Prognostic factors obtained by a pathologic examination in completely resected non-small-cell lung cancer. An analysis in each pathologic stage

Are elastic stain and specialty sign out necessary to evaluate pleural invasion in lung cancers?

The seventh edition of American Joint Committee on Cancer (AJCC) staging system assigns lung cancers with visceral pleural invasion in the tumor size of 3 cm or less than 3 cm as T2 and without pleural invasion as T1. However, it may be difficult to distinguish with certainty between PL0 (no pleural invasion) and PL1 (extends through the elastic layer) on routine hematoxylin and eosin (H&E) stain. In this study, 25 cases of peripherally located lung adenocarcinoma were retrieved from the surgical pathology archives at the Asan Medical Center from May through June 2009. One representative H&E-stained slide was selected from each case and circulated to 31 pathology trainees and board-certified pathologists at Asan Medical Center who evaluated presence or absence of pleural invasion on H&E-stained slides. Elastic stain was used to determine the final status of pleural invasion for each case. The concordance rate of all pathologists with elastic stain results was, overall, 60.5%. The concordance rate of 2 lung specialists was 64%, better than the remaining faculty (54.7%). Fellows' and residents' evaluations were slightly more concordant than those of faculty responses (faculty overall, 56.4%; fellows, 62%; residents, 63.6%), but this difference was not statistically significant (P = .228). Our results confirm that pleural invasion status is difficult to discern with certainty on H&E-stained sections alone. Therefore, we recommend the routine use of elastic stain in evaluation of pleural invasion in all peripherally located lung cancers. Furthermore, our study indicates that subspecialty sign out may be preferable in evaluation of pleural invasion status.

Blood vessel invasion as a strong independent prognostic indicator in non-small cell lung cancer: a systematic review and meta-analysis

Background and Objective

Blood vessel invasion plays a very important role in the progression and metastasis of cancer. However, blood vessel invasion as a prognostic factor for survival in non-small cell lung cancer (NSCLC) remains controversial. The aim of this study is to explore the relationship between blood vessel invasion and outcome in patients with NSCLC using meta-analysis.

Methods

A meta-analysis of published studies was conducted to investigate the effects of blood vessel invasion on both relapse-free survival (RFS) and overall survival (OS) for patients with NSCLC. Hazard ratios (HRs) with 95% confidence intervals (95% CIs) were used to assess the strength of this association.

Results

A total of 16,535 patients from 52 eligible studies were included in the systematic review and meta-analysis. In total, blood vessel invasion was detected in 29.8% (median; range from 6.2% to 77.0%) of patients with NSCLC. The univariate and multivariate estimates for RFS were 3.28 (95% CI: 2.14–5.05; P<0.0001) and 3.98 (95% CI: 2.24–7.06; P<0.0001), respectively. For the analyses of blood vessel invasion and OS, the pooled HR estimate was 2.22 (95% CI: 1.93–2.56; P<0.0001) by univariate analysis and 1.90 (95% CI: 1.65–2.19; P<0.0001) by multivariate analysis. Furthermore, in stage I NSCLC patients, the meta-risk for recurrence (HR = 6.93, 95% CI: 4.23–11.37, P<0.0001) and death (HR = 2.15, 95% CI: 1.68–2.75; P<0.0001) remained highly significant by multivariate analysis.

Conclusions

This study shows that blood vessel invasion appears to be an independent negative prognosticator in surgically managed NSCLC. However, adequately designed large prospective studies and investigations are warranted to confirm the present findings.

Elevated progesterone receptor membrane component 1/sigma-2 receptor levels in lung tumors and plasma from lung cancer patients

Cancer is one of the leading causes of death, and there is an urgent need for new biomarkers and therapeutic targets. The progesterone receptor membrane component 1 (Pgrmc1) protein is upregulated in multiple types of cancer, and Pgrmc1 is required for tumor cell proliferation, motility and tumor formation in vivo. Furthermore, a small molecule inhibitor of Pgrmc1 suppressed the growth of lung, breast and cervical cancer cell lines. Recently, Pgrmc1 was identified as the sigma-2 receptor, a putative type of opioid receptor, and sigma-2 receptors are induced in cancers. However, Pgrmc1 shares no homology with known opioid or hormone receptors but is related to cytochrome b(5), and Pgrmc1 binds to heme and has reducing activity. In this study, we have analyzed Pgrmc1 levels in clinical tumor samples from squamous cell lung cancers (SCLC) and lung adenocarcinomas compared to corresponding nonmalignant tissue. Pgrmc1 levels increased significantly (p ≤ 0.05) in 12/15 SCLC samples and was elevated in poorly differentiated tumors. Pgrmc1 was highly expressed in SCLC cell lines, and SCLC cell survival was inhibited by siRNA knockdown of Pgrmc1 or the Pgrmc1 inhibitor AG-205. In adenocarcinomas, 6/15 tumors significantly had elevated Pgrmc1 levels, which correlated with patient survival. Pgrmc1 localizes to secretory vesicles in cancer cells, and Pgrmc1 was secreted by lung cancer cells. Furthermore, Pgrmc1 was significantly elevated in the plasma of lung cancer patients compared to noncancer patients. Together, the results demonstrate that Pgrmc1 is a potential tumor and serum biomarker, as well as a therapeutic target, for lung cancer.

How close are we to customizing chemotherapy in early non-small cell lung cancer?

Although surgery is the only potentially curative treatment for early-stage non-small cell lung cancer (NSCLC), 5-year survival rates range from 77% for stage IA tumors to 23% in stage IIIA disease. Adjuvant chemotherapy has recently been established as a standard of care for resected stage II-III NSCLC, on the basis of large-scale clinical trials employing third-generation platinum-based regimens. As the overall absolute 5-year survival benefit from this approach does not exceed 5% and potential long-term complications are an issue of concern, the aim of customized adjuvant systemic treatment is to optimize the toxicity/benefit ratio, so that low-risk individuals are spared from unnecessary intervention, while avoiding undertreatment of high-risk patients, including those with stage I disease. Therefore, the application of reliable prognostic and predictive biomarkers would enable to identify appropriate patients for the most effective treatment.This is an overview of the data available on the most promising clinicopathological and molecular biomarkers that could affect adjuvant and neoadjuvant chemotherapy decisions for operable NSCLC in routine practice. Among the numerous candidate molecular biomarkers, only few gene-expression profiling signatures provide clinically relevant information warranting further validation. On the other hand, real-time quantitative polymerase-chain reaction strategy involving relatively small number of genes offers a practical alternative, with high cross-platform performance. Although data extrapolation from the metastatic setting should be cautious, the concept of personalized, pharmacogenomics-guided chemotherapy for early NSCLC seems feasible, and is currently being evaluated in randomized phase 2 and 3 trials. The mRNA and/or protein expression levels of excision repair cross-complementation group 1, ribonucleotide reductase M1 and breast cancer susceptibility gene 1 are among the most potential biomarkers for early disease, with stage-independent prognostic and predictive values, the clinical utility of which is being validated prospectively. Inter-assay discordance in determining the biomarker status and association with clinical outcomes is noteworthing.

Prognostic impact of MMP-2 and MMP-9 expression in pathologic stage IA non-small cell lung cancer

BACKGROUND

The purpose of the present study was to assess the value of matrix metalloproteinase (MMP)-2 and MMP-9 expression and other potential prognostic factors in predicting the clinical outcome of patients after definitive surgery for pathologic stage IA non-small cell lung cancer (NSCLC).

METHODS

One hundred and forty-six consecutive and non-selected patients who underwent definitive surgery for stage IA NSCLC were included in this study. Formalin-fixed paraffin-embedded specimens were stained for MMP-2 and MMP-9, which were statistically evaluated for their prognostic value and other clinicopathological parameters.

RESULTS

Of the 146 patients studied, 102 (69.9%) cases were classified as having high expression for MMP-2. A total of 89 carcinomas (61.0%) had high expression for MMP-9. MMP-9 expression correlated with Eastern Cooperative Oncology Group (ECOG) performance status, pT stage, and differentiation (P = 0.005, <0.001, and <0.001, respectively). Vessel invasion, pT stage, and MMP-9 expression maintained their independent prognostic influence on overall survival (P = 0.037, <0.001, and <0.001, respectively).

CONCLUSIONS

From results of our relatively large database, MMP-9 may be considered as a viable biomarker that can be used in conjunction with other prognostic factors such as vessel invasion and pT stage to predict the prognosis of patients with completely resected pathologic stage IA NSCLC.

Significance of the presence of microscopic vascular invasion after complete resection of Stage I-II pT1-T2N0 non-small cell lung cancer and its relation with T-Size categories: did the 2009 7th edition of the TNM staging system miss something?

INTRODUCTION

The aim of this study was to assess the significance of microscopic vascular invasion (MVI) in a population of resected patients with early-stage non-small cell lung cancer (NSCLC), along with an analysis of the effect of the combination of MVI and tumor size for the T-size categories T1a-T2b according to the 2009 7th edition of the tumor, node, metastasis (TNM) classification.

METHODS

From January 1993 to August 2008, 746 patients with pT1-T2N0 NSCLC received resection at our institution. MVI was ascertained using histopathological and immunohistochemical techniques.

RESULTS

MVI was observed in 257 patients (34%). Prevalence was higher in adenocarcinoma (ADK) than in squamous cell carcinoma (p = 0.002). A significant correlation was found between MVI and ADK (p = 0.03), increased tumor dimension (p = 0.05), and the presence of tumor-infiltrating lymphocytes (p = 0.02). The presence of MVI was associated with a reduced 5-year survival overall (p = 0.003) and in ADK (p = 0.0002). In a multivariate survival analysis, MVI was an indicator of poor survival overall (p = 0.003) and in ADK (p = 0.0005). In each T category (T1a-T2b) of the 2009 TNM staging system, survival of MVI+ patients was significantly lower than the corresponding MVI- patients; T1a and T1b MVI+ patients had a survival similar to MVI- T2 patients.

CONCLUSIONS

The finding of MVI in pT1-T2N0 NSCLC is frequent. MVI correlates with adenocarcinoma histotype, increased tumor dimensions, and tumor-infiltrating lymphocytes. The presence of MVI is an independent negative prognostic factor. In our experience, MVI was a stronger prognostic indicator than T size in T1a-T2b categories according to the 2009 TNM staging system.

Positron emission tomography/computed tomography and lymphovascular invasion predict recurrence in stage I lung cancers

BACKGROUND

Although pathologic stage I lung cancers generally have a favorable prognosis, approximately 20% of patients experience recurrence after surgery. Therefore, a method of selecting patients who need adjuvant therapy is necessary. The goal of this study was to evaluate the significance of positron emission tomography (PET)/computed tomography (CT) results after lung cancer surgery and to identify the predictive factors for recurrence in cases of pathologic stage I lung cancer.

METHODS

From January 2004 to December 2008, 356 patients with lung cancer underwent surgery at our institution. Of these, 282 patients received F-18 fluorodeoxyglucose PET/CT, and the maximum standardized uptake value (max SUV) was measured. There were 201 patients with pathologic stages IA and IB evaluated. The associations between disease-free survival (DFS) and the following clinicopathological factors were analyzed: age, gender, smoking history, carcinoembryonic antigen level, tumor size, max SUV values, histology, and lymphovascular and pleural invasion.

RESULTS

The 4-year DFS rate was 86.3%. Multivariate analysis revealed lymphovascular invasion (LVI; p < 0.01) and max SUV ≥4.7 (p < 0.01) to be independent predictive factors. Patients with a max SUV more than 4.7 had a significantly high risk of recurrence. DFS of patients with high max SUVs and LVI (n = 18) was significantly reduced compared with other patients (n = 183, p < 0.01).

CONCLUSIONS

The PET-CT results significantly correlated with recurrence in pathologic stage I lung cancers. Patients with high max SUVs and LVI were more likely to have recurrence and should be candidates for adjuvant chemotherapy.

Prognostic stratification of patients with T3N1M0 non-small cell lung cancer: which phase should it be?

In the 1997 revision of the TNM staging system for lung cancer, patients with T3N0M0 disease were moved from stage IIIA to stage IIB since these patients have a better prognosis. Despite this modification, the local lymph node metastasis remained the most important prognostic factor in patients with lung cancer. The present study aimed to evaluate the prognosis of patients with T3N1 disease as compared with that of patients with stages IIIA and IIB disease. During 7-year period, 313 patients with non-small cell lung cancer (297 men, 16 women) who had resection were enrolled. The patients were staged according the 2007 revision of Lung Cancer Staging by American Joint Committee on Cancer. The Kaplan-Meier statistics was used for survival analysis, and comparisons were made using Cox proportional hazard method. The 5-year survival of patients with stage IIIA disease excluding T3N1 patients was 40%, whereas the survival of the patients with stage IIB disease was 66% at 5 years. The 5-year survival rates of stage III T3N1 patients (single-station N1) was found to be higher than those of patients with stage IIIA disease (excluding pT3N1 patients, P = 0.04), while those were found to be similar with those of patients with stage IIB disease (P = 0.4). Survival of the present cohort of patients with T3N1M0 disease represented the survival of IIB disease rather than IIIA non-small cell lung cancer. Further studies are needed to suggest further revisions in the recent staging system regarding T3N1MO disease.

Prognostic impact of histology on early-stage non-small cell lung cancer

BACKGROUND

The purpose of this study is to evaluate the significance of histology as a predictor of recurrence after resection in patients with early-stage non-small cell lung cancer.

METHODS

A total of 1,870 consecutive patients in stage I and II with adenocarcinoma or squamous cell carcinoma (SCC) who underwent complete tumor resection with systematic lymph node dissection between August 1992 and December 2007 were included.

RESULTS

In patients with SCC, significantly more tumors were stage IB or higher. Ever smokers were more common in patients with SCC, and more patients with SCC died of other diseases. In stage IA, a statistically significant difference in the 5-year recurrence-free probability was observed between adenocarcinoma and SCC (91.4% and 82.6%, respectively; P < .001), whereas no such difference was observed in stage IB (74.4% and 73.6%, respectively; P = .934). In stage II, the 5-year recurrence-free probability for adenocarcinoma was significantly lower than that for SCC (47% and 73%, respectively; P < .001). In stage IA, patients with predominantly bronchioloalveolar carcinoma subtype were more common compared with stage IB or higher in patients with adenocarcinoma.

CONCLUSIONS

It is important to offset the prognostic impact of comorbidities associated with cigarette smoking because more patients with SCC died of other diseases. When evaluating its significance as a predictor of recurrence stratified by stage, histology showed a different impact on postoperative recurrence within different substages. Histologic subtype distribution was different among substages in patients with adenocarcinoma. Disease stages should be considered while evaluating histology as a predictor of recurrence.

Extratumoral vascular invasion is a significant prognostic indicator and a predicting factor of distant metastasis in non-small cell lung cancer

INTRODUCTION

Vascular invasion is thought to be a fundamental step in hematogenous metastasis. The aim of this study was to assess whether the qualitative evaluation of vascular invasion according to its location (intratumoral or extratumoral) could provide an appropriate means of predicting the prognostic outcome and potential patterns of recurrence in non-small cell lung cancer.

METHODS

We reviewed the cases of 1000 consecutive patients in whom complete resection of non-small cell lung cancer had been performed. Sections stained by the Victoria blue van Gieson method were examined for the presence of vascular invasion and the evaluation of its location (v0: absence, n = 540; v1: intratumoral, n = 428; v2: extratumoral, n = 32). Survival was estimated using the Kaplan-Meier method. To determine independent prognostic factors, univariate and multivariate analyses were conducted.

RESULTS

The study cohort included 605 men and 395 women, with a mean age of 66 years (range, 20-90 years). The 5-year overall survival rate of the vascular invasion-negative group and the vascular invasion-positive group was 82.5% and 55.1%, respectively (p < 0.001), and the 5-year overall survival rates of the v1 group and v2 groups were 55.9% and 44.0%, respectively (p = 0.010). Multivariate analysis showed that location of the vascular invasion (v0-1 versus v2) (p = 0.049), age (p = 0.030), tumor size (p = 0.004), lymph node metastasis (p < 0.001), and pleural invasion (p < 0.001) were significant prognostic factors. The proportion of patients who developed distant metastasis was significantly higher in the v2 group than in the v1 group (p = 0.026).

CONCLUSION

Evaluation of vascular invasion location was a statistically significant predictor of prognosis and potential recurrence patterns.

Poor prognostic factors in patients with stage IB non-small cell lung cancer according to the seventh edition TNM classification

BACKGROUND

This study investigated poor prognostic factors in patients with stage IB non-small cell lung cancer (NSCLC) according to the seventh edition of the TNM classification.

METHODS

Between July 1992 and December 2004, 1,204 consecutive patients with stage I NSCLC diagnosed based on the sixth edition TNM classification underwent complete resection with systematic node dissection. Of these patients, 434 were reclassified as stage IB according to the seventh edition TNM classification. Univariate analyses were performed using the log-rank test to select prognostic factors. The Cox proportional hazards regression model was used for multivariate analyses to identify independent factors indicating an unfavorable prognosis.

RESULTS

On multivariate analyses, two variables were independent significant factors indicating an unfavorable prognosis: presence of intratumoral vascular invasion and presence of visceral pleural invasion. According to subgroup analyses combining these two risk factors, 5-year disease-specific survival probabilities were 93%, 83%, and 73% for patients with zero, one, or two risk factors, respectively. The 5-year disease-specific survival of patients without risk factors was not statistically different from that of patients with stage IA cancer. In addition, the 5-year disease-specific survival curve of patients with two risk factors lay beneath that of patients with T2b or T3N0M0, stage II cancer, and there were no statistically significant differences between them.

CONCLUSIONS

We identified the presence of intratumoral vascular invasion and the presence of visceral pleural invasion as independent poor prognostic factors in patients with stage IB NSCLC. When these two factors are combined, higher- and lower-risk subgroups can be identified, which will help to personalize adjuvant chemotherapy.

A histochemical approach to the diagnosis of visceral pleural infiltration by non-small cell lung cancer

INTRODUCTION

Although invasion of the visceral pleura (VPI) by non-small cell lung cancer (NSCLC) is a TNM-relevant diagnostic criterion and is known to affect the patients' prognoses, until recently there were no standardized or internationally accepted guidelines. This resulted in a diagnostic ambiguity leading to different tumor staging systems and to hardly comparable patient collectives in research studies world wide. The major problem in this issue is to exactly define what constitutes for the diagnosis of VPI with respect to anatomical landmarks.

METHODS

In order to address this problem we investigated the pleural infiltration depth of 173 NSCLC specimens without lymph node metastases and proven tumor-related death using elastic stains and a scoring system referring to prominent pleural elastic layers, the lamina elastica externa and interna, as anatomical landmarks.

RESULTS

Performing comparative Kaplan-Meier survival analyses for each patient collective we could not find any significant difference in the patients' survival. This indicates that a differential evaluation of the tumor infiltration depth according to the elastic layers is not practicable.

CONCLUSIONS

Our findings support the consequent application of the recently proposed, pragmatic approach of the international staging committee for lung cancer (IASLC) to define an internationally accepted and standardized staging system for VPI.

Resection of secondary pulmonary malignancies in head and neck cancer patients

BACKGROUND

This study aimed to evaluate a single institute's experience with resection of metachronous pulmonary malignancy in patients treated for squamous cell carcinoma of the head and neck.

METHODS

Sixty-three consecutive patients treated curatively for head and neck squamous cell carcinoma underwent surgical resection of malignant lung lesions. Survival was estimated and potential prognostic factors investigated.

RESULTS

The median overall survival for the total group was 22.2 months. Fifty-one patients (81 per cent) had one lung lesion, while the remainder had multiple lesions (range, two to seven). In the 63 patients, 35 lobectomies, 4 pneumonectomies and 24 wedge resections were performed. For patients with pulmonary squamous cell carcinoma (n = 52), the three-year survival rate was 35 per cent (95 per cent confidence interval, 22-48); for patients with resected adenocarcinoma (n = 10), it was 50 per cent (95 per cent confidence interval, 18-75). The overall five-year survival rate was 30 per cent (95 per cent confidence interval, 19-42).

CONCLUSION

In patients treated curatively for head and neck squamous cell carcinoma, resection of secondary pulmonary cancer is associated with favourable long term overall survival, especially for patients with adenocarcinoma lesions.

Long-term survival and risk factors for recurrence in stage I non-small cell lung cancer patients with tumors up to 3 cm in maximum dimension

BACKGROUND

The purpose of this study was to evaluate patients with stage I non-small cell lung cancer (NSCLC) and tumors up to 3 cm in maximum dimension who underwent surgical resection on the revised TNM classification and to investigate the risk factors for recurrence.

METHODS

Between 1994 and 2003, 713 consecutive stage I NSCLC patients with tumors up to 3 cm in maximum dimension underwent complete resection. Recurrence-free probability was estimated from the date of the primary tumor resection to the date of the first recurrence or the last follow-up using the Kaplan-Meier method.

RESULTS

The recurrence-free probability of stage I NSCLC patients with tumors up to 3 cm in maximum dimension was 87% at 5 years. On multivariate analyses, three variables were shown to be independently significant recurrence risk factors: histologic differentiation (hazard ratio, 2.3), intratumoral vessel invasion (hazard ratio, 2.9), and visceral pleural invasion (VPI) (hazard ratio, 1.8). According to subgroup analyses combining these three risk factors, the 5-year recurrence-free probability was 94% for patients with zero or one factor (n = 492) and 71% for patients with two or three factors (n = 221), respectively (P < .001).

CONCLUSION

In stage I NSCLC patients with tumors up to 3 cm in maximum dimension, we identified three risk factors for recurrence that independently increase their risk of recurrence. In addition to VPI, histologic differentiation and intratumoral vessel invasion should be examined and their data collected for the next revision of the TNM staging system.

Tumor location is not an independent prognostic factor in early stage non-small cell lung cancer

BACKGROUND

Conventional thoracic surgical teaching suggests a worse outcome for lower lobe lung cancers. It is unclear whether this is due to stage migration or whether lobar location is an independent negative prognostic factor.

METHODS

We performed a retrospective review of our institutional database of patients undergoing resection for pathologic stage I or stage II lung cancer between Jan 2000 and December 2006. Survival analysis was used to compare outcomes in various groups using the log-rank test. Logistic regression analysis was used to compare the primary dependent variables; age, size, and location of tumor (both laterality and lobe), histology (adenocarcinoma, squamous, large cell, or neuroendocrine and others) and type of resection (wedge, lobectomy or segmentectomy, and pneumonectomy).

RESULTS

A total of 841 patients met the inclusion criteria. The mean age of patients was 64.9 years, mean tumor size 3.3 cm, and, 144 patients had N1 disease. The three-year and five-year survivals for stage I tumors were 346 of 478 (72.4%) and 277 of 497 (55.7%), respectively. There was no difference in survival based upon lobar location. The three-year and five-year survivals for stage II tumors were 81 of 175 (46.3%) and 39 of 150 (26%), respectively, and lobar location did not influence survival. Logistic regression analysis showed that for stage I tumors increasing age and having undergone a pneumonectomy were associated with worse survival, and for stage II tumors increasing age and adenocarcinoma histology were associated with worse survival.

CONCLUSIONS

Tumor location within the lung does not predict survival in pathologic stage I/II non-small cell lung carcinoma. Increasing age, adenocarcinoma histology, and pneumonectomy as the resection may lead to worse long-term survival.

Prognostic significance of intratumoral blood vessel invasion in pathologic stage IA non-small cell lung cancer

BACKGROUND

The 5-year survival rate of pathologic stage IA non-small cell lung cancer (NSCLC) is excellent; however, up to 10% of patients with pathologic stage IA NSCLC still relapse postoperatively and die. This study retrospectively analyzed the clinicopathologic features of patients with pathologic stage IA NSCLC to identify the prognostic factors and investigate the effect of a combination of intratumoral vessel invasion and tumor size.

METHODS

From December 1991 to December 2003, 217 consecutive patients with stage IA NSCLC were selected, and disease-free survival (DFS) was analyzed.

RESULTS

Intratumoral blood vessel invasion (BVI) was identified as an independent poor prognostic factor (p = 0.0006). The relative risk for patients with BVI was 4.599 times higher than that for patients without BVI (95% confidence interval, 1.913 to 11.056). According to the new T N M system, the difference in DFS between the patients with and without BVI was statistically significant, not only in tumors exceeding 2 cm (T1b with BVI vs T1b without BVI, p = 0.0020) but also in tumors smaller than 2 cm (T1a with BVI vs T1a without BVI, p < 0.0001). The survival curve of T1b patients without BVI was similar to that of T1a patients without BVI (p = 0.0892). Distant recurrence was frequently observed in both T1a and T1b patients with BVI.

CONCLUSIONS

BVI is an independent poor prognostic factor in patients with pathologic stage IA NSCLC. These T1a and T1b patients with BVI both might benefit from adjuvant chemotherapy.

Pleomorphic carcinoma of the lung: clinicopathologic characteristics of 70 cases

Pleomorphic carcinoma (PC) of the lung is rare, and it is classified as a subtype of sarcomatoid carcinoma of the lung in the World Health Organization histologic classification of lung tumors. In this study, 70 cases of PC surgically resected were reviewed to identify its clinicopathologic characteristics. There were 57 men and 13 women, and their mean age was 66 years (range: 29 to 80 y). Sixty-eight tumors contained identifiable epithelial components, and the other 2 consisted of spindle cells and giant cells alone. An adenocarcinoma component was found in 34 cases, a squamous cell carcinoma component in 13, and a large cell carcinoma component in 40. The overall survival rate and disease-free survival rate were 36.6% and 40.7%, respectively, and both rates were significantly lower than for other nonsmall cell lung carcinomas. When the PC patients were divided into 3 groups according to the predominant epithelial component, an adenocarcinoma group, squamous cell carcinoma group, and large cell carcinoma group, there were no significant differences in the overall survival rate and median survival time between the 3 groups. Univariate analysis revealed that advanced stage (stage III), mediastinal lymph node metastasis, lymphatic permeation, and histologically diagnosed massive coagulation necrosis (>25% of the tumor) predicted poorer disease-free survival. Multivariate analysis showed that massive necrosis alone was an independent prognostic factor. We concluded that PC should be considered as an aggressive disease and massive necrosis should be routinely reported and used as a factor in clinical assessments.

Prognostic value and therapeutic consequences of vascular invasion in non-small cell lung carcinoma

The prognostic relevance of blood vessel invasion (BVI) in non-small cell lung carcinoma (NSCLC) remains controversial, as is the question of whether its finding should influence therapeutic decisions after an R0 resection. One hundred and twelve cases of NSCLC were included in the study. All had been treated by potentially curative surgical resection of the primary tumor and systematic lymphadenectomy. In all cases, lymphatic metastatic spread was at its earliest stage and only one regional lymph node was involved, 27.0+/-8.9 nodes per patient being examined histologically. Most of the cases were pT2 (75.9%) and pN1 (81.3%), and all were MX/M0 and R0. 62.5% were at stage IIB, 25.9% at stage IIIA, and 9.8% at stage IIA. BVI was found in 45.5% of the tumors (V1), and 18.8% exhibited both lymphatic invasion and BVI (L1V1). Local recurrence occurred in 10.7% of the patients, distant metastasis in 24.1%, and both forms of tumor progression simultaneously in a further 7.1%. Thus 31.2% of the patients developed distant metastases by hematogenous spread (to the brain, bones, lung, adrenal, and liver, in descending order of frequency), mostly within two years of surgery. Late metastasis is not typical of NSCLC. Adenocarcinomas showed a strong tendency to be associated with a poorer prognosis than squamous cell carcinomas, probably because of their more frequent involvement of blood vessels. Five-year survival (Kaplan-Meier method) was significantly lower in V1 cases (37.2%) than in V0 cases (56.0%; p = 0.0249). Adjuvant mediastinal radiation in node-positive cases of NSCLC may prevent local recurrence but is unlikely to influence the development of distant metastases. The histological detection of BVI is of prognostic relevance and should be considered for inclusion in the staging criteria and indications for adjuvant chemotherapy.

Prognostic impact of intratumoral vessel invasion in completely resected pathologic stage I non-small cell lung cancer

OBJECTIVE

Intratumoral vessel invasion of non-small cell lung cancer is a readily available tumor-related factor that provides direct evidence of microscopic tumor invasion. We assessed the prognostic influence of intratumoral vessel invasion and its ability to provide a differential prediction of prognosis for completely resected pathologic stage I non-small cell lung cancer.

METHODS

We analyzed 258 patients with non-small cell lung cancer who underwent complete resection between January of 1996 and December of 2005 and were diagnosed with pathologic stage I disease. In addition to the conventional staging factors, intratumoral vessel invasion in the primary lesion was histologically evaluated by both hematoxylin-eosin and elastic staining. We examined the significance of intratumoral vessel invasion in prognosis and compared the outcomes between patients with and without this factor with stage IA and IB disease, respectively.

RESULTS

Intratumoral vessel invasion was found in 124 patients (48%). Five-year survival of patients with or without intratumoral vessel invasion was 74% and 93%, respectively. On multivariate analysis, intratumoral vessel invasion and pleural invasion were shown to be independent prognostic factors. Subgroup analyses suggested that patients with pathologic-stage IA with intratumoral vessel invasion and patients with pathologic-stage IB with both intratumoral vessel and pleural invasion had significantly worse prognosis than patients with the same pathologic stage without these factors.

CONCLUSION

The current study indicated that intratumoral vessel invasion and pleural invasion are independent prognostic factors. Intratumoral vessel invasion status can complement the size-dependent TNM staging system in pathologic stage I non-small cell lung cancer.

A clinical model to estimate recurrence risk in resected stage I non-small cell lung cancer

OBJECTIVE

There are no reliable markers to predict recurrence in resected Stage I non-small cell lung cancer (NSCLC). A validated clinical model to estimate the risk of recurrence would help select patients for adjuvant therapy.

METHODS

We reviewed the medical records of 715 patients who had a potentially curative resection for Stage I NSCLC at our institution from 1990 to 2000. Recurrence rates were estimated by the Kaplan-Meier method. A model to estimate risk of recurrence was developed by combining independent risk factors.

RESULTS

With a median follow-up of 4.7 years, the 5-year survival rates for Stages IA and IB were 66% and 55% respectively, and 5-year recurrence rates were 19% and 30%, respectively. Four factors were independently associated with tumor recurrence: tumor size >3 cm (hazard ratio [HR] = 2.4), surgery other than lobectomy (HR = 2.0), nonsquamous histology (HR = 1.4), and high-grade cellular differentiation (HR = 1.4). A scoring system for recurrence was developed by assigning 2 points for each major risk factor (tumor size and surgery) and 1 point for each minor risk factor (histologic subtype and cellular grade). Scores were grouped as low (0-1), intermediate (2-3), and high (>3), yielding 5-year estimates of risk of recurrence of 14%, 27%, and 43%, respectively.

CONCLUSION

This model, based upon readily available clinicopathologic characteristics, can estimate the risk of recurrence in Stage I NSCLC, independent of T classification. This model could be used to select patients for adjuvant therapy if validated in independent data sets.

Prognostic significance of the non-size-based AJCC T2 descriptors: visceral pleura invasion, hilar atelectasis, or obstructive pneumonitis in stage IB non-small cell lung cancer is dependent on tumor size

BACKGROUND

The T2 descriptor for staging non-small cell lung cancer (NSCLC) contains several non-size-based criteria. It remains unknown whether the prognostic significance of these non-size-based criteria is dependent on tumor size.

METHODS

A total of 10,545 patients with stage IB NSCLC from the California Cancer Registry between 1989 to 2003 were categorized into the following three nonoverlapping criteria: (1) tumor size (T2S); (2) visceral pleura invasion, hilar atelectasis, or obstructive pneumonitis (T2P); and (3) main bronchus involvement > or = 2 cm from the carina (T2C). Univariate survival analyses were performed using the Kaplan-Meier method. Multivariate survival analyses were performed using Cox proportional hazards ratios.

RESULTS

A total of 51.1% of patients with stage IB NSCLC were staged by T2S, 43.2% by T2P, and 5.7% by T2C; 2,224 stage IB patients (total, 21.1%; 18.9% T2P + 2.2% T2C) had tumors < or = 3 cm in size. The 5-year survival rate and the median survival time of these stage IB patients with tumors < or = 3 cm in size were as follows: T2P, 51.2% and 64 months, respectively; T2C, 49.0% and 58 months, respectively. These values were similar to the 53.2% 5-year survival rate and 67-month median survival time for patients with stage IA NSCLC (p = 0.40). Cox proportional hazards model revealed T2P of > 3 cm was a poor prognostic factor for survival (vs T2S; hazard ratio [HR], 1.16; 95% confidence interval [CI], 1.08 to 1.24). Conversely, T2P < or = 3 cm was a favorable prognostic factor for survival (vs T2S; HR, 0.89; 95% CI, 0.82 to 0.96). T2C was not an independent prognostic factor for survival.

CONCLUSIONS

Prognostic significance of the non-size-based T2 descriptor T2P is dependent on tumor size.

Prognostic value of histology in resected lung cancer with emphasis on the relevance of the adenocarcinoma subtyping

BACKGROUND

Adenocarcinoma (AC) is the most common lung cancer, followed by squamous cell carcinoma (SCC). Controversy exists concerning both cell types. Our purpose was to compare their prognosis after resection and determine whether AC subtyping may have any significance.

METHODS

From 1993 to 2002, 574 patients with SCC and 565 with AC underwent a curative resection and were compared according to sex, age, type of resection, TNM system classification, and survival. One hundred fifty-nine patients with ACs demonstrated a pure histologic pattern according to the 1999 World Health Organization classification, and 406 were of the mixed subtype including cell types with potentially different aggressiveness. Therefore, we compared subgroups according to presence or not of bronchioloalveolar carcinoma or solid adenocarcinoma with mucin component, or both.

RESULTS

Compared with ACs, SCCs had a higher number of males and older patients, and incidences of endobronchial tumors, pneumonectomies, and stage II tumors were higher. Global survival rates were not different. The ACs with solid AC with mucin components (n = 239) were characterized by more males and stage IIB patients, and had poorer survival rates (38.6% vs 61.4%; p < 0.0014) than the ACs without solid AC with mucin component. When comparing these with SCCs, 5-year survival rates were: ACs without solid AC with mucin component (58.1%), SCCs (50.2%), and ACs with solid AC with mucin component (36.8%) (p < 0.000019). Multivariate analysis demonstrated these subgroups and SCCs to be independent factors of prognosis.

CONCLUSIONS

Solid ACs with a mucin component demonstrated the poorest prognosis after resection. Further studies of this cell type, which should be looked for carefully, may help improve targetting adjuvant therapies.

Prognostic factors in resected stage I non-small cell lung cancer with a diameter of 3 cm or less: visceral pleural invasion did not influence overall and disease-free survival

OBJECTIVE

Resection is the treatment of choice for patients with stage I non-small cell lung cancer. Stage I non-small cell lung cancer has been further subdivided into IA (T1N0M0, tumor size < or = 3 cm without visceral pleural invasion) and IB (T2N0M0, tumor size > 3 cm or any size with visceral pleural invasion). The aim of this study was to evaluate the prognostic factors in patients with resected stage I non-small cell lung cancer with a diameter of 3 cm or less.

METHODS

We retrospectively reviewed the clinicopathologic characteristics of 445 patients with resected stage I non-small cell lung cancer with a diameter of 3 cm or less who were treated at Taipei Veterans General Hospital between 1980 and 2000. Disease-free survival, overall survival, and their predictors were analyzed.

RESULTS

The 5- and 10-year overall survivals were 61.4% and 40.0%, respectively. The 5- and 10-year disease-free survivals were 74.5% and 73.4%, respectively. Tumor size, smoking index, and number of mediastinal lymph nodes dissected were significant predictors for both disease-free survival (P = .009, P = .002, and P = .006, respectively) and overall survival (P = .004, P < .001, and P = .001, respectively) in multivariate analyses. Visceral pleural invasion did not influence overall survival or disease-free survival.

CONCLUSIONS

Tumor size, smoking index, and number of mediastinal lymph nodes dissected were prognostic factors for both overall survival and disease-free survival in resected stage I non-small cell lung cancer with a diameter of 3 cm or less. Small tumors (<3 cm) of stage IB (T2N0M0) non-small cell lung cancer with visceral pleural invasion should be treated as T1 disease and not T2 disease.

Surgical assessment and intraoperative management of mediastinal lymph nodes in non-small cell lung cancer

Mediastinal lymph node status has important prognostic and therapeutic implications for nonsmall cell lung cancer patients. Consequently, an accurate pathologic assessment of mediastinal lymph nodes for metastasis is essential. Despite the significance of nodal assessment, practice patterns among surgeons vary widely. Therefore we reviewed the literature to provide evidence-based recommendations regarding the ideal means and extent of preoperative and intraoperative pathologic mediastinal lymph node staging in non-small cell lung cancer patients. We found that the most sensitive and accurate intraoperative method is a complete mediastinal lymph node dissection. Pathologic evaluation of at least 10 mediastinal lymph node from at least three stations should be performed at the time of surgery.

Risk Factors for Recurrence and Unfavorable Prognosis in Patients with Stage I Non-small Cell Lung Cancer and a Tumor Diameter of 20 mm or Less

BACKGROUND

The purpose of this study was to identify risk factors for disease recurrence and unfavorable prognosis after surgical resection for stage I non-small cell lung cancer in patients with tumor diameters of < or =20 mm.

METHODS

One hundred sixty-three patients who had pathologic stage I non-small cell lung cancer with tumor diameters < or =20 mm and who had undergone a lobectomy with mediastinal lymph node dissection were retrospectively reviewed. The relationships between clinicopathologic factors and clinical outcomes, including recurrence and survival, were then examined. The clinicopathologic factors examined in this study were age, sex, smoking status, preoperative serum carcinoembryonic antigen level, pathologic tumor size, histologic subtype, histologic grade, and visceral pleural invasion.

RESULTS

Among the clinicopathologic factors that were examined, the histologic grade of the carcinoma status was significantly related to a high risk of recurrence when analyzed using univariate (p = 0.01) and multivariate analyses (p = 0.049). Regarding survival, patients with poorly differentiated carcinomas showed a significantly unfavorable overall survival (p < 0.001), disease-specific survival (p = 0.003), and disease-free survival (p = 0.002) compared with patients with well-/moderately differentiated carcinomas according to univariate analyses. A Cox proportional hazards model indicated that a poorly differentiated carcinoma status was the only independent factor for an unfavorable overall survival (p = 0.02), disease-specific survival (p = 0.046), and disease-free survival (p = 0.04).

CONCLUSIONS

Poor differentiation of tumor was the only risk factor for recurrence and an unfavorable prognosis for stage I non-small cell lung cancer patients with tumor diameters of < or =20 mm.

Impact of Elastic Staining on the Staging of Peripheral Lung Cancers

Accurate staging of lung cancer has a profound impact on patient management. For stage I nonsmall cell lung carcinomas (NSCLCs), the absence (stage IA) or presence (stage IB) of visceral pleural invasion represents a critical therapeutic branch point: patients with stage IB NSCLC benefit from adjuvant chemotherapy, whereas patients with stage IA NSCLC do not. Elastic staining has been advocated as a simple method for visualizing pleural invasion. The purpose of this study was to determine whether routine elastic staining of the resected peripheral NSCLCs alters tumor staging in a meaningful way. The study cases consisted of 100 consecutive peripheral NSCLCs resections that were pathologically staged as IA based on routine histologic assessment. Each case was stained with the Movats pentachrome elastic stain to aid identification of visceral pleural invasion. To assess current standards of surgical pathology practice, members of the American Association of Directors of Anatomic and Surgical Pathology were asked whether they never, sometimes, or always order elastic stains for peripheral NSCLCs that abut the pleura. Elastic staining resulted in a change of tumor stage from IA to IB in 19 (19%) cases. Of the 49 pathologists that responded to the survey, 25 (51%) never, 14 (29%) sometimes, and 10 (20%) always order an elastic stain for NSCLCs abutting the pleura. Elastic staining is currently not standard surgical pathology practice for the evaluation of peripheral NSCLCs, but it should be. Invasion of the pleura is an elusive finding that is best appreciated with an elastic stain. Our experience suggests that routine elastic tissue staining should be performed as a standard method of assessing pleural involvement for pleural-based nonsmall cell lung carcinomas.

Significance of extranodal extension of regional lymph nodes in surgically resected non-small cell lung cancer

STUDY OBJECTIVES

Regional lymph node (LN) involvement affects the prognosis of patients with surgically resected non-small cell lung cancer (NSCLC). The significance of extranodal extension in these groups of patients was prospectively studied to determine its clinicopathologic relationships and its influence on patient survival.

METHODS

A total of 199 NSCLC patients who were proved to have regional LN involvement after resection were included. Histologic examinations including tumor cell type, grade of differentiation, vascular invasion, regional LN metastasis emphasizing the number and station of LN involvement, the presence or absence of extranodal extension, and the immunohistochemistry of p53 expression were obtained. The relationships between extranodal extension and histologic type, grade of differentiation, vascular invasion, tumor size, pathologic stage, p53 expression, or patient survival were analyzed.

RESULTS

Extranodal extension was significantly higher in women, adenocarcinoma, advanced stage, tumors with vascular invasion, or p53 overexpression. The total number and positive rate of resected LNs with extranodal extension were significantly correlated with advanced stage, tumors with vascular invasion, or p53 overexpression. By multivariate analysis of survival, the presence or total number of LNs with extranodal extension, tumor stage, and p53 expression were significant prognostic factors. The 5-year survival rate of stage IIIA patients without extranodal extension (30.4%) was significantly better than that of stage II patients with extranodal extension (16.8%). No survival difference between extranodal positive stage II and IIIA patients was noted.

CONCLUSIONS

Extranodal extension of regional LNs is an important prognostic factor in patients with surgically resected NSCLC.

Adenoviral transduction of MRP-1/CD9 and KAI1/CD82 inhibits lymph node metastasis in orthotopic lung cancer model

Conventional therapies still remain less effective for metastasis of lung cancer, thus leading to a poor prognosis for this disorder. Although the processes involved in metastasis have not yet been clearly elucidated, our previous studies have shown that higher expression levels of MRP-1/CD9 and KAI1/CD82 in cancer cells are significantly correlated with less metastatic potency. To determine whether the gene transfer of these tetraspanins into lung tumor cells may be a useful strategy to regulate metastasis, we adopted an orthotopic lung cancer model produced by the intrapulmonary implantation of Lewis lung carcinoma (LLC) cells and evaluated the metastatic growth in the mediastinal lymph nodes using two different methods of gene delivery as follows: (a) the implantation of LLC cells preinfected with adenovirus encoding either MRP-1/CD9 cDNA, KAI1/CD82 cDNA, or LacZ gene into the mouse lung and (b) the intratracheal administration of these adenoviruses into the mice orthotopically preimplanted with LLC cells. In both cases, we found that the delivery of either MRP-1/CD9 or KAI1/CD82 cDNA dramatically reduced the metastases to the mediastinal lymph nodes in comparison with those of LacZ gene delivery, without affecting the primary tumor growth at the implanted site. These results reemphasize the important role of MRP-1/CD9 and KAI1/CD82 in the suppression of the metastatic process and also show the feasibility of gene therapy when using these tetraspanins for lung cancer to prevent metastasis to the regional lymph nodes. This strategy may therefore be clinically applicable as a prophylactic treatment to suppress the occurrence of lymph node metastasis.

Completely resected N1 non–small cell lung cancer: Factors affecting recurrence and long-term survival

OBJECTIVE

N1 disease in non-small cell lung cancer represents a heterogeneous patient subgroup with a 5-year survival of approximately 40%. Few reports have evaluated the correlation between N1 disease and tumor recurrence or which subgroup of patients would most benefit from adjuvant chemotherapy.

METHODS

From 1997 through 2002, all patients with pathologic T1-4 N1 M0 non-small cell lung cancer who had a complete resection with systematic mediastinal lymphadenectomy were retrospectively analyzed and evaluated for factors associated with recurrence and long-term survival.

RESULTS

One hundred eighty patients with N1 disease were evaluated. Sixty-six (37%) patients had either locoregional recurrence (n = 39 [22%]), distant metastasis (n = 41 [23%]), or both during follow-up. Univariate analysis demonstrated that visceral pleural invasion and age were associated with locoregional recurrence, whereas visceral pleural invasion, distinct N1 metastasis (as opposed to direct N1 invasion by the primary tumor), and multistation lymph node involvement were associated with distant metastasis (P < .05). Multivariable analysis demonstrated that visceral pleural invasion, multistation N1 involvement, and distinct N1 metastasis were the only independent predisposing factors for locoregional recurrence and distant metastasis. Overall 5-year survival was 42.5%. Survival was significantly decreased by advanced pathologic T classification (P = .015), visceral pleural invasion (P < .0001), and higher tumor grade (P = .014).

CONCLUSIONS

In patients with N1-positive non-small cell lung cancer, visceral pleural invasion, multistation N1 disease, and distinct N1 metastasis are independent predictors of subsequent locoregional recurrence and distant metastasis. Advanced T classification, visceral pleural invasion, and higher tumor grade were predictors of poor survival. These patients represent a subgroup of patients with N1 disease who might benefit from additional therapy, including adjuvant chemotherapy.

Histologic grade is an independent prognostic factor for survival in non-small cell lung cancer: an analysis of 5018 hospital- and 712 population-based cases

OBJECTIVE

Our objective was to determine whether histologic grade independently contributes to the prognosis of non-small cell lung cancer.

METHODS

A total of 5018 hospital-based patients diagnosed from 1997 to 2003 and 712 population-based patients diagnosed from 1984 to 2003 were followed up through the end of 2004. The effect of histologic grade on postdiagnosis survival or postresection recurrence was evaluated by Cox proportional hazards models. Relative risks (RR) were estimated by comparing undifferentiated, poorly differentiated, and moderately differentiated carcinoma with well-differentiated carcinoma.

RESULTS

Histologic grade was significantly associated with survival after adjustment for the effects of age, gender, smoking history, tumor stage, histologic cell type, and treatment modality. Patients with undifferentiated carcinoma had an 80% elevated risk of death (RR = 1.83; 95% confidence interval [CI], 1.4-2.4) compared with those with well-differentiated carcinoma; 70% and 40% elevated risks were observed for patients with poorly and moderately differentiated carcinoma, respectively (RR, 1.7 [1.5-2.0] and 1.4 [1.2-1.6]). Similar results were observed for 718 incidence cases in which the relative risks were 1.6 (1.1-2.2) and 1.4 (1.0-1.9) for poorly/undifferentiated carcinoma and moderately differentiated carcinoma, respectively. Patients with less-differentiated carcinoma after tumor resection had a higher risk of recurrence, with adjusted hazard ratios of 2.1 (95% CI: 1.4-2.9) and 1.4 (1.0-1.9) for poorly/undifferentiated and moderately differentiated carcinoma compared with well-differentiated carcinoma.

CONCLUSIONS

Histologic grade has significant prognostic value for survival of patients with non-small cell lung cancer. Histologic grade may provide useful information in defining the aggressiveness of tumors and should be considered as an independent factor affecting survival beyond TNM staging.

Outcome following lung resections for pT1 non-small cell lung cancer

AIMS

To analyse the outcome of patients with pT1 NSCLC treated at our institution by antero-lateral thoracotomy, anatomical lung resections and mediastinal lymph node dissection between 1980 and 2001.

METHODS

Follow-up data were obtained retrospectively from 1980 to 1990 and prospectively after 1990. Survival was analysed using the Kaplan-Meier method.

RESULTS

Histopathological examinations revealed mediastinal lymph node infiltration in 27.6% (pN1 17.8% and pN2 9.8%). pN2 was classified in 14.1% of adenocarcinomas compared to 6.2% of squamous cell carcinomas. Median overall survival of patients with pT1 carcinomas was 89+16 months (median+standard error). Histopathological N-classification indicates differential prognostic and therapeutic implications in pT1 adeno- and squamous cell carcinomas.

CONCLUSIONS

Complete lymph node dissection is required for all patients with T1 NSCLC treated by either open surgery or VATS resection. Histopathological N-classification indicates differential prognostic and therapeutic implications in pT1 adeno- and squamous cell carcinomas.

Classification of parietal pleural invasion at adhesion sites with surgical specimens of lung cancer and implications for prognosis

Parietal pleural invasion of non-small cell lung cancer (NSCLC) is a factor for poor prognosis, and a tumor of any size that invades the parietal pleura is classified as T3. However, with microscopic invasion beyond elastic fibers of the visceral pleura but no penetration to the parietal pleura at tight adhesion sites (we term this p1-3), classification as to the T factor is unclear. Among 1,179 consecutive patients with NSCLCs who underwent curative surgery between 1980 and 2002, 20 were in this category. Here, a comparison was made with subgroups of p stages IB, II, and IIIA with regard to histology, pleural invasion, and survival rates. To maximize the power of assessing prognostic potential, we set the significance level at 0.10, one-sided. The p1-3 condition sites of the 20 cases were the parietal pleura for 17 cases and the pericardium, diaphragm, and chest wall for one each of the remainder. The 5-year survival rate for these p1-3 patients was 71.6%. Significant differences were observed between p1-3 and IIIA groups. Although the 5-year survival rates did not significantly differ between p1-3 and T3N0 or unequivocal T3 subgroups, the prognosis of p1-3 patients was rather better than that of T3 and identical to T2. It was demonstrated that p1-3 status is not a factor warranting T3 classification for NSCLCs. Considering the prognosis, pathologic p1-3 tumors should be managed as a T2 disease for the present.

Prognosis of Stage II non-small cell lung cancer according to tumor and nodal status at diagnosis

PURPOSE

To evaluate the prognostic significance of tumor and node status among patients with Stage II non-small cell lung cancer using a population-based national database.

METHODS

We identified all primary cases of Stage II non-small cell lung cancer diagnosed prior to autopsy from the Surveillance, Epidemiology and End Results (SEER) registry. Lung cancer-specific survival curves were obtained for the 5254 patients who had curative surgical resection, stratifying for tumor and node status (T1-2N1M0, T3N0M0). The 12.5-year Kaplan-Meier estimator of survival was used as a measure of lung cancer cure rate. The influence of gender, age, cell type, pathologic tumor status, nodal metastasis, surgical method, and post-operative radiation therapy were evaluated using Cox regression.

RESULTS

Survival was better for T1N1 cases during the first 3--4 years after diagnosis. Five-year survival for T1N1 and T3N0 cases however, was not significantly different (46% versus 48%, p=0.4) and the cure rate was somewhat higher for T3N0 cases (33% versus to 27%, p=0.10). T2N1 cases had the worst overall survival. Multivariate analysis revealed that gender, age, tumor and nodal status, and histology were independent prognostic factors.

CONCLUSIONS

Among Stage II cancers, T3N0 cases have the highest cure rate and an overall survival pattern that more closely resembles T1N1 tumors. Several clinico-pathologic characteristics are significantly associated with survival and may explain some of the heterogeneity in outcomes among Stage II patients. These results suggest that T3N0 cases may be better classified as Stage IIA disease.

Visceral pleural invasion is an invasive and aggressive indicator of non-small cell lung cancer

OBJECTIVE

Although visceral pleural invasion by non-small cell lung cancer is considered a poor-prognostic factor, further information is lacking, especially in relation to other clinicopathologic prognostic factors. We assessed the relationship between visceral pleural invasion and other clinicopathologic characteristics and evaluated its significance as a prognostic factor.

METHODS

We reviewed 1074 patients with surgically resected T1/2 non-small cell lung cancer for their clinicopathologic characteristics and prognoses. The patients were divided into 2 groups according to visceral pleural invasion status (visceral pleural invasion group and non-visceral pleural invasion group). Both groups were compared with regard to age, sex, histology, tumor size, tumor differentiation, lymph node involvement, lymphatic invasion, vascular invasion, scar grade, nuclear atypia, mitotic index, serum carcinoembryonic antigen level, and survival. Univariate and multivariate analyses were conducted.

RESULTS

Visceral pleural invasion was identified in 288 (26.8%) of the resected specimens. Survival was 76.0% at 5 years and 53.2% at 10 years in the non-visceral pleural invasion group and was 49.8% at 5 years and 37.0% at 10 years in the visceral pleural invasion group. The difference between groups was highly significant ( P < .0001). Visceral pleural invasion was also significantly associated with a higher frequency of lymph node involvement. However, regardless of N status (N0 or N1/2), there was a significant difference in survival when the visceral pleura was invaded. Visceral pleural invasion was observed significantly more frequently in tumors with factors indicative of tumor aggressiveness/invasiveness: moderate/poor differentiation, lymphatic invasion, vascular invasion, high scar grade, high nuclear atypia grade, high mitotic index, and high serum carcinoembryonic antigen level. By multivariate analysis, visceral pleural invasion proved to be a significant independent predictor of poor prognosis in non-small-cell lung cancer patients with or without lymph node involvement.

CONCLUSIONS

Visceral pleural invasion is a significant poor-prognostic factor, regardless of N status. Our analyses indicated that visceral pleural invasion is an independent indicator of non-small cell lung cancer invasiveness and aggressiveness.

Association of CK19 mRNA detection of occult cancer cells in mediastinal lymph nodes in non-small cell lung carcinoma and high risk of early recurrence

This study was designed to screen occult cancer cells by CK19 mRNA detection using reverse transcriptase-polymerase chain reaction (RT-PCR) in mediastinal lymph nodes stations (MLNS) in non-small cell lung carcinoma (NSCLC). In 49 NSCLC patients free of mediastinal adenopathy on computed tomograph, 254 MLNS were evaluated by histopathology, immunohistochemistry (IHC) and RT-PCR. Of 225 non-tumoral MLNS on histopathology, 32 (14.2%) were positive by RT-PCR. IHC did not provide significant additional results. Seventeen patients were without mediastinal tumoral extension on histopathology and RT-PCR (Group 1), 16 were upgraded by RT-PCR (Group 2) and 16 pN2 on histopathology (Group 3). The two-year cancer-related death survival in Groups 1 (100%) and 2 (64.5%) was significantly different (P=0.04). The relative risk of recurrence in Group 2 compared with Group 1, evaluated by the Cox model multivariate analysis, was 5.61 (P=0.02). In conclusion, CK19 mRNA detected by RT-PCR in MLNS was significantly associated with an increased risk of rapid recurrence.

The Prospect of Biologic Staging of Non–Small-Cell Lung Cancer

The reductionistic approach to cancer research has led to an enormous amount of information and publications regarding the molecular biologic processes that take place in cancer tissue. However, the specific influence of this information on clinical practice has been limited. With the advent of new reductionistic tools like the transcriptomic and proteomic technologies, many would argue that further advances in the field of lung cancer research will be dominated by advances on the technical level. However, we anticipate that the most revolutionary advances will be those at a conceptual level. Medical science has always been reductionistic in essence, reducing and analyzing the composing elements of our complex biologic machinery, overlooking the fact that the interrelation among a set of simple determinants creates a new dimension of characteristics and functions. Problems emerging from a reductionistic approach are heterogeneity and variability. This review addresses the current conceptual problems in the field of lung cancer biology and provides a new conceptual model based on recent publications.

Visceral pleural invasion in lung cancer: recognizing histologic parameters that impact staging and prognosis

Visceral pleural involvement (VPI) is a critical component in the staging of non-small cell lung carcinoma (NSCLC). Tumors < or =3 cm that involve the visceral pleura are classified as T2 lesions, underscoring the prognostic significance of this histologic parameter. Accurate staging of small NSCLCs depends on appropriately assessing the presence or absence of VPI. Elastic stains can be instrumental in detecting disruptions of the visceral pleural elastic layer by tumor, a finding that has prognostic and staging implications similar to tumor that is present on the visceral pleural surface.

Metachronous and Synchronous Lung Tumors: Five Malignant Lung Pathologies in 1 Patient During 7 Years

We present the case of a 70-year-old man who previously had a left upper lobectomy for nonsmall cell lung carcinoma that subsequently developed into small cell carcinoma, which was successfully treated, and finally he had a right upper lobectomy that revealed three synchronous lung malignancies. We were unable to find a previous case report with a total of five separate lung malignancies with a combination of metachronous and synchronous tumors. This case demonstrates the importance of screening after the diagnosis and treatment of lung carcinoma.