[Analysis of Postoperative Complications and Risk Factors of Patients with Lung Cancer through Clavien-Dindo Classification]

[Comparison of Short-term Efficacy of Neoadjuvant Immunotherapy Combined with Chemotherapy and Surgery Alone for Locally Advanced Resectable Non-small Cell Lung Cancer]

BACKGROUND

Lung cancer is the cancer with the highest incidence and mortality rates in China, and non-small cell lung cancer (NSCLC) accounts for 80%-85% of all malignant lung tumors. Currently, surgical treatment remains the primary treatment modality for lung cancer. In recent years, the effectiveness of immune checkpoint inhibitors for NSCLC has become a consensus, and neoadjuvant immunochemotherapy (nICT) has shown promising efficacy and safety in early to intermediate stage NSCLC. However, there are fewer studies related to nICT for locally advanced NSCLC. This study aims to evaluate the efficacy and safety of nICT therapy in locally advanced resectable NSCLC.

METHODS

85 confirmed resectable stage IIIA and IIIB patients treated in the Department of Thoracic Surgery, Second Hospital of Lanzhou University, from January 2021 to April 2024, were divided into the nICT group (n=32) and the surgery alone group (n=53). Clinical baseline data, perioperative indicators, postoperative complications, imaging response rate, pathological response rate, incidence of adverse events, and quality of life were compared between the two groups.

RESULTS

There were no statistically significant differences in clinical baseline data between the two groups (P>0.05). Incidence of choosing thoracotomy was higher in the nICT group than in the surgery alone group (P=0.002). There were no significant differences in surgical time, intraoperative blood loss, number of dissected lymph nodes, duration of chest tube placement, postoperative hospital stay, and R0 resection rate between the two groups (P>0.05). The overall incidence of postoperative complications was 31.25% in the nICT group and 22.64% in the surgery alone group, with no statistically significant difference (P=0.380). In the nICT group, the objective response rate (ORR) was 84.38%, with 5 cases of complete response (CR)(15.63%), 22 cases of partial response (PR)(68.75%), 15 cases of pathological response rate (pCR)(46.88%), and 11 cases of major pathological reaponse (MPR) (34.38%). During nICT treatment, 12 cases (37.50%) experienced grade 3 treatment-related adverse events, no death induced by adverse events or immune related adverse events. Moreover, the symptoms of the patients were improved after nICT treatment.

CONCLUSIONS

Neoadjuvant immunochemotherapy shows promising efficacy in locally advanced resectable NSCLC, with manageable treatment-related adverse events. It is a safe and feasible neoadjuvant treatment modality for locally advanced resectable NSCLC.

[Variation of Main Postoperative Symptoms in Lung Cancer Patients Undergoing Video-assisted Thoracoscopic Surgery]

BACKGROUND

Patients with pulmonary nodules are treated by minimally invasive surgery, and postoperative symptoms have become the main factors affecting patients' emotion and quality of life. This study aimed to analyze the changes of postoperative symptoms in lung cancer patients with pulmonary nodules.

METHODS

The clinical data of eighty-eight lung cancer patients admitted to the same medical group of Department of Thoracic Surgery, West China Hospital of Sichuan University from June 2021 to September 2021 were prospectively collected and analyzed. The types and severity of clinical symptoms before operation, on discharge day, 30-day and 90-day after operation were analyzed.

RESULTS

The incidence of postoperative symptoms in lung cancer patients was 79.5%, and most patients suffered from mild (54.3%) and moderate (32.9%) symptoms. The main postoperative symptoms of lung cancer patients were pain (55.7%) and cough (37.2%). The incidence of pain at discharge (55.7%) was significantly higher than that at 30-day (23.7%, P=0.01) and 90-day (12.0%, P=0.01) after discharge. The incidence of cough was significantly higher at 30-day (66.1%) and 90-day (66.0%) than that at discharge (37.2%) (P=0.01, P=0.04).

CONCLUSIONS

The main postoperative symptoms of lung cancer patients with pulmonary nodules are pain and cough. The incidence and severity of pain decreases with time, and the incidence of cough increases but the severity decreased gradually.

[Research Updates: Standardized Reporting and Evaluation Instruments for Postoperative Complications]

Postoperative complications are important indicators for evaluating surgical outcomes, and mortality and the incidence of various specific complications are often used to measure the efficacy of surgical and perioperative management strategies. With the progress of medical technology, there has been a dramatic decline in mortality and the incidence of complications. As a result, reporting and evaluation in the traditional methods no longer meets the actual needs of the world. There has arisen an urgent need for an instrument of standardized reporting and evaluation. The instrument should be aligned with the actual circumstances and should represent the patient's overall burden of postoperative complications. We herein reviewed the latest research findings on Clavien-Dindo Classification (CDC) system and comprehensive complication index (CCI), two instruments of standardized reporting and evaluation of postoperative complications, and discussed the space for improvement and prospects of application of CDC and CCI.

[Can Perioperative Oscillating Positive Expiratory Pressure Practice Enhance Recovery in Lung Cancer Patients Undergoing Thorascopic Lobectomy?]

背景与目的

振动正压呼气（oscillatory positive expiratory pressure, OPEP）训练是一种通过正压呼气装置（acapella）进行的呼吸训练。OPEP在慢性阻塞性肺疾病、支气管扩张症、肺囊肿等疾病的临床价值已经得到广泛探讨，但其在肺癌手术患者围术期的应用价值尚有待探索。本研究旨在探索围术期进行振动正压呼气训练对胸腔镜肺癌患者术后并发症发生率、肺功能、生活质量的影响。

方法

前瞻性收集2017年9月15日-2018年1月15日四川大学华西医院胸外科单个医疗组行胸腔镜肺叶切除的原发性非小细胞癌患者69例，随机分成实验组（35例）和对照组（34例）。实验组（acapella group, AG）围手术期采用振动正压呼气训练，对照组（control group, CG）进行常规围术期处理。对比分析两组在术后并发症发生率、肺功能、生活质量方面的差异。

结果

术后肺部并发症和肺不张在AG（2.9%, 0.0%）显著低于CG（20.6%, 14.7%）（P=0.03, P=0.03）；平均住院日和术后住院日在AG（10.86±5.64, 5.09±4.55）d显著短于CG（14.41±4.58, 7.59±3.21）d（P=0.01, P=0.01）；住院药物费用在AG（4, 413.60±1, 772.35）￥显著低于CG（6, 490.35±3, 367.66）￥（P=0.01）。出院当日第1秒用力呼气容积（forced expiratory volume in the first second, FEV₁）和呼气峰流速（peak expiratory flow, PEF）在AG[(1.50±0.32) L, (252.06±75.27) L/min]显著高于CG[(1.34±0.19) L, (216.94±49.72) L/min]（P=0.03, P=0.03）。

结论

肺癌患者围手术期使用振动正压呼气训练有助于降低肺部并发症，同时能够加速患者康复。

[Clinical Value Evaluation of Perioperative Prophylactic Anticoagulation Therapy for Lung Cancer Patients]

BACKGROUND

The incidence of pulmonary embolism (PE) in lung cancer patients who underwent surgery increased during the perioperative period, and prophylactic anticoagulation therapy was important part of enhanced recovery after surgery (ERAS). However, the timing of preventive anticoagulation in patients with lung cancer remained controversial. This study was designed to investigate the safety and efficacy of perioperative prophylactic anticoagulation therapy for lung cancer patients.

METHODS

Retrospective research was conducted on 562 lung cancer patients who underwent video-assisted thoracoscopic (VATS) anatomic pulmonary resections in West China Hospital from June 2016 to December 2016. 56 patients were treated with low molecular weight heparin (LMWH) anticoagulation 12 hours before operation until discharge, while the other 506 patients were treated with LMWH 24 hours after operation until discharge. The postoperative chest drainage volume, postoperative bleeding, pulmonary embolism incidence, and respiratory complications were analyzed.

RESULTS

(1) There were no significant differences in prothrombin time (PT), activated partial thromboplastin time (APTT) and international normalized ratio (INR) between the pre-operation prophylactic anticoagulation group (PRE group) [(11.5±3.9) s, (27.8±3.5) s, (0.96±0.06) s] and the post-operation prophylactic anticoagulation group (POST group) [(11.4±1.4) s, (28.3±4.0) s, (0.98±0.07) s] (P=0.796, P=0.250, P=0.137), and there was no significant difference in Caprini score between the PRE group (3.1±1.8) and the POST group (3.3±1.5) (P=0.104). (2) There were no significant differences in anesthesia time and intraoperative bleeding between PRE group [(130.2±53.9) min, (76.8±49.3) mL] and POST group [(142.2±56.5) min, (73.7±41.6) mL] (P=0.067, P=0.201). (3) The total drainage volume in 72 hours after operation in PRE group [(728.1±505.7) mL] was significantly higher than that of POST group [(596.4±373.5) mL] (P=0.005), while there were no significant differences between the two groups in total postoperative drainage volume [(1,066.8±1,314.6) mL vs (907.8±999.8) mL, P=0.203]. (4) There were no significant differences between the two groups in pulmonary embolism incidence (1.785% vs 0.019%, P=0.525) and postoperative bleeding rates (1.785% vs 0.039%, P=0.300). (5) There were no significant differences between PRE group and POST group in subcutaneous emphysema incidence (1.785% vs 1.581%, P=0.989) and pulmonary infection rates (14.285% vs 6.324%, P=0.085).

CONCLUSIONS

The clinical value of preoperative prophylactic anticoagulation is equal to postoperative prophylactic anticoagulation for lung cancer patients.

[Establishment and Optimization of Enhanced Recovery after Surgery System for Lung Cancer]

加速康复外科（enhanced recovery after surgery, ERAS）理念应用于不同疾病及学科均有其相应的关键技术及流程与体系。肺癌微创外科的核心是加速肺康复（enhanced lung recovery after surgery, ELRAS），而加速肺康复的关键技术是气道管理和肺保护。气道管理和肺保护的实现需要医、护、康一体及多学科协作，从而形成肺癌患者加速肺康复的完整体系。主要包括以下几方面：一是ERAS方案实施的各个环节均有准确、客观的评估体系；二是ERAS方案简单、易行且具有可重复性；三是ERAS方案临床应用效果具有精准严谨评价体系；四是以问题为导向的团队架构。总之，加速肺康复外科体系需要在临床实践中不断优化与完善。

Effects of degree of pulmonary fissure completeness on major in-hospital outcomes after video-assisted thoracoscopic lung cancer lobectomy: a retrospective-cohort study

Background

To evaluate the clinical significance of degree of pulmonary fissure completeness (PFC) on major in-hospital outcomes following video-assisted thoracoscopic (VATS) lobectomy for non-small-cell lung cancer (NSCLC).

Materials and methods

We carried out a single-center retrospective analysis on the prospectively maintained database at our unit between August 2014 and October 2015. Patients were divided into two groups based on their fissure sum average (FSA). Patients with FSA >1 (1< FSA ≤3) were considered to have incomplete pulmonary fissures (group A), while patients with FSA of 0–1 were considered to have complete pulmonary fissures (group B). Demographic differences in perioperative characteristics and surgical outcomes between these two groups were initially assessed. Then, a multivariate logistic-regression analysis was further conducted to identify the independent predictors for major in-hospital outcomes.

Results

A total of 563 patients undergoing VATS lobectomy for NSCLC were enrolled. There were 190 patients in group A and 373 patients in group B. The overall morbidity and mortality rates of our cohort were 30.6% and 0.5%, respectively. Group A patients had a significantly higher overall morbidity rate than group B patients (42.1% vs 24.7%, P<0.001). Both minor morbidity (40.5% vs 22%, P<0.001) and major morbidity (11.1% vs 5.6%, P=0.021) rates in group A patients were also significantly higher than group B patients. No significant difference was observed in mortality rate between these two groups (1.1% vs 0.3%, P=0.26). The incomplete degree of PFC was significantly correlated with length of stay and chest-tube duration (log-rank P<0.001) after surgery. Finally, the incomplete degree of PFC was found to be predictive of overall morbidity (OR 2.08, P<0.001), minor morbidity (OR 2.39, P<0.001), and major morbidity (OR 2.06, P=0.031) by multivariate logistic-regression analyses.

Conclusion

Degree of PFC is an excellent categorical predictor for both major and minor morbidity after VATS lobectomy for NSCLC.

[Enhanced Lung Recovery after Surgery, Is It A Necessary for Precision Therapy?]

背景与目的

绿原酸类物质可通过调节细胞周期、诱导凋亡、抑制细胞生长等途径产生抗癌作用，Notch信号通路与人类许多肿瘤都存在密切的关系，本研究旨在探讨绿原酸通过Notch1信号通路控制非小细胞肺癌细胞凋亡的作用机制，为临床应用以及Notch1靶向药物的研究提供依据。

方法

MTT法检测不同浓度的绿原酸对非小细胞肺癌细胞系A549细胞形态和细胞增殖的影响；流式细胞仪检测绿原酸对A549细胞的凋亡和细胞周期的影响；建立A549细胞的裸鼠荷瘤模型；测量肿瘤大小和重量；实时荧光定量PCR法检测Notch信号通路相关因子的mRNA表达水平；免疫印迹法检测Notch信号通路相关因子的蛋白表达水平。

结果

绿原酸抑制A549细胞增殖，诱导A549细胞凋亡，增加细胞G₂期/M期细胞百分比增加（P < 0.05），并且呈现剂量依赖趋势。在A549细胞的裸鼠荷瘤模型中，实验组肿瘤大小和体积明显小于对照组，差异具有统计学意义（P < 0.01）。试验组Notch1、VEGF、Delta4、HES1、HEY1 mRNA表达量较对照组明显减少（P < 0.05）。实验组Notch1蛋白明显减少，PTEN、p-PTEN、p-AKT明显增加（P < 0.05）。

结论

在动物水平，绿原酸可能通过Notch1信号通路调控非小细胞肺癌的凋亡，可能是通过减少VEGF的表达，下调Delta 4水平，从而抑制Notch1信号通路的活化。Notch1信号通路可能通过PTEN与PI3K/AKT通路存在交叉调控作用。