A retrospective analysis of 10-year survivors from carcinoma of the lung

Synchronous Triple Carcinoma of the Lung in One Patient

A case is reported of the simultaneous occurrence of a squamous cell carcinoma and a small cell carcinoma, both centrally located, in the right upper lobe and a peripheral adenocarcinoma in the right lower lobe. The simultaneous occurrence of three primary lung carcinomas is discussed in the light of a probable common cell origin.

Five-year survival does not equal cure in non-small cell lung cancer: a Surveillance, Epidemiology, and End Results-based analysis of variables affecting 10- to 18-year survival

OBJECTIVE

Five-year survival after the diagnosis of non-small cell lung cancer is the most common benchmark used to evaluate long-term survival. Data on survival beyond 5 years are sparse. We sought to elucidate variables affecting 10- to 18-year survival.

METHODS

A total of 31,206 patients alive at least 5 years after diagnosis of non-small cell lung cancer who were registered in the Surveillance, Epidemiology, and End Results database from 1988 to 2001 were examined. Primary end points were disease-specific survival and overall survival. Survival analysis was performed with Kaplan-Meier estimates, multivariable Cox proportional hazards regression, and competing risk models.

RESULTS

Overall survival at 10, 15, and 18 years was 55.4%, 33.1%, and 24.3%, respectively. Disease-specific survival at 10, 15, and 18 years was 76.6%, 65.4%, and 59.4%, respectively. In multivariable regression analysis, squamous cell cancers had a disease-specific survival advantage (hazard ratio, 0.88; P < .0001) but an overall survival disadvantage (hazard ratio, 1.082; P = .0002) compared with adenocarcinoma. Pneumonectomy (hazard ratio, 0.44) and lobectomy (hazard ratio, 0.474) had improved disease-specific survival compared with no surgery (P < .0001). Left-sided tumors (hazard ratio, 0.723; P = .036) and node-negative cancers (hazard ratio, 0.562; P < .001) also had a better disease-specific survival and, to a lesser extent, overall survival advantage.

CONCLUSIONS

Five-year survivors of non-small cell lung cancer have a persistent risk of death from lung cancer up to 18 years from diagnosis. More than one half of all deaths in 5-year survivors are related to lung cancer. In multivariable regression analysis, age, node-negative disease, and lobar or greater resection were strong predictors of long-term survival (ie, 10-18 years).

[High dose endobronchial brachytherapy: a curative treatment]

PURPOSE

New endobronchial techniques of treatment allow a good unblocking. Nevertheless, only high dose rate brachytherapy delivers a curative treatment for invasive carcinomas. This study analyses the results of the first 33 consecutive patients treated with curative intent by this technique from 1994 to 1997, and followed-up more than one year.

PATIENTS AND METHODS

Thirty-seven lesions were treated, with usual schedule delivering 30 Gy at 1 cm depth in six fractions and three to five weeks. All the patients were meticulously selected on the local involvement of the tumour and absolute contraindications to a surgical treatment. All of them have a pulmonary disease history or a general contraindication.

RESULTS

With a 14-month follow-up, the local control at two months after the treatment was 95% (endoscopic and histologic), and 90% of the patients presented a prolonged local control. Four patients died of the treated cancer, another of a controlateral cancer. Ten patients died of another disease, five of them from a respiratory insufficiency. The overall survival rate at two years was 53% and the specific survival rate 80%. The acute tolerance was good, without incident. Asymptomatic bronchial stenoses, described by endoscopic follow-up, were described for seven patients.

CONCLUSION

We conclude that, on the basis of a good selection of the patients and a respect of the indications, high dose rate endobronchial brachytherapy is an effective curative treatment. It offers a new curative option and must be proposed for the small invasive carcinomas in non-operable patients.

Mediastinal lymph node involvement as the initial manifestation of occult thyroid cancer in the surgical treatment of lung cancer: report of a case

A 63-year-old man was referred to our institute for the treatment of squamous cell carcinoma of the upper lobe of his right lung. A right upper lobectomy of the lung was performed with a mediastinal lymph node dissection. The postoperative pathological examination of the dissected specimens revealed one of the superior mediastinal lymph nodes to be morbid with micrometastasis of occult thyroid cancer, while no node involvement was seen due to lung cancer. A right lobectomy of the thyroid gland with a modified radical neck dissection was done 4 years later after the confirmation of the absence of any recurrent sign of lung cancer. In the resected specimen, papillary thyroid microcarcinoma was observed with several intraglandular metastases and right regional lymph node involvement. Eight months later, a new primary lung cancer developed in the left lung, and a left upper lobectomy of the lung with a mediastinal lymph node dissection was performed. At that time, the absence of mediastinal lymph node metastasis from lung cancer or thyroid cancer was confirmed. Mediastinal lymph node involvement as the initial manifestation of occult thyroid cancer in surgical treatment for lung cancer is rare, but it is important to be aware of the possibility of incidentally detecting occult thyroid cancer in surgical dissections in this area for lung cancer. The appropriate surgical treatment should be determined while carefully considering the prognosis of the lung cancer as well as that of any coexisting malignancy.

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

OBJECTIVE

The purpose of this study was to determine (in survivors of 5 years after resection of their lung cancer) whether age, sex, histologic condition, and age have any influence on furthering survival beyond 5 years.

METHODS

From 1973 to 1989, 686 patients were alive and well 5 years after complete resection of their lung cancers. Survival analysis was carried out with only deaths from lung cancer treated as deaths. Deaths from other causes were treated as withdrawals. Multivariate Cox regression was used to test the relationship of survival to age, sex, histologic condition, and stage.

RESULTS

The population in this study had the following characteristics at the time of operation: The male/female ratio was 1.38:1, and the median age was 61 years. The histologic condition of their lung cancer was adenocarcinoma in 412 patients, squamous cell in 244 patients, large cell carcinoma in 29 patients, and small cell carcinoma in 1 patient. The stage of the disease was stage IA in 263 patients, IB in 261 patients, IIA in 12 patients, IIB in 68 patients, and IIIA in 82 patients. The extent of resection was a lobectomy or bilobectomy in 579 patients, pneumonectomy in 55 patients, and wedge resection or segmentectomy in 52 patients. A recurrence or a new lung primary occurrence was considered as failure to remain free of lung cancer. The median follow-up on all patients was 122 months from initial treatment. Of the 686 patients, 26 patients experienced the development of late recurrence and 36 new cancers, beyond 5 years. Overall survival for 5 additional years after a 5-year check point was 92.4%. Likewise, survival by nodal status was 93% for N0 tumors, 95% for N1 tumors, and 90% for N2 tumors. Survival by stage was 93% for stage I tumors and 91% for stage II or IIIA tumors.

CONCLUSIONS

In patients with surgically treated lung cancer, neither age, sex, histologic condition, nor stage is a predictor of the risk of late recurrence or new lung cancer. The only prognostic factor appears to be the survival of the patient free of lung cancer for 5 years from the initial treatment, with a resultant favorable outlook to remain well for 10 or more years.

Second primary cancer of the larynx in patients with lung cancer

Synchronous or metachronous second primary malignancies of the lung are sometimes encountered in patients with laryngeal cancer while the occurrence of a laryngeal second primary following cancer of the lung is rare. A two-armed study was conducted. A prospective arm in which the larynges of 56 terminal lung cancer patients were examined, and a retrospective arm incorporating both a chart study of 126 terminal head and neck cancer patients (HNCP) and a computerized search of all hospital records of patients with laryngeal and lung cancers. No laryngeal malignancy was found in the lung cancer patients' group and no antedating pulmonary malignancy was recorded in the terminal HNCP. The computerized search of 1778 lung cancer patients and 213 laryngeal cancer patients also failed to demonstrate cases where the former preceded the latter. In conclusion. No second primary of the larynx was found in lung cancer patients. These results compare with reports of large databases where cancer of the larynx was found in a negligible percentage of lung cancer survivors and theories explaining this are discussed.

The results of modern surgical therapy for multiple primary lung cancers

STUDY OBJECTIVES

The purpose of this report is to review our experience with multiple primary lung cancers (MPLC) at the Walter Reed Army Medical Center, Washington, DC, and to determine the outcome of our surgical management of this complex problem.

PATIENTS AND METHODS

The data from the Lung Cancer Registry on patients with MPLC from January 1984 to December 1995 were reviewed. We used the criteria of Martini and Melamed modified by Antakli for the diagnosis of synchronous and metachronous MPLC. Survival probabilities were calculated by the Kaplan-Meier actuarial method with the dates of resection as the starting point and included deaths from all causes. The log rank test was used to compare survival rates between groups and Wilcoxon rank sum test was used to compare the intervals between the first and the second metachronous cancers. A p value of 0.05 was considered statistically significant.

RESULTS

Fifty-two patients, consisting of 51 patients who had "curative" pulmonary resections and 1 patient who had radiation therapy for previous primary lung cancer, developed second or third primary lung cancers. Thirty-seven patients developed metachronous cancers within 1 to 15 years of the first operation (median, 24 months) while 15 patients had synchronous cancers (10 unilateral, 5 bilateral). The probability of cancer-free interval among patients with metachronous cancers was 41% at 3 years, 16% at 5 years, and 3% at 10 years. Two of the 36 patients who had pulmonary resection for the second metachronous cancer died in the perioperative period (operative mortality, 5.6%), and one patient had radiation therapy for the second metachronous cancer. There were no deaths among patients with synchronous cancers. The actuarial 5-year survival for second metachronous cancers was 37% and for synchronous cancers was 0%.

CONCLUSIONS

We conclude that an aggressive surgical approach is safe and justified in most patients with MPLC, especially patients with metachronous cancers, while patients with synchronous lung cancers have poorer prognosis. The operative morbidity and mortality are acceptable and long-term survival is possible in many patients with metachronous lung cancer.

How tumor stage affects surgeons' surveillance strategies after lung cancer surgery

The factors that influence decision making among surgeons are not well understood. We evaluated how tumor stage in patients subjected to potentially curative surgery for lung cancer affects the self-reported follow-up strategies employed by practicing surgeons. Hypothetical patient profiles and a detailed questionnaire based on these profiles were mailed to the 3,700 members of the Society of Thoracic Surgeons. The effect of TNM stage on the surveillance strategies chosen by the respondents was analyzed. All of the ten most commonly employed surveillance modalities were ordered significantly more frequently with increasing TNM stage, although the differences are small. Only 23% of respondents modified their strategies according to the patient's TNM stage. This effect persisted through 5 years of follow-up. We conclude that most surgeons performing surveillance after potentially curative surgery for otherwise healthy patients with lung cancer use the same follow-up strategy irrespective of TNM stage. These data should help in the design of prospective trials of this topic.

Nuclear p53 overexpression is an independent prognostic parameter in node-negative non-small cell lung carcinoma

The prognosis of operated patients with non-small cell lung cancer (NSCLC) is poor despite thorough pre-operative staging. An improved preselection is needed of patients likely to profit from surgery. This study was undertaken to evaluate the prognostic significance of nuclear p53 overexpression in a cohort of 247 surgically treated patients with NSCLC. It showed that the prevalence of immunohistochemically detectable p53 overexpression varied between different tumour types. p53 overexpression was equally frequent in large cell carcinoma (53 per cent) and in squamous cell carcinoma (54 per cent), but significantly less frequent in adenocarcinoma (34 per cent; P = 0.009). p53 overexpression was particularly rare in bronchioloalveolar carcinoma (positivity in 1 of 17 cases). These variations may reflect aetiological differences between the histological subtypes. p53 overexpression was also associated with high tumour grade (P = 0.0157) and the presence of lymph node metastasis (P = 0.0259), but not with advanced tumour stage. Survival analysis showed no difference in clinical outcome between p53-positive and p53-negative tumours within 101 node-positive tumours. In contrast, survival time was significantly better in p53-negative tumours than in p53-positive tumours within the group of 113 node-negative tumours (P = 0.032). Stepwise regression analysis showed that p53 overexpression is an independent prognostic factor in node-negative NSCLC.

Long-term survival of surgical cases of lung cancer

The survival rate and important prognostic factors were studied in patients observed for more than 10 years after surgery for squamous cell carcinoma and adenocarcinoma. The causes of death of long-term survivors and whether 5- or 10-year survival assures complete cure were also examined. The records of 324 patients operated on at Kyoto University Chest Disease Research Institute between January 1976 and May 1984 were analyzed. Five- and 10-year survival of these patients was 34.4 and 26.8%, respectively. There was no difference between the survival rate of adenocarcinoma and squamous cell carcinoma. Significant difference were noted in survival curves between stage I, II and IIIa, and stage IIIa and IIIb cancers (P = 0.001, P = 0.005, and P = 0.001, respectively). A significant difference in the survival curve was also observed between those with complete and with incomplete resection (P < 0.0001). Multivariate analysis using Cox proportional hazards method showed that ages, pathological N-factor, and complete resection were significant prognostic factors. Nine of the 16 patients who died between 5 and 10 years after surgery had recurrent or second primary lung cancer. Five of these nine patients were diagnosed as recurrence or distant metastases. Of the 39 patients who survived disease-free for 10 or more years after surgery, none died of new recurrence. It is speculated that 5-year survival would not indicate complete cure after surgery for lung cancer and patients should be followed up for more than 10 years.

Clinico-pathological features and survival of lung cancer patients in Paris, France

We studied the clinico-pathological features of 750 lung cancers identified in Paris, France, during 1988. An internal comparison was performed between adenocarcinomas and other subtypes. Survival of 502 patients was studied. 85% of patients were males; 93% were smokers or ex-smokers. Squamous cell carcinomas, adenocarcinomas, small cell carcinomas and large cell cancers accounted for 51, 22, 15 and 12% of all cases, respectively. Differences were found for the distribution of histological subtyping according to sex (P = 0.001) and smoking status (P = 0.0001) with a greater proportion of adenocarcinomas for women and non-smokers. Median overall survival was less than one year. In multiple regression analysis, small cell lung cancer patients appeared to have a worse prognosis than other histological subtypes. This study describes patients who were treated in community practice and might be more representative of the real clinico-pathological profile of this disease in France.

S100 positive dendritic cells in human lung tumors associated with cell differentiation and enhanced survival

Antigen presenting S100 positive dendritic cells have been quantified in normal trachea, lung, bronchial lymph nodes, 130 lung tumors and in 100 lymph nodes regional to tumor. Dendritic cells are rarely seen as intraepithelial components of the normal bronchial mucosa, but are more commonly observed in the perivascular lymphoid tissue of the submucosa and in the alveolar septae of normal lung parenchyma (6 +/- 4.85 cells/HPF). The density of these dendritic cells is marked in histologically normal bronchial lymph nodes. Bronchioalveolar (Alveolar II), well and moderately differentiated squamous cell carcinomas contain the highest density of S100 positive dendritic cells, while small cell lung cancer and poorly differentiated squamous cell carcinoma show the lowest density. Regional lymph nodes to lung tumors with lymphocytic predominance and active germinal centres show the highest density of dendritic cells, while unstimulated lymph nodes contain the lowest number of S100 positive dendritic cells. Tumor infiltrating lymphocytes are marked in and around lung tumors with the higher density of dendritic cells. Survival of patients whose tumors contain high density of S100 positive dendritic cells is more favourable compared to tumors with low density of these cells. It is concluded that the density of the antigen presenting S100 dendritic cells in lung tumors is related to subtype, and tumor differentiation. A high dendritic cell density is associated with enhanced patient survival.

Smoking history and survival among lung cancer patients

Two population-based case-control studies of lung cancer were conducted on the Island of Oahu, Hawaii, between 1979 and 1985. Interview information concerning smoking habits and other characteristics was obtained from a total of 463 men and 212 women with histologically confirmed lung cancer. Records from the Hawaii Tumor Registry were reviewed for information on the stage, histology, and follow-up status of these patients. Cigarette smoking was found to be positively related to the age-adjusted risk of death among women (relative risk (RR) = 1.6; 95 percent confidence interval (CI) = 1.0-2.4), but not among men (RR = 0.8; 95 percent CI = 0.5-1.2). Among women, the age-adjusted median survival time for never smokers was 33 months (n = 53) compared with a median survival of 18 months (n = 159) for smokers. Both past and current female smokers were at greater risk of death than never-smokers, and there was a significant trend in the risk of death by the number of cigarettes smoked per day (P = 0.04), and the age at which the subjects started smoking (P = 0.01). The effects of tumor stage and histology upon the association between tobacco smoking and survival were also explored.

The adult cancer survivor: psychosocial consequences of cure

This article has summarized the psychosocial sequelae identified for the adult cancer survivor. The themes that have been identified relate to loss, compromise, and uncertainty. There is, as yet, no evidence of increased psychopathology in this population. Research on this subject is sparse and difficult to interpret. Consistent definitions of survival across studies is needed in order to compare findings. Although no specific length of time is precise for a given individual, information does exist that would assist in defining long-term survival for a given disease. The use of sensitive measures and appropriate comparison groups is an important consideration in future studies. Instruments that measure psychopathology have often been used; however, these instruments appear not to be sensitive to the more subtle levels of psychological distress and problems associated with long-term survival. Schipper and Levitt have emphasized the need for more discriminating tools. Spitzer and colleagues propose the use of in-depth psychological interviews as optimal in this regard. Comparison groups have varied from neighbors, friends, college students, psychiatric patients, and national surveys. In addition to a lack of consistency among these groups, questions have been raised in the literature as to what degree these groups represent the general population. Schipper and Levitt suggest that patients might best be used as their own controls and followed over time. Through increased understanding, strategies for prevention and intervention can be designed. An editorial in the newsletter for the National Coalition for Cancer Survivorship states, "the strength of the survivorship movement can be measured, in part, by the fact that these activities have developed independently, without coordination.(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic factors from a randomized clinical trial in resected lung cancer

Prognostic information has three main uses: prediction of the course of evolution of disease, decisions about treatment and limitation of complementary tests. Using data from a randomized controlled clinical trial of immunotherapy in resected lung cancer, we identified factors of prognostic importance. In particular we demonstrated that a time-consuming and expensive cell-mediated immunity test is not of prognostic value. Our cooperative group decided to cancel this test in the routine examination of patients with resected lung cancer. Disease stage was confirmed as the main prognostic factor.