Association between imaging surveillance frequency and outcomes following surgical treatment of early-stage lung cancer

Clinical practice guidelines for perioperative multimodality treatment of non-small cell lung cancer

BACKGROUND

Lung cancer is currently the most prevalent malignancy and the leading cause of cancer deaths worldwide. Although the early stage non-small cell lung cancer (NSCLC) presents a relatively good prognosis, a considerable number of lung cancer cases are still detected and diagnosed at locally advanced or late stages. Surgical treatment combined with perioperative multimodality treatment is the mainstay of treatment for locally advanced NSCLC and has been shown to improve patient survival. Following the standard methods of neoadjuvant therapy, perioperative management, postoperative adjuvant therapy, and other therapeutic strategies are important for improving patients' prognosis and quality of life. However, controversies remain over the perioperative management of NSCLC and presently consensus and standardized guidelines are lacking for addressing critical clinical issues in multimodality treatment.

METHODS

The working group consisted of 91 multidisciplinary experts from thoracic surgery, medical oncology, radiotherapy, epidemiology, and psychology. This guideline was developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The clinical questions were collected and selected based on preliminary open-ended questionnaires and subsequent discussions during the Guideline Working Group meetings. PubMed, Web of Science, Cochrane Library, Scopus, and China National Knowledge Infrastructure (CNKI) were searched for available evidence. The GRADE system was used to evaluate the quality of evidence and grade the strengths of recommendations. Finally, the recommendations were developed through a structured consensus-building process.

RESULTS

The Guideline Development Group initially collected a total of 62 important clinical questions. After a series of consensus-building conferences, 24 clinical questions were identified and corresponding recommendation were ultimately developed, focusing on neoadjuvant therapy, perioperative management, adjuvant therapy, postoperative psychological rehabilitation, prognosis assement, and follow-up protocols for NSCLC.

CONCLUSIONS

This guideline puts forward reasonable recommendations focusing on neoadjuvant therapy, perioperative management, adjuvant therapy, postoperative psychological rehabilitation, prognosis assessment, and follow-up protocol of NSCLC. It standardizes perioperative multimodality treatment and provides guidance for clinical practice among thoracic surgeons, medical oncologists, and radiotherapists, aiming to reduce postoperative recurrence, improve patient survival, accelerate recovery, and minimize postoperative complications such as atelectasis.

Impact of Socioeconomic Deprivation on Care Quality and Surgical Outcomes for Early-Stage Non-Small Cell Lung Cancer in United States Veterans

Background: Socioeconomic deprivation has been associated with higher lung cancer risk and mortality in non-Veteran populations. However, the impact of socioeconomic deprivation on outcomes for non-small cell lung cancer (NSCLC) in an integrated and equal-access healthcare system, such as the Veterans Health Administration (VHA), remains unclear. Hence, we investigated the impact of area-level socioeconomic deprivation on access to care and postoperative outcomes for early-stage NSCLC in United States Veterans. Methods: We conducted a retrospective cohort study of patients with clinical stage I NSCLC receiving surgical treatment in the VHA between 1 October 2006 and 30 September 2016. A total of 9704 Veterans were included in the study and assigned an area deprivation index (ADI) score, a measure of socioeconomic deprivation incorporating multiple poverty, education, housing, and employment indicators. We used multivariable analyses to evaluate the relationship between ADI and postoperative outcomes as well as adherence to guideline-concordant care quality measures (QMs) for stage I NSCLC in the preoperative (positron emission tomography [PET] imaging, appropriate smoking management, pulmonary function testing [PFT], and timely surgery [≤12 weeks after diagnosis]) and postoperative periods (appropriate surveillance imaging, smoking management, and oncology referral). Results: Compared to Veterans with low socioeconomic deprivation (ADI ≤ 50), those residing in areas with high socioeconomic deprivation (ADI > 75) were less likely to have timely surgery (multivariable-adjusted odds ratio [aOR] 0.832, 95% confidence interval [CI] 0.732-0.945) and receive PET imaging (aOR 0.592, 95% CI 0.502-0.698) and PFT (aOR 0.816, 95% CI 0.694-0.959) prior to surgery. In the postoperative period, Veterans with high socioeconomic deprivation had an increased risk of 30-day readmission (aOR 1.380, 95% CI 1.103-1.726) and decreased odds of meeting all postoperative care QMs (aOR 0.856, 95% CI 0.750-0.978) compared to those with low socioeconomic deprivation. There was no association between ADI and overall survival (adjusted hazard ratio [aHR] 0.984, 95% CI 0.911-1.062) or cumulative incidence of cancer recurrence (aHR 1.047, 95% CI 0.930-1.179). Conclusions: Our results suggest that Veterans with high socioeconomic deprivation have suboptimal adherence to care QMs for stage I NSCLC yet do not have inferior long-term outcomes after curative-intent resection. Collectively, these findings demonstrate the efficacy of an integrated, equal-access healthcare system in mitigating disparities in lung cancer survival that are frequently present in other populations. Future VHA policies should continue to target increasing adherence to QMs and reducing postoperative readmission for socioeconomically disadvantaged Veterans with early-stage NSCLC.

Unlocking the potential of RGD-conjugated gold nanoparticles: a new frontier in targeted cancer therapy, imaging, and metastasis inhibition

In the rapidly evolving field of cancer therapeutics, the potential of gold nanoparticles (AuNPs) conjugated with RGD peptides has emerged as a promising avenue for targeted therapy and imaging. Despite numerous studies demonstrating the effectiveness of RGD-conjugated AuNPs in specifically targeting tumor cells and enhancing radiation therapy (RT), a comprehensive review of these advancements is currently lacking. This review aims to fill this critical gap in the literature. Our analysis reveals that RGD-conjugated AuNPs have shown significant promise in improving the diagnosis and treatment of various types of cancer, including breast cancer. However, the full potential of this technology is yet to be realized. The development of multifunctional nanoplatforms incorporating AuNPs has opened new horizons for targeted therapy, dual-mode imaging, and inhibition of tumor growth and metastasis. This review is of paramount importance as it provides a comprehensive overview of the current state of research in this area, and highlights the areas where further research is needed. It is hoped that this review will inspire further investigations into this promising nanotechnology, ultimately leading to improved cancer diagnosis and therapy. Therefore, the findings presented in this review underscore the potential of AuNPs conjugated with RGD peptides as a revolutionary approach in cancer therapeutics. It is our fervent hope that this review will serve as a catalyst for further research in this exciting field.

The clinical effect of thoracoscopic segmentectomy in the treatment of lung malignancies less than 2CM in diameter

OBJECTIVE

To investigate the clinical effect of thoracoscopic segmentectomy in the treatment of lung malignancies less than 2CM in diameter.

METHODS

In this retrospective study, a total of 103 patients with lung cancer who received outpatient or inpatient treatment from December 2020 to May 2022 were selected and divided into the lobectomy group (n = 48) and the segmentectomy group (n = 55) according to different surgical methods. The lobectomy group was treated with thoracoscopic lobectomy, while the segmentectomy group was treated with thoracoscopic segmentectomy. The prognostic effect, complications, blood gas level and respiratory function indexes of the two groups were observed and compared.

RESULTS

The general data of the two groups of patients, such as gender, age, course of disease, body mass index, lesion diameter, lesion site and pathological type, were analyzed by statistical software. There was no statistical significance in the operation time and the number of lymph node dissection between the two groups (P > 0.05), while the drainage volume and intraoperative blood loss in the segmentectomy group were lower than those in the lobectomy group, and the drainage time and hospital stay were shorter than those in the lobectomy group, with statistical significance (P < 0.05). Before treatment, there were no statistically significant differences in various lung function indexes between the two groups (P > 0.05). After treatment, the values of FVC, FEV1 and FEV1/FVC in each group had different amplitude changes, and the values of FVC, FEV1 and FEV1/FVC in the segmentectomy group were significantly higher than those in the lobectomy group, with statistical significance (P < 0.05). Thoracoscopic segmentectomy showed a lower incidence of respiratory complications (P = 0.042) and higher pulmonary air leak (P = 0.023) than thoracoscopic lobectomy. After propensity score-matched analysis, respiratory complications remained significantly higher in thoracoscopic segmentectomy (P = 0.017). However, the difference in the total complication rate between the two groups was not statistically significant (P > 0.05). There were no differences during the 2-year follow-up (median follow-up in months: 18.4; interquartile range, 14.8-21.3) in terms of overall survival (P = 0.49) and disease-free survival (P = 0.34) between groups (P > 0.05).

CONCLUSIONS

For patients with lung cancer less than 2 cm in diameter, thoracoscopic segmentectomy can achieve good short-term efficacy, with rapid postoperative recovery and little impact on lung function, which may be helpful to improve patients' postoperative quality of life.

Impact of radiological follow-up frequency on resected lung cancer: a propensity score matching analysis

Background

Despite advances in lung cancer treatment and the subsequent improvement in oncological outcomes, the optimal frequency of radiological follow-up remains unclear. Current recommendations lack consensus and do not consider individual patient characteristics and tumor factors. This study aimed to examine the impact of radiological follow-up frequency on oncological outcomes following lung cancer resection.

Methods

A prospective multicenter study, involving patients who underwent anatomical lung resection in the GEVATS database between December 2016 and March 2018. The relationship between surveillance frequency and oncological outcomes was evaluated. Two groups were established based on follow-up frequency: low frequency (LF) and high frequency (HF). Subgroup analyses were performed based on tumor stage, histology, lymphadenectomy, and adjuvant therapy. Propensity score matching (PSM) was applied to balance the groups.

Results

A total of 1,916 patients were included in the study, LF 444 (23.17%), HF 1,472 (76.83%). Factors associated with HF surveillance included higher stage, adjuvant chemotherapy and adjuvant radiotherapy. Subanalyses were performed after PSM for various factors, revealing significant differences between LF and HF groups in cancer-specific survival among who received adjuvant therapy {LF 53.021 months [95% confidence interval (CI): 48.622-57.421] vs. HF 58.836 months (95% CI: 55.343-62.330); HR 0.453, 95% CI: 0.242-0.849; P=0.013}, as well as overall survival for patients with squamous cell carcinoma [LF 54.394 months (95% CI: 51.424-57.364) vs. HF 61.578 months (95% CI: 59.091-64.065); HR 0.491, 95% CI: 0.299-0.806; P=0.005] and those who received adjuvant therapy LF 50.176 months [95% CI: 45.609-54.742) vs. HF 57.189 months (95% CI: 53.599-60.778); HR 0.503, 95% CI: 0.293-0.865; P=0.013].

Conclusions

Findings suggest that high-frequency surveillance only improves survival outcomes in lung cancer patients who received adjuvant treatment or had squamous cell carcinoma. Therefore, future guidelines for lung cancer follow-up should consider individualizing the frequency of radiological surveillance based on patients' risk profiles.

Lobe-specific lymph node sampling is associated with lower risk of cancer recurrence

Objective

Adequate intraoperative lymph node (LN) assessment is a critical component of early-stage non-small cell lung cancer (NSCLC) resection. The National Comprehensive Cancer Network and the American College of Surgeons Commission on Cancer (CoC) recommend station-based sampling minimums agnostic to tumor location. Other institutions advocate for lobe-specific LN sampling strategies that consider the anatomic likelihood of LN metastases. We examined the relationship between lobe-specific LN assessment and long-term outcomes using a robust, highly curated cohort of stage I NSCLC patients.

Methods

We performed a cohort study using a uniquely compiled dataset from the Veterans Health Administration and manually abstracted data from operative and pathology reports for patients with clinical stage I NSCLC (2006-2016). For simplicity in comparison, we included patients who had right upper lobe (RUL) or left upper lobe (LUL) tumors. Based on modified European Society of Thoracic Surgeons guidelines, lobe-specific sampling was defined for RUL tumors (stations 2, 4, 7, and 10 or 11) and LUL tumors (stations 5 or 6, 7, and 10 or 11). Our primary outcome was the risk of cancer recurrence, as assessed by Fine and Gray competing risks modeling. Secondary outcomes included overall survival (OS) and pathologic upstaging. Analyses were adjusted for relevant patient, disease, and treatment variables.

Results

Our study included 3534 patients with RUL tumors and 2667 patients with LUL tumors. Of these, 277 patients (7.8%) with RUL tumors and 621 patients (23.2%) with LUL tumors met lobe-specific assessment criteria. Comparatively, 34.7% of patients met the criteria for count-based assessment, and 25.8% met the criteria for station-based sampling (ie, any 3 N2 stations and 1 N1 station). Adherence to lobe-specific assessment was associated with lower cumulative incidence of recurrence (adjusted hazard ratio [aHR], 0.83; 95% confidence interval [CI], 0.70-0.98) and a higher likelihood of pathologic upstaging (aHR, 1.49; 95% CI, 1.20-1.86). Lobe-specific assessment was not associated with OS.

Conclusions

Adherence to intraoperative LN sampling guidelines is low. Lobe-specific assessment is associated with superior outcomes in early-stage NSCLC. Quality metrics that assess adherence to intraoperative LN sampling, such as the CoC Operative Standards manual, also should consider lobe-specific criteria.

[Questions and Answers in Lung Cancer]

Over the past 2 decades, scientific evidence has strongly supported the use of low-radiation dose chest computed tomography (CT) as a screening technique for lung cancer. This approach has resulted in a significant reduction in mortality rates by enabling the detection of early-stage lung cancer amenable to potentially curative treatments. Regarding diagnosis, there are also novel methods under study, such as liquid biopsy, identification of the pulmonary microbiome, and the use of artificial intelligence techniques, which will play a key role in the near future. At present, there is a growing trend towards less invasive surgical procedures, such as segmentectomy, as an alternative to lobectomy. This procedure is based on 2 recent clinical trials conducted on peripheral tumors measuring less than 2 cm. Although these approaches have demonstrated comparable survival rates, there remains controversy due to uncertainties surrounding recurrence rates and functional capacity preservation. With regard to adjuvant therapy, immunotherapy, either as a monotherapy or in conjunction with chemotherapy, has shown encouraging results in resectable stages of locally advanced lung cancer, demonstrating complete pathologic responses and improved overall survival.After surgery treatment, despite the lack of solid evidence for long-term follow-up of these patients, clinical practice recommends periodic CT scans during the early years.In conclusion, there have been significant advances in lung cancer that have improved diagnostic techniques using new technologies and screening programs. Furthermore, the treatment of lung cancer is increasingly personalized, resulting in an improvement in the survival of patients.