三种类型肺癌18氟脱氧葡萄糖摄取量的初步研究

目的探讨肺鳞癌、腺癌、细支气管肺泡癌对18氟脱氧葡萄糖(fluorine -18 fluorode～oxyglucose,FDG)摄取的差异以及影响肺癌摄取FDG的常见因素. 方法对82例肺癌患者行全身或肺部正电子发射体层显像(positron emission tomography,PET)检查,测定肿瘤组织FDG的标准摄取值(standard uptake value,SUV)、最大与平均标准摄取值(SUVmax、SUVmean)、正常肺组织的SUV(SUVlung). 结果 82例患者中,肿瘤组织对FDG的摄取能力均高于相应的正常肺组织(P＜0.01).肺鳞癌、腺癌、细支气管肺泡癌的SUVmax分别为8.42±4.05,5.91±3.91和 2.97±1.10;SUVmean 分别为6.12±2.90,4.35±3.10和 2.25±0.99,三者差异有显著性意义(P＜0.01).SUV与肿瘤的大小呈正相关(P＜0.01).血糖水平与正常肺组织的SUV对肿瘤的SUV有影响(P＜0.05).结论 (1)肺癌组织对FDG的摄取能力高于正常肺组织,而且不同组织类型的肺癌之间SUV值差异有显著性意义.(2)肿瘤的大小与FDG摄取量存在着正相关性.(3)临床上解释肺癌患者PET检查结果时应考虑到血糖等因素的影响.     

18-fluorodeoxyglucose positron emission tomography in predicting survival of patients with pancreatic carcinoma

The prediction of survival of patients with pancreatic cancer is usually based on tumor staging and grading and on the level of tumor markers. However, accurate tumor staging can be obtained only after resection, and still there is a great difference in survival rates among patients with the same clinicopathologic parameters. Recently the uptake of 18-fluorodeoxyglucose (FDG) by positron emission tomography (PET) has been found to be correlated with survival in patients with pancreatic cancer. This study evaluated the role of ¹⁸FDG PET as a prognostic factor for patients with pancreatic cancer. From June 1996 to July 2002, a total of 118 patients underwent PET for pancreatic cancer. The standardized uptake value (SUV) of ¹⁸FDG was calculated in 60 of them, and these patients were divided into high (>4) and low (≦4) SUV groups. They were also evaluated according to the tumor node metastasis (TNM) classification system of the International Union Against Cancer, and by tumor grade, medical or surgical treatment, diabetes, age, sex, and CA19-9 serum levels. Twenty-nine cancers showed high and 31 showed low SUVs. Survival was significantly influenced by tumor stage (P = 0.0001), tumor grade (P = 0.01), and SUV (P = 0.005). Multivariate analysis showed that only stage (P = 0.001) and SUV (P = 0.0002)were independent predictors of survival. When patients who were analyzed for SUV were stratified according to the other variables, FDG uptake was related to survival also after stratification for the following: stage III to IVa (P = 0.002), stage IVb (P = 0.01), tumor resection (P = 0.006), moderately differentiated tumors (P = 0.01), age less than 65 years (P = 0.006), CA 19–9 levels greater than 300 kU/L (P = 0.002), and absence of diabetes (P = 0.0001). The SUV calculated with ¹⁸FDG PET is an important prognostic factor for patients with pancreatic cancer and may be useful in selecting patients for therapeutic management. Presented at the Forty-Fourth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Florida, May 17–22, 2003 (oral presentation); and the Sixth National Congress of the Italian Association of Nuclear Medicine, Genoa, Italy, November 15–19, 2002.     

肺鳞癌中葡萄糖易化扩散转运蛋白-1过度表达与18 氟脱氧葡萄糖摄取的关系

目的　了解葡萄糖易化扩散转运蛋白 1(Glut1)在肺鳞癌组织中过度表达与肿瘤对18氟脱氧葡萄糖 (FDG)摄取之间的关系。　方法　 1999年 4月～ 2 0 0 1年 3月对 2 3例肺鳞癌患者行全身正电子发射体层显像 (PET)检查 ,测定肿瘤对FDG的最大与平均标准摄取值 (SUVmax与SUVmean)及健侧正常肺组织的标准摄取值 (SUVlung)。所有肿瘤均手术切除。应用标准链霉菌抗生物素蛋白 过氧化物酶亲和 (SP)免疫组织化学方法 ,对肿瘤及正常支气管肺组织的Glut1表达情况进行检测 ,以染色阳性细胞率与染色强度 (染色强度 1～ 5 )表示。　结果　 2 3例肺癌组织均有Glut1过度表达 [阳性细胞率 (6 9± 18) % ,染色强度 4 6± 0 7],正常支气管肺组织无Glut1过度表达。肿瘤FDG摄取高于相应的正常肺组织 ,SUVmax、SUVmean与SUVlung分别为 8 33± 4 14、6 10± 3 0 0与 0 38± 0 13(P <0 0 1)。Glut1过度表达程度、FDG摄取、肿瘤大小之间呈正相关性 (P <0 0 1)。结论　肺鳞癌组织中的Glut1过度表达与其FDG摄取有直接的关系。     

肺腺癌葡萄糖易化扩散转运蛋白-1过度表达与18氟脱氧葡萄糖摄取的关系

目的　探讨葡萄糖易化扩散转运蛋白 1(Glut1)在肺腺癌组织中的表达与肿瘤对18氟脱氧葡萄糖 (FDG)摄取之间的关系。方法　对 1999年 4月至 2 0 0 1年 3月收治的 2 4例肺腺癌患者行正电子发射体层显像 (PET)检查 ,测定肿瘤最大与平均标准摄取值 (SUVmax与SUVmean)及正常肺组织的标准摄取值 (SUVlung)。应用标准链霉菌抗生物素蛋白—过氧化物酶亲和 (SP)免疫组织化学方法对手术切除的肿瘤及正常支气管肺组织的Glut1表达情况进行检测 ,以染色阳性细胞率与染色强度 ( 1～ 5 )表示。结果　 2 4例肺癌组织均有Glut1过度表达 [阳性细胞率 35 %± 2 3% ,染色强度 3 7± 0 9],正常支气管肺组织无Glut1过度表达。肿瘤SUVmax、SUVmean( 5 4 6± 3 32、4 0 5± 2 5 4 )明显高于SUVlung( 0 4 3± 0 15 ,Z分别为 - 2 92 9、- 3 4 6 5 ,P均 <0 0 1)。Glut1过度表达程度、FDG摄取、肿瘤大小之间呈正相关 (P <0 0 1)。结论　肺腺癌组织有Glut1过度表达 ,并与FDG摄取相关。     

(18)F]Fluorodeoxyglucose positron emission tomography and its prognostic value in lung cancer.

OBJECTIVE: Positron emission tomography (PET) is being increasingly used as an accurate and non-invasive modality in diagnosis, staging and post-therapy assessment in patients with lung cancer. In this study, we examine whether the uptake of [(18)F]fluorodeoxyglucose (FDG), a marker of increased glucose metabolism in neoplastic cells, is of prognostic value in patients with primary lung cancer. METHODS: We have retrospectively analyzed 77 patients (mean age, 63. 0 years; male/female ratio, 53:24) with primary lung cancers who underwent whole body and localized thoracic PET as part of their diagnostic and staging procedures prior to consideration of surgical resection. The standardized uptake value (SUV) of injected FDG for each primary lesion was correlated with tumour histology and the patient's clinical outcome. RESULTS: A SUV of 20 or greater was found to be of significant prognostic value. The chance of survival (with 95% confidence intervals (CI)) at 12 months post-surgery for the various SUV groups was as follows: 75.2% (59.6-85.5) for SUV<10; 67.5% (29.0-88.2) for SUV 10-<12; 63.6% (29.7-84.5) for SUV 12-<15; 66.7% (19.5-90.4) for SUV 15-<20; 16.7% (0.01-0.52) for SUV>20. A SUV of 20 or more is associated with a 4.66 times increase in hazard, compared with lower levels of SUV. We found no significant correlation between tumour histology and SUV. CONCLUSION: We have previously reported on the significant advantages of PET in the staging and surgical care of patients with lung cancer. The present study adds further support for an additional prognostic role for PET in the management of thoracic malignancy as determined by the amount of labelled-FDG taken up by the primary lesion.     

Vascular endothelial growth factor expression in metastatic pulmonary tumor from colorectal carcinoma: utility as a prognostic factor

OBJECTIVE: To define the most reliable prognostic factor, we studied the 5-year survival of patients after resection of pulmonary metastases from colorectal cancer in relation to various prognostic factors, including vascular endothelial growth factor expression in primary and metastatic tumors. METHODS: A retrospective study was undertaken in 49 patients who had undergone complete resection of pulmonary metastasis from colorectal carcinoma. All patients were retrospectively analyzed for sex, age, location and stage of primary tumor, number of pulmonary metastases, type of pulmonary resection, size of metastatic tumor, lymph node metastasis, and prethoracotomy carcinoembryonic antigen level. Furthermore, vascular endothelial growth factor expression of both primary and metastatic tumors was investigated. RESULTS: Overall 5-year survival was 34.3%. In the univariate analysis the number of pulmonary metastases (P =.007) and vascular endothelial growth factor expression in metastatic tumors (P =.008) and primary colorectal tumors (P =.011) were significantly associated with poor survival. In the multivariate analysis the number of pulmonary metastases (P =.0031), vascular endothelial growth factor expression in metastatic tumors (P =.0057), and stage of primary tumor (P =.0321) were characteristics that retained a significant independent prognostic effect on overall survival. A statistically significant difference was not found in the 5-year survival of patients with solitary and negative vascular endothelial growth factor expression in metastatic tumors (59.1%) versus those with multiple and positive vascular endothelial growth factor expression in metastatic tumors (10.0%; P 相似文献   

Selective or routine axillary disease staging for patients with clinically lymph node-negative breast cancer?

BACKGROUND: Although sentinel lymph node biopsy (SLNB) has become the standard for patients with clinically lymph node-negative breast cancer, less than one third of patients who undergo SLNB will have lymph node metastases. Therefore, we hypothesized that a subset of patients in whom SLNB can be avoided can be identified before operation. METHODS: We prospectively studied 220 patients with early stage breast cancer who underwent SLNB. We analyzed primary tumor features, biologic markers, and demographic data. RESULTS: Overall, 31% of the patients had lymph node metastases. Although patients with lymph node metastases had larger neoplasms than patients who were lymph node negative (mean, 2.3 +/- 0.1 cm versus 1.5 +/- 0.1 cm; P < .0001), 10% of patients with T1a tumors, 19% of patients with T1b tumors, and 30% of patients with T1c tumors had lymph node metastases. Palpable tumors were lymph node positive in 41% of patients versus 17% for nonpalpable tumors (P = .0001). Lymph node metastases were seen in 71% of patients with tumor angio or lymphatic invasion versus 17% of patients without (P < .0001). Seventy-five percent of patients with an increased preoperative serum CA 27.29 had lymph node metastases, and the mean levels were greater among patients who were lymph node positive (27 U/ml +/- 2 versus 20 +/- 1; P = .0002). There was no significant association between any other demographic, histologic, or molecular feature that was investigated and lymph node metastases. CONCLUSION: We did not identify histologic, demographic, or molecular variables that can exclude the risk of associated lymphatic metastases reliably. Furthermore, not all predictive factors are known before the operation (eg, whether the tumor is T1a or T1b). Therefore, we recommend that SLNB be performed in all patients with clinically lymph node-negative invasive breast cancer.     

Prognostic significance of preoperative [18-F] fluorodeoxyglucose (FDG) positron emission tomography (PET) imaging in patients with resectable soft tissue sarcomas

OBJECTIVE: The objective of this study was to evaluate the prognostic significance of preoperative positron emission tomography (PET) using 2-fluoro-2-deoxy-D-glucose (FDG) by calculating the mean standardized uptake values (SUV) in patients with resectable soft tissue sarcomas (STS). SUMMARY AND BACKGROUND DATA: FDG-PET might be used as an adjunctive tool (in addition to biopsy and radiologic tomography) in the preoperative prognostic assessment of resectable STS. METHODS: A total of 74 adult patients with STS underwent preoperative FDG-PET imaging with calculation of the SUV. Clinicopathologic data and the SUV were analyzed for an association with the clinical outcome. The first and the third quartiles of the SUV distribution function were used as cutoff values (1.59 and 3.6). Survival was estimated by the Kaplan-Meier method. Univariate and multivariate analyses were performed using log-rank test and the Cox proportional hazards regression model. RESULTS: In 55 cases, STS were completely resected (follow up 40 months): 5-year recurrence-free survival rates in patients with SUV <1.59, 1.59 to <3.6, and > or =3.6 were 66%, 24%, and 11%, respectively (P = 0.0034). SUV was a predictor for overall survival (5-year rates: 84% [SUV <1.59], 45% [SUV 1.59 to <3.6], and 38% [SUV > or =3.6]; P = 0.057) and local tumor control (5-year rates: 93% [SUV <1.59], 43% [SUV 1.59 to <3.6], and 15% [SUV > or =3.6]; P = 0.0017). By multivariate analysis, SUV was found to be predictive for recurrence-free survival. The prognostic differences with respect to the SUV were associated with tumor grade (P = 0.002). CONCLUSION: The semiquantitative FDG uptake, as measured by the mean SUV on preoperative PET images in patients with resectable STS, is a useful prognostic parameter. SUV with cutoff values at the first and the third quartiles of the SUV distribution predicted overall survival, recurrence-free survival, and local tumor control. Therefore, FDG-PET can be used to improve the preoperative prognostic assessment in patients with resectable STS.     

18F-FDG PET在胰腺癌患者预后评估中的价值

目的 评估18F-FDG PET判断胰腺癌患者预后的价值.方法 回顾性分析54例胰腺癌病例资料.取所有病例PET检查的标准摄取值(standard uptake value,SUV)平均值4为截断点分组,A组22例(SUV≤4),B组32例(SUV＞4),分析两组患者的预后.结果 A组1、3年生存率为68.18%、34.91%;B组1、3年生存率为33.61%、11.95%,两组生存率比较差异有统计学意义(P=0.01);Cox回归分析提示肿瘤分期和SUV是胰腺癌患者预后的独立危险因素.结论 18F-FDG PET在判断胰腺癌预后方面有一定的价值.     

The relationships among clinician delay of diagnosis of breast cancer and tumor size, nodal status, and stage

BACKGROUND: The objective of this study was to determine the impact of delay of diagnosis by clinicians on breast cancer prognostic factors and survival. METHODS: The medical records of patients whose breast cancer diagnosis was delayed by clinicians were reviewed. Data collected included primary tumor diameter, number of positive lymph nodes, tumor grade, pathologic stage, length of diagnostic delay, and follow-up status. Data were analyzed for correlations between prognostic factors and length of delay. The Fisher exact test was used to correlate delay and stage with survival. RESULTS: Forty patients had delays from 3 to 36 months. There were no significant correlations between delay and natural log of primary tumor diameter (r = -.16, P = .33), number of positive lymph nodes (r = .22, P = .90), tumor grade (R = -.16, P = .36), or pathologic stage (R = -.09, P = .59). A higher stage correlated with decreased survival (P = .03), but delay did not. CONCLUSIONS: Clinician diagnostic delays of up to 36 months did not correlate with worsening prognostic factors or with survival rates.     

The prevalence and clinicopathologic correlate of p16INK4a, retinoblastoma and p53 immunoreactivity in locally advanced urinary bladder cancer

The purpose of the study was to investigate the prognostic value and clinicopathological correlate of tumor p53, p16 and Rb protein expression in patients with locally advanced urinary bladder cancer. Sixty-five patients (44 men and 21 women; 40 to 84 yrs old) with locally advanced urinary bladder cancer (21 pT2, 27pT3, 17pT4) undergoing radical cystectomy and bilateral pelvic lymph node dissection were followed up for 2 to 116 months (mean +/- SD: 30.02 +/- 6.46 months). Immunohistochemical staining for p53, Rb and p16 proteins were performed on surgically obtained, formalin fixed and paraffin embedded tissue sections. Thirty of the tumors (46.2%) were p53+, 52 of the tumors (80%) were p16- and 41 (63%) were Rb-. Only 5 of the tumors (7.7%) had normal expression of all three proteins. The tumor expression status of p53 could not be correlated with p16 (P = 1.000) or Rb (P = 1.000). Only a marginal inverse relationship was found between the expression of p16 and Rb (P = 0.056). Higher grade tumors had significantly lower percentage of p16 abnormality (P = 0.05), while higher grade (not higher stage) tumors had higher percentage of Rb abnormality (P = 0.0245). Univariate analysis showed that tumor expression of Rb or p16, alone or combined, had no predictive value on progression-free and disease-specific survival. It did, however, show a significant correlation between progression-free survival and tumor p53 and LN status (P = 0.032 and P = 0.0304) and a significant correlation between tumor stage disease-specific survival (P = 0.042). Multivariate analysis showed tumor stage and nodal status to be two significant independent indicators for progression-free survival (P = 0.0038 and P = 0.0049) and disease-specific survival (P = 0.0066 and P = 0.0484). It was also noteworthy that, after receiving postoperative adjuvant systemic M-VEC chemotherapy, patients with node-positive p53-normal tumors had significantly better progression-free and disease-specific survivals than those with node-positive p53-abnormal tumors (P = 0.036 and P = 0.0479, respectively). This study has found tumor expression of p53, p16 and Rb proteins in locally advanced bladder cancer to be frequently abnormal. Although multivariate analysis showed tumor stage and nodal status to be the only two statistically significant parameters, p53 may also serve as an additional prognostic predictor of the outcome of postoperative adjuvant systemic chemotherapy in patients with regional lymph node tumor involvement. Such patients with p53-normal tumors experienced significantly better progression-free and disease-specific survivals than those with p53-abnormal tumors.     

Histomorphologic tumor regression and lymph node metastases determine prognosis following neoadjuvant radiochemotherapy for esophageal cancer: implications for response classification

OBJECTIVE: We sought to quantitatively and objectively evaluate histomorphologic tumor regression and establish a relevant prognostic regression classification system for esophageal cancer patients receiving neoadjuvant radiochemotherapy. PATIENTS AND METHODS: Eighty-five consecutive patients with localized esophageal cancers (cT2-4, Nx, M0) received standardized neoadjuvant radiochemotherapy (cisplatin, 5-fluorouracil, 36 Gy). Seventy-four (87%) patients were resected by transthoracic en bloc esophagectomy and 2-field lymphadenectomy. The entire tumor beds of the resected specimens were evaluated histomorphologically, and regression was categorized into grades I to IV based on the percentage of vital residual tumor cells (VRTCs). A major response was achieved when specimens contained either less than 10% VRTCs (grade III) or a pathologic complete remission (grade IV). RESULTS: Complete resections (R0) were performed in 66 of 74 (89%) patients with 3-year survival rates of 54% +/- 7.05% for R0-resected cases and 0% for patients with incomplete resections or tumor progression during neoadjuvant therapy (P < 0.01). Minor histopathologic response was present in 44 (59.5%) and major histopathologic response in 30 (40.5%) tumors. Significantly different 3-year survival rates (38.8% +/- 8.1% for minor versus 70.7 +/- 10.1% for major response) were observed. Univariate survival analysis identified histomorphologic tumor regression (P < 0.004) and lymph node category (P < 0.01) as significant prognostic factors. Pathologic T category (P < 0.08), histologic type (P = 0.15), or grading (P = 0.33) had no significant impact on survival. Cox regression analysis identified dichotomized regression grades (minor and major histomorphologic regression, P < 0.028) and lymph node status (ypN0 and ypN1, P < 0.036) as significant independent prognostic parameters. A 2-parameter regression classification system that includes histomorphologic regression (major versus minor) and nodal status (ypN0 versus ypN1) was established (P < 0.001). CONCLUSIONS: Histomorphologic tumor regression and lymph node status (ypN) were significant prognostic parameters for patients with complete resections (R0) following neoadjuvant radiochemotherapy for esophageal cancer. A regression classification based on 2 parameters could lead to improved objective evaluation of the effectiveness of treatment protocols, accuracy of staging and restaging modalities, and molecular response prediction.     

Fluorodeoxyglucose positron emission tomography integrated with computed tomography to determine resectability of primary lung cancer

PURPOSE: Fluorodeoxyglucose positron emission tomography integrated with computed tomography (FDGPET/CT) was evaluated as a routine staging technique for primary lung cancer. MATERIALS AND METHODS: We prospectively compared FDG-PET/CT in determining clinical stage and surgical indication with conventional staging not including positron emission tomography (PET). A total of 50 consecutive patients diagnosed with primary lung cancer by cytological or histological examination were studied; 20 of them underwent surgery. RESULTS: Discrepancies between the two staging methods were observed in 14 patients (28%). The stage assigned by PET increased in 12 cases (24%) and decreased in 2 (4%). PET staging was accurate in eight cases with otherwise undetected distant metastases (M1) but was incorrect in six cases, including five where it overdiagnosed nodal metastases (N). Two clinical N3 patients (4%) would have missed a chance of surgery if the surgical indication had been determined by PET staging alone. According to our criteria for surgery, other patients were assigned correctly to surgery by PET staging. The maximum standard uptake value (maxSUV) of all primary lesions ranged from 0 to 23.0 (mean +/- SD, 8.0 +/- 4.4). The mean maxSUV among surgical cases (5.8 +/- 3.6) was significantly smaller than among nonsurgical cases (9.5 +/- 4.2) (P < 0.05). CONCLUSION: Staging examination including FDG-PET/CT and brain magnetic resonance imaging ordinarily can determine the clinical stage and resectability of primary lung cancer. False-positive findings in regional lymph nodes, possibly reflecting past infectious disease, are the most important remaining problem.     

Inverse correlation of microvessel density with metastasis and prognosis in renal cell carcinoma

BACKGROUND: Although a correlation between microvessel density (MVD) and tumor aggressiveness has been established for several malignancies, the data for renal cell carcinoma (RCC) is conflicting. In order to clarify the significance of MVD, we investigated the relationships between MVD and tumor stage, grade, size, occurrence of metastasis and patient survival. METHODS: Tumor specimens from 70 patients with primary renal cell carcinoma were examined by immunohistochemical staining for CD34. RESULTS: There was a tendency for MVD to decrease from G1 to G3 tumors or from stage T1 to T3 tumors, although this was not statistically significant. However, the MVD for 56 non-metastatic and 14 metastatic tumors were significantly different (P = 0.005) at 109 +/- 67 and 58 +/- 35 per x400 field (mean +/- SD), respectively. Microvessel density for 36 large and 34 small tumors was also significantly different (P < 0.0001) at 48 +/- 22 and 142 +/- 54 per x400 field, respectively. The survival rate of patients with small, low grade and hypervascular tumors was significantly higher than that of patients with large (P = 0.0015), high grade (P = 0.05) or low MVD (P = 0.039) tumors. Cox proportional hazards regression analysis showed that tumor grade and size emerged as independent prognostic factors. CONCLUSION: High MVD in RCC was inversely associated with tumor aggressiveness, but MVD was not the independent prognostic factor.     

Cholangiocarcinoma: advocate an aggressive operative approach with adjuvant chemotherapy

Cholangiocarcinoma presents many challenges. Prognosis is thought to be determined by conventional predictors of survival; margin status, pathologic criteria, stage, and comorbid disease. Ninety-four patients, 57 males and 37 females, underwent resections for cholangiocarcinoma between 1989 and 2000. Thirty-two patients (34%) had distal tumors, 10 had midduct lesions, and 52 had proximal/intrahepatic lesions. Thirty-four patients underwent pancreaticoduodenectomies, 23 bile duct resections alone, and 37 bile duct and concomitant hepatic resections. Tumor location did not influence mean survival (distal, 28 months +/- 23; midduct, 28 months +/- 21; and proximal, 31 months +/- 36). Operation undertaken did not alter survival (bile duct resection, 30 months +/- 37; pancreaticoduodenectomy, 27 months +/- 23; and concomitant bile duct/hepatic resection, 32 months +/- 32). TNM stage failed to predict survival: 5 stage I (29 months +/- 22), 12 stage II (41 months +/- 33), 12 stage III (33 months +/- 19), and 64 stage IV (27 months +/- 32). Tumor size did not influence survival: T1-2 (32 months +/- 33) versus T3-4 lesions (29 months +/- 25). Mean survival with negative margin (n = 67) was 34 months +/- 33, whereas microscopically positive (n = 13, 23.9 months +/- 25) or grossly positive (n = 14, 20.4 months +/- 20) margins were predictive of significantly shorter survival (P < 0.03). Adjuvant treatment (n = 41) was associated with significantly longer survival (40.5 months +/- 36) than those who received no further therapy (n = 53; 24 months +/- 24) (P = 0.05). TNM stage, tumor size, operation undertaken, and location were not associated with duration of survival after resection. Margin status was associated with duration of survival, though extended survival is possible even with positive margins. Advanced stage should not preclude aggressive resection. Without specific contraindications, an aggressive operative approach is advocated followed by adjuvant therapy.     

T2 tumors larger than five centimeters in diameter can be upgraded to T3 in non-small cell lung cancer.

OBJECTIVE: Among the TNM criteria, tumor size is a well-assessed factor in the prognosis of small tumors. A 3-cm cutoff point separates T1 from T2 tumors, whereas a size larger than 3 cm is not ascribed any prognostic value. Instead, N2 is considered to be the worst prognostic factor for intrathoracic extended disease. METHOD: The prognosis of 545 patients with non-small cell lung cancer larger than 3 cm in diameter (T2, T3, and T4) was studied. These tumors were completely resected by pneumonectomy (n = 126) or lobectomy (n = 411) or were partially resected (n = 8). Survivals were compared according to the following factors: tumor size (3.1-5 cm, 5.1-7 cm, >7 cm), nodal status, age, sex, histologic type, degree of pleural involvement, operative procedure, stage, and T factor. For the multivariate analysis, the Cox proportional hazard model was used with the same variables. RESULTS: The univariate analysis showed that age, sex, degree of pleural involvement, operative procedure, tumor size, nodal status, and stage were all significant prognostic factors. Further comparison of survival between different tumor sizes (< or =5 cm vs >5 cm) in the same nodal category demonstrated a significantly poor prognosis for larger tumors in N0 (P =.00374) and N2+N3 (P =.0157), but not in N1 (P =.3452). T2 tumors (n = 349) were divided, according to size, into T2a (n = 238) and T2b (n = 111), and survival was compared with those in T3 and T4. The 5-year survivals were 51.3%, 35.1%, 47.8%, and 25.3%, respectively. The difference between T2a and T2b was statistically significant (log-rank P =.0170, Breslow P =.0055). CONCLUSIONS: A tumor size of more than 5 cm in diameter was indicative of a poor prognosis in non-small cell lung cancer, because patients with T2b tumors had a significantly different survival from that of patients with T2a tumors, and the survival curve was located between those for patients with T3 and T4 tumors. Consequently, T2b might be upgraded to at least T3.     

The risk of second primary tumors after resection of stage I nonsmall cell lung cancer

BACKGROUND: The incidence of second primary lung cancers (SPLC) after resection of nonsmall cell lung cancer (NSCLC) is estimated to be 1% to 4% per patient year. The overall effect of SPLC on survival after resection of stage I NSCLC is unknown. Here we report the incidence, management, and outcome of SPLC in a large prospective cohort of patients who underwent careful follow-up. METHODS: National Cancer Institute Intergroup Trial NCI #I91-0001 examined the effectiveness of isotretinoin A for chemoprevention of second primary tumors, the primary endpoint in that trial. Prospective data from patients randomly assigned to the placebo arm were analyzed. RESULTS: Five hundred sixty-nine patients underwent complete resection of pathologic stage I NSCLC. The median follow-up was 5.9 years. Second primary tumors developed in 88 (15%) patients. Of these, 49 (56%) were SPLC (incidence = 1.99/100 patient-years), with a median interval from initial surgery of 4.2 years. Second primary lung cancer never developed in patients who had never smoked (n = 44, p = 0.046; never versus ever smokers). Current smokers had a higher incidence of SPLC than former smokers (hazard ratio = 1.91, p = 0.03). Age, sex, stage, histology, tumor location and initial surgery had no effect on SPLC development. Despite semiannual follow-up with chest radiographs, 12 (24%) patients had metastatic disease at the time of diagnosis of SPLC. Surgical resection was performed in 31 (63%) SPLC patients. Median survival was 4.1 years in those who underwent surgery and 1.4 years in those who did not (p = 0.003). Overall SPLC-related mortality in the original cohort was 3.7%. CONCLUSIONS: Patients who undergo surgery for SPLC can achieve prolonged survival. Despite close follow-up however many patients with SPLC present with advanced disease. That indicates a need for continued lifelong postoperative surveillance.     

Clinicopathologic analysis of small-sized non-small cell lung cancer

We reviewed the data on 149 patients who underwent complete resection for small-sized (≤ 2 cm)peripheral non-small cell lung cancer at our institution between January 2002 and July 2010. Patients with small-sized lung cancer underwent a lobectomy in 121, segmentectomy in 13, and wedge resection in 15 cases. The overall and 5-year disease-free survivals were 89% and 82%, respectively. The 5-year disease-free survival of patients with tumors exceeding 1.5 cm was lower than that of patients with tumors 1.5 cm or smaller (p=0.01). The 5-year disease-free survival for patients without pleulal invasion was 87%, whereas it was 45% for those with pleulal invasion (p=0.004). The 5-year disease-free survival according to the serum level of carcinoembrionic antigen( CEA) were 82% for the normal group and 70% for the high group( p=0.007). Although the results were not significantly different, patients with tumors with high maximum standardized uptake value (SUV) on FDG-PET/CT showed a trend toward a lower 5-year disease-free survival rate( p=0.10). There were no recurrences in patients with ground-glass opacity (GGO) or GGO-dominant lesion including those who underwent sublober resection. Multivariate analysis showed that tumor size and pleural invasion were independent prognostic factors. Indication of sublober resection for solid-type small-sized non-small cell lung cancer (NSCLC) should be carefully determined considering tumor size, pleural involvement, serum carcinoembryonic antigen( CEA) level, and maximum SUV.     

Renal cell carcinoma: prognostic significance of incidentally detected tumors

PURPOSE: We determined the prognostic significance of incidentally discovered renal cell carcinoma in the era of increased incidental detection. MATERIALS AND METHODS: We reviewed the records of 633 consecutive patients who underwent radical or partial nephrectomy for renal cell carcinoma at our institution between 1987 and 1998. Patients were divided into those who were asymptomatic and tumor was diagnosed incidentally and those diagnosed after presenting with any of the classic symptoms of renal cell carcinoma or subsequent metastasis. All renal cell carcinoma lesions were assigned a stage and grade according to 1997 TNM criteria. All patients were followed postoperatively to assess survival rates, and monitor recurrence and metastasis. RESULTS: Of the 633 patients 95 (15%) were treated for incidentally discovered renal cell carcinoma and 538 (85%) presented with symptoms secondary to renal cell carcinoma at diagnosis. Patient age and sex distribution were similar in the 2 groups. Stage I lesions were observed in 62.1% of patients with incidental renal cell carcinoma and in 23% with symptomatic renal cell carcinoma. In contrast, stage IV lesions were present in 27.4% of patients with incidental versus 54% with symptomatic renal cell carcinoma. Thus, incidental lesions were of significantly lower stage than those causing symptoms (p <0.001). Similarly 15.8% of incidental but 42.4% of symptomatic lesions were grade 3 or 4 (p = 0.006). Patients were followed postoperatively for a mean of 47 months plus or minus 40 months. The 5-year cancer specific survival rate was significantly higher for incidental than for symptomatic tumors (85.3% versus 62.5%). Likewise, the local and distal recurrence rates were higher for symptomatic lesions. When adjusted for stage, no difference in survival was noted in the 2 groups for stages I to III disease and a minimally significant difference was noted for stage IV cancer. Multivariate analysis of stage and grade attributed the survival difference in stage IV disease to the significantly higher grade of symptomatic lesions. CONCLUSIONS: At presentation incidental tumors are of significantly lower stage and grade than tumors producing symptoms. Subsequently these clinically and histologically less aggressive lesions lead to better patient survival and decreased recurrence. Thus, the detection of renal cell carcinoma before symptom onset enables treatment of less aggressive tumors and provides a better prognosis for patients. Given these data efforts should be directed toward the development of a screening protocol to detect these lesions early, so that they may be prevented from progressing to the point when symptoms are apparent and prognosis becomes worse. In addition, the significant correlation of tumor grade with survival in our study further demonstrates the prognostic value of tumor grade and molecular markers for the future evaluation and treatment of renal cell carcinoma.