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Tasoudis P, Loufopoulos G, Manaki V, Doerr M, Agala CB, Long JM, Haithcock BE. Long term outcomes after lobar versus sublobar resection for patients with Non-Small cell lung Cancer: Systematic review and individual patient data Meta-Analysis. Lung Cancer 2024; 195:107929. [PMID: 39173232 DOI: 10.1016/j.lungcan.2024.107929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 08/09/2024] [Accepted: 08/10/2024] [Indexed: 08/24/2024]
Abstract
OBJECTIVES Surgical resection remains the primary treatment for early-stage non-small cell lung cancer (NSCLC), with lobectomy considered the standard approach. However, recent evidence suggests that sublobar resection may be an alternative option for select patients. MATERIALS AND METHODS A systematic review and meta-analysis were conducted following PRISMA guidelines. Randomized controlled trials (RCTs) and propensity-score matched (PSM) cohort studies comparing lobectomy and sublobar resection in NSCLC patients were included. The primary outcome was overall survival (OS), and secondary outcomes included disease-free survival (DFS), 30-day mortality, and cancer recurrence rates. Individual patient data (IPD) were reconstructed from Kaplan-Meier curves, and one-stage and two-stage meta-analyses were performed. RESULTS A total of 18 studies involving 6,075 NSCLC patients (3,119 undergoing lobectomy, 2,956 undergoing sublobar resection) were included. Lobectomy was associated with significantly better OS compared to sublobar resection (hazard ratio [HR]: 0.78, 95 % confidence interval [CI]: 0.68-0.89, p < 0.001). However, when sublobar resection was further divided into segmentectomy and wedge resection, no significant difference in OS was observed between lobectomy and segmentectomy (HR:0.92, 95 %CI: 0.75-1.14, p = 0.464) whereas lobar resection was associated with better OS compared to wedge resection (HR:0.52, 95 %CI: 0.41-0.67, p < 0.001). DFS outcomes were similar between lobectomy and sublobar resection (HR:0.98, 95 %CI: 0.84-1.14, p = 0.778). CONCLUSION Lobectomy is associated with better overall survival compared to sublobar resection in NSCLC patients. However, when sublobar resection is subdivided, segmentectomy shows comparable outcomes to lobectomy, while wedge resection is inferior. These findings support the consideration of segmentectomy as the surgical option of choice for Stage IA NSCLC patients.
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Affiliation(s)
- Panagiotis Tasoudis
- Division of Cardiothoracic Surgery, Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Georgios Loufopoulos
- Department of Surgery, Saint Imier Hospital, Switzerland; Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece
| | - Vasiliki Manaki
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece; Aristotle University of Thessaloniki, School of Medicine, Thessaloniki, Greece
| | - Mitchell Doerr
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece
| | - Chris B Agala
- Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, NC, USA
| | - Jason M Long
- Division of Cardiothoracic Surgery, Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Benjamin E Haithcock
- Division of Cardiothoracic Surgery, Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Fatima M, Sehar A, Zaheer Z, Khan MH, Rehman OU, Abid SF, Ahmad U, Bajwa A, Cheema HA, Maqsood HA, Martins RS, Naqi SA. Oncological Outcomes of Sub-Lobar Resection Versus Lobectomy for Stage I Non-Small Cell Lung Cancer. J Surg Res 2024; 302:302-316. [PMID: 39121798 DOI: 10.1016/j.jss.2024.07.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 06/20/2024] [Accepted: 07/06/2024] [Indexed: 08/12/2024]
Abstract
INTRODUCTION Although lobectomy has been the treatment of choice for early-stage non-small cell lung cancer (NSCLC), sub-lobar resection (i.e., segmentectomy or wedge resection) has emerged as an alternative over time due to its ability to preserve additional lung function. This meta-analysis explores the survival outcomes of sub-lobar resection versus lobectomy in patients with stage I NSCLC (tumor size: ≤2 cm). MATERIAL AND METHODS We conducted a systematic search of PubMed, EMBASE, and the Cochrane Library from inception up to July 28, 2023. The hazard ratios and odds ratios for overall survival (OS), disease-free survival (DFS), and mortality were calculated using the random effects model. RESULTS A total of 27 studies, comprising 10,449 patients, were included. Sub-lobar resection demonstrated comparable OS and DFS to that of lobectomy. Similarly, there was no significant risk of mortality associated with any of the groups. However, the subgroup analysis according to patient selection (intentional, compromised, not specified, and both [intentional and compromised]) showed that the patients in the compromised subgroup had a poor DFS with sub-lobar resection as compared to lobectomy (hazard ratio: 1.52, confidence interval: 1.14-2.02, P = 0.004). Additionally, there was no significant difference in OS, DFS, or overall mortality in the results stratified by surgical procedure or patient selection. CONCLUSIONS The patients with stage I NSCLC who underwent sub-lobar resection showed a significantly worse DFS and OS in the "compromised group." However, there was no overall significant difference in OS, DFS, or mortality in the sub-lobar resection group as compared to lobectomy.
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Affiliation(s)
- Maurish Fatima
- Department of Surgery, King Edward Medical University Lahore, Lahore, Pakistan.
| | - Ayesha Sehar
- Department of Surgery, King Edward Medical University Lahore, Lahore, Pakistan
| | - Zaofashan Zaheer
- Department of Surgery, King Edward Medical University Lahore, Lahore, Pakistan
| | | | - Obaid Ur Rehman
- Services Institute of Medical Sciences, Department of Medicine, Lahore, Pakistan
| | - Syeda Fatima Abid
- Department of Surgery, King Edward Medical University Lahore, Lahore, Pakistan
| | - Unaiza Ahmad
- Department of Medicine, Punjab Medical College, Faisalabad, Pakistan
| | - Ahmed Bajwa
- Department of Surgery, King Edward Medical University Lahore, Lahore, Pakistan
| | | | | | - Russell Seth Martins
- Department of Thoracic Surgery, Hackensack Meridian Health, Hackensack, New Jersey
| | - Syed Asghar Naqi
- Department of Surgery, King Edward Medical University Lahore, Lahore, Pakistan
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Li T, He W, Zhang X, Zhou Y, Wang D, Huang S, Li X, Fu Y. Survival outcomes of segmentectomy and lobectomy for early stage non-small cell lung cancer: a systematic review and meta-analysis. J Cardiothorac Surg 2024; 19:353. [PMID: 38909240 PMCID: PMC11193294 DOI: 10.1186/s13019-024-02832-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 06/14/2024] [Indexed: 06/24/2024] Open
Abstract
BACKGROUND The question of whether segmentectomy and lobectomy have similar survival outcomes for patients with early-stage non-small cell lung cancer (NSCLC) is a matter of debate. METHODS A cohort study and randomized controlled trial were included, comparing segmentectomy and lobectomy, by utilizing computerized access to the Pubmed, Web of Science, and Cochrane Library databases up until July 2022. The Cochrane Collaboration tool was used to evaluate the randomized controlled trials, while the Newcastle-Ottawa Scale (NOS) was used to evaluate the cohort studies. Sensitivity analyses were also carried out. RESULTS The analysis incorporated 17 literature studies, including one randomized controlled trial and 16 cohort studies, and was divided into a segmentectomy group (n = 2081) and a lobectomy group (n = 2395) based on the type of surgery the patient underwent. Each study was followed up from 27 months to 130.8 months after surgery. Over survival (OS): HR = 1.14, 95%CI(0.97,1.32), P = 0.10; disease-free survival (DFS): HR = 1.13, 95%CI(0.91,1.41), P = 0.27; recurrence-free survival (RFS): HR = 0.95, 95%CI(0.81,1.12), P = 0.54. CONCLUSION The results of the study suggest that the survival outcomes of the segmentectomy group were not inferior to that of the lobectomy group. Segmentectomy should therefore be considered as a treatment option for early stage NSCLC.
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Affiliation(s)
- Tongxin Li
- Department of Cardiothoracic Surgery, Dianjiang People's Hospital of Chongqing, Chongqing. No.116 Beijie, Guixi Street, Dianjiang County, Chongqing, 408300, China
| | - Wang He
- Department of Cardiothoracic Surgery, Dianjiang People's Hospital of Chongqing, Chongqing. No.116 Beijie, Guixi Street, Dianjiang County, Chongqing, 408300, China
| | - Xiaolong Zhang
- Department of Cardiothoracic Surgery, Dianjiang People's Hospital of Chongqing, Chongqing. No.116 Beijie, Guixi Street, Dianjiang County, Chongqing, 408300, China
| | - Yu Zhou
- Department of Cardiothoracic Surgery, Dianjiang People's Hospital of Chongqing, Chongqing. No.116 Beijie, Guixi Street, Dianjiang County, Chongqing, 408300, China
| | - Dong Wang
- Department of Cardiothoracic Surgery, Dianjiang People's Hospital of Chongqing, Chongqing. No.116 Beijie, Guixi Street, Dianjiang County, Chongqing, 408300, China
| | - Shengyuan Huang
- Department of Cardiothoracic Surgery, Dianjiang People's Hospital of Chongqing, Chongqing. No.116 Beijie, Guixi Street, Dianjiang County, Chongqing, 408300, China
| | - Xiangyang Li
- Department of Cardiothoracic Surgery, Dianjiang People's Hospital of Chongqing, Chongqing. No.116 Beijie, Guixi Street, Dianjiang County, Chongqing, 408300, China
| | - Yong Fu
- Department of Cardiothoracic Surgery, Dianjiang People's Hospital of Chongqing, Chongqing. No.116 Beijie, Guixi Street, Dianjiang County, Chongqing, 408300, China.
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Ren H, Wang Q, Xiao Z, Mo R, Guo J, Hide GR, Tu M, Zeng Y, Ling C, Li P. Fusing Diverse Decision Rules in 3D-Radiomics for Assisting Diagnosis of Lung Adenocarcinoma. JOURNAL OF IMAGING INFORMATICS IN MEDICINE 2024:10.1007/s10278-024-00967-5. [PMID: 38565729 DOI: 10.1007/s10278-024-00967-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/01/2023] [Accepted: 11/14/2023] [Indexed: 04/04/2024]
Abstract
This study aimed to develop an interpretable diagnostic model for subtyping of pulmonary adenocarcinoma, including minimally invasive adenocarcinoma (MIA), adenocarcinoma in situ (AIS), and invasive adenocarcinoma (IAC), by integrating 3D-radiomic features and clinical data. Data from multiple hospitals were collected, and 10 key features were selected from 1600 3D radiomic signatures and 11 radiological features. Diverse decision rules were extracted using ensemble learning methods (gradient boosting, random forest, and AdaBoost), fused, ranked, and selected via RuleFit and SHAP to construct a rule-based diagnostic model. The model's performance was evaluated using AUC, precision, accuracy, recall, and F1-score and compared with other models. The rule-based diagnostic model exhibited excellent performance in the training, testing, and validation cohorts, with AUC values of 0.9621, 0.9529, and 0.8953, respectively. This model outperformed counterparts relying solely on selected features and previous research models. Specifically, the AUC values for the previous research models in the three cohorts were 0.851, 0.893, and 0.836. It is noteworthy that individual models employing GBDT, random forest, and AdaBoost demonstrated AUC values of 0.9391, 0.8681, and 0.9449 in the training cohort, 0.9093, 0.8722, and 0.9363 in the testing cohort, and 0.8440, 0.8640, and 0.8750 in the validation cohort, respectively. These results highlight the superiority of the rule-based diagnostic model in the assessment of lung adenocarcinoma subtypes, while also providing insights into the performance of individual models. Integrating diverse decision rules enhanced the accuracy and interpretability of the diagnostic model for lung adenocarcinoma subtypes. This approach bridges the gap between complex predictive models and clinical utility, offering valuable support to healthcare professionals and patients.
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Affiliation(s)
- He Ren
- Respiratory Department, Zhoupu Hospital, Shanghai University of Medicine and Health Sciences, Shanghai, China
- College of Medical Instrumentation and Collaborative Innovation Canter, Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - Qiubo Wang
- Respiratory Department, Zhoupu Hospital, Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - Zhengguang Xiao
- Department of Radiology, Shanghai Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Runwei Mo
- School of Mechanical and Power Engineering, East China University of Science and Technology, Shanghai, 200030, China
| | - Jiachen Guo
- College of Medical Instrumentation and Collaborative Innovation Canter, Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - Gareth Richard Hide
- Department of Surgery, Faculty of Health Sciences Medical School, University of the Witwatersrand, Parktown, Johannesburg, South Africa
| | - Mengting Tu
- College of Medical Instrumentation and Collaborative Innovation Canter, Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - Yanan Zeng
- College of Medical Instrumentation and Collaborative Innovation Canter, Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - Chen Ling
- College of Medical Instrumentation and Collaborative Innovation Canter, Shanghai University of Medicine and Health Sciences, Shanghai, China.
| | - Ping Li
- College of Medical Instrumentation and Collaborative Innovation Canter, Shanghai University of Medicine and Health Sciences, Shanghai, China.
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Zhao F, Zhao Y, Zhang Y, Sun H, Ye Z, Zhou G. Predictability and Utility of Contrast-Enhanced CT on Occult Lymph Node Metastasis for Patients with Clinical Stage IA-IIA Lung Adenocarcinoma: A Double-Center Study. Acad Radiol 2023; 30:2870-2879. [PMID: 37003873 DOI: 10.1016/j.acra.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/27/2023] [Accepted: 03/03/2023] [Indexed: 04/03/2023]
Abstract
RATIONALE AND OBJECTIVES With the advantage of minimizing damage and preserving more functional lung tissue, limited surgery is considered depend on the lymph node (LN) involvement situation. However, occult lymph node metastasis (OLM) may be ignored by limited surgery and become a risk factor for local recurrence after surgical resection. The aim of this study was to assess the risk factors for OLM based on computed tomography enhanced image in patients with clinical lung adenocarcinoma (ADC). MATERIALS AND METHODS From January 2016 to July 2022, 707 patients with clinical stage IA-IIA ADC underwent lobectomy with systematic LN dissection and were divided into training and validation group based on different institution. Univariate analysis followed by multivariable logistic regression were performed to estimate different risk factors of OLM. A predictive model was established with visual nomogram and external validation, and evaluated in terms of accuracy, sensitivity, specificity, and area under the receiver operating characteristic curve (AUC). RESULTS Fifty-nine patients were diagnosed with OLM (11.9%), and four independent predictors of LN involvement were identified: larger consolidation diameter (odds ratio [OR], 2.35, 95% confidence interval [CI]: 1.06, 5.22, p = 0.013), bronchovascular bundle thickening (OR, 1.99, 95% CI: 1.00, 3.95, p = 0.049), lobulation (OR, 2.92, 95% CI: 1.22, 6.99, p = 0.016) and obstructive change (OR, 1.69, 95% CI: 1.17, 6.16, p = 0.020). The model showed good calibration (Hosmer-Lemeshow goodness-of-fit, p = 0.816) with an AUC of 0.821 (95% CI: 0.775, 0.853). For the validation group, the AUC was 0.788 (95% CI: 0.732, 0.806). CONCLUSION Our predictive model can non-invasively assess the risk of OLM in patients with clinical stage IA-IIA ADC, enable surgeons perform an individualized prediction preoperatively, and assist the clinical decision-making procedure.
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Affiliation(s)
- Fengnian Zhao
- Department of Ultrasound, Tianjin Medical University General Hospital, Tianjin, China
| | - Yunqing Zhao
- Department of Radiology, Chinese Academy of Medical Sciences Institute of Hematology and Blood Diseases Hospital, Tianjin, China
| | - Yanyan Zhang
- Department of Radiology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Haoran Sun
- Department of Radiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Zhaoxiang Ye
- Department of Radiology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research canter, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Guiming Zhou
- Department of Ultrasound, Tianjin Medical University General Hospital, Anshan Road, Heping District, Tianjin, 300052, China.
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Righi I, Maiorca S, Diotti C, Bonitta G, Mendogni P, Tosi D, Nosotti M, Rosso L. Oncological Outcomes of Segmentectomy versus Lobectomy in Clinical Stage I Non-Small Cell Lung Cancer up to Two Centimeters: Systematic Review and Meta-Analysis. Life (Basel) 2023; 13:life13040947. [PMID: 37109476 PMCID: PMC10146149 DOI: 10.3390/life13040947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 03/30/2023] [Accepted: 04/01/2023] [Indexed: 04/09/2023] Open
Abstract
Objective. In recent years, pulmonary segmentectomy has emerged as an alternative to lobectomy for the treatment of patients with clinical stage I non-small cell lung cancer. Considering the conflicting results reported in the literature, the oncological effectiveness of segmentectomy remains controversial. To provide new insight into oncological results, we reviewed the literature, including recent randomized trials. Methods. We performed a systematic review for surgical treatment of stage I NSCLC up to 2 cm using MEDLINE and the Cochrane Database from 1990 to December 2022. Primary outcomes for pooled analysis were overall and disease-free survival; secondary outcomes were postoperative complications and 30-day mortality. Results. Eleven studies were considered for the meta-analysis. The pooled analysis included 3074 and 2278 patients who received lobectomy and segmentectomy, respectively. The estimated pooled hazard ratio showed a similar hazard for segmentectomy compared to lobectomy in terms of overall and disease-free survival. The restricted mean survival time difference between the two procedures was statistically and clinically not significant for overall and disease-free survival. Nevertheless, the overall survival hazard ratio was time-dependent: segmentectomy was at a disadvantage starting from 40 months after surgery. Six papers reported 30-day mortality: there were no events on 1766 procedures. The overall relative risk showed that the postoperative complication rate was higher in segmentectomy compared to lobectomy, without statistical significance. Conclusions. Our results suggest that segmentectomy might be a useful alternative to lobectomy for stage I NSCLC up to 2 cm. However, this appears to be time-dependent; in fact, the risk ratio for overall mortality becomes unfavorable for segmentectomy starting at 40 months after surgery. This last observation, together with some still undefined questions (solid/non-solid ratio, depth of the lesion, modest functional savings, etc.), leave room for further investigations on the real oncological effectiveness of segmentectomy.
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Affiliation(s)
- Ilaria Righi
- Department of Cardio-Thoracic and Vascular Diseases, Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Sebastiano Maiorca
- Department of Patho-Physiology and Transplantation, University of Milan, 20122 Milan, Italy
| | - Cristina Diotti
- Department of Thoracic Surgery, European Institute of Oncology, 20141 Milan, Italy
| | - Gianluca Bonitta
- Department of Patho-Physiology and Transplantation, University of Milan, 20122 Milan, Italy
| | - Paolo Mendogni
- Department of Cardio-Thoracic and Vascular Diseases, Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Davide Tosi
- Department of Cardio-Thoracic and Vascular Diseases, Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Mario Nosotti
- Department of Cardio-Thoracic and Vascular Diseases, Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Patho-Physiology and Transplantation, University of Milan, 20122 Milan, Italy
| | - Lorenzo Rosso
- Department of Cardio-Thoracic and Vascular Diseases, Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Patho-Physiology and Transplantation, University of Milan, 20122 Milan, Italy
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Gao X, Dai W, Zhang Q, Liu W, Liu Y, Yang L, Wei X, Shi Q, Pompili C, Pu Y, Xie S, Xiang R, Tian B, Hu B, Yang X, Wang X, Yang X, Xie T, Tang Y, Qiao G, Sun N, Gao S, Zhang G, Chen D, Cui Y, Chen X, He Y, Zhang R, Li Q, Zhuang X. Longitudinal patient-reported outcomes 1 year after thoracoscopic segmentectomy versus lobectomy for early-stage lung cancer: a multicentre, prospective cohort study protocol. BMJ Open 2023; 13:e067841. [PMID: 36657755 PMCID: PMC9853240 DOI: 10.1136/bmjopen-2022-067841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Segmentectomy and lobectomy are the main surgical procedures for early-stage lung cancer. However, few studies have analysed patient-reported outcomes after segmentectomy versus lobectomy. This study aims to compare patient-reported outcomes-such as symptoms, daily functioning and quality of life-between thoracoscopic segmentectomy and lobectomy for early-stage lung cancer during the 1 year after surgery. METHODS AND ANALYSIS Overall, 788 newly diagnosed patients with early-stage lung cancer (tumour size ≤2 cm), who are scheduled to undergo thoracoscopic segmentectomy or lobectomy, will be recruited in this multicentre, prospective cohort study. The patients will receive standardised care after surgery. The Perioperative Symptom Assessment for Lung Surgery-a validated lung cancer surgery-specific scale-will be used to assess the symptoms and functions at baseline, at discharge and monthly after discharge for 1 year. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 and Lung Cancer module 29 will be used to assess the patients' quality of life at the same time points. The primary outcome will be the shortness of breath scores during the first year after thoracoscopic segmentectomy and lobectomy and will be compared using mixed-effects models. The secondary outcomes will include other symptoms, indicators of daily functioning, quality of life scores and traditional clinical outcomes. These will be compared using mixed-effects models and the Student's t-test, non-parametric test or Χ2 test. Propensity score matching will be used to ensure an even distribution of known confounders between the groups. ETHICS AND DISSEMINATION The Ethics Committee for Medical Research and New Medical Technology of Sichuan Cancer Hospital approved this study (approval number: SCCHEC-02-2022-002). All participants will be instructed to provide informed consent. The manuscript is based on protocol version 3.0. The study results will be presented at medical conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER ChiCTR2200060753.
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Affiliation(s)
- Xin Gao
- Department of Thoracic Surgery, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Wei Dai
- Department of Thoracic Surgery, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Qi Zhang
- Department of Thoracic Surgery, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
- Graduate School, Chengdu Medical College, Chengdu, Sichuan, China
| | - Wenwu Liu
- Department of Thoracic Surgery, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Yangjun Liu
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Lingjia Yang
- College of Medical and Dental Science, University of Birmingham, Birmingham, UK
| | - Xing Wei
- Department of Thoracic Surgery, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Qiuling Shi
- Center for Cancer Prevention Research, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
- School of Public Health, Chongqing Medical University, Chongqing, China
| | - Cecilia Pompili
- Thoracic Surgery Unit, University and Hospital Trust - Ospedale Borgo Trento, Verona, Italy
- Section of Patient Centered Outcomes Research, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Yang Pu
- School of Public Health, Chongqing Medical University, Chongqing, China
| | - Shaohua Xie
- Department of Thoracic Surgery, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Run Xiang
- Department of Thoracic Surgery, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Bo Tian
- Department of Thoracic Surgery, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Bin Hu
- Department of Thoracic Surgery, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Xiaozun Yang
- Department of Thoracic Surgery, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Xiang Wang
- Department of Thoracic Surgery, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Xiaojun Yang
- Department of Thoracic Surgery, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Tianpeng Xie
- Department of Thoracic Surgery, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Yong Tang
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangzhou, Guangdong, China
| | - Guibin Qiao
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital, Guangzhou, Guangdong, China
| | - Nan Sun
- Department of Thoracic Surgery, Liaoning Cancer Hospital & Institute, Shenyang, Liaoning, China
| | - Shan Gao
- Department of Thoracic Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Guangjian Zhang
- Department of Thoracic Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Dan Chen
- Department of Thoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, Chongqing, China
| | - Yue Cui
- Department of Thoracic Surgery, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Xiaobo Chen
- Department of Thoracic Surgery, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Yu He
- Department of Thoracic Surgery, Ya'an People's Hospital, Ya'an, Sichuan, China
| | - Rong Zhang
- Department of Thoracic Surgery, Ya'an People's Hospital, Ya'an, Sichuan, China
| | - Qiang Li
- Department of Thoracic Surgery, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Xiang Zhuang
- Department of Thoracic Surgery, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
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Zuo ZC, Wang LD, Peng K, Yang J, Li X, Zhong Z, Zhang HM, Ouyang X, Xue Q. Development and Validation of a Nomogram for Predicting the 1-, 3-, and 5-year Survival in Patients with Acinar-predominant Lung Adenocarcinoma. Curr Med Sci 2022; 42:1178-1185. [PMID: 36542324 DOI: 10.1007/s11596-022-2672-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 11/02/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE This study aimed to develop a nomogram to predict the overall survival (OS) of patients with acinar-predominant adenocarcinoma (APA). METHODS Data from patients with APA obtained from the Surveillance, Epidemiology, and End Results (SEER) database between 2008 and 2016 were used. Significant prognostic factors were incorporated to construct a nomogram for predicting the 1-, 3-, and 5-year OS in these patients. The discrimination and calibration abilities of the nomogram were assessed using a C-index and calibration curves, respectively. RESULTS A total of 2242 patients with APA were randomly divided into a training cohort (n=1576) and validation cohort (n=666). The independent prognostic factors for OS incorporated into the nomogram included marital status, age, gender, differentiation grade, T stage, N stage, and M stage. The nomogram showed good prediction capability, as indicated by the C-index [0.713, 95% confidence interval (CI): 0.705-0.721 in the training cohort, and 0.662, 95% CI: 0.649-0.775 in the validation cohort]. The calibration curves demonstrated that the 1-, 3-, and 5-year OS probabilities were consistent between the observed and predicted outcome frequencies. Patients were divided into the high-risk and low-risk groups with the former showing significantly worse survival than the latter (P<0.001). CONCLUSION Using the SEER database, a nomogram was established to predict the 1-, 3-, and 5-year OS of patients with APA and was superior to the tumor size, lymph node, and metastasis staging system in terms of evaluating long-term prognosis.
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Affiliation(s)
- Zhi-Chao Zuo
- Department of Radiology, Xiangtan Central Hospital, Xiangtan, 411000, China
| | - Li-de Wang
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Ke Peng
- Department of Spine Surgery, the Second Xiangya Hospital, Central South University, Changsha, 410011, China
| | - Jing Yang
- Department of Plastic Surgery, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, 441000, China
| | - Xiong Li
- Department of Radiology, Xiangtan Central Hospital, Xiangtan, 411000, China
| | - Zhi Zhong
- Department of Radiology, Xiangtan Central Hospital, Xiangtan, 411000, China
| | - Huan-Ming Zhang
- Department of Radiology, Xiangtan Central Hospital, Xiangtan, 411000, China
| | - Xin Ouyang
- Department of Radiology, Xiangtan Central Hospital, Xiangtan, 411000, China.
| | - Qi Xue
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
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9
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Wu Z, Huang Z, Qin Y, Jiao W. Progress in three-dimensional computed tomography reconstruction in anatomic pulmonary segmentectomy. Thorac Cancer 2022; 13:1881-1887. [PMID: 35585765 PMCID: PMC9250838 DOI: 10.1111/1759-7714.14443] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 11/30/2022] Open
Abstract
The number of minimally invasive surgeries, such as video-assisted thoracoscopic surgery and robot-assisted thoracoscopic surgery, has increased enormously in recent years. More and more relevant studies report that anatomic pulmonary segmentectomy has the same effect as traditional lobectomy in the surgical treatment of early stage non-small cell lung cancer (diameter less than 2.0 cm). Segmentectomy requires sufficient knowledge of the location of the pulmonary nodules, as well as the anatomy of the target segments, blood vessels, and bronchi. With the rapid development of imaging technology and three-dimensional technology, three-dimensional reconstruction has been widely used in the medical field. It can effectively assess the vascular branching patterns, discover the anatomic variations of the blood vessels and bronchi, determine the location of the lesion, and clarify the division of the segments. Therefore, it is helpful for preoperative positioning, surgical planning, preoperative simulation and intraoperative navigation, and provides a reference for formulating an individualized surgical plan. It therefore plays a positive role in anatomic pulmonary segmentectomy. This study reviews the progress made in three-dimensional computed tomography reconstruction in anatomic pulmonary segmentectomy.
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Affiliation(s)
- Zhe Wu
- Department of Thoracic Surgery, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zhangfeng Huang
- Department of Thoracic Surgery, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yi Qin
- Department of Thoracic Surgery, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Wenjie Jiao
- Department of Thoracic Surgery, the Affiliated Hospital of Qingdao University, Qingdao, China
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10
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6545819. [DOI: 10.1093/ejcts/ezac180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 03/01/2022] [Indexed: 11/12/2022] Open
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11
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Dai W, Chang S, Pompili C, Qiu B, Wei X, Mu Y, Zhang R, Shen C, Shi Q, Li Q, Wu Z, Che G. Early Postoperative Patient-Reported Outcomes After Thoracoscopic Segmentectomy Versus Lobectomy for Small-Sized Peripheral Non-small-cell Lung Cancer. Ann Surg Oncol 2021; 29:547-556. [PMID: 34743281 DOI: 10.1245/s10434-021-10946-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 09/04/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patient-reported outcomes are critical for obtaining valuable patient insight into different surgical treatment options with comparable clinical outcomes. This study aimed to compare early postoperative patient-reported symptoms and functioning between thoracoscopic segmentectomy and lobectomy for small-sized (≤ 2 cm) peripheral non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS This study included 110 patients who underwent thoracoscopic segmentectomy or lobectomy for peripheral NSCLC ≤ 2 cm in a multicenter prospective longitudinal study (CN-PRO-Lung 1). Symptom severity, functional status, and short-term clinical outcomes were compared between the groups. Symptom severity and functional status were measured using the MD Anderson Symptom Inventory-Lung Cancer at baseline, daily post-surgery, and weekly post-discharge for up to 4 weeks. Both the proportion of moderate-to-severe scores and mean scores on a 0-10 scale were compared between the groups. RESULTS Overall, 48 and 62 patients underwent thoracoscopic segmentectomy and lobectomy, respectively. No significant between-group differences were found in the severity of the top five symptoms (coughing, shortness of breath, pain, fatigue, and disturbed sleep) or in the impairment of all six function items (work, walking, general activity, enjoyment of life, mood, and relations with others) during both the 6-day postoperative hospitalization and the 4-week post-discharge (all p > 0.05). Short-term clinical outcomes of postoperative hospital stay, operative time, drainage time, postoperative in-hospital oral morphine equivalent dose, and complication rate were also comparable (all p > 0.05). CONCLUSIONS In patients with peripheral NSCLC ≤ 2 cm, thoracoscopic segmentectomy and lobectomy might produce comparable symptom burden and functional impairment during the early postoperative period.
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Affiliation(s)
- Wei Dai
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China.,Department of Thoracic Surgery, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Shuai Chang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Cecilia Pompili
- Section of Patient Centred Outcomes Research, Leeds Institute for Medical Research at St James's, University of Leeds, Leeds, UK.,Department of Thoracic Surgery, Leeds Teaching Hospital Trust, Leeds, UK
| | - Bin Qiu
- Department of Thoracic Surgery, National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xing Wei
- Department of Thoracic Surgery, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yunfei Mu
- Department of Thoracic Surgery, Chengdu Third People's Hospital, Chengdu, China
| | - Rui Zhang
- Department of Thoracic Surgery, Chengdu Seventh People's Hospital, Chengdu, China
| | - Cheng Shen
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Qiuling Shi
- Center for Cancer Prevention Research, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Qiang Li
- Department of Thoracic Surgery, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Zhong Wu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, China.
| | - Guowei Che
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China.
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12
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Shi L, Shi W, Peng X, Zhan Y, Zhou L, Wang Y, Feng M, Zhao J, Shan F, Liu L. Development and Validation a Nomogram Incorporating CT Radiomics Signatures and Radiological Features for Differentiating Invasive Adenocarcinoma From Adenocarcinoma In Situ and Minimally Invasive Adenocarcinoma Presenting as Ground-Glass Nodules Measuring 5-10mm in Diameter. Front Oncol 2021; 11:618677. [PMID: 33968722 PMCID: PMC8096901 DOI: 10.3389/fonc.2021.618677] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 03/25/2021] [Indexed: 12/09/2022] Open
Abstract
Purpose To develop and validate a nomogram for differentiating invasive adenocarcinoma (IAC) from adenocarcinoma in situ (AIS) and minimally invasive adenocarcinoma (MIA) presenting as ground-glass nodules (GGNs) measuring 5-10mm in diameter. Materials and Methods This retrospective study included 446 patients with 478 GGNs histopathologically confirmed AIS, MIA or IAC. These patients were assigned to a primary cohort, an internal validation cohort and an external validation cohort. The segmentation of these GGNs on thin-slice computed tomography (CT) were performed semi-automatically with in-house software. Radiomics features were then extracted from unenhanced CT images with PyRadiomics. Radiological features of these GGNs were also collected. Radiomics features were investigated for usefulness in building radiomics signatures by spearman correlation analysis, minimum redundancy maximum relevance (mRMR) feature ranking method and least absolute shrinkage and selection operator (LASSO) classifier. Multivariable logistic regression analysis was used to develop a nomogram incorporating the radiomics signature and radiological features. The performance of the nomogram was assessed with discrimination, calibration, clinical usefulness and evaluated on the validation cohorts. Results Five radiomics features remained after features selection. The model incorporating radiomics signatures and four radiological features (bubble-like appearance, tumor-lung interface, mean CT value, average diameter) showed good calibration and good discrimination with AUC of 0.831(95%CI, 0.772~0.890). Application of the nomogram in the internal validation cohort with AUC of 0.792 (95%CI, 0.712~0.871) and in the external validation cohort with AUC of 0.833 (95%CI, 0.729-0.938) also indicated good calibration and good discrimination. The decision curve analysis demonstrated that the nomogram was clinically useful. Conclusion This study presents a nomogram incorporating the radiomics signatures and radiological features, which can be used to predict the risk of IAC in patients with GGNs measuring 5-10mm in diameter individually.
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Affiliation(s)
- Lili Shi
- Shanghai Public Health Clinical Center and Institutes of Biomedical Sciences, Fudan University, Shanghai, China.,Medical School, Nantong University, Nantong, China
| | - Weiya Shi
- Shanghai Public Health Clinical Center and Institutes of Biomedical Sciences, Fudan University, Shanghai, China
| | - Xueqing Peng
- Shanghai Public Health Clinical Center and Institutes of Biomedical Sciences, Fudan University, Shanghai, China
| | - Yi Zhan
- Shanghai Public Health Clinical Center and Institutes of Biomedical Sciences, Fudan University, Shanghai, China
| | - Linxiao Zhou
- Shanghai Public Health Clinical Center and Institutes of Biomedical Sciences, Fudan University, Shanghai, China
| | - Yunpeng Wang
- Shanghai Public Health Clinical Center and Institutes of Biomedical Sciences, Fudan University, Shanghai, China
| | - Mingxiang Feng
- Chest Surgery Department, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jinli Zhao
- Radiology Department, Affiliated Hospital of Nantong University, Nantong, China
| | - Fei Shan
- Shanghai Public Health Clinical Center and Institutes of Biomedical Sciences, Fudan University, Shanghai, China
| | - Lei Liu
- Shanghai Public Health Clinical Center and Institutes of Biomedical Sciences, Fudan University, Shanghai, China.,School of Basic Medical Sciences, and Academy of Engineering and Technology, Fudan University, Shanghai, China
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13
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Kodia K, Razi SS, Alnajar A, Nguyen DM, Villamizar N. Comparative Analysis of Robotic Segmentectomy For Non-Small Cell Lung Cancer: A National Cancer Database Study. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2021; 16:280-287. [PMID: 33866844 DOI: 10.1177/1556984521997805] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The use of segmentectomy for peripheral T ≤2 cm, N0 non-small cell lung cancer (NSCLC) has increased in the last decade. We sought to compare clinical outcomes and overall survival between robotic, video-assisted thoracoscopic surgery (VATS), and open segmentectomy. METHODS The National Cancer Database was queried for patients with clinical T ≤2 cm, N0 NSCLC who underwent segmentectomy via robotic, thoracoscopic (VATS), and open approaches (2010 to 2015). Univariate and Cox regression analyses were used to compare surgical approaches and to evaluate predictors of overall survival. Statistical analyses were done using SPSS Version 21.0. RESULTS Segmentectomy was performed in 3,888 patients during the study period with 406 robotic, 1,837 VATS, and 1,645 open patients. VATS and robotic segmentectomy were performed more often at academic or comprehensive community cancer programs as compared to community programs (P < 0.05). Conversion to open thoracotomy was similar between robotic and VATS groups when stratified by hospital volume. Lymph node yield was significantly higher for robotic (median = 6), compared to VATS (median = 5) or open (median = 4; P < 0.001). Length of stay was decreased for robotic versus open (P < 0.01). No differences in 30-day readmissions (P = 0.12) were observed among the 3 modalities. Overall survival was similar among groups (P = 0.18). CONCLUSIONS Robotic segmentectomy provides similar clinical outcomes compared to other standardized approaches for clinical T ≤2 cm, N0 NSCLC. A higher lymph node yield in robotic segmentectomy was not associated with improved survival in this study population.
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Affiliation(s)
- Karishma Kodia
- 1584247824 Division of Thoracic Surgery, University of Miami Hospital, FL, USA
| | - Syed S Razi
- 23457 Division of Thoracic Surgery, Memorial Healthcare System, South Broward, FL, USA
| | - Ahmed Alnajar
- 1584247824 Division of Thoracic Surgery, University of Miami Hospital, FL, USA
| | - Dao M Nguyen
- 1584247824 Division of Thoracic Surgery, University of Miami Hospital, FL, USA
| | - Nestor Villamizar
- 1584247824 Division of Thoracic Surgery, University of Miami Hospital, FL, USA
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14
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Bai W, Li S. Prognosis of segmentectomy in the treatment of stage IA non-small cell lung cancer. Oncol Lett 2020; 21:74. [PMID: 33365085 PMCID: PMC7716705 DOI: 10.3892/ol.2020.12335] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 10/26/2020] [Indexed: 12/24/2022] Open
Abstract
With improvements in detection technology, increasing numbers of patients with non-small cell lung cancer (NSCLC) are being diagnosed at an early stage. In order to treat the illness with minimal invasion and preserve lung function to the greatest possible extent, there has been an increasing tendency towards treating early-stage NSCLC by segmentectomy. However, questions remain regarding whether patients may benefit from this procedure considering the surgical and oncological outcomes. Whether adequate margin distance and lymph node dissection may be achieved is one of the most important issues associated with this procedure. The present study reviews the prognosis of segmentectomy in the treatment of stage IA NSCLC.
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Affiliation(s)
- Wenliang Bai
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, P.R. China
| | - Shanqing Li
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, P.R. China
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