Pulmonary Recurrence Research Articles

Association between initial and residual pulmonary vascular obstruction and pulmonary embolism recurrence, a pooled analysis

Introduction The best treatment option (short-term or extended anticoagulant treatment) after a first unprovoked pulmonary embolism (PE) is debated. Pulmonary vascular obstruction, measured by the pulmonary vascular obstruction index (PVOI) at diagnosis or during the follow-up, has been associated with an increased risk of venous thromboembolism (VTE) recurrence when anticoagulants are stopped [1] . But results are not entirely consistent [2] , and PVOI classification cut-offs vary among studies. We therefore conducted a pooled analysis of 3 studies of the F-CRIN INNOVTE network. The primary objective of this work is to assess if elevated PVOI at the time of PE diagnosis and after months of anticoagulation are independent risk factors of VTE recurrence after a first episode of PE, and if so, to estimate which PVOI cut-off values would be the most discriminating for predicting VTE recurrence. Method We performed a pooled analysis of individual data from 3 French studies conducted within the F-CRIN INNOVTE network: a randomised double-blind controlled clinical trial and two observational longitudinal cohort studies. PVOI was measured by ventilation/perfusion lung scan during two periods; one at the time of index PE (initial PVOI), and one several months later, after anticoagulation treatment of the acute phase (post-treatment PVOI). PVOI was expressed in percentage of vascular obstruction. VTE recurrence was defined as objectively confirmed PE episode or deep vein thrombosis. The associations between PVOI (both initial and post-treatment) and VTE recurrence were jointly estimated using a multivariate Cox proportional hazards regression model. To manage confounding, the model was further stratified on the study, as well as adjusted on anticoagulant treatment duration, which could have been affected by PVOI measurement in the two observational cohort studies. By this means, the direct effect of PVOI on VTE recurrence may be estimated. Optimal PVOI thresholds were estimated by 10-fold cross-validation, using areas under curve (AUC) computed from time-dependant receiver-operating characteristic (ROC) curves. Results The total number of patients was 922. The median duration of follow-up was 42 months (IQR: 38–60). Mean age was 60 ± 18 years, 56% of patients were female. VTE recurrences occurred in 149 patients (4.2 events per 100 person-years). The most discriminating cut-offs were > 35% for initial PVOI (AUC: 0.71, 95% CI: 0.71–0.71), and > 5% for post-treatment PVOI (AUC: 0.69, 95% CI: 0.68–0.69). Initial PVOI > 35% and post-treatment PVOI > 5% were significantly associated with the risk of VTE recurrences (HR 1.61, 95% CI: 1.07–2.43 and HR 1.63, 95% CI: 1.06–2.50, respectively). Conclusion After a first episode of PE, initial PVOI > 35% and post-treatment PVOI > 5% were found to be independent predictors of VTE recurrence. Those results could in the future help detect more accurately patients with high-risk of VTE recurrence, and thus provide help in clinical decision-making for adapting anticoagulation therapy.

Undifferentiated embryonal sarcoma of the liver in adults: Retrospective analysis of a case series and systematic review

Adult undifferentiated embryonal sarcoma of the liver (UESL) is an aggressive malignant tumor. As UESL is rare, the literature predominantly includes case reports, with a limited number of small case series. The aim of the present study was to investigate the presentation, treatment modalities and outcomes of this rare tumor. The present study includes a case series of adult UESL and a systematic review. A single-institution case series of adult UESL were retrospectively analyzed, and a systematic review of adult UESL was performed by searching MEDLINE, Web of Science, EMBASE, the Google Scholar database and the Cochrane Library. For all identified adult UESL cases, the demographic variables, treatments and survival were analyzed. Three female adult patients with UESL (median age, 21 years) were successfully treated by complete tumor resection, with or without adjuvant chemotherapy, at Beijing Tsinghua Changgung Hospital between 2015 and 2018. Of these patients, two are currently alive (follow-up, 9 and 41 months), and one died after pulmonary recurrence 17 months post-diagnosis. The present systematic review identified 108 cases of adult UESL. Among all 111 analyzed cases, the median overall and disease-free survival rates were as follows: 1-year, 72 and 67%; 3-year, 56 and 40%; and 5-year, 47 and 35%, respectively. Treatment strategies combining complete tumor resection and chemotherapy promoted improved overall and disease free survival time compared with radical tumor resection alone. The present analysis included one of the largest case series of UESL in adults, and is the first such study to present survival rates. The results of the present study confirmed that survival was improved by treatment strategies combining complete tumor resection and chemotherapy.

Pulmonary recurrence after radical hysterectomy for uterine cervical carcinoma

Pulmonary spread from carcinoma of the uterine cervix, though uncommon, has been reported in 2.2–9.1% of all cervical cancers. The aim of this study was to evaluate the surgical, clinical, pathological factors and clinical outcomes of cervical cancer patients with pulmonary recurrence (PR).This study included 17 cervical cancer patients with PR after radical hysterectomy. The entire cohort consisted of 413 patients whose surgeries (type III radical hysterectomy + pelvic ± para-aortic lymphadenectomy) had been performed in our Gynaecologic Oncology Clinic between 1993 and 2018. Tumour size, lymph node metastasis and receiving adjuvant therapy were found to be effective for PR on univariate analyses in the main cohort (p = .042, p < .001 and p = .001, respectively). Therefore, performing adjuvant therapy to reduce the PR must be assessed properly with the information of lymph node status and tumour size obtained from the final pathology reports.Impact StatementWhat is already known on this subject? Pulmonary spread from carcinoma of the uterine cervix has been reported in 2.2–9.1% of all cervical cancers. Data related to clinico-pathological features of patients with pulmonary recurrence (PR) is limited. Diagnosis of a PR is considered to worsen the prognosis.What do the results of this study add? Tumour size, lymph node metastasis and receiving adjuvant therapy were found to be effective for PR on univariate analyses.What are the implications of these findings for clinical practice and/or further research? Performing adjuvant therapy to reduce the PR must be assessed properly with the information of lymph node status and tumour size obtained from the final pathology reports in patients with uterine cervical carcinoma.

Pulmonary recurrence of lymphomatoid granulomatosis diagnosed on F-18 FDG PET/CT

Lymphomatoid granulomatosis (LYG) is a rare, extranodal B-cell lymphoproliferative disorder. The disease commonly presents with nonspecific symptoms and imaging features, making the diagnosis and therapeutic response assessment difficult. While histopathology is the mainstay of diagnosis, different imaging modalities such as computed tomography (CT), magnetic resonance imaging, or F18-fluorodeoxyglucose positron emission tomography/computed tomography (F-18 FDG PET/CT) can help in identifying the different organs involved. We present a case of LYG, post chemotherapy in remission for the past 5 years, presenting with symptoms of disease recurrence.

Pulmonary metastasectomy in primary extremity osteosarcoma: Choosing wisely, along with a brief review of literature.

Despite the advances in systemic treatment, about 30%-40% of the patients with extremity osteosarcomas relapse and more than 80% of these relapses localize in the lungs. Our understanding of the management of pulmonary metastases from extremity osteosarcomas is largely based on retrospective data from single institutions or compiled from registries; hence, there is great degree of variability in the reported management of pulmonary metastasis in patients with osteosarcomas. To analyze the demographic profile, disease characteristics and survival outcomes of patients who had undergone potentially curative pulmonary metastasectomies from extremity osteosarcomas. Retrospective analysis of the 37 patients with resectable pulmonary metastasis (both synchronous and metachronous) from osteosarcoma of the extremity, treated from January 1, 2003 to December 31, 2017 at a tertiary regional cancer center in South India. The median overall survival (OS) of our patient cohort was 38 ± 2.7 months. The 2-, 3-, and 5-year OS were 86 ± 5.8%, 60.8 ± 8.6%, and 20.7 ± 7.4%, respectively. A formal analysis of the various prognostic factors revealed disease-free interval >2 years, completion of the planned systemic chemotherapy, and absence of pulmonary recurrence post-metastasectomy to be significantly influencing the survival outcomes. Our study reiterates the need for consideration of pulmonary metastasectomy in carefully selected patients of extremity osteosarcomas. There is a paucity of data on pulmonary metastasectomies from India and our cohort is possibly the largest series for pulmonary metastasectomies from an osteosarcoma primary. In routine clinical practice, we recommend that the final decision to proceed with pulmonary metastasectomy should ideally be taken by a multidisciplinary tumor board on a case-by-case basis.

The impact of hepatic arterial infusion pump chemotherapy on hepatic recurrences and survival in patients with resected colorectal liver metastases

BackgroundThe objective was to investigate the impact of adjuvant hepatic arterial infusion pump (HAIP) chemotherapy on the rates and patterns of recurrence and survival in patients with resected colorectal liver metastases (CRLM). MethodsRecurrence rates, patterns, and survival were compared between patients treated with and without adjuvant HAIP using competing risk analyses. Results2128 patients were included, of which 601 patients (28.2%) received adjuvant HAIP and systemic chemotherapy (HAIP + SYS). The overall recurrence rate was similar with HAIP + SYS or SYS (63.5% versus 64.2%,p = 0.74). The 5-year cumulative incidence of initial intrahepatic recurrences was lower with HAIP + SYS (22.9% versus 38.4%,p < 0.001). The 5-year cumulative incidence of initial extrahepatic recurrences was higher with HAIP + SYS (48.5% versus 40.3%,p = 0.005), because patients remained at risk for extrahepatic recurrence in the absence of intrahepatic recurrence, which was largely attributable to more pulmonary recurrences with HAIP + SYS (33.6% versus 23.7%,p < 0.001). HAIP was an independent prognostic factor for DFS (adjusted HR 0.69, 95% CI 0.60–0.79, p < 0.001), and OS (adjusted HR 0.67, 95% CI 0.57–0.78,p < 0.001). ConclusionAdjuvant HAIP chemotherapy is associated with lower intrahepatic recurrence rates and better DFS and OS after resection of CRLM.

The effect of obstructive sleep apnea and CPAP therapy on the pulmonary embolism recurrence

The effect of obstructive sleep apnea and CPAP therapy on the pulmonary embolism recurrence

Anatomical Resections Improve Survival Following Lung Metastasectomy of Colorectal Cancer Harboring KRAS Mutations

The aim of this study was to evaluate the benefit of anatomical resection (AR) in lung metastasectomy (LM) of colorectal cancer (CRC) harboring KRAS mutations SUMMARY BACKGROUND DATA:: KRAS mutations are related to high aggressiveness in the lung metastasis of CRC. It is unknown whether AR can lead to better outcomes than can non-AR (NAR) in KRAS patients. We retrospectively reviewed the data from 574 consecutive patients who underwent a LM for CRC. We focused on patients exhibiting 1 lung metastasis who underwent an AR (segmentectomy) or an NAR (wedge) and for whom the KRAS mutational status was known. Overall survival (OS) and time to pulmonary recurrence (TTPR) were analyzed. We included 168 patients, of whom 95 (56.5%) harbored KRAS mutations. An AR was performed in 74 patients (44%). The type of resection did not impact the median OS in wild-type (WT) patients (P = 0.67) but was significantly better following AR in KRAS patients (101 vs 45 months, P = 0.02) according to the multivariate analysis [hazard ratio (HR): 6.524; 95% confidence interval (CI), 2.312-18.405; P < 0.0001). TTPR was not affected by the type of resection in WT patients (P = 0.32) but was significantly better for AR in KRAS patients (50 vs 15 months, P = 0.01) in the multivariate analysis (HR: 5.273; 95% CI, 1.731-16.064; P = 0.003). The resection-margin recurrence rate was significantly higher for NAR in KRAS patients (4.8% vs 54.2%, P = 0.001) but not in WT patients (P = 0.97). AR seems to improve both the OS and TTPR in LM of CRC harboring KRAS mutations.

1734TiP - Pulmonary resectable metastases of osteosarcoma with apatinib and chemotherapy (PROACH): A multi-center phase II randomized clinical trial

BackgroundThe prognosis of osteosarcoma at its metastatic stage remains unchanged over the last several decades. Although 60∼80% first pulmonary recurrences were reportedly to be resectable, it’s surprising that the vast majority of trials to date were designed for metastatic osteosarcoma that were considered inoperable. Apatinib, a VEGFR2 inhibitor, is marked by its superior overall response rate (ORR) of ∼55% compared with other anti-angiogenic agents. Therefore, we aim to assess the efficacy and safety of incorporating apatinib with second-line chemotherapy preoperatively for resectable pulmonary metastatic osteosarcoma, with the intent to shrink the lesions for easier resection and eradicate the micro-metastatic residue using the combination therapy. Trial designThis study is a multicenter, open-label, randomized phase II trial (ClinicalTrials ID: NCT03742193) in which ∼180 participants were to be randomized to an active control arm and an intervention arm in 1:1 ratio. Patients in the intervention arm will receive 250mg apatinib twice daily combined with gemcitabine-docetaxel (GD) regimen before and after the pulmonary metastasectomy, while the control arm will receive gemcitabine-docetaxel (GD) regimen only. Osteosarcoma patients with pulmonary recurrence only, which are potentially resectable at baseline will be recruited in the trial. The primary endpoint is progression-free survival (PFS) and the pre-specified target is an at least 30% decrease of hazard rate of progression in the experimental arm compared with the control arm. Error rate level of the trial was set at an one-sided α value of 0.1 and a power (1-β value) of 0.8, with mid-term assessment for both early efficacy and futility. Secondary objectives are to analyze the effect of the new regimen on overall survival, total resectability, objective response rate, clinical benefit rate, tolerability, as well as the potential predictive biomarker(s). Clinical trial identificationNCT03742193; release date: March 2018. Legal entity responsible for the studyAn IIT trial by Ruijin Hospital, Orthopaedic oncology group. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

Two cases that show the effects of bevacizumab on the recurrence of cervical cancer with pleural effusion

Abstract Introduction Bevacizumab has been applied clinically to advanced and recurrent cervical cancer, after showing improved overall survival in the GOG 240 trial. We report two cases of patients with recurrent cervical cancer who showed remarkable decrease in pleural effusion by chemotherapy combined with bevacizumab. Case 1 A 41-year-old patient with stage IIB cervical adenocarcinoma who presented with cervical carcinoma recurrence in the lung and paraaortic/ supraclavicular lymph nodes after primary treatments with concurrent chemoradiotherapy (CCRT), total hysterectomy, and paclitaxel-carboplatin (TC) therapy. As symptomatic pleural effusion emerged after irinotecan-cisplatin therapy and radiotherapy, paclitaxel-cisplatin-bevacizumab (Pac-Cis-Bev) was administered and relieved the pleural effusion promptly and the respiratory distress and back pain symptoms over 13 months. Case 2 The second case involved a 53-year-old patient with stage IIIB cervical squamous cell carcinoma who had a pulmonary recurrence following treatment with CCRT. As pleural effusion emerged at the end of the six-month drug holiday, after a total of 21 cycles of TC or Pac-Cis-Bev therapy to treat the recurrence, topotecan-paclitaxel-bevacizumab (Topo-Pac-Bev) was administered. Respiratory distress was relieved in two weeks, and the pleural effusion disappeared almost completely after two months. The patient received 12 cycles of Topo-Pac-Bev, in total. Conclusion The present two patients have survived over three years, without problematic symptoms, after pulmonary recurrences with pleural effusion, despite that the three-year survival rate for recurrent/metastatic cervical cancer has been reported to be less than 5% without bevacizumab therapy. Chemotherapies that contain bevacizumab present promising regimens for recurrent cases with pleural effusion, despite the uncommon risks of bladder-vaginal or recto-vaginal fistulas.

P1914Relationship between myocardial injury, inflammation and early, late recurrence after pulmonary vein isolation may be different between radiofrequency catheter ablation and cryoballoon ablation

Abstract Background High sensitive cardiac troponin I (hs-TnI), subunit of cardiac troponin complex, is a sensitive and specific marker of myocardium injury as troponin T. Several studies showed hs-TnI was associated with worse cardiovascular outcomes but relationship between serum hs-TnI level in patients with atrial fibrillation (AF) after pulmonary vein isolation (PVI) and AF recurrence remains unclear. Methods We enrolled 444 consecutive AF patients who underwent PVI from May 2017 to September 2018. We investigated the difference of relationship between serum hs-TnI, inflammation markers at 48 hours after PVI and early or late recurrence of AF (ERAF, &lt;3 months and LRAF, during 1 year after PVI in patients with AF) between radiofrequency ablation (RFA) group and cryoballoon ablation (CBA) group. Results RFA and CBA were performed in 328 and 116 patients, respectively. There were no significant differences in patient characteristics between RFA group and CBA group. Serum hs-TnI in RFA group was significantly lower than in CBA group (1.93 ng/ml±3.28 vs 5.08 ng/ml±4.29, p&lt;0.001), while hs-CRP was significantly higher in RFA group than CB group (1.97±2.38 mg/dl vs 1.10±0.84 mg/dl, p&lt;0.001). The incidence of ERAF was similar between the two groups (RFA group: 26.8% and CBA group: 21.6%, p=0.262). There was no significant difference of hs-TnI and hs-CRP between patients with ERAF and without ERAF (table). In 213 patients who were followed during 1 year (PVIs were performed from May 2017 to January 2018, RFA 149 and CBA 64 patients), there was no significant association between hs-TnI, hs-CRP and incidence of LRAF (table). TnI and CRP between RFA and CBA RFA (n=328) CBA (n=116) P value hs-TnI 1.93±3.28 5.08±4.29 &lt;0.001 hs-CRP 1.97±2.38 1.10±0.84 &lt;0.001 3 months follow-up RFA (n=328) CBA (n=116) ERAF (+) ERAF (−) P value ERAF (+) ERAF (−) P value hs-TnI 1.68±1.90 2.02±3.66 0.410 5.03±3.17 5.10±4.56 0.943 hs-CRP 2.23±2.65 1.88±2.27 0.238 1.01±0.84 1.13±0.85 0.524 1 year follow-up RFA (n=149) CBA (n=64) LRAF (+) LRAF (−) P value LRAF (+) LRAF(−) P value hs-TnI 1.61±1.77 1.87±2.69 0.570 4.71±2.14 5.60±5.69 0.664 hs-CRP 2.18±2.24 1.92±2.24 0.550 1.12±0.64 1.12±0.98 0.991 Conclusion CBA may cause more myocardial injury than RFA, on the contrary RFA may cause more inflammation than CBA. These markers did not affect ERAF and LRAF after PVI.

Unknown Synchronous Pulmonary Lesions and Cancer Recurrence: Can We Predict Outcomes?

Unknown Synchronous Pulmonary Lesions and Cancer Recurrence: Can We Predict Outcomes?

Surgical treatment of pulmonary oligorecurrence after curative resection for non-small-cell lung cancer.

The most appropriate therapeutic strategy for patients with pulmonary oligorecurrence after curative resection of non-small-cell lung cancer (NSCLC) is unclear; therefore, characterizing the results of various treatments for pulmonary oligorecurrence would be valuable. This study compared the prognosis of operative and non-operative treatment for pulmonary oligorecurrence after complete resection of NSCLC. Among 2230 patients from a prospective lung cancer database who underwent surgical resection between 2004 and 2014, 486 patients (22%) experienced recurrence, including 254 with pulmonary recurrence and 102 with pulmonary oligorecurrence (5 or fewer metastatic lesions). Post-recurrence survival (PRS) rates were compared between those who received operative or non-operative treatment, including chemotherapy, radiotherapy, chemoradiotherapy and best supportive care. Among 102 patients with pulmonary oligorecurrence, 41 patients received operative treatment and 61 received non-operative treatment (34 chemotherapy, 15 radiotherapy, 9 chemoradiotherapy and 3 best supportive care). The patients who received operative treatment were significantly younger at the first operation than those in the non-operative group and had better performance status, lower pathological T stage at the first operation, younger age at recurrence and fewer metastatic lesions. The median PRS was 46.4 months, and the 5-year PRS rates were 67% and 26% in the operative and non-operative groups, respectively. The multivariable analysis revealed that undergoing video-assisted thoracoscopic surgery at the first operation and receiving operative treatment for recurrence were independent prognostic factors for more favourable PRS. Operative treatment of pulmonary oligorecurrence after curative resection significantly prolonged the PRS in patients who underwent curative resection for NSCLC.

Recurrence Patterns After Resection of Colorectal Liver Metastasis are Modified by Perioperative Systemic Chemotherapy

BackgroundThis study investigated the impact of perioperative systemic chemotherapy on the recurrence rate and pattern following resection of colorectal liver metastases.MethodsA retrospective cohort study was conducted in two centers. Rates and patterns of recurrence and overall survival (OS) were compared between patients treated with and without perioperative systemic chemotherapy. The clinical risk score (CRS) was used to stratify patients in low risk (CRS 0–2) and high risk (CRS 3–5) of recurrence.ResultsA total of 2020 patients were included, of whom 1442 (71%) received perioperative systemic chemotherapy. The median follow-up was 88 months, and 1289 patients (64%) developed a recurrence. The recurrence pattern was independent of chemotherapy in low-risk patients: intrahepatic recurrences (30% vs. 30%, p = 0.97) and extrahepatic recurrences (38% vs. 39%, p = 0.52). In high-risk patients, no difference in intrahepatic recurrences was found (48% vs. 50%, p = 0.59). However, a lower rate of extrahepatic recurrences (43% vs. 55%, p = 0.007) was observed with perioperative systemic chemotherapy, mainly due to a reduction in pulmonary recurrences (25% vs. 35%, p = 0.007). In competing risk analysis, the cumulative incidence of extrahepatic recurrence was significantly lower with perioperative systemic chemotherapy in high-risk patients only (5-year cumulative incidence 44% vs. 59%, p < 0.001). Perioperative chemotherapy was associated with improved OS in high-risk patients (adjusted HR 0.73, 95% CI 0.57–0.94, p = 0.02), but not in low-risk patients (adjusted HR 0.99, 95% CI 0.82–1.19, p = 0.90).ConclusionsPerioperative systemic chemotherapy had no association with intrahepatic recurrence, but was associated with fewer pulmonary recurrences and superior OS in high-risk patients only.

Influence of Molecular Status on Recurrence Site in Patients Treated for a Stage III Colon Cancer: a Post Hoc Analysis of the PETACC-8 Trial

Recurrence patterns in stage III colon cancer (CC) patients according to molecular markers remain unclear. The objective of the study was to assess recurrence patterns according to microsatellite instability (MSI), RAS and BRAFV600E status in stage III CC patients. All stage III CC patients from the PETACC-8 randomized trial tested for MSI, RAS and BRAFV600E status were included. The site and characteristics of recurrence were analyzed according to molecular status. Survival after recurrence (SAR) was analyzed. A total of 1650 patients were included. Recurrence occurred in 434 patients (26.3%). Microsatellite stable (MSS) patients had a significantly higher recurrence rate (27.2% vs. 18.7%, P = 0.02) with a trend to more pulmonary recurrence (28.8% vs. 12.9%, P = 0.06) when compared to MSI patients. MSI patients experienced more regional lymph nodes compared to MSS (12.9% vs. 4%, P = 0.046). In the MSS population, the recurrence rate was significantly higher in RAS (32.2%) or BRAF (32.3%) patients when compared to double wild-type patients (19.9%) (p < 0.001); no preferential site of recurrence was observed according to RAS and BRAFV600E mutations. Finally, decreased SAR was observed in the case of peritoneal recurrence or more than two recurrence sites. Microsatellite, RAS and BRAFV600E status influences recurrence rates in stage III CC patients. However, only microsatellite status seems to be associated with specific recurrence patterns. More than two recurrence sites and recurrence in the peritoneum were associated with poorer SAR.

Management of isolated recurrence after surgery for pancreatic adenocarcinoma.

Recurrence of pancreatic cancer after primary pancreatectomy occurs in the vast majority of patients. The role of surgical treatment for recurrent pancreatic cancer is not well established. Patients who underwent primary pancreatectomy with curative intent from 2000 to 2014 at a single large-volume centre were evaluated retrospectively. CT or PET was used to select patients with an isolated recurrence. The clinicopathological features and survival outcomes were compared according to treatment modalities. Of the 1610 patients with pancreatic cancer who underwent resection, 1346 (83·6 per cent) were diagnosed with recurrent pancreatic cancer. Recurrence was locoregional in 366 patients (27·2 per cent), distant multifocal in 251 (18·6 per cent), distant isolated in 188 (14·0 per cent), locoregional plus distant in 153 (11·4 per cent) and peritoneal seeding in 388 (28·8 per cent). Of the 1346 patients with recurrence, 197 (14·6 per cent) had isolated recurrence; of these, 48 (24·4 per cent of all isolated recurrences; 3·6 per cent of all recurrences) underwent resection. Median survival of the 197 patients after diagnosis of isolated recurrence was 14·7 months; it was longer in patients who underwent surgical resection than among those treated non-surgically (23·5 versus 12·0 months; P= 0·014). Multivariable analysis showed that chemotherapy and resection for recurrence were associated with better prognosis. Median survival after recurrence was longest in the 23 patients with isolated pulmonary recurrence (33·3 months). Survival after recurrence was better in patients who underwent resection of isolated recurrence in the remnant pancreas (median 28·0 versus 12·0 months, P= 0·010) and lung (median 36·5 versus 9·5 months; P= 0·010) than in those who did not undergo resection. Surgical resection may be considered an option for treatment of patients with isolated recurrent pancreatic cancer.

Isolated pulmonary recurrence after resection of pancreatic cancer: the effect of patient factors and treatment modalities on survival

BackgroundThe literature suggests favorable survival for patients with isolated pulmonary recurrence after resection of pancreatic ductal adenocarcinoma (PDAC) as compared to other recurrence patterns. Within this cohort, it remains unclear what factors are associated with improved survival. MethodsPatients who developed pulmonary recurrence after pancreatectomy were selected from a prospective database. Predictors for post-recurrence survival (PRS) were analyzed using a multivariable Cox regression model. ResultsNinety-six patients were included. Median recurrence-free survival (RFS), PRS and overall survival (OS) were 16.3, 18.8 and 39.6 months, respectively. Further systemic treatment and/or metastasectomy (n = 64, 67%) was associated with significantly improved PRS and OS when compared to best supportive care (n = 35, 22%) (26.3 vs. 5.3 and 48.1 vs. 18.4, respectively; both P < 0.001). Patients who were able to undergo metastasectomy (n = 19) achieved a PRS and OS of 35.0 and 68.9 months, respectively. More than 5 pulmonary lesions, symptoms and CA 19-9 ≥100 U/mL at time of recurrence were predictive of decreased PRS. A recurrence-free interval of >16 months and treatment for recurrence were independently associated with improved PRS. ConclusionsIsolated pulmonary recurrence occurs in 13% of patients with recurrent PDAC and is associated with a median OS of 40 months. Aggressive treatment in highly selected patients was correlated with improved survival.

Long-term outcomes of surgical resection of lung metastases from colorectal cancer.

655 Background: The lungs are one of the most frequent sites of metastases from colorectal cancer(CRC). Surgical resection has been widely performed on patients with pulmonary metastases from CRC with favorable outcomes. Surgical treatment is considered an effective option, but the surgical indications of lung resection have institutional bias. In our hospital, we aggressively perform surgery for lung metastases when the primary tumor and other metastases are controlled and all lung metastases are resectable. In this study, the aim is to investigate the long-term outcomes of resections of lung metastases from CRC in our institute. Methods: Between April 2009 and November 2017, patients who underwent lung resections for metastases from CRC with curative intent in our hospital were investigated retrospectively. Kaplan-Meier survival curves, log-rank tests, chi-squared test and T-test were used to analyze the survival rates and the factors predicting recurrence. Results: Sixty-seven patients underwent lung resection of metastases from CRC. The median follow-up period was 25.3 (6-60) months. Five-year disease free survival was 33.6 % and 5-year overall survival was 63.9%. Because of pulmonary recurrence, second surgery was performed in 16 patients and a third surgery in three patients. 5-year overall survival rate after first lung resection in patients who underwent repeated lung resection was 49.2%. There was no significant difference between the number of patients with pulmonary recurrence and those with no recurrence after lung resection (p = 0.38). Twenty-one patients had experienced prior liver resection; the 5-year overall survival rate after lung resection in these patients was 57.9 %. Factors predicting recurrence were vascular invasion (v ≥ 2) of primary tumor (p = 0.02), pre-operative serum CEA (p = 0.03) and CA-19-9 (p = 0.04). Conclusions: The outcome of lung resection of metastases from CRC in our hospital was satisfactory. Aggressive lung resection for cases even after liver resection and repeated pulmonary recurrence may improve long-term outcomes.Vascular invasion of primary tumor and the pre-operative serum CEA and CA 19-9 level can be predictive markers for recurrence.

Validity of Surgical Resection for Lymph Node or Pulmonary Recurrence of Esophageal Cancer After Definitive Treatment

BackgroundDespite the poor prognosis of recurrent esophageal squamous cell cancer (ESCC), long-term survival could be achieved in a subset of patients who successfully underwent surgical resection for recurrence. In this study, we investigated the outcomes of surgical resection for lymph node (LN) or pulmonary (PUL) recurrence in ESCC patients.MethodsWe retrospectively analyzed the outcomes of ESCC patients who underwent surgical resection between January 2008 and March 2015 for either LN or PUL recurrence after complete response (CR) by chemoradiotherapy or R0 esophagectomy. Every patient fulfilled the original institutional criteria: no recurrence at primary site; recurrence involving in only one organ; expectation of complete resection; and for PUL recurrence, no rapid growth with at least 2 months of observation.ResultsAmong the 13 patients analyzed, surgical resection was performed in nine and four patients with LN and PUL recurrence, respectively. R0 resection was achieved in all patients with no fatal surgical complications. Mean duration from the day of the first CR/R0 to the recurrence was 809 (110–2575) days. Median recurrence-free survival following surgical resection for recurrence and overall survival following the first diagnosis of recurrence was 387 and 1297 days, respectively.ConclusionSurgical resection for LN or PUL recurrence of ESCC according to our institutional criteria can be performed safely for selected patients.

Prognostic value of neutrophil to lymphocyte ratio in lung metastasectomy for colorectal cancer.

Neutrophil to lymphocyte ratio (NLR) has been shown to be a promising biomarker in several cancers. Prognostic biomarkers are still needed to define good candidates for lung metastasectomy for colorectal cancer. We aimed to evaluate the role of NLR. Data from 574 patients who underwent lung metastasectomy for colorectal cancer in 3 departments of thoracic surgery from 2004 to 2014 were retrospectively reviewed. Overall survival (OS) and the time to pulmonary recurrence (TTPR) were the main end points. Correlations between NLR and OS (R2 = 0.53), and NLR and TTPR (R2 = 0.389) were significant (P < 0.0001 for both), with corresponding Pearson R of -0.728 (P < 0.0001) and -0.624 (P < 0.0001), respectively. A receiver operating characteristic curve analysis highlighted an NLR cut-off value of 4.05 as the best predictor of OS and TTPR. NLR ≤4.05 was observed in 238 patients (41.4%). In the univariable analysis, the median OS was 117 months for patients with NLR ≤4.05 and decreased to 40 months for patients with NLR >4.05 (P < 0.0001). The median TTPR reached 52 months in case of NLR ≤4.05 and decreased to 12 months in patients with NLR >4.05. In the multivariable analysis, NLR ≤4.05 remained an independent favourable prognostic factor on both OS [hazard ratio [HR] 0.29, 95% confidence interval (CI) 0.167-0.503; P < 0.0001] and TTPR (HR 0.346, 95% CI 0.221-0.54; P < 0.0001). Significant correlations between NLR >4.05 and KRAS (Cramer's V = 0.241, P < 0.0001) and BRAF (Cramer's V = 0.153, P = 0.003) mutations were observed. NLR is a simple and powerful predictor of outcomes in patients undergoing pulmonary metastasectomy for colorectal cancer.