Treatment patterns and clinical outcomes of patients with resectable non-small cell lung cancer receiving neoadjuvant immunochemotherapy: A large-scale, multicenter, real-world study (NeoR-World).

BACKGROUND: Neoadjuvant immunotherapy has ushered in a new era of perioperative treatment for resectable non-small cell lung cancer (NSCLC). However, large-scale data for verifying the efficacy and optimizing the therapeutic strategies of neoadjuvant immunochemotherapy in routine clinical practice are scarce. METHODS: NeoR-World (NCT05974007) was a multicenter, retrospective cohort study involving patients who received neoadjuvant immunotherapy plus chemotherapy or chemotherapy alone in routine clinical practice from 11 medical centers in China between January 2010 and March 2022. Propensity score matching was performed to address indication bias. RESULTS: A total of 408 patients receiving neoadjuvant immunochemotherapy and 684 patients receiving neoadjuvant chemotherapy were included. The pathologic complete response (pCR) and major pathologic response (MPR) rates of the real-world neoadjuvant immunochemotherapy cohort were 32.8% and 58.1%, respectively. Notably, patients with squamous cell carcinoma exhibited significantly higher pCR and MPR rates than those with adenocarcinoma (pCR, 39.2% vs 16.5% [P < .001]; MPR, 66.6% vs 36.5% [P < .001]), whereas pCR and MPR rates were comparable among patients receiving different neoadjuvant cycles. In addition, the 2-year rates of disease-free survival (DFS) and overall survival (OS) rate were 82.0% and 93.1%, respectively. Multivariate analyses identified adjuvant therapy as an independent prognostic factor for DFS (hazard ratio [HR], 0.51; 95% confidence interval [CI], 0.29-0.89; P = .018) and OS (HR, 0.28; 95% CI, 0.13-0.58; P < .001). A significantly longer DFS with adjuvant therapy was observed in patients with non-pCR or 2 neoadjuvant cycles. We observed significant benefits in pCR rate (32.4% vs 6.4%; P < .001), DFS (HR, 0.50; 95% CI, 0.38-0.68; P < .001) and OS (HR, 0.61; 95% CI, 0.40-0.94; P = .024) with immunotherapy plus chemotherapy compared to chemotherapy alone both in the primary propensity-matched cohort and across most key subgroups. CONCLUSIONS: The study validates the superior efficacy of neoadjuvant immunochemotherapy over chemotherapy alone for NSCLC. Adjuvant therapy could prolong DFS in patients receiving neoadjuvant immunochemotherapy, and patients with non-pCR or those who underwent 2 neoadjuvant cycles were identified as potential beneficiaries of adjuvant therapy.

Neoadjuvant chemotherapy combined with immunotherapy versus neoadjuvant chemoradiotherapy in patients with locally advanced esophageal squamous cell carcinoma.

BACKGROUND: To date, few studies have compared effectiveness and survival rates of neoadjuvant chemotherapy combined with immunotherapy (NACI) and conventional neoadjuvant chemoradiotherapy (NCRT) in patients with locally advanced esophageal squamous cell carcinoma (ESCC). The present study was conducted to compare therapeutic response and survival between NACI and NCRT. METHODS: The study cohort comprised patients with locally advanced ESCC treated with either NACI or NCRT followed by surgery between June 2018 and March 2021. The 2 groups were compared for treatment response, 3-year overall survival (OS), and disease-free survival (DFS). Survival curves were created using the Kaplan-Meier method, differences were compared using the log-rank test, and potential imbalances were corrected for using the inverse probability of treatment weighting (IPTW) method. RESULTS: Among 202 patients with locally advanced ESCC, 81 received NACI and 121 received conventional NCRT. After IPTW adjustment, the R0 resection rate (85.2% vs 92.3%; P = .227) and the pathologic complete response (pCR) rate (27.5% vs 36.4%; P = .239) were comparable between the 2 groups. Nevertheless, patients who received NACI exhibited both a better 3-year OS rate (91.7% vs 79.8%; P = .032) and a better 3-year DFS rate (87.4% vs 72.8%; P = .039) compared with NCRT recipients. CONCLUSIONS: NACI has R0 resection and pCR rates comparable to those of NCRT and seems to be correlated with better prognosis than NCRT. NACI followed by surgery may be an effective treatment strategy for locally advanced ESCC.

Pathologic responses and surgical outcomes after neoadjuvant immunochemotherapy versus neoadjuvant chemoradiotherapy in patients with locally advanced esophageal squamous cell carcinoma.

Background: Currently, the role of immunotherapy in neoadjuvant setting for patients with locally advanced esophageal squamous cell carcinoma (ESCC) is gradually attracting attention. Few studies compared the efficacy of neoadjuvant immunochemotherapy (NICT) and neoadjuvant chemoradiotherapy (NCRT). Our study aimed to compare treatment response and postoperative complications after NICT followed by surgery with that after conventional NCRT in patients with locally advanced ESCC. Methods: Of 468 patients with locally advanced ESCC, 154 received conventional NCRT, whereas 314 received NICT. Treatment response, postoperative complications and mortality between two groups were compared. Pathological response of primary tumor was evaluated using the Mandard tumor regression grade (TRG) scoring system. Pathological complete response (pCR) of metastatic lymph nodes (LNs) was defined as no viable tumor cell within all resected metastatic LNs. According to regression directionality, tumor regression pattern was summarized into four categories: type I, regression toward the lumen; type II, regression toward the invasive front; type III, concentric regression; and type IV, scattered regression. Inverse probability propensity score weighting was performed to minimize the influence of confounding factors. Results: After adjusting for baseline characteristics, the R0 resection rates (90.9% vs. 89.0%, P=0.302) and pCR (ypT0N0) rates (29.8% vs. 34.0%, P=0.167) were comparable between two groups. Patients receiving NCRT showed lower TRG score (P<0.001) and higher major pathological response (MPR) rate (64.7% vs. 53.6%, P=0.001) compared to those receiving NICT. However, NICT brought a higher pCR rate of metastatic LNs than conventional NCRT (53.9% vs. 37.1%, P<0.001). The rates of type I/II/III/IV regression patterns were 44.6%, 6.8%, 11.4% and 37.1% in the NICT group, 16.9%, 8.2%, 18.3% and 56.6% in the NCRT group, indicating a significant difference (P<0.001). Moreover, there were no significant differences in the incidence of total postoperative complications (35.8% vs. 39.9%, P=0.189) and 30-d mortality (0.0% vs. 1.1%, P=0.062). Conclusion: For patients with locally advanced ESCC, NICT showed a R0 resection rate and pCR (ypT0N0) rate comparable to conventional NCRT, without increased incidence of postoperative complications and mortality. Notablely, NICT followed by surgery might bring a promising treatment response of metastatic LNs.

Is it necessary for patients with potentially resectable esophageal squamous cell cancer to receive routine preoperative brain MRI/CT?

BACKGROUND: This study aimed to investigate the value and efficiency of routine brain MRI or CT in the preoperative workup for patients with potentially resectable (cT1-4a N0-3 ) thoracic esophageal squamous cell cancer (ESCC). METHODS: This was a prospective cross-sectional clinical trial (ChiCTR1800020304). A total of 385 patients with potentially resectable (cT1-4a N0-3 ) thoracic ESCC diagnosed from October 2018 to August 2020 were included. Plain brain MRI or CT was performed preoperatively to detect brain metastases (BrM). The primary endpoint was BrM detected by imaging. RESULTS: Of all 385 patients, the rate of positive brain MRI/CT findings was 1% (n = 4). BrM Patients received chemoradiotherapy, and the median OS was 6 months (95% CI: 4.303-7.697). All 381 remaining patients with initial negative brain MRI/CT diagnosis revealed no brain-associated symptoms within 6 months. The median follow-up for patients without BrM was 20 months (range, from 6 to 32). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of plain MRI or CT to detect BrM were all 100%. CONCLUSIONS: Preoperative plain MRI or CT is an effective method to detect BrM for potentially resectable (cT1-4a N0-3 ) thoracic ESCC. However, due to the low incidence, the value of brain MRI/CT as a routinely preoperational examination in potentially resectable esophageal squamous cell cancer is rather limited. Therefore, preoperative brain MRI/CT should not be recommended as a routine preoperative examination for ESCC.

Development and validation of a nomogram model for the prediction of 4L lymph node metastasis in thoracic esophageal squamous cell carcinoma.

Objectives: The left tracheobronchial (4L) lymph nodes (LNs) are considered as regional LNs for esophageal squamous cell carcinoma (ESCC), but there is a controversy about routine prophylactic 4L LN dissection for all resectable ESCCs. This study aimed to develop a nomogram for preoperative prediction of station 4L lymph node metastases (LNMs). Methods: A total of 522 EC patients in the training cohort and 370 in the external validation cohort were included. The prognostic impact of station 4L LNM was evaluated, and multivariable logistic regression analyses were performed to identify independent risk factors of station 4L LNM. A nomogram model was developed based on multivariable logistic regression analysis. Model performance was evaluated in both cohorts in terms of calibration, discrimination, and clinical usefulness. Results: The incidence of station 4L LNM was 7.9% (41/522) in the training cohort. Patients with station 4L LNM exhibited a poorer 5-year overall survival rate than those without (43.2% vs. 71.6%, p < 0.001). In multivariate logistic regression analyses, six variables were confirmed as independent 4L LNM risk factors: sex (p = 0.039), depth of invasion (p = 0.002), tumor differentiation (p = 0.016), short axis of the largest 4L LNs (p = 0.001), 4L conglomeration (p = 0.006), and 4L necrosis (p = 0.002). A nomogram model, containing six independent risk factors, demonstrated a good performance, with the area under the curve (AUC) of 0.921 (95% CI: 0.878-0.964) in the training cohort and 0.892 (95% CI: 0.830-0.954) in the validation cohort. The calibration curve showed a good agreement on the presence of station 4L LNM between the risk estimation according to the model and histopathologic results on surgical specimens. The Hosmer-Lemeshow test demonstrated a non-significant statistic (p = 0.691 and 0.897) in the training and validation cohorts, which indicated no departure from the perfect fit. Decision curve analysis indicated that the model had better diagnostic power for 4L LNM than the traditional LN size criteria. Conclusions: This model integrated the available clinical and radiological risk factors, facilitating in the precise prediction of 4L LNM in patients with ESCC and aiding in personalized therapeutic decision-making regarding the need for routine prophylactic 4L lymphadenectomy.

99m Tc bone scintigraphy does not affect preoperative workup for patients with potentially resectable esophageal squamous cell carcinoma.

BACKGROUND: 99m Tc bone scintigraphy (BS) is the mainstay and most widely used technique in evaluation of bone metastasis (BM) in China. This study aimed to investigate the value of 99m Tc BS in preoperative workup for patients with potentially resectable (cT1-4a N0-3 ) esophageal squamous cell carcinoma (ESCC). METHODS: This prospective cross-section clinical trial (ChiCTR1800020304) enrolled a total of 385 patients with ESCC diagnosed at thoracic surgery clinic from October 2018 to September 2020. All patients were diagnosed with stage cT1-4a N0-3 and were potential candidates for surgical resection. BS was performed preoperatively and the treatment strategy was changed after confirmation of BM. The primary endpoint was the rate of change of the treatment regimen because of BM, while the secondary endpoint was the rate of positive BS findings. RESULTS: Out of the 385 patients, only two (0.5%) changed their treatment regimen because of BM. The rate of positive BS findings was 1%, while two patients (0.5%) had false-positive or false-negative results. The BS diagnostic performance for BM was sensitivity 50%, specificity 99.5%, positive predictive value 50%, negative predictive value 99.5%, and accuracy 99.0%. There was no significant difference in BM in relation to age, sex, tumor location or clinical stage. CONCLUSION: Our data demonstrated that 99m Tc bone scintigraphy does not significantly affect the preoperative workup in patients with potentially resectable ESCC, especially in early clinical stage patients.

Safety and efficacy of vagus nerve preservation technique during minimally invasive esophagectomy.

Background: This study aimed to assess the feasibility, efficacy and safety of McKeown surgery with vagal-sparing using minimally invasive esophagectomy (MIE). Methods: McKeown surgery with vagal-sparing technique using MIE was adopted on patients diagnosed with resectable esophageal cancer. From June 2020 to January 2021, a total of 20 patients from the Department of Thoracic Surgery of the National Clinical Research Center for Cancer were enrolled. Results: The study group included 17 (85%) males and 3 (15%) females, with an average age of 62.6 (±7.1) years. The most common tumor location was lower thoracic esophagus (n=9, 45%), followed by middle thoracic esophagus (n=8, 40%) and upper thoracic esophagus (n=3, 15%). Nine (45%) patients had T1b disease, followed by T2 (n=8, 40%), T1a (n=2, 10%), and Tis (n=1, 5%). The average operation time was 221.5 (±61.2) minutes. Postoperative complications were as follow: 2 (10%) with hoarseness, 2 (10%) with pulmonary infection, 1 (5%) with arrhythmia, 1 (5%) with anastomotic leakage, 1 (5%) with delayed gastric emptying, 1 (5%) with pleural effusion, and 1 (5%) with diarrhea. Dumping syndrome, cholestasis, and chylothorax were not observed, and there was no perioperative death. Conclusions: MIE with vagus nerve preservation is a feasible and safe technique, with the possibility to be an alternative for esophageal carcinoma. Further study is needed to explore the functional outcome of preserving vagus nerve.

Neoadjuvant therapy combined with surgery is superior to chemoradiotherapy in esophageal squamous cell cancer patients with resectable supraclavicular lymph node metastasis: a propensity score-matched analysis.

Background: Multiple clinical trials were conducted to evaluate the efficacy of neoadjuvant therapy in esophageal cancer but exhibited mixed results, indicating that the efficacy of neoadjuvant therapy remains controversial in the treatment of esophageal cancer. Our study was conducted to investigate the value of neoadjuvant therapy in patients with esophageal cancer with supraclavicular lymph node metastases. Methods: We retrospectively enrolled 231 patients who had resectable esophageal squamous cell carcinoma (ESCC) with supraclavicular lymph node metastases from June 2008 to November 2018. All patients were divided into three groups: the neoadjuvant therapy combined with surgery (Neo + S) group, the radical chemoradiotherapy (CRT) group, and the single radiotherapy (RT) group. Propensity score matching (PSM) was conducted to exclude the impact of potential interferences. Kaplan-Meier analysis, the log-rank test, and competitive risk model analysis were used to assess the efficacy of different therapeutic methods. Results: Patients in the Neo + S group had a better 3-year survival rate (72.0% vs. 35.8%; P=0.005), progression-free survival (PFS) (24 vs. 14 months; P<0.0001), and lower 3-year tumor-specific mortality risk (25.1% vs. 53.7%; P=0.005) than those in the CRT group. Furthermore, patients in the CRT group had a better 3-year survival (30.1% vs. 18.6%; P=0.012) and lower 3-year tumor-specific mortality risk (57.9% vs. 76.8%; P=0.011) than those in the RT group. Additionally, the supraclavicular lymph node metastasis rate was higher than the mediastinal lymph node metastasis rate in patients with upper esophageal cancer compared to middle and lower esophageal cancer. Conclusions: Neoadjuvant chemotherapy combined with surgery showed better efficacy than radical CRT in patients who had resectable ESCC with supraclavicular lymph nodes metastasis. Supraclavicular lymph nodes are more likely to be regional lymph nodes for upper and middle esophageal cancer.

Clinical significance of left tracheobronchial lymph node dissection in thoracic esophageal squamous cell carcinoma.

OBJECTIVE: The left tracheobronchial lymph nodes are considered as regional lymph nodes for esophageal squamous cell carcinoma, but routine prophylactic left tracheobronchial lymph node dissection for all resectable esophageal squamous cell carcinoma has been controversial. This study aimed to evaluate the prognostic impact of left tracheobronchial lymph node dissection and left tracheobronchial lymph node metastases in thoracic esophageal squamous cell carcinoma and to analyze the risk factors of left tracheobronchial lymph node metastases. METHODS: A total of 3522 patients with esophageal squamous cell carcinoma undergoing esophagectomy were included. Overall survival was calculated by a Kaplan-Meier method and compared using the log-rank test. Propensity score matching was conducted to adjust confounding factors. Univariable and multivariable logistic regression analyses were used to identify independent risk factors of left tracheobronchial lymph node metastases. RESULTS: In this study, 608 patients underwent left tracheobronchial lymph node dissection and 45 patients had left tracheobronchial lymph node metastases (7.4%). After propensity score matching, the 5-year overall survival in patients receiving left tracheobronchial lymph node dissection was better than in patients who did not (68.2% vs 64.6%, P = .012). In patients receiving left tracheobronchial lymph node dissection, patients with left tracheobronchial lymph node metastases had a significantly poorer survival than patients without (5-year overall survival: 40.5% vs 62.2%, P = .029). Multivariable logistic analyses showed that clinical T stage and tumor differentiation were independent risk factors for left tracheobronchial lymph node metastases. CONCLUSIONS: In thoracic esophageal squamous cell carcinoma, station left tracheobronchial lymph node metastases indicate a poor prognosis and left tracheobronchial lymph nodes dissection seems to be associated with a more favorable prognosis. Clinical T stage and tumor differentiation were independent risk factors for left tracheobronchial lymph node metastases. For patients with high risk, routine prophylactic left tracheobronchial lymph node dissection should be performed.

Reconstruction of upper mediastinal pleura reduces postoperative complications in enhanced recovery surgery system after esophagectomy: A propensity score matching study.

OBJECTIVES: This study aimed to explore the effect of suturing upper mediastinum pleura on postoperative complications, surgery-related mortality, and hospital stay. METHODS: Four hundred and thirty-eight patients with esophageal cancer who underwent esophagectomy were identified. Patients were divided into two groups: those in the test group who received reconstruction of upper mediastinal pleura, those in the conventional group who did not. The incidence of postoperative complications, surgery-related mortality, and hospital stay were compared. To reduce the impact of confounding factors, a propensity score matching (PSM) method was performed. RESULTS: A total of 273 patients were treated with suturing upper mediastinal pleura and 165 were not. After PSM, compared with the conventional group, the incidence of atelectasis (7.2% vs. 1.4%, p = 0.035), anastomotic leakage (5.8% vs. 0.7%, p = 0.036), and delayed gastric emptying (10.8% vs. 3.6%, p = 0.034) were significantly lower in the test group. And suturing the upper mediastinal pleura could reduce the severity of leakage (p = 0.045), consistent with the results before PSM. Moreover, there were no significant differences in the incidence of other complications, postoperative hospital stay, and 30-day mortality (all p > 0.05). CONCLUSIONS: In this study, suturing the upper mediastinal pleura can reduce the incidence of atelectasis, anastomotic leakage, and delayed gastric emptying, and the severity of leakage, without increasing the incidence of other complications, surgery-related death, and postoperative hospital stay.

Treatment and Prognosis of Resectable Cervical Esophageal Cancer: A Population-Based Study.

BACKGROUND: The optimal treatment strategy for resectable cervical esophageal cancer remains controversial. This study aimed to explore prognostic factors and optimal treatment strategies in the context of staging. METHODS: In this population-based study, 1371 patients with resectable cervical esophageal cancer were identified in the Surveillance, Epidemiology, and End Results database. Univariate analysis and multivariable Cox regression model were performed to evaluate factors related to overall survival (OS). Subgroup analysis based on staging was performed to assess the effect of treatments on survival and propensity score matching was conducted to adjust confounding factors. RESULTS: Univariate and multivariable analyses revealed that age, sex, year of diagnosis, histological type, tumor size, cN stage, surgery, radiotherapy, and chemotherapy are independent prognostic factors. After propensity score matching, patients with local disease (cT1-2N0M0) who received surgery alone had a higher 10-year OS rate than those received chemoradiotherapy (CRT) (20.7% vs 11.4%, P = .023). Compared with CRT, surgery-based multimodal therapy did not increase the OS rate of patients (14.8% vs 11.1%, P = .084). For regional disease (cT3-4aN0M0/cT1-4aN1-3M0), although surgery alone did not improve the OS rate of patients compared with CRT (7.3% vs 8.2%, P = .18), we observed a significant difference in 10-year OS among patients who underwent surgery-based multimodal therapy vs those who underwent CRT (20.4% vs 9.0%, P = .031). CONCLUSIONS: Compared with CRT, surgery alone improves the long-term survival of patients with localized disease, and surgery-based multimodal therapy increases the survival rate of patients with regional disease. Further studies are required to confirm our findings.

Patient prognostic scores and association with survival improvement offered by postoperative radiotherapy for resected IIIA/N2 non-small cell lung cancer: A population-based study.

BACKGROUND: Currently, there is no consensus on the role of postoperative adjuvant radiotherapy (PORT) for resected stage IIIA/N2 non-small cell lung cancer (NSCLC). Our study sought to determine which patients may be able to benefit from PORT, based on a patient prognostic score. METHODS: A retrospective cohort study was conducted to identify patients diagnosed with IIIA/N2 NSCLC between 1988 and 2016 in the SEER database. Eligible patients were divided into the following two groups: PORT group and non-PORT group. We classified patient prognostic scores as an ordinal factor and stratified patients based on prognostic scores. A Cox proportional hazards model with propensity score weighting was performed to evaluate cancer-specific mortality (CSM) between the two groups. RESULTS: We identified 7060 eligible patients with IIIA/N2 NSCLC, 2833 (40.1%) in the PORT group and 4227 (59.9%) in the non-PORT group. Overall, the 10-year CSM rate in the weighted cohorts was 70.4% in the PORT group, 72.0% in the non-PORT group, and patients who received PORT had a lower CSM rate (p = 0.001). Compared with the non-PORT group, significant survival improvements in the PORT group were observed in patients with higher age, grade, T stage and lymph node ratio (LNR), and without chemotherapy. The improved survival of patients receiving PORT was significantly correlated with patient prognostic scores (p < 0.001). CONCLUSIONS: In our population-based study, the prognostic score was associated with the survival improvement offered by PORT in IIIA/N2 NSCLC, suggesting that prognostic scores and clinicopathological characteristics may be helpful in proper candidate selection for PORT.

A randomized controlled trial of oral nutritional supplementation versus standard diet following McKeown minimally invasive esophagectomy in patients with esophageal malignancy: a pilot study.

BACKGROUND: Body weight loss (BWL) following esophagectomy is a common complication in esophageal cancer (EC) which represents a deterioration in quality of life (QoL) and poor long-term prognosis. A pilot randomized controlled study was initiated to evaluate the feasibility, safety, and efficacy of a short-term oral nutritional supplementation (ONS) on postoperative BWL and QoL in patients undergoing esophagectomy. METHODS: Patients enrolled in this study were randomly divided into two different groups: the intervention group which received oral nutritional intervention (300 mL/day for 4 weeks) and the control group which received standard diet alone. Participants were assessed at discharge and 1, 3, and 6 months following discharge for BWL and QoL. At the same time, the data of clinical baseline characteristics, nutrition-related complications, and feasibility were prospectively collected and analyzed. RESULTS: A total of 77 patients were enrolled in this study. However, owing to severe postoperative complications and discontinuation of the program, 33 participants in the ONS group and 31 participants in the control group were eligible for final analysis of body weight change and QoL. Significant differences in percentage of BWL (%BWL) between the two groups were discovered at 3 and 6 months follow-up: participants in the ONS group had lower %BWL than those in the control group (P=0.024; P=0.025, respectively). There were significant differences in body mass index (BMI) loss between the two groups. At 1 month, QoL was significantly improved in the ONS group (P=0.031); however, no differences of QoL were noticed at 3 and 6 months. Compared with the control group, ONS improved the physical function and role function and eased the symptom of fatigue (P=0.014, P=0.030, and P=0.008, respectively). It was also noted that ONS increased the nutrition-related complications compared to the standard diet (50% vs. 42.9%), although the difference was not statistically significant (P=0.647). CONCLUSIONS: This pilot study indicated that addition of ONS was feasible, safe, and might prevent the loss of body weight and BMI and have a positive impact on the QoL in esophagectomy patients. The effectiveness of ONS requires further confirmation in an appropriately powered study. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR2100045303.

The Improved Mediastinal Drainage Strategy for the Enhanced Recovery System After Esophagectomy.

BACKGROUND: The improved drainage strategy was the transperitoneal placement of a single mediastinal drainage tube after esophagectomy. This study aimed to explore its effect on the incidence of postoperative complications, pain scores, and hospital stay. METHODS: Data from 108 patients who underwent minimally invasive esophagectomy were retrospectively analyzed. Patients were divided into 2 groups: those in group A were treated with transthoracic placement of mediastinal drain and those in group B were treated with transperitoneal placement. The incidence of postoperative complications, pain scores, and postoperative hospital stay were compared. RESULTS: The maximum pain scores in group B were significantly lower than those in group A from the first to the fourth postoperative days (PODs): POD1, 3.9 ± 0.7 vs 2.3 ± 0.7; POD2, 3.5 ± 0.8 vs 2.1 ± 0.7; POD3, 3.3 ± 0.8 vs 1.7 ± 0.8; and POD4, 3.1 ± 0.7 vs 1.7 ± 0.8 (all P < .001). Compared with group A, there were fewer postoperative analgesic drug users in group B (44.6% vs 17.9%; P = .005), fewer cases of pleural effusion (10.7% vs 0%; P = .045), and fewer cases of closed thoracic drainage due to pleural effusion or pneumothorax (14.3% vs 0%; P = .014). There were no significant differences in the incidence of anastomotic leakage, mediastinitis, major pulmonary complications, major abdominal complications, surgical site infection, and total postoperative complications, without statistical differences in postoperative hospital stay and 30-d mortality (all P > .05). CONCLUSIONS: The transperitoneal placement of a single mediastinal drain can reduce postoperative pain and the incidence of pleural effusion, without increasing the incidence of other major postoperative complications and postoperative hospital stay.

Clinicopathologic factors associated with pathologic upstaging in patients clinically diagnosed stage T2N0M0 squamous cell esophageal carcinoma.

BACKGROUND: Even with the use of contrast-enhanced thin-layer chest computed tomography (CT) and endoscopic ultrasonography (EUS), the likelihood of cT2N0M0 squamous cell esophageal cancer correlating with the final pathologic outcome is exceedingly low. We therefore sought to investigate the associations between different risk factors and pathologic upstaging in stage T2N0M0 esophageal cancer patients who underwent esophagectomy. MATERIALS AND METHODS: We retrospectively reviewed the clinicopathological characteristics of 224 stage T2N0M0 squamous cell esophageal cancer patients who underwent complete resection over a 2-year period (October 2016-September 2018). The tumor volume (TV) was automatically measured from thin-layer chest CT scans using imaging software. Univariate and multivariate analyses were performed to identify the risk factors associated with upstaging. A receiver operating characteristic (ROC) curve was plotted, and its ability to identify pathological upstaging was assessed. RESULTS: A total of 224 patients with clinical stage T2N0M0 squamous cell esophageal carcinoma (SCEC) underwent esophagectomy; of these patients, 96 (42.86%) had a more advanced stage during the final pathologic review than during the initial diagnosis. The risk factors for pathologic upstaging included a large TV, high total cholesterol (TC), high triglycerides (TGs), high platelet-to-lymphocyte ratio (PLR), and high number of lymph nodes examined. The ROC analysis demonstrated an area under the curve of 0.845 (95% confidence interval 0.794-0.895). CONCLUSIONS: In SECC diagnosed as stage T2N0M0 by CT and EUS, the incidence of postoperative pathologic upstaging increases with a large TV, high TC, high TGs, high PLR, and high number of lymph nodes examined.

Chyle test is not a valuable laboratory index in identifying chylothorax after pulmonary resection and lymph node dissection for primary non-small cell lung cancer.

OBJECTIVE: Chyle test is widely used to identify chylothorax after pulmonary resection and lymph node dissection for primary non-small cell lung cancer (NSCLC). Low accuracy of chyle test in identifying chylothorax is rarely reported. This observational study was designed to identify the diagnostic value of chyle test. PATIENTS AND METHODS: From September 2016 to March 2017, 185 consecutive patients either suspected or histologically documented lung cancer were screened for this observational study. Except exclusion, 108 patients were eligible for further analysis. Daily chest-tube output as well as the postoperative day of chest tube removal was documented. Chyle test was analyzed with 108 cases, and the results were blinded to the thoracic surgeons. Chest tube was timely removed regardless of the results of chyle test. A high-output pleural effusion and an associated change in quality of the pleural fluid, from serous to milky yellowish after normal diet, led to the diagnosis of chylothorax. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of chyle test in identifying chylothorax were calculated. RESULTS: Of 108 patients, 4 (3.7%) were observed with chylothorax after pulmonary resection and lymph node dissection for primary NSCLC. Postoperative chylothorax was conservatively managed in three patients and chest tubes were removed 12 days (from 10 to 16) after surgery. Failed in conservative treatment, one patient underwent thoracic duct ligation performed by video-assisted thoracic surgery. For patients without chylothorax, the median day of chest tube removal was postoperative day 4. Among the 108 patients, 75.9% (82/108) was found with a positive chyle test result, of which 95.1% (78/82) was false positive in identifying chylothorax. The sensitivity and specificity of chyle test in identifying chylothorax were 100% and 25%, respectively. The positive predictive value, negative predictive value, and accuracy of chyle test for chylothorax diagnosis were 4.9%, 100%, and 27.8%, respectively. CONCLUSIONS: It was suggested that the specificity and accuracy of chyle test in identifying chylothorax were relatively low. Chyle test is not a good laboratory index in identifying chylothorax. With highly positive result, chyle test should not preclude the removal of chest tube in patients after pulmonary resection and lymph node dissection for primary NSCLC.

Gefitinib Versus Adjuvant Chemotherapy in Patients With Stage II-IIIA Non-Small-Cell Lung Cancer Harboring Positive EGFR Mutations: A Single-Center Retrospective Study.

BACKGROUND: The superior efficacy of first-line treatment with gefitinib over that of standard chemotherapy was demonstrated in patients with advanced non-small-cell lung cancer (NSCLC) harboring sensitive mutation of epidermal growth factor receptor (EGFR). However, scarce evidence showing the superiority of gefitinib to chemotherapy exists regarding the postoperative adjuvant therapy of EGFR mutation-positive patients with stage II-IIIA NSCLC. To address this important gap, we undertook a retrospective study to assess the efficacy of adjuvant gefitinib versus adjuvant chemotherapy (AC) in patients with completely resected EGFR-mutant stage II-IIIA NSCLC. PATIENTS AND METHODS: A total of 116 patients with completely resected II-IIIA NSCLC and confirmed positive EGFR mutation (exon 19 deletion or exon 21 Leu858Arg) between January 2013 and March 2017 were included in our study. Disease-free survival (DFS) was analyzed in 55 patients treated with gefitinib and 61 patients treated with a platinum-based 2-drug-combination AC. Propensity score matching allowed the generation of best matched pairs for the 2 categories (1:1 ratio). Factors affecting survival were assessed by the Kaplan-Meier method and Cox regression analysis. RESULTS: The matched cohort consisted of 52 gefitinib and 52 AC patients with a median follow-up of 37.1 and 31.5 months, respectively. DFS was significantly longer in the gefitinib group than that in the AC group (34.9 months [95% confidence interval (CI), 21.1-48.7] versus 19.3 months [95% CI, 13.3-25.3]; hazard ratio = 0.36 [95% CI, 0.19-0.68], log-rank P = .001). In the gefitinib group the most common adverse events (AEs) were rash (76.9%), aminotransferase elevation (53.8%), and diarrhea (46.2%), whereas in the AC group the most common AEs were neutropenia (67.3%), nausea or vomiting (63.5%), and anemia (44.2%). Less frequent grade 3 or higher AEs were observed in the gefitinib group (15.4% vs. 38.5% in the AC group). After receiving gefitinib for 3 months, one patient was diagnosed with interstitial lung disease, which was regarded as the most severe treatment-related AE. No deaths were treatment related. CONCLUSION: In this retrospective study, compared to AC, gefitinib provided a statistically significant DFS benefit, reduced toxicity in EGFR mutation-positive patients with resected II-IIIA NSCLC. These results require further validation by prospective randomized trials.

Analysis of giant thoracic neoplasms: Correlations between imaging, pathology and surgical management.

BACKGROUND: A giant thoracic neoplasm is extremely rare and poorly understood. Our systemic study introduced computed tomography angiography (CTA) with three-dimensional (3D) reconstruction imaging and evaluated correlations between imaging, pathology, and surgical management. METHODS: Data from 45 patients undergoing surgery for giant thoracic neoplasm in our institution between May 2007 and November 2015 were collected. The clinical characteristics, imaging manifestations, preoperative biopsy, surgical management, postoperative pathology, and prognosis and their correlation were analyzed. RESULTS: The clinical characteristics, imaging manifestations, and pathological types were complicated. Four patients underwent CTA with 3D reconstruction imaging and feeding vessels were found in three cases. Twenty-four selected patients accepted preoperative biopsy, eight of which were inconsistent with postoperative pathology. Complete resection was performed in 39 cases, 20 of which underwent extended excision. The median survival duration of all patients was 58 months (range 3.0-118.0). The one, three, and five-year survival rates were 86.0%, 64.4%, and 47.0%, respectively. Univariate analyses showed tumor size and resection status were prognostic factors for survival (P = 0.003 and P < 0.001, respectively). CONCLUSIONS: A giant thoracic neoplasm should preferably be treated in experienced centers for precise diagnosis and optimal therapy schemes with comprehensive consideration of clinical characters, imaging manifestations, pathology, surgical management, and prognosis. Innovative CTA with 3D reconstruction imaging together with preoperative biopsy are feasible and effective in therapeutic decision-making and surgical planning. Complete surgical resection remains the mainstay of curative therapy for all resectable tumors.

[Surgical Treatment and Prognosis for Patients with 
Synchronous Multiple Primary Lung Adenocarcinomas].

BACKGROUND: With the popularization of high-resolution computed tomography (HRCT), there is a rising trend of the detection of multiple primary lung cancers (MPLC). Adenocarcinomas is the major pathological type of MPLC. At present, reports on MPLC are relatively common, but few study focused on synchronous multiple primary lung adenocarcinomas (SMPLA). We carried out this study in an attempt to enhance our understanding about SMPLA. METHODS: Data from 38 patients undergoing surgery for SMPLA in our institution frrom December 2012 and July 2016 were retrospectively collected. RESULTS: Among the 38 patients, 12 patients were male, 26 patients were female, with a median age of 58 (ranging from 39 to 73). Surgical outcomes verified 29 patients with 2 tumors and 9 patients with more than 2 tumors. There were 26 patients with tumors in ipsilateral lung while 12 patients in contralateral lung. Eight patients underwent one-stage surgical treatment for contralateral tumors with mean postoperative hospitalization of 10 days. The gene detection results of 5 patients showed different epidermal growth factor receptor (EGFR) mutations can be found in one patient's different tumors. The 1-year and 3-year overall survival (OS) rate were 96.6% and 74.2%. Larger maximal tumor dimension (P<0.001), advanced pT stage (P=0.003), lymph nodes metastases positive (P=0.001), advanced TNM stage (P=0.022) and postoperative adjuvant chemoradiotherapy (P=0.009) were correlated with poor OS. CONCLUSIONS: Multiple lung malignant lesions should not be taken as metastasis for granted and the possibility of MPLC also should be considered. Mutational status of EGFR could be used as a clinical reference to diagnose patients with SMPLA.