Prediction of visceral pleural invasion of clinical stage I lung adenocarcinoma using thoracoscopic images and deep learning

PURPOSE

To develop deep learning models using thoracoscopic images to identify visceral pleural invasion (VPI) in patients with clinical stage I lung adenocarcinoma, and to verify if these models can be applied clinically.

METHODS

Two deep learning models, one based on a convolutional neural network (CNN) and the other based on a vision transformer (ViT), were applied and trained via 463 images (VPI negative: 269 images, VPI positive: 194 images) captured from surgical videos of 81 patients. Model performances were validated via an independent test dataset containing 46 images (VPI negative: 28 images, VPI positive: 18 images) from 46 test patients.

RESULTS

The areas under the receiver operating characteristic curves of the CNN-based and ViT-based models were 0.77 and 0.84 (p = 0.304), respectively. The accuracy, sensitivity, specificity, and positive and negative predictive values were 73.91, 83.33, 67.86, 62.50, and 86.36% for the CNN-based model and 78.26, 77.78, 78.57, 70.00, and 84.62% for the ViT-based model, respectively. These models' diagnostic abilities were comparable to those of board-certified thoracic surgeons and tended to be superior to those of non-board-certified thoracic surgeons.

CONCLUSION

The deep learning model systems can be utilized in clinical applications via data expansion.

The International Association for the Study of Lung Cancer (IASLC) Staging Project for Lung Cancer: Recommendation to Introduce Spread Through Air Spaces as a Histologic Descriptor in the Ninth Edition of the TNM Classification of Lung Cancer. Analysis of 4061 Pathologic Stage I NSCLC

INTRODUCTION

Spread through air spaces (STAS) consists of lung cancer tumor cells that are identified beyond the edge of the main tumor in the surrounding alveolar parenchyma. It has been reported by meta-analyses to be an independent prognostic factor in the major histologic types of lung cancer, but its role in lung cancer staging is not established.

METHODS

To assess the clinical importance of STAS in lung cancer staging, we evaluated 4061 surgically resected pathologic stage I R0 NSCLC collected from around the world in the International Association for the Study of Lung Cancer database. We focused on whether STAS could be a useful additional histologic descriptor to supplement the existing ones of visceral pleural invasion (VPI) and lymphovascular invasion (LVI).

RESULTS

STAS was found in 930 of 4061 of the pathologic stage I NSCLC (22.9%). Patients with tumors exhibiting STAS had a significantly worse recurrence-free and overall survival in both univariate and multivariable analyses involving cohorts consisting of all NSCLC, specific histologic types (adenocarcinoma and other NSCLC), and extent of resection (lobar and sublobar). Interestingly, STAS was independent of VPI in all of these analyses.

CONCLUSIONS

These data support our recommendation to include STAS as a histologic descriptor for the Ninth Edition of the TNM Classification of Lung Cancer. Hopefully, gathering these data in the coming years will facilitate a thorough analysis to better understand the relative impact of STAS, LVI, and VPI on lung cancer staging for the Tenth Edition TNM Stage Classification.

Prognostic Analysis of Stage I Non-Small Cell Lung Cancer Abutting Adjacent Structures on Preoperative Computed Tomography

Background

Early non-small cell lung cancer (NSCLC) that abuts adjacent structures requires careful evaluation due to its potential impact on postoperative outcomes and prognosis. We examined stage I NSCLC with invasion into adjacent structures, focusing on the prognostic implications after curative surgical resection.

Methods

We retrospectively analyzed the records of 796 patients who underwent curative surgical resection for pathologic stage IA/IB NSCLC (i.e., visceral pleural invasion only) at a single center from 2008 to 2017. Patients were classified based on tumor abutment and then reclassified by the presence of visceral pleural invasion. Clinical characteristics, pathological features, and survival rates were compared.

Results

The study included 181 patients with abutting NSCLC (22.7% of all participants) and 615 with non-abutting tumors (77.3%). Those with tumor abutment exhibited higher rates of non-adenocarcinoma (26.5% vs. 9.9%, p<0.01) and visceral/lymphatic/vascular invasion (30.4%/33.1%/12.7% vs. 8.5%/22.4%/5.7%, respectively; p<0.01) compared to those without abutment. Multivariable analysis identified lymphatic invasion and male sex as risk factors for overall survival (OS) and disease-free survival (DFS) in stage I NSCLC measuring 3 cm or smaller. Age, smoking history, vascular invasion, and recurrence emerged as risk factors for OS, whereas the presence of non-pure ground-glass opacity was a risk factor for DFS.

Conclusion

NSCLC lesions 3 cm or smaller that abut adjacent structures present higher rates of various risk factors than non-abutting lesions, necessitating evaluation of tumor invasion into adjacent structures and lymph node metastasis. In isolation, however, the presence of tumor abutment without visceral pleural invasion does not constitute a risk factor.

Pleural Carcinoembryonic Antigen and Maximum Standardized Uptake Value as Predictive Indicators of Visceral Pleural Invasion in Clinical T1N0M0 Lung Adenocarcinoma

Background

Visceral pleural invasion (VPI) is a poor prognostic factor that contributes to the upstaging of early lung cancers. However, the preoperative assessment of VPI presents challenges. This study was conducted to examine intraoperative pleural carcinoembryonic antigen (pCEA) level and maximum standardized uptake value (SUVmax) as predictive markers of VPI in patients with clinical T1N0M0 lung adenocarcinoma.

Methods

A retrospective review was conducted of the medical records of 613 patients who underwent intraoperative pCEA sampling and lung resection for non-small cell lung cancer. Of these, 390 individuals with clinical stage I adenocarcinoma and tumors ≤30 mm were included. Based on computed tomography findings, these patients were divided into pleural contact (n=186) and non-pleural contact (n=204) groups. A receiver operating characteristic (ROC) curve was constructed to analyze the association between pCEA and SUVmax in relation to VPI. Additionally, logistic regression analysis was performed to evaluate risk factors for VPI in each group.

Results

ROC curve analysis revealed that pCEA level greater than 2.565 ng/mL (area under the curve [AUC]=0.751) and SUVmax above 4.25 (AUC=0.801) were highly predictive of VPI in patients exhibiting pleural contact. Based on multivariable analysis, pCEA (odds ratio [OR], 3.00; 95% confidence interval [CI], 1.14-7.87; p=0.026) and SUVmax (OR, 5.25; 95% CI, 1.90-14.50; p=0.001) were significant risk factors for VPI in the pleural contact group.

Conclusion

In patients with clinical stage I lung adenocarcinoma exhibiting pleural contact, pCEA and SUVmax are potential predictive indicators of VPI. These markers may be helpful in planning for lung cancer surgery.

Development and validation of 18F-FDG PET/CT radiomics-based nomogram to predict visceral pleural invasion in solid lung adenocarcinoma

OBJECTIVES

This study aimed to establish a radiomics model based on 18F-FDG PET/CT images to predict visceral pleural invasion (VPI) of solid lung adenocarcinoma preoperatively.

METHODS

We retrospectively enrolled 165 solid lung adenocarcinoma patients confirmed by histopathology with 18F-FDG PET/CT images. Patients were divided into training and validation at a ratio of 0.7. To find significant VPI predictors, we collected clinicopathological information and metabolic parameters measured from PET/CT images. Three-dimensional (3D) radiomics features were extracted from each PET and CT volume of interest (VOI). Receiver operating characteristic (ROC) curve was performed to determine the performance of the model. Accuracy, sensitivity, specificity and area under curve (AUC) were calculated. Finally, their performance was evaluated by concordance index (C-index) and decision curve analysis (DCA) in training and validation cohorts.

RESULTS

165 patients were divided into training cohort (n = 116) and validation cohort (n = 49). Multivariate analysis showed that histology grade, maximum standardized uptake value (SUVmax), distance from the lesion to the pleura (DLP) and the radiomics features had statistically significant differences between patients with and without VPI (P < 0.05). A nomogram was developed based on the logistic regression method. The accuracy of ROC curve analysis of this model was 75.86% in the training cohort (AUC: 0.867; C-index: 0.867; sensitivity: 0.694; specificity: 0.889) and the accuracy rate in validation cohort was 71.55% (AUC: 0.889; C-index: 0.819; sensitivity: 0.654; specificity: 0.739).

CONCLUSIONS

A PET/CT-based radiomics model was developed with SUVmax, histology grade, DLP, and radiomics features. It can be easily used for individualized VPI prediction.

Upstaged from cT1a-c to pT2a lung cancer, related to visceral pleural invasion patients, after segmentectomy: is it an indication to complete resection to lobectomy?

OBJECTIVES

Segmentectomy may be indicated for T1a-cN0 non-small-cell lung cancer. However, several patients are upstaged pT2a at final pathological examination due to visceral pleural invasion (VPI). As resection is usually not completed to lobectomy, this may raise issue of potential worse prognosis. The aim of this study is to compare prognosis of VPI upstaged cT1N0 patients operated on by segmentectomy or lobectomy.

METHODS

Data of patients from 3 centres were analysed. This was a retrospective study, of patients operated on from April 2007 to December 2019. Survival and recurrence were assessed by Kaplan-Meier method and cox regression analysis.

RESULTS

Lobectomy and segmentectomy were performed in 191 (75.4%) and in 62 (24.5%) patients, respectively. No difference in 5-year disease-free survival rate between lobectomy (70%) and segmentectomy (64.7%) was observed. There was no difference in loco-regional recurrence, nor in ipsilateral pleural recurrence. The distant recurrence rate was higher (P = 0.027) in the segmentectomy group. Five-year overall survival rate was similar for both lobectomy (73%) and segmentectomy (75.8%) groups. After propensity score matching, there was no difference in 5-year disease-free survival rate (P = 0.27) between lobectomy (85%) and segmentectomy (66.9%), and in 5-year overall survival rate (P = 0.42) between the 2 groups (lobectomy 76.3% vs segmentectomy 80.1%). Segmentectomy was not impacting neither recurrence, nor survival.

CONCLUSIONS

Detection of VPI (pT2a upstage) in patients who underwent segmentectomy for cT1a-c non-small-cell lung cancer does not seem to be an indication to extend resection to lobectomy.

The location of visceral pleural invasion in stage IB patients with non-small cell lung cancer: Comparison and prognosis

OBJECTIVES

Recently, early-stage lung cancer has been drawing more attention, especially in screening and treatment. Visceral pleural invasion in stage IB cancer is considered as risk factor for poor prognosis. Herein, we aimed to study the distinction between the different locations of visceral pleural invasion.

METHODS

In this retrospective cohort study, we summarized 58,242 patient cases that underwent surgery from 2015 to 2018 at Shanghai Chest Hospital. Of those patients, 389 met the inclusion criteria. Patients with PL3 pleural invasion were excluded. The patients were dichotomized into the interlobar pleural and peripheral pleural groups. The outcomes measured were overall survival (OS) and recurrence-free survival (RFS) rates.

RESULTS

According to the initial analysis, the baseline characteristics of the two groups were largely balanced. In multivariate Cox analyses, we found that the location of visceral pleural invasion was not a risk factor for prognosis in the overall population (RFS: P = 0.726, OS: P = 0.599). However, we discovered that relative to patients with peripheral pleura invasion, those with interlobar pleura invasion, PL1 invasion, lesions with greater than 3 cm solid components, and those who underwent segmentectomy had a compromised prognosis. Additionally, tumors larger than 3 cm in size with interlobar pleura invasion showed poor prognosis in patients who underwent postoperative chemotherapy.

CONCLUSIONS

In most cases, the location of tumor invasion did not worsen the postoperative prognosis of stage IB non-small cell lung cancer patients with visceral pleural invasion. However, interlobar pleural invasion still had some potential risks compared to that of peripheral pleural invasion.

Postoperative tegafur-uracil for stage I lung adenocarcinoma: first real-world data with an exploratory subgroup analysis

PURPOSE

The effect of postoperative tegafur-uracil on overall survival (OS) after resection of stage I adenocarcinoma has been shown in clinical trials. The purpose of this study was to investigate whether findings from randomized trials of adjuvant tegafur-uracil are reproducible in a real-world setting.

METHODS

A retrospective cohort study was performed using a multi-institutional database that included all patients who underwent complete resection of pathological stage I adenocarcinoma between 2014 and 2016. Survival outcomes for patients managed with and without tegafur-uracil were analyzed using the Kaplan-Meier method and a Cox proportional hazards model for the whole patient cohort and in a selected cohort based on eligibility criteria of a previous randomized trial. Propensity score matching was used to adjust for confounding effects.

RESULTS

After propensity score matching, the hazard ratios for OS were 0.57 (95% confidence interval (CI) 0.29-1.14, P = 0.11) in the whole cohort and 0.69 (95% CI 0.32-1.50, P = 0.35) in the selected cohort.

CONCLUSIONS

The effects of tegafur-uracil in this retrospective study appear to be consistent with those found in randomized clinical trials. These effects may be maximized in patients aged from 45 to 75 years.

[Research Progress of Relationship between Pleural Deformation and Visceral Pleural Invasion in Lung Cancer Manifesting as Ground-glass Opacity]

Visceral pleural invasion (VPI) is one of the negative prognostic factors of non-small cell lung cancer (NSCLC). With the popularization of computed tomography (CT) screening for lung cancer, more and more ground-glass nodule (GGN) have been found. However, it remains unclear whether the relationship between the pleural deformation of lung cancer manifesting as ground-glass opacity (GGO) and VPI affects the effect of sub-lobectomy, which is reviewed in this paper.
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The prognosis of different types of pleural tags based on radiologic-pathologic comparison

Objectives

There are increasing numbers of studies of pleural tags (PTs). The purpose of this case series was to classify the PTs in patients with peripheral pulmonary adenocarcinoma based on radiologic-pathologic comparison and to study the prognosis.

Methods

The clinical, imaging, pathological and prognostic data of 161 patients with peripheral pulmonary adenocarcinoma in three hospitals were analyzed retrospectively. We classified PTs using computed tomography (CT) for pathologic comparison.

Results

According to the relationship between tumors and pleural on CT images, PTs were classified into four types: type 1, one or more linear pleural tag; type 2, one or more linear pleural tag with soft tissue component at the pleural end; type 3, one soft tissue cord-like pleural tag; type 4, directly abutting the visceral pleura, pulling or pushing the visceral pleura. In these PTs, the incidence of visceral pleural invasion (VPI) was high in type 2 (46.88%) and type 3 (56.41%) of PTs. Our prognostic analysis showed that micropapillary or solid histological subtype (HR = 5.766, 95% CI: 1.435–23.159, P = 0.014) and type 3 of PTs (HR = 11.058, 95% CI: 1.349–90.623, P = 0.025) were two independent risk factors for tumor progression.

Conclusions

PT is a risk factor for poor prognosis in patients with peripheral pulmonary adenocarcinoma, the presence of which on CT images can remind us to provide patients with a more reasonable treatment.

Non-small Cell Lung Cancer Surpassing the Elastic Layer Should Remain Classified as pT2a

We aimed to evaluate the prognostic value of visceral pleural invasion on the survival of node-negative non-small cell lung cancer ≤3 cm using a large cohort. The Kaplan-Meier method was used to compare overall survival (OS); competing risk analysis with Fine-Gray's test was used to compare cancer- specific survival between groups. The least absolute shrinkage and selection operator penalized Cox regression model was used to identify prognostic factors. In total, 9725 eligible cases were included in this study, and they were separated into 3 groups: tumor invasion beneath the elastic layer (PL0), 8837 cases; tumor invasion surpassing the elastic layer (PL1), 505 cases; and tumor invasion to the visceral pleural surface (PL2), 383 cases. Visceral pleural invasion was more likely to occur in poorly differentiated and larger-sized tumors. Survival curves displayed that PL0 conferred better survival rates than PL1 and PL2, and PL1 achieved outcomes equivalent to those of PL2. Tumor size and histology subset analyses further corroborated this conclusion. Least absolute shrinkage and selection operator -penalized Cox regression analysis confirmed that PL status was an independent prognostic factor for both OS and cancer- specific survival. This study supported the notion that in node-negative non-small cell lung cancer ≤3 cm, PL1 patients should remain classified as pT2a, which could improve staging accuracy.

A risk classification system predicting the cancer-specific survival for postoperative stage IB non-small-cell lung cancer patients without lymphovascular and visceral pleural invasion

BACKGROUND

This study aims to formulate a risk classification system predicting the cancer-specific survival (CSS) for postoperative stage IB NSCLC patients without lymphovascular (LVI) and visceral pleural (VPI) invasion to guide treatment decision making and assist patient counseling.

METHOD

A total of 4,238 patients were included in this study. Patients were randomly divided into training and validation cohorts (7:3). The risk factors were identified by Cox regression. Concordance index (C-index), calibration curves, and Decision Curve Analyses (DCAs) were used to evaluate the performance of nomogram. We applied X-tile to calculate the optimal cut-off points and develop a risk classification system. The Kaplan-Meier method was conducted to evaluate CSS in different risk groups, and the significance was evaluated by log-rank test.

RESULT

Among the 4,238 patients, 1,014(23.9%) suffered cancer-specific death. In the training cohort, univariable and multivariable Cox regression analyses revealed that age, gender, pathological subtype, grade, tumor size, the number of removed lymph nodes and surgical type were significantly associated with CSS. According to these results, the nomogram was formulated. The C-index of the prediction model was 0.755 in the training cohort (95%CI: 0.733-0.777) and 0.726 (95%CI: 0.695-0.757) in the validation cohort. The calibration curves in training and validation cohort exhibited good agreement between the predictions and actual observations. The Decision Curve Analyses (DCAs) showed net benefit can be achieved for nomogram. A risk classification system was further constructed that could perfectly classify patients into three risk groups.

CONCLUSION

In this study, we constructed a nomogram to support individualized evaluation of CSS and a risk classification system to identify patients in the different risk groups in stage IB NSCLC patients without LVI and VPI. These tools could be useful in guiding treatment decision making and assisting patient counseling.

Clinical significance of visceral pleural and lymphovascular invasion in surgically resected adenosquamous lung cancer

OBJECTIVES

The aim of this study was to assess the relationship between visceral pleural invasion (VPI), lymphovascular invasion (LVI) and other clinicopathological characteristics and their prognostic impact on surgically resected adenosquamous carcinoma (ASC).

METHODS

We retrospectively reviewed 256 patients with radically resected ASC between January 2010 and December 2015. Patients were divided into 2 groups: those with VPI and those with LVI. The effects of VPI and LVI on disease-free survival and overall survival were evaluated, further stratified by tumour size and lymph node status.

RESULTS

Finally, 213 patients with ASC were enrolled in our study. VPI was correlated with tumour location (P < 0.001), pT stage (P < 0.001) and pN stage (P = 0.012). LVI was related to age (P = 0.005) and pN stage (P = 0.003). Both VPI and LVI were adverse prognostic factors for disease-free survival (P = 0.008, P = 0.028) and overall survival (P = 0.005, P = 0.009) using the Kaplan-Meier method. In multivariable analysis only, VPI was an independent risk factor for disease-free survival [hazard ratio (HR) 0.61, 95% confidence interval (CI) 0.42-0.87; false discovery rate, adjusted P = 0.020] and overall survival (HR 0.60, 95% CI 0.42-0.86; false discovery rate, adjusted P = 0.017). When the prognostic value of VPI was stratified by tumour size and lymph node status, we observed that only patients with VPI in tumours ≤4 cm and patients with N0 status had a worse prognosis than those without visceral invasion (P < 0.05).

CONCLUSIONS

VPI and LVI were poor prognostic factors in patients with ASC, but only VPI was an independent factor for survival, especially in patients with tumours ≤4 cm and pN0 status.

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).

Clinical Value of 18F-FDG PET/CT in Prediction of Visceral Pleural Invasion of Subsolid Nodule Stage I Lung Adenocarcinoma

RATIONALE AND OBJECTIVES

This study investigated the utility of ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) for predicting visceral pleural invasion (VPI) of subsolid nodule (SSN) stage I lung adenocarcinoma.

MATERIALS AND METHODS

A retrospective analysis of ¹⁸F-FDG PET/CT data from 65 postsurgical cases with surgical pathology-confirmed SSN lung adenocarcinoma identified significant VPI predictors using multivariate logistic regression.

RESULTS

Nodule and solid component sizes, solid component-to-tumor ratios, pleural indentations, distances between nodules and pleura, and maximum standardized uptake values (SUVmax) differed significantly between VPI-positive (n = 30) and VPI-negative (n = 35) cases on univariate analysis. The distance between the nodule and pleura and SUVmax were significant independent VPI predictors on multivariate analysis. Areas under the curve of the distance between the nodule and pleura and SUVmax on receiver operating characteristic curves were 0.76 and 0.79, respectively; both factors were 0.90. The area under the curve of combined predictors was significantly superior to the distance between the nodule and pleura only but not SUVmax alone. The threshold of the distance between the nodule and pleura, to predict VPI was 4.50 mm, with 96.67% sensitivity, and 57.14% specificity. The threshold of SUVmax to predict VPI was 1.05, with 100% sensitivity and 60% specificity. The sensitivity and specificity of model 2 using the independent predictive factors were 96.67%, and 71.43%, respectively.

CONCLUSION

Distance between the nodule and pleura and SUVmax are independent predictors of VPI in SSN stage I lung adenocarcinoma. Further, combining these factors improves their predictive ability.

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.

Prognostic value of visceral pleural invasion in the stage pT1-2N2M0 non-small cell lung cancer: A study based on the SEER registry

BACKGROUND

Visceral pleural invasion (VPI) is considered an adverse prognostic factor in non-small cell lung cancer (NSCLC). However, the prognostic roles of VPI in Ⅲ/N2 NSCLC remain controversial. Therefore, this study aims to evaluate the prognostic value of VPI in patients with postoperative stage pT_1-2N₂M₀ NSCLC.

METHODS

Using the Surveillance, Epidemiology, and End Results (SEER) database, we screened for patients with stage T1-2N2M0 NSCLC who received surgery from 2010 to 2015. To reduce baseline differences between Non-VPI group and VPI group, two-to-one propensity score matching (PSM) was performed. Cox proportional hazards regression was used to identify factors associated with survival. Overall survival (OS) was between the Non-VPI group and the VPI+ group by the Kaplan-Meier analysis.

RESULTS

We identified 1374 postoperative NSCLC patients with stage pT_1-2N₂M₀. The majority of cases (N = 1047, 76.8%) are Non-VPI patients. The factors associated with VPI+ group included white race (P < 0.0001), and adenocarcinoma (P < 0.0001). When analyzed in the total study population, VPI status remained a significant independent predictor of worse OS compared with the Non-VPI group (HR, 1.343; 95% CI, 1.083-1.665 [P=0.007]). Besides, in a subgroup analysis by VPI status, the results showed that patients without treatment exhibited a higher risk level in the Non-VPI group (P<0.0001). However, we did not find statistically significant differences among treatments in the VPI+ group (P=0.199). Mean survival time was 49.5 months (95% CI: 45.7-53.3 months) for chemotherapy alone in the Non-VPI group, compared with 41.2 months (95% CI: 35.8-46.6 months) in VPI+ groups. In both the VPI group and the non-VPI group, there is no statistical difference between adjuvant chemotherapy combined with PORT and chemotherapy alone.

CONCLUSION

This study emphasizes that the presence of VPI is a poor prognostic factor, even in patients with Ⅲ/N2 NSCLC. As the study shows, chemotherapy significantly improved overall survival of patients with postoperative stage pT_1-2N₂M₀ NSCLC, especially for Non-VPI patients. However, the significance of PORT is still worth further exploration.

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.

Use of Autofluorescence to Intraoperatively Diagnose Visceral Pleural Invasion From Frozen Sections in Patients With Lung Adenocarcinoma 2 cm or Less

OBJECTIVES

We prospectively investigate the accuracy of frozen sections for diagnosing visceral pleural invasion (VPI) by autofluorescence and evaluated its usefulness in sublobar resection.

METHODS

We included patients with lung adenocarcinoma 2 cm or less to evaluate the diagnostic performance of autofluorescence for VPI in frozen sections via a fluorescence microscope. Furthermore, the impact of VPI on patients treated with sublobar resection was assessed in another cohort.

RESULTS

A total of 112 patients were enrolled. The accuracy, sensitivity, and specificity of autofluorescence for VPI diagnosis was 95.5%, 86.8%, and 100%, respectively. Sublobar resection was an independent risk factor for recurrence in patients with lung adenocarcinomas 2 cm or less with VPI positivity (hazard ratio, 3.30; P = .023), whereas it was not in those with VPI negativity.

CONCLUSIONS

Using autofluorescence in frozen sections appears to be an accurate method for diagnosing VPI, which is helpful for surgical decision making.

Contact of a tumour with the pleura is not associated with regional recurrence following stereotactic ablative radiotherapy for early stage non-small cell lung cancer

BACKGROUND AND PURPOSE

The aim was to investigate the incidence of isolated regional failure following stereotactic ablative radiotherapy (SABR) and risk factors for recurrence.

MATERIALS AND METHODS

Early stage non-small cell lung cancer (NSCLC) patients treated with SABR were included in this retrospective cohort study, with isolated regional recurrence (IRR) as primary endpoint, distant recurrence (DR) and overall survival (OS) as secondary endpoints. Survival analyses were performed using the cumulative incidence function (IRR and DR) or the Kaplan-Meier method (OS) and Cox proportional hazards modelling for univariate and multivariate analyses. The prognostic effect of contact between the tumour and the pleura was investigated using the CT scans used for SABR planning.

RESULTS

A total of 554 patients were included, of whom 494 could be analysed for IRR. The median follow-up for surviving patients was 48.1 months. Twenty-one patients developed an IRR (4%). The cumulative incidence of IRR and DR after 1-, 2-, and 5 years was 2%, 3%, 7% and 8%, 15% and 21%, respectively. Two year OS was 71%. The presence and type of pleural contact was not associated with any of the studied outcomes.

CONCLUSION

The presence, type and length of pleural contact as surrogate for visceral pleural invasion were not predictive for outcome. Further studies focussing on risk factors for occult nodal involvement, (I)RR, distant metastases and mortality in early stage NSCLC are warranted for the development of risk adapted diagnostic, treatment and follow-up strategies as more younger, operable and fitter patients receive SABR.

Ipsilateral pleural recurrence after diagnostic transthoracic needle biopsy in pathological stage I lung cancer patients who underwent curative resection

OBJECTIVES

The relationship between transthoracic needle biopsy (TTNB) and pleural recurrence of cancer after curative lung resection remains unclear. We aimed to assess whether TTNB increases the ipsilateral pleural recurrence (IPR) rate and identify other potential risk factors for pleural recurrence after surgery.

MATERIALS AND METHODS

This retrospective study included 392 patients with p-stage I non-small cell lung cancer with solid or part-solid nodules after curative lung resection in 2009-2010. Imbalances among the characteristics were adjusted using an inverse probability-weighted method based on propensity scoring. Multivariate Cox's regression analysis and the Kaplan-Meier method were used to determine independent risk factors for IPR.

RESULTS

A total of 243 (62%) patients received TTNB, while 149 (38%) underwent an alternate, or no, diagnostic technique. IPR was significantly more frequent in the TTNB group (p=0.004), while total recurrence was similar between the groups (p=0.098). After applying the weighted model, diagnostic TTNB (hazard ratio [HR], 5.27; 95% confidence interval [CI], 1.49-18.69; p=0.010), microscopic visceral pleural invasion (HR, 2.76; 95% CI, 1.08-7.01; p=0.033) and microscopic lymphatic invasion (HR, 3.25; 95% CI, 1.30-8.10; p=0.012) were associated with an increased frequency of IPR. Among patients who received TTNB, microscopic lymphatic invasion was a risk factor for IPR (HR, 2.74; 95% CI, 1.10-6.79; p=0.030).

CONCLUSIONS

The diagnostic TTNB procedure is associated with pleural recurrence but may be unrelated to overall recurrence-free survival in early lung cancer. Moreover, microscopic lymphatic invasion could be a risk factor for pleural recurrence. TTNB should be carefully considered before lung resection and close follow-up to detect if pleural recurrence is needed.