Optimal Treatment Strategy for Oligo-Recurrence Lung Cancer Patients with Driver Mutations.

BACKGROUND: The efficacy of local therapies for lung cancer patients with postoperative oligo-recurrence has been reported. However, whether local therapies should be chosen over molecular targeted therapies for oligo-recurrence patients with driver mutations remains controversial. Therefore, we aimed to investigate the optimal initial treatment strategy for oligo-recurrence in lung cancer patients with driver mutations. METHODS: Among 2152 patients with lung adenocarcinoma who underwent surgical resection at our institute between 2008 and 2020, 66 patients with driver mutations who experienced cancer oligo-recurrence after surgery and were treated with local or molecularly targeted therapy as an initial therapy after recurrence were evaluated. Oligo-recurrence was characterized by the presence of 1 to 3 recurrent lesions. These patients were investigated, focusing on their post-recurrence therapies and prognoses. RESULTS: The median follow-up period was 71 months. Local and molecular targeted therapies were administered to 41 and 25 patients, respectively. The number of recurrence lesions tended to be lower in the initial local therapy group than in the molecular targeted therapy group. In the initial local therapy group, 23 patients (56%) subsequently received molecular targeted therapies. The time from recurrence to the initiation of molecular targeted therapy was significantly longer in the local therapy group than in the molecular targeted therapy group (p < 0.001). There was no significant difference in post-recurrence overall survival (hazard ratio, 1.429; 95% confidence interval, 0.701-2.912; log-rank, p = 0.324) and post-recurrence progression-free survival (hazard ratio, 0.799; 95% confidence interval, 0.459-1.390; log-rank, p = 0.426) in the initial local ablative therapy group compared with the initial molecular targeted therapy group. CONCLUSIONS: Local therapies as a first-line treatment did not show statistically significant differences in post-recurrence survival or progression-free survival compared with molecular targeted therapies. However, local therapies as an initial treatment should be considered preferably, as they can cure the recurrence and can delay the start of administration of molecular targeted therapies.

Laser-assisted direct roller imprinting of large-area microstructured optical surfaces.

In this study, a high-throughput fabrication method called laser-assisted direct roller imprinting (LADRI) was developed to lower the cost of nanoimprinting large-area polymer films and to address problems associated with nanoimprinting, namely, microstructural damage and precision in flatness of entire film. With LADRI, the laser directly heats the microstructured surface of the roller mold, which heats and melts the surface of a polymethyl methacrylate (PMMA) film to replicate the microstructures on the mold rapidly. In this study, the effects of laser power density, scanning speed, size of the microstructures, and contact pressure on the replication speed were investigated experimentally. The replication speed increased as the power and scanning speed increased. However, because the film required heating until it filled the entire depth of the microstructure, an appropriate replication speed was necessary. This result was supported by simulation of the temperature distribution inside the mold and the PMMA using transient heat conduction analyses. To demonstrate the applications of LADRI, two different optical surfaces were replicated: an antireflection (AR) structure with conical structures sized several hundred nanometers and a light-extraction structure with a microlens array (MLA) comprising 10 µm lenses, for display and illumination, respectively. The replication degree of the MLA was governed by the contact pressure. Polymer flow simulation indicated that the heat conduction and flow speeds of the melted PMMA surface were comparable within several tens of micrometers. In addition, the reflectivity of the AR structure decreased from 4 to 0.5%, and the light intensity of the light-extraction structure increased by a factor of 1.47.

Prediction of Tumor PD-L1 Expression in Resectable Non-Small Cell Lung Cancer by Machine Learning Models Based on Clinical and Radiological Features: Performance Comparison With Preoperative Biopsy.

OBJECTIVE: We investigated if PD-L1 expression can be predicted by machine learning using clinical and imaging features. METHODS: We included 117 patients with c-stage I/II non-small cell lung cancer who underwent radical resection. A total of 3951 radiomic features were extracted by defining the tumor (within tumor contour), rim (contour ±3 mm) and exterior (contour +10 mm) on preoperative contrast computed tomography. After feature selection by Boruta algorithm, prediction models of tumor PD-L1 expression (22C3: ≥1%, <1%) of resected specimens were constructed using Random Forest: radiomics, clinical, and combined models. Their performance was evaluated by 5-fold cross-validation, and AUCs were compared using Delong test. Next, study groups were categorized as patients without biopsy (training set), and those with biopsy (test set). Predictive ability of biopsy was compared to each prediction model. RESULTS: Of 117 patients (66 ± 10 years old, 48% male), 33 (28.2%) had PD-L1≥1%. Mean AUC of PD-L1≥1% for the validation set in radiomics, clinical, and combined models were 0.80, 0.80, and 0.83 (P = .32 vs. clinical model), respectively. The diagnosis of malignancy was made in 22 of 38 (58%) patients with attempted biopsies, and PD-L1 was measurable in 19 of 38 (50%) patients. Diagnostic accuracies of PD-L1≥1% from 19 determinable biopsies and 38 all attempted biopsies were 0.68 and 0.34, respectively. These were out performed by machine learning: 0.71, 0.71, and 0.74 for radiomics, clinical, and combined models, respectively. CONCLUSIONS: Our machine learning could be an adjunctive tool in estimating PD-L1 expression prior to neoadjuvant treatment, particularly when PD-L1 is indeterminable with biopsy.

Paving the Way for Memory Enhancement: Development and Examination of a Neurofeedback System Targeting the Medial Temporal Lobe.

Neurofeedback (NF) shows promise in enhancing memory, but its application to the medial temporal lobe (MTL) still needs to be studied. Therefore, we aimed to develop an NF system for the memory function of the MTL and examine neural activity changes and memory task score changes through NF training. We created a memory NF system using intracranial electrodes to acquire and visualise the neural activity of the MTL during memory encoding. Twenty trials of a tug-of-war game per session were employed for NF and designed to control neural activity bidirectionally (Up/Down condition). NF training was conducted with three patients with drug-resistant epilepsy, and we observed an increasing difference in NF signal between conditions (Up-Down) as NF training progressed. Similarities and negative correlation tendencies between the transition of neural activity and the transition of memory function were also observed. Our findings demonstrate NF's potential to modulate MTL activity and memory encoding. Future research needs further improvements to the NF system to validate its effects on memory functions. Nonetheless, this study represents a crucial step in understanding NF's application to memory and provides valuable insights into developing more efficient memory enhancement strategies.

Prognostication Using the Japanese Risk Calculator for Lung Cancer Surgery.

INTRODUCTION: Various calculation models to predict surgical risk have been developed globally. These have been reported to be helpful for estimating the long-term prognosis. In Japan, a similar model for lung cancer surgery was developed in 2017; however, there have been no reports investigating its association with the long-term prognosis. The objective of this study was to assess the association of the model's predictions with the long-term prognosis. PATIENTS AND METHODS: In this retrospective single-institutional study, we analyzed lung cancer patients who underwent radical lobectomy between 2010 and 2016. We calculated the predicted rates of mortality (PRM) and composite outcomes of mortality with major morbidity (PRMM) in eligible patients (N = 1054) using this model and classified them into 2 classes (class A, PRM ≥0.8% and PRMM ≥5.9%; class B, others) based on their models' predictions. We assessed the prognostic impact and clinical utility of the model's predictions. RESULTS: Class A included patients with significantly poorer postoperative overall survival than class B (log-rank, P < .001; hazard ratio, 3.160; 95% confidence interval, 2.390-4.178). Time-dependent receiver operating characteristic curve analyses revealed that the model's predictions correlated strongly with 1- and 2-year overall survival and decision curve analysis showed that they had high net benefits for prediction of those. CONCLUSION: The Japanese risk calculator could stratify the long-term prognosis for lung cancer patients after surgery. This model may be a valuable tool not only for multidisciplinary thoracic oncology teams to discuss treatment strategies for high-risk cases but also for them to share the decision-making process with patients.

Outcomes of lung oligometastasis in pancreatic cancer.

OBJECTIVE: Pancreatic cancer with lung oligometastasis may have favourable overall survival. The aim of this study was to evaluate outcomes of pancreatic cancer with lung oligometastases including both synchronous and metachronous metastases. METHODS: Consecutive pancreatic cancer patients with lung metastasis treated at our institution between February 2015 and December 2021 were identified from our prospectively maintained database. Clinical characteristics and outcomes were compared and analysed according to the extent of lung metastases. Predictors for overall survival were analysed using the Cox proportional hazards model. RESULTS: A totoal of 171 patients were included (oligometastasis/polymetastasis/multi-organ metastasis: 34/50/87). Patients with oligometastases were more likely to undergo surgical resection (41% vs. 0% vs. 2%) and showed a longer median overall survival (41.3 vs. 17.6 vs. 13.1 months) compared with those with other types of metastases. Oligometastasis (hazard ratio, 0.43; 95% confidence interval, 0.24-0.76; P = 0.004) was identified as an independent factor predicting favourable overall survival in patients with lung-only metastasis. Disease status (synchronous vs. metachronous) was not associated with survival in patients with oligometastasis (29.4 vs. 41.3 months, P = 0.527) and polymetastasis (17.9 vs. 16.7 months, P = 0.545). Selected patients who underwent surgical resection showed a median overall survival of 52.7 months. CONCLUSIONS: Patients with lung oligometastases presented a favourable prognosis. Surgical resection in selected patients was associated with a long median overall survival.

Intracranial Neurofeedback Modulating Neural Activity in the Mesial Temporal Lobe During Memory Encoding: A Pilot Study.

Removal of the mesial temporal lobe (MTL) is an established surgical procedure that leads to seizure freedom in patients with intractable MTL epilepsy; however, it carries the potential risk of memory damage. Neurofeedback (NF), which regulates brain function by converting brain activity into perceptible information and providing feedback, has attracted considerable attention in recent years for its potential as a novel complementary treatment for many neurological disorders. However, no research has attempted to artificially reorganize memory functions by applying NF before resective surgery to preserve memory functions. Thus, this study aimed (1) to construct a memory NF system that used intracranial electrodes to feedback neural activity on the language-dominant side of the MTL during memory encoding and (2) to verify whether neural activity and memory function in the MTL change with NF training. Two intractable epilepsy patients with implanted intracranial electrodes underwent at least five sessions of memory NF training to increase the theta power in the MTL. There was an increase in theta power and a decrease in fast beta and gamma powers in one of the patients in the late stage of memory NF sessions. NF signals were not correlated with memory function. Despite its limitations as a pilot study, to our best knowledge, this study is the first to report that intracranial NF may modulate neural activity in the MTL, which is involved in memory encoding. The findings provide important insights into the future development of NF systems for the artificial reorganization of memory functions.

Risk factors for bronchopleural fistula after lobectomy for lung cancer.

Background: Bronchopleural fistula (BPF) after lobectomy for lung cancer is a rare but serious complication. This study aimed to stratify the risk factors of BPF. Methods: Patients who underwent lobectomy without bronchoplasty and preoperative treatment for lung cancer between 2005 and 2020 were retrospectively reviewed. We examined the association between the incidence of BPF and background factors, including comorbidities, preoperative blood test results, respiratory function, surgical procedure, and extent of lymphadenectomy. Results: Among the 3,180 patients who underwent lobectomy, 14 (0.44%) developed BPF. The median interval from surgery to BPF onset was 21 days (range, 10-287). Two of the 14 patients died of BPF (mortality rate, 14%). All 14 patients who developed BPF were men and had undergone right lower lobectomy. Other factors significantly associated with the development of BPF were older age, heavy smoking, obstructive ventilatory failure, interstitial pneumonia, history of malignancy, history of gastric cancer surgery, low serum albumin levels, and histology. Multivariable analysis in the subgroup of men who underwent right lower lobectomy revealed that high level of serum C-reactive protein and a history of gastric cancer surgery were significantly associated with BPF, whereas bronchial stump coverage was inversely associated with BPF. Conclusions: Men who underwent right lower lobectomy were at increased risk of BPF. The risk was higher when the patient had high serum C-reactive protein or a history of gastric cancer surgery. Bronchial stump coverage might be effective in patients at high risk of BPF.

A new surgical tape with a mesh designed to prevent skin tears and reduce pain during tape removal.

We devised a surgical tape that prevents skin tears while maintaining adhesive strength. Under the assumption that microscopic damage to the skin is reflected in pain felt on the skin, we statistically analyzed skin pain when the tape was peeled off to show the skin protection effect of the mesh on the new tape. This tape has a three-layer structure consisting of a tape substrate, adhesive, and mesh. When the tape is applied to the skin, a mesh is located between the adhesive and the skin. The adhesive contacts the skin through the mesh holes and fixes the substrate to the skin; it does not come into contact with the skin at the mesh body; therefore, the adhesive-skin contact area is reduced. In this experiment, we used surgical tape with and without mesh. At 8 hours after the application of each tape to the forearm of five adult males, it was removed. All tapes were peeled off while maintaining an angle of approximately 120° between the skin and tape substrate. For the tape with mesh, the tape substrate was peeled off in two ways: peeling off the substrate together with the mesh and peeling off the substrate, leaving the mesh on the skin. A perception and pain quantification analyzer (Pain Vision™) was used to quantify pain. The data were compared and examined statistically (Friedman's test and Wilcoxon's coded rank test). The least pain was experienced while peeling off the tape substrate, leaving the mesh on the skin. There was a significant difference in pain levels among the three tape removal methods. There was also a significant difference between the two peeling methods in the experimental group. The skin protection effect of the mesh reduced pain when the surgical tape was removed.

Detection of EGFR mutations in early-stage lung adenocarcinoma by machine learning-based radiomics.

Background: We hypothesized that epidermal growth factor receptor (EGFR) mutations could be detected in early-stage lung adenocarcinoma using radiomics. Methods: This retrospective study included consecutive patients with clinical stage I/II lung adenocarcinoma who underwent curative-intent pulmonary resection from March-December 2016. Using preoperative enhanced chest computed tomography, 3,951 radiomic features were extracted in total from the tumor (area within the tumor boundary), tumor rim (area within ±3 mm of the tumor boundary), and tumor exterior (area between +10 mm outside the tumor and tumor boundary). A machine learning-based radiomics model was constructed to detect EGFR mutations. The combined model incorporated both radiomic and clinical features (gender and smoking history). The performance was validated with five-fold cross-validation and evaluated using the mean area under the curve (AUC). Results: Of 99 patients (mean age, 66±11 years; female, 66.6%; clinical stage I/II, 89.9%/10.1%), EGFR mutations in the surgical specimen were detected in 46 (46.5%). A median of 4 (range, 2 to 8) radiomic features was selected for each validation session. The mean AUCs in the radiomics and combined models were 0.75 and 0.83, respectively. The two top-ranked features in the combined model were the radiomic features extracted from the tumor exterior and the tumor, indicating a higher impact of radiomic features over relevant clinical features. Conclusions: Radiomic features, including those in the peri-tumoral area, may help detect EGFR mutations in lung adenocarcinomas in preoperative settings. This non-invasive image-based technology could help guide future precision neoadjuvant therapy.

Sublobar Resection for Non-Small Cell Lung Cancer in Octogenarians: A Prospective, Multicenter Study.

BACKGROUND: Segmentectomy is a good surgical option for peripheral, early, non-small cell lung cancer (NSCLC) ≤2 cm. However, the role of sublobar resection including wedge resection and segmentectomy remains unclear for octogenarians with >2-cm but ≤4-cm early-stage NSCLC, for which lobectomy is a standard treatment. METHODS: By use of a prospective registry, 892 patients aged ≥80 years with operable lung cancer were enrolled at 82 institutions. Of these, we analyzed the clinicopathologic findings and surgical outcomes of 419 patients with NSCLC tumors of 2 to 4 cm during a median follow-up of 50.9 months between April 2015 and December 2016. RESULTS: Five-year overall survival (OS) was slightly but not significantly worse after sublobar resection than after lobectomy in the entire cohort (54.7% [95% CI, 43.2%-93.0%] vs 66.8% [95% CI, 60.8%-72.1%]; P = .09). Multivariable Cox regression analysis of OS revealed that these surgical procedures were not independent prognostic predictors (hazard ratio, 0.8 [0.5-1.1]; P = .16). The 5-year OS was comparable between 192 patients who could tolerate lobectomy but were treated by sublobar resection or lobectomy (67.5% [95% CI, 48.8%-80.6%] vs 71.5% [95% CI, 62.9%-78.4%]; P = .79). Recurrence after sublobar resection and lobectomy was locoregional in 11 (11%) of 97 and in 23 (7%) of 322 patients, respectively. CONCLUSIONS: OS might be equivalent between sublobar resection with a secure surgical margin and lobectomy for selected patients aged ≥80 years with peripheral early-stage NSCLC tumors of 2 to 4 cm who can tolerate lobectomy.

Initial perioperative outcomes of robot-assisted thoracoscopic lobectomy using a confronting setting.

PURPOSE: Most robot-assisted thoracoscopic surgery (RATS) is performed from the vertical view. This study evaluates the initial outcomes of our novel confronting RATS technique, in which the patient was viewed horizontally, as in open thoracotomy. METHODS: We reviewed data on patients who underwent thoracoscopic lobectomy between January, 2019 and April, 2022. Perioperative outcomes were compared between RATS and video-assisted thoracoscopic surgery (VATS), using propensity-score matching. RESULTS: RATS and VATS were performed for 83 and 571 patients, respectively. After propensity-score matching, data on 81 patients from each of the two groups were retrieved. The operative time was significantly longer for RATS than for VATS (199 ± 44 min vs. 173 ± 37 min, p < 0.001). There was no mortality or conversion to thoracotomy in either of the groups. The rates of overall complications and prolonged air leak did not differ significantly between the groups. The serum creatine phosphokinase level on postoperative day 4 was higher after RATS than after VATS. The number of resected lymph nodes and the rates of nodal upstaging did not differ significantly between the groups. CONCLUSION: The initial perioperative outcomes of RATS using the confronting settings were comparable to those of VATS.

Ringlike Peripheral Increased Iodine Concentration for the Differentiation of Primary Lung Cancer and Pulmonary Metastases on Contrast-Enhanced Dual-Energy CT.

BACKGROUND. Differentiation of primary lung cancers and pulmonary metastases may present a diagnostic dilemma given overlapping CT findings. OBJECTIVE. The purpose of this study was to compare the utility of ringlike peripheral increased iodine concentration and conventional findings for differentiating primary lung cancers from pulmonary metastases on dual-energy CT (DECT). METHODS. This retrospective study included 93 patients (64 men, 29 women; median age, 70 years) who underwent resection of a primary lung cancer (n = 68) or pulmonary metastasis (n = 25) corresponding to a solid lesion on preoperative contrast-enhanced DECT performed between April 2020 and March 2021. Venous phase 120-keV single-energy images, equilibrium phase 66-keV virtual monoenergetic images, and iodine concentration maps were reconstructed. Two radiologists independently assessed lesions for spiculated margins, air bronchograms, rim enhancement, and thin ringlike peripheral high iodine concentration; differences were resolved by consensus. Inter-reader agreement and diagnostic performance were assessed. Multivariable logistic regression analysis incorporated additional patient and lesion characteristics. RESULTS. Interobserver agreement, expressed as kappa, was 0.26 for spiculated margins, 0.60 for air bronchograms, 0.56 for rim enhancement, and 0.80 for ringlike peripheral high iodine concentration. Pulmonary metastases, compared with primary lung cancers, exhibited significantly higher frequency of ringlike peripheral high iodine concentration (52% vs 19%; p = .004) but no significant difference in frequency of spiculated margins (49% vs 32%; p = .17), air bronchograms (36% vs 51%; p = .24), or rim enhancement (4% vs 4%; p > .99). Sensitivity and specificity for diagnosing pulmonary metastasis were 68% and 49% for absence of spiculated margins, 64% and 51% for absence of air bronchograms, 4% and 96% for presence of rim enhancement, and 52% and 81% for presence of ringlike peripheral high iodine concentration. In multivariable analysis including smoking history, lesion diameter, multiple resected lesions, and ringlike peripheral high iodine concentration, the only independent significant predictor of pulmonary metastasis was ringlike peripheral high iodine concentration (OR, 7.81 [95% CI, 2.28-29.60); p = .001). CONCLUSION. Ringlike peripheral high iodine concentration had excellent interobserver agreement and high specificity (albeit poor sensitivity) for differentiating pulmonary metastasis from primary lung cancer and was independently predictive of pulmonary metastasis. CLINICAL IMPACT. Ringlike peripheral high iodine concentration could help guide management of patients with known cancer and an indeterminate solitary nodule.

Distinct Prognostic Impact of PET Findings Based on Radiological Appearance in Clinical Stage IA Lung Adenocarcinoma.

INTRODUCTION: Although solid appearance on computed tomography and positive findings on positron emission tomography (PET) have been both associated with poor outcome in lung adenocarcinoma, the extent to which these findings overlap is unknown. This study aimed to determine the differences in prognostic significance of PET findings in part-solid nodules (PSNs) and solid nodules. MATERIALS AND METHODS: We retrospectively investigated 417 patients with clinical stage IA adenocarcinoma who underwent curative resection between 2010 and 2017. We compared disease-free survival (DFS), cumulative incidence of disease recurrence (CIR) and clinicopathological characters between PET-positive and negative groups among PSNs and solid nodules, respectively. We used 2.5 as a cut-off value of maximum standardized uptake value (SUV max). RESULTS: In PSNs (n = 235), PET-positive group (n = 59) showed more aggressive features in several clinicopathological variables, poorer DFS (P < .001) and higher CIR (P < .001) than PET-negative group (n = 176). In contrast, in solid nodules (n = 182), DFS (P = .521) and CIR (P = .311) were not significantly different between PET-positive (n = 128) and negative groups (n = 54). SUV max was proved to be the independent prognostic factor of DFS by multivariate analysis (HR, 1.155; 95% CI, 1.036-1.287) only in PSNs. CONCLUSION: These findings showed distinct impact on prognosis of PET findings between PSNs and solid nodules. PET-positive finding was more important prognostic factor in PSNs than in solid nodules among clinical stage IA lung adenocarcinoma.

Advances in the treatment of postoperative recurrence of non-small cell lung cancer and their impact on survival in Asian patients.

OBJECTIVES: We investigated the effect of tyrosine kinase inhibitors (TKIs) and immunotherapy on survival after postoperative recurrence of non-small cell lung cancer (NSCLC). METHODS: This single-center retrospective study included patients with NSCLC who underwent lobectomy or more with complete pathological resection between 2008 and 2018 (N = 2254). Median follow-up was 5.1 years. Survival trends and the effect of TKIs/immunotherapy were analyzed using Joinpoint (National Cancer Institute) and Cox regression. RESULTS: In 443 (19.7%) postoperative recurrences, median time to recurrence was 1.1 years; epidermal growth factor receptor mutation (EGFR+), 191 (43.1%); anaplastic lymphoma kinase rearrangement (ALK+), 13 (2.9%); not detected or unknown (ND), 239 (54.0%). In multivariable analysis, age, time to recurrence, adenocarcinoma, symptomatic recurrence, any treatment for recurrence, use of the epidermal growth factor receptor TKI, use of the anaplastic lymphoma kinase TKI, and use of immunotherapy were significant prognostic factors. Survival was significantly better in the EGFR+/ALK+ group than in the ND group (median, 4.7 vs 2.1 years; P < .01). Between 2010 and 2018, 2-year postrecurrence survival improved significantly (annual percentage change [APC], 4.2; 95% CI, 1.5-7.0). In subset analyses, neither change in 2-year survival nor TKI use was significant over time in the EGFR+/ALK+ group, but the ND group experienced significant improvement in 2-year survival (APC, 13.5; 95% CI, 5.4-22.2) and increasing trend in immunotherapy use (APC, 23.0; 95% CI, -5.9 to 60) after 2013. CONCLUSIONS: Survival after postoperative recurrence of NSCLC has improved significantly since 2010. Use of immunotherapy in patients without driver mutations may have contributed to that improvement. Prognosis in patients with driver mutations remains favorable with the TKIs introduced before the study period.

Impact of previous upper gastrointestinal cancer surgery on complications after lobectomy for lung cancer.

Background: The number of lung cancer patients with a history of other malignancies is increasing. Previous upper gastrointestinal cancer (UGIC) surgery may increase the risk of complications after lung cancer surgery due to malnutrition and susceptibility in patients; therefore, we investigated its short-term outcomes. Methods: We retrospectively examined patients with lung cancer who underwent thoracoscopic lobectomy between 2011 and 2021 and collected data regarding postoperative complications and postoperative pulmonary complications ≥ grade II of the Clavien-Dindo classification that developed within 3 months post-surgery. The effect of UGIC surgery on the postoperative complications was evaluated by multivariable analysis using logistic regression. Results: Among the 1,385 included patients, 377 patients had a history of cancer surgery and 65 (4.7%) of them had undergone UGIC surgery. Postoperative and pulmonary complications were observed in 155 (11.2%) and 39 (2.9%) patients, respectively. The frequency of pulmonary complications was significantly higher in patients with previous UGIC surgery (9.2% vs. 2.5%, P=0.003) with no significant difference in all complications (16.9% vs. 10.9%, P=0.137). Multivariable analysis showed that previous UGIC surgery is an independent factor associated with postoperative pulmonary complications (odds ratio =2.923, P=0.029). In contrast, previous surgery for cancer other than UGIC was not associated with postoperative pulmonary complications (the rate was 1.2% after lower gastrointestinal cancer surgery and 3.0% after non-gastrointestinal cancer surgery). Conclusions: Previous UGIC surgery was an independent factor associated with postoperative pulmonary complications after lung cancer surgery.

Optimal timing for lung metastasectomy in patients with colorectal cancer.

OBJECTIVES: The possibility of occult metastasis remains a concern when deciding on lung metastasectomy. This study aimed to evaluate the utility of our two-step determination, which required confirmation that no new metastases had occurred over 3 months before surgery. METHODS: Patients who were referred for colorectal lung metastases between 2007 and 2015 were reviewed. Immediate wedge resection was performed for cases with a single peripheral metastasis, whereas surgical indications for others were determined by the two-step determination. Early increase was defined as the emergence of new metastases within 4 months after the diagnosis of lung metastases. RESULTS: Among 369 patients included, 92 were unresectable upon initial diagnosis, and 74 with single peripheral metastasis underwent immediate wedge resection. Surgical indications for the remaining 203 patients were ascertained based on the two-step determination. Surgery was not indicated in 48 patients (24%) due to new metastases or a favourable response to chemotherapy, with a median waiting duration of 4.8 months. Those who did not receive surgery had a worse prognosis than those who did (5-year overall survival: 21% vs 69%, P < 0.001) and were comparable to the initially unresectable group (5-year overall survival: 23%). Thirty-eight patients with early increase had lower surgical resection rates and worse prognoses than those without. Multivariable analysis identified early increase as an independent prognostic factor (hazard ratio: 4.49, P < 0.001). CONCLUSIONS: Patients with colorectal lung metastasis who developed new metastasis during the waiting period exhibited poor prognosis, suggesting the utility of the two-step determination of surgical indications.