Resected Early Lung Cancer Research Articles

Thoracic Surgery and the Elderly; Is Lobectomy Safe in Octogenarians?

Non-small cell lung cancer is the most common malignancy of the elderly, with 5-year survival estimates of 16.8%. The prognostic benefit of surgical resection for early lung cancer is irrefutable and maintained irrespective of age, even in patients over 75 years. Concerningly, despite the prognostic benefit of surgery there are deviations from standard treatment protocols with increasing age due to concerns of increased morbidity and mortality with surgery, without evidence to support this. A state-wide retrospective registry study of Queensland's Cardiac Outcomes Registry's (QCOR) Thoracic Database examining the influence of age on the safety of Lung Resection (1 January 2016-20 April 2022). This included 1,232 patients, mean age at surgery was 66 years (range 14-91 years), with 918 thoracotomies performed. Three deaths occurred within 30-days (0.24%). Octogenarians (n=60) had lower rates of smoking (26% vs 6%), respiratory, cardiovascular, and cerebrovascular disease suggesting this subset of patients is carefully selected. Octogenarian status was not associated with an increased all-cause morbidity (p=0.09) or 30-day mortality (p=0.06). Further to this it was not associated with re-operation (4.4% vs 8.3%, p=0.1), increased postoperative stay (6.66 vs 6.65 days, p=0.99) or myocardial infarction. An independent predictor of morbidity was male sex (OR 1.58, CI 1.2-2.1 p=0.001). Age ≥80 years did not increase surgical morbidity or mortality in the appropriately selected patient and should not be a barrier to referral for consideration of surgical resection.

Thoracic Surgery and the Elderly: Is Lobectomy Safe in Octogenarians?

Non-small cell lung cancer is the most common malignancy of the elderly, with 5-year survival estimates of 16.8%. The prognostic benefit of surgical resection for early lung cancer is irrefutable, with lobectomy producing 10-year survival between 66–94%. The prognostic benefit of surgery over radiation is maintained irrespective of age, even in patients aged >75 years. Despite the prognostic benefit of surgery, there are deviations from standard treatment protocols with increasing age due to concerns of increased morbidity and mortality with surgery, without evidence to support this.

A case of successful conversion surgery for locally advanced pancreatic cancer with synchronous triple cancer of the lung and esophagus: a case report

BackgroundThe number of reports of multiple primary cancer (MPC) is increasing because of the advancement in diagnostic imaging technology. However, the treatment strategy for MPCs involving pancreatic cancer is controversial because of the extremely poor prognosis. We herein report a patient with synchronous triple cancer involving the pancreas, esophagus, and lung who underwent conversion surgery after intensive chemotherapy for unresectable locally advanced pancreatic cancer.Case presentationA 59-year-old man was admitted to our hospital with epigastric pain, anorexia, and weight loss. Computed tomography and upper gastrointestinal endoscopy revealed that the patient had synchronous triple cancer of the pancreas, esophagus, and lung. While the esophageal and lung cancer were relatively non-progressive, the pancreatic tail cancer had invaded the aorta, celiac axis, and left kidney, and the patient was diagnosed with unresectable locally advanced disease. Because the described lesion could have been the prognostic determinant for this patient, we initiated intensive chemotherapy (gemcitabine plus nab-paclitaxel) for pancreatic cancer. After six courses of chemotherapy, the tumor size shrank remarkably and no invasion to the aorta or celiac axis was observed. No significant changes were observed in the esophageal and lung cancers; endoscopic submucosal dissection could be still a curative treatment for the esophageal cancer. Therefore, we performed curative resection for pancreatic cancer (distal pancreatomy, splenectomy, and left nephrectomy; ypT3N0cM0, ypStage IIA, UICC 8th). Pathologically, complete resection was achieved. The patient then underwent endoscopic submucosal dissection for early esophageal cancer (pT1a[M]-LPM) and video-assisted thoracoscopic right upper lobectomy in combination with right lower partial resection for early lung cancer (pT2aN0M0, pStage IB, UICC 8th). Eight months after pancreatic cancer surgery, the patient is alive and has no sign of recurrence; as a result of the successful treatment, the patient has a good quality of life.ConclusionsTreatment of MPC is challenging, especially for cases with unresectable tumors. Although synchronous triple cancer can involve unresectable pancreatic cancer, radical resection may be possible after careful assessment of the appropriate treatment strategy and downstaging of unresectable tumors.

Indication of uniportal video-assisted thoracoscopic surgery

: Uniportal video-assisted thoracoscopic surgery (U-VATS) has been recognized as a one of minimally invasive surgery among thoracic surgeons. For some diseases such as some benign inflammatory diseases, mediastinal tumor, metastatic lung tumor, and lung cancer in thoracic surgery, U-VATS has already been applied. There is no definite indication of U-VATS even in lung cancer. According to the surgeon’s ability at the institute, indication of U-VATS for the lesion that is benign or malignant is determined at this moment. The clarification of indication of U-VATS is also essential for doing safe surgery. On the other hand, prognosis of U-VATS anatomical lung resection for early lung cancer remains still unclear in detail. Recently, U-VATS has been started to perform even in advanced lung cancer. In spite of the vague surgical outcomes of U-VATS, it is certain that indication of U-VATS has gradually expanded. Oncologically, there is a room to argue on U-VATS anatomical lung resection for lung cancer still more. Additionally, the application of U-VATS for advanced lung cancer possesses a little unreliable due to possibility of incomplete lymph node dissection. Because the unfavorable outcomes for the patients with lung cancer such as local recurrence and severe troubles during surgery causes, the clarification of indication of U-VATS is an urgent issue. Based on our experience, we reviewed the indication of U-VATS for lung cancer.

Intersegmental plane simulation based on the bronchus-vein-artery triad in pulmonary segmentectomy.

BackgroundFew reliable methods to simulate and evaluate the intersegmental plane have been reported. We introduce intersegmental plane simulation based on the bronchus-vein-artery triad in three-dimensionally reconstructed images from patients who underwent segmentectomy for early lung cancer.MethodsWe collected clinical data of consecutive patients with early-stage lung cancer who underwent three-dimensional imaging-guided single-port thoracoscopic segmentectomy at Department No. 1 of Thoracic Surgery at Fujian Medical University Fujian Union Hospital from January 2019 to July 2019. Patients were divided into two groups according to the application of intersegmental plane simulation and nodule analysis: the intersegmental plane group and the non-intersegmental plane group. General clinical characteristics, operation status, and postoperative recovery were compared between groups. The three-dimensional reconstruction results in the intersegmental plane group were analyzed and summarized.ResultsA total of 120 patients were included (61 in the intersegmental plane group and 59 in the non-intersegmental plane group). There were no significant differences between the two groups in general characteristics (all P>0.05). All target lesions were resected in both groups. There were no significant differences between groups in operation characteristics or postoperative recovery, with the exception of the duration of chest drainage and the rate of gross margin insufficiency. There were five cases of gross margin insufficiency in the non-intersegmental plane group. With three-dimensional imaging reconstruction, a total of 131 intersegmental veins could be used to evaluate the simulated intersegmental plane in 61 patients, with an average of 2.1±0.5 veins per patient. Two patients (3.3%) had one vein that could be used to evaluate the intersegmental plane, 50 patients (82.3%) had two, seven patients (11.3%) had three, and two patients (3.3%) had four. The total number of intersegmental veins located on the simulated intersegmental plane was 124 (94.7%), with an average of 2.0±0.6 veins per patient. The accuracy of intersegmental plane simulation was 91.8% (56/61).ConclusionsThe bronchus-vein-artery triad in intersegmental plane simulation can assist surgeons in preoperative planning and can facilitate complete resection of early lung cancer with sufficient surgical margins.

The 4-hook anchor coaxial needle with scaled suture is superior to the double spring coil for preoperative localization.

BackgroundPreoperative localization of small size pulmonary nodules is challenging, but it is necessary for surgical resection of early lung cancer. As a new device for preoperative localization, the 4-hook-anchor coaxial needle with scaled suture was tentatively applied in our department to improve the effect of preoperative localization. However, double spring coil, as a proven positioning technology, used to be our preferred method in the past. We did a retrospective single-centre research driven by the interest on which one should be the first choice for preoperative localization among these two approaches.MethodsWe performed a retrospective analysis on 100 patients undergoing surgery with the new coaxial needle from 2019 to 2020, and 98 patients undergoing double spring coil from 2017 to 2019. The duration of localization, success rate, operation time, intraoperative bleeding, and positioning-related complications of these two groups of patients were examined in this study.ResultsThere were no significant differences between the two groups of patients in terms of the success rate. However, the new coaxial needle seemed to be able to shorten the duration of preparative localization and operation time by accelerating the efficiency of exploring small nodules intraoperatively, and also decreased the risk of positioning-related pneumothorax and pulmonary hemorrhage. The logistic analysis indicated that the puncture depth was an independent risk factor for overall complications. Meanwhile, previous lung diseases and positioning time were independent risk factors for pneumothorax, besides pneumorrhagia and depth of penetration as well.ConclusionsThe new coaxial needle can save time for both radiologists and thoracic surgeons, while reducing the risk of positioning-related complications. We support its application clinically instead of the double spring coil.

Surgical treatment for early stage non-small cell lung cancer.

Surgery is the standard of care for early stage non-small cell lung cancer. There is significant debate about the type of operation most effective for lung cancer. Minimally invasive techniques like video-assisted (VATS) and robot-assisted thoracoscopic surgery (RATS) have been shown to reduce postoperative complications and shorten hospitalization. However, there remains skepticism about their oncologic effectiveness when compared to an open approach, though recent literature suggests no differences in upstaging or survival between VATS and thoracotomy. The extent of resection for early lung cancer also remains a matter of debate. Lobectomy remains the preferred operation and is associated with better survival and lower locoregional recurrence, but there is increased interest in the role of sublobar resections. Sublobar resections have similar mortality to lobar resections in small ground glass-predominant tumors. We examine the literature surrounding these controversies in this review.

Nonintubated uniportal thoracoscopic wedge resection for early lung cancer

Minimal invasive surgery is current choice of treatment for lung cancer. Combined nonintubated anesthesia with uniportal thoracoscopic surgery is not well understood. Here, we report the experience of nonintubated uniportal thoracoscopic surgery in the treatment of primary non-small cell lung cancer (NSCLC). From January 2014 to December 2015, we retrospectively reviewed 131 consecutive patients with primary NSCLC who underwent nonintubated uniportal thoracoscopic wedge resection and mediastinal lymph node dissection at a single medical center. Of the 131 patients, 110 (84%) received preoperative computed tomography-guided dye localization. Most of them were diagnosed with early stage invasive adenocarcinoma (N=112, 85.5%; pathological stage IA: 84.7%, N=111), and the mean size of the nodule was small (diameter: 0.85±0.40 cm). All section margins were free of malignancy. In total, 7 of the 131 patients (5.3%) had their treatment converted from uniportal to multi-portal video-assisted thoracoscopic surgery (VATS), and 1 (0.8%) had his treatment converted to endotracheal intubation with general anesthesia. The mean operation time was 91.1±32.6 minutes, and the postoperative complications included pneumonia (0.8%), prolonged air leaks (0.8%), and subcutaneous emphysema (1.5%). Overall, nonintubated uniportal VATS is a feasible, effective and safe procedure for the treatment of early primary lung cancer.

Correlation Between Tumor Necrosis Factor-α and Interleukin-1β in Exhaled Breath Condensate and Pulmonary Function

BackgroundExhaled breath condensate (EBC) has emerged as a noninvasive method for assessing inflammation in lung diseases. Our aim is to investigate the correlation between tumor necrosis factor α (TNF-α) and interleukin 1β (IL-1β) in EBC and in lung tissue, and between these values in EBC with pulmonary function tests in patients with chronic obstructive pulmonary disease (COPD). Materials and MethodsTo ensure the availability of lung tissue, 60 patients undergoing resection for early lung cancer were divided into 3 groups: a COPD treatment group, a COPD control group and a non-COPD group. Patients in the COPD treatment group received what was termed “lung-protective treatment” including ambroxol, budesonide and ipratropium bromide in addition to chest physiotherapy. Patients underwent pulmonary function testing and EBC collection, and TNF-α and IL-1β were detected by enzyme-linked immunosorbent assay (ELISA). TNF-α and IL-1β in lung tissues were evaluated by immunoflorescense. Correlations were analyzed by Pearson correlation coefficients. ResultsThe TNF-α and IL-1β levels in EBC were significantly higher in the COPD groups compared with the non-COPD group before surgery (all P < 0.01), and the levels were significantly decreased after lung-protective treatment was received before surgery (all P < 0.01). TNF-α and IL-1β levels in EBC were significantly decreased in all patients after surgery with lung-protective treatment (P = 0.027, P = 0.004). TNF-α and IL-1β content in lung tissues was significantly higher in the COPD groups (all P < 0.05), and the histologic analysis showed similar results. Negative correlations between FEV1/FVC and expression of TNF-α and IL-1β were observed. There was a positive correlation between TNF-α and IL-1β in lung tissues and in EBC. ConclusionsTNF-α and IL-1β in EBC are potential biomarkers for evaluating pulmonary function and inflammation in patients with COPD. Furthermore, lung-protective treatment is effective in reducing inflammation in patients with COPD.

P1.08-073 Experience of Third Primary Lung Tumors after Treatment of First and Second Primary Lung Cancer

Widespread adoption of lung cancer screening and development of high-resolution computed tomography (HRCT) have led to a marked increase in the detection of early lung cancer in Japan. After curative resection for early lung cancer, second primary lung cancers develop in a significant proportion. The majority of these cancers are detected at an early stage because of careful follow-up using HRCT. In our experience, more than 80% of these patients were treated with surgery or radiation therapy, and some of them have acquired with long-term survival. Recently we have experienced with third primary lung tumors in long-term survivors. In this paper, we reviewed the incidence, management, and outcome of third primary lung tumors. Between April 1996 and March 2016, 1194 patients underwent complete resection for primary lung cancer in our institution. Of these individuals, patients who developed a third primary lung tumor were selected for this study. Of 1194 consecutive patient, 105 patients (8.8%) developed second primary lung cancers, and 11 patients (1%) of them developed third primary lung tumors. The patients included 10 men and one woman. The initial resection for primary lung cancer was lobectomy in 9 patients and segmentectomy in 2. Surgical resection for second primary lung cancer was performed in 8 patients, and radiation therapy was performed in 3. Four of the 11 patients underwent resection for third primary lung tumors. One patient had completion pneumonectomy, 1 had segmentectomy, and 2 had wedge resections. Five patients were treated by radiation therapy. The two remaining patients received best supportive care. Survival after resection of first primary lung cancer ranged from 50 months to 185 months, with a median survival of 138 months and an average survival of 137 months. Currently, 4 patients are alive without evidence of recurrence. Among them, three patients were treated by their third pulmonary resection, and one patient was treated by radiation therapy. During 20 years, third primary lung tumors were diagnosed in only 11 patients (1%). But long-term survivors after resection of lung cancer are increasing. Careful follow-up and early detection of second primary lung cancers using HRCT will induce the increase of experience for treatment of third primary lung tumors. In our little experience, aggressive surgery for third primary lung tumors may improve survival.

P1.08-041 Disease Free and Overall Survival is Equal in Open and VATS Resection for Early Lung Cancer in a Multivariate Analysis

P1.08-041 Disease Free and Overall Survival is Equal in Open and VATS Resection for Early Lung Cancer in a Multivariate Analysis

Cost-effectiveness of stereotactic radiation, sublobar resection, and lobectomy for early non-small cell lung cancers in older adults.

Stereotactic ablative radiation (SABR) is a promising alternative to lobectomy or sublobar resection for early lung cancer, but the value of SABR in comparison to surgical therapy remains debated. We examined the cost-effectiveness of SABR relative to surgery using SEER-Medicare data. Patients age ≥66 years with localized (<5 cm) non-small cell lung cancers diagnosed from 2003-2009 were selected. Propensity score matching generated cohorts comparing SABR with either sublobar resection or lobectomy. Costs were determined via claims. Median survival was calculated using the Kaplan-Meier method. Incremental cost-effectiveness ratios (ICERs) were calculated and cost-effectiveness acceptability curves (CEACs) were constructed from joint distribution of incremental costs and effects estimated by non-parametric bootstrap. In comparing SABR to sublobar resection, 5-year total costs were $55,120 with SABR vs. $77,964 with sublobar resection (P<0.001) and median survival was 3.6 years with SABR vs. 4.1 years with sublobar resection (P=0.95). The ICER for sublobar resection compared to SABR was $45,683/life-year gained, yielding a 46% probability that sublobar resection is cost-effective. In comparing SABR to lobectomy, 5-year total costs were $54,968 with SABR vs. $82,641 with lobectomy (P<0.001) and median survival was 3.8 years with SABR vs. 4.7 years with lobectomy (P=0.81). The ICER for lobectomy compared to SABR was $28,645/life-year gained, yielding a 78% probability that lobectomy is cost-effective. SABR is less costly than surgery. While lobectomy may be cost-effective compared to SABR, sublobar resection is less likely to be cost-effective. Assessment of the relative value of SABR versus surgical therapy requires further research.

Lobectomy for Patients With Limited Lung Function

Increasingly, lung cancer is being diagnosed at an early stage. This trend is likely to increase with computerized tomographic screening as a result of the findings of the National Lung Screening Trial. Even in 2011, anatomical lobectomy is the gold standard for curative resection for early lung cancer. However, a significant proportion of patients with early lung cancer have limited lung function that places them at higher risk of complications from lobectomy. This article reviews the existing data for lobectomy in patients with limited lung function.

How do I treat a patient after resection of early lung cancer?

How do I treat a patient after resection of early lung cancer?

Stereotactic ablative radiotherapy (SABR) for lung cancer: What does the future hold?

While radiation therapy has long been one of the pillars of therapy for potentially curable stages of lung cancer, outcomes have largely remained disappointing overall. The best outcomes in lung cancer have been achieved with surgery and only in early stage disease, because in early stages complete tumor ablation by surgery is possible in most patients who can tolerate the appropriate resection (lobectomy). Even so, many patients with anatomically resectable early lung cancer are not treated with surgery: in the United States, up to over one third of such patients do not have surgery for reasons including older age and multiple comorbidities (1). Conventional radiation therapy, while modestly effective, does not approach surgical cure rates because it has not been possible or practical to achieve ablative radiation dose intensities tolerably using such techniques (2).

Evaluation of class III beta-tubulin (bTubIII) expression as a prognostic marker in patients with resectable non-small cell lung cancer (NSCLC) treated by perioperative chemotherapy (CT) in the phase III trial IFCT-0002

7526 Background: IFCT-0002 phase III trial compared two timings of CT in early lung cancer, all before surgery (PRE) versus PERIoperative, and two CT regimens, CDDP-Gem vs. CBDCA-Pac. 528 patients were randomized. Paraffin embedded post- chemo pathological specimens were collected in the 490 non complete responder patients for tissue expression of the putative biomarker beta-tubulin III (bTubIII). Methods: 423 surgical pathological specimens with enough remaining viable tumor tissue after neoadjuvant chemo were processed for immunohistochemistry as published in the Bio-IALT study. A semi-quantitative score was attributed taking account the number of stained cells and the intensity of staining. Semi-quantitative scores were studied as continuous variables, without any pre- determined cut-off. Multivariate analysis for progression-free (PFS) and overall survival (OS) were corrected with Bonferroni-Holm method for multiple analyses. Median follow-up was 42 months. Results: bTubIII was the only IHC marker significantly associated with poor PFS in univariate (p=0.014) or multivariate analysis, adjusted for histology, T and stage (HR= 1.50 [1.07–2.10]; p=0.020). In patients with a pathological specimen showing a bTubIII positive immunostaining, median PFS was 30.6 months, versus 60.1 months (HR=1.46 [1.08–1.99]) for bTubIII negative patients. bTubIII IHC score remained predictive of poor OS in univariate (p= 0.0065) as in multivariate analysis (p=0.019 with Bonferroni correction, HR=1.75 [1.15–2.68] ). Median OS was not reached for bTubIII negative patients whereas it was 71.7 months in patients with bTubIII immunostaining of any intensity score (HR=1.61, [1.11–2.35]). Conclusions: This study showed a dramatic negative prognostic impact for bTubIII immunostaining in resectable early lung cancer. A subset of bTubIII expressing patients with poor prognosis did not take any advantage from perioperative chemo. Hence, those patients could rather have beneficiated from personalized adjuvant treatment with alternative approaches. No significant financial relationships to disclose.

The dosimetric quality of mesh brachytherapy implant following wedge resection of early lung cancer

The dosimetric quality of mesh brachytherapy implant following wedge resection of early lung cancer

Resected early lung cancer with pulmonary aspergilloma

Pulmonary aspergillosis and lung cancer rarely occur simultaneously. We report a 66-year-old man with a round shadow in the thin-wall cavity of the right upper lobe. Radiological findings and transbronchial biopsy revealed squamous cell carcinoma complicated by aspergilloma at the site. Right upper lobectomy suggested that early lung cancer arose from preexisting lung scars containing an aspergilloma.