The effect of histological cell type on the prognosis of patients with bronchogenic carcinoma

Results of EN Bloc Resections for Lung Cancer

The results of en bloc resection carried out in 33 patients with lung cancer involving the chest wall are described. Microscopic examination of the lung specimen revealed large cell anaplastic carcinoma in 14 cases, squamous carcinoma in 10, adenocarcinoma in 5, microcytoma and fibrosarcoma in 2 cases respectively. The 5 year survival, calculated according to the actuarial method, was 32 %, only slightly lower than the 5 year overall survival observed in our survey. The long-term prognosis was essentially related to the presence of lymphnodal metastases, which were found to occur at a late stage of the clinical evolution.

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.

Flexible transbronchial needle aspiration for staging of bronchogenic carcinoma

Flexible transbronchial needle aspiration (TBNA) provides access to mediastinal lymph nodes, but its role in staging bronchogenic carcinoma is unknown. To determine the efficacy and safety of this procedure for staging the extent of mediastinal disease, the results of TBNA performed during fiberoptic bronchoscopy in 39 patients without known extrathoracic metastases were reviewed. Flexible TBNA was found to be a safe, effective method for determining the presence or absence of mediastinal metastases from bronchogenic carcinoma. Furthermore, TBNA results compare favorably with roentgenographic staging techniques, with the added advantage of providing cytopathologic information.

Intracellular acidic mucins and their identification in diagnostic cytology

Exfoliative, abrasive and aspiration cytology were increasingly relied upon for tissue diagnosis of tumours. The established histological stains for the differentiation of mucin and non-mucin-secreting tumours are not ideal for alcohol-fixed cytology smears and a more reliable cytological technique for the preservation and staining of intra-cellular acidic mucins using Alcohol Alcian Blue 8GX is presented.

Evaluation of adjuvant postoperative radiotherapy for lung cancer

One hundred eighteen patients with lung cancer were retrospectively analyzed to determine whether postoperative radiotherapy (RT) improves survival. Patterns of treatment failure and three year NED (no evidence of disease) survival rates were assessed according to extent of tumor spread, histology, and treatment method. Patients with hilar or mediastinal node metastases were at higher risk of local failure compared to those with negative nodes. Postoperative RT reduced local recurrence and improved 3 year survival among patients with positive nodes. However, postoperative RT did not improve survival among those with negative nodes. Our data indicated that patients with positive hilar or mediastinal nodes may require postoperative RT to improve survival.

Radiation therapy, local tumor control, and prognosis in bronchogenic carcinoma: current status and future prospects

While the overall prognosis for cure of bronchogenic carcinoma remains poor for most patients, there is a growing body of evidence suggesting that rationally optimized local therapy may benefit a significant subset of patients. Local therapy in this context includes any systemic therapy (such as chemotherapy or immunotherapy) that enhances local tumor control in the chest. Compared with many other human epithelial cancers, the total local tumor burden is large for many nonresectable lung cancers and not within the tolerance for control by radiation alone. Thus there is growing evidence that combined surgery and radiation treatment will improve results, especially in the differentiated tumors. Proper selection of patients is important and must include histologic stratification in addition to conventional TNM staging. It is projected that much useful research can be conducted during this decade using clinical tools now available and those that are being tested in early clinical trials throughout the world. Likely candidates for such improvements are both oxic and hypoxic radiosensitizing drugs that should decrease the death rate from uncontrolled local cancer in the chest.

Mediastinal metastases in bronchogenic carcinoma: influence of postoperative irradiation, cell type, and location

A 17-year experience with 136 patients with bronchogenic carcinoma and mediastinal metastases is reported. Six died postoperatively. Postoperative mediastinal irradiation was given to 110 patients surviving curative resection who had evidence of tumor spreading to the mediastinal lymph nodes. The remaining 20 patients did not receive radiation therapy. Of the 136 patients, 29 (21.3%) lived 5 years free from disease and 9 survived 10 or more years. Of the 110 patients who survived operation and underwent irradiation, 29 (26.4%) survived 5 years. None of the 20 patients not receiving radiation therapy lived 5 years. Of the patients who underwent irradiation, 18 of the 50 patients with squamous cell carcinoma survived 5 years, while only 7 of 55 with adenocarcinoma survived 5 years. We do not believe that the discovery of mediastinal lymph node involvement in bronchogenic carcinoma is a contraindication to pulmonary resection. As in our previous reports, histological cell type has proved to be an important indicator of absolute survival. Patients with squamous cell carcinoma had an absolute-5-year survival of 33.9%, while the patients with adenocarcinoma had an absolute survival of 12.3%. The level of lymph node metastasis has an influence on prognosis as well. Patients with subcarinal lymph node metastases had a lower survival than patients with superior mediastinal involvement.

The characteristics of long-term survivors of lung cancer treated with radiation

Between 1968 and 1974, 348 patients with lung cancer were primarily treated with radiation therapy. There were 66 such patients (19%) who survived a minimum of 18 months and are the subject of this report. Of this group, 30 patients have no evidence of disease from 18-96 months, with a median follow-up of 38 months. Thirty-three patients are dead of disease. The five-year actuarial survival of the total group of 348 patients was 5.6%. There were 14 stage I and II patients who survived a minimum of 18 months, of whom 11 had no evidence of disease. Of the 42 Stage III patients, 18 presently show no evidence of disease. There were 13 patients who failed with locally recurrent disease; in this group a dose-response relationship was demonstrated. A local failure rate of 50% (4/8) was observed for patients who received fewer than 5000 rad, 22% (6/27) for patients receiving 5000-5500 rad, 18% (2/11) in patients receiving 5500-5900 rad, and 5% (1/20) for patients who received more than 5900 rad. Radiotherapeutic technique was a significant variable in local failure. Forty-six percent (6/13) of those patient failures may have been eliminated with the use of careful treatment planning with simulation. A statistically significant difference in dose was noted for patients with central recurrence, mean dose 4725 rad, 1561 RET, 81 TDF, when compared with patients with control of gross disease with radiation, mean dose 5740, 1880 RET, 108 TDF. There were four patients with marked early complications (6%) and eight patients with late complications (12%). There were no deaths attributable to radiation. Although most patients with advanced lung carcinoma die of distant disease, a significant number of patients can achieve long-term survival when radically treated with high-dose radiation therapy.

The role of gallium-67 scanning in the clinical staging and preoperative evaluation of patients with carcinoma of the lung

Gallium-67 scanning was evaluated in 100 patients with proved carcinoma of the lung. It was valuable in separating primary from secondary lung tumors, determining the extent of contralateral hilar or mediastinal lymph node involvement, and detecting distant organ metastases. In addition to multiplane whole-body Ga-67 tomographic scanning, colloid liver scans, bone scans, and computerized axial tomography scans of the brain were obtained to determine the presence of distant metastasis. The gallium scan detected 11 of 12 occult metastases and identified 7 of 7 liver, 9 of 14 brain, 4 of 4 soft tissues, 1 of 4 contralateral lung, and 9 of 11 bone metastases. The whole-body gallium scan accurately detected or excluded extrathoracic metastatic disease in 11 of 12 patients examined postmortem within three months of a gallium scan. An approach is recommended using gallium scanning along with chest roentgenograms for clinical staging and preoperative evaluation of patients with carcinoma of the lung. Specific organ scans should be reserved for the occasional symptomatic patient with a negative gallium scan or for clarification of an indeterminate gallium scan.

Surgical management of bronchial carcinoma invading the chest wall

In a 20-year period (1958-77) 43 patients underwent combined pulmonary and chest wall resection for bronchial carcinoma with local invasion of the thoracic wall. The clinical data, symptoms, surgical procedures, pathology, and results are reviewed. Pain was the usual presenting symptom. The operative mortality was 16%, respiratory complications causing most of the postoperative morbidity and mortality. These complications were less common after pneumonectomy. Long-term survival was achieved in only three cases with a corrected three-year survival rate of 10%. The survivors had certain pathological and operative features in common that may have prognostic significance. Recurrent carcinoma was responsible for most late deaths. Despite the poor overall prognosis, surgical management provided reasonable palliation and occasionally resulted in prolonged disease-free survival.

Prognostic value of pre-treatment lymphocyte count and T cell levels in localized bronchogenic carcinoma

In the patient with clinically localized bronchogenic carcinoma, the pre-treatment peripheral blood lymphocyte count and the thymus-dependent lymphocyte (T cell) level correlated with the prognosis of the tumor histology was either squamous cell, oat cell, or undifferentiated carcinoma. Patients whose pre-treatment lymphocyte count was less than 1,000/ml or whose T cell level was less than 750/ml either died or developed distant metastases by nine months after treatment of their localized tumor. By contrast, 55% of patients whose pre-treatment T cell level was greater than 750/ml were alive and without evidence of metastases nine months after treatment (P less than 0.02). Analysis of survival of these patients by the life-table method through the first post-treatment year further demonstrates the prognostic value of a low pre-treatment lymphocyte count or T cell level. The pre-treatment lymphocyte count and T cell level in patients with adenocarcinoma did not correlate with prognosis.

An aggressive approach to marginally resectable lung cancer

Between July 1968 and December 1974, 53 patients with lung cancer were planned for preoperative irradiation and surgery. All patients were considered clinically marginally resectable because of advanced local disease, 4 Stage II patients, with limited pulmonary reserve and 49 Stage III patients. Most patients received 3000 to 4000 rad followed in two weeks by thoracotomy. Forty-six patients were explored and 38 were resectable. Twelve patients are alive with a median follow-up of 48 months. The cumulative 5-year survival of all resectable patients is 27%. The survival of patients with marginally resectable lung cancer treated by accelerated radiotherapy followed by aggressive surgery approaches the survival experience of patients with primary resectable lung cancer and is superior to such patients treated with radiation therapy alone.

Lung cancer: the pathologist's role in management

The prognosis of lung cancer is poor, although there is hope for improvement based on early detection through cytologic screening and the use of newer treatment protocols. Although there are difficulties inherent in classifying tumors by type on the basis of very small samples of lesions that are not necessarily homogeneous, the pathologist should use a standard classification that sets forth definite criteria for the differentiated types. Among the common tumors, a small, well-differentiated epidermoid carcinoma with no evidence of lymph node involvement has the most favorable prognosis, and a small-cell anaplastic or oat cell carcinoma the worst. Results of therapy for tumors of other types show much variation. Future studies of lung cancer should include careful clinical staging and, when resection is done, pathologic staging. More study of the immunomorphology of lymph nodes is needed, as this may provide highly useful prognostic information.

Survival with inoperable lung cancer: an integration of prognostic variables based on simple clinical criteria

The objectives are to identify and integrate through regression analysis those fundamental clinical variables predicting survival of patients with inoperable lung cancer managed in a modern setting. Median survival time from first treatment in 129 patients with limited disease and 187 patients with extensive disease was 36 and 14 weeks, respectively. Within the proposed survival model for limited disease, weight loss was the major prognosticator followed by symptom status, supraclavicular metastases, and age. Within extensive disease, symptom status and age were dominant variables followed by weight loss and metastases to liver, opposite hemithorax, brain, and bone. Survival by cell type was similar within the limited and extensive disease groups. The data identify the essential factors which must be controlled or accounted for in studies analyzing survival as a dependent variable.

Major pulmonary resection for bronchogenic carcinoma in the elderly

The results of major pulmonary resection in 58 patients greater than 70 years of age were reviewed. The histological distribution and extent of nodal metastases in this age group are the same as in younger patients. The absolute five-year survival rate for the 55 patients undergoing curative resection was 30% (17 patients). It was 36% (11 patients) for those patients with squamous cell carcinoma and 22% (5 patients) for those with adenocarcinoma. The operative mortality was only 14% (8 patients). Of the 49 patients treated by lobectomy, 17 lived five years or more free of disease, whereas none of the 6 patients treated by pneumonectomy survived five years. The five-year survival rate of 30% in this series of elderly patients treated by major pulmonary resection makes resections in such patients with bronchogenic carcinoma worthwhile.

Carcinoma of the lung: results of treatment over ten years

Mediastinal lymph node dissection in conjunction with pulmonary resection was performed on 437 patients with bronchogenic carcinoma at the University of Michigan Medical Center from 1959 to 1969. The absolute five- and ten-year survival rates for patients undergoing curative resection were 36.2 and 14.4%, respectively. The five-year survival of those without nodal metastases was 49.3%, and it was 31.1% in patients with hilar metastases only. The five-year survival of patients with mediastinal metastases who received radiation therapy was 23.1%. Of the 193 patients with squamous cell carcinoma, 43% lived five years free from disease. The five-year survival of patients undergoing resection who had no hilar lymph node metastases was 53%, and it was 47.5% in those with hilar metastases only. The five-year survival in patients with mediastinal metastases who received postoperative irradiation was 34.4%.

Relationship of cell type and lymph node metastasis to survival after resection of bronchial carcinoma

In the completed adjuvant chemotherapy lung trials conducted by the Veterans Administration Surgical Group, the cell type was recorded in 2,341 of 2,349 curative resections; extent of lymph node involvement was known in all cases. Nodes were normal in 1,231 patients. Five- and ten-year survival computed by the life-table method was 33.7% and 20.4%, respectively. These rates were significantly greater than the 16.2% and 8.8% recorded in 1,118 patients whose nodes showed metastases. Among patients whose cell type was known, five-year survival in 484 with hilar node involvement was 17.4% and was not significantly different from 20.1% in 364 patients in whom only lobar nodes were involved. The survival was 8.9% in 268 patients with cancer in the mediastinal nodes; this was significantly worse than either of the aforementioned groups. A five-year survival of 26.8% in 1,482 patients with squamous cell carcinoma was greater than the 24.3% in 359 with adenocarcinoma and 22.4% in 500 with undifferentiated cell types, but the differences were not significant. Variations between these groups remained nonsignificant when nodes were normal and were of only borderline significance, at the 5% level, when they showed metastasis. When a curative resection has been accomplished, cell-type as classified in this study has little bearing on long-term survival, whereas the presence of node metastasis as well as its location is of the utmost importance.

Mediastinoscopy in the surgical management of lung carcinoma

Up to December 1973, we had performed 100 mediastinoscopies for lung carcinoma. Fifty-two were positive and 48 negative. In 80 cases there was clinical or radiological suspicion of mediastinal invasion. With radiological evidence of mediastinal node involvement exploration was positive in 32 out of 35 cases, when chest radiography findings were equivocal in 19 out of 45, and when radiology of the mediastinum was normal in only one of 20 cases. Mediastinoscopy was more frequently positive when the carcinoma was oat-cell or anaplastic. Of 48 patients with negative biopsies, 41 were explored. In 26 the carcinoma extended beyond the lung. In 1973 we circularized 83 thoracic surgeons concerning (1) the use of mediastinoscopy for patients with lung carcinoma assessed for surgery, (2) the significance of mediastinal node involvement, (3) the results of radiotherapy alone in patients rejected for surgery, and (4) the survival rate in patients with positive mediastinal nodes treated with surgery alone or together with radiotherapy. The replies to the questionnaire are summarized. The authors emphasize the usefulness of mediastinoscopy but state that care must be taken when deciding to withhold operation for a possible cure.

Thymus-dependent lymphocyte levels in bronchogenic carcinoma: correlations with histology, clinical stage, and clinical course after surgical treatment

The in vitro spontaneous lymphocyte rosette (T cell) assay was used to determine cellular immunologic competence in 112 patients with bronchogenic carcinoma. Among preoperative patients with localized tumors. T cell levels were significantly lower than in 237 normal controls. With advanced stages of disease, T cell levels declined progressively among patients with squamous cell carcinoma, oat cell carcinoma, and undifferentiated carcinoma, but not among patients with adenocarcinoma. Squamous carcinoma patients considered cured had persisting low T cell levels, but cured adenocarcinoma patients had normal levels. Serial determinations that showed a fall in T cell levels preceded the development of clinically evident metastases by an average of 2.5 months. Postoperative patients with rising T cell levels have remained clinically free of disease. The data indicate that T cell levels correlate with extent of tumor and clinical course of patients with bronchogenic carcinoma. The assay may, therefore, provide a rational basis for the selection of patients who are at high risk for the development of recurrence after surgical resection and who may benefit from the early institution of adjunctive therapy.

Adenocarcinoma of the lung: clinicopathological study

A review of our 247 patients with adenocarcinoma of the lung revealed the overall five year survival rate to be only 0.81%. Lung resection offers the chance of cure if the lesion is peripherally located and without lymph node involvement. Direct chest wall invasion by tumor is not contraindication to surgery. Radiation therapy was not especially effective in our series. Several chemotherapeutic agents gave an overall response of 31.1%.

Survival rates of lung cancer according to histological type

The post-operative survival in 554 lung carcinomata, classified according to the histological type, was calculated by the actuarial method. On the whole, squamous cell carcinoma was the most favourable and anaplastic small cell carcinoma the least favourable lesion. However, in tumours smaller than 4 cm, confined to the lung and with negative lymph nodes (stage I), small cell carcinoma had the highest percentage of 5 year survivors, followed by large cell carcinoma, squamous cell carcinoma and adenocarcinoma. When tumours had attained a larger size and/or spread to neighbouring structures and regional lymph nodes (stage II and III), the histological type was a much more determining factor in survival, squamous cell carcinoma being a significantly more favourable lesion. On the other hand, no difference in survival in relation to the histological type was found when distant metastases were probably present (stage IV). It was concluded that in assessing the role of histopathology in the prognosis of lung cancer, the mutual relationship to other pathological factors must be taken into account.