Pneumonectomy for Non-Small Cell Lung Cancer

Comparison of uniportal video-assisted thoracoscopic versus thoracotomy bronchial sleeve lobectomy with pulmonary arterioplasty for centrally located non-small-cell lung cancer

OBJECTIVES

This study aimed to investigate the efficacy of bronchial sleeve lobectomy with pulmonary arterioplasty by uniportal video-assisted thoracoscopic surgery (UniVATS) in centrally located non-small-cell lung cancer.

METHODS

One hundred and two thoracotomy and 31 UniVATS cases were included in this retrospective, single-centre study. Baseline characteristics, perioperative performance and survival outcomes were compared between the 2 groups.

RESULTS

Compared with the thoracotomy group, the UniVATS group was associated with lower postoperative blood transfusion rate (P = 0.043), decreased postoperative hospital stays (P = 0.008), shorter drainage duration (P = 0.003) and less drainage volume during the first postoperative 24 h (P = 0.005). Besides, the 3-year overall survival and recurrence-free survival were comparable between the 2 groups (log-rank, P = 0.81 and P = 0.78, respectively). In addition, squamous cell carcinoma was proved to be the independent favourable predictor for overall survival [hazard ratio (HR) 0.44, 95% confidence interval (CI) 0.24-0.80; P = 0.008], and advanced pathological stage was found to be independently associated with worse overall survival (IIIB stage: HR 3.21, 95% CI 1.13-9.12; P = 0.028) and recurrence-free survival (IIIB stage: HR 3.54, 95% CI 1.32-9.51; P = 0.012).

CONCLUSIONS

With appropriate patient selection, UniVATS sleeve lobectomy with pulmonary arterioplasty is feasible and safe for centrally located lung cancer in the hands of thoracic surgeons with extensive thoracoscopy experience.

Total Psoas Area and Total Muscular Parietal Area Affect Long-Term Survival of Patients Undergoing Pneumonectomy for Non-Small Cell Lung Cancer

There is no standardization in methods to assess sarcopenia; in particular the prognostic significance of muscular fatty infiltration in lung cancer patients undergoing surgery has not been evaluated so far. We thus performed several computed tomography (CT)-based morphometric measurements of sarcopenia in 238 consecutive non-small cell lung-cancer patients undergoing pneumonectomy from 1 January 2007 to 31 December 2015. Sarcopenia was assessed by the following CT-based parameters: cross-sectional total psoas area (TPA), cross-sectional total muscle area (TMA), and total parietal muscle area (TPMA), defined as TMA without TPA. Measures were performed at the level of the third lumbar vertebra and were obtained for the entire muscle surface, as well as by excluding fatty infiltration based on CT attenuation. Findings were stratified for gender, and a threshold of the 33rd percentile was set to define sarcopenia. Furthermore, we assessed the possibility of being sarcopenic at both the TPA and TPMA level, or not, by taking into account of not fatty infiltration. Five-year survival was 39.1% for the whole population. Lower TPA, TMA, and TPA were associated with lower survival at univariate analysis; taking into account muscular fatty infiltration did not result in more powerful discrimination. Being sarcopenic at both psoas and parietal muscle level had the optimum discriminating power. At the multivariable analysis, being sarcopenic at both psoas and parietal muscles (considering the whole muscle areas, including muscular fat), male sex, increasing age, and tumor stage, as well as Charlson Comorbidity Index (CCI), were independently associated with worse long-term outcomes. We conclude that sarcopenia is a powerful negative prognostic factor in patients with lung cancer treated by pneumonectomy.

Dynamic nomogram for long-term survival in patients with non-small cell lung cancer after pneumonectomy

Background

The study aims to identify prognostic factors of overall survival (OS) in patients who had pneumonectomy, in order to develop a practical dynamic nomogram model.

Methods

A total of 2,255 patients with non-small cell lung cancer (NSCLC) who underwent pneumonectomy were identified from 2010-2015 in the Surveillance, Epidemiology, and End Results (SEER) database. The cohort was divided into a training (2011-2015) and a validation [2010] cohort. A nomogram and a risk classification system were constructed from the independent survival factors in multivariable analysis. The predictive accuracy of the nomogram was measured through internal and external validation.

Results

Independent prognostic factors associated with OS were gender, age, pathology, tumor size, N stage, chemotherapy, and radiotherapy. The C-index of the nomogram for OS was 0.675 (95% CI: 0.655-0.694). Similarly, the AUC of the model was 0.733, 0.709, and 0.701 for the 1-, 3-, and 5-year OS, respectively. The calibration curves for survival demonstrated good agreement. Significant statistical differences were found in the OS of patients within different risk groups. An online calculation tool was established for clinical use.

Conclusions

This novel nomogram was able to provide a reliable prognosis for survival in patients with NSCLC undergoing pneumonectomy.

Study of the predictors for radiation pneumonitis in patient with non-small cell lung cancer received radiotherapy after pneumonectomy

PURPOSE

To identify the valuable predictors of grade≥2 radiation pneumonitis (RP) in patient treated with radiotherapy after pneumonectomy for non-small cell lung cancer (NSCLC); and to construct a nomogram predicting the incidence of grade≥2 RP in such patients.

PATIENTS AND METHODS

We reviewed 82 patients with NSCLC received radiotherapy after pneumonectomy from 2008 to 2018. The endpoint was grade≥2 RP. Univariate and multivariate regression analysis were conducted to evaluate significant factors of grade≥2 RP. Receiver operating characteristic (ROC) curve was used to establish optimal cutoff values and the nomogram was built to make the predictive model visualized. Descriptive analysis was performed on 5 patients with grade 3 RP.

RESULTS

A total of 22(26.8%) patients developed grade 2 RP and 5(6.1%) patients were grade 3 RP. V5, V10, V20, V30, MLD, PTV, and PTV/TLV were associated with the occurrence of grade≥2 RP in univariate analysis, while none of the clinical factors was significant; V5(OR,1.213;95%CI,1.099-1.339; P<0.001) and V20(OR,1.435;95%CI,1.166-1.765; P=0.001) were the independent significant predictors by multivariate analysis and were included in the nomogram. The ROC analysis for the cutoff values for predicting grade≥2 RP were V5>23% (AUC=0.819, sensitivity:0.701, specificity:0.832) and V20>8% (AUC=0.812, sensitivity:0.683, specificity:0.811). Additionally, grade≥3 RP did not occur when V5<30%, V20<13% and MLD<751.2cGy, respectively.

CONCLUSIONS

Our study showed that V5 and V20 were independent predictors for grade≥2 RP in NSCLC patients receiving radiotherapy after pneumonectomy. Grade 3 RP did not occur whenV5<30%, V20<13% and MLD<751.2cGy, respectively. In addition, patient underwent right pneumonectomy may have a lower tolerance to radiation compared to left pneumonectomy.

Postoperative radiotherapy is effective in improving survival of patients with stage pIII-N2 non-small-cell lung Cancer after pneumonectomy

Background

There were few reports of postoperative radiotherapy (PORT) in stage pIII-N2 Non-small-cell Lung Cancer (NSCLC) patients receiving pneumonectomy followed by adjuvant chemotherapy. This study aims to evaluate safety and efficacy of PORT among these patients.

Methods

Between Jan. 2004 and Dec. 2015, stage pIII-N2 NSCLC patients receiving pneumonectomy and adjuvant chemotherapy with or without PORT in our institution were retrospectively reviewed.

Results

Totally 119 patients were included, 32 patients receiving adjuvant chemotherapy and PORT (PORT group) and 87 receiving adjuvant chemotherapy alone (Control group). There were more patients with non-R0 resection in PORT group than Control group (25% vs. 8%, p = 0.031). In PORT group, ≥Grade 2 radiation-induced pneumonitis was 2/32. No severe radiation-related heart injury was observed. There was no PORT-related death. Of all patients, median follow-up time was 25 months. Median overall survival time (mOS) and median disease-free survival time (mDFS) were 46 months and 15 months, respectively. The PORT group had significantly better OS (not reached vs. 34 months, p = 0.003), DFS (19 months vs. 13 months, p = 0.024), local recurrence free survival (LRFS, p = 0.012), and distant metastasis free survival (DMFS, p = 0.047) than the Control group. As for failure pattern, PORT significantly reduced local regional failure rate (39.1% vs. 15.6%, p = 0.016). In subgroup analysis, patients with R0 resection (n = 104), OS and LRFS in PORT group were significantly longer, and PORT tended to increase DFS and DMFS.

Conclusion

For patients with stage pIII-N2 NSCLC after pneumonectomy and adjuvant chemotherapy, PORT can improve OS, DFS, LRFS and DMFS with tolerable toxicity.

Risk factors for postoperative infection in Chinese lung cancer patients: A meta-analysis

OBJECTIVE

The objective of this study was to identify risk factors for postoperative infection in Chinese lung cancer patients.

METHODS

A comprehensive search was performed in PubMed, EMbase, CNKI, and WanFang Data databases to identify studies investigating risk factors for postoperative infection in Chinese lung cancer patients. Meta-analysis was performed by using Revman 5.2 software.

RESULTS

A total of 12 studies were included. The results of meta-analysis showed that old age, male gender, diabetes, cigarette smoking, squamous cell carcinoma, pulmonary diseases, longer of mechanical ventilation, and longer time of surgery procedure were associated with increased risk of postoperative infection. In addition, prophylactic antibiotic was associated with decreased risk of postoperative infection.

CONCLUSION

The current meta-analysis suggests that the old age, male gender, diabetes mellitus, cigarette smoking, squamous cell carcinoma, pulmonary diseases, longer of mechanical ventilation, and longer of surgery time are risk factors for postoperative infection in Chinese lung cancer patients. Due to the limited quality and quantity of included studies, more high-quality studies are needed to verify the above results.