Yanchu Tian

Severe intraoperative complications during VATS Lobectomy compared with thoracotomy lobectomy for early stage non-small cell lung cancer

BACKGROUND Video-assisted thoracic surgery (VATS) lobectomy has been proved to have shorter hospital stay, less perioperative complications and less pain compared with lobectomy by thoracotomy, but severe intraoperative complications during VATS lobectomy is rare reported. We compared intraoperative safety between VATS lobectomy and lobectomy by thoracotomy. METHODS 659 patients with postoperative stage I and IIa non-small cell lung cancer (NSCLC) who underwent lobectomy in China-Japan Friendship Hospital from February 2008 to June 2012 were analyzed retrospectively, in which 277 were performed by thoracotomy, 357 performed by VATS, and 25 performed by VATS converted to open. Outcomes were analyzed to compare the incidence of significant bleeding, with conversion cases were included into VATS group. RESULTS Ten severe intraoperative complications were identified in 10 patients (6 in VATS, 4 in open), with no intraoperative deaths. The incidence of severe intraoperative complications was similar between VATS group and thoracotomy group [1.57% (6/382) vs. 1.44% (4/277), P=1.0]. Most severe intraoperative complications were related to the injury of major pulmonary vessels (9/10), and most of these complications occurred during upper lobectomy (8/10). There was no statistically significant difference in blood loss (242.85±220.47 vs. 240.43±144.36, P=0.865), and operative time (198.00±75.24 vs. 208.05±61.97, P=0.061) between the open and VATS groups, respectively, but blood loss and operative time are significant different after elimination of conversion cases (214.34±151.85 vs. 240.43±144.36, P<0.01; 193.24±72.64 vs. 208.05±61.97, P<0.01). CONCLUSIONS Our preliminary study demonstrated that the incidence of severe intraoperative complication during VATS lobectomy was low and similar to open lobectomy. The severe intraoperative complications during VATS lobectomy are manageable and the surgeons need to take proper caution in performing VATS lobectomy.

Novel and Convenient Method to Evaluate the Character of Solitary Pulmonary Nodule-Comparison of Three Mathematical Prediction Models and Further Stratification of Risk Factors

Objective To study risk factors that affect the evaluation of malignancy in patients with solitary pulmonary nodules (SPN) and verify different predictive models for malignant probability of SPN. Methods Retrospectively analyzed 107 cases of SPN with definite post-operative histological diagnosis whom underwent surgical procedures in China-Japan Friendship Hospital from November of 2010 to February of 2013. Age, gender, smoking history, malignancy history of patients, imaging features of the nodule including maximum diameter, position, spiculation, lobulation, calcification and serum level of CEA and Cyfra21-1 were assessed as potential risk factors. Univariate analysis model was used to establish statistical correlation between risk factors and post-operative histological diagnosis. Receiver operating characteristic (ROC) curves were drawn using different predictive models for malignant probability of SPN to get areas under the curves (AUC values), sensitivity, specificity, positive predictive values, negative predictive values for each model, respectively. The predictive effectiveness of each model was statistically assessed subsequently. Results In 107 patients, 78 cases were malignant (72.9%), 29 cases were benign (27.1%). Statistical significant difference was found between benign and malignant group in age, maximum diameter, serum level of Cyfra21-1, spiculation, lobulation and calcification of the nodules. The AUC values were 0.786±0.053 (Mayo model), 0.682±0.060 (VA model) and 0.810±0.051 (Peking University People’s Hospital model), respectively. Conclusions Serum level of Cyfra21-1, patient’s age, maximum diameter of the nodule, spiculation, lobulation and calcification of the nodule are independent risk factors associated with the malignant probability of SPN. Peking University People’s Hospital model is of high accuracy and clinical value for patients with SPN. Adding serum index (e.g. Cyfra21-1) into the prediction models as a new risk factor and adjusting the weight of age in the models might improve the accuracy of prediction for SPN.

Prognostic significance of platelet-to-lymphocyte ratio in non-small-cell lung cancer: a meta-analysis.

Background The platelet-to-lymphocyte ratio (PLR) is a useful predictive factor in several cancers. However, the prognostic value of PLR in patients with non-small-cell lung cancer (NSCLC) is still indistinct. Therefore, it was necessary for us to perform a meta-analysis to assess the prognostic value of PLR in patients with NSCLC. Methods A systematic literature search was performed by using PubMed, EMBASE, and Web of Science databases for relevant studies until May 2015. Published studies investigating the association between PLR and overall survival (OS) and disease-free survival (DFS) were selected. Data from each eligible study were extracted. A meta-analysis was performed to analyze the prognostic value of PLR by using the hazard ratio (HR) and 95% confidence intervals (95% CI). Results A total of seven studies involving 1,554 patients were included in our meta-analysis. Our pooled results demonstrated that high PLR was associated with poor OS (HR: 1.60, 95% CI: 1.34–1.90, I2=22.3%, Pheterogeneity = 0.259) and DFS (HR: 1.38, 95% CI: 1.11–1.73, I 2=0%, Pheterogeneity = 0.482). Subgroup analysis between PLR and OS was performed in a further investigation. When the patients were segregated according to ethnicity, sample size, cutoff value, stage, and treatment modality, high PLR was also significantly correlated with OS. There was no significant heterogeneity among included studies. Conclusion High PLR is associated with poor prognosis in patients with NSCLC. PLR may be a significant predictive biomarker in patients with NSCLC.

Impact of chronic obstructive pulmonary disease on postoperative recurrence in patients with resected non-small-cell lung cancer.

Purpose This study aimed to determine whether the severity of chronic obstructive pulmonary disease (COPD) affects recurrence-free survival in non-small-cell lung cancer (NSCLC) patients after surgical resection. Patients and methods A retrospective study was performed on 421 consecutive patients who had undergone lobectomy for NSCLC from January 2008 to June 2011. Classification of COPD severity was based on guidelines of the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Characteristics among the three subgroups were compared and recurrence-free survivals were analyzed. Results A total of 172 patients were diagnosed with COPD (124 as GOLD-1, 46 as GOLD-2, and two as GOLD-3). The frequencies of recurrence were significantly higher in patients with higher COPD grades (P<0.001). Recurrence-free survival at 5 years was 78.1%, 70.4%, and 46.4% in non-COPD, mild COPD, and moderate/severe COPD groups, respectively (P<0.001). By univariate analysis, the age, sex, smoking history, COPD severity, tumor size, histology, and pathological stage were associated with recurrence-free survival. Multivariate analysis showed that older age, male, moderate/severe COPD, and advanced stage were independent risk factors associated with recurrence-free survival. Conclusion NSCLC patients with COPD are at high risk for postoperative recurrence, and moderate/severe COPD is an independent unfavorable prognostic factor.

The Common Causes of Conversion of VATS during Operation for 248 Non-small Cell Lung Cancers

BACKGROUND AND OBJECTIVE VATS-lobectomy has been used as regular surgical procedure clinically for non-small cell lung cancer. The aim of this study is to evaluate the surgical emergencies during VATS and the related factors postoperatively. METHODS Clinical data were reviewed for patients who were performed with pulmonary related surgery between January 2006 and July 2008 in our department. RESULTS 248 (117 CVATS and 131 AVATS) VATS lobectomy were performed, including 13 cases that were transferred into AVATS or OPEN. The common related reasons were bleeding of pulmonary branches, adhesion, anatomic deformity, bleeding of azygos and bleeding of middle-lobe-vein. 129 thoracotomy cases were enrolled. Compared with OPEN surgery, VATS got the merits of short in-hospital duration (20 days vs 27 days, P=0.015), less bleeding (197 mL vs 250 mL, P=0.005) and less pain (4.6 vs 6.2, P=0.003). CONCLUSION VATS is a safe surgical procedure for early stage NSCLC with merits of lower morbidity and sooner recovery. So it could be concluded that in some circumstances, VATS could be chosen as an alternate of thoractomy.

For non-small cell lung cancer with T3 (central) disease, sleeve lobectomy or pneumonectomy?

BACKGROUND Pneumonectomy (PN) has traditionally been the treatment of choice for central lung tumors for which the alternative is sleeve lobectomy (SL). The aim of this study was to compare early and long-term results after SL and PN in focusing on T3 central non-small cell lung cancer (NSCLC). METHODS Patients who underwent SL (n=58) or PN (n=42) were retrospectively analyzed. For bias reduction, these 100 patients had been selected according to the following criteria: (I) tumor located in the main bronchus less than 2 cm distal to the carina; (II) there were no N2 disease; (III) no induction therapy was applied; (IV) complete resection (R0) was achieved. RESULTS SL and PN patients had comparable mean ages, gender distribution, mean forced expiratory volume in 1 second (FEV1), stage and tumor grade. Postoperative mortality (3.4% vs. 4.8%, P=1.0) and morbidity (41% vs. 38%, P=0.74) were similar between the two groups. Recurrences occurred in 48% of patients after SL and in 31% of those after PN (P=0.08). The 5-year survival after SL (64.8%) and PN (61.4%) was not significantly different (P=0.20). Multivariable survival analysis showed that there were no independent prognostic factors. CONCLUSIONS SL does not compromise survival for NSCLC with T3 central disease compared with PN. It is an adequate oncologic resection and should be treated as the first line intervention whenever complete resection can be achieved.

Risk factors for recurrence after complete resection of pathological stage N2 non-small cell lung cancer.

Tumor recurrence is the most common cause of treatment failure, especially after complete resection of pathological stage N2 non‐small cell lung cancer (NSCLC). In this study, we investigated the clinicopathological characteristics in order to identify independent risk factors for postoperative recurrence.

Video-assisted thoracoscopic lobectomy for elderly nonsmall cell lung cancer: Short-term and long-term outcomes.

BACKGROUND Lung cancer is the leading cause of cancer-related death worldwide, and the number of elderly patients with nonsmall-cell lung cancer (NSCLC) has risen with increasing life-expectancy. AIMS To evaluate safety and efficacy of thoracoscopic lobectomy for NSCLC patients above 75 years old. PATIENTS AND METHODS We reviewed the data of 795 consecutive patients with NSCLC, who underwent video-assisted thoracoscopic lobectomy from January 2006 to December 2013. Patients were divided into two groups: The elderly group aged at least 75 years old (n = 54), the contrast group aged <75 years old (n = 741). The general characteristic, comorbidity, intraoperative observations, complications, operative mortality and long-term survival were compared between the two groups. RESULTS The elderly group had a higher incidence of squamous cell carcinoma (40.74% vs. 29.69%) and a lower incidence of adenocarcinoma (37.04% vs. 52.63%) than the contrast group (P = 0.083). The ratio of smoking (61.11% vs. 41.97%), preoperative comorbidities (62.96% vs. 38.06%), perioperative blood transfusion (25.93% vs. 13.50%) and thoracic intubation indwelling time (10.3 vs. 8.2 days) in the elderly group were higher (P < 0.01). There was no significant difference in duration of surgery (222.9 vs. 226.6 min), intraoperative blood loss (299.8 vs. 253.5 min), hospital stay (18.2 vs. 15.8 days) or postoperative hospital stay (10.3 vs. 8.4 days) between the two groups. Postoperative morbidities occurred more frequently in the elderly group than the contrast group (24.07% vs. 12.01%, P = 0.018). Thirty-day mortality rate of two groups showed no significant difference (1.85% vs. 0.40%, P = 0.246). The overall survival and recurrence-free survival in the elderly group were comparable with the contrast group (P = 0.114 and 0.092, respectively). CONCLUSIONS Video-assisted thoracoscopic lobectomy is a safe and reliable approach with acceptable short- and long-term outcome in the elderly.

Survival rate and prognostic factors of surgically resected clinically synchronous multiple primary non-small cell lung cancer and further differentiation from intrapulmonary metastasis

BACKGROUND The diagnosis, staging, and therapeutic strategy for synchronous multiple primary non-small cell lung cancer (SMP-NSCLC) remain unclear. Distinguishing SMP-NSCLC from intrapulmonary metastasis is difficult but of great importance for selecting the surgical procedure and prognoses. METHODS Fifty-two patients diagnosed with SMP-NSCLC according to the modified Martini-Melamed criteria in the thoracic surgery department of the China-Japan Friendship Hospital from November 2004 to December 2015 were enrolled in this retrospective study. A total of 106 tumors were subjected to pathological examination. Close follow-up and survival analysis were performed. RESULTS The perioperative morbidity rate was 5.8%, with no cases of perioperative death. The overall 5-year survival rate was 40.6%, the cancer-specific 5-year survival rate was 54.5%, and the median survival time was 52 months. Older age (P=0.553), sex (P=0.600), smoking history (P=0.496), tumor distribution (P=0.461), video-assisted thoracoscopic surgery (VATS) (P=0.398), and adjuvant chemotherapy (P=0.078) did not affect survival. Preoperative percentage of forced expiratory volume in the first second (P=0.022), Charlson comorbidity index (P=0.034), surgical procedure (P=0.040), and highest pT stage (P=0.022) were independent risk factors in the multivariate analysis. Different pathological subtypes were identified in 13 of 18 cases of multiple adenocarcinomas. Different gene mutation types and correlations between tumors were identified through NGS in those with the same pathological subtype. CONCLUSIONS Postoperative survival rates in SMP-NSCLC were satisfactory. Non-radical resection might improve the prognosis for patients with a tolerable general condition and pulmonary function. Higher pT stage might result in poorer survival rates. Larger sample size and future study are still needed to identify the prognostic factors. Comprehensive histologic assessment and next generation sequencing (NGS) could be effective methods for screening SMP-NSCLC.

Fibrobronchoscopic cryosurgery for secondary malignant tumors of the trachea and main bronchi

Patients with secondary malignant tracheal and main bronchial tumors may suffer severe symptoms as a result of major airway obstruction. Curative surgical resection is usually not suitable because of the presence of metastatic disease and poor performance status. In this study, the use of bronchoscopic cryosurgery to reopen the airway is analyzed.