Teruaki Koike

Lymph Node Metastasis In Small Peripheral Adenocarcinoma Of The Lung

OBJECTIVE Our aim in this study is to clarify the clinical and pathologic features of small peripheral adenocarcinoma of the lung with special emphasis on intraoperative identification of lymph node metastasis. PATIENTS AND METHODS Between 1980 and 1996, 157 patients underwent lobectomy and complete hilar/mediastinal lymphadenectomy for small (1.1 to 2.0 cm in diameter) peripheral adenocarcinoma of the lung. The intraoperative assessment, the distribution of metastatic lymph nodes, and the association between the tumors histopathologic characteristics and lymph node metastasis were retrospectively investigated in this study. RESULTS Postoperative examination revealed lymph node metastasis in 27 (17%) patients. Lymph node metastases were not noticed during the operation in 19 of these 27 patients. Metastases were localized in single lymph nodes in 10 patients; the metastases were distributed over a segmental, a lobar, an interlobar, and a mediastinal lymph node. The prevalence of lymph node metastasis was as follows: Of 92 patients with well-differentiated adenocarcinoma, seven (8%) had lymph node metastases; of the 65 patients with other types of tumors, 20 (31%) had lymph node metastases. Of 120 patients without pleural involvement, 13 (11%) had lymph node metastases; of the 37 with pleural involvement, 14 (38%) had lymph node metastases. Five-year survivals were estimated at 91% +/- 6% (mean +/- 95% confidence interval) for 130 patients with N0 tumor and 30% +/- 22% for 27 patients with N1 or N2 tumor. CONCLUSIONS Intraoperative assessment is not reliable for identifying lymph node metastasis. Lobectomy and complete hilar/ mediastinal lymphadenectomy are necessary to determine N stage rigidly. Histologic degree of differentiation and pleural involvement are significantly associated with lymph node metastasis.

Clinical analysis of small-sized peripheral lung cancer☆☆☆★★★

OBJECTIVE In Japan, with the initiation of the lung cancer screening program, small-sized peripheral lung cancer in which the diameter is 2 cm or less has been increasing. The purpose of this study is to determine the clinicopathologic behavior of small-sized lung cancer. METHODS Four hundred ninety-six patients with cT1 N0, peripheral, resected non-small-cell lung cancer, who were operated on between 1980 and 1996, were selected, grouped by tumor diameter or histologic type, and then analyzed for clinicopathologic behavior. On the basis of measured diameter roentgenographically, the patients were divided into two groups; group c-S with lesions 2 cm or less in diameter and group c-L with lesions 2.1 to 3 cm in diameter. RESULTS Lymph node metastasis was recognized in 18% of group c-S, in 23% of group c-L, and in 21% for the entire clinical group. The rate of those with the progressive state was 19% in group c-S and 26% in group c-L. The 5-year survival was 79.5% in group c-S and 69.3% in group c-L (i.e., there was a significant difference between the two groups). CONCLUSION Compared with the patients with lesions 2.1 to 3 cm in diameter, the patients with small-sized lung cancer had a milder progressive state and a better prognosis.

Mediastinal lymph node metastasis in patients with clinical stage I peripheral non-small-cell lung cancer

Our aim in this study was to determine the mediastinal areas where lymphadenectomy should be done at the time of surgical resection of clinical stage I lung cancer. Between 1984 and 1994, 575 patients with clinical stage I non-small-cell lung cancer underwent lobectomy and systematic mediastinal lymphadenectomy. Mediastinal lymph nodes were pathologically positive for disease in 79 patients (14%), and positive nodes appeared normal intraoperatively in 54 patients (68%). Thirty-three percent of those patients with positive N2 (mediastinal) nodes had negative lobar (N1) nodes. In cancer of the right upper lobe, all N2 cases had the lymph node metastases in the superior mediastinal compartment. In cancer of the right middle lobe, all N2 cases but one had the metastases in subcarinal or anterior mediastinal nodes. In cancer of the right lower lobe, all N2 cases but one the metastases in subcarinal nodes. In cancer of the left upper lobe, all N2 cases had the lymph node metastases in the subaortic compartment. In cancer of the left lower lobe, all N2 cases but one had the lymph node metastases in the subcarinal area or subaortic compartment. In conclusion, systematic staging of mediastinal lymph nodes is necessary for all patients with resectable clinical stage I lung cancer. The location of the primary tumor determines the mediastinal areas where lymphadenectomy should be done to examine all lymph nodes.

Risk factor analysis of locoregional recurrence after sublobar resection in patients with clinical stage IA non-small cell lung cancer.

OBJECTIVE Although lobectomy is the standard surgical procedure for operable non-small cell lung cancer (NSCLC), sublobar resection also has been undertaken for various reasons. The aim of this study was to identify risk factors of locoregional recurrence and poor disease-specific survival in patients with clinical stage IA NSCLC undergoing sublobar resection. METHODS We retrospectively reviewed 328 patients with clinical stage IA NSCLC who underwent segmentectomy or wedge resection. Demographic, clinical, and pathologic factors were analyzed using the log-rank test as univariate analyses, and all factors were entered into a Cox proportional hazards regression model for multivariate analyses to identify independent predictors of locoregional recurrence and poor disease-specific survival. RESULTS The 5- and 10-year locoregional recurrence-free probabilities were 84.8% and 83.6%, respectively, and the 5- and 10-year disease-specific survivals were 83.6% and 73.6%, respectively. Four independent predictors of locoregional recurrence were identified: wedge resection (hazard ratio [HR], 5.787), microscopic positive surgical margin (HR, 3.888), visceral pleural invasion (HR, 2.272), and lymphatic permeation (HR, 3.824). Independent predictors of poor disease-specific survival were identified as follows: smoking status (Brinkman Index; HR, 1.001), wedge resection (HR, 3.183), microscopic positive surgical margin (HR, 3.211), visceral pleural invasion (HR, 2.553), and lymphatic permeation (HR, 3.223). All 4 predictors of locoregional recurrence also were identified as independent predictors of poor disease-specific survival. CONCLUSIONS Segmentectomy should be the surgical procedure of first choice in patients with clinical stage IA NSCLC who are being considered for sublobar resection. Patients having tumors presenting with no suspicious of pleural involvement would be suitable candidates for sublobar resection.

Surgical strategy for clinical stage I non-small cell lung cancer in octogenarians

OBJECTIVE The purpose of this study was to determine whether lobectomy without radical systematic mediastinal lymphadenectomy (LA) is a satisfactory alternative surgical treatment for octogenarians with clinical stage I non-small cell lung cancer (NSCLC). METHODS From April 1985 through December 2001, 49 patients aged 80 years and older who underwent surgical treatment for clinical stage I NSCLC were reviewed. Lobectomy without radical systematic mediastinal LA was performed for 27 patients (LA0 group) and lobectomy with radical systematic mediastinal LA was performed for 22 patients (LA group). RESULTS The mortality rate was 0% in the LA0 group and 4.5% in the LA group. Five-year survival rate according to the type of surgery was 44.8% in the LA0 group and 55.5% in the LA group, a difference that was not significant (P=0.88). Although there was no significant statistical difference, postoperative pulmonary complication was more frequent in the LA group than in the LA0 group (32% in the LA group versus 11% in the LA0 group P=0.07). Five-year survival rates according to serum carcinoembryonic antigen (CEA) levels were 0% for patients with elevated CEA levels (n=9) and 56.5% for patients with normal CEA levels (n=40) (P<0.01). CONCLUSION Lobectomy without radical systematic mediastinal LA appears to be a satisfactory surgical procedure for octogenarians with clinical stage I NSCLC. However, mediastinoscopy is necessary in such octogenarians if their serum CEA level is elevated so that the precise clinical stage can be determined and an accurate prognosis can be given.

Prognostic Factors in 3315 Completely Resected Cases of Clinical Stage I Non-small Cell Lung Cancer in Japan

Background: The objective of this retrospective study was to identify prognostic factors in completely resected clinical (c-) stage I non-small cell lung cancer cases. Methods: In 2001, the Japanese Joint Committee of Lung Cancer Registry collected data on the outcome and clinicopathological profiles of 7408 patients who had undergone resection for primary lung cancer in 1994. They included 3315 c-stage I patients who underwent complete resection, and in this study attempted to identify prognostic factors in the c-stage IA and c-stage IB cases. Results: The overall 5-year survival rate was 66.5%: 74.7% in the 2085 c-stage IA cases and 52.5% in the 1230 c-stage IB cases. The survival curve of the c-stage IA cases was higher than that of the c-stage IB cases. Multivariate analysis of the c-stage IA cases revealed six factors that predicted a significantly better outcome: age, gender, pathological (p-) T status, p-N status, nodal dissection, and tumor diameter (≤2 cm), and the same analysis of the c-stage IB cases revealed six factors: age, gender, p-T status, p-N status, operative procedure, and tumor diameter (<5 cm). The c-stage IA patients whose tumor diameter was 2 cm or less had a higher survival rate than the patients whose tumor diameter was more than 2 cm, and the c-stage IB patients whose tumor diameter was less than 5 cm had a higher survival rate than the patients whose tumor diameter was 5 cm or more. Conclusion: Tumor size is an independent prognostic factor for postoperative survival in c-stage I patients.

The influence of lung cancer mass screening on surgical results

BACKGROUND After the introduction of the mass screening program for lung cancer, the number of patients detected by mass screening increased as well as the number of early staged patients. Therefore, we examined the influence of lung cancer mass screening on surgical results. METHODS A total of 1177 primary lung cancer cases, who underwent surgery from 1963 to 1992, were retrospectively reviewed. They were grouped according to the changes in the mass screening system: the first period (1963-1977) before lung cancer screening started, the second period (1978-1986) when mass screening was conducted by the local government, and the third period (1987-1992) after the launching of the national screening program. RESULTS The rate of cases detected by mass screening increased over time and the 5-year survival rate improved significantly, from 33.7% in the first period, to 51.8% in the second period and finally, to 58.4% in the third period. The improvement is attributable to a relative increase of rate of stage I cases and better stage I survival rate. Specifically, in stage I cases, improvement resulted from a relative increase of stage IA in peripheral type and roentgenographically occult lung cancer cases and from better survival rate of these two groups. CONCLUSION As lung cancer screening has come into widespread use, detection of peripheral small-sized lung cancer and roentgenographically occult lung cancer have increased and consequently, surgical results have improved.

Prognosis of resected non-small cell lung cancer patients with carcinomatous pleuritis of minimal disease

OBJECTIVE The purpose of this study was to clarify the prognosis of resected non-small cell lung cancer (NSCLC) patients with carcinomatous pleuritis of minimal disease which might be considered as the next advanced stage of positive pleural lavage cytology. METHOD The data were collected from a questionnaire survey on the survival of the patients with carcinomatous pleuritis found at thoracotomy from 1985 to December 1994 which was conducted by the Japan Clinical Oncology Group (JCOG). RESULTS Out of 227 patients with carcinomatous pleuritis found at thoracotomy who had available information on a survival, 100 patients who underwent a resection of the primary tumor had carcinomatous pleuritis of minimal disease defined based on the criteria of the Japan Lung Cancer Society. The mean malignant fluid volume (+/-S.E.) was 37.1 (6.3) ml and the mean number of pleural disseminated nodules was 5.6 (0.9). A lobectomy was performed in 79 patients, a pneumonectomy in 11 and a limited resection in ten. The 3- and 5-year survival rates were 31.8 and 22.8%, respectively. CONCLUSIONS The prognosis of resected NSCLC patients with carcinomatous pleuritis of minimal disease was unexpectedly good. This indicates that no fine line may exist between positive pleural lavage cytology findings and the aforementioned lesion.

Predictive Risk Factors for Mediastinal Lymph Node Metastasis in Clinical Stage IA Non–Small-Cell Lung Cancer Patients

Introduction: Even for patients with clinical N0 non–small-cell lung cancer (NSCLC), several invasive tests are available to pathologically confirm the presumptive mediastinal stage by radiologic modalities. The aim of this study was to determine a high-risk population for mediastinal nodal metastasis in patients with clinical stage IA NSCLC, which would be suitable for mediastinal staging by invasive modalities, such as mediastinoscopy or endobronchial ultrasound-guided transbronchial needle aspiration. Methods: We retrospectively reviewed peripheral clinical stage IA NSCLC patients who had undergone surgical resection with systematic mediastinal lymphadenectomy from 1998 to 2011. To identify predictors for mediastinal nodal metastasis, univariate and multivariate logistic regression analyses were performed. For the significant factors, optimal cutoff points were determined with a receiver operating characteristic analysis. Results: Among the 894 patients eligible for this study, the overall prevalence of mediastinal nodal metastasis was 7.5%. The following four predictors for mediastinal nodal metastasis were identified: age, preoperative serum carcinoembryonic antigen level, tumor size on preoperative radiologic findings, and consolidation/tumor ratio on high-resolution computed tomography. Of the patients with all four predictors identified by the multivariate analyses and receiver operating characteristic analyses (age ⩽67 years, carcinoembryonic antigen ≥ 3.5 ng/ml, tumor size ≥ 2.0 cm, and consolidation/tumor ratio ≥ 89%), the prevalence of mediastinal nodal metastasis was 33.8%. Conclusions: Among the clinical stage IA NSCLC patients in whom all four predictors were identified, one third of the patients showed mediastinal nodal metastasis, and thus, those patients should be a target for mediastinal node assessment by invasive modalities, such as mediastinoscopy or endobronchial ultrasound-guided transbronchial needle aspiration.

Improvements in surgical results for lung cancer from 1989 to 1999 in Japan.

Background: In 1986, Japanese Association for Thoracic Surgery started a nationwide survey of the number of primary lung cancer undergoing resection and this survey was continued annually. Thereafter, investigations of lung cancer surgical results have been conducted three times. The postoperative overall 5-year survival rate was 47.8% in resected cases in 1989, 52.3% in 1994, and 62.0% in 1999, showing improvement over the decade (p < 0.01). Objective: To clarify the factors influencing survival improvements retrospectively. Patients and Methods: The subjects of the investigation are the patients who underwent resection for primary lung cancers in 1989, 1994, and 1999. Postoperatively, after 5 years, surveys of surgical results were sent to institutes where lung cancer resection had been performed. The subjects undergoing resection who provided 10 items (age, sex, pathologic T factor, pathologic N factor, pathologic M factor, date of resection, histology, curability, prognosis, and survival time) numbered 3004 in 1989, 6895 in 1994, and 12,235 in 1999. They were classified according to the Union International Contre le Cancer 1997 revised tumor, node, and metastasis classification. Differences in age, gender, histology, pathologic stage, curability, and operative death rates were analyzed for each survey year. Results: According to the changes in proportions, the cases over 70 years of age, women, and pathologic stage I increased significantly (p < 0.001), whereas in cases with small cell lung cancer, incomplete resection and operative death decreased significantly over time (p < 0.001). Conclusion: The postoperative 5-year survival rate in Japan improved between 1989 and 1999. The main cause of this improvement was the increase in early stage lung cancer, especially cases with tumors 2 cm or less in size.