Results of T4 surgical cases in the Japanese Lung Cancer Registry Study: should mediastinal fat tissue invasion really be included in the T4 category?

Multimodal Therapy for T4 N2 Non-Small Cell Lung Cancer With Additional Ipsilateral Pulmonary Nodules

Background

The optimal treatment strategy for T4 non-small cell lung cancer (NSCLC) with additional intrapulmonary nodules in a different ipsilateral lobe (T4-Add) is not well characterized across clinical N stages. This study evaluated long-term survival of patients with T4-Add N2 NSCLC who received multimodal therapy including surgical resection and chemotherapy vs concurrent chemoradiation.

Methods

Patients with T4-Add N2 M0 NSCLC in the National Cancer Database from 2010 to 2015 were included. Long-term survival was evaluated and compared between patients who underwent primary site surgical resection with chemotherapy and those who received concurrent chemoradiation by Kaplan-Meier analysis, Cox proportional hazards modeling, and propensity score matching on 9 common prognostic variables including comorbidities.

Results

Of the 499 patients diagnosed with T4-Add N2 M0 NSCLC who satisfied study eligibility criteria, 220 (44.1%) received primary site surgical resection with chemotherapy and 279 (55.9%) received chemoradiation. After multivariable adjusted Cox proportional hazards modeling, surgical resection with chemotherapy was associated with better long-term survival than chemoradiation. In a propensity score-matched analysis of 100 patients who received surgical resection with chemotherapy and 100 patients who received chemoradiation, patients who received surgical resection with chemotherapy had better 5-year overall survival.

Conclusions

The results of this national analysis of patients with T4 N2 NSCLC with additional nodules in a different ipsilateral lobe suggest that multimodal therapy including surgery may confer a survival benefit compared with chemoradiation alone. These findings support further evaluation of surgical resection as part of multimodal therapy for carefully selected patients with T4-Add N2 disease.

Carinal sleeve resections

Carinal resections are frequently performed for carinal tumors. Resection of the carina due to distal tracheal tumors may be required, and the extension of main bronchial tumors to the carina may lead to carinal resection. This is one of the rarely performed operations in thoracic surgery, which is technically challenging and has a high complication rate. In the early series, perioperative mortality rate was reported as 29% and the five-year survival rate as 15%. Due to its technical difficulties and high complication rates, it is performed only in certain centers. In this review, we discuss techniques related to carinal sleeve resection and prognostic factors in the light of literature data.

The preoperative assessment of thoracic wall adhesions using four-dimensional computed tomography

OBJECTIVE

Pleural adhesions are challenging during lung cancer surgery and may be associated with a long surgery time and excessive blood loss due to pleural adhesiolysis. We used preoperative four-dimensional computed tomography to quantitatively assess parietal pleural adhesions and determine its diagnostic accuracy.

METHODS

A total of 216 patients with lung cancer underwent four-dimensional computed tomography during the study period. Pleural adhesions were subsequently confirmed by surgery in 85 of these patients, whereas 126 patients had no adhesions. The movements of the tumor or target vessels (α) was tracked. Receiver-operating characteristic curve analysis was used to identify the relationship between adhesions and (α).

RESULTS

The movement of (α) was smaller in patients with adhesions than in those without adhesions. The greater the adhesion, the shorter the movement distance (p < 0.001). Receiver-operating characteristic curve analysis demonstrated an area under the curve for the moving (α) point at 0.71 (95% confidence interval: 0.62-0.80) in the upper lung field and at 0.75 (95% confidence interval: 0.64-0.85) in the lower field. To identify adhesions, a cut off of 11.3 mm (sensitivity = 43.6%, specificity = 93.2%) in the upper lung field and a cut off of 41.2 mm (sensitivity = 71.4%, specificity = 66.0%) in the lower lung field were established.

CONCLUSIONS

Four-dimensional computed tomography is a novel and helpful modality for predicting the presence of parietal pleural adhesions. To obtain robust evidence, further accumulation of cases and re-examination of the analysis methods are needed.

Prognostic Factors in Patients with Clinic Locally Advanced T4 Lung Cancer: Surgical Considerations

Background Inclusion of surgery in the treatment of T4 lung cancer has been a debate for the last two decades. The aim of this study is to investigate the potential prognostic factors which could affect the outcome.

Methods Fifty-seven clinical T4 non-small cell lung carcinoma (NSCLC) patients out of 716 lung resections, who were operated at a single institution in 7 years period, were included in this study. Patients are grouped into three groups as patients with neoadjuvant treatment group (group 1 n: 16), salvage surgery group (surgery after 3 months of definitive chemotherapy and radiotherapy) (group 2 n: 14), and straightforward surgery group (group 3 n: 27) with adjuvant treatment. Groups were analyzed and compared in terms of postoperative complications, 30 days of mortality, disease free survival, and overall survival.

Results Mean overall survival (OS) was 48.43 ± 4.4 months and mean disease-free survival (DFS) 40.55 ± 4.46 months for all patients. Thirty days mortality was 5.2% and complication rates were 63.1%. Two years OS was 61.4 ± 6.4%, DFS was 58.1 ± 7.8%. Group 1, Group 2, and Group 3 patients had mean 39.14 ± 5.6, 44.7 ± 7.1, and 62.9 ± 4.8 months for OS (p: 0.09), and 29.6 ± 7.2, 38.4 ± 9.1, and 46.9 ± 6 months for DFS (p: 0.27). Patients who received blood transfusion showed significantly worse outcomes (p: 0.001 for DFS and p: 0.004 for OS).

Conclusion According to our outcomes, surgery should be included in the treatment of clinical T4 lung cancer when physiologically and oncologically possible with careful patient selection. This study demonstrates that patients receiving straightforward surgery have longer survival, in spite of higher perioperative mortality rate. Risks and benefits should be considered carefully.

Left upper lobectomy with combined distal aortic arch and left subclavian artery resection after neoadjuvant chemoradiotherapy for locally advanced lung squamous cell carcinoma

T4 locally advanced non-small cell lung cancer (NSCLC) is a heterogeneous group with a great variety of involved organs and is associated with a poor prognosis. However, appropriately selected patients benefit from surgical resection. The surgical indication must be carefully considered based on the risk-benefit between high surgical stress and expected prognosis, particularly in cases with probable aortic involvement. Here, we report a long-term survival case of left upper lobe squamous cell carcinoma, in which lobectomy and combined distal aortic arch and left subclavian artery resection achieved a complete resection after induction chemoradiotherapy (CRT). Appropriate patient selection considering expected prognosis, induction CRT and complete resection under well-planned cardiopulmonary bypass are essential to achieve a long-term survival on T4 NSCLC with a probable aortic involvement.

Long-term outcome after en bloc resection and reconstruction of the spinal column and posterior chest wall in the treatment of malignant tumors

BACKGROUND

Malignant tumors occurring around both the spinal column and posterior chest wall are uncommon. Surgical resection of chest wall tumors adjacent to the spinal column is still challenging due to the surrounding anatomical structures. The purpose of the present study was to evaluate the long-term outcomes of surgical management in malignant tumors involving the spinal column and posterior chest wall.

METHODS

Between 1999 and 2007, 10 consecutive patients underwent en bloc resection combined with the posterior chest wall in the treatment of malignant tumors around the spinal column. There were 6 males and 4 females with a mean age at the surgery of 40.9 years old (range, 14-62 years old). The mean postoperative follow-up period was 159.7 months (range, 84-245 months). The clinical history, physical examination, laboratory data, radiological findings, and operative findings for each patient were retrospectively reviewed.

RESULTS

All surgeries were performed via a combined anterior and posterior approach. The mean numbers of partially resected vertebrae and ribs were 3.1 and 4.1, respectively. Lower or upper lobectomy was performed in four patients, and the diaphragm was partially resected in two patients. The surgical margin was wide in seven patients and marginal in two patients. Although five patients had postoperative respiratory problem, all patients improved immediately without life-threatening complications. There were no patients with respiratory insufficiency after surgery. One patient with osteosarcoma died of lung metastases 99 months after surgery. At the final follow-up, only one patient had local recurrence, five had been continuously disease-free, and three were alive with no evidence of disease.

CONCLUSIONS

En bloc resection and reconstruction in selected patients with malignant tumors involving both the spinal column and posterior chest wall demonstrated good long-term results for local control and the respiratory function.

Usefulness of a temporary shunt by cannulation during superior vena cava combined resection

Superior vena cava invasive thoracic malignancy requires combined resection of the superior vena cava to achieve en bloc resection of the involved structures with negative margins. The superior vena cava combined resection requires the creation of collateral circulation from the head to the heart before performing the combined resection. Even for a short time, total superior vena cava clamping without a procedure is unsafe and should be avoided. We will present a surgical resection with superior vena cava reconstruction, involving a temporary extrathoracic shunt from the left brachiocephalic vein to the right auricle using a venous return cannula. This is an optional technique for convenient and safe superior vena cava combined resection. It provides an excellent intrathoracic surgical view by venous return via the unilateral brachiocephalic vein, with the advantages of being a simple procedure requiring short surgical time.

Prognostic factors related to postoperative survival in the newly classified clinical T4 lung cancer

OBJECTIVES

T4 lung cancer has become a more heterogeneous group since the 8th edition of tumour, node, metastasis classification. The aim of this study was to identify predictive factors related to post-surgical survival in patients with clinical T4 non-small-cell lung cancer (NSCLC), based on the 8th edition of the classification.

METHODS

We retrospectively reviewed consecutive patients with clinical T4 NSCLC who underwent resection between January 2006 and December 2016, to identify factors associated with overall survival.

RESULTS

Ninety-three patients were identified. The criteria for clinical T4 disease included tumours larger than 7 cm (n = 54), great vessels or left atrial invasion (n = 22), mediastinal invasion (n = 11), vertebral invasion (n = 3), tracheal or carina invasion (n = 3), diaphragm invasion (n = 1) and ipsilateral different lobe pulmonary metastasis (n = 2). The postoperative nodal status was 0, 1, 2 and 3 in 59, 18, 15 and 1 patient, respectively. R0 resection was achieved in 80 patients, and the 30-day mortality was 0%. The median follow-up time was 37.6 months, and the 5-year overall survival rate was 56.3%. The multivariable analysis revealed that nodal status and R-status were significant prognostic factors for postoperative survival [hazard ratio (HR) 2.62, 95% confidence interval (CI) 1.20-5.72, P = 0.016 and HR 3.29, 95% CI 1.45-7.44, P = 0.004].

CONCLUSIONS

Surgery provided encouraging survival outcomes for clinical T4 NSCLC based on the 8th edition of classification. The nodal status and R-status were significant prognostic factors for postoperative survival.

Salvage Photon or Proton Radiotherapy for Oligo-recurrence in Regional Lymph Nodes After Surgery for Non-small Cell Lung Cancer

BACKGROUND/AIM

To evaluate the outcome of definitive salvage radiotherapy (RT) in non-small cell lung cancer (NSCLC) patients with oligo-recurrence in regional lymph nodes after surgery.

PATIENTS AND METHODS

Between January 2003 and December 2016, 33 patients with NSCLC were reviewed from radiotherapy database at our hospital. All patients received photon or proton salvage RT for metastases in the regional lymph nodes.

RESULTS

The median follow-up from salvage RT was 35.2 (range=5.9-89.6) months. Recurrences occurred in 18 (55%) patients, and the 3-year overall and progression-free survival rates were 63.8% and 45.1%, respectively. Regional and local control improved patients' survival and these control rates were increased by use of concurrent chemotherapy (p=0.039) and proton RT (p=0.084). No grade 4 acute or late non-hematologic toxicities were observed.

CONCLUSION

Salvage RT is an effective treatment for NSCLC patients with oligo-recurrence at regional lymph nodes.

The prognostic impact of the mediastinal fat tissue invasion in patients with non-small cell lung cancer

BACKGROUND

The prognosis of the mediastinal fat tissue invasion in non-small cell lung cancer (NSCLC) patients has not yet been clearly defined. The present study aimed to investigate the prognostic impact of the mediastinal fat tissue invasion in NSCLC patients.

METHOD

We analyzed 36 patients who were found mediastinal fat tissue invasion by pathological evaluation (mediastinal fat group) and 248 patients who were classified as T4-NSCLC according to the 8th TNM classification (T4 group; invasion of other mediastinal structures in 78 patients, ipsilateral different lobe satellite pulmonary nodule in 32 patients, and tumor diameter > 7 cm in 138 patients).

RESULT

Resection was regarded as complete (R0) in 255 patients (89.7%). Mediastinal fat group showed significantly higher incidence of incomplete resection (R1) and more left-sided tumors than the T4 group (p = 0.01, and p = 0.002, respectively). The survival was better in T4 group than mediastinal fat group (median 57 months versus 31 months), although it was not significant (p = 0.205). Even when only N0/1 or R0 patients were analyzed, the survival was not different between two groups (p = 0.420, and p = 0.418, respectively). 5-year survival rates for T4 subcategories (invasion of other structures, ipsilateral different lobe pulmonary nodule, and tumor diameter > 7 cm) were 39.4%, 41.9%, and 50.3%, respectively (p = 0.109). Multivariate analysis showed that age (p < 0.0001), nodal status (p = 0.0003), and complete resection (p < 0.0001) were independently influenced survival.

CONCLUSION

There is no significant difference in the prognosis between mediastinal fat tissue invasion and T4 disease in NSCLC patients.

Stereotactic body radiotherapy for primary non-small cell lung cancer patients with clinical T3-4N0M0 (UICC 8th edition): outcomes and patterns of failure

The evidence for stereotactic body radiotherapy (SBRT) is meagre for patients with clinical T3-4N0M0 non-small cell lung cancer (8th Edition of the Union for International Cancer Control (UICC)). This study retrospectively investigated clinical outcomes following SBRT for such patients. Among consecutive patients treated with SBRT, patients staged as cT3-4N0M0 by all criteria were examined, most of whom were unsuitable to chemoradiotherapy due to their fragile characters. Clinical outcomes were evaluated and factors associated with outcomes were investigated. Between 2005 and 2017, 70 eligible patients (T3: 58, T4: 12; median age 81 (63-93) years) were identified. Median follow-up duration was 28.6 (1.0-142.5) months. No adjuvant chemotherapy was administered. The 3-year local recurrence rates were 15.8% and 16.7% in T3 and T4 patients, respectively, and they were significantly lower in the high-dose group (3.1% vs 28.6%, P < 0.01). Multivariate analyses showed that the dose-volumetric factor was the significant factor for local recurrence. The 3-year regional and distant metastasis rates, cancer-specific mortality, and overall survival in T3 and T4 patients were 22.7% and 25.0%, 26.5% and 33.3%, 32.2% and 41.7%, and 39.5% and 41.7%, respectively. Only age was correlated with overall survival. Radiation pneumonitis ≥grade 3 and fatal hemoptysis occurred in 3 and 1 patients, respectively. SBRT for cT3-4N0M0 lung cancer patients achieved good local control. Survival was rather good considering that patients were usually frail, staged with clinical staging, and were not given adjuvant chemotherapy, and it may be comparable to surgery. To validate these outcomes following SBRT, a prospective study is warranted.

Demographics, Safety and Quality, and Prognostic Information in Both the Seventh and Eighth Editions of the TNM Classification in 18,973 Surgical Cases of the Japanese Joint Committee of Lung Cancer Registry Database in 2010

INTRODUCTION

The Japanese Joint Committee of Lung Cancer Registry performed the fourth nationwide registry study of surgical cases. Demographics, safety and quality, prognostic information, and correlations between the seventh and the eighth editions of the TNM classification were investigated. The principal results were compared with those of previous Japanese Joint Committee of Lung Cancer Registry studies.

METHODS

The clinicopathologic profiles, staging, and prognosis of patients who had an operation for primary lung cancer in 2010 were retrospectively collected in 2016 and analyzed.

RESULTS

The cohort consisted of 18,973 patients from 297 hospitals (11,771 males, mean age 68.3 years). Tumor smaller than 2.0 cm was seen in 39.0% of patients, and limited resection was performed in 22.7%. The 30- and 90-day mortality rates were 0.43 and 1.26%, respectively. The overall and disease-free survival rates at 5 years were 74.7 and 67.8%, respectively. The respective 5-year survival rates by pathological stage in the seventh edition in the present study (2010) and in the previous study (2004) were 88.9% and 86.8% for stage IA, 76.7% and 73.9% for stage IB, 64.1% and 61.6% for stage IIA, 56.1% and 49.8% for stage IIB, 47.9% and 40.9% for stage IIIA, 30.2% and 27.8% for stage IIIB, and 36.1% and 27.9% for stage IV. The 5-year survival rates by clinical stage in the eighth edition in the present study were 97.0% for stage 0, 91.6% for stage IA1, 81.4% for stage IA2, 74.8% for stage IA3, 71.5% for stage IB, 60.2% for stage IIA, 58.1% for stage IIB, 50.6% for stage IIIA, 40.5% for stage IIIB, 37.5% for stage IIIC, and 36.0% for IVA/B. With restaging, the overall survival rates of clinical stage IA and IB in the seventh edition were stratified into stages 0 to IA3 and stages IA1 to IIA in the eighth edition, respectively.

CONCLUSIONS

This study demonstrates improved surgical results for lung cancer in Japan. The TNM revision for the eighth edition was supported by the assessment of stage migration from the previous edition and the prognostic stratification.

Surgery for malignant lesions of the chest which extensively involved the mediastinum, lung, and heart

OBJECTIVE

Radical resection for thoracic malignancies that invade the great vessels or heart structure is an uncommon, high-risk operation. To help surgeons determine therapeutic strategy, we reviewed the patient characteristics and outcomes of combined thoracic and cardiovascular surgery for thoracic malignancies.

METHODS

Surgical resections of lung cancer, mediastinal tumor and pulmonary artery sarcoma invading great vessels or heart structures were reviewed from the literature.

RESULTS

Pneumonectomy was often performed for lung cancer invading the aorta, superior vena cava, and left atrium. Complete resection (R0), no mediastinal lymph node metastasis and without using cardiopulmonary bypass led to a good prognosis. Induction therapy was often performed for complete resection. Regarding mediastinal tumors, thymic epithelial tumors or germ cell tumors occasionally invaded the great vessels or heart structures. For these malignancies, multimodality therapy was often performed, and complete resection could be one of the prognostic factors. The resection of primary pulmonary artery sarcoma (PPAS) is also a combined thoracic and cardiovascular surgery. The primary treatment for PPAS is surgical resection; specifically, pulmonary endarterectomy and pneumonectomy, because PPAS has substantial resistance to chemotherapy or radiotherapy. The prognosis of PPAS is poor, but surgical resection has potential for long-term survival.

CONCLUSION

Although these surgeries are uncommon and invasive for the patients, selecting appropriate patients, aggressive multimodality therapy, and performing combined thoracic and cardiovascular surgery can contribute to a good outcome.

Trends and current status of general thoracic surgery in Japan revealed by review of nationwide databases

Nationwide databases of cases treated for thoracic disease have been established by several academic associations in Japan, which contain information showing trends and current status in regard to surgical treatment. The Japanese Association of Thoracic Surgery (JATS), Japanese Association of Chest Surgery (JACS), Japan Lung Cancer Society (JLCS), Japanese Respiratory Society (JRS), and Japan Society for Respiratory Endoscopy (JSRE) have maintained databases of lung cancer cases treated in Japan. In 1986, the number of general thoracic surgery cases was 15,544, which increased to 75,306 in 2013. Furthermore, the number of lung cancer operations performed in 2013 was 37,008, occupying 49.1% of all general thoracic operations. Also, the proportions of adenocarcinoma, female patients, aged patients, stage I disease, and limited resection procedures are increasing in lung cancer surgery cases. While the 5-year overall post-operative survival rate of lung cancer patients was 47.8% in those undergoing surgery in 1989, it was 69.6% in those of 2004, which means 22% increase during 15 years. JATS, JACS, and the Japanese Association for Research of the Thymus (JART) have maintained retrospective databases of thymic epithelial tumor cases. The number of mediastinal tumors surgically treated is also increasing and was 4,780 in 2013, among which thymoma was the most prevalent. The Japanese Association for Lung and Heart-Lung Transplantation has developed a prospective nationwide database of lung transplantation cases in Japan, which contains clinical data for 466 patients who received lung transplantation or heart-lung transplantation from 1998 to 2015. Nationwide databases are currently being utilized for clinical studies and will also contribute to international projects related to the Union for International Cancer Control (UICC) tumor, node, and metastasis (TNM) classification system.