Search

INTRODUCTION: To analyze the feasibility and efficacy of sleeve lobectomy after neoadjuvant immunotherapy in multicenter patients with squamous cell lung cancer. METHODS: We retrospectively identified patients who received neoadjuvant immunotherapy (n = 14) or chemotherapy alone (n = 33) at five thoracic surgery centers between 2018 and 2020. The primary end point was 30-day major complications. The secondary end point was major pathologic response. Multivariate analysis was performed with a log-binomial regression model adjusting potential risk factors. RESULTS: All patients received induction therapy and underwent sleeve lobectomy without 90-day postoperative deaths. The distribution of age, sex, nutrition status, pulmonary and cardiac function, tumor stage, surgical approach, and location of the pulmonary lobe was well balanced between the two cohorts. In the immunotherapy cohort, two patients (14.3%) experienced a pulmonary major complication, whereas nine pulmonary major complications and one cardiac major complication (30.3%) occurred in the chemotherapy cohort (p = 0.302). CONCLUSIONS: Neoadjuvant immunotherapy in addition to chemotherapy did not increase 30-day risk of postoperative complications, and immunotherapy is a favorable factor affecting pathologic downstage and response. Therefore, sleeve lobectomy after induction chemoimmunotherapy appears safe and feasible.

Neoadjuvant PD-(L)1 inhibitors may be promising for locally advanced non-small cell lung cancer (NSCLC) with potential pathological and survival benefits. But severe immune-related adverse events (irAEs) may cause fatal consequences which require early identification and timely intervention. The basis for most of these adverse events is a reactive hyperactivated T-cell response to normal tissues that results in the production of high levels of CD4 T-helper cell cytokines or increased migration of cytolytic CD8 T cells in normal tissues. It is recommended that all patients receiving PD-(L)1 inhibitors routinely have thyroid function studies, complete blood counts, and liver function and metabolic panels at each treatment and at intervals of 6 to 12 weeks for the first 6 months after finishing treatment. Herein, we report a rare case who had two grade 3–4 irAEs consecutively occurring after PD-1 induction therapy and surgery. A 59-year-old man with stage IIIA squamous cell lung cancer receiving 3 cycles of neoadjuvant nab-paclitaxel, carboplatin, and nivolumab was reevaluated for resectability. The patient experienced acute serum transaminase elevation right after induction therapy. Seven days after surgery he had severe pneumonia. These two serious complications were both eventually relieved by a month long treatment of corticosteroids but not regular medicine which verified the diagnosis of irAEs. Although results of clinical trials of neoadjuvant immunotherapy are worth expecting, our case calls attention to careful surveillance and timely management of irAEs during the perioperative use of PD-(L)1 inhibitors. We also further discuss the standard use of corticosteroids for irAEs based on a review of literature.

Background The recent novel conception of neoadjuvant immunotherapy has generated interest among surgeons worldwide, especially the lack of experience involving surgical treatment for the neoadjuvant immunotherapy population. Methods Patients with non-small cell lung cancer (NSCLC), who underwent neoadjuvant immunotherapy or chemo-immunotherapy, were retrospectively collected between September 2018 and April 2020. Demographic data, pathological and clinical features, therapeutic regimens and outcome data of all individuals were collected by retrospective chart review. Operative details, information of neoadjuvant therapy, were also abstracted. Results In total, 31 patients were included in the final analysis. The patients’ median age was 61 years. In total, 29 of the patients were males, while 2 were females. Patients received a median of 3 doses before resection. The median duration from final treatment to surgery was 34 days. After neoadjuvant treatment, post-treatment computed tomography scan showed that 24 patients had partial response. In total, 12 of 31 patients had a major pathological response, 15 pathological downstaging. Three patients had no residual viable tumor. A positive surgical margin was identified in 7 cases. One or more postoperative complications occurred in 18 of all 31 patients. In total, 26 patients underwent next-generation sequencing before surgery in total. Among them, 2 patients were detected STK11 mutations, none of whom had a major pathological response by final pathological examination. Conclusions Pulmonary resection after neoadjuvant immunotherapy or chemo-immunotherapy for resectable NSCLC appears to be safe with low operative mortality and morbidity rate in the current population.

BACKGROUND: The role of surgery in combined modality therapy for selected stage IV oligometastatic (OM) non-small cell lung cancer (NSCLC) is still controversial. Tyrosine kinase inhibitors (TKIs) targeting epidermal growth factor receptor (EGFR) significantly improved the survival in adjuvant therapy in metastatic NSCLC but has rare evidence in inductive setting. This is the first case report about uniportal video-assisted thoracic surgery after induction therapy of TKI for OM-NSCLC. CASE DESCRIPTION: A 50-year-old Chinese woman presented to hospital with headache and blurred vision and was diagnosed with an intracranial tumor. The craniotomy confirmed the metastasis from primary lung cancer. Positron emission tomography/computed tomography (PET/CT) showed the mass located in the left upper lobe and left hilar lymph node involvement. Next-generation sequencing found an EGFR mutation (exon 21 p.L858R missense), and osimertinib, a third-generation TKI, was used 80 mg per day as the induction therapy due to the EGFR mutation detected from the metastatic tumor. A favorable treatment response was observed of the lung tumor with lymph node regression, followed by uniportal thoracoscopic left upper lobectomy and systematic lymphadenectomy. The postoperative pathology evaluated both the lung lesion and lymph nodes and confirmed the OM status of this patient. No complications were observed and postoperative osimertinib 80 mg per day continued. CONCLUSIONS: Our case suggests that the role of surgery should be appropriately reevaluated for EGFR-mutated OM-NSCLC with the emerging development of EGFR-TKI.

Background Stage III non-small cell lung cancer (NSCLC) encompasses a variety of local invasion and nodal involvement and its management is still under debate. Immune checkpoint inhibitors (ICIs) have been shown to improve the survival in metastatic NSCLC, but are far from being accepted as an induction therapy. Methods We retrospectively collected data of all patients who received induction ICIs (nivolumab or pembrolizumab) and chemotherapy (carboplatin with paclitaxel) for stage IIIA-B NSCLC followed by surgery in our unit between January 2019 and March 2020. Results Of the 12 patients (9 men, 3 women) 6 had a squamous cell carcinoma, 4 had adenocarcinoma, 1 had an undifferentiated adenocarcinoma, and 1 had adeno-squamous carcinoma. Seven patients had stage IIIA disease and 5 had stage IIIB. After induction therapy, 6 patients had stable disease and 6 had a partial response. The median tumor reduction was 3.05 cm (range, 2.30-8.70 cm). All patients, but 1 due to the COVID-19 outbreak, had no delay in surgery. Two patients experienced myelosuppression after induction therapy, 2 had minor adverse effects. Three patients had postoperative complications not related to the induction therapy. All patients had a pathologic response: 5 complete, 4 major, and 3 partial. Eleven patients are alive (mean follow-up, 18.17 ± 4.97 months) and free of disease. Conclusions Induction ICI chemotherapy may be a valid treatment in patients with locally advanced NSCLC, providing important tumor downstaging and rendering patients operable. In our experience patients had few side effects and a good pathologic response.

(1) Background: Despite the fact that robotic-assisted thoracoscopic lobectomy (RATL) has been prevalently applied for early stage non-small cell lung cancer (NSCLC), its superiorities are still to be fully revealed for patients with metastatic N1 lymph nodes (LNs). We aim to evaluate the advantages of RATL for N1 NSCLC. (2) Methods: This retrospective study identified consecutive pathological N1 NSCLC patients undergoing RATL, video-assisted thoracoscopic lobectomy (VATL), or open lobectomy (OL) in Shanghai Chest Hospital between 2014 and 2020. Further, perioperative and oncological outcomes were investigated. (3) Results: A total of 855 cases (70 RATL, 435 VATL, and 350 OL) were included. Propensity score matching resulted in 70, 140, and 140 cases in the RATL, VATL, and OL groups, respectively. RATL led to (1) the shortest surgical time (p = 0.005) and lowest intraoperative blood loss (p < 0.001); (2) the shortest ICU (p < 0.001) and postsurgical hospital (p < 0.001) stays as well as chest tube duration (p < 0.001); and (3) the lowest morbidities of postsurgical complications (p = 0.016). Moreover, RATL dissected more N1 (p = 0.027), more N1 + N2 (p = 0.027) LNs, and led to a higher upstaging incidence rate (p < 0.050) than VATL. Finally, RATL achieved a comparable 5-year disease-free and overall survival in relation to VATL and OL. (4) Conclusions: RATL led to the most optimal perioperative outcomes among the three surgical approaches and showed superiority in assessing N1 and total LNs over VATL, though it did achieve comparable oncological outcomes in relation to VATL and OL for N1 NSCLC patients.

Background: Uni-portal video-assisted thoracoscopic surgery (VATS) has become a popular type of thoracic surgery. However, improvements to the closure of the single drainage tube hole are still in need. Methods: From February 2019 to May 2019, we included 50 patients who received uni-portal VATS for lung disease or mediastinal disease and simple continuous suture to strengthen the closure of intra- muscle combined with removal-free stitches on the skin. Follow-up items included incision length, chest tube drainage amount, chest tube drainage time, incision effusion leakage, postoperative subcutaneous emphysema, postoperative pain score. Results: A total of 50 patients were included in this study, including 23 males and 27 females, with an average age of 60.08±9.73 years old. The mean drainage on the first day after operation was 236.56±141.50 mL, while the mean pain score on the first day after operation was 4.16±1.70. Among 50 patients, only two cases of subcutaneous emphysema occurred. Conclusions: Applying innovative simple continuous suture to strengthen the closure of intra-muscle combined with removal-free stitches on the skin into the closure of uni-portal VATS is safe and feasible.

BACKGROUND: Tumor spread through air spaces (STAS) was defined as a unique tumor invasion pattern in adenocarcinoma (ADC) by The World Health Organization Classification of Lung Tumors in 2015. Since then, STAS had been shown to be associated with local recurrence and poor survival results, as the typical signature and potential mechanisms of STAS remained unclear. Our objectives were to comprehensively demonstrate the clinicopathological and genetic signatures in STAS-positive lung cancer patients. METHODS: The clinicopathological and gene alteration characteristics of 878 STAS-positive lung cancer patients were presented. Associations between parameters were evaluated using the Chi-square test, Fisher’s exact test, and logistic regression. The capture-based targeted next generation sequencing (NGS) with a platform of 68 lung cancer-related genes was conducted in 139 cases, and the mutational spectrum was summarized. RESULTS: STAS was identified in 391 female and 481 male patients, of which ADC accounted for the majority of cases (92.6%). The concomitant solid or micropapillary subtype was observed in 92.12% patients with ADC. Poorly differentiated histological subtypes were more frequent and negatively correlated with tumor size in smaller tumor cases (P=0.036, Pearson’s R=−0.075). Furthermore, in the subgroup of nodules within 3 cm, the distribution of the solid and micropapillary subtypes were significantly frequent in lymph node-positive patients (P