Lobar emphysema ratio of more than 1% in the lobe with lung cancer as poor predictor for recurrence and overall survival in patients with stage I non-small cell lung cancer

BACKGROUND

The purpose of this study was to examine the relationship between the lobar emphysema ratio (LER) and tumor recurrence and survival in patients with stage I non-small cell lung cancer (NSCLC).

METHODS

We enrolled 258 patients with surgically proven stage I NSCLC. These patients underwent noncontrast chest CT, and pulmonary lobe segmentation and lobar emphysema quantification were performed using commercially available software. We assessed the LER in the lobe with lung cancer. We divided the patients into two groups according to the LER, and the cut-off value was 1. Furthermore, we analyzed the disease-free survival of high LER and other clinical factors after surgical resection.

RESULTS

The 258 patients were divided into two groups: low LER (n = 195) and high LER (n = 63). The right upper lobe was the most frequent location in lung cancer and the most severe location in emphysema. In the Kaplan‒Meier curve, high LER showed a significantly lower disease-free survival (8.21 ± 0.27 years vs 6.53 ± 0.60 years, p = 0.005) and overall survival (9.56 ± 0.15 years vs. 8.51 ± 0.49 years, p = 0.011) than low LER. Stage Ib (2.812 [1.661-4.762], p<0.001) and high LER (2.062 [1.191-3.571], p = 0.010) were poor predictors for disease-free survival in multivariate Cox regression analysis. Stage Ib (4.729 [1.674-13.356], p = 0.003) and high LER (3.346 [1.208-9.269], p = 0.020) were significant predictors for overall survival in multivariate Cox regression analysis.

CONCLUSION

A LER of more than 1% in the lobe with lung cancer is a poor predictor for cancer recurrence and overall survival in patients with stage I NSCLC.

The benefits and harms of adjuvant chemotherapy for non-small cell lung cancer in patients with major comorbidities: A simulation study

BACKGROUND

Randomized controlled trials (RCTs) have demonstrated a survival benefit for adjuvant platinum-based chemotherapy after resection of locoregional non-small cell lung cancer (NSCLC). The relative benefits and harms and optimal approach to treatment for NSCLC patients who have major comorbidities (chronic obstructive pulmonary disease [COPD], coronary artery disease [CAD], and congestive heart failure [CHF]) are unclear, however.

METHODS

We used a simulation model to run in-silico comparative trials of adjuvant chemotherapy versus observation in locoregional NSCLC in patients with comorbidities. The model estimated quality-adjusted life years (QALYs) gained by each treatment strategy stratified by age, comorbidity, and stage. The model was parameterized using outcomes and quality-of-life data from RCTs and primary analyses from large cancer databases.

RESULTS

Adjuvant chemotherapy was associated with clinically significant QALY gains for all patient age/stage combinations with COPD except for patients >80 years old with Stage IB and IIA cancers. For patients with CHF and Stage IB and IIA disease, adjuvant chemotherapy was not advantageous; in contrast, it was associated with QALY gains for more advanced stages for younger patients with CHF. For stages IIB and IIIA NSCLC, most patient groups benefited from adjuvant chemotherapy. However, In general, patients with multiple comorbidities benefited less from adjuvant chemotherapy than those with single comorbidities and women with comorbidities in older age categories benefited more from adjuvant chemotherapy than their male counterparts.

CONCLUSIONS

Older, multimorbid patients may derive QALY gains from adjuvant chemotherapy after NSCLC surgery. These results help extend existing clinical trial data to specific unstudied, high-risk populations and may reduce the uncertainty regarding adjuvant chemotherapy use in these patients.

Severity of emphysema as a prognosticator of resected early lung cancer: an analysis classified by Goddard score

OBJECTIVES

This study aimed to investigate whether the severity of emphysema as classified by Goddard score influences the prognosis of patients with early lung cancer, there are few reports about that.

METHODS

From April 2009 to December 2016, we recruited 412 consecutive patients with completely resected clinical stage 0/IA/IB non-small cell lung cancer. The Goddard score assessed on preoperative computed tomography scan was retrospectively reviewed. Kaplan-Meier and Cox regression analyses were performed to assess the relationship between the Goddard score and early lung cancer prognosis.

RESULTS

The patients were classified into two groups: Goddard score ≤ 4 points and ≥5 points according to the results of receiver operating characteristic curve analysis for recurrence events. The 3-year relapse-free survival rate of emphysema with Goddard score ≤ 4 points (88.6%) was higher than that of emphysema with Goddard score ≥ 5 points (60.8%) (P < 0.001). There was a higher proportion of cancer-related deaths in the group with Goddard score ≥ 5 points compared with the group with Goddard score ≤ 4 points (50% and 32.1%, respectively) (P = 0.082). A Goddard score ≥ 5 points was a significant prognostic factor for relapse-free survival in the univariate (P < 0.001) and multivariate (P = 0.022) analyses. A Goddard score ≥ 5 points was also a significant prognostic factor for overall survival in the univariate (P < 0.001) and multivariate (P = 0.041) analyses.

CONCLUSION

Our findings suggest that emphysema with a Goddard score of ≥5 points may be a factor that can influence the prognosis of patients with primary lung cancer.

The impact of emphysema on surgical outcomes of early-stage lung cancer: a retrospective study

BACKGROUND

The presence of emphysema on computed tomography (CT) is associated with an increased frequency of lung cancer, but the postoperative outcomes of patients with pulmonary emphysema are not well known. The objective of this study was to investigate the association between the extent of emphysema and long-term outcomes, as well as mortality and postoperative complications, in early-stage lung cancer patients after pulmonary resection.

METHODS

The clinical records of 566 consecutive lung cancer patients who underwent pulmonary resection in our department were retrospectively reviewed. Among these, the data sets of 364 pathological stage I patients were available. The associations between the extent of lung emphysema and long-term outcomes and postoperative complications were investigated. Emphysema was assessed on the basis of semiquantitative CT. Surgery-related complications of Grade ≥ II according to the Clavien-Dindo classification were included in this study.

RESULTS

Emphysema was present in 63 patients. The overall survival and relapse-free survival of the non-emphysema and emphysema groups at 5 years were 89.0 and 61.3% (P < 0.001), respectively, and 81.0 and 51.7%, respectively (P < 0.001). On multivariate analysis, significant prognostic factors were emphysema, higher smoking index, and higher histologic grade (p < 0.05). Significant risk factors for poor recurrence-free survival were emphysema, higher smoking index, higher histologic grade, and presence of pleural invasion (P < 0.05). Regarding Grade ≥ II postoperative complications, pneumonia and supraventricular tachycardia were more frequent in the emphysema group than in the non-emphysema group (P = 0.003 and P = 0.021, respectively).

CONCLUSION

The presence of emphysema affects the long-term outcomes and the development of postoperative complications in early-stage lung cancer patients.

Quantitative severity of pulmonary emphysema as a prognostic factor for recurrence in patients with surgically resected non-small cell lung cancer

Background

Pulmonary emphysema is a major component of chronic obstructive pulmonary disease and lung cancer. However the prognostic significance of quantitative emphysema severity in patients with lung cancer is unclear. We analyzed whether numerical emphysema value is a prognostic factor for recurrence in patients with surgically resected non‐small cell lung cancer.

Methods

We quantified emphysema severity of the whole lung and regional lobes in 45 patients (mean age 68.0 years) using an automated chest computed tomography‐based program. Predictive factors for recurrence were investigated using a Cox proportional hazards model. Recurrence‐free and overall survival was compared after dichotomization of patients according to whole lung emphysema severity.

Results

The mean percentage emphysema ratio of the whole lung was 1.21 ± 2.04. Regional lobar emphysema severity was highest in the right middle lobe (1.93 ± 0.36), followed by right upper (1.35 ± 2.50), left upper (1.34 ± 2.12), left lower (1.05 ± 2.52), and right lower (0.78 ± 2.28) lobes. The low severity group showed significantly longer overall survival compared to the high severity group (log‐rank test, P = 0.018). Quantitative emphysema severity of the whole lung (hazard ratio 1.36; 95% confidence interval 1.0–1.73) and stage III (hazard ratio 6.17; 95% confidence interval 1.52–25.0) were independent predictors of recurrence after adjusting for age, gender, smoking status, and forced expiratory volume in one second.

Conclusion

The severity of whole lung emphysema was independently associated with recurrence. Patients with non‐small cell lung cancer and marginal pulmonary emphysema at lower severity survive longer after curative‐intent surgery.

Preoperative risk assessment with computed tomography in patients undergoing lung cancer surgery

Background

Although whole lung computed tomography (CT) is included in the routine workup before lung cancer surgery, it is not utilized to assess the preoperative pulmonary function.

Methods

Two hundred ninety patients (development cohort) who underwent lung lobectomy for cancer in our institute and another 100 patients (validation cohort) who subsequently underwent the same operation in a referral hospital were included. The total lung volume (TLV) and emphysematous lung volume (ELV) were obtained by quantitative CT.

Results

The TLV was higher in patients with a smoking history than in those without. The ELV to the TLV was higher in elderly patients than in younger patients. The regression equation for forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV₁) were developed using CT-derived variables, together with sex, age, height, and smoking habit, by a multiple regression analysis in the development cohort. The regression equation-based FVC and FEV₁ were significantly correlated with the actual FVC and FEV₁ in the development cohort, as well as in the validation cohort. The predicted postoperative FEV₁ (ppo%FEV₁) calculated based on the regression equation was also correlated with the postoperative FEV₁ value obtained by the conventional method (R=0.53), and the regression equation-based ppo%FEV₁ was a significant predictor of postoperative cardiopulmonary complications (P=0.02).

Conclusions

Whole lung CT can be used to assess the preoperative pulmonary function in patients undergoing lobectomy for cancer. This method may be helpful in preoperative risk assessment, particularly in patients who have difficulty in implementation of spirometry.

Lung cancer and chronic obstructive pulmonary disease: From a clinical perspective

Chronic obstructive pulmonary disease (COPD) and lung cancer are devastating pulmonary diseases that commonly coexist and present a number of clinical challenges. COPD confers a higher risk for lung cancer development, but available chemopreventive measures remain rudimentary. Current studies have shown a marked benefit of cancer screening in the COPD population, although challenges remain, including the common underdiagnosis of COPD. COPD-associated lung cancer presents distinct clinical features. Treatment for lung cancer coexisting with COPD is challenging as COPD may increase postoperative morbidities and decrease survival. In this review, we outline current progress in the understanding of the clinical association between COPD and lung cancer, and suggest possible cancer prevention strategies in this patient population.

Regional Emphysema Score Predicting Overall Survival, Quality of Life, and Pulmonary Function Recovery in Early-Stage Lung Cancer Patients

INTRODUCTION

Pulmonary emphysema is a frequent comorbidity in lung cancer, but its role in tumor prognosis remains obscure. Our aim was to evaluate the impact of the regional emphysema score (RES) on a patient's overall survival, quality of life (QOL), and recovery of pulmonary function in stage I to II lung cancer.

METHODS

Between 1997 and 2009, a total of 1073 patients were identified and divided into two surgical groups-cancer in the emphysematous (group 1 [n = 565]) and nonemphysematous (group 2 [n = 435]) regions-and one nonsurgical group (group 3 [n = 73]). RES was derived from the emphysematous region and categorized as mild (≤5%), moderate (6%-24%), or severe (25%-60%).

RESULTS

In group 1, patients with a moderate or severe RES experienced slight decreases in postoperative forced expiratory volume in 1 second, but increases in the ratio of forced expiratory volume in 1 second to forced vital capacity compared with those with a mild RES (p < 0.01); however, this correlation was not observed in group 2. Posttreatment QOL was lower in patients with higher RESs in all groups, mainly owing to dyspnea (p < 0.05). Cox regression analysis revealed that patients with a higher RES had significantly poorer survival in both surgical groups, with adjusted hazard ratios of 1.41 and 1.43 for a moderate RES and 1.63 and 2.04 for a severe RES, respectively; however, this association was insignificant in the nonsurgical group (adjusted hazard ratio of 0.99 for a moderate or severe RES).

CONCLUSIONS

In surgically treated patients with cancer in the emphysematous region, RES is associated with postoperative changes in lung function. RES is also predictive of posttreatment QOL related to dyspnea in early-stage lung cancer. In both surgical groups, RES is an independent predictor of survival.

Lung cancer in chronic obstructive pulmonary disease patients, it is not just the cigarette smoke

PURPOSE OF REVIEW

An important association has been described between chronic obstructive pulmonary disease (COPD) and lung cancer, where different mechanisms have been proposed. There is no unique cause for this association, as COPD is by itself a heterogeneous disease, in which their classical phenotypes (i.e., emphysema and chronic bronchitis) each play an important role in lung cancer development. We will discuss recent evidence that links these two diseases and specific characteristics found in lung cancers from patients with COPD.

RECENT FINDINGS

Molecular studies have found specific gene expressions (reduction and overexpression) in lung tumors from patients with COPD, which likely predispose to increased methylation during lung carcinogenesis, and are associated with aggressiveness. Recent evidence suggests that lung cancer risk is higher in individuals with long telomeres, and that this effect takes place well in advance of diagnosis. Lung cancer is likely to develop in areas of the lung with greater emphysema and the severity of the latter is associated with larger and more aggressive tumors.

SUMMARY

Clinical and molecular studies have found that lung cancers that develop in patients with COPD and/or emphysema appear to be more aggressive and have a distinct molecular profile when compared with tumors from patients without an underlying lung disease. This could have important implications when deciding on personalized treatments.

Impact of Thin-Section Computed Tomography-Determined Combined Pulmonary Fibrosis and Emphysema on Outcomes Among Patients With Resected Lung Cancer

BACKGROUND

There is only limited information on the clinical impact of combined pulmonary fibrosis and emphysema (CPFE) on postoperative and survival outcomes among patients with resected lung cancer.

METHODS

In a retrospective analysis, data were reviewed from 685 patients with resected lung cancer between 2006 and 2011. The clinical impact of thin-section computed tomography (TSCT)-determined emphysema, fibrosis, and CPFE on postoperative and survival outcomes was evaluated.

RESULTS

The emphysema group comprised 32.4% of the study population, the fibrosis group 2.8%, and the CPFE group 8.3%. The CPFE group had a more advanced pathologic stage and higher prevalence of squamous cell carcinoma as compared with the normal group without emphysema or fibrosis findings on TSCT. The incidence of postoperative complications was significantly higher in the CPFE group. Overall, the 30-day mortality in the CPFE group was 5.3%. Cancer recurrence at pathologic stage I and death due to either cancer or other causes were significantly higher in the CPFE group. Survival curves indicated that a finding of CPFE was associated with worse overall survival for patients with any stage disease. Multivariate analysis suggested that pathologic stage and CPFE were independent factors associated with worse overall survival. The adjusted hazard ratio of overall survival for the CPFE group versus the normal group was 2.990 (95% confidence interval: 1.801 to 4.962).

CONCLUSIONS

Among patients with resected lung cancer, the presence of TSCT-determined CPFE might predict worse postoperative and survival outcomes.

Clinical impact of the lower limit of normal of FEV1/FVC on survival in lung cancer patients undergoing thoracic surgery

BACKGROUND

Previously, it has been shown that using a fixed ratio of FEV1/FVC of 0.7 to classify airway obstruction could not predict survival outcomes in lung cancer patients undergoing thoracic surgery. We demonstrated that use of the lower limit of normal (LLN) of FEV1/FVC may allow better risk stratification for postoperative outcomes in patients with chronic obstructive pulmonary disease (COPD) patients. Nevertheless, it remained unclear whether survival outcomes in this population could be predicted by LLN-defined airway obstruction.

OBJECTIVE

To evaluate the clinical relevance of LLN-defined airway obstruction to survival outcomes.

METHODS

The clinical relevance of LLN-defined airway obstruction was analyzed and compared in 699 subjects, using Kaplan-Meier curves and the log-rank test. A Cox regression model was used to explore prognostic risk factors.

RESULTS

One hundred-and-seventy-eight subjects were assigned to the below-LLN group, in which airflow obstruction determined by the FEV1/FVC ratio was below the LLN. Five hundred-and-twenty-one subjects were assigned to the above-LLN group. The below-LLN group had a worse overall survival (OS) and disease-free survival (DFS) than the above-LLN group. The diffusing capacity of the lung for carbon monoxide and the ratio of the inspiratory capacity divided to the total lung capacity were independent risk factors for OS and DFS.

CONCLUSIONS

A standardized assessment of LLN-defined airway obstruction may allow risk stratification for survival likelihood in lung cancer patients who undergo thoracic surgery.