Prognostic impact of ground-glass opacity components in lung cancer with lymph node metastasis.

Background: In early-stage non-small cell lung cancer (NSCLC), the presence of a ground-glass opacity (GGO) component in the primary lesion on high-resolution computed tomography (CT) is recognized as a favorable prognostic factor. Even in NSCLC with a GGO component, lymph node metastases are occasionally detected during or after surgery. However, the prognostic impact of GGO components in these patients has not been clarified. We aimed to examine the prognostic significance of GGO components as radiological findings of primary lesions of completely resected NSCLC with pathological nodal involvement. Methods: This study included 290 patients (11%) with pathological nodal involvement among 2,546 patients who underwent complete resection of NSCLC at our institution. Patients with an unknown primary lesion (T0) or centrally located lung cancer were excluded. The 290 patients were divided into two groups [i.e., the part-solid ("PS") and "Solid" groups] according to the radiological findings of the primary lesion, and their clinicopathological characteristics and prognoses were compared. Furthermore, a multivariate analysis was performed using the Cox proportional hazards model to examine the factors affecting the overall survival (OS). Results: The OS in the PS group (n=58) was significantly longer than that in the Solid group (n=232; P=0.039). However, multivariate analysis only revealed age [hazard ratio (HR) =1.77; 95% confidence interval (CI): 1.15-2.72] and the clinical T factor (HR =1.58; 95% CI: 1.01-2.47), but not the radiological findings of primary lesions, as the independent prognostic factors. Furthermore, the OS did not differ significantly between the PS and Solid groups matched for the clinical T and N factors (n=58 patients each). Conclusions: GGO components in the primary lesion, considered a decisive prognostic factor in early-stage NSCLC, did not affect the prognosis of patients with NSCLC and pathological nodal involvement.

Utility of visualization and quantification of surgical techniques using motion analysis software for thoracoscopic surgery.

In this era of endoscopic surgery, feedback from recorded surgical videos is useful and efficient; therefore, effective methods of obtaining this feedback are needed. We analyzed surgical videos using motion analysis software and verified the usefulness of visualizing and objectively evaluating surgical procedures. We measured the grasping and traction angles of the vascular sheath when using forceps and the trajectory of the forceps tip for the upper pulmonary vein during right upper lobectomy during video-assisted thoracoscopic surgery performed by three trainers and trainees. Compared with the trainers, the trainees exhibited insufficient traction of the vascular sheath, performed many slow and unnecessary manipulations, and sometimes performed sudden and fast movements. By visualizing the surgical procedures, the trainee will be better able to identify dangerous or futile movements. It may also make it easier to objectively recognize improvements in one's technique. Motion analysis software could allow for efficient surgical education and self-learning.

Micropapillary and solid components as high-grade patterns in IASLC grading system of lung adenocarcinoma: Clinical implications and management.

OBJECTIVES: The grading system proposed by the International Association for the Study of Lung Cancer is based on a combination of predominant histologic subtypes and the proportion of high-grade components with a cutoff of 20%. We aimed to examine the clinical implications of the grading system beyond the discrimination of patient prognosis, while assessing the biological differences among high-grade subtypes. METHODS: We retrospectively reviewed 648 consecutive patients with resected lung adenocarcinomas and examined their clinicopathologic, genotypic, and immunophenotypic features and treatment outcomes. Besides the differences among grades, the clinical impact of different high-grade components: micropapillary (MIP) and solid (SOL) patterns, was individually evaluated. RESULTS: Survival outcomes were well-stratified according to the grading system. Grade 3 tumors exhibited aggressive clinicopathologic features, while being an independent prognostic factor in multivariable analysis. A small proportion (<20 %) of high-grade components in grade 2 had a negative prognostic impact. The prognostic difference bordering on the 20 % cutoff of the MIP proportion was validated; however, the proportion of SOL component did not affect prognosis. A survival benefit from adjuvant chemotherapy was observed in grade 3 tumors regardless of histologic subtype, but not in grade 1-2 tumors. The molecular and immunophenotypic features were different among grades, but still heterogeneous in grade 3, with MIP harboring frequent EGFR mutation and SOL exhibiting high PD-L1 expression. The treatment outcome after recurrence was worse in grade 3, but tumors with MIP pattern had an equivalent prognosis to that of grade 1-2 tumors, reflecting the high frequency of molecular targeted therapy. CONCLUSIONS: In addition to stratifying patient prognosis, the current grading system could discriminate clinical course, therapeutic effects of adjuvant chemotherapy, and molecular and immunophenotypic features. Further stratification based on biological heterogeneity in grade 3 remains necessary to enhance the role of the grading system in guiding patient management.

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.

Factors associated with lymph node metastasis upstage after resection for patients with micropapillary lung adenocarcinoma.

BACKGROUND: Micropapillary adenocarcinoma has a poor prognostic histological pattern. Additionally, preoperative detection of lymph node metastases by preoperative examination is difficult in some patients with micropapillary adenocarcinoma, and postoperative upstage may occur. However, clinicopathological features of patients with micropapillary adenocarcinoma with nodal upstage have not been established, therefore this study aimed to identify the factors associated with potential lymph node metastases during preoperative examination to ensure effective surgical procedures. METHODS: Between January 2011 and December 2020, 1029 patients received complete resection for primary non-small-cell lung cancer by lobectomy or more extensive resection with systematic lymph node dissection at this institution. One hundred and thirty-one patients diagnosed with adenocarcinoma with micropapillary component were included in this study. The clinicopathological features of patients with nodal upstage whose postoperative N stage was more advanced than the preoperative N stage were examined. RESULTS: Forty patients had nodal upstage after resection. 18 F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-CT) revealed that a maximum standardized uptake value (SUVmax) ≥5 for the primary lesion was significantly associated with postoperative nodal upstage. There were no significant differences in terms of sex, age, smoking history, surgical procedure, and diabetes. Among 38 patients with nodal upstage, 23 patients had no significant preoperative lymphadenopathy and showed no abnormal FDG uptake in the lymph nodes on 18 F-FDG-PET-CT, respectively. CONCLUSIONS: Lymph node metastases were suspected in patients preoperatively diagnosed with micropapillary adenocarcinoma with FDG SUVmax ≥5 for the primary tumor. Therefore, standard surgical resection and careful lymph node dissection should be performed for such patients.

Selection of preoperative stress electrocardiography test for appropriate patients with non-small cell lung cancer.

OBJECTIVE: Lobectomy is an established surgical procedure for treating non-small cell lung cancer; however, it significantly impacts postoperative cardiac function. The stress electrocardiography test is relatively easy to perform and is used to confirm the presence of coronary artery stenotic lesions. However, it has a low pre-test probability and may yield many false positives. We examined the factors that would enable the appropriate selection of patients for stress electrocardiography as a preoperative cardiovascular examination preceding lobectomy for non-small cell lung cancer. METHODS: From June 2016 to July 2018, 240 patients at our institution who underwent stress electrocardiography before lobectomy for primary lung cancer were included in this study. Clinical information was extracted from electronic medical records and evaluated retrospectively. Smoking history, diabetes, hypertension, dyslipidemia, and ischemic heart disease were considered risk factors for coronary artery stenosis. We determined the coronary risk factors that were applicable to each participant and calculated the total number of coronary risk factors as a risk score. RESULTS: Patients with coronary risk factor scores of ≥ 3 were significantly more likely to have abnormal stress electrocardiography results. In addition, these patients also underwent more comprehensive examinations to identify coronary diseases. There were no patients with complications that could be attributed to ischemic heart disease. CONCLUSION: Stress electrocardiography may be more useful before lobectomy in non-small cell lung cancer patients if the patients are appropriately selected, with the test utilized mainly in patients with coronary risk factor scores of ≥ 3.