Favourable outcomes in patients with early-stage non-small-cell lung cancer operated on by video-assisted thoracoscopic surgery: a propensity score-matched analysis

Postoperative leukocyte counts as a surrogate for surgical stress response in matched robot- and video-assisted thoracoscopic surgery cohorts of patients: A preliminary report

The objective is to preliminary evaluated postoperative leukocyte counts as a surrogate for the surgical stress response in NSCLC patients who underwent RATS or VATS for further prospective analyses with proper assessment of surgical stress response and tissue trauma. We retrospectively analyzed patients with stageI-IIIA NSCLC who underwent RATS or VATS at a hospital between 8 May 2020 and 31 December 2021. Analysis of leukocytes (including neutrophils and lymphocytes) and albumin on postoperative days (PODs) 1 and 3 in patients with NSCLC treated with RATS or VATS after propensity score matching (PSM). In total, 1824 patients (565 RATS and 1259 VATS) were investigated. The two MIS groups differed significantly with regard to operative time (p < 0.001), chronic lung disease (p < 0.001), the type of pulmonary resection (p < 0.001), the excision site of lobectomy (p = 0.004), and histology of the tumor (p = 0.028). After PSM, leukocyte and neutrophil levels in the RATS group were lower than those in the VATS group on PODs 1 and 3, with those on POD 3 (p < 0.001) being particularly notable. While lymphocyte levels in the RATS group were significantly lower than those in the VATS group only at POD 1 (p = 0.016). There was no difference in albumin levels between the RATS and VATS groups on PODs 1 and 3. The surgical stress response and tissue trauma was less severe in NSCLC patients who underwent RATS than in those who underwent VATS, especially reflected in the neutrophils of leukocytes.

Real-world surgical treatment patterns and clinical outcomes in patients with stages IA-IIIA non-small cell lung cancer: a retrospective multicentric observational study involving 11,958 patients

PURPOSE

Surgical resection is cornerstone treatment for early-stage non-small cell lung cancer (NSCLC) and offers a chance for cure. This study was conducted to determine current surgical treatment patterns and outcomes of Chinese patients with NSCLC.

METHODS

Data of patients with histologically confirmed NSCLC of stages IA-IIIA and who underwent surgery between July 2014 and July 2020 were retrospectively collected from 9 tertiary hospitals in China. Cox model was used for multivariate analyses.

RESULTS

This study included 11,958 patients, among whom 59.1%, 19.2%, and 21.7% were in stages I, II, and IIIA, respectively. Lobectomy was the most common operation method (78.4%), followed by wedge resection (8.2%), segmentectomy (5.4%), pneumonectomy (5.2%), and bronchial sleeve lobectomy (2.8%). Among patients who underwent wedge resection and segmentectomy, majority had stage I NSCLC (87.2% and 93.3%, respectively), and sublobectomy accounted for 20.7% of stage I operations. With a median follow-up time of 30.2 months, disease-free survival (DFS) and overall survival (OS) rates of entire population were 88.9% and 96.1% at 1 year, 75.2% and 85.1% at 3 years, and 65.3% and 77.0% at 5 years, respectively. The 5-year OS rates for stages IA, IB, IIA, IIB, and IIIA disease were 93.2%, 82.7%, 70.3%, 67.0%, and 52.1%, respectively.

CONCLUSION

This is the largest real-world cohort study of patients with NSCLC who underwent surgery in China, where we described characteristics of surgical treatment and survival outcomes. The results of our study provide insights into real-world surgical treatment status for surgeons and clinicians.

Sex and Survival After Surgery for Lung Cancer: A Swedish Nationwide Cohort

BACKGROUND

Prior reports on a possible female survival advantage in both surgical and nonsurgical cohorts of patients with lung cancer are conflicting. Previously reported differences in survival after lung cancer surgery could be the result of insufficient control for disparities in risk factor profiles in men and women.

RESEARCH QUESTION

Do women who undergo pulmonary resections for lung cancer have a better prognosis than men when taking a wide range of prognostic factors into account?

STUDY DESIGN AND METHODS

We performed a nationwide population-based observational cohort study analyzing sex-specific survival after pulmonary resections for lung cancer. We identified 6356 patients from the Swedish National Quality Register for General Thoracic Surgery and performed individual-level record linkage to other national health-data registers to acquire detailed information regarding comorbidity, socioeconomic status, and vital status. Inverse probability of treatment weighting was used to account for differences in baseline characteristics. The association between female sex and all-cause mortality was assessed with Cox regression models, and flexible parametric survival models were used to estimate the absolute survival differences with 95% CIs. We also estimated the difference in restricted mean survival time.

RESULTS

We observed a lower risk of death in women compared with men (hazard ratio, 0.73; 95% CI, 0.67-0.79). The absolute survival difference at 1, 5, and 10 years was 3.0% (95% CI, 2.2%-3.8%), 10% (95% CI, 7.0%-12%), and 12% (95% CI, 8.5%-15%), respectively. The restricted mean survival time difference at 10 years was 0.84 year (95% CI, 0.61-1.07 years). The findings were consistent across several subgroups.

INTERPRETATION

Women who underwent pulmonary resections for lung cancer had a significantly better prognosis than men. The survival advantage was evident regardless of age, common comorbidities, socioeconomic status, lifestyle factors, physical performance, type and extent of surgery, tumor characteristics, and stage of disease.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT03567538; URL: www.clinicaltrials.gov.

Short- and long-term outcomes of thoracoscopic pneumonectomy - single center experience

Introduction

The video-assisted thoracic surgery (VATS) approach is widely used for pulmonary lobectomy, but its application for pneumonectomy is much less common and outcomes are ambiguous.

Aim

To evaluate the feasibility and outcomes of VATS pneumonectomy.

Material and methods

This retrospective study included 19 patients with the mean age of 62.6 ±5.5 years who were qualified for VATS pneumonectomy between September 1, 2010, and January 31, 2020. Indications and technical aspects were analyzed. Moreover, short- and long-term outcomes were assessed.

Results

There were no intraoperative deaths. Conversion to thoracotomy was necessary in 2 (10.5%) patients, because of bleeding in 1 patient and technical reasons in another. One patient died during the in-hospital period due to multi-organ failure as a result of bronchopleural fistula. Five other subjects developed postoperative complications, most often atrial fibrillation (n = 3). One patient was readmitted for empyema of the postpneumonectomy space without bronchopleural fistula. Histopathological examination revealed that the resection was complete (R0) in all cases and the most common type of cancer was squamous cell carcinoma (79%). Seven patients died during the follow-up: 1 because of surgical complications, 4 as a result of cancer progression, and 2 for non-cancer related reasons. Median survival was 47 months. One- and five-year probability of survival estimated by means of the Kaplan-Meier method was 0.88 ±0.07 and 0.43 ±0.15, respectively.

Conclusions

VATS pneumonectomy can be performed safely, without increased risk of intraoperative and postoperative complications. It enables a complete lung cancer resection and is likely to provide good short- and long-term outcomes.

A narrative review of invasive diagnostics and treatment of early lung cancer

The diagnosis and treatment of early-stage lung cancer remains a clinical challenge. The broadening implementation of lung cancer screening has resulted in positive findings in numerous patients that are mostly non-malignant. Many other patients have indeterminate nodules that are difficult to assess through simple observation. The critical interpretation of such screening results remains a challenge for radiologists and multidisciplinary teams involved in screening for lung cancer. The evaluation and diagnosis of each participant suspected for malignancy should be based on the basic clinical principles such as a carefully collected medical history, physical examination, and detailed analysis of all imaging tests performed. Indeed, the decision to go ahead with more invasive diagnostics requires consideration of the both the risks and benefits, with reflection upon the complete clinical and radiological picture. Although transthoracic needle aspiration biopsy remains the first-choice method of diagnosis, several newer technologies have slowly begun to emerge as potential replacements. The guiding strategy for method selection is to choose the least harmful approach that offers the most relevant potential insights. Transthoracic biopsy is an effective method that allows the collection of cytological and tissue material from small, peripheral tumors, but it carries a moderate risk of complications. Bronchofiberoscopy, especially in combination with electromagnetic navigation, fluoroscopy or radial EBUS, also allows effective diagnosis of the peripheral pulmonary nodules. One of the most important diagnostic methods is the EBUS examination, which allows determining of staging in addition to diagnosis. Anatomical lung lobe resection and lymphadenectomy or sampling of the hilar and mediastinal lymph nodes is currently the treatment of choice for patients with stage I and II non-small cell lung cancer (NSCLC), but sublobar resections are recommended when a patient has limited pulmonary function or other significant comorbidities. Notably, several studies have highlighted the potential utility of more limited resections in small malignant lesions less than 2cm in diameter, with pure AIS histology, when more than 50% of the diameter of pulmonary nodule has ground-glass opacity (GGO) attenuation on CT, or long volume doubling time (VDT). Videothoracoscopy is the preferred surgical approach for resection of early-stage lung cancer. Patients who are not candidates for surgery or do not agree to surgery can be offered radical radiotherapy. Stereotactic body radiation therapy (SBRT) is a type of radical radiotherapy with proven effectiveness, a high rate of local control and an acceptable risk of the development of later complications. Future trials are expected to define the role of SBRT in the treatment of early lung cancer in healthy subjects.

Perioperative comparison of video-assisted thoracic surgery and open lobectomy for pT1-stage non-small cell lung cancer patients in China: a multi-center propensity score-matched analysis

Background

Compared with open surgery, video-assisted thoracic surgery (VATS) has innovated the concept of the minimally invasive approach for non-small cell lung cancer (NSCLC) patients in past decades. This present study aimed to compare the perioperative and lymph node dissection outcomes between VATS lobectomy and open lobectomy for pathological stage T1 (pT1) NSCLC patients from both surgical and oncologic perspectives.

Methods

This was a retrospective multicenter study. Patients who underwent surgical resection for pT1 NSCLC between January 2014 and September 2017 were retrospectively reviewed from 10 thoracic surgery centers in China. Perioperative and lymph node dissection outcomes of pT1 NSCLC patients who accepted VATS or open lobectomies were compared by propensity score matching (PSM) analysis.

Results

Of the 11,360 patients who underwent surgery for pT1 NSCLC, 7,726 were enrolled based on the selection criteria, including 1,222 cases of open lobectomies and 6,504 cases of VATS lobectomies. PSM resulted in 1,184 cases of open lobectomies and 1,184 cases of VATS lobectomies being well matched by common prognostic variables, including age, sex, and surgical side. VATS lobectomy led to better perioperative outcomes, including less blood loss (133.5±200.1 vs. 233.3±318.4, P<0.001), lower blood transfusion rate (2.4% vs. 6.4%, P<0.001), shorter postoperative hospital stay (8.6±5.7 vs. 10.1±5.1, P<0.001), less chest drainage volume (1,109.5±854.0 vs. 1,324.1±948.8, P<0.001), and less postoperative complications (4.9% vs. 8.2%, P<0.001). However, open lobectomy had better lymph node dissection outcomes than VATS, with increased lymph node dissection numbers (16.1±9.4 vs. 13.7±7.7, P<0.001) and more positive lymph nodes being dissected (1.5±3.9 vs. 1.1±2.5, P=0.002). Compared with VATS, open lobectomy harvested more lymph node stations (5.5±1.9 vs. 5.2±1.8, P=0.001), including more pathological N2 (pN2) lymph node stations (3.4±1.4 vs. 3.1±1.3, P<0.001).

Conclusions

VATS lobectomy was associated with better perioperative outcomes, such as less blood loss, lower blood transfusion rate, shorter postoperative hospital stay, less chest drainage volume and less postoperative complications. Open lobectomy has improved lymph node dissection outcomes, as more lymph nodes and positive lymph nodes were dissected for pT1 NSCLC patients during surgery.

Comparison of the Short- and Long-term Outcomes of Video-assisted Thoracoscopic Surgery versus Open Thoracotomy Bronchial Sleeve Lobectomy for Central Lung Cancer: A Retrospective Propensity Score Matched Cohort Study

PURPOSE

The purpose of this study was to evaluate the short- and long-term outcomes of video-assisted thoracoscopic surgery (VATS) versus open thoracotomy bronchial sleeve lobectomy (BSL) for patients with central lung cancer.

METHODS

This is a retrospective cohort study. Perioperative outcomes and long-term survival of patients who underwent VATS versus open thoracotomy BSL for central lung cancer from June 2010 and June 2018 in the Western China Lung Cancer Database were compared using propensity score matching (PSM) between the two surgical approaches.

RESULTS

The retrospective study included 187 patients who divided into VATS group (n = 44) and open group (n = 143) according to surgical approach, and PSM resulted in 43 patients in each group, which were well matched by 11 potential prognostic factors. The VATS group was associated with lower overall incidence of postoperative complications (20.3% vs. 30.2%, P = 0.029), less postoperative drainage (875 ml [250-3960] vs. 1280 ml [100-4890], P = 0.039). The 5-year overall survival (OS) and disease-free survival (DFS) were comparable between the VATS and open groups (55.9% vs. 65.2% P = 0.836 and 54.1% vs. 60.2% P = 0.391, respectively) after matching. Multivariable adjusted analysis demonstrated that the surgical approach was not an independent favorable prognostic factor for OS (hazard ratio [HR] = 0.922; 95% confidence interval [CI], 0.427-1.993; P = 0.836) but just the pTNM stage (HR = 2.003; 95% CI 1.187-3.382; P = 0.009).

CONCLUSIONS

VATS BSL may achieve equivalent long-term outcomes for central lung cancer patients when comparing with open thoracotomy. Although slightly longer duration of surgery, VATS approach may be a feasible option for lung cancer patients requiring BSL.

Household disposable income and long-term survival after pulmonary resections for lung cancer

Introduction

Socioeconomic disparities have been linked to survival differences in patients with lung cancer. Swedish healthcare is tax-funded and provides equal access to care, therefore, survival following lung cancer surgery should be unrelated to household income. The aim of this study was to investigate the association between household disposable income and survival following surgery for lung cancer in Sweden.

Methods

We conducted a nationwide population-based cohort study including all patients who underwent pulmonary resections for lung cancer in Sweden 2008–2017. Individual-level record linkages between national quality and health-data registers were performed to acquire information regarding socioeconomic status and medical history. Cox regression by quintiles of household disposable income was used to estimate the adjusted risk for all-cause mortality.

Results

We included 5500 patients and the age-adjusted and sex-adjusted incidence rate of death per 100 person-years was 15 and 9.4 in the lowest and highest income quintile, respectively (mean follow-up time 3.2 years). Deprived patients were older, had more comorbidities and were less likely to have preoperative positron emission tomography or minimally invasive surgery, compared with patients with higher income. The adjusted HR for death was 0.77 (95% CI: 0.62 to 0.96) for the highest income quintile compared with the lowest.

Conclusions

We found an association between household disposable income and survival in patients who underwent surgery for lung cancer in Sweden, despite tax-funded universal health coverage. The association remained after adjustment for differences in baseline characteristics.

Uniportal versus multiportal video-assisted thoracic surgery for lung cancer

Background

Video-assisted thoracic surgery (VATS) lobectomy is the recommended surgical approach for patients with stage I lung cancer. Whether a multiportal or a uniportal approach is preferable remains unclear. The aim of this study was to evaluate the safety of implementing uniportal VATS lobectomy into the treatment program of lung cancer patients.

Methods

We used the national quality register for general thoracic surgery in Sweden and included all patients who underwent VATS lobectomy for lung cancer at the Karolinska University Hospital between 2016-2018. Early postoperative complications were compared in patients undergoing uniportal (n=122) and multiportal (n=211) VATS lobectomy for lung cancer. Inverse probability of treatment weighting and standardized mean differences were used to limit differences in baseline characteristics and to assess balance after weighting.

Results

The proportion of uniportal VATS lobectomies increased during the study period and the conversion rates declined significantly. Baseline characteristics were similar in the two groups with the exception of a higher percentage of patients without any comorbidity in the uniportal group (59.8% vs. 44.5%, P=0.010). After inverse probability of treatment weighting the groups were well balanced. Postoperative complications were rare regardless of surgical approach, 94% in both groups had no complications. The 30-day mortality and overall survival at 1 year was 0% and 97% in the uniportal group, and 0.5% and 98% in the multiportal group (P=0.71). Patients undergoing uniportal VATS lobectomy were discharged directly to home to a higher extent than multiportal VATS patients (76.2% vs. 62.1%, P=0.008).

Conclusions

We found that uniportal VATS lobectomy was feasible and safe, and might entail advantages in terms of a faster recovery after surgery as compared to multiportal VATS lobectomy in patients with lung cancer.

Comparison of robotic-assisted lobectomy with video-assisted thoracic surgery for stage IIB-IIIA non-small cell lung cancer

Background

With the rapid development of surgical technics and instruments, more and more locally advanced non-small cell lung cancer (NSCLC) patients are being treated by minimally invasive surgery (MIS), including video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracic surgery (RATS). The aim of this retrospective study was to compare the perioperative and long-term outcomes of patients who underwent lobectomy by these two surgical approaches.

Methods

We performed a retrospective review of the prospectively collected database of our hospital to identify patients with clinical stage IIB-IIIA NSCLC who underwent video-assisted thoracoscopic or robotic lobectomy. Perioperative outcomes, recurrence, and overall survival (OS) were compared.

Results

From January 2014 to January 2017, there were at total of 121 patients, including 36 robotic lobectomy patients and 85 VATS lobectomy patients. One patient (2.8%) in the RATS group and 5 patients (5.9%) in the VATS group were converted to thoracotomy (P=0.79). No perioperative death was observed in both groups. The postoperative morbidity was similar between the two groups (13.9% for RATS vs. 15.3% for VATS; P=0.84). Robotic lobectomy was associated with a shorter length of postoperative hospital stay (4 vs. 5 d, P<0.01) and more counts of lymph nodes harvested (13 vs. 10, P<0.01). The median disease-free survival (DFS) for the RATS and VATS groups were 31.1 and 33.8 months, respectively. The corresponding 3-year DFS was 40.3% in the RATS group and 47.6% in the VATS group (P=0.74). The 3-year OS was 75.7% in RATS and 77.0% in the VATS group (P=0.75).

Conclusions

For selected NSCLC patients with lymph node involvement, robotic lobectomy is safe and effective with a low complication rate and similar long-term outcome compared with VATS lobectomy. Moreover, the robotic approach resulted in shorter postoperative length of stay and greater lymph node assessment.

Implementation of lung cancer screening at the national level: Polish example

In Poland the national demonstration lung cancer screening program is about to be started in 2019. We share our concerns and discussing most important topics to be resolved while preparing such a program. The decisions made are virtually based on available scientific data and the results of two randomized controlled trials but also on the personal experience gained during the lung cancer screening studies performed in Poland. The most important and comprehensive guidelines and statements, both European and American, have been searched to find an optimal solution adjusted to the Polish national circumstances-as we assume that should be done in each country implementing such a program.

Long-term survival outcomes of video-assisted thoracic surgery lobectomy for stage I-II non-small cell lung cancer are more favorable than thoracotomy: a propensity score-matched analysis from a high-volume center in China

Background

Video-assisted thoracic surgery (VATS) has been considered as the better choice for the surgical treatment of resectable non-small cell lung cancer (NSCLC). This study aimed to evaluate the short- and long-term outcomes of VATS versus open thoracotomy lobectomy for patients with pathological stage (p-stage) I-II NSCLC in one of the high-volume center in China.

Methods

Perioperative outcomes and long-term survival of patients who underwent VATS versus open lobectomies for p-stage I-II NSCLC from May 2006 to June 2013 in the Western China Lung Cancer Database (WCLCD) were studied using propensity score matching (PSM). The VATS lobectomy was mainly carried out using the single-direction technique.

Results

Of the 3,678 patients who underwent surgery for lung malignancies, 1,485 patients with stage I-II NSCLC were enrolled for the study, including 737 cases of VATS lobectomies and 748 cases of open lobectomies. PSM resulted in 464 cases of VATS lobectomies and 464 cases of open lobectomies who were well matched by ten potential prognostic factors including tumor size, T- and N-stage. VATS lobectomy was associated with less blood loss than open surgery (median: 60 vs. 100 mL, P=0.000), as well as fewer postoperative complications (15.1% vs. 20.3%, P=0.039). In addition, the VATS approach removed more lymph node stations (4.9±1.5 vs. 4.2±1.8, P=0.000). The postoperative hospital stay was shorter in the VATS group (7.7±3.8 vs. 8.3±4.3, P=0.019), but the total hospital costs were more expensive (48.4±11.3 vs. 35.5±9.4 kRMB, P=0.000). The matched cohorts revealed that VATS lobectomy for stage I-II NSCLC had improved 5-year overall survival (OS) than the open approach (71.1% vs. 65.4%, P=0.045).

Conclusions

The VATS lobectomy is associated with less blood loss, fewer postoperative complications, and shorter postoperative hospital stay when comparing with the open approach for stage I-II NSCLC. Despite more hospital costs, VATS lobectomy offer improved 5-year OS than the open approach. It is reasonable to recommend the VATS approach as the preferred option for the surgical treatment of stage I-II NSCLC.

Tumor-derived exosomal proteins as diagnostic biomarkers in non-small cell lung cancer

Accumulating evidence supports a role for exosomal protein in diagnosis. The purpose of this study was to identify the tumor‐derived exosomal biomarkers in the serum that improve the diagnostic value in Chinese non‐small cell lung cancer (NSCLC) patients. Serum exosomes were isolated from healthy donors (n = 46) and NSCLC patients (n = 125) by ultracentrifugation and were characterized using transmission electron microscopy, qNano, and immunoblotting. Proteomic profiles (by mass spectrometry) revealed multiple differentially expressed proteins in the healthy and NSCLC groups. The exosomal expression levels of alpha‐2‐HS‐glycoprotein (AHSG) and extracellular matrix protein 1 (ECM1) increased significantly in the NSCLC patients compared to the healthy group. Alpha‐2‐HS‐glycoprotein showed diagnostic values with a maximum area under the receiver operating characteristic curve (AUC) as 0.736 for NSCLC vs healthy individuals (P < .0001) and 0.682 for early stage NSCLC vs healthy individuals (P < .01). Extracellular matrix protein 1 showed the diagnostic capacity with AUC values of 0.683 (P < .001) and 0.656 (P < .05) in cancer and early stage NSCLC compared to healthy individuals. When AHSG was combined with ECM1, the AUCs were 0.795 and 0.739 in NSCLC and early stage patients, respectively. Taken together, the combination of AHSG, ECM1, and carcinoembryonic antigen improved the diagnostic potential of NSCLC. The diagnosis values were AUC of 0.938 for NSCLC and 0.911 for early stage NSCLC vs healthy individuals. Our results suggest that novel proteomic signatures found in serum exosomes of NSCLC patients show potential usefulness as diagnostic tools.

Video-assisted thoracoscopic versus open thoracotomy lobectomy: a Swedish nationwide cohort study

Background

The aim of this nationwide observational cohort study was to investigate the early postoperative complications and long-term survival following video-assisted thoracoscopic surgery (VATS) lobectomy compared to open thoracotomy lobectomy for early stage non-small cell lung cancer (NSCLC).

Methods

We used the Swedish national quality register for general thoracic surgery and included all patients who underwent lobectomy for NSCLC during 2012-2015. We compared postoperative complications and long-term survival in patients who underwent VATS lobectomy at our institution to patients who underwent open lobectomy at the other seven hospitals in Sweden. We used inverse probability of treatment weighting to limit differences in baseline characteristics between the groups and used standardized mean differences to assess balance after weighting.

Results

We included 1,601 patients who underwent open (n=1,316) or VATS (n=285) lobectomy for NSCLC. The mean age was 67.7 years in both groups and comorbidities were well balanced, but the open thoracotomy group had a higher proportion of patients with more advanced cancer stage. After weighting, all baseline characteristics were well balanced. Most patients (84%) did not have postoperative complications; 83% vs. 86% in the open and VATS group, respectively (P=0.41). The 30- and 90-day mortality was 0.7% vs. 0.3% (P=0.38) and 1.7% vs. 0.3% (P=0.09) in the open thoracotomy and VATS group, respectively. There were significantly more transfusions (5.0% vs. 1.4%, P=0.008) and pneumonia (5.5% vs. 0.6%, P=0.002) in the in the open thoracotomy and VATS group, respectively. The overall survival at 1 and 5 years was 92% vs. 97% and 63% vs. 78% in the open thoracotomy and VATS group, respectively; HR (95% CI): 0.47 (0.33-0.68).

Conclusions

We found less postoperative complications and better long-term survival following VATS lobectomy compared to open thoracotomy lobectomy for NSCLC. The implementation of a VATS lobectomy program did not compromise patient safety or the oncological efficacy.