Visceral pleura invasion by non-small cell lung cancer: an underrated bad prognostic factor

Preoperative evaluation of visceral pleural invasion in peripheral lung cancer utilizing deep learning technology

PURPOSE

This study aimed to assess the efficiency of artificial intelligence (AI) in the detection of visceral pleural invasion (VPI) of lung cancer using high-resolution computed tomography (HRCT) images, which is challenging for experts because of its significance in T-classification and lymph node metastasis prediction.

METHODS

This retrospective analysis was conducted on preoperative HRCT images of 472 patients with stage I non-small cell lung cancer (NSCLC), focusing on lesions adjacent to the pleura to predict VPI. YOLOv4.0 was utilized for tumor localization, and EfficientNetv2 was applied for VPI prediction with HRCT images meticulously annotated for AI model training and validation.

RESULTS

Of the 472 lung cancer cases (500 CT images) studied, the AI algorithm successfully identified tumors, with YOLOv4.0 accurately localizing tumors in 98% of the test images. In the EfficientNet v2-M analysis, the receiver operating characteristic curve exhibited an area under the curve of 0.78. It demonstrated powerful diagnostic performance with a sensitivity, specificity, and precision of 76.4% in VPI prediction.

CONCLUSION

AI is a promising tool for improving the diagnostic accuracy of VPI for NSCLC. Furthermore, incorporating AI into the diagnostic workflow is advocated because of its potential to improve the accuracy of preoperative diagnosis and patient outcomes in NSCLC.

Segmentectomy vs Lobectomy for Early Non-Small Cell Lung Cancer With Visceral Pleural Invasion

BACKGROUND

Recent prospective trials have demonstrated the noninferiority of segmentectomy to lobectomy in the surgical management of early non-small cell lung cancer (NSCLC). It remains unknown, however, whether segmentectomy is sufficient for treating small tumors with visceral pleural invasion (VPI), a known indicator of aggressive disease biology and poor prognosis in NSCLC.

METHODS

Patients in the National Cancer Database (2010-2020) with cT1a-bN0M0 NSCLC and VPI and additional high-risk features who underwent segmentectomy or lobectomy were identified for analysis. Only patients with no comorbidities were included in this analysis to reduce selection bias. Overall survival of patients who underwent segmentectomy vs lobectomy was evaluated using multivariable-adjusted Cox proportional hazards and propensity score- matched analyses. Short-term and pathologic outcomes were also evaluated.

RESULTS

Of the 2568 patients with cT1a-bN0M0 NSCLC and VPI included in our overall cohort, 178 (7%) underwent segmentectomy and 2390 (93%) underwent lobectomy. No significant differences were found in the 5-year overall survival between patients undergoing segmentectomy vs lobectomy in multivariable-adjusted and propensity score-matched analyses (adjusted hazard ratio, 0.91 [95% CI, 0.55-1.51], P = .72; 86% [95% CI, 75%-92%] vs 76% [95% CI, 65%-84%], P = .15, respectively). There were also no differences in surgical margin positivity, 30-day readmission, and 30- and 90-day mortality between patients undergoing either surgical approach.

CONCLUSIONS

In this national analysis, no differences were found in survival or in short-term outcomes between patients undergoing segmentectomy vs lobectomy for early-stage NSCLC with VPI. Our findings suggest that if VPI is detected after segmentectomy for cT1a-bN0M0 tumors, completion lobectomy is unlikely to confer an additional survival advantage.

Prognostic Factors for Survival of Stage IB Non-small Cell Lung Cancer Patients: A 10-Year Follow-Up Retrospective Study

BACKGROUND

This study aimed to determine the prognostic factors for the long-term outcome of stage IB non-small cell lung cancer (NSCLC).

METHODS

Surgically resected patients with stage IB NSCLC diagnosed (based on TNM 8th edition) between April 2008 and December 2013 were retrospectively reviewed. The prognosis and possible risk factors among the stage IB NSCLC patients were evaluated.

RESULTS

Of the 349 patients identified for the study, 80 (22.9%) received post-surgery adjuvant chemotherapy (ACT). The median follow-up time after surgery was 123.3 months. The 10-year overall survival (OS) rate was 69.6%, and the 10-year recurrence-free survival (RFS) rate was 62.8%. The patients in this cohort were divided into three groups (T1 with visceral pleural invasion [VPI], T2a without VPI, and T2a with VPI), and no significant differences in OS or RFS were found among the groups. Furthermore, survival analysis indicated that the absence of ground-glass opacity (GGO) components portends an adverse long-term OS and RFS. In a subgroup of patients with solid nodules, age older than 65 years (hazard ratio [HR] 1.987; 95% confidence interval [CI] 1.312-3.010; p = 0.001) and ACT (HR 0.392; 95% CI 0.225-0.684; p < 0.001) were independent prognostic factors for OS, whereas lymphovascular invasion (HR 1.792; 95% CI 0.995-3.227; p = 0.052) should be considered as an independent unfavorable prognostic factor for RFS.

CONCLUSIONS

As an upstaging factor, VPI did not further stratify prognosis for the stage IB patients in our cohort. The presence of GGO components had a notable impact on a favorable prognosis in stage IB NSCLCs.

Predictive value of SUVmax in visceral pleural invasive lung adenocarcinoma with different diameters

OBJECTIVES

This study aimed to investigate predictive visceral pleural invasion (VPI) occurrence value of the maximum standardized uptake value (SUVmax) in patients with lung adenocarcinoma (LA).

PATIENTS AND METHODS

A total of 388 LA patients were divided into D1ab, D1c, D1, D2, D2a, D2b, D3, and all patient groups based on their tumor diameter (D). Patients were also classified into negative VPI (VPI-n) and positive VPI (VPI-p) groups according to VPI presence. SUVmax of patients was measured with 18F-fluorodeoxyglucose (FDG) by PET/computed tomography (18F-PET/CT). Receiver operating characteristic (ROC) analysis and the area under curve (AUC) of SUVmax were applied to determine optimal cut-off value for predicting VPI occurrence.

RESULTS

There were significant differences in SUVmax between VPI-n and VPI-p groups ( P  < 0.05) at the same tumor diameter. SUVmax cut-off value and sensitivity (Se,%) of VPI occurrence in each group were following: D1ab was 3.79 [AUC = 0.764, P  < 0.001], Se86.11%; D1c was 5.47 (AUC = 0.706, P  < 0.001), Se 93.75%; D1 was 5.49 (AUC = 0.731, P  < 0.001), Se 79.76%; D2 was 7.36 (AUC = 0.726, P  < 0.001), Se81.67%. All patient group was 7.26 (AUC = 0.735, P  < 0.001), Se74.19%.

CONCLUSION

In LA patients with the same diameter, SUVmax of the VPI-p group was significantly higher than that of the VPI-n group. The cut-off value of SUVmax for predicting VPI of T1 stage, T1 substages, and T2 stage LA could be determined through ROC curve. SUVmax measurement by PET/CT scan in stratified tumor size is helpful for predicting VPI occurrences of the physician.

Clinical Significance of Dual-Block Elastic Stain Evaluating Visceral Pleural Invasion in Peripheral Non-Small Cell Lung Cancer

Visceral pleural invasion (VPI) is a critical component in the staging of peripheral non-small cell lung carcinoma (NSCLC). We aim to investigate whether dual-block elastic stain increases visceral pleural invasion positivity compared with single-block elastic stain. We further analyze the potential predictors of visceral pleural invasion. 8419 peripheral NSCLC patients (including 6008 patients with tumor size≤3 cm in stage I) were divided into a cohort using one paraffin block (single-block group, n = 5184) and a cohort using dual paraffin blocks (dual-block group, n = 3235) for elastic stain. The VPI-positive rate demonstrated by the dual-block elastic stains group was significantly higher than that of the single-block elastic stain group (17.7% (573/3235) versus 9.1% (474/5184), respectively, P < .001). The presence of visceral pleural invasion in T1 (≤3 cm) patients detected by single- and dual-block elastic stain was 6.3% (235/3730) and 12.0% (273/2278), respectively (P < .001). 5.7% of T1 patients (stage IA) were additionally upstaged to T2a (stage IB) by dual-block elastic stain. However, the incidence of visceral pleural invasion in pT2a patients showed no significant difference between the single-block group and the dual-block group (16.8% vs. 17.1%, P = .916). Lymphovascular invasion, lymph node metastasis, dedifferentiated carcinomas, the presence of spread through airspaces (STAS) and a poorly differentiated adenocarcinomatous growth pattern could be significant predictors of visceral pleural invasion (P < .001). Our results indicate that using dual-block elastic stain identifies more visceral pleural invasion positive T1 NSCLC patients who are upstaged to T2a, and who could benefit from optimal management post-operatively. The application of dual-block elastic stain is an efficient and practical method to detect visceral pleural invasion status.

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.

The prognosis of different types of pleural tags based on radiologic-pathologic comparison

Objectives

There are increasing numbers of studies of pleural tags (PTs). The purpose of this case series was to classify the PTs in patients with peripheral pulmonary adenocarcinoma based on radiologic-pathologic comparison and to study the prognosis.

Methods

The clinical, imaging, pathological and prognostic data of 161 patients with peripheral pulmonary adenocarcinoma in three hospitals were analyzed retrospectively. We classified PTs using computed tomography (CT) for pathologic comparison.

Results

According to the relationship between tumors and pleural on CT images, PTs were classified into four types: type 1, one or more linear pleural tag; type 2, one or more linear pleural tag with soft tissue component at the pleural end; type 3, one soft tissue cord-like pleural tag; type 4, directly abutting the visceral pleura, pulling or pushing the visceral pleura. In these PTs, the incidence of visceral pleural invasion (VPI) was high in type 2 (46.88%) and type 3 (56.41%) of PTs. Our prognostic analysis showed that micropapillary or solid histological subtype (HR = 5.766, 95% CI: 1.435–23.159, P = 0.014) and type 3 of PTs (HR = 11.058, 95% CI: 1.349–90.623, P = 0.025) were two independent risk factors for tumor progression.

Conclusions

PT is a risk factor for poor prognosis in patients with peripheral pulmonary adenocarcinoma, the presence of which on CT images can remind us to provide patients with a more reasonable treatment.

Diagnostic pitfall in a large cell lung cancer with testicular metastasis synchronous malignant pleural mesothelioma patient: A case report

Large cell lung cancer metastases to the testis are scarce, although it is the most common malignancy and the most common site of metastases for breast, colorectal and kidney cancers. We hereby report a 28-year-old male patient admitted to our hospital with a chief complaint of scrotal enlargement, accompanied by chest pain and progressive dyspnea. The definite diagnosis was malignant pleural mesothelioma with the synchronous occurrence of large cell lung cancer with testicular metastasis. Sophisticated clinical manifestation of symptoms led to a time-consuming diagnosis, while the patient's condition deteriorated rapidly. Herein, we present this case to share our hard-learnt experience to increase clinician awareness and contribute to the information in the literature.

Is lobectomy superior to sub-lobectomy in non-small cell lung cancer with pleural invasion? A population-based competing risk analysis

Background

Pleural invasion (PL) has been regarded as an unfavorable prognostic factor for non-small cell lung cancer (NSCLC). But there was no agreement on the optimal surgical extent in NSCLC patients with PL. We aimed to compare the survival outcomes of lobectomy and sub-lobectomy in these patients.

Method

2717 patients were included in the Surveillance, Epidemiology, and End Results (SEER) database and divided into the lobectomy and sub-lobectomy groups. The propensity score matching (PSM) and competing risk analysis were implemented. Then the predictive nomogram was constructed and validated.

Results

2230 Patients received lobectomy while the other 487 patients underwent sub-lobectomy. After 1:1 PSM, the cumulative incidence of cancer-specific death (CSD) was lower in the lobectomy group compared with the sub-lobectomy group (1-year: 12% vs. 15%; 3-year: 30% vs. 37%, 5-year: 34% vs. 45%, P = 0.04). According to the subgroup analysis, the patients who underwent lobectomy suffered lower CSD in the N0–1 stage, adenocarcinoma, and PL-2 cohort (p < 0.05). And there was a significant relationship between the sub-lobectomy group and CSD in the multivariate competing risks regression analysis (HR, 1.26; 95%CI, 1.02–1.56; P = 0.034). Furthermore, a competing event nomogram was constructed to assess the 1-, 3-, and 5-year chances of CSD based on the variables from the multivariate analysis. The 1-, 3-, 5-year area under the receiver operating characteristic curve (AUC) values were 0.720, 0.706, and 0.708 in the training cohort, and 0.738, 0.696, 0.680 in the validation cohorts, respectively. And calibration curves demonstrated ideal consistency between the predicted and observed probabilities of CSD.

Conclusion

Lobectomy should be considered the preferred surgery compared to sub-lobectomy for NSCLC patients with PL. The proposed nomograms presented great prediction ability for these patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09634-w.

Prognostic significance of visceral pleural invasion in patients with surgically resected small-cell lung cancer: a population-based study

OBJECTIVE

Visceral pleural invasion is an adverse prognostic factor in non-small-cell lung cancer, but its value in small-cell lung cancer remains unclear. Thus, we investigated the prognostic impact of visceral pleural invasion in patients with surgically resected small-cell lung cancer.

METHODS

We queried the Surveillance, Epidemiology and End Results Program database for patients diagnosed with stages I-III (excluding N3 and nodal metastasis cannot be evaluated (NX)) small-cell lung cancer from 2004 to 2016, who underwent surgery. To minimize unbalanced baseline characteristics between the visceral pleural invasion and non-visceral pleural invasion groups, one-to-one propensity score matching was employed. A Kaplan-Meier curve was used to compare the overall survival of the two cohorts. A Cox proportional hazards model was adopted to determine the impact of visceral pleural invasion on survival.

RESULTS

Of the 1416 patients included, 372 (26.27%) presented with visceral pleural invasion. Patients with visceral pleural invasion showed significantly worse overall survival (P < 0.001) both before and after propensity score matching. Multivariable analysis indicated that visceral pleural invasion was an independent adverse factor affecting survival. Patients with visceral pleural invasion showed poorer overall survival (hazard ratio: 1.44; 95% confidence interval: 1.17-1.76; P < 0.001). Subgroup analyses revealed that the non-visceral pleural invasion group was associated with favourable overall survival in N0 patients (P = 0.003) but not in N1 or N2 patients (P = 0.774 and 0.248, respectively). Patients diagnosed at younger ages, females, lower N stage, resection with a lobectomy and adjuvant chemotherapy were associated with improved overall survival in the visceral pleural invasion group.

CONCLUSIONS

Visceral pleural invasion was an indicator of a poor prognosis for small-cell lung cancer, especially in those with N0 disease. Adjuvant chemotherapy significantly improves patient outcomes for patients with visceral pleural invasion.

[Clinical Characteristics and Risk Factors Analysis for Visceral Pleural Invasion in Mixed Ground-glass Nodular Lung Adenocarcinoma]

BACKGROUND

Lung cancer is still the malignant tumor with the highest morbidity and mortality in China. Lung adenocarcinoma is the most common subtype, and the number of lung cancer presenting as mixed ground glass nodule (mGGN) in imaging is gradually increasing. Visceral pleural invasion (VPI) is an important factor affecting the prognosis of mGGN type lung adenocarcinoma. The aim of the study is to explore and analyze the risk factors for VPI in mGGN type lung adenocarcinoma.

METHODS

From November 2016 to November 2019, 128 patients with mGGN lung adenocarcinoma underwent radical surgical resection in the First Affiliated Hospital of Nanjing Medical University. Their clinical data, including imaging, pathological and biological features, were collected and analyzed retrospectively. There were 40 males and 88 females, aged 60.3±9.3 years ranging from 30 to 81 years. Single factor Chi-square test and multivariate Logistic regression were used to analyze the risk factors of VPI in mGGN type lung adenocarcinoma.

RESULTS

Among 128 mGGN patients who met the inclusion criteria, 57 cases were pathologically confirmed with pleural invasion. Between the VPI (+) and VPI (-) group (P<0.05), there were significant differences in gender, maximum diameter of solid component, consolidation tumor ratio (CTR), spicule sign, history of lung disease, family history of hypertension, relation of lesion to pleura (RLP), coursing relationship between bronchi and nodules. In multivariate Logistic regression analysis, RLP (OR=3.529, 95%CI: 1.430-8.713, P=0.006) and coursing relationship between bronchi and nodules (OR=3.993, 95%CI: 1.517-10.51, P=0.005) were found to be independent risk factors for VPI (P<0.05).

CONCLUSIONS

The possibility of VPI in m GGN lung adenocarcinoma should be evaluated by combining these parameters in clinical diagnosis and treatment. As independent risk factors, RLP and coursing relationship between bronchi and nodules are instructive to identify VPI in mGGN type lung adenocarcinoma.

Small-sized peripheral squamous cell lung carcinoma with chest wall invasion

In lung cancer, chest wall infiltration caused by a tumor with a small diameter is extremely rare. The pathophysiologic features and prognosis of this phenomenon are poorly understood. Here, we report on a case in which a small peripheral lung cancer showed marked invasion into the chest wall. Although complete resection and postoperative adjuvant treatment were performed, lymph node recurrence developed and the patient died in one and a half years. Peripheral lung cancer can show exophytic development and infiltration of the chest wall, leading to poor prognosis, even if the tumor size is relatively small.

•

Chest wall invasion by small-sized lung carcinoma

•

Lung tumor adjacent to intrapulmonary air space can show exophytic development

•

Lymph node metastasis with lung cancer with chest wall invasion after complete resection

Prognostic relevance of pleural invasion for resected NSCLC patients undergoing adjuvant treatments: A propensity score-matched analysis of SEER database

BACKGROUND

Adjuvant chemotherapy demonstrated a clear benefit in resected non-small cell lung cancer (NSCLC) with nodal disease (stages II-III), and a minimal benefit in tumors >4 cm (stage II, TNM 8th edition). Pleural invasion (PL), classified as visceral pleural invasion (VPI, which includes PL1 and PL2, and parietal pleural invasion (PL3), is an established negative prognostic factor. However, whether PL should influence the decisional algorithm of postoperative chemotherapy is controversial.

METHODS

A survival analysis of NSCLC patients who underwent radical surgery between 2010 and 2015 included in the SEER database was performed. Tumor stage and size, number of examined and positive nodes, histology, PL, and treatment data were extracted. Propensity score matching was performed. The benefit of chemotherapy was analyzed in two subgroups: standard of care (SOC), including patients with positive nodes or tumors ≥ 4 cm; non-SOC, including patients with tumors < 4 cm and negative nodes.

RESULTS

Records of 30,858 patients were extracted. 11,708 patients were included in the propensity score-matched analysis. In the SOC subgroup, including 8089 patients, all pleural invasion degrees were associated with progressively increased risk for death and shorter overall survival (OS), independently from chemotherapy administration. However, chemotherapy significantly improved the median OS regardless of the extent of PL. In the non-SOC subgroup, including 3619 patients, only PL3 was associated with increased mortality. The administration of chemotherapy did not improve survival outcomes.

CONCLUSION

Chemotherapy should be strongly recommended in patients in the SOC-subgroup with pleural invasion. VPI is not associated with unfavorable prognosis in the non-SOC subgroup.

Modification of Pathologic T Classification for Non-small Cell Lung Cancer With Visceral Pleural Invasion: Data From 1,055 Cases of Cancers ≤ 3 cm

BACKGROUND

Visceral pleural invasion (VPI) with PL1 or PL2 increases the T classification from T1 to T2 in non-small cell lung cancers (NSCLCs) ≤ 3 cm. We proposed a modified T classification based on VPI to guide adjuvant therapy.

RESEARCH QUESTION

Is it reasonable to upstage PL1-positive cases from T1 to T2 for NSCLCs ≤ 3 cm?

STUDY DESIGN AND METHODS

In total, 1,055 patients with resected NSCLC were retrospectively included. Tumor sections were restained with hematoxylin and eosin stain and Victoria blue elastic stain for the elastic layer. Disease-free survival (DFS) and overall survival (OS) were calculated by the Kaplan-Meier method. Subgroup analysis and a Cox proportional hazards model were used to further determine the impact of VPI on survival.

RESULTS

The extent of VPI was diagnosed as PL0 in 824 patients, PL1 in 133 patients, and PL2 in 98 patients. The 5-year DFS rates of patients with PL0, PL1, and PL2 were 62.6%, 60.2%, and 28.8% (P < .01), whereas the corresponding 5-year OS rates were 78.6%, 74.4%, and 50.0% (P < .01), respectively. As predicted, the DFS and OS of patients with PL2 were much worse than those of patients with PL0 (P < .01) and PL1 (P < .01). However, both the DFS and OS of patients with PL0 and PL1 were comparable (DFS: P = .198; OS: P = .150). For node-negative cases, the DFS and OS of patients with PL0 and PL1 were also comparable (DFS: P = .468; OS: P = .388), but patients with PL2 had much worse DFS and OS than patients with PL0 (P < .01) and PL1 (P < .01). Multivariable analyses suggested that PL2, together with node positivity and poor cell differentiation, was an independent adverse prognostic factor.

INTERPRETATION

In NSCLCs ≤ 3 cm, tumors with PL1 should remain defined as T1, not T2. Overtreatment by adjuvant chemotherapy in node-negative NSCLCs ≤ 3 cm might be avoided in PL1 cases.

Clinical significance of visceral pleural and lymphovascular invasion in surgically resected adenosquamous lung cancer

OBJECTIVES

The aim of this study was to assess the relationship between visceral pleural invasion (VPI), lymphovascular invasion (LVI) and other clinicopathological characteristics and their prognostic impact on surgically resected adenosquamous carcinoma (ASC).

METHODS

We retrospectively reviewed 256 patients with radically resected ASC between January 2010 and December 2015. Patients were divided into 2 groups: those with VPI and those with LVI. The effects of VPI and LVI on disease-free survival and overall survival were evaluated, further stratified by tumour size and lymph node status.

RESULTS

Finally, 213 patients with ASC were enrolled in our study. VPI was correlated with tumour location (P < 0.001), pT stage (P < 0.001) and pN stage (P = 0.012). LVI was related to age (P = 0.005) and pN stage (P = 0.003). Both VPI and LVI were adverse prognostic factors for disease-free survival (P = 0.008, P = 0.028) and overall survival (P = 0.005, P = 0.009) using the Kaplan-Meier method. In multivariable analysis only, VPI was an independent risk factor for disease-free survival [hazard ratio (HR) 0.61, 95% confidence interval (CI) 0.42-0.87; false discovery rate, adjusted P = 0.020] and overall survival (HR 0.60, 95% CI 0.42-0.86; false discovery rate, adjusted P = 0.017). When the prognostic value of VPI was stratified by tumour size and lymph node status, we observed that only patients with VPI in tumours ≤4 cm and patients with N0 status had a worse prognosis than those without visceral invasion (P < 0.05).

CONCLUSIONS

VPI and LVI were poor prognostic factors in patients with ASC, but only VPI was an independent factor for survival, especially in patients with tumours ≤4 cm and pN0 status.

Nomogram for Predicting the Relationship between the Extent of Visceral Pleural Invasion and Survival in Non-Small-Cell Lung Cancer

Objective

Although visceral pleural invasion (VPI) has already been incorporated into the TNM staging system, few studies have been conducted to evaluate the prognostic value of the extent of VPI for the survival of non-small-cell lung cancer (NSCLC) patients. Thus, we utilized the Surveillance, Epidemiology, and End Results (SEER) database to assess the correlation between the extent of VPI and survival in NSCLC.

Methods

We identified and incorporated the extent of VPI to build a prognostic nomogram in this study. Patients in the SEER database diagnosed with NSCLC (n = 87,045) from 2010 to 2015 were further analyzed and randomly assigned into either the training group (n = 60,933) or validation group (n = 26,112). Clinical variables were calculated by means of multivariate Cox regressions and incorporated into the predictive model. Subsequently, the accuracy and discrimination of nomogram were further assessed through the concordance index (C-index), calibration curves, and Kaplan–Meier curves.

Results

Multivariate analysis demonstrated that the extent of visceral pleural invasion was an independent and unfavorable prognostic factor. The C-indexes of the training and validation groups were 0.772 (95% CI: 0.770–0.774) and 0.769 (95% CI: 0.765–0.773), respectively, which revealed that the nomogram had sufficient credibility and stable predictive accuracy. The calibration curve displayed consistency between the actual and predictive values in both training and validation groups.

Conclusion

The prognostic nomogram with the extent of VPI could offer an accurate risk evaluation for patients with NSCLC. Independent external validation of this research should be conducted in the future.

The Significance of Skip Mediastinal Lymph Node Metastasis in the Prognosis of Patients with Resected Non-Small-Cell Lung Carcinoma: Is It Really a Better N2 Disease Subtype?

Objective: In this study, we aimed to reveal the prognostic differences between skip and non-skip metastasis mediastinal lymph node (MLN) metastasis.

Methods: A total of 202 patients (179 males and 23 females; mean age, 59.66 ± 9.89 years; range: 29–84 years) who had ipsilateral single-station MLN metastasis were analyzed in two groups retrospectively between January 2009 and December 2017: “skip ipsilateral MLN metastasis” group (sN2) (n = 55,27.3%) [N1(–), N2(+)], “non-skip ipsilateral MLN metastasis” group (nsN2) (n = 147,72.7%) [N1(+), N2(+)].

Results: The mean follow-up was 42.63 ± 34.91 months (range: 2–117 months). Among all patients, and in the sN2 and nsN2 groups, the median overall survival times were 63.5 ± 4.56, 68.8 ± 7, and 59.3 ± 5.35 months, respectively, and the 5-year overall survival rates were 38.2%, 46.3%, and 36.4%.

Conclusion: Skip metastasis did not take its rightful place in TNM classification; thus, further studies will be performed. To detect micrometastasis, future studies on skip metastasis should examine non-metastatic hilar lymph nodes (LNs) through staining methods so that heterogeneity in patient groups can be avoided, that is, to ensure that only true skip metastasis cases are included. Afterwards, more accurate and elucidative studies on skip metastasis can be achieved to propound its prognostic importance in the group of N2 disease.

Value of CT features for predicting EGFR mutations and ALK positivity in patients with lung adenocarcinoma

The aim of this study was to identify the relationships of epidermal growth factor receptor (EGFR) mutations and anaplastic large-cell lymphoma kinase (ALK) status with CT characteristics in adenocarcinoma using the largest patient cohort to date. In this study, preoperative chest CT findings prior to treatment were retrospectively evaluated in 827 surgically resected lung adenocarcinomas. All patients were tested for EGFR mutations and ALK status. EGFR mutations were found in 489 (59.1%) patients, and ALK positivity was found in 57 (7.0%). By logistic regression, the most significant independent prognostic factors of EGFR effective mutations were female sex, nonsmoker status, GGO air bronchograms and pleural retraction. For EGFR mutation prediction, receiver operating characteristic (ROC) curves yielded areas under the curve (AUCs) of 0.682 and 0.758 for clinical only or combined CT features, respectively, with a significant difference (p < 0.001). Furthermore, the exon 21 mutation rate in GGO was significantly higher than the exon 19 mutation rate(p = 0.029). The most significant independent prognostic factors of ALK positivity were age, solid-predominant-subtype tumours, mucinous lung adenocarcinoma, solid tumours and no air bronchograms on CT. ROC curve analysis showed that for predicting ALK positivity, the use of clinical variables combined with CT features (AUC = 0.739) was superior to the use of clinical variables alone (AUC = 0.657), with a significant difference (p = 0.0082). The use of CT features for patients may allow analyses of tumours and more accurately predict patient populations who will benefit from therapies targeting treatment.

Clinical Value of 18F-FDG PET/CT in Prediction of Visceral Pleural Invasion of Subsolid Nodule Stage I Lung Adenocarcinoma

RATIONALE AND OBJECTIVES

This study investigated the utility of ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) for predicting visceral pleural invasion (VPI) of subsolid nodule (SSN) stage I lung adenocarcinoma.

MATERIALS AND METHODS

A retrospective analysis of ¹⁸F-FDG PET/CT data from 65 postsurgical cases with surgical pathology-confirmed SSN lung adenocarcinoma identified significant VPI predictors using multivariate logistic regression.

RESULTS

Nodule and solid component sizes, solid component-to-tumor ratios, pleural indentations, distances between nodules and pleura, and maximum standardized uptake values (SUVmax) differed significantly between VPI-positive (n = 30) and VPI-negative (n = 35) cases on univariate analysis. The distance between the nodule and pleura and SUVmax were significant independent VPI predictors on multivariate analysis. Areas under the curve of the distance between the nodule and pleura and SUVmax on receiver operating characteristic curves were 0.76 and 0.79, respectively; both factors were 0.90. The area under the curve of combined predictors was significantly superior to the distance between the nodule and pleura only but not SUVmax alone. The threshold of the distance between the nodule and pleura, to predict VPI was 4.50 mm, with 96.67% sensitivity, and 57.14% specificity. The threshold of SUVmax to predict VPI was 1.05, with 100% sensitivity and 60% specificity. The sensitivity and specificity of model 2 using the independent predictive factors were 96.67%, and 71.43%, respectively.

CONCLUSION

Distance between the nodule and pleura and SUVmax are independent predictors of VPI in SSN stage I lung adenocarcinoma. Further, combining these factors improves their predictive ability.

Prognostic value of visceral pleural invasion in pure-solid and part-solid lung cancer patients

OBJECTIVE

Visceral pleural invasion (VPI) indicates poor prognosis in non-small cell lung cancer (NSCLC), and is defined as a T2 descriptor for T1-sized tumor. However, whether its prognostic impact differs between pure-solid and part-solid tumors as preoperative diagnostic imaging is controversial. We aimed to elucidate the prognostic difference of VPI in cT1-sized NSCLC according to radiological tumor type (pure-solid or part-solid).

METHODS

We retrospectively reviewed 498 NSCLC patients who underwent complete anatomical lung resection between 2009 and 2014. Patients with node-negative, cT1-sized (consolidation size, ≤ 3 cm) NSCLCs were included. VPI included pathological PL1 and PL2. The prognostic impact of VPI according to radiological tumor type was assessed using multivariate Cox regression analyses.

RESULTS

We evaluated 227 pure-solid and 271 part-solid tumors; median follow-up period was 57 months. VPI was found in 40 (17.6%) and 15 (5.5%) patients with pure-solid and part-solid tumors, respectively (p < 0.001). In pure-solid group, VPI patients showed significantly poorer overall survival (OS) rates than non-VPI patients (p = 0.003). In part-solid group, OS rates did not differ significantly according to VPI (p = 0.770). Multivariate analysis revealed that the adjusted hazard ratio (95% confidence interval) for poor OS was 2.129 (1.048-4.132, p = 0.037) for pure-solid tumors with VPI compared to pure-solid tumors without VPI, and 0.925 (0.050-4.920, p = 0.941) for part-solid tumors with VPI compared to part-solid tumors without VPI.

CONCLUSIONS

VPI had a negative prognostic impact on cT1-sized pure-solid tumors but not on part-solid tumors. Upstaging of the T-category by VPI in cT1-sized NSCLCs may be considered for pure-solid tumors.

Novel Prognostic Nomograms for Hepatocellular Carcinoma Patients with Microvascular Invasion: Experience from a Single Center

Background/Aims

Microvascular invasion (MVI) is an established risk factor for hepatocellular carcinoma (HCC). However, prediction models that specifically focus on the individual prognoses of HCC patients with MVI is lacking.

Methods

A total of 385 HCC patients with MVI were randomly assigned to training and validation cohorts in a 2:1 ratio. The outcomes were disease-free survival (DFS) and overall survival (OS). Prognostic nomograms were established based on the results of multivariate analyses. The concordance index (C-index), calibration plots and Kaplan-Meier curves were employed to evaluate the accuracy, calibration and discriminatory ability of the models.

Results

The independent risk factors for both DFS and OS included age, tumor size, tumor number, the presence of gross vascular invasion, and the presence of Glisson’s capsule invasion. The platelet-to-lymphocyte ratio was another risk factor for OS. On the basis of these predictors, two nomograms for DFS and OS were constructed. The C-index values of the nomograms for DFS and OS were 0.712 (95% confidence interval [CI], 0.679 to 0.745; p<0.001) and 0.698 (95% CI, 0.657 to 0.739; p<0.001), respectively, in the training cohort and 0.704 (95% CI, 0.650 to 0.708; p<0.001) and 0.673 (95% CI, 0.607 to 0.739; p<0.001), respectively, in the validation cohort. The calibration curves showed optimal agreement between the predicted and observed survival rates. The Kaplan-Meier curves suggested that these two nomograms had satisfactory discriminatory abilities.

Conclusions

These novel predictive models have satisfactory accuracy and discriminatory abilities in predicting the prognosis of HCC patients with MVI after hepatectomy.

Clinicopathological features of small-sized peripheral squamous cell lung cancer

Recent advances in imaging technology have enhanced the detection rate of small-sized peripheral lung cancers. The present study aimed to identify the clinicopathological differences between patients with small-sized peripheral squamous cell carcinoma (SCC) and adenocarcinoma (ADC). Patients with lung cancer who underwent radical surgical resection at Gunma University Hospital between July 2007 and October 2012 were retrospectively analyzed. Patients who exhibited small-sized peripheral tumors (pathological size, ≤2 cm) located within the outer-third of the lung field on preoperative computed tomography were enrolled in the present study. A total of 26 patients were diagnosed with SCC and 214 with ADC. The results revealed that patients with SCC exhibited higher rates of pleural invasion, vascular invasion and lymphatic invasion compared with ADC patients. Additionally, the rate of postoperative recurrence was higher in patients with SCC compared with ADC patients. Patients with ADC were subsequently into two groups: Solid ADCs (sADC) and non-solid ADCs (nsADC), which included pure ground glass nodules and part-solid ADCs. The results revealed that the incidence of pleural invasion, vascular invasion and lymphatic invasion, and the rate of postoperative recurrence in patients with sADCs were similar to those with SCC, but were also significantly higher when compared with nsADC patients. The present study concluded that patients with SCC and sADC may not be suitable candidates for sublobar resection, despite exhibiting small tumors that are located in the peripheral lung.

Klotho expression and nodal involvement as predictive factors for large cell lung carcinoma

INTRODUCTION

Klotho has been recently described as a carcinogenesis suppressor. Large cell neuroendocrine lung carcinoma (LCNEC) is a rare, highly malignant neoplasm. In the light of increasing incidence of neuroendocrine tumours, biomarkers predicting survival are needed. We consider that Klotho might be one.

MATERIAL AND METHODS

We analysed records of all patients diagnosed with LCNEC, atypical carcinoid and typical carcinoid operated on in our institution between 2007 and 2015. Initially, we found 134 cases. Forty-six specimens were unattainable and thus excluded from research. All patients diagnosed with LCNEC according to the WHO classification were included in the study. Immunohistochemical staining for Klotho was performed. We retrospectively reviewed patient charts and analysed multiple variables.

RESULTS

Positive staining for Klotho was present in 36 tissue specimens, while 12 patients were Klotho-negative. Survival length was significantly higher in Klotho-positive cases (p = 0.024), while advanced nodal status (N1 and N2) represented a marker of poor outcome (p = 0.011). In multivariate analysis, both Klotho presence (p = 0.015; HR = 0.37; 95% CI: 0.17-0.86) and nodal involvement (p = 0.007; HR = 3.04; 95% CI: 1.37-6.82) were independent prognostic factors. Tumour vessel invasion and visceral pleura infiltration were not associated with worse treatment results. Klotho presence predicted a favourable prognosis in these groups (p = 0.018; p = 0.007).

CONCLUSIONS

Our results suggest that Klotho might be a positive factor for predicting survival in LCNEC and nodal involvement a negative one. Thus, these two markers may assist in the selection of subjects with unfavourable prognosis and to personalise therapy regimens.

EGFR mutations are significantly associated with visceral pleural invasion development in non-small-cell lung cancer patients

Objectives

A retrospective study was performed to investigate the association between EGFR mutations and visceral pleural invasion (VPI), and evaluate the prognostic value of EGFR in resected non-small-cell lung cancer (NSCLC) patients with VPI.

Materials and methods

Clinicopathological characteristics and follow-up information were collected from 508 consecutive patients with surgically resected stage I–III NSCLC, and EGFR mutations were detected based on real-time PCR technology. Significant results (P<0.05) from univariate logistic regression analysis were involved as covariates to adjust confounding factors in the analysis of independent factors.

Results

VPI and EGFR mutations were detected in 229 (45.1%) and 243 (47.8%) cases in NSCLC, respectively. There was a significant association between EGFR mutations and VPI development. Both 19-del (adjusted OR =2.13, 95%CI =1.13–3.99, P=0.019) and L858R (adjusted OR =2.89, 95%CI =1.59–5.29, P=0.001) could significantly increase the risk of VPI development compared with EGFR wild-type. Higher frequency of L858R (adjusted OR =2.63, 95%CI =1.42–4.88, P=0.002) was detected in VPI patients compared with non-VPI patients. 19-del (adjusted HR =0.31, 95%CI =0.12–0.80, P=0.015) was an independent prognostic factor for a better disease-free survival (DFS) in non-VPI patients. No significant association was shown between EGFR mutations and DFS in VPI patients.

Conclusion

EGFR mutations were significantly associated with VPI development in NSCLC, but no significant association was observed between EGFR mutations and DFS in the patients with VPI. 19-del was a favorable prognostic factor for DFS in non-VPI patients.

Lymph node metastasis outside of a tumor-bearing lobe in primary lung cancer and the status of interlobar fissures: The necessity for removing lymph nodes from an adjacent lobe

The new Tumor Node Metastasis staging system does not recognize fissure status with respect to adjacent lobe invasion (ALI) in lung cancer. Furthermore, no specific surgical strategies have been recommended for lymph node dissections around adjacent nontumor-bearing lobes (NTBLs) according to fissure status. Therefore, this study was undertaken to investigate the necessity of removing additional adjacent lobe lymph nodes in patients with nonsmall cell lung cancer (NSCLC) for lesions limited to in the vicinity of the interlobar fissure.From August 2013 to March 2015, the records of 332 patients, who underwent systematic mediastinal lymph node dissection, were reviewed in this retrospective study. The bronchial lymph nodes had been subjected to pathological examination, and the status of the fissures was also recorded. A statistical analysis was performed to identify the significant predictors of lymph node metastasis.The patients were divided into a nonadjacent lobe invasion (NALI) group (n = 295) and an ALI group (n = 37). There was a significant difference in tumors with pN2 disease between the ALI and NALI groups (37.8% vs 8.8%, P = .001). ALI tumors had significantly more frequent pleural involvement than NALI tumors (62.2% vs 43.1%, P = .035). The frequency of N2 involvement among tumors invading across the complete fissure was higher than that of the tumors invading across the incomplete fissure (44.4% vs 14.3%, P = .015). However, the frequency of N1 involvement among tumors invading across the incomplete fissure was not statistically different than that of tumors not invading across incomplete fissure (32.1% vs 24.2%, P = .357). Regarding lymph node metastasis in NTBL, 15 (12.7%) patients had lymph node metastases in NTBLs. Pleural involvement was an independent predictor of lymph node metastasis in an NTBL.A greater frequency of N2 lymph nodes existed in NSCLC with invading adjacent lobe across complete fissure, extensive lymphatic resection within the hilum, and NTBL in tumors with pleural involvement are justifiable and necessary.

Pleural contact decreases survival in clinical T1N0M0 lung cancer patients undergoing SBRT

BACKGROUND

Clinical staging, as used for patients treated with stereotactic body radiotherapy (SBRT) for early-stage lung cancer, inadequately accounts for pleural invasion, which is a pathologic criteria. Considering the current situation, we analyzed effects of relationships between tumors and the pleura on treatment outcomes of SBRT for early-stage lung cancer.

MATERIALS AND METHODS

Among consecutive patients treated with SBRT between 2006 and 2017, we retrospectively identified non-small cell lung cancer patients with primary tumor diameters ≤4 cm and N0M0. The relationships between tumors and the pleura were investigated. The effects of these findings on treatment outcomes were analyzed.

RESULTS

We identified 386 patients which met the inclusion criteria. Among these patients, 323 patients were with tumors of 0.1-3.0 cm (T1-size), and 63 patients were with tumors of 3.1-4.0 cm (T2a-size). Among patients with T1-size tumors, 120, 134, and 23 had findings of pleural contact, pleural indentation, and pleural thickening, respectively. When we divided T1-size patients into 2 groups based on pleural contact (contact- or contact+), the 3-year cause-specific mortality and overall survival in patients with T1-size & contact+ were significantly worse than those in patients with T1-size & contact- (17.6% (95% confidence interval (CI), 10.7-25.9%) vs. 6.6% (95% CI, 3.5-11.1%), p < 0.01), and 58.2% (95% CI, 47.6-67.5%) vs. 77.6% (95% CI, 70.5-83.2%), p < 0.01). Local recurrence, regional recurrence, pleural cavity recurrence, and distant metastasis were associated with worse cause-specific mortality and overall survival. On multivariate analysis, pleural contact was associated with cause-specific mortality (hazard ratio (HR), 1.96; 95% CI, 1.09-3.52; p = 0.03) and overall survival (HR, 1.59; 95% CI, 1.08-2.34; p = 0.02).

CONCLUSION

Pleural contact in clinical T1N0M0 lung cancer patients was associated with significantly worse survivals.

Lung squamous cell carcinoma: A postoperative recurrence analysis of keratinizing and nonkeratinizing subtypes

BACKGROUND

There is currently no definite clinical implication for the subtypes of lung squamous cell carcinoma according to the 2015 WHO classification. This study aimed to investigate postoperative recurrence of the two major subtypes of lung squamous cell carcinoma: keratinizing squamous cell carcinoma (KSCC) and nonkeratinizing squamous cell carcinoma (NKSCC).

METHODS

We identified the patients with KSCC and NKSCC who had undergone complete resection in Shanghai Chest Hospital between April 2015 and June 2016. Disease-free survival (DFS) was compared using Kaplan-Meier statistical analysis. Variables selected by univariate analysis were evaluated in multivariate analysis using the Cox proportional hazard model.

RESULTS

A total of 334 patients included 231 (69.2%) cases with KSCC and 103 (30.8%) cases with NKSCC. There were more smokers in keratinizing than nonkeratinizing subtype (84.8% versus 72.8%, p = 0.009). The percentage of stage Ⅲ was higher in NKSCC than that in KSCC (35% versus 22.9%, p = 0.012). The 2-year DFS rates of stage Ⅰ, stage Ⅱ and stage Ⅲ were 90.1%, 66.4% and 37.7% in KSCC, 83.3%, 67.7% and 52.8% in NKSCC, respectively. There were no significant differences of 2-year DFS rates between KSCC and NKSCC. Furthermore, KSCC and NKSCC had no significant differences in recurrence patterns and metastatic sites.

CONCLUSION

There were no significant differences of postoperative recurrence between KSCC and NKSCC.

Level of pleural invasion effects on prognosis in lung cancer

Objective:

To analyze the extent of visceral pleural invasion (VPI) and its effect on survival along with its place in determining the T descriptor in TNM staging in our patients.

Methods:

A total of 233 patients underwent lung resection. The data were retrospectively analyzed in terms of sex, age, histopathologic type, stage of the tumor, extent of VPI, and survival. Patients who had neoadjuvant chemotherapy or chemoradiotherapy, distant metastasis, parietal pleural invasion, and operative mortality were excluded.

Results:

The median follow-up was 59 months (range 4–126). The extent of VPI was PL0 in 119 (65.7%) patients, PL1 in 47 (26%) patients, and PL2 in 15 (8%) patients. The median survival rates were 65 (range 43–96) months for PL0, 54 (range 37–72) months for PL1, and 39 (range 12–69) months for PL2. The 5-year overall survival rates were 74.7% for PL0, 77.8% for PL1, and 53.3% for PL2. There were statistically significant differences in overall survival among PL0, PL1, and PL2 ( p = 0.03). In subgroup analysis, the difference was insignificant in PL0 vs PL1 ( p = 0.81), but significant in PL0 vs PL2 ( p = 0.02) and PL1 vs PL2 ( p = 0.04) groups.

Conclusions:

This study emphasizes that the presence of VPI is related with poor prognosis independent of lymph node positivity, histologic subtypes, and tumor size. As the study shows, PL0 and PL1 have similar survival rates and these two groups may be considered as VPI (−) patients whereas PL2 disease affects survival outcomes.

Visceral pleural invasion by pulmonary adenocarcinoma ≤3 cm: the pathological correlation with pleural signs on computed tomography

Background

(I) To categorize and quantitatively analyze pleural signs on CT of pulmonary adenocarcinoma (≤3 cm); (II) to evaluate the association between pleural signs and visceral pleural invasion (VPI) of adenocarcinoma.

Methods

The clinical data of 52 pulmonary adenocarcinoma patients with 91 involved pleurae were retrospectively analyzed in one single institution. Pleural signs were categorized into five types of non-interlobar fissure pleura (group A) and four types of interlobar fissure pleura (group B). A new parameter called pleural indentation fraction (PIF) was firstly defined to quantitatively evaluate the level of pleural shift.

Results

In group A, type I pleural sign accounted for 15.79%, type II for 31.58%, type III for 21.05%, type IV for 10.53%, type V for 21.05%. The PIF of type II-III was 0.494±0.204. In group B, type I accounted for 67.65%, type II for 14.71%, type III for 8.82%, type IV for 8.82%. The PIF of type I was 0.188±0.083, significantly different with type II-III of group A (t=-7.444, P<0.001). The PIF of type I in group B had significant linear correlation with the tumor distance to the primary pleura. 41 patients with 75 involved pleurae formed the study part of pathological correlation with pleural signs. The rate of VPI was 87.5% (type III), 80% (type IV) in group A and 84.2% (type I), 40% (type II) in group B (t=30.895, P<0.001). The ratio of type III in group B was 2/2. Four cases with non-intact extrapleural fat layer were pathologically confirmed with VPI in type IV of group A. Six of seven cases with mediastinal pleural abnormality (type II-IV) were confirmed with VPI.

Conclusions

Pleural signs can be categorized into five types of group A and four types of group B in the study. Type III-IV of group A and type I and III of group B may be indicators to VPI. Non-intact extrapleural fat layer and mediastinal pleural abnormality may increase the diagnosis accuracy of VPI.

Efficacy of adjuvant chemotherapy for completely resected stage IB non-small cell lung cancer: a retrospective study

Background

Lung cancer is being increasingly detected in the early stages, highlighting the importance of lung cancer screening. However, there is no consensus on the post-operative management of stage IB non-small cell lung cancer (NSCLC). Therefore, this study aimed to identify the predictive factors for prognosis of stage IB NSCLC and determine the efficacy of adjuvant chemotherapy on recurrence and survival.

Methods

We enrolled 89 patients with stage IB NSCLC who underwent complete resection surgery at Gangnam Severance Hospital from Jan 2008 to Dec 2014. As per the National Comprehensive Cancer Network guidelines, patients were considered to be at high risk when they showed poorly differentiated tumors, lymphovascular invasion, tumor size >4 cm, and visceral pleural invasion (VPI).

Results

Among the 89 patients, 27 underwent adjuvant chemotherapy. Young patients or patients with squamous cell lung cancer received adjuvant chemotherapy frequently. Adjuvant chemotherapy was not a significant factor for disease-free survival and overall survival. Adjuvant chemotherapy did not show a significant protective effect for survival, even for high-risk patients. However, VPI was a significant risk factor for disease-free survival [hazard ratio (HR): 7.051; 95% confidence interval (CI): 1.570-31.659; P=0.011] and overall survival (HR: 8.289; 95% CI: 1.036-66.307; P=0.046), even after adjustment for various factors.

Conclusions

Adjuvant chemotherapy does not affect the prognosis of stage IB NSCLC, even in high-risk patients. Additionally, VPI is a strong prognostic factor of stage IB NSCLC.

Lung adenocarcinoma with intraoperatively diagnosed pleural seeding: Is main tumor resection beneficial for prognosis?

OBJECTIVE

To evaluate whether main tumor resection improves survival compared with pleural biopsy alone in patients with lung adenocarcinoma with intraoperatively diagnosed pleural seeding.

METHODS

Forty-three patients with lung adenocarcinoma with pleural seeding diagnosed unexpectedly during surgery performed between January 2006 and December 2014 were included in this retrospective study using a prospectively collected lung cancer database. Each surgeon decided whether to perform main tumor resection or pleural biopsy alone.

RESULTS

Main tumor and visible pleural nodule resection was performed in 30 patients (tumor resection group). The remaining 13 patients underwent pleural nodule biopsy alone (open-close group). The clinical T stage was higher in the open-close group than in the tumor resection group (P = .02). The tumor resection group had longer operative times compared with the open-close group (mean, 141.8 vs 80.3 minutes). There were no other statistically significant differences in perioperative parameters. The surgical method was the sole statistically significant prognostic factor. Patients in the tumor resection group had better progression-free survival (3-year survival: 44.5% vs 0%; P = .009) and overall survival (3-year survival: 82.9% vs 38.5%; P = .013) than did the open-close group. There was no significant survival difference between sublobar resection and lobectomy for the main tumor resection.

CONCLUSIONS

Our study demonstrated improved progression-free and overall survival after main tumor and visible pleural nodule resection in patients with lung adenocarcinoma with intraoperatively diagnosed pleural seeding. Further randomized trials are needed to define the role of main tumor resection in these patients.

Risk factors of lymph node metastasis in patients with non-small cell lung cancer ≤ 2 cm in size: A monocentric population-based analysis

Aim

This study was designed to determine the risk factors of lymph node metastasis in non‐small cell lung cancer (NSCLC) patients with tumors ≤ 2 cm, using the Shanghai Chest Hospital Lung Cancer Database.

Methods

Five hundred and eighteen patients with NSCLC ≤ 2 cm were included in this study, and were classified into lymph node‐positive and lymph node‐negative groups. Univariate and multivariate logistic regression analyses were performed to select the independent risk factors for lymph node metastasis in NSCLC patients.

Results

No evidence of metastasis was found in tumors ≤ 1 cm, all positive results were in tumors sized 1–2 cm. Imaging characteristics, including solid and part‐solid nodules, were strongly associated with lymph node metastasis (odds ratio [OR] 24.959, 95% confidence interval [CI] 5.999–103.835, P < 0.001; OR 12.559, 95% CI 3.564–44.259, P < 0.001) and subgroup logistic analysis (OR 21.384, 95% CI 5.058–90.407, P < 0.001; OR 11.632, 95% CI 3.290–41.126, P < 0.001). Greater lymph node metastasis was observed in non‐adeno non‐squamous carcinoma. The presence of pleural invasion and carcinoembryonic antigen levels indicated lymph node dissection. Similar results were revealed in subgroup analysis in tumors ≤ 2 to > 1 cm.

Conclusion

Size had a great impact on lymph node metastasis, especially tumors of 1–2 cm. Preoperative imaging, non‐adeno non‐squamous carcinoma, pleural invasion, and carcinoembryonic antigen all indicated lymph node dissection. There was no discrepancy between N1 and N2 positive lymph nodes.

Peripheral lung adenocarcinomas harboring epithelial growth factor receptor mutations with microRNA-135b overexpression are more likely to invade visceral pleura

Lung adenocarcinoma, characterized by its early and aggressive local invasion and high metastatic potential, is the most frequently observed histological type of non-small-cell lung cancer (NSCLC). Visceral pleural invasion (VPI) caused by peripheral lung adenocarcinomas is closely associated with the poor prognosis of patients with NSCLC. The association between VPI and some clinicopathological characteristics has been observed in the past few decades. However, the molecular mechanism of VPI in lung adenocarcinomas is unknown. In the present, the expression level of microRNA (miR-)135b and epidermal growth factor receptor (EGFR) mutations using the reverse transcription-quantitative polymerase chain reaction and DNA sequencing, respectively. In addition, the present study aimed at exploring the association between the miR-135b level, EGFR mutations and VPI in peripheral lung adenocarcinoma. The results of the present study demonstrated that miR-135b was significantly upregulated in lung adenocarcinoma compared with adjacent normal tissue and positively associated EGFR mutations in peripheral lung adenocarcinoma. Furthermore, it was identified that lung adenocarcinomas with EGFR mutations and miR-135b overexpression were more likely to invade visceral pleura. Taken together, these findings indicate that miR-135b overexpression is positively associated with mutations to EGFR, which may promote the development of peripheral lung adenocarcinomas by the formation of VPI. This indicates that the two factors may serve as prognostic markers and molecular targets for the treatment of peripheral lung adenocarcinomas.

Risk factors for relapse of resectable pathologic N2 non small lung cancer and prediction model for time-to-progression

Background

Pathologic N2 non-small-cell lung cancer (NSCLC) was demonstrated with poor survival among literature. In this study, we retrospectively reviewed patients with pathologic N2 NSCLC and received anatomic resection (i.e. lobectomy) for further relapse risk factor analysis. The aim of this study is to identify the clinicopathologic factors related to relapse among resectable N2 NSCLC patients and to help clinicians in developing individualized follow up program and treatment plan.

Method

From January 2005 to July 2012, 90 diagnosed pathologic N2 NSCLC patients were enrolled into this study. We retrospectively reviewed medical records, image studies, and pathology reports to collect the patient clinico-pathologic factors.

Result

We identified that patients with visceral pleural invasion (p = 0.001) and skip metastases along mediastinal lymph node (p = 0.01) had a significant relationship to distant and disseminated metastases. Patients who had 2 or more risk factors for relapse demonstrated poor disease free survival than those who had less than 2 risk factors (p = 0.02). The number of involved metastatic area were significantly influential to the period of time-to-progression. The duration of time-to-progression was correlated with square of number of involved metastatic areas. (Pearson correlation coefficient = −0.29; p = 0.036).

Conclusion

Relapse risk factors of resectable pathologic N2 NSCLC patient after anatomic resection were visceral pleural invasion, skip mediastinal lymph node involvement, and the receipt of neoadjuvant therapy. The duration of time-to-progression was correlated with square of number of involved metastatic areas.

Extent of visceral pleural invasion and the prognosis of surgically resected node-negative non-small cell lung cancer

Background

Visceral pleural invasion (VPI) is generally considered a poor prognostic factor in non‐small cell lung cancer (NSCLC). VPI is defined as penetration beyond the elastic layer of visceral pleura (PL1), including the visceral pleural surface without the involvement of adjacent structures (PL2) by cancer cells. The aim of this study was to evaluate the influence of the extent of VPI on NSCLC prognosis.

Methods

This was a retrospective study of 90 patients with resected node‐negative NSCLC with VPI. The overall survival (OS) and disease‐free survival (DFS) rates were estimated using the Kaplan–Meier method. Multivariate analysis for prognostic factors was performed using a Cox proportional hazards regression model. The pattern of recurrence was also compared between PL1 and PL2 groups.

Results

Seventy‐three patients had PL1. The three‐year OS rates for the PL1 and PL2 groups were 97.4% and 82.4%, respectively (P = 0.004). The two‐year DFS rates for PL1 and PL2 groups were 81.0% and 76.5%, respectively (P = 0.419). According to the multivariate analysis, PL2 was not a significant prognostic factor for survival outcome in node‐negative NSCLC with VPI compared to PL1 (hazard ratio for DFS 1.753, 95% confidence interval 0.582–5.284; P = 0.319). In this study, six patients in the PL1 and one in PL2 group developed ipsilateral pleural recurrence (P = 1.000).

Conclusion

VPI extent may not influence survival outcomes in patients with surgically resected node‐negative NSCLC with VPI.

Effect of visceral pleural invasion on the prognosis of patients with lymph node negative non-small cell lung cancer

Background

Visceral pleural invasion (VPI) is an adverse prognostic factor in non‐small cell lung cancer (NSCLC); however, its effect in relation to tumor size remains under debate. To better understand the prognostic impact and potential consequences for staging, we examined correlations between VPI and clinicopathologic characteristics in patients with NSCLC, particularly those with lymph node negative NSCLC.

Methods

We retrospectively analyzed 813 cases of radically resected NSCLC treated in our institution between December 2005 and December 2011. Patients were divided into two groups according to VPI status to compare their clinicopathologic characteristics. Survival analysis was performed in 521 cases with pN0 NSCLC.

Results

VPI was diagnosed in 379 (46.6%) cases. It was more common in women, patients with non‐squamous cell carcinoma, elevated preoperative serum carcinoembryonic antigen levels, moderately or poorly differentiated tumors, and larger‐sized tumors. The incidence of mediastinal lymph node metastasis, particularly multi‐station metastasis, was higher in patients with VPI. Patients with pN0 NSCLC, 2–3 cm tumors, and VPI had a significantly poorer prognosis (VPI vs. non‐VPI: five‐year overall survival 78.3% vs. 84.5%, P = 0.039; five‐year disease‐free survival 69.2% vs. 80.0%, P = 0.046, respectively); however, no significant effect was observed for tumors ≤2, 3–5, and 5–7 cm. P‐N0 patients with VPI had a significantly higher incidence of postoperative local recurrence and distant metastasis than those without VPI (P = 0.01), especially ipsilateral pleural recurrence.

Conclusion

VPI was an adverse prognostic factor in radically resected pN0 NSCLC, especially for tumors 2–3 cm in size.

Visceral pleural invasion in lung adenocarcinoma ≤3 cm with ground-glass opacity: a clinical, pathological and radiological study

BACKGROUND

Visceral pleural invasion (VPI) had been demonstrated as an aggressive sign in non-small cell lung cancers (NSCLC). However, its incidence and clinical relevance in early lung cancer showing ground glass nodules (GGNs) has not been clarified.

METHODS

All consecutive surgically treated patients with solitary GGNs between 2009 and 2013 were reviewed retrospectively. Inclusion criteria were defined as lesions ≤3 cm with pleura abutting on computed tomography (CT) scan and pathologically confirmed NSCLC.

RESULTS

Out of 156 enrolled patients, 38 had pathologically confirmed VPI. The incidence of VPI was 41.5% (27/65) if the tumor diameter was larger than 2.0 cm and 14.3% (13/91) if diameter was smaller than 2.0 cm (P<0.001). Further, the incidence was 17.4% (12/69) in pure GGNs and 32.2% (28/87) in part-solid GGNs (P=0.040). The tumor size and the nodule nodule-pleural relationship were significant predictors of positive VPI. In cases with pleural indentation, attachment, and closeness, the incidence was 38.1%, 25.5%, and 5.3%, respectively (P=0.001). All cases were PL0 and PL1, with no PL2 cases observed.

CONCLUSIONS

Although VPI was visible in both pure/mix GGNs, it was more common in larger (>2 cm) GGNs. The radiographic findings of nodule abutment or a pleural tag did not reliably predict or exclude VPI. In patients with GGNs, a low rate of PL2 invasion may be observed.

Prognostic Factors for Disease-Free Survival in pT2N0 Non-Small Cell Lung Cancer

To clarify the prognostic factors for disease-free survival in completely resected pT2N0 non-small cell lung cancer, 81 consecutive patients who were treated between 1998 and 2001 were retrospectively reviewed. Follow-up was complete for all patients and the median follow-up time was 37.5 months. The overall 5-year survival rate was 68.6%, and the 5-year disease-free survival rate was 62.5%. Four factors (age, sex, visceral pleural invasion, and administration of tegafur and uracil) were proposed as prognostic factors for disease-free survival by univariate analysis. In multivariate analysis, visceral pleural invasion by the tumor (hazard ratio = 2.709, 95% confidence interval: 1.085 to 6.765, p = 0.033) and administration of tegafur and uracil (hazard ratio = 0.327, 95% confidence interval: 0.147 to 0.730, p = 0.006) were significant factors. Visceral pleural invasion was a prognostic factor for reduced disease-free survival in completely resected pT2N0 non-small cell lung cancer, and postoperative treatment with tegafur and uracil significantly improved disease-free survival.

[Lung cancer measuring 1cm or less: A miniature subset requiring surgery]

INTRODUCTION

Lung cancer measuring 1cm or less has an apparently very good outcome. However, the characteristics permitting their oncological management are unappreciated.

PATIENT AND METHOD

We reviewed 187 patients with such a cancer (145 men and 42 women, mean age 60.2years) and studied the type of surgery performed, the pTNM, and the histological features.

RESULTS

Surgery (19 wedge-resections, 12 segmentectomies, 136 lobectomies, 20 pneumonectomies) was complete (R0) in 97.3%. The tumors, each precisely defined among 98 adenocarcinomas (52.4%), 83 squamous cell carcinomas (44.4%), and 6 others, measured 1mm to 10mm:<5mm (n=41), 6 to 9mm (n=43), and 10mm (n=103). There were 161 pT1 (86.1%), 22 pT2 (11.8%) and 4 pT3; 148 pN0 (79.6%), 18 pN1 (9.7%) and 20 pN2 (10.7%). pN1 and pN2 were present in tumors<5mm (12/41, 29.3%) as well as in the others (26/146, 17.8% P=0.11). Histological examination frequently discovered visceral pleura involvement (tumors:<5mm 12.2% (5/41), 6 to 9mm 7% (3/43), 10mm 13.6% (14/103), P=0.53) and lympho-vascular invasion (12.9%). Five-year survival rate (66.4%) was adversely influenced by age, type of resection, pN and histological features. The survival rate was not better in tumor<5mm.

CONCLUSION

Surgical resection allows the local control of lung cancers<1cm and their complete histological study, a key issue in the therapy of the future, which renders surgery an absolute must even in very small tumors.

Microscopic Invasions, Prognoses, and Recurrence Patterns of Stage I Adenocarcinomas Manifesting as Part-Solid Ground-Glass Nodules: Comparison With Adenocarcinomas Appearing as Solid Nodules After Matching Their Solid Parts' Size

The purpose of the present study was to compare the frequency of microscopic invasions, disease-free-survival (DFS), and the frequency and pattern of disease recurrence between stage I pulmonary adenocarcinomas appearing as solid nodules and those appearing as part-solid ground-glass nodules (GGNs) after matching their solid parts' size (D(solid)) and patients' age. Among 501 patients who underwent curative surgery for stage I pulmonary adenocarcinomas between 2003 and 2011, 172 patients (86 with solid nodules [M: F = 36: 50; mean age, 62.8 years] and 86 with part-solid GGNs [M:F = 30:56; mean age, 63.0 years]) matched for D(solid) and patients' age were included. DFS, frequency of microscopic invasions, recurrence, and recurrence pattern were compared between the two groups. No significant difference was observed in the frequency of microscopic invasions between the two groups (visceral pleural invasion, 30.23% vs. 29.07%, P = 0.867; lymphatic invasion, 5.81% vs. 3.49%, P = 0.720; vascular invasion, 1.16% vs. 0%, P = 1.000; solid nodules vs. part-slid GGNs, respectively) and DFS (estimated 5-year DFS, 83.6% vs. 81.9%, P = 0.744; solid nodules vs. part-slid GGNs, respectively). As for recurrence and recurrence pattern, there were no significant differences between the solid nodule group (14/86), and part-solid GGN group (12/86) (P = 0.670). Lung parenchymal nodules were the most frequent pattern of disease recurrence in both groups, followed by pleural seeding. In conclusion, after matching D(solid) and patients' age, there was no significant difference in the frequency of microscopic invasions, DFS, and the frequency and pattern of recurrence between stage I pulmonary adenocarcinomas appearing as solid nodules and part-solid GGNs.

Results of surgical treatment and impact on T staging of non-small-cell lung cancer adjacent lobe invasion

OBJECTIVES

To assess the results of surgical treatment of T-ALI (adjacent lobe invasion) tumours in patients with non-small-cell lung carcinoma.

METHODS

Multicentric retrospective analysis of a prospectively maintained database of 13 065 patients, aged 32-89 years (mean 52.9, median 63 years), who underwent resection between January 2009 and September 2014.

RESULTS

In the whole study group, T-ALI was observed in 324 patients (2.5%): 201 patients (62.0%) with a tumour invading the pleura in the inter-lobar fissure (T-ALI-A), and 123 patients (38.0%) with a tumour in the adjacent lobe but without pleural invasion in the fissure (T-ALI-D). With regard to N0 patients, the 3- and 5-year survival rates in the T2 group were significantly higher than that of the T-ALI group (76.1 and 68.4%, P = 0.002 vs 58.3 and 51.0%, P = 0.008, respectively). On the other hand, when the N1 group was analysed, the 5-year survival rates were 54.3 and 48%, respectively (P = 0.041). In the N2 group, the 5-year survival rates in the T2 and T-ALI groups were 40.2 and 35.0%, respectively (P = 0.241). The comparison of the T-ALI and T3 groups for stages N0, N1 and N2 revealed differences in 5-year survival rates as follows: 68.4 vs 62.9% (P = 0.048), 48.0 vs 37.6% (P = 0.08) and 35.0 vs 27.6% (P = 0.121), respectively. In the whole group, the difference in survival rate between T-ALI N0 and T2N0 was statistically significant (P = 0.008) and statistically significant for the T3N0 group (P = 0.048). The 3-year survival rate in the T-ALI N0 group was statistically lower following pneumonectomy than following lobectomy (56.4 vs 61.3%, P = 0.03). The best survival rate was observed following bilobectomy (75.6%).

CONCLUSIONS

In our study, a tumour with ALI (T-ALI) represented a separate stage of cancer between T2 and T3. The survival rate in the T-ALI-A group was significantly poorer than that in the T-ALI-D group. Overall treatment results were similar for stage T3, suggesting that it may be necessary to divide this group into T3a and T3b. We would suggest that all tumours between 5 and 7 cm be classified as T3b, and any tumour smaller than 5 cm but with ALI be classified as T3a. Treatment of choice should include lobectomy or bilobectomy. Pneumonectomy should be performed only in a selected group of patients.

Predictors of Recurrence after Curative Resection in Patients with Early-Stage Non-Small Cell Lung Cancer

Background

There have been various results from studies concerning the predictors of recurrence in early-stage nonsmall cell lung cancer (NSCLC). Therefore, an accurate assessment is needed to guide effective adjuvant therapy. We investigated the predictors of a recurrence in patients with resected, early-stage NSCLC and the risk factors associated with locoregional or distant recurrence.

Methods

This retrospective study was conducted on patients at the Pusan National University Hospital from January 2006 to December 2011. Patients with pathological stages I or II were included in this study, as based on the seventh edition TNM staging system. Multivariate Cox proportional hazard models were used to identify factors associated with recurrence.

Results

Two hundred and forty-nine patients were included. Among them, 180 patients were stage I, and 69 were stage II. Overall, by multivariate analysis, the independent factors associated with a 5-year total recurrence were the presence of visceral pleural invasion (VPI) (p=0.018) and maximal standardized uptake values (SUVs) of tumors on positron emission tomography (PET) >4.5 (p=0.037). The VPI was the only independent risk factor associated with both locoregional and distant recurrence, in the analysis of the patterns of tumor recurrence and their risk factors. In the subgroup analysis of stage I patients, three variables (male, VPI and resection margin positive) were significantly associated with a 5-year recurrence.

Conclusion

The independent factors associated with postoperative recurrence in early-stage NSCLC were as follows: PET SUV >4.5 and the presence of VPI. For patients with those factors adjuvant therapy should be recommended as a more efficacious treatment.

Pleural involvement in lung cancer

The pleural space, a sterile secluded environment in the thoracic cavity, represents an attractive metastatic site for various cancers of lung, breast and gastrointestinal origins. Whereas lung and breast adenocarcinomas could invade the pleural space because of their anatomic proximity, "distant" cancers like ovarian or gastrointestinal tract adenocarcinomas may employ more active mechanisms to the same end. A pleural metastasis is often accompanied by a malignant pleural effusion (MPE), an unfavorable complication that severely restricts the quality of life and expectancy of the cancer patient. MPE is the net "product" of three different processes, namely inflammation, enhanced angiogenesis and vascular leakage. Current efforts are focusing on the identification of cancer cell autocrine (specific mutation spectra and biochemical pathways) and paracrine (cytokine and chemokine signals) characteristics as well as host features (immunological or other) that underlie the MPE phenotype. Herein we examine the pleural histology, cytology and molecular characteristics that make the pleural cavity an attractive metastasis destination for lung adenocarcinoma. Mesothelial and tumor features that may account for the tumor's ability to invade the pleural space are highlighted. Finally, possible therapeutic interventions specifically targeting MPE are discussed.