Factors influencing ten-year survival in resected stages I to IIIa non-small cell lung cancer

Long term outcomes beyond 5 years after pulmonary resection for non-small-cell lung cancer

OBJECTIVES

We investigated the incidence of late recurrence beyond 5 years after pulmonary resection and aimed to identify candidates for long-term surveillance.

METHODS

We retrospectively reviewed the medical records of 978 non-small-cell lung cancer patients who underwent pulmonary resection between 2002 and 2015 and survived without recurrence for 5 years. Clinicopathological factors associated with recurrence-free survival beyond 5 years after surgery were investigated using univariate and multivariate analyses. The development of late metachronous malignancies was also investigated.

RESULTS

The median follow-up period from 5 years post-surgery was 27 months in the whole cohort. Late recurrence occurred in 37 (3.8%) patients. Late metachronous malignancies were diagnosed in 116 patients (11.9%), including 57 (5.8%) with lung cancer. One-, three-, and five-year recurrence-free survival rates beyond 5 years after surgery were 97.6%, 94.7%, and 94.7%, respectively. The recurrence-free survival of patients with pN1-2 was significantly poorer than that of patients with pN0 disease. Multivariate analysis revealed that adenocarcinoma and pN1-2 status were significantly associated with poor recurrence-free survival beyond 5 years post-surgery (P = 0.009 and 0.007, respectively).

CONCLUSIONS

Non-adenocarcinoma histology and pN0 status were significant favorable factors for recurrence-free survival beyond 5 years post-surgery. The efficacies of long-term surveillance for the detection of late recurrence were considered limited for these populations. Twelve percent of the patients experienced late metachronous malignancies after pulmonary resection.

Brain Metastasis of Non-small Cell Lung Cancer After Disease-Free Survival of 5 years: Case Series and Comprehensive Literature Review

BACKGROUND

In the treatment of nonsmall cell lung cancer (NSCLC), a disease-free survival of 5 years is a criterion for cure. This study aimed to evaluate the characteristics and outcomes of patients with brain metastases of NSCLC after a disease-free survival of 5 years (late recurrent brain metastasis [LRBM]).

METHODS

We reviewed 1281 consecutive patients with brain metastasis of lung cancer at a single institute between November 2014 and December 2022. Relevant articles were retrieved from PubMed. Only peer-reviewed journals published in English were included.

RESULTS

Six patients (0.47%) showed LRBM. Three were male. The median age at lung cancer diagnosis was 45 years. The histological diagnosis of all patients was adenocarcinoma. Driver gene mutations were observed in five patients. The median latency period from lung cancer treatment to the development of brain metastasis was 13 years. All patients had no metastasis to any other organs and underwent craniotomies. The median follow-up duration after craniotomy was 3.5 years. No local intracranial recurrences were observed. Three patients had distant intracranial recurrences at 7, 2, and 0.6 years after craniotomy. Five patients survived for 8, 4, 3, 2, and 0.3 years after craniotomy. One patient experienced re-recurrence in the lung 4 years after craniotomy and died 3.7 years later. In our systematic review, only six studies described LRBM of NSCLC.

CONCLUSIONS

LRBM is rare in patients with NSCLC. In our institution, many of these patients harbored driver gene mutations, and achieved long-term survival with aggressive local therapy. Multicenter analysis is mandatory.

Pathological Pleural Invasion is a Risk Factor for Late Recurrence in Long-Term Survivors of Non-small Cell Lung Cancer after Complete Resection

BACKGROUND

Information regarding late recurrence after pulmonary resection for non-small cell lung cancer (NSCLC) is limited. This study aimed to analyze the risk factors for late recurrence after surgery for NSCLC in the current era.

PATIENTS AND METHODS

We conducted a retrospective study of patients who underwent complete resection for pathological I-III NSCLC between 2006 and 2015. Late recurrence was defined as a recurrence that met the following conditions: (1) the patient underwent chest computed tomography (CT) at or after 54 months after surgery and recurrence was not detected at that time, and (2) recurrence that occurred more than 5 years after surgery. The factors influencing late recurrence, relapse-free survival (RFS), and overall survival (OS) after surgery were analyzed.

RESULTS

A total of 1275 with 5-year relapse-free survival after surgery were enrolled in this study. The mean age of the patients was 66.4 years and 54% of the patients were men. The median interval between surgery and the latest follow-up examination was 98 months. In total, 35 patients (2.7%) experienced late recurrence and 138 patients have died thus far. The cumulative recurrence, RFS, and OS rates at 10 years were 3.9%, 84.9%, and 86.3%, respectively. A multivariate analysis revealed that pleural invasion was an independent risk factor for late recurrence. Pleural invasion was a poor prognostic factor for both RFS and OS.

CONCLUSIONS

Pleural invasion was a predictor of late recurrence. Age > 67 years, preoperative serum carcinoembryonic antigen (CEA) > 5 ng/ml, non-adenocarcinoma, and pleural invasion were poor prognostic factors for RFS.

Ten-year follow-up outcomes of limited resection trial for radiologically less-invasive lung cancer

BACKGROUND

The JCOG0804/WJOG4507L single-arm confirmatory trial indicated a satisfactory 10-year prognosis for patients who underwent limited resection for radiologically less-invasive lung cancer. However, only one prospective trial has reported a 10-year prognosis.

METHODS

We conducted a multicenter prospective study coordinated by the National Cancer Center Hospital East and Kanagawa Cancer Center. We analyzed the long-term prognosis of 100 patients who underwent limited resection of a radiologically less-invasive lung cancer in the peripheral lung field. We defined radiologically less-invasive lung cancer as lung adenocarcinoma with a maximum tumor diameter of ≤2 cm, tumor disappearance ratio of ≥0.5 and cN0. The primary endpoint was the 10-year local recurrence-free survival.

RESULTS

Our patients, with a median age of 62 years, included 39 males. A total of 58 patients were non-smokers; 87 had undergone wide wedge resection and 9 underwent segmentectomy. A total of four cases were converted to lobectomy because of the presence of poorly differentiated components in the frozen specimen or insufficient margin with segmentectomy. The median follow-up duration was 120.9 months. The 10-year recurrence-free survival and overall survival rates of patients with lung cancer were both 96.0%. Following the 10-year long-term follow-up, two patients experienced recurrences at resection ends after wedge resection.

CONCLUSIONS

Limited resection imparted a satisfactory prognosis for patients with radiologically less-invasive lung cancer, except two cases of local recurrence >5 years after surgery. These findings suggest that patients with this condition who underwent limited resection may require continued follow-up >5 years after surgery.

Long-term outcomes of 5-year survivors without recurrence after the complete resection of non-small cell lung cancer after lobectomy: a landmark analysis in consideration of competing risks

PURPOSE

Among non-small cell lung cancers (NSCLC), 5 years is a benchmark in cancer control and treatment, but a certain percentage of cases recur after 5 years. The long-term post-recurrence outcomes remain controversial. To examine the accurate prognostic factors associated with survival and cancer recurrence among 5-year survivors, a landmark analysis that considered competing risks was performed.

METHODS

Complete resection of NSCLC was performed in 2482 patients between January 2003 and December 2015. A total of 1431 patients were 5-year survivors without recurrence. A landmark time analysis was applied to the overall survival (OS) and recurrence-free survival (RFS) from 5 years after surgery, and the findings were calculated using the Kaplan-Meier method. The cumulative incidence of cause-specific death and recurrence was estimated using the cumulative incidence function, while carefully considering the competing risks.

RESULTS

Postoperative recurrence was detected in 732 patients, of whom 68 (9.3%) had recurrence after 5 years. The median follow-up period was 8.2 years. In the competing risk analysis, the independent poor prognostic factors associated with cause-specific death were age ≥ 75 years, lymph node metastasis and pleural invasion.

CONCLUSIONS

Patients requiring a follow-up for > 5 years were aged ≥ 75 years and had either lymph node metastasis or pleural invasion.

Tumor hyaluronan as a novel biomarker in non-small cell lung cancer: A retrospective study

INTRODUCTION

Hyaluronan (HA) accumulation is associated with tumorigenesis and aggressive tumor behavior.

AIMS

We investigated the biomarker potential of HA in non-small cell lung cancer (NSCLC).

METHODS

HA levels were scored using affinity histochemistry in 137 NSCLC samples stratified by HA score ≤10, 11-20, 21-30, and >30 with HA-high defined as ≥25% expression in the extracellular matrix (ECM) of the tumor surface area. Overall survival (OS) and time to progression from initiation of taxane therapy (TTP) were compared using log-rank tests based on HA score.

RESULTS

Of 122 patients with recurrent/metastatic NSCLC, 93 had mean HA scores that were not significantly different across clinicopathologic variables. Frequency of HA-high tumors did not differ by histology (34/68 adenocarcinomas vs. 12/25 squamous tumors, Fisher's p = 1.0000). Median OS for recurrent/metastatic adenocarcinoma was 35.5 months (95%, 23.6-50.3) vs. 17.9 months for squamous (95%, 12.7-37.0, log-rank test, p = 0.0165). OS was not significantly different by HA quartiles, high or low (<25) HA score and tumor histology, and HA biopsy site (all p > 0.05). Median TTP (n = 98) significantly differed by HA quartile (2.8 months for HA score ≤10; 5.0 months for 11-20; 7.9 months for 21-30; 3.9 months for >30, p = 0.0265). Improved TTP trended in HA-high over HA-low tumors (n = 98, p = 0.0911).

CONCLUSION

In this NSCLC cohort, tumor HA level represents a potential biomarker for TTP, which remains a cornerstone of NSCLC therapy. Further validation is warranted to identify the HA accumulation threshold associated with clinical benefit.

Clinical characteristics and survival outcomes of patients with pneumonectomies: A population-based study

Background

Prognostic factors in a pneumonectomy (PN) are not yet fully defined. This study sought to analyze and evaluate long-term survival after pneumonectomies (PNs) for patients with non-small cell lung cancer (NSCLC).

Methods

We obtained data from the Surveillance, Epidemiology, and End Results (SEER) database for patients who underwent PNs between 2004 and 2015. Propensity score matching (PSM) analysis and Kaplan–Meier curves were used to estimate overall survival (OS), while univariate and multivariable Cox proportional hazards regression analyses were applied to create a forest plot.

Results

In total, 1,376 patients were grouped according to right/left PNs. Before matching, OS was worse after a right PN [hazard ratio (HR): 1.459; 95% CI 1.254–1.697; P &lt; 0.001] and after matching, survival differences between groups were not significant (HR: 1.060; 95% CI 0.906–1.240; P = 0.465). Regression analysis revealed that age, gender, grade, lymph node dissection, N-stage, and chemotherapy were independent predictors of OS (P &lt; 0.05). Chemotherapy was associated with improved OS (P &lt; 0.001).

Conclusions

Laterality was not a significant prognostic factor for long-term survival after a PN for NSCLC. Chemotherapy was a significant independent predictor of improved OS. Long-term survival and outcomes analyses should be conducted on larger numbers of patients.

Positive nodal status is still a risk factor for long-term survivors of non-small cell lung cancer 5 years after complete resection

Background

Lung cancer has a poor prognosis; the number of long-term survivors (LTSs) is small compared with that of other cancers. Few studies have focused on late recurrence in LTSs with lung cancer. The purpose of this study was to analyze the risk factors for survival and late recurrence in LTSs after disease-free period of 5 years.

Methods

A retrospective analysis of patients with a disease-free survival of at least 5 years after surgical resection for non-small cell lung cancer (NSCLC) between January 1998 and December 2012 was conducted. Patients who underwent neo-adjuvant therapy, had an incomplete resection, or had advanced stage (stages IIIb and IV) cancer were excluded.

Results

A total of 1,254 (53.2%) of 2,357 patients were enrolled. Of these, 759 (60.5%) were men, and the mean patient age was 61.9±10.1 (range, 10-87 years) years. Pathologic N0 (997 patients, 79.5%) and stage I (860 patients, 68.6%) were the dominant stages. Late recurrence occurred in 22 patients (1.8%) 5 years postoperatively. On multivariate analysis, male sex, older age, node-positive status, and late recurrence were found to be independent risk factors for overall survival (OS), while a node-positive status was the only independent risk factor for disease-free survival [hazard ratio (HR) =3.824; P=0.002; 95% confidence interval (CI): 1.658-8.821].

Conclusions

The nodal stage at the time of surgical resection was found to be an independent risk factor for both OS and disease-free survival 5 years after initial treatment in patients with completely resected NSCLC.

Clinical and Molecular Differentiation Between Malignant Rhabdoid Tumor of the Kidney and Normal Tissue: A Two-Case Report

BACKGROUND

Malignant rhabdoid tumor of the kidney (MRTK) is a rare type of tumor that lacks typical clinical manifestations. Herein, we presented clinical data of 2 children with MRTK. In addition, we used a high-throughput RNA-sequencing (RNA-seq), GO analysis, and KEGG signaling pathway analysis to examine gene expression differences at the transcripts level between 2 patients with MRTK and 3 patients with non-tumor diseases without other symptoms.

CASE REPORT

Preoperative B-scan ultrasonography and computed tomography (CT) examination in 2 cases suggested nephroblastoma. Both patients were treated with radical nephrectomy. After the operation, MRTK was confirmed by pathological examination. Child 1 and Child 2 then received 7 courses and 12 courses of regular chemotherapy, respectively. Child 1 was followed up for 2 years, and Child 2 for 3.1 years without showing symptoms. RNA-seq results showed 2203 differential genes (DEGs) in the kidney tissue of children with MRTK compared to normal tissue (p <0.01). GO analysis suggested that most DEGs participate in protein binding. KEGG results showed that the DEGs were mainly involved in the PI3K-Akt signaling pathway and microRNA-related proteins.

CONCLUSION

The PI3K-Akt signaling pathway and microRNA-related proteins as targets have extremely high potential value for the diagnosis and treatment of MRTK.

Survival analysis and factors affecting survival in patients who presented to the medical oncology unit with non-small cell lung cancer

Background/aim

This study aimed to investigate the effect of clinical and pathological indicators at the time of the diagnosis on overall survival in patients recently diagnosed with non-small cell lung cancer.

Materials and methods

The study population consisted of patients who were diagnosed at the Faculty of Medicine at Isparta Süleyman Demirel University Hospital between January 1, 2010 and December 31, 2017 and presented to the medical oncology outpatient clinic.

Results

A total of 518 patients were evaluated, including 260 patients with squamous cell carcinoma, 207 patients with adenocarcinoma, 50 patients with non-small cell lung cancer-not otherwise specified, and 1 patient with large cell carcinoma. The average life expectancy was found to be 11.50 ± 1.40 months in patients with squamous cell carcinoma, 12.60 ± 1.59 months in patients with adenocarcinoma, and 8.70 ± 1.87 months in the other patients. The estimated 5-year relative survival rate for non-small cell lung cancer was 8% (7% for men and 18% for women). In the multivariate analysis, sex being male (HR, 2.41; P < 0.001), a performance status >2 (HR, 1.70; P < 0.001), the stage of cancer (HR, 1.37; P = 0.045), the presence of bone or liver metastasis (HR, 1.44, P = 0.009, HR, 1.57; P = 0.016, respectively), and the patient not having received radiotherapy (HR, 3.25; P < 0.001) or chemotherapy (HR, 1.85; P = 0.001) were defined as statistically significant predictive factors that reduced the overall survival.

Conclusions

In this study, sex, stage, performance status, the presence of liver or bone metastases, and treatment had an effect on overall survival.

Cancer progression and the invisible phase of metastatic colonization

Metastatic dissemination occurs very early in the malignant progression of a cancer but the clinical manifestation of metastases often takes years. In recent decades, 5-year survival of patients with many solid cancers has increased due to earlier detection, local disease control and adjuvant therapies. As a consequence, we are confronted with an increase in late relapses as more antiproliferative cancer therapies prolong disease courses, raising questions about how cancer cells survive, evolve or stop growing and finally expand during periods of clinical latency. I argue here that the understanding of early metastasis formation, particularly of the currently invisible phase of metastatic colonization, will be essential for the next stage in adjuvant therapy development that reliably prevents metachronous metastasis.

A prognostic model for overall survival of patients with early-stage non-small cell lung cancer: a multicentre, retrospective study

Background

Intratumoural heterogeneity has been previously shown to be related to clonal evolution and genetic instability and associated with tumour progression. Phenotypically, it is reflected in the diversity of appearance and morphology within cell populations. Computer-extracted features relating to tumour cellular diversity on routine tissue images might correlate with outcome. This study investigated the prognostic ability of computer-extracted features of tumour cellular diversity (CellDiv) from haematoxylin and eosin (H&E)-stained histology images of non-small cell lung carcinomas (NSCLCs).

Methods

In this multicentre, retrospective study, we included 1057 patients with early-stage NSCLC with corresponding diagnostic histology slides and overall survival information from four different centres. CellDiv features quantifying local cellular morphological diversity from H&E-stained histology images were extracted from the tumour epithelium region. A Cox proportional hazards model based on CellDiv was used to construct risk scores for lung adenocarcinoma (LUAD; 270 patients) and lung squamous cell carcinoma (LUSC; 216 patients) separately using data from two of the cohorts, and was validated in the two remaining independent cohorts (comprising 236 patients with LUAD and 335 patients with LUSC). We used multivariable Cox regression analysis to examine the predictive ability of CellDiv features for 5-year overall survival, controlling for the effects of clinical and pathological parameters. We did a gene set enrichment and Gene Ontology analysis on 405 patients to identify associations with differentially expressed biological pathways implicated in lung cancer pathogenesis.

Findings

For prognosis of patients with early-stage LUSC, the CellDiv LUSC model included 11 discriminative CellDiv features, whereas for patients with early-stage LUAD, the model included 23 features. In the independent validation cohorts, patients predicted to be at a higher risk by the univariable CellDiv model had significantly worse 5-year overall survival (hazard ratio 1·48 [95% CI 1·06–2·08]; p=0·022 for The Cancer Genome Atlas [TCGA] LUSC group, 2·24 [1·04–4·80]; p=0·039 for the University of Bern LUSC group, and 1·62 [1·15–2·30]; p=0·0058 for the TCGA LUAD group). The identified CellDiv features were also found to be strongly associated with apoptotic signalling and cell differentiation pathways.

Interpretation

CellDiv features were strongly prognostic of 5-year overall survival in patients with early-stage NSCLC and also associated with apoptotic signalling and cell differentiation pathways. The CellDiv-based risk stratification model could potentially help to determine which patients with early-stage NSCLC might receive added benefit from adjuvant therapy.

Funding

National Institue of Health and US Department of Defense.

Prognostic Significance of Ground-Glass Opacity Components in 5-Year Survivors With Resected Lung Adenocarcinoma

BACKGROUND

Reports on the prognosis for 5-year survivors with lung adenocarcinoma after resection are sparse. This study aimed to identify factors associated with overall survival (OS) and cancer-specific survival (CSS) for 5-year survivors with completely resected lung adenocarcinoma, and to determine whether preoperative imaging factors, including the presence of ground-glass opacity (GGO) components, affect late recurrence in long-term survivors.

METHODS

Complete resection of lung adenocarcinoma was performed for 1681 patients between January 2000 and December 2013. Of these patients, 936 who survived 5 years or longer after surgery were identified, and factors associated with OS and CSS were determined using the Cox proportional hazard model.

RESULTS

Multivariable analysis demonstrated that lymph node metastasis (p < 0.01) and absence of GGO components (p < 0.01) were independently associated with OS and CSS for the 5-year survivors. The absence of GGO components was significantly associated with OS (p < 0.01) and CSS (p < 0.01) also for the 5-year survivors with stage 1 disease (n = 782) and for the 5-year survivors without recurrence (n = 809). The incidence of recurrence anytime during the 10-year postoperative follow-up period differed significantly between the 5-year survivors with and without GGO components.

CONCLUSIONS

The absence of GGO components was significantly associated with an unfavorable prognosis for the 5-year survivors with completely resected lung adenocarcinoma regardless whether they had recurrences not.

Comparison of early tumour-associated versus late deaths in patients with central or >7 cm T4 N0/1 M0 non-small-cell lung-cancer undergoing trimodal treatment: Only few risks left to improve

BACKGROUND

The optimal treatment for patients with locally advanced non-small-cell lung-cancer (NSCLC) cT4 cN0/1 cM0 is still under debate. The purpose of this study was to examine the long-term survival of cT4 cN0/1 cM0 NSCLC patients undergoing induction chemotherapy and concurrent radiochemotherapy before surgery.

METHODS

All consecutive patients with confirmed NSCLC (cT4 cN0/1 cM0) treated with neoadjuvant chemotherapy, concurrent radiochemotherapy (RT/CTx) (45-46 Gy) and surgical resection between 2000 and 2015 were included. According to the UICC guidelines (8th edition), T4 stage was reanalysed by an expert radiologist. The mediastinal staging was performed by systematic EBUS-TBNA or mediastinoscopy. The primary end-point was overall-survival (OS). The power to detect an increase of early tumour-associated mortality (hazard ratio > 3.5) within the first 5 years after treatment in comparison to late deaths beyond 96 months was >80%.

RESULTS

Overall, 67 patients were treated with concurrent RT/CTx. T4 criteria were fulfilled by all patients, and multiple T4 criteria by 53 patients. Seventy percent of patients had an initial PET/CT staging. The median follow-up period was 134 months. OS rates at 2, 5, 10 and 15 years were 83.6 ± 4.5%, 65.4 ± 5.9%, 53.3 ± 6.3% and 36.6 ± 6.8%, respectively. A total of 44.8% of patients achieved a pathologic complete response. In multivariable analysis, ypT category was the most predictive factor. OS at 5 years for ypT0 (n = 31) was 80.5%, and ypT1 (n = 11) was 62.5%. Main sites of failure were brain and pulmonary metastases in seven and three patients, respectively. The intercurrent annual death rate was estimated from the survival curve beyond 96 months and was found to be 4.75% (95% CI 2.40-9.27%). No significant increased mortality was observed during the first 5 years (annual death rate: 8.31% [95% CI 5.60-12.24%], hazard-ratio = 1.72 [95% CI 0.81-3.65]).

CONCLUSIONS

The effectiveness of this trimodality schedule is high in patients with cT4 cN0/1 cM0 NSCLC with excellent local control rates. Considering the annual death rate beyond 8 years of survival as an intercurrent death rate due to comorbidity, this treatment schedule reduces annual mortality to background even in the first 5 years after therapy.

Adjuvant chemotherapy following SBRT for early stage non-small cell lung cancer (NSCLC) in older patients

Adjuvant chemotherapy improves overall survival (OS) following stereotactic body radiotherapy (SBRT) in patients with early stage non-small cell lung cancer and tumors ≥four cm. Here, we aim to evaluate its role following SBRT in older patients. Patients >70 years diagnosed with clinical stages I-II NSCLC, (N0 disease), who received SBRT, were identified using the National Cancer Database (n = 7042). The Kaplan-Meier method was used to estimate OS, and the log-rank test was used to compare distributions by treatment strategy overall and within clinical stages I and II. There were 3533 female patients (50.2%), and 6074 (86.3%) had stage I disease. Among stage I patients, 643 (10.6%) received adjuvant chemotherapy, compared to 372 stage II patients (38.4%). Median OS was better with SBRT in patients with stage I disease (25.4 vs. 20.3 months; p < .001); while patients with stage II NSCLC had better OS with SBRT + chemotherapy (20.2 vs. 14.2 months; p < .001). On multivariate analysis, patients with stage I NSCLC who received SBRT alone had better overall survival (HR: 0.79; 95% CI, 0.73, 0.87). SBRT alone was associated with an increased risk of death in patients with stage II disease (HR: 1.34; 95% CI, 1.15, 1.55). Patients with tumors ≥4 cm had better OS with SBRT + chemotherapy (18.5 vs. 15.5 months; p = .003), while patients with tumors <4 cm did better with SBRT (median OS of 24.1 vs. 20.3 months; p < .001). In >70 years old patients with tumors ≥4 cm, adjuvant chemotherapy following SBRT was associated with improved OS.

Hazards of Recurrence, Second Primary, or Other Tumor at Ten Years After Surgery for Non-Small-Cell Lung Cancer

INTRODUCTION

Better treatment options entail the risk of multiple tumors in a patient's lifetime. We studied the incidence, risk factors, and prognostic impact of second primaries and other malignancies in patients with operated non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

We retrospectively analyzed 342 consecutive patients with curatively resected NSCLC between 2003 and 2007.

RESULTS

Among the 342 patients analyzed, 172 (50.3%) developed locoregional and/or distant recurrence; 25 (7.3%) had a second primary lung cancer, 97 (28.3%) had 1 or more malignancies other than NSCLC either in their history (n = 61; 17.8%) or following resection (n = 64; 18.7%). One hundred fifteen patients (33.6%) had a malignancy other than primary NSCLC. Eight patients developed both a second primary lung cancer and another malignancy. Older age and lower N-stage were significantly correlated with the occurrence of an additional tumor, as shown by a logistic regression nomogram. Whereas the risk of recurrence decreases over time, the risk of developing a second tumor, particularly a second primary lung cancer, remains high during up to 10 years of follow-up. One hundred seventy patients (49.7%) died of the primary (n = 158; 46.2%) or second primary (n = 12; 3.5%) NSCLC, 23 (6.7%) died of another malignancy, and 66 (19.3%) died due to unrelated causes (overall 10-year survival, 33.3%).

CONCLUSIONS

Second primary lung cancer or other malignancy occurs in 33% of patients with NSCLC; 26% of patients are affected within 10 years after resection of lung cancer. With curative treatment of secondary tumors, there is no negative influence on long-term prognosis of NSCLC; therefore, follow-up beyond 5 years is strongly advisable.

Long-term survival outcome after lobectomy in patients with clinical T1 N0 lung cancer

OBJECTIVE

The aim of this study was to assess long-term outcomes after lobectomy in patients with clinical T1 N0 lung cancer based on thin-section computed tomography.

METHODS

We collected the data of patients with pathological adenocarcinoma who had undergone lobectomy. The patients were categorized into 4 groups according to a consolidation tumor ratio and tumor size. Groups A and B included tumors with consolidation tumor ratio ≤0.5 and size ≤3 cm. Group A consisted of tumors ≤2 cm. Group B consisted of the remaining tumors. Groups C and D consisted of tumors with consolidation tumor ratio >0.5. Group C consisted of those with tumors ≤2 cm and Group D consisted of tumors of size 2 to 3 cm. The 10-year overall survival and recurrence-free survival rates were examined.

RESULTS

Among the 543 patients, the 10-year overall survival was 80.4% and the 10-year recurrence-free survival rate was 77.1%. The 10-year overall survival for group A was 94.0%, 92.7% for group B, 84.1% for group C, and 68.8% for group D, and the 10-year recurrence-free survival rate for each group was 94.0%, 89.0%, 79.7%, and 66.1%, respectively. Group A + B showed better overall survival than group C + D (hazard ratio, 2.78; 95% confidence interval, 1.45-5.06) and better 10-year recurrence-free survival (hazard ratio, 2.74; 95% confidence interval, 1.55-4.88). No patient in group A had recurrence.

CONCLUSIONS

Those patients with total tumor size ≤3 cm and consolidation tumor ratio ≤0.5 showed excellent prognosis and might be suitable candidates for sublobar resection. If noninferior survival of segmentectomy compared with lobectomy is confirmed in an ongoing Japan Clinical Oncology Group trial, segmentectomy will be included in the standard of care.

Prognostic relevance of regional lymph-node distribution in patients with N1-positive non-small cell lung cancer: A retrospective single-center analysis

OBJECTIVE

Lymph node (LN) metastases predict survival in patients with non-small cell lung cancer (NSCLC) treated with curative surgery. Nevertheless, prognostic differences within the same nodal (N) status have been reported. Consequently, the International Association for the Study of Lung Cancer (IASLC) proposed to stratify patients with limited nodal disease (pN1) from low (pN1a) to high (pN1b) nodal tumor burden. This study aimed to validate the IASLC proposal in a large single-center surgical cohort of patients with pN1 NSCLC.

MATERIAL AND METHODS

Data from 317 patients with pN1 NSCLC treated between January 2012 and December 2016, were retrospectively analyzed. Associations between distribution of LN metastases and survival were analyzed for different classification models-toward nodal extension (pN1a: one station involved; pN1b: multiple stations involved) and toward location (pN1 in the hilar [LN#10/11] or peripheral zone [LN#12-14]).

RESULTS

Tumor-specific survival (TSS) in the entire pN1 cohort was 67.1% at five years. Five-year TSS rates for pN1a and pN1b patients were comparable (67.6% vs. 66.5%, p = 0.623). Significant survival differences from pN1a to pN1b were observed only in patients with adenocarcinoma histology and completed adjuvant chemotherapy (5-year TSS: pN1a, 80.4% vs. pN1b, 49.6%; p = 0.005). TSS for LN metastases in the hilar zone/peripheral zone or in both zones was 68.2% and 59.9%, respectively (p = 0.068). In multivariate analysis, adjuvant chemotherapy, squamous cell histology, and nodal disease limited to one zone nodal disease were identified as independent beneficial prognostic factors (p < 0.05).

CONCLUSION

pN1 in only one region (hilar or lobar) was associated with better outcome than metastatic affection of both regions after surgery and adjuvant therapy. A stratification towards single (pN1a) and multiple (pN1b) N1-metastases was found of prognostic relevance only in adenocarcinoma. Prospective multicenter analysis of prognostic subgroups in N1 NSCLC is required to evaluate its clinical impact for consideration in future TNM classification.

Let us not underestimate the long-term risk of SPLC after surgical resection of NSCLC

OBJECTIVES

Several studies have reported that patients operated on for non-small cell lung cancer (NSCLC) are at high risk of second primary lung cancer (SPLC). However, widely varying estimates of this risk have been reported, with very few studies taking into account that these patients are at particularly high competing risk of death, due to recurrence of the initial disease and to comorbidities. Risk factor evaluation over time has significant repercussions on the post-surgery surveillance strategy offered for NSCLC. This study primarily sought to measure the risk of SPLC in a long-term follow-up series, using statistical methods considering competing risks of death.

MATERIALS AND METHODS

The cumulative SPLC risk was estimated using the cumulative incidence of patients with completely resected Stage I-III NSCLC diagnosed between 2002 and 2015 based on the Doubs and Belfort cancer registry (France). A proportional sub-distribution hazard model (_sdRH) was used to investigate factors associated with SPLC risk in the presence of competing risks.

RESULTS

Among the 522 patients, adenocarcinoma and Stage I or II disease accounted for 52.3% and 75.7% of patients, respectively. Overall, 84 patients developed SPLC (16.1%). The cumulative risk of SPLC was 20.2% at 10 years post-surgery (95% confidence interval [CI]: 15.3-23.2), and 25.2% (CI: 19.4-31.3) at 14 years post-surgery. On multivariate analysis, the SPLC risk was significantly higher in patients with postoperative thoracic radiotherapy (_sdRH 2.79; 95% CI: 1.41-5.52; p = 0.003).

CONCLUSION

This study using appropriate statistical methods to consider competing risks showed that after complete NSCLC resection, the cumulative incidence function of SPLC was high, with patients receiving postoperative thoracic radiotherapy at higher risk. These data support the need for life-long follow-up of patients who undergo NSCLC surgery, with the objective of screening for SPLC.

Ultra-late recurrence of non-small cell lung cancer over 10 years after curative resection

Purpose

Most postoperative recurrences of non-small cell lung cancer (NSCLC) develop within 5 years after curative resection, with ultra-late recurrences developing over 10 years after the resection being rare. This study aimed to analyze the features of ultra-late recurrence in cases with NSCLC who had undergone curative resection.

Patients and methods

Among 1458 consecutive cases with NSCLC who underwent curative resection with systematic lymph node dissection during 1990–2006, 12 cases developed recurrence over 10 years after the resection. We defined the recurrence developing over 10 years after the resection as ultra-late recurrence and analyzed the factors related to it.

Results

Among the 1458 cases, recurrence developed in 476 (32.6%) cases. Of them, ultra-late recurrence developed in 12 (2.5%) cases. The ultra-late recurrence was histopathologically classified as adenocarcinoma in 11 cases and atypical carcinoid in 1 case. All cases were of invasive carcinoma. We compared ultra-late recurrence cases with non-recurrence cases and showed that none of the examined factors significantly influenced ultra-late recurrence; however, lymphatic invasion was close to significantly influencing it. There were two cases in which recurrence developed over 15 years after the resection; both cases were of adenocarcinoma with anaplastic lymphoma kinase (ALK) rearrangement.

Conclusion

There is a possibility of ultra-late recurrence developing over 10 years after the resection of any invasive NSCLC. Lymphatic invasion is close to significantly influencing ultra-late recurrence. Furthermore, a long follow-up period may be required in cases with adenocarcinoma with ALK rearrangement because it has the possibility of recurrence over 15 years after the resection.

Factors influencing recurrence following anatomic lung resection for clinical stage I non-small cell lung cancer

OBJECTIVES

Anatomic lung resection provides the best opportunity for long-term survival in the setting of early-stage non-small cell lung cancer (NSCLC). However, 20-30% of patients develop recurrent disease following complete (R0) resection for Stage I disease. In the current study, we analyze the impact of patient, surgical and pathologic variables upon recurrence patterns following anatomic lung resection for clinical stage I NSCLC.

PATIENTS AND METHODS

A total of 1132 patients (384 segmentectomies, 748 lobectomies) with clinical stage I NSCLC were evaluated. Predictors of recurrence were identified by proportional hazards regression. Differences in recurrence patterns between groups are illustrated by log rank tests applied to Kaplan-Maier estimates.

RESULTS

A total of 227 recurrences (20.0%) were recorded at a median follow-up of 36.8 months (65 locoregional, 155 distant). There was no significant difference in recurrence patterns when comparing segmentectomy and lobectomy. Multivariate analysis demonstrated that angiolymphatic invasion, tumor size, tumor grade and the presence of only mild-moderate tumor inflammation were independent predictors of recurrence risk.

CONCLUSIONS

Recurrence following anatomic lung resection is influenced predominantly by pathological variables (tumor size, tumor grade, angiolymphatic invasion, tumor inflammation). Optimization of surgical margin in relation to tumor size may improve outcomes. Extent of resection (segmentectomy vs. lobectomy) does not appear to have an impact on recurrence-free survival when adequate margins are obtained.

Lymphatic invasion is a significant indicator of poor patient prognosis in lung squamous cell carcinoma

Pathological stage is the most important prognostic factor in patients with lung cancer, and is defined according to the tumor node metastasis classification system. The present study aimed to investigate the clinicopathological significance of lymphatic invasion in 103 patients who underwent surgical resection of lung squamous cell carcinoma (SqCC). The patients were divided into two groups, according to the degree of lymphatic invasion: Those with no or mild lymphatic invasion (ly0-1) and those with moderate or severe lymphatic invasion (ly2-3). Ly2-3 was associated with tumor size (P=0.028), lymph node metastasis (P<0.001), venous invasion (P=0.001) and histological differentiation (P=0.047). Statistical analysis using the Kaplan-Meier method and the log-rank test indicated that overall survival was significantly reduced in patients with ly2-3 compared with those with ly0-1 (P<0.001). Multivariate analysis identified ly2-3 as an independent predictor of mortality (hazard ratio, 2.580; 95% confidence interval, 1.376–4.839). In conclusion, moderate or severe lymphatic invasion (ly2-3) indicated a high malignant potential and may be considered an independent predictor of poor prognosis in patients with SqCC of the lung.

Prognostic factors and the significance of treatment after recurrence in completely resected stage I non-small cell lung cancer

OBJECTIVE

The objective of this study was to identify the clinicopathologic factors influencing postrecurrence survival (PRS) in and the effect of postrecurrence therapy (PRT) on patients with completely resected stage I non-small cell lung cancer (NSCLC).

METHODS

We reviewed the data of 919 patients in whom complete resection of stage I NSCLC had been performed.

RESULTS

Of the 919 patients, 170 (18.5%) had recurrent disease. Initial PRT was performed in 118 patients (69.1%) (surgery in eight, chemotherapy in 79, radiotherapy in 10, and chemoradiotherapy in 21). On multivariate analyses, PRT (hazard ratio [HR], 0.542; 95% CI, 0.344-0.853; P = .008), female sex (HR, 0.487; 95% CI, 0.297-0.801; P = .005), and differentiation (HR, 1.810; 95% CI, 1.194-2.743; P = .005) demonstrated a statistically significant association with favorable PRS. Bone metastasis (HR, 3.288; 95% CI, 1.783-6.062; P &lt; .001), liver metastasis (HR, 4.518; 95% CI, 1.793-11.379; P = .001), chemotherapy (HR, 0.478; 95% CI, 0.236-0.975; P = .040), epidermal growth factor receptor-tyrosine kinase inhibitors treatment (EGFR-TKIs) (HR, 0.460; 95% CI, 0.245-0.862; P = .015), and nonadenocarcinoma (HR, 2.136; 95% CI, 1.273-3.585; P = .004) were independently and significantly associated with PRS in the 118 patients who underwent any PRT. Subgroup analysis with a combination of these five PRS factors in the patients who underwent any PRT revealed median PRS times of 42.4 months for 20 patients lacking all five risk factors and 18.8 months for 98 patients with at least one of these risk factors (P = .001).

CONCLUSIONS

PRT, sex, and differentiation were independently associated with PRS. In the patients who underwent any PRT, PRS was related to EGFR-TKIs, chemotherapy, histology, and initial recurrence sites. One challenge for the future will be to create systematic treatment strategies for recurrent NSCLC according to the risk factor status of individual patients.

Surgeon's view: is palliative resection of lung cancer ever justified?

Thoracic surgeons are often asked to see patients with locally advanced primary lung cancer in whom the goal of treatment is palliation for relief of disabling symptoms. The last four decades have brought great changes in the care of patients with primary lung cancer. The goals of the treatment must be well-defined by the interdisciplinary team. The thoracic surgeon has to make the final decision on whether to consider an operation for palliation and what is the expectation of the recommended treatment.

Role of particle beam therapy in a trimodality approach to locally advanced non-small cell lung cancer

Lung cancer accounts for nearly one-fifth of all cancer deaths worldwide and is the most common cause of cancer-related death in the United States. Outcomes for locally advanced non-small cell lung cancer remain extremely poor with regards to both local control and overall survival. Modest gains in local control were obtained with the incorporation of multimodality treatment, including preoperative chemotherapy followed by surgical resection; combination chemoradiotherapy also improved survival, secondary to improved local control. While the natural progression to trimodality therapy resulted in superior local control, it did not translate to improved overall survival, secondary to increased toxicity. The additional morbidity is likely from radiation toxicity, the minimization of which will be crucial to the future success of trimodality therapy. One strategy to decrease toxicity is to utilize charged particles, such as protons, which deposit a high dose at the Bragg peak with a minimal dose beyond the peak, thereby reducing the dose to distal normal tissues. Trimodality therapy incorporating preoperative proton radiation therapy and chemotherapy, followed by surgery, is currently being evaluated as a potential strategy to achieve improved local control and overall survival in locally advanced non-small cell lung cancer.

Surface layer-preserving photodynamic therapy (SPPDT) in a subcutaneous mouse model of lung cancer

BACKGROUND AND OBJECTIVES

Photodynamic therapy (PDT) may be a less invasive treatment for lung cancer. Our newly developed surface layer-preserving PDT (SPPDT) technique enables us to irradiate deep tumor while preserving the overlying tissue. The aim of this basic study was to verify that the SPPDT technique might be applied to lung cancer.

STUDY DESIGN/MATERIALS AND METHODS

PDT with talaporfin sodium was performed using a pulsed laser with different pulse dose rates (PDRs, 2.5-20.0 mJ/cm(2) /pulse) in a mouse model of subcutaneous tumor. To mimic the tracheal wall structure and a thoracic tumor in the tracheobronchus, we also made a mouse model in which a piece of swine cartilage was placed between the dermis and the tumor, and PDT was carried out 2 weeks after implantation. In both experiments, the tissue samples were collected 48 hours after PDT and evaluated microscopically.

RESULTS

SPPDT using a high-PDR laser damaged the underlying tissue but left the superficial tissue intact in the mouse subcutaneous tumor model. In SPPDT, a higher PDR produced a thicker layer of intact superficial tissue than a lower PDR, while a lower PDR produced a deeper layer of damaged tissue than a higher PDR. SPPDT was also able to preserve the superficial tissue and to damage the tumor tissue beneath the cartilage implant.

CONCLUSION

SPPDT was able to damage tumor beneath the superficial normal tissue layer, which included tracheal cartilage in the mouse model. The thickness control of SPPDT was provided by controlling laser pulse intensity. SPPDT is a new technology, whose future potential is unknown. The initial clinical application of this technology could be endoscopic treatment (e.g., palliative therapy of thoracic malignancies via bronchoscopy).

Five-year survival does not equal cure in non-small cell lung cancer: a Surveillance, Epidemiology, and End Results-based analysis of variables affecting 10- to 18-year survival

OBJECTIVE

Five-year survival after the diagnosis of non-small cell lung cancer is the most common benchmark used to evaluate long-term survival. Data on survival beyond 5 years are sparse. We sought to elucidate variables affecting 10- to 18-year survival.

METHODS

A total of 31,206 patients alive at least 5 years after diagnosis of non-small cell lung cancer who were registered in the Surveillance, Epidemiology, and End Results database from 1988 to 2001 were examined. Primary end points were disease-specific survival and overall survival. Survival analysis was performed with Kaplan-Meier estimates, multivariable Cox proportional hazards regression, and competing risk models.

RESULTS

Overall survival at 10, 15, and 18 years was 55.4%, 33.1%, and 24.3%, respectively. Disease-specific survival at 10, 15, and 18 years was 76.6%, 65.4%, and 59.4%, respectively. In multivariable regression analysis, squamous cell cancers had a disease-specific survival advantage (hazard ratio, 0.88; P < .0001) but an overall survival disadvantage (hazard ratio, 1.082; P = .0002) compared with adenocarcinoma. Pneumonectomy (hazard ratio, 0.44) and lobectomy (hazard ratio, 0.474) had improved disease-specific survival compared with no surgery (P < .0001). Left-sided tumors (hazard ratio, 0.723; P = .036) and node-negative cancers (hazard ratio, 0.562; P < .001) also had a better disease-specific survival and, to a lesser extent, overall survival advantage.

CONCLUSIONS

Five-year survivors of non-small cell lung cancer have a persistent risk of death from lung cancer up to 18 years from diagnosis. More than one half of all deaths in 5-year survivors are related to lung cancer. In multivariable regression analysis, age, node-negative disease, and lobar or greater resection were strong predictors of long-term survival (ie, 10-18 years).

Conditional cancer-specific versus cardiovascular-specific survival after lobectomy for stage I non-small cell lung cancer

BACKGROUND

Conditional cancer-specific survival rates account for changes in the risk of death from cancer over time. There may be a point during follow-up when patients who undergo lobectomy for stage I non-small cell lung cancer (NSCLC) are as likely to die of cardiovascular disease as of cancer.

METHODS

Using the Surveillance Epidemiology and End Results Database (1988 through 2005), we identified patients 50 years old and older who underwent lobectomy for stage I NSCLC. We used competing risks methods to calculate conditional survival rates and to ascertain if there is a point in follow-up where the risk of dying of cancer is equivalent to the risk of dying of cardiovascular disease.

RESULTS

In all, 22,518 patients met our inclusion criteria. The difference in the 5-year conditional probability of dying of cancer and the 5-year conditional probability of dying of cardiovascular disease decreased with time; in the whole cohort, these probabilities were equivalent if patients survived to 7 years after lobectomy (p = 0.11). With increasing age, the probability of dying of cancer and the probability of dying of cardiovascular disease became equivalent at earlier time points. Furthermore, the 5-year probability of dying of cardiovascular disease was significantly greater than the 5-year probability of dying of cancer for patients aged 70 to 79 years who survived to 7 years and for patients aged 80 years and older who survived to 5 years after lobectomy.

CONCLUSIONS

For patients undergoing lobectomy for stage I NSCLC, cardiovascular-specific mortality becomes increasingly important over the course of follow-up, especially among elderly patients.

Perifissural nodules seen at CT screening for lung cancer

PURPOSE

To describe and characterize the potential for malignancy of noncalcified lung nodules adjacent to fissures that are often found in current or former heavy smokers who undergo computed tomography (CT) for lung cancer screening.

MATERIALS AND METHODS

Institutional review board approval and informed consent were obtained. Baseline and follow-up thin-section multidetector CT scans obtained in 146 consecutive subjects at high risk for lung cancer (age range, 50-75 years; > 30 pack-year smoking history) were retrospectively reviewed. Noncalcified nodules (NCNs) were categorized according to location (parenchymal, perifissural), shape, septal connection, manually measured diameter, diameter change, and lung cancer outcome at 7(1/2) years.

RESULTS

Retrospective review of images from 146 baseline and 311 follow-up CT examinations revealed 837 NCNs in 128 subjects. Of those 837 nodules, 234 (28%), in 98 subjects, were adjacent to a fissure and thus classified as perifissural nodules (PFNs). Multiple (range, 2-14) PFNs were seen in 47 subjects. Most PFNs were triangular (102/234, 44%) or oval (98/234, 42%), were located inferior to the carina (196/234, 84%), and had a septal connection (171/234, 73%). The mean maximal length was 3.2 mm (range, 1-13 mm). During 2-year follow-up in 71 subjects, seven of 159 PFNs increased in size on one scan but were then stable. The authors searched a lung cancer registry 7(1/2) years after study entry and found 10 lung cancers in 139 of 146 study subjects who underwent complete follow-up; none of these cancers had originated from a PFN.

CONCLUSION

PFNs are frequently seen on screening CT scans obtained in high-risk subjects. Although PFNs may show increased size at follow-up CT, the authors in this study found none that had developed into lung cancer; this suggests that the malignancy potential of PFNs is low. (c) RSNA, 2010.

Late recurrence of non-small cell lung cancer more than 5 years after complete resection: incidence and clinical implications in patient follow-up

BACKGROUND

The purpose of this study was to evaluate the risk of late recurrence in patients who had undergone complete resection for non-small cell lung cancer (NSCLC) and remained recurrence-free for > or = 5 years.

METHODS

Between 1993 and 2002, 1,358 patients with NSCLC underwent complete primary tumor resection and systematic lymph node dissection. Of these, 819 patients remained recurrence-free for 5 years. Recurrence-free probability was estimated from the benchmark of 5 years after primary tumor resection to the date of first recurrence or last follow-up, using the Kaplan-Meier method. Multivariate Cox regression was used to test the relationship of recurrence-free probability to various clinicopathologic factors.

RESULTS

Of the 819 patients who were free of recurrence at 5 years, 87 (11%) developed a subsequent recurrence. The recurrence-free probabilities at 3 years and 5 years from the point of 5 years after primary tumor resection were 92% and 87%, respectively. The 5-year recurrence-free probabilities from the point of 5 years after primary tumor resection were 81% for patients with intratumoral vascular invasion (P < .001), and 89%, 84%, and 65% for patients with N0, N1, and N2 cancers, respectively (P < .001). Multivariate Cox analysis demonstrated that intratumoral vascular invasion and nodal involvement significantly influenced recurrence 5 years after complete resection (P = .030, P = .022, respectively).

CONCLUSIONS

Patients with NSCLC with selected tumor characteristics have a significant risk of late recurrence. Therefore, 5 years might not be a sufficient amount of time to declare that NSCLC has been cured.

Lung cancer outcomes in women

Lung cancer remains the leading cause of cancer death in men and women. Since the 1970s, there has been evidence for improved survival of women with lung cancer compared to men. Multiple analyses have demonstrated a survival advantage in women regardless of stage, histology, or treatment. The etiology for the improved prognosis is not yet fully elucidated, but is likely related to underlying biologic differences, including hormonal interactions. More recently, gender differences in response to newer agents such as epidermal growth factor receptor inhibitors and anti-angiogenesis agents have been identified. Further exploration of tumor molecular, biologic, hormonal, and pharmacogenomic interactions may provide additional insight into the observed survival benefit for women and, ultimately, permit exploitation of these differences in our treatment selection for both women and men.

Epidemiology of lung cancer prognosis: quantity and quality of life

Primary lung cancer is very heterogeneous in its clinical presentation, histopathology, and treatment response; and like other diseases, the prognosis consists of two essential facets: survival and quality of life (QOL). Lung cancer survival is mostly determined by disease stage and treatment modality, and the 5-Year survival rate has been in a plateau of 15% for three decades. QOL is focused on life aspects that are affected by health conditions and medical interventions; the balance of physical functioning and suffering from treatment side effects has long been a concern of care providers as well as patients. Obviously needed are easily measurable biologic markers to stratify patients before treatment for optimal results in survival and QOL and to monitor treatment responses and toxicities. Targeted therapies toward the mechanisms of tumor development, growth, and metastasis are promising and actively translated into clinical practice. Long-term lung cancer (LTLC) survivors are people who are alive 5 Years after the diagnosis. Knowledge about the health and QOL in LTLC survivors is limited because outcome research in lung cancer has been focused mainly on short-term survival. The independent or combined effects of lung cancer treatment, aging, smoking and drinking, comorbid conditions, and psychosocial factors likely cause late effects, including organ malfunction, chronic fatigue, pain, or premature death among lung cancer survivors. New knowledge to be gained should help lung cancer survivors, their healthcare providers, and their caregivers by providing evidence for establishing clinical recommendations to enhance their long-term survival and health-related QOL.

[IFCT-0302 trial: randomised study comparing two follow-up schedules in completely resected non-small cell lung cancer]

BACKGROUND

The authorities advocate a minimalist attitude towards the follow-up of resected bronchial carcinoma (clinical examination and chest x-ray). A survey showed that 70% of French respiratory physicians have chosen to use the CT scanner and often endoscopy. The published data are equivocal and are often based on retrospective studies. Lung cancer is a good model for a study of post-operative surveillance. Recurrences often occur in easily observed areas, they may be detected while still asymptomatic and are sometimes potentially curable. Second primary tumours may develop at the same site.

METHODS

The Intergroupe Francophone de Cancerologie Thoracique (IFCT) has initiated a trial comparing simple follow-up (clinical examination, chest x-ray) with a more intensive follow-up (CT scan, fibreoptic bronchoscopy). The surveillance will take place every 6 months for 2 years and then annually until 5 years.

EXPECTED RESULTS

The main aim is to determine whether intensive follow-up improves patient survival. The opposite question is equally important. If an expensive and demanding follow-up does not affect the chances of cure these results will influence our practice.

Long-term survival following pneumonectomy for non-small cell lung cancer: clinical implications for follow-up care

BACKGROUND

The aim of this study was to determine the risk of overall death in long-term survivors (> 5 years) after pneumonectomy for non-small cell lung cancer (NSCLC), and to establish the optimal follow-up strategy for these patients.

METHODS

We analyzed a single-center experience with 94 long-term survivors who underwent pneumonectomy (group A) for NSCLC between January 1992 and December 2000. Prospective tumor registry data were compared with data for 147 long-term survivors who underwent lobectomy (group B) during the same period.

RESULTS

Clinical characteristics at the time of operation differed between the two groups with more squamous histology, larger tumor size, and more advanced stage in group A compared with group B. During follow-up, late lung cancer relapses were rare in both groups (2.1% vs 1.4%), and second primary malignancies were less frequent in group A (2.1% vs 9.5%, p = 0.032). The overall 10-year survival rate was lower in group A than in group B (67.3% vs 82.8%); however, there was no significant difference in lung cancer-specific survival (93.5% vs 95.1%). Intercurrent disease was the leading cause of death in group A (14 patients, 14.9%), most commonly respiratory failure resulting from community-acquired pneumonia.

CONCLUSION

Late cancer relapse or second primary malignancies were rare in long-term survivors after pneumonectomy, but the overall mortality remained high as a result of intercurrent diseases. Continued surveillance should focus on prevention, early detection and aggressive management of intercurrent disease during follow-up care of these patients.

Small peripheral pulmonary adenocarcinoma: morphologic and molecular update

The dichotomous histopathologic separation of lung carcinoma into "small cell" and "nonsmall cell" categories is validated by marked clinical and biologic differences between these groups of tumors. However, nonsmall cell carcinoma represents a heterogenous group of tumors, and the subclassification of nonsmall cell lung carcinoma at the molecular, morphologic, and epidemiologic levels has led to the promise of precise treatment and better prognostication. Histomorphologic aspects of small peripheral adenocarcinomas that represent good prognosis include pure bronchioloalveolar carcinoma, minimal invasion within a mixed invasive and lepidic growth pattern tumor, and minimal scar within a lepidic growth pattern tumor. Activating mutations and increased gene copy number of the epidermal growth factor receptor protein and locus, respectively, have been shown to help predict responsiveness to small molecule receptor tyrosine kinase inhibitors in lung adenocarcinoma. These important concepts of morphology and molecular pathology are reviewed, and recommendations for application of these concepts to the practice of surgical pathology are provided.

Postsurgical chemotherapy in stage IB nonsmall cell lung cancer: Long-term survival in a randomized study

Although surgical resection is considered the adequate treatment in early stages of nonsmall cell lung cancer, long-term survival is not satisfactory and recurrence rate is high. We previously showed that postoperative chemotherapy at stage IB reduces recurrences and prolongs overall survival. We extended size and observation period of the study sample and performed a separate analysis for minimally resected patients. The trial was designed as a randomized, 2-armed study with postoperative adjuvant chemotherapy versus surgery alone as control group. All patients had stage IB disease (pT2N0) assessed after a radical surgical procedure (defined as anatomical or minimal). Chemotherapy consisted of cisplatin (100 mg/m2 day 1) and etoposide (120 mg/m2 days 1-3) for 6 cycles. The primary endpoint was overall survival; secondary endpoint was disease-free survival (DFS). One hundred and forty patients entered the study: 70 were assigned to the adjuvant chemotherapy group and 70 to the control group. Groups were homogeneous for conventional risk factors. There was no clinically significant morbidity associated to chemotherapy. Patients were followed for a mean period of 40.31 +/- 30.86 months. A significant difference in overall (p = 0.02) and disease-free (p = 0.0001) survival was observed between patients undergoing adjuvant chemotherapy vs. control group. Adjuvant chemotherapy significantly improved both overall (p = 0.02) and DFS (p = 0.003) of anatomically resected patients, but only the DFS (p = 0.02) of minimally resected patients. Our results confirm that adjuvant chemotherapy may have a real impact on long-term survival in patients with stage IB nonsmall cell lung cancer being this effect especially evident for those anatomically resected.

Long-term survivorship in lung cancer: a review

While outcome research in lung cancer has focused mainly on short-term survival and quality of life (QoL), information on long-term (ie, > 5 years postdiagnosis) lung cancer survivorship remains limited. This review addresses the epidemiologic significance of long-term lung cancer (LTLC) survivors, summarizes the current knowledge on their health and QoL, and suggests areas for further research in LTLC survivorship. Based on a small body of literature, lung cancer survivors do not experience the same quantity and QoL as their age-matched peers or as survivors of other cancers. Survival among 5-year survivors of lung cancer relative to the general US population with the same demographic characteristics is approximately 60%, and lung cancer survivors score lowest in health utility among long-term survivors of other cancers. Approximately one-quarter of long-term lung cancer (LTLC) survivors were significantly restricted in physical ability or reported significant depressive symptoms. There is a need to identify and intervene with subgroups of survivors who are at an elevated risk of premature death and diminished QoL. Lung cancer-specific survival alone does not reflect the overall illness burden in LTLC survivors. Patient care in lung cancer survivors should be continuous and comprehensive in considering multiple causes of health deterioration. Multidisciplinary research in epidemiologic, clinical, and basic science approaches is warranted to further our knowledge base for optimal long-term management and to develop the necessary intervention strategies among LTLC survivors.

Postoperative adjuvant cisplatin, vindesine, plus uracil-tegafur chemotherapy increased survival of patients with completely resected p-stage I non-small cell lung cancer

PURPOSE

To evaluate the efficacy of postoperative adjuvant chemotherapy for completely resected p-stage I non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

Patients who underwent complete resection with lymph node dissection for p-stage I NSCLC (T1N0, T2N0, adenocarcinoma or squamous cell carcinoma, were eligible. After surgery, 150 patients were stratified according to tumor size and histologic type, and then randomly assigned to 1 of 3 groups (50 patients each group): surgery alone (control group), surgery with chemotherapy; PVU group (2 courses of cisplatin 80 mg/m2, i.v. x 1 (day 1), vindesine 3 mg/m2, i.v. x 1 (days 1 and 8) and UFT 400 mg/day, p.o. for a period of 2 years), and UFT group (UFT 400 mg/day, p.o. for 2 years).

RESULTS

The 5-year survival rates of the PVU group, the UFT group, and the control group were 87.9, 67.7, and 66.3%, respectively. The difference in 5-year survival between the PVU group and the control group was statistically significant (p = 0.045, log rank). The 5-year disease-free survival rate of the PVU group (81.1%) was also significantly better than that of the control group (66.5%) (p = 0.042, log rank). According to multivariate analysis using Cox's proportional hazard model, the only significantly positive factor on outcome was PVU chemotherapy after surgery.

CONCLUSION

Postoperative PVU chemotherapy is effective for Japanese patients with completely resected p-stage I NSCLC.

Clinical Issues in the Management of Early Lung Cancer

Lung cancer is commonly diagnosed after metastatic spread, when therapies are rarely curative, providing an impetus for continued research directed at exploring approaches for cost-effective early lung cancer detection. Recently published pilot studies across three continents support a benefit of spiral computed tomography (CT) in detecting earlier stage non-small cell lung cancer. Improved resolution of early lung cancer is a result of significant changes in CT imaging hardware and software. The status and implications of these developments are reviewed. Many aspects of the management of screening for early lung cancer could be informed by optimizing the downstream clinical management of potential lung cancers identified by CT screening. The first and most critical issue is whether or not this improved detection rate is clearly associated with a reduction in lung cancer-related mortality. However, other related issues such as cost-benefit evaluations are also considered. If smaller, truly localized primary cancer can be routinely detected, then options for less morbid interventions would also be desirable. The rapid improvement in resolution and cost of spiral CT has provided a powerful impetus to reconsider the possibilities for achieving safe, economical, and meaningful early lung cancer detection.

Cost-effectiveness analysis of screening for lung cancer with low dose spiral CT (computed tomography) in the Australian setting

INTRODUCTION

Low dose spiral computed tomography (CT) is a sensitive screening tool for lung cancer that is currently being evaluated in both non-randomised studies and randomised controlled trials.

METHODS

We conducted a quantitative decision analysis using a Markov model to determine whether, in the Australian setting, offering spiral CT screening for lung cancer to high risk individuals would be cost-effective compared with current practice. This exploratory analysis was undertaken predominantly from the perspective of the government as third-party funder. In the base-case analysis, the costs and health outcomes (life-years saved and quality-adjusted life years) were calculated in a hypothetical cohort of 10,000 male current smokers for two alternatives: (1) screen for lung cancer with annual CT for 5 years starting at age 60 year and treat those diagnosed with cancer or (2) no screening and treat only those who present with symptomatic cancer.

RESULTS

For male smokers aged 60-64 years, with an annual incidence of lung cancer of 552 per 100,000, the incremental cost-effectiveness ratio was 57,325 dollars per life-year saved and 105,090 dollars per QALY saved. For females aged 60-64 years with the same annual incidence of lung cancer, the cost-effectiveness ratio was 51,001 dollars per life-year saved and 88,583 dollars per QALY saved. The model was used to examine the relationship between efficacy in terms of the expected reduction in lung cancer mortality at 7 years and cost-effectiveness. In the base-case analysis lung cancer mortality was reduced by 27% and all cause mortality by 2.1%. Changes in the estimated proportion of stage I cancers detected by screening had the greatest impact on the efficacy of the intervention and the cost-effectiveness. The results were also sensitive to assumptions about the test performance characteristics of CT scanning, the proportion of lung cancer cases overdiagnosed by screening, intervention rates for benign disease, the discount rate, the cost of CT, the quality of life in individuals with early stage screen-detected cancer and disutility associated with false positive diagnoses. Given current knowledge and practice, even under favourable assumptions, reductions in lung cancer mortality of less than 20% are unlikely to be cost-effective, using a value of 50,000 dollars per life-year saved as the threshold to define a "cost-effective" intervention.

CONCLUSION

The most feasible scenario under which CT screening for lung cancer could be cost-effective would be if very high-risk individuals are targeted and screening is either highly effective or CT screening costs fall substantially.