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Major pulmonary resection after neoadjuvant chemotherapy or chemoradiation in potentially resectable stage III non-small cell lung carcinoma. Sci Rep 2021; 11:20232. [PMID: 34642407 PMCID: PMC8511337 DOI: 10.1038/s41598-021-99271-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 09/13/2021] [Indexed: 12/25/2022] Open
Abstract
The aim of this study was to identify predictors of postoperative outcome and survival of locally advanced non-small cell lung carcinoma (NSCLC) resections after neoadjuvant chemotherapy or chemoradiation. Medical records of all patients with clinical stage III potentially resectable NSCLC initially treated by neoadjuvant chemotherapy or chemoradiation followed by major pulmonary resections were retrieved from the databases of four Israeli Medical Centers between 1999 to 2019. The 124 suitable patients included, 86 males (69.4%) and 38 females (30.6%), with an average age of 64.2 years (range 37-82) and an average hospital stay of 12.6 days (range 5-123). Complete resection was achieved in 92.7% of the patients, while complete pathologic response was achieved in 35.5%. The overall readmission rate was 16.1%. The overall 5-year survival rate was 47.9%. One patient (0.8%) had local recurrence. Postoperative complications were reported in 49.2% of the patients, mainly atrial fibrillation (15.9%) and pneumonia (13.7%), empyema (10.3%), and early bronchopleural fistula (7.3%). The early in-hospital mortality rate was 6.5%, and the 6-month mortality rate was 5.6%. Pre-neoadjuvant bulky mediastinal disease (lymph nodes > 20 mm) (p = 0.034), persistent postoperative N2 disease (p = 0.016), R1 resection (p = 0.027), preoperative N2 multistation disease (p = 0.053) and postoperative stage IIIA (p = 0.001) emerged as negative predictive factors for survival. Our findings demonstrate that neoadjuvant chemotherapy or chemoradiation in locally advanced potentially resectable NSCLC, followed by major pulmonary resection, is a beneficial approach in selected cases.
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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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Does Induction Therapy Increase Anastomotic Complications in Bronchial Sleeve Resections? World J Surg 2019; 43:1385-1392. [PMID: 30659342 DOI: 10.1007/s00268-019-04908-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Sleeve lobectomy represents a safe and effective treatment for central NSCLC to avoid the risks of pneumonectomy. Induction therapy (IT) may be indicated in advanced stages; however, the effect of IT on bronchial anastomoses remains uncertain. The purpose of the study was to evaluate the impact of IT on the complications of the anastomoses. METHODS Between 2000 and 2012, 159 consecutive patients were submitted to sleeve lobectomy for NSCLC at our Institution. We retrospectively compared the results of patients who underwent IT before operation with those who received upfront surgery. RESULTS In the study period, 49 (30.8%) patients received IT (37 chemotherapy, 1 radiotherapy and 11 chemo-radiotherapy) and 110 (69.2%) patients were directly submitted to surgery (S). The two groups were comparable for sex, age, comorbidities, ASA score, pulmonary function, side, type of procedure and histology. Pathological stage was statistically higher for IT group (p = 0.001). No differences between IT and S groups were observed in terms of post-operative mortality (2% vs 0%, p = NS), morbidity (45% vs 38%, p = NS), including early (6% vs 9%, p = NS) and long-term (16% vs 14%, p = NS) bronchial complication rates. Patients undergoing induction mediastinal radiotherapy, however, are at higher risk of bronchial complications. CONCLUSION In our experience, the use of induction chemotherapy did not significantly increase mortality and morbidity rates, in particular, neither for early nor for late anastomotic complications. We, therefore, conclude that sleeve lobectomy after induction chemotherapy is safe and reliable procedure for the treatment of locally advanced NSCLC.
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Brandt WS, Yan W, Leeman JE, Tan KS, Park BJ, Adusumilli PS, Bott MJ, Molena D, Isbell J, Chaft J, Rimner A, Jones DR. Postoperative Radiotherapy for Surgically Resected ypN2 Non-Small Cell Lung Cancer. Ann Thorac Surg 2018; 106:848-855. [PMID: 29807005 DOI: 10.1016/j.athoracsur.2018.04.064] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 03/22/2018] [Accepted: 04/23/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND The role of postoperative radiotherapy (PORT) in patients with clinical stage III-N2 (cIII-N2) non-small cell lung cancer (NSCLC) treated with induction chemotherapy and surgical resection with persistent ypN2 disease is not well established. METHODS We retrospectively reviewed a prospectively maintained database for patients with cIII-N2 NSCLC who underwent induction chemotherapy followed by resection (2004-2016). Exclusion criteria included induction radiotherapy, non-biopsy-confirmed cN2 disease, incomplete resection, ypN0/1, and nonanatomic resection. The primary outcome was locoregional recurrence (LR); secondary outcomes were disease-free survival (DFS), lung cancer-specific death (LCSD), and overall survival (OS). Associations between variables and outcomes were assessed using Fine and Gray competing risk regression for LR/LCSD and Cox proportional hazard models for survival. RESULTS Of the 501 patients identified with cIII-N2 disease, 99 met the inclusion criteria. Median follow-up was 25 months (range, 3-137 months). Sixty-nine patients (70%) received PORT. Sixty (61%) developed a recurrence: 3 (5%) with an initial isolated LR and 57 (95%) with an initial distant recurrence. On multivariable analysis, PORT was not associated with LR (HR, 0.51 [95% CI, 0.22-1.21], p = 0.13). PORT was also not associated with DFS (p = 0.6) or LCSD (p = 0.1). PORT was associated with improved 3-year OS (55% [95% CI, 42%-71%]) versus the no-PORT group (50% [95% CI, 34%-74%]) (p = 0.04). CONCLUSIONS PORT is not independently associated with decreased LR or improved DFS/LCSD in this patient population. Given that the predominant failure pattern was distant recurrence, future clinical trials should focus on adjuvant systemic therapies, which may decrease distant recurrences in ypN2 patients.
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Affiliation(s)
- Whitney S Brandt
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Wanpu Yan
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan E Leeman
- Department of Radiation Oncology, 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
| | - Bernard J Park
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Prasad S Adusumilli
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Matthew J Bott
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniela Molena
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - James Isbell
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jamie Chaft
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David R Jones
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
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Mungo B, Zogg CK, Schlottmann F, Barbetta A, Hooker CM, Molena D. Surgical outcomes of pulmonary resection for lung cancer after neo-adjuvant treatment. World J Surg Proced 2016; 6:19-29. [DOI: 10.5412/wjsp.v6.i2.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 07/08/2016] [Accepted: 07/22/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the outcomes of surgery for lung cancer after induction therapy.
METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2012), we identified 4063 patients who underwent a pulmonary resection for lung cancer. Two hundred and thirty-six (5.8%) received neo-adjuvant therapy prior to surgery (64 chemo-radiation, 103 radiation alone, 69 chemotherapy alone). The outcomes were compared to 3827 patients (94.2%) treated with surgery alone. Primary outcome was 30-d mortality, and secondary outcomes included length of stay, operative time and NSQIP measured postoperative complications.
RESULTS: Lung cancer patients who received preoperative treatment were younger (66 vs 69, P < 0.001), were more likely to have experienced recent weight loss (6.8% vs 3.5%; P = 0.011), to be active smokers (48.3 vs 34.9, P < 0.001), and had lower preoperative hematological cell counts (abnormal white blood cell: 25.6 vs 13.4; P < 0.001; low hematocrit 53% vs 17.3%, P < 0.001). On unadjusted analysis, neo-adjuvant patients had significantly higher 30-d mortality, overall and serious morbidity (all P < 0.001). Adjusted analysis showed similar findings, while matched cohorts comparison confirmed higher morbidity, but not higher early mortality.
CONCLUSION: Our data suggest that patients who receive neo-adjuvant therapy for lung cancer have worse early surgical outcomes. Although NSQIP does not provide stage information, this analysis shows important findings that should be considered when selecting patients for induction treatment.
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Koufos N, Syrios J, Michailidou D, Xynos ID, Lazaris A, Kavantzas N, Tomos P, Kakaris S, Kosmas C, Tsavaris N. Distinct patterns of angiogenic factor expression as a predictive factor of response to chemotherapy in stage IIIA non-small-cell lung cancer patients. Mol Clin Oncol 2016; 5:440-446. [PMID: 27699040 DOI: 10.3892/mco.2016.966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 02/03/2016] [Indexed: 11/06/2022] Open
Abstract
The expression of various angiogenic factors was assessed in tumour samples of patients with stage III non-small-cell lung cancer (NSCLC) and further evaluated in terms of response to induction paclitaxel-ifosfamide-cisplatin chemotherapy. Freshly isolated lung tumour specimens obtained by bronchoscopy from 70 stage IIIA NSCLC chemotherapy-naïve patients were sampled and analysed for vascular endothelial growth factor receptor (VEGFR)-1, VEGFR-2 and VEGFR-3. Microvessel density was assessed through evaluating the angiogenic markers CD34 and CD105. Immunostaining scores were calculated by multiplying the percentage of labeled cells by the intensity of staining for each examined parameter. The overall mean immunostaining score value from all NSCLC samples was 7.83, 5.56 and 15.86 for VEGFR-1, VEGFR-2 and VEGFR-3, respectively. The overall mean value of the endothelial antigen CD34 was 16.29, whereas the expression of the CD105 antigen in endothelial cells yielded a multivariate distribution. Patients who responded to chemotherapy expressed significantly higher VEGFR-1 and VEGFR-3 mean values compared with non-responders (P<0.001). No significant difference was noted in VEGFR-2 mean values between these two groups (P=0.06). The CD34 mean value was significantly higher in responders (P<0.001), whereas there was no significant difference in CD105 expression between the two groups (P=0.07). Angiogenic marker expression proved to be a potential predictive factor of response to chemotherapy in stage III NSCLC. which merits further investigation.
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Affiliation(s)
- Nikolaos Koufos
- Oncology Unit, Department of Pathophysiology, Laiko General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - John Syrios
- 2nd Department of Medical Oncology, 'St. Savvas' Cancer Hospital, 11522 Athens, Greece
| | - Despina Michailidou
- Oncology Unit, Department of Pathophysiology, Laiko General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Ioannis D Xynos
- Imperial Clinical Trials Unit-Cancer, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College, London W6 8RF, UK
| | - Andreas Lazaris
- 1st Department of Pathology, Laiko General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Nicolaos Kavantzas
- 1st Department of Pathology, Laiko General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Periclis Tomos
- 2nd Department of Propedeutic Surgery, Laiko General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Stamatis Kakaris
- 1st Department of Thoracic Surgery, 'Sotiria' General Hospital of Chest Diseases, 11527 Athens, Greece
| | - Christos Kosmas
- 2nd Division of Medical Oncology, Department of Medicine, Metaxa Cancer Hospital, 18537 Piraeus, Greece
| | - Nikolas Tsavaris
- Oncology Unit, Department of Pathophysiology, Laiko General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
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Outcomes of neoadjuvant concurrent chemoradiotherapy followed by surgery for non-small-cell lung cancer with N2 disease. Lung Cancer 2016; 96:56-62. [DOI: 10.1016/j.lungcan.2016.03.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 03/09/2016] [Accepted: 03/28/2016] [Indexed: 11/19/2022]
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8
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Li WW, Burgers JA, Klomp HM, Hartemink KJ. COUNTERPOINT: Is N2 Disease a Contraindication for Surgical Resection for Superior Sulcus Tumors? No. Chest 2016; 148:1375-1379. [PMID: 26110487 DOI: 10.1378/chest.15-1196] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Wilson W Li
- Department of Cardiothoracic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | | | - Houke M Klomp
- Department of Thoracic Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Koen J Hartemink
- Department of Thoracic Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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Mordant P, McRae K, Cho J, Keshavjee S, Waddell TK, Feld R, de Perrot M. Impact of induction therapy on postoperative outcome after extrapleural pneumonectomy for malignant pleural mesothelioma: does induction-accelerated hemithoracic radiation increase the surgical risk? Eur J Cardiothorac Surg 2016; 50:433-8. [PMID: 27005976 DOI: 10.1093/ejcts/ezw074] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 01/28/2016] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Patients with malignant pleural mesothelioma (MPM) eligible for extrapleural pneumonectomy (EPP) may benefit from induction chemotherapy (CT) as historically described, or from induction-accelerated hemithoracic intensity-modulated radiation therapy (IMRT) as a potential alternative. However, the impact of the type of induction therapy on postoperative morbidity and mortality remains unknown. METHODS We performed a retrospective study including every patient who underwent EPP for MPM in our institution between January 2001 and December 2014. Patients without induction treatment (n = 7) or undergoing both induction CT and IMRT (n = 2) were then excluded. The remaining patients (study group) were divided according to the type of induction treatment in Group 1-CT and Group 2-IMRT. Major complications were defined by complications of Grade 3 or higher according to the National Cancer Institute Common Terminology Criteria for Adverse Events 4.0 guidelines. Red blood cell (RBC) transfusion was analysed as a number of packs, and dichotomized as <3 vs ≥3 packs. Plasma and platelet transfusion were analysed as a number of units, and dichotomized as no transfusion versus any plasma or platelet transfusion. RESULTS Altogether, 126 patients (mean age 61.3 ± 8.1 years, males 82.5%, right side 60.3%, 90-day mortality rate 4.8%) accounted for the study group. Sixty-four patients were included in Group 1-CT and 62 patients were included in Group 2-IMRT. When compared with Group 1-CT, Group 2-IMRT was characterized by older patients (59.3 ± 9.2 vs 63.3 ± 8.3 years, P = 0.012), more right-sided resections (46.8 vs 74.1%, P = 0.003), more advanced disease (pathological stage IV: 28.1 vs 53.2%, P = 0.007), less RBC transfusions (5.1 ± 3.0 vs 3.0 ± 2.4 packs, P < 0.001), less plasma or platelet transfusions (31.2 vs 9.6%, P = 0.005) and similar rate of major complications (29.6 vs 35.4%, P = 0.614). The 90-day mortality rate was 6.2% in Group 1-CT (n = 4) and 3.2% in Group 2-RT (n = 2, P = 0.680). Induction with IMRT was significantly associated with a decreased risk of transfusion with RBCs [odds ratio (OR) = 0.10, 95% confidence interval (CI) 0.04-0.23, P < 0.001] as well as plasma and platelets (OR = 0.25, 95% CI 0.086-0.67, P = 0.008). CONCLUSIONS In this large single-centre series of EPP for MPM, the implementation of induction IMRT was not associated with any significant increase in the surgical risks above and beyond induction CT. The switch from induction CT to induction IMRT was associated with resection in older patients with more advanced tumours, less transfusion requirements, comparable postoperative morbidity and 90-day mortality.
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Affiliation(s)
- Pierre Mordant
- Division of Thoracic Surgery, Toronto General Hospital and Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Karen McRae
- Department of Anesthesia and Pain Management, Toronto General Hospital and Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - John Cho
- Department of Radiation Oncology, Toronto General Hospital and Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Shaf Keshavjee
- Division of Thoracic Surgery, Toronto General Hospital and Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Thomas K Waddell
- Division of Thoracic Surgery, Toronto General Hospital and Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Ronald Feld
- Department of Medical Oncology, Toronto General Hospital and Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital and Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
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Postinduction positron emission tomography assessment of N2 nodes is not associated with ypN2 disease or overall survival in stage IIIA non-small cell lung cancer. J Thorac Cardiovasc Surg 2015; 151:969-77, 979.e1-3. [PMID: 26614420 DOI: 10.1016/j.jtcvs.2015.09.127] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 09/11/2015] [Accepted: 09/23/2015] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Induction therapy is often recommended for patients with clinical stage IIIA-N2 (cIIIA/pN2) lung cancer. We examined whether postinduction positron emission tomography (PET) scans were associated with ypN2 disease and survival of patients with cIIIA/pN2 disease. METHODS We performed a retrospective review of a prospectively maintained database to identify patients with cIIIA/pN2 non-small cell lung cancer treated with induction chemotherapy followed by surgery between January 2007 and December 2012. The primary aim was the association between postinduction PET avidity and ypN2 status; the secondary aims were overall survival, disease-free survival, and recurrence. RESULTS Persistent pathologic N2 disease was present in 61% of patients (61 out of 100). PET N2-negative disease increased from 7% (6 out of 92) before induction therapy to 47% (36 out of 77) afterward. The sensitivity, specificity, and accuracy of postinduction PET for identification of ypN2 disease were 59%, 55%, and 57%, respectively. Logistic regression analysis indicated that postinduction PET N2 status was not associated with ypN2 disease. Of the 39 patients with both pre- and postinduction PET N2-avidity, 25 (64%) had ypN2 disease. The 5-year overall survival was 40% for ypN2 disease versus 38% for N2-persistent disease (P = .936); the 5-year overall survival was 43% for postinduction PET N2-negative disease versus 39% for N2-avid disease (P = .251). The 5-year disease-free survival was 34% for ypN2-negative disease versus 9% for N2-persistent disease (P = .079). CONCLUSIONS Postinduction PET avidity for N2 nodes is not associated with ypN2 disease, overall survival, or disease-free survival in patients undergoing induction chemotherapy for stage IIIA/pN2 disease.
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11
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Yang CFJ, Gulack BC, Gu L, Speicher PJ, Wang X, Harpole DH, Onaitis MW, D'Amico TA, Berry MF, Hartwig MG. Adding radiation to induction chemotherapy does not improve survival of patients with operable clinical N2 non-small cell lung cancer. J Thorac Cardiovasc Surg 2015; 150:1484-92; discussion 1492-3. [PMID: 26259994 DOI: 10.1016/j.jtcvs.2015.06.062] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 05/05/2015] [Accepted: 06/03/2015] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Radiotherapy is commonly used in induction regimens for patients with non-small cell lung cancer with operable mediastinal nodal disease, although evidence has not shown a benefit over induction chemotherapy alone. We compared outcomes between induction chemotherapy and induction chemoradiation using the National Cancer Data Base. METHODS Induction radiation use and survival of patients who underwent lobectomy or pneumonectomy after induction chemotherapy for clinical T1-3N2M0 non-small cell lung cancer in the National Cancer Data Base from 2003 to 2006 were assessed using logistic regression, general linear regression, Kaplan-Meier, and Cox proportional hazard analysis. RESULTS Of 1362 patients who met study criteria, 834 (61%) underwent induction chemoradiation and 528 (39%) underwent induction chemotherapy. Lobectomy was performed in 82% of patients (n = 1111), and pneumonectomy was performed in 18% of patients (n = 251). Pneumonectomy was performed more often after induction chemoradiation than after induction chemotherapy (20% vs 16%, P = .04). Downstaging from N2 to N0/N1 was more common with induction chemoradiation compared with induction chemotherapy (58% vs 46%, P < .01), but 5-year survival of patients receiving induction chemoradiation and patients receiving induction chemotherapy was similar in unadjusted analysis (41% vs 41%, P = .41). In multivariable analysis, the addition of radiation to induction chemotherapy also was not associated with a survival benefit (hazard ratio, 1.03; 95% confidence interval, 0.89-1.18; P = .73). CONCLUSIONS Induction chemoradiation is used in the majority of patients with non-small cell lung cancer with N2 disease who undergo induction therapy before surgical resection, but it is not associated with improved survival compared with induction chemotherapy.
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Affiliation(s)
| | - Brian C Gulack
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Lin Gu
- Department of Biostatistics, Duke University, Durham, NC
| | - Paul J Speicher
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Xiaofei Wang
- Department of Biostatistics, Duke University, Durham, NC
| | - David H Harpole
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Mark W Onaitis
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Thomas A D'Amico
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Mark F Berry
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, Calif
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Al-Shahrabani F, Vallböhmer D, Angenendt S, Knoefel WT. Surgical strategies in the therapy of non-small cell lung cancer. World J Clin Oncol 2014; 5:595-603. [PMID: 25302164 PMCID: PMC4129525 DOI: 10.5306/wjco.v5.i4.595] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 06/06/2014] [Accepted: 06/27/2014] [Indexed: 02/06/2023] Open
Abstract
Lung cancer represents the leading cause of cancer mortality worldwide. Despite improvements in preoperative staging, surgical techniques, neoadjuvant/adjuvant options and postoperative care, there are still major difficulties in significantly improving survival, especially in locally advanced non-small cell lung cancer (NSCLC). To date, surgical resection is the primary mode of treatment for stage I and II NSCLC and has become an important component of the multimodality therapy of even more advanced disease with a curative intention. In fact, in NSCLC patients with solitary distant metastases, surgical interventions have been discussed in the last years. Accordingly, this review displays the recent surgical strategies implemented in the therapy of NSCLC patients.
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Dickhoff C, Hartemink K, van de Ven P, van Reij E, Senan S, Paul M, Smit E, Dahele M. Trimodality therapy for stage IIIA non-small cell lung cancer: Benchmarking multi-disciplinary team decision-making and function. Lung Cancer 2014; 85:218-23. [DOI: 10.1016/j.lungcan.2014.06.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 06/01/2014] [Accepted: 06/08/2014] [Indexed: 10/25/2022]
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Baltayiannis N, Chandrinos M, Anagnostopoulos D, Zarogoulidis P, Tsakiridis K, Mpakas A, Machairiotis N, Katsikogiannis N, Kougioumtzi I, Courcoutsakis N, Zarogoulidis K. Lung cancer surgery: an up to date. J Thorac Dis 2014; 5 Suppl 4:S425-39. [PMID: 24102017 DOI: 10.3978/j.issn.2072-1439.2013.09.17] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 09/24/2013] [Indexed: 12/25/2022]
Abstract
According to the International Agency for Research on Cancer (IARC) GLOBOCAN World Cancer Report, lung cancer affects more than 1 million people a year worldwide. In Greece according to the 2008 GLOBOCAN report, there were 6,667 cases recorded, 18% of the total incidence of all cancers in the population. Furthermore, there were 6,402 deaths due to lung cancer, 23.5% of all deaths due to cancer. Therefore, in our country, lung cancer is the most common and deadly form of cancer for the male population. The most important prognostic indicator in lung cancer is the extent of disease. The Union Internationale Contre le Cancer (UICC) and the American Joint Committee for Cancer Staging (AJCC) developed the tumour, node, and metastases (TNM) staging system which attempts to define those patients who might be suitable for radical surgery or radical radiotherapy, from the majority, who will only be suitable for palliative measures. Surgery has an important part for the therapy of patients with lung cancer. "Lobectomy is the gold standard treatment". This statement may be challenged in cases of stage Ia cancer or in patients with limited pulmonary function. In these cases an anatomical segmentectomy with lymph node dissection is an acceptable alternative. Chest wall invasion is not a contraindication to resection. En-bloc rib resection and reconstruction is the treatment of choice. N2 disease represents both a spectrum of disease and the interface between surgical and non-surgical treatment of lung cancer Evidence from trials suggests that multizone or unresectable N2 disease should be treated primarily by chemoradiotherapy. There may be a role for surgery if N2 is downstaged to N0 and lobectomy is possible, but pneumonectomy is avoidable. Small cell lung cancer (SCLC) is considered a systemic disease at diagnosis, because the potential for hematogenous and lymphogenic metastases is very high. The efficacy of surgical intervention for SCLC is not clear. Lung cancer resection can be performed using several surgical techniques. Video-assisted thoracoscopic surgery (VATS) lobectomy is a safe, efficient, well accepted and widespread technique among thoracic surgeons. The 5-year survival rate following complete resection of lung cancer is stage dependent. Incomplete resection rarely is useful and cures the patient.
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Mordant P, Fabre É, Gibault L, Arame A, Pricopi C, Dujon A, Le Pimpec-Barthes F, Riquet M. [Impact of induction therapies on pathology and outcome after surgical resection of non-small lung cancer: a 30-year experience of 859 patients]. REVUE DE PNEUMOLOGIE CLINIQUE 2014; 70:9-15. [PMID: 24566030 DOI: 10.1016/j.pneumo.2013.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 12/19/2013] [Accepted: 12/19/2013] [Indexed: 06/03/2023]
Abstract
UNLABELLED The management of localized non-small cell lung cancer (NSCLC) has been modified over the last decades, with induction therapies being increasingly recommended as a prerequisite to surgical resection. However, the relative impact of chemo- and chemoradiotherapy on tumours' pathology and patients' survival is still discussed. METHODS We set a retrospective study including every patient who underwent surgical resection for NSCLC in 2 French centres from 1980 to 2009. We then compared the tumours' pathology and patients' survival according to the use of induction chemotherapy (group 1) or induction chemoradiotherapy (group 2). RESULTS There were 733 patients in group 1 and 126 patients in group 2. In group 1, 669 patients (91%) had platinum-based chemotherapy, for 2 to 3 cycles in 564 cases (77%). In group 2, chemoradiotheray was concomitant in 68 patients (54%), and sequential in 58 patients (46%). As compared with group 1, group 2 was characterized by younger age (mean 59.8±9.5 vs 56.4±9.6, respectively, P<.001), a higher rate of tumours deemed unresectable before induction treatment (25% vs 44%, P<.001), and a higher proportion of T4 (25% vs 44%, P<.001) or N2 diseases (56% vs 69%, P=.005). The type of resection, postoperative complications, and postoperative mortality were not significantly different between groups. On final pathologic report, as compared with group 1, there were more N0 and N1 disease in group 2 (N0: 43% vs 58%, P=.002; N1: 22% vs 10%, P=.002) while the rate of N2 disease was comparable (34% vs 32%, P=ns). The median, 5-, and 10-year survivals were 28 months, 35%, and 21% for group 1, and 29 months, 36%, and 23% for group 2, respectively (P=ns). CONCLUSION As compared with induction chemotherapy, induction chemoradiotherapy was performed in more advanced NSCLC, and resulted in better downstaging, similar postoperative course, and comparable long-term outcome after surgical resection.
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Affiliation(s)
- P Mordant
- Service de chirurgie thoracique, hôpital européen Georges-Pompidou, université Descartes, 20, rue Leblanc, 75015 Paris, France
| | - É Fabre
- Service d'oncologie médicale, hôpital européen Georges-Pompidou, université Descartes, 20, rue Leblanc, 75015 Paris, France
| | - L Gibault
- Service d'anatomopathologie, hôpital européen Georges-Pompidou, université Descartes, 20, rue Leblanc, 75015 Paris, France
| | - A Arame
- Service de chirurgie thoracique, hôpital européen Georges-Pompidou, université Descartes, 20, rue Leblanc, 75015 Paris, France
| | - C Pricopi
- Service de chirurgie thoracique, hôpital européen Georges-Pompidou, université Descartes, 20, rue Leblanc, 75015 Paris, France
| | - A Dujon
- Service de chirurgie thoracique, centre médico-chirurgical du Cèdre, 76230 Bois-Guillaume, France
| | - F Le Pimpec-Barthes
- Service de chirurgie thoracique, hôpital européen Georges-Pompidou, université Descartes, 20, rue Leblanc, 75015 Paris, France
| | - M Riquet
- Service de chirurgie thoracique, hôpital européen Georges-Pompidou, université Descartes, 20, rue Leblanc, 75015 Paris, France.
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Naidoo R, Windsor MN, Goldstraw P. Surgery in 2013 and beyond. J Thorac Dis 2013; 5 Suppl 5:S593-606. [PMID: 24163751 PMCID: PMC3804869 DOI: 10.3978/j.issn.2072-1439.2013.07.39] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 07/29/2013] [Indexed: 01/12/2023]
Abstract
Lung cancer is a leading cause of cancer related mortality. The role of surgery continues to evolve and in the last ten years there have been a number of significant changes in the surgical management of lung cancer. These changes extend across the entire surgical spectrum of lung cancer management including diagnosis, staging, treatment and pathology. Positron Emission Tomography (PET) scanning and ultrasound (EBUS) have redefined traditional staging paradigms, and surgical techniques, including video-assisted thoracoscopy (VATS), robotic surgery and uniportal surgery, are now accepted as standard of care in many centers. The changing pathology of lung cancer, with more peripheral tumours and an increase in adenocarcinomas has important implications for the Thoracic surgeon. Screening, using Low-Dose CT scanning, is having an impact, with not only a higher percentage of lower stage cancers detected, but also redefining the role of sublobar resection. The incidence of pneumonectomy has reduced as have the rates of "exploratory thoracotomy". In general, lung resection is considered for stage I and II patients with a selected role in more advanced stage disease as part of a multimodality approach. This paper will look at these issues and how they impact on Thoracic Surgical practice in 2013 and beyond.
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Affiliation(s)
- Rishendran Naidoo
- Department of Cardiothoracic Surgery, The Prince Charles Hospital, Brisbane, Australia
| | - Morgan N. Windsor
- Department of Cardiothoracic Surgery, The Prince Charles Hospital, Brisbane, Australia
| | - Peter Goldstraw
- Academic Department of Thoracic Surgery, Royal Brompton Hospital, London, UK
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