Hes A.P. Brokx

Surgical Treatment for Octogenarians with Lung Cancer: Results from a Population-Based Series of 124 Patients

Introduction: With the increasing life span in the Western world, the number of octogenarians with resectable, localized non-small cell lung cancer is increasing. Previous reports on the outcome of surgery for lung cancer in octogenarians were mainly derived from single institutions. In contrast, this study presents results for all hospitals in a region of 3 million inhabitants. Methods: General data on all patients diagnosed with lung cancer in the period 1989 to 2004 were retrieved from the Amsterdam Cancer Registry. Incidence and type of treatment were tabulated and tested for significance with &khgr;2 analysis. Survival was calculated using actuarial analysis. Absolute and relative survival for octogenarians relative to other age groups and relative to other treatment modalities in octogenarians with clinical stage I/II lung cancer was performed. Results: Non-small cell lung cancer was diagnosed in 1993 octogenarians (14% of all lung cancer patients). One hundred twenty-four patients (6%) underwent surgery. Five patients died within 30 days of surgery (4%). Relative survival after 1, 2, and 5 years was 83%, 69%, and 47%, respectively. These relative survival figures are comparable with other age groups. There was a survival benefit for surgical resection versus radiotherapy and other or no treatment (relative 5-year survival of 47% versus 3% and 0%, respectively). Conclusions: Resection rates in octogenarians are low but satisfactory postoperative mortality and acceptable survival suggest that selection criteria should be adapted. Until effective alternative treatment becomes available, surgical resection, preceded by a thorough preoperative assessment, should be considered in the “old but fit” octogenarian.

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.

Detection and Staging of Preinvasive Lesions and Occult Lung Cancer in the Central Airways with 18F-Fluorodeoxyglucose Positron Emission Tomography: A Pilot Study

Purpose: To evaluate the role of 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) in radiologically occult preinvasive lesions and lung cancer in the central airways. Experimental Design: Twenty-two patients with 24 preinvasive lesions and early squamous cell cancer (SCC) being occult on high-resolution computed tomography were studied. All lesions were diagnosed based on histology sampled using autofluorescence bronchoscopy. FDG-PET findings were correlated with WHO histologic classification. FDG-PET was considered true-positive when the final diagnosis was SCC and true-negative when the lesions were classified as severe dysplasia or less. Results: FDG-PET was true-positive in 8 of 11 and true-negative in 11 of 13 cases corresponding with a sensitivity of 73% [95% confidence interval (CI), 0.43-0.91] and specificity of 85% (95% CI, 0.57-0.97). Positive and negative predictive values were 80% (95% CI, 0.48-0.96) and 79% (95% CI, 0.52-0.93), respectively. Conclusions: Our very preliminary data suggest that FDG-PET might be useful for the evaluation of early central airway lesions, being positive in most SCC and negative in cases of severe dysplasia. Validation in a larger multicenter study is needed.

Long-term follow-up after first-line bronchoscopic therapy in patients with bronchial carcinoids

Background Carcinoid of the lung is considered to be a low-grade malignancy. A subgroup presents as an endobronchial tumour. Surgical resection is considered the standard approach because of its metastatic potential and the possibility of an iceberg phenomenon for the endobronchial subgroup. Advances in non-invasive and minimally invasive technologies seem to justify a more lung parenchyma-sparing approach. Methods In patients presenting with bronchial carcinoids, initial bronchoscopic treatment (IBT) is first attempted for complete tumour eradication and sufficient tissue sampling for the proper differentiation of typical (TC) versus atypical (AC) histological type. Furthermore in cases with postobstruction problems the desobstruction is aimed at improving the patients condition and by that alleviate surgery if that is needed. High resolution CT is performed 6 weeks post IBT to determine local tumour growth. Surgical resection follows in case of extraluminal disease, residual carcinoid inaccessible for IBT, or late recurrences not salvaged by repeat IBT. Results Minimum follow-up was 5 years from start of treatment for 112 patients (65 women, 47 men), with a median age of 47 years (range 16–77 years). Eighty-three patients (74%) had TC, and 29 (26%) AC. IBT only was ultimately curative in 42% of the cases (47/112): 42 TC, 5 AC. Disease-specific mortality including surgical mortality has been 2.6% (3/112) in patients with extraluminal carcinoids (3 AC). Conclusions IBT, if with unsuccessful rescue surgery, is justifiable with excellent long-term outcome. IBT made surgery unnecessary in 42% of the cases. Iceberg phenomenon and metastatic potential in this group of patients with bronchial carcinoids are clinically insignificant.

Primary lung cancer after treatment of head and neck cancer without lymph node metastasis: Is there a role for autofluorescence bronchoscopy?

BACKGROUND Head and neck cancer (HNC) is the 5th most common cancer worldwide. As good locoregional tumor control can be achieved with current treatment strategies, patients who develop second primary tumors from field cancerization have poorer prognosis. OBJECTIVES To determine if autofluorescence bronchoscopy (AF) played a role in the detection of second primary lung cancer (SPLC), and impact of SPLC on survival of patients with HNC and no cervical lymph node metastasis (N0). METHODS Patients with HNC(N0) referred for symptoms and/or radiology suspicious for lung cancer were assessed with AF. Data on patient demographics, smoking, cancer characteristics, and outcome were prospectively collected. RESULTS Fifty-one patients (44 males) with curatively treated HNC(N0) were evaluated. Median age was 70 years, all were current or former smokers of 35 pack years, and 25 had chronic obstructive lung disease. Over a median follow up of 60 months, 8 patients were diagnosed with synchronous and 26 with metachronous SPLC. Forty-two SPLC were found; 12 (29%) affected the tracheobronchial tree and 30 (71%) involved the lung parenchyma. Median time to metachronous SPLC was 22 months. Most of SPLC were surgically resectable. Five radiographically occult lung cancers detected by AF were successfully treated with endobronchial therapy. Lung cancer mortality was 24%. HNC patients who developed synchronous and metachronous SPLCs had significantly shorter survival (51 and 144 months) compared to those without (240 months) (p=0.0005). CONCLUSION SPLC impacted negatively on the survival of patients with HNC. Close surveillance with AF and CT for SPLC combined with aggressive treatment of early stage lung cancer might be a strategy to improve outcome.

Cutting Edge without Cutting Corners: Bronchoscopic Treatment for Bronchial Carcinoids

In line with this normal tissue-sparing approach, bronchoscopic treatment has been utilized in selected patients who were either unfit to undergo surgical resection or who had too extensive disease progression and were treated in a palliative setting, for tumor located in the central tracheobronchial tree. Current understanding of tumor growth and behavior with regard to the development of local and distant disease has enabled us to consider alternative strategies that are aimed toward optimal outcome in terms of maximum preservation of quality of life. Furthermore, an increased use of minimally invasive techniques has improved our abilities for a more tailored approach and evaluation of disease processes, allowing us to consider more balanced tissue-sparing alternatives to surgical intervention. A tendency towards tissue-preserving treatment modalities, respecting oncologic principles, accounts for treatment in nearly all fields of oncology nowadays. With respect to the treatment of bronchial carcinoids, more and more authors report on ever-expanding tissue-preserving curative modalities (i.e. intraluminal bronchoscopic treatment) as sound alternatives to (immediate) surgical resection. They increasingly question the firmly based dogma that surgical resection is the only justifiable treatIn this issue of Respiration Katsenos et al. [1] report on the long-term palliation by bronchoscopic treatment of a patient with recurrent atypical carcinoid. They show that multiple recurrences of a bronchial carcinoid can be controlled with local, i.e. bronchoscopic, treatment over a long period of time. It is of special interest that although the initial treatment modality in this case was surgical resection, i.e. ‘enucleation’ as described, the tumor recurred at another site in the lungs 9 years later, making surgical resection necessary. In the course of many years of follow-up, several recurrences developed and were treated sufficiently by bronchoscopic means and by liver segmentectomy for a distant metastasis. The gold standard for treatment of bronchial carcinoids traditionally has been radical surgical resection. From an oncologic point of view, radical surgery should be regarded as the standard approach. However, more conservative resection is now considered to be an accepted strategy in the treatment of bronchial carcinoids because it is more parenchymal sparing with justifiable long-term survival results for a disease entity that may harbor a low malignant potential [2–4] . Some authors advocated more aggressive therapeutic approaches based on the classification of atypical histology [5] . Published online: January 25, 2011

Can quantifying free-circulating DNA in plasma be used to identify subjects with high-grade pre-invasive endobronchial lesions?

Increased concentrations of free-circulating plasma DNA (cpDNA) are observed in patients with invasive cancer, including lung cancer. Whether cpDNA levels are elevated in subjects with high-grade pre-invasive lesions of lung squamous cell carcinoma (SqCC) and whether its detection may be of value for identifying subjects at the highest risk of developing lung SqCC is currently unknown. The present study assessed cpDNA levels in subjects with high- and low-grade pre-invasive squamous endobronchial lesions relative to patients with clinically overt lung SqCC and healthy controls using real-time quantitative PCR methodology. The median cpDNA levels of the patients with invasive lung SqCC (n=16) were significantly higher compared with those of the healthy controls (n=16; P<0.01), whereas the cpDNA levels in the subjects with pre-invasive lesions (n=20) did not differ from those of the controls (P=0.29). The cpDNA levels in subjects with high-grade pre-invasive lesions were highly similar to those diagnosed with low-grade pre-invasive lesions (P=0.85). Our data suggest that cpDNA levels are not increased during the pre-invasive stages of lung squamous carcinogenesis.