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Walsh LC, Brunelli A, Kidane B, Eckhaus J, Fiset PO, Spicer JD, Antonoff MB. Surveying surgeon practices and perspectives on extent of intraoperative nodal evaluation in non-small cell lung cancer. JTCVS OPEN 2025; 24:376-382. [PMID: 40309672 PMCID: PMC12039416 DOI: 10.1016/j.xjon.2025.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2024] [Revised: 12/08/2024] [Accepted: 12/24/2024] [Indexed: 05/02/2025]
Abstract
Objective The National Comprehensive Cancer Network and Commission on Cancer guidelines encourage surgeons to obtain tissue from 1 or more N1 and 3 N2 nodal stations during resection for non-small cell lung cancer. We aimed to characterize surgeons' familiarity with and adherence to recommended guidelines and to elucidate factors influencing surgical practices globally. Methods A questionnaire was designed to assess surgeon behaviors regarding intraoperative nodal assessment decisions during lung cancer resection. Survey items included demographics, case-based scenarios, self-perceived behaviors regarding nodal decision-making, and knowledge-based questions regarding nodal assessment guidelines. The survey was distributed to the General Thoracic Surgical Club, European Society of Thoracic Surgeons, Canadian Association of Thoracic Surgeons, and Australian & New Zealand Society of Cardiac & Thoracic Surgeons. Results Altogether, 236 of 2396 surgeons (9.8%) from 46 countries responded. The majority were men (192/236) and general thoracic surgeons (204/236). Participants were subcategorized into North America (n = 96), Europe (n = 96), and All Other (n = 44). The importance of 4 variables that impact lymph node excision varied by region: length of procedure (P = .04), patient age (P = .0004), patient frailty (P = .0034), and institutional guidelines (P = .01). Surgeons stated that in patients who received neoadjuvant treatment, most would opt for a full lymphadenectomy. A total of 80.5% (n = 190) claimed familiarity with guidelines, yet only 56.4% (n = 133) could identify the guidelines. Conclusions The variables driving intraoperative decision-making for nodal dissection vary by region. Moreover, surgeons tend to overstate their knowledge of existing guidelines. To optimize cancer care around the world, education needs to be provided uniformly to drive positive patient outcomes.
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Affiliation(s)
- Lyndon C. Walsh
- Department of Cardiovascular and Thoracic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex
- Department of Thoracic Surgery, Montréal General Hospital, Montréal, Québec, Canada
| | - Alessandro Brunelli
- Department of Thoracic Surgery, St James's University Hospital, Leeds, United Kingdom
| | - Biniam Kidane
- Section of Thoracic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jazmin Eckhaus
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Pierre Olivier Fiset
- Department of Pathology, McGill University Health Centre, Montréal, Québec, Canada
| | - Jonathan D. Spicer
- Department of Thoracic Surgery, Montréal General Hospital, Montréal, Québec, Canada
| | - Mara B. Antonoff
- Department of Cardiovascular and Thoracic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Tex
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Mankidy BJ, Mohammad G, Trinh K, Ayyappan AP, Huang Q, Bujarski S, Jafferji MS, Ghanta R, Hanania AN, Lazarus DR. High risk lung nodule: A multidisciplinary approach to diagnosis and management. Respir Med 2023; 214:107277. [PMID: 37187432 DOI: 10.1016/j.rmed.2023.107277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 04/28/2023] [Accepted: 05/04/2023] [Indexed: 05/17/2023]
Abstract
Pulmonary nodules are often discovered incidentally during CT scans performed for other reasons. While the vast majority of nodules are benign, a small percentage may represent early-stage lung cancer with the potential for curative treatments. With the growing use of CT for both clinical purposes and lung cancer screening, the number of pulmonary nodules detected is expected to increase substantially. Despite well-established guidelines, many nodules do not receive proper evaluation due to a variety of factors, including inadequate coordination of care and financial and social barriers. To address this quality gap, novel approaches such as multidisciplinary nodule clinics and multidisciplinary boards may be necessary. As pulmonary nodules may indicate early-stage lung cancer, it is crucial to adopt a risk-stratified approach to identify potential lung cancers at an early stage, while minimizing the risk of harm and expense associated with over investigation of low-risk nodules. This article, authored by multiple specialists involved in nodule management, delves into the diagnostic approach to lung nodules. It covers the process of determining whether a patient requires tissue sampling or continued surveillance. Additionally, the article provides an in-depth examination of the various biopsy and therapeutic options available for malignant lung nodules. The article also emphasizes the significance of early detection in reducing lung cancer mortality, especially among high-risk populations. Furthermore, it addresses the creation of a comprehensive lung nodule program, which involves smoking cessation, lung cancer screening, and systematic evaluation and follow-up of both incidental and screen-detected nodules.
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Affiliation(s)
- Babith J Mankidy
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, 1Baylor Plaza, Houston, TX, 77030, USA.
| | - GhasemiRad Mohammad
- Department of Radiology, Division of Vascular and Interventional Radiology, Baylor College of Medicine, USA.
| | - Kelly Trinh
- Texas Tech University Health Sciences Center, School of Medicine, USA.
| | - Anoop P Ayyappan
- Department of Radiology, Division of Thoracic Radiology, Baylor College of Medicine, USA.
| | - Quillan Huang
- Department of Oncology, Baylor College of Medicine, USA.
| | - Steven Bujarski
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, 1Baylor Plaza, Houston, TX, 77030, USA.
| | | | - Ravi Ghanta
- Department of Cardiothoracic Surgery, Baylor College of Medicine, USA.
| | | | - Donald R Lazarus
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, 1Baylor Plaza, Houston, TX, 77030, USA.
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Hui WK, Charaf Z, Hendriks JMH, Van Schil PE. True Prevalence of Unforeseen N2 Disease in NSCLC: A Systematic Review + Meta-Analysis. Cancers (Basel) 2023; 15:3475. [PMID: 37444585 DOI: 10.3390/cancers15133475] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/25/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023] Open
Abstract
Patients with unforeseen N2 (uN2) disease are traditionally considered to have an unfavorable prognosis. As preoperative and intraoperative mediastinal staging improved over time, the prevalence of uN2 changed. In this review, the current evidence on uN2 disease and its prevalence will be evaluated. A systematic literature search was performed to identify all studies or completed, published trials that included uN2 disease until 6 April 2023, without language restrictions. The Newcastle-Ottawa Scale (NOS) was used to score the included papers. A total of 512 articles were initially identified, of which a total of 22 studies met the predefined inclusion criteria. Despite adequate mediastinal staging, the pooled prevalence of true unforeseen pN2 (9387 patients) was 7.97% (95% CI 6.67-9.27%), with a pooled OS after five years (892 patients) of 44% (95% CI 31-58%). Substantial heterogeneity regarding the characteristics of uN2 disease limited our meta-analysis considerably. However, it seems patients with uN2 disease represent a subcategory with a similar prognosis to stage IIb if complete surgical resection can be achieved, and the contribution of adjuvant therapy is to be further explored.
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Affiliation(s)
- Wing Kea Hui
- Department of Thoracic and Vascular Surgery, University Hospital Antwerp, Drie Eikenstraat 655, 2650 Edegem, Belgium
| | - Zohra Charaf
- Department of Cardiothoracic Surgery, University Hospital Brussels, Laarbeeklaan 101, 1090 Jette, Belgium
| | - Jeroen M H Hendriks
- Department of Thoracic and Vascular Surgery, University Hospital Antwerp, Drie Eikenstraat 655, 2650 Edegem, Belgium
- ASTARC (Antwerp Surgical Training, Anatomy and Research Centre), University Hospital Antwerp, Drie Eikenstraat 655, 2650 Edegem, Belgium
| | - Paul E Van Schil
- Department of Thoracic and Vascular Surgery, University Hospital Antwerp, Drie Eikenstraat 655, 2650 Edegem, Belgium
- ASTARC (Antwerp Surgical Training, Anatomy and Research Centre), University Hospital Antwerp, Drie Eikenstraat 655, 2650 Edegem, Belgium
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Nath TS, Mohamed N, Gill PK, Khan S. A Comparative Analysis of Video-Assisted Thoracoscopic Surgery and Thoracotomy in Non-Small-Cell Lung Cancer in Terms of Their Oncological Efficacy in Resection: A Systematic Review. Cureus 2022; 14:e25443. [PMID: 35774656 PMCID: PMC9238107 DOI: 10.7759/cureus.25443] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 05/29/2022] [Indexed: 12/24/2022] Open
Abstract
Video-assisted thoracoscopic surgery (VATS) is considered the standard procedure for surgical resection in non-small-cell lung cancer (NSCLC). However, there is still lingering speculation on its adequacy of lymph node (LN) dissection or sampling and the long-term survival benefits when compared to open thoracotomy. Given the above, we conducted a systematic review comparing VATS and thoracotomy in terms of their oncological effectiveness in resection. We explored major research literature databases and search engines such as MEDLINE, PubMed, PubMed Central, Google Scholar, and ResearchGate to find pertinent articles. After the meticulous screening, quality check, and applying relevant filters according to our eligibility criteria, we identified 16 studies relevant to our research question, out of which one was a randomized controlled trial, one meta-analysis, and 14 were observational studies. The study comprised 44,673 patients with NSCLC, out of whom 15,093 patients were operated by VATS and the remaining 29,580 patients by thoracotomy. The results indicate that VATS is equivalent to thoracotomy in total LNs (N1 + N2) and LN stations dissected. However, a thoracotomy may achieve slightly better mediastinal lymph node dissection (N2) in terms of assessing a greater number of mediastinal lymph nodes and nodal stations. This may be attributed to a better visual field during mediastinal nodal clearance by an open approach. Also, nodal upstaging was consistently more common with an open approach. In terms of long-term outcomes, both overall survival and disease-free survival rates were similar between the two groups, with VATS offering a slightly better survival benefit. Irrespective of the increased rates of nodal upstaging by an open approach, we conclude that VATS should be considered a highly efficient alternative to thoracotomy in both early and locally advanced NSCLC.
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Affiliation(s)
- Tuheen S Nath
- Surgical Oncology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Surgical Oncology, Tata Medical Centre, Kolkata, IND
| | - Nida Mohamed
- Trauma and Acute Care Surgery, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Paramjot K Gill
- Obstetrics and Gynaecology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Health Leadership, Royal Roads University, Victoria, CAN
- General Practice, Dashmesh Hospital, Ropar, IND
| | - Safeera Khan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Tantraworasin A, Taioli E, Liu B, Flores RM, Kaufman AJ. The influence of insurance type on stage at presentation, treatment, and survival between Asian American and non-Hispanic White lung cancer patients. Cancer Med 2018; 7:1612-1629. [PMID: 29575647 PMCID: PMC5943464 DOI: 10.1002/cam4.1331] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 12/08/2017] [Accepted: 12/15/2017] [Indexed: 12/19/2022] Open
Abstract
The effect of insurance type on lung cancer diagnosis, treatment, and survival in Asian patients living in the United States is still under debate. We have analyzed this issue using the Surveillance, Epidemiology, and End Results database. There were 102,733 lung cancer patients age 18–64 years diagnosed between 2007 and 2013. Multilevel regression analysis was performed to identify the association between insurance types, stage at diagnosis, treatment modalities, and overall mortality in Asian and non‐Hispanic White (NHW) patients. Clinical characteristics were significantly different between Asian and NHW patients, except for gender. Asian patients were more likely to present with advanced disease than NHW patients (ORadj = 1.12, 95% CI = 1.06–1.19). Asian patients with non‐Medicaid insurance underwent lobectomy more than NHW patients with Medicaid or uninsured; were more likely to undergo mediastinal lymph node evaluation (MLNE) (ORadj = 1.98, 95% CI = 1.72–2.28) and cancer‐directed surgery and/or radiation therapy (ORadj = 1.41, 95% CI = 1.20–1.65). Asian patients with non‐Medicaid insurance had the best overall survival. Uninsured or Medicaid‐covered Asian patients were more likely to be diagnosed with advanced disease, less likely to undergo MLNE and cancer‐directed treatments, and had shorter overall survival than their NHW counterpart.
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Affiliation(s)
- Apichat Tantraworasin
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1023 Annenberg Building, 7-56, New York City, 10029, New York.,Department of Surgery, Faculty of Medicine, Chiang Mai University, 110 Intawaroros Road, Chiang Mai, 50200, Thailand.,Pharmacoepidemiology and Statistics Research Center (PESRC), Faculty of Pharmacy, Chiang Mai University, 239 Suthep Road, Chiang Mai, 50200, Thailand
| | - Emanuela Taioli
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1023 Annenberg Building, 7-56, New York City, 10029, New York.,Department of Population Health Science and Policy and Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1133, New York City, 10029, New York
| | - Bian Liu
- Department of Population Health Science and Policy and Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1133, New York City, 10029, New York
| | - Raja M Flores
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1023 Annenberg Building, 7-56, New York City, 10029, New York
| | - Andrew J Kaufman
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1023 Annenberg Building, 7-56, New York City, 10029, New York
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Gao XL, Wang SS, Cao DB, Liu W. The role of plasma D-dimer levels for predicting lymph node and mediastinal lymph node involvement in non-small cell lung cancer. CLINICAL RESPIRATORY JOURNAL 2018; 12:2151-2156. [PMID: 29498801 DOI: 10.1111/crj.12786] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 01/26/2018] [Accepted: 02/23/2018] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Elevated plasma D-dimer levels have been suggested as a predictor of poor prognosis in NSCLC. But rare study showed the relationship between D-dimer levels and lymph node involvement. OBJECTIVES To evaluate the role of plasma D-dimer levels in predicting lymph node and mediastinal lymph node involvement in NSCLC. METHODS Preoperative plasma D-dimer levels were quantified in 253 NSCLC patients that underwent radical lung resection with systemic lymph node dissection. Patients were classified as lymph node negative (N0) versus lymph node positive (N1 + N2) and mediastinal lymph node negative (N0 + N1) versus mediastinal lymph node positive (N2). RESULTS Median plasma D-dimer level was significantly lower in Group N0 (94.0 μg/L) compared to Group N1 + N2 (177.0 μg/L) and in Group N0 + N1 (122.0 μg/L) compared to Group N2 (198.0 μg/L). Similar results were found in patients stratified by age, sex, smoking status and histological type, expect in patients with squamous carcinoma. The Receiver Operating Characteristic (ROC) curve for plasma D-dimer levels of N0 versus N1 + N2 showed an area under the curve (AUC) of 0.757 and when a cutoff value was 124.0 μg/L DDU, the sensitivity and specificity was 0.80 and 0.68. The ROC curve for plasma D-dimer levels of N0 + N1 versus N2 showed an AUC of 0.720 and when a cutoff value was 147.0 μg/L DDU, the sensitivity and specificity was 0.75 and 0.67. CONCLUSIONS Plasma D-dimer level has utility for predicting lymph node and mediastinal lymph node status in patients with operable NSCLC.
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Affiliation(s)
- Xin-Liang Gao
- Department of Thoracic Surgery, The First Hospital of Jilin University, Jilin Province, Changchun, 130021, People's Republic of China
| | - Si-Si Wang
- Department of Translational medicine, The First Hospital of Jilin University, Jilin Province, Changchun, 130021, People's Republic of China
| | - Dian-Bo Cao
- Department of Radiology, The First Hospital of Jilin University, Jilin Province, Changchun, 130021, People's Republic of China
| | - Wei Liu
- Department of Thoracic Surgery, The First Hospital of Jilin University, Jilin Province, Changchun, 130021, People's Republic of China
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Underperformance of Mediastinal Lymph Node Evaluation in Resectable Non-Small Cell Lung Cancer. Ann Thorac Surg 2018; 105:943-949. [PMID: 29397099 DOI: 10.1016/j.athoracsur.2017.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 08/22/2017] [Accepted: 10/05/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Mediastinal lymph node evaluation (MLNE) is considered to be the standard of care in curative lung cancer surgery although it is not always performed. This study identifies factors associated with patients not being evaluated (non-MLNE) in cases of resectable non-small cell lung cancer. METHODS A retrospective observational study using the Surveillance, Epidemiology, and End Results Program database was conducted. Adult patients diagnosed with non-small cell lung cancer stage I to IIIA (2004 to 2013) were included. Multilevel logistic regression analysis was performed to identify factors that were associated with non-MLNE. RESULTS There were 86,721 patients included in this study: 73,034 (84.2%) with MLNE and 13,687 (15.8%) without. The use of MLNE gradually increased from 82.7% in 2004 to 85.8% in 2013. In multivariable analysis, factors associated with non-MLNE included the following: age more than 75 years (adjusted odds ratio [ORadj] 1.20, 95% confidence interval [CI]: 1.13 to 1.27); black (ORadj 1.11, 95% CI: 1.32 to 1.20); Native American/Alaskan (ORadj 1.63, 95% CI: 1.15 to 2.31); uninsured (ORadj 1.28, 95% CI: 1.05 to 1.56); residing in a low-income county (ORadj 1.12, 95% CI: 1.04 to 1.21); lesion at the middle lobe (ORadj 1.42, 95% CI: 1.29 to 1.56); lower lobe (ORadj 1.06, 95% CI: 1.01 to 1.11) or main bronchus (ORadj 2.38, 95% CI: 1.93 to 2.94); stage IA (ORadj 1.24, 95% CI: 1.17 to 1.32); sublobar resection (ORadj 11.08, 95% CI: 11.30 to 12.33); and preoperative treatment (ORadj 1.21, 95% CI: 1.08 to 1.36). Non-MLNE was less likely to occur in patients with adenocarcinoma (ORadj 0.88, 95% CI: 0.83 to 0.92) and more likely in other cell types (ORadj 1.23, 95% CI: 1.15 to 1.32), compared with squamous cell carcinoma. CONCLUSIONS Patient demographics and socioeconomic status are associated with the decision to perform MLNE. Thoracic surgeons should access these factors and perform MLNE to accurately determine tumor stage and improve survival.
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Wang X, Yan S, Wang Y, Li X, Lyu C, Wang Y, Wang J, Li S, Zhang L, Yang Y, Wu N. Adjuvant chemotherapy may improve outcome of patients with non-small-cell lung cancer with metastasis of intrapulmonary lymph nodes after systematic dissection of N1 nodes. Chin J Cancer Res 2018; 30:588-595. [PMID: 30700927 PMCID: PMC6328508 DOI: 10.21147/j.issn.1000-9604.2018.06.03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objective Survival benefit of adjuvant chemotherapy (AC) of patients with intrapulmonary lymph node (IPLN) metastasis (level 12−14) needs investigation. We evaluated the impact of AC on patients whose metastatic nodes were limited to intrapulmonary levels after systematic dissection of N1 nodes. Methods First, 155 consective cases of lung cancer confirmed as pathologic N1 were collected and evaluated. Patients received systematic dissection of N2 and N1 nodes. For patients with IPLN metastasis, survival outcomes were compared between those receiving AC and those not receiving AC. Results In this group, 112 cases (72.3%) had IPLN metastasis and 55 cases (35.5%) had N1 involvement limited to level 13−14 without further disease spread to higher levels. Patients with IPLN involvement had a better prognosis than that of patients with hilar-interlobar involvement. For the intrapulmonary N1 group (level 12−14-positive, level 10−11-negative or unknown, n=112), no survival benefit was found between the AC group and non-AC group [5-year overall survival (OS): 54.6±1.6vs. 50.4±2.4 months, P=0.177]. However, 76 of 112 cases for whom harvesting of level-10 and level-11 nodes was done did not show cancer involvement in pathology reports (level 12−14-positive, level 10−11 both negative), oncologic outcome was better for patients receiving AC than those not receiving AC in this subgroup (5-year OS: 57.3±1.5vs. 47.1±3.2 months, P=0.002).
Conclusions Oncologic outcome may be improved by AC for patients with involvement of N1 nodes limited to intrapulmonary levels after complete examination of N1 nodes.
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Affiliation(s)
- Xing Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Shi Yan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Yaqi Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Xiang Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Chao Lyu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Yuzhao Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Jia Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Shaolei Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Lijian Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Yue Yang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Nan Wu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China
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Tantraworasin A, Taioli E, Siwachat S, Saeteng S. Role of intrapulmonary lymph node retrieval for pathological examination in resectable non-small cell lung cancer. J Thorac Dis 2017; 9:4280-4282. [PMID: 29268491 DOI: 10.21037/jtd.2017.10.118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Apichat Tantraworasin
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Emanuela Taioli
- Population Health Science and Policy and Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Sophon Siwachat
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Somcharoen Saeteng
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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10
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Nodal recurrence after stereotactic body radiotherapy for early stage non-small cell lung cancer: Incidence and proposed risk factors. Cancer Treat Rev 2017; 56:8-15. [PMID: 28437679 DOI: 10.1016/j.ctrv.2017.04.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 03/30/2017] [Accepted: 04/02/2017] [Indexed: 12/15/2022]
Abstract
Stereotactic body radiotherapy (SBRT) is an alternative to surgery for patients with early stage non-small cell lung cancer (NSCLC) who are inoperable due to comorbid disease or who refuse surgery. SBRT results in an excellent local control rate of more than 90%, which is comparable to surgery, while short and long-term overall toxicity is low. Surgically treated patients are often more extensively staged pre-operatively, e.g. with endobronchial ultrasound and/or mediastinoscopy, and typically undergo intra-operative lymph node dissection or sampling. Occult nodal metastases (ONM), detected by lymph node dissection, have been shown to increase the incidence of regional recurrence (RR) after surgery, which is associated with poor outcome. In patients undergoing SBRT, however, definite pathological nodal staging is lacking and so other ways to identify patients at high risk for ONM and RR are desirable. The aim of this systematic review is to summarize the incidence of, and risk factors for, RR after SBRT and compare these to those after surgery. The available evidence shows the incidence of RR after SBRT or surgery to be comparable, despite more elaborate pre- and intra-operative lymph node evaluation in surgical patients. However, the fact that this finding is based on mostly retrospective studies in which the majority of patients treated with SBRT were inoperable, needs to be taken into consideration. For now, there is no evidence that inoperable clinical stage I patients with no indication of pathological lymph nodes on PET/CT will benefit from more invasive lymph node staging prior to SBRT.
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Tantraworasin A, Saeteng S, Siwachat S, Jiarawasupornchai T, Lertprasertsuke N, Kongkarnka S, Ruengorn C, Patumanond J, Taioli E, Flores RM. Impact of lymph node management on resectable non-small cell lung cancer patients. J Thorac Dis 2017; 9:666-674. [PMID: 28449474 DOI: 10.21037/jtd.2017.02.90] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND A surgical lung resection with systematic mediastinal lymph node (LN) dissection is recommended by the National Comprehensive Cancer Network guideline. However, the effective number of dissected LNs, stations and positivity is still controversial. The aim of this study is to identify the impact of total numbers, LN stations and positivity of dissected LNs on tumor recurrence and overall death in resectable non-small cell lung cancer (NSCLC). METHODS This prognostic study used a retrospective data collection design. Adult patients with clinical resectable NSCLC who underwent pulmonary resection and mediastinal lymphadenectomy at Chiang Mai University between June 2000 and June 2012 were enrolled in this study. A multilevel mixed-effects parametric survival model was used to identify the effect of numbers, LN stations and positivity of dissected LNs to tumor recurrence and mortality. RESULTS The average number of dissected LNs was 22.7±12.8. Tumor recurrence was found in 51.3% and overall mortality was 43.3%. The number of dissected LNs was a prognostic factor for tumor recurrence [HR 0.98, 95% confidence interval (CI): 0.96-0.99]. There was a significant difference at the cut-pointed value of 11 dissected LNs for tumor recurrence (HR 2.22, 95% CI: 1.26-3.92). Dissection less than 11 nodes and less than 5 stations indicated a poor prognostic factor for tumor recurrence: for 3-4 stations (HR 3.01, 95% CI: 1.22-7.42) and for 1-2 stations (HR 1.96, 95% CI: 1.04-3.72). The positivity of dissected LNs was also a prognostic factor for tumor recurrence and overall mortality (HR 1.01, 95% CI: 1.01-1.02 and HR 1.01, 95% CI: 1.01-1.03, respectively). CONCLUSIONS Eleven or more LN dissection with at least 5 stations influenced recurrent-free survival. Systematic LN dissection (SLND) should be performed not only to identify the positivity of dissected LNs but also to determine an accurate tumor nodal stage. A larger cohort should be further conducted to support these findings.
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Affiliation(s)
- Apichat Tantraworasin
- Department of Surgery, Faculty of Medicine, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Somcharoen Saeteng
- Department of Surgery, Faculty of Medicine, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Sophon Siwachat
- Department of Surgery, Faculty of Medicine, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Tawatchai Jiarawasupornchai
- Department of Surgery, Faculty of Medicine, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Nirush Lertprasertsuke
- Department of Pathology, Faculty of Medicine, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Sarawut Kongkarnka
- Department of Pathology, Faculty of Medicine, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Chidchanok Ruengorn
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | | | - Emanuela Taioli
- Population Health Science and Policy and Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, USA
| | - Raja M Flores
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, USA
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12
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Pezzi TA, Mohamed ASR, Fuller CD, Blanchard P, Pezzi C, Sepesi B, Hahn SM, Gomez DR, Chun SG. Radiation Therapy is Independently Associated with Worse Survival After R0-Resection for Stage I-II Non-small Cell Lung Cancer: An Analysis of the National Cancer Data Base. Ann Surg Oncol 2017; 24:1419-1427. [PMID: 28154950 DOI: 10.1245/s10434-017-5786-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND The 1998 post-operative radiotherapy meta-analysis for lung cancer showed a survival detriment associated with radiation for stage I-II resected non-small cell lung cancer (NSCLC), but has been criticized for including antiquated radiation techniques. We analyzed the National Cancer Database (NCDB) to determine the impact of radiation after margin-negative (R0) resection for stage I-II NSCLC on survival. METHODS Adult patients from 2004 to 2014 were analyzed from the NCDB with respect to receiving radiation as part of their first course of treatment for resected stage I-II NSCLC; the primary outcome measure was overall survival. RESULTS A total of 197,969 patients underwent R0 resection for stage I-II NSCLC, and 4613 received radiation. Median radiation dose was 55 Gy with a 50-60 Gy interquartile range. On adjusted analysis, treatment at a community cancer program, sublobectomy, tumor size (3-7 cm), and pN1/Nx were associated with receiving radiation (odds ratio > 1, p < 0.05). The irradiated group had shorter median survival (45.8 vs. 77.5 months, p < 0.001), and radiation was independently associated with worse overall survival (hazard ratio (HR) 1.339, 95% confidence interval (CI) 1.282-1.399). After propensity score matching, radiation remained associated with worse overall survival (HR 1.313, 95% CI 1.237-1.394, p < 0.001). CONCLUSIONS Radiotherapy was independently associated with worse survival after R0 resection of stage I-II NSCLC in the NCDB and was more likely to be delivered in community cancer programs.
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Affiliation(s)
| | - Abdallah S R Mohamed
- Division of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA.,Department of Clinical Oncology and Nuclear Medicine, Alexandria University, Alexandria, Egypt
| | - Clifton D Fuller
- Division of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Pierre Blanchard
- Division of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA.,Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Christopher Pezzi
- Department of Surgery, Abington Hospital-Jefferson Health, Abington, PA, USA
| | - Boris Sepesi
- Division of Surgery, Department of Thoracic and Cardiovascular Surgery, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Stephen M Hahn
- Division of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Daniel R Gomez
- Division of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Stephen G Chun
- Division of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA.
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