Application of video-assisted thoracic surgery in the standard operation for thoracic tumors

Objective: To evaluate the short-term outcomes of video-assisted thoracic surgery (VATS) for thoracic tumors. Methods: The data of 1,790 consecutive patients were retrospectively reviewed. These patients underwent VATS pulmonary resections, VATS esophagectomies, and VATS resections of mediastinal tumors or biopsies at the Cancer Institute & Hospital, Chinese Academy of Medical Sciences between January 2009 and January 2012. Results: There were 33 patients converted to open thoracotomy (OT, 1.84%). The overall morbidity and mortality rate was 2.79% (50/1790) and 0.28% (5/1790), respectively. The overall hospitalization and chest tube duration were shorter in the VATS lobectomy group (n=949) than in the open thoracotomy (OT) lobectomy group (n=753). There were no significant differences in morbidity rate, mortality rate and operation time between the two groups. In the esophageal cancer patients, no significant difference was found in the number of nodal dissection, chest tube duration, morbidity rate, mortality rate, and hospital length of stay between the VATS esophagectomy group (n=81) and open esophagectomy group (n=81). However, the operation time was longer in the VATS esophagectomy group. In the thymoma patients, there was no significant difference in the chest tube duration, morbidity rate, mortality rate, and hospital length of stay between the VATS thymectomy group (n=41) and open thymectomy group (n=41). However, the operation time was longer in the VATS group. The median tumor size in the VATS thymectomy group was comparable with that in the OT group. Conclusions: In early-stage (I/II) non-small cell lung cancer patients who underwent lobectomies, VATS is comparable with the OT approach with similar short-term outcomes. In patients with resectable esophageal cancer, VATS esophagectomy is comparable with OT esophagectomy with similar morbidity and mortality. VATS thymectomy for Masaoka stage I and II thymoma is feasible and safe, and tumor size is not contraindicated. Longer follow-ups are needed to determine the oncologic equivalency of VATS lobectomy, esophagectomy, and thymectomy for thymoma vs. OT.

Updated experiences with minimally invasive Mc Keown esophagectomy for esophageal cancer

AIM: To update our experiences with minimally invasive Mc Keown esophagectomy for esophageal cancer.METHODS: we retrospectively reviewed the medical records of 445 consecutive patients who underwent minimally invasive Mc Keown esophagectomy between January 2009 and July 2015 at the Cancer Hospital of Chinese Academy of Medical Sciences and used 103 patients who underwent open Mc Keown esophagectomy in the same period as controls. Among 375 patients who underwent total minimally invasive Mc Keown esophagectomy, 180 in the early period were chosen for the study of learning curve of total minimally invasive Mc Keown esophagectomy. These 180 minimally invasive Mc Keown esophagectomies performed by five surgeons were divided into three groups according to time sequence as group 1(n = 60), group 2(n = 60) and group 3(n = 60).RESULTS: Patients who underwent total minimally invasive Mc Keown esophagectomy had significantly less intraoperative blood loss than patients who underwent hybrid minimally invasive Mc Keown esophagectomy or open Mc Keown esophagectomy(100 ml vs 300 ml vs 200 ml, P = 0.001). However, there were no significant differences in operation time, number of harvested lymph nodes, or postoperative morbidity includingincidence of pulmonary complication and anastomotic leak between total minimally invasive Mc Keown esophagectomy, hybrid minimally invasive Mc Keown esophagectomy and open Mc Keown esophagectomy groups. There were no significant differences in 5-year survival between these three groups(60.5% vs 47.9% vs 35.6%, P = 0.735). Patients in group 1 had significantly longer duration of operation than those in groups 2 and 3. There were no significant differences in intraoperative blood loss, number of harvested lymph nodes, or postoperative morbidity including incidence of pulmonary complication and anastomotic leak between groups 1, 2 and 3.CONCLUSION: Total minimally invasive Mc Keown esophagectomy was associated with reduced intraoperative blood loss and comparable short term and long term survival compared with hybrid minimally invasive Mc Keown esophagectomy or open Mckeown esophagectomy. At least 12 cases are needed to master total minimally invasive Mc Keown esophagectomy in a high volume center.

Long.term outcomes of 307 patients after complete thymoma resection

Background: Thymoma is an uncommon tumor without a widely accepted standard care to date. We aimed to investigate the clinicopathologic variables of patients with thymoma and identify possible predictors of survival and recurrence after initial resection.Methods: We retrospectively selected 307 patients with thymoma who underwent complete resection at the Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College(Beijing, China) between January 2003 and December 2014. The associations of patients' clinical characteristics with prognosis were estimated using Cox regression and Kaplan–Meier survival analyses.Results: During follow?up(median, 86 months; range, 24–160 months), the 5? and 10?year disease?free survival(DFS) rates were 84.0% and 73.0%, respectively, and the 5? and 10?year overall survival(OS) rates were 91.0% and 74.0%, respectively. Masaoka stage(P < 0.001), World Health Organization(WHO) histological classification(P < 0.001), and postoperative radiotherapy after initial resection(P = 0.006) were associated with recurrence(52/307, 16.9%). Multivariate analysis revealed that, after initial resection, WHO histological classification and Masaoka stage were independent predictors of DFS and OS. The pleura(25/52, 48.0%) were the most common site of recurrence, and locoregional recurrence(41/52, 79.0%) was the most common recurrence pattern. The recurrence pattern was an independent predictor of post?recurrence survival. Patients with recurrent thymoma who underwent repeated resec?tion had increased post?recurrence survival rates compared with those who underwent therapies other than surgery(P = 0.017).Conclusions: Masaoka stage and WHO histological classification were independent prognostic factors of thymoma after initial complete resection. The recurrence pattern was an independent predictor of post?recurrence survival. Locoregional recurrence and repeated resection of the recurrent tumor were associated with favorable prognosis.

Clinicopathological parameters predicting recurrence of pT1N0 esophageal squamous cell carcinoma

AIM To identify the clinicopathological characteristics of pT1 N0 esophageal squamous cell carcinoma(ESCC) that are associated with tumor recurrence. METHODS We reviewed 216 pT1 N0 thoracic ESCC cases who underwent esophagectomy and thoracoabdominal two-field lymphadenectomy without preoperative chemoradiotherapy. After excluding those cases with clinical follow-up recorded fewer than 3 mo and those who died within 3 mo of surgery, we included 199 cases in the current analysis. Overall survival and recurrencefree survival were assessed by the Kaplan-Meier method, and clinicopathological characteristics associated with any recurrence or distant recurrence were evaluated using univariate and multivariate Cox proportional hazards models. Early recurrence(≤ 24 mo) and correlated parameters were assessed using univariate and multivariate logistic regression models.RESULTS Forty-seven(24%) patients had a recurrence at 3 to 178(median, 33) mo. The 5-year recurrence-free survival rate was 80.7%. None of 13 asymptomatic cases had a recurrence. Preoperative clinical symptoms, upper thoracic location, ulcerative or intraluminal mass macroscopic tumor type, tumor invasion depth level, basaloid histology, angiolymphatic invasion, tumor thickness, submucosal invasion thickness, diameter of the largest single tongue of invasion, and complete negative aberrant p53 expression were significantly related to tumor recurrence and/or recurrence-free survival. Upper thoracic tumor location, angiolymphatic invasion, and submucosal invasion thickness were independent predictors of tumor recurrence(Hazard ratios = 3.26, 3.42, and 2.06, P < 0.001, P < 0.001, and P = 0.002, respectively), and a nomogram for predicting recurrence-free survival with these three predictors was constructed. Upper thoracic tumor location and angiolymphatic invasion were independent predictors of distant recurrence. Upper thoracic tumor location, angiolymphatic invasion, submucosal invasion thickness, and diameter of the largest single tongue of invasion were independent predictors of early recurrence.CONCLUSION These results should be useful for designing optimal individual follow-up and therapy for patients with T1 N0 ESCC.

Log odds of positive lymph nodes is a better prognostic factor for oesophageal signet ring cell carcinoma than N stage

BACKGROUND Signet ring cell carcinoma is a rare type of oesophageal cancer,and we hypothesized that log odds of positive lymph nodes(LODDS)is a better prognostic factor for oesophageal signet ring cell carcinoma.AIM To explore a novel prognostic factor for oesophageal signet ring cell carcinoma by comparing two lymph node-related prognostic factors,log odds of positive LODDS and N stage.METHODS A total of 259 cases of oesophageal signet ring cell carcinoma after oesophagectomy were obtained from the Surveillance,Epidemiology,and End Results database between 2006 and 2016.The prognostic value of LODDS and N stage for oesophageal signet ring cell carcinoma was evaluated by univariate and multivariate analyses.The Akaike information criterion and Harrell’s C-index were used to assess the value of two prediction models based on lymph nodes.External validation was performed to further confirm the conclusion.RESULTS The 5-year cancer-specific survival(CSS)and 5-year overall survival(OS)rates of all the cases were 41.3%and 27.0%,respectively.The Kaplan-Meier method showed that LODDS had a higher score of log rank chi-squared(OS:46.162,CSS:41.178)than N stage(OS:36.215,CSS:31.583).Univariate analyses showed that insurance,race,T stage,M stage,TNM stage,radiation therapy,N stage,and LODDS were potential prognostic factors for OS(P<0.1).The multivariate Cox regression model showed that LODDS was an significant independent prognostic factor for oesophageal signet ring carcinoma patients after surgical resection(P<0.05),while N stage was not considered to be a significant prognostic factor(P=0.122).Model 2(LODDS)had a higher degree of discrimination and fit than Model 1(N stage)(LODDS vs N stage,Harell’s C-index 0.673 vs 0.656,P<0.001;Akaike information criterion 1688.824 vs 1697.519,P<0.001).The results of external validation were consistent with those in the study cohort.CONCLUSION LODDS is a superior prognostic factor to N stage for patients with oesophageal signet ring cell carcinoma after oesophagectomy.

A Model Predicting Lymph Node Status for Patients with Clinical Stage TlaNO-2MO Nonsmall Cell Lung Cancer

Background： Lymph node status of patients with early-stage nonsmall cell lung cancer has an influence on the choice of surgery. To assess the lymph node status more correspondingly and accurately, we evaluated the relationship between the preoperative clinical variables and lymph node status and developed one model for predicting lymph node involvement. Methods： We collected clinical and dissected lymph node information of 474 patients with clinical stage TlaN0-2M0 nonsmall cell lung cancer （NSCLC）. Logistic regression analysis of clinical characteristics was used to estimate independent predictors of lymph node metastasis. The prediction model was validated by another group. Results： Eighty-two patients were diagnosed with positive lymph nodes （17.3%）, and four independent predictors of lymph node disease were identified： larger consolidation size （odds ratio [OR] = 2.356, 95% confidence interval [CI]： 1.517-3.658, P 〈 0.001）, central tumor location （OR = 2.810, 95% CI： 1.545-5.109, P = 0.001 ）, abnormal status of tumor marker （OR = 3.190, 95% CI： 1.797-5.661, P 〈 0.001 ）, and clinical N1-N2 stage （OR = 6.518, 95% CI： 3.242-11.697, P 〈 0.001）. The model showed good calibration （Hosmer-Lemeshow goodness-of-fit, P 〈 0.766） with an area under the receiver operating characteristics curve （AUC） of 0.842 （95% [CI]： 0.797-0.886）. For the validation group, the AUC was 0.810 （95% CI： 0.731-0.889）. Conclusions： The model can assess the lymph node status of patients with clinical stage TlaN0-2M0 NSCLC, enable surgeons perform an individualized prediction preoperatively, and assist the clinical decision-making procedure.

Programmed cell death ligand 1 expression in esophageal squamous cell carcinoma:a comparative analysis of three different assays

As one of the most aggressive and lethal malignant tumors,the 5-year survival rate of oesophageal cancer is less than 20%.[1]There are two main pathological subtypes of esophageal cancer:esophageal squamous cell carcinoma(ESCC)and esophageal adenocarcinoma.[1]In China,more than 95%of esophageal cancer is ESCC.Encourag-ingly,cancer immunotherapy has entered a new era recently with the discovery of drugs that interfere with specific immune checkpoints.Moreover,due to the good effect of immunotherapy in squamous cell carcinoma,it may be a new strategy for ESCC treatment in the future.

Development and validation of m6A RNA methylation regulatorsbased signature in lung adenocarcinoma

To the Editor:Primary lung cancer is the most commonly diagnosed type ofmalignant tumor and is the leading cause of cancer deathworldwide.Non-small cell lung cancer(NSCLC)makes up 80%to 85%of the overall incidents of primary lung cancer and is classified into two distinct histological subtypes:lung adenocarcinoma(LUAD)and lung squamous cell carcinoma(LUSC).LUAD constitutes nearly 30%to 35%of all primary lung cancer cases,and the recurrence of it seems to be increasing in most countries.[1]As a prevalent mRNA internal modification,N6-methyladenosine(m6A)methylation modification is of great significance for triggering the development of cancer and can be used as a cancer-promoting factor in many cancers.[2,3]In this study,we aim to develop an m6A RNA methylation regulators-premised prognostic signature for LUAD patients.

Collision tumor of the esophagus:a report of five cases

To the Editor:Collision tumors are rare neoplasms comprising two cell populations that develop in juxtaposition to one another with minimal to no areas of intermingling.[1]The most common sites at which collision tumors occur have been reported to include the lungs,cranium,rectum,liver,uterus,bladder,and testis.[2,3]However,the biologic behavior of esophageal collision tumors remains largely unknown,with only a small number of studies originating from case reports having been published.This study reports five cases of esophageal collision tumors to provide evidence-based recommendations for the care of future patients.

Identification of prognostic genes in lung adenocarcinoma immune microenvironment

To the Editor:Lung adenocarcinoma(LUAD)with a high degree of malignancy is the most common histological subtype of lung cancer,and the leading cause of cancerrelated death in the world.[1]Tumor immune microenvironment is mainly composed of infiltrating immune and stromal cells,which have an important influence on the prognosis of LUAD patients.[2]In recent years,rapid advances in high-throughput sequencing technology have profoundly changed our understanding of tumor research.It uses a large amount of public clinical data to help researchers more effectively to study the characteristics of tumors and improve our ability to diagnose,treat,and prevent cancer.The purpose of this study was to use the estimation of stromal and immune cells in malignant tumor tissues using expression data(ESTIMATE)algorithm to calculate the immune and stromal scores of LUAD patients from The Cancer Genome Atlas(TCGA)database,explore the correlation between the scores and the survival of LUAD patients,and identify differentially expressed genes(DEGs)based on the immune/stromal scores.In addition,we also judged the prognostic value of DEGs and further studied their potential molecular functions.