Kil Dong Kim

Prognostic value of visceral pleura invasion in non-small cell lung cancer.

OBJECTIVES The purpose of this study was to clarify the prognostic significance of visceral pleura invasion in T2 non-small cell lung cancer (NSCLC). MATERIALS AND METHODS Between 1990 and 2001, 439 consecutive patients with T2 NSCLC underwent curative surgical resection. The subjects included 234 patients with stage IB, 95 with stage IIB, and 110 with stage IIIA and B disease. The patients were divided into two groups according to the existence of visceral pleura invasion (group I without, group II with). Both groups were compared with regard to tumor size, histology, associated mediastinal lymph node involvement, and survival rates. RESULTS Visceral pleura invasion (group II) was identified in 114 patients (26%), and was present in 22% of patients with NSCLC with a tumor size of 3 cm or less and in 27% of those with a tumor larger than 3 cm (P=0.37). Visceral pleura invasion was associated with a higher frequency of mediastinal lymph node involvement (group I=22%, group II=34%, P=0.009). Five- and 10-year survival rates were 50 and 45% in group I, and 36 and 22% in group II (P=0.0006). In stage IB, visceral pleura invasion was identified in 53 patients (23%), and 5- and 10-year survival rates were 63 and 60% in the visceral pleura non-invasion group, and 44 and 28% in visceral pleura invasion group (P=0.0018). By multivariate Cox model analysis, age at intervention (relative risk=1.03, P=0.0017), N status (relative risk=1.53, P<0.0001), tumor size (relative risk=1.83, P=0.0452) and visceral pleura invasion (relative risk=1.42, P=0.0291) were independent predictors of poor prognosis. CONCLUSIONS We were able to demonstrate that visceral pleura invasion was a factor of poor prognosis in T2 NSCLC. It was found to correlate with more extensive mediastinal lymph node involvement and a decreased survival rates. Therefore, the patients with visceral pleura invasion should be closely followed up especially.

Basaloid carcinoma of the lung: a really dismal histologic variant?

BACKGROUND Basaloid carcinoma of the lung has been reported as an uncommon and highly aggressive form of nonsmall cell lung cancers. Even in stage I and II of basaloid carcinoma, a 5-year survival rate of only 15% has been reported and it has been suggested that different treatment modalities for basaloid carcinoma should be considered. The aim of this study was to determine the prognostic implications of a basaloid carcinoma of the lung. METHODS This study included a series of 291 surgically resected lung tumors, which were originally diagnosed as a poorly or undifferentiated carcinoma, a small cell carcinoma, or an atypical carcinoid. Of these, 35 basaloid carcinoma patients were identified and compared with 167 poorly differentiated squamous cell carcinoma (PDSC) patients in terms of the preoperative clinical data, the procedure performed, and the survival outcome. RESULTS The overall incidence of basaloid carcinoma was 4.8%. The actuarial 5-year survival rate was 40.6% in patients with PDSC and 36.5% in those with basaloid carcinoma (p = 0.86). In stage I and II patients, the actuarial 5-year survival rate was 53.9% in the PDSC group and 57.2% in the basaloid group (p = 0.97). There were no differences in the recurrence rate and the relapse pattern (p = 0.584). Coxs proportional hazards model revealed that an age equal to 60 years old (hazard ratio 2.179, p = 0.000) and an advanced stage (hazard ratio 2.264, p = 0.000) were the risk factors for postoperative survival in both groups. CONCLUSIONS Basaloid carcinoma of the lung does not have a worse prognosis than the other nonsmall cell lung cancers. Although it is obvious that a basaloid carcinoma is a unique histologic entity, it does not require a different treatment modality due to the similar clinical behavior with other nonsmall cell lung cancers.

Validity of International Association for the Study Of Lung Cancer proposals for the revision of N descriptors in lung cancer.

Objective: This study was conducted to assess the validity of the pending suggestions for N descriptors by the International Association for the Study of Lung Cancer. Methods: Medical records from 1032 patients with non-small cell lung cancer who had pulmonary resection and proven stage I–III were retrospectively reviewed. Lymph node stations were grouped together into six “zones”: peripheral or hilar for N1 and upper or lower mediastinal, aortopulmonary, and subcarinal for N2. Survival was analyzed according to the proposed subdividing N descriptors: single-zone N1 (N1a), multizone N1 (N1b), single-zone N2 (N2a), and multizone N2 (N2b). Results: The 5-year survival rate was 63.8% for N0, 42.3% for N1a, 36.5% for N1b, 35.8% for N2a, and 17.4% for N2b. There were three distinct prognostic groups for N1 and N2 nodes: N1a, N1b or N2a, and N2b disease. In multivariate analysis, age, sex, type of surgery, T stage, and node status were independent prognostic factors. Hazard ratios versus N0 for N1a, N1b or N2b, N2b, and N3 were 1.577, 2.164, 3.291, and 5.897, respectively. Conclusion: Amalgamating lymph node stations into zones and subdividing N descriptors described a significant stepwise deterioration of disease status. Although more studies are needed, the lymph node zone and subdivided N descriptors could be one of step for desirable approach of forthcoming tumor, node, metastasis classification in non-small cell lung cancer.

The prognostic significance of multiple station N2 in patients with surgically resected stage IIIA N2 non-small cell lung cancer.

Mediastinal (N2) lymph node involvement is heterogenous with huge variation in the extent and grouped together under stage IIIA. However, they showed a different survival even in the same stage. We tried to determine the prognostic implication of the multiple station N2 lymph node metastasis in stage IIIA N2 non-small cell lung cancer (NSCLC). The survival of stage IIIA N2 was analyzed according to the number of N2 station and their survival was compared with that of stage IIIB. In stage IIIA N2 NSCLC, multivariate analysis indicated that multiple station N2 was one of the independent prognostic factors for poor survival. The 5-yr survival of multiple station N2 IIIA (20.4%) was lower than that of single station N2 IIIA (33.8%) significantly (p=0.016). but when it was compared with that of stage IIIB (15.5%), there was no difference. Therefore, we suggest that multiple station N2 should be considered similar to stage IIIB disease with regard to predicting survival and accordingly should receive a new position in the TNM staging system.

Idiopathic bronchiolitis obliterans with organizing pneumonia presenting with spontaneous hydropneumothorax and solitary pulmonary nodule.

The first case of idiopathic bronchiolitis obliterans with organizing pneumonia (BOOP) presenting as solitary pulmonary nodule with spontaneous hydropneumothorax is reported in a 54‐year‐old man. A wedge resection of the right lower lobe was performed to show typical histological features of BOOP. This case report demonstrates that BOOP has a very diverse clinical manifestation and stresses the need to include solitary pulmonary nodule with hydropneumothorax in the spectrum of BOOP.

Modified blowhole skin incision using negative pressure wound therapy in the treatment of ventilator-related severe subcutaneous emphysema

OBJECTIVES A 2-3-cm blowhole incision in the supraclavicular or infraclavicular area is widely used to eliminate the presence of subcutaneous air in cases of life-threatening subcutaneous emphysema (SE). However, when the patient is supported by mechanical ventilation, it is difficult to eliminate completely such air because mechanical ventilation leads consistently to the formation of large amounts of air. To overcome this, we applied negative pressure wound therapy (NPWT) along with blowhole incisions for the treatment of severe SE. METHODS To evaluate the feasibility of NPWT, we retrospectively analysed the clinical outcomes of 10 patients who developed severe SE during ventilator care and were treated with a modified blowhole incision using NPWT from January 2009 to November 2013. RESULTS All patients showed immediate improvement in SE after NPWT, and no symptom aggravation occurred after NPWT. The mean duration of NPWT was 7.5 ± 5.1 (range, 3-14) days, and the mean number of dressing changes was 1.5 ± 0.7 (range, 1-2). There were no blowhole-incision-related wound infections or any other complications. CONCLUSIONS While it is not necessary to apply a blowhole incision with NPWT in all cases of SE, this therapy can be helpful for patients with severe SE associated with mechanical ventilation requiring rapid decompression.

The Effect of ZD 1839 (Iressa(R)) in the Treatment of Refractory Non Small Cell Lung Cancer.

PURPOSE The aim of this study was to evaluate the efficacy and the safety of ZD 1839 (Iressa(R)) as a 3rd or 4th line chemotherapy regimen in NSCLC patients who are refractory to a previous chemotherapy regimen. MATERIALS AND METHODS Twenty-five patients who were refractory to previous chemotherapy were selected for this study. The eligible patients had an ECOG performance status of 0 to 2, and an appropriate end organ function. ZD 1839 (Iressa(R))250 mg/d was orally administered until the patients experienced disease progression or unacceptable toxicity. RESULTS Twenty-five patients were analyzed. The median age of the patients was 57 years. The response rate was 12.0% with partial responses in 3 patients. Fourteen patients (56%) remained in the stable disease state and 8 patients progressed. The median overall survival was 9.0 months (95% CI 6.7~11.2). The median progression free survival was 3 months (95% CI 2.2~3.8). Hematological toxicities of grade 3 or 4 neutropenia, anemia and thrombocytopenia were absent. Non-hematological toxicities were grade 2 or 3 skin rashes in 10 (40.0%) patients and 1 (4.0%) patient and grade 3 nausea in 3 (12.0%) patients. No patient failed to continue chemotherapy due to any drug-related adverse events. CONCLUSION The results suggest that ZD 1839 (Iressa(R)) monotherapy is effective and tolerable as a 3rd or 4th line salvage treatment for NSCLC patients refractory to previous chemotherapy regimens.

Feasibility and early outcomes of intensivist-led critical care after major trauma in the Korean ICU.

Purpose Substantial evidence supports the benefits of an intensivist model of critical care delivery. However, currently, this mode of critical care delivery has not been widely adopted in Korea. We hypothesized that intensivist-led critical care is feasible and would improve ICU mortality after major trauma. Materials and Methods A trauma registry from May 2009 to April 2011 was reviewed retrospectively. We evaluated the relationship between modes of ICU care (open vs. intensivist) and in-hospital mortality following severe injury [Injury Severity Score (ISS) >15]. An intensivist-model was defined as ICU care delivered by a board-certified physician who had no other clinical responsibilities outside the ICU and who is primarily available to the critically ill or injured patients. ISS and Revised Trauma Score were used as measure of injury severity. The Trauma and Injury Severity Score methodology was used to calculate each individual patients probability of survival. Results Of the 251 patients, 57 patients were treated by an intensivist [intensivist group (IG)] while 194 patients were not [non-intensivist group (NIG)]. The ISS of IG was significantly higher than that for NIG (26.5 vs. 22.3, p=0.023). The hospital mortality rate for IG was significantly lower than that for NIG (15.8% and 27.8%, p<0.001). Conclusion The intensivist model of critical care is feasible, and there is room for improvement in the care of major trauma patients. Although trauma systems take time to mature, future studies are needed to evaluate the best model of critical care delivery for severely injured patients in Korea.

Prognostic Factors for Disease-Free Survival in pT2N0 Non-Small Cell Lung Cancer

To clarify the prognostic factors for disease-free survival in completely resected pT2N0 non-small cell lung cancer, 81 consecutive patients who were treated between 1998 and 2001 were retrospectively reviewed. Follow-up was complete for all patients and the median follow-up time was 37.5 months. The overall 5-year survival rate was 68.6%, and the 5-year disease-free survival rate was 62.5%. Four factors (age, sex, visceral pleural invasion, and administration of tegafur and uracil) were proposed as prognostic factors for disease-free survival by univariate analysis. In multivariate analysis, visceral pleural invasion by the tumor (hazard ratio = 2.709, 95% confidence interval: 1.085 to 6.765, p = 0.033) and administration of tegafur and uracil (hazard ratio = 0.327, 95% confidence interval: 0.147 to 0.730, p = 0.006) were significant factors. Visceral pleural invasion was a prognostic factor for reduced disease-free survival in completely resected pT2N0 non-small cell lung cancer, and postoperative treatment with tegafur and uracil significantly improved disease-free survival.

Clinical Features of Pulmonary Large Cell Neuroendocrine Carcinoma

PURPOSE This study was performed to investigate the clinical features of large cell neuroendocrine carcinomas (LCNEC). MATERIALS AND METHODS We retrospectively reviewed the histopathology and clinical information of 37 patients with LCNEC, diagnosed between June 1992 and May 2002 at the Severance Hospital, and performed immunohistochemical (IHC) staining. RESULTS The prevalence of LCNEC among primary lung cancers was 0.3%, 37 out of 13, 012 cases over a 10 year period. The mean age was 61+/-12 years old, with 34 (92%) males and 3 (8%) females. 30 patients smoked, with an average of 42 packs per year. A cough was the most frequent symptom. The tumor was located at the periphery of the lung in 24 cases (65%). Among the 30 cases that underwent surgery, 4 were diagnosed pathological stage IA, 11 IB, 1 IIB, 13 IIIA and 1 IIIB. The 7 clinically non-operable cases were IIIB in 3, and IV in 4. The positive rates of CD56, thyroid transcription factor-1 (TTF-1), chromogranin A, synaptophysin and 34betaE12 for tumor cells were 88.9, 55.6, 42.1, 31.6 and 21.1%, respectively, from the IHC staining. The median survival time and 5 year-survival rate were 24 months and 27%, respectively. The group that underwent surgery had a better prognosis than those that did not. CONCLUSION The positive rates for the tumor markers varied, but those of the CD56 and TFT-1 were the highest. The possibility of LCNEC needs to be evaluated for the following situations: small cell carcinomas located at the periphery and not responding chemotherapy, small cell carcinomas diagnosed by percutaneous needle aspiration, poorly differentiated non-mall cell carcinomas, with uncertain histologic type, and unclassified neuroendocrine tumor, etc.