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Kim BG, Jeong BH, Park G, Kim HK, Shim YM, Shin SH, Lee K, Um SW, Kim H, Cho JH. Clinical Effect of Endosonography on Overall Survival in Patients with Radiological N1 Non-Small Cell Lung Cancer. Cancer Res Treat 2024; 56:502-512. [PMID: 38062710 PMCID: PMC11016646 DOI: 10.4143/crt.2023.840] [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: 07/15/2023] [Accepted: 12/02/2023] [Indexed: 04/13/2024] Open
Abstract
PURPOSE It is unclear whether performing endosonography first in non-small cell lung cancer (NSCLC) patients with radiological N1 (rN1) has any advantages over surgery without nodal staging. We aimed to compare surgery without endosonography to performing endosonography first in rN1 on the overall survival (OS) of patients with NSCLC. MATERIALS AND METHODS This is a retrospective analysis of patients with rN1 NSCLC between 2013 and 2019. Patients were divided into 'no endosonography' and 'endosonography first' groups. We investigated the effect of nodal staging through endosonography on OS using propensity score matching (PSM) and multivariable Cox proportional hazard regression analysis. RESULTS In the no endosonography group, pathologic N2 occurred in 23.0% of patients. In the endosonography first group, endosonographic N2 and N3 occurred in 8.6% and 1.6% of patients, respectively. Additionally, 51 patients were pathologic N2 among 249 patients who underwent surgery and mediastinal lymph node dissection (MLND) in endosonography first group. After PSM, the 5-year OSs were 68.1% and 70.6% in the no endosonography and endosonography first groups, respectively. However, the 5-year OS was 80.2% in the subgroup who underwent surgery and MLND of the endosonography first group. Moreover, in patients receiving surgical resection with MLND, the endosonography first group tended to have a better OS than the no endosonography group in adjusted analysis using various models. CONCLUSION In rN1 NSCLC, preoperative endosonography shows better OS than surgery without endosonography. For patients with rN1 NSCLC who are candidates for surgery, preoperative endosonography may help improve survival through patient selection.
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Affiliation(s)
- Bo-Guen Kim
- Division of Pulmonary Medicine and Allergy, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Byeong-Ho Jeong
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Goeun Park
- Biomedical Statistics Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Korea
| | - Hong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Mog Shim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sun Hye Shin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyungjong Lee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang-Won Um
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hojoong Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Ho Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Tsai PC, Liu C, Yeh YC, Hsu PK, Huang CS, Hsieh CC, Hsu HS. Prognostic factors for recurrence-free survival in resected pathologic N2-stage III non-small cell lung cancer treated with upfront surgery. J Chin Med Assoc 2024; 87:212-218. [PMID: 38156883 DOI: 10.1097/jcma.0000000000001050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND The standard treatment for pathological N2 (pN2) non-small-cell lung cancer (NSCLC) patients is definitive chemoradiation. Surgery might be beneficial for resectable pN2 disease, so we investigated the recurrence-free interval of upfront surgery for selected patients with resectable pN2 disease. METHODS The clinicopathologic characteristics of patients with pN2 NSCLC who underwent upfront anatomical resection at Taipei Veterans General Hospital from 2011 January to 2019 December were retrospectively reviewed. A Cox regression model was used to identify prognostic factors of recurrence-free survival (RFS). RESULTS In total, 84 patients after curative lung anatomic resection were analyzed, with a 44-month median survival. The 1-, 3-, and 5-year RFS rates were 63.1%, 31.3%, and 19.9%, respectively, with a median RFS of 18.9 months. Multivariable cox regression analysis identified that the significant predictor for RFS was a tumor size of more than 3 cm (hazard ratio [HR] = 1.74, 95% CI, 1.07-2.83, p = 0.027). Visceral pleural invasion, LN harvest number, tumor stage, and N2 status including single zone (N2a) or multiple zones (N2b) were not prognostic factors in this study. CONCLUSION Upfront surgery for resectable N2 disease achieved favorable outcomes in selected patients, especially better recurrence control with limited tumor size. Therapeutic advances might encourage surgeons to aggressive intervention.
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Affiliation(s)
- Ping-Chung Tsai
- Division of Thoracic Surgery, Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- Department of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Chia Liu
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yi-Chen Yeh
- Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Po-Kuei Hsu
- Department of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chien-Sheng Huang
- Department of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chih-Cheng Hsieh
- Department of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Han-Shui Hsu
- Department of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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Hui WK, Charaf Z, Hendriks JMH, Van Schil PE. True Prevalence of Unforeseen N2 Disease in NSCLC: A Systematic Review + Meta-Analysis. Cancers (Basel) 2023; 15:3475. [PMID: 37444585 DOI: 10.3390/cancers15133475] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/25/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023] Open
Abstract
Patients with unforeseen N2 (uN2) disease are traditionally considered to have an unfavorable prognosis. As preoperative and intraoperative mediastinal staging improved over time, the prevalence of uN2 changed. In this review, the current evidence on uN2 disease and its prevalence will be evaluated. A systematic literature search was performed to identify all studies or completed, published trials that included uN2 disease until 6 April 2023, without language restrictions. The Newcastle-Ottawa Scale (NOS) was used to score the included papers. A total of 512 articles were initially identified, of which a total of 22 studies met the predefined inclusion criteria. Despite adequate mediastinal staging, the pooled prevalence of true unforeseen pN2 (9387 patients) was 7.97% (95% CI 6.67-9.27%), with a pooled OS after five years (892 patients) of 44% (95% CI 31-58%). Substantial heterogeneity regarding the characteristics of uN2 disease limited our meta-analysis considerably. However, it seems patients with uN2 disease represent a subcategory with a similar prognosis to stage IIb if complete surgical resection can be achieved, and the contribution of adjuvant therapy is to be further explored.
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Affiliation(s)
- Wing Kea Hui
- Department of Thoracic and Vascular Surgery, University Hospital Antwerp, Drie Eikenstraat 655, 2650 Edegem, Belgium
| | - Zohra Charaf
- Department of Cardiothoracic Surgery, University Hospital Brussels, Laarbeeklaan 101, 1090 Jette, Belgium
| | - Jeroen M H Hendriks
- Department of Thoracic and Vascular Surgery, University Hospital Antwerp, Drie Eikenstraat 655, 2650 Edegem, Belgium
- ASTARC (Antwerp Surgical Training, Anatomy and Research Centre), University Hospital Antwerp, Drie Eikenstraat 655, 2650 Edegem, Belgium
| | - Paul E Van Schil
- Department of Thoracic and Vascular Surgery, University Hospital Antwerp, Drie Eikenstraat 655, 2650 Edegem, Belgium
- ASTARC (Antwerp Surgical Training, Anatomy and Research Centre), University Hospital Antwerp, Drie Eikenstraat 655, 2650 Edegem, Belgium
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Sezen CB, Kalafat CE, Doğru MV, Aker C, Erdogu V, Saydam O, Metin M. The effect of lymph node ratio on survival in non-small-cell lung cancer. Acta Chir Belg 2023; 123:36-42. [PMID: 34006183 DOI: 10.1080/00015458.2021.1932181] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the effect of prognostic factors and lymph node ratio (LNR) on survival in patients with resected non-small-cell lung cancer (NSCLC). METHODS Data from 421 patients with NSCLC who underwent complete resection between 2009 and 2015 were evaluated retrospectively. LNR was defined as the ratio of positive lymph nodes to the total number of lymph nodes removed. Associations between overall survival (OS) and LNR, node (N) status, and histopathologic status were evaluated. RESULTS The 5-year survival rate was 42.5% among all patients and 26.6% for patients aged 65 years or older. In the multivariate analysis, age ≥65 years, advanced-stage disease, non-squamous cell carcinomas, pN status, and having multiple-station pN2 and multiple-station pN1 disease were found to be poor prognostic factors (p < 0.05). There was no statistical difference in survival between patients with LNR (hazard ratio: 1.04, p = 0.45). CONCLUSION The results of our study indicate that pN stage, histopathologic type, pT stage, and geriatric age were the most important poor prognostic factors associated with survival after NSCLC resection. Although LNR is a factor associated with survival in gastrointestinal cancers, it did not impact survival in our study.
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Affiliation(s)
- Celal Bugra Sezen
- Department of Thoracic Surgery, Science of Health University, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul, Turkey
| | - Cem Emrah Kalafat
- Department of Thoracic Surgery, Science of Health University, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul, Turkey
| | - Mustafa Vedat Doğru
- Department of Thoracic Surgery, Science of Health University, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul, Turkey
| | - Cemal Aker
- Department of Thoracic Surgery, Science of Health University, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul, Turkey
| | - Volkan Erdogu
- Department of Thoracic Surgery, Science of Health University, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul, Turkey
| | - Ozkan Saydam
- Department of Thoracic Surgery, Science of Health University, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul, Turkey
| | - Muzaffer Metin
- Department of Thoracic Surgery, Science of Health University, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul, Turkey
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Erdoğu V, Çıtak N, Sezen CB, Kizir D, Tanrıkulu G, Doğru MV, Seyrek Y, Cansever L, Saydam Ö, Metin M. Survival impact of unexpected N2 in stage IIIB/N2 non-small cell lung cancer patients. Asian Cardiovasc Thorac Ann 2023; 31:238-243. [PMID: 36683332 DOI: 10.1177/02184923231151503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND We investigated the effect of unexpected N2 on survival in stage IIIB/N2 cases. METHODS We retrospectively analyzed 1803 non-small cell lung cancer patients between 2010 and 2016. There were 89 patients (4.9%) with unexpected N2 (pathological (p) IIIB/N2 group), whereas 49 patients (2.7%) with cN2 (clinical (c) IIIB/N2 group). Although pIIIB/N2 group underwent surgery followed by adjuvant therapy, the cIIIB/N2 group of patients had multimodality treatment including induction chemotherapy ± radiotherapy followed by surgery. RESULTS The five-year overall survival (OS) for all patients was 36.0% [median survival time (MST) 27.9 months], and disease-free survival (DFS) was 28.9% (MST, 18.2 months). The OS was 39.6% (MST: 34.4 months) and the median DFS time was 31.1% (Median: 23.1 months) in the pIIIB/N2 group, whereas it was 29.2% (MST: 23.0 months) for OS and 22% (median: 12.4 months) for DFS in the cIIIB/N2 group. There were no significant OS and DFS differences between the pIIIB/N2 group and the cIIIB/N2 group (p = 0.124 and p = 0.168, respectively). CONCLUSIONS In stage IIIB/N2 cases, the fact that N2 could not be detected preoperatively with minimally invasive or invasive methods and was detected in the pathological examination after surgery does not provide a survival advantage.
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Affiliation(s)
- Volkan Erdoğu
- Department of Thoracic Surgery, 147022Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Necati Çıtak
- Department of Thoracic Surgery, Dr Suat Seren Chest Diseases and Surgery Training and Research Hospital İzmir, Istanbul, Turkey
| | - Celal Buğra Sezen
- Department of Thoracic Surgery, 147022Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Dilekhan Kizir
- Department of Thoracic Surgery, 147022Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Gamze Tanrıkulu
- Department of Thoracic Surgery, 147022Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Mustafa Vedat Doğru
- Department of Thoracic Surgery, 147022Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Yunus Seyrek
- Department of Thoracic Surgery, 147022Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Levent Cansever
- Department of Thoracic Surgery, 147022Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Özkan Saydam
- Department of Thoracic Surgery, 147022Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Muzaffer Metin
- Department of Thoracic Surgery, 147022Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
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Hwangbo B, Park EY, Yang B, Lee GK, Kim TS, Kim HY, Kim MS, Lee JM. Long-Term Survival According to N Stage Diagnosed by Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in Non-Small Cell Lung Cancer. Chest 2021; 161:1382-1392. [PMID: 34896095 DOI: 10.1016/j.chest.2021.11.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 11/22/2021] [Accepted: 11/29/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the main procedure for mediastinal staging. However, long-term survival analyses according to cN stage diagnosed by EBUS-TBNA (abbreviated to eN stage) have not been reported. The value of EBUS-TBNA has not been assessed through an analysis of survival in false-negative EBUS-TBNA cases. RESEARCH QUESTIONS What is the prognostic impact of eN stage in non-small cell lung cancer (NSCLC)? What is the survival rate in false-negative EBUS-TBNA cases? STUDY DESIGN AND METHODS We retrospectively (January 2006-December 2011) reviewed the medical records of NSCLC patients who underwent EBUS-TBNA (± transesophageal approach) for initial staging (n=1,089). Mediastinoscopy was not performed for EBUS-TBNA negative cases. We performed 5-year survival analyses according to eN stage and treatment modality. Survival in false-negative EBUS cases was compared with that in pN0-1 patients, including 941 non-EBUS cases, during the same period. RESULTS Among 1,089 EBUS patients (eN0-1=681, eN2=314, eN3=94), we observed significant differences in survival between the eN stages [eN0-1 vs eN2; p <0.0001, eN2 vs eN3; p=0.0118, estimated 5-year overall survival (5YOS) rate: eN0-1=57.4%, eN2=23.2%, eN3=12.8%]. Surgery cases had better survival than non-surgery cases among eN0-1 and eN2 patients (eN0-1/surgery vs. eN0-1/no surgery; p<0.0001, eN2/surgery vs. eN2/no surgery; p<0.0001). Among eN0-1 patients, there were 55 false-negative cases (eN0-1/pN2-3, pN2=54, pN3=1). The 5YOS rates of pN0, pN1, and eN0-1/pN2-3 patients were 76.4%, 56.0% and 56.4%, respectively. eN0-1/pN2-3 patients had worse survival than pN0 patients (p=0.0061), whereas there was no significant difference compared with pN1 patients (p=0.9191). INTERPRETATIONS Long-term survival significantly differed according to eN stage in NSCLC, highlighting the importance of EBUS-TBNA in NSCLC staging. False-negative EBUS-TBNA cases had favorable survival which was similar to that of pN1 patients, which may provide a rationale for performing surgery after negative EBUS-TBNA results.
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Affiliation(s)
- Bin Hwangbo
- Division of Pulmonology, Center for Lung Cancer, National Cancer Center, Goyang, Korea.
| | - Eun Young Park
- Biostatistics Collaboration Team, Research Core Center, National Cancer Center, Goyang, Korea
| | - Bumhee Yang
- Division of Pulmonology, Center for Lung Cancer, National Cancer Center, Goyang, Korea; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Geon Kook Lee
- Department of Pathology, National Cancer Center, Goyang, Korea
| | - Tae Sung Kim
- Department of Nuclear Medicine, National Cancer Center, Goyang, Korea
| | - Hyae Young Kim
- Department of Radiology, Center for Lung Cancer, National Cancer Center, Goyang, Korea
| | - Moon Soo Kim
- Department of Thoracic Surgery, Center for Lung Cancer, National Cancer Center, Goyang, Korea
| | - Jong Mog Lee
- Department of Thoracic Surgery, Center for Lung Cancer, National Cancer Center, Goyang, Korea
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Rogasch JMM, Frost N, Bluemel S, Michaels L, Penzkofer T, von Laffert M, Temmesfeld-Wollbrück B, Neudecker J, Rückert JC, Ochsenreither S, Böhmer D, Amthauer H, Furth C. FDG-PET/CT for pretherapeutic lymph node staging in non-small cell lung cancer: A tailored approach to the ESTS/ESMO guideline workflow. Lung Cancer 2021; 157:66-74. [PMID: 33994197 DOI: 10.1016/j.lungcan.2021.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 04/23/2021] [Accepted: 05/01/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVES In patients with NSCLC, current ESTS and ESMO guidelines recommend invasive lymph node (LN) staging with EBUS-TBNA even if FDG-PET/CT is negative for mediastinal LNs if at least one of three risk factors is present (cN1, non-peripheral primary or primary >3 cm). Modified workflows to avoid unnecessary invasive procedures were evaluated. MATERIALS AND METHODS Monocentric retrospective analysis of pretherapeutic FDG-PET/CT in 247 patients with NSCLC (62 % male; age, 68 [43-88] years) using an analog or digital PET/CT scanner. PET windowing was standardized. LNs were positive if 'LN uptake > mediastinal blood pool' or short axis >10 mm. Surgery or EBUS-TBNA served as reference for diagnostic accuracy per LN station. In all patients with negative mediastinal LNs by PET/CT, LN histology from surgery was available. RESULTS Among 700 L N stations analyzed, 180 were malignant. Sensitivity and specificity of PET/CT per LN station were 93 % and 71 %. Following current guidelines, 76 patients with mediastinal negative PET/CT required confirmatory invasive staging. Only 5/76 patients had unexpected pN2 (all had adenocarcinoma). In a modified approach, confirmatory invasive staging was confined to patients with mediastinal negative PET/CT who showed all three risk factors. Using this modification, EBUS-TBNA could have been omitted in 62 (82 %) of the 76 patients who required EBUS-TBNA based on current recommendation. Among these 62 patients, only one patient had unsuspected pN2 (single-level) while the remaining 61 of 62 omitted EBUS-TBNA were deemed unnecessary because mediastinal LNs were confirmed to be negative. No multi-level pN2 would have been missed. CONCLUSION In the current analysis, 82 % of EBUS-TBNA procedures in patients with mediastinal negative PET/CT could have been omitted by modifying the current guideline workflow as proposed (i.e., restricting EBUS-TBNA in patients with cN0/1 to those with all three risk factors). This was consistent with different PET/CT scanners. Prospective confirmation is required.
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Affiliation(s)
- Julian M M Rogasch
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Nuclear Medicine, Augustenburger Platz 1, 13353 Berlin, Germany; Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, 10178 Berlin, Germany.
| | - Nikolaj Frost
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Infectious Diseases and Pulmonary Medicine, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Stephanie Bluemel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Nuclear Medicine, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Liza Michaels
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Nuclear Medicine, Augustenburger Platz 1, 13353 Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiology, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Tobias Penzkofer
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, 10178 Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiology, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Maximilian von Laffert
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Pathology, Charitéplatz 1, 10117 Berlin, Germany.
| | - Bettina Temmesfeld-Wollbrück
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Infectious Diseases and Pulmonary Medicine, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Jens Neudecker
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of General, Visceral, Vascular and Thoracic Surgery, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Jens-Carsten Rückert
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of General, Visceral, Vascular and Thoracic Surgery, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Sebastian Ochsenreither
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Hematology and Medical Oncology, Hindenburgdamm 30, 12203 Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité Comprehensive Cancer Center, Charitéplatz 1, 10115 Berlin, Germany.
| | - Dirk Böhmer
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology, Hindenburgdamm 30, 12203 Berlin, Germany.
| | - Holger Amthauer
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Nuclear Medicine, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Christian Furth
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Nuclear Medicine, Augustenburger Platz 1, 13353 Berlin, Germany.
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8
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IJsseldijk MA, Ten Broek RPG, Wiering B, Hekma E, de Roos MAJ. Oncological outcomes of unsuspected pN2 in patients with non-small-cell lung cancer: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2021; 32:727-736. [PMID: 33517373 DOI: 10.1093/icvts/ivaa334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 11/20/2020] [Accepted: 12/06/2020] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES Optimal treatment of stage IIIA (N2) non-small-cell lung cancer (NSCLC) is controversial. Guidelines advise induction therapy before surgical resection. A proportion of patients with cN0 NSCLC are postoperatively upstaged due to unsuspected N2 disease. Survival of unsuspected N2 NSCLC treated with surgery varies and technical feasibility of video-assisted thoracic surgery (VATS) is unknown. The purpose of this study was to assess prevalence and survival of unsuspected N2 NSCLC treated with thoracotomy or VATS. METHODS A systematic review and meta-analysis was performed of all available literatures through Pubmed, Cochrane, EMBASE, Web of Science, Trials registries and System for Information on Grey Literature (SIGLE) from 2000 to 2019. Outcomes of interest were prevalence, overall survival (OS) and disease-free survival of unsuspected N2 NSCLC. Secondary outcomes were number of harvested lymph nodes, postoperative complications and survival of unsuspected N2 NSCLC treated with VATS. RESULTS Seventeen studies with patients with clinical stage N0-1 and unsuspected pN2 NSCLC were included. Prevalence of unsuspected pN2 was 8.6%. Three- and 5-year OS was 58% [95% confidence interval (CI) 37-78%) (N = 4337] and 35% (95% CI 28-43%) (N = 4337). Three- and 5-y ear disease-free survival was 48% (95% CI 30-66%) (N = 109) and 35% (95% CI 24-46%) (N = 517). VATS resulted in a low complication rate with similar 5-year OS as thoracotomy. CONCLUSIONS In patients with cN0-1 NSCLC, a minority has unsuspected pN2 NSCLC. Even for these patients, 5-year OS and disease-free survival are reasonable. VATS with adequate lymph node dissection is the treatment of choice when in experienced hands. Adjuvant therapy should be provided in absence of relevant comorbidity.
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Affiliation(s)
- Michiel A IJsseldijk
- Division of Surgery, Radboud University Medical Center, Nijmegen, Netherlands.,Division of Surgery, Slingeland Ziekenhuis, Doetinchem, Netherlands
| | - Richard P G Ten Broek
- Division of Surgery, Radboud University Medical Center, Nijmegen, Netherlands.,Division of Surgery, Slingeland Ziekenhuis, Doetinchem, Netherlands
| | - Bastiaan Wiering
- Division of Surgery, Slingeland Ziekenhuis, Doetinchem, Netherlands
| | - Edo Hekma
- Division of Surgery, Rijnstate Hospital, Arnhem, Netherlands
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Sezen CB, Aksoy Y, Sonmezoglu Y, Citak N, Saydam O, Metin M. Prognostic factors for survival in patients with completely resected pN2 non-small-cell lung cancer. Acta Chir Belg 2021; 121:23-29. [PMID: 31437115 DOI: 10.1080/00015458.2019.1658355] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND This study examined the incidence of pathologic N2 (pN2) non-small-cell lung cancer (NSCLC) and prognostic factors affecting survival of these patients. METHODS A total of 119 patients who underwent surgery for NSCLC (lobectomy and pneumonectomy) between January 2008 and December 2016 were evaluated retrospectively. The patients with pN2 included in this study were assessed in two groups; single pN2 and multiple pN2. RESULTS The most common type of resection was lobectomy (56.3%). Ninety-four patients (79%) received adjuvant therapy. Eighty-six patients (72.3%) had single-station pN2 and 33 (27.7%) had multiple pN2. The 5-year survival rates were 29.3% overall, 38.6% in single-station pN2, and 11% in multiple-station pN2 (hazard ratio [HR]: 0.581, p = .037). There was no statistically significant difference in 5-year survival rates between patients with pN1N2 and those with pN0N2 involvement (39.1% vs. 37.1%) (p = .625). Not receiving adjuvant therapy was associated with poor survival prognosis (HR: 8.2 p < .001). The 5-year survival rate was 36.2% among patients with pN2 involvement with 2 or more positive lymph nodes and 19.5% among those with fewer than 2 positive lymph nodes (HR: 0.83, p = .463). CONCLUSIONS The most significant prognostic factors associated with survival were pN2 status. Non-skip metastases (pN1N2) and positive lymph node count were not associated with prognosis.
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Affiliation(s)
- Celal Bugra Sezen
- Department of Thoracic Surgery, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul, Turkey
| | - Yunus Aksoy
- Department of Thoracic Surgery, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul, Turkey
| | - Yasar Sonmezoglu
- Department of Thoracic Surgery, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul, Turkey
| | - Necati Citak
- Department of Thoracic Surgery, Bakırkoy Education and Research Hospital, Istanbul, Turkey
| | - Ozkan Saydam
- Department of Thoracic Surgery, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul, Turkey
| | - Muzaffer Metin
- Department of Thoracic Surgery, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul, Turkey
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Nasralla A, Lee J, Dang J, Turner S. Elevated preoperative CEA is associated with subclinical nodal involvement and worse survival in stage I non-small cell lung cancer: a systematic review and meta-analysis. J Cardiothorac Surg 2020; 15:318. [PMID: 33059696 PMCID: PMC7565320 DOI: 10.1186/s13019-020-01353-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/28/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The standard for clinical staging of lung cancer is the use of CT and PET scans, however, these may underestimate the burden of the disease. The use of serum tumor markers might aid in the detection of subclinical advanced disease. The aim of this study is to review the predictive value of tumor markers in patients with clinical stage I NSCLC. METHODS A comprehensive search was performed using the Medline, EMBASE, Scopus data bases. Abstracts included based on the following inclusion criteria: 1) adult ≥18 years old, 2) clinical stage I NSCLC, 3) Tumor markers (CEA, SCC, CYFRA 21-1), 4) further imaging or procedure, 5) > 5 patients, 6) articles in English language. The primary outcome of interest was utility of tumour markers for predicting nodal involvement and oncologic outcomes in patients with clinical stage I NSCLC. Secondary outcomes included sub-type of lung cancer, procedure performed, and follow-up duration. RESULTS Two hundred seventy articles were screened, 86 studies received full-text assessment for eligibility. Of those, 12 studies were included. Total of 4666 patients were involved. All studies had used CEA, while less than 50% used CYFRA 21-1 or SCC. The most common tumor sub-type was adenocarcinoma, and the most frequently performed procedure was lobectomy. Meta-analysis revealed that higher CEA level is associated with higher rates of lymph node involvement and higher mortality. CONCLUSION There is significant correlation between the CEA level and both nodal involvement and survival. Higher serum CEA is associated with advanced stage, and poor prognosis. Measuring preoperative CEA in patient with early stage NSCLC might help to identify patients with more advanced disease which is not detected by CT scans, and potentially identify candidates for invasive mediastinal lymph node staging, helping to select the most effective therapy for patients with potentially subclinical nodal disease. Further prospective studies are needed to standardize the use of CEA as an adjunct for NSCLC staging.
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Affiliation(s)
- Awrad Nasralla
- Division of General Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.
| | - Jeremy Lee
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Jerry Dang
- Division of General Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Simon Turner
- Division of Thoracic Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
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11
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Herb JN, Kindell DG, Strassle PD, Stitzenberg KB, Haithcock BE, Mody GN, Long JM. Trends and Outcomes in Minimally Invasive Surgery for Locally Advanced Non-Small-Cell Lung Cancer With N2 Disease. Semin Thorac Cardiovasc Surg 2020; 33:547-555. [PMID: 32979480 PMCID: PMC10715223 DOI: 10.1053/j.semtcvs.2020.09.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/08/2020] [Indexed: 11/11/2022]
Abstract
Few studies examine outcomes by surgical approach in non-small-cell lung cancer (NSCLC) with N2 disease. We examined time trends in surgical approach and outcomes among patients undergoing minimally invasive (MIS, robotic and video-assisted thoracoscopic surgery [VATS]) vs open lobectomy in this patient population. We performed a retrospective analysis of patients from the National Cancer Database diagnosed with clinical Stage IIIA-N2 NSCLC from 2010 to 2016. We examined the yearly proportion of MIS vs open resections. Multivariable regression was used to assess the association of surgical approach with length of stay, unplanned readmissions, 30-day and 90-day mortality. Multivariable Cox proportional hazards modeling was used to assess the association of surgical approach with 5-year overall mortality. We identified 5741 patients who underwent lobectomy for Stage IIIA-N2 NSCLC (459 robotic, 1403 VATS, 3879 open). From 2010 to 2016, the proportion of minimally invasive procedures increased from 20% to 45%. MIS patients, on average, stayed 1 day less in the hospital (95% confidence interval [CI] 0.7, 1.5) and had lower odds of 90-day (odds ratio [OR] 0.74; 95% CI 0.54, 0.99) and 5-year mortality (OR 0.82; 95% CI 0.75, 0.91), compared to open resections. There was no difference in odds of readmission by surgical approach (OR 0.97; 95% CI 0.71, 1.33). Among MIS procedures, robotic resections had lower odds of 90-day mortality (OR 0.42; 95% CI 0.18, 0.97) than VATS. Among patients undergoing lobectomy for locally advanced N2 NSCLC robotic and VATS techniques appear safe and effective compared to open surgery and may offer short- and long-term advantages.
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Affiliation(s)
- Joshua N Herb
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Daniel G Kindell
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Paula D Strassle
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Karyn B Stitzenberg
- Division of Surgical Oncology, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Benjamin E Haithcock
- Division of Cardiothoracic Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Gita N Mody
- Division of Cardiothoracic Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jason M Long
- Division of Cardiothoracic Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Keshava HB, Tan KS, Dycoco J, Livschitz J, Bott MJ, Huang J, Rusch VW, Isbell JM, Molena D, Bains MS, Jones DR, Rocco G. How Effective Is Neoadjuvant Therapy Followed by Surgery for Pathologic Single-Station N2 Non-Small Cell Lung Cancer? Semin Thorac Cardiovasc Surg 2020; 33:206-216. [PMID: 32853736 DOI: 10.1053/j.semtcvs.2020.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 08/20/2020] [Indexed: 12/17/2022]
Abstract
The optimal treatment strategy for pathologic single-station N2 (pN2a1) non-small cell lung cancer (NSCLC)-surgery first followed by adjuvant treatment (SF) or neoadjuvant therapy followed by surgery (NS)-remains unclear. We compared disease-free survival (DFS) and overall survival (OS) after NS versus SF for pN2a1 NSCLC. We retrospectively identified patients with pN2a1 NSCLC resected between 2000 and 2018. Patients in the SF group had cN0 disease and were treated with surgery before adjuvant chemotherapy; patients in the NS group had known preoperative nodal disease, cN2 disease, and were treated with neoadjuvant therapy before surgery. The matching-weights procedure was applied to generate a cohort with similar characteristics between groups. DFS and OS were calculated using the Kaplan-Meier approach and compared between groups using weighted log-rank test and Cox proportional hazards models. We identified 227 patients with pN2a1 disease: 121 treated with SF and 106 with NS. After the matching-weights procedure, 5- and 10-year DFS were 45% and 27% for SF versus 26% and 21% for NS (log-rank P = 0.056; hazard ratio [HR], 1.61; 95% confidence interval [CI], 0.98-2.65); 5- and 10-year OS were 49% and 30% for SF versus 43% and 20% for NS (log-rank P = 0.428; HR, 1.24; 95% CI, 0.67-2.28). SF and NS for pN2a1 NSCLC resulted in similar survival. A study comparing SF for known preresectional pN2a1 with occult pN2a1 disease could be a next step. Further investigation of SF for known N2a1 versus occult pN2a1 disease could power a clinical trial focused on N2a NSCLC.
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Affiliation(s)
- Hari B Keshava
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kay See Tan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joseph Dycoco
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jennifer Livschitz
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Matthew J Bott
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - James Huang
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Valerie W Rusch
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - James M Isbell
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniela Molena
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Manjit S Bains
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David R Jones
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Gaetano Rocco
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
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Brascia D, De Iaco G, Schiavone M, Panza T, Signore F, Geronimo A, Sampietro D, Montrone M, Galetta D, Marulli G. Resectable IIIA-N2 Non-Small-Cell Lung Cancer (NSCLC): In Search for the Proper Treatment. Cancers (Basel) 2020; 12:cancers12082050. [PMID: 32722386 PMCID: PMC7465235 DOI: 10.3390/cancers12082050] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 07/18/2020] [Accepted: 07/21/2020] [Indexed: 12/25/2022] Open
Abstract
Locally advanced non-small cell lung cancer accounts for one third of non-small cell lung cancer (NSCLC) at the time of initial diagnosis and presents with a wide range of clinical and pathological heterogeneity. To date, the combined multimodality approach involving both local and systemic control is the gold standard for these patients, since occult distant micrometastatic disease should always be suspected. With the rapid increase in treatment options, the need for an interdisciplinary discussion involving oncologists, surgeons, radiation oncologists and radiologists has become essential. Surgery should be recommended to patients with non-bulky, discrete, or single-level N2 involvement and be included in the multimodality treatment. Resectable stage IIIA patients have been the subject of a number of clinical trials and retrospective analysis, discussing the efficiency and survival benefits on patients treated with the available therapeutic approaches. However, most of them have some limitations due to their retrospective nature, lack of exact pretreatment staging, and the involvement of heterogeneous populations leading to the awareness that each patient should undergo a tailored therapy in light of the nature of his tumor, its extension and his performance status.
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Affiliation(s)
- Debora Brascia
- Thoracic Surgery Unit, Department of Organ Transplantation and Emergency, University Hospital of Bari, 70121 Bari, Italy; (D.B.); (G.D.I.); (M.S.); (T.P.); (F.S.); (A.G.); (D.S.)
| | - Giulia De Iaco
- Thoracic Surgery Unit, Department of Organ Transplantation and Emergency, University Hospital of Bari, 70121 Bari, Italy; (D.B.); (G.D.I.); (M.S.); (T.P.); (F.S.); (A.G.); (D.S.)
| | - Marcella Schiavone
- Thoracic Surgery Unit, Department of Organ Transplantation and Emergency, University Hospital of Bari, 70121 Bari, Italy; (D.B.); (G.D.I.); (M.S.); (T.P.); (F.S.); (A.G.); (D.S.)
| | - Teodora Panza
- Thoracic Surgery Unit, Department of Organ Transplantation and Emergency, University Hospital of Bari, 70121 Bari, Italy; (D.B.); (G.D.I.); (M.S.); (T.P.); (F.S.); (A.G.); (D.S.)
| | - Francesca Signore
- Thoracic Surgery Unit, Department of Organ Transplantation and Emergency, University Hospital of Bari, 70121 Bari, Italy; (D.B.); (G.D.I.); (M.S.); (T.P.); (F.S.); (A.G.); (D.S.)
| | - Alessandro Geronimo
- Thoracic Surgery Unit, Department of Organ Transplantation and Emergency, University Hospital of Bari, 70121 Bari, Italy; (D.B.); (G.D.I.); (M.S.); (T.P.); (F.S.); (A.G.); (D.S.)
| | - Doroty Sampietro
- Thoracic Surgery Unit, Department of Organ Transplantation and Emergency, University Hospital of Bari, 70121 Bari, Italy; (D.B.); (G.D.I.); (M.S.); (T.P.); (F.S.); (A.G.); (D.S.)
| | - Michele Montrone
- Medical Thoracic Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, 70121 Bari, Italy; (M.M.); (D.G.)
| | - Domenico Galetta
- Medical Thoracic Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, 70121 Bari, Italy; (M.M.); (D.G.)
| | - Giuseppe Marulli
- Thoracic Surgery Unit, Department of Organ Transplantation and Emergency, University Hospital of Bari, 70121 Bari, Italy; (D.B.); (G.D.I.); (M.S.); (T.P.); (F.S.); (A.G.); (D.S.)
- Correspondence: or
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14
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Chen CY, Wu BR, Chen CH, Cheng WC, Chen WC, Liao WC, Chen CY, Hsia TC, Tu CY. Prognostic Value of Tumor Size in Resected Stage IIIA-N2 Non-Small-Cell Lung Cancer. J Clin Med 2020; 9:jcm9051307. [PMID: 32370082 PMCID: PMC7290400 DOI: 10.3390/jcm9051307] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 12/25/2022] Open
Abstract
The eighth edition of the American Joint Committee on Cancer (AJCC) staging system for lung cancer was introduced in 2017 and included major revisions, especially of stage III. For the subgroup stage IIIA-N2 non-small-cell lung cancer (NSCLC), surgical resection remains controversial due to heterogeneous disease entity. The aim of this study was to evaluate the clinicopathologic features and prognostic factors of patients with completely resected stage IIIA-N2 NSCLC. We retrospectively evaluated 77 consecutive patients with pathologic stage IIIA-N2 NSCLC (AJCC eighth edition) who underwent surgical resection with curative intent in China Medical University Hospital between 2006 and 2014. Survival analysis was conducted, using the Kaplan–Meier method. Prognostic factors predicting overall survival (OS) and disease-free survival (DFS) were analyzed, using log-rank tests and multivariate Cox proportional hazards models. Of the 77 patients with pathologic stage IIIA-N2 NSCLC examined, 35 (45.5%) were diagnosed before surgery and 42 (54.5%) were diagnosed unexpectedly during surgery. The mean age of patients was 59 years, and the mean length of follow-up was 38.1 months. The overall one-, three-, and five-year OS rates were 91.9%, 61.3%, and 33.5%, respectively. Multivariate analysis showed that tumor size <3 cm (hazards ratio (HR): 0.373, p = 0.003) and video-assisted thoracoscopic surgery (VATS) approach (HR: 0.383, p = 0.014) were significant predictors for improved OS. For patients with surgically treated, pathologic stage IIIA-N2 NSCLC, tumor size <3 cm and the VATS approach seemed to be associated with better prognosis.
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Affiliation(s)
- Chih-Yu Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung 40447, Taiwan; (C.-Y.C.); (B.-R.W.); (C.-H.C.); (W.-C.C.); (W.-C.C.); (T.-C.H.); (C.-Y.T.)
- School of Medicine, China Medical University, Taichung 40402, Taiwan
| | - Bing-Ru Wu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung 40447, Taiwan; (C.-Y.C.); (B.-R.W.); (C.-H.C.); (W.-C.C.); (W.-C.C.); (T.-C.H.); (C.-Y.T.)
- School of Medicine, China Medical University, Taichung 40402, Taiwan
| | - Chia-Hung Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung 40447, Taiwan; (C.-Y.C.); (B.-R.W.); (C.-H.C.); (W.-C.C.); (W.-C.C.); (T.-C.H.); (C.-Y.T.)
- School of Medicine, China Medical University, Taichung 40402, Taiwan
| | - Wen-Chien Cheng
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung 40447, Taiwan; (C.-Y.C.); (B.-R.W.); (C.-H.C.); (W.-C.C.); (W.-C.C.); (T.-C.H.); (C.-Y.T.)
- School of Medicine, China Medical University, Taichung 40402, Taiwan
| | - Wei-Chun Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung 40447, Taiwan; (C.-Y.C.); (B.-R.W.); (C.-H.C.); (W.-C.C.); (W.-C.C.); (T.-C.H.); (C.-Y.T.)
- Department of Respiratory Therapy, China Medical University, Taichung 40402, Taiwan
- Hyperbaric oxygen therapy center, China Medical University Hospital, Taichung 40447, Taiwan
| | - Wei-Chih Liao
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung 40447, Taiwan; (C.-Y.C.); (B.-R.W.); (C.-H.C.); (W.-C.C.); (W.-C.C.); (T.-C.H.); (C.-Y.T.)
- School of Medicine, China Medical University, Taichung 40402, Taiwan
- Hyperbaric oxygen therapy center, China Medical University Hospital, Taichung 40447, Taiwan
- Correspondence: ; Tel.: +886-4-2205-2121 (ext. 4661)
| | - Chih-Yi Chen
- Department of Surgery, Chung Shan Medical University Hospital, Taichung 40201, Taiwan;
| | - Te-Chun Hsia
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung 40447, Taiwan; (C.-Y.C.); (B.-R.W.); (C.-H.C.); (W.-C.C.); (W.-C.C.); (T.-C.H.); (C.-Y.T.)
- Department of Respiratory Therapy, China Medical University, Taichung 40402, Taiwan
- Hyperbaric oxygen therapy center, China Medical University Hospital, Taichung 40447, Taiwan
| | - Chih-Yen Tu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung 40447, Taiwan; (C.-Y.C.); (B.-R.W.); (C.-H.C.); (W.-C.C.); (W.-C.C.); (T.-C.H.); (C.-Y.T.)
- School of Medicine, China Medical University, Taichung 40402, Taiwan
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Utility of FDG PET/CT for Preoperative Staging of Non-Small Cell Lung Cancers Manifesting as Subsolid Nodules With a Solid Portion of 3 cm or Smaller. AJR Am J Roentgenol 2019; 214:514-523. [PMID: 31846374 DOI: 10.2214/ajr.19.21811] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE. The objective of our study was to investigate the utility of FDG PET/CT for the preoperative staging of subsolid non-small cell lung cancers (NSCLCs) with a solid portion size of 3 cm or smaller. MATERIALS AND METHODS. We retrospectively enrolled 855 patients with pathologically proven NSCLCs manifesting as subsolid nodules with a solid portion of 3 cm or smaller on CT. We then compared the diagnostic performances of FDG PET/CT and chest CT for detecting lymph node (LN), intrathoracic, or distant metastases in patients who underwent preoperative chest CT and FDG PET/CT. After propensity score matching, we compared the diagnostic performance of FDG PET/CT in the group who underwent both chest CT and FDG PET/CT with that of chest CT in patients who did not undergo FDG PET/CT. RESULTS. There were LN metastases in 25 of 765 patients (3.3%) who underwent surgical LN dissection or biopsy and intrathoracic or distant metastasis in two of 855 patients (0.2%). For LN staging, FDG PET/CT showed a sensitivity of 44.0%, specificity of 81.5%, positive predictive value of 9.6%, negative predictive value of 97.0%, and accuracy of 79.9%, which were lower than those of chest CT for accuracy (p < 0.0001). FDG PET/CT could not accurately detect any intrathoracic or distant metastasis. After propensity score matching, the diagnostic accuracy for LN staging of FDG PET/CT in the group who underwent both CT and FDG PET/CT was lower than that of chest CT in the group who did not undergo FDG PET/CT (p = 0.002), and the diagnostic accuracy for intrathoracic and distant metastases was not different (p > 0.999). CONCLUSION. FDG PET/CT has limited utility in preoperatively detecting LN or distant metastasis in patients with subsolid NSCLCs with a solid portion size of 3 cm or smaller.
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Zhang S, Wang L, Lu F, Pei Y, Yang Y. [Correlation between Lymph Node Ratio and Clinicopathological Features and Prognosis of IIIa-N2 Non-small Cell Lung Cancer]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2019; 22:702-708. [PMID: 31771739 PMCID: PMC6885420 DOI: 10.3779/j.issn.1009-3419.2019.11.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND IIIa-N2 non-small cell lung cancer was significant different in survival, although N stage of lung cancer based on anatomic location of metastasis lymph node. Lymph node ratio considered of prognostic factor might be the evaluation index for IIIa-N2 non-small cell lung cancer prognosis. Therefore, the aim of the study was to evaluate the correlation between lymph node ratio and clinicopathological features and prognosis of IIIa-N2 non-small cell lung cancer prognosis. METHODS A total of 288 cases of pathological IIIa-N2 non-small cell lung cancer were enrolled who received radical resection at the Department of Thoracic Surgery II, Peking University Cancer Hospital from January 2006 to December 2016. The univariate analysis between clinicopathological variables and lymph node ratio used Pearson's chi-squared test. Cox regression was conducted to identify the independent prognosis factors for IIIa-N2 non-small cell lung cancer. RESULTS There were 139 cases in the lower lymph node ratio group, another 149 cases in the higher lymph node ratio group. Adenocarcinoma (χ²=5.924, P=0.015), highest mediastinal lymph node metastasis (χ²=46.136, P<0.001), multiple-number N2 metastasis (χ²=59.347, P<0.001), multiple-station N2 metastasis (χ²=77.387, P<0.001) and skip N2 lymph node metastasis (χ²=61.524, P<0.001) significantly impacted lymph node ratio. The total number of lymph node dissection was not correlated with the lymph node ratio (χ²=0.537, P=0.464). Cox regression analysis confirmed that adenocarcinoma (P=0.008), multiple-number N2 metastasis (P=0.025) and lymph node ratio (P=0.001) were the independent prognosis factors of disease free survival. The 5-year disease free survival was 18.1% in the higher lymph node ratio group, and 44.1% in the lower. Lymph node ratio was the independent prognosis factor of overall survival (P<0.001). The 5-year overall survival was 36.7% in the higher lymph node ratio group, and 64.1% in the lower. CONCLUSIONS Lymph node ratio was correlative with the pathology, highest mediastinal lymph node metastasis, multiple-number N2 metastasis, multiple-station N2 metastasis and skip N2 lymph node metastasis. Lymph node ratio was the independent prognosis factor for IIIa-N2 non-small cell lung cancer.
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Affiliation(s)
- Shanyuan Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Thoracic Surgery II, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Liang Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Thoracic Surgery II, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Fangliang Lu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Thoracic Surgery II, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Yuquan Pei
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Thoracic Surgery II, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Yue Yang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Thoracic Surgery II, Peking University Cancer Hospital and Institute, Beijing 100142, China
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Kim MP, Swisher SG. Heterogeneity of stage IIIA leads to difficulty in determining optimal treatment. J Thorac Dis 2019; 11:S2043-S2045. [PMID: 31632824 DOI: 10.21037/jtd.2019.08.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Min P Kim
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Stephen G Swisher
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Chen B, Xia W, Wang Z, Zhao H, Li X, Liu L, Liu Y, Hu J, Fu X, Li Y, Xu Y, Liu D, Yang H, Xu L, Jiang F. Risk analyses of N2 lymph-node metastases in patients with T1 non-small cell lung cancer: a multi-center real-world observational study in China. J Cancer Res Clin Oncol 2019; 145:2771-2777. [PMID: 31428933 DOI: 10.1007/s00432-019-03006-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 08/16/2019] [Indexed: 02/05/2023]
Abstract
PURPOSE N2 lymph-node metastases occur in approximately 6-17% of the patients with T1-2 non-small cell lung cancer (NSCLC). However, the clinical characteristics of N2 patients are not fully understood. METHODS This retrospective, multi-center analysis included T1 NSCLC patients receiving surgical resection during a period from Jan 2nd, 2014 to Dec 27th, 2017. The diagnosis was pathologically verified in all cases. Univariate and multivariate logistic regression analyses were conducted to analyze the factors that are associated with pN2 lymph-node metastases. RESULTS A total of 10,885 patients (48.4% men; 84.7% adenocarcinoma) were included in the analysis. The mean age was 59.0 ± 9.9 years. The mean tumor size was 1.8 ± 0.8 cm. Of the patients, 3260 (29.9%) were smokers or ex-smokers. Lymph-node metastases were verified in 1808 (16.6%) patients, and 1167 (10.7%) patients had N2 lymph-node metastases. The multivariate analyses indicated that larger tumor size, lower differentiation, CEA level ≥ 5 ng/mL, vascular invasion (+), and pleural involvement (+) were associated with higher percentages of N2 lymph-node metastases (p < 0.001 for all). CONCLUSIONS This study demonstrated the significant association between N2 lymph-node metastases and tumor size and differentiation, CEA levels, and status of vascular invasion and pleural involvement.
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Affiliation(s)
- Bing Chen
- Department of Thoracic Surgery, Nanjing Medical University Affiliated Cancer Hospital, No.42, Baiziting, Xuanwu District, Nanjing, 210009, Jiangsu, China
- Department of Thoracic Surgery, Jiangsu Cancer Hospital and Jiangsu Institute of Cancer Research, Nanjing, 210009, China
- Jiangsu Key Laboratory of Molecular and Translational Cancer Research, Cancer Institute of Jiangsu Province, Nanjing, 210009, China
| | - Wenjie Xia
- Department of Thoracic Surgery, Nanjing Medical University Affiliated Cancer Hospital, No.42, Baiziting, Xuanwu District, Nanjing, 210009, Jiangsu, China
- Department of Thoracic Surgery, Jiangsu Cancer Hospital and Jiangsu Institute of Cancer Research, Nanjing, 210009, China
- Jiangsu Key Laboratory of Molecular and Translational Cancer Research, Cancer Institute of Jiangsu Province, Nanjing, 210009, China
| | - Zhongqiu Wang
- Department of Thoracic Surgery, Nanjing Medical University Affiliated Cancer Hospital, No.42, Baiziting, Xuanwu District, Nanjing, 210009, Jiangsu, China
- Department of Thoracic Surgery, Jiangsu Cancer Hospital and Jiangsu Institute of Cancer Research, Nanjing, 210009, China
| | - Heng Zhao
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai, 200030, China
| | - Xiaofei Li
- Department of Thoracic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, China
| | - Lunxu Liu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yang Liu
- Department of Thoracic Surgery, Chinese People's Liberation Army General Hospital, Beijing, 1000853, China
| | - Jian Hu
- Department of Thoracic Surgery, First Hospital Affiliated to Medical College of Zhejiang University, Hangzhou, 310000, China
| | - Xiangning Fu
- Department of Thoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Yin Li
- Department of Thoracic Surgery, Henan Cancer Hospital, Zhengzhou, 450008, China
| | - Yijun Xu
- Department of Thoracic Surgery, Tianjin Chest Hospital, Tianjin, 300051, China
| | - Deruo Liu
- Department of Thoracic Surgery, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Haiying Yang
- Medical Affairs, Linkdoc Technology Co, Ltd, Beijing, 100080, China
| | - Lin Xu
- Department of Thoracic Surgery, Nanjing Medical University Affiliated Cancer Hospital, No.42, Baiziting, Xuanwu District, Nanjing, 210009, Jiangsu, China.
- Department of Thoracic Surgery, Jiangsu Cancer Hospital and Jiangsu Institute of Cancer Research, Nanjing, 210009, China.
- Jiangsu Key Laboratory of Molecular and Translational Cancer Research, Cancer Institute of Jiangsu Province, Nanjing, 210009, China.
| | - Feng Jiang
- Department of Thoracic Surgery, Nanjing Medical University Affiliated Cancer Hospital, No.42, Baiziting, Xuanwu District, Nanjing, 210009, Jiangsu, China.
- Department of Thoracic Surgery, Jiangsu Cancer Hospital and Jiangsu Institute of Cancer Research, Nanjing, 210009, China.
- Jiangsu Key Laboratory of Molecular and Translational Cancer Research, Cancer Institute of Jiangsu Province, Nanjing, 210009, China.
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Induction Therapies Plus Surgery Versus Exclusive Radiochemotherapy in Stage IIIA/N2 Non-Small Cell Lung Cancer (NSCLC). Am J Clin Oncol 2019; 41:267-273. [PMID: 29116951 DOI: 10.1097/coc.0000000000000416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
In spite of the growing body of data from prospective randomized clinical trials (PRCTs) and meta-analyses, the optimal treatment approach in patients with stage IIIA non-small cell lung cancer remains unknown. This review focuses on the available data directly confronting induction chemotherapy or induction radiochemotherapy (RT-CHT) when followed by surgery with exclusive RT-CHT. Seven PRCTs and 4 meta-analyses investigated this issue. In addition, numerous retrospective studies attempted to identify potential predictors and/or prognosticators that may have influenced the decision to offer surgery in a particular patient subgroup. Several retrospective studies also evaluated exclusive RT-CHT in this setting. There is not a single piece of the highest level of evidence (PRCT or MA) showing any advantage of induction therapies followed by surgery over exclusive RT-CHT with the former treatment option leading to significantly more morbidity and mortality. Although several studies attempted to identify patient subgroups favoring induction therapies followed by surgery, they have invariably been retrospective in nature, and their results have never been reproduced even in other retrospective setting. Furthermore, no PRCT investigated potential pretreatment patient and/or tumor-related predictors of surgical multimodality success. Exclusive RT-CHT achieves similar results to induction therapies followed by surgery but with less morbidity and mortality. This is accompanied with the finding that no pretreatment predictor exists to enable identification of even a subgroup of stage IIIA/pN2 patients benefiting from any surgical approach.
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20
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Hofmann HS, Braess J, Leipelt S, Allgäuer M, Klinkhammer-Schalke M, Szoeke T, Grosser C, Pfeifer M, Ried M. Multimodality therapy in subclassified stage IIIA-N2 non-small cell lung cancer patients according to the Robinson classification: heterogeneity and management. J Thorac Dis 2018; 10:3585-3594. [PMID: 30069356 DOI: 10.21037/jtd.2018.05.203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Non-small cell lung cancer (NSCLC) with mediastinal lymph node involvement (N2) is a heterogeneous entity. The objective of this analysis is to investigate the results of treatment strategies for N2-positive patients. Methods Retrospective study (2009-2014) of 104 consecutive patients with stage IIIA-N2 NSCLC classified according to the Robinson classification (IIIA1-IIIA4) and treated within a multimodality treatment regime. Results The Robinson subgroups were: IIIA1 (n=27), IIIA3 (n=60) and IIIA4 (n=17). We had no stage IIIA2 samples because we did not perform an intraoperative frozen section of lymph nodes. Surgical resection with systematic lymph node dissection was performed in all patients with stage IIIA1 (n=27). After chemotherapy or chemo-/radiotherapy, 53.3% of patients in stage IIIA3 (n=32) and 11.7% of patients in stage IIIA4 (n=2) underwent surgery with curative intention. R0 was achieved in 92.6% in stage IIIA1, 93.8% in stage IIIA3 and 100% in stage IIIA4. The 30-day mortality was 3.2%. The overall median survival was 31.7 months (5-year survival was 30.5%). There were no significant differences (P=0.583) in survival regarding the Robinson subgroups. Patients who underwent tumour resection had significantly better median survival (39.8 vs. 19.6 months; P=0.014) compared to patients treated conservatively. Deviation from the interdisciplinary recommended therapy (12%) led to a reduced median survival (11.4 vs. 31.8 months; P=0.137). Conclusions N2-patients should be subclassified according to the Robinson classification and discussed in the tumour board. Surgical resection should be recommended in specific cases of N2-disease (non-bulky, sensitivity to systemic treatment).
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Affiliation(s)
- Hans-Stefan Hofmann
- Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Prüfeninger Straße 86, 93049 Regensburg, Germany.,Department of Thoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Jan Braess
- Department of Oncology and Hematology, Hospital Barmherzige Brüder Regensburg, Prüfeninger Straße 86, 93049 Regensburg, Germany
| | - Susanne Leipelt
- Department of Oncology and Hematology, Hospital Barmherzige Brüder Regensburg, Prüfeninger Straße 86, 93049 Regensburg, Germany
| | - Michael Allgäuer
- Department of Radiotherapy, Hospital Barmherzige Brüder Regensburg, Prüfeninger Straße 86, 93049 Regensburg, Germany
| | | | - Tamas Szoeke
- Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Prüfeninger Straße 86, 93049 Regensburg, Germany
| | - Christian Grosser
- Department of Thoracic Surgery, Hospital Barmherzige Brüder Regensburg, Prüfeninger Straße 86, 93049 Regensburg, Germany
| | - Michael Pfeifer
- Department of Pneumology, Hospital Barmherzige Brüder Regensburg, Prüfeninger Straße 86, 93049 Regensburg, Germany
| | - Michael Ried
- Department of Thoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
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Shafique MR, Robinson LA, Antonia S. Durvalumab: a potential maintenance therapy in surgery-ineligible non-small-cell lung cancer. Cancer Manag Res 2018; 10:931-940. [PMID: 29760563 PMCID: PMC5937504 DOI: 10.2147/cmar.s148009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Lung cancer is the most common cancer worldwide and the most common cause of cancer-related death. Non-small-cell lung cancer comprises ~87% of newly diagnosed cases of lung cancer, and nearly one-third of these patients have stage III disease. Despite improvements in the treatment of stage IV lung cancer, particularly with the introduction and dissemination of checkpoint inhibitors, very little progress has been made in the treatment of stage III lung cancer. In this article, we discuss the general staging criteria and treatment options for stage III lung cancer. We review how concurrent radiation and chemotherapy can have immunomodulatory effects, supporting the rationale for incorporating immunotherapy into existing treatment paradigms. Finally, we discuss the results of the PACIFIC trial and implications for the treatment of stage III lung cancer. In the PACIFIC trial, adding durvalumab as a maintenance therapy following the completion of chemoradiotherapy improved progression-free survival in patients with locally advanced unresectable stage III lung cancer. On the strength of these results, durvalumab has been approved by the US Food and Drug Administration for use in this setting, representing the first advance in the treatment of stage III lung cancer in nearly a decade.
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Affiliation(s)
- Michael R Shafique
- Department of Thoracic Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Lary A Robinson
- Department of Thoracic Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Scott Antonia
- Department of Thoracic Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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22
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Jones CM, Brunelli A, Callister ME, Franks KN. Multimodality Treatment of Advanced Non-small Cell Lung Cancer: Where are we with the Evidence? CURRENT SURGERY REPORTS 2018; 6:5. [PMID: 29456881 PMCID: PMC5805813 DOI: 10.1007/s40137-018-0202-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW The majority of patients with non-small cell lung cancer (NSCLC) present with advanced disease and overall survival rates are poor. This article outlines the current and outstanding evidence for the use of multimodality treatment in this group of patients, including in combination with an increasing number of treatment options, such as immunotherapy and genotype-targeted small molecule inhibitors. RECENT FINDINGS Optimal therapy for surgically resectable stage III disease remains debatable and currently the choice of treatment reflects each individual patient's disease characteristics and the expertise and opinion of the thoracic multi-disciplinary team. Evidence for a distinct oligometastatic state in which improved outcomes can be achieved remains minimal and there is as yet no consensus definition for oligometastatic lung cancer. Whilst there is supporting evidence for the aggressive management of isolated metastases, the use of consolidative therapy for multiple metastases remains unproven. SUMMARY Evolution of new RT technologies, improved surgical technique and a plethora of interventional-radiology-guided ablative therapies are widening the choice of available treatment modalities to patients with NSCLC. In the setting of resectable locally advanced disease and the oligometastatic state, there is a growing need for randomised comparison of the available treatment modalities to guide both treatment and patient selection.
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Affiliation(s)
- Christopher M. Jones
- Leeds Institute of Cancer & Pathology, Faculty of Medicine & Health, University of Leeds, Leeds, UK
- Radiotherapy Research Group, Leeds Cancer Centre, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
- School of Molecular & Cellular Biology, Faculty of Biological Sciences, University of Leeds, Leeds, UK
| | - Alessandro Brunelli
- Department of Thoracic Surgery, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Matthew E. Callister
- Department of Respiratory Medicine, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kevin N. Franks
- Leeds Institute of Cancer & Pathology, Faculty of Medicine & Health, University of Leeds, Leeds, UK
- Radiotherapy Research Group, Leeds Cancer Centre, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
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23
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Kowalewski J, Szczęsny TJ. Is single-station N2 disease on PET-CT an indication for primary surgery in lung cancer patients? J Thorac Dis 2017; 9:4828-4831. [PMID: 29312668 DOI: 10.21037/jtd.2017.10.154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Janusz Kowalewski
- Department of Thoracic Surgery and Tumours, Faculty of Medicine, Nicolaus Copernicus University in Torun, Torun, Poland.,Department of Thoracic Surgery and Tumours, Oncology Centre, Bydgoszcz, Poland
| | - Tomasz J Szczęsny
- Department of Thoracic Surgery and Tumours, Faculty of Medicine, Nicolaus Copernicus University in Torun, Torun, Poland.,Department of Thoracic Surgery and Tumours, Oncology Centre, Bydgoszcz, Poland
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24
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Honguero Martínez A, García Jiménez M, García Vicente A, Genovés Crespo M, Rodríguez Ortega C, Lázaro Sahuquillo M, Soriano Castrejón Á, León Atance P. Is the prognosis of occult N2 disease similar to that of positive positron emission tomography-computed tomography (PET/CT) scan single-station N2 disease in patients with non-small cell lung cancer treated by surgical resection? Rev Esp Med Nucl Imagen Mol 2017. [DOI: 10.1016/j.remnie.2017.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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25
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Is the prognosis of occult N2 disease similar to that of positive positron emission tomography-computed tomography (PET/CT) scan single-station N2 disease in patients with non-small cell lung cancer treated by surgical resection? Rev Esp Med Nucl Imagen Mol 2017; 36:350-355. [PMID: 28552624 DOI: 10.1016/j.remn.2017.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 03/20/2017] [Accepted: 03/27/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVE A retrospective study, using a prospective database, was conducted on patients treated with surgery in order to analyze the prognosis between two groups: NSCLC (non-small cell lung cancer) patients with occult N2 disease and patients with single station N2 disease observed on pre-operative integrated PET/CT scan. METHODS A total of 772 patients underwent surgical treatment for lung cancer from January 2007 to December 2014. All of them had an integrated PET/CT scan in the pre-operative work-up and a pulmonary resection plus mediastinal lymphadenectomy were performed in all cases. In the selected cases, no one received induction treatment. All patients from both groups had N2 disease after examination of the histopathology specimen. Clinical and pathological characteristics, disease free survival, and overall survival, were analyzed in both groups. RESULTS A total of 34 cases presented occult N2 disease, whereas 11 cases showed single station N2 disease on pre-operative PET/CT scan. Mean disease free survival and mean overall survival for occult N2 disease compared to single-station N2 disease on PET/CT scan was 36.0 months (95% CI: 24.9-47.1) and 38.9 months (95% CI: 20.6-57.1), p=.586; and 52.3 months (95% CI: 38.9-65.7) and 38.2 months (95% CI: 21.9-54.5), p=.349, respectively. CONCLUSION The prognosis of patients with single-station N2 disease on PET/CT scan treated by surgical resection and mediastinal lymphadenectomy as first line treatment was similar to those with occult N2 disease. More studies are needed to support our findings.
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Tian D, Pei Y, Zheng Q, Zhang J, Li S, Wang X, Lin D, Yang Y. Effect of visceral pleural invasion on the prognosis of patients with lymph node negative non-small cell lung cancer. Thorac Cancer 2017; 8:97-105. [PMID: 28256095 PMCID: PMC5334291 DOI: 10.1111/1759-7714.12412] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 12/14/2016] [Accepted: 12/15/2016] [Indexed: 11/06/2022] Open
Abstract
Background Visceral pleural invasion (VPI) is an adverse prognostic factor in non‐small cell lung cancer (NSCLC); however, its effect in relation to tumor size remains under debate. To better understand the prognostic impact and potential consequences for staging, we examined correlations between VPI and clinicopathologic characteristics in patients with NSCLC, particularly those with lymph node negative NSCLC. Methods We retrospectively analyzed 813 cases of radically resected NSCLC treated in our institution between December 2005 and December 2011. Patients were divided into two groups according to VPI status to compare their clinicopathologic characteristics. Survival analysis was performed in 521 cases with pN0 NSCLC. Results VPI was diagnosed in 379 (46.6%) cases. It was more common in women, patients with non‐squamous cell carcinoma, elevated preoperative serum carcinoembryonic antigen levels, moderately or poorly differentiated tumors, and larger‐sized tumors. The incidence of mediastinal lymph node metastasis, particularly multi‐station metastasis, was higher in patients with VPI. Patients with pN0 NSCLC, 2–3 cm tumors, and VPI had a significantly poorer prognosis (VPI vs. non‐VPI: five‐year overall survival 78.3% vs. 84.5%, P = 0.039; five‐year disease‐free survival 69.2% vs. 80.0%, P = 0.046, respectively); however, no significant effect was observed for tumors ≤2, 3–5, and 5–7 cm. P‐N0 patients with VPI had a significantly higher incidence of postoperative local recurrence and distant metastasis than those without VPI (P = 0.01), especially ipsilateral pleural recurrence. Conclusion VPI was an adverse prognostic factor in radically resected pN0 NSCLC, especially for tumors 2–3 cm in size.
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Affiliation(s)
- Dan Tian
- Department of Thoracic Surgery, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yuquan Pei
- Department of Thoracic Surgery II, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University School of Oncology, Beijing Cancer Hospital and Institute, Beijing, China
| | - Qingfeng Zheng
- Department of Thoracic Surgery II, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University School of Oncology, Beijing Cancer Hospital and Institute, Beijing, China
| | - Jianzhi Zhang
- Department of Thoracic Surgery II, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University School of Oncology, Beijing Cancer Hospital and Institute, Beijing, China
| | - Shaolei Li
- Department of Thoracic Surgery II, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University School of Oncology, Beijing Cancer Hospital and Institute, Beijing, China
| | - Xing Wang
- Department of Thoracic Surgery II, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University School of Oncology, Beijing Cancer Hospital and Institute, Beijing, China
| | - Dongmei Lin
- Department of Pathology, Peking University School of Oncology, Beijing Cancer Hospital and Institute, Beijing, China
| | - Yue Yang
- Department of Thoracic Surgery II, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University School of Oncology, Beijing Cancer Hospital and Institute, Beijing, China
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27
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Lin J. Hecate: The many faces of N2 disease. J Thorac Cardiovasc Surg 2016; 152:1464-1465. [PMID: 27751251 DOI: 10.1016/j.jtcvs.2016.07.050] [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: 07/22/2016] [Accepted: 07/25/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Jules Lin
- Section of Thoracic Surgery, Department of Surgery, University of Michigan Medical Center, Ann Arbor, Mich
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28
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Rocco G, Nason K, Brunelli A, Varela G, Waddell T, Jones DR. Management of stage IIIA (N2) non–small cell lung cancer: A transatlantic perspective. J Thorac Cardiovasc Surg 2016; 151:1235-8. [DOI: 10.1016/j.jtcvs.2016.01.035] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 01/07/2016] [Indexed: 12/25/2022]
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Pawełczyk K, Marciniak M, Błasiak P. Evaluation of new classifications of N descriptor in non-small cell lung cancer (NSCLC) based on the number and the ratio of metastatic lymph nodes. J Cardiothorac Surg 2016; 11:68. [PMID: 27079794 PMCID: PMC4832480 DOI: 10.1186/s13019-016-0456-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 04/05/2016] [Indexed: 11/17/2022] Open
Abstract
Background The aim of the study was to evaluate the prognostic power of new classifications of N descriptor created basing on the number (NLN) and the ratio of metastatic lymph nodes (RLN) in NSCLC compared to the current classification (CLN). Methods The data of 529 patients with NSCLC operated with the intention of radical resection, were analyzed. The new categories of N descriptor were created as follows: 1) NLN - median number of metastatic nodes was 3, thus in NLN0 the number of metastatic nodes =0, in NLN1 1-2, in NLN2 ≥ 3, 2) RLN - median ratio (number of metastatic lymph nodes to all nodes removed) was 12.4 %, thus in RLN0 the ratio was 0, in RLN1 < 13 %, in RLN2 > 13 %. The prognostic value of each classification was calculated on the basis of hazard ratios defined in multivariate Cox proportional hazard model. Results The new classifications of N descriptor turned out to be an independent strong prognostic factor (p <0.001) with a 5-year survival rate NLN0-62 %, NLN1-39 %, NLN2-26 % and RLN0-62 %, RLN1-37 % and RLN2-26 %. For 5-year survival rates in CLN0-62 %, CLN1-42 %, CLN2-24 % (p < 0.001), a higher prognostic value of new classifications was not demonstrated, the hazard ratio amounted to 2.22, 2.08, 2.49 for NLN2, RLN2 and CLN2 respectively. Conclusion Despite the significantly high prognostic power, the new classifications cannot be considered superior over CLN. There are some deficiencies in the current classification, therefore further studies on its improvement are needed.
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Affiliation(s)
- Konrad Pawełczyk
- Department of General Thoracic Surgery, Wroclaw Thoracic Surgery Centre, Wroclaw Medical University, Wroclaw, Poland.
| | - Marek Marciniak
- Department of General Thoracic Surgery, Wroclaw Thoracic Surgery Centre, Wroclaw Medical University, Wroclaw, Poland
| | - Piotr Błasiak
- Department of General Thoracic Surgery, Wroclaw Thoracic Surgery Centre, Wroclaw Medical University, Wroclaw, Poland
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Wang X, Yan S, Phan K, Yan TD, Zhang L, Yang Y, Wu N. Mediastinal lymphadenectomy fulfilling NCCN criteria may improve the outcome of clinical N0-1 and pathological N2 non-small cell lung cancer. J Thorac Dis 2016; 8:342-9. [PMID: 27076928 DOI: 10.21037/jtd.2016.02.49] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND This retrospective study investigated whether mediastinal lymphadenectomy compliant with the National Comprehensive Cancer Network (NCCN) criteria will improve the oncological outcomes of clinical early-stage lung cancer. METHODS From 2003-2010, 712 consecutive cases of clinical N0/1 were included for retrospective analysis, including 152 confirmed cases of pN2 and 560 of pN0-1 disease following surgery. Group A was defined as the cases fulfilling NCCN lymphadenectomy criteria (≥ three stations of N2 nodes dissection) and group B included all other cases. The groups were stratified according to pN status and the outcomes were assessed. RESULTS Five-year overall survival (OS) and 5-year disease-free survival (DFS) were significantly different between group A versus B [72%±2% vs. 63%±4% (OS), P=0.014; 58.0%±2% vs. 49%±4% (DFS), P=0.038] in the whole cohort. After stratification by pN status, this difference was remained in pN2 subgroup [50%±5% vs. 25%±9% (OS), P=0.006; 31.0%±4% vs. 13%±7% (DFS), P=0.014], but not in pN0-1 subgroups. Cox regression analysis showed that performing a lymphadenectomy fulfilling NCCN criteria was a significant prognostic factor for OS either in the whole cohort [P=0.003, hazard ratio (HR): 0.598, 95% confidence interval (CI): 0.425-0.841] or in patients of pN2 status (P=0.038, HR: 0.559, 95% CI: 0.323-0.968). Cases with ≥4 N2 stations dissected did not achieve better survival benefit compared to those harvesting 3 stations in cN0/1-pN2 group (P=0.152). CONCLUSIONS Mediastinal lymphadenectomy fulfilling NCCN criteria appears to improve the survival of unexpected N2 group (cN0/1-pN2) among early-stage lung cancer patients. More extended N2 node dissection may not further improve the outcome in this group.
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Affiliation(s)
- Xing Wang
- 1 Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China ; 2 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Shi Yan
- 1 Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China ; 2 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Kevin Phan
- 1 Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China ; 2 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Tristan D Yan
- 1 Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China ; 2 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Lijian Zhang
- 1 Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China ; 2 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Yue Yang
- 1 Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China ; 2 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Nan Wu
- 1 Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Thoracic Surgery II, Peking University Cancer Hospital & Institute, Beijing 100142, China ; 2 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
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31
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Rocco G, Nason K, Brunelli A, Varela G, Waddell T, Jones DR. Management of stage IIIA (N2) non-small-cell lung cancer: a transatlantic perspective†. Eur J Cardiothorac Surg 2016; 49:1025-7. [PMID: 26985072 PMCID: PMC4794446 DOI: 10.1093/ejcts/ezw040] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Gaetano Rocco
- Division of Thoracic Surgery, Istituto Nazionale Tumori, IRCCS, Naples, Italy
| | - Katie Nason
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alex Brunelli
- Division of Thoracic Surgery, St. James's University Hospital, Leeds, UK
| | - Gonzalo Varela
- Division of Thoracic Surgery, Salamanca University Hospital, Salamanca, Spain
| | - Thomas Waddell
- Division of Thoracic Surgery, University of Toronto, Toronto, ON, Canada
| | - David R Jones
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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32
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Rocco G, Nason K, Brunelli A, Varela G, Waddell T, Jones DR. Management of Stage IIIA (N2) Non-Small Cell Lung Cancer: A Transatlantic Perspective. Ann Thorac Surg 2016; 101:1247-50. [PMID: 26997577 DOI: 10.1016/j.athoracsur.2016.01.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 01/04/2016] [Accepted: 01/07/2016] [Indexed: 12/25/2022]
Affiliation(s)
- Gaetano Rocco
- Division of Thoracic Surgery, Istituto Nazionale Tumori, IRCCS, Naples, Italy
| | - Katie Nason
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alex Brunelli
- Division of Thoracic Surgery, St. James's University Hospital, Leeds, United Kingdom
| | - Gonzalo Varela
- Division of Thoracic Surgery, Salamanca University Hospital, Salamanca, Spain
| | - Thomas Waddell
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - David R Jones
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
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Kumar T, Jiwnani S, Karimundackal G, Pramesh CS. Issues in management of N2 disease in NSCLC. Ann Thorac Surg 2015; 99:744-5. [PMID: 25639431 DOI: 10.1016/j.athoracsur.2014.09.032] [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: 09/07/2014] [Revised: 09/07/2014] [Accepted: 09/19/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Tarun Kumar
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Mumbai 400012, India
| | - Sabita Jiwnani
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Mumbai 400012, India
| | - George Karimundackal
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Mumbai 400012, India
| | - C S Pramesh
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Mumbai 400012, India.
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Affiliation(s)
- Jacob A Klapper
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Chadrick E Denlinger
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC.
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35
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Rocco G. Invited commentary. Ann Thorac Surg 2014; 97:1925. [PMID: 24882281 DOI: 10.1016/j.athoracsur.2014.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 04/01/2014] [Accepted: 04/04/2014] [Indexed: 11/18/2022]
Affiliation(s)
- Gaetano Rocco
- Division of Thoracic Surgery, Department of Thoracic Surgery and Oncology, Istituto Nazionale Tumori, Fondazione Pascale, IRCCS, Via M Semmola, 81, Naples, Italy 80131.
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