Pathological lymph node involvement is not a predictor of adverse outcomes in patients undergoing thoracoscopic lobectomy for lung cancer†

Conversion to Thoracotomy During Thoracoscopic versus Robotic Lobectomy: Predictors and Outcomes

BACKGROUND

Conversion to thoracotomy during minimally invasive lobectomy for lung cancer is occasionally necessary. Differences between video-assisted thoracoscopic (VATS) and robotic-assisted (RATS) lobectomy conversion have not been described.

METHODS

We queried The Society of Thoracic Surgeons (STS) General Thoracic Surgery Database (GTSD) from January 1, 2015 to December 31, 2018. Patients with prior thoracic operations and metastatic disease were excluded. Univariable comparisons with Chi-squared and Kruskal-Wallis tests and multivariable logistic regression modeling were performed.

RESULTS

There were 27,695 minimally invasive lobectomies from 269 centers. Conversion to thoracotomy occurred in 11.0% of VATS and 6.0% of RATS (p<0.001). Conversion was associated with increased mortality (p<0.001), major complications (p<0.001), and intra- (p<0.001) and post-operative (p<0.001) blood transfusions. Conversion from RATS occurred emergently (p<0.001) and for vascular injury (p<0.001) more frequently than from VATS, but there was no difference in overall major complications or mortality. Mortality following conversion was 3.1% for RATS and 2.2% for VATS (p=0.24). Clinical cancer stage II or III (p<0.001), preoperative chemotherapy (p=0.003), FEV1 (p=0.006), BMI (p<0.001), and left-sided resection (p=0.0002) independently predicted VATS conversion. For RATS, clinical stage III (p=0.037), left-sided resection (0.041), and FEV1 (p=0.002) predicted conversion. Lower volume centers had increased rates of conversion (p<0.001) in both groups.

CONCLUSIONS

Conversion from minimally invasive to open lobectomy is associated with increased morbidity and mortality. Conversion occurs more frequently during VATS compared to RATS, although less often emergently, and with similar rates of overall mortality and major complication. Predictors, urgency, and reasons for conversion differ between RATS and VATS lobectomy and may assist in patient selection.

Carbohydrate antigen-125, calcium, and hemoglobin as predictive clinical indicator for ocular metastasis in male liver cancer patients

Background Primary liver cancer (PLC) is a common type of cancer among men worldwide. Little is known regarding the relationship of liver cancer with ocular metastasis (OM). Drinking has been also reported to be related not only to the occurrence of liver cancer but also to the causes of some ocular lesions. Purpose A diagnostic standard for the levels of serum biomarkers associated with OM derived from liver cancer in men is urgently needed. Material and methods We examined the association between OM in liver cancer and its serum biomarkers. A total of 1254 male patients with liver cancer were recruited in this retrospective study between July 2002 and December 2012. We assessed the relationship between drinking preference and OM in male patients with liver cancer, and aimed to identify an independent prognostic factor or establish a quantitative indicator for OM. Results By assessing the potential indicators, carbohydrate antigen-125 (CA-125), calcium, and hemoglobin (Hb) were found to be most valuable in the diagnosis of OM in male patients with liver cancer. Conclusion CA-125, calcium, and Hb are independent risk factors of OM in patients with liver cancer who consume alcohol.

CA-125, CA-153, and CYFRA21-1 as clinical indicators in male lung cancer with ocular metastasis

Despite recent improvements in diagnosis and therapy, lung cancer remains the most common malignant tumor in males, with high morbidity and mortality. As the annual incidence continues to increase worldwide, the prognosis for male patients with lung cancer remains unsatisfactory. Interestingly, smoking is associated with lung cancer and ocular lesions by altering risk factors such as carbohydrate antigen (CA)-125, CA-153 and cytokeratin-19 fragment (CYFRA21-1). A diagnostic standard for serum biomarker levels of ocular metastasis (OM) in males with lung cancer is therefore urgently needed. In this retrospective analysis, we examined the relationship between smoking preference and OM in male patients with lung cancer to identify an independent prognostic factor or establish a quantitative indicated standard for OM using the clinical indexes from 2238 cases of male lung cancer. The combination of CA-125, CA-153 and CYFRA21-1 could help diagnose OM in male lung cancer patients. This finding might lead to more timely diagnosis and effective therapies.

What counts more: the patient, the surgical technique, or the hospital? A multivariable analysis of factors affecting perioperative complications of pulmonary lobectomy by video-assisted thoracoscopic surgery from a large nationwide registry

OBJECTIVES

Inherent technical aspects of pulmonary lobectomy by video-assisted thoracoscopic surgery (VATS) may limit surgeons' ability to deal with factors predisposing to complications. We analysed complication rates after VATS lobectomy in a prospectively maintained nationwide registry.

METHODS

The registry was queried for all consecutive VATS lobectomy procedures from 49 Italian Thoracic Units. Baseline condition, tumour features, surgical techniques, devices, postoperative care, complications, conversions and the reasons thereof were detailed. Univariable and multivariable regressions were used to assess factors potentially linked to complications.

RESULTS

Four thousand one hundred and ninety-one VATS lobectomies in 4156 patients (2480 men, 1676 women) were analysed. The median age-adjusted Charlson index of the patients was 4 (interquartile range 3-6). Grade 1 and 2 and Grade 3-5 complications were observed in 20.1% and in 5.8%, respectively. Ninety-day mortality was 0.55%. The overall conversion rate was 9.2% and significantly higher in low-volume centres (<100 cases, P < 0.001), but there was no significant difference between intermediate- and high-volume centres under this aspect. Low-volume centres were significantly more likely to convert due to issues with difficult local anatomy, but not significantly so for bleeding. Conversion, lower case-volume, comorbidity burden, male gender, adhesions, blood loss, operative time, sealants and epidural analgesia were significantly associated with increased postoperative morbidity.

CONCLUSIONS

VATS lobectomy is a safe procedure even in medically compromised patients. An improved classification system for conversions is proposed and prevention strategies are suggested to reduce conversion rates and possibly complications in less-experienced centres.

Inflammatory cell indexes as preoperative predictors of hospital stay in open elective thoracic surgery

BACKGROUND

Shorter and safer hospital stay (HS) is a desired outcome for patients undergoing thoracic surgery. The aim of the present study was to evaluate the predictive capacity of a series of pre-defined inflammatory cell indexes based on preoperative complete blood counts, towards length of HS in open elective thoracic surgery.

METHODS

We retrospectively studied 157 consecutive patients undergoing open elective thoracic surgery. Preoperative neutrophil to lymphocyte, platelet to lymphocyte and lymphocyte to monocyte ratios were calculated, and the red cell distribution width and mean platelet volume were registered. In addition, the systemic inflammation response index (SIRI) and a further derivative index, the aggregate inflammation systemic index (AISI) were calculated.

RESULTS

Statistically significant and positive correlations were observed between HS and SIRI, and between HS and AISI. In multiple logistic regression analysis, after dividing the patients in groups with normal and prolonged HS and adjusting for several confounders, only AISI was independently associated with HS.

CONCLUSIONS

Our results suggest that simple, inexpensive and widely available inflammatory cell indexes like SIRI and, particularly AISI, can be useful for the early identification of patients at risk of prolonged HS in open elective thoracic surgery.