Distribution and Likelihood of Lymph Node Metastasis Based on the Lobar Location of Nonsmall-Cell Lung Cancer

Mediastinal staging of NSCLC with endoscopic and endobronchial ultrasound

Mediastinal staging of non-small-cell lung cancer (NSCLC) is of paramount importance. It distinguishes operable from inoperable disease, guides prognosis and allows accurate comparison of outcomes in clinical trials. Noninvasive imaging modalities for mediastinal staging include CT, PET and integrated PET-CT. Mediastinoscopy is considered the current gold standard; however, each of these techniques has limitations in sensitivity or specificity. These inadequacies mean that 10% of operations performed with curative intent in patients with NSCLC are futile, owing to inaccurate locoregional lymph-node staging. Endoscopic and endobronchial ultrasound-guided mediastinal lymph-node aspiration are important and promising innovative techniques with reported sensitivities and specificities higher than standard investigations. The role of these techniques in mediastinal lymph-node staging is evolving rapidly and early data suggest that they may diminish the need for invasive surgical staging of the mediastinum. Furthermore, these are outpatient procedures that do not require general anesthesia and may be combined safely in the same sitting, for optimal accuracy of mediastinal staging. We propose a new algorithm for the diagnosis and staging of NSCLC, based on the current evidence, which incorporates endoscopic and endobronchial ultrasound as a first investigation after CT in patients with intrathoracic disease.

The significance of one-station N2 disease in the prognosis of patients with nonsmall-cell lung cancer

BACKGROUND

A retrospective study was conducted to define the characteristics and the prognosis of N2 disease subgroups according to their patterns of spread.

METHODS

From January 1993 to December 2004, 1,329 patients underwent lung resection for bronchogenic carcinoma The records of all patients with positive mediastinal lymph nodes at the surgical specimen (pIIIA/N2) after radical resection were analyzed, and the pattern of mediastinal lymphatic spread was classified according to regional spread, to skip metastasis, and to one or two or more lymph node stations, in relation to primary tumor location. Age, sex, type of resection, right or left lesion, T status, primary tumor location, tumor size, tumor central or peripheral location, histology, and survival were recorded and analyzed. Survival was analyzed according to regional spread or not, number of mediastinal lymph node stations involved, and skip metastasis status.

RESULTS

Among 302 cases (22.7%) with positive mediastinal lymph nodes pIIIA/N2, 66 (22%) were skip metastases, 72 (24%) had a nonregional mode of spread, and 199 (66%) included two or more stations of mediastinal lymph node invasion. Cox regression analysis of all cases disclosed malignant invasion in only one mediastinal lymph node station as the only favorable factor of survival (p < 0.001, odds ratio 0.57, 95% confidence interval: 0.42 to 0.78).

CONCLUSIONS

The presence of one-station mediastinal lymph node metastasis in patients with nonsmall-cell lung cancer who underwent major lung resection with complete mediastinal lymph node dissection proved to be a good prognostic factor that should be taken into account in the future.

Results of a prospective algorithm to remove chest tubes after pulmonary resection with high output

OBJECTIVE

Many patients have their hospital discharge delayed because their chest tube drainage is too high, despite the fact that there are no data to support the commonly used 250 mL/day threshold.

METHODS

A retrospective cohort study was conducted with a prospective database and prospective algorithm from one surgeon. All patients underwent elective pulmonary resection. The last chest tube was removed if there was no air leak and nonchylous drainage of 450 mL/day or less.

RESULTS

The study comprised 8608 operations and 2077 patients who underwent an elective (nonpneumonectomy) pulmonary resection via thoracotomy by one general thoracic surgeon over a 10-year period. Eighty-nine patients went home with a chest tube owing to air leak. The remaining 1988 patients were discharged without a chest tube. Types of pulmonary resection were wedge resection in 729 patients, segmentectomy in 214, lobectomy in 1104, and bilobectomy in 30. The median day of discharge was postoperative day 4. One hundred one (5%) were readmitted to the hospital within 60 days of discharge. The most common reason for readmission was dehydration and fatigue. Only 11 (0.55%) had readmissions owing to recurrent symptomatic effusion and most were treated with video-assisted thoracoscopy. Follow-up was 100% at 4 weeks and 93% at 8 weeks.

CONCLUSIONS

Chest tubes can be removed with up to 450 mL/day of nonchylous drainage after pulmonary resection, and perhaps a higher volume could be accepted. Readmission owing to a recurrent effusion is exceedingly uncommon, and the practice of leaving the tube in longer for drainage less than 450 mL/day is unsupported in the literature.

Prognostic factors for survival of stage I nonsmall cell lung cancer patients

BACKGROUND

Platinum-based adjuvant chemotherapy in randomized trials has failed to provide a survival benefit in patients with resected stage I nonsmall cell lung cancer (NSCLC). Using data from the California Cancer Registry (CCR), we explored factors that had detrimental effects on survival in patients with stage I NSCLC to identify a subset of patients at high risk for disease recurrence and subsequent mortality.

METHODS

Between 1989 and 2003, 19,702 incident cases of stage I NSCLC in the CCR were identified and subgrouped into stage IA and IB disease. Patient demographic factors, tumor characteristics, and treatment delivered were examined. Kaplan-Meier survival curves were calculated to estimate survival rates. Cox proportional-hazards ratios were used to identify independent prognostic factors for survival.

RESULTS

Advanced age at diagnosis, male sex, low socioeconomic status (SES), nonsurgical treatment, and poor histologic grade (stage IA NSCLC: hazards ratio [HR], 1.13; 95% confidence interval [95% CI], 1.08-1.19; stage IB NSCLC: HR, 1.11; 95% CI, 1.07-1.16) were associated with increased mortality risk on multivariate analysis. Non-upper lobe tumor location (right middle lobe, right and left lower lobes) and tumor size > or =4 cm (vs <4 cm: HR, 1.23; 95% CI, 1.15-1.30) were additional factors that increased the risk of mortality among patients with stage IB disease. Bronchioloalveolar carcinoma and Asian ethnicity were associated with decreased mortality risk in stage I NSCLC.

CONCLUSIONS

Stage I NSCLC with poorly differentiated histology and stage IB NSCLC with non-upper lobar tumor location or tumor size > or =4 cm carried an increased mortality risk.

Routine Mediastinoscopy and Esophageal Ultrasound Fine-Needle Aspiration in Patients With Non-small Cell Lung Cancer Who Are Clinically N2 Negative

BACKGROUND

Despite normal mediastinal (N2) lymph nodes shown on positron emission tomography (PET) and CT, some physicians routinely perform mediastinoscopy and/or endoscopic ultrasound fine-needle aspiration (EUS-FNA) in patients with non-small cell lung cancer (NSCLC).

METHODS

A prospective trial on patients with NSCLC who were clinically staged N2 negative by both integrated PET/CT and CT scan. All underwent mediastinoscopy and EUS-FNA and if N2 negative underwent thoracotomy with thoracic lymphadenectomy.

RESULTS

There were 153 patients (107 men). Of these, 136 patients were clinically staged N0 and 17 patients were clinically staged N1. Of the 136 patients who were staged as N0, 5 patients (3.7%) had positive EUS-FNA results (three in the subcarinal node), and 4 patients (2.9%) had positive mediastinoscopy results (all in the #4R node; one was N3). Six of the remaining 127 patients (4.7%) had N2 disease after resection. Seventeen patients were clinically staged as N1 by integrated PET/CT. Four patients (23.5%) had positive EUS-FNA results (two in the subcarinal node), 3 patients (17.6%) had positive mediastinoscopy results (all in #4R node; two were N2 and one was N3), and none of the remaining 10 patients had N2 disease after resection. Patients with unsuspected N2 disease were twice as likely (relative risk, 2.1; 95% confidence interval, 1.24 to 2.51; p = 0.02) to have a maximum standardized uptake value (maxSUV) > 10 and poorly differentiated cancer (relative risk, 2.1; 95% confidence interval, 1.14 to 2.38; p = 0.03).

CONCLUSION

We do not recommend routine mediastinoscopy or EUS-FNA in patients who are clinically staged as N0 after both integrated PET/CT and CT. However, these procedures should both be considered in patients clinically staged as N1 after PET/CT, and/or in those with adenocarcinoma, upper-lobe tumors, or tumors with a maxSUV > or = 10.

Survival and Outcomes of Pulmonary Resection for Non-Small Cell Lung Cancer in the Elderly: A Nested Case-Control Study

BACKGROUND

We assessed the morbidity, mortality, and long-term survival of pulmonary resection for non-small cell lung cancer (NSCLC) in elderly patients in three subgroups: 70 years or greater, 75 years or greater, and 80 years or greater.

METHODS

A nested case-control study over a 5-year period using an electronic prospective database (n = 6,450) of patients with NSCLC who underwent complete resection. Patients 70 years or older, 75 years or older, and 80 years or older were matched 1:1 to younger controls for stage, pulmonary function, performance status, and type of pulmonary resection.

RESULTS

There were 726 patients: 363 were 70 years of age or older (191 patients were 70 to 74 years old, 121 were 75 to 79, and 51 patients were 80 or older). There were 363 patients younger than 70 years of age. There was no significant difference in length of stay, major morbidity, or operative mortality between any of the elderly groups and the younger controls. However, elderly patients who received neoadjuvant therapy had three times the risk of developing major morbidity (odds ratio [OR] 2.8, 95% confidence interval [CI] 1.14 to 7.41). There was a statistically significant better 5-year survival in elderly patients with stage I NSCLC (78% vs 69%, p = 0.01); however, survival was similar for all other stages.

CONCLUSIONS

Elderly patients with NSCLC should not be denied pulmonary resection based on chronologic age. Their short-term risks and long-term survival are similar to younger patients. Additionally, there seems to be no increased risk in selected octogenarians. However, elderly patients had double the risk for developing major morbidity after resection if they underwent neoadjuvant therapy.

Maximum Standard Uptake Value of Mediastinal Lymph Nodes on Integrated FDG-PET-CT Predicts Pathology in Patients with Non-Small Cell Lung Cancer

BACKGROUND

Positron emission tomography (PET) scans often help direct biopsies of mediastinal lymph nodes in patients with non-small cell lung cancer (NSCLC), but the maximum standard uptake value (maxSUV) of individual nodes has not been evaluated.

METHODS

This is a prospective study of consecutive patients with NSCLC, all of whom underwent integrated fluorodeoxyglucose-positron emission-computed tomography (FDG-PET-CT) and had biopsy or resection of their mediastinal lymph nodes.

RESULTS

There were 397 patients. One-hundred and forty-three patients had N2 disease and 1,252 N2 nodes were pathologically examined. The median maxSUV of the nodes that had metastatic disease were the following: for the 2R node, 10.4 (range, 0-18.6); for 4R, 8.6 (range, 0-18.3); for 5, 8.9 (range, 0-26.3); for 6, 7.6 (range, 0-19.6); for 7, 7.7 (range, 0-14); for 8 and 9, 5.4 (range, 0-8.9). The median maxSUV for all of the N2 nodes that were benign was 0 (range, 0-18.8) (p < 0.05 for all stations except for nodes 8 and 9). When a maxSUV of 5.3 is used the accuracy of integrated FDG-PET-CT for each N2 nodal station is maximized and is at least 92% for each.

CONCLUSIONS

The maxSUV of individual mediastinal lymph nodes is a predictor of malignancy. There is overlap between false and true positives. Definitive biopsies are required to prove cancer irrespective of the maxSUV value. However, when a maxSUV of 5.3 is used instead of the traditional value of 2.5, the accuracy for FDG-PET-CT for each N2 nodal station increases to at least 92%.