Survival of Octogenarians with Early-Stage Non-small Cell Lung Cancer is Comparable Between Wedge Resection and Lobectomy/Segmentectomy: JACS1303

Lobar or sublobar resection of peripheral stage I non-small cell lung cancer

PURPOSE OF REVIEW

We aim to highlight two recent clinical trials that have altered the approach of the management of stage I nonsmall cell lung cancer.

RECENT FINDINGS

The JCOG 0802 and CALGB 140503 trials demonstrated that sublobar resection is noninferior to lobectomy for overall and disease-free survival in patients with stage I nonsmall cell lung cancer.

SUMMARY

Since 1962, lobectomy has been deemed the gold standard treatment for operable lung cancer. However, two recent clinical trials have demonstrated that, for select patients, sublobar resection is oncologically noninferior; results, which are leading us into a new era for the surgical management of lung cancer. Notwithstanding the progress made by these studies and the opportunities that have been put forth, questions remain. This review aims at reviewing the results of both trials and to discuss future perspectives for the surgical treatment of lung cancer.

Robotic Versus Thoracoscopic Sub-lobar Resection for Octogenarians with Clinical Stage IA Non-small Cell Lung Cancer: A Propensity Score-Matched Real-World Study

BACKGROUND

Minimally invasive sub-lobectomy is sufficient in treating small early-stage non-small cell lung cancer (NSCLC). However, comparison of the feasibility and oncologic efficacy between robot-assisted thoracoscopic surgery (RATS) and video-assisted thoracoscopic surgery (VATS) in performing sub-lobectomy for early-stage NSCLC patients age 80 years or older is scarce.

METHODS

Octogenarians with clinical stage IA NSCLC (tumor size, ≤ 2 cm) undergoing minimally invasive wedge resection or segmentectomy at Shanghai Chest Hospital from 2011 to 2020 were retrospectively reviewed from a prospectively maintained database. Propensity score-matching (PSM) with a RATS versus VATS ratio of 1:4 was performed. Perioperative and long-term outcomes were analyzed.

RESULTS

The study identified 594 patients (48 RATS and 546 VATS patients), and PSM resulted in 45 cases in the RATS group and 180 cases in the VATS group. The RATS patients experienced less intraoperative bleeding (60 mL [interquartile range (IQR), 50-100 mL] vs. 80 mL [IQR, 50-100 mL]; P = 0.027) and a shorter postoperative hospital stay (4 days [IQR, 3-5 days] vs. 5 days [IQR, 4-6 days]; P = 0.041) than the VATS patients. The two surgical approaches were comparable concerning other perioperative outcomes and postoperative complications (20.00% vs. 26.11%; P = 0.396). Additionally, during a median follow-up period of 66 months, RATS and VATS achieved comparable 5-year overall survival (90.48% vs. 87.93%; P = 0.891), recurrence-free survival (83.37% vs. 83.18%; P = 0.782), and cumulative incidence of death. Further subgroup comparison also demonstrated comparable long-term outcomes between the two approaches. Finally, multivariate Cox analysis indicated that the surgical approach was not independently correlated with long-term outcomes.

CONCLUSIONS

The RATS approach shortened the postoperative hospital stay, reduced intraoperative bleeding by a statistically notable but clinically insignificant amount, and achieved long-term outcomes comparable with VATS in performing sub-lobectomy for octogenarians with early-stage small NSCLC.

Sublobar Resection in Early Non-Small Cell Lung Cancer With Epidermal Growth Factor Receptor Mutant

BACKGROUND

Lobectomy is a standard surgical procedure for peripherally located early-stage non-small cell lung cancers (NSCLCs) measuring 2 to 4 cm. However, it is unclear whether sublobar resections, such as wedge resection and segmentectomy, are effective in treating tumors with driver mutations in the epidermal growth factor receptor (EGFR).

METHODS

We analyzed the clinicopathologic findings and surgical outcomes of 1395 patients with radiologically solid-dominant NSCLC measuring 2 to 4 cm, without clinical lymph node involvement, who underwent complete resection between 2010 and 2020. The patients, who underwent sublobar resections (n = 231) or lobectomy (n = 1164), were categorized by their EGFR mutation status and the surgical procedures performed. The follow-up was conducted for a median of 45.3 months.

RESULTS

The 5-year overall survival (OS) rates after sublobar resections (n = 39) were comparable to those after lobectomy (n = 359) in patients with EGFR mutation-positive tumors (80.5% [95% CI, 51.3%-93.2%] vs 88.8% [95% CI, 84.1%-92.1%], respectively; P = .16). Multivariable Cox regression analysis of OS revealed that the surgical procedure was an independent prognostic predictor in the entire cohort (hazard ratio, 0.6; 95% CI, 0.4-1.0; P = .028), but it was not an independent prognostic predictor in patients with EGFR-mutated tumors (hazard ratio, 0.6; 95% CI, 0.2-1.7; P = .32).

CONCLUSIONS

Sublobar resection with a secure surgical margin could be a viable option for appropriately selected patients with peripheral early-stage NSCLC tumors measuring 2 to 4 cm and harboring EGFR mutations, because it provides comparable OS to that of lobectomy.

Asian Perspective on Lung Cancer Screening

Lung cancer is the leading cause of cancer-related mortality in Japan and worldwide. Early detection of lung cancer is an important strategy for decreasing mortality. Advances in diagnostic imaging have made it possible to detect lung cancer at an early stage in medical practice. Conversely, screening of asymptomatic healthy populations is recommended only when the evidence shows the benefits of regular intervention. Due to a variety of evidence and racial differences, screening methods vary from country to country. This article focused on the perspective of lung cancer screening in Japan.

Sublobar Resection for Non-Small Cell Lung Cancer in Octogenarians: A Prospective, Multicenter Study

BACKGROUND

Segmentectomy is a good surgical option for peripheral, early, non-small cell lung cancer (NSCLC) ≤2 cm. However, the role of sublobar resection including wedge resection and segmentectomy remains unclear for octogenarians with >2-cm but ≤4-cm early-stage NSCLC, for which lobectomy is a standard treatment.

METHODS

By use of a prospective registry, 892 patients aged ≥80 years with operable lung cancer were enrolled at 82 institutions. Of these, we analyzed the clinicopathologic findings and surgical outcomes of 419 patients with NSCLC tumors of 2 to 4 cm during a median follow-up of 50.9 months between April 2015 and December 2016.

RESULTS

Five-year overall survival (OS) was slightly but not significantly worse after sublobar resection than after lobectomy in the entire cohort (54.7% [95% CI, 43.2%-93.0%] vs 66.8% [95% CI, 60.8%-72.1%]; P = .09). Multivariable Cox regression analysis of OS revealed that these surgical procedures were not independent prognostic predictors (hazard ratio, 0.8 [0.5-1.1]; P = .16). The 5-year OS was comparable between 192 patients who could tolerate lobectomy but were treated by sublobar resection or lobectomy (67.5% [95% CI, 48.8%-80.6%] vs 71.5% [95% CI, 62.9%-78.4%]; P = .79). Recurrence after sublobar resection and lobectomy was locoregional in 11 (11%) of 97 and in 23 (7%) of 322 patients, respectively.

CONCLUSIONS

OS might be equivalent between sublobar resection with a secure surgical margin and lobectomy for selected patients aged ≥80 years with peripheral early-stage NSCLC tumors of 2 to 4 cm who can tolerate lobectomy.

Real-world survival outcomes of wedge resection versus lobectomy for cT1a/b cN0 cM0 non-small cell lung cancer: a single center retrospective analysis

Background

JCOG0802/WJOG4607L showed benefits in overall survival (OS) of segmentectomy. CALGB 140503 confirmed that sublobar resection was not inferior to lobectomy concerning recurrence-free survival (RFS) but did not provide specific OS and RFS according to the techniques of sublobar resections. Hence, we retrospectively analyze the survival differences between wedge resection and lobectomies for stage IA lung cancer.

Methods

We reviewed the clinical records of patients with clinical stage IA NSCLC over 20 years. The inclusion criteria were: preoperative staging with CT scan and whole body CT/PET; tumor size <20 mm; wedge resections or lobectomies with or without lymph node dissection; NSCLC as the only primary tumor during the follow-up period. We excluded: multiple invasive lung cancer; positive resection margin; preoperative evidence of nodal disease; distant metastasis at presentation; follow-up time <5 years. The reverse Kaplan - Meier method estimated the median OS and PFS and compared them by the log-rank test. The stratified backward stepwise Cox regression model was employed for multivariable survival analyses.

Results

539 patients were identified: 476 (88.3%) lobectomies and 63 (11.7%) wedge resections. The median OS time for the whole cohort was 189.7 months (range: 173.7 - 213.9 months). The 5-year wedge resection and lobectomy OS were 82.2% and 87.0%. The 5-year RFS of wedge resection and lobectomy were 17.8% and 28.9%. The log-rank test showed no significant differences (p = 0.39) between wedge resections and lobectomies regarding OS and RFS (p = 0.23).

Conclusions

Lobectomy and wedge resection are equivalent oncologic treatments for individuals with cN0/cM0 stage IA NSCLC <20 mm. Validating the current findings requires a prospective, randomized comparison between wedge resection and standard lobectomy to establish the prognostic significance of wedge resection.

Prediction of Surgical Outcome by Tumor Volume Doubling Time via Stereo Imaging Software in Early Non-Small Cell Lung Cancer

BACKGROUND

Volume doubling time (VDT) has been proven to be a powerful predictor of lung cancer progression. In non-small cell lung cancer patients receiving sublobar resection, the discussion of correlation between VDT and surgery was absent. We proposed to investigate the surgical outcomes according to VDT.

METHODS

We retrospectively studied 96 cases post sublobar resection from 2012 to 2018, collecting two chest CT scans preoperatively of each case and calculating the VDT. The receiver operating characteristic curve was constructed to identify the optimal cut-off point of VDTs as 133 days. We divided patients into two groups: VDT < 133 days and VDT ≥ 133 days. Univariable and multivariable analyses were performed for comparative purposes.

RESULTS

Univariable and multivariable analyses revealed that the consolidation and tumor diameter ratio was the factor of overall survival (OS), and VDT was the only factor of disease-free survival (DFS). The five year OS rates of patients with VDTs ≥ 133 days and VDTs < 133 days, respectively, were 89.9% and 71.9%, and the five year DFS rates were 95.9% and 61.5%.

CONCLUSION

As VDT serves as a powerful prognostic predictor and provides an essential role in planning surgical procedures, the evaluation of VDT preoperatively is highly suggested.

Sub-Lobar Resection: The New Standard of Care for Early-Stage Lung Cancer

The Lung Cancer Study Group previously established lobectomy as the standard of care for treatment of clinical T1N0 NSCLC. Advances in imaging technology and refinements in staging have prompted a re-investigation to determine the non-inferiority of sub-lobar resections to lobectomies. Two recent randomized studies, JCOG 0802 and CALGB 140503, are reviewed here in the context of LCSG 0821. The studies confirm non-inferiority for sub-lobar resection (wedge or segmentectomy) compared to lobectomy for peripheral T1N0 NSCLC less than or equal to 2 cm. Sub-lobar resection should therefore be considered the new standard of care in this sub-set of patients with NSCLC.

[Surgery of old people-Thoracic surgery]

Background

The incidence of a large number of diseases relevant to thoracic surgery increases with age; however, old age is still frequently considered a contraindication per se for curative interventions and extensive surgical procedures.

Objective

Overview of the current relevant literature, derivation of recommendations for patient selection as well as preoperative, perioperative and postoperative optimization.

Material and methods

Analysis of the current study situation.

Results

Recent data show that for most thoracic diseases, age alone is not a reason to withhold surgical treatment. Much more important for the selection are comorbidities, frailty, malnutrition and cognitive impairment. A lobectomy or segmentectomy for stage I non-small cell lung cancer (NSCLC) in carefully selected octogenarians can provide acceptable to even comparably good short-term and long-term results as in younger patients. Selected > 75-year-old patients with stages II-IIIA NSCLC even benefit from adjuvant chemotherapy. With appropriate selection high-risk interventions, such as pneumonectomy in > 70-year-old patients and pulmonary endarterectomy in > 80-year-old patients can be performed without an increase in mortality rates. Even lung transplantation can lead to good long-term results in carefully selected > 70-year-old patients. Minimally invasive surgical techniques and nonintubated anesthesia contribute to risk reduction in marginal patients.

Discussion

In thoracic surgery the biological age rather than the chronological age is decisive. In view of the increasingly older population, further studies are urgently needed to optimize patient selection, type of intervention, preoperative planning and postoperative treatment as well as the quality of life.

Sublobar Resections

Sublobar resections are commonly performed operations that have seen an increase in applicability. The sublobar approach, comprising segmentectomy and wedge resections, can provide lung preservation and thus is better tolerated in select patients in comparison to lobectomy. These operations are offered for a variety of benign and malignant lesions. Understanding the indications and technical aspects of these approaches is paramount as improvements in lung cancer screening protocols and the imaging modalities has led to an increase in the detection of early-stage cancer. In this article, we discuss the anatomy, indications, technical approaches, and outcomes for sublobar resection.

Wedge resection is an acceptable treatment option for radiologically low-grade lung cancer with solid predominance

OBJECTIVES

This study aimed to determine the clinical characteristics for predicting low-grade cancer in radiologically solid predominant non-small-cell lung cancer (NSCLC) and compare the survival outcomes of wedge resection with those of anatomical resection for patients with and without these characteristics.

METHODS

Consecutive patients with clinical stages IA1-IA2 NSCLC showing radiologically solid predominance ≤2 cm at 3 institutions were retrospectively evaluated. Low-grade cancer was defined as the absence of nodal involvement and blood vessel, lymphatic and pleural invasion. The predictive criteria for low-grade cancer were established by multivariable analysis. The prognosis of wedge resection was compared with that of anatomical resection for patients who met the criteria, using the propensity score-matched analysis.

RESULTS

Among 669 patients, multivariable analysis showed that ground-glass opacity (GGO) (P < 0.001) on thin-section computed tomography and an increased maximum standardized uptake value on 18-fluoro-2-deoxyglucose positron emission tomography/computed tomography (P < 0.001) were independent predictors of low-grade cancer. The predictive criteria were defined as GGO presence and maximum standardized uptake value ≤1.1 (specificity: 97.8%, sensitivity: 21.4%). In the propensity score-matched pairs (n = 189), overall survival (P = 0.41) and relapse-free survival (P = 0.18) were not significantly different between patients who underwent wedge resection and anatomical resection among those who fulfilled the criteria.

CONCLUSIONS

The radiologic criteria for GGO and a low maximum standardized uptake value could predict low-grade cancer, even in solid-dominant NSCLC sized ≤2 cm. Wedge resection could be an acceptable surgical option for patients with radiologically predicted indolent NSCLC showing a solid-dominant appearance.

[Surgery of old people-Thoracic surgery]

BACKGROUND

The incidence of a large number of diseases relevant to thoracic surgery increases with age; however, old age is still frequently considered a contraindication per se for curative interventions and extensive surgical procedures.

OBJECTIVE

Overview of the current relevant literature, derivation of recommendations for patient selection as well as preoperative, perioperative and postoperative optimization.

MATERIAL AND METHODS

Analysis of the current study situation.

RESULTS

Recent data show that for most thoracic diseases, age alone is not a reason to withhold surgical treatment. Much more important for the selection are comorbidities, frailty, malnutrition and cognitive impairment. A lobectomy or segmentectomy for stage I non-small cell lung cancer (NSCLC) in carefully selected octogenarians can provide acceptable to even comparably good short-term and long-term results as in younger patients. Selected > 75-year-old patients with stages II-IIIA NSCLC even benefit from adjuvant chemotherapy. With appropriate selection high-risk interventions, such as pneumonectomy in > 70-year-old patients and pulmonary endarterectomy in > 80-year-old patients can be performed without an increase in mortality rates. Even lung transplantation can lead to good long-term results in carefully selected > 70-year-old patients. Minimally invasive surgical techniques and nonintubated anesthesia contribute to risk reduction in marginal patients.

DISCUSSION

In thoracic surgery the biological age rather than the chronological age is decisive. In view of the increasingly older population, further studies are urgently needed to optimize patient selection, type of intervention, preoperative planning and postoperative treatment as well as the quality of life.

Development and validation of a nomogram for predicting survival time and making treatment decisions for clinical stage IA NSCLC based on the SEER database

Background

The aim of this study was to establish and validate a nomogram model for accurate prediction of patients' survival with T1aN0M0 none small cell lung cancer (NSCLC).

Methods

The patients, diagnosed with the stage IA NSCLC from 2004-2015, were identified from the Surveillance, Epidemiology and End Results (SEER) database. The variables with a P-value < 0.05 in a multivariate Cox regression were selected to establish the nomogram. The discriminative ability of the model was evaluated by the concordance index (C-index). The proximity of the nomogram prediction to the actual risk was depicted by a calibration plot. The clinical usefulness was estimated by the decision curve analysis (DCA). Survival curves were made with Kaplan-Meier method and compared by Log-Rank test.

Results

Eight variables, including treatment, age, sex, race, marriage, tumor size, histology, and grade were selected to develop the nomogram model by univariate and multivariate cox regression. The C-index was 0.704 (95% CI, 0.694-0.714) in the training set and 0.713 (95% CI, 0.697-0.728) in the test set, which performed significantly better than 8th edition AJCC TNM stage system (0.550, 95% CI, 0.408-0.683, P < 0.001). The calibration curve showed that the prediction ability of 3-years and 5-years survival rate demonstrated a high degree of agreement between the nomogram model and the actual observation. The DCA curves also proved that the nomogram-assisted decisions could improve patient outcomes.

Conclusion

We established and validated a prognostic nomogram to predict 3-years and 5-years overall survival in stage IA NSCLC.

Surgery versus radiotherapy in octogenarians with stage Ia non‑small cell lung cancer: propensity score matching analysis of the SEER database

Objectives

To compare overall survival (OS) and cancer-specific survival (CSS) outcomes of surgery with radiotherapy in octogenarians with stage Ia non-small cell lung cancer (NSCLC).

Materials and methods

Patients aged ≥ 80 years with clinical stage Ia (T1N0M0) NSCLC between 2012 and 2017 were identified from the population-based Surveillance, Epidemiology, and End Results (SEER) database. Patients were assigned into surgery and radiotherapy groups. Multivariate Cox regression analysis was used to identify survival-associated factors. Treatment groups were adjusted by propensity score matching (PSM) analysis while OS and CSS outcomes were compared among groups by Kaplan–Meier analysis.

Results

A total of 1641 patients were identified, with 46.0% in the surgical group and 54.0% in the radiotherapy group. Compared to surgery, radiotherapy-treated patients were older, later diagnosed, had more often unmarried, more squamous cell carcinoma, more unknown grade and increased tumor sizes. Radiotherapy was associated with a significantly worse OS, compared to surgery (hazard ratio 2.426; 95% CI 2.003–2.939; P < .001). After PSM, OS (P < 0.001) and CSS (P < 0.001) were higher in the surgery group. The 1-, 3-, and 5-year OS rates of surgical and radiotherapy group were 90.0%, 76.9%, 59.9%, and 86.0%, 54.3%, 28.0%, respectively. The 1-, 3-, and 5-year CSS rates of surgical and radiotherapy group were 94.5%, 86.1%, 78.0% and 90.7%, 74.5%, 61.0%, respectively. There were no survival differences between the matched surgery without lymph node examination (LNE) and radiotherapy group, as well as between the matched surgery and radiotherapy who were recommended but refused surgery group.

Conclusions

In octogenarians with stage Ia NSCLC, surgery with lymph node dissection offers better OS and CSS outcomes than radiotherapy.

Outcome of Resected Lung Cancers with Subcentimeter Solid Component on Computed Tomography

Background Although the opportunity to treat subcentimeter lung cancers has increased, the optimal surgical methods remain unclear. We performed a retrospective study to examine the clinical outcome of subcentimeter lung cancers.

Patients and Methods In total, 118 patients who underwent curative resection for subcentimeter lung cancer from January 2005 to December 2013 were analyzed. Multivariate Cox proportional hazards models were used to calculate the hazard ratio to identify independent predictors of recurrence-free survival (RFS) and overall survival (OS).

Results Anatomical resections were performed for 64 patients (59 lobectomies and 5 segmentectomies) and wedge resections for 54 patients. Recurrence developed in six patients who had consolidation-predominant tumors (consolidation/tumor [C/T] ratio of >0.5) and underwent wedge resections. The first recurrence patterns were regional recurrences in three patients, both regional and distant in one, and distant in two. Seventeen patients died of other causes. The multivariate analysis revealed that the C/T ratio was the independent predictor of RFS (p = 0.008) and OS (p = 0.011).

Conclusion Patients with subcentimeter lung cancer rarely developed recurrence. The C/T ratio was the independent prognostic factor, and all relapsed patients received wedge resections. Even for subcentimeter lung cancers, we should select the extent of pulmonary resection after thoroughly considering whether wedge resection (less invasiveness) is a reasonable alternative to anatomical resection (superior oncologic efficacy) considering the C/T ratio of the lesion.

Lobectomy Provides the Best Survival for Stage I Lung Cancer Patients Despite Advanced Age

BACKGROUND

The Lung Cancer Study Group has shown that lobectomy provides the best survival in patients with non-small cell lung cancer. However, as patients become older, lobectomy may not provide a survival advantage compared with sublobar resection.

METHODS

We analyzed the National Cancer Database for octogenarians with pathologic stage I lung cancer from 2004 to 2016. We then evaluated the patients who underwent lobectomy or sublobar (segmentectomy or wedge) resection for the treatment of cancer. We analyzed the 5-year survival rates of the groups as well as a cubic spline plot to determine age cutoffs where lobectomy does not provide improved survival.

RESULTS

Among the octogenarians (227 134), there were 25 362 (26%) who had pathologic stage I lung cancer. There were 6370 (30%) patients who had sublobar resections (segmentectomy [n = 1192] and wedge resection [n = 5178]), whereas 14 594 (70%) patients had a lobectomy. There was significantly improved survival at 5 years with lobectomy compared with sublobar resection (48.5% vs 41.1%; P < .001). The cubic spline plot provided evidence that there was no age at which sublobar resection provided survival better than or equal to lobectomy (P < .001).

CONCLUSIONS

In octogenarians with pathologic stage I lung cancer, lobectomy provided better 5-year survival compared with sublobar resection regardless of the age at surgical procedure. Hence, all patients with stage I cancer should be considered for a lobectomy if they are medically able to tolerate such a procedure.

Lobe-Specific Analysis of Sublobar Lung Resection for NSCLC Patients with Tumors ≤ 2 cm

Simple Summary

With the increase of the use of sublobar resection, the optimal strategy for early-stage NSCLC patients is essential. Previous studies showed tumors in different lobes are associated with different prognoses after radiotherapy and immunotherapy, inspiring us that each lobes had a different prognosis. Thus, we investigated the best surgical procedure for sublobar resection in patients with NSCLC ≤ 2 cm based on a lobe-specific analysis using propensity score matching. The results of this study will make it easier for surgeons to screen out patients with NSCLC ≤ 2 cm for segmentectomy or wedge resection, although this must be validated in larger cohorts.

Abstract

(1) Background: Sublobar resection can be used as an alternative surgical strategy for early-stage non-small-cell lung cancer (NSCLC) patients. However, the choice between wedge resection and segmentectomy remains contentious. In this study, we investigated the optimal surgical procedure for sublobar resection in patients with NSCLC ≤ 2 cm with a lobe-specific analysis; (2) Methods: Data for patients with T1N0M0 with a diameter of ≤2 cm who had undergone sublobar resection were retrieved. Propensity score matching (PSM) was used to reduce the inherent bias, and the Kaplan–Meier method and log-rank tests were used to assess the differences in survival; (3) Results: A total of 1882 patients were identified after the PSM. Patients with NSCLC ≤ 2 cm who had undergone segmentectomy showed better survival than those who had undergone wedge resection. However, when NSCLC was ≤1 cm, there was no significant difference in OS between the two groups. This demonstrated an OS advantage of segmentectomy over wedge resection for patients with NSCLC tumors of 1–2 cm (p = 0.024). Further analysis indicated that this survival benefit was only observed in patients with right upper NSCLC of 1–2 cm, but not with NSCLC in the other four lobes; (4) Conclusions: Segmentectomy showed a greater survival benefit than wedge resection only in patients with NSCLC of 1–2 cm, particularly those with primary tumors in the right upper lobe. Therefore, we propose a lobe-specific sublobar resection strategy for early-stage NSCLC patients (tumors of 1–2 cm) who cannot tolerate lobectomy.

Comparison of outcomes following lobectomy, segmentectomy, and wedge resection based on pathological subtyping in patients with pN0 invasive lung adenocarcinoma ≤1 cm

PURPOSE

We sought to analyze the prognostic significance of lung adenocarcinoma classification for patients with pathological N0 (pN0) lung invasive adenocarcinomas ≤1 cm who underwent surgical resection and investigate the optimal surgical procedure according to lung adenocarcinoma classification.

METHODS

A total of 1409 consecutive patients with resected pN0 invasive lung adenocarcinoma ≤1 cm were retrospectively reviewed. Comprehensive histologic subtyping was determined according to IASLC/ATS/ERS lung adenocarcinoma classification. Recurrence-free survival (RFS) and overall survival (OS) were compared between patients receiving lobectomy, segmentectomy, and wedge resection.

RESULTS

RFS and OS favored lobectomy and segmentectomy compared with wedge resection in the entire cohort. Five-year RFS rates were 100%, 98.2%, 97.3%, 77.8%, and 82.8% (p < 0.001) for lepidic, acinar, papillary, micropapillary, and solid predominant subtypes, while 5-year OS rates were 100%, 98.4%, 98.1%, 88.9%, and 96.5% (p < 0.001), respectively. Multivariate analysis showed that adenocarcinoma predominant pathological subtype and CT appearance were independent prognostic factors for RFS, and surgical procedure was independent factor for both RFS and OS. Specifically, wedge resection showed worse survival compared with anatomical resection in patients with papillary, micropapillary, or solid predominant subtypes, whereas in patients with lepidic predominant and acinar predominant subtypes, wedge resection showed comparable RFS with anatomical resection.

CONCLUSIONS

Anatomical resection showed better survival for patients with pN0 invasive lung adenocarcinoma ≤1 cm. For patients with invasive adenocarcinoma ≤1 cm in whom anatomical resection is not feasible, wedge resection could provide similar oncological effect when tumor is lepidic predominant or acinar predominant.

The C-reactive protein to albumin ratio is a prognostic factor for stage I non-small cell lung cancer in elderly patients: JACS1303

PURPOSE

To establish the prognostic significance of C-reactive protein (CRP) and albumin in octogenarians with non-small cell lung cancer (NSCLC) based on the study of the Japanese Association for Chest Surgery (JACS 1303).

METHODS

A total of 618 octogenarians with pathological stage I NSCLC, who underwent pulmonary resection, were included in the analysis. We conducted multivariable Cox regression analysis to evaluate the CRP to albumin ratio (CAR) as a potential prognostic factor. Other clinicopathological factors were also evaluated.

RESULTS

The median age was 82 years. Operations included lobectomy (n = 388; 62.8%) segmentectomy (n = 95; 15%), and wedge resection (n = 135; 22%). Pathological stage IA was diagnosed in 380 (61.5%) patients. The 3-year (OS) and cancer-specific survival (CS) rates were 86.7% and 94.6%, respectively. OS was significantly higher for patients with low CAR (< 0.106) than for those with high CAR (≥ 0.106) (hazard ratio = 3.13, 95% confidence interval: 1.99-4.93, p < 0.0001). Univariate analysis identified sex, poor performance status, smoking status, comorbidity, solid tumor, histology, high Glasgow prognostic scale, and high CAR as significant prognostic factors. Multivariate analysis identified only the CAR as a significant prognostic factor for both OS and CS.

CONCLUSIONS

Our analysis of the nationwide data demonstrated that the CAR is a useful prognostic factor for elderly patients with stage I NSCLC.

Surgical Outcomes in Patients With Centrally Located Non-small Cell Lung Cancer

BACKGROUND/AIM

Identification of prognostic factors is helpful in selecting optimal treatment for centrally-located non-small cell lung cancer (NSCLC). This study aimed to detect prognostic factors in patients with centrally-located NSCLC.

PATIENTS AND METHODS

NSCLCs in the hilar area requiring pneumonectomy or sleeve lobectomy for complete removal are defined as centrally-located NSCLCs. We retrospectively investigated the clinical courses of 45 patients with such lesions.

RESULTS

Sleeve lobectomies were performed on 33 patients and pneumonectomies on 12. Three and five-year survival rates were 72% and 62%, respectively. Presence of comorbidities (p=0.013), severe symptoms (p=0.001), high white cell count (p=0.001), and pathological T3-4 stage (p=0.004) were identified as independent predictors of poor prognosis. Operative procedures did not correlate with outcomes (p=0.722).

CONCLUSION

Presence of comorbidities, severe symptoms, high white cell counts, and pathological T stage are independent predictors of poor prognosis. These data can contribute in selecting appropriate treatments for such lesions.