Propensity score analysis comparing survival between definitive chemoradiotherapy and esophagectomy with adjuvant chemoradiotherapy in patients with esophageal squamous cell carcinoma.

INTRODUCTION: The purpose of the current study is to compare definitive chemoradiotherapy and esophagectomy with adjuvant chemoradiotherapy in patients with cT1-3/N0-3 esophageal squamous cell carcinoma in survival. METHODS: Records from 2008 to 2014 of 4931 patients with clinical T1-3/N0-3 esophageal squamous cell carcinoma receiving definitive chemoradiotherapy or esophagectomy with adjuvant chemoradiotherapy were obtained from the Taiwan Cancer Registry. Univariable and multivariable analyses were performed and propensity score matching was used to minimize the bias. Overall survival was compared between definitive chemoradiotherapy and esophagectomy with adjuvant chemoradiotherapy, and also in the three different clinical stages. RESULTS: Definitive chemoradiotherapy was performed on 4381 patients, and 550 patients received esophagectomy adjuvant chemoradiotherapy. Each group produced 456 patients for comparison after propensity score matching. The 1-year, 2-year, and 3-year overall survival rates for matched patients in with definitive chemoradiotherapy group were 57.18%, 31.92%, and 23.8%. The 1-year, 2-year, and 3-year overall survival rates for matched patients treated in the esophagectomy with adjuvant chemoradiotherapy group were 72.35%, 45.74%, and 34.04%(p<0.0001). In multivariable analysis, treatment modality was an independent prognostic factor. Esophagectomy with adjuvant chemoradiotherapy provided better survival outcome than definitive chemoradiotherapy for patients with clinical stage II/III disease. As for patients with clinical stage I disease, there was no significant survival difference between definitive chemoradiotherapy and esophagectomy with adjuvant chemoradiotherapy. CONCLUSIONS: Esophagectomy with adjuvant chemoradiotherapy provided better survival than definitive chemoradiotherapy in clinical II/III esophageal squamous cell carcinoma. However, more data are needed to conduct a convincing conclusion in clinical stage I patients.

Bilateral lung nodules resection by image-guided video-assisted thoracoscopic surgery: a case series.

BACKGROUND: We demonstrated the safety and feasibility of image-guided video-assisted thoracoscopic surgery (iVATS) of bilateral lung lesions in a hybrid operating room. METHODS: This study was a retrospective analysis of a case series. A total of 7 patients with 15 small lung nodules underwent bilateral iVATS between July 2018 and May 2019. All procedures were completed within a single anesthesia procedure and performed in a hybrid operating room that had a cone-beam computed tomography (CT) apparatus equipped with a laser navigation system. The lesion characteristics, operation methods, and peri-operative clinical outcomes were summarized. RESULTS: A total of 7 patients with 15 resected lung nodules were analyzed. The most common pathological result of our bilateral iVATS was metastasis. The median length of hospital stay was 5 days (range from 3 to 10 days). The median right chest tube duration was 2 days (range from 1 to 8 days), and the median left chest tube duration was 3 days (range from 2 to 5 days). Only one patient had a complication during his hospitalization period. There was no surgery-related mortality observed. CONCLUSIONS: For bilateral pulmonary nodules, the iVATS procedure seems to be a feasible and cost-effective approach.

Image-guided video-assisted thoracoscopic surgery with Artis Pheno for pulmonary nodule resection.

BACKGROUND: One challenging aspect of video-assisted thoracoscopic surgery (VATS) is finding the small pulmonary lung nodules for resection. Pre-operative localization of nodules is important for resection. Recently, image-guided VATS (iVATS) in a hybrid room has received attention. Our study aims to compare pros and cons between traditional CT room localization and iVATS localization with Artis Pheno. METHODS: This study was a retrospective analysis in our institute (Changhua Christian Hospital, Changhua). Patients with pulmonary nodules who received localization between January 2018 and December 2018 were included in the study. There were 126 patients included in the study. Among these, 63 patients received localization in a CT room and the other 63 patients received iVATS. We measured the time from localization to skin incision, success rate, complication rate, operation time, blood loss and length of hospital stay. RESULTS: Time from localization to skin incision was significantly shorter in the iVATS group than in the CT room group (23.57 vs. 372.11 min, P<0.001). The CT room group had a significantly higher complication rate than the iVATS group (n=49, 77.8% vs. n=2, 3.2%, P<0.001). There were no significant differences in operation methods, operation time, blood loss and length of hospital stay. CONCLUSIONS: iVATS provides shorter time from localization to skin incision and fewer complications than CT room localization.

Comparison of Treatment Strategies for Patients With Clinical Stage T1-3/N2 Lung Cancer.

BACKGROUND: The therapeutic strategies for clinical stage T1-3N2 (cT1-3N2) lung cancer are controversial. For operable tumors, treatment can vary by center, region, and continent. This study aimed to identify the optimal therapeutic method and type of surgical strategy for cT1-3N2 lung cancer. METHODS: This retrospective evaluation analyzed the records of 17,954 patients with cT1-3N2 lung cancer treated in 2010 through 2015 from the SEER database. The effects of different therapeutic methods and types of surgical strategies on overall survival (OS) were assessed. Univariate and multivariate analyses were performed using a Cox proportional hazards model. RESULTS: The 5-year OS rates were 27.7% for patients with T1N2 disease, 21.8% for those with T2N2 disease, and 19.9% for T3N2 disease. Neoadjuvant therapy plus operation (OP) plus adjuvant therapy, and OP plus adjuvant therapy, provided better 5-year OS rates than OP alone or concurrent chemoradiotherapy (34.1%, 37.7%, 29.3%, and 16.1%, respectively). In the T1N2, T2N2, and T3N2 groups, lobectomy provided better 5-year OS than pneumonectomy, sublobectomy, and no surgery. Both univariate and multivariate analyses showed that young age, female sex, well-differentiated histologic grade, adenocarcinoma cell type, neoadjuvant and adjuvant therapy, lobectomy, and T1 stage were statistically associated with better 5-year OS rates. CONCLUSIONS: In cT1-3N2 lung cancer, multimodal treatments tended to provide better 5-year OS than OP alone or concurrent chemoradiotherapy. In addition, lobectomy was associated with better survival than other operative methods.

The comparison between adenocarcinoma and squamous cell carcinoma in lung cancer patients.

BACKGROUND: There are several studies comparing the difference between adenocarcinoma (AC) and squamous cell carcinoma (SqCC) of lung cancer. However, seldom studies compare the different overall survival (OS) between AC and SqCC at same clinical or pathological stage. The aim of the study was to investigate the 5-year OS between AC and SqCC groups. METHODS: Data were obtained from the Taiwan Society of Cancer Registry. There were 48,296 non-small cell lung cancer (NSCLC) patients analyzed between 2009 and 2014 in this retrospective study. We analyzed both the AC and SqCC groups by age, gender, smoking status, Charlson co-morbidity index (CCI) score, clinical TNM stage, pathological stage, tumor location, histologic grade, pleura invasion, performance status, treatment, stage-specific 5-year OS rate in each clinical stage I-IV and causes of death. We used propensity score matching to reduce the bias. RESULTS: The AC and SqCC groups are significantly different in age, gender, smoking status, CCI score, clinical TNM stage, pathological stage, tumor location, histologic grade, pleura invasion, performance status, treatment, stage-specific 5-year OS rate in each clinical stage and causes of death (p < 0.0001). The stage-specific 5-year OS rates between AC and SqCC were 79% vs. 47% in stage I; 50% vs. 32% in stage II; 27% vs. 13% in stage III; 6% vs. 2% in stage IV, respectively (all p values < 0.0001). CONCLUSIONS: AC and SqCC have significantly different outcomes in lung cancer. We suggest that these two different cancers should be analyzed separately to provide more precise outcomes in the future.

Comparison Between Esophagectomy and Definitive Chemoradiotherapy in Patients With Esophageal Cancer.

BACKGROUND: This study compared survival between definitive chemoradiotherapy (CRT) and esophagectomy alone among patients with locoregional esophageal squamous cell carcinoma (SCC). METHODS: Data were obtained from the Taiwan Cancer Registry between 2008 and 2014. Included were 5,487 patients with clinical I, II, or III esophageal SCC who received definitive CRT or esophagectomy alone. Patients were stratified according to clinical stage. Overall survival was compared between patients treated with definitive CRT versus esophagectomy alone, and between patients in the three different clinical stages. Propensity-matched analysis along with univariate and multivariate analysis were performed. RESULTS: Treatment was with definitive CRT in 4,251 patients (77.50%) and esophagectomy alone in 1,236 (22.50%). Propensity score matching produced 1,020 patients for comparison. The overall survival rates at 1, 2, and 3 years were 60.92%, 34.96%, and 26.14%, respectively, for propensity-matched patients treated with definitive CRT and were 71.15%, 56.50%, and 46.17%, respectively, for propensity-matched patients treated with esophagectomy alone (p < 0.001). Multivariate analysis showed treatment strategy was an independent prognostic factor. Esophagectomy alone was associated with significantly better overall survival than definitive CRT for patients with clinical stage I/II disease. There was no survival risk difference between definitive CRT and esophagectomy only for patients with clinical stage III disease. CONCLUSIONS: Esophagectomy alone could provide better survival than definitive CRT for patients with clinical stage I/II esophageal SCC. However, definitive CRT and esophagectomy yield similar overall survival rates in clinical stage III patients.

Survival Impact of Total Resected Lymph Nodes in Esophageal Cancer Patients With and Without Neoadjuvant Chemoradiation.

BACKGROUND: Current esophageal treatment guidelines suggest that, when more than 15 lymph nodes are detected, dissection should be done as the minimum requirement for staging in esophageal squamous cell carcinoma (ESCC) patients undergoing esophagectomy without induction chemoradiotherapy (CRT). However, for neoadjuvant CRT, there is limited information. We sought to clarify the role of lymphadenectomy in ESCC patients with and without neoadjuvant CRT. PATIENTS AND METHODS: Data on 3156 ESCC patients receiving esophagectomy with (group 1, n = 1399) and without (group 2, n = 1757) neoadjuvant CRT between 2008 and 2014 were collected from a national cancer registry in Taiwan. The impact of the resected lymph nodes on overall survival was assessed according to pathologic stages. A Cox regression model was used to identify prognostic factors for overall survival. RESULTS: Five-year overall survival rates were 35.6% for the entire group, 30.32% for group 1, and 39.55% for group 2 (p < 0.0001 for group 1 vs group 2). The best cutoff value was 21 lymph nodes in both group 1 and group 2. In group 1, the independent prognostic factors included age ≥ 54 years, clinical N status, y-pathologic T, y-pathologic N, y-pathologic stage, grade, location, margin status, esophagectomy (thoracoscopic vs open), and number of total resected lymph nodes (≤ 21 vs > 21). For group 2, the independent prognostic factors were gender, clinical stage, pathologic T, pathologic N, tumor length, grade, and margin status. CONCLUSIONS: Extent of lymphadenectomy was associated with survival in patients with neoadjuvant CRT followed by esophagectomy. The optimum lymphadenectomy should be modulated by pathologic stage.

Effects and mechanisms of betulinic acid on improving EGFR TKI-resistance of lung cancer cells.

Epidermal growth factor receptor (EGFR) mutations have been identified in approximately 55% of lung cancer patients in Taiwan. Gefitinib (Iressa) and Erlotinib (Tarceva) are the first-generation targeting drugs to patients with EGFR gene mutants a work by inhibiting tyrosine kinase activity. However, resistance in EGFR-mutated patients to first-generation tyrosine kinase inhibitor (TKI) therapy after 8-11 months of treatment has occurred. Betulinic acid (BetA) is a pentacyclic triterpenoid natural product derived from widespread plants. BetA has been reported to have a cytotoxic effect in several cancers. The purpose of this study is to investigate the effects and mechanisms of BetA on dampening EGFR TKI-resistance of lung cancer cells. Our study has demonstrated by MTT assay that combining BetA and an EGFR TKI increased the cytotoxicity against EGFR TKI-resistance lung cancer cells. Based on flow cytometry, combination treatments of BetA with an EGFR TKI enhanced Sub-G1 accumulation, induced apoptosis and induced mitochondrial membrane potential loss. Using western blotting, BetA and EGFR TKI combined treatments inhibited cell cycle related protein and triggered apoptosis- and autophagy- related protein expression. Taken together, our data suggests that a target therapy combining BetA with an EGFR TKI improves drug efficacy in EGFR TKI-resistant lung cancer cells.

Esophageal squamous cell carcinoma and prognosis in Taiwan.

The prognosis of esophageal squamous cell carcinoma is poor. In order to find out appropriate treatment for each group of patients, we aim to examine the prognostic factors influencing survival for esophageal cancer patients in Taiwan. Data were obtained from the Taiwan Society of Cancer Registry. There were 14,394 esophageal cancer patients analyzed between 2008 and 2014 in this retrospective review. The impact of the clinicopathologic factors on overall survival was assessed. The following clinic-pathologic factors were included to analyses: age, sex, tumor location, tumor length, histologic grade, clinical T, clinical N, clinical M, clinical stage, and all therapeutic methods within 3 months after diagnosis. The 5-year survival rate was 16.8%, with a median survival of 343 days. The distribution of patients by their clinical stage is as follows: stage 0 (n = 162; 1.1%); stage I (n = 964; 6.7%); stage II (n = 2392; 16.6%); stage III (n = 6636; 46.1%); and stage IV (n = 3661; 25.4%). In the multivariate analysis, age, sex, tumor location, tumor length, clinical T, clinical N, clinical M, and treatment remained independent prognostic factors. Our data indicated that age, sex, tumor location, tumor length, clinical T, clinical N, clinical M, and treatment remained independent prognostic factors. Patients who could receive surgery had significantly better outcomes.

Thoracoscopic Tracheal Resection and Reconstruction With Single-Incision Method.

Tracheal resection and reconstruction are traditionally approached with a right lateral thoracotomy or a median sternotomy. The thoracoscopic approach is usually applied in lung resection surgery in most hospitals but seldom used in tracheal resection. Three or more incisions are usually created during a thoracoscopic tracheal resection. We prescribed a method of single-incision thoracoscopic tracheal resection and reconstruction in a case of squamous cell carcinoma of the right tracheal wall.

Thoracoscopic plication for a huge thoracic meningocele in a patient with neurofibromatosis.

Intrathoracic meningoceles associated with neurofibromatosis type I are rare, and the optimal treatment is still unknown. Herein, we present the case of a 48-year-old Asian female with a huge thoracic meningocele associated with cutaneous neurofibromatosis type I and kyphoscoliosis of the thoracic spine. The large thoracic meningocele was successfully treated through thoracoscopic plication.

Tracheomediastinal fistula caused by non-Hodgkin's lymphoma.

Non-Hodgkin's lymphoma involving the tracheobronchial tree is uncommon. A 60-year-old man presented with severe cough for two months. Bronchoscopy disclosed an ulcerative lesion at the lower trachea and carina with anterior tracheomediastinal fistula, and biopsy revealed tracheal wall B-cell lymphoma. After chemo-radiotherapy, the tracheomediastinal fistula healed, but eight months later, tracheal stenosis was diagnosed by bronchoscopy. A self-expansible metallic stent was placed, which successfully maintained the airway.

Lung abscess predicts the surgical outcome in patients with pleural empyema.

OBJECTIVES: Most cases of pleural empyema are caused by pulmonary infections, which are usually combined with pneumonia or lung abscess. The mortality of patients with pleural empyema remains high (up to 20%). It also contributes to higher hospital costs and longer hospital stays. We studied pleural empyema with combined lung abscess to determine if abscess was associated with mortality. METHODS: From January 2004 to December 2006, we retrospectively reviewed 259 patients diagnosed with pleural empyema who received thoracscopic decortications of the pleura in a single medical center. We evaluated their clinical data and analyzed their chest computed tomography scans. Outcomes of pleural empyema were compared between groups with and without lung abscess. RESULTS: Twenty-two pleural empyema patients had lung abscesses. Clinical data showed significantly higher incidences in the lung abscess group of pre-operative leukocytosis, need for an intensive care unit stay and mortality. CONCLUSION: Patients with pleural empyema and lung abscess have higher intensive care unit admission rate, higher mortality during 30 days and overall mortality than patients with pleural empyema. The odds ratio of lung abscess is 4.685. Physician shall pay more attention on high risk patient of lung abscess for early detection and management.