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Gallina FT, Chiappetta M, Tajè R, Forcella D, Sassorossi C, Congedo MT, Evangelista J, Sperduti I, Lococo F, Cappuzzo F, Melis E, Margaritora S, Facciolo F. Neutrophil-to-Lymphocyte Ratio and Risk of Nodal Metastasis in Early-Stage Lung Adenocarcinoma: A Brief Report From a Multicentric Analysis. Clin Lung Cancer 2024; 25:e196-e200.e1. [PMID: 38627156 DOI: 10.1016/j.cllc.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 06/01/2024]
Affiliation(s)
| | - Marco Chiappetta
- Thoracic Surgery Unit, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Riccardo Tajè
- Thoracic Surgery Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Daniele Forcella
- Thoracic Surgery Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Carolina Sassorossi
- Thoracic Surgery Unit, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria Teresa Congedo
- Thoracic Surgery Unit, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Jessica Evangelista
- Thoracic Surgery Unit, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Isabella Sperduti
- Biostatistics, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Filippo Lococo
- Thoracic Surgery Unit, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Federico Cappuzzo
- Medical Oncology 2, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Enrico Melis
- Thoracic Surgery Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Stefano Margaritora
- Thoracic Surgery Unit, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Facciolo
- Thoracic Surgery Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
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Choi S, Yoon DW, Shin S, Kim HK, Choi YS, Kim J, Shim YM, Cho JH. Importance of Lymph Node Evaluation in ≤2-cm Pure-Solid Non-Small Cell Lung Cancer. Ann Thorac Surg 2024; 117:586-593. [PMID: 36608755 DOI: 10.1016/j.athoracsur.2022.11.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 11/12/2022] [Accepted: 11/21/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND The prevalence of lymph node (LN) metastasis in small-sized lung cancer varies depending on the tumor size and proportion of ground-glass opacity. We investigated occult LN metastasis and prognosis in patients with small-sized non-small cell lung cancer (NSCLC), mainly focusing on the pure-solid tumor. METHODS We retrospectively reviewed patients with ≤2-cm clinical N0 NSCLC who underwent lung resection with curative intent from 2003 to 2017. Among them we analyzed patients who also underwent adequate complete systematic LN dissection. Pathologic results and disease-free survival of the radiologically mixed ground-glass nodule (mGGN) and pure-solid nodule (PSN) groups were analyzed. RESULTS Of 1329 patients analyzed, 591 had mGGNs and PSNs. As tumor size increased, patients in the mGGN group showed no difference in LN metastasis: ≤1 cm, 2.27%; 1.0 to 1.5 cm, 2.19%; and 1.5 to 2.0 cm, 2.18% (P = .999). However the PSN group showed a significant difference in LN metastasis as the tumor size increased: ≤1 cm, 2.67%; 1.0 to 1.5 cm, 12.46%; and 1.5 to 2.0 cm, 21.31% (P < .001). In the multivariate analysis tumor size was a significant predictor of nodal metastasis in the PSN group but not in the mGGN group. In terms of 5-year disease-free survival, the mGGN group showed a better prognosis than the PSN group (94.4% vs 71.2%, P < .001). CONCLUSIONS We need to conduct a thorough LN dissection during surgery for small-sized NSCLC, especially for pure-solid tumors ≥ 1 cm.
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Affiliation(s)
- Soohwan Choi
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, SungkyunKwan University School of Medicine, Seoul, Korea; Department of Thoracic and Cardiovascular Surgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Seoul, Korea
| | - Dong Woog Yoon
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, SungkyunKwan University School of Medicine, Seoul, Korea; Department of Thoracic and Cardiovascular Surgery, Chung-ang University Hospital, Seoul, Korea
| | - Sumin Shin
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, SungkyunKwan University School of Medicine, Seoul, Korea; Department of Thoracic and Cardiovascular Surgery, School of Medicine, Ewha Womans University, Mok-dong Hospital, Seoul, Korea
| | - Hong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, SungkyunKwan University School of Medicine, Seoul, Korea
| | - Yong Soo Choi
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, SungkyunKwan University School of Medicine, Seoul, Korea
| | - Jhingook 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
| | - Jong Ho Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, SungkyunKwan University School of Medicine, Seoul, Korea.
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Xue M, Liu J, Li Z, Lu M, Zhang H, Liu W, Tian H. The role of adenocarcinoma subtypes and immunohistochemistry in predicting lymph node metastasis in early invasive lung adenocarcinoma. BMC Cancer 2024; 24:139. [PMID: 38287300 PMCID: PMC10823663 DOI: 10.1186/s12885-024-11843-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/04/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND Identifying lymph node metastasis areas during surgery for early invasive lung adenocarcinoma remains challenging. The aim of this study was to develop a nomogram mathematical model before the end of surgery for predicting lymph node metastasis in patients with early invasive lung adenocarcinoma. METHODS In this study, we included patients with invasive lung adenocarcinoma measuring ≤ 2 cm who underwent pulmonary resection with definite pathology at Qilu Hospital of Shandong University from January 2020 to January 2022. Preoperative biomarker results, clinical features, and computed tomography characteristics were collected. The enrolled patients were randomized into a training cohort and a validation cohort in a 7:3 ratio. The training cohort was used to construct the predictive model, while the validation cohort was used to test the model independently. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors. The prediction model and nomogram were established based on the independent risk factors. Recipient operating characteristic (ROC) curves were used to assess the discrimination ability of the model. Calibration capability was assessed using the Hosmer-Lemeshow test and calibration curves. The clinical utility of the nomogram was assessed using decision curve analysis (DCA). RESULTS The overall incidence of lymph node metastasis was 13.23% (61/461). Six indicators were finally determined to be independently associated with lymph node metastasis. These six indicators were: age (P < 0.001), serum amyloid (SA) (P = 0.008); carcinoma antigen 125 (CA125) (P = 0. 042); mucus composition (P = 0.003); novel aspartic proteinase of the pepsin family A (Napsin A) (P = 0.007); and cytokeratin 5/6 (CK5/6) (P = 0.042). The area under the ROC curve (AUC) was 0.843 (95% CI: 0.779-0.908) in the training cohort and 0.838 (95% CI: 0.748-0.927) in the validation cohort. the P-value of the Hosmer-Lemeshow test was 0.0613 in the training cohort and 0.8628 in the validation cohort. the bias of the training cohort corrected C-index was 0.8444 and the bias-corrected C-index for the validation cohort was 0.8375. demonstrating that the prediction model has good discriminative power and good calibration. CONCLUSIONS The column line graphs created showed excellent discrimination and calibration to predict lymph node status in patients with ≤ 2 cm invasive lung adenocarcinoma. In addition, the predictive model has predictive potential before the end of surgery and can inform clinical decision making.
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Affiliation(s)
- Mengchao Xue
- Department of Thoracic Surgery, Qilu Hospital, Shandong University, Lixia District, Jinan City, Shandong Province, China
| | - Junjie Liu
- Department of Thoracic Surgery, Qilu Hospital, Shandong University, Lixia District, Jinan City, Shandong Province, China
| | - Zhenyi Li
- Department of Thoracic Surgery, Qilu Hospital, Shandong University, Lixia District, Jinan City, Shandong Province, China
| | - Ming Lu
- Department of Thoracic Surgery, Qilu Hospital, Shandong University, Lixia District, Jinan City, Shandong Province, China
| | - Huiying Zhang
- Department of Thoracic Surgery, Qilu Hospital, Shandong University, Lixia District, Jinan City, Shandong Province, China
| | - Wen Liu
- Department of Thoracic Surgery, Qilu Hospital, Shandong University, Lixia District, Jinan City, Shandong Province, China
| | - Hui Tian
- Department of Thoracic Surgery, Qilu Hospital, Shandong University, Lixia District, Jinan City, Shandong Province, China.
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Xu L, Su H, Zhao S, Si H, Xie H, Ren Y, Gao J, Wang F, Xie X, Dai C, Wu C, Zhao D, Chen C. Development of the semi-dry dot-blot method for intraoperative detecting micropapillary component in lung adenocarcinoma based on proteomics analysis. Br J Cancer 2023; 128:2116-2125. [PMID: 37016102 PMCID: PMC10206083 DOI: 10.1038/s41416-023-02241-x] [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: 08/16/2022] [Revised: 03/06/2023] [Accepted: 03/16/2023] [Indexed: 04/06/2023] Open
Abstract
BACKGROUND Micropapillary (MIP) component was a major concern in determining surgical strategy in lung adenocarcinoma (LUAD). We sought to develop a novel method for detecting MIP component during surgery. METHODS Differentially expressed proteins between MIP-positive and MIP-negative LUAD were identified through proteomics analysis. The semi-dry dot-blot (SDB) method which visualises the targeted protein was developed to detect MIP component. RESULTS Cellular retinoic acid-binding protein 2 (CRABP2) was significantly upregulated in MIP-positive LUAD (P < 0.001), and the high CRABP2 expression zone showed spatial consistency with MIP component. CRABP2 expression was also associated with decreased recurrence-free survival (P < 0.001). In the prospective cohort, the accuracy and sensitivity of detecting MIP component using SDB method by visualising CRABP2 were 82.2% and 72.7%, which were comparable to these of pathologist. Pathologist with the aid of SDB method would improve greatly in diagnostic accuracy (86.4%) and sensitivity (78.2%). In patients with minor MIP component (≤5%), the sensitivity of SDB method (63.6%) was significantly higher than pathologist (45.4%). CONCLUSIONS Intraoperative examination of CRABP2 using SDB method to detect MIP component reached comparable performance to pathologist, and SDB method had notable superiority than pathologist in detecting minor MIP component.
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Affiliation(s)
- Long Xu
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Hang Su
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Shengnan Zhao
- Department of Pathology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Haojie Si
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Huikang Xie
- Department of Pathology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Yijiu Ren
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Jiani Gao
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Fang Wang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Xiaofeng Xie
- Department of Pathology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Chenyang Dai
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Chunyan Wu
- Department of Pathology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Deping Zhao
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China.
| | - Chang Chen
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Clinical Center for Thoracic Surgery Research, Tongji University, Shanghai, People's Republic of China.
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Zeng C, Zhang W, Liu M, Liu J, Zheng Q, Li J, Wang Z, Sun G. Efficacy of radiomics model based on the concept of gross tumor volume and clinical target volume in predicting occult lymph node metastasis in non-small cell lung cancer. Front Oncol 2023; 13:1096364. [PMID: 37293586 PMCID: PMC10246750 DOI: 10.3389/fonc.2023.1096364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 05/09/2023] [Indexed: 06/10/2023] Open
Abstract
Objective This study aimed to establish a predictive model for occult lymph node metastasis (LNM) in patients with clinical stage I-A non-small cell lung cancer (NSCLC) based on contrast-enhanced CT. Methods A total of 598 patients with stage I-IIA NSCLC from different hospitals were randomized into the training and validation group. The "Radiomics" tool kit of AccuContour software was employed to extract the radiomics features of GTV and CTV from chest-enhanced CT arterial phase pictures. Then, the least absolute shrinkage and selection operator (LASSO) regression analysis was applied to reduce the number of variables and develop GTV, CTV, and GTV+CTV models for predicting occult lymph node metastasis (LNM). Results Eight optimal radiomics features related to occult LNM were finally identified. The receiver operating characteristic (ROC) curves of the three models showed good predictive effects. The area under the curve (AUC) value of GTV, CTV, and GTV+CTV model in the training group was 0.845, 0.843, and 0.869, respectively. Similarly, the corresponding AUC values in the validation group were 0.821, 0.812, and 0.906. The combined GTV+CTV model exhibited a better predictive performance in the training and validation group by the Delong test (p<0.05). Moreover, the decision curve showed that the combined GTV+CTV predictive model was superior to the GTV or CTV model. Conclusion The radiomics prediction models based on GTV and CTV can predict occult LNM in patients with clinical stage I-IIA NSCLC preoperatively, and the combined GTV+CTV model is the optimal strategy for clinical application.
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Affiliation(s)
- Chao Zeng
- Hebei Key Laboratory of Medical-industrial Integration Precision Medicine, Clinical Medicine College, Affiliated Hospital, North China University of Science and Technology, Tangshan, Hebei, China
| | - Wei Zhang
- Department of Radiotherapy, Yantai Yuhuangding Hospital, The Affiliated Hospital of Qingdao University, Yantai, Shandong, China
| | - Meiyue Liu
- Hebei Key Laboratory of Medical-industrial Integration Precision Medicine, Clinical Medicine College, Affiliated Hospital, North China University of Science and Technology, Tangshan, Hebei, China
| | - Jianping Liu
- Department of Chemoradiation, Tangshan People’s Hospital, Tangshan, Hebei, China
| | - Qiangxin Zheng
- Hebei Key Laboratory of Medical-industrial Integration Precision Medicine, Clinical Medicine College, Affiliated Hospital, North China University of Science and Technology, Tangshan, Hebei, China
| | - Jianing Li
- Hebei Key Laboratory of Medical-industrial Integration Precision Medicine, Clinical Medicine College, Affiliated Hospital, North China University of Science and Technology, Tangshan, Hebei, China
| | - Zhiwu Wang
- Department of Chemoradiation, Tangshan People’s Hospital, Tangshan, Hebei, China
| | - Guogui Sun
- Hebei Key Laboratory of Medical-industrial Integration Precision Medicine, Clinical Medicine College, Affiliated Hospital, North China University of Science and Technology, Tangshan, Hebei, China
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Li M, Ruan Y, Feng Z, Sun F, Wang M, Zhang L. Preoperative CT-Based Radiomics Combined With Nodule Type to Predict the Micropapillary Pattern in Lung Adenocarcinoma of Size 2 cm or Less: A Multicenter Study. Front Oncol 2021; 11:788424. [PMID: 34926304 PMCID: PMC8674565 DOI: 10.3389/fonc.2021.788424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 11/15/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose To construct an optimal radiomics model for preoperative prediction micropapillary pattern (MPP) in adenocarcinoma (ADC) of size ≤ 2 cm, nodule type was used for stratification to construct two radiomics models based on high-resolution computed tomography (HRCT) images. Materials and Methods We retrospectively analyzed patients with pathologically confirmed ADC of size ≤ 2 cm who presented to three hospitals. Patients presenting to the hospital with the greater number of patients were included in the training set (n = 2386) and those presenting to the other two hospitals were included in the external validation set (n = 119). HRCT images were used for delineation of region of interest of tumor and extraction of radiomics features; dimensionality reduction was performed for the features. Nodule type was used to stratify the data and the random forest method was used to construct two models for preoperative prediction MPP in ADC of size ≤ 2 cm. Model 1 included all nodule types and model 2 included only solid nodules. The receiver operating characteristic curve was used to assess the prediction performance of the two models and independent validation was used to assess its generalizability. Results Both models predicted ADC with MPP preoperatively. The area under the curve (AUC) of prediction performance of models 1 and 2 were 0.91 and 0.78, respectively. The prediction performance of model 2 was lower than that of model 1. The AUCs in the external validation set were 0.81 and 0.72, respectively. The DeLong test showed statistically significant differences between the training and validation sets in model 1 (p = 0.0296) with weak generalizability. There was no statistically significant difference between the training and validation sets in model 2 (p = 0.2865) with some generalizability. Conclusion Nodule type is an important factor that affects the performance of radiomics predictor model for MPP with ADC of size ≤ 2 cm. The radiomics prediction model constructed based on solid nodules alone, can be used to evaluate MPP and may contribute to proper surgical planning in patients with ADC of size ≤ 2 cm.
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Affiliation(s)
- Meirong Li
- Department of Radiology, The First Affiliated Hospital, Zhejiang University, School of Medicine, Hangzhou, China
| | - Yachao Ruan
- Department of Radiology, The First Affiliated Hospital, Zhejiang University, School of Medicine, Hangzhou, China
| | - Zhan Feng
- Department of Radiology, The First Affiliated Hospital, Zhejiang University, School of Medicine, Hangzhou, China
| | - Fangyu Sun
- Department of Radiology, Xiaoshan Hospital of Traditional Chinese Medicine, Hangzhou, China
| | - Minhong Wang
- Department of Radiology, First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Liang Zhang
- Department of Radiology, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China
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Zhang S, Lin D, Yu Y, Cao Q, Liu G, Jiang D, Wang H, Fang Y, Shen Y, Yin J, Hou Y, Shi H, Ge D, Wang Q, Tan L. Which will carry more weight when CTR > 0.5, solid component size, CTR, tumor size or SUVmax? Lung Cancer 2021; 164:14-22. [PMID: 34974221 DOI: 10.1016/j.lungcan.2021.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 12/01/2021] [Accepted: 12/09/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND This study was conducted to explore the clinical significance of the maximum standard uptake value (SUVmax) in the clinical stage IA lung adenocarcinoma with tumor size ≤ 2 cm and consolidation to tumor ratio (CTR) > 0.5. METHODS We retrospectively reviewed non-small cell lung cancer patients who underwent surgeries between January 2014 and March 2017. Clinical stage IA lung adenocarcinoma patients with tumor of size ≤ 2 cm and CTR > 0.5 were enrolled. The patients were divided into two groups: part-solid and pure-solid based on whether CTR = 1.0 or not. Nodules with any amount of solid or micropapillary components were regarded as the high-risk subtype. Time-dependent ROC curve was used to determine the best cut-off value. Finally, we analyzed the relationship between SUVmax, high-risk subtypes, node metastasis and 5-year relapse-free survival and overall survival. RESULTS Totally, 270 patients were included. The distribution of pathological subtypes (p < 0.001), SUVmax (p < 0.001), and pathological N stage (p < 0.001) were different between the two groups. Multivariable analysis indicated that SUVmax could predict high-risk subtypes in cases of part-solid nodules (p < 0.001) and both high-risk subtypes (p = 0.022) and node metastasis (p < 0.001) in cases of pure-solid ones. SUVmax ≥ 2.6 and SUVmax ≥ 5.1 were strongly associated with 5-year relapse-free survival (p < 0.001) and 5-year overall survival (p < 0.001) among all the patients, respectively. CONCLUSION Part-solid nodules with 0.5 < CTR < 1 and pure-solid nodules in lung adenocarcinoma show different clinicopathological characteristics, especially in SUVmax. SUVmax is significantly associated with high-risk subtypes, node metastasis, 5-year relapse-free survival and overall survival.
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Affiliation(s)
- Shaoyuan Zhang
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China; Cancer Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Dong Lin
- Department of Thoracic Surgery, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200080, China
| | - Yangli Yu
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Qiqi Cao
- Department of Radiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Guobing Liu
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China; Cancer Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Dongxian Jiang
- Department of Pathology, Zhongshan Hospital, Fudan University, Shanghai 200032, China; Cancer Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Hao Wang
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China; Cancer Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yong Fang
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China; Cancer Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yaxing Shen
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China; Cancer Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Jun Yin
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China; Cancer Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yingyong Hou
- Department of Pathology, Zhongshan Hospital, Fudan University, Shanghai 200032, China; Cancer Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Hongcheng Shi
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China; Cancer Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Di Ge
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China; Cancer Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Qun Wang
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China; Cancer Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Lijie Tan
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China; Cancer Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China.
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Cho HH, Lee HY, Kim E, Lee G, Kim J, Kwon J, Park H. Radiomics-guided deep neural networks stratify lung adenocarcinoma prognosis from CT scans. Commun Biol 2021; 4:1286. [PMID: 34773070 PMCID: PMC8590002 DOI: 10.1038/s42003-021-02814-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 10/27/2021] [Indexed: 02/07/2023] Open
Abstract
Deep learning (DL) is a breakthrough technology for medical imaging with high sample size requirements and interpretability issues. Using a pretrained DL model through a radiomics-guided approach, we propose a methodology for stratifying the prognosis of lung adenocarcinomas based on pretreatment CT. Our approach allows us to apply DL with smaller sample size requirements and enhanced interpretability. Baseline radiomics and DL models for the prognosis of lung adenocarcinomas were developed and tested using local (n = 617) cohort. The DL models were further tested in an external validation (n = 70) cohort. The local cohort was divided into training and test cohorts. A radiomics risk score (RRS) was developed using Cox-LASSO. Three pretrained DL networks derived from natural images were used to extract the DL features. The features were further guided using radiomics by retaining those DL features whose correlations with the radiomics features were high and Bonferroni-corrected p-values were low. The retained DL features were subject to a Cox-LASSO when constructing DL risk scores (DRS). The risk groups stratified by the RRS and DRS showed a significant difference in training, testing, and validation cohorts. The DL features were interpreted using existing radiomics features, and the texture features explained the DL features well.
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Affiliation(s)
- Hwan-Ho Cho
- Department of Electrical and Computer Engineering, Sungkyunkwan University, Suwon, Republic of Korea
- Center for Neuroscience Imaging Research, Institute for Basic Science, Suwon, Republic of Korea
| | - Ho Yun Lee
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Seoul, Republic of Korea.
| | - Eunjin Kim
- Department of Electrical and Computer Engineering, Sungkyunkwan University, Suwon, Republic of Korea
- Center for Neuroscience Imaging Research, Institute for Basic Science, Suwon, Republic of Korea
| | - Geewon Lee
- Department of Radiology and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Jonghoon Kim
- Department of Electrical and Computer Engineering, Sungkyunkwan University, Suwon, Republic of Korea
| | - Junmo Kwon
- Department of Electrical and Computer Engineering, Sungkyunkwan University, Suwon, Republic of Korea
- Center for Neuroscience Imaging Research, Institute for Basic Science, Suwon, Republic of Korea
| | - Hyunjin Park
- Center for Neuroscience Imaging Research, Institute for Basic Science, Suwon, Republic of Korea.
- School of Electronic and Electrical Engineering, Sungkyunkwan University, Suwon, Republic of Korea.
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Chong Y, Wu Y, Liu J, Han C, Gong L, Liu X, Liang N, Li S. Clinicopathological models for predicting lymph node metastasis in patients with early-stage lung adenocarcinoma: the application of machine learning algorithms. J Thorac Dis 2021; 13:4033-4042. [PMID: 34422333 PMCID: PMC8339794 DOI: 10.21037/jtd-21-98] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 05/21/2021] [Indexed: 12/25/2022]
Abstract
Background Lymph node metastasis (LNM) status can be a critical decisive factor for clinical management of lung cancer. Accurately evaluating the risk of LNM during or after the surgery can be helpful for making clinical decisions. This study aims to incorporate clinicopathological characteristics to develop reliable machine learning (ML)-based models for predicting LNM in patients with early-stage lung adenocarcinoma. Methods A total of 709 lung adenocarcinoma patients with tumor size ≤2 cm were enrolled for analysis and modeling by multiple ML algorithms. The receiver operating characteristic (ROC) curve and decision curve were used for evaluating model’s predictive performance and clinical usefulness. Feature selection based on potential models was performed to identify most-contributed predictive factors. Results LNM occurred in 11.3% (80/709) of patients with lung adenocarcinoma. Most models reached high areas under the ROC curve (AUCs) >0.9. In the decision curve, all models performed better than the treat-all and treat-none lines. The random forest classifier (RFC) model, with a minimal number of five variables introduced (including carcinoembryonic antigen, solid component, micropapillary component, lymphovascular invasion and pleural invasion), was identified as the optimal model for predicting LNM, because of its excellent performance in both ROC and decision curves. Conclusions The cost-efficient application of RFC model could precisely predict LNM during or after the operation of early-stage adenocarcinomas (sensitivity: 87.5%; specificity: 82.2%). Incorporating clinicopathological characteristics, it is feasible to predict LNM intraoperatively or postoperatively by ML algorithms.
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Affiliation(s)
- Yuming Chong
- Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yijun Wu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jianghao Liu
- Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Chang Han
- Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Liang Gong
- Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xinyu Liu
- Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Naixin Liang
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Shanqing Li
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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10
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Liang J, Wu Q, Ma S, Zhang S. [Pathological and Molecular Features of Lung Micropapillary Adenocarcinoma]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2021; 23:1007-1013. [PMID: 33203200 PMCID: PMC7679217 DOI: 10.3779/j.issn.1009-3419.2020.102.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
肺微乳头腺癌作为高级别肺腺癌,具频发转移、淋巴结浸润、复发率高和总体生存率低的临床特征。该亚型肿瘤中存在特征致癌因子通路的激活和肿瘤免疫微环境的建立。本文拟对近年来微乳头腺癌的病理学表现及分子学特征研究进展作一综述,旨在加深对微乳头型病变的认识,进而为制定特异性治疗策略奠定基础。
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Affiliation(s)
- Jiafeng Liang
- Translational Medicine Research Center, Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine,
Hangzhou 310006, China
| | - Qiong Wu
- Translational Medicine Research Center, Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine,
Hangzhou 310006, China
| | - Shenglin Ma
- Translational Medicine Research Center, Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine,
Hangzhou 310006, China.,Department of Oncology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine,
Hangzhou 310006, China
| | - Shirong Zhang
- Translational Medicine Research Center, Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine,
Hangzhou 310006, China
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11
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Lanuti M, Lin J, Ng T, Burt BM. A year in general thoracic surgery published in the Journal of Thoracic and Cardiovascular Surgery: 2020. J Thorac Cardiovasc Surg 2021; 162:253-258. [PMID: 34024614 PMCID: PMC8139187 DOI: 10.1016/j.jtcvs.2021.03.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 03/17/2021] [Accepted: 03/19/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Michael Lanuti
- Division of Thoracic, Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Jules Lin
- Section of Thoracic Surgery, University of Michigan, Ann Arbor, Mich
| | - Thomas Ng
- Division of Thoracic Surgery, College of Medicine, University of Tennessee Health Science Center, Memphis, Tenn
| | - Bryan M Burt
- Division of General Thoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex.
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12
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Wang Z, Wu Y, Wang L, Gong L, Han C, Liang N, Li S. Predicting occult lymph node metastasis by nomogram in patients with lung adenocarcinoma ≤2 cm. Future Oncol 2021; 17:2005-2013. [PMID: 33784826 DOI: 10.2217/fon-2020-0905] [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: 11/21/2022] Open
Abstract
Background: Previous researches had not proposed any prediction models for occult lymph node metastasis (OLNM). Considering the occurrence of OLNM and the importance of OLNM management, we aimed to develop a nomogram to predict OLNM of patients with lung adenocarcinoma ≤2 cm. Methods: Characteristics of patients with lung adenocarcinoma of ≤2 cm diameter at the Peking Union Medical College Hospital were retrospectively reviewed. Univariate and multivariate logistic regressions were performed. A nomogram model was developed. The concordance index (C-index) and calibration and decision curves were used to evaluate the predictive ability. Results: A total of 473 patients were enrolled, with an OLNM incidence of 7.4%. Four factors were selected as risk factors. The model had a C-index of 0.932. Calibration and decision curves were determined. Conclusion: Patients with pure ground-glass opacity (pGGO) or noninvasive adenocarcinoma have significantly lower risk of OLNM. SUVmax, CEA, micropapillary and solid component were identified as independent risk factors. The nomogram model was effective in predicting OLNM preoperatively.
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Affiliation(s)
- Zhile Wang
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.,Peking Union Medical College, Eight-Year MD Program, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yijun Wu
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.,Peking Union Medical College, Eight-Year MD Program, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Li Wang
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.,Peking Union Medical College, Eight-Year MD Program, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Liang Gong
- Peking Union Medical College, Eight-Year MD Program, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Chang Han
- Peking Union Medical College, Eight-Year MD Program, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Naixin Liang
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Shanqing Li
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
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13
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Zeng J, Cui X, Cheng L, Chen Y, Du X, Sheng L. Micropapillary pattern of stage IIIA-N 2 lung adenocarcinoma is a prognostic factor after adjuvant chemoradiotherapy. Future Oncol 2020; 16:3075-3084. [PMID: 32869661 DOI: 10.2217/fon-2020-0597] [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] [Indexed: 12/25/2022] Open
Abstract
Aim: This study aims to investigate the significance of a micropapillary pattern in stage IIIA-N2 lung adenocarcinoma after adjuvant chemoradiotherapy. Patients & methods: A total of 257 patients with stage IIIA-N2 lung adenocarcinoma were enrolled in this study. Patients were classified into three groups based on the proportion of micropapillary components: micropapillary negative, micropapillary minor component and micropapillary predominant component. Results: The micropapillary predominant group had the shortest median disease-free survival and overall survival times compared with the micropapillary minor component and micropapillary negative groups (median overall survival time: 54 months vs 64 months vs not reached; p = 0.004). Furthermore, the micropapillary pattern was an independent prognostic factor for disease-free survival and overall survival (p < 0.05). Conclusion: The micropapillary pattern of IIIA-N2 lung adenocarcinoma is related to worse prognosis.
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Affiliation(s)
- Jian Zeng
- Department of Thoracic Surgery, Cancer Hospital of The University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, Zhejiang, China.,Institute of Cancer & Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, Zhejiang, China.,Department of Radiotherapy, Cancer Hospital of The University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, Zhejiang, China
| | - Xiaoying Cui
- Institute of Cancer & Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, Zhejiang, China.,Department of Radiotherapy, Cancer Hospital of The University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, Zhejiang, China.,Key Laboratory Diagnosis & Treatment Technology on Thoracic Oncology, Zhejiang, China.,The Second Clinical Medical College, Zhejiang Chinese Medical University
| | - Lei Cheng
- Institute of Cancer & Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, Zhejiang, China.,Department of Radiotherapy, Cancer Hospital of The University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, Zhejiang, China.,Key Laboratory Diagnosis & Treatment Technology on Thoracic Oncology, Zhejiang, China
| | - Ying Chen
- Department of Thoracic Surgery, Cancer Hospital of The University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, Zhejiang, China.,Institute of Cancer & Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, Zhejiang, China.,Department of Radiotherapy, Cancer Hospital of The University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, Zhejiang, China.,Key Laboratory Diagnosis & Treatment Technology on Thoracic Oncology, Zhejiang, China
| | - Xianghui Du
- Institute of Cancer & Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, Zhejiang, China.,Department of Radiotherapy, Cancer Hospital of The University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, Zhejiang, China.,Key Laboratory Diagnosis & Treatment Technology on Thoracic Oncology, Zhejiang, China
| | - Liming Sheng
- Institute of Cancer & Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, Zhejiang, China.,Department of Radiotherapy, Cancer Hospital of The University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, Zhejiang, China.,Key Laboratory Diagnosis & Treatment Technology on Thoracic Oncology, Zhejiang, China
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14
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Wu Y, Liu J, Han C, Liu X, Chong Y, Wang Z, Gong L, Zhang J, Gao X, Guo C, Liang N, Li S. Preoperative Prediction of Lymph Node Metastasis in Patients With Early-T-Stage Non-small Cell Lung Cancer by Machine Learning Algorithms. Front Oncol 2020; 10:743. [PMID: 32477952 PMCID: PMC7237747 DOI: 10.3389/fonc.2020.00743] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 04/20/2020] [Indexed: 12/13/2022] Open
Abstract
Background: Lymph node metastasis (LNM) is difficult to precisely predict before surgery in patients with early-T-stage non-small cell lung cancer (NSCLC). This study aimed to develop machine learning (ML)-based predictive models for LNM. Methods: Clinical characteristics and imaging features were retrospectively collected from 1,102 NSCLC ≤ 2 cm patients. A total of 23 variables were included to develop predictive models for LNM by multiple ML algorithms. The models were evaluated by the receiver operating characteristic (ROC) curve for predictive performance and decision curve analysis (DCA) for clinical values. A feature selection approach was used to identify optimal predictive factors. Results: The areas under the ROC curve (AUCs) of the 8 models ranged from 0.784 to 0.899. Some ML-based models performed better than models using conventional statistical methods in both ROC curves and decision curves. The random forest classifier (RFC) model with 9 variables introduced was identified as the best predictive model. The feature selection indicated the top five predictors were tumor size, imaging density, carcinoembryonic antigen (CEA), maximal standardized uptake value (SUVmax), and age. Conclusions: By incorporating clinical characteristics and radiographical features, it is feasible to develop ML-based models for the preoperative prediction of LNM in early-T-stage NSCLC, and the RFC model performed best.
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Affiliation(s)
- Yijun Wu
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Peking Union Medical College, Eight-year MD Program, Chinese Academy of Medical Sciences, Beijing, China
| | - Jianghao Liu
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Peking Union Medical College, Eight-year MD Program, Chinese Academy of Medical Sciences, Beijing, China
| | - Chang Han
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Peking Union Medical College, Eight-year MD Program, Chinese Academy of Medical Sciences, Beijing, China
| | - Xinyu Liu
- Peking Union Medical College, Eight-year MD Program, Chinese Academy of Medical Sciences, Beijing, China.,Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuming Chong
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Peking Union Medical College, Eight-year MD Program, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhile Wang
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Peking Union Medical College, Eight-year MD Program, Chinese Academy of Medical Sciences, Beijing, China
| | - Liang Gong
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Peking Union Medical College, Eight-year MD Program, Chinese Academy of Medical Sciences, Beijing, China
| | - Jiaqi Zhang
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xuehan Gao
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chao Guo
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Naixin Liang
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shanqing Li
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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15
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Hanna WC. Commentary: Seek (the nodes) and you shall find (the nodes). J Thorac Cardiovasc Surg 2019; 159:1097-1098. [PMID: 31668530 DOI: 10.1016/j.jtcvs.2019.09.022] [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: 09/08/2019] [Revised: 09/08/2019] [Accepted: 09/10/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Waël C Hanna
- Division of Thoracic Surgery, McMaster University, Hamilton, Ontario, Canada.
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