Long-term outcomes after lung-sparing surgery for epithelial mesothelioma.

BACKGROUND: This observational study evaluates retrospectively the long-term outcomes after pleurectomy/decortication for pleural mesothelioma, with and without the resection/reconstruction of diaphragm and pericardium. METHODS: Data from 155 consecutive patients undergoing lung-sparing surgery for epithelial pleural mesothelioma were reviewed. Selection criteria for surgery were cT1-3, cN0-1, good performance status, age <80 years. Perioperative Pemetrexed-Platinum regimen was administered as induction in 101 cases (65.2%) and as adjuvant treatment in 54 cases (34.8%). Extended pleurectomy/decortication was performed in 87 cases (56.12%). In 68 patients (43.87%) standard pleurectomy/decortication was performed without resection/reconstruction of diaphragm and pericardium, when tumour infiltration was deemed absent after intraoperative frozen section. The log-rank test and Cox regression model were used to assess the factors affecting overall survival and recurrence free survival. RESULTS: Median follow-up was 20 months. The 2- and 5-year survival rate was 60.9% and 29.2% with a median survival of 34 months. An improved survival was observed when standard pleurectomy/decortication was carried out (P=0.007). A significant impact on survival was found comparing the TNM-stages (P=0.001), pT (P=0.002) and pN variables (P=0.001). Multivariate analysis identified the pN-status (P=0.003) and standard pleurectomy/decortication (P=0.017) as predictive for longer survival. The recurrence-free survival >12 months was strongly related to the overall survival (P<0.001). The macroscopic complete resection (P=0.001), TNM-stage (P=0.003) and pT-status (P=0.001) are related to relapse. CONCLUSIONS: Within multimodal management of pleural mesothelioma, lung-sparing surgery is a valid option even with more conservative technique. A benefit for a longer survival was observed in the early stage of disease, with pN0 and when pleurectomy/decortication is carried out, preserving diaphragm and pericardium. Recurrence is not affected by the type of surgery, and a recurrence-free interval >12 months is predictive of an increased survival when the macroscopic complete resection is achieved.

Correction to: Predictors of nodal upstaging in patients with cT1-3N0 non-small cell lung cancer (NSCLC): results from the Italian VATS Group Registry.

In the original publication, Carlo Curcio was not included in the author list. The correct author list is included in this Correction.

Predictors of nodal upstaging in patients with cT1-3N0 non-small cell lung cancer (NSCLC): results from the Italian VATS Group Registry.

PURPOSE: Accurate staging of early non-small cell lung cancer is fundamental for selecting the best treatment. The aim of this study was to identify risk factors for nodal upstaging after video-assisted thoracoscopic lobectomy for clinical T1-3N0 tumors. METHODS: From 2014 to 2017, 3276 thoracoscopic lobectomies were recorded in the prospective database "Italian VATS Group". Linear and multiple logistic regression models were adapted to identify independent predictors of nodal upstaging and factors associated with progression in postoperative N status. RESULTS: Nodal upstaging was found in 417 cases (12.7%), including 206 cases (6.2%) of N1-positive nodes, 81 cases of N2 nodes (2.4%), and 130 cases (4%) of involvement of both N1 + N2 nodes. A total of 241 (7.3%) patients had single-station nodal involvement, whereas 176 (5.3%) had multiple-station involvement. In the final regression model, the tumor grade, histology, pathologic T status, and > 12 resected nodes were independent predictors of nodal upstaging. CONCLUSIONS: The number of resected lymph nodes seems to predict nodal upstaging better than the type of intraoperative lymph node management. Other preoperative risk factors correspond to those for which the current guidelines of the European Society of Thoracic Surgery recommend more extensive preoperative mediastinal staging.

Enhanced recovery after elective surgery for lung cancer patients: analysis of current pathways and perspectives.

The concept of enhanced recovery after surgery (ERAS), initially introduced in the field of colorectal surgery, has been developed in order to optimize the postoperative course. In recent years the number of authors analyzing the role of ERAS in lung cancer surgery is increasing, highlighting several interventions with positive effects on the postoperative course. Yet it is still difficult to draw definite conclusions and specific guidelines, as most of these studies largely differ for their methodological aspects and study populations. Herein we focus on the key elements of each single intervention, trying to identify what we can apply in a common pathway, and which aspects are still to be evaluated for the validation of an ERAS program.

Does Induction Therapy Increase Anastomotic Complications in Bronchial Sleeve Resections?

BACKGROUND: Sleeve lobectomy represents a safe and effective treatment for central NSCLC to avoid the risks of pneumonectomy. Induction therapy (IT) may be indicated in advanced stages; however, the effect of IT on bronchial anastomoses remains uncertain. The purpose of the study was to evaluate the impact of IT on the complications of the anastomoses. METHODS: Between 2000 and 2012, 159 consecutive patients were submitted to sleeve lobectomy for NSCLC at our Institution. We retrospectively compared the results of patients who underwent IT before operation with those who received upfront surgery. RESULTS: In the study period, 49 (30.8%) patients received IT (37 chemotherapy, 1 radiotherapy and 11 chemo-radiotherapy) and 110 (69.2%) patients were directly submitted to surgery (S). The two groups were comparable for sex, age, comorbidities, ASA score, pulmonary function, side, type of procedure and histology. Pathological stage was statistically higher for IT group (p = 0.001). No differences between IT and S groups were observed in terms of post-operative mortality (2% vs 0%, p = NS), morbidity (45% vs 38%, p = NS), including early (6% vs 9%, p = NS) and long-term (16% vs 14%, p = NS) bronchial complication rates. Patients undergoing induction mediastinal radiotherapy, however, are at higher risk of bronchial complications. CONCLUSION: In our experience, the use of induction chemotherapy did not significantly increase mortality and morbidity rates, in particular, neither for early nor for late anastomotic complications. We, therefore, conclude that sleeve lobectomy after induction chemotherapy is safe and reliable procedure for the treatment of locally advanced NSCLC.

Predictors of unexpected nodal upstaging in patients with cT1-3N0 non-small cell lung cancer (NSCLC) submitted to thoracoscopic lobectomy.

BACKGROUND: In the last decades, the use of video-assisted thoracoscopic surgery (VATS) lobectomy for the treatment of early stage non-small cell lung cancer is continuously growing. This is mainly due to the development of more advanced surgical devices, to the rising incidence of peripheral lung tumors and is also favored by the increased reliability of preoperative staging techniques. Despite this progress, postoperative unexpected nodal upstaging is still a relevant issue. Aim of this study is to identify possible predictors of unexpected nodal upstaging in patients affected by cT1-3N0 NSCLC submitted to VATS lobectomy. METHODS: A total of 231 cases of cT1-3N0 patients submitted to thoracoscopic lobectomy at our centre between June 2012 and October 2016 were retrospectively reviewed. All data regarding clinical staging by means of computed tomography (CT) and positron-emission tomography (PET)/CT were collected and reviewed. The subsequent pathological staging has been analyzed, with special regards to the possible type of nodal involvement, and the number of pathological nodal stations. RESULTS: Most of the patients included in this study were in a clinical stage cT1aN0, cT1bN0 (stage IA) and cT2aN0 (stage IB), 86 (37.2%) patients, 73 (31.6%) patients and 62 (26.8%) patients, respectively. Postoperative histopathological analysis showed that the most frequent tumor histotype was adenocarcinoma (192 patients, 83.1%). Thirty-eight (16.5%) patients had a nodal upstaging; among these, 17 (7.4%) patients had N2 disease (8 patients with isolated mediastinal nodal involvement, 9 patients with N1 + N2 disease) and 21 (9.1%) patients had an isolated hilar nodal involvement (N1). At bivariate analysis, the clinical T (cT)-parameter (P=0.023), the histotype (P=0.029) and the pathological T (pT)-parameter (P=0.003) were identified as statistically significant predictors of nodal upstaging. Concerning the type of nodal upstaging, the pT was found to be statistically significant (P=0.042). At bivariate analysis for the number of involved nodal stations, a statistical significance was highlighted for the parameters cT (P=0.030) and pT (P=0.027). With linear logistic regression, histology as well as pT reached statistical significance (P=0.0275 and P=0.0382, respectively). No correlation was found between nodal upstaging and the intensity of FDG uptake in the primary lung tumor or with the timing between PET and surgery. CONCLUSIONS: There is a strong correlation between the clinical staging of the parameter T evaluated with CT and the possible unexpected nodal upstaging. The same correlation with nodal upstaging is found for pT. At equal clinical stage, in patients affected by adenocarcinoma of the lung the relative risk of having a postoperative unexpected nodal upstaging is almost 7 times higher than in patients with squamous cell carcinoma.

Outcomes and prognostic factors of non-small-cell lung cancer with lymph node involvement treated with induction treatment and surgical resection.

OBJECTIVES: Induction therapy (IT) has gained popularity in recent years, becoming a standard of treatment in resectable lymph node-positive NSCLC. IT aims to downstage the disease (shrinkage of tumour and clearance of lymph node-metastases), clear distant micrometastases and prolong survival. Potential disadvantages are increased morbidity and/or mortality after surgery and risk of progression of disease that could have been initially resected. The purpose of this study was to evaluate the outcomes and prognostic factors in a series of patients with lymph node-positive NSCLC receiving IT followed by surgery. METHODS: A total of 86 patients (75.6% males, median age 63 years) affected by NSCLC in clinical stage IIIA (n = 80) or IIIB (n = 6), with pathologically proven lymph node involvement, underwent platinum-based IT followed by surgery between 2000 and 2009. RESULTS: Eighty (93%) patients received a median of 3 cycles of chemotherapy, and 6 (7%) underwent induction chemoradiotherapy. Response to IT was complete in 3.5%, partial in 59.3% and stable disease in 37.2% of patients. Postoperative morbidity and mortality were 25.6 and 2.3%, respectively. At pathological evaluation, 38.4% of patients had a downstaging of disease with a complete lymph node clearance in 31.4%. Median overall survival was 23 months (5-year survival 33%). Univariate analysis found clinical stage (P = 0.02), histology (P = 0.01), response to IT (P = 0.02) and type of intervention (P = 0.047) to have predictive roles in survival. A better but not significant survival was also found for pN0 vs pN+ (P = 0.22), downstaged tumours (P = 0.08) and left side (P = 0.06). On multivariate analysis, clinical response to neoadjuvant therapy (P = 0.01) and age (P = 0.03) were the only independent predictors of survival. CONCLUSIONS: The use of IT for lymph node-positive NSCLC seems justified by low morbidity and/or mortality and good survival rates. Patients with response to IT showed greater benefit in the long term.