• Shiyou Wei, Chenglin Guo, Jintao He, Qunyou Tan, Jiandong Mei, Zhenyu Yang, Chengwu Liu, Qiang Pu, Lin Ma, Yong Yuan, Feng Lin, Yunke Zhu, Hu Liao, Wenping Wang, Zheng Liu, Qiang Li, Bin Jiang, Chuan Li, Liang Xia, Kejia Zhao, Fanyi Gan, Jiahan Cheng, Zhu Wu, Yun Wang, Yidan Lin, Yingli Kou, Guowei Che, Longqi Chen, Jing Li, and Lunxu Liu.
• Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China.
• JAMA Surg. 2019 Jul 1; 154 (7): e190972.

ImportanceIt is important to develop a surgical technique to reduce dissemination of tumor cells into the blood during surgery.ObjectiveTo compare the outcomes of different sequences of vessel ligation during surgery on the dissemination of tumor cells and survival in patients with non-small cell lung cancer.Design, Setting, And ParticipantsThis multicenter, randomized clinical trial was conducted from December 2016 to March 2018 with patients with non-small cell lung cancer who received thoracoscopic lobectomy in West China Hospital, Daping Hospital, and Sichuan Cancer Hospital. To further compare survival outcomes of the 2 procedures, we reviewed the Western China Lung Cancer database (2005-2017) using the same inclusion criteria.InterventionsVein-first procedure vs artery-first procedure.Main Outcomes And MeasuresChanges in folate receptor-positive circulating tumor cells (FR+CTCs) after surgery and 5-year overall, disease-free, and lung cancer-specific survival.ResultsA total of 86 individuals were randomized; 22 patients (25.6%) were younger and 64 (74.4%) older than 60 years. Of these, 78 patients were analyzed. After surgery, an incremental change in FR+CTCs was observed in 26 of 40 patients (65.0%) in the artery-first group and 12 of 38 (31.6%) in the vein-first group (P = .003) (median change, 0.73 [interquartile range (IQR), -0.86 to 1.58] FU per 3 mL vs -0.50 [IQR, -2.53 to 0.79] FU per 3 mL; P = .006). Multivariate analysis confirmed that the artery-first procedure was a risk factor for FR+CTC increase during surgery (hazard ratio [HR], 4.03 [95% CI, 1.53-10.63]; P = .005). The propensity-matched analysis included 420 patients (210 with vein-first procedures and 210 with artery-first procedures). The vein-first group had significantly better outcomes than the artery-first group for 5-year overall survival (73.6% [95% CI, 64.4%-82.8%] vs 57.6% [95% CI, 48.4%-66.8%]; P = .002), disease-free survival (63.6% [95% CI, 55.4%-73.8%] vs 48.4% [95% CI, 40.0%-56.8%]; P = .001), and lung cancer-specific survival (76.4% [95% CI, 67.6%-85.2%] vs 59.9% [95% CI, 50.5%-69.3%]; P = .002). Multivariate analyses revealed that the artery-first procedure was a prognostic factor of poorer 5-year overall survival (HR, 1.65 [95% CI, 1.07-2.56]; P = .03), disease-free survival (HR, 1.43 [95% CI, 1.01-2.04]; P = .05) and lung cancer-specific survival (HR = 1.65 [95% CI, 1.04-2.61]; P = .03).Conclusions And RelevanceLigating effluent veins first during surgery may reduce tumor cell dissemination and improve survival outcomes in patients with non-small cell lung cancer.Trial RegistrationClinicalTrials.gov identifier: NCT03436329.

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