Carcinoma of the lung. Evaluation of satellite nodules as a factor influencing prognosis after resection

Satellite nodules are considered to be predictive of poor prognosis in breast cancer and in melanoma. In lung cancer, there is no information as to their definition, prevalence, or implication as a prognosis factor of survival after resection. Over the past 18 years (1969 to 1987), 84 patients underwent pulmonary resection for primary lung cancer accompanied by satellite nodules. These nodules were defined as well-circumscribed accessory carcinoma foci clearly separated from the main tumor but with identical histologic characteristics. All were smaller than the primary carcinoma and most were located within the same lobe. Survival rates of patients with satellite nodules were compared to those of 1021 patients without satellite nodules who underwent resection during the same time interval. The 1-, 3-, and 5-year survival rates for all patients classified as having no satellite nodules were 78%, 54%, and 44%, respectively, and the median survival for the entire group was 30 months. In patients with satellite nodules, these survival rates were 60.9%, 32.7%, and 21.6%, respectively, with a median survival of 15 months. The deleterious effect of satellite nodules was more significant in patients with stage I disease (p = 0.0008) than in patients with stage II (p = 0.0354) or stage III (p = 0.0145) disease. Survival data obtained by comparison of satellite nodule status and histologic characteristics shows that 5-year survival figures are better for patients with no satellite nodules in both the squamous and the nonsquamous groups. This study demonstrates that satellite nodules associated with lung cancer are indicative of locally advanced and/or premetastatic disease. These patients should be included in the stage group IIIa of the TNM stage grouping classification.

Scar cancer of the lung

A case of scar carcinoma developing over lung abscess scar is presented. When the lung scars begin to increase in size and the patient does not respond to the treatment which was effective earlier, the possibility of malignant change in the scar tissue should be considered rather than the recurrence of the previous illness.

[Bronchogenic carcinoma with extramucosal development. Diagnostic problems]

Bronchogenic carcinoma is characterized by three different patterns of spread: endobronchial, the commonest, submucosal, and peribronchial. While the diagnostic yield of bronchoscopy is very high for endobronchial masses, both submucosal and peribronchial tumors are more difficult to detect, and standard forceps biopsy can be negative. In such cases transbronchial needle aspiration biopsy allows higher diagnostic accuracy. CT findings of extramucosal neoplastic spread are not specific. Thickening of the bronchial walls is the commonest sign, but CT is inaccurate in predicting whether bronchial thickening will result in endobronchial/extramucosal neoplasm, fibrosis or bronchial wall edema. Despite this inaccuracy, CT is complementary to bronchoscopy since it allows to: 1) detect a pathology in the bronchial walls, which appear thickened; 2) delineate the extent of extraluminal spread; 3) help plan transbronchial needle aspiration biopsy.

T1N0M0 lung cancer: evaluation with CT

Although computed tomography (CT) is widely used in the evaluation of lung cancer, its use in the evaluation of clinical stage T1N0M0 lung cancer remains controversial. To evaluate the utility of CT, the authors studied 35 patients with clinical stage T1N0M0 lung cancer who underwent CT. Thoracotomy, mediastinoscopy, or fine-needle aspiration biopsy were performed in 26 of the patients. Metastases were proved in six of these patients, with CT demonstrating adenopathy in four of the six and a contralateral mass in one. Chest wall invasion was not demonstrated with CT in one patient. The overall prevalence of metastatic lesions in this group of 26 patients was 23.1%, with 15.4% of the 26 having unresectable lesions. CT demonstrated all metastatic lesions that precluded curative surgery. The results suggest that CT is clinically useful in the evaluation of clinical stage T1N0M0 lung cancer.

Results of resection for bronchogenic carcinoma in patients over the age of 80

Thirty three patients aged over 80 years underwent resection for bronchogenic carcinoma. The operations performed were: lobectomy (21), segmentectomy (4), wedge resection (2), pneumonectomy (3), carinal resection (1). In two patients no resection was feasible. Three patients died within two months of surgery. The cumulative five year survival rate was 55%, 79% for patients with stage I carcinoma and 31% for stage III. It is considered that resection has an acceptable outcome in patients over 80 years.

Effects of human bone marrow stroma on the growth of human tumor cells

As some tumors metastasize frequently to marrow we modified the clonogenic assay for human tumor cell growth by culturing tumor cells in the presence of human bone marrow stromal cells. In a bilayer soft agar assay, human tumor cells which had been passaged in nude mice were plated in the agar overlayer on an underlayer containing a suspension of trypsinized human bone marrow stromal cells. These marrow stromal cells stimulated the growth of tumor cells in a dose-dependent fashion, with a growth peak at a stromal cell density of 5-10 x 10(5)/ml. The maximal stimulation of tumour cell growth was 13-fold. We evaluated clonal growth of six separate tumors of five different histological types (small and large cell bronchogenic carcinoma; mammary carcinoma; malignant melanoma; pleural mesothelioma) and demonstrated that in 9 of 11 experiments tumor cell colonies formed in the absence of stromal cells, but colony growth was markedly stimulated by stromal cells in every case. Stromal stimulation persisted after irradiation of the stromal cells with 10 Gy. Growth of five fresh human tumor samples was similarly stimulated by the presence of human bone marrow stromal cells. Tumor cell colonies were characterized morphologically by Pappenheim stain and immunologically for surface antigens by peroxidase-antiperoxidase immunostaining utilizing monoclonal antibodies (carcinoembryonic antigen 26/3/13 and 26/5/1, EMA, HEA125, Sam 2 and Sam 10) which detected epithelial cell antigens. Colonies consisted of cytologically malignant cells which expressed epithelial cell antigens. Thus, the tumor cell origin of colonies from mammary carcinoma and bronchogenic small cell, large cell, and adenocarcinoma was proven. This tumor stem cell assay permits further analyses of human tumor cell biology and may be useful for testing drug sensitivity.

Failure of preoperative staging to assess unresectability in M0 bronchogenic carcinoma

Despite extensive preoperative staging, unresectability of a bronchogenic carcinoma may not be known until an exploratory thoracotomy is done. Failures in anatomic staging occur because of inability to detect local extent of hilar lesions and inability to detect small deposits of metastatic disease. At the University of South Carolina, nine of 75 patients who underwent thoracotomies were found to be unresectable. Using an extensive staging protocol, the "back out" thoracotomy rate can be reduced to a minimum whereas no patient is denied a chance for surgical cure.

[Surgery of bronchus carcinoma]

Indications for surgical treatment of lung cancer are based on histology and staging of the tumour and on the general condition of the patient.

HISTOLOGY

The current therapy for non-small cell cancer of the lung is operative excision. Small cell cancer however is best treated by chemotherapy or radiotherapy or by both in combination. Small or peripheral small cell cancer should also be removed surgically, but only in combination with chemotherapy or radiotherapy. Stage: Non-small cell tumours, which are assessed to be limited to the thorax and locally resectable have to be removed surgically. If the tumour involves the chest wall, pre- and postoperative radio-therapy is advisable. If lymph nodes in the upper mediastinum or in the contralateral hilus are involved, or if distant metastases are proven, surgical intervention is indicated only in exceptional cases.

PATIENT

The patient's general condition should allow tolerance of thoracotomy and extensive resection of lung parenchyma and adjacent tissue. Adequate ventilatory reserve is mandatory. In this regard it is important to realize that part of the lung may already be excluded from ventilation by obstruction, and resection of such parenchyma does not further impede ventilation. Indeed, resection of non-ventilated segments of lung parenchyma will even improve cardio-pulmonary reserve since the procedure might eliminate pulmonary av-shunting.

[Clinical staging of bronchial carcinoma]

Histology and stage make it possible to predict statistical life expectancy in patients with bronchial carcinoma. These data serve to select the appropriate therapeutic modality which may influence an individual patient's life expectancy and quality. If the tumor is presumably resectable, a search for extrathoracic metastases is conducted by computed tomography and bone scan only if clinically suspected. If ct-scans reveal enlarged and therefore probably malignant mediastinal lymph nodes, curative resection is evaluated by mediastinoscopy. Correlations also exist between stage and spontaneous course as well as the probability of treatment-induced remission and life prolongation in small cell lung cancer.

[Radiological diagnosis of bronchus carcinoma]

Chest radiography is the basic imaging method in lung cancer. It allows early detection of peripheral and, with lower sensitivity, detection of central neoplasms. The subsequent staging procedure includes other imaging tools, first of all computed tomography (CT) for a noninvasive estimate of the local and regional extent. Because of high sensitivity and lower specificity for mediastinal disease, positive CT scans suggesting inoperability ask for cytological verification whereas negative studies justify surgery unless other contraindications exist. During and after treatment, chest radiography again affords a morphological follow up. Systematic comparison of the current with recent and early post-treatment studies is a prerequisite for detecting tiny signs of recurrent disease and for differentiating them from iatrogenic changes and infection.

[Systemic tumor emboli from primary bronchogenic carcinoma]

A 59-year-old man underwent left pneumonectomy for bronchogenic carcinoma. During operation, his right arm pulse became suddenly unmeasurable. He was unconscious after operation and brain CT scan revealed cerebral infarction of the left hemisphere. Histopathological examination of the resected specimen showed a large cell carcinoma. Massive invasion into the inferior pulmonary vein of malignant tissue was recognized without nodal involvement. Twenty-six cases including ours in which systemic tumor emboli arise from primary bronchogenic carcinoma were reviewed. In 19 of these cases, tumor emboli occurred during or after pulmonary operation and in 7 cases spontaneously. The most common features of these cases were large tumor mass and poorly differentiated structures.

Transbronchial needle aspiration in the practice of bronchoscopy

We reviewed the records of all patients who underwent bronchoscopy with a flexible fiberoptic instrument and transbronchial needle aspiration (TBNA) at our institution between August 1983 and December 1985. During 85 bronchoscopy sessions, 89 TBNAs were performed in 84 patients. Seventy-three aspirates were obtained from 68 patients who were eventually proved to have a malignant lesion. Of these 68 patients, 25 had positive results of TBNA (37%). Of these 25 patients, 15 had non-small-cell cancers (11 bronchogenic and 4 metastatic from extrapulmonary sites), and 10 had small-cell carcinomas. In patients with a malignant lesion, 23% of the central aspirates (from paratracheal regions or within 2 cm of the carina) and 65% of the distal aspirates (beyond 2 cm from the carina) were positive (a total yield of 34%). Five of the distal aspirates were obtained from peripheral lesions under fluoroscopic guidance, and three were positive for a malignant process. In eight patients, the only malignant finding at bronchoscopy was the aspirate. Two of the eight patients had carcinoma metastatic to the lung, three had small-cell carcinoma, and the other three had bronchogenic carcinoma. In five patients, TBNA obviated more invasive diagnostic measures. We find TBNA to be useful in selected patients. It increases our diagnostic yield for small-cell carcinoma and carcinoma metastatic to the chest. TBNA should be considered when a submucosal process is present, extrinsic compression is evident, or an accessible extrabronchial mass is found radiographically.

Recent trends in pulmonary resection

The charts of 131 consecutive pulmonary resections were reviewed at the Jackson VA Medical Center and analyzed for trends in etiology, pathology and types of resection. Analysis of this group, as well as follow-up, are presented. We feel that this review has delineated some current trends in pulmonary resectional surgery and identified some areas for progress in the future. Only by careful assessment of one's work can one evaluate performance and plan for the future.

Accuracy of cytologic diagnosis and cytotyping of sputum in primary lung cancer: analysis of 161 cases

Sputum cytologic examination is still an important method for diagnosing lung cancer, and it is simple to perform. The present report is an analysis of 161 cases of primary lung cancer proved by thoracotomy. A detection rate of 73.3% in sputum and 84.5% in combination with other cytologic methods have been obtained. Cytotyping accuracy as compared with histologic classification in 105 cases was 79.0%. The importance of examining more than three sputum samples from a patient with suspected lung cancer is stressed.

Mediastinoscopy: not needed preoperatively in CT-negative lung carcinoma?

The objective was to investigate the necessity of mediastinoscopy in preoperative staging of lung carcinoma in 57 operable patients. Noninvasive radiology was compared to mediastinoscopy and thoracotomy. Computed tomography (CT-scan) and mediastinoscopy were in agreement in 40 cases (70%). CT-scan was negative in 26 patients, of which 4 were false negatives. Mediastinoscopy is therefore of no benefit preoperatively for 85% (22 out of 26) of patients. Consequently, we have changed our staging policy and only patients with positive CT-scan are now subjected to mediastinoscopy.

[MRI of bronchogenic carcinoma]

47 patients with histologic/cytologic confirmed bronchogenic carcinoma were examined with CT and MRI. Negative and contrast enhanced CT examinations were performed, MR images were obtained with ECG gated T1- and T2-weighted SE sequences in axial and coronal planes. Both methods were evaluated with respect to tumor imaging and delineating of tumor extensions. CT and MRI were generally in agreement for primary tumor and lymph node staging. 7 out of 10 patients with malignant pericardial involvement and 3 out of 27 patients with mediastinal subcarinal lymph node metastases were identified only in MR images. MRI was superior to CT in demonstration of aortic involvement, poststenotic syndrome and extension of chest wall invasion. Additionally MRI gave functional informations about blood flow in case of superior vena cava obstruction.

Repeat mediastinoscopy

The author reports 18 cases with repeated mediastinoscopy. The surgical procedure was performed twice on 16 patients and three times on 2 patients. Mediastinal shadow was the indication in 6 patients and bronchogenic carcinoma in 3 patients. Average time lag between the procedures was 35 months. In 56% of the cases, repeated mediastinoscopy was regarded as positive. Strong peritracheal fibrosis disturbing the procedure was verified in 16 patients. No complications were observed.

[Is short-term follow-up by skeletal scintigraphy of use in deciding on curative irradiation of inoperable non-small cell bronchial carcinoma? The experiences with 363 cases]

In a series of 363 patients, it was investigated if close-meshed bone scintigraphy is valuable for the decision whether or not to perform a high-dose curative radiotherapy of non-small cell bronchial carcinomas. The control of the bone scintigram made at the time of diagnosis, which was performed during the last phase of the treatment period before finally defining the treatment aim, was only helpful in some exceptional cases. Therefore a control of the first examination is not necessary if the latter has been performed not more than six months ago and if in the meantime no suspicious findings or other symptoms of a formation of skeletal metastases have been observed.

Value of bilateral iliac crest needle biopsy for pretherapeutic tumor staging of bronchogenic carcinomas

Two hundred and forty-three patients with lung cancer were biopsied pretherapeutically and bilaterally on the anterior iliac crest. Tumor infiltration into the bone marrow could be demonstrated in 7 patients. No tumor-positive biopsies were found in the 163 patients with non-small cell lung cancer (NSCLC). In small cell lung cancer (SCLC), however, the infiltration rate was 9% (7/80). In 3 of the 7 patients (43%) only 1 of the 2 sides biopsied had been infiltrated. All 7 patients with tumor-positive bone marrow samples were found to have additional metastases elsewhere (stage IV, 7/26; 27%). Therefore, according to our results, we cannot recommend iliac crest biopsy as a routine pretherapeutic procedure to aid in the staging of SCLC and NSCLC.

Multicentricity of adenocarcinoma of the lung

In a consecutive series of 62 lung resections for bronchogenic adenocarcinoma, 12 patients (19 percent) were found to have two or more adenocarcinomas on careful pathologic examination. These tumors all met the criteria for separate primary malignancy. In only two of the patients were the additional lesions suspected preoperatively. This incidence of multiple primary lung adenocarcinomas in apparently operable patients is several fold higher than would be anticipated from the literature. The phenomenon has important implications for preoperative radiologic evaluation, postoperative pathologic examination, assignment of TNM stage, and clinical follow-up of patients undergoing successful resection.

Leukotriene generation and metabolism in isolated human lung macrophages

We studied the generation and metabolism of leukotrienes (LTs) in human lung macrophages obtained from lung tissue of patients with central bronchial carcinoma. By counterflow centrifugation macrophages were enriched with a purity of more than 95-100%. A time and dose dependent generation of LTB4 and LTC4 was determined by specific radioimmunoassays after stimulation with the Ca-ionophore and anti-IgE. The amount of LTB4 exceeded the amount of LTC4. The concentrations of leukotrienes in the macrophage fraction amounted to 4.3 +/- 2.2 ng LTB4 and 0.6 +/- 0.05 ng LTC4/1 x 10(7) cells after 5 min of incubation with the Ca-ionophore. The LTB4 levels decreased to 3.0 +/- 0.6 ng after 60 min indicating the metabolism of the generated LTB4 by human lung macrophages. This was confirmed by incubation of the cells with exogenously added [3H]LTB4. LTB4 was converted into unpolar products as was identified by thin-layer chromatography and high-performance liquid chromatography; a comparison with the fibroblast cell line L929 which is known to convert LTB4 into the dihydro-LTB4 metabolite (5,12-dihydroxyeicosatrienoic acid) indicates that human lung macrophages use the same pathway of metabolization. Biological inactivation as determined by chemotaxis and cross-reaction with the LTB4 antiserum correlates with the degree of LTB4 metabolism. Moreover, the macrophages convert LTC4 into LTD4 and LTE4 by the enzymatic activity of the gamma-glutamyltranspeptidase and dipeptidase. Our data emphasize that the human alveolar macrophage not only produces arachidonic acid metabolites but modulates the local inflammatory potential by its metabolizing capacity for leukotrienes.