54-60 Gy in 3-8 fractions), hypofractionated radiotherapy (HFR, n=6, dose 39-60 Gy in 12-23 fractions) and conventional radiotherapy (RT, n=1, 60 Gy in 30 fractions). Clinical follow-up with a CT scan at 3, 6 and 12 months, then yearly was performed. Toxicities were scored using the common toxicity criteria for adverse events (version 4.0). RESULTS The median overall survival was 39 months (95% CI, 33-44 months). After a median follow-up of 52 months (95% CI, 37-67 months), any recurrence was observed in four (15%) patients. Actuarial 3-year rates of local, regional and distant recurrences were 8% (95% CI, 0-21 months), 10% (95% CI, 0-23%) and 9% (95% CI, 0-20%), respectively. Patients receiving HFR or RT all had centrally located tumors. Of the patients treated with HFR delivered 12 fractions, 75% (3/4) developed grade 3 or higher radiation pneumonitis (RP), including one probable grade 5 toxicity. Of those receiving RT or HFR in 13 or more fractions no (0/3) grade 3 or worse RP was observed, despite such treatment being used for larger tumors and resulting in worse lung dose-volume histogram metrics. All the patients who developed RP had radiotherapy plans, which prioritized the sparing of central structures over lung sparing. No non-RP grade 3 or higher toxicities were observed. CONCLUSIONS Curative radiotherapy is an effective treatment for SPLC arising post-pneumonectomy. For larger central tumors, our data suggests that plans should prioritize reducing lung doses above the sparing of central structures.
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Affiliation(s)
- Sashendra Senthi
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
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Donington J, Ferguson M, Mazzone P, Handy J, Schuchert M, Fernando H, Loo B, Lanuti M, de Hoyos A, Detterbeck F, Pennathur A, Howington J, Landreneau R, Silvestri G. American College of Chest Physicians and Society of Thoracic Surgeons consensus statement for evaluation and management for high-risk patients with stage I non-small cell lung cancer. Chest 2013. [PMID: 23208335 DOI: 10.1378/chest.12-0790] [Citation(s) in RCA: 175] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The standard treatment of stage I non-small cell lung cancer (NSCLC) is lobectomy with systematic mediastinal lymph node evaluation. Unfortunately, up to 25% of patients with stage I NSCLC are not candidates for lobectomy because of severe medical comorbidity. METHODS A panel of experts was convened through the Thoracic Oncology Network of the American College of Chest Physicians and the Workforce on Evidence-Based Surgery of the Society of Thoracic Surgeons. Following a literature review, the panel developed 13 suggestions for evaluation and treatment through iterative discussion and debate until unanimous agreement was achieved. RESULTS Pretreatment evaluation should focus primarily on measures of cardiopulmonary physiology, as respiratory failure represents the greatest interventional risk. Alternative treatment options to lobectomy for high-risk patients include sublobar resection with or without brachytherapy, stereotactic body radiation therapy, and radiofrequency ablation. Each is associated with decreased procedural morbidity and mortality but increased risk for involved lobe and regional recurrence compared with lobectomy, but direct comparisons between modalities are lacking. CONCLUSIONS Therapeutic options for the treatment of high-risk patients are evolving quickly. Improved radiographic staging and the diagnosis of smaller and more indolent tumors push the risk-benefit decision toward parenchymal-sparing or nonoperative therapies in high-risk patients. Unbiased assessment of treatment options requires uniform reporting of treatment populations and outcomes in clinical series, which has been lacking to date.
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Affiliation(s)
- Jessica Donington
- Department of Cardiothoracic Surgery, NYU School of Medicine, New York, NY.
| | - Mark Ferguson
- Department of Surgery, University of Chicago, Chicago, IL
| | - Peter Mazzone
- Department of Pulmonary, Allergy, and Critical Care Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | | | - Matthew Schuchert
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Hiran Fernando
- Department of Cardiothoracic Surgery, Boston Medical Center, Boston, MA
| | - Billy Loo
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA
| | - Michael Lanuti
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA
| | - Alberto de Hoyos
- Department of Cardiothoracic Surgery, Northwestern Memorial Hospital, Chicago, IL
| | - Frank Detterbeck
- Department of Thoracic Surgery, Yale University School of Medicine, New Haven, CT
| | - Arjun Pennathur
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - John Howington
- Department of Surgery, Northshore University Health System, Evanston, IL
| | - Rodney Landreneau
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Gerard Silvestri
- Division of Pulmonary Medicine and Critical Care, Medical University of South Carolina, Charleston, SC
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Outcomes of stereotactic ablative radiotherapy for central lung tumours: a systematic review. Radiother Oncol 2013; 106:276-82. [PMID: 23462705 DOI: 10.1016/j.radonc.2013.01.004] [Citation(s) in RCA: 190] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 01/09/2013] [Accepted: 01/14/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Stereotactic ablative radiotherapy (SABR) has improved the survival for medically inoperable patients with peripheral early-stage non-small cell lung cancer (NSCLC). We performed a systematic review of outcomes for central lung tumours. MATERIAL AND METHODS The systematic review was performed following PRISMA guidelines. Survival outcomes were evaluated for central early-stage NSCLC. Local control and toxicity outcomes were evaluated for any centrally-located lung tumour. RESULTS Twenty publications met the inclusion criteria, reporting outcomes for 563 central lung tumours, including 315 patients with early-stage NSCLC. There was heterogeneity in the planning, prescribing and delivery of SABR and the common toxicity criteria used to define toxicities (versions 2.0-4.0). Tumour location (central versus peripheral) did not impact overall survival. Local control rates were ≥ 85% when the prescribed biologically equivalent tumour dose was ≥ 100 Gy. Treatment-related mortality was 2.7% overall, and 1.0% when the biologically equivalent normal tissue dose was ≤ 210 Gy. Grade 3 or 4 toxicities may be more common following SABR for central tumours, but occurred in less than 9% of patients. CONCLUSIONS Post-SABR survival for early-stage NSCLC is not affected by tumour location. SABR achieves high local control with limited toxicity when appropriate fractionation schedules are used for central tumours.
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D'Amico TA. The best that surgery has to offer. J Thorac Cardiovasc Surg 2013; 145:699-701. [PMID: 23312096 DOI: 10.1016/j.jtcvs.2012.12.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 12/05/2012] [Indexed: 10/27/2022]
Affiliation(s)
- Thomas A D'Amico
- Division of Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA.
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Hennon MW, Yendamuri S. Advances in lung cancer surgery. J Carcinog 2012; 11:21. [PMID: 23346014 PMCID: PMC3548435 DOI: 10.4103/1477-3163.105341] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Accepted: 12/13/2012] [Indexed: 11/09/2022] Open
Abstract
The last few years have witnessed an explosion of the use of minimally invasive techniques for the detection, diagnosis, and treatment of all stages of lung Cancer. The use of these techniques has improved the risk-benefit ratio of surgery and has made it more acceptable to patients considering lung surgery. They have also facilitated the delivery of multi-modality therapy to patients with advanced lung cancer. This review article summarizes current surgical techniques that represent the “cutting edge” of thoracic surgery for lung cancer.
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Affiliation(s)
- Mark W Hennon
- Department of Thoracic Surgery, Roswell Park Cancer Institute, NY, USA ; Department of Surgery, State University of New York, Buffalo, NY, USA
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Abstract
BACKGROUND This is an updated version of the original review published in Issue 2, 2008 of The Cochrane Library. Non-small cell lung cancers (NSCLC) constitute about 80% of all lung cancer cases. Although surgery is the only curative treatment of NSCLC, fewer than 20% of tumors can be radically resected. Radiotherapy is one of the main treatment modalities in lung cancer, contributing to both its cure and palliation. Endobronchial brachytherapy (EBB) has been used as one approach to improve local control either alone or in combination with other treatments. OBJECTIVES To assess the effectiveness of palliative EBB compared with external beam radiation therapy (EBRT) or other alternative endoluminal treatments in controlling thoracic symptoms and increasing survival in patients with advanced NSCLC. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL,The Cochrane Library, Issue 1 2012), MEDLINE (OvidSP) (1966 to January 2012), EMBASE (Ovid) (1974 to January 2012) and other databases as well as reference lists, and we handsearched selected journals and conference proceedings. SELECTION CRITERIA Randomized controlled trials (RCTs) comparing different regimens of palliative EBB with EBRT or other endobronchial interventions in patients with advanced NSCLC. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and conducted risk of bias assessment. MAIN RESULTS We included fourteen RCTs involving 953 participants. We included a new study assessing a variety of different fractionation schedules of high dose rate palliative EBB in this update. There were important differences in the doses of radiotherapy investigated, in the patient characteristics and in the outcomes measured. We found trials comparing EBB to EBRT alone, EBB plus EBRT to EBRT alone, EBB plus chemotherapy to EBB alone, EBB to neodymium: yttrium-aluminum-garnet (Nd-YAG) laser and comparisons between various fractionation schedules of high dose rate EBB. From the heterogeneous information obtained from several small RCTs, we concluded that EBRT alone is more effective for palliation of NSCLC symptoms than EBB alone. Our findings did not provide conclusive evidence to recommend EBB plus EBRT to relieve symptoms compared to EBRT alone. Overall, for the primary endpoint of survival there was no evidence of benefit for EBB compared to EBRT and Nd-YAG laser or for the combination of EBB with chemotherapy. Additionally, findings from one trial suggested that twice 7.4 Gy was superior to the four times per week 3.8 Gy schedule for mean time of local control and fatal hemoptysis. No significant differences were found for fatal hemoptysis as an adverse event of EBB. AUTHORS' CONCLUSIONS The evidence did not provide conclusive results that EBB plus EBRT improved symptom relief over EBRT alone. We were not able to provide conclusive evidence to recommend EBB with EBRT, EBB in preference to EBRT, chemotherapy or Nd-YAG laser. From heterogeneous information obtained from several small RCTs, we conclude that EBRT alone is more effective for palliation than EBB alone. For patients previously treated by EBRT who are symptomatic from recurrent endobronchial central obstruction, EBB may be considered in selected cases.
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Affiliation(s)
- Ludovic Reveiz
- Research Promotion and Development Team, Health Systems Based on Primary Health Care (HSS), Pan American Health Organization,Washington DC, USA.
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Crabtree T, Puri V, Timmerman R, Fernando H, Bradley J, Decker PA, Paulus R, Putnum JB, Dupuy DE, Meyers B. Treatment of stage I lung cancer in high-risk and inoperable patients: comparison of prospective clinical trials using stereotactic body radiotherapy (RTOG 0236), sublobar resection (ACOSOG Z4032), and radiofrequency ablation (ACOSOG Z4033). J Thorac Cardiovasc Surg 2012; 145:692-9. [PMID: 23174176 DOI: 10.1016/j.jtcvs.2012.10.038] [Citation(s) in RCA: 123] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Revised: 09/07/2012] [Accepted: 10/22/2012] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The purpose of the present study was to compare the selection criteria and short-term outcomes among 3 prospective clinical trials using stereotactic body radiotherapy (Radiation Therapy Oncology Group [RTOG] trial 0236), sublobar resection (American College of Surgeons Oncology Group [ACOSOG] trial Z4032), and radiofrequency ablation (ACOSOG trial Z4033). METHODS The selection criteria and outcomes were compared among RTOG 0236 (n = 55), ACOSOG Z4032 (n = 211), and ACOSOG Z4033 (n = 51). Age, Eastern Cooperative Oncology Group performance status, percentage of predicted forced expiratory volume in 1 second, and percentage of predicted carbon monoxide diffusing capacity of the lung were used to perform a propensity-matched analysis among patients with clinical stage 1A in RTOG 0236 and ACOSOG Z4032. RESULTS The patients in ACOSOG Z4033 undergoing radiofrequency ablation were older (75.6 ± 7.5 years) than those in RTOG 0236 (72.5 ± 8.8 years) and ACOSOG Z4032 (70.2 ± 8.5 years; P = .0003). The pretreatment percentage of predicted forced expiratory volume in 1 second was 61.3% ± 33.4% for RTOG 0236, 53.8% ± 19.6% for ACOSOG Z4032, and 48.8% ± 20.3% for ACOSOG Z4033 (P = .15). The pretreatment percentage of predicted carbon monoxide diffusing capacity of the lung was 61.6% ± 30.2% for RTOG 0236, 46.4% ± 15.6% for ACOSOG Z4032, and 43.7% ± 18.0% for ACOSOG Z4033 (P = .001). The overall 90-day mortality for stereotactic body radiotherapy, surgery, and radiofrequency ablation was 0%, 2.4% (5/211), and 2.0% (1/51), respectively (P = .5). Overall, the unadjusted 30-day grade 3+ adverse events were more common with surgery than with stereotactic body radiotherapy (28% vs 9.1%, P = .004), although no difference was between the 2 groups at 90 days. Among the patients with clinical stage IA in ACOSOG Z4032, 29.3% had a more advanced pathologic stage at surgery. A propensity-matched comparison showed no difference between stereotactic body radiotherapy and surgery for 30-day grade 3+ adverse events (odds ratio, 2.37; 95% confidence interval, 0.75-9.90; P = .18). CONCLUSIONS Among appropriately matched patients, no difference was seen in early morbidity between sublobar resection and stereotactic body radiotherapy. These results underscore the need for a randomized trial to delineate the relative survival benefit of each modality and to help stratify patients considered high risk.
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Affiliation(s)
- Traves Crabtree
- Division of Thoracic Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA.
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