Patients Undergoing Lung Cancer Resection Research Articles

Comparison of a Risk Calculator With Frailty Indices in Patients Undergoing Lung Cancer Resection.

While frailty has gained attention for its utility in risk stratification, no studies have directly compared them to existing risk calculators. The objective of this study was to compare the risk stratification of the American College of Surgeons Surgical Risk Calculator (ACS-SRC), the Revised Risk Analysis Index (RAI-rev), and the Modified Frailty Index (5-mFI). The primary outcomes were 30-day postoperative morbidity, 30-day postoperative mortality, unplanned readmission, unplanned reoperation, and discharge disposition other than home. Patients undergoing anatomic lung resection for primary, nonsmall cell lung cancer were identified within the ACS National Quality Improvement Program (ACS NSQIP) database. Tools were compared for discrimination in the primary outcomes. 9663 patients undergoing anatomic lung resection for cancer between 2012 and 2014 were included. The cohort was 53.1% female. Median age at diagnosis was 67 (IQR 59-74) years. Perioperative morbidity and mortality rates were 10.9% (n = 1048) and 1.6% (n = 158). Rates of 30-day postoperative unplanned readmission and reoperation were 7.5% (n = 725) and 4.8% (n = 468). The ACS-SRC had the highest discrimination for all measured outcomes, as measured by the area under the receiver operating curve (AUC) and corresponding confidence interval (95% CI). This included perioperative mortality (AUC 0.74, 95% CI 0.71-0.78), compared to RAI-rev (AUC 0.66, 95% CI 0.62-0.69) and 5-mFI (AUC 0.61, 95% CI 0.57-0.65; p < 0.001). The RAI-rev and 5-mFI had similar discrimination for all measured outcomes. ACS-SRC was the perioperative risk stratification tool with the highest predictive discrimination for adverse, 30-day, postoperative events for patients with cancer treated with anatomic lung resection.

Comparison of a risk calculator with frailty indices in patients undergoing lung cancer resection.

Perioperative risk stratification is an essential component of preoperative planning for cancer surgery. While frailty has gained attention for its utility in risk stratification, no studies have directly compared it to existing risk calculators. Therefore, the objective of this study was to compare the risk stratification of the American College of Surgeons Surgical Risk Calculator (ACS-SRC), the Revised Risk Analysis Index (RAI-rev), and the Modified Frailty Index (5-mFI). The primary outcomes were 30-day postoperative morbidity, 30-day postoperative mortality, unplanned readmission, unplanned reoperation, and discharge disposition other-than-home. Patients undergoing anatomic lung resection for primary, non-small cell lung cancer were identified within the American College of Surgeons National Quality Improvement Program (ACS NSQIP) database. The ACS-SRC, RAI-rev, and 5-mFI tools were used to predict adverse postoperative events. Tools were compared for discrimination in the primary outcomes. 9663 patients undergoing anatomic lung resection for cancer between 2012 and 2014 were included. The cohort was 53.1% female. Median age at diagnosis was 67 (interquartile range = 59-74) years. Cardiothoracic surgeons performed 89% and general surgeons performed 11.0% of the operations. Perioperative morbidity and mortality rates were 10.9% (n = 1048) and 1.6% (n = 158). Rates of 30-day postoperative unplanned readmission and reoperation were 7.5% (n = 725) and 4.8% (n = 468). The ACS-SRC had the highest discrimination for all measured outcomes, as measured by the area under the receiver operating curve (AUC) and corresponding confidence interval (95% confidence interval [CI]). This included perioperative mortality (AUC = 0.74, 95% CI = 0.71-0.78), compared to RAI-rev (AUC = 0.66, 95% CI = 0.62-0.69) and 5-mFI (AUC = 0.61, 95% CI = 0.57-0.65; p < 0.001). The RAI-rev and 5-mFI had similar discrimination for all measured outcomes. ACS-SRC was the perioperative risk stratification tool with the highest predictive discrimination for adverse, 30-day, postoperative events for patients with cancer treated with anatomic lung resection.

The Impact of COVID-19 Infection Prior to Lung Resection on Postoperative Complications

BackgroundWe hypothesize that previous COVID-19 infection could be associated with postoperative complications (POCs) and outcomes of thoracic surgery for lung cancer. It is unknown whether the respiratory damage caused by COVID-19 infection is permanent. In addition, there is a lack of studies investigating POCs and prior COVID-19 infection in thoracic surgery. MethodsA retrospective study was performed on patients who underwent resections for lung cancer between May 2020 and July 2022. Variables relevant to the Society of Thoracic Surgeons database were collected, as well as COVID-19 status. The primary outcome was postoperative complications. ResultsA total of 361 patients underwent a resection for lung cancer. Patients with a prior COVID-19 infection (n = 21) had significantly more POCs than patients without a history of COVID-19 infection (n = 340, P < .05). Pneumothorax and infections requiring intravenous antibiotics were significantly enriched in patients with a prior COVID-19 infection. COVID-19 infection was independently associated with increased POCs at multivariable analysis (adjust odds ratio, 4.36; 95% CI, 1.48-12.8). Matched case-control analysis also reviewed similar findings, where COVID-19 infection was the only significant variable as a risk factor for POCs (P < .05). ConclusionsAfter a COVID-19 infection, patients undergoing lung cancer resections were at an increased risk of POCs. This suggests that a previous COVID-19 infection should be considered as a potential risk factor for complications after lung cancer resections.

Risk factors for enhanced recovery after surgery failure in patients undergoing lung cancer resection with concomitant cardiovascular disease: A single-center retrospective study

ObjectiveEnhanced recovery after surgery (ERAS) has been widely used in patients with lung cancer, and its effectiveness has been confirmed; however, some lung cancers with poor clinical outcomes lead to ERAS failure after radical resection. This study aimed to analyze risk factors associated with ERAS failure after radical resection in patients with lung cancer and concomitant cardiovascular disease. MethodsIn total, 198 patients who underwent ERAS following radical lung cancer surgery for concomitant cardiovascular disease between January 2022 and September 2023 were enrolled in this retrospective study. The patients were categorized into two groups based on the definition of ERAS failure: ERAS success group (n = 152) and ERAS failure group (n = 46). Univariate and multivariate analyses were performed to investigate the risk factors of ERAS failure. ResultsUnivariate analysis showed that gender, tumor location, operation time, estimated blood loss (EBL), suction drainage, and total cholesterol were associated with ERAS failure. Multivariate analysis showed that operation time (odds ratio [OR] = 1.015; P = 0.011) and suction drainage (OR = 3.343; P = 0.008) were independent risk factors for ERAS failure. ConclusionsOperation time and suction drainage were independent risk factors for ERAS failure after radical resection of combined cardiovascular lung cancer. Therefore, improving surgical efficiency and postoperative chest drain management are important for successful ERAS.

Association Between Utilization of Services and Perioperative Outcomes for Lung Cancer Resection

IntroductionLung cancer resection has largely focused on perioperative outcomes (eg, mortality) to benchmark performance. While variations in perioperative outcomes and in utilization of services (eg, ambulatory procedures, hospitalization) have been independently demonstrated, there has been limited evaluation of associations between these outcomes. We evaluated the association between perioperative outcomes and utilization of services to evaluate provider performance across a broader context of care. Patients and MethodsThis was a retrospective cohort study of patients undergoing lung cancer resection in 2017 to 2019. We utilized hierarchical logistic regression models to determine risk- and reliability-adjusted mortality and risk-adjusted utilization of services, at the hospital-level. We then evaluated utilization of services across quartiles of perioperative mortality. ResultsA total of 15,168 patients across 297 hospitals underwent lung cancer resection. Mean risk- and reliability-adjusted 90-day mortality varied between 1.58% (95% CI, 1.54%-1.62%) and 2.74% (95% CI, 2.59%-2.90%) across quartiles. Risk-adjusted utilization of all ambulatory procedures was highest in the best performing (lowest mortality) quartile at 37.7% (95% CI, 33.6%-41.8%). Additionally, risk-adjusted inpatient utilization prior to and after surgery was lowest in the best performing quartile at 15% (95% CI, 13.7%-16.3%) and 19.3% (95% CI, 17.5%-21.0%), respectively. ConclusionsHospitals with the lowest perioperative mortality demonstrated trends towards using more outpatient resources prior to surgery, but fewer inpatient services surrounding lung cancer resection. This correlation highlights the importance of incorporating utilization of services in addition to other metrics to profile the efficiency and effectiveness of centers performing lung cancer resection across a broader spectrum of care.

Geographic Variation in the Utilization of Services Surrounding Lung Cancer Resection

BackgroundAs value-based care models continue to gain emphasis, along with the need for improved profiling across the continuum of lung cancer care, a better understanding of geographic variation in utilization of services surrounding episodes of care is needed. MethodsIn this retrospective cohort study of patients undergoing lung cancer resection from 2017 to 2019, we examined geographic variation in utilization of services surrounding episodes of lung cancer resection. We utilized hierarchical logistic regression models to determine risk-adjusted utilization of services. This study utilized inpatient and ambulatory databases across 4 states: New Jersey, Pennsylvania, Florida, and Maryland. All patients undergoing lung cancer resection were included. The primary outcome was risk-adjusted utilization of services. ResultsMean risk-adjusted utilization of ambulatory procedures across all hospital referral regions (HRRs) was 34.1% (95% CI 30.7%-37.6%), while the individual HRR utilization varied from 10.9% to 54.9% (P < .01). Mean risk-adjusted utilization of inpatient admissions in the 6 months prior to surgery was 15.3% (95% CI 13.9%-16.7%), ranging from 7.4% to 24.7% (P = .07) across HRRs. Finally, mean risk-adjusted utilization of inpatient hospitalizations in the 6 months following surgery was 19.4% (95% CI 17.7-21.0%), ranging from 10.0% to 33.6% (P = .19) across HRRs. ConclusionsOverall, we observed that utilization of ambulatory services varied significantly across HRRs, while inpatient utilization did not demonstrate significant variation. Given these findings, there may be geographic drivers of variation in the utilization of services surrounding lung cancer resection.

Evaluation of preoperative cardiopulmonary reserve and surgical risk of patients undergoing lung cancer resection.

Lung cancer represents the second most frequent neoplasm and the leading cause of neoplastic death among both women and men, causing almost 25% of all cancer deaths. Patients undergoing lung resection-both for primary and secondary tumors-require careful preoperative cardiopulmonary functional evaluation to confirm the safety of the planned resection, to assess the maximum tolerable volume of resection or to exclude surgery, thus shifting the therapeutic approach toward less invasive options. Cardiopulmonary reserve, pulmonary lung function and mechanical respiratory function represent the cornerstones of preoperative assessment of patients undergoing major lung resection. Spirometry with carbon monoxide diffusing capacity, split function tests, exercise tests and cardiologic evaluation are the gold standard instruments to safely assess the entire cardiorespiratory function before pulmonary resection. Although pulmonary mechanical and parenchymal function, together with cardiorespiratory compliance represent the mainstay of preoperative evaluation in thoracic surgery, the variables that are responsible for fitness in patients who have undergone lung resection have expanded and are being continually investigated. Nevertheless, because of the shift to older patients who undergo lung resection, a global approach is required, taking into consideration variables like frailty status and likelihood of postoperative functional deterioration. Finally, the decision to go ahead with surgery in fragile patients being consideredfor lung resection should be evaluated in a multispecialty preoperative discussion to provide a personalized risk stratification. The aim of this review is to focus on preoperative evaluation of cardiopulmonary reserve and surgical risk stratification of patients candidate for lung cancer resection. It does so by a literature search of clinical guidelines, expert consensus statements, meta-analyses, clinical recommendations, book chapters and randomized trials (1980-2022).

Comparison of failure to rescue in younger versus elderly patients following lung cancer resection

ObjectiveFailure to rescue (FTR), defined as in-hospital death following a major complication, has been increasingly studied in patients who undergo cardiothoracic surgery. This study tested the hypothesis that elderly patients undergoing lung cancer resection have greater rates of FTR compared with younger patients. MethodsPatients who underwent surgery for primary lung cancer between 2011 and 2020 and had at least 1 major postoperative complication were identified using the National Surgical Quality Improvement Program database. Patients who died following complications (FTR) were compared with those who survived in an elderly (80+ years) and younger (<80 years) cohort. ResultsOf the 2823 study patients, the younger cohort comprised 2497 patients (FTR: n = 139 [5.6%]), whereas the elderly cohort comprised 326 patients (FTR: n = 39 [12.0%]). Pneumonia was the most common complication in younger (877/2497, 35.1%) and elderly patients (118/326, 36.2%) but was not associated with FTR on adjusted analysis. Increasing age was associated with FTR (adjusted odds ratio [AOR], 1.55 per decade, P < .001), whereas unplanned reoperation was associated with reduced risk (AOR, 0.55, P = .01). Within the elderly cohort, surgery conducted by a thoracic surgeon was associated with lower FTR risk (AOR, 0.29, P = .028). ConclusionsFTR following lung cancer resection was more frequent with increasing age. Pneumonia was the most common complication but not a predictor of FTR. Unplanned reoperation was associated with reduced FTR, as was treatment by a thoracic surgeon for elderly patients. Surgical therapy for complications after lung cancer resection and elderly patients managed by a thoracic specialist may mitigate the risk of death following an adverse postoperative event.

Risk stratification of postoperative pulmonary complications in elderly patients undergoing lung cancer resection: a propensity score-matched study.

In China, lung cancer mainly affects the elderly population. Surgery remains the standard treatment for lung cancer in elderly patients, however, postoperative pulmonary complications (PPCs) are major contributors to morbidity and mortality following lung resection. This study aimed to identify perioperative predictors of PPCs among elderly patients undergoing pulmonary resection for lung cancer to provide evidence for better prevention and intervention for PPCs. A retrospective study was conducted with 456 patients (age >65 years) undergoing pulmonary resection for lung cancer in Yunnan, China from January 2016 to March 2019. Propensity score matching (PSM) was performed to compare preoperative data and clinical characteristics between the PPC and non-PPC groups, followed by binary logistic regression to evaluate predictors of PPCs. Pulmonary complications occurred in 142/456 (31.1%) patients age >65 years, with pneumonia being the most common event (21.7%). Both PSM and binary logistic regression analysis identified American Society of Anesthesiologists (ASA) class <II [odds ratio (OR): 0.177, 95% confidence interval (CI): 0.037-0.854] and video-assisted thoracoscopic surgery (VATS) (OR: 0.576, 95% CI: 0.334-0.992) as protective factors for PPCs. PPCs following lung cancer resection in elderly patients were associated with a higher ASA classification and open thoracotomy. An adequate and comprehensive evaluation of the operative strategies and enhanced recovery methods should be implemented among elderly patients undergoing lung resection with an ASA class > II or those undergoing an open thoracotomy to help prevent the occurrence of PPCs.

Financial Toxicity in Patients With Resected Lung Cancer.

To describe financial toxicity (FT) in patients with resected lung cancer and identify risk factors in this population. FT describes the financial burden associated with cancer care and its impact on the quality of survivorship. Few prior studies have examined FT in patients with lung cancer. Patients who underwent lung cancer resection at our institution between January 1, 2016 and December 31, 2021, were surveyed to gather demographic information and evaluate FT using a validated questionnaire. A multivariable model was built to identify risk factors for FT. Of the total, 1477 patients were contacted, of whom 463 responded (31.3%). Most patients were stage I (n = 349, 75.4%) and lobectomy was performed often (n = 290, 62.8%). There were 196 patients (42.3%) who experienced FT. Upon multivariable analyses, divorced marital status [odds ratio (OR) = 3.658, 95% CI: 1.180-11.337], household income <$40,000 (OR = 2.544, 95% CI: 1.003-6.455), credit score below 739 (OR = 2.744, 95% CI: 1.326-5.679), clinical stage >I (OR = 2.053, 95% CI: 1.088-3.877), and change in work hours or work cessation (all P < 0.05) were associated with FT. Coping mechanisms, such as decreased spending on food or clothing and increased use of savings or borrowing money, were more likely to be reported by patients experiencing FT than those who did not ( P < 0.001). Patients undergoing lung cancer resection often experienced significant financial stress with several identifiable risk factors. FT should be considered early in the care of these patients to alleviate detrimental coping mechanisms and enhance their quality of survivorship.

Abstract 4651: Comparison of the tumor and lymph node immune microenvironment in early non-small cell lung cancer through multimodal single cell sequencing

Abstract Background/Purpose: Previous studies have analyzed the tumor and local immune microenvironments in lung cancers and suggest immune modulation is associated with worse clinical outcome. However, the tumor-immune microenvironment in early stage lung tumors and lymph nodes (LNs) have not been fully described. We aim to compare cell states in the immune microenvironments between lung tumors and LNs through multi-modal profiling of the transcriptome and surface proteins. Methods: Needle biopsy samples were taken from 10 treatment-naive early stage lung cancer patients undergoing lung cancer resections. Tissues were obtained from normal lung, lung tumor, and multiple mediastinal LNs, and processed for scRNA-seq including labeling with Total-Seq C CITE-seq panel to quantify the levels of 130 cell surface proteins. In total, 76,721 cells (4,462 normal lung; 39,019 tumor; 33,240 LN) were identified with a median of 1,673 genes and 92 protein features detected per cell. Protein expression was decontaminated through the decontX algorithm. Weighted-Nearest Neighbor analysis from the Seurat R package was applied to integrate the CITE-seq and RNA-seq level data for clustering cells into subpopulations. Results: Six broad cell populations were identified including T/NK, myeloid (CD14+), B (CD19+), mast (TPSAB1+), pDC (IRF8+), and epithelial (EPCAM+) cells. Among 8 CD4+ T lymphocyte subpopulations and 11 CD8+ T lymphocyte subpopulations observed through clustering, a naïve CD4+ and a CD8+ T subpopulation (LEF1+, TCF7+) was observed respectively. These naïve T lymphocyte populations displayed increased proportions in LNs in comparison to tumors. In addition, 5 of the 8 observed CD4+ T lymphocyte populations were enriched in LNs. Immune populations enriched in LNs were largely shared and uniform across different patients. In contrast, a single CD4+ and CD8+ T lymphocyte subpopulation displayed expression of T lymphocyte exhaustion markers (TIGIT+, LAG3+, PD-1+) and were enriched in tumors. 6 of the 11 observed CD8+ T lymphocyte populations were enriched in tumor samples in comparison to LNs. Two alveolar macrophage populations (MARCO+) were enriched in normal lung tissue, in which one showed a heightened stress response. Conclusion: Single-cell profiling reveals diversity in immune cell populations between LNs, tumor, and adjacent normal tissue in early-stage LUAD. The results suggest the composition of immune cell type is fairly consistent across LNs but more heterogeneous in the tumor and adjacent normal tissue in early-stage patients. In the future, we aim to determine if these immune subpopulations are associated with survival, recurrence, aggressiveness, and predict responses for neoadjuvant treatments, which could improve prognosis and patient quality of life. Citation Format: Zhanhao Xi, Yusuke Koga, Shannon McDermott, Jennifer Beane, Sarah A. Mazzilli, Kei Suzuki, Joshua D. Campbell. Comparison of the tumor and lymph node immune microenvironment in early non-small cell lung cancer through multimodal single cell sequencing. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4651.

Surgical Approach and Persistent Opioid Use in Medicare Patients Undergoing Lung Cancer Resection

BackgroundRobotic and video-assisted thoracoscopic surgery (VATS) approaches for lung resection are associated with decreased inpatient opioid use compared with open surgery. Whether these approaches affect outpatient persistent opioid use remains unknown. MethodsNon-small cell lung cancer patients aged 66 years or more who underwent lung resection between 2008 and 2017 were identified from the Surveillance, Epidemiology, and End Results-Medicare database. Persistent opioid use was defined as filling an opioid prescription 3 to 6 months after lung resection. Adjusted analyses were performed to evaluate surgical approach and persistent opioid use. ResultsWe identified 19,673 patients: 7479 (38%) underwent open surgery, 10,388 (52.8%) VATS, and 1806 (9.2%) robotic surgery. Persistent opioid use was 38% in the entire cohort, including 27% of opioid naïve patients, and highest after open surgery (42.5%), followed by VATS (35.3%) and robotic (33.1%, P < .001). In multivariable analyses, robotic (odds ratio 0.84; 95% CI, 0.72-0.98; P = .028) and VATS (odds ratio 0.87; 95% CI, 0.79-0.95; P = .003) approaches were both associated with decreased persistent opioid use compared with open surgery in opioid naïve patients. At 12 months, patients resected using a robotic approach had the lowest oral morphine equivalent per month compared with VATS (133 vs 160, P < .001) and open surgery (133 vs 200, P < .001). Among chronic opioid patients, surgical approach was not associated with postoperative opioid use. ConclusionsPersistent opioid use after lung resection is common. Both robotic and VATS approaches were associated with decreased persistent opioid use compared with open surgery among opioid naïve patients. Whether a robotic approach yields additional long-term advantages over VATS warrants further investigation.

Abstract P075: Comparison of the tumor and lymph node immune microenvironment in early non-small cell lung cancer through multimodal single cell sequencing

Abstract Background/Purpose: Previous studies have analyzed the tumor and local immune microenvironments in lung cancers and suggest immune modulation is associated with worse clinical outcome. However, the tumor-immune microenvironment in early-stage lung tumors and lymph nodes (LNs) have not been fully described. We aim to compare cell states in the immune microenvironments between lung tumors and LNs through multi-modal profiling of the transcriptome and surface proteins. Methods: Needle biopsy samples were taken from 10 treatment-naive early-stage lung cancer patients undergoing lung cancer resections. Tissues were obtained from normal lung, lung tumor, and multiple mediastinal LNs, and processed with scRNA-seq along with the Total-Seq C panel to quantify the levels of 130 cell surface proteins. In total, 98,337 cells (4,661 normal lung; 52,119 tumor; 42,117 LN) were identified with a median of 1,401 genes and 23 protein features detected per cell. Weighted-Nearest Neighbor analysis from the Seurat R package was applied to integrate the CITE-seq and RNA-seq level data for clustering cells into subpopulations. Results: Six broad cell populations were identified including T/NK, myeloid (CD14+), B (CD19+), mast (TPSAB1+), pDC (IRF8+), and epithelial (EPCAM+) cells. Protein expression measured with CITE-seq revealed additional T cell populations not captured by scRNA-seq. Preliminary results have identified cell populations enriched in LNs, which include naive CD4+ (CD4, FHIT, LEF1, CCR7) and CD8+ T cells (CD8A, TCF7, LEF1, CD27, CCR7). Additionally, we have identified numerous other CD8+ T-cell subpopulations enriched in tumors, including resident memory CD8+ T cells (KLRC1, ITGAE, ITGA1, VIM, JUN). Furthermore, immune populations enriched in LNs were similarly shared across different patients, while those enriched in tumors displayed patient-level specificity. Conclusion: Single-cell profiling reveals diversity in immune cell populations between LNs, tumor, and adjacent normal tissue in early-stage LUAD. The results suggest the composition of immune cell type is consistent across LNs but more heterogeneous in the tumor and adjacent normal tissue. In the future, we aim to determine if these markers for various immune subpopulations are associated with survival, recurrence, aggressiveness, and predict responses for neoadjuvant treatments, which could improve prognosis and patient quality of life. Citation Format: Zhan Xi, Yusuke Koga, Shannon McDermott, Jennifer E. Beane, Sarah A. Mazzilli, Kei Suzuki, Joshua D. Campbell. Comparison of the tumor and lymph node immune microenvironment in early non-small cell lung cancer through multimodal single cell sequencing. [abstract]. In: Proceedings of the AACR Special Conference: Precision Prevention, Early Detection, and Interception of Cancer; 2022 Nov 17-19; Austin, TX. Philadelphia (PA): AACR; Can Prev Res 2023;16(1 Suppl): Abstract nr P075.

The efficacy of pulmonary rehabilitation exercise training on complications and mortality after lung cancer resection: a systematic review and meta-analysis.

BackgroundThe efficacy of pulmonary rehabilitation exercise training for patients after lung cancer resection has been controversial. We sought to evaluate the efficacy of pulmonary rehabilitation on the incidence of complications and mortality in patients after lung cancer resection.MethodsSearch English databases PubMed, EMBASE, Medline to obtain literature. The literature compared the effect of pulmonary rehabilitation exercise training intervention or not on the efficacy of patients after lung cancer resection, and the outcomes included postoperative complications and mortality. The quality of the included literature was assessed according to the Cochrane risk of bias assessment work. The chi-square test was used to test for heterogeneity. When there is heterogeneity, a random effect model is used; when there is no heterogeneity, a fixed effect model is used.ResultsA total of 9 prospective clinical studies (comprising 1,338 patients) were included in this meta-analysis. Among the patients, there were 571 cases in the rehabilitation group and 767 cases in the control group. The incidence of postoperative complications in the rehabilitation group was lower than that in the control group. The odds ratio (OR) value was 0.66 and 95% confidence interval (CI) was 0.47–0.94 (P=0.02). There was no heterogeneity among studies and no publication bias. The incidence of postoperative pulmonary complications in the rehabilitation group was lower than that in the control group, OR =0.33 (95% CI: 0.22–0.50) (P<0.00001). There was no heterogeneity among studies and no publication bias. There was no significant difference in postoperative mortality between the 2 groups (OR =0.77; 95% CI: 0.26–2.30; P=0.65). There was no heterogeneity among studies and no publication bias.DiscussionImplementing pulmonary rehabilitation significantly reduced postoperative complications and the risk of pulmonary complications in lung cancer patients, but had no significant effect on mortality. Pulmonary rehabilitation exercise training is recommended for patients undergoing lung cancer resection.

Sugammadex Versus Neostigmine for Neuromuscular Block Reversal and Postoperative Pulmonary Complications in Patients Undergoing Resection of Lung Cancer

This study aimed to compare the effect of sugammadex and neostigmine on neuromuscular block reversal and the incidence of postoperative pulmonary complications in patients undergoing lung cancer resection. A double-blind, randomized, prospective study. A single major urban teaching and university hospital. One hundred adult patients underwent elective radical resection of lung cancer under general anesthesia. Patients were assigned into neostigmine (0.05 mg/kg)+atropine 0.02 mg/kg group and sugammadex (2 mg/kg) group. The primary outcomes were the incidence of any postoperative pulmonary complications, and the time to achieve 90% of train-of-four (TOF) after the administration of sugammadex or neostigmine. The secondary endpoints were the number of patients with TOF ratio (TOFr) <0.9 at the time of tracheal extubation, the incidence of readmission 30 days after discharge, and specific postoperative pulmonary complications. Results showed that the average time of recovery to TOFr ≥0.9 with sugammadex was 164.5 ± 27.7 seconds versus 562.9 ± 59.7 seconds with neostigmine+atropine treatment. Fewer sugammadex-treated patients did not achieve TOFr of 0.9 at the time of tracheal extubation than did neostigmine-treated participants. Patients in the sugammadex group had lower incidence of postoperative lung complications, and shorter durations of postanesthesia care unit stay and postoperative hospital stay than those in the neostigmine group. There was no significant difference in the incidence of readmission between the 2 groups. Administration of sugammadex provided faster recovery of rocuronium-induced neuromuscular block when compared with neostigmine. Moreover, for patients undergoing lung cancer resection, administration of sugammadex could reduce the incidence of postoperative pulmonary complications and duration of postoperative hospital stay.

Everybody knows that smokin’ ain’t allowed (in school) before lung surgery!

In the 1973 classic ‘Smokin’ in the Boys Room’, the Brownsville Station’s singer refrain is—‘don’t want the teacher to fill me up with your rules, but everybody knows that smokin’ ain’t allowed in school!’ [1] Similarly, the universal medical directive including pre-op lung cancer resection is ‘Stop Smoking’. Kadomatsu, Sugiyama and others in the article ‘Relationship of smoking cessation period with the incidence of complications in lung cancer surgery’ [2] re-evaluates the length of smoking cessation and pack-years of smoking on lung cancer resection morbidity and outcomes. The authors have shown in 911 patients undergoing lung cancer resection from 2014 to 2017 that pulmonary complications including pneumonia, prolonged air-leak and empyema and total complications are 5 times and 2 times higher respectively in smokers as compared to the non-smoker groups. The pre-op smoking cessation intervals included—9.6% patients in the current (<4 weeks) group, 17% patients in recent (4 weeks to 12 months) group, 13% in the distant (12 months to 5 years) group and 30% ex-smokers (>5 years) group. Using this classification, postoperative complications were greater in current versus recent groups but both were less than distant and ex-smoker cohorts. Interestingly, the ex-smoker group had fewer post-op complications than the distant group and the distant cohort had more complications than the current and recent smoking groups.

Assessment of systemic immune-inflammation index in predicting postoperative pulmonary complications in patients undergoing lung cancer resection

BackgroundHematological inflammatory parameters, including neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio, are good predictors of postoperative pulmonary complications after lung cancer resection. However, the clinical value of the systemic immune-inflammation index has not been extensively studied. MethodsWe retrospectively analyzed a cohort of patients that underwent lung cancer resection in our center, and we analyzed the hematological inflammatory parameters (including systemic immune-inflammation index) and postoperative pulmonary complications after lung cancer resection. The receiver operating characteristic curve was applied to determine the best cut-off value. Multivariable analysis was applied to assess which of the factors was the most important. ResultsTwo hundred and four patients were enrolled in this study. Of these, 47 postoperative pulmonary complications events were observed in 40 patients in this cohort. Surgery method, white blood cell count, albumin, forced expiratory volume in 1 second, carbon monoxide diffusing capacity, intensive care unit stay, and systemic immune-inflammation index were found to be significantly different between the postoperative pulmonary complications and non–postoperative pulmonary complications groups. We then used the receiver operating characteristic curves and the Youden index to determine the best cutoff value. Multivariable analysis revealed that systemic immune-inflammation index and forced expiratory volume in 1 second were the most important predictive factors of postoperative pulmonary complications after lung cancer resection. ConclusionHematological inflammatory parameters of systemic immune-inflammation index and forced expiratory volume in 1 second could be a favorable index to predict postoperative pulmonary complications after lung cancer resection.

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

ObjectiveTo 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). MethodsProspective 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. ResultsAfter 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. ConclusionsThoracotomy 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.

Dynamic Changes and Influencing Factors for the Quality of Life in Nursing Care after Lung Cancer Resection.

To investigate the dynamic changes and influencing factors for the quality of life in nursing care in patients with lung cancer after resection. Totally, 136 patients undergoing lung cancer resection in our hospital from January 2019 to January 2022 were prospectively enrolled as subjects. The quality of life was measured before and 1 and 2 weeks and 1, 3, 6, and 12 months after the operation to analyze the dynamic changes in the quality of life in nursing care. Clinical data of patients were collected at the time of discharge. The patients were divided into high-quality and low-quality groups according to the median level of quality of life in nursing care at the final follow-up. The logistic regression equation was applied to analyze the influencing factors for the quality of life in nursing care after lung cancer resection. Of 136 patients receiving lung cancer resection, 32 were lost to follow-up until the final follow-up, so 104 patients were finally included. According to the median level of quality of life in nursing care at the final follow-up, the patients were divided into high-quality and low-quality groups (n = 52 per group). The quality of life in nursing care first decreased, then increased, and then stabilized after lung cancer resection. The comparison of clinical data between the two groups exhibited that albumin level was higher in the high-quality group than that in the control group. The age, proportion of living alone, S-AI score, and FoP-Q-SF score were lower in the high-quality group than those in the low-quality group (P < 0.05). Univariate logistic regression analysis demonstrated that high albumin (OR = 0.884) was a protective factor for the quality of life in nursing care after lung cancer resection (P < 0.05). Living alone (OR = 1.333), high S-AI score (OR = 1.211), high FoP-Q-SF score (OR = 1.221), and advanced age (OR = 1.209) were the risk factors for the quality of life in nursing care after lung cancer resection (P < 0.05). Multivariate logistic regression analysis demonstrated that high albumin (OR = 0.861) was a protective factor for the quality of life in nursing care after lung cancer resection (P < 0.05). Living alone (OR = 1.144), high S-AI score (OR = 1.170), high FoP-Q-SF score (OR = 1.161), and advanced age (OR = 1.181) were the risk factors for the quality of life after lung cancer resection (P < 0.05). The quality of life in nursing care first decreased, then increased, and then stabilized after lung cancer resection. Albumin, age, living alone, and S-AI and FoP-Q-SF scores were the influencing factors for the quality of life in nursing care after lung cancer resection. In the nursing care process after lung cancer resection, we should focus on elderly patients living alone who are affected by anxiety and fear of recurrence to improve the quality of life of these patients.

Surgery without preoperative histological confirmation of lung cancer: what is the current clinical practice?

BackgroundThere are discordances in the guidelines regarding the need to acquire histological diagnosis before surgical treatment of (presumed) lung cancer. Preoperative histological confirmation is always encouraged in this setting to prevent unnecessary surgery or when sublobar resection for small-sized tumors is considered. The aim of this retrospective cohort study was to assess the proportion of patients undergoing lung cancer resection in the Netherlands without preoperative pathological confirmation, based on the intraoperative pathological diagnosis (IOD) rate, and to determine characteristics that may influence IOD frequency.MethodsData on 10,226 patients, who underwent surgical treatment for lung cancer from 2010 to 2015, were retrieved from the Netherlands National Cancer Registry. We registered an IOD when the date of diagnosis equaled the date of the first surgical intervention. Tabulations and multivariable logistic regression were used to identify predictive parameters for IOD.Results36% of surgical procedures were classified as IOD, and decreased with increasing tumor size and extent of surgery (57% for segmentectomy, 39% for lobectomy and 11% for pneumonectomy). IOD was more frequently observed in adenocarcinoma (41%), varied between hospitals from 13% to 66% and was less common when patients were referred from a hospital where thoracic surgery was not performed. Previous history of cancer did not affect IOD.ConclusionsMore than one-third of patients with suspected lung cancer in the Netherlands was operated without preoperative histological confirmation. There was significant variation in IOD rates between different hospitals, which deserves further detailed analysis when striving for uniform surgical quality of care for patients with lung cancer.