Nodal upstaging: effects of instrumentation and three-dimensional view in clinical stage I lung cancer

Increased Systemic Immune-Inflammatory Index and Association with Occult Nodal Disease in Non-Small Cell Lung Cancer

BACKGROUND

It has been proposed that more aggressive tumors trigger a stronger inflammatory response than less aggressive types. We hypothesize that systemic immune-inflammatory index (SII) is associated with occult nodal disease (OND) in clinically node-negative patients undergoing lung resection for non-small cell lung cancer (NSCLC).

STUDY DESIGN

The study included patients who underwent lung resection with nodal dissection, according to current guidelines, at a single center between 2010 and 2021 for NSCLC. Preoperative SII within 3 weeks of surgery was calculated. OND was defined as a clinically node-negative patient found to be pathologically node-positive. Cut-point analysis for SII was performed to identify the level most strongly associated with OND. Univariable and multivariable logistic regressions were used to examine the association between SII, clinical factors, and OND.

RESULTS

A total of 199 patients met inclusion criteria, of whom 51% (102 of 199) were women. The median number of nodes and nodal stations examined was 13 (interquartile range 9 to 17) and 6 (interquartile range 5 to 6), respectively. The cut point was determined to be SII 112 or more. On univariable analysis, high SII was associated with OND (odds ratio 15.75, 95% CI 2.09 to 118.73, p = 0.007). On multivariable analysis, after controlling for age, BMI, approach, sex, smoking history (pack-years), forced expiratory volume in 1 second, performance status, comorbidity, histology, lymphovascular invasion, tumor differentiation, and tumor size, high SII was associated with OND (odds ratio 34.59, 95% CI 2.69 to 444.88, p = 0.007).

CONCLUSIONS

Increased SII is associated with OND in patients undergoing lung resection for NSCLC.

Propensity score matched comparison of lymph node upstaging in early-stage lung cancer: open versus minimally invasive surgery with standardized lymphadenectomy

BACKGROUND

Lymph node upstaging represents a quality criterion for standardized lymphadenectomy in lung cancer surgery. The aim of the study was to compare whether the quality of standardized lymphadenectomy in lung cancer surgery is comparable in minimally invasive (video-assisted thoracoscopic surgery) and the open approach (thoracotomy). Furthermore, factors associated with lymph node upstaging were assessed, as was its impact on overall survival and progression-free survival.

METHODS

This retrospective study reviewed data of all patients undergoing lobectomy at the Lung Tumor Center Munich between 2011 and 2020. Inclusion factors were non-small cell lung cancer without nodal involvement (N0) or metastasis (M0) and standardized lymphadenectomy. A propensity score matched analyses was performed. Frequency of categorical outcomes was compared with Chi [2]-test, mean values with t-test. We used logistic and Cox regression models to assess factors associated with upstaging, overall survival and progression-free survival, restrictively.

RESULTS

Of 1691 patients undergoing lobectomy, 637 met our inclusion criteria. After propensity score matching 198 patients remained in each group. Univariate analysis showed no significant difference in lymph node upstaging between the two groups. (p = 0.12). Overall affected lymph nodes (p = 0.45) and overall affected lymph node stations (p = 0.26) were not significantly different. Multivariate Cox regression analysis showed that overall survival and progression free survival were also independent of the surgical approach. L1 status was the only factor associated with progression-free survival.

CONCLUSION

Minimally invasive approaches achieves comparable lymph node upstaging in patients undergone standardized lymphadenectomy.

Uniportal thoracoscopic mediastinal lymphadenectomy using appropriate surgical steps

Background

Although lymphadenectomies play an important role in the surgical treatment of patients with non-small cell lung cancer (NSCLC), the quality of lymphadenectomies via a uniportal approach has only been evaluated in a few studies. We describe the surgical steps for a mediastinal lymphadenectomy via uniportal video-assisted thoracoscopic surgery (uVATS) and compare the quality of mediastinal lymphadenectomies using uVATS versus multiportal video-assisted thoracoscopic surgery (mVATS).

Methods

Between April 2017 and January 2023, we analyzed data from 304 patients with NSCLC who underwent (bi-)lobectomy with nodal dissection (ND)2a-1 or greater lymphadenectomy via uVATS or mVATS. We compared patient characteristics and perioperative results, including the number of harvested lymph nodes (LNs), between the two approaches. In addition, the factors associated with N-upstage were identified.

Results

No significant differences in the total number of harvested LNs were detected between the two approaches. Significantly more LN#2R/4R zone LNs were harvested in the uVATS group compared with the number harvested in the mVATS group [uVATS group: 8.5, interquartile range (IQR), 5-12.3; mVATS group: 7, IQR, 5-9, P=0.0177], while no significant differences in total nodes or nodes harvested in other zones were detected. Multivariable analysis revealed that pathologic invasion size [odds ratio: 1.0200, 95% confidence interval (CI): 1.0100-1.0400, P=0.0050], but not approach (uVATS, odds ratio: 0.6240, 95% CI: 0.3160-1.2300, P=0.1750), significantly contributed to N factor upstages.

Conclusions

The use of appropriate surgical steps enabled us to achieve similar quality lymphadenectomies via mVATS or uVATS.

Segmentectomy versus lobectomy. Which factors are decisive for an optimal oncological outcome?

Low-dose computed tomography is being used for lung cancer screening in high-risk groups. Detecting lung cancer at an early stage improves the chance of optimal treatment and increases overall survival. This article compares segmentectomy vs. lobectomy as surgical options, in the case of stage I non-small cell lung carcinoma, ideally IA. To compare the 2 previously referred strategies, data were collected from articles (40 studies were reviewed), reviews, and systematic analyses in PubMed Central, as well as reviewing recent literature. Segmentectomy could be an equal alternative to lobectomy in early-stage NSCLC (tumour < 2 cm). It could be preferred for patients with a low cardiopulmonary reserve, who struggle to survive a lobectomy. As far as early-stage NSCLC is concerned, anatomic segmentectomy is an acceptable procedure in a selective group of patients. For better tumour and stage classification, a systematic lymph node dissection should be performed.

A Systematic Review of Short-Term Outcomes of Minimally Invasive Thoracoscopic Surgery for Lung Cancer after Neoadjuvant Systemic Therapy

BACKGROUND

Minimally invasive surgeries for non-small cell lung cancers (NSCLCs) such as video-assisted thoracoscopic surgeries (VATSs) and robotic-assisted thoracoscopic surgeries (RATSs) have become standard of care for patients needing surgical resection in early stages. The role for neoadjuvant systemic therapy has increased with patients receiving neoadjuvant systemic chemotherapy and immunotherapy. However, there has been some equipoise over the intraoperative and overall outcomes for these patients. Here, we review the current data regarding outcomes of patients undergoing minimally invasive thoracic surgical resection after systemic chemotherapy, immunotherapy, or both.

METHODS

A systematic literature review of randomized controlled trials and observational studies presenting data on patients with NSCLC that underwent neoadjuvant systemic therapy followed by minimally invasive surgery was performed assessing complications, conversion rates, and lymph node yield.

RESULTS

Our search strategy and review of references resulted in 239 publications to screen with 88 full texts assessed and 21 studies included in our final review. VATS had a statistically significant higher lymph node yield in five studies. The reported conversion rates ranged from 0 to 54%. Dense adhesions, bleeding, and difficult anatomy were the most common reported reasons for conversion to open surgeries. The most common complications between both groups were prolonged air leak, arrythmia, and pneumonia. VATS was found to have significantly fewer complications in three papers.

CONCLUSIONS

The current literature supports VATS as safe and feasible for patients with NSCLC after neoadjuvant systemic treatment. Surgeons should remain prepared to convert to open surgeries in those patients with dense adhesions and bleeding risk.

Comparison of the Outcomes between Systematic Lymph Node Dissection and Lobe-Specific Lymph Node Dissection for Stage I Non-small Cell Lung Cancer

BACKGROUND

This study compares the surgical and long-term outcomes, including disease-free survival (DFS), overall survival (OS), and cancer-specific survival (CSS), between lobe-specific lymph node dissection (L-SND) and systematic lymph node dissection (SND) among patients with stage I non-small cell lung cancer (NSCLC).

METHODS

In this retrospective study, 107 patients diagnosed with clinical stage I NSCLC undergoing video-assisted thoracic surgery lobectomy (exclusion of the right middle lobe) from January 2011 to December 2018 were enrolled. The patients were assigned to the L-SND (n = 28) and SND (n = 79) groups according to the procedure performed on them. Demographics, perioperative data, and surgical and long-term oncological outcomes were collected and compared between the L-SND and SND groups.

RESULTS

The mean follow-duration was 60.6 months. The demographic data and surgical outcomes and long-term oncological outcomes were not significantly different between the two groups. The 5-year OS of the L-SND and SND groups was 82% and 84%, respectively. The 5-year DFS of the L-SND and SND groups was 70% and 65%, respectively. The 5-year CSS of the L-SND and SND groups was 80% and 86%, respectively. All the surgical and long-term outcomes were not statistically different between the two groups.

CONCLUSION

L-SND showed comparable surgical and oncologic outcomes with SND for clinical stage I NSCLC. L-SND could be a treatment choice for stage I NSCLC.

Rate and Predictors of Unforeseen PN1/PN2-Disease in Surgically Treated cN0 NSCLC-Patients with Primary Tumor > 3 cm: Nationwide Results from Italian VATS-Group Database

Background. Since no robust data are available on the real rate of unforeseen N1-N2 disease (uN) and the relative predictive factors in clinical-N0 NSCLC with peripheral tumours > 3 cm, the usefulness of performing a (mini)invasive mediastinal staging in this setting is debated. Herein, we investigated these issues in a nationwide database. Methods. From 01/2014 to 06/2020, 15,784 thoracoscopic major lung resections were prospectively recorded in the “Italian VATS-Group” database. Among them, 1982 clinical-N0 peripheral solid-type NSCLC > 3 cm were identified, and information was retrospectively reviewed. A mean comparison of more than two groups was made by ANOVA (Bonferroni correction for multiple comparisons), while associations between the categorical variables were estimated with a Chi-square test. The multivariate logistic regression model and Kaplan–Meyer method were used to identify the independent predictors of nodal upstaging and survival results, respectively. Results. At pathological staging, 229 patients had N1-involvement (11.6%), and 169 had uN2 disease (8.5%). Independent predictors of uN1 were SUVmax (OR: 1.98; CI 95: 1.44–2.73, p = 0.0001) and tumour-size (OR: 1.52; CI: 1.11–2.10, p = 0.01), while independent predictors of uN2 were age (OR: 0.98; CI 95: 0.96–0.99, p = 0.039), histology (OR: 0.48; CI 95: 0.30–0.78, p = 0.003), SUVmax (OR: 2.07; CI 95: 1.15–3.72, p = 0.015), and the number of resected lymph nodes (OR: 1.03; CI 95: 1.01–1.05, p = 0.002). Conclusions. The unforeseen N1-N2 disease in cN0/NSCLCs > 3 cm undergoing VATS resection is observable in between 12 and 8% of all cases. We have identified predictors that could guide physicians in selecting the best candidate for (mini)invasive mediastinal staging.

Surgical Effectiveness of Uniportal-VATS Lobectomy Compared to Open Surgery in Early-Stage Lung Cancer

Background

Although the feasibility and safety of Uniportal-Video-Assisted thoracic surgery (U-VATS) has been proven, its surgical effectiveness is still debated. The aim of this study is to assess the equivalence of the U-VATS approach compared with an open technique in terms of surgical (nodal-upstaging, complications, and post-operative results) and short-term survival outcomes.

Methods

The clinical data of patients undergoing lobectomy for NSCLC at our center, from January 2014 to December 2019, were analyzed retrospectively. All patients undergoing open or U-VATS lobectomy with lymphadenectomy for early-stage lung cancer (cT1-T3N0, stages IA-IIB) were included in the study. Only 230 patients satisfied the inclusion criteria. Group bias was reduced through 1:1 propensity score matching, which resulted in 46 patients in each group (open surgery and U-VATS).

Results

The intra- and post-operative mortality were null in both groups. There was no difference in the post-operative complications (p: 1.00) between U-VATS and open lobectomy. There was also no recorded difference in the pathological nodal up-staging [11 (23.9%) after thoracotomy vs. 8 (17.4%) after U-VATS, p: 0.440). The chest tube duration was longer in the open group (p: 0.025), with a higher post-operative pain (p: 0.001). Additionally, the 3-year overall survival (OS) was 78% after U-VATS lobectomy vs. 74% after open lobectomy (p: 0.204), while 3-year disease-specific survival (DSS) was 97 vs. 89% (p: 0.371), respectively. The 3-year disease-free survival (DFS) was 62% in the U-VATS group and 66% in the thoracotomy group, respectively (p: 0.917).

Conclusions

Uniportal-VATS lobectomy for the treatment of early-stage lung cancer seems to be a safe and effective technique with similar surgical and short-term survival outcomes as open surgery, but with lower post-operative pain and shorter in-hospital stay.

Factors Associated with Nodal Upstaging in Clinical T1a-bN0M0 Non-Small Cell Lung Cancers

Nodal upstaging of lung adenocarcinoma occurs when unexpected pathological lymph node metastasis is found after surgical intervention, and may be associated with a worse prognosis. In this study, we aimed to determine the predictive factors of nodal upstaging in cT1a-bN0M0 primary lung adenocarcinoma. We retrospectively reviewed a prospective database (January 2011 to May 2017) at National Taiwan University Hospital and identified patients with cT1a-bN0M0 (solid part tumor diameter ≤ 2 cm) lung adenocarcinoma who underwent video-assisted thoracoscopic lobectomy. Logistic regression models and survival analysis were used to examine and compare the predictive factors of nodal upstaging. A total of 352 patients were included. Among them, 28 (7.8%) patients had nodal upstaging. Abnormal preoperative serum carcinoembryonic antigen (CEA) levels, solid part tumor diameter ≥ 1.3 cm, and consolidation-tumor (C/T) ratio ≥ 0.50 on chest computed tomography (CT) were significant predictive factors associated with nodal upstaging, and patients with nodal upstaging tended to have worse survival. Standard lobectomy is recommended for patients with these predictive factors. If neither of the predictive factors are positive, a less invasive procedure may be a reasonable alternative. Further studies are needed to verify these data.

Nodal Outcomes of Uniportal versus Multiportal Video-Assisted Thoracoscopic Surgery for Clinical Stage I Lung Cancer

Background

Accurate intraoperative assessment of mediastinal lymph nodes is a critical aspect of lung cancer surgery. The efficacy and potential for upstaging implicit in these dissections must therefore be revisited in the current era of uniportal video-assisted thoracoscopic surgery (VATS).

Methods

A retrospective study was conducted in which 544 patients with stage I (T1abc–T2a, N0, M0) primary lung cancer were analyzed. To assess risk factors for nodal upstaging and to limit any imbalance imposed by surgical choices, we constructed an inverse probability of treatment-weighted (IPTW) logistic regression model (in addition to non-weighted logistic models). We also evaluated risk factors for early locoregional recurrence using IPTW logistic regression analysis.

Results

In the comparison of uniportal and multiportal VATS, the resected lymph node count (14.03±8.02 vs. 14.41±7.41, respectively; p=0.48) and rate of nodal upstaging (6.5% vs. 8.7%, respectively; p=0.51) appeared similar. Predictors of nodal upstaging included tumor size (odds ratio [OR], 1.74; 95% confidence interval [CI], 1.12–2.70), carcinoembryonic antigen level (OR, 1.11; 95% CI, 1.04–1.18), and histologically confirmed pleural invasion (OR, 3.97; 95% CI, 1.89–8.34). The risk factors for locoregional recurrence within 1 year were found to be number of resected N2 nodes, age, and nodal upstaging.

Conclusion

Uniportal and multiportal VATS appear similar with regard to accuracy and thoroughness, showing no significant difference in the extent of nodal dissection.

Thoracoscopic instruments do not interfere in the outcome of uncomplicated, experimental, video-assisted pulmonary lobectomy

OBJECTIVE

Since its first report, video-assisted thoracic surgery (VATS) lung lobectomy was carried out with the use of conventional surgical instruments, used in laparoscopy and open thoracotomy. These instruments are expensive, not standardized and there are a variety of models and manufacturers. The aim of this study was to determine the impact of the use of these instruments on the experimental pulmonary lobectomy.

METHODS

We used a modified surgical simulator that uses a porcine heart-lung block filled with tomato sauce, and tested specific (Group 1) and regular (Group 2) instruments. Each group includes 15 experiments.

RESULTS

The median total time, excluding the time spent to correct the lesions, was 45.08 and 45.81 minutes, respectively in Group 1 and Group 2. There was no statistical difference between the total times (p=0.58). The only statistically different was seen for partial times regarding the elapsed time to cut and suture of lung fissures (p=0.03 and 0.04, respectively). There were more direct lesions and indirect leaks in Group 2, but without statistical significance (p=1.000 and p=0.203, respectively). The mean time spent for the diagnosis and correction of these events was 1.77 minutes with a standard deviation of 1.18 for Group 1 and 2.72 ± 1.11 minutes for Group 2 (p=0.044).

CONCLUSION

The use of minimally invasive instruments is not associated with time improvement spent with experimental video-assisted lung lobectomy and does not lead to a faster or safer surgery. The use of VATS instruments makes correction of adverse events faster when they occur.

Lymph node upstaging for non-small cell lung cancer after uniportal video-assisted thoracoscopy

Background

Radical lymph node dissection (LND) plays a major role in the treatment of non-small cell lung cancer (NSCLC). This study presents the analysis of the results after uniportal video-assisted thoracoscopy (VATS) lymphadenectomy during anatomical lung resections for NSCLC, focusing on pathological nodal upstaging. Any possible risk factor affecting nodal upstaging was also investigated.

Methods

The prospectively collected clinical data of 136 patients undergone uniportal VATS anatomical lung resections, from June 2012 to September 2017, were reviewed. In particular, all details inherent the clinical and pathological node stage and any possible risk factor affecting nodal upstaging were analyzed.

Results

The patient population consisted of 90 males and 46 females; their mean age was 67.42±10.64 years. The mean number of lymph nodes retrieved during uniportal VATS lymphadenectomy was 20.14±10.73 (7.27±5.90 and 12.60±7.96 in N1 and N2 stations, respectively). The incidence of nodal upstaging was 13.3% (18 cases). In particular there was a N0-1 upstaging in 10 cases (7.4%), a N1-2 upstaging in 3 (2.2%) and a N0-2 in 4 (3%). The ROC analysis showed that the resection of 18 lymph nodes was the best predictor of a general upstaging with an AUC-ROC of 0.595, while the resection of 7 hilar lymph nodes was the best predictor of N1 upstaging (AUC-ROC: 0.554) and 11 mediastinal nodes was the best predictor of N2 upstaging (AUC-ROC: 0.671). The number of positive lymph nodes of stations 5-6 (OR: 2.035, 95% CI: 1.082-3.826, P=0.027) and stations 2-3-4 (OR: 6.198, 95% CI: 1.580-24.321, P=0.009) were confirmed to be the only independent risk factors for N2 upstaging by multivariate analysis.

Conclusions

According to our experience, uniportal VATS allows a safe and effective radical lymphadenectomy, with a satisfactory pathological nodal upstaging, comparable to other minimally invasive techniques.