The modification of T description according to visceral pleural invasion and tumor size from 3.1 cm to 4.0 cm in non-small cell lung cancer: A retrospective analysis based on the SEER database

Correlation Between the Number of Pathological Risk Factors and Postoperative Prognosis in Patients with Stage I Lung Adenocarcinoma

BACKGROUND

Although visceral pleural invasion, lymphovascular invasion, tumor spread through air spaces, and poor differentiation are pathological risk factors associated with unfavorable prognosis in patients with lung adenocarcinoma, the cumulative impact of these factors on prognosis remains unclear.

METHODS

We enrolled 1532 patients with stage I lung adenocarcinoma. Patients were divided according to the number of risk factors as follows: Group A (without risk factors), Group B (one risk factor), and Group C (multiple risk factors). Moreover, we stratified patients into two subgroups based on tumor size (≤ 3 cm, 3-4 cm). Kaplan-Meier analysis was used to evaluate 5-year disease-free survival (DFS) and overall survival (OS).

RESULTS

Overall, 949, 404, and 179 patients were included in Groups A, B, and C, respectively. Group C had a larger tumor size and more cases of extrathoracic recurrence than the other groups. The 5-year DFS and OS gradually decreased across Groups A to C (DFS: 94.3%, 80.6%, and 64.3%, respectively, p < 0.001; OS: 97.2%, 92.7%, and 77%, respectively, p < 0.001). A similar trend was observed for tumors ≤ 3 cm in size (DFS: 95.2%, 83.2%, and 68.5%, respectively, p < 0.001; OS: 97.6%, 94.1%, and 79.6%, respectively, p < 0.001), but a less pronounced trend was observed for tumors between 3 and 4 cm in size (DFS: 72.1, 60.8, and 43.3%, respectively, p = 0.054; OS: 85.7, 82.1, and 64.7%, respectively, p = 0.16).

CONCLUSIONS

Postoperative survival worsened with increasing pathological risk factors in patients with stage I lung adenocarcinoma, especially those with tumor size ≤ 3 cm.

Using the length of pleural tag to predetermine pleural invasion by lung adenocarcinomas

Introduction

Pleural contact is present when the underlying pathology of the pleural tag (PT) involves the pleura. This study aimed to preoperatively predict PI by lung adenocarcinomas (ACCs) with PT, exploring CT imaging parameters indicative of PT consisting of pleura and tumor invasiveness.

Methods

This single-center, retrospective study included 84 consecutive patients diagnosed with solid ACCs with PT, who underwent resection at our hospital between May 2019 and July 2023. CT imaging parameters analyzed included: LPT (the length of PT), defined as the shortest distance from the tumor edge to the retracted pleura. Patients were divided into PI -ve group and PI +ve group according to PI status. Regression analyses were used to determine predictive factors for PI.

Results

The study evaluated 84 patients (mean age, 62.0 ± 13.8 years; 45 females) pathologically diagnosed with ACCs with PT on CT. Multivariate regression analysis identified tumor size (OR 1.18, 95% CI 1.09-1.29, p = 0.000), LPT (OR 0.48, 95% CI 0.25-0.91, p = 0.03) and multiple PTs to multiple types of pleura (OR 3.58, 95% CI 1.13-11.20, p = 0.03) as independent predictors for PI. The combination of these CT features improved the predictive performance for preoperatively identifying PI, achieving high specificity and moderate accuracy. The sensitivity of predicting PI with only LPT < 3 mm was 96.9%.

Conclusion

This study determined that LPT is effective for predetermining PI in ACCs with PT.

Diagnostic performance and prognostic value of CT-defined visceral pleural invasion in early-stage lung adenocarcinomas

OBJECTIVES

To analyze the diagnostic performance and prognostic value of CT-defined visceral pleural invasion (CT-VPI) in early-stage lung adenocarcinomas.

METHODS

Among patients with clinical stage I lung adenocarcinomas, half of patients were randomly selected for a diagnostic study, in which five thoracic radiologists determined the presence of CT-VPI. Probabilities for CT-VPI were obtained using deep learning (DL). Areas under the receiver operating characteristic curve (AUCs) and binary diagnostic measures were calculated and compared. Inter-rater agreement was assessed. For all patients, the prognostic value of CT-VPI by two radiologists and DL (using high-sensitivity and high-specificity cutoffs) was investigated using Cox regression.

RESULTS

In 681 patients (median age, 65 years [interquartile range, 58-71]; 382 women), pathologic VPI was positive in 130 patients. For the diagnostic study (n = 339), the pooled AUC of five radiologists was similar to that of DL (0.78 vs. 0.79; p = 0.76). The binary diagnostic performance of radiologists was variable (sensitivity, 45.3-71.9%; specificity, 71.6-88.7%). Inter-rater agreement was moderate (weighted Fleiss κ, 0.51; 95%CI: 0.43-0.55). For overall survival (n = 680), CT-VPI by radiologists (adjusted hazard ratio [HR], 1.27 and 0.99; 95%CI: 0.84-1.92 and 0.63-1.56; p = 0.26 and 0.97) or DL (HR, 1.44 and 1.06; 95%CI: 0.86-2.42 and 0.67-1.68; p = 0.17 and 0.80) was not prognostic. CT-VPI by an attending radiologist was prognostic only in radiologically solid tumors (HR, 1.82; 95%CI: 1.07-3.07; p = 0.03).

CONCLUSION

The diagnostic performance and prognostic value of CT-VPI are limited in clinical stage I lung adenocarcinomas. This feature may be applied for radiologically solid tumors, but substantial reader variability should be overcome.

CLINICAL RELEVANCE STATEMENT

Although the diagnostic performance and prognostic value of CT-VPI are limited in clinical stage I lung adenocarcinomas, this parameter may be applied for radiologically solid tumors with appropriate caution regarding inter-reader variability.

KEY POINTS

• Use of CT-defined visceral pleural invasion in clinical staging should be cautious, because prognostic value of CT-defined visceral pleural invasion remains unexplored. • Diagnostic performance and prognostic value of CT-defined visceral pleural invasion varied among radiologists and deep learning. • Role of CT-defined visceral pleural invasion in clinical staging may be limited to radiologically solid tumors.

Diagnosis, treatment, and prognosis of stage IB non-small cell lung cancer with visceral pleural invasion

With the increasing implementation of early lung cancer screening and the increasing emphasis on physical examinations, the early-stage lung cancer detection rate continues to rise. Visceral pleural invasion (VPI), which denotes the tumor's breach of the elastic layer or reaching the surface of the visceral pleura, stands as a pivotal factor that impacts the prognosis of patients with non-small cell lung cancer (NSCLC) and directly influences the pathological staging of early-stage cases. According to the latest 9th edition of the TNM staging system for NSCLC, even when the tumor diameter is less than 3 cm, the final T stage remains T2a if VPI is present. There is considerable controversy within the guidelines regarding treatment options for stage IB NSCLC, especially among patients exhibiting VPI. Moreover, the precise determination of VPI is important in guiding treatment selection and prognostic evaluation in individuals with NSCLC. This article aims to provide a comprehensive review of the current status and advancements in studies pertaining to stage IB NSCLC accompanied by VPI.

Investigation of Early-Stage Non-Small Cell Lung Cancer Patients with Different T2 Descriptors: Real Word Data From a Large Database

INTRODUCTION

The current study evaluated a large cohort of T2N0M0 NSCLC patients with different T2 descriptors to investigate the prognostic disparities and further externally validate the T category of these patients.

METHODS

The Kaplan-Meier Method with the log-rank test was used to plot survival curves. The propensity score matching (PSM) method was used to reduce bias. Univariable and multivariable Cox analyses were used to determine prognostic factors.

RESULTS

A total of 13,015 eligible T2N0M0 NSCLC patients were included. There were 5,287, 2,577 and 5,151 patients in the T2a, T2b and non-sized determined T2N0M0 (T2non-sized) groups, respectively. Before PSM, the survival of T2non-sized patients was comparable to that of T2a patients (P = 0.080) but was superior to that of T2b patients (P < 0.001). After PSM, the survival of T2non-sized patients was inferior to that of T2a patients (P = 0.028) but was similar to that of T2b patients (P = 0.325). The T category was further subdivided based on the specific non-sized T2 descriptors and tumor size. The results of the multivariate Cox analysis found that the prognosis of T2 tumors with visceral pleural invasion (size: 0-30 mm) was better than that of T2a tumors, and the prognosis of T2 tumors with visceral pleural invasion (size: 30-40 mm) was inferior to that of T2a tumors but comparable to that of T2b tumors.

CONCLUSION

T2 tumors with visceral pleural invasion (size: 30-40 mm) should be assigned to the T2b category, and those with a size interval of 0-30 mm should be assigned to a better prognostic T2a category.

The location of visceral pleural invasion in stage IB patients with non-small cell lung cancer: Comparison and prognosis

OBJECTIVES

Recently, early-stage lung cancer has been drawing more attention, especially in screening and treatment. Visceral pleural invasion in stage IB cancer is considered as risk factor for poor prognosis. Herein, we aimed to study the distinction between the different locations of visceral pleural invasion.

METHODS

In this retrospective cohort study, we summarized 58,242 patient cases that underwent surgery from 2015 to 2018 at Shanghai Chest Hospital. Of those patients, 389 met the inclusion criteria. Patients with PL3 pleural invasion were excluded. The patients were dichotomized into the interlobar pleural and peripheral pleural groups. The outcomes measured were overall survival (OS) and recurrence-free survival (RFS) rates.

RESULTS

According to the initial analysis, the baseline characteristics of the two groups were largely balanced. In multivariate Cox analyses, we found that the location of visceral pleural invasion was not a risk factor for prognosis in the overall population (RFS: P = 0.726, OS: P = 0.599). However, we discovered that relative to patients with peripheral pleura invasion, those with interlobar pleura invasion, PL1 invasion, lesions with greater than 3 cm solid components, and those who underwent segmentectomy had a compromised prognosis. Additionally, tumors larger than 3 cm in size with interlobar pleura invasion showed poor prognosis in patients who underwent postoperative chemotherapy.

CONCLUSIONS

In most cases, the location of tumor invasion did not worsen the postoperative prognosis of stage IB non-small cell lung cancer patients with visceral pleural invasion. However, interlobar pleural invasion still had some potential risks compared to that of peripheral pleural invasion.

Effect of pleural invasion on survival of patients with small cell lung cancer: Propensity score analysis and nomogram establishment based on the SEER database

Objectives

Pleural invasion (PI) is identified as an adverse prognostic factor for non-small cell lung cancer (NSCLC), but its value in small cell lung cancer (SCLC) remains unclear. We aimed to evaluate the survival effect of PI on overall survival (OS) in SCLC, meanwhile, we established a predictive nomogram based on related risk factors for OS in SCLC patients with PI.

Methods

We extracted the data of patients diagnosed with primary SCLC between 2010 and 2018 from the Surveillance, Epidemiology, and End Results (SEER) database. The propensity score matching (PSM) method was used to minimize the baseline difference between the non-PI and PI groups. Kaplan-Meier curves and the log-rank test were used for survival analysis. Univariate and multivariate Cox regression analyses were applied to identify the independent prognostic factors. Randomly divided the patients with PI into training (70%) and validation (30%) cohorts. A prognostic nomogram was established based on the training cohort and was evaluated in the validation cohort. The C-index, receiver operating characteristic curves (ROC), calibration curves, and decision curve analysis (DCA) were applied to assess the performance of the nomogram.

Results

A total of 1,770 primary SCLC patients were enrolled, including1321patients with non-PI and 449 patients with PI. After PSM, the 387 patients in the PI group matched the 387 patients in the non-PI group. By Kaplan-Meier survival analysis, we observed the exact beneficial effect of non-PI on OS in both original and matched cohorts. Multivariate Cox analysis showed similar results to demonstrate a statistically significant benefit for patients with non-PI in both original and matched cohorts. Age, N stage, M stage, surgery, radiotherapy, and chemotherapy were independent prognostic factors for SCLC patients with PI. The C-index of the nomogram in the training and validation cohort was 0.714 and 0.746, respectively. The ROC curves, calibration curves, and DCA curves also demonstrated good predictive performance in the training and validation cohorts of the prognostic nomogram.

Conclusion

Our study shows that PI is an independent poor prognostic factor for SCLC patients. The nomogram is a useful and reliable tool to predict the OS in SCLC patients with PI. The nomogram can provide strong references to clinicians to facilitate clinic decisions.

Non-small Cell Lung Cancer Surpassing the Elastic Layer Should Remain Classified as pT2a

We aimed to evaluate the prognostic value of visceral pleural invasion on the survival of node-negative non-small cell lung cancer ≤3 cm using a large cohort. The Kaplan-Meier method was used to compare overall survival (OS); competing risk analysis with Fine-Gray's test was used to compare cancer- specific survival between groups. The least absolute shrinkage and selection operator penalized Cox regression model was used to identify prognostic factors. In total, 9725 eligible cases were included in this study, and they were separated into 3 groups: tumor invasion beneath the elastic layer (PL0), 8837 cases; tumor invasion surpassing the elastic layer (PL1), 505 cases; and tumor invasion to the visceral pleural surface (PL2), 383 cases. Visceral pleural invasion was more likely to occur in poorly differentiated and larger-sized tumors. Survival curves displayed that PL0 conferred better survival rates than PL1 and PL2, and PL1 achieved outcomes equivalent to those of PL2. Tumor size and histology subset analyses further corroborated this conclusion. Least absolute shrinkage and selection operator -penalized Cox regression analysis confirmed that PL status was an independent prognostic factor for both OS and cancer- specific survival. This study supported the notion that in node-negative non-small cell lung cancer ≤3 cm, PL1 patients should remain classified as pT2a, which could improve staging accuracy.

The Difference and Significance of Parietal Pleura Invasion and Rib Invasion in Pathological T Classification With Non-Small Cell Lung Cancer

OBJECTIVE

This study was to explore the difference and significance of parietal pleura invasion and rib invasion in pathological T classification with non-small cell lung cancer.

METHODS

A total of 8681 patients after lung resection were selected to perform analyses. Multivariable Cox analysis was used to identify the mortality differences in patients between parietal pleura invasion and rib invasion. Eligible patients with chest wall invasion were re-categorized according to the prognosis. Cancer-specific survival curves for different pathological T (pT) classifications were presented.

RESULTS

There were 466 patients considered parietal pleura invasion, and 237 patients served as rib invasion. Cases with rib invasion had poorer survival than those with the invasion of parietal pleura (adjusted hazard ratio [HR]= 1.627, P =0.004). In the cohort for parietal pleura invasion, patients with tumor size ≤5cm reached more satisfactory survival outcomes than patients with tumor size >5cm (unadjusted HR =1.598, P =0.006). However, there was no predictive difference in the cohort of rib invasion. The results of the multivariable analysis revealed that the mortality with parietal pleura invasion plus tumor size ≤5cm were similar to patients with classification pT3 (P =0.761), and patients for parietal pleura invasion plus tumor size >5cm and pT4 had no stratified survival outcome (P =0.809). Patients identified as rib invasion had a poorer prognosis than patients for pT4 (P =0.037).

CONCLUSIONS

Rib invasion has a poorer prognosis than pT4. Patients with parietal pleura invasion and tumor size with 5.1-7.0cm could be appropriately up-classified from pT3 to pT4.