Characteristics and prognosis of resected T3 non-small cell lung cancer

Prognostic relevance of rib invasion and modification of T description for resected NSCLC patients: A propensity score matching analysis of the SEER database

Introduction

The impact of rib invasion on the non-small cell lung cancer (NSCLC) T classifications remains unclear. Our study aims to verify the impact of rib invasion on survival in patients with NSCLC through multicenter data from the Surveillance, Epidemiology, and End Results (SEER) database, and proposed a more appropriate pT for the forthcoming 9^th tumor-node-metastasis (TNM) classifications.

Method

The SEER database was used to collect T_2b-4N_0-2M₀ NSCLC cases from the period of 2010-2015 according to the 7^th TNM classification system. Subsequently, the T classification was restaged according to the 8^th TNM classification system based on the following codes: tumor size and tumor extension. Cases with T1-2 disease and incomplete clinicopathological information were excluded. Finally, 6479 T3 and T4 NSCLC patients were included in the present study and divided into a rib invasion group (n = 131), other pT3 group (n = 3835), and pT4 group (n = 2513). Propensity-score matching (PSM) balanced the known confounders of the prognosis, resulting in two sets (rib invasion group vs. other pT3 and pT4 group). Overall survival (OS) and cancer-specific survival (CSS) were investigated using Kaplan-Meier survival curves, and predictive factors of OS and CSS were assessed by Cox regression.

Result

Survival outcomes of the rib invasion group were worse than the other pT3 group (OS: 40.5% vs. 46.5%, p = 0.035; CSS: 49.2% vs. 55.5%, p = 0.047), but comparable to the pT4 group (OS: 40.5% vs. 39.9%, p = 0.876; CSS: 49.2% vs. 46.3%, p = 0.659). Similar results were obtained after PSM. Multivariate analyses for all patients revealed that age at diagnosis, gender, N stage, T stage, surgical modalities, and adjuvant therapy had a predictive value for the prognosis.

Conclusion

The rib invasion group had a worse prognosis than the other pT3 groups, but was similar to the pT4 group. Our recommendation is to change the classification of rib invasion to pT4 disease and further validate this in the forthcoming 9^th TNM classification.

The Difference and Significance of Parietal Pleura Invasion and Rib Invasion in Pathological T Classification With Non-Small Cell Lung Cancer

Objective

This study was to explore the difference and significance of parietal pleura invasion and rib invasion in pathological T classification with non-small cell lung cancer.

Methods

A total of 8681 patients after lung resection were selected to perform analyses. Multivariable Cox analysis was used to identify the mortality differences in patients between parietal pleura invasion and rib invasion. Eligible patients with chest wall invasion were re-categorized according to the prognosis. Cancer-specific survival curves for different pathological T (pT) classifications were presented.

Results

There were 466 patients considered parietal pleura invasion, and 237 patients served as rib invasion. Cases with rib invasion had poorer survival than those with the invasion of parietal pleura (adjusted hazard ratio [HR]= 1.627, P =0.004). In the cohort for parietal pleura invasion, patients with tumor size ≤5cm reached more satisfactory survival outcomes than patients with tumor size >5cm (unadjusted HR =1.598, P =0.006). However, there was no predictive difference in the cohort of rib invasion. The results of the multivariable analysis revealed that the mortality with parietal pleura invasion plus tumor size ≤5cm were similar to patients with classification pT3 (P =0.761), and patients for parietal pleura invasion plus tumor size >5cm and pT4 had no stratified survival outcome (P =0.809). Patients identified as rib invasion had a poorer prognosis than patients for pT4 (P =0.037).

Conclusions

Rib invasion has a poorer prognosis than pT4. Patients with parietal pleura invasion and tumor size with 5.1-7.0cm could be appropriately up-classified from pT3 to pT4.

Expert consensus on resection of chest wall tumors and chest wall reconstruction

Chest wall tumors are a relatively uncommon disease in clinical practice. Most of the published studies about chest wall tumors are usually single-center retrospective studies, involving few patients. Therefore, evidences regarding clinical conclusions about chest wall tumors are lacking, and some controversial issues have still to be agreed upon. In January 2019, 73 experts in thoracic surgery, plastic surgery, science, and engineering jointly released the Chinese Expert Consensus on Chest Wall Tumor Resection and Chest Wall Reconstruction (2018 edition). After that, numerous experts put forward new perspectives on some academic issues in this version of the consensus, pointing out the necessity to further discuss the points of contention. Thus, we conducted a survey through the administration of a questionnaire among 85 experts in the world. Consensus has been reached on some major points as follows. (I) Wide excision should be performed for desmoid tumor (DT) of chest wall. After excluding the distant metastasis by multi-disciplinary team, solitary sternal plasmacytoma can be treated with extensive resection and adjuvant radiotherapy. (II) Wide excision with above 2 cm margin distance should be attempted to obtain R0 resection margin for chest wall tumor unless the tumor involves vital organs or structures, including the great vessels, heart, trachea, joints, and spine. (III) For patients with chest wall tumors undergoing unplanned excision (UE) for the first time, it is necessary to carry out wide excision as soon as possible within 1–3 months following the previous surgery. (IV) Current Tumor Node Metastasis staging criteria (American Joint Committee on Cancer) of bone tumor and soft tissue sarcoma are not suitable for chest wall sarcomas. (V) It is necessary to use rigid implants for chest wall reconstruction once the maximum diameter of the chest wall defect exceeds 5 cm in adults and adolescents. (VI) For non-small cell lung cancer (NSCLC) invading the chest wall, wide excision with neoadjuvant and/or adjuvant therapy are recommended for patients with stage T_3-4N_0-1M₀. As clear guidelines are lacking, these consensus statements on controversial issues on chest wall tumors and resection could possibly serve as further guidance in clinical practice during the upcoming years.

[Surgical treatment of chest wall tumors]

The term chest wall tumor summarizes a heterogeneous group of malignant and benign tumors, whereby primary and secondary chest wall tumors are differentiated. The incidence of secondary chest wall tumors is higher than that of primary tumors. Primary chest wall tumors can arise from any anatomic structure of the chest wall. Surgical resection is usually the treatment of choice. Resection status and tumor differentiation are relevant prognostic factors. Treatment of secondary chest wall tumors is performed depending on the patient's symptoms and prognosis of the underlying disease. Lung carcinomas infiltrating the chest wall can be resected primarily or secondarily as part of multimodal therapeutic strategies. Anatomic lung resections combined with chest wall resection have a higher mortality than standard resections. Chest wall reconstruction after resection has the goal of reducing paradoxical respiratory motion, although not every chest wall defect requires reconstruction.

Proposal for Rib invasion as an independent T descriptor for non-small cell lung cancer: A propensity-score matching analysis

INTRODUCTION

To evaluate the prognosis between patients with non-small cell lung cancer (NSCLC) invading difference depth of chest wall and estimate the impact of rib invasion on the pathological T classifications (pT).

METHODS

We retrospectively evaluated 521 patients with resected pT3-4 NSCLC. Propensity-score matching (PSM) balanced the known confounders of the prognosis, resulting in two sets (rib invasion vs the pT3 and pT4 group). Recurrence-free survival (RFS) and Overall survival (OS) was assessed by Cox regression and Kaplan-Meier methods. Time-dependent receiver operating characteristic (ROC) curves were used to assess the additional benefit for survival prediction after reclassifying rib invasion cases.

RESULTS

Chest wall invasion occurred in 171 patients (62 rib invasion, 51 parietal pleural invasion [PL3] and 58 soft tissue invasion). Rib invasion was found to be an independent prognostic factor for both RFS (p = 0.006) and OS (p < 0.001) of pT3-4 NSCLC. The survival of rib invasion group was the worst (RFS: 13.1%; OS: 19.8%), followed by PL3 (RFS: 34.2%, P = 0.001; OS: 48.8%; p < 0.001) and the soft tissue invasion group (RFS: 40.6%, p = 0.001; OS: 57.7%, p < 0.001). Besides, the prognosis of rib invasion group was also found to be worse than those of pT3 (RFS: p < 0.001; OS: p < 0.001) and pT4 group (RFS: p = 0.002; OS: p < 0.001). After PSM, the 5-year RFS rate of rib invasion group were still lower than that of pT3 and pT4 group (p < 0.001); the 5-year OS rate of rib invasion was similar with that of pT4 group (p = 0.066) but lower than that of pT3 group (p = 0.014). The time-dependent ROC curves demonstrated that reclassifying rib invasion as pT4 disease provided an additional benefit for survival prediction (p < 0.001).

CONCLUSION

The rib invasion group had a worse prognosis than the PL3 and pT3 groups. The prognostic impact of rib invasion should be further validated as a pT4 disease in the TNM classification.

Does the carinal involvement have the same surgical outcome as the main bronchus involvement in patients with non-small cell lung cancer?

OBJECTIVE

Carinal and main bronchus involvement were compared in terms of the survival of patients with N0-1 non-small cell lung cancer (NSCLC).

METHODS

Sixty-six NSCLC patients who underwent complete surgical carinal resection/reconstruction (Carina group) and complete resection because of main bronchus involvement (Main Bronchus group) between 2006 and 2016 were retrospectively analyzed. The Carina group included 30 patients and the Main Bronchus group included 36. In the Carina group, conditions other than carinal involvement that rendered patients pathological (p) T4, and in the Main Bronchus group, conditions that would upstage the pT status from pT2 were excluded. Patients with mediastinal lymph node metastases were excluded. Thus, an isolated main bronchial invasion and isolated carinal invasion patient population was tried to be obtained.

RESULTS

The overall 5-year survival rate was 49.4% (median 61.5 ± 19.9 months). The 5-year survival rates of patients in the Carina group was 49.2% (median 63.3 months), and that of patients in the Main Bronchus group was 46.4% (median 55.9 months). The difference between survival rates was not statistically significant (p = 0.761). The survival rates of pN0 and pN1 patients also did not differ significantly (63.2% vs. 45.5%, p = 0.207). Recurrence was significantly more common in the Main Bronchus group than the Carina group (28.1% vs. 7.1%; p = 0.04).

CONCLUSIONS

Isolated carinal invasion had a comparable outcome to isolated main bronchus invasion in pN0-1 patients with NSCLC who are undergoing anatomical surgical resection.

Video-assisted thoracoscopic surgery lobectomy with chest wall resection

Lung cancer presents with chest wall invasion in 5-8% of patients, which imparts some treatment challenges. Surgical resection is currently the standard of care, and there are some controversies regarding the best approach. Published series and case reports confirm the safety and feasibility of video-assisted thoracoscopic surgery (VATS) in highly complex surgical cases including lobectomy with chest wall resection of locally advanced lung cancer. In this article, we present the clinical indications of locally advanced lung cancer that infiltrates the chest wall, the modalities for and importance of accurately staging lung cancers with chest wall invasion, and the technical aspects of accomplishing a safe and oncologically sound extended resection through VATS.

Prognostic factors in operated T3 non-small cell lung cancer: A retrospective, single-center study of 129 patients

Background

This study aims to investigate the prognostic factors that affect survival rates and durations in patients with T3 non-small cell lung cancer who underwent surgery.

Methods

A total of 129 patients with T3 n on-small c ell l ung c ancer (125 males, 4 females; mean age 60±9.3 years; range 23 to 80 years) who were performed surgery in our clinic between January 1997 and December 2013 were evaluated retrospectively in terms of age, gender, type of resection, tumor histopathology, tumor, node and metastasis staging, lymph node invasion, chemotherapy and radiotherapy, and recurrence.

Results

During the evaluation, while 61 patients (47.3%) were alive, 68 (52.7%) had lost their lives. One-, two- and five-year survival rates of the study population were 79.8%, 56.9% and 23.2%, respectively. Mean duration of survival was 41.5±4.0 months (range 33.7-49.4 months). Patient's age or tumor histopathology did not affect the duration of survival. Overall duration of survival was significantly longer in patients of stage IIB, patients who had low stages of lymph node invasion, who were performed lobectomy, who received chemotherapy or radiotherapy or who were without recurrence (p<0.05 for each). Multivariate regression analysis revealed that lymph node invasion, presence of recurrence or pneumonectomy, or failure to have been administered chemotherapy increased mortality risk significantly (hazard ratios 0.217, 3.369, 2.791 and 2.254, respectively).

Conclusion

Our findings revealed that lymph node invasion, presence of recurrence or pneumonectomy, or failure to have been administered chemotherapy are poor prognostic factors in T₃ non-small cell lung cancer. Prognostic factors should be taken into consideration during treatment and follow-up periods of patients with T₃ non-small cell lung cancer.

Adjuvant Chemotherapy Is Associated With Improved Survival in Locally Invasive Node Negative Non-Small Cell Lung Cancer

BACKGROUND

The objectives of this study are to explore factors that are associated with use of adjuvant chemotherapy and to evaluate its impact on overall survival in node-negative patients who undergo lung and chest wall resection for non-small cell lung cancer (NSCLC).

METHODS

Patients who underwent concomitant lung and chest wall resection for NSCLC were abstracted from the National Cancer Database. Clinical, pathologic, treatment, and follow-up data were obtained. Patients with pathologic nodal metastases or patients who received any radiation treatment were excluded, and the cohort was dichotomized based on administration of adjuvant postoperative chemotherapy.

RESULTS

Between 1998 and 2010, 824 patients met the inclusion criteria. This cohort exclusively consisted of pT3 N0 patients who did not receive any induction treatment or adjuvant radiation treatment. Adjuvant chemotherapy was administered to 255 patients (31%). Patients in the chemotherapy group were younger and had shorter inpatient length of stay. Both groups had similar comorbidities, tumor size, unplanned readmission rate, and incomplete resection rate. In multivariable analysis, younger age and shorter length of stay were associated with a greater likelihood of receiving adjuvant chemotherapy. Adjuvant chemotherapy was associated with improved survival (hazard ratio 0.74, 95% CI: 0.6 to 0.9), whereas increasing age, white race, length of inpatient stay, tumor size, and residual tumor were independently associated with greater risk of death.

CONCLUSIONS

Patients who undergo lobectomy with chest wall resection for locally advanced NSCLC should be strongly considered for postoperative adjuvant chemotherapy even in the absence of nodal disease. Actual selection of patients for adjuvant chemotherapy is affected by perioperative factors.

Relationship between EGFR gene mutation and local metastasis of resectable lung adenocarcinoma

Background

Resectable lung adenocarcinoma is dominated by peripheral distribution, and surgical resection is the main treatment protocol. However, high recurrence rate remains after surgery. Lung adenocarcinoma with epidermal growth factor receptor (EGFR) mutation has strong invasion ability, but the effects of this mutation on local invasion in early lung adenocarcinoma have been rarely studied. This study aimed to assess the effects of EGFR mutation on local invasion in resectable lung adenocarcinoma.

Methods

A retrospective analysis of 103 patients clinically diagnosed with peripheral lung adenocarcinoma was included. They underwent preoperative bronchoscopy, which indicated grades 2 or 3 bronchial involvement (lumen of the lobe or segment). The associations of EGFR mutation with pleural invasion, endobronchial metastasis, and lymph node metastasis were analyzed according to pathologies of pleural invasion and lymph node metastasis, as well as EGFR gene mutation detected by postoperative pathological specimens. Statistical analyses were performed by unpaired Chi-square test using the SPSS16.0 software.

Results

In patients with EGFR mutation, pleural invasion, endobronchial metastasis, and lymph node metastasis rates were 62.5, 39.1, and 34.4%, respectively, indicating statistically significant differences (p = 0.003). Meanwhile, the pleural invasion rate in patients with wild-type EGFR was 43.6%, significantly reduced compared with patients with mutated EGFR (62.5%; p = 0.018). In addition, the endobronchial metastasis rate in patients with wild-type EGFR was 17.9%, significantly lower than in patients with EGFR mutation (39.1%; p = 0.005). However, lymph node metastasis rates were similar between EGFR mutated and wild-type patients (34.4 vs 25.6%, respectively, p > 0.05).

Conclusions

Early resectable lung adenocarcinoma patients with EGFR mutation showed a higher rate of local invasion compared with those harboring wild-type EGFR. This finding provides a basis for improved therapy.

Trial registration

This study was supported by Project of Medical and Health Science Technology in Shandong Province (2015WS0376)

Patterns of Failure After Surgery for Non-Small-cell Lung Cancer Invading the Chest Wall

INTRODUCTION

The patterns of failure after resection of non-small-cell lung cancer (NSCLC) invading the chest wall are not well documented, and the role of adjuvant radiation therapy (RT) is unclear, prompting the present analysis.

MATERIALS AND METHODS

The present institutional review board-approved study evaluated patients who had undergone surgery from 1995 to 2014 for localized NSCLC invading the chest wall. Patients with superior sulcus tumors were excluded. The clinical outcomes were estimated using the Kaplan-Meier method and compared using a log-rank test. The prognostic factors were assessed using a multivariate analysis, and the patterns of failure were scored.

RESULTS

Seventy-four patients were evaluated. Most patients had undergone lobectomy or pneumonectomy (85%) with en bloc chest wall resection (80%) and had pathologically node negative findings (81%). The surgical margins were positive in 10 patients (14%) and most commonly involved the chest wall (7 of 10). Adjuvant treatment included RT in 21 (28%) and chemotherapy in 28 (38%). A total of 24 local recurrences developed. The chest wall was a component of local disease recurrence in 19 of 24 cases (79%). The local control rate at 5 years for the entire population was 60% (95% confidence interval, 46%-74%). The local control rate was 74% with adjuvant RT versus 55% without RT (P = .43). On multivariate analysis, only resection less than lobectomy or pneumonectomy was associated with worse local control. The overall survival rate was 38% with RT versus 34% without RT (P = .59).

CONCLUSION

Positive surgical margins and local disease recurrence were common after resection of NSCLC invading the chest wall. The primary pattern of failure was local recurrence in the chest wall. Adjuvant RT was not associated with improved local control or survival.

Primary lung tumors invading the chest wall

Chest wall (CW) involvement occurs in approximately 5% of all primary lung neoplasms. According to the most recent TNM classification, lung tumors invading CW are classified as T3, and they represent approximately 45% of all T3 lung cancers. The most common clinical symptom at presentation is chest pain (>60%), which is highly specific of CW infiltration (>90%). Dyspnoea and hemoptysis are also described, especially in case of large lesions. A realistic chance to cure locally advanced tumors invading CW is a surgical resection, consisting in the excision of the primary lung cancer along with the involved CW (sometimes an "en-bloc" resection) and an appropriate lymph-nodal dissection. However, such patients are at high-risk of facing postoperative complications; prognosis mainly depends on: (I) the completeness of resection; and (II) the lymph-nodal involvement. Hence, due to these reasons (incidence, symptoms, prognosis, post-operative complications), such category of patients are to be carefully assessed preoperatively and if deemed practicable, surgery should be taken into consideration. In this view, the aim of this paper is to critically review the most recent series of lung tumors invading the CW, with a particular focus on patients' preoperative evaluation, surgical techniques, postoperative complications and overall outcome.

Prognostic Differences in Subgroups of Patients With Surgically Resected T3 Non-Small Cell Lung Cancer

BACKGROUND

This study determined the characteristics and prognosis of each descriptor of T3 non-small cell lung cancer (NSCLC).

METHODS

A total of 3,241 patients underwent an operation for NSCLC between 2001 and 2013, and this study included 461 patients who received complete anatomic resection of T3 NSCLC. The T3 descriptors were coded as follows: tumor invading main bronchus within 2 cm of the carina (T3-cent), tumor invading beyond visceral pleura (T3-inv), tumor larger than 7 cm (T3-size), separate tumor nodules (T3-sep), or tumor with combined T3 descriptors (T3-comb).

RESULTS

The T3 distribution was as follows: T3-cent, 75 patients (16.3%); T3-inv, 157 patients (34.1%); T3-size, 132 patients (28.6%); T3-sep, 34 patients (7.4%); and T3-comb, 63 patients (13.7%). Subgroup analyses revealed a significant survival benefit in the T3-cent group compared with the other groups (all p < 0.05). The 5-year disease-free survival (DFS) values were 55.4%, 36.7%, 40.9%, 30.3%, and 32.0% in the T3-cent, T3-inv, T3-size, T3-sep, and T3-comb subgroups, respectively. Multivariable analyses revealed that age (p = 0.019), N status (p = 0.001), adjuvant chemotherapy (p < 0.001), and T3 descriptors (T3-cent versus others, p < 0.001) were the most important independent prognostic factors for DFS. Additional analyses were performed to evaluate prognostic factors for DFS in the T3-cent group. Multivariable analysis revealed that bronchoplastic procedures (p = 0.004) was an independent prognostic factor for DFS.

CONCLUSIONS

Survival for centrally located T3 NSCLC is better than other types of T3 NSCLC. Lung-preserving operations such as bronchoplastic procedures might result in improved survival of these patients.

Multi-institutional analysis of T3 subtypes and adjuvant radiotherapy effects in resected T3N0 non-small cell lung cancer patients

Purpose

We evaluated the prognostic significance of T3 subtypes and the role of adjuvant radiotherapy in patients with resected the American Joint Committee on Cancer stage IIB T3N0M0 non-small cell lung cancer (NSCLC).

Materials and Methods

T3N0 NSCLC patients who underwent resection from January 1990 to October 2009 (n = 102) were enrolled and categorized into 6 subgroups according to the extent of invasion: parietal pleura chest wall invasion, mediastinal pleural invasion, diaphragm invasion, separated tumor nodules in the same lobe, endobronchial tumor <2 cm distal to the carina, and tumor-associated collapse.

Results

The median overall survival (OS) and disease-free survival (DFS) were 55.3 months and 51.2 months, respectively. In postoperative T3N0M0 patients, the tumor size was a significant prognostic factor for survival (OS, p = 0.035 and DFS, p = 0.035, respectively). Patients with endobronchial tumors within 2 cm of the carina also showed better OS and DFS than those in the other T3 subtypes (p = 0.018 and p = 0.016, respectively). However, adjuvant radiotherapy did not cause any improvement in survival (OS, p = 0.518 and DFS, p = 0.463, respectively). Only patients with mediastinal pleural invasion (n = 25) demonstrated improved OS and DFS after adjuvant radiotherapy (n = 18) (p = 0.012 and p = 0.040, respectively).

Conclusion

The T3N0 NSCLC subtype that showed the most favorable prognosis is the one with endobronchial tumors within 2 cm of the carina. Adjuvant radiotherapy is not effective in improving survival outcome in resected T3N0 NSCLC.

[Squamous cell carcinoma of the trachea: imaging lymph node mapping]

The anatomy of the trachea lymphatics is poorly understood and the only researches date back to more than one century. Tracheal tumors are very rare, miscellaneous and variously lymphophilic. The cancers of the trachea have no TNM and their lymph node metastases are little studied despite their poor prognosis. We observed 2 cases of squamous cell carcinoma, one in the cervical and the other in the intrathoracic trachea. TDM-3D reformats demonstrated metastatic lymph nodes of the right para-tracheal lymph node chain (2R and 4R) in both patients and in the cervical lymph nodes (right recurrent nerve lymph node chain) in the patient with cervical tumor. Right location of the mediastinal metastases may be explained by the anatomy of the lymph node chain drainage of the lung segments, the right para-tracheal chain being the only one to regularly possess lymph nodes at that level. The right recurrent nerve lymph node metastases of the cervical tumor are explained by common lymph drainage of the cervical trachea towards larynx lymph centres. Besides lymph node metastases, cancers prognosis may also depends on its location in the trachea. Thus, the tracheal tumors are complex and constitute quite as many orphan tumors. Multicentric studies are mandatory to better understand their behavior. Means provided by new imaging techniques might permit establishing a veritable TNM lymph node mapping of these tumors.

Induction therapy followed by surgery for T3-T4/N0 non-small cell lung cancer: long-term results

BACKGROUND

The aim of this study was to analyze the impact of the induction chemoradiotherapy (IT) on the survival pattern in T3/T4-N0 non-small cell lung cancer (NSCLC) patients.

METHODS

The data of 71 patients treated from January 1992 to May 2007 were reviewed. Of these, 31 patients received IT prior to surgery (IT group: T3, 20 patients; and T4, 11 patients), and 40 directly underwent surgery (S group: T3, 34 patients; and T4, 6 patients). Survival rates were compared using the Kaplan-Meier analysis and the Cox proportional hazards models.

RESULTS

Mean ages were 62.5±9.9 years in the IT group and 67.7±7.1 in the S group. All patients but 1 completed the IT treatment and 27 patients (87%) were operated. A radical resection was possible in 21 patients (78%). In the IT group a complete pathologic response was obtained in 6 patients (22%), where 8 patients ended up in pI stage, 7 in pII stage, and 6 in pIII stage. The overall 5-year survival (long-term survival [LTS]) and disease-free 5-year survival (DFS) for the entire cohort were 40% and 34%, respectively. No significant differences were found when LTS in the IT group (44%) and in the S group (37%) were compared. At multivariate analysis, the completeness of resection was the only independent predictive factor (hazard ratio [HR]=5.18; 95% confidence interval [CI]=2.55 to 10.28) while Cox multivariate analysis (on the IT group only) confirmed the critical role of the pathologic downstaging (HR=4.62; 95% CI=1.54 to 13.89).

CONCLUSIONS

A multimodal strategy with IT treatment followed by surgery is a safe and reasonable treatment in T3/T4-N0 NSCLC patients, but no clear evidence of prognostic improvement may be assumed at the present time. Nevertheless, patients with radical resection and complete pathologic response have a very rewarding survival.

Extensive resections: pancoast tumors, chest wall resections, en bloc vascular resections

Infiltration by lung tumor of adjacent anatomic structures including major vessels, main bronchi, and chest wall not only influences the oncologic severity of the disease but also increases the technical complexity of surgery, requiring extended resections and demanding reconstructive procedures. Completeness of resection represents in every case one of the main factors influencing the long-term outcome of patients. Technical and oncologic aspects of extended operations, including resection of Pancoast tumors and chest wall, bronchovascular sleeve resections, and en bloc resections of major thoracic vessels, are reported in this article.

Predictors of postoperative survival in patients with locally advanced non-small cell lung carcinoma

PURPOSE

A surgical resection for locally advanced non-small cell lung carcinoma (NSCLC) remains controversial. This study analyzed the clinicopathological profile and surgical outcome of patients with locally advanced NSCLC to identify the predictors of survival.

METHODS

This study retrospectively analyzed clinical data from 86 patients with pathological T3 or T4 primary NSCLC treated at Chiba University Hospital, and evaluated prognostic factors.

RESULTS

Sixty-eight of 86 cases were treated with a complete resection, and 18 were evaluated as an incomplete resection. The 5-year overall survival rate of all cases was 45.7%. Univariate analyses of survival were performed to determine the predictors of overall survival in patients with pathological T3 or T4 NSCLC. Age of 70 years or more, tumor length more than 5 cm, lymph node metastases, incomplete resection, and histology of non-adenocarcinoma were significantly associated with an unfavorable prognosis. Multivariate analyses revealed that older age, incomplete resection, and lymph node metastases were independent predictors of shorter survival.

CONCLUSION

A complete resection for selected cases is acceptable in the management of T3 or T4 NSCLC.

[Lung cancer before 40 years and after 80 years: surgical aspects]

Lung cancer rarely affects patients at the extreme ages of life. However, changes in epidemiology and therapy led us to review characteristics of both these younger and older populations. We retrospectively reviewed epidemiologic, clinical and pathological characteristics of patients aged 40 years or less (group 1, n=113) and 80 years or more (group 2, n=78) who underwent surgery between 1983 and 2003. Carcinoid tumors were more frequent in the group 1 (n=59 vs 5). Non small cell lung cancer (NSCLC) occurrence rates decreased with time in group 1, whereas increasing rates were observed in group 2 (p=0.0017). Concomitant diseases were significantly more frequent in group 2. The pneumonectomy rates of non small cell lung cancer were the same in each group (group 1, 35.5%; group 2, 34.8%). Five-year survival rates were better in group 1 (58.9% vs 30%, p=0.0048). No 5-year survival was observed for N2 disease in group 2 and mortality unrelated to cancer was more frequent in this group. Otherwise, both groups were similar except for higher rates of adenocarcinomas in group 1. Lung cancer is more and more frequent in the octogenarians. Surgery remains the best treatment in this population except in case of stage III due to N2 involvement.

[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.

En bloc resection for lung cancer with chest wall invasion

BACKGROUND

The aim of this study was to retrospectively assess the results of en bloc chest wall plus lung resection for patients with non-small cell lung cancer (NSCLC) invading the chest wall.

METHODS

From January 1986 to December 2000, of 1,820 patients having surgery for NSCLC, 42 (2.3%) patients with neoplasms involving the chest wall underwent en bloc chest wall and lung resection. Patient demographics, preoperative symptoms, operative procedures, tumor cell type and size, removed nodal status, and pathologic stage were summarized. The 5-year survival rates of the groups were compared.

RESULTS

Postoperative staging revealed 28 were T3N0M0, 4 were T3N1M0, and 10 were T3N2M0. The in-hospital mortality rate was 11.9% (5/42). The mean age was 79.0 +/- 2.8 years in the patients who died of complications, which was significantly older than the mean age of 67.9 +/- 8.1 years in the patients who survived the surgery (p = 0.005). The overall 5-year survival was 28.4%. The 5-year survival was significantly longer in the patients with negative (N0) nodal metastasis than in those with N1 and/or N2 nodal metastasis (39.6% versus 7.1%, p = 0.01). Eleven patients had tumor involvement of the parietal pleura. Thirty-one patients had tumor involvement of the soft tissue and/or bone. There was no significant difference of 5-year survival rate between the patients with involvement of the parietal pleura only and the patients with involvement of the parietal pleura and the soft tissue and/or bone (10.9% versus 33.5%, p = 0.94).

CONCLUSION

En bloc resection for bronchogenic carcinoma invading the chest wall provides a favorable prognosis in cases without nodal metastasis. Significant postoperative mortality is associated with old age (> 80 years). The 5-year survival rate is not significantly different between the patients with involvement of the parietal pleura only and the patients with involvement of the parietal pleura and the soft tissue and/or bone.

Lung Cancer Invading the Chest Wall: A Plea for En-Bloc Resection but the Need for New Treatment Strategies

BACKGROUND

Factors influencing survival of patients with a nonsmall-cell lung cancer (NSCLC) invading the parietal pleura or the chest wall are still controversial. The aim of this study was to assess prognostic factors in completely resected pT3 chest wall NSCLC patients.

METHODS

We retrospectively reviewed a three-center experience between 1984 and 2002 with 309 patients.

RESULTS

There were 269 male and 40 female patients. Pulmonary resections consisted of 13 wedge resections or segmentectomies, 211 lobectomies, 6 bilobectomies, and 79 pneumonectomies. One hundred patients underwent extrapleural mobilization, and 209, en-bloc resection. Tumors were staged as stages IIB (n = 212) and IIIA (n = 97). Overall 5-year survival rates were 40% and 12% for stage IIB and IIIA, respectively (p < 10(4)). Multivariate analysis shows male sex and bigger tumor size as independent indicators of poor prognosis in stage IIB patients. In stage IIB patients with a chest wall invasion limited to the parietal pleura, en-bloc resections provided higher 5-year survival rates when compared with extrapleural resections (60.3% versus 39.1%; p = 0.03). In stage IIIA patients, multivariate analysis disclosed two independent prognostic factors: the number of resected ribs and adjuvant parietal and mediastinal radiotherapy.

CONCLUSIONS

The presence of lymph node metastases has a disastrous impact on survival in this subset of patients. En-bloc resection is strongly suggested to be the standard of surgical care, and adjuvant radiotherapy does not seem to be necessary in N0 patients when a complete R0 resection has been achieved. For huge tumors (larger than 6 cm), this report suggests that the role of perioperative chemotherapy needs further evaluation.

Ki-67 expression and prognosis for smokers with resected stage I non-small cell lung cancer

BACKGROUND

The cigarette smoking status of patients before surgery is an important prognostic factor in evaluation of stage I non-small cell lung cancer, and the proliferative activity of lung tumors is also related to the patient's prognosis. This study evaluates relationships between various clinicopathologic factors, including tumor proliferative activity and smoking status, and the patient's prognosis in stage I non-small cell lung cancer.

METHODS

One hundred eighty-seven stage I adenocarcinoma and squamous cell carcinoma cases were evaluated. The patients underwent complete resection between 1988 and 1993 at Chiba University Hospital. Expression levels of Ki-67 nuclear antigen, p53 protein, and retinoblastoma protein were determined immunohistochemically, and postoperative survival rates for patients in the categories of clinicopathologic factors were estimated.

RESULTS

The mean Ki-67 labeling index (LI) for all cases was 19.3%. Labeling index values were significantly higher in squamous cell carcinoma than in adenocarcinoma (p < 0.0001). Postoperative survival of adenocarcinoma patients was significantly related to the LI values and to the patient's smoking status (p = 0.0164 and 0.0268, respectively). The LI values were also related to smoking status and the extent of histologic differentiation (p = 0.0112 and p < 0.0001, respectively). For non-smoking adenocarcinoma patients, higher LI values were associated with abnormalities in p53 expression (p = 0.0048). Retinoblastoma protein abnormalities were not related to LI values.

CONCLUSIONS

In smokers with stage I pulmonary adenocarcinoma, tumor proliferative activity and smoking status before surgery were important prognostic determinants. The LI values were related to several clinicopathologic factors.