Long-term survival in locally advanced non-small cell lung cancer invading the great vessels and heart

Investigating the predictive factors of thoracic aortic invasion and surgical outcomes in patients with primary lung cancer: A retrospective study

BACKGROUND

This study aimed to investigate predictors of thoracic aortic invasion in lung cancer patients using preoperative clinical and imaging characteristics and elucidate surgical outcomes in cases of aortic invasion.

METHODS

Of the 4751 lung cancer patients who underwent surgery at our hospital, we included 126 (6.8%) who underwent left-sided surgery and in whom tumor appeared to be in contact with the thoracic aorta on preoperative imaging. The patients were divided into two groups: group A, 23 patients (18%) who underwent combined aortic resection (+); group B, 103 patients (82%) who did not undergo combined aortic resection (-).

RESULTS

The percentage of aortic invasion for tumor diameter <3 cm, 3-4 cm, 4-5 cm, 5-7 cm, and >7 cm was 0%, 13%, 23%, 16%, and 35%, respectively. The percentages of aortic invasion were 27%, 16%, and 0% for tumor localization in the upper division, S6, and S10, respectively. Multivariate analysis revealed that aortic depression due to tumor or loss of fatty tissue between tumor and mediastinum in the chest CT significantly predicted aortic invasion (odds ratio = 23.83, 16.66). Group A demonstrated significantly more blood loss, longer operative time, prolonged hospital stay, and increased percentage of recurrent nerve palsy (13%) compared to group B. The 1-, 3-, and 5-year survival rates for patients in group A were 53.4%, 24.3%, and 24.3%, respectively.

CONCLUSION

If the chest CT of a patient demonstrates aortic depression due to tumor or loss of fatty tissue between tumor and mediastinum, aortic complications should be considered when planning surgery.

Atrial resection for T4 non-small cell lung cancer with left atrium involvement: a systematic review and meta-analysis of survival

PURPOSE

Extended resection for non-small cell lung cancer (NSCLC) with T4 left atrium involvement is controversial. We performed a systematic review and meta-analysis to evaluate the short- and long-term outcomes of this treatment strategy.

METHODS

We searched the PubMed database for studies on atrial resection in NSCLC patients. The primary investigated outcome was the effectiveness of the surgery represented by survival data and the secondary outcomes were postoperative morbidity, mortality, and recurrence.

RESULTS

Our search identified 18 eligible studies including a total of 483 patients. Eleven studies reported median overall survival and 17 studies reported overall survival rates. The estimated pooled 1, 3, 5-year overall survival rates were 69.1% (95% CI 61.7-76.0%), 21.5% (95% CI 12.3-32.3%), and 19.9% (95% CI 13.9-26.6%), respectively. The median overall survival was 24 months (95% CI 17.7-27 months). Most studies reported significant associations between better survival and N0/1 status, complete resection status, and neoadjuvant therapy.

CONCLUSION

Extended lung resection, including the left atrium, for NSCLC is feasible with acceptable morbidity and mortality when complete resection is achieved. Lymph node N0/1 status coupled with the use of neoadjuvant therapies is associated with better outcomes.

Endovascular Surgery of Descending Thoracic Aorta Involved in T4 Lung Tumor

PURPOSE

Surgical treatment of primary lung T4 tumors is controversial especially when the cancer invades the mediastinal structures or the descending thoracic aorta. Conventional surgical treatment is associated with a high perioperative mortality and morbidity rate. Thoracic EndoVascular Aortic Repair has emerged as a valid off-label alternative to conventional surgery. We aimed to assess perioperative and midterm aortic-related outcome of patients who have undergone aortic stent-graft implantation, followed by en bloc surgical treatment of the involved aorta and lung cancer resection.

MATERIALS AND METHODS

From July 2017 to May 2020, we treated 5 patients diagnosed with a T4 lung cancer by the involvement of the descending thoracic aorta. When only the descending thoracic aorta is involved, a 2-stage procedure was considered, with aortic stent-graft implantation performed before tumor resection. One-stage strategy, with stent-graft implantation carried out before thoracotomy, was preferred for patients with the involvement of cardiac and/or other vascular mediastinal structures.

RESULTS

The mean age was 58.4 ± 6.2 years. All patients were affected by non-small cell lung cancer. All 5 patients required a single stent-graft to completely cover the involved segment of aorta. Four patients underwent a 2-stage procedure. One patient, with the involvement of the left inferior pulmonary vein, required a 1-stage en bloc resection of the left lower lobe, aortic wall adventitia, left inferior pulmonary vein, and reconstruction of the left atrial wall. Primary procedural success was achieved in all. At follow-up, no patient developed aortic-related complications. One patient died 2 years after surgery, due to local recurrence of the tumor.

CONCLUSION

T4 lung resection combined with aortic stent-graft implantation can be safely performed. Endovascular surgery, by avoiding the use of cardiopulmonary bypass, aortic cross-clamping, and graft replacement, can reduce significant morbidity and mortality rate. Postoperative and long-term outcome of these patients treated with endovascular surgery is mainly related to pulmonary disease, not to aortic treatment.

Extrinsic compression of coronary and pulmonary vasculature

Coronary artery disease from atherosclerosis induced stenosis remains the leading cause of acute coronary syndrome (ACS) and death worldwide, however extrinsic compression of coronary arteries from adjacent anatomical and pathological structures is an infrequent but important diagnosis to be aware of, especially given the nonspecific symptoms of chest pain that mimic angina in patients with pulmonary hypertension (PHT) and congenital heart disease. Non-invasive CT angiography is an invaluable diagnostic tool for detection of coronary artery compression, pulmonary artery dilatation and pulmonary vascular compression. Although established guidelines are not available for management of left main coronary artery (LMCA) compression syndrome, percutaneous coronary intervention and stent implantation remain a feasible option for the treatment, specifically for patients with a high surgical risk. Treatment of pulmonary vein or artery compression is more varied and determined by etiology. This review article is focused on detailed discussion of extrinsic compression of coronary arteries, mainly the LMCA and brief discussion on pulmonary vasculature compression by surrounding anatomical and pathological entities, with focus on pathophysiology, clinical features, complications and role of imaging in its diagnosis and management.

Correlation between outcomes and tumor size in >7 cm T4 non-small cell lung cancer patients: A tumor size-based comparison study

BACKGROUND

We investigated whether all size-based pathological T4N0-N1 non-small cell lung cancer patients with tumors at any size >7 cm had the same outcomes.

METHODS

We reviewed non-small cell lung cancer patients with tumors >7 cm who underwent anatomical lung resection between 2010 and 2016. A total of 251 size-based T4N0-N1 patients were divided into two groups based on tumor size. Group S (n = 192) included patients with tumors of 7.1-9.9 cm and Group L (n = 59) as tumor size ≥10 cm.

RESULTS

The mean tumor size was 8.83 ± 1.7 cm (Group S: 8.06 ± 0.6 cm, Group L: 11.3 ± 1.6 cm). There were 146 patients with pathological N0 and 105 patients with pathological N1 disease. Mean overall survival and disease-free survival were 64.2 and 51.4 months, respectively. The five-year overall survival and disease-free survival rates were 51.2% and 43.5% (five-year OS; pT4N0:52.7%, pT4N1:47.9%, DFS; pT4N0:44.3%, pT4N1: 42.3%). No significant differences were observed between T4N0 and T4N1 patients in terms of five-year OS or DFS (p = 0.325, p = 0.505 respectively). The five-year overall survival and disease-free survival rates were 52% and 44.6% in Group S, and 48.5% and 38.9% in Group L. No significant difference was observed between the groups in terms of five-year overall survival or disease-free survival (p = 0.699, p = 0.608, respectively).

CONCLUSIONS

Above 7 cm, any further increase in tumor size in non-small cell lung cancer patients had no significant effect on survival, confirming it is not necessary to further discriminate among patients with tumors in that size class.

Direct Cross-Clamping for Resection of Lung Cancer Invading the Aortic Arch or the Subclavian Artery

BACKGROUND

Resection of lung cancer infiltrating the aortic arch or the subclavian artery can be accomplished in selected patients with the use of cardiopulmonary bypass (CPB). Direct cross-clamping of the aortic arch and the left subclavian artery without CPB for radical resection of the tumor can be an alternative. This study presents one group's experience with this technique.

METHODS

Between October 2016 and May 2019, 9 patients (5 male, 4 female) underwent radical resection of lung cancer infiltrating the aortic arch (n = 5) or the left subclavian artery (n = 4) by direct cross-clamping technique at Sapienza University of Rome, Italy. Seven left upper lobectomies, 1 left pneumonectomy, and 1 left upper sleeve lobectomy were performed. Reconstruction of the aortic arch was performed by direct suturing or polyethylene terephthalate (Dacron) patch, whereas the subclavian artery was reconstructed with a Dacron conduit. Three patients received neoadjuvant chemotherapy.

RESULTS

Patients' mean age was 64.7 ± 13.3 years (range, 36 to 78 years). Aortic arch resection was partial in all cases (adventitial in 1 and full thickness in 4); left subclavian artery resection was adventitial in 2 patients and circumferential in 2. All the resections were complete. Prosthetic reconstruction was performed in 4 cases. Mean operative time was 130 ± 25.6 minutes; mean vascular clamping time was 28.2 ± 3.2 minutes. No mortality occurred. The major complication rate was 11.1 %. At a mean follow-up of 17 ± 9 months (range, 5 to 29 months), the recurrence rate was 33.3%. Median survival was 20 months.

CONCLUSIONS

Direct cross-clamping as an alternative to CPB for resection of lung cancer infiltrating the aortic arch or the subclavian artery is a feasible, safe, and reliable procedure in selected patients.

Systems pharmacology unravels the synergic target space and therapeutic potential of Rhodiola rosea L. for non-small cell lung cancer

BACKGROUND

Lung cancer is the most common and mortal cancer worldwide. Rhodiola rosea L. (RR), a well-known traditional Chinese medicine (TCM), has been turned out to be effective in anti-lung cancer therapy, but its molecular mechanism of action has not been clearly understood.

PURPOSE

In this study, we aimed to elucidate the possible molecular mechanism underlying the effect of RR against non-small cell lung cancer (NSCLC) by systems pharmacology.

METHODS

The effects of RR on NSCLC were examined in Lewis lung carcinoma (LLC) tumor-bearing mice models. The possible molecular mechanism was unraveled by systems pharmacology, which includes pharmacokinetics evaluation, active compounds screening, target prediction and network analysis. Cell proliferation was examined by cell counting kit-8 (CCK-8) assay; cell apoptosis was detected by flow cytometry; protein and proinflammatory cytokines expression were evaluated by Western blot and qRT-PCR.

RESULTS

In vivo, RR significantly inhibited the tumor growth and prolonged the survival of the tumor bearing mice. In silico, we identified 19 potential active molecules (e.g., salidroside and rhodiosin), 112 targets (e.g., COX-2 and AKT) and 27 pathways (e.g., PI3K/AKT signaling pathway and NF-κB signaling pathway) for RR. Additionally, targets analysis and networks construction further revealed that RR exerted anti-cancer effects by regulating apoptosis, angiogenesis and inflammation. In vitro, salidroside could significantly decrease expression of pro-angiogenic factors (e.g., VEGF and eNOS) and proinflammatory cytokines (e.g., COX-2, iNOS and TNF-α). Also, Bcl-2, an anti-apoptotic protein was decreased whereas Bax, a pro-apoptotic protein, was increased. Further flow cytometry analysis showed that salidroside could induce apoptosis in H1975 cells.

CONCLUSIONS

Mechanistically, the antitumor effect of RR on NSCLC was responsible for the synergy among anti-inflammatory, anti-angiogenic and pro-apoptotic.