Survival with residual tumor on the bronchial margin after resection for bronchogenic carcinoma

Postoperative radiotherapy for pathological stage IIIA-N2 non-small cell lung cancer with positive surgical margins

Background

The aim of this study was to evaluate the efficacy of postoperative radiotherapy (PORT) in stage pIIIA‐N2 non‐small cell lung cancer (NSCLC) patients with positive surgical margins.

Methods

Between January 2003 and December 2015, patients who had undergone lobectomy or pneumonectomy plus mediastinal lymph node dissection or systematic sampling in our single institution were retrospectively reviewed. Those with pIIIA‐N2 NSCLC and positive surgical margins were enrolled into the study. The Kaplan‐Meier method was used for survival analysis, and the log‐rank test was used to analyze differences between the groups. Univariate and multivariate analyses using Cox proportional hazards regression models were performed to evaluate potential prognostic factors for OS. Statistically significant difference was set as P < 0.05.

Results

Of all the 1547 patients with pIIIA‐N2 NSCLC reviewed, 113 patients had positive surgical margins, including 76 patients with R1 resection and 37 with R2 resection. The median overall survival (OS) was 28.3 months in the PORT group and 22.6 months in the non‐PORT group (P = 0.568). Subset analysis showed that for patients with R1 resection, the median OS was 52.4 months in the PORT group which was nonsignificantly longer than that of 22.6 months in the non‐PORT group (P = 0.127), whereas PORT combined with chemotherapy could significantly improve OS, with a median OS of 52.4 months versus 17.2 months (P = 0.027). For patients with R2 resection, PORT made no significant difference in OS (17.6 vs. 63.8 months, P = 0.529).

Conclusions

For pIIIA‐N2 NSCLC patients with positive surgical margins, PORT did not improve OS, but OS was improved in those patients who underwent R1 resection combined with chemotherapy.

Key points

Significant findings of the study

Significant findings of the study: Postoperative radiotherapy (PORT) has been recommended to treat patients with positive surgical margins. However, the existing evidence is controversial and high‐level evidence is lacking.

What this study adds

What this study adds: The PORT group had markedly, but not statistically significant, longer median OS compared with the non‐PORT group in patients with R1 resection. OS was significantly longer in the patients with R1 resection receiving adjuvant CRT than the surgery alone group.

Near-infrared imaging and optical coherence tomography for intraoperative visualization of tumors

Surgical excision is the foundation of treatment for early-stage solid tumors in man and companion animals. Complete excision with appropriate margins of surrounding tumor-free tissue is crucial to survival. Intraoperative imaging allows real-time visualization of tumors, assessment of surgical margins, and, potentially, lymph nodes and satellite metastatic lesions, allowing surgeons to perform complete tumor resections while sparing surrounding vital anatomic structures. This Review will focus on the use of near-infrared imaging and optical coherence tomography for intraoperative tumor visualization.

Intraoperative near-infrared fluorescence imaging targeting folate receptors identifies lung cancer in a large-animal model

BACKGROUND

Complete tumor resection is the most important predictor of patient survival with non-small cell lung cancer. Methods for intraoperative margin assessment after lung cancer excision are lacking. This study evaluated near-infrared (NIR) intraoperative imaging with a folate-targeted molecular contrast agent (OTL0038) for the localization of primary lung adenocarcinomas, lymph node sampling, and margin assessment.

METHODS

Ten dogs with lung cancer underwent either video-assisted thoracoscopic surgery or open thoracotomy and tumor excision after an intravenous injection of OTL0038. Lungs were imaged with an NIR imaging device both in vivo and ex vivo. The wound bed was re-imaged for retained fluorescence suspicious for positive tumor margins. The tumor signal-to-background ratio (SBR) was measured in all cases. Next, 3 human patients were enrolled in a proof-of-principle study. Tumor fluorescence was measured both in situ and ex vivo.

RESULTS

All canine tumors fluoresced in situ (mean Fluoptics SBR, 5.2 [range, 2.7-8.1]; mean Karl Storz SBR 1.9 [range, 1.4-2.6]). In addition, the fluorescence was consistent with tumor margins on pathology. Three positive lymph nodes were discovered with NIR imaging. Also, a positive retained tumor margin was discovered upon NIR imaging of the wound bed. Human pulmonary adenocarcinomas were also fluorescent both in situ and ex vivo (mean SBR, > 2.0).

CONCLUSIONS

NIR imaging can identify lung cancer in a large-animal model. In addition, NIR imaging can discriminate lymph nodes harboring cancer cells and also bring attention to a positive tumor margin. In humans, pulmonary adenocarcinomas fluoresce after the injection of the targeted contrast agent. Cancer 2017;123:1051-60. © 2016 American Cancer Society.

Prevalence, Prognostic Implications, and Survival Modulators of Incompletely Resected Non-Small Cell Lung Cancer in the U.S. National Cancer Data Base

INTRODUCTION

The impact of incomplete lung cancer resection on survival has never been systematically quantified, nor has the value of postoperative adjuvant therapy in this setting been determined.

METHODS

We evaluated lung cancer resections in the National Cancer Data Base from 2004 to 2011 to identify factors associated with margin involvement. We compared the survival of patients with and without positive margins and evaluated the impact of postoperative adjuvant therapy.

RESULTS

Of 112,998 resections performed during the 8 years, 5,335 (4.7%) had positive margins. Patient demographic and clinical factors associated with an increased adjusted OR of incomplete resection included black race (p = 0.006), age-based Medicare insurance (p = 0.006), urban residence (p = 0.01), histologic diagnosis of squamous cell carcinoma, high tumor grade, tumor overlapping more than one lobe, and advanced pathologic stage (p < 0.001 for all clinical factors). Community cancer programs (p = 0.002), institutions with high proportions of underinsured patients (p = 0.01), and institutions with a lower volume of cancer resections (p = 0.006) also had an increased adjusted OR. The crude 5-year survival rates of patients with complete versus incomplete resections were 58.5% versus 33.8% (log-rank p < 0.001). After an incomplete resection, adjuvant chemotherapy was associated with improved 5-year survival across all stages (p < 0.01); radiotherapy was associated with worse survival in patients with stage I disease (p < 0.001).

CONCLUSIONS

Margin involvement significantly impaired survival after lung cancer resection irrespective of stage. Causative institutional and provider practices should be identified to minimize this adverse outcome. Postoperative adjuvant chemotherapy mitigated mortality risk independently of stage, whereas postoperative radiotherapy exacerbated the risk in patients with stage I disease. These findings need validation in prospective trials.

Significance of R1-resection at the bronchial margin after surgery for non-small-cell lung cancer

OBJECTIVES

We aimed to evaluate the significance of microscopic residual disease at the bronchial resection margin (R1-BRM) after curative surgery for non-small cell lung cancer (NSCLC).

METHODS

Retrospective review was performed on 1800 patients from 1994 to 2012. We compared recurrence and survival between 1740 patients with R0-resection at the BRM (R0-BRM) and 60 patients with R1-resection at the BRM (R1-BRM), comprising 18 cases of mucosal carcinoma in situ (R1-CIS) and 42 cases of extramucosal residual disease (R1-EMD).

RESULTS

Stump recurrence occurred in 43 patients. The 5-year cumulative incidence of stump recurrence in group R0, R1-CIS and R1-EMD was 3.1, 5.6 and 12.2%, respectively. Significant differences of stump recurrence were observed between the groups (R0 versus R1-CIS, P = 0.008; R0 versus R1-EMD, P = 0.007). In Stage IB or II disease, the overall survival rate for R1-EMD was significantly lower than that for R0-BRM (P = 0.014), whereas the difference in overall survival rate between the R1-CIS group and the R0-BRM was not significant (P = 0.37). In Stage IIIA disease, the overall survival rates for R1-CIS (P = 0.87) and R1-EMD (P = 0.45) were not significantly different from that for R0-BRM.

CONCLUSIONS

R1-BRM comprises a higher rate of stump recurrence, compared with that of R0-BRM. Herein, R1-EMD was associated with poor overall survival in Stage IB/II disease. In Stage IIIA disease, R1-BRM showed similar overall survival rate to that for R0-BRM, although the number of patients was too small to draw definitive conclusions thereon.

[Postoperative radiotherapy for non-small cell lung cancer: Efficacy, target volume, dose]

The rate of local failure of stage IIIA-N2 non-small cell lung cancer is 20 to 40%, even if they are managed with surgery and adjuvant chemotherapy. Postoperative radiotherapy improves local control, but its benefit on global survival remains to be demonstrated. Considered for many years as an adjuvant treatment option for pN2 cancers, it continues nevertheless to be deemed too toxic. What is the current status of postoperative radiotherapy? The Lung Adjuvant Radiotherapy Trial (Lung ART) phase III trial should give us a definitive, objective response on global survival, but inclusion of patients is difficult. The results are consequently delayed. The aim of this review is to show all the results about efficacy and tolerance of postoperative radiotherapy and to define the target volume and dose to prescribe.

Use of adjuvant chemotherapy (CT) and radiotherapy (RT) in incompletely resected (R1) early stage Non-Small Cell Lung Cancer (NSCLC): a European survey conducted by the European Society for Medical Oncology (ESMO) young oncologists committee

BACKGROUND

Early stage Non-Small Cell Lung Cancer (NSCLC) is potentially curable with surgery. ESMO guidelines recommend cisplatin-based adjuvant chemotherapy (CT) for completely resected stage II-III NSCLC. There is limited evidence for the use of adjuvant CT and/or radiotherapy (RT) in incompletely resected (R1) early stage NSCLC.

MATERIALS AND METHODS

A European survey of thoracic oncologists was conducted to evaluate use of adjuvant CT and RT for R1-resected NSCLC and to identify factors influencing treatment decisions. Demographics and information on clinical stage, regimens, cycles planned, radiotherapy sites, multidisciplinary management and discussion about inconclusive evidence with the patient were collected. Univariate and multivariate analyses were performed.

RESULTS

768 surveys were collected from 41 European countries. 82.9% of participants were medical oncologists; 49.3% ESMO members; 37.1% based in University Hospitals; 32.6% practicing oncology for over 15 years and 81.4% active in research. 91.4% of participants prescribed adjuvant CT and mostly cisplatin/vinorelbine (81.2%) or cisplatin/gemcitabine (42.9%). 85% discussed limited clinical evidence with the patient. In the univariate analysis, a statistically significant association with CT prescription was found for medical oncology specialty (p<0.001), ESMO membership (p<0.001), activity in clinical research (p=0.002) and increased frequency of ESMO guidelines consultation (p for trend <0.001). 48.3% of participants prescribed adjuvant RT and its prescription were associated with radiation oncology specialty (p<0.001), not being an ESMO member (p<0.001), years practicing specialty (p for trend=0.001), workload of lung cancer patients (p for trend=0.027) and decreased frequency in consulting ESMO guidelines (p<0.001). In the multivariate analysis, medical oncology and radiation oncology were the best discriminator for prescription of adjuvant CT and RT, respectively.

CONCLUSION

This survey demonstrates that adjuvant CT and RT are commonly used in clinical practice for R1-resected NSCLC despite limited evidence. Prospective trials are necessary to clarify optimal management in this setting.

Pneumonectomy: risk factor or innocent bystander?

Background

Pneumonectomy is associated with a higher operative mortality rate and worse 5-year survival after resection for non-small-cell lung cancer, compared to lobectomy. We investigated whether pneumonectomy is an independent risk factor for hospital mortality and poor long-term survival, after risk factor adjustment.

Methods

We analyzed a prospectively validated thoracic surgery database. Kaplan-Meier survival curves were constructed for patients who had undergone lobectomy ( n = 1484) or pneumonectomy ( n = 266). Logistic and Cox multivariate regression analysis and propensity matching were performed on hospital mortality and long-term survival data.

Results

Univariate analysis demonstrated that pneumonectomy was a significant risk factor for hospital death ( p = 0.02) and long-term survival ( p < 0.001). Logistic regression failed to demonstrate pneumonectomy as a risk factor for hospital mortality. Cox regression analysis failed to identify pneumonectomy as a statistically significant risk factor. Propensity analysis ( n = 266 in each group with 1:1 matching) demonstrated that pneumonectomy was not associated with hospital mortality ( p = 0.37) or poorer long-term survival ( p = 0.19) compared to lobectomy.

Conclusion

Pneumonectomy is not an independent risk factor for hospital mortality or long-term survival, after adjustment for confounding factors.

Patterns of failure after postoperative radiotherapy for incompletely resected (R1) non-small cell lung cancer: implications for radiation target volume design

OBJECTIVE

Overall survival (OS) and pattern of failure in R1-resected non-small cell lung cancer (NSCLC) patients treated with 3D-planned postoperative radiotherapy (PORT) was retrospectively evaluated. The outcomes and patterns of failure in patients with (+) and without (-) extracapsular nodal extension (ECE) were compared and analyzed with respect to the radiation target volume design.

MATERIALS AND METHODS

Eighty R1-resected (37 ECE+ and 43 ECE-) patients received PORT (60Gy, 2Gy daily) between 2002 and 2011. Patients with N2 disease received limited elective nodal irradiation (ENI); for pN0-1 disease the use of ENI was optional. Among ECE- (extranodal-R1) patients there were 35 pN0-1 and eight pN2 cases; in pN0-1 patients, patterns of failure and outcomes were analyzed with respect to the use of ENI. Loco-regional failure (LRF) was defined as in-field relapse; isolated nodal failure (INF) was defined as out-of-field regional nodal recurrence occurring without LRF, irrespective of distant metastases.

RESULTS

The actuarial 3-year OS rate was 36.3% (median: 30 months). Three-year OS rates in the ECE- and ECE+ group were 40.4% and 31.4%, with median OS of 31 and 24 months, respectively (p=0.43). In multivariate analysis, the presence of ECE was correlated with OS (HR=3.02; 95% CI: 1.00-9.16; p=0.05). Three-year cumulative incidence of LRF (CILRF) was 14.5% and 15.5% in the ECE- and ECE+ groups, respectively (p=0.98). Three-year cumulative incidence of INF (CIINF) was 14.1% in the ECE- group and 11.1% in the ECE+ group (p=0.76). For pN0-1 patients treated with and without ENI (13 and 22 patients) 3-year CILRF rates were 7.7% and 20.8%, respectively (p=0.20); 3-year CIINF rates were 9.1% and 16.3%, respectively (p=0.65).

CONCLUSION

PORT resulted in a relatively good survival of R1-resected NSCLC patients. Relatively high incidence of INF was found in both ECE+ and ECE- patients. For ECE+ patients, treated with limited ENI, distant failure remains a major concern, so the design of ENI fields seems of lesser importance. Omission of ENI in pN0-1 (extranodal-R1) patients resulted in an unacceptably high incidence of INF. We postulate the use of some form of ENI in this setting.

[Indications and limitations of fresh frozen sections in the pulmonary apparatus]

Recommendations for the diagnosis of lung tumors almost limit the use of fresh frozen sections to the evaluation of resection margins. In pathology pretherapeutic methods for assessment of clinically suspected lung cancer are favored over intraoperative frozen section diagnosis. For the interdisciplinary management of uncertain lung findings diagnostic methods, such as cytopathology and examination of biopsy material are available. The use of rapid on-site evaluation (ROSE) in cytopathology is limited due to the lack of necessary personnel. Diagnosis of unclear pulmonary lesions or distinction of metastases from primary lung tumors by intraoperative frozen sections is therefore limited to exceptional cases that were not resolved by preoperative biopsies. Such rare cases require a common consensus strategy between thoracic surgeons and pathologists in a preoperative tumor board.

Postoperative radiotherapy for incompletely resected non-small cell lung cancer: clinical outcomes and prognostic value of the histological subtype

The purpose of this study was to evaluate the efficacy and toxicity of the postoperative radiotherapy in patients with incompletely resected NSCLC, and to investigate whether the histological subtype is a prognostic factor. Forty-one incompletely resected NSCLC patients who underwent postoperative radiotherapy were retrospectively analyzed. The microscopic residual tumor (R1 group) was recognized in 23 patients, and the macroscopic residual tumor (R2 group) in 18. The postoperative pathological stages were I (n = 3), II (n = 8), IIIA (n = 17), and IIIB (n = 13). The histology included squamous cell carcinoma (n = 23), adenocarcinoma (n = 14) or other types (n = 4). The first site of disease progression was distant metastases alone for 3 (13%) of 23 with squamous cell carcinoma, and for 9 (64%) of 14 with adenocarcinoma (p < 0.01). The 5-year overall, local control, disease-free, and distant metastasis-free survival rates were 56%, 63%, 37% and 49%. Univariate analyses showed that squamous cell carcinoma histology, N0-1 stage and the R1 group were significant predictors for better disease-free and distant metastasis-free survival. Multivariate showed that squamous cell carcinoma and N0-1 stage were significant predictors for better distant metastasis-free survival. Toxicity was generally mild; Grade 3 toxicities occurred in 3 patients (neutropenia, radiation pneumonia and esophageal stenosis), and no acute and late toxicities of Grade 4 to 5 were observed. In conclusion, postoperative radiotherapy for incompletely resected NSCLC could achieve a relatively high local control rate without severe toxicity. However, different treatment strategies for non-squamous cell carcinoma should be considered, because of the higher risk for the distant metastases.

Significance of microscopic invasion into hilar peribronchovascular soft tissue in resection specimens of primary non-small cell lung cancer

INTRODUCTION

The significance and handling of microscopic invasion of non-small cell lung cancer (NSCLC) into hilar peribronchovascular soft tissue (SHEATH+) have not been defined in the TNM classification by AJCC/UICC; nevertheless, SHEATH+ may be equivalent to spread into the mediastinum. Also, assessment of the margin of peribronchial resection is challenging because of the technical difficulty of inking, and intraoperative and postoperative artifacts.

METHODS

Records of 592 consecutive Asian patients with primary NSCLC (excluding adenocarcinoma in situ) who had, without any preoperative therapy, undergone lobectomy, sleeve lobectomy and pneumonectomy were examined. SHEATH+, simply defined as invasion of hilar peribronchovascular soft tissue, without categorizing any invasive patterns, and its significance were statistically analyzed.

RESULTS

Forty-four SHEATH+ cases demonstrated significantly advanced TNM stages, and were statistically associated with central occurrence, pN1-3, and vascular invasion, as assessed by logistic regression analysis. No statistically significant differences were observed between TNM stage-adjusted frequency of recurrence and recurrence-free intervals. Kaplan-Meier's estimates of the rate of overall and recurrence-free survival after surgery showed no statistically significant differences between SHEATH+ and SHEATH-. Cox's multivariate analysis suggested SHEATH was not a statistically independent prognostic factor under the TNM classification by AJCC/UICC (7th edition).

CONCLUSIONS

SHEATH+ in NSCLC was simply associated with central occurrence and advanced TNM stages. To the best of our knowledge, this is the first report on the significance of SHEATH+ in NSCLC.

Coping with the unexpected at surgery

In lung cancer surgery, it is best to avoid surprises; this requires knowledge of the reliability of preoperative assessment and careful planning. If this has been done, most of the more common situations should be manageable. If there is limited chest wall, mediastinal or N2 node involvement, one should proceed with resection. Unanticipated T4 tumors or bulky pN2 disease should not come as a surprise, and such patients should be sent to a more experienced center. One has to be careful to practice within the scope of one's knowledge and abilities as well as the sophistication of the institution. It only makes a mistake worse if an intraoperative surprise prompts one to embark on an operation that is beyond the means at hand. Collaborative organization via multidisciplinary tumor boards or inter-institutional interaction allows collective wisdom to promote better outcomes for all.

Problems in pathologic staging of lung cancer

CONTEXT

Tumor stage is the most important prognostic and predictive factor for patients with lung cancer, the most lethal neoplasm in the United States. It is used by thoracic surgeons, radiation therapists, and oncologists to determine whether patients with these neoplasms will be treated surgically with curative intent or with palliative radiation therapy and/or chemotherapy.

OBJECTIVE

To review the variety of practical problems that can arise during the assessment of the pathologic stage and other prognostic/predictive factors included in the College of American Pathologist checklist for evaluation of resected lung neoplasms.

DATA SOURCES

Potential practical difficulties that can arise during the pathologic staging of lung cancer patients include the distinction between pT1, pT2, and pT3 lesions based on their location and the presence of visceral pleura and/or parietal pleura invasion; the differential diagnosis between multiple synchronous or metachronous primary lung neoplasms (pT1m) and intrapulmonary metastasis of non-small cell carcinoma of the lung (pT4 or pM1 according to their location); and the role of the recent American Joint Committee on Cancer terminology for the classification of lymph nodes (isolated tumor cells, micrometastases, and metastases).

CONCLUSIONS

The variety of practical problems that can arise during the assessment of important prognostic and predictive features such as resection margin status and evaluation of lymphovascular invasion are reviewed. A brief discussion of the assessment of the effects of neoadjuvant therapy on resected lung neoplasms is also included.

The natural history of carcinoma in situ involving bronchial resection margins

STUDY OBJECTIVES

Microscopic residual disease in the bronchial resection margins after surgical resection of lung cancer is rare, and its clinical significance remains unsettled. We studied the natural history of patients with carcinoma in situ (CIS) at their bronchial resection margins to focus on the issue of stump recurrence.

METHODS

Eleven individuals who had undergone radical surgery for N0M0 lung tumors were found to have CIS at the bronchial resection margins. All of the resection specimens were reviewed with respect to the pattern of CIS extension and reclassified as follows: superficial CIS, involving surface epithelium only (CIS-S), CIS extending into the submucosal gland ducts but not deeper (CIS-D), and CIS extending into submucosal gland acini (CIS-A). Patients were followed using autofluorescence bronchoscopy and high-resolution computer tomography. Clinical parameters and the local extent of CIS at histology review were correlated with outcome.

RESULTS

Median follow-up was 35 months (range, 15 to 89). Histology review showed two CIS-S cases, six CIS-D cases, and three CIS-A cases. All of the patients with CIS-A developed stump recurrences in contrast with those with only CIS-S. Three patients with CIS-D have developed metachronous primaries in the contralateral lung, whereas the stump region remained free of tumor.

CONCLUSIONS

The presence of CIS in the bronchial resection margin after resection of lung cancers is associated with stump recurrences. Although absolute numbers are too small for firm conclusions, our data suggest that those with deep glandular extension of CIS bear the highest risk of early recurrence. However, the development of new primaries away from the stump region and the possible development of distant disease are equally relevant considerations with respect to the choice of additional therapy.

Promoter hypermethylation of resected bronchial margins: a field defect of changes?

PURPOSE

Histologically positive bronchial margins after resection for non-small cell lung cancer are associated with shortened patient survival due to local recurrence. We hypothesized that DNA promoter hypermethylation changes at bronchial margins could be detected in patients with no histological evidence of malignancy and that they would reflect epigenetic events in the primary tumor.

EXPERIMENTAL DESIGN

Bronchial margins, primary tumor, bronchoalveolar fluid, and paired nonmalignant lung were obtained from 20 non-small cell lung cancer patients who underwent a lobectomy or greater resection. Disease-specific recurrence was the primary end point. The methylation status of p16, MGMT, DAPK, SOCS1, RASSF1A, COX2, and RARbeta was examined using methylation-specific polymerase chain reaction.

RESULTS

All malignancies had methylation in at least one locus. Concordance of one gene with an identical epigenetic change in the tumor or bronchial margin was observed in 85% of patients. Only one patient had methylation at the bronchial margin for a gene that was not methylated in the corresponding tumor. Median time to recurrence was 37 months (range, 5-71 months). There were two local recurrences and five metastases. There were no significant correlations between DNA methylation in tumor, margins, or bronchoalveolar fluid specimens and either regional recurrence or distant metastases.

CONCLUSIONS

Histologically negative bronchial margins of resected non-small cell lung cancer exhibit frequent hypermethylation changes in multiple genes. These hyper-methylation abnormalities are also present in the primary tumor and thus may represent a field defect of preneoplastic changes that occurs early in carcinogenesis.

Bronchial margins in lung cancer resection specimens: utility of frozen section and gross evaluation

Pathology reports for all lobectomy and pneumonectomy specimens at UNC Hospitals between 1991 and 2000 (n=405) were reviewed for correlation between frozen section and final bronchial margin, gross distance between tumor and margin and tumor type. Frozen section was performed in 268 cases (66%). A total of 243 were true negatives (90.6 %), 16 (6.0%) were true positives, four (1.5%) were false positives and five (1.9%) were false negatives. The site of tumor in true-positive cases was mucosal (11), submucosal (three), lymphatics (one), peribronchial (one). The site of tumor in false-negative cases was submucosal (two), lymphatics (one), peribronchial (two). In 137 cases, no bronchial frozen section was performed; there was one case (0.7%) with positive margin. There was no correlation between final margin positivity and distance between gross tumor and margin. Tumor distance to margin in positive margin cases varied from grossly involved to 3 cm away. There were 72 cases in which wedge resection was performed before lobectomy in which no gross tumor remained in the lobectomy, and in all cases final bronchial margins were negative. In all, 373 of cases (92%) were nonsmall carcinomas. Of these, 10 (2.7%) had positive margins. Tumors other than nonsmall cell carcinoma accounted for a disproportionate number of positive margins. In all, 3/6 of adenoid cystic/mucoepidermoid carcinoma, 1/7 small cell carcinoma and 1/1 lymphoma cases had positive margins. In conclusion, frozen section evaluation of bronchial margins is helpful in central lung tumors. Mucosal tumor is preferentially identified in frozen section. Gross evaluation of margins is problematic, as intramucosal carcinoma or tumor in lymphatics may not be detected, but 3 cm was a 'safe' distance for gross tumor from margin. In lobectomies following wedge resection in which no gross tumor remained, all had negative margins. Salivary gland-type tumors have a high incidence of positive margins, and frozen section is particularly indicated in these tumors.

Prognostic implications of microscopic proximal bronchial extension in non-small cell lung cancer

BACKGROUND

The loss of approximately one third of early stage lung cancer patients undergoing complete resection by the end of 5 years implies the existence of unknown or undetected factors at the time of operation. We investigated the possible correlation between microscopic proximal bronchial extension (MPBE) and survival with clinicopathologic features in patients with non-small cell lung cancer.

METHODS

The bronchial tree with the tumor was dissected and extracted from the lung parenchyma in a total of 62 surgical specimens with non-small cell lung cancer. The tumor-related bronchus was sectioned into serial blocks at a thickness of 5 mm in the transverse plane. Histologically, cut serial sections were examined for MPBE.

RESULTS

A total of 15 (24.2%) specimens showed MPBE, whereas 47 (75.8%) specimens showed no evidence of MPBE. The median survival time of MPBE-positive patients was 10.0 months, whereas that of MPBE-negative patients was 42.0 months. The 5-year survival rates of MPBE-positive and MPBE-negative groups were 13.3% and 35.8%, respectively, which was a significant difference (p = 0.0203). Multivariate analysis revealed lymph node status (p = 0.0161), histology (p = 0.0268), and MPBE-positivity (p = 0.0447) as independent prognostic factors.

CONCLUSIONS

Microscopic proximal bronchial extension has an adverse effect on survival in non-small cell lung cancer.

Therapy for stage I and stage II non-small cell lung cancer

Despite complete resection of what seems to be all evident tumor, one third to three quarters of patients with stages I and II NSCLC ultimately succumb to this neoplasm. Patients who are cured of an original NSCLC or small cell cancer remain at risk for a new primary lung cancer. Although the importance of lifelong surveillance is clear, the extent and timing of optimal follow-up remain undefined. Although clinicians refer to the development after treatment of clinically discernible sites of tumor as "recurrence," it is probably more accurate to consider these foci as "persistence"--that is, the locoregional site was not sterilized by surgery, and the distant implants were present from the outset but undetected. Although data are sparse, induction and improved adjuvant therapy for early NSCLC may be helpful. Much further experience is needed. Further study and application of biologic indicators in addition to TNM staging likely will help identify patients at high risk for surgical failure who may benefit by combination treatment.

Significance of lymphangiosis carcinomatosa at the bronchial resection margin in patients with non-small cell lung cancer

BACKGROUND

Treatment options for patients with microscopic residual disease at the bronchial margin (R1-resection) after resection for non-small cell lung cancer include observation, radiotherapy, reoperation, or even systemic therapy. The present study was performed to identify a parameter that would estimate the prognosis of these patients more precisely to permit a well-founded treatment recommendation for the individual patient.

METHODS

A total of 1,162 patients with resected non-small cell lung cancer were analyzed in this retrospective study. Fifty-four patients (4.6%) had R1-resections at the bronchial margin. Type of residual disease (mucosal, extramucosal, or involvement of the entire bronchial wall) and occurrence of tumor cells in the lymphatic vessels (lymphangiosis carcinomatosa) were recorded as distinct parameters and analyzed by univariate and multivariate analyses (Log rank test; Cox regression model).

RESULTS

Lymphangiosis carcinomatosa at the bronchial margin was detected in 22 patients (40.7%) and was associated with a significantly shortened survival (median survival with lymphangiosis carcinomatosa, 13.3 months; without lymphangiosis carcinomatosa, 20.1 months; p = 0.026). Early stage patients (stage I-II) without lymphangiosis carcinomatosa showed a median survival of 49 months. Multivariate analysis revealed that lymphangiosis carcinomatosa at the resection margin is an independent prognostic parameter (p = 0.038). Even after postoperative radiotherapy the prognosis was still poor if a lymphangiosis carcinomatosa was detected (median survival, 17.1 months). All other parameters (T-stage, N-stage, tumor histology, type of bronchial wall involvement) were not of prognostic significance in R1-resected patients.

CONCLUSIONS

Lymphangiosis carcinomatosa at the bronchial resection margin predicts a poor prognosis in patients with non-small cell lung cancer. It is more than questionable whether these patients would benefit from local treatment options like radiotherapy.

Proximal bronchial extension with special reference to tumor localization in non-small cell lung cancer

OBJECTIVE

Surgery is the optimal treatment in patients with non-small cell lung cancer (NSCLC) and tumor-negative bronchial resection margins should be maintained for a curative resection. The epidemiology of NSCLC, including the aspects of tumor localization, has been changing during the recent decades. The aim of this study was to evaluate microscopic proximal bronchial extension with special reference to the site of the tumor.

METHODS

Surgical specimens of 70 NSCLC cases were examined histologically for proximal bronchial extension of the tumor. The entire bronchial tree with the tumor was extracted from the specimen and serially cut at a thickness of 5 mm in the transverse plane of the bronchus. Microscopic proximal extension of the tumor was classified as either endobronchial or peribronchial.

RESULTS

Thirty-three (47.1%) tumors had central and 37 (52.9%) had peripheral localization. Among the central and peripheral tumors, 10 (30.3%) and seven (18.9%) had microscopic proximal extension, respectively. In total, the mean length of proximal extension was 10.94 +/- 7.07 mm. The mean length of extension for peripheral tumors was 15.71 +/- 8.38 mm, significantly greater than that of central tumors, which was 7.60 +/- 3.47 mm (P = 0.026). Peripheral tumors showed a significant peribronchial extension (P = 0.024).

CONCLUSIONS

A greater percentage of central tumors show microscopic proximal bronchial extension, whereas the length of microscopic proximal bronchial extension is significantly greater in peripheral tumors. Peripheral tumors preferentially have a peribronchial extension pattern.

Changing patterns of lung cancer; (3/4 in.) 1.9 cm; still a safe length for bronchial resection margin?

BACKGROUND

Surgical resection is the best treatment modality in non-small cell lung cancer (NSCLC). As a guideline, it is suggested that at least a bronchial resection margin of 1.9 cm from the macroscopic tumor might provide a tumor-free margin in lung cancer. In some recent reports, there is great emphasis on the changing histopathological patterns of lung cancer, but no concern for the proximal extension of lung cancer. The aim of this study was to determine the validity of this guideline in the current time.

METHODS

Surgically resected specimens of NSCLC cases (n = 70) were examined. The bronchial tree including tumor was dissected and beginning from the edge of the visible tumor, the bronchus were cut into serials in its transverse plane, 5 mm apart from each other. Cut sections were examined for proximal extension of tumor at different levels.

RESULTS

Microscopic proximal extension was observed in 24.2% (n = 17/70) of all the cases. Peribronchial extension (n = 9/17) (52.9%) was more predominant compared with bronchial extension (n = 8/17) (47.0%). Squamous cell carcinoma (n = 11/38) (28.9%) showed proximal extension more than adenocarcinoma (n = 5/23) (21.7%). Adenocarcinoma showed more peribronchial extension (n = 4/5) (80.0%) whereas squamous cell carcinoma (n = 7/11) (63.6%) showed more bronchial extension. The farthest extension was 3.0 cm for adenocarcinoma and 2.0 cm for squamous cell carcinoma. Excluding tumor positive specimens beyond 1.5 cm level to the bronchial resection margin, all tumors accounted for 96% of the whole series.

CONCLUSIONS

Microscopic proximal extension of lung cancer occurs in 24.2% of NSCLC cases. Squamous cell carcinoma extends more proximally compared with adenocarcinoma in ratio whereas adenocarcinoma extends more in length. A bronchial resection of 1.5 cm in length from the macroscopic tumor will provide clear margins in 93% of NSCLC cases.

Prognostic implications of a positive bronchial resection margin

OBJECTIVE

This retrospective study evaluates probability of survival and mode of recurrence in patients with a microscopically positive bronchial resection margin following resection for primary bronchogenic carcinoma, as well as influence of radiotherapy on survival.

METHODS

From January 1986 to July 1997, 40 patients had a microscopically positive bronchial resection margin following a macroscopically complete resection (17 lobectomies, three bilobectomies, four sleeve-lobectomies, and 16 pneumonectomies). Tissue diagnosis was squamous cell carcinoma in 32 patients, adenocarcinoma in four, adenosquamous carcinoma in two and neuroendocrine carcinoma in two. Lymph node status was N0 in 14 patients, N1 in 10, and N2 in 16. The bronchial margin contained carcinoma in situ in 20 patients, invasive mucosal carcinoma in five, and peribronchial infiltration in 15. All patients except the three most recent underwent adjuvant radiation therapy.

RESULTS

At the conclusion of the study (January 31st, 1999), 30 patients had died: two with post-operative complications, 17 with progressive disease, ten without relation to cancer, and one under undefined circumstances. Six of 10 unrelated deaths were interpreted as respiratory complications of radiotherapy. Recurrent disease appeared in 24 patients (60%). Nineteen had progression of initial disease (47.5%): metastatic spread in 12 (30%), isolated local recurrence in four (10%), and combined local recurrence and metastases in three (7.5%). Five patients developed metachronous cancer, with bronchial location in four (10%) and laryngeal in one (2.5%). 5-year survival (Kaplan-Meier) in 20 patients with carcinoma in situ was 38.7+/-13.7% (median 31 months), but rose to 55.0+/-16. 6% when excluding seven deaths not related to cancer (five of whom were secondary to radiotherapy) (chi(2)=3.080; P=0.0792). Survival in 13 patients classified N0 was 51.3+/-16.3% (median 61 months), and 71.1+/-18.0% following exclusion of unrelated deaths (chi(2)=3. 939; P=0.0472). Adverse prognosis of peribronchial infiltration was correlated to a positive N status (13 N2 and 2 N1), 5-year survival being 20.0+/-10.3% (median: 18 months).

CONCLUSIONS

Prognosis of peribronchial infiltration is similar to N2 disease. In situ carcinoma does not influence survival per se. Local control of disease is probably in part due to radiotherapy. However, the high prevalence of unrelated late deaths suggests an adverse impact of radiotherapy on survival.

Treatment and survival after lung resection for non-small cell lung cancer in patients with microscopic residual disease at the bronchial stump

OBJECTIVE

The aim of this study is a retrospective evaluation of survival in patients who had undergone lung resection for non-small cell lung cancer and in whose microscopic residual disease at the bronchial resection margin was found, according to the type of infiltration, histology, lymph node involvement and postoperative treatment.

METHODS

A total of 1384 patients underwent lung resection for non-small cell lung cancer at the Thoracic Surgery Unit of the University of Siena from 1983 through 1998. All patients underwent complete mediastinal lymphadenectomy and this guaranteed an accurate stadiation. Staging was done according to the TNM and UICC classifications. Residual microscopic disease at the bronchial resection margin was divided in mucosal microscopic residual disease and extramucosal microscopic residual disease. Patients dying within 30 days from operation were excluded from survival analyses. Survival was analysed by the product limit method of Kaplan and Meier and curves were compared using the log-rank test.

RESULTS

Microscopic residual disease was found postoperatively at the bronchial margin in 3.39% (47/1384), of all patients undergoing lung resection for non-small cell lung cancer. Thirty patients (2.16%) had extramucosal microscopic residual disease and 17 (1.22%) had mucosal microscopic residual disease. Seventeen patients received adjuvant radiotherapy after operation, two patients underwent completion pneumonectomy; no chemotherapy was given. Median survival for the whole group was 22 months. The probability of survival was not significantly (P > 0.05) correlated with the type of infiltration, nor with lymph node disease, neither with histology, although patients with squamous cell carcinoma had a median survival of 30 versus 12 months of patients with adenocarcinoma. The probability of survival could not be correlated with the administration of adjuvant radiotherapy.

CONCLUSIONS

A frozen-section analysis of the bronchial resection margin and peribronchial tissue should be made in all patients with endobronchial tumour. We suggest that patients with microscopic residual tumour and stage I or II disease should undergo re-operation, if possible. In patients with documented N2 disease we don't recommend re-operation; extending the magnitude of the resection is unlikely to alter their outcome. Choice treatment for these patients is radiotherapy.

"Incomplete resection" in non-small cell lung cancer: need for a new definition. Canadian Lung Oncology Group

BACKGROUND

This study was designed to determine the prognostic value of positive surgical resection margin or highest nodal station sampled at thoracotomy in patients with non-small cell lung cancer.

METHODS

Two reviewers independently examined the surgical records and pathologic reports from a randomized trial comparing computed tomography versus mediastinoscopy for staging of lung cancer. They recorded pathologic findings at the surgical resection margin, the highest mediastinal nodal station sampled at thoracotomy, histologic type, tumor size, N status, and evidence of vascular or lymphatic invasion. These variables formed the independent variables in logistic regression models to predict recurrence.

RESULTS

Except for 1 patient, follow-up at 3 years for 399 included patients was complete. Significant predictors of recurrence were tumor size (odds ratio [OR], 1.2 (per centimeter); 99% CI [confidence interval], 1.1 to 1.4), and N status (compared with N0, N1: OR, 1.6; CI, 0.8 to 3.1; N2: OR, 3.2; CI, 1.4 to 7.5). Other variables, including positive surgical resection margin, did not predict early recurrence or death.

CONCLUSIONS

In patients with non-small cell lung cancer, surgical resection margin or highest nodal station sampled at thoracotomy that are involved by carcinoma do not predict recurrence. The current definition of incomplete resection has limited prognostic significance.

Survival in resected stage I lung cancer with residual tumor at the bronchial resection margin

BACKGROUND

Sometimes microscopic residual tumor is found at the bronchial resection margin despite an apparently complete resection of lung cancer. This may adversely affect the patient's prognosis. Its impact on survival is unclear.

METHODS

The records of 834 patients with resected stage I non-small cell lung cancer were studied. Patients with complete resection were assigned to the complete resection group (n = 802); patients with microscopic residual tumor at the bronchial resection margin that was accepted were assigned to the residual tumor group (n = 23). Residual tumor was classified as carcinoma in situ, mucosal residual disease, or peribronchial residual disease.

RESULTS

The 5-year survival in the patients in the complete resection group was 54%; it was 58% in the residual tumor group with carcinoma in situ and 27.3% in the residual tumor group with invasive tumor (mucosal residual disease or peribronchial residual disease). The difference in survival between patients in the complete resection group and patients in the residual tumor group with invasive tumor was significant (p = 0.03).

CONCLUSIONS

The presence of mucosal or peribronchial residual disease, but not carcinoma in situ, at the bronchial resection margin in patients with stage I non-small cell lung cancer has an adverse effect on survival.

Significance of extramucosal residual tumor at the bronchial resection margin

Extramucosal microscopic residual disease (MRD) at the bronchial resection margin was identified in 45 (1.6%) of 2,890 patients who underwent resection of primary non-small cell lung cancer between 1975 and 1985. In 9 of these patients, residual tumor was confined to submucosal lymphatics, whereas in the other 36, MRD was found in peribronchial soft tissue. All patients underwent complete mediastinal lymphadenectomy. Three patients had stage I disease, 3 had stage II, 33 had stage IIIa, 4 had stage IIIb, and 2 had stage IV. Recurrent disease developed in 34 (81%) of the evaluable patients; the recurrence was local in 11 (32%). Median time from operation to diagnosis of local recurrence was 8 months. Sixty percent of the recurrences in the N0 group were local, and only 23% of those in the N2 group were local. Extramucosal MRD is most frequently associated with advanced-stage disease. Postoperative therapy had no effect on the development of recurrent disease. We found no difference in survival between patients whose initial site of recurrence was local as opposed to distant. Median survival after the identification of either local or distant recurrence was 5 months. The finding of extramucosal MRD identifies a subset of patients with a poorer prognosis compared with those with clear resection margins.

Carcinoma of the bronchus with unsuspected microscopic resection-line involvement

In a series of 560 pulmonary resections for bronchial carcinoma, unsuspected microscopic tumor was present at the bronchial resection margin in 26 patients (4.5%). Adjuvant chemotherapy or radiotherapy was given in two patients. In follow-up times ranging from 1 to 72 months (mean, 22 months), 58% of patients were alive and free of recurrent disease. Twelve patients underwent periodic surveillance bronchoscopy in an attempt to identify early local recurrence. Eighty-three percent of these patients were alive and disease-free in follow-up times from 4 to 72 months (mean, 29.7 months). Only one choscopies. It was concluded that microscopic residual resection-line tumor does not preclude prolonged survival and that no benefit from surveillance bronchoscopy could be demonstrated in this small patient sample.

Management of bronchopleural fistula following pneumonectomy

Bronchopleural fistula developed in 28 (12.5%) of 225 pneumonectomies performed for pulmonary carcinoma of non-small cell types during a 10-year period. The incidence of fistula apparently decreased significantly when chromic catgut was replaced by Dexon for closure of the bronchial stump. The fistula presented as an emergency in nine cases and was subacute in 19. The overall mortality from bronchopleural fistula was 28.6%. Conservative treatment, i.e. bronchoscopic application of silver nitrate to destroy the epithelium in the bronchial stump and induce granulation, achieved closure of fistula in all the surviving patients. In the seven patients with sterile pleural cavity the pleura was not drained. The results justified our principle of conservative management when a bronchopleural fistula does not present as an emergency. In emergency situations, however, or if the pleural fluid is purulent, pleural drainage should be instituted.

Ultrastructural subtypes of pulmonary adenocarcinoma. A correlation with patient survival

A retrospective study of 34 patients (33 male and one female) was conducted to evaluate a potential correlation between patient survival, propensity to metastasize and specific subtypes of pulmonary adenocarcinomas as determined by ultrastructural examination. Previous electron microscopic studies of pulmonary adenocarcinomas have demonstrated proliferations of three types of cells: mucus, Clara, and alveolar cells. Specific ultrastructural markers of these cell types were assessed in the 34 cases. All cases in this study had a light microscopic diagnosis of adenocarcinoma originating in the pulmonary parenchyma and a follow-up of at least one year. Features such as patient survival time, extent of metastatic involvement, response to therapy, and overall tumor behavior were compared in reference to the cell of origin, in an effort to try to elucidate if such ultrastructural subclassification lent itself to any clinical correlations. Light microscopic growth patterns and special stains were not found to distinguish these neoplasms histogenetically, emphasizing the important role of electron microscopy for an accurate classification.

Common-sense untoward factors in lung cancer resection

Four common-sense untoward factors (age over 60, pneumonectomy, microresidual disease, and postoperative empyema) were retrospectively evaluated in a consecutive series of 199 surgically apparently complete non-oat cell lung cancer resections. By single-factor analysis all factors showed a lower survival that was contingent for microresidual disease and age over 60. For stage I tumors the negative impact on survival was significant for all except empyema, and for stage II and III tumors only for empyema. Without confounding factors, microresidual disease and age over 60 were negative prognostic factors only for distant mortality, empyema a negative prognostic factor only for early mortality, and pneumonectomy a probable negative prognostic factor for both early and distinct mortality. It is concluded that the scientific method used confirmed the prognostic assessment of common sense for these four factors.

Autologous x-irradiated tumour cells and percutaneous BCG in operable lung cancer

To determine the value of specific immunotherapy with adjuvant BCG in operable lung cancer, the immunological and clinical results of serial postoperative injections of autologous irradiated tumour cells and BCG were compared with those of a single preoperative injection of BCG in two randomly selected groups of patients undergoing resection of their tumours. There was a significant rise in tuberculin skin reactivity from seven weeks to 11 months after operation in the treated group. Actuarial curves for survival and freedom from tumour recurrence and median survival times showed an advantage for the treated patients who had stage I tumours, but these differences were significant only at the levels p = 0.07 - 0.09. Survival and duration of freedom from tumour recurrence was greater in autograft-treated patients whose skin responded to a weak test dose of dinitrochlorobenzene (DNCB) after sensitisation with 2% DNCB than in control DNCB-positive patients (p = 0.02). There were no significant differences in the actual proportion of patients from each group surviving at two years. The results show that this form of specific immunotherapy with adjuvant may have a beneficial effect in patients with stage I tumours and those who become sensitised to 2% DNCB after the first exposure.

Implications of histologically reported residual tumour on the bronchial margin after resection for bronchial carcinoma

A group of 64 cases with histologically reported residual tumour on the bronchial margin after resection for bronchial carcinoma has been examined. Carcinoma in situ of the bronchial mucosa was described in nine cases, invasive carcinoma of the bronchial mucosa in 29, peribronchial malignancy in 18, and lymphatic permeation in eight. Survival with peribronchial malignancy and lymphatic permeation was poor. Nevertheless, the finding of earlier workers that residual mucosal tumour at the margin of the resected bronchus may not adversely affect survival has been confirmed. The reason for the prolonged survival of some patients despite reported tumours of the bronchial stump mucosa may be that such reports are sometimes artefactual, and two possible mechanisms for this are discussed.