T. Lerut

Lymph node staging in non-small-cell lung cancer with FDG-PET scan: a prospective study on 690 lymph node stations from 68 patients.

PURPOSEnTo compare the accuracy of computed tomography-(CT) scan and the radiolabeled glucose analog 18F-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) visually correlated with CT (PET + CT) in the locoregional lymph node (LN) staging of non-small-cell lung cancer (NSCLC).nnnPATIENTS AND METHODSnSixty-eight patients with potentially operable NSCLC underwent thoracic CT, PET, and invasive surgical staging (ISS). Imaging studies were read prospectively and blinded to the surgical and pathologic data. A five-point visual scale was used for the interpretation of LNs on PET. Afterwards, with knowledge of the pathology, the relationship between standardized uptake values (SUVs) and the presence of metastasis in LNs was explored in a receiver operating characteristic (ROC) analysis, and the likelihood ratios (LRs) for SUVs of LNs were determined.nnnRESULTSnISS was available for 690 LN stations. CT correctly identified the nodal stage in 40 of 68 patients (59%), with understaging in 12 patients and overstaging in 16 patients. PET + CT was accurate in 59 patients (87%), with understaging in five patients and overstaging in four patients. In the detection of locally advanced disease (N2/N3), the sensitivity, specificity, and accuracy of CT were 75%, 63%, and 68%, respectively. For PET + CT, this was 93%, 95%, and 94% (P = .0004). In the ROC curve, the best SUV threshold to distinguish benign from malignant LNs was 4.40. The analysis with this SUV threshold was not superior to the use of a five-point visual scale. The LR of a SUV less than 3.5 in an LN was 0.152; for a SUV between 3.5 and 4.5, it was 3.157; and for a SUV greater than 4.5, it was 253.096.nnnCONCLUSIONnPET + CT is significantly more accurate than CT alone in LN staging of NSCLC. A five-point visual scale is as accurate as the use of an SUV threshold for LNs in the distinction between benign and malignant nodes. The very high negative predictive value of mediastinal PET could reduce the need for mediastinal ISS in NSCLC substantially.

Three-field lymphadenectomy for carcinoma of the esophagus and gastroesophageal junction in 174 R0 resections: impact on staging, disease-free survival, and outcome: a plea for adaptation of TNM classification in upper-half esophageal carcinoma

Objective:To determine the impact of esophagectomy with 3-field lymphadenectomy on staging, disease-free survival, and 5-year survival in patients with carcinoma of the esophagus and gastroesophageal junction (GEJ). Background:Esophagectomy with 3-field lymphadenectomy is mainly performed in Japan. Data from Western experience with 3-field lymphadenectomy are scarce and dealing with relatively small numbers. As a result, its role in the surgical practice of cancer of the esophagus and GEJ remains controversial. Methods:Between 1991 and 1999, primary surgery with 3-field lymphadenectomy was performed in 192 patients, of whom a cohort of 174 R0 resections was used for further analysis. Results:Hospital mortality of the whole series was 1.2%. Overall morbidity was 58%. Pulmonary complications occurred in 32.8%, cardiac dysrhythmias in 10.9%, and persistent recurrent nerve problems in 2.6%. pTNM staging was as follows: stage 0, 0.6%; stage I, 9.2%; stage II, 27.6%; stage III, 28.7%; and stage IV, 33.9%. Overall 3- and 5-year survival was 51% and 41.9%, respectively. The 3- and 5-year disease-free survival was 51.4% and 46.3%, respectively. Locoregional lymph node recurrence was 5.2%; no patient developed an isolated cervical lymph node recurrence. Five-year survival for node-negative patients was 80.2% versus 24.5% for node-positive patients. Five-year survival by stage was 100% in stages 0 and I, 59.1% in stage II, 36.8% in stage III, and 13.3% in stage IV. Twenty-three percent of the patients with adenocarcinoma (25.8% distal third and 17.6% GEJ) and 25% of the patients with squamous cell carcinoma (26.2% middle third) had positive cervical nodes resulting in a change of pTNM staging specifically related to the unforeseen cervical lymph node involvement in 12%. Cervical lymph node involvement was unforeseen in 75.6% of patients with cervical nodes at pathologic examinations. Five-year survival for patients with positive cervical nodes was 27.7% for middle third squamous cell carcinoma. For distal third adenocarcinomas, 4-year survival was 35.7% and 5-year survival 11.9%. No GEJ adenocarcinoma with positive cervical nodes survived for 5 years. Conclusions:Esophagectomy with 3-field lymph node dissection can be performed with low mortality and acceptable morbidity. The prevalence of involved cervical nodes is high, regardless of the type and location of tumor resulting in a change of final staging specifically related to the cervical field in 12% of this series. Overall 5-year and disease-free survival after R0 resection of 41.9% and 46.3%, respectively, may indicate a real survival benefit. A 5-year survival of 27.2% in patients with positive cervical nodes in middle third carcinomas indicates that these nodes should be considered as regional (N1) rather than distant metastasis (M1b) in middle third carcinomas. These patients seem to benefit from a 3-field lymphadenectomy. The role of 3-field lymphadenectomy in distal third adenocarcinoma remains investigational.

Surgical strategies in esophageal carcinoma with emphasis on radical lymphadenectomy.

From 1975 through 1988, 257 patients with carcinoma of the thoracic esophagus have been treated in our department. Operability was 90% (232/257); overall resectability, 77% (198/257), and for the operated group, 85% (198/232). Hospital mortality rate was 9.6% but decreased to 3% over the period 1986 to 1988. There were 65% squamous cell epitheliomas and 35% adenocarcinomas. Tumor, nodes, and metastases (pTNM) staging was as follows: stage I, 11.6%; stage II, 23.2%; stage III, 37.9%; stage IV, 27.3%. Overall survival rate was 62.5% at 1 year, 42.4% at 2 years, and 30% at 5 years. According to the pTNM staging, 5-year survival was 90% for stage I, 56% for stage II, 15.3% for stage III, and 0 for stage IV. There were no statistically significant differences according to tumor localization, pathologic type, sex, or age. Introducing extensive resection and extended lymphadenectomy seems to improve significantly survival in patients in whom an operation with curative intention was performed, the 1 year survival rate being 90.8% versus 72%; 2-year survival, 81% versus 46%; and 5-year survival, 48.5% versus 41% for radical and nonradical resections, respectively. Based on multivariate Cox regression analysis, only TNM stage and presence or absence of lymph nodes are important factors in predicting survival: stage 1 tumors have lower risk, and involvement of lymph nodes creates higher risk. Using this analysis, there was only for the patients with involved lymph nodes (N1) a significantly better prognosis when a radical lymph node dissection was performed (p = 0.0055). Barrett adenocarcinomas have no worse prognosis than other esophageal carcinomas, with a 5-year survival rate of 91.5% if lymph nodes are negative, and a 54% overall 5-year survival rate. Functional results after restoration of continuity with gastric tubulation were judged excellent to very good in 86.5% at 1 year, but infra-aortic anastomoses have a much higher incidence of peptic esophagitis: 53% versus 8% for cervical anastomoses. From this study it can be concluded that in experienced hands surgery today offers the best chances for optimal staging, potential cure, and prolonged high-quality palliation.

Clinical prognostic factors in surgically treated stage IIIA-N2 non-small cell lung cancer: analysis of the literature

There remains controversy on the prognostic value of several common clinical factors in NSCLC patients with resected N2-disease. The aim of this paper is to give a comprehensive overview of the available data on this issue. Literature data on surgically treated N2-NSCLC-patients from 1980-1995, peer reviewed and listed in Index Medicus, were analysed. Reported and calculated or estimated survival data were indexed. Eighteen series were selected: in 12 of them, direct comparisons between survival curves of subgroups are reported; six contained sufficient data to make comparisons of survivors at 5 years; three of them also made a multivariate Cox model. The analysis of prognostic factors in a single study was often hampered by the limited number of patients. Nonetheless, it could be concluded that patients with a clinical N0- or N1-status (so-called unforeseen N2) do better. There was no clear difference between patients undergoing lobectomy or pneumonectomy. There was strong evidence that N2-patients with a less advanced primary tumour (T-stage) have a better prognosis, and this is the case for all operable T-stages (T1 versus T2, T1 versus T3, T2 versus T3). Squamous cell type was a favourable prognostic factor, as was the presence of only one metastatic mediastinal lymph node station or absence of metastases to the subcarinal nodes. There was some evidence that the presence of extracapsular spread in metastatic MLN is an unfavourable finding. Stratification for these prognostic factors could help in the planning of future trials on combined modality treatment in N2-NSCLC.

Warm ischemic tolerance in collapsed pulmonary grafts is limited to 1 hour

OBJECTIVEnTo determine the length of warm ischemic tolerance in pulmonary grafts from non-heart-beating donors.nnnSUMMARY BACKGROUND DATAnIf lungs could be retrieved for transplant after circulatory arrest, the shortage of donors might be significantly alleviated. Great concern, however, exists about the length of tolerable warm ischemia before cold preservation of pulmonary grafts retrieved from such non-heart-beating donors.nnnMETHODSnThe authors compared the influence of an increasing postmortem interval on graft function in an isolated, room air-ventilated rabbit lung model during blood reperfusion up to 4 hours. Four groups of cadavers (four animals per group) were studied. In group 1, lungs were immediately reperfused. In the other groups, cadavers with lungs deflated were left at room temperature for 1 hour (group 2), 2 hours (group 3), or 4 hours (group 4).nnnRESULTSnPulmonary vascular resistance was enhanced in all ischemic groups compared with the control group. An increase was noted with longer postmortem intervals in peak airway pressure and in weight gain. A concomitant decline was observed in the venoarterial oxygen pressure gradient caused by progressive edema formation, as reflected by the wet-to-dry weight ratio at the end of reperfusion.nnnCONCLUSIONSnWarm ischemia resulted in increased pulmonary vascular resistance. Graft function in lungs retrieved 1 hour after death was not significantly worse than in nonischemic lungs. Therefore, 60 minutes of warm ischemia with the lung collapsed may be tolerated before cold storage. Further studies are necessary to investigate whether lungs retrieved from non-heart-beating donors will become a realistic alternative for transplant.

Surgery for non-small cell lung cancer with unsuspected metastasis to ipsilateral mediastinal or subcarinal nodes (N2 disease)

OBJECTIVEnAlthough the results after surgery for N2 disease are disappointing, there seems to be a subgroup of patients which may benefit from primary resection. These patients have clinically unrecognized N2 involvement that is discovered only at the time of thoracotomy (unsuspected or unforeseen N2 disease). It was the aim of this retrospective study to analyze the survival after resection for unforeseen N2 disease and to evaluate different prognostic factors. We were interested to see whether our strategy of rigorous staging of the mediastinum with mediastinoscopy or anterior mediastinotomy had an effect on the resectability rate and survival of unsuspected N2 disease.nnnMETHODSnBetween 1985 and 1990, 859 patients with potentially operable non-small cell lung cancer were referred to our surgical department. Despite rigorous preoperative staging with computed tomography scan and cervical mediastinoscopy and/or anterior mediastinotomy, 103 patients (14.5%) had unsuspected N2 disease at thoracotomy. The tumor could be completely resected in 90 patients (87.5%).nnnRESULTSnThe 5-year survival after complete resection was 22%. Histology of the tumor, number of involved levels and extent of nodal disease had no effect on survival.nnnCONCLUSIONnWe conclude that resection is justified in patients with unforeseen N2 disease. Rigorous staging of the mediastinum by cervical mediastinoscopy or anterior mediastinotomy results in a high resectability rate and avoids unnecessary thoracotomies. Mediastinoscopy plays a central role in the staging of patients with carcinoma of the lung.

Early and late functional results in patients with intrathoracic gastric replacement after oesophagectomy for carcinoma

The function of the gastric substitute after oesophagectomy for carcinoma was studied retrospectively in 80 patients. At 3 months and 1 year postoperatively, a clinical and endoscopical examination was performed. A modified Visick grading of the results was used for scoring the final result. At 3 months 90% of the patients lost weight, compared with their preoperative status. At 1 year postoperatively, however, only 10% of the patients noted a further weight loss. One-fourth of the patients suffered 3 months postprandial fullness and diarrhoea, while 18% had dumping symptoms. These symptoms are mostly temporarily and disappear almost completely at 1 year. Three months postoperatively, 27% of patients had dysphagia, and 15% had heartburn and/or regurgitation. At 1 year, heartburn and/or regurgitation were increasingly reported (up to 21%), while less dysphagia was noted (15%). Early stricture requiring one or more dilatations was present in 18.7% of the patients. Five patients developed a late anastomotic stricture; 4 were located at the level of the intrathoracic anastomosis and were associated with severe oesophagitis. At 1 year there was a statistically significant difference between patients with cervical anastomosis and those with intrathoracic anastomosis when comparing reflux symptoms (4% vs. 50%; p = 0.0001) and oesophagitis (8% vs. 53%; p = 0.001). In all, 86% of patients had an excellent or very good late functional result, but only 6% of patients who underwent cervical anastomosis have a Visick score 3 or 4 vs. 23% after intrathoracic anastomosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Cancer of the esophagus and gastro-esophageal junction: potentially curative therapies

The definition of potential curative tumors of the esophagus and gastro-esophageal junction remains problematic. This is due to a lack of accuracy in clinical staging despite recent advances in CT, endoscopic ultrasonography (EUS), positron emission tomography scan and minimally invasive staging modalities. As a result much controversy persists regarding indications for surgery and extent of resection and lymphadenectomy. Today surgery with curative option results in five-year survival of over 30%. Multimodality regimens, especially neoadjuvant chemoradiotherapy, seem to be beneficial in patients with a complete response on pathologic staging. Other indications are investigational and should be studied within carefully monitored study protocols. In early carcinoma T(is)-T(1a) endoluminal ablation technique seem to open promising perspectives provided of discrimination between T(is)-T(1a) and T(1b) can be made by the use of 20mhz EUS probes.

Practical approach to patients presenting with multiple synchronous suspect lung lesions: a reflection on the current TNM classification based on 54 cases with complete follow-up.

OBJECTIVESnTo examine the survival after surgical treatment of patients presenting with two synchronous suspect lung lesions, and to reflect on the recent TNM classification, which has upgraded patients with two malignant lung lesions of the same histology into the T4 (both lesions in the same ipsilateral lobe) or M1 (different lobes or lungs) category.nnnMETHODSnRetrieval of all consecutive patients with a diagnosis of two synchronous suspect lung lesions in the prospective database of the Leuven Lung Cancer Group in the interval between 1990 and 1994. Analysis of characteristics and survival of all patients, who underwent surgical resection with intention to cure for both lesions.nnnRESULTSnForty-eight of 54 patients had surgical resection with curative intent. Thirty-five of these proved to have two malignant lesions, in 13 the second lesion was benign. The 5-year survival rate in the patients with two malignant lesions was 33% (95% CI: 17-49). The median survival time was 28 months. Although the number of patients in the subgroups was small, there were no obvious differences between patients with two lesions in the same or in different lobes, if a complete resection could be achieved.nnnCONCLUSIONSnAn aggressive surgical approach in carefully selected patients presenting with two suspect pulmonary lesions can be rewarding. Although some degree of upstaging is appropriate in patients with two malignant lung tumours of the same histology, their current stage IIIB or IV classification probably underestimates their prospects for long-term survival after radical resection.

Possible recurrence of desquamative interstitial pneumonitis in a single lung transplant recipient

Idiopathic pulmonary fibrosis (cryptogenic fibrosing alveolitis) is a disorder with a very poor prognosis for patients who do not respond to therapy with corticosteroids alone or in combination with immunosuppressive drugs, e.g. cyclophosphamide or azathioprine. For patients with end-stage disease, lung transplantation remains the only possibility for long-term survival. We describe a patient who received a left single lung transplant for end-stage desquamative interstitial pneumonitis. One year later, the patient again began complaining of exertional dyspnoea and a gradual decline in the transfer factor of the lung for carbon monoxide (TL,CO) was apparent. A recurrence of the primary disease in the transplanted lung was suspected on transbronchial biopsies. During treatment with high doses of steroids, a Pneumocystis carinii pneumonia developed, which was treated with co-trimoxazole. The patient completely recovered and, after a period of over 2 yrs, remained in an excellent condition, after which time he was lost from follow-up.