Stepwise flowchart for decision making on sublobar resection through the estimation of spread through air space in early stage lung cancer1.

OBJECTIVES: The sensitivity for tumor spread through air space (STAS), an independent risk factor for locoregional recurrence after sublobar resection for lung cancer, has been relatively low in frozen sections. We aimed to determine predictors with high negative predictive value for the presence of STAS and to provide the flowchart in combination with these predictors for the decision-making for sublobar resection. MATERIALS AND METHODS: Between July 2015 and December 2017, 387 patients who underwent surgery for non-small cell lung cancer (NSCLC) with pathologic findings of the total masses measuring ≤ 2 cm were enrolled. The lesions were divided into two groups according to presence of STAS. We compared the preoperative characteristics, operative data, and developed a flowchart for STAS prediction using receiver operator characteristic curve analysis and multivariable logistic regression. RESULTS: The STAS-positive group (N = 111) had a significantly higher preoperative tumor size (1.70 [1.5] vs 1.50 [0.69], p < 0.001) and standardized uptake value tumor-to-liver (SUV T/L) ratio (1.40 [1.60] vs 0.60 [1.10], p < 0.001) and a significantly lower two-dimensional ground-glass opacity (GGO) percentage (35.86 [61.00] vs 78.14 [39.00], p < 0.001). Meanwhile, the STAS-negative group (N = 286) had higher lepidic predominance (41.6% vs. 1.8%, p < 0.001). We developed a flowchart for predicting STAS in combination with two-dimensional GGO percentage on computed tomography (CT), SUV T/L ratio on positron-emission CT, and lepidic predominant pattern. The sensitivity, specificity, and negative predictive value for STAS positivity were 79.3%, 68.5%, and 89.5%, respectively. CONCLUSIONS: The stepwise flowchart using two-dimensional GGO percentage on CT, maximum SUV, and lepidic predominance might be helpful in selecting patients with early NSCLC for sublobar resection.

Clinical implications of uncertain resection in scenarios of metastasis of the highest or most distant mediastinal lymph node station following surgical treatment of non-small-cell lung cancer.

OBJECTIVES: The positive highest nodal station after operation is one of the definitions of "uncertain resection" proposed by the International Association for the Study of Lung Cancer. This study was performed to determine the prognostic value of positive highest or the most distant nodal station in patients with N2 non-small-cell lung cancer (NSCLC). MATERIALS AND METHODS: Three hundred thirty-nine patients who underwent complete anatomical resection and mediastinal lymph node (LN) dissection for N2 NSCLC between 2000 and 2015 were reviewed. Cases of operative mortality, extracapsular invasion of LN and incomplete resection were excluded from analysis. RESULTS: The mean age was 61.58 ±â€¯9.43 years, and 235(69.3%) patients were male. The numbers of total dissected LNs and positive LNs were 29.90 ±â€¯11.92 and 5.49 ±â€¯5.90, respectively. The subcategory of N stage was divided as follows: N2a1, 91(26.8%); N2a2, 132(38.9%); and N2b, 116(34.2%). One hundred forty-two (41.9%) patients showed highest LN metastasis, and 162(47.8%) patients showed most distant LN metastasis. Kaplan-Meier analysis revealed no differences between distant LN negative and positive patients regarding 5-year overall survival (43.1% vs. 39.2%; p = 0.428) and between highest LN negative and positive patients regarding 5-year overall survival (42.1% vs. 40.0%; p = 0.539). On multivariable analysis, metastasis to the most distant mediastinal LN (hazard ratio (HR): 1.050; p = 0.755) and metastasis to the highest mediastinal LN (HR: 1.015; p = 0.924) were not related to overall survival. CONCLUSION: The current definition of uncertain resection based on metastasis of the highest or most distant LNs did not show survival differences in completely resected N2 NSCLC.

Feasibility and surgical outcomes of video-assisted thoracoscopic pulmonary resection in patients with advanced-stage lung cancer after neoadjuvant chemoradiotherapy.

Video-assisted thoracoscopic surgery (VATS) is regarded as the standard treatment for lung cancer. However, the feasibility and safety of VATS for lung cancer after neoadjuvant chemoradiotherapy (CRT) is unclear. This study evaluated the feasibility and safety of VATS in patients who had received neoadjuvant CRT. METHODS: Between January 2008 and December 2017, 85 patients who were administered neoadjuvant CRT and underwent anatomic lung resection were enrolled. Fifty-nine patients underwent open thoracotomy and 26 patients underwent VATS. The clinical characteristics and perioperative outcomes were reviewed. RESULTS: In six of the initial 32 patients who underwent VATS, the procedure was converted to thoracotomy. Adjacent structural invasion (33.9% vs. 11.5%; P = 0.037) and combined resection (16.9% vs. 0%; P = 0.025) were higher in the open group than in the VATS group. Surgical duration was higher in the open group than in the VATS group (203.86 ± 65.97 vs. 173.27 ± 59.87 minutes; P = 0.046). With regard to postoperative outcomes, the length of the hospital stay was longer in the open group compared to the VATS group (14.46 ± 16.94 vs. 8.62 ± 4.72 days; P = 0.017). There was no significant difference in the three-year disease-free survival (69.3% vs. 67.9%; P = 0.879) or overall survival rates (76.6% vs. 61.9%; P = 0.516). CONCLUSION: In selected patients, VATS pulmonary resection after neoadjuvant CRT showed results comparable to that of thoracotomy in terms of postoperative outcomes, operative morbidities, and survival rate.

Neoadjuvant therapy for thymic neoplasms reduces tumor volume per 3D-reconstructed images but does not improve the complete resection rate.

OBJECTIVES: Complete resection of thymic neoplasms is important for achieving a favorable prognosis; however, the efficacy of neoadjuvant therapy remains controversial. We investigated the effect of induction therapy on complete resection and survival using 3-dimensionally reconstructed images to measure tumor volume. METHODS: Eighty-nine patients who underwent surgical resection for Masaoka-Koga stage III-IV thymic neoplasms between January 2000 and December 2013 were enrolled, including 71 and 18 in the primary surgery and neoadjuvant therapy groups, respectively. Baseline characteristics, postoperative outcomes, and survival rates were analyzed. Moreover, baseline and post-neoadjuvant therapy tumor volumes were compared among patients in the neoadjuvant group. RESULTS: Adjacent mediastinal structure invasion was significantly rarer in the primary surgery group than in the neoadjuvant group (1.27±1.09 vs. 2.61±1.42, p<0.001). On subgroup analysis of patients who underwent neoadjuvant therapy, tumor volumes decreased significantly from 206.08±132.32 cm3 to 81.25±71.24 cm3 post-therapy (p = 0.001). Interestingly, only the pre-neoadjuvant tumor volume was significantly associated with complete resection, while the post-neoadjuvant volume was not (p = 0.012 and p = 0.458, respectively). Moreover, despite significantly reduced tumor volumes, patients in the neoadjuvant therapy group did not exhibit significantly different R0 resection rates (odds ratio 1.490, p = 0.581) or overall survival (p = 0.285) compared to those in the primary surgery group. CONCLUSIONS: Neoadjuvant therapy does not significantly influence the R0 resection rate or overall survival relative to primary surgery. Nevertheless, it may by useful for patients planning surgical resection because it significantly reduces the presurgical tumor volume and extent of invasion.

A nomogram for predicting recurrence after complete resection for thymic epithelial tumors based on the TNM classification: A multi-institutional retrospective analysis.

OBJECTIVES: This study aimed to compare the predictive ability between the Masaoka-Koga (M-K) staging system and the 8th TNM staging system for the recurrence of thymic epithelial tumors (TETs). In addition, a nomogram was developed on the basis of the proposed TNM classification to predict individual recurrence rate. METHODS: A retrospective study was performed on 445 patients who underwent complete resection (R0) of TETs between January 2000 and February 2013. Concordance index (C-index) was used as a statistical indicator to quantify the prediction power of the prediction models. RESULTS: In multivariate analysis, tumor stage and WHO classification were independent recurrence factors in a predictive model on the basis of M-K and TNM stage. The TNM model showed higher C-index than the M-K model (0.837 vs 0.817). The nomogram, on the basis of the TNM model, revealed a highly predictive performance, with a bootstrap-corrected C-index of 0.85 (95% CI, 0.76 to 0.93). CONCLUSIONS: A predictive model based on the 8th TNM stage was slightly better than that based on M-K stage with respect to recurrence after R0 of TETs. The proposed nomogram could be applied to estimate the individual recurrence rate and make decisions for proper surveillance.

Near-Infrared Lymphatic Mapping of the Recurrent Laryngeal Nerve Nodes in T1 Esophageal Cancer.

BACKGROUND: It is still unclear that dissection of recurrent laryngeal nerve nodes is mandatory in patients with cT1 middle or lower thoracic esophageal squamous cell carcinoma when the nodes are negative in preoperative staging workup. We aimed to evaluate the feasibility of near-infrared image-guided lymphatic mapping of bilateral recurrent laryngeal nerve nodes. METHODS: The day before operation, we injected indocyanine green (ICG) into the submucosal layer by endoscopy. At the time of upper mediastinal dissection, ICG-stained basins were identified along the bilateral recurrent laryngeal nerves and retrieved under guidance of the Firefly system. After the operation, remnant ICG-unstained basins were dissected from the specimen to assess the presence of metastasis. RESULTS: Of 29 patients enrolled, ICG-stained basins could be identified in 25 patients (86.2%), and 6 of them (24.0%) had nodal metastasis; 4 in the right recurrent laryngeal nerve chain, 1 in the left recurrent laryngeal nerve chain, and 1 in both recurrent laryngeal nerve chains. On pathologic examination of 345 recurrent laryngeal nerve nodes, two metastatic nodes were identified in ICG-unstained basins along the left recurrent laryngeal nerve in a patient who had lymph node metastases in ICG-stained basins along both recurrent laryngeal nerves. Negative predictive value in detection of nodal metastasis was 100% for the right recurrent laryngeal nerve chain and 98.2% for the left recurrent laryngeal nerve chain. CONCLUSIONS: Real-time assessment of recurrent laryngeal nerve nodes with near-infrared image was technically feasible, and we could detect lymphatic basins that most likely have nodal metastasis. Our technique might be useful in determining the optimal extent of lymphadenectomy.

Feasibility of four-arm robotic lobectomy as solo surgery in patients with clinical stage I lung cancer.

BACKGROUND: This study was performed to investigate the feasibility of four-arm robotic lobectomy (FARL) as a solo surgical technique in patients with non-small cell lung cancer (NSCLC). Early outcome and long-term survival of FARL were compared with those of video-assisted thoracoscopic lobectomy (VATL). METHODS: Prospective enrollment of patients with clinical stage I NSCLC undergoing FARL or VATL (20 patients in each group) was planned. Interim analysis for early postoperative outcome was performed after the initial 10 cases in each group. RESULTS: The study was terminated early because of safety issues in the FARL group after enrollment of 12 FARL and 17 VATL patients from 2011 to 2012. There were no differences in clinical characteristics between groups. Lobectomy time and total operation time were significantly longer in the FARL group (P=0.003). There were three life-threatening events in the FARL group (2 bleedings, 1 bronchus tear) that necessitated thoracotomy conversion in 1 patient. There were no differences in other operative outcomes including pain score, complications, or length of hospital stay. Pathologic stage and number of dissected lymph nodes (LNs) were also comparable. During a follow-up of 48.9±9.5 months, recurrence was identified in 2 (16.7%) patients in FARL group and 3 (23.5%) in VATL group. Five-year overall survival (100% vs. 87.5%, P=0.386) and disease-free survival (82.5% vs. 75.6%, P=0.589) were comparable. CONCLUSIONS: FARL as solo surgery could not be recommended because of safety issues. It required a longer operation time and had no benefits over VATL in terms of early postoperative outcome or long-term survival.