Treatment of stage I and II non-small-cell lung cancer

Sublobar resection is associated with better perioperative outcomes in elderly patients with clinical stage I non-small cell lung cancer: a multicenter retrospective cohort study

BACKGROUND

Sublobar resection has emerged as an alternative to lobectomy for management of early-stage non-small cell lung cancer (NSCLC). However, controversy remains as to whether it is adequate for elderly patients. The present study aimed to comparatively study the perioperative outcomes and overall survival of sublobar resection vs. lobectomy for management of elderly patients (≥65 years) with clinical stage I NSCLC.

METHODS

This is a multicenter retrospective cohort study. Clinical stage I NSCLC patients who underwent lobar or sublobar resection (segmentectomy and wedge resection) at the Department of Thoracic Surgery of 10 tertiary hospitals between January 2014 and September 2017 were retrospectively reviewed from the national collaborative prospective lung cancer database (LinkDoc Technology Co, Ltd., Beijing, China). Clinical data on demographic and tumor characteristics, surgical details were collected. Perioperative outcomes and overall survival were analyzed by using propensity score matching to adjust for selection bias. Subgroup analysis was further carried out to explore the potential sources of heterogeneity.

RESULTS

Among the 1,579 eligible patients, 1,164 (73.7%) underwent lobectomy and 415 (26.3%) underwent sublobar resection (106 segmentectomy and 309 wedge resection). Sublobar resection was more frequently performed in patients who were elder, had more comorbidities and smaller, left-sided adenocarcinoma (P<0.001). Propensity-matched analysis showed significant association of sublobar resection with less blood loss, shorter operation time, chest drainage and hospital stay, while with less lymph node removal when compared with lobectomy (P<0.001). Short term survival analysis showed comparable results even after adjusted in the matched analysis. Similar results were obtained when limiting patients to those aged >75 years, at pathologic stage I, and those who smoking or undergoing video-assisted thoracoscopic surgery (VATS) or segmentectomy and lobectomy.

CONCLUSIONS

Sublobar resection was associated with significantly better perioperative outcomes without compromising short term survival in elderly patients with clinical stage I NSCLC. However, the importance of patient selection and management process, as well as accurate lymph node staging must be acknowledged when making the surgical decision (clinical registration number: NCT03429673).

Meta-analysis of diagnostic value of 18F-FDG PET or PET/CT for detecting lymph node and distant metastases in patients with nasopharyngeal carcinoma

OBJECTIVE

We performed this meta-analysis to comprehensively assess the diagnostic performance of positron emission tomography (PET) or PET/CT for detecting lymph node and distant metastases in patients with nasopharyngeal carcinoma (NPC).

METHODS

Through a search of four English and three Chinese databases (January 1990 to June 2013), pooled estimated sensitivity, specificity and diagnostic odds ratio (DOR) were calculated based on the data extracted from the included studies. We also constructed summary receiver operating characteristic curves, with the area under the curve (AUC) and obtained the Q* index. Heterogeneity and subgroup analysis were also performed.

RESULTS

In total, 18 articles consisting 20 studies were included in this meta-analysis. On a per-patient basis, the overall pooled estimates for sensitivity and specificity of PET or PET/CT in N and M staging of NPC were 0.89 [95% confidence interval (CI), 0.86-0.91] and 0.96 (95% CI, 0.95-0.96), respectively. The overall DOR, AUC and Q* index were 162.07 (95% CI, 90.72-289.55), 0.9689 and 0.9181, respectively. Subgroup analysis showed that AUC and Q* index were 0.9734 and 0.9255 for N staging and 0.9715 and 0.9223 for M staging, respectively.

CONCLUSION

The present meta-analysis showed that PET or PET/CT has excellent diagnostic performance for detecting lymph node and distant metastases in patients with NPC.

ADVANCES IN KNOWLEDGE

To provide evidence to assess the role of PET or PET/CT in staging of NPC.

The Surgical Management of Lung Cancer

Since the introduction of the pneumonectomy as a technically feasible strategy for the treatment of lung cancer, surgical resection has played a pivotal role in the management of early stage non-small cell lung carcinoma (NSCLC). In the last two decades, surgical, medical, and radiation oncologists have produced a growing body of evidence to support the combination of neoadjuvant or adjuvant treatments with standard surgical resection, to improve disease-free and overall survival for specific patient subgroups. Furthermore, alternatives to aggressive surgical management have evolved for patients who are medically inoperable due to compromised pulmonary function or other comorbidities. In this review, surgical options and multimodal treatment strategies are discussed, as well as completed and ongoing clinical trials addressing the surgical management of NSCLC.

PET/CT for the staging and follow-up of patients with malignancies

Positron emission tomography (PET) and computed tomography (CT) complement each other's strengths in integrated PET/CT. PET is a highly sensitive modality to depict the whole-body distribution of positron-emitting biomarkers indicating tumour metabolic activity. However, conventional PET imaging is lacking detailed anatomical information to precisely localise pathologic findings. CT imaging can readily provide the required morphological data. Thus, integrated PET/CT represents an efficient tool for whole-body staging and functional assessment within one examination. Due to developments in system technology PET/CT devices are continually gaining spatial resolution and imaging speed. Whole-body imaging from the head to the upper thighs is accomplished in less than 20 min. Spatial resolution approaches 2-4mm. Most PET/CT studies in oncology are performed with (18)F-labelled fluoro-deoxy-D-glucose (FDG). FDG is a glucose analogue that is taken up and trapped within viable cells. An increased glycolytic activity is a characteristic in many types of cancers resulting in avid accumulation of FDG. These tumours excel as "hot spots" in FDG-PET/CT imaging. FDG-PET/CT proved to be of high diagnostic value in staging and restaging of different malignant diseases, such as colorectal cancer, lung cancer, breast cancer, head and neck cancer, malignant lymphomas, and many more. The standard whole-body coverage simplifies staging and speeds up decision processes to determine appropriate therapeutic strategies. Further development and implementation of new PET-tracers in clinical routine will continually increase the number of PET/CT indications. This promotes PET/CT as the imaging modality of choice for working-up of the most common tumour entities as well as some of the rare malignancies.

PET versus PET/CT dual-modality imaging in evaluation of lung cancer

Non-small cell lung cancer (NSCLC) accounts for approximately 80% of bronchogenic malignancies. The choice of therapy options, including surgery, radiation therapy, and chemotherapy-used alone or in combination-is based on the tumor stage. Consequently, the accurate determination of tumor size, potential infiltration of adjacent structures, mediastinal lymph node involvement, and the detection of distant metastases are of central importance. The purpose of this article is to summarize the accuracy of dual-modality FDG-PET/CT imaging in staging of NSCLC as compared with FDG-PET alone, and with FDG-PET as well as CT read side by side. Furthermore, an optimized PET/CT protocol for patients who have lung cancer is outlined.

Advances in positron emission tomography technology have increased the need for surgical staging in non–small cell lung cancer

OBJECTIVES

Pretreatment staging of patients with non-small cell lung cancer is critically important in determining an appropriate treatment plan. As positron emission tomography (PET) and computed tomography (CT) are proven complementary modalities in clinical staging, recent advances in PET technology have brought forth integrated PET/CT as the new standard. We tested the hypothesis that improvements in PET technology have not increased the sensitivity or specificity of PET in the staging of non-small cell lung cancer to an extent that surgical staging is no longer required.

METHODS

This is a retrospective, single-institution review of 336 patients from 1995 to 2005 with biopsy-proven non-small cell lung cancer who underwent [18F] fluoro-2-deoxy-D-glucose-PET before mediastinal lymph node sampling by cervical mediastinoscopy or thoracotomy. Clinical records, histopathologic reports, and PET findings were reviewed. Data were analyzed by the Pearson chi2 test.

RESULTS

Within the study population, 210 patients had routine PET and 126 had integrated PET/CT. For detecting mediastinal metastases the sensitivities of PET versus integrated PET/CT were 61.1% versus 85.7% (P < .05), specificities were 94.3% versus 80.6% (P < .001), positive predictive values were 68.8% versus 55.8%, negative predictive values were 92.1% versus 95.2%, and overall accuracy was 88.6% versus 81.7%.

CONCLUSIONS

Improvements in PET technology have increased integrated PET/CT sensitivity at the cost of significantly decreased specificity. Although it may appear that integrated PET/CT incurs fewer false negative results, the dramatic increase in false positive results reinforces the notion that integrated PET/CT should be used only as an adjunct to clinical staging and that surgical staging remains the gold standard in non-small cell lung cancer.

Postoperative survival and the number of lymph nodes sampled during resection of node-negative non-small cell lung cancer

STUDY OBJECTIVE

To examine the association between postoperative survival and the number of lymph nodes (LNs) examined during surgery among persons who underwent definitive resection of node-negative (stage IA or stage IB) non-small cell lung cancer (NSCLC).

DESIGN AND SETTING

Information on postoperative survival and the number of LNs examined during surgery for stage I NSCLC treated with definitive surgical resection was retrieved from the population-based Surveillance, Epidemiology and End Results database for the period from 1990 to 2000. The association between survival and the number of LNs was examined using multivariate Cox proportional hazard models with adjustment for age, race, sex, type of surgery performed, and tumor size, grade, and histology.

RESULTS

A total of 16,800 patients were included in the study. The overall survival analysis for patients without radiation therapy (RT) demonstrated that in comparison to the reference group (one to four LNs), patients with five to eight LNs examined during surgery had a modest but statistically significant increase in survival, with a proportionate hazard ratio (HR) of 0.90 and a 95% confidence interval (CI) of 0.84 to 0.97. Similar results for 9 to 12 LNs and 13 to 16 LNs examined produced further increases in survival, with HRs of 0.86 (95% CI, 0.79 to 0.95) and 0.78 (95% CI, 0.68 to 0.90), respectively. There appeared to be no incremental improvement after evaluating > 16 LNs. The corresponding results for lung cancer-specific mortality and for patients receiving RT were not substantially different. The highest median survival (97 months) occurred in patients with 10 to 11 LNs evaluated.

CONCLUSIONS

Our results indicate that patient survival following resection for NSCLC is associated with the number of LNs evaluated during surgery. This is likely due to reduction of staging error: a decreased likelihood of missing positive LNs with an increasing number of LNs sampled. Although we are reluctant to recommend a definitive "optimal number," our data support the conclusion that an evaluation of nodal status should include somewhere from 11 to 16 LNs.

[Whole-body tumor staging: MRI or FDG-PET/CT?]

Technical innovations such as the availability of movable patient platforms and the introduction of 32-channel systems have made whole-body MRI for tumor staging feasible. In addition, the development of dual-modality PET/CT systems offers the opportunity to perform anatometabolic tumor staging with whole-body coverage in a single session. Based on an increase in patient survival when applying a stage-adapted therapy in different malignant diseases the relevant question relates to the accuracies of whole-body MRI and whole-body PET/CT for TNM staging. This review article addresses whole-body tumor staging with MRI and FDG-PET/CT with special emphasis on diagnostic accuracies for staging different malignant diseases.

Accuracy of whole-body dual-modality fluorine-18-2-fluoro-2-deoxy-D-glucose positron emission tomography and computed tomography (FDG-PET/CT) for tumor staging in solid tumors: comparison with CT and PET

PURPOSE

To assess the accuracy of positron emission tomography/computed tomography (PET/CT) when staging different malignant diseases.

PATIENTS AND METHODS

This was a retrospective, blinded, investigator-initiated study of 260 patients with various oncological diseases who underwent fluorine-18-2-fluoro-2-deoxy-d-glucose PET/CT for tumor staging. CT images alone, PET images alone, PET + CT data viewed side by side, and fused PET/CT images were evaluated separately according to the tumor-node-metastasis system. One hundred forty patients with tumors not staged according to the tumor-node-metastasis system or a lack of reference standard were excluded from data analysis; 260 patients were included. Diagnostic accuracies were determined for each of the four image sets. Histopathology and a clinical follow-up of 311 (+/- 125) days served as standards of reference.

RESULTS

PET/CT proved significantly more accurate in assessing tumor-node-metastasis system stage compared with CT alone, PET alone, and side-by-side PET + CT (P < .0001). Of 260 patients, 218 (84%; 95% CI, 79% to 88%) were correctly staged with PET/CT, 197 (76%; 95% CI, 70% to 81%) with side-by-side PET + CT, 163 (63%; 95% CI, 57% to 69%) with CT alone, and 166 (64%; 95% CI, 58% to 70%) with PET alone. Combined PET/CT had an impact on the treatment plan in 16, 39, and 43 patients when compared with PET + CT, CT alone, and PET alone, respectively.

CONCLUSION

Tumor staging with PET/CT is significantly more accurate than CT alone, PET alone, and side-by-side PET + CT. This diagnostic advantage translates into treatment plan changes in a substantial number of patients.

Growth and Functional Reactivity of Lymphocytes Obtained from Three Anatomic Compartments in Patients with Non–Small-Cell Lung Cancer (NSCLC)

Non-small-cell lung cancer (NSCLC) claims the lives of both men and women worldwide. In this study, we describe the ability to expand lymphocytes from solid tumor biopsies, pleural fluid, and peripheral blood of patients with NSCLC. While lymphocytes readily expanded from both solid biopsies and pleural fluids, the incidence of obtaining tumor-specific lymphocytes was low. Specific cytolytic and/or cytokine-releasing activity was observed in tumor-infiltrating lymphocytes (TIL) from 3/15 solid tumor biopsies (20%) and 2 of 4 pleural fluid samples (50%). Two of the CTL derived from solid tumor were cytolytic, one being HLA-A2 restricted while the other was either restricted at HLA-A30 or - B18. One of the pleural fluid cytotoxic T lymphocyte (CTL) was also HLA-A2 restricted. Peripheral blood from NSCLC patients was studied using mixed lymphocyte tumor cell cultures (MLTC) as reported previously. Peripheral blood lymphocytes were cultured with allogeneic NSCLC-TC line 29.7, which expressed by gene transfer the lymphocyte costimulatory molecule CD80. Of 9 HLA-A2 patient samples tested, 8 gave rise to lymphocytes, which lysed NSCLC tumor cells expressing HLA-A2 in an major histocompatibility complex (MHC)-restricted fashion. While specific CTL can be generated from all anatomic sites, for clinical trials peripheral blood appears to be the site of choice for obtaining specific precursors.

Non-small cell lung cancer: dual-modality PET/CT in preoperative staging

PURPOSE

To determine the accuracy of dual-modality positron emission tomographic (PET)-computed tomographic (CT) imaging, as compared with PET alone and CT alone, in the staging of non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

Twenty-seven patients with NSCLC underwent staging with combined fluorine 18 fluorodeoxyglucose PET and CT. CT, PET, and coregistered PET/CT images were evaluated separately by two different physicians for each imaging modality, and disease stage was determined by using TNM and American Joint Committee on Cancer staging systems. Histopathologic results served as the reference standard. The statistical significance of differences among CT, PET, and PET/CT was determined by using the McNemar test.

RESULTS

Overall tumor stage was correctly classified as 0-IV with CT in 19 patients, with PET in 20 patients, and with PET/CT in 26 patients. PET/CT findings when compared with PET findings led to a treatment change for four patients (15%) and when compared with CT findings led to a treatment change for five patients (19%). Differences in the accuracy of overall tumor staging between PET/CT and CT (P =.008) and between PET/CT and PET (P =.031) were significant. Primary tumor stage was correctly determined in more patients with PET/CT than with either PET alone or CT alone. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of regional lymph node staging, respectively, were 89%, 94%, 89%, 94%, and 93%, with PET/CT; 89%, 89%, 80%, 94%, and 89% with PET; and 70%, 59%, 50%, 77%, and 63% with CT. Fourteen distant metastases were detected in four patients with CT, four were detected in two patients with PET, and 17 were detected in four patients with PET/CT.

CONCLUSION

Use of dual-modality PET/CT significantly increases the number of patients with correctly staged NSCLC and thus has a positive effect on treatment.

Potentiation of the effect of paclitaxel and carboplatin by antioxidant mixture on human lung cancer h520 cells

OBJECTIVE

Antioxidants have been shown to enhance the effect of certain chemotherapeutic agents on tumor cells in culture. However, this effect differs depending upon the type of tumor and the drugs. In this study, the objective was to see whether pretreatment with antioxidant mixture could enhance the cytotoxic and apoptotic effect of commonly used chemotherapeutic agents, paclitaxel and carboplatin for the treatment of NSCLC.

METHODS

Human lung squamous cell carcinoma cell line, H520, was treated with antioxidant mixture (vitamin C, vitamin E and beta carotene), paclitaxel and carboplatin, individually and in combination of different doses in different sequences. Growth inhibition and induction of apoptosis was studied by morphological changes, MTT assay and flow-cytometric analysis.

RESULTS

The antioxidant mixture by itself led to 15% apoptosis in H520 cells. Paclitaxel treatment 24 hours prior to carboplatin caused 54% apoptosis, more than that produced by simultaneous treatment with both agents (40%). A statistically significant improvement in the degree of apoptosis, induced by paclitaxel and carboplatin combination, was seen when the cells were pretreated with antioxidant mixture immediately before paclitaxel exposure (70%) or 24 hours before paclitaxel exposure (89%).

CONCLUSION

The data suggests that the apoptotic effects of paclitaxel and carboplatin are enhanced by pretreatment with the antioxidant mixture. Thus, the most promising sequence of these agents, which emerged in this study, was pretreatment with antioxidant mixture for 24 hours followed by paclitaxel treatment for 24 hours followed by carboplatin exposure for 24 hours.