Current status of surgical resection for lung cancer

A Study of laser dose in Photodynamic Therapy with Talaporfin Sodium for Malignant Central Airway Stenosis

Photodynamic therapy (PDT) has been shown to be effective and safe in the treatment of malignant central airway stenosis. However, the laser dose for talaporfin PDT is unclear. We herein review cases where talaporfin PDT was used to treat malignant central airway stenosis. A total of 17 lesions were treated with talaporfin PDT at laser doses of 50-150 J/cm². Improvement of airway stenosis was observed in all cases except for 1 lesion treated with a dose of 50 J/cm². The results show that talaporfin PDT with 100 J/cm² of laser dose is a feasible treatment for malignant central airway stenosis. (This is a secondary publication from the Journal of Japan Society for Laser Surgery and Medicine 2022; 43(1): 9-12.).

Disparities in localized malignant lung cancer surgical treatment: A population‐based cancer registry analysis

BACKGROUND

Lung cancer (LC) continues to be the leading cause of cancer deaths in the United States. Surgical treatment has proven to offer a favorable prognosis and a better 5-year relative survival for patients with early or localized tumors. This novel study investigates the factors associated with the odds of receiving surgical treatment for localized malignant LC in Tennessee.

METHODS

Population-based data of 9679 localized malignant LC patients from the Tennessee Cancer Registry (2005-2015) were utilized to examine the factors associated with receiving surgical treatment for localized malignant LC. Bivariate and multivariate logistic regression analyses, cross-tabulation, and Chi-Square ( χ ² ) tests were conducted to assess these factors.

RESULTS

Patients with localized malignant LC who initiated treatment after 2.7 weeks were 46% less likely to receive surgery (adjusted odds ratio [AOR] = 0.54; 95% confidence interval [CI] = 0.50-0.59; p < 0.0001). Females had a greater likelihood (AOR = 1.14; CI = 1.03-1.24) of receiving surgical treatment compared to men. Blacks had lower odds (AOR = 0.76; CI = 0.65-0.98) of receiving surgical treatment compared to Whites. All marital groups had higher odds of receiving surgical treatment compared to those who were single/never married. Patients living in Appalachian county had lower odds of receiving surgical treatment (AOR = 0.65; CI = 0.59-0.71) compared with those in the non-Appalachian county. Patients with private (AOR = 2.09; CI = 1.55-2.820) or public (AOR = 1.42; CI = 1.06-1.91) insurance coverage were more likely to receive surgical treatment compared to self-pay/uninsured patients. Overall, the likelihood of patients receiving surgical treatment for localized malignant LC decreases with age.

CONCLUSION

Disparities exist in the receipt of surgical treatment among patients with localized malignant LC in Tennessee. Health policies should target reducing these disparities to improve the survival of these patients.

Delays in Managing Lung Cancer: The Importance of Fast-Tracking in the Clinical Care

Early diagnosis in lung cancer is desirable, because surgical resection offers the only hope of cure. In the face of suggestive symptoms, a normal plain chest radiograph does not exclude the diagnosis, and investigation is essential. The various imaging changes seen on computerized tomography and PET scan provide strong suggestive evidence of lung cancer, but proof of diagnosis rests on histologic examination, material that may be obtained by one of the following diagnostic procedures: bronchoscopy, mediastinoscopy, fine needle aspiration biopsy, thoracentesis and pleural biopsy, lymph node biopsy, and exploratory thoracotomy.

Patient size matters: Effect of tube current modulation on size-specific dose estimates (SSDE) and image quality in low-dose lung cancer screening CT

Purpose

We compare the effect of tube current modulation (TCM) and fixed tube current (FTC) on size‐specific dose estimates (SSDE) and image quality in lung cancer screening with low‐dose CT (LDCT) for patients of all sizes.

Methods

Initially, 107 lung screening examinations were performed using FTC, which satisfied the Centers for Medicare & Medicaid Services' volumetric CT dose index (CTDI_vol) limit of 3.0 mGy for standard‐sized patients. Following protocol modification, 287 examinations were performed using TCM. Patient size and examination parameters were collected and water‐equivalent diameter (D_w) and SSDE were determined for each patient. Regression models were used to correlate CTDI_vol and SSDE with D_w. Objective and subjective image quality were measured in 20 patients who had consecutive annual screenings with both FTC and TCM.

Results

CTDI_vol was 2.3 mGy for all FTC scans and increased exponentially with D_w (range = 0.96–4.50 mGy, R² = 0.73) for TCM scans. As patient D_w increased, SSDE decreased for FTC examinations (R² = 1) and increased for TCM examinations (R² = 0.54). Image quality measurements were superior with FTC for smaller sized patients and with TCM for larger sized patients (R² > 0.5, P < 0.005). Radiologist graded all images acceptable for diagnostic evaluation of lung cancer screening.

Conclusion

Although FTC protocol offered a consistently low CTDI_vol for all patients, it yielded unnecessarily high SSDE for small patients and increased image noise for large patients. Lung cancer screening with LDCT using TCM produces radiation doses that are appropriately reduced for small patients and increased for large patients with diagnostic image quality for all patients.

Outcome of advanced lung cancer with central airway obstruction versus without central airway obstruction

Patients with central airway obstruction (CAO) from advanced lung cancer present with significant morbidity and are assumed to have lower survival. Hence, they are offered only palliative support. We asked if patients who have advanced lung cancer with CAO (recanalised and treated) will behave similarly to those with advanced lung cancer without CAO. This study was a retrospective review of the medical records of the patients managed for advanced lung cancer during 2010 and 2015 at our institution. 85 patients were studied. Median survival and 1-, 2- and 5-year survival were 5.8 months, 30.3%, 11.7% and 2.3% versus 9.3 months, 35.7%, 9.6% and 4.7%, respectively, in the CAO and no CAO groups (p=0.30). More patients presented with respiratory failure (15 (35%) versus none; p=0.0001) and required assisted mechanical ventilation (10 (23.3%) versus none; p=0.001) in the CAO group compared with the no CAO group. Fewer patients received chemotherapy in the CAO group (11 (25.5%)) compared with the no CAO group (23 (54.7%); p=0.008). There was no difference in survival among patients with advanced lung cancer whether they presented with CAO or without CAO. Survival was similar to those without CAO in patients with recanalised CAO despite greater morbidity and lesser use of chemotherapy, strongly advocating bronchoscopic recanalisation of CAO. These findings dispel the nihilism associated with such cases.

Radiofrequency ablation for lung tumors: outcomes, effects on survival, and prognostic factors

PURPOSE

We aimed to evaluate the survival benefit achieved with radiofrequency (RF) ablation of primary and metastatic lung tumors and determine significant prognostic factors for recurrence-free survival.

METHODS

Forty-nine patients with lung cancer (10 primary and 39 metastatic) underwent computed tomography-guided percutaneous RF ablation between June 2005 and October 2013. A total of 112 tumors (101 metastatic and 11 primary non-small cell lung cancer) were treated with RF ablation. Tumor diameter ranged from 0.6 to 4 cm (median 1.5 cm). Effectiveness of treatment, complications, and survival were analyzed.

RESULTS

Primary success rate was 79.5% and local tumor progression occurred in 23 tumors. Among tumors showing progression, 10 were re-treated with RF ablation and secondary success rate was 87.5%. One-, two-, and three-year overall survival rates of 10 patients with primary lung cancer were 100%, 86%, and 43%, respectively. One-, two-, three-, four-, and five-year overall survival rates for 39 patients with metastatic lung tumors were 90%, 73%, 59%, 55%, and 38%, respectively. One-, two-, three-, and four-year overall survival rates for 16 patients with colorectal pulmonary metastases were 94%, 80%, 68%, and 23%, respectively. Complications occurred in 30 sessions (24.6%). Pneumothorax occurred in 19 sessions with seven requiring image-guided percutaneous chest tube drainage. Tumor status (solitary or multiple) and presence of extrapulmonary metastasis at initial RF ablation were significant prognostic factors in terms of recurrence-free survival.

CONCLUSION

RF ablation is a safe and effective treatment with a survival benefit for selected patients with primary and secondary lung tumors.

Efficacy of Systemic Postoperative Pulmonary Rehabilitation After Lung Resection Surgery

OBJECTIVE

To investigate the efficacy of systemic pulmonary rehabilitation (PR) after lung resection in patients with lung cancer.

METHODS

Forty-one patients undergoing lung resection were enrolled and classified into the experimental (n=31) and control groups (n=10). The experimental group underwent post-operative systemic PR which was conducted 30 min/day on every hospitalization day by an expert physical therapist. The control group received the same education about the PR exercises and were encouraged to self-exercise without supervision of the physical therapist. The PR group was taught a self-PR program and feedback was provided regularly until 6 months after surgery. We conducted pulmonary function testing (PFT) and used a visual analog scale (VAS) to evaluate pain, and the modified Borg Dyspnea Scale (mBS) to measure perceived respiratory exertion shortly before and 2 weeks, 1, 3, and 6 months after surgery.

RESULTS

A significant improvement on the VAS was observed in patients who received systemic PR >3 months. Significant improvements in forced vital capacity (FVC) and mBS score were observed in patients who received systemic PR >6 months (p<0.05). Other PFT results were not different compared with those in the control group.

CONCLUSION

Patients who received lung resection suffered a significant decline in functional reserve and increases in pain and subjective dyspnea deteriorating quality of life (QoL). Systemic PR supervised by a therapist helped improve reduced pulmonary FVC and QoL and minimized discomfort during the postoperative periods in patients who underwent lung resection.

PET-based radiation therapy planning

In this review, we review the literature on the use of PET in radiation treatment planning, with an emphasis on describing our institutional methodology (where applicable). This discussion is intended to provide other radiation oncologists with methodological details on the use of PET imaging for treatment planning in radiation oncology, or other oncologists with an introduction to the use of PET in planning radiation therapy.

Survival of patients with or without symptoms undergoing potentially curative resections for primary lung cancer

BACKGROUND

Numerous historical screening programs to detect lung cancer have been undertaken. With technologic advances, complimentary diagnostic tests have been developed; however, only the National Lung Cancer Trial has demonstrated increased survival. Following the success of this study, screening programs are being trialled in several countries. Screening should, in theory, reduce lung cancer deaths by identifying asymptomatic patients with earlier tumors. This study asked whether lung cancer patients who are asymptomatic at presentation have a better survival than those who present with symptoms.

METHODS

This was a retrospective analysis of a validated prospective thoracic surgery database from a tertiary center in the Northwest of England. Included were 1,546 consecutive patients (826 men, 720 women) who received operative intervention for non-small cell lung cancer. The main outcome measures included 5-year survival and univariate and multivariate Cox regression analysis.

RESULTS

Cancer stage, age, and operation type were confirmed as being of prognostic importance, validating previous studies. Survival between asymptomatic or symptomatic patients did not differ significantly (p = 0.489), regardless of stage. The hazard ratios (with 95% confidence intervals) for variables associated with poorer outcome identified by Cox's regression analysis were male sex, 1.34 (1.15 to 1.56); advancing age, 1.03 (1.02 to 1.04); advancing stage, 3.30 (2.69 to 4.04); and pneumonectomy, 1.24 (1.01 to 1.52). Symptoms were not a significant variable affecting survival on multivariate analysis.

CONCLUSIONS

This retrospective study from the Northwest of England showed that in our subset of lung cancer patients undergoing resection, asymptomatic patients with non-small cell lung cancer do not have improved survival, implying it is a systemic disease in many at diagnosis. Care should be taken when generalizing the results of the National Lung Screening Trial to all populations until further validation has been performed.

Relationship between angiogenic squamous dysplasia and bronchogenic carcinoma in patients undergoing white light bronchoscopy

OBJECTIVE

To better understand the characteristic morphology of angiogenic squamous dysplasia (ASD) and its association with different types of common bronchogenic carcinomas using routine white light bronchoscopy.

METHODS

Using a case-control design, 186 formalin-fixed paraffin-embedded blocks of bronchial tissue (136 cases, 50 controls) obtained from patients who underwent routine nonfluorescence bronchoscopy between 2004 and 2005 were studied.

RESULTS

ASD occurred at a higher frequency in patients with neoplastic lesions compared with those without neoplastic lesions (28 of 136 versus one of 50). ASD was also more prevalent in patients with squamous cell carcinoma compared with other neoplasms. Seventy six per cent of the ASD patients (22 of 29) smoked cigarettes. The morphology of ASD on hematoxylin and eosin- and CD31-stained sections was characterized by prominent microvasculature and capillary projections closely juxtaposed to variable degrees of dysplasia in all of the bronchogenic carcinoma specimens, and to metaplasia in one case in the control group.

CONCLUSION

ASD is a unique morphological entity that should be considered by pathologists even on bronchoscopic biopsies from patients who undergo white light bronchoscopy. The presence of ASD may represent a risk biomarker of bronchogenic carcinoma in screening programs and in chemoprevention of lung cancer.

Social differences in lung cancer management and survival in South East England: a cohort study

OBJECTIVE

To examine possible social variations in lung cancer survival and assess if any such gradients can be attributed to social differences in comorbidity, stage at diagnosis or treatment.

DESIGN

Population-based cohort identified in the Thames Cancer Registry.

SETTING

South East England.

PARTICIPANTS

15 582 lung cancer patients diagnosed between 2006 and 2008.

MAIN OUTCOME MEASURES

Stage at diagnosis, surgery, radiotherapy, chemotherapy and survival.

RESULTS

The likelihood of being diagnosed as having early-stage disease did not vary by socioeconomic quintiles (p=0.58). In early-stage non-small-cell lung cancer, the likelihood of undergoing surgery was lowest in the most deprived group. There were no socioeconomic differences in the likelihood of receiving radiotherapy in stage III disease, while in advanced disease and in small-cell lung cancer, receipt of chemotherapy differed over socioeconomic quintiles (p<0.01). In early-stage disease and following adjustment for confounders, the HR between the most deprived and the most affluent group was 1.24 (95% CI 0.98 to 1.56). Corresponding estimates in stage III and advanced disease or small-cell lung cancer were 1.16 (95% CI 1.01 to 1.34) and 1.12 (95% CI 1.05 to 1.20), respectively. In early-stage disease, the crude HR between the most deprived and the most affluent group was approximately 1.4 and constant through follow-up, while in patients with advanced disease or small-cell lung cancer, no difference was detectable after 3 months.

CONCLUSION

We observed socioeconomic variations in management and survival in patients diagnosed as having lung cancer in South East England between 2006 and 2008, differences which could not fully be explained by social differences in stage at diagnosis, co-morbidity and treatment. The survival observed in the most affluent group should set the target for what is achievable for all lung cancer patients, managed in the same healthcare system.

Preoperative evaluation for thoracic surgery

The goal of the preoperative evaluation for thoracic surgery is to assess and implement measures to decrease perioperative complications and prepare high-risk patients for surgery. Major respiratory complications, such as atelectasis, pneumonia, and respiratory failure, occur in 15% to 20% of patients and account for most of the 3% to 4% mortality rate. Development of pulmonary complications has been associated with higher postoperative mortality rates. Strategies aimed at preventing postoperative difficulties have the potential to reduce morbidity and mortality, decrease hospital stay, and improve resource use. One lung ventilation leads to a significant derangement of gas exchange, and hypoxemia can develop due to increased intrapulmonary shunting. Recent advances in anesthetic management, monitoring devices, improved lung isolation techniques, and improved critical care management have increased the number of patients who were previously considered inoperable. In addition, there is a growing tendency to offer surgery to patients with significant lung function impairment; hence a higher incidence of intraoperative gas-exchange abnormalities can be expected. The anesthesiologist must also consider the risks of denying or postponing a potentially curative operation in patients with lung cancer. Detailed consideration of the information provided by preoperative testing is essential to successful outcomes following thoracic surgery.

A systematic review of radiofrequency ablation for lung tumors

BACKGROUND

Radiofrequency ablation (RFA) has been increasingly utilized as a non-surgical treatment option for patients with primary and metastatic lung tumors. We performed the present systematic review to assess the safety and efficacy of RFA.

METHODS

Searches for all relevant studies prior to November 2006 were performed on six databases. Two reviewers independently appraised each study using predetermined criteria. Clinical effectiveness was synthesized through a narrative review, with full tabulation of results of all included studies.

RESULTS

A total of 17 of the most recent updates from each institution were included for appraisal and data extraction. All were case series and were classified as level-4 evidence. The mean number of lesions treated ranged from 1 to 2.8, and the mean size ranged from 1.7 cm to 5.2 cm. The overall procedure-related morbidity rate ranged from 15.2% to 55.6% and mortality from 0% to 5.6%. The most commonly reported complication was pneumothorax (4.5-61.1%). Most pneumothoraces were self-limiting and only 3.3-38.9% (median = 11%) required chest drain insertion. The local recurrence of tumors at the site of RFA ranged from 3% to 38.1% (median = 11.2%). The median progression-free interval ranged from 15 months to 26.7 months (median = 21 months), and 1-, 2- and 3-year survival rates were 63-85%, 55-65% and 15-46%, respectively.

CONCLUSIONS

Only observational studies were available for evaluation, which demonstrated some promising safety profiles of RFA.

Nonsmall cell lung cancer: evaluation of 737 consecutive patients in a single institution

OBJECTIVE: To analyze surgical and pathological parameters and outcome and prognostic factors of patients with nonsmall cell lung cancer (NSCLC) who were admitted to a single institution, as well as to correlate these findings to the current staging system. METHOD: Seven hundred and thirty seven patients were diagnosed with NSCLC and admitted to Hospital do Cancer A. C. Camargo from 1990 to 2000. All patients were included in a continuous prospective database, and their data was analyzed. Following staging, a multidisciplinary team decision on adequate management was established. Variables included in this analysis were age, gender, histology, Karnofsky index, weight loss, clinical stage, surgical stage, chemotherapy, radiotherapy, and survival rates. RESULTS: 75.5% of patients were males. The distribution of histologic type was squamous cell carcinoma 51.8%, adenocarcinoma 43.1%, and undifferentiated large cell carcinoma 5.1%. Most patients (73%) presented significant weight loss and a Karnofsky index of 80%. Clinical staging was IA 3.8%, IB 9.2%, IIA 1.4%, IIB 8.1%, IIIA 20.9%, IIIB 22.4%, IV 30.9%. Complete tumor resection was performed in 24.6% of all patients. Surgical stage distribution was IA 25.3%, IB 1.4%, IIB 17.1%, IIIA 16.1%, IIIB 20.3%, IV 11.5%. Chemotherapy and radiotherapy were considered therapeutic options in 43% and 72%, respectively. The overall 5-year survival rate of nonsmall cell lung cancer patients in our study was 28%. Median survival was 18.9 months. CONCLUSIONS: Patients with NSCLC who were admitted to our institution presented with histopathologic and clinical characteristics that were similar to previously published series in cancer hospitals. The best prognosis was associated with complete tumor resection with lymph node dissection, which is only achievable in earlier clinical stages.

Trends in incidence and prognosis of the histological subtypes of lung cancer in North America, Australia, New Zealand and Europe

BACKGROUND

Since the incidence of the histological subtypes of lung cancer in industrialised countries has changed dramatically over the last two decades, we reviewed trends in the incidence and prognosis in North America, Australia, New Zealand and Europe, according to period of diagnosis and birth cohort and summarized explanations for changes in mortality.

METHODS

Review of the literature based on a computerised search (Medline database 1966-2000).

RESULTS

Although the incidence of lung cancer has been decreasing since the 1970s/1980s among men in North America, Australia, New Zealand and north-western Europe, the age-adjusted rate continues to increase among women in these countries, and among both men and women in southern and eastern Europe. These trends followed changes in smoking behaviour. The proportion of adenocarcinoma has been increasing over time; the most likely explanation is the shift to low-tar filter cigarettes during the 1960s and 1970s. Despite improvement in both the diagnosis and treatment, the overall prognosis for patients with non-small-cell lung cancer hardly improved over time. In contrast, the introduction and improvement of chemotherapy since the 1970s gave rise to an improvement in - only short-term (<2 years) - survival for patients with small-cell lung cancer.

CONCLUSIONS

The epidemic of lung cancer is not over yet, especially in southern and eastern Europe. Except for short-term survival of small cell tumours, the prognosis for patients with lung cancer has not improved significantly.

Video-assisted thoracic surgical non-rib spreading simultaneously stapled lobectomy: a more patient-friendly oncologic resection

OBJECTIVE

To evaluate the outcomes from a new surgical technique for lobectomy.

PATIENTS

Two hundred fifty consecutive patients with an average age of 67.3 years underwent simultaneously stapled lobectomy.

METHODS

Video-assisted thoracic surgical non-rib spreading lobectomy (VNSSL) is a new technique that has been evolving for approximately 6.5 years. During 1990, we began using video-assisted thoracic surgery (VATS) for simple, benign diseases. Throughout 1991, VATS was applied to malignant problems, ie, mediastinal masses, staging of lymph nodes, malignant effusions, and coin lesions. As experience was acquired, more complex procedures were attempted, such as lobectomy. On September 9, 1991, our first VATS lobectomy, using anatomic hilar dissection and lymph node sampling, was performed for primary carcinoma of the lung. One year later, we performed our first VNSSL using simultaneous stapling.

RESULTS

Currently, 400 VNSSLs have been performed. In this entire series, there have been no surgical mortality, bronchopleural fistulas, port implantations, or transfusions. Bronchial stumps have averaged 4 mm in length, and all have been microscopically negative for neoplasm. In order to evaluate long-term survival for primary carcinoma of the lung in patients with an adequate duration of follow-up, the first 250 consecutive VNSSLs have been reviewed. There were 120 male and 130 female patients ranging in age from 20 to 92 years old who had 62 right upper lobe, 20 right middle lobe, 58 right lower lobe, 63 left upper lobe, and 33 left lower lobe lobectomies, and 14 bilobectomies. The lesions consisted of 214 primary carcinomas, 8 metastatic lesions, and 28 benign problems. Seven to 18 lymph nodes could be resected during staging of the primary neoplasms. The tumors ranged in size from 1 to 9 cm, and operating times averaged 78.6 min. Hospitalization averaged 2.83 days. No patient was admitted to the ICU. Intensive monitoring or narcotic analgesia were not needed. No epidural or intercostal anesthesia was used. Complications were infrequent and minor. Most patients returned to preoperative levels of physical activity within 7 to 10 days. Overall survival at a mean of 34 months, when all stages of neoplasms were combined, is 83%. For stage I, overall survival is 92%. The cost of VNSSL is approximately 50% less than the traditional open thoracotomy.

CONCLUSIONS

VNSSL is an oncologic technique that has been clinically rewarding and economically beneficial for patients with malignant lesions. Long-term survival for primary carcinoma currently exceeds reports being published for the traditional open thoracotomy. Scientific reasons for this extraordinary survival are emerging. Complications, surgical mortality, pain, and length of stay have all been reduced. Patient recovery, comfort, and satisfaction have been extraordinary.

Lymph node metastasis in small peripheral adenocarcinoma of the lung

OBJECTIVE

Our aim in this study is to clarify the clinical and pathologic features of small peripheral adenocarcinoma of the lung with special emphasis on intraoperative identification of lymph node metastasis.

PATIENTS AND METHODS

Between 1980 and 1996, 157 patients underwent lobectomy and complete hilar/mediastinal lymphadenectomy for small (1.1 to 2.0 cm in diameter) peripheral adenocarcinoma of the lung. The intraoperative assessment, the distribution of metastatic lymph nodes, and the association between the tumor's histopathologic characteristics and lymph node metastasis were retrospectively investigated in this study.

RESULTS

Postoperative examination revealed lymph node metastasis in 27 (17%) patients. Lymph node metastases were not noticed during the operation in 19 of these 27 patients. Metastases were localized in single lymph nodes in 10 patients; the metastases were distributed over a segmental, a lobar, an interlobar, and a mediastinal lymph node. The prevalence of lymph node metastasis was as follows: Of 92 patients with well-differentiated adenocarcinoma, seven (8%) had lymph node metastases; of the 65 patients with other types of tumors, 20 (31%) had lymph node metastases. Of 120 patients without pleural involvement, 13 (11%) had lymph node metastases; of the 37 with pleural involvement, 14 (38%) had lymph node metastases. Five-year survivals were estimated at 91% +/- 6% (mean +/- 95% confidence interval) for 130 patients with N0 tumor and 30% +/- 22% for 27 patients with N1 or N2 tumor.

CONCLUSIONS

Intraoperative assessment is not reliable for identifying lymph node metastasis. Lobectomy and complete hilar/ mediastinal lymphadenectomy are necessary to determine N stage rigidly. Histologic degree of differentiation and pleural involvement are significantly associated with lymph node metastasis.

Results of pneumonectomy for non-small cell lung cancer

To assess the role of pneumonectomy for lung cancer and the factors affecting the prognosis, 107 patients who had undergone pneumonectomy for non-small cell lung cancer (NSCLC) between January, 1985 and March, 1996, were analyzed. They included 81 squamous cell carcinoma, 22 adenocarcinoma, 3 large cell carcinoma, and one adenosquamous cell carcinoma, with 8 patients in post-operative stage I, 15 in stage II, 51 in stage IIIA, and 33 in stage IIIB of the disease. The 5-year survival rate was 54.7% in stages I + II, 38.0% in stage IIIA, and <4% in stage IIIB. In stages I-IIIA, the patients with squamous cell carcinoma showed a significantly better prognosis than those with adenocarcinoma (50.6 vs. 0%, p < 0.01). The prognosis was also better, but not statistically significant, for patients with central type compared with those with peripheral type in both all histologic types (58.0 vs. 8.4%) and only squamous cell type (59.3 vs. 18.8%). A better prognosis observed in squamous histologic type or central type seemed to be related to a better N factor. Pneumonectomy remains the treatment of choice for lung cancer, but seems not to be justified for patients with stage IIIB due to their poor prognosis.

Extended operation for non-small cell lung cancer invading great vessels and left atrium

OBJECTIVE

We analyzed the results of surgical treatment in patients with non-small cell lung cancer invading the great vessels (GV) and left atrium (LA) by direct extension and without distant metastases.

METHODS

From 1976 to 1993, 42 patients (37/male, 5/female) with lung cancer invading the GV and LA were treated surgically, 13 had invasion of the superior vena cava and innominate vein, 15 of the aorta and subclavian artery, and 14 of the left atrium. In all 42 the diagnosis was confirmed by pathological examination. Surgical resection included pneumonectomy (16 patients) and lobectomy (26 patients). The histologic type was squamous cell carcinoma in 27 patients, adenocarcinoma in 12, and large cell carcinoma in 3. Preoperatively, 13 patients were treated with radiation and chemotherapy. Postoperatively, further treatment was given to 22 patients. All were staged according to the international TNM staging system. Survival was calculated by the Kaplan-Meler method.

RESULTS

A total of 15 patients underwent complete resection. Reliability of clinical N factor was 80%. The overall survival was 17% at 3 years (median survival time (MST), 14 months). The operative mortality was 2.4%. Patients with lung cancer invading GV (MST, 19 months) had significantly longer survival than did those with cancer invading LA (MST, 10 months, P = 0.036). There were significant prognostic differences between N0-1 and N2-3 (MST, 22 months; MST, 9 months, respectively, P = 0.0013). Cox regression analysis identified pathological N factor, completeness of resection, and pre- and postoperative radiotherapy as important in affecting survival.

CONCLUSIONS

We conclude that patients with pathological N0-1 non-small cell lung cancer invading great vessels can achieve long-term survival with adequate surgical treatment.

Delays in the diagnosis and surgical treatment of lung cancer

BACKGROUND

Patients admitted for resection of lung tumours frequently experience lengthy delays in diagnosis and preoperative investigations. This study was conducted to quantify this delay between presentation and definitive treatment and to assess the factors responsible for such a delay.

METHODS

All patients undergoing lung resection for a tumour at a single surgical unit in 1993 were studied. The date of each consultation, investigation, and referral was identified, and the extent of any delay determined.

RESULTS

The mean total delay from presentation to operation was 109 days. Within this period an average of one month occurred before referral to a respiratory specialist who then spent two months investigating the patient. After referral to a surgeon, surgery took place within a mean interval of 24 days.

CONCLUSIONS

These delays to definitive treatment appear unacceptable. Points at which the efficiency of the diagnostic process could be improved are discussed. The length of delay did not correlate with tumour stage in this study.

Lymph node involvement, recurrence, and prognosis in resected small, peripheral, non-small-cell lung carcinomas: are these carcinomas candidates for video-assisted lobectomy?

To determine the clinicopathologic characteristics of peripheral non-small-cell carcinomas, the cases of 337 patients undergoing major pulmonary resection with complete lymphadenectomy were retrospectively reviewed with regard to lymph node involvement, recurrence, and prognosis. All of the tumors were 3.0 cm or less in diameter and were categorized as T1 (318 patients) or T2 (19). Eighty-eight patients (26.1%) had lymph node involvement: 32 (9.5%) at N1 nodes, 55 (16.3%) at N2 nodes, and 1 (0.3%) at N3 nodes. Although the prevalence of lymph node involvement did not differ significantly with tumor histologic type, it was quite low in squamous cell carcinomas 2.0 cm or less in diameter. Of the 56 N2/3 metastases, 14 (25%) occurred in a "skipping" manner, and all but one had a nonsquamous histologic makeup. Of the 213 patients with a follow-up period of 5 years or more, 59 patients (27.7%) showed cancer recurrence. This occurred at a distant site in 67.8% of the cases. Five-year survival rates based on nodal status were 91.9% (NO), 61.8% (N1), 44.5% (N2), and 0% (N3). Because of the relatively high prevalence of lymph node involvement, complete hilar/mediastinal lymphadenectomy should be routinely done regardless of tumor histologic type and size, as long as patients are at good risk. However, in squamous cell histologic types, mediastinal lymphadenectomy might be dispensable if the tumor is less than 2.0 cm in diameter, or if the hilar node is proved to be tumor-free on pathologic examination of the frozen section during operation. Although video-assisted major pulmonary resection currently has limited application, this new technique may represent a surgical option in resection without complete lymphadenectomy.