A therapeutic approach to roentgenographically occult squamous cell carcinoma of the lung

Unusual local and distant metastases after complete resection of roentgenographically occult squamous cell carcinoma

Roentgenographically occult squamous cell carcinoma (ROSCC) was reported to have been cured after complete resection. We experienced unusual local and distant metastases after complete resection of a ROSCC of left B6 bronchus. During the operation due to the proximal bronchial stump being positive for squamous cell carcinoma (SCC), a left lower sleeve lobectomy was performed. Six years after the operation, a chest CT showed no abnormal shadows. 6 months later a PET-CT showed metastases on bilateral supraclavicular lymph nodes, mediastinal lymph nodes, and the right adrenal glands. A biopsy of the right supraclavicular lymph node revealed that it was a metastatic SCC. The possibility of recurrence from a second pulmonary SCC might still remain. A prolonged follow-up over many years is desirable for a heavy smoker with a ROSCC.

Relationship Between Emphysema Severity and the Location of Lung Cancer in Patients With Chronic Obstructive Lung Disease

OBJECTIVE

New phenotypes of chronic obstructive pulmonary disease (COPD) based on emphysema severity have been recognized recently. The purpose of this study was to determine the relationship between emphysema severity (phenotype) and lung cancer location in patients with COPD.

MATERIALS AND METHODS

Four hundred patients with 405 primary lung cancers confirmed pathologically between January 2010 and March 2014 were included in the study. Of these, 193 patients received a diagnosis of COPD according to the Global Initiative for Chronic Obstructive Lung Disease guidelines. We scored emphysema severity (0-4) on thin-section CT and assigned the anatomic tumor location of lung cancer as peripheral or central.

RESULTS

Patients with COPD had a higher proportion of centrally located lung cancer compared with those without COPD (36.4% vs 17.4%; p < 0.001). In patients with COPD, lower emphysema grades (odds ratio [OR], 0.69; 95% CI, 0.51-0.93; p = 0.016) and reduced ratio of forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) (OR, 0.94; 95% CI, 0.89-0.99; p = 0.024) were associated with central location. After adjusting for age, smoking, and spirometry results, the proportion of central location was approximately four times higher in patients with lower emphysema grades (0-2, < 25%) than in those with severe grades (grade 4, > 51%).

CONCLUSION

Lower emphysema grades and reduced FEV1/FVC seemed to be independent predictors of central location of lung cancer in COPD. Therefore, in patients with COPD with lower grade emphysema and airway-predominant disease, additional screening tools may have to be considered for central lung cancer detection along with thin-section CT.

Diagnosis and treatment of bronchial intraepithelial neoplasia and early lung cancer of the central airways: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

Bronchial intraepithelial lesions may be precursors of central airway lung carcinomas. Identification and early treatment of these preinvasive lesions might prevent progression to invasive carcinoma.

METHODS

We systematically reviewed the literature to develop evidence-based recommendations regarding the diagnosis and treatment of intraepithelial lesions.

RESULTS

The risk and timeline for progression of bronchial intraepithelial lesions to carcinoma in situ (CIS) or invasive carcinoma are not well understood. Multiple studies show that autofluorescence bronchoscopy (AFB) is more sensitive that white light bronchoscopy (WLB) to identify these lesions. In patients with severe dysplasia or CIS in sputum cytology who have chest imaging studies showing no localizing abnormality, we suggest use of WLB; AFB may be used as an adjunct when available. Patients with known severe dysplasia or CIS of central airways should be followed with WLB or AFB, when available. WLB or AFB is also suggested for patients with early lung cancer who will undergo resection for delineation of tumor margins and assessment of synchronous lesions. However, AFB is not recommended prior to endobronchial therapy for CIS or early central lung cancer. Several endobronchial techniques are recommended for the treatment of patients with superficial limited mucosal lung cancer who are not candidates for resection.

CONCLUSION

Additional information is needed about the natural history and rate of progression of preinvasive central airway lesions. Patients with severe dysplasia or CIS may be treated endobronchially; however, it remains unclear if these therapies are associated with improved patient outcomes.

Detection and minimally invasive treatment of early squamous lung cancer

Non-small cell lung cancer (NSCLC) is the most common cause of cancer deaths worldwide. The majority of patents presenting with NSCLC have advanced disease, which precludes curative treatment. Early detection and treatment might result in the identification of more patients with early central lung cancer and improve survival. In addition, the study of early lung cancer improves understanding of lung carcinogenesis and might also reveal new treatment targets for advanced lung cancer. Bronchoscopic investigation of the central airways can reveal both early central lung cancer in situ (stage 0) and other preinvasive lesions such as dysplasia. In the current review we discuss the detection of early squamous lung cancer, the natural history of preinvasive lesions and whether biomarkers can be used to predict progression to cancer. Finally we will review the staging and management of preinvasive lung cancer lesions and the different therapeutic modalities that are available.

Clinical relevance of sputum cytology and chest X-ray in patients with suspected lung tumors

OBJECTIVE

To review diagnostic procedures, therapeutic modalities, and follow-up methods in patients with suspected lung tumors.

METHODS

We retrospectively examined 70 patients who underwent a complete medical checkup because they had been positive for sputum cytology and had presented no chest X-ray findings for the 10-year period between 1994 and 2004. To make a diagnosis, we conducted the first complete medical checkup that included chest X-ray, sputum cytology, chest computed tomography (CT), and bronchoscopy. In the case that no diagnosis could be made, we repeated the chest X-ray and sputum cytology every 3 to 6 months and additionally conducted chest CT and bronchoscopy according to abnormal findings.

RESULTS

Among 70 patients, there were 36 and 13 who were diagnosed during the first complete medical checkup and follow-up, respectively, 13 who remained undiagnosed, and eight for whom follow-up was discontinued. Among the 49 diagnosed patients, 40, 8, and 1 patient had lung cancer, upper respiratory tract carcinoma (URTC), and esophageal carcinoma (EC), respectively. Among the 40 patients with lung cancer, 34 had a stage 0 or I tumor and 15 were radically treatable by photodynamic therapy and endobronchial irradiation. Nine among 11 patients whose lung cancer was detected during follow-up had a stage 0 or IA tumor.

CONCLUSION

Not only lung cancer but also URTC and EC were successfully detected in patients who were positive for sputum cytology and presented negative chest X-ray. Radical treatment was possible in 38 (76%) of 50 diagnosed patients, thus indicating the importance of follow-up through these procedures.

Bronchial Intraepithelial Neoplasia/Early Central Airways Lung Cancer

BACKGROUND

An evidence-based approach is necessary for the localization and management of intraepithelial and microinvasive non-small cell lung cancer in the central airways.

METHODS

Material appropriate to this topic was obtained by literature search of a computerized database. Recommendations were developed by the writing committee and then reviewed by the entire guidelines panel. The final recommendations were made by the Chair and were voted on by the entire committee.

RESULTS

White light bronchoscopy has diagnostic limitations in the detection of microinvasive lesions. Autofluorescence bronchoscopy (AFB) is a technique that has been shown to be a sensitive method for detecting these lesions. In patients with moderate dysplasia or worse on sputum cytology and normal chest radiographic findings, bronchoscopy should be performed. If moderate/severe dysplasia or carcinoma in situ (CIS) is detected in the central airways, then bronchoscopic surveillance is recommended. The use of AFB is preferred if available. In a patient being considered for curative endobronchial therapy to treat microinvasive lesions, AFB is useful. A number of endobronchial techniques as therapeutic options are available for the management of CIS and can be recommended to patients with inoperable disease. In patients with operable disease, surgery remains the mainstay of treatment, although patients may be counseled about these techniques.

CONCLUSIONS

AFB is a useful tool for the localization of microinvasive neoplasia. A number of endobronchial techniques available for the curative treatment can be considered first-line therapy in inoperable cases. For operable cases, the techniques may be considered and discussed with the patients.

Endobronchial photodynamic therapy for lung cancer

BACKGROUND AND OBJECTIVE

Endobronchial photodynamic therapy (PDT) is a minimally invasive technique for the palliation of major airway obstruction from lung cancer, and for the treatment of endobronchial microinvasive lung cancer.

STUDY DESIGN

Results of reported clinical trials were compared, and the author's preliminary results with second generation photosensitizers were also reviewed.

RESULTS

A review of the clinical experience with endobronchial PDT is provided. Potential advantages of PDT include the duration of palliation achieved through the delayed cellular effects of PDT within tumor. Side-effects from FDA-approved photosensitizer (Photofrin, Porfimer sodium, Axcan Scandipharm, Montreal, Quebec) include skin photosensitivity. HPPH (2-[1-hexyloxyethyl]-2 devinyl pyropheophorbide) is an example of a second-generation photosensitize that shows promise in the treatment of lung cancer, and appears to be free from significant skin photosensitivity.

CONCLUSION

PDT is an effective tool for the palliation of endobronchial lung cancers which obstruct the central airways and is also effective for the treatment of central microinvasive carcinoma and carcinoma in situ of the central airways.

A New Technique for Endobronchial Ultrasonography and Comparison of Two Ultrasonic Probes

STUDY OBJECTIVES

Endobronchial ultrasonography (EBUS) is currently the sole clinical method available for delineating the bronchial wall structure; however, the image resolution is inadequate. Thus, an improved image analysis system is needed for both a more accurate and more readily interpretable endobronchial ultrasonogram.

MATERIALS AND METHODS

A total of 10 patients underwent pulmonary resection for lung cancer. EBUS was performed on the bronchi of the resected lungs, which had been immersed in physiologic saline solution. The same bronchial lesion in each specimen was imaged with two probes: 20 MHz and 30 MHz. The images were analyzed using the plot profile derived from freeware image analysis software: NIH Image (National Institutes of Health; Bethesda, MD). The measured echo intensity of the bronchial wall was statistically analyzed.

RESULTS

A normal bronchial wall image consists of five layers, and the plot profile shows a W-shaped curve. The mean value of the echo intensity of each peak or trough of the W-shaped curve was calculated and compared for both probes. The differences in the mean echo intensity between both the third and fourth layer and the second and fourth layer were found to be significantly greater with the 30-MHz probe than with the 20-MHz probe. The echo intensity curve of a central-type lung cancer was not W shaped, indicating that the bronchial wall was not composed of the normal five layers.

CONCLUSION

We employed image analysis software and drew a plot to obtain a W-shaped curve from the EBUS image data. This enabled us to make an objective assessment of the laminar structure of the bronchial wall. In order to clearly recognize the laminar structure of the bronchial wall, the 30-MHz probe was found to be more useful than the 20-MHz probe.

A prospective evaluation of transbronchial ultrasonography for assessment of depth of invasion in early bronchogenic squamous cell carcinoma

In order to determine the appropriate treatment modality for roentgenographically occult bronchogenic squamous cell carcinoma (ROSCC), it is essential to evaluate the depth of invasion, because ROSCC invading beyond the cartilaginous layer cannot be effectively treated by photodynamic therapy (PDT) due to spread of disease. Transtracheal endoscopic ultrasonography (TUS) was useful for predicting the depth of invasion in some ROSCCs. In order to assess the actual significance of TUS as a diagnostic tool for predicting the depth of carcinoma invasion, we have conducted a prospective trial with 22 lesions of ROSCCs. We ultrasonographically classified the degree of the depth of invasion into two groups; A: "invasion does not reach cartilaginous layer" and B: "invasion involves cartilaginous layer". Then the patients were treated by irradiation, PDT, or surgical resection. Pathological findings were also classified into A or B. In order to calculate the sensitivity for evaluating the depth of invasion by TUS, the cases without any tumor and/or malignant cells after PDT were regarded as pathological A. In the evaluation of the depth of carcinoma invasion staying inside the cartilaginous layer, the sensitivity and the positive predictive value were 85.7%, the specificity was 66.7%, and the accuracy was 80.0%. With TUS, preoperative evaluation of the depth of invasion would be more accurate, and the decision of treatment modality would be more appropriate, compared with the conventional bronchoscopic observation alone.

hnRNP B1 protein may be a possible prognostic factor in squamous cell carcinoma of the lung

Heterogeneous nuclear ribonucleoprotein (hnRNP) B1 is an RNA-binding protein that is required for the maturation of mRNA precursor. It was previously reported that hnRNP A2/B1 was overexpressed at the early clinical stage of lung cancer, and that hnRNP B1 protein, a splicing variant of hnRNP A2 mRNA, was elevated in lung cancer tissues. In this study, we applied the immunohistochemical method, using anti-hnRNP B1 antibody to analyze the usefulness of the hnRNP B1 antibody as a prognostic marker and also as a marker useful for early detection. A total of 206 specimens were examined. Histological examination revealed this protein to be positive in 79 (71.2%) of 111 squamous cell carcinomas and in 45 (64.3%) of 70 adenocarcinomas, respectively. This protein was also expressed in 24 (63.2%) of 38 roentgenographically occult carcinomas and in seven (63.6%) of 11 dysplastic lesions. These findings suggest the possible participation of this protein in early carcinogenesis. Furthermore, the survival curve of the squamous cell carcinoma patients with hnRNP B1 overexpresseion showed a better prognosis compared with that of the patients without hnRNP B1 expression (P=0.014), whereas in adenocarcinoma patients, there was no such a difference between them (P=0.889). These findings indicate that hnRNP B1 could be a useful marker for the early detection of bronchogenic squamous cell carcinoma and that it may be a prognostic factor in this cell type.

[Endobronchial brachytherapy: technique and indications]

The endobronchial brachytherapy procedure involves the insertion of an afterloading catheter into bronchus in close proximity to an endoluminal lesion, and to perform limited irradiation sparing as much as possible normal health tissues. The catheter is inserted during a classical flexible bronchoscopy. Three types of indications have been discussed: (i) palliative treatment of lung carcinoma, with or without laser desobstruction: an improvement in respiratory symptoms was observed in 60 to 80% of the cases; (ii) curative treatment for localised endobronchial carcinomas, in previously irradiated patients, or in case of contraindication of surgery or external beam irradiation; local control rate range from 60 to 70% at 2 years; (iii) combination of external irradiation and brachytherapy in the first line treatment of lung cancers. Two randomised trials did not show any improvement in survival for this approach; however, they have included advanced diseases. In the opposite, this association seems very effective for early stage lung carcinomas. Two major complications were regularly reported, haemoptysis and radiation bronchitis. Predictive factors for these toxicities are actually better known: haemoptysis could be due to a progressive disease more often than to brachytherapy itself; technical factors (dose, volume, fractionation), however, could explain a number of radiation bronchitis, and their incidence could decrease in the future.

Treatment of early stage non-small cell lung cancer

Photodynamic therapy (PDT), brachytherapy, electrocautery, cryotherapy, and Nd-YAG laser therapy are therapeutic options available for management of endobronchial malignancies. All of these treatment modalities have been used for both palliation of late obstructing cancers, and more recently have been used as primary treatment of early radiographically occult cancers. We reviewed the evidence for the use of these treatment options in the management of early lung cancer.

A case-control study for evaluating the efficacy of mass screening program for lung cancer in Miyagi Prefecture, Japan

BACKGROUND

In Miyagi Prefecture, Japan, a mass screening program for lung cancer has been conducted since 1982 (miniature chest X-ray for all screenees and sputum cytology for those with a smoking index > or = 600) [smoking index 600 = 30 pack years, the average number of cigarettes smoked per day multiplied by the number of years of regular smoking]. Over 1500 lung carcinomas, including 250 roentgenographically occult lung tumors, were detected and treated up to 1999. In the current study, a nested case-control study was conducted in the population that was screened in 1989 to evaluate the efficacy of the screening program for lung cancer.

METHODS

To reduce self-selection bias, the source population was defined as screenees with negative results in 1989 (284,226 individuals). In the population, 474 individuals died of lung carcinoma during 1992-1994. After exclusion, 328 patients who died of primary lung carcinoma at between ages 40 years and 79 years were defined as the cases. Six controls were supposed to be selected in the source population for each case and matched by gender, year of birth, municipality, and smoking habits. Controls who had died or moved before the matched case was diagnosed were excluded. Finally, 328 cases and 1886 controls were selected. Screening histories were compared, and odds ratios were calculated using conditional logistic regression analysis.

RESULTS

Within the 12 months before diagnosis, 241 of 328 cases (73.5%) had attended the screening compared with 1557 of 1886 controls (82.6%). The smoking-adjusted odds ratio was 0.54 (95% confidence interval, 0.41-0.73).

CONCLUSIONS

The mass screening program for lung cancer in Miyagi Prefecture was capable of reducing by 46% the risk of death from carcinoma of the lung.

Segmentectomy for roentgenographically occult bronchogenic squamous cell carcinoma

BACKGROUND

Roentgenographically occult bronchogenic squamous cell carcinomas (ROSCCs) are early squamous cell lung cancers of central type. Some of them cannot be treated with intrabronchial therapy. Although surgical treatment was performed for such tumors, it was unknown whether lobectomy was indispensable or not.

METHODS

The clinicopathologic information of the 58 patients who underwent segmentectomy for ROSCCs were collected from 16 hospitals and reviewed retrospectively, compared with 98 patients who underwent lobectomy for ROSCCs.

RESULTS

Five-year survival rate of the 58 patients based on lung cancer deaths was 96.8%, and 82.6% including all causes of death. The duration of chest tube drainage in the segmentectomy group was slightly longer than in the lobectomy group. Operative mortality and the frequency of postoperative complications were not statistically different in both groups. Postoperative/preoperative vital capacity and forced expiratory volume in 1 second were higher in the segmentectomy group.

CONCLUSIONS

These results suggest that segmentectomy may be an alternative for surgical therapy of carefully selected ROSCCs. More prospective studies are required to fully demonstrate clinical benefit.