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Park HK, Kwon Y, Lee GD, Choi S, Kim HR, Kim YH, Kim DK, Park SI, Yun JK. Prognostic Implications of Selective Dissection of Left Lower Paratracheal Lymph Nodes in Patients with Left-Sided Non-Small Cell Lung Cancer. J Chest Surg 2024; 57:467-476. [PMID: 39115199 PMCID: PMC11392705 DOI: 10.5090/jcs.24.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/07/2024] [Accepted: 06/13/2024] [Indexed: 09/05/2024] Open
Abstract
Background This study aimed to examine the clinical implications of selective station 4L lymph node dissection (S4L-LND) on survival in non-small cell lung cancer (NSCLC) and to evaluate its potential advantages. Methods We enrolled patients with primary left-sided NSCLC who underwent upfront video-assisted thoracoscopic surgery with R0 resection including lobectomy and segmentectomy, with or without S4L-LND, at our institution between January 2007 and December 2021. Following 1:1 propensity score matching (PSM), we compared overall survival (OS) and recurrence-free survival (RFS) between patients with and without S4L-LND. Results The study included 2,601 patients, of whom 1,126 underwent S4L-LND and 1,475 did not. PSM yielded 1,036 patient pairs. Among those who underwent S4L-LND, 87 (7.7%) exhibited S4L-LN involvement. Neither OS (p=0.12) nor RFS (p=0.24) differed significantly between matched patients with and without S4L-LND. In patients with S4L-LN involvement, metastases were more common in the left upper lobe (LUL) than in the left lower lobe (LLL) (3.6% vs. 2.0%, p=0.061). Metastasis became significantly more frequent with more advanced clinical N (cN) stage (cN0, 2.3%; cN1, 5.8%; cN2, 32.6%; p<0.001). Multivariate logistic regression analysis revealed that cN stage and tumor location were independently associated with S4L-LN involvement (p<0.001 for both). Conclusion OS and RFS did not differ significantly between matched patients with and without S4L-LND. Among participants with S4L-LN involvement, metastases occurred more frequently in the LUL than the LLL, and their incidence increased significantly with more advanced cN stage. Thus, patients with LUL or advanced cN lung cancers may benefit from S4L-LND.
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Affiliation(s)
- Hyo Kyen Park
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yelee Kwon
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Geun Dong Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sehoon Choi
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyeong Ryul Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong-Hee Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Il Park
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Kwang Yun
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Cimenoglu B, Ozdemir A, Buz M, Dogruyol T, Turan N, Demirhan R. What alters prognosis in patients who were operated for lung cancer with lymph node metastasis? ANZ J Surg 2024. [PMID: 39205444 DOI: 10.1111/ans.19177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 06/10/2024] [Accepted: 07/10/2024] [Indexed: 09/04/2024]
Abstract
INTRODUCTION In this study, we investigated the clinical outcomes of patients who underwent surgery with proven lymph node metastasis. METHODS Patients who were operated for lung cancer with pN1 or pN2 were examined in the study. The clinicopathological features and survival of the subjects were evaluated according to pN1-pN2 status, presence of neoadjuvant treatment, Positron emission tomography and computed tomography (PET/CT) avidity on mediastinal lymph nodes and specific lymph node stations. RESULTS The study examines 100 patients operated from January 2016 to December 2021. Number of cases with pN1 and pN2 disease were 45 (45%) and 55 (55%) respectively. Thirty (30%) patients received neoadjuvant treatment. The 5-year overall survival (OS) and disease-free survival (DFS) of the patients were computed as 42.5% and 42.4% correspondingly. The 5-year cancer-related survival was 55.3%. In pN2 cohort, 5-year DFS was 67.9% in the neoadjuvant group and 15.9% in the non-neoadjuvant group (P = 0.042). In non-neoadjuvant group, 5-year DFS was 19.9% in cases with mediastinal PET/CT avidity and 56.3% in patients without mediastinal PET/CT avidity (P = 0.018). In pN2 disease, the presence of subcarinal or paratracheal lymph node metastasis did not create a significant difference in 5-year OS or DFS, but pulmonary ligament lymph node metastasis was found to be linked with worse survival in both 5-year OS (P = 0.005) and DFS (P = 0.017). CONCLUSION The main elements related with poor prognosis were absence of neoadjuvant treatment and pulmonary ligament lymph node metastasis in pN2 disease, detecting PET/CT avid mediastinal lymph nodes in non-neoadjuvant group.
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Affiliation(s)
- Berk Cimenoglu
- Thoracic Surgery Department, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Attila Ozdemir
- Thoracic Surgery Department, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Mesut Buz
- Thoracic Surgery Department, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Talha Dogruyol
- Thoracic Surgery Department, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Nedim Turan
- Medical Oncology Department, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Recep Demirhan
- Thoracic Surgery Department, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
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Kim JY, Lee HP, Yun JK, Lee GD, Choi S, Kim HR, Kim YH, Kim DK, Park SI. Risk prediction of multiple-station N2 metastasis in patients with upfront surgery for clinical single-station N2 non-small cell lung cancer. Sci Rep 2024; 14:18800. [PMID: 39138302 PMCID: PMC11322601 DOI: 10.1038/s41598-024-69260-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 08/02/2024] [Indexed: 08/15/2024] Open
Abstract
To investigate long-term outcomes and develop a risk model for pathological multi-station N2 (pN2b) in patients who underwent upfront surgery for clinical single-station N2 (cN2a) non-small cell lung cancer (NSCLC). From 2006 to 2018, 547 patients who had upfront surgery for suspected cN2a NSCLC underwent analysis. A risk model for predicting pN2b metastasis was developed using preoperative clinical variables via multivariable logistic analysis. Among 547 clinical cN2a NSCLC patients, 118 (21.6%), 58 (10.6%), and 371 (67.8%) had pN0, pN1, and pN2. Among 371 pN2 NSCLC patients, 77 (20.8%), 165 (44.5%), and 129 (34.7%) had pN2a1, pN2a2, and pN2b. The 5-year overall survival rates for pN2a1 and pN2a2 were significantly higher than for pN2b (p = 0.041). Histologic type (p < 0.001), age ≤ 50 years (p < 0.001), preoperatively confirmed N2 metastasis (p < 0.001), and clinical stage IIIB (vs. IIIA) (p = 0.003) were independent risk factors for pN2b metastasis. The risk scoring system based on this model demonstrated good discriminant ability for pN2b disease (area under receiver operating characteristic: 0.779). In cN2a NSCLC patients, those with multiple N2 metastases indicate worse prognosis than those with a single N2 metastasis. Our risk scoring system effectively predicts pN2b in these patients.
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Affiliation(s)
- Joon Young Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Han Pil Lee
- Department of Thoracic and Cardiovascular Surgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Republic of Korea
- Department of Thoracic and Cardiovascular Surgery, Kangwon National University School of Medicine, Chuncheon, Republic of Korea
| | - Jae Kwang Yun
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
| | - Geun Dong Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Sehoon Choi
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Hyeong Ryul Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Yong-Hee Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Dong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Seung-Il Park
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
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Oh NE, Choe J, Yun JK, Ji W, Kim S, Chae EJ, Lee SM, Seo JB. Prognostic Value of Preoperative N Subcategories in Patients with Stage IIIA N2 Non-Small Cell Lung Cancer. Radiol Cardiothorac Imaging 2024; 6:e230347. [PMID: 38990133 PMCID: PMC11369650 DOI: 10.1148/ryct.230347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 04/23/2024] [Accepted: 05/30/2024] [Indexed: 07/12/2024]
Abstract
Purpose To evaluate the preoperative risk factors in patients with pathologic IIIA N2 non-small cell lung cancer (NSCLC) who underwent upfront surgery and to evaluate the prognostic value of new N subcategories. Materials and Methods Patients with pathologic stage IIIA N2 NSCLC who underwent upfront surgery in a single tertiary center from January 2015 to April 2021 were retrospectively reviewed. Each patient's clinical N (cN) was assigned to one of six subcategories (cN0, cN1a, cN1b, cN2a1, cN2a2, and cN2b) based on recently proposed N descriptors. Cox regression analysis was used to identify the significant prognostic factors for recurrence-free survival (RFS) and overall survival (OS). Results A total of 366 patients (mean age ± SD, 62.0 years ± 10.1; 202 male patients [55%]) were analyzed. The recurrence rate was 55% (203 of 366 patients) over a median follow-up of 37.3 months. Multivariable analysis demonstrated that cN (hazard ratios [HRs] for cN1 and cN2b compared with cN0, 1.66 [95% CI: 1.11, 2.48] and 2.11 [95% CI: 1.32, 3.38], respectively) and maximum lymph node (LN) size at N1 station (≥12 mm; HR, 1.62 [95% CI: 1.15, 2.29]), in addition to clinical T category (HR, 1.51 [95% CI: 1.14, 1.99]), were independent prognostic factors for RFS. For OS, clinical N subcategories (cN1, cN2a2, and cN2b vs cN0; HRs, 1.91 [95% CI: 1.11, 3.27], 1.89 [95% CI: 1.13, 2.18], and 2.02 [95% CI: 1.07, 3.80], respectively) and LN size at N1 station (HR, 1.75 [95% CI: 1.12, 2.71]) were independent prognostic factors. For clinical N1, OS was further stratified according to LN size (log-rank test, P < .001). Conclusion Assessing the proposed N subcategories by reporting single versus multistation involvement of N2 disease and maximum size of metastatic LN, reflecting metastatic burden, at preoperative CT may offer useful prognostic information for planning optimal treatment strategies. Keywords: CT, Lung, Staging, Non-Small Cell Lung Cancer Supplemental material is available for this article. ©RSNA, 2024.
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Affiliation(s)
- Na Eun Oh
- From the Department of Radiology and Research Institute of Radiology
(N.E.O., J.C., E.J.C., S.M.L., J.B.S.), Department of Thoracic and
Cardiovascular Surgery (J.K.Y.), Department of Internal Medicine, Division of
Pulmonology and Critical Care Medicine (W.J.), and Department of Clinical
Epidemiology and Biostatistics (S.K.), University of Ulsan College of Medicine,
Asan Medical Center, 88 Olympic-ro 43 Gil, Songpa-gu, Seoul 138-736,
Korea
| | - Jooae Choe
- From the Department of Radiology and Research Institute of Radiology
(N.E.O., J.C., E.J.C., S.M.L., J.B.S.), Department of Thoracic and
Cardiovascular Surgery (J.K.Y.), Department of Internal Medicine, Division of
Pulmonology and Critical Care Medicine (W.J.), and Department of Clinical
Epidemiology and Biostatistics (S.K.), University of Ulsan College of Medicine,
Asan Medical Center, 88 Olympic-ro 43 Gil, Songpa-gu, Seoul 138-736,
Korea
| | - Jae Kwang Yun
- From the Department of Radiology and Research Institute of Radiology
(N.E.O., J.C., E.J.C., S.M.L., J.B.S.), Department of Thoracic and
Cardiovascular Surgery (J.K.Y.), Department of Internal Medicine, Division of
Pulmonology and Critical Care Medicine (W.J.), and Department of Clinical
Epidemiology and Biostatistics (S.K.), University of Ulsan College of Medicine,
Asan Medical Center, 88 Olympic-ro 43 Gil, Songpa-gu, Seoul 138-736,
Korea
| | - Wonjun Ji
- From the Department of Radiology and Research Institute of Radiology
(N.E.O., J.C., E.J.C., S.M.L., J.B.S.), Department of Thoracic and
Cardiovascular Surgery (J.K.Y.), Department of Internal Medicine, Division of
Pulmonology and Critical Care Medicine (W.J.), and Department of Clinical
Epidemiology and Biostatistics (S.K.), University of Ulsan College of Medicine,
Asan Medical Center, 88 Olympic-ro 43 Gil, Songpa-gu, Seoul 138-736,
Korea
| | - Seonok Kim
- From the Department of Radiology and Research Institute of Radiology
(N.E.O., J.C., E.J.C., S.M.L., J.B.S.), Department of Thoracic and
Cardiovascular Surgery (J.K.Y.), Department of Internal Medicine, Division of
Pulmonology and Critical Care Medicine (W.J.), and Department of Clinical
Epidemiology and Biostatistics (S.K.), University of Ulsan College of Medicine,
Asan Medical Center, 88 Olympic-ro 43 Gil, Songpa-gu, Seoul 138-736,
Korea
| | - Eun Jin Chae
- From the Department of Radiology and Research Institute of Radiology
(N.E.O., J.C., E.J.C., S.M.L., J.B.S.), Department of Thoracic and
Cardiovascular Surgery (J.K.Y.), Department of Internal Medicine, Division of
Pulmonology and Critical Care Medicine (W.J.), and Department of Clinical
Epidemiology and Biostatistics (S.K.), University of Ulsan College of Medicine,
Asan Medical Center, 88 Olympic-ro 43 Gil, Songpa-gu, Seoul 138-736,
Korea
| | - Sang Min Lee
- From the Department of Radiology and Research Institute of Radiology
(N.E.O., J.C., E.J.C., S.M.L., J.B.S.), Department of Thoracic and
Cardiovascular Surgery (J.K.Y.), Department of Internal Medicine, Division of
Pulmonology and Critical Care Medicine (W.J.), and Department of Clinical
Epidemiology and Biostatistics (S.K.), University of Ulsan College of Medicine,
Asan Medical Center, 88 Olympic-ro 43 Gil, Songpa-gu, Seoul 138-736,
Korea
| | - Joon Beom Seo
- From the Department of Radiology and Research Institute of Radiology
(N.E.O., J.C., E.J.C., S.M.L., J.B.S.), Department of Thoracic and
Cardiovascular Surgery (J.K.Y.), Department of Internal Medicine, Division of
Pulmonology and Critical Care Medicine (W.J.), and Department of Clinical
Epidemiology and Biostatistics (S.K.), University of Ulsan College of Medicine,
Asan Medical Center, 88 Olympic-ro 43 Gil, Songpa-gu, Seoul 138-736,
Korea
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Tsai PC, Liu C, Yeh YC, Hsu PK, Huang CS, Hsieh CC, Hsu HS. Prognostic factors for recurrence-free survival in resected pathologic N2-stage III non-small cell lung cancer treated with upfront surgery. J Chin Med Assoc 2024; 87:212-218. [PMID: 38156883 DOI: 10.1097/jcma.0000000000001050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND The standard treatment for pathological N2 (pN2) non-small-cell lung cancer (NSCLC) patients is definitive chemoradiation. Surgery might be beneficial for resectable pN2 disease, so we investigated the recurrence-free interval of upfront surgery for selected patients with resectable pN2 disease. METHODS The clinicopathologic characteristics of patients with pN2 NSCLC who underwent upfront anatomical resection at Taipei Veterans General Hospital from 2011 January to 2019 December were retrospectively reviewed. A Cox regression model was used to identify prognostic factors of recurrence-free survival (RFS). RESULTS In total, 84 patients after curative lung anatomic resection were analyzed, with a 44-month median survival. The 1-, 3-, and 5-year RFS rates were 63.1%, 31.3%, and 19.9%, respectively, with a median RFS of 18.9 months. Multivariable cox regression analysis identified that the significant predictor for RFS was a tumor size of more than 3 cm (hazard ratio [HR] = 1.74, 95% CI, 1.07-2.83, p = 0.027). Visceral pleural invasion, LN harvest number, tumor stage, and N2 status including single zone (N2a) or multiple zones (N2b) were not prognostic factors in this study. CONCLUSION Upfront surgery for resectable N2 disease achieved favorable outcomes in selected patients, especially better recurrence control with limited tumor size. Therapeutic advances might encourage surgeons to aggressive intervention.
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Affiliation(s)
- Ping-Chung Tsai
- Division of Thoracic Surgery, Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- Department of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Chia Liu
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yi-Chen Yeh
- Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Po-Kuei Hsu
- Department of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chien-Sheng Huang
- Department of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chih-Cheng Hsieh
- Department of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Han-Shui Hsu
- Department of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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Mizuno K, Isaka M, Terada Y, Konno H, Mizuno T, Tone K, Kawata T, Nakajima T, Funai K, Ohde Y. Intraoperative rapid diagnosis of pleural lavage cytology in non-small cell lung cancer. Gen Thorac Cardiovasc Surg 2024; 72:127-133. [PMID: 37395938 DOI: 10.1007/s11748-023-01954-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 06/17/2023] [Indexed: 07/04/2023]
Abstract
OBJECTIVE Positive pleural lavage cytology (PLC +) is a poor prognostic factor for non-small cell lung cancer (NSCLC). However, data on the impact of intraoperative rapid diagnosis of PLC (rPLC) are lacking. Therefore, we evaluated the efficacy of rPLC before resection during surgery. METHODS A total of 1,838 patients who underwent rPLC for NSCLC between September 2002 and December 2014 were studied retrospectively. We assessed the clinicopathological factors between rPLC findings and the impact on survival of patients with curative resection. RESULTS The rPLC + status was observed in 96 (5.3%) among 1,838 patients. The rPLC + group had more unsuspected N2 (30%) than the rPLC- group (p < 0.001). The 5-year overall survival (OS) of patients who underwent lobectomy or more extensive resection with rPLC + , negative rPLC (rPLC-), and microscopic pleural dissemination (PD) and/or malignant pleural effusion (PE) were 67.3, 81.3, and 11.0%, respectively. In the rPLC + group, the prognosis of patients with pN2 was equal to that of pN0-1 (5-year OS: 77.9% vs. 63.4%, p = 0.263). Undetectable dissemination in the first evaluation immediately after starting surgery was found in 9% of rPLC + patients by additional evaluation of the thoracic cavity. CONCLUSIONS Patients with rPLC + have more favorable survival than those with microscopic PD/PE after surgery. Curative resection should be performed in patients with rPLC + , even if N2 is detected during surgery. However, the rPLC + group often has N2 upstaging; therefore, systematic nodal dissection should be performed in rPLC + patients for exact staging. rPLC may contribute to preventing oversight PD by re-evaluation during surgery.
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Affiliation(s)
- Kiyomichi Mizuno
- Division of Thoracic Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, Japan
- First Department of Surgery, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Mitsuhiro Isaka
- Division of Thoracic Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, Japan.
| | - Yukihiro Terada
- Division of Thoracic Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, Japan
| | - Hayato Konno
- Division of Thoracic Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, Japan
| | - Tetsuya Mizuno
- Division of Thoracic Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, Japan
| | - Kiyoshi Tone
- Division of Pathology, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, Japan
| | - Takuya Kawata
- Division of Pathology, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, Japan
| | - Takashi Nakajima
- Division of Pathology, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, Japan
| | - Kazuhito Funai
- First Department of Surgery, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Yasuhisa Ohde
- Division of Thoracic Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, Japan
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Campisi A, Catelli C, Gabryel P, Giovannetti R, Dell'Amore A, Kasprzyk M, Piwkowski C, Infante M. Upfront surgery for N2 NSCLC: a large retrospective multicenter cohort study. Gen Thorac Cardiovasc Surg 2023; 71:715-722. [PMID: 37179506 DOI: 10.1007/s11748-023-01942-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/07/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND The optimal sequence and combination of surgery, chemotherapy and radiotherapy in patients with N2 non-small cell lung cancer (NSCLC) remain undefined. The aim of our study was to compare two treatment options for N2 NSCLC-induction therapy with subsequent surgery versus upfront surgery with adjuvant treatment. METHODS We retrospectively reviewed 405 patients with N2 disease in two centers, between January 2010 and December 2016. They were divided into two groups: the Induction Group, composed of patients who received neoadjuvant chemotherapy, and the Upfront surgery Group, composed of patients who underwent surgery as first-line therapy. Propensity score-matched (PSM) analysis was performed, and 52 patients were included in each group. Primary endpoints were: recurrence, overall survival (OS) and disease-free survival (DFS). RESULTS After the PSM, no differences were observed in general characteristics, perioperative results, rates and severity of complications, and histopathology results. Seventeen patients (32.7%) of the induction group and 21 (40.4%) of the upfront surgery group had mediastinal lymph nodal involvement with skipping (p = 0.415). Recurrence rate was not different between the two groups (57.7% vs 50.0%, p = 0.478). No differences were observed in terms of OS (40.98 ± 35.78 vs 37.0 ± 40.69 months, p = 0.246) and DFS (29.67 ± 36.01 vs 27.96 ± 40.08 months, p = 0.697). The multivariable analysis identified the pT stage and skipping lymph node metastasis as independent predictive factors for OS. CONCLUSIONS Upfront surgery followed by adjuvant therapy does not appear inferior in terms of recurrence, OS and DFS, compared to induction chemotherapy with subsequent surgery.
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Affiliation(s)
- Alessio Campisi
- Thoracic Surgery Department, University and Hospital Trust-Borgo Trento, P.Le A. Stefani, 1-37126, Verona, Italy.
| | - Chiara Catelli
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery and Vascular Sciences, Padua University Hospital, University of Padua, Via Giustiniani 1, Padua, PD, Italy
| | - Piotr Gabryel
- Department of Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Riccardo Giovannetti
- Thoracic Surgery Department, University and Hospital Trust-Borgo Trento, P.Le A. Stefani, 1-37126, Verona, Italy
| | - Andrea Dell'Amore
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery and Vascular Sciences, Padua University Hospital, University of Padua, Via Giustiniani 1, Padua, PD, Italy
| | - Mariusz Kasprzyk
- Department of Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Cezary Piwkowski
- Department of Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Maurizio Infante
- Thoracic Surgery Department, University and Hospital Trust-Borgo Trento, P.Le A. Stefani, 1-37126, Verona, Italy
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Hui WK, Charaf Z, Hendriks JMH, Van Schil PE. True Prevalence of Unforeseen N2 Disease in NSCLC: A Systematic Review + Meta-Analysis. Cancers (Basel) 2023; 15:3475. [PMID: 37444585 DOI: 10.3390/cancers15133475] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/25/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023] Open
Abstract
Patients with unforeseen N2 (uN2) disease are traditionally considered to have an unfavorable prognosis. As preoperative and intraoperative mediastinal staging improved over time, the prevalence of uN2 changed. In this review, the current evidence on uN2 disease and its prevalence will be evaluated. A systematic literature search was performed to identify all studies or completed, published trials that included uN2 disease until 6 April 2023, without language restrictions. The Newcastle-Ottawa Scale (NOS) was used to score the included papers. A total of 512 articles were initially identified, of which a total of 22 studies met the predefined inclusion criteria. Despite adequate mediastinal staging, the pooled prevalence of true unforeseen pN2 (9387 patients) was 7.97% (95% CI 6.67-9.27%), with a pooled OS after five years (892 patients) of 44% (95% CI 31-58%). Substantial heterogeneity regarding the characteristics of uN2 disease limited our meta-analysis considerably. However, it seems patients with uN2 disease represent a subcategory with a similar prognosis to stage IIb if complete surgical resection can be achieved, and the contribution of adjuvant therapy is to be further explored.
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Affiliation(s)
- Wing Kea Hui
- Department of Thoracic and Vascular Surgery, University Hospital Antwerp, Drie Eikenstraat 655, 2650 Edegem, Belgium
| | - Zohra Charaf
- Department of Cardiothoracic Surgery, University Hospital Brussels, Laarbeeklaan 101, 1090 Jette, Belgium
| | - Jeroen M H Hendriks
- Department of Thoracic and Vascular Surgery, University Hospital Antwerp, Drie Eikenstraat 655, 2650 Edegem, Belgium
- ASTARC (Antwerp Surgical Training, Anatomy and Research Centre), University Hospital Antwerp, Drie Eikenstraat 655, 2650 Edegem, Belgium
| | - Paul E Van Schil
- Department of Thoracic and Vascular Surgery, University Hospital Antwerp, Drie Eikenstraat 655, 2650 Edegem, Belgium
- ASTARC (Antwerp Surgical Training, Anatomy and Research Centre), University Hospital Antwerp, Drie Eikenstraat 655, 2650 Edegem, Belgium
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9
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Zhu Q, Chen G, Liu Y, Zhou Y. Neoadjuvant immunotherapy versus chemoimmunotherapy in non-small cell lung cancer: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2023; 102:e33166. [PMID: 36862876 PMCID: PMC9981425 DOI: 10.1097/md.0000000000033166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Worldwide, lung cancer is the most common cause of cancer morbidity and mortality. Non-small cell lung cancer (NSCLC) accounts for approximately 80 to 85% of all lung cancers. Recently, a few studies have reported the use of neoadjuvant immunotherapy or chemoimmunotherapy in NSCLC. However, no meta-analysis comparing neoadjuvant immunotherapy with chemoimmunotherapy has yet been reported. We perform a protocol for systematic review and meta-analysis to compare the efficacy and safety of neoadjuvant immunotherapy and chemoimmunotherapy in NSCLC. METHODS The statement of preferred reporting items for systematic review and meta-analysis protocols will be used as guidelines for reporting the present review protocol. Original clinical randomized controlled trials assessing the beneficial effects and safety of neoadjuvant immunotherapy and chemoimmunotherapy in NSCLC will be included. Databases searched include China National Knowledge Infrastructure, Chinese Scientific Journals Database, Wanfang Database, China Biological Medicine Database, PubMed, EMBASE Database, and Cochrane Central Register of Controlled Trials. Cochrane Collaboration's tool is used to assess the risk of bias in included randomized controlled trials. All calculations are carried out with Stata 11.0 (The Cochrane Collaboration, Oxford, UK). RESULTS The results of this systematic review and meta-analysis will be publicly available and published in a peer-reviewed journal. CONCLUSION This evidence will be useful to practitioners, patients, and health policy-makers regarding the use of neoadjuvant chemoimmunotherapy in NSCLC.
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Affiliation(s)
- Qunying Zhu
- Department of Cardiothoracic Surgery, the First Affiliated Hospital of Hainan Medical University, Hainan, China
| | - Guini Chen
- Department of Cardiothoracic Surgery, the First Affiliated Hospital of Hainan Medical University, Hainan, China
| | - Yunzhong Liu
- Department of Cardiothoracic Surgery, the First Affiliated Hospital of Hainan Medical University, Hainan, China
| | - Yu Zhou
- Department of General Surgery, the First Affiliated Hospital of Hainan Medical University, Hainan, China
- * Correspondence: Yu Zhou, Department of Cardiothoracic Surgery, the First Affiliated Hospital of Hainan Medical University, Hainan 570102, China (e-mail: )
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10
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Baudoux N, Friedlaender A, Addeo A. Evolving Therapeutic Scenario of Stage III Non-Small-Cell Lung Cancer. Clin Med Insights Oncol 2023; 17:11795549231152948. [PMID: 36818454 PMCID: PMC9932776 DOI: 10.1177/11795549231152948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 01/09/2023] [Indexed: 02/16/2023] Open
Abstract
Lung cancer remains the leading cause of cancer-related death with an incidence that continues to increase in both sexes and all ages. However, 80% to 90% of lung cancers are non-small cell lung cancer (NSCLC) and the remaining 10% to 20% are small cell lung cancer. Adenocarcinoma is the most common histologic subtype of lung cancer worldwide. More frequently, lung cancer diagnosis is made in advanced stages. Stage III NSCLC refers to locoregionally advanced disease without metastases and represents about 30% NSCLC cases. Despite the absence of metastases at diagnosis, the outcome is generally poor. Stage III comprises a heterogeneous group and optimal management requires the input of a multidisciplinary team. All modalities of oncologic treatment are involved: surgery, chemotherapy, radiotherapy, and more recently, immunotherapy and targeted therapy. We will discuss the different therapeutic options in stage III NSCLC, both in operable and inoperable scenarios, and the role of immunotherapy and targeted therapy.
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Affiliation(s)
- Nathalie Baudoux
- Oncology Department, Geneva University
Hospitals, Geneva, Switzerland
| | - Alex Friedlaender
- Oncology Department, Geneva University
Hospitals, Geneva, Switzerland
- Oncology Service, Clinique Générale
Beaulieu, Geneva, Switzerland
| | - Alfredo Addeo
- Oncology Department, Geneva University
Hospitals, Geneva, Switzerland
- Alfredo Addeo, Oncology Department, Geneva
University Hospitals, Geneva, 1205, Switzerland.
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11
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Clinical impact of histologic type on survival and recurrence in patients with surgically resected stage II and III non-small cell lung cancer. Lung Cancer 2023; 176:24-30. [PMID: 36580727 DOI: 10.1016/j.lungcan.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 11/29/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES This study aimed to investigate the clinical impact of histologic type on the survival and recurrence outcomes of patients with stage II and III non-small cell lung cancer (NSCLC). MATERIALS AND METHODS A total of 2155 consecutive adult patients who underwent complete resection of stage II and III NSCLC between 2008 and 2018 were enrolled. The primary endpoints were freedom from recurrence (FFR) and overall survival (OS). The secondary endpoint was the time to lung cancer or non-lung cancer death. RESULTS Of the 2155 patients, 1436 (66.6 %) had adenocarcinoma (ADC) and 719 (33.4 %) had squamous cell carcinoma (SqCC). Patients with SqCC had better FFR than those with ADC (stage II, p < 0.001; stage III, p < 0.001). Although patients with ADC showed a slightly better OS until 5 years than those with SqCC, the difference was insignificant (stage II, p = 0.292; stage III, p = 0.196). Patients with SqCC had higher rates of non-lung cancer death than patients with ADC (stage II, p < 0.001; stage III, p = 0.039). The time from lung cancer recurrence to death was shorter in patients with SqCC than in those with ADC (stage II, median 13 vs 37 months, p < 0.001; stage III, median 11 vs 26 months, p < 0.001). CONCLUSIONS In stage II and III NSCLC, ADC had a higher risk of recurrence than SqCC, with no difference in OS. These results were related to significant differences in non-lung cancer mortality and recurrence-to-death time between the two histologic types.
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Hayakawa T, Isaka M, Konno H, Mizuno T, Kawata T, Kenmotsu H, Takahashi T, Ohde Y. Survival outcome of upfront surgery for clinical single-station N2 non-small cell lung cancer. Jpn J Clin Oncol 2023; 53:429-435. [PMID: 36655315 DOI: 10.1093/jjco/hyac209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/24/2022] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Pathological N2 (pN2) non-small cell lung cancer (NSCLC) is diverse; its treatment depends on the clinical N (cN) status. We aimed to determine the efficacy of upfront surgery for cN2pN2 NSCLC. METHODS The study included 43 cN2pN2 NSCLC patients who underwent upfront surgery at the Shizuoka Cancer Center between 2002 and 2017. Survival outcome, focusing on cN2 status, was retrospectively investigated. Mediastinal lymph nodes were pre-operatively evaluated using computed tomography and positron emission tomography. Surgical eligibility criteria included single-station cN2. N2 with N1 and skip N2 were defined as N2 with and without ipsilateral hilar lymph node metastasis, respectively. A platinum-doublet regimen was used for adjuvant chemotherapy. Survival curves were analysed using the Kaplan-Meier method. Univariate and multivariate analyses were performed using the Cox proportional hazard regression model. RESULTS Clinical-skip N2 and cN2 with N1 cases included 22 and 21 patients, respectively. Twenty-three patients received adjuvant chemotherapy. The median follow-up duration was 73 months. Clinical-skip N2 had a significantly better 5-year recurrence-free survival (RFS) than cN2 with N1 (58.3 vs 28.6%, P = 0.038) and was an independent favorable RFS predictor. Recurrence within 18 months occurred in 71% of cN2 with N1 cases. Five-year overall survival and RFS rates in patients receiving adjuvant chemotherapy vs those without adjuvant chemotherapy were 82.2 vs 41.9% (P = 0.019) and 56.5 vs 28.0% (P = 0.049), respectively. CONCLUSIONS Clinical-skip N2 had an excellent prognosis, and upfront surgery was acceptable. Conversely, upfront surgery followed by chemotherapy is not recommended for cN2 with N1 patients because of early recurrence.
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Affiliation(s)
- Takamitsu Hayakawa
- Division of Thoracic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Mitsuhiro Isaka
- Division of Thoracic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Hayato Konno
- Division of Thoracic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Tetsuya Mizuno
- Division of Thoracic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Takuya Kawata
- Division of Pathology, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Hirotsugu Kenmotsu
- Division of Thoracic Oncology, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Toshiaki Takahashi
- Division of Thoracic Oncology, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Yasuhisa Ohde
- Division of Thoracic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
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13
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Real-life long-term outcomes of upfront surgery in patients with resectable stage I-IIIA non-small cell lung cancer. Radiol Oncol 2022; 56:346-354. [PMID: 35962955 PMCID: PMC9400448 DOI: 10.2478/raon-2022-0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 06/10/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Treatment of early-stage non-small cell lung cancer (NSCLC) is rapidly evolving. When introducing novelties, real-life data on effectiveness of currently used treatment strategies are needed. The present study evaluated outcomes of stage I-IIIA NSCLC patients treated with upfront radical surgery in everyday clinical practice, between 2010-2017. PATIENTS AND METHODS Data of 539 consecutive patients were retrieved from a prospective hospital-based registry. All diagnostic, treatment and follow-up procedures were performed at the same thoracic oncology centre according to the valid guidelines. The primary outcome was overall survival (OS) analysed by clinical(c) and pathological(p) TNM (tumour, node, metastases) stage. The impact of clinicopathological characteristics on OS was evaluated using univariable (UVA) and multivariable regression analysis (MVA). RESULTS With a median follow-up of 53.9 months, median OS and 5-year OS rate in the overall population were 90.4 months and 64.4%. Five-year OS rates by pTNM stage I, II and IIIA were 70.2%, 60.21%, and 49.9%, respectively. Both cTNM and pTNM stages were associated with OS; but only pTNM retained its independent prognostic value (p = 0.003) in MVA. Agreement between cTNM and pTNM was 69.0%. Next to pTNM, age (p = 0.001) and gender (p = 0.004) retained their independent prognostic value for OS. CONCLUSIONS The study showed favourable outcomes of resectable stage I-IIIA NSCLC treated with upfront surgery in real-life. Relatively low agreement between cTNM and pTNM stages and independent prognostic value of only pTNM, observed in real-life data, suggest that surgery remains the most accurate provider of the anatomical stage of disease and important upfront therapy.
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14
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Bertolaccini L, Prisciandaro E, Guarize J, Girelli L, Sedda G, Filippi N, de Marinis F, Spaggiari L. Long-term clinical outcomes and prognostic factors of upfront surgery as a first-line therapy in biopsy-proven clinical N2 non-small cell lung cancer. Front Oncol 2022; 12:933278. [PMID: 35965495 PMCID: PMC9366141 DOI: 10.3389/fonc.2022.933278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 06/29/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundMultimodality therapy offers the best opportunity to improve pathological N2 non-small cell lung cancer (NSCLC) prognosis. This paper aimed to evaluate the long-term clinical outcomes and the prognostic factors of upfront surgery as first-line therapy in biopsy-proven clinical N2.MethodsRetrospective review of biopsy-proven cN2 NSCLC patients operated between 2007 and 2017. Upfront surgery was considered if the primary tumour was deemed completely resectable, with mediastinal nodal involvement confined to a single station and no preoperative evidence of extranodal tumour invasion.ResultsTwo hundred eighty-five patients who underwent radical resections were included. One hundred fifty-nine patients (55.8%) received induction chemotherapy. At follow-up completion, 127 (44.6%) patients had died. For the induction chemotherapy group, the median overall survival (OS) was 49 months [95% confidence interval (CI): 38–70 months], and the 5-year OS was 44.4%. The median and 5-year OS for the up front surgery group was 66 months (95% CI: 40–119 months) and 66.3%, respectively. There were no statistically significant differences between treatment approaches (p = 0.48). One hundred thirty-four patients (47.0%) developed recurrence. The recurrence-free survival (RFS) at 5 years was 17% (95% CI: 11–25%) for induction chemotherapy and 22% (95% CI: 9–32%) for upfront surgery; there were no statistically significant differences between groups (p = 0.93). No significant differences were observed based on the clinical N status (OS, p = 0.36; RFS, p = 0.65).ConclusionsUpfront surgery as first-line therapy for biopsy-proven cN2 NSCLC showed favourable clinical outcomes, similar to those obtained after induction chemotherapy followed by surgery. Therefore, it should be considered one of the multimodality treatment options in resectable N2 NSCLC.
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Affiliation(s)
- Luca Bertolaccini
- Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
- *Correspondence: Luca Bertolaccini,
| | - Elena Prisciandaro
- Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Juliana Guarize
- Unit of Interventional Pneumology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Lara Girelli
- Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Giulia Sedda
- Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Niccolò Filippi
- Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Filippo de Marinis
- Department of Thoracic Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Lorenzo Spaggiari
- Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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15
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Zhang CC, Yu W, Zhang Q, Cai XW, Feng W, Fu XL. A decision support framework for postoperative radiotherapy in patients with pathological N2 non-small cell lung cancer. Radiother Oncol 2022; 173:313-318. [PMID: 35764192 DOI: 10.1016/j.radonc.2022.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 06/16/2022] [Accepted: 06/21/2022] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Postoperative radiotherapy (PORT) plays a highly controversial role in pathological N2 (pN2) non-small cell lung cancer (NSCLC) disease. Recent studies reveal that not all patients can benefit from PORT. Further research is needed to identify predictors of PORT. METHODS A total of 1044 pathologic stage T1-3N2M0 NSCLC patients were analyzed. Risk factors of distant metastasis were identified by the log-rank tests and the multivariable Cox models. We integrated risk factors of distant metastasis and our previously published loco-regional recurrence (LRR) related prognostic index into a decision support framework (DSF) to predict the outcomes of PORT. An independent cohort was used to validate the DSF. RESULTS We defined patients with more than two of three identified LRR-related features (heavy cigarette smoking history, clinical N2 status, and more than four positive lymph nodes) as a high LRR risk group. We found the high-intermediate-risk histological type (with micropapillary and/or solid components) was associated with a higher risk of distant metastasis (HR=1.207, 95% CI 1.062 to 1.371, P=0.0129), but not LRR. We built the DSF by combining these two types of features. Patients were stratified into four groups by using the DSF. PORT significantly improved OS only in the subgroup without high-risk histological features (without micropapillary or solid components) and with a high risk for LRR (three-year OS: 66.7% in the PORT group vs. 50.2% in the non-PORT group; P=0.023). CONCLUSIONS A particular pN2 subgroup with a high risk of LRR and without micropapillary or solid components could benefit from PORT.
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Affiliation(s)
- Chen-Chen Zhang
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, China
| | - Wen Yu
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, China
| | - Qin Zhang
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, China
| | - Xu-Wei Cai
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, China
| | - Wen Feng
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, China.
| | - Xiao-Long Fu
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, China; Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, China.
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16
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Yun JK, Yoo S, Lee GD, Choi S, Kim HR, Kim DK, Park SI, Kim YH. Comparison of Long-Term Outcomes Between Minimally Invasive Pulmonary Resection With and Without Video-Assisted Mediastinoscopic Lymphadenectomy for Left-Sided Lung Cancer. Ann Surg Oncol 2022; 29:2830-2839. [DOI: 10.1245/s10434-021-11191-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 11/21/2021] [Indexed: 12/18/2022]
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17
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Hwangbo B, Park EY, Yang B, Lee GK, Kim TS, Kim HY, Kim MS, Lee JM. Long-Term Survival According to N Stage Diagnosed by Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in Non-Small Cell Lung Cancer. Chest 2021; 161:1382-1392. [PMID: 34896095 DOI: 10.1016/j.chest.2021.11.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 11/22/2021] [Accepted: 11/29/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the main procedure for mediastinal staging. However, long-term survival analyses according to cN stage diagnosed by EBUS-TBNA (abbreviated to eN stage) have not been reported. The value of EBUS-TBNA has not been assessed through an analysis of survival in false-negative EBUS-TBNA cases. RESEARCH QUESTIONS What is the prognostic impact of eN stage in non-small cell lung cancer (NSCLC)? What is the survival rate in false-negative EBUS-TBNA cases? STUDY DESIGN AND METHODS We retrospectively (January 2006-December 2011) reviewed the medical records of NSCLC patients who underwent EBUS-TBNA (± transesophageal approach) for initial staging (n=1,089). Mediastinoscopy was not performed for EBUS-TBNA negative cases. We performed 5-year survival analyses according to eN stage and treatment modality. Survival in false-negative EBUS cases was compared with that in pN0-1 patients, including 941 non-EBUS cases, during the same period. RESULTS Among 1,089 EBUS patients (eN0-1=681, eN2=314, eN3=94), we observed significant differences in survival between the eN stages [eN0-1 vs eN2; p <0.0001, eN2 vs eN3; p=0.0118, estimated 5-year overall survival (5YOS) rate: eN0-1=57.4%, eN2=23.2%, eN3=12.8%]. Surgery cases had better survival than non-surgery cases among eN0-1 and eN2 patients (eN0-1/surgery vs. eN0-1/no surgery; p<0.0001, eN2/surgery vs. eN2/no surgery; p<0.0001). Among eN0-1 patients, there were 55 false-negative cases (eN0-1/pN2-3, pN2=54, pN3=1). The 5YOS rates of pN0, pN1, and eN0-1/pN2-3 patients were 76.4%, 56.0% and 56.4%, respectively. eN0-1/pN2-3 patients had worse survival than pN0 patients (p=0.0061), whereas there was no significant difference compared with pN1 patients (p=0.9191). INTERPRETATIONS Long-term survival significantly differed according to eN stage in NSCLC, highlighting the importance of EBUS-TBNA in NSCLC staging. False-negative EBUS-TBNA cases had favorable survival which was similar to that of pN1 patients, which may provide a rationale for performing surgery after negative EBUS-TBNA results.
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Affiliation(s)
- Bin Hwangbo
- Division of Pulmonology, Center for Lung Cancer, National Cancer Center, Goyang, Korea.
| | - Eun Young Park
- Biostatistics Collaboration Team, Research Core Center, National Cancer Center, Goyang, Korea
| | - Bumhee Yang
- Division of Pulmonology, Center for Lung Cancer, National Cancer Center, Goyang, Korea; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Geon Kook Lee
- Department of Pathology, National Cancer Center, Goyang, Korea
| | - Tae Sung Kim
- Department of Nuclear Medicine, National Cancer Center, Goyang, Korea
| | - Hyae Young Kim
- Department of Radiology, Center for Lung Cancer, National Cancer Center, Goyang, Korea
| | - Moon Soo Kim
- Department of Thoracic Surgery, Center for Lung Cancer, National Cancer Center, Goyang, Korea
| | - Jong Mog Lee
- Department of Thoracic Surgery, Center for Lung Cancer, National Cancer Center, Goyang, Korea
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Heldwein MB, Schlachtenberger G, Doerr F, Menghesha H, Bennink G, Schroeder KM, Schaefer SC, Wahlers T, Hekmat K. Different pulmonary adenocarcinoma growth patterns significantly affect survival. Surg Oncol 2021; 40:101674. [PMID: 34896910 DOI: 10.1016/j.suronc.2021.101674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/14/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Adenocarcinoma (AC) is the number one pathological entity of lung cancer with approximately 30-40% of cases. It is known to be heterogeneous and has 5 histopathological growth patterns. We evaluated the long-term survival rates of patients with predominant subtypes. METHODS 290 patients with AC underwent pulmonary resection between 2012 and 2017 at our institution. We excluded all patients with lymph node involvement and distant metastases. Hence, 163 patients were included for further analysis. Predominant growth pattern was defined if more than 10% of cells showed a growth pattern. 1, 3, and 5-year survival rates were evaluated. Survival was assessed by Kaplan-Meier curves and the Cox proportional hazards model was used to identify prognostic factors for overall survival. RESULTS Predominant growth patterns >10% were compared to <10% growth patterns of the same subtype. 1-year, 3-year, and 5-year overall survival rates of patients with predominant solid tumor growth >10% differed significantly from patients with <10% (88.4% vs. 97.6%, p = 0.04; 65.8% vs. 87.4% p = 0.001, 36.4% vs. 65.9% p = 0.01). Survival rates did not differ between >10% papillary and acinar growth compared to <10%. Kaplan-Meier curves showed reduced overall survival for patients with solid tumor growth >10% (log-rank 0.002). Solid tumor growth >10% was an independent prognostic factor for worse long-term survival (Hazard ratio: 3.05, p = 0.01). CONCLUSION Our study demonstrates that the presence of a predominant solid pattern in pulmonary adenocarcinoma is a factor for an unfavorable prognosis. This should be kept in mind in daily clinical practice.
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Affiliation(s)
- Matthias B Heldwein
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Faculty of Medicine and University Hospital Kerpener Strasse 62, 50937, Cologne, Germany
| | - Georg Schlachtenberger
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Faculty of Medicine and University Hospital Kerpener Strasse 62, 50937, Cologne, Germany.
| | - Fabian Doerr
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Faculty of Medicine and University Hospital Kerpener Strasse 62, 50937, Cologne, Germany
| | - Hruy Menghesha
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Faculty of Medicine and University Hospital Kerpener Strasse 62, 50937, Cologne, Germany
| | - Gerardus Bennink
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Faculty of Medicine and University Hospital Kerpener Strasse 62, 50937, Cologne, Germany
| | - Karl-Moritz Schroeder
- School of Medicine, University of Cologne, Cologne, Germany Albertus-Magnus-Platz, 50923, Cologne, Germany
| | - Stephan C Schaefer
- Institute of Pathology, University of Cologne, Faculty of Medicine and University Hospital Kerpener Strasse 62, 50937, Cologne, Germany; Institute of Pathology of the Medical Campus Bodensee Roentgen Strasse 2, 88048, Friedrichshafen, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Faculty of Medicine and University Hospital Kerpener Strasse 62, 50937, Cologne, Germany
| | - Khosro Hekmat
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Faculty of Medicine and University Hospital Kerpener Strasse 62, 50937, Cologne, Germany
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Rogasch JMM, Frost N, Bluemel S, Michaels L, Penzkofer T, von Laffert M, Temmesfeld-Wollbrück B, Neudecker J, Rückert JC, Ochsenreither S, Böhmer D, Amthauer H, Furth C. FDG-PET/CT for pretherapeutic lymph node staging in non-small cell lung cancer: A tailored approach to the ESTS/ESMO guideline workflow. Lung Cancer 2021; 157:66-74. [PMID: 33994197 DOI: 10.1016/j.lungcan.2021.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 04/23/2021] [Accepted: 05/01/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVES In patients with NSCLC, current ESTS and ESMO guidelines recommend invasive lymph node (LN) staging with EBUS-TBNA even if FDG-PET/CT is negative for mediastinal LNs if at least one of three risk factors is present (cN1, non-peripheral primary or primary >3 cm). Modified workflows to avoid unnecessary invasive procedures were evaluated. MATERIALS AND METHODS Monocentric retrospective analysis of pretherapeutic FDG-PET/CT in 247 patients with NSCLC (62 % male; age, 68 [43-88] years) using an analog or digital PET/CT scanner. PET windowing was standardized. LNs were positive if 'LN uptake > mediastinal blood pool' or short axis >10 mm. Surgery or EBUS-TBNA served as reference for diagnostic accuracy per LN station. In all patients with negative mediastinal LNs by PET/CT, LN histology from surgery was available. RESULTS Among 700 L N stations analyzed, 180 were malignant. Sensitivity and specificity of PET/CT per LN station were 93 % and 71 %. Following current guidelines, 76 patients with mediastinal negative PET/CT required confirmatory invasive staging. Only 5/76 patients had unexpected pN2 (all had adenocarcinoma). In a modified approach, confirmatory invasive staging was confined to patients with mediastinal negative PET/CT who showed all three risk factors. Using this modification, EBUS-TBNA could have been omitted in 62 (82 %) of the 76 patients who required EBUS-TBNA based on current recommendation. Among these 62 patients, only one patient had unsuspected pN2 (single-level) while the remaining 61 of 62 omitted EBUS-TBNA were deemed unnecessary because mediastinal LNs were confirmed to be negative. No multi-level pN2 would have been missed. CONCLUSION In the current analysis, 82 % of EBUS-TBNA procedures in patients with mediastinal negative PET/CT could have been omitted by modifying the current guideline workflow as proposed (i.e., restricting EBUS-TBNA in patients with cN0/1 to those with all three risk factors). This was consistent with different PET/CT scanners. Prospective confirmation is required.
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Affiliation(s)
- Julian M M Rogasch
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Nuclear Medicine, Augustenburger Platz 1, 13353 Berlin, Germany; Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, 10178 Berlin, Germany.
| | - Nikolaj Frost
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Infectious Diseases and Pulmonary Medicine, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Stephanie Bluemel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Nuclear Medicine, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Liza Michaels
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Nuclear Medicine, Augustenburger Platz 1, 13353 Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiology, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Tobias Penzkofer
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, 10178 Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiology, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Maximilian von Laffert
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Pathology, Charitéplatz 1, 10117 Berlin, Germany.
| | - Bettina Temmesfeld-Wollbrück
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Infectious Diseases and Pulmonary Medicine, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Jens Neudecker
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of General, Visceral, Vascular and Thoracic Surgery, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Jens-Carsten Rückert
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of General, Visceral, Vascular and Thoracic Surgery, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Sebastian Ochsenreither
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Hematology and Medical Oncology, Hindenburgdamm 30, 12203 Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité Comprehensive Cancer Center, Charitéplatz 1, 10115 Berlin, Germany.
| | - Dirk Böhmer
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology, Hindenburgdamm 30, 12203 Berlin, Germany.
| | - Holger Amthauer
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Nuclear Medicine, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Christian Furth
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Nuclear Medicine, Augustenburger Platz 1, 13353 Berlin, Germany.
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Chen T, Ning J, Campisi A, Dell'Amore A, Ciarrocchi AP, Li Z, Song L, Huang J, Yang Y, Stella F, Luo Q. Neoadjuvant PD-1 inhibitors and chemotherapy for locally advanced NSCLC: A retrospective study. Ann Thorac Surg 2021; 113:993-999. [PMID: 33781737 DOI: 10.1016/j.athoracsur.2021.03.041] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 02/13/2021] [Accepted: 03/11/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Stage III non-small cell lung cancer (NSCLC) encompasses a variety of local invasion and nodal involvement and its management is still under debate. Immune checkpoint inhibitors (ICI) have been shown to improve the survival in metastatic NSCLC, but are far from being accepted as an induction therapy. METHODS We retrospectively collected data of all patients who received induction ICI (nivolumab or pembrolizumab) and chemotherapy (carboplatin with paclitaxel) for stage IIIA-B NSCLC followed by surgery in our unit between January 2019 and March 2020. RESULTS Of the 12 patients (9 males, 3 females) 6 had a squamous cell carcinoma, 3 had adenocarcinoma, 1 had an undifferentiated adenocarcinoma and 1 had adeno-squamous carcinoma. Seven patients had stage IIIA disease and 5 had stage IIIB. After induction therapy, 6 patients had stable disease and 6 had a partial response. The median tumor reduction was 3.05 cm (range 2.30-8.70). All patients, but one due to the Coronavirus Disease 2019 outbreak, had no delay in surgery. Two patients experienced myelosuppression after induction therapy, two had minor adverse effects. Three patients had postoperative complications not related to the induction therapy. All patients had a pathological response: 5 complete, 4 major and 3 partial. Eleven patients are alive (mean months of follow-up 18.17±4.97) and free of disease. CONCLUSIONS Induction ICI-chemotherapy may be a valid treatment in patients with locally advanced NSCLC, providing important tumor downstaging and rendering patients operable. In our experience patients had few side effects and a good pathological response.
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Affiliation(s)
- Tianxiang Chen
- Shanghai Lung Cancer Center, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Junwei Ning
- Shanghai Lung Cancer Center, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Alessio Campisi
- Shanghai Lung Cancer Center, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China; Thoracic Surgery Unit, Department of Thoracic Diseases, University of Bologna, G.B. Morgagni-L. Pierantoni Hospital, Forlì, Italy
| | - Andrea Dell'Amore
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery and Vascular Sciences, Padua University Hospital, University of Padua, Padua, Italy
| | - Angelo Paolo Ciarrocchi
- Thoracic Surgery Unit, Department of Thoracic Diseases, University of Bologna, G.B. Morgagni-L. Pierantoni Hospital, Forlì, Italy
| | - Ziming Li
- Shanghai Lung Cancer Center, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Liwei Song
- Shanghai Lung Cancer Center, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jia Huang
- Shanghai Lung Cancer Center, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yunhai Yang
- Shanghai Lung Cancer Center, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Franco Stella
- Thoracic Surgery Unit, Department of Thoracic Diseases, University of Bologna, G.B. Morgagni-L. Pierantoni Hospital, Forlì, Italy
| | - Qingquan Luo
- Shanghai Lung Cancer Center, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.
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Yun JK, Lee GD, Choi S, Kim HR, Kim YH, Park SI, Kim DK. The addition of radiotherapy to adjuvant chemotherapy has a combinatorial effect in pN2 non-small cell lung cancer only with extranodal invasion or multiple N2 metastasis. Lung Cancer 2021; 155:94-102. [PMID: 33765654 DOI: 10.1016/j.lungcan.2021.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/14/2021] [Accepted: 03/11/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The benefit of adjuvant therapy for heterogenous group of pathological N2 (pN2) non-small cell lung cancer (NSCLC) remains unclear. We evaluated the prognostic effect of adjuvant therapy after stratifying patients with pN2 according to subdivided N2 descriptors. MATERIALS AND METHODS We performed a retrospective analysis of clinical outcomes in patients with pN2 NSCLC who underwent upfront surgery. N2 descriptors were subdivided as single N2 metastasis without N1 involvement (pN2a1), single N2 with metastasis with N1 involvement (pN2a2), and multiple N2 metastasis (pN2b). RESULTS From 2005-2017, 838 patients with pN2 NSCLC underwent complete resection. There were 173 (21.0 %), 338 (40.3 %), and 324 (38.7 %) in the pN2a1, pN2a2, and pN2b groups. Patients who received chemoradiotherapy (CRTx; n = 389, 46.4 %) or chemotherapy (CTx; n = 204, 24.3 %) had similar prognoses, which were better than prognoses in patients who received with radiotherapy (RTx; n = 116, 13.8 %) or those who did not receive adjuvant therapy (n = 129, 15.4 %). According to the stratified multivariable Cox analysis, patients with pN2b stage in the CTx group had a significantly poor prognosis than those in the CRTx group (hazard ratio, 1.38; 95 % confidence interval, 1.03-1.98; p = 0.046). The difference in survival outcomes between the CRTx and CTx groups was significant in patients with extranodal invasion (ENI) (p = 0.011), but not in those without ENI (p = 0.527) CONCLUSIONS: Adjuvant CTx improves the overall and recurrence-free survival in patients with pN2 NSCLC undergoing upfront surgery with complete resection. RTx with adjuvant chemotherapy has a combinatorial effect on pN2 NSCLC only with ENI or multiple N2 metastasis.
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Affiliation(s)
- Jae Kwang Yun
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Geun Dong Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Sehoon Choi
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Hyeong Ryul Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Yong-Hee Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Seung-Il Park
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Dong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea.
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22
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Kim HC, Ji W, Lee JC, Kim HR, Song SY, Choi CM. Prognostic Factor and Clinical Outcome in Stage III Non-Small Cell Lung Cancer: A Study Based on Real-World Clinical Data in the Korean Population. Cancer Res Treat 2021; 53:1033-1041. [PMID: 33592139 PMCID: PMC8524024 DOI: 10.4143/crt.2020.1350] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/14/2021] [Indexed: 12/25/2022] Open
Abstract
Purpose The optimal treatment for patients with stage III non–small cell lung cancer (NSCLC) remains controversial. This study aimed to investigate prognostic factors and clinical outcome in stage III NSCLC using real-world clinical data in the Korean population. Materials and Methods Among 8,110 patients with lung cancer selected from 52 hospitals in Korea during 2014–2016, only patients with stage III NSCLC were recruited and analyzed. A standardized protocol was used to collect clinical information and Cox proportional hazards models were used to identify risk factors for mortality. Results A total of 1,383 patients (46.5% had squamous cell carcinoma and 40.9% had adenocarcinoma) with stage III NSCLC were enrolled, and their median age was 70 years. Regarding clinical stage, 548 patients (39.6%) had stage IIIA, 517 (37.4%) had stage IIIB, and 318 (23.0%) had stage IIIC. Pertaining to the initial treatment method, the surgery group (median survival period, 36 months) showed better survival outcomes than the non-surgical treatment group (median survival period, 18 months; p=0.001) in patients with stage IIIA. Moreover, among patients with stage IIIB and stage IIIC, those who received concurrent chemotherapy and radiation therapy (CCRT; median survival period, 24 months) showed better survival outcomes than those who received chemotherapy (median survival period, 11 months), or radiation therapy (median survival period, 10 months; p < 0.001). Conclusion While surgery might be feasible as the initial treatment option in patients with stage IIIA NSCLC, CCRT showed a beneficial role in patients with stage IIIB and IIIC NSCLC.
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Affiliation(s)
- Ho Cheol Kim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Wonjun Ji
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Cheol Lee
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyeong Ryul Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Si Yeol Song
- Department of Radiation Oncology,Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang-Min Choi
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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23
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Yun JK, Lee GD, Choi S, Kim YH, Kim DK, Park SI, Kim HR. A Validation Study of the Recommended Change in Residual Tumor Descriptors Proposed by the International Association for the Study of Lung Cancer for Patients With pN2 NSCLC. J Thorac Oncol 2021; 16:817-826. [PMID: 33607310 DOI: 10.1016/j.jtho.2021.01.1621] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 01/15/2023]
Abstract
INTRODUCTION This study aimed to validate the residual tumor (R) descriptors proposed by the International Association for the Study of Lung Cancer (IASLC) for patients with pathologic N2 (pN2) NSCLC. METHODS We retrospectively reviewed the data of patients with pN2 NSCLC who underwent anatomical resection during the period 2004 to 2018. The R status classified using the Union for International Cancer Control (UICC) criteria was compared with that reassigned using the IASLC criteria. Survival analysis was performed using Cox proportional hazards models to assess the prognostic significance of IASLC R descriptors. RESULTS Among 1039 patients, 91.1%, 8.1%, and 0.8% of the patients respectively received complete resection (R0), R1, and R2 defined using the UICC criteria, whereas 41.6%, 20.4%, and 38% respectively received R0, uncertain resection (R[un]), and R1/2 resection defined using the IASLC criteria. Furthermore, 206 patients (21.8%) were reclassified from having UICC R0 to having IASLC R(un) mainly owing to the highest mediastinal lymph node involvement (89.8%). Owing to extracapsular extension, 309 patients (32.6%) with UICC R0 were reclassified as having IASLC R1/2. Patients with IASLC R(un) had significantly worse and better prognosis than those with IASLC R0 and IASLC R1/2, respectively. In multivariable analysis, the prognostic difference between IASLC R0 and R(un) was similar after adjustment for subdivided N2 descriptors including pN2a1, pN2a2, and pN2b. CONCLUSIONS Along with subdivided N descriptors, detailed R descriptors proposed on the basis of the IASLC criteria can ensure optimal staging, enabling the most appropriate decision-making on adjuvant therapy for patients with pN2 NSCLC.
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Affiliation(s)
- Jae Kwang Yun
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Geun Dong Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Sehoon Choi
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Yong-Hee Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Dong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Seung-Il Park
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Hyeong Ryul Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea.
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Zhao J, Li W, Wang M, Liu L, Fu X, Li Y, Xu L, Liu Y, Zhao H, Hu J, Liu D, Shen J, Yang H, Li X. Video-assisted thoracoscopic surgery lobectomy might be a feasible alternative for surgically resectable pathological N2 non-small cell lung cancer patients. Thorac Cancer 2020; 12:21-29. [PMID: 33205914 PMCID: PMC7779187 DOI: 10.1111/1759-7714.13680] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/10/2020] [Accepted: 09/11/2020] [Indexed: 02/05/2023] Open
Abstract
Background The majority of previous studies of the clinical outcome of video‐assisted thoracoscopic surgery (VATS) versus open lobectomy for pathological N2 non‐small cell lung cancer (pN2 NSCLC) have been single‐center experiences with small patient numbers. The aim of this study was therefore to investigate these procedures but in a large cohort of Chinese patients with pathological N2 NSCLC in real‐world conditions. Methods Patients who underwent lobectomy for pN2 NSCLC by either VATS or thoracotomy were retrospectively reviewed from 10 tertiary hospitals between January 2014 and September 2017. Perioperative outcomes and overall survival of the patients were analyzed. Cox regression analysis was performed to identify potential prognostic factors. Propensity‐score analysis was performed to reduce cofounding biases and compare the clinical outcomes between both groups. Results Among 2144 pN2 NSCLC, 1244 patients were managed by VATS and 900 by open procedure. A total of 305 (24.5%) and 344 patients died during VATS and the thoracotomy group during a median follow‐up of 16.7 and 15.6 months, respectively. VATS lobectomy patients had better overall survival when compared with those undergoing the open procedure (P < 0.0001). Multivariate COX regression analysis showed VATS lobectomy independently favored overall survival (HR = 0.75, 95% CI: 0.621–0.896, P = 0.0017). Better perioperative outcomes, including less blood loss, shorter drainage time and hospital stay, were also observed in patients undergoing VATS lobectomy (P < 0.05). After propensity‐score matching, 169 patients in each group were analyzed, and no survival difference were found between the two groups. Less blood loss was observed in the VATS group, but there was a longer operation time. Conclusions VATS lobectomy might be a feasible alternative to conventional open surgery for resectable pN2 NSCLC. Key points Significant findings of the study: VATS lobectomy has comparative OS in pN2 NSCLC versus open procedure in resectable patients. What this study adds: VATS lobectomy might be feasible for pN2 NSCLC.
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Affiliation(s)
- Jinbo Zhao
- Department of Thoracic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Weimiao Li
- Department of Oncology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Meng Wang
- Department of Thoracic Surgery, Tianjin Chest Hospital, Tianjin, China
| | - Lunxu Liu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xiangning Fu
- Department of Thoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yin Li
- Department of Thoracic Surgery, Henan Cancer Hospital, Zhengzhou, China
| | - Lin Xu
- Department of Thoracic Surgery, Nanjing Medical University Affiliated Cancer Hospital, Cancer Institute of Jiangsu Province, Nanjing, China.,Jiangsu Key Laboratory of Molecular and Translational Cancer Research, Cancer Institute of Jiangsu Province, Nanjing, China
| | - Yang Liu
- Department of Thoracic Surgery, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Heng Zhao
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai, China
| | - Jian Hu
- Department of Thoracic Surgery, First Hospital Affiliated to Medical College of Zhejiang University, Hangzhou, China
| | - Deruo Liu
- Department of Thoracic Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Jianfei Shen
- Department of Thoracic Surgery, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Linhai, China
| | - Haiying Yang
- Medical Affairs, Linkdoc Technology Co, Ltd, Beijing, China
| | - Xiaofei Li
- Department of Thoracic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
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Yun JK, Park I, Kim HR, Choi YS, Lee GD, Choi S, Kim YH, Kim DK, Park SI, Cho JH, Shin S, Kim HK, Kim J, Zo JI, Kim K, Shim YM. Long-term outcomes of video-assisted thoracoscopic lobectomy for clinical N1 non-small cell lung cancer: A propensity score-weighted comparison with open thoracotomy. Lung Cancer 2020; 150:201-208. [PMID: 33197685 DOI: 10.1016/j.lungcan.2020.10.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/28/2020] [Accepted: 10/18/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Although the video-assisted thoracic surgery (VATS) approach has been accepted as a safe and effective alternative to lobectomy, its advantage remains unclear in advanced-stage lung cancer. This study is aimed to evaluate the feasibility and long-term outcomes of VATS in lung cancer with clinical N1 (cN1) disease. MATERIALS AND METHODS We retrospectively reviewed the records of 1149 consecutive patients who underwent lobectomy for cN1 disease from 2006 to 2016. Perioperative outcomes and long-term survival rates were compared using a propensity score-based inverse probability of treatment weighting (IPTW) technique. RESULTS We performed VATS and open thoracotomy for 500 and 649 patients, respectively. All preoperative characteristics became similar between the two groups after IPTW adjustment. Compared to thoracotomy, VATS was associated with shorter hospitalization (7.7 days vs. 9.2 days, p < 0.001), earlier adjuvant chemotherapy (41.7 days vs. 46.6 days, p = 0.028), similar complete resection rates (95.2 % vs. 94.0 %, p = 0.583), and equivalent dissected lymph nodes (27.5 vs. 27.8, p = 0.704). On IPTW-adjusted analysis, overall survival (OS) (59.4 % vs. 60.3 %, p = 0.588) and recurrence-free survival (RFS) (59.2 % vs. 56.9 %, p = 0.651) at 5 years were also similar between the two groups. Multivariable Cox analysis revealed that VATS was not a significant prognostic factor for cN1 disease (p = 0.764 for OS and p = 0.879 for RFS). CONCLUSIONS VATS lobectomy is feasible for patients with cN1 disease, providing comparable perioperative outcomes, oncologic efficacy, and long-term outcomes as open thoracotomy.
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Affiliation(s)
- Jae Kwang Yun
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Ilkun Park
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyeong Ryul Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea.
| | - Yong Soo Choi
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Geun Dong Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Sehoon Choi
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Yong-Hee Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Dong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Seung-Il Park
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Ulsan University College of Medicine, Seoul, Republic of Korea
| | - Jong Ho Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sumin Shin
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jhingook Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae Il Zo
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kwhanmien Kim
- Department of Thoracic and Cardiovascular Surgery, Bundang Hospital, Seoul National University School of Medicine, Seoul, Republic of Korea
| | - Young Mog Shim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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26
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Yun JK, Lee GD, Choi S, Kim HR, Kim YH, Park SI, Kim DK. Video-assisted thoracoscopic lobectomy is feasible for selected patients with clinical N2 non-small cell lung cancer. Sci Rep 2020; 10:15217. [PMID: 32939008 PMCID: PMC7495470 DOI: 10.1038/s41598-020-72272-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 08/28/2020] [Indexed: 12/17/2022] Open
Abstract
Few studies have evaluated the usefulness of video-assisted thoracoscopic surgery (VATS) for advanced-stage lung cancer. We aimed to evaluate the feasibility of VATS for treating clinical N2 (cN2) lung cancer. A retrospective cohort analysis was performed with data from 268 patients who underwent lobectomy for cN2 disease from 2007 to 2016. Using propensity score-based inverse probability of treatment weighting (IPTW), perioperative and long-term survival outcomes were compared. We performed VATS and open thoracotomy on 121 and 147 patients, respectively. Overall, VATS was preferred for patients with peripherally located tumors (p < 0.001). After IPTW-adjustment, all preoperative information became similar between the groups. Compared to thoracotomy, VATS was associated with shorter hospitalization (7.7 days vs. 9.1 days, p = 0.028), despite equivalent complete resection rates (92.6% vs. 90.5%, p = 0.488) and dissected lymph nodes (mean, 31.9 vs. 29.4, p = 0.100). On IPTW-adjusted analysis, overall survival (50.5% vs. 48.4%, p = 0.127) and recurrence-free survival (60.5% vs 44.6%, p = 0.069) at 5 years were also similar between the groups. Among selected patients with resectable cN2 disease and peripherally located tumors, VATS is feasible, associated with shorter hospitalization and comparable perioperative and long-term survival outcomes, compared with open thoracotomy.
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Affiliation(s)
- Jae Kwang Yun
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Geun Dong Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Sehoon Choi
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Hyeong Ryul Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Yong-Hee Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Seung-Il Park
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Dong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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Brascia D, De Iaco G, Schiavone M, Panza T, Signore F, Geronimo A, Sampietro D, Montrone M, Galetta D, Marulli G. Resectable IIIA-N2 Non-Small-Cell Lung Cancer (NSCLC): In Search for the Proper Treatment. Cancers (Basel) 2020; 12:cancers12082050. [PMID: 32722386 PMCID: PMC7465235 DOI: 10.3390/cancers12082050] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 07/18/2020] [Accepted: 07/21/2020] [Indexed: 12/25/2022] Open
Abstract
Locally advanced non-small cell lung cancer accounts for one third of non-small cell lung cancer (NSCLC) at the time of initial diagnosis and presents with a wide range of clinical and pathological heterogeneity. To date, the combined multimodality approach involving both local and systemic control is the gold standard for these patients, since occult distant micrometastatic disease should always be suspected. With the rapid increase in treatment options, the need for an interdisciplinary discussion involving oncologists, surgeons, radiation oncologists and radiologists has become essential. Surgery should be recommended to patients with non-bulky, discrete, or single-level N2 involvement and be included in the multimodality treatment. Resectable stage IIIA patients have been the subject of a number of clinical trials and retrospective analysis, discussing the efficiency and survival benefits on patients treated with the available therapeutic approaches. However, most of them have some limitations due to their retrospective nature, lack of exact pretreatment staging, and the involvement of heterogeneous populations leading to the awareness that each patient should undergo a tailored therapy in light of the nature of his tumor, its extension and his performance status.
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Affiliation(s)
- Debora Brascia
- Thoracic Surgery Unit, Department of Organ Transplantation and Emergency, University Hospital of Bari, 70121 Bari, Italy; (D.B.); (G.D.I.); (M.S.); (T.P.); (F.S.); (A.G.); (D.S.)
| | - Giulia De Iaco
- Thoracic Surgery Unit, Department of Organ Transplantation and Emergency, University Hospital of Bari, 70121 Bari, Italy; (D.B.); (G.D.I.); (M.S.); (T.P.); (F.S.); (A.G.); (D.S.)
| | - Marcella Schiavone
- Thoracic Surgery Unit, Department of Organ Transplantation and Emergency, University Hospital of Bari, 70121 Bari, Italy; (D.B.); (G.D.I.); (M.S.); (T.P.); (F.S.); (A.G.); (D.S.)
| | - Teodora Panza
- Thoracic Surgery Unit, Department of Organ Transplantation and Emergency, University Hospital of Bari, 70121 Bari, Italy; (D.B.); (G.D.I.); (M.S.); (T.P.); (F.S.); (A.G.); (D.S.)
| | - Francesca Signore
- Thoracic Surgery Unit, Department of Organ Transplantation and Emergency, University Hospital of Bari, 70121 Bari, Italy; (D.B.); (G.D.I.); (M.S.); (T.P.); (F.S.); (A.G.); (D.S.)
| | - Alessandro Geronimo
- Thoracic Surgery Unit, Department of Organ Transplantation and Emergency, University Hospital of Bari, 70121 Bari, Italy; (D.B.); (G.D.I.); (M.S.); (T.P.); (F.S.); (A.G.); (D.S.)
| | - Doroty Sampietro
- Thoracic Surgery Unit, Department of Organ Transplantation and Emergency, University Hospital of Bari, 70121 Bari, Italy; (D.B.); (G.D.I.); (M.S.); (T.P.); (F.S.); (A.G.); (D.S.)
| | - Michele Montrone
- Medical Thoracic Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, 70121 Bari, Italy; (M.M.); (D.G.)
| | - Domenico Galetta
- Medical Thoracic Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, 70121 Bari, Italy; (M.M.); (D.G.)
| | - Giuseppe Marulli
- Thoracic Surgery Unit, Department of Organ Transplantation and Emergency, University Hospital of Bari, 70121 Bari, Italy; (D.B.); (G.D.I.); (M.S.); (T.P.); (F.S.); (A.G.); (D.S.)
- Correspondence: or
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