Surgical treatment of non-small cell lung cancer 1 cm or less in diameter

BACKGROUND: Routine lung cancer screening does not currently exist in the United States. Computed tomography can detect small cancers and may well be the screening choice in the future. Controversy exists, however, regarding the surgical management of these small lung cancers. METHODS: The records of all patients were reviewed who underwent resection of solitary non-small cell lung cancers 1 cm or less in diameter from 1980 through 1999. RESULTS: The study included 100 patients (56 men and 44 women) with a median age of 67 years (range 43 to 84 years). Lobectomy was performed in 71 patients, bilobectomy in 4, segmentectomy in 12, and wedge excision in 13. Ninety-four patients had complete mediastinal lymph node dissection. The cancer was an adenocarcinoma in 48 patients, squamous cell carcinoma in 26, bronchioloalveolar carcinoma in 19, large cell carcinoma in 4, adenosquamous cell carcinoma in 2, and undifferentiated in 1. Tumor diameter ranged from 3 to 10 mm. Seven patients had lymph node metastases (N1, 5 patients; N2, 2 patients). Postsurgical stage was IA in 92 patients, IB in 1, IIA in 5, and IIIA in 2. There were four operative deaths. Follow-up was complete in all patients and ranged from 4 to 214 months (median 43 months). Eighteen patients (18.0%) developed recurrent lung cancer. Overall and lung cancer-specific 5-year survivals were 64.1% and 85.4%, respectively. Patients who underwent lobectomy had significantly better survival and fewer recurrences than patients who had wedge excision or segmentectomy (p = 0.04). CONCLUSIONS: Because recurrent cancer and lymph node metastasis can occur in patients with non-small cell lung cancers 1 cm or less in size, lobectomy with lymph node dissection is warranted when medically possible.     

Intentional limited resection for lung adenocarcinoma of 2 cm in size or less according to intraoperative frozen section and high-resolution computed tomography

One hundred twenty-six cases of resected lung adenocarcinoma of 2 cm in size or less were studied about intra and postoperative Noguchi's classification, high-resolution computed tomography (HRCT) findings and lymph node metastases in cases of lobectomy. Intentional limited resection for lung adenocarcinoma of 2 cm in size or less was recommended for selected patients with tumors of type A of Noguchi's classification diagnosed by intraoperative frozen diagnosis or tumors of intraoperative type B of 0.5 in ground-glass opacity (GGO) diameter ratio or more of HRCT. These patients are almost equal to patients of 0.5 in GGO diameter ratio or more with any type of Noguchi's classification. This GGO diameter ratio of 0.5 is easily available as a criteria of intentional limited resection for lung adenocarcinoma of 2 cm in size or less.     

Video-assisted thoracic surgery for pure ground-glass opacities 2 cm or less in diameter

BACKGROUND: Small, well-circumscribed pure ground-glass opacities on high-resolution computed tomography can represent either localized bronchioloalveolar carcinoma without foci of active fibroblastic proliferation, or atypical adenomatous hyperplasia. Since neither lesion displays lymph node metastasis, excellent prognosis can be expected even with limited surgical resection. In this study, video-assisted thoracic surgery was performed for patients with pure ground-glass-opacity to evaluate efficacy for both diagnostic and therapeutic purposes. METHODS: Thirty-nine patients with pure ground-glass opacity less than or equal to 2 cm in diameter (62 lesions) underwent video-assisted thoracic surgery with wedge resection as primary therapy. Histologic diagnoses were made according to Noguchi classifications. RESULTS: Single lesions were observed in 30 patients, with multiple lesions (mean, 4 lesions) in 9 patients. Twenty-eight patients underwent wedge resection. Seven patients underwent lobectomy or segmentectomy for technical reasons. Four patients underwent conversion of wedge resection to lobectomy (due to active fibroblastic proliferation in 2 patients, and other reasons in 2 patients). All procedures were performed under videoscopic observation. Histologic diagnoses comprised localized bronchioloalveolar carcinoma without active fibroblastic proliferation either alone or in combination with atypical adenomatous hyperplasia in 29 patients, atypical adenomatous hyperplasia in 8 patients, and localized bronchioloalveolar carcinoma with active fibroblastic proliferation in 2 patients. All patients with localized bronchioloalveolar carcinoma underwent follow-up for a median period of 29.3 months, and have survived without sign of recurrence. CONCLUSIONS: Video-assisted thoracic surgery may be appropriate for management of small pure ground-glass opacities.     

2 cm以下的胰头癌的临床特点和外科治疗

目的:探讨瘤径<2cm胰头癌的临床病理学特点和外科治疗效果。方法:回顾性整理我院普外科1996年1月至2004年12月收治的48例瘤径<2cm胰头癌的临床资料,并结合随访情况进行分析。结果:本组48例,男29例,女19例,年龄30～83岁。均行胰十二指肠切除术,其中3例合并肠系膜上静脉切除重建术,10例合并区域淋巴结清扫。病理检查:肿瘤直径均2cm以下;其中管状腺癌45例,乳头状腺癌2例,腺鳞癌1例。有淋巴结转移者17例,胰周神经侵犯者25例。随访表明,无淋巴结转移和胰周神经侵犯病例的术后平均生存期(28.7±16.8个月),比淋巴结阳性和(或)有胰周神经侵犯者明显延长。结论:<2cm的胰头癌超过半数以上存在淋巴结转移和神经侵犯,而两者均是影响预后的重要因素。应求扩大淋巴结清扫范围和广泛的腹膜后软组织切除以获得阴性切缘。     

Clinicopathological study of small lung cancer (diameter of 2 cm or less) by uptake value of 18F-fluorodeoxyglucose

18F-fluorodeoxyglucose (FDG)-positron emission tomography (PET) for lung cancer may be a biomarker for malignancy as well as a useful tool for detection of nodal involvement and distant metastasis. The goal of this study was to clarify a relationship between clinicopathological findings and maximum standardized uptake value( SUVmax) obtained by preoperative PET in patients with non-small cell lung cancer in diameter of 2 cm or less. Between January 2008 and April 2011, 124 patients( 54 men and 70 women) with non-small cell lung cancer in diameter of 2 cm or less undergoing lobectomy or segmentectomy were enrolled. The relationship between SUVmax and clinicopathological findings as tumor diameter, histological type, pleural invasion, vascular invasion, lymphatic permeation and nodal involvement were analyzed. Correlation between SUVmax and findings such as vascular invasion and lymphatic permeation showed relatively strong in the patients with adenocarcinoma, on the contrary to the correlation in the patients with non-adenocarcinoma. No tumor showing SUVmax of 2 or less showed vascular invasion and/or lymphatic permeation as well as nodal involvement in any patients with adenocarcinoma. SUVmax of the primary tumor in diameter of 2 cm or less, can be a useful biomarker which indicates a surgical candidate for sublobar pulmonary resection as well as mediastinal nodal dissection, especially in patients with adenocarcinoma.     

Surgical management for lung cancer in less than 1 cm

Recently, the greater utilization of computed tomography (CT) has led to an increasing proportion of small-sized stage I A lung cancer in less than 1 cm in diameter. However, a treatment strategy for these small-sized lung cancers has not yet been defined. The aim of this study was to investigate surgical outcomes regarding these lung cancers. A total of 123 patients who underwent complete surgical resection for lung cancer in less than 1 cm between January 1995 and March 2010 were retrospectively evaluated. The 123 study subjects consisted of 54 male and 69 female patients. The mean age was 64.0 (43~82) years. The mean tumor size was 0.9( 0.3~1.0) cm. In this study, 70 patients underwent lobectomy (56.9%). Segmentectomy and wedge resection were underwent 23( 18.7%) and 30 patients( 24.4%), respectively. The 3-, 5- and 10-year survival rates were 95.7, 92.3 and 85.7%, respectively, after the operation for lung cancer in less than 1 cm. There were no significant difference between sublobar resection and lobectomy. However, 2 patients( 1.6%) had recurrent cancer and 7 patients (5.7%) had lymph node metastasis. We suggested surgical procedure for patients with lung cancers in less than 1 cm should be selected with the greatest care, because recurrent cancer and lymph node metastasis can occur in patients.     

微小肝癌的经皮消融疗效观察

目的评估经皮消融治疗微小肝癌的临床疗效。方法2003年7月至2006年7月，对中山大学附属第一医院肝胆外科收治的单个结节直径≤2cm的33例微小肝癌病人行超声引导经皮消融，视肿瘤所在部位分别采用水冷式低杆温微波消融或多极无水酒精消融，每个肿瘤治疗1次。结果肿瘤完全消融率为93．9％，局部复发率9．1％，远处复发率33．3％，1年、2年和3年无瘤存活率分别为62．6％、62．6％和62．6％，总存活率84．0％、74．5％和63．9％。单因素预后相关分析显示甲胎蛋白基线水平与无瘤存活率显著相关，甲胎蛋白、治疗后远处复发与总存活率显著相关。多因素相关分析显示甲胎蛋白和远处复发是影响总存活率的独立危险因子。结论经皮消融对微小肝癌疗效良好，病人的甲胎蛋白基线水平和治疗后远处复发是影响预后的重要因素。     

早期肾癌保肾手术切除范围的探讨

目的　探讨直径 4cm以下肾癌保肾手术的安全切除范围。　方法　直径≤ 4cm肾癌根治术标本 82例 ,标本分层切开 ,确定多中心病灶 ,假包膜外 15mm范围连续取材确定假包膜完整性及可能存在的假包膜外癌性浸润灶 ,并测量包膜外癌灶与原发灶的最大距离。采用免疫组织化学技术检测 41例直径≤ 4cm肾癌的增值细胞核抗原 (PCNA)蛋白表达 ,其中假包膜外癌灶阳性组 8例 ,阴性组 3 3例。　结果　 82例肾癌平均直径 (3 4± 0 8)cm (1 5～ 4 0cm)。其中 3 1 7% (2 6/82 )缺乏完整假包膜 ,17 1% (14/82 )存在 1种以上假包膜外癌灶 ,其中肾实质浸润 8例 ,小静脉癌栓 2例 ,多中心病灶 4例。假包膜外癌灶与原发灶距离平均 (0 5± 1 3 )mm ,95 %可信区间 (0 11,0 94)。取单侧百分位数P95为 4 9mm ,P97 5、P10 0 均为 5 0mm。 41例肾癌平均PCNA指数为 (2 9 5± 17 6) % (5 5 %～85 6% ) ,其中阳性组为 (49 6± 2 1 5 ) % ,明显高于阴性组 (2 4 6± 12 7) % (t=3 162 ,P =0 0 13 )。阳性组 8例中 ,PCNA高表达 5例 ,而阴性组 3 3例中 ,高表达率仅 18 2 % (6/3 3 ) ,(χ2 =6 44 2 ,P =0 0 11)。结论　直径≤ 4cm肾癌保肾手术安全切缘须包括假包膜外 5mm以上的正常肾实质。单纯肿瘤剜除术易造成肿瘤残留及局部复发     

Indication of limited pulmonary resection for small-sized lung cancer based on preoperative clinical data

Limited pulmonary resection is performed mostly based on the size of lung cancer and ground-glass opacity (GGO). It has been proposed to determine the indication of segmentectomy according to hilar lymph node involvement. There is a potential risk of underestimation for lymph node involvement since there may be a skip mediastinal lymph node metastasis without hilar involvement. We propose to use standardized uptake value( SUV) max of primary lung cancer as an indicator of non-invasive lung cancer. None of 44 small-sized lung cancers with SUVmax lower than 1 had lymph node metastasis or vessel invasion. A small-sized lung cancer ≤ 2 cm with SUVmax ≤ 1 is indicated wedge resection if GGO area is greater than 75% of tumor. Segmentectomy is indicated if the GGO area is less than 75%. We also propose selective lymphadenectomy for small-sized lung cancer. The lower mediastinal lymphadenectomy may be omitted if a small-sized tumor is located in the right upper lobe or the left upper segment. The upper mediastinal lymphadenectomy may be omitted if a small-sized lung cancer is located in the lower lobe and if the lower mediastinal lymph node involvement is excluded.     

Clinicopathological features of peripheral small-sized (2 cm or less in diameter) non-small cell lung cancer

Ninety-three patients with completely resected peripheral non-small cell lung cancer, clinically diagnosed 2 cm or less in diameter, were retrospectively reviewed. Their preoperative computed tomography (CT) and positron emission tomography (PET) findings, carcinoembryonic antigen (CEA) values, clinico-pathological features and postoperative outcomes were analysed. Ground-glass opacity (GGO) ratio( soft tissue density area of the tumor/maximum area of the tumor in diameter) was measured. The overall survival rate at 3 years was 93.3% and the relapse-free survival rate at 3 years was 89.4% with a median follow-up period of 38.5 months. Patients with GGO ratio 0.25 or less had no lymph node (LN) involvement nor lymph vascular invasion. Only 2 of them (8%) had vascular invasion. Fisher's exact probability test revealed CEA ≥ 5 ng/ ml as risk factor for LN involvement( p=0.0400). Multiple logistic regression analysis showed that solid adenocarcinoma and squamous cell carcinoma recurred more frequently than adenocarcinoma with GGO (p=0.0619, odds ratio 4.969, 95%CI 0.9242~37.67).     

Surgical results of small sized (less than 3 cm) advanced lung cancer]

We studied the surgical results in 31 patients with small sized but advanced lung cancer. Twenty-two patients had mediastinal lymph node metastasis, 6 had pulmonary metastasis, 3 had pleural dissemination. Histological type were adenocarcinoma in 21 patients, large cell carcinoma in 5 patients, small cell carcinoma in 4 patients. The 5-year survival rate in patients with mediastinal lymph node metastasis (pT1N2) was 24.1%. The 5-year survival rate in patients (pT1N2) for clinical N0, N1 was 34.6%, but no patient with clinical N2 disease survived more than 2 years after the operation. In the patients with pulmonary metastasis or pleural dissemination none survived more than 5 years after the operation.     

Indication and results of thoracoscopic segmentectomy for small peripheral lung cancer

Since 2008, 46 patients have undergone thoracoscopic segmentectomy without mini-thoracotomy for almost pure ground-glass opacity (GGO) lesion by thin-section computed tomography (CT) finding which was difficult to be performed wedge resection. No patient was converted to both thoracotomy and lobectomy. The operation time ranged from 75 to 240 min (mean, 161 min), and blood loss ranged from 1 to 110 g( mean, 25 g). We used stapler in 29 patients and electrocautery in 17 patients to deviate inter segmental plane. Postoperative complications were seen in 6 patients (13%), major complication was air leakage in 6 patients. There was no in-hospital mortality. Only 1 patient had bone metastasis on 11 months after operation. Thoracoscopic segmentectomy considered to be a safe and feasible procedure for the selected patients with small-sized peripheral lung cancer.     

Strategy for lymphadenectomy in lung cancer three centimeters or less in diameter

We have surgically treated 221 patients with a primary lung cancer 3.0 cm or less in diameter. There were 8 patients with a tumor 1.0 cm or less in diameter (group A), 84 with a tumor 1.1 to 2.0 cm in diameter (group B), and 129 with a tumor 2.1 to 3.0 cm in diameter (group C). The incidence of N0, N1, and N2 disease was 100%, 0%, and 0%, respectively, for patients in group A; 83%, 5%, and 12% in group B; and 62%, 12%, and 25% in group C (N0 versus N2, p less than 0.01). For the 63 patients with regional lymph node involvement, "skipping" metastasis was present in 28.6%. The 5-year survival rate was 80% for group A, 74% for group B, and 51% for group C (group B versus group C, p less than 0.01). Of the 121 patients who underwent complete resection and were followed up for 5 years, 41% had recurrence, 8% with local recurrence and 33% with distant metastasis. Therefore, it is important to do as complete a resection as possible together with mediastinal lymphadenectomy. Efforts to detect systemic spread should be made at the time of preoperative evaluation, even when the lung tumor is small.     

Surgical indications for small advanced lung cancer: especially from resected cases of peripheral non-small cell lung cancer less than 2 cm in diameter]

During the period from 1978 to 1987, 30 cases of peripheral non-small cell lung cancer with primary lesions less than 2 cm in diameter were resected at our hospital. Histopathologically, these cases consisted of 24 adenocarcinomas, 5 squamous cell carcinomas and one adenosquamous carcinoma. Twenty-one cases were in early stages (p-stage I) and 9 in advanced stages (6 p-stage IIIA, one p-stage IIIB and 2 p-stage IV). Serum levels of CEA in the advanced stages exceeded those in the early stages. However, clinically no cases of the advanced stages are being assessed preoperatively. Thus, for cases of small peripheral lung cancer less than 2 cm, the possibility of advanced stages should be considered and for the complete cure of lung cancer, mediastinal lymph nodes dissection with lobectomy and appropriate adjuvant chemotherapy should be conducted.     

A study of high-resolution computed tomography (HRCT) findings of resected small pulmonary nodules 2 cm or less in diameter with reference to the malignant nature

To identify the characteristics of peripheral small lung mass lesions on high-resolution computed tomography (HRCT) and discriminate between malignant and benign, 223 mass lesions 2 cm or less resected surgically were evaluated about following points. 1) Density : 90.7% of lesions with mixed solid and ground-glass opacity (GGO) components were adenocarcinomas. Pure GGO lesions without scale-down between several months were all adenocarcinomas or atypical adenomatous hyperplasia (AAH). Thereby, patients with these findings are good candidates for surgical resection. 2) Spicular or pleural indentation :75.2% (88 of 117 cases) of adenocarcinomas and all squamous cell carcinomas (18 cases) showed these findings, but 26.6% (41 of 154 cases) of positive cases were benign lesion (non-specific inflammation, mycobacterisis, and so on). Accordingly, they are not peculiar to malignancy. 3) Satellite lesion : all lesions with this one showed benign, therefore it was thought that this finding could exclude malignant lesion. Thus, recognition of certain characteristics at HRCT can be helpful in discrimination between small malignant mass and benign mass.     

Nodal occult metastasis in patients with peripheral lung adenocarcinoma of 2.0 cm or less in diameter

Background. Detection of occult micrometastasis in regional lymph nodes is crucial for diagnosis and selection of appropriate therapy for patients with pN0 nonsmall-cell lung carcinoma. Using immunohistochemical staining, we evaluated the impact of detection of occult micrometastasis on the prevalence and prognosis of patients with lung adenocarcinoma of 2.0 cm or less in diameter.

Methods. A total of 103 pN0 disease patients with peripheral lung adenocarcinomas of 2.0 cm or less in diameter were enrolled in this study. We studied 1,438 regional lymph nodes for occult micrometastasis by immunohistochemical staining for cytokeratins.

Results. Micrometastasis was detected in 49 lymph nodes (3.4%) of 21 patients (20.4%) but not in patients with localized bronchioloalveolar carcinoma or localized bronchioloalveolar carcinoma with foci of collapse of alveolar structure. The 5-year survival rate (61.9%) of patients with micrometastasis was significantly (p = 0.0041) lower than that of patients without micrometastasis (86.3%).

Conclusions. There still remains a risk of nodal micrometastasis in patients with primary peripheral lung adenocarcinoma, even if the diameter of the tumor is smaller than 2.0 cm. Selection of patients for limited surgery should be done prudently, taking into consideration the risk of nodal micrometastasis.     

Surgical treatment of pathological stage III and IV lung cancer less than 3 cm in diameter

We analyzed stage III and IV lung cancer with tumor size smaller than 3.0 cm. The percentage of adenocarcinoma among the patients with stage III A lung cancer was high. In survival rate, there was no observable difference between the patients with tumor size smaller than 3.0 cm and the patients with tumor size larger than 3.1 cm. But the ratio of the people who had a long survival was high in the latter group. Among the stage IV patients, the pm 1 group with N0 or N1 had a good prognosis (52%, 50% at 5 years).     

Diagnostic yield of preoperative computed tomography imaging and the importance of a clinical decision for lung cancer surgery

Purpose  

This study aimed to evaluate the diagnostic yield of preoperative computed tomography (CT) imaging and the validity of surgical intervention based on the clinical decision to perform surgery for lung cancer or suspected lung cancer.     

A preoperative prognostic nomogram for solid enhancing renal tumors 7 cm or less amenable to partial nephrectomy

PURPOSE: Small renal masses are increasing in incidence. Most tumors 7 cm or less are treated with radical or partial nephrectomy but clinicians are increasingly relying on ablative therapies and observation for some small renal masses. We present novel nomograms that predict the likelihood of benign, likely indolent or potentially aggressive pathological findings based only on readily identifiable preoperative factors. MATERIALS AND METHODS: Information on all partial nephrectomies performed at a single institution was collected in an institutional review board approved registry. Using retrospectively collected data on all 862 patients who underwent partial nephrectomy for a single, solid, enhancing, clinical T1 (7 cm or less) tumor between 1999 and 2005 tumors were classified as benign or malignant. Grade 3 clear cell renal cell carcinoma, grade 4 renal cell carcinoma of any type and any renal cell carcinoma with vascular, fat or collecting system invasion were considered potentially aggressive. The likelihood of benign, likely indolent or potentially aggressive pathological findings was modeled using multivariable logistic regression models based on age, gender, radiographic tumor size, symptoms at presentation and smoking history. RESULTS: Of 862 small renal masses 20% were benign and 80% were malignant but only 30% of cancers (24% of small renal masses) were potentially aggressive. All 11 patients with systemic symptoms had cancer. The remaining 851 patients underwent further analysis. Factors that were most strongly associated with the likelihood of benign pathology were age, gender, tumor size and smoking history. A nomogram constructed to predict benign histology proved to be relatively accurate and discriminating (bootstrap corrected concordance index 0.644) and calibrated. Small renal masses in older men and younger women were more likely to be benign. With regard to differentiating indolent from potentially aggressive cancers, only advanced age was independently significant on multivariate analysis (p <0.005). The nomogram for this outcome performed with limited ability (concordance index 0.557). CONCLUSIONS: Clinical factors provide substantial predictive ability to predict benign vs malignant pathology for small renal masses amenable to partial nephrectomy. Although most of these small renal masses are benign or indolent, our ability to predict potentially aggressive cancer in this population remains limited.