T2 tumors larger than five centimeters in diameter can be upgraded to T3 in non-small cell lung cancer

Should patients with stage IB non-small cell lung cancer receive adjuvant chemotherapy? A comparison of survival between the 8th and 7th editions of the AJCC TNM staging system for stage IB patients

INTRODUCTION

The aims of this study were to compare the efficacy of platinum-based adjuvant chemotherapy in resected patients with stage IB NSCLC according to the 7th and 8th editions of the American Joint Committee on Cancer (AJCC) staging manuals on tumor, node, and metastasis (TNM) staging systems, respectively.

METHODS

This retrospective analysis included 569 patients who underwent pulmonary resection for primary non-small cell lung cancer. 5-year overall survival (OS) was compared in stage IB disease using the 8th and 7th editions of the TNM classification, respectively. Survival curves were plotted using the Kaplan-Meier method, and log-rank test was used to evaluate differences between subgroups.

RESULTS

The 5-year overall survival was 76.9% and 83.5% (p = 0.044) for patients in the observation and adjuvant groups, respectively. The presence of adjuvant chemotherapy, lymphovascular invasion, TNM stage, and performance status (PS) were risk factors for OS in univariate analysis. In multivariate analysis, TNM stage [hazard ratio (HR) 5.403, 95% confidence interval (CI) 3.743-7.801, p < 0.001], PS (HR 4.375, 95% CI 2.856-6.703, p < 0.001) and adjuvant chemotherapy (HR 1.476, 95% CI 1.028-2.119, p = 0.035) were risk factors for OS. Subgroup analysis showed that for patients with 8th edition stage IB NSCLC, 5-year OS was 87.6% in the observation group (n = 265) and 82.4% in the adjuvant group (p = 0.021). For patients with 8th edition stage IIA NSCLC, 5-year OS was 48.1% and 87.7% in the observation group and the adjuvant group (p < 0.001), respectively. For patients with an Eastern Cooperative Oncology Group (ECOG) performance status (PS) score of 0, a better 5-year OS was seen in the adjuvant group (79.3% vs 91.6%, p = 0.001) By contrast, for patients with a PS score of ECOG 1, the 5-year OS was significantly improved in the observation group (58.6% vs 17.2%, p = 0.021).

CONCLUSION

The 8th edition of the AJCC staging identified the beneficiary population of platinum-based adjuvant chemotherapy in early-stage NSCLC. Moreover, patients with good PS (ECOG 0) benefited from adjuvant chemotherapy. A large prospective randomized clinical trial is needed to determine the real role of adjuvant chemotherapy in this setting.

Adjuvant Chemotherapy for Patients with T2N0M0 NSCLC

BACKGROUND

Adjuvant chemotherapy improves survival in patients with completely resected stage II and III NSCLC. However, its role in patients with stage IB NSCLC disease remains unclear. We evaluated the role of adjuvant chemotherapy in a large data set of patients with completely resected T2N0M0 NSCLC.

METHODS

Patients with pathologic stage T2N0M0 NSCLC who underwent complete (R0) resection between 2004 and 2011 were identified from the National Cancer Data Base and classified into four groups based on tumor size: 3.1 to 3.9 cm, 4 to 4.9 cm, 5 to 5.9 cm, and 6 to 7 cm. Patients who died within 1 month after their operation were excluded. Survival curves were estimated by the Kaplan-Meier product-limit method and compared by log-rank test.

RESULTS

Among the 25,267 patients who met the inclusion criteria, there were 4996 (19.7%) who received adjuvant chemotherapy. Adjuvant chemotherapy was associated with improved median and 5-year overall survival compared with observation for all tumor size groups. In patients with T2 tumors smaller than 4 cm, adjuvant chemotherapy was associated with improved median and 5-year overall survival in univariate (101.6 versus 68.2 months [67% versus 55%], hazard ratio [HR] = 0.66, 95% confidence interval [CI]: 0.61-0.72, p < 0.0001) and multivariable analysis (HR = 0.77, 95% CI: 0.70-0.83, p < 0.001) as well as propensity-matched score (101.6 versus 78.9 months [68% versus 60%], HR = 0.75, 95% CI: 0.70-0.86; p < 0.0001).

CONCLUSIONS

In patients with completely resected T2N0M0, adjuvant chemotherapy is associated with improved survival in all tumor size groups. The benefit in patients with tumors smaller than 4 cm strongly suggests a role for chemotherapy in this patient population and counters its current status as an exclusion criteria for adjuvant trials.

Surgical Outcome of Video-Assisted Thoracoscopic Surgery vs. Thoracotomy for Primary Lung Cancer >5 cm in Diameter

OBJECTIVES

The indications for video-assisted thoracoscopic surgery (VATS) for advanced-stage lung cancer are expanding, but the criteria vary among institutions. This study compared the minimal invasiveness and oncologic validity of VATS lobectomy and thoracotomy lobectomy for the treatment of large-diameter primary lung cancer.

METHODS

We retrospectively reviewed clinical features and surgical outcomes of 68 patients who underwent anatomical pulmonary resection for primary lung cancer of >5-cm diameter from July 2006 to March 2013. The patients were divided into a VATS group (Group V, n = 35) and a thoracotomy group (Group T, n = 33).

RESULTS

Group V exhibited less intraoperative bleeding (p = 0.012) and had a shorter length of postoperative hospital stay (p = 0.024). The 1- and 5-year overall survival rates were 91.3% and 39.3% in Group V and 84.8% and 56.9% in Group T, respectively (p = 0.48). Multivariate analysis showed that limited lymph node dissection contributed to local recurrence. The extraction bag lavage cytology in Group V revealed that the positivity rate was 35.7%.

CONCLUSIONS

VATS for primary lung cancer of >5-cm diameter is similar to thoracotomy in terms of surgical outcomes. Large tumors must be carefully maneuvered during VATS to prevent cancer cell spillage.

Use of CT to evaluate pleural invasion in non-small cell lung cancer: measurement of the ratio of the interface between tumor and neighboring structures to maximum tumor diameter

PURPOSE

To develop a simple noninvasive technique for evaluating pleural invasion by using routine preoperative computed tomography (CT).

MATERIALS AND METHODS

The institutional review board approved this retrospective study, and written informed consent was obtained for performing the initial and follow-up CT studies. Preoperative CT findings (169 patients with possible pleural invasion) and pathologic diagnoses after surgical resection were evaluated. The length of the interface between the primary tumor and neighboring structures (arch distance) and the maximum tumor diameter were measured on CT images, after which arch distance-to-maximum tumor diameter ratios were calculated. Receiver operating characteristic (ROC) curves were used to analyze the ratios.

RESULTS

Median arch distance-to-maximum tumor diameter ratios for pleural invasion categories (pl1, pl2, pl3) assessed by using the Union Internationale Contre le Cancer TNM staging system were as follows: pl1, 0.206 (25th-75th percentile, 0-0.486); pl2, 0.638 (25th-75th percentile, 0.385-0.830); and pl3, 1.092 (25th-75th percentile, 1.045-1.214) (P < .001 between groups). On the basis of the ROC curves, the cut-off value for invasion was an arch distance-to-maximum tumor diameter ratio of 0.9. When the ratio was greater than 0.9, the sensitivity and specificity for thoracic invasion and area under the ROC curve were 89.7%, 96.0%, and 0.976, respectively, which represents an improvement over values obtained by using conventional criteria (radiologists A and B: 46.7% and 74.2% and 91.3% and 84.8%, respectively).

CONCLUSION

When diagnosing T3 or T4 lung cancer based on arch distance-to-maximum tumor diameter ratios, a higher performance level was achieved than that with use of conventional criteria. Measurement of the ratios is a simple noninvasive technique for evaluating pleural invasion at CT.

A decade of advances in treatment of early-stage lung cancer

Emerging from the past decade, there has been a diversification of options for the treatment of early-stage lung cancer. Video-assisted thoracoscopic surgery is now more widely performed, with oncologic outcomes equivalent to those with open thoracotomy. Although lobectomy remains the standard approach to surgical resection, lesser resections, such as segmentectomy and wedge resection, are considerations for some patients. Advances in surgical, radiation, and medical therapies continue to evolve. Future research questions will focus on comparing long-term outcomes with these modalities, including survival, as well as patient-centered endpoints, such as quality of life.

Gemcitabine plus cisplatin chemotherapy with concurrent para-toluenesulfonamide local injection therapy for peripherally advanced nonsmall cell lung cancer larger than 3 cm in the greatest dimension

Para-toluenesulfonamide (PTS), active ingredient being PTS, is a new anticancer drug applied through local intratumoral injection. The aim of this phase II clinical trial was to investigate the response and toxicity of standard gemcitabine (GEM) plus cisplatin (CIS) chemotherapy with concurrent intratumoral injection of PTS in peripherally advanced nonsmall cell lung cancer. Patients received 1250 mg/m of GEM on day 1, 8, and 75 mg/m of CIS on day 1, every 21 days for four cycles. PTS was injected intratumorally through percutaneous injection under computed tomography guidance on days 5, 12, 15, and 18 of cycle 1, and repeated on days 5 and 12 of cycle 2 if a less than 50% necrotic area was achieved after the first cycle according to the computed tomography scan. Twelve (46.2%) patients had metastatic disease, whereas 14 (53.8%) patients had stage IIIB disease. All 26 patients were assessable for response. Overall response rate by intention-to-treat was 53.8% (95% confidence interval: 34.6-73.0%). Median progression-free survival and overall survival were 6.5 months (95% confidence interval: 3.8-10.2 months) and 14.5 months (10.0-18.0 months), respectively. One-year and 2-year survivals were 57.7 and 22.4%, respectively. The grade 3-4 hematologic adverse events were neutropenia in six patients (23.1%), anemia in three (11.5%), and thrombocytopenia in four patients (15.4%). Nonhematologic toxicities were generally mild and usually not dose-limiting. Although grade 1-2 emesis occurred in nine patients (34.6%), only one had grade 3 vomiting. Grade 1-2 cough, local pain, and peripheral neurotoxocity developed in 12 (46.2%), three (11.5%), and five (19.2%) patients, respectively. There were no treatment-related deaths. GEM/CIS chemotherapy with concurrent PTS local injection therapy is a well-tolerated modality with potential activity in previously untreated peripheral advanced nonsmall cell lung cancer patients.

Analysis of the T descriptors and other prognosis factors in pathologic stage I non-small cell lung cancer in China

BACKGROUND

The seventh edition of the tumor, node, metastasis Classification of Malignant Tumors is due to be published in 2009. The recommendations of International Association for the Study of Lung Cancer for changes to the T descriptors have been published. We combined this new parameter with other well-established prognostic factors and performed multivariate survival analyses to validate its value in Chinese stage I non-small cell lung cancer (NSCLC).

METHODS

We try to validate the new staging project in 325 patients who underwent complete surgical resection for stage I NSCLC in Single Institution of Shanghai Chest Hospital from 1998 to 2003. Variables in the analysis included age, gender, performance status, history of smoking, pathologic type, type of resection (pneumonectomy, lobectomy, and bilobectomy), tumor size (greatest dimension of tumor), T-status (T1 or T2), type of lymph node resection (systematic mediastinal lymphadenectomy or mediastinal lymph node sampling), lymphovascular vessel invasion, and adjuvant chemotherapy.

RESULTS

The 5-year overall survival (OS) of patients whose tumor measured no larger than 2 cm in largest diameter or larger than 2 cm but no larger than 3 cm were 75.49 and 74.58%, respectively. For those with tumors measured larger than 3 cm but smaller than 5 cm or larger than 5 cm but smaller than 7 cm were 60.87 and 55.63%. The 5-year OS of patients whose tumor measured larger than 7 cm was 46.15% (p = 0.025). The 5-year disease-free survival rates of patients whose tumor measured no larger than 2 cm in largest diameter or larger than 2 cm but no larger than 3 cm were 67.65 and 66.67%, respectively. For those with tumors measured larger than 3 cm but smaller than 5 cm or larger than 5 cm but smaller than 7 cm were 53.14 and 52.63%. The 5-year disease-free survival rate of patients whose tumor measured larger than 7 cm was 30.77% (p = 0.009). Multivariate analyses revealed that age, gender, type of resection (pneumonectomy, lobectomy, and bilobectomy), tumor size (greatest dimension of tumor), type of lymph node resection (systematic mediastinal lymphadenectomy or mediastinal lymph node sampling), and lymphovascular vessel invasion were significant predictive factors for OS.

CONCLUSIONS

The tumor size is a significant independent prognostic factors in stage I NSCLC.

Prognostic impact of intratumoral vessel invasion in completely resected pathologic stage I non-small cell lung cancer

OBJECTIVE

Intratumoral vessel invasion of non-small cell lung cancer is a readily available tumor-related factor that provides direct evidence of microscopic tumor invasion. We assessed the prognostic influence of intratumoral vessel invasion and its ability to provide a differential prediction of prognosis for completely resected pathologic stage I non-small cell lung cancer.

METHODS

We analyzed 258 patients with non-small cell lung cancer who underwent complete resection between January of 1996 and December of 2005 and were diagnosed with pathologic stage I disease. In addition to the conventional staging factors, intratumoral vessel invasion in the primary lesion was histologically evaluated by both hematoxylin-eosin and elastic staining. We examined the significance of intratumoral vessel invasion in prognosis and compared the outcomes between patients with and without this factor with stage IA and IB disease, respectively.

RESULTS

Intratumoral vessel invasion was found in 124 patients (48%). Five-year survival of patients with or without intratumoral vessel invasion was 74% and 93%, respectively. On multivariate analysis, intratumoral vessel invasion and pleural invasion were shown to be independent prognostic factors. Subgroup analyses suggested that patients with pathologic-stage IA with intratumoral vessel invasion and patients with pathologic-stage IB with both intratumoral vessel and pleural invasion had significantly worse prognosis than patients with the same pathologic stage without these factors.

CONCLUSION

The current study indicated that intratumoral vessel invasion and pleural invasion are independent prognostic factors. Intratumoral vessel invasion status can complement the size-dependent TNM staging system in pathologic stage I non-small cell lung cancer.

CT, positron emission tomography, and MRI in staging lung cancer

Lung cancer is a common malignancy and remains the leading cause of cancer-related deaths in both men and women in the United States. Imaging plays an important role in the detection, diagnosis, and staging of the disease as well as in assessing response to therapy and monitoring for tumor recurrence after treatment. This article reviews the staging of the two major histologic categories of lung cancer-non-small-cell lung carcinoma (NSCLC) and small-cell lung carcinoma-and emphasizes the appropriate use of CT, MRI, and positron emission tomography imaging in patient management. Also discussed are proposed revisions of the International Association for the Study of Lung Cancer's terms used to describe the extent of NSCLC in terms of the primary tumor, lymph nodes, and metastases descriptors.

The IASLC Lung Cancer Staging Project: validation of the proposals for revision of the T, N, and M descriptors and consequent stage groupings in the forthcoming (seventh) edition of the TNM classification of malignant tumours

INTRODUCTION

In 1996, the International Association for the Study of Lung Cancer (IASLC) launched a worldwide TNM staging project to inform the next edition (seventh) of the TNM lung cancer staging system. In this article, we describe the methods and validation approaches used and discuss the internal and external validity of the recommended changes.

METHODS

The International Staging Committee agreed on a number of general principles that guided the decision-making process. Internal validity was addressed by visually assessing the consistency of Kaplan-Meier curves across database types, geographic regions and addressing external validity, by assessing the similarity of curves generated using the population-based Surveillance Epidemiology and End Results cancer registry data to those generated using the project database. Cox proportional hazards regression was used to calculate hazard ratios between the proposed stage groupings with adjustment for cell type, sex, age, and region.

RESULTS

Calls for data by the International Staging Committee resulted in the creation of an international database containing information on more than 100,000 cases. The present work is based on analyses of the 67,725 cases of non-small cell lung cancer. Validation checks were robust, demonstrating that the suggested staging changes are stable within the data sources used and externally. For example, suggested changes based on tumor size were well supported, with statistically significant hazard ratios ranging from 1.14 to 1.51 between adjacent pairs in the Surveillance Epidemiology and End Results data.

CONCLUSIONS

Lung cancer stage definitions have never been subjected to such an intense validation process. We do accept, however, that this work is limited in ways that can only be addressed by a prospective database, which we intend to develop. In the meantime, we think that this new system will greatly improve the usefulness of TNM lung staging across all of its purposes.

Prognostic significance of the non-size-based AJCC T2 descriptors: visceral pleura invasion, hilar atelectasis, or obstructive pneumonitis in stage IB non-small cell lung cancer is dependent on tumor size

BACKGROUND

The T2 descriptor for staging non-small cell lung cancer (NSCLC) contains several non-size-based criteria. It remains unknown whether the prognostic significance of these non-size-based criteria is dependent on tumor size.

METHODS

A total of 10,545 patients with stage IB NSCLC from the California Cancer Registry between 1989 to 2003 were categorized into the following three nonoverlapping criteria: (1) tumor size (T2S); (2) visceral pleura invasion, hilar atelectasis, or obstructive pneumonitis (T2P); and (3) main bronchus involvement > or = 2 cm from the carina (T2C). Univariate survival analyses were performed using the Kaplan-Meier method. Multivariate survival analyses were performed using Cox proportional hazards ratios.

RESULTS

A total of 51.1% of patients with stage IB NSCLC were staged by T2S, 43.2% by T2P, and 5.7% by T2C; 2,224 stage IB patients (total, 21.1%; 18.9% T2P + 2.2% T2C) had tumors < or = 3 cm in size. The 5-year survival rate and the median survival time of these stage IB patients with tumors < or = 3 cm in size were as follows: T2P, 51.2% and 64 months, respectively; T2C, 49.0% and 58 months, respectively. These values were similar to the 53.2% 5-year survival rate and 67-month median survival time for patients with stage IA NSCLC (p = 0.40). Cox proportional hazards model revealed T2P of > 3 cm was a poor prognostic factor for survival (vs T2S; hazard ratio [HR], 1.16; 95% confidence interval [CI], 1.08 to 1.24). Conversely, T2P < or = 3 cm was a favorable prognostic factor for survival (vs T2S; HR, 0.89; 95% CI, 0.82 to 0.96). T2C was not an independent prognostic factor for survival.

CONCLUSIONS

Prognostic significance of the non-size-based T2 descriptor T2P is dependent on tumor size.

Stage IB nonsmall cell lung cancers: are they all the same?

BACKGROUND

There is renewed interest in adjuvant chemotherapy after complete resection of nonsmall cell lung cancer, including stage IB (T2N0) cancers. Given the heterogeneity of the T2 classification, we hypothesize that there are survival differences in patients with stage IB NSCLC based on specific histopathologic tumor characteristics.

METHODS

A retrospective evaluation of 119 consecutive patients from 1999 to 2004 with a pathologic diagnosis of T2N0 nonsmall cell lung cancer was performed. Patient follow-up was 97%. Overall survival and disease-free survival rates were calculated by the Kaplan-Meier method. Univariate analysis was performed using the log rank test and multivariate analysis by Cox's proportional hazard model. Data were significant if p < 0.05.

RESULTS

The 4-year overall survival and disease-free survival rates were 62% and 60%, respectively. The local and distant recurrence rates were 5% and 18%, respectively. Tumor size (p = 0.001), histologic grade (p = 0.002), the Eastern Cooperative Oncology Group performance status (p = 0.002), angioinvasion (p = 0.03), and visceral pleural involvement (p = 0.02) were predictors of overall survival by univariate analysis. Multivariate analysis demonstrated increasing tumor size (1.26 [95% confidence intervals 1.12, 1.64]) and histologic grade (4.05 [95% confidence intervals 1.38, 11.90]) to be significant independent predictors of a worse overall survival. The 4-year survival of patients without any of these variables was 89% compared with 56% if one or more of these factors were present (p = 0.03).

CONCLUSIONS

There is significant heterogeneity in the T2N0 class of nonsmall cell lung cancer. Risk stratification using specific histopathologic variables may help determine which patients will benefit most from adjuvant therapy.

The IASLC Lung Cancer Staging Project: proposals for the revision of the T descriptors in the forthcoming (seventh) edition of the TNM classification for lung cancer

PURPOSE

To propose changes in the seventh revision of the tumor, node, metastasis (TNM) classification for lung cancer.

METHODS

Data on 100,869 patients were submitted to the international database, and data for 18,198 of these patients fulfilled the inclusion criteria for the T component analysis. Survival was calculated for clinical and pathologic T1, T2, T3, T4NOMO completely resected (R0), and for each T descriptor. A running log-rank test was used to assess cutpoints by tumor size. Results were internally and externally validated.

RESULTS

On the basis of the optimal cutpoints, pT1NOR0 was divided into pT1a < or =2 cm (n = 1816) and pT1b >2 to 3 cm (n = 1653) with 5-year survival rates of 77 and 71% (p < 0.0001). The pT2NOR0 cutpoints resulted in pT2a >3 to 5 cm (n = 2822), pT2b >5 to 7 cm (n = 825), and pT2c >7 cm (n = 364). Their 5-year survival rates were 58, 49, and 35% (p < 0.0001). For clinically staged N0, 5-year survival was 53% for cT1a, 47% for cT1b, 43% for cT2a, 36% for cT2b, and 26% for cT2c. pT3NO (n = 711) and pT4 (any N) (n = 340) had 5-year survival rates of 38 and 22%. pT4 (additional nodule(s) in the same lobe) (n = 363) had a 5-year survival rate of 28%, similar to pT3 (p = 0.28) and better than other pT4 (p = 0.0029). For pM1 (ipsilateral pulmonary nodules) (n = 180), 5-year survival was 22%, similar to pT4. For cT4-malignant pleural effusion/nodules, 5-year survival was 2%.

CONCLUSION

Recommended changes in the T classification are to subclassify T1 into T1a and T1b, and T2 into T2a and T2b; and to reclassify T2c and additional nodule(s) in the same lobe as T3, nodule(s) in the ipsilateral nonprimary lobe as T4, and malignant pleural or pericardial effusions as M1.

The Rationale for Adjuvant Chemotherapy in Stage I Non-small Cell Lung Cancer

The past decade has witnessed renewed interest in studies exploring the benefits of adjuvant (postoperative) chemotherapy (+/- radiation therapy) in patients with resected non-small cell lung cancer (NSCLC). Recently completed adjuvant trials have included a heterogeneous group of patients with resected stages I to IIIA NSCLC. With rare exception, the published results of these studies indicate adjuvant chemotherapy imparts a significant overall survival advantage. Subset analyses suggest survival benefit occurs primarily in patients with resected stage II or IIIA and is less likely to occur in stage I patients. This apparent lack of survival benefit in stage I patients was seemingly validated in a prospective trial conducted by the Cancer and Leukemia Group B in which stage IB patients were randomized to observation or adjuvant carboplatin and paclitaxel. Survival at 5 -years was identical in the two arms of this trial. By contrast, two contemporary postoperative chemotherapy trials also conducted exclusively in stage I NSCLC patients yielded positive survival results. The divergent outcome of the prospective trials along with the negative subset analyses has created uncertainty as to the utility of postoperative adjuvant chemotherapy in stage I NSCLC. Herein we review the data underlying this controversy and offer a proposed algorithm to aid the clinician in selecting patients whom we believe may benefit from adjuvant chemotherapy. The treatment algorithm is based on currently available tumor- and host-related factors that affect prognosis.

Clinical predictors of metastatic disease to the brain from non-small cell lung carcinoma: primary tumor size, cell type, and lymph node metastases

PURPOSE

To retrospectively assess possible clinical predictors of metastatic disease to the brain in patients with non-small cell lung carcinoma (NSCLC).

MATERIALS AND METHODS

Institutional review board approval was obtained, informed consent was waived, and data and other information were obtained prior to implementation of HIPAA. A review was performed of 264 patients (mean age, 65 years; 158 men and 106 women) with NSCLC who had undergone imaging studies of the chest and head. Hierarchical logistic regression was used to determine the predicted probability of metastatic disease to the brain as a function of patient age and sex and of size, cell type, peripheral versus central location, and lymph node stage of the primary NSCLC.

RESULTS

Ninety-five (36%) patients had evidence of metastatic disease to the brain. Mean diameter of the primary tumors was 4.0 cm +/- 2.2 (standard deviation). Cell types included adenocarcinoma (136 [52%] patients), undifferentiated (68 [26%] patients), and squamous (47 [18%] patients), for which metastatic disease to the brain occurred in 43%, 41%, and 13% (P = .003) of patients, respectively. The predicted probability of metastatic disease to the brain correlated positively with size of the primary tumor (P < .001), cell type (adenocarcinoma and undifferentiated vs squamous, P = .001), and lymph node stage (P < .017) but did not correlate with age, sex, or primary tumor location. For primary adenocarcinoma without lymph node spread, the predicted probabilities of metastatic disease to the brain from 2- and 6-cm primary tumors were .14 (95% confidence interval: .06, .27) and .72 (95% confidence interval: .48, .88), respectively (P < .02).

CONCLUSION

The probability of metastatic disease to the brain from primary NSCLC is correlated with size of the primary tumor, cell type, and intrathoracic lymph node stage.

Prognostic assessment after surgical resection for non-small cell lung cancer: experiences in 2083 patients

The importance of the TNM staging system for patient management, clinical research and communicating information about lung cancer is of international importance. Modifications of the TNM classification system is scheduled for the near future. A retrospective review of 2376 patients with primary non-small cell lung cancer treated in a monocentric institution between 1996 and 2005 was performed. The overall 5-year survival rate was 46.8%. A total of 2083 patients had complete resections with a 5-year survival of 50.7%. After complete resection the 5-year survival rates by pathological stage of the disease were as follows: 68.5% for IA, 66.6% for IB, 55.3% for IIA, 49.0% for IIB, 35.8% for IIIA, 35.4% for IIIB, and not defined (3-year survival: 33.1%) for IV. The difference in prognosis between stage IIB and IIIA was significant (p=0.001) there was no significant difference between IA and IB, between IB and IIA, between IIA and IIB, between IIIA and IIIB, or between IIIB and IV. In stage IV there was a significant difference in survival between patients with pulmonary metastases or distant extrapulmonary metastases (p=0.001). In multivariate analysis, we also found gender and histology to be independent significant prognostic factors for survival. Multiple factors influence the long-term survival of patients with non-small cell lung cancer after surgical resection. The present stage related prognosis seems to characterize patient prognosis and outcome reliable. For further data review there should be a focus on stage IV disease.

The prognostic impact of tumor size in resected stage I non-small cell lung cancer: Evidence for a two thresholds tumor diameters classification

PURPOSE

The current TNM staging system for non-small cell lung cancer subdivides stage IA and IB according to a tumor size threshold of 3 cm. Some authors have suggested that tumor size behaves as a continuous, but the optimal diameter thresholds to be adopted remain debated.

METHODS

We conducted a retrospective study on 548 patients who underwent a complete surgical resection at our institute for stage IA and IB non-small cell lung cancer according to the current TNM staging system. Univariate and multiaviate analysis of overall and disease-specific survival were performed.

RESULTS

Stage IA had an overall 5 years survival of 67% and a 5 years disease-specific survival of 85%. Stage IB had an overall 5 years of 49% and 5 years disease-specific survival of 53%. Tumors <2 cm had a significantly better survival than tumors > or =2 cm (overall survival: p=0.007; disease-specific survival: p=0.026), as well as tumors ranging from 2 to 5 cm in comparison with larger ones (overall survival: p=0.031; disease-specific survival: p=0.013). No significant difference was found between groups ranging from 2 to 5 cm. Tumors of 2-5 cm had 57% higher probability of death in comparison with tumors <2 cm and tumors >5 cm had a probability of death 60% higher than tumor of 2-5 cm. Age and tumor size (two thresholds diameter classification) resulted independent variables at multivariate analysis.

CONCLUSION

the definition of T factor in the staging system of non-small cell lung cancer should consider two cutoffs according to tumor size. Two and 5 cm represent appropriate thresholds diameters that define subgroups with significant different prognosis.

Surgical Results in T2N0M0 Nonsmall Cell Lung Cancer Patients With Large Tumors 5 cm or Greater in Diameter: What Regulates Outcome?

BACKGROUND

We assessed the surgical results along with the clinical and biological features of nonsmall-cell lung cancer (NSCLC) patients with localized large tumors.

METHODS

The study population consisted of 86 NSCLC patients who underwent complete resection of tumors 5 cm or larger in diameter in stage IB (T2N0M0). We immunohistochemically assessed the expression of angiostatin and endostatin.

RESULTS

The median tumor size was 6.0 cm (range, 5 to 14 cm). The operative procedures used were lobectomy in 71 cases, bilobectomy in 8 cases, and pneumonectomy in 11 cases. Fifty patients (58.1%) relapsed during the mean follow-up period of 33.6 +/- 4.5 months. The median disease-free interval was 9 months. Of 44 recurrent patients whose disease-free interval could be identified, 25 patients (56.8%) relapsed within 12 months after the operation. The overall 5- and 10-year survival rates were 42.0% and 24.2%, respectively. Multivariate analysis showed that the degree of pleural involvement and angiostatin expression within the tumor were independent prognostic indicators. The endostatin expression within tumors also had a weaker relationship with outcome.

CONCLUSIONS

Long-term surgical results were poor and early relapse was common in this cohort. In addition to pleural involvement, the tumor-induced expression of angiostatin and endostatin merit further investigation to gain possible insights into selection of patients who will benefit from surgery as the first line treatment.

How should the TNM staging system for lung cancer be revised? A simulation based on the Japanese Lung Cancer Registry populations

OBJECTIVE

The 1997 version of the TNM staging system for lung cancer has several prognostic problems. Among these, the overlapping survival of stages IB and IIA is the most serious. We performed this retrospective study to test a revised TNM staging system for lung cancer.

METHODS

We revised the T1 descriptor definition and stage grouping for testing as follows. According to the greatest tumor diameter, T1 tumors were divided into T1a tumors (< or =2.0 cm) and T1b tumors (2.1-3.0 cm). With these descriptors, new IA, IB, and IIA stages were defined as T1a N0 M0, T1b N0 M0, and T2 N0 M0 + T1 N1 M0, respectively. For 6644 patients with histologically non-small cell lung cancers resected in 1994 and reported in the Japanese Lung Cancer Registry Study, the survivals and prognostic difference between neighboring stages were studied.

RESULTS

The 5-year survival of the entire population was 52.6%. In the clinical setting, the 5-year survivals of the new IA, new IB, new IIA, IIB, IIIA, IIIB, and IV stages were 77.5%, 69.3%, 49.8%, 40.6%, 35.8%, 28.0%, and 20.8%, respectively. In the pathologic setting, they were 83.7%, 76.0%, 60.0%, 42.2%, 29.8%, 19.3%, and 20.0%, respectively. For both clinical and pathologic settings, differences between all neighboring stages were statistically significant, except for that between IIIB and IV.

CONCLUSION

Subcategorization of T1 and minor changes in stage grouping results in a system with significant differences in prognosis between neighboring stages. The unification of stages IB and IIA, especially, improves the discriminatory power of the staging system.

Relationship of tumor size to survival in patients with pT2N0 lung cancer

Lung cancer extending beyond 3 cm in diameter without lymph node or distant metastasis is defined as T2. The purpose of this study was to analyze the prognosis based on tumor size for patients with resected T2N0M0 non-small cell lung cancer. The 268 patients who underwent complete resection of a lung tumor > 3 cm in diameter were reviewed retrospectively. They were divided into 3 groups based on tumor size: 3-5 cm, > 5-7 cm, and > 7 cm. There were significant differences in the 5-year survival rates of 61.4%, 47.9%, and 21.9% in each group, respectively. In the two subgroups with tumor sizes 3-4 cm and > 4 cm, the 5-year survival was 63.8% and 48.1%, respectively. Tumors > 4 cm in diameter indicate a poor long-term prognosis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Survival of 2,991 Patients With Surgical Lung Cancer

OBJECTIVE

To evaluate the current staging system of lung cancer, taking into account different selection criteria for the studied population.

POPULATION

A total of 2,991 consecutive patients with surgical lung cancer were prospectively compiled from 19 Spanish hospitals (Bronchogenic Carcinoma Cooperative Group of the Spanish Society of Pneumology and Thoracic Surgery) between 1993 and 1997.

METHODS

The Kaplan-Meier method was used to calculate survival at 5 years (S5) for each pathologic stage, and the log-rank test was used for comparison purposes. These studies were performed in the total group (population 1, n = 2,972); excluding operative mortality and small cell lung cancer cases (population 2, n = 2,697); excluding cases with induction therapy (population 3, n = 2,542); excluding cases with exploratory thoracotomy (population 4, n = 2,304); and, lastly, excluding cases with incomplete resection (population 5, n = 2082) [70% of the initial population].

RESULTS

The global S5 was similar in populations 1, 2, and 3: 34% (95% confidence interval [CI] 32 to 36%), 37% (95% CI, 35 to 39%), and 38% (95% CI, 35 to 39%), but different from that of populations 4 and 5: 40% (95% CI, 39 to 43%) and 43% (41 to 45%), respectively. For pathologic stage I, pathologic stage II, and pathologic state IIIA (pIIIA), S5 was similar in the five reported populations. In pathologic stage IIIB (pIIIB), there were differences in S5 between populations 1, 2, and 3 (13 to 15%; 95% CI, 10 to 19%) and populations 4 and 5 (26 to 29%; 95% CI, 19 to 38%). In population 4, there was no significant prognostic difference between two specific stage groups, that is between pathologic stage IB (pIB) and pathologic state IIA (pIIA) [p = 0.70] and between pIIIA and pIIIB (p = 0.79); the pathologic T3N2M0 combination has a S5 (13%) lower than that for pIIIB (26%).

CONCLUSION

The definition of the population that constitutes the denominator for the analysis of survival in surgical lung cancer is important in pIIIB. The inclusion or exclusion of cases without resection is the most important factor for the selection of such population. This study detected that there are no prognostic differences between pIB and pIIA, and between pIIIA and pIIIB.

Prognosis of 6644 resected non-small cell lung cancers in Japan: a Japanese lung cancer registry study

For the scheduled future revision of the TNM staging system for lung cancer, it is important that the present 1997 version be evaluated in a large population. In 2001, the Japanese Joint Committee of Lung Cancer Registry sent a questionnaire to 320 Japanese institutions regarding the prognosis and clinicopathological profiles of patients who underwent the resection for primary lung neoplasms in 1994. We compiled the data for 7408 patients from 303 institutions (94.7%). Among these, 6644 patients with non-small cell histology were studied in terms of prognosis. The 5-year survival rate of the entire group was 52.6%. The 5-year survival rates by clinical (c-) stage were as follows: 72.1% for IA (n = 2423), 49.9% for IB (n = 1542), 48.7% for IIA (n = 150), 40.6% for IIB (n = 746), 35.8% for IIIA (n = 1270), 28.0% for IIIB (n = 366) and 20.8% for IV (n = 147). The difference in prognosis between neighboring stages was significant except for between IB and IIA and between IIIB and IV. The 5-year survival rates by pathological (p-) stage were as follows: 79.5% for IA (n = 2009), 60.1% for IB (n = 1418), 59.9% for IIA (n = 232), 42.2% for IIB (n = 757), 29.8% for IIIA (n = 1250), 19.3% for IIIB (n = 719) and 20.0% for IV (n = 259). The difference in prognosis between neighboring stages was significant except for between IB and IIA and between IIIB and IV. The survival curves of stages IB and IIA were almost superimposed in both c- and p-settings. These findings indicated that the present stages IB and IIA should be merged into the same stage category. Otherwise, the present TNM staging system seemed to well characterize the stage-specific prognosis in non-small cell lung cancer. The future revision should focus on the subdivision of stages I and II.

Impact of Large Tumor Size on Survival After Resection of Pathologically Node Negative (pN0) Non–Small Cell Lung Cancer

BACKGROUND

The current TNM staging system first adopted the tumor size of 3 cm for subdivision of stage I and II disease. The aim of the present study was to evaluate the impact of tumor size on survival in patients with pathologically node negative (pN0) non-small cell lung cancer after complete resection.

METHODS

We retrospectively reviewed the records of 603 patients with pN0 non-small cell lung cancer patients (403 men and 200 women) who underwent a complete resection in five national chest hospitals between 1992 and 1996, with follow-up duration of more than 5 years, and analyzed tumor size and survival. Survival rate was estimated by the Kaplan-Meier method, and differences were compared by log-rank test. For the multivariate analysis, the Cox proportional hazard model was used to identify variables that significantly affected survival.

RESULTS

There were 355 adenocarcinomas, 208 squamous cell carcinomas, and 40 large cell carcinomas completely resected. No significant prognostic differences were seen among three groups with smaller-sized tumors (< or =2 cm [n = 171], 2.1 to 3 cm [n = 202], and 3.1 to 5 cm [n = 170]); however, patients with a tumor size greater than 5 cm (n = 60) showed a significantly worse prognosis. The 5-year survival rates were 79.6%, 72.7%, 68.1%, and 46.6%, respectively, in these four groups. Multivariate analysis showed the tumor size to be an independent prognostic predictor in patients with pN0 tumors.

CONCLUSIONS

We found that a tumor size of greater than 5 cm was an independent prognostic predictor in pN0 disease; therefore, upgrading the T factor of tumor diameter to greater than 5 cm may be necessary in the next reversion of the TNM staging system.

The effect of tumor size on curability of stage I non-small cell lung cancers

OBJECTIVE

The objective of this study was to determine the relationship between tumor size and curability of stage I non-small cell lung cancer.

METHODS

From the Surveillance, Epidemiology, and End Results registry 2003, we identified all primary non-small cell lung cancer cases that were diagnosed prior to autopsy. Among these cases, we narrowed the focus to those diagnosed in 1988 or later, and to 7,620 patients who had undergone curative surgical resection. Kaplan-Meier survival curves were obtained for these stage I malignancies for five tumor size categories (ie, 5 to 15 mm, 16 to 25 mm, 26 to 35 mm, 36 to 45 mm, and > 45 mm). The 12-year Kaplan-Meier estimator of survival was used as a measure of lung cancer cure rate.

RESULTS

Among 7,620 stage I cancers, cure rates decreased with increasing tumor size. The 12-year survival rates for patients with tumors 5 to 15 mm in diameter was 69% (95% confidence interval [CI], 64 to 74%), 63% for those with tumors 16 to 25 mm in diameter (95% CI, 60 to 67%), 58% for those with tumors 26 to 35 mm in diameter (95% CI, 54 to 61%), 53% for those with tumors 36 to 45 mm in diameter (95% CI, 48 to 57%), and 43% for those with tumors > 45 mm in diameter (95% CI, 39 to 48%). Cure rates were statistically significantly different for all tumor size categories (p < 0.05) except for the groups with tumors 26 to 35 mm and 36 to 45 mm in diameter (p = 0.10).

CONCLUSIONS

Smaller tumor size at diagnosis is associated with improved curability within stage I non-small cell lung cancers. These results suggest that further subclassification by size within stage I may be important.

[Prognostic indicators in stage I non-small cell lung cancer]

INTRODUCTION

Determinating the prognosis of patients with stage I non-small cell lung cancer (NSCLC) is a challenge. Since up to 30% of patients who have undergone surgical resection experience recurrence, generally in distant organs, it is reasonable to postulate that neo-adjuvant or adjuvant treatments might be useful. Better knowledge of prognostic factors could perhaps define which patient populations should be targeted with such treatments.

STATE OF THE ART

Numerous potential prognostic factors, relating to the disease (TNM classification, histology, tumor size, blood vessels invasion, micro-metastasis, serum or molecular markers), the patient (gender, age, co-morbidity) as well as the treatment (delay, resection, lymph node dissection, neo-adjuvant and adjuvant treatments), are discussed.

PERSPECTIVES

These prognostic factors should be integrated into the design of future clinical trials of chemotherapy and/or radiotherapy attempting to evaluate the effectiveness of various combinations of neo-adjuvant or adjuvant therapies.

CONCLUSIONS

These factors may offer the opportunity to clinically and biologically characterize the different subgroups of patients, leading to a more rational, and perhaps individualized, choice of therapy.

Visceral pleural involvement in nonsmall cell lung cancer: prognostic significance

BACKGROUND

A tumor of any size that invades the visceral pleura is classified in the T2 category; however, the definition of the visceral pleural involvement has remained somewhat ambiguous. It is unclear whether the T2 category includes the p2 status alone or incorporates the extent of the p1 status.

METHODS

We retrospectively analyzed the survival of 474 patients with T1 and T2 nonsmall cell lung cancer to evaluate the influence of the degree of visceral pleural involvement (p0, p1, and p2) on the prognosis and to clarify the definition of the visceral pleural involvement.

RESULTS

The 5-year survival rates according to the degree of visceral pleural involvement were 68.0% in p0 (n = 345), 43.9% in p1 (n = 110), and 54.9% in p2 (n = 19; p0 versus p1, p = 0.0004; p0 versus p2, p = 0.013; and p1 versus p2, p = 0.61). The degree of visceral pleural involvement (p0 versus p1/p2) was a significant independent prognostic factor from tumor size and lymph node involvement, by multivariate analysis (relative risk = 1.47, p = 0.033). The prognosis of pN0 patients with p1 and tumor size 3 cm or less was significantly poorer than that of those with p0 and tumor size 3 cm or less (p = 0.0004), and the prognosis of patients with p1 and tumor size more than 3 cm was significantly poorer than that of those with p0 and tumor size more than 3 cm (p = 0.024).

CONCLUSIONS

The degree of visceral pleural involvement (p0 versus p1/p2) is an important component of the lung cancer staging system. Tumors with p1 and p2 status should be regarded as representing visceral pleural involvement and T2 disease.