What kind of hilar lung cancer can be a candidate for segmentectomy with curative intent?: Retrospective clinicopathological study of completely resected roentgenographically occult bronchogenic squamous cell carcinoma

Early central airways lung cancer

Early central airways lung cancer accounts for very small percentage of all lung cancers. Given this fact, it is much difficult to carry out a prospective randomized comparative clinical trial. Even retrospective studies can offer important information. Early central airways lung cancer is usually detected by sputum cytology. If sputum cytology shows atypical epithelial cells implying malignancy, the next thing we have to do is bronchoscopy. Both autofluorescence bronchoscopy and white light bronchoscopy were superior to white light bronchoscopy alone in detecting this type of lung cancer. Natural history of this cancer showed about the two-thirds of the patients die from original disease within 10 years. If the tumor length is 10 mm or less, photodynamic therapy is a first-line modality. After photodynamic therapy, a 5-year overall survival of about 80 % and a 10-year overall survival of 70 % can be expected. If a cancer does not meet the criteria for photodynamic therapy, surgical resection is recommended, and 5-year overall survival of about 80 % can be expected. Segmentectomy should be considered because of pulmonary function preservation if a tumor is located at segmental bronchi or beyond it. The frequency of multicentricity is high. Treatment strategy for subsequent primary lung cancer is an important key for the prognosis of patients with treated early central airways lung cancer. Surgical resection is still the most reliable treatment of subsequent primary lung cancer, except for in situ or microinvasive carcinoma located centrally, which could be cured by photodynamic therapy.

Results of long-term follow-up of photodynamic therapy for roentgenographically occult bronchogenic squamous cell carcinoma

BACKGROUND

Photodynamic therapy (PDT) is considered a useful and minimally invasive modality for treating centrally located early lung cancer. To date, there has been limited information on the long-term outcome of patients treated with PDT, especially those who are medically operable.

METHODS

Beginning in 1994, patients with roentgenographically occult bronchogenic squamous cell carcinoma (ROSCC) who met our criteria underwent PDT at Tohoku University Hospital and were followed up through 2006. Our criteria were as follows: (1) ROSCC without distant metastasis; (2) medically operable by means of lobectomy or further resection; (3) longitudinal tumor length of <or= 10 mm; and (4) superficial bronchoscopic tumor findings.

RESULTS

A total of 48 patients with ROSCC underwent PDT. The complete response (CR) rate was 94% (45 of 48 of patients). Nine patients (20%) had local recurrence after CR. A total of 11 deaths was observed, with 6 resulting from multiple primary lung cancer and only 1 from the original ROSCC. The 5-year and 10-year overall survival rates for all 48 patients were 81% and 71%, respectively. The Cox proportional hazard model showed that only metachronous multiple primary lung cancer was an independent poor prognostic factor.

CONCLUSIONS

PDT is thought to be a first-line modality for patients who have ROSCC with a tumor length of <or= 10 mm, even if the tumor is medically operable. Most local recurrence can be cured by active therapy such as surgery, radiotherapy, or PDT. Multiple primary lung cancer subsequent to PDT is an important issue from the viewpoint of survival.

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.

Initial bronchoscopic treatment for patients with intraluminal bronchial carcinoids

OBJECTIVE

Carcinoid of the lung is considered low-grade malignancy, and less invasive treatment may therefore be considered. We analyzed the long-term outcome of initial bronchoscopic treatment in patients with intraluminal bronchial carcinoids.

METHODS

Initial bronchoscopic treatment was applied to improve presurgical condition, to obtain tissue samples for proper histologic classification, and to enable less extensive parenchymal resection. For intraluminal bronchial carcinoid, complete tumor eradication with initial bronchoscopic treatment was attempted. High-resolution computed tomography in addition to bronchoscopy was used to determine intraluminal versus extraluminal tumor growth. Surgery followed in cases of atypical carcinoid, residue, or recurrence.

RESULTS

Seventy-two patients, 43 of them female, have been treated (median age 47 years, range 16-80 years). Median follow-up has been 65 months (range 2-180 months). Fifty-seven (79%) had typical carcinoids and 15 (21%) had atypical carcinoids. Initial bronchoscopic treatment resulted in complete tumor eradication in 33 of 72 cases (46%), 30 typical and 3 atypical. Thirty-seven of 72 cases (51%), 11 atypical, required surgery (2 for late detected recurrences). Two patients had metastatic atypical carcinoid, 1 already at referral. Of the 6 deaths, 1 was tumor related.

CONCLUSIONS

Initial bronchoscopic treatment is a potentially more tissue-sparing alternative than immediate surgical resection in patients with intraluminal bronchial carcinoids. For successful tumor eradication with initial bronchoscopic treatment in central carcinoids, assessment of intraluminal versus extraluminal growth may be of much more importance than histologic division between typical and atypical carcinoid. Disease-specific mortality is low, and long-term outcome has been excellent. Implementation of initial bronchoscopic treatment had no negative impact on surgical treatment outcome.

Cost-effectiveness of early intervention: comparison between intraluminal bronchoscopic treatment and surgical resection for T1N0 lung cancer patients

BACKGROUND

For patients with early-stage lung cancer (ESLC) and severe comorbidities, the cost-effectiveness of early intervention may be reduced by screening and treatment-related morbidity and mortality in addition to the risk for non-cancer-related deaths.

OBJECTIVES

The use of bronchoscopic treatment (BT) for centrally located ESLC as minimally invasive technique has raised questions whether this approach will be more cost-effective than standard surgical resection in the above-mentioned cohort of patients.

METHODS

The cost-effectiveness of BT of 32 medically inoperable patients with intraluminal tumor has been compared to a matched control group of surgically treated stage IA cancer patients.

RESULTS

Median follow-up after BT for ESLC has been 5 years (range 2-10) versus 6.7 years (range 2-10) for the surgical group. Five patients (16%) developed subsequent primaries/local recurrences after BT versus 4 (12.5%) in the surgical group. The respective percentages of actual survival during follow-up have been 50 and 41%, non-lung-cancer-related death 22 and 31% and lung-cancer-related death 28% in both groups, respectively. So far, the average costs per individual for early management by BT have been Euro 22,638 by surgery, and total expenses have been Euro 209,492 and Euro 724,403, respectively.

CONCLUSIONS

Despite the worse initial health status of patients treated with BT, actual survival rates and costs for early intervention underscore the superior cost-effectiveness of BT as early intervention in properly selected individuals with ESLC in the central airways.

What is early lung cancer? A review of the literature

The dismal cure rate of patients with lung cancer and the stage shift hypothesis have propelled the interest to perform screening at large, despite that previous randomized clinical trials failed to show any mortality benefit and the controversial issue of overdiagnosis. Due to early detection programs, a larger number of individuals at risk will be found to harbor small and potentially malignant early stage lesions. The application of non- and minimal invasive techniques for early detection, staging and treatment will become increasingly important. This review deals with the available clinical, surgical and pathological data focusing on early lung cancer lesions < or =1 cm. Literature data from both centrally located and parenchymal lesions < or =3 cm. have been analyzed. For all sub-centimeter lesions, minimal invasive staging and treatment approaches must still be considered inappropriate. Less invasive and less extensive treatment methods may be considered in high risk individuals with < or =1 cm. peripheral lesion showing > or =50 ground glass opacity on high resolution CT scan and those with superficial lesion in their central airways without deeper tumor invasion in the bronchial wall. Caution is necessary, however, as clinical staging remains inferior to pathological staging which is based on tissue samples collected after complete tumor removal and mediastinal lymph nodes dissection have been performed.

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.

Surgical results for centrally-located early stage lung cancer

BACKGROUND

With the increasing use of mass screening programs for lung cancer, and especially the use of sputum cytology, the incidence of roentgenographically occult lung cancer has been increasing. These occult cancers comprise mainly histologically centrally-located early stage lung cancers. This study examined the clinicopathologic characteristics and surgical results of centrally-located early stage lung cancer.

RESULTS

From 1980 to 1998, there were 98 patients and 99 lesions of centrally-located early stage lung cancer resected. A total of 64 patients were detected by mass screening. Histologic examination revealed that 96 lesions were squamous cell carcinoma, and in these patients, there were 10 lesions of carcinoma in situ. The 5-year survival rate was 81.4% in all patients, and 88.9% in carcinoma in situ patients. In the postoperative follow-up period, a second lung cancer occurred in 13 patients.

CONCLUSIONS

The surgical results for centrally-located early lung cancer were good. However, sometimes these cancers are accompanied by a second centrally-located primary lung cancer, so it is necessary to follow-up with sputum cytology to allow early detection of additional centrally-located lung cancer.