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Liao Y, Li Z, Song L, Xue Y, Chen X, Feng G. Development and validation of a model for predicting upstage in minimally invasive lung adenocarcinoma in Chinese people. World J Surg Oncol 2024; 22:135. [PMID: 38778366 PMCID: PMC11112920 DOI: 10.1186/s12957-024-03414-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 05/20/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Sublobar resection for ground-glass opacity became a recommend surgery choice supported by the JCOG0804/JCOG0802/JCOG1211 results. Sublobar resection includes segmentectomy and wedge resection, wedge resection is suitable for non-invasive lesions, but in clinical practice, when pathologists are uncertain about the intraoperative frozen diagnosis of invasive lesions, difficulty in choosing the appropriate operation occurs. The purpose of this study was to analyze how to select invasive lesions with clinic-pathological characters. METHODS A retrospective study was conducted on 134 cases of pulmonary nodules diagnosed with minimally invasive adenocarcinoma by intraoperative freezing examination. The patients were divided into two groups according to intraoperative frozen results: the minimally invasive adenocarcinoma group and the at least minimally invasive adenocarcinoma group. A variety of clinical features were collected. Chi-square tests and multiple regression logistic analysis were used to screen out independent risk factors related to pathological upstage, and then ROC curves were established. In addition, an independent validation set included 1164 cases was collected. RESULTS Independent risk factors related to pathological upstage were CT value, maximum tumor diameter, and frozen result of AL-MIA. The AUC of diagnostic mode was 71.1% [95%CI: 60.8-81.3%]. The independent validation included 1164 patients, 417 (35.8%) patients had paraffin-based pathology of invasive adenocarcinoma. The AUC of diagnostic mode was 75.7% [95%CI: 72.9-78.4%]. CONCLUSIONS The intraoperative frozen diagnosis was AL-MIA, maximum tumor diameter larger than 15 mm and CT value is more than - 450Hu, highly suggesting that the lung GGO was invasive adenocarcinoma which represent a higher risk to recurrence. For these patients, sublobectomy would be insufficient, lobectomy or complementary treatment is encouraged.
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Affiliation(s)
- Yida Liao
- Department of Thoracic Surgery, School of Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China.
| | - Zhixin Li
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, 200433, P.R. China
| | - Linhong Song
- Department of Pathology, School of Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Yang Xue
- Department of Thoracic Surgery, School of Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiangru Chen
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, 200433, P.R. China
| | - Gang Feng
- Department of Thoracic Surgery, School of Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
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Huo J, Min X, Luo T, Lv F, Feng Y, Fan Q, Wang D, Ma D, Li Q. Computed tomography-based 3D convolutional neural network deep learning model for predicting micropapillary or solid growth pattern of invasive lung adenocarcinoma. LA RADIOLOGIA MEDICA 2024; 129:776-784. [PMID: 38512613 PMCID: PMC11088553 DOI: 10.1007/s11547-024-01800-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 02/14/2024] [Indexed: 03/23/2024]
Abstract
PURPOSE To investigate the value of a computed tomography (CT)-based deep learning (DL) model to predict the presence of micropapillary or solid (M/S) growth pattern in invasive lung adenocarcinoma (ILADC). MATERIALS AND METHODS From June 2019 to October 2022, 617 patients with ILADC who underwent preoperative chest CT scans in our institution were randomly placed into training and internal validation sets in a 4:1 ratio, and 353 patients with ILADC from another institution were included as an external validation set. Then, a self-paced learning (SPL) 3D Net was used to establish two DL models: model 1 was used to predict the M/S growth pattern in ILADC, and model 2 was used to predict that pattern in ≤ 2-cm-diameter ILADC. RESULTS For model 1, the training cohort's area under the curve (AUC), accuracy, recall, precision, and F1-score were 0.924, 0.845, 0.851, 0.842, and 0.843; the internal validation cohort's were 0.807, 0.744, 0.756, 0.750, and 0.743; and the external validation cohort's were 0.857, 0.805, 0.804, 0.806, and 0.804, respectively. For model 2, the training cohort's AUC, accuracy, recall, precision, and F1-score were 0.946, 0.858, 0.881,0.844, and 0.851; the internal validation cohort's were 0.869, 0.809, 0.786, 0.794, and 0.790; and the external validation cohort's were 0.831, 0.792, 0.789, 0.790, and 0.790, respectively. The SPL 3D Net model performed better than the ResNet34, ResNet50, ResNeXt50, and DenseNet121 models. CONCLUSION The CT-based DL model performed well as a noninvasive screening tool capable of reliably detecting and distinguishing the subtypes of ILADC, even in small-sized tumors.
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Affiliation(s)
- Jiwen Huo
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yu Zhong District, Chongqing, 400016, China
| | - Xuhong Min
- Anhui Chest Hospital, 397 Jixi Road, Hefei, 230022, Anhui Province, China
| | - Tianyou Luo
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yu Zhong District, Chongqing, 400016, China
| | - Fajin Lv
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yu Zhong District, Chongqing, 400016, China
| | - Yibo Feng
- Institute of Research, Infervision Medical Technology Co., Ltd, 25F Building E, Yuanyang International Center, Chaoyang District, Beijing, 100025, China
| | - Qianrui Fan
- Institute of Research, Infervision Medical Technology Co., Ltd, 25F Building E, Yuanyang International Center, Chaoyang District, Beijing, 100025, China
| | - Dawei Wang
- Institute of Research, Infervision Medical Technology Co., Ltd, 25F Building E, Yuanyang International Center, Chaoyang District, Beijing, 100025, China
| | - Dongchun Ma
- Anhui Chest Hospital, 397 Jixi Road, Hefei, 230022, Anhui Province, China.
| | - Qi Li
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yu Zhong District, Chongqing, 400016, China.
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Brunelli A, Decaluwe H, Gonzalez M, Gossot D, Petersen RH. Which extent of surgical resection thoracic surgeons would choose if they were diagnosed with an early-stage lung cancer: a European survey. Eur J Cardiothorac Surg 2024; 65:ezae015. [PMID: 38327176 DOI: 10.1093/ejcts/ezae015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/03/2024] [Accepted: 01/11/2024] [Indexed: 02/09/2024] Open
Affiliation(s)
| | - Herbert Decaluwe
- Department of Thoracovascular Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Michel Gonzalez
- Department of Thoracic Surgery, University Hospital of Lausanne, Lausanne, Switzerland
| | - Dominique Gossot
- Department of Thoracic Surgery, IMM-Curie-Montsouris Thoracic Institute, Paris, France
| | - Rene Horsleben Petersen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Willner J, Narula N, Moreira AL. Updates on lung adenocarcinoma: invasive size, grading and STAS. Histopathology 2024; 84:6-17. [PMID: 37872108 DOI: 10.1111/his.15077] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/29/2023] [Accepted: 10/04/2023] [Indexed: 10/25/2023]
Abstract
Advancements in the classification of lung adenocarcinoma have resulted in significant changes in pathological reporting. The eighth edition of the tumour-node-metastasis (TNM) staging guidelines calls for the use of invasive size in staging in place of total tumour size. This shift improves prognostic stratification and requires a more nuanced approach to tumour measurements in challenging situations. Similarly, the adoption of new grading criteria based on the predominant and highest-grade pattern proposed by the International Association for the Study of Lung Cancer (IASLC) shows improved prognostication, and therefore clinical utility, relative to previous grading systems. Spread through airspaces (STAS) is a form of tumour invasion involving tumour cells spreading through the airspaces, which has been highly researched in recent years. This review discusses updates in pathological T staging, adenocarcinoma grading and STAS and illustrates the utility and limitations of current concepts in lung adenocarcinoma.
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Affiliation(s)
- Jonathan Willner
- Department of Pathology, New York University Grossman School of Medicine, New York, NY, USA
| | - Navneet Narula
- Department of Pathology, New York University Grossman School of Medicine, New York, NY, USA
| | - Andre L Moreira
- Department of Pathology, New York University Grossman School of Medicine, New York, NY, USA
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Li SJ, Shen KF, He L, Zhang YP, Ming L, Wu ZF. Clinical Analysis of Intranasal Dexmedetomidine Combined With Midazolam in Pediatric Cranial Magnetic Resonance Examinations. J Perianesth Nurs 2023; 38:925-929. [PMID: 37278686 DOI: 10.1016/j.jopan.2023.02.005] [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: 09/24/2022] [Revised: 02/01/2023] [Accepted: 02/03/2023] [Indexed: 06/07/2023]
Abstract
PURPOSE To observe the efficacy and safety of intranasal dexmedetomidine combined with midazolam in cranial magnetic resonance imaging of children. DESIGN A prospective, observational, single-arm, one-center study. METHODS A total of 474 children were scheduled for cranial 3.0 T MRI at the first time. All patients were initially given 3 mcg/kg dexmedetomidine combined with 0.15 mg/kg midazolam. The one-time success rate, vital signs before and after treatment, onset time, recovery time, and incidence of adverse reactions were recorded. FINDINGS The one-time success rate was 78.1%. There were significant differences in respiration, heart rate, and blood oxygen saturation before and after treatment (P < .001). The onset time was 10 (8-15) minutes. The average recovery time was 2.58 ± 1.10 hours. Only 1.27% (6 cases) of adverse reactions were observed, including bradycardia (3 cases, 0.6%), tachycardia (1 case, 0.2%), and startle (2 cases, 0.4%). No special treatment was needed. The success of the examination was significantly correlated with age (OR 1.320, 95% CI 1.019-1.710, P = .035) and onset time (OR 0.959, 95% CI 0.921-0.998, P = .038). CONCLUSION Dexmedetomidine 3 mcg/kg combined with midazolam 0.15 mg/kg intranasally has a good sedative effect in pediatric cranial magnetic resonance examinations, little impact on breathing and circulation, and few adverse reactions. Age and onset time are related factors affecting the one-time success rate.
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Affiliation(s)
- Si-Jie Li
- Department of Pediatrics, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Kai-Feng Shen
- Department of Neurosurgery, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Li He
- Department of Pediatrics, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Yu-Ping Zhang
- Department of Pediatrics, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Li Ming
- Department of Pediatrics, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Zhi-Feng Wu
- Department of Pediatrics, Xinqiao Hospital, Army Medical University, Chongqing, China.
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Liu HC, Lin MH, Chang WC, Zeng RC, Wang YM, Sun CW. Rapid On-Site AI-Assisted Grading for Lung Surgery Based on Optical Coherence Tomography. Cancers (Basel) 2023; 15:5388. [PMID: 38001648 PMCID: PMC10670228 DOI: 10.3390/cancers15225388] [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: 10/03/2023] [Revised: 11/02/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023] Open
Abstract
The determination of resection extent traditionally relies on the microscopic invasiveness of frozen sections (FSs) and is crucial for surgery of early lung cancer with preoperatively unknown histology. While previous research has shown the value of optical coherence tomography (OCT) for instant lung cancer diagnosis, tumor grading through OCT remains challenging. Therefore, this study proposes an interactive human-machine interface (HMI) that integrates a mobile OCT system, deep learning algorithms, and attention mechanisms. The system is designed to mark the lesion's location on the image smartly and perform tumor grading in real time, potentially facilitating clinical decision making. Twelve patients with a preoperatively unknown tumor but a final diagnosis of adenocarcinoma underwent thoracoscopic resection, and the artificial intelligence (AI)-designed system mentioned above was used to measure fresh specimens. Results were compared to FSs benchmarked on permanent pathologic reports. Current results show better differentiating power among minimally invasive adenocarcinoma (MIA), invasive adenocarcinoma (IA), and normal tissue, with an overall accuracy of 84.9%, compared to 20% for FSs. Additionally, the sensitivity and specificity, the sensitivity and specificity were 89% and 82.7% for MIA and 94% and 80.6% for IA, respectively. The results suggest that this AI system can potentially produce rapid and efficient diagnoses and ultimately improve patient outcomes.
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Affiliation(s)
- Hung-Chang Liu
- Section of Thoracic Surgery, Mackay Memorial Hospital, Taipei City 10449, Taiwan;
- Intensive Care Unit, Mackay Memorial Hospital, Taipei City 10449, Taiwan
- Department of Medicine, Mackay Medical College, New Taipei City 25245, Taiwan
- Department of Optometry, Mackay Junior College of Medicine, Nursing, and Management, Taipei City 11260, Taiwan
| | - Miao-Hui Lin
- Biomedical Optical Imaging Lab, Department of Photonics, College of Electrical and Computer Engineering, National Yang Ming Chiao Tung University, Hsinchu City 30010, Taiwan; (M.-H.L.); (R.-C.Z.); (Y.-M.W.)
| | - Wei-Chin Chang
- Department of Pathology, Mackay Memorial Hospital, New Taipei City 25160, Taiwan;
- Department of Pathology, Taipei Medical University Hospital, Taipei City 11030, Taiwan
- Department of Pathology, School of Medicine, College of Medicine, Taipei Medical University, Taipei City 11030, Taiwan
| | - Rui-Cheng Zeng
- Biomedical Optical Imaging Lab, Department of Photonics, College of Electrical and Computer Engineering, National Yang Ming Chiao Tung University, Hsinchu City 30010, Taiwan; (M.-H.L.); (R.-C.Z.); (Y.-M.W.)
| | - Yi-Min Wang
- Biomedical Optical Imaging Lab, Department of Photonics, College of Electrical and Computer Engineering, National Yang Ming Chiao Tung University, Hsinchu City 30010, Taiwan; (M.-H.L.); (R.-C.Z.); (Y.-M.W.)
| | - Chia-Wei Sun
- Biomedical Optical Imaging Lab, Department of Photonics, College of Electrical and Computer Engineering, National Yang Ming Chiao Tung University, Hsinchu City 30010, Taiwan; (M.-H.L.); (R.-C.Z.); (Y.-M.W.)
- Institute of Biomedical Engineering, College of Electrical and Computer Engineering, National Yang Ming Chiao Tung University, Hsinchu City 30010, Taiwan
- Medical Device Innovation and Translation Center, National Yang Ming Chiao Tung University, Taipei City 11259, Taiwan
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Liu HC, Lin MH, Ting CH, Wang YM, Sun CW. Intraoperative application of optical coherence tomography for lung tumor. JOURNAL OF BIOPHOTONICS 2023; 16:e202200344. [PMID: 36755475 DOI: 10.1002/jbio.202200344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/06/2023] [Accepted: 01/18/2023] [Indexed: 06/07/2023]
Abstract
On-site instant determination of benign or malignant tumors for deciding the types of resection is crucial during pulmonary surgery. We designed a portable spectral-domain optical coherence tomography (SD-OCT) system to do real-time scanning intraoperatively for the distinction of fresh tumor specimens in the lung. A total of 12 ex vivo lung specimens from six patients were enrolled. Three patients were diagnosed with invasive adenocarcinoma (IA), while the others were benign. After OCT-imaged reconstruction, we compared the qualitative morphology of OCT and histology among malignant, benign, and normal tissues. In addition, through analysis of the quantitative data, a discrete difference in optical attenuation coefficients around the junctional surface was shown by our data processing. This study demonstrated a feasible OCT-assisted resection guide by a rapid on-site tumor diagnosis. The results indicate that future deep learning of OCT-captured image systems able to improve diagnostic and therapeutic efficiency is warranted.
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Affiliation(s)
- Hung-Chang Liu
- Department of Thoracic Surgery, Mackay Memorial Hospital, Taipei City, Taiwan
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
- Department of Nursing, Mackay Junior College of Medicine, Nursing, and Management, Taipei City, Taiwan
| | - Miao-Hui Lin
- Biomedical Optical Imaging Lab, Department of Photonics, College of Electrical and Computer Engineering, National Yang Ming Chiao Tung University, Hsinchu City, Taiwan
| | - Ching-Heng Ting
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
- Department of Nursing, Mackay Junior College of Medicine, Nursing, and Management, Taipei City, Taiwan
- Department of Pathology, Mackay Memorial Hospital, New Taipei City, Taiwan
| | - Yi-Min Wang
- Biomedical Optical Imaging Lab, Department of Photonics, College of Electrical and Computer Engineering, National Yang Ming Chiao Tung University, Hsinchu City, Taiwan
| | - Chia-Wei Sun
- Biomedical Optical Imaging Lab, Department of Photonics, College of Electrical and Computer Engineering, National Yang Ming Chiao Tung University, Hsinchu City, Taiwan
- Institute of Biomedical Engineering, College of Electrical and Computer Engineering, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
- Medical Device Innovation and Translation Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Liu D, Chen L, Wang X, Lin Y, Gu J. Use of Computed Tomography-Guided Percutaneous Biopsy of Invasive Non-Mucinous Lung Adenocarcinoma to Predict the Degree of Histological Differentiation. Clin Med Insights Oncol 2022; 16:11795549221102752. [PMID: 35694138 PMCID: PMC9178743 DOI: 10.1177/11795549221102752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 05/02/2022] [Indexed: 11/15/2022] Open
Abstract
Background The International Association for the Study of Lung Cancer (IASLC) published a grading system for invasive pulmonary adenocarcinoma that is closely associated with prognosis. This study aimed to investigate the accuracy of computed tomography (CT)-guided biopsy specimen grading and surgery-guided grading systems for detecting invasive non-mucinous lung adenocarcinoma and to determine whether CT-guided biopsy can predict the degree of histological differentiation. Methods In total, 130 patients with invasive non-mucinous lung adenocarcinoma who underwent CT-guided biopsy before surgical excision were retrospectively studied. Biopsy and surgical specimen pathologies were compared. Grading was performed according to different subtypes proposed by the International Association for the Study of Lung Cancer. Sensitivity, specificity, positive and negative predictive values (PPV/NPV), and accuracy were calculated for each subtype and grade. Results The concordance rates of biopsy and surgical pathology subtypes and grades were 73.1% and 72.3%, respectively. Sensitivity, specificity, PPV, NPV, and accuracy of grade 3 were 54.8%, 100%, 100%, 87.6%, and 89.2%, respectively. Pathology grades were primarily discrepant with respect to two aspects of biopsy and surgical samples in the same patient. First, the biopsy and surgical specimen pathology findings indicated lepidic and acinar subtypes as the main subtypes in the same patient, respectively. Second, biopsy specimen histology did not find solid types; however, >20% of solid subtypes were identified in surgical pathology samples in the same patient. Conclusions The preoperative CT-guided biopsy specimen grading system showed relatively high accuracy and could predict the prognosis of invasive non-mucinous lung adenocarcinoma.
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Affiliation(s)
- Dehao Liu
- Department of Radiology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Lichun Chen
- Department of Radiology, Xiamen Hospital of Traditional Chinese Medicine, Xiamen, China
| | - Xiaoping Wang
- Department of Radiology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Yikai Lin
- Department of Radiology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Jianwei Gu
- Department of Radiology, The First Affiliated Hospital of Xiamen University, Xiamen, China
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Huang L, Tang L, Dai L, Shi Y. The prognostic significance of tumor spread through air space in stage I lung adenocarcinoma. Thorac Cancer 2022; 13:997-1005. [PMID: 35174646 PMCID: PMC8977166 DOI: 10.1111/1759-7714.14348] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 12/25/2022] Open
Abstract
Aim There are still patients of stage I lung adenocarcinoma (ADC) suffering from local or distant recurrence. Herein we conducted a meta‐analysis to investigate the prognostic value of tumor spread through air space (STAS), a new form of invasion pattern, in patients with pathologically confirmed stage I lung ADC. Methods Related literature was searched using PubMed, Embase, Cochrane Library, and Web of Science databases from the inception dates to September 4, 2021. Recurrence‐free survival (RFS) and overall survival (OS) were set as primary outcome endpoints. In addition, subgroup analyses on operation mode, edition of the American Joint Committee on Cancer TNM staging, sample size, and research regions were also investigated. Results A total of 17 studies involving 9785 patients were included. The presence of STAS was detected in 31.2% of patients and was associated with poor RFS (adjusted hazard ratio [HR] = 1.93, p < 0.001) and OS (HR = 2.02, p < 0.001). In subgroup analysis on operation mode, the prognostic value of STAS was prominently shown in patients who underwent limited resection (RFS: HR = 3.58, p < 0.001; OS: HR = 3.37, p < 0.001), while for patients who underwent lobectomy, adverse impact of STAS on RFS was observed (HR = 1.60, p = 0.019), but no significant difference was observed on OS (HR = 1.56, p = 0.061). The results fluctuated in different regions while other factors did not alter the independent predictive value of STAS. Conclusion Tumor STAS should be considered as an adverse prognostic indicator for patients with stage I lung ADC, especially for those under limited resection. More intensive medical care for those patients needs to be investigated in further studies.
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Affiliation(s)
- Liling Huang
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, China
| | - Le Tang
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, China
| | - Liyuan Dai
- Department of Clinical Laboratory, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, China
| | - Yuankai Shi
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, China
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10
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Zhou F, Villalba JA, Sayo TMS, Narula N, Pass H, Mino-Kenudson M, Moreira AL. Assessment of the feasibility of frozen sections for the detection of spread through air spaces (STAS) in pulmonary adenocarcinoma. Mod Pathol 2022; 35:210-217. [PMID: 34326485 PMCID: PMC8792146 DOI: 10.1038/s41379-021-00875-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 02/03/2023]
Abstract
Spread through air spaces (STAS) is reportedly associated with worse prognosis in sublobar resections of lung adenocarcinoma. Recently, it was proposed that STAS detected on frozen sections can be an indication for lobectomy instead of sublobar resection. We undertook this study to evaluate the reliability of STAS assessment on frozen sections compared to permanent sections, as well as the associations among STAS, tumor grade, and recurrence-free survival (RFS) after sublobar resection. A total of 163 stage I lung adenocarcinoma resections with frozen sections were identified retrospectively. For each case, and for frozen and permanent sections separately, the presence or absence of STAS, as well as the tumor grade, were recorded. Compared to permanent sections, STAS detection on frozen sections had low sensitivity (55%), low positive predictive value (48%), and fair agreement (K = 0.34), whereas there was higher specificity (80%) and negative predictive value (85%). Accuracy was 74%. Tumor grade assessment on frozen sections showed higher sensitivity (77%), positive predictive value (90%), agreement (K = 0.72), specificity (94%), and accuracy (87%), and the same negative predictive value (85%). High-grade histology on frozen sections was associated with shorter RFS (p = 0.02), whereas STAS on frozen sections was not (p = 0.47). Our results suggest that the intraoperative detection of STAS has low sensitivity and positive predictive value. False-positive results may lead to overtreatment of patients with lung cancer. The determination of tumor grade on frozen sections offers better sensitivity and specificity, plus it is associated with RFS, whereas STAS on frozen sections is not. Further study is needed to explore the utility of assessing tumor grade on frozen sections.
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Affiliation(s)
- Fang Zhou
- Department of Pathology, New York University Langone Health, New York, NY, USA.
| | - Julian A Villalba
- Department of Pathology, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA
| | - Treah May S Sayo
- Department of Pathology, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA
- Lung Center of the Philippines, Metro Manila, Philippines
| | - Navneet Narula
- Department of Pathology, New York University Langone Health, New York, NY, USA
| | - Harvey Pass
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY, USA
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA
| | - Andre L Moreira
- Department of Pathology, New York University Langone Health, New York, NY, USA
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11
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Ghamati MR, Li WWL, van der Heijden EHFM, Verhagen AFTM, Damhuis RA. Surgery without preoperative histological confirmation of lung cancer: what is the current clinical practice? J Thorac Dis 2021; 13:5765-5775. [PMID: 34795925 PMCID: PMC8575862 DOI: 10.21037/jtd-21-617] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/13/2021] [Indexed: 12/16/2022]
Abstract
Background There are discordances in the guidelines regarding the need to acquire histological diagnosis before surgical treatment of (presumed) lung cancer. Preoperative histological confirmation is always encouraged in this setting to prevent unnecessary surgery or when sublobar resection for small-sized tumors is considered. The aim of this retrospective cohort study was to assess the proportion of patients undergoing lung cancer resection in the Netherlands without preoperative pathological confirmation, based on the intraoperative pathological diagnosis (IOD) rate, and to determine characteristics that may influence IOD frequency. Methods Data on 10,226 patients, who underwent surgical treatment for lung cancer from 2010 to 2015, were retrieved from the Netherlands National Cancer Registry. We registered an IOD when the date of diagnosis equaled the date of the first surgical intervention. Tabulations and multivariable logistic regression were used to identify predictive parameters for IOD. Results 36% of surgical procedures were classified as IOD, and decreased with increasing tumor size and extent of surgery (57% for segmentectomy, 39% for lobectomy and 11% for pneumonectomy). IOD was more frequently observed in adenocarcinoma (41%), varied between hospitals from 13% to 66% and was less common when patients were referred from a hospital where thoracic surgery was not performed. Previous history of cancer did not affect IOD. Conclusions More than one-third of patients with suspected lung cancer in the Netherlands was operated without preoperative histological confirmation. There was significant variation in IOD rates between different hospitals, which deserves further detailed analysis when striving for uniform surgical quality of care for patients with lung cancer.
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Affiliation(s)
- Mohammad R Ghamati
- Department of Cardiothoracic Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands.,Department of Cardiothoracic Surgery, Isala Heart Centre, Zwolle, The Netherlands
| | - Wilson W L Li
- Department of Cardiothoracic Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Ad F T M Verhagen
- Department of Cardiothoracic Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ronald A Damhuis
- Department of Research, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands
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12
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Zhou S, Qian K, Yu S, Zhao Y, Shen Q, Li Y. MiR-4429 Alleviates Malignant Behaviors of Lung Adenocarcioma Through Wnt/β-Catenin Pathway. Cancer Biother Radiopharm 2021. [PMID: 34491827 DOI: 10.1089/cbr.2021.0154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Lung adenocarcinoma (ADC) is a common subtype of non-small cell lung cancer. MicroRNAs have been reported to be effective biomarkers for diagnosis and an important target for therapy. MiR-4429 is a newly identified miRNA, which can take part in tumor progression as a tumor inhibitor. Moreover, it is an exosomal miRNA that can be taken by lung ADC cell line A549. Nevertheless, its role in lung ADC has been poorly studied. This research discovered that miR-4429 was low expressed in lung ADC cells. MiR-4429 mimics could alleviate the capacities of cell proliferation and metastasis. The mimics are able to reverse epithelial-mesenchymal transition at the same time. Furthermore, it was verified that miR-4429 could bind to β-catenin and negatively regulate β-catenin expression. Interestingly, SKL2001 can reverse the role of miR-4429 on tumor. Consequently, miR-4429 can inactivate Wnt/β-catenin signaling pathway by targeting β-catenin and prevent oncogene expression in lung ADC cells.
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Affiliation(s)
- Shaoqiang Zhou
- Department of Breast Surgery, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Kebao Qian
- Department of Thoracic Surgery, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Shuhui Yu
- Department of Radiation Therapy Center, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yutao Zhao
- Department of Radiation Therapy Center, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Qin Shen
- Institute of Neuroscience, School of Basic Medical Sciences, Kunming Medical University, Kunming, Yunnan Province, China
| | - Ya Li
- Department of Radiation Therapy Center, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, China
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13
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Choi Y, Aum J, Lee SH, Kim HK, Kim J, Shin S, Jeong JY, Ock CY, Lee HY. Deep Learning Analysis of CT Images Reveals High-Grade Pathological Features to Predict Survival in Lung Adenocarcinoma. Cancers (Basel) 2021; 13:4077. [PMID: 34439230 PMCID: PMC8391458 DOI: 10.3390/cancers13164077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/02/2021] [Accepted: 08/09/2021] [Indexed: 01/18/2023] Open
Abstract
We aimed to develop a deep learning (DL) model for predicting high-grade patterns in lung adenocarcinomas (ADC) and to assess the prognostic performance of model in advanced lung cancer patients who underwent neoadjuvant or definitive concurrent chemoradiation therapy (CCRT). We included 275 patients with 290 early lung ADCs from an ongoing prospective clinical trial in the training dataset, which we split into internal-training and internal-validation datasets. We constructed a diagnostic DL model of high-grade patterns of lung ADC considering both morphologic view of the tumor and context view of the area surrounding the tumor (MC3DN; morphologic-view context-view 3D network). Validation was performed on an independent dataset of 417 patients with advanced non-small cell lung cancer who underwent neoadjuvant or definitive CCRT. The area under the curve value of the DL model was 0.8 for the prediction of high-grade histologic patterns such as micropapillary and solid patterns (MPSol). When our model was applied to the validation set, a high probability of MPSol was associated with worse overall survival (probability of MPSol >0.5 vs. <0.5; 5-year OS rate 56.1% vs. 70.7%), indicating that our model could predict the clinical outcomes of advanced lung cancer patients. The subgroup with a high probability of MPSol estimated by the DL model showed a 1.76-fold higher risk of death (HR 1.76, 95% CI 1.16-2.68). Our DL model can be useful in estimating high-grade histologic patterns in lung ADCs and predicting clinical outcomes of patients with advanced lung cancer who underwent neoadjuvant or definitive CCRT.
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Affiliation(s)
- Yeonu Choi
- Department of Radiology, Sungkyunkwan University School of Medicine (SKKU-SOM), Samsung Medical Center, Seoul 06351, Korea;
| | - Jaehong Aum
- Lunit Inc., Seoul 06241, Korea; (J.A.); (S.S.)
| | - Se-Hoon Lee
- Division of Hemato-Oncology, Department of Medicine, Sungkyunkwan University School of Medicine (SKKU-SOM), Samsung Medical Center, Seoul 06351, Korea;
| | - Hong-Kwan Kim
- Department of Thoracic Surgery, Sungkyunkwan University School of Medicine (SKKU-SOM), Samsung Medical Center, Seoul 06351, Korea; (H.-K.K.); (J.K.)
| | - Jhingook Kim
- Department of Thoracic Surgery, Sungkyunkwan University School of Medicine (SKKU-SOM), Samsung Medical Center, Seoul 06351, Korea; (H.-K.K.); (J.K.)
| | | | - Ji Yun Jeong
- Department of Pathology, Kyungpook National University School of Medicine, Kyungpook National University Chilgok Hospital, Daegu 41404, Korea;
| | | | - Ho Yun Lee
- Department of Radiology, Sungkyunkwan University School of Medicine (SKKU-SOM), Samsung Medical Center, Seoul 06351, Korea;
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14
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Fourdrain A, Epailly J, Blanchard C, Georges O, Meynier J, Berna P. Lymphatic drainage of lung cancer follows an intersegmental pathway within the visceral pleura. Lung Cancer 2021; 154:118-123. [PMID: 33652227 DOI: 10.1016/j.lungcan.2021.02.023] [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: 11/07/2020] [Revised: 02/13/2021] [Accepted: 02/16/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Lung cancer tumors are known to be highly lymphophilic. There are two different pattern of lymphatic drainage of the lung: one peribronchial lymphatic pathway, and another one within the visceral pleura which appears to be more intersegmental than the peribronchial pathway. We aimed to assess the prevalence of an intersegmental pathway in the lymphatic drainage of lung tumors within the visceral pleura and determine potential influential factors. METHODS In this prospective study, we included all patients for whom a major pulmonary resection (lobar) was indicated and performed for suspected or proven lung cancer. An immediate ex-vivo evaluation of the surgical specimen after resection was conducted by trans-pleural injection of blue dye within the tumor. The pathways followed by the lymphatic vessels under the visceral pleura were assessed to define the occurrence of an intersegmental pathway, which was defined by the presence of blue dye within the lymphatic vessel crossing to a neighboring pulmonary segment, distinct from the tumorous segment. RESULTS Fifty-three patients met the inclusion criteria and were assessed over a three-year period. Lymphatic drainage within the visceral pleura followed an intersegmental pathway in 35 of 53 patients (66 %). When the lymphatic drainage of the tumor was intersegmental, it drained in a single other segment in 21/35 cases and two or more in 14/35 cases. Logistic regression with multivariate analysis showed a peripheral location of the tumor to be a risk factor for the intersegmental pathway of visceral pleura lymphatic drainage (OR = 0.87 [079-0.95], p = 0.003). CONCLUSION These results confirm that lymphatic drainage of lung cancer in the visceral pleura appears to largely follow an intersegmental pathway, especially when the tumor is peripheral, close to the visceral pleura.
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Affiliation(s)
- Alex Fourdrain
- Department of Thoracic Surgery, Amiens University Hospital, Amiens, France; Research Unit SSPC (Simplification des Soins des Patients chirurgicaux Complexes), Amiens University Hospital, Amiens, France.
| | - Julien Epailly
- Department of Thoracic Surgery, Amiens University Hospital, Amiens, France
| | - Chloé Blanchard
- Department of Thoracic Surgery, Amiens University Hospital, Amiens, France
| | - Olivier Georges
- Department of Thoracic Surgery, Amiens University Hospital, Amiens, France
| | - Jonathan Meynier
- Department of Biostatistics, Clinical Research and Innovation Directorate, Amiens University Hospital, Amiens, France
| | - Pascal Berna
- Department of Thoracic Surgery, Amiens University Hospital, Amiens, France
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15
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Predicting the Clinical Outcome of Lung Adenocarcinoma Using a Novel Gene Pair Signature Related to RNA-Binding Protein. BIOMED RESEARCH INTERNATIONAL 2020; 2020:8896511. [PMID: 33195699 PMCID: PMC7643376 DOI: 10.1155/2020/8896511] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 10/05/2020] [Indexed: 12/11/2022]
Abstract
Adenocarcinoma is the most common type of lung cancer, and patients have varying prognoses. RNA-binding proteins (RBP) are deemed to be closely associated with tumorigenesis and development, but the exact mechanism is currently unknown. This study was aimed at constructing a new robust prognostic model based on RNA-binding protein-related gene pair scores for better clinical guidance. The model for this study was constructed based on data of lung adenocarcinoma from The Cancer Genome Atlas (TCGA) database. Prognosis-related RBP gene pair models were created based on differentially expressed genes, and the accuracy of the models was verified in a different age, staging, and other subdatasets. A total of 379 RNA-binding protein-related genes were differentially expressed in tumor tissue. From these genes, we constructed a prognostic model consisting of 33 gene pairs, which were found to be significantly associated with survival in TCGA dataset (P < 0.0001, hazard ratio (HR) = 4.380 (3.139 to 6.111)) and different subdatasets. As expected, the results were verified in the GEO validation cohort (P = 7.8 × 10−3, HR = 1.597 (1.095 to 2.325)). We found that the signature exhibited an independent prognostic factor in both the univariate and multivariate Cox regression analyses (P < 0.001). CIBERSORT was applied to estimate the fractions of infiltrated immune cells in bulk tumor tissues. CD8 T cells, activated dendritic cells, regulatory T cells (Tregs), and activated CD4 memory T cells presented a significantly lower fraction in the high-risk group (P < 0.01). Patients in the high-risk group had significantly higher tumor mutational burden (TMB) (P = 4.953e − 04) and lower levels of immune cells (P = 3.473e − 05) and stromal cells (P = 0.005) in the tumor microenvironment than those in the low-risk group. Furthermore, the Protein-protein interaction (PPI) network and various enrichment analyses have genuinely uncovered the interrelationships and potential functions of the RBP genes within the model. The results of the present study validated the importance of RNA-binding proteins in tumorigenesis and progression and support the RBP gene-related signature as a promising marker for prognosis prediction in lung adenocarcinoma.
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16
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Mino-Kenudson M. Significance of tumor spread through air spaces (STAS) in lung cancer from the pathologist perspective. Transl Lung Cancer Res 2020; 9:847-859. [PMID: 32676351 PMCID: PMC7354155 DOI: 10.21037/tlcr.2020.01.06] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Airspace invasion in lung cancer has been known over the last 30 years, but it was only recently that WHO 2015 formally recognized it as a mechanism of invasion with the terminology of tumor spread through air spaces (STAS). Multiple studies have shown the association of STAS with lower survival and suggest that STAS is an independent prognostic factor across lung adenocarcinoma of all stages and in other histologic subtypes of lung cancer as well. Consequently, STAS is designated as an exclusion criterion of adenocarcinoma in situ and minimally invasive adenocarcinoma; thus, the presence of STAS impacts the diagnosis and staging of lung adenocarcinoma. Further, wedge resection and segmentectomy have been increasingly applied for small node negative tumors and the presence of STAS in those specimens may indicate the requirement of completion lobectomy. Given these significant clinical implications, we, pathologists, need to recognize and appropriately report STAS (possibly including at the time of intraoperative consultation). However, emerging data suggests that more work should be done to improve consensus and identification of STAS, including at frozen section. In this review, the evolution of our understanding of airspace invasion over the past decade, the clinical significance of STAS, and controversies and practical issues associated with the diagnosis of STAS are discussed.
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Affiliation(s)
- Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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17
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Xiang Z, Zhang J, Zhao J, Shao J, Zhao L, Zhang Y, Qin G, Xing J, Han Y, Yu K. An effective inflation treatment for frozen section diagnosis of small-sized lesions of the lung. J Thorac Dis 2020; 12:1488-1495. [PMID: 32395286 PMCID: PMC7212135 DOI: 10.21037/jtd.2020.02.34] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The accuracy of intraoperative pathological diagnosis of small-sized pulmonary nodules including ground-glass opacity (GGO) is important for the surgeon to choose a suitable surgical procedure. Diagnosis of the small-sized lesions of the lung by frozen section (FS) is very difficult for the pathologist because of limited FS technology. Here we tested an effective inflation treatment for FS to improve the diagnostic accuracy of small-sized lung lesions. Methods The lung specimens were derived from 113 patients who underwent the surgery at Shanghai Chest Hospital in 2018–2019. The specimens were randomly divided into two groups—uninflated or inflated with diluted embedding medium (Tissue-Tek OCT; Sakura Finetek-USA, CA). The qualities of the FSs were compared with that of corresponding permanent paraffin sections. The FS diagnoses were compared with the final pathologic diagnoses of corresponding permanent sections. Results Our results showed that the quality of FS of lung tissue was excellent after inflation with diluted embedding medium (1:1). The total consistency between diagnosis of inflated FS and final pathological diagnosis was 85.7%. In control group, however, the consistency was only 70.2%. When the lesions were less than 1cm, the consistency between diagnosis of inflated FS and final pathological diagnosis was 90.3%, compared to 64.9% consistency in uninflated group (P=0.014, <0.05). When the lesions’ computed tomography (CT) measurement threshold ≤−350 HU, the consistency between diagnosis of inflated FS and final pathological diagnosis was 88% compared to 73.2% consistency in uninflated group (P=0.071, >0.05). Accuracy, sensitivity and specificity were observed about 90% for adenocarcinoma in situ (AIS), whereas it is drop to more than 80% for minimally invasive adenocarcinoma (MIA) in inflated FS. Conclusions Inflation with diluted embedding medium (1:1) could make lung tissue expand well during FS. By using this method, small-sized lesions (especially less than 1 cm) could be correctly diagnosed to enable adequate surgical procedure, and evaluation of which can be easily based on the intraoperative pathological diagnosis. The small lesions especially AIS could be readily identified on FS. Therefore, this method improves the diagnostic accuracy of FSs for small-sized lung lesions, and has important practical consequences for further therapy.
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Affiliation(s)
- Zhenzhen Xiang
- Department of Pathology, Shanghai Chest Hospital, Shanghai JiaoTong University, Shanghai 230000, China
| | - Jie Zhang
- Department of Pathology, Shanghai Chest Hospital, Shanghai JiaoTong University, Shanghai 230000, China
| | - Jikai Zhao
- Department of Pathology, Shanghai Chest Hospital, Shanghai JiaoTong University, Shanghai 230000, China
| | - Jinchen Shao
- Department of Pathology, Shanghai Chest Hospital, Shanghai JiaoTong University, Shanghai 230000, China
| | - Lanxiang Zhao
- Department of Pathology, Shanghai Chest Hospital, Shanghai JiaoTong University, Shanghai 230000, China
| | - Ye Zhang
- Department of Pathology, Shanghai Chest Hospital, Shanghai JiaoTong University, Shanghai 230000, China
| | - Gang Qin
- Department of Pathology, Shanghai Chest Hospital, Shanghai JiaoTong University, Shanghai 230000, China
| | - Jie Xing
- Department of Pathology, Shanghai Chest Hospital, Shanghai JiaoTong University, Shanghai 230000, China
| | - Yuchen Han
- Department of Pathology, Shanghai Chest Hospital, Shanghai JiaoTong University, Shanghai 230000, China
| | - Keke Yu
- Department of Pathology, Shanghai Chest Hospital, Shanghai JiaoTong University, Shanghai 230000, China
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18
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Ain QU, Majeed N. A commentary on "Intraoperative frozen section for identifying the invasion status of lung adenocarcinoma: A systematic review and meta-analysis" (Int J Surg 2019; 72:175-84). Int J Surg 2019; 74:2. [PMID: 31870752 DOI: 10.1016/j.ijsu.2019.11.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 11/22/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Qurat Ul Ain
- Armed Forces Institute of Pathology, Rawalpindi, Pakistan.
| | - Numan Majeed
- Department of pathology, Chemical Pathology Laboratory, Military Hospital, Rawalpindi, Pakistan.
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