Survival and risk factors for progression after resection of the dominant tumor in multifocal, lepidic-type pulmonary adenocarcinoma

Predictors of residual simultaneous multiple ground-glass nodule progression after dominant lesion resection

OBJECTIVE

This study aimed to identify the predictive factors for the progression of residual simultaneous multifocal ground-glass nodules (SMGGNs) after resection of the dominant lesion.

METHODS

Patients (n = 3420) with primary lung cancer who underwent lung resections at our hospital between 2006 and 2016 were screened, and the data from 82 patients who had residual SMGGNs after undergoing surgery for the dominant lesion (pathologically stage 0-IIA) were retrospectively analyzed. Clinicopathological factors that predicted the growth of residual second dominant GGNs were identified.

RESULTS

Median total tumor and solid component sizes of the residual second dominant GGNs were 1.3 cm (interquartile range [IQR]: 0.6-2.0) and 0 cm (IQR: 0-0.7), respectively. During a median follow-up period of 54 months (IQR: 37-78 months), 35 (43%) lesions progressed. Logistic regression analysis revealed that age younger than 70 (OR: 10.54, 95% CI: 1.71-65.11), a dominant lesion with pure solid appearance (reference: GGN, OR: 18.16, 95% CI: 1.66-198.60), a second dominant GGN total size larger than 1.0 cm (OR: 12.27, 95% CI: 1.85-81.17), and a second dominant GGN solid component size larger than 0.5 cm (OR: 17.59, 95% CI: 3.58-86.47) were significant predictive factors for the progression of residual GGNs (all p values < 0.03). Based on an analysis of growth patterns, rapid growth was higher in second dominant GGNs with a part-solid appearance.

CONCLUSIONS

If the resected dominant lesion or the residual second dominant GGN exhibits high-risk factors, the second dominant GGN should be meticulously observed.

Diagnosis and treatment of high-risk bilateral lung ground-glass opacity nodules

In recent years, there has been a significant increase in the detection rate of Ground Glass Opacity (GGO) nodules through high-resolution computed tomography (HRCT). GGO is an imaging finding that encompasses various pathological types, some of which exhibit indolent growth, while others may represent early lung cancer or remain relatively stable, not significantly impacting the surgical treatment outcome. In clinical practice, patients often experience psychological anxiety when multiple pulmonary GGO nodules are present, and they may request simultaneous resection. However, there is currently no standardized criterion for determining when multiple GGO nodules should be resected. As personalized medicine continues to advance, the treatment approach for multiple pulmonary GGO nodules needs to prioritize accuracy. High-risk factors associated with multiple pulmonary GGO nodules may necessitate surgical intervention along with mediastinal lymph node dissection or sampling. This article provides a review of the characteristics, treatment methods, and clinical experiences related to multiple pulmonary GGO nodules, offering practical insights and guidance for healthcare professionals.

Single Anesthesia Strategy for Definitive Management of Bilateral Ground Glass Opacities Using Robotic Bronchoscopic Localization and Resection

This case series describes 2 patients who underwent a single anesthesia strategy for definitive management of bilateral ground-glass opacities harboring adenocarcinoma-spectrum lesions using robotic navigational localization paired with robotic thoracoscopic resection.

Progress in genome-inspired treatment decisions for multifocal lung adenocarcinoma

INTRODUCTION

Multifocal lung adenocarcinoma (MFLA) is becoming increasingly recognized as a distinct subset of lung cancer, with unique biology, disease course, and treatment outcomes. While definitions remain controversial, MFLA is characterized by the development and concurrent presence of multiple independent (non-metastatic) lesions on the lung adenocarcinoma spectrum. Disease progression typically follows an indolent course measured in years, with a lower propensity for nodal and distant metastases than other more common forms of non-small cell lung cancer.

AREAS COVERED

Traditional imaging and histopathological analyses of tumor biopsies are frequently unable to fully characterize the disease, prompting interest in molecular diagnosis. We highlight some of the key questions in the field, including accurate definitions to identify and stage MLFA, molecular tests to stratify patients and treatment decisions, and the lack of clinical trial data to delineate best management for this poorly understood subset of lung cancer patients. We review the existing literature and progress toward a genomic diagnosis for this unique disease entity.

EXPERT OPINION

Multifocal lung adenocarcinoma behaves differently than other forms of non-small cell lung cancer. Progress in molecular diagnosis may enhance potential for accurate definition, diagnosis, and optimizing treatment approach.

Comparative genomics between matched solid and lepidic portions of semi-solid lung adenocarcinomas

BACKGROUND

Genetic changes that drive the transition from lepidic to invasive cancer development within a radiographic ground glass or semi-solid lung lesion (SSL) are not well understood. Biomarkers to predict the transition to solid, invasive cancer within SSL are needed.

METHODS

Patients with surgically resected SSL were identified retrospectively from a surgical database. Clinical characteristics and survival were compared between stage I SSL (n = 65) and solid adenocarcinomas (n = 120) resected during the same time period. Areas of normal lung, in situ lepidic, and invasive solid tumor were microdissected from within the same SSL specimens and next generation sequencing (NGS) and Affymetrix microarray of gene expression were performed.

RESULTS

There were more never smokers, Asian patients, and sub-lobar resections among SSL but no difference in 5-year survival between SSL and solid adenocarcinoma. Driver mutations found in both lepidic and solid invasive portion were EGFR (43%), KRAS (21%), and DNMT3A (5%). CEACAM5 was the most upregulated gene found in solid, invasive portions of SSL. Lepidic and invasive solid areas had many similarities in gene expression, however there were some significant differences with the gene SPP1 being a unique biomarker for the invasive component of a SSL.

CONCLUSIONS

Common lung cancer driver mutations are present in in situ lepidic as well as invasive solid portions of a SSL, suggesting early development of driver mutations. CEACAM5 and SPP1 emerged as promising biomarkers of invasive potential in semi-solid lesions. Other studies have shown both genes to correlate with poor prognosis in lung cancer and their role in evolution of semi-solid lung lesions warrants further study.

Plasma metabolomics study in screening and differential diagnosis of multiple primary lung cancer

BACKGROUND

Multiple primary lung cancer (MPLC) is becoming increasingly common in clinical practice. Imaging examination is sometimes difficult to differentiate from intrapulmonary metastasis (IM) or single primary lung cancer (SPLC) before surgery. There is a lack of effective blood biomarkers as an auxiliary diagnostic method.

PARTICIPANTS AND METHODS

A total of 179 patients who were hospitalized and operated in our department from January to June 2019 were collected, and they were divided into SPLC with 136 patients, MPLC with 24 patients, and IM with 19 patients. In total, 96 healthy people without lung cancer were enrolled. Medical history, imaging, and pathology data were assembled from all participants. Plasma metabolomics analysis was performed by quadrupole time-of-flight tandem mass spectrometry, and data were analyzed using SPSS19.0/Simca 14.1/MetaboAnalyst5.0 software. Significant metabolites were selected by variable importance in projection, P value, and fold change. The area under the receiver operating characteristic curve was used to evaluate their diagnostic ability.

RESULTS

There were significant differences in plasma metabolite profiles between IM and MPLC. Seven metabolites were screened out. Two metabolites had higher levels in IM, and five metabolites had higher levels in MPLC. All had favorable discriminating capacity. Phosphatidyl ethanolamine (38:5) showed the highest sensitivity (0.95) and specificity (0.92). It was followed by l -histidine with sensitivity 0.92 and specificity 0.84. l -tyrosine can be used to identify SPLC and MPLC. The panel composed of related metabolites exhibited higher diagnostic ability. Eight principal metabolites caused remarkable differences between healthy people and MPLC, and five of them had area under the curves greater than 0.85, showing good discriminating power.

CONCLUSION

Through the study of plasma metabolomics, it was found that there were obvious differences in the metabolite profiles of MPLC, IM, SPLC, and the healthy population. Some discovered metabolites possessed excellent diagnostic competence with high sensitivity and specificity. They had the potential to act as biomarkers for the screening and differential diagnosis of MPLCs.

Using the robotic platform in the therapy of multifocal ground glass opacities

Due to their association with invasive adenocarcinoma, ground glass opacities that reach 3 cm in size, develop a solid component ≥2 mm on mediastinal windows, or exhibit ≥25% annual growth warrant operative resection. Minimally invasive techniques are preferred given that approximately one third of patients will present with multifocal focal disease and may require additional operations. A robotic-assisted thoracoscopic surgical approach can be used with percutaneous or bronchoscopic localization techniques and are compatible with developing intraoperative molecular targeting techniques.

Osimertinib showed efficacy on contralateral multiple ground-glass nodules after segmentectomy for lung adenocarcinoma harboring primary EGFR-T790M mutation: a case report and review of the literature

BACKGROUND

Multiple ground-glass nodules (mGGNs) in the lung has been defined as synchronous multiple primary lung cancer (SMPLC), it is has been very difficult challenging to differentiate SMPLC from intrapulmonary metastases, and its treatment remains controversial.

CASE PRESENTATION

We report a case simultaneously involving mGGNs and lung adenocarcinoma harboring primary EGFR-T790M mutation, in which the patient underwent the radical resection of lesions in the left upper lung, and continued the osimertinib treatment for the residual mGGNs in all lobes of the right lung. These mGGNs displayed different responses to osimertinib.

CONCLUSIONS

We reported a successful strategy on the postoperative treatment for mGGNs. For those that cannot be completely resected, the chemotherapy, radiotherapy, stereotactic body radiation therapy, immunotherapy and targeted therapy have been performed instead. The EGFR-TKI therapy strategy showed significant advantages, but how to achieve even better therapeutic effect needs more researches.

V7 ENB-guided thoracoscopic sublobectomy for stage IA synchronous multiple primary lung cancer

BACKGROUND

An increasing number of patients are being diagnosed with synchronous multiple primary lung cancer (SMPLC) with the popularization of lung cancer screening programs. However, a strategy for accurate location and suitable surgery therapy is still lacking. The present study aimed to explore the accuracy and feasibility of electromagnetic navigation bronchoscopy (ENB)-guided thoracoscopic sublobectomy for stage IA SMPLC.

METHODS

Patients with SMPLC who underwent ENB-guided sublobectomy from January 2020 to June 2022 were enrolled in this study. The analysis of localization accuracy of ENB and surgical outcome was conducted.

RESULTS

Overall, 138 patients with 353 malignant nodules were enrolled. The tumor size was 0.7 cm (range from 0.5 to 1.1 cm). ENB localization was performed on 162 nodules, and a customized scoring system was developed to evaluate localization accuracy. The success rate of localization was 98.3% (178/181). Notably, localization accuracy was positively correlated with bronchial signs (p < 0.01) and negatively correlated with the distance from the nodule to the pleura (p = 0.02). All nodules were completely resected. Operation time, drainage volume on the third postoperative day, and catheter time were significantly correlated with the resected lesion numbers (p = 0.009, p = 0.004, and p = 0.01, respectively).

CONCLUSIONS

ENB-guided uniportal video-assisted thoracoscopic sublobectomy provides accurate preoperative localization and avoids unnecessary lung resection of patients with stage IA SMPLC. However, complete resection of multilocation nodules (more than four lesions) increases the risk of postoperative complications. A new combined treatment strategy for SMPLC should be explored.

Prognostic Impact of Very Small Ground-Glass Opacity Component in Stage IA Solid Predominant Non-small Cell Lung Cancer

We evaluated the prognostic role of the presence of a very small ground glass opacity (GGO) component in stage IA solid-predominant non-small cell lung cancer (NSCLC). We evaluated surgically resected 1471 patients diagnosed with stage IA solid-predominant NSCLC. They were classified into 3 groups; that is, GGO group (0.5 Collapse

Key Words

• Clinical stage IA
• Ground-glass opacity
• Lung cancer
• Prognosis

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MESH Headings

• Humans
• Carcinoma, Non-Small-Cell Lung/mortality
• Carcinoma, Non-Small-Cell Lung/diagnostic imaging
• Carcinoma, Non-Small-Cell Lung/surgery
• Carcinoma, Non-Small-Cell Lung/pathology
• Lung Neoplasms/mortality
• Lung Neoplasms/pathology
• Lung Neoplasms/diagnostic imaging
• Lung Neoplasms/surgery
• Male
• Female
• Neoplasm Staging
• Middle Aged
• Aged
• Pneumonectomy/mortality
• Time Factors
• Risk Factors
• Retrospective Studies
• Predictive Value of Tests
• Risk Assessment
• Tomography, X-Ray Computed
• Adult
• Treatment Outcome
• Aged, 80 and over

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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
Mariko Fukui Department of General Thoracic Surgery, Juntendo University School of Medicine, Tokyo, Japan
Kazuhiro Suzuki Department of Radiology, Juntendo University School of Medicine, Tokyo, Japan
Kazuya Takamochi 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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Clinicopathologic Characteristics and Outcomes of Simultaneous Multiple Primary Lung Cancer

Background

Simultaneous multiple primary lung cancer has been detected increasingly nowadays with the development of image technology. However, the clinicopathologic characteristics and outcomes are not clear.

Methods

All consecutive patients diagnosed as simultaneous multiple primary lung cancer according to Martini–Melamed and American College of Chest Physicians criteria from June 2010 to June 2019 in our center were enrolled. The clinicopathologic characteristics and outcomes were compared between patients with the same histological type and different histological types.

Results

A total of 336 patients were enrolled, consisting of 297 (88.4%) patients with the same histological type and 39 (11.6%) patients with different histological types. Compared to patients with the same histological type, patients with different histological types were more commonly males (87.2% vs. 34.0%; p < 0.001) with an older age (65 [62–69] vs. 59 [52–65] yrs; p < 0.001) at diagnosis. Also, patients with different histological types showed worse respiratory function and more advanced stage according to TNM staging. The 1-, 2-, and 3-year overall survival of overall patients was 97.7%, 96.1%, and 92.2%, and the 1-, 2-, and 3-year recurrence-free survival of overall patients was 96.8%, 92.9% and 85.7%, respectively. Importantly, patients with different histological types showed worse overall survival (p < 0.001) and recurrence-free survival (p=0.002) than patients with same histological type. The multivariable Cox proportional hazard model revealed that presence of different histological types was significant predictor for worse overall survival (adjusted hazard ratio: 10.00; 95% confidence interval: 2.92–34.48; p < 0.001) and recurrence-free survival (adjusted hazard ratio: 2.59; 95% confidence interval: 1.14–5.88; p=0.023).

Conclusions

Although relatively less common in simultaneous multiple primary lung cancer, patients with different histological types showed worse clinical characteristics and outcomes.

Comparison of Clinical and Pathological Characteristics Between Extremely Multiple GGNs and Single GGNs

Objective

This study aims to compare the clinical and pathological characteristics between patients undergoing surgery for extremely multiple ground-glass nodules (GGNs) and those for single GGN.

Methods

We defined extremely multiple GGNs as follows: (i) number of GGNs ≥3, (ii) GGN diameter between 3 and 30 mm, and (iii) no less than three nodules that were surgically removed and pathologically diagnosed. Patients with extremely multiple GGNs and single GGNs who underwent surgery at the same time were retrospectively analyzed. The patients were divided into three groups according to the number of nodules: exceedingly multiple nodules (EMN) group (>10), highly multiple nodules (HMN) group (three to 10), and single nodule (SN) group. The clinical and pathological characteristics, surgical methods and prognosis were analyzed.

Results

Ninety-nine patients with single nodules and 102 patients with extremely multiple nodules were enrolled. Among the patients with extremely multiple nodules, 43 (42.2%) had >10 nodules. There were no significant differences in demographic characteristics, such as age, sex, and smoking history, between the groups, but there were differences in tumor characteristics. All patients with >10 nodules showed bilateral pulmonary nodules and presented with both pure and mixed GGNs. The single GGNs were smaller in diameter, and the proportion of mixed GGNs and pathologically invasive adenocarcinoma was lower than that of the primary nodules in the exceedingly multiple GGNs group (p < 0.05). However, the proportion of both mixed GGNs and malignant nodules decreased significantly with the increasing number of total lesions. During postoperative follow-up, one patient in the highly multiple nodules group had a local recurrence, and 16 (15.7%) patients in the extremely multiple GGNs group and 10 (9.8%) patients in the single GGN group had enlarged unresected GGNs or additional GGNs.

Conclusions

Our study revealed the clinical and pathologic characteristics, surgical methods, and prognosis of patients with extremely multiple GGNs and compared them with those of patients with a single GGN. Although the primary nodules in extremely multiple GGNs may have higher malignancy than those in the single nodule group, the proportion of both mGGNs and malignant nodules decreased significantly with the increasing number of lesions, and the prognosis of patients with extremely multiple GGNs was satisfied.

Managing screening-detected subsolid nodules-the Asian perspective

The broad application of low-dose computed tomography (CT) screening has resulted in the detection of many small pulmonary nodules. In Asia, a large number of these detected nodules with a radiological ground glass pattern are reported as lung adenocarcinomas or premalignant lesions, especially among female non-smokers. In this review article, we discuss controversial issues and conditions involving these subsolid pulmonary nodules that we often face in Asia, including a lack or insufficiency of current guidelines; the roles of preoperative biopsy and imaging; the location of lesions; appropriate selection of localization techniques; the roles of dissection and sampling of frozen sections and lymph nodes; multifocal lesions; and the roles of non-surgical treatment modalities. For these complex issues, we have tried to present up-to-date evidence and our own opinions regarding the management of subsolid nodules. It is our hope that this article helps surgeons and physicians to manage the complex issues involving ground glass nodules (GGNs) in a balanced manner in their daily practice and provokes further discussion towards better guidelines and/or algorithms.

Management for Residual Ground-Glass Opacity Lesions After Resection of Main Tumor in Multifocal Lung Cancer: A Case Report and Literature Review

There are increasing numbers of synchronous multiple primary lung cancer (SMPLC) patients in clinical practice, with most lesions presenting as ground-glass opacity (GGO). For SMPLC patients, surgical resection should be a prior option for all lesions suspected of being malignant, if medically and technically feasible. However, it is frequently a dilemma for the management of residual GGO lesions that were unresected simultaneously with the main tumor in SMPLC patients. We report a case of SMPLC, in which the patient underwent surgical resection of the major lesion with EGFR mutation and then received compelling EGFR-TKI treatment for one enlarging residual GGO lesion after 12 months since operation. Furthermore, a comprehensive literature review about the risk for the progress of GGOs unresected simultaneously with the main lesion and the management of these residual GGOs was also summarized. With the treatment of EGFR-TKI gefitinib for 3 months, the biggest residual GGO lesion (more than 10mm) achieved a complete response (CR), three lesions reduced in size, and the other three lesions remained stable in this case. Surgical resection for major lesion and EGFR-TKI treatment on unresected GGOs might bring favorable outcome for patients with EGFR-mutated multifocal lung cancer. This strategy is safe and effective, which could be a promising therapeutic approach for unresectable GGO lesions in EGFR-mutated SMPLC patients after primary surgery. Notably, folate receptor-positive circulating tumor cell (FR⁺-CTC) for therapeutic monitoring was more sensitive for GGO-featured lung adenocarcinoma than serum markers.

Surgical Prognosis of Synchronous Multiple Primary Lung Cancer: Systematic Review and Meta-Analysis

BACKGROUND

We evaluated the long-term prognosis of synchronous multiple primary lung cancer (SMPLC) patients after surgical treatment and explored prognostic factors for overall survival (OS).

MATERIALS AND METHODS

A systematic review and meta-analysis was performed regarding the surgical prognosis of SMPLC. A literature search was performed using online databases. All studies were rigorously categorized following the 8th edition of the tumor, node, metastasis classification (TNM) staging rules for multiple lung cancers: SMPLC and multifocal ground-glass/lepidic (GG/L) lung cancers. Five-year OS after surgery was pooled, and hazard ratios (HRs) for prognostic factors were synthesized. Specific subgroup analysis and sensitivity analysis were conducted (PROSPERO registration CRD42019142420).

RESULTS

An analysis of 26 studies including 1788 patients was performed. The pooled 5-year OS was 45% (95% confidence interval [CI], 37-53) of true SMPLC patients and 62% (95% CI, 57-67) of patients with pathologic stage I disease, which was different from the 5-year OS of 93% (95% CI, 85-100) of patients with multifocal GG/L lung cancers. Poor prognostic factors for SMPLC were lymph node metastasis (HR = 2.36; 95% CI, 1.75-3.20; P < .001) and pneumonectomy (HR = 2.96; 95% CI, 1.36-6.45; P = .006], whereas histology (HR = 1.11; 95% CI, 0.82-1.50; P = .508), laterality (HR = 1.16; 95% CI, 0.93-1.44, P = .190), sublobar resection (HR = 1.29; 95% CI, 0.90-1.84; P = .159), and adjuvant therapy (HR = 1.07; 95% CI, 0.64-1.80; P = .791) were not found to influence the outcome.

CONCLUSION

The long-term prognosis of SMPLC patients after surgery is acceptable, especially in patients with early-stage disease. Sublobar resection can be applied, although pneumonectomy should be avoided. Advanced criteria are needed to diagnose SMPLC and distinguish it from multifocal GG/L lung cancer to perform accurate surgical evaluation.

Risk Factors for The Growth of Residual Nodule in Surgical Patients with Adenocarcinoma Presenting as Multifocal Ground-glass Nodules

PURPOSE

We aim to investigate the risk factors influencing the growth of residual nodule (RN) in surgical patients with adenocarcinoma presenting as multifocal ground-glass nodules (GGNs).

METHOD

From January 2014 to June 2018, we enrolled 238 patients with multiple GGNs in a retrospective review. Patients were categorized into growth group 63 (26.5%), and non-growth group 175 (73.5%). The median follow-up time was 28.2 months (range, 6.3-73.0 months). To obtain the time of RN growth and find the risk factors for growth, data such as age, gender, history of smoking, history of malignancy, type of surgery, pathology and radiological characteristics were analyzed to use Kaplan-Meier method with the log-rank test and Cox regression analysis.

RESULTS

The median growth time of RN was 56.0 months (95% CI, 45.0-67.0 months) in all 238 patients. Roundness (HR 4.62, 95% CI 2.20-9.68), part-solid nodule (CTR ≥ 50%) (HR 4.39, 95% CI 2.29-8.45), vascular convergence sign (HR 2.32, 95% CI 1.36-3.96) of RN, and age (HR 1.04, 95% CI 1.01-1.07) were independent predictors of further nodule growth. However, radiological characteristics and pathology of domain tumour (DT) cannot be used as indicators to predict RN growth.

CONCLUSIONS

RN showed an indolent growth pattern in surgical patients with multifocal GGNs. RN with a higher roundness, presence of vascular convergence sign, more solid component, and in the elder was likely to grow. However, the growth of RN showed no association with the radiological features and pathology of DT.

Comparative postoperative outcomes of GGN-dominant vs single lesion lung adenocarcinomas

Background

Multiple synchronous ground glass nodules (GGNs) are known to be malignant, however, they tend to progress slowly. Multiple synchronous lesions in the same patient which show different characteristics must be treated individually.

Methods

This was a retrospective review of 34 lung adenocarcinoma patients with multiple synchronous GGNs in an Asian population. One hundred twenty-seven single lung adenocarcinoma patients were included for comparison purposes. The follow-up period was 5 years for all patients.

Results

The 5-year overall survival (OS) patients with multiple lesions did not differ from that of the patients with single lesions to a statistically significant extent (Single: 81.8% vs. Multiple: 88.2%, P = 0.3602). Dominant tumors (DTs) with a ground glass component and consolidation were divided into three categories based on the consolidation-to-tumor ratio on radiological imaging. No significant differences were observed among the three DT categories. Twenty-four patients had unresected GGNs, while a progression of the unresected GGN occurred in 10 of these cases. The OS and disease-free survival (DFS) curves of patients with and without GGN progression did not differ to a statistically significant extent (OS: 80% vs. 92.9%, P = 0.3870; DFS: 80% vs. 100%, P = 0.0977).

Conclusions

The outcomes were best predicted by the stage of the DT. After surgery patients require a careful follow-up because unresected GGNs may show progression. At the same time, the increase in residual lesions and the appearance of new GGNs were not related to OS. The management of such patients should be determined according to the DT with the worst prognosis.

Sub-solid lung adenocarcinoma in Asian versus Caucasian patients: different biology but similar outcomes

Background

Asian and Caucasian patients with lung cancer have been compared in several database studies, with conflicting findings regarding survival. However, these studies did not include proportion of ground-glass opacity or mutational status in their analyses. Asian patients commonly develop sub-solid lung adenocarcinomas that harbor EGFR mutations, which have a better prognosis. We hypothesized that among patients undergoing surgery for sub-solid lung adenocarcinomas, Asian patients have better survival compared to Caucasian patients.

Methods

We identified Asian and Caucasian patients who underwent surgical resection for a sub-solid lung adenocarcinoma from 2002 to 2015 at our institution. Sub-solid was defined as ≥10% ground-glass opacity on preoperative CT scan or ≥10% lepidic component on surgical pathology. Time-to-event multivariable analysis was performed to determine which characteristics were associated with recurrence and survival.

Results

Two hundred twenty-four patients were included with median follow up 48 months. Asian patients were more likely to be never smokers (76.3% vs. 29.0%, P<0.01) and have an EGFR mutation (69.4% vs. 25.6% of those tested, P<0.01), while Caucasian patients were more likely to have a KRAS mutation (23.5% vs. 4.9% of those tested, P<0.01). There was a trend towards Asian patients having a higher proportion of ground-glass opacity (38.8% vs. 30.5%, P=0.11). Time-to-event multivariable analysis showed that higher proportion of ground-glass opacity was significantly associated with better recurrence-free survival (HR 0.76 per 20% increase, P=0.02). However, mutational status and race did not have a significant impact on recurrence-free or overall survival.

Conclusions

Asian and Caucasian patients with sub-solid lung adenocarcinoma have different tumor biology, but recurrence-free and overall survival after surgical resection is similar.

Profiles of Lung Adenocarcinoma With Multiple Ground-Glass Opacities and the Fate of Residual Lesions

BACKGROUND

We aimed to clarify clinical profiles of patients with adenocarcinoma presenting as multifocal ground-glass opacities (MGGOs) to assess their prognosis and the optimal management method for residual satellite lesions.

METHODS

We identified 190 patients with cN0 MGGOs (MGGO cohort) and 1426 patients with solitary lung adenocarcinoma (control cohort) who underwent complete resection between 2004 and 2016. Propensity score matching was performed to adjust for differences in baseline characteristics of both cohorts for survival analyses. MGGOs consist of a main tumor and satellite lesions and were subdivided into 3 groups: the PG group, with multifocal pure GGOs; the GD group, in which the main tumor presented as GGO dominant; and the SD group, where the main tumor presented as solid dominant.

RESULTS

No significant differences in recurrence-free survival were observed between the 2 cohorts before and after the propensity score matching. For patients with MGGOs, 22 were in the PG group, 47 in the GD group, and 121 in the SD group. Type of MGGOs was a significant factor for recurrence-free survival recurrence-free survival both in the entire population (SD vs PG-GD, P = .008) and in p-stage I cohorts (P = .004) on multivariable analysis. Among 116 patients (61.1%) with residual satellite lesions, 38 patients had progressed lesions and 69 stable lesions. Although the emergence of new lesions during the follow-up period was an independent predictor for satellite lesion progression, neither progressed lesions nor the emergence of new lesions influenced survival.

CONCLUSIONS

Patients with MGGOs and solitary adenocarcinoma had a similar prognosis. The biologic behavior of main tumors dominates clinical outcomes in patients with MGGOs.

Prognostic Classification of Multiple Primary Lung Cancers Based on a Ground-Glass Opacity Component

BACKGROUND

We evaluated the prognostic impact of the presence of a ground-glass opacity (GGO) component on thin-section computed tomography for the refined clinical T classification of multiple primary lung cancers.

METHODS

We reviewed 272 surgically resected, clinically node-negative multiple lung cancers. Dominant tumors were classified into 2 groups based on the presence of a GGO component; that is, a GGO tumor (consolidation tumor ratio, 0 to <1.0) or pure-solid (PS) tumor (consolidation tumor ratio, 1.0). Furthermore, multifocal GGOs (MFGGOs) were defined as lesions showing a GGO component for all tumors. Their prognoses were evaluated using Cox proportional hazard model.

RESULTS

There were 153 MFGGOs (56%) with a significantly better 5-year overall survival than non-MFGGOs (97.2% vs 68.5%, P < .001). A multivariable analysis revealed that MFGGO and absence of nodal involvement were independently significant prognosticators of better survival (P = .007 and P = .012, respectively). Furthermore, among the patients of non-MFGGO groups, multivariate analysis showed that a PS + PS pattern and presence of nodal involvement were independently significant prognosticators of poorer survival (P = .008 and P = .001, respectively). We divided the tumors into 3 groups based on the results and focusing on the presence of a GGO; that is, MFGGO (n = 153), PS + additional GGO (n = 81), and PS + PS (n = 38). The 5-year overall survival was clearly split among them: MFGGO, 97.2%; PS + additional GGO, 82.1%; and PS + PS, 41.3% (P < .001).

CONCLUSIONS

Our results suggest that presence of a GGO component has the ability to distinguish the survival even for multiple lung cancers. Further investigations including multicenter trials are certainly warranted to address the revision of T variable of multiple lung cancers considering a presence of GGO component.

[Shanghai Pulmonary Hospital Experts Consensus on the Management of Ground-Glass Nodules Suspected as Lung Adenocarcinoma (Version 1)]

随着胸部计算机断层扫描（computed tomography, CT）检查，尤其是低剂量薄层CT筛查项目在中国的广泛开展，越来越多的无症状肺部磨玻璃结节（ground-glass nodules, GGNs）被发现。虽然国内及国际上已发布了一系列针对肺部GGNs的指南，但是这些指南的撰写者多来自呼吸、肿瘤及影像专业，可能缺乏对现代微创胸外科的充分认识，造成外科手术在肺部GGNs诊治中的作用不明确，甚至被低估；而且，肺部肿瘤相关的各学科对于早期肺癌，尤其是浸润前病变的处理也缺乏统一规范。因此，基于国内外现有文献及上海市肺科医院多年积累的经验，上海市肺科医院撰写了此诊疗共识。本共识推荐对于疑似肺腺癌的GGNs进行多学科评估，依据诊断，选择合理的处置方式。对于疑似原位腺癌，推荐进行胸部薄层CT随访，或在特定情况下进行不超过肺段切除的限制性肺切除；对于疑似微浸润腺癌，推荐进行限制性肺切除或肺叶切除；对于疑似浸润性腺癌，建议依据病灶是否含有磨玻璃成分、位置、大小、个数及患者躯体情况选择合理的手术方式；而肺多发结节的处理原则推荐为主病灶优先，兼顾次要病灶，综合选择治疗方案。