Is Surgery Worthwhile in Locally-advanced NSCLC Patients with Persistent N2-disease After Neoadjuvant Therapy?

AIMS: To explore the long-term survival in lung cancer patients with persistent mediastinal lymph nodal disease after neoadjuvant followed by surgical resection and to analyse prognostic factors in this specific subset of patients. BACKGROUND: Surgery in non-small-cell lung cancer (NSCLC) patients with N2-disease after neoadjuvant therapy (NAD) has been debated and has been even more questioned with the advent of immunotherapy. OBJECTIVE: Describe long-term results of a multimodal approach in locally-advanced NSCLC patients with persistence of N2-disease and identify prognostic factors to target the strategy of care. METHODS: We retrospectively reviewed data of 121 consecutive Stage IIIA-N2 NSCLC patients who underwent NAD (chemoradiotherapy or chemotherapy) from 01/00 to 12/19, focusing our analysis on 37 patients with persistent N2s status after surgery. Kaplan-Meier and Cox regression analysis explored the associations between mortality and potential risk factors. RESULTS: The 5-year survival was 29.8%. Cox regression analysis suggested that young age (HR=0.98, C.I.95%: 0.97- 1.00; p=0.062), male sex (HR=3.8,C.I.95%:1.06-13.73;p=0.04), and adjuvant therapy (HR=6.81,C.I.95%:0.96-53.94;p=0.06) influenced long-term outcomes in these patients. CONCLUSION: We herein observed suboptimal long-term results in this NSCLC patient subset, and, considering emerging results adopting immunotherapy following chemoradiotherapy, surgery should be carefully considered in very selected cases (young and clinically fit patients) and combined with adjuvant therapy after surgery.

Prognostic score for survival with pulmonary carcinoids: the importance of associating clinical with pathological characteristics.

OBJECTIVES: Lung carcinoids (LCs) are staged using the non-small-cell lung cancer tumour/node/metastasis staging system; the possibility of an LC-specific staging system is still being debated. The goal of our study was to construct a composite prognostic score for LC. METHODS: From January 2002 to December 2014, data from 293 patients who underwent surgical treatment for LC in 7 research institutes were retrospectively analysed. A panel of established prognostic factors in addition to lymph node metastasis patterns (single/multiple N1-N2 station, skip metastasis, lobe specific), numbers of lymph nodes resected and the ratio between the numbers of metastatic lymph nodes and the numbers of lymph nodes resected (node ratio) were correlated to overall survival (OS) and disease-free survival (DFS). The log-hazard ratio (HR), obtained from the Cox model, was used to derive weighting factors for a continuous prognostic index, designed to identify differential outcome risks. The score was dichotomized according to maximally selected log-rank statistics. RESULTS: Pathological analysis showed typical carcinoids in 223 (76.1%) and atypical carcinoids in 70 (23.9%) patients; the tumour/node/metastasis pattern was stage I in 72.4%, stage II in 18.1%, stage III in 9.5% and stage IV in 0.03% cases. The median numbers of lymph nodes resected was 12 (range 0-53); hilar and mediastinal node metastases were identified in 14% and 6.8% of cases, respectively. Overall, the 5-year OS and 5-year DFS rates were 90.6% and 76.7%, respectively. At multivariable analysis, sex, age, pathological T stage and node ratio were significantly related to a better OS; age, histological type, pathological T stage and node ratio were related to DFS. These factors were used to generate the prognostic score, which showed statistically significant differences between the high-risk and low-risk groups: 5-year OS = 96.6% if score <3.1 vs 63.5% if score ≥3.1 [P < 0.0001; HR 17.56, 95% confidence interval (CI) 5.45-56.53]; 5-year DFS 92.3% if score <1.5 vs 52.5% if score ≥ 1.5 (P < 0.0001; HR 7.95, 95% CI 3.48-18.16). CONCLUSIONS: The proposed prognostic scores seem to be effective in predicting outcomes for patients with LCs.

Agreement between chest ultrasonography and chest X-ray in patients who have undergone thoracic surgery: preliminary results.

BACKGROUND: Chest Ultrasonography (chest US) has shown good sensibility in detecting pneumothorax, pleural effusions and peripheral consolidations and it can be performed bedside. OBJECTIVES: The aim of the study was to analyze agreement between chest US and chest X-ray in patients who have undergone thoracic surgery and discuss cases of discordance. METHODS: Patients undergoing thoracic surgery were retrospectively selected. Patients underwent routinely Chest X-ray (CXR) during the first 48 h after surgery. Chest US have been routinely performed in all selected patients in the same date of CXR. Chest US operators were blind to both reports and images of CXR. Ultrasonographic findings regarding pneumothorax (PNX), subcutaneous emphysema (SCE), lung consolidations (LC), pleural effusions (PE) and hemi-diaphragm position were collected and compared to corresponding CXR findings. Inter-rater agreement between two techniques was determined by Cohen's kappa-coefficient. RESULTS: Twenty-four patients were selected. Inter-rater agreement showed a moderate magnitude for PNX (Cohen's Kappa 0.5), a slight/fair magnitude for SCE (Cohen's Kappa 0.21), a fair magnitude for PE (Cohen's Kappa 0.39), no agreement for LCs (Cohen's Kappa 0.06), high levels of agreement for position of hemi-diaphragm (Cohen's Kappa 0.7). CONCLUSION: Analysis of agreement between chest X-ray and chest US showed that ultrasonography is able to detect important findings for surgeons. Limitations and advantages have been found for both chest X-ray and chest US. Knowing the limits of each one is important to really justify and optimize the use of ionizing radiations.

Digital Devices Improve Chest Tube Management: Results from a Prospective Randomized Trial.

BACKGROUND: Digital devices could help clinical practice measuring the air leak, but their role is still debated. Aim of this study is to test advantages using these devices. METHODS: From June 2012 to May 2015, we enrolled 95 patients undergoing lobectomy or wedge resection in a prospective randomized trial. Patients were divided into two groups: group D (digital, 50 patients) evaluated with digital device and group E (empirical, 45 patients) evaluated with water seal. Logistic regression analysis and receiver operating characteristic (ROC) curve analysis were used to select and assess predictors of persistent air leak. In group D, chest drain was removed if the air leak was absent or < 0.5 L/h for 12 consecutive hours and in group E if clinical signs of air leak were absent. RESULTS: Mean hospitalization and mean chest tube stay was 6.0 ± 3.3 and 4.4 ± 3.2 days, respectively, prolonged air leak occurred in nine (8%). Hospitalization was 5.8 ± 2.5 versus 6.2 ± 4.2 days (p = 0.5), while mean chest tube stay was 4.1 ± 2.0 versus 4.6 ± 3.5 days (p = 0.4) in group D and group E, respectively. Clamping test was needed in one patient in group D and in seven in group E (p = 0.019). At multivariate analysis, heart disease (p < 0.0001), lobectomy (p < 0.0001), fused fissure (p < 0.0001), and air leakage in first postoperative (p.o.) day were predictors of persistent air leak (AUC on the ROC curve of 69.7%, sensibility: 77.8%). In group D, an air leak value > 0.2 L/h with spikes over 0.5 L/h in third p.o. was predictive of persistent air leak, with chest tube duration of 7.73 ± 5.20 versus 4.32 ± 1.33 days (AUC: 83%, sensitivity: 80%, p < 0.0001). CONCLUSION: In our experience, digital devices reduced observer variability and mistakes in chest tube management, thus identifying patients at risk for prolonged air leak.

Lung metastasectomy following kidney tumors: outcomes and prognostic factors from a single-center experience.

BACKGROUND: The lung is one of the sites most frequently affected by metastatic renal cell carcinoma (mRCC). Nonsurgical therapy for mRCC has limited efficacy, while the 5-year survival rates data published in literature after pulmonary surgery for metastasectomy, emphasize the role of surgery as the treatment that guarantees the best effectiveness in pulmonary resectable metastases. METHODS: From January 2000 to March 2016, 27 patients underwent pulmonary metastasectomy for metastatic renal cancer was retrospectively reviewed. Primary renal cancer was controlled in all patients and there was no other metastatic site in addition to the lung, at the time of metastasectomy. The aim of the study was to identify outcomes and prognostic factors in association with survival after complete pulmonary resection of metastases in a subgroup of patients with isolated pulmonary metastases from RCC. RESULTS: Five- and 10-year overall survival (OS) from first pulmonary metastasectomy was 75% and 59%, respectively. Independent prognostic factor influencing survival were: dimension of pulmonary metastases ≥2 cm (3-year survival: 67% vs. 100%; P=0.014) and disease free interval (DFI) ≥5 years (3-year survival: 94% vs. 28%; P=0.05). The only independent prognostic factors affecting DFI was the dimension of pulmonary metastases ≥2 cm (5-year DFI: 67% vs. 89%; P=0.03) at univariate analysis. CONCLUSIONS: Considering the good results based on high long-term efficacy and low morbidity after metastases surgical resection, we always recommend metastasectomy in patients with technically resectable metastases, especially in case of long DFI and reduced dimension of pulmonary lesions.