Non-small cell lung cancer

Most patients with non-small cell lung cancer (NSCLC) are diagnosed with advanced cancer. These guidelines only include information about stage IV NSCLC. Patients with widespread metastatic disease (stage IV) are candidates for systemic therapy, clinical trials, and/or palliative treatment. The goal is to identify patients with metastatic disease before initiating aggressive treatment, thus sparing these patients from unnecessary futile treatment. If metastatic disease is discovered during surgery, then extensive surgery is often aborted. Decisions about treatment should be based on multidisciplinary discussion.

Incomplete Intrapulmonary Lymph Node Retrieval After Routine Pathologic Examination of Resected Lung Cancer

Purpose

Pathologic nodal stage affects prognosis in patients with surgically resected non–small-cell lung cancer (NSCLC). Unlike examination of mediastinal lymph nodes (LNs), which depends on surgical practice, accurate examination of intrapulmonary (N1) nodes depends primarily on pathology practice. We investigated the completeness of N1 LN examination in NSCLC resection specimens and its potential impact on stage.

Patients and Methods

We performed a case-control study of a special pathologic examination (SPE) protocol using thin gross dissection with retrieval and microscopic examination of all LN-like material on remnant NSCLC resection specimens after routine pathologic examination (RPE). We compared LNs retrieved by the SPE protocol with nodes examined after RPE of the same lung specimens and with those of an external control cohort.

Results

We retrieved additional LNs in 66 (90%) of 73 patient cases and discovered metastasis in 56 (11%) of 514 retrieved LNs from 27% of all patients. We found unexpected LN metastasis in six (12%) of 50 node-negative patients. Three other patients had undetected satellite metastatic nodules. Pathologic stage was upgraded in eight (11%) of 73 patients. The time required for the SPE protocol decreased significantly with experience, with no change in the number of LNs found.

Conclusion

Standard pathology practice frequently leaves large numbers of N1 LNs unexamined, a clinically significant proportion of which harbor metastasis. By improving N1 LN examination, SPE can have an impact on prognosis and adjuvant management. We suggest adoption of the SPE to improve pathologic staging of resected NSCLC.

Prognostic impact of the number of examined lymph nodes (LNs) in resected node negative (pNo) non-small cell lung cancer (NSCLC)

7025

Background: In the US, 29% of patients undergo curative-intent surgery for NSCLC. Absence of LN metastasis and the extent of LN examination influence survival. 44% of patients with pathological node negative (pN0) disease die within 5 years. There is no consensus on the optimal number of LNs to be examined to determine pN0 stage. We hypothesized that patients with few examined nodes may have missed nodal metastasis and increasing the number of LNs examined would improve survival. Methods: Retrospective SEER database analysis of NSCLC resections from 1998 to 2002, with survival updated to 2008. Patients with first primary, pN0 NSCLC, with one or more LNs examined, met our study criteria. Cox regression and competing risk models were used for survival analysis. A p value <0.05 was considered statistically significant. Results: 8,137 patients met inclusion criteria and were evaluated. A median of 6 LNs were examined in this cohort. Patients who underwent pneumonectomy and lobectomy had more LNs examined than those who had sub-lobar resections. Higher number of LNs examined was associated with better overall survival (OS) and lung cancer specific survival (LCSS), at a plateau of 8 LNs for both outcomes (Table). Having mediastinal LNs examined also resulted in increased OS and LCSS (p<0.05). Conclusions: The pathologic assessment of LNs in surgical specimens is often suboptimal. Examining more LNs may have increased the likelihood of correct staging. Lower numbers of LNs examined probably result in understaging. Examining 8 or more total LNs and mediastinal LNs examined improved both OS and LCSS. [Table: see text]

Size distribution and metastasis in discarded intrapulmonary lymph nodes (LN) after lung cancer resection

7072^

Background: Lymph node (LN) status is the most important prognostic determinant after resection of lung cancer. 18% of a SEER cohort and 12% of a Memphis cohort had no LNs examined (pNx). Patients with pNx have inferior survival to T-category matched pN0 patients with at least 1 LN examined. The optimal number of LN needed to safely declare a patient pN0 may be >10. Less than 20% of resections in SEER achieve this. We hypothesized that a significant number of intrapulmonary LNs are left unexamined and some may harbor metastatic disease. We report the size characteristics of materials examined in a re-dissection protocol to test this hypothesis. Methods: Prospective study of lung resection specimens re-dissected after signout of the final pathology report. Remnant lung material was dissected with thin cuts and all LN-like material was retrieved for microscopic examination, irrespective of size or location. The size of non-LN tissue, LN without metastasis and LN with metastases were compared using the Wilcoxon-Mann-Whitney test. Results: 112 specimens were examined and 1,094 LN-like materials were retrieved. 749 (69%) proved to be LN tissue. 71 (10%) LNs retrieved had metastasis. Non-LN tissue was significantly smaller than LN tissue (p<0.0001). LNs with metastasis were significantly larger than those without metastasis (p <0.0001). 60% of materials >2cm were LNs with metastasis. 7% of materials <1cm were LN with metastasis. 52% of LNs with metastasis, and 55% of LNs without metastasis measured from 0.5 to 1.5cm (Table). Majority of LNs >2cm had metastatic disease, but 40% did not; a notable proportion of LNs with metastasis were small. Nearly equal percentages of LNs with and without metastasis were found in the range of 0.5-1.5cm. Conclusions: Statistical differences in size between lymph nodes with and without metastasis is clinically meaningless due to broad overlap. LN size alone is not an adequate predictor of LN metastasis. [Table: see text]

Mediastinal lymph node examination and survival in resected early-stage non-small cell lung cancer in the Surveillance, Epidemiology, and End Results (SEER) database

7069

Background: Pathologic nodal stage is a key prognostic factor in resectable non-small cell lung cancer (NSCLC). Mediastinal lymph node (MLN) metastasis connotes a poor prognosis. Yet, some NSCLC resections in the US do not include MLN examination. Methods: We analyzed SEER data from 1998 to 2002 to quantify the long-term survival impact of failure to examine MLN in resected NSCLC. We used Kaplan-Meier methods to compare the unadjusted survival difference between patients with, and without, MLN examination. We used Cox proportional hazards and competing risk models to serially adjust for the impact of risk factors on survival differences. Results: Sixty-two percent of patients with pathologic N0 or N1 NSCLC had no MLN examined. Men, African-Americans, patients with more advanced stage, and those who had less than pneumonectomy were less likely to have MLN examination. Five-year all-cause mortality (46.9% v 51.7%, p<.001), and lung cancer-specific mortality (31.5% v 36%, p<.001), rates were higher in those without MLN examination. After adjustment for potential confounders, MLN examination was associated with a 6% reduction in all-cause mortality (HR, 0.94; CI, 0.89-0.99; p=.014), and 10% reduction in lung cancer-specific mortality (HR, 0.90; 95% CI, 0.84-0.96; p=.002) rates. The excess risk in 1 year’s cohort of U.S. lung resections was 2,700 lives over 5 years. Conclusions: Failure to examine MLN was a common practice in "MLN-negative" NSCLC resections, which significantly impaired long-term survival. Efforts to understand the etiology of this quality gap, and measures to eliminate it, are warranted.

A feasibility study of interventions to improve intraoperative lymph node (LN) collection and pathologic examination of lung cancer resection specimens

e17531^

Background: The number of LNs examined following lung cancer resection has prognostic value. The International Association for the Study of Lung Cancer (IASCLC) recommends a minimum of 6 LNs and other series have recommended greater than 11. Most resections in the United States fail to meet these recommendations. We hypothesized that simple interventions could improve on the number of LNs examined. Methods: We used a pre-labeled specimen collection kit to aid in collection of N2 LNs and developed a re-dissection protocol to retrieve discarded N1 LNs. We performed a 3 era case control study: Era 1, routine surgical examination (RSE) + routine pathology examination. Era 2, RSE + special pathology examination (SPE). Era 3, SPE + special surgical examination. The Chi-Square, Fishers Exact, Wilcoxon-Mann-Whitney and Kruskal-Wallis tests were used where appropriate for comparisons. Results: Patient demographic and tumor characteristics were similar across three groups. Significantly more N1 and total LNs were examined in eras 2 and 3 compared to era 1 (Table). Significantly more N2 LNs were examined in era 3 compared to eras 1 and 2. There was a non-significant trend toward detection of metastatic LNs. More cases met both IASLC recommendations and had at least 11 LNs examined LNs in eras 2 and 3 compared to era 1. Conclusions: The interventions were feasible and effective in improving LN examination. The number of LNs examined using these interventions exceeded consensus recommendations. A phase III trial incorporating these interventions is being designed. [Table: see text]

Pathologic lymph node staging practice and stage-predicted survival after resection of lung cancer

BACKGROUND

Lymph node status is the most important prognostic factor in resectable nonsmall-cell lung cancer (NSCLC). We examined the relationship between the pattern of lymph node examination (including the number and anatomic location of resected lymph nodes), pathologic nodal stage, and survival after NSCLC resection.

METHODS

Retrospective review of all NSCLC resections in the Memphis Metropolitan Area from January 1, 2004, to December 31, 2007.

RESULTS

In 656 resections, the number of lymph nodes examined differed significantly between patients grouped by pathologic nodal stage (p<0.0001) and extent of resection (p<0.001). Thirty-seven percent of "mediastinal node-negative" patients had no mediastinal lymph nodes examined. Patients with pN1 and no mediastinal lymph node examination had better [corrected] survival than patients with mediastinal lymph node examination (p < 0.02) . Approximately 10% of patients with pN0 and pN2 disease had no hilar/intrapulmonary lymph nodes examined.

CONCLUSIONS

Suboptimal lymph node staging was prevalent in this cohort. Large proportions of pN1 and pN0 patients were probably understaged. In patients with pathologic positive pulmonary/hilar lymph nodes, mediastinal lymph node examination was associated with poorer survival [corrected]. Interventions are needed to improve lymph node staging of NSCLC.

Pattern of use of adjuvant chemotherapy for stage II colon cancer: a single-institution experience

PURPOSE

American Society of Clinical Oncology (ASCO) guidelines define high-risk prognostic features (HRFs) in stage II colon cancer and recommend limiting adjuvant chemotherapy to patients with HRFs. We evaluated the extent to which HRFs influenced decisions on adjuvant chemotherapy before and after publication of the guidelines.

PATIENTS AND METHODS

We reviewed data from 100 consecutive patients with stage II colon cancer resected between January 2000 and June 2007. Practice pattern in the pre-guideline era (2000 through 2004) was compared with the post-guideline era (2005-2007).

RESULTS

The median age of the cohort was 65.8 years. A total of 60 patients had > or = 1 HRF. Overall, 38% of the patients with HRFs did not receive chemotherapy; 37.5% without HRFs did. Seventy-one percent of the patients given adjuvant chemotherapy had HRFs versus 48% of the patients not given chemotherapy. There was no association between the presence/absence of HRFs and chemotherapy (P = .25). The association between number of HRFs per individual and chemotherapy was significant (P = .0255). Bowel obstruction and T4 disease were the only individual HRFs significantly associated with chemotherapy (P = .0059 and .0294, respectively). A significant drop in use of chemotherapy for all patients occurred after publication of the guidelines, but this was caused mostly by a drop in treatment for patients with HRFs from 80% to 36% (P = .001).

CONCLUSION

Decisions for or against adjuvant chemotherapy did not adhere completely to ASCO guidelines. Publication of the guidelines led to a significant drop in appropriate use of adjuvant chemotherapy in high-risk patients.

Hand-Assisted Laparoscopic Colectomy Compared with Open Colectomy in a Nontertiary Care Setting

BACKGROUND

Laparoscopic colectomy allows oncologic resection equivalent to open colectomy while reducing postoperative morbidity, at the cost of longer operating time. Hand-assisted laparoscopy might yield the benefits of laparoscopy while reducing operating time.

PATIENTS AND METHODS

We compared the intraoperative and postoperative experience of patients undergoing hand-assisted laparoscopic colectomy (HALC) to those who had open colectomy. In this retrospective case review of consecutive patients undergoing HALC for colon tumors from April 2003 to September 2004 compared with patients who had open colectomy, patients with rectal cancer and stage IV disease were excluded, and reported variables were compared by the nonparametric Mann-Whitney U test; all P values are 2-tailed.

RESULTS

The number of patients with HALC versus open colectomy was 39 and 55, respectively. The locations of tumors were as follows: right colon, 62% versus 56%; left colon, 2.5% versus 11%; sigmoid colon, 31% versus 33%; and rectosigmoid colon, 5% versus 0. Stage distribution was as follows: stage 0, 23% versus 11%; stage I, 23% versus 23%; stage II, 31% versus 36%; and stage III, 23% versus 31%. Median operating room time was 139 minutes versus 137 minutes (P = 0.94). Four 39 (10%) HALC procedures were converted to open colectomy. Duration of hospitalization was 6 days versus 10 days (P = 0.007). Median number of lymph nodes in resection specimen was 12 versus 9 (P = 0.043). There were 3 cases of serious postoperative infection in the HALC group versus 9 in the open colectomy cohort.

CONCLUSION

Hand-assisted laparoscopic colectomy is technically feasible in the nontertiary care setting, with duration of surgery equivalent to that of open colectomy but significantly shorter duration of hospitalization and equivalent or superior quality resection and pathologic staging.

Esophageal Cancer Clinical Practice Guidelines

Carcinomas originating in the upper gastrointestinal (GI) tract (esophagus, gastroesophageal junction, and stomach) constitute a worldwide major health problem. Unfortunately, esophageal carcinoma is often diagnosed late, and most therapeutic approaches are palliative, although advances have been made in staging procedures and therapy. The guidelines emphasize that palpable advances have been made in the treatment of locoregional esophageal carcinoma. Similarly, endoscopic palliation of esophageal carcinoma has improved substantially because of improving technology.

For the most recent version of the guidelines, please visit NCCN.org

Genetic/Familial High-Risk Assessment: Breast and Ovarian Clinical Practice Guidelines

Recent advances in molecular genetics have identified several genes associated with inherited susceptibility to cancer and have provided a means to begin identifying individuals and families with an increased risk of cancer. This rapid expansion of knowledge about cancer genetics has implications for all aspects of cancer management, including prevention, screening, and treatment. These guidelines specifically address hereditary breast/ovarian cancer syndrome (HBOC), Li-Fraumeni syndrome, and Cowden syndrome. These guidelines were developed understanding that much of our knowledge of how the rapidly emerging field of molecular genetics can be applied clinically is preliminary and that flexibility is needed when applying these guidelines to individual families.

For the most recent version of the guidelines, please visit NCCN.org

CMV antigenemia following bone marrow transplantation: risk factors and outcomes

Cytomegalovirus (CMV) infection remains a major problem in blood and bone marrow transplant (BMT) recipients. Recent efforts have been directed at prevention, early diagnosis, and treatment of CMV disease following BMT. Assay for CMV early antigen pp65 on circulating leukocytes has been shown to be sensitive, and specific in detecting early CMV infection. We examined the frequency, risk factors, and outcomes of a positive CMV antigen assay in 118 consecutive BMT patients. Forty-three (36%) of the 118 patients developed CMV antigenemia a median of 26 days post-BMT (range, -6 to 209 days). The incidence of antigenemia in autologous, related donor, and unrelated donor BMT recipients was 15%, 50%, and 48%, respectively (P < .01) and was lower in CMV-seronegative patients (19% versus 51% in seropositive patients; P < .01). Patients with grade II to IV acute graft-versus-host disease (GVHD) had 2.2 times the risk of antigenemia of patients with no or only limited GVHD (P = .03). Age at transplantation, underlying disease, CMV prophylaxis regimen, and GVHD prophylaxis regimen did not affect the risk of CMV antigenemia. Ten of the 43 antigenemic patients, all CMV-seropositive allogeneic BMT (alloBMT) recipients, developed CMV organ disease a median of 101 days (range, 28-283 daya) post-BMT. These data suggest that CMV-seropositive alloBMT patients are at highest risk for CMV antigenemia and for organ disease as well. CMV disease may occur before antigenemia is detectable in leukopenic patients and may also develop late post-BMT, even in patients still receiving antiviral prophylaxis. In high-risk groups, intensive surveillance continuing for more than 6 months after BMT may be indicated.