Abstract
OBJECTIVES: Anatomical lobar resection and mediastinal lymphadenectomy remain the standard for the treatment of early stage non-small-cell lung cancer (NSCLC) and are preferred over ...procedures such as segmentectomy or wedge resection. However, there is an ongoing debate concerning the influence of the extent of the resection on overall survival. The aim of this article was to assess the overall survival for different types of resection for Stage I NSCLC.
METHODS: We performed a retrospective analysis of the results of the surgical treatment of Stage I NSCLC. Between 1 January 2007 and 31 December 2013, the data from 6905 patients who underwent Stage I NSCLC operations were collected in the Polish National Lung Cancer Registry (PNLCR) and overall survival was assessed. A propensity score-matched analysis was used to compare 3 groups of patients, each consisting of 231 patients who underwent lobectomy, segmentectomy, or wedge resection.
RESULTS: In the unmatched and matched patient groups, lobectomy and segmentectomy were associated with a significant benefit compared to wedge resection regarding overall survival (log-rank P < 0.001 and P = 0.001). The Cox proportional hazard ratio comparing segmentectomy and lobectomy to wedge resection was 0.54 95% confidence interval (CI): 0.37–0.77) and 0.44 (95% CI: 0.38–0.50), respectively, indicating a significant improvement in survival. There was no difference in the 5-year survival of patients after lobectomy (79.1%; 95% CI: 77.7–80.4%) or segmentectomy (78.3%; 95% CI: 70.6–86.0%). The 30-day mortality rate was 1.6, 2.6 and 1.4% for lobectomy, segmentectomy and wedge resection, respectively. Wedge resection was associated with a significantly lower 5-year survival rate (58.1%; 95% CI: 53.6–62.5%) compared to segmentectomy (78.3%; 95% CI: 70.6–86.0%) and lobectomy (79.1%; 95% CI: 77.7–80.5%). The propensity score matched analysis confirmed most of the results of the comparisons of unmatched study groups.
CONCLUSIONS: Wedge resection was associated with significantly lower 3-year and 5-year survival rates compared to the other methods of resection. There was no significant difference in 3-year or 5-year survival rates between lobectomy and segmentectomy. Segmentectomy, but not wedge resection, could be considered an alternative to lobectomy in the treatment of patients with Stage I NSCLC.
Studies have demonstrated a lower incidence of complications after video-assisted thoracoscopic surgery (VATS) lobectomy compared with thoracotomy, but the data on in-hospital and 90-day mortality ...are inconclusive. This study analyzed whether surgical approach, VATS or thoracotomy, was related to early mortality of lobectomy in lung cancer and determined the differences between in-hospital and 90-day mortality.
Data of all patients with non-small cell lung cancer who underwent lobectomy between January 1, 2007, and July 30, 2018, were retrieved from Polish National Lung Cancer Registry. Included were 31 433 patients who met all study criteria. After propensity score matching, 4946 patients in the VATS group were compared with 4946 patients in the thoracotomy group.
Compared with thoracotomy, VATS lobectomy was related to lower in-hospital (1.5% vs 0.9%, P = .004) and 90-day mortality (3.4% vs 1.8%, P < .001). Mortality at 90 days was twice as high as in-hospital mortality in both the VATS (1.8% vs 0.9%, P < .001) and thoracotomy groups (3.4% vs 1.5%, P < .001). Postoperative complications were less common after VATS compared with thoracotomy (23.6% vs 31.8%, P < .001).
VATS lobectomy is associated with lower in-hospital and 90-day mortality compared with thoracotomy and should be recommended for lung cancer treatment, if feasible. Patients should also be closely monitored after discharge from the hospital, because 90-day mortality is significant higher than in-hospital mortality.
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We aimed to study the clinical significance of the lack of lymph node assessment (pNx status) and its impact on survival in non-small-cell lung cancer patients.
We retrospectively analysed the Polish ...Lung Cancer Study Group database. pNx status was defined as 0 lymph nodes removed. We included 17,192 patients.
A total of 1080 patients (6%) had pNx status. pNx patients were more likely to be younger, be female, have a different pT distribution, have squamous cell carcinoma, undergo open thoracotomy, be operated on in non-academic hospitals, and have a lower rate of some comorbidities. pNx was more likely to be cN0 than pN1 and pN2 but less likely than pN0 (p < 0.001). pNx patients were less likely to undergo preoperative invasive mediastinal diagnostics than pN1 and pN2 patients but more likely than pN0 patients (p < 0.001). Overall, the five-year overall survival rates were 64%, 45%, 32% and 50% for pN0, pN1, pN2 and pNx, respectively. In pairwise comparisons, all pN descriptors differed significantly from each other (all p < 0.0001 but pNx vs. pN1 p = 0.016). The placement of the pNx survival curve and survival rate depended on histopathology, surgical approach and pT status. In multivariable analysis, pNx was an independent prognostic risk factor (HR = 1.37, 95%CI: 1.23–1.51, p < 0.01).
The resection of lymph nodes in lung cancer remains a crucial step in the surgical treatment of this disease. The survival of pNx patients is similar to that of pN1 patients. pNx survival curve placement depends on the other variables which could be useful in clinical decisions.
•Impact of pNx (0 lymph nodes) status on lung cancer patients survival was analysed.•We found pNx status in 6% of cases.•The 5-year OS rates were 64%, 45%, 32%, 50% for pN0, pN1, pN2, pNx, respectively.•The survival of pNx is similar to that of pN1 rather than pN0.•pNx survival depends on the other variables that could be useful in daily practice.
Background and ObjectivePulmonary vascular variations are a major factor in thoracic surgeries. Minimally invasive techniques, such as video-assisted thoracic surgery (VATS) used in non-small lung ...cancer treatment, have a limited field of view and no haptic feedback. Additionally, new studies suggest that segmentectomies are beneficial for patients. Accurate knowledge of vascular patterns and variants is crucial for conducting such procedures safely. The aim of this review was to systematize data in a useful manner from studies and case reports concerning pulmonary vascular variations and patterns.MethodsWe conducted a search on the PubMed and Embase databases. We used classifications of Nagashima, Yamashita, Boyden, Maciejewski, and Shimizu.Key Content and FindingsThe analysis showed that more data on the incidence rate and vascular patterns of certain bronchopulmonary segments are needed. Venous variations are a major factor in segmental resections, but additional data regarding incidence and pattern types are needed. Surgeons need to be aware of vascular variations as they can influence procedures in seemingly unrelated areas. The majority of studies emphasize the use of three-dimensional (3D) reconstruction of computed tomography (CT) for accurate planning of any thoracic procedures.ConclusionsAbnormal vessels pose a risk in various procedures performed within the thorax, and the data in this review could be valuable in different medical areas in this regard.
This study aimed to determine whether three preoperative cycles of gemcitabine plus cisplatin followed by radical surgery provides a reduction in the risk of progression compared with surgery alone ...in patients with stages IB to IIIA non-small-cell lung cancer (NSCLC).
Patients with chemotherapy-naive NSCLC (stages IB, II, or IIIA) were randomly assigned to receive either three cycles of gemcitabine 1,250 mg/m(2) days 1 and 8 every 3 weeks plus cisplatin 75 mg/m(2) day 1 every 3 weeks followed by surgery, or surgery alone. Randomization was stratified by center and disease stage (IB/IIA v IIB/IIIA). The primary end point was progression-free survival (PFS). Results The study was prematurely closed after the random assignment of 270 patients: 129 to chemotherapy plus surgery and 141 to surgery alone. Median age was 61.8 years and 83.3% were male. Slightly more patients in the surgery alone arm had disease stage IB/IIA (55.3% v 48.8%). The chemotherapy response rate was 35.4%. The hazard ratios for PFS and overall survival were 0.70 (95% CI, 0.50 to 0.97; P = .003) and 0.63 (95% CI, 0.43 to 0.92; P = .02), respectively, both in favor of chemotherapy plus surgery. A statistically significant impact of preoperative chemotherapy on outcomes was observed in the stage IIB/IIIA subgroup (3-year PFS rate: 36.1% v 55.4%; P = .002). The most common grade 3 or 4 chemotherapy-related adverse events were neutropenia and thrombocytopenia. No treatment-by-histology interaction effect was apparent.
Although the study was terminated early, preoperative gemcitabine plus cisplatin followed by radical surgery improved survival in patients with clinical stage IIB/IIIA NSCLC.
Abstract
OBJECTIVES
We aimed to investigate the clinical significance of left lower paratracheal nodes (#4L) and their impact on survival in patients with left-sided lung cancer.
METHODS
This was a ...retrospective analysis of prospective data. The study included 5369 patients who underwent surgery between 2005 and 2015. Six hundred fifty-nine patients underwent #4L dissection (4LND+), and 4710 did not (4LND−). Propensity score matching was used to minimize analytic error (659 vs 659).
RESULTS
The percentage of #4L metastasis increased with tumour size. Between pT2a and pT2b, it nearly doubled from 8% to 14%. The mean percentage of #4L metastasis in the pN2 group was 46, which was higher in left upper lobectomy compared to left lower lobectomy (63% vs 43%, respectively, P < 0.001). In univariable analysis, no differences in 5-year survival were observed between 4LND+ and 4LND− (48% vs 50%, respectively, P = 0.65). However, we detected a significant difference among non-metastatic 4LND+, 4LND− and metastatic 4LND+ (P < 0.0001). After propensity score matching, there were no significant differences in survival among the pN2 subgroups (pN2a1, pN2a2, pN2b1, pN2b2). Multivariable analysis after propensity score matching for each pN2 subgroup did not confirm the effect of #4L metastasis as an independent prognostic factor.
CONCLUSIONS
Despite #4L nodes not being an independent prognostic factor in lung cancer, the percentage of nodal metastases notably increases above pT2a grade and is comparable to the percentage of #5 and #7 metastasis. Therefore, lymphadenectomy in advanced stages of cancer could benefit from resections of the #4L nodes.
The International Association for the Study of Lung Cancer has proposed a new classification of N descriptor based on the number of metastatic lymph nodes (LNs) stations, including skip metastasis. ...The aim of the study was to determine the effect of removed LNs on the adequacy of this new classification.
The material was collected retrospectively based on the database of the Polish Lung Cancer Group, including information on 8016 patients with non-small cell lung cancer operated in 23 thoracic surgery centers in Poland. The material covered the period from January 2005 to September 2015. We divided patients into two groups: ≤6LNs and >6LNs removed.
In the whole group, an average of 13.4 nodes and 4.54 nodal stations were removed. 5-year survivals in the >6LNs group vs ≤ 6LNs group were: 62.3% and 55.1% (N0), 44.5% and 35.9% (N1a), 34.1% and 31,7% (N1b), 37.3% and 26.3% (N2a1), 32.4% and 26.7% (N2a2), 29.4% and 29.2% (N2b1), and 22.0% and 23.0% (N2b2), respectively. Comparing these groups, we detected significant differences at N0 (p < 0.001) and N2a1 (p = 0.022). In the ≤6LNs group, the survival curves for N2a1, N2a2, N2b1, and N2b2 overlapped (p > 0.05). In the >6LNs group, the survival curves were significantly different between grades, with survival for N2a1 better than N1b (p = 0.232).
The proposed classification N descriptor is potentially better at differentiating patients into different stages. The accuracy of the classification depends on the number of lymph nodes removed. Therefore, the extent of lymphadenectomy has a significant impact on the staging of surgically-treated lung cancer.
•New method of lymph node staging in lung cancer possibly better predict survival.•This method benefits from a number of lymph nodes removed during surgery.•Therefore, these two factors have significant impact on lung cancer staging.
More information is needed on gender differences in lung cancer surgery. Thus, we conducted a retrospective study on thoracic treatment of non-small cell lung cancer (NSCLC) patients between 2007 and ...2020 in Poland. The aim was to characterize sex differences in survival after complete surgical resection and to compare postoperative complications between Polish men and women. The main aspects that were compared between women and men were as follows: type of surgery and postoperative staging, morbidity and mortality, thoracic surgery complications, comorbidities, and overall survival based on a univariate analysis including propensity score matching (PSM) and a multivariate analysis.
Data were collected retrospectively from the Polish Lung Cancer Study Group database. Patients who were surgically treated for NSCLC between 2007 and 2020 (n = 17,192) were included in the study.
The univariate analysis showed significantly better survival in women than in men. Women had better 5-year survival compared to men both for adenocarcinoma and squamous cell carcinoma (66% vs. 53%, p < 0.0001 and 65% vs. 51%, p<0.0001%, respectively), for both smokers and non-smokers (65% vs. 52%, p < 0.0001 and 65% vs. 51%, p < 0.0001, respectively), all age groups, and all stages (IA1 to III B). In the PSM analysis, statistically significant differences in favor of women were found for lower lobectomy (67% vs. 50%, p < 0.0001) and upper lobectomy (67% vs. 56%, p < 0.0001). Overall, postoperative complications occurred in 33.1% of patients and were observed more often in men than in women (35.8% vs. 28.6%, p < 0.001).
Women with NSCLC who were treated surgically had a better long-term outcome compared to men, with no significant difference in disease severity. In addition to gender, the histological type, comorbidities, and type of surgery and surgical approach are also important.
•Gender has important role in survival for NSCLC.•Women had better 5-year survival compared to men overall and in various subgroups.•Women treated surgically for NSCLC have better outcomes in lower and upper lobectomy.
BackgroundWe aimed to assess the clinical significance and impact on survival of prevascular mediastinal lymph nodes (3A) in patients with right-sided lung cancer. MethodsProspective data of 6,348 ...patients, who underwent lung resection from 2005 to 2015, were retrospectively analysed. There were 221 patients who underwent 3A dissection (3ALN+), while 6,127 did not (3ALN-). We performed propensity score matching (PSM) to decrease selection bias (221 vs. 221). ResultsThe incidence of 3A metastasis was 8%, and it elevated with pT stage. Between pT1c and pT2a, there was a significant increase in the 3A metastasis incidence, which doubled from 4% to 9%. For pT4, the incidence was 15%. The highest incidence was found among patients undergoing pneumonectomy (10%) and in the N2b1 and N2b2 subgroups (33% and 64%). In univariable analysis, we found no differences in 5-year survival between 3ALN+ and 3ALN- (51% vs. 51%, P=0.74). But, non-metastatic 3ALN+, 3ALN-, and metastatic 3ALN+ differed significantly (P<0.0001). pN2 subgroups (pN2a1, pN2a2, pN2b1, pN2b2) within PSM analysis did not differ significantly in terms of survival. 3A metastasis failed to be an independent prognostic factor in the multivariable analysis of matched pN2 subgroups. ConclusionsRegardless of 3A lymph nodes failing to be an independent prognostic factor in our cohort, the incidence of metastases in lymph nodes increases notably in advanced stages. 3A metastasis rate is comparable to other lymph node stations. Therefore, superior mediastinal lymphadenectomy in advanced cancers may improve from resections of the 3A lymph node station.