Surgical management of locally advanced lung cancer

Proximal Femoral Metastasis From Epidermal Growth Factor Receptor-Mutated Lung Adenocarcinoma Mimicking Osteosarcoma on Magnetic Resonance Imaging

The aggressive nature of lung cancer is frequently accompanied by a high incidence of bone metastasis; however, proximal femoral metastasis from lung cancer is comparatively uncommon when compared to other malignancies. In this report, we present the case of a 53-year-old Asian male who presented with pain in the left thigh and back. Magnetic resonance imaging revealed severe bone destruction with involvement of adjacent soft tissue mass at the left thigh, exhibiting imaging findings that mimic osteosarcoma. Subsequent bone biopsy confirmed the diagnosis of epidermal growth factor receptor (EGFR)-mutated lung adenocarcinoma with bone metastasis. The patient achieved survival following administration of osimertinib and underwent surgery for femoral metastases without palliative surgery for lung cancer. Therefore, proximal femoral metastasis from EGFR-mutated lung adenocarcinoma should be considered as a differential diagnosis in patients suspected to have osteosarcoma. The imaging findings of proximal femoral metastasis from EGFR-mutated lung adenocarcinoma were presented, and their therapeutic management was discussed.

The consideration of surgery on primary lesion of advanced non-small cell lung cancer

BACKGROUND

Numerous reports have shown that medical treatment confers excellent survival benefits to patients with advanced stage IV non-small cell lung cancer (NSCLC). However, the implications of surgery for primary lesions as palliative treatment remain inconclusive.

METHODS

We retrospectively extracted clinical data from the Surveillance, Epidemiology, and End Results Program (SEER) database and selected patients with stage IV NSCLC. Patients were classified into non-surgery and surgery groups, and propensity score matching (PSM) analysis was performed to balance the baseline information. Patients in the surgery group, whose overall survival (OS) was longer than the median survival time of those in the non-surgery group, were deemed to benefit from surgery. We evaluated the efficacy of three surgical techniques, namely, local destruction, sub-lobectomy, and lobectomy, on the primary site in the beneficial population.

RESULTS

The results of Cox regression analyses revealed that surgery was an independent risk factor for both OS (hazard ratio [HR]: 0.441; confidence interval [CI]: 0.426-0.456; P < 0.001) and cancer-specific survival (CSS) (HR: 0397; CI: 0.380-0.414; P < 0.001). Notably, patients who underwent surgery had a better prognosis than those who did not (OS: P < 0.001; CSS: P < 0.001). Moreover, local destruction and sub-lobectomy significantly compromised survival compared to lobectomy in the beneficial group (P < 0.001). After PSM, patients with stage IV disease who underwent lobectomy needed routine mediastinal lymph node clearing (OS: P = 0.0038; CSS: P = 0.039).

CONCLUSION

Based on these findings, we recommend that patients with stage IV NSCLC undergo palliative surgery for the primary site and that lobectomy plus lymph node resection should be conventionally performed on those who can tolerate the surgery.

Induction therapy is not associated with improved survival in large cT4N0 non-small cell lung cancers

BACKGROUND

The 8^th edition staging for non-small cell lung cancer reclassified tumors >7 cm as stage IIIA (T4N0); previously, such tumors without nodal disease were considered stage IIB (T3N0). This study tested the hypothesis that induction chemotherapy for these stage IIIA patients does not improve survival compared to primary surgery.

METHODS

The National Cancer Database was queried for non-small cell lung cancer patients with tumor size >7 cm who underwent surgical resection from 2010 - 2015. Patients with clinically node-positive disease or tumor invasion of major structures were excluded. Patients undergoing induction chemotherapy followed by surgery (IC) were compared to patients undergoing primary surgery (PS). Propensity-score matching was performed.

RESULTS

In total, 1,610 patients with cT4N0 disease based on tumor size >7 cm and no tumor invasion underwent surgical resection: 1,346 (83.6%) comprised the PS group and 264 (16.4%) the IC group. After propensity-score matching, IC had a higher rate of pN0 (78.4% vs 66.0%, p<0.001) and less lymphovascular invasion (13.9% vs 26.3%, p<0.001), but longer postoperative stay (6 vs 5 days, p<0.001) and higher 30-day mortality (3.5% vs 0%, p=0.002). Median 5-year survival was similar between IC and PS (53.5% vs 62.2%, p=0.075), and IC was not independently associated with survival (HR 1.45, p=0.146).

CONCLUSIONS

Patients with cT4N0 non-small cell lung cancer based on tumor size >7 cm and no tumor invasion of major structures have similar overall survival with either IC or PS. IC should not be routinely given for this subset of stage IIIA patients.

Direct Cross-Clamping for Resection of Lung Cancer Invading the Aortic Arch or the Subclavian Artery

BACKGROUND

Resection of lung cancer infiltrating the aortic arch or the subclavian artery can be accomplished in selected patients with the use of cardiopulmonary bypass (CPB). Direct cross-clamping of the aortic arch and the left subclavian artery without CPB for radical resection of the tumor can be an alternative. This study presents one group's experience with this technique.

METHODS

Between October 2016 and May 2019, 9 patients (5 male, 4 female) underwent radical resection of lung cancer infiltrating the aortic arch (n = 5) or the left subclavian artery (n = 4) by direct cross-clamping technique at Sapienza University of Rome, Italy. Seven left upper lobectomies, 1 left pneumonectomy, and 1 left upper sleeve lobectomy were performed. Reconstruction of the aortic arch was performed by direct suturing or polyethylene terephthalate (Dacron) patch, whereas the subclavian artery was reconstructed with a Dacron conduit. Three patients received neoadjuvant chemotherapy.

RESULTS

Patients' mean age was 64.7 ± 13.3 years (range, 36 to 78 years). Aortic arch resection was partial in all cases (adventitial in 1 and full thickness in 4); left subclavian artery resection was adventitial in 2 patients and circumferential in 2. All the resections were complete. Prosthetic reconstruction was performed in 4 cases. Mean operative time was 130 ± 25.6 minutes; mean vascular clamping time was 28.2 ± 3.2 minutes. No mortality occurred. The major complication rate was 11.1 %. At a mean follow-up of 17 ± 9 months (range, 5 to 29 months), the recurrence rate was 33.3%. Median survival was 20 months.

CONCLUSIONS

Direct cross-clamping as an alternative to CPB for resection of lung cancer infiltrating the aortic arch or the subclavian artery is a feasible, safe, and reliable procedure in selected patients.

Neoadjuvant Treatment Is Associated With Superior Outcomes in T4 Lung Cancers With Local Extension

BACKGROUND

Neoadjuvant chemoradiation is associated with improved survival of superior sulcus cancers, but little data exists regarding clinical T4 lung cancers with mediastinal invasion. We hypothesized that neoadjuvant treatment would be associated with improved survival in T4 lung cancer patients with mediastinal invasion.

METHODS

Clinical T4-N0/1-M0 non-small cell lung cancers from 2006-2015 were identified in the National Cancer Database. Patients with T4 extension to mediastinal structures undergoing lobectomy, bilobectomy, or pneumonectomy were included. Neoadjuvant treatment was defined as preoperative chemotherapy and/or radiation. Patients receiving surgery >120 days after radiation were excluded. Study endpoints were pathologic margin status and overall survival. To adjust for heterogeneity, a 1:1 propensity match analysis was performed.

RESULTS

A total of 1101 patients with cT4N0/1M0 cancers were analyzed; 595 (54.0%) received primary surgery and 506 (46.0%) received neoadjuvant treatment. Neoadjuvant therapy was associated with fewer positive surgical margins (46 of 506 [9.3%] vs 186 of 595 [33.1%], P < .001). Multivariate analysis showed an association of neoadjuvant therapy with a lower rate of positive margin (odds ratio 0.220, P < .001). Overall survival was longer among patients receiving neoadjuvant treatment (65.9 vs 27.5 months, P < .001). Propensity matching identified 331 matched pairs of patients. Among these, positive margins were less likely after receiving neoadjuvant treatment (10.5% vs 31.3%, P < .001). Overall survival among the matched pairs was improved in those receiving neoadjuvant treatment (57.0 vs 27.5 months, P < .001).

CONCLUSIONS

In the NCDB, T4N0/1 mediastinal invasion patients who receive neoadjuvant treatment have decreased rates of positive surgical margins and improved overall survival. The use of neoadjuvant treatment should be considered in these patients.

The Outcomes of Induction Chemoradiotherapy Followed by Surgery for Clinical T3-4 Non-Small Cell Lung Cancer

Purpose:

Information on the short- and long-term outcomes of induction chemoradiotherapy followed by surgery for cT3-4 non-small cell lung cancer is limited. We analyzed the short- and long-term outcomes of induction chemoradiotherapy followed by surgery for cT3-4 non-small cell lung cancer.

Methods:

Patients with non-small cell lung cancer who underwent induction chemoradiotherapy followed by surgery for cT3-4 non-small cell lung cancer were retrospectively reviewed (initial treatment group, n = 31). Their results were compared to those patients who underwent surgery as an initial treatment during the same period (initial surgery group, n = 35).

Results:

Downstaging was achieved in 14 (45%) patients in the initial treatment group. R0 resection was achieved in 28 (90%) patients in the initial treatment group and 31 (88%) patients in the initial surgery group. The 90-day mortality rate was 3% in each group. Postoperative complications occurred in 16 (52%) patients in the initial treatment group and 13 (37%) patients in the initial surgery group. The 5-year overall survival rate of the initial treatment group was significantly higher than that of the initial surgery group (62.6% vs 43.5%, P = .04). The 5-year overall survival rates of the initial treatment N0-1 group and the initial surgery N0-1 group were 88.9% and 49.3%, respectively; the difference was statistically significant (P = .02). Multivariate analysis using 4 factors (age [≤65 vs >65], cN [cN0-1 vs cN2], general condition [chemoradiotherapy fit vs chemoradiotherapy unfit], and treatment mode [induction chemoradiotherapy followed by surgery vs surgery as an initial treatment]) revealed that treatment mode (induction chemoradiotherapy followed by surgery) and cN status (cN0-1) were significantly associated with good overall survival and disease-free survival.

Conclusions:

Induction chemoradiotherapy followed by surgery for cT3-4 non-small cell lung cancer could be performed with an acceptable degree of surgical risk. At present, it is thought to be one of the reasonable treatment approaches for selected patients with cT3-4 disease, even those with a cN0-1 status.

Construction of subtype-specific prognostic gene signatures for early-stage non-small cell lung cancer using meta feature selection methods

Feature selection in the framework of meta-analyses (meta feature selection), combines meta-analysis with a feature selection process and thus allows meta-analysis feature selection across multiple datasets. In the present study, a meta feature selection procedure that fitted a multiple Cox regression model to estimate the effect size of a gene in individual studies and to identify the overall effect of the gene using a meta-analysis model was proposed. The method was used to identify prognostic gene signatures for lung adenocarcinoma and lung squamous cell carcinoma. Furthermore, redundant gene elimination (RGE) is of crucial importance during feature selection, and is also essential for a meta feature selection process. The current study demonstrated that the proposed meta feature selection procedure with RGE outperforms that without RGE in terms of predictive ability, model parsimony and biological interpretation.

En Bloc Resection of Thoracic Tumors Invading the Spine: A Single-Center Experience

BACKGROUND

Vertebral involvement by a thoracic tumor has long been considered as a limit to surgical treatment, and despite advances, such an invasive operation remains controversial. The aim of this study was to characterize a single-center cohort and to evaluate the outcome, focusing on survival and complications.

METHODS

We retrospectively reviewed the data of all patients operated on for tumors involving the thoracic spine in an 8-year period. En bloc resection was generally performed by a double team involving thoracic and orthopedic surgeons. Distant follow-up was recorded for oncologic and functional analysis.

RESULTS

There were 31 patients operated on. An induction therapy was administered in 20 patients. Spinal resection (mostly including ≥2 vertebral levels) was combined with lobectomy in 48.3% of the patients, and osteosynthesis was required in 22 patients. We observed no in-hospital death and a major complications rate of 32.3%, including 5 patients with early neurologic complications. There were 61.3% primary lung carcinomas, 12.9% extrapulmonary primaries, 9.7% metastases, and 16.1% benign tumors. Mean follow-up was 32.1 months. The 5-year overall survival rate was 81.3% in the entire cohort and 75.0% in patients with a malignant tumor. Occurrence of an early postoperative major complication was the only factor significantly associated with shorter overall survival (p = 0.03). The 5-year disease-free survival rate was 37.0% in malignancies. Delayed complications occurred in 35.5% of patients, including persistent neurologic deficit in 12.9%, instrumentation migration in 19.4%, and local infection in 12.9%.

CONCLUSIONS

En bloc resection of spinal thoracic tumors offers long-term survival and few recurrences in highly selected patients but is associated with significant delayed mechanical or infectious complications.

Combined Aortic Arch Resection for Lung Cancer Using Total Rerouting of Supra-Arch Vessels

Surgery for aortic arch involvement in lung cancer cases is challenging, and generally requires extracorporeal circulation with circulatory arrest or a cerebral protection technique. To reduce morbidity, we developed a novel surgical technique for total aortic arch replacement for lung cancer with aortic arch involvement that features total rerouting of supra-arch vessels under a beating heart condition. A 56-year-old man was diagnosed with lung cancer, and aortic arch invasion was suspected. After concurrent chemoradiotherapy, a left upper lobectomy with total arch replacement was performed using our new technique. Thirty-six months after the operation, there was no recurrence.

Long-term survival in locally advanced non-small cell lung cancer invading the great vessels and heart

Background

The aim of this study was to analyze the surgical outcomes of locally advanced lung cancer invading the great vessels or heart, according to the extension of cancer invasion.

Methods

From 1995 to 2015, 59 patients who were surgically treated and pathologically diagnosed with T4N0–1 non‐small cell lung cancer with invasion to the great vessels or heart were enrolled. Surgical outcomes were compared between patient groups with and without intrapericardial invasion.

Results

The median age was 64 years (interquartile range [IQR] 57–68) and 56 patients (95%) were male. In‐hospital mortality was 9% and median overall survival was 30 months (IQR 12–83). One and five‐year overall survival rates were 75% and 44%, respectively. The median overall survival in patients with lung cancer invasion to the intrapericardial space (n = 45) was 27 months (IQR 10–63), while it was 42 months (IQR 18–104) in patients without intrapericardial invasion (n = 14). Median disease‐free survival was significantly poorer in patients with intrapericardial invasion (12 months; IQR 6–55), especially in patients with heart invasion (n = 11, 7 months, IQR 5–27), than in patients without intrapericardial invasion (30 months, IQR 13–103).

Conclusion

Patients with lung cancer invading the intrapericardial space showed worse surgical outcomes in both overall and disease‐free survival. Therefore, surgical management should be carefully considered in patients with intrapericardial invasion.

Collaborative operation with cardiovascular surgeons in general thoracic surgery

OBJECTIVES

The aim of this study was to investigate the feasibility and safety of our surgical experiences conducted in collaboration with cardiovascular surgeons at our institution.

METHODS

From May 2002 to December 2015, among 3595 general thoracic surgeries, 75 (2.1%) operations were carried out collaboratively with cardiovascular surgeons at Nagoya University Hospital. We investigated the surgical procedures, manipulated organs, morbidity and mortality, completeness of surgical resection, and prognosis of these 75 cases.

RESULTS

The study cohort consisted of 56 males and 19 females, ranging in age from 18 to 79 years (median 60 years). Fifty-eight patients had a malignant disease, and 17 had a benign disease. Out of 75 collaborative surgeries, 53 (71%) were scheduled cases (cardiovascular surgeons' support was considered to be necessary preoperatively), and 22 (29%) were emergent cases (cardiovascular surgeons' support was considered to be necessary intraoperatively). No 30- or 90-day mortality was observed. Respiratory failure, defined as the requirement of mechanical ventilation or non-invasive positive pressure ventilation for ≥5 days, was the most common morbidity (n = 14, 18%). Forty-three patients (78%) out of 55 with thoracic neoplasms achieved microscopic complete resection. The resection status of the remaining 12 (22%) was microscopic residual tumor.

CONCLUSION

Collaborative surgeries with cardiovascular surgeons at our institution were feasible. High-quality surgeries with a good balance between safety and completeness of resection are important not only for treatment, but also in terms of education for general thoracic surgeons.

Clinic application of tissue engineered bronchus for lung cancer treatment

BACKGROUND

Delayed revascularization process and substitute infection remain to be key challenges in tissue engineered (TE) airway reconstruction. We propose an "in-vivo bioreactor" design, defined as an implanted TE substitutes perfused with an intra-scaffold medium flow created by an extracorporeal portable pump system for in situ organ regeneration. The perfusate keeps pre-seeded cells alive before revascularization. Meanwhile the antibiotic inside the perfusate controls topical infection.

METHODS

A stage IIIA squamous lung cancer patient received a 5-cm TE airway substitute, bridging left basal segment bronchus to carina, with the in-vivo bioreactor design to avoid left pneumonectomy. Continuous intra-scaffold Ringer's-gentamicin perfusion lasted for 1 month, together with orthotopic peripheral total nucleated cells (TNCs) injection twice a week.

RESULTS

The patient recovered uneventfully. Bronchoscopy follow-up confirmed complete revascularization and reepithelialization four months postoperatively. Perfusate waste test demonstrated various revascularization growth factors secreted by TNCs. The patient received two cycles of chemotherapy and 30 Gy radiotherapy thereafter without complications related to the TE substitute.

CONCLUSIONS

In-vivo bioreactor design combines the traditionally separated in vitro 3D cell-scaffold culture system and the in vivo regenerative processes associated with TE substitutes, while treating the recipients as bioreactors for their own TE prostheses. This design can be applied clinically. We also proved for the first time that TE airway substitute is able to tolerate chemo-radiotherapy and suitable to be used in cancer treatment.

Patterns of Failure After Surgery for Non-Small-cell Lung Cancer Invading the Chest Wall

INTRODUCTION

The patterns of failure after resection of non-small-cell lung cancer (NSCLC) invading the chest wall are not well documented, and the role of adjuvant radiation therapy (RT) is unclear, prompting the present analysis.

MATERIALS AND METHODS

The present institutional review board-approved study evaluated patients who had undergone surgery from 1995 to 2014 for localized NSCLC invading the chest wall. Patients with superior sulcus tumors were excluded. The clinical outcomes were estimated using the Kaplan-Meier method and compared using a log-rank test. The prognostic factors were assessed using a multivariate analysis, and the patterns of failure were scored.

RESULTS

Seventy-four patients were evaluated. Most patients had undergone lobectomy or pneumonectomy (85%) with en bloc chest wall resection (80%) and had pathologically node negative findings (81%). The surgical margins were positive in 10 patients (14%) and most commonly involved the chest wall (7 of 10). Adjuvant treatment included RT in 21 (28%) and chemotherapy in 28 (38%). A total of 24 local recurrences developed. The chest wall was a component of local disease recurrence in 19 of 24 cases (79%). The local control rate at 5 years for the entire population was 60% (95% confidence interval, 46%-74%). The local control rate was 74% with adjuvant RT versus 55% without RT (P = .43). On multivariate analysis, only resection less than lobectomy or pneumonectomy was associated with worse local control. The overall survival rate was 38% with RT versus 34% without RT (P = .59).

CONCLUSION

Positive surgical margins and local disease recurrence were common after resection of NSCLC invading the chest wall. The primary pattern of failure was local recurrence in the chest wall. Adjuvant RT was not associated with improved local control or survival.