Explainable artificial intelligence (XAI) for exploring spatial variability of lung and bronchus cancer (LBC) mortality rates in the contiguous USA

Machine learning (ML) has demonstrated promise in predicting mortality; however, understanding spatial variation in risk factor contributions to mortality rate requires explainability. We applied explainable artificial intelligence (XAI) on a stack-ensemble machine learning model framework to explore and visualize the spatial distribution of the contributions of known risk factors to lung and bronchus cancer (LBC) mortality rates in the conterminous United States. We used five base-learners-generalized linear model (GLM), random forest (RF), Gradient boosting machine (GBM), extreme Gradient boosting machine (XGBoost), and Deep Neural Network (DNN) for developing stack-ensemble models. Then we applied several model-agnostic approaches to interpret and visualize the stack ensemble model's output in global and local scales (at the county level). The stack ensemble generally performs better than all the base learners and three spatial regression models. A permutation-based feature importance technique ranked smoking prevalence as the most important predictor, followed by poverty and elevation. However, the impact of these risk factors on LBC mortality rates varies spatially. This is the first study to use ensemble machine learning with explainable algorithms to explore and visualize the spatial heterogeneity of the relationships between LBC mortality and risk factors in the contiguous USA.

Effective Radiotherapy in Tracheobronchial Adenoid Cystic Carcinoma With Positive Surgical Margin

BACKGROUND

The study aimed to evaluate the role of postoperative radiotherapy (PORT) in the treatment of trachea and main bronchus adenoid cystic carcinoma (ACC) with a positive surgical margin.

METHODS

Patients with pathologically confirmed trachea or main bronchus ACC operated on at Shanghai Chest Hospital were enrolled. Survival, univariate, and multivariate analyses were performed. The χ² test was applied to analyze the failure patterns among different groups (R0/0: negative margin resection without PORT; R1/0: positive margin resection without PORT; R1/1: positive margin resection with PORT).

RESULTS

From January 2001 to December 2014, 77 patients were deemed eligible for the study. Pairwise comparisons showed that the overall survival rate of group R1/1 was comparable to that of group R0/0 (P = .438), and significantly longer than the rate of group R1/0 (P = .032). Additionally, the local disease-free survival rate of group R1/1 was much higher than that of group R0/0 (P = .023) and R1/0 (P = .001). Cox multivariate analysis identified the radiologic feature (P = .012) and PORT (P = .006) as significantly favorable prognostic factors for locoregional disease-free survival. By contrast, for overall survival, PORT (P = .032) was the only corresponding variable identified by univariate analysis. Furthermore, PORT significantly decreased the locoregional recurrence rate (P = .002) but not distant metastases (P > .999).

CONCLUSIONS

PORT helped patients with tracheobronchial ACC and microscopic positive surgical margins to achieve a similar outcome as patients with complete resection. R0 resection may not be necessary for tracheobronchial ACC if it is difficult to be completely resected.

Associations of county-level cumulative environmental quality with mortality of chronic obstructive pulmonary disease and mortality of tracheal, bronchus and lung cancers

Chronic obstructive pulmonary disease (COPD) and tracheal, bronchus, and lung (TBL) cancers are among the leading causes of mortality worldwide. Many environmental factors have been linked to COPD and TBL cancers. This study examined the associations of cumulative environmental quality indices with COPD mortality and TBL cancers mortality, respectively. Environmental Quality Index (EQI) was constructed to represent cumulative environmental quality for the overall environment and 5 major environmental domains (e.g., air, water, built). Associations of each EQI indices with COPD mortality and TBL cancers mortality, across 3109 counties in the 48 contiguous states of the US, were examined using simultaneous autoregressive (SAR) models. Stratified analyses were conducted in females versus males and according to rural-urban continuum codes (RUCC) to assess the heterogeneity across the overall population. Overall poor environmental quality was associated with a percent difference (PD) of 0.75 [95% confidence intervals (95% CI), 0.46, 1.05] in COPD mortality and an PD of 1.22 (95% CI, 0.97, 1.46) in TBL cancers mortality. PDs were higher in females than in males for both COPD and TBL cancers. The built domain had the largest effect on COPD mortality (PD, 0.85; 95% CI, 0.58, 1.12) while the air domain had the largest effect on TBL cancers mortality (PD, 1.54; 95% CI, 1.31, 1.76). The EQI-mortality associations varied among different RUCCs, but no consistent trend was found. This result suggests that poor environmental quality, particularly poor air quality and built environment quality may increase the mortality risk for COPD and that for TBL cancers. Females appear to be more susceptible to the effect of cumulative environmental quality. Our findings highlight the importance of improving overall and domain-specific cumulative environmental quality in reducing COPD and TBL cancer mortalities in the United States.

NEP-Score Thresholds Predict Survival of Patients With Bronchial Carcinoids

Survival prognostic markers are extremely needed to better define therapeutic strategies in patients with bronchial carcinoids (BC). We aim to verify the applicability of the NEP-Score in a homogeneous BC cohort and identify a derivative prognostic marker, the NEP-Score at diagnosis (NEP-D) that does not consider new metastases during follow-up. Sixty-four patients (38 females, and 26 males, mean age at diagnosis 58.9 ± 1.7 years) with BC were retrospectively evaluated. NEP-Score was calculated at the end of follow-up (NEP-T). A derivative score, the NEP-Score at diagnosis (NEP-D) that does not consider new metastases during follow-up, was then assessed. Patients were subdivided according to their living status at the end of follow-up. A NEP-Score threshold was investigated to predict survival. Mean NEP-T and mean NEP-D were significantly lower in live patients at end of follow-up. A NEP-T cut-off >138 significantly predicts survival. Atypical BC relapsed more frequently than Typical BC. Male gender and previous malignancy were negative prognostic factors for survival. We confirmed NEP-Score applicability in BC and NEP-D utility, being the latter a simple, quick, and cheap prognostic score that can help clinicians in decision making. The identified NEP-D threshold can predict NEN aggressiveness and may be used to define the best personalized therapeutic strategy. In this context, a validation study is needed.

Hyperbaric oxygenation for tumour sensitisation to radiotherapy

BACKGROUND

Cancer is a common disease and radiotherapy is one well-established treatment for some solid tumours. Hyperbaric oxygenation therapy (HBOT) may improve the ability of radiotherapy to kill hypoxic cancer cells, so the administration of radiotherapy while breathing hyperbaric oxygen may result in a reduction in mortality and recurrence.

OBJECTIVES

To assess the benefits and harms of administering radiotherapy for the treatment of malignant tumours while breathing HBO.

SEARCH METHODS

In September 2017 we searched the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Library Issue 8, 2017, MEDLINE, Embase, and the Database of Randomised Trials in Hyperbaric Medicine using the same strategies used in 2011 and 2015, and examined the reference lists of included articles.

SELECTION CRITERIA

Randomised and quasi-randomised studies comparing the outcome of malignant tumours following radiation therapy while breathing HBO versus air or an alternative sensitising agent.

DATA COLLECTION AND ANALYSIS

Three review authors independently evaluated the quality of and extracted data from the included trials.

MAIN RESULTS

We included 19 trials in this review (2286 participants: 1103 allocated to HBOT and 1153 to control).For head and neck cancer, there was an overall reduction in the risk of dying at both one year and five years after therapy (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.70 to 0.98, number needed to treat for an additional beneficial outcome (NNTB) = 11 and RR 0.82, 95% CI 0.69 to 0.98, high-quality evidence), and some evidence of improved local tumour control immediately following irradiation (RR with HBOT 0.58, 95% CI 0.39 to 0.85, moderate-quality evidence due to imprecision). There was a lower incidence of local recurrence of tumour when using HBOT at both one and five years (RR at one year 0.66, 95% CI 0.56 to 0.78, high-quality evidence; RR at five years 0.77, 95% CI 0.62 to 0.95, moderate-quality evidence due to inconsistency between trials). There was also some evidence with regard to the chance of metastasis at five years (RR with HBOT 0.45 95% CI 0.09 to 2.30, single trial moderate quality evidence imprecision). No trials reported a quality of life assessment. Any benefits come at the cost of an increased risk of severe local radiation reactions with HBOT (severe radiation reaction RR 2.64, 95% CI 1.65 to 4.23, high-quality evidence). However, the available evidence failed to clearly demonstrate an increased risk of seizures from acute oxygen toxicity (RR 4.3, 95% CI 0.47 to 39.6, moderate-quality evidence).For carcinoma of the uterine cervix, there was no clear benefit in terms of mortality at either one year or five years (RR with HBOT at one year 0.88, 95% CI 0.69 to 1.11, high-quality evidence; RR at five years 0.95, 95% CI 0.80 to 1.14, moderate-quality evidence due to inconsistency between trials). Similarly, there was no clear evidence of a benefit of HBOT in the reported rate of local recurrence (RR with HBOT at one year 0.82, 95% CI 0.63 to 1.06, high-quality evidence; RR at five years 0.85, 95% CI 0.65 to 1.13, moderate-quality evidence due to inconsistency between trials). We also found no clear evidence for any effect of HBOT on the rate of development of metastases at both two years and five years (two years RR with HBOT 1.05, 95% CI 0.84 to 1.31, high quality evidence; five years RR 0.79, 95% CI 0.50 to 1.26, moderate-quality evidence due to inconsistency). There were, however, increased adverse effects with HBOT. The risk of a severe radiation injury at the time of treatment with HBOT was 2.05, 95% CI 1.22 to 3.46, high-quality evidence. No trials reported any failure of local tumour control, quality of life assessments, or the risk of seizures during treatment.With regard to the treatment of urinary bladder cancer, there was no clear evidence of a benefit in terms of mortality from HBOT at one year (RR 0.97, 95% CI 0.74 to 1.27, high-quality evidence), nor any benefit in the risk of developing metastases at two years (RR 2.0, 95% CI 0.58 to 6.91, moderate-quality evidence due to imprecision). No trial reported on failure of local control, local recurrence, quality of life, or adverse effects.When all cancer types were combined, there was evidence for an increased risk of severe radiation tissue injury during the course of radiotherapy with HBOT (RR 2.35, 95% CI 1.66 to 3.33, high-quality evidence) and of oxygen toxic seizures during treatment (RR with HBOT 6.76, 96% CI 1.16 to 39.31, moderate-quality evidence due to imprecision).

AUTHORS' CONCLUSIONS

We found evidence that HBOT improves local tumour control, mortality, and local tumour recurrence for cancers of the head and neck. These benefits may only occur with unusual fractionation schemes. Hyperbaric oxygenation therapy is associated with severe tissue radiation injury. Given the methodological and reporting inadequacies of the included studies, our results demand a cautious interpretation. More research is needed for head and neck cancer, but is probably not justified for uterine cervical or bladder cancer. There is little evidence available concerning malignancies at other anatomical sites.

QuickStats: Age-Adjusted Death Rates* for Top Five Causes of Cancer Death,(†) by Race/Hispanic Ethnicity - United States, 2014

In 2014, the top five causes of cancer deaths for the total population were lung, colorectal, female breast, pancreatic, and prostate cancer. The non-Hispanic black population had the highest age-adjusted death rates for each of these five cancers, followed by non-Hispanic white and Hispanic groups. The age-adjusted death rate for lung cancer, the leading cause of cancer death in all groups, was 42.1 per 100,000 standard population for the total population, 45.4 for non-Hispanic white, 45.7 for non-Hispanic black, and 18.3 for Hispanic populations.

Comparative Analysis of Clinicopathologic Features of, Treatment in, and Survival of Americans with Lung or Bronchial Cancer

Ethnic disparities in lung and bronchial cancer diagnoses and disease-specific survival (DSS) rates in the United States are well known. However, few studies have specifically assessed these differences in Asian subgroups. The primary objectives of the retrospective analysis described herein were to identify any significant differences in clinicopathologic features, treatment, and survival rate between Asian lung cancer patients and lung cancer patients in other broad ethnic groups in the United States and to determine the reasons for these differences among subgroups of Asian patients with lung or bronchial cancer. We searched the Surveillance, Epidemiology, and End Results Program database to identify patients diagnosed with lung or bronchial cancer from 1990 to 2012. Differences in clinicopathologic features, treatment, and DSS rate in four broad ethnic groups and eight Asian subgroups were compared. The study population consisted of 849,088 patients, 5.2% of whom were of Asian descent. Female Asian patients had the lowest lung and bronchial cancer incidence rates, whereas male black patients had the highest rates. Asian patients had the best 5-year DSS rate. In our Asian subgroup analysis, Indian/Pakistani patients had the best 5-year DSS rate, whereas Hawaiian/Pacific Islander patients had the worst 5-year DSS rates. We found the differences in DSS rate among the four broad ethnic groups and eight Asian subgroups when we grouped patients by age and disease stage, as well. Asian patients had better DSS rates than those in the other three broad ethnic groups in almost every age and disease-stage group, especially in older patients and those with advanced-stage disease. In conclusion, we found that clinicopathologic features and treatment of lung and bronchial cancer differ by ethnicity in the United States, and the differences impact survival in each ethnic group.

Asbestos-related occupational cancers compensated under the Spanish National Insurance System, 1978-2011

BACKGROUND

In 1978, asbestos-related occupational cancers were added to the Spanish list of occupational diseases. However, there are no full accounts of compensated cases since their inclusion.

OBJECTIVE

To analyze the cases of asbestos-related cancer recognized as occupational in Spain between 1978 and 2011.

METHODS

Cases were obtained from the Spanish Employment Ministry. Specific incidence rates by year, economic activity, and occupation were obtained. We compared mortality rates of mesothelioma and bronchus and lung cancer mortality in Spain and the European Union.

RESULTS

Between 1978 and 2011, 164 asbestos-related occupational cancers were recognized in Spain, with a mean annual rate of 0·08 per 10(5) employees (0·13 in males, 0·002 in females). Under-recognition rates were an estimated 93·6% (males) and 99·7% (females) for pleural mesothelioma and 98·8% (males) and 100% (females) for bronchus and lung cancer. In Europe for the year 2000, asbestos-related occupational cancer rates ranged from 0·04 per 10(5) employees in Spain to 7·32 per 10(5) employees in Norway.

CONCLUSIONS

These findings provide evidence of gross under-recognition of asbestos-related occupational cancers in Spain. Future work should investigate cases treated in the National Healthcare System to better establish the impact of asbestos on health in Spain.

Effect of temozolomide in patients with metastatic bronchial carcinoids

INTRODUCTION

Metastatic bronchial carcinoids are rare neoplasms, where efforts of medical treatment so far have been disappointing. A previous study from our center indicated that temozolomide might be of value.

MATERIALS AND METHODS

All patients with progressive metastatic bronchial carcinoid treated with temozolomide as monotherapy at our center between 2004 and 2010 (n = 31) were included in this retrospective study. 14 tumors were classified as typical and 15 as atypical carcinoids, whereas 2 tumors could not be classified. Temozolomide was given on 5 consecutive days every 4 weeks. Toxicity was evaluable in 28 of 31 patients, and 22 patients were evaluable by RECIST 1.1.

RESULTS

There were no complete responses. A partial response was seen in 3 patients (14%), stable disease in 11 (52%) and progressive disease in 7 patients (33%). Median progression-free survival was 5.3 months and median overall survival was 23.2 months from the start of temozolomide. Toxicities grade 3-4 were noted in 4 patients, thrombocytopenia (n = 3) and leukopenia (n = 1).

CONCLUSION

Temozolomide as monotherapy shows activity in metastatic bronchial carcinoids. Regimens combining temozolomide with other agents (e.g. capecitabine and/or bevacizumab, everolimus, radiolabeled somatostatin analogues) should be further studied in these patients.

Hyperbaric oxygenation for tumour sensitisation to radiotherapy

BACKGROUND

Cancer is a common disease and radiotherapy is one well-established treatment for some solid tumours. Hyperbaric oxygenation therapy (HBOT) may improve the ability of radiotherapy to kill hypoxic cancer cells, so the administration of radiotherapy while breathing hyperbaric oxygen may result in a reduction in mortality and recurrence.

OBJECTIVES

To assess the benefits and harms of radiotherapy while breathing HBO.

SEARCH METHODS

In March 2011 we searched The Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library, Issue 3), MEDLINE, EMBASE, DORCTHIM and reference lists of articles.

SELECTION CRITERIA

Randomised and quasi-randomised studies comparing the outcome of malignant tumours following radiation therapy while breathing HBO versus air.

DATA COLLECTION AND ANALYSIS

Three review authors independently evaluated the quality of the relevant trials and extracted the data from the included trials.

MAIN RESULTS

Nineteen trials contributed to this review (2286 patients: 1103 allocated to HBOT and 1153 to control). With HBOT, there was a reduction in mortality for head and neck cancers at both one year and five years after therapy (risk ratio (RR) 0.83, P = 0.03, number needed to treat (NNT) = 11; and RR 0.82, P = 0.03, NNT = 5 respectively), as well as improved local tumour control at three months (RR with HBOT 0.58, P = 0.006, NNT = 7). The effect of HBOT varied with different fractionation schemes. Local tumour recurrence was less likely with HBOT at one year (head and neck: RR 0.66, P < 0.0001, NNT = 5), two years (uterine cervix: RR 0.60, P = 0.04, NNT = 5) and five years (head and neck: (RR 0.77, P = 0.01, NNT = 6). Any advantage is achieved at the cost of some adverse effects. There was a significant increase in the rate of both severe radiation tissue injury (RR 2.35, P < 0.0001, (number needed to harm (NNH) = 8) and the chance of seizures during therapy (RR 6.76, P = 0.03, NNH = 22) with HBOT.

AUTHORS' CONCLUSIONS

There is some evidence that HBOT improves local tumour control and mortality for cancers of the head and neck, and local tumour recurrence in cancers of the head and neck, and uterine cervix. These benefits may only occur with unusual fractionation schemes. HBOT is associated with significant adverse effects including oxygen toxic seizures and severe tissue radiation injury. The methodological and reporting inadequacies of the studies included demand a cautious interpretation. More research is needed for head and neck cancer, but is probably not justified for bladder cancer. There is little evidence available concerning malignancies at other anatomical sites on which to base a recommendation.

Lung and bronchus cancer in Puerto Rico: changes in incidence and mortality rates by histology and sex during 1987-2003

OBJECTIVE

Major changes in the incidence of the most common histological types of lung and bronchus cancer have been observed around the world. Herein we report the overall incidence, stage at diagnosis and overall mortality of lung and bronchus cancer in Puerto Rico, and the incidence of the different histologic types.

METHODS

Aggregate lung and bronchus cancer data from 1987 to 2003 were obtained from the Puerto Rico Central Cancer Registry. Incidence and mortality rates were age-standardized by the direct method to the 2000 standard population of the United States. For the incidence (overall, by histologic type, and by sex), and mortality we calculated the annual percent change (APC) using the Joinpoint Regression Program.

RESULTS

There were 9,886 cases of lung and bronchus cancer (6,772 men, 3,114 women), for an overall age-adjusted incidence of 18.8 per 100,000. The incidence decreased significantly for the whole group, falling from 18.9 per 100,000 in 1987 to 17.1 in 2003 (APC: -0.74, p < 0.05); for men, incidence decreased from 28.1 per 100,000 to 24.4 (APC: -1.02, p < 0.05) over the same period of time. The mortality rate has decreased overall (APC: -0.62, p < 0.05) and in men (APC: -0.71, p < 0.05). Squamous cell carcinoma was the most common histologic type in 1987, but it decreased from 6.2 per 100,000 in 1987 to 3.5 in 2003 (APC: -3.86, p < 0.05), while adenocarcinoma increased from 3.7 per 100,000 to 4.6 (APC: +1.51, p < 0.05).

CONCLUSION

In Puerto Rico, over the period of 1987 to 2003, squamous cell carcinoma of the lung and bronchus decreased, while adenocarcinoma increased. As of 1999, the most common type of lung and bronchus cancer is adenocarcinoma. Both the incidence and the mortality of lung and bronchus cancer decreased for men but not for women.

Endoscopic cryotherapy of lung and bronchial tumors: a systematic review

BACKGROUND/AIMS

We made a systematic review and evaluation of endoscopic cryotherapy of endobronchial tumors, investigating safety and efficacy.

METHODS

Qualified studies regarding endoscopic cryotherapy of lung tumors were systemically evaluated using available databases according to predefined criteria.

RESULTS

In total, 16 publications were included in the final assessment. A narrative synthesis was performed because a formal meta-analysis was not viable due to the lack of controlled studies and study heterogeneity. Overall success rates for significant recanalization of the obstruction were approximately 80%, although they varied, depending on disease status in the patient population. Complications from the procedure developed in 0-11.1% of cases, most of which were minor and controlled by conservative management. Although limited data were available on comprehensive functional assessment, some studies showed that respiratory symptoms, pulmonary function tests, and performance status were significantly improved.

CONCLUSIONS

Endoscopic cryotherapy was found to be a safe and useful procedure in the management of endobronchial tumors although its efficacy and appropriate indications have yet to be determined in well-designed controlled studies.

Clinical prognostic factors and outcome of surgical treatment in patients with early-stage bronchial carcinoid tumors

PURPOSE

Surgical resection is the treatment of choice for bronchial carcinoids (BC). The primary endpoint of this study was to look at the survival of patients with BC after the surgical treatment and to identify some clinicopathological prognostic factors influencing survival.

METHODS

The analysis included 57 patients with early- stage BC submitted to surgical treatment in the period 2000-2008. Major inclusion criteria were: pathologically confirmed BC, ECOG performance status 0-2, and surgical resection of the tumor.

RESULTS

No significant difference in survival in relation to gender was registered. N0, N1 and N2 status was registered in 39, 9 and 2 patients, respectively. There were statistically significant differences in survival according to N status (p=0.032). Twenty-two patients had T1N0 stage, 21 T2N0, and 4 T1N1. There was a trend for significant differences in survival according to TN stage (p=0.063). Also, analysis revealed significant differences in survival depending on tumor size (p=0.000), as well as on the type of the tumor (typical vs. atypical) (p=0.010).

CONCLUSION

Nodal status and TN stage affect patients' survival. Tumor size and typical/atypical tumor are also significant prognostic factors for survival of surgically treated patients.

[Diagnosis and treatment of tracheal or bronchuotracheal adenoid cystic carcinoma]

BACKGROUND AND OBJECTIVE

Adenoid cystic carcinoma is primary bronchopulmonary carcinoma with low malignancy, and 43 patients treated in the past 50 years in our hospital were retrospectively studied. The aim of this study is to discuss the clinical symptoms, pathologic characteristic and therapeutic method of primary tracheal or bronchuotracheal adenoid cystic carcinoma.

METHODS

This study summarized total 43 patients of primary tracheal or bronchus adenoid cystic carcinoma treated in our hospital from Jan. 1958 to Dec. 2007. Among them, 40 patients were treated by surgical resection, and 3 patients were treated by fiberoptic bronchoscope's interventional treatment.

RESULTS

The 1-yr, 3-yr, 5-yr survival rates of the 43 patients above were 100% (41/41), 89.5% (34/38), 87.1% (27/31), respectively.

CONCLUSION

Primary tracheal or bronchus adenoid cystic carcinoma are rare and low malignancy carcinoma. The clinical symptoms of them are not typical. The best treatment is early detection and taking measures of operation plus radiotherapy. The other palliative treatment is fiberoptic bronchoscope's interventional treatment.

[Histology does not accurately predict the clinical behaviour of bronchopulmonary carcinoids - results from an Icelandic population-based study]

BACKGROUND AND AIMS

Bronchopulmonary carcinoids (BPC) are rare tumors of neuroendocrine origin. These tumors are histologically classified into two distinctive forms, typical and the more malignant atypical BPC. We evaluated the epidemiology and results of treatment for BPC in Iceland with special emphasis on how atypical vs. typical histology relates to clinical behavior.

MATERIAL AND METHODS

This retrospective nation-wide study included all cases of BPC diagnosed in Iceland from 1955-2005. Histology of all the cases was reviewed and survival was based on data obtained from medical records and vital statistics.

RESULTS

BPC was diagnosed in 64 patients (22 males, mean age 49 yrs.), accounting for 1.9% of all lung neoplasms in Iceland. Average tumor-diameter was 2.5 cm (range 0.4-5.5), with typical histology in 54 (84%) and atypical in 10 patients (16%). Altogether 56 patients (87.5%) were operated on, most with lobectomy (82.1%). Forty eight patients were diagnosed in TNM stage I, two patients in stage II, four patients had mediastinal lymph node metastases (stage III) and distant metastases were diagnosed in 6 patients (stage IV), 2 of whom had typical histology. At follow-up, 5 out of 64 patients had died of the disease (7.8%), two of them with typical histology. Five-year disease specific survival was 96% for patients with typical and 70% with atypical histology (p<0.05).

CONCLUSION

BPCs usually behave as benign neoplasms, with excellent long-term survival after surgical removal. Metastases are more common in patients with atypical histology (40%), and their survival is worse. However patients with typical histology can metastasize (14.8%) and die from the disease. Therefore, histology (typical vs. atypical) can not be used with certainty to predict the clinical behaviour of these tumors.

[Geographical distribution of mortality caused by stomach, trachea, bronchi and lung malignant tumors in Chile]

BACKGROUND

Maps have played a critical role in public health since 1855, when John Snow associated a cholera outbreak with contaminated water source in London. After cardiovascular diseases, cancer is the second leading cause of death in Chile. Cancer was responsible for 22.7% of all deaths in 1997-2004 period.

AIM

To describe the geographical distribution of stomach, trachea, bronchi and lung cancer mortality.

MATERIAL AND METHODS

Mortality statistics for the years 1997-2004, published by the National Statistics Institute and Chilean Ministry of Health, were used. The standardized mortality ratio (SMR) for sex and age quinquennium was calculated for 341 counties in the country. A hierarchical Bayesian analysis of Poisson regression models for SMR was performed. The maps were developed using adjusted SMR (or smoothed) by the Poisson model.

RESULTS

There is an excess mortality caused by stomach cancer in south central Chile, from Teno to Valdivia. There is an excess mortality caused by trachea, bronchi and lung cancer in northern Chile, from Copiapó to Iquique.

CONCLUSIONS

The geographical analysis of mortality caused by cancer shows cluster of counties with an excess risk. These areas should be considered for health care decision making and resource allocation.

[Evaluation of clinical practice in pulmonary oncology: a review of the literature]

INTRODUCTION

Evaluation of clinical practice in pulmonary oncology aims to improve both the quality of care and the control of costs.

REVIEW OF THE LITERATURE

A Medline search of the literature allowed analysis of the published studies of the evaluation of clinical practice. They showed that though 82-95% of patients with small cell bronchial carcinoma were treated with a combination of etoposide and cisplatin, less than half of the patients with non-small cell cancer received treatment.

VIEWPOINT

Various factors such as age, comorbidity, race, socio-economic status and gender affect the treatment decisions. There is also a discrepancy between the trial data and clinical practice that could be explained by two factors. On one hand advances are not always adopted by doctors and on the other hand the patient populations treated may sometimes be different from those in the trials.

CONCLUSION

Though the number of published studies is still low an increase is to be expected on account of the publication of new regulations concerning the evaluation of clinical practice and the appropriate use of drugs.

Palliation of tracheobronchial carcinoma: the role of cryosurgery

Bronchoscopy is a common day case procedure that can aid in the diagnosis and treatment of tracheobronchial disorders. The controlled application of extreme cold through a bronchoscope to endobronchial lesions (malignant and benign) is known as endobronchial cryosurgery. This procedure improves respiratory function and reduces shortness of breath and is performed in a cycle of three treatments. This article describes the instrumentation required, how cryosurgery is performed and how endobronchial cryosurgery can improve the patient's functional status and survival.

Endobronchial palliation using Nd:YAG laser is associated with improved survival when combined with multimodal adjuvant treatments

BACKGROUND

Endobronchial neodymium:yttrium aluminum garnet (Nd:YAG) laser therapy has been shown to be safe and effective in palliating large airway malignancies. The role of multimodal therapy with stenting, brachytherapy, chemotherapy, and radiotherapy together with Nd:YAG laser therapy is unclear.

AIM

This study aims to confirm the safety and effectiveness of Nd:YAG laser therapy in the contemporary setting and to investigate the effectiveness of multimodal therapy compared with laser alone.

METHODS

One hundred fifty-three Nd:YAG laser treatments on 110 patients between 1999 and 2004 were reviewed retrospectively. Symptom scores for dyspnoea, hemoptysis, and cough before and after the procedure were compared. Survival and time to reintervention were analyzed using the Kaplan-Meier method. Multimodality treatment was compared with Nd:YAG laser therapy alone to determine differences in survival and time to reintervention. p values less than 0.05 were considered significant.

RESULTS

There were no operative mortalities directly caused by laser intervention, although 30-day mortality was 6.5%. Deaths were attributable to progression of advanced neoplastic processes rather than laser intervention, and 6.5% of patients had some postoperative morbidity. After Nd:YAG laser intervention, 76% of patients reported improvement to dyspnoea, 94% for hemoptysis, and 75% for cough. Median survival after Nd:YAG laser treatment was 6.64 months; 21% of patients required repeated laser treatment. Compared with Nd:YAG laser treatment alone, multimodality treatments significantly prolonged median time to reintervention by 1.7 months (p = 0.002) and prolonged median survival by 4.9 months (p < 0.001) in patients with NSCLC.

CONCLUSION

Nd:YAG laser intervention is safe and effective for palliation of endobronchial malignancies. In most cases, it only needs to be performed once. Compared with Nd:YAG laser therapy alone, multimodal treatment prolonged survival.

Long-term follow-up of ultraflex metallic stents in benign and malignant central airway obstruction

BACKGROUND

We report experience with Ultraflex metallic stents (Boston Scientific, Natick, MA) inserted at rigid bronchoscopy under general anesthesia for palliation of benign and malignant upper airway obstruction.

METHODS

Notes of all patients treated with Ultraflex stents from 1999 to 2003 were reviewed for symptomatic response, spirometric data, and any complications before discharge home. Long-term outcome was assessed by questionnaires sent to patients' general practitioners.

RESULTS

Recruited were 66 patients (12 benign, 54 malignant airway obstructions). Before discharge home, breathlessness improved in 11 of 12 patients with benign obstruction and in 39 of 54 with malignancies. Postoperative complications in 10 patients with malignant obstructions and in 2 patients with benign obstruction were successfully controlled. It was not possible to perform preoperative pulmonary function tests in most of the patients who presented as emergencies. Mean improvement in forced expiratory volume in 1 second was 0.88 liters in 3 patients with benign obstruction and 0.28 liters in 14 patients with malignant obstruction, and mean peak expiratory flow rate improved by 109 L/min and 97 L/min, respectively. General practitioners completed questionnaires for 12 benign patients and 46 of 54 patients with malignancies. At a mean follow-up of 1017 days (range, 46 to 1120 days), 10 of the 12 patients with benign disease were alive and 7 of 46 patients with malignant airway obstruction were alive, with a median survival of 128 days (mean, 361; range, 3 to 1859 days). Most survivors had Medical Research Council grade III breathlessness or better, with few stent-related symptoms.

CONCLUSIONS

Ultraflex stents proved safe and effective in prolonged palliation of benign and malignant airways obstruction.

[Prognosis of mucoepidermoid carcinoma of the bronchi]

BACKGROUND

Mucoepidermoid cancer is exceptional in the respiratory tract, accounting for only 0.2% of primary lung cancers.

CASE REPORTS

We report three cases of mucoepidermoid carcinoma. The inaugural signs were hemoptysia in a 10-year-old child, recurrent lower respiratory tract infections in a 13-year-old child, and dyspnea with chest pain in a 32-year-old adult. Bronchial fibroscopy disclosed a proximal endobronchial tumor in all three patients. Pathology study of the operative specimen identified low-grade malignant mucoepidermoid carcinoma in the two children and high-grade malignant mucoepidermoid carcinoma in the adult. Surgical resection was performed for the pediatric cases. Outcome was favorable with recurrence-free survival at eight years in the first child. The surgical resection was less radical in the second child due to locoregional extension. This child was lost to follow-up. The clinical course was rapidly fatal in the third patient who presented metastatic spread at diagnosis and died one month later.

DISCUSSION

The prognosis of mucoepidermoid tumors of the bronchi is closely related to tumor grade and extension at diagnosis. Unlike high-grade mucoepidermoid carcinoma, the progression of low-grade tumors, which predominate in children, is generally slow, enabling good prognosis if diagnosis is established early. Early search for these tumors in patients presenting chronic or recurrent respiratory manifestations would avoid late diagnosis and improve prognosis.

Outcome and surgical strategy in bronchial carcinoid tumors: single institution experience with 252 patients

OBJECTIVE

To evaluate type of surgery, long-term survival and factors influencing outcome in pulmonary carcinoid tumors.

PATIENTS AND METHODS

We reviewed data of 252 patients who underwent surgery for carcinoid tumor in 1968-1989 (Group A) and in 1990-2005 (Group B). All cases were reviewed and classified as typical (TC) or atypical carcinoid (AC) according to WHO criteria (1999).

RESULTS

There were 174 (69%) patients with TC (167 N0, 6 N1 and 1 N2) and 78 (31%) with AC (56 N0, 13 N1, 9 N2). Surgery consisted of 163 (64.7%) formal lung resections (121 lobectomies, 18 bilobectomies, 14 segmentectomies, 10 pneumonectomies), 76 (30.1%) sleeve or bronchoplastic resections and 13 (5.2%) wedge resections. No perioperative mortality occurred, 17 (6.7%) patients experienced complications. Overall 5, 10 and 15-year survival rate was 90%, 83% and 77%. TC showed a more favourable prognosis than AC (10-year survival rate 93% and 64%; p=0.00001) as well as N0 patients in comparison with N1-2 patients (10-year survival rate 87% and 50%; p=0.00005). Group A received lymph-node sampling, Group B received a systematic lymphadenectomy. No difference was found between Group A and B in detection of nodal metastases (10.9% versus 11.9%; p=0.79), but in Group A we observed 2 lymph-node relapses. In Group B number of sleeve resections significantly increased (2.7% versus 20.4%; p=0.0001) and number of pneumonectomies showed a significant reduction (7.2% versus 1.4%; p=0.01).

CONCLUSIONS

Typical histology and N0 status were important prognostic factors in carcinoid tumors. Parenchyma-sparing procedures must be considered the treatment of choice with systematic lymphadenectomy.

ADENOID CYSTIC CARCINOMA OF THE TRACHEA: A LONG-TERM PROBLEM

Adenoid cystic carcinoma of the trachea, although rare, is the second most common primary tumour of the trachea. It is a slow-growing tumour found in younger patients than the more common squamous cell carcinoma and is relatively resistant to treatment, but metastasizes late in the course of disease and even in unresectable cases can be palliated successfully for many years. We present a retrospective 20-year series of this condition from a single institute encompassing 13 patients of whom 6 were resected and 7 treated by palliative methods. A review of hospital records was carried out over the period 1984-2003. Details collected included symptoms before diagnosis, length of time from onset of the first symptom to diagnosis, resection details, survival statistics and accessory procedures tried before and after consideration of resection. The overall 5-year survival was 38.5%, but the mean survival in resected patients was 66 months as against 36 months for unresectable patients. Although most patients presented with dyspnoea, this was initially often attributed to other factors. The mean time of diagnosis from the onset of symptoms was 16 months. Although complete resection remains the management of choice if feasible, modern techniques of maintaining the airway in unresectable patients can give useful palliation for years.

[Surgical treatment for tumors of trachea, carina and main bronchus]

OBJECTIVE

To review the experience in surgical treatment for tumors of trachea, carina and main bronchus.

METHODS

From Jan. 1996 to Jun. 2004, 27 patients with tumor of trachea, carina or main bronchus underwent surgery including resection and reconstruction of trachea in 8, right/left pneumonectomy and carinal resection and reconstruction in 9 (6/3), right sleeve upper lobectomy and carnial resection with reconstruction of trachea and carina in 2, carina resection and reconstruction in 3, tumor removal through tracheal windows in 5. CPB (cardiopulmonary bypass) was used in 2 patients during surgery.

RESULTS

There were 3 peri-operative deaths caused by acute respiratory failure in 2 and severe postoperative bleeding in 1 case. After follow-up of more than 6 months, no death or post-operative complication occurred.

CONCLUSION

Resection and reconstruction for patients with tumor of trachea, main bronchus or carina can be performed with excellent results using effective surgical and anaesthetic methods with or without CPB assistance.

Prognosis and morphometrical features of non-bronchioloalveolar cell adenocarcinoma: an assessment of the non-alveolar replacing area and high grade atypical area

AIM

It has become obvious that the prognosis of bronchioloalveolar cell carcinoma (BAC) in small peripheral adenocarcinoma of the lung is good, but most cases actually treated as pulmonary adenocarcinoma in hospitals tend to be non-bronchioloalveolar cell carcinoma (non-BAC). The prognoses of non-BAC are greatly varied. We studied the relationships between the morphometrical features and the prognoses of non-BAC.

METHODS

In total, 69 cases of non-BAC measuring <or=20 mm in diameter across their greatest dimension were evaluated. We considered that the non-alveolar replacing area and the high grade atypical area were related to the prognosis, and therefore defined the ratio of both areas to the total area at the maximum face of the tumours as the non-alveolar replacing area ratio (NAAR) and the high grade atypical area ratio (HAAR), respectively. We thereafter analysed the relationships between both ratios and the prognosis.

RESULTS

The NAAR and HAAR were significantly higher in the recurrent cases than in the recurrence free cases. We divided the non-BAC cases at the centre of both ratios into two groups, high and low. The 5 year survival rate of the high NAAR and high HAAR group was 48.3%, while that of the low NAAR and low HAAR group was 72.2%. The groups showing high rates for both ratios had significantly worse prognoses. A multivariate analysis indicated that the HAAR contributes most to the prognosis.

CONCLUSIONS

These results suggest that the NAAR and HAAR are closely associated with the prognosis of non-BAC.

The application of photodynamic therapy in the treatment of metastatic endobronchial disease

BACKGROUND AND OBJECTIVE

We utilized photodynamic therapy (PDT) for palliation of metastatic endobronchial tumors employing sensitization with synthetic porphyrin, application of non-thermal light, and endoscopic debridement of necrotic tumor.

STUDY DESIGN/MATERIALS AND METHODS

Nine patients with symptomatic endobronchial metastasis from carcinomas of the colon(3), breast(3), kidney(2), and tongue(1) received PDT.

RESULTS

After two PDT treatments, patients showed substantial response, which was complete in all but one. One patient had perioperative complications and expired 2 days after developing massive hemoptysis during tumor debridement. Patient survival was 6.38 months (mean) and 4.2 months (median). Most patients died from advanced metastatic disease. One patient with metastasis limited to the airway is still alive 24 months following endobronchial presentation.

CONCLUSIONS

PDT ameliorates symptoms of metastatic airway obstruction, is easy to apply, has low morbidity and improves the quality of life.

Aggressive resection of the airway invaded by thyroid carcinoma

BACKGROUND

The aim of this study was to investigate the hypothesis that outcome following concomitant airway resection is superior to that after shaving of the tumour in patients with airway invasion of thyroid carcinoma.

METHODS

The records of 34 patients with thyroid cancer with airway invasion were reviewed retrospectively. In addition to total thyroidectomy, airway resection was performed in 18 patients (group 1), whereas the tumour was shaved away from the airway in the other 16 patients (group 2). 131I was used as postoperative adjuvant therapy in all patients. Metastasis and recurrence of the primary lesion were determined by 131I whole-body scans, serum thyroglobulin levels, and computed tomography or ultrasonography of the neck.

RESULTS

In group 1, two anastomotic dehiscences resulted in one death. Patients in group 2 had a higher rate of local recurrence (relative risk 8.0, P = 0.013) and earlier recurrence (mean(s.e.m.) 2.6(0.8) versus 7.0(1.1) years; P = 0.026) than those in group 1. Median survival was 5.8 and 4.3 years in the 18 patients of group 1 and 16 patients of group 2 (P = 0.259), and the respective 5-year survival rates were 88 and 84 per cent (P = 0.783).

CONCLUSION

Aggressive airway resection can minimize local recurrence of thyroid carcinoma with airway invasion.

Survival analyses of patients with thoracic complications secondary to bronchial carcinoma at the time of diagnosis

BACKGROUND

The impact on survival of thoracic complications secondary to bronchial carcinoma has not been clearly analyzed.

OBJECTIVES

The purpose of this study was to assess the significance of these complications for the survival of lung cancer patients.

METHODS

All patients diagnosed at our center from March 2000 to January 2004 were analyzed to estimate survival among patients with or without thoracic complication. Any intrathoracic change or abnormality secondary to bronchial carcinoma such as atelectasis or pleural effusion was defined a thoracic complication. Survival was calculated using the Kaplan-Meier method, and the complications predicting survival were evaluated using Cox's regression analysis.

RESULTS

Of the 182 eligible patients, 61.5% had at least one thoracic complication. The complications were atelectasis, pulmonary metastases, pleural effusion, laryngeal nerve involvement, vena cava superior syndrome and others. Specific survival times for each complication were not different, except in the case of atelectasis. Median survival was significantly longer in patients with atelectasis, as opposed to nonatelectatic patients. Survival times in patients with at least one complication were not different than those of patients without complication. However, median survival of patients with one of the complications, excluding atelectasis (since this was associated with improved survival), was 3 months shorter (p = 0.029). Cox's regression analysis also predicted atelectasis for improved survival.

CONCLUSION

Atelectasis, which was determined to be the most frequent thoracic complication, was identified as a favorable prognostic factor in patients with advanced stage lung cancer.

Cryosurgery for malignant endobronchial tumors: analysis of outcome

STUDY OBJECTIVES

More than 80% of patients with lung cancer are unsuitable for curative surgical treatment. Palliative relief of symptoms, often caused by airway obstruction, is very important. Endobronchial cryosurgery is used for destruction of intraluminal tumors. This study analyzes the effects of cryosurgery on patients with obstructive endobronchial carcinoma.

DESIGN

Retrospective analysis of data extracted from a prospective computerized database.

SETTING

Tertiary referral thoracic surgical center.

PATIENTS

Data of the 172 patients who underwent at least two sessions of endobronchial cryosurgery (group A) were compared with 157 patients who underwent one session of cryosurgery (group B) for malignant primary or metastatic obstructive lung carcinoma over a 5-year period.

INTERVENTION

Endobronchial cryosurgery is performed under general anesthesia. A nitrous oxide cryoprobe is inserted through a rigid bronchoscope. The probe achieves a temperature of - 70 degrees C at its tip and is applied to the tumor for two 3-min periods. Statistical analysis assessed the effects of cryosurgery on symptoms, lung function, Karnofsky performance score, and survival.

RESULTS

Symptoms of dyspnea, cough, and hemoptysis were significantly reduced in both groups after cryosurgery (p < 0.001), although group A benefited more than group B. Lung function test results improved significantly in group A. The mean Karnofsky performance score (+/- SD) increased from 67 +/- 9 to 74 +/- 10 (group A) and from 67 +/- 10 to 73 +/- 11 (group B). The mean survival was 15 months (median, 11 months) for group A and 8.3 months (median, 6 months) for group B (p = 0.006). Univariate regression analysis showed that no particular patient or tumor characteristic was associated with reduction of symptoms. Patients who had cryosurgery and external beam radiotherapy showed longer survival (p < 0.01). Females and patients with stage IIIa and IIIb tumors achieved significantly improved Karnofsky scores (p < 0.02). Female sex was also a factor for increase in FEV at 1 min (p = 0.003) and FVC (p < 0.001).

CONCLUSIONS

Cryosurgery is a safe method for palliation of endobronchial malignancies causing airway obstruction. Statistical analysis showed improvement of dyspnea, cough, and hemoptysis. Cryosurgery can be considered in patients with inoperable obstructive endobronchial carcinoma.

[Evolution of lung cancer in the North of the province of Castellón, Spain, 1993-2002]

OBJECTIVE

To investigate the changes in lung cancer incidence, histological type, and survival in patients in the north of the province of Castellón, Spain, during a follow-up period of 10 years, and to compare the findings with other national and international studies.

PATIENTS AND METHOD

All patients diagnosed with lung cancer between January 1, 1993 and December 31, 2002 were included in this prospective, observational study. Disease was confirmed by biopsy or suspected from clinical, radiological, and/or bronchoscopic findings.

RESULTS

In the study period, 271 patients were diagnosed with lung cancer (239 men and 32 women), with a mean (SD) age of 66.8 (11.8) years. The age-adjusted incidence rate standardized to the world population was 20.42 cases per 100,000 population. Smokers or ex-smokers comprised 88.1% of the study population, and 72.6% of patients were over 60 years old. Biopsy confirmation was obtained in 262 cases (96.7%). Squamous cell carcinoma predominated (46.5%) but the proportion of adenocarcinoma increased (23.6%). Surgery was possible in only 22% of the patients. Mean overall 5-year survival was 15.7 months.

CONCLUSIONS

In the north of the province of Castellón, the incidence of lung cancer continues to increase in men but has decreased slightly in women. Squamous cell carcinoma is the most common type, but the incidence of adenocarcinoma has clearly increased. Overall, survival did not improve during the 10 years of follow up despite advances in treatment.

[Survival and pattern of failure in palliative endobronchial HDR -- brachytherapy using iridium 192 in recurring bronchial carcinoma]

To evaluate the impact of palliative high dose rate brachytherapy on survival and a pattern of failure, we performed a matched pair study. 94 patients with tumor recurrence after external beam radiation received endobronchial brachytherapy. They were followed prospectively and matched retrospectively with 94 comparable patients who had not received brachytherapy. Matched parameters were age, gender, smoking behaviour, histology, tumor stage, EBRT-dose and fractionation. The leading cause of death in both groups was generalized tumor growth. In the combined therapy group, fatal hemorrage was 27.7 %, two and a half times higher than in the EBRT group with 10.6 %, whereas respiratory insufficiency in the brachytherapy group was 6.4 % and 11.7 % in the EBRT group. A complete remission after brachytherapy yielded a 10.5 months longer mean survival. Patients dying from fatal hemorrhage after endobronchial brachytherapy lived on average 10.2 months longer than matched EBRT patients dying from the same cause. Analyzing the time-course of fatal hemorrage in the brachytherapy group we conclude that - because of its early onset in the first 10 months after induction of therapy roughly 20 % of the deaths can be attributed to a radiation damage. In those patients who died after 10 months the major cause of fatal hemorrhage was the natural course of sqamous cell carcinoma with prolonged survival.

[Occupational lung cancer]

Bronchopulmonary carcinoma is the first cause of death by cancer in males, its principal cause being tobacco consumption. Nonetheless, different studies have attributed a certain, by no means negligible percent of its aetiology to the occupational exposure to agents considered carcinogenic such as asbestos, with which half of the cases of occupational lung cancer are related. Given the low survival rate of this pathology, preventive measures directed at identifying carcinogenic agents and reducing exposure to them are extremely important. Given that the clinical presentation does not differ from tobacco-related carcinoma, a high level of suspicion, based on a meticulous occupational history, is fundamental to its diagnosis. Due to the synergic effect of tobacco, measures aimed at reducing its consumption continue to be extremely important in the exposed population.

Use of the Dumon Y-stent in the management of malignant disease involving the carina: a retrospective review of 86 patients

OBJECTIVE

To study the efficacy of symptom relief and the safety of the Dumon Y-stent for central airway obstruction in malignant main carinal involvement and in malignant tracheoesophageal fistulas.

DESIGN

A retrospective review.

SETTING

Thoracic endoscopy referral center.

PATIENTS AND METHODS

The medical records of 86 patients who had undergone the placement of a Dumon Y-stent at our institution were reviewed and analyzed.

RESULTS

Ninety Dumon Y-stents were placed in 86 patients to relieve symptoms of dyspnea, cough, and/or hemoptysis. Four of these patients required removal of that stent and replacement with a longer Dumon Y-stent due to tumor progression. There were only two instances of procedure-related adverse effects, which included coughing following stent placement lasting 1 week in one patient and stent migration in another patient. In the case of stent migration, the stent required immediate removal, and the patient experienced no adverse consequences. The remaining patients tolerated the stent well, and all experienced subjective symptomatic relief. There were no stent-related deaths. The average duration of a stent after placement was 133 days. The median time of survival following stent insertion was 181 days. Forty-five percent of all patients died at 3 months, and 72% died at 6 months.

CONCLUSION

The Dumon Y-stent proved to be useful and was well-tolerated in the management of malignant disease involving the main carina. It also provided successful palliation in patients with malignant tracheoesophageal fistulas.

Expérience française du géfitinib dans le cancer bronchique non à petites cellules

INTRODUCTION

Gefitinib (Iressa, ZD 1839; AstraZeneca) is a selective Epidermal Growth Factor receptor tyrosine kinase inhibitor. In two randomized phase II trials (IDEAL 1 and IDEAL 2), it has demonstrated an activity against NSCLC, showing partial response and symptoms improvement rates respectively in about 20% and 40% of patients. Multivariate analyses revealed that being a woman, a non-smoker and having an adenocarcinoma was associated with response rate.

METHODS

We describe a retrospective study of patients receiving Gefitinib as a third line compassionate treatment of NSCLC.

RESULTS

We enrolled 37 patients (29 men, 8 women). Tumors included 25 adenocarcinoma, 4 squamous cell carcinoma, 7 large cell carcinoma, and 1 neuroendocrine carcinoma. Partial response rate was 8.1%, and stable disease rate 27.0%. The 3 responders were all non-smoker women, with an histological type of adenocarcinoma. Symptoms improvement was observed in 59.5% of patients. Main toxicities were diarrhoea and skin reactions. We observed that responding patients had more adverse drugs-related reactions than stable or non-responding patients.

CONCLUSIONS

Gefitinib is a meaningful active therapy in NSCLC with a favorable toxicity profile. We suggest that being a woman, a never-smoker and having an adenocarcinoma may be clinical predictive factors of response to Gefitinib.

[Bronchial carcinoid tumor: a retrospective analysis of 62 surgically treated cases]

OBJECTIVE

To evaluate the results of surgical treatment for lung carcinoid tumor.

PATIENTS AND METHOD

The medical records of 62 patients who underwent surgical intervention for lung carcinoid tumor between May 1985 and October 2000 were reviewed.

RESULTS

Fifty-two patients had typical carcinoid tumors and 10 had atypical carcinoid tumors. Hilar or mediastinal lymph node metastases were present in 9 patients. Distant metastasis occurred in 5 patients and was significantly more frequent in those with the atypical carcinoid histological subtype. The overall survival rate at 15 years was 70%, with a mean survival rate of 138 (SD 11) months, calculated with the Kaplan-Meier method. We found no statistically significant correlation between smoking and the development of carcinoid tumors.

CONCLUSIONS

Although carcinoid tumors behave like low-grade malignant tumors, they should be treated in the same way as other malignant lung tumors. Curative surgical resection is the technique of choice whenever possible.

Bronchial-associated lymphoid tissue lymphoma: a clinical study of a rare disease

Bronchial-associated lymphoid tissue (BALT) lymphoma is a distinct subgroup of low-grade B-cell extranodal non-Hodgkin's lymphoma, classified as marginal-zone lymphoma. This study was performed in order to assess the natural history of this rare entity. We evaluated retrospectively the clinical data of 22 patients with biopsy-proven BALT lymphoma at two tertiary-care institutions from 1996 to 2002. Immunophenotyping was done to confirm the abnormal populations of B-lymphoid cells in all cases, and clonality was determined by flow cytometry or molecular studies. There were 11 men and 11 women in the sample, median age 61 years (range 21-80 years); nine were asymptomatic at diagnosis. All 13 symptomatic patients had non-specific pulmonary complaints. On computed tomographic examination of the chest, 11 patients had bilateral disease, 12 had lung nodules, and 10 had a mass or air-space consolidation. In all but one case the disease was localised to the lung at diagnosis and none had peripheral blood or bone marrow involvement. Out of 22 patients, 20 received treatment in various combinations, 12 had chemotherapy and/or rituximab, six had surgery, and two received radiation therapy as primary treatment. A complete response (CR) was achieved in nine patients and a partial response was obtained in 10 patients. Seven of 10 patients who had unilateral disease achieved a CR. The estimated progression-free survival was 53 months. All patients were alive during the median follow-up period of 36 months (range 12-76 months). It appears that BALT lymphoma tends to be localised to lung at the time of diagnosis, responds well to local or systemic therapy, and has a favourable prognosis.

Co-expression of Cox-2 and EGFR in stage I human bronchial adenocarcinomas

Cyclooxygenase (Cox)-2 plays an important role in cell proliferation, carcinogenesis and tumor growth, in part through the synthesis of prostaglandin E2 (PGE2) as well as through other yet unknown routes. Epidermal growth factor receptor (EGFR) signaling regulates Cox-2 expression, which has not been thoroughly examined in bronchial carcinomas. The current study examined the expression of Cox-2, EGFR, P53 and proliferative marker Ki-67 immunoreactivities by immunohistochemistry in 71 surgically removed stage I bronchial adenocarcinomas. Furthermore, we evaluated the prognostic value of these molecules to elucidate the biological significance of Cox-2 expression. Higher Cox-2 expression (more than 10% immunoreactivities in tumor cells) was strongly associated with higher EGFR and P53 expression as well as a Ki-67 LI above 20% (P < 0.01). Cox-2 and EGFR immunoreactive tumor cells showed a similar distribution pattern. Five-year survival rate was 73% in 57 cases showing higher Cox-2 expression and 100% in 14 cases showing lower expression, indicating a significant difference in survival (P = 0.040). Higher Cox-2 expression might be associated with tumor progression and worse prognosis through EGFR signaling interaction in Stage I bronchial adenocarcinomas.

Bronchial carcinoid tumors: nodal status and long-term survival after resection

BACKGROUND

Bronchial carcinoid tumors show a favorable outcome. We sought to determinate the variables influencing the long-term survival of patients treated for bronchial carcinoid tumors.

METHODS

We conducted a retrospective single institutional review of 163 patients surgically treated from January 1990 to April 2002. According to 1999 World Health Organization criteria, cases were segregated into typical (<2 mitoses per 2 mm, no necrosis) and atypical carcinoids (2 to 10 mitoses per 2 mm or necrosis).

RESULTS

There were 86 men and 77 women with a mean age of 49.5 +/- 11 years. Symptoms were present in 89 patients (54.6%). Operations included 145 formal lung resections (89%), 9 wedge resections (5.52%), 8 sleeve lobectomies (4.9%), and 1 segmental resection (0.61%) plus radical mediastinal lymphadenectomy in all cases. No operative mortality was reported. Histologic examination showed 121 (74.2%) typical carcinoids (107 N0 and 14 N1), and 42 (25.8%) atypical carcinoids (15 N0, 18 N1, 9 N2). All patients were included in a follow-up (median, 54 months; mean, 58 months; range, 4 to 150 months), which included total body computed tomographic scan and bronchoscopy every year. Overall 5-year survival was 90.3% with a mean survival time of 139 months (95% confidence interval, 133 to 145). In N0 patients with either typical or atypical carcinoid tumors, no disease-related mortality was reported (100% 5-year survival). In N1 patients, 5-year survival was 90.0% for those with typical carcinoids, and 78.8% for those with atypical carcinoids (p = 0.394). In atypical carcinoids with N2 disease, 5-year survival was 22.2%.

CONCLUSIONS

Prognosis in bronchial carcinoid tumors is more related to nodal status than to histologic subtype. In N0 and N1 patients no statistical significant difference has been found between typical and atypical subtype. However, N2 bronchial carcinoid tumors show a dismal prognosis.

Bronchial carcinoid tumors: long-term outcome after surgery

The objective of the present study was to evaluate clinical condition and results of surgical treatment of patients with typical and atypical bronchial carcinoids. The study was based on retrospective analysis of a total of 96 patients (mean age 47.3 year, age range 21-76, 44 men and women 52), who were surgically treated for bronchial carcinoid between 1985-2001. We assessed symptomatology of the disease, type of surgical intervention, tumor histology and staging, and postoperative 5-year and 10 year survival rates. The main sign of disease was respiratory inflammation. The carcinoid syndrome was not found in any patient. Most patients (n=68) were operated for central form of the tumor. The micromorphological tumor diagnosis was established prior to surgery in 76.5% patients with the central form of carcinoid. Surgical treatment included lobectomy (n=49), bronchoplastic procedure (n=14), sleeve lobectomy (n=9), atypical resection and segmentectomy (n=11), pneumonectomy (n=7) and tumor enucleation (n=5). Histological analysis revealed typical carcinoid in 77 cases (80.2%) and atypical carcinoid in 19 (19.8%). Lymph nodes (N1 and/or N2) were examined by histology in 84 patients and lymph node metastases were found in 13 (19.4%) of 67 patients with typical carcinoid and in 5 cases (29.4%) of 17 with atypical carcinoid. In the postoperative period on patient died from embolism to the arteria pulmonalis. Postoperative complications (atelectasis, prolonged air leak, bronchopleural fistula) were observed in 11.4% of patients. Tumor relapse occurred only in two patients with typical carcinoid. Postoperative 5-year and 10-year rates amounted to 98.6% and 87.3%, respectively, in typical carcinoid 94.5% and 73.5% in atypical carcinoid. The survival rates of patients with typical and atypical bronchial carcinoids were not significantly different (p>0.05). The surgical management is the treatment of choice in bronchial carcinoids. Results of this study indicate that the 5-year survival in patients with either histological type of bronchial carcinoid is excellent and the prognosis of operated patients is very good even in the case of regional lymph nodes infiltration by the tumors.