Long-Term Outcomes After Sublobar Resection Versus Lobectomy in Patients With Clinical Stage IA Lung Adenocarcinoma Meeting the Node-Negative Criteria Defined by High-Resolution Computed Tomography and [18F]-Fluoro-2-Deoxy-d-Glucose Positron Emission Tomography

PurposeTo evaluate long-term outcomes after sublobar resection for patients with clinical stage IA lung adenocarcinoma who met our proposed node-negative (N0) criteria, namely solid component size < 0.8 cm on high-resolution computed tomography (HRCT) or a maximum standardized uptake value (SUV_max) of < 1.5 on [¹⁸F]-fluoro-2-deoxy-d-glucose positron emission tomography/computed tomography (FDG-PET/CT).Patients and MethodsBetween April 2006 and December 2010, a total of 347 patients with clinical stage IA lung adenocarcinoma underwent complete resection in two medical centers. Long-term outcomes of patients with disease that met the N0 criteria after sublobar resection were evaluated.ResultsThe disease of 201 patients (57.9%) met the N0 criteria. Meeting N0 criteria was significantly associated with low-grade adenocarcinoma subtype (P < .001) and absence of lymphatic invasion (P < .001), vascular invasion (P < .001), and pleural invasion (P < .001). One patient (0.5%) had lymph node metastasis. The median follow-up period was 86.1 months. There was a significant difference in the overall survival (OS) rates between patients with disease that met the N0 criteria (5-year OS, 93.9%; 10-year OS, 90.3%) and disease that did not (5-year OS, 81.5%; 10-year OS, 64.3%; P < .001). Among patients with disease that met the N0 criteria, there was no significant difference in the OS between those who underwent lobectomy (5-year OS, 94.3%; 10-year OS, 92.6%) and those who underwent sublobar resection (5-year OS, 93.8%; 10-year OS, 89.3%; P = .64).ConclusionsSublobar resection of clinical stage IA lung adenocarcinoma is feasible in selected patients with disease that meets the N0 criteria, with excellent long-term survival.     

Surgical Procedure Selection for Stage I Lung Cancer: Complex Segmentectomy versus Wedge Resection

BackgroundAlthough sublobar resection has become widely used for lung cancer treatment, very limited data comparing outcomes following complex segmentectomy or wedge resection have been available. Questions remain regarding mortality, morbidity, surgical margin, lymph node dissection, and long-term survival outcomes. This study compares operative and postoperative outcomes of complex segmentectomy and wedge resection.Patients and MethodsA total of 216 patients with clinical stage I lung cancer who underwent complex segmentectomy (n = 110) or wedge resection (n = 106) between April 2007 and March 2017 were retrospectively reviewed, and 61 propensity score–matched pairs were analyzed. Operative and postoperative results were compared. Factors affecting survival were assessed using the Kaplan-Meier method.ResultsAlthough the complex segmentectomy group tended to have higher overall complications (26.2% vs. 16.4%; P = .27) and prolonged air leakage (11.5% vs. 6.6%; P = .53) rates than the wedge resection group, major complications (≥grade IIIa) (0% vs. 3.3%; P = .50) and 30-day mortality (0% vs. 0%; P = 1.00) rates were comparable between both groups. Complex segmentectomy provided better median surgical margin distance (15.0 vs. 10.0 mm; P = .052) and number of dissected lymph nodes (6.0 vs. 0.0 nodes; P = .0002) than wedge resection. The complex segmentectomy group tended to have better prognosis than the wedge resection group (5-year overall survival rates, 94.7% vs. 79.4% and 5-year recurrence-free survival rates, 94.0% vs. 76.5%, respectively).ConclusionsComplex segmentectomy could provide better oncological and survival outcomes with acceptable perioperative safety compared with wedge resection.     

Nomograms for Predicting Overall and Recurrence-free Survival From Pathologic Stage IA and IB Lung Cancer After Lobectomy

BackgroundStage I non–small-cell lung cancer (NSCLC) is potentially curable with surgical resection. Significant proportions of patients may still experience recurrence and death despite undergoing curative surgery. This study describes predictive nomograms for recurrence-free (RFS) and overall survival (OS) after lobectomy.Patients and MethodsA total of 301 patients with the American Joint Committee on Cancer pathologic stage IA and IB NSCLC who underwent open, thoracoscopic, or robotic lobectomy from January 2011 to April 2017 were analyzed. Multivariate Cox proportional hazards regression models were used to create nomograms for OS and RFS. Kaplan-Meier survival curves were calculated for OS and RFS comparing high-risk and low-risk cohorts based on nomogram scores.ResultsHistology (hazard ratio [HR], 0.24; 95% confidence interval [CI], 0.10-0.56; P = .002), lymphovascular invasion (HR, 0.46; 95% CI, 0.29-0.74; P = .001), smoking status (HR, 3.46; 95% CI, 1.25-9.55: P = .02), and total lymph nodes removed (HR, 1.05; 95% CI, 1.01-1.10; P = .021) were significant predictors for OS in a multivariate model. Lymphovascular invasion (HR, 0.55; 95% CI, 0.36-0.83; P = .0040), smoking status (HR, 2.56; 95% CI, 1.16-5.62; P = .02), total lymph nodes removed (HR, 1.04; 95% CI, 1.00-1.08; P = .029), and tumor size (HR, 1.30; 95% CI, 1.30-1.68; P = .047) were significant predictors of RFS in a multivariate model.ConclusionNomograms can predict OS and RFS for pathologic stage IA and IB NSCLC after lobectomy regardless of operative approach. The risk for death and recurrence after stratification by the nomogram scores may provide guidance regarding adjuvant therapy and surveillance.     

肺癌肺楔(段)形切除和肺叶切除

本文介绍我院用肺楔(段)形切除治疗肺癌92例的情况,和同期肺叶切除对比,合并症少,安全度高,在相同条件下(分期、病理和年龄),术后5年生存无显著差异。提示肺楔(段)形切除治疗肺癌与肺叶切除具有同样的生存效果。认为凡有肺楔(段)形切除条件者,应考虑此种术式,并提示适应症和手术方法。     

Impact of Surveillance After Lobectomy for Lung Cancer on Disease Detection and Survival

IntroductionExisting guidelines for surveillance after non–small-cell lung cancer (NSCLC) treatment are inconsistent and have relatively sparse supporting literature. This study characterizes detection rates of metachronous and recurrent disease during surveillance with computed tomography scans after definitive treatment of early stage NSCLC.Materials and MethodsThe incidence of metachronous and recurrent disease in patients who previously underwent complete resection via lobectomy for stage IA NSCLC at a single center from 1996 to 2010 were evaluated. A subgroup analysis was used to compare survival of patients whose initial surveillance scan was 6 ± 3 months (early) versus 12 ± 3 months (late) after lobectomy.ResultsOf 294 eligible patients, 49 (17%) developed recurrent disease (14 local only, 35 distant), and 45 (15%) developed new NSCLC. Recurrent disease was found at a mean of 22 ± 19 months, and new primaries were found at a mean of 52 ± 31 months after lobectomy (P < .01). Five-year survival after diagnosis of recurrent disease was significantly lower than after diagnosis of second primaries (2.3% vs. 57.5%; P < .001). In the subgroup analysis of 187 patients, both disease detection on the initial scan (2% [2/94] vs. 4% [4/93]; P = .44) and 5-year survival (early, 80.8% vs. late, 86.7%; P = .61) were not significantly different between the early (n = 94) and the late (n = 93) groups.ConclusionSurveillance after lobectomy for stage IA NSCLC is useful for identifying both new primary as well as recurrent disease, but waiting to start surveillance until 12 ± 3 months after surgery is unlikely to miss clinically important findings.     

Postoperative Recurrence and Survival After Segmentectomy for Clinical Stage 0 or IA Lung Cancer

BackgroundAlthough radical segmentectomy is an accepted treatment option for small-sized lung cancer, the outcomes remain unclear. The present study aimed to elucidate recurrence patterns and to identify predictors of time to recurrence after intentional segmentectomy for early lung cancer.Patients and MethodsProspectively collected data of 166 patients who could tolerate lobectomy and underwent intentional segmentectomy for clinical stage 0 or IA non–small-cell lung cancer between 2007 and 2016 were retrospectively analyzed. Surgical indication for intentional segmentectomy was clinical stage 0 or IA ground glass opacity-dominant tumor ≤ 3 cm or solid-dominant tumor ≤ 2 cm on high-resolution computed tomography.ResultsThe median follow-up duration was 48.8 months, during which 6 (3.6%) patients developed recurrences. The 5-year recurrence-free survival and 5-year overall survival rates were 93.1% (95% confidence interval [CI], 87.9%-96.1%) and 93.5% (95% CI, 87.7%-96.4%), respectively. Two (1.2%) patients who developed local-only recurrences subsequently underwent completion lobectomy; no cancer-related deaths were seen for these patients. In multivariable analysis, consolidation to maximum tumor diameter (C/T) ratio (hazard ratio, 1.07; 95% CI, 1.01-1.22; P = .02) was an independent predictive factor for time to recurrence. All 6 patients with recurrence had a tumor with a C/T ratio of 86% or higher.ConclusionsBased on these findings, favorable survival is expected after intentional segmentectomy for selected patients with clinical stage 0 or IA non–small-cell lung cancer. Patients with a higher C/T ratio tumor appear to be at higher risk of recurrence after intentional segmentectomy.     

Presence of Even a Small Ground-Glass Component in Lung Adenocarcinoma Predicts Better Survival

Background

While lepidic-predominant lung adenocarcinomas are known to have better outcomes than similarly sized solid tumors, the impact of smaller noninvasive foci within predominantly solid tumors is less clearly characterized. We tested the hypothesis that lung adenocarcinomas with even a small ground-glass opacity (GGO) component have a better prognosis than otherwise similar pure solid (PS) adenocarcinomas.

Lobectomy Is Associated with Better Outcomes than Sublobar Resection in Spread through Air Spaces (STAS)-Positive T1 Lung Adenocarcinoma: A Propensity Score–Matched Analysis

Introduction

Spread through air spaces (STAS) is a form of invasion wherein tumor cells extend beyond the tumor edge within the lung parenchyma. In lung adenocarcinoma (ADC), we investigated the (1) association between STAS and procedure-specific outcomes (sublobar resection and lobectomy), (2) effect of surgical margin-to-tumor diameter ratio in STAS-positive patients, and (3) potential utility of frozen sections (FSs) for detecting STAS intraoperatively.

The Influence of the Evolution of First-Line Chemotherapy on Steadily Improving Survival in Advanced Non-Small-Cell Lung Cancer Clinical Trials

Over the past three decades, survival in advanced non–small-cell lung cancer (NSCLC) clinical trials has doubled with an increase in 1-year survival from 25% to 50 to 55%. This has been mainly attributed to improvements in systemic therapy. Although modern first-line chemotherapy regimens have more favorable toxicity profiles, a statistically significant improvement in overall survival has not been demonstrated in existing meta-analyses of second-generation versus third-generation combinations. Moreover, pivotal trials demonstrating statistically significant survival superiority of third-generation regimens are consistently not reproducible even for nonsquamous populations using pemetrexed–platinum combinations. As enhancement in the efficacy of first-line systemic therapy in patients without identifiable driver mutations is questionable, other factors are discussed that explain the doubling of 1-year survival reported in clinical trials. These factors include second-line or third-line therapy, maintenance chemotherapy, performance status selection, stage migration, sex migration, improved treatment of brain metastases, and better palliative care.     

Extended Sleeve Lobectomy is an Alternative for Centrally Located Lung Cancer With Superior Short- and Long-term Outcomes

IntroductionExtended sleeve lobectomy (ESL) is a feasible alternative to pneumonectomy; however, the survival benefit is unclear, and preoperative selection of potential candidates for ESL remains a problem.Matierals and MethodsESL was performed on selected candidates with double sleeve lobectomy for more than 1 lobe (eg, left upper lobe and S6 segment resection). Three-dimensional (3-D) reconstruction was routinely validated. Patients were candidates for ESL if the predicted distal stump length was > 6 mm and the pulmonary vein of the remaining segments was not invaded.ResultsOf the 1809 patients with centrally located lung cancer for surgical resection, 86 patients with tumors invading more than 1 lobe were enrolled in the study. After evaluation by 3-D reconstruction, 22 (95.7%) of 23 selected candidates underwent ESL, and 63 patients were deemed unsuitable for ESL and underwent pneumonectomy (43 cases) or thoracic exploration (20 cases). Surgical outcomes between the ESL and pneumonectomy groups were similar in terms of complications, blood loss and surgical duration, but the 6-minute walking distance was significantly improved in the ESL group (371 ± 111 m vs. 191 ± 55 m, respectively; P < .001). The mean forced expiratory volume in 1 second was 1.6 ± 0.3 L at the 1-year follow up examination in the ESL group. In the survival analysis, no difference was observed between the ESL and pneumonectomy groups in terms of 3-year overall survival (85% vs. 89%, respectively; P = .626) and 3-year disease-free survival (75% vs. 76%, respectively; P = .625).ConclusionsESL is a feasible and superior surgical procedure in terms of its short-term and long-term outcomes, and we suggest 3-D reconstruction to identify candidates for ESL.     

Considerations for the Surgical Management of Early Stage Lung Cancer During the COVID-19 Pandemic

The highly transmissible novel coronavirus (COVID-19) has infected over 8.8 million people globally and has upended the delivery of health care in the United States, creating unprecedented challenges to providing care to patients with early stage non–small cell lung cancer (NSCLC). The initial surge of patients with COVID-19 that have flooded hospitals has put a strain on physical space, workforce, and supplies. In addition, social distancing and the risk of COVID-19 transmission has created significant barriers for thoracic surgeons to diagnose and treat patients. Many hospitals across the country have temporarily suspended elective operations to preserve hospital beds, ventilators, and personal protective equipment. Currently, the pandemic has greatly disrupted the current standard of resection after adequate staging with imaging and/or surgical staging for early stage NSCLC well beyond the initial acute phase; therefore, a new paradigm for effective management will need to be devised until the COVID-19 pandemic is eradicated with systematic vaccination and herd immunity. Thoracic surgeons will need to recalibrate their approach to ensure that patients receive timely and effective treatment for early stage NSCLC. The management of early stage NSCLC during the COVID-19 pandemic should be balanced with available hospital resources, risk of progression of disease, risk of transmission of COVID-19 to patient and surgeon, and the availability of alternative therapies. This article will address the current challenges with treating early stage NSCLC during the COVID-19 pandemic and provide a clinical framework for providing effective surgical therapy while mitigating the risk of transmission of the SARS-CoV-2 virus to patients and surgeons.     

Expanding Access to Lung Cancer Clinical Trials by Reducing the Use of Restrictive Exclusion Criteria: Perspectives of a Multistakeholder Working Group

Low rates of adult patient participation have been a persistent problem in cancer clinical trials and have continued to be a barrier to efficient drug development. The routine use of significant exclusion criteria has contributed to this problem by limiting participation in studies and creating significant clinical differences between the study cohorts and the real-world cancer patient populations. These routine exclusions also unnecessarily restrict opportunities for many patients to access potentially promising new therapies during clinical development. Multiple efforts are underway to broaden eligibility criteria, allowing more patients to enroll in studies and generating more robust data regarding the effect of novel therapies in the population at large. Focusing specifically on lung cancer as an example, a multistakeholder working group empaneled by the LUNGevity Foundation identified 14 restrictive and potentially outdated exclusion criteria that appear frequently in lung cancer clinical trials. As a part of the project, the group evaluated data from multiple recent lung cancer studies to ascertain the extent to which these 14 criteria appeared in study protocols and played a role in excluding patients (screen failures). The present report describes the working group’s efforts to limit the use of these routine exclusions and presents clinical justifications for reducing the use of 14 criteria as routine exclusions in lung cancer studies, potentially expanding trial eligibility and improving the generalizability of the results from lung cancer trials.