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ORIGINAL ARTICLE
European Journal of Cardio-Thoracic Surgery 49 (2016) 1624–1631
doi:10.1093/ejcts/ezv462 Advance Access publication 19 January 2016
Cite this article as: Watanabe K, Tsuboi M, Sakamaki K, Nishii T, Yamamoto T, Nagashima T et al. Postoperative follow-up strategy based on recurrence dynamics
for non-small-cell lung cancer. Eur J Cardiothorac Surg 2016;49:1624–31.
Postoperative follow-up strategy based on recurrence dynamics
for non-small-cell lung cancer†
Katsuya Watanabea,*, Masahiro Tsuboib, Kentaro Sakamakic, Teppei Nishiia, Taketsugu Yamamotoa,
Takuya Nagashimaa, Kohei Andoa, Yoshihiro Ishikawaa, Tekkan Wooa, Hiroyuki Adachia, Yutaka Kumakiria,
Takamitsu Maeharaa, Haruhiko Nakayamaa and Munetaka Masudaa
a
b
c
Department of Surgery, Yokohama City University, Yokohama, Japan
Division of Thoracic Surgery, National Cancer Center Hospital East, Kashiwa, Japan
Department of Biostatistics and Epidemiology, Yokohama City University, Yokohama, Japan
* Corresponding author. Department of General Thoracic Surgery, Kanto Rosai Hospital, 1-1, Kizukisumiyoshi, Nakahara Ward, Kawasaki, Kanagawa 211-8510, Japan.
Tel: +81-44-4113131; fax: +81-44-4333150; e-mail: [email protected] (K. Watanabe).
Received 5 September 2015; received in revised form 17 November 2015; accepted 19 November 2015
Abstract
OBJECTIVES: Our study was designed to visually represent recurrence patterns after surgery for non-small-cell lung cancer (NSCLC) with
the use of event dynamics and to clarify postoperative follow-up methods based on the times of recurrence.
METHODS: A total of 829 patients with NSCLC who underwent complete pulmonary resection from 2005 to 2007 in 9 hospitals affiliated
with the Yokohama Consortium of Thoracic Surgeons were studied. Event dynamics, based on the hazard rate, were evaluated. Only first
events involving the development of distant metastases, local recurrence or both were considered. The effects of sex, histological type,
pathological stage and age were studied.
RESULTS: The hazard rate curve displayed an initial surge that peaked about 6–8 months after surgery. The next distinct peak was noted at
the end of the second year of follow-up. On non-parametric kernel smoothing, the maximum peak was found 6–8 months after surgery in
men. In women, the highest peak occurred 22–24 months after surgery, which was about 16 months later than the peak in men. The peak
timing of the hazard curve was not affected by histological type, pathological stage or age in either sex.
CONCLUSIONS: Our results suggest that the timing of recurrence after surgery for lung cancer is characterized by a bimodal pattern, and
the times with the highest risk of recurrence were suggested to differ between men and women. Postoperative follow-up strategies should
be based on currently recommended follow-up programmes, take into account the recurrence patterns of lung cancer, and be modified
as required to meet the needs of individual patients.
Keywords: Non-small-cell lung cancer • Postoperative • Follow-up • Recurrence dynamics
INTRODUCTION
Lung cancer is the leading cause of cancer-related death in
Japan and many countries around the world, and non-small-cell
lung cancer (NSCLC) accounts for 75–85% of all cases [1].
Surgery is the mainstay of treatment for early-stage NSCLC [2].
Unfortunately, local or distant recurrence (or both) often develops even in patients with early disease who undergo complete
resection. Although adjuvant platinum-based chemotherapy
improves survival, the benefits are modest. Several recent studies
have evaluated combinations of chemotherapy and biological
targeted therapies [3].
†
Presented at the 29th Annual Meeting of the European Association for CardioThoracic Surgery, Amsterdam, Netherlands, 3–7 October 2015.
Alternative statistical methods have been used to analyse the
risks of recurrence in relation to the time after surgery in a population of patients. Cumulative incidence curves, which indicate the
cumulative risk of incurring an event over time, are used most frequently. Another variable used to express risk is the median interval from surgery to recurrence. In NSCLC, the median time from
surgery to local failure is 13.9 months and that to distant failure is
12.5 months in patients who have recurrence [4]. However, such
methods do not provide direct information about changes in
event probabilities over the course of time (i.e. event dynamics),
which can be estimated by calculating event-specific hazard rates
over the follow-up time interval [5].
At present, evidence-based methods for postoperative followup remain to be established, and guidelines recommended
by major organizations in western countries differ considerably.
© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
K. Watanabe et al. / European Journal of Cardio-Thoracic Surgery
Table 1: Patient, treatment and tumour characteristics
(n = 829)
Characteristics
PATIENTS AND METHODS
A total of 829 patients (538 men, 291 women) with NSCLC who
underwent complete pulmonary resection from January 2005
through December 2007 in 9 hospitals affiliated with the Yokohama
Consortium of Thoracic Surgeons (Yokohama City University Hospital
and affiliated hospitals) were studied. Preoperative staging investigations were routinely performed using computed tomographic (CT)
scans of the chest and abdomen. Magnetic resonance imaging (MRI)
scans or CT scans of the brain and nuclear medicine scans of bone
were done to exclude possible distant metastases. During the study
period, positron emission tomography (PET) was generally not performed for disease staging. However, PET was performed along with
the standard examinations in selected patients. A single primary
tumour was diagnosed in all patients, and no patient had a history of
lung cancer (excluding those with multicentric cancers).
Patients who died in the immediate postoperative period
(within 30 days after surgery or during the initial hospitalization)
were excluded. Postsurgical pathological tumour–node–metastasis
(TNM) staging was performed according to the guidelines of the
American Joint Cancer Committee (AJCC), 6th edition.
The postoperative follow-up schedule consisted of a clinic visit
every 3–6 months through the fifth year, and annually thereafter.
Follow-up evaluations included physical examination, serum
tumour markers, chest radiography and CT scanning of the chest
and abdomen. In general, chest radiography was done every 3–6
months for the first 2–3 years and then at 6-month intervals or annually thereafter. CT scans were obtained every 6 months in the
first 2–3 years after resection and annually thereafter during
follow-up. In patients who had signs or symptoms of recurrence,
CT scans of the chest and abdomen, brain MRI, bone scintigraphy
and PET scanning were performed as required.
Recurrence was diagnosed on the basis of the results of physical
examinations and diagnostic imaging and was confirmed by
pathological examination of biopsy specimens if necessary. The
date of recurrence was defined as the date of confirmation of recurrence based on clinical and radiological findings. Local recurrence was defined as tumour recurrence in the ipsilateral lung or
lymph nodes, and distant metastasis was defined as tumour recurrence in the contralateral lung or lymph nodes or in a distant
organ such as the brain, liver or bone (or both). Second primary
lung cancers (diagnosed when a new lung tumour with different
histological features was detected on standard histological and immunological studies or when the clinical scenario was more consistent with a new primary tumour than a local recurrence) were
excluded. Time to treatment failure was defined as the interval
between the date of surgery and the date of disease recurrence
(local recurrence or distant metastasis). Only first events were
considered.
Event dynamics were studied by using life-table methods to
estimate the discrete hazard rate for the considered event, i.e. the
conditional probability of the event occurring within a defined
time interval, given that the patient did not previously have the
event at the beginning of the interval [6]. A discretization of the
time axis in 2-month units was applied, and all hazard rate levels
were measured as ‘events/patients at risk per 2-month interval’.
Age (years)
Median
Range
Sex
Male
Female
Pathological stage
IA
IB
IIA
IIB
IIIA
IIIB
Tumour size (mm)
Mean
Median
Range
Location
Right upper lobe
Right middle lobe
Right lower lobe
Right lung, NOS
Left upper lobe
Left lower lobe
Left lung, NOS
Surgical approach
VATS
Hybrid VATS
Open
Surgical procedure
Segmentectomy
Lobectomy
Bilobectomy
Pneumonectomy
Visceral pleural invasion
Yes
No
NS
Histology
Adenocarcinoma
Squamous cell
Large cell
NSCLC, NOS
Adjuvant chemotherapy
Yes
Adjuvant radiotherapy
Yes
No. of patients (%)
69
16–85
538 (64.9)
291 (35.1)
392 (47.3)
211 (25.5)
25 (3.0)
73 (8.8)
94 (11.3)
34 (4.1)
31.4
27
2.3–165
275 (33.2)
64 (7.7)
181 (21.8)
1 (0.1)
202 (24.4)
105 (12.7)
1 (0.1)
294 (35.5)
150 (18.1)
385 (46.4)
80 (9.6)
712 (85.9)
9 (1.1)
28 (3.4)
265 (32.0)
544 (65.6)
20 (2.4)
518 (62.5)
208 (25.1)
41 (4.9)
62 (7.5)
200 (24.1)
42 (5.1)
VATS: video-assisted thoracoscopic surgery; NSCLC: non-small-cell lung
cancer; NOS: not otherwise specified; NS: not stated.
Because the hazard rate estimates showed some instability owing
to random variation, a kernel-like smoothing procedure was used,
and the smoothed curve was graphically represented to facilitate
understanding of the underlying pattern [7].
In addition to the kernel smoothing approach with discrete
hazards, a flexible piecewise exponential regression model was
used to obtain smoothed hazard estimates [8]. Potential covariates
were sex, histological type, pathological stage and age. Natural
cubic splines were used to model the time dependence of each
variable with internal knots placed equidistantly within the month
range (0–72 months). The number of knots, which corresponded to
THORACIC
Our study was designed to visually represent recurrence patterns
after surgery for lung cancer with the use of event dynamics and
to clarify postoperative follow-up methods based on the times of
recurrence.
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K. Watanabe et al. / European Journal of Cardio-Thoracic Surgery
the number of basic functions between 4 and 10, was chosen
according to the Akaike Information Criteria (AIC).
RESULTS
Patient, tumour and treatment characteristics are given in Table 1.
At a median follow-up of 65.6 months (range, 1–98.7 months),
disease recurrence developed in 274 patients (128 with only local
recurrence and 146 patients with only distant metastasis or local
recurrence plus distant metastasis).
We first analysed the hazard rate for treatment failure in all 829
patients. The resulting curve (Fig. 1) displayed an initial surge in
the hazard rate, which peaked about 6–8 months after surgery.
Another distinct peak was noted at the end of the second year of
follow-up. A small peak was found even 5 years after surgery.
On non-parametric kernel smoothing, the hazard rate curve
displayed an initial sharp, high peak 6–8 months after surgery for
men (Fig. 2). In women, several small peaks were noted during the
first year, and the highest peak occurred 22–24 months after
surgery, which was about 16 months later than the peak in men.
As for histological type, squamous cell carcinomas had a higher
risk of recurrence than adenocarcinomas during follow-up (Fig. 3A).
Squamous cell carcinomas showed a sharp peak in the hazard rate
in the first year, followed by four or five small peaks. In contrast, the
hazard rate for adenocarcinomas showed a different pattern. After
a gradual increase during the first 6–14 months, the hazard rate
moderately decreased subsequently.
Although the hazard rate for the first event after surgery differed
according to histological type at 1 year, there was only a slight difference in the timing of the first peak and the second peak of recurrence. When the hazard rate curves were compared between
men with squamous cell carcinoma and those with adenocarcinoma, the first maximum peak of recurrence was found 6–8
months after surgery in both groups. When women with squamous cell carcinoma were compared with women with adenocarcinoma, the first maximum peak was noted at 22–24 months in
both groups (Fig. 3B).
As for pathological stage, as expected, the absolute magnitude
of the recurrence peaks was higher in patients with advanced
disease in both sexes, but the maximum peak of recurrence was
found 6–8 months after surgery in both groups (Fig. 4). With
respect to age, the hazard rates and timing of recurrence did not
distinctly differ between patients younger than 70 years and those
70 years or older.
DISCUSSION
Figure 1: Smoothed hazard rate estimates for first event. LR: local recurrence;
DM: distant metastasis.
In the present study, we examined recurrence dynamics in patients
with NSCLC and found several recurrence peaks during postoperative follow-up. We confirmed that the hazard of postoperative
recurrence peaked at certain times after surgery and was not always
constant. A structured, multiple-peak pattern of recurrence risk is
Figure 2: Smoothed hazard rate estimates for first event (LR and DM) in 538 men and 291 women. LR: local recurrence; DM: distant metastasis.
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THORACIC
K. Watanabe et al. / European Journal of Cardio-Thoracic Surgery
Figure 3: (A) Smoothed hazard rate estimates for first event (LR and DM) according to histological type. (B) Smoothed hazard rate estimates for first event (LR and
DM) according to histological type and sex. LR: local recurrence; DM: distant metastasis.
not a new finding and has been reported in patients with cancer
arising in organs other than the lung, such as breast cancer [9] and
head and neck cancer [10]. Demicheli et al. [6] and Kelsey et al. [11]
reported that patients with NSCLC showed a bimodal recurrence
pattern similar to that in patients with breast cancer. Despite differences in various patient characteristics, including race, sex and
histological types of cancer, it is extremely interesting that we
obtained results similar to those of their study. The fact that the
presence of cancer in multiple organs including the lung is apparently associated with a certain pattern of postoperative recurrence
casts doubt on the conventional concept that tumour cells continue
to proliferate in a disordered manner, leading to disease progression. To date, many concepts have been proposed to convincingly
explain the clinical behaviour of breast cancer, such as tumour
homeostasis, tumour dormancy and surgery-related enhancement
of metastatic growth [12]. The fact that the first peak of recurrence
occurs within 1 year after surgery suggests that surgical invasion disrupts homeostasis, accelerating the proliferation of dormant
tumour cells. The second and subsequent peaks of recurrence
found in our study can be explained by the hypothesis that residual
tumour cells proliferated and micrometastases developed after
entering a transient state of dormancy. Our findings suggested that
tumour cells gradually proliferate after passing through a relatively
long dormancy period in certain types of lung cancer. At present,
however, the detailed mechanisms underlying the hypothesis of
tumour dormancy remain to be clarified.
Another interesting finding in our study was that the hazard rate
and the peak times of recurrence differed considerably between
men and women. In men, the first peak in recurrence appeared
6–8 months after surgery, and the hazard rate then showed a
downward sloping tendency. In women, however, there was only
a small peak within the first year after surgery. The hazard rate
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Figure 4: Smoothed hazard rate estimates for first event (LR and DM) according to pathological stage. LR: local recurrence; DM: distant metastasis.
Table 2: Current recommendations for surveillance after curative-intent therapy of NSCLC
Organization
Summary of recommendations
Classification of
recommendations
ACCP [18]
Surveillance by clinical examination and chest radiography or CT should be performed every 6 months for 2 years
and then yearly for patients with good performance status and pulmonary function
A follow-up visit every 3–6 months is recommended during 2–3 years, less often—e.g. annually—thereafter
For follow-up, history and physical examination, chest CT and, to a lesser extent, chest X-ray are appropriate tools
History and physical examination with contrast-enhanced CT scan every 4–6 months for 2 years
Then history and physical examination and non-contrast-enhanced CT scan annually
For patients treated with curative intent, in the absence of symptoms, a history and physical examination should be
performed every 3 months during the first 2 years; every 6 months thereafter through year 5; and yearly thereafter
For patients treated with curative intent, there is no clear role for routine studies in asymptomatic patients and
patients in whom no interventions are planned
Offer all patients an initial specialist follow-up appointment within 6 weeks of completing treatment to discuss
ongoing care. Offer regular appointments thereafter, rather than relying on patients requesting appointments when
they experience symptoms
Offer protocol-driven follow-up led by a lung cancer clinical nurse specialist as an option for patients with a life
expectancy of more than 3 months
Ensure that patients know how to contact the lung cancer clinical nurse specialist involved in their care between their
scheduled hospital visits
Grade 1C
ESMO [19]
NCCN [20]
ASCO [21]
NICE [22]
III, B
III, B
2B
2B
None
None
ACCP: American College of Chest Physicians; ESMO: European Society of Medical Oncology; NCCN: National Comprehensive Cancer Network; ASCO:
American Society of Clinical Oncology; NICE: National Institute for Health and Clinical Excellence.
then gradually increased to reach its peak value 22–24 months
after surgery. Our results also suggested that recurrence of cancer
peaks during the first year in male patients, whereas female
patients lack such a large peak during the first year and instead
have two small peaks during the second year after surgery.
Initially, we assumed that the timing of recurrence was somewhat
affected by histological type because the peak timing of recurrence was later for adenocarcinoma than for squamous cell carcinoma. However, the hazard rate curve did not differ markedly
between men with squamous cell carcinoma and those with
adenocarcinoma. In addition, the highest peak of recurrence in
women was noted 22–24 months after surgery for both histological types. We therefore speculated that the delayed time of peak
recurrence of adenocarcinoma might be attributed to the high
rate of adenocarcinoma in women (85%). The timing of
recurrence thus appeared to be more strongly influenced by sex
than by histological type. Moreover, pathological stage and age
did not affect the peak timing of the hazard curve in either sex.
These findings suggested that the recurrence dynamics of lung
cancer show a bimodal characteristic pattern and that the timing
of recurrence after surgery is probably sex-dependent. However,
definitive evidence supporting a sex-dependent difference in
recurrence patterns has yet to be obtained. Further prospective
studies in larger numbers of patients are needed.
As for postoperative follow-up of lung cancer, many previous
studies have examined methods potentially contributing to overall
survival [13]. Westeel et al. [14] reported that asymptomatic
patients in whom recurrence was detected on intensive imaging
studies after surgery for NSCLC had better survival than symptomatic patients with recurrence. On the other hand, Virgo et al. [15]
K. Watanabe et al. / European Journal of Cardio-Thoracic Surgery
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Figure 6: Time to first event and numbers of patients still at risk.
reported no significant difference in the detection of recurrence
or in outcomes between patients who were ‘intensively’ followed
up and those who were ‘non-intensively’ followed up. Similarly,
Younes et al. [16] reported that disease-free survival and median
survival did not differ significantly between patients who were
followed up according to a routine follow-up protocol and those
who were followed up based on symptoms. They therefore concluded that intensive screening of asymptomatic patients was unwarranted from the viewpoint of cost-effectiveness. At present,
there is thus no clear-cut basis to recommend aggressive routine
screening, and it remains unclear whether the early detection of
recurrence contributes to improved outcomes. Therefore, the
optimal follow-up protocol for postoperative patients with lung
cancer remains to be established [17]. However, history taking and
physical examinations should be regularly performed to facilitate
the detection of postoperative complications on an outpatient
basis, an understanding of the patient’s condition and the provision of mental support. Although guidelines proposed by major
organizations in Europe and North America have consistently
recommended intensive follow-up during the first 2 years after
surgery, followed by annual follow-up examinations from postoperative year 3 or year 5, major differences exist among current
guidelines, including who should perform follow-up and when
and what follow-up examinations should be performed [18–22]
(Table 2).
Recent studies have reported that the accuracy of imaging
studies has improved and that CT is useful for follow-up, contributing to longer survival [23]. Progress in drug therapy, the development of new anticancer agents and the advent of molecular
targeted agents have prolonged survival [24] and improved the
quality of life (QOL) [25] of patients with advanced, recurrent
NSCLC. In such patients, CT-based imaging studies should be
aggressively performed at times of high risk of recurrence to facilitate the early detection and early treatment of recurrence and
thereby most likely contribute to improved QOL and outcomes.
As the methodology for personalized treatment of lung cancer
gradually becomes more widely accepted, individually designed
follow-up programmes based on the biological characteristics of
tumours and risk factors for recurrence, rather than conventional
follow-up in which standardized imaging studies are performed at
predefined intervals in all patients, will most likely be required.
Based on the current situation and our results, hospital visitation
programmes should be designed to focus on 6–8 and 22–24
months after surgery (i.e. the times of peak hazard rates of recurrence), and appropriate CT-based imaging studies should be performed at these times. In addition, because the peak times of
recurrence differed between men and women, imaging studies
should be planned according to sex to most intensively cover the
period from 6–8 months during the first year after surgery in men
and 22–24 months during the second year after surgery in women
(Fig. 5). If CT examinations are performed every 6 months during
THORACIC
Figure 5: Postoperative follow-up schedules for men (left) and women (right). CT: computed tomography.
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K. Watanabe et al. / European Journal of Cardio-Thoracic Surgery
the first 2 years after surgery, followed by once per year from
3 years onwards in accordance with the guidelines issued by the
American College of Chest Physicians (ACCP) and the European
Society for Medical Oncology (ESMO), CT would be performed
four times during the first 2 years and seven times during the
first 5 years. Potential cost-benefits, patient satisfaction and postoperative treatment strategies should be taken into account,
and the numbers of hospital visits and CT examinations should
be designed individually. In this respect, the use of recurrence
dynamics allows the times of peak recurrence to be visualized,
potentially allowing more efficient follow-up surveillance.
An important limitation of our study is that it was retrospective
and therefore subject to the effects of lead-time and length-time
bias. All hazard rate levels were measured at 2-month intervals in
our study. However, the timing of the first event largely depends
on the timing of imaging studies or hospital visits. Obviously,
follow-up and analysis at shorter assessment intervals would be
needed to more precisely estimate the risk of recurrence (Fig. 6).
There is no doubt that a randomized, prospective study should be
performed to evaluate whether follow-up surveillance based on
recurrence dynamics is more useful than conventional protocols
for postoperative follow-up in terms of the early detection of recurrence, survival outcomes, health-related QOL, costeffectiveness factors and other factors. At present, postoperative
follow-up strategies should be based on currently recommended
follow-up programmes, give adequate consideration to costeffectiveness and be modified as required to meet the needs of
individual patients.
CONCLUSIONS
The timing of recurrence after surgery for lung cancer was characterized by a bimodal pattern, and the times with the highest risk
of recurrence were suggested to differ between men and women.
Postoperative follow-up strategies should be based on currently
recommended follow-up programmes, take into account the recurrence patterns of lung cancer, and be modified as required to
meet the needs of individual patients.
Conflict of interest: none declared.
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APPENDIX. CONFERENCE DISCUSSION
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Dr L. Luzzi (Siena, Italy): Just two questions because the paper is interesting.
The follow-up problem is crucial in patients operated on for non-small cell lung
cancer because an early detection of a recurrence allows patients second
surgery or treatment with the biological drugs that have an impact on survival.
But I would like to ask you, you show us that males and females have two different patterns of recurrence; however, you don’t compare the two groups
based on the stage of disease. Because as you showed, the stage of disease is
the most important prognostic factor and also the most important impact in recurrence. Then in your paper and in your presentation, you never compare the
two groups, female and male, based on the stage. Because if we have statistically more patients, more high-stage patients in the male group, the curve is
similar to the pattern of recurrence that you showed for higher stage based on
the stage.
K. Watanabe et al. / European Journal of Cardio-Thoracic Surgery
seven months, by CT scan or any other imaging studies or by symptoms or
even just by chest X-ray?
Dr Van Schil: How do you perform the follow-up? Which kind of imaging do
you do, at what time intervals?
Dr Watanabe: All patients have routine follow-up programs with imaging
studies including chest CT, and our follow-up program is based on the guidelines by Japan Lung Cancer Society. Like guidelines by ACCP, it recommends intensive follow-up during the two years after surgery. And generally we see
patients every three to six months after surgery for five years.
Dr Van Schil: So, the next question is, when you do such intensive follow-up
and you detect a recurrence, is it a local or distant recurrence, and are those
patients treated and can you say something about the outcome of those
patients?
You said in your conclusion that you have to do an intensive follow-up
according to histology, sex. But if you detect something, is it a local recurrence
or distant recurrence, and can you treat those patients? Do those patients have
a better outcome?
Dr Watanabe: At present there is no clear-cut basis to recommend intensive
follow-up, and it is a retrospective study. We don’t study the outcome of early
detection of early treatment.
Dr A. Wai Sing Suen Do you arbitrarily do a CT scan at six months or nine
months or twelve months after the operation?
Dr Watanabe: In our nine hospitals, follow-up intervals and the choice of
imaging studies are not standardized. It is different in each hospital.
Dr A. Ciccone (Rome, Italy): But what about yours?
Dr Watanabe: In my hospital, every six-month intervals we perform chest CT
and every three months a chest X-ray.
THORACIC
Dr Watanabe: In men, stage 1 is about 70%, and in women, stage 1 is about
80%. Most patients are in stage 1 group and the recurrence rate in men is about
37%, and in women recurrence rate was 27%. Because the two groups are very
similar, I think, almost 70% to 80% is in stage 1 group.
Dr Luzzi: Anyway, you should do a statistical analysis, compare the two
groups in order of all these prognostic factors because you have to put and to
check if there is a statistical difference in the two groups before you say that we
should change our follow-up based on your results. This is my idea.
The last question is, that in your paper you write that probably you have
patients who have earlier recurrence probably of an immunosuppression due
to surgery. Do you compare the recurrence, the type of recurrence between
the group who receive the video-assisted thoracoscopic surgery lobectomy
or video-assisted thoracoscopic surgery, minimally invasive resection and the
patient who receive open surgery in order to assess if the minimally invasive
surgery could have less of an impact in immunosuppression and then in
recurrence?
Dr Watanabe: In our patients, about 60% of patients was performed by
video-assisted thoracoscopic surgery lobectomy, and 85% of patients complete
resection by lobectomies, and 9% is pneumonectomy with lymph node
dissection.
Also in our study, we don’t show the data, but the impact of operative
modality, there was no difference in the open surgery and videoassisted thoracoscopic surgery lobectomy. There was no impact on overall
survival.
Dr A. Wai Sing Suen (Hong Kong, China): I noticed that your recurrence time
is early, six or seven months after operation. In that amount of time, it’s not that
great period of follow-up. Can I ask how do you pick up these patients at six or
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