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Ishiguro F, Matsuo K, Fukui T, Mori S, Hatooka S, Mitsudomi T. Effect of selective lymph node dissection based on patterns of lobe-specific lymph node metastases on patient outcome in patients with resectable non-small cell lung cancer: a large-scale retrospective cohort study applying a propensity score. J Thorac Cardiovasc Surg 2009; 139:1001-6. [PMID: 19733863 DOI: 10.1016/j.jtcvs.2009.07.024] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2009] [Revised: 05/20/2009] [Accepted: 07/08/2009] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Lobectomy with systematic complete mediastinal lymph node dissection is standard surgical treatment for localized non-small cell lung cancer. However, selective mediastinal lymph node dissection based on lobe-specific metastases (selective dissection) has often been performed. This study was designed to evaluate the validity of the selective lymph node dissection. METHODS From 1995 through 2003, 625 patients in our hospital had surgery for complete mediastinal lymph node dissection and 147 for selective dissection. We evaluated whether selective dissection adversely affected overall survival. To minimize possible biases due to confounding by treatment indication, we performed a retrospective cohort analysis by applying a propensity score. The propensity score was calculated by logistic regression based on 15 factors available that were potentially associated with treatment indication. Patients were divided into 4 groups according to quartile, and comparison between selective dissection and complete mediastinal lymph node dissection was made using propensity score quartile-stratified Cox proportional hazard models. RESULTS Comparison of baseline characteristics between patients having selective dissection and patients having complete mediastinal lymph node dissection according to propensity score quartile supported comparability of the 2 groups. The 5-year overall survival rates were 76.0% for selective dissection versus 71.9% for complete mediastinal lymph node dissection. The 5-year survival probabilities stratified by propensity score quartile consistently showed no marked difference. In multivariate models, there was no significant difference between the 2 groups (hazard ratio = 1.17, P = .500) as also seen in the analysis without propensity score (hazard ratio = 1.06; 95% confidence interval, 0.68-1.64; P = .810). Therefore, selective dissection showed no significant impact on poor survival compared with complete mediastinal lymph node dissection. CONCLUSIONS Selective lymph node dissection did not worsen the survival of patients with non-small cell lung cancer.
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Affiliation(s)
- Futoshi Ishiguro
- Department of Thoracic Surgery, Aichi Cancer Center Hospital, Nagoya 461-8681, Japan
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Rusch VW, Asamura H, Watanabe H, Giroux DJ, Rami-Porta R, Goldstraw P. The IASLC lung cancer staging project: a proposal for a new international lymph node map in the forthcoming seventh edition of the TNM classification for lung cancer. J Thorac Oncol 2009; 4:568-77. [PMID: 19357537 DOI: 10.1097/jto.0b013e3181a0d82e] [Citation(s) in RCA: 762] [Impact Index Per Article: 50.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The accurate assessment of lymph node involvement is an important part of the management of lung cancer. Lymph node "maps" have been used to describe the location of nodal metastases. However, discrepancies in nomenclature among maps used by Asian and Western countries hinder analyses of lung cancer treatment outcome. To achieve uniformity and to promote future analyses of a planned prospective international database, the International Association for the Study of Lung Cancer proposes a new lymph node map which reconciles differences among currently used maps, and provides precise anatomic definitions for all lymph node stations. A method of grouping lymph node stations together into "zones" is also proposed for the purposes of future survival analyses.
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Affiliation(s)
- Valerie W Rusch
- Thoracic Surgery Service, Memorial Sloan-Kettering Cancer Center, New York City, New York 10065, USA.
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Koenig AM, Prenzel KL, Bogoevski D, Yekebas EF, Bubenheim M, Faithova L, Vashist YK, Gawad KA, Baldus SE, Pantel K, Schneider PM, Hölscher AH, Izbicki JR. Strong impact of micrometastatic tumor cell load in patients with esophageal carcinoma. Ann Surg Oncol 2008; 16:454-62. [PMID: 19015923 DOI: 10.1245/s10434-008-0169-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2007] [Revised: 08/22/2008] [Accepted: 08/23/2008] [Indexed: 01/26/2023]
Abstract
BACKGROUND To assess the role of immunohistochemically detectable nodal microinvolvement of patients with "curatively" resected esophageal carcinoma. METHODS In 73 patients with resectable esophageal carcinoma [squamous cell carcinoma (SCC), n = 45 (61.6%); adenocarcinoma (AC), n = 28 (38.4%)] a total of 2174 lymph nodes (LN) were removed. In each of the 1958 LN classified as negative on conventional histopathology, immunohistochemistry was performed using the anticytokeratin antibody AE1/AE3. To determine the role of the amount of residual tumor load, the patients were grouped according to the percentage of LN affected with micrometastasis (0%, <11%, and > or =11%). RESULTS Tumor cells were immunohistochemically detected in 47 LN (2.4%) from 25 (34.2%) patients. Five-year overall survival probability (5-YSP) of 30% in pN(0 )patients with detected occult tumor cells in LN was significantly worse than that in those without nodal microinvolvement (76%, P = 0.021), hereby resembling that of pN1-patients (24%, P = 0.84). Median overall survival in patients with no (0%), low (<11%), and high (>11%) micrometastatic tumor load was 43, 27, and 11 months, respectively. Substratification according to histological type showed that, in patients with AC, the presence of nodal microinvolvement had a significant impact on 5-YSP (0% versus 65%; P = 0.03), whereas in patients with SCC, differences of 5-YSP were only of borderline significance (24% versus 53%; P = 0.081). CONCLUSION Minimal tumor cell load as assessed by the ratio of micrometastatically affected LN is a complementary tool for better risk stratification of patients with esophageal carcinoma.
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Affiliation(s)
- Alexandra M Koenig
- Department of General, Visceral and Thoracic Surgery, University Medical Centre of Hamburg-Eppendorf, Germany.
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Nodal microinvolvement in patients with carcinoma of the papilla of vater receiving no adjuvant chemotherapy. J Gastrointest Surg 2008; 12:1830-7; discussion 1837-8. [PMID: 18791769 DOI: 10.1007/s11605-008-0683-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2008] [Accepted: 08/20/2008] [Indexed: 01/31/2023]
Abstract
BACKGROUND To assess the prognostic significance of nodal microinvolvement in patients with carcinoma of the papilla of Vater. METHODS From 1993 to 2003 at the University Clinic Hamburg, 777 patients were operated upon pancreatic and periampullary carcinomas. The vast majority of patients were operated upon pancreatic ductal adenocarcinoma (n = 566, 73%), followed by carcinomas of the papilla of Vater (n = 112, 14%), pancreatic neuroendocrine carcinomas (n = 39, 5%), intraductal papillary mucinous neoplasms (n = 33, 4%), and distal bile duct carcinomas (n = 27, 3%). Fresh-frozen tissue sections from 169 lymph nodes (LNs) classified as tumor free by routine histopathology from 57 patients with R0 resected carcinoma of the papilla of Vater who had been spared from adjuvant chemotherapy were immunohistochemically (IHC) examined, using a sensitive IHC assay with the anti-epithelial monoclonal antibody Ber-EP4 for tumor cell detection. With regard to histopathology, 39 (63%) of the patients were staged as pT1/pT2, 21 (37%) as pT3/pT4, 30 (53%) as pN0, while 38 (67%) as G1/G2. RESULTS Of the 169 "tumor-free" LNs, 91 LNs (53.8%) contained Ber-EP4-positive tumor cells. These 91 LNs were from 40 (70%) patients. The mean overall survival in patients without nodal microinvolvement of 35.8 months (median-not yet reached) was significantly longer than that in patients with nodal microinvolvement (mean 16.6; median 13; p = 0.019). Multivariate Cox regression analysis for overall survival revealed that grading was the most significant independent prognostic factor (p = 0.001), followed by nodal microinvolvement (p = 0.013). CONCLUSIONS The influence of occult tumor cell dissemination in LNs of patients with histologically proven carcinoma of the papilla of Vater supports the need for further tumor staging through immunohistochemistry.
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Burrows WM. Anatomical lung resection after neoadjuvant chemoradiotherapy. Semin Thorac Cardiovasc Surg 2008; 19:360-5. [PMID: 18395639 DOI: 10.1053/j.semtcvs.2007.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2007] [Indexed: 11/11/2022]
Abstract
The critical role for anatomical lung resection -- segmentectomy, lobectomy, pneumonectomy -- in the treatment of Stage I and II non-small cell lung cancer is undisputed. In contrast, the primacy of surgery in the management of Stage III disease is not established. Increasingly, however, the multimodality approach to locally advanced lung cancer has gained acceptance, and the integration of surgery into the treatment algorithms for Stage III cancers, particularly N2 spread, has evolved. Herein, the important steps in this evolution are defined. The concept of induction or neoadjuvant chemoradiotherapy followed by resection is emphasized, and evidence supporting surgery's therapeutic value in this schema is provided. Our center's strategy for the successful and safe delivery of trimodality care is comprehensively outlined.
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Affiliation(s)
- Whitney M Burrows
- Department of Thoracic Surgery, University of Maryland Medical Center, Baltimore, MD 21201, USA.
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Intraoperative sentinel lymph node mapping in stage I non-small cell lung cancer: detection of micrometastases by polymerase chain reaction. Eur J Cardiothorac Surg 2008; 34:181-6. [DOI: 10.1016/j.ejcts.2008.03.059] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2007] [Revised: 02/18/2008] [Accepted: 03/04/2008] [Indexed: 01/11/2023] Open
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Complete mediastinal lymphadenectomy: the core component of the multidisciplinary therapy in resectable non-small cell lung cancer. Eur J Cardiothorac Surg 2008; 34:187-95. [PMID: 18457958 DOI: 10.1016/j.ejcts.2008.03.060] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2007] [Revised: 03/27/2008] [Accepted: 03/31/2008] [Indexed: 11/21/2022] Open
Abstract
There is a great deal of concern about metastasis of lung cancer to regional lymph nodes, due partly to the work of groups of thoracic surgeons in Japan and North America beginning in the 1970s. The classification of regional lymph node stations for lung cancer staging published by Mountain and Dresler has been widely adopted for more than ten years. Anatomic landmarks for 14 levels of intrapulmonary, hilar, and mediastinal lymph nodes stations are designated. Skip transfer and occult lymph node metastasis, confirmed by studies regarding the mode of spread of intrathoracic lymphatic metastasis, are two theoretical bases for complete mediastinal lymphadenectomy of lung cancer. However, whether or not the degree of the dissection influences prognosis, the role of systematic nodal dissection (SND) vs mediastinal lymph node sampling (MLD) in resectable non-small cell lung cancer (NSCLC) remains controversial. A systematic literature search was performed to identify relevant reports, making full use of the 'Cited by,' 'Related Records,' 'References,' and 'Author Index' functions in the PubMed and ISI Web of Science databases. This paper presents a review of the role of mediastinal lymph node distribution and methods of determining suitability for hilar and mediastinal lymphadenectomy based on the four subsets of stage IIIA-N2, balancing the cost vs effect of mediastinal lymph node dissection in resectable NSCLC, focusing on the stage migration bias in clinical trials comparing SND and MLS, recommending a reasonable node dissection sequence, improving the prospects for the perioperative anti-tumor therapy based on mediastinal lymphadenectomy, and evaluating the various preoperative staging techniques. Finally, we believe that, besides the role of complete resection and accurate staging, the complete mediastinal lymphadenectomy is the core component of the lung cancer multidisciplinary therapy, and suggest that the values of lymphadenectomy should be further assessed using decision-tree analysis based on large-scale prospective randomized trials and pooled analysis to evaluate the costs vs effects.
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Abstract
PURPOSE To investigate the importance of lymph node yield (LNY) and the ratio of afflicted lymph nodes in esophageal carcinoma patients. PATIENTS AND METHODS Between 1992 and 2004, 368 patients with esophageal carcinoma underwent surgery. Esophagectomy with curative intent was performed in 255 patients. Subtotal esophagectomy was performed either by thoracoabdominal (104 patients, 40.8%) or by transhiatal approach (151 patients, 59.2%). RESULTS According to the LNY, patients were grouped into 3 groups. Twenty-six patients had < or =5, 96 had 6 to 18, and 113 had > or =19 dissected lymph nodes. In patients with nodal involvement (pN1), no significant overall survival differences were identified when stratifying subgroups according to the LNY. However, LNY had striking prognostic relevance in pN0 patients. The median overall survival was 23 (< or =5 LN), 36 (6-18 LN), and 88 months (> or =19). Even for patients with tripled LNY than the proposed minimum by the International Union Against Cancer (UICC) (18 LN), the rate of patients with detected lymph node metastases was only 46%, compared with 61% for patients with a LNY of > or =19 (P = 0.002). In pN1 patients classified according to the ratio of afflicted lymph nodes, median overall survival was 27 months in patients with a ratio <11%, compared with 15 and 13 months in patients with a ratio of 11% to 33% and >33%, respectively (P < 0.001). Multivariate Cox regression modeling identified ratio as the strongest independent prognostic factor for overall survival in pN1 and the LNY in pN0 patients. CONCLUSIONS The minimal regional LNY of 6 lymph nodes as recommended by the UICC for esophageal carcinoma is far too low to appropriately stage the disease. The LNY and the ratio should be reflected in the next version of the UICC classification.
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What to do with “Surprise” N2?: Intraoperative Management of Patients with Non-small Cell Lung Cancer. J Thorac Oncol 2008; 3:289-302. [DOI: 10.1097/jto.0b013e3181630ebd] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bogoevski D, Strate T, Yekebas EF, Izbicki JR. Pancreatic cancer: a generalized disease--prognostic impact of cancer cell dissemination. Langenbecks Arch Surg 2008; 393:911-7. [PMID: 18202848 DOI: 10.1007/s00423-007-0278-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2007] [Accepted: 11/28/2007] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma is the fifth leading cause of death among all malignancies, leading to approximately 40,000 deaths each year in Europe. The annual incidence rate for all types of pancreatic cancer is approximately nine new cases per 100,000 people, ranking it as the 11th among all cancers. Stage, grade and resection margin status are currently accepted as the most accurate pathologic variables predicting survival. All classification systems fail prognostically to distinguish between different stages. Even in patients with seemingly early tumours (T1, N0), the likelihood of relapse is high. This reflects the shortcomings of the pathologic staging to sufficiently discriminate patients with a high risk to develop tumour recurrence from those that carry a lower risk. RESULTS On the other hand, none of the currently used systems includes or takes into consideration the role of disseminated tumour cells neither in the lymph nodes nor in the bone marrow. Occult residual tumour disease is suggested when either bone marrow or lymph nodes, from which tumour relapse may originate, are affected by micrometastatic lesions undetectable by conventional histopathology. For detection, antibodies against tumour-associated targets can be used to detect individual epithelial tumour cells both in lymph nodes and in bone marrow. The clinical significance of these immunohistochemical analyses is still controversial. Various monoclonal antibodies are still in use for micrometastatic detection, thus contributing to the incongruity of data and validity of results. These assays have been rarely used in patients with pancreatic carcinoma. CONCLUSION The presence or absence of lymph-node metastases can predict the likelihood of survival for most, if not all, patients with pancreatic ductal adenocancer and the likelihood that metastases will develop at distant sites.
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Affiliation(s)
- D Bogoevski
- Department of General, Visceral- and Thoracic-Surgery, University Medical Centre of Hamburg-Eppendorf, Hamburg, Germany.
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63
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Takahashi K, Stanford W, Van Beek E, Thompson B, Mullan B, Sato Y. Mediastinal lymphatic drainage from pulmonary lobe based on CT observations of histoplasmosis: implications for minimal N2 disease of non-small-cell lung cancer. ACTA ACUST UNITED AC 2007; 25:393-401. [PMID: 17952543 DOI: 10.1007/s11604-007-0156-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2007] [Accepted: 05/11/2007] [Indexed: 11/28/2022]
Abstract
PURPOSE The aim of this study was to assess mediastinal lymphatic drainage patterns from each pulmonary lobe using computed tomographic (CT) observations of calcified primary complex pulmonary histoplasmosis. MATERIALS AND METHODS We assessed 400 CT studies of patients with primary complex histoplasmosis consisting of a single lobe pulmonary lesion and mediastinal nodal disease. We assessed the distribution of mediastinal nodal involvement depending on pulmonary lobes for the total number of involved nodes, the number with single-station involvement (which suggests the initial site of involvement), and the number with skip involvement which suggests direct drainage to the mediastinum. RESULTS The most commonly involved mediastinal nodal stations from the right upper lobe, left upper lobe, and left lower lobe were the right lower paratracheal node (97%, 74/76), the subaortic node (72%, 49/68), and the left pulmonary ligament node (61%, 66/108), respectively. These nodes were the most common site of skip involvement in each lobe. In the right lower lobe and middle lobe, the subcarinal node was most commonly involved: 62% (65/105) and 81% (35/43), respectively. By contrast, skip involvement was uncommon in the drainage to this node. CONCLUSION Our data show a predictable pattern of lobar lymphatic drainage to the mediastinum. This may have implications on the minimal N2 disease of non-small-cell lung cancer.
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Affiliation(s)
- Koji Takahashi
- Department of Radiology, Asahikawa Medical College and Hospital, 2-1-1-1 Midorigaoka-Higashi, Asahikawa, Japan.
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Detterbeck FC. Integration of Mediastinal Staging Techniques for Lung Cancer. Semin Thorac Cardiovasc Surg 2007; 19:217-24. [PMID: 17983948 DOI: 10.1053/j.semtcvs.2007.07.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2007] [Indexed: 11/11/2022]
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Toschi L, Cappuzzo F, Jänne PA. Evolution and future perspectives in the treatment of locally advanced non-small cell lung cancer. Ann Oncol 2007; 18 Suppl 9:ix150-5. [PMID: 17631569 DOI: 10.1093/annonc/mdm311] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
MESH Headings
- Antibodies, Monoclonal/therapeutic use
- Antineoplastic Agents/therapeutic use
- Carcinoma, Non-Small-Cell Lung/diagnosis
- Carcinoma, Non-Small-Cell Lung/diagnostic imaging
- Carcinoma, Non-Small-Cell Lung/drug therapy
- Carcinoma, Non-Small-Cell Lung/pathology
- Carcinoma, Non-Small-Cell Lung/radiotherapy
- Carcinoma, Non-Small-Cell Lung/surgery
- Carcinoma, Non-Small-Cell Lung/therapy
- Clinical Trials, Phase II as Topic
- Clinical Trials, Phase III as Topic
- Combined Modality Therapy
- Humans
- Lung Neoplasms/diagnosis
- Lung Neoplasms/diagnostic imaging
- Lung Neoplasms/drug therapy
- Lung Neoplasms/pathology
- Lung Neoplasms/radiotherapy
- Lung Neoplasms/surgery
- Lung Neoplasms/therapy
- Neoplasm Staging
- Preoperative Care
- Prognosis
- Radiography
- Randomized Controlled Trials as Topic
- Survival Analysis
- Treatment Outcome
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Affiliation(s)
- L Toschi
- Istituto Clinico Humanitas, Department of Oncology and Hematology, Rozzano, Italy
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Lee YC, Wu CT, Kuo SW, Tseng YT, Chang YL. Significance of extranodal extension of regional lymph nodes in surgically resected non-small cell lung cancer. Chest 2007; 131:993-9. [PMID: 17426201 DOI: 10.1378/chest.06-1810] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
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.
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Affiliation(s)
- Yung-Chie Lee
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan, Republic of China
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Miyamoto M, Morikawa T, Kaga K, Ohtake S, Cho Y, Hirano S, Kondo S. Subcarinal node is the significant node that affects survival in resected small cell lung cancer. Surg Today 2007; 36:671-5. [PMID: 16865508 DOI: 10.1007/s00595-006-3222-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2004] [Accepted: 01/17/2006] [Indexed: 10/24/2022]
Abstract
PURPOSE Our aim was to clarify the significance of surgery and the prognostic factors in patients with small cell lung cancer (SCLC). METHOD A retrospective review of 50 patients with limited SCLC who underwent a pulmonary resection and mediastinal nodal dissection during the 10-year period from 1988 to 1997 was undertaken. The TNM classification was applied to all cases of SCLC. RESULTS A Cox regression multivariate analysis indicated lymph node metastasis (P = 0.0117) and adjuvant therapy (P = 0.0429) to be independent prognostic factors in SCLC patients. Concerning the patients with lymph node metastasis, the prognosis was related only to the involvement of the subcarinal node (station 7). Although no patient with lymph node involvement in station 7 could be a 2-year survivor, in the case of patients with lymph node involvement except in station 7, 47.1% of them were 2-year survivors and 25.1% were 4-year survivors. Among the patients with lymph node metastasis, a univariate analysis indicated the prognosis to be significantly poorer in patients with station 7 involvement than in those without station 7 involvement (P = 0.0224). CONCLUSION Involvement in the subcarinal node might be a prognostic factor for SCLC.
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Affiliation(s)
- Masaki Miyamoto
- Department of Surgical Oncology, Division of Cancer Medicine, Hokkaido University Graduate School of Medicine, N-14 W-7, Kita-ku, Sapporo 060-8648, Japan
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Ohno Y, Koyama H, Nogami M, Takenaka D, Yoshikawa T, Yoshimura M, Ohbayashi C, Sugimura K. STIR turbo SE MR imaging vs. coregistered FDG-PET/CT: Quantitative and qualitative assessment of N-stage in non-small-cell lung cancer patients. J Magn Reson Imaging 2007; 26:1071-80. [PMID: 17896365 DOI: 10.1002/jmri.21106] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To conduct a prospective comparison of the accuracy of short inversion time (TI) inversion-recovery (STIR) turbo spin-echo (SE) imaging and coregistered 2-[fluorine-18] fluoro-2-deoxy-D-glucose (FDG)-positron emission tomography (PET) with computed tomography (CT) (coregistered FDG-PET/CT) to assess the N-stage in non-small-cell lung cancer (NSCLC) patients. MATERIALS AND METHODS A total of 115 consecutive NSCLC patients prospectively underwent CT, STIR turbo SE imaging, and FDG-PET, as well as surgical and pathological examinations. All STIR turbo SE images were obtained with a 0.9% saline phantom, which was placed alongside the chest wall of each patient, and coregistered FDG-PET/CTs were reconstructed using commercially available software. For quantitative assessments, the ratio of signal intensity (SI) of each lymph node to that of 0.9% saline phantom (lymph node-saline ratio [LSR]) and maximal standardized uptake value (SUV(max)) of each lymph node were calculated. Feasible threshold values were determined by using the receiver operating characteristic (ROC) curve-based positive test, and diagnostic capabilities of N-stage were compared by McNemar's test on a per patient basis. RESULTS When feasible, threshold values were adopted, quantitative sensitivity (90.1%) and accuracy (92.2%) of STIR turbo SE imaging were significantly higher than those of quantitative and qualitative sensitivities (76.7% and 74.4%) and accuracies (83.5% and 82.6%) of coregistered FDG-PET/CT on a per patient basis (P < 0.05). CONCLUSION STIR turbo SE imaging is at least as valid as coregistered FDG-PET/CT for quantitative and qualitative assessment of the N-stage for NSCLC patients.
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Affiliation(s)
- Yoshiharu Ohno
- Department of Radiology, Kobe University Graduate School of Medicine, Kobe, Japan
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Yekebas EF, Bogoevski D, Bubenheim M, Link BC, Kaifi JT, Wachowiak R, Mann O, Kutup A, Cataldegirmen G, Wolfram L, Erbersdobler A, Klein C, Pantel K, Izbicki JR. Strong prognostic value of nodal and bone marrow micro-involvement in patients with pancreatic ductal carcinoma receiving no adjuvant chemotherapy. World J Gastroenterol 2006; 12:6515-21. [PMID: 17072983 PMCID: PMC4100640 DOI: 10.3748/wjg.v12.i40.6515] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To study the prognostic value of adjuvant chemo-therapy in patients with pancreatic, ductal adenocar-cinoma.
METHODS: Lymph nodes from 106 patients with resectable pancreatic ductal adenocarcinoma were systematically sampled. A total of 318 lymph nodes classified histopathologically as tumor-free were examined using sensitive immunohistochemical assays. Forty-three (41%) of the 106 patients were staged as pT1/2, 63 (59%) as pT3/4, 51 (48%) as pN0, and 55 (52%) as pN1. The study population included 59 (56%) patients exhibiting G1/2, and 47 (44%) patients with G3 tumors. Patients received no adjuvant chemo- or radiation therapy and were followed up for a median of 12 (range: 3.5 to 139) mo.
RESULTS: Immunostaining with Ber-EP4 revealed nodal microinvolvement in lymph nodes classified as “tumor free” by conventional histopathology in 73 (69%) out of the 106 patients. Twenty-nine (57%) of 51 patients staged histopathologically as pN0 had nodal microinvolvement. The five-year survival probability for pN0-patients was 54% for those without nodal microinvolvement and 0% for those with nodal microinvolvement. Cox-regression modeling revealed the independent prognostic effect of nodal microinvolvement on recurrence-free (relative risk 2.92, P = 0.005) and overall (relative risk 2.49, P = 0.009) survival.
CONCLUSION: The study reveals strong and independent prognostic significance of nodal microinvolvement in patients with pancreatic ductal adenocarcinoma who have received no adjuvant therapy. The addition of immunohistochemical findings to histopathology reports may help to improve risk stratification of patients with pancreatic cancer.
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Affiliation(s)
- Emre-F Yekebas
- Department of General, Visceral and Thoracic Surgery, University Medical Centre of Hamburg-Eppendorf, MartinistraBe 52, 20246 Hamburg, Germany
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71
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Mandell L, Hilaris B, Sullivan M, Sundaresan N, Nori D, Kim JH, Martini N, Fuks Z. The treatment of single brain metastasis from non-oat cell lung: Carcinoma surgery and radiation. Versus radiation therapy alone. Cancer 2006. [DOI: 10.1002/1097-0142(19860801)58:3<641::aid-cncr2820580308>3.0.co;2-4] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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72
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Benoit L, Anusca A, Ortega-Deballon P, Cheynel N, Bernard A, Favre JP. Analysis of risk factors for skip lymphatic metastasis and their prognostic value in operated N2 non-small-cell lung carcinoma. Eur J Surg Oncol 2006; 32:583-7. [PMID: 16621424 DOI: 10.1016/j.ejso.2006.02.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2004] [Revised: 02/03/2006] [Accepted: 02/03/2006] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The aim of this study is to report a series and to analyze risk factors for skip lymphatic metastasis an their prognostic value in operated N2 non-small-cell lung carcinoma. METHODS From 1997 to 2002, 142 patients classified pN2 were included in the study. Tumours were classified according to the TNM classification. Skips metastases were defined by the cases of N2 disease without lobar and interlobar and hilar lymph node involvement. A skip (+) and a skip (-) group were defined. Characteristics of tumours, ganglionar involvement and survival were analysed in both groups. RESULTS Forty-two patients fulfilled the criteria for skip metastasis. The average number of mediastinal lymph nodes resected by patient was similar in both groups, whereas more intrapulmonary nodes were dissected in the skip (-) group (4.7 +/- 3 vs 3 +/- 3; p < 0.002). The ratio of involved to resected lymph nodes was 0.47 +/- 0.27 in the skip (-) group vs 0.23 +/- 0.20 in the skip (+) group (p < 0.0001). In the skip (+) group, 85% of the patients presenting with a right upper lobe tumour had involvement of the superior mediastinal lymph nodes against 40% in the skip (-) group. The 5-year survival rate was 48% in the skip (-) group vs 37% in the skip (+) group (p = 0.49). In multivariate analysis, incomplete resection, tumour size, extended resection and pT were significant prognostic factors. CONCLUSIONS Skip metastasis are frequent in non-small-cell lung cancer and complete dissection of hilar and mediastinal lymph nodes should remain the surgical standard procedure for this disease. However, skip metastasis are not an independent prognostic factor in survival.
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Affiliation(s)
- L Benoit
- Department of General Thoracic Surgery, Hôpital Universitaire du Bocage, Dijon, France
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73
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Albain KS. Candidates for surgery in the combined modality therapy of stage III non-small cell lung cancer. EJC Suppl 2005. [DOI: 10.1016/s1359-6349(05)80261-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Chapet O, Kong FM, Quint LE, Chang AC, Ten Haken RK, Eisbruch A, Hayman JA. CT-based definition of thoracic lymph node stations: An atlas from the University of Michigan. Int J Radiat Oncol Biol Phys 2005; 63:170-8. [PMID: 16111586 DOI: 10.1016/j.ijrobp.2004.12.060] [Citation(s) in RCA: 112] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2004] [Revised: 12/09/2004] [Accepted: 12/16/2004] [Indexed: 11/26/2022]
Abstract
PURPOSE Accurate delineation of the mediastinal and hilar lymph node regions is essential for a reproducible definition of target volumes used in conformal irradiation of non-small-cell lung cancer. The goal of this work was to generate a consensus to delineate these nodal regions based on definitions from the American Joint Committee on Cancer. METHODS AND MATERIALS A dedicated thoracic radiologist, thoracic surgeon, medical physicist, and three radiation oncologists were gathered to generate a three-dimensional radiologic description for the mediastinal and hilar nodal regions on axial CT scans. This paper proposes an atlas of most of the lymph node stations described by Mountain and Dresler. RESULTS The CT boundaries of lymph node stations 1-2, 3, 4, 5, 6, 7, 8, 10-11 were defined on axial CT, along with image illustrations. CONCLUSION These CT-based illustrative definitions will provide guidelines for clinical practice and studies evaluating incidental radiation in radiotherapy. Studies are ongoing at the University of Michigan to measure quantitatively the incidental nodal radiation received by patients with non-small-cell lung cancer.
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Affiliation(s)
- Olivier Chapet
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI 48109, USA
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75
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Soltesz EG, Kim S, Laurence RG, DeGrand AM, Parungo CP, Dor DM, Cohn LH, Bawendi MG, Frangioni JV, Mihaljevic T. Intraoperative sentinel lymph node mapping of the lung using near-infrared fluorescent quantum dots. Ann Thorac Surg 2005; 79:269-77; discussion 269-77. [PMID: 15620956 PMCID: PMC1421510 DOI: 10.1016/j.athoracsur.2004.06.055] [Citation(s) in RCA: 196] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/04/2004] [Indexed: 11/21/2022]
Abstract
BACKGROUND The presence of lymph node metastases is an important prognostic marker with regard to non-small-cell lung cancer (NSCLC). Assessment of the sentinel lymph node (SLN) for the presence of tumor may improve staging. Our objective was to develop an optical noninvasive imaging tool that would permit intraoperative SLN mapping and provide real-time visual feedback for image-guided localization and resection. METHODS Invisible near-infrared (NIR) light penetrates relatively deeply into tissue and background autofluorescence is low. We have developed a NIR fluorescence imaging system that simultaneously displays color video and NIR images of the surgical field. We recently engineered 15 nm nonradioactive NIR fluorescent quantum dots (QDs) as optimal lymphotrophic optical probes. The introduction of these QDs into lung tissue allows real-time visualization of draining lymphatic channels and nodes. RESULTS In 12 Yorkshire pigs (mean weight 35 kg) we demonstrated that 200 pmol of NIR QDs injected into lobar parenchyma accurately maps lymphatic drainage and the SLN. All SLNs were strongly fluorescent and easily visualized within 5 minutes of injection. In 14 separate injections QDs localized to a mediastinal node, whereas in 2 injections QDs localized to a hilar intraparenchymal node. Histologic analysis in all cases confirmed the presence of nodal tissue. CONCLUSIONS We report a highly sensitive rapid technique for SLN mapping of the lung. This technique permits precise real-time imaging and therefore overcomes many limitations of currently available techniques.
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Affiliation(s)
- Edward G Soltesz
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
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Atinkaya C, Ozlem Küçük N, Koparal H, Aras G, Sak SD, Ozdemir N. Mediastinal intraoperative radioisotope sentinel lymph node mapping in non-small-cell lung cancer. Nucl Med Commun 2005; 26:717-20. [PMID: 16000990 DOI: 10.1097/01.mnm.0000169381.99894.2f] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lymph node metastases are significant prognostic factors in localized non-small-cell lung cancer (NSCLC). Nodal micrometastases may not be detected using current histological methods. AIM To determine the accuracy and role of sentinel lymph nodes (SLNs) in patients with NSCLC. METHODS Intraoperative technetium-99m (Tc) sulphur colloid SLN mapping was performed in patients with NSCLC. Serial section histology and immunohistochemistry were used to validate the SLNs and to identify the presence of micrometastatic disease. The study was carried out on 28 consecutive patients (male/female, 25/3; mean age, 57.05+/-7.1 years) with resectable NSCLC. During thoracotomy, 0.25 mCi of Tc sulphur colloid was injected into four quadrants peritumorally. Radioactivity was counted intraoperatively, a mean of 45 min (range, 30-60 min) after injection. SLN was defined as the node with the highest count rate using a hand-held gamma probe counter. Resection with mediastinal node dissection was performed and the findings were correlated with histological examination. RESULTS SLNs were identified in 26 of 28 patients (92.8%) with a total number of 32 SLNs. Seven of 32 (21.8%) of these SLNs were positive for metastatic involvement after histological and immunohistochemical examination. In two patients (7.1%), SLNs could not be found. CONCLUSIONS These results demonstrate the feasibility of this procedure in identifying the first site of potential nodal metastasis of NSCLC. This method may improve the precision of pathological staging.
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Affiliation(s)
- Cansel Atinkaya
- Department of Thoracic Surgery, Ankara University School of Medicine, Ankara, Turkey
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Rami-Porta R, Wittekind C, Goldstraw P. Complete resection in lung cancer surgery: proposed definition. Lung Cancer 2005; 49:25-33. [PMID: 15949587 DOI: 10.1016/j.lungcan.2005.01.001] [Citation(s) in RCA: 312] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2005] [Revised: 01/20/2005] [Accepted: 01/27/2005] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To propose an internationally accepted definition of complete resection in lung cancer surgery. MATERIAL AND METHODS The International Association for the Study of Lung Cancer (IASLC) Staging Committee created the Complete Resection Subcommittee in 2001 to work on an international definition of complete resection in lung cancer surgery. The previous definitions of complete resection and the rules of the International Union Against Cancer regarding the TNM residual tumor classification, together with a thorough review of the pertinent literature, and the input of the members of the IASLC Staging Committee were considered in order to get an international consensus on the definition of complete resection in lung cancer surgery. RESULTS Complete resection requires all of the following: free resection margins proved microscopically; systematic nodal dissection or lobe-specific systematic nodal dissection; no extracapsular nodal extension of the tumor; and the highest mediastinal node removed must be negative. Whenever there is involvement of resection margins, extracapsular nodal extension, unremoved positive lymph nodes or positive pleural or pericardial effusions, the resection is defined as incomplete. When the resection margins are free and no residual tumor is left, but the resection does not fulfill the criteria for complete resection, there is carcinoma in situ at the bronchial margin or positive pleural lavage cytology, the term uncertain resection is proposed. CONCLUSION The proposed definitions of complete, incomplete and uncertain resections are clear and reproducible in an international setting to study their prognostic impact prospectively.
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Affiliation(s)
- Ramón Rami-Porta
- Complete Resection Subcommittee of the IASLC Staging Committee, Thoracic Surgery Service, Hospital Mutua de Terrassa, University of Barcelona, Plaza Dr. Robert, 5, 08221 Terrassa, Barcelona, Spain.
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Abstract
Staging of the mediastinum for lung cancer has matured dramatically with the advent of newer technologies in imaging and endoscopic surveillance. Some of these technologies such as positron emission tomography (PET) scanning are becoming mainstream in the evaluation of patients with clinically suspicious mediastinal disease as seen on computed tomography (CT), while others such as endobronchial ultrasound are reserved for specialty expertise and await validation. While much improvement has been made in the accurate preoperative staging of patients having surgery as the primary modality in lung cancer, controversy exists regarding the restaging of locally advanced cases after induction chemotherapy or chemoradiotherapy. A major concentration on these restaging issues is warranted since it is now generally agreed that sterilization of the mediastinum after induction therapy has an impact on the prognosis of patients with stage IIIA disease, and accurate staging after therapy may rationally guide diverse therapeutic interventions in these patients.
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Affiliation(s)
- Harvey I Pass
- Thoracic Oncology Section, Multidisciplinary Lung Team, Karmanos Cancer Institute, Detroit, MI, USA.
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79
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Okada M, Sakamoto T, Yuki T, Mimura T, Nitanda H, Miyoshi K, Tsubota N. Border between N1 and N2 stations in lung carcinoma: lessons from lymph node metastatic patterns of lower lobe tumors. J Thorac Cardiovasc Surg 2005; 129:825-30. [PMID: 15821650 DOI: 10.1016/j.jtcvs.2004.06.016] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Distinction of lymph node stations is one of the most crucial topics still not entirely resolved by many lung cancer surgeons. The nodes around the junction of the hilum and mediastinum are key points at issue. We examined the spread pattern of lymph node metastases, investigated the prognosis according to the level of the involved nodes, and conclusively analyzed the border between N1 and N2 stations. METHODS We reviewed the records of 604 consecutive patients who underwent complete resection for non-small cell lung carcinoma of the lower lobe. RESULTS There were 390 patients (64.6%) with N0 disease, 127 (21.0%) with N1, and 87 (14.4%) with N2. Whereas 11.3% of patients with right N2 disease had skip metastases limited to the subcarinal nodes, 32.6% of patients with left N2 disease had skip metastases, of which 64.2% had involvement of N2 station nodes, except the subcarinal ones. The overall 5-year survivals of patients with N0, N1, and N2 disease were 71.0%, 50.8%, and 16.7%, respectively (N0 vs N1 P = .0001, N1 vs N2, P < .0001). Although there were no significant differences in survival according to the side of the tumor among patients with N0 or N1 disease, patients with a left N2 tumor had a worse prognosis than those with a right N2 tumor (P = .0387). The overall 5-year survivals of patients with N0, intralobar N1, hilar N1, lower mediastinal N2, and upper mediastinal N2 disease were 71.0%, 60.1%, 38.8%, 24.8%, and 0%, respectively. Significant differences were observed between intralobar N1 and hilar N1 disease ( P = .0489), hilar N1 and lower mediastinal N2 disease (P = .0158), and lower and upper mediastinal N2 disease (P = .0446). Also, the 5-year survivals of patients with involvement up to station 11, up to station 10, and up to station 7 were 41.4%, 37.9% and 37.7%, respectively (difference not significant). CONCLUSIONS N1 and N2 diseases appeared as a combination of subgroups: intralobar N1 disease, hilar N1 disease, lower mediastinal N2 disease, and upper mediastinal N2 disease. Interestingly, the survivals of patients with involvement up to interlobar nodes (station 11), main bronchus nodes (station 10), and subcarinal nodes (station 7) were identical. These data constitute the basis for a larger investigation to develop a lymph node map in lung cancer.
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Affiliation(s)
- Morihito Okada
- Department of Thoracic Surgery, Hyogo Medical Center for Adults, Akashi city, Japan.
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80
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Farray D, Mirkovic N, Albain KS. Multimodality Therapy for Stage III Non–Small-Cell Lung Cancer. J Clin Oncol 2005; 23:3257-69. [PMID: 15886313 DOI: 10.1200/jco.2005.03.008] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The treatment of stage III non–small-cell lung cancer has evolved over the last two decades, with combined-modality therapy the current standard of care. As a result, intermediate and long-term survival has improved for patients in this common stage category, compared to the poor outcomes achieved with the historical standard of once-daily radiation therapy alone. This review summarizes two decades of clinical research regarding bimodality and trimodality approaches for the heterogenous stage subsets within the stage III designation, discusses the rationale and status of prophylactic brain irradiation, and concludes with perspectives on progress and future directions. Chemotherapy plus radiotherapy given concurrently is the optimal treatment for the group of patients with advanced stage III disease. The potential role of a surgical resection following chemotherapy (with or without radiation) in this setting is still controversial. The only subsets for which trimodality treatments are clearly preferred include T4N0-1 disease and superior sulcus tumors. The other major stage III subgroup has a minimal disease burden with low tumor volume and/or microscopic N2 disease, thus technically could undergo a surgical resection upfront. Induction chemotherapy before surgery may yield a survival advantage, although the phase III trials in this area are not conclusive. Given the marked survival benefit from adjuvant chemotherapy after surgery in even earlier stages of non–small-cell lung cancer, the proper sequence of surgery and chemotherapy (before v after surgery) remains an important unresolved question in this subgroup. Furthermore, how to incorporate radiation therapy, as well as whether it should be given at all in this subset of patients, are other important issues actively under study in ongoing trials.
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Affiliation(s)
- Daniel Farray
- Loyola University Medical Center, Cardinal Bernardin Cancer Center, 2160 South First Avenue, Maywood, IL 60153-5589, USA
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81
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Patel V, Shrager JB. Which Patients with Stage III Non‐Small Cell Lung Cancer Should Undergo Surgical Resection? Oncologist 2005; 10:335-44. [PMID: 15851792 DOI: 10.1634/theoncologist.10-5-335] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The treatment of patients with stage III NSCLC remains controversial. Stage III NSCLC comprises a fairly heterogeneous group of tumors, and furthermore only sparse data from randomized clinical trials exist to guide therapy decisions. This review article proposes a management algorithm for patients with stage III NSCLC that is based upon the currently available data on surgical therapy, chemotherapy, and radiation therapy. By necessity, given the paucity of strong data, a good deal of opinion is offered. The choice to proceed with aggressive, combined modality treatment is presented in light of extent of local disease as well as patient performance status.
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Affiliation(s)
- Vivek Patel
- University of Pennsylvania School of Medicine and Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
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82
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Abstract
Surgical resection of early-stage non-small-cell lung cancer (NSCLC) remains the standard of care in patients fit for surgery. Careful preoperative staging is imperative, as is pathologic documentation of the mediastinal nodal contents. Adjuvant postoperative thoracic radiation therapy (RT) clearly has an impact in reducing locoregional recurrence but has no clear impact on survival. The Postoperative RT (PORT) metaanalysis raised concerns about PORT, particularly in stage I/II NSCLC, suggesting it may negatively impact survival. This was not a concern in stage III NSCLC, in which the risk of locoregional recurrence is higher. However, distant recurrence remains the dominant pattern in resected NSCLC, suggesting that the majority of patients with early-stage resected NSCLC harbor occult micrometastatic disease. Historically, the role of adjuvant chemotherapy has been controversial, and its routine use was not supported by the published data, which consisted of a small number of underpowered trials using inadequately delivered, antiquated chemotherapy. More recently, larger trials have been reported with conflicting results. Like adjuvant PORT, chemotherapy combined with RT has not improved survival over PORT alone. The use of adjuvant cisplatin-based therapy did not show a survival advantage in the Adjuvant Lung Project Italy study but did in the International Adjuvant Lung Trial, creating controversy in the routine implementation of adjuvant therapy in all patients. Recently completed randomized trials by the Cancer and Leukemia Group B and the National Cancer Institute of Canada provide convincing evidence of a substantial benefit from adjuvant therapy in well-staged and completely resected stage I/II NSCLC. Currently, the totality of the data supports a discussion with patients with resected NSCLC regarding the potential benefits of adjuvant therapy.
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Affiliation(s)
- Mark A Socinski
- Multidisciplinary Thoracic Oncology Program, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, USA.
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83
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Abstract
BACKGROUND Surgical resection (usually lobectomy) is considered the treatment of choice for individuals with stage I and II non-small cell lung cancer (NSCLC) and for some patients with resectable stage IIIA NSCLC. However much of the evidence supporting surgery is observational. OBJECTIVES To determine whether, in patients with early stage non-small cell lung cancer, surgical resection of cancer improves disease-specific and all-cause mortality compared with no treatment, radiotherapy or chemotherapy. To compare the effectiveness of different surgical approaches (e.g. lobectomy versus limited resection) in improving disease-specific or all-cause mortality in patients with early stage lung cancer. SEARCH STRATEGY Electronic databases (the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE (1966 to December 2003)), bibliographies, handsearching of a journal and discussion with experts were used to identify published and unpublished trials. SELECTION CRITERIA Randomised controlled trials comparing surgery alone (or in combination with other therapy) with non-surgical therapy and randomised trials comparing different surgical approaches. DATA COLLECTION AND ANALYSIS A pooled hazard ratio was calculated where possible. Tests for statistical heterogeneity were performed. MAIN RESULTS Eleven trials were included with a total of 1910 subjects. There were no studies with an untreated control group. In a pooled analysis of three trials, four-year survival was superior in patients with resectable stage I to IIIA NSCLC who underwent resection and complete mediastinal lymph node dissection compared with those undergoing resection and lymph node sampling, the hazard ratio was estimated to be 0.78 (95% CI 0.65-0.93, P = 0.005). A further trial found an increased rate of local recurrence in patients with stage I NSCLC treated with limited resection compared with lobectomy. One small trial found a survival advantage in favour of chemotherapy followed by surgery compared to chemotherapy followed by radiotherapy in patients with stage IIIA NSCLC. However none of the other trials included in the review demonstrated a significant improvement in survival in patients treated with surgery compared with non surgical therapy. Several of the included trials had potential methodological weaknesses. AUTHORS' CONCLUSIONS Conclusions about the efficacy of surgery for local and loco-regional NSCLC are limited by the small number of participants studied to date and potential methodological weaknesses of trials. Current evidence suggests that lung cancer resection combined with complete mediastinal lymph node dissection is associated with a small to modest improvement in survival compared with lung cancer resection combined with systematic sampling of mediastinal nodes in patients with stage I to IIIA NSCLC.
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Affiliation(s)
- R Manser
- Clinical Epidemiology and Health Service Evaluation Unit, Royal Melbourne Hospital, Grattan Street, Parkville, Victoria, Australia, 3050.
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84
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Bogoevski D, Yekebas EF, Schurr P, Kaifi JT, Kutup A, Erbersdobler A, Pantel K, Izbicki JR. Mode of spread in the early phase of lymphatic metastasis in pancreatic ductal adenocarcinoma: prognostic significance of nodal microinvolvement. Ann Surg 2004; 240:993-1000; discussion 1000-1. [PMID: 15570205 PMCID: PMC1356515 DOI: 10.1097/01.sla.0000145922.25106.e3] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The aim of this study was to assess the prognostic significance of nodal microinvolvement as well as the mode of spread in the early phase of lymphatic metastasis in patients with node-negative pancreatic ductal adenocarcinoma. METHODS Lymph nodes from 48 node-negative patients with R0 resected pancreatic ductal adenocarcinoma were sampled from 3 different compartments: 1) distal hepatoduodenal ligament, 2) superior-anterior compartment, and 3) posterior-inferior. Tissue sections of 148 lymph nodes classified as tumor free by routine histopathology were examined, using a sensitive immunohistochemical assay with the antiepithelial monoclonal antibody Ber-EP4 for tumor cell detection. With regard to histopathologic tumor staging and grading, 26 (54.2%) of the patients were staged as pT1/pT2, 22 (45.8%) as pT3/pT4, while 31 (64.6%) as G1/G2 and 17 (35.4%) patients as G3. Of the 148 "tumor free" lymph nodes, 56 contained Ber-EP4-positive tumor cells. These 56 lymph nodes were from 28 of the 48 patients. The multivariate Cox regression analysis revealed the independent prognostic impact of nodal microinvolvement on relapse-free and overall survival. Analysis by compartment, from which the lymph nodes were collected, revealed that overall survival time (P = 0.006) and time to local recurrence (P = 0.015) depend on the presence of nodal microinvolvement in the superior-anterior compartment. CONCLUSIONS The influence of occult tumor cell dissemination in lymph nodes of patients with histologically proven pancreatic ductal adenocarcinoma supports the need for further tumor staging through immunohistochemistry. This could be a helpful tool in proper selection of patients for adjuvant chemotherapy.
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Affiliation(s)
- Dean Bogoevski
- Department of General, Visceral and Thoracic Surgery, University Medical Centre of Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
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85
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Lorent N, De Leyn P, Lievens Y, Verbeken E, Nackaerts K, Dooms C, Van Raemdonck D, Anrys B, Vansteenkiste J. Long-term survival of surgically staged IIIA-N2 non-small-cell lung cancer treated with surgical combined modality approach: analysis of a 7-year prospective experience. Ann Oncol 2004; 15:1645-53. [PMID: 15520066 DOI: 10.1093/annonc/mdh435] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The aim of this study was to analyse the outcome of surgically staged IIIA-N2 non-small-cell lung cancer (NSCLC) treated with induction chemotherapy followed by surgical exploration. METHODS Univariate and multivariate analyses were carried out on a prospective cohort of 131 mediastinoscopy-proven IIIA-N2 NSCLC patients. Three preoperative cycles of vindesine-ifosfamide-cisplatin (VIP) were given. Patients with at least stable disease (SD) were considered for surgery, or radical radiotherapy in selected cases. RESULTS The response rate after VIP was 54% (95% confidence interval 45% to 63%) and was important for the final outcome. The median and 5-year survival for the total group were 24 months and 21% (38 months and 30% in responders), respectively. Involvement of subcarinal nodes at diagnosis was the most important prognostic factor (P=0.022). Seventy-five patients were considered for surgery. Downstaging occurred in 34 of 70 resection specimens, with a pathological complete response in six. Median and 5-year survival in the surgical cohort were 45 months and 35%, respectively. Surgery was rewarding both in patients with a response and in those with SD, although the complete resection rate was significantly lower in the latter. On multivariate analysis, favourable prognostic factors were low pathological T-stage (P=0.001) and downstaging of mediastinal nodes in the resection specimen (P=0.008). CONCLUSIONS VIP induction chemotherapy followed by surgical exploration was rewarding in mediastinoscopy-proven stage IIIA-N2 NSCLC, both in cases of response and SD, despite a lower complete resection rate in the latter. Patients with subcarinal nodes at diagnosis (5-year survival 8.5%) or without nodal downstaging at post-induction surgery (13.7%) might preferably be treated with a non-surgical approach.
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Affiliation(s)
- N Lorent
- Respiratory Oncology (Pulmonology), University Hospital Gasthuisberg, Catholic University, Leuven, Belgium
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86
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Lynch TJ, Wright CD, Choi NC, Aquino SL, Mark EJ. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 26-2004. A 56-year-old woman with cough and a lung nodule. N Engl J Med 2004; 351:809-17. [PMID: 15317895 DOI: 10.1056/nejmcpc049012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Thomas J Lynch
- Department of Medical Oncology, Massachusetts General Hospital, USA
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Keller SM, Vangel MG, Wagner H, Schiller JH, Herskovic A, Komaki R, Marks RS, Perry MC, Livingston RB, Johnson DH. Prolonged survival in patients with resected non-small cell lung cancer and single-level N2 disease. J Thorac Cardiovasc Surg 2004; 128:130-7. [PMID: 15224032 DOI: 10.1016/j.jtcvs.2003.11.061] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To test the hypothesis that patients with non-small cell lung cancer and single-level N2 metastases constitute a favorable subgroup of patients with mediastinal metastases, we analyzed the results of the Eastern Cooperative Oncology Group 3590 (a randomized prospective trial of adjuvant therapy in patients with resected stages II and IIIa non-small cell lung cancer) by site of primary tumor and pattern of lymph node metastases. METHODS Accurate staging was ensured by mandating either systematic sampling or complete dissection of the ipsilateral mediastinal lymph nodes. The overall survival of patients with left lung non-small cell lung cancer and metastases in only 1 of lymph node levels 5, 6, or 7 and right lung non-small cell lung cancer with metastases in only 1 of levels 4 or 7 was compared with that of patients with N1 disease originating in the same lobe. RESULTS The median survival of the 172 patients with single-level N2 disease was 35 months (95% confidence interval: 27-40 months) versus 65 months (95% confidence interval: 45-84 months) for the 150 patients with N1 disease (median follow-up 84 months, P =.01). However, among patients with left upper lobe tumors, survival was not significantly different between patients with N1 disease and patients with single-level N2 disease (49 vs 51 months, P =.63). The median survival of the 71 patients with single-level N2 metastases without concomitant N1 disease (skip metastases) was 59 months (95% confidence interval: 36-107 months) versus 26 months (95% confidence interval: 16-36 months) for the 145 patients with both N1 and N2 metastases (P =.001). CONCLUSIONS Survival of patients with left upper lobe non-small cell lung cancer and metastases to single-level N2 lymph nodes is not significantly different from that of patients with N1 disease. The presence of isolate N2 skip metastases is associated with improved survival when compared with patients with both N1 and N2 disease. Survival should be reported by the lobe of primary tumor and metastatic pattern to guide future clinical trial development, treatment strategies, and revisions of the TNM staging system.
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Affiliation(s)
- Steven M Keller
- Cardiothoracic Surgery, Montefiore Medical Center, Bronx, NY 10467, USA.
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88
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Kotoulas CS, Foroulis CN, Kostikas K, Konstantinou M, Kalkandi P, Dimadi M, Bouros D, Lioulias A. Involvement of lymphatic metastatic spread in non-small cell lung cancer accordingly to the primary cancer location. Lung Cancer 2004; 44:183-91. [PMID: 15084383 DOI: 10.1016/j.lungcan.2003.10.012] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2003] [Revised: 10/07/2003] [Accepted: 10/20/2003] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The purpose of the study is to investigate the contribution of lymphatic spread in operable non-small cell lung cancer (NSCLC) in relation to the cancer location. METHODS We retrospectively studied 557 consecutive patients [514 males and 43 females, mean age 62.5 +/- 9.1 years (range, 20-84)] who underwent a major lung resection due to NSCLC in our department, from January 1995 to December 1999. Preoperative staging for metastatic disease was negative. Extended mediastinal lymph node dissection was performed in all lung resections. RESULTS The pathology report revealed 220 adenocarcinomas, 276 squamous-cell, 34 undifferentiated, 25 adenosquamous and 2 large-cell carcinomas. The TNM stage was IA in 52 patients, IB in 109, IIA in 20, IIB in 146, IIIA in 190, IIIB in 35 and IV in 5. The classification of disease was N0 in 240 (40.1%) patients, N1 in 179 (32.1%) and N2 in 138 (24.8%). Twenty-eight patients (5.03%) presented a skip metastasis to hilar lymph nodes, while 27 patients (4.85%) presented with skip metastasis to the mediastinum. The size of the primary tumors presenting with metastases was significantly smaller in adenocarcinomas compared to squamous-cell carcinomas (P = 0.046). Regarding the right lung, tumors originating in the upper lobe mainly metastasized to level No. 4, while tumors of the middle lobe spread to stations Nos. 4 and 7, and those in the lower lobe to level No. 7. Regarding the left lung, tumors originating in the upper lobe metastasized to level No. 5, while tumors within the lower lobe spread to stations, Nos. 7-9. CONCLUSIONS Mediastinal lymph nodal dissection is necessary for the accurate determination of pTNM stage. It seems that there is no definite way for lymphatic spreading in relation to the location of the cancer. Skip metastasis to the mediastinal lymph nodes was present in 4.85% of our patients, while adenocarcinomas, even small-sized ones, are more aggressive than squamous-cell carcinomas.
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Affiliation(s)
- Christophoros S Kotoulas
- Department of Thoracic Surgery, 401 General Military Hospital of Athens, Bakoyanni 70c, Vrilissia, GR-152 35 Athens, Greece.
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89
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Argiris A, Liptay M, LaCombe M, Marymont M, Kies MS, Sundaresan S, Masters G. A phase I/II trial of induction chemotherapy with carboplatin and gemcitabine followed by concurrent vinorelbine and paclitaxel with chest radiation in patients with stage III non-small cell lung cancer. Lung Cancer 2004; 45:243-53. [PMID: 15246197 DOI: 10.1016/j.lungcan.2004.02.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2003] [Revised: 02/11/2004] [Accepted: 02/17/2004] [Indexed: 01/02/2023]
Abstract
PURPOSE We designed a phase I/II trial in order to evaluate the efficacy and tolerability of induction carboplatin and gemcitabine and the maximum tolerated dose (MTD) and dose-limiting toxicity (DLT) of subsequent chemoradiotherapy with weekly vinorelbine and paclitaxel in patients with stage III non-small cell lung cancer (NSCLC). PATIENTS AND METHODS Patients had pathologically confirmed N2-N3 stage NSCLC, adequate end-organ function, and ECOG performance status 0-2. Carboplatin was administered at an AUC of 5 on day 1 and gemcitabine 1000 mg/m2 on days 1 and 8, every 21 days, for two cycles, followed by weekly vinorelbine 10-15 mg/m2 and paclitaxel 50 mg/m2 and conventional chest radiotherapy up to 66 Gy. Patients with resectable disease underwent thoracotomy after 40-45 Gy. RESULTS Thirty-nine eligible patients were enrolled; 17 had stage IIIB NSCLC. Grade 3 esophagitis developed in 4/5 patients on the second dose level of chemoradiotherapy (i.e. vinorelbine 15 mg/m2) and was considered dose-limiting. Of 34 patients treated at the maximum tolerated dose (i.e. vinorelbine 10 mg/m2), 2 patients (6%) had pneumonitis >grade 2 and 3 (9%), esophagitis >grade 2. Induction chemotherapy was well tolerated with only one patient developing >grade 2 non-hematologic toxicity (nausea). Forty-one percent of patients had an objective response after induction chemotherapy and 51% after chemoradiotherapy. Nineteen patients, 16 of whom had stage IIIA, underwent surgical resection. The pathologic complete response rate was 16% (42% in the mediastinal lymph nodes). With a median follow-up of 31 months, the 3-year progression-free survival (PFS) and overall survival (OS) rates were 23 and 34%, respectively, and the median OS was 25 months. CONCLUSIONS We identified a well-tolerated and active chemoradiotherapy regimen. Survival results are promising and the addition of a biologic agent to this regimen is of interest.
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Affiliation(s)
- A Argiris
- Division of Hematology-Oncology, Department of Medicine, The Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA.
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90
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Coello MC, Luketich JD, Litle VR, Godfrey TE. Prognostic significance of micrometastasis in non-small-cell lung cancer. Clin Lung Cancer 2004; 5:214-25. [PMID: 14967073 DOI: 10.3816/clc.2004.n.002] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Accurate staging of non-small-cell lung cancer (NSCLC) determines prognosis and facilitates decisions regarding treatment options. Unfortunately, even after an apparently complete resection in patients with stage I disease, the recurrence rates range from 25% to 50%, and overall survival is not encouraging. One possible reason for this may be that those patients with a poor outcome actually have more extensive disease, with occult locoregional and/or distant metastasis than originally identified by routine pathologic staging techniques. There is now a sizable body of literature on the detection and possible prognostic role of occult disease in lung cancer. The majority of these studies are based on immunohistochemical analysis of lymph nodes and/or bone marrow, but a handful of studies use molecular approaches. The purpose of this review is to summarize and critique the current literature on occult tumor cell spread to lymph nodes and bone marrow in patients with NSCLC. Based on this literature, we believe that the prognostic significance of bone marrow micrometastasis remains unclear. However, the majority of studies indicate that occult lymph node disease is associated with a poor outcome. Thus, our ability to detect individual tumor cells could result in more accurate staging of NSCLC in patients and would potentially lead to the development of novel therapies, as well as influence decisions regarding the use of appropriate multimodality treatment strategies, the choice of surgical technique, and extent of dissection. As data accumulate, the presence or absence of occult nodal involvement should probably be considered at the next revision of the staging system for NSCLC.
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Affiliation(s)
- Michael C Coello
- Division of Thoracic Surgery, University of Pittsburgh, PA 15213, USA
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Sakurai H, Asamura H, Watanabe SI, Suzuki K, Tsuchiya R. Clinicopathologic features of peripheral squamous cell carcinoma of the lung. Ann Thorac Surg 2004; 78:222-7. [PMID: 15223433 DOI: 10.1016/j.athoracsur.2004.01.029] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/22/2004] [Indexed: 11/16/2022]
Abstract
BACKGROUND The clinicopathologic features are still unknown in peripheral squamous cell carcinoma of the lung, unlike centrally located carcinomas. In this retrospective study, we investigated the clinicopathologic characteristics of patients with peripheral squamous cell carcinomas. METHODS Of 1,381 primary lung carcinomas surgically resected at the National Cancer Center Hospital, Tokyo, from 1995 through 2001, 70 (5.1%) peripheral squamous cell carcinomas of 3.0 cm or less in diameter were studied retrospectively in terms of clinicopathologic characteristics such as age, sex, past history, smoking, tumor size, mode of operation, extent of lymph node dissection, pathologic lymph node status, mode of recurrence, and cause of death. RESULTS These patients ranged in age from 49 to 82 years, with a mean age of 69.2 years. Thirty-nine patients (56%) were at increased risk preoperatively. The incidence of lymph node metastasis was 25%, and larger tumors tended to be associated with a higher prevalence, although this difference was not significant (p = 0.12). None of the patients with N2 disease had skipping metastasis. Recurrence was observed in 13 patients (19%). There was no significant correlation between recurrence and the extent of lymphadenectomy or the mode of operation. The 5-year overall and disease-specific survival rates were 73.4% and 85.9%, respectively. The cause of death was recurrence in 53% and other disease in 47%. CONCLUSIONS We propose that mediastinal hilar lymphadenectomy should be routinely conducted as a curative operation for low-risk patients with small peripheral squamous cell carcinoma. We further propose that for patients who may have difficulty tolerating this procedure, pathologic examination of intraoperative frozen sections from the hilar node could be useful for planning a surgical strategy.
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Affiliation(s)
- Hiroyuki Sakurai
- Division of Thoracic Surgery, National Cancer Center Hospital, Tokyo, Japan.
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92
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Inoue M, Sawabata N, Takeda SI, Ohta M, Ohno Y, Maeda H. Results of surgical intervention for p-stage IIIA (N2) non-small cell lung cancer: acceptable prognosis predicted by complete resection in patients with single N2 disease with primary tumor in the upper lobe. J Thorac Cardiovasc Surg 2004; 127:1100-6. [PMID: 15052208 DOI: 10.1016/j.jtcvs.2003.09.012] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Non-small cell lung cancer with mediastinal lymph node involvement is a heterogeneous entity different from single mediastinal lymph node metastasis to multiple nodes or extranodal disease. The objective of this study was to identify the subpopulation of patients with N2 disease who can benefit from surgical intervention. METHODS We reviewed 219 consecutive patients with N2 non-small cell lung cancer treated with a thoracotomy between November 1980 and June 2002 and retrospectively analyzed 154 of those who had p-stage IIIA disease and underwent a complete resection. Age, sex, side (right or left), histology, location (upper or middle-lower lobe), tumor size, c-N factor, and N2 level (single or multiple) were used as prognostic variables. RESULTS The 3- and 5-year survivals were 45.3% and 28.1%, respectively, in patients with p-stage IIIA (N2) disease. Survival for those with single N2 non-small cell lung cancer was significantly better than in those with multiple N2 disease (P =.0001), and patients with a tumor in the upper lobe showed a significantly longer survival than those with middle-lower lobe involvement (P =.0467). The 3- and 5-year survivals for patients with single N2 disease with a primary tumor in the upper lobe were 74.9% and 53.5%, respectively. A multivariate analysis with Cox regression identified 5 predictors of better prognosis: younger age, squamous cell carcinoma as determined by histology, primary tumor location in the upper lobe, c-N0 status, and a single station of mediastinal node metastasis. CONCLUSION Our results suggest that of the heterogeneity of N2 diseases, patients with single N2 disease with non-small cell lung cancer in the upper lobe are good candidates for pulmonary resection.
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MESH Headings
- Adenocarcinoma/diagnostic imaging
- Adenocarcinoma/pathology
- Adenocarcinoma/surgery
- Adult
- Age Factors
- Aged
- Aged, 80 and over
- Carcinoma, Large Cell/diagnostic imaging
- Carcinoma, Large Cell/pathology
- Carcinoma, Large Cell/surgery
- Carcinoma, Non-Small-Cell Lung/diagnostic imaging
- Carcinoma, Non-Small-Cell Lung/pathology
- Carcinoma, Non-Small-Cell Lung/surgery
- Carcinoma, Squamous Cell/diagnostic imaging
- Carcinoma, Squamous Cell/pathology
- Carcinoma, Squamous Cell/surgery
- Female
- Humans
- Japan
- Lung Neoplasms/diagnostic imaging
- Lung Neoplasms/pathology
- Lung Neoplasms/surgery
- Lymphatic Metastasis
- Male
- Mediastinal Neoplasms/pathology
- Mediastinal Neoplasms/secondary
- Mediastinal Neoplasms/surgery
- Middle Aged
- Neoplasm Staging
- Predictive Value of Tests
- Prognosis
- Retrospective Studies
- Survival Analysis
- Thoracotomy
- Tomography, X-Ray Computed
- Treatment Outcome
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Affiliation(s)
- Masayoshi Inoue
- Department of Thoracic Surgery, Toneyama National Hospital, Toyonaka-city, Osaka, Japan.
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93
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Ohno Y, Hatabu H, Takenaka D, Higashino T, Watanabe H, Ohbayashi C, Yoshimura M, Satouchi M, Nishimura Y, Sugimura K. Metastases in Mediastinal and Hilar Lymph Nodes in Patients with Non–Small Cell Lung Cancer: Quantitative and Qualitative Assessment with STIR Turbo Spin-Echo MR Imaging. Radiology 2004; 231:872-9. [PMID: 15163823 DOI: 10.1148/radiol.2313030103] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To evaluate short inversion time inversion-recovery (STIR) turbo spin-echo (TSE) magnetic resonance (MR) imaging for detection of metastases in lymph nodes by using quantitative and qualitative analyses. MATERIALS AND METHODS One hundred ten patients (68 men and 42 women) with non-small cell lung cancer who ranged in age from 36 to 82 years (mean age, 64 years) were examined with respiratory-triggered STIR TSE MR imaging. Ratios of signal intensity in a lymph node to that in a 0.9% saline phantom (lymph node-saline ratios [LSRs]) for all lymph nodes were classified into three groups according to nodal short-axis diameter. LSRs of each group were compared by using pathologic diagnosis as the standard of reference. For quantitative analysis, the LSR threshold value for a positive test was determined on a per-node basis and tested for ability to enable a correct diagnosis on a per-patient basis. For qualitative analysis, signal intensities of lymph nodes were assessed by using a five-point visual scoring system. Results of quantitative and qualitative analyses were compared on a per-patient basis with McNemar testing. RESULTS In 110 patients, 92 of 802 lymph nodes were pathologically diagnosed as containing metastases, while 710 lymph nodes did not contain metastases. Mean LSR in the lymph node group with metastasis was higher than that in the group without metastasis (P <.05). When an LSR of 0.6 was used as the positive-test threshold at quantitative analysis, sensitivity was 93% (37 of 40 patients) and specificity was 87% (61 of 70 patients) on a per-patient basis. With a score of 4 as the positive-test threshold at qualitative analysis, sensitivity was 88% (35 of 40 patients) and specificity was 86% (60 of 70 patients) on a per-patient basis. There was no significant difference (P >.05) between results of quantitative and those of qualitative analysis. CONCLUSION Quantitative and qualitative analyses of STIR TSE MR images enable differentiation of lymph nodes with metastasis from those without. Qualitative analysis can substitute for quantitative analysis of STIR TSE MR imaging data.
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Affiliation(s)
- Yoshiharu Ohno
- Department of Radiology, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan.
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Ohtsuka T, Nomori H, Horio H, Naruke T, Suemasu K. Is Major Pulmonary Resection by Video-Assisted Thoracic Surgery an Adequate Procedure in Clinical Stage I Lung Cancer? Chest 2004; 125:1742-6. [PMID: 15136385 DOI: 10.1378/chest.125.5.1742] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE Although several studies have shown that video-assisted thoracic surgery (VATS) for major pulmonary resection is less invasive than open thoracotomy, VATS for lung cancer has been performed in only a limited number of institutions. We aimed to review our experience of VATS for major pulmonary resections, and to determine its safety and adequacy in stage I lung cancer. METHODS Between August 1999 and March 2003, we performed major pulmonary resection by VATS in 106 patients with lung cancer and preoperatively determined clinical stage I disease. We evaluated the number of procedures converted to open thoracotomy and the reasons for conversion, the intraoperative blood loss, interval between surgery and chest tube removal, length of postoperative hospital stay, postoperative complications, mortality rate, prognoses, and patterns of recurrence. RESULTS We successfully performed VATS in 95 patients, whereas in another 11 patients (10%) conversion to open thoracotomy was required. The operative procedures were lobectomy in 86 patients, segmentectomy in 8 patients, and bilobectomy in 1 patient. In 95 patients who underwent VATS, postoperative complications developed in 9 patients (9%), and 1 patient (1%) died from pneumonia. In the 86 patients without complications, the mean postoperative hospital stay was 7.6 days (range, 4 to 15 days). In a mean follow-up period of 25 months (range, 6 to 48 months) in patients with non-small cell lung cancer (NSCLC), including the one perioperative death, the 3-year survival rate was 93% in 82 patients with clinical stage I disease, and 97% in 68 patients with pathologic stage I disease. The 3-year disease-free survival rate was 79% in patients with clinical stage I disease, and 89% in patients with pathologic stage I disease. Local recurrence was observed in six patients (6%): recurrence in mediastinal lymph nodes in five patients, and in the bronchial stump in one patient. CONCLUSIONS Major pulmonary resection by VATS is acceptable in view of its low perioperative mortality and morbidity, and is an adequate procedure for the achievement of local control and good prognosis in patients with clinical stage I NSCLC.
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Affiliation(s)
- Takashi Ohtsuka
- Department of Thoracic Surgery, Saiseikai Central Hospital, Tokyo, Japan.
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95
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Prenzel KL, Baldus SE, Mönig SP, Tack D, Sinning JM, Gutschow CA, Grass G, Schneider PM, Dienes HP, Hölscher AH. Skip metastasis in nonsmall cell lung carcinoma. Cancer 2004; 100:1909-17. [PMID: 15112272 DOI: 10.1002/cncr.20165] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Skip metastasis to mediastinal lymph nodes is a prognostic factor for patients with nonsmall cell lung carcinoma (NSCLC). Little is known about the biologic behavior of tumors with noncontinuous spread to the mediastinal lymph nodes. In patients with pN2 skip metastases, micrometastases to N1 lymph nodes, which only mimic skip metastases, have not been investigated. METHODS In a retrospective study, the authors analyzed the primary tumor specimens from 45 patients with pN2 NSCLC (18 patients had squamous cell carcinomas, 23 had adenocarcinomas, and 4 had large cell carcinomas). They immunohistochemically evaluated the expression of p21, p53, MUC-1, Bcl-2, c-ErbB-2, and E-cadherin. Survival rates and biomarker expression levels were compared between patients with pN2 disease and infiltration of N1 lymph nodes (without skip metastasis [n = 28]) and patients with pN2 disease without N1 infiltration (with skip metastasis [n = 17]). To evaluate micrometastasis in the pN1 lymph nodes of 17 patients with skip metastases, lymph nodes were stained using the anticytokeratin antibody, AE1/AE3. RESULTS The 5-year survival rate of patients with skip metastases was 41%, compared with 14% for patients without skip metastases (P = 0.019). In a multivariate analysis, the incidence of skip metastases did not vary significantly according to gender, age, histology, pT status, or cM status. Three skip-positive patients (17.6%) had micrometastatic tumor involvement of pN1 lymph nodes. After adding these patients to the group of patients without skip metastases, there was still a significant difference in survival between the two groups. p53, MUC-1, c-ErbB-2, and E-cadherin expression levels in primary tumor specimens were not significantly different in patients with continuous metastasis and patients with skip metastases. Patients with skip metastases expressed lower levels of p21 (P = 0.026), whereas Bcl-2 expression levels were considerably higher (P = 0.019) compared with the corresponding levels in patients without skip metastases. CONCLUSIONS Patients with NSCLC and pN2 skip metastases have a more favorable prognosis than do patients with pN2 disease without skip metastases. Tumor specimens from these patients exhibit elevated expression of the antiapoptosis gene BCL2 and lower expression levels of p21 relative to patients with pN2 disease without skip metastases. Micrometastases occurred in 3 of 17 (17.6%) patients with pN2 disease and skip metastases diagnosed by routine histopathology.
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Affiliation(s)
- Klaus L Prenzel
- Department of Visceral and Vascular Surgery, University of Cologne, Cologne, Germany.
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96
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Taylor NA, Liao ZX, Cox JD, Stevens C, Roth J, Walsh G, Chang JY, Guerrero T, Jeter M, Putnam J, Fossella FV, Allen P, Komaki R. Equivalent outcome of patients with clinical Stage IIIA non–small-cell lung cancer treated with concurrent chemoradiation compared with induction chemotherapy followed by surgical resection. Int J Radiat Oncol Biol Phys 2004; 58:204-12. [PMID: 14697440 DOI: 10.1016/s0360-3016(03)01575-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE To compare the outcome of induction chemotherapy followed by surgery (C/S) and concurrent chemoradiotherapy (CRT) for clinical Stage IIIA non-small-cell lung cancer (NSCLC). METHODS AND MATERIALS Between 1990 and 2000, 107 patients underwent either induction C/S (n = 55) or concurrent CRT (n = 52) for clinical Stage IIIA NSCLC at The University of Texas M. D. Anderson Cancer Center. Patient and tumor characteristics were balanced in the two treatment groups with respect to T and N stage, race, median age, performance status, weight loss, and histologic findings. In the C/S group, induction chemotherapy included two to four cycles of cisplatin-based chemotherapy followed by lobectomy and mediastinal lymph node dissection. Postoperative RT was delivered in 35 patients, with referral for RT made at the discretion of the treating physician. CRT consisted of three cycles of cisplatin-based chemotherapy given every 3 weeks concurrent with RT to 60-63 Gy in 30-35 fractions in 27 patients and 69.6 Gy in 58 fractions (b.i.d.) in 25 patients. Local control, overall disease-free survival, and distant metastasis-free survival rates were calculated using the Kaplan-Meier method. The median follow-up duration was 20 months in all patients and 32 months in surviving patients. RESULTS No statistically significant differences were found in the end points measured in the two treatment groups. Specifically, the median survival time was 31 and 27 months and the 5-year overall survival rate was 33% and 30% in the C/S and CRT groups, respectively. Likewise, the 5-year local control (58% vs. 61%), disease-free (24% vs. 23%), and distant metastasis-free (44% vs. 36%) survival rates in the two groups were not significantly different. In the C/S group, postoperative RT significantly improved the 5-year local control rate from 33.8% to 81.5% (p = 0.007) but did not significantly improve overall survival. Additionally, patients in the C/S group whose disease responded to induction chemotherapy had a significantly improved 5-year overall survival rate (50%) compared with those who had stable or progressive disease (16%, p = 0001). CONCLUSION Treatment of Stage IIIA NSCLC using either induction C/S or CRT resulted in similar outcomes in terms of local control and median overall, 5-year overall, distant metastasis-free, and disease-free survival. However, patients undergoing induction C/S often needed postoperative RT to achieve local control equivalent to that achieved with concurrent CRT. Advances in radiation-based treatment as reflected in this study have resulted in similar outcomes compared with modern induction C/S. To improve survival, however, newer systemic agents that reduce and control distant metastasis are required.
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Affiliation(s)
- Noah A Taylor
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA
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Wendland MMM, Sause WT. Induction chemotherapy followed by radical local therapy for locally advanced non-small cell lung cancer. ACTA ACUST UNITED AC 2003; 21:111-21. [PMID: 14508861 DOI: 10.1002/ssu.10028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Many patients who receive a diagnosis of non-small cell lung cancer (NSCLC) have locally advanced disease at initial presentation. Historically, these patients were treated with primary thoracic radiation therapy and had poor long-term survival rates, secondary to both progression of local disease and development of distant metastases. With the goal of improving clinical outcomes, multiple concepts of combined-modality therapy for locally advanced NSCLC have been investigated. The rationale for using chemotherapy in the induction regimen is to eliminate subclinical metastatic disease while improving local control. The optimal treatment of locally advanced NSCLC continues to evolve, but combined-modality therapy has led to improved survival rates compared to treatment with radiation alone and has become the new standard of care. This report reviews the major trials that have investigated various combinations of surgery, radiation therapy, and chemotherapy in the treatment of locally advanced NSCLC.
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Affiliation(s)
- Merideth M M Wendland
- Department of Radiation Oncology, University of Utah, Salt Lake City, Utah 84143, USA
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Taylor NA, Liao ZX, Stevens C, Walsh G, Roth J, Putnam J, Fossella F, Allen P, Cox JD, Komaki R. Postoperative radiotherapy increases locoregional control of patients with stage IIIA non-small-cell lung cancer treated with induction chemotherapy followed by surgery. Int J Radiat Oncol Biol Phys 2003; 56:616-25. [PMID: 12788166 DOI: 10.1016/s0360-3016(03)00063-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To determine the effectiveness of postoperative radiotherapy (RT) in patients with Stage IIB and Stage IIIA non-small-cell lung cancer (NSCLC) treated with induction chemotherapy followed by surgery. METHODS AND MATERIALS We retrospectively reviewed the treatment records of 98 patients (58 men and 40 women; median age 61 years, range 31-91) with Stage IIB and Stage IIIA NSCLC who were treated with induction chemotherapy followed by surgery at our institution between January 1990 and December 2000. Patients were grouped by treatment (chemotherapy/surgery alone vs. chemotherapy/surgery/RT), by disease stage and nodal classification. The rates of local control (LC), disease-specific survival, disease-free survival, and overall survival (OS) were calculated using the Kaplan-Meier method. RESULTS Of the 98 patients, 40 had Stage IIB and 58 had Stage IIIA. The clinical disease stage and N stage were significantly greater in those patients who underwent RT than in those who did not; however, no statistically significant differences were identified in the additional characteristics between those receiving and not receiving RT within each stage or nodal group. The overall 5-year actuarial LC rate was 81% in the RT group and 54% in the chemotherapy/surgery-alone group (p = 0.07). Postoperative RT significantly improved the 5-year LC rate in patients with Stage IIIA disease (from 35% to 82%, p = 0.01). Postoperative RT did not significantly improve the 5-year OS rate (30% with RT vs. 49% without) for all patients or for patients with Stage IIIA disease. The disease-specific survival and disease-free survival rates did not differ between the treatment groups. Patients who responded to induction chemotherapy had a significantly greater 5-year OS rate (49%) than did those with stable or progressive disease (22%, p = 0.003). CONCLUSION Postoperative RT in patients with Stage IIIA NSCLC treated with induction chemotherapy followed by surgery significantly improved LC without improving OS. Significantly improved survival was observed in all patients who responded to induction chemotherapy compared with those with stable or progressive disease.
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MESH Headings
- Adenocarcinoma/mortality
- Adenocarcinoma/pathology
- Adenocarcinoma/radiotherapy
- Adult
- Aged
- Aged, 80 and over
- Carcinoma, Large Cell/mortality
- Carcinoma, Large Cell/pathology
- Carcinoma, Large Cell/radiotherapy
- Carcinoma, Non-Small-Cell Lung/mortality
- Carcinoma, Non-Small-Cell Lung/pathology
- Carcinoma, Non-Small-Cell Lung/radiotherapy
- Carcinoma, Squamous Cell/mortality
- Carcinoma, Squamous Cell/pathology
- Carcinoma, Squamous Cell/radiotherapy
- Chemotherapy, Adjuvant
- Combined Modality Therapy
- Disease-Free Survival
- Female
- Humans
- Lung Neoplasms/mortality
- Lung Neoplasms/pathology
- Lung Neoplasms/radiotherapy
- Male
- Middle Aged
- Neoplasm Staging
- Radiotherapy Dosage
- Remission Induction
- Retrospective Studies
- Survival Analysis
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Affiliation(s)
- N A Taylor
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA
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Relationship between lymph node metastases in esophageal carcinoma and its prognosis. Chin J Cancer Res 2002. [DOI: 10.1007/s11670-002-0065-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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100
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Takenaka D, Ohno Y, Hatabu H, Ohbayashi C, Yoshimura M, Ohkita Y, Sugimura K. Differentiation of metastatic versus non-metastatic mediastinal lymph nodes in patients with non-small cell lung cancer using respiratory-triggered short inversion time inversion recovery (STIR) turbo spin-echo MR imaging. Eur J Radiol 2002; 44:216-24. [PMID: 12468071 DOI: 10.1016/s0720-048x(02)00271-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To differentiate between metastatic and non-metastatic lymph nodes in patients with non-small cell lung cancer using respiratory-triggered short inversion time inversion recovery (STIR) turbo spin-echo (SE) MR imaging. METHODS AND PATIENTS One hundred and forty mediastinal lymph nodes were detected in 25 patients with non-small cell lung cancer who underwent respiratory-triggered STIR turbo SE imaging. Ratios of signal intensity of lymph nodes to 0.9% saline phantoms (lymph node-saline ratio) were compared by Student's t-test using the pathological diagnosis as the gold standard. The threshold value of the lymph node-saline ratio was determined for a positive test, and tested for its capability to provide a differential diagnosis. RESULTS One hundred and forty lymph nodes were diagnosed and classified into two groups: metastatic lymph node (n=21) and non-metastatic lymph node (n=119). The mean lymph node-saline ratio in the non-metastatic lymph node group (0.42+/-0.01; mean+/-standard error) was significantly lower than that of the metastatic lymph node group (0.77+/-0.02, P<0.0001). When 0.6 was adapted as the threshold for a positive test, sensitivity, specificity, and accuracy for differentiating metastatic lymph node from non-metastatic lymph node per lymph nodes were 100, 96, and 96%, and sensitivity, specificity, and accuracy for differentiating metastatic lymph node from non-metastatic lymph node per patients were 100, 75, and 88%, respectively. CONCLUSIONS Both metastatic and non-metastatic lymph nodes in patients with non-small cell lung cancer were well differentiated using respiratory-triggered STIR turbo SE imaging.
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Affiliation(s)
- Daisuke Takenaka
- Department of Radiology, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
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