Long-term survival outcomes after lobe-specific nodal dissection in patients with early non-small-cell lung cancer

OBJECTIVES

We investigated the long-term outcomes of lobe-specific nodal dissection (LSD) and systematic nodal dissection (SND) in patients with non-small-cell lung cancer (NSCLC).

METHODS

Patients with c-stage I and II NSCLC who underwent lobectomy with mediastinal nodal dissection were retrospectively analysed. After propensity score matching, we assessed the overall survival (OS), recurrence-free survival (RFS) and cumulative incidence of death (CID) from primary lung cancer and other diseases.

RESULTS

The median follow-up period was 8.4 years. Among 438 propensity score-matched pairs, OS and RFS were similar between the LSD and SND groups [hazard ratio (HR), 0.979; 95% confidence interval (CI), 0.799-1.199; and HR, 0.912; 95% CI, 0.762-1.092, respectively], but the LSD group showed a better prognosis after 5 years postoperatively. CID from primary lung cancer was similar between the 2 groups (HR, 1.239; 95% CI, 0.940-1.633). However, the CID from other diseases was lower in the LSD group than in the SND group (HR, 0.702; 95% CI, 0.525-0.938). According to c-stage, the LSD group tended towards worse OS and RFS, with higher CID from primary lung cancer than the SND group, in patients with c-stage II.

CONCLUSIONS

LSD provides acceptable long-term survival for patients with early-stage NSCLC. However, LSD may not be suitable for patients with c-stage II NSCLC due to the higher mortality risk from primary lung cancer.

Reclassifying the International Association for the Study of Lung Cancer Residual Tumor Classification According to the Extent of Nodal Dissection for NSCLC: One Size Does Not Fit All

INTRODUCTION

The extent of nodal assessment may require risk-based adjustments in NSCLC. We reclassified the International Association for the Study of Lung Cancer Residual tumor classification according to the extent of nodal dissection and evaluated its long-term prognosis by tumor stage and histologic subtype.

METHODS

We reclassified 5117 patients who underwent resection for clinical stages I to III NSCLC and had complete or uncertain resection by International Association for the Study of Lung Cancer classification into the following 3 groups according to compliance with three components (N1, N2, and subcarinal node) of systematic nodal dissection criteria: fully compliant group (FCG), partially compliant group (PCG), and noncompliant group (NCG). Recurrence-free survival (RFS) and overall survival (OS) were compared.

RESULTS

Of the 5117 patients, 2806 (55%), 1959 (38%), and 359 (7%) were FCG, PCG, and NCG, respectively. PCG and NCG were more likely to be of lower clinical stage and adenocarcinoma with lepidic component than FCG. The 5-year RFS and OS were significantly better in NCG than in FCG or PCG (RFS, 86% versus 70% or 74%, p < 0.001; OS, 90% versus 80% or 83%, p < 0.001). In particular, NCG had better RFS and OS than FCG or PCG in clinical stage I and in lepidic-type adenocarcinoma.

CONCLUSIONS

In early stage NSCLC with low-risk histologic subtype, a less rigorous nodal assessment was not associated with a worse prognosis. Although surgeons should continue to aim for complete resection and thorough nodal assessment, a uniform approach to the extent and invasiveness of nodal assessment may need to be reconsidered.

Radicality of lymphadenectomy in lung cancer resections by thoracotomy and video-assisted thoracoscopic approach: A prospective, multicentre and propensity-score adjusted study

OBJECTIVE

To analyse differences in intraoperative nodal assessment in patients undergoing lung cancer resection by thoracotomy and video-assisted thoracoscopy (VATS) in the Spanish Video-Assisted Thoracic Surgery Group (GEVATS).

METHODS

Prospective multicentre cohort study of anatomic pulmonary resections (n = 3533) performed from December 2016 to March 2018. Main surgical, clinical and oncological variables related with lymphadenectomy were compared according to surgical approach. Corresponding tests for homogeneity were performed. Multiple logistic regression analyses were used to determine the odds ratio (OR) and 95% confidence interval (95%CI). Covariate adjustment using the propensity score (PS) was performed to reduce confounding effects.

RESULTS

After exclusions, 2532 patients were analysed. Systematic nodal dissection (SND) was performed in 65%, with a median of resected/sampled lymph nodes (LN) of 7 (IQR 4-12) and pathologic (p) N2 and uncertain (u) pNu rates of 9.4% and 28.9%, respectively. At multivariate analysis, the following were associated with thoracotomy (OR; 95%CI): SND (1.4; 1.08-1.96; p = 0.014), staging mediastinoscopy (2.6; 1.59-4.25; p < 0.001), tumor > 3 cm (2.1; 1.66-2.78; p < 0.001), central tumor (2.5; 1.90-3.24; p < 0.001); pN1 (1.8; 1.25-2.67; p < 0.002), pN2 (1.8; 1.18-2.76; p = 0.006), lower FEV1 (0.9; 0.98-0.99; p < 0.001), squamous cell carcinoma (1.5; 1.16-1.98; p = 0.002) and inexperienced surgeons in VATS (compared with > 100 VATS experience) (37.6; 13.55-104.6; p < 0.001). After PS adjustment, SND maintained the OR, but in the limit of signification (1.4; 1-1.98; p = 0.05). Nodal upstaging was significantly higher in the thoracotomy group. Complication rates of SND and no SND were similar.

CONCLUSIONS

Thoracotomy was associated with a more thorough lymphadenectomy in GEVATS. Therefore, intraoperative lymph node evaluation performed at VATS should be improved to have better prognostic information and more solid grounds to indicate adjuvant therapy.

Non-energy devices to dissect recurrent laryngeal nerve lymph nodes of non-small cell lung cancer under video-assisted thoracic surgery

Background

Systematic nodal dissection plays a crucial role in improving survival and staging in resectable non-small cell lung cancer (NSCLC) patients but at the cost of increasing the occurrence of recurrent laryngeal nerve injury. Technology should be improved to protect the recurrent laryngeal nerve (RLN) during surgery.

Methods

NSCLC patients who underwent video-assisted thoracic surgery (VATS) surgical treatment by the same surgeon at our hospital from January 2016 to December 2017 were included as the research subjects and were divided into an energy-device group and a non-energy-device group. Their procedures included anatomic pulmonary resection, normative N1 dissection, and systemic N2 dissection.

Results

The rate of metastatically involved recurrent laryngeal nerve lymph nodes (RLNLNs) was 5.19% (39/752). Dissection device, side of primary, FEV1, operative time and BMI were independent predictors of recurrent laryngeal nerve injury (RLNI) (hazard ratio (HR) = 3.576, 95% confidence interval (CI): 1.490–8.583, P = 0.004; HR = 0.175, 95% CI: 0.072–0.424, P =  < 0.001; HR = 3.008, 95% CI: 1.30–6.927, P = 0.010; HR = 0.328, 95% CI: 0.136–0.794, P = 0.013; HR = 0.344, 95%CI: 0.147–0.801, P = 0.013, respectively). Patients in the non-energy-device group had significantly less RLNI than the energy-device group (P = 0.016) and nearly half of the non-thermal RLNI recovered in 2 weeks (P = 0.025) whereas most thermal RLNI required 3 months for recovery.

Conclusions

Every station of RLNLN had some degree of cancer metastasis in NSCLC patients and when dissecting RLNLNs, dissection device was an independent and artificially controlled predictor of RLNI. Using a non-energy device is a feasible method to protect the RLN as well as an improved recovery time of RLNI.

Combined one-stage minimally invasive surgery for primary pulmonary carcinoma and mitral regurgitation

Background

We report the first successful short-term outcome of one-stage minimally invasive surgery (MIS) mitral valve repair and video-assisted thoracoscopic surgery (VATS) lobectomy.

Case presentation

We report the first successful short-term outcome of combined one-stage video-assisted thoracoscopic surgery lobectomy and minimally invasive surgery in a patient with operable primary right upper lobe adenocarcinoma and mitral regurgitation. Post- operative recovery was uneventful, and follow-up at 6 weeks confirmed an excellent surgical and oncologic outcome.

Conclusions

We think one-stage minimally invasive surgery (MIS) cardiac surgery and video-assisted thoracoscopic surgery (VATS) lobectomy would benefit patients with satisfactory cardiac and pulmonary function.

Predictive value of primary fluorine-18 fluorodeoxyglucose standard uptake value for a better choice of systematic nodal dissection or sampling in clinical stage ia non--small-cell lung cancer

PURPOSE

To determine whether the standard uptake value (SUV) of the primary lesion can predict mediastinal lymph node metastasis in clinical stage IA non--small-cell lung cancer (NSCLC).

MATERIALS AND METHODS

At 5 centers, patients with clinical stage IA NSCLC from February 2004 to August 2010 were analyzed retrospectively. Data from Shandong Cancer Hospital and from the Cancer Hospital Affiliated to Harbin Medical University were used as a testing set, and data from the other 3 institutions were used as the validation set. Final diagnosis was established based on the histopathologic examination.

RESULTS

Data from 144 patients were collected for the study. The primary results in our study showed that maximal SUV (SUVmax) of primary tumor might be a predictor of lymph node metastasis (χ(2) = 10.424; P = .001) and the best cutoff value was 7.25 (P = .029). For the testing set, lymph node metastasis rates in low-grade group (SUVmax < 7.25) and high-grade group (SUVmax > 7.25) were 5% (2/43) and 36% (9/25) (P = .001) For the total data set, lymph node metastasis rate was 7% (6/93) in low-grade group (SUVmax < 7.25) and 26% (13/51) in high-grade group (SUVmax > 7.25) (χ(2)= 10.424; P = .001). A multivariate analysis revealed that no factors were applied to predict the probability of metastasis. But the analysis showed a weak correlation between SUVmax and nodal status (r = 0.21; P = .011) with bivariate correlation.

CONCLUSION

Analysis of our data suggested that fluorine-18 fluorodeoxyglucose SUVmax of the primary tumor might be a predictor of lymph node involvement in stage IA NSCLC. The rate of mediastinal lymph node metastasis of patients with a lower fluorine-18 fluorodeoxyglucose positron emission tomography-computed tomography SUVmax might be relatively low, which provides more evidence for clinical procedures of clinical stage IA NSCLC.