Extent of visceral pleural invasion and the prognosis of surgically resected node-negative non-small cell lung cancer

Impact of adjuvant chemotherapy on patients with stage IB non-small cell lung cancer with visceral pleural invasion

Background

Adjuvant chemotherapy has reduced the risk of recurrence and death in stage IB non-small cell lung cancer (NSCLC) with high-risk factors; however, the impact of visceral pleural invasion (VPI) on outcomes in stage IB NSCLC treated with adjuvant chemotherapy remains controversial. The aim of this study was to explore the clinical and prognostic significance of adjuvant chemotherapy for stage IB (1-4 cm) NSCLC with VPI.

Methods

This retrospective study included 251 patients admitted between January 2008 and May 2018 from four hospitals who underwent complete resection for Tumor-Node-Metastasis (TNM) 8th edition stage IB NSCLC with VPI. The relationship between adjuvant chemotherapy and overall survival (OS) or recurrence-free survival (RFS) was analyzed using the Kaplan-Meier method and Cox proportional hazards model.

Results

Of 251 patients with stage IB NSCLC with VPI, 122 (48.6%) received adjuvant chemotherapy after surgical resection and 129 (51.4%) were placed under observation. Multivariable analysis showed that adjuvant chemotherapy was an independent predictor of RFS [adjusted hazard ratio (aHR), 0.57; 95% confidence interval (CI): 0.33-0.96; P=0.036]. A micropapillary pattern (aHR, 2.46; 95% CI: 1.33-4.55; P=0.004) and lymphovascular invasion (aHR, 2.86; 95% CI: 1.49-5.48; P=0.002) were associated with a higher risk of recurrence. Multivariable analysis also showed that adjuvant chemotherapy was an independent predictor of OS (aHR, 0.22; 95% CI: 0.09-0.58; P=0.002). In a subgroup analysis of patients with a tumor size of 1-3 cm, adjuvant chemotherapy was associated with improved RFS and OS, and this association was maintained even when patients with VPI had additional risk factors.

Conclusions

Our study shows that adjuvant chemotherapy is appropriate for patients with stage IB (1-4 cm) NSCLC with VPI, and even those with smaller tumors (1-3 cm).

Diagnosis, treatment, and prognosis of stage IB non-small cell lung cancer with visceral pleural invasion

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.

Predictive value of SUVmax in visceral pleural invasive lung adenocarcinoma with different diameters

OBJECTIVES

This study aimed to investigate predictive visceral pleural invasion (VPI) occurrence value of the maximum standardized uptake value (SUVmax) in patients with lung adenocarcinoma (LA).

PATIENTS AND METHODS

A total of 388 LA patients were divided into D1ab, D1c, D1, D2, D2a, D2b, D3, and all patient groups based on their tumor diameter (D). Patients were also classified into negative VPI (VPI-n) and positive VPI (VPI-p) groups according to VPI presence. SUVmax of patients was measured with 18F-fluorodeoxyglucose (FDG) by PET/computed tomography (18F-PET/CT). Receiver operating characteristic (ROC) analysis and the area under curve (AUC) of SUVmax were applied to determine optimal cut-off value for predicting VPI occurrence.

RESULTS

There were significant differences in SUVmax between VPI-n and VPI-p groups ( P  < 0.05) at the same tumor diameter. SUVmax cut-off value and sensitivity (Se,%) of VPI occurrence in each group were following: D1ab was 3.79 [AUC = 0.764, P  < 0.001], Se86.11%; D1c was 5.47 (AUC = 0.706, P  < 0.001), Se 93.75%; D1 was 5.49 (AUC = 0.731, P  < 0.001), Se 79.76%; D2 was 7.36 (AUC = 0.726, P  < 0.001), Se81.67%. All patient group was 7.26 (AUC = 0.735, P  < 0.001), Se74.19%.

CONCLUSION

In LA patients with the same diameter, SUVmax of the VPI-p group was significantly higher than that of the VPI-n group. The cut-off value of SUVmax for predicting VPI of T1 stage, T1 substages, and T2 stage LA could be determined through ROC curve. SUVmax measurement by PET/CT scan in stratified tumor size is helpful for predicting VPI occurrences of the physician.

The location of visceral pleural invasion in stage IB patients with non-small cell lung cancer: Comparison and prognosis

OBJECTIVES

Recently, early-stage lung cancer has been drawing more attention, especially in screening and treatment. Visceral pleural invasion in stage IB cancer is considered as risk factor for poor prognosis. Herein, we aimed to study the distinction between the different locations of visceral pleural invasion.

METHODS

In this retrospective cohort study, we summarized 58,242 patient cases that underwent surgery from 2015 to 2018 at Shanghai Chest Hospital. Of those patients, 389 met the inclusion criteria. Patients with PL3 pleural invasion were excluded. The patients were dichotomized into the interlobar pleural and peripheral pleural groups. The outcomes measured were overall survival (OS) and recurrence-free survival (RFS) rates.

RESULTS

According to the initial analysis, the baseline characteristics of the two groups were largely balanced. In multivariate Cox analyses, we found that the location of visceral pleural invasion was not a risk factor for prognosis in the overall population (RFS: P = 0.726, OS: P = 0.599). However, we discovered that relative to patients with peripheral pleura invasion, those with interlobar pleura invasion, PL1 invasion, lesions with greater than 3 cm solid components, and those who underwent segmentectomy had a compromised prognosis. Additionally, tumors larger than 3 cm in size with interlobar pleura invasion showed poor prognosis in patients who underwent postoperative chemotherapy.

CONCLUSIONS

In most cases, the location of tumor invasion did not worsen the postoperative prognosis of stage IB non-small cell lung cancer patients with visceral pleural invasion. However, interlobar pleural invasion still had some potential risks compared to that of peripheral pleural invasion.

Prognostic impact of tumor microenvironment-related markers in patients with adenocarcinoma of the lung

Cancer-associated fibroblasts (CAFs) are a prominent component in the tumor microenvironment (TME), which plays an important role in lung carcinogenesis. Here, we investigated microenvironmental markers expressed by CAFs, including α-smooth muscle actin, CD10, podoplanin, fibroblast-specific protein 1, platelet-derived growth factor α and β, fibroblast-associated protein, tenascin-C, zinc finger E-box binding homeobox 1 (ZEB1), and twist-related protein 1 expression levels. We evaluated samples from 257 patients with lung adenocarcinoma (LAD) to assess the associations of CAF-related protein expression patterns with prognosis. LAD cases were stratified using cluster analysis. To determine the utility of prognostic markers in LAD, univariate and multivariate analyses were performed. LAD cases were classified into subgroups 1 and 2. Subgroup 2 was shown to be significantly correlated with disease-free and overall survival using univariate and multivariate analyses in this group. Upregulation of podoplanin was identified as a single prognostic marker in this study by univariate and multivariate analyses. In addition, ZEB1 overexpression was correlated with disease-free survival. Our current results suggested that the specific CAF phenotype (e.g., the expression pattern of CAF-related proteins) could predict outcomes in patients with LAD. In addition, podoplanin upregulation may predict outcomes in these patients.

Non-small Cell Lung Cancer Surpassing the Elastic Layer Should Remain Classified as pT2a

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.

Effects of adjuvant chemotherapy on survival of patients with stage IB non-small cell lung cancer with visceral pleural invasion

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.

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

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.