The International Association for the Study of Lung Cancer Lung Cancer Staging Project: Proposals for the Revision of the Clinical and Pathologic Staging of Small Cell Lung Cancer in the Forthcoming Eighth Edition of the TNM Classification for Lung Cancer

INTRODUCTION

Small cell lung cancer (SCLC) is commonly classified as either limited or extensive, but the Union for International Cancer Control TNM Classification of Malignant Tumours seventh edition (2009) recommended tumor, node, and metastasis (TNM) staging based on analysis of the International Association for the Study of Lung Cancer (IASLC) database.

METHODS

Survival analyses were performed for clinically and pathologically staged patients presenting with SCLC from 1999 through 2010. Prognosis was compared in relation to the TNM seventh edition staging to serve as validation and analyzed in relation to proposed changes to the T descriptors found in the eighth edition.

RESULTS

There were 5002 patients: 4848 patients with clinical and 582 with pathological stages. Among these, 428 had both. Survival differences were confirmed for T and N categories and maintained in relation to proposed revisions to T descriptors for seventh edition TNM categories and proposed changes in the eighth edition. There were also survival differences, notably at 12 months, in patients with brain-only single-site metastasis (SSM) compared to SSM at other sites, and SSM without a pleural effusion showed a better prognosis than other patients in the M1b category.

CONCLUSION

We confirm the prognostic value of clinical and pathological TNM staging in patients with SCLC, and recommend continued usage for SCLC in relation to proposed changes to T, N, and M descriptors for NSCLC in the eighth edition. However, for M descriptors, it remains uncertain whether survival differences in patients with SSM in the brain simply reflect better treatment options rather than better survival based on anatomic extent of disease.

[Surgical repair of postpneumonectomy syndrome with vascular compromise]

Postpneumonectomy syndrome is a rare complication of pneumonectomy that develops as a result of excessive displacement of mediastinal structures into the empty cavity. We report the case of a 72-year-old man who developed dysphagia and progressive weakness, along with signs of hypotension due to low cardiac output, following removal of the left lung for lung cancer. Intubation and transfer to the intensive care unit was necessary. When such causes as pulmonary embolism, pneumonia and COPD exacerbation had been ruled out, postpneumonectomy syndrome was diagnosed. Two tissue expansion prostheses (100 mL and 400 mL) were implanted surgically to keep the mediastinum in position and reverse symptoms immediately. We conclude that postpneumonectomy syndrome after left pneumonectomy is a rare complication that may be more frequent than the literature suggests, given that signs may be masked by a diagnosis of cardiogenic shock that leads to death. Surgical repair is simple, reversing symptoms immediately.

[The effect of peroperative transfusion on survival in resected lung carcinomas]

This paper analyzes the influence of perioperative transfusion on survival after lung cancer surgery. Between January 1991 and December 1995, we enrolled 405 patients, 196 of whom received transfusions and 209 of whom did not. Follow-up extended to December 1997. Excluded were patients undergoing exploratory thoracotomy (n = 92), those who died during the postoperative period (n = 19) and those lost to follow-up (n = 13). The final number of patients in the study was 281 (136 who received transfusions and 145 who did not). We analyzed age, sex, general clinical status measured on the Eastern Cooperative Oncology Group (ECOG) scale, histological type and TNM staging. Single and multiple variable analyses were performed. At the end of the study 158 patients were alive and 123 had died. Transfusions were used more often in pneumonectomies (p < 0.001) and in patients with an ECOG score of 2 (p < 0.01). Survival at 36 and 60 months, calculated using the Kaplan-Meier method was 52% and 30%, respectively, for those who had received transfusions, and 53% and 49%, respectively, for those who had not. The differences were not statistically significant (p > 0.1). Multivariant analysis failed to demonstrate an influence of transfusion on survival (relative risk of 1.08; 95% confidence interval 0.72-1.61; p > 0.1). We conclude that there is no negative prognostic effect of perioperative transfusion.

[Usefulness of urokinase in multilocular pleural effusion]

Recognizing the confirmed efficacy of urokinase as a thrombolytic and proteolytic agent, we assess its usefulness in the treatment of multiloculated pleural effusion, empyema and hematoma as a substitute of other more invasive procedures. Treatment with urokinase was applied in 18 consecutive cases. Inclusion criteria were a well-placed thoracic probe that did not drain and a radiological image showing occupation. Patients were excluded if they had bronchial fistulas or hemothorax of less than 7 days duration. Effusion in the included cases had developed after pneumonia, after surgery or after trauma. Treatment lasted 3 to 4 days ant was considered effective or not based on the volume of liquid drained and on radiological evidence of change. The amount of liquid drained was highly variable (mean 1,282 and S.D. 1,224; range 100-3,975). Radiological change was considered completely satisfactory in 10 cases, with 6 patients continuing to show occupation of the costophrenic sinus with no clinical repercussions. Two patients died of causes unrelated to administration of the drug. There were two mild relapses that did not require a second round of treatment with urokinase. Patients were followed for a least 30 days after discharge and no new recurrences were detected. We have found urokinase to be a useful fibrinolytic agent for treating multiloculated effusion. Contraindications are few and therefore urokinase should be considered the first-choice treatment to be applied before other more invasive measures are taken.

[Endoscopic treatment of bronchopleural fistula using fibrin biological adhesive]

Three cases are reported of bronchopleural fistula successfully resolved by using biological adhesives through the intrabronchial way. In the three cases the rigid bronchoscope was used to prepare the field and the passage of the adhesive material. The results obtained allow the consideration of this procedure as useful for small fistulas and as a initial therapeutical approach for other fistulas due to the small morbidity rate associated with this procedure compared with others.