The prognostic significance of PD-1 and its ligands in non-small cell lung cancer.

Background: In this study, we aimed to investigate the prognostic value of programmed cell death protein 1 (PD-1), programmed cell death ligand 1 (PD-L1), and programmed cell death ligand 2 (PD-L2) expressions on immune and cancer cells in terms of survival in patients with lung adenocarcinoma, squamous cell carcinoma, and large cell carcinoma. Methods: Between January 2000 and December 2012, a total of 191 patients (172 males, 19 females; mean age: 60.3±8.4 years; range, 38 to 78 years) who were diagnosed with non-small cell lung cancer and underwent anatomic resection and mediastinal lymph node dissection were retrospectively analyzed. The patients were evaluated in three groups including lung squamous cell carcinoma (n=61), adenocarcinoma (n=66), and large-cell carcinoma (n=64). The survival rates of all three groups were compared in terms of immunohistochemical expression levels of PD-1, PD-L1, and PD-L2. Results: The mean follow-up was 71.8±47.9 months. In all histological subtypes, PD-1 expressions on tumor and immune cells were observed in 33% (61/191) and in 53.1% (102/191) of the patients, respectively. Higher expression levels of PD-L1 and PD-L2 at any intensity on tumor and immune cells were defined only in lung adenocarcinomas, and PD-L1 and PD-L2 values were detected in 36.4% (22/64) of these patients. The PD-L1 expressions on tumor and immune cells were observed in 41.7% (10/24) and 25% (6/24) of the patients, respectively. The PD-L2 expressions on tumor and immune cells were detected in 16.7% (4/24) and 8.4% (2/24) of the patients, respectively. Univariate and multivariate analyses revealed that PD-1 expression in tumor cells was an independent prognostic factor in all histological subtypes. Conclusion: Our study results suggest that PD-1 expression is a poor prognostic factor for overall survival in patients with completely resected adenocarcinoma, squamous cell carcinoma, and large cell carcinoma.

Evaluation of the effect of PET/CT Fluorodeoxyglucose inclusion on mortality and survival in operated thymoma patients.

PURPOSE: In recent years, the use of fluorodeoxyglucose PET-computed tomography (PET-CT) has become widespread to evaluate the diagnosis, metabolism, stage and distant metastases of thymoma. In this study, it was aimed to investigate the connection of malignancy potential, survival and maximum standardized uptake value (SUV max ) measured by PET-CT before surgery according to the histological classification of the WHO in patients operated for thymoma. In addition, the predictive value of the Glasgow prognostic score (GPS) generated by C-reactive protein (CRP) and albumin values on recurrence and survival was investigated and its potential as a prognostic biomarker was evaluated. METHODS: Forty-five patients who underwent surgical resection for thymoma and were examined with PET-CT in the preoperative period between January 2010 and January 2022 were included in the study. The relationship between WHO histological classification, tumor size and SUV max values on PET-CT according to TNM classification of retrospectively analyzed corticoafferents were evaluated. Preoperative albumin and CRP values were used to determine GPS. RESULTS: The cutoff value for SUV max was found to be 5.65 in the patients and the overall survival rate of low-risk (<5.65) and high-risk (>5.65) patients was compared according to the SUV max threshold value (5.65) and found to be statistically significant. In addition, the power of PET/CT SUV max value to predict mortality (according to receiver operating characteristics analysis) was statistically significant ( P  = 0.048). Survival expectancy was 127.6 months in patients with mild GPS (O points), 96.7 months in patients with moderate GPS (1 point), and 25.9 months in patients with severe GPS (2 points). CONCLUSION: PET/CT SUV max values can be used to predict histological sub-type in thymoma patients, and preoperative SUV max and GPS are parameters that can provide information about survival times and mortality in thymoma patients.

The effect of platelet-to-lymphocyte ratio (PLR) and glasgow prognostic score (GPS) on recurrence, and survival in patients undergoing lobectomy for early-stage non-small cell lung cancer (NSCLC).

Tumor markers are indicators that can be used not only for cancer diagnosis but also for determining prognosis. Unfortunately, there is currently no tumor marker that reliably predicts the prognosis of lung cancer. In this study, we investigated the prognostic impact of the platelet-to-lymphocyte ratio (PLR) and Glasgow Prognostic Score (GPS), known as inflammation markers in peripheral blood, in patients who underwent resection for early-stage non-small cell lung cancer (NSCLC). We retrospectively analyzed the medical records of a total of 3300 patients who underwent surgery for NSCLC between 2010 and 2020. Among these patients, 250 met the inclusion criteria of lobectomy, pT1-T2N0 stage, and histology of adenocarcinoma or squamous cell carcinoma. Preoperative albumin, C-reactive protein (CRP), preoperative PLR, and postoperative 5th-day PLR values were determined from patient's peripheral blood data. The impact of these values on postoperative recurrence and survival was investigated. GPS was calculated based on preoperative CRP and albumin values, and patients were divided into 3 groups: 0 (mild), 1 (moderate), and 2 (severe). The relationship between preoperative GPS and survival was analysed. Among the included patients, 155 (62%) had adenocarcinoma and 95 (38%) had squamous cell carcinoma. A total of 185 (74%) patients had pT1 tumors, while 65 (26%) had pT2 tumors. During the postoperative follow-up period, local recurrence was observed in 28 (11.2%) patients and distant metastasis in 51 (20.4%) patients. The overall mortality rate was 19.6%. The 5-year survival rates for pT1 and pT2 tumors were 80.4% and 72.5%, respectively. Significant associations were found between preoperative PLR, postoperative PLR, and recurrence (p = 0.005 and p = 0.011). The expected overall survival (OS) was 103.4 months in the mild GPS group, 91.8 months in the moderate GPS group, and 50 months in the severe GPS group. The relationship between GPS groups and OS was statistically significant (p = 0.005). Preoperative analysis of PLR and GPS may provide prognostic value in NSCLC patients who undergo surgical resection. Our study provides a rationale for further investigation of peripheral blood immune markers for prognostic purposes.

Adjacent lobe invasion of T2 tumor in non-small cell lung cancer has T3 disease-like survival fissure invasion: T2 or T3?

Controversy still exists regarding the staging of non-small cell lung cancer (NSCLC) with adjacent lobe invasion (T-ALI) according to the TNM system in terms of T factor and the appropriate surgical resection method. We performed an analysis to compare the prognosis of T-ALI with T2 and T3 disease and to see the effect of our surgical method for these tumors. Two hundred consecutive patients between January 2012 and November 2020, with anatomical lobectomy for T2 or T3 tumor (Group-1) and non-anatomical lobectomy resection (lobectomy plus wedge resection [LWR]) (Group-2) for T-ALI (T2-ALI and T3-ALI) due to primary NSCLC, who did not have lymph node metastases were analyzed retrospectively. All surgeries were performed by two experienced surgeons who adopted the same surgical technique. Those who underwent additional segmentectomy and bilobectomy due to fissure invasion were excluded from the study. Overall survival rates of all patients were determined and factors affecting survival were evaluated by performing univariate and multivariate analyses. Of the patients with a mean age of 62.2 ± 7.8 years, 175 (87.5%) were male and 25 (12.5%) were female. There were 137 (68.5%) patients in Group 1 and 63 (31.5%) patients in Group 2. The mean tumor size in Group 1 (4.4 ± 1.4 cm) was significantly smaller than that in Group 2 (4.9 ± 1.4 cm) (p = 0.014). When T distribution within the groups was considered, the rate of pathological T3 in Group 1 (33.6%) was significantly lower than that in Group 2 (55.6%) (p = 0.005). While the 5-year overall survival rate was 70.1% in Group 1, it was 50.6% in Group 2 (p = 0.022). When tumors were grouped as T2, T2-ALI, T3, and T3-ALI according to T factor, the 5-year overall survival rates were 71.4% and 67.8% in T2 and T3 tumors, respectively, and 49.2% and 51.5% in T2-ALI and T3-ALI tumors, respectively. In the multivariate analysis of these four groups, the overall survival rates for T2-ALI and T3-ALI were significantly lower than those of T2 tumors (p = 0.046 and p = 0.025, respectively). In the analysis made between the T2 tumor group and the new T3 group (T2-ALI, T3, T3-ALI), which was formed by upgrading T2-ALI tumors to the T3 group, T2 tumors were found to have a significantly better survival rate (p = 0.019). The disease-free survival of pT2 patients and new T3 group patients was statistically significant, 63.7% and 45.7%, respectively (p = 0.050). Our results suggest that LWR for T-ALI can be performed with acceptable oncologic outcomes when compared to anatomical lobectomy. T2-ALI has a worse overall survival than T2 tumor and offers a similar prognosis to T3. Given this situation, it is more appropriate to classify T2-ALI as T3. Further studies based on larger series are needed to confirm these preliminary data.

Analysis of prognostic factors in pT1-2 N1 lung cancer patients in the light surgical results.

Nodal metastasis status is an important parameter affecting the prognosis in lung cancer. Although surgical treatment is possible in most cases of N1 positive non-small cell lung cancer, this group of patients is clinically, radiologically and histologically heterogeneous. The aim of our study is to investigate the prognostic factors affecting survival in patients with pT1-2 N1 who underwent lung resection. From January 2010 to December 2019, patients who underwent lobectomy, bilobectomy or pneumonectomy for pT1-T2 N1 NSCLC in our center were included in the study. The preoperative, intraoperative and postoperative data of the patients were recorded by accessing the patient files and hospital records. The mean follow-up time was 39.8 months. The mean overall survival was 73.8 ± 3.6, and the mean disease-free survival was 67.5 ± 3.8. In multivariate analysis, age, N1 nodal metastasis pattern (occult vs obvious) and histology were found as independent variables affecting survival. In our study, age, histology, and clinical N1 status were found to be independent variables effective on overall survival.

The impact of dissection of station 9 on survival and the necessity of pulmonary ligament division during upper lobectomy for lung cancer.

BACKGROUND: We conducted this study to investigate the need for dissection of station 9 lymph nodes during upper lobectomy for non-small-cell lung cancer (NSCLC) and to find out the operative results of inferior pulmonary ligament division. METHODS: A total of 840 patients who underwent upper lobectomy for NSCLC between January 2007 and June 2020 were evaluated retrospectively. The patients were separated into two groups - those having undergone lymph node dissection of station 9 and inferior pulmonary ligament dissection (Group I) and those who did not (Group II). In these groups, the prognostic value of station 9 lymph nodes and postoperative effects (drainage time, prolonged air leak, dead space and length of hospital stay) of ligament division or preservation were analyzed. RESULTS: The number of patients with station 9 lymph node metastasis was only one (0.1%) and that was multi-station pN2 disease. Station 9 lymph nodes were found in 675 (80.4%) patients, while 22 (2.6%) patients had no lymph nodes in the dissected material. In the other 143 (17%) patients, the inferior pulmonary ligament and station 9 were not dissected. While 5-year survival was 64.9% in 697 patients of Group I, it was 61.3% in 143 patients of Group II (p = 0.56). There was no statistically significant difference between the groups in postoperative effects of ligament division or preservation. CONCLUSIONS: In upper lobectomies, status of station 9 does not have a significant impact on patients' survival and lymph node staging. Additionally, preservation or division of the inferior pulmonary ligament has no significant advantage or disadvantage.

Video-assisted thoracoscopic lobectomy and bilobectomy versus open thoracotomy for non-small cell lung cancer: Mortality and survival.

Background: In this study, we aimed to evaluate patients who had non-small cell lung cancer and underwent resection, to investigate our tendency to prefer video-assisted thoracic surgery or open thoracotomy, and to compare 30- and 90-day mortalities and survival rates. Methods: Between January 2013 and January 2019, a total of 706 patients (577 males, 129 females; mean age: 61.9±8.6 years; range, 17 to 84 years) who underwent lobectomy or bilobectomy due to primary non-small cell lung cancer were retrospectively analyzed. The patients were divided into two groups as operated on through video-assisted thoracic surgery and through open thoracotomy. The 30- and 90-day mortality rates and survival rates were compared. Results: Of the patients, 202 (28.6%) underwent video-assisted thoracic surgery and 504 (71.4%) underwent open thoracotomy. Lobectomy was performed in 632 patients (89.5%) and bilobectomy was performed in 74 patients (10.5%). Patients who were chosen for video-assisted thoracic surgery were statistically significantly older, did not require any procedure other than lobectomy, did not receive neoadjuvant therapy, had a small tumor, and did not have lymph node metastases. The 30- and 90-day mortality rates in the video-assisted thoracic surgery and open thoracotomy groups were 1.8% vs. 2% and 2.6% vs. 2.5%, respectively. The five-year survival rates of video-assisted thoracic surgery and open thoracotomy groups were 74.1% and 65.2%, respectively (p>0.05). The 30- and 90-day mortality and five-year survival rates were 2.1%, 2.6%, and 73.5% in the video-assisted thoracic surgery group and 2.1%, 2.1%, and 68.5% in the open thoracotomy group, respectively, indicating no statistically significant difference between the two groups. Conclusion: Throughout the study period, video-assisted thoracic surgery was more preferred in patients with advanced age, in those who had a small tumor, who did not receive neoadjuvant therapy, did not have lymph node metastasis, and did not require any procedure other than lobectomy. In the video-assisted thoracic surgery and open thoracotomy groups, 30- and 90-day mortality and five-year survival rates were similar. Based on these findings, both procedures seem to be acceptable in this patient population.

Correlation of preoperative PET/computer tomography 18F-fluorodeoxyglucose uptake (maximum standardized uptake value) with prognosis in patients with operated lung cancer.

PURPOSE: The aim of this study was to investigate the correlation of preoperative 18F-fluorodeoxyglucose PET/computed tomography maximum standardized uptake value (SUVmax) in operated non-small cell lung cancer (NSCLC) cases with other prognostic parameters and survival. PATIENTS AND METHODS: NSCLC patients treated by surgical resection were imaged with PET within 60 days before surgery. RESULTS: Overall, 525 cases consecutive patients were retrospectively reviewed. The median value of SUVmax in a total of 525 cases was 12.1, and the mean was 13.3 ± 7.13. Logistic regression analysis performed to identify the variables that have an impact on SUVmax revealed that histology [hazard ratio (HR: 1.893; 95% CI; P = 0.001) and T status (HR: 8.991; 95% CI; P = 0.000) are correlated with SUVmax. Kaplan-Meier analysis revealed a mean survival of 73.7 ± 1.95 months and a median survival of 85.6 ± 6.03 months. In the group with an SUVmax value of less than 10, the mean survival was 81.9 ± 3.02 months (76.0-87.8), and in the group with SUVmax greater than 10.1, the mean survival was 68.6 ± 2.4 months (63.9-73.3) (P = 0.000). In the multivariate analysis, SUVmax, age, tumor histology, lymph node metastasis, comorbid diseases and complete/incomplete status of the resection were identified as the factors predictive of prognosis. CONCLUSION: It is seen that preoperative SUVmax is a parameter with prognostic significance at least as much as histopathology, age, complete/incomplete status of resection and lymph node involvement.

Surgery in congenital lung malformations: the evolution from thoracotomy to VATS, 10-year experience in a single center.

BACKGROUND: Congenital lung malformation is an umbrella term and consist of various kind of parenchymal and mediastinal pathologies. Surgical resection is often required for diagnosis and curative treatment. We aimed to review our experience in surgical treatment for congenital lung disease and present the role of minimally invasive surgery. METHODS: Surgical resections performed for benign lesions of the lung and mediastinum between January 2009 and May 2019 were retrospectively analyzed. Patients who were found to have congenital lung malformation as a result of pathological examination were included in our study. Distribution characteristics of the patients according to congenital lung malformation subtypes, differences in surgical approach and postoperative results were investigated. RESULTS: A total of 94 patients who underwent surgical resection and were diagnosed with the bronchogenic cyst, sequestration, bronchial atresia, congenital cystic adenomatoid malformation (CCAM), or enteric cyst as a result of pathological examination were included the study. There were no significant differences between pathological subtypes in the postoperative length of hospital stay and drainage duration however, perioperative complication rate was higher in the sequestration group. In addition, in the first three days postoperatively, the mean pain score was found to be lower in the VATS group compared to thoracotomy. CONCLUSIONS: Congenital lung malformations consist of a heterogeneous group of diseases and the surgical treatment in these patients can range from a simple cyst excision to pneumonectomy. Video-assisted thoracoscopic surgery should be considered as the first choice in the surgical treatment of these patients in experienced centers.

Emergency pulmonary resection in massive hemoptysis: analysis of 39 patients.

INTRODUCTION: The mortality of massive hemoptysis is high, and it is important to make quick decisions. Emergency pulmonary resection continues to be a mandatory option when conservative methods cannot prevent massive hemoptysis, as it is life-threatening. AIM: We report our experience with patients undergoing pulmonary resection for massive hemoptysis. MATERIAL AND METHODS: This study is a retrospective analysis of 39 consecutive patients who were referred to the thoracic surgery intensive care unit of a tertiary hospital for massive hemoptysis and underwent emergency pulmonary resection by thoracotomy between January 2007 and March 2021. RESULTS: Male dominance with an average age of 49.3 (16-70) and a gender ratio of 3.3 were recorded. The most common underlying cause of massive hemoptysis was bronchiectasis (n = 16). Bronchiectasis was followed by aspergilloma (n = 11) and previous tuberculosis (n = 8). Bronchial artery embolization was performed in 20.5% of patients. Twenty-nine (74.4%) lobectomies, 7 (17.9%) pneumonectomies, and 3 (7.7%) segmentectomies were performed. The mean operation duration was 253.6 ±71 minutes. Recurrent hemoptysis was recorded in 7.7% of patients. Postoperative life-threatening complications were seen in 28.2%, while minor complications developed in 28.2% of patients. Postoperative complications were significantly higher in patients with tuberculosis sequelae (p = 0.006). Hospital mortality was observed in 5.1% of patients. CONCLUSIONS: The postoperative period is more problematic in patients with a history of tuberculosis who undergo emergency pulmonary resection due to massive hemoptysis. Despite this, emergency pulmonary resection is a curative method with acceptable postoperative complications and low hospital mortality in all tolerant patients according to their clinical condition.

Iterative surgical resections in non-small cell lung cancer.

INTRODUCTION: We reviewed our surgical preferences and the prognosis for recurrent and second primary tumors in patients who underwent surgical treatment for non-small cell lung carcinoma (NSCLC). AIM: We report our experience with patients undergoing iterative pulmonary resection for lung cancer. MATERIAL AND METHODS: Among patients who underwent anatomical resection for primary NSCLC, those who underwent a second surgical resection between 2010 and 2020 due to recurrent or second primary tumor were included in the study. Operative mortality, survival, and prognostic factors were investigated. RESULTS: In total, 77 cases were included: 31 (40.3%) underwent the second resection for the recurrent disease and 46 (59.7%) underwent the second resection for the second primary tumor. Postoperative mortality occurred in 8 (10.4%) patients. All patients with postoperative mortality were in the group that underwent thoracotomy in both surgical procedures. The 5-year survival rate was 46.5%. The 5-year survival of those operated on for recurrent or second primary tumor was 32.8% and 51.1%, respectively (p = 0.81). The 5-year survival rate was 68.8% in patients under the age of 60 years, while it was 27.5% in patients aged 60 years and above (p = 0.004). The 5-year survival was 21.8% in patients with an interval of 36 months or less between two operations and 72.2% in those with a longer interval (p = 0.028). CONCLUSIONS: Our study shows that survival results similar to or better than primary NSCLC surgery can be obtained with lower mortality if more limited resections are performed via video-assisted thoracic surgery, especially in young patients. In addition, the prognosis is better in patients with an interval of more than 36 months between two operations.

Surgical Experience of Video-Assisted Mediastinoscopy for Nonlung Cancer Diseases.

BACKGROUND: Video-assisted mediastinoscopy (VAM) is a valuable method in the investigation of diseases with mediastinal lymphadenopathy or those localized in the mediastinum. The aim of this study was to determine the diagnostic value of VAM in the investigation of mediastinal involvement of nonlung cancer diseases and to describe our institutional surgical experience. METHODS: Clinical parameters such as age, sex, histological diagnosis, morbidity, and mortality of all patients who underwent VAM for the investigation of mediastinal involvement of diseases except lung cancer between January 2006 and July 2018 were retrospectively reviewed, and the diagnostic efficacy of VAM was determined statistically. RESULTS: During the study period, 388 patients underwent VAM, and 536 lymph nodes were sampled for histopathological evaluation of mediastinum due to mediastinal lymphadenopathy or paratracheal lesions. The most common diagnoses were sarcoidosis (n = 178 [45.9%]), tuberculous lymphadenitis (n = 108 [27.8%]), lymphadenitis with anthracosis (n = 72 [18.6%]), and lymphoma (n = 15 [3.9%]). CONCLUSION: The results of the study show that VAM should be used because of its high diagnostic benefit in mediastinal lymphadenopathies, which are difficult to diagnose, or mediastinal lesions located in the paratracheal region. Despite the increase in the number of new diagnostic modalities, VAM is still the most effective method and a gold standard.

Changes in the Surgical Treatment Strategies for Nonsmall Cell Lung Cancer in the Past 20 Years: A Single-Center Experience.

OBJECTIVES: Nonsmall cell lung cancer (NSCLC) is a multifactorial disease, and differences in the characteristics of surgical patients may develop over the years. This study aimed to evaluate the patients who underwent curative surgical resection for NSCLC in the past 20 years at our center and analyze the changes in the treatment strategies based on demographics, surgical strategies, and histopathology. MATERIALS AND METHODS: In this retrospective single-center cohort study, 1995 patients who had undergone lobectomy, bilobectomy, or pneumonectomy for primary NSCLC from January 1997 to January 2017 were analyzed. Patients were divided into two groups: Group I included patients operated in the first 10 years and Group II included patients operated in the last 10 years. RESULTS: Overall, 77% of patients were operated in the last 10 years (458 vs. 1537 patients). Sleeve lobectomies performed in Group II reduced the rate of pneumonectomy from 37% to 20% (p<0.001). The operation rates for adenocarcinomas increased significantly during the study period, increasing from 31.4% to 36.2% (p=0.049). The 30- and 90-day postoperative mortality rates were 4.6% and 8.5% in Group I and 4.1% and 5.7% in Group II, respectively (p=0.69 and p=0.037, respectively). When the groups were compared, the median and 5-year survival rates were 44.1 months (95% confidence interval [CI], 35.6-52.6) and 42.9% in Group I and 73.6 months (95% CI, 63.3-83.9) and 53.9% in Group II, respectively (p<0.001). CONCLUSION: This study demonstrates an improvement in long-term outcomes following lung cancer surgery with an increasing rate of surgical procedures in the last 10 years. There was an increase in the proportion of females affected and the rate of adenocarcinoma. However, the pneumonectomy and postoperative N2 disease rates have decreased with advancing preoperative evaluation techniques and parenchyma-saving surgical methods. Postoperative mortality has decreased, and the survival rate has increased.

Prognosis of Resected Non-small Cell Lung Cancer with Ipsilateral Pulmonary Metastasis.

BACKGROUND: Ipsilateral pulmonary metastasis (PM) in the same lobe (T3Satell) or different lobe (T4Ipsi Nod) constitutes a small proportion of patients with non-small cell lung cancer (NSCLC). In our study, we aimed to determine prognostic factors and to evaluate long-term survival outcomes in the patients who underwent complete resection due to NSCLC. METHODS: Data of 1,502 surgically treated patients with NSCLC from January 2007 to December 2016 were retrospectively reviewed. Fifty (3.3%) patients diagnosed with PM were the basis of the study. Demographic and histopathological characteristics, surgical procedures, and prognostic factors for survival were analyzed, categorizing patients according to the presence of PM in the same lobe or different lobe. RESULTS: Among the 50 patients, 23 (46%) had PM in the same lobe as the primary tumor and 27 (54%) had PM in different ipsilateral lobes. The mean size of nodules was 11.5 mm. While T3Satell was detected mostly in squamous cell carcinoma (SCC) (65.2%), T4Ipsi Nod was more common in adenocarcinoma (AC) (70.4%), and the difference was statistically significant (p = 0.022). Survival was significantly better in the SCC-T3Satell group than the AC-T3Satell group (64 and 58.3%, respectively; p = 0.043). Although the overall 5-year survival was better in the T3Satell group, the difference between survival outcomes of both groups was not statistically significant (61.2 and 37.2%, respectively; p = 0.27). In the T3Satell group, nodule size was found to be a negative prognostic factor in survival (p = 0.042), whereas the number of nodules was found to be a negative prognostic factor in the T4Ipsi Nod group (p = 0.046). In multivariate analysis, advanced age was a poor prognostic factor for PM (p = 0.03). CONCLUSION: There was no significant difference in survival between T3Satell and T4Ipsi Nod patients. Among surgically treated patients due to NSCLC, poor prognostic factors were advanced age for the patients with PM, nodule size and AC for T3Satell patients, and the number of nodules for T4Ipsi Nod patients.

Long-term results of sleeve lobectomy with continuous suture technique in non-small cell lung cancer.

BACKGROUND: This study aims to investigate the operation-related complications, recurrence frequency, morbidity, mortality and survival rates as well as variables effective on survival of patients undergoing bronchial sleeve lobectomy due to primary non-small cell lung cancer. METHODS: A total of 85 patients ( 80 males, 5 females; mean age 59.9±8.4 years; range, 35 to 77 years) of bronchial sleeve lobectomy operated with the same surgical technique by the same team in our clinic between May 2007 and November 2015 were analyzed retrospectively. Survival and 30- and 90-day mortality rates were analyzed. Variables effective on survival rate were evaluated statistically. Complications related to bronchial anastomosis and the frequency of local recurrence in postoperative period were investigated. RESULTS: Twenty-five patients (29.4%) received neoadjuvant therapy and two of these patients (8%) developed complication in the anastomosis line. Local recurrence rate in the postoperative follow-up was 16.5%. Mean duration of follow-up was 35±29.9 months, median survival was 65.2 months, and five-year survival rate was 50.9%. Thirty- and 90-day mortality rates were 1.2% and 2.4%, respectively. In univariate analysis, patients with larger tumors, N2 disease, or those who underwent extended surgery had statistically significantly worse survival rates (p=0.001, p=0.002, and p=0.0001, respectively). In the Cox regression analysis, variables effective on survival were presence of extended surgery and node status (p=0.03 and p=0.012, respectively). CONCLUSION: Sleeve lobectomy can be achieved with acceptable anastomotic complications, good survival and low mortality rates using continuous suture technique. When performed due to oncological reasons, its long-term results are not different from pneumonectomy.

A promising tool for T-staging of lung cancer: Is convex probe endobronchial ultrasound superior to computed tomography in detecting invasion of mediastinal and hilar vessels?

BACKGROUND: In the present study, we aimed to compare performance of convex probe endobronchial ultrasound and computed tomography in detecting vascular invasion of mediastinal and hilar lesions. METHODS: Medical data of a total of 55 patients (47 males, 8 females; mean age 59.6±7.7 years; range, 29 to 76 years) who underwent convex probe endobronchial ultrasound for diagnosis and staging of lung cancer in a tertiary care hospital between May 2016 and December 2017 were retrospectively analyzed. The presence of vascular invasion was determined according to two main criteria: visualization of the tumor tissue within the vessel lumen and loss of vessel-tumor hyperechoic interface. All available contrast enhanced computed tomography images were retrospectively re-evaluated by a blinded radiologist. The intra-rater agreement between convex probe endobronchial ultrasound and computed tomography was analyzed. The sensitivity, specificity, positive and negative predictive values, and accuracy of both modalities were calculated. RESULTS: A total of 65 vessel-tumor interface areas of 55 patients were analyzed. Almost all mediastinal and hilar vascular structures including pulmonary arteries and veins, aorta, superior vena cava and its branches, and left atrium with pulmonary veno-atrial junctions could be easily assessed by convex probe endobronchial ultrasound. The intra-agreement of both modalities in detecting vascular invasion was k=0.268 (p=0.028). In nine patients with a surgical confirmation, the sensitivity, specificity, positive and negative predictive values, and accuracy values were 100%, 33.3%, 75.0%, 100%, and 77.7%, respectively for convex probe endobronchial ultrasound and 66.6%, 33.3%, 66.6%, 33.3%, and 55.5%, respectively for computed tomography. CONCLUSION: Convex probe endobronchial ultrasound can be used to detect vascular invasion alone or in conjunction with contrast-enhanced computed tomography. Hence, a T4 lesion would be better differentiated from T3 in clinical staging of lung cancer.

Single-station skip-N2 disease: good prognosis in resected non-small-cell lung cancer (long-term results in skip-N2 disease).

OBJECTIVES: Pathological N2 (pN2) involvement has a negative impact on prognosis in patients operated on due to non-small-cell lung cancer (NSCLC). pN2 disease may cause skip (pN0N2) or non-skip (pN1N2) metastases with pathological N1 (pN1) involvement. The effect of pN2 subgroups on prognosis is still controversial. We analysed the effect of pN1 disease and single-station pN2 disease subgroups on survival outcomes. METHODS: The medical records of patients who underwent anatomical lung resection due to NSCLC at a single centre between January 2007 and January 2017 were prospectively collected and retrospectively analysed. Operative mortality, sublobar resection, Stage IV disease, incomplete resection and carcinoid tumour were considered exclusion criteria. After histopathological examination, the prognosis of patients with pN1, pN0N2 and pN1N2 was compared statistically. Univariable and multivariable analyses were made to define independent risk factors for overall survival rates. RESULTS: The mean follow-up time for 358 patients with 228 pN1 disease (63.7%), 59 pN0N2 disease (16.5%) and 71 pN1N2 disease (19.8%) was 40.4 ± 30.4 months. Median and 5-year overall survival rates for pN1, pN0N2 and pN1N2 diseases were 73.6 months [95% confidence interval (CI) 55.5-91.7] and 54.1%, 60.3 months (95% CI 26.8-93.8) and 51.2%, 20.8 months (95% CI 16.1-25.5) and 21.5%, respectively. The survival CIs of pN1 and pN0N2 diseases were similar, and the survival rates of these 2 groups were significantly better than those with pN1N2 (P < 0.001, P = 0.001, respectively). In multivariable analysis, patients over the age of 60 [hazard ratio (HR) 2.13, P < 0.001], patients not receiving adjuvant therapy (HR 1.52, P = 0.01) and patients with pN1N2 disease (HR 2.91, P < 0.001) had a poor prognosis. CONCLUSIONS: Advanced age, not receiving adjuvant therapy and having pN1N2 disease are negative prognostic factors in patients with nodal involvement who underwent curative resection due to NSCLC. The overall survival and recurrence-free survival rates of pN1 disease and single-station pN0N2 disease are similar, and they have significantly better survival rates than pN1N2 disease. Based on these results, surgical treatment may be considered an appropriate choice in patients with histopathologically diagnosed single-station skip-N2 disease.

Postpneumonectomy bronchopleural fistula in non-small cell lung cancer patients: incidence, survival, mortality, and treatment analysis.

PURPOSE: Bronchopleural fistula (BPF) is a catastrophic complication after pneumonectomy, still associated with high mortality. We reviewed our recent experience of managing BPF, particularly after right pneumonectomy for non-small cell lung cancer (NSCLC), and analyzed our findings. METHODS: A total of 436 patients underwent pneumonectomy for NSCLC in our department between January 2000 and June 2017. BPF developed during follow-up in 47 of these patients, who are the subjects of this retrospective analysis. RESULTS: The overall incidence of BPF was 10.8% (47/436), being 22.8% (33/145) after right pneumonectomy and 4.8% (14/291) after left pneumonectomy (P = 0.0001). The incidence of BPF in patients with a history of tuberculosis was 33.3% (6/18; P = 0.008). The fistula healed in 48.9% (23/47) of the patients and the rate of mortality caused by the fistula was 19.1% (9/47). CONCLUSIONS: The side of the pneumonectomy and previous tuberculosis were the two most important risk factors independent of the bronchial closure methods. The incidence of BPF was much higher after right pneumonectomy than after left pneumonectomy. The high mortality and morbidity rates show that the treatment of BPF is still not satisfactory.

Rethoracotomy for early complications: A marker for increased morbidity and mortality.

BACKGROUND: This study aims to examine the indications, timing and risk factors of rethoracotomy, analyze the postoperative results, and give suggestions to reduce the risks. METHODS: A total of 3,292 patients operated via thoracotomy between January 2006 and January 2017 were evaluated retrospectively. Demographic data, initial operative indications, surgical procedures, indications for rethoracotomy and preoperative risk factors, intraoperative findings and surgical methods, timing of rethoracotomy, morbidity and mortality results were analyzed of 66 patients (60 males, 6 females; mean age 59.4±12.4 years; range, 17 to 80 years) who were performed rethoracotomy before being discharged. Rethoracotomies performed within 72 hours after the first operation constituted the early and those performed after 72 hours constituted the late rethoracotomy group. RESULTS: Rethoracotomy was performed in average 4.7 days (range, 1 to 17 days). Early rethoracotomy was performed on 42 patients (1.3%) and 38 (90.4%) of these were due to hemorrhage. The most frequent indication for rethoracotomy was hemorrhage (n=41, 1.2%), followed by bronchopleural fistula (n=17, 0.5%). The other indications were chylothorax, lobe torsion, parenchymal air leak and collapse, and diaphragmatic laceration. Eight patients had rib fractures and all of these patients were over the age of 60. Eight patients who were performed rethoracotomy due to hemorrhage were using antiaggregant drugs. The postoperative morbidity and mortality rates were 33.3% (n=22) and 24.2% (n=16), respectively. CONCLUSION: Rethoracotomy still has high morbidity and mortality rates. The main cause of rethoracotomy performed due to hemorrhage may be rib fractures or antiaggregant drugs. The most remarkable indications of rethoracotomy are hemorrhage and bronchopleural fistula.

Completion pneumonectomy: Indications and outcomes in non-small cell lung cancer.

BACKGROUND: This retrospective single-center study aims to review the indications and outcomes of completion pneumonectomy after primary resection due to non-small cell lung cancer. METHODS: Of a total of 452 patients who underwent pneumonectomy between January 2004 and August 2017 for non-small cell lung cancer, 29 (24 males, 5 females; mean age 59.9±7.1 years; range, 45 to 72 years) were performed completion pneumonectomy. Patients" indications, factors affecting early and late-term outcomes, operative mortality and survival rates were analyzed. RESULTS: Operative mortality rate was 24.1%, including two intraoperative and five postoperative deaths. Complication rate was 44.8% and the most frequent complication was bronchopleural fistula with 24.1%. Study population was divided into two groups. While elective completion pneumonectomy group (n=19) consisted of recurrent malignant tumor patients, rescue completion pneumonectomy group (n=10) consisted of patients performed urgent pneumonectomy due to a bronchopulmonary complication developing after an anatomic lung resection. The morbidity and mortality rates for elective completion pneumonectomy and rescue completion pneumonectomy were 26.3% and 21.1%; and 70% and 30%, respectively. The morbidity for rescue completion pneumonectomy was significantly higher than elective completion pneumonectomy (p=0.016). Advanced age and presence of any preoperative risk (comorbidity and neoadjuvant treatment) were related to higher operative mortality (p=0.019 and p=0.049, respectively). The median survival after completion pneumonectomy was 19.5 months (95% confidence interval 17.2 to 21.9 months). CONCLUSION: The morbidity and mortality rates of completion pneumonectomy are higher than standard pneumonectomy. Rescue completion pneumonectomy is related to higher postoperative risk, but has better survival. The most significant complication after completion pneumonectomy is bronchopleural fistula. Advanced age and presence of any preoperative risk are related to statistically significantly higher mortality in completion pneumonectomy. Nevertheless, completion pneumonectomy is still a significant treatment option in selected patients.