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INTRODUCTION: Unlike most malignancies, higher body mass index (BMI) is associated with a reduced risk of lung cancer and improved prognosis after surgery. However, it remains controversial whether height, one of determinants of BMI, is associated with survival independently of BMI and other confounders. METHODS: We extracted data on all consecutive patients with resectable non-small cell lung cancer included in Epithor, the French Society of Thoracic and Cardiovascular Surgery database, over a 16-year period. Height was analysed as a continuous variable, and then categorised into four or three categories, according to sex-specific quantiles. Cox proportional hazards regression was used to estimate the association of height with survival, adjusted for age, tobacco consumption, forced expiratory volume in one second (FEV1), WHO performance status (WHO PS), American Society of Anesthesiologists (ASA) score, extent of resection, histological type, stage of disease and centre as a random effect, as well as BMI in a further analysis. RESULTS: The study included 61 379 patients. Higher height was significantly associated with better long-term survival after adjustment for other variables (adjusted HR 0.97 per 10 cm higher height, 95% CI 0.95 to 0.99); additional adjustment for BMI resulted in an identical HR. The prognostic impact of height was further confirmed by stratifying by age, ASA class, WHO PS and histological type. When stratifying by BMI class, there was no evidence of a differential association (p=0.93). When stratifying by stage of disease, the prognostic significance of height was maintained for all stages except IIIB-IV. CONCLUSIONS: Our study shows that height is an independent prognostic factor of resectable lung cancer.
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Carcinoma Pulmonar de Células não Pequenas , Neoplasias Pulmonares , Masculino , Feminino , Humanos , Neoplasias Pulmonares/patologia , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Carcinoma Pulmonar de Células não Pequenas/patologia , Prognóstico , Estudos RetrospectivosRESUMO
BACKGROUND: Lungsco01 is the first study assessing the real benefits and the medico-economic impact of video-thoracoscopy versus open thoracotomy for non-small cell lung cancer in the French context. METHODS: Two hundred and fifty nine adult patients from 10 French centres were randomised in this prospective multicentre randomised controlled trial, between July 29, 2016, and November 24, 2020. Survival from surgical intervention to day 30 and later was compared with the log-rank test. Total quality-adjusted-life-years (QALYs) were calculated using the EQ-5D-3L®. For medico-economic analyses at 30 days and at 3 months after surgery, resources consumed were valorised ( 2018) from a hospital perspective. First, since mortality was infrequent and not different between the two arms, cost-minimisation analyses were performed considering only the cost differential. Second, based on complete cases on QALYs, cost-utility analyses were performed taking into account cost and QALY differential. Acceptability curves and the 95% confidence intervals for the incremental ratios were then obtained using the non-parametric bootstrap method (10,000 replications). Sensitivity analyses were performed using multiple imputations with the chained equation method. RESULTS: The average cumulative costs of thoracotomy were lower than those of video-thoracoscopy at 30 days (9,730 (SD = 3,597) vs. 11,290 (SD = 4,729)) and at 3 months (9,863 (SD = 3,508) vs. 11,912 (SD = 5,159)). In the cost-utility analyses, the incremental cost-utility ratio was 19,162 per additional QALY gained at 30 days (36,733 at 3 months). The acceptability curve revealed a 64% probability of efficiency at 30 days for video-thoracoscopy, at a widely-accepted willingness-to-pay threshold of 25,000 (34% at 3 months). Ratios increased after multiple imputations, implying a higher cost for video-thoracoscopy for an additional QALY gain (ratios: 26,015 at 30 days, 42,779 at 3 months). CONCLUSIONS: Given our results, the economic efficiency of video-thoracoscopy at 30 days remains fragile at a willingness-to-pay threshold of 25,000/QALY. The economic efficiency is not established beyond that time horizon. The acceptability curves given will allow decision-makers to judge the probability of efficiency of this technology at other willingness-to-pay thresholds. TRIAL REGISTRATION: NCT02502318.
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Carcinoma Pulmonar de Células não Pequenas , Neoplasias Pulmonares , Adulto , Humanos , Neoplasias Pulmonares/cirurgia , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Estudos Prospectivos , Toracotomia , Análise Custo-Benefício , ToracoscopiaRESUMO
Our aim was to determine the effect of a national strategy for quality improvement in cancer management (the "Plan Cancer") according to time period and to assess the influence of type and volume of hospital activity on in-hospital mortality (IHM) within a large national cohort of patients operated on for lung cancer.From January 2005 to December 2013, 76â235 patients were included in the French Administrative Database. Patient characteristics, hospital volume of activity and hospital type were analysed over three periods: 2005-2007, 2008-2010 and 2011-2013.Global crude IHM was 3.9%: 4.3% during 2005-2007, 4% during 2008-2010 and 3.5% during 2011-2013 (p<0.01). 296, 259 and 209 centres performed pulmonary resections in 2005-2007, 2008-2010 and 2011-2013, respectively (p<0.01). The risk of death was higher in centres performing <13 resections per year than in centres performing >43 resections per year (adjusted (a)OR 1.48, 95% CI 1.197-1.834). The risk of death was lower in the period 2011-2013 than in the period 2008-2010 (aOR 0.841, 95% CI 0.764-0.926). Adjustment variables (age, sex, Charlson score and type of resection) were significantly linked to IHM, whereas the type of hospital was not.The French national strategy for quality improvement seems to have induced a significant decrease in IHM.
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Mortalidade Hospitalar , Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/cirurgia , Pneumonectomia/mortalidade , Idoso , Estudos de Coortes , Coleta de Dados , Bases de Dados Factuais , Feminino , França , Hospitalização , Hospitais , Humanos , Pulmão/cirurgia , Neoplasias Pulmonares/epidemiologia , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Colorectal cancer (CRC) is the third most diagnosed cancer worldwide, with up to 25% of patients who will develop metastases. Pulmonary metastases (PMs) resection for CRC might improve long-term survival, but the selection criteria for patients who would benefit remain unclear. The aim of this study was to identify preoperative predictive factors in patients eligible for this surgical strategy. MATERIALS AND METHODS: We retrospectively reviewed data of patients from five thoracic surgery departments who underwent PM resection for CRC with intent to cure between 2005 and 2010. Univariate and multivariate analyses were performed to identify predictive factors influencing long-term survival and recurrence after pulmonary resection. RESULTS: Three hundred fifty-four patients were eligible. Forty-eight patients had pulmonary recurrence (13.5%). Thirty-day postoperative mortality was 0.3% (n = 1). Five- and 8-y overall survival (OS) were 64.3 ± 3.99% and 60.72 ± 4.5%, respectively. In univariate analysis, 5-y OS was significantly associated with an American Society of Anesthesiologists score of 1 (P = 0.02), a low number of PM (P = 0.001), and single wedge resection (P = 0.00001). In multivariate analysis, an American Society of Anesthesiologists score of 3 or higher (P = 0.05), two or more PMs (P = 0.034) and pneumonectomy (P = 0.021) were significant predictors of a poor outcome. In univariate analysis, 5-y cumulative recurrence was significantly associated with the absence of mediastinal lymph node dissection (P = 0.01). CONCLUSIONS: Given its high 5-y OS with low postoperative morbidity, thus allowing repeat surgical management, resection of PM could be performed. Resection of PM could improve long-term survival.
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Neoplasias Colorretais/patologia , Neoplasias Pulmonares/secundário , Neoplasias Pulmonares/cirurgia , Metastasectomia , Recidiva Local de Neoplasia/etiologia , Pneumonectomia , Adulto , Idoso , Neoplasias Colorretais/mortalidade , Feminino , Seguimentos , Humanos , Neoplasias Pulmonares/mortalidade , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/mortalidade , Seleção de Pacientes , Período Pré-Operatório , Estudos Retrospectivos , Fatores de Risco , Análise de Sobrevida , Resultado do TratamentoRESUMO
The aim of this study was to assess the evolution of survival in patients treated surgically for non-small cell lung cancer (NSCLC) between 2005 and 2012.From January 2005 to December 2012, 34 006 patients underwent pulmonary resection for NSCLC and were included in the French national database Epithor. Patients' characteristics, procedures and survival were analysed. Survival according to the management was evaluated for each 2-year period separately: 2005-2006, 2007-2008, 2009-2010 and 2011-2012.The proportions of early-stage cancers and adenocarcinomas increased significantly over the periods. 3-year overall survival (OS) increased significantly from 80.5% for the first period to 81.4% for the last period. For the periods 2005-2006 and 2007-2008, 3-year OS was lower after segmentectomy than after lobectomy (77 and 73% versus 82 and 83%, respectively). For the periods 2009-2010 and 2011-2012, 3-year OS in the two sub-groups was similar. OS after bi-lobectomy or pneumonectomy was lower than after lobectomy for all periods analysed. Systematic nodal dissection increased OS for all periods. Chemotherapy but not radiotherapy improved OS in the first 12 postoperative months for all periods.Changes in histological type and stage linked to advances in surgical and medical practices since 2005 led to an increase in OS in patients with surgical-stage NSCLC.
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Carcinoma Pulmonar de Células não Pequenas/cirurgia , Neoplasias Pulmonares/cirurgia , Taxa de Sobrevida/tendências , Adenocarcinoma/epidemiologia , Adenocarcinoma/mortalidade , Adenocarcinoma/cirurgia , Idoso , Carcinoma Pulmonar de Células não Pequenas/epidemiologia , Carcinoma Pulmonar de Células não Pequenas/mortalidade , Comorbidade , Feminino , França , Mortalidade Hospitalar , Humanos , Estimativa de Kaplan-Meier , Pulmão/cirurgia , Neoplasias Pulmonares/epidemiologia , Neoplasias Pulmonares/mortalidade , Masculino , Estadiamento de Neoplasias , Período Perioperatório , Pneumonectomia , Complicações Pós-Operatórias , Curva ROC , Sistema de Registros , Reprodutibilidade dos Testes , Estudos Retrospectivos , Resultado do TratamentoRESUMO
We report the case of a 21-year-old man, with a Candida-related endocarditis causing multiple emboli and bilateral false aneurysms of the internal iliac arteries. As the distal runoff vasculatures of both internal iliac arteries were occluded, these arteries required ligation. Although there were few consequences with the procedure, multiple emboli and recurrence of endocarditis after cardiac surgery led to the patient's death.
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Aneurisma Infectado/microbiologia , Candida albicans/isolamento & purificação , Candidíase/microbiologia , Endocardite/microbiologia , Aneurisma Ilíaco/microbiologia , Abuso de Substâncias por Via Intravenosa/microbiologia , Aneurisma Infectado/diagnóstico , Aneurisma Infectado/cirurgia , Candidíase/diagnóstico , Candidíase/cirurgia , Procedimentos Cirúrgicos Cardíacos , Endocardite/diagnóstico , Endocardite/cirurgia , Evolução Fatal , Humanos , Aneurisma Ilíaco/diagnóstico , Aneurisma Ilíaco/cirurgia , Masculino , Insuficiência de Múltiplos Órgãos/microbiologia , Recidiva , Abuso de Substâncias por Via Intravenosa/complicações , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares , Adulto JovemRESUMO
OBJECTIVES: To determine safety and survival outcomes associated with lobectomy, segmentectomy and wedge resection for early-stage lung cancer by quiring the French population-based registry EPIdemiology in THORacic surgery (EPITHOR). METHODS: Retrospective analysis of 19 452 patients with stage c IA lung carcinoma who underwent lobectomy, segmentectomy or wedge resection between 2016 and 2022 with curative-intent. Main outcome measures were 90-day mortality and 5-year overall survival estimates. Proportional hazards regression and propensity score matching were used to adjust outcomes for key patient, tumour and practice environment factors. RESULTS: The treatment distribution was 72.2% for lobectomy, 21.5% for segmentectomy and 6.3% for wedge. Unadjusted 90-day mortality rates were 1.6%, 1.2% and 1.1%, respectively (P = 0.10). Unadjusted 5-year overall survival estimates were 80%, 78% and 70%, with significant inter-group survival curves differences (P < 0.0001). Multivariable proportional hazards regression showed that wedge was associated with worse overall survival [adjusted hazard ratio (AHR), 1.23 (95% confidence interval 1.03-1.47); P = 0.021] compared with lobectomy, while no significant difference was disclosed when comparing segmentectomy to lobectomy (1.08 [0.97-1.20]; P = 0.162). The three-way propensity score analyses confirmed similar 90-day mortality rate for wedge resection and segmentectomy compared with lobectomy (hazard ratio: 0.43; 95% confidence interval 0.16-1.11; P = 0.081 and 0.99; 0.48-2.10; P = 0.998, respectively), but poorer overall survival (1.45; 1.13-1.86; P = 0.003 and 1.31; 1-1.71; P = 0.048, respectively). CONCLUSIONS: Wedge resection was associated with comparable 90-day mortality but lower overall survival when compared to lobectomy. Overall, all types of sublobar resections may not offer equivalent oncologic effectiveness in real-world settings.
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Neoplasias Pulmonares , Estadiamento de Neoplasias , Pneumonectomia , Humanos , Neoplasias Pulmonares/cirurgia , Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/patologia , Pneumonectomia/métodos , Pneumonectomia/mortalidade , Pneumonectomia/efeitos adversos , Masculino , Feminino , Estudos Retrospectivos , Idoso , Pessoa de Meia-Idade , Resultado do Tratamento , Pontuação de Propensão , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Carcinoma Pulmonar de Células não Pequenas/mortalidade , Carcinoma Pulmonar de Células não Pequenas/patologiaRESUMO
OBJECTIVES: Evaluate theoretical and practical training of thoracic surgeons-in-training in robotic-assisted thoracic surgery (RATS) in France. METHODS: A survey was distributed to thoracic surgeons-in-training in France from November 2022 to February 2023. RESULTS: We recruited 101 thoracic surgeons-in-training (77% response rate). Over half had access to a surgical robotics system at their current institution. Most (74%) considered robotic surgery training essential, 90% had attended a robotic procedure. Only 18% had performed a complete thoracic robotic procedure as the main operator. A complete RATS procedure was performed by 42% of fellows and 6% of residents. Of the remaining surgeons, 23% had performed part of a robotic procedure. Theoretical courses and simulation are well developed; 72% of residents and 91% of fellows had undergone simulation training in the operating room, at training facilities, or during congress amounting to <10 h (for 73% of the fellows and residents), 10-20 h (17%), 20-30 h (8%) or >30 h (3%). Access to RATS was ≥1 day/week in 71% of thoracic departments with robotic access. Fellows spent a median of 2 (IQR 1-3) semesters in departments performing robotic surgery. Compared with low-volume centres, trainees at high-volume centres performed significantly more complete robotic procedures (47% vs 13%; P = 0.001), as did fellows compared with residents. CONCLUSIONS: Few young surgeons perform complete thoracic robotic procedures during practical training, and access remains centre dependent. Opportunities increase with seniority and exposure; however, increasing availability of robotic devices, theoretical formation, and simulation courses will increase opportunities.
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Introduction: Non-small cell lung cancer (NSCLC) is often associated with compromised lung function. Real-world data on the impact of surgical approach in NSCLC patients with compromised lung function are still lacking. The objective of this study is to assess the potential impact of minimally invasive surgery (MIS) on 90-day post-operative mortality after anatomic lung resection in high-risk operable NSCLC patients. Methods: We conducted a retrospective multicentre study including all patients who underwent anatomic lung resection between January 2010 and October 2021 and registered in the Epithor database. High-risk patients were defined as those with a forced expiratory volume in 1â s (FEV1) or diffusing capacity of the lung for carbon monoxide (DLCO) value below 50%. Co-primary end-points were the impact of risk status on 90-day mortality and the impact of MIS on 90-day mortality in high-risk patients. Results: Of the 46 909 patients who met the inclusion criteria, 42 214 patients (90%) with both preoperative FEV1 and DLCO above 50% were included in the low-risk group, and 4695 patients (10%) with preoperative FEV1 and/or preoperative DLCO below 50% were included in the high-risk group. The 90-day mortality rate was significantly higher in the high-risk group compared to the low-risk group (280 (5.96%) versus 1301 (3.18%); p<0.0001). In high-risk patients, MIS was associated with lower 90-day mortality compared to open surgery in univariate analysis (OR=0.04 (0.02-0.05), p<0.001) and in multivariable analysis after propensity score matching (OR=0.46 (0.30-0.69), p<0.001). High-risk patients operated through MIS had a similar 90-day mortality rate compared to low-risk patients in general (3.10% versus 3.18% respectively). Conclusion: By examining the impact of surgical approaches on 90-day mortality using a nationwide database, we found that either preoperative FEV1 or DLCO below 50% is associated with higher 90-day mortality, which can be reduced by using minimally invasive surgical approaches. High-risk patients operated through MIS have a similar 90-day mortality rate as low-risk patients.
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OBJECTIVES: To estimate the evolution of quality indicators (30-day mortality and failure-to-rescue) inpatients who underwent lung cancer surgery in France over the past 15 years and to study the potential influencing factors. DESIGN: Retrospective cohort study using data from the French hospital database (PMSI). SETTING: Nationwide population-based study. PARTICIPANTS: All patients who underwent pulmonary resection for lung cancer in France (2005-2020) were included (N=1 57 566). Characteristics of patients (age, gender, comorbidities), surgery (surgical approach, type of resection, extent of resection) and hospital (type of hospital, hospital volume for pulmonary resections) were retrieved. PRIMARY AND SECONDARY OUTCOME MEASURES: We studied two outcome indicators: 30-day mortality and failure-to-rescue. We used regression-based techniques (including interrupted time-series) to assess the effects of patient and hospital characteristics on 30-day mortality and failure-to-rescue (number of deaths among patients with at least one major postoperative complication within the 30 days after surgery), adjusting for case mix. RESULTS: The 30-day mortality rate increased from 3.8% in 2005 to 4.9% in 2010 and then decreased to 2.9% in 2020. The failure-to-rescue rate decreased from 12.2% in 2005 to 7.1% in 2020. The pneumonectomy rate decreased significantly over time (18.1% in 2005 to 4.8% in 2020) and had the greatest contribution on the reduction of mortality between two periods (2005-2010/2015-2020). The use of video-assisted thoracoscopic surgery or robot-assisted surgery had a great influence on the reduction of mortality (16% of the observed difference in mortality) between the two periods, as did hospital volume. CONCLUSIONS: The change in surgical practices, particularly the reduction in pneumonectomies, could be one of the main reasons for reduction in postoperative mortality and failure-to-rescue in France since 2011. Hospital volume is another important factor in reducing postoperative mortality. Our study should encourage the use of technological or organisational innovation, such as changes in surgical practice and cancer surgery authorisations, to improve quality of care.
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Neoplasias Pulmonares , Procedimentos Cirúrgicos Robóticos , Humanos , Estudos Retrospectivos , Pneumonectomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Neoplasias Pulmonares/cirurgiaRESUMO
BACKGROUND: The minimally invasive approach (MIA) has gained popularity thanks to its efficacy and safety. Our work consisted of evaluating the diffusion of the MIA in hospitals and the variability of this approach (within and between regions). METHODS: All patients who underwent limited resection or lobectomy for lung cancer in France were included from the national hospital administrative database (2013-2020). We described between-hospital differences in the MIA rate over four periods (2013-2014, 2015-2016, 2017-2018, and 2019-2020). The potential influence of the hospital volume, hospital type, and period on the adjusted MIA rate was estimated by a multilevel linear regression. RESULTS: From 2013 to 2020, 77,965 patients underwent a lobectomy or limited resection for lung cancer. The rate of the MIA increased significantly over the four periods (50% in 2019-2020). Variability decreased over time in 7/12 regions. The variables included in the multilevel model were significantly related to the adjusted rate of the MIA. Variability between regions was considerable since 18% of the variance was due to systematic differences between regions. CONCLUSIONS: We confirm that the MIA is part of the surgical techniques used on a daily basis for the treatment of lung cancer. However, this technology is mostly used by surgeons in high volume institutions.
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Introduction: The practice of thoracic surgery for lung cancer is subject to authorization in France. We evaluated the performance of hospitals using 30-day post-operative mortality as a quality indicator, estimating its distribution within each region and measuring its variability between regions. Material and methods: All data for patients who underwent pulmonary resection for lung cancer in France (2013-2020) were collected from the national hospital administrative database. Thirty-day mortality was defined as any patient who died in hospital (including transferred patients) within the first 30 days after the operation and those who died later during the initial hospitalization. The Standardized Mortality ratio (SMR) was the smoothed, adjusted, hospital-specific mortality rate divided by the expected mortality. To describe the variation in hospital mortality between hospitals in each region, we used different commonly used indicators of variation such as coefficients of variation (CV), interquartile interval or range (IQR), extreme ratio, and systematic component of variance (SCV). Results: In 2013-2020, 87,232 patients underwent lung resection for cancer in France. The number of deaths was 2,537, a rate of 2.91%. The median SMR of 199 hospitals was 0.99 with an IQR of 0.86 to 1.18 and a CV of 0.25. Among the regions that had the most hospitals performing lung resections for cancer, the extreme ratio was >2, which means that the maximum value is twice as high as the minimum value. The SCV between hospitals was >10 for two of these regions, which is considered indicative of very high variation. For the other regions (with few hospitals performing lung resections for cancer), the variation between hospitals was lower. Globally, the variability between regions concerning the SMR was moderate, 6% of the variance was due to differences across regions. On the contrary, the hospital volume was significantly related to the SMR (p = 0.003) with a negative linear trend, whatever the region. Conclusion: This work shows significant differences in the practices of the various hospitals within regions. However, overall, the variability in the 30-day mortality rate between regions was moderate. Our findings raises questions regarding the regionalization of major surgical procedures in France.
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Introduction: We aimed to compare postoperative outcomes after pulmonary resection for lung cancer after open thoracotomy (OT), video-assisted (VATS), and robotic-assisted (RA) thoracic surgery using a propensity score analysis. Methods: From 2010 to 2020, 38,423 patients underwent resection for lung cancer. In total, 58.05% (n = 22,306) were operated by thoracotomy, 35.35% (n = 13,581) by VATS, and 6.6% (n = 2536) by RA. A propensity score was used to create balanced groups with weighting. End points were in-hospital mortality, postoperative complications, and length of hospital stay, reported by odds ratios (ORs) and 95% confidence intervals (CIs). Results: VATS decreased in-hospital mortality compared with OT (OR, 0.64; 95% CI, 0.58-0.79; P < .0001) but not compared with RA (OR, 1.09; 95% CI, 0.77-1.52; P = .61). VATS reduced major postoperative complications compared with OT (OR, 0.83; 95% CI, 0.76-0.92; P < .0001) but not RA (OR, 1.01; 95% CI, 0.84-1.21; P = .17). VATS reduced prolonged air leaks rate compared with OT (OR, 0.9; 95% CI, 0.84-0.98; P = .015) but not RA (OR, 1.02; 95% CI, 0.88-1.18; P = .77). As compared with OT, VATS and RA decreased the incidence of atelectasis (respectively: OR, 0.57; 95% CI, 0.50-0.65; P < .0001 and OR, 0.75; 95% CI, 0.60-0.95; P = .016); the incidence of pneumonia (OR, 0.75; 95% CI, 0.67-0.83; P < .0001 and OR, 0.62; 95% CI, 0.50-0.78; P < .0001); and the number of postoperative arrhythmias (OR, 0.69; 95% CI, 0.61-0.78; P < .0001 and OR, 0.75; 95% CI, 0.59-0.96; P = .024). Both VATS and RA resulted in shorter hospital stays (-1.91 days [-2.24; -1.58]; P < .0001 and -2.73 days [-3.1; -2.36]; P < .0001, respectively). Conclusions: RA appeared to decrease postoperative pulmonary complications as well as VATS compared with OT. VATS decreased postoperative mortality as compared with RA and OT.
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OBJECTIVES: According to a nation-based study, we intend to report the data of the patients operated on for lung cancer invading the chest wall, taking into consideration the completion of induction chemotherapy (Ind_CT), induction radiochemotherapy (Ind_RCT) or no induction therapy (0_Ind). MATERIALS AND METHODS: All patients with a primary lung cancer invading the chest wall who underwent radical resection from 2004 to 2019 were included. Superior sulcus tumors were excluded. RESULTS: Overall, 688 patients were included: 522 operated without induction therapy, 101 with Ind_CT and 65 with Ind_RCT. Postoperative 90-day mortality was 10.7% in the 0_Ind group, 5.0% in the Ind_CT group, 7.7% in the Ind_RCT group (p = 0.17). Incomplete resection rate was 14.0% in the 0_Ind group, 6.9% in the Ind_CT group, 6.2% in the Ind_RCT group (p = 0.04). In the 0_Ind group, 70% of the patients received adjuvant therapies. Overall survival (OS) analysis disclosed the best long-term outcomes in the Ind_RCT group (5-year OS probability: 56.5% versus 40.0% and 40.5% for 0_Ind and Ind_CT groups, respectively; p = 0.035). At multivariable analysis, Ind_RCT (HR = 0.571; p = 0.008), age > 60 years old (HR = 1,373; p = 0.005), male sex (HR = 1.710; p < 0.001), pneumonectomy (HR = 1.368; p = 0.025), pN2 status (HR = 1.981; p < 0.001), ≥3 resected ribs (HR = 1.329; p = 0.019), incomplete resection (HR = 2.284; p < 0.001) and lack of adjuvant therapy (HR = 1.959; p < 0.001) were associated with OS. Ind_CT was not associated with survival (HR = 0.848; p = 0.257). CONCLUSION: Induction chemoradiation therapy seems to improve survival. Therefore, the present results should be confirmed by a prospective randomized trial testing the benefit of induction radiochemotherapy for NSCLC invading the chest wall.
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Carcinoma Pulmonar de Células não Pequenas , Neoplasias Pulmonares , Parede Torácica , Humanos , Masculino , Pessoa de Meia-Idade , Carcinoma Pulmonar de Células não Pequenas/tratamento farmacológico , Neoplasias Pulmonares/tratamento farmacológico , Estadiamento de Neoplasias , Pneumonectomia/métodos , Estudos Prospectivos , Estudos Retrospectivos , FemininoRESUMO
Background: Prognostic assessment in patients undergoing cancer treatments is of paramount importance to plan subsequent management. In resectable lung cancer availability of an easy-to use nomogram to predict long-term outcome would be extremely useful to identify high-risk patients in the era of perioperative targeted and immune therapies. Methods: We retrieved clinical, surgical and pathological data of all consecutive patients included in Epithor, the database of French Society of Thoracic and Cardiovascular Surgery, and operated on between 2003 and 2020 for non-small cell lung cancer in a curative intent. The primary endpoint was overall survival up to 5 years. We assessed prognostic significance of available variables using Cox modelling, in the whole dataset, and in men and in women separately, and performed temporal validation. Finally, we constructed two sex-specific nomograms. Survivals by fifths of score were assessed in the development and temporal validation sets. Findings: The study included 62,633 patients (43,551 men and 19,082 women). Median survival time was 9.2 years. Nine factors had strong prognostic impact and were used to construct nomograms. The optimism-corrected c statistic for the prognostic score was 0.689 in the development sample, and 0.726 (95% CI 0.718-0.735) in the temporal validation sample. All differences between adjacent fifths of score were significant (P < 0.0001). Figures of 3-year OS by fifths of score were 92.2%, 83.0%, 74.3%, 64.0%, and 43.4%, respectively, in the development set and 93.3%, 88.4%, 81.0%, 73.7%, 55.7% in the temporal validation set. Performance of score was maintained when stratifying by stage of diseases. Interpretation: In the present work, we report evidence that long-term overall survival after resection of NSCLC can be predicted by an easy to construct and use composite score taking into account both host and tumour related factors. Funding: Epithor is funded by FSTCVS.
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Background: While much progress has been accomplished in the understanding of radiation-induced immune effects in tumors, little is known regarding the mechanisms involved at the tumor draining lymph node (TDLN) level. The objective of this retrospective study was to assess the immune and biological changes arising in non-involved TDLNs upon node sparing concurrent chemoradiotherapy (CRT) of non-small cell lung cancer (NSCLC) tumors. Methods: Patients with proven localized (cN0M0) NSCLC, treated by radical surgery plus lymph node dissection with (CRT+) or without (CRT-) neoadjuvant chemoradiotherapy, whereby radiotherapy was targeted on the primary tumor with no significant incidental irradiation of the non-involved TDLN station (stations XI), were identified. Bulk RNA sequencing of TDLNs was performed and data were analyzed based on differential gene expression (DGE) and gene sets enrichment. Results: Sixteen patients were included and 25 TDLNs were analyzed: 6 patients in the CRT+ group (12 samples) and 10 patients in the CRT- group (13 samples). Overall, 1001 genes were differentially expressed between the two groups (CRT+ and CRT-). Analysis with g-profiler revealed that gene sets associated with antitumor immune response, inflammatory response, hypoxia, angiogenesis, epithelial mesenchymal transition and extra-cellular matrix remodeling were enriched in the CRT+ group, whereas only gene sets associated with B cells and B-cell receptor signaling were enriched in the CRT- group. Unsupervised dimensionality reduction identified two clusters of TDLNs from CRT+ patients, of which one cluster (cluster 1) exhibited higher expression of pathways identified as enriched in the overall CRT+ group in comparison to the CRT- group. In CRT+ cluster 1, 3 out of 3 patients had pathological complete response (pCR) or major pathological response (MPR) to neoadjuvant CRT, whereas only 1 out of 3 patients in the other CRT+ cluster (cluster 2) experienced MPR and none exhibited pCR. Conclusion: Neoadjuvant node sparing concurrent CRT of NSCLC patients is associated with distinct microenvironment and immunological patterns in non-involved TDLNs as compared to non-involved TDLNs from patients with non-irradiated tumors. Our data are in line with studies showing superiority of lymph node sparing irradiation of the primary tumor in the induction of antitumor immunity.
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BACKGROUND: The usual treatments for pleural malignancies are mostly palliative. In contrast, peritoneal malignancies are often treated with a curative intent by cytoreductive surgery and intraperitoneal chemotherapy. As pressure has been shown to increase antitumor efficacy, we applied the concept of high-pressure intracavitary chemotherapy to the pleural space in a swine model. METHODS: Cisplatin and gemcitabine were selected because of their antineoplasic efficacy in vitro in a wide spectrum of cancer cell lines. The pleural cavity of 21 pigs was filled with saline solution; haemodynamic and respiratory parameters were monitored. The pressure was increased to 15-25 cm H2O. This treatment was associated with pneumonectomy in 6 pigs. Five pigs were treated with chemotherapy under pressure. RESULTS: The combination of gemcitabine (100 mg/l) and cisplatin (30 mg/l) was highly cytotoxic in vitro. The maximum tolerated pressure was 20 cm H20, due to haemodynamic failure. Pneumonectomy was not tolerated, either before or after pleural infusion. Five pigs survived intrapleural chemotherapy associating gemcitabine and cisplatin with 20 cm H2O pressure for 60 min. CONCLUSIONS: High-pressure intrapleural chemotherapy is feasible in pigs. Further experiments will establish the pharmacokinetics and determine whether the benefit already shown in the peritoneum is also obtained in the pleura.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias Pleurais/tratamento farmacológico , Neoplasias Pleurais/patologia , Animais , Cisplatino/administração & dosagem , Desoxicitidina/administração & dosagem , Desoxicitidina/análogos & derivados , Estudos de Viabilidade , Feminino , Humanos , Neoplasias/tratamento farmacológico , Pressão , Suínos , Células Tumorais Cultivadas , GencitabinaRESUMO
Few studies have investigated the link between SARS-CoV-2 and health restrictions and its effects on the health of lung cancer (LC) patients. The aim of this study was to assess the impact of the SARS-CoV-2 epidemic on surgical activity volume, postoperative complications and in-hospital mortality (IHM) for LC resections in France. All data for adult patients who underwent pulmonary resection for LC in France in 2020, collected from the national administrative database, were compared to 2018-2019. The effect of SARS-CoV-2 on the risk of IHM and severe complications within 30 days among LC surgery patients was examined using a logistic regression analysis adjusted for age, sex, comorbidities and type of resection. There was a slight decrease in the volume of LC resections in 2020 (n = 11,634), as compared to 2018 (n = 12,153) and 2019 (n = 12,227), with a noticeable decrease in April 2020 (the peak of the first wave of epidemic in France). We found that SARS-CoV-2 (0.43% of 2020 resections) was associated with IHM and severe complications, with, respectively, a sevenfold (aOR = 7.17 (3.30-15.55)) and almost a fivefold (aOR = 4.76 (2.31-9.80)) increase in risk. Our study suggests that LC surgery is feasible even during a pandemic, provided that general guidance protocols edited by the surgical societies are respected.
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BACKGROUND: Anatomical segmentectomy is an alternative to lobectomy for early-stage lung cancer (LC) or in patients at high risk. The main objective of this study was to compare the morbidity and mortality associated with these two types of pulmonary resection using data from the French National Epithor database. METHODS: All patients who underwent lobectomy or segmentectomy for early-stage LC from January 1st 2014 to December 31st 2016 were identified in the Epithor database. The primary endpoint was morbidity; the secondary endpoint was postoperative mortality. Propensity score matching was implemented and used to balance groups. The results were reported as odds ratios (OR) and 95% confidence intervals (CI). RESULTS: During the study period, 1,604 segmentectomies (9.78%) and 14,786 lobectomies (90.22%) were performed. After matching, the segmentectomy group experienced significantly less atelectasis (OR 0.54; 95% CI: 0.4-0.75, P<0.0001), pneumonia (OR 0.72; 95% CI: 0.55-0.95, P=0.02), prolonged air leaks (OR 0.75; 95% CI: 0.64-0.89, P=0.001) or bronchopleural fistula (OR 0.35; 95% CI: 0.14-0.83, P=0.017), and fewer patients had at least one complication (OR 0.7; 95% CI: 0.62-0.78, P<0.0001). According to the Clavien-Dindo classification, postoperative complications were significantly less severe in the segmentectomy group (OR 0.52; 95% CI: 0.37-0.74, P<0.0001). There was no significant difference in postoperative mortality at 30 days (OR 0.67; 95% CI: 0.38-1.20, P=0.18), 60 days (OR 0.78; 95% CI: 0.42-1.47, P=0.4), or 90 days (OR 0.77; 95% CI: 0.45-1.34, P=0.36). CONCLUSIONS: Anatomical segmentectomy is an alternative surgical approach that could reduce postoperative morbidity, but it does not appear to affect mortality.
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Obesity could have a protective effect in patients with lung cancer. We assessed the prognostic role of preoperative BMI on survival in patients who underwent lung resection for NSCLC. A total of 54,631 consecutive patients with resectable lung cancer within a 15-year period were extracted from Epithor (the French Society of Thoracic and Cardiovascular Surgery database). Patient subgroups were defined according to body mass index (BMI): underweight (BMI < 18.5 kg/m2), normal weight (18.5 ≤ BMI < 25 kg/m2), overweight (25 ≤ BMI < 30 kg/m2), and obese (BMI ≥ 30 kg/m2). Underweight was associated with lower survival (unadjusted HRs 1.24 (1.16-1.33)) compared to normal weight, whereas overweight and obesity were associated with improved survival (0.95 (0.92-0.98) and 0.88 (0.84-0.92), respectively). The impact of BMI was confirmed when stratifying for sex or Charlson comorbidities index (CCI). Among patients with obesity, a higher BMI was associated with improved survival. After adjusting for period of study, age, sex, WHO performance status, CCI, side of tumor, extent of resection, histologic type, and stage of disease, the HRs for underweight, overweight, and obesity were 1.51 (1.41-1.63), 0.84 (0.81-0.87), and 0.80 (0.76-0.84), respectively. BMI is a strong and independent predictor of survival in patients undergoing surgery for NSCLC.