Efficacy of Para-Aortic Lymphadenectomy in Early-Stage Endometrioid Uterine Corpus Cancer

Purpose

The objective of this study was to assess whether para-aortic lymphadenectomy has therapeutic efficacy for patients with early-stage endometrioid uterine cancer who underwent systematic pelvic lymphadenectomy.

Methods

The authors retrospectively reviewed the medical records and pathological findings of 547 patients with histologically proven FIGO stage I-II endometrioid uterine cancer, based on comprehensive surgical staging, including pelvic with or without para-aortic lymphadenectomy.

Results

Among 547 patients, 330 patients had systematic pelvic lymphadenectomy only, and 217 had systematic pelvic with para-aortic lymphadenectomy. There were no significant differences in histopathological factors in the high-risk group, even though deep myometrial invasion (p = 0.02) and lymphvascular space invasion (p = 0.01) were more common in patients who underwent systematic pelvic with para-aortic lymphadenectomy in all study populations. Within a median follow-up of 31 (range, 5–120) months, there was no significant difference in overall survival between the pelvic lymphadenectomy only and pelvic with para-aortic lymphadenectomy groups in all populations (p = 0.77), even in high-risk patients (p = 0.82). Upon multivariate analysis, patients with lymphvascular space invasion had significantly worse overall survival (odds ratio (OR) = 7.38; 95% confidence interval (CI) = 1.86–29.23; p = 0.004).

Conclusions

Although a prospective, randomized study needs to be performed for confirmation, our data suggest that the therapeutic benefit of para-aortic lymphadenectomy is uncertain in stage I and II endometrioid uterine corpus cancer, even in patients at high-risk for recurrence.     

Prognosis After Sublobar Resection of Small-sized Non-small Cell Lung Cancer with Visceral Pleural or Lymphovascular Invasion

Background

Although standard surgical treatment of stage I non-small cell lung cancer (NSCLC) is lobectomy, sublobar resection may be elected for small-sized (≤2 cm) peripheral tumors. Our aim was examine the need for completion lobectomy in the event of confirmed pleural or lymphovascular invasion after sublobar resection of NSCLC.

Methods

A total of 271 consecutive patients undergoing curative resection of stage I NSCLC ≤2 cm were reviewed retrospectively, analyzing clinicopathologic findings and survival times of those with invasion-positive (visceral pleural or lymphovascular invasion) or invasion-negative (neither visceral pleural nor lymphovascular invasion) tumors by surgical approach (sublobar resection vs lobectomy).

Results

Aside from age and pulmonary function, clinicopathologic characteristics of the patient subsets did not differ significantly, nor did 5-year recurrence-free survival rates of surgical subsets (sublobar resection vs lobectomy) in respective tumor groups (invasion-positive 78.9 vs 79.8%, p = 0.928; invasion-negative 80.2 vs 85.4%, p = 0.505). In multivariate analysis, dissected lymph node count was the sole parameter significantly impacting recurrence of stage I invasion-positive NSCLC (hazard ratio = 0.914, 95% confidence interval 0.845–0.988; p = 0.023). Sublobar resection was not a risk factor for recurrence.

Conclusions

Survival rates for patients with small-sized (≤2 cm) NSCLC and visceral pleural or lymphovascular invasion did not differ significantly, whether sublobar resection or lobectomy was done. Hence, completion lobectomy is unnecessary in this setting.

     

Management of the Pulmonary Artery during Video-Assisted Thoracoscopic Left Upper Lobectomy

Background

Complete video-assisted thoracoscopic surgery (c-VATS) for left upper lobectomy is difficult due to the branching pattern of the left pulmonary artery.

Objective

Our purpose was to report outcomes of a modified technique of c-VATS left upper lobectomy.

Methods

We retrospectively compared the outcomes of 83 patients with stage I/II non-small-cell lung cancer (NSCLC) who received left upper lobectomy between 2008 and 2011; 32 underwent conventional c-VATS and 50 received modified c-VATS. In the modified procedure, the order in which hilum of lung was treated was from the lingular segmental artery to the superior pulmonary vein to the bronchus, and then finally the pulmonary artery.

Results

The mean patient age was 63.6 ± 8.4 years, and no differences were observed in age, gender, and largest tumor diameter between the two groups. No conversion occurred in either group. The surgical time for modified c-VATS was significantly shorter than that for conventional c-VATS (210 vs. 270 min, p < 0.001). Drainage time after surgery and length of hospitalization for the modified c-VATS group were significantly less than those for the conventional group (drainage 3 vs. 4 days, respectively, p = 0.041; length of hospitalization 7 versus 12 days, respectively; p < 0.001). Surgical margins were clear in all cases. Four (8.0 %) complications occurred in the modified procedure group compared with ten (31.3 %) in the conventional group (p = 0.015).

Conclusion

This new technique offers shorter surgical and postoperative drainage time, shorter hospital stays, and fewer complications than conventional c-VATS upper left lobectomy.     

Outcomes of lymphadenectomy for lymph node recurrence after esophagectomy or definitive chemoradiotherapy for squamous cell carcinoma of the esophagus

Objective

The aim of this study was to determine the significance of lymphadenectomy for recurrence after treatment for esophageal squamous cell carcinoma.

Methods

Short- and long-term outcomes of 24 patients who underwent lymphadenectomy for recurrence in 3 hospitals between April 2004 and March 2013 were retrospectively analyzed. There were 17 cases with lymph node recurrence after esophagectomy (11 cervical, 4 mediastinal, and 2 abdominal node recurrences) and 7 cases with remnant or recurrent lymphatic diseases after definitive chemoradiotherapy (3 cervical, 1 mediastinal, and 3 abdominal node recurrences).

Results

Three minor complications were observed among 24 patients and the median postoperative hospital stay was 7 days. The 3-year progression-free and overall survivals of patients who underwent secondary lymphadenectomy for recurrence after esophagectomy were 51.5 and 75.5 %, respectively. The overall survival of patients with cervical node recurrence was significantly better than that of patients with mediastinal or abdominal node recurrence in this group (P = 0.0097). The median progression-free and overall survivals of patients who underwent salvage lymphadenectomy after definitive chemoradiotherapy were 2 and 15 months, respectively. Although only 1 patient experienced local recurrence after secondary lymphadenectomy, locoregional failures occurred in 6 of 7 patients who underwent salvage lymphadenectomy after definitive chemoradiotherapy.

Conclusion

Secondary or salvage lymphadenectomy can be performed safely in the selected patients. Secondary lymphadenectomy achieves locoregional disease control and results in a favorable long-term outcome, particularly for cervical node recurrence. Further large-scale cohort studies are needed to determine the prognostic significance of salvage lymphadenectomy after definitive chemoradiotherapy.     

Long-Term Survival Outcomes of Video-assisted Thoracic Surgery (VATS) Lobectomy After Transitioning from Open Lobectomy

Background

Open lobectomy continues to be more commonly performed than video-assisted thoracic surgery (VATS) lobectomy. We previously described the short-term safety of an approach for transitioning from open lobectomy to VATS. We now assess its long-term safety by evaluating survival results of the initial VATS cases after transition.

Methods

From a prospective database, survival of stage I non–small cell lung cancer was compared between the first 40 VATS lobectomy and the 40 open lobectomy performed just before the transitioning to VATS. All patients underwent staging by positron emission tomographic scan and mediastinoscopy. Survival was estimated by the Kaplan–Meier method and compared by the log-rank test.

Results

Patient and intraoperative characteristics were not different between the two groups, except for operative time, which was longer for VATS (median 132 vs. 150 min, p = 0.023) and tumor size, which was smaller for VATS (median 2 vs. 2.5 cm, p = 0.002). There was no difference in morbidity and mortality. Median follow-up was 118 months for the open group and 81 months for the VATS group. The 5-year disease-free survival for stage IA (90 % open vs. 97 % VATS, p = 0.439) and IB (74 % open vs. 79 % VATS, p = 0.478) were not different. The 5-year overall survival for stage IA (91 % open vs. 97 % VATS, p = 0.152) and IB (55 % open vs. 67 % VATS, p = 0.198) were also not different.

Conclusions

The transition from open to VATS lobectomy is safe with regards to both short-term morbidity and long-term survival. Surgeons currently performing open lobectomy should consider transitioning to the VATS procedure.     

Oncologic Outcomes After Completion Thyroidectomy for Patients with Well-Differentiated Thyroid Carcinoma

Background

At our institution, thyroid lobectomy is employed as a definitive operation for unifocal intrathyroidal low risk cancers and thus completion thyroidectomy is rarely performed. The purpose of this study was to identify the indications for selective completion thyroidectomy and to report oncologic outcomes.

Methods

A retrospective review was performed to identify patients who underwent planned completion thyroidectomy for well-differentiated thyroid carcinoma (WDTC) from 2001 to 2010 based on initial lobectomy pathology. Assessment for risk of recurrence was based on the American Thyroid Association Initial Risk Stratification.

Results

During the 10-year study period, 79 patients underwent completion thyroidectomy for WDTC. Forty-four (56 %) patients were low risk and 35 (44 %) were intermediate risk. Completion thyroidectomy was recommended for 64 patients, whereas 15 patients were given an option of surveillance but ultimately decided to have surgery. Patients in the “recommended group” had more T3 tumors and fewer T1a tumors (p = 0.005 and 0.006, respectively). These patients also were more likely to be intermediate risk (p = 0.008) and to present with aggressive histology (p = 0.002). The rate of contralateral tumors (n = 27) was similar between both groups (35 and 33 %, respectively). Contralateral cancers were micropapillary in 24 of 27 (89 %) patients, 10 (40 %) of whom had multifocal disease. There were two pulmonary recurrences and no local-regional recurrences (median follow-up of 42.3 months).

Conclusions

Completion thyroidectomy is infrequent and performed for a select group of intermediate and low risk WDTCs at our institution with low recurrence rates. Incidental multifocal and unifocal contralateral cancers are common after completion thyroidectomy.     

Thoracoscopic lobectomy: is a training program feasible with low postoperative morbidity?

Objective

To evaluate the feasibility of training program in video assisted thoracic surgery (VATS) lobectomy comparing intraoperative and postoperative data of patients operated on by an established consultant and trainees.

Methods

Retrospective analysis of 100 consecutive patients who underwent VATS lobectomies between May 2008 and May 2012. 66 patients were operated on by an established consultant (Group A) and 34 by trainees (Group B).

Results

The groups were comparable for clinical characteristics and pathological staging. The mean operating time in Group A was 125 ± 30 min and in Group B was 133 ± 26 min (p = 0.18). The rate of conversion was similar in both groups: 9.1 % in Group A and 8.8 % in Group B (p = 0.6). The complication rate was comparable (p = 0.4): 36.3 % in Group A and 32.3 % in Group B. Median time to drain removal and median length of hospital stay was 3 and 5.5 days in Group A and 3 and 5 days in Group B, showing no statistical differences between the two groups (p = 0.3 and 0.5). There were no differences in term of long-term complications between the two groups.

Conclusion

Our study showed that a training program in VATS lobectomy is feasible, without increasing the operative time, conversion rate, postoperative complication, time to drain removal, and length of hospital stay.     

Patterns of Recurrence and Survival After Lymphadenectomy in Melanoma Patients: Clarifying the Effects of Timing of Surgery and Lymph Node Tumor Burden

Background

Melanoma patients with lymph node (LN) metastases have variable survival after lymphadenectomy. This study investigates whether lymphadenectomy at different times in the course of disease progression influences disease-free survival (DFS; time from primary diagnosis to first recurrence after lymphadenectomy), post recurrence survival (PRS; time from first recurrence after lymphadenectomy to death), and overall survival (OS; time from diagnosis to death).

Methods

Between 1992 and 2010, a total of 1,704 patients underwent lymphadenectomy; 502 underwent immediate completion lymphadenectomy (ICL) after positive sentinel node biopsy (SNB), 214 had delayed completion lymphadenectomy (DCL) for regional recurrence after positive SNB with no ICL or after an earlier false-negative SNB, 709 had no SNB and later required delayed therapeutic lymphadenectomy (DTL) for clinically evident metastasis, and 279 had immediate therapeutic lymphadenectomy (ITL) for clinically positive LNs at primary melanoma diagnosis.

Results

Median DFS for ICL, DCL, DTL, and ITL was 68, 48, 82, and 16 months, respectively (p < 0.001). Median PRS for ICL, DCL, DTL, and ITL was 14, 8, 9, and 9 months, respectively (p < 0.001). Median OS for ICL was not reached whilst for DCL, DTL, and ITL it was 71, 101, and 29 months, respectively (p < 0.001). Extranodal spread and tumor, node, metastasis classification system N stage were the only significant prognostic factors for OS within each group. ICL patients had significantly improved DFS (p = 0.005) and OS (p = 0.012) beyond 5 years compared to DTL patients.

Conclusions

Variable outcomes after lymphadenectomy were observed with different timing of surgery and LN tumor burden. ICL patients had the best outcome.     

Association of Depression and Anxiety on Quality of Life, Treatment Adherence, and Prognosis in Patients with Advanced Non-small Cell Lung Cancer

Background

Symptoms of depression and anxiety are common in patients with lung cancer and may produce an impact on both health-related quality of life (HRQL) and survival. The aim of the present study was to evaluate the association of depression and anxiety on HRQL, treatment adherence, and prognosis in patients with non-small cell lung cancer (NSCLC).

Methods

This is a prospective study of patients with stage IIIB or IV NSCLC. Depression and anxiety were measured using the hospital anxiety and depression scale, the International Neuropsychiatric Interview, and the HRQL with the EORTC QLQ-C30 and QLQ-LC13 questionnaires. Instruments were applied before treatment and repeated at 3 and 6 months. Lack of treatment adherence was considered as patients who stopped going to their consultation appointments.

Results

A total of 82 patients were included. At the initial evaluation, depression and anxiety were found in 32.9 and 34.1 % of patients, respectively. Depression was associated with feminine gender (p = 0.034) and poor performance status (p = 0.048). Depression and anxiety showed an association with HRQL. Patients with depression showed median overall survival of 6.8 months, whereas that for nondepressed patients was 14 months (hazard ratio [HR], 1.9; 95 % confidence interval (95 % CI), 1.03–3.7; p = 0.042). The 58 % of patients with depression had poor treatment adherence versus 42 % of patients without depression (p = 0.004).

Conclusions

Depression and anxiety were present in one-third of patients with recently diagnosed NSCLC. Depression and anxiety were associated with decreased HRQL scales, and depression was independently associated with treatment adherence and with poor prognosis.     

Video-assisted thoracoscopic lobectomy with the patient in the semi-prone position: initial experience and benefits of lymph node dissection

Objectives

Recently, the prone position has been used for thoracoscopic oesophagectomy for oesophageal cancer because it is known to facilitate mediastinal dissection. We hypothesized that this advantage of the prone position could apply to video-assisted thoracoscopic surgery, which has been commonly performed with the patient in the lateral position.

Methods

Forty-six patients with clinical stage I, right-sided, non-small cell lung cancer were enrolled in this study. They were classified into three groups: conventional thoracotomy using rib retractors (n = 17), and the lateral (n = 15) and semi-prone (n = 14) positions in video-assisted thoracoscopic surgery. Surgical parameters, such as operation time, the amount of blood loss, and the number of dissected lymph nodes, of each group of patients were compared.

Results

There were three (6.5 %) minor complications in this study, chylothorax and heart failure in the thoracotomy group and atelectasis with the video-assisted thoracoscopic surgery in the lateral position group. No complications were seen in the semi-prone group. The number of dissected lymph nodes was significantly higher in the video-assisted thoracoscopic surgery in the semi-prone position group than in the conventional thoracotomy group for inferior mediastinal nodes (subcarinal, paraeosophageal, and pulmonary ligament, average 8.9 and 5.9 lymph nodes, p = 0.04).

Conclusions

To the best of our knowledge, this is the first report that has described video-assisted thoracoscopic lobectomy with the patient in the semi-prone position. Although the number of cases was limited, the results of this study show that the semi-prone position could be attempted especially for right lower lobe lung cancer.     

Surgical treatment for non-small cell lung cancer with ipsilateral pulmonary metastases

Purpose

The aim of this retrospective study was to evaluate the relevance of surgery in non-small cell lung cancer (NSCLC) patients with ipsilateral pulmonary metastases.

Methods

The clinical records of 1,623 consecutive NSCLC patients who underwent surgery between 1990 and 2007 were retrospectively reviewed. Overall, 161 (9.9 %) and 21 (1.3 %) patients had additional nodules in the same lobe as the primary lesion (PM1) and additional nodules in the ipsilateral different lobe (PM2), respectively.

Results

The 5-year survival rate was 54.4 % in the PM1 patients and 19.3 % in the PM2 patients (log-rank test: p = 0.001). Tumor size ≤3 cm, N0-1 status and surgical procedures less extensive than bilobectomy were identified as favorable prognostic factors in the PM1 patients. The 5-year survival rate in the PM1-N0-1 patients was 68.7 %, while that in the PM1-N2-3 patients was 29.1 % (p < 0.0001). Compared to the non-PM1 stage IIIA patients, the stage IIIA patients with PM1 disease (PM1-N1) tended to experience longer survival times (p = 0.06). Squamous cell types and bilobectomy or more extensive procedures were found to be unfavorable factors in the PM2 patients. The survival of the PM2 patients was significantly worse than that of the other T4 patients (p = 0.007).

Conclusions

PM1 patients with N0-1 disease are good candidates for surgery, whereas PM2 patients do not appear to benefit from surgery.     

Predictors of early and late outcome after total arch replacement for atherosclerotic aortic arch aneurysm

Objectives

This study aimed to identify predictors of early and late outcome after total arch replacement (TAR) for atherosclerotic aortic arch aneurysm.

Methods

TAR with separate arch vessel grafting and selective cerebral perfusion was performed in 130 patients. The median age at operation was 72.9 ± 6.1 years (57–86 years). Emergency operation was performed in 9 patients (6.9 %) and the frozen elephant trunk technique was used in 51 patients (39.2 %).

Results

The in-hospital mortality rate was 3.8 %. Chronic renal failure (CRF) was identified as an independent predictor of in-hospital mortality (p = 0.0001). Permanent neurological dysfunction occurred in nine patients (6.9 %). Clot or atheroma in the aneurysm (p = 0.01) and the duration of selective cerebral perfusion (p = 0.011) were identified as independent predictors of permanent neurological dysfunction. Long-term survival rates were 82.0 % at 3 years, 70.0 % at 5 years, and 52.4 % at 8 years postoperatively. CRF (p = 0.0190), age (p = 0.0147), and permanent neurological dysfunction (p = 0.0048) were identified as independent predictors of long-term mortality.

Conclusions

Prevention of permanent neurological dysfunction is crucial for long-term survival after TAR. Older patients with renal dysfunction may have reduced long-term survival after TAR.     

Predictors for Locoregional Recurrence for Clinical Stage III-N2 Non-small Cell Lung Cancer with Nodal Downstaging After Induction Chemotherapy and Surgery

Purpose

Pathologic downstaging following chemotherapy for stage III-N2 NSCLC is a well-known positive prognostic indicator. However, the predictive factors for locoregional recurrence (LRR) in these patients are largely unknown.

Methods

Between 1998 and 2008, 153 patients with clinically or pathologically staged III-N2 NSCLC from two cancer centers in the United States were treated with induction chemotherapy and surgery. All had pathologic N0-1 disease, and none received postoperative radiotherapy. LRR were defined as recurrence at the surgical site, lymph nodes (levels 1–14 including supraclavicular), or both.

Results

Median follow-up was 39.3 months. Pretreatment N2 status was confirmed pathologically (18.2 %) or by PET/CT (81.8 %). Overall, the 5-year LRR rate was 30.8 % (n = 38), with LRR being the first site of failure in 51 % (22/+99877943). Five-year overall survival for patients with LRR compared with those without was 21 versus 60.1 % (p < 0.001). Using multivariate analysis, significant predictors for LRR were pN1 disease at time of surgery (p < 0.001, HR 3.43, 95 % CI 1.80–6.56) and a trend for squamous histology (p = 0.072, HR 1.93, 95 % CI 0.94–3.98). Five-year LRR rate for pN1 versus pN0 disease was 62 versus 20 %. Neither single versus multistation N2 disease (p = 0.291) nor initial staging technique (p = 0.306) were predictors for LRR. N1 status also was predictive for higher distant recurrence (p = 0.021, HR 1.91, 95 % CI 1.1–3.3) but only trended for poorer survival (p = 0.123, HR 1.48, 95 % CI 0.9–2.44).

Conclusions

LRR remains high in resected stage III-N2 NSCLC patients after induction chemotherapy and nodal downstaging, particularly in patients with persistent N1 disease.     

Increased Platelet Counts after Transthoracic En Bloc Resection for Esophageal Cancer is Associated with Significantly Improved Survival

Background

We analyzed perioperative platelet counts as a potential clinical marker for survival after transthoracic en bloc resection for esophageal cancer. Recent data described preoperative thrombocytosis in malignancies to be associated with poor prognosis.

Methods

A retrospective analysis from a prospective database (1997–2006) was performed for 291 consecutive patients with esophageal cancer who underwent transthoracic en bloc esophagectomy and extended lymphadenectomy. Squamous cell cancer was found in 47.0% and adenocarcinoma in 50.9% (2.1% had rare histologies). Neoadjuvant chemoradiation was performed in 152 (52%) patients. Platelet counts before surgery and on postoperative days (PODs) 1, 10, and 30 were evaluated. We used the published cutoff value of 293 × 10⁹/l (mean of 80 healthy controls ± standard deviation) for platelet counts.

Results

High platelet counts before surgery missed significance for poorer survival (p = 0.054). Following a perioperative fall in thrombocytes, a significant rise at POD 10 after surgery was evident. Platelet counts of more than 293 × 10⁹/l at this time correlated with a significantly improved survival rate (p = 0.027). Patients with no increase in thrombocytes until POD 10 had significantly poorer survival (p = 0.012). Multivariate analysis confirmed that a thrombocyte increase between the preoperative count and that on POD 10 is an independent prognostic indicator (p = 0.035) for patients with completely (R0) resected tumors.

Conclusions

An increase in platelet counts measured on POD 10 following transthoracic en bloc esophagectomy and extended lymphadenectomy is an independent prognostic indicator for improved survival in patients with esophageal cancer.     

Morbidity and Outcomes Following Axillary Lymphadenectomy for Melanoma: Weighing the Risk of Surgery in the Era of MSLT-II

Background

Limited data exist characterizing complications after axillary lymphadenectomy for melanoma. With high rates of complications reported after dissection for breast cancer and data suggesting that completion lymphadenectomy may have limited therapeutic benefit, this study characterized morbidity to facilitate clinical decision-making.

Methods

Using a broad definition for complications, patients who underwent axillary dissection for melanoma at a single center (from 2003 to 2015) were assessed through retrospective chart review. Patients were stratified by potential risk factors for complications; outcomes were compared.

Results

Two hundred fifty-four axillary dissections in 239 patients were identified. Assessed risk factors for complications included age > 55 years (n = 133, 52%), body mass index (BMI) ≥ 30 kg/m² (n = 90, 40%), diabetes (n = 40, 16%), smoking (n = 81, 32%), extremity primary (n = 71, 28%), therapeutic lymphadenectomy (n = 105, 41%), and adjuvant radiation (n = 33, 13%). Wound complications were observed in 51 patients with 38 (15%) seromas, 3 (1%) dehiscences, and 10 (4%) hematomas. There were 5 (2%) reoperations, all for hematoma. Thirty-day readmission rate was 6% (n = 14). Importantly, lymphedema occurred in only 13 (5%) patients. Wound dehiscence occurred only in smokers (p = 0.03) and was associated with adjuvant radiation (p = 0.04). Twenty-eight (11%) patients developed frozen shoulder, which was related to smoking (p = 0.02). Lymphedema was more likely in patients after therapeutic dissection (p = 0.04). All other risk factors were not associated with increased complications.

Conclusions

This analysis supports historical data that axillary dissection for melanoma is a low-risk procedure, with smoking, therapeutic lymphadenectomy, and adjuvant radiation associated with increased morbidity. Although morbidity of lymphadenectomy is often cited as a reason to alter surgical approach or even forgo intervention, this may be less of a concern for axillary dissection.

     

Minimum Nodal Yield in Oral Squamous Cell Carcinoma: Defining the Standard of Care in a Multicenter International Pooled Validation Study

Purpose

There is evidence to suggest that a nodal yield <18 is an independent prognostic factor in patients with clinically node negative (cN0) oral squamous cell carcinoma (SCC) treated with elective neck dissection (END). We sought to evaluate this hypothesis with external validation and to investigate for heterogeneity between institutions.

Patients and Methods

We analyzed pooled individual data from 1,567 patients treated at nine comprehensive cancer centers worldwide between 1970 and 2011. Nodal yield was assessed with Cox proportional hazard models, stratified by study center, and adjusted for age, sex, pathological T and N stage, margin status, extracapsular nodal spread, time period of primary treatment, and adjuvant therapy. Two-stage random-effects meta-analyses were used to investigate for heterogeneity between institutions.

Results

In multivariable analyses of patients undergoing selective neck dissection, nodal yield <18 was associated with reduced overall survival [hazard ratio (HR) 1.69; 95 % confidence interval (CI) 1.22–2.34; p = 0.002] and disease-specific survival (HR 1.88; 95 % CI 1.21–2.91; p = 0.005), and increased risk of locoregional recurrence (HR 1.53; 95 % CI 1.04–2.26; p = 0.032). Despite significant differences between institutions in terms of patient clinicopathological factors, nodal yield, and outcomes, random-effects meta-analysis demonstrated no evidence of heterogeneity between centers in regards to the impact of nodal yield on disease-specific survival (p = 0.663; I ² statistic = 0).

Conclusion

Our data confirm that nodal yield is a robust independent prognostic factor in patients undergoing END for cN0 oral SCC, and may be applied irrespective of the underlying patient population and treating institution. A minimum adequate lymphadenectomy in this setting should include at least 18 nodes.     

Intrapleural chemotherapy improves the survival of non-small cell lung cancer patients with positive pleural lavage cytology

Purpose

Information regarding the treatment of pleural lavage cytology (PLC)-positive patients is still limited. This study evaluated the efficacy of intrapleural chemotherapy (IPC) in PLC-positive patients.

Methods

Three hundred eighty-six of the 567 lung cancer patients who underwent surgery had undergone PLC after thoracotomy, following by a complete resection were evaluated. IPC was performed after surgery, and cisplatin or adriamycin was injected intrapleurally through the thoracic tube.

Results

The pathological diagnosis showed that 17 patients (4.4 %) were positive for (or suspected to have) malignancy in their PLC. The univariate and multivariate analysis showed that only pleural invasion was a significant predictor of a PLC-positive status. The 5-year overall survival in PLC-positive patients was 38 % and that in PLC-negative patients was 84 %. Both the univariate (p < 0.01) and multivariate (p = 0.045) analyses showed that the status of PLC was significantly associated with the overall survival. Eight of the 17 PLC-positive patients underwent IPC. The 2-year OS rate in the patients treated with IPC was 88 % and that of those without IPC was 44 (p = 0.04).

Conclusion

IPC improved the postoperative survival in PLC-positive NSCLC patients, and a further prospective evaluation regarding this therapy is warranted.     

Video-assisted mediastinoscopy as a therapeutic tool

Background

Video-assisted mediastinoscopy (VAM) is a well-known method for surgical exploration of superior retrovascular mediastinal disease and for determining the staging of lung cancer. This study aimed to report the authors’ experience using VAM therapeutically.

Methods

Between 1998 and 2007, 765 patients had VAM in the authors’ service. For 742 of these patients, VAM was used to diagnose or stage a disease. The remaining 23 patients (3%) had VAM as a therapeutic procedure. Two groups of patients were studied: those who had VAM alone and those who had VAM associated with another procedure. These studies focused on indications, results, and specific morbidity and mortality.

Results

The VAM alone group (14 patients) underwent mediastinal lymphadenectomy for thyroid cancer (mean number of lymph nodes/positives, 16/6) (n = 4), closure of the left post-pneumonectomy bronchopleural fistula (n = 3), mediastinal cyst resection (n = 5), ectopic hyperfunctioning parathyroid resection (n = 1), and mediastinal hematoma evacuation (n = 1). This group had an operative time of 40 to 160 min and a hospital stay of 2 to 10 days. The group that had VAM associated with another approach (9 patients) had VAM during transhiatal esophagectomy for cancer (mean number of lymph nodes, 8) (n = 7), VAM combined with video-assisted thoracoscopic surgery (n = 1), and minithoracotomy for masses in the aortopulmonary window (unique metastasis from melanoma or thyroid cancer) (n = 1). This group had an operative time of 60 to 135 min and a hospital stay of 7 to 52 days. No specific mortality or morbidity occurred. Meanwhile, three patients died: two after bronchopleural fistula (respiratory insufficiency, severe sepsis) and one because of liver insufficiency. Two patients experienced myocardial ischemia or pneumonia after transhiatal esophagectomy.

Conclusions

“Exploratory” VAM for mediastinal disease is an important training tool that can be applied further for a therapeutic purpose. The authors’ experience has shown its potential. Its surgical indications and benefits deserve better identification.     

Spirometric and radiological evaluation of the remnant lung long after major pulmonary resection: can compensatory phenomena be recognized in clinical cases?

Purposes

The purpose of this study was to investigate the compensatory phenomena after lung resection in clinical cases by evaluating the spirometric and radiological parameters.

Methods

Forty patients undergoing lobectomy for stage IA lung cancer were divided into the following groups: (A) patients with <10 (n = 20) and (B) patients with ≥10 resected subsegments (n = 20). Comparisons were made of the predicted and observed postoperative values of spirometry and radiological parameters, such as lung volumetry and the “estimated lung weight”. Predicted values were based on the number of resected subsegments. The postoperative time to re-evaluation was at least 1 year for both groups.

Results

The predicted postoperative values of spirometry underestimated the actual values, and the differences were more significant in group B (forced vital capacity, p = 0.006, forced expiratory volume in 1 s, p = 0.011). Focusing on the remnant lungs on the surgical side, group B had significantly larger % postoperative lung volumes (161 ± 6.0 %) and % estimated lung weight (124 ± 5.4 %) than did group A (114 ± 3.8 %, p < 0.0001; 89.5 ± 4.4 %, p < 0.0001, respectively).

Conclusions

Major lung resection in clinical cases causes a compensatory restoration of the pulmonary function and tissue.     

Evolution of a Lung-Sparing Strategy with Sleeve Lobectomy and Induction Therapy for Non-small Cell Lung Cancer: 20-Year Experience at a Single Institution

Background

To elucidate the evolution of a lung-sparing strategy with sleeve lobectomy (SL) and induction therapy for non-small cell lung cancer (NSCLC).

Methods

We retrospectively reviewed 205 patients with NSCLC who underwent pneumonectomy (PN, n = 54) or SL (n = 151) from 1994 to 2013. The study period was divided into four 5-year periods, and surgical trends were analyzed, focusing on the PN:SL ratio.

Results

PN was associated with a significantly advanced pathological stage, a larger tumor size and less pulmonary function compared with SL. The PN group had higher 30-day (3.7 vs. 0 %, p = 0.018) and 90-day (13.0 vs. 1.3 %, p = 0.0003) mortality than the SL group. The overall 5-year survival rate was significantly higher with SL (71.5 %) versus PN (42.8 %, p = 0.011) for patients with pN0–1. The ratio of PN among total surgeries decreased significantly over the four periods (1994–1998, 1999–2003, 2004–2008, and 2009–2013) from 5.63 % to 3.17, 1.40, and 1.38 %, respectively (p < 0.0001); in contrast, the PN:SL ratio increased significantly from 1.64 to 2.50, 3.71, and 5.44, respectively (p = 0.041). During the last period, when we introduced induction therapy, 38 of 651 who received surgery underwent induction therapy. The PN:SL ratios of those who did and did not undergo induction therapy were 15 (PN: 1, SL: 15) and 4.25 (PN: 8, SL: 34), respectively.

Conclusions

A lung-sparing strategy with SL for NSCLC can decrease the PN rate to less than 2 % with less mortality. Induction therapy may facilitate SL and increase the PN:SL ratio.