Urban-Rural Disparities in the Lung Cancer Surgical Treatment Pathway: The Paradox of a Rich, Small Region.

Introduction: Rural populations in large countries often receive delayed or less effective diagnosis and treatment for lung cancer. Differences are related to population-based factors such as lower pro capita income or increased risk factors or to differences in access to facilities. Switzerland is a small, rich country with peculiar geographic and urban characteristics.We explored the relationship between lung cancer diagnostic-surgical pathway and urban-rural residency in our region. Methods: We retrospectively analyzed the medical records of 280 consecutive patients treated for primary non-small cell lung cancer at our institution (2017-2021). This is a regional tertiary center for diagnosis and treatment, and data were extracted from a prospectively collected clinical database. We included anatomical lung resection. Collected variables included patients and surgical characteristics, risk factors, comorbidities, histology and staging, symptoms (vs. incidental diagnosis), general practitioner (GP) involvement, health insurance, and suspected test-treatment interval. The exposure was rurality, defined by the 2009 rural-urban residency classification from the Department of Land. Results: A total of 150 patients (54%) lived in rural areas. Rural patients had a higher rate of smoking history (93% vs. 82%; p = 0.007). Symptomatic vs. incidental diagnosis did not differ as well as previous cancer rate, insurance, and pathological staging. In rural patients, there was a greater burden of comorbidities (mean Charlson Comorbidity Index Age-Adjusted 5.3 in rural population vs. 4.8 in urban population, p = 0.05), and GP was more involved in the diagnostic pathway (51% vs. 39%, p = 0.04). The interval between the first suspected test and treatment was significantly shorter (56 vs. 66.5 days, p = 0.03). Multiple linear regression with backward elimination was run. These variables statistically predicted the time from the first suspected test and surgical treatment [F(3, 270), p < .05, R 2 = 0.24]: rurality (p = 0.04), GP involvement (p = 0.04), and presence of lung cancer-related symptoms (p = 0.02). Conclusions: In our territory with inhomogeneous population distribution and geographic barriers, residency has an impact on the lung cancer pathway. It seems paradoxical that rural patients had a shorter route. The more constant involvement of GP might explain this finding, having suggested more tests for high-risk patients in the absence of symptoms or follow-ups. This did not change the staging of surgical patients, but it might be essential for the organization of an effective lung cancer screening program.

A methodological quality evaluation of the published guidelines and recommendations about the lung cancer screening.

BACKGROUND: A project to assess the existing literature and to benchmark the quality of past guidelines and recommendations on lung cancer screening projects was developed with a particular focus on the assessment of the methodology used in producing them. METHODS: Each guideline was assessed in the different items and domains with the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument and scored on a seven-point scale. RESULTS: Eight guidelines matched the inclusion criteria and were assessed. A multinational collaboration produced three out of five guidelines. The multivariable analysis shows that improved scores of stakeholders' involvement were related to internationally developed guidelines. Improved methodological quality was related to the involvement of scientific societies due to the better rigor of development and editorial independence. Countries with higher expenditure on healthcare produced significantly better guidelines. CONCLUSIONS: Assessed by the AGREE II criteria, the methodological quality of previous guidelines was relatively low. Nevertheless, the National Comprehensive Cancer Network Guidelines should be recommended as a model for the development of best methodological quality guidelines.

Tracking the outcomes of surgical treatment of Stage 2 and 3 empyema: introduction and consolidation of minimally invasive approach.

BACKGROUND: We described the results of surgical treatment of empyema, tracing outcomes throughout the passage from the open thoracotomy (OT) approach to video-assisted thoracoscopic surgery (VATS) in a single institute. METHODS: We retrospectively analyzed the records of 88 consecutive patients treated for Stage 2 and 3 empyema (2010-2019). We divided the study period into three groups: OT period (2010-2013), early VATS (2014-2017, from the introduction of VATS program, until acme of learning curve), and late VATS (2018-2019). Groups were compared to investigate the outcomes evolution. RESULTS: Most relevant findings of the study were significant variation in postoperative length of stay (median [interquartile range]: 9 days [7.5-10], 10 [7.5-17.5], and 7 [5-10] for OT period, early VATS, and late VATS, respectively, p = 0.005), hospital admission referral to thoracic surgery interval (7.5 days [4.5-11], 6.5 [3-9], and 2.5 [1.5-5.5], p = 0.003), chest tube duration (5.5 days [5-7.5], 6 [4-6], 4 [3-5], p = 0.003), and proportion of operation performed by residents (3 [15%], 6 [16.7%], 14 [43.6%], p = 0.01). CONCLUSIONS: Our findings pictured the trajectory evolution of outcomes during introduction and consolidation of VATS treatment of empyema. During the early phase, we observed a decline in some indicators that improved significantly in the late VATS period. After a learning curve, all outcomes showed better results and we entered into a teaching phase.

Surgical treatment of pleural empyema in Coronavirus disease 19 patients: the Southern Switzerland experience.

We report the first surgical series of patients developing pleural empyema after severe bilateral interstitial lung disease in confirmed severe acute respiratory syndrome coronavirus 2 infection. The empyema results in a complex medical challenge that requires combination of medical therapies, mechanical ventilation and surgery. The chest drainage approach was not successful to relieve the symptomatology and to drain the excess fluid. After multidisciplinary discussion, a surgical approach was recommended. Even though decortication and pleurectomy are high-risk procedures, they must be considered as an option for pleural effusion in Coronavirus disease-positive patients. This is a life-treating condition, which can worsen the coronavirus disease manifestation and should be treated immediately to improve patient's status and chance of recovery.

Postoperative outcomes of robotic-assisted lobectomy in obese patients with non-small-cell lung cancer.

OBJECTIVES: The aim of this study was to assess the postoperative outcomes of robotic-assisted lobectomy in obese patients to determine the impact of the robotic approach on a high-risk population who were candidates for major pulmonary resection for non-small-cell lung cancer (NSCLC). METHODS: Between January 2007 and August 2018, we retrospectively reviewed the medical records of 224 obese patients (body mass index ≥ 30) who underwent pulmonary lobectomy at our institution via robotic-assisted thoracic surgery (RATS, n = 51) or lateral muscle-sparing thoracotomy (n = 173). RESULTS: Forty-two patients were individually matched with those who had the same pathological tumour stage and similar comorbidities and presurgical treatment. The median operative time was significantly longer in the RATS group compared to that in the thoracotomy group (200 vs 158 min; P = 0.003), whereas the length of stay was significantly better for the RATS group (5 vs 6 days; P = 0.047). Postoperative complications were significantly more frequent after open lobectomy than in the RATS group (42.9% vs 16.7%; P = 0.027). After a median follow-up of 4.4 years, the 5-year overall survival rate was 67.6% [95% confidence interval (CI) 45.7-82.2] for the RATS group, and 66.1% (95% CI 46.8-79.9) for the open surgery group (log-rank P = 0.54). The 5-year cumulative incidence of cancer-related deaths was 24.8% (95% CI 9.7-43.5) for the RATS group and 23.6% (95% CI 10.8-39.2) for the open surgery group (Gray's test, P = 0.69). CONCLUSIONS: RATS is feasible and safe for obese patients with NSCLC with advantages compared to open surgery in terms of early postoperative outcomes. In addition, the long-term survival rate was comparable to that of the open approach.

A Brief Report on Survival After Robotic Lobectomy for Early-Stage Lung Cancer.

INTRODUCTION: Robotic-assisted surgery has become the first choice for several conditions since its introduction in clinical practice in 2000. However, the U.S. Food and Drug Administration has recently raised a warning against the use of robotic surgical approaches for the cure and prevention of cancer following the publication of two studies focused on endometrial cancer. We conducted an internal audit to retrospectively analyze our experience to assess the safety and feasibility of robotic-assisted surgery compared to open surgery. METHODS: We selected a 5-year period to guarantee at least 2 years of follow-up (2011-2016) and identified 1139 patients who underwent lobectomy for NSCLC in our division. The primary data set analyzed included 544 early-stage clinical N0 patients (348 open and 196 robotic surgeries). We compared 131 patients of each group individually matched, with demographic and clinical characteristics almost identical. RESULTS: No difference was observed between the cohorts, either in terms of recurrence-free survival (hazard ratio: 1.09; p = 0.55) or overall survival (hazard ratio: 0.86; p = 0.36). The 5-year recurrence of disease risk and overall survival were 24.9% and 83.2%, respectively, in the open group and 24.6% and 86.1%, respectively, in the robotic group. CONCLUSIONS: These data underline that robotic-assisted lobectomy for early NSCLC is a safe and feasible technique with adequate long-term and progression-free survival compared to open surgery.

Ten Years' Experience in Robotic-Assisted Thoracic Surgery for Early Stage Lung Cancer.

BACKGROUND: This study analyzed the short- and long-term outcomes of robotic-assisted thoracic surgery (RATS) for early stage non-small cell lung cancer (NSCLC). METHODS: From November 2006 to December 2016, we performed 363 RATS procedures. This study retrospectively reviewed 339 patients who underwent RATS for clinical stages I (n = 318) or II (n = 21) NSCLC. RESULTS: Twenty-nine patients underwent segmentectomy, 307 lobectomy, and 3 pneumonectomy. Conversion occurred in 22 patients (6.5%): 15 (4.4%) due to technical issues, 4 (1.2%) for oncological reasons, and 3 (0.9%) for bleeding. The median number of N1 and N2 stations resected was 2 and 3, respectively, and the median number of N1 and N2 lymph nodes resected was 9 and 6, respectively. Median operative time was 192 minutes for lobectomy, 172 minutes for segmentectomy, and 275 minutes for pneumonectomy. Median length of hospital stay was 5 days (2-191). The most common postoperative complication was prolonged air leak (12.1%). Major complications occurred in eight patients (2.4%). The 30-day and 90-day operative mortality was 0% and 0.3%, respectively. Two and 5-year cancer-specific survival rate was 96.1% and 91.5%, respectively. Five-year survival rate was 96.2% for patients who underwent segmentectomy, and 89.1% for lobectomy. All three patients who underwent pneumonectomy were alive at 5 years with no disease. CONCLUSIONS: Besides the well-known short-term outcomes showing very low morbidity and mortality rates, mediastinal lymph node dissection during RATS adequately assesses lymph node stations detecting occult lymph node metastasis and leading to excellent oncologic results. However, these results await longer follow-up studies.

Primary Sarcoma of Descending Aorta.

Primitive aortic sarcomas are rare tumors characterized by resistance to medical treatment and a poor prognosis with high metastatic rates and local recurrences. Surgery remains the mainstay treatment and is based on challenging and technically demanding resections with high rate of major intraoperative and postoperative complications. We report the case of a patient with primitive intimal sarcoma of the aorta, who underwent a descending aortic resection and reconstruction with a prosthetic tube.

Acute kidney injury after lung cancer surgery: Incidence and clinical relevance, predictors, and role of N-terminal pro B-type natriuretic peptide.

BACKGROUND: Acute kidney injury (AKI) frequently occurs in several medical and surgical settings, and it is associated with increased morbidity and mortality. In patients undergoing lung cancer surgery, AKI has not been fully investigated. We prospectively evaluated the incidence, clinical relevance, and risk factors of AKI in patients undergoing lung cancer surgery. Moreover, we estimated the accuracy of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in the prediction of AKI. METHODS: Patients undergoing lung cancer surgery were included in the study. Plasma NT-proBNP was measured before and soon after surgery. Postoperative AKI was defined according to the Acute Kidney Injury Network (AKIN) classification. RESULTS: A total of 2179 patients were enrolled. Of them, 222 (10%) developed AKI and had a more complicated in-hospital clinical course (overall complication rate: 35% vs. 16%; P < 0.0001), and a longer hospital stay (10 ± 7 vs. 7 ± 4 days; P < 0.0001). The incidence of AKI increased in parallel with the extent of lung resection. Among the independent predictors of AKI, serum creatinine (area under the curve [AUC] 0.70 [95% CI 0.67-0.74]) and NT-proBNP (AUC 0.71 [95% CI 0.67-0.74]) provided the highest predictive accuracy, and their combination further significantly improved AKI prediction (AUC 0.74 [95% CI 0.71-0.77]). No difference in AKI prediction was observed between preoperative and postoperative NT-proBNP (P = 0.84). CONCLUSIONS: Acute kidney injury occurs in 10% of patients undergoing lung cancer surgery, and it is associated with a high incidence of postoperative complications. The risk of AKI can be accurately predicted by the combined evaluation of preoperative serum creatinine and NT-proBNP.

Pleural catheters after thoracoscopic treatment of malignant pleural effusion: a randomized comparative study on quality of life.

BACKGROUND: Malignant pleural effusion (MPE) complicates many neoplasms and its incidence is expected to rise in parallel with the aging population and longer survival of cancer patients. Although a clear consensus exists on indwelling catheters in patients with poor performance status, no study has hitherto compared different devices in patients requiring temporary or definitive drainage following talc poudrage. METHODS: This is a prospective, two-arm, pilot study on patients with MPE undergoing talc poudrage, comparing two different catheters (PleurX® versus Pleurocath®) positioned because of the inefficacy of the procedure or the high risk of short-term failure. End points of the study were quality of life (QoL), median dyspnea and chest pain assessment by EORTC questionnaires and a 100 mm visual analog scale, total in-hospital length of stay and frequency of serious adverse events. RESULTS: No difference was observed between the two groups in in mean dyspnea and mean chest pain in any questions of the EORTC QLQ-C30 and QLQ-LC13 questionnaires. Duration of the procedure was significantly longer in the PleurX® group versus the Pleurocath® group (72±33 versus 44±13 minutes; P=0.03). No difference was observed between the two groups in total length of hospital stay (P=1.00) or complication rate (P=1.00). CONCLUSIONS: For the cohort of patients still needing indwelling pleural catheters (PC) after thoracoscopic talc poudrage, PleurX® is suggested when drain removal is unlikely due to short life expectancy or the high chance of pleurodesis failure. Conversely, Pleurocath® should be recommended in all other patients as it is faster to place and easier to remove. KEYWORDS: Malignant pleural effusion (MPE); talc poudrage; indwelling pleural catheter (indwelling PC).

Robotic-assisted thymectomy for early-stage thymoma: a propensity-score matched analysis.

The aim of this study was to analyse the feasibility and safety of robotic-assisted thymectomy (RoT) in patients with clinically early stage thymoma, investigating clinical and early oncological results. Between 1998 and 2017, we retrospectively reviewed 76 (42.2%) patients who underwent radical thymectomy for clinically early stage thymoma (Masaoka-Koga I and II), identifying all patients who underwent RoT (n = 28) or open thymectomy (OT) with eligibility criteria for robotic surgery (n = 48). Using a propensity-score matched for tumor size (3.9 ± 1.8 cm) and stage (35% stage I, 42% stage IIA, 23% stage IIB), we paired 24 patients who had RoT with 24 patients undergoing OT. RoT was left-sided in 19 (79.2%) patients. None of the patients required conversion to open surgery. OT was via sternotomy in 21 (87.5%) patients and thoracotomy in 3 (12.5%). Mean operating time was shorter in the RoT group (117 ± 40 min) than in the OT (141 ± 46 min) (p = 0.06), even if not statistically significant. Length of stay was significantly shorter in the RoT group (mean 4.0 ± 1.9 days) than in the OT (mean 5.9 ± 1.7 days) (p = 0.0009). No significant difference between the two groups regarding post-operative complications. Five patients died in the OT group after a median follow-up of 6.1 years (only one for recurrence). After a median follow-up of 1.3 years, all patients in the RoT group were alive without disease. RoT is feasible and safe for early stage thymoma with clear advantage compared to OT in term of short term outcomes. A longer follow-up is needed to better evaluate the oncological results.

Chest wall resection and reconstruction for locally recurrent breast cancer: From technical aspects to biological assessment.

INTRODUCTION: Breast cancer is the leading cause of cancer death among women in the industrialized countries. The incidence of local recurrences after mastectomy and breast-conserving therapy varies between 5% and 40% depending on risk factors and primary therapy. METHODS: From April 1999 to April 2011, 40 patients underwent chest wall resection and reconstruction for locally recurrent breast carcinoma with chest wall invasion. The main goal of surgery was local disease control to palliate clinical symptoms. RESULTS: Local radical resection was achieved in 26 patients (65%). One, 2 and 5 year overall survival rates were 94.4%, 82.0% and 68.5%; 1, 2 and 5 year disease-free survival rates were 94.4%, 73.6% and 45.5% respectively. Univariate analysis indicated age (p = 0.002) and synchronous distant metastases (p = 0.020) as factors having a negative impact on overall survival; multivariate analysis disclosed age (p = 0.052) and synchronous metastases (p = 0.059) as factors with a slight negative impact on overall survival. Older age was associated with improved overall survival. Univariate analysis indicated synchronous distant metastases (p = 0.029) and the need of post resectional additional treatments (p = 0.022) as factors adversely conditioning disease-free survival or time to progression; multivariate analysis disclosed the need of post resectional additional treatments (p = 0.036) as the only factor adversely conditioning disease-free survival or time to progression. CONCLUSIONS: Chest wall resection and reconstruction for locally recurrent breast cancer is a feasible and safe procedure providing adequate local disease control and an excellent palliation of very disabling symptoms in a selected group of patients.

Operative rigid bronchoscopy: indications, basic techniques and results.

Palliative airway treatments are essential to improve quality and length of life in lung cancer patients with central airway obstruction. Rigid bronchoscopy has proved to be an excellent tool to provide airway access and control in this cohort of patients. The main indication for rigid bronchoscopy in adult bronchology remains central airway obstruction due to neoplastic or non-neoplastic disease. We routinely use negative pressure ventilation (NPV) under general anaesthesia to prevent intraoperative apnoea and respiratory acidosis. This procedure allows opioid sparing, a shorter recovery time and avoids manually assisted ventilation, thereby reducing the amount of oxygen needed, while maintaining optimal surgical conditions. The major indication for NPV rigid bronchoscopy at our institution has been airway obstruction by neoplastic tracheobronchial tissue, mainly treated by laser-assisted mechanical dissection. When strictly necessary, we use silicone stents for neoplastic or cicatricial strictures, reserving metal stents to cover tracheo-oesophageal fistulae. NPV rigid bronchoscopy is an excellent tool for the endoscopic treatment of locally advanced tumours of the lung, especially when patients have exhausted the conventional therapeutic resources. Laser-assisted mechanical resection and stent placement are the most effective procedures for preserving quality of life in patients with advanced stage cancer.

Outcome and prognostic factors of resected non-small-cell lung cancer invading the diaphragm.

OBJECTIVES: Diaphragmatic infiltration by non-small-cell lung cancer (NSCLC) is a rare occurrence and surgical results are unclear. We assessed our experience with en bloc resection of lung cancer invading the diaphragm, analysing prognostic factors and long-term outcomes. METHODS: We analysed a prospective database of patients with NSCLC infiltrating the diaphragm who underwent en bloc resection. Univariate analysis was performed to identify prognostic factors. Survival was calculated by the Kaplan-Meier method. RESULTS: Nineteen patients (14 men, mean age 64 ± 11 years) were identified. Surgery included nine pneumonectomies, eight lobectomies and two segmentectomies. A partial diaphragmatic infiltration was observed in 10 patients (53%) and full-depth invasion in 9 (47%). Diaphragmatic reconstruction was done primarily in 13 patients (68%), and by prosthetic material in 6 (32%). Pathological nodal status included nine N0, four N1 and six N2. The median hospital stay was 7 days (range, 4-36 days). The postoperative mortality rate was 5% (1/19). Two patients (10%) had major complications (acute respiratory distress syndrome and bleeding) and 10 minor complications, arrhythmia in 7 (37%) and pneumonia in 3 (16%). The 5-year survival was 30 ± 11%. The median survival and disease-free survival were 15 ± 9 months (range, 1-164 months) and 9 ± 7 months (range, 1-83 months), respectively. Factors adversely affecting survival were diaphragmatic infiltration (50% superficial vs 0% full-depth infiltration; log-rank test, P = 0.04) and nodal involvement (43% N0 vs 20% N1-2; log-rank test, P = 0.03). CONCLUSIONS: Resection of NSCLC invading the diaphragm is technically feasible and could be a valid therapeutic option with acceptable morbidity and mortality and long-term survival in highly selected patients.

Survival after extended resection for mediastinal advanced lung cancer: lessons learned on 167 consecutive cases.

BACKGROUND: Extended resections (ER) for lung cancer may improve survival in selected patients. However, analysis on large series is still lacking. We reviewed our experience to identify prognostic factors useful for patient selection. METHODS: Between 1998 and 2010, 167 patients with involvement of one or more mediastinal organs underwent operations with the intent to perform ER. At thoracotomy, 42 patients (25%) were considered unresectable (explorative thoracotomy [ET]), and 125 (75%) underwent ER. The types of ER were superior vena cava in 43 patients (34.4%), carina in 33 (26.4%), combined with superior vena cava in 18 (14.4%), with the left atrium in 35 (28%), and with the aorta in 14 (11.2%). We excluded Pancoast tumors and vertebral resections. The minimum follow-up was 6 months. Kaplan-Meier method and log-rank test were used for statistical analysis of survival. RESULTS: There were 136 men (81.4%), with mean age of 63 years (range, 36 to 81 years). Of the 167 patients, induction chemotherapy was administered in 119 (71.3%), including 34 ET patients (81%) and 85 ER patients (68%). Complete resection was achieved in 106 patients (84.8%). The overall 5-year survival was 23% (27% in ER and 13% in ET, p = 0.41). Overall 30-day mortality was 4.8% and morbidity was 34.1%. Factors affecting survival were complete resection (p < 0.01), pStage 0-I-II disease (p < 0.0007), and age younger than 60 years (p < 0.01). CONCLUSIONS: ER for lung cancer invading mediastinal organs could improve long-term survival (46% at 5-years in pN0). The best surgical candidates are young patients without lymph nodes involvement who undergo radical resection. Multimodality treatment is suggested in case of mediastinal lymph node involvement.

Perioperative blood transfusion practices in oncologic thoracic surgery: when, why, and how.

INTRODUCTION: Available information on perioperative blood transfusion practices in oncologic thoracic surgery is scant and outdated. The purpose of this study was to investigate transfusion requirements in patients undergoing curative resection for lung cancer and to identify possible factors predictive of perioperative blood transfusion in our cohort of patients. METHODS: From 1st January 2009 to 31st December 2009, 317 patients underwent anatomic pulmonary resection. Patients who received at least 1 unit of red blood cells comprised the "transfused" group. Each case in this group was matched for surgical procedure with a control subject who did not require blood transfusion and was operated on during the same year; these patients comprised the "not transfused" group. RESULTS: A total of 75 patients (23.6%) received at least 1 unit of red blood cells during the perioperative period. Factors conditioning perioperative blood transfusion were: preoperative hemoglobin level (p < 0.0001); procedure duration (p = 0.017); body mass index (p < 0.001); induction therapies (p = 0.017); redo procedure (p = 0.021). Age, sex, histology, stage, ASA score, side, intraoperative blood loss, and fluid infusion did not affect perioperative blood transfusion practices. CONCLUSIONS: Preoperative hemoglobin level is the major risk factor for perioperative blood transfusion practices in oncologic thoracic surgery; procedure duration, body mass index, induction therapies, and redo procedure may condition transfusional needs, although they were actually not predictive on multivariate analysis.

A 10-year single-center experience on 708 lung metastasectomies: the evidence of the "international registry of lung metastases".

INTRODUCTION: The International Registry of Lung Metastases defined a new staging system based on identified prognostic factors for long-term survival after metastasectomy. The aim of our study was to confirm the validity of the International Registry of Lung Metastases classification system in patients who underwent curative lung metastasectomy in a single center. METHODS: We retrospectively reviewed 575 patients who underwent 708 lung metastasectomies from January 1998 to October 2008. Complete curative pulmonary resections were performed in 490 cases (85%). Three hundred seventy-two patients developed lung metastases from epithelial tumors, 80 from sarcomas, 27 from melanomas, and 11 from germ cell tumors. The mean disease-free interval (DFI) was 46.6 months. Open surgical resection was performed in 479 patients. One hundred eighty-five patients had a single-lung metastasis. Lymph node dissection was performed in 353 cases. RESULTS: After a mean follow-up of 34 months, 247 patients (43%) had died. Multivariate analysis disclosed that completeness of resection (p < 0.0001), patients with germ cell tumors (p = 0.04), and DFI ≥36 months (p = 0.01) were also associated with a better prognosis. The actuarial survival after complete metastasectomy was 74% at 2 years and 46% at 5 years. CONCLUSIONS: We confirmed completeness of surgery, histology, and DFI ≥36 months as independent prognostic factors. Number of metastases, presence of lymph node metastases, surgical approach, and number of metastasectomies did not statistically influence long-term survival.

Lymph node involvement in T1 non-small-cell lung cancer: could glucose uptake and maximal diameter be predictive criteria?

OBJECTIVE: The introduction of modern staging systems such as computed tomography (CT) and positron emission tomography/CT (PET/CT) with fluorodeoxyglucose ([(18)F]FDG) has increased the detection of small peripheral lung cancers at an early stage. We analyzed the behavior of pathological T1 non-small-cell lung cancer (NSCLC) to identify criteria predictive of nodal involvement, and the role of cancer size in lymph node metastases. METHODS: We retrospectively analyzed 219 patients with pathological T1 NSCLC. All patients were staged by high-resolution CT and PET as stage I, and underwent anatomical resection and radical lymphadenectomy. Our data were collected based on pathological nodule size (0-10 mm; 11-20 mm; and 21-30 mm); morphological features of lung nodule and FDG uptake of the tumor measured by standardized uptake value (SUV). RESULTS: A total of 190 patients (87%) were pN0, 14 (6%) pN1, and 15 (7%) pN2. No nodal involvement was observed in any of the 62 patients with nodule size less than 10 mm, in 20 out of 120 patients (17%) with nodule size 11-20 mm, and in nine out of 37 tumors (28%) 21-30 mm in size (p=0.0007). All 55 patients with nodule SUV<2.0 and all 26 non-solid lesions were pN0 (respectively, p=0.0001 and p=0.03). All nodal metastases occurred among the group of 132 patients with size larger than 10 mm and SUV higher than 2.0 with a 22% rate of nodal involvement of (29 patients) (p<0.0001). CONCLUSIONS: The low probability of lymph node involvement in NSCLC <1 cm or showing glucose uptake <2 suggests lymphadenectomy could be avoided. A randomized trial should be performed to validate our data.