Treatment of stage I lung cancer (T1N0M0, T2N0M0)

Patients with stage I lung cancer can be offered surgical treatment with an excellent prognosis for recovery and long-term cure. The recent revision of the staging definition has rearranged the prognostic categories, further improving the prognosis in Stage I disease by eliminating patients with a higher risk of recurrence. The most vexing issues remaining are the infrequency of diagnosis of lung cancer at this stage and the increasing incidence of lung cancer of all stages, even among nonsmokers. Economical screening, abolition of cigarette smoking, control of airborne environmental carcinogens, and the continued search for effective systemic treatment remain challenges for the future.     

Endocavitary contact radiation therapy for ultrasonographically staged T1 N0 and T2 N0 rectal cancer

Background:

The purpose of this study was to determine the long‐term outcomes of patients undergoing endocavitary contact radiation therapy (ECR) for stage I rectal cancer.

Methods:

A database of patients treated with ECR for biopsy‐proven rectal adenocarcinoma from July 1986 to June 2006 was reviewed retrospectively. Only patients with primary, non‐metastatic, ultrasonographically staged T1 N0 and T2 N0 cancer who had no adjuvant treatment were included. Patients received a median of 90 (range 60–190) Gy contact radiation, delivered transanally by a 50‐kV X‐ray tube in two to five fractions.

Results:

Of 149 patients, 77 (40 T1, 37 T2) met the inclusion criteria. Median age was 74 (range 38–104) years, and median follow‐up 69 (range 10–219) months. ECR failed in 21 patients (27 per cent) (persistent disease, four; recurrence, 17), of whom ten remained disease free after salvage therapy. The estimated 5‐year disease‐free survival rate was 74 (95 per cent confidence interval 63 to 83) per cent after ECR alone, and 87 (76 to 93) per cent when survival after salvage therapy for recurrence was included.

Conclusion:

ECR is a minimally invasive treatment option for early‐stage rectal cancer. However, similar to other local therapies, ECR has a worse oncological outcome than radical surgery. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Treatment of Clinical T2N0M0 Esophageal Cancer

Background

Management of clinical T2N0M0 (cT2N0M0) esophageal cancer remains controversial. We reviewed our institutional experience over 21 years (1990–2011) to determine clinical staging accuracy, optimal treatment approaches, and factors predictive of survival in this patient population.

Methods

Patients with cT2N0M0 esophageal cancer determined by endoscopic ultrasound (EUS) were identified through a prospectively collected database. Demographics, perioperative data, and outcomes were examined. Cox regression model and Kaplan–Meier plots were used for statistical survival analysis.

Results

A total of 731 patients underwent esophagectomy, of whom 68 cT2N0M0 patients (9 %) were identified. Fifty-seven patients (84 %) had adenocarcinoma. Thirty-three patients (48.5 %) were treated with neoadjuvant chemoradiation followed by surgery, and 35 underwent surgical resection alone. All resections except one included a transthoracic approach with two-field lymph node dissection. Thirty-day operative mortality was 2.9 %. Only 3 patients (8.5 %) who underwent surgery alone had T2N0M0 disease identified by pathology: the disease of 15 (42.8 %) was found to be overstaged and 17 (48.5 %) understaged after surgery. Understaging was more common in poorly differentiated tumors (p = 0.03). Nine patients (27.2 %) had complete pathologic response after chemoradiotherapy. Absence of lymph node metastases (pN0) was significantly more frequent in the neoadjuvant group (29 of 33 vs. 21 of 35, p = 0.01). Median follow-up was 44.2 months. Overall 5-year survival was 50.8 %. On multivariate analysis, adenocarcinoma (p = 0.001) and pN0 after resection (p = 0.01) were significant predictors of survival.

Conclusions

EUS was inaccurate in staging cT2N0M0 esophageal cancer in this study. Poorly differentiated tumors were more frequently understaged. Adenocarcinoma and absence of lymph node metastases (pN0) were independently predictive of long-term survival. pN0 status was significantly more common in patients undergoing neoadjuvant therapy, but long-term survival was not affected by neoadjuvant therapy. A strategy of neoadjuvant therapy followed by resection may be optimal in this group, especially in patients with disease likely to be understaged.     

Management of T3 N0 and T4 N0 glottic carcinomas: results of a national survey.

OBJECTIVE: A survey was undertaken to document the clinical management of T3 and T4 pure glottic primary carcinomas and the management of the N0 neck by otolaryngologists and radiation oncologists. STUDY DESIGN AND SETTING: This study represents the results of a national survey of 250 otolaryngologists and 250 radiation oncologists regarding management of T3 N0 M0 and T4 N0 M0 glottic carcinomas. RESULTS: Of the surveys sent, 208 completed questionnaires were received. Results of this survey suggest that 87% and 90% will treat the neck for a T3 N0 M0 and T4 N0 M0 glottic tumor, respectively, with a large number choosing to perform a radical neck dissection. CONCLUSIONS: A significant percentage of otolaryngologists perform neck dissections in the management of T3 N0 M0 and T4 N0 M0 glottic carcinomas. Given the relatively low risk of occult metastasis, potentially high morbidity associated with overtreatment, and the lack of a well-designed outcome study investigating treatment alternatives, a prospective randomized study is needed to address the issue.     

The content of tumor DNA as an indicator of prognosis in patients with T1N0M0 and T2N0M0 carcinoma of the breast

To determine if the flow cytometric measurement of the content of the tumor DNA could provide prognostic information in T1N0M0 and T2N0M0 carcinoma of the breast, we isolated nuclei from paraffin-embedded tumor specimens from 128 consecutive patients who underwent modified radical mastectomy and were found to have a T1 or T2N0M0 carcinoma of the breast. The content of DNA of the nuclei was determined by flow cytometry. Although the average tumor size was not significantly different, 17 of 56 patients with aneuploid tumors died of cancer compared with 2 of 72 with euploid tumors. The 10-year overall actuarial survival rate of the euploid and aneuploid groups was 72% and 67%, respectively (p less than 0.02). A hazards model of the data shows that the DNA content of the tumor is the most significant indicator of prognosis, with a 2.25-fold increased risk of death for patients with aneuploid tumors. These data show that the tumor DNA content can be used to identify a group of patients with T1 or T2N0M0 carcinoma of the breast with the same prognosis as a group of patients without carcinoma of the breast that would be unlikely to benefit from adjuvant therapy.     

Results treatment of laryngeal cancer in T4N0M0 stage

Experience of treatment of 127 patients with cancerous laryngeal tumor in T4N0M0 stage was summarized. In 25 patients radiation therapy was done, in 16--chemoradiation treatment, in 42--surgical, in 44--the combined one. Difference between results of application of radiation therapy and chemoradiation treatment was not significant. After conduction of combined treatment with preoperative radiation the 5-year survival index had constituted (53.1 +/- 10.8)%. High efficacy of surgical prophylaxis of the regional metastases occurrence was noted in patients with stenosing laryngeal cancer. When radiation resistant laryngeal cancer is revealed it is necessary to study up the efficacy of surgical prophylaxis of the regional metastases occurrence in such patients.     

Modified stage I (T1N0M0, T2N0M0), nonsmall cell lung cancer: treatment results, recurrence patterns, and adjuvant immunotherapy

We analyzed 96 patients who had surgery with T1N0M0 or T2N0M0 nonsmall cell lung cancer (NSCLC) to identify survival rates and recurrence patterns in well-staged patients and to evaluate adjuvant therapy. Preoperative staging included chest x-ray, gallium 67 scanning, and bronchoscopy in all patients. At thoracotomy, multiple mediastinal lymph node sites were routinely sampled. The results included an operative mortality rate of 5.2%, and the actuarial 5-year survival rate of all patients was 70.0%. Survival of T1N0 (n = 44) and T2N0 (n = 47) patients was 72.1% and 68.3%, respectively (p = NS). Survival was not affected by type of surgery, cell type, sex, age, or race. Late death was due to recurrence in 12 patients, a new airway malignancy in three, and a noncancer problem in six. Disease recurred in 15 patients: four (9.1%) T1N0 patients versus 11 (23.4%) T2N0 patients, p less than 0.05. Recurrence was local in four patients and distant in 11. Second lung cancers developed in six patients at a mean interval of 65.7 months after resection. A prospective, randomized trial of systemic immunotherapy with bacillus Calmette-Guerin (BCG) skin scarification was carried out in 29 patients. Survival in those patients receiving BCG was 85.9% compared with 63.9% for control subjects (p = 0.075) and 69.6% for patients not in the study (p = 0.077). The following conclusions can be made: Resection for well-staged, modified stage I NSCLC results in a 5-year survival rate of 70%. Nearly half the deaths are unrelated to recurrence of the original cancer. Recurrences are more frequent in T2N0 patients, but there is no survival difference compared with T1N0 patients. Systemic recurrences are more frequent than local recurrences, and there is an appreciable incidence of second lung cancers. Adjuvant chemotherapy or radiation therapy does not seem justified, but systemic immunotherapy holds sufficient promise to warrant further investigation.     

Efficacy of treatment of mammary gland carcinoma stage T2N0M0

Results of treatment of 218 patients with mammary gland cancer (MGC) stage T2N0M0 were analyzed. Surgical intervention was performed using mastectomy according to Holstad, Patey, Madden methods or organpreserving operation was done. Surgical treatment was added by preoperative and postoperative radiation therapy (RTH). In several patients chemotherapy and hormonotherapy was administered. There was established that in MGC stage T2N0M0 mostly efficient procedures were mastectomy according to Madden method and radical resection of the organ. The surgical intervention extension and excision of I-III orders of lymphatic nodes worsens the prognosis. If after the operation RTH is administered the result of treatment improves.     

The role of adjuvant therapy after resection of T1 N1 M0 and T2 N1 M0 non-small cell lung cancer

Thirty-four consecutive patients with non-small cell lung cancer plus N1 nodal metastases (eight with T1 N1 M0 and 26 with T2 N1 M0) were retrospectively reviewed. Nineteen had adenocarcinoma, 11 had squamous disease, and four had large cell carcinoma. Eleven patients had surgical resection alone (32.3%), with a median survival of 13 months. Seven patients (20.6%) had resection followed by radiation therapy, with a median survival of 19.2 months. Sixteen patients (47.1%) had resection followed by radiation therapy and chemotherapy, consisting of cyclophosphamide, doxorubicin, methotrexate, and procarbazine. Median survival for the latter group was 45.5 months, significantly greater than for those treated with resection alone (p less than 0.005). We did not observe any relationship between survival and age, cell type, number or location of diseased hilar nodes, distance of tumor from the resected bronchial margin, tumor size, the presence or absence of visceral pleural involvement, or the type of resection performed. Resection in combination with adjuvant radiation therapy and chemotherapy offers improved median survival over resection alone in patients with T1 N1 M0 and T2 N1 M0 non-small cell lung cancer.     

Survival after conservative resection for T1 N0 M0 non-small cell lung cancer

Two hundred forty-four veterans, with a mean age of 62.4 years, mainly asymptomatic (pulmonary), were admitted generally for other disease or pension evaluation and underwent lobectomy (131), segmentectomy (107), or wedge resection (6) for T1 N0 M0 lung cancer between 1966 and 1988. Conservative resection was preferred during the past decade. The average lesion diameter was 2 cm. Thirty-day mortality was 2.9%, similar for the three procedures. Absolute 5-year survival, 51%, was 78% if only deaths from the initial lesion are considered; 19% died of comorbidity, and 8% died of second lung cancers. Routine preoperative computed tomographic staging and intraoperative sampling of even normal-sized hilar and mediastinal nodes, conducted after 1982, improved survival (p less than 0.006). Patients with lesions less than 2 cm in diameter (146) did better (p less than 0.04), and those with squamous tumors improved similarly (p less than 0.02). Lesions that communicated with a bronchus (88) were more malignant than those (156) that did not (p less than 0.02), because from that locus undifferentiated nonsquamous tumors metastasized widely. These results suggest that the T1 N0 M0 category is not uniform. Histology, size, and location in the lung are significant variables. Results of conservative resection were similar or better than those of lobectomy. The latter was used more in deep-seated lesions, however, when major intersegmental planes were transgressed, and before modern preoperative and intraoperative staging. The T1 N0 M0 category should include lesions 2 cm or less in diameter as a discrete entity.     

Surgical approach in T4N0M0 (vertebral involvement) lung cancer

Approximately 5% of the cancers involve the chest wall and spine by direct extension and remain localized at the time of diagnosis. T4 lesions invading the vertebra are considered inoperable. We reviewed a new evolution in the surgical treatment of lung cancer involving the vertebra (T4N0M0) and report preliminary results of our approach. Four patients with T4N0M0 (vertebral involvement) lung cancer underwent en bloc surgical resection of tumor between 1998 and 2002. Posterior stabilization, hemilaminectomy, and osteotomy of the involved vertebral bodies below the corresponding pedicle were performed in the prone position and then, in the lateral position, en bloc resection was completed along with the lung resection (large wedge resection or lobectomy) and involved vertebral bodies. There was no immediate postoperative mortality. Three patients died during the follow-up period at the 6th, 8th, and 14th postoperative months with a postoperative recognized metastasis. The fourth patient was in follow-up at 20 months. Although T4N0M0 (vertebral involvement) lung cancers are considered inoperable, lung resection with hemivertebrectomy of the involved vertebra after neoadjuvant chemotherapy and radiotherapy is an alternative treatment in this type of lung cancer. Staging should be made meticulously for the expected surveillance.     

Intentional limited pulmonary resection for peripheral T1 N0 M0 small-sized lung cancer

OBJECTIVE: The present study was undertaken to demonstrate that limited pulmonary resection for peripheral small-sized lung cancer yields outcomes not inferior to those of lobectomy. METHODS: During the 9-year period from 1992 to 2000, patients with cT1 N0 M0 peripheral non-small cell lung cancer whose maximum tumor diameter was 2 cm or less on diagnostic imaging and in whom lobectomy was determined to be feasible were treated with limited resection if the patient consented to the procedure and with lobectomy if consent to limited resection was not obtained. The survival and clinical outcome of the patients whose tumors were postoperatively staged as pT1 N0 M0 were compared between the limited resection group (n = 74) and the lobectomy group (n = 159). RESULTS: The limited resection group consisted of 60 patients treated with segmentectomy and 14 patients treated with wedge resection. Among patients followed up for a mean period of 52 months after the operation, neither the 3-year nor 5-year survivals differed significantly between the limited resection group (3-year survival, 94.0%; 5-year survival, 89.1%) and the lobectomy group (3-year survival, 97.0%; 5-year survival, 90.1%). Postoperative tumor recurrence was noted in 5 patients after limited resection and in 9 patients after lobectomy, and the difference in the incidence of postoperative recurrence between the 2 groups was not significant. CONCLUSIONS: The results of this study indicate that in patients with peripheral T1 N0 M0 non-small cell lung cancer whose maximum tumor diameter was 2 cm or less, the outcome of limited pulmonary resection is comparable with that of pulmonary lobectomy.     

Pneumonectomy for stage I (T1N0 and T2N0) nonsmall cell lung cancer has potent, adverse impact on survival

BACKGROUND: Surgically treated, stage I (T1N0 and T2N0) nonsmall cell lung cancer has a relatively favorable prognosis. Our aim was to determine whether performing a pneumonectomy in this group of patients has an impact on survival. METHODS: Four hundred eighty-five patients with stage I nonsmall cell lung cancer undergoing lung resection between 1991 and 2000 were studied. Three hundred seventy-four patients underwent a smaller resection than a pneumonectomy and 111 had a pneumonectomy. RESULTS: Patients undergoing less extensive resections were older (mean age, 65 vs 63 years) (p = 0.01); these patients were also more likely to have a history of chronic obstructive airway disease (9% vs 2%) (p = 0.01) or asthma (10% vs 3%) (p = 0.04), nonsquamous cell type (56% vs 27%) (p < 0.0001), and T1 tumor stage (66% vs 17%) (p = 0.002) than patients having a pneumonectomy. Operative mortality was 2.4% versus 8% (p = 0.01). Overall 1-, 3-, and 5-year Kaplan-Meier survival rates (95% confidence interval [CI]) after less extensive resections were 85% (CI, 82% to 90%), 63% (CI, 56% to 69%), and 50% (CI, 42% to 57%), respectively, and after pneumonectomy the survival rates were 66% (CI, 53% to 73%), 47% (CI, 35% to 57%), and 44% (CI, 32% to 55%), respectively (p = 0.0006). When the Cox proportional hazards model was applied to all study patients (n = 485), pneumonectomy (p = 0.001), T2 stage (p = 0.006), older age (p = 0.03), and male gender (p = 0.03) were independent adverse predictors of survival. When the analysis was limited to the patients having T1N0 disease (n = 145), pneumonectomy (p = 0.0008), older age (p = 0.05), and nonsquamous cell type (p = 0.02) were independent adverse determinants of survival. When only the patients with T2N0 disease were analyzed (n = 340), male gender (p = 0.0005) and pneumonectomy (p = 0.01) were independent negative predictors of survival. CONCLUSIONS: In this study, the patients who underwent pneumonectomy for stage T1N0 or T2N0 nonsmall cell lung cancer had a significantly poorer survival than those patients who underwent smaller lung resections.     

Radical laser segmentectomy for T1 N0 lung cancer.

Over the last 40 months, 18 lung cancer patients with T1 N0 non-small cell lung carcinoma have been treated with radical laser segmentectomy. This innovative operative method consists of a combination of anatomical or nonanatomical segmentectomy by neodymium:yttrium-aluminum garnet laser parenchyma sparing with complete hilar lymph node dissection. Although the median follow-up period is too short, there is no local recurrence and no cancer deaths. There have been no major complications. Even deep-seated tumors can be resected with a clear safety margin using this method. Radical laser segmentectomy may be a useful adjunct to preserve normal lung tissue and to perform very radical resection.