Normativa actualizada (1998) sobre diagnóstico y estadifícación del carcinoma broncogénico

Validation of the Proposed International Association for the Study of Lung Cancer Residual Tumor Classification to Upgrade Extracapsular Extension of Tumor in Nodes From R0 to Incomplete Resection

INTRODUCTION

The International Association for the Study of Lung Cancer (IASLC) proposed a revised R classification to upstage extracapsular extension (ECE) of tumor in nodes from R0 to R1. Nevertheless, evidence to confirm this proposal is insufficient.

METHODS

The study included 4061 surgical patients with NSCLC. After reclassification by IASLC-R classification, overall survival (OS) was analyzed to compare patients with ECE with those with R0, R(un), and incomplete resection (R1 and R2). The recurrence pattern of ECE was evaluated to determine whether it correlated with incomplete resection.

RESULTS

Among 1136 patients with N disease, those without ECE (n = 754, 67%) had a significantly better OS than those with ECE (n = 382, 33%) (p < 0.001). This negative prognostic significance was consistent across multiple subgroups. Multivariate analysis revealed that ECE was an independent prognostic risk factor (p < 0.001). When patients with ECE were separated from the IASLC-R1 group, their OS was significantly worse than that of IASLC-R(un) patients, but comparable to that of the remaining patients in the IASLC-R1 patients when analyzing all patients and patients with N disease. Moreover, patients with ECE had an increased risk of local recurrence in the mediastinum (p < 0.001), ipsilateral lung (p = 0.031), and malignant pleural effusion or nodes (p = 0.004) but not distant recurrence including contralateral or both lungs (p = 0.268), liver (p = 0.728), brain (p = 0.252), or bone (p = 0.322).

CONCLUSIONS

The prognosis of ECE patients is comparable with that of R1 patients. Moreover, their higher risk of local recurrence strongly suggests the presence of occult residual tumor cells in the surgical hemithoracic cavity. Therefore, upgrading ECE into incomplete resection is reasonable.

Prognostic evaluation of the proposed residual tumor classification in a Chinese non-small cell lung cancer population

BACKGROUND

This study aimed to validate the R classification including uncertain resection (R-un) proposed by the International Association for the Study of Lung Cancer (IASLC) in a Chinese non-small cell lung cancer (NSCLC) population.

METHODS

The study retrospectively investigated a 2009-2013 single-institutional NSCLC resection cohort in China. After reclassification, recurrence-free survival (RFS) and overall survival (OS) were calculated using survival analyses and compared with those using the 2005 version IASLC R classification.

RESULTS

Under the proposed stratification, 3819 (72.1%) individuals were classified as R0, 1371 (25.9%) as R-un, 71 (1.3%) as R1, and 32 (0.6%) as R2. The 5-year OS probabilities for the R0, R-un, and R1/R2 groups were 71%, 46%, and 34%, respectively. The prognostic stratification remained significant in the fully adjusted Cox models (p < 0.001). Compared with the original classification, Harrell's concordance index of reclassification improved significantly, from 0.508 to 0.679 for RFS and from 0.510 to 0.692 for OS (RFS: p = 0.007; OS: p = 0.001). The survival analysis showed that R-un patients with highest mediastinal lymph node station metastasis had significantly worse survival than R0 patients with mediastinal nodal metastasis (RFS: 44 vs. 36 months, hazard ratio [HR]: 1.29, p < 0.001; OS: 59 vs. 50 months, HR: 1.34, p < 0.001). Cox proportional hazards regression analysis showed that highest mediastinal lymph node station metastasis was an independent risk factor for RFS (HR: 1.22) and OS (HR: 1.25).

CONCLUSIONS

The proposed R classification showed valid prognostic stratification, including highest mediastinal nodal station metastasis.

The Evolving Concept of Complete Resection in Lung Cancer Surgery

Simple Summary

In the surgical treatment of lung cancer, the complete removal of the portion of the lung where the cancer is and of the involved adjacent structures is of paramount importance to achieve long-term survival. The International Association for the Study of Lung Cancer (IASLC) proposed a definition of complete resection that included a well-defined type of removal of the regional lymph nodes as a fundamental step. The lymph nodes may contain cancer cells and, if left behind, cancer will soon progress. The IASLC also defined incomplete resection when there is any evidence of persistent cancer after the operation. It also defined an intermediate condition, uncertain resection, when no evidence of residual disease can be proved, but all the conditions of complete resection are not fulfilled. Four validations of the definitions have proved their prognostic value and, therefore, the definitions should be followed when a surgical resection of lung cancer is planned.

Abstract

Different definitions of complete resection were formulated to complement the residual tumor (R) descriptor proposed by the American Joint Committee on Cancer in 1977. The definitions went beyond resection margins to include the status of the visceral pleura, the most distant nodes and the nodal capsule and the performance of a complete mediastinal lymphadenectomy. In 2005, the International Association for the Study of Lung Cancer (IASLC) proposed definitions for complete, incomplete and uncertain resections for international implementation. Central to the IASLC definition of complete resection is an adequate nodal evaluation either by systematic nodal dissection or lobe-specific systematic nodal dissection, as well as the integrity of the highest mediastinal node, the nodal capsule and the resection margins. When there is evidence of cancer remaining after treatment, the resection is incomplete, and when all margins are free of tumor, but the conditions for complete resection are not fulfilled, the resection is defined as uncertain. The prognostic relevance of the definitions has been validated by four studies. The definitions can be improved in the future by considering the cells spread through air spaces, the residual tumor cells, DNA or RNA in the blood, and the determination of the adequate margins and lymphadenectomy in sublobar resections.

Relationship of immunohistochemical biomarker expression and lymph node involvement in patients undergoing surgical treatment of NSCLC with long-term follow-up

We try to identify the relationship between immunohistochemical marker expression and lymph node involvement in a cohort of 282 patients followed for 5 years after curative resection for NSCLC. In 189 patients (67%), lymph nodes were unaffected while 93 patients (33%) showed nodal involvement. The expression of 15 molecular markers was determined from each patient by tissue-array immunohistochemistry. Univariate analysis indicated significantly higher expression of E-cadherin, γ-catenin, p27, and p53 in patients with lymph node involvement. In those with unaffected nodes, p16 and Rb were expressed. E-cadherin expression was related to a 50% mortality reduction in patients with node involvement (hazard ratio (HR) 0.5; p = 0.017). c-erbB-2 expression was correlated with a 3.4-fold increase in mortality compared to patients without expression of this marker in subjects without node involvement (HR 3.41; p = 0.017). Multivariate analysis identified c-erbB-2 (HR 2.22; p = 0.089) and p27 (HR 1.44; p = 0.019) as prognostics of mortality while Rb (HR 0.74) indicated a good prognosis. The expression of proteins encoded by oncogenes and tumor suppressor genes was different according to lymph node involvement. The increased mortality related to c-erbB-2 expression in patients with unaffected lymph nodes would suggests a need for adjuvant treatment.

Timeliness of care and prognosis in patients with lung cancer

BACKGROUND

Timeliness of care is an important dimension of health care quality. The determining factors of less timely care and their influence on the survival of patients with lung cancer (LC) remain uncertain.

AIMS

To analyse the delays in the diagnosis and treatment of LC in our health area, the factors associated with the timeliness of care and their possible relationship with the survival of these patients.

METHODS

A retrospective study was conducted on all patients with a cytohistologically confirmed diagnosis of LC between 1 June 2005 and 31 May 2008. The time delays for consultation (specialist delay), diagnosis (diagnosis delay), and treatment (treatment delay), were analysed, as well as the factors associated with these delays and the influence of the timeliness of care on survival.

RESULTS

A total of 307 cases were included (87 % males). The mean specialist delay was 53.6 days (median 35 days), diagnosis delay 31.5 days (median 18 days), treatment delay 23.5 days (median 14 days). The greater age of the patient and a more advanced stage were associated with a shorter specialist delay. Male sex, a more advanced stage, and poor general status were associated with a shorter treatment delay. The survival is longer in patients with a longer treatment delay.

CONCLUSIONS

The delay in the diagnosis in our population seems to be excessively long. The greater the age, a more advanced tumour stage, male sex, and poor general health status are associated with shorter delays. A longer treatment delay is associated with a longer survival.

SEPAR guidelines for lung cancer staging

The latest tumour, lymph node and metastasis (TNM) classification by the International Association for the Study of Lung Cancer (IASLC), based on the analysis of patients from all over the world, has incorporated changes in the descriptors, especially those regarding tumor size, while proposing new group staging. A new lymph node map has also been developed with the intention of facilitating the classification of the "N" component. SEPAR recommends using this new classification. As for the procedures recommended for staging, in addition to the generalized use of computed tomography (CT), it points to the role of positron emission tomography (PET) or image fusion methods (PET/CT), which provide a better evaluation of the mediastinum and extrathoracic metastases. Endobronchial ultrasound (EBUS) and esophageal ultrasound (EUS) for obtaining cytohistological samples have been incorporated in the staging algorithm, and it emphasizes the importance of precise re-staging after induction treatment in order to make new therapeutic decisions. Comment is made on the foreseeable incorporation in the near future of molecular staging, and systematic lymph node dissection is recommended with the intention of making a more exact surgical-pathological classification.

Significance of the presence of lymphocytes in the cytological analysis of transbronchial needle aspiration

AIM

To evaluate the clinical relevance of the presence of lymphocytes in transbronchial needle aspiration (TBNA) samples from pathological mediastinal lymph nodes in patients with suspected lung cancer.

METHODS

Retrospective observational study evaluating the negative predictive value (NPV) of TBNA samples containing lymphocytes but not malignant cells.

RESULTS

A total of 266 TBNA were performed in 252 patients with pathological lymph nodes. One hundred and fifteen TBNA samples had evidence of malignant cells (43%), and 94 (35%) samples were considered as inadequate (absence of adequate cytological material or exclusive presence of bronchial epithelial cells). Out of the 57 TBNA samples remaining (21%), 15 could not be confirmed; in 32, TBNA samples were confirmed with alternative diagnostic techniques and in 10, they were confirmed after clinical and radiological follow-up. The NPV of the 32 samples that were confirmed with alternative diagnostic techniques was 84% decreasing down to 76% when the 10 TBNA samples confirmed after clinical and radiological follow-up were included.

CONCLUSIONS

The presence of lymphocytes in the TBNA sample does not exclude the neoplasic invasion of the specific lymph node analyzed.

Lung cancer in a health area of Spain: incidence, characteristics and survival

To examine the incidence, characteristics, therapeutic approach and survival of diagnosed lung cancer (LC) in the Santiago de Compostela Health Area. A retrospective study was carried out on LC for a period of 3 years. Of the 481 cases collected, 92.7% were male. The median age was 66.93 years. The crude incidence for men and women was 80.71 and 5.84 per 100,000 inhabitants respectively. Among the non-small cell lung cancers (NSCLC), 68.1% were diagnosed in stage IIIB or IV. The cancer had already spread in 62.2% of the small cell lung cancer (SCLC). Chemotherapy was used in 51.6% of patients. The survival probability from the first to the fifth year was 47.7%, 24.3%, 12.9%, 10% and 8.9% respectively. The median survival at 5 years was 12.12 months for NSCLC, rising to 29.8 months in stage I, and 8.85 months in SCLC. In our Health Area LC occurs more often in men, in whom the prevalence of smoking is very high. The most common histology type was squamous cell carcinoma. In the majority of cases, the diagnosis is made in the advanced stages, which accounts for the low percentage of surgical treatments and the short survival.

[Lung transplantation: bronchogenic carcinoma in the native lung]

In lung transplantation, the presence of bronchogenic carcinoma in the native organ is uncommon, but doubtless affects patient survival, independently of the transplantation process itself. We describe 2 cases in which a primary tumor was found in the explanted lung--1 case of adenocarcinoma in a patient with pulmonary emphysema and 1 case of bronchioloalveolar carcinoma in a patient with idiopathic pulmonary fibrosis. Both patients died due to the recurrence of the neoplastic disease. Distant metastasis was the initial manifestation of the recurrence.

Effect of Different Bronchial Washing Sequences on Diagnostic Yield in Endoscopically Visible Lung Cancer

OBJECTIVE

Aspiration of bronchial wash fluid is commonly used in conjunction with brushing and forceps biopsy to diagnose endoscopically visible lung cancer. However, the optimal sequence of these procedures is subject to debate. The objective of this study was to determine if the order in which bronchial washing is performed relative to bronchial brushing and forceps biopsy has any effect on the diagnostic yield.

PATIENTS AND METHODS

A prospective, cross-sectional study was carried out on patients with endoscopically visible lung cancer who underwent video-assisted fiberoptic bronchoscopy for diagnostic purposes. Aspiration of bronchial wash fluid was performed on all patients both before and after bronchial brushing and forceps biopsy. The results were analyzed separately for each type of endobronchial lesion and for both together.

RESULTS

The study included 75 patients, with a mean age of 63.3 years; 81% were men. Bronchoscopy was diagnostic in 71 (94.7%) cases. Findings from bronchial washing fluid were positive in 40 (53.3%) patients when washing was performed prior to brushing and forceps biopsy; when washing was performed after these procedures, findings were positive in 43 (57.3%) patients (P=.6). The combined diagnostic yield of washing before and after brushing and forceps biopsy was 69.3%, a significantly better result than either washing before (P=.001) or after (P=.004) the other sampling techniques. In cases where findings from washing done after brushing and forceps biopsy were negative (14 of 32, 43.7%), blood in the aspirated sample interfered with cytology. In comparison, when washing was performed prior to brushing and biopsy, that problem arose in only 3 of the 35 cases (8.5%) (P=.002).

CONCLUSIONS

The order in which bronchial washing is performed in relation to other sampling techniques for diagnosing bronchial tumors does not influence the diagnostic yield. This is probably because the aspirated fluid sample is more likely to contain excessive blood when washing is performed after brushing and forceps biopsy. However, the diagnostic yield can be significantly increased by combining the findings from bronchial washings performed both before and after other sample collection procedures.

[Characteristics of lung cancer in a region in northern Spain]

OBJECTIVE

To gather information on the disease characteristics and survival rate of patients diagnosed with bronchogenic carcinoma in the respiratory medicine departments of hospitals in Asturias, Spain.

PATIENTS AND METHODS

This was a retrospective observational study carried out using a standardized data collection protocol. All cases of lung cancer diagnosed during 2001 were included provided there was cytologic or histologic confirmation or they fulfilled a series of clinical, radiological, and/or endoscopic criteria consistent with such a diagnosis.

RESULTS

Standard incidence rates adjusted to the world population were 22.4, 42.6, and 4.6 per 100,000 population for the whole population, men, and women respectively. The mean (SD) age was 67 (10.9) years, and 92% of the patients were men. Overall, 98% of the men and 44% of the women were smokers. Diagnosis was confirmed by cytologic or histologic findings in 92% of patients, and the majority were non-small cell tumors (81.4%). At the time of diagnosis, 65% of the patients had advanced disease, with distant metastasis in 26.6% of the non-small cell cancers and 52.8% of the small cell cancers. Patients received surgical treatment in 21.3% of cases, chemotherapy alone or combined with radiation therapy in 43.1%, and radiation therapy alone in 9.3%. In 26.2% of patients only palliative care was given. Overall, median survival in weeks was 36.4 (95% confidence interval [CI], 29.4-43.4). Median survival by treatment type was as follows: 69.3 (95% CI, 49-9.5) for surgery; 39.6 (95% CI, 31.2-48) for chemotherapy alone or with radiation therapy; 30 (95% CI, 15.4-44.6) for radiation therapy alone; and 13.3 (95% CI, 5.9-20.6) for patients who received palliative care alone (P< .05).

CONCLUSIONS

The findings with respect to age, sex, incidence, histology, extent of tumor, and smoking status of patients with bronchogenic carcinoma in our region does not differ significantly from those reported for other areas of Spain. Current smoking is the primary cause of the high prevalence of this disease. Twenty-six percent of patients received only palliative care. The percentage of patients treated with surgery was low.

[Use of blood products in patients treated surgically for stage I non-small cell lung cancer]

OBJECTIVE

Retrospective study on the relation between the use of blood products and survival rates in patients treated surgically for stage I non-small cell lung cancer (NSCLC).

PATIENTS AND METHODS

The study included 856 patients who underwent surgical resection from 1969 to 2000 for stage I NSCLC, classified histologically according to the current guidelines of the Spanish Society of Pulmonary and Thoracic Surgery (SEPAR). Patients who died in the postoperative period were excluded from the study. A series of clinicopathological variables were recorded, including the perioperative use or not of blood products. Descriptive, univariate, and multivariate statistical analyses were performed. Follow up concluded in December of 2003.

RESULTS

One hundred twenty-five patients (14.6%) underwent a perioperative transfusion. A significant association was found between the use of blood products and tumor size (P<.001), pneumectomy (P<.001), and cell type (P<.05). The respective 2, 5, and 10-year survival rates were 78%, 63%, and 54% for the nontransfusion group, and 73%, 59%, and 46% for the transfusion group. Both survival curves were compared and no significant differences were found (P=.23). Multivariate regression analysis included tumor size, patient age, and histologic cell type (squamous cell carcinoma or not); no relation between transfusion and survival was found.

CONCLUSIONS

In our series, we found no difference in survival rates for patients with stage I NSCLC after perioperative blood transfusion.

[T2N1M0 non-small cell lung cancer: surgery and prognostic factors]

OBJECTIVE

To determine the prognostic factors for the survival in a group of patients operated on for a non-small cell lung cancer classified as T2N1M0.

PATIENTS AND METHODS

Two hundred sixteen patients treated exclusively with surgery were studied. Kaplan-Meier survival and Cox multivariable regression analyses were used.

RESULTS

The overall survival rate was 39.8% at 5 years and 29.9% at 10 years. Sex, age, presence or absence of symptoms, type of resection, number, and location of affected lymph nodes had no effect on survival. Tumor size (P=.04) and histologic type (P=.03) did significantly affect prognosis. Both variables entered into the Cox multivariable regression model.

CONCLUSIONS

Patients operated on for non-small cell lung cancer classified as T2N1M0 have an overall probability of 5-year survival of approximately 40%. However, the prognosis for this group of patients is heterogeneous: in our study it was affected by the histologic type (45.5% for squamous cell and 25% for non-squamous cell cancers) and tumor size (53% for tumors with a diameter of <or=3 cm, 45% for tumors between 3.1 and 5 cm, and 29% for a tumor diameter >5 cm).

Transbronchial Needle Aspiration of Diseased Mediastinal Lymph Nodes: Predictors of Positive Findings

OBJECTIVE

To assess the factors that may determine the effectiveness of transbronchial needle aspiration through a flexible bronchoscope in the diagnosis of diseased mediastinal lymph nodes in patients with lung or extrapulmonary tumors.

METHODS

Prospective study carried out at 2 hospitals between 1998 and 2004 that included all transbronchial needle aspirations performed on patients who had diseased mediastinal lymph nodes larger than 10 mm and nonlymphoid neoplasms. Univariate and multivariate analysis of the diagnostic results of transbronchial needle aspiration were performed according to the type and location of the primary neoplasm and the lymph node station biopsied, the diameter of the affected node, endoscopic findings, and the results of other bronchoscopic techniques.

RESULTS

The study evaluated the transbronchial needle aspiration of 230 lymph node stations in 207 patients. Histologic examination revealed 151 cases (72.9%) of non-small cell lung cancer, 42 cases (20.3%) of small cell lung cancer, and 14 cases (6.8%) of extrapulmonary cancer. The best predictors of obtaining a diagnostic sample were a diameter of the diseased node greater than 20 mm in diameter (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.2-4.7; P=.01) and a histologic diagnosis of small cell lung cancer (OR, 2.7; 95% CI, 0.9-8.2; P=.07).

CONCLUSIONS

The size of the diseased node and the tumor type are the best predictors of obtaining a diagnostic sample with transbronchial needle aspiration of diseased mediastinal lymph nodes in patients with lung or extrapulmonary tumors.

Complete resection in lung cancer surgery: proposed definition

OBJECTIVE

To propose an internationally accepted definition of complete resection in lung cancer surgery.

MATERIAL AND METHODS

The International Association for the Study of Lung Cancer (IASLC) Staging Committee created the Complete Resection Subcommittee in 2001 to work on an international definition of complete resection in lung cancer surgery. The previous definitions of complete resection and the rules of the International Union Against Cancer regarding the TNM residual tumor classification, together with a thorough review of the pertinent literature, and the input of the members of the IASLC Staging Committee were considered in order to get an international consensus on the definition of complete resection in lung cancer surgery.

RESULTS

Complete resection requires all of the following: free resection margins proved microscopically; systematic nodal dissection or lobe-specific systematic nodal dissection; no extracapsular nodal extension of the tumor; and the highest mediastinal node removed must be negative. Whenever there is involvement of resection margins, extracapsular nodal extension, unremoved positive lymph nodes or positive pleural or pericardial effusions, the resection is defined as incomplete. When the resection margins are free and no residual tumor is left, but the resection does not fulfill the criteria for complete resection, there is carcinoma in situ at the bronchial margin or positive pleural lavage cytology, the term uncertain resection is proposed.

CONCLUSION

The proposed definitions of complete, incomplete and uncertain resections are clear and reproducible in an international setting to study their prognostic impact prospectively.

[Non-small cell bronchogenic cancer in stage IA: mortality patterns after surgery]

OBJECTIVE

To determine the causes of death in patients treated surgically for nonsmall cell lung cancer (NSCLC) in stage IA and to evaluate the impact on survival of not performing systematic lymph node dissection and of the number of nodes resected.

PATIENTS AND METHODS

The study sample consisted of 156 patients operated on for NSCLC and classified in stage IA according to TNM staging. Only palpable or visible lymph nodes were dissected. Kaplan-Meier survival curves were compared using a log-rank test.

RESULTS

At the end of the study, 85 (54.5%) patients had died, 67 (42.9%) were alive, and 4 (2.5%) were lost to follow up. Twenty-three (14.7%) died from a recurrence of NSCLC: 2 with local tumors (1.2%), 2 with mediastinal node involvement (1.2%), and 19 (12.1%) with distant metastasis. The cause of death was unrelated to NSCLC in 62 (39.7%) cases: 33 (21.1%) had a new tumor, 18 of which were bronchogenic, and 29 (18.5%) had nonmalignant disease. The 5-year survival rate was 81.4%. The rate was 88.9% among patients from whom no lymph nodes were excised and 79.9% among those with node excision, although the difference was not statistically significant (P=.4073).

CONCLUSIONS

Our experience suggests that neither the fact of not performing systematic lymph node dissection nor the number of nodes resected has an impact on survival. A substantial number of patients died of causes unrelated to the NSCLC for which they had been treated.

[Lung cancer risk in shoe manufacturing]

OBJECTIVE

Workers in shoe manufacturing have been reported to be at a greater relative risk for bronchogenic carcinoma. Given the implications for our practice setting, we carried out a study to a) clarify whether working in shoe manufacturing is a risk factor for lung cancer and b) detect histological differences between lung cancers in shoe manufacturers and in other lung cancer patients.

PATIENTS AND METHODS

This case-control study compared all lung cancer patients diagnosed in Hospital Elda, Alicante, Spain, between January 1994 and December 1999, with a control group composed of patients admitted to the same hospital for accidental fractures. Information on occupational history and tobacco dependency was collected from all patients by telephone questionnaire.

RESULTS

One hundred and ninety-one case patients and 192 control patients were included in the study; 52 of the cases (27.2%) and 48 controls (25%) worked in shoe manufacturing. No statistically significant differences were found between the 2 groups, not even when we limited the cases and controls to only those who had worked more than 30 years in shoe manufacturing or when we analyzed only subjects who had had especially high risk occupations. No differences in tumor histology were found between cancer patients who worked in shoe manufacture and those who did not.

CONCLUSIONS

Working in shoe manufacturing has not proven to be a risk factor for bronchogenic carcinoma.

[Evolution of lung cancer in the North of the province of Castellón, Spain, 1993-2002]

OBJECTIVE

To investigate the changes in lung cancer incidence, histological type, and survival in patients in the north of the province of Castellón, Spain, during a follow-up period of 10 years, and to compare the findings with other national and international studies.

PATIENTS AND METHOD

All patients diagnosed with lung cancer between January 1, 1993 and December 31, 2002 were included in this prospective, observational study. Disease was confirmed by biopsy or suspected from clinical, radiological, and/or bronchoscopic findings.

RESULTS

In the study period, 271 patients were diagnosed with lung cancer (239 men and 32 women), with a mean (SD) age of 66.8 (11.8) years. The age-adjusted incidence rate standardized to the world population was 20.42 cases per 100,000 population. Smokers or ex-smokers comprised 88.1% of the study population, and 72.6% of patients were over 60 years old. Biopsy confirmation was obtained in 262 cases (96.7%). Squamous cell carcinoma predominated (46.5%) but the proportion of adenocarcinoma increased (23.6%). Surgery was possible in only 22% of the patients. Mean overall 5-year survival was 15.7 months.

CONCLUSIONS

In the north of the province of Castellón, the incidence of lung cancer continues to increase in men but has decreased slightly in women. Squamous cell carcinoma is the most common type, but the incidence of adenocarcinoma has clearly increased. Overall, survival did not improve during the 10 years of follow up despite advances in treatment.

[Stage I nonsmall cell lung cancer up to 3 cm in diameter. Prognostic factors]

OBJECTIVE

To assess the prognostic value of a series of clinicopathological variables in stage I nonsmall cell lung cancer, for tumors up to 3 cm in diameter.

PATIENTS AND METHOD

The study included 271 patients. Survival was analyzed with the Kaplan-Meier method. The Cox model was used for multivariate analysis.

RESULTS

Five- and ten-year survival were 78.63% and 67.59%, respectively. Survival did not significantly depend on sex, age, extent of resection, histology, visceral pleural invasion, level of bronchial invasion or T1 versus T2. The decade in which resection was performed did affect survival (P=.0037). Five-year survival was 58% for operations between 1970 and 1980, 77% for operations between 1981 and 1990, and 84% for operations between 1991 and 2000. Tumor size also affected survival (P=.0046), which was 86% for patients with tumors of less than or equal to 2 cm in diameter and 73% for those with tumors of more than 2 cm in diameter. In the multivariate analysis both variables entered into regression, remaining predictive of survival.

CONCLUSION

We found evidence for a prognostic stage migration (Will Rogers phenomenon) according to the decade in which resection was performed and that tumor size affected survival in our population. Finally, the current system of TNM staging fails in conforming groups of patients with a homogenous prognosis.

[Transbronchial needle aspiration in bronchogenic carcinoma with visible lesions: diagnostic yield and cost]

BACKGROUND

Transbronchial needle aspiration (TBNA) is a bronchoscopic technique whose usefulness in diagnosing endobronchial lesions has not yet been clearly established.

OBJECTIVE

We aimed to determine whether the diagnostic yield of fiberoptic bronchoscopy could be increased, without a negative impact on diagnostic costs, if TBNA were used in combination with conventional diagnostic techniques (bronchial washings and bronchial brushings and forceps biopsy).

PATIENTS AND METHODS

The cases of 130 patients diagnosed with bronchogenic carcinoma with endoscopically visible lesions were analyzed retrospectively. All had undergone conventional diagnostic procedures; TBNA was also performed if the bronchoscopist considered it was indicated. The final cost was calculated in euros for each diagnosis as the sum of the cost of the procedures needed to reach the diagnosis, including both endoscopic procedures and others (transthoracic needle aspiration, lymph node biopsy). Diagnostic yield and costs in cases diagnosed using only conventional techniques were compared to the yield and costs in cases in which both conventional techniques and TBNA were used.

RESULTS

TBNA was performed in 49 patients and provided the diagnosis in 85.7%. Conventional techniques led to cytological and histological diagnosis in 80.2% of the cases, and the combination of conventional techniques and TBNA gave a diagnosis in 89.7% (P=.01). Significant differences were observed in extrinsic compression (conventional 37.5%; conventional+TBNA 100%; P=.01), submucosal infiltration (conventional 54.6%; conventional+TBNA 85%; P=.03), and exophytic mass with necrosis (conventional 80%; conventional+TBNA 100%; P=.01). The mean (SD) cost of diagnosis was euros 381.60 (euros 156.53) using conventional techniques and euros 413.25 (euros 112.91) for conventional techniques in combination with TBNA. By adding TBNA, costs decreased for diagnoses of submucosal infiltration, exophytic mass with necrosis and extrinsic compression, although the saving was significant only for extrinsic compression.

CONCLUSION

The diagnostic yield of TBNA is high for endoscopically visible bronchial anomalies suggesting neoplasm, particularly when the lesion is due to extrinsic compression, submucosal infiltration, or exophytic mass with necrosis.

[Delays in the diagnosis of lung cancer]

OBJECTIVE

To study the clinical and demographic factors associated with delays in the diagnosis of lung cancer.

PATIENTS AND METHODS

A 2-year prospective study of patients admitted to the respiratory medicine ward with a suspected diagnosis of lung cancer. We studied demographic factors, health care received, place of residence, and delays in carrying out diagnostic procedures. The following diagnostic time periods were defined: consultation (from first symptom to first medical visit), middle period (from first medical visit to hospital admission) and diagnostic (from hospital admission to histological diagnosis and clinical staging).

RESULTS

One hundred thirteen patients with a mean age of 65 years (range, 36-90), 103 men and 10 women, were studied. The most frequent symptoms leading to consultation were coughing (10.6%), hemoptysis (19.5%), chest pain (26.5%), and shortness of breath (9.7%). First visits were to a primary care physician for 72%, to the hospital emergency room for 22%, or to a pulmonologist for 6%. Forty-four percent of the patients visited the doctor 2 or 3 times. The mean SD, numbers of days for the different time periods were as follows: consultation, 30.3 60; diagnosis, 18.6 19; middle period 37.9 63. The mean total time from first symptom to diagnosis was 85.7 87 days. The middle period, the time in hospital until diagnosis, and the total time were shorter when patients were referred by the primary care physician to the emergency room or were directly admitted to the hospital (P<.001). Only 25.7% of the staged lung cancers were operable.

CONCLUSIONS

Delays in lung cancer diagnosis are long. The attitudes of primary care physicians and their relations with specialized care providers are crucial for reducing delays.

[Non-small cell lung cancer. Survival after radiotherapy and prognostic factors]

OBJECTIVE

To analyze the results of radiotherapy for non-small cell lung cancer and identify the clinical and therapeutic variables that might influence prognosis.

PATIENTS AND METHODS

In a population base of 109 patients, 87 met the enrollment criteria. The patients received thoracic radiotherapy over the macroscopic tumor volume and lymph drainage areas, using conventional fractions. Systemic cytostatic therapy was also given to 61% of the patients.

RESULTS

Staging was as follows: 33% (28/87) I and II, 20% (18/87) IIIA and 47% (41/87) IIIB. The mean radiotherapy dose was 66.7 Gy (95% CI, 65-67). Full clinical remission was achieved by 22% (18/87), half of whom later suffered recurrences. Partial remission was achieved by 26% (21/87). No response was observed in 52% (42/87). Statistically significant differences in actuarial survival rates were found for staging and tumor response. Mean survival for stages I and II was 29 months (95% CI, 19-39), for IIIA it was 22 (95% CI, 16-28) months, and for IIIB 16 months (95% CI, 12-20). The most common complications were cutaneous, esophageal and pulmonary, with a low incidence of grade 3 toxicity (less than 3%) and absence of grade 4.

CONCLUSIONS

No differences in survival were observed for age, tumor location or histological type. Local control of the disease decisively influenced patient survival.