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OBJECTIVES Invasive mucinous adenocarcinoma exhibits distinct prognostic outcomes compared to non-mucinous adenocarcinoma (ADC). This study investigated and compared the clinical outcomes and prognostic factors of invasive mucinous and non-mucinous ADC patients. METHODS This retrospective study included patients who underwent curative surgery for ADC between 2011 and 2021. Patient characteristics were balanced using propensity score matching. Cumulative incidence was analysed to evaluate cancer recurrence incidence, and the Kaplan–Meier method was used to calculate overall survival (OS) for each group. RESULTS A total of 6101 patients were included. After matching, the non-mucinous group and mucinous groups comprised 798 and 408 patients, respectively. The patients in the mucinous group had a lower recurrence incidence than those in the non-mucinous group (P  = 0.014). The recurrence incidence in the mucinous group was between those of grades 1 (P  = 0.011) and 2 (P  = 0.012) and the OS rates were comparable to those of grades 2 (P  = 0.6) and 3 (P  = 0.2). Multivariable analysis revealed that the maximal standardized uptake value [hazard ratio (HR): 1.13, P  = 0.11] and progressed pathological stages (pStage II, HR: 3.9, P  = 0.028; pStage III, HR: 8.33, P  = 0.038) served as adverse prognostic factors for the mucinous group. CONCLUSIONS Patients with mucinous ADC demonstrated lower recurrence incidence and similar OS rates compared to those with non-mucinous ADC. The recurrence incidence of mucinous ADC was between those of International Association for the Study of Lung Cancer grades 1 and 2, with the OS rates comparable to those of grades 2 and 3. CLINICAL REGISTRATION NUMBER None. [ABSTRACT FROM AUTHOR]

OBJECTIVES In patients with oligometastatic non-small-cell lung cancer (NSCLC), systemic therapy in combination with local ablative treatment of the primary tumour and all metastatic sites is associated with improved prognosis. For patient selection and treatment allocation, further knowledge about the molecular characteristics of the oligometastatic state is necessary. Here, we performed a genetic characterization of primary NSCLC and corresponding brain metastases (BM). METHODS We retrospectively identified patients with oligometastatic NSCLC and synchronous (<3 months) or metachronous (>3 months) BM who underwent surgical resection of both primary tumour and BM. Mutation profiling of formalin-fixed paraffin-embedded tumour cell blocks was performed by targeted next-generation sequencing using the Oncomine Focus Assay panel. RESULTS Sequencing was successful in 46 paired samples. An oncogenic alteration was present in 31 primary tumours (67.4%) and 40 BM (86.9%). The alteration of the primary tumours was preserved in the corresponding BM in 29 out of 31 cases (93.5%). The most prevalent oncogenic driver in both primary tumours and BM was a KRAS (Kirsten rat sarcoma viral oncogene) mutation (s  = 21). In 16 patients (34.8%), the BM harboured additional oncogenic alterations. The presence of a private genetic alteration in the BM was an independent predictor of shorter overall survival. CONCLUSIONS In oligometastatic NSCLC, BM retain the main genetic alterations of the primary tumours. Patients may profit from targeted inhibition of mutated KRAS. Additional private genetic alterations in the BM are dismal. [ABSTRACT FROM AUTHOR]

OBJECTIVES The aim of this study was to assess the self-reported current dyspnoea and perioperative changes of dyspnoea in long-term survivors after minimally invasive segmentectomy or lobectomy for early-stage lung cancer. METHODS Cross-sectional telephonic survey of patients alive and disease-free as of March 2023, with pathologic stage IA1–2, non-small-cell lung cancer, assessed 1–5 years after minimally invasive segmentectomy or lobectomy (performed from January 2018 to January 2022). Current dyspnoea level: Baseline Dyspnoea Index score <10. Perioperative changes of dyspnoea were assessed using the Transition Dyspnoea Index. A negative Transition Dyspnoea Index focal score indicates perioperative deterioration in dyspnoea. Mixed effect models were used to examine demographic, medical and health-related correlates of current dyspnoea and changes in dyspnoea level. RESULTS A total of 152 of 236 eligible patients consented or were available to respond to the telephonic interview(67% response rate): 90 lobectomies and 62 segmentectomies. The Baseline Dyspnoea Index score was lower (greater dyspnoea) in lobectomy patients (median 7, interquartile range 6–10) compared to segmentectomy (median 9, interquartile range 6–11), P  = 0.034. 70% of lobectomy patients declared to have a current dyspnoea vs 53% after segmentectomy, P  = 0.035. 82% of patients after lobectomy reported a perioperative deterioration in their dyspnoea compared to 57% after segmentectomy, P  = 0.002. Mixed effect logistic regression analysis adjusting for patient-related factors and time elapsed from operation showed that segmentectomy was associated with a reduced risk of perioperative dyspnoea deterioration (as opposed to lobectomy) (Odds ratio (OR) 0.31, P  = 0.004). CONCLUSIONS Our findings may be valuable to inform the shared decision-making process by complementing objective data on perioperative changes of pulmonary function. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES To validate or refute the hypothesis that non-small-cell lung cancers (NSCLC) with ground-glass areas (GGA+) within the tumour on high-resolution computed tomography are associated with a more favourable prognosis than those without GGA (GGA−). METHODS We analysed data from a multicentre observational cohort study in Japan including 5005 patients with completely resected pathological stage I NSCLC, who were excluded from the Japan Clinical Oncology Group (JCOG) 0707 trial on oral adjuvant treatment during the enrolment period. The patients' medical and pathological records were assessed retrospectively by physicians and re-staged according to the 8th tumour, node, metastasis edition. RESULTS Of the 5005 patients, 2388 (48%) were ineligible for the JCOG0707 trial and 2617 (52%) were eligible but were not enrolled. A total of 958 patients (19.1%) died. Patients with GGA+ NSCLC and pathological invasion ≤3 cm showed significantly better overall survival than others. In patients with tumours with an invasive portion ≤4 cm, GGA+ was associated with better survival. The prognoses of patients with GGA+ T2a and GGA− T1c tumours were similar (5-year overall survival: 84.6% vs 83.1%, respectively). The survival with T2b or more tumours appeared unaffected by GGA, and GGA was not prognostic in these larger tumours. CONCLUSIONS Patients with GGA+ NSCLC on high-resolution computed tomography and ≤4 cm invasion size may have a better prognosis than patients with solid GGA− tumours of the same T-stage. However, the presence or absence of radiological GGA has little impact on the prognosis of patients with NSCLC with greater (>4 cm) pathological invasion. [ABSTRACT FROM AUTHOR]

This document summarizes the results of a survey conducted among European thoracic surgeons regarding their preferences for surgical approaches in early-stage lung cancer. The majority of surgeons preferred minimally invasive approaches, such as video-assisted thoracoscopic surgery (VATS), and valued the experience of the surgeon and center with the procedure. Surgeons had varying preferences for the extent of resection based on tumor size and location, with segmentectomy favored for smaller tumors and lobectomy preferred for larger tumors. The survey also explored preferences for lymph node dissection and other factors. The authors caution that the survey results should not be seen as standard of care, but rather as a reflection of current perceptions. [Extracted from the article]

Open in new tab Download slide OBJECTIVES CALGB140503, in which nodal sampling was mandated, reported non-inferior disease-free survival for patients undergoing sublobar resection (SLR) compared to lobectomy (L). Outside of trial settings, the adequacy of lymphadenectomy during SLR has been questioned. We sought to evaluate whether SLR is associated with suboptimal lymphadenectomy, differences in pathologic upstaging and survival in patients with 1.5- to 2.0-cm tumours using real-world data. MATERIALS AND METHODS Using the National Cancer Database(2018–2019), we evaluated patients with 1.5- to 2.0-cm non-small-cell lung cancer who underwent resection (sublobar versus lobectomy). We studied factors associated with nodal upstaging (logistic regression) and survival (Cox regression and Kaplan–Meier method) after propensity matching to adjust for differences among groups. RESULTS Among 3196 patients included, SLR was performed in 839 (26.3%) (of which 588 were wedge resections) and L was performed in 2357 (73.7%) patients. More patients undergoing SLR (21.7%) compared to L (2.1%) had no lymph nodes sampled (P  < 0.001). Those undergoing SLR had fewer total lymph nodes examined (4 vs 11, P  < 0.001) and were less likely to have pathologic nodal metastases (4.7% vs 9%, P  < 0.001) compared to L. Multivariable analysis identified L [adjusted odds ratio (aOR) 2.21, 95% confidence interval, 1.47–3.35] to be independently associated with pathologic N+ disease. Overall survival was not associated with the type of procedure but was significantly decreased in those with N+ disease. CONCLUSIONS Despite comparable overall survival to L, SLR is associated with suboptimal lymphadenectomy in patients with 1.5–2.0 cm non-small-cell lung cancer. Surgeons should be careful to perform adequate lymphadenectomy when performing SLR to mitigate nodal under-staging and to identify appropriate patients for systemic therapy. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Although adjuvant systemic therapy (AT) has demonstrated improved survival in patients with resected non-small-cell lung cancer (NSCLC), it remains underutilized. Recent trials demonstrating improved outcomes with adjuvant immunotherapy and targeted treatment imply that low uptake of systemic therapy in at-risk populations may widen existing outcome gaps. We, therefore, sought to determine factors associated with the underutilization of AT. METHODS The National Cancer Database (2010–2018) was queried for patients with completely resected stage II–IIIA NSCLC and stratified based on the receipt of AT. Logistic regression was used to identify factors associated with AT delivery. The Kaplan–Meier method was applied to estimate survival after propensity-matching to adjust for confounders. RESULTS Of 37 571 eligible patients, only 20 616 (54.9%) received AT. While AT rates increased over time, multivariable analysis showed that older age [adjusted odds ratio (aOR) 0.45, 95% confidence interval (CI) 0.43–0.47], male sex (aOR 0.88, 95% CI 0.85–0.93) and multiple comorbidities (aOR 0.86, 95% CI: 0.81–0.91) were associated with decreased AT. Socioeconomic factors were additionally associated with underutilization, including public insurance (aOR 0.70, 95% CI: 0.66–0.74), lower education indicators (aOR 0.93, 95% CI: 0.88–0.97) and living more than 10 miles from a treatment facility (aOR 0.89, 95% CI: 0.85–0.93). After propensity matching, receipt of adjuvant therapy was associated with improved overall survival (median 76.35 vs 47.57 months, P ≤ 0.001). CONCLUSIONS AT underutilization in patients with resected stage II–III NSCLC is associated with patient, institutional and socioeconomic factors. It is critical to implement measures to address these inequities, especially in light of newer adjuvant immunotherapy and targeted therapy treatment options which are expected to improve survival. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Non-small-cell lung cancer mortality has declined at a faster rate than incidence due to multiple factors, including changes in smoking behaviour, early detection which shifts diagnosis, and novel therapies. Limited resources require that we quantify the contribution of early detection versus novel therapies in improving lung cancer survival outcomes. METHODS Non-small-cell lung cancer patients from the Surveillance, Epidemiology, and End Results-Medicare data were queried and divided into: (i) stage IV diagnosed in 2015 (n  = 3774) and (ii) stage I–III diagnosed in 2010–2012 (n  = 15 817). Multivariable Cox-proportional hazards models were performed to assess the independent association of immunotherapy or diagnosis at stage I/II versus III with survival. RESULTS Patients treated with immunotherapy had significantly better survival than those who did not (HRadj: 0.49, 95% confidence interval: 0.43–0.56), as did those diagnosed at stage I/II versus stage III (HRadj: 0.36, 95% confidence interval: 0.35–0.37). Patients on immunotherapy had a 10.7-month longer survival than those who were not. Stage I/II patients had an average survival benefit of 34 months, compared to stage III. If 25%% of stage IV patients not on immunotherapy received it, there would be a gain of 22 292 person-years survival per 100 000 diagnoses. A switch of only 25% from stage III to stage I/II would correspond to 70 833 person-years survival per 100 000 diagnoses. CONCLUSIONS In this cohort study, earlier stage at diagnosis contributed to life expectancy by almost 3 years, while gains from immunotherapy would contribute ½ year of survival. Given the relative affordability of early detection, risk reduction through increased screening should be optimized. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Skip-N2 metastasis (N0N2), thus N2 metastasis in the absence of N1 metastasis, occurs in ∼20–30% of non-small-cell lung cancer patients. N0N2 patients have a better prognosis than continuous-N2 metastasis (N1N2) patients following surgery. However, this effect remains controversial. Therefore, we conducted a multicentre study to compare the long-term survival and disease-free interval (DFI) of N1N2- and N0N2 patients. METHODS One- and 3-year survival rates were measured. Kaplan–Meier curves and a Cox proportional hazards model assessed survival and were used to identify prognostic factors for overall survival. In addition, we performed propensity score matching (PSM) to rule out confounding factors. All patients received adjuvant chemoradiation therapy according to European guidelines. RESULTS Between January 2010 and December 2020, 218 stage IIIA/B N2 patients were included in our analysis. The Cox regression analysis revealed that N1N2 significantly influenced the overall survival rate. Before PSM, N1N2 patients showed significantly more metastatic lymph nodes (P  < 0.001) and significantly larger tumours (P  = 0.05). After PSM, baseline characteristics did not differ between groups. Before and after PSM, N0N2 patients showed significantly better 1- (P  = 0.01; P  = 0.009) and 3-year (P  < 0.001) survival rates than N1N2 patients. Furthermore, N0N2 patients showed significantly longer DFI than N1N2 patients before and after PSM (P  < 000.1). CONCLUSIONS Prior and after PSM analysis, N0N2 patients were confirmed to have better survival and DFI than N1N2 patients. Our results demonstrate that stage IIIA/B N2 patients are heterogeneous and would benefit from a more precise subdivision and differential treatment. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES This study aimed to explore the prognostic disparity among T4N0-2M0 non-small-cell lung cancer (NSCLC) patients with different T4 descriptors. METHODS T3-4N0-2M0 NSCLC patients were included. Patients were assigned to 7 subgroups: T3, T4 tumours with size larger than 70 mm (T4-size), T4 tumours with aorta/vena cava/heart invasion (T4-blood vessels), T4 tumours with vertebra invasion (T4-vertebra), T4 tumours with carina/trachea invasion (T4-carina/trachea), T4 tumours with additional tumour nodules in different lobes of ipsilateral lung (T4-add) and T4 tumours had at least 2 T4 descriptors (T4-multiple). Univariable and multivariable Cox analyses were used to explore the effect of T4 category on overall survival. Kaplan–Meier method with log-rank test was used to compare survival differences among subgroups. Propensity score matching was used to minimize the bias caused by imbalanced covariates between groups. RESULTS A total of 41 303 eligible T3-4N0-2M0 NSCLC cases were included (17 057 T3 cases and 24 246 T4 cases). There were 10 682 cases, 573 cases, 557 cases, 64 cases, 2888 cases and 9482 cases in the T4-size, T4-blood vessels, T4-vertebra, T4-carina/trachea, T4-add and T4-multiple subgroups, respectively. Multivariable Cox analyses revealed that T4-add patients had the best prognosis in the entire cohort and in several subgroups. In the matched cohort of T4-add and T4-size and T4-add and T3, the survival of T4-add patients was superior to that of T4-size patients (P  <   0.001) but was comparable to that of T3 patients (P  =   0.115). CONCLUSIONS Among NSCLC patients with different T4 descriptors, T4-add patients had the best prognosis. T4-add patients and T3 patients had similar survivals. Herein, we proposed that T4-add patients should be downstaged from T4 to T3 category. Our results served as a novel supplement to the proposals for the T category revision. [ABSTRACT FROM AUTHOR]

A frozen section on the segmental nodes should be performed in all cases (with the exception of pure GGO lesions or patient unfit for lobectomy), and in case of a positive node found at frozen section examination, the segmentectomy should be extended to lobectomy. Keywords: Segmentectomy; Sublobar resection; Non-small-cell lung cancer; Operative technique; Quality; Guidelines EN Segmentectomy Sublobar resection Non-small-cell lung cancer Operative technique Quality Guidelines 1 13 13 07/04/23 20230601 NES 230601 INTRODUCTION The recent findings from the JCOG0802 and CALGB randomized control trials [[1]] have corroborated previous observational reports series [[3], [5], [7]] showing favourable short-term and long-term results of segmentectomy in patients operated for peripheral (outer third of the lung), early-stage non-small-cell lung cancer (NSCLC) (2 cm or less). There was consensus among the panellists in this study to the statement: in case of unexpected positive station lymph nodes stations 10 or mediastinal lymph nodes node found only on the final pathological report, the patient should be referred to adjuvant chemotherapy and NOT for completion lobectomy with 79% and 89% agreement. Similarly, in a series of 1991 lepidic adenocarcinomas submitted to either lobectomy or segmentectomy, survival was significantly better after lobectomy, except in the sublobar resections subgroup associated with lymph node dissection [[50]]. In addition, some studies have shown that a larger number of sampled lymph nodes during segmentectomy is associated with a higher rate of metastatic lymph nodes (>6 nodes associated with 9.4% positive ones vs 6 or less nodes sampled associated with 1.5% positive nodes) and better survival at 5-year [[48]]. [Extracted from the article]

Open in new tab Download slide OBJECTIVES With recent improvements in surgical techniques for segmentectomy, we hypothesized that segmentectomy is feasible and more effective than wedge resection for non-small-cell lung cancer (NSCLC). We compared perioperative and oncological outcomes for segmentectomy and wedge resection. METHODS We performed a retrospective analysis of 720 patients who underwent sublobar resection (segmentectomy, 479; wedge resection, 241) for clinical stage 0 or I NSCLC from January 2017 to June 2020. An adequate surgical margin was defined as a surgical margin distance of ≥2 cm or ≥ the total tumour size. Recurrence-free survival (RFS) was estimated using the Kaplan–Meier method for clinical stage IA. RESULTS There was no significant difference in the rate of major (grade ≥III) complications between segmentectomy (1.7%) and wedge resection (1.2%) (P = 0.76). The probability of obtaining adequate surgical margins was significantly higher with segmentectomy (71.4%) versus wedge resection (59.5%) (P = 0.002), and the difference was especially prominent for clinical stage IA2 (75.3% vs 56.9%; P = 0.012). Among patients with clinical stage IA, segmentectomy significantly improved the RFS compared with wedge resection (hazard ratio 2.7; 95% confidence interval 1.60–4.61; log-rank P < 0.001). Subgroup analysis based on the tumour status revealed that segmentectomy had a better RFS in clinical stage IA2 (P < 0.001) and in pure-solid tumours (P = 0.022) than wedge resection. CONCLUSIONS We demonstrate that segmentectomy is a feasible procedure with comparable safety outcomes and better surgical margins and cancer control than wedge resection, particularly for clinical stage IA2 NSCLC. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES We investigated the long-term outcomes of lobe-specific nodal dissection (LSD) and systematic nodal dissection (SND) in patients with non-small-cell lung cancer (NSCLC). METHODS Patients with c-stage I and II NSCLC who underwent lobectomy with mediastinal nodal dissection were retrospectively analysed. After propensity score matching, we assessed the overall survival (OS), recurrence-free survival (RFS) and cumulative incidence of death (CID) from primary lung cancer and other diseases. RESULTS The median follow-up period was 8.4 years. Among 438 propensity score-matched pairs, OS and RFS were similar between the LSD and SND groups [hazard ratio (HR), 0.979; 95% confidence interval (CI), 0.799–1.199; and HR, 0.912; 95% CI, 0.762–1.092, respectively], but the LSD group showed a better prognosis after 5 years postoperatively. CID from primary lung cancer was similar between the 2 groups (HR, 1.239; 95% CI, 0.940–1.633). However, the CID from other diseases was lower in the LSD group than in the SND group (HR, 0.702; 95% CI, 0.525–0.938). According to c-stage, the LSD group tended towards worse OS and RFS, with higher CID from primary lung cancer than the SND group, in patients with c-stage II. CONCLUSIONS LSD provides acceptable long-term survival for patients with early-stage NSCLC. However, LSD may not be suitable for patients with c-stage II NSCLC due to the higher mortality risk from primary lung cancer. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES To investigate the rate of hypoxaemic acute respiratory failure (hARF) on patients undergoing surgery for non-small-cell lung cancer (NSCLC) after neoadjuvant chemotherapy, to describe clinical and radiological findings and to explore potential risk factors for this complication. METHODS Retrospective review of medical records of all patients who underwent surgery for NSCLC after neoadjuvant chemotherapy at a single centre between 2014 and 2021. Computed tomography scans of patients who developed hARF were reviewed by an experienced radiologist to provide a quantitative assessment of radiologic alterations. RESULTS The final cohort consisted of 211 patients. Major morbidity was 13.3% (28/211) and hARF was the most common major complication (n  = 11, 5.2%). Postoperative mortality was 1.9% (4/211) and occurred only in patients who experienced hARF. Most patients who experienced hARF underwent major procedures, including pneumonectomy (n  = 3), lobectomy with chest wall resection (n  = 3), bronchial or vascular reconstructions (n  = 3) and extended or bilateral resections (n  = 2). Analysis of computed tomography findings revealed that crazy paving and ground glass were the most common alterations and were more represented in the non-operated lung. Male gender, current smoking status, pathologic stage III–IV and operative time resulted significant risk factors for hARF at univariable analysis (P  < 0.05). CONCLUSIONS hARF is the main cause of major morbidity and mortality after neoadjuvant therapy and surgery for NSCLC and occurs more frequently after complex and lengthier surgical procedures. Overall, our findings suggest that operative time may represent the most important risk factor for hARF. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES We retrospectively analysed the surgical prognosis of patients with pathological stage I non-small-cell lung cancer (NSCLC) who after complete resection underwent low-dose computed tomography (LDCT) or conventional CT as postoperative surveillance. METHODS We investigated 416 patients who underwent lobectomy or segmentectomy between January 2013 and December 2016. We compared the prognosis between the LDCT and conventional CT groups using the propensity score-matched analysis. RESULTS The median follow-up period was 57 months. Cancer recurrence occurred in 47 patients (11.3%). In the entire cohort (n  = 416), recurrence-free survival (RFS) and overall survival (OS) were better in the LDCT group (P  = 0.001 and 0.002, respectively). Both intrathoracic recurrence and distant metastasis were higher in the conventional group (P  = 0.015 and 0.009, respectively). However, there was no statistical difference in the factors leading to recurrence detection (routine radiological examination, symptoms and elevated tumour markers: all P  > 0.05). Both groups were matched using a ratio of 1:1. The area under the receiver operating characteristic curve was 0.788. A total of 226 patients were successfully matched. After matching, there was no statistical difference between the 2 groups for RFS and OS (P  = 0.263 and 0.226). There were also no statistical differences in recurrence rate, the factors leading to recurrence detection or recurrence site (all P  > 0.05). CONCLUSIONS After using propensity score matched, RFS and OS did not differ significantly between LDCT and conventional CT groups. Retrospective comparisons suggest no disadvantages of using LDCT for postoperative surveillance of pathological stage I NSCLC. Further validation will be needed in the future. [ABSTRACT FROM AUTHOR]

The article "Reply to Wei-Zhen Tang et al." published in the European Journal of Cardio-Thoracic Surgery compares the surgical outcomes of sleeve lobectomy (SL) and pneumonectomy (PN) following neoadjuvant therapy. Out of 175 patients, 29.1% underwent complex SL procedures, with varying complexities such as carinoplasty, vascular reconstruction, extended SL, and chest wall resection. The study found that complex SL procedures had longer operating times compared to PN, but similar 30-day morbidity, mortality rates, disease-free survival, and overall survival. The decision to perform complex SL after neoadjuvant therapy depends on factors like tumor location, surgeon experience, and patient condition. [Extracted from the article]

Segmentectomy is increasingly being chosen as a standard procedure for patients with small peripheral non-small-cell lung cancer. However, a recent study found that only 12.6% of segmentectomies adhered to quality criteria, and adherence to these criteria was associated with increased overall survival. Another study found that incomplete segmentectomy was associated with poorer survival and increased risk of recurrences. To standardize the technical steps of segmentectomy and ensure safe implementation, the European Society of Thoracic Surgeons has generated expert consensus statements. However, many surgeons are still reluctant to receive or offer segmentectomy due to perceived skill requirements. Surgical quality is crucial for achieving clear resection margins and preventing medico-legal consequences. [Extracted from the article]

OBJECTIVES Only few studies compared the surgical morbidity and mortality of thoracoscopic segmentectomy versus lobectomy for non-small-cell lung cancer, in particular, by relating the segmental resections with the corresponding anatomical lobes. METHODS We enrolled a total of 7487 patients who underwent VATS lobectomy (7269) or segmentectomy (218) from January 2014 to July 2019. A propensity score matching approach was used to account for potential confounding factors between the 2 groups. After matching, 349 lobectomies and 208 segmentectomies were included in the analysis. We analysed the operative and postoperative outcomes of video-assisted anatomical segmentectomy compared with video-assisted lobectomy and, in details, the results of segmentectomy with its corresponding lobectomy in a large cohort of patients from the Italian VATS Group Registry. RESULTS The overall conversion rate to thoracotomy was not statistically different between the groups (27 patients 8% vs 7 patients 3%, P  = 0.1). The lobectomy group had a greater number of resected lymph nodes (median 11 vs 8, P  = 0.006). No significant differences were detected in 30-day mortality (1.4%, 5 patients vs 0.9%, 2 patients), overall complications (18%, 62 patients vs 14%, 29 patients) and prolonged air leakage (31 patients, 9% vs 12 patients, 6%) between lobectomy and segmentectomy, respectively. No statistical differences were found regarding the median duration of drainage (3.2 days, P  = 1) and the overall median length of hospital stay (6.4 days, P  = 0.1) between the 2 groups. In the context of segmentectomy versus corresponding lobectomy, the right upper lobectomy compared with right upper segmentectomy showed a higher number of resected lymph nodes (P  = 0.027). No statistical differences were reported in terms of conversion rate and postoperative complication and mortality. CONCLUSIONS Segmentectomy could be considered a safe procedure without significant differences compared to thoracoscopic lobectomy in terms of postoperative morbidity and mortality. [ABSTRACT FROM AUTHOR]

This article discusses the atypical mutations of the epidermal growth factor receptor (EGFR) in resected stage I non-small-cell lung cancers (NSCLC). The study found that patients with atypical EGFR mutations had similar disease-free survival (DFS) compared to those with typical EGFR mutations. However, patients with the L861Q mutation had the poorest DFS among those with atypical mutations. The study also explored the differences in DFS between patients with exon 20 insertion mutation and major atypical mutation, suggesting that segmentectomy may not be the best option for patients with major atypical EGFR mutations and solid nodules of less than 2 cm. The article highlights the importance of EGFR testing in personalized care and raises new questions for future studies. [Extracted from the article]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Even with current diagnostic technology, it is difficult to accurately predict pathological lymph node status (PLNS). This study aimed to develop a prediction model of PLNS in peripheral adenocarcinoma with a dominant solid component, based on clinical and radiological factors on thin-section computed tomography, to identify patients to whom wedge resection or other local therapies could be applied. METHODS Of 811 patients enrolled in a prospective multi-institutional study (JCOG0201), 420 patients with clinical stage IA peripheral lung adenocarcinoma having a dominant solid component were included. Multivariable logistic regression was performed to develop a model based on clinical and centrally reviewed radiological factors. Leave-one-out cross-validation and external validation analyses were performed, using independent data from 221 patients. Sensitivity, specificity and concordance statistics were calculated to evaluate diagnostic performance. RESULTS The formula for calculating the probability of pathological lymph node metastasis included the following variables: tumour diameter (including ground-glass opacity), consolidation-to-tumour ratio and density of solid component. The concordance statistic was 0.8041. When the cut-off value associated with the risk of incorrectly predicting negative pathological lymph node metastasis (pN−) was 4.9%, diagnostic sensitivity and specificity in predicting PLNS were 95.7% and 46.0%, respectively. The concordance statistic for the external validation set was 0.7972, and diagnostic sensitivity and specificity in predicting PLNS were 95.4% and 40.5%, respectively. CONCLUSIONS The proposed model is clinically useful and successfully predicts pN− in patients with clinical stage IA peripheral lung adenocarcinoma with a dominant solid component. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Pleural invasion (pl) is strongly associated with the pleural lavage cytology (PLC) status. We analysed tumours with pl and evaluated the relationship between the PLC status and pl. METHODS We retrospectively reviewed 428 surgically treated patients who had been diagnosed with non-small-cell lung cancer with pl and had their PLC status examined between 2000 and 2016. We investigated the influence of a PLC-positive status on the prognosis and searched for the factors predictive of a PLC-positive status. RESULTS Seventy-eight (18%) patients were PLC positive. The recurrence-free survival of PLC-positive patients was significantly worse than that of PLC-negative patients in pl1 and pl2, but not in pl3 (5-year recurrence-free survival rate, PLC positive versus PLC negative: pl1, 22.0% vs 60.0%, P  = 0.002; pl2, 30.4% vs 59.7%, P  = 0.015; pl3, 50.0% vs 59.6%, P  = 0.427). A multivariable analysis showed that the degree of pl (pl2–3 versus pl1) [odds ratio (OR) 5.34, P  < 0.001] was an independent predictive factor for PLC positivity. Epidermal growth factor receptor (EGFR) mutation positivity (OR 5.48, P  = 0.042) and carcinoembryonic antigen (CEA) ≥5 ng/ml (OR 3.78, P  = 0.042) were associated with a PLC-positive status in patients with pl2–3. We found that the PLC-positive rate in patients with pl2–3 was 35.6%; however, if the tumour was EGFR mutation positive and had CEA ≥5 ng/ml, the PLC-positive rate increased to 77%. CONCLUSIONS If a tumour was suspected of being pl2–3 and had EGFR mutation positivity and CEA ≥5 ng/ml, the PLC-positive rate was extremely high. Clinical trial registration number Hyogo Cancer Center, G-138. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES To investigate lymph node (LN) metastasis according to tumour location and assess the impact of lobe-specific LN dissection on survival in stage IA non-small-cell lung cancer (NSCLC). METHODS We retrospectively analysed the data of patients with clinical stage IA NSCLC treated with lobectomy and systematic LN dissection at Asan Medical Center (Seoul, Korea) between June 2005 and April 2017. Patients who received neoadjuvant therapy had multiple primary tumours or missed the follow-up during the first postoperative year were excluded. The patients were divided into five groups according to involved lung lobes: right upper lobe (RUL), right middle lobe (RML), right lower lobe (RLL), left upper lobe (LUL) and left lower lobe (LLL), which were further divided into subgroups according to LN station metastasis. Overall survival (OS) and the incidence of metastasis were calculated for each subgroup. Efficacy indices (EIs) were calculated to determine the correlation between each lung lobe and LN station, and the impact of the dissection of these stations on survival. RESULTS A total of 1202 patients were analysed. The 5-year OS in the RUL, RML, RLL, LUL and LLL groups was 74%, 88%, 78%, 80% and 75%, respectively. The incidence of single LN station metastasis was 11%, 10%, 10%, 16% and 14%, respectively. The lobe-specific LNs for RUL, RML, RLL, LUL and LLL were stations 2/3/4, 4/7, 2/4/7, 4/5/6 and 6/7/9, respectively. Moreover, the LN stations with high EIs for RUL, RML, RLL, LUL and LLL were 4, 7, 7, 5 and 7, respectively. In the RUL group, the incidence of metastasis to stations 2, 3 and 4 was 2.3%, 0.5% and 7.6%, and the EI was 0.8, 0.3 and 4.3, respectively. In RML, the incidence of metastasis to stations 4 and 7 was 4% and 6%, and the EI was 1.3 and 2.4, respectively. In RLL, the incidence of metastasis to stations 2, 4 and 7 was 4.4%, 5.6% and 8.3%, and the EI was 1.3, 1.4 and 3.3, respectively. In LUL, the incidence of metastasis to stations 4, 5 and 6 was 1.4%, 11.8% and 2.5%, and the EI was 0.4, 7.1 and 0.5, respectively. In LLL, the incidence of metastasis to stations 6, 7 and 9 was 1.1%, 5.7% and 1.7%, and the EI was 0.6, 2.3 and 0.5, respectively. Furthermore, the OS of patients with lobe-specific LN metastasis was statistically significantly different from that of the non-lobe-specific LN metastasis group with P -values of <0.001 for RUL, 0.002 for RML, 0.002 for RLL, 0.001 for LUL and 0.003 for LLL. CONCLUSIONS Our findings support the use of lobe-specific LN dissection in stage IA NSCLC. When LN stations with high EI were negative, LN metastasis in other stations was unlikely. The incidence of LN metastasis beyond lobe-specific LN stations was ∼1% in all subgroups. Dissection of non-lobe-specific LNs may not improve the OS; however, prospective randomized controlled trials are needed to modify the standard approach. [ABSTRACT FROM AUTHOR]

OBJECTIVES The number of positive lymph node stations has been viewed as a subclassification in the N1 category in the new revision of tumour node metastasis (TNM) staging. However, the survival curve of these patients overlapped with that of some patients in the N2 categories. Our study focused on the prognostic significance of different subclassifications for N1 patients. METHODS We systematically searched PubMed, Ovid, Web of Science and the Cochrane Library on the topic of N1 lymph node dissection. Hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) were used to assess the prognostic significance of N1 metastases. I 2 statistics was used to evaluate heterogeneity among the studies: If significant heterogeneity existed (P  ≤ 0.10; I 2 >50%), a random effect model was adopted. RESULTS After a careful investigation, a total of 17 articles were included in the analysis. The results showed that patients with non-small-cell lung cancer with multistation N1 disease have worse survival compared with those with single-station N1 disease (HR 1.53, 95% CI 1.32–1.77; P  < 0.001; I 2 = 5.1%). No significant difference was observed between groups when we assessed the number of positive lymph nodes (single or multiple) (HR 1.25, 95% CI 0.96–1.64; P  = 0.097; I 2 = 72.5%). Patients with positive hilar zone lymph nodes had poorer survival than those limited to the intrapulmonary zone (HR 1.80, 95% CI 1.57–2.07; P  < 0.001; I 2 = 0%). A subgroup analysis conducted according to the different validated lymph node maps showed a stable result. CONCLUSIONS Our result confirmed the prognostic significance of the N1 subclassification based on station number. Meanwhile, location-based classifications, especially zone-based, were also identified as prognostically significant, which may need further confirmation and validation in the staged population. [ABSTRACT FROM AUTHOR]

OBJECTIVES The aim of the study was to investigate the relationship between ground-glass opacity (GGO) and tumour spread through air space (STAS), as well as their joint influence on the prognosis of stage I lung adenocarcinoma. METHODS A total of 620 consecutive patients with surgically resected lung adenocarcinoma between January 2011 and December 2012 were reviewed retrospectively. The relevance of STAS and GGO was analysed by logistic regression, and their prognostic significance was investigated via the Kaplan–Meier method and Cox regression models. Furthermore, to determine the magnitude of the prognostic impact of GGO and STAS, we respectively performed survival analysis in subgroups according to the presence of STAS and GGO. RESULTS Of all 620 cases, 26.7% were positive for STAS, and 32.9% had a GGO component. STAS was present in 10.8% of part-solid lesions and 34.9% of pure solid nodules (P  < 0.001). Lepidic-predominant histologic subtype, GGO component and pathological T stage exhibited significant relevance to the presence of STAS. For the whole population, STAS and GGO component were each revealed as independent predictors for overall survival and recurrence-free survival (each with P  < 0.001). Interestingly, in the GGO-present subgroup, STAS failed to significantly stratify prognosis. However, in the STAS-positive subgroup, the presence of a GGO component was independently associated with favourable oncological results. CONCLUSIONS STAS is associated with a GGO component, and each factor was a significant predictor for the prognosis of stage I lung adenocarcinoma. Moreover, the favourable prognostic impact of a GGO component was greater than the adverse prognostic influence of STAS, indicating that GGO is a more reliable prognostic predictor in stage I lung adenocarcinoma. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES We queried the European Society of Thoracic Surgeons (ESTS) database with the aim to assess cardiopulmonary morbidity and 30-day mortality of segmentectomies and lobectomies in patients with a Eurolung-predicted mortality above the upper interquartile and classified as high risk. METHODS A total of 61 492 patients registered in the ESTS database (2007–2018) and submitted to lobectomy (55 353) or segmentectomy (6139) were divided into high risk or low risk according to a Eurolung-predicted mortality cut-off of 2.5% (corresponding in our population to the upper interquartile). Predicted versus observed mortalities were compared within each type of operation by using binomial test of proportion. Observed morbidity and mortality rates were compared between the 2 procedures using the χ 2 test. RESULTS A total of 14 007 lobectomies and 1251 segmentectomies were classified as high risk. In the high-risk group, the cardiopulmonary morbidity and 30-day mortality rates observed in segmentectomies were lower than in lobectomies (morbidity: 12% vs 17%, P  < 0.0001; mortality: 2.4% vs 3.7%, P  = 0.018). In segmentectomy patients, the observed mortality rate was lower than the Eurolung-predicted one (2.4% vs 3.8%, P  = 0.009), while in the lobectomy patients, there was no difference between observed and predicted mortality (3.7% vs 3.8%, P  = 0.9). In the low-risk group, the cardiopulmonary morbidity and 30-day mortality rates observed in segmentectomies were lower than in lobectomies (morbidity: 4.5% vs 7.8%, P  < 0.0001; mortality: 0.6% vs 1.0%, P  = 0.01). In segmentectomy patients, the observed mortality rate was lower than the Eurolung-predicted one (0.6% vs 1.0%, P  = 0.0003), while in the lobectomy patients, there was no difference between observed and predicted mortality (1.0% vs 1.1%, P  = 0.06). CONCLUSIONS Segmentectomy was found associated with a 0.65 relative risk of mortality rate compared to lobectomy in patients deemed at higher surgical risk. [ABSTRACT FROM AUTHOR]

OBJECTIVES Open in new tab Download slide Open in new tab Download slide Major pathological response (MPR) is prognostic of outcomes for patients with non-small-cell lung cancer following neoadjuvant chemotherapy and is used as the primary end point in neoadjuvant immunotherapy trials. We studied the influence of pathological nodal disease on patterns and timing of recurrence among patients with MPR. METHODS Patients treated with neoadjuvant chemotherapy for stages I–III non-small-cell lung cancer were identified. Surgical specimens were histopathologically examined for tumour viability, categorized as ≤10% viability (MPR) or >10% (NoMPR). Overall survival and disease-free survival were evaluated with emphasis upon MPR and pathological nodal disease. RESULTS Among 307 patients, 58 (19%) had MPR within primary tumour and 42 (14%) had MPRypN0. In the MPR group, the frequency of cN0 and cN+ disease was 18 (31%) and 40 (69%); similarly, the frequency of ypN0, ypN1 and ypN2 was 72% (42/58), 16% (9/58) and 12% (7/58), respectively. When evaluating only those with MPR, recurrence rates among those with MPRypN0, MPRypN1 and MPRypN2 were 33% (14/42), 44% (4/9) and 71% (5/7) (P  =   0.16). The median time-to-recurrence in MPRypN0, MPRypN1 and MPRypN2 was 40, 10 and 14 months (P  =   0.006). Distant recurrences were less common among those with MPRypN0 [MPRypN0, 26% (11/42); MPRypN1, 44% (4/9); MPRypN2, 71% (5/7); P =  0.047]. Though the median disease-free survival was prolonged among those with MPR vs NoMPR (120 vs 25 months, P  <   0.0001), only those with MPRypN0 had prolonged disease-free survival in comparison to other groups upon pairwise comparisons, while MPRypN+ experienced no benefit. CONCLUSIONS MPRypN0 represents the most favourable surrogate end point following neoadjuvant chemotherapy. Patients with ypN1-2 are at the risk of early recurrence regardless of primary tumour MPR, warranting intensive surveillance and consideration for additional adjuvant therapy. We highlight that MPRypN0 is the most rigorous end point and should be considered as a surrogate end point in future neoadjuvant trials. [ABSTRACT FROM AUTHOR]

OBJECTIVES Open in new tab Download slide Open in new tab Download slide Quality assessment is an important element in providing surgical cancer care. The main objective of this study was to develop a new composite measure 'textbook outcome', to evaluate and improve quality of surgical care for patients undergoing a resection for non-small-cell lung cancer (NSCLC). METHODS All patients undergoing an anatomical resection for NSCLC from 2012 to 2016 registered in the nationwide Dutch Lung Cancer Audit were included in an analysis to assess usefulness of a composite measure as a quality indicator. Based on expert opinion, textbook outcome was defined as having a complete resection (negative resection margins and sufficient lymph node dissection), plus no 30-day or in-hospital mortality, no reintervention in 30 days, no readmission to the intensive care unit, no prolonged hospital stay (<14 days), no hospital readmission after discharge and no major complications. The percentage of patients with a textbook outcome was calculated per hospital. Between-hospital variation in textbook outcome was analysed using case-mix adjustment models. RESULTS In total, 5513 patients were included in this study. Textbook outcome was achieved in 26.4% of patients. Insufficient lymph node dissection had the most substantial effect on not realizing textbook outcome. If 'sufficient lymph node dissection' was not included as a criterion, textbook outcome would be 60.7%. Case-mix adjusted textbook outcome proportions per hospitals varied between 13.2% and 37.7%. CONCLUSIONS In contrast to focusing on a single aspect, the composite measure textbook outcome provides insight into comprehensive performance in NSCLC surgery. It can be used to evaluate both individual hospitals and national performance and provides the opportunity to give benchmarked feedback to thoracic surgeons. [ABSTRACT FROM AUTHOR]

OBJECTIVES Open in new tab Download slide Open in new tab Download slide The prognosis of patients with mediastinal lymph node (LN) metastasis (pN2 stage III disease) is still unsatisfactory. Both systemic and local recurrence should be prevented after curative surgery. The aim of this study was to explore the pattern of recurrence in patients with completely resected pN2 non-small-cell lung cancer (NSCLC) in the era of adjuvant chemotherapy. METHODS We investigated 337 patients with completely resected cN0-1 and pN2 NSCLC from 2005 to 2016 at National Cancer Center Hospital, Japan. The patterns of recurrence were compared between patients who were managed by observation alone and those with adjuvant chemotherapy. In patients with regional LN recurrence, the pattern and site of recurrence were also explored. RESULTS There were 195 (58.5%) men and 142 (41.5%) women with a mean age of 63.2 years. Fifty-five (16.3%) patients developed only regional LN recurrence, 116 (32.6%) patients developed only distant recurrence and 65 (19.3%) patients developed both regional LN recurrence and distant recurrence. The difference in the pattern of recurrence between patients with observation alone and those with adjuvant chemotherapy was not statistically significant (P  =   0.145). As for the pattern of regional LN recurrence, 68 (20.2%) patients had LN recurrence inside the systematic nodal dissection area. CONCLUSIONS Regional LN recurrence was observed in >30% of patients with completely resected pN2 NSCLC. About 20% of patients had recurrence inside the systematic nodal dissection area. Postoperative radiotherapy might be considered as an additional treatment strategy for these patients. [ABSTRACT FROM AUTHOR]

OBJECTIVES Open in new tab Download slide Open in new tab Download slide The purpose of this study was to determine the radiological characteristics of aggressive small-sized lung cancer and to compare the outcomes between segmentectomy and lobectomy in patients with these lung cancers. METHODS A series of 1046 patients with clinical stage IA1–IA2 lung cancer who underwent lobectomy or segmentectomy at 3 institutions was retrospectively evaluated to identify radiologically aggressive small-sized (solid tumour size ≤ 2 cm) lung cancers. Prognosis of segmentectomy was compared with that of lobectomy in 522 patients with radiologically aggressive small-sized lung cancer using propensity score matching. RESULTS Multivariable analysis showed that increasing consolidation-to-tumour ratio on preoperative high-resolution computed tomography (CT) (P  =   0.037) and maximum standardized uptake on 18 fluoro-2-deoxyglucose positron emission tomography/CT (P  =   0.029) was independently associated with worse recurrence-free survival. Based on analysis of the receiver operating characteristic curve, radiologically aggressive lung cancer was defined as a radiologically solid (consolidation-to-tumour ratio ≥ 0.8) or highly metabolic (maximum standardized uptake ≥ 2.5) tumour. Among patients with radiologically aggressive lung cancer, no significant statistical differences in 5-year recurrence-free (81% vs 90%; P  =   0.33) and overall (88% vs 93%; P  =   0.76) survival comparing lobectomy (n  = 392) to segmentectomy (n  = 130) were observed. Among 115 propensity-matched pairs, 5-year recurrence-free survival and overall survival were similar between patients who underwent lobectomy and those who underwent segmentectomy (83.3% and 88.3% vs 90.9% and 94.5%, respectively). CONCLUSIONS Difference in survival was not identified with segmentectomy and lobectomy in patients with radiologically aggressive small-sized lung cancer with high risk of recurrence. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES The feasibility and safety of spontaneous ventilation (SV) video-assisted thoracoscopic surgery (VATS) for non-small-cell lung cancer (NSCLC) in patients with excess body weight [defined as body mass index (BMI) ≥ 25 kg/m2] remain unclear. METHODS Patients with NSCLC with excess body weight who underwent SV-VATS or mechanical ventilation (MV) VATS (MV-VATS) between April 2012 and July 2018 were analysed retrospectively. Propensity score matching was applied to balance the distribution of demographic characteristics. The short-term outcomes between the SV-VATS group and MV-VATS group were compared. RESULTS From April 2012 to July 2018, a total of 703 patients with excess body weight were included, 68 of whom underwent SV-VATS and 635 of whom underwent MV-VATS. After propensity score matching, the distribution of demographic characteristics was well balanced. BMIs (26.65 ± 1.74 vs 27.18 ± 2.36 kg/m2; P  = 0.29) were similar between the groups. Patients who underwent SV-VATS had similar anaesthesia times (213 ± 57 vs 233 ± 67 min; P  = 0.16) and similar operative times (122 ± 44 vs 142 ± 56 min; P  = 0.086). The intraoperative bleeding volume, postoperative chest tube duration, volume of pleural drainage, number of dissected N1 and N2 station lymph nodes, length of hospitalization and incidence of complications were comparable between the 2 groups. CONCLUSIONS Primary lung cancer resection is feasible and not associated with safety issues under SV-VATS in selected patients with NSCLC with excess body weight. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Locally advanced non-small-cell lung cancer (NSCLC) with chest wall invasion carries a high risk of recurrence and portends poor survival (30–40% and 20–50%, respectively). No studies have identified prognostic factors in patients who underwent R0 resection for non-superior sulcus NSCLC. METHODS A retrospective review was conducted for all chest wall resections for NSCLC from 2004 to 2018. Patients with superior sulcus tumours, partial (<1 rib) or incomplete (R1/R2) resection or distant metastasis were excluded. Disease-free survival (DFS) and overall survival (OS) were estimated using the Kaplan–Meier method. Cox proportional hazards modelling was used to determine factors associated with DFS and OS. RESULTS A total of 100 patients met inclusion criteria. Seventy-three (73%) patients underwent induction therapy, and all but 12 (16%) patients experienced a partial radiological response. A median of 3 ribs was resected (range 1–7), and 67 (67%) patients underwent chest wall reconstruction. The 5-year DFS and OS were 36% and 45%, respectively. Pathological N2 status [hazard ratio (HR) 3.12, confidence interval (CI) 1.56–6.25; P  =   0.001], intraoperative blood transfusion (HR 2.24, CI 1.28–3.92; P  =   0.005) and preoperative forced vital capacity (per % forced vital capacity, HR 0.97, CI 0.96–0.99; P  =   0.013) were associated with DFS. Increasing pathological stage, lack of radiological response to induction therapy (HR 7.35, CI 2.35–22.99; P  =   0.001) and cardiovascular comorbidity (HR 2.43, CI 1.36–4.36; P  =   0.003) were associated with OS. CONCLUSIONS We demonstrate that blood transfusion and forced vital capacity are associated with DFS after R0 resection for non-superior sulcus NSCLC, while radiological response to induction therapy greatly influences OS. We confirm that pathological nodal status and pathological stage are reproducible determinants of DFS and OS, respectively. [ABSTRACT FROM AUTHOR]

OBJECTIVES The role of segmentectomy in early-stage non-small-cell lung cancer (NSCLC) remains a matter of debate. We performed a meta-analysis to evaluate the oncological outcomes following segmentectomy versus lobectomy for stage I, stage IA only and stage IA <2 cm only. METHODS We systematically searched the literature for articles reporting on overall survival (OS), cancer-specific survival (CSS) or recurrence-free survival (RFS). The hazard ratios (HRs) were retrieved and pooled using an inverse variance-weighted approach. RESULTS Twenty-eight studies were included in the analysis. In stage I, segmentectomy was found to be inferior to lobectomy for all 3 outcomes with HR: 1.25 (P  = 0.01) for OS, 1.59 (P  = 0.02) for CSS and 1.40 (P  < 0.001) for RFS. In stage IA, the differences were significant for OS and CSS, though not for RFS with HR: 1.31 (P  = 0.04), 1.56 (P  = 0.02) and 1.22 (P  = 0.11), respectively. In stage IA <2 cm, no significant differences were found between segmentectomy and lobectomy with HR: 1.13 (P  = 0.37) for OS, 1.02 (P  = 0.95) for CSS and 1.24 (P  = 0.11) for RFS. CONCLUSIONS For stages I and IA, lobectomy showed superior results whereas for tumours <2 cm, our study did not find significant differences in oncological outcomes between both groups. These results suggest that segmentectomy might be a valuable alternative to lobectomy for NSCLC in tumours <2 cm. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES We investigated the impact of level 4 (L4) lymph node dissection (LND) on overall survival (OS) in left-side resectable non-small-cell lung cancer (NSCLC), with the aim of guiding lymphadenectomy. METHODS A total of 1929 patients with left-side NSCLC who underwent R0 resection between 2001 and 2014 were included in the study. The patients were divided into a group with L4 LND (L4 LND+) and a group without L4 LND (L4 LND−). Propensity score matching was applied to minimize selection bias. The Kaplan–Meier method and Cox proportional hazards model were used to assess the impact of L4 LND on OS. RESULTS A total of 317 pairs were matched. Of the cohort of patients, 20.3% (391/1929) had L4 LND. Of these patients, 11.8% (46/391) presented with L4 lymph node metastasis. L4 lymph node metastasis was not associated with the primary tumour lobes (P  =   0.61). Before propensity score matching, the 5-year OS was comparable between the L4 LND+ and L4 LND− groups (69.0% vs 65.2%, P  =   0.091). However, after propensity score matching, the 5-year OS of the L4 LND+ group was much improved compared to that of the L4 LND− group (72.9% vs 62.3%, P  =   0.002) and L4 LND was an independent factor favouring OS (hazard ratio 0.678, 95% confidence interval 0.513–0.897; P  =   0.006). Subgroup analysis suggested that L4 LND was an independent factor favouring OS in left upper lobe tumours. CONCLUSIONS In patients with left-side operable NSCLC, L4 lymph node metastasis was not rare and L4 LND should be routinely performed. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES No significant data are available to assess whether complex sleeve lobectomy (complex-SL) can be considered comparable to conventional lobectomy (CL) in terms of surgical outcome. The purpose of this study was to compare surgical and oncological outcomes of complex-SL with CL in patients with lung cancer. METHODS Between 2000 and 2015, a total of 568 patients who underwent open CL (defined as resection of only 1 lobe) and 187 patients who underwent SL were analysed. The SL group was divided into 2 subgroups: standard-SL (bronchial SL, n  = 106) and complex-SL (n  = 81) (defined as bronchial sleeve resection together with another surgical intervention: bronchovascular SL, n  = 40; vascular SL, n  = 26; atypical bronchoplasty with resection of more than 1 lobe, n  = 12; bronchial SL + chest wall resection, n  = 3). RESULTS The complex-SL group had more patients with chronic obstructive pulmonary disease (COPD) (25.9% vs 12.5%, P  = 0.001), neoadjuvant treatment (39.5% vs 12.0%, P  < 0.001), advanced-stage non-small-cell lung cancer (53.2% vs 33.1%, P  = 0.001) and low preoperative forced expiratory volume in 1 s (77.2% vs 84.3%, P  = 0.004) than the CL group. The overall surgical mortality (in-hospital or 30-day) was 2.6% (n  = 20); it was 2.8% for CL and 2.8% for complex-SL. Postoperative complications occurred in 34.9% of the CL group and 39.5% of the complex-SL group (P  = 0.413). The pulmonary complication rate was similar between the groups (24.1% for CL, 27.2% for complex-SL, P  = 0.552). The 5-year survival in the CL group was 57.1%, and in the complex-SL group it was 56.2% (P  = 0.888). Multivariate analysis showed that TNM stage (P  < 0.001) and N status (P  < 0.001) were significant and independent negative prognostic factors for survival. CONCLUSIONS Complex-SL had a comparable outcome to CL, although the complex-SL group had more patients with advanced-stage NSCLC, low preoperative forced expiratory volume in 1 s and COPD. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES T4 lung cancer has become a more heterogeneous group since the 8th edition of tumour, node, metastasis classification. The aim of this study was to identify predictive factors related to post-surgical survival in patients with clinical T4 non-small-cell lung cancer (NSCLC), based on the 8th edition of the classification. METHODS We retrospectively reviewed consecutive patients with clinical T4 NSCLC who underwent resection between January 2006 and December 2016, to identify factors associated with overall survival. RESULTS Ninety-three patients were identified. The criteria for clinical T4 disease included tumours larger than 7 cm (n  =   54), great vessels or left atrial invasion (n  =   22), mediastinal invasion (n  =   11), vertebral invasion (n  =   3), tracheal or carina invasion (n  =   3), diaphragm invasion (n  =   1) and ipsilateral different lobe pulmonary metastasis (n  =   2). The postoperative nodal status was 0, 1, 2 and 3 in 59, 18, 15 and 1 patient, respectively. R0 resection was achieved in 80 patients, and the 30-day mortality was 0%. The median follow-up time was 37.6 months, and the 5-year overall survival rate was 56.3%. The multivariable analysis revealed that nodal status and R-status were significant prognostic factors for postoperative survival [hazard ratio (HR) 2.62, 95% confidence interval (CI) 1.20–5.72, P  =   0.016 and HR 3.29, 95% CI 1.45–7.44, P  =   0.004]. CONCLUSIONS Surgery provided encouraging survival outcomes for clinical T4 NSCLC based on the 8th edition of classification. The nodal status and R-status were significant prognostic factors for postoperative survival. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES To evaluate the postoperative complications and 30-day mortality rates associated with neoadjuvant chemotherapy before major anatomic lung resections registered in the European Society of Thoracic Surgeons (ESTS) database. METHODS Retrospective analysis on 52 982 anatomic lung resections registered in the ESTS database (July 2007–31 December 2017) (6587 pneumonectomies and 46 395 lobectomies); 5143 patients received neoadjuvant treatment (9.7%) (3993 chemotherapy alone and 1150 chemoradiotherapy). To adjust for possible confounders, a propensity case-matched analysis was performed. The postoperative outcomes (morbidity and 30-day mortality) of matched patients with and without induction treatment were compared. RESULTS 8.2% of all patients undergoing lobectomies and 20% of all patients undergoing pneumonectomies received induction treatment. Lobectomy analysis: propensity score analysis yielded 3824 pairs of patients with and without induction treatment. The incidence of cardiopulmonary complications was higher in the neoadjuvant group (626 patients, 16% vs 446 patients, 12%, P  < 0.001), but 30-day mortality rates were similar (71 patients, 1.9% vs 75 patients, 2.0%, P  = 0.73). The incidence of bronchopleural fistula and prolonged air leak >5 days were similar between the 2 groups (neoadjuvant: 0.5% vs 0.4%, P  = 0.87; 9.2% vs 9.9%, P  = 0.27). Pneumonectomy analysis: propensity score analysis yielded 1312 pairs of patients with and without induction treatment. The incidence of cardiopulmonary complications was higher in the treated patients compared to those without neoadjuvant treatment (neoadjuvant 275 cases, 21% vs 18%, P  = 0.030). However, the 30-day mortality was similar between the matched groups (neoadjuvant 68 cases, 5.2% vs 5.3%, P  = 0.86). Finally, the incidence of bronchopleural fistula was also similar between the 2 groups (neoadjuvant 1.8% vs 1.4%, P  = 0.44). CONCLUSIONS Neoadjuvant chemotherapy is not associated with an increased perioperative risk after either lobectomy or pneumonectomy, warranting a more liberal use of this approach for patients with locally advanced operable lung cancer. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Although segmentectomy for lung cancer has been widely accepted, complex segmentectomy, which creates several, intricate intersegmental planes, remains controversial. Potential arguments include risk of incurability and 'failure of cancer control'. We compared the outcomes of complex segmentectomy versus lobectomy and evaluated its use in lung cancer treatment. METHODS We retrospectively reviewed clinical stage IA lung cancer patients who underwent complex segmentectomy (n  =   99) or location-adjusted lobectomy (n  =   94) between April 2009 and December 2017. Clinicopathological and postoperative results were compared. Factors affecting survival were assessed by the Kaplan–Meier method and the Cox regression analysis. RESULTS No significant differences were detected in 30-day mortality (0% vs 0%), overall complications (26.3% vs 21.3%) and prolonged air leakage (11.1% vs 9.6%) rates between the 2 groups, respectively. Comparable results were obtained for 5-year overall (93.5% vs 96.4%, respectively; P =  0.21) or recurrence-free (92.3% vs 88.5%, respectively; P =  0.82) survivals after complex segmentectomy or lobectomy. There were 2 (2.0%) recurrences after complex segmentectomy and 7 (7.5%) after lobectomy (P =  0.094), with 0 (0%) margin relapses in each group. Multivariable Cox regression analysis revealed that complex segmentectomy and lobectomy had a numerically similar impact on recurrence-free survival (hazard ratio 0.93, 95% confidence interval 0.32–2.69; P  =   0.90). CONCLUSIONS Complex segmentectomy can provide acceptable short- and long-term outcomes in lung cancer treatment. [ABSTRACT FROM AUTHOR]

These results should stimulate an accurate follow-up of patients following a first resection for lung cancer and a systematic meticulous assessment for operability in case of ipsilateral metachronous lung cancer. Keywords: Surgical outcome; Ipsilateral anatomical resection; Non-small-cell lung cancer; Pulmonary lobectomy; Overall survival EN Surgical outcome Ipsilateral anatomical resection Non-small-cell lung cancer Pulmonary lobectomy Overall survival 1 2 2 04/04/23 20230301 NES 230301 The standard of care in operable patients with early-stage lung cancer is surgery, consisting of anatomical parenchymal resection with systematic lymph node dissection. They conducted a multicentre retrospective study of a cohort of 6293 patients from 23 institutes over a 7-year period (2012-2018), identifying 51 patients who underwent ipsilateral redo lung resections for a new primary lung cancer. [Extracted from the article]

T-add patients had the best prognosis in both the pathological and clinical TNM stage cohorts, followed by T-size and T-multiple patients, and T-multiple patients had the worst prognosis. In the present study, although T3-add provided the greatest survival benefit for T3 NSCLC patients compared to other T3 descriptors, the pathological definition of T3-add was made by surgical resection in only 51% of cases [[2]]. Keywords: Non-small-cell lung cancer; TNM staging; T3 descriptors EN Non-small-cell lung cancer TNM staging T3 descriptors 1 2 2 04/04/23 20230301 NES 230301 The American Joint Committee on Cancer tumour-node-metastasis (TNM) staging manual is revised every few years. [Extracted from the article]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Sublobar resection (SLR) is an alternative to lobectomy for non-small-cell lung cancer (NSCLC). Outcomes following SLR for tumours >2 cm are not well described. We sought to determine the utilization of SLR for stage I tumours >2–5 cm in size and to determine predictors of outcome. METHODS We utilized the Surveillance, Epidemiology and End Results Program (SEER)-Medicare database to identify NSCLC patients with primary lung cancer ≥66 years old with stage I cancers >2–5 cm in size. We evaluated overall survival and cancer-specific survival among cohorts undergoing lobectomy versus SLR. Propensity score matching was performed. We compared patient characteristics and survival between groups. RESULTS For the study time period (2007–2012), among patients with tumours >2 cm and ≤5 cm (n  = 4582), 3890 lobectomies (85%) and 692 SLR (15%) were performed. Patients undergoing SLR were older, had smaller tumours and more comorbidities. Patients undergoing lobectomy were much more likely to have any lymph nodes removed (95.6% vs 65.6%, P  < 0.001) and to have >10 nodes removed (29.6% vs 7.5%, P  < 0.001). All-cause mortality [hazard ratio (HR) 1.65, confidence interval (CI) 1.48–1.85] and cancer-specific (HR 1.63, CI 1.29–2.06) mortality were higher following SLR. At 3 years, overall survival (60.9%, CI 57.0–64.6% vs 54.4%, CI 50.4–58.2%) and cancer-specific survival (87.3%, CI 83.5–90.3% vs 76.5%, CI 71.0–81.1%) favoured lobectomy over SLR. In propensity-matched groups, both all-cause (HR 1.27, CI 1.10–1.47) and cancer-specific (HR 1.54, CI 1.11–2.16) mortality rates were higher with SLR. CONCLUSIONS In pathologically staged patients, SLR appears inferior to lobectomy for stage I NSCLC 2–5 cm in size. SLR is associated with less extensive lymphadenectomy and with worse survival than lobectomy in this cohort of patients. However, the 76.5% 3-year cancer-specific survival in patients undergoing SLR may exceed that of other localized treatment options for NSCLC. As such, SLR may be an appropriate option for high-risk patients with carefully staged 2–5 cm N0 tumours. [ABSTRACT FROM AUTHOR]

The article focuses on the investigation of the incidence and distribution of mediastinal lymph node metastases (MLNM) in non-small-cell lung cancers (NSCLC) 3 cm or less, with the purpose of guiding mediastinal lymph node dissection. For tumours no larger than 1 cm, a lower zone mediastinal lymph node dissection might be unnecessary for upper lobe tumours and an upper zone mediastinal lymph node dissection might be unnecessary for lower lobe tumours.

View large Download slide View large Download slide OBJECTIVES Non-small-cell lung cancer (NSCLC) patients with ipsilateral pleural dissemination (M1a) are generally contraindicated for surgery. However, several small-sample studies have demonstrated that they might benefit from surgery. We investigated the effects of primary tumour resection on survival in these patients. METHODS Stage IV NSCLC patients with ipsilateral pleural dissemination were identified from the US National Cancer Institute Surveillance, Epidemiology and End Results database entries from 2010 to 2015. Survival analysis was performed before and after matching. Multivariable regression models were built to identify prognostic factors. RESULTS Of the 5513 patients with ipsilateral pleural dissemination, 309 underwent primary tumour resection. In the entire cohort, surgery was associated with improved overall survival (OS) in both the unmatched and matched cohorts (both log rank, P  < 0.001). In the surgery-recommended cohort, patients treated with surgery also had significantly longer OS before and after matching. Multivariable regression models showed that surgery was an independent favourable prognostic factor for OS [hazard ratio (HR) 0.56, 95% confidence interval (CI) 0.48–0.65; P  < 0.001] and lung cancer-specific mortality (subhazard ratio 0.60, 95% CI 0.51–0.70; P  < 0.001). Surgery was independently associated with improved survival in all subgroups except for those with pericardial effusion (P  = 0.065) or N3 disease (P  = 0.17). In the surgical cohort, patients who underwent lobe/bilobectomy had significantly better OS than those who underwent sublobar resection (log rank, P  < 0.001). CONCLUSIONS Inclusion of primary tumour resection in multimodal therapy of NSCLC was associated with improved survival in selected patients with ipsilateral pleural dissemination, except for those with pericardial effusion or N3 disease. [ABSTRACT FROM AUTHOR]

View large Download slide View large Download slide OBJECTIVES T4N0–1 non-small-cell lung cancer (NSCLC) was historically considered curable but now includes tumours of size >7 cm according to the 8th edition tumour, node and metastasis (TNM) staging. This study was set out to evaluate the role of surgery and predictors of long-term survival after surgery in this renewed group of patients. METHODS Patients, with clinical T4N0–2M0 NSCLC diagnosed in 2010–2013, in the National Cancer Database were queried. A Cox regression analysis was applied to investigate independent predictors of survival in 1588 N0–1 surgical cases. For previous T3 cases, the efficacy of treatment including and not including surgery was compared after propensity score matching by age, gender, race, facility type, comorbidity, laterality, clinical N stage, histology and tumour grade. RESULTS In newly defined T4N0–1 NSCLC patients undergoing surgery, age, gender, comorbidity, nodal status, resection margin, tumour grade, chemotherapy and extension–size group were shown to be independent predictors of survival. In particular, patients with only T4 extension showed better survival than patients with tumour size > 7 cm only [hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.62–0.92, P  =   0.016]. In the latter group, surgical treatment was associated with better survival than non-surgical treatment after matching (HR 0.45, 95% CI 0.42–0.48, P  <   0.001). CONCLUSIONS In the newly defined T4 NSCLC, tumour size >7 cm is a descriptor that is more predictive of worse survival than local extension alone for patients whose treatment included surgery. For T4-extended, N0–1 NSCLC with a tumour size ≤ 7 cm, surgery might be associated with favourable long-term outcomes and should be further encouraged as a treatment option. [ABSTRACT FROM AUTHOR]

View large Download slide View large Download slide OBJECTIVES The prognostic role of the number of resected and metastatic lymph nodes in non-small-cell lung cancer (NSCLC) is still being debated. The aim of this study was to evaluate the impact of lymphadenectomy in addition to the already validated variables in NSCLC survival. METHODS From January 2002 to December 2012, data on 4858 patients with NSCLC undergoing anatomical lung resection and hilomediastinal lymphadenectomy in 6 institutions were analysed retrospectively. Established prognostic factors in addition to the number of resected lymph nodes and the ratio between the number of metastatic lymph nodes and the number of resected lymph nodes (NR) were correlated to overall survival (OS) and disease-free survival (DFS) using the multivariable Cox regression model. Harrell's C-statistic with the 95% confidence interval (CI) was determined. Analysis by means of maximally selected log-rank statistics was performed to find optimal cut-off points in order to split patients into groups with different outcome probabilities. RESULTS The median numbers of resected lymph nodes and of metastatic lymph nodes were 17 (range 6–85) and 2 (1–36), respectively. Hilar (N1) and mediastinal (N2) metastases were identified in 21.3% and 20.0% of cases, respectively. Overall, the 5-year OS and DFS rates were 54.6% and 44.8%, respectively. At multivariable analysis, age, gender, pathological stage, R0 resection, type of surgery and NR correlated with longer OS rates; the same variables plus tumour grading were further related to DFS. C-statistics were 66.0 (95% CI 62.7–69.4) for DFS and 60.5 (95% CI 58.3–62.6) for OS. An NR <40% significantly correlated with a higher 5-year survival rate in the total sample (OS 57.6% vs 23.8%, P  < 0.001; DFS 48.2% vs 11.4, P  < 0.001) and in patients with N1 (OS 47.9% vs 36.1%, P  = 0.03; DFS 39% vs 24.2%, P  = 0.02) and N2 (OS 36.9% vs 21.8%, P  < 0.001 DFS 23.9% vs 9.1%, P  < 0.001). CONCLUSIONS Our study confirms that the number of resected lymph nodes is a strong prognostic indicator in NSCLC. In particular, an NR cut-off value of 40% may predict both OS and DFS. [ABSTRACT FROM AUTHOR]

Lung cancer is a leading cause of cancer-related deaths worldwide, with non-small-cell lung cancer (NSCLC) accounting for the majority of cases. Risk factors for NSCLC include cigarette smoking, vaping, environmental factors, alcohol consumption, and air pollution. Early detection of NSCLC is crucial for improving survival rates, as patients diagnosed at earlier stages have a significantly higher chance of survival. Recent studies have emphasized the need for increased research in early detection and screening methods, with the use of radiomics analysis and artificial intelligence showing promise in improving outcomes. Efforts to enhance screening accessibility and risk assessment methods should be prioritized to reduce the burden of NSCLC and improve patient outcomes. [Extracted from the article]

The article discusses the importance of lung cancer screening and the need to improve access to it globally. It emphasizes the need to identify high-risk individuals and incorporate relevant risk factors, such as family history and exposure to asbestos, into screening criteria. The authors argue that investing in lung cancer CT screenings can save more lives than other treatments like chemotherapy or targeted therapy. While radiomics shows promise for the future, the immediate priority should be expanding access to screenings and enhancing early detection. [Extracted from the article]

The 2 randomized trials comparing lobectomy and sublobar resections [[3]] mandated the intraoperative sampling of hilar nodes to rule out N1 disease. Keywords: Segmentectomy; Sublobar resection; Non-small-cell lung cancer; Operative technique; Quality; Guidelines EN Segmentectomy Sublobar resection Non-small-cell lung cancer Operative technique Quality Guidelines 1 1 1 10/04/23 20230901 NES 230901 We thank Waller I et al. i [[1]] for their insightful comments on statements 13 and 14 of our expert consensus recommendations [[2]]. Segmentectomy, Sublobar resection, Non-small-cell lung cancer, Operative technique, Quality, Guidelines. [Extracted from the article]

- A systematic review and meta-analysis of sublobar resections versus lobectomy for non-small cell lung cancer according to patient selection. First, the authors excluded thoracotomy procedures due to their association with higher morbidity but included video-assisted thoracotomies that involved rib spreading and/or thoracotomy with thoracoscopic assistance. Keywords: Segmentectomy; Lobectomy; Postoperative outcomes; Non-small-cell lung cancer EN Segmentectomy Lobectomy Postoperative outcomes Non-small-cell lung cancer 1 2 2 02/07/23 20230101 NES 230101 The preference for lobectomy over sublobar resections as the standard of care for early-stage non-small-cell lung cancer (NSCLC) was widely accepted after the Lung Cancer Study Group published the first randomized controlled trial with patients recruited from the 1980s [[1]]. [Extracted from the article]