SURGICAL TREATMENT OF CARCINOMA OF THE BRONCHUS

Lymph node type as a prognostic factor for survival in T2 N1 M0 non-small cell lung carcinoma

BACKGROUND

Patients with stage II non-small cell lung carcinoma represent a group with varying 5-year survival rates. The influence of specific types of lymph node involvement on survival was investigated.

METHODS

Of 2,009 patients operated on from 1977 through 1993, the cases of 391 patients with pathologic T2 N1 M0 disease were reviewed. The N1 status was refined into lymph node involvement by direct extension or by metastases in lobar or hilar lymph nodes.

RESULTS

The cumulative 5-year survival rate of all hospital survivors (n = 369) was 37.8%. The 5-year survival rate of patients with lobar metastases was superior to that of patients with hilar metastases (57.3% versus 30.3%; p = 0.0028) and that of patients with lymph node involvement by direct extension (57.3% versus 39.1%; p = 0.03). The survival rate did not differ between those with hilar metastases and those with direct extension. Survival was significantly poorer in patients with visceral pleural involvement, in patients with adenocarcinoma, and in patients older than 60 years. Survival was not related to sex, type of resection, central growth, or tumor size.

CONCLUSIONS

Survival differs according to the type of lymph node involvement: lobar lymph node metastasis seems to be an early stage of the disease, whereas hilar lymph node metastasis represents a more advanced form. However, in T2 N1 M0 disease, other factors besides nodal status also seem to play an important role in postoperative survival.

Type of lymph node involvement influences survival rates in T1N1M0 non-small cell lung carcinoma. Lymph node involvement by direct extension compared with lobar and hilar node metastases

Stage II non-small cell lung cancer represents a group of patients with varying 5-year survival rates. Of 2,009 patients, we reviewed 58 patients with pT1N1M0 disease operated on from 1977 through 1994. The N1 status was refined into lymph node involvement by direct extension and/or involvement by metastases (lobar or hilar). The cumulative 5-year survival of all hospital survivors (n = 57) was 45.7%. The 5-year survival of patients with N1 direct extension was superior to survival of patients with N1 metastases (68.6% vs 31.2%; p = 0.0038). Survival of patients with N1 direct extension was better then survival of patients with N1 hilar metastases (p = 0.0006), but did not differ from survival of patients with lobar metastases. Survival was not related to histologic features, sex, and type of resection. Recurrence of malignancy occurred less in patients with N1 direct extension. In patients with N1 hilar nodes, the most common pattern was distant metastases. Survival differs according to the type of lymph node involvement: "direct extension" seems to be an early stage of the disease, while lymph node metastases represent a more advanced form.

Adenocarcinoma of the lung--clinical features and survival

Four thousand patients were registered by the Edinburgh Lung Cancer Group in 1981-1987; 9.5% had adenocarcinoma. Of these, 102 patients with pathological confirmation of the diagnosis, presenting to one hospital group in Edinburgh, were reviewed. Two cases were excluded after case note review. Of the remaining 100, 64 were male and 36 were female, with a mean age of 73 years. The majority (89%) were smokers or ex-smokers, and 52% had a poor performance status (Karnofsky Index 10-70). Significantly, more adenocarcinoma patients underwent surgery compared to other cell types (39 vs. 19%, P < 0.01), and less were treated with radiotherapy (19 vs. 31%). The 5-yr survival rate for the adenocarcinoma patients was 19 vs. 7% in the remainder of patients. Of 39 patients referred for surgery, 37 had lung resections and their 5-yr survival rate was 42%. Post-operative staging showed 48% in Stage I, 27% in Stage II and 24% in Stage III. The majority of the long-term survivors had Stage I disease (64%). Forty-two percent of the patients received palliative therapy alone (all died within 10 months). Ten percent of patients receiving radiotherapy survived for 5 yr. Review of these cases suggested two patterns of presentations: (1) patients with poor performance status, extensive disease and often pleural involvement (16%); and (2) patients with more localized disease (39%), many of whom were suitable for surgical resection with surprisingly good prognosis.

Lung cancer in young patients

During 1981-1986 the Edinburgh Lung Cancer Group prespectively registered 3560 new patients with lung cancer of whom only 48 (1.3%) were aged less than 45 years. When compared with 3512 older patients aged more than 45 years, a similar proportion of young patients were female (17/48; 35% vs. 28% of the older patients) and had equally advanced disease (30/48; 62% vs. 58% in stage III). Slightly more young patients were in better Karnofsky performance status groups (28/48; 59% vs. 45%, score > 80) and duration of symptoms was considerably shorter (median 45 vs. 93 days); only three of the younger patients were non-smokers. A pathological diagnosis was obtained more often in young patients (47/48; 98% vs. 81%). The commonest cell type was small cell (16/48; 34% vs. 24%) with 10/48 adenocarcinoma (20% vs. 13%) and less squamous carcinoma (11/48; 23% vs. 48%). Although only 12/48 young patients (25% vs. 19%) underwent surgical resection, six of these were still alive after 5 years (50% vs. 30% in older patients). More young patients received chemotherapy either alone (14) or combined with radiotherapy (6)--42% vs. 16% in older patients. There were no long-term survivors and the median survival was 8 months in 13 patients with small cell and only 4 months in seven with non-small cell carcinoma.

Survival of Lung Cancer in East London: A Prospective Survey

Five hundred men and 76 women all under the care of one physician at the London Chest Hospital were diagnosed as having bronchogenic carcinoma and admitted to a prospective survey between May 1966 and April 1978. The survey was completed in December 1984 when all but 19 of the 500 men had died. None was lost to follow up. The longest period of surveillance was 18 years 7 months, the shortest 6 years 8 months. The five-year survival of the group of 500 men was 7.6% (38), and 22% (32) for the 145 patients who had had resections. Of the 78 patients (63 men, 15 women) who had small cell carcinoma, only one survived 3 years; the others died in under 2 years, giving a median survival of 5 months. The median survival of the 21 untreated cases in this group of small cell carcinoma was 2 months.

Detection of occult cardiac invasion by two dimensional echocardiography in patients with bronchial carcinoma

Cardiac invasion by bronchial carcinoma may prevent successful resection but may be undetected before operation. In a retrospective analysis of 100 consecutive thoracotomies nine patients had unsuspected cardiac invasion by tumour. A prospective study of preoperative two dimensional echocardiography was therefore undertaken in patients with bronchial carcinoma who had no clinical evidence of cardiac tumour. Comparison with anatomical findings was possible in 65 patients in whom an echocardiogram of suitable quality had been obtained. There was one false negative among 55 negative echocardiograms and three false positives among 10 positive echocardiograms; non-malignant pericardial disease accounted for the echocardiographic finding in one of the latter. The predictive value of a negative test was 98%, and the predictive value of a positive test was highest (80%) if the echocardiogram suggested atrial invasion.

Fifteen-year follow-up of all patients in a study of post-operative chemotherapy for bronchial carcinoma

The 15-year findings are presented of a double-blind, randomised study planned in 1964 in which cytotoxic chemotherapy with either busulphan or cyclophosphamide prescribed to be given daily for 2 years as an adjuvant to surgery was compared with placebo in the treatment of 726 patients with carcinoma of the bronchus. The two cytotoxic agents administered in this way did not influence survival. At 15y, 8% of the 243 patients allocated busulphan, 9% of the 234 cyclophosphamide, and 10% of the 249 placebo were alive, these being 10% of the patients who had had epidermoid cancers, 12% large-cell, 5% small-cell, 5% adenocarcinomas, and 8% other histological types. The study provides data on long-term results in a large group of patients who were, in effect, treated by surgery alone. Survival was significantly shorter in patients with histological involvement of the resected intrathoracic nodes (log-rank test P much less than 0.001). A finding of particular interest is that the histological type of the tumour did not influence survival in the 390 patients whose nodes were not involved, although, as expected, it did in the 336 whose nodes were involved, the 226 with epidermoid cancers surviving longer than the 57 with small cell carcinoma, the 31 with adenocarcinoma and all 110 with non-epidermoid carcinomas (P much less than 0.001 in each comparison).

A retrospective analysis of 10-year survivors from carcinoma of the lung

From 1949 to 1972, 4732 patients with carcinomas of the lung were seen. Of these, 118 patients were found alive at 10 years from their initial diagnosis and treatment. This number represents only 2.5% of all lung cancers seen because many have been lost to follow-up within the first ten years, and their true status is not known. The authors attempted to look at the patient characteristics that might have influenced long-term survival. A case-matched study was also done of patients with carcinoma of the lung who lived less than 2 years and who had the same age, sex, histology, and year of diagnosis. In the long-term survivors, the median age was 57 years, 2 of 3 had epidermoid carcinoma, 86% were smokers, 76% were symptomatic, and 70% had one or both parents alive at age 70 years or older. There was no difference in these variables in the case-matched group. Of the 118 long-term survivors, 91 were men and 27 were women. Sixty-seven percent had Stage I disease, 13% Stage II, and 20% Stage III. None had distant metastasis at presentation. Of the 118 patients, 115 had surgery. Eighteen of the 115 surgically treated patients also had postoperative external radiation. Three patients with Stage III disease received radiation without surgery. None had recurrence of their cancer, 27 developed new cancers, and 70% of these were new lung cancers. Although the majority of the long-term survivors had Stage I cancers, a third had Stage II or III disease. No long-term survivor died of his original disease, suggesting that a 10-year survival is adequate proof of cure in carcinoma of the lung.

Thirty years of surgery for carcinoma of the bronchus

A study has been made of 8781 patients with bronchial carcinoma who were operated on by seven surgeons in England during the years 1949-80. There were 3865 pneumonectomies, 3790 lobectomies, and 1126 thoracotomies. During this period the operative mortality has fallen. Neither the resection rate nor the proportion of lobectomies bears any relation to the survival rate in any series. There has been remarkable similarity between the various survival rates in that the difference at five years was only 1.3% (25.5-26.8%) and at 10 years 4.2% (13.6-17.8%). These figures are reflected in reports published worldwide, where there is also great similarity between the results. If the improvement in operative mortality is excluded, there has been no improvement in the survival rates in the last thirty years.

Role of lung scanning in assessing the resectability of bronchial carcinoma

Ventilation and perfusion lung scans were performed in 58 patients before operation for bronchial carcinoma to determine in which patients the lung scan was most useful for assessing mediastinal spread and resectability of the tumour. Perfusion of the affected lung was less with larger and more centrally situated tumours. Perfusion was also less for left-sided than for right-sided tumours but this is explained by the normal differential perfusion of the right and left lungs. The lung scan was unhelpful in predicting resectability of peripheral tumours, but with central tumours if perfusion of the affected lung was less than 25% of the total perfusion the lesion was likely to be non-resectable because of spread to the mediastinum. Airways obstruction was present in 67% of the patients but did not interfere with the interpretation of the scans. In most cases ventilation scans provided no additional information, and the use of krypton-81 m as a sensitive indicator of regional ventilation did not improve on the predictive value of the perfusion scan.

Outcome of carcinoma in situ and early invasive carcinoma of the bronchus

Seventeen patients in whom a squamous carcinoma in situ of the bronchus had been resected have been followed for up to 16 years. The crude mortality rate for these patients is remarkably high, with seven (41%) dead after five years and 14 (82%) after 10 years. Half the patients had died as a direct result of malignant disease by 10 years--because of recurrence, metastatic disease, or the development of a second tumour. A guarded long-term prognosis must be given in these patients owing to the many deaths (mainly from other respiratory diseases) besides those from recurrent cancer.

Bronchogenic carcinoma in Northern India

A study of 336 patients with bronchogenic carcinoma was carried out in Chandigarh, Northern India. The findings suggest that its epidemiology differs in several respects from that in Western countries. Almost a third of all patients and 94.4% of the 54 women had never smoked. The peak frequency of bronchogenic carcinoma occurred between the ages of 51 and 60 years, 14.6% of the patients being aged less than 41 years. Of the 232 smokers and ex-smokers, 48.3% had smoked only cigarettes, 28.4% only bidis (made of naturally cured tobacco), 19.8% both cigarettes and bidis, and 3.4% hukkas. There was a clear association between duration of smoking and frequency of carcinoma. Tumours were classified in 287 (85%) of the patients. Squamous-cell carcinoma was relatively more frequent (32.4%) than any other tumour type and occurred almost exclusively in smokers. Adenocarcinoma was found in 13.2% of patients and was the most frequent tumour in non-smokers. No differences of histological type were found between cigarette smokers and bidi smokers.

Lobectomy with sleeve resection in the treatment of tumors of the bronchus

We evaluated the results of right upper lobectomy with a sleeve resection of the right main bronchus in 50 patients with a bronchial neoplasm. Four patients (8 percent) died during surgery or postoperatively. Eight of the 22 patients who underwent surgery for carcinoma between the years 1960 and 1974 had tumor-positive hilar lymph nodes. They died as a result of subsequent extension of the resected carcinoma. Fourteen of the 22 patients had no lymph node metastasis and nine of them (64 percent) were alive after five years without detectable recurrence. The finding of positive hilar lymph nodes contraindicates sleeve resection. In these cases, when pneumonectomy is impossible from a functional point of view, sleeve resection is to be regarded as a palliative procedure.

Selection by mediastinoscopy and long-term survival in bronchial carcinoma

In order to reduce the high rate of inoperability in patients with bronchial carcinoma, mediastinoscopy was carried out as a routine preoperative selection in 874 patients during 13 years. Two hundred thirty-six patients (27%) were found to have involved lymph nodes at mediastinoscopy and were not treated surgically. Follow-up data were available on 210 of them: 165 (79%) died within a year, 16 survived for 2 years, and 4 for 5 years. Pulmonary resection was carried out in 638 patients. Five-year survival in the series was 24.5% and 10-year survival (based on 104 eligible patients), 16.3%, including the operative mortality of 5.5%. Mediastinoscopy has not improved long-term survival to any great extent. However, it has raised the rate of resectability to 97.1% and lowered the operative mortality without denying the patient a chance of cure.

Surgical management of bronchial carcinoma invading the chest wall

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

Major pulmonary resection for bronchogenic carcinoma in the elderly

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

Second primary lung carcinoma

Ffity-five patients suffering from second primary lung carcinoma, 10 synchronous and 45 after resection for lung carcinoma (metachronous), have been observed from 1400 resections. The first manifestation of a second carcinoma in this series has always been the appearance of a new shadow in the follow-up radiograph. In our experience, second primary lung carcinoma is a disease affecting only heavy cigarette smokers. Heavy cigarette smokers suffering from squamous-cell carcinoma are at special risk. The results of re-operation, the significance of the time interval between the original operation and the appearance of the second primary carcinoma, and the slow growth rate of some second primaries are briefly discussed. No clear-cut methods exist for distinguishing a second primary from a metastasis from the original carcinoma.

5-year follow-up of cytotoxic chemotherapy as an adjuvant to surgery in carcinoma of the bronchus

This report gives the 5-year findings of a double-blind study of long-term cytotoxic chemotherapy as an adjuvant to surgery in patients receiving busulphan or cyclophosphamide for carcinoma of the bronchus compared with a group receiving a placebo. Of 243 patients initially allocated busulphan, 234 cyclophosphamide and 249 placebo, 28%, 27% and 34% respectively were alive at 5 years. There were significant associations between mortality from bronchial carcinoma and histological involvement of the resected intrathoracic nodes and the histology of the tumour. Haematological toxicity, especially thrombocytopenia, was frequent and severe in the busulphan series, and low platelet counts continued long after chemotherapy was stopped.

Cancer of the lung in women

A study from Wales of 132 women with cancer of the lung admitted consecutively during the five years 1964-68, and of 13 other women submitted to surgery at an earlier period, showed that the prognosis for women was worse than for men. Every woman except one was followed up for more than five years. Of the 132 women in the consecutive series only five survived for five years, while the five-year survival rate after resection in 35 women was less than one-half of that of men. The cause of the worse prognosis for women in Wales appears to be due to some sex-linked factor. It cannot be explained by the age of the patient or by the histology, location, early or resectability of the growth. The prognosis of cancer of the lung in English, French, and American women is considered. The relative incidence of the disease in women and men is discussed. Sex and nationality appear to be of importance, but the influence of tobacco and other atmospheric carcinogens is obscure.

Carcinoma of the lung: results of treatment over ten years

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

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

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

The changing pattern of bronchial carcinoma

1. The age incidence of bronchial carcinoma in England and Wales is rising. 2. In one series the proportion of the patients operated on over the age of 65 years rose from 12% in 1950-5 to 37% in 1970-4. 3. Thes change reflects the national figures in both men and women. 4. The proportion of the population in the ages at risk has risen substantially, particularly amongst men, in the last 20 years, but this does not nearly account for the rise in the incidence in the older age groups. 5. The rate continues to rise in the patients over 65 years of age, but is now falling in all groups of men below that age. It is still rising in all age groups of women. 6. As time has passed the rate has begun to fall in men of older age groups. 7. The sex ratio continues to fall. 8. The process described has been going on for at least 50 years, and it is suggested that the decline in the younger age groups represents the natural history of bronchial carcinoma in the community. 9. The timing of the change in mortality is different in different parts of the world and in the two sexes. 10. It is predicted that the number of men with broncial carcinoma fit for surgery may shortly start to fall in this country.

The Possibilities of Surgery in Locally Invasive Pulmonary Carcinoma

The authors have studied the survival of 30 patients suffering from bronchogenic carcinoma invading the surrounding tissues treated with radical resection. This study shows that the prognosis is very poor. Only a quarter of the patients have survived for more than two years after the operation. The prognosis is similar to that for non-invasive tumors with regional lymphnode involvement. Despite the few cases examined, central tumors with lymphnode involvement and those invading the ribs or the pericardium seem to have the poorest prognosis.

Mediastinoscopy. An analysis of 320 consecutive cases

Three hundred and twenty consecutive cases of mediastinoscopy are analysed. Mediastinoscopy is a safe procedure and causes little disturbance to the patient.The preoperative assessment of patients with presumably resectable bronchial carcinoma was the main indication for mediastinoscopy, and its use was associated with a fall in the non-resectability rate at thoracotomy from 28 to 15 per cent over two 3-year periods.The policy of exclusion from exploratory thoracotomy of patients with bronchial carcinoma and mediastinal lymph-node metastases is discussed in relation to the histological nature of the lesion and the site and extent of the mediastinal node involvement.It is concluded that there is a case for offering resection to selected patients with limited mediastinal node invasion from bronchial carcinoma.The value of mediastinoscopy as a diagnostic procedure for mediastinal and pulmonary hilar masses and for undiagnosed pulmonary opacities is shown.

Lung scanning in carcinoma of the bronchus

The lung scans of 101 patients with carcinoma of the bronchus have been compared with the bronchoscopic and radiographic findings. As the tumour approaches the hilum as judged by bronchoscopy or the chest radiograph the relative perfusion of the affected lung decreases. When the relative perfusion of the affected lung is less than one third of the total the tumour is likely to be inoperable. The reduction in perfusion is related to involvement of the vessels in the hilum by tumour and to a lesser extent to bronchial obstruction.

Defects in perfusion in the unaffected lung were seen in 53 patients and were usually due to chronic bronchitis and emphysema or inactive pulmonary tuberculosis.

In the management of patients with carcinoma of the bronchus lung scans are of value in predicting when a tumour is likely to be inoperable and also in giving an indication as to whether a pneumonectomy or lobectomy will be possible. In addition, defects in the contralateral lung may be sufficiently large to contraindicate surgery.

Cavitary pulmonary metastases

Cavitation in pulmonary metastases is more common than might be supposed from the small number of cases (75) previously reported. Twenty-five cases of cavitary pulmonary metastases were seen at the London Chest Hospital from 1964 to 1969. The primary sites were the large intestine (8), opposite lung (4), cervix (3), stomach, oesophagus, pancreas, and larynx (2 each) and anal canal and kidney (1 each). The size of the cavities ranged from 1·0 to 6·0 cm., and their wall thickness from 0·3 to 2·5 cm. Only in three cases was there an identifiable communication with the bronchial tree and only in these three cases were neoplastic cells found in the sputum. The main microscopic feature was vascular invasion, which was found in the vicinity of every metastasis; thrombosis was seen in 14 cases. It seems that the principal cause of necrosis and subsequent cavitation in metastatic tumours of the lung is interference with their blood supply by vascular involvement.

Long-term clinical follow-up after operation for lung carcinoma

From 1951 to July 1969, 964 lung resections for primary lung carcinoma have personally been carried out. All except eight patients, whose follow-up has been continued by colleagues elsewhere, have been examined at intervals in the outpatient department and chest radiographs have been taken. No patient has been lost from follow-up. The results of this follow-up are presented. The quality of the patient's life after operation, the cause of death, the results, and the relationship of survival to extent of operation are discussed. Details of 151 patients surviving more than five years, and of 49 surviving more than 10 years, are given. Information on the aspects under consideration is believed to be as complete as possible. The cause of death is doubtful in only two patients.

Results of surgery for bronchial carcinoma in patients aged 70 and over

The number of elderly patients who are developing carcinoma of the bronchus and who are also fit for surgical treatment is increasing. One hundred patients are reviewed who had operations for this condition. The histological distribution of growths in this age group is the same as in younger patients, and the rate of growth can be just as rapid. The importance of a high resectability rate and a low mortality rate in this age group is stressed. Pneumonectomy should be performed only for the strictest of reasons, as the mortality rate is too high, but the mortality rate for lobectomy is acceptable, and this is the operation of choice.