Paired Phase II Studies of Erlotinib/Bevacizumab for Advanced Bronchioloalveolar Carcinoma or Never Smokers With Advanced Non-Small-cell Lung Cancer: SWOG S0635 and S0636 Trials

BACKGROUND

Before mutation testing of the epidermal growth factor receptor (EGFR) gene was recognized as highly associated with the activity of EGFR tyrosine kinase inhibitors (TKIs), clinically defined patient populations with bronchioloalveolar carcinoma (BAC) and never smokers were identified as likely to benefit from EGFR TKIs. From preclinical and clinical data suggesting potentially improved efficacy with a combination of an EGFR TKI and the antiangiogenic agent bevacizumab, the Southwestern Oncology Group (SWOG) initiated paired phase II trials to evaluate the combination of erlotinib/bevacizumab in patients with advanced BAC (SWOG S0635) or never smokers with advanced lung adenocarcinoma (SWOG S0636).

MATERIALS AND METHODS

Eligible patients with BAC or adenocarcinoma with BAC features (SWOG S0635) or never smokers with advanced lung adenocarcinoma (SWOG S0636) received erlotinib 150 mg/day with bevacizumab 15 mg/kg until progression or prohibitive toxicity. Never smokers with BAC were preferentially enrolled to SWOG S0636. The primary endpoint for both trials was overall survival.

RESULTS

A total of 84 patients were enrolled in the SWOG S0635 trial and 85 in the SWOG S0636 trial. The objective response rate was 22% (3% complete response) in the SWOG S0635 trial and 50% (38% confirmed; 3% complete response) in the SWOG S0636 trial. The median progression-free survival was 5 and 7.4 months in the S0635 and S0636 trials, respectively. The median overall survival was 21 and 29.8 months, respectively. Toxicity consisted mainly of rash and diarrhea in both trials.

CONCLUSION

Although the field has moved toward molecular, rather than clinical, selection of patients as optimal candidates for EGFR TKI therapy, these results support the hypothesis that a subset of patients in whom erlotinib is particularly active could receive an incremental benefit from the addition of bevacizumab.

How do social factors explain outcomes in non-small-cell lung cancer among Hispanics in California? Explaining the Hispanic paradox

PURPOSE

Hispanics in the United States have lower age-adjusted mortality resulting from non-small-cell lung cancer (NSCLC) compared with non-Hispanic whites (NHWs). The purpose of this study was to evaluate individual, clinical, and neighborhood factors in survival among Hispanics with NSCLC.

PATIENTS AND METHODS

We performed a retrospective analysis of NHWs and Hispanics with NSCLC between 1998 and 2007 in the California Cancer Registry (follow-up to December 2009). Kaplan-Meier curves depict survival by nativity for Hispanics with NSCLC. Cox proportional hazards models estimated hazard of mortality by race with adjustment for individual (age, sex, marital status), clinical (histologic grade, surgery, irradiation, chemotherapy), and neighborhood factors (neighborhood socioeconomic status, ethnic enclave).

RESULTS

We included 14,280 Hispanic patients with NSCLC. Foreign-born Hispanics had 15% decreased risk of disease-specific mortality resulting from NSCLC compared with NHWs (hazard ratio [HR], 0.85; 95% CI, 0.83 to 0.88) after adjustment for individual, clinical, and neighborhood factors. After adjustment for individual factors, compared with US-born Hispanics, foreign-born Hispanics had 10% decreased risk of disease-specific mortality (HR, 0.90; 95% CI, 0.87 to 0.96). Clinical and neighborhood factors slightly moderated the survival benefit for foreign-born patients. A modestly more pronounced survival advantage was seen for foreign-born Hispanics living in low socioeconomic and high Hispanic enclave neighborhoods as compared with US-born Hispanics (HR, 0.86; 95% CI, 0.81 to 0.90).

CONCLUSION

Foreign-born Hispanics with NSCLC have a decreased risk of disease-specific mortality compared with NHWs and US-born Hispanics with NSCLC. Neighborhood factors slightly moderate this survival advantage. This survival advantage is slightly more pronounced in lower socioeconomic and higher Hispanic enclave neighborhoods.

Southwestern oncology group phase II trial (S0526) of pemetrexed in bronchioloalveolar carcinoma subtypes of advanced adenocarcinoma

BACKGROUND

Pemetrexed, a multitargeted antifolate drug, is an active agent in non-small-cell lung cancer (NSCLC), especially adenocarcinomas. Based on preclinical data supporting the relevance of alpha-folate receptors in adenocarcinoma of the bronchioloalveolar carcinoma (BAC) subtype, this trial was designed to assess pemetrexed in patients with this pathologic subtype of lung adenocarcinoma.

PATIENTS AND METHODS

Patients with histologically confirmed stage IIIB (with malignant pleural effusion) or stage IV adenocarcinoma with BAC features or pure BAC were eligible. Treatment consisted of pemetrexed, 500 mg/m(2), administered intravenously every 21 days.

RESULTS

Of 27 patients enrolled, 24 were eligible and assessable for adverse events: Toxicity was primarily hematologic, consisting of leukopenia/neutropenia, thrombocytopenia, and anemia. The median follow-up among patients still alive (n = 8) was 35 months (range, 26-47 months). Among 17 patients with measurable disease, the response rate was 23% (all partial responses; 95% confidence interval [CI], 10%-56%). The median progression-free survival (PFS) and overall survival (OS) were 6 and 25 months, respectively.

CONCLUSION

Pemetrexed is active and well tolerated and, in patients with adenocarcinoma BAC subtypes, likely related to its underlying mechanism of action as a multitargeted antifolate drug.

Postoperative survival of lung cancer patients: are there predictors beyond TNM?

BACKGROUND/AIM

We report on survival data of 595 patients with stage I-III lung cancer with respect to TNM classification.

MATERIALS AND METHODS

We constructed a basic model consisting of stage and grade, and assessed the improvement of survival prediction after adding comorbidity data, spirometric data, clinical and laboratory parameters.

RESULTS

Body mass index (BMI) and presence of a cardiac disease reached statistical significance for prediction of overall survival in a Cox regression model. In addition to BMI (<25 kg/m(2)) and the presence of cardiovascular disease, the spirometric variable (FEV1) predicted early death (less than five months postoperatively). When the survival random forest method was employed to predict disease outcome, creatinine levels and VO2 max became additional variables of interest for predicting survival.

CONCLUSION

We propose that our lung cancer database may help to identify variables (aside from histomorphological variables) that are suitable for identifying patients at risk of death after surgical treatment of lung cancer.

Mechanisms Involved in A/J Mouse Lung Tumorigenesis Induced by Inhalation of an Environmental Tobacco Smoke Surrogate

Lung tumors have been reproducibly induced in A/J mice exposed to a surrogate for experimental environmental tobacco smoke (ETSS) in a 5-mo inhalation period followed by 4 mo without further exposure. In order to increase our mechanistic understanding of this model, male mice were whole-body exposed for 6 h/d, 5 d/wk to ETSS with a particulate matter concentration of 100 mg/m(3). Food restriction regimens were included to model or exceed the ETSS-related impairment of body weight development. Half of the mice were pretreated with a single ip injection of urethane to study the effect of the above treatments on lung tumor development induced by this substance. At 5 mo, the tumor response was statistically the same for all groups of non-pretreated mice; however, the expected urethane-induced lung tumorigenesis was significantly inhibited by approximately 25% by ETSS and food restriction. This inhibition was accompanied by a threefold increase in blood corticosterone as a common stress marker for both ETSS and food restriction. At 9 mo, in mice not pretreated, the lung tumor incidence and multiplicity were significantly increased by twofold in the ETSS group; in the urethane-treated groups, the same high tumor multiplicity was reached regardless of previous treatment. The predominant tumor type in all groups was bronchiolo-alveolar adenoma. There was no induction of a specific K-ras mutation pattern by ETSS exposure. These data suggest a stress-induced inhibition of lung tumorigenesis in this model, explaining the need for the posttreatment period.

[Tumor size and survival in lung cancer, stage IA]

TNM staging is an important long-term predictor for survival of lung cancer patients. Some studies have shown, however, that tumor size may have intrinsic prognostic value independent of TNM stage. The relationship between tumor size and survival is particularly unclear in T1 tumors. The objective of this study was to assess the prognostic value of tumor size in surgically resected stage I of non-small cell lung cancer (NSCLC). Clinical records of 79 patients with stage IA NSCLC were reviewed. In 34.4% of patients (n = 28) size was < or = 1.5 cm. Surgical mortality was 1.3%. Disease recurrence was noted in 19%. Patients with tumors < or = 15 mm had a significantly higher 5-year survival (95% CI:0.05 vs. 77% CI: 0.07 in > 15mm group). Disease-free survival was 95% for tumors less than 15 mm vs. 72% in larger tumors. Using Cox Multivariate analysis, the most determinant factor for higher risk of mortality was size > 15 mm (relative risk 25.9, IC: 2.3-292, p = 0.004). The independent influence of tumor size in stage IA NSCLC may have practical implications with regards to proposals for screening asymptomatic individuals at high risk for lung cancer.

[Operative treatment and remote results in patients with bronchoalveolar lung cancer]

Bronchoalveolar pulmonary carcinoma (BAC) is a type of adenocarcinoma with an increasing frequency. Because BAC rarely metastasize outside the thorax, the postoperative results are good.

MATERIAL AND METHOD

We present 28 patients with BAC, operated in the clinic for a period of 7 years--12 patients with an infiltrative form of BAC, 16 patients with nodular form

RESULTS

12 patients underwent lobectomy, 15 patients--pneumonectomy, and 1 patient--bilobectomy. The 5-years-survival rate is 50%.

CONCLUSIONS

We found a better 5-years survival rate for the patients with BAC in comparison with the other histological types of non-small cell pulmonary carcinoma

Prognostic value of histology in resected lung cancer with emphasis on the relevance of the adenocarcinoma subtyping

BACKGROUND

Adenocarcinoma (AC) is the most common lung cancer, followed by squamous cell carcinoma (SCC). Controversy exists concerning both cell types. Our purpose was to compare their prognosis after resection and determine whether AC subtyping may have any significance.

METHODS

From 1993 to 2002, 574 patients with SCC and 565 with AC underwent a curative resection and were compared according to sex, age, type of resection, TNM system classification, and survival. One hundred fifty-nine patients with ACs demonstrated a pure histologic pattern according to the 1999 World Health Organization classification, and 406 were of the mixed subtype including cell types with potentially different aggressiveness. Therefore, we compared subgroups according to presence or not of bronchioloalveolar carcinoma or solid adenocarcinoma with mucin component, or both.

RESULTS

Compared with ACs, SCCs had a higher number of males and older patients, and incidences of endobronchial tumors, pneumonectomies, and stage II tumors were higher. Global survival rates were not different. The ACs with solid AC with mucin components (n = 239) were characterized by more males and stage IIB patients, and had poorer survival rates (38.6% vs 61.4%; p < 0.0014) than the ACs without solid AC with mucin component. When comparing these with SCCs, 5-year survival rates were: ACs without solid AC with mucin component (58.1%), SCCs (50.2%), and ACs with solid AC with mucin component (36.8%) (p < 0.000019). Multivariate analysis demonstrated these subgroups and SCCs to be independent factors of prognosis.

CONCLUSIONS

Solid ACs with a mucin component demonstrated the poorest prognosis after resection. Further studies of this cell type, which should be looked for carefully, may help improve targetting adjuvant therapies.

Lung cancer in octogenarians: factors affecting long-term survival following resection

OBJECTIVE

To identify factors associated with long-term survival following pulmonary resection for lung cancer in patients 80 years of age or older.

METHODS

The medical records of all patients >or=80 years, who underwent pulmonary resection for lung cancer from 1985 to 2002, were reviewed.

RESULTS

There were 294 patients (192 men, 102 women). Median age was 82 years (range 80-94 years). Overall 1-, 2-, and 5-year survival was 80%, 62%, and 34%, respectively. Histologic subtype, diabetes, renal insufficiency, prior myocardial infarction, congestive heart failure or stroke were not significantly associated with differences in 5-year survival. Female gender was associated with increased survival (36.2% vs 32.7% at 5 years, p=0.04). Extent of preoperative forced expiratory volume in 1s (FEV1) limitation did not influence survival. However, there were no 5-year survivors amongst patients with dyspnea as their presenting chief complaint, whereas there was a 35% 5-year survival in patients presenting without dyspnea (p<0.001). Five-year survival by pathologic stage was IA, 48%; IB, 39%; IIA, 17%; IIB, 23%; IIIA, 9%; and IIIB, 0% (p<0.001). Five-year survival of patients undergoing a lobectomy was 42% versus 11% for pneumonectomy (p<0.001).

CONCLUSIONS

Meaningful long-term survival is obtainable in elderly patients undergoing surgical resection for lung cancer. Careful patient evaluation and selection is necessary to identify patients who will benefit most from resection. Shorter survival was observed in male patients and those presenting with dyspnea. As could be expected, survival was also dependent on extent of resection and initial pathologic stage.

Comparison in prognosis after VATS lobectomy and open lobectomy for stage I lung cancer

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) has become an attractive surgical procedure, but several issues remain to be resolved. Prognosis after VATS lobectomy is important to evaluate the adequacy of VATS lobectomy as a cancer operation. Interestingly, several investigators, including us, have reported that prognosis after VATS lobectomy was superior to that after open lobectomy in early non-small-cell lung cancer (NSCLC). One of the possible reasons is the low invasiveness of VATS lobectomy. But we considered that patient bias might have some influence favoring VATS lobectomy. To evaluate our hypothesis, we reviewed medical records of stage I NSCLC patients undergoing operation between 1993 and 2002. We compared and evaluated the relationship between patient characteristics and prognosis after VATS and open lobectomy. We focused particularly on histological type, classifying it into four subgroups; (1) bronchioloalveolar carcinoma (BAC), (2) mixed BAC + papillary adenocarcinoma (BAC + Pap), (3) other adenocarcinoma (Other adeno), (4) squamous cell carcinoma + others (Sq + others).

RESULTS

A total of 165 patients underwent VATS lobectomy, and 123 patients underwent open lobectomy. The 5-year survival rate of the VATS lobectomy group was 94.5% and that of the open lobectomy group was 81.5%. Univariate Cox regression of survival revealed that male, CEA > 5, Other adeno, Sq + others, open lobectomy, and tumor size > 3 cm were significant negative prognostic variables. Multivariate Cox regression of survival revealed that histological subtype and tumor size were independent prognostic factors, but surgical procedure was not an independent prognostic factor.

COMMENTS

Prognosis after VATS lobectomy was superior to that after open lobectomy, but patient bias influenced the prognosis in favor of VATS lobectomy, and the surgical procedure itself was not a prognostic factor.

Prognostic significance of a histologic subtype in small adenocarcinoma of the lung: the impact of nonbronchioloalveolar carcinoma components

BACKGROUND

We tried to clarify whether the histologic subtypes and the size of the solid component of an adenocarcinoma are more important predictive factors for invasiveness or prognosis than is total tumor size, even in lung adenocarcinomas that were 2 cm or smaller.

METHODS

Between 1996 and December 2005, after standard surgical treatment, 82 patients were diagnosed as having adenocarcinoma with a maximum diameter of 2 cm or less. The group comprised 37 females and 45 males, with ages ranging from 41 to 80 years (median, 64). The clinicopathologic records of the patients were examined with regard to age, sex, nodal status, tumor size (largest diameter of the total tumor as well as the largest diameter without the bronchioloalveolar carcinoma [BAC] component [solid component]), serum carcinoembryonic antigen level, and histologic type. These variables were analyzed as risk factors for vascular or lymphatic invasion, lymph node metastasis, and prognosis. Histologic subtype was classified into two groups: mixed BAC (mixed adenocarcinoma with BAC) and minimal or non-BAC (tumors with little or no BAC component).

RESULTS

Histologic subtype was a significant predictive factor both for invasiveness (vascular or lymph vessels) and lymph node metastasis, in both univariate and multivariate analysis. Tumor diameter was not a significant factor in either univariate or multivariate analysis (p = 0.28, 0.15, respectively). However, diameter excluding the BAC component was a significant factor for invasiveness in mixed BAC type (p = 0.035), whereas total diameter was not significant (p = 0.28). Finally, histologic subtype and lymph node metastasis were significant prognostic factors for survival in both univariate (p = 0.03, 0.05, respectively) and multivariate (p = 0.04, 0.05, respectively) analyses. The 5-year survival rate was 94.4% (94.1% for pN0) for the mixed BAC type and 71.4% (78.7% for pN0) for the minimal or non-BAC type (p = 0.009; p = 0.04 for pN0 nodes).

CONCLUSIONS

Small adenocarcinomas can be classified into two categories. The first category is a minimal or non-BAC adenocarcinoma that shows aggressive biological behavior. The second category is a mixed BAC, which demonstrates less invasive or aggressive biological behavior than the minimal or non-BAC type, with the degree of invasiveness being associated with the size of the non-BAC component.

Prognostic factors for survival of stage I nonsmall cell lung cancer patients

BACKGROUND

Platinum-based adjuvant chemotherapy in randomized trials has failed to provide a survival benefit in patients with resected stage I nonsmall cell lung cancer (NSCLC). Using data from the California Cancer Registry (CCR), we explored factors that had detrimental effects on survival in patients with stage I NSCLC to identify a subset of patients at high risk for disease recurrence and subsequent mortality.

METHODS

Between 1989 and 2003, 19,702 incident cases of stage I NSCLC in the CCR were identified and subgrouped into stage IA and IB disease. Patient demographic factors, tumor characteristics, and treatment delivered were examined. Kaplan-Meier survival curves were calculated to estimate survival rates. Cox proportional-hazards ratios were used to identify independent prognostic factors for survival.

RESULTS

Advanced age at diagnosis, male sex, low socioeconomic status (SES), nonsurgical treatment, and poor histologic grade (stage IA NSCLC: hazards ratio [HR], 1.13; 95% confidence interval [95% CI], 1.08-1.19; stage IB NSCLC: HR, 1.11; 95% CI, 1.07-1.16) were associated with increased mortality risk on multivariate analysis. Non-upper lobe tumor location (right middle lobe, right and left lower lobes) and tumor size > or =4 cm (vs <4 cm: HR, 1.23; 95% CI, 1.15-1.30) were additional factors that increased the risk of mortality among patients with stage IB disease. Bronchioloalveolar carcinoma and Asian ethnicity were associated with decreased mortality risk in stage I NSCLC.

CONCLUSIONS

Stage I NSCLC with poorly differentiated histology and stage IB NSCLC with non-upper lobar tumor location or tumor size > or =4 cm carried an increased mortality risk.

Tumor fluoro-2-deoxy-D-glucose avidity on positron emission tomographic scan predicts mortality in patients with early-stage pure and mixed bronchioloalveolar carcinoma

OBJECTIVE

Bronchioloalveolar carcinoma is a clinically heterogeneous subtype of non-small cell lung carcinoma that frequently has low 2-[18F]fluoro-D-glucose (FDG) uptake on positron emission tomographic scanning. We investigated whether tumor FDG avidity was associated with worse survival among patients with completely resected node-negative pure and mixed bronchioloalveolar carcinoma.

METHODS

We performed a cohort study of 36 patients who had completely resected pure and mixed bronchioloalveolar carcinoma between 1998 and 2004, who had no hilar or mediastinal lymph node metastases, and who had undergone a preoperative positron emission tomographic scan. Tumor FDG avidity was defined as a standardized uptake value of 2.5 or greater. Survival analysis was performed with a proportional hazards model.

RESULTS

Of 36 patients studied, 26 patients (72%) were alive and 10 patients (28%) were dead after a median follow-up of 31 months (interquartile range 17-41 months). Seventeen patients (47%) had FDG-avid tumors, and 19 patients (53%) had non-avid tumors. Three-year survival was 49% in the FDG-avid group and 95% in the non-avid group (P = .005). FDG avidity had a hazard ratio of death of 8.6 (95% confidence interval 1.4-244.7, P = .02) after adjusting for tumor size, the presence of multifocal bronchioloalveolar carcinoma, and the presence of histologically mixed bronchioloalveolar carcinoma.

CONCLUSIONS

Preoperative tumor FDG standardized uptake value of 2.5 or greater on positron emission tomography is a powerful predictor of long-term mortality in patients with lymph node-negative pure and mixed bronchioloalveolar carcinoma who undergo complete surgical resection. Patients with a high level of FDG uptake (standardized uptake value > or = 2.5) may benefit from adjuvant chemotherapy or more frequent clinical follow-up.

Surgery for bronchioloalveolar carcinoma and "very early" adenocarcinoma: an evolving standard of care?

Lobectomy and mediastinal lymph node dissection is the standard surgical management of early stage non-small cell lung cancer (NSCLC) because more limited resections have been associated with a higher risk of local recurrence. Nevertheless, recent lung cancer screening studies have led to the detection of an increasing number of "very early" NSCLC (defined as less than 2 cm in size) and of good-prognosis histologic subtypes, bronchioloalveolar carcinoma (BAC), and adenocarcinoma (AC), mixed subtypes that are potentially appropriate for sublobar resection. The precise indications for sublobar resection remain unclear and are the subject of ongoing clinical trials, but it seems that very early, peripherally located, node-negative AC of a predominantly BAC pattern may be adequately treated in this manner. Multifocal AC and BAC, either synchronous or metachronous, are also effectively treated by complete resection, using limited resections whenever possible. The pneumonic form of BAC, the rarest variant of this disease spectrum, continues to have a poor prognosis despite complete resection. Very limited experience suggests that lung transplantation leads to prolonged survival in highly selected patients with this histologic subtype. To improve our management of very early AC, much more information is needed about the molecular abnormalities of AC and their relationship to clinical outcomes.

Systemic therapy of bronchioloalveolar carcinoma: results of the first IASLC/ASCO consensus conference on bronchioloalveolar carcinoma

INTRODUCTION

Bronchioloalveolar carcinoma (BAC) is a subtype of adenocarcinoma of the lung with unique pathological, clinical, and molecular characteristics.

METHODS

This consensus conference group reviewed studies performed specifically in BAC and data from patients with BAC who were included in clinical trials of all non-small-cell lung cancer (NSCLC) subtypes.

RESULTS

Although BAC as defined by the World Health Organization represents less than 5% of adenocarcinomas, as many as 20% of adenocarcinomas have BAC features. These latter tumors are more likely to have mutations in the epidermal growth factor receptor (EGFR) gene and to be sensitive to the EGFR tyrosine kinase inhibitors gefitinib and erlotinib. Although most patients are men and have a history of smoking cigarettes, proportionally more are women and never smokers. Patients with BAC are routinely treated with drugs and regimens appropriate for patients with all subtypes of adenocarcinoma of the lung; four studies have been performed specifically in this disease.

CONCLUSIONS

There is insufficient evidence to confirm or refute the assertion that the sensitivity of BAC to chemotherapy is different from that of other lung cancer histologic types. The unique clinical and molecular characteristics associated with BAC led this panel to conclude that future clinical trials should be designed specifically for persons with BAC. Recommendations for trial design and research questions are proposed.

[Bronchioloalveolar carcinoma in Spain: a rare and different form of lung cancer]

OBJECTIVE

To describe a series of cases of bronchioloalveolar carcinoma (BAC) treated surgically between 1993 and 1997 in the 19 hospitals that make up the Bronchogenic Carcinoma Cooperative Group of the Spanish Society of Pulmonology and Thoracic Surgery (GCCB-S).

PATIENTS AND METHODS

From a total of 2,944 cases of non-small cell lung cancer (NSCLC), 82 (3%) were BAC. The clinical characteristics and prognosis of patients with BAC were compared with those of the remaining 2,862 patients with NSCLC.

RESULTS

The percentage of men was lower for BAC than for other types of NSCLC (64.6% compared with 93.5%; P< .001) and BAC was associated with less comorbidity (50% vs 62%; P< .05), particularly in terms of chronic obstructive pulmonary disease (33% vs 47.2%; P< .05). Other characteristics showing significant differences were the higher frequency of BAC as a chance finding and the lower likelihood of weight loss or reduced performance status at the time of diagnosis. Classification as stage cI was significantly more common in patients with BAC (87% vs 75%; P.001), and this difference between groups was more pronounced for stage pI (68.5% vs 47%; P< .01). Only taking into account patients classified as stage pI with complete resection of NSCLC and following exclusion of operative mortality, patients with BAC presented an overall 5-year survival of 65% (95% confidence interval [CI], 51%-79%), compared with a significantly lower survival of 53% (95% CI, 50%-56%; P< .05) in patients with other forms of NSCLC.

CONCLUSIONS

In Spain, among cases of lung cancer treated by surgery, BAC is very rare (3%) and displays clinical characteristics that are different from other forms of NSCLC. Controlling for the most basic prognostic factors (stage pI and complete resection), survival is significantly higher for BAC.

Long-term survival differences for bronchiolo-alveolar carcinoma patients with ipsilateral intrapulmonary metastasis at diagnosis

BACKGROUND

It has been suggested that the current staging system does not accurately reflect survival outcomes for advanced bronchiolo-alveolar carcinoma (BAC) patients.

METHODS

We conducted a case-only analysis of US Surveillance, Epidemiology, and End Results (SEER) data (1998-2002). Overall survival (OS) and lung cancer-specific survival (LCSS) univariate analyses were conducted using the Kaplan-Meier method. Multivariate survival analyses were performed using Cox proportional hazards ratios.

RESULTS

2345 incident cases of BAC were analyzed, including 707 patients with stage IIIB or IV BAC. Patients with stage IIIB BAC due to multiple lesions in the same lobe (n=93) had significantly improved median OS (46m) and LCSS (>58m) compared to other stage IIIB BAC patients (n=111; OS=9m, P<0.0001; LCSS=10m, P<0.0001). Among stage IV BAC patients, those with intrapulmonary metastasis (n=278) had significantly improved median OS (13m) and LCSS (15m) compared to those with distant metastasis (n=225; OS=7m, P<0.0001; LCSS=7m, P=0.0001). These survival differences persisted after adjustment for age, gender, ethnicity, and surgical treatment status.

CONCLUSIONS

Among stage IIIB and IV BAC patients, those presenting with ipsilateral intrapulmonary metastasis have improved survival outcomes. Our results add further support for modification to the current staging system for BAC.

[Bronchioalveolar carcinoma: five year survival]

The epidemiology and prognosis of bronchioalveolar carcinoma (BAC) is different from adenocarcinoma. We studied 28 patients who underwent surgical resection and in whom a final histologic diagnosis of bronchioalveolar carcinoma was made. Sixty one percent of patients were asymptomatic at the time of diagnosis. The most usual radiological presentations were pulmonary nodule (11), pulmonary mass (6) and diffuse infiltrate (6). Nine patients (9/25) were never smokers. Bronchoscopy provided the diagnosis only in 4/26 patients. Patients were classified as stage IA 11/24, IB 5/24 IIIB in 2/24 and IV in 6/24. Five-year survival for the entire group was 65%. Patients with focal lesions had a longer survival. The survival in patients who underwent potentially curative resections was 62.8 +/- 44.0 months. When surgery was considered non-curative, survival was 21.2 +/- 19.5 months (p = 0.0064). Five-year survival in stage IA patients was 80%. Survival of patients with non-mucinous histology was longer than those with mucinous type carcinomas (54.9 +/- 25.0 months vs. 5.33 +/- 4.04, p < 0.0001) but the 5-year-survival was not statistically different. In conclusion, BAC has a favourable prognosis. The best survival rate was found in focal forms, represented by early tumor, nodes, metastasis (TNM) stages and non-mucinous BAC among the histological groups.

[Prognosis of patients after resection for lung cancer with intrapulmonary metastasis in different lobes]

BACKGROUND

The prognosis of lung cancer patients with intrapulmonary metastasis in different lobes (pm2) is poor. However, some patients achieve long-term survival. We retrospectively investigated the prognosis of resected primary lung cancer patients with pm2.

METHOD

Among 845 patients with primary lung cancer who underwent complete resection from 1984 to 2003, 14 cases that had lung cancer with pm2 were evaluated about prognostic factors.

RESULTS

The overall 5-year survival rate was 9.5%. The analysis of survival curve based on clinicopathological factors (surgical procedure, histology, tumor size, lymph nodal metastasis, pleural invasion, pleural dissemination and number of pm2) revealed that bronchioloalveolar carcinoma (BAC), the absence of pleural invasion and the absence of pleural dissemination are better prognostic factors.

CONCLUSION

Lung cancer patients with pm2 whose lesions show BAC histology, the absence of pleural invasion or pleural dissemination may achieve long-term survival and could be candidates for surgical treatment.

Epidemiology of bronchioloalveolar carcinoma: improvement in survival after release of the 1999 WHO classification of lung tumors

PURPOSE

Classification changes for bronchioloalveolar carcinoma (BAC) by the WHO in May 1999 narrowed its definition. This study was undertaken in an attempt to characterize the impact of these changes on the epidemiology of BAC.

PATIENTS AND METHODS

This retrospective study involves data analysis from the population-based Cancer Surveillance Programs of three Southern California counties from 1995 to 2003. BAC cases diagnosed after May 1999 are compared with BAC cases before that time by clinicopathologic variables including survival.

RESULTS

Incident cases (11,969) of non-small-cell lung cancer (NSCLC) were analyzed, including 626 cases of BAC (5.2%). Median overall survival (OS) for BAC patients diagnosed after May 1999 (> 53 months) was significantly improved over median OS for BAC patients before May 1999 (32 months; P = .012). This survival benefit remained after adjustment for sex, smoking status, and stage at presentation (hazard ratio for time of diagnosis before May 1999 compared with a diagnosis after May 1999 = 1.43; P = .015). Median OS for non-BAC NSCLC patients diagnosed before May 1999 (9 months) did not differ from the median OS of such patients afterwards (10 months; P = .09).

CONCLUSION

This epidemiologic study is the first to demonstrate a survival advantage for BAC patients diagnosed after May 1999 compared with BAC patients diagnosed before this time-a finding that persists after adjustment for sex, smoking status, and stage at presentation. We believe that this observed survival benefit likely reflects changes in the revised 1999 WHO classification.

Surgical treatments for multiple primary adenocarcinoma of the lung

BACKGROUND

The aim of this study was to identify the clinical characteristics of multiple primary adenocarcinomas and to evaluate the efficacy of surgical treatments.

METHODS

Three-hundred sixty-nine patients who underwent pulmonary resection for adenocarcinoma from January 1994 to December 2002 were reviewed.

RESULTS

Thirty-one patients (8.4%) were determined to have multiple primary adenocarcinomas that could be detected on chest x-rays or computed tomography (CT). Twenty-six patients were synchronous and five patients were metachronous with a median interval of 59.0 months. Forty-nine (72.1%) of the total 68 lesions exhibited ground-glass opacity on high-resolution CT (HRCT). Pathologically well-differentiated adenocarcinoma with mixed bronchioloalveolar pattern was the most common subtype (39.7%). Taking into consideration pulmonary function, size, location, and HRCT findings of the lesions the procedures performed were lobectomy with mediastinal lymph-node dissection for 32 patients, segmentectomy with hilar node dissection for 8 patients, and wedge resection for 28 patients. Of 17 patients with bilateral synchronous cancers, simultaneous bilateral pulmonary resection was performed in 14 patients including simultaneous bilateral video-assisted thoracic surgery (VATS) in 11 patients. After a median follow-up period of 27.7 months, the 3-year overall survival rate was 92.9% and the 3-year disease-free survival rates of synchronous cancer and metachronous cancer were 77.9% and 100%, respectively.

CONCLUSIONS

The incidence of multiple primary adenocarcinomas was relatively common. Early radiographic detection and surgical excision could yield a favorable prognosis. The use of VATS, even for synchronous bilateral patients, was a safe and beneficial procedure.

Prognostic analysis of pulmonary adenocarcinoma subclassification with special consideration of papillary and bronchioloalveolar types

AIMS

The third edition of the World Health Organization (WHO) classification of lung tumours has been published and is expected to become the standard nomenclature. The aim of this study was to assess the usability and prognostic significance of the WHO classification in comparison with other recent classifications.

METHODS AND RESULTS

One hundred and forty-seven resected pulmonary adenocarcinoma cases were reviewed and histologically classified according to the WHO classification (1999) and the classification by Noguchi (1995). Papillary carcinomas as described by Silver and Askin (1997) were also identified. Since the papillary type in the WHO classification is not strictly defined, we compared the following two kinds of WHO classification: (i) WHO-N; WHO classification adopting Noguchi Type F as the definition of the papillary type, namely, pure papillary adenocarcinoma without a bronchioloalveolar component; (ii) WHO-SA; WHO classification adopting papillary carcinoma by Silver and Askin as the definition of the papillary type, namely, tumour with papillary structure constituting at least 75% of the lesion. The bronchioloalveolar carcinoma of the WHO classification showed a better prognosis than other subtypes in both overall and Stage I disease limited survival analysis. In analysis limited to Stage III disease, only the papillary type of WHO-SA showed a significantly worse prognosis.

CONCLUSIONS

WHO-SA is recommended for prognostic correlation.

SCCRO expression correlates with invasive progression in bronchioloalveolar carcinoma

BACKGROUND

Overexpression of squamous cell carcinoma-related oncogene (SCCRO) is associated with invasive progression and poor outcomes in non-small cell lung cancer. We assessed the role of SCCRO as a tumor marker in bronchioloalveolar carcinoma (BAC), a subtype of adenocarcinoma exhibiting evidence of histologic tumor progression. We hypothesized that SCCRO expression would correlate with invasive tumor phenotypes and worse survival in BAC.

METHODS

We classified 150 tumors as pure BAC, BAC with focal invasion, or adenocarcinoma with BAC features. A tissue microarray was constructed from areas of benign lung, BAC, and invasive adenocarcinoma in these tumors. Squamous cell carcinoma-related oncogene expression was graded by immunohistochemistry from 0 to 3 (absent, low, moderate, or high), with positive SCCRO phenotype defined as grade 3. Squamous cell carcinoma-related oncogene specificity was determined by Wilcoxon rank test and area under the receiver-operator curve, survival by the Kaplan-Meier method, and correlation with prognostic factors by log-rank test.

RESULTS

Of the 86.0% (129 of 150) of specimens suitable for analysis, positive SCCRO phenotype was seen in 16.3% (21 of 129) and was 100.0% specific for tumor versus benign tissue (area under receiver-operator curve, 0.92). Positive SCCRO phenotype was greater in tumors with increasing degrees of invasive histologic type (7.0% pure BAC, 13.6% BAC with focal invasion, and 28.6% adenocarcinoma with BAC features; p = 0.02). Low-level SCCRO expression was present in 83.9% (99 of 118) of benign tissues and correlated with tobacco use and poor survival (p = 0.05).

CONCLUSIONS

Squamous cell carcinoma-related oncogene is a marker of invasive tumor progression in BAC. Low-level expression in adjacent benign lung predicts worse survival, and may represent field cancerization or host-tumor effects.

Bronchioloalveolar carcinoma of the lung 3 centimeters or less in diameter: a prognostic assessment

BACKGROUND

Bronchioloalveolar carcinoma (BAC) of the lung is a subtype of adenocarcinoma for which the incidence is actually rising, but the histologic definition of BAC has been recently changed by the revised World Health Organization (WHO) classification in 1999. The clinical features of patients with BAC diagnosed according to the recently revised WHO classification have not yet been clarified. In this retrospective study, we investigated the pattern of recurrence and survival outcome for patients with resected BAC by pathology review, compared with those in patients who had adenocarcinoma other than BAC.

METHODS

From 1985 through 2002, 108 patients underwent surgical resection for pulmonary adenocarcinoma 3 cm or less in diameter at the University of Yamanashi, Japan. All of the resected specimens of these 108 patients were pathologically reviewed again to confirm the diagnosis as BAC or adenocarcinoma other than BAC. The tumor was defined as BAC when the adenocarcinoma lesion had a pure bronchioloalveolar growth pattern and no evidence of stromal, vascular, or pleural invasion according to the WHO classification (third edition).

RESULTS

Twenty-five patients (23%) had a diagnosis of BAC, and 83 (77%) had a diagnosis of other adenocarcinoma. There was a female predominance among both patients with BAC and those with other adenocarcinoma. Lymph node involvement was seen for 30 lesions (36%) of adenocarcinoma other than BAC, but not for any BAC lesions. The median duration of follow-up after surgery was 5.1 years. There was no recurrence in the postoperative course in patients with BAC for a 5-year disease-free survival rate of 100%, whereas the 5-year disease-free survival rate for other adenocarcinoma was 63.5%.

CONCLUSIONS

The patients with resected BAC, which is defined as a noninvasive adenocarcinoma by the revised WHO classification, had an excellent prognosis. However, these results may depend on a strictly accurate pathology diagnosis as BAC. Limited resection might be curative in patients with focal BAC based on evidence of pathologic noninvasive features.

[Bronchioloalveolar carcinoma]

Bronchioloalveolar carcinoma (BALC) is a sub-type of adenocarcinoma, accounting for 3-5% of all lung cancer cases. It is characterized by peripheral location in lung parenchyma, without visible changes in main bronchi and tumor spread occurs along the walls of the peripheral airspaces without destruction of the pulmonary interstitium. Their carcinomas were classified into three clinicopathologic types: nodular or tumoral, pneumonic, and diffuse types. The disease may take an asymptomatic form for several months or even years. This form of cancer spreads by way of air tracts creating multiple changes in lungs. Metastases to lymph nodes and other organs occur rarely. It is difficult to provide a correct diagnosis. The complete surgical resection of localized BAL C offers the best chances of long-term survival. Patient prognosis is usually more positive than in other histological types, since the disease is frequently diagnosed at its early development stages.

MCM2 and Ki-67 Expression in Human Lung Adenocarcinoma: Prognostic Implications

OBJECTIVE

The expressions of minichromosome maintenance protein 2 (MCM2), Ki-67, and p53 were examined to analyze their pathobiological significance in human lung adenocarcinomas.

METHODS

We performed Western blot analysis in six human lung adenocarcinoma cell lines and immunohistochemistry in 145 surgically removed adenocarcinomas to examine the MCM2 expression. Labeling indices (LIs; %) of MCM2, Ki-67, and p53 in the tumor cells were compared with clinicopathological profiles and overall survival rates.

RESULTS

MCM2 protein was detected in all cell lines examined, with specific bands. MCM2 LIs were significantly correlated with sex, histological type, differentiation, pathological stage, and LIs of Ki-67 and p53 (p < 0.05). Significantly higher LIs of MCM2 and Ki-67 were noted in the 122 non-pure bronchioloalveolar carcinomas than in the 23 pure bronchioloalveolar carcinomas (p < 0.01), and the prognosis was poorer in the former than in the latter (p < 0.01). Sex, pathological stage, and high LIs of MCM2 and/or Ki-67 were independent prognostic factors (p < 0.05).

CONCLUSION

High LIs of MCM2 and/or Ki-67 suggest a poor prognosis in patients with lung adenocarcinoma (non-pure bronchioloalveolar carcinoma).

[Prognosis of resected stage I bronchioloalveolar carcinoma of the lung]

In this retrospective study, we investigated the prognosis of 25 patients with resected bronchioloalveolar carcinoma (BAC) of 3.0 cm or less in diameter. We assigned a diagnosis of BAC for non-invasive tumors as defined by the World Health Organization (WHO) classification. The patients ranged in age from 47 to 78 years with an average of 64.0 years. Eighteen patients (72%) were male and 7 patients (28%) were female. All the patients underwent complete resection. As the mode of surgical resection, at least lobectomy was performed in 84%. Sections of the resected tumor were stained by HE and Elastica, and then examined by light microscopy. The tumors ranged in size from 0.5 to 3.0 cm with an average of 1.9 cm. Neither pleural involvement nor vascular permeation was seen in BACs. There was also no lymph node involvement for BACs. The 5-year disease-free survival rate of all 25 patients with BAC was 100%. The unequivocally recognizing invasive features by morphology is important for a prospect of the prognosis of resected BACs.

Prognostic significance of thyroid transcription factor-1 expression in both early-stage conventional adenocarcinoma and bronchioloalveolar carcinoma of the lung

Thyroid transcription factor 1 (TTF-1) is a diagnostic immunohistochemical marker for primary pulmonary neoplasms, but its utility as a prognostic marker is not well established. Surgical specimens from 100 cases of pulmonary adenocarcinoma were retrieved from the hospital computer system, including 50 cases of conventional adenocarcinoma (CA) and 50 cases of bronchioloalveolar adenocarcinoma (BAC) (32 nonmucinous type and 18 mucinous type). Representative sections were immunostained for TTF-1. Positive immunohistochemical study was correlated with other prognostic parameters. In the CA group, strong or moderate TTF-1 expression was seen in 30 of 50 (60%) patients and was associated with significantly better survival compared with those patients having weak staining (7 cases; 14%) or negative staining (13 cases; 26%) (P <0.01; log-rank test). Spearman and Pearson's correlation showed no significant correlation between TTF-1 expression and tumor grade, size, recurrence, or vascular invasion; therefore, TTF-1 was considered an independent predictor of survival. In the BAC group, TTF-1 was strongly expressed in 34 of 50 cases (68%) and was negative in 16 of 50 cases (32%), including 14 mucinous BACs. Although TTF-1 immunoreactivity was not statistically associated with good survival in BAC patients, those patients with strong immunohistochemical expression showed a trend toward longer survival. Our results indicate that TTF-1 positivity is an independent predictor of better survival, especially in patients with CA. Mucinous and nonmucinous BACs exhibit disparate staining patterns with TTF-1, with nonmucinous BAC demonstrating greater positivity. Although nonmucinous BAC patients showing strong positive staining had longer survival, the difference was not statistically significant, which is probably related to the overall good survival of patients with early-stage BAC.

Expression and significance of cyclin D1, p27kip1 protein in bronchioloalveolar carcinoma

PURPOSE

To investigate the relationship between expression of cell cycle-related protein cyclin D1, p27kip1 and the pathogenesis of bronchioloalveolar carcinoma (BAC) and the value of prediction of prognosis.

METHODS

Cyclin D1 and p27kip1 protein were detected by immunohistochemical En Vision method in 43 BACs.

RESULTS

The positivity of cyclin D1 in BAC was 65.1% (28/43), which was significantly higher than that in normal pulmonary tissue (0/13), P<0.01. No statistically significant association was found between cyclin D1 expression data and sex, age, tobacco-use history, histologic subtype (mucinous vs nonmucinous), stromal fibrosis, lymph node metastasis, clinical stage or postoperative survival period (P>0.05), while cyclin D1 expression was found to be negatively correlated with tumor size (P<0.05). The positivity of p27kip1 in BACs was 51.2% (22/43), significantly lower than that in normal pulmonary tissue (12/13), P<0.01. p27kip1 expression level was not associated with sex, age, tobacco-use history, tumor size or histologic subtype (P>0.05), but was negatively correlated with stromal fibrosis, lymph node metastasis and clinical stage (P<0.05); and positively associated with postoperative survival period (P<0.01). The survival rate of p27kip1 positive group was significantly higher than that of p27kip1 negative group (P<0.01). No statistically significant correlation was found between cyclin D1 and p27kip1 expression.

CONCLUSIONS

Increased cyclin D1 expression and decreased p27kip1 expression are related to the pathogenesis of BAC; decreased p27kip1 expression is associated with metastasis progression; immunodetection of p27kip1 is useful for assessment of prognosis.

[Clinicopathologic features of small-sized peripheral lung cancer; is intentional limited resection appropriate for selected patients?]

We sought to determine the eligibility of patients with early peripheral lung cancer for intentional limited resection. The clinicopathologic features of 103 patients who underwent lobectomy and mediastinal nodal dissection for early stage peripheral lung cancer measuring 2 cm or less in maximum dimension between 1992 and 2002 were examined retrospectively. The lymph node metastasis and residual cancer after thoracoscopic partial resection were analyzed by the following categories. Three groups were divided by maximum dimension of the primary lesion in the resected specimen; 10 mm or less (n = 11), 15 mm or less (n = 33), and 20 mm or less (n = 59). Two groups were divided by lesion histology; bronchioloalveolar adenocarcinoma (BAC) [n = 42] and invasive lung cancer (n = 61). Residual cancer was found in the residual lobe after thoracoscopic partial resection in 3 of 43 patients who had no diagnosis preoperatively. Their maximum dimensions were 15 mm or less. No lymph node metastasis was detected in the patients with tumor measuring 10 mm or less, and BAC. Intentional limited resection without mediastinal nodal dissection is appropriate for patients with tumor measuring 10 mm or less and BAC. Further investigation associated with partial resection is necessary.

Resection of multifocal non–small cell lung cancer when the bronchioloalveolar subtype is involved

OBJECTIVE

Bronchioloalveolar lung cancer is commonly multifocal and can also present with other non-small cell types. The staging and treatment of multifocal non-small cell cancer are controversial. We evaluated the current staging of multifocal bronchioloalveolar carcinoma and the therapeutic effectiveness of resection when this tumor type is involved.

METHODS

We reviewed our experience between 1992 and 2000 with complete pulmonary resections for bronchioloalveolar carcinoma. Kaplan-Meier survival curves were calculated from the dates of pulmonary resection.

RESULTS

Among 73 patients with bronchioloalveolar carcinoma, 14 patients, 7 male and 7 female with a mean age of 65 years (51-87 years), had multifocal lesions without lymph node metastases. Follow-up was 100% for a median of 5 years (range 2.6-8.5 years). Tumor distribution was unilateral in 9 patients and bilateral in 5 patients. The multifocal nature of the disease was discovered intraoperatively in 4 patients. Nine patients had 2 lesions, 4 patients had 3 lesions, and 1 patient had innumerable discrete foci in a single lobe. Operative mortality was 0. Postoperatively, 10 patients were staged pIIIB or pIV on the basis of multiple foci of similar morphology; 4 patients had some differences in histology (implying multiple stage 1 primaries). The median survival time to death from cancer was 14 months (141 days-5.6 years). The overall 5-year survival after resection of multifocal bronchioloalveolar carcinoma was 64%. Unilateral or bilateral distribution had no impact on survival.

CONCLUSIONS

The current staging system is not prognostic for multifocal bronchioloalveolar carcinoma without lymph node metastases. Complete resection of multifocal non-small cell lung cancer when bronchioloalveolar carcinoma is a component may achieve survivals similar to that of stage I and II unifocal non-small cell lung cancer. When bronchioloalveolar carcinoma is believed to be one of the cell types in multifocal disease without lymph node metastases, consideration should be given to surgical resection.

Comparison of human lung cancer/SCID mouse tumor xenografts and cell culture growth with patient clinical outcomes

Leukemic cell growth in SCID mice has been reported as a predictor of disease relapse. However, there is a paucity of literature regarding xenograft growth and clinical outcomes in non-small cell lung cancer (NSCLC). Seventy-nine specimens from patients with NSCLC were either subcutaneously implanted into SCID mice and/or placed in tissue culture. Retrospective chart review was correlated with stage, histology, necrosis, disease-free interval, and survival. Tumor xenografts were successfully established with 17 of 37 (46%) tumor biopsy tissues. Thirteen of 59 (22%) specimens grew in cell culture. Patients whose tumors grew in SCID mice had no difference in survival compared to those with no growth ( n=20, p=0.42). Median survival was 36 months in 13 patients whose tumors grew in cell culture compared to 39 months in 46 patients without growth. Eight of 12 (67%) patients with metastasis showed SCID/human xenograft growth, whereas nine of 25 (36%) without metastases did so ( p=0.08). Growth of tumor cells in vitro occurred in 11 of 31 (35%) adenocarcinomas, one of 25 (4%) squamous cell carcinomas, and one of three (33%) large cell carcinomas ( p=0.02). Well or moderately differentiated tumors grew in cell culture in only two of 22 (9%), whereas poorly or undifferentiated tumors grew in 11 of 32 (34%) cases ( p=0.03). We conclude that neither the ability of a tumor to engraft and grow in SCID mice nor its ability to grow in vitro in cell culture is a reliable predictor of disease outcome or survival in patients with NSCLC. The ability to propagate tumors in vitro appears to be more dependent upon the histological type of tumor and its degree of differentiation.

Bronchioloalveolar lung cancer: occurrence, surgical treatment and survival

OBJECTIVE

The prevalence of pulmonary adenocarcinoma has risen worldwide. Bronchioloalveolar carcinoma (BAC) was studied with regard to whether it exhibits a similar tendency, and its typical features were analysed.

METHODS

Between 1992 and 2001, 278 lung resections were carried out for adenocarcinoma. Of these, 67 (24.1%) proved to involve BAC. Whereas BAC accounted for 6.9% of the cases in 1992, in 2001 the proportion was 46.9%. There were 37 men (55.2%) and 30 women (44.7%); the average age was 60.5 years. 58.2% of them had no complaints. Of the 26 non-smokers, 69.2% were women; of the 41 smokers, 29.2% were women. In consequence of the tumour, 49 lobectomies, three bilobectomies, six pneumonectomies and nine wedge resections were performed.

RESULTS

The surgical mortality was 1.6%. The pathology revealed that 26 (38.8%) tumours were in stage I/A. In 15 cases (22.4%), tuberculosis (TB) could be revealed besides the BAC: by skin tests in four cases, by CT in three cases, by case history in four cases, and by pathology in four cases. For the overall group of 67 patients, the 5-year survival rate was 61.9%, and the mean survival time was 75.7 months. The 5-year survival rate among the women (74%) was significantly better than that among the men (37%) (P=0.030). There was no significant difference in survival with regard to the multiple BAC (85%). The 5-year survival rate was significantly worse in the mixed BAC group (20%) than in the non-mucinous (62.7%) and in mucinous (59%) group. The overall 5-year survival rate among the smokers and TB patients was 61 and 79%, respectively, which is higher than that among the non-smokers (47%) and non-TB patients (56%). The survival rate for the wedge resection cases was 37%, which was lower than that for the cases involving major resections (60%) (P=0.939).

CONCLUSION

BAC has a favourable survival, particularly in women. In spite of this, resection smaller than lobectomy is recommended only as a compromise. A multiple appearance does not imply a worse survival. The best survival rate was found in the non-mucinous BAC among the histological groups. TB seems to be frequent among BAC patients.

Pulmonary transplantation for advanced bronchioloalveolar carcinoma

BACKGROUND

No effective therapy is currently available for the diffuse stage of bronchioloalveolar carcinoma.

OBJECTIVE

We tested the hypothesis that total lung replacement with standard lung transplantation techniques would provide curative therapy.

METHODS

Nine patients aged 31 to 58 years with bronchioloalveolar carcinoma were entered in the study. Five patients initially had bilateral diffuse tumor. Four patients had recurrence in the contralateral lung after pulmonary resection.

RESULTS

Between 1993 and 1998, all 9 patients underwent transplantation (2 single-lung and 7 bilateral transplants, 1 reoperative single-lung transplant, and 1 reoperative bilateral transplant). Two patients had mediastinal node metastasis (level 7) at the time of transplantation, and 1 of these had a frankly invasive adenocarcinoma. Of the 8 patients with pure bronchioloalveolar carcinoma, 6 had recurrent pulmonary tumor after transplantation. In 2 of these patients the tumor was localized and could be resected with left lower lobectomy in one case and left pneumonectomy in the other. One is alive 89 months after transplantation; the other died 82 months after transplantation. Four other patients had a diffuse pattern of pulmonary recurrence. Two died of progressive pulmonary failure; 1 of these had retransplantation with recurrence. A third patient died of cerebral edema shortly after bilateral retransplantation. The other patient is alive with recurrence 39 months after transplantation and has bronchiolitis obliterans. Two patients without recurrence are well with unrestricted performance levels 87 and 76 months after transplantation.

CONCLUSIONS

Transplantation produces a powerful palliative outcome in patients with advanced bronchioloalveolar carcinoma, but the recurrence rate is high. Transplantation for this indication remains controversial.

Clinical pattern and pathologic stage but not histologic features predict outcome for bronchioloalveolar carcinoma

BACKGROUND

The histologic criteria defining bronchioloalveolar carcinoma (BAC) were recently revised, but it is unclear whether these criteria predict clinical behavior. This study determined the outcome of resected BAC in relationship to clinical and radiologic disease pattern, and pathologic features.

METHODS

Between 1989 and 2000, 100 consecutive surgically treated patients with adenocarcinomas exhibiting various degrees of BAC features were retrospectively studied. Histology was reviewed; tumors were classified as pure BAC, BAC with focal invasion, and adenocarcinoma with BAC features. Clinical and radiologic pattern were classified as unifocal, multifocal, or pneumonic. Demographic data, tumor stage, and outcome were recorded. Survival was analyzed by the Kaplan-Meier method, and prognostic factors were determined by the log-rank test.

RESULTS

Patient median age was 65, and 74% of the patients were female. Pure BAC, BAC with focal invasion, and adenocarcinoma with BAC features occurred in 47, 21, and 32 patients, respectively. Unifocal disease occurred in 64 patients, multifocal in 29, and pneumonic in 7. Seventy-one patients had stage I/II tumors, 22 had stage III/IV, and 7 patients had Stage X tumors. Overall 5-year survival was 74%. There was no significant difference in survival among the three histologic subtypes. The pneumonic pattern had significantly worse survival compared with unifocal and multifocal patterns. Pathologic stage predicted survival, with 5-year survivals for I/II and III/IV of 83.7% and 59.6%, respectively.

CONCLUSIONS

Clinical pattern and pathologic stage, but not the degree of invasion on histologic examination predict survival. Multifocal disease is associated with excellent long-term survival after resection. The favorable survival of stage III/IV BAC indicates that the current staging system does not fully describe this disease in patients undergoing resection because of its distinct tumor behavior.

Surgical treatment of stage I lung cancer. Results and prognostic factors

BACKGROUND

The aims of the present study were: 1) to study the type and extent of resection in patients with pathological stage I lung cancer; 2) to evaluate the results of surgical treatment; 3) to assess prognostic factors.

SETTING

a tertiary referral general hospital.

METHODS

Retrospective review of clinical records of 296 patients operated on for pathologic stage I lung cancer between 1989 and 1998. Mean follow-up period was 33.1+/-28.1 months. Survivals were calculated by the actuarial method and compared by the long-rank test. Age, sex, tumor size, type and extent of resection and histologic type were evaluated by univariate and multivariate analisis.

RESULTS

Two hundred and forty-five lobectomies, 39 pneumonectomies, 5 segmental resections and 7 wedge resections were performed. Overall actuarial 5- and 10-year survivals were 62 and 49%, respectively. Stage Ia patients showed significantly better 5- and 10-year survivals (76 and 54%, respectively) as compared to Stage Ib patients (57 and 46%, p=0.007). Univariate analysis showed no significant difference in survival according to the age, the sex or the extent of resection. The histological type influenced the outcome (p=0.05): 5-year survival rate were 57, 67, 75% in squamous cell carcinoma, adenocarcinoma and bronchoalveolar carcinoma, respectively. At multivariate analysis stage and histology were identified as independent prognostic factors.

CONCLUSIONS

Satisfactory results in terms of suvival can be achieved following surgery for stage I lung cancer. The T status and the histologic type significantly influence survival.

Detection of early invasion on the basis of basement membrane destruction in small adenocarcinomas of the lung and its clinical implications

To evaluate the correlation between the degree of basement membrane (BM) preservation and clinicopathological characteristics in the replacement-growth type (lepidic growth type) of small peripheral adenocarcinomas of the lung, the BM components of 72 surgically resected replacement-growth type adenocarcinomas of the lung, 2 cm or less in diameter, were evaluated immunohistochemically by using a monoclonal antibody to Type IV collagen and polyclonal antibodies to 7S collagen and laminin. The tumors were classified into the following three distinctive histological types according to the condition of the elastic framework: Type I, bronchioloalveolar carcinoma without fibrotic foci; Type II, sclerosing bronchioloalveolar carcinoma without elastic framework destruction; and Type III, sclerosing bronchioloalveolar carcinoma with elastic framework destruction. The BM was well preserved in the area of bronchioloalveolar spread along fully expanded alveoli in all tumor types; however, BM preservation was significantly lost in the areas of collapsed alveoli in Type III tumors. There were no BM component staining reactions in the scarred regions of Type III tumors. In addition, lymph node metastasis was significantly greater in Type III tumors and BM-destroyed tumors. We concluded that the BM was largely destroyed by tumor cell invasion in the scarred region of Type III adenocarcinomas. Type III tumors had discontinuous BMs in the area of collapsed alveoli, indicating that this BM-destructive pattern must be the first step in tumor invasion. Type I and II tumors were concluded to be noninvasive adenocarcinomas, because their BM components were well preserved and they had a good outcome.

Prognostic significance of percentage of bronchioloalveolar pattern in adenocarcinomas of the lung

Bronchioloalveolar (BA) carcinoma of the lung is considered to have a better prognosis than that of common adenocarcinomas of the lung. However, a minor component of the BA pattern is common in many lung adenocarcinomas and the criteria for designating an adenocarcinoma as BA are not well defined. We assessed the clinicopathologic features of 238 cases of lung adenocarcinoma with a partial or predominant BA pattern. Tumors were classified as BA if more than 75% of the tumor had a BA growth pattern. In other words, the tumor grew along pre-existing lung structures without invasion or destruction of parenchyma. Tumors with 50% to 75% BA pattern were considered mixed and tumors with less than 50% BA pattern were designated as solid/acinar (S/A). Fixed, paraffin-embedded tissue sections of each neoplasm were also assessed using immunohistochemical methods with a panel of antibodies specific for p53, retinoblastoma protein, p16, cyclin D1, and cyclin E, and the results were correlated with clinical and pathologic parameters. Our results show that the 5-year survival rate of patients with BA and mixed tumors, 63% and 60%, respectively, was significantly better than that of patients with S/A tumors (P =.026). Patients with BA tumors were more frequently women (55.9%) compared with patients with mixed (48.3%) and S/A (43.8%) tumors. Bronchioloalveolar and mixed tumors were similarly associated with tobacco use, 88.2% and 85%, respectively; slightly less than S/A tumors (93.8%). Clinical and pathologic parameters did not correlate with immunohistochemical results. In conclusion, patients with BA or mixed tumors have similar 5-year survival, better than that of patients with S/A tumors, suggesting that adenocarcinomas can be designated as BA when at least 50% of the tumor has a BA pattern.

Evaluation of radiological and pathological prognostic factors in surgically-treated patients with bronchoalveolar carcinoma

OBJECTIVE

The incidence of adenocarcinoma and bronchoalveolar carcinoma has increased in recent years. The aim of this study was to retrospectively evaluate radiological and pathological factors affecting survival in patients with bronchoalveolar carcinoma (BAC) or BAC associated with adenocarcinoma who underwent surgical treatment.

METHODS

From May 1988 to September 1999, 49 patients with BAC or BAC and adenocarcinoma underwent surgical treatment. Complete resection was performed in 42 patients. In these patients the impact of the following factors on survival was evaluated: stage, TNM status, radiological and pathological findings (percentage of bronchoalveolar carcinoma in the tumour, presence or absence of sclerosing and mucinous patterns, vascular invasion and lymphocytic infiltration).

RESULTS

Twenty-nine patients were male and 20 female. Mean age was 63 years. Five-year survival was 54%. Univariate analysis of the patients who underwent complete resection demonstrated a favourable impact on survival in stages Ia and Ib (P = 0.01) and in the absence of nodal involvement (P = 0.02) and mucinous patterns (P = 0.02). Mucinous pattern was also prognostically relevant at multivariate analysis (P = 0.02). In the 27 patients with stage Ia and Ib disease, univariate analysis demonstrated that the absence of mucinous pattern (P = 0.006) and a higher percentage of BAC (P = 0.01) favourably influenced survival. The latter data were also confirmed by multivariate analysis (P = 0.01).

CONCLUSION

Surgical treatment of early-stage BAC and combined BAC and adenocarcinoma is associated with favourable results. However, the definition of prognostic factors is of utmost importance to improve the results of the treatment. In our series tumours of the mucinous subtype and with a lower percentage of BAC had a worse prognosis.

[Bronchioloalveolar carcinoma: a retrospective analysis of 52 patients]

OBJECTIVE

To present the treatment and prognosis of bronchioloalveolar carcinoma (BAC).

METHODS

A retrospective study was conducted on 52 bronchioloalveolar carcinoma patients admitted from April 1990 to April 2000 with emphasis on clinical manifestations, treatment and survival. All lesions were pathologically proved as either localized or diffused type.

RESULTS

These 52 cases comprised 2.5% lung tumors treated in the same period. Its clinical symptoms were similar to those of the other lung cancers. Short of breath and positive physical chest findings were more common in the diffused type. Forty-seven of these 52 patients underwent surgery and 5, chemotherapy. Follow-up showed that 28 (53.8%) patients have died; 10 (19.2%) of recurrence and 18 (34.6%) of metastasis with a median survival of 24.3 months for the localized type and 5.3 months for the diffused type (P < 0.05), The median survival of stage II BAC was 26.8 months in contrast of 42.5 months of stage II non-BAC adenocarcinoma group(P < 0.05). However, there was no significant difference in the overall survival rates of BAC and non-BAC squamous carcinoma (P > 0.05). Even though, trend analysis still showed that there is a tendency of decline in the survival rates from squamous cancer, non-BAC and BAC though (P < 0.05).

CONCLUSION

Localized BAC gives a better prognosis than diffused BAC of which the biological characteristics are different from those of the non-BAC. Compared with the non-BAC, a more active postoperative treatment should be considered for the BAC patients, such as postoperative chemotherapy and or radiotherapy, especially for stage II BAC lesions.

Bronchioloalveolar carcinoma: clinical, radiographic, and pathological findings. Surgical results

BACKGROUND

Bronchioloalveolar carcinoma (BAC) remains one of the most controversial of lung cancer subtypes.

METHODS

From 1980 to 1998, 374 resected patients for NSCLC were followed up in our department. Of the 147 cases histologically defined as adenocarcinoma, 34 were pure BAC. The records of these 34 patients were retrospectively reviewed in order to evaluate patient and tumor characteristics and to identify which variables had a prognostic impact on survival and recurrence rate.

RESULTS

Patient age, sex, smoking habits and symptoms were not differentiating characteristics when related to radiographic presentation or to natural history. Mucinous cell-type (23.6% of cases) was more frequent with non-smokers, presence of a single nodule or mass and stage I. Favorable characteristics were: a) the prevalence of stage I and N0 cases (59% and 76.7% of cases, respectively) with a mean survival time of 66 and 77 months, respectively; and b) the radiographic presentation of a solitary pulmonary nodule or mass (76.4% of cases), that, independently of nodal involvement, showed a higher mean survival time (62 months). Independently significant adverse prognostic factors were: stage II-IV, lymph node involvement, and patient age over sixty years. The radiographic presence of multiple or satellite nodules was related to a significantly adverse prognosis (mean survival time: 18 months) by univariate analysis; this was not confirmed by multivariate analysis.

CONCLUSIONS

In our experience BAC was the NSCLC subtype more frequently associated with a good outcome after resection; surgery should not to be denied also in patients with multiple nodules, when under sixty years of age and no lymph node involvement.

[Lung cancer]

INTRODUCTION

The aim of this study was to examine our lung cancer patients, particularly their smoking habits and survival rates.

MATERIAL AND METHODS

Information was recorded prospectively on 219 patients seen in our hospital from 1987 to 1992.

RESULTS

Average age was 65.5 years (39-85 years). 27% were female. 9% were 49 years or younger, 13 men and seven women. Only six patient (3%) were non-smokers, 77% were smokers and 20% ex-smokers. 52 patients (24%) had small cell lung cancer (SCLC) and 167 (76%) non-small cell lung cancer (NSCLC). All six non-smokers had adenocarcinoma (two bronchioloalveolar cell carcinoma). 63% had advanced disease (stage IIIB and IV or small cell cancer, extensive disease). Only 22 patients (10%) were alive at five years: 19 patients with NSCLC who had got surgical treatment, one patient with NSCLC (stage IIIB) who had recieved radiotherapy, and two patients with SCLC, limited disease, treated with chemo- and radiotherapy. The surgically treated patients (23%) had a five-year survival of 50% (17/33) at stage I, 33% (2/6) at stage II, and none (0/7) at stage IIIA.

INTERPRETATION

This poor outlook for patients with lung cancer and the fact that there are few non-smokers among them, tell us that the major emphasis must be on prevention.

Alveolar soft part sarcoma: clinical course and patterns of metastasis in 70 patients treated at a single institution

BACKGROUND

Alveolar soft part sarcoma (ASPS) is a rare form of soft tissue sarcoma. Brain metastases have been reported to be a common feature of Stage IV ASPS, and recent practice guidelines recommend routine intracranial imaging as part of the staging evaluation in all patients who present with ASPS.

METHODS

The authors performed a comprehensive retrospective review of the clinical presentation, treatment, outcome, and patterns of failure in a consecutive series of patients with localized (American Joint Committee on Cancer [AJCC] Stages II/III) or metastatic (AJCC Stage IV) ASPS who presented to a tertiary care cancer center between 1959 and 1998.

RESULTS

Seventy-four patients were identified from the database searches. The anatomic distribution of their primary tumors included: extremities, 44 patients (60%); trunk, 15 patients (20%); head and neck, 9 patients (12%); and retroperitoneum, 6 patients (8%). The median tumor size was 6.5 cm (range, 1.2-24 cm). The AJCC stage at presentation was Stage II or III in 35% of the patients and Stage IV in 65% of the patients. The 5-year actuarial local recurrence free, distant recurrence free, disease free, and overall survival rates among the 22 patients with localized ASPS were 88%, 84%, 71%%, and 87%, respectively. At a median follow-up of 9 years, 2 of 22 patients with localized disease had developed local recurrences and 3 had developed metastatic disease (all to the lung only). Brain metastases were noted in 9 of 48 patients who presented with Stage IV (M1) disease (19%) and always were noted in association with metastasis to other sites. The median survival of patients with M1 disease was 40 months, with a 5-year survival rate of 20%.

CONCLUSIONS

Long term follow-up of patients with localized ASPS reveals a relatively indolent clinical course with relatively low rates of local and distant recurrence. In patients with Stage IV ASPS, brain metastases were observed only as part of more disseminated disease. The observations of the current study do not support current practice guidelines for the staging of patients with ASPS and suggest that selective rather than routine intracranial imaging should be used in patients presenting with ASPS.

Bronchioloalveolar carcinoma of the lung: recurrences and survival in patients with stage I disease

OBJECTIVES

The aim of our study was to retrospectively compare the patient characteristics, the frequency and pattern of recurrent disease, and survival in patients with stage I bronchioloalveolar carcinoma and adenocarcinoma of the lung.

METHODS

Patients with stage I bronchioloalveolar carcinoma or adenocarcinoma other than bronchioloalveolar carcinoma resected between 1984 and 1992 with adequate clinical follow-up were studied. The clinical characteristics of the patients, extent of initial surgical resection, sites of recurrent disease, and overall survival were examined and compared between the 2 groups. The median follow-up for patients with bronchioloalveolar carcinoma and adenocarcinoma was 6.2 years and 5.9 years, respectively.

RESULTS

A total of 138 patients were identified. Thirty-three patients had bronchioloalveolar carcinoma and 105 patients had adenocarcinoma. Eleven (33%) of the patients with bronchioloalveolar carcinoma had never smoked cigarettes versus 9 (9%) of the patients with adenocarcinoma (P =.0036). There were no significant differences between patients with bronchioloalveolar carcinoma and adenocarcinoma in sex distribution and overall recurrence rate. Of the 12 patients with recurrent bronchioloalveolar carcinoma, 1 patient (8%) had extrathoracic disease develop at the site of first recurrence compared with 49% of patients with recurrent adenocarcinoma (P <.001). The 5-year survival in patients with bronchioloalveolar carcinoma and in those with adenocarcinoma was 83% and 63%, respectively (P =.04).

CONCLUSIONS

Stage I bronchioloalveolar carcinoma is more likely to occur in nonsmokers. Survival is longer in patients with bronchioloalveolar carcinoma. Further research is warranted to define the etiology, clinical course, and molecular abnormalities in patients with bronchioloalveolar carcinoma to generate more effective therapeutic approaches.

Prognosis and recurrent patterns in bronchioloalveolar carcinoma

STUDY OBJECTIVE

Bronchioloalveolar carcinoma (BAC) is an uncommon pulmonary neoplasm with various radiologic and clinical presentations. In this article, we analyze the initial radiologic findings, TNM stagings, surgical types, and radiologic features of recurrence, and correlate them with patient survival.

DESIGN

A retrospective review of 93 patients who underwent resection for BAC from February 1989 to May 1999.

PATIENTS

There were a total of 153 patients with BAC diagnosed during this period. Among them, 60 patients (39.2%) had diffuse disease and received medical therapy only, and the remaining 93 patients (60.8%), who had localized disease, underwent surgical resection. Patients who received surgical resection were enrolled in this study.

MEASUREMENTS

Data regarding demographics, presentation symptoms, initial radiologic features, surgical type, tumor staging, recurrence status, radiologic patterns of recurrence, and survival were obtained from all patients.

RESULTS

Female patients were significantly younger than male patients. Patients who were female, nonsmoking, undergoing curative surgery, lobectomy, or bilobectomy, and with early tumor staging and no nodal involvement had a better prognosis. Patients with a right lung tumor had a longer survival than those with a left lung tumor, with borderline significance. Among those who suffered from recurrent diseases, a second resection yielded a better survival. Multivariate analysis showed curative surgery, initial surgical type, recurrence status, radiologic patterns of recurrence, and duration from surgical resection to recurrence all had a significant impact on survival.

CONCLUSIONS

Those patients with localized, early-stage BAC who underwent curative surgery had a better survival. Patients with localized recurrence after the initial surgery warranted a second resection. Those with a diffuse radiologic pattern of recurrence and/or early recurrence had a worse prognosis.