Complete Resection Of Lung Cancer Research Articles

Risk factors for progressive sarcopenia 6 months after complete resection of lung cancer: what can thoracic surgeons do against sarcopenia?

BackgroundOur previous report described how postoperative progression of sarcopenia predicted long-term prognosis after complete resection of non-small cell lung cancer (NSCLC) in heavy smokers. However, there are currently no effective means to treat progressive sarcopenia. In this study, we aimed to confirm our previous findings in a larger population and to identify factors associated with postoperative progression of sarcopenia to propose possible preventative measures.MethodsThis retrospective study analyzed the data of 1,095 patients who underwent curative lobar resection for NSCLC at Kanagawa Cancer Center. We divided patients into four groups according to sex and Brinkman index (BI) above or below 600. Six-month postoperative changes in the skeletal muscle index (SMI) were calculated and associations between clinicopathological factors including changes in SMI and mortality from postoperative 6 months were examined. Only in groups in which postoperative depletion of SMI was shown to be associated with the prognosis, we identified clinicopathological factors associated with depletive SMI.ResultsThe overall survival rates of 1,095 patients were 89.8% and 82.5% at 3 and 5 years, respectively. The median 6-month change in SMI was –3.4% (range, −22.3% to +17.9%). Multivariate analysis revealed that poor prognosis was independently predicted by a large reduction in the SMI (cut-off value: −10%) in males with a BI ≥600. In 391 heavy-smoking males, factors associated with a postoperative change in SMI ≤−10% were history of other cancers (including gastric cancer) low forced expiratory volume in one second (FEV 1.0, cut-off value: 1,870 mL), and prolonged operation time (cut-off value: 200 minutes).ConclusionsPerioperative measures to prevent postoperative sarcopenia are appropriate for heavy smokers. We obtained some clues regarding countermeasures, one of which may be avoiding long-time operation. Further studies including clinical trials to assess perioperative anti-sarcopenia treatments, are needed.

Effect of progressive sarcopenia during postoperative 6 months on long-term prognosis of completely resected lung cancer.

Preoperative sarcopenia has been indicated to be a potential prognostic factor for patients after complete resection of lung cancer. This study evaluated whether changes in the skeletal muscle mass index (SMI) over postoperative 6 months could predict long-term prognosis from 6 months after complete resection of non-small cell lung cancer (NSCLC). This retrospective study analyzed data of 468 patients who underwent curative lobar resection for non-small cell lung cancer at our hospital. The 6-month postoperative change in SMI was calculated, and associations between clinicopathological factors (including the change in SMI) and postoperative mortality were examined. Rates of overall survival were 90.6% after 3 years and 80.7% after 5 years. The median 6-month change in SMI was -3.4% (range, -22.3% to 14.7%). Multivariate analysis revealed that poor outcomes were independently predicted by a large change in SMI, age, pathological stage, lymphovascular invasion, and a Brinkman index of ≥600. Through the analysis in training and validation sets, we determined a cut-off value of -9.9% for the 6-month postoperative change in SMI. Subgroup analysis showed that depletion of SMI during postoperative 6 months was a risk factor for poorer prognosis only in heavy smokers with a Brinkman index of ≥600. A reduction in SMI during the 6 months after complete resection of non-small cell lung cancer significantly predicted prognosis, especially in heavy smokers. These results suggest that attention should be given to prevent the perioperative progression of sarcopenia after curative resection of lung cancer. Thoracic surgeons should take how to manage perioperatively against sarcopenia into consideration.

Computer-aided Quantification of Pulmonary Fibrosis in Patients with Lung Cancer: Relationship to Disease-free Survival.

Background Interstitial lung abnormalities (ILAs) are present at CT in about 10% of individuals undergoing lung cancer screening. The relationship between histologic findings of ILAs and their influence on patient prognosis remains unknown. Purpose To evaluate the percentage of ILAs at preoperative CT, as measured by radiologists and a computer-aided detection (CAD) software, as a predictor of disease-free survival in patients with lung cancer. Materials and Methods This retrospective study evaluated 217 consecutive patients who underwent complete resection of lung cancer from April 2010 to December 2015. Two radiologists, blinded to the patients' clinical information, scored percentage fibrosis extent and determined whether ILAs and the usual interstitial pneumonia (UIP) pattern were present. They assessed ILA progression at follow-up CT. Two pathologists determined the presence of an UIP pattern. Percentage fibrosis extent was also measured by using CAD. Binary logistic regression analysis was performed to determine whether the CAD percentage fibrosis extent was associated with ILA at CT. Multivariable Cox regression analysis was used to evaluate the significance of CAD percentage fibrosis extent as a predictor of prognosis. Results The radiologists classified 47 patients with ILAs and 24 patients with a UIP pattern at chest CT. The pathologists detected a UIP pattern in 25 patients. CT abnormalities showed progression over a 2-year period in all patients with histologic evidence of UIP. After adjustment for age, sex, and smoking index, the CAD percentage fibrosis extent was independently associated with ILA (odds ratio: 3.1; 95% confidence interval [CI]: 2.1, 4.7; P < .001). After adjustment for age, forced expiratory volume in 1 second (percentage predicted) radiologist-assessed percentage fibrosis extent, and pathologic stage, CAD percentage fibrosis extent was independently associated with worse disease-free survival (hazard ratio: 1.3; 95% CI: 1.1, 1.6; P < .001). Conclusion Greater computer-aided detection percentage fibrosis extent at preoperative CT independently predicted worse disease-free survival in patients with lung cancer. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Goo in this issue.

Spread through air spaces in lung cancer patients is a risk factor for pulmonary metastasis after surgery.

Spread through air spaces (STAS) is regarded as a significant risk factor for lung cancer recurrence. STAS consists of micropapillary clusters, solid nests, or single cells beyond the edge of the tumor into air spaces in the surrounding lung parenchyma. However, the patterns of lung cancer recurrence have not been clarified in patients with STAS. The aim of this study was to explore STAS and recurrence patterns in patients who underwent lung cancer surgery. Between January 2000 and December 2017, a total of 1,426 patients underwent complete resection of lung cancer. We studied 848 patients with pathological stage I disease who underwent surgery. Recurrence patterns and recurrence-free rates were determined from pathological findings, particularly the presence of STAS. Locoregional recurrences included surgical margin recurrences, hilar and mediastinal lymph node metastases, ipsilateral lobe metastases, and pleural dissemination, whereas distant recurrences included extrathoracic organ and contralateral lobe metastases. STAS was observed in 139 of 848 (16.4%) cases. Recurrences developed in 108 (12.7%) cases: locoregional recurrences in 76 (9.0%), distant metastases in 27 (3.2%), and both in 5 (0.6%) cases. Among recurrences, pleural dissemination developed in 12 (1.4%) and pulmonary metastases in 46 (5.4%) cases. Five-year recurrence-free rates were 65.4% among patients with STAS and 89.0% among patients without STAS. Univariate and multivariate analyses revealed that STAS was a significant risk factor for recurrence (P<0.001), particularly locoregional recurrence (P=0.005). In addition, STAS was a significant risk factor for pulmonary metastasis (P=0.009). Among pathological stage I patients who undergo complete resection of lung cancer, patients with STAS tend to develop locoregional recurrence and pulmonary metastases.

Extended pneumonectomy for advanced lung cancer with cardiovascular structural invasions.

This study aims to investigate the predictive factors in relation to tumor stages, mediastinal involvements, perioperative adjuvant therapies and surgical techniques in advanced lung cancer patients who underwent extended pneumonectomy with cardiovascular structural resection. A comprehensive literature review was performed for extended pneumonectomies with cardiovascular structural resections in the PubMed, Google Scholar and HighWire Press for the year range 2000-2016. Data were carefully extracted regarding details such as the study population, demographics, clinical features, types of lung cancer, pathologic stages, nodal involvement, extent of pneumonectomy, cardiovascular structural resections, use of cardiopulmonary bypass, completeness of resection, pre- and postoperative adjuvant therapies, 1-5-year survival, median survival duration, comorbidity and mortality. Patients undergoing extended pneumonectomy with cardiovascular structural resection were characterized more by squamous carcinomas, N0 or N1, T4, stage 3 and left atrial invasions. More patients received postoperative radiochemotherapy than radioor chemotherapy. The five-year survival rate was 30.5±11.5% and the median survival duration was 23.0±10.7 months. Level 1 left atrial, aortic adventitial, and partial superior vena cava resections could be performed without cardiopulmonary bypass, while levels 2 and 3 left atrial resections with aorta or superior/inferior vena cava replacement should be performed under cardiopulmonary bypass. The advent of cardiopulmonary bypass facilitated complete resection of lung cancer, while leading to potential risks of metastasis and reoccurrence. Pathological status, surgical techniques and pre- and postoperative adjuvant therapies affect survival significantly. Surgical indications and negative predictive risk factors for patients' survival warrant further evaluations.

P1.08-014 Usefulness of Chest CT in Follow-Up of Patients with Completely Resected Lung Cancer

There is no consensus about the best method to follow up patients after complete resection of lung cancer. This study was performed to identify how often follow-up chest-CT detected recurrence or a second primary lung cancer in asymptomatic patients. This is a retrospective study. Patients with diagnosis of non-small cell lung cancer submitted to complete surgical resection were included. They were followed-up with regular visits to the clinic and chest CTs. The visits to the clinic were every three months in the first two years, semiannually up to the fifth year, and annually thereafter. Patients were classified in symptomatic and asymptomatic according to the presence of clinical manifestations at each visit. From 2003 to 2013, 134 patients were included. Median age was 63.5 years. Seventy three (54.5%) were male. Current or former-smokers were 70.1% of the patients. Adenocarcinoma was the most common histologic type, observed in 82 (61.2%) of the patients. Lobectomy/bilobectomy was performed in 99 (73.8%), segmentectomy in 31 (23.1%), and pneumonectomy in 4 (3%). Pathological stage was: IA(53%), IB(10.2%), IIA(11.7%), IIB(6,6%), IIIA(13.3%), IIIB(3.1%), and IV (2.1%). Forty six (44.3%) patients were submitted to adjuvant treatment. Median follow-up was 30.2 months. Recurrence was detected in 18 (13.4%) patients, being local (including mediastinal) in 10 (7.4%), and distant in 8 (5.9%). Local recurrences were mainly detected by chest CT in asymptomatic patients. Distant recurrence was detected mostly by clinical symptoms (Table 1). Second primary lung cancers were found by chest CT in 15 (11.2%) asymptomatic patients.Table 1Correlation between type of recurrence and presence of symptoms.Local recurrenceDistant recurrenceCT (Asymptomatic)9 (90%)2 (25%)CT (Symptomatic)1 (10%)6 (75%)Total10 (100%)8 (100%) Open table in a new tab p = 0.09. Routine chest-CT detected most cases of local recurrence and second primary lung cancers in asymptomatic patients after curative resection of non-small cell lung cancer. Clinical examination and chest CT should be recommended for follow up after complete surgical resection.

Bronchial Stump Recurrence after Complete Resection of Lung Cancer: Effect of the Distance between the Tumor and Bronchial Resection Margin.

The purpose of this study was to evaluate the following parameters after complete resection in established lung cancer patients: the frequency of bronchial stump recurrence (BSR), the effect of the distance between the tumor and bronchial resection margin (DBTM) on BSR, the survival of patients with BSR, and the effect of the DBTM on survival. We retrospectively evaluated 553 consecutive lung cancer patients who underwent complete lung resection. The patients were classified as DBTM: ≤ 10 mm (group 1), 11 to 20 mm (group 2), and > 20 mm (group 3). We found BSR in eight (1.5%) patients. Six patients were in group 1, and two were in group 2. The difference was found to be statistically significant (p = 0004; groups 1 vs. 3). In multivariable analysis, we observed a trend toward significance for the effect of a DBTM on BSR development (p = 0.1). The DBTM did not significantly affect survival (p = 0.61). The survival of patients who developed BSR was significantly poor compared with those who did not develop BSR (p = 0.001). BSR can develop even after complete resection of lung cancer. The DBTM is associated with BSR risk, and the survival of patients who develop BSR is poor.

Lung cancer surgery: an up to date.

According to the International Agency for Research on Cancer (IARC) GLOBOCAN World Cancer Report, lung cancer affects more than 1 million people a year worldwide. In Greece according to the 2008 GLOBOCAN report, there were 6,667 cases recorded, 18% of the total incidence of all cancers in the population. Furthermore, there were 6,402 deaths due to lung cancer, 23.5% of all deaths due to cancer. Therefore, in our country, lung cancer is the most common and deadly form of cancer for the male population. The most important prognostic indicator in lung cancer is the extent of disease. The Union Internationale Contre le Cancer (UICC) and the American Joint Committee for Cancer Staging (AJCC) developed the tumour, node, and metastases (TNM) staging system which attempts to define those patients who might be suitable for radical surgery or radical radiotherapy, from the majority, who will only be suitable for palliative measures. Surgery has an important part for the therapy of patients with lung cancer. "Lobectomy is the gold standard treatment". This statement may be challenged in cases of stage Ia cancer or in patients with limited pulmonary function. In these cases an anatomical segmentectomy with lymph node dissection is an acceptable alternative. Chest wall invasion is not a contraindication to resection. En-bloc rib resection and reconstruction is the treatment of choice. N2 disease represents both a spectrum of disease and the interface between surgical and non-surgical treatment of lung cancer Evidence from trials suggests that multizone or unresectable N2 disease should be treated primarily by chemoradiotherapy. There may be a role for surgery if N2 is downstaged to N0 and lobectomy is possible, but pneumonectomy is avoidable. Small cell lung cancer (SCLC) is considered a systemic disease at diagnosis, because the potential for hematogenous and lymphogenic metastases is very high. The efficacy of surgical intervention for SCLC is not clear. Lung cancer resection can be performed using several surgical techniques. Video-assisted thoracoscopic surgery (VATS) lobectomy is a safe, efficient, well accepted and widespread technique among thoracic surgeons. The 5-year survival rate following complete resection of lung cancer is stage dependent. Incomplete resection rarely is useful and cures the patient.

Left upper lobectomy with combined resection of the distal arch aorta after chemoradiotherapy for locally advanced lung cancer

We report a case of complete resection of lung cancer involving the thoracic aorta, after induction chemoradiotherapy in a 55-year-old man. The chemoradiotherapy, which consisted of two courses of platinum-based chemotherapy with concurrent radiation to a total of 40 Gy, resulted in a partial response. Left upper lobectomy with combined resection and reconstruction of the distal arch aorta and left subclavian artery was performed under cardiopulmonary bypass. The patient was given two courses of platinum-based adjuvant chemotherapy, and there has been no sign of recurrence in the 34 months since his operation.

Modification of the surgical procedure to enable the complete resection of lung cancer with carcinomatous pleuritis

Carcinomatous pleuritis, accompanied by pleural dissemination or malignant pleural effusion, is listed as one of the factors limiting adequate surgical treatment. It is relatively easy to peel the parietal pleura of the chest wall and mediastinum during a pleuropneumonectomy, but it is quite difficult to peel the parietal pleura of the diaphragm. A pleuropneumonectomy was conducted with the combined resection of the pericardium and all layers of the diaphragm without opening of the peritoneum through a posterolateral subcostal approach. This approach thus made it possible to perform a complete resection of the diaphragm relatively easily in a reliable manner, and also contributed to a more thorough resection of pleural dissemination without a second thoracotomy.

Genetic fingerprint concerned with lymphatic metastasis of human lung squamous cancer.

With the most recent introduction of microarray technology to biology, it becomes possible to perform comprehensive analysis of gene expression in cancer cell. In this study the laser microdissection technique and cDNA microarray analysis were combined to obtain accurate molecular profiles of lymphatic metastasis in patients with lung squamous cell carcinoma. Primary lung squamous cancer tissues and regional lymph nodes were obtained from 10 patients who underwent complete resection of lung cancer. According to the source of lung cancer cells, the samples were classified into three groups: the primary tumor with lymphatic metastasis (TxN+, n=5), the primary tumor without lymphatic metastasis (TxN-, n=5) and matched tumor cells from metastatic lymph nodes (N+, n=5). Total RNA was extracted from laser microdissected tumor samples. Adequate RNA starting material of mRNA from primary tumor or metastatic nodes were labeled and then hybridized into the same microarray containing 6 000 known, named human genes/ESTs. After scanning, data analysis was performed using GeneSpring6.2. A total of 37 genes were found to be able to separate TxN+ from TxN-. TxN+ have higher levels of genes concerned with structural protein, signal transducer, chaperone and enzyme. TxN- have higher levels of genes coding for cell cycle regulator, transporter, signal transducer and apoptosis regulator. Interestingly, there were no differentially expressed genes between N+ and TxN+. The acquisition of the metastatic phenotype might occur early in the development of lung squamous cancer. We raise the hypothesis that the gene-expression signature described herein is valuable to elucidate the molecular mechanisms regarding lymphatic metastasis and to look for novel therapeutic targets.

Bronchial sleeve resection and reconstruction of pulmonary artery by video-assisted thoracic small incision surgery for lung cancer

The mini-invasive surgery is now performed widely and these operations have been used in complete resection of lung cancer. The aim of this study is to summarize the results and to explore practicability of bronchial sleeve resection and reconstruction of pulmonary artery by video-assisted thoracic small incision surgery for lung neoplasms. A total of 109 patients were retrospectively reviewed, who underwent sleeve lobectomy and bronchoplasty by video-assisted thoracic small incision surgery for lung neoplasms from January 1995 to December 2005. Operations were performed successfully for all the patients. The small incisions' length ranged from 3 to 15 cm and the mean length was 10 cm. The surgical time was 125-180 min and the mean was 150 min; blood loss was 210-450 mL and the mean was 320 mL. There was no operative mortality, occurrence of anastomosis stenosis and fistula. Follow-up results showed that there was no sign of re-perfusion hurt and no edema in remaining lobes. There was no blood transfusion in 80.7% of cases (88/109), no shoulder hurt in 94.5% of cases (103/109). The stay in hospital was 7-15 days, and the average was 9 days. The bronchial sleeve resection and reconstruction of pulmonary artery by video-assisted thoracic small incision surgery for lung cancer could finish the same work as traditional thoracic lateral incision, with less trauma, less bleeding and blood transfusion, less time in opening and closing thorax.

Survival in Resected Stage I Lung Cancer With Residual Tumor at the Bronchial Resection Margin

Background. Sometimes microscopic residual tumor is found at the bronchial resection margin despite an apparently complete resection of lung cancer. This may adversely affect the patient’s prognosis. Its impact on survival is unclear. Methods. The records of 834 patients with resected stage I non–small cell lung cancer were studied. Patients with complete resection were assigned to the complete resection group (n = 802); patients with microscopic residual tumor at the bronchial resection margin that was accepted were assigned to the residual tumor group (n = 23). Residual tumor was classified as carcinoma in situ, mucosal residual disease, or peribronchial residual disease. Results. The 5-year survival in the patients in the complete resection group was 54%; it was 58% in the residual tumor group with carcinoma in situ and 27.3% in the residual tumor group with invasive tumor (mucosal residual disease or peribronchial residual disease). The difference in survival between patients in the complete resection group and patients in the residual tumor group with invasive tumor was significant ( p = 0.03). Conclusions. The presence of mucosal or peribronchial residual disease, but not carcinoma in situ, at the bronchial resection margin in patients with stage I non–small cell lung cancer has an adverse effect on survival.

Beware the Medical-Industrial Complex

Beware the Medical-Industrial Complex

Isolated incisional recurrence after curative resection for primary lung cancer

We present a long-term survivor with isolated recurrent tumor in the incisional scar that developed 9 months after a curative resection for primary lung adenocarcinoma. She underwent an excision of the tumor followed by systemic chemotherapy, and is currently alive with no evidence of disease 69 months after the recurrence. Isolated incisional recurrence after complete resection of lung cancer is a rare phenomenon and may be curable using multimodal treatment.

Role of tumor-infiltrating lymphocytes in the host defense mechanism against lung cancer.

Tumor-infiltrating lymphocytes (TIL) and tumor-associated macrophages (TAM) were recovered from 22 patients with primary lung cancer. The TIL did not exhibit any cytolytic activity against various target cells. The average percentage of TIL recovered was 6.7 +/- 1.3% in patients without recurrence, as compared to 3.6 +/- 0.6% in those with recurrence within 2 years after complete resection of lung cancer (P less than 0.05). The average cytostatic activity of TAM was 38.5 +/- 6.8% in patients without recurrence, although it was 25.2 +/- 4.6% in those with recurrence within 2 years after complete resection (P less than 0.1). The activity of macrophage activating factor (MAF) induced by TIL was also higher in patients showing no recurrence. A significant positive correlation was observed between MAF activity induced by TIL and the cytostatic activity of individual TAM. These results suggest that antitumor activity of TAM may be controlled by specifically sensitized TIL through lymphokines.