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Kamtam DN, Shrager JB. We should be considering lung cancer screening for never-smoking Asian American females. J Thorac Cardiovasc Surg 2024; 168:272-277.e1. [PMID: 37844730 DOI: 10.1016/j.jtcvs.2023.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/06/2023] [Accepted: 10/11/2023] [Indexed: 10/18/2023]
Affiliation(s)
- Devanish N Kamtam
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Joseph B Shrager
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif; Department of Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif.
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Detterbeck FC, Ostrowski M, Hoffmann H, Rami-Porta R, Osarogiagbon RU, Donnington J, Infante M, Marino M, Marom EM, Nakajima J, Nicholson AG, van Schil P, Travis WD, Tsao MS, Edwards JG, Asamura H. The International Association for the Study of Lung Cancer Lung Cancer Staging Project: Proposals for Revision of the Classification of Residual Tumor After Resection for the Forthcoming (Ninth) Edition of the TNM Classification of Lung Cancer. J Thorac Oncol 2024; 19:1052-1072. [PMID: 38569931 DOI: 10.1016/j.jtho.2024.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 03/20/2024] [Accepted: 03/25/2024] [Indexed: 04/05/2024]
Abstract
INTRODUCTION The goal of surgical resection is to completely remove a cancer; it is useful to have a system to describe how well this was accomplished. This is captured by the residual tumor (R) classification, which is separate from the TNM classification that describes the anatomic extent of a cancer independent of treatment. The traditional R-classification designates as R0 a complete resection, as R1 a macroscopically complete resection but with microscopic tumor at the surgical margin, and as R2 a resection that leaves gross tumor behind. For lung cancer, an additional category encompasses situations in which the presence of residual tumor is uncertain. METHODS This paper represents a comprehensive review of evidence regarding these R categories and the descriptors thereof, focusing on studies published after the year 2000 and with adjustment for potential confounders. RESULTS Consistent discrimination between complete, uncertain, and incomplete resection is revealed with respect to overall survival. Evidence regarding specific descriptors is generally somewhat limited and only partially consistent; nevertheless, the data suggest retaining all descriptors but with clarifications to address ambiguities. CONCLUSION On the basis of this review, the R-classification for the ninth edition of stage classification of lung cancer is proposed to retain the same overall framework and descriptors, with more precise definitions of descriptors. These refinements should facilitate application and further research.
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Affiliation(s)
- Frank C Detterbeck
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.
| | - Marcin Ostrowski
- Department of Thoracic Surgery, Medical University of Gdansk, Gdansk, Poland
| | - Hans Hoffmann
- Division of Thoracic Surgery, Department of Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Ramón Rami-Porta
- Department of Thoracic Surgery, Hospital Universitari Mutua Terrassa, University of Barcelona, Terrassa, Barcelona, Spain
| | - Ray U Osarogiagbon
- Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
| | | | - Maurizio Infante
- Department of Thoracic Surgery, Ospedale Borgo Trento, Verona, Italy
| | - Mirella Marino
- Department of Pathology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Edith M Marom
- Department of Diagnostic Imaging, The Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Jun Nakajima
- Department of Thoracic Surgery, The University of Tokyo, Tokyo, Japan
| | - Andrew G Nicholson
- Department of Histopathology, Royal Brompton and Harefield NHS Hospitals, Guy's and St. Thomas' NHS Foundation Trust and National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Paul van Schil
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem (Antwerp), Belgium
| | - William D Travis
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Ming S Tsao
- Department of Pathology, The Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - John G Edwards
- Department of Cardiothoracic Surgery, Sheffield Teaching Hospitals National Health Service Foundation Trust, Northern General Hospital, Sheffield, United Kingdom
| | - Hisao Asamura
- Division of Thoracic Surgery, Keio School of Medicine, Tokyo, Japan
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Detterbeck FC, Blasberg JD, Woodard GA, Decker RH, Kumbasar U, Park HS, Mase VJ, Bade BC, Li AX, Brandt WS, Madoff DC. A guide for managing patients with stage I NSCLC: deciding between lobectomy, segmentectomy, wedge, SBRT and ablation-part 1: a guide to decision-making. J Thorac Dis 2022; 14:2340-2356. [PMID: 35813719 PMCID: PMC9264102 DOI: 10.21037/jtd-21-1823] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 04/21/2022] [Indexed: 12/02/2022]
Abstract
Background Clinical decision-making for patients with stage I lung cancer is complex. It involves multiple options (lobectomy, segmentectomy, wedge, Stereotactic Body Radiotherapy, thermal ablation), weighing multiple outcomes (e.g., short-, intermediate-, long-term) and multiple aspects of each (e.g., magnitude of a difference, the degree of confidence in the evidence, and the applicability to the patient and setting at hand). A structure is needed to summarize the relevant evidence for an individual patient and to identify which outcomes have the greatest impact on the decision-making. Methods Based on a systematic review from 2000-2021, evidence regarding relevant outcomes was assembled, with attention to aspects of applicability, uncertainty and effect modifiers. A framework was developed to present this information a format that enhances decision-making at the point of care for individual patients. Results While patients often cross over several boundaries, the evidence fits into categories of healthy patients, compromised patients, and favorable tumors. In healthy patients with typical (i.e., solid spiculated) lung cancers, the impact on long-term outcomes is the major driver of treatment selection. This is only slightly ameliorated in older patients. In compromised patients increasing frailty accentuates short-term differences and diminishes long-term differences especially when considering non-surgical vs. surgical approaches; nuances of patient selection (technical treatment feasibility, anticipated risk of acute toxicity, delayed toxicity, and long-term outcomes) as well as patient values are increasingly influential. Favorable (less-aggressive) tumors generally have good long-term outcomes regardless of the treatment approach. Discussion A framework is provided that organizes the evidence and identifies the major drivers of decision-making for an individual patient. This facilitates blending available evidence and clinical judgment in a flexible, nuanced manner that enhances individualized clinical care.
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Affiliation(s)
| | - Justin D. Blasberg
- Thoracic Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Gavitt A. Woodard
- Thoracic Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Roy H. Decker
- Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Ulas Kumbasar
- Thoracic Surgery, Hacettepe University School of Medicine, Ankara, Turkey
| | - Henry S. Park
- Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Vincent J. Mase
- Thoracic Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Brett C. Bade
- Pulmonary Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Andrew X. Li
- General Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Whitney S. Brandt
- Cardiothoracic Surgery, Washington University School of Medicine, St louis, MO, USA
| | - David C. Madoff
- Radiology & Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
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Bade BC, Blasberg JD, Mase VJ, Kumbasar U, Li AX, Park HS, Decker RH, Madoff DC, Brandt WS, Woodard GA, Detterbeck FC. A guide for managing patients with stage I NSCLC: deciding between lobectomy, segmentectomy, wedge, SBRT and ablation-part 3: systematic review of evidence regarding surgery in compromised patients or specific tumors. J Thorac Dis 2022; 14:2387-2411. [PMID: 35813753 PMCID: PMC9264070 DOI: 10.21037/jtd-21-1825] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 05/09/2022] [Indexed: 11/06/2022]
Abstract
Background Clinical decision-making for patients with stage I lung cancer is complex. It involves multiple options [lobectomy, segmentectomy, wedge, stereotactic body radiotherapy (SBRT), thermal ablation], weighing multiple outcomes (e.g., short-, intermediate-, long-term) and multiple aspects of each (e.g., magnitude of a difference, the degree of confidence in the evidence, and the applicability to the patient and setting at hand). A structure is needed to summarize the relevant evidence for an individual patient and to identify which outcomes have the greatest impact on the decision-making. Methods A PubMed systematic review from 2000-2021 of outcomes after lobectomy, segmentectomy and wedge resection in older patients, patients with limited pulmonary reserve and favorable tumors is the focus of this paper. Evidence was abstracted from randomized trials and non-randomized comparisons (NRCs) with adjustment for confounders. The analysis involved careful assessment, including characteristics of patients, settings, residual confounding etc. to expose degrees of uncertainty and applicability to individual patients. Evidence is summarized that provides an at-a-glance overall impression as well as the ability to delve into layers of details of the patients, settings and treatments involved. Results In older patients, perioperative mortality is minimally altered by resection extent and only slightly affected by increasing age; sublobar resection may slightly decrease morbidity. Long-term outcomes are worse after lesser resection; the difference is slightly attenuated with increasing age. Reported short-term outcomes are quite acceptable in (selected) patients with severely limited pulmonary reserve, not clearly altered by resection extent but substantially improved by a minimally invasive approach. Quality-of-life (QOL) and impact on pulmonary function hasn't been well studied, but there appears to be little difference by resection extent in older or compromised patients. Patient selection is paramount but not well defined. Ground-glass and screen-detected tumors exhibit favorable long-term outcomes regardless of resection extent; however solid tumors <1 cm are not a reliably favorable group. Conclusions A systematic, comprehensive summary of evidence regarding resection extent in compromised patients and favorable tumors with attention to aspects of applicability, uncertainty and effect modifiers provides a foundation for a framework for individualized decision-making.
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Affiliation(s)
- Brett C. Bade
- Department of Pulmonary Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Justin D. Blasberg
- Department of Thoracic Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Vincent J. Mase
- Department of Thoracic Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Ulas Kumbasar
- Department of Thoracic Surgery, Hacettepe University School of Medicine, Ankara, Turkey
| | - Andrew X. Li
- Department of General Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Henry S. Park
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Roy H. Decker
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - David C. Madoff
- Department of Radiology & Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Whitney S. Brandt
- Department of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Gavitt A. Woodard
- Department of Thoracic Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Frank C. Detterbeck
- Department of Thoracic Surgery, Yale University School of Medicine, New Haven, CT, USA
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Li Q, Dai J, Zhang P, Jiang G. Management of Pulmonary Ground Glass Nodules: Less Is More. Ann Thorac Surg 2021; 112:1-2. [PMID: 33689736 DOI: 10.1016/j.athoracsur.2021.01.077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 01/22/2021] [Indexed: 12/17/2022]
Affiliation(s)
- Qiuyuan Li
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital Tongji University, Shanghai, China
| | - Jie Dai
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital Tongji University, Shanghai, China
| | - Peng Zhang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital Tongji University, Shanghai, China
| | - Gening Jiang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital Tongji University, Shanghai, China.
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Surgical Outcomes of Lobectomy Versus Limited Resection for Clinical Stage I Ground-Glass Opacity Lung Adenocarcinoma 2 Centimeters or Smaller. Clin Lung Cancer 2020; 22:e160-e168. [PMID: 33160898 DOI: 10.1016/j.cllc.2020.09.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 06/30/2020] [Accepted: 09/23/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND To compare the surgical outcomes of patients with clinical stage I ground-glass opacity (GGO) lung adenocarcinomas with maximum diameters of ≤ 2 cm who underwent lobectomy versus limited resection. PATIENTS AND METHODS We retrospectively reviewed cases of clinical stage I GGO lung adenocarcinoma with a diameter ≤ 2 cm that were treated via lobectomy or limited resection in our department between January 2011 and September 2018. The clinical characteristics and surgical outcomes were analyzed using a propensity score-matched comparison and a Cox regression model. RESULTS A total of 552 patients were identified; 128 patients with pure GGO were excluded. Four hundred twenty-four patients met our criteria, including 242 (57.1%) who underwent lobectomy and 182 (42.9%) who underwent limited resection. No perioperative mortality occurred in either group. The overall 5-year survival rate of the entire cohort was 88%. Patients who underwent limited resection tended to have a shorter operation time, smaller blood loss volume, fewer removed nodes, and a shorter postoperative stay. However, the groups did not differ in terms of postoperative complications. Lobectomy and limited resection could lead to equivalent overall survival in patients with GGO-dominant tumor, while lobectomy showed better overall survival than limited resection in patients with solid-dominant tumor. CONCLUSION Patients with small GGO lung adenocarcinoma had a favorable prognosis after surgery. The oncologic surgical procedures of lobectomy and limited resection yielded comparable outcomes in patients with clinical stage I GGO-dominant lung adenocarcinomas ≤ 2 cm, while lobectomy showed better survival than limited resection in patients with solid-dominant tumor.
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Zhang R, Tian P, Chen B, Zhou Y, Li W. Predicting Lung Cancer Risk of Incidental Solid and Subsolid Pulmonary Nodules in Different Sizes. Cancer Manag Res 2020; 12:8057-8066. [PMID: 32943938 PMCID: PMC7481308 DOI: 10.2147/cmar.s256719] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 08/13/2020] [Indexed: 02/05/2023] Open
Abstract
Objective Malignancy prediction models for pulmonary nodules are most accurate when used within nodules similar to those in which they were developed. This study was to establish models that respectively predict malignancy risk of incidental solid and subsolid pulmonary nodules of different size. Materials and Methods This retrospective study enrolled patients with 5-30 mm pulmonary nodules who had a histopathologic diagnosis of benign or malignant. The median time to lung cancer diagnosis was 25 days. Four training/validation datasets were assembled based on nodule texture and size: subsolid nodules (SSNs) ≤15 mm, SSNs between 15 and 30 mm, solid nodules ≤15 mm and those between 15 and 30 mm. Univariate logistic regression was used to identify potential predictors, and multivariate analysis was used to build four models. Results The study identified 1008 benign and 1813 malignant nodules from a single hospital, and by random selection 1008 malignant nodules were enrolled for further analysis. There was a much higher malignancy rate among SSNs than solid nodules (rate, 75% vs 39%, P<0.001). Four distinguishing models were respectively developed and the areas under the curve (AUC) in training sets and validation sets were 0.83 (0.78-0.88) and 0.70 (0.61-0.80) for SSNs ≤15 mm, 0.84 (0.74-0.93) and 0.72 (0.57-0.87) for SSNs between 15 and 30 mm, 0.82 (0.77-0.87) and 0.71 (0.61-0.80) for solid nodules ≤15 mm, 0.82 (0.79-0.85) and 0.81 (0.76-0.86) for solid nodules between 15 and 30 mm. Each model showed good calibration and potential clinical applications. Different independent predictors were identified for solid nodules and SSNs of different size. Conclusion We developed four models to help characterize subsolid and solid pulmonary nodules of different sizes. The established models may provide decision-making information for thoracic radiologists and clinicians.
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Affiliation(s)
- Rui Zhang
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Panwen Tian
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.,Department of Lung Cancer Treatment Center, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Bojiang Chen
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Yongzhao Zhou
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Weimin Li
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
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