The Incidence and Effect of Different Organ Metastasis on the Prognosis of NSCLC.

OBJECTIVE: The aim of this study was to explore the effect of different organ metastasis on the prognosis of non-small cell lung cancer (NSCLC). METHODS: Patients with distant metastatic NSCLC were selected from Surveillance, Epidemiology, and End Results database during 2016 to 2019. The incidence of different organ metastasis and their association with clinicopathological factors were explored. Overall survival (OS) and lung cancer-specific survival (LCSS) for metastatic NSCLC were calculated, and multivariate Cox regression analysis was performed with a nomogram for OS being constructed based on Cox regression. RESULTS: Total 26,210 patients with distant metastatic NSCLC were included in this study. Around 48.9% of the metastatic NSCLC were multiple-organ metastasis and bone was the most commonly involved organ (44.4%). For patients with single-organ metastasis, the prognosis for lung or distant lymph nodes (LNs) metastasis was better than others (with median OS of 15 and 16 months for lung and distant LNs metastasis, respectively), and liver metastasis resulted in the worst prognosis with median OS of 8 months. A nomogram was constructed to visualize Cox regression model, along with the receiver operating characteristic (ROC) curve demonstrated good discrimination for the predictive model with 1- and 2-year area under the curve of ROC of 0.687 and 0.702, respectively. CONCLUSION: The prognosis of NSCLC patients with distant metastasis was poor. Liver metastasis results in the worst prognosis among the single-organ metastasis. The nomogram developed based on the Cox regression model has provided a useful tool to estimate the probability of OS of the metastatic NSCLC.

Reconstruction of the Esophagus with Sternohyoid Flap after Resection of a Large Cervical Esophageal Leiomyosarcoma.

PURPOSE: Reconstruction of the esophagus with sternohyoid muscle after enucleation of the cervical esophageal leiomyosarcoma (ELS) was rarely reported. METHODS: A case of 55-year-old female with a large leiomyosarcoma in the cervical esophagus was reported. The tumor was enucleated, and the defect of the esophagus was patched with left sternohyoid muscle flap. RESULTS: The patient recovered uneventfully after surgery. She has not had any discomfort with swallowing since surgery, and nowadays, there is not any recurrence and metastasis being detected. CONCLUSION: It is minimal invasive and simple to enucleate the cervical ELS and patch the defect of esophagus with sternohyoid muscle flap. For some selected patients, this method may be a promising surgical procedure to achieve both good swallowing function and satisfying prognosis.

Propensity Score Matching Analysis for the Role of Surgery in Small Cell Lung Cancer.

BACKGROUND: The role of surgery for small cell lung cancer (SCLC) is not clear. We aimed to evaluate this issue using a population-based database. METHODS: Patients diagnosed between 2004 and 2014 with SCLC staged T1-4 N0-2 M0 disease were retrieved from the Surveillance, Epidemiology, and End Results database. Propensity score matching (PSM) was used to reduce bias between the surgical and nonsurgical patient groups. The Kaplan-Meier method and Cox regression analysis were used to compare overall survival (OS) for the matched patients. RESULTS: A total of 8,811 patients were retrieved, including 863 patients who underwent surgical resection. After 1:1 PSM, a matched cohort with 1,562 patients was generated. In the matched cohort, surgery was associated with 5-year OS improvement (from 16.8 to 36.7%, p < 0.001) and lung cancer-specific survival improvement (from 21.6 to 43.2%, p < 0.001). Survival benefits of surgery were significant in all subgroups, including N1-2 disease, except for patients with a tumor size >5.0 cm or T3 disease. CONCLUSIONS: Patients with SCLC of limited stage can benefit from surgery, including N1-2 disease. However, patients with a tumor size >5.0 cm or advanced T stage may be unable to benefit from surgery.

Comparison of treatment strategies for patients with limited-stage small cell lung cancer who received chemotherapy.

BACKGROUND: The standard care for limited-stage small cell lung cancer (SCLC) is unclear. The purpose of this study is to compare the outcome for patients receiving chemotherapy alone, chemotherapy plus surgery (CS), chemotherapy plus radiation (CR), or chemotherapy plus surgery and radiation (CSR) for limited-stage SCLC. METHODS: Patients with T1-4N0-2M0 SCLC who received chemotherapy from 2004 to 2014 were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. The overall survival (OS) of these patients, stratified by different stage, was compared in accordance to the method of receiving different treatments using Kaplan-Meier method and Cox regression analysis. RESULTS: A total of 7,204 patients were included, where 1,347 (18.7%) patients received chemotherapy alone, 296 (4.1%) undergone CS, 5,296 (73.5%) patients were subjected to CR and 267 (3.7%) patients were managed by the three combination of CSR. Chemotherapy alone was associated with the worst survival in comparison to the other two method of combination i.e., chemotherapy with radiation or surgery. When compared with CR, CS had no survival benefit in patients with stage in excess of T1-2N0 disease, but was associated with improved 5-year OS in patients with T1-2N0 disease, which ranged from 29.1% to 54.3% (P<0.001). For patients with T1-2N2 disease who received CSR demonstrated superior OS over those who received CR (P=0.004) or CS (P=0.036). Cox regression analysis showed CS was associated with improved OS when compared with CR in patients with N0 disease (HR, 0.54; 95% CI, 0.43-0.68; P=0.000) and CSR was associated with better OS in comparison with CR in patients with N2 disease (HR, 0.71; 95% CI, 0.55-0.93; P=0.013). CONCLUSIONS: Patients with limited-stage SCLC can benefit from local treatment such as surgery, radiation, and surgery plus radiation. For patients with N0 disease, CS was associated with improved survival in comparison to CR. If N2 was identified after surgery, radiation may be added to improve OS.

Effect of second primary cancer on the prognosis of patients with non-small cell lung cancer.

BACKGROUND: Second primary cancer (SPC) is not a rare event for patients with non-small cell lung cancer (NSCLC), especially for those who survive for a longer period of time. This study was aimed to explore the effects of SPC on the survival of NSLCL patients. METHODS: A total of 241,805 patients with primary NSCLC were identified between 2004 and 2014 from the Surveillance, Epidemiology, and End Results (SEER) database. The incidence of SPC and its effect on the overall survival (OS) and lung cancer-specific survival (LCSS) was explored and analyzed using Cox regression model with SPC being treated as a time-dependent covariate. RESULTS: The incidence of SPCs after the diagnosis of NSCLC was 6.4%, with the second primary lung cancer being the most common one (45.1%). About half of the SPCs (50.7%) occurred during the first year after the diagnosis of NSCLC. It seemed that patients who developed SPC late in the follow-up period tended to have poor prognosis. Multivariable analysis with Cox regression showed that the occurrence of SPC was a poor prognostic factor for patients with NSCLC [hazard ratio (HR), 1.298; 95% confidence interval (CI), 1.270-1.326; P=0.000], and it increased the risk of LCSS (versus no SPC, HR, 1.094; 95% CI, 1.066-1.123; P=0.000). CONCLUSIONS: The occurrence of SPC after the diagnosis of NSCLC was not a rare event, and it indicated a poorer prognosis compared with patients without it. During the follow-up, attention should be paid to the screening of SPC especially the second primary lung cancer, and a rational surveillance policy should be formed and implemented.

[Comparison of the Survival Time in the Non-small Cell Lung Cancer Patients with Different Organ Metastasis].

BACKGROUND: The purpose of this study is to compare the survival time of non-small cell lung cancer (NSCLC) patients with different organ metastasis. Among all cancers, the morbidity and mortality of lung cancer is the highest worldwide, which may caused by local recurrence and distant metastasis, and the location of metastasis may predict the prognosis of patients. METHODS: A total of 117,542 patients with NSCLC diagnosed between 2010 and 2014 were enrolled from Surveillance, Epidemiology, and End Result (SEER) databases, and the relationship between distant metastasis and survival time was retrospectively analyzed. RESULTS: Of all the 117,542 patients diagnosed with non-small cell lung cancer, 42,071 (35.8%) patients had different degrees of distant metastasis during their medical history, including 26,932 single organ metastases and 15,139 multiple organ metastases, accounting for 64.0% and 36.0% of the metastatic patients respectively. Compared with patients with no metastasis, whose median survival time was 21 months, the median survival time of patients with metastases was 7 months (lung), 6 months (brain), 5 months (bone), 4 months (liver), and 3 months (multiple organ) respectively, and the difference was significant (P<0.001, except liver vs multiple organ P=0.650); Most patients with NSCLC (88.4%) eventually died of lung cancer. CONCLUSIONS: Distant metastasis of NSCLC patients indicates poor prognosis. In NSCLC patients with single organ metastasis, the prognosis of lung metastasis is the best, and liver metastasis is the worst, and multiple organ metastasis is worse than single organ metastasis.

Alterations of Notch pathway in patients with adenoid cystic carcinoma of the trachea and its impact on survival.

INTRODUCTION: Adenoid cystic carcinoma (ACC) of the trachea lacks of well-characterized molecular markers. There is currently no specific treatment for metastatic ACC of the trachea. This study aimed to identify genomic mutations of Notch pathway and investigate the efficacy of NOTCH inhibitor in ACC of the trachea. METHODS: 73 Patients with ACC of the trachea at four institutions from 2008 to 2016 were identified. Analysis of hotspot mutations in cancer-related genes of Notch pathway was performed using next generation sequencing. Gene-expression and functional analyses were performed to study the mechanism of activation through mutation. Univariable and multivariable Cox regression models were used to predict overall survival (OS). Patient-derived xenograft (PDX) models were established and treated with NOTCH inhibitor Brontictuzumab. RESULTS: Gain-of-function mutations of the NOTCH1 gene occurred in 12 (16.4%) tumors, leading to stabilization of the intracellular cleaved form of NOTCH1 (ICN1). NOTCH1 mutation was associated with increased NOTCH1 activation and its target gene HES1. Mutations in NOTCH2 (3/73), NOTCH4 (2/73), JAG1 (1/73) and FBXW7 (2/73) were also identified in 8 (11.0%) patients. A strong inverse correlation of expression was observed between FBXW7 and HES1. NOTCH1 mutation was associated with solid subtype (P = 0.02), younger age at diagnosis (P = 0.041) and shorter overall survival (OS) (P = 0.017). NOTCH1 mutation was not an independent prognostic factor in the presence of histologic subtype and resection margin. Brontictuzumab significantly reduced tumor growth in NOTCH1-mutated PDX. CONCLUSION: NOTCH1 mutation is associated with activation of Notch pathway in ACC of the trachea. NOTCH1 is a potential target for therapeutic intervention in patients with ACC of the trachea.

An unusual case of lung abscess secondary to round pneumonia caused by recurrent Klebsiella pneumoniae strain and the role of occult metastases tumor.

Round pneumonia is an uncommon form of community-acquired pneumonia usually found in children. To this date, there has been no report on local pulmonary complications in this entity in adult patients. The present study reports a case of a 77-year-old male with lung abscess secondary to round pneumonia caused by recurrent Klebsiella pneumoniae infection accompanied by occult metastases tumor. Occult metastases may have played an important role in leading to cavity as in this present case. Further investigation regarding the relationship between recurrent infection and metastases is needed.

Sublobar resections for small-sized stage Ia lung adenocarcinoma: a Sino-Japanese multicenter study.

BACKGROUND: Segmentectomy for small-sized stage Ia non-small cell lung cancer (NSCLC) may be comparable to lobectomy regarding prognosis and local recurrence. However, the clinical results of wedge resection for such patients are still under debate. In this international multicenter study, we retrospectively studied surgical outcomes of sublobar resections for patients with small-sized stage Ia adenocarcinoma to elucidate whether wedge resection is inferior to segmentectomy for such patients. METHODS: Between March 2000 and August 2011, 173 patients underwent segmentectomy (group I), and 181 patients underwent wedge resection (group II) at three institutions in Japan and China. The tumor was defined as Ground glass opacity (GGO) type when the proportion of GGO was equal or more than 50% in HRCT, while solid type was defined as the proportion of GGO less than 50%. Clinicopathologic factors, local recurrence rate, and survival were compared. RESULTS: The two groups were similar in sex, comorbidity rate, and composition of Noguchi type. There was no in-hospital death. Postoperative morbidity rate of group I was significantly higher than that of group II (11.0% vs. 2.2%, P=0.016). Local recurrence rates were similar between group I (4.0%) and group II (4.4%), while no patient with GGO type tumors had local recurrence. Overall and lung cancer-specific survivals were of no significant difference between the two groups. Lung cancer-specific survival rates at 10 years were significantly better in patients with GGO type tumors than in those with solid type tumors (100% vs. 76.9%, P<0.001). In multivariate Cox regression analyses of lung cancer-specific survival of all patients, GGO type turned out to be an independent prognostic factor, while extent of resection did not have any influence. CONCLUSIONS: Our data suggests that sublobar resection is an acceptable procedure for small lung adenocarcinomas without nodal involvement, and wedge resection may not be inferior to segmentectomy for small GGO type tumors. Our study also demonstrates that GGO type is an independent prognostic factor of disease-free survival for small-sized (diameter ≤2.0 cm) stage Ia lung adenocarcinomas.

Causes of death and competing risk analysis of the associated factors for non-small cell lung cancer using the Surveillance, Epidemiology, and End Results database.

PURPOSE: To investigate the probability of death (POD) from any causes by time after diagnosis of non-small cell lung cancer (NSCLC) and the factors associated with survival for NSCLC patients. METHODS: A total of 202,914 patients with NSCLC from 2004 to 2013 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. The overall survival (OS) and lung cancer-specific survival (LCSS) were calculated and POD from any causes at different time periods after diagnosis was explored. The predictive factors for OS, LCSS and survival from non-lung cancer deaths were investigated using multivariate analysis with Cox proportional hazards regression and competing risk regression analysis. RESULTS: The 5- and 10-year OS were 20.4% and 11.5%, accordingly that for LCSS were 25.5% and 18.4%, respectively. Lung cancer contributed 88.3% (n = 128,402) of the deaths. The POD from lung cancer decreased with time after diagnosis. In multivariate analysis, advanced age and advanced stage of NSCLC were associated with decreased OS and LCSS. Comparing to no surgery, any kind of resection conferred lower risk of death from lung cancer and higher risk of dying from non-lung cancer conditions except lobectomy or bilobectomy, which was associated with lower risk of death from both lung cancer and non-lung cancer conditions. CONCLUSIONS: Most of the patients with NSCLC died from lung cancer. Rational surveillance and treatment policies should be made for them. Early stage and lobectomy or bilobectomy were associated with improved OS and LCSS. It is reasonable to focus on early detection and optimal surgical treatment for NSCLC.

The Prognostic Significance of Notch1 and Fatty Acid Binding Protein 7 (FABP7) Expression in Resected Tracheobronchial Adenoid Cystic Carcinoma: A Multicenter Retrospective Study.

PURPOSE: Adenoid cystic carcinoma (ACC) of the trachea and bronchus is a rare tumor. Although MYB-NFIB oncogene fusion and Notch1 mutation have been identified in ACC, little is known about the expression and clinical significance of Notch1 and its target gene fatty acid binding protein 7 (FABP7) in tracheobronchial ACC. MATERIALS AND METHODS: Primary tracheobronchial ACC that were resected between 1998 and 2014 were identified through the pathology and oncology database from five thoracic oncology centers in China. A tissue array was constructed from the patients' samples and the expressions of Notch1 and FABP7 were evaluated by immunohistochemistry. The association between the expression of both markers and survival was determined. RESULTS: Overexpression of Notch1 and FABP7, detected in 37.8% and 38.3% of 368 patients with tracheobronchial ACC, respectively, was an independent prognostic indicator for recurrencefree survival (RFS) by multivariable Cox proportional hazard model (p=0.032 and p=0.048, respectively). Overexpression of Notch1, but not of FABP7, predicted overall survival (OS) (p=0.018). When categorized into four groups according to coexpression of Notch1 and FABP7, patients with overexpression of both Notch1 and FABP7 belonged to the group with the shortest RFS and OS (p=0.01 and p=0.048, respectively). CONCLUSION: Expression of Notch1 and FABP7, and coexpression of Notch1 and FABP7, is strongly associated with poor survival in resected tracheobronchial ACC. These data are consistent with the hypothesis that poor differentiation of tracheobronchial ACC correlates with the activation of Notch signaling.

Propensity score-matching analysis of postoperative radiotherapy for stage IIIA-N2 non-small cell lung cancer using the Surveillance, Epidemiology, and End Results database.

BACKGROUND: To investigate the effects of postoperative radiotherapy (PORT) on the survival of patients with resected stage IIIA-N2 non-small cell lung cancer (NSCLC). METHODS: A total of 3,334 patients with resected stage IIIA-N2 NSCLC in 2004 to 2013 were identified in the Surveillance, Epidemiology, and End Results database and stratified according to use of PORT. Propensity score-matching (PSM) methods were used to balance the baseline characteristics of patients who did (n = 744) or did not (n = 744) undergo PORT. Overall survival (OS) and lung cancer-specific survival (LCSS) were compared between these two patient groups. RESULTS: After PSM, PORT increased OS (hazard ratio, 0.793; p = 0.001) and LCSS (hazard ratio, 0.837; p = 0.022) compared with no PORT. The OS benefit for PORT was mainly seen in patients aged <60 years (5-year OS, 35.4% versus 28.9% for PORT versus no PORT, respectively; p = 0.026) and in those who underwent lobectomy (5-year OS, 43.5% versus 34.5% for PORT versus no PORT, respectively; p = 0.001). The LCSS benefit for PORT was significant in patients undergoing lobectomy (5-year LCSS, 48.3% versus 42.3% for PORT versus no PORT, respectively; p = 0.036). CONCLUSIONS: The survival benefits of PORT were primarily observed in patients with resected stage IIIA-N2 NSCLC who were <60 years of age or had undergone lobectomy.

Extracorporeal instrument knotting technique for minimal access thoracic surgery.

Knot-tying technique is essential for surgery. We described here a novel instrument knotting technique that is simple, safe and useful in minithoracotomy. This technique was used on 14 consecutive patients that underwent selective minithoracotomy during the past half year. Both knot security and loop security could be easily achieved with this technique. No unraveling or dislodgement of the knot was noted. This method is simple, convenient and reliable to achieve secure flat square knots in limited, deep operating spaces. Its clinical advantages render it as a promising knot-tying technique that can be routinely used in a variety of thoracic surgery.

[Relationship between Expression of TGF-ß1, Smad2, Smad4 and Prognosis 
of Patients with Resected Non-small Cell Lung Cancer].

BACKGROUND AND OBJECTIVE: It has been proven that any changes of transforming growth factor ß (TGF-ß)-Smad signal transduction pathway will lead to abnormalities of signal transmission and the out of control during cell growth and differentiation, resulting in cancer development. The aim of this study is to investigate the prognostic values of TGF-ß1, Smad2 and Smad4 in resected non-small cell lung cancer (NSCLC). METHODS: The expression of TGF-ß1, Smad2, and Smad4 was evaluated by immunohistochemistry in 85 patients with NSCLC. The relationships among the expression of these proteins, clinicopathological factors, and prognosis were also analyzed. RESULTS: TGF-ß1 positive expression was significantly correlated with the late stage and lymph node involvement. No significant association existed between the expression of Smad2 and the clinicopathological characteristics. The lack of Smad4 expression was associated with the advanced tumor stage (P=0.014). Multivariate analysis indicated that lymph node involvement (P=0.001) was an independent prognostic factor in the 85 NSCLC patients. The positive expression levels of TGF-ß1 (P=0.032) and N stage (P=0.028) were demonstrated to be independent risk factors for survival among 47 lung adenocarcinoma patients. Adenocarcinoma patients with TGF-ß1 positive expression demonstrated an unfavorable survival outcome (P=0.0376). CONCLUSIONS: TGF-ß1 may be an independent predictor of survival in resected lung adenocarcinoma patients.
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γ Secretase inhibitor BMS-708163 reverses resistance to EGFR inhibitor via the PI3K/Akt pathway in lung cancer.

Lung adenocarcinoma cells harboring epidermal growth factor receptor (EGFR) mutations are sensitive to EGFR tyrosine kinase inhibitor (TKI). Acquired resistance to EGFR TKI develops after prolonged treatment. The aim of this study was to investigate the effect of the novel γ secretase inhibitor BMS-708163 on acquired resistance to the EGFR TKI gefitinib. We did not observe known mechanisms of acquired resistance to EGFR TKI, including the EGFR T790M mutation and MET gene amplification in the gefitinib-resistant PC9/AB2 cells. BMS-708163 inhibited PI3K/Akt expression and sensitized PC9/AB2 cells to gefitinib-induced cytotoxicity. In contrast, BMS-708163 had no significant effect on gefitinib sensitivity in PC9 parental cells. Combined treatment with BMS-708163 and gefitinib induced high levels of apoptosis. Our in vivo studies showed that combined treatment of gefitinib and BMS-708163 inhibited the growth of PC9/AB2 xenografts. In conclusion, our data show that combined treatment of gefitinib and γ secretase inhibitors may be useful for treating lung adenocarcinomas harboring EGFR mutations with acquired gefitinib resistance.

Notch-1 contributes to epidermal growth factor receptor tyrosine kinase inhibitor acquired resistance in non-small cell lung cancer in vitro and in vivo.

Acquired resistance to epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) occurs in non-small cell lung cancer (NSCLC) patients who initially respond to TKI treatment but whose cancer then progresses. Recent studies have shown that Notch signal is associated with drug resistance. However, the exact mechanism of Notch during acquisition of resistance to EGFR-TKI in human lung cancer remains unclear. In the present study, we showed that the expression of Notch-1 was highly upregulated in EGFR-TKI acquired resistant lung cancer cells. More importantly, Notch-1 contributed to the acquisition of the epithelial-mesenchymal transition (EMT) phenotype, which was critically associated with acquired resistance to EGFR-TKI. Silencing of Notch-1 using siRNA resulted in mesenchymal-epithelial transition (MET), which was associated with impaired invasion and anchorage-independent growth of lung cancer and resensitisation to gefitinib in acquired resistant NSCLC cells. Finally, gefitinib treatment of Balb/c nu/nu with acquired resistant lung cancer xenografts in combination with Notch inhibitor N-[N-(3,5-difluorophenacetyl)-L-alanyl]-(S)-phenylglycine t-butyl ester (DAPT) resulted in effective tumour growth retardation, with decreased proliferative activity and increased apoptotic activity. Collectively, these data suggest that Notch-1 might play a novel role in acquired resistance to gefitinib, which could be reversed by inhibiting Notch-1.

Atrial arrhythmias after pulmonary resection: the important role of pulmonary vein resection.

BACKGROUND: Atrial arrhythmias (AAs) remain one of the most common complications after pulmonary resection. The association between postoperative AAs and pulmonary vein (PV) resection has not previously been clearly elucidated. A retrospective study on this issue is reported. METHODS: A total of 125 patients were involved in this study and all the performed surgical procedures and all postoperative AAs were carefully reviewed and recorded. A univariate and multivariate analyses were utilized to clarify the effect of PV resection on postoperative AAs. RESULTS: The overall incidence of postoperative AAs was 14.4% (n = 18). A stepwise increase in the incidence of AAs was observed from none, to the inferior of PV resection only, superior PV resection only and up to both inferior and superior PV resection (0, 3.1, 14.3, and 38.5%, respectively; p = 0.000). During multivariate analysis, PV resection was identified as an independent risk factor for postoperative AAs when it was entered either as an ordinal or as a categorical variable. The area under the receiver operating characteristic curve of PV resection revealed 0.786 (95% confidence interval [CI], 0.685-0.887), which was significantly larger than the extent of pulmonary resection (0.724; 95% CI, 0.637-0.800; p = 0.015). CONCLUSION: PV resection plays an important role in the development of postoperative AAs after pulmonary resection and could be used as a good predictor for postoperative AAs.

Which is the better prognostic factor for resected non-small cell lung cancer: the number of metastatic lymph nodes or the currently used nodal stage classification?

INTRODUCTION: This retrospective study was conducted to evaluate the prognostic significance of the number of metastatic lymph nodes (nN) in resected non-small cell lung cancer (NSCLC) in comparison with the currently used pathologic nodal (pN) category in the staging system. METHODS: A total of 1659 patients who underwent potentially curative resection for NSCLC from 2000 to 2006 were included in this study. The association between the nN and survival was explored, and the results were compared with those using the location-based pN stage classification. RESULTS: The patients were divided into four categories according to the number of metastatic nodes: nN0, absence of metastatic nodes; nN1, metastasis in one to two nodes; nN2, metastasis in three to six nodes; and nN3, metastasis in seven or more nodes. The 5-year overall survival for nN0, nN1, nN2, and nN3 was 89.2%, 65.1%, 42.1%, and 22.4%, respectively (p < 0.001). The nN category could be used to subdivide pN1 and pN2 patients into two (nN1 and nN2) and three (nN1, nN2, and nN3) prognostically distinct subgroups, respectively. Multivariate analysis showed the nN category was an independent prognostic factor for resected NSCLC. The difference in overall survival between pN1 and pN2 was not significant (55.4% versus 47.8%, p = 0.245). Patients in each nN category could not be subdivided into different prognostic subgroups according to the pN classification. CONCLUSIONS: The nN category in this study was shown to be a better prognostic determinant than the location-based pN stage classification.

Evaluating community health centers in the City of Dalian, China: how satisfied are patients with the medical services provided and their health professionals?

Around 58 community health centers (CHCs) were investigated to evaluate their performance, and 372 residents were surveyed randomly about their satisfaction towards these centers. State-owned CHCs gained the least benefits and received most patient visits. Residents' opinions about health professionals working in these centers showed marked distrust due to their insufficient work experience and low education level; however, affordability, availability and access to services and drugs among CHCs generated comparatively high satisfaction. Therefore, enhancing CHCs' service delivery is a necessity to improve the quality of community doctors and nurses, increase enrolment and training programs, and augmenting hospitals' support to CHCs.

Association of perioperative fluid balance and adverse surgical outcomes in esophageal cancer and esophagogastric junction cancer.

BACKGROUND: Perioperative fluid balance and its association with surgical outcomes in patients with esophageal and esophagogastric junction cancer have not been clearly elucidated. A retrospective study of this association is reported. METHODS: A retrospective study involving 99 patients undergoing transthoracic esophagectomy or esophagogastrectomy was conducted. The intraoperative and postoperative fluid inputs and outputs as well as postoperative morbidity and mortality were recorded. Univariate analysis and multivariate logistic regression analysis were performed to clarify the effect of fluid balance on postoperative outcomes. RESULTS: There were 78 men and 21 women with an average age of 61.1 +/- 10.9 years in the study. Among them, 68 patients had esophageal cancer and 31 had esophagogastric junction cancer. The postoperative morbidity and mortality were 38.4% and 7.1%, respectively. Compared with favorable outcomes, adverse surgical outcomes were significantly related to larger fluid balance on postoperative day 1 and day 2, and to cumulative fluid balance from the intraoperative period to postoperative day 2 (605.0 +/- 931.5 mL versus 200.1 +/- 712 mL; p = 0.016; 607.8 +/- 743.9 mL versus 200.1 +/- 678.6 mL; p = 0.005; 2,818.5 +/- 1,456.5 mL versus 1,797.1 +/- 1,704.0 mL; p = 0.002, respectively). On multivariate logistic regression analysis, cumulative fluid balance from intraoperative period to postoperative day 2 was independently related to adverse surgical outcomes (odds ratio, 1.000; 95% confidence interval, 1.000 to 1.001; p = 0.014). CONCLUSIONS: The cumulative fluid balance from the intraoperative period to postoperative day 2 is a good predictor of surgical outcomes. It can be used as a prognostic tool to evaluate the risk of adverse surgical outcomes.