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Ruan Z, Zhuo X, Xu C. Diagnosis, treatment, and prognosis of stage IB non-small cell lung cancer with visceral pleural invasion. Front Oncol 2024; 13:1310471. [PMID: 38288109 PMCID: PMC10822888 DOI: 10.3389/fonc.2023.1310471] [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: 10/09/2023] [Accepted: 12/28/2023] [Indexed: 01/31/2024] Open
Abstract
With the increasing implementation of early lung cancer screening and the increasing emphasis on physical examinations, the early-stage lung cancer detection rate continues to rise. Visceral pleural invasion (VPI), which denotes the tumor's breach of the elastic layer or reaching the surface of the visceral pleura, stands as a pivotal factor that impacts the prognosis of patients with non-small cell lung cancer (NSCLC) and directly influences the pathological staging of early-stage cases. According to the latest 9th edition of the TNM staging system for NSCLC, even when the tumor diameter is less than 3 cm, the final T stage remains T2a if VPI is present. There is considerable controversy within the guidelines regarding treatment options for stage IB NSCLC, especially among patients exhibiting VPI. Moreover, the precise determination of VPI is important in guiding treatment selection and prognostic evaluation in individuals with NSCLC. This article aims to provide a comprehensive review of the current status and advancements in studies pertaining to stage IB NSCLC accompanied by VPI.
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Affiliation(s)
| | | | - Chenyang Xu
- Department of Thoracic Surgery, Ganzhou People’s Hospital, Jiangxi Medical College, Nanchang University, Ganzhou, Jiangxi, China
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Liang S, Wu C, Chang C, Keng L, Lee M, Wang J, Ko J, Liao W, Chen K, Ho C, Shih J, Yu C. Oral uracil-tegafur compared with intravenous chemotherapy as adjuvant therapy for resected early-stage non-small cell lung cancer patients. Cancer Med 2023; 12:17993-18004. [PMID: 37559409 PMCID: PMC10523960 DOI: 10.1002/cam4.6440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 07/22/2023] [Accepted: 07/31/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Studies comparing the effectiveness of either adjuvant oral uracil-tegafur (UFT) or intravenous chemotherapy on early-stage (stage I and II) non-small cell lung cancer (NSCLC) patients treated with complete surgical treatment remain limited. METHODS From January 2011 to December 2017, patients with early-stage NSCLC (defined as tumor size >3 cm without mediastinal lymph node involvement or any distant metastasis) receiving either adjuvant oral UFT or intravenous chemotherapy after surgical resection were identified from the Taiwan Cancer Registry. Overall survival (OS) and relapse-free survival (RFS) were the primary and secondary outcomes, respectively. Propensity matching was used for controlling confounders. RESULTS A total of 840 patients receiving adjuvant therapy after surgery (including 595 oral UFT and 245 intravenous chemotherapy) were enrolled. Before matching, patients using oral UFT had significantly longer OS (HR: 0.69, 95% CI: 0.49-0.98, p = 0.0387) and RFS (HR: 0.79, 95% CI: 0.61-0.97, p = 0.0392) than those with intravenous chemotherapy. A matched cohort of 352 patients was created using 1:1 propensity score-matching. In the Cox regression analysis, the UFT and the matched chemotherapy groups had similar OS (HR: 0.80, 95% CI: 0.48-1.32, p = 0.3753) and RFS (HR: 0.98, 95% CI: 0.72-1.34, p = 0.9149). Among subgroup analysis, oral UFT use was associated with longer RFS among the subgroups of non-drinker (HR: 0.66, 95% CI: 0.34-0.99, p = 0.0478) and patients with stage IB disease (HR: 0.67, 95% CI: 0.42-0.97, p = 0.0341). CONCLUSIONS This population-based study in the real-world setting of Taiwan demonstrates comparable effectiveness between oral UFT and intravenous chemotherapy in terms of clinical outcomes for early-stage NSCLC patients after surgery.
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Affiliation(s)
- Sheng‐Kai Liang
- Department of MedicineNational Taiwan University Cancer CenterTaipeiTaiwan
- Department of Internal MedicineNational Taiwan University Hospital, Hsinchu BranchHsinchuTaiwan
| | - Chang‐Wei Wu
- Department of Internal MedicineNational Taiwan University Hospital, Hsinchu BranchHsinchuTaiwan
| | - Ching‐I Chang
- Department of Nursing, National Taiwan University Hospital and School of Nursing, College of MedicineNational Taiwan UniversityTaipeiTaiwan
- Department of Internal Medicine, National Taiwan University Hospital and College of MedicineNational Taiwan UniversityTaipeiTaiwan
| | - Li‐Ta Keng
- Department of Internal MedicineNational Taiwan University Hospital, Hsinchu BranchHsinchuTaiwan
| | - Meng‐Rui Lee
- Department of Internal MedicineNational Taiwan University Hospital, Hsinchu BranchHsinchuTaiwan
- Department of Internal Medicine, National Taiwan University Hospital and College of MedicineNational Taiwan UniversityTaipeiTaiwan
| | - Jann‐Yuan Wang
- Department of Internal Medicine, National Taiwan University Hospital and College of MedicineNational Taiwan UniversityTaipeiTaiwan
| | - Jen‐Chung Ko
- Department of Internal MedicineNational Taiwan University Hospital, Hsinchu BranchHsinchuTaiwan
| | - Wei‐Yu Liao
- Department of Internal Medicine, National Taiwan University Hospital and College of MedicineNational Taiwan UniversityTaipeiTaiwan
| | - Kuan‐Yu Chen
- Department of Internal Medicine, National Taiwan University Hospital and College of MedicineNational Taiwan UniversityTaipeiTaiwan
| | - Chao‐Chi Ho
- Department of Internal Medicine, National Taiwan University Hospital and College of MedicineNational Taiwan UniversityTaipeiTaiwan
| | - Jin‐Yuan Shih
- Department of Internal Medicine, National Taiwan University Hospital and College of MedicineNational Taiwan UniversityTaipeiTaiwan
| | - Chong‐Jen Yu
- Department of Internal MedicineNational Taiwan University Hospital, Hsinchu BranchHsinchuTaiwan
- Department of Internal Medicine, National Taiwan University Hospital and College of MedicineNational Taiwan UniversityTaipeiTaiwan
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Kong Q, Wang W, Wang Q, Yang Y, Chen G, Jiang T. Clinical characteristics and establishment of a 2-year-OS predictive model of EGFR mutation-positive patients with pleural invasion of lung adenocarcinoma. Medicine (Baltimore) 2023; 102:e34184. [PMID: 37390230 PMCID: PMC10313287 DOI: 10.1097/md.0000000000034184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/13/2023] [Indexed: 07/02/2023] Open
Abstract
To investigate the differences between lung adenocarcinoma with the pleural invasion that has EGFR (epidermal growth factor receptor) 19-del or 21L858R mutations in terms of clinical characteristics and outcomes. EGFR mutation-positive patients with pleural metastasis of lung adenocarcinoma diagnosed in the Department of Respiratory Medicine of Yuhuangding Hospital of Yantai City, Shandong Province, from January 2014 to January 2022 were selected. The clinical data of the patients were collected to retrospectively analyze whether the clinical characteristics and prognosis of patients with 19-del or 21L858R mutation subtype were different and analyze the impact of clinical characteristics on the prognosis of patients. The difference in clinical characteristics between the 2 groups was analyzed by SPSS, P < .05. There was statistical significance. Univariate and multivariate regression analysis was performed with R soft. To establish a 2-year overall survival predictive model for patients with EGFR gene 19-del and 21L858R mutations in patients with pleural invasion of lung adenomas and to provide predictive model maps. Receiver operating characteristic curve, calibration curve, and decision curve analysis were used to evaluate the value of the prediction model in this study. Of the 74 patients included, the 19-del mutation group had a higher incidence of pleural thickening (P = .023) and a lower Ki-67 level (P = .035). There was no difference in 2-year overall survival and progression-free survival between the 2 mutations. There were differences in pleural thickening and Ki-67 index between the 2 groups, but no differences in disease outcome between the 2 groups. The nomogram model established based on gender, treatment regimen, CEA, lymph node metastasis, and pleural changes is accurate and feasible.
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Affiliation(s)
- Qing Kong
- Clinical Medical College, Weifang Medical University, Weifang, People’s Republic of China
| | - Wei Wang
- Clinical Medical College, Weifang Medical University, Weifang, People’s Republic of China
| | - Qingqing Wang
- Yantai Yuhuangding Hospital, Yantai, People’s Republic of China
| | - Yuxia Yang
- Clinical Medical College, Yangzhou University, Yangzhou, China
| | - Gengye Chen
- Respiratory Department of Emergency Center, People’s Hospital of Ningxia Hui Autonomous Region, Yinchuan, People’s Republic of China
| | - Tingshu Jiang
- Department of Respiratory and Critical Care Medicine, Yantai Yuhuangding Hospital, Yantai, People’s Republic of China
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Yang J, Yin H, Liu M, Zou G, Yu B. Effect of pleural invasion on survival of patients with small cell lung cancer: Propensity score analysis and nomogram establishment based on the SEER database. Front Surg 2023; 10:1108732. [PMID: 36911624 PMCID: PMC9995427 DOI: 10.3389/fsurg.2023.1108732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 02/08/2023] [Indexed: 02/25/2023] Open
Abstract
Objectives Pleural invasion (PI) is identified as an adverse prognostic factor for non-small cell lung cancer (NSCLC), but its value in small cell lung cancer (SCLC) remains unclear. We aimed to evaluate the survival effect of PI on overall survival (OS) in SCLC, meanwhile, we established a predictive nomogram based on related risk factors for OS in SCLC patients with PI. Methods We extracted the data of patients diagnosed with primary SCLC between 2010 and 2018 from the Surveillance, Epidemiology, and End Results (SEER) database. The propensity score matching (PSM) method was used to minimize the baseline difference between the non-PI and PI groups. Kaplan-Meier curves and the log-rank test were used for survival analysis. Univariate and multivariate Cox regression analyses were applied to identify the independent prognostic factors. Randomly divided the patients with PI into training (70%) and validation (30%) cohorts. A prognostic nomogram was established based on the training cohort and was evaluated in the validation cohort. The C-index, receiver operating characteristic curves (ROC), calibration curves, and decision curve analysis (DCA) were applied to assess the performance of the nomogram. Results A total of 1,770 primary SCLC patients were enrolled, including1321patients with non-PI and 449 patients with PI. After PSM, the 387 patients in the PI group matched the 387 patients in the non-PI group. By Kaplan-Meier survival analysis, we observed the exact beneficial effect of non-PI on OS in both original and matched cohorts. Multivariate Cox analysis showed similar results to demonstrate a statistically significant benefit for patients with non-PI in both original and matched cohorts. Age, N stage, M stage, surgery, radiotherapy, and chemotherapy were independent prognostic factors for SCLC patients with PI. The C-index of the nomogram in the training and validation cohort was 0.714 and 0.746, respectively. The ROC curves, calibration curves, and DCA curves also demonstrated good predictive performance in the training and validation cohorts of the prognostic nomogram. Conclusion Our study shows that PI is an independent poor prognostic factor for SCLC patients. The nomogram is a useful and reliable tool to predict the OS in SCLC patients with PI. The nomogram can provide strong references to clinicians to facilitate clinic decisions.
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Affiliation(s)
- Jie Yang
- Department of Thoracic Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Hui Yin
- Department of Thoracic Surgery, The First Affiliated Hospital of Shaoyang University, Shaoyang, China
| | - Mingshan Liu
- Department of Thoracic Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Guowen Zou
- Department of Thoracic Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Bentong Yu
- Department of Thoracic Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
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Wang ML, Zhang H, Yu HJ, Tan H, Hu LZ, Kong HJ, Mao WJ, Xiao J, Shi HC. An initial study on the comparison of diagnostic performance of 18F-FDG PET/MR and 18F-FDG PET/CT for thoracic staging of non-small cell lung cancer: Focus on pleural invasion. Rev Esp Med Nucl Imagen Mol 2023; 42:16-23. [PMID: 36243657 DOI: 10.1016/j.remnie.2021.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 12/16/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To compare the diagnostic performance of 18F-FDG PET/MR and PET/CT preliminarily for the thoracic staging of non-small cell lung cancer (NSCLC) with a special focus on pleural invasion evaluation. METHODS 52 patients with pathologically confirmed NSCLC were included and followed for another year. Whole-body 18F-FDG PET/CT and subsequent thoracic PET/MR were performed for initial thoracic staging. Thoracic (simultaneous) PET/MR acquired PET images and MRI sequences including T2 weighted imaging, with and without fat saturation, T1 weighted imaging, and diffusion weighted imaging (DWI). Two radiologists independently assessed the thoracic T, N staging and pleural involvement. The McNemar Chi-square test was used to compare the differences between PET/CT and PET/MR in the criteria. The area under the receiver-operating-characteristic curves (AUC) was calculated. RESULTS Compared to PET/CT, PET/MR exhibited higher sensitivity, specificity in the detection of pleural invasion; 82 % vs. 64% (p = 0.625), 98 % vs. 95% (p = 1.000), PET/MR to PET/CT respectively. The receiver-operating-characteristic analysis results of PET/CT vs PET/MR for the pleural invasion were as follow: AUCPET/CT = 0.79, AUCPET/MR = 0.90, p = 0.21. Both T staging results and N staging results were approximately identical in PET/CT and PET/MR. Differences between PET/CT and PET/MR in T staging, N staging as well as pleural invasion accuracy were not statistically significant (p > 0.05, each). CONCLUSION PET/MR and PET/CT demonstrated equivalent performance about the evaluation of preoperative thoracic staging of NSCLC patients. PET/MR may have greater potential in pleural invasion evaluation for NSCLC, especially for solid nodules, crucial to clinical decision-making, though our results did not demonstrate statistical significance.
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Affiliation(s)
- Ma-Li Wang
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China; Nuclear Medicine Institute of Fudan University, Shanghai, China; Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - He Zhang
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China; Nuclear Medicine Institute of Fudan University, Shanghai, China; Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hao-Jun Yu
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China; Nuclear Medicine Institute of Fudan University, Shanghai, China; Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hui Tan
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China; Nuclear Medicine Institute of Fudan University, Shanghai, China; Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | | | - Han-Jing Kong
- Central Research Institute, UIH Group, Beijing, China
| | - Wu-Jian Mao
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China; Nuclear Medicine Institute of Fudan University, Shanghai, China; Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jie Xiao
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China; Nuclear Medicine Institute of Fudan University, Shanghai, China; Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hong-Cheng Shi
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China; Nuclear Medicine Institute of Fudan University, Shanghai, China; Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China.
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Estudio inicial sobre la comparación del rendimiento diagnóstico de la PET/RM con [18F]FDG y la PET/TC con [18F]FDG para la estadificación torácica del cáncer de pulmón de células no pequeñas: enfoque en la invasión pleural. Rev Esp Med Nucl Imagen Mol 2022. [DOI: 10.1016/j.remn.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Cai JS, Dou XM. Non-small Cell Lung Cancer Surpassing the Elastic Layer Should Remain Classified as pT2a. Semin Thorac Cardiovasc Surg 2022; 35:583-593. [PMID: 35550846 DOI: 10.1053/j.semtcvs.2022.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 04/29/2022] [Indexed: 11/11/2022]
Abstract
We aimed to evaluate the prognostic value of visceral pleural invasion on the survival of node-negative non-small cell lung cancer ≤3 cm using a large cohort. The Kaplan-Meier method was used to compare overall survival (OS); competing risk analysis with Fine-Gray's test was used to compare cancer- specific survival between groups. The least absolute shrinkage and selection operator penalized Cox regression model was used to identify prognostic factors. In total, 9725 eligible cases were included in this study, and they were separated into 3 groups: tumor invasion beneath the elastic layer (PL0), 8837 cases; tumor invasion surpassing the elastic layer (PL1), 505 cases; and tumor invasion to the visceral pleural surface (PL2), 383 cases. Visceral pleural invasion was more likely to occur in poorly differentiated and larger-sized tumors. Survival curves displayed that PL0 conferred better survival rates than PL1 and PL2, and PL1 achieved outcomes equivalent to those of PL2. Tumor size and histology subset analyses further corroborated this conclusion. Least absolute shrinkage and selection operator -penalized Cox regression analysis confirmed that PL status was an independent prognostic factor for both OS and cancer- specific survival. This study supported the notion that in node-negative non-small cell lung cancer ≤3 cm, PL1 patients should remain classified as pT2a, which could improve staging accuracy.
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Affiliation(s)
- Jing-Sheng Cai
- Department of Thoracic Surgery, Peking University People's Hospital, Beijing, P.R. China
| | - Xiao-Meng Dou
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, P.R. China.; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, P.R. China..
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Yang H, Mei T. Prognostic significance of visceral pleural invasion in patients with surgically resected small-cell lung cancer: a population-based study. Jpn J Clin Oncol 2022; 52:1045-1055. [PMID: 35472081 DOI: 10.1093/jjco/hyac062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 04/07/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Visceral pleural invasion is an adverse prognostic factor in non-small-cell lung cancer, but its value in small-cell lung cancer remains unclear. Thus, we investigated the prognostic impact of visceral pleural invasion in patients with surgically resected small-cell lung cancer. METHODS We queried the Surveillance, Epidemiology and End Results Program database for patients diagnosed with stages I-III (excluding N3 and nodal metastasis cannot be evaluated (NX)) small-cell lung cancer from 2004 to 2016, who underwent surgery. To minimize unbalanced baseline characteristics between the visceral pleural invasion and non-visceral pleural invasion groups, one-to-one propensity score matching was employed. A Kaplan-Meier curve was used to compare the overall survival of the two cohorts. A Cox proportional hazards model was adopted to determine the impact of visceral pleural invasion on survival. RESULTS Of the 1416 patients included, 372 (26.27%) presented with visceral pleural invasion. Patients with visceral pleural invasion showed significantly worse overall survival (P < 0.001) both before and after propensity score matching. Multivariable analysis indicated that visceral pleural invasion was an independent adverse factor affecting survival. Patients with visceral pleural invasion showed poorer overall survival (hazard ratio: 1.44; 95% confidence interval: 1.17-1.76; P < 0.001). Subgroup analyses revealed that the non-visceral pleural invasion group was associated with favourable overall survival in N0 patients (P = 0.003) but not in N1 or N2 patients (P = 0.774 and 0.248, respectively). Patients diagnosed at younger ages, females, lower N stage, resection with a lobectomy and adjuvant chemotherapy were associated with improved overall survival in the visceral pleural invasion group. CONCLUSIONS Visceral pleural invasion was an indicator of a poor prognosis for small-cell lung cancer, especially in those with N0 disease. Adjuvant chemotherapy significantly improves patient outcomes for patients with visceral pleural invasion.
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Affiliation(s)
- Hao Yang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing Medical University, Chongqing, P. R. China
| | - Tonghua Mei
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing Medical University, Chongqing, P. R. China
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Huang W, Deng HY, Lin MY, Xu K, Zhang YX, Yuan C, Zhou Q. Treatment Modality for Stage IB Peripheral Non-Small Cell Lung Cancer With Visceral Pleural Invasion and ≤3 cm in Size. Front Oncol 2022; 12:830470. [PMID: 35280762 PMCID: PMC8905598 DOI: 10.3389/fonc.2022.830470] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 01/25/2022] [Indexed: 11/22/2022] Open
Abstract
Purpose To compare the survival difference among lobectomy, segmentectomy, and wedge resection and investigate the role of adjuvant chemotherapy for early-stage small-sized non-small cell lung cancer (NSCLC) with visceral pleural invasion (VPI). Methods Patients diagnosed with stage IB peripheral NSCLC with VPI and ≤3 cm in size in the Surveillance, Epidemiology, and End Results database between 2004 and 2015 were included, and the pleural layer (PL) invasion status was identified to recognize the tumors with VPI, including PL1 and PL2. We conducted Cox proportional hazards model in multivariable analysis and subgroup analysis via propensity score matching (PSM) method and Cox regression method to figure out the optimal therapy for these patients. Results A total of 1,993 patients were included, all of whom received surgery, and the median follow-up was 33 months (range, 1–83 months). In multivariable analysis, age, gender, histology, pathological grade, lymph node examination, surgical approaches, and radiotherapy were independent prognostic factors for overall survival (OS). Lobectomy was superior to sublobar resection [hazard ratio (HR) = 1.41; 95% CI, 1.08–1.83], and wedge resection was associated with impaired survival compared to lobectomy (HR = 1.64; 95% CI, 1.22–2.20) in PSM analyses. In subgroup analysis, lobectomy was superior to sublobar resection among those aged <70 years (HR = 1.81; 95% CI, 1.13–2.90), female (HR = 1.75; 95% CI, 1.21–2.53), and 1–20 mm in size (HR = 1.61; 95% CI, 1.11–2.33). No survival benefit was observed for adjuvant chemotherapy. Conclusions Lobectomy was superior to wedge resection and comparable with segmentectomy for stage IB NSCLC (≤3 cm) with VPI, and adjuvant chemotherapy could not benefit these patients, even in those with sublobar resection. The preferred surgical procedure remains to be studied in prospective controlled trials.
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Affiliation(s)
- Weijia Huang
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Han-Yu Deng
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Han-Yu Deng, ; Qinghua Zhou,
| | - Ming-Ying Lin
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Kai Xu
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Yu-Xiao Zhang
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Chi Yuan
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Qinghua Zhou
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Han-Yu Deng, ; Qinghua Zhou,
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Sui Q, Liang J, Hu Z, Xu X, Chen Z, Huang Y, Zhao M, Zhan C, Wang L, Lin Z, Wang Q. The clinical prognostic factors of patients with stage IB lung adenocarcinoma. Transl Cancer Res 2022; 10:4727-4738. [PMID: 35116327 PMCID: PMC8799094 DOI: 10.21037/tcr-21-1174] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 09/14/2021] [Indexed: 12/24/2022]
Abstract
Background Lung adenocarcinoma (ADC) at stage IB has its own prognostic characteristics. This study aimed to investigate the clinical factors that may affect the prognosis of patients with stage IB ADC. Methods The data of ADC cases were selected from the Surveillance, Epidemiology, and End Results (SEER) database (2010–2016) and patients in Zhongshan Hospital, Fudan University (Department of Thoracic Surgery, 2015–2016). Kaplan-Meier method was used to obtain the overall survival (OS). Factors that significantly related to the prognosis were evaluated by univariate and multivariate analysis (UVA, MVA) using the Cox model. A nomogram was developed and validated to predict the 3-year OSs of those patients. Results 7,605 patients with stage IB ADC were included ultimately and were divided into two groups, a training cohort (n=5,324) and a test cohort (n=2,281). Besides, there was a validation cohort (n=272) for the verification of the nomogram model. Those with significantly older age, male, the white race, lower grades of tumor differentiation, larger tumor size (31–40 mm) without pleural layer (PL) invasion as well as receiving sublobectomy suffered from poorer survival (P<0.001), which were identified as independent factors for stage IB ADC (P<0.001), and according to which, a nomogram model was created. Conclusions Age, sex, race, histological grade, surgery to the primary site, and tumor size combined with PL invasion were independent risk factors for stage IB ADC, based on which a nomogram was constructed to predict the prognosis.
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Affiliation(s)
- Qihai Sui
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiaqi Liang
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhengyang Hu
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xinming Xu
- School of Basic Medical Sciences, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhencong Chen
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yiwei Huang
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Mengnan Zhao
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Cheng Zhan
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lin Wang
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zongwu Lin
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qun Wang
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
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De Giglio A, Di Federico A, Gelsomino F, Ardizzoni A. Prognostic relevance of pleural invasion for resected NSCLC patients undergoing adjuvant treatments: A propensity score-matched analysis of SEER database. Lung Cancer 2021; 161:18-25. [PMID: 34492552 DOI: 10.1016/j.lungcan.2021.08.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 08/27/2021] [Accepted: 08/30/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Adjuvant chemotherapy demonstrated a clear benefit in resected non-small cell lung cancer (NSCLC) with nodal disease (stages II-III), and a minimal benefit in tumors >4 cm (stage II, TNM 8th edition). Pleural invasion (PL), classified as visceral pleural invasion (VPI, which includes PL1 and PL2, and parietal pleural invasion (PL3), is an established negative prognostic factor. However, whether PL should influence the decisional algorithm of postoperative chemotherapy is controversial. METHODS A survival analysis of NSCLC patients who underwent radical surgery between 2010 and 2015 included in the SEER database was performed. Tumor stage and size, number of examined and positive nodes, histology, PL, and treatment data were extracted. Propensity score matching was performed. The benefit of chemotherapy was analyzed in two subgroups: standard of care (SOC), including patients with positive nodes or tumors ≥ 4 cm; non-SOC, including patients with tumors < 4 cm and negative nodes. RESULTS Records of 30,858 patients were extracted. 11,708 patients were included in the propensity score-matched analysis. In the SOC subgroup, including 8089 patients, all pleural invasion degrees were associated with progressively increased risk for death and shorter overall survival (OS), independently from chemotherapy administration. However, chemotherapy significantly improved the median OS regardless of the extent of PL. In the non-SOC subgroup, including 3619 patients, only PL3 was associated with increased mortality. The administration of chemotherapy did not improve survival outcomes. CONCLUSION Chemotherapy should be strongly recommended in patients in the SOC-subgroup with pleural invasion. VPI is not associated with unfavorable prognosis in the non-SOC subgroup.
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Affiliation(s)
- Andrea De Giglio
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy; Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
| | - Alessandro Di Federico
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Francesco Gelsomino
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy; Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andrea Ardizzoni
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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12
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Wang Y, Qian F, Hu M, Chen Y, Yang Z, Han B. Clinical significance of visceral pleural and lymphovascular invasion in surgically resected adenosquamous lung cancer. Eur J Cardiothorac Surg 2021; 59:617-623. [PMID: 33200178 DOI: 10.1093/ejcts/ezaa353] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/13/2020] [Accepted: 08/14/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The aim of this study was to assess the relationship between visceral pleural invasion (VPI), lymphovascular invasion (LVI) and other clinicopathological characteristics and their prognostic impact on surgically resected adenosquamous carcinoma (ASC). METHODS We retrospectively reviewed 256 patients with radically resected ASC between January 2010 and December 2015. Patients were divided into 2 groups: those with VPI and those with LVI. The effects of VPI and LVI on disease-free survival and overall survival were evaluated, further stratified by tumour size and lymph node status. RESULTS Finally, 213 patients with ASC were enrolled in our study. VPI was correlated with tumour location (P < 0.001), pT stage (P < 0.001) and pN stage (P = 0.012). LVI was related to age (P = 0.005) and pN stage (P = 0.003). Both VPI and LVI were adverse prognostic factors for disease-free survival (P = 0.008, P = 0.028) and overall survival (P = 0.005, P = 0.009) using the Kaplan-Meier method. In multivariable analysis only, VPI was an independent risk factor for disease-free survival [hazard ratio (HR) 0.61, 95% confidence interval (CI) 0.42-0.87; false discovery rate, adjusted P = 0.020] and overall survival (HR 0.60, 95% CI 0.42-0.86; false discovery rate, adjusted P = 0.017). When the prognostic value of VPI was stratified by tumour size and lymph node status, we observed that only patients with VPI in tumours ≤4 cm and patients with N0 status had a worse prognosis than those without visceral invasion (P < 0.05). CONCLUSIONS VPI and LVI were poor prognostic factors in patients with ASC, but only VPI was an independent factor for survival, especially in patients with tumours ≤4 cm and pN0 status.
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Affiliation(s)
- Yanan Wang
- Department of Pulmonary, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Fangfei Qian
- Department of Pulmonary, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Minjuan Hu
- Department of Pulmonary, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ya Chen
- Department of Pulmonary, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zhengyu Yang
- Department of Pulmonary, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Baohui Han
- Department of Pulmonary, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
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Qi M, Bian D, Zhang J, Zhu X, Zhou C, Zhang L. The modification of T description according to visceral pleural invasion and tumor size from 3.1 cm to 4.0 cm in non-small cell lung cancer: A retrospective analysis based on the SEER database. Lung Cancer 2021; 158:47-54. [PMID: 34119932 DOI: 10.1016/j.lungcan.2021.06.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 05/31/2021] [Accepted: 06/02/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVES As a poor prognostic factor, visceral pleural invasion (VPI) was incorporated into non-small cell lung cancer (NSCLC) staging system. For modifying the T description of NSCLC, the prognostic value of VPI was assessed. MATERIALS AND METHODS From 2010-2015, data on stage pT2N0M0 NSCLC patients with tumor size (TS) from 3.1 cm to 5.0 cm who received surgery from the Surveillance, Epidemiology, and End Results (SEER) database were enrolled retrospectively. Propensity score matching was utilized to balance the baseline factors according to different TS intervals. Overall survival (OS) was assessed by the Kaplan-Meier method and log-rank test. Univariate and multivariate analysis were applied to identify the prognostic factors. The risk factors of VPI were calculated by logistic regression model. RESULT The sum of 4005 resected stage pT2N0M0 NSCLC patients with TS from 3.1 cm to 5.0 cm were recruited, which had 1084 patients with VPI and 2921 patients without VPI respectively. As TS interval of 3.1-4.0 cm, the 5-year OS of patients without VPI was significantly better than those with VPI (62.6 % vs 58.7 %, P = 0.015), while the 5-year OS of patients with VPI and TS interval of 3.1-4.0 cm had no significant difference compared with patients whose TS interval of 4.1-5.0 cm (58.7 % vs 58.8 %, P = 0.918). Logistic regressive analysis manifested that older age, female, worse differentiation grade and larger TS had higher incidence of VPI (OR = 1.01, 1.25, 1.25, 1.16, respectively; P < 0.05 for all). CONCLUSION This study underlined the prognostic effect of VPI and suggested that early-stage NSCLC with VPI and TS interval of 3.1-4.0 cm could be appropriately upstaged from pT2a (stage pIB) to pT2b (modified stage pIIA).
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Affiliation(s)
- Mengfan Qi
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Dongliang Bian
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jing Zhang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xinsheng Zhu
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Caicun Zhou
- Department of Oncology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.
| | - Lei Zhang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.
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Zhang X, Xie J, Hu S, Peng W, Xu B, Li Y, Li C. Prognostic value of visceral pleural invasion in the stage pT 1-2N 2M 0 non-small cell lung cancer: A study based on the SEER registry. Curr Probl Cancer 2020; 45:100640. [PMID: 32828574 DOI: 10.1016/j.currproblcancer.2020.100640] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 07/22/2020] [Accepted: 07/23/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Visceral pleural invasion (VPI) is considered an adverse prognostic factor in non-small cell lung cancer (NSCLC). However, the prognostic roles of VPI in Ⅲ/N2 NSCLC remain controversial. Therefore, this study aims to evaluate the prognostic value of VPI in patients with postoperative stage pT1-2N2M0 NSCLC. METHODS Using the Surveillance, Epidemiology, and End Results (SEER) database, we screened for patients with stage T1-2N2M0 NSCLC who received surgery from 2010 to 2015. To reduce baseline differences between Non-VPI group and VPI group, two-to-one propensity score matching (PSM) was performed. Cox proportional hazards regression was used to identify factors associated with survival. Overall survival (OS) was between the Non-VPI group and the VPI+ group by the Kaplan-Meier analysis. RESULTS We identified 1374 postoperative NSCLC patients with stage pT1-2N2M0. The majority of cases (N = 1047, 76.8%) are Non-VPI patients. The factors associated with VPI+ group included white race (P < 0.0001), and adenocarcinoma (P < 0.0001). When analyzed in the total study population, VPI status remained a significant independent predictor of worse OS compared with the Non-VPI group (HR, 1.343; 95% CI, 1.083-1.665 [P=0.007]). Besides, in a subgroup analysis by VPI status, the results showed that patients without treatment exhibited a higher risk level in the Non-VPI group (P<0.0001). However, we did not find statistically significant differences among treatments in the VPI+ group (P=0.199). Mean survival time was 49.5 months (95% CI: 45.7-53.3 months) for chemotherapy alone in the Non-VPI group, compared with 41.2 months (95% CI: 35.8-46.6 months) in VPI+ groups. In both the VPI group and the non-VPI group, there is no statistical difference between adjuvant chemotherapy combined with PORT and chemotherapy alone. CONCLUSION This study emphasizes that the presence of VPI is a poor prognostic factor, even in patients with Ⅲ/N2 NSCLC. As the study shows, chemotherapy significantly improved overall survival of patients with postoperative stage pT1-2N2M0 NSCLC, especially for Non-VPI patients. However, the significance of PORT is still worth further exploration.
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Affiliation(s)
- Xian Zhang
- Department of Respiration, First People's Hospital of Changzhou, Third Affiliated Hospital of Soochow University, Juqian Road No.185, Changzhou, China
| | - Jun Xie
- Department of Respiration, First People's Hospital of Changzhou, Third Affiliated Hospital of Soochow University, Juqian Road No.185, Changzhou, China
| | - Song Hu
- Department of Respiration, First People's Hospital of Changzhou, Third Affiliated Hospital of Soochow University, Juqian Road No.185, Changzhou, China
| | - WanDa Peng
- Department of Respiration, First People's Hospital of Changzhou, Third Affiliated Hospital of Soochow University, Juqian Road No.185, Changzhou, China
| | - Bin Xu
- Department of Tumor Biological Treatment, First People's Hospital of Changzhou, Third Affiliated Hospital of Soochow University, Juqian Road No.185, Changzhou, China
| | - Yan Li
- Department of Respiration, First People's Hospital of Changzhou, Third Affiliated Hospital of Soochow University, Juqian Road No.185, Changzhou, China
| | - Chong Li
- Department of Respiration, First People's Hospital of Changzhou, Third Affiliated Hospital of Soochow University, Juqian Road No.185, Changzhou, China.
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Effects of adjuvant chemotherapy on survival of patients with stage IB non-small cell lung cancer with visceral pleural invasion. J Cancer Res Clin Oncol 2020; 146:2231-2239. [PMID: 32533405 DOI: 10.1007/s00432-020-03276-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 05/29/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Adjuvant chemotherapy could improve the prognosis of stage II-III non-small cell lung cancer (NSCLC). However, its influences on stage IB were controversial. The purpose of this study was to investigate whether patients with stage IB NSCLC could benefit from adjuvant chemotherapy. METHODS Stage IB NSCLC in 2010-2015 was selected from the surveillance, epidemiology, and end result database. Chi square test was used to compare the clinical characteristics of patients with different adjuvant chemotherapy status. Kaplan-Meier survival curves were plotted by the log-rank test. Cox proportional hazard regression was used to perform multivariate analysis on overall survival (OS), and the life table method was employed to calculate 1-, 3-, and 5-year survival rates. RESULTS A total of 2915 patients were included in this study, and the number of patients with visceral pleural invasion (VPI) was 1096 (37.6%), of which 145 (13.2%) received adjuvant chemotherapy. There was no statistical difference in OS among the total population with or without chemotherapy (p = 0.295), nor in patients with VPI (p = 0.216). In patients with VPI, the 1-, 3-, 5-year survival curves of patients who are receiving adjuvant chemotherapy showed an upward trend compared with patients who did not. Additionally, female, high differentiated, adenocarcinoma, and tumor size ≤ 3 cm were also independent prognostic factors for improving the prognosis of patients with VPI. CONCLUSION In our study, stage IB NSCLC did not benefit from adjuvant chemotherapy, even in patients with VPI. However, the significance of adjuvant chemotherapy in patients with VPI is still worth further exploration.
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Yu Y, Huang R, Wang P, Wang S, Ling X, Zhang P, Yu J, Wang J, Xiao J, Wang Z. Sublobectomy versus lobectomy for long-term survival outcomes of early-stage non-small cell lung cancer with a tumor size ≤2 cm accompanied by visceral pleural invasion: a SEER population-based study. J Thorac Dis 2020; 12:592-604. [PMID: 32274125 PMCID: PMC7138986 DOI: 10.21037/jtd.2019.12.121] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background The optimal surgical strategy for early-stage non-small cell lung cancer (NSCLC) with visceral pleural invasion (VPI) remains unclear. Due to limited prospective comparative data for these surgical modalities, the objective of the current study was to compare the long-term survival outcomes of sublobectomy (Sub) versus lobectomy (Lob) for NSCLC with a tumor size ≤2 cm and VPI. Methods Patients with early-stage NSCLC characterized by VPI diagnosed between 2004 and 2013 were identified from the Surveillance, Epidemiology, and End Results (SEER) program. The baseline demographic and cancer characteristics, treatment information as well as survival outcome data were extracted from the SEER database, and confounders were balanced by propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) analyses. Lung disease-specific survival (DSS) and overall survival (OS) rates were compared with Cox proportional hazards (PH) regression models based on the unmatched cohort, the propensity-based matched cohort, and the IPTW cohort. Results Of the 1,386 patients enrolled, 1,000 (72.15%) and 386 (27.85%) underwent lobectomy and sublobectomy, respectively. The 5-year DSS rate was 78.64% for the lobectomy group and 59.47% for the sublobectomy group. Cox regression models demonstrated that the operation type (Sub vs. Lob) was an independent prognostic factor for early-stage NSCLC with VPI based on the three different cohorts. Patients who underwent lobectomy showed better long-term DSS and OS rates than those treated with sublobectomy after PSM [DSS: hazard ratio (HR) 0.689, 95% confidence interval (CI): 0.490–0.968, P=0.032; OS: HR 0.723, 95% CI: 0.549–0.953, P=0.021]. The IPTW analysis yielded similar results. Conclusions Lobectomy showed superior long-term survival compared with sublobectomy in patients with early-stage NSCLC with a tumor size ≤2 cm and VPI.
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Affiliation(s)
- Yue Yu
- Department of Cardiothoracic Surgery, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Renhong Huang
- Department of General Surgery, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Pei Wang
- Department of Cardiothoracic Surgery, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Suyu Wang
- Department of Cardiothoracic Surgery, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Xinyu Ling
- Department of Cardiothoracic Surgery, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Peng Zhang
- Department of Cardiothoracic Surgery, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Jingwen Yu
- Department of Cardiothoracic Surgery, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Jun Wang
- Department of Cardiothoracic Surgery, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Jian Xiao
- Department of Cardiothoracic Surgery, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Zhinong Wang
- Department of Cardiothoracic Surgery, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
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Wo Y, Zhao Y, Qiu T, Li S, Wang Y, Lu T, Qin Y, Song G, Miao S, Sun X, Liu A, Kong D, Dong Y, Leng X, Du W, Jiao W. Impact of visceral pleural invasion on the association of extent of lymphadenectomy and survival in stage I non-small cell lung cancer. Cancer Med 2019; 8:669-678. [PMID: 30706688 PMCID: PMC6382711 DOI: 10.1002/cam4.1990] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 12/26/2018] [Accepted: 01/05/2019] [Indexed: 12/25/2022] Open
Abstract
Visceral pleural invasion (VPI) has been identified as an adverse prognostic factor for non‐small cell lung cancer (NSCLC). Accurate nodal staging for NSCLC correlates with improved survival, but it is unclear whether tumors with VPI require a more extensive lymph nodes (LNs) dissection to optimize survival. We aimed to evaluate the impact of VPI status on the optimal extent of LNs dissection in stage I NSCLC, using the Surveillance, Epidemiology, and End Results (SEER) database. We identified 9297 surgically treated T1‐2aN0M0 NSCLC patients with at least one examined LNs. Propensity score matching was conducted to balance the baseline clinicopathologic characteristics between the VPI group and non‐VPI group. Log‐rank tests along with Cox proportional hazards regression methods were performed to evaluate the impact of extent of LNs dissection on survival. VPI was correlated with a significant worse survival, but there was no significant difference in survival rate between PL1 and PL2. Patients who underwent sublobectomy had slightly decreased survival than those who underwent lobectomy. Pathologic LNs examination was significantly correlated with survival. Examination of 7‐8 LNs and 14‐16 LNs conferred the lowest hazard ratio for T1‐sized/non‐VPI tumors (stage IA) and T1‐sized/VPI tumors (stage IB), respectively. The optimal extent of LNs dissection varied by VPI status, with T1‐sized/VPI tumors (stage IB) requiring a more extensive LNs dissection than T1‐sized/non‐VPI tumors (stage IA). These results might provide guidelines for surgical procedure in early stage NSCLC.
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Affiliation(s)
- Yang Wo
- Department of Thoracic SurgeryAffiliated Hospital of Qingdao UniversityQingdaoChina
| | - Yandong Zhao
- Department of Thoracic SurgeryAffiliated Hospital of Qingdao UniversityQingdaoChina
| | - Tong Qiu
- Department of Thoracic SurgeryAffiliated Hospital of Qingdao UniversityQingdaoChina
| | - Shicheng Li
- Department of Thoracic SurgeryAffiliated Hospital of Qingdao UniversityQingdaoChina
| | - Yuanyong Wang
- Department of Thoracic SurgeryAffiliated Hospital of Qingdao UniversityQingdaoChina
| | - Tong Lu
- Department of Thoracic SurgeryAffiliated Hospital of Qingdao UniversityQingdaoChina
| | - Yi Qin
- Department of Thoracic SurgeryAffiliated Hospital of Qingdao UniversityQingdaoChina
| | - Guisong Song
- Department of Thoracic SurgeryAffiliated Hospital of Qingdao UniversityQingdaoChina
| | - Shuncheng Miao
- Department of Thoracic SurgeryAffiliated Hospital of Qingdao UniversityQingdaoChina
| | - Xiao Sun
- Department of Thoracic SurgeryAffiliated Hospital of Qingdao UniversityQingdaoChina
| | - Ao Liu
- Department of Thoracic SurgeryAffiliated Hospital of Qingdao UniversityQingdaoChina
| | - Dezhi Kong
- Department of Thoracic SurgeryAffiliated Hospital of Qingdao UniversityQingdaoChina
| | - Yanting Dong
- Department of Thoracic SurgeryAffiliated Hospital of Qingdao UniversityQingdaoChina
| | - Xiaoliang Leng
- Department of Thoracic SurgeryAffiliated Hospital of Qingdao UniversityQingdaoChina
| | - Wenxing Du
- Department of Thoracic SurgeryAffiliated Hospital of Qingdao UniversityQingdaoChina
| | - Wenjie Jiao
- Department of Thoracic SurgeryAffiliated Hospital of Qingdao UniversityQingdaoChina
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Yip R, Ma T, Flores RM, Yankelevitz D, Henschke CI. Survival with Parenchymal and Pleural Invasion of Non-Small Cell Lung Cancers Less than 30 mm. J Thorac Oncol 2019; 14:890-902. [PMID: 30685507 DOI: 10.1016/j.jtho.2019.01.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 12/12/2018] [Accepted: 01/06/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To determine long-term survival of visceral pleural invasion (VPI) and parenchymal invasion (PAI) (angiolymphatic and/or vascular) on survival of NSCLCs less than 30 mm in maximum diameter. METHODS Kaplan-Meier survivals for NSCLCs, with and without VPI and/or PAI, were determined for a prospective cohort of screening participants stratified by pathologic tumor size (≤10 mm, 11-20 mm, and 21-30 mm) and nodule consistency. Log-rank test statistics were calculated. RESULTS The frequency of PAI versus VPI was significantly lower in patients with subsolid nodules than in those with solid nodules (4.9% versus 27.7% [p < 0.0001]), and correspondingly, Kaplan-Meier lung cancer survival was significantly higher among patients with subsolid nodules (99.1% versus 91.3% [p = 0.0009]). Multivariable Cox regression found that only tumor diameter (adjusted hazard ratio [HR] =1.07, 95% confidence interval [CI]: 1.01-1.14, p = 0.02) and PAI (adjusted HR = 3.15, 95% CI: 1.25-7.90, p = 0.01) remained significant, whereas VPI was not significant (p = 0.15). When clinical and computed tomography findings were included with the pathologic findings, Cox regression showed that the risk of dying of lung cancer increased 10-fold (HR = 10.06, 95% CI: 1.35-75.30) for NSCLCs in patients with solid nodules and more than twofold (by a factor of 2.27) in patients with moderate to severe emphysema (HR = 2.27, 95% CI: 1.01-5.11), as well as with increasing tumor diameter (HR = 1.06, 95% CI: 1.01-1.13), whereas PAI was no longer significant (p = 0.19). CONCLUSIONS Nodule consistency on computed tomography was a more significant prognostic indicator than either PAI or VPI. We propose that patients with NSCLC with VPI and a maximum tumor diameter of 30 mm or less not be upstaged to T2 without further large, multicenter studies of NSCLCs, stratified by the new T status and that classification be considered separately for patients with subsolid or solid nodules.
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Affiliation(s)
- Rowena Yip
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Teng Ma
- Department of Diagnostic Ultrasound, Tong Ren Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Raja M Flores
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - David Yankelevitz
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Claudia I Henschke
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York.
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Tanju S, Erus S, Selçukbiricik F, İliaz S, Kapdağlı M, Bulutay P, Sevinç TE, Mandel NM, Dilege Ş. Level of pleural invasion effects on prognosis in lung cancer. TUMORI JOURNAL 2018; 105:155-160. [DOI: 10.1177/0300891618792463] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To analyze the extent of visceral pleural invasion (VPI) and its effect on survival along with its place in determining the T descriptor in TNM staging in our patients. Methods: A total of 233 patients underwent lung resection. The data were retrospectively analyzed in terms of sex, age, histopathologic type, stage of the tumor, extent of VPI, and survival. Patients who had neoadjuvant chemotherapy or chemoradiotherapy, distant metastasis, parietal pleural invasion, and operative mortality were excluded. Results: The median follow-up was 59 months (range 4–126). The extent of VPI was PL0 in 119 (65.7%) patients, PL1 in 47 (26%) patients, and PL2 in 15 (8%) patients. The median survival rates were 65 (range 43–96) months for PL0, 54 (range 37–72) months for PL1, and 39 (range 12–69) months for PL2. The 5-year overall survival rates were 74.7% for PL0, 77.8% for PL1, and 53.3% for PL2. There were statistically significant differences in overall survival among PL0, PL1, and PL2 ( p = 0.03). In subgroup analysis, the difference was insignificant in PL0 vs PL1 ( p = 0.81), but significant in PL0 vs PL2 ( p = 0.02) and PL1 vs PL2 ( p = 0.04) groups. Conclusions: This study emphasizes that the presence of VPI is related with poor prognosis independent of lymph node positivity, histologic subtypes, and tumor size. As the study shows, PL0 and PL1 have similar survival rates and these two groups may be considered as VPI (−) patients whereas PL2 disease affects survival outcomes.
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Affiliation(s)
- Serhan Tanju
- Department of General Thoracic Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Suat Erus
- Department of General Thoracic Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Fatih Selçukbiricik
- Department of Medical Oncology, Koç University School of Medicine, Istanbul, Turkey
| | - Sinem İliaz
- Department of Pulmonary Medicine, Koç University School of Medicine, Istanbul, Turkey
| | - Murat Kapdağlı
- Department of General Thoracic Surgery, VKF American Hospital, Istanbul, Turkey
| | - Pınar Bulutay
- Department of Pathology, Koç University School of Medicine, Istanbul, Turkey
| | - Tolga Evrim Sevinç
- Department of General Thoracic Surgery, Koç University School of Medicine, Istanbul, Turkey
| | - Nil Molinas Mandel
- Department of Pulmonary Medicine, Koç University School of Medicine, Istanbul, Turkey
| | - Şükrü Dilege
- Department of General Thoracic Surgery, Koç University School of Medicine, Istanbul, Turkey
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CT diagnosis of pleural and stromal invasion in malignant subpleural pure ground-glass nodules: an exploratory study. Eur Radiol 2018; 29:279-286. [DOI: 10.1007/s00330-018-5558-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 04/23/2018] [Accepted: 05/23/2018] [Indexed: 12/19/2022]
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Deng HY, Li G, Luo J, Alai G, Zhuo ZG, Lin YD. Novel biologic factors correlated to visceral pleural invasion in early-stage non-small cell lung cancer less than 3 cm. J Thorac Dis 2018; 10:2357-2364. [PMID: 29850141 DOI: 10.21037/jtd.2018.03.185] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background Visceral pleural invasion (VPI) in early-stage non-small cell lung cancer (NSCLC) is traditionally believed as the result of too much close distance between cancerous lesion and the visceral pleura, but whether there are any other biologic factors correlated to VPI beyond our instinctive thoughts remains unclear. Therefore, we conducted this study to investigate potential factors correlated to VPI comprehensively. Methods Both clinical and pathological characteristics of patients undergoing surgery for NSCLC with a size of ≤3 cm were retrospectively analysed. Results A total of 403 patients were included for analysis. Patients with VPI had older age than those without (61.1 vs. 56.1 years; P<0.001). The mean size of NSCLCs with VPI was larger than those without (2.1 vs. 1.6 cm; P<0.001). Moreover, NSCLCs with VPI were located closer to visceral pleura (0.8 vs. 1.3 cm; P<0.001) and showed larger rates of pleural indentation (86.8% vs. 45.6%; P<0.001) and spiculation (59.7% vs. 34.7%; P<0.001) than those without. Pathologically, NSCLCs with VPI tended more likely to be adenocarcinomas (96.9% vs. 92.7%; P=0.097), and was more likely to be poorly differentiated (38.0% vs. 15.3%; P<0.001), to have cancer embolus (6.2% vs. 0.7%; P=0.001) and lymph node metastasis (29.5% vs. 10.2%; P<0.001) than those without. Besides shorter distance to visceral pleura [odds ratio (OR)=2.169, 95% CI: 1.221-3.855; P=0.008], older age [OR =2.119, 95% confidence interval (CI): 1.255-3.503; P=0.005], pleural indentation (OR =3.679, 95% CI: 1.888-7.169; P<0.001), adenocarcinoma (OR =4.741, 95% CI: 1.383-16.255; P=0.013), and poor tumor differentiation (OR =11.816, 95% CI: 4.470-31.234; P<0.001) were also found to be closely correlated to VPI in early-stage NSCLC. Conclusions Besides shorter distance to visceral pleura and pleural indentation, elderly, adenocarcinoma, and poor tumor differentiation were novel biologic factors correlated to VPI in early-stage NSCLC, which may explain why VPI was an unfavorable prognostic factor for early-stage NSCLC.
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Affiliation(s)
- Han-Yu Deng
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China.,Lung Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Gang Li
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jun Luo
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Guha Alai
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Ze-Guo Zhuo
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yi-Dan Lin
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
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22
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Hashimoto M, Tanaka F, Yoneda K, Takuwa T, Matsumoto S, Okumura Y, Kondo N, Tsujimura T, Nakano T, Hasegawa S. Positive correlation between postoperative tumor recurrence and changes in circulating tumor cell counts in pulmonary venous blood (pvCTC) during surgical manipulation in non-small cell lung cancer. J Thorac Dis 2018; 10:298-306. [PMID: 29600060 DOI: 10.21037/jtd.2017.12.56] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background In non-small cell lung cancer (NSCLC), circulating tumor cells (CTC) are shed and circulate to the peripheral blood through the pulmonary vein. Previously, CTC count in pulmonary venous blood (pvCTC) was shown to significantly increase after surgical manipulation. Therefore, we assessed the correlation between the changes in the pvCTC count (ΔpvCTC) and clinical outcomes. Methods Consecutive patients with peripheral-type, NSCLC, who underwent lobectomy or bi-lobectomy through open thoracotomy, were enrolled prospectively. Before and after lobectomy, 2.5 mL of blood was drawn from the associated lobar pulmonary vein (PV), and was served for the quantitative evaluation of CTC using the CellSearch® system. The cut-off point of ΔpvCTC was determined according to clinical outcomes and ΔpvCTC using receiver operation characteristic (ROC) curve. Then the correlation between ΔpvCTC and clinical outcomes was evaluated by Kaplan-Meier analyses and log-rank test. In addition, the correlation between ΔpvCTC and perioperative variables was assessed. Results A total of 30 patients were enrolled, tumor recurrence occurred in 11 patients over a median follow-up of 64.4 months. Of these, 7 patients had distant metastasis and 4 had local recurrence. The median ΔpvCTC was 49 cells/2.5 mL, and pvCTC-count was increased during surgical manipulation in 24 patients (80%). We divided patients into two groups based on ΔpvCTC with the cut-off value as 119 cells/2.5 mL according to ROC curve. Significant shorter time to distant metastasis (TDM) (P=0.0123) was observed in high ΔpvCTC group (ΔpvCTC ≥119 cells/2.5 mL) than low ΔpvCTC group (ΔpvCTC <119 cells/ 2.5mL). Neither disease-free survival (DFS) nor overall survival (OS) was significantly correlated with ΔpvCTC. Conclusions Increasing pvCTC count during surgical manipulation was significantly correlated with postoperative distant metastasis in completely resected NSCLC patients. Significant shorter TDM was observed in patient with high ΔpvCTC group.
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Affiliation(s)
- Masaki Hashimoto
- Department of Thoracic Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Fumihiro Tanaka
- Second Department of Surgery (Chest Surgery), University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kazue Yoneda
- Second Department of Surgery (Chest Surgery), University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Teruhisa Takuwa
- Department of Thoracic Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Seiji Matsumoto
- Department of Thoracic Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | | | - Nobuyuki Kondo
- Department of Thoracic Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Tohru Tsujimura
- Department of Pathology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Takashi Nakano
- Center for Respiratory Medicine, Otemae Hospital, Osaka, Japan
| | - Seiki Hasegawa
- Department of Thoracic Surgery, Hyogo College of Medicine, Nishinomiya, Japan
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23
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Hsu JS, Jaw TS, Yang CJ, Lin SF, Shih MCP, Chou SH, Chong IW, Lin MY, Chiang IC. Convex border of peripheral non-small cell lung cancer on CT images as a potential indicator of pleural invasion. Medicine (Baltimore) 2017; 96:e7323. [PMID: 29049171 PMCID: PMC5662337 DOI: 10.1097/md.0000000000007323] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The aim of the study is to evaluate the use of the tumor border in peripheral non-small cell lung cancer (NSCLC) as an indicator of pleural invasion.This retrospective study was performed at a single tertiary center. The analysis of 136 patients with peripheral NSCLC included 101 (74.3%) patients with pathologically proven pleural invasion and 35 (25.7%) patients without pleural invasion. The tumor borders on conventional computed tomography (CT) were classified into 5 types on lung window setting: type 1, S or reverse S border with a blunt angle; type 2, sharp angle; type 3, concave border with a blunt angle; type 4, straight border with a perpendicular angle; and type 5, convex border with a perpendicular or blunt angle. In patients with more than 1 tumor border type, the priority was type 5, 4, 3, 2, and 1. Blunt angle, pleural contact >3 cm, and adjacent pleural thickening were also recorded for comparison with pleural invasion of peripheral tumors.Tumor border types 2 and 5 significantly differed between patients with and without pleural invasion (P = .001 and P < .001, respectively). Patients with and without pleural invasion did not significantly differ in tumor border type 1, tumor border type 3, tumor border type 4, blunt angle, pleural contact >3 cm, or pleural thickening. Tumor border type 5 was a moderate indicator of pleural invasion with positive LR, 5.20; accuracy, 57%; sensitivity, 45%; specificity, 91%; PPV, 94%; and NPV, 36%. Tumor border type 2 was a weak indicator of pleural invasion with positive LR, 0.51; accuracy, 34%; sensitivity, 34%; specificity, 34%; PPV, 60%; and NPV, 15%.Tumor border type 5 has a high PPV and high specificity for predicting pleural invasion by peripheral NSCLC.
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Affiliation(s)
- Jui-Sheng Hsu
- Department of Radiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung
- Department of Medical Imaging, Kaohsiung Medical University Hospital, Kaohsiung
| | - Twei-Shiun Jaw
- Department of Radiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung
- Department of Medical Imaging, Kaohsiung Medical University Hospital, Kaohsiung
| | - Chih-Jen Yang
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung
| | - Shiou-Fu Lin
- Department of Pathology, Taipei Hospital, Ministry of Health and Welfare, New Taipei City
| | - Ming-Chen Paul Shih
- Department of Medical Imaging, Kaohsiung Medical University Hospital, Kaohsiung
| | - Shah-Hwa Chou
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung
- Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University, Kaohsiung
| | - Inn-Wen Chong
- Division of Chest Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung
- Division of Chest Medicine, Department of Internal Medicine, Kaohsiung Medical University, Kaohsiung
| | - Ming-Yen Lin
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung
- Faculty of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - I-Chan Chiang
- Department of Medical Imaging, Kaohsiung Medical University Hospital, Kaohsiung
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24
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Ipsilateral pleural recurrence after diagnostic transthoracic needle biopsy in pathological stage I lung cancer patients who underwent curative resection. Lung Cancer 2017; 111:69-74. [PMID: 28838402 DOI: 10.1016/j.lungcan.2017.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 07/04/2017] [Accepted: 07/07/2017] [Indexed: 12/26/2022]
Abstract
OBJECTIVES The relationship between transthoracic needle biopsy (TTNB) and pleural recurrence of cancer after curative lung resection remains unclear. We aimed to assess whether TTNB increases the ipsilateral pleural recurrence (IPR) rate and identify other potential risk factors for pleural recurrence after surgery. MATERIALS AND METHODS This retrospective study included 392 patients with p-stage I non-small cell lung cancer with solid or part-solid nodules after curative lung resection in 2009-2010. Imbalances among the characteristics were adjusted using an inverse probability-weighted method based on propensity scoring. Multivariate Cox's regression analysis and the Kaplan-Meier method were used to determine independent risk factors for IPR. RESULTS A total of 243 (62%) patients received TTNB, while 149 (38%) underwent an alternate, or no, diagnostic technique. IPR was significantly more frequent in the TTNB group (p=0.004), while total recurrence was similar between the groups (p=0.098). After applying the weighted model, diagnostic TTNB (hazard ratio [HR], 5.27; 95% confidence interval [CI], 1.49-18.69; p=0.010), microscopic visceral pleural invasion (HR, 2.76; 95% CI, 1.08-7.01; p=0.033) and microscopic lymphatic invasion (HR, 3.25; 95% CI, 1.30-8.10; p=0.012) were associated with an increased frequency of IPR. Among patients who received TTNB, microscopic lymphatic invasion was a risk factor for IPR (HR, 2.74; 95% CI, 1.10-6.79; p=0.030). CONCLUSIONS The diagnostic TTNB procedure is associated with pleural recurrence but may be unrelated to overall recurrence-free survival in early lung cancer. Moreover, microscopic lymphatic invasion could be a risk factor for pleural recurrence. TTNB should be carefully considered before lung resection and close follow-up to detect if pleural recurrence is needed.
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25
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Yang X, Sun F, Chen L, Shi M, Shi Y, Lin Z, Feng M, Zhan C, Jiang W, Wang Q. Prognostic value of visceral pleural invasion in non-small cell lung cancer: A propensity score matching study based on the SEER registry. J Surg Oncol 2017; 116:398-406. [PMID: 28543219 DOI: 10.1002/jso.24677] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 04/22/2017] [Indexed: 12/25/2022]
Affiliation(s)
- Xiaodong Yang
- Department of Thoracic Surgery; Zhongshan Hospital of Fudan University; Shanghai China
| | - Fenghao Sun
- Department of Thoracic Surgery; Zhongshan Hospital of Fudan University; Shanghai China
| | - Li Chen
- Department of Thoracic Surgery; Zhongshan Hospital of Fudan University; Shanghai China
| | - Mengkun Shi
- Department of Thoracic Surgery; Zhongshan Hospital of Fudan University; Shanghai China
| | - Yu Shi
- Department of Thoracic Surgery; Zhongshan Hospital of Fudan University; Shanghai China
| | - Zongwu Lin
- Department of Thoracic Surgery; Zhongshan Hospital of Fudan University; Shanghai China
| | - Mingxiang Feng
- Department of Thoracic Surgery; Zhongshan Hospital of Fudan University; Shanghai China
| | - Cheng Zhan
- Department of Thoracic Surgery; Zhongshan Hospital of Fudan University; Shanghai China
| | - Wei Jiang
- Department of Thoracic Surgery; Zhongshan Hospital of Fudan University; Shanghai China
| | - Qun Wang
- Department of Thoracic Surgery; Zhongshan Hospital of Fudan University; Shanghai China
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26
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Wang T, Zhou C, Zhou Q. Extent of Visceral Pleural Invasion Affects Prognosis of Resected Non-small Cell Lung Cancer: A meta-analysis. Sci Rep 2017; 7:1527. [PMID: 28484235 PMCID: PMC5431474 DOI: 10.1038/s41598-017-01845-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 04/04/2017] [Indexed: 02/05/2023] Open
Abstract
Visceral pleural invasion (VPI) has been known to be an adverse prognostic factor in non-small cell lung cancer (NSCLC). However, the prognostic significance of extent of VPI (PL0, PL1 and PL2) remains controversial. We conduct a meta-analysis to summarize available evidence on this topic. PubMed, EMBASE, OVID and The Cochrane Library were searched for published studies from inception to May 9, 2016. A total of 16 studies were included in meta-analysis. Our results showed that patients with PL1 or PL2 had poorer overall survival compared with PL0 (HR = 1.555, 95% CI 1.399, 1.730; HR = 2.447, 95% CI 1.913, 3.130) and patients with PL2 had even poorer overall survival than PL1 (HR = 1.287, 95% CI 1.114, 1.487). Patients with PL1 or PL2 had lower 5-year survival rate than PL0 patients (OR = 0.515, 95% CI 0.415, 0.640; OR = 0.441, 95% CI 0.336, 0.579) and patients with PL2 had even lower 5-year survival rate than PL1 (OR = 0.706, 95% CI 0.545, 0.915). In conclusion, extent of VPI impacts the prognosis of resected NSCLC and VPI should be categorized as PL1 and PL2 in the terms of clinical practice and trials.
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Affiliation(s)
- Ting Wang
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,Department of Medical Oncology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Chengya Zhou
- Department of Medical Oncology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Qinghua Zhou
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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27
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Seok Y, Jeong JY, Lee E. Extent of visceral pleural invasion and the prognosis of surgically resected node-negative non-small cell lung cancer. Thorac Cancer 2017; 8:197-202. [PMID: 28220643 PMCID: PMC5415476 DOI: 10.1111/1759-7714.12424] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 01/12/2017] [Accepted: 01/12/2017] [Indexed: 11/28/2022] Open
Abstract
Background Visceral pleural invasion (VPI) is generally considered a poor prognostic factor in non‐small cell lung cancer (NSCLC). VPI is defined as penetration beyond the elastic layer of visceral pleura (PL1), including the visceral pleural surface without the involvement of adjacent structures (PL2) by cancer cells. The aim of this study was to evaluate the influence of the extent of VPI on NSCLC prognosis. Methods This was a retrospective study of 90 patients with resected node‐negative NSCLC with VPI. The overall survival (OS) and disease‐free survival (DFS) rates were estimated using the Kaplan–Meier method. Multivariate analysis for prognostic factors was performed using a Cox proportional hazards regression model. The pattern of recurrence was also compared between PL1 and PL2 groups. Results Seventy‐three patients had PL1. The three‐year OS rates for the PL1 and PL2 groups were 97.4% and 82.4%, respectively (P = 0.004). The two‐year DFS rates for PL1 and PL2 groups were 81.0% and 76.5%, respectively (P = 0.419). According to the multivariate analysis, PL2 was not a significant prognostic factor for survival outcome in node‐negative NSCLC with VPI compared to PL1 (hazard ratio for DFS 1.753, 95% confidence interval 0.582–5.284; P = 0.319). In this study, six patients in the PL1 and one in PL2 group developed ipsilateral pleural recurrence (P = 1.000). Conclusion VPI extent may not influence survival outcomes in patients with surgically resected node‐negative NSCLC with VPI.
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Affiliation(s)
- Yangki Seok
- Department of Thoracic and Cardiovascular Surgery, Kyungpook National University Medical Center, Daegu, South Korea
| | - Ji Yun Jeong
- Department of Pathology, Kyungpook National University Medical Center, Daegu, South Korea
| | - Eungbae Lee
- Department of Thoracic and Cardiovascular Surgery, Kyungpook National University Medical Center, Daegu, South Korea
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28
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Zhao LL, Xie HK, Zhang LP, Zha JY, Zhou FY, Jiang GN, Chen C. Visceral pleural invasion in lung adenocarcinoma ≤3 cm with ground-glass opacity: a clinical, pathological and radiological study. J Thorac Dis 2016; 8:1788-97. [PMID: 27499970 DOI: 10.21037/jtd.2016.05.90] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Visceral pleural invasion (VPI) had been demonstrated as an aggressive sign in non-small cell lung cancers (NSCLC). However, its incidence and clinical relevance in early lung cancer showing ground glass nodules (GGNs) has not been clarified. METHODS All consecutive surgically treated patients with solitary GGNs between 2009 and 2013 were reviewed retrospectively. Inclusion criteria were defined as lesions ≤3 cm with pleura abutting on computed tomography (CT) scan and pathologically confirmed NSCLC. RESULTS Out of 156 enrolled patients, 38 had pathologically confirmed VPI. The incidence of VPI was 41.5% (27/65) if the tumor diameter was larger than 2.0 cm and 14.3% (13/91) if diameter was smaller than 2.0 cm (P<0.001). Further, the incidence was 17.4% (12/69) in pure GGNs and 32.2% (28/87) in part-solid GGNs (P=0.040). The tumor size and the nodule nodule-pleural relationship were significant predictors of positive VPI. In cases with pleural indentation, attachment, and closeness, the incidence was 38.1%, 25.5%, and 5.3%, respectively (P=0.001). All cases were PL0 and PL1, with no PL2 cases observed. CONCLUSIONS Although VPI was visible in both pure/mix GGNs, it was more common in larger (>2 cm) GGNs. The radiographic findings of nodule abutment or a pleural tag did not reliably predict or exclude VPI. In patients with GGNs, a low rate of PL2 invasion may be observed.
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Affiliation(s)
- Li-Lan Zhao
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Hui-Kang Xie
- Department of Pathology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Li-Ping Zhang
- Department of Pathology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Jun-Yan Zha
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Fang-Yu Zhou
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Ge-Ning Jiang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Chang Chen
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
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29
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Adachi H, Maehara T, Nakayama H, Masuda M. Reply to Riquet et al. Eur J Cardiothorac Surg 2016; 50:193-4. [PMID: 27325800 DOI: 10.1093/ejcts/ezw010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 01/08/2016] [Indexed: 11/13/2022] Open
Affiliation(s)
- Hiroyuki Adachi
- Department of Surgery, Yokohama City University, Yokohama, Japan Department of General Thoracic Surgery, Yokosuka Kyosai Hospital, Yokosuka, Kanagawa, Japan
| | | | | | - Munetaka Masuda
- Department of Surgery, Yokohama City University, Yokohama, Japan
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30
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Riquet M, Arame A, Pricopi C, Foucault C. Visceral pleura and pN involvement in lung cancer. Eur J Cardiothorac Surg 2016; 50:193. [PMID: 27325799 DOI: 10.1093/ejcts/ezw009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 01/08/2016] [Indexed: 11/14/2022] Open
Affiliation(s)
- Marc Riquet
- Department of General Thoracic Surgery, Georges Pompidou European Hospital, Paris, France
| | - Alex Arame
- Department of General Thoracic Surgery, Georges Pompidou European Hospital, Paris, France
| | - Ciprian Pricopi
- Department of General Thoracic Surgery, Georges Pompidou European Hospital, Paris, France
| | - Christophe Foucault
- Department of General Thoracic Surgery, Georges Pompidou European Hospital, Paris, France
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31
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Hsu JS, Han IT, Tsai TH, Lin SF, Jaw TS, Liu GC, Chou SH, Chong IW, Chen CY. Pleural Tags on CT Scans to Predict Visceral Pleural Invasion of Non-Small Cell Lung Cancer That Does Not Abut the Pleura. Radiology 2015; 279:590-6. [PMID: 26653684 DOI: 10.1148/radiol.2015151120] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To evaluate the association of pleural tags with visceral pleural invasion of non-small cell lung cancer (NSCLC) that does not abut the pleural surface. MATERIALS AND METHODS This retrospective study was approved by the institutional review board. Informed consent was waived. The study of NSCLC that does not abut the pleura in 141 patients (44 patients [31.2%] with visceral pleural invasion proved by pathologic analysis and 97 patients [68.8%] without pleural invasion) was conducted at a single tertiary center. The pleural tags were classified into three types (type 1, one or more linear pleural tag; type 2, one or more linear pleural tag with soft tissue component at the pleural end; and type 3, one or more soft tissue cord-like pleural tag) and prioritized into types 3, 2, and 1 when more than one type was present. Diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and positive likelihood ratio (LR) were calculated. RESULTS In the absence of pleural tags, no pleural invasion was found. The presence of type 2 pleural tags was moderately associated with visceral pleural invasion with the following results: positive LR, 5.06; accuracy, 71%; sensitivity, 36.4%; specificity, 92.8%; PPV, 76.2%; and NPV, 69.6%. Type 1 pleural tags provided weak evidence to rule out visceral pleural invasion (positive LR, 0.38). Type 3 pleural tags indicated minimal increase in the likelihood of visceral pleural invasion (positive LR, 1.68). CONCLUSION Type 2 pleural tags on conventional CT images can increase the accuracy of early diagnosis of visceral pleural invasion by NSCLC that does not abut the pleura.
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Affiliation(s)
- Jui-Sheng Hsu
- From the Department of Radiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (J.S.H., T.S.J., G.C.L., C.Y.C.); Department of Medical Imaging, Kaohsiung Medical University Hospital, 100 Tz You 1st Road, Kaohsiung 807, Taiwan (J.S.H., I.T.H., T.H.T., T.S.J., G.C.L., C.Y.C.); Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (S.F.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (G.C.L.); Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (S.H.C.); Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (S.H.C.); Division of Chest Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (I.W.C.); Division of Chest Medicine, Department of Internal Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (I.W.C.); and Center for Stem Cell Research, Kaohsiung Medical University, Kaohsiung, Taiwan (C.Y.C.)
| | - I-Ting Han
- From the Department of Radiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (J.S.H., T.S.J., G.C.L., C.Y.C.); Department of Medical Imaging, Kaohsiung Medical University Hospital, 100 Tz You 1st Road, Kaohsiung 807, Taiwan (J.S.H., I.T.H., T.H.T., T.S.J., G.C.L., C.Y.C.); Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (S.F.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (G.C.L.); Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (S.H.C.); Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (S.H.C.); Division of Chest Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (I.W.C.); Division of Chest Medicine, Department of Internal Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (I.W.C.); and Center for Stem Cell Research, Kaohsiung Medical University, Kaohsiung, Taiwan (C.Y.C.)
| | - Tzu-Hsueh Tsai
- From the Department of Radiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (J.S.H., T.S.J., G.C.L., C.Y.C.); Department of Medical Imaging, Kaohsiung Medical University Hospital, 100 Tz You 1st Road, Kaohsiung 807, Taiwan (J.S.H., I.T.H., T.H.T., T.S.J., G.C.L., C.Y.C.); Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (S.F.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (G.C.L.); Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (S.H.C.); Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (S.H.C.); Division of Chest Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (I.W.C.); Division of Chest Medicine, Department of Internal Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (I.W.C.); and Center for Stem Cell Research, Kaohsiung Medical University, Kaohsiung, Taiwan (C.Y.C.)
| | - Shiou-Fu Lin
- From the Department of Radiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (J.S.H., T.S.J., G.C.L., C.Y.C.); Department of Medical Imaging, Kaohsiung Medical University Hospital, 100 Tz You 1st Road, Kaohsiung 807, Taiwan (J.S.H., I.T.H., T.H.T., T.S.J., G.C.L., C.Y.C.); Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (S.F.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (G.C.L.); Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (S.H.C.); Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (S.H.C.); Division of Chest Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (I.W.C.); Division of Chest Medicine, Department of Internal Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (I.W.C.); and Center for Stem Cell Research, Kaohsiung Medical University, Kaohsiung, Taiwan (C.Y.C.)
| | - Twei-Shiun Jaw
- From the Department of Radiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (J.S.H., T.S.J., G.C.L., C.Y.C.); Department of Medical Imaging, Kaohsiung Medical University Hospital, 100 Tz You 1st Road, Kaohsiung 807, Taiwan (J.S.H., I.T.H., T.H.T., T.S.J., G.C.L., C.Y.C.); Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (S.F.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (G.C.L.); Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (S.H.C.); Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (S.H.C.); Division of Chest Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (I.W.C.); Division of Chest Medicine, Department of Internal Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (I.W.C.); and Center for Stem Cell Research, Kaohsiung Medical University, Kaohsiung, Taiwan (C.Y.C.)
| | - Gin-Chung Liu
- From the Department of Radiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (J.S.H., T.S.J., G.C.L., C.Y.C.); Department of Medical Imaging, Kaohsiung Medical University Hospital, 100 Tz You 1st Road, Kaohsiung 807, Taiwan (J.S.H., I.T.H., T.H.T., T.S.J., G.C.L., C.Y.C.); Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (S.F.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (G.C.L.); Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (S.H.C.); Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (S.H.C.); Division of Chest Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (I.W.C.); Division of Chest Medicine, Department of Internal Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (I.W.C.); and Center for Stem Cell Research, Kaohsiung Medical University, Kaohsiung, Taiwan (C.Y.C.)
| | - Shah-Hwa Chou
- From the Department of Radiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (J.S.H., T.S.J., G.C.L., C.Y.C.); Department of Medical Imaging, Kaohsiung Medical University Hospital, 100 Tz You 1st Road, Kaohsiung 807, Taiwan (J.S.H., I.T.H., T.H.T., T.S.J., G.C.L., C.Y.C.); Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (S.F.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (G.C.L.); Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (S.H.C.); Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (S.H.C.); Division of Chest Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (I.W.C.); Division of Chest Medicine, Department of Internal Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (I.W.C.); and Center for Stem Cell Research, Kaohsiung Medical University, Kaohsiung, Taiwan (C.Y.C.)
| | - Inn-Wen Chong
- From the Department of Radiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (J.S.H., T.S.J., G.C.L., C.Y.C.); Department of Medical Imaging, Kaohsiung Medical University Hospital, 100 Tz You 1st Road, Kaohsiung 807, Taiwan (J.S.H., I.T.H., T.H.T., T.S.J., G.C.L., C.Y.C.); Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (S.F.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (G.C.L.); Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (S.H.C.); Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (S.H.C.); Division of Chest Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (I.W.C.); Division of Chest Medicine, Department of Internal Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (I.W.C.); and Center for Stem Cell Research, Kaohsiung Medical University, Kaohsiung, Taiwan (C.Y.C.)
| | - Chiao-Yun Chen
- From the Department of Radiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (J.S.H., T.S.J., G.C.L., C.Y.C.); Department of Medical Imaging, Kaohsiung Medical University Hospital, 100 Tz You 1st Road, Kaohsiung 807, Taiwan (J.S.H., I.T.H., T.H.T., T.S.J., G.C.L., C.Y.C.); Department of Pathology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (S.F.L.); Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (G.C.L.); Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (S.H.C.); Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (S.H.C.); Division of Chest Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (I.W.C.); Division of Chest Medicine, Department of Internal Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (I.W.C.); and Center for Stem Cell Research, Kaohsiung Medical University, Kaohsiung, Taiwan (C.Y.C.)
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