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

Peritumoral lymph nodes in pancreatic cancer revisited; is it truly equivalent to lymph node metastasis?

BACKGROUND

Lymph node (LN) metastasis is a well-known poor prognostic factor of pancreatic cancer. LN metastasis, through direct invasion of tumor cell to peritumoral lymph nodes (PTLN), is treated as the same as those which spread through lymphatic channels. This study aimed to evaluate the impact of PTLN invasion on the oncologic outcome of pancreatic cancer.

METHODS

Five hundred and six patients who underwent operation for pancreatic ductal adenocarcinoma from 2012 to 2018 were reviewed. PTLN invasion was defined as direct invasion of tumor cells in contact with main tumor.

RESULTS

Among the 506 patients, 112 patients (22.1%) had PTLN invasion. PTLN invasion group (PTLNI) showed better disease-free survival than regional LN metastasis group (RLNM) and combined LN metastasis group (CLNM) (PTLNI 21 vs RLNM 11 vs CLNM 12 months, P = .003). There was no significant difference between N0 and PTLNI (PTLNI 21 vs N0 23 months, P = .999). In multivariate analysis, conventional LN metastasis was a significant factor compared to N0, but PTLN invasion was not (hazard ratio 0.786 [0.507-1.220], P = .283).

CONCLUSION

Because PTLN invasion does not adversely affect survival in the same way as LN metastasis does, pancreatic cancer-may be overstaged if PTLN invasion were dealt in the same manner as a metastatic LN. Therefore, PTLN invasion should be disregarded from current nodal staging system.

Prognostic significance of the pattern of pathological N1 lymph node metastases for non-small cell lung cancer

Background

In patients with non-small cell lung cancer (NSCLC) the pathologic lymph node status N1 is a heterogeneous entity, and different forms of lymph node involvement may represent different prognoses. For methodological reasons, the 8th edition of the TNM staging system for NSCLC makes no official changes to the N descriptor. However, there is evidence that different subforms of N1 disease are associated with different prognoses, and it is now recommended that clinicians record the number of affected lymph nodes and nodal stations for further analyses. In this investigation we sought to determine whether patients with different levels and types of N1 lymph node involvement had significantly different 5-year survival rates.

Methods

We retrospectively identified 90 patients with NSCLC (61 men, 29 women), who were treated between 2008 and 2012 and found to have pathologic N1 lymph node involvement and tumor sizes corresponding to T1 or T2. All patients were treated in curative intent with surgical lung resection and systematic mediastinal and hilar lymph node dissection.

Results

The overall 5-year survival rate was 56.3%. In the univariate analysis, lower tumor stage and tumor histology other than large-cell carcinoma were significantly associated with better long-term survival. Patients with solitary lymph node metastases also had longer disease-free survival than those with multiple nodal metastases. In the multivariate analysis, large-cell carcinoma and Union for International Cancer Control (UICC) stage IIB were independently associated with worse survival, while pneumonectomy, compared to lobar or sublobar resection, was independently associated with better survival.

Conclusions

Although we did not observe significant prognostic differences between N1 subcategories within our patient population, other analyses may yield different results. Therefore, these data highlight the need for large, well-designed multicenter studies to confirm the clinical significance of N1 subcategories.

Comparison of prognostic values of primary tumor and nodal 18F-fluorodeoxyglucose uptake in non-small cell lung cancer with N1 disease

INTRODUCTION

We hypothesized that, in non-small cell lung cancer (NSCLC) with N1 metastasis, N1 nodal ¹⁸F-fluorodeoxyglucose (FDG) status offers independent and incremental prognostic value.

METHODS

We enrolled 106 NSCLC patients with pathology-confirmed N1 metastasis. N1 node FDG positivity, primary tumor maximum standard uptake value (SUV_max), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) were measured. Kaplan-Meier method and Cox regression analyses were performed for cancer-specific survival (CSS) and disease-free survival (DFS).

RESULTS

Subjects were 67 males and 39 females (61.9 ± 9.4 years). Eighty-one (76.4%) and 25 (23.6%) had pathologic stage IIB and IIIA NSCLC, respectively. All underwent complete tumor resection. FDG-positive N1 nodes were larger and had higher primary tumor SUV_max. During a follow-up of 42 months, there were 56 recurrences and 31 cancer deaths. Significant univariate predictors were stage, no adjuvant therapy, and FDG-positive nodes for DFS, and stage, no adjuvant therapy, node size, tumor MTV, TLG, and SUV_max, and FDG-positive nodes for CSS. Independent predictors on multivariate analyses were FDG-positive nodes (HR = 3.071, p = 0.003), greater tumor TLG (HR = 3.224, p = 0.002), and no adjuvant therapy (HR = 3.631, p < 0.001) for poor CSS, and FDG-positive nodes (HR = 1.771, p = 0.040) and no adjuvant therapy (HR = 2.666, p = 0.002) for poor DFS. Harrell's concordance and net reclassification improvement tests showed that CSS prediction was significantly improved by the addition of N1 FDG status to a model containing tumor TLG.

CONCLUSION

N1 node FDG status can be useful for predicting the outcome of NSCLC patients with N1 metastasis beyond that provided by other prognostic variables.

KEY POINTS

• In NSCLC with N1 disease, N1 node FDG status is useful as a prognostic predictor. • FDG-positive N1 nodes provide additional prognostic value beyond TLG of primary tumor. • Combining TLG of primary tumor and N1 node uptake can stratify the survival of patients.

Eighth Edition Staging of Thoracic Malignancies: Implications for the Reporting Pathologist

Context The Staging and Prognostic Factors Committee of the International Association for the Study of Lung Cancer, in conjunction with the International Mesothelioma Interest Group, the International Thymic Malignancy Interest Group, and the Worldwide Esophageal Cancer Collaboration, developed proposals for the 8th edition of their respective tumor, node, metastasis (TNM) staging classification systems. Objective To review these changes and discuss issues for the reporting pathologist. Data Sources Proposals were based on international databases of lung (N = 94 708), with an external validation using the US National Cancer Database; mesothelioma (N = 3519); thymic epithelial tumors (10 808); and epithelial cancers of the esophagus and esophagogastric junction (N = 22 654). Conclusions These proposals have been mostly accepted by the Union for International Cancer Control and the American Joint Committee on Cancer and incorporated into their respective staging manuals (2017). The Union for International Cancer Control recommended implementation beginning in January 2017; however, the American Joint Committee on Cancer has deferred deployment of the eighth TNM until January 1, 2018, to ensure appropriate infrastructure for data collection. This manuscript summarizes the updated staging of thoracic malignancies, specifically highlighting changes from the 7th edition that are relevant to pathologic staging. Histopathologists should become familiar with, and start to incorporate, the 8th edition staging in their daily reporting of thoracic cancers henceforth.

Extranodal extension of nodal metastases is a poor prognostic moderator in non-small cell lung cancer: a meta-analysis

Extranodal extension (ENE) of nodal metastasis is defined as the extension of metastatic cells through the nodal capsule into the perinodal tissue. This morphological parameter, recently proposed as an important prognostic factor in different types of malignancy, has not been included in the TNM staging system for non-small cell lung cancer (NSCLC). In this systematic review with meta-analysis, we weighted the prognostic role of ENE in patients with lymph node-positive NSCLC. Two independent authors searched SCOPUS and PubMed through 28 February 2017. Prospective and retrospective studies on NSCLC, comparing patients with presence of ENE (ENE+) ENE+) vs. only intranodal extension (ENE-) and including data regarding prognosis, were considered as eligible. Data were summarized using risk ratios (RR) for the number of deaths/recurrences, and hazard ratios (HR) with 95% confidence intervals (CI) for time-dependent risk related to ENE+, adjusted for potential confounders. We identified 13 studies, including 1709 patients (573 ENE+ and 1136 ENE-) with a median follow-up of 60 months. ENE was associated with a significantly increased risk of mortality of all causes (RR = 1.39, 95% CI: 1.18-1.65, P < 0.0001, I² = 70%; HR = 1.30, 95% CI: 1.01-1.67, P = 0.04, I² = 0%) and of disease recurrence (RR = 1.32, 95% CI: 1.04-1.68, P = 0.02, I² = 42%; HR = 1.93, 95% CI: 1.53-2.44, P < 0.0001, I² = 0%). We conclude that in NSCLC, requirements for assessment of ENE should be included in gross sampling and ENE status should be included in the pathology report. Inclusion of ENE status in oncology staging systems will allow further assessment of its role as prognostic parameter.

Predictors for hilar/intrapulmonary lymph node metastasis in discrete type of clinical N1 non-small cell lung cancer

OBJECTIVE

Accurate preoperative evaluation of lymph nodes can provide optimal treatment for patients. However, in patients with clinical N1 disease (cN1) non-small cell lung cancer (NSCLC), no suitable predictor has been identified for hilar/intrapulmonary lymph node metastasis (pathological N1 disease; pN1). The purpose of this study was to identify pN1 in cN1 NSCLC patients.

METHODS

We retrospectively reviewed the clinicoradiological features of 109 patients with a discrete type of cN1 NSCLC who had undergone complete resection at our institution from 2004 to 2015. The association between clinicoradiological variables and nodal status was analyzed to identify predictors for pN1.

RESULTS

The cohort consisted of 77 males and 32 females, ranging in age from 39 to 84 years. The breakdown by pathological N category was 40 (37%) pN0, 41 (38%) pN1, and 28 (25%) pN2 patients. Maximum lymph node diameter was identified as a significant predictor for pN1, with an odds ratio of 1.25 (P = 0.010). When limited to 63 patients who underwent positron emission tomography (FDG-PET) at our institution, the maximum standardized uptake value (SUV_max) of the lymph node was an independent predictor, with an odds ratio of 1.91 with logistic regression analysis (P = 0.004). The size of lymph node and the SUV_max were significant factors for pN1, with optimal cut-off values of 13 mm and 4.28, respectively.

CONCLUSIONS

Among the patients with cN1, maximum lymph node size and SUV_max of the FDG-PET were significant predictors for pN1.

Nodal management and upstaging of disease: initial results from the Italian VATS Lobectomy Registry

BACKGROUND

VATS lobectomy is an established option for the treatment of early-stage NSCLC. Complete lymph node dissection (CD), systematic sampling (SS) or resecting a specific number of lymph nodes (LNs) and stations are possible intra-operative LN management strategies.

METHODS

All VATS lobectomies from the "Italian VATS Group" prospective database were retrospectively reviewed. The type of surgical approach (CD or SS), number of LN resected (RN), the positive/resected LN ratio (LNR) and the number and types of positive LN stations were recorded. The rates of nodal upstaging were assessed based on different LN management strategies.

RESULTS

CD was the most frequent approach (72.3%). Nodal upstaging rates were 6.03% (N0-to-N1), 5.45% (N0-to-N2), and 0.58% (N1-to-N2). There was no difference in N1 or N2 upstaging rates between CD and SS. The number of resected nodes was correlated with both N1 (OR =1.02; CI, 1.01-1.04; P=0.03) and N2 (OR =1.02; CI, 1.01-1.05; P=0.001) upstaging. Resecting 12 nodes had the best ability to predict upstaging (6 N1 LN or 7 N2 LN). The finding of two positive LN stations best predicted N2 upstaging [area under the curve (AUC) of receiver operating characteristic (ROC) =0.98].

CONCLUSIONS

Nodal upstaging (and, indirectly, the effectiveness of intra-operative nodal management) cannot be predicted based on the surgical technique (CD or SS). A quantitative assessment of intra-operative LN management may be a more appropriate and measurable approach to justify the extension of LN resection during VATS lobectomy.

Interleukin-17 potently increases non-small cell lung cancer growth

The aim of the present study was to explore the effects of interleukin (IL)-17 on the growth and metastasis of tumors that were subcutaneously implanted into C57BL/6 mice. Lewis lung carcinoma (LLC) cells were subcutaneously injected into C57BL/6 mice followed by intraperitoneal injection of mouse recombinant IL-17 protein (IL-17 groups) or phosphate-buffered saline (control groups). Tumor growth and metastasis were assessed by measuring the size and weight of tumors and cervical lymph nodes, respectively. Cytokine expression in tumor masses was quantified by reverse transcription-quantitative polymerase chain reaction and western blotting, respectively. CCR2-positive macrophage infiltration in tumor masses was detected by flow cytometric analysis. The proliferation and migration of LLC cells, stimulated by the IL-17 protein were detected by Cell Counting kit (CCK)-8 and wound scratch assays in vitro. Tumors were grafted into the C57BL/6 mice. The mice that were intraperitoneally injected with IL-17 exhibited significantly larger tumors compared with the control mice. After day 7 of injection and beyond, the weight of cervical lymph nodes in IL-17 groups was higher than that in the control mice. It was also demonstrated that the number of CCR2-positive macrophages that infiltrated the tumor masses in the IL-17 groups was higher than that of the control mice. CD34 expression in vascular endothelial cells was also higher in tumors grafted in IL-17 mice than those grafted in control mice. Furthermore, the tumor tissue mRNA and protein expression levels of vascular endothelial growth factor, matrix metalloproteinase (MMP)-2, MMP-9 and tumor necrosis factor-α were greater in mice from the IL-17 group than the control mice, while levels of migration inhibitory factor and thrombospondin-1 were lower in mice from the IL-17 group than in the control. IL-17 also increased the migration of LLC cells in vitro. In conclusion, IL-17 exhibited the ability to promote tumor growth by increasing angiogenesis, metastasis and increasing CCR2+ macrophage infiltration into tumors.

Heat shock protein B6 potently increases non-small cell lung cancer growth

The aim of the present study was to address the effects of heat shock protein B6 (HspB6) on tumor growth and metastasis in BALB/c mice. Lewis lung carcinoma (LLC) cells were subcutaneously injected into BALB/c mice followed by intraperitoneal injection of recombinant HspB6 (HspB6 groups) or phosphate‑buffered saline (control groups). Tumor growth and metastasis were assessed by size measurement and weighing of tumors and cervical lymph nodes, respectively. Chemokine expression in tumor masses was quantified quantitative polymerase chain reaction and western blotting. Tumor cell apoptosis was detected by flow cytometric analysis. The proliferation and migration of LLC cells, stimulated with HspB6, were detected using Cell Counting Kit 8 and wound scratch assays in vitro. Tumors grafted into the BALB/c mice and intraperitoneally injected with HspB6 were significantly bigger in size than those grafted into the control mice. From 7 days following the injection, the weight of cervical lymph nodes in HspB6 groups was higher than that in the control mice. We also revealed that the apoptotic cell number in tumor masses in the HspB6 groups was lower than that of the control mice. CD31 expression of vascular endothelial cells was higher in tumors grafted in HspB6 groups than those grafted in the control mice. Concomitantly, the tumor tissue mRNA and protein expression enhancement of vascular endothelial growth factor, basic fibroblast growth factor and intercellular adhesion molecule 1 were greater in HspB6 mice than in the control mice. HspB6 also inhibited cell apoptosis and enhanced the migration and proliferation of LLCs in vitro. In conclusion, HspB6 exhibited tumor promotion through increasing tumor angiogenesis, tumor metastasis and inhibiting tumor cell apoptosis.

Prognostic significance of the extent of lymph node involvement in stage II-N1 non-small cell lung cancer

BACKGROUND

The non-small cell lung cancer (NSCLC) staging system (published in 2009 in the seventh edition of the cancer staging manuals of the Union for International Cancer Control and American Joint Commission on Cancer) did not include any changes to current N descriptors for NSCLC. However, the prognostic significance of the extent of lymph node (LN) involvement (including the LN zones involved [hilar/interlobar or peripheral], cancer-involved LN ratios [LNRs], and the number of involved LNs) remains unknown. The aim of this report is to evaluate the extent of LN involvement and other prognostic factors in predicting outcome after definitive surgery among Chinese patients with stage II-N1 NSCLC.

METHODS

We retrospectively reviewed the clinicopathologic characteristics of 206 patients with stage II (T1a-T2bN1M0) NSCLC who had undergone complete surgical resection at Shanghai Chest Hospital from June 1999 to June 2009. Overall survival (OS) and disease-free survival (DFS) were compared using Kaplan-Meier statistical analysis. Stratified and Cox regression analyses were used to evaluate the relationship between the LN involvement and survival.

RESULTS

Peripheral zone LN involvement, cancer-involved LNR, smaller tumor size, and squamous cell carcinoma were shown to be statistically significant indicators of higher OS and DFS by univariate analyses. Visceral pleural involvement was also shown to share a statistically significant relationship with DFS by univariate analyses. Multivariate analyses showed that tumor size and zone of LN involvement were significant predictors of OS.

CONCLUSIONS

Zone of N1 LN, LN ratios, and tumor size were found to provide independent prognostic information in patients with stage II NSCLC. This information may be used to stratify patients into groups by risk for recurrence.

Risk factors for local and regional recurrence in patients with resected N0-N1 non-small-cell lung cancer, with implications for patient selection for adjuvant radiation therapy

BACKGROUND

The purpose of this study was to evaluate the actuarial risk of local and regional failure in patients with completely resected non-small-cell lung cancer (NSCLC), and to assess surgical and pathological factors affecting this risk.

PATIENTS AND METHODS

Between January 1998 and December 2009, 1402 consecutive stage I-III (N0-N1) NSCLC patients underwent complete resection without adjuvant radiation therapy. The median follow-up was 42 months.

RESULTS

Local-regional recurrence was identified in 9% of patients, with local failure alone in 3% of patients, regional failure alone in 4% of patients, and both local and regional failure simultaneously in 2% of patients. Patients who had local failure were found to be at increased risk of mortality. By multivariate analyses, three variables were shown to be independently significant risk factors for local [surgical procedure (single/multiple wedges+segmentectomy versus lobectomy+bilobectomy+pneumonectomy), tumor size>2.7 cm, and visceral pleural invasion] and regional (pathologic N1 stage, visceral pleural invasion, and lymphovascular space invasion, LVI) recurrence, respectively.

CONCLUSION

Patients with N0-N1 disease have low rates of locoregional recurrence after surgical resection. However, several prognostic factors can be identified that increase this risk and identify patients who may benefit from adjuvant treatment.

Tumor invasion of extralobar soft tissue beyond the hilar region does not affect the prognosis of surgically resected lung cancer patients

INTRODUCTION

Visceral pleural invasion, which is defined as tumor extension beyond the elastic lamina, is one of the most important prognostic factors in patients who have undergone curative resection for non-small cell lung cancer. However, in pathologic slides, pleural elastic lamina could not be found in the hilar region in which the pleura is reflected. Till date, when cancer cells are seen in this region, a basical agreement dealing with T factor is controversial among pathologists. The purpose of this study is to evaluate the significance of tumor invasion of that region as a prognostic factor.

METHODS

We reviewed 91 cases of surgically resected lung cancer in which invasion of the hilar region was visible macroscopically. By microscopic examination, we divided them into three groups: a group in which no cancer cells are seen in the soft tissue beyond the hilar region (group A), a group in which cancer cells are seen in the soft tissue beyond the hilar region (group B), and a group in which cancer cells could not be seen in the soft tissue beyond the hilar region but invade into the mediastinal visceral pleura at some other site (group C). We then evaluated the clinicopathologic characteristics of the patients and their outcome.

RESULTS

There was no statistically significant difference in the 5-year overall survival rate or disease-free survival rate between group A and group B (overall: 55 versus 48%; disease free: 43 versus 42%), but disease-free survival of group C was significantly lesser than that of group A and group B (A versus C: p = 0.022; B versus C: p = 0.040).

CONCLUSION

Tumor invasion of the soft tissue beyond hilar region would not be a prognostic factor in patients who have undergone curative resection for primary lung cancer, although investigation of larger number of cases will be needed to confirm the validity of our conclusion.

Prognostic impact of node involvement pattern in pN1 non-small cell lung cancer patients

INTRODUCTION

We previously showed that squamous cell carcinoma (SCC) patients with directly involved N1 nodes resulted in outcomes significantly better than those with separately involved N1 nodes. The purpose of this study was to evaluate the prognostic effect of node involvement patterns in pN1 non-small cell lung cancer (NSCLC) patients, with special attention given to any differences between SCC and adenocarcinoma (AD).

METHODS

We reviewed 324 consecutive patients with completely resected pN1 NSCLC and classified them into two groups based on their node involvement patterns: directly or separately involved N1 groups. To compare survival rates, 1545 pN0 patients and 330 pN2 patients were also investigated.

RESULTS

Univariate and multivariate analyses showed that the node involvement pattern was significantly associated with pN1 NSCLC patient outcome. The directly involved N1 group had a much better 5-year overall survival rate of 60.1% compared with 45.0% for the separately involved N1 group. In SCC patients, the directly involved N1 group showed an overall survival similar to pN0 patients, whereas overall survival of the separately involved N1 group was identical to that of pN2 patients, and their survival rates were significantly different. In AD patients, however, the survival rates were marginally different between the directly and separately involved N1 groups, and they were intermediate between pN0 and pN2 patient survival rates.

CONCLUSIONS

Node involvement patterns had significant prognostic effect in pN1 NSCLC patients. This effect was different between SCC and AD cases. The subclassification of N1 based on node involvement pattern is of significance for SCC patients but not for AD patients.

Prognostic significance of surgical-pathologic N1 lymph node involvement in non-small cell lung cancer

BACKGROUND

Patients with N1 non-small cell lung cancer represent a heterogeneous population with varying long-term survival. To better define the importance of N1 disease and its subgroups in non-small cell lung cancer staging, we analyzed patients with N1 disease using the sixth edition and proposed seventh edition TNM classifications.

METHODS

From January 1995 to November 2006, 540 patients with N1 non-small cell lung cancer who had at least lobectomy with systematic mediastinal lymphadenectomy were analyzed retrospectively.

RESULTS

For completely resected patients, the median survival rate and 5-year survival rate were 63 months and 50.3%, respectively. The 5-year survival rates for patients with hilar N1 (station 10), interlobar (station 11), and peripheral N1 (stations 12 to 14) involvement were 39%, 51%, and 53%, respectively. Patients with hilar lymph node metastasis showed a shorter survival period than patients with peripheral lymph node involvement (p = 0.02). Patients with hilar zone N1 (stations 10 and 11) involvement tended to show poorer survival than patients with peripheral zone N1 (12 to 14) metastasis (p = 0.08). Multiple-station lymph node metastasis indicated a poorer prognosis than single-station involvement (5-year survival 39% versus 51%, respectively, p = 0.01). Patients with multiple-zone N1 involvement showed poorer survival than patients with single-zone N1 metastasis (p = 0.04). A significant survival difference was observed between N1 patients with T1a versus T1b tumors (p = 0.02). Multivariate analysis revealed that only multiple-station lymph node metastasis was predictive of poor prognosis (p = 0.05).

CONCLUSIONS

Multiple-station versus single-station N1 disease and multiple-zone versus single-zone N1 involvement indicate poorer survival rate. Patients with hilar lymph node involvement had lower survival rates than patients with peripheral N1. The impact of T factor seemed to be veiled by the heterogenous nature of N1 disease. Further studies of adjusted postoperative strategies for different N1 subgroups are warranted.

Prognostic Variability in Completely Resected pN1 Non-Small-Cell Lung Cancer

We used the Tuscan Cancer Registry archives to retrieve records of 2,896 patients with a histological diagnosis of lung tumor from January 1996 to December 2000. Of 2,410 patients with non-small-cell lung cancer, 767 (31.8%) underwent complete resection. The following variables were analyzed for their influence on survival in the 157 patients with pathologic N1 status: sex, age, cell type, pathologic tumor status, number and level of involved lymph nodes, tumor grade, and type of surgery. Overall 5-year survival rates were 43.9% for 417 patients with pN0 disease, 10.8% for 176 with pN2 disease, and 31.6% for those with pN1 disease. In pN1 disease, the overall 5-year survival rates for patients with hilar and non-hilar lymph node involvement were 27.4% and 39.6%, respectively. Univariate analysis demonstrated that pathological T status and level of N1 involvement weresignificant prognostic factors. Cox proportional hazards analysis indicated that hilar lymph node involvement was an independent prognostic factor. N1 lymph node status was identified as an independent prognostic factor in a combination of subgroups with different prognoses.

Predictors of Survival and Disease-Free Survival in Patients With Resected N1 Non-Small Cell Lung Cancer

BACKGROUND

Factors that predict poor survival or increased risk of recurrence for patients with N1 disease may be dependent on tumor characteristics.

METHODS

This study was a retrospective review of a prospective database of consecutive patients who had clinical or pathologic N1 non-small cell lung cancer (NSCLC) who underwent preoperative 2-[18F] fluoro-2-deoxy-D-glucose (FDG)-positron emission tomography (PET) scans and complete resection with thoracic lymphadenectomy.

RESULTS

There were 135 patients (88 men). The 5-year disease-free rate was 55%. Kaplan-Meier analysis showed that poor differentiation (p = 0.036), multiple N1 stations (p = 0.010), and the lack of adjuvant chemotherapy (p = 0.039) were all associated with a shorter 5-year disease-free rate. Multivariate disease-free analysis demonstrated that only multiple stations (p = 0.002) were independently associated with recurrence. The overall 5-year survival was 48%. Univariate analysis showed that multiple nodes within one station (p = 0.016), multiple station involvement (p = 0.041), and lack of adjuvant chemotherapy (p = 0.039) and moderate-to-poor tumor differentiation (p = 0.046) were associated with decreased survival. Multivariate analysis found that multiple stations, multiple nodes, and lack of adjuvant chemotherapy were independent predictors of poor survival. Integrated PET-computed tomography (CT) was significantly more sensitive for staging N1 disease than dedicated FDG-PET (p = 0.032). Neoadjuvant chemotherapy given to 48 nonrandomized patients did not seem to impact disease recurrence or overall 5-year survival rates (p = 0.349).

CONCLUSIONS

Factors that predict a poor outcome in patients with resected N1 NSCLC are the involvement of multiple N1 stations, multiple N1 nodes, and the lack of adjuvant chemotherapy. Integrated PET-CT is more sensitive for detecting N1 disease then dedicated PET. These data may influence preoperative or postoperative therapy, or both.

The IASLC Lung Cancer Staging Project: Proposals for the Revision of the N Descriptors in the Forthcoming Seventh Edition of the TNM Classification for Lung Cancer

INTRODUCTION

Accurate staging of lymph node involvement is a critical aspect of the initial management of nonmetastatic non-small cell lung cancer (NSCLC). We sought to determine whether the current N descriptors should be maintained or revised for the next edition of the international lung cancer staging system.

METHODS

A retrospective international lung cancer database was developed and analyzed. Anatomical location of lymph node involvement was defined by the Naruke (for Japanese data) and American Thoracic Society (for non-Japanese data) nodal maps. Survival was calculated by the Kaplan-Meier method, and prognostic groups were assessed by Cox regression analysis.

RESULTS

Current N0 to N3 descriptors defined distinct prognostic groups for both clinical and pathologic staging. Exploratory analyses indicated that lymph node stations could be grouped together into six "zones": peripheral or hilar for N1, and upper or lower mediastinal, aortopulmonary, and subcarinal for N2 nodes. Among patients undergoing resection without induction therapy, there were three distinct prognostic groups: single-zone N1, multiple-zone N1 or single N2, and multiple-zone N2 disease. Nevertheless, there were insufficient data to determine whether the N descriptors should be subdivided (e.g., N1a, N1b, N2a, N2b).

CONCLUSIONS

Current N descriptors should be maintained in the NSCLC staging system. Prospective studies are needed to validate amalgamating lymph node stations into zones and subdividing N descriptors.

Adenoviral transduction of MRP-1/CD9 and KAI1/CD82 inhibits lymph node metastasis in orthotopic lung cancer model

Conventional therapies still remain less effective for metastasis of lung cancer, thus leading to a poor prognosis for this disorder. Although the processes involved in metastasis have not yet been clearly elucidated, our previous studies have shown that higher expression levels of MRP-1/CD9 and KAI1/CD82 in cancer cells are significantly correlated with less metastatic potency. To determine whether the gene transfer of these tetraspanins into lung tumor cells may be a useful strategy to regulate metastasis, we adopted an orthotopic lung cancer model produced by the intrapulmonary implantation of Lewis lung carcinoma (LLC) cells and evaluated the metastatic growth in the mediastinal lymph nodes using two different methods of gene delivery as follows: (a) the implantation of LLC cells preinfected with adenovirus encoding either MRP-1/CD9 cDNA, KAI1/CD82 cDNA, or LacZ gene into the mouse lung and (b) the intratracheal administration of these adenoviruses into the mice orthotopically preimplanted with LLC cells. In both cases, we found that the delivery of either MRP-1/CD9 or KAI1/CD82 cDNA dramatically reduced the metastases to the mediastinal lymph nodes in comparison with those of LacZ gene delivery, without affecting the primary tumor growth at the implanted site. These results reemphasize the important role of MRP-1/CD9 and KAI1/CD82 in the suppression of the metastatic process and also show the feasibility of gene therapy when using these tetraspanins for lung cancer to prevent metastasis to the regional lymph nodes. This strategy may therefore be clinically applicable as a prophylactic treatment to suppress the occurrence of lymph node metastasis.

Completely resected N1 non–small cell lung cancer: Factors affecting recurrence and long-term survival

OBJECTIVE

N1 disease in non-small cell lung cancer represents a heterogeneous patient subgroup with a 5-year survival of approximately 40%. Few reports have evaluated the correlation between N1 disease and tumor recurrence or which subgroup of patients would most benefit from adjuvant chemotherapy.

METHODS

From 1997 through 2002, all patients with pathologic T1-4 N1 M0 non-small cell lung cancer who had a complete resection with systematic mediastinal lymphadenectomy were retrospectively analyzed and evaluated for factors associated with recurrence and long-term survival.

RESULTS

One hundred eighty patients with N1 disease were evaluated. Sixty-six (37%) patients had either locoregional recurrence (n = 39 [22%]), distant metastasis (n = 41 [23%]), or both during follow-up. Univariate analysis demonstrated that visceral pleural invasion and age were associated with locoregional recurrence, whereas visceral pleural invasion, distinct N1 metastasis (as opposed to direct N1 invasion by the primary tumor), and multistation lymph node involvement were associated with distant metastasis (P < .05). Multivariable analysis demonstrated that visceral pleural invasion, multistation N1 involvement, and distinct N1 metastasis were the only independent predisposing factors for locoregional recurrence and distant metastasis. Overall 5-year survival was 42.5%. Survival was significantly decreased by advanced pathologic T classification (P = .015), visceral pleural invasion (P < .0001), and higher tumor grade (P = .014).

CONCLUSIONS

In patients with N1-positive non-small cell lung cancer, visceral pleural invasion, multistation N1 disease, and distinct N1 metastasis are independent predictors of subsequent locoregional recurrence and distant metastasis. Advanced T classification, visceral pleural invasion, and higher tumor grade were predictors of poor survival. These patients represent a subgroup of patients with N1 disease who might benefit from additional therapy, including adjuvant chemotherapy.

Prognostic variability among nonsmall cell lung cancer patients with pathologic N1 lymph node involvement

BACKGROUND

Patients who have nonsmall cell lung cancer with N1 lymph node status are an intermediate group of patients who have a variable prognosis. Differences in lymph node level (hilar or pulmonary lymph nodes) may influence patient survival. The authors retrospectively analyzed the factors that influenced prognosis, including the level of N1 lymph node involvement.

METHODS

The authors used the Tuscan Cancer Registry archives to retrieve records on 2523 patients who had lung tumors diagnosed during the period from 1996 and 1998 in the provinces of Florence and Prato, central Italy. To analyze the survival of patients according to the level of lymph node involvement, the prognoses of patients with nonsmall cell lung cancer who had N1 lymph node status were compared in a population-based case series. Among 112 patients with pathologic N1 status, the following variables were analyzed for their influence on postoperative survival: gender, age, cell type, pathologic tumor status, the number of metastatic lymph nodes, the level of metastatic lymph nodes (hilar or pulmonary), and the type of surgical resection.

RESULTS

The 5-year survival rates for patients who had involvement of pulmonary and hilar lymph nodes were 41.2% and 21.8%, respectively (P =.005). A Cox proportional hazards model analysis indicated that the presence of hilar lymph node involvement was an independent prognostic factor.

CONCLUSIONS

N1 pathologic lymph node status was identified in a combination of subgroups with different prognoses, and the presence of hilar lymph node disease had prognostic significance. This difference in survival may lead to the use of different therapies for these subgroups of patients with pathologic N1 non-small cell lung cancer.

Complete resection in lung cancer surgery: proposed definition

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Survival and characteristics of lymph node involvement in patients with N1 non-small cell lung cancer

N1 non-small cell lung cancer (NSCLC) encompasses a heterogeneous subgroup with differential lymph node involvement. Among 738 patients with NSCLC who underwent surgical resection, including 579 patients (78.5%) with systematic hilar and mediastinal lymph nodal dissection, from 1992 to 2001, 82 patients were pathologically defined as having N1 disease. We retrospectively analyzed the factors influencing survival, including the characteristics of lymph node involvement; the location of involved stations, the number of involved stations, the number of involved nodes, and the status of nodal involvement (microscopic N1, nodal involvement first defined by postoperative histological examination; or macroscopic N1, nodal involvement obviously recognized by preoperative examinations or surgical explorations). The overall 5-year survival rate of the 82 patients with N1 disease was 50.9%. No significant differences in the overall survival were found with regard to gender, age, histologic type, type of resection, or adjuvant therapies. Pathologic T status significantly influenced the overall survival (T1 versus T2 disease, P=0.008). According to the characteristics of lymph node involvement, the prognosis of patients with multiple-node N1 involvement was significantly poorer than that of those with single-node N1 involvement (5-year survival: 29.6% versus 61.5%, p=0.003). The prognosis of patients with macroscopic N1 disease was significantly poorer than that of those with microscopic N1 disease (5-year survival: 43.0% versus 65.0%, P=0.046). By comparison with the survival of patients who underwent surgical resection during the same period for pathologic N0 (pN0) and pathologic N2 (pN2) diseases, no survival differences were observed between microscopic N1/single-node N1 and pN0, or between multiple-node N1 and pN2 diseases. In patients with pathologic N1 disease, microscopic N1 and single-node N1 diseases may be an early stage, whereas multiple-node N1 disease behaves like an advanced stage.

Pathologic N1 non-small cell lung cancer: correlation between pattern of lymphatic spread and prognosis

OBJECTIVES

Patients with N1 non-small cell lung cancer represent a heterogeneous population with varying long-term survivals. Prognosis and pattern of recurrence seem to be particularly affected by the level of lymph node involvement.

METHODS

From 1990 to 1995, a total of 1954 consecutive patients underwent surgical resection for non-small cell lung cancer: 549 (28%) had ipsilateral pulmonary lymph node metastases (N1). The hospital survivors (n = 535) were reviewed. Three levels of lymph node metastases (hilar, interlobar, and lobar) were identified according to the new Regional Lymph Node Classification for Lung Cancer Staging and differentiated from lymph node involvement on the basis of direct invasion.

RESULTS

1 The overall 5-year survival of patients with N1 disease was 40%. Survival was related in the univariate analysis to T classification, level-type of N1 involvement, number of involved nodes, multilevel involvement, Karnofsky Index, R status, and adjuvant therapy. In the multivariate analysis, only T classification and level-type of N1 involvement clearly showed statistical power (P =.000 and P =.001, respectively). The pattern of cancer relapse according to level-type of N1 involvement differed significantly: hilar N1 disease recurred at distant sites in 41% of patients and locoregionally in 12% of patients, whereas N1 disease by direct invasion occurred in 24% and 17% of patients, respectively (P =.030).

CONCLUSIONS

Metastases to ipsilateral hilar, interlobar, or both, lymph nodes are associated with a poorer prognosis compared with metastases in intralobar lymph nodes or with lymph node involvement by means of direct invasion. Although surgical resection remains the mainstay of treatment, the high rate of tumor recurrence in both groups mandates further randomized studies with multimodality therapy approaches.

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

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

Prognostic factors in patients with resected pathologic (p-) T1-2N1M0 non-small cell lung cancer (NSCLC)

OBJECTIVES

To clarify prognostic factors in resected pathologic (p-) T1-2N1M0 non-small cell lung cancer (NSCLC).

METHODS

A total of 95 consecutive patients who underwent complete tumor resection and mediastinal dissection for pT1-2N1M0 NSCLC between 1976 and 1997 were retrospectively reviewed. p53 status and proliferative activity were evaluated immunohistochemically.

RESULTS

The extent of N1 stations and p53 status proved to be significant prognostic factors. The 5-year survival rate for tumor without hilar node (#10) involvement was 66%, significantly higher than that for tumor with #10 involvement (39%, P<0.01). The 5-year survival rate for tumor with aberrant p53 expression was 37%, significantly lower than that for tumor without aberrant p53 expression (74%, P<0.01). There proved to be no significant difference in the prognosis between pT1 disease and pT2 disease; the 5-year survival rates for pT1 and pT2 diseases were 62 and 56%, respectively. Age, gender, performance status, grade of tumor differentiation, histological type, or proliferative activity were not significant factors. Multivariate analysis of prognostic factors using Cox's proportional hazard model confirmed these results.

CONCLUSIONS

Involvement of the hilar node and aberrant p53 expression were significant factors to predict a worse prognosis in resected T1-2N1M0 NSCLC.

Prognostic assessment of 2,361 patients who underwent pulmonary resection for non-small cell lung cancer, stage I, II, and IIIA

STUDY OBJECTIVES

Staging and classification in lung cancer are important for both patient management and clinical research. Results of survival after resection in patients with primary non-small cell lung cancer (NSCLC) are analyzed in order to validate recent refinements of the staging system.

DESIGN

Retrospective study; period from 1970 to 1992; follow-up > or = 5 years.

PATIENTS

A total of 2,361 previously untreated patients who underwent resection for stage I, II, or IIIA primary NSCLC.

MEASUREMENTS

Survival was estimated from the date of operation using the Kaplan-Meier survival analysis method. Deaths within 30 days of operation were excluded. Survival comparisons of different surgical-pathologic TNM classification (based on pathologic examination of resected specimens) as well as further discriminative factors were analyzed by log-rank test.

RESULTS

Postoperative death occurred in 3.9% of patients. For survival analyses, 2,263 patients were included. The overall 5-year survival was 937/2,263 (41.4%). Five-year survival in stage IA was 255/404 (63%); in stage IB, 367/797 (46%); in stage IIA, 43/83 (52%); in stage IIB, 210/642 (33%); and in stage IIIA, 63/337 (19%). No significant difference in survival was demonstrated between stages IB and IIA. Until 4 years after surgery, age at operation did not influence survival; after 5 years, patients > 65 years old had a significantly lower survival.

CONCLUSION

The TNM staging system accurately reflects the prognosis in primary NSCLC, but some stage definitions can be discussed. Despite the fact that the staging system is built on clinical data, the present analysis, which includes postsurgical data, confirms the similar survival of patients with T2N0M0 and T1N1M0. These results also stress the use of two separate substages, especially because these patients are offered surgery when possible.

Type of lymph node involvement and survival in pathologic N1 stage III non-small cell lung carcinoma

BACKGROUND

Survival of patients with stage II non-small lung cancer by the 1986 classification depends on the type of lymph node involvement (by direct extension or by metastases in lobar or hilar lymph nodes). The influence of these types of lymph node involvement on survival was investigated in pathologic N1 stage III patients.

METHODS

Of 2,009 patients having operation from 1977 through 1993, the cases of 123 patients with pathologic N1 stage III disease (80 T3 N1 and 43 T4 N1) were reviewed. The N1 status was refined by the specific type of lymph node involvement.

RESULTS

The cumulative 5-year survival rate of all hospital survivors (n = 111) was 27.2%. A significant difference in mean 5-year survival rate was observed between patients who underwent complete resection and those with incomplete resection (34.4% versus 11.4%; p = 0.0001). Further analysis was performed with hospital survivors having complete resection only (n = 76). The cumulative 5-year survival rate was 34.4%. Type of lymph node involvement did not relate to survival for the group as a whole or for the T3 and T4 subsets. Survival was not related to age, histology, type of resection, or tumor size.

CONCLUSIONS

Moderately good results can be obtained with surgical resection for stage III patients with pathologic N1 disease. In contrast with stage II, complete resection of pathologic N1 higher-stage non-small cell lung carcinoma is not influenced by type of lymph node involvement.

The impact of surgical adjuvant thoracic radiation for different stages of non-small cell lung cancer: the experience from a single institution

A retrospective analysis is performed of 223 patients receiving radiotherapy after complete surgery or microscopic-positive resection margins for non-small cell lung cancer. All patients received a total dose of 55 Gy. For 98 stage II (T1, T2N1), a 5-year survival rate of 37% was found. First failure analysis showed 15% (15/98) local and 39% (38/98) distant failures. Patients with hilar-positive lymph nodes had a 5-year survival rate of 32%, compared with 41% for lobar-positive nodes due to more distant failures. Patients with squamous histology had a better survival than non-squamous tumours. There were 48 patients with pN2 tumours. First failure analysis gave 23% (11/48) local and 39.5% (19/48) distant failures resulting in 35% 5-year survival. Patients with pT3N0 with microscopic-positive resection margins and pT3N1 tumours had 5-year survival rates of 21.5 and 17%. Postoperative radiotherapy should be advised in cases of positive hilar nodes, and in all cases of mediastinal-positive nodes. A combination schedule with chemotherapy seems necessary.

Photodynamic therapy for early stage squamous cell carcinoma of the lung

OBJECTIVE

To study the effectiveness of photodynamic therapy (PDT) as a therapeutic strategy in roentgenographically occult squamous cell carcinoma of the lung.

MATERIAL AND METHODS

A carefully selected group of 21 patients (with 23 cancers) who had early stage squamous cell carcinoma of the lung and were eligible for surgical treatment were offered PDT as an alternative to resection. Patients underwent close follow-up with bronchoscopic surveillance and were offered resection if cancer persisted after no more than two sessions of PDT.

RESULTS

A complete response was identified in 15 patients (16 cancers) after an initial PDT session. A complete response that lasted longer than 12 months was noted in 11 patients (52%). After PDT, the minimal follow-up period was 24 months. A subsequent primary lung cancer developed in 5 of the 21 patients (24%). Ten patients ultimately had surgical treatment, in 3 (30%) of whom N1 disease was identified at the time of resection. Two patients refused a surgical procedure and received alternative therapy. Therefore, nine patients (43%) were spared an operation (95% confidence interval, 21.8 to 66.6%). The mean duration of follow-up for these nine patients was 68 months (range, 24 to 116).

CONCLUSION

On the basis of this investigation, we can conclude with 95% confidence that at least 22% of patients with early stage squamous cell lung cancer who are candidates for PDT can be spared surgical resection.

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.