Longer survival after resection of non-small cell lung cancer in Japanese women

Non-small cell lung cancer in surgically treated women

Aim and background

To determine whether female patients operated on for non-small cell lung cancer (NSCLC) have a survival advantage compared to male patients.

Methods and study design

We analyzed data from 1,426 prospectively collected patients submitted to lung resection for NSCLC between 1999 and 2008.

Results

Two groups, including 1,014 male and 412 female patients, were compared. Female patients were significantly younger, were more frequently asymptomatic, were less likely to be smokers, had better preoperative respiratory function, had a lower frequency of COPD, and were less commonly affected by cardiovascular comorbidity than men. Adenocarcinoma was more frequently present and early pathological stage (stage IA) more frequently detected in women at diagnosis. The operative mortality was significantly lower among women (1.6% vs 4.6%) (P = 0.012), and women underwent significantly more segmentectomies and fewer pneumonectomies (P = 0.001). The disease-related 5-year survival rate was significantly higher in women (66% vs 51%) (P= 0.0008). At univariate analysis the absence of symptoms at presentation, lower pathological stage, squamous cell type, and female gender were positive factors influencing long-term survival. At multivariate analysis low pathological stage, squamous cell type and female gender were confirmed as independent positive prognostic predictors. Women had a significant survival advantage irrespective of the histological subtype at pathological stage IA, IB, IIB and IIIA disease (P <0.05).

Conclusions

Female gender was confirmed to be a particular subset amongst patients affected by NSCLC and exerted a positive effect on disease-related survival of patients submitted to surgical resection. This important effect of gender should be cautiously kept in mind in analyzing the results of current and future trials for lung cancer therapy.

Lung cancer in women: the differences in epidemiology, biology and treatment outcomes

Although the prevalence of lung cancer in men has been decreasing, it has been increasing in women. Without a doubt, lung cancer is a major health problem for women in the USA, not only owing to its high incidence rate but, more alarming, the high mortality rate. Lung cancer kills more women each year than breast, ovarian and uterine cancers combined. One of the most important risk factors for the development of lung cancer in both men and women is cigarette smoking. Unfortunately, the prevalence of smoking among women has increased significantly since 1980, which is a major concern as epidemiologic data suggest that women may be more susceptible to developing lung cancer than men. Many will argue, however, that after adjusting for tobacco exposure, some studies have failed to show that women are at a higher risk for developing lung cancer. Indeed, the increased risk of lung cancer in women remains controversial. There is, however, little controversy to the fact that the biology of lung cancer differs between the sexes. This paper summarizes the explanations for the sex differences in lung cancer, including differences in molecular abnormalities, growth factor receptors, hormonal influences, differences in cytochrome P-450 enzymes and DNA repair capacity, as well as variations in treatment outcomes.

Non-small cell lung cancer in never smokers as a representative 'non-smoking-associated lung cancer': epidemiology and clinical features

Recent interest in lung cancer without a history of tobacco smoking has led to the classification of a distinct disease entity of 'non-smoking-associated lung cancer'. In this review article, we have made an overview of the recent literature concerning both the epidemiology and clinical features of lung cancer in never smokers, and have brought 'non-smoking-associated lung cancer' into relief. The etiology of lung cancer in never smokers remains indefinite although many putative risk factors have been described including secondhand smoking, occupational exposures, pre-existing lung diseases, diet, estrogen exposure, etc. Non-small cell lung cancer (NSCLC) in never smokers is clinically characterized by an increased incidence in females and a higher occurrence of adenocarcinoma in comparison to NSCLC in ever smokers in both surgical patients and non-resectable advanced-stage patients. Furthermore, the prognosis of never-smoking NSCLC is better than that of smoking-related NSCLC in both surgical patients and non-resectable advanced-stage patients. Recently recognized novel gene mutations such as EGFR (epidermal growth factor receptor) mutations are largely limited to never smokers or light smokers, and the expression of this gene is responsible for the clinical efficacy of gefitinib, an epidermal growth factor receptor-tyrosine kinase inhibitor. NSCLC with the EML4 (echinoderm microtubule-associated protein-like 4)-ALK (anaplastic lymphoma kinase) fusion gene is also more likely to occur in never smokers and in those with adenocarcinoma histology, and is expected to benefit from ALK inhibitors. In consideration of the future increase in never-smoking NSCLC or 'non-smoking-associated lung cancer', both clinical trials and investigations are needed.

Sex differences in susceptibility to carcinogens

Lung cancer has reached epidemic proportions in women, and is now the most common cause of cancer death among both men and women in the United States. While smoking rates have declined marginally in women, the rising impact of lung cancer in women may imply that women are at higher risk from carcinogens secondary to underlying factors related to sex. These factors include differences in female physiology such as bronchial responsiveness and airway size, sex-based differences in nicotine metabolism via the cytochrome p450 system driven by hormones, and differences in DNA repair capacity, as well as the evolution of cigarettes. These hypotheses will be explored in depth in this article.

Lung cancer in women: exploring sex differences in susceptibility, biology, and therapeutic response

Src tyrosine kinases regulate a large number of important mechanisms in normal and cancerous cells, are overexpressed in a broad range of tumors including lung cancer, and thus represent a potential target for cancer therapy. Preclinical experiments indicate that small-molecule inhibitors of Src block tumor growth, metastasis, and angiogenesis. Phase I data from healthy volunteers also suggest that inhibitors of Src prevent bone resorption. Several phase II trials with small-molecule inhibitors of Src are under way or have been initiated in lung cancer and in other malignancies, as discussed herein.

[Lung cancer in women: surgical aspects related to gender]

INTRODUCTION

Lung cancer is becoming more and more common in women where it presents significant differences at both clinical and therapeutic levels. Our purpose was to study those associated with surgical treatment.

PATIENTS AND METHODS

2972 patients were operated on between 1984 and 2002: 2480 men and 492 women. These two populations were compared (age, past history, investigations, interventions, TNM stage, long term survival and causes of death).

RESULTS

The number of women increased with time; they were younger than the men, smoked less, had the same past history of cancer but less past medical history, and comorbidity. They underwent less pneumonectomies and had a lower postoperative mortality. Tumour size was smaller (39.5 vs 43.5cm, p=0.0001); N0 and stage I tumours were more frequent (52.6% vs 46% p=0.0074). Long term survival was better (48.6% vs 43.1%, p=0.016), particularly in stage I and with a past history of cancer. It was identical in stage III despite a higher incidence of multisite N2 disease. Smoking and adenocarcinoma were more frequent before the menopause and N2 prognosis deteriorated with age.

CONCLUSION

These results confirm characteristics peculiar to lung cancer in women and warrant further investigation aimed at their better understanding. However, in multivariate analysis gender does not appear to be an independent prognostic factor.

CohorteKbp-2000-Cphg : évaluation des facteurs pronostiques de la survie du cancer bronchique primitif à 2 et 5 ans

INTRODUCTION

Lung cancer continues to have a poor prognosis despite some therapeutic advances.

BACKGROUND

The last fifteen years has seen a dramatic increase in the incidence of lung cancer in women and an increased proportion of adenocarcinomas in both sexes. A study of overall survival as a function of gender and other prognostic factors has been established using the cohort of patients from the study KBP-2000-CPHG.

METHODS

KBP-2000-CPHG is an epidemiological study carried out throughout the year 2000 looking at histologically confirmed primary lung cancers managed in general hospitals. 5,667 patients have been included. The study of survival looks at 2 and 5-year outcomes. The date and cause of death are recorded for each patient. In the absence of these data the date of the last contact is noted. If this is less than 4 months the patient is considered to be alive. If more than four months have elapsed a graduated strategy for establishing vital status is pursued which involves reviewing records from various different sources. RESULTS AWAITED: A preliminary review of the data was undertaken between September 2004 and March 2005 which obtained data on 5 567 patients. The analysis of survival according to sex and other forecast prognostic factors is underway.

Lung cancer in women: emerging differences in epidemiology, biology, and therapy

Lung cancer is the major cause of cancer-related death in both men and women in the United States. Emerging evidence indicates that there are differences in the pathogenesis and possibly increased susceptibility to lung cancer in women. In addition, considerable data support small, but important differences favoring women in terms of response to therapy and long-term survival after the diagnosis of lung cancer, regardless of histology or stage. These differences in both biology and outcome will be important considerations in the design of future trials of screening and therapy for lung cancer.

Women and small cell lung cancer: social characteristics, medical history, management and survival

The literature make it clear that lung cancer in women differs from that in men in several specific aspects. We conducted a retrospective study of the 967 consecutive recorded patients (696 men and 91 women after exclusions) diagnosed with small cell lung cancers (SCLC) between 1981 and 1994 in the Bas-Rhin population-based cancer registry to determine if such particularities could be observed in SCLC. Data included demographic and social characteristics, medical and smoking history, management (diagnosis and treatment), hospitalisation and survival. The end point for survival was 31 December 1998. Women were more frequently single, divorced, or widowed (P=0.007) and lived more often in urban areas (places with more than 10,000 inhabitants) (P=0.017). They differed significantly from men in their tobacco exposure (P=0.0001) and non-smoking rates (P=0.0003) but not in clinical presentation, except for more frequently elevated LDH levels (P=0.02). Bone marrow biopsies were more often performed in men (P=0.004), but management was otherwise comparable. The mean number of hospitalisations (for any reason) was comparable in both sexes but women tended to remain hospitalised longer (P=0.057). Overall survival did not differ, but women older than 70 years died sooner than their male counterparts (P=0.026). Our study confirms that some of gender differences reported in the lung cancer literature exist in SCLC. Sex-related differences in LDH levels have not previously been reported, to our knowledge. North American and European data concerning survival among women and men are discordant. Whether these gender differences are related to a real difference between the sexes or simply to differential exposure to carcinogens remains to be determined.

The influence of gender on survival and tumor recurrence following adjuvant therapy of completely resected stages II and IIIa non-small cell lung cancer

This study evaluates the influence of gender on survival and tumor recurrence following adjuvant therapy of completely resected stages II and IIIa non-small cell lung cancer (NSCLC). The Eastern Cooperative Oncology Group conducted a randomized prospective trial of adjuvant therapy in patients with completely resected stages II and IIIa NSCLC. A laboratory correlative study assessed the prevalence and prognostic significance of p53 and K-ras mutations. Patients were randomized to receive either radiotherapy (RT) alone or four cycles of cisplatin and VP-16 administered concurrently with radiotherapy (CRT). Median survival was 35 months for the 285 men and 41 months for the 203 women enrolled in the study (P = 0.12). The relative risk (RR) of death for men vs women was 1.19 (95% confidence interval [CI], 0.95-1.49). Median survival of the 147 men and 95 women randomized to the RT arm was 39 months each (P = 0.35). Median survival of the 138 men and 108 women randomized to the CRT arm was 30 and 42 months, respectively (P = 0.18). Disease recurrence patterns were similar between the genders. Univariate and multivariate analyses demonstrated improved survival for women with tumors of non-squamous histology (P < 0.01). The distribution of p53 and K-ras mutations was similar between the genders and had no influence on survival. Gender does not influence survival following adjuvant RT or CRT administered to patients with completely resected stages II and IIIa NSCLC. However, women with non-squamous histology have increased survival when compared to men.

Immunologic parameters as significant prognostic factors in lung cancer

Immunologic prognostic factors in lung cancer have not been fully clarified. We report the results of a prospective study undertaken to clarify the correlation between various cellular immunologic parameters and the survival of lung cancer patients. A total of 287 lung cancer patients were enrolled in this study. Representative in vitro cellular immune activities including lymphoblastogenesis and natural killer cell activities, in addition to the percentage of main lymphocyte subsets (CD3, CD4, CD8, HLA-DR, and Fc gamma R III on T cells) in the peripheral blood were evaluated before the initiation of therapy. The immune factors that influence the prognosis were analyzed by the log rank test and a multivariate analysis using the Cox proportional hazards model. Univariate analysis of the survival curves revealed a significant difference with regard to disease stage (P<0.0001), age (P=0.007), gender (P=0.0037), and HLA-DR (%) (P=0.048), when all the non-small cell lung cancer (NSCLC) patients (n=257) were analyzed together. This analysis, based on the histologic type, revealed that HLA-DR (%) was a significant predictor of survival in squamous cell carcinoma (P=0.0013) and small cell carcinoma (P=0.0025). A decreased CD4/CD8 ratio in small cell carcinoma (P=0.0062) and male gender in adenocarcinoma (P=0.0086) were factors associated with a worse prognosis. Multivariate analysis identified a significant correlation between survival and disease stage (P<0.0001) and gender (P=0.0243) in adenocarcinoma, disease stage (P<0.0001), age (P=0.0436) and HLA-DR (%) (P=0.0142) in squamous cell carcinoma, and HLA-DR (%) (P=0.0212) and CD4/CD8 (P=0.0112) in small cell carcinoma, suggesting independent prognostic significance. A variety of immunologic indices have prognostic significance for the different types of lung cancer. Among these, the HLA-DR (%) in the peripheral blood is the most reliable factor for squamous cell carcinoma and small cell carcinoma.

Do women live longer following lung resection for carcinoma?

OBJECTIVE

To determine whether patient gender affects the outlook following lung resection for non-small cell lung cancer (NSCLC).

PATIENTS AND METHODS

Prospectively collected data on 833 patients undergoing lung resection for NSCLC between 1990 and 2000 in a single unit were analysed.

RESULTS

581 patients were male (mean age 64.7 +/- 7 years) and 252 were female (mean age 62.6 +/- 7.8 years) (P=0.006). Male patients were more likely to have a history of ischaemic heart disease (P=0.03), to have poorer preoperative spirometry as demonstrated by their % predicted FEV1 (P=0.02) and to need pneumonectomy (P=0.0001) than their female counterparts. Squamous cell carcinoma was the predominant histological cell type in men and adenocarcinoma in women (P<0.0001). There was a trend towards a lower pathological stage among women, but this was not significant. Operative mortality for men was 4.6 and 1.2% for women (P=0.01). Overall 5-year survival for men was 34.2 +/- 2.65% and 47.5 +/ - 4.2% for women (P=0.001) and, for the hospital survivors, was 36.5 +/- 2.7% and 48.1 +/- 4.2%, respectively (P=0.01). On univariate analysis, older age, the need for pneumonectomy and higher pathological stage were significant adverse factors whereas squamous cell type and female gender were significant favourable factors for survival (P<0.05). On Cox proportional hazards model (with and without hospital deaths), pathological stage (P<0.0001), female gender (P=0.0006) and squamous cell type (P=0.001) were independent predictors of survival. The survival was significantly better for women having squamous cell (P=0.01) or non-squamous cell cancers (adenocarcinoma and other) (P=0.002). Regarding the stage, women had a significant survival advantage at pathological stage I (P=0.01) and a relatively better survival at stage II and stage III disease (P=0.3).

CONCLUSIONS

This study suggests that female gender exerts a significant positive effect on survival following lung resection for NSCLC. This effect is pronounced at early disease stage and persists after adjusting for important differences in the clinical, histo-pathological features and extent of pulmonary resection between male and female patients.

Women and lung cancer: does oestrogen play a role?

Smoking-related disease remains a major public-health problem. Large numbers of women continue to smoke, and new smokers are almost as likely to be female as male. Lung cancer is still a largely incurable disease; annual lung-cancer mortality in women exceeds that of breast cancer, and lung cancer now accounts for 12% of all new female cancer cases. The results of several studies suggest that women are more susceptible than men to lung cancer and to conditions that predispose to this cancer, such as chronic obstructive pulmonary disease. There is still much controversy about whether there is an increased lung-cancer risk in women across all populations. Many epidemiological studies have been negative or equivocal when comparing male and female lung-cancer risk. This article is not intended to be a comprehensive review of all epidemiological studies, or of all possible lung-cancer risk factors. Lung-cancer incidence and risk in women are discussed, and evidence for possible mechanisms of increased female risk are presented, including the role of oestrogen in the development of lung cancer.

Lung cancer in women: sex-associated differences in survival of patients undergoing resection for lung cancer

STUDY OBJECTIVES

The aim of this study was to analyze various characteristics and survival in female patients treated surgically for lung cancer.

DESIGN

Retrospective clinical study.

PATIENTS

From 1,242 consecutive cases of primary non-small cell lung cancer treated with pulmonary resection between June 1984 and December 1998, 337 female patients (27.1%) were chosen.

RESULTS

Female patients had the following characteristics: a significantly younger age at onset (62.5 +/- 0.56 years vs 64.1 +/- 0.31 years for men), a higher frequency of adenocarcinoma (86.0% vs 48.3% for men), and smaller tumors (32.7 mm vs 38.3 mm in diameter for men). Peripheral tumors were significantly more common in women than men (71.8% vs 50.6%, respectively). Among 686 patients with a history of smoking, the women smoked significantly less often (12.8% vs 91.4% for men). Complete resection was achieved significantly less often in women (79.6% vs 85.2% for men); however, women having complete resection survived significantly longer than their male counterparts. Women with a postoperative negative carcinoembryonic antigen (CEA) had a significantly better prognosis than men; however, women with a postoperative positive CEA did not. Women > or = 60 years old survived significantly longer than their male counterparts, while women < 60 years old did not.

CONCLUSIONS

Once the tumor was resected completely, women survived longer, partly due to the influence of life expectancy. However, the incidence of malignant effusion was higher and the rate of complete resection was lower in women.

Cigarette smoking and women's respiratory health

Cigarette smoking is claiming an increasing health toll among women, with rising morbidity and mortality related to lung cancer and COPD. Whether women are more susceptible to the effects of cigarettes with regard to carcinogenesis and development of COPD remains controversial. Gender differences clearly exist in certain aspects of cigarette-related disease, including histologic distribution of lung cancer and the ability of smokers to quit. It is likely that gender differences also exist in the reasons that individuals choose to smoke. Understanding those reasons will be important in developing targeted programs for smoking cessation and in addressing the challenge of the prevention of smoking initiation in women.

Sex differences in presentation, management, and prognosis of patients with non-small cell lung carcinoma

OBJECTIVE AND METHODS

To characterize gender differences in lung cancer, we conducted a retrospective analysis including all patients undergoing surgery for non-small cell lung carcinoma in a single institution over a 20-year period.

RESULTS

Compared with men (n = 839), women (n = 198) were more likely to be asymptomatic (32% vs 20%, P =.006), nonsmokers (27% vs 2%, P <.001), or light smokers (31 pack-years vs 52 pack-years; P <.001). Squamous cell carcinoma predominated in men (65%), and adenocarcinoma predominated in women (54%). Preoperative bronchoscopy contributed more frequently to a histologic diagnosis in men (69% vs 49% in women, P <.001), and fewer pneumonectomies were performed in women (22% vs 32% in men, P =.01). After multivariate Cox regression analysis, women survived longer than men (hazard ratio, 0.72; 95% confidence interval, 0.56-0. 92; P =.009) independently of age, presence of symptoms, smoking habits, type of operation, histologic characteristics, and stage of disease. The protective effect linked to female sex was present in early-stage carcinoma (stage I and II) and absent in more advanced-stage carcinoma (stage III and IV).

CONCLUSIONS

This study emphasizes strong sex differences in presentation, management, and prognosis of patients with non-small cell lung cancer.

Sex-associated differences in survival of patients undergoing resection for lung cancer

BACKGROUND

The increasing incidence of lung cancer among women prompted us to assess whether sex-associated differences exist in the presentation and survival of patients who undergo major lung resection for lung cancer.

METHODS

We performed a retrospective review of patients who had major lung resection for lung cancer from January 1980 to June 1998.

RESULTS

There were 265 men and 186 women. Women were younger (60.7+/-0.8 versus 63.6+/-0.6 years; p = 0.005). Adenocarcinoma was more common among women (48% versus 40%; p = 0.001). Pathologic stages for men were: I = 43%, II = 26%, IIIA = 25%, IIIB or IV = 6%, and for women: I = 52%, II = 20%, IIIA = 22%, IIIB or IV = 6% (p = 0.146). Median survival was better for women (41.8 versus 26.9 months; p = 0.006). This was due both to a difference in stage at presentation and to a better median survival rate for adenocarcinoma compared with squamous cell cancer. The data suggest an association between sex and survival, although this failed to reach statistical significance. Sex influenced survival with a relative risk for women of 0.67 (95% confidence interval 0.35 to 1.29; p = 0.231 adjusted for stage, cell type, age, and spirometry).

CONCLUSIONS

There are sex-associated differences in the presentation and possibly in the survival of patients with lung cancer. This finding has possible implications regarding the selection of patients for therapy and for the design of randomized therapeutic trials.

Irradiation of brain metastases from lung cancer: a retrospective study

A total of 94 patients with brain metastases from lung carcinomas were treated with irradiation of their brain metastases. Two fractionation schedules were applied, a non-conventional one (76 patients) mixing hypofractionation and accelerated hyperfractionation to a total dose of 47 Gy and a conventional one (18 patients), with 3 Gy once a day to a total dose of 30 or 36 Gy. No benefit was found for the non-conventional treatment schedule over the conventional one. A difference in survival was demonstrated between patients whose brain metastases originated from adenocarcinoma or squamous cell carcinoma of the lung with a median survival of 3.5 and 1.9 months, respectively (P = 0.006). Median survival of patients with brain metastases from small cell lung cancer (SCLC) was 2.8 months, and when compared with the squamous cell carcinoma group, there was no statistically improved survival (P = 0.12). There were indications of a better palliative effect in adenocarcinomas compared with squamous or large cell carcinomas. In a few patients (1/22 adenocarcinoma and 7/32 SCLC), the patients were free from malignant cells in the brain at autopsy, demonstrating that irradiation of brain metastases might be efficient in certain patients.

Microsatellite instability in female non-small-cell lung cancer patients with familial clustering of malignancy

There is accumulating evidence of an increased risk of familial clustering of cancer in the first-degree relatives of lung cancer probands. However, no explanation has been proposed for these epidemiological data. We reviewed 379 female non-small-cell lung cancer (NSCLC) patients to obtain their family histories of malignancy. Among them, nine female NSCLC patients with three or more relatives diagnosed with malignancy and 28 control patients without a family history of malignancy were selected to be analysed for instability at six different microsatellite loci. We observed microsatellite instability (MSI) more frequently in the patients with three or more family histories of malignancy (six out of nine, 67%) than the control patients (5 out of 28, 18%). The incidence of MSI in the former was significantly higher than that in the control (P=0.011: Fisher's exact test). We detected no significant difference in clinicopathological characteristics between the cases with MSI and those without MSI, except for their family histories of cancer. Our results show that a significantly higher rate of MSI is associated with familial clustering of malignancy. MSI could be one of the underlying mechanisms for familial clustering of malignancy in female NSCLC patients.

Women and lung cancer: waiting to exhale

Lung cancer is now the leading cause of cancer deaths among women. In the United States, 64,300 women are expected to die of lung cancer in 1996. Smoking is responsible for about 80% of lung cancer cases. Unfortunately, the prevalence of smoking among women remains unacceptably high at about 22% and is expected to surpass the rate in men by the year 2000. Smoking rates are highest among young girls and the less educated. Whether lung cancer represents a different disease in women than in men is unclear. Data are conflicting regarding the magnitude of the relative risk of developing lung cancer due to smoking between the genders. There appears to be a difference in the relative distribution of lung cancer histologic features between men and women that is not explained entirely by differences in smoking patterns. Women who smoke appear to be at higher risk of developing small cell lung cancer than squamous cell lung cancer, whereas men who smoke have a similar risk for the two histologic conditions. Furthermore, women smokers are more likely to develop adenocarcinoma of the lung, and estrogens may play a causative role in this phenomenon. Data are unclear regarding whether the outcome of lung cancer treatment differs between genders. Solutions to the lung cancer epidemic among US women include (1) prevention of the disease by reducing smoking rates, (2) improving early detection methods, and (3) exploring new therapeutic strategies.

Kinetic analysis of recurrence and survival after potentially curative resection of nonsmall cell lung cancer

BACKGROUND

About two-thirds of the patients with nonsmall cell lung cancer (NSCLC) who undergo a potentially curative resection eventually suffer from recurrent disease. However, it has yet to be elucidated as to how survival after recurrence is influenced by different variables, including timing, type of recurrence, or other clinicopathological features. There have been few studies concentrating on the kinetics of growth of occult micrometastatic tumor cells that eventually manifest as tumor recurrence.

METHODS

We retrospectively reviewed the charts of 197 patients who developed recurrence after a potentially curative resection for NSCLC.

RESULTS

The median disease-free interval was a little over 1 year (395 days), as was the median postrecurrence survival-383 days. We created a model for the kinetics of recurrence by assuming that: (1) a tumor of 10(9) cells is the usual limit of detection, (2) patients generally die before the tumor reaches 10(12) cells, and (3) it takes 1 year for average lung cancer cells to show a 10-fold increase. The model indicated that as much as 10(9) tumor cells should have been present immediately after the operation. Alternatively, the residual tumor cells should have an accelerated growth after the surgery.

CONCLUSIONS

These models indicate the importance of developing a sensitive detection method for occult metastatic cells and to understand the tumor dormancy mechanism.

Survival after surgical treatment of brain metastases from lung cancer: a follow-up study of 231 patients treated between 1976 and 1991

The authors reviewed the records of 231 patients who underwent resection of brain metastases from nonsmall-cell lung cancer between 1976 and 1991. Data regarding the primary disease and the characteristics of brain metastasis were retrospectively collected. Median survival in the group from the time of first craniotomy was 11 months; post-operative mortality was 3%. Survival rates of 1, 2, 3, and 5 years were 46.3%, 24.2%, 14.7%, and 12.5%, respectively. One hundred twelve women survived significantly longer than 119 men (13.8 vs. 9.5 months, p < 0.02). Patients with single metastatic lesions (200 patients) survived longer than those (31 patients) with multiple metastases (11.1 vs. 8.5 months, p < 0.02). Patients with supratentorial tumors survived longer than patients with cerebellar lesions. A high Karnofsky performance scale score before surgery also indicated increased survival. In multivariate analyses, incomplete resection or no resection of primary lung tumor, male gender, infratentorial location, presence of systemic metastases, and age older than 60 years were significantly correlated with shorter survival. Approximately one-third of the patients died of neurological causes, one-third of systemic disease, and one-third of a combination of both. The results of this series confirm that the overall prognosis for patients with even a single resectable brain metastasis is poor, but that aggressive therapy can prolong life with quality of life preserved and can occasionally permit long-term survival.

Influence of sex on the results of abdominal aortic aneurysm repair. Canadian Society for Vascular Surgery Aneurysm Study Group

PURPOSE

The purpose of this study is to determine the effect of sex on the survival rate and complications after repair of nonruptured and ruptured abdominal aortic aneurysms (AAA).

METHODS

The Canadian Society for Vascular Surgery Aneurysm Registry formed the database for analysis and provided current, ongoing follow-up of the patients. Statistical methods included t tests, chi-squared analysis, Kaplan-Meier analysis, and Cox regression analysis.

RESULTS

Of the 679 patients undergoing repair of a nonruptured AAA, 19.7% were women and 82.3% men. The following risk factors were significantly different (p < 0.05) in women and men: women were older; more had never smoked; more had a positive family history of AAA; fewer had an electrocardiogram showing evidence of an old myocardial infarction; more had coexisting aortoiliac occlusive disease; fewer had popliteal or femoral aneurysms; and the average size of the AAA was smaller. In spite of potential differences in risk, the in-hospital mortality rates were not affected by sex: 5.2% mortality rate for women and 4.4% for men. Early and late vascular complications occurred with a similar prevalence. The late survival rates were not different in women and men: for women, the 1-, 3-, and 5-year cumulative survival rates were 93.0%, 74.2%, and 63.3%, respectively, and for men 90.3%, 82.8%, and 68.9%. To control for the potential effects of other confounding variables on survival, the Cox proportional hazards method was used. When sex was included in a model along with other significant predictive variables of late survival, sex was not found to be a significant predictor of late results. Of the 146 patients with a ruptured AAA, 13.7% were women and 83.3% men. The in-hospital mortality rates were not significantly different: 55.0% for women and 49.2% for men. There was no difference between the cumulative survival rates: the 3- and 5-year survival rates for women were 36.0% and 9.0%, respectively, and for men 33.9% and 26.9%.

CONCLUSIONS

Sex was not found to have an effect on the early or late results after repair of nonruptured or ruptured AAA. However, a literature review suggests the possibility of a gender bias in the diagnosis and/or selection of patients for surgical treatment because the proportion of women in surgical series is generally less than the proportion determined from autopsy studies, ultrasound studies, hospital discharge data, and national mortality information.

Prognosis for surgically treated gastric cancer patients is poorer for women than men in all patients under age 50

From 1965 to 1983, 1031 patients (689 men and 342 women) with advanced gastric cancer underwent gastric resection in our department. A retrospective study was done with special reference to the sex of the patients. The age, tumour size and location, Borrmann type, and histology were considered as the sex-related associations. The survival rate of women under age 50 years was lower than that of men, with a significant difference (P less than 0.01), and the 10-year survival rate was 39.2% for the men and 29.3% for the women. A multivariate analysis showed that the operative curability (relative risk: 2.11), lymph node metastasis (relative risk: 1.37), depth of invasion (relative risk: 1.30) and tumour size (relative risk: 1.05), all significant prognostic factors, differed between the men and women under age 50 years, and the survival rate for women was lower. Thus, early detection of gastric cancer is crucial to improve the survival of women under age 50 years. Postoperative chemotherapy may be considered for those with an advanced gastric cancer.

Surgically resected lung cancer in young adults

Twenty-two patients, 40 years old or younger, were surgically treated for lung cancer between 1974 and 1989. The male to female ratio was 1.2:1. Ten patients were symptomatic, with the average duration of symptoms being 3.6 months. There were 13 patients with adenocarcinoma and 9 patients with large cell carcinoma. In terms, of postoperative stages, 5 patients were classified in stage I, 10 in stage IIIa, 5 in stage IIIb, and 2 in stage IV. Complete resection was performed in 14 patients, incomplete resection in 6, and exploratory thoracotomy in 2. The 3-year survival rate after complete resection was 66.2% in young patients, which was not significantly different from the 65.2% 3-year survival rate in older patients. There was no significant difference between the young and older groups according to histological cell type and TNM staging. In cases of incomplete resection or exploratory thoracotomy, 4 of 8 patients had been alive more than 2 years after operation. These results suggest that a long-term survival in the young patients is expected to be almost the same as that in the older patients after either complete resection or incomplete resection.

DNA polymerase-alpha as a putative early relapse marker in non-small cell lung cancer. An immunohistochemical study

The authors examined 72 fresh frozen sections of primary lung cancer using a monoclonal antibody for DNA polymerase-alpha (POL-alpha). The percentage of POL-alpha-positive cells was 17.3%. The tumors were divided into two groups. In one group, more than 5% of the POL-alpha-positive cells were designed POL-alpha-positive, and in the other group less than 5% were POL-alpha-negative. The incidence of POL-alpha-positive in men was statistically higher than that in women (P less than 0.05). The incidence correlated with the T (tumor) status, with a significance. Based on data on 43 patients with non-small cell lung cancer and who underwent a complete resection, the 3-year disease-free survival rates of POL-alpha-positive and POL-alpha-negative cells were 42% and 81%, respectively (P less than 0.05). When the patients were restricted to the class of N0 disease or Stage I, all the patients diagnosed as a cases of a relapse of lung cancer were POL-alpha positive. The 3-year disease-free survival rate of patients with POL-alpha negative was 100%. Our data suggest that in cases of non-small cell lung cancer, POL-alpha expression is associated with the extent of malignancy and a recurrence. Thus POL-alpha may prove to be a pertinent marker of an early relapse.

Long-term results of operation for non-small cell lung cancer in the elderly

We surgically treated 185 patients with non-small cell lung cancer who were 70 years old or older. The operative mortality rate was 3%, and the 5-year survival rate was 48%. The mortality and prognosis were similar to those in younger patients. The number of elderly patients who smoked heavily or who had ventilatory defects was high, but the incidence of pneumonectomy was low. There were no differences based on age in regard to histological type, TNM classification, and curability. Pulmonary complications occurred in 21% of the elderly patients and were correlated with preoperative pulmonary function and smoking habits. When the elderly are to undergo elective pulmonary resection for lung cancer, the preoperative evaluation of pulmonary function should be thorough, and both preoperative and postoperative physical therapy should be given. If postoperative pulmonary function is predicted to be less than 0.8 L/m2 of vital capacity and 0.6 L/m2 of forced expiratory volume in 1 second, a limited resection or nonsurgical therapy should be considered.