Factors influencing ten-year survival in resected stages I to IIIa non-small cell lung cancer

PET imaging for suspected residual tumour or thoracic recurrence of non-small cell lung cancer after pneumonectomy

F-18 fluorodeoxyglucose-positron emission tomography (PET) was investigated in patients with suspected residual disease or intrathoracic recurrence after pneumonectomy. Patients were identified from a prospective database. Impact of PET on staging and patient management was assessed. Clinical outcome was used to assess appropriateness of management. PET was performed in 17 cases, either post-operatively (n = 8), or later for suspected recurrence (n = 9) in patients with good performance status and without extensive disease on conventional imaging. PET changed treatment in 10 cases (59%). In five patients (29%), PET changed treatment intent (curative versus non-curative) from radical radiotherapy (RT) to palliative RT (n = 1), or observation or supportive care (n = 3), or from palliative to radical RT (n = 1). In a further patient with unexplained pain, PET appropriately showed no evidence of disease. In additional five cases (29%), PET influenced choice of RT dose and the use of concurrent chemotherapy (n = 3) or target volume (n = 2). Patients without tumour or with limited disease on PET had favourable outcomes whereas those with extensive disease suffered early tumour progression. PET was discordant with conventional assessment in >50% of cases. PET may be valuable after pneumonectomy if the patient is being considered for adjuvant or salvage radiotherapy although specificity may be reduced due to post-operative inflammatory changes.

Pancreatic tumors in patients with lung malignancies: a spectrum of clinicopathologic considerations

OBJECTIVES

Lung cancer and pancreatic cancer are the most lethal tobacco-associated malignancies. To elucidate possible clinical interrelationships, the authors reviewed the clinicopathologic characteristics of patients treated for both pulmonary and pancreatic neoplasms.

METHODS

Patients presenting with a potentially resectable pancreatic mass and a diagnosis of metachronous malignant neoplasm of the lung were studied by retrospective chart audit and review of histopathologic material.

RESULTS

Seven patients were identified over 6 years, representing five different clinical entities: metachronous presence of lung cancer and pancreatic cancer (n = 3), lung cancer metastatic to the pancreas (n = 1), lung cancer with a benign pancreatic neoplasm (n = 1), periampullary cancer metastatic to the lung (n = 1), and malignant melanoma metastatic to both lung and pancreas (n = 1). A tobacco history was present in all patients but one. Primary treatment modality was complete resection of isolated sites whenever feasible (lung resection, n = 6; pancreatic resection, n = 5). In four cases, a differential diagnosis of adenocarcinomas of both lung and pancreas was obtained after cytokeratin (CK) 7 and CK 20 immunohistochemistry. All patients with evidence of nodal or visceral metastasis from either primary site (n = 4) died within 5 to 9 months after the last operation. Three of four patients who had undergone resection of both pulmonary and pancreatic tumors were alive between 17 and 67 months after the last operation. All three survivors had presented with early disease stages and/or a protracted course (diagnostic interval, 16-66 months).

CONCLUSIONS

Our experience with neoplastic conditions that can involve lungs and pancreas metachronously may be useful to the clinician who is confronted with a similar situation. If therapeutic decision-making depends on differential diagnostic analysis, examination of CK 20 expression appears to be helpful. Although biologically favorable circumstances are rarely present, long-term survival seems possible after complete operative treatment in selected patients with early-stage disease.

Lung cancer screening: a different paradigm

Thoracic computed tomography (CT) is a sensitive method for detecting early lung cancer but has a high false-positive rate and is not sensitive for detecting central preinvasive and microinvasive cancer. Our hypothesis was that automated quantitative image cytometry (AQC) of sputum cells as the first screening method may improve detection rate by identifying individuals at highest risk for lung cancer. A total of 561 volunteer current or former smokers 50 years of age or older, with a smoking history of more than or equal to 30 pack/years, were studied. Among these, 423 were found to have sputum atypia defined as five cells or more with abnormal DNA content using AQC. Noncalcified pulmonary nodules were found in 46% (259/561). Of the 14 detected cancers, 13 were detected in subjects with sputum atypia-nine by CT and four carcinoma in situ/microinvasive cancers by autofluorescence bronchoscopy. One cancer was detected by CT alone. AQC of sputum cells improved the detection rate of lung cancer from 1.8 to 3.1%. CT scan alone would have missed 29% of the cancers. This screening paradigm shift has the additional potential of reducing the number of initial CT scans by at least 25% with further savings in follow-up investigations and treatment.

Tumour cell and stromal features in metastatic and non-metastatic non-small cell lung carcinomas

AIMS

Tumour cell behaviour depends on the interactions between nuclear genetic changes in the malignant cells and a stroma favourable for growth, invasion and metastasis. To evaluate such interactions, we studied the relationship between tumour cell and stromal features for proliferative factors, p53, microvessel density and metalloproteinases, controlled for the extent of the primary lesion (T1 to T4), in early (non-metastatic) and late (metastatic) non-small cell lung carcinomas (NSCLC).

METHODS AND RESULTS

Variables were examined for differences and correlations in the frequency of p53, AgNOR, CD34 and MMP-9 expression in primary lesions and metastases of NSCLC using a general linear model. The patients included 58 males and 22 females (mean age 62 +/- 9 years) with 19 T1 (23.8%), 40 T2 (50.0%), 14 T3 (17.5%) and seven T4 (8.8%). In late disease, AgNOR and p53 were statistically related to the extent of the primary lesion, whereas in early disease AgNOR tended to be increased in tumours without metastasis, while p53 expression tended to decrease progressively in tumours with metastasis. Microvessel density in late disease was of no statistical significance, whereas in early disease strong CD34 expression was seen in tumours with metastasis, being at its maximum in T3 primary lesions. The best marker for the extent of the lesion and its progression was MMP-9, with greater expression by tumours with metastasis than those without.

CONCLUSIONS

Different tumour cell and stromal interactions control metastasis and therefore the biological risk of NSCLC. A panel of molecular markers, such as p53, MMP-9 and CD34 could help to identify subgroups of patients that could benefit from adjuvant therapy.

Long-term survival and prognostic factors of five-year survivors with complete resection of non-small cell lung carcinoma

OBJECTIVE

We analyzed the long-term follow-up data on cancer-related death in 5-year survivors of complete resection of their non-small cell lung cancer and examined the prognostic factors having an impact on subsequent survival.

METHODS

Of 848 consecutive patients with proven primary non-small cell carcinoma who underwent complete removal of the primary tumor together with hilar and mediastinal lymph nodes, 421 patients (49.6%) survived 5 years or longer after the initial surgical treatment. Of all the data analyzed, only death related to cancer was treated as death.

RESULTS

The median follow-up of 5-year survivors was 84 months from the original treatment (range, 60 to 200 months). Their overall survival rate at 10 years was 91.0%. Multivariable Cox analysis demonstrated that although advanced surgical-pathological stage (P =.0001), nodal involvement (P =.0245), male gender (P =.0313), and non-squamous type of the tumor (P =.0034) were significant, independent, unfavorable prognostic determinants in all patients, none of the variables investigated significantly influenced the long-term survival of 5-year survivors. The rate of recurrence beyond 5 years was much lower compared with that within 5 years. In contrast, the rate of occurrence of new malignancies was unchanged throughout the long-term postoperative period.

CONCLUSIONS

Among 5-year survivors of complete resection of non-small cell lung cancer, neither stage, nodal status, sex, nor histologic condition further affected subsequent survival, suggesting that the 5-year interval might be sufficient to declare that a patient with lung cancer has been cured.

The role of radiotherapy in treatment of stage I non-small cell lung cancer

Most information on results with radiotherapy (RT) for stage I non-small cell lung cancer (NSCLC) is based on retrospective studies on RT-treated inoperable NSCLC cases. Thus, the role of RT for stage I NSCLC, as a curative modality, has not yet been established. A literature search for studies on stage I non-small cell lung carcinoma (NSCLC) treated by RT alone resulted in 18 papers published between 1988 and 2000. The majority of stage I patients received RT treatment because they were medically inoperable. The main contraindications for surgery were grave impairment of pulmonary function and serious cardiovascular disease. Local recurrence was the most common reason for treatment failure (median value 40%) but varied highly between the studies, ranging from 6.4 to 70%. In contrast with local recurrence, regional failure was not a major problem (0-3.2%). Generally, smaller tumour size, low T-stage and increased dose had a favourable impact on local control and increased local control was followed by increased survival. No serious treatment complications were recorded in the majority of these studies. Overall treatment results were, however, disappointing. The median survival in these studies ranged from 18 to 33 months. The 3- and 5-year overall survival was 34+/-9 and 21+/-8% (mean value+/-1 S.E.), respectively. The cause-specific survival at 3 and 5 years was 39+/-10 and 25+/-9% (mean value+/-1 S.E.), respectively. Dose escalation, in a setting with conformal RT using involved field or stereotactic RT, should be the focus of developmental therapeutic strategies with inoperable stage I NSCLC to improve local control and survival.

Persistent excess mortality from lung cancer in patients with stage I non-small-cell lung cancer, disease-free after 5 years

Among patients with non-small-cell lung cancer (NSCLC), those with pathological stage I have the best expectation of survival; however, survival is reduced to less than 50% in the long term. At present, it is unclear when patients can be reasonably defined as cured, and if they experience a higher incidence of malignant/nonmalignant diseases and a lower expectation of survival than the general population. A total of 134 stage I NSCLC patients, who had undergone resection at the Thoracic Surgery Unit of the General Hospital of Verona (north-eastern Italy) from October 1987 to December 1993, were still disease-free at 5 years. These subjects were further followed up, and morbidity and mortality rates were compared with those recorded in the general population of the same geographical area. The standardised incidence ratios (SIRs) for all malignancies and for lung cancer were higher than expected (2.39, 95% CI=1.6-3.5, P<0.001; 10.1, 95% CI=6.2-15.6, P<0.0001, respectively). The standardised mortality ratio (SMR) was also significantly increased (1.73, 95% CI=1.1-2.6, P=0.013). The excess mortality could be entirely explained by an increase in mortality from lung cancer (5.7, 95% CI=2.8-10.1, P<0.0001). This study shows that patients, resected for pathological stage I NSCLC and tumour-free after 5 years, have a higher incidence of new lung cancer compared with the general population, which in turn determines an excess in all-cause mortality in the following years.

Screening for lung cancer: in pursuit of pre-metastatic disease

One reason for the high death rate of lung cancer is that tumours are not usually detected until the disease is at a late stage, at which point the cancer is non-curable. Spiral computerized tomography is a highly sensitive imaging method that could be used to screen high-risk populations, such as current or former smokers, for early-stage tumours. Trials to validate this tool are just underway, but beyond the imaging tools, population-based care of pre-metastatic lung cancer requires considerable evolution in clinical management approaches. More sensitive imaging tools might also provide a window into earlier biology, enabling the molecular dynamics of lung cancer progression to be elucidated.

Late events and clinical prognostic factors in stage I non small cell lung cancer

Two hundred and forty six consecutive patients with pathological T1-2 N0 M0 non-small cell lung cancer were reviewed. Median follow-up was 79 months (range 3-144). So far, 110 patients have relapsed (45.6%). Actuarial median time to recurrence was 26 months in the 45 patients with thoracic relapses versus 12 months of the 65 metastatic (P<0.001). Disease-free survival (DFS) rates at 5 and 10-year were 62 and 49%, respectively. Fifteen percent of the patients (20) disease-free at 5 years relapsed in the following years; of them, 40% (8) underwent new surgery. Extrapulmonary malignancies other than lung cancer occurred in 27 patients (11.2%), mostly (21) after the diagnosis of lung cancer; in this subset median time to occurrence was 52 months (range 8-105) with a rate of occurrence remaining constant over the years after operation. Univariate and multivariate analysis demonstrated that large cell histology, lower performance status (PS) and presence of symptoms were unfavourable prognostic factors both for DFS and survival.

IN CONCLUSION

this study found a non-negligible proportion of late events and identified some prognostic factors (PS, presence of symptoms and large cell histology) using information obtained from routine data.

Pneumonectomy for non-small cell lung cancer: predictors of operative mortality and survival

OBJECTIVE

The purpose of this study was to identify predictors of operative mortality and survival following pneumonectomy for non-small cell lung cancer (NSCLC).

METHODS

All 206 patients having a pneumonectomy for NSCLC between 1991 and 1997 in our unit were prospectively studied. There were 162 males (79%) and 44 females (21%) with a mean age (+/- standard deviation) of 61+/-7.7 years (range 34-81 years). Squamous cell (75%) and adenocarcinoma (17.0%) were the predominant histological types. The possible impact of 29 parameters on operative mortality and survival was tested with univariate and multivariate analysis. The mean follow-up was 2.3+/-1.2 years, ranging between 0 and 6.8 years, and it was complete.

RESULTS

Operative mortality was 6.8% (14 deaths). On multiple logistic regression older age (P=0.04) and the development post-operatively of bronchopleural fistula (BPF) (P=0.01) were independent predictors of operative mortality. The overall, Kaplan-Meier, 1-, 3- and 5-year survival (+/- standard error from the mean), inclusive of operative mortality, was 68+/-3.3, 42+/-4.1 and 35+/-4.5%. On Cox proportional hazards regression adenocarcinoma (P=0.006), the development of BPF (P=0.003), older age (P=0.03) and higher pathological stage (P=0.02) were independent adverse predictors of survival.

CONCLUSION

Pneumonectomy for NSCLC carries a considerable, but acceptable, operative mortality and provides an important survival benefit. This study suggests that older age and BPF are major determinants of an unfavourable in-hospital outcome; older age, BPF, adenocarcinoma cell type and higher pathological stage significantly reduce the probability of a long-term survival.

Postoperative adjuvant therapy for stage IB non-small-cell lung cancer

OBJECTIVE

Although surgical resection alone is considered adequate treatment in stage IB non-small-cell lung cancer (NSCLC), long-term survival is not satisfactory and the recurrence rate is quite high. The validity of postoperative chemotherapy at stage IB in terms of disease-free and overall survival was assessed in a randomised trial.

METHODS

The trial was designed as a randomised, two-group study with postoperative adjuvant chemotherapy versus surgery alone as control group. All patients had stage IB disease (pT2N0) assessed after a radical surgical procedure. Chemotherapy consisted of treatment with cisplatin (100 mg/m(2) on day 1) and etoposide (120 mg/m(2) on days 1--3) for a total of six cycles.

RESULTS

Between January 1988 and December 1994, 66 patients were included in the study. Thirty-three belonged to the adjuvant chemotherapy group and 33 to the control group. Groups were homogeneous for conventional risk factors. There was no clinical significant morbidity associated to chemotherapy. Patients were followed for a minimum period of 5 years. The rates of locoregional recurrence and distant metastases were 18 and 30%, respectively, in the adjuvant chemotherapy group and 24 and 43%, respectively, in the control group. The 5-year disease-free survival rates were 59% in the adjuvant group and 30% in the control group (P = 0.02). The difference in the Kaplan--Meier survival between the groups was significant as assessed using the log-rank test (P = 0.04).

CONCLUSIONS

Our results suggest that adjuvant chemotherapy may reduce recurrences and prolong overall survival in patients at stage IB NSCLC deemed radically operated. Despite being difficult to accept, the use of adjuvant chemotherapy might have better long-term results.

Radiotherapy versus follow-up in the treatment of pathological stage Ia and Ib non-small cell lung cancer. Early stopped analysis of a randomized controlled study

OBJECTIVE

This is an analysis of a randomized controlled clinical trial planned to evaluate the effects of adjuvant radiotherapy (AR) on the local recurrence rate in patients with non-small cell lung cancer (NSCLC) with pathological stage (pStage) Ia (pT1N0) and Ib (pT2N0). The effects of AR on the long-term survival have also been marginally evaluated.

MATERIALS AND METHODS

This clinical trial was planned with the hypothesis that AR on pStage Ia and Ib, R0 NSCLCs was effective on local recurrence rate. From July 1989 through March 1997, 104 patients with NSCLC who presented with pStage Ia and Ib have been observed and treated and entered the study. Male/female ratio was 91:13; the mean age was 62 years (range 41-75 years). All patients underwent major pulmonary resection and homolateral standard hilar and mediastinal lymph node dissection. pStage was T1N0 in 29 and T2N0 in 75 cases. Patients have been randomized 'by chance' into two groups (G1 and G2). G1 received radiotherapy, G2 did not receive any adjuvant treatment. Fifty-two patients entered G1 and 52 entered G2.

RESULTS

Post-operative mortality was nil. Seven patients have been excluded from the study (four in G1 and three in G2), due to incomplete follow-up data. We do not report any radiotherapy-related complication or deterioration of lung function. The treatment effect on the local recurrence rate demonstrated a clearly significant protective effect of the AR. No statistically significant difference was found from the comparison of the 5-year survival rate of the treated (83%) versus untreated (70%) patients. No detrimental effect of the radiotherapy has been assessed.

CONCLUSIONS

AR in the treatment of pStage Ia and Ib NSCLC has been well tolerated and had a significant relative effect on the local recurrence rate but did not significantly modify overall survival even if a positive trend in the group of treated patients is reported.