Survival rate and prognostic factors of surgically resected clinically synchronous multiple primary non-small cell lung cancer and further differentiation from intrapulmonary metastasis.

BACKGROUND: The diagnosis, staging, and therapeutic strategy for synchronous multiple primary non-small cell lung cancer (SMP-NSCLC) remain unclear. Distinguishing SMP-NSCLC from intrapulmonary metastasis is difficult but of great importance for selecting the surgical procedure and prognoses. METHODS: Fifty-two patients diagnosed with SMP-NSCLC according to the modified Martini-Melamed criteria in the thoracic surgery department of the China-Japan Friendship Hospital from November 2004 to December 2015 were enrolled in this retrospective study. A total of 106 tumors were subjected to pathological examination. Close follow-up and survival analysis were performed. RESULTS: The perioperative morbidity rate was 5.8%, with no cases of perioperative death. The overall 5-year survival rate was 40.6%, the cancer-specific 5-year survival rate was 54.5%, and the median survival time was 52 months. Older age (P=0.553), sex (P=0.600), smoking history (P=0.496), tumor distribution (P=0.461), video-assisted thoracoscopic surgery (VATS) (P=0.398), and adjuvant chemotherapy (P=0.078) did not affect survival. Preoperative percentage of forced expiratory volume in the first second (P=0.022), Charlson comorbidity index (P=0.034), surgical procedure (P=0.040), and highest pT stage (P=0.022) were independent risk factors in the multivariate analysis. Different pathological subtypes were identified in 13 of 18 cases of multiple adenocarcinomas. Different gene mutation types and correlations between tumors were identified through NGS in those with the same pathological subtype. CONCLUSIONS: Postoperative survival rates in SMP-NSCLC were satisfactory. Non-radical resection might improve the prognosis for patients with a tolerable general condition and pulmonary function. Higher pT stage might result in poorer survival rates. Larger sample size and future study are still needed to identify the prognostic factors. Comprehensive histologic assessment and next generation sequencing (NGS) could be effective methods for screening SMP-NSCLC.

Fibrobronchoscopic cryosurgery for secondary malignant tumors of the trachea and main bronchi.

BACKGROUND: Patients with secondary malignant tracheal and main bronchial tumors may suffer severe symptoms as a result of major airway obstruction. Curative surgical resection is usually not suitable because of the presence of metastatic disease and poor performance status. In this study, the use of bronchoscopic cryosurgery to reopen the airway is analyzed. METHODS: The clinical records of 37 patients who experienced secondary maglinancies from December 2001 to January 2013 were retrospectively reviewed. Low temperature cryotherapy (-50°C to -70°C) was delivered to the central part of the tumor by cryoprobe for four to six minutes causing destruction of the tumor mass (Cryo-melt method). Subsequently, the edge of the tumor was frozen for 30 seconds to two minutes, followed by piecemeal removal of the frozen tumor tissue (Cryo-resection method). RESULTS: The endpoints of the study were degree of symptomatic improvement and survival. The rates of dramatic and partial symptomatic alleviation were 57.1% and 28.6%, respectively, there were no intraoperative deaths, and median survival was 16.0 months. Prolonged survival was significantly correlated to age (under 60 years of age 22.2% vs. over 60 100%, P = 0.011), tumor location (main bronchi 0% vs. trachea 77.8%, P = 0.003), and cryorecanalization times (once 33.3% vs. twice or more 80.0%, P = 0.037). CONCLUSION: Bronchoscopic cryorecanalization is a safe, effective, non-invasive choice for improving the symptoms of malignant airway obstruction. In addition to achieving local-regional control, the technique may also contribute to improved survival.

For non-small cell lung cancer with T3 (central) disease, sleeve lobectomy or pneumonectomy?

BACKGROUND: Pneumonectomy (PN) has traditionally been the treatment of choice for central lung tumors for which the alternative is sleeve lobectomy (SL). The aim of this study was to compare early and long-term results after SL and PN in focusing on T3 central non-small cell lung cancer (NSCLC). METHODS: Patients who underwent SL (n=58) or PN (n=42) were retrospectively analyzed. For bias reduction, these 100 patients had been selected according to the following criteria: (I) tumor located in the main bronchus less than 2 cm distal to the carina; (II) there were no N2 disease; (III) no induction therapy was applied; (IV) complete resection (R0) was achieved. RESULTS: SL and PN patients had comparable mean ages, gender distribution, mean forced expiratory volume in 1 second (FEV1), stage and tumor grade. Postoperative mortality (3.4% vs. 4.8%, P=1.0) and morbidity (41% vs. 38%, P=0.74) were similar between the two groups. Recurrences occurred in 48% of patients after SL and in 31% of those after PN (P=0.08). The 5-year survival after SL (64.8%) and PN (61.4%) was not significantly different (P=0.20). Multivariable survival analysis showed that there were no independent prognostic factors. CONCLUSIONS: SL does not compromise survival for NSCLC with T3 central disease compared with PN. It is an adequate oncologic resection and should be treated as the first line intervention whenever complete resection can be achieved.

Prognostic significance of platelet-to-lymphocyte ratio in non-small-cell lung cancer: a meta-analysis.

BACKGROUND: The platelet-to-lymphocyte ratio (PLR) is a useful predictive factor in several cancers. However, the prognostic value of PLR in patients with non-small-cell lung cancer (NSCLC) is still indistinct. Therefore, it was necessary for us to perform a meta-analysis to assess the prognostic value of PLR in patients with NSCLC. METHODS: A systematic literature search was performed by using PubMed, EMBASE, and Web of Science databases for relevant studies until May 2015. Published studies investigating the association between PLR and overall survival (OS) and disease-free survival (DFS) were selected. Data from each eligible study were extracted. A meta-analysis was performed to analyze the prognostic value of PLR by using the hazard ratio (HR) and 95% confidence intervals (95% CI). RESULTS: A total of seven studies involving 1,554 patients were included in our meta-analysis. Our pooled results demonstrated that high PLR was associated with poor OS (HR: 1.60, 95% CI: 1.34-1.90, I (2)=22.3%, P heterogeneity = 0.259) and DFS (HR: 1.38, 95% CI: 1.11-1.73, I 2=0%, P heterogeneity = 0.482). Subgroup analysis between PLR and OS was performed in a further investigation. When the patients were segregated according to ethnicity, sample size, cutoff value, stage, and treatment modality, high PLR was also significantly correlated with OS. There was no significant heterogeneity among included studies. CONCLUSION: High PLR is associated with poor prognosis in patients with NSCLC. PLR may be a significant predictive biomarker in patients with NSCLC.

Impact of chronic obstructive pulmonary disease on postoperative recurrence in patients with resected non-small-cell lung cancer.

PURPOSE: This study aimed to determine whether the severity of chronic obstructive pulmonary disease (COPD) affects recurrence-free survival in non-small-cell lung cancer (NSCLC) patients after surgical resection. PATIENTS AND METHODS: A retrospective study was performed on 421 consecutive patients who had undergone lobectomy for NSCLC from January 2008 to June 2011. Classification of COPD severity was based on guidelines of the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Characteristics among the three subgroups were compared and recurrence-free survivals were analyzed. RESULTS: A total of 172 patients were diagnosed with COPD (124 as GOLD-1, 46 as GOLD-2, and two as GOLD-3). The frequencies of recurrence were significantly higher in patients with higher COPD grades (P<0.001). Recurrence-free survival at 5 years was 78.1%, 70.4%, and 46.4% in non-COPD, mild COPD, and moderate/severe COPD groups, respectively (P<0.001). By univariate analysis, the age, sex, smoking history, COPD severity, tumor size, histology, and pathological stage were associated with recurrence-free survival. Multivariate analysis showed that older age, male, moderate/severe COPD, and advanced stage were independent risk factors associated with recurrence-free survival. CONCLUSION: NSCLC patients with COPD are at high risk for postoperative recurrence, and moderate/severe COPD is an independent unfavorable prognostic factor.

Risk factors for recurrence after complete resection of pathological stage N2 non-small cell lung cancer.

BACKGROUND: Tumor recurrence is the most common cause of treatment failure, especially after complete resection of pathological stage N2 non-small cell lung cancer (NSCLC). In this study, we investigated the clinicopathological characteristics in order to identify independent risk factors for postoperative recurrence. METHODS: Between January 2001 and December 2013, 96 patients who underwent surgical resection for pathological N2 NSCLC were retrospectively reviewed. Recurrence-free survival (RFS) was calculated by the Kaplan-Meier method to explore risk factors, while the Cox proportional hazard model was used to assess independent predictors. RESULTS: The median and five-year RFS rates were 15 months and 27.4%, respectively. Univariate analysis showed a significantly poorer prognosis for non-regional N2 metastasis, more than three metastatic N2 lymph nodes, multiple N2 station, and multiple N2 zone involvement. Multivariate analysis demonstrated that non-regional N2 metastasis (hazard ratio [HR] 1.857, 95% confidence interval [CI] 1.061-3.249, P = 0.030) and more than three metastatic N2 lymph nodes (HR 2.555, 95% CI 1.164-5.606, P = 0.019) were independent risk factors for RFS. Additionally, the incidence of non-regional N2 metastasis was higher in patients with a primary tumor in the left lower (57.1%) or right lower lobe (48.1%), followed by left upper (31.8%), right middle (14.3%) and right upper lobe (7.7%). CONCLUSION: The combination of the distribution and number of metastatic N2 lymph nodes provides a more accurate prediction for N2 NSCLC regarding recurrence. Non-regional N2 metastasis could occur with a primary tumor in any lobe, but occurs more frequently in the lower lobe.

Video-assisted thoracoscopic lobectomy for elderly nonsmall cell lung cancer: Short-term and long-term outcomes.

BACKGROUND: Lung cancer is the leading cause of cancer-related death worldwide, and the number of elderly patients with nonsmall-cell lung cancer (NSCLC) has risen with increasing life-expectancy. AIMS: To evaluate safety and efficacy of thoracoscopic lobectomy for NSCLC patients above 75 years old. PATIENTS AND METHODS: We reviewed the data of 795 consecutive patients with NSCLC, who underwent video-assisted thoracoscopic lobectomy from January 2006 to December 2013. Patients were divided into two groups: The elderly group aged at least 75 years old (n = 54), the contrast group aged <75 years old (n = 741). The general characteristic, comorbidity, intraoperative observations, complications, operative mortality and long-term survival were compared between the two groups. RESULTS: The elderly group had a higher incidence of squamous cell carcinoma (40.74% vs. 29.69%) and a lower incidence of adenocarcinoma (37.04% vs. 52.63%) than the contrast group (P = 0.083). The ratio of smoking (61.11% vs. 41.97%), preoperative comorbidities (62.96% vs. 38.06%), perioperative blood transfusion (25.93% vs. 13.50%) and thoracic intubation indwelling time (10.3 vs. 8.2 days) in the elderly group were higher (P < 0.01). There was no significant difference in duration of surgery (222.9 vs. 226.6 min), intraoperative blood loss (299.8 vs. 253.5 min), hospital stay (18.2 vs. 15.8 days) or postoperative hospital stay (10.3 vs. 8.4 days) between the two groups. Postoperative morbidities occurred more frequently in the elderly group than the contrast group (24.07% vs. 12.01%, P = 0.018). Thirty-day mortality rate of two groups showed no significant difference (1.85% vs. 0.40%, P = 0.246). The overall survival and recurrence-free survival in the elderly group were comparable with the contrast group (P = 0.114 and 0.092, respectively). CONCLUSIONS: Video-assisted thoracoscopic lobectomy is a safe and reliable approach with acceptable short- and long-term outcome in the elderly.

[Fibro-bronchoscopic cryosurgery for unresectable endobronchial tumors].

BACKGROUND: Patients with tracheobronchial tumor are too frail for curative surgical treatment, and the original sites are unsuitable for radical resection. They always suffered from dyspnea, hymoptosis, obstructive pneumonia, and fever. Airway obstruction has a strong bad impact on the quality of life, and is the main cause of respiratory failure and death. An effective method of palliative is very important. We choose fibro-bronchoscopic cryosurgery for destruction of endobronchial tumors and analyze the outcomes. METHODS: Clinical records of 126 cases who under went endobronchoscopic cryosurgery were reviewed retrospectively from August 2004 to February 2014. Techniques and survival outcomes were analyzed. The precise position and length of the cryosurgery was evaluated through three dimension chest computed tomography (CT) and reconstruction of trachea and bronchus. Local infiltration and general intravenous anesthesia are two options before surgical procedure. Endobronchial tumor was removed by combining two methods of "Cryo-Resecion" and "Cryo-Melt". Bronchoscopic examination was rechecked 2 weeks later to evaluate if it is necessary to redo the endobronchoscopic cryosurgery. RESULTS: The symptoms of cough, short of breath, and hemoptysis were alleviated to different extend. The rate of dramatically improved and partial improved were 65.1% and 77.0% respectively. The mortality is 0.79%. Postoperative Complications included 2 cases of airway bleeding, 4 cases of bronchial stenosis, 2 cases of trachea burning injury, 2 cases of tracheomalacia, and 3 cases of atrium fibrillation. The median survival is 14 months, 1-, 2-, 3-yr survival rates were 58.6%, 24.2%, and 12.2% respectively, based on Kaplan-Meier estimates. CONCLUSIONS: Endobronchial cryosurgery is an easy and effective minimally invasive choice for controlling and releasing the airway obstructive symptoms resulting from the trachea or bronchial tumors. Besides, the problem of difficult endotracheal intubation could be resolved after removing the tracheal tumor with the benefit of cryotreatment. Some patients could get the chance for further treatment or radical resection. Therefore, the patients' quality of life could be improved and the lifetime could be prolonged.

[Analyses of risk factors for postoperative recurrence after curative resection of stage III A-N2 non-small cell lung cancer].

OBJECTIVE: To explore the patterns of mediastinal lymph node metastases and prognostic factors of recurrence in patients undergoing curative resection of stage IIIA-N2 non-small cell lung cancer (NSCLC). METHODS: A total of 92 patients underwent curative operation and pathologically diagnosed as stage IIIA-N2 NSCLC were retrospectively reviewed. The clinicopathological data were compared between the recurrence and non-recurrence groups. And the potential prognostic factors were included for multivariate analysis using Cox proportional hazard model. RESULTS: The 3 and 5-year recurrence rates were 61.0% and 70.2% respectively. For univariate analysis, the prognostic factors were number of metastatic lymph nodes, positive lymph node ratio, number of metastatic mediastinal lymph nodes (MLN), positive MLN ratio, number of MLN metastasis > 3, multiple station metastasis, trans-regional metastasis and multi-zonal metastasis. A multivariate analysis using Cox regression identified 2 independent factors of prognosis: trans-regional MLN metastasis (P = 0.035) and number of MLN metastasis >3 (P = 0.045). The recurrence risk of patients with trans-regional MLN metastasis was 2.0 times higher than those with regional MLN metastasis while the recurrence risk of patients with number of MLN metastasis >3 was 2.2 times higher than those with number of MLN metastasis of 1-3. CONCLUSION: Recurrence risk of stage IIIA-N2 non-small cell lung cancer (NSCLC) after curative resection may be estimated by location and number of MLN metastasis. And the subgroup with trans-regional MLN metastasis and number of MLN metastasis >3 carries the highest risk of recurrence.

Surgical techniques and results of the pulmonary artery reconstruction for patients with central non-small cell lung cancer.

BACKGROUND: It is difficult to achieve a margin-negative resection (R0) for non-small cell lung cancer (NSCLC) patients with infiltration of the pulmonary artery. We report our experience of the pulmonary artery reconstruction with regard to long-term survival. METHODS: Clinical records of 118 patients with NSCLC who underwent partial or circumferential pulmonary artery resection during a 21-year period were reviewed retrospectively. Techniques and survival outcomes were analyzed. RESULTS: We performed 22 pulmonary artery sleeve resections, 51 reconstructions by autologous pericardial patch, 36 tangential resections, 3 left main pulmonary artery (PA) angioplasties during pneumonectomy without cardiopulmonary bypass, and 6 by only preserving the apical and anterior (1(st)) branch of pulmonary arterial trunk. In 41 patients, bronchial sleeve resection was associated; in 7 cases, superior vena cava reconstruction was also required. Thirty-one patients received induction therapy. Thirteen patients had stage IB disease, 41 stage II, 53 IIIA, and 11 IIIB. Ninety-three patients had squamous cell carcinoma, 22 adenocarcinoma, 2 mixed and 1 large cell carcinoma. Negative vascular margins were achieved in all. 5 positive bronchial margins were due to limited lung function. The analysis of 118 cases yielded follow-up data in 94 cases. The mean follow-up was 70 months (range 1-156 months). There was no in hospital death, and the overall 5-year survival was 50.2%. Five-year survivals for stages I and II versus III were 63.9% versus 37.0% (p = 0.0059). Multivariate analysis yielded non-squamous cell carcinoma, stage III and patch pulmonary arterioplasty as negative prognosis factors. PA reconstruction associated with bronchial sleeve resection was the positive prognostic factor. CONCLUSIONS: Pulmonary artery resection and reconstruction is feasible and safe, with favorable long-term survival. Our results support this technique as an effective alternative to selected patients with infiltration of the pulmonary artery, such as stage I and II and those who proved down-staged from stage III. Accurate preoperative evaluation, precise and suitable surgical techniques are crucial to achieve good results. Only preserving the anterior and apical pulmonary arteries and reconstruction of the main pulmonary artery by using the artery conduit technique without cardiopulmonary bypass in association with left pneumonectomy can be performed successfully. Postoperative anticoagulation is unnecessary.

Novel and convenient method to evaluate the character of solitary pulmonary nodule-comparison of three mathematical prediction models and further stratification of risk factors.

OBJECTIVE: To study risk factors that affect the evaluation of malignancy in patients with solitary pulmonary nodules (SPN) and verify different predictive models for malignant probability of SPN. METHODS: Retrospectively analyzed 107 cases of SPN with definite post-operative histological diagnosis whom underwent surgical procedures in China-Japan Friendship Hospital from November of 2010 to February of 2013. Age, gender, smoking history, malignancy history of patients, imaging features of the nodule including maximum diameter, position, spiculation, lobulation, calcification and serum level of CEA and Cyfra21-1 were assessed as potential risk factors. Univariate analysis model was used to establish statistical correlation between risk factors and post-operative histological diagnosis. Receiver operating characteristic (ROC) curves were drawn using different predictive models for malignant probability of SPN to get areas under the curves (AUC values), sensitivity, specificity, positive predictive values, negative predictive values for each model, respectively. The predictive effectiveness of each model was statistically assessed subsequently. RESULTS: In 107 patients, 78 cases were malignant (72.9%), 29 cases were benign (27.1%). Statistical significant difference was found between benign and malignant group in age, maximum diameter, serum level of Cyfra21-1, spiculation, lobulation and calcification of the nodules. The AUC values were 0.786±0.053 (Mayo model), 0.682±0.060 (VA model) and 0.810±0.051 (Peking University People's Hospital model), respectively. CONCLUSIONS: Serum level of Cyfra21-1, patient's age, maximum diameter of the nodule, spiculation, lobulation and calcification of the nodule are independent risk factors associated with the malignant probability of SPN. Peking University People's Hospital model is of high accuracy and clinical value for patients with SPN. Adding serum index (e.g. Cyfra21-1) into the prediction models as a new risk factor and adjusting the weight of age in the models might improve the accuracy of prediction for SPN.

Severe intraoperative complications during VATS Lobectomy compared with thoracotomy lobectomy for early stage non-small cell lung cancer.

BACKGROUND: Video-assisted thoracic surgery (VATS) lobectomy has been proved to have shorter hospital stay, less perioperative complications and less pain compared with lobectomy by thoracotomy, but severe intraoperative complications during VATS lobectomy is rare reported. We compared intraoperative safety between VATS lobectomy and lobectomy by thoracotomy. METHODS: 659 patients with postoperative stage I and IIa non-small cell lung cancer (NSCLC) who underwent lobectomy in China-Japan Friendship Hospital from February 2008 to June 2012 were analyzed retrospectively, in which 277 were performed by thoracotomy, 357 performed by VATS, and 25 performed by VATS converted to open. Outcomes were analyzed to compare the incidence of significant bleeding, with conversion cases were included into VATS group. RESULTS: Ten severe intraoperative complications were identified in 10 patients (6 in VATS, 4 in open), with no intraoperative deaths. The incidence of severe intraoperative complications was similar between VATS group and thoracotomy group [1.57% (6/382) vs. 1.44% (4/277), P=1.0]. Most severe intraoperative complications were related to the injury of major pulmonary vessels (9/10), and most of these complications occurred during upper lobectomy (8/10). There was no statistically significant difference in blood loss (242.85±220.47 vs. 240.43±144.36, P=0.865), and operative time (198.00±75.24 vs. 208.05±61.97, P=0.061) between the open and VATS groups, respectively, but blood loss and operative time are significant different after elimination of conversion cases (214.34±151.85 vs. 240.43±144.36, P<0.01; 193.24±72.64 vs. 208.05±61.97, P<0.01). CONCLUSIONS: Our preliminary study demonstrated that the incidence of severe intraoperative complication during VATS lobectomy was low and similar to open lobectomy. The severe intraoperative complications during VATS lobectomy are manageable and the surgeons need to take proper caution in performing VATS lobectomy.

Preferred surgical procedure for posterior mediastinal neurogenic tumor.

AIM: To compare the outcomes of video-assisted thoracoscopic surgery (VATS) with those of thoracotomy for the removal of posterior mediastinal neurogenic tumors. METHODS: Twenty-four patients were enrolled in the VATS group and 29 were enrolled in thoracotomy group between 1996 and 2010. RESULTS: When compared with the thoracotomy group, patients in the VATS group had a shorter operation time (90 ± 29 min vs. 136 ± 41 min, P < 0.001), less blood loss (42 ± 12 mL vs. 209 ± 162 mL, P < 0.001), shorter time to extubation and discharge (2.5 ± 0.7 days vs. 3.1 ± 1.0 days, P= 0.027; 3.6 ± 0.6 days vs. 4.1 ± 1.0 days, P= 0.045). CONCLUSION: VATS is a safe and effective surgical procedure for posterior mediastinal neurogenic tumors with better outcomes than thoracotomy.

[The common causes of conversion of VATS during operation for 248 non-small cell lung cancers].

BACKGROUND AND OBJECTIVE: VATS-lobectomy has been used as regular surgical procedure clinically for non-small cell lung cancer. The aim of this study is to evaluate the surgical emergencies during VATS and the related factors postoperatively. METHODS: Clinical data were reviewed for patients who were performed with pulmonary related surgery between January 2006 and July 2008 in our department. RESULTS: 248 (117 CVATS and 131 AVATS) VATS lobectomy were performed, including 13 cases that were transferred into AVATS or OPEN. The common related reasons were bleeding of pulmonary branches, adhesion, anatomic deformity, bleeding of azygos and bleeding of middle-lobe-vein. 129 thoracotomy cases were enrolled. Compared with OPEN surgery, VATS got the merits of short in-hospital duration (20 days vs 27 days, P=0.015), less bleeding (197 mL vs 250 mL, P=0.005) and less pain (4.6 vs 6.2, P=0.003). CONCLUSION: VATS is a safe surgical procedure for early stage NSCLC with merits of lower morbidity and sooner recovery. So it could be concluded that in some circumstances, VATS could be chosen as an alternate of thoractomy.

[Effects of multiple factors on the prognosis of pIIIa/N2 patients with non-small cell lung cancer].

BACKGROUND AND OBJECTIVE: Thoracic surgery hasn't got consensus on therapy of pIIIa/N2 non-small cell lung cancer (NSCLC). The aim of this study is to identify prognostic factors in NSCLC with N2 nodal involvement. METHODS: A retrospective review of disease free survival and 5-year survival for NSCLC patients who underwent primary surgical resection without neoadjuvant chemotherapy was performed. Between January 1998 and May 2004, 133 patients were enrolled. Several factors such as age, sex, skip metastasis, number of N2 lymph node stations, type of resection, histology and adjuvant therapy were recorded and analyzed. SPSS 16.0 was used for calculating survival. RESULTS: Overall 5-year survival for 133 patients was 32.33%, and 5-year survival for single N2 station and multiple N2 station sub-group were 39.62% and 27.50%, respectively. 5-year survival for cN0-1 and cN2 sub-group were 37.78% and 20.93%, respectively. Cox regression analysis revealed that number of N2 station (P=0.013, OR=0.490, 95%CI: 0.427-0.781) and cN status (P=0.009, OR=0.607, 95%CI: 0.372-0.992) were two favorable prognostic factors of survival. CONCLUSION: Number of N2 station and cN status are two favorable prognostic factors of survival. In restrict enrolled circumstances, after combined therapy made up of surgery and postoperative adjuvant therapy have been performed, satisfied survival can be achieved.

Surgical therapeutic strategy for non-small cell lung cancer with mediastinal lymph node metastasis (N2).

BACKGROUND AND OBJECTIVE: Approximately 30% of patients who are diagnosed with non-small cell lung cancer (NSCLC) are classified as N2 on the basis of metastasis to the mediastinal lymph nodes. The effectiveness of surgery for these patients remains controversial. Although surgeries in recent years are proved to be effective to some extent, yet due to many reasons, 5-year survival rate after surgery varies greatly from patient to patient. Thus it is necessary to select patients who have a high probability of being be cured through an operation, who are suitable to receive surgery and the best surgical methods so as to figure out the conditions under which surgical treatment can be chosen and the factors that may influence prognosis. METHODS: 165 out of 173 patients with N2 NSCLC were treated with surgery in our department from January 1999 to May 2003, among whom 130 were male, 43 female and the sex ratio was 3:1, average age 53, ranging from 29 to 79. The database covers the patients' complete medical history including the information of their age, sex, location and size of tumor, date of operation, surgical methods, histologic diagnosis, clinical stage, post-operative TNM stage, neoadjuvant treatment and chemoradiotherapy. The methods of clinical stage verification include chest X-ray, chest CT, PET, mediastinoscopy, bronchoscope (+?), brain CT or MRI, abdominal B ultrasound (or CT), and bone ECT. The pathological classification was based on the international standard for lung cancer (UICC 1997). Survival time was analyzed from the operation date to May 2008 with the aid of SPSS (Statistical Package for the Social Sciences) program. Kaplan-Meier survival analysis, Log-rank test and Cox multiplicity were adopted respectively to obtain patients' survival curve, survival rate and the impact possible factors may have on their survival rate. RESULTS: The median survival time was 22 months, with 3-year survival rate reaching 28.1% and 5-year survival rate reaching 19.0%. Age, sex, different histological classification and postoperative chemoradiotherapy seem to have no correlation with 5-year survival rate. In all N2 subtypes, 5-year survival rate is remarkably higher for unexpected N2 discovered at thoractomy and proven N2 stage before preoperative work-up and receive a mediastinal down-staging after induction therapy (P < 0.01), reaching 30.4% and 27.3% respectively. 5-year survival rate for single station lymph node metastasis were 27.8%, much higher compared with 9.3% for multiple stations (P < 0.001). Induction therapy which downstages proven N2 in 73.3% patients gains them the opportunity of surgery. The 5-year survival rate were 23.6% and 13.0% for patients who had complete resection and those who had incomplete resection (P < 0.001). Patients who underwent lobectomy (23.2%) have higher survival rate, less incidence rate of complication and mortality rate, compared with pneumonectomy (14.8%) (P < 0.01). T4 patients has a 5-year survival rate as low as 11.1%, much less than T1 (31.5%) and T2 (24.3%) patients (P = 0.01). It is noted through Cox analysis that completeness of resection, number of positive lymph node stations and primary T status have significant correlativity with 5-year survival rate. CONCLUSION: It is suggested that surgery (lobectomy preferentially) is the best solution for T1 and T2 with primary tumor have not invaded pleura or the distance to carina of trachea no less than 2 cm, unexpected N2 discovered at thoractomy when a complete resection can be applied, and proven N2 discovered during preoperative work-up and is down-staged after induction therapy. Surgical treatment is the best option, lobectomy should be prioritized in operational methods since ise rate of complication and morality are lower than that of pneumonectomy. Patients' survival time will not benefit from surgery if they are with lymph nodes metastasis of multiple stations (Bulky N2 included) and T4 which can be partially removed. Neoadjuvant chemotherapy increases long-term survival rate of those with N2 proven prior to surgery. However, postoperative radiotherapy decreases local recurrence rate but does not contribute to patients' long-term survival rate.

Tracheal carinal reconstruction and bronchovasculoplasty in central type bronchogenic carcinoma.

BACKGROUND AND OBJECTIVE: Because radical resection for lung cancer invading the initial borderline of different lobes and carina is difficult, we tried to analyse the variables of successful tracheal carinoplasty and bronchovasculoplasty to discover a proper approach for appropriate early and long-term results. METHODS: Of 1 399 lung resections for primary lung cancer performed in our hospital from April 1985 to December 2006, 133 underwent bronchoplastic surgeries, including 15 carinoplasty cases and 118 sleeve lobectomy (SL) cases, and 118 pneumoectomy (PN) cases were compared at the same time. RESULTS: Complications occurred in 18 cases, with no operative related mortality. For all patients, the 1 year, 3 year, and 5 year survival rates were 79.8%, 56.7% and 31.2%, respectively. The 5 year survival rate by cancer stage was 69.2% for Ib, 40.6% for IIb, 19.6% for IIIa, and 16.6% for IIIa (N2). CONCLUSION: Selection of cases, clearance of lymph nodes, disposal of the bronchus and pulmonary vessel and replacement or restoration of the superior vena cava are the main factors influencing prognosis.

[Prognostic analysis of N2 non-small cell lung cancer].

OBJECTIVE: To evaluate the surgical therapeutic strategy and prognostic factors for non-small cell lung cancer (NSCLC) with mediastinal lymph node metastasis (N2). METHODS: The survival rate of 117 patients with N2 NSCLC treated surgically from January 1999 to May 2003 were analyzed. There were 88 male cases and 29 female cases, aged from 29 to 79 years. The procedure of operation (lobectomy, pneumonectomy and palliative resection), histological classification (squamous cell carcinoma, adenocarcinoma, mixed carcinoma, and large cell carcinoma and others), T primary tumor status, and adjuvant therapy were analyzed to determine their impact on the 5-year survival rate. RESULTS: The median survival time was 22 months, and the over-all 3- and 5-year survival rate was 28.1% and 19.0%. Survival was higher in patients with lobectomy than with palliative resection, with T1 and T2 than with T4. The 5-year survival rate had no deference in age, sex and different histological classification. The 5-year survival rates of lobectomy and pneumonectomy (22.2% and 25.0% respectively) was higher than palliative resection (9.1%). CONCLUSIONS: Surgical procedures (especially lobectomy) is the best choice for N2 NSCLC patients with T1 or T2. But it can not prolong T4 patients' life significantly.

[The cryosurgery of central lung cancer by rigid bronchoscopy].

OBJECTIVE: To evaluate the method and effectiveness of rigid-bronchoscopic cryosurgery for advanced central lung cancer. METHODS: Forty-eight patients were enrolled in this study from June 2002 to December 2008, including 33 male and 15 female. The average age was 70 years (ranged from 45 to 83 years old). For the 48 patients, 38 cases were patients with advanced central lung cancer who were not suitable for surgery, and the remaining 10 cases were patients with local recurrence in trachea or main bronchus postoperatively. Cryosurgery was performed 120 times for all patients, 2.5 times per patient on average. The trachea or bronchus station, symptom such as dyspnea, hemoptysis, respiratory function and quality of life were observed. RESULTS: The unblocked ratio of trachea and bronchi was 97%. All patients got satisfied improvement ratio of symptoms, 87.5% for dyspnea, 72.9% for cough, 93.8% for hemoptysis and 62.5% for chest pain. Respiratory function tests showed that both the mean forced expiratory volume in first second and forced vital capacity got an improvement from (1.03+/-0.05) L to (1.85+/-0.13) L and from (1.69+/-0.18) L to (2.96+/-0.14) L respectively (P<0.01). Karnofsky score also got no less than 20 scores improvement. The Follow-up time was 6 to 62 months. The longest survival was 62 months. The median survival time was 20 months. There was no severe perioperative complications and mortality except for 3 cases of moderate exeduation. CONCLUSIONS: Cryosurgery is easy to perform with minimal complications. Not only could it provide an effective and rapid control of symptoms caused by central lung cancer, it could also unobstructed bronchus promptly and improve patients' quality of life.

[Results of myasthenia gravis treated with thymectomy].

OBJECTIVE: To evaluate the effectiveness of thymectomy for myasthenia gravis (MG) and the relative risk factors for postoperative myasthenic crisis. METHODS: The clinic data of 78 cases with MG who underwent thymectomy from June 1985 to June 2005 were analyzed retrospectively. The relative risk factors of postoperative myasthenic crisis were analyzed and the differences between new and old region of perioperative management were compared. RESULTS: The symptom of MG was complete remission in 21 cases, significantly improved in 38 cases, improved in 11 cases and unchanged in 8 cases, respectively. The symptom duration before operation, preoperative serum level of anti-acetylcholine receptor antibody, Osserman stage and pathological type of thymoma were independent relative risk factors for postoperative myasthenic crisis. The new region of perioperative management was significant better than the old one. CONCLUSION: Surgical treatment shows significant clinical benefits for patients with MG.