Prognostic factors following complete resection of non-superior sulcus lung cancer invading the chest wall

Abstract

OBJECTIVES Locally advanced non-small-cell lung cancer (NSCLC) with chest wall invasion carries a high risk of recurrence and portends poor survival (30–40% and 20–50%, respectively). No studies have identified prognostic factors in patients who underwent R0 resection for non-superior sulcus NSCLC. METHODS A retrospective review was conducted for all chest wall resections for NSCLC from 2004 to 2018. Patients with superior sulcus tumours, partial (<1 rib) or incomplete (R1/R2) resection or distant metastasis were excluded. Disease-free survival (DFS) and overall survival (OS) were estimated using the Kaplan–Meier method. Cox proportional hazards modelling was used to determine factors associated with DFS and OS. RESULTS A total of 100 patients met inclusion criteria. Seventy-three (73%) patients underwent induction therapy, and all but 12 (16%) patients experienced a partial radiological response. A median of 3 ribs was resected (range 1–7), and 67 (67%) patients underwent chest wall reconstruction. The 5-year DFS and OS were 36% and 45%, respectively. Pathological N2 status [hazard ratio (HR) 3.12, confidence interval (CI) 1.56–6.25; P = 0.001], intraoperative blood transfusion (HR 2.24, CI 1.28–3.92; P = 0.005) and preoperative forced vital capacity (per % forced vital capacity, HR 0.97, CI 0.96–0.99; P = 0.013) were associated with DFS. Increasing pathological stage, lack of radiological response to induction therapy (HR 7.35, CI 2.35–22.99; P = 0.001) and cardiovascular comorbidity (HR 2.43, CI 1.36–4.36; P = 0.003) were associated with OS. CONCLUSIONS We demonstrate that blood transfusion and forced vital capacity are associated with DFS after R0 resection for non-superior sulcus NSCLC, while radiological response to induction therapy greatly influences OS. We confirm that pathological nodal status and pathological stage are reproducible determinants of DFS and OS, respectively.

Association Between Surgical Stress and Biochemical Recurrence After Robotic Radical Prostatectomy

“…Blood loss and the need for blood transfusion during surgery reportedly worsened the rate of disease-free survival in another cancer. 29 However, lack of a significant association between EBL and the rate of BCR in our study could have been because none of our patients required blood transfusion during the peri-operative period due to the lower EBL. Also, in the present study, two types of analgesics, i.e., NSAIDs and pentazocine, were used after surgery.…”

Extended resections and other special cases in lung cancer surgery: Real‐world population‐based outcomes

“…Despite clear recommendations, after neoadjuvant therapy and surgery, 42.5% of patients received further adjuvant therapy similar to esophageal cancer protocols 19 . Finally, the rate of confirmed N2 nodal disease, an indicator of poor prognosis, was detected in only 15% of the extended group and was not statistically higher than those in other groups 20 . Furthermore, the nodal disease burden of N2 patients, shown to correlate with survival, was lowest in the extended group with a median of only one positive node 21 .…”

“…19 Finally, the rate of confirmed N2 nodal disease, an indicator of poor prognosis, was detected in only 15% of the extended group and was not statistically higher than those in other groups. 20 Furthermore, the nodal disease burden of N2 patients, shown to correlate with survival, was lowest in the extended group with a median of only one positive node. 21 Overall, the results indicate that after guidelinebased patient evaluation, complete radical resection combined with oncological therapies can be offered to these special cases, resulting in a low complication rate and good long-term survival.…”

A narrative review of surgical management of lung cancer involving the chest wall: oncologic results

“…Despite evidence that supports induction chemoradiotherapy for superior sulcus tumors, there is little evidence to support adjuvant chemotherapy or radiation around completely resected T3N0 disease. Induction chemoradiotherapy for chest wall invasion of NSCLC that excludes the superior sulcus has not been vetted in a randomized controlled trial but some institutions have been exploring this option by extrapolating from the success of multi-modality treatment of Pancoast tumors (32). Although many studies suggest that T3N1 disease has worse outcome compared to N0 disease, most surgeons will offer en-bloc resection of chest wall and lung since the hilar (N1) disease can be encompassed in a complete resection.…”

“…The Memorial Sloan-Kettering Group reported 49% 5-year survival in completely resected T3N0 disease compared to 27% in T3N1 disease and 15% in T3N2 disease (P<0.0003) (10). In a multivariate analysis of a more contemporary study (32) examining outcomes in 100 patients treated for NSCLC invading the chest wall (excluding superior sulcus tumors), no radiographic response to induction therapy was the strongest predictor of worse overall survival (OR =7.35) where 73% of the patients underwent induction therapy. Pathologic N2 disease was associated with worse disease-free survival with OR =3.12.…”