Follow-up and surveillance of the lung cancer patient following curative intent therapy: ACCP evidence-based clinical practice guideline (2nd edition)

Efficacy of contrast versus non-contrast CT surveillance among patients surviving two years without recurrence after surgery for stage I lung cancer

Contrast-enhanced chest CT (CECT) is more sensitive than non-contrast-enhanced chest CT (NCECT), but NCECT may have comparable efficacy in detecting new primary lung cancer among stage I NSCLC survivors after two years of surveillance. This study aimed to evaluate the efficacy of NCECT versus CECT for surveillance among stage I NSCLC patients surviving two years after curative resection without disease recurrence. We conducted a retrospective cohort study of patients with stage I NSCLC who underwent curative-intent lung resection between January 2009 and December 2017 using the Registry for Thoracic Cancer Surgery at the Samsung Medical Center, Seoul, Korea. Overall survival, recurrence-free survival, and cost effectiveness were compared between patients undergoing surveillance with CECT and NCECT. Among 3248 patients, 1002 (38.8%) patients underwent NCECT surveillance. During a median follow-up of 2.3 years (interquartile range, 1.5-3.9 years), a total of 208 deaths were observed. Although patients undergoing NCECT surveillance had 0.04 more deaths per 100 person-year compared with patients undergoing CECT surveillance (95% CI -0.36 to 0.44), this difference did not reach statistical significance (1.27 vs. 1.31 per 100 person-years; HR, 1.10; 95% CI 0.81-1.50). Regarding cost effectiveness, CECT group had a gain of 0.024 quality-adjusted life-year but $785 higher total cumulative cost per patient compared to NCECT. There was no difference in recurrence and mortality between NCECT and CECT for surveillance among stage I NSCLC patients who survived two years after surgery without disease recurrence. Further randomized clinical trials are required to confirm the findings.

Advancements in lung cancer: a comprehensive perspective on diagnosis, staging, therapy and follow-up from the SAKK Working Group on Imaging in Diagnosis and Therapy Monitoring

In 2015, around 4400 individuals received a diagnosis of lung cancer, and Switzerland recorded approximately 3200 deaths related to lung cancer. Advances in detection, such as lung cancer screening and improved treatments, have led to increased identification of early-stage lung cancer and higher chances of long-term survival. This progress has introduced new considerations in imaging, emphasising non-invasive diagnosis and characterisation techniques like radiomics. Treatment aspects, such as preoperative assessment and the implementation of immune response evaluation criteria in solid tumours (iRECIST), have also seen advancements. For those undergoing curative treatment for lung cancer, guidelines propose follow-up with computed tomography (CT) scans within a specific timeframe. However, discrepancies exist in published guidelines, and there is a lack of universally accepted recommendations for follow-up procedures. This white paper aims to provide a certain standard regarding the use of imaging on the diagnosis, staging, treatment and follow-up of patients with lung cancer.

Utility of auto fluorescence-guided biopsy in suspected lung cancer patients with bronchial mucosal lesions

BACKGROUND

Bronchoscopy is currently the most common technique for lung cancer diagnosis. Patients suspected of malignancy often undergo bronchoscopic examination, and biopsy is routinely used in patients with visible bronchial lesions. However, it is difficult to differentially diagnose lung cancer in patients with bronchial mucosal lesions. Thus, this study was conducted to investigate the utility of fluorescence-guided biopsy in suspected lung cancer patients with bronchial mucosal lesions.

METHODS

We conducted a retrospective study in a single screening center to assess the sensitivity and specificity of fluorescence-guided biopsy compared with white light bronchoscopy (WLB) in patients with bronchial mucosal lesions.

RESULTS

A total of 301 patients with bronchial mucosal lesions were enrolled in this study. The sensitivity for patients with fluorescence-guided biopsy was 60.3 % (95 % confidence interval [CI]: 53.1 %-67.1 %), which was higher than that of patients with WLB alone (45.2 %, 95 % CI: 38.2-52.4 %) (P = 0.0026). Additionally, compared with the WLB group, the fluorescence -guided biopsy group was found to have a significantly higher specificity (100 %, 95 % CI: 95.5-100 % versus 69.6 %, 95 % CI: 59.6-78.1 %), positive predictive value (100 %, 95 % CI: 96.1-100 % versus 74.3 %, 95 % CI: 65.5-81.7 %) and negative predictive value (56.3 %, 95 % CI: 48.8-63.6 % versus 39.4 %, 95 % CI: 32.3-47.0 %).

CONCLUSION

Fluorescence-guided biopsy can serve as an important adjunct to WLB for the differential diagnosis of lung cancer in patients with bronchial mucosal lesions.

Evaluation of surgical outcomes and prognostic factors of second primary lung cancer based on a systematic review and meta-analysis

BACKGROUND

Although surgery has been widely applied for SPLC therapy, there is still no uniform treatment approach. Whether SPLC and primary lung cancer have similar prognostic characteristics remains controversial. Herein, based on a systematic review and meta-analysis, we aimed to enucleate the influences of diverse surgical strategies and underlying prognostic factors on the prognosis of patients with both the first primary lung cancer and SPLC underwent surgical resection.

METHODS

A comprehensive and systematic literature search was implemented in three databases (MEDLINE, EMBASE, and Cochrane), and eligible studies were screened following inclusion and exclusion criteria. Meanwhile, we extracted the hazard ratios (HR) together with 95% confidence intervals (CI) for each prognostic factor, either directly or indirectly, from the enrolled literature.

RESULTS

Eleven studies (published between 2000 and 2022) were included in this study, including 1,131 SPLC patients. The overall survival (OS) exhibited no difference between patients with lobectomy and sublobar resection after SPLC (HR: 0.87, 95%CI: 0.62-1.21, P = 0.41). The patients after completion pneumonectomy had a poor prognosis (HR: 1.85, 95% CI: 1.34-2.55, P < 0.01). Poor prognostic factors after SPLC surgery included synchronous SPLC (HR: 3.38, 95%CI: 1.53-7.46, P < 0.01), tumor diameter > 2 cm (HR: 2.44, 95%CI: 1.73-3.44, P < 0.01), solid predominant in CT morphology (HR: 3.08, 95% CI: 1.14-8.33, P = 0.03), lymph node metastasis (HR: 2.79, 95%CI: 1.40-5.56), and smoking (HR: 2.37, 95%CI: 1.08-26.82, P < 0.01). Tumor disease-free interval (DFI), tumor histological type, and gender had no impact on the prognosis of patients received SPLC surgery.

CONCLUSIONS

Patients with SPLC, especially those with poor cardiopulmonary function reserve, should be prioritized for sublobar resection for treatment. These patients should also try to avoid completion pneumonectomy. Patients with synchronous SPLC, tumor diameter > 2 cm, solid predominant in CT morphology, lymph node metastasis, and smoking had a poor prognosis. Meanwhile, SPLC has similar prognostic characteristics with single primary lung cancer. However, the study has some limitations and more evidence is warranted to verify the findings.

Barriers to surveillance imaging adherence in early-staged lung cancer

Background

Frequency of post-treatment surveillance is highly variable following curative resection of non-small cell lung cancer (NSCLC). We sought to characterize surveillance practices after lobectomy for early-stage NSCLC and to identify the impact of various demographic factors on patterns of surveillance.

Methods

We included patients who underwent anatomic lobectomy for pathologic stage I NSCLC from 2007-2017. Demographic characteristics, post-operative imaging studies (internal and external), and travel distance were recorded. We defined the minimal standard of surveillance imaging studies (MSSIS) as ≥7 studies in the first 5 years (computed tomography/positron emission tomography). Patient sex, ethnicity, marital status, and distance traveled were evaluated as predictors of imaging receipt. Standard descriptive statistics, univariate, and multivariate analysis (MVR) were performed.

Results

A total of 1,288 patients were included. The mean age was 65.5±10.1 years, 589 (45.7%) were male, 1,081 (83.9%) were Caucasian, and 924 (71.7%) were married. Only 464 (36%) achieved MSSIS; being married [75.6% (351/464) vs. 68.8% (567/824), P=0.01] and having larger tumor size (2.63±0.04 vs. 2.49±0.05 cm, P=0.03) were both associated with MSSIS. Patients residing <100 miles from the hospital were more likely to have MSSIS, and more imaging at 24 months (4.1±2.2 vs. 3.7±2.0; P=0.006), 60 months (8.0±5.1 vs. 6.6±4.2, P=0.001) and overall (10±7.3 vs. 8.2±6.3; P=0.001). On MVR, tumor size and marital status were associated with MSSIS.

Conclusions

Two-thirds of patients at our institution did not undergo recommended surveillance imaging. Tumor size, being married, and living <100 miles from the medical center were associated with an increased number of imaging studies and greater adherence to guidelines.

Prognostic Nomogram and Therapeutic Option of Cancer-Specific Death in the Patients with Metachronous Second Primary Lung Cancer

With the increase of long-term primary lung cancer survivors, studies focused on metachronous second primary lung cancer (SPLC) have become very urgent. This study aimed to develop a prognostic nomogram and determine therapeutic options of cancer-specific death for patients with metachronous SPLC with and without the competing risk of other-specific death. Study population came from the SEER-18 database between 2006 and 2016. According to the clinical practice guideline of SPLC, the interval time of IPLC and metachronous SPLC was set to 4 years. We constructed nomograms with Lasso + Cox regression model and competing risk model to predict the prognosis and identify therapeutic options of metachronous SPLC patients with the assessment of model performance by the C-index, calibration plot, and decision curve analysis. In addition, two subgroup analyses stratified by histology and tumor size were used to better select therapeutic options for a certain population. 1300 patients with metachronous SPLC were incorporated in this study with 50.1% of the 5-year cumulative incidence in cancer-specific death. Compared with Lasso + Cox regression analysis, competing risk analysis harbored a higher C-index (0.811 vs. 0.76) and better net benefit in predicting cancer-specific death of metachronous SPLC. Two statistical analyses suggested that surgery alone was a preferentially therapeutic option of metachronous SPLC, whereas the effect of surgery + radiation in treating metachronous SPLC was similar to radiation alone. Subgroup analyses indicated that patients with metachronous SPLC were considered receiving different therapeutic options in different histology and tumor size but preferred to receive surgical treatment as the first choice. For primary lung cancer survivors, aggressive surgical treatment was the first-line selection of metachronous SPLC, followed by radiation alone, surgery + radiation, and no surgery + radiation.

Routine follow-up after surgical treatment of lung cancer: is chest CT useful?

Objective:

To report the experience of a routine follow-up program based on medical visits and chest CT.

Methods:

This was a retrospective study involving patients followed after complete surgical resection of non-small cell lung cancer between April of 2007 and December of 2015. The follow-up program consisted of clinical examination and chest CT. Each follow-up visit was classified as a routine or non-routine consultation, and patients were considered symptomatic or asymptomatic. The outcomes of the follow-up program were no evidence of cancer, recurrence, or second primary lung cancer.

Results:

The sample comprised 148 patients. The median time of follow-up was 40.1 months, and 74.3% of the patients underwent fewer chest CTs than those recommended in our follow-up program. Recurrence and second primary lung cancer were found in 17.6% and 11.5% of the patients, respectively. Recurrence was diagnosed in a routine medical consultation in 69.2% of the cases, 57.7% of the patients being asymptomatic. Second primary lung cancer was diagnosed in a routine medical appointment in 94.1% of the cases, 88.2% of the patients being asymptomatic. Of the 53 patients who presented with abnormalities on chest CT, 41 (77.3%) were diagnosed with cancer.

Conclusion:

Most of the cases of recurrence, especially those of second primary lung cancer, were confirmed by chest CT in asymptomatic patients, indicating the importance of a strict follow-up program that includes chest CTs after surgical resection of lung cancer.

Second primary pleomorphic carcinoma arising from the pneumonectomy cavity of non-small cell lung cancer: A case report

Here, we report a thirteen years’ survivor of initial primary lung cancer, who successfully diagnosed with second primary lung cancer(SPLC). It was arising from the pneumonectomy cavity of a non-small cell lung cancer(NSCLC). Few cases of SPLC associated with the post-pneumonectomy cavity have been reported in the literature. The histologic results of SPLC was metastatic pleomorphic carcinoma. It is a rare type of lung cancer; which incidence has been reported to range from 0.1% to 0.4% among all lung cancers. Based on regular follow-up with chest computed tomography(CT) and an understanding of post-pneumonectomy changes, the second primary pleomorphic carcinoma was correctly diagnosed and appropriately treated.

Cost-Effectiveness of Surveillance Scanning Strategies after Curative Treatment of Non-Small-Cell Lung Cancer

BACKGROUND

After curative treatment of primary non-small-cell lung cancer (NSCLC), patients undergo intensive surveillance with the aim to detect recurrences from the primary tumor or metachronous second primary lung cancer as early as possible and improve overall survival. However, the benefit of surveillance is debated. Available evidence is of low quality and conflicting. Microsimulation modeling facilitates the exploration of the impact of different surveillance strategies and provides insight into the cost-effectiveness of surveillance.

METHODS

A microsimulation model was used to simulate a range of computed tomography (CT)-based surveillance schedules, differing in the frequency and duration of CT surveillance. The impact on survival, quality-adjusted life-years, costs, and cost-effectiveness of each schedule was assessed.

RESULTS

Ten of 108 strategies formed the cost-effectiveness frontier; that is, these were the strategies with the optimal cost-health benefit balance. Per person, the discounted QALYs of these strategies varied between 5.72 and 5.81 y, and discounted costs varied between €9892 and €19,259. Below a willingness-to-pay threshold of €50,000/QALY, no scanning is the preferred option. For a willingness-to-pay threshold of €80,000/QALY, surveillance scanning every 2 y starting 1 y after curative treatment becomes the best option, with €11,860 discounted costs and 5.76 discounted QALYs per person. The European Society for Medical Oncology guideline strategy was more expensive and less effective than several other strategies.

CONCLUSION

Model simulations suggest that limited CT surveillance scanning after the treatment of primary NSCLC is cost-effective, but the incremental health-benefit remains marginal. However, model simulations do suggest that the guideline strategy is not cost-effective.

Benefits and Limitations of a Multidisciplinary Approach in Cancer Patient Management

Over the years, a growing body of literature has confirmed as beneficial the implementation of a multidisciplinary approach in the so-often-intricate scenario of cancer patients' management. Together with the consolidation of tumor-board experience in clinical practice, certain aspects have emerged as controversial and a source of current debate. In this systematic literature review, we focused our attention on the impact of multidisciplinary tumor boards, assessing benefits and limitations as a result of the dissemination of such approaches. On the bright side, adherence to clinical guidelines, treatment outcomes, and overall improvement in decision-making processes have been recognized as advantages. On the other side, our analysis highlights a few limitations that should be taken into account to optimize cancer patients' management. Of note, some issues, such as costs, legal responsibility, geographic barriers, and treatment delays, have yet to be resolved. In order partly to address this matter, software platforms and novel methods of computational analysis may provide the needed support. Therefore, the aim of our analysis was to describe the multidisciplinary approach in cancer care in terms of adherence to clinical guidelines, treatment outcomes, and overall improvement in decision-making processes through a systematic review of the literature.

Impact of Surveillance After Lobectomy for Lung Cancer on Disease Detection and Survival

INTRODUCTION

Existing guidelines for surveillance after non-small-cell lung cancer (NSCLC) treatment are inconsistent and have relatively sparse supporting literature. This study characterizes detection rates of metachronous and recurrent disease during surveillance with computed tomography scans after definitive treatment of early stage NSCLC.

MATERIALS AND METHODS

The incidence of metachronous and recurrent disease in patients who previously underwent complete resection via lobectomy for stage IA NSCLC at a single center from 1996 to 2010 were evaluated. A subgroup analysis was used to compare survival of patients whose initial surveillance scan was 6 ± 3 months (early) versus 12 ± 3 months (late) after lobectomy.

RESULTS

Of 294 eligible patients, 49 (17%) developed recurrent disease (14 local only, 35 distant), and 45 (15%) developed new NSCLC. Recurrent disease was found at a mean of 22 ± 19 months, and new primaries were found at a mean of 52 ± 31 months after lobectomy (P < .01). Five-year survival after diagnosis of recurrent disease was significantly lower than after diagnosis of second primaries (2.3% vs. 57.5%; P < .001). In the subgroup analysis of 187 patients, both disease detection on the initial scan (2% [2/94] vs. 4% [4/93]; P = .44) and 5-year survival (early, 80.8% vs. late, 86.7%; P = .61) were not significantly different between the early (n = 94) and the late (n = 93) groups.

CONCLUSION

Surveillance after lobectomy for stage IA NSCLC is useful for identifying both new primary as well as recurrent disease, but waiting to start surveillance until 12 ± 3 months after surgery is unlikely to miss clinically important findings.

Clinicopathological variables influencing overall survival, recurrence and post-recurrence survival in resected stage I non-small-cell lung cancer

BACKGROUND

To investigate clinicopathological variables influencing overall survival, overall recurrence, and post-recurrence survival (PRS) in patients who experienced curative-intent surgical resection of stage I non-small-cell lung cancer (NSCLC).

METHODS

We investigated a series of 1387 patients with stage I NSCLC who underwent surgical resection from 2008 to 2015. The effect clinicopathological factors on death, recurrence, and PRS were evaluated by Kaplan-Meier estimates and cox regression analysis.

RESULTS

Among the 1387 stage I patients, 301 (21.7%) experienced recurrence. The 5-year cumulative incidence of recurrence (CIR) for all patients was 20.2% and median PRS was 25.5 months. The older age (P = 0.036), p-stage IB (P = 0.001), sublobar resection(P<0.001), histology subtype (P<0.001), and lymphovascular invasion (LVI) (P = 0.042) were significantly associated with worse overall survival. Among 301 recurrent patients, univariable analysis indicated that p-stage IB (versus IA) (P<0.001), LVI (P<0.001) and visceral pleural invasion (VPI) (P<0.001) were remarkably correlated with the higher incidence of recurrence. Taking the effect of clinicopathological variables on PRS into consideration, smoking history (P = 0.043), non-adenocarcinoma (P = 0.013), high architectural grade of LUAD (P = 0.019), EGFR wild status (P = 0.002), bone metastasis (P =0.040) and brain metastasis (P = 0.042) were substantially related with poorer PRS. Multivariate analysis demonstrated that high architectural grade of LUAD (P = 0.008), brain metastasis (P = 0.010) and bone metastasis (P = 0.043) were independently associated with PRS.

CONCLUSION

In patients with resected stage I NSCLC, the older age, p-stage IB (versus IA), sublobar resection, histology subtype, and LVI were significantly associated with worse overall survival. P-stage IB (versus IA), LVI, and VPI were significantly correlated with the higher incidence of recurrence. High architectural grade of LUAD, brain metastasis and bone metastasis were independent risk factors with PRS.

Solid Tumor Size of 2 cm Divides Outcomes of Patients With Mixed Ground Glass Opacity Lung Tumors

BACKGROUND

The prognosis of patients with cT1N0 lung adenocarcinoma is better when tumors include mixed ground glass opacity (GGO), compared with pure solid tumors. However, whether the prognosis of patients with mixed GGO tumors is favorable regardless of the solid component size remains unknown. Therefore, we aimed to determine the prognostic role of the solid component size in mixed GGO.

METHODS

We retrospectively analyzed the clinicopathological findings and prognoses of 856 patients with mixed GGO tumors based on solid component size during a median follow-up of 45 months, among 1215 patients with cT1N0 lung adenocarcinoma according to the TNM Classification of Malignant Tumors, Eighth Edition, who underwent R0 resection at 3 institutions between 2010 and 2015.

RESULTS

Four-year recurrence-free survival rates were significantly worse for patients with mixed GGO cT1c tumors (solid component size: 2-3 cm; 81.5%; 95% confidence interval [CI], 72.8%-87.7%) than for those with cT1mi+1a tumors (0-1 cm; 96.8%; 95% CI, 94.2%-98.2%) and cT1b (1-2 cm; 95.3%; 95% CI, 92.1%-97.2%) (both P < .001), although that for cT1b tumors was comparably favorable to those of T1mi+1a tumors. Multivariable Cox regression analysis of recurrence-free survival revealed that a solid component size of 2 cm to 3 cm (cT1c) vs less than or equal to 2 cm (cT1mi+1a+1b) was an independent prognostic factor (hazard ratio, 4.16; 95% CI, 2.24-7.72; P < .001).

CONCLUSIONS

The prognostic impact of a solid component size less than or equal to 2 cm and greater than 2 cm significantly differs after complete resection of GGO-mixed T1N0 lung adenocarcinoma. The prognosis of patients with solid components less than or equal to 2 cm is favorable, whereas the behavior of those solid components greater than 2 cm is more aggressive.

Deep Learning Predicts Lung Cancer Treatment Response from Serial Medical Imaging

PURPOSE

Tumors are continuously evolving biological systems, and medical imaging is uniquely positioned to monitor changes throughout treatment. Although qualitatively tracking lesions over space and time may be trivial, the development of clinically relevant, automated radiomics methods that incorporate serial imaging data is far more challenging. In this study, we evaluated deep learning networks for predicting clinical outcomes through analyzing time series CT images of patients with locally advanced non-small cell lung cancer (NSCLC).Experimental Design: Dataset A consists of 179 patients with stage III NSCLC treated with definitive chemoradiation, with pretreatment and posttreatment CT images at 1, 3, and 6 months follow-up (581 scans). Models were developed using transfer learning of convolutional neural networks (CNN) with recurrent neural networks (RNN), using single seed-point tumor localization. Pathologic response validation was performed on dataset B, comprising 89 patients with NSCLC treated with chemoradiation and surgery (178 scans).

RESULTS

Deep learning models using time series scans were significantly predictive of survival and cancer-specific outcomes (progression, distant metastases, and local-regional recurrence). Model performance was enhanced with each additional follow-up scan into the CNN model (e.g., 2-year overall survival: AUC = 0.74, P < 0.05). The models stratified patients into low and high mortality risk groups, which were significantly associated with overall survival [HR = 6.16; 95% confidence interval (CI), 2.17-17.44; P < 0.001]. The model also significantly predicted pathologic response in dataset B (P = 0.016).

CONCLUSIONS

We demonstrate that deep learning can integrate imaging scans at multiple timepoints to improve clinical outcome predictions. AI-based noninvasive radiomics biomarkers can have a significant impact in the clinic given their low cost and minimal requirements for human input.

Imaging Surveillance for Surgically Resected Stage I Non-Small Cell Lung Cancer: Is More Always Better?

Objective

Routine surveillance imaging for patients with resected non-small cell lung cancer is standard for the detection of disease recurrence and new primary lung cancers. However, surveillance intensity varies widely in practice, and its impact on long-term outcomes is poorly understood. We hypothesized that surveillance intensity was not associated with 5-year overall survival in patients with resected stage I non-small cell lung cancer. Additionally, we examined patterns of recurrence and new primary lung cancer development.

Methods

Cancer registrars at Commission on Cancer accredited institutions re-abstracted records to augment National Cancer Database patient data with information on comorbidities, imaging surveillance including intent and result of imaging, and recurrence (2007-2012). Pathologic stage I non-small cell lung cancer patients undergoing computed-tomography surveillance were placed into three imaging surveillance groups based on clinical practice guidelines: high intensity (3 month), moderate intensity (6 month), and low intensity (annual). Kaplan Meier analysis and Cox regression were used to compare overall survival among the three surveillance groups.

Results

2442 patients were identified, with 805 (33%), 1216 (50%), and 421 (17%) patients in the high, moderate, and low surveillance intensity groups, respectively. Five-year overall survival was similar between intensity groups (p=0.547). Surveillance on asymptomatic patients detected 210 (63%) cases of locoregional recurrences and 128 (72%) cases of new primary lung cancer.

Conclusions

In a unique national dataset of long-term outcomes for stage I non-small cell lung cancer, surveillance intensity was not associated with 5-year overall survival.

Survival after repeated surgery for lung cancer with idiopathic pulmonary fibrosis: a retrospective study

BACKGROUND

Patients with idiopathic pulmonary fibrosis (IPF) have a high risk of developing lung cancer, but few studies have investigated the long-term outcomes of repeated surgery in such patients. The purpose of this study was to evaluate the surgical outcomes of repeated lung cancer surgery in patients with IPF.

METHODS

From January 2001 to December 2015, 108 lung cancer patients with IPF underwent pulmonary resection at two institutions; 13 of these patients underwent repeated surgery for lung cancer, and their data were reviewed.

RESULTS

The initial procedures of the 13 patients were lobectomy in 8, segmentectomy in 2, and wedge resection in 3. The subsequent procedures were wedge resection in 10 and segmentectomy in 3. The clinical stage of the second tumor was stage IA in 12 and stage IB in 1. Postoperatively, 3 patients (23.1%) developed acute exacerbation (AE) of IPF and died. The rate of decrease in percent vital capacity was significantly higher in patients with AE than in those without AE (p = 0.011). The 3-year overall survival rate was 34.6%. The causes of death were cancer-related in 7, AE of IPF in 3, and metachronous lung cancer in 1.

CONCLUSIONS

Despite limited resection, a high incidence of AE was identified. The early and long-term outcomes of repeated surgery in lung cancer patients with IPF were poor because of the high risk of AE of IPF and lung cancer recurrence. Long-term intensive surveillance will be required to determine whether surgical intervention is justified in patients with multiple primary lung cancers and IPF.

Neoadjuvant Therapy in Non-Small Cell Lung Cancer

Locally advanced (stage IIIA) non-small cell lung cancer (NSCLC) is confined to the chest, but requires more than surgery to maximize cure. Therapy given preoperatively is termed neoadjuvant, whereas postoperative therapy is termed adjuvant. Trimodality therapy (chemotherapy, radiation, and surgery) has become the standard treatment regimen for resectable, locally advanced NSCLC. During the past 2 decades, several prospective, randomized, and nonrandomized studies have explored various regimens for preoperative treatment of NSCLC. The evaluation of potential candidates with NSCLC for neoadjuvant therapy as well as the currently available therapeutic regimens are reviewed.

Cost Analysis of PET/CT Versus CT as Surveillance for Stage III Non-Small-Cell Lung Cancer After Definitive Radiation Therapy

INTRODUCTION

A previous study showed that use of positron emission tomography (PET)/computed tomography (CT) for surveillance after treatment of non-small-cell lung cancer (NSCLC) does not yield a detection or survival benefit over the use of chest CT. However, PET/CT remains a common method of follow-up imaging. Here we estimated and compared the costs of PET/CT versus CT for surveillance of patients with stage III NSCLC and identified patient and provider demographic characteristics associated with preference for use of PET/CT.

PATIENTS AND METHODS

We reviewed 178 patients with stage III NSCLC who had received ≥ 1 PET/CT scan within 6 months of completing radiotherapy (n = 89) or had received CT after radiotherapy (n = 89) from 2000 to 2011. Costs were measured according to Medicare payments converted from institutional billing records. Total and imaging costs were analyzed at 6, 12, 18, and 24 months after the end of treatment. Patient and provider demographic characteristics were also evaluated for potential associations with PET/CT use.

RESULTS

Total costs in the PET/CT group were higher during the first 18 months after treatment (P = .002 at 6 months, P = .019 at 12 months, and P = .018 at 18 months) but was marginally significant (P = .05) at 24 months. In univariate analysis of demographic variables, patients who lived in a state different from the treatment center might have been more likely to receive PET/CT (odds ratio [OR], 1.76; P = .051). In multivariate analysis, patients treated in 2007 to 2010 (OR, 29.9; P < .001) or 2003 to 2006 (OR, 11.6; P = .002) were more likely to receive PET/CT than patients treated in 1999 to 2002. In addition, radiation oncologists with > 10 years of experience were more likely to use PET/CT than those with less experience, although this result might be confounded by the small number of providers.

CONCLUSION

Use of PET/CT was associated with higher costs for 18 months after treatment, but the difference was at the borderline of statistical significance at 24 months.

Vinorelbine-Based Chemo-Radiotherapy in Non-Small Cell Lung Cancer

Aims and background

Concomitant radio-chemotherapy improves survival of patients with locally advanced non-small cell lung cancer, with a better local-regional control.

Methods and study design

We report our experience with vinorelbine-based chemotherapy in neoadjuvant and radical settings in 43 patients. Regimens consisted of cisplatin plus vinorelbine in 74.4% patients and carboplatin plus vinorelbine in 14.0%; 11.6% underwent mono-chemotherapy with oral vinorelbine. We estimated the crude probability of death or local recurrence by the Kaplan-Meier method. Cox regression models were used to identify the main significant predictors of death or local recurrence.

Results

A significant effect of the response to treatment was shown on both local disease free-survival (P = 0.004) and overall survival (P <0.0001). Patients with progressive disease after primary treatment had a significantly higher risk of further relapse at both univariate (P = 0.046) and multivariate regression analysis (P = 0.014) than patients with a complete response. They also showed a significantly higher risk of death at both univariate (P = 0.0005) and multivariate regression analysis (P <0.0001) than patients with a complete response. The most common toxicity was hematologic and gastroenteric. We recorded grade III/IV leukopenia in 11%, anemia in 6%, and esophagitis in 14% of the patients.

Conclusions

Our experience showed that vinorelbine-based chemotherapy is an effective and safe regimen, in association with a platinum compound and thoracic radiotherapy.

Isolated Chest Wall Implantation of Non-Small Cell Lung Cancer after Fine-Needle Aspiration: A Case Report and Review of the Literature

Percutaneous fine-needle aspiration biopsy (FNAB) is a well-established and useful procedure in the diagnosis of lung squamous cell carcinoma (LSCC). Tumor seeding has been shown to be a potential risk. We report the case and management of a 78-year-old patient affected by LSCC who developed a chest wall metastasis in a straight line from the primary lesion along the FNAB needle track. Although tumor seeding after FNAB is a rare but possible complication, we suggest that careful examination for implantation (with periodical CT scans) should be performed for at least three years after FNAB.

Pattern of Imaging after Lung Cancer Resection. 1992-2005

RATIONALE

Imaging intensity after lung cancer resection performed with curative intent is unknown.

OBJECTIVES

To describe the pattern and trends in the use of computed tomography (CT) and positron emission tomography (PET) scans in patients after resection of early-stage lung cancer.

METHODS

Retrospective analysis of the linked Surveillance, Epidemiology and End Results (SEER)-Medicare database. Subjects included 8,621 Medicare beneficiaries (age, ≥66 yr) who underwent lung cancer resection with curative intent between 1992 and 2005. A surveillance CT or PET examination was defined as CT or PET imaging performed in an outpatient setting on patients who did not undergo chest radiography in the preceding 30 days.

MEASUREMENTS AND MAIN RESULTS

Overall, imaging use was higher within the first 2 years versus Years 3-5 after surgical resection. Use of surveillance CT scans increased sharply from 13.7 to 57.3% of those diagnosed in 1996-1997 and 2004-2005, respectively. PET scan use increased threefold, from 6.2% in 2000-2001 to 19.6% in 2004-2005. In multivariable analyses, we observed a 32% increase in the odds of undergoing surveillance CT or PET imaging for every year of diagnosis between 1998 and 2005. There was no substantial decline in the odds of having a surveillance CT or PET scan during each successive follow-up period, suggesting no change in the intensity of surveillance over the first 5 years after surgical resection. The proportion of surveillance CT imaging performed at freestanding imaging centers increased from 18.0% in 1998-1999 to 30.6% in 2004-2005.

CONCLUSIONS

The use of CT and PET imaging for surveillance after curative-intent surgical resection of early-stage lung cancer increased sharply in the United States between 1997-1998 and 2005. In the absence of evidence demonstrating favorable outcomes, this practice was likely driven by prevailing expert opinion embedded in clinical practice guidelines made available during that time. Research is clearly needed to determine the role and optimal approach to surveillance thoracic imaging after surgical resection of lung cancer.

Podoplanin expression in cancer-associated fibroblasts predicts unfavourable prognosis in patients with pathological stage IA lung adenocarcinoma

AIMS

Podoplanin expression in cancer-associated fibroblasts (CAFs) has been proposed as an unfavourable indicator in squamous cell carcinoma of the lung, but little is known about its clinical significance in early-stage lung adenocarcinoma. We evaluated the prognostic impact of podoplanin expression in patients with pathological stage (p-stage) IA lung adenocarcinoma as categorised by the 8th edition of the tumour-node-metastasis classification for lung cancer.

METHODS AND RESULTS

Immunohistochemical analyses using anti-podoplanin antibody were performed on resected specimens from 158 patients with p-stage IA lung adenocarcinoma. When more than 10% of cancer cells or CAFs showed immunoreactivity with podoplanin, the specimens were classified as podoplanin-positive. Podoplanin-positive status in cancer cells (n = 8) was not correlated with clinicopathological factors or with patient prognosis. Podoplanin-positive status in CAFs (n = 41) was correlated significantly with poorer tumour differentiation (P < 0.001), the presence of lymphatic invasion (P < 0.001) and high-grade (solid and/or micropapillary) components constituting ≥1% of the entire tumour (P < 0.001). The log-rank test showed that podoplanin-positive status in CAFs was associated significantly with shorter disease-free survival (DFS) (P < 0.001) and disease-specific survival (P = 0.015). In Cox's multivariate analysis, podoplanin-positive status in CAFs had the most significant effect on shorter DFS [hazard ratio (HR) = 4.411, P = 0.004], followed by the presence of high-grade components (HR = 3.581, P = 0.013).

CONCLUSIONS

Podoplanin expression in CAFs could be an independent predictor of increased risk of recurrence in patients with p-stage IA lung adenocarcinoma.

[Clinical and Prognosic Anylasis of 30 Cases with Double Primary Lung Cancer]

背景与目的

多原发肺癌（multiple primary lung cancer, MPLC）是一种临床中较为少见的肺癌类型，双原发肺癌（double primary lung cancer, DPLC）是其中最常见的一种，近年来由于诊疗手段的进步检出率逐渐升高。本研究总结分析了30例DPLC患者的临床资料，以期为DPLC的诊疗提供理论依据。

方法

回顾郑州大学附属肿瘤医院2010年1月-2015年12月收治的30例DPLC患者的临床资料，对临床特征及预后相关因素进行分析。

结果

30例中，同时性双原发癌（synchronous DPLC, sDPLC）占3例（3/30, 10%），异时性双原发癌（metachronous DPLC, mDPLC）占27例（27/30, 90.0%）。病灶好发于右肺上叶（20/60, 33.3%），病理类型以腺癌（25/60, 41.7%）为主，病理类型相同者（17/30, 56.7%）多于不同者（13/30, 43.3%），病理类型相同者以腺-腺（10/16, 62.5%）最常见。生存分析显示淋巴结转移（HR=4.349, 95%CI: 1.435-13.178, P=0.009）和重度吸烟史（HR=2.996, 95%CI: 1.089-8.240, P=0.034）是DPLC的不良预后因素。

结论

DPLC好发于右肺上叶，病理类型以腺癌为主，早期诊断、积极的治疗和严格的戒烟策略有望改善其预后。

Surveillance imaging following definitive radiotherapy for non-small cell lung cancer: What is the clinical impact?

Lung cancer is the leading cause of cancer death worldwide. Recurrence rates at all stages are high, but evidence-based post-treatment surveillance imaging strategies to detect recurrence are poorly defined, and salvage options are frequently limited. A number of national and international oncology guidelines address post-treatment imaging, but are largely based on low-level, retrospective evidence because of a paucity of high-quality data, particularly in regard to cost-effectiveness and quality-of-life endpoints. Given the lack of randomized data addressing appropriate surveillance imaging modality and interval following definitive treatment of lung cancer, there remains an unmet clinical need. Meaningful surveillance endpoints should include the financial impact, patient quality-of-life outcomes, and access-to-care issues associated with intensive follow-up to ensure that guidelines reflect quality and sustainability. A need for prospective randomized data on the subject of imaging surveillance after definitive local therapy remains an unmet need, and an opportunity for collaboration and further research.

Patterns of metastatic progression after definitive radiation therapy for early-stage and locally advanced non-small cell lung cancer

Current preclinical models of metastatic disease (particularly oligometastases) suggest that metastases appear in a hierarchical order. We attempted to identify systematic patterns of metastasis in non-small cell lung cancer (NSCLC) after radiation therapy (XRT). We analyzed 1074 patients treated from 12/21/1998 through 8/20/2012 with ≥60 Gy definitive radiation for initially non-metastatic NSCLC. Location and time of metastases were recorded. Regional nodal failure was noted, as was subsequent distal failure. For further analysis, we considered only the five most common sites of metastasis (bone, brain, liver, adrenal, and lung). Metastatic progression over time was defined and patterns elucidated with Chi square tests. Histologic findings were analyzed with Wilcoxon rank sum tests. A significant multistep linear progression was not apparent. Having a first metastasis in lung or bone was associated with respective 16% (median 2.4 months) and 15% likelihoods (median 7.9 months) of secondary brain metastasis. Initial metastasis in the brain led to metastasis in another organ 29.3% of the time, most often in the lung, bone, and liver (medians 3.6, 7.9, and 3.1 months). Adenocarcinoma was more likely than squamous to metastasize to the brain (18 vs. 9%) and any of the five major sites (41 vs. 27%). We did not appreciate dominant patterns suggesting a multi-step hierarchical order of metastasis. Rather, our findings suggest that certain subgroups may develop different patterns of spread depending on a variety of factors.

Clinical Impact of Frequent Surveillance Imaging in the First Year Following Chemoradiation for Locally Advanced Non-small-cell Lung Cancer

OBJECTIVE

Uncertainty exists regarding the optimal surveillance imaging schedule following definitive chemoradiation (CRT) for locally advanced non-small-cell lung cancer (LA-NSCLC) with regards to both frequency and modality. We sought to document the clinical impact of frequent (at least every 4 months) surveillance imaging.

MATERIALS AND METHODS

The records of all patients treated with CRT for stage IIIA/IIIB NSCLC between August 1999 and April 2014 were reviewed. Patients were included if they underwent frequent (at least every 4 months) chest computed tomography or positron emission tomography for routine surveillance following CRT for at least 1 year or until progression or death. Radiographic findings and clinical interventions within the first year were identified.

RESULTS

We identified 145 patients with LA-NSCLC treated with CRT, 63 with eligible imaging. Median age was 63.6 years (range, 41.0-86.9 years). Asymptomatic recurrence was radiographically detected in 38 (60.3%). Twenty-one (33.3%) initiated systemic therapy. Two (3.2%) underwent definitive-intent treatment for isolated disease, including lobectomy for a histologically distinct primary NSCLC and stereotactic radiotherapy for an isolated recurrence, both of whom subsequently progressed. Eleven patients (17.5%) received no further therapy. Five patients (7.9%) underwent additional diagnostic procedures for false-positive findings.

CONCLUSIONS

Frequent surveillance within the first year following CRT for LA-NSCLC lung cancer detects asymptomatic recurrence in a high proportion of patients. However, definitive-intent interventions were infrequent. The predominant benefit of frequent surveillance appears to be expedient initiation of palliative systemic therapy. Evidence-based algorithms for surveillance are needed, and should account for expected patient tolerance of and willingness to undergo additional cancer-directed therapies.

Influence of Surveillance PET/CT on Detection of Early Recurrence After Definitive Radiation in Stage III Non-small-cell Lung Cancer

BACKGROUND

There are few data to support the use of varying imaging modalities in evaluating recurrence in non-small-cell lung cancer (NSCLC). We compared the efficacy of surveillance positron emission tomography (PET)/computed tomography (CT) versus CT scans of the chest in detecting recurrences after definitive radiation for NSCLC.

MATERIALS AND METHODS

We retrospectively analyzed 200 patients treated between 2000 and 2011 who met the inclusion criteria of stage III NSCLC, completion of definitive radiation treatment, and absence of recurrence within the initial 6 months. These patients were then grouped on the basis of the use of PET/CT imaging during postradiation surveillance. Patients who received ≥ 1 PET/CT scans within 6 months of the end of radiation treatment were placed in the PET group whereas all others were placed in the CT group. We compared survival times from the end of treatment to the date of death or last follow-up using log rank tests. Multivariate analysis was conducted to identify factors associated with decreased survival.

RESULTS

In the entire cohort, median event-free survival (EFS) was 26.7 months, and median overall survival (OS) was 41.2 months. The CT group had a median EFS of 21.4 months versus 29.4 months for the PET group (P = .59). There was no difference in OS between the CT and PET groups (median OS of 41.2 and 41.3 months, respectively; P = .59). There was also no difference in local recurrence-free survival or distant metastases-free survival between the CT-only and PET/CT groups (P = .92 and P = .30, respectively). Similarly, in multivariate analysis, stratification into the PET group was not associated with improved EFS (hazard ratio [HR], 0.90; 95% confidence interval [CI], 0.61-1.34; P = .60) or OS (HR, 1.2; 95% CI, 0.83-1.7; P = .34).

CONCLUSIONS

In stage III NSCLC patients treated with definitive radiation and without early recurrence, PET/CT scan surveillance did not result in decreased time to detection of locoregional or distant recurrence or improved survival.

Surveillance Practice Patterns after Curative Intent Therapy for Stage I Non-Small-Cell Lung Cancer in the Medicare Population

OBJECTIVES

Recurrence after treatment for non-small cell lung cancer (NSCLC) is common, and routine imaging surveillance is recommended by evidence-based guidelines. Little is known about surveillance patterns after curative intent therapy for early stage NSCLC. We sought to understand recent practice patterns for surveillance of stage I NSCLC in the first two years after curative intent therapy in the Medicare population.

MATERIALS AND METHODS

Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database we selected patients diagnosed with stage I NSCLC between 1998 and 2008. We studied adherence to surveillance guidelines based on specialty society recommendations for chest radiography and computed tomography (CT) scanning. We also tracked the use of Positron Emission Tomography (PET) scans, which are not recommended for surveillance. We calculated the percent of patients who received guideline-adherent surveillance imaging and used logistic regression to determine associations between patient and provider factors and guideline adherence.

RESULTS

Overall, 61.4% of patients received guideline-adherent surveillance during the initial 2 years after treatment. Use of CT scans in the first year after treatment increased from 47.4% in 1998-78.5% in 2008, and PET use increased from 5.8% to 28.9%. Adherence with surveillance imaging was associated with younger age, higher income, more comorbidities, access to primary care, and receipt of SBRT as the primary treatment.

CONCLUSIONS

Adherence to specialty society guidelines for surveillance after treatment for stage I NSCLC was poor in this population of Medicare beneficiaries, with less than two-thirds of patients receiving recommended imaging, and almost 30% receiving non-recommended PET scans.

Prognosis and predictors of site of first metastasis after definitive radiation therapy for non-small cell lung cancer

Background and purpose Evidence suggests that distinct biologic phenomenon produce different patterns of distant metastatic (DM) failures. We attempted to identify prognostically poor sites of first DM and to define factors predictive of their development. Methods and materials A total of 1074 patients treated with ≥60 Gy definitive radiation for initially non-metastatic non-small cell lung cancer (NSCLC) were analyzed. Uni- and multivariate Cox regression was utilized to associate clinical factors with DM site, and metastatic site with overall survival (OS). To account for competing events, multivariate Fine and Gray regression was utilized to identify treatment and disease factors predictive of site-specific metastases. Results Sites of first DM associated with worse survival were liver (median OS: 5 months after DM) and bone (median OS: 6.7 months after DM). Multivariate regression identified non-squamous histology to be associated with first DM within the liver (HR = 2.04, 95% CI 1.16-3.60, p = 0.01), while delay between diagnosis and RT (third vs. first tertile: HR = 2.3, 95% CI 1.26-4.21, p = 0.007) in addition to advanced stage (stage III vs. II/I: HR = 2.37, 95% CI 1.11-5.06, p = 0.03) were associated with first DM within bone. Conclusions Liver and bone as site of first DM is associated with worse prognosis and are predicted by different disease and treatment factors.

Detection of Recurrence Patterns After Wedge Resection for Early Stage Lung Cancer: Rationale for Radiologic Follow-Up

BACKGROUND

Wedge resection for selected patients with early stage non-small cell lung cancer is considered to be a valid treatment option. The aim of this study was to evaluate the recurrence patterns after wedge resection, to analyze the survival of patients under routine follow-up, and to recommend a follow-up regimen.

METHODS

A retrospective analysis was done of 446 consecutive patients between May 2000 and December 2012 who underwent a wedge resection for clinical stage I non-small cell lung cancer. All patients were followed up with a computed tomography scan with or without contrast. The recurrence was recorded as local (involving the same lobe of wedge resection), regional (involving mediastinal or hilar lymph nodes or a different lobe), or distant (including distant metastasis and pleural disease).

RESULTS

Median follow-up for survivors (n = 283) was 44.6 months. In all, 163 patients died; median overall survival was 82.6 months. Thirty-six patients were diagnosed with new primary non-small cell lung cancer, and 152 with recurrence (79 local, 45 regional, and 28 distant). There was no difference in the incidence of recurrence detection detected by computed tomography scans with versus without contrast (p = 0.18). The cumulative incidence of local recurrences at 1, 2, and 3 years was higher than the cumulative incidence for local, regional, and distant recurrences: 5.2%, 11.1%, and 14.9% versus 3.7%, 6.6%, and 9.5% versus 2.3%, 4.7%, and 6.4%, respectively. Primary tumor diameter was associated with local recurrence in univariate analysis.

CONCLUSIONS

Wedge resection for early stage non-small cell lung cancer is associated with a significant risk for local and regional recurrence. Long-term follow-up using noncontrast computed tomography scans at consistent intervals is appropriate to monitor for these recurrences.

Noninvasive risk stratification of lung adenocarcinoma using quantitative computed tomography

INTRODUCTION

Lung cancer remains the leading cause of cancer-related deaths in the United States and worldwide. Adenocarcinoma is the most common type of lung cancer and encompasses lesions with widely variable clinical outcomes. In the absence of noninvasive risk stratification, individualized patient management remains challenging. Consequently a subgroup of pulmonary nodules of the lung adenocarcinoma spectrum is likely treated more aggressively than necessary.

METHODS

Consecutive patients with surgically resected pulmonary nodules of the lung adenocarcinoma spectrum (lesion size ≤3 cm, 2006-2009) and available presurgical high-resolution computed tomography (HRCT) imaging were identified at Mayo Clinic Rochester. All cases were classified using an unbiased Computer-Aided Nodule Assessment and Risk Yield (CANARY) approach based on the quantification of presurgical HRCT characteristics. CANARY-based classification was independently correlated to postsurgical progression-free survival.

RESULTS

CANARY analysis of 264 consecutive patients identified three distinct subgroups. Independent comparisons of 5-year disease-free survival (DFS) between these subgroups demonstrated statistically significant differences in 5-year DFS, 100%, 72.7%, and 51.4%, respectively (p = 0.0005).

CONCLUSIONS

Noninvasive CANARY-based risk stratification identifies subgroups of patients with pulmonary nodules of the adenocarcinoma spectrum characterized by distinct clinical outcomes. This technique may ultimately improve the current expert opinion-based approach to the management of these lesions by facilitating individualized patient management.

Surgical resection of solitary omental metastasis from non-small cell lung cancer: Report of three cases

In the present study we report three cases of solitary omental metastasis from non-small cell lung cancer, which had been surgically resected at our institute. The primary site was resected in one patient (case 1) and the other two patients were treated with chemotherapy and demonstrated complete response (cases 2 and 3). The omental metastasis appeared 4 months after pneumonectomy in case 1. Two metachronous omental tumors appeared 55 and 79 months after the initial chemotherapy in case 2. In Case 3, an omental tumor appeared 6 months after chemotherapy. Case 1 succumbed to recurrence 8 months after the resection of the omental tumor. Case 2 survives with recurrent disease 8 months after resection of the second omental metastasis, and case 3 survives 6 months after resection of the omental tumor. Although omental metastasis from non-small cell lung cancer is extremely rare, it should be considered when a patient with history of lung cancer has a tumor around the stomach.

Prognostic value of the new IASLC/ATS/ERS classification of clinical stage IA lung adenocarcinoma

OBJECTIVES

We analyzed and validated the prognostic utility of the new International Association for the Study of Lung Cancer (IASLC)/American Thoracic Society (ATS)/European Respiratory Society (ERS) for clinical stage IA lung adenocarcinoma (ADC) classification of adenocarcinoma (ADC).

METHODS

We retrospectively reviewed 347 patients with clinical stage IA nonmucinous ADC, who had undergone complete resection. The histological subtype was classified according to the predominant subtype, as proposed by the new IASLC/ATS/ERS ADC classification.

RESULTS

The histopathological subtypes, defined according to the new IASLC/ATS/ERS ADC classification, were ADC in situ (AIS) in 56 patients (16.1%), minimally invasive ADC (MIA) in 15 (4.3%), lepidic-predominant ADC in 109 (31.4%), papillary-predominant ADC in 70 (20.2%), acinar-predominant ADC in 61 (17.6%), solid-predominant ADC in 30 (8.6%), and micropapillary-predominant ADC in 6 (1.7%). The 5-year disease-free survival (DFS) rate was 100% for both AIS and MIA. All cases of recurrence involved invasive ADC. The 5-year DFS for lepidic-predominant ADC was 99.0%; acinar-predominant ADC, 82.4%; papillary-predominant ADC, 80.8%; solid-predominant ADC, 73.6%; and micropapillary-predominant ADC, 33.3%. The predominant subtype of ADC was significantly correlated with DFS (P<0.0001). Multivariate analysis indicated that the pathological stage was an independent predictor of DFS (P=0.031). Other independent predictors of increased risk of recurrence were the presence of vascular or lymphatic invasion (HR=4.96, P=0.001), and a pathological stage more advanced than IB (HR=2.87, P=0.010). The coincidence between the clinical stage and pathological stage was 79.8%. The stage migration was found in 53.3% of solid-predominat ADC and in 83.3% of micropapillary-predominant ADC.

CONCLUSION

The new IASLC/ATS/ERS ADC classification has prognostic value in predicting the recurrence and survival of patients with clinical stage IA ADC. The frequency of stage migration was found in more than half of solid and micropapillary predominant ADCs.

Metachronous second primary lung cancer surgically treated five years or more after the initial surgery

Surgical treatment for metachronous second primary lung cancer following curative resection of primary lung cancer may be challenging. Standard surgical strategies for metachronous second primary lung cancer have not yet been established. The purpose of this study was to evaluate the outcomes of patients who underwent surgical resection for metachronous second primary lung cancer. A total of 12 patients surgically treated for metachronous second primary lung cancer ≥5 years after the initial surgery were retrospectively analyzed. The overall 5-year survival after the second surgery was 56.5%. There was no operative mortality. Patients with T1aN0M0 metachronous second primary lung cancer experienced a significantly higher 5-year overall survival rate compared with other patients (100 vs. 26.7%, respectively; P=0.0336). Among patients who underwent sublobar resection, all 3 patients with T1aN0M0 disease remained alive at the last follow-up, while 4 of the 5 patients (80%) with non-T1aN0M0 disease had developed recurrence. Surgery for metachronous second primary lung cancer may be safely performed. Early-stage metachronous second primary lung cancer was associated with a good prognosis, even among patients who underwent sublobar resection. Early detection of metachronous second primary lung cancer with close long-term follow-up following initial surgery may improve surgical outcomes.

Post-therapeutic positron emission tomography/computed tomography for early detection of non-small cell lung cancer recurrence

Patients after curative treatment of non-small cell lung cancer (NSCLC) have a high risk of loco-regional and/or distant tumor recurrence, especially within the first two years. Timely and accurate detection of recurrence is crucial in order to start salvage or palliative therapies with the overall goal of increasing patients' survival and quality of life. However, with the emerging use of non-surgical curative-intended therapies, follow-up of patients becomes even more challenging, as local recurrence has to be distinguished from various post-therapeutic changes at the site of the primary cancer. Integrated positron emission tomography/computed tomography (PET/CT), which is already an established imaging modality in the staging of NSCLC, is increasingly used in recurrence surveillance algorithms. By detailed morphological information being combined with additional information about the metabolic activity of suspicious sites, determination of suspicious lesions as benign or malignant can be improved. This article reviews the value of integrated PET/CT in assessing recurrence in NSCLC patients after potentially curative surgery and after curative-intended non-surgical therapies and raises as well the issue of cost-effectiveness of PET/CT for follow-up.

A meta-analysis of resected metachronous second non-small cell lung cancer

This meta-analysis was designed to determine the effect of surgical treatment on overall survival of patients treated surgically for a second non-small cell lung cancer (NSCLC) that occurred after resection of an initial NSCLC. PubMed and Scopus databases were queried. Nine studies were identified. Meta-analyses revealed pooled operative mortality of 7% for the second resection, pooled 5-year overall survival of 46% after resection of the second NSCLC, and 79% after resection of the first NSCLC. These results suggest that surgical resection can be considered for patients who have a second primary NSCLC after resection of an initial lung cancer.

Thrombus Removal by Acute-phase Endovascular Reperfusion Therapy to Treat Cerebral Embolism Caused by Thrombus in the Pulmonary Vein Stump after Left Upper Pulmonary Lobectomy: Case Report

Thrombus formation in a pulmonary vein stump after pulmonary lobectomy is extremely rare, but can trigger cerebral embolism of unknown cause. We encountered a case of cerebral embolism in a 58-year-old man 2 days after left upper lobectomy. Since intravenous administration of recombinant tissue plasminogen activator was contraindicated, thrombus removal by endovascular reperfusion therapy was performed. Cerebral angiography showed left internal carotid artery occlusion. Thrombus removal using a retrieval device was performed and complete recanalization of the left internal carotid artery was obtained. Although blood abnormalities or arrhythmia such as atrial fibrillation were not observed, thrombus in the left upper pulmonary vein stump was detected with contrast-enhanced computed tomography of the body trunk, which was therefore considered as the source of cerebral embolism. The patient is continuing on anticoagulant therapy to prevent embolism recurrence caused by thrombus formation in the pulmonary vein resection stump. To the best of our knowledge, this is the first report of thrombus removal by acute-phase endovascular reperfusion therapy to treat cerebral embolism likely caused by thrombus formation in the pulmonary vein stump after left upper lobectomy. When cerebral embolism of unknown cause develops after left upper lobectomy, thrombus formation in the pulmonary vein stump should be considered among the differential diagnoses. For acute-phase onset of cerebral embolism after pulmonary lobectomy, thrombus removal by endovascular reperfusion therapy may be considered as one of the therapies.