Visceral pleural invasion does not affect recurrence or overall survival among patients with lung adenocarcinoma ≤ 2 cm: a proposal to reclassify T1 lung adenocarcinoma

Recurrence of Non-Small Cell Lung Cancer With Visceral Pleural Invasion: A Seconday Analysis of a Randomized Clinical Trial

Importance

The randomized clinical trial Cancer and Leukemia Group B (CALGB) 140503 showed that for patients with clinically staged T1N0 non-small cell lung cancer (NSCLC; ≤2 cm), sublobar resections were associated with similar oncological outcomes to those after lobar resection. The association of the extent of parenchymal resection with recurrence and survival in patients with tumors pathologically upstaged to T2 based on visceral pleural invasion (VPI) is controversial.

Objective

To determine survival and recurrence rates in patients with small peripheral pT2 NSCLC (≤2 cm) that was treated by either lobar or sublobar resection in CALGB 140503.

Design, Participants, and Setting

CALGB 140503, a randomized multicenter noninferiority trial, included 697 patients with small peripheral NSCLC that was clinically staged as T1N0. Enrollment was from June 2007 through March 2017 at 83 participating institutions, and after a median follow-up of 7 years, the primary outcome of disease-free survival after sublobar resection was noninferior to that after lobar resection.

Intervention

Lobar or sublobar resection.

Main Outcomes and Measures

Survival end points were estimated by the Kaplan-Meier estimator. Hazard ratios and 95% CIs were estimated using stratified Cox proportional hazard models.

Results

Of 679 participants, 390 (57.4%) were female, and the median (range) age was 67.8 (37.8-89.7) years. Among 697 patients randomized, 566 (81.2%) had pT1 tumors (no VPI) and 113 (16.2%) had pT2 tumors (VPI). Five-year disease-free survival was 65.9% (95% CI, 61.9%-70.2%) in patients with pT1 compared with 53.3% (95% CI, 44.3%-64.1%) in patients with pT2 tumors (stratified log-rank: P = .02). Disease recurrence developed in 27.6% of patients with pT1 (locoregional only: 60 [10.8%]; distant only: 81 [14.6%]) and 41.6% of those with pT2 (locoregional only: 17 [15.0%]; distant only: 27 [23.9%]). Five-year recurrence-free survival was 73.1% (95% CI, 69.2%-77.1%) for pT1 tumors and 58.2% (95% CI, 49.2%-68.8%) for pT2 tumors (stratified log-rank: P = .01). There were no intergroup differences in disease-free or recurrence-free survival based on the extent of parenchymal resection.

Conclusions and Relevance

The results of this secondary analysis suggest that compared with patients with tumors without VPI, patients who had tumors with VPI had worse disease-free and recurrence-free survival and a higher rate of local and distant disease recurrence. These high rates of recurrence were independent of the extent of parenchymal resection, and these data support the inclusion of these patients in adjuvant therapy trials.

Trial Registration

ClinicalTrials.gov Identifier: NCT0049933.

Preoperative evaluation of visceral pleural invasion in peripheral lung cancer utilizing deep learning technology

PURPOSE

This study aimed to assess the efficiency of artificial intelligence (AI) in the detection of visceral pleural invasion (VPI) of lung cancer using high-resolution computed tomography (HRCT) images, which is challenging for experts because of its significance in T-classification and lymph node metastasis prediction.

METHODS

This retrospective analysis was conducted on preoperative HRCT images of 472 patients with stage I non-small cell lung cancer (NSCLC), focusing on lesions adjacent to the pleura to predict VPI. YOLOv4.0 was utilized for tumor localization, and EfficientNetv2 was applied for VPI prediction with HRCT images meticulously annotated for AI model training and validation.

RESULTS

Of the 472 lung cancer cases (500 CT images) studied, the AI algorithm successfully identified tumors, with YOLOv4.0 accurately localizing tumors in 98% of the test images. In the EfficientNet v2-M analysis, the receiver operating characteristic curve exhibited an area under the curve of 0.78. It demonstrated powerful diagnostic performance with a sensitivity, specificity, and precision of 76.4% in VPI prediction.

CONCLUSION

AI is a promising tool for improving the diagnostic accuracy of VPI for NSCLC. Furthermore, incorporating AI into the diagnostic workflow is advocated because of its potential to improve the accuracy of preoperative diagnosis and patient outcomes in NSCLC.

The association of visceral pleural invasion with skip N2 metastasis on clinical stage IA NSCLC

BACKGROUND

Lung lymphatic drainage occurs mainly through a peribronchial path, but it is hypothesized that visceral pleural invasion could alter this path. This study aims to investigate the association between visceral pleural invasion, node upstaging, and N2 skip metastasis and the impact on survival in a population of patients with non-small cell lung cancer of 3 cm or smaller.

METHODS

We retrospectively queried our institutional database of lung cancer resection for all patients with clinical stage IA NSCLC between June 2009 and June 2022. We collected baseline characteristics and clinical and pathological staging data. Patients were classified into two groups: The non-VPI group with negative visceral pleural invasion and the VPI group with positive. The primary results analyzed were the occurrence of nodal upstaging, skip N2 metastasis and recurrence.

RESULTS

There were 320 patients analyzed. 61.3 % were women; the median age was 65.4 years. The pleural invasion occurred in 44 patients (13.7 %). VPI group had larger nodules (2.3 vs. 1.7 cm; p < 0.0001), higher 18F-FDG uptake (7.4 vs. 3.4; p < 0.0001), and lymph-vascular invasion (35.7 % vs. 13.5 %, p = 0.001). Also, the VPI group had more nodal disease (25.6 % vs. 8.7 %; p = 0.001) and skip N2 metastasis (9.3 % vs. 1.8 %; p = 0.006). VPI was a statistically independent factor for skip N2 metastasis. Recurrence occurred in 17.2 % of the population. 5-year disease-free and overall survival were worse in the VPI group.

CONCLUSIONS

The visceral pleural invasion was an independent factor associated with N2 skip metastasis and had worse disease-free and overall survival.

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

With the increasing implementation of early lung cancer screening and the increasing emphasis on physical examinations, the early-stage lung cancer detection rate continues to rise. Visceral pleural invasion (VPI), which denotes the tumor's breach of the elastic layer or reaching the surface of the visceral pleura, stands as a pivotal factor that impacts the prognosis of patients with non-small cell lung cancer (NSCLC) and directly influences the pathological staging of early-stage cases. According to the latest 9th edition of the TNM staging system for NSCLC, even when the tumor diameter is less than 3 cm, the final T stage remains T2a if VPI is present. There is considerable controversy within the guidelines regarding treatment options for stage IB NSCLC, especially among patients exhibiting VPI. Moreover, the precise determination of VPI is important in guiding treatment selection and prognostic evaluation in individuals with NSCLC. This article aims to provide a comprehensive review of the current status and advancements in studies pertaining to stage IB NSCLC accompanied by VPI.

Rethinking the Selection of Pathological T-Classification for Non-Small-Cell Lung Cancer in Varying Degrees of Visceral Pleural Invasion: A SEER-Based Study

Background

The T classification of non-small-cell lung cancer (NSCLC) was upgraded from T1 to T2 when accompanied by visceral pleural invasion (VPI). However, the association between VPI and prognostic outcomes was obscure in NSCLC patients with ≤3 cm tumor size (TS), which leaded the controversy of selection of T classification. The goal was to evaluate the effect of VPI on the prognosis of NSCLC with ≤ 3cm TS and present a modified T classification.

Methods

A total of 14,934 NSCLC patients without distant metastasis were recruited through a retrospective study in the SEER database. The effect of VPI on lung cancer specific survival (LCSS) was evaluated using survival curve and COX regression analysis in NSCLC patients with ≤3 cm TS.

Results

Although there was no difference of the LCSS of PL0 and PL1 patients with ≤2 cm TS in patients without lymph node (LN) metastasis, the LCSS was lower in PL2 patients than those in PL0 (T1a: p < 0.001; T1b: p = 0.001). Moreover, the LCSS was decreased in PL1 and PL2 patients with 2–3 cm TS compared with PL0 (T1c: PL1, p < 0.001; PL2, p = 0.009) of patients without LN metastasis. No difference of LCSS was observed in patients with LN metastasis between PL0 with PL1 and PL2.

Conclusion

In NSCLC patients without LN metastasis and TS ≤ 2 cm, tumor with PL1 should remain defined as T1, tumor with PL2 should be defined as T2. However, 2–3 cm TS patients with PL1 or PL2 should both defined as T2. Meanwhile, ≤3 cm TS patients with LN metastasis can be regarded as T1, whether NSCLC patients accompanied with PL1 or PL2.

Prognostic significance of visceral pleural invasion in patients with surgically resected small-cell lung cancer: a population-based study

OBJECTIVE

Visceral pleural invasion is an adverse prognostic factor in non-small-cell lung cancer, but its value in small-cell lung cancer remains unclear. Thus, we investigated the prognostic impact of visceral pleural invasion in patients with surgically resected small-cell lung cancer.

METHODS

We queried the Surveillance, Epidemiology and End Results Program database for patients diagnosed with stages I-III (excluding N3 and nodal metastasis cannot be evaluated (NX)) small-cell lung cancer from 2004 to 2016, who underwent surgery. To minimize unbalanced baseline characteristics between the visceral pleural invasion and non-visceral pleural invasion groups, one-to-one propensity score matching was employed. A Kaplan-Meier curve was used to compare the overall survival of the two cohorts. A Cox proportional hazards model was adopted to determine the impact of visceral pleural invasion on survival.

RESULTS

Of the 1416 patients included, 372 (26.27%) presented with visceral pleural invasion. Patients with visceral pleural invasion showed significantly worse overall survival (P < 0.001) both before and after propensity score matching. Multivariable analysis indicated that visceral pleural invasion was an independent adverse factor affecting survival. Patients with visceral pleural invasion showed poorer overall survival (hazard ratio: 1.44; 95% confidence interval: 1.17-1.76; P < 0.001). Subgroup analyses revealed that the non-visceral pleural invasion group was associated with favourable overall survival in N0 patients (P = 0.003) but not in N1 or N2 patients (P = 0.774 and 0.248, respectively). Patients diagnosed at younger ages, females, lower N stage, resection with a lobectomy and adjuvant chemotherapy were associated with improved overall survival in the visceral pleural invasion group.

CONCLUSIONS

Visceral pleural invasion was an indicator of a poor prognosis for small-cell lung cancer, especially in those with N0 disease. Adjuvant chemotherapy significantly improves patient outcomes for patients with visceral pleural invasion.

The clinical prognostic factors of patients with stage IB lung adenocarcinoma

Background

Lung adenocarcinoma (ADC) at stage IB has its own prognostic characteristics. This study aimed to investigate the clinical factors that may affect the prognosis of patients with stage IB ADC.

Methods

The data of ADC cases were selected from the Surveillance, Epidemiology, and End Results (SEER) database (2010–2016) and patients in Zhongshan Hospital, Fudan University (Department of Thoracic Surgery, 2015–2016). Kaplan-Meier method was used to obtain the overall survival (OS). Factors that significantly related to the prognosis were evaluated by univariate and multivariate analysis (UVA, MVA) using the Cox model. A nomogram was developed and validated to predict the 3-year OSs of those patients.

Results

7,605 patients with stage IB ADC were included ultimately and were divided into two groups, a training cohort (n=5,324) and a test cohort (n=2,281). Besides, there was a validation cohort (n=272) for the verification of the nomogram model. Those with significantly older age, male, the white race, lower grades of tumor differentiation, larger tumor size (31–40 mm) without pleural layer (PL) invasion as well as receiving sublobectomy suffered from poorer survival (P<0.001), which were identified as independent factors for stage IB ADC (P<0.001), and according to which, a nomogram model was created.

Conclusions

Age, sex, race, histological grade, surgery to the primary site, and tumor size combined with PL invasion were independent risk factors for stage IB ADC, based on which a nomogram was constructed to predict the prognosis.

Risk stratification and adjuvant chemotherapy after radical resection based on the clinical risk scores of patients with stage IB-IIA non-small cell lung cancer

INTRODUCTION

Despite the heterogeneity among patients with stage IB-IIA non-small cell lung cancer (NSCLC), clinically applicable models to identify patients most suitable for receiving adjuvant chemotherapy (ACT) are limited. We aimed to develop a model for risk stratification and the individualized application of ACT.

METHODS

Between January 2008 and March 2018, patients with T2N0M0 NSCLC at Sun Yat-sen University Cancer Center were retrospectively enrolled. Survival curves were estimated by Kaplan-Meier method and compared with log-rank test. Cox regression models were used to identify prognostic factors for disease-free survival (DFS) and overall survival (OS). Propensity score matching (PSM) was implemented. Subgroup analysis was performed based on clinical risk score (CRS) value and epidermal growth factor receptor (EGFR) mutation status.

RESULTS

Of 1063 patients with T2N0 NSCLC enrolled, 272 patients received ACT. Before PSM, patients with high CRS (>1) had a significantly worse OS and DFS outcomes. In the PSM, the baseline characteristics of the 270 pairs of patients were well matched. ACT was associated with improved OS outcomes for patients with a high CRS, while ACT was associated with improved OS and DFS outcomes in patients with wild-type EGFR. The interaction analysis showed an apparent interaction effect between ACT and EGFR-activating mutations as well as chemotherapy regimens and histology.

CONCLUSIONS

The CRS can predict the prognosis of patients with stage IB-IIA NSCLC. ACT could improve the outcome of patients with a high CRS. Patients with non-squamous cell histology receiving pemetrexed plus platinum might benefit more, but not those with EGFR-activating mutations.

The modification of T description according to visceral pleural invasion and tumor size from 3.1 cm to 4.0 cm in non-small cell lung cancer: A retrospective analysis based on the SEER database

OBJECTIVES

As a poor prognostic factor, visceral pleural invasion (VPI) was incorporated into non-small cell lung cancer (NSCLC) staging system. For modifying the T description of NSCLC, the prognostic value of VPI was assessed.

MATERIALS AND METHODS

From 2010-2015, data on stage pT2N0M0 NSCLC patients with tumor size (TS) from 3.1 cm to 5.0 cm who received surgery from the Surveillance, Epidemiology, and End Results (SEER) database were enrolled retrospectively. Propensity score matching was utilized to balance the baseline factors according to different TS intervals. Overall survival (OS) was assessed by the Kaplan-Meier method and log-rank test. Univariate and multivariate analysis were applied to identify the prognostic factors. The risk factors of VPI were calculated by logistic regression model.

RESULT

The sum of 4005 resected stage pT2N0M0 NSCLC patients with TS from 3.1 cm to 5.0 cm were recruited, which had 1084 patients with VPI and 2921 patients without VPI respectively. As TS interval of 3.1-4.0 cm, the 5-year OS of patients without VPI was significantly better than those with VPI (62.6 % vs 58.7 %, P = 0.015), while the 5-year OS of patients with VPI and TS interval of 3.1-4.0 cm had no significant difference compared with patients whose TS interval of 4.1-5.0 cm (58.7 % vs 58.8 %, P = 0.918). Logistic regressive analysis manifested that older age, female, worse differentiation grade and larger TS had higher incidence of VPI (OR = 1.01, 1.25, 1.25, 1.16, respectively; P < 0.05 for all).

CONCLUSION

This study underlined the prognostic effect of VPI and suggested that early-stage NSCLC with VPI and TS interval of 3.1-4.0 cm could be appropriately upstaged from pT2a (stage pIB) to pT2b (modified stage pIIA).

Survival Nomogram for Stage IB Non-Small-Cell Lung Cancer Patients, Based on the SEER Database and an External Validation Cohort

OBJECTIVE

This study aimed to construct a nomogram to effectively predict the overall survival (OS) of patients with stage IB non-small-cell lung cancer (NSCLC).

METHODS

In total, 5513 patients with stage IB NSCLC were extracted from the Surveillance, Epidemiology, and End Results (SEER) database and used as the training cohort. We enrolled 440 patients from the Cancer Hospital, Chinese Academy of Medical Sciences, for the external validation cohort. A nomogram was constructed based on the risk factors affecting prognosis using a Cox proportional hazards regression model. The discrimination and calibration of the nomogram were evaluated by C-indexes and calibration curves.

RESULTS

Six independent risk factors for OS were identified and integrated into the nomogram. The discrimination of the nomogram revealed good prognostic accuracy and clinical applicability as indicated by C-index values of 0.637 (95% CI 0.634-0.641) and 0.667 (95% CI 0.656-0.678) for the training cohort and the external validation cohort, respectively. Additionally, the patients were divided into two groups according to risk (sum-score > 185), and significant differences in OS were observed between the high-risk and low-risk groups in the training and external validation cohorts (P < 0.001). Finally, chemotherapy was significantly associated with OS in patients with differentiation grades II-IV (P = 0.004) and patients with adenocarcinoma (P = 0.005).

CONCLUSION

This nomogram provides a convenient and reliable tool for individual evaluations and clinical decision-making for patients with stage IB NSCLC; among these patients, those with differentiation grades II-IV or adenocarcinoma could benefit from chemotherapy.

Prognostic value of visceral pleural invasion in pure-solid and part-solid lung cancer patients

OBJECTIVE

Visceral pleural invasion (VPI) indicates poor prognosis in non-small cell lung cancer (NSCLC), and is defined as a T2 descriptor for T1-sized tumor. However, whether its prognostic impact differs between pure-solid and part-solid tumors as preoperative diagnostic imaging is controversial. We aimed to elucidate the prognostic difference of VPI in cT1-sized NSCLC according to radiological tumor type (pure-solid or part-solid).

METHODS

We retrospectively reviewed 498 NSCLC patients who underwent complete anatomical lung resection between 2009 and 2014. Patients with node-negative, cT1-sized (consolidation size, ≤ 3 cm) NSCLCs were included. VPI included pathological PL1 and PL2. The prognostic impact of VPI according to radiological tumor type was assessed using multivariate Cox regression analyses.

RESULTS

We evaluated 227 pure-solid and 271 part-solid tumors; median follow-up period was 57 months. VPI was found in 40 (17.6%) and 15 (5.5%) patients with pure-solid and part-solid tumors, respectively (p < 0.001). In pure-solid group, VPI patients showed significantly poorer overall survival (OS) rates than non-VPI patients (p = 0.003). In part-solid group, OS rates did not differ significantly according to VPI (p = 0.770). Multivariate analysis revealed that the adjusted hazard ratio (95% confidence interval) for poor OS was 2.129 (1.048-4.132, p = 0.037) for pure-solid tumors with VPI compared to pure-solid tumors without VPI, and 0.925 (0.050-4.920, p = 0.941) for part-solid tumors with VPI compared to part-solid tumors without VPI.

CONCLUSIONS

VPI had a negative prognostic impact on cT1-sized pure-solid tumors but not on part-solid tumors. Upstaging of the T-category by VPI in cT1-sized NSCLCs may be considered for pure-solid tumors.

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

BACKGROUND

Adjuvant chemotherapy could improve the prognosis of stage II-III non-small cell lung cancer (NSCLC). However, its influences on stage IB were controversial. The purpose of this study was to investigate whether patients with stage IB NSCLC could benefit from adjuvant chemotherapy.

METHODS

Stage IB NSCLC in 2010-2015 was selected from the surveillance, epidemiology, and end result database. Chi square test was used to compare the clinical characteristics of patients with different adjuvant chemotherapy status. Kaplan-Meier survival curves were plotted by the log-rank test. Cox proportional hazard regression was used to perform multivariate analysis on overall survival (OS), and the life table method was employed to calculate 1-, 3-, and 5-year survival rates.

RESULTS

A total of 2915 patients were included in this study, and the number of patients with visceral pleural invasion (VPI) was 1096 (37.6%), of which 145 (13.2%) received adjuvant chemotherapy. There was no statistical difference in OS among the total population with or without chemotherapy (p = 0.295), nor in patients with VPI (p = 0.216). In patients with VPI, the 1-, 3-, 5-year survival curves of patients who are receiving adjuvant chemotherapy showed an upward trend compared with patients who did not. Additionally, female, high differentiated, adenocarcinoma, and tumor size ≤ 3 cm were also independent prognostic factors for improving the prognosis of patients with VPI.

CONCLUSION

In our study, stage IB NSCLC did not benefit from adjuvant chemotherapy, even in patients with VPI. However, the significance of adjuvant chemotherapy in patients with VPI is still worth further exploration.

PNO1, which is negatively regulated by miR-340-5p, promotes lung adenocarcinoma progression through Notch signaling pathway

Many studies have shown that the hyperactivation of ribosome biogenesis plays essential roles in the initiation and progression of cancers. As a ribosome assembly factor, PNO1 plays an important role in ribosome biogenesis. However, little is known about the expression and function of PNO1 in human tumors. In our present study, we aimed to explore the functional roles and the underlying molecular mechanisms of PNO1 in human lung adenocarcinoma (LUAD). Both bioinformatics databases and tumor tissues demonstrated that the expression of PNO1 in LUAD tissues was higher than that in adjacent tissues and predicted poor survival in LUAD patients. In vitro and in vivo assays suggested that downregulation of PNO1 expression suppressed LUAD cell proliferation and invasion. Further studies found that miR-340-5p depressed PNO1 expression via direct binding to the 3′ untranslated region (UTR) of PNO1. PNO1 expression was negatively correlated with miR-340-5p expression in LUAD cells and tissue samples. Moreover, upregulation or downregulation of miR-340-5p expression reversed the effects of PNO1 inhibition and overexpression, respectively. Meanwhile, downregulation of PNO1 inhibited Notch signaling pathway which modulated epithelial mesenchymal transition (EMT). These results indicate that PNO1, negatively regulated by miR-340-5p, played an important role in LUAD progression via Notch signaling pathway. The miR-340-5p/PNO1/Notch axis might be a potential target for individualized and precise treatment of LUAD patients in the future.

Sublobectomy versus lobectomy for long-term survival outcomes of early-stage non-small cell lung cancer with a tumor size ≤2 cm accompanied by visceral pleural invasion: a SEER population-based study

Background

The optimal surgical strategy for early-stage non-small cell lung cancer (NSCLC) with visceral pleural invasion (VPI) remains unclear. Due to limited prospective comparative data for these surgical modalities, the objective of the current study was to compare the long-term survival outcomes of sublobectomy (Sub) versus lobectomy (Lob) for NSCLC with a tumor size ≤2 cm and VPI.

Methods

Patients with early-stage NSCLC characterized by VPI diagnosed between 2004 and 2013 were identified from the Surveillance, Epidemiology, and End Results (SEER) program. The baseline demographic and cancer characteristics, treatment information as well as survival outcome data were extracted from the SEER database, and confounders were balanced by propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) analyses. Lung disease-specific survival (DSS) and overall survival (OS) rates were compared with Cox proportional hazards (PH) regression models based on the unmatched cohort, the propensity-based matched cohort, and the IPTW cohort.

Results

Of the 1,386 patients enrolled, 1,000 (72.15%) and 386 (27.85%) underwent lobectomy and sublobectomy, respectively. The 5-year DSS rate was 78.64% for the lobectomy group and 59.47% for the sublobectomy group. Cox regression models demonstrated that the operation type (Sub vs. Lob) was an independent prognostic factor for early-stage NSCLC with VPI based on the three different cohorts. Patients who underwent lobectomy showed better long-term DSS and OS rates than those treated with sublobectomy after PSM [DSS: hazard ratio (HR) 0.689, 95% confidence interval (CI): 0.490–0.968, P=0.032; OS: HR 0.723, 95% CI: 0.549–0.953, P=0.021]. The IPTW analysis yielded similar results.

Conclusions

Lobectomy showed superior long-term survival compared with sublobectomy in patients with early-stage NSCLC with a tumor size ≤2 cm and VPI.

[Clinical Characteristics and Prognosis of Sub-centimeter Lung Adenocarcinoma]

背景与目的

随着肺癌筛查的逐渐推广，越来越多的患者被确诊为亚厘米(直径≤1 cm)肺腺癌。亚厘米肺腺癌多为早期肺癌，但目前关于亚厘米肺腺癌的研究仍不充分。本研究针对亚厘米肺腺癌患者临床特征及预后进行分析，为该类患者的诊疗提供依据。

方法

回顾性分析2012年1月-2016年12月北京大学人民医院经胸腔镜手术病理确诊为亚厘米肺腺癌患者的临床及预后资料。根据结节影像学特征将患者分为纯磨玻璃结节(pure ground-glass nodules, pGGN)、混杂性磨玻璃结节(mixed ground-glass nodules, mGGN)和实性结节(solid nodules, SN)组，对比三组患者临床特征并对不同直径结节行亚组分析。此外，通过多因素分析筛选亚厘米肺浸润性腺癌的独立危险因素。

结果

本组共182例患者，中位年龄54(27-75)岁。男性57例，女性125例。女性亚厘米肺腺癌患者无吸烟史比例显著高于男性(P < 0.001)。所有1 mm-10 mm pGGN、1 mm-5 mm mGGN及1 mm-5 mm SN患者术后病理除原发灶外无其他阳性发现。46例6 mm-10 mm mGGN患者中有3例侵犯胸膜，1例发现脉管癌栓。39例6 mm-10 mm SN患者中有5例侵犯胸膜，2例发现脉管癌栓，2例出现淋巴结转移。侵犯胸膜、发现脉管癌栓或淋巴结转移的患者其病理类型均为浸润性腺癌。多因素Logistic回归分析发现吸烟史、既往肿瘤病史、mGGN、SN和肿瘤直径 > 5 mm是病理为肺浸润性腺癌的独立危险因素。中位随访时间44(22-82)个月，全组患者5年无复发生存率100.0%，总生存率98.9%。

结论

亚厘米肺腺癌患者发病年龄相对较小。影像学表现为6 mm-10 mm mGGN和6 mm-10 mm SN的亚厘米肺浸润性腺癌患者存在侵犯胸膜或淋巴结转移可能。吸烟史、既往肿瘤病史、mGGN、SN和肿瘤直径 > 5 mm为亚厘米肺浸润性腺癌的独立危险因素。对于亚厘米肺腺癌患者，早期发现并采取合适且有效的外科干预可获得良好的预后。

Visceral Pleural Invasion in Pulmonary Adenocarcinoma: Differences in CT Patterns between Solid and Subsolid Cancers

PURPOSE

To analyze the incidence and CT patterns of visceral pleural invasion (VPI) in adenocarcinomas on the basis of their CT presentation as solid or subsolid nodules.

MATERIALS AND METHODS

A total of 286 adenocarcinomas in direct contact with a pleural surface, resected at an institution between 2005 and 2016, were included in this retrospective, institutional review board-approved study. CT size and longest contact length with a pleural surface were measured and their ratios computed. Pleural deviation, pleural thickening, spiculations, different pleural tag types, pleural effusion, and the CT appearance of transgression into an adjacent lobe or infiltration of surrounding tissue were evaluated. Fisher exact tests and simple and multiple logistic regression models were used.

RESULTS

Of the 286 nodules, 179 of 286 (62.6%) were solid and 107 of 286 (37.4%) were subsolid. VPI was present in 49 of 286 (17.1%) nodules and was significantly more frequent in solid (44 of 179; 24.6%) than in subsolid nodules (five of 107; 4.7%; P < .001). In solid nodules, multiple regression analysis showed an association of higher contact length-to-size ratio (adjusted odds ratio [OR], 1.02; P = .007) and the presence of multiple pleural tag types (adjusted OR, 5.88; P = .002) with VPI. In subsolid nodules, longer pleural contact length of the solid nodular component (adjusted OR, 1.27; P = .017) and the CT appearance of transgression or infiltration (adjusted OR, 10.75; P = .037) were associated with VPI.

CONCLUSION

During preoperative evaluation of adenocarcinomas for the likelihood of VPI, whether a tumor manifests as a solid or a subsolid nodule is important to consider because the incidence of VPI is significantly higher in solid than in subsolid nodules. In addition, this study showed that the CT patterns associated with VPI differ between solid and subsolid nodules.© RSNA, 2019Supplemental material is available for this article.See also the commentary by Elicker in this issue.

Visceral pleural invasion in T1 tumors (≤3 cm), particularly T1a, in the eighth tumor-node-metastasis classification system for non-small cell lung cancer: a population-based study

BACKGROUND

We aimed to validate the tumor (T) descriptors of visceral pleural invasion (VPI) for T1 tumors (<3 cm) in the 8th edition of the tumor-node-metastasis (TNM) classification system and the prognostic value of VPI for resected T1a tumors.

METHODS

The external cohort consisted of 23,501 patients with resected pN0 non-small cell lung cancer (NSCLC) selected from the Surveillance, Epidemiology, and End Results (SEER) database (2010 to 2013). The classification of T1 tumors with VPI was investigated using survival curves. The internal cohort consisted of patients diagnosed with pN0 NSCLC between 2011 and 2013 at Guangdong Lung Cancer Institute. The prognostic value of VPI for T1a tumors (<1 cm) was further assessed in these two cohorts.

RESULTS

The overall survival (OS) and lung cancer-specific survival (LCSS) of the T1-VPI group and groups of each T stage (size only) were compared in the external (SEER) cohort. There were no significant survival differences between the T1-VPI and T2a groups (OS: P=0.706; LCSS: P=0.792) and T1-VPI and T2b groups, although the latter showed a trend toward lower P-values (OS: P=0.117; LCSS: P=0.094). In the internal cohort, a significant difference in OS was observed between patients with T1-VPI and those with T2b (P=0.049). Among patients with T1a tumors and VPI in the SEER database, the prognosis of the non-sub-lobectomy group was superior to that of the sub-lobectomy group, with intrathoracic recurrence as the predominant relapse pattern of T1 tumors with VPI (69.2%).

CONCLUSIONS

T1 tumors (<3 cm) with VPI can be staged as T2a in the 8th TNM staging system and surgical resection of T1a tumors is a concern when VPI is present.

Survival with Parenchymal and Pleural Invasion of Non-Small Cell Lung Cancers Less than 30 mm

OBJECTIVE

To determine long-term survival of visceral pleural invasion (VPI) and parenchymal invasion (PAI) (angiolymphatic and/or vascular) on survival of NSCLCs less than 30 mm in maximum diameter.

METHODS

Kaplan-Meier survivals for NSCLCs, with and without VPI and/or PAI, were determined for a prospective cohort of screening participants stratified by pathologic tumor size (≤10 mm, 11-20 mm, and 21-30 mm) and nodule consistency. Log-rank test statistics were calculated.

RESULTS

The frequency of PAI versus VPI was significantly lower in patients with subsolid nodules than in those with solid nodules (4.9% versus 27.7% [p < 0.0001]), and correspondingly, Kaplan-Meier lung cancer survival was significantly higher among patients with subsolid nodules (99.1% versus 91.3% [p = 0.0009]). Multivariable Cox regression found that only tumor diameter (adjusted hazard ratio [HR] =1.07, 95% confidence interval [CI]: 1.01-1.14, p = 0.02) and PAI (adjusted HR = 3.15, 95% CI: 1.25-7.90, p = 0.01) remained significant, whereas VPI was not significant (p = 0.15). When clinical and computed tomography findings were included with the pathologic findings, Cox regression showed that the risk of dying of lung cancer increased 10-fold (HR = 10.06, 95% CI: 1.35-75.30) for NSCLCs in patients with solid nodules and more than twofold (by a factor of 2.27) in patients with moderate to severe emphysema (HR = 2.27, 95% CI: 1.01-5.11), as well as with increasing tumor diameter (HR = 1.06, 95% CI: 1.01-1.13), whereas PAI was no longer significant (p = 0.19).

CONCLUSIONS

Nodule consistency on computed tomography was a more significant prognostic indicator than either PAI or VPI. We propose that patients with NSCLC with VPI and a maximum tumor diameter of 30 mm or less not be upstaged to T2 without further large, multicenter studies of NSCLCs, stratified by the new T status and that classification be considered separately for patients with subsolid or solid nodules.

Novel biologic factors correlated to visceral pleural invasion in early-stage non-small cell lung cancer less than 3 cm

Background

Visceral pleural invasion (VPI) in early-stage non-small cell lung cancer (NSCLC) is traditionally believed as the result of too much close distance between cancerous lesion and the visceral pleura, but whether there are any other biologic factors correlated to VPI beyond our instinctive thoughts remains unclear. Therefore, we conducted this study to investigate potential factors correlated to VPI comprehensively.

Methods

Both clinical and pathological characteristics of patients undergoing surgery for NSCLC with a size of ≤3 cm were retrospectively analysed.

Results

A total of 403 patients were included for analysis. Patients with VPI had older age than those without (61.1 vs. 56.1 years; P<0.001). The mean size of NSCLCs with VPI was larger than those without (2.1 vs. 1.6 cm; P<0.001). Moreover, NSCLCs with VPI were located closer to visceral pleura (0.8 vs. 1.3 cm; P<0.001) and showed larger rates of pleural indentation (86.8% vs. 45.6%; P<0.001) and spiculation (59.7% vs. 34.7%; P<0.001) than those without. Pathologically, NSCLCs with VPI tended more likely to be adenocarcinomas (96.9% vs. 92.7%; P=0.097), and was more likely to be poorly differentiated (38.0% vs. 15.3%; P<0.001), to have cancer embolus (6.2% vs. 0.7%; P=0.001) and lymph node metastasis (29.5% vs. 10.2%; P<0.001) than those without. Besides shorter distance to visceral pleura [odds ratio (OR)=2.169, 95% CI: 1.221-3.855; P=0.008], older age [OR =2.119, 95% confidence interval (CI): 1.255-3.503; P=0.005], pleural indentation (OR =3.679, 95% CI: 1.888-7.169; P<0.001), adenocarcinoma (OR =4.741, 95% CI: 1.383-16.255; P=0.013), and poor tumor differentiation (OR =11.816, 95% CI: 4.470-31.234; P<0.001) were also found to be closely correlated to VPI in early-stage NSCLC.

Conclusions

Besides shorter distance to visceral pleura and pleural indentation, elderly, adenocarcinoma, and poor tumor differentiation were novel biologic factors correlated to VPI in early-stage NSCLC, which may explain why VPI was an unfavorable prognostic factor for early-stage NSCLC.

Characteristics and prognostic factors of node-negative non-small cell lung cancer larger than 5 cm

OBJECTIVES

In the 7th edition of the tumour, node and metastasis staging system, a primary tumour size larger than 5 cm was shifted to Stage II. Therefore, we aimed to evaluate the characteristics and prognostic factors of node-negative non-small cell lung cancer (NSCLC) larger than 5 cm.

METHODS

We included 109 patients who underwent curative resection and had pathologically confirmed node-negative NSCLC >5 cm (Group 1). We compared the clinicopathological characteristics and prognosis of these patients with 85 patients with node-positive NSCLC >5 cm (Group 2) and 383 patients who had node-positive NSCLC ≤5 cm (Group 3).

RESULTS

Compared with Group 2, old age and absence of lymphovascular invasion was significantly more common in Group 1. Compared with Group 3, frequency of non-adenocarcinoma type and visceral pleural invasion were significantly higher in Group 1; however, the frequency of lymphovascular invasion was higher in Group 3. A Cox proportional hazards model showed that the maximized standardized uptake value and visceral pleural invasion was a statistically worse prognostic factor. Compared with Group 2, Group 1 showed significantly longer overall survival; however, there was no difference in recurrence-free survival. Compared with Group 3, there was no significant difference in recurrence-free survival and overall survival. In Group 1, recurrence in the contralateral lung was the most common recurrence pattern, and there was no metastasis in the mediastinal lymph nodes.

CONCLUSIONS

Patients with node-negative NSCLC >5 cm had a lower incidence of lymphovascular invasion and a more common contralateral recurrence than patients with node-positive NSCLC, and visceral pleural invasion was identified as independent prognostic factors.

Extent of Visceral Pleural Invasion Affects Prognosis of Resected Non-small Cell Lung Cancer: A meta-analysis

Visceral pleural invasion (VPI) has been known to be an adverse prognostic factor in non-small cell lung cancer (NSCLC). However, the prognostic significance of extent of VPI (PL0, PL1 and PL2) remains controversial. We conduct a meta-analysis to summarize available evidence on this topic. PubMed, EMBASE, OVID and The Cochrane Library were searched for published studies from inception to May 9, 2016. A total of 16 studies were included in meta-analysis. Our results showed that patients with PL1 or PL2 had poorer overall survival compared with PL0 (HR = 1.555, 95% CI 1.399, 1.730; HR = 2.447, 95% CI 1.913, 3.130) and patients with PL2 had even poorer overall survival than PL1 (HR = 1.287, 95% CI 1.114, 1.487). Patients with PL1 or PL2 had lower 5-year survival rate than PL0 patients (OR = 0.515, 95% CI 0.415, 0.640; OR = 0.441, 95% CI 0.336, 0.579) and patients with PL2 had even lower 5-year survival rate than PL1 (OR = 0.706, 95% CI 0.545, 0.915). In conclusion, extent of VPI impacts the prognosis of resected NSCLC and VPI should be categorized as PL1 and PL2 in the terms of clinical practice and trials.

Vascular invasion is an adverse prognostic factor in resected non-small-cell lung cancer

Lung cancer is a leading cause of death, and there is a need for better prognostic factors in treatment decisions. Vascular invasion is a known negative prognosticator, but it is not clear how to evaluate this feature. Here, we studied the prevalence and prognostic impact of blood and lymphatic vascular invasion (BVI, LVI), tumour grade, necrosis, inflammation and pleural invasion on cancer-specific survival (LCSS) and time to recurrence (TTR) in non-small-cell lung cancer (NSCLC). A total of 438 patients surgically treated for NSCLC (1993-2010) were examined, including 213 adenocarcinomas (AC), 135 squamous cell carcinomas (SCC) and 90 other NSCLC. BVI and LVI were found in 25% and 21% of the cases, with reduced LCSS and TTR for both markers in AC and SCC (p < 0.005 for all). BVI and LVI remained independent prognostic factors for LCSS and TTR in separate multivariate models for AC and SCC. Combined BVI/LVI (7%) showed significantly reduced LCSS and TTR (p < 0.001), also by multivariate analysis. Our results support that BVI and LVI are valuable for prognostic staging. Vascular invasion identifies a group of patients at higher risk of recurrence and lung cancer-related death, and this could influence stratification of patients for treatment and follow-up.

Predicting the recurrence risk factors and clinical outcomes of peripheral pulmonary adenocarcinoma ≤3 cm with wedge resection

PURPOSE

This study was designed to investigate the risk factors of recurrence and survival of clinical stage I lung adenocarcinoma underwent wedge resection by the use of Shanghai Chest Hospital Lung Cancer Database.

PATIENTS AND METHODS

A total of 746 patients with clinical stage I adenocarcinoma underwent wedge resection from 2010 to 2015 in our database were included in this study. Univariable and multivariable Cox proportional hazards regression were performed successively to select significant risk factors and then nomograms as well as the concordance indexes for RFS, OS and LCSS were developed, respectively. Kaplan-Meier survival curves were performed if necessary, with the identification of log-rank test.

RESULTS

The 5-year RFS, OS and LCSS of clinical stage I adenocarcinoma underwent wedge resection were 86.1, 83.6 and 85.2%, respectively. There were three independent risk factors related with RFS (sex, pathology, pleural invasion), two related with OS (sex, volume ratio) and two with LCSS (sex, volume ratio) with the analysis of Cox regression and were selected to develop nomograms. The C-indexes of RFS, OS and LCSS were 0.767 (95% CI 0.667-0.867), 0.782 (95% CI 0.660-0.904) and 0.794 (95% CI 0.669-0.919), respectively. Lymphadenectomy did not show differences statistically but had tendencies of better RFS, OS and LCSS among the subgroup of invasive adenocarcinoma.

CONCLUSION

Sex, pathology and pleural invasion could be recommended as criteria for clinical stage I adenocarcinoma undergoing wedge resection. And the larger the wedge volume and/or the smaller the tumor volume was, the better OS and LCSS were. If the volume ratio reached 10:1 or more, the survival rate was approximately 90% for both OS and LCSS. Whether lymphadenectomy was necessary for WR, especially in invasive adenocarcinoma, needed further research.

Effect of Adjuvant Chemotherapy after Complete Resection for Pathologic Stage IB Lung Adenocarcinoma in High-Risk Patients as Defined by a New Recurrence Risk Scoring Model

Purpose

We conducted a retrospective analysis to determine if adjuvant chemotherapy prolongs overall survival in patients with pathologic stage IB lung adenocarcinoma who had undergone complete resection and were defined as high-risk by a newly developed recurrence risk scoring model.

Materials and Methods

Patients who underwent curative resection for stage IB lung adenocarcinoma were analyzed with a newly developed recurrence risk scoring model and divided into a low-risk group and a high-risk group. The patients in the high-risk group were retrospectively divided into two groups based on whether they underwent adjuvant chemotherapy or observation. Recurrence-free survival and overall survival were compared between these two groups.

Results

A total of 328 patients who underwent curative resection between 2000 and 2009 were included in this study, of whom 110 (34%) received adjuvant chemotherapy and 218 (67%) underwent observation without additional treatment. According to our risk model, 167 patients (51%) were high-risk and 161 (49%) were low-risk. The 5-year recurrence-free survival rates and overall survival were 84.4% and 91.5% in low-risk patients and 53.9% and 74.7% in high-risk patients (p < 0.001). In high-risk patients, the 5-year overall survival rates were 77% among patients who underwent observation and 87% among those who underwent adjuvant chemotherapy (p=0.019).

Conclusion

Adjuvant chemotherapy prolonged overall survival among high-risk patients who had undergone complete resection for stage IB lung adenocarcinoma.

The IASLC Lung Cancer Staging Project: Proposals for the Revisions of the T Descriptors in the Forthcoming Eighth Edition of the TNM Classification for Lung Cancer

INTRODUCTION

An international database was collected to inform the 8 edition of the anatomic classification of lung cancer. The present analyses concern its primary tumor (T) component.

METHODS

From 1999 to 2010, 77,156 evaluable patients, 70,967 with non-small-cell lung cancer, were collected; and 33,115 had either a clinical or a pathological classification, known tumor size, sufficient T information, and no metastases. Survival was measured from date of diagnosis or surgery for clinically and pathologically staged tumors. Tumor-size cutpoints were evaluated by the running log-rank statistics. T descriptors were evaluated in a multivariate Cox regression analysis adjusted for age, gender, histological type, and geographic region.

RESULTS

The 3-cm cutpoint significantly separates T1 from T2. From 1 to 5 cm, each centimeter separates tumors of significantly different prognosis. Prognosis of tumors greater than 5 cm but less than or equal to 7 cm is equivalent to T3, and that of those greater than 7 cm to T4. Bronchial involvement less than 2 cm from carina, but without involving it, and total atelectasis/pneumonitis have a T2 prognosis. Involvement of the diaphragm has a T4 prognosis. Invasion of the mediastinal pleura is a descriptor seldom used.

CONCLUSIONS

Recommended changes are as follows: to subclassify T1 into T1a (≤1 cm), T1b (>1 to ≤2 cm), and T1c (>2 to ≤3 cm); to subclassify T2 into T2a (>3 to ≤4 cm) and T2b (>4 to ≤5 cm); to reclassify tumors greater than 5 to less than or equal to 7 cm as T3; to reclassify tumors greater than 7 cm as T4; to group involvement of main bronchus as T2 regardless of distance from carina; to group partial and total atelectasis/pneumonitis as T2; to reclassify diaphragm invasion as T4; and to delete mediastinal pleura invasion as a T descriptor.

The predictive and prognostic values of factors associated with visceral pleural involvement in resected lung adenocarcinomas

Background

The predictive and prognostic impact of factors associated with visceral pleural invasion (VPI) on survival and recurrence in patients with resected lung adenocarcinomas is not clearly defined.

Patients and methods

A total of 505 consecutive patients with stage Ia–IIIa lung adenocarcinomas treated with radical resection were included. The predominant growth pattern was classified according to the new classification system for lung adenocarcinoma proposed by the International Association for the Study of Lung Cancer, the American Thoracic Society, and the European Respiratory Society. The correlations of VPI with clinical and pathologic parameters were analyzed.

Results

The incidence of VPI was significantly lower in lepidic predominant group (15.5% vs 4.5%, P<0.001) and higher in solid and micropapillary predominant group (28.6% vs 17.6%, P=0.004 and 14.7% vs 4.2%, P<0.001, respectively). VPI correlated with higher risk in regional postoperative recurrence (hazard ratio, 2.341; 95% confidence interval, 1.564–3.504) and distant recurrence (hazard ratio, 2.193; 95% confidence interval, 1.665–2.89) in surgically resected lung adenocarcinomas. However, when growth patterns of adenocarcinoma were lumped into multivariate analysis, VPI was not a significant independent predictive factor for survival (P=0.854 for overall survival [OS] and P=0.575 for disease-free survival [DFS]) and recurrence (P=0.38 for regional recurrence and P=0.089 for distant recurrence). Of the 95 patients with stage Ib, those who received adjuvant chemotherapy had longer DFS and OS than the patients who received no chemotherapy after surgery. However, these differences in DFS and OS did not reach statistical significance (P=0.063 for DFS, P=0.85 for OS).

Conclusion

VPI was associated with solid and micropapillary histology. In addition, stage Ib patients with solid histologic subtype tumor showed longer DFS and OS, highlighting a potential benefit in this subgroup of patients and necessitating the need for larger clinical trials.

Clinical analysis of sixty-four patients with T1aN2M0 stage non-small cell lung cancer who had undergone resection

Background

The aim of this study was to evaluate the clinical features of T1aN2M0 stage non‐small cell lung cancer (NSCLC).

Method

From November 2008 to May 2013, 498 patients with T1a‐stage NSCLC who visited the Shanghai Cancer Center were included in the study. All patients underwent a lobectomy or segmentectomy with systematic nodal resection for primary lung cancer. Analyses of gender, smoking history, primary tumor site, tumor location, tumor size, pathological classification, cancer gene, pleural invasion, number of positive lymph nodes, skip N2, single or multiple station N2, progression‐free survival (PFS), and overall survival (OS) were performed.

Result

There were significant differences in tumor size, tumor size distribution, adenocarcinoma subgroup, and number of positive lymph nodes between patients at T1aN2M0 and T1aN0M0 stages. The most common histology of the T1aN2M0 subgroup was adenocarcinoma. Epidermal growth factor receptor mutations were the most common gene mutation in T1aN2M0 stage NSCLC. There were significant differences in five‐year OS and PFS rates between patients with T1aN2M0, T1aN0M0, and T1aN1M0 stages. Multivariate analyses of mediastinal lymph node metastasis showed that gender, tumor size distribution, and histology type were significant predictive factors. Multivariate analyses of OS and PFS rates in the T1aN2M0 subgroup showed that the number of positive lymph nodes was a significant predictive factor.

Conclusion

Gender, tumor size distribution, and histology type were independent predictors of mediastinal lymph node metastasis in patients with T1a stage. The number of positive lymph nodes was significantly associated with OS and PFS rates in patients with T1aN2M0 stage NSCLC.

Solid Predominant Histologic Subtype in Resected Stage I Lung Adenocarcinoma Is an Independent Predictor of Early, Extrathoracic, Multisite Recurrence and of Poor Postrecurrence Survival

PURPOSE

To examine the significance of the proposed International Association for the Study of Lung Cancer, American Thoracic Society, and European Respiratory Society (IASLC/ATS/ERS) histologic subtypes of lung adenocarcinoma for patterns of recurrence and, among patients who recur following resection of stage I lung adenocarcinoma, for postrecurrence survival (PRS).

PATIENTS AND METHODS

We reviewed patients with stage I lung adenocarcinoma who had undergone complete surgical resection from 1999 to 2009 (N = 1,120). Tumors were subtyped by using the IASLC/ATS/ERS classification. The effects of the dominant subtype on recurrence and, among patients who recurred, on PRS were investigated.

RESULTS

Of 1,120 patients identified, 188 had recurrent disease, 103 of whom died as a result of lung cancer. Among patients who recurred, 2-year PRS was 45%, and median PRS was 26.1 months. Compared with patients with nonsolid tumors, patients with solid predominant tumors had earlier (P = .007), more extrathoracic (P < .001), and more multisite (P = .011) recurrences. Multivariable analysis of primary tumor factors revealed that, among patients who recurred, solid predominant histologic pattern in the primary tumor (hazard ratio [HR], 1.76; P = .016), age older than 65 years (HR, 1.63; P = .01), and sublobar resection (HR, 1.6; P = .01) were significantly associated with worse PRS. Presence of extrathoracic metastasis (HR, 1.76; P = .013) and age older than 65 years at the time of recurrence (HR, 1.7; P = .014) were also significantly associated with worse PRS.

CONCLUSION

In patients with stage I primary lung adenocarcinoma, solid predominant subtype is an independent predictor of early recurrence and, among those patients who recur, of worse PRS. Our findings provide a rationale for investigating adjuvant therapy and identify novel therapeutic targets for patients with solid predominant lung adenocarcinoma.

Prognostic significance of visceral pleural involvement in early-stage lung cancer

BACKGROUND

Visceral pleural invasion (VPI) may impact non-small cell lung cancer (NSCLC) survival. However, previous studies are mixed as to whether VPI is an independent prognostic factor in early-stage cancers and whether its effect is size dependent. In the current American Joint Committee on Cancer (AJCC) staging system, VPI leads to upstaging of cancers < 3 cm but not of those 3 to 7 cm in size.

METHODS

Using the Surveillance, Epidemiology, and End Results (SEER) registry, we identified 16,315 patients with stage I-II NSCLC treated with lobectomy. We used the Kaplan-Meier method and Cox regression to assess the association of VPI with lung cancer-specific (primary outcome) and overall survival. Based on these results, we created a revised VPI staging classification.

RESULTS

Overall, 3,389 patients (21%) had VPI. Kaplan-Meier analysis stratified by tumor size showed worse cancer-specific survival in patients with VPI (P < .0001). VPI was independently associated with decreased lung cancer-specific survival (hazard ratio, 1.38; 95% CI, 1.29-1.47) after controlling for tumor size and other confounders; this effect was not size dependent. In our revised classification, tumors < 7 cm with VPI were upstaged to the next T category.

CONCLUSIONS

VPI is a prevalent finding associated with worse prognosis in early-stage lung cancer, even among patients with tumors > 3 cm, a factor not captured in the current staging system. Patients with VPI may be considered candidates for more aggressive treatment.

Visceral pleural invasion remains a size-independent prognostic factor in stage I non-small cell lung cancer

BACKGROUND

The prognostic effect of visceral pleural invasion remains controversial when a tumor is less than 3 cm in stage I non-small cell lung cancer patients. We conducted this meta-analysis to evaluate the prognostic impact of visceral pleural invasion in these early patients.

METHODS

We searched PubMed, EMBASE, Cochrane Library, and China National Knowledge Infrastructure and included published studies on the prognostic significance of visceral pleural invasion in stage I non-small cell lung cancer. Meta-analysis was performed and heterogeneity and publication bias were also evaluated.

RESULTS

Twenty-two studies were included in the meta-analysis. In all stage I patients, visceral pleural invasion was associated with death (hazard ratio1.427; p = 0.000) and recurrence (hazard ratio1.600; p = 0.000). In subgroup analyses, visceral pleural invasions were consistently associated with death in each tumor size subgroup and recurrence in tumor less than 3 cm subgroup. Publication bias was not found.

CONCLUSIONS

Visceral pleural invasion is a size-independent poor prognostic factor in stage I non-small cell lung cancer patients. We suggest adjuvant treatment should be considered in stage I patients with visceral pleural invasion.

Risk factors of recurrence for resected T1aN0M0 invasive lung adenocarcinoma: a clinicopathologic study of 177 patients

Background

This study aimed at identifying risk factors of recurrence for completely resected pathologic T1aN0M0 lung adenocarcinomas.

Methods

We reviewed the records of 177 T1aN0M0 invasive adenocarcinoma patients, and re-classified achieved surgical specimens according to the new International Association for the Study of Lung Cancer, American Thoracic Society, and European Respiratory Society (IASLC/ATS/ERS) lung adenocarcinoma classification. Impact on recurrence-free survival (RFS) for age, gender, smoking history, lymphovascular invasion (LVI) and new classification was analyzed by log-rank test and Cox regression. Two existing prognostic grouping schemes of new classification were compared, and subsequently, the correlation of high-grade group in the better prognostic grouping model with clinical data was investigated statistically.

Results

The 5-year recurrence-free rate was 83.7%. The LVI and new adenocarcinoma classification were significantly associated with 5-year RFS (P = 0.012; P = 0.022, respectively). The designation of papillary predominant subtype in the low-grade group, along with lepidic- and acinar predominant subtype had more prognostic significance than the model of combining papillary-, solid- and micropapillary predominant subtypes as the high-grade group (P = 0.005 versus P = 0.181). This high-grade group has increased risk of recurrence in a multivariate Cox regression (adjusted HR 2.815, 95% CI: 1.239 to 6.397, P = 0.013), and is associated significantly more with male gender (adjusted OR 2.214, 95% CI: 1.050 to 4.668, P = 0.037), and, with borderline significance, the presence of LVI (adjusted OR 2.091, 95% CI: 0.938 to 4.662, P = 0.071).

Conclusions

Our results showed that the solid- and micropapillary predominant subtype of IASLC/ATS/ERS classification remains the only risk factor for post-operative recurrence of T1aN0M0 adenocarcinomas, suggesting that they can be indicators of aggressive tumor behaviors.