Predictors of Outcomes after Surgical Treatment of Synchronous Primary Lung Cancers

Novel Strategy for Synchronous Multiple Primary Lung Cancer Displaying Unique Molecular Profiles

We report a rare case of multiple primary lung tumors displaying heterogeneous EGFR and KRAS molecular profiles, in which the patient underwent surgical resection of the gefitinib-insensitive peripheral lesion and continued gefitinib treatment for the gefitinib-sensitive bilateral multiple ground-glass opacity (GGO) lesions. The patient achieved complete remission and has been free of disease for 1.5 years. To the best of our knowledge, this novel strategy has not been previously reported. We consider our strategy to be safe and effective, and it appears to be a promising therapeutic approach for synchronous multiple primary lung cancer (SMPLC).

Surgical treatment of synchronous multiple primary lung cancers: a retrospective analysis of 122 patients

BACKGROUND

Synchronous multiple primary lung cancers (SMPLC) become more common in clinical practice. To identify factors attributed to SMPLC treatment outcomes, we have reviewed our experiences with surgical resections of SMPLC and analyzed the treatment outcomes in this paper.

METHODS

We retrospectively analyzed clinical characteristics and treatment outcomes of patients who have been diagnosed as SMPLC and underwent surgical resection between 1990 and 2010. Based on EGFR and KRAS mutations, we identified 27 cases as SMPLC out of 50 cases, which were difficult to distinguish primary lung cancers from metastases. A total of 265 tumors from 122 patients were studied.

RESULTS

The 5-year survival rate for all patients was 40.5%. There was a significant difference in the 5-year survival between smokers and never-smokers (30.8% vs. 55.6%, P=0.011). Survival rate was also different between patients with same tumor histology and those with different tumor histology (46.9% vs. 24.8%, P=0.036). In addition, Solid nodule and pneumonectomy were associated with the worse survival (P=0.026, P=0.030). Multivariable analysis identified smoking status, stage, lymph node metastasis and pneumonectomy as significant independent predictive factors for overall survival.

CONCLUSIONS

Surgical treatment is a safe approach for patients with SMPLC; pneumonectomy should be avoided as far as possible given the poor prognosis. Mutational status of EGFR and KRAS may be advocated as a diagnostic criteria of synchronous lung cancer rather metastasis mainly in case of adenocarcinoma histology.

Surgical Outcomes of Synchronous Multiple Primary Non-Small Cell Lung Cancers

The prognostic indicators for synchronous multiple primary non-small cell lung cancer (NSCLC) vary across reports. In present study, the prognostic factors for the patients with synchronous multiple primary NSCLC were analyzed in a large cohort. A total of 285 patients with synchronous multiple primary NSCLC who underwent radical surgical resection and with complete follow-up information were included in this study. The Kaplan-Meier method were used for survival analysis, Cox proportional hazards regression models were used for risk factors evaluation. Among them, 94 (33.0%) patients had bilateral tumors and 51 (17.9%) had multiple (≥3) tumors. The 5-year disease-free survival (DFS) and overall survival (OS) rate was 58.7% and 77.6%, respectively. Univariate analysis identified parameters conferring shorter OS including male gender, symptomatic disease, negative family history, large maximal tumor size, not all adenocarcinomas, advanced highest T stage, and lymph node involvement. Multivariate analysis showed that male gender (p = 0.020), symptomatic disease (p = 0.017), and lymph node involvement (p < 0.001) were independent adverse prognosticators. For patients with multiple adenocarcinomas, the 5-year DFS and OS rate was 59.6% and 82.4%, respectively. The subtypes other than lepidic predominant (p < 0.001) and lymph node involvement (p = 0.002) were the independent unfavorable prognosticators. In conclusion, we identified independent prognosticators which will provide the valuable clues for postoperative management of patients with synchronous multiple primary NSCLC.

SUVmax and Tumor Size Predict Surgical Outcome of Synchronous Multiple Primary Lung Cancers

To assess surgical outcomes in synchronous multiple primary lung cancer (SMPLC) and correlations with clinicopathological features and prognostic/predictive factors.We retrospectively reviewed patients diagnosed with early-stage nonsmall cell lung cancer (NSCLC) between January 2006 and June 2012. In total, 564 patients with resectable NSCLC underwent a preoperative positron emission tomography-computed tomography scan followed by anatomic resection. We reviewed the clinical features of 35 SMPLC patients. Surgical outcomes, prognosis, and tumor imaging features were evaluated (median follow-up = 44 months).In total, 35 eligible SMPLC patients (6.21%) were identified (11 men [31%], 24 women [69%], mean age = 65 years]). The tumors were bilateral in 17 patients (49%) and in different lobes of the ipsilateral lung in 18 patients (51%). Most patients (26/35, 74%) had 2 primary tumors, and 26% (9/35) had more than 2 tumors (6 with 3 tumors; 3 with 4 tumors). The median size of the most advanced tumor was 3.0 cm (range 0.9-54). The median standard uptake value (SUV) of the largest tumor was 3.1 (range 1.0-13.3). The patients were treated as follows: 30 lobectomies, 2 sublobar resections, 2 sequential bilateral lobectomies, and 1 bi-lobectomy. Twenty-four patients (69%) received adjuvant therapy. The overall cumulative 5-year survival was 91.5% (median overall survival = 45.5 months). Patients with a reference tumor ≤ 3 cm and SUV ≤ 3.1 had an expected 5-year survival of 100%. Patients with a reference tumor > 3 cm and SUV > 3.1 had an expected 5-year survival rate of 53.3%.SMPLC patients can benefit from aggressive surgery. The size and SUVmax of the reference tumor may predict postoperative outcomes.

Pathologic Staging and Survival of Patients With Synchronous Bilateral Lung Carcinomas

OBJECTIVES

To compare survival data in patients with resected bilateral synchronous pulmonary carcinomas with survival data from patients with lung cancer in pStages I through IV and to evaluate the usefulness of comprehensive histologic evaluation (CHE) of tumor histologic patterns to distinguish between synchronous primaries and intrapulmonary metastases.

METHODS

Ten-year overall survival (OS) data from 18 patients with 44 resected synchronous bilateral lung cancers, classified as "synchronous primaries" or "metastases" using CHE, were compared with survival data of 2,879 patients with lung cancer in pStages I through IV.

RESULTS

Forty and four tumors from 16 and two patients, respectively, were classified as synchronous primaries and metastases. There were no significant differences in survival between these 18 patients and pStage I controls or between the synchronous primaries and the metastases patient groups. However, there were significant differences in survival between the patients with resected synchronous bilateral tumors and each of the pStage II through IV control groups (P < .05).

CONCLUSIONS

Patients with resected synchronous bilateral lung cancers had similar 10-year OS to patients with stage I disease, regardless of CHE data. Most resected tumors were synchronous primaries by CHE.

Molecular Testing in Multiple Synchronous Lung Adenocarcinomas

Discovery of driver mutations in pulmonary adenocarcinoma has revolutionized the field of thoracic oncology with major impact on therapy and diagnosis. Testing for EGFR, ALK, and KRAS mutations has become part of everyday practice. We report a case with multiple synchronous primary pulmonary adenocarcinomas in a 72-year-old female with previous history of smoking. The patient presented with cough and bilateral lung ground glass opacities. A positron emission tomography/computed tomography scan showed no activity in mediastinal lymph nodes. She underwent a left upper lobe biopsy and a right upper lobe wedge resection. Pathology revealed 4 morphologically distinct adenocarcinoma foci, suggestive of synchronous primary lung tumors. Molecular testing demonstrated no mutation in the left tumor. Three different driver mutations were present in the right lung tumors: KRAS codon 12 G12D and G12V and EGFR exon 21 L858R mutation, confirming the initial histologic impression. Subsequently, left upper lobe lobectomy showed 3 additional foci of adenocarcinoma with different morphologies, suggestive of synchronous primaries as well. No additional molecular testing was performed. Synchronous pulmonary adenocarcinomas are not uncommon; however, 4 or more synchronous tumors are rare. Distinguishing multiple primary tumors from intrapulmonary metastases is a common problem in thoracic oncology with major implications for staging, prognosis, and treatment. Lung adenocarcinoma subclassification based on predominant and coexisting histologic patterns can greatly facilitate differentiation between intrapulmonary metastases and multiple synchronous tumors. Use of molecular profiling is recommended since it further increases confidence in the diagnostic workup of multiple pulmonary adenocarcinomas and helps guiding therapy.

Double primary non-small cell lung cancer with synchronous small cell lung cancer N2 nodes: a case report

Synchronous multiple primary lung cancer (SMPLC) is rare and very hard to distinguish from metastatic disease. Recent studies indicate the presence of this entity in the lung, with no mention to the involvement of the mediastinum. An extremely rare case of a 68-year-old male with double primary non-small cell lung cancer (NSCLC) in the left upper lobe and N2 positive nodes for small cell lung cancer (SCLC) is presented. Modern diagnostic criteria as well as aggressive curative strategies are encouraged, in order to achieve better survival rates for such patients.

Staging of lung cancer

Primary lung cancer is the leading cause of cancer mortality in the world. Thorough clinical staging of patients with lung cancer is important, because therapeutic options and management are to a considerable degree dependent on stage at presentation. Radiologic imaging is an essential component of clinical staging, including chest radiography in some cases, computed tomography, MRI, and PET. Multiplanar imaging modalities allow assessment of features that are important for surgical, oncologic, and radiation therapy planning, including size of the primary tumor, location and relationship to normal anatomic structures in the thorax, and existence of nodal and/or metastatic disease.

Survival of a surgical series of lung cancer patients with synchronous multiple ground-glass opacities, and the management of their residual lesions

OBJECTIVES

We reviewed the medical record of a series of patients with synchronous multiple lung cancers (SMLC), in an attempt to identify the optimal treatment strategy for multiple ground-glass opacities (GGOs).

MATERIALS AND METHODS

From 2004 to 2010, 1223 patients underwent complete resection of non-small cell lung cancer. Among these, there were 67 patients (5.5%) with SMLC with at least 1 of the nodules showing GGO appearance. SMLC was divided into the main cancer (MC) which was a main target based on its tumor size or radiological invasiveness and sub-nodules. According to consolidation/tumor ratio (CTR) on thin-section computed tomography, 67 cases were classified into GG-group (MC showing GGO-dominant lesion; CTR≤0.5) and GS-group (MC showing solid-dominant lesion; CTR>0.5).

RESULTS

There were 24 patients in the GG-group (36%) and 43 patients in the GS-group (64%). Surgical resections included 11 sublobar resections (SLs), 32 lobectomies, 19 lobectomy+SLs, and 4 bilobectomies. There were 39 patients with a total of 118 unresected GGOs after the initial surgery. Among them, the frequency of growth was 8% on a per-nodule basis with the median tumor doubling time of 1373 days, and new GGOs emerged in 15 patients (23%). Multivariate analysis demonstrated that larger size of MC and the GS-group was associated with poor prognosis, whereas growth of the residual GGOs, the development of new GGOs, or whether or not all GGOs were treated did not affect survival. The 5-year OS proportions were 95.8% for the GG-group and 68.0% for the GS-group (p=0.009), and 92.4% for a MC of ≤25 mm and 53.6% for a MC of >25 mm (p=0.008).

CONCLUSION

Survival of patients with multifocal GGOs is strongly affected by radiological findings of the MC. Strict surgical control for MC could be most important.

Prognosis of synchronous and metachronous multiple primary lung cancers: systematic review and meta-analysis

BACKGROUND

With the development of imaging technology, an increasing number of multiple primary lung cancers (MPLC) are diagnosed in recent years. However, there is still ambiguity in the stage classification rules for patients with MPLC. Our purpose was to access the prognosis of synchronous and metachronous MPLC.

METHODS

A systematic literature search was performed on four databases (EBSCO, Pubmed, OVID and Springer) to obtain relevant articles. We used published hazard ratios (HRs) of overall survival (OS) if available or estimates from the published survival data.

RESULTS

There were 1796 patients with MPLC in 22 relevant studies, who were eligible for analysis. We found that the OS of patients with synchronous MPLC was inferior to the one of metachronous MPLC patients when starting from the diagnosis of the first metachronous tumor (HR 3.36, 95% CI 2.39-4.74; p<0.001). However, there was no difference when starting from the diagnosis of the second metachronous tumor (HR 1.19, 95% CI 0.86-1.66; p=0.29). From further analysis we found the OS of patients with MPLC was superior to that of patients with intrapulmonary metastasis (HR 2.66, 95% CI 1.30-5.44; p=0.007). Besides, we found no difference in OS between synchronous (HR 1.39, 95% CI 0.98-1.96; p=0.06) and metachronous (HR 1.05, 95% CI 0.75-1.47; p=0.77) patients, in spite of the histology. In terms of unilateral and bilateral MPLC patients, the OS had no difference either (HR 1.30, 95% CI 1.00-1.69; p=0.05).

CONCLUSION

We found that MPLC had better OS than the lung cancer patients with intrapulmonary metastasis. And despite the tumor-free interval, the OS for metachronous MPLC was as good as that for synchronous MPLC. Furthermore, there was no difference of OS in different subgroups, including histology and position.

The 2011 IASLC/ATS/ERS pulmonary adenocarcinoma classification: a landmark in personalized medicine for lung cancer management

In 2011, three authoritative academic communities, International Association for the Study of Lung Cancer, the American Thoracic Society, and the European Respiratory Society (IASLC/ATS/ERS), published a novel lung adenocarcinoma histologic classification. The major modifications of this classification include the abolishment of the term "bronchioloalveolar carcinoma (BAC)", the establishment of new classification systems for resection and small biopsy or cytology specimens, the emphasis of molecular test and comprehensive histologic evaluation for tumor specimens, etc. This new lung adenocarcinoma classification signifies the era of personalized medicine comes to real-world practice in lung cancer field. Here, we introduce the background why the lung adenocarcinoma classification needs to be revised, and what we should consider in clinical practice according to this new classification.

Implementing the new IASLC/ATS/ERS classification of lung adenocarcinomas: results from international and Chinese cohorts

A new histologic classification of lung adenocarcinoma was proposed by the International Association for the Study of Lung Cancer, American Thoracic Society, and European Respiratory Society (IASLC/ATS/ERS) in 2011 to provide uniform terminology and diagnostic criteria for multidisciplinary strategic management. This classification proposed a comprehensive histologic subtyping (lepidic, acinar, papillary, micropapillary, and solid pattern) and a semi-quantitative assessment of histologic patterns (in 5% increments) in an effort to choose a single, predominant pattern in invasive adenocarcinomas. The prognostic value of this classification has been validated in large, independent cohorts from multiple countries. In patients who underwent curative-intent surgery, those with either an adenocarcinoma in situ (AIS) or a minimal invasive adenocarcinoma have nearly 100% disease-free survival and are designated "low grade tumors". For invasive adenocarcinomas, the acinar and papillary predominant histologic subtypes were usually designated as "intermediate grade" while the solid and micropapillary predominant histologic subtypes were designated "high grade" tumors; this was based on the statistic difference of overall survival. This classification, coupled with additional prognostic factors [nuclear grade, cribriform pattern, high Ki-67 labeling index, thyroid transcription factor-1 (TTF-1) immunohistochemistry, immune markers, and (18)F-fluorodeoxyglucose uptake on positron emission tomography (PET)] that we have published on, could further stratify patients into prognostic subgroups and may prove helpful for individual patient care. With regard to Chinese oncologists, the implementation of this new classification only requires hematoxylin and eosin (H&E) stained slides and basic pathologic training, both of which require no additional costs. More importantly, this new classification system could provide informative data for better selection and stratification of clinical trials and molecular studies.

The lung adenocarcinoma guidelines: what to be considered by surgeons

In 2011 the International Association for the Study of Lung Cancer (IASLC), the American Thoracic Society (ATS), and the European Respiratory Society (ERS), have proposed a new subclassification of lung adenocarcinomas. This new classification was founded on an evidence-based approach to a systematic review of 11,368 citations from the related literature. Validation has involved projects relating to histologic and cytologic analysis of small biopsy specimens, histologic subtyping, grading, and observer variation among expert pathologists. As enormous resources are being spent on trials involving molecular and therapeutic aspects of adenocarcinoma of the lung, the development of standardized criteria is of great importance and should help advance the field, increasing the impact of research, and improving patient care. This classification is needed to assist in determining patient therapy and predicting outcome. The 2011 IASLC/ATS/ERS adenocarcinoma classification can have an impact on TNM staging. It may help in comparing histologic characteristics of multiple lung adenocarcinomas to determine whether they are intrapulmonary metastases versus separate primaries. Use of comprehensive histologic subtyping along with other histologic characteristics has been shown to have good correlation with molecular analyses and clinical behavior. Also, it may be more meaningful clinically to measure tumor size in lung adenocarcinomas that have a lepidic component by using invasive size rather than total size to determine the size T factor.

Characteristics and outcomes of secondary nodules identified on initial computed tomography scan for patients undergoing resection for primary non-small cell lung cancer

OBJECTIVE

We sought to define the prevalence, malignancy rate, and outcome of secondary nodules (SNs) detected on computed tomography (CT) scan for patients undergoing resection for primary non-small cell lung cancer (NSCLC).

METHODS

In consecutive patients with NSCLC, we reviewed all CT scan reports obtained at diagnosis of the dominant tumor for description of SNs. When resected, pathology was reviewed. Serial CT reports for 2 years postoperatively were evaluated to follow SNs not resected.

RESULTS

Among 155 patients, 88 (57%) were found to have SNs. A total of 137 SNs were evaluated (median size, 0.5 cm). Thirty-two nodules were resected at primary resection. Nineteen (61%) resected nodules were benign, whereas 13 (39%) were malignant (8 synchronous primary tumors and 5 lobar metastases). A total of 105 unresected nodules were followed by CT. Of these, 32 (30%) resolved completely, 20 (19%) shrunk, and 28 (27%) were stable, whereas 11 (11%) were lost to follow-up. Fourteen SNs (13%) grew, of which 5 were found to be malignant, each a new primary. Overall 5-year survival was not different between patients with or without SNs (67% vs 64%; P = .88).

DISCUSSION

The prevalence of SNs on CT scan in patients undergoing resection for primary NSCLC is high. Only a low proportion of SNs are ever found to be malignant, predominantly those on the ipsilateral side as the dominant tumor. The presence of SNs has no effect on survival. Patients with SNs, if otherwise appropriately staged, should not be denied surgical therapy.

Surgical management of advanced non-small cell lung cancer

More than 75% of the cases of non-small cell lung cancer (NSCLC) are diagnosed in advanced stages (IIIA-IV). Although in these patients the role of surgery is unclear, complete tumor resection can be achieved in selected cases, with good long-term survival. In this review, current indications for surgery in advanced NSCLC are discussed. In stage IIIA (N2), surgery after induction chemotherapy seems to be the best option. The indication of induction chemotherapy plus radiotherapy is debatable due to potential postoperative complications but recently reported experiences have not shown a higher postoperative risk in patients after chemo and radiotherapy induction even if pneumonectomy is performed. In cases of unexpected N2 found during thoracotomy, lobectomy plus systematic nodal dissection is recommended mostly for patients with single station disease. In stage IIIB, surgery is only the choice for resectable T4N0-1 cases and should not be indicated in cases of N2 disease. Favorable outcomes are reported after extended resections to the spine and mediastinal structures. Thorough and individualized discussion of each stage IIIB case is encouraged in the context of a multidisciplinary team. For stage IV oligometastatic cases, surgery can still be included when planning multimodality treatment. Brain and adrenal gland are the two most common sites of oligometastases considered for local ablative therapy.

Clinical features of multiple lung cancers based on thin-section computed tomography: what are the appropriate surgical strategies for second lung cancers?

PURPOSE

We investigated the proper surgical strategies for second lung cancers based on the findings of thin-section CT.

METHODS

We classified 59 patients with second lung cancers into two categories based on the thin-section CT findings. In the ground glass nodule (GGN) group (n = 29), the first and/or the second lung cancers showed a GGN on thin-section CT. In the Solid group (n = 30), both the first and second lung cancers showed a solid appearance.

RESULTS

The overall 5-year survival rate after second surgery was 71.7 %. The univariate analyses revealed that the presence of more than three lung tumors was significantly more common in the GGN group. Regarding the surgical strategies, all the patients in the GGN group underwent limited resection for at least one of the operations, whereas 36 % of those in the Solid group underwent bilateral lobectomy. The 5-year survival in the GGN group (89.1 %) was significantly better than that in the Solid group (40.8 %) (p = 0.0305).

CONCLUSIONS

Limited resection should be performed for GGN patients as much as possible to preserve lung function, due to the possible presence of more than three lung cancers. Despite the higher likelihood of having more tumors, the GGN patients had a better survival. In contrast, lobectomy for second lesions should be aggressively considered for solid tumor patients whenever possible.

Surgical results of synchronous multiple primary lung cancers: similar to the stage-matched solitary primary lung cancers?

BACKGROUND

Treatment for synchronous multiple primary lung cancers (SMPLC) remains controversial. Some surgeons treat SMPLC like advanced lung cancer, whereas other surgeons treat SMPLC as separate primary lung cancers. In this study, survival of SMPLC patients and matched-stage solitary primary lung cancer (SPLC) patients after surgical treatment were compared.

METHODS

Prospective medical records between 2001 and 2011 were retrospectively reviewed.

RESULTS

A total of 1,995 patients underwent pulmonary resection for lung cancer in a tertiary referral center. Only 97 patients met the modified criteria of Martini and Melamed for SMPLC. The median follow-up time was 38.3 months. The 3-year and 5-year overall survival rates were 83.1% and 69.6%, respectively. In the univariate analysis, males, smokers, and tumor size greater than 3 cm demonstrated significantly worse survival. After multivariate analysis, only tumor size (p = 0.018; hazard ratio 3.199) was identified as an independent predictor of survival. In addition, there was no significant difference in overall survival between the matched-stage SMPLC and SPLC without mediastinal lymph node involvement. Subgroup analysis in the multiple synchronous adenocarcinoma (n = 78) group demonstrated no significant difference between similar and different comprehensive histologic subtyping with respect to overall survival (61.3% versus 68.8%, p = 0.474).

CONCLUSIONS

The surgical results for SMPLC were compatible and acceptable with those for SPLC even with similar histologic subtyping, instead of T4 or M1 stages in the current TNM classification system. Preoperatively, tumor size was the only independent prognostic factor for SMPLC with surgical intervention.

The stage classification of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

The current Lung Cancer Stage Classification system is the seventh edition, which took effect in January 2010. This article reviews the definitions for the TNM descriptors and the stage grouping in this system.

Special treatment issues in non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

This guideline updates the second edition and addresses patients with particular forms of non-small cell lung cancer that require special considerations, including Pancoast tumors, T4 N0,1 M0 tumors, additional nodules in the same lobe (T3), ipsilateral different lobe (T4) or contralateral lung (M1a), synchronous and metachronous second primary lung cancers, solitary brain and adrenal metastases, and chest wall involvement.

METHODS

The nature of these special clinical cases is such that in most cases, meta-analyses or large prospective studies of patients are not available. To ensure that these guidelines were supported by the most current data available, publications appropriate to the topics covered in this article were obtained by performing a literature search of the MEDLINE computerized database. Where possible, we also reference other consensus opinion statements. Recommendations were developed by the writing committee, graded by a standardized method, and reviewed by all members of the Lung Cancer Guidelines panel prior to approval by the Thoracic Oncology NetWork, Guidelines Oversight Committee, and the Board of Regents of the American College of Chest Physicians.

RESULTS

In patients with a Pancoast tumor, a multimodality approach appears to be optimal, involving chemoradiotherapy and surgical resection, provided that appropriate staging has been carried out. Carefully selected patients with central T4 tumors that do not have mediastinal node involvement are uncommon, but surgical resection appears to be beneficial as part of their treatment rather than definitive chemoradiotherapy alone. Patients with lung cancer and an additional malignant nodule are difficult to categorize, and the current stage classification rules are ambiguous. Such patients should be evaluated by an experienced multidisciplinary team to determine whether the additional lesion represents a second primary lung cancer or an additional tumor nodule corresponding to the dominant cancer. Highly selected patients with a solitary focus of metastatic disease in the brain or adrenal gland appear to benefit from resection or stereotactic radiosurgery. This is particularly true in patients with a long disease-free interval. Finally, in patients with chest wall involvement, provided that the tumor can be completely resected and N2 nodal disease is absent, primary surgical resection should be considered.

CONCLUSIONS

Carefully selected patients with more uncommon presentations of lung cancer may benefit from an aggressive surgical approach.

IASLC/ATS/ERS International Multidisciplinary Classification of Lung Adenocarcinoma: novel concepts and radiologic implications

In 2011, the International Association for the Study of Lung Cancer, American Thoracic Society, and European Respiratory Society proposed a new classification for lung adenocarcinoma that included a number of changes to previous classifications. This classification now considers resection specimens, small biopsies, and cytology specimens. Two former histopathologic terms, bronchioloalveolar carcinoma and mixed subtype adenocarcinoma, are no longer to be used. For resection specimens, the new terms of adenocarcinoma in situ and minimally invasive adenocarcinoma are introduced for small adenocarcinomas showing pure lepidic growth and predominantly lepidic growth, with invasion ≤5 mm, respectively. Invasive adenocarcinomas are now classified by their predominant pattern as lepidic, acinar, papillary, and solid; a micropapillary pattern is newly added. This classification also provides guidance for small biopsies and cytology specimens. For adenocarcinomas that include both an invasive and a lepidic component, it is suggested that for T staging the size of the T-factor may be best measured on the basis of the size of the invasive component rather than on the total size of tumors including lepidic components, both on pathologic and computed tomography assessment. This suggestion awaits confirmation in clinical-radiologic trials. An implication for M staging is that comprehensive histologic subtyping along with other histologic and molecular features can be very helpful in determining whether multiple pulmonary nodules are separate primaries or intrapulmonary metastases. In this review article, we provide an illustrated overview of the proposed new classification for lung adenocarcinoma with an emphasis upon what the radiologist needs to know in order to successfully contribute to the multidisciplinary strategic management of patients with this common histologic subtype of lung cancer.

Prognostic factors for survival after complete resections of synchronous lung cancers in multiple lobes: pooled analysis based on individual patient data

BACKGROUND

Some reports suggest that patients with synchronous multiple foci of nonsmall-cell lung cancers (NSCLC) distributed in multiple lobes have a poor prognosis, even when there is no extrathoracic metastasis. The vast majority of such patients do not receive surgical treatment. For those who undergo surgery, prognostic factors are unclear.

PATIENTS AND METHODS

We systematically reviewed the literature on surgery for synchronous NSCLC in multiple lobes published between 1990 and 2011. Individual patient data were used to obtain adjusted hazard ratios (HRs) in each dataset and pooled analyses were carried out.

RESULTS

Six studies contributed 467 eligible patients for analysis. The median overall survival was 52.0 months [95% confidence interval 45.6-63.7]. Male gender and advanced age were associated with a decreased survival: HRs 1.64 (1.22, 2.22) and 1.40 (1.20, 1.80) per 20-year increment, respectively. Patients with cancers distributed in one lung had a higher mortality risk than those with bilateral disease: HRs 1.45 (1.06, 2.00). N1 or N2 had a decreased survival compared with N0: HRs 1.68 (1.12, 2.51) and 1.94 (1.33, 2.82), respectively. There was a trend toward increased mortality among patients with different histology: HRs 1.29 (0.96, 1.75).

CONCLUSION

Advanced age, male gender, nodal involvement, and unilateral tumor location were poor prognostic factors.

New pathologic classification of lung cancer: relevance for clinical practice and clinical trials

We summarize significant changes in pathologic classification of lung cancer resulting from the 2011 International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society (IASLC/ATS/ERS) lung adenocarcinoma classification. The classification was developed by an international core panel of experts representing IASLC, ATS, and ERS with oncologists/pulmonologists, pathologists, radiologists, molecular biologists, and thoracic surgeons. Because 70% of patients with lung cancer present with advanced stages, a new approach to small biopsies and cytology with specific terminology and criteria focused on the need for distinguishing squamous cell carcinoma from adenocarcinoma and on molecular testing for EGFR mutations and ALK rearrangement. Tumors previously classified as non-small-cell carcinoma, not otherwise specified, because of the lack of clear squamous or adenocarcinoma morphology should be classified further by using a limited immunohistochemical workup to preserve tissue for molecular testing. The terms "bronchioloalveolar carcinoma" and "mixed subtype adenocarcinoma" have been discontinued. For resected adenocarcinomas, new concepts of adenocarcinoma in situ and minimally invasive adenocarcinoma define patients who, if they undergo complete resection, will have 100% disease-free survival. Invasive adenocarcinomas are now classified by predominant pattern after using comprehensive histologic subtyping with lepidic, acinar, papillary, and solid patterns; micropapillary is added as a new histologic subtype with poor prognosis. Former mucinous bronchioloalveolar carcinomas are now called "invasive mucinous adenocarcinoma." Because the lung cancer field is now rapidly evolving with new advances occurring on a frequent basis, particularly in the molecular arena, this classification provides a much needed standard for pathologic diagnosis not only for patient care but also for clinical trials and TNM classification.

Outcome of strict patient selection for surgical treatment of hepatic and pulmonary metastases from colorectal cancer

BACKGROUND

Surgery is currently the only potentially curative treatment for hepatic or pulmonary metastases from colorectal cancer. However, the benefit of surgery and the criteria for the inclusion of patients developing hepatic and pulmonary metastases are not well defined.

OBJECTIVE

The aim of this study was to describe the outcome for patients who undergo surgery for both hepatic and pulmonary metastases from colorectal cancer, to present a set of preoperative criteria for use in patient selection, and to analyze potential prognostic factors related to survival.

DESIGN

This was an observational study with retrospective analysis of data collected with a prospective protocol.

SETTINGS

This investigation was conducted at a tertiary centre.

PATIENTS

Between January 1996 and January 2010, of 319 patients who underwent surgery for hepatic metastases from colorectal cancer, 44 also had resection of pulmonary metastases. A set of strict selection criteria established by a panel of liver surgeons, chest surgeons, oncologists, and radiologists was used.

MAIN OUTCOME MEASURES

Survival was estimated with the Kaplan-Meier method, and univariate analyses were performed to evaluate potential prognostic factors for survival, including variables related to patient, primary tumour, hepatic, and pulmonary metastases and chemotherapy.

RESULTS

The 44 patients received a total of 53 pulmonary resections: 36 patients had 1, 7 patients had 2, and 1 patient had 3 resections. There was no postoperative mortality and the morbidity rate after pulmonary resection was 1.8%. No patient was lost to follow-up. Overall survival was 93% at 1 year, 81% at 3 years, and 64% at 5 years. Factors related to poor prognosis in the univariate analysis were presence of more than 1 pulmonary metastasis (p = 0.04), invasion of the surgical margin (p = 0.006), and administration of neoadjuvant chemotherapy (p = 0.01 for hepatic metastases and p = 0.02 for pulmonary metastases).

LIMITATIONS

The study was limited by its observational nature and the relatively small number of patients.

CONCLUSION

In patients with hepatic and pulmonary metastases from colorectal cancer selected according to strict inclusion criteria, surgical treatment performed in a specialized center is a safe option that offers prolonged survival.

Recommendations for the management of subsolid pulmonary nodules detected at CT: a statement from the Fleischner Society

This report is to complement the original Fleischner Society recommendations for incidentally detected solid nodules by proposing a set of recommendations specifically aimed at subsolid nodules. The development of a standardized approach to the interpretation and management of subsolid nodules remains critically important given that peripheral adenocarcinomas represent the most common type of lung cancer, with evidence of increasing frequency. Following an initial consideration of appropriate terminology to describe subsolid nodules and a brief review of the new classification system for peripheral lung adenocarcinomas sponsored by the International Association for the Study of Lung Cancer (IASLC), American Thoracic Society (ATS), and European Respiratory Society (ERS), six specific recommendations were made, three with regard to solitary subsolid nodules and three with regard to multiple subsolid nodules. Each recommendation is followed first by the rationales underlying the recommendation and then by specific pertinent remarks. Finally, issues for which future research is needed are discussed. The recommendations are the result of careful review of the literature now available regarding subsolid nodules. Given the complexity of these lesions, the current recommendations are more varied than the original Fleischner Society guidelines for solid nodules. It cannot be overemphasized that these guidelines must be interpreted in light of an individual's clinical history. Given the frequency with which subsolid nodules are encountered in daily clinical practice, and notwithstanding continuing controversy on many of these issues, it is anticipated that further refinements and modifications to these recommendations will be forthcoming as information continues to emerge from ongoing research.

[Non-small cell lung cancer with oligometastases: treatment with curative intent]

Published series suggest that, in carefully selected patients, long-term survival can be obtained when a complete resection of the primary site and metastasis is achieved. It comprises resection of additional malignant nodules in the contralateral lung (at present classified as M1a, but the additional nodule may be a second primary lung cancer), complete resection of the primary associated with limited metastatic pleural involvement (M1a), and resection of the primary with an isolated extrathoracic metastasis (mostly a single brain or adrenal). All these topics are discussed.

Multiple synchronous primary tumours in a single lobe

We present the case of a 70-year-old man with three synchronous histologically different primary tumours in the same lobe. He initially presented with an intermittent productive cough, dyspnoea and non-specific abdominal pains. Radiological investigation revealed three areas of high-intensity fludeoxyglucose uptake of varying size within the right upper lobe. He underwent thoracoscopic right upper lobectomy. Histological analysis confirmed the three lesions to be undifferentiated squamous cell carcinoma, adenocarcinoma and atypical adenomatous hyperplasia. The reclassification of the T descriptors of the tumour-node-metastasis staging of a lung cancer has lead to the transition of classification of tumour nodules in the ipsilateral primary tumour lobe from T4 to T3. In the case of our patient, this has lead to the downstaging of the tumour allowing consideration for surgical management.

International association for the study of lung cancer/american thoracic society/european respiratory society international multidisciplinary classification of lung adenocarcinoma

INTRODUCTION

Adenocarcinoma is the most common histologic type of lung cancer. To address advances in oncology, molecular biology, pathology, radiology, and surgery of lung adenocarcinoma, an international multidisciplinary classification was sponsored by the International Association for the Study of Lung Cancer, American Thoracic Society, and European Respiratory Society. This new adenocarcinoma classification is needed to provide uniform terminology and diagnostic criteria, especially for bronchioloalveolar carcinoma (BAC), the overall approach to small nonresection cancer specimens, and for multidisciplinary strategic management of tissue for molecular and immunohistochemical studies.

METHODS

An international core panel of experts representing all three societies was formed with oncologists/pulmonologists, pathologists, radiologists, molecular biologists, and thoracic surgeons. A systematic review was performed under the guidance of the American Thoracic Society Documents Development and Implementation Committee. The search strategy identified 11,368 citations of which 312 articles met specified eligibility criteria and were retrieved for full text review. A series of meetings were held to discuss the development of the new classification, to develop the recommendations, and to write the current document. Recommendations for key questions were graded by strength and quality of the evidence according to the Grades of Recommendation, Assessment, Development, and Evaluation approach.

RESULTS

The classification addresses both resection specimens, and small biopsies and cytology. The terms BAC and mixed subtype adenocarcinoma are no longer used. For resection specimens, new concepts are introduced such as adenocarcinoma in situ (AIS) and minimally invasive adenocarcinoma (MIA) for small solitary adenocarcinomas with either pure lepidic growth (AIS) or predominant lepidic growth with ≤ 5 mm invasion (MIA) to define patients who, if they undergo complete resection, will have 100% or near 100% disease-specific survival, respectively. AIS and MIA are usually nonmucinous but rarely may be mucinous. Invasive adenocarcinomas are classified by predominant pattern after using comprehensive histologic subtyping with lepidic (formerly most mixed subtype tumors with nonmucinous BAC), acinar, papillary, and solid patterns; micropapillary is added as a new histologic subtype. Variants include invasive mucinous adenocarcinoma (formerly mucinous BAC), colloid, fetal, and enteric adenocarcinoma. This classification provides guidance for small biopsies and cytology specimens, as approximately 70% of lung cancers are diagnosed in such samples. Non-small cell lung carcinomas (NSCLCs), in patients with advanced-stage disease, are to be classified into more specific types such as adenocarcinoma or squamous cell carcinoma, whenever possible for several reasons: (1) adenocarcinoma or NSCLC not otherwise specified should be tested for epidermal growth factor receptor (EGFR) mutations as the presence of these mutations is predictive of responsiveness to EGFR tyrosine kinase inhibitors, (2) adenocarcinoma histology is a strong predictor for improved outcome with pemetrexed therapy compared with squamous cell carcinoma, and (3) potential life-threatening hemorrhage may occur in patients with squamous cell carcinoma who receive bevacizumab. If the tumor cannot be classified based on light microscopy alone, special studies such as immunohistochemistry and/or mucin stains should be applied to classify the tumor further. Use of the term NSCLC not otherwise specified should be minimized.

CONCLUSIONS

This new classification strategy is based on a multidisciplinary approach to diagnosis of lung adenocarcinoma that incorporates clinical, molecular, radiologic, and surgical issues, but it is primarily based on histology. This classification is intended to support clinical practice, and research investigation and clinical trials. As EGFR mutation is a validated predictive marker for response and progression-free survival with EGFR tyrosine kinase inhibitors in advanced lung adenocarcinoma, we recommend that patients with advanced adenocarcinomas be tested for EGFR mutation. This has implications for strategic management of tissue, particularly for small biopsies and cytology samples, to maximize high-quality tissue available for molecular studies. Potential impact for tumor, node, and metastasis staging include adjustment of the size T factor according to only the invasive component (1) pathologically in invasive tumors with lepidic areas or (2) radiologically by measuring the solid component of part-solid nodules.

Patterns of recurrence and incidence of second primary tumors after lobectomy by means of video-assisted thoracoscopic surgery (VATS) versus thoracotomy for lung cancer

OBJECTIVE

Reports have questioned the oncologic efficacy of video-assisted thoracoscopic surgery when compared with thoracotomy despite similar survival results. In response, we investigated the pattern of recurrent disease and the incidence of second primary tumors after lobectomy by means of video-assisted thoracoscopic surgery and thoracotomy.

METHODS

All patients who underwent lobectomy for clinical stage IA lung cancer determined by means of computed tomographic and positron emission tomographic analysis were identified from a prospective database at a single institution. All patients were selected for video-assisted thoracoscopic surgery or thoracotomy by an individual surgeon. Patients' characteristics, perioperative results, recurrences, and second primary tumors were recorded. Variables were compared by using Student's t test, the Pearson χ(2) test, and Fisher's exact test. A logistic regression model was constructed to identify variables influencing the development of recurrent disease or metachronous tumors.

RESULTS

From 2002 to 2009, 520 patients underwent lobectomy by means of video-assisted thoracoscopic surgery, and 652 underwent lobectomy by means of thoracotomy. Final pathological stage was similar in the video-assisted thoracoscopic surgery and thoracotomy groups. Logistic regression demonstrated a lower risk (odds ratio, 0.65; P = .01) of recurrent disease in patients undergoing video-assisted thoracoscopic surgery after adjusting for age, stage, sex, histology, tumor location, and synchronous primary tumors.

CONCLUSIONS

Recurrence rates for video-assisted thoracoscopic surgery appear to be at least equivalent to those for thoracotomy. This study supports lobectomy by means of video-assisted thoracoscopic surgery as an oncologically sound technique.