Efficacy of repeated surgery is superior to that of non-surgery for recurrent/second primary lung cancer after initial operation for primary lung cancer

Diagnosis and management of multiple primary lung cancer

Multiple primary lung cancer (MPLC), can be categorized as synchronous multiple primary lung cancer (sMPLC) and metachronous multiple primary lung cancer (mMPLC), which are becoming increasingly common in clinical practice. A precise differential diagnosis between MPLC and intrapulmonary metastases (IPM) is essential for determining the appropriate management strategy. MPLC is primarily diagnosed through histology, imaging, and molecular methods. Imaging serves as an essential foundation for preoperative diagnosis, while histology is a critical tool for establishing a definitive diagnosis. As molecular biology advances, the diagnosis of MPLC has stepped into the era of molecular precision. Surgery is the preferred treatment approach, with stereotactic radiotherapy and ablation being viable options for unresectable lesions. Targeted therapy and immunotherapy can be considered for specific patients. A multidisciplinary team approach to evaluation and the application of combination therapy can benefit more patients. Looking ahead, the development of more authoritative guidelines will be instrumental in streamlining the diagnosis and management of MPLC.

Characteristics and classification of first primary cancer patients with second primary cancer: a population-based cohort study

Cancer survivors have an increased risk of developing subsequent primary tumors. However, the characteristics of first primary cancers (FPCs) with various types of second primary cancers (SPCs) are poorly understood, which hinders screening strategies. We analyzed data from 1,893,258 patients from the Surveillance, Epidemiology, and End Results (SEER) database to characterize and classify of FPC patients with subsequent SPCs at the pan-cancer level. In total, 3% of patients had SPC, with varied incidence rates observed depending on the types of FPC. Their onset patterns of SPC and diversity of SPC varied. Based on the diversity of the high-incidence sites of SPC, we classified FPCs into two categories: FPCs that require whole-body screening and those that need screening of particular body parts. Moreover, according to the different timing of high incidence of SPCs, our system classifies FPCs into two subtypes: FPCs that require long-term monitoring for the occurrence of SPCs and those that require screening at specific time points for SPCs. Furthermore, we identified 11 anatomical sites where over half of FPC types are prone to SPC occurrence at these locations. The risk factors for SPC occurrence in different FPC types and prognostic factors were also elucidated. Overall, we characterize and classify of FPC patients with subsequent SPCs at the pan-cancer level, which can guide the development of distinct screening strategies for each FPC type.

Lifespan and medical expenditure prognosis for cancer metastasis - a simulation modeling using semi-Markov process

BACKGROUND AND OBJECTIVE

A key reason of high mortality of cancers is attributed to the metastasized cancer, whereas, the medical expense for the treatment of cancer metastases generates heavily financial burden. The population size of metastases cases is small and comprehensive inferencing and prognosis is hard to conduct.

METHODS

Because metastases and finance state can develop dynamic transitions over time, this study proposes a semi-Markov model to perform risk and economic evaluation associated to major cancer metastasis (i.e., lung, brain, liver and lymphoma cancer) against rare cases. A nationwide medical database in Taiwan was employed to derive a baseline study population and costs data. The time until development of metastasis and survivability from metastasis, as well as the medical costs were estimated through a semi-Markov based Monte Carlo simulation.

RESULTS

In terms of the survivability and risk associated to metastatic cancer patients, 80% lung and liver cancer cases are tended to metastasize to other part of the body. The highest cost is generated by brain cancer-liver metastasis patients. The survivors group generated approximately 5 times more costs, in average, than the non-survivors group.

CONCLUSIONS

The proposed model provides a healthcare decision-support tool to evaluate the survivability and expenditure of major cancer metastases.

Ultrasound-Guided Bilateral Sequential Thoracic Paravertebral Block for Simultaneous Bilateral Uniportal Video-Assisted Thoracoscopic Surgery: Study Protocol for a Randomized Controlled Trial

Purpose

Simultaneous bilateral pulmonary resection via uniportal video-assisted thoracoscopic surgery (UVATS) was safe and feasible for the treatment of bilateral multiple pulmonary nodules. But, it should be noted that considerable postoperative pain at the bilateral surgical site was a crucial issue. The safety and efficacy of bilateral thoracic paravertebral block (TPVB) have been reported for postoperative analgesia. But, whether bilateral sequential TPVB can be safely and effectively used in simultaneous bilateral UVATS remains unknown. Therefore, this study aimed to determine the analgesic efficacy and safety of bilateral sequential TPVB after simultaneous bilateral UVATS.

Study Design and Methods

In this study, 80 participants scheduled for UVATS will be randomly allocated to the bilateral sequential TPVB group (G2) and the control group (G1). The patient of G2 will be performed bilateral TPVB at 2 time-points: before the start of the first side of pulmonary resection and before the start of the contralateral pulmonary resection. G1 will only receive standard analgesia protocol. The primary outcome is the numeric rating scale score during coughing at 24 h postoperatively. The secondary outcomes include the Prince Henry Pain Score scores, sufentanil consumption, postoperative nausea and vomiting, levels of inflammatory factors, and the Quality of Recovery-40 scores at different time points, as well as chronic pain at postoperative day (POD) 90.

Discussion

This is the first prospective trial to determine the safety and effectiveness of ultrasound-guided bilateral sequential TPVB for postoperative analgesia following simultaneous bilateral UVATS. This study also intended to evaluate the effect of this intervention on postoperative quality of recovery and inflammation levels. The final results will provide clinical evidence related to bilateral sequential TPVB, and promote the application of that acting as a more appropriate analgesic method for simultaneous bilateral UVATS.

Feasibility and safety of secondary video-assisted thoracoscopic surgery for ipsilateral lung cancer after prior pulmonary resection

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) is the preferred treatment for resectable non-small cell lung cancer. The increased survival of patients after a first operation has caused increases in the incidence of locoregional recurrence or second primary lung cancer and a concomitant increase in the number of patients who require secondary surgery. Ipsilateral secondary operation is also commonly practiced, albeit with enhanced difficulty. Therefore, it is necessary to evaluate the feasibility and safety of VATS for ipsilateral lung cancer after pulmonary resection.

METHODS

Patients who underwent ipsilateral secondary VATS in the West China Hospital, Sichuan University from 2012 to 2021 were assessed retrospectively. All included patients had a pulmonary resection. Clinical characteristics, perioperative outcomes, and survival data were collected, with an emphasis on conversion to thoracotomy, postoperative complications, 30-day mortality, and survival. Logistic regression analysis was used to identify predictors of postoperative complications.

RESULTS

Seventy patients were enrolled, of which 10 (14.3%) had converted thoracotomy, 17 (24.3%) had postoperative complications, and two (2.9%) had grade III complications. No patient died within 30 days after surgery. High Charlson comorbidity index (CCI) and severe pleural adhesion were independent predictors for complications. The median follow-up was 50 months (range: 3-120), and the 5-year overall survival was 78.2%.

CONCLUSION

Secondary VATS for ipsilateral lung cancer for patients who had pulmonary resection was feasible and safe. Strict preoperative evaluation and careful management of pleural adhesion are crucial for the success of the surgery.

Outcome and prognosis of secondary lung cancer surgery with interstitial lung disease

Background

The initial surgery for lung cancer with interstitial lung disease (ILD) is often followed by passive treatment due to the surgery‐induced deterioration in respiratory function, and only a few studies have summarized the findings associated with a second surgery for lung cancer patients with ILD.

Methods

Of the 3932 lung cancer patients who underwent surgery at our hospital from August 2008 to July 2019, 404 (10%) patients (1) underwent preoperative computed tomography for imaging of interstitial pneumonia and (2) underwent initial surgery. We analyzed 45 cases (11%) suspected of showing metachronous lung cancer during the postoperative course.

Results

Thirty‐four patients (76%) underwent a second surgery. The group that underwent a second surgery showed a significantly better prognosis than the group that did not (p = 0.0009). The surgical procedure was wide‐wedge resection/segmentectomy/lobectomy and above in 15/7/12 cases, respectively. Postoperative complications were observed in nine cases (26%) (prolonged pulmonary fistula in five cases, ILD acute exacerbation in two cases, and wound dissection in two cases). Mortality within 30 days occurred in one case (ILD acute exacerbation at postoperative day 15). Twelve patients (35%) experienced recurrence. In the wide‐wedge resection group, 2/15 (13%) patients showed stump recurrence. The 1‐, 2‐, 3‐, and 5‐year survival rates after surgery for secondary lung cancer were 80.4, 72.5, 68.2, and 39.4%, respectively.

Conclusion

Surgery can be considered an effective treatment method for secondary lung cancer with ILD if the cases are carefully selected.

Prognostic Nomogram and Therapeutic Option of Cancer-Specific Death in the Patients with Metachronous Second Primary Lung Cancer

With the increase of long-term primary lung cancer survivors, studies focused on metachronous second primary lung cancer (SPLC) have become very urgent. This study aimed to develop a prognostic nomogram and determine therapeutic options of cancer-specific death for patients with metachronous SPLC with and without the competing risk of other-specific death. Study population came from the SEER-18 database between 2006 and 2016. According to the clinical practice guideline of SPLC, the interval time of IPLC and metachronous SPLC was set to 4 years. We constructed nomograms with Lasso + Cox regression model and competing risk model to predict the prognosis and identify therapeutic options of metachronous SPLC patients with the assessment of model performance by the C-index, calibration plot, and decision curve analysis. In addition, two subgroup analyses stratified by histology and tumor size were used to better select therapeutic options for a certain population. 1300 patients with metachronous SPLC were incorporated in this study with 50.1% of the 5-year cumulative incidence in cancer-specific death. Compared with Lasso + Cox regression analysis, competing risk analysis harbored a higher C-index (0.811 vs. 0.76) and better net benefit in predicting cancer-specific death of metachronous SPLC. Two statistical analyses suggested that surgery alone was a preferentially therapeutic option of metachronous SPLC, whereas the effect of surgery + radiation in treating metachronous SPLC was similar to radiation alone. Subgroup analyses indicated that patients with metachronous SPLC were considered receiving different therapeutic options in different histology and tumor size but preferred to receive surgical treatment as the first choice. For primary lung cancer survivors, aggressive surgical treatment was the first-line selection of metachronous SPLC, followed by radiation alone, surgery + radiation, and no surgery + radiation.

Comparison of perioperative and survival outcomes between sublobar resection and lobectomy of patients who underwent a second pulmonary resection

Background

Repeat pulmonary resection is widely accepted in clinical practice. This study aimed to compare sublobar resection (segmentectomy or wedge resection) with lobectomy in the treatment of patients who underwent a second pulmonary resection.

Methods

This study retrospectively included patients who underwent lobectomy or sublobar resection for second pulmonary resection. 1:1 propensity score matching (PSM) was performed to balance selection bias. Clinicopathological features, perioperative and survival outcomes of lobectomy and sublobar resection were compared.

Results

A total of 308 patients who underwent second pulmonary resection were identified: 71 (23.1%) who underwent lobectomy and 237 (76.9%) who underwent sublobar resection. After PSM, 58 patients for each group were selected with well‐balanced clinicopathological characteristics. In patients who underwent sublobar resection, significantly shorter chest tube duration (days) (median, 4 vs. 2, p < 0.001) and postoperative hospital stay (days) (median, 6 vs. 4, p < 0.001) were observed. There was no significant difference in overall survival between these two groups after the second and first surgery (p = 0.65, p = 0.98), respectively. Subgroup analysis according to the type of the first resection showed consistent results.

Conclusions

Sublobar resection may be considered as an alternative option for second pulmonary resection due to its perioperative advantages and similar survival outcomes compared with lobectomy.

Simultaneous Uniportal video-assisted thoracic surgery of bilateral pulmonary nodules

Background

Surgical resection is an appropriate treatment option for synchronous bilateral pulmonary nodules with ground-glass opacities. The applicability of simultaneous uniportal video-assisted thoracic surgery is not fully understood. We evaluated the feasibility and safety of performing such surgeries at our hospital.

Methods

Clinical data of 35 patients who underwent simultaneous bilateral pulmonary resection with uniportal video-assisted thoracic surgery at our hospital were reviewed retrospectively.

Results

Simultaneous bilateral pulmonary resection with uniportal video-assisted thoracic surgery was performed for 35 patients (15 men, 20 women); 97 nodules were operated on, and the average nodule diameter was 11.4 mm (range, 1–38 mm). Computerized tomography showed that most nodules had ground-glass opacity (52/97, 53.6%); solid nodules (24/97, 24.7%) and nodules with mixed ground-glass opacity (21/97, 21.7%) were noted. Surgical resection included lobar-sublobar resection (11/35, 31.4%) and sublobar-sublobar resection (24/35, 68.6%). Wound infection and postoperative 30-day mortality were not observed. Pneumonia was the major postoperative complication, with a higher incidence in the lobar-sublobar group (6/10, 60%) than in the sublobar-sublobar group (4/25, 16%; P = 0.016). Pneumonia did not correlate with operative time (mean, 262.3 ± 108.1 vs. 261.9 ± 87.5 min, P = 0.991), duration of chest drainage (mean, 7.0 ± 4.0 vs 5.4 ± 2.1 days, P = 0.124), and postoperative hospital stay (mean, 10.2 ± 3.6 vs 10.2 ± 6.4 days, P = 0.978). The mean follow-up time was 8 (range, 3–22) months. Recurrence of primary lung cancer or mortality was not noted at the final follow-up.

Conclusions

Simultaneous bilateral pulmonary resection with uniportal video-assisted thoracic surgery is feasible and safe for appropriate patients. Simultaneous lobar-sublobar pulmonary resection for bilateral nodules can increase the risk of developing pneumonia.

Outcomes after Contralateral Anatomic Surgical Resection in Multiple Lung Cancer

BACKGROUND

Patients treated surgically for lung cancer may present synchronous or metachronous lung cancers. The aim of this study was to evaluate outcomes after a second contralateral anatomic surgical resection for lung cancer.

METHODS

We performed a retrospective two-center study, based on a prospective indexed database. Included patients were treated surgically by bilateral anatomic surgical resection for a second primary lung cancer. We excluded nonanatomic resections, benign lesions, and ipsilateral second surgical resections.

RESULTS

Between January 2011 and September 2018, 55 patients underwent contralateral anatomic surgical resections for lung cancer, mostly for metachronous cancers. The first surgical resection was a lobectomy in most cases (45 lobectomies: 81.8%, 9 segmentectomies: 16.4%, and 1 bilobectomy: 1.8%), and a video-assisted thoracic surgery (VATS) procedure was used in 23 cases (41.8%). The mean interval between the operations was 38 months, and lobectomy was less frequent for the second surgical resection (35 lobectomies: 63.6% and 20 segmentectomies: 36.4%), with VATS procedures performed in 41 cases (74.5%). Ninety-day mortality was 10.9% (n = 6), and 3-year survival was 77%. Risk factor analysis identified the number of resected segments during the second intervention or the total number of resected segments, extent of resection (lobectomy vs. segmentectomy), surgical approach (thoracotomy vs. VATS), tumor stage, and nodal involvement as potential prognostic factors for long-term survival.

CONCLUSION

A second contralateral anatomic surgical resection for multiple primary lung cancer is possible, with a higher early mortality rate, but acceptable long-term survival, and should be indicated for carefully selected patients.