Impact of lymphadenectomy extent on immunotherapy efficacy in postresectional recurred non-small cell lung cancer: a multi-institutional retrospective cohort study.

BACKGROUND: Lymph node (LN) dissection is a common procedure for non-small cell lung cancer (NSCLC) to ascertain disease severity and treatment options. However, murine studies have indicated that excising tumor-draining LNs diminished immunotherapy effectiveness, though its applicability to clinical patients remains uncertain. Hence, the authors aim to illustrate the immunological implications of LN dissection by analyzing the impact of dissected LN (DLN) count on immunotherapy efficacy, and to propose a novel 'immunotherapy-driven' LN dissection strategy. MATERIALS AND METHODS: The authors conducted a retrospective analysis of NSCLC patients underwent anti-PD-1 immunotherapy for recurrence between 2018 and 2020, assessing outcomes based on DLN count stratification. RESULTS: A total of 144 patients were included, of whom 59 had a DLN count less than or equal to 16 (median, IQR: 11, 7-13); 66 had a DLN count greater than 16 (median, IQR: 23, 19-29). With a median follow-up time of 14.3 months (95% CI: 11.0-17.6), the overall median progression-free survival (PFS) was 7.9 (95% CI: 4.1-11.7) months, 11.7 (95% CI: 7.9-15.6) months in the combination therapy subgroup, and 4.8 (95% CI: 3.1-6.4) months in the immunotherapy alone subgroup, respectively. In multivariable Cox analysis, DLN count less than or equal to 16 is associated with an improved PFS in all cohorts [primary cohort: HR=0.26 (95% CI: 0.07-0.89), P =0.03]; [validation cohort: HR=0.46 (95% CI: 0.22-0.96), P =0.04]; [entire cohort: HR=0.53 (95% CI: 0.32-0.89), P =0.02]. The prognostic benefit of DLN count less than or equal to 16 was more significant in immunotherapy alone, no adjuvant treatment, pN1, female, and squamous carcinoma subgroups. A higher level of CD8+ central memory T cell (Tcm) within LNs was associated with improved PFS (HR: 0.235, 95% CI: 0.065-0.845, P =0.027). CONCLUSIONS: An elevated DLN count (cutoff: 16) was associated with poorer immunotherapy efficacy in recurrent NSCLC, especially pronounced in the immunotherapy alone subgroup. CD8+Tcm proportions in LNs may also impact immunotherapy efficacy. Therefore, for patients planned for adjuvant immunotherapy, a precise rather than expanded lymphadenectomy strategy to preserve immune-depending LNs is recommended.

Factors influencing patient satisfaction after treatments for early-stage non-small cell lung cancer.

PURPOSE: Patient-reported outcome measures, including satisfaction with treatment decisions, provide important information in addition to clinical outcomes, survival and decision-making in lung cancer surgery. We investigated associations between preoperative clinical and socio-demographic factors and patient-reported satisfaction 6 weeks after radical treatment for early-stage non-small cell lung cancer (NSCLC). METHODS: We conducted a sub-group analysis of the prospective observational longitudinal study of 225 participants in two treatment groups-surgical (VATS) and radiotherapy (SABR). The Patient Satisfaction Questionnaire-18 (PSQ-18) was used to measure patient satisfaction 6 weeks after treatment. Clinical variables, Index of Multiple Deprivation decile and Decision self-efficacy scores were used in regression analysis. Variables with a p level < 0.1 were used as independent predictors in generalised linear logistic regression analyses. RESULTS: As expected, the two groups differed in pre-treatment clinical features. The SABR group experienced more grade 1-2 complications than the VATS group. No differences were found between the groups in any subscale of the PSQ-18 questionnaire. Patients experiencing complications or living in more deprived areas were more satisfied with care. Properative factors independently associated with patient satisfaction were the efficacy in decision-making and age. CONCLUSION: We showed that efficacy in treatment decision-making and age was the sole predictor of patient satisfaction with their care after radical treatment for early-stage NSCLC. Patients from more deprived areas and patients who suffered complications reported greater subsequent satisfaction. Involving patients in their care may improve satisfaction after treatment for early-stage NSCLC.

Thoracic Anesthesia during the COVID-19 Pandemic: 2021 Updated Recommendations by the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) Thoracic Subspecialty Committee.

The novel coronavirus pandemic has radically changed the landscape of normal surgical practice. Lifesaving cancer surgery, however, remains a clinical priority, and there is an increasing need to fully define the optimal oncologic management of patients with varying stages of lung cancer, allowing prioritization of which thoracic procedures should be performed in the current era. Healthcare providers and managers should not ignore the risk of a bimodal peak of mortality in patients with lung cancer; an imminent spike due to mortality from acute coronavirus disease 2019 (COVID-19) infection, and a secondary peak reflecting an excess of cancer-related mortality among patients whose treatments were deemed less urgent, delayed, or cancelled. The European Association of Cardiothoracic Anaesthesiology and Intensive Care Thoracic Anesthesia Subspecialty group has considered these challenges and developed an updated set of expert recommendations concerning the infectious period, timing of surgery, vaccination, preoperative screening and evaluation, airway management, and ventilation of thoracic surgical patients during the COVID-19 pandemic.

Anatomical segmentectomy versus pulmonary lobectomy for stage I non-small-cell lung cancer: patients selection and outcomes from the European Society of Thoracic Surgeons database analysis.

OBJECTIVES: The aims of this study were to describe the potential selection criteria for patients scheduled for lobectomy versus segmentectomy for stage I non-small-cell lung cancer and to compare the 2 procedures in terms of intraoperative variables and postoperative outcomes using the European Society of Thoracic Surgeons (ESTS) Registry. METHODS: This observational multicentre retrospective cross-sectional study was based on data collected from the ESTS database. The following were set as inclusion criteria: pulmonary lobectomy or segmentectomy for stage I primary lung cancer (according to 8th TNM edition), no previous lung surgery and no induction chemotherapy or radiotherapy. Statistical significance was examined using Mann-Whitney or 2 proportions Z tests. RESULTS: Among 63 542 patients enrolled in the ESTS database (2007-2018), 17 692 met the inclusion criteria: 15 845 patients received lobectomy and 1847 segmentectomy. Video-assisted thoracic surgery (VATS) lobectomy and VATS segmentectomy were the 27.8% and 31.9% of the procedures, respectively. Lobectomy group was significantly younger and had a lower American Society of Anaesthesiology (ASA) score, lower comorbidities prevalence and better respiratory function. The segmentectomy group had lower complications rate (25.6% vs 33.8%). When considering only the last 5 years, ASA score was similar between the 2 groups, although pulmonary function remained significantly lower in the segmentectomy group. CONCLUSIONS: According to the ESTS database, segmentectomy was preferably offered to 'compromised' patients, with limited respiratory function, higher ASA score and relevant comorbidities. Nevertheless, the procedure showed lower complications rate and similar short-term outcomes compared to lobectomy. During the last 5 years, segmentectomy appeared to be regarded as a valid alternative, even for selected patients who could tolerate both procedures.

Multicentric evaluation of the impact of central tumour location when comparing rates of N1 upstaging in patients undergoing video-assisted and open surgery for clinical Stage I non-small-cell lung cancer†.

OBJECTIVES: Large retrospective series have indicated lower rates of cN0 to pN1 nodal upstaging after video-assisted thoracic surgery (VATS) compared with open resections for Stage I non-small-cell lung cancer (NSCLC). The objective of our multicentre study was to investigate whether the presumed lower rate of N1 upstaging after VATS disappears after correction for central tumour location in a multivariable analysis. METHODS: Consecutive patients operated for PET-CT based clinical Stage I NSCLC were selected from prospectively managed surgical databases in 11 European centres. Central tumour location was defined as contact with bronchovascular structures on computer tomography and/or visibility on standard bronchoscopy. RESULTS: Eight hundred and ninety-five patients underwent pulmonary resection by VATS (n = 699, 9% conversions) or an open technique (n = 196) in 2014. Incidence of nodal pN1 and pN2 upstaging was 8% and 7% after VATS and 15% and 6% after open surgery, respectively. pN1 was found in 27% of patients with central tumours. Less central tumours were operated on by VATS compared with the open technique (12% vs 28%, P < 0.001). Logistic regression analysis showed that only tumour location had a significant impact on N1 upstaging (OR 6.2, confidence interval 3.6-10.8; P < 0.001) and that the effect of surgical technique (VATS versus open surgery) was no longer significant when accounting for tumour location. CONCLUSIONS: A quarter of patients with central clinical Stage I NSCLC was upstaged to pN1 at resection. Central tumour location was the only independent factor associated with N1 upstaging, undermining the evidence for lower N1 upstaging after VATS resections. Studies investigating N1 upstaging after VATS compared with open surgery should be interpreted with caution due to possible selection bias, i.e. relatively more central tumours in the open group with a higher chance of N1 upstaging.

Prediction of major cardiovascular events after lung resection using a modified scoring system.

BACKGROUND: Cardiovascular complications occur in 10% to 15% of patients after major lung resection. We evaluated the utility of a revised scoring system (thoracic revised cardiac risk index; ThRCRI) in identifying patients at increased risk for major cardiovascular complications. METHODS: We analyzed outcomes from the Society of Thoracic Surgeons General Thoracic Database for the period 2003 to 2011 for elective major lung resection. The ThRCRI risk score was based on weighted values for serum creatinine, coronary artery disease, cerebrovascular disease, and extent of lung resection, and was stratified into the following 4 risk categories: 0 (A); 1 to 1.5 (B); 2 to 2.5 (C); and >2.5 (D). Major cardiovascular complications included myocardial infarction, adult respiratory distress syndrome, ventricular arrhythmia requiring treatment, and all-cause death. RESULTS: A total of 26,085 patients (mean age 65.4±11.4 years; 51.3% men) underwent lobectomy (21,679; 83.2%), bilobectomy (1,446; 5.5%) or pneumonectomy (1,697; 6.5%). Major cardiovascular complications occurred in 1,125 patients (4.3%). ThRCRI scores in patients without and with major cardiovascular complications were 0.6±0.9 and 1.1±1.1 (p<0.0001). Score categories yielded incremental risks of major cardiovascular complications (A: 2.9%; B: 5.8%; C: 11.9%; D: 11.1%; p<0.0001). CONCLUSIONS: The ThRCRI score stratified risk moderately well for major postoperative cardiovascular events after major lung resection. Use of this scoring system might help in identifying patients who would benefit from additional preoperative evaluation and from closer perioperative monitoring.