Surgery for locally advanced non-small cell lung cancer

Robot-assisted thoracic surgery for stages IIB-IVA non-small cell lung cancer: retrospective study of feasibility and outcome

Robot-assisted thoracic surgery (RATS) for higher stages non-small cell lung carcinoma (NSCLC) remains controversial. This study reports the feasibility of RATS in patients with stages IIB-IVA NSCLC. A single-institute, retrospective study was conducted with patients undergoing RATS for stages IIB-IVA NSCLC, from January 2015 until January 2020. Unforeseen N2 disease was excluded. Data were collected from the Dutch Lung Cancer Audit database. Conversion rate, radical (R0) resection rate, local recurrence rate and complications were analyzed, as were risk factors for conversion. RATS was performed in 95 patients with NSCLC clinical or pathological stages IIB (N = 51), IIIA (N = 39), IIIB (N = 2) and IVA (N = 3). 10.5% had received neoadjuvant chemoradiotherapy. Pathological staging was T3 in 33.7% and T4 in 34.7%. RATS was completed in 77.9% with a radical resection rate of 94.8%. Lobectomy was performed in 67.4% of the total resections. Conversion was for strategic (18.9%) and emergency (3.2%) reasons. Pneumonectomy (p = 0.001), squamous cell carcinoma (p < 0.001), additional resection of adjacent structures (p = 0.025) and neoadjuvant chemoradiation (p = 0.017) were independent risk factors for conversion. Major post-operative complications occurred in ten patients (10.5%) including an in-hospital mortality of 2.1% (n = 2). Median recurrence-free survival was estimated at 39.4 months (CI 16.4-62.5). Two- and 5-year recurrence-free survival rates were 53.8% and 36.7%, respectively. This study concludes that RATS is safe and feasible in higher staged NSCLC tumors after exclusion of unforeseen N2 disease. It brings new perspective on the potential of RATS in higher stages, dealing with larger and more invasive tumors.

Results of T4 surgical cases in the Japanese Lung Cancer Registry Study: should mediastinal fat tissue invasion really be included in the T4 category?

INTRODUCTION

T4 lung cancer is a heterogeneous group of locally advanced disease. We hypothesized that patients in whom T4 lung cancer invaded only mediastinal fat tissue would show better prognosis after surgery than patients in whom T4 disease invaded other organs. The present study aimed to investigate how different invasive features of T4 disease impacted prognosis, and what types of patients with T4 disease could benefit most from surgical treatment.

METHODS

A nationwide registry study on lung cancer surgical cases during 2004 was conducted by the Japanese Joint Committee of Lung Cancer Registry, including registries of 11,663 cases within Japan. The present study analyzed 215 of these cases involving T4 structures or with ipsilateral nonprimary lobe pulmonary metastasis (PM).

RESULTS

Reasons for T4 classification included invasion of only mediastinal tissue in 32 cases (15%), invasion of other structures in 96 cases (45%), and ipsilateral different lobe PM in 87 cases (40%); among these three groups, there were no significant differences in survival, nodal status, and patterns of first recurrence. Multivariate analysis showed an age of 70 years or above (p = 0.022) and nodal status (p = 0.004) to be significant prognostic factors. T4N0 patients less than 70 years of age showed significantly better prognosis than those who were T4N1-2 and 70 years of age or older (p = 0.0001; 5-year survival rate 50.3 versus 19.9%).

CONCLUSIONS

There was no significant difference in survival between T4 patients with only mediastinal fat invasion and those with other T4 organ invasion and ipsilateral different lobe PM, demonstrating appropriateness of the T4 category definition in the current tumor, node, metastasis staging system. Age and nodal status were significant independent prognostic factors in T4 patients, and the best surgical candidates were shown to be T4N0 patients who were less than 70 years of age and had a 5-year survival rate of more than 50%.

Can LMWH improve the outcome of patients with inoperable stage III non-small cell lung cancer?

AIM OF THE STUDY

Lung cancer is the most common malignancy, accounting for one-third of all deaths from cancer. Some studies have shown that low molecular weight heparin (LMWH) significantly prolongs the survival of patients with non-small cell lung cancer (NSCLC). The aim of this study was to determine the effects of treating inoperable stage III NSCLC with LMWH in addition to concurrent chemoradiotherapy.

MATERIAL AND METHODS

Eighty-two patients with inoperable stage III NSCLC were evaluated at Dicle University's Medical Oncology Department between 2005 and 2010. All patients were treated with concurrent chemoradiotherapy (CRT) with or without LMWH (enoxaparin 4000 IU/day) depending on the patient's risk of thrombosis. The primary objectives were to determine disease-free survival (DFS) and overall survival (OS) for patients treated with LMWH.

RESULTS

A total of 38 patients in the LMWH negative group and 44 patients in the LMWH positive group were included in the study. The median OS was 11.2 months for the enoxaparin recipients and 12.7 months for the non-enoxaparin group (p = 0.4). The median DFS was 9.3 months with CRT alone and 10.0 months with CRT plus enoxaparin (p = 0.9). The one-year OS rates were 47% and 34% for groups treated with CRT and enoxaparin plus CRT, respectively, while the two-year OS rates were 23% and 21%, respectively. No significant difference was noted between the two groups in terms of grade 3-4 hematologic toxicity and mucositis (p = 0.3).

CONCLUSIONS

This study did not demonstrate improvements in survival for patients with NSCLC treated with enoxaparin. LMWH's positive contribution is still controversial.

Locally advanced non-small cell lung cancer, pretreatment prognostic factors: Disease stage, tumor histopathological characteristics, the patient-related factors

Background: The existing tumor-node-metastasis staging system ignores numerous clinical, therapeutic, and biological characteristics of lung cancer and psychomotor condition of a patient because it is based on the anatomic extent of disease. Therefore, there is a possibility of inadequate choice of therapy for any individual patient. Based on the disease stage, histopathological characteristics of the tumor and the patient-related factors (sex, age, Karnofsky status, accompanying diseases) the outcome of the disease can be predicted in patients with inoperable and unresectable non-small lung cancer. Methods: This report is a prospective clinical study that included patients with histopathological verified non-small cell lung cancer, followed up for a six-month period, from the beginning of the treatment. The following data were recorded: sex, age, histological cancer type, stage, Karnofsky status, and comorbid diseases. Results: The study showed planocellular carcinoma was more dominant among men than among women and that and at the diagnosis, most patients were in IIIb or IV stage. There was a decrease in psychomotor status of patients. The length of survival depended on Karnofsky index (p= 0.000), comorbidities - chronic myocardiopathy (p= 0.001), diabetes mellitus type 2 (p =0.007), myocardial infraction (p= 0.005), and the stage of the disease (p= 0.001) Conclusion: Psychomotor status of a patient, comborid diseases, and the stage of disease are the factors that determine patient?s tolerance to oncology treatment.

Thin-section multiplanar reformats from multidetector-row CT data: Utility for assessment of regional tumor extent in non-small cell lung cancer

PURPOSE

To determine the clinical utility of thin-section multiplanar reformats (MPRs) from multidetector-row CT (MDCT) data sets for assessing the extent of regional tumors in non-small cell lung cancer (NSCLC) patients.

MATERIALS AND METHODS

Sixty consecutive NSCLC patients, who were considered candidates for surgical treatment, underwent contrast-enhanced MDCT examinations, surgical resection and pathological examinations. All MDCT examinations were performed with a 4-detector row computed tomography (CT). From each raw CT data set, 5mm section thickness CT images (routine CT), 1.25 mm section thickness CT images (thin-section CT) and 1.25 mm section thickness sagittal (thin-section sagittal MPR) and coronal images (thin-section coronal MPR) were reconstructed. A 4-point visual score was used to assess mediastinal, interlobar and chest wall invasions on each image set. For assessment of utility in routine clinical practice, mean reading times for each image set were compared by means of Fisher's protected least significant difference (PLSD) test. A receiver operator characteristic (ROC) analysis was performed to determine the diagnostic capability of each of the image data sets. Finally, sensitivity, specificity and accuracy of the reconstructed images were compared by McNemar test.

RESULTS

Mean reading times for thin-section sagittal and coronal MPRs were significantly shorter than those for routine CT and thin-section CT (p<0.05). Areas under the curve (Azs) showing interlobar invasion on thin-section sagittal and coronal MPRs were significantly larger than that on routine CT (p=0.03), and the Az on thin-section sagittal MPR was also significantly larger than that on routine CT (p=0.02). Accuracy of chest wall invasion by thin-section sagittal MPR was significantly higher than that by routine CT (p=0.04).

CONCLUSION

Thin-section multiplanar reformats from multidetector-row CT data sets are useful for assessing the extent of regional tumors in non-small cell lung cancer patients.

Surgical management of T3 and T4 lung cancer

Locally advanced lung cancer (T(3) or T(4)) has a significantly worse prognosis than lower stage disease. However, this diagnosis is usually made radiologically, and experienced thoracic surgeons are familiar with the low radiologic to pathologic correlation in tumors that abut the great vessels, mediastinum, or chest wall. Commonly these tumors do not directly invade adjacent structures and are, in fact, T(1) or T(2) tumors that are resectable through standard techniques. Where there is no clearly evident invasion of unresectable structures, the patient should be given the benefit of the doubt and considered at a lower (resectable) stage until proven otherwise. The curability of T(3) tumors varies according to the involved site. A T(3)N(0) tumor involving the chest wall provides the most favorable prognosis among the resected T(3) lesions, with a 5-year survival of >50% in lymph node-negative patients if resection is complete. Palliative incomplete resections of T(4) disease, in which tumor has invaded mediastinal structures, have not shown any survival benefit and are associated with very high morbidity and mortality. However, patients with limited invasion of the carina, left atrium, superior vena cava, or pulmonary artery may be able to be completely resected despite their T(4) classification. Surgical resection remains an important part of the therapy for patients with locally advanced lung cancer. Modern techniques of chest wall resection and reconstruction and bronchoplastic procedures allow complete resection of locally advanced tumors with favorable 5-year survival rates and low morbidity and mortality.

Le traitement chirurgical du cancer bronchique non à petites cellules

INTRODUCTION

Surgery remains the best option for curative treatment of early stages Non-small cell lung cancer (NSCLC). In this article we review the current status and future perspectives of surgical treatment of NSCLC.

STATE OF ART

An important part of the surgical procedure is the final determination of the staging with evaluation of the resectability of the tumor and its nodal status. This requires a systematic hilar and mediastinal nodal dissection and a complete resection that remains a major prognostic factor.

PERSPECTIVES

In order to preserve pulmonary function, lobectomies with the use of broncho- or arterioplasty have been developed with reduction in the number of pneumonectomies. For peripheral T1N0 NSCLC, video-assisted (VATS) lobectomy has become technically feasible with survival, in non-randomised studies, at least as good as the survival after open resection. While VATS has a clear role in staging of lung cancer, its role in the treatment of lung cancer however remains debatable. In case of involved mediastinal nodes (N2 disease) induction therapy is given in many centers and patients with mediastinal downstaging have a significantly better survival than non-responders. Restaging of the mediastinum is at the moment far from accurate. In case of locally advanced tumour (cT4), new surgical techniques and approaches make resection of carina, vena cava superior, vertebrae feasible with acceptable morbidity and mortality but additional studies are required.

CONCLUSIONS

Surgery remains the treatment of choice for curative treatment of NSCLC. The evolution of surgical techniques and the use of multimodality treatment further improve the results of surgical management. Rigorous patient selection, meticulous surgical technique and adequate peri- and postoperative management can keep operative morbidity and morbidity acceptable.