Shanghai Chest Hospital Research Articles

A pemetrexed-based genetic study of Chinese Han patients with advanced non-small cell lung cancer (NSCLC).

e19014 Background: Pemetrexed has been approved for first- and second-line treatment in patients with non-small cell lung cancer (NSCLC). Two studies have confirmed the role of polymorphisms (SNPs) in reduced folate carrier (SLC19A1) is related with the survival differences in pemetrexed-treated NSCLC in Caucasian population. Considering different genetic backgrounds in different populations, our study was aimed to identify candidate SNPs for pemetrexed-treated NSCLC in Chinese Han population. Methods: Fifty-seven patients with previously treated NSCLC received pemetrexed-based third-line treatment from Shanghai Chest Hospital from Nov 2006 to Jul 2011. Four genes, SLC19A1, gamma-glutamyl hydrolase (GGH), methylenetetrahydrofolate reductase (MTHFR), and methionine synthase (MTR), responsible for pemetrexed transport and activation were evaluated. The five SNPs (rs4819128, rs914232, rs4818789, rs3788189, rs1051298) in SLC19A1, two SNPs (rs3780130, rs3780126) in GGH, two SNPs (rs1801133, rs180131) in MTHER, and one SNP (rs1805087) in MTR were selected based on the HapMap Chinese Han databases. All SNP genotyping was performed by TaqMan PCR using the ABI Prism 7900HT Sequence Detection System. Kaplan-Meier cumulative probability and Cox multivariate analyses were used to evaluate the relationship between genetic variations with survival outcome. Results: Fifty-seven patients received a median of three cycles (range, 1-16 cycles) of pemetrexed-based treatment. Median overall survival (OS) and progression-free survival (PFS) times were 23.0 and 3.2 months, respectively. Patients with AA/AG genotype of SLC19A1 rs1051298 had the better PFS and OS compared with GG genotype (5.5m vs 1.9m for PFS, P=0.047; 45.5m vs 17m for OS, P=0.001). The TT/TA genotype of novel GGH rs3780130 was correlated with better PFS compared with AA genotype (5.8m vs 2.5m, P=0.029). Conclusions: This study in Chinese Han NSCLC patients identified the unique result that novel TT/TA genotype of GGH rs3780130 was related with better PFS for pemetrexed-based treatment. Meanwhile, we obtained the same result with that in Caucasian study, AA/AG genotype of SLC19A1 rs1051298 was related with better PFS and OS.

Segmentectomy as a safe and equally effective surgical option under complete video-assisted thoracic surgery for patients of stage I non-small cell lung cancer

BackgroundWhile video-assisted thoracic surgery lobectomy has been widely accepted for the treatment of non–small cell lung cancer, the debate over video-assisted thoracic surgery segmentectomy still remains. This study compared the clinical outcomes using the two procedures for stage I non–small cell lung cancer patients.MethodsRetrospective review was conducted on patients who underwent video-assisted thoracic surgery segmentectomy or lobectomy for clinical stage I non–small cell lung cancer at Shanghai Chest Hospital between November 2009 and May 2012. Video-assisted thoracic surgery segmentectomy was performed on 36 patients and video-assisted thoracic surgery lobectomy on 138 patients. Comparisons between the 2 groups were performed in patient demographic and clinical characteristics, intraoperative parameters and oncology outcomes.ResultsMean volume of chest tube drainage after operation was smaller for segmentectomy than for lobectomy (1021 ml vs. 1328 ml, P=0.036). Other parameters analysis including blood loss, operation time, chest tube duration and length of hospital stay favors the segmentectomy group numerically without significance. There was no significant difference in distributions in both intra and post operative complications. There was one peri-operative mortality from segmentectomy group and all other patients are alive with a median follow up of 327 days. There were 1 (2.8%) locoregional recurrence after segmentectomy and 6 recurrences (4.4%) after lobectomy (P=1.00). Multivariate survival analysis revealed no significant difference in recurrence-free survivals between the two groups. Two patients successfully underwent bilateral segmentectomies and are free of disease.ConclusionsFor patients with stage I non–small cell lung cancer, video-assisted thoracic surgery segmentectomy offers a safe and equally effective option and can be applied to complicated operation such as bilateral segmentectomy.

Clinical Outcomes of Thoracoscopic Lobectomy for Patients With Clinical N0 and Pathologic N2 Non-Small Cell Lung Cancer

We compared the surgical outcomes in patients with clinical N0 and pathologic N2 (cN0-pN2) non-small cell lung cancer (NSCLC) who underwent video-assisted thoracoscopic surgery (VATS) lobectomy and open thoracotomy to evaluate the role of VATS lobectomy for cN0-pN2 disease. Between March 2006 and August 2011, 1,456 patients with clinical N0 NSCLC disease underwent lobectomy with systematic node dissection (SND) at Shanghai Chest Hospital. Of those patients, 157 were shown to have cN0-pN2 NSCLC. Of those, 67 patients underwent VATS lobectomy, and 90 patients underwent open lobectomy. SND was performed in all 157 patients. Clinicopathologic factors, local recurrence rates, and survival rates were compared. The two groups were similar in age, sex, and pulmonary function. The VATS approach was associated with significantly shorter chest tube duration and postoperative stay than was the thoracotomy approach. Operative mortality, morbidity, and recurrence did not differ between the two groups. There was no significant difference between the two types of operation in numbers of total lymph nodes removed (17.4 ± 6.1 in the VATS group vs 18.1 ± 7.2 in the open group, p = 0.78) and mediastinal lymph nodes removed (11.7 ± 5.6 in the VATS group vs 12.0 ± 5.1 in the open group, p = 0.84). Similarly, the two groups were not significantly different with regard to stations of total lymph nodes removed (7.6 ± 1.9 in the VATS group vs 7.8 ± 2.3 in the open group, p = 0.81) and mediastinal lymph nodes removed (4.5 ± 1.1 in the VATS group vs 4.7 ± 1.3 in the open group, p = 0.71). The rates of overall survival and disease-free 5-year survival were not significantly different between the two groups. The clinical outcomes of thoracoscopic lobectomy were comparable to those of thoracotomy for patients with cN0-pN2 NSCLC. Single-station N2 is a good prognostic factor for disease-free survival in these patients.

Retrospective study on lobe-specific lymph node dissection for patients with early-stage non-small cell lung cancer

背景与目的本研究旨在探讨不同淋巴结清扫方式对Ⅰ期肺癌患者生存率的影响，考察影响预后的相关因素，探讨肺叶特异性淋巴结清扫的临床应用指征。方法回顾性分析1998年-2005年上海市胸科医院病理Ⅰ期且符合完全性切除的379例肺癌患者，其中系统性淋巴结清扫组148例，肺叶特异性淋巴结清扫组150例，术后病理均为T1a-2aN0M0，比对研究两组手术相关因素并进行预后分析。结果两组临床病理特征无统计学差异（P > 0.05）；两组总体3年及5年生存率无统计学差异（P > 0.05），但不同病理分期、病理类型和肿瘤直径之间的生存率存在明显差异（P < 0.01）；在手术时间、术中失血、胸管引流量、拔管时间及住院天数等方面，两组存在明显差异（P < 0.01）；两组术后并发症亦有统计学差异（P < 0.05）。结论系统性淋巴结清扫并未增加Ⅰ期肺癌患者5年生存率；病理分期、病理类型和肿瘤直径是影响患者预后的重要因素；肺叶特异性淋巴结清扫可明显减少手术并发症并降低围手术期风险。

Risk Factors for Intraoperative Atrial Fibrillation: A Retrospective Analysis of 10,563 Lung Operations in a Single Center

Risk factors of postoperative atrial fibrillation (AF) in patients undergoing general thoracic operations have been extensively studied. This study investigated risk factors for intraoperative AF. Identification of patients vulnerable for intraoperative AF during lung operations will benefit from improved preoperative and intraoperative management that will ultimately decrease intraoperative complications. This study retrospectively evaluated the risk factors for intraoperative AF during lung operations. Medical records of 10,638 patients who underwent lung operations from January 1, 2006, to May 20, 2011, at the Shanghai Chest Hospital were reviewed. The analysis excluded 75 patients with preoperative AF or nonsinus rhythm or who were taking antiarrhythmic drugs before the operation. The final analysis included 10,563 patients. Univariate and multivariate analyses were performed to identify risk factors for intraoperative AF. The overall incidence of intraoperative AF was 3.27% (346 of 10,563). Multivariable logistic analysis identified increasing age, male sex, lung cancer, general anesthesia plus paravertebral block, open operation, resection of one or more lobes, and increased operation time as risk factors of intraoperative AF. In 40.73% of patients, intraoperative AF occurred during lymph node dissection. We identified seven risk factors for intraoperative AF in patients receiving lung operations. These findings may eventually help us to improve preoperative and intraoperative management to minimize intraoperative AF.

Multivariate survival analysis of patients with stage I NSCLC

背景与目的Ⅰ期患者尤其是Ⅰb期术后非小细胞肺癌(non-small cell lung cancer, NSCLC)患者能否从辅助化疗中获益备受争议。2009年第7版肺癌TNM分期发表。本研究的目的是明确新版TNM分期对Ⅰ期NSCLC患者的价值, 以及评估术后辅助化疗是否能提高早期肺癌患者的生存率。方法研究纳入了上海市胸科医院1998年6月-2010年6月早期NSCLC完全切除术的433例患者, 按照新的分期标准重新分期。把新分期的参数与其它已被证明与肺癌预后相关的因子结合起来, 进行多因素分析。研究纳入变量包括年龄、性别、吸烟史、病理类型、手术切除方式(叶切、双叶切、袖切和全切)、肿瘤大小(肿瘤最长径)、T分期、淋巴管血管癌栓和辅助化疗。结果女性患者3年生存率优于男性(89.22% vs 77.53%, P=0.001, 8)。老年患者预后不佳, ≥70岁的NSCLC患者3年生存率为70.64%, < 70岁为85.85%, P=0.000, 1)。肿瘤最长径≤2 cm患者的3年生存率优于 > 2 cm且≤3 cm患者(95.15% vs 85.71%), 肿瘤最长径 > 3 cm且≤5 cm及 > 5 cm且≤7 cm者3年生存率为74.80% vs 60.47%(P < 0.000, 1)。多因素分析显示年龄、性别、血管癌栓、病理类型、胸膜侵犯是影响生存期的预后因素。结论对Ⅰ期NSCLC患者而言, 肿瘤最长径及病理类型是独立的预后因素。腺癌患者的生存期优于其它病理类型。女性和非吸烟患者结局较好。Ⅰb期患者可能从术后辅助化疗中获益。

Clinical significance of C-reactive protein in patients with stage I non-small cell lung cancer

The aim of this study was to investigate the association between preoperative C-reactive protein (CRP) level and pathologic features in patients with stage I non-small cell lung cancer (NSCLC), and also to analyze if CRP provides prognostic information for NSCLC patients. The clinicopathological data of 105 patients with stage I NSCLC, who underwent pulmonary resection in Shanghai Chest hospital from Mar 1999 to Jul 2004, were retrospectively reviewed. The association between preoperative CRP levels and several clinical variables was analyzed by chi square test. Logistic regression analysis was used for multivariate analysis. Kaplan-Meier method and Cox multivariate regression model was used to examine the prognostic significance of the covariates on survival. Among the 105 cases, 69 had CRP at normal level (≤ 5 mg/L) and 36 at increased level (> 5 mg/L). The patients who were male (P < 0.001), smoking (P = 0.002), with squamous cell carcinoma (P < 0.001), poor differentiation (P < 0.001), tumor size larger than 3 cm (P < 0.001) had a higher serum CRP level. The maxmal tumor diameter (P = 0.037) was an independent risk factor for preoperative serum CRP level elevation. The five-year survival rate and five-year disease free survival rate of the higher CRP group were lower than that in the normal CRP group (55.6% vs. 79.7%, P < 0.05, and 41.7%vs. 68.1%, P < 0.05, respectively). Cox regression analysis demonstrated that the CRP level had effect on overall survival (P = 0.009) and disease free survival (P = 0.019). Our findings indicate that the maximal tumor diameter is an independent risk factor for preoperative serum CRP level elevation. The overall survival, disease free survival, five-year survival rate and five-year disease free survival rate of the higher CRP group are lower than that in the normal CRP group.

The Biobank Unit of Shanghai Chest Hospital

The Biobank Unit of Shanghai Chest Hospital

The Oncologist Chinese Edition: A Global Mission, A Unifying Bond

(Editorial for first issue of the Chinese Edition of The Oncologist) On behalf of our global editorial board, we are honored and delighted to make The Oncologist available in a fully translated Chinese Edition to the members of the Chinese Society for Clinical Oncology (CSCO). Our Chinese Edition represents a milestone in our progress toward a seamless practice of cancer specialties across the world. As physicians who serve the citizens of China, you will now be in direct communication with other leaders in oncology practice around the world, and all of us will have the benefit of your ongoing practice experience and clinical research in China. We are deeply grateful for the leadership and vision of our distinguished co-Editors, Professor Shukui QIN, CSCO President and Director of PLA Cancer Center at Nanjing Yanggongjing Hospital, and Professor Yi-Long WU, CSCO President-elect and Chief of the Guangdong Lung Cancer Institute. We also welcome our associate editors: Professor Jun MA, CSCO Immediate Past President and Director of Harbin Institute of Hematology and Oncology, Professor Jin LI, CSCO Secretary from Fudan University Cancer Hospital, and Professor Shun LU of Shanghai Jiaotong University and Shanghai Chest Hospital. My close colleague, Dr. Andrew ZHU, an internationally recognized expert in hepatocellular cancer at Massachusetts General Hospital Cancer Center, will provide invaluable support as an associate editor under the leadership of co-Editors Qin and Wu. By uniting our efforts with those of CSCO's visionary leaders, we pledge to bring the latest in cancer therapeutics and diagnosis to you, our readership in China, and thereby we seek to encourage and facilitate collaborations among colleagues worldwide. We join Professors Qin and Wu and our other CSCO colleagues and friends in expressing our appreciation to the many who have made this precedent-setting publication possible. In particular, we extend our appreciation to our benefactors, sanofi-aventis and Boehringer Ingelheim, who volunteered their support on behalf of cancer patients. With this new edition, the readership of The Oncologist has grown to more than 40,000 cancer specialists. We thank our executive editor, Dr. Martin Murphy, and our managing editor, Dr. Ann Murphy, for nurturing this vibrant collaboration with CSCO's inspiring leaders. We hope that our colleagues in China will find this new journal a significant addition to the literature available to the practicing oncologist in China. We invite you to share your opinions and suggestions with us. We will read each letter carefully and, more importantly, we promise to discuss your recommendations with our fellow editors. We have a unifying mission to bring the most important cancer news to your desktop, your mobile device, and to your doorstep. We further have a singular and powerful bond—and that is our dedication to bringing about better outcomes for all our cancer patients. Xie! Xie!

Survival analysis of 1,742 patients with stage IV non-small cell lung cancer

背景与目的目前非小细胞肺癌（non-small cell lung cancer, NSCLC）仍是导致癌症死亡的首要原因，本研究旨在探讨影响晚期NSCLC预后的重要因素。方法收集2000年1月4日-2008年12月25日1, 742例Ⅳ期NSCLC临床资料，所有病例经细胞学或组织病理学确诊。分析性别、年龄、吸烟史、病理类型、分型、临床TN分期、转移器官数目、治疗方法对预后的影响，应用Kaplan-Meire方法计算生存率，Log-rank检验生存率差别，采用Cox多因素回归对预后因素进行分析。结果本组1, 742例患者的中位生存期为10.0个月（9.5个月-10.5个月），1年、2年、3年、4年、5年生存率分别为44%、22%、13%、9%、6%。单器官发生转移与多器官转移中位生存期分别为11个月vs 7个月（P < 0.001）。不同器官发生转移后生存期不同，中位生存期分别为肺12个月（11.0个月-12.9个月），骨9个月（8.3个月-9.6个月），脑8个月（6.8个月-9.1个月），肝、肾上腺、远处淋巴结转移均为5个月（3.8个月-6.1个月），皮下3个月（1.7个月-4.3个月）。腺癌患者1, 086例（62%），鳞癌305例（17.5%），中位生存期分别为12个月vs 8个月（P < 0.001）。化疗与最佳支持治疗者中位生存期分别为11个月vs 6个月（P < 0.001）。放疗与否的中位生存期分别为11个月vs 9个月（P=0.017）。结论性别、年龄、大体分型、病理类型、临床T分期、N分期、转移器官数目、吸烟史、治疗方法是晚期NSCLC预后的独立影响因素。

Safety analysis of ambulatory chemotherapy in lung cancer

背景与目的日间化疗因具经济成本低、毒副反应不高的特点成为发达国家普遍采用的一种化疗模式，本文探讨上海市胸科医院日间化疗模式的可行性及安全性，为今后日间化疗模式的推广提供借鉴。方法对所有入住日间化疗病房和普通化疗病房患者进行统计和记录，主要内容包括患者一般状况、化疗次数、病理类型、住院期间毒副反应、出院后出现的毒副反应。结果2008年10月-2009年4月，我院日间病房共收治化疗患者416人次，普通病房共收治患者1 157人次，两组化疗的毒副反应总体差异不大，日间化疗患者的Ⅱ度以上胃肠道反应（21.88%）较住院患者低（38.89%）（P < 0.01），白细胞降低比例（49.28%）较住院患者（35.0%）为多（P < 0.01），日间化疗病房住院天数缩短（4.48天vs 14.04天，P < 0.01），医疗支出也大大降低（6 911.32元vs 14 623.59元，P < 0.01）。结论日间化疗的住院时间和费用缩短，主要毒副反应为白细胞降低，化疗的累积毒性是其主要原因，需要引起注意，其它毒副反应未见明显差异，日间化疗是一种值得推广和借鉴的方式。

The Clinical Analysis of 21 Patients with Lymphoepithelioma-like Carcinoma after Operation.

Lung lymphoepithelioma-like carcinoma is a rare subtype of large cell carcinomas of the lung. The aim of this study is to retrospectively analyze the clinical characteristics, surgical methods, laboratory inspection, chemotherapy, radiotherapy and prognosis of LELC. From 2004 to 2008, clinical data were collected from 21 patients who were treated in Shanghai Chest Hospital. The correlation between clinicopathological characteristics and prognosis was evaluated. Of the 21 patients, 15 patients had lobectomy; 4 patients had wedge resection; 1 patient had pneumonectomy and 1 patient had sleeve resection. 12 patients received chemotherapy and 3 patients received radiotherapy after operation. Until 2009-4-31, 4 patients died, and the median survival time (MST) was 49 months. Lymphoepitheliomalike carcinoma of the lung is a very rare and unique subtype of large cell carcinomas of the lung, which has a better prognosis with surgical, chemotherapy and radiotherapy.

Analysis of the T Descriptors and Other Prognosis Factors in Pathologic Stage I Non-small Cell Lung Cancer in China

The seventh edition of the tumor, node, metastasis Classification of Malignant Tumors is due to be published in 2009. The recommendations of International Association for the Study of Lung Cancer for changes to the T descriptors have been published. We combined this new parameter with other well-established prognostic factors and performed multivariate survival analyses to validate its value in Chinese stage I non-small cell lung cancer (NSCLC). We try to validate the new staging project in 325 patients who underwent complete surgical resection for stage I NSCLC in Single Institution of Shanghai Chest Hospital from 1998 to 2003. Variables in the analysis included age, gender, performance status, history of smoking, pathologic type, type of resection (pneumonectomy, lobectomy, and bilobectomy), tumor size (greatest dimension of tumor), T-status (T1 or T2), type of lymph node resection (systematic mediastinal lymphadenectomy or mediastinal lymph node sampling), lymphovascular vessel invasion, and adjuvant chemotherapy. The 5-year overall survival (OS) of patients whose tumor measured no larger than 2 cm in largest diameter or larger than 2 cm but no larger than 3 cm were 75.49 and 74.58%, respectively. For those with tumors measured larger than 3 cm but smaller than 5 cm or larger than 5 cm but smaller than 7 cm were 60.87 and 55.63%. The 5-year OS of patients whose tumor measured larger than 7 cm was 46.15% (p = 0.025). The 5-year disease-free survival rates of patients whose tumor measured no larger than 2 cm in largest diameter or larger than 2 cm but no larger than 3 cm were 67.65 and 66.67%, respectively. For those with tumors measured larger than 3 cm but smaller than 5 cm or larger than 5 cm but smaller than 7 cm were 53.14 and 52.63%. The 5-year disease-free survival rate of patients whose tumor measured larger than 7 cm was 30.77% (p = 0.009). Multivariate analyses revealed that age, gender, type of resection (pneumonectomy, lobectomy, and bilobectomy), tumor size (greatest dimension of tumor), type of lymph node resection (systematic mediastinal lymphadenectomy or mediastinal lymph node sampling), and lymphovascular vessel invasion were significant predictive factors for OS. The tumor size is a significant independent prognostic factors in stage I NSCLC.

Prognosis factors of pathological stage I non-small cell lung cancer

22210 Background: The IASLC Lung Cancer Staging Project recommend changes in the T classification are to subclassify T1 into T1a and T1b, and T2 into T2a and T2b; and to reclassify T2c and additional nodule(s) in the same lobe as T3. But other well-known clinical and histopathological factors were also possible prognostic factors. Methods: We try to validate the new staging project in 325 patients who underwent complete surgical resection for stage I NSCLC in Single Institution of Shanghai Chest Hospital from 1998 to 2003. All the patients were followed up four years. Data were analyzed by SPSS 11.0 software. Results: The pT1NOR0 was divided into pT1a ≤2 cm (n=28) and pT1b>2 to 3 cm (n=15) and pT2NOR0 was divided into pT1a ≤2 cm (n=40), pT1b>2 to 3 cm (n=84),pT2a>3 to 5 cm (n=107), pT2b>5 to 7 cm (n=38), and pT2c >7 cm (n=13). The results validate the IASLC recommend changes(table 1). Table 1, Comparisons of Overall Survival between Tumor Size The 4-year survival rate for patients with systematic mediastinal lymphadenectomy (n=68) was 72.75% while patients with mediastinal lymph node sampling (n=257) was 49.63% (p=0.026). Female patients (n=116) was associated with a better survival than men's (n=209; 77.76% vs 68.13%, p=0.022). Patients without lymphovascular invasion (n=309) was associated with a better survival than patients with lymphovascular invasion (n=16; 72.75% vs 49.63%, p=0.025). Conclusions: We get the same results which shows the tumor diameter is significant independent prognostic factors in non-small cell lung cancer and lymphovascular invasion may add new information of the current TNM classification. Mediastinal lymphadenectomy is also a significant independent prognostic factor in resection non-small cell lung cancer. It needs further research. Stage T 4-year survival rate P value T1NOR0 pT1a ≤2 cm (n = 28) 78.42% 0.6488 pT1b >2 to 3 cm (n = 15) 74.33% T2NOR0 pT1a ≤2 cm (n = 40) 79.15% 0.027 pT1b >2 to 3 cm (n = 84) 79.28% pT2a >3 to 5 cm (n = 107) 66.41% pT2b >5 to 7 cm (n = 38) 61.07% pT2c >7 cm (n = 13) 46.15% T1NOR0 +T2NOR0 pT1a ≤2 cm (n = 68) 79.15% 0.026 pT1b >2 to 3 cm (n = 99) 79.28% pT2a >3 to 5 cm (n = 107) 66.41% pT2b >5 to 7 cm (n = 38) 61.07% pT2c >7 cm (n = 13) 46.15% No significant financial relationships to disclose.

Prognostic factors in patients with stage IV non-small cell lung cancer

Objective: To investigate the prognostic factors for stage IV non-small cell lung cancer (NSCLC) with distant metastasis and establish a reliable model of clinical prognostic index. Methods: From January 1990 to April 2005, 313 primary NSCLC patients with metastasis, who had been treated in Shanghai Chest Hospital, were reviewed. Survival time was estimated according to the Kaplan-Meier method. Cox proportional hazard regression model was used for multivariate analysis. Results: Among the 313 cases of non-small cell lung cancer (NSCLC) at stage IV, there were 218 and 95 patients with metastasis to single and different organs, respectively. The overall median survival time for all 313 cases of NSCLC patients was 10.8 (9.00, 12.30) months and the overall 1-, 2-, 3-, 4-and 5-year survival rate was 45%, 18%, 12%, 4% and 0%. There were 63, 174, 127, 36, 18, 11 and 5 patients with metastasis to brain (20.13%), bone (55.59%), lung (40.58%), liver (11.50%), adrenal gland (5.75%), subcutaneous (3.51%) and others, respectively. The survival time was shortest in subcutaneous metastasis (4.6 months), and liver 7.0 months, brain 8.0 months, adrenal gland 8.6 months, bone 10.6 months, lung 11.8 months. Kaplan-Meier estimation showed that patients anatomic typing, KPS, numbers of organ with metastasis, appetite, liver, adrenal gland and subcutaneous metastasis, body weight loss, smoking, index of smoking, chemotherapy, cycles of chemotherapy were the predictors of survival. Multivariate analysis showed survival statistically significant correlation with anatomic typing, KPS, appetite, liver and subcutaneous metastasis, body weight loss, cycles of chemotherapy. The relative risk (RR) was 1.51, 1.97, 1.55, 1.67, 2.56, and 2.56 respectively. Conclusion: Survival time decreases distinctly in patients who had distant metastasis to more than two different organs (P<0.01). Bone is the commonest organ for distant metastasis in lung cancer. The prognosis is poor when lung cancer appears subcutaneous metastasis and liver metastasis. Independent prognostic factors in patient with stage IV non-small cell lung cancer were liver and subcutaneous metastasis, anatomic typing, KPS, appetite, body weight loss, cycles of chemotherapy.

New WHO histologic classification predicts prognosis of thymic epithelial tumors: a clinicopathologic study of 200 thymoma cases from China.

In 1999, a World Health Organization (WHO) committee published histologic criteria for distinct thymoma entities (labeled as Type A, AB, B1, B2, B3 thymomas) and for the heterogeneous group of thymic carcinomas, collectively called Type C thymomas. Whether WHO-defined histologic thymoma subtypes are of independent prognostic relevance has yet to be proved. Two hundred thymomas from the Shanghai Chest Hospital with a mean follow-up time of 15 years (range, 1-246 months) were studied for the relevance of WHO histologic subtype and other factors (stage, therapy, and myasthenia gravis [MG]) for survival. In order of frequency, 68 patients (34.0%) had Type AB, 39 (19.5%) had Type B2, 36 (18.0%) had Type C, 27 (13.5%) had Type B3, 17 (8.5%) had Type B1, and 8 (4.0%) had Type A thymoma. Five cases (2.5%) were rare thymomas not mentioned in the WHO classification. Survival data showed significant differences among the histologic subtypes (log rank test: P < 0.001). Among patients with Type A and AB thymomas, none died of tumor; of the Type B1 thymoma patients, only one (5.9%) died at 22 months. Type B2, B3, and C thymomas had a significantly worse prognosis with 5-year survival rates of 75.0%, 70.0%, and 48.0%, respectively. Ninety-six patients (48.0%) were in Masaoka Stage I, 26 (13.0%) were in Stage II, 65 (32.5%) were in Stage III, and 13 (6.5%) were in Stage IV. Stage was highly significant in predicting survival (log rank, test P < 0.001). The association between histologic subtype and invasive behavior (stage) was statistically significant (P < 0.001). However, histology was an independent predictive factor of survival in Stage I and II thymomas: Type B2, B3, and C thymomas had a worse prognosis than Type A, AB, and B1 thymomas (log rank test: P < 0.003). Thirty patients (15.0%) presented with MG. MG was significantly more frequent in Type B2 and B3 than in Type A, AB, and B1 thymomas (P < 0.01). On multivariate analysis, MG had no adverse effect on survival (P = 0.17). Radiation or chemotherapy improved patients' survival at 5 and 10 years in Type B2, B3, and C thymomas (log rank test: P < 0.003). Tumor stage is the most important determinant of survival in thymoma patients, but the WHO histologic subtype is an independent prognostic factor in Stage I and II thymomas, among which WHO Type A, AB, and B1 thymomas form a low-risk group. Patients with high-risk thymomas might profit from novel adjuvant radiochemotherapy regimens.

Value of cardiopulmonary risk index in predicting postoperative short-term prognosis in patients with lung cancer

To determine the value of preoperative cardiopulmonary risk index (CPRI) in predicting the short-term prognosis after lung resection in patients with lung cancer. Preoperative clinical data were used to generate a cardiac risk index (CRI) and a pulmonary risk index (PRI). And the value of cardiopulmonary risk index (CPRI) consisting of CRI and PRI in predicting postoperative prognosis was estimated in patients who underwent lung resection at Shanghai Chest Hospital in 1999. A total of 625 consecutive patients were studied. Postoperative complications occurred in 49 patients (7.8%), including 8 deaths within 30 days of operation. In the total group, CRI, PRI and CPRI scores ranged from 1 to 3, 0 to 5 and 1 to 7, respectively. There were 489 patients with CPRI < 4, and 136 with CPRI≥4. Using CPRI≥4 as a threshold for predicting postoperative complications, the sensitivity, specificity and accuracy rate were 75.5%, 82.8% and 82.2% respectively. The preoperative CPRI is one of the important indexes in predicting the short-term postoperative prognosis for patients with lung cancer. However, it can not completely predict all of postoperative risks, and should be used together with other factors.

Treatment and outcome of sinus of valsalva aneurysm

Background: In order to understand the long-term outcome after surgical repair of sinus of Valsalva aneurysms or fistulas (SVAF), the operative results for patients treated at Shanghai Chest Hospital were retrospectively assessed. Methods: Between 1960 and 1999, 216 patients were operated on for SVAF. Of these 143 (66.2%) had a ventricular septal defect (VSD), 60 (28.0%) had aortic regurgitation and of these 12 underwent aortic valve replacement (AVR). Results: There were eight in-hospital deaths (3.7%). Another patient had aortic regurgitation postoperatively requiring AVR. Conclusion: Resection and repair of SVAF entails an acceptably low operative risk and yields long-term freedom from symptoms. Early, aggressive operation is recommended to prevent development of complications.

Surgical Correction of Ruptured Aneurysm of the Sinus of Valsalva

Between January 1983 and December 1996, 108 patients with ruptured aneurysms of the sinus of Valsalva underwent surgical correction in Shanghai Chest Hospital. The aneurysms ruptured into the right ventricle in 91 patients, into the right atrium in 16, and into the left atrium in 1. The aneurysm originated from the right coronary sinus in 82 patients, from the noncoronary sinus in 25, and from the left coronary sinus in 1. Associated intracardiac defects included ventricular septal defect in 52, aortic valve insufficiency in 67, and patent ductus arteriosus in 2. A ruptured aneurysm of the sinus of Valsalva without aortic valve insufficiency was approached via the cardiac chamber into which it ruptured. When the aneurysm was associated with moderate or severe aortic valve insufficiency we preferred the transaortic approach for repair. The aneurysm was excised at its base and repaired with a Dacron patch regardless of the size of the base of the aneurysm. Active surgical management of aortic valve insufficiency was performed at the initial operation using valve suspension in 25 patients with moderate aortic valve insufficiency and replacement with a mechanical valve prosthesis in 6 cases of severe aortic insufficiency. The early mortality was 2.78%. The median follow-up period was 3.9 years. Of the 72 patients who were followed up, 67 are in New. York Heart Association functional class I or II and 5 are in class III or IV due to severe aortic valve insufficiency. Considering the pathoanatomic features and hemodynamic changes associated with ruptured aneurysms of the sinus of Valsalva in Oriental patients, we advocate repairing the defect with a patch in all cases and stress the importance of active surgical management for aortic valve insufficiency at the initial surgical correction.

Management of Tricuspid Valve Disease in Patients Undergoing Double Valve Replacement

The management of mild tricuspid valve disease associated with left-sided valve lesions remains controversial. Between January 1985 and September 1995, 87 patients underwent combined double (aortic and mitral) valve replacement and tricuspid valve repair at the Shanghai Chest Hospital. The early mortality was 16.1%. Predictors of early mortality were found to be New York Heart Association functional class IV and right ventricular systolic pressure of 65 mm Hg or more, by multivariable regression analysis. The mean follow-up was 4.6 years. Cumulative 3-year and 5-year survival rates in patients discharged from hospital were 80% ± 4% and 63% ± 7%. Late mortality was due to sudden death (18.7%), myocardial infarction (6.5%), and cerebral embolism or hemorrhage (31.2%). Of 48 patients still alive, 45 are in New York Heart Association functional class I or II. None of them has mild or moderate tricuspid regurgitation. Based on these results, we recommend early surgical treatment prior to the appearance of severe hemodynamic deterioration and we propose a policy of liberal indication for tricuspid annuloplasty for mild functional tricuspid insufficiency at the initial double valve replacement.