Model of lung cancer surgery risk derived from a Japanese nationwide web-based database of 78 594 patients during 2014-2015

Risk factors for bronchopleural fistula based on surgical procedure and sex in 4794 consecutive patients undergoing anatomical pulmonary resection

PURPOSE

Bronchopleural fistula (BPF) is a lethal complication, even in the modern era. Therefore, we investigated the details of patients with BPF to select an appropriate surgical strategy.

METHODS

This retrospective study included 4794 consecutive patients who underwent anatomical pulmonary resection between 2008 and 2022. We evaluated the predictors of BPF using a multivariable analysis and investigated the mortality and clinical course after BPF in detail.

RESULTS

BPF was observed in 32 patients (0.67%). In the multivariable analysis, the predictors for BPF were male sex (odds ratio [OR], 6.91), the body mass index (OR, 2.40), the vital capacity (%VC) (OR, 2.93), surgery performed (right lower lobectomy [OR, 10.92], right middle and lower lobectomy [OR, 6.97], and right pneumonectomy [OR, 16.68]), and additional resection of surrounding organs (OR, 3.47). Among the risk factors, surgery performed and male sex were very strong risk factors, with the frequency itself very low in females (0.1%). The 90-day mortality was 15.6%, and the 5-year overall survival in patients with BPF was 28.1%.

CONCLUSION

Our study revealed that independent risk factors and consideration of the surgical methods and sex might help determine whether or not special attention should be given to the bronchial stump, which will be of great help in surgical strategies.

Salivary metabolites as potential predictive biomarkers for lung surgery complications: a retrospective cross-sectional study

PURPOSE

Saliva is often used as a tool for identifying systemic diseases because of the noninvasive nature of its collection. Moreover, salivary metabolites can be potential predictive factors for postoperative survival. We conducted the present study to establish whether salivary metabolites can function as predictive biomarkers for lung surgery complications.

METHODS

Unstimulated salivary samples were collected from 412 patients before lung surgery. Salivary metabolites were analyzed comprehensively by capillary electrophoresis mass spectrometry. Clinical data with the discriminatory ability of biomarkers were assessed to predict lung surgery complications using multivariate logistic regression analysis. The primary endpoint was the risk factors for postoperative complications of Clavien-Dindo grade ≥ III.

RESULTS

Postoperative complications of Clavien-Dindo grade ≥ III developed in 36 patients (8.7%). There was no postoperative 30-day mortality. Male sex (odds ratio [OR], 3.852; 95% confidence interval CI 1.455-10.199; p = 0.007) and salivary gamma-butyrobetaine (OR, 0.809; 95% CI 0.694-0.943; p = 0.007) were identified as significant risk factors for postoperative complications of Clavien-Dindo grade ≥ III.

CONCLUSION

Salivary metabolites are potential noninvasive biomarkers for predicting postoperative complications of lung surgery.

Reintubation After Lung Cancer Resection: Development and External Validation of a Predictive Score

BACKGROUND

Reintubation after lung cancer resection is an important quality metric because of increased disability, mortality and cost. However, no validated predictive instrument is in use to reduce reintubation after lung resection. This study aimed to create and validate the PRediction Of REintubation After Lung cancer resection (PROREAL) score.

METHODS

The study analyzed lung resection cases from 2 university hospitals. The primary end point was reintubation within 7 days after surgery. Predictors were selected through backward stepwise logistic regression and bootstrap resampling. The investigators used reclassification and receiver-operating characteristic (ROC) curve analyses to assess score performance and compare it with an established score for all surgical patients (Score for Prediction of Postoperative Respiratory Complications [SPORC]).

RESULTS

The study included 2672 patients who underwent resection for lung cancer (1754, development cohort; 918, validation cohort) between 2008 and 2020, of whom 71 (2.7%) were reintubated within 7 days after surgery. Identified score variables were surgical extent and approach, American Society of Anesthesiologists physical status, heart failure, renal disease, and diffusing capacity of the lung for carbon monoxide. The score achieved excellent discrimination in the development cohort (ROC AUC, 0.90; 95% CI, 0.87-0.94) and good discrimination in the validation cohort (ROC AUC, 0.74, 95% CI; 0.66-0.82), thus outperforming the SPORC in both cohorts (P < .001 and P = .018, respectively; validation cohort net reclassification improvement, 0.39; 95% CI, 0.18-0.60; P = .001). The score cutoff of ≥5 yielded a sensitivity of 88% (95% CI, 72-95) and a specificity of 81% (95% CI,79-83) in the development cohort.

CONCLUSIONS

A simple score (PROREAL) specific to lung cancer predicts postoperative reintubation more accurately than the nonspecific SPORC score. Operative candidates at risk may be identified for preventive intervention or alternative oncologic therapy.

Prognostication Using the Japanese Risk Calculator for Lung Cancer Surgery

INTRODUCTION

Various calculation models to predict surgical risk have been developed globally. These have been reported to be helpful for estimating the long-term prognosis. In Japan, a similar model for lung cancer surgery was developed in 2017; however, there have been no reports investigating its association with the long-term prognosis. The objective of this study was to assess the association of the model's predictions with the long-term prognosis.

PATIENTS AND METHODS

In this retrospective single-institutional study, we analyzed lung cancer patients who underwent radical lobectomy between 2010 and 2016. We calculated the predicted rates of mortality (PRM) and composite outcomes of mortality with major morbidity (PRMM) in eligible patients (N = 1054) using this model and classified them into 2 classes (class A, PRM ≥0.8% and PRMM ≥5.9%; class B, others) based on their models' predictions. We assessed the prognostic impact and clinical utility of the model's predictions.

RESULTS

Class A included patients with significantly poorer postoperative overall survival than class B (log-rank, P < .001; hazard ratio, 3.160; 95% confidence interval, 2.390-4.178). Time-dependent receiver operating characteristic curve analyses revealed that the model's predictions correlated strongly with 1- and 2-year overall survival and decision curve analysis showed that they had high net benefits for prediction of those.

CONCLUSION

The Japanese risk calculator could stratify the long-term prognosis for lung cancer patients after surgery. This model may be a valuable tool not only for multidisciplinary thoracic oncology teams to discuss treatment strategies for high-risk cases but also for them to share the decision-making process with patients.

The surgical Apgar score predicts postoperative complications and the survival in lung cancer patients

PURPOSE

The surgical Apgar score (SAS)-calculated using the intraoperative variables estimated blood loss, lowest heart rate, and lowest mean systolic pressure-is associated with mortality in cancer surgery. We investigated the utility of the SAS in patients with lung cancer undergoing surgery.

METHODS

We retrospectively analyzed the data of 691 patients who underwent surgery for primary lung cancer between 2015 and 2019 in a single institute and analyzed the impact of the SAS.

RESULTS

Of the 691 patients, 138 (20%), 57 (8.2%), and 7 (1.0%) had postoperative complications of all grades, grades ≥ III, and grade V, respectively, according to the Clavien-Dindo classification. The C-index for postoperative complications of grades ≥ III was 0.605. A lower score (0-5 points) (odds ratio 3.09 against 8-10 points, P = 0.04) and a lower percentage of vital capacity (odds ratio 0.97, P = 0.04) were independent negative risk factors for major postoperative complications. Patients with a lower score (0-5 points) had poor 5-year overall and cancer-specific survival rates (60.1% and 72.3%, respectively; P < 0.05 for both).

CONCLUSIONS

The surgical Apgar score predicted postoperative complications and the long-term survival. Surgeons may improve surgical results using the SAS.

Postoperative mortality analysis on nationwide data from diagnosis procedure combination database in Japan

INTRODUCTION

The present study aimed to investigate the postoperative mortality due to all surgeries at the prefectural level using a nationwide diagnosis procedure combination (DPC) database in Japan and to evaluate the data according to temporal changes and regional differences.

METHODS

Data were provided in accordance with the guidelines indicated on the Ministry of Health, Labor and Welfare, Japan. The number of cases and in-hospital mortality were calculated for each representative surgery for each hospitalization according to fiscal year of discharge from 2011 to 2018 and according to prefecture. Values of ≥10 in each aggregated data cell were presented.

RESULTS AND DISCUSSION

The aggregated result data contain 474,154 records, with about 2,000 different surgical codes. More than 10 mortalities were recorded in only 16,890 data cells, which can be used in the mortality analysis. In the analyses of artificial head insertion, cerebral aneurysm neck clipping, coronary artery and aortic bypass grafting, and tracheotomy, regional differences and a declining trend were observed in some categories.

CONCLUSION

In addition to considering categories that can be used in the analysis, careful consideration must be given to the inclusion of background context such as the quality of care.

Impact of segmentectomy and lobectomy on non-lung cancer death in early-stage lung cancer patients

OBJECTIVES

This study aimed to analyse the risk of death from non-lung cancer after segmentectomy or lobectomy for early-stage lung cancer.

METHODS

A total of 1385 patients underwent lobectomy or segmentectomy for clinical stage 0-I primary lung cancer, with no evidence of recurrence after surgery, between January 2008 and December 2018. Risk factors for non-lung cancer deaths (NLCD) were analysed using multivariable logistic regression analysis. The overall survival (OS) of patients with low and high comorbidities who underwent lobectomy and segmentectomy was compared using a log-rank test.

RESULTS

Patients with NLCD (n = 126) were more likely to have undergone lobectomy than patients with non-recurrence survival (n = 1259). Multivariable analysis revealed that age (≥65 years), smoking index (≥600), body mass index (≤18.5 kg/m2), interstitial pneumonia, values for percentage of predicted vital capacity (≤9.4%) and lobectomy were risk factors for NLCD. Patients who underwent segmentectomy had significantly better 5-year OS than those who underwent lobectomy, after propensity score matching (94.6% vs 90.4%, P = 0.027). Patients with high comorbidities (patients with ≥2 of the following risks: age ≥65 years, smoking index ≥600, body mass index ≤18.5 kg/m2, Charlson Comorbidity Index ≥1, values for percentage of predicted vital capacity ≤96.4%) who underwent segmentectomy had a better 5-year OS than those who underwent lobectomy (92.8% vs 87.8%, P = 0.016). However, there was no difference in 5-year OS between segmentectomy and lobectomy in patients with low comorbidities (98.5% vs 97.4%, P = 0.867).

CONCLUSIONS

The impact of lobectomy and segmentectomy on NLCD depends on the extent of the patients' comorbidities.

Mortality and lung function decline in patients who develop chronic pulmonary aspergillosis after lung cancer surgery

BACKGROUND

Lung cancer surgery is reported as a risk factor for chronic pulmonary aspergillosis (CPA). However, limited data are available on its clinical impact. We aimed to determine the effect of developed CPA after lung cancer surgery on mortality and lung function decline.

METHODS

We retrospectively identified the development of CPA after lung cancer surgery between 2010 and 2016. The effect of CPA on mortality was evaluated using multivariable Cox proportional hazard analyses. The effect of CPA on lung function decline was evaluated using multiple linear regression analyses.

RESULTS

During a median follow-up duration of 5.01 (IQR, 3.41-6.70) years in 6777 patients, 93 developed CPA at a median of 3.01 (IQR, 1.60-4.64) years. The development of CPA did not affect mortality in multivariable analysis. However, the decline in forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV₁) were greater in patients with CPA than in those without (FVC, - 71.0 [- 272.9 to - 19.4] vs. - 10.9 [- 82.6 to 57.9] mL/year, p < 0.001; FEV₁, - 52.9 [- 192.2 to 3.9] vs. - 20.0 [- 72.6 to 28.6] mL/year, p = 0.010). After adjusting for confounding factors, patients with CPA had greater FVC decline (β coefficient, - 103.6; 95% CI - 179.2 to - 27.9; p = 0.007) than those without CPA. However, the FEV₁ decline (β coefficient, - 14.4; 95% CI - 72.1 to 43.4; p = 0.626) was not significantly different.

CONCLUSION

Although the development of CPA after lung cancer surgery did not increase mortality, the impact on restrictive lung function deterioration was profound.

Predictive value of modified systemic inflammation score for postoperative unplanned ICU admission in patients with NSCLC

Background

The purpose of this study was to investigate the predictive value of the modified systemic inflammation score (mSIS) in postoperative unplanned admission to the intensive care unit (ICU) in patients with non-small-cell lung cancer (NSCLC).

Methods

The clinical data of 1,321 patients with NSCLC treated with thoracic surgery in our hospital from August 2019 to June 2021 were analyzed retrospectively. The preoperative mSIS, which takes into account the serum albumin (ALB) level and lymphocyte-to-monocyte ratio (LMR), was recorded as 0, 1 or 2 and then was used to identify high-risk patients with unplanned admission to the ICU. The independent risk factors for unplanned admission to the ICU in patients with NSCLC after surgery were identified by multivariate logistic regression analysis.

Results

A total of 1,321 patients, including 549 (41.6%) males and 772 (58.4%) females, were included. The median age was 57 years (range 16–95 years). The incidence of unplanned admission to the ICU in patients with mSIS = 2 was significantly higher than that in those with mSIS = 0 and mSIS = 1. The multivariate analysis showed that an mSIS of 2 (OR = 3.728; P = 0.004; 95% CI, 1.520–9.143), an alcohol consumption history (OR = 2.791, P = 0.011; 95% CI, 1.262–6.171), intraoperative infusion volume (OR = 1.001, P = 0.021; 95% CI, 1.000–1.001) and preoperative underlying diseases (OR = 3. 57, P = 0.004; 95% CI, 1.497–8.552) were independent risk factors for unplanned admission to the ICU after lung cancer surgery. In addition, the multivariate logistic regression model showed that the C-statistic value was 0.799 (95% CI: 0.726∼0.872, P &lt; 0.001).

Conclusions

The mSIS scoring system can be used as a simplified and effective predictive tool for unplanned ICU admission in patients with NSCLC.

Clinicopathological features of male patients with breast cancer based on a nationwide registry database in Japan

BACKGROUND

Male breast cancer (MBC) is rare; however, its incidence is increasing. There have been no large-scale reports on the clinicopathological characteristics of MBC in Japan.

METHODS

We investigated patients diagnosed with breast cancer in the Japanese National Clinical Database (NCD) between January 2012 and December 2018.

RESULTS

A total of 594,316 cases of breast cancer, including 3780 MBC (0.6%) and 590,536 female breast cancer (FBC) (99.4%), were evaluated. The median age at MBC and FBC diagnosis was 71 (45-86, 5-95%) and 60 years (39-83) (p < 0.001), respectively. MBC cases had a higher clinical stage than FBC cases: 7.4 vs. 13.3% stage 0, 37.2 vs. 44.3% stage I, 25.6 vs. 23.9% stage IIA, 8.8 vs. 8.4% stage IIB, 1.9 vs. 2.4% stage IIIA, 10.1 vs. 3.3% stage IIIB, and 1.1 vs. 1.3% stage IIIC (p < 0.001). Breast-conserving surgery was more frequent in FBC (14.6 vs. 46.7%, p = 0.02). Axillary lymph node dissection was more frequent in MBC cases (32.9 vs. 25.2%, p < 0.001). Estrogen receptor(ER)-positive disease was observed in 95.6% of MBC and 85.3% of FBC cases (p < 0.001). The HER2-positive disease rates were 9.5% and 15.7%, respectively (p < 0.001). Comorbidities were more frequent in MBC (57.3 vs. 32.8%) (p < 0.001). Chemotherapy was less common in MBC, while endocrine therapy use was similar in ER-positive MBC and FBC. Perioperative radiation therapy was performed in 14.3% and 44.3% of cases.

CONCLUSION

Japanese MBC had an older age of onset, were more likely to be hormone receptor-positive disease, and received less perioperative chemotherapy than FBC.

Analysis of risk factors for postoperative complications in non-small cell lung cancer: comparison with the Japanese National Clinical Database risk calculator

Background

Although the risk calculator of the National Clinical Database (RC-NCD) has been widely used to predict the occurrence of mortality and major morbidity in Japan, it has not been demonstrated whether a correlation between the calculated RC-NCD risk score and the actual occurrence of mortality and severe morbidity exists.

Methods

The clinical data of 585 patients who underwent pulmonary resection for non-small cell lung cancer were collected, and the risk factors for postoperative morbidity were analyzed to verify the validity of the RC-NCD.

Results

The coexistence of asthma (p = 0.02), nutrition lymphocyte ratio (p = 0.04), and pulmonary lobe (p < 0.01) were significant risk factors for postoperative morbidity in the present study, and the percent-predicted vital capacity (p < 0.01), pulmonary lobe (p = 0.03), and type of operative procedure (p = 0.01) were significant risk factors for severe postoperative morbidity. Furthermore, in patients received lobectomy, coexistence of asthma (p = 0.01) and pulmonary lobe (p < 0.01) were identified as significant risk factors for postoperative morbidity. Meanwhile, male sex (p = 0.01), high BMI (p < 0.01), low vital capacity (p = 0.04), and pulmonary lobe (p = 0.03) were identified as significant risk factors for severe postoperative morbidity.

Conclusions

Given that the pulmonary lobe was a significant risk factor for postoperative morbidity in patients received pulmonary resection and for severe postoperative morbidity in patients received lobectomy, the RC-NCD for postoperative morbidity needs to be modified according to high-risk lobes.

Trial registration: The Institutional Review Board of Kanazawa Medical University approved the protocol of this retrospective study (approval number: I392), and written informed consent was obtained from all patients.

Lobe-specific nodal dissection with intraoperative frozen section analysis for clinical stage-I non-small cell lung cancer: a validation study by propensity score matching

OBJECTIVE

Lobe-specific nodal dissection (LND) is increasingly used for non-small cell lung cancer (NSCLC) in Japan; however, its treatment validity remains unclarified. Since 2013, LND has been used as a standard procedure for clinical stage-I (c-stage-I) NSCLC at our institution. We aimed to evaluate its validity using intraoperative frozen section analysis (FSA) for c-stage-I NSCLC.

METHODS

The participants comprised patients with NSCLC who underwent LND between 2013 and 2016 (n = 307) or systematic nodal dissection (SND) between 2002 and 2013 (n = 367) for c-stage-I disease. FSA was routinely performed in LND to examine at least three stations. Outcomes were compared between the LND and SND groups. Patients in whom LND was converted to SND due to metastasis on FSA of the sampled lymph node were still categorized into the LND group, i.e., intention-to-treat analysis. The prognostic impact was compared using propensity score matching.

RESULTS

The rate of conversion from LND to SND was 10.4%. Of the patients converted to SND, 12.5% had metastases outside the LND area. False-negative N2 results were detected in only 0.7% of the LND group patients after FSA. After matching, each group had 220 patients. There were no significant between-group differences in the lymph-node recurrence rate (7% vs. 6%), 5-year recurrence-free survival (80.1% vs. 79.0%), and overall survival (90.4% vs. 90.3%).

CONCLUSIONS

LND with intraoperative FSA is a valid modality that could serve as a standard surgical procedure for c-stage-I NSCLC. Intraoperative FSA may lower the residual lymph-node metastasis risk in LND.

Exosomal LncRNA RP5-977B1 as a novel minimally invasive biomarker for diagnosis and prognosis in non-small cell lung cancer

BACKGROUND

Lung cancer is the leading cause of cancer-related deaths in the world. Non-small cell lung cancer (NSCLC) accounts for 85% of all lung cancer cases. For lack of conveniently sensitive and specific biomarkers, the majority of patients are in the late stage at initial diagnosis. Long non-coding RNAs (LncRNAs), a novel type of non-coding RNA, have recently been recognized as critical factors in tumor initiation and progression, but the role of exosomal LncRNAs has not been thoroughly excavated in NSCLC yet.

METHODS

We isolated exosomes from the serum of patients with NSCLC and healthy controls. Exosome RNA deep sequencing was subsequently performed to detect differentially expressed exosomal LncRNAs. qRT-PCR assay was then utilized to validate dysregulated LncRNAs in both testing and multicentric validation cohort. Receiver operating characteristic (ROC) curve was used to detect the diagnostic capability of exosomal biomarkers. Furthermore, Kaplan-Meier analysis was applied to evaluate the prognostic values of these molecules.

RESULTS

On the basis of analysis, we found that novel exosomal LncRNA RP5-977B1 exhibited higher levels in NSCLC than that in the healthy controls. The area under the curve (AUC) value of exosomal RP5-977B1 was 0.8899 and superior to conventional biomarkers CEA and CYFRA21-1 both in testing and multicentric validation cohort. Interestingly, the diagnostic capability of exosomal RP5-977B1 was also validated in early-stage patients with NSCLC. Furthermore, high expression of exosomal RP5-977B1was closely related with worse prognosis in NSCLC (P = 0.036).

CONCLUSIONS

Our results suggested that exosomal RP5-977B1 might serve as a novel "liquid biopsy" diagnostic and prognostic biomarker to monitor NSCLC and improve possible therapy.

Photodynamic therapy can be safely performed with Talaporfin sodium as a day treatment for central-type early-stage lung cancer

BACKGROUNDS/AIM

Photodynamic therapy (PDT) with Talaporfin sodium (Talaporfin) is an effective and safe treatment for central-type early-stage lung cancer (CELC) that is associated with less skin photosensitivity. However, PDT is mostly performed in hospital for the purpose of light shading management in Japan. It is expected that it will be possible to perform PDT with Talaporfin (Talaporfin-PDT) as a day treatment with ≥14 days of shading management at home. This study aimed to confirm the safety of Talaporfin-PDT as day treatment.

METHODS

We retrospectively investigated the occurrence of adverse events among consecutive patients who received PDT for CELC in a day treatment setting in the Respiratory Endoscopy Division of our institution between January 2010 and February 2020.

RESULTS

A total of 12 patients (16 treatments) received day treatment of Talaporfin-PDT. Among the 12 patients, one patient (one treatment) was followed at another hospital. No severe adverse events after treatment were observed among the remaining 11 patients (15 treatments). Mild photosensitivity on a photosensitivity test was observed in 3 (3 treatments) of the 11 patients (15 treatments) but no major photosensitivity was observed. This photosensitivity was a temporary reaction.

CONCLUSION

Talaporfin-PDT for CELC was safely performed as a day treatment.

Impact of Volume on Mortality and Hospital Stay After Lung Cancer Surgery in a Single-Payer System

BACKGROUND

There is a literature gap for hospitals in single-payer healthcare systems quantifying the influence of hospital volume on outcomes following major lung cancer resection. We aimed to determine the effect of hospital volume on mortality, and length of stay (LOS).

METHODS

A retrospective cohort study using administrative, population-based data from a single-payer universal healthcare system was performed in adults with non-small cell lung cancer who underwent lobectomy or pneumonectomy between 2008 and 2017. Hospital volume was defined as the average annual number of major lung resections performed at each institution. Length of stay and post-operative mortality was compared using multivariable linear and non-linear regression between hospital volume categories and continuously. Adjusted association between hospital volume and post-operative mortality was determined by multivariable logistic regression.

RESULTS

10,831 lung resections were performed: 1237 pneumonectomies; 9594 lobectomies. Patients undergoing lobectomy at high-volume hospitals had shorter median LOS (6 vs 8 days, p = 0.001) compared with low-volume hospitals. After adjusting for confounders, surgery at a high-volume center was significantly associated with shorter LOS after lobectomy and overall resections (p=<0.001), but not after pneumonectomy (p=0.787). Surgery at a high-volume center was positively associated with improved 90-day mortality in lobectomy and overall procedures (OR 0.607; [0.399-0.925]; and 0.632 [0.441-0.904], respectively). Volume was not a predictor of 90-day mortality after pneumonectomy (OR 0.533 [0.257-1.104], p=0.090).

CONCLUSIONS

Surgery at a high-volume center was positively correlated with improved 90-day survival and shorter hospital LOS. The results support regionalized lung cancer care in a single-payer healthcare system.

Preoperative renal dysfunction and long-term survival after surgery for non-small cell lung cancer

OBJECTIVE

To investigate the association of preoperative renal dysfunction and long-term outcomes following lung cancer surgery.

METHODS

Using the Japanese Lung Cancer Registry data, we retrospectively examined 16,377 patients who underwent surgery for non-small cell lung cancer during 2010. Patients' renal function status was categorized as follows: serum creatinine <1.5 mg/dL (control, n = 16,169), serum creatinine ≥1.5 mg/dL with no dialysis (nondialysis-dependent chronic kidney disease, n = 113), and dialysis-dependent end-stage renal disease (n = 95). The association of patients' characteristics with overall survival was evaluated using multivariate Cox proportional hazard model.

RESULTS

The 5-year overall survival rates in patients with dialysis-dependent end-stage renal disease and with nondialysis-dependent chronic kidney disease were significantly worse than that in the control group (52.9% and 57.5% vs 78.0%; P < .001 for both comparisons), but were comparable to the reported 5-year overall survival rates in the natural history of end-stage renal disease (∼60%) and moderate to severe chronic kidney disease (∼50%). Cancer causes not related to lung cancer accounted for 62.2% of deaths in dialysis-dependent end-stage renal disease, which was more frequent than that in the control group (P = .002). Dialysis-dependent end-stage renal disease and nondialysis-dependent chronic kidney disease were independent risk factors for overall survival after lung cancer surgery (hazard ratio, 2.05 [P < .001] and hazard ratio, 2.04 [P = .001], respectively).

CONCLUSIONS

Preoperative renal dysfunction may be adversely associated with overall survival after lung cancer surgery. Our findings could aid patients to set proper expectation of the risks and benefits about surgery for lung cancer.

How often segmentectomy is feasible in lung cancer surgery: a population-based evaluation

OBJECTIVES

Despite promising outcomes in lung cancer surgery, segmentectomy has not gained wide acceptance at the population level. Our aim was to evaluate the potential role of segmentectomy in real-world practice.

METHODS

All patients diagnosed with lung cancer and operated between January 2013 and December 2019 in Central Finland and Ostrobothnia were included. This intent-to-treat analysis sub-grouped segmentectomy patients by indications: (i) high-risk patients with stage I disease (n = 40), (ii) ≤20 mm ground-glass opacity (n = 12), (iii) carcinoid (n = 12), (iv) special indication (n = 20) including synchronous and metachronous disease, fissure-crossing tumour, and synchronous other solid cancers requiring surgery, (v) solid ≤2 cm tumour (n = 14) in medically fit patient. To evaluate the potential role of segmentectomy, all preoperative CT scans were re-evaluated.

RESULTS

Of 269 patients, in 98 (36.4%) intention of surgery was segmentectomy. Indication was high risk in 40 (14.9%), ground-glass opacity in 12 (4.5%), carcinoid in 12 (4.5%), special indication in 20 (7.4%) and ≤2 cm solid tumour in medically fit patients in 14 (5.2%). The major complication rate was ≤15% in all groups with excellent 3-year recurrence-free survival between 76.5% and 100%. Segmentectomy could have been technically potential in up to 46.8% of patients. This was exactly the rate performed in the last 3-year period of this study.

CONCLUSIONS

Performed and potential segmentectomy rates underline the importance of adaptation of this technique with possibility to offer curative surgery to many high risk and special patients with low morbidity and mortality.

A systematic review of risk prediction models for perioperative mortality after thoracic surgery

OBJECTIVES

Guidelines advocate that patients being considered for thoracic surgery should undergo a comprehensive preoperative risk assessment. Multiple risk prediction models to estimate the risk of mortality after thoracic surgery have been developed, but their quality and performance has not been reviewed in a systematic way. The objective was to systematically review these models and critically appraise their performance.

METHODS

The Cochrane Library and the MEDLINE database were searched for articles published between 1990 and 2019. Studies that developed or validated a model predicting perioperative mortality after thoracic surgery were included. Data were extracted based on the checklist for critical appraisal and data extraction for systematic reviews of prediction modelling studies.

RESULTS

A total of 31 studies describing 22 different risk prediction models were identified. There were 20 models developed specifically for thoracic surgery with two developed in other surgical specialties. A total of 57 different predictors were included across the identified models. Age, sex and pneumonectomy were the most frequently included predictors in 19, 13 and 11 models, respectively. Model performance based on either discrimination or calibration was inadequate for all externally validated models. The most recent data included in validation studies were from 2018. Risk of bias (assessed using Prediction model Risk Of Bias ASsessment Tool) was high for all except two models.

CONCLUSIONS

Despite multiple risk prediction models being developed to predict perioperative mortality after thoracic surgery, none could be described as appropriate for contemporary thoracic surgery. Contemporary validation of available models or new model development is required to ensure that appropriate estimates of operative risk are available for contemporary thoracic surgical practice.

A risk model for prolonged air leak after lobectomy using the National Clinical Database in Japan

PURPOSE

The objective of our study was to develop a clinical prediction model for prolonged air leak (PAL) after lobectomy for lung cancer using preoperative variables in a large patient dataset from the National Clinical Database (NCD) in Japan.

METHODS

The preoperative characteristics of 57,532 and 30,967 patients who had undergone standard lobectomy for lung cancer were derived from the 2014 to 2015 and 2016 NCD datasets, respectively. PAL was defined as air leak persisting ≥ 7 days postoperatively or requiring postoperative interventional treatment, such as pleurodesis or reoperation. Risk models were developed from the 2014 to 2015 dataset and validated using the 2016 dataset. When performing model derivation, the least absolute shrinkage and selection operator (LASSO) method were applied for parameter selection.

RESULTS

The rate of PAL was 4.5% in 2014-2015 and 5.3% in 2016. The age, sex, body mass index, comorbid interstitial pneumonia, smoking habits, forced expiratory volume in 1 s, tumor histology, multiple lung cancer, and tumor location were selected as important variables for PAL. Our risk model for predicting PAL was fair with a concordance index of 0.6895.

CONCLUSION

The LASSO-based risk model for PAL after lobectomy provided important preoperative variables for PAL and risk weighting for each variable.

Japanese Current Status of Curative-Intent Surgery for Malignant Pleural Mesothelioma

BACKGROUND

Few reports about surgical outcomes in malignant pleural mesothelioma (MPM) were based on reliable nationwide databases. Here we analyzed the incidence, surgical outcome, and operative risk factors using Japanese nationwide database.

METHODS

Characteristics and perioperative data from 622 patients who underwent curative-intent surgery for MPM between January 2014 and December 2017 were recorded from National Clinical Database of Japan. We analyzed the incidence, surgical outcomes, and risk factors for surgical complications after two surgical procedures (extrapleural pneumonectomy, EPP; and pleurectomy/decortication, P/D).

RESULTS

During 4 years, EPP was performed in 279 patients and P/D in 343. EPP was more frequently performed in less-MPM-experienced institutions, while P/D was more frequently performed in well-MPM-experienced institutions (P < .001), especially in high-volume centers with more than 10 cases during this period. P/D was more frequently performed, especially in high-volume centers. The morbidity rates were 45.2% in EPP and 35.9% in P/D. Heart failure and pneumonia were most frequent in EPP, while prolonged air leakage was most frequent in P/D. Thirty-day- and in-hospital mortality rates were 1.1% and 3.2% (EPP) and 1.2% and 3.2% (P/D), respectively. Regression analyses revealed that higher age (>65 years) was associated with operative complications in EPP (odds ratio, OR: 3.56 [1.26-8.56]), whereas no risk factor was observed in P/D.

CONCLUSIONS

In Japanese nationwide annual database, P/D was more frequently performed, especially in high-volume centers. Morbidity was higher in EPP than P/D; however, the mortality rates were quite low in Japan regardless surgical procedures.

Validation of the Japanese National Clinical Database Risk calculator for lung cancer surgery focused on postoperative morbidity

OBJECTIVES

To validate the efficacy of the Japanese National Clinical Database risk calculator, which predicts major morbidity in lung cancer surgery based on preoperative clinical characteristics.

METHODS

In total, 660 patients who underwent complete surgical resection of primary lung cancer were enrolled. The predicted rate of major morbidity determined using the risk calculator was compared between the patients with and without major morbidity. We performed receiver operating characteristic curve analysis to determine their cut-off values to predict major morbidity and assessed the associated factors with major morbidity. Major morbidity was defined as the Clavien-Dindo classification grade IIIa or greater.

RESULTS

The predicted rate of major morbidity was significantly higher in patients with major morbidity than in those without (P < 0.001). The cut-off value of the predicted rate of major morbidity to predict major morbidity was 3.0% (area under curve 0.741; sensitivity and specificity, 85.3% and 54.3%, respectively). The predicted rate of major morbidity ≥ 3.0% was significantly associated with occurrence of major morbidities (odds ratio 6.9; 95% confidence interval 2.63-18.04; P < 0.001) and the predicted rate of major morbidity had the highest odds ratio over other risk factors. This condition, namely the predicted rate of major morbidity ≥ 3.0%, was met in 315 (47%) of the total cases. However, only 29 (9%) of these cases had major morbidity in practice.

CONCLUSIONS

The risk calculator was fairly useful for estimating high-risk patients; however, it was not possible to identify a specific cut-off value to predict major morbidity in this cohort.

Preoperative Cumulative Smoking Dose on Lung Cancer Surgery in a Japanese Nationwide Database

BACKGROUND

Smoking is a known risk factor for postoperative mortality and morbidity. However, the significance of cumulative smoking dose in preoperative risk assessment has not been established. We examined the influence of preoperative cumulative smoking dose on surgical outcomes after lobectomy for primary lung cancer.

METHODS

A total of 80,989 patients with primary lung cancer undergoing lobectomy from 2014 to 2016 were enrolled. Preoperative cumulative smoking dose was categorized by pack-years (PY): nonsmokers, PY = 0; light smokers, 0 < PY < 10; moderate smokers, 10 ≤ PY < 30; and heavy smokers, 30 ≤ PY. The risk of short-term outcomes was assessed according to PY by multivariable analysis adjusted for other covariates.

RESULTS

Postoperative 30-day mortality, as well as pulmonary, cardiovascular, and infectious complications, increased with preoperative PY. Multivariable analysis revealed that the odds ratios (ORs) for postoperative mortality compared with nonsmokers were 1.76 for light smokers (P = .044), 1.60 for moderate smokers (P = .026), and 1.73 for heavy smokers (P = .003). The ORs for pulmonary complications compared with nonsmokers were 1.20 for light smokers (P = .022), 1.40 for moderate smokers (P < .001), and 1.72 for heavy smokers (P < .001). Heavy smokers had a significantly increased risk of postoperative cardiovascular (OR, 1.26; P = .002) and infectious (OR, 1.39; P = .007) complications compared with nonsmokers.

CONCLUSIONS

The risk of mortality and morbidity after lung resection could be predicted according to preoperative cumulative smoking dose. These findings contribute to the development of strategies in perioperative management of lung resection patients.

Certified thoracic surgeons in Japan: a national database survey on risk-adjusted mortality associated with lung resection

PURPOSE

We investigated the association between the number of certified general thoracic surgeons (GTSs) and the mortality after lung cancer surgery, based on the data from the National Clinical Database (NCD).

METHODS

We analyzed the characteristics and operative and postoperative data of 120,946 patients who underwent lung cancer surgery in one of the 905 hospitals in Japan. The number of GTSs in each hospital was categorized as 0, 1-2, or 3 or more. Multivariable analysis was applied to adjust the patients' preoperative risk factors, as identified in a previous study. We calculated 95% confidence intervals (CI) for the mortality rate based on the odds ratios (ORs).

RESULTS

The patients' characteristics were distributed almost uniformly regardless of the number of GTSs. Crude mortality according to the number of GTSs of 0, 1-2, or 3 or more was 0.9%, 0.8%, and 0.7%, respectively (p = 0.03). However, after adjustment, the ORs for 1-2 and 3 or more GTSs (reference: 0) were 0.86 (p = 0.23, 95% CI: 0.67-1.10) and 0.84 (p = 0.18, 95% CI: 0.64-1.09), respectively. The number of GTSs did not have a significant association with mortality. Similar results were observed for patients in the lobectomy cohort.

CONCLUSION

Low surgical mortality was consistent, regardless of the number of GTSs in each hospital.

Can the Japanese National Clinical Database risk calculator predict long-term survival of patients who undergo palliative segmentectomy for primary lung cancer?

Objectives

Selection criteria for palliative limited surgery in patients with non-small cell lung cancer (NSCLC) can vary by institution or surgeon. We retrospectively reviewed outcomes of poor-risk patients who underwent palliative segmentectomy (PS), using the National Clinical Database Risk Calculator (RC).

Methods

We retrospectively analyzed medical records of patients with NSCLC tumors ≥ 20 mm and consolidation/tumor ratios ≥ 0.5 on computed tomography, who underwent PS from January 2009 to March 2016. Median follow-up time was 47 months (range 2–102 months).

Results

We enrolled 67 patients (median age: 73.0 years), of whom 54 received thoracoscopic surgery and 28 received medial lymph-node dissection. The RC’s mean predictive probability rate for perioperative mortality or severe complications was 7.1%. Of the 67 patients, 24 patients (43.0%) suffered post-surgical complications, including 2 (3%) who died in hospital; 17 eventually suffered NSCLC recurrences and/or metastases, 11 eventually died from NSCLC, and 17 died from other diseases. Five-year overall survival (OS) was 59.4%. When the patients were divided into high-risk (HR) and low-risk (LR) groups based on the RC, 5-year OS was significantly less in the HR group (43.9%) than in the LR group (82.2%; P < 0.05).

Conclusion

The RC, which was developed primarily to determine perioperative risk, can predict long-term prognosis for compromised patients who undergo PS.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11748-021-01585-6.

Factors Associated with Unexpected Readmission Following Lung Resection

BACKGROUND

Identification of the predictors of readmission can facilitate appropriate perioperative management. The current study aimed to investigate the potential predictors of unexpected readmission after lung resection for primary lung cancers.

METHODS

This retrospective study enrolled 1000 patients who underwent pulmonary resection for lung cancer at our institution between January 2016 and December 2017. Unexpected readmission was defined as unscheduled readmission to our hospital within 30 days after discharge. Univariate and multivariate analyses were performed for identification of perioperative factors associated with readmission.

RESULTS

Forty-three patients (4.3%) required unexpected readmission, and the median interval between the day of discharge and readmission was 10 days (range 1-29 days). The reasons for readmission included empyema and pleural effusion (n = 11), acute exacerbation of idiopathic pulmonary fibrosis (n = 7), pneumothorax (n = 7), and others (n = 18). The median hospitalization length after readmission was 14 days (range 2-90 days). Four patients (9.3%) died in the hospital because of acute exacerbation of idiopathic pulmonary fibrosis after readmission. In multivariate logistic regression analysis, postoperative refractory air leakage, defined as prolonged air leakage lasting > 5 days or requiring reoperation, was identified as a significant predictor associated with an increased risk of readmission (odds ratio 2.87; 95% confidence interval 1.22-6.72; p = 0.015).

CONCLUSIONS

Unexpected readmission was an inevitable event following lung resection. Patients with readmission had an increased risk of death. Refractory air leakage after lung resection for primary lung cancer was strongly associated with unexpected readmission.

Ninety-Day Mortality: Redefining the Perioperative Period After Lung Resection

Operative mortality is an important outcome for patients, surgeons, healthcare institutions, and policy makers. Although measures of perioperative mortality have conventionally been limited to in-hospital and 30-day mortality (or a composite endpoint combining both), there is a large body of evidence emerging to support the extension of the perioperative period after lung resection to a minimum of 90 days after surgery. Several large-volume studies from centers across the world have reported that 90-day mortality after lung resection is double 30-day mortality. Hence, true perioperative mortality after lung resection is likely to be significantly higher than what is currently reported. In the contemporary era, where new treatment modalities such as stereotactic ablative body radiotherapy are emerging as viable nonsurgical alternatives for the treatment of lung cancer, accurate estimation of perioperative risk and reliable reporting of perioperative mortality are of particular importance. It is likely that shifting the discussion from 30-day to 90-day mortality will lead to altered decision making, particularly for specific patient subgroups at an increased risk of 90-day mortality. We believe that 90-day mortality should be adopted as the standard measure of perioperative mortality after lung resection and that strategies to reduce the risk of mortality within 90 days of surgery should be investigated.

Salvage Surgery for Non-Small Cell Lung Cancer After Definitive Radiotherapy

BACKGROUND

The aim of this study was to describe the characteristics and outcomes of patients with non-small cell lung cancer undergoing salvage surgery after chemoradiotherapy, conventional external beam, stereotactic body radiotherapy, and ion beam radiotherapy.

METHODS

We retrospectively evaluated patients who underwent salvage surgery between 2010 and 2016. Data on perioperative morbidity and mortality and patient outcomes were analyzed.

RESULTS

In total, 156 patients were included; of those, 110 were categorized into category 1, chemoradiotherapy or conventional external beam; and 46 into category 2, stereotactic body radiotherapy or ion beam radiotherapy. Three-year overall survival (OS) and recurrence-free survival (RFS) in category 1 were 67.3% and 49.8%, respectively. In category 1, pathological nodal stage was an independent prognosticator of both OS (hazard ratio [HR] = 3.53, 95% confidence interval [CI], 1.05-11.83) and RFS (HR = 4.32, 95% CI, 1.32-14.14). In category 2, 3-year OS and RFS were 57.7% and 46.4%, respectively. Age 70 years and greater at initial treatment was the only independent prognosticator of OS (HR = 5.61; 95% CI, 1.44-21.87), whereas age at initial treatment (HR = 6.13; 95% CI, 1.38-27.12) and pathological nodal metastasis (HR = 3.84; 95% CI, 1.40-10.57) were independent prognosticators for RFS. Overall 30- and 90-day mortality were 0% and 0.9% in category 1 and 0% and 4.3% in category 2, respectively.

CONCLUSIONS

Patients who undergo salvage surgery can have reasonable outcomes, and salvage surgery can be considered in selected patients.

Airway inflammation and lung function recovery after lobectomy in patients with primary lung cancer

OBJECTIVE

Fractional exhaled nitric oxide (FeNO), which represents airway inflammation, is an indicator of postoperative complication after lung surgery. However, its effects in the late postoperative period are unknown. The aim of this prospective study was to clarify the impact of FeNO on postoperative lung function in patients with lung cancer.

METHODS

We measured preoperative FeNO using NIOX VERO® in patients with primary lung cancer. Patients were divided into two groups according to their potential airway inflammatory status: preoperative FeNO levels below 25 ppb (N group) and above 25 ppb (H group). They were evaluated by spirometry at 3 and 6 months after surgery during follow-up. The relationship between postoperative lung function and preoperative FeNO was evaluated.

RESULTS

Between September 2017 and March 2019, 61 participants were enrolled. All of them underwent lobectomy as a curative surgery. There were no significant background variables between the two groups. Postoperative vital capacity (VC) and forced expiratory volume in 1 s (FEV1) in the H group achieved less predictive values than those in the N group, which were not significant. The postoperative VC and FEV1 from 3 to 6 months in the H group were significantly increased as compared to those in the N group (p < 0.001).

CONCLUSIONS

Preoperative FeNO is a predictor of delayed lung function recovery 3 months after lobectomy in lung cancer patients. The impact had extended to VC and FEV1. Although this impact is temporary, early postoperative intervention is expected to reduce the adverse effect.

Risk and treatment of non-hepatic cancers in patients with cirrhosis

Patients with cirrhosis are at a high risk for hepatocellular carcinoma. However, it remains controversial about whether or not there is a high risk for non-hepatic cancers in patients with liver cirrhosis. Additionally, the management of non-hepatic cancers in cirrhotic patients is a clinical challenge, because the use of surgery and anticancer drugs is often compromised by the presence of liver dysfunction. This editorial aims to briefly summarize the findings on the risk and management of non-hepatic cancers in patients with cirrhosis.

Current status of surgery for clinical stage IA lung cancer in Japan: analysis of the national clinical database

Purpose

As the number of cases of early lung cancer in Japan grows, an analysis of the present status of surgical treatments for clinical stage IA lung cancer using a nationwide database with web-based data entry is warranted.

Methods

The operative and perioperative data from 47,921 patients who underwent surgery for clinical stage IA lung cancer in 2014 and 2015 were obtained from the National Clinical Database (NCD) of Japan. Clinicopathological characteristics, surgical procedure, mortality, and morbidity were analyzed, and thoracotomy and video-assisted thoracic surgery (VATS) were compared.

Results

The patients comprised 27,208 men (56.8%) and 20,713 women (43.2%); mean age, 69.3 years. Lobectomy was performed in 64.8%, segmentectomy in 15.2%, and wedge resection in 19.8%. The surgical procedures were thoracotomy in 12,194 patients (25.4%) and a minimally invasive approach (MIA) in 35,727 patients (74.6%). MIA was divided into VATS + mini-thoracotomy (n = 13,422, 28.0%) and complete VATS (n = 22,305, 46.5%). The overall postoperative mortality rate was 0.4%, being significantly lower in the MIA group than in the thoracotomy group (0.3% vs 0.8%, P < 0.001).

Conclusions

Our analysis of data from the NCD indicates that MIA has become the new standard treatment for clinical stage IA lung cancer.

Electronic supplementary material

The online version of this article (10.1007/s00595-020-02063-x) contains supplementary material, which is available to authorized users.

The predictive value of preoperative risk assessments and frailty for surgical complications in lung cancer patients

PURPOSE

To assess the predictive value of frailty and risk assessments for postoperative complications in lung cancer patients, we reviewed various risk indicators: including FEV1, ppoFEV1, the Zubrod performance status, the American Society of Anesthesiologist score, and risk models based on the Japan National Clinical Database (NCD) and the European Society of Thoracic Surgeons (ESTS) database.

METHODS

Patients who underwent elective surgery between April 2016 and May 2019 were enrolled. A statistical analysis was performed to compare any differences among the risk indicators.

RESULTS

The total number of patients enrolled was 193. Thirteen patients (6.7%) were classified as frail and 28 (14.5%) as pre-frail. Among the various risk indicators, the risk models based on the Japan NCD and the ESTS database revealed statistically significant differences in patients with and without postoperative complications (p value < 0.0001 and 0.0049, respectively), although there were no significant differences in frailty. The area under the receiver operating characteristic curve for risk models based on the Japan NCD registry and the ESTS registry was 0.70 and 0.64, respectively.

CONCLUSIONS

Our analyses of a series of lung cancer patients showed that frailty was not a significant predictor of postoperative outcomes, while risk models based on academic society databases were found to have a significant predictive value.

Impact of postoperative complications on outcomes of second surgery for second primary lung cancer

PURPOSE

The best surgical approach for second primary lung cancer remains a subject of debate. The purpose of this study was to review the postoperative complications after second surgery for second primary lung cancer and to investigate the outcomes based on these complications.

METHODS

The clinical data of 105 consecutive patients who underwent pulmonary resection for multiple primary lung cancers between January, 1996 and December, 2017, were reviewed according to the Martini-Melamed criteria.

RESULTS

After the second surgery, low body mass index (BMI) (< 18.5 kg/m²) (P = 0.004) and high Charlson comorbidity index (CCI) (P = 0.002) were independent predictors of postoperative complications. Survival analysis revealed the 5-year overall survival rates of 74.5% and 61.4% for patients without postoperative complications and those with postoperative complications (P = 0.044), respectively, but the 5-year cancer-specific survival rates of 82.5% and 80.0% (P = 0.926), respectively. During this period, there were significantly more respiratory-related deaths of patients with complications than of those without complications (P = 0.011).

CONCLUSION

Surgical intervention is feasible and potentially effective for second primary lung cancer but may not achieve positive perioperative and long-term outcomes for patients with a low BMI or a high CCI. Treatment options should be considered carefully for these patients.

Does liver cirrhosis have any impact on patients with lung cancer after surgical resection?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: does cirrhosis have any impact on patients with lung cancer after surgical resection? Altogether, 134 papers were found using the reported search, of which 6 cohort studies represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. Five of the cohort studies found that liver cirrhosis was correlated to higher postoperative mortality after lung cancer surgery, 4 also showed a correlation with higher postoperative morbidity and 2 of them found that patients with Child grade B or above experienced a higher risk of morbidity and mortality than those with Child grade A. Four of the cohort studies found that cirrhotic patients had poorer long-term survival, with 2 studies showing patients with Child grade B or above having a worse overall survival than those with Child grade A. Therefore, we conclude that liver cirrhosis (especially Child grade B or above) imposed a significant unfavourable impact on both short-term and long-term outcomes for patients intended for lung cancer surgery.

Impact of Previous Malignancy on Outcome in Surgically Resected Non-Small Cell Lung Cancer

BACKGROUND

Patients with lung cancer with a history of treatment often undergo curative surgical resection. However, the impact of previous cancer treatment on the outcome of lung cancer remains unclear.

METHODS

We conducted a retrospective study of patients who underwent curative resection for non-small cell lung cancer between 1998 and 2011. We collected clinicopathologic data and patients were divided into groups by previous history of cancer treatment. Comparisons between groups, estimation of survival rates, and multivariate analyses were performed. Propensity score matching was used to create cohorts with reduced bias.

RESULTS

Of 878 patients, 196 (22.3%) had previous extrathoracic malignancies, and stage I lung cancer was more frequent in this group (P < .001). In multivariate analysis of the whole cohort, older patients, men, non-adenocarcinoma histologic type, more advanced pathologic stage of lung cancer, interstitial pneumonia, and previous extrathoracic malignancies were associated with appreciably worse prognosis. When propensity score matched cohorts were compared, prognosis was significantly worse in patients with previous extrathoracic malignancies than patients without (5-year survival rates, 75.3% vs 82.7%; P = .009), although recurrence was not frequently seen (5-year recurrence-free rates, 78.7% vs 83.0%; P = .491).

CONCLUSIONS

Because treatment history of extrathoracic malignancy was not associated with postsurgical lung cancer recurrence, proposing curative resection could be justifiable if the previous cancer is deemed cured or controlled. However, the results showing that patients with previous cancer history have a worse survival rate than patients without should be taken into account when curative surgery is considered.

Current status of site-specific cancer registry system for the clinical researches: aiming for future contribution by the assessment of present medical care

BACKGROUND

The current status of site-specific cancer registry has not been elucidated, but sufficient system is found in some societies. The purpose of this study was to clear the present condition of site-specific cancer registries in Japan and to suggest for the improvement.

METHODS

The questionnaire was conducted by the study group of the Ministry of Health, Labor, and Welfare. It consisted of 38 questions, conflicts of interest, clinical research method, informed consent and funding for registry. We distributed this questionnaire to 28 academic societies, which had published the clinical practice guideline(s) assessed under Medical Information Network Distribution Service (MINDS).

RESULTS

The concept of the importance in assessment for medical quality by the data of the site-specific cancer registry was in good consensus. But the number of the society with the mature registry was limited. The whole-year registry with the scientific researches in the National Clinical Database (NCD) and in the Translational Research Informatics Center (TRI) might seem to be in success, because assured enhancement may be estimated. Now, academic societies have the structural factors, i.e., the financial limitation in the registry maintenance and the data analysis, and in the difficulty of employment of the researchers with skill and talent.

CONCLUSIONS

To manage the site-specific cancer registry effectively, the scientific registry system will be essentially important. Each academic society had much experienced highly qualified clinical researches in past. Accordingly, the scientific suggestion and co-operation should be of great importance for the improvement.

Chylothorax after spinal fusion surgery: A case report and literature review

Chylothorax is reported as a postoperative complication, mainly in the field of thoracic surgery, but there are only 14 reports in the field of spinal surgery.

A 64-year-old woman underwent spinal fusion surgery by the anterior and posterior approach for her scoliosis. She developed leg edema and right pleural effusion 2 months after the surgery. Laboratory findings showed decreased total protein and albumin levels in serum. The color of the thoracentesis sample was pinkish white, and the Triglyceride level in the pleural effusion was high. So, her leg edema was found to be associated with malnutrition and the pleural effusion was caused by chylothorax. The point of leakage from the lymph duct was confirmed in the right thoracic cavity of the slice that corresponded to that with the screw at Th11 by lymphatic scintigraphy. Her symptoms did not improve by diet restriction and lipidol lymphography, but her pleural effusion and albumin levels improved by the administration of octreotide. In the clinical course, serum albumin levels appeared to show an inverse correlation with the amount of pleural effusion, so it was thought that her serum albumin level decreased owing to leakage of protein, including albumin, into the thoracic cavity via the injured thoracic duct.

We concluded that the chylothorax was owing to complications of the surgery. Although reports of chylothorax occurring as a complication of spinal fusion surgery are rare, when prolonged hypoalbuminemia or unilateral pleural effusion is observed, chylothorax should be considered as a differential diagnosis.

Nodule Size After Chemotherapy and Primary-Tumor Teratoma Components Predict Malignancy of Residual Pulmonary Nodules in Metastatic Nonseminomatous Germ Cell Tumor

BACKGROUND

The treatment goal for visceral metastatic nonseminomatous germ cell tumor (NSGCT) is to remove any residual teratoma or viable NSGCT after chemotherapy. However, this provides no therapeutic benefit to patients whose metastases necrotize on their own. This study therefore analyzed NSGCTs with pulmonary metastases to determine preoperative factors that predict necrosis and could help identify patients who might be treated with monitoring rather than surgery.

METHODS

The study retrospectively analyzed 41 patients (135 metastatic pulmonary nodules) treated from 1997 to 2016 for NSGCT who showed tumor marker normalization after chemotherapy. Relationships between clinicopathologic characteristics and necrosis in resected pulmonary specimens were analyzed.

RESULTS

Receiver operating characteristic analysis of the pulmonary nodules showed 9 mm to be the optimal cutoff length for predicting necrosis. The logistic regression model showed that absence of teratoma components in the primary tumor and all pulmonary nodules shorter than 10 mm after chemotherapy both were independent predictors of pathologic necrosis in pulmonary specimens. No patients experienced late recurrence (i.e., > 2 years afterward).

CONCLUSIONS

The presence of teratoma components in primary tumors and nodular size after chemotherapy predict the pathology of residual pulmonary nodules. Patients whose residual nodules all are shorter than 10 mm and who have no primary-tumor teratoma components might be candidates for careful monitoring before pulmonary resection.

A risk score to predict postoperative complications after lobectomy in elderly lung cancer patients

OBJECTIVE

In elderly patients with lung cancer, the presumed fear of postoperative complications has resulted in the delivery of limited resection. Surgical decision-making for such patients would become easier if clinicians could predict who is at high risk of postoperative complications. The purpose of this study is to propose a scoring system to predict the risk of postoperative complications for elderly patients with lung cancer.

METHODS

We reviewed patients aged 75 years or older who underwent lobectomy for lung cancer at a single hospital (n = 199). A multivariable logistic regression model was utilized to determine risk factors for postoperative complications.

RESULTS

Six risk factors for postoperative complications were identified, and we derived a risk score by assigning weights to these factors based on their odds ratios, as follows: Risk score = 7 × (performance status of 2) + 6 × (coronary artery disease) + 3 × (a history of cerebrovascular accident) + 2 × (restrictive ventilatory impairment) + 1 × (male sex) + 1 × (interstitial pneumonia). The postoperative complication rates in patients with risk scores of 0, 1-2, 3-5, 6-8, and 9-14 were 19, 29, 56, 68, and 90%, respectively.

CONCLUSIONS

The proposed risk score was able to predict the incidence of postoperative complications. The risk score can be used to identify high-risk patients and to select proper treatment strategies.

Recommendations for perioperative management of lung cancer patients with comorbidities

Objectives

To improve surgical outcomes, clinicians must provide optimal perioperative care for comorbidities identified as significant factors in risk models for patients undergoing lung cancer surgery.

Methods

We reviewed trends in perioperative care for idiopathic pulmonary fibrosis, cardiovascular diseases, and end-stage renal diseases in patients undergoing lung cancer surgery, as large clinical databases indicate that these comorbidities are significant risk factors for lung cancer surgery. Articles identified by keyword searches were included in the analysis.

Results

Significant predictive factors for acute exacerbation of idiopathic pulmonary fibrosis were identified. However, no effective perioperative care was identified for prevention of acute exacerbation of interstitial pneumonia. The timing of coronary revascularization and antithrombotic management for cardiovascular diseases are subjects of ongoing research, and acid–base balance is essential in the management of hemodialysis patients with end-stage renal diseases.

Conclusions

To improve surgical outcomes for lung cancer patients, future studies should continue to study optimal perioperative management of comorbidities.