Carcinoma of the lung: results of treatment over ten years

Comparison of Two Different Segmentation Methods on Planar Lung Perfusion Scan with Reference to Quantitative Value on SPECT/CT

PURPOSE

Until now, there was no single standardized regional segmentation method of planar lung perfusion scan. We compared planar scan based two segmentation methods, which are frequently used in the Society of Nuclear Medicine, with reference to the lung perfusion single photon emission computed tomography (SPECT)/computed tomography (CT) derived values in lung cancer patients.

METHODS

Fifty-five lung cancer patients (male:female, 37:18; age, 67.8 ± 10.7 years) were evaluated. The patients underwent planar scan and SPECT/CT after injection of technetium-99 m macroaggregated albumin (Tc-99 m-MAA). The % uptake and predicted postoperative percentage forced expiratory volume in 1 s (ppoFEV1%) derived from both posterior oblique (PO) and anterior posterior (AP) methods were compared with SPECT/CT derived parameters. Concordance analysis, paired comparison, reproducibility analysis and spearman correlation analysis were conducted.

RESULTS

The % uptake derived from PO method showed higher concordance with SPECT/CT derived % uptake in every lobe compared to AP method. Both methods showed significantly different lobar distribution of % uptake compared to SPECT/CT. For the target region, ppoFEV1% measured from PO method showed higher concordance with SPECT/CT, but lower reproducibility compared to AP method. Preliminary data revealed that every method significantly correlated with actual postoperative FEV1%, with SPECT/CT showing the best correlation.

CONCLUSION

The PO method derived values showed better concordance with SPECT/CT compared to the AP method. Both PO and AP methods showed significantly different lobar distribution compared to SPECT/CT. In clinical practice such difference according to different methods and lobes should be considered for more accurate postoperative lung function prediction.

Changes in Simple Spirometric Parameters After Lobectomy for Bronchial Carcinoma

Introduction: The purpose of this study was to describe the postoperative changes in lung function after pure open lobectomy for lung carcinoma.

Methods: 30 patients (mean age 64 ± 7 years old, 16 men and 14 women) underwent a left or right lobectomy. They underwent spirometric pulmonary tests preoperatively, and at 1 and 6 months after the operation.

Results: The average preoperative forced expiratory volume in 1 second (FEV1) was 2.55±0.62lt and the mean postoperative FEV1 at 1 and 6 months was 1.97 ± 0.59 L and 2.15±0.66 L respectively. The percentage losses for FEV1 were 22.7% and 15.4% after 1 and 6 months respectively. An average percentage increase of 9.4% for FEV1 was estimated at the time of 6 months in comparison with this of 1 month after the operation. The average preoperative forced vital capacity (FVC) was 3.17 ± 0.81 L and the mean postoperative FVC at 1 and 6 months after the operation was 2.50 ± 0.63 L and 2.72 ± 0.67 L respectively. The percentage losses for FVC were 21.1% and 14.2% after 1 and 6 months respectively. An average percentage increase of 8.7% was observed at the time period of 6 months in comparison with this of 1 month after the operation.

Conclusion: Although, we observed a significant decrease in FEV1 and FVC after the operation, all patients were in excellent clinical status. FEV1 and FVC of 6 months were increased in comparison with the respective values of 1 month after the operation, but did not reach the preoperative values in any patient.

One Hundred Years of Lung Cancer

A hundred years ago, lung cancer was a reportable disease, and it is now the commonest cause of death from cancer in both men and women in the developed world, and before long, will reach that level in the developing world as well. The disease has no particular symptoms or signs for its detection at an early stage. Most patients therefore present with advanced stage IIIB or IV disease. Screening tests began in the 1950s with annual chest x-ray films and sputum cytology but they resulted in no improvement in overall mortality compared with control subjects. The same question is now being asked of spiral low-dose computed tomographic scanning. There have been big refinements in the staging classification of lung cancer and advances in stage identification using minimally invasive technology. Postsurgical mortality has declined from the early days of the 1950s but 5-year cure rates have only barely improved. The addition of chemotherapy to radical radiotherapy, together with novel radiotherapy techniques, is gradually improving the outcome for locally advanced, inoperable non-small cell lung cancer. Chemotherapy offers modest survival improvement for patients with non-small cell lung cancer, the modern agents being better tolerated resulting in an improved quality of life. The management of small cell lung cancer, which appeared so promising at the beginning of the 1970s, has hit a plateau with very little advance in outcome over the last 15 years. The most important and cost-effective management for lung cancer is smoking cessation, but for those with the disease, novel agents and treatment approaches are urgently needed.

Clinical features of bronchogenic large cell carcinoma confirmed by surgical resection

BACKGROUND

To define the final outcome of large cell carcinomas (LCC) after surgical treatment, the histopathology, clinical features and follow-up results of 28 cases were reviewed.

METHODS

Twenty eight patients, with LCC that underwent a surgical resection between 1986 and 2001, at the Severance Hospital, were retrospectively reviewed. We analyzed clinical data, radiological findings, pathologic findings, treatment modalities, and survival.

RESULTS

The prevalence of LCC was 2.9% (29 cases) among the surgically resected primary lung cancer cases (1003 cases) during the 15 year period of the study. The mean age of the patients was 59 years old, with 25 male cases. There were 23 smokers, smoking an average of 33 pack years. A cough was the most frequent symptom. There were 15 cases located in the peripheral part of the lung and 26 consisted of a lobulated mass. From a chest CT scan, 26 cases had necrotic portions, which appeared to be low density. The postoperative stages were IA, IB, IIB, IIIA and IV in 1 (3.6%), 11 (39.3%) 8 (28.5%), 7 (25%), 1 case (3.6%), respectively. The concordance rate of the pre- and postoperative stage was 43%. The median survival time and 5 year-survival rate were 54.5 months and 45%, respectively.

CONCLUSION

Our results suggested that a LCC in the lung was predominant in males, and equally located at the center and periphery of the lung in the surgically resected cases. To define the treatment outcome and risk factors of a LCC of the lung, further multicenter studies are needed.

Cell membrane fluidity and prognosis of lung cancer

BACKGROUND

Membranes of tumor cells have been found to posses higher fluidity than membranes of non-tumor cells. Plasma membrane fluidity is significantly correlated with malignant potential of these cells.

METHODS

Seventy-five patients operated on for lung cancer were studied prospectively. During the operation, lung tumor samples were taken from the resected lung for evaluation by electron paramagnetic resonance. The fluidity variable H13, which is proportional to the plasma membrane fluidity, was determined from the electron paramagnetic resonance spectra. The association between H13 and survival was determined by survival analysis using Kaplan-Meier curves and Cox regression.

RESULTS

Pathologic TNM stage and the fluidity variable H13 were the only prognostic variables significantly associated with survival time in multivariate proportional hazards regression model. Thus, H13 was shown to be an independent prognostic variable for survival, which was also confirmed by a separate analysis relating the TNM stage and H13. Dividing the patients into two groups, one with an H13 value higher than the median and another with H13 below the median, resulted in significantly different survival curves (p = 0.01).

CONCLUSIONS

Patients with high plasma membrane fluidity, indicated by high H13 of the resected lung tumor tissue, seem to have poorer prognosis than those with less fluid membranes. We suggest that the fluidity variable could be used as an independent additional prognostic factor and a tool to identify patients who may be helped by adjuvant postoperative therapy.

Risk of death from intercurrent disease is not excessively increased by modern postoperative radiotherapy for high-risk resected non-small-cell lung carcinoma

PURPOSE

Some studies report a high risk of death from intercurrent disease (DID) after postoperative radiotherapy (XRT) for non-small-cell lung cancer (NSCLC). This study determines the risk of DID after modern-technique postoperative XRT.

PATIENTS AND METHODS

A total of 202 patients were treated with surgery and postoperative XRT for NSCLC. Most patients (97%) had pathologic stage II or III disease. Many patients (41%) had positive/close/uncertain resection margins. The median XRT dose was 55 Gy with fraction size of 1.8 to 2 Gy. The risk of DID was calculated actuarially and included patients who died of unknown/uncertain causes. Median follow-up was 24 months for all patients and 62 months for survivors.

RESULTS

A total of 25 patients (12.5%) died from intercurrent disease, 16 from confirmed noncancer causes and nine from unknown causes. The 4-year actuarial rate of DID was 13.5%. This is minimally increased compared with the expected rate for a matched population (approximately 10% at 4 years). On multivariate analysis, age and radiotherapy dose were borderline significant factors associated with a higher risk of DID (P =.06). The crude risk of DID for patients receiving less than 54 Gy was 2% (4-year actuarial risk 0%) versus 17% for XRT dose > or = 54 Gy. The 4-year actuarial overall survival was 34%; local control was 84%; and freedom from distant metastases was 37%.

CONCLUSION

Modern postoperative XRT for NSCLC does not excessively increase the risk of intercurrent deaths. Further study of postoperative XRT, particularly when using more sophisticated treatment planning and reasonable total doses, for carefully selected high-risk resected NSCLC is warranted.

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.

Neoadjuvant and adjuvant trials in non-small cell lung cancer

Adjuvant therapy in non-small cell lung cancer has become a controversial topic during this present decade. Postoperative thoracic irradiation has the potential to decrease local recurrence and lessen the probability of postobstructive pneumonia or atelectasis. However, as a single modality, in several randomized studies, it has failed to have a favorable impact on survival. Most postoperative adjuvant chemotherapy studies, likewise, have not improved survival compared with operation alone. Recently, there has been a resurgence of interest in preoperative (neoadjuvant) chemotherapy in clinical stage IIIA disease, based on two very positive, albeit small, phase III studies. Improved chemotherapy in stage IV disease using newer and more effective agents, such as vinorelbine (Navelbine), paclitaxel (Taxol), or gemcitabine (Gemzar), is now available. It is hoped that the modest gains in stage IV disease can translate to more significant improvement in earlier stage disease.

Incentive spirometry performance. A reliable indicator of pulmonary function in the early postoperative period after lobectomy?

OBJECTIVES

The purpose of our study was to validate the incentive spirometry (IS) as a simple mean to follow pulmonary function at the bedside after lung surgery.

MATERIALS AND METHODS

We studied prospectively 19 patients (16 men, 3 women; mean +/- SE age, 60 +/- 2.8 years) undergoing lobectomy for lung cancer. All the patients had an obstructive pattern with FEV1/FVC below 75%. Lung volumes, including functional residual capacity (FRC) and residual volume (RV), measured using spirometry and the helium dilution technique, and IS were measured preoperatively and postoperatively at days 1, 2, 3, and 8, and at 2 months.

RESULTS

Our results showed that in the postoperative period after lung resection, IS performance was well correlated (R) during the first 8 postoperative days with vital capacity (VC) (R between 0.667 and 0.870) mainly due to the excellent correlation with the inspiratory reserve volume (IRV, R between 0.680 and 0.895) but was poorly correlated with expiratory reserve volume (R below 0.340), RV (R below 0.180), and FRC (R below 0.470).

CONCLUSIONS

IS can be used as a simple mean to follow lung function, especially VC and IRV, in the postoperative period in spontaneously breathing patients. IS is noninvasive and can be performed repeatedly at the bedside in the intensive care setting.

The effect of incentive spirometry and inspiratory muscle training on pulmonary function after lung resection

BACKGROUND

A predicted postoperative forced expiratory volume in 1 second (FEV1) of less than 800 ml or 40% of predicted is a common criterion for exclusion of patients from lung resection for cancer. Usually, the predicted postoperative lung function is calculated according to a formula based on the number of lung segments that will be resected. Incentive spirometry and specific inspiratory muscle training are two maneuvers that have been used to enhance lung expansion and inspiratory muscle strength in patients with chronic obstructive pulmonary disease and after lung operation.

METHODS

Thirty-two patients with chronic obstructive pulmonary disease who were candidates for lung resection were randomized into two groups: 17 patients received specific inspiratory muscle training and incentive spirometry, 1 hour per day, six times a week, for 2 weeks before and 3 months after lung resection (group A) and 15 patients were assigned to the control group and received no training (group B).

RESULTS

Inspiratory muscle strength increased significantly in the training group, both before and 3 months after the operation. In group B, the predicted postoperative FEV1 value consistently underestimated the actual postoperative FEV1 by approximately 70 ml in the lobectomy subgroup and by 110 ml in the pneumonectomy subgroup. In group A, the actual postoperative FEV1 was higher than the predicted postoperative FEV1 by 570 ml in the lobectomy subgroup and by 680 ml in the pneumonectomy subgroup of patients.

CONCLUSIONS

In patients undergoing lung resection the simple calculation of predicted postoperative FEV1 underestimates the actual postoperative FEV1 by a small fraction. Lung functions can be increased significantly when incentive spirometry and specific inspiratory muscle training are used before and after operation.

[Postoperative radiotherapy in non-small cell lung cancer. Apropos of a series of 374 cases]

PURPOSE

Several randomized trials have led us to address the usefulness of post-surgical external beam therapy (EBT) in non-oat cell bronchial carcinoma. Results that were obtained in a group of 374 patients submitted between 1977 and 1994 to identical therapy-the follow-up being done by the same team-and results of six randomized trials are analyzed.

PATIENTS AND METHODS

The tumor stages were the following: T1, 13%; T2, 56%; T3, 29%; and T4, 2%; N0, 31%; N1, 34%; and N2, 35%. There were 85% histologically complete resections. EBT was administered according to either the classical irradiation scheme (C) or as an 'equivalent hypofractionated dose' (H) in the case of complete resection. When resection was not complete, 60 to 65 Gy were administered according to a C or an H irradiation scheme. The irradiation scheme was C in 73% of the cases and H in 27%. The EBT technique has been chosen to ensure maximum lung sparing. Following a 45 Gy-irradiation with anteroposterior beams, orthogonal or, when necessary, oblique beams were used. Non homogeneity of the lungs was taken into account in establishing the treatment planning. The treatment file was collectively checked by the medical staff in 75% of the cases. EBT was indicated for N+(N1+N2), T3 and incomplete resections.

RESULTS

The overall survival was 42% at 5 years and 27% at 10 years. The 5-year survival was 52% for stage I cancer (T1N0-T2N0), 60% for stage II cancer (T1N1-T2N1), 31% for stage IIIa cancer (T3N0, T1-3N2), 45% for complete resection and 30% when resection was not complete.

CONCLUSION

Regarding the benefits of post-surgical radiotherapy, the analysis of the six randomized trials does not allow any conclusion. This might be due to either the insufficient number of cases, a follow-up time not long enough, incorrect radiotherapy, or insufficient available data. Comparison of the results pertaining to the six trials with those of our series shows an advantage for the current series, indicating that survival is likely to be improved if EBT is correctly done with regard to the dose, volume and technique used.

The role of post-operative radiotherapy in non-small-cell lung cancer: a multicentre randomised trial in patients with pathologically staged T1-2, N1-2, M0 disease. Medical Research Council Lung Cancer Working Party

The role of post-operative radiotherapy for patients with non-small-cell lung cancer (NSCLC) is unclear despite five previous randomised trials. One deficiency with these trials was that they did not include adequate TNM staging, and so the present randomised trial was designed to compare surgery alone (S) with surgery plus post-operative radiotherapy (SR) in patients with pathologically staged T1-2, N1-2. M0 NSCLC. Between July 1986 and October 1993, 308 patients (154 S, 154 SR) were entered from 16 centres in the UK. The median age of the patients was 62 years, 74% were male, > 85% had normal or near normal levels of general condition, activity and breathlessness, 68% had squamous carcinoma, 52% had had a pneumonectomy, 63% had N1 disease and 37% N2 disease. SR patients received 40 Gy in 15 fractions starting 4-6 weeks post-operatively. Overall there was no advantage to either group in terms of survival, although definite local recurrence and bony metastases appeared less frequently and later in the SR group. In a subgroup analysis, in the N1 group no differences between the treatment groups were seen, but in the N2 group SR patients appeared to gain a one month survival advantage, delayed time to local recurrence and time to appearance of the bone metastases. There is, therefore, no clear indication for post-operative radiotherapy in N1 disease, but the question remains unresolved in N2 disease.

Risk analysis and long-term survival in patients undergoing extended resection of locally advanced lung cancer

Although locally advanced lung cancer frequently necessitates extended resections to preserve a chance for cure, a higher morbidity is associated with extended resections. It is not known whether the increased morbidity is of relevance for the long-term outcome. It also remains unclear whether exclusion of certain patients according to their risk factors can diminish mortality in these patients. This study therefore investigated whether certain risk factors predispose patients undergoing extended pulmonary resections to increased morbidity or mortality. It also assessed the long-term survival. The cases of 126 consecutive patients with locally advanced lung cancer (stage T3 or T4) were prospectively documented. Seventy-five percent of the patients required an extended resection and 25% a nonextended resection. Extended resections were associated with a significantly increased overall morbidity (p < 0.002). However, mortality, severe complications, or multiple complications were not significantly increased after extended resections. No risk factor predisposed to an increased mortality. Risk factors that were associated with particular postoperative complications were pathologic ergonometry (p < 0.002), a positive cardiac score (p < 0.003), coronary artery disease (p = 0.021), and an increased pulmonary risk score (p < 0.05). Overall 3-year survival was 31%. Patients undergoing extended resections for stage T3 or T4 tumors with no residual tumor (70% of the patients) showed a 3-year survival of 33%. We conclude that postoperative mortality cannot be reduced by excluding patients on the basis of particular risk factors from operations that require extended resections. If a patient is considered to be eligible to undergo pulmonary resection, he or she can be considered to be eligible to undergo extended pulmonary resection. Because prognosis is dismal in nonresected locally advanced lung cancer, we recommend an aggressive surgical approach.

Review of the curative role of radiotherapy in the treatment of non-small cell lung cancer

The present paper is a comprehensive review of available data concerning the role of radiotherapy as an intended curative treatment in patients with non-small cell lung cancer (NSCL). The following issues are reviewed (1) optimal dose, (2) optimal fractionation, (3) optimal treatment planning, (4) clinical results in terms of single treatment and combined treatment with either surgery or chemotherapy. In resectable NSCLC high dose radiotherapy to small localized tumours gives a 5-year survival rate of 7-38%. It is concluded that this treatment modality is appropriate for certain selected patients who refuse to have surgery, who have medical contradications for surgery, or who are of old age. It is discussed whether the treatment should be split course, continuous, hypo-og hyperfraction. A total dose of 55 Gy must be given. CT scanning should be mandatory for optimal planning and therapy. The literature does not give a conclusive answer to whether preoperative or postoperative radiotherapy is indicated. The data indicate that patients with Stage III NSCLC will benefit from a combined treatment modality in terms of chemotherapy based on high dose cisplatinum and radiotherapy. The main conclusion of the review is that many areas with randomized controlled trials are needed in order to answer the critical issue of the role of radiotherapy in the treatment of NSCLS.

Elective pneumonectomy: factors associated with morbidity and operative mortality

We have retrospectively reviewed hospital records of 197 consecutive patients undergoing pneumonectomy for neoplastic disease between 1985 and 1990 to identify predictors of outcome. Seventeen of the 197 patients died during their hospital stay (8.6%; 95% confidence intervals, 6.7% to 11.2%). The most significant predictors of in-hospital mortality were presence of coexisting medical conditions (p less than 0.001), respiratory function tests showing an obstructive picture with a forced expiratory volume in 1 second/forced vital capacity ratio of less than 0.55 (p less than 0.001), 24-hour fluid replacement of more than 3 L (p less than 0.05), postoperative pulmonary edema (p less than 0.001), respiratory tract infection with positive sputum culture (p less than 0.01), postoperative renal failure (p less than 0.001), and cardiac arrhythmias (p less than 0.001). There were 232 postoperative management, problems occurring in 197 patients. The most significant predictors of postoperative morbidity were continued cigarette smoking up to the time of operation (p less than 0.05), perioperative blood loss or more than 2 L (p less than 0.05), and infusion of more than 3 L of fluid in the first 24 hours (p less than 0.05). Although retrospective analyses must be interpreted with caution, this study has identified preoperative and perioperative factors associated with in-hospital morbidity and mortality after pneumonectomy.

Patient and hospital characteristics related to in-hospital mortality after lung cancer resection

Several recent reports from academic centers have documented very low postoperative mortality after lung cancer surgery. However, generalizing these studies to community hospitals is potentially limited by reporting bias. From California hospital discharge abstracts, we identified 12,439 adults who underwent pulmonary resection for lung or bronchial tumors between January 1983 and December 1986. In-hospital mortality was 3.8 percent after wedge resection, 3.7 percent after segmental resection, 4.2 percent after lobectomy, and 11.6 percent after pneumonectomy. In multivariate regression models, the significant predictors of in-hospital death included age 60 years or more, male gender, extended resection, chronic lung or heart disease, diabetes and hospital volume. High-volume hospitals experienced better outcomes than low-volume hospitals, although unmeasured severity of illness may be a confounder. The overall mortality in this community-based sample exceeds that reported by selected centers and provides a better foundation for advising patients.

Non-small cell lung cancer. Part II: Treatment

Squamous, large cell, and adenocarcinoma, collectively termed non-small cell lung cancer (NSCLC), are diagnosed in approximately 75% of patients with lung cancer in the United States. The treatment of these three tumor cell types is approached in virtually identical fashion because, in contrast to small cell carcinoma of the lung, NSCLC more frequently presents with localized disease at the time of diagnosis and is thus more often amenable to surgical resection but less frequently responds to chemotherapy and irradiation. Cigarette smoking is etiologically related to the development of NSCLC in the great majority of cases. Genetic mutations in dominant oncogenes such as K-ras, loss of genetic material on chromosomes 3p, 11p, and 17p, and deletions or mutations in tumor suppressor genes such as rb and p53 have been documented in NSCLC tumors and tumor cell lines. NSCLC is diagnosed because of symptoms related to the primary tumor or regional or distant metastases, as an incidental finding on chest radiograph, or rarely because of a paraneoplastic syndrome such as hypercalcemia or hypertrophic pulmonary osteoarthropathy. Screening smokers with periodic chest radiographs and sputum cytologic examination has not been shown to reduce mortality. The diagnosis of NSCLC is usually established by fiberoptic bronchoscopy or percutaneous fine-needle aspiration, by biopsy of a regional or distant metastatic site, or at the time of thoracotomy. Pathologically, NSCLC arises in a setting of bronchial mucosal metaplasia and dysplasia that progressively increase over time. Squamous carcinoma more often presents as a central endobronchial lesion, while large cell and adenocarcinoma have a tendency to arise in the lung periphery and invade the pleura. Once the diagnosis is made, the extent of tumor dissemination is determined. Since most NSCLC patients who survive 5 years or longer have undergone surgical resection of their cancers, the focus of the staging process is to determine whether the patient is a candidate for thoracotomy with curative intent. The dominant prognostic factors in NSCLC are extent of tumor dissemination, ambulatory or performance status, and degree of weight loss. Stages I and II NSCLC, which are confined within the pleural reflection, are managed by surgical resection whenever possible, with approximate 5-year survival of 45% and 25%, respectively. Patients with stage IIIa cancers, in which the primary tumor has extended through the pleura or metastasized to ipsilateral or subcarinal lymph nodes, can occasionally be surgically resected but are often managed with definitive thoracic irradiation and have 5-year survival of approximately 15%.(ABSTRACT TRUNCATED AT 400 WORDS)

Role of postoperative radiation therapy in stage IIIa non-small cell lung cancer

One hundred forty-six patients with pathological stage IIIa non-small cell lung cancer were retrospectively analyzed to determine whether postoperative radiation therapy improves survival and reduces locoregional recurrences. The survival rate of the overall group at 1, 3, and 5 years was 56%, 24%, and 17%, respectively. Regarding the type of resection and histology, we did not observe statistically significant differences. Patients with N0 and N1 disease were grouped and compared with the N2 group, and survival at 3 and 5 years was 41% and 27%, respectively, for the T3 N0-1 group and 17% and 15%, respectively, for the T3 N2 group (p less than 0.001 and p = 0.05, respectively). Eighty-six patients received postoperative irradiation (45 to 50 Gy) and 60 did not. We have not observed any improvement in survival with postoperative radiation therapy, except in those patients with N2 disease. Median survival time was 6 months for patients without irradiation and 15 months for those with irradiation (p = 0.071). According to locoregional recurrences, a slight benefit with postoperative radiation therapy was observed.

Carcinoma of the lung. Who will benefit from surgery?

The present staging methods for non-small-cell lung cancer provide little more than epidemiologic assessment of prognosis for grossly defined groups of patients. Except in extreme instances, physicians can tell patients very little about their prognosis or the need for supplemental therapy. More effective and less toxic chemotherapeutic agents are needed to treat this disease. Although improved results have been attained with combination therapy in patients with good functional status and less advanced disease, little help is available for lung cancer patients with advanced disease. Treating this large group of patients remains a great challenge for the surgical and medical oncologist.

Preoperative assessment as a predictor of mortality and morbidity after lung resection

To refine the functional guidelines for operability for lung resection, we prospectively studied 55 consecutive patients with suspected lung malignancy thought to be surgically resectable. Lung function and exercise capacity were measured preoperatively and at 3 and 12 months postoperatively. Preoperative pulmonary scintigraphy was used to calculate the contribution to overall function by the affected lung or lobe and to predict postoperative lung function. Pneumonectomy was performed in 18 patients, lobectomy in 29, and thoracotomy without resection in six. No surgery was attempted in two patients who were considered functionally inoperable. Cardiopulmonary complications developed in 16 patients within 30 days of surgery, including three deaths. The predictions of postoperative function correlated well with the measured values at 3 months. For FEV1, r = 0.51 in pneumonectomy (p less than 0.05) and 0.89 in lobectomy (p less than 0.001). Predicted postoperative FEV1 (FEV1-ppo), diffusing capacity (DLCO), predicted postoperative DLCO (DLCO-ppo) and exercise-induced arterial O2 desaturation (delta SaO2) were predictive of postoperative complications including death and respiratory failure. In patients who underwent pneumonectomy, the best predictor of death was FEV1-ppo. The predictions were enhanced by expressing the value as a percentage of the predicted normal value (% pred) rather than in absolute units. For the entire surgical group a FEV1-ppo greater than or equal to 40% pred was associated with no postoperative mortality (n = 47), whereas a value less than 40% pred was associated with a 50% mortality (n = 6), suggesting that resection is feasible when FEV1-ppo is greater than or equal to 40% pred.(ABSTRACT TRUNCATED AT 250 WORDS)

Neoadjuvant chemotherapy in marginally resectable stage III M0 non-small cell lung cancer: long-term follow-up in 41 patients

Forty-one patients with marginally resectable stage III M0 non-small cell lung cancer (NSCLC) were entered into a study evaluating neoadjuvant cyclophosphamide, adriamycin, and cisplatin chemotherapy (CAP) followed by radiotherapy and subsequent resection. Postoperative radiotherapy and additional CAP were also administered. The objective disease regression rate prior to surgery was 72% (2 complete, 12 partial, and 7 minimal responses). Thoracotomy was carried out in 37 patients (90%), with resection of all gross disease in 36 patients (97%). Relapse occurred in 22 (61%) of the resected patients, involving chest only (four patients), chest and extra thoracic (nine patients), and extra thoracic only (nine patients). Subsequent CNS relapse developed in 9 (25%) of 36 postop patients in association with other sites of relapse (five patients) or as a solitary location (four patients). Only one of seven patients receiving prophylactic cranial irradiation (PCI) developed CNS relapse compared with 7 (26%) of 27 patients not receiving PCI. The median long-term follow-up for 14 living patients is 53+ months, with a rang of 38+ to 71+ months. Median survival for all patients is 32 months, with 1-year survival being 75%. The survival curve shows a plateau of 31% from 3 to 5+ years. Using a log rank test, no prognostic subgroups could be identified that significantly affected response rate, disease-free survival, or overall survival. While neoadjuvant CAP followed by radiotherapy appears to improve survival, more effective chemotherapy along with randomized studies are needed to determine the role of initial chemotherapy in marginally resectable NSCLC.

Prediction of postoperative respiratory failure in patients undergoing lung resection for lung cancer

To evaluate the correlation between predicted postoperative lung function and postoperative respiratory morbidity, 156 patients with lung cancer who underwent resection were classified into four groups based on the degree of postoperative problems: Group 1--no problems (116 patients); Group 2--retention of sputum or atelectasis requiring bronchofiberscopy two or more times (17 patients); Group 3--tracheostomy or mechanical ventilation for more than 2 days or both (14 patients); and Group 4--postoperative death (9 patients). The mean ages of Groups 2, 3, and 4 were significantly (p less than 0.05) higher than the mean age of Group 1. The predicted postoperative lung function (F) was assessed by the formula F = [1-(b-n)/(42-n)] x f, where f is the preoperative vital capacity or forced expiratory volume in one second, b is the number of subsegments of the resected lung lobe, and n is the number of subsegments obstructed by the tumor, which was assessed by the findings on the chest tomogram, on the bronchogram, at bronchofiberscopy, or a combination of these. The total number of subsegments was assumed to be 42. The predicted postoperative % FEV1 was 65.1 +/- 19.3% in Group 1,55.3 +/- 10.6% in Group 2,37.6 +/- 12.1% in Group 3, and 42.3 +/- 18.4% in Group 4. It was significantly (p less than 0.05) different between all the groups except between Groups 3 and 4. All 10 patients with a predicted postoperative % FEV1 of less than 30% were in Groups 3 and 4. We conclude that special attention to postoperative management is needed for patients whose predicted postoperative %FEV1 is lower than 30%.

Neoadjuvant therapy of stage III non-small cell lung cancer

During the past several years, there has been a resurgence of interest in preoperative or postoperative chemotherapy in patients with Stage III lung cancer. The staging system for lung cancer has recently been modified, and at the present time Stage III disease is now subdivided into Stage III-A (potentially surgically resectable for cure) and Stage III-B (unresectable). This article will review five recently completed studies utilizing neoadjuvant therapy in various types of Stage III lung cancer. The thoracic surgeon is faced with the dilemma of reviewing this literature and trying to make a conclusion as to what is appropriate therapy for Stage III disease. Unquestionably, neoadjuvant therapy appears to increase the resectability rate in Stage III-A disease and can make some Stage III-B patients anatomically resectable. It is hoped that future well-designed phase III studies can be accomplished in Stages III-A and III-B disease so that we can determine whether neoadjuvant chemotherapy is or is not beneficial for these patients.

A new catheter system with remote tip guidance for endobronchial brachytherapy

Endobronchial brachytherapy is being used with increased frequency in the treatment of recurrent neoplastic obstruction of the major airways, alone or in combination with Nd-YAG laser ablation of the occluding tumor mass. Currently available catheter systems are not reliable with respect to accurate and simple bronchoscopic guidance during placement. Flexibility, wall strength and radiation transmission characteristics are not optimized. We describe a system that meets these goals which has been designed and tested in our department. It is composed of an external handle, deflecting guidewire, and catheter specially modified for endobronchial brachytherapy, with a tip that can be maneuvered in any direction with one hand from outside the patient. Major advantages of the system are ease of concurrent bronchoscopy and catheter guidance, good dosimetric characteristics of the catheter, reasonable cost, and ready availability for adaptation to various techniques of endobronchial brachytherapy.

Diaphragm function after pulmonary resection. Relationship to postoperative respiratory failure

We studied the lung mechanics and respiratory muscle function in 20 patients undergoing pulmonary resection. Transdiaphragmatic pressure (delta Pdi) during quiet breathing did not show any remarkable change after the operation (9.5 +/- 1.1 to 10.9 +/- 1.0 cm H2O), while the ratio of abdominal to transdiaphragmatic pressure changes (delta Pab/delta Pdi) revealed a significant difference between the preoperative and the early postoperative periods (0.32 +/- 0.06 to 0.00 +/- 0.11, p less than 0.05). The postoperative delta Pab/delta Pdi correlated significantly with the work of breathing (r = -0.60, p less than 0.01). The maximal transdiaphragmatic pressure (Pdimax) decreased significantly after operation (75.0 +/- 15.8 to 32.8 +/- 12.4 cm H2O, p less than 0.05), with no significant change in the maximal inspiratory mouth pressure (MIP) (74.2 +/- 16.8 to 39.5 +/- 11.6 cm H2O). Four of 20 patients developed respiratory failure postoperatively and required mechanical ventilation. delta Pab/delta Pdi in these patients was significantly lower than in the other patients (-0.62 +/- 0.24 versus 0.16 +/- 0.09, p less than 0.005). Our results suggested that during quiet breathing diaphragmatic function was preserved and intercostal/accessory muscles recruitment increased, but maximal strength of the diaphragm might be reduced in patients undergoing pulmonary resection.

The role of surgery in N2 lung cancer

Whereas most physicians believe that long-term survival is unlikely when mediastinal lymph node metastases are present, a significant number of these patients do have resectable tumors with encouraging long-term survival results. Data are presented to support this view, and steps identified to guide the physicians in selecting the patients who can benefit from this surgical approach.

Prognosis after resection of non-small cell lung cancer of the right middle lobe

In a previous study at Roswell Park Memorial Institute, it was noted that in patients whose resected non-small-cell lung cancer had originated in the right middle lobe, the prognosis was much worse than when it had originated in any other lobe. A review of a longer period and exclusion of patients who might introduce a bias resulted in a group of 18 patients whose fate was compared to the findings reported in other comparable series. Three out of those are alive at 8-96 months after operation. Five-year survival was 22% (30% counting only survivors of the operations). These findings indicate that the results of surgery for non-small-cell carcinoma of the right middle lobe fall within the lower range of lung cancer generally.

Prophylactic cranial irradiation in adenocarcinoma of the lung. A possible role

Seventy-eight patients with modified Stage II or Stage IIIM0 adenocarcinoma of the lung were evaluated retrospectively with regard to the impact of prophylactic cranial irradiation (PCI) (30 Gy in 15 fractions) in preventing central nervous system (CNS) metastases. Twenty patients received PCI and 58 did not. There were no significant differences between these groups with respect to age, sex, stage, or median survival (17.4 months with PCI versus 16.9 months without PCI; P = 0.6). One (5%) of 20 patients receiving PCI developed CNS metastases, compared with 14 (24%) of 58 patients not receiving PCI (P = 0.06). The time from diagnosis to development of CNS metastases and survival after CNS involvement was 51 weeks and 14 weeks, respectively, for the patient who received PCI; and a median time of 50 weeks and 26 weeks, respectively, for the patients not receiving PCI. In nine (64%) of the 14 non-PCI patients the CNS was the first and only site of relapse. A Cox regression analysis demonstrated that nodal involvement was significantly associated with an increased risk of CNS metastases. These data suggest that PCI may decrease the incidence of CNS metastases, and that it may be beneficial in the management of patients with N1 or N2 disease.

Effects of postoperative mediastinal radiation on completely resected stage II and stage III epidermoid cancer of the lung

We randomly assigned 230 patients with resected Stage II or III epidermoid (squamous-cell) lung cancer to receive postoperative adjuvant radiotherapy or no adjuvant treatment. Careful intraoperative staging had been performed in all patients. Before randomization, patients were stratified according to stage, weight loss, age, and institution. Prognostic variables, such as stage, weight loss, age, nodal-disease status, and tumor status, were equally distributed between the two groups. The mean time from randomization to analysis was 3.5 years among the 210 eligible patients. There was no evidence that radiotherapy improved survival, and although recurrence rates appeared to be somewhat reduced among patients assigned to radiotherapy, these decreases were not statistically significant. However, radiotherapy did produce a striking and significant reduction in recurrences to the ipsilateral lung and mediastinum. Moreover, overall recurrence rates were reduced by radiotherapy in patients with N2 disease (P less than 0.05), although even this subgroup had no evidence of improved survival. We conclude that radiotherapy can reduce local recurrences after resection of epidermoid carcinoma of the lung, but that it does not increase survival rates.

Large cell carcinoma of the lung. Ultrastructural and immunohistochemical features

Forty one cases of large cell anaplastic carcinoma of the lung (LCACL) were investigated by electron microscopy and immunoperoxidase studies for cytokeratin, enolase, and carcinoembryonic antigen. The results indicated that these neoplasias, grouped as an unique entity by ordinary histopathologic findings, may be further divided into five groups as follows: squamous, adenomatous, adenosquamous, neuroendocrine, and undifferentiated. The authors suggest that this subclassification may be useful in treatment orientation and in the prognostic evaluation of these neoplasias.