Mediastinal small cell carcinoma: a unique clinical entity?

Purpose

Mediastinal small cell carcinoma (MSCC) is a rare tumor with limited published literature. In view of diagnostic confusion pertaining to this tumor, we investigated its origin, clinical features, management and survival.

Methods

Clinical data of MSCC patients were retrospectively reviewed. Eligible patients showed pathologically proven small cell carcinoma (SCC) with the primary lesions confined to the mediastinum. Survival information was collected through follow-up studies.

Results

Among 25 MSCC patients identified, 22 were classified to have limited disease (LD), while 3 were with extensive disease (ED). The 5 patients (20 %) underwent surgery and 20 patients (80 %) underwent non-surgical treatment. The 4 patients with LD MSCC received chemotherapy alone, while 13 of them received chemoradiotherapy. Overall median survival time (MST) of all patients was 22 months, and the 1-, 3- and 5-year overall survival rates were 67.4, 16.8, and 8.4 %, respectively. The MST of LD and ED patients separately was 23 and 8 months, respectively, with significant difference (P = 0.005). But, the MST of patients who received surgical and non-surgical treatment was 25 and 21 months, respectively, with no significant difference (P = 0.757). The MST of LD patients receiving chemotherapy and chemoradiotherapy was 12 and 29 months, respectively, but somehow did not show significant difference (P = 0.482).

Conclusions

Our data suggested that MSCC may be a separate clinical entity like extrapulmonary small cell carcinomas (EPSCCs). Despite, multimodal treatment is currently the main treatment option, but for patients with LD MSCC, chemoradiotherapy is recommended to be preferred treatment modality.

     

Mediastinal lymphadenectomy influences postoperative immune response after lung cancer surgery

The aim of the study was to calculate the amount of surgical injury caused by systematic lymphadenectomy of mediastinum in patients operated on due to non-small cell lung cancer,with uneventful postoperative course.The study group consisted of 11 patients with cancer of the right lung(Group 1).The control group consisted of 12 patients with left lung cancer(Group 2).In patients with right lung cancer systematic lymphadenectomy,while in patients with left lung cancer systematic sampling was performed.Serum IL-6 and IL-1ra concentration was measured before and after surgery,and on postoperative day 1,3,and 7,as well as in sputum at the end of surgery and in pleural fluid on postoperative day 1,by ELISA test.Peripheral blood lymphocyte(PBL) count was measured with flow cytometry.Time of surgery was higher in patients with right than left lung cancer(154.1±31.29) vs(119.6±24.81) min;P=0.008) .The number of resected mediastinal lymph nodes was higher in patients with right than left lung cancer(27.6±7.6) vs(11.1 ±8.1);P=0.00006) .Postoperative decrease of PBL was significantly higher in group 1 than 2(1.25±0.37) vs(1.75 ±0.64) ×103/μL;P=0.04) .No significant differences were found in serum,pleural fluid and sputum concentration of IL-6 and IL -1ra between groups.Negative correlation between concentration of these cytokines in pleural fluid and number of resected mediastinal lymph nodes was found(Spearman test for IL-6:r=-0.723;P<0.001;for IL-1ra:r=-0.768;P<0.001).Number of "positive" N2 lymph nodes did not correlate with pleural fluid concentration of cytokines.Systematic lymphadenectomy of the mediastinum causes immunosuppression,as measured by decreased count of PBL and a negative correlation between number of resected mediastinal lymph nodes and concentration of cytokines in pleural fluid.     

Primary Mediastinal Large B-Cell Lymphoma, Classic Hodgkin Lymphoma Presenting in the Mediastinum, and Mediastinal Gray Zone Lymphoma: What is the Oncologist To Do?

In recent years, an overlap in biologic and clinical features has been identified between classic Hodgkin lymphoma (CHL) and primary mediastinal large B-cell lymphoma (PMBL). Further strengthening this relationship is the identification of lymphomas with clinical and morphologic features transitional between the two, known as gray zone lymphomas (GZL). However, this diagnostic gray zone is not just of theoretical interest: it presents a practical problem, as the treatment approaches for CHL traditionally differ from those for aggressive B-cell lymphomas. This article reviews the treatment approach for mediastinal lymphomas, including CHL of the nodular sclerosis subtype (CHL-NS), PMBL, and mediastinal GZL. Though several trials have evaluated different regimens with or without radiation in PMBL and CHL-NS, there is a lack of prospective experience in treating GZL because of the rarity of these tumors. Historical data indicate that they have done poorly with traditional approaches developed for the treatment of either CHL or diffuse large B-cell lymphoma.     

Incidental Anterior Mediastinal Nodular Lesions on Chest CT in Asymptomatic Subjects

Objective

The aim of this study was to investigate the prevalence and characteristics of nodular lesions in the anterior mediastinum that had been found incidentally on screening chest computed tomography (CT) in asymptomatic subjects.

Mediastinal (thymic) large B-cell lymphoma: where do we stand?

Mediastinal (thymic) B-cell lymphoma (MBL) is a locally highly aggressive tumour that was first definitively described in the early 1980s. The incidence of MBL is low, which made disease characterisation difficult initially. However, MBL has several peculiar clinical, morphological, immunological, and genetic features. Collectively, these characteristics distinguish it from other diffuse, large B-cell lymphomas. Consequently, MBL has become a defined subtype of diffuse large B-cell lymphoma with its own code (9679/3) in the International Classification of Diseases. New insights into the biological and clinical aspects of MBL have been gained from the study of large numbers of cases. Nevertheless, the histogenesis of the disease is not yet fully understood. We review the available data on MBL with special emphasis on its morphological, immunological, and genetic properties. Also discussed are recent data on molecular genetics, biology, and treatment.     

Gray Zone Lymphoma: Better Treated Like Hodgkin Lymphoma or Mediastinal Large B-Cell Lymphoma?

Although primary mediastinal large B-cell lymphoma (PMBL) and classic Hodgkin lymphoma of the nodular sclerosis type (CHL-NS) are distinct diseases, they share several clinical characteristics and biologic features. Given that, it is not surprising that there exist mediastinal lymphomas that do not fit well into either category but have clinical and morphologic features overlapping and transitional between PMBL and CHL-NS. The term mediastinal gray zone lymphoma (MGZL) has been used for these tumors, which are included in the World Health Organization classification as "B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma and classic Hodgkin lymphoma." Although several studies have evaluated different therapeutic strategies in PMBL and CHL-NS, there is a paucity of prospective experience treating MGZL, given its rarity and relatively recent recognition. Historically, diseases that today would be categorized as MGZL were probably called "anaplastic large-cell lymphoma Hodgkin-like," and their outcome with standard approaches was poor, with short overall survivals. In this review-following a discussion of the biology and clinical features of MGZL, and how they compare to PMBL and CHL-NS-we outline how the treatment of PMBL and CHL-NS has evolved in recent years, and how we believe MGZL should be approached therapeutically.     

Skipping Metastasis to Mediastinal Lymph Nodes in Non-small Cell Lung Cancer: A Clinical Study on the Reasonable Extent of Dissection

1　ＩｎｔｒｏｄｕｃｔｉｏｎＭｅｔａｓｔａｓｉｓｔｏｍｅｄｉａｓｔｉｎａｌｌｙｍｐｈｎｏｄｅｓｗｉｔｈｏｕｔｉｎｖｏｌｖｅ ｍｅｎｔｏｆｔｈｅｈｉｌａｒｎｏｄｅｉｓｄｅｆｉｎｅｄａｓｓｋｉｐｐｉｎｇｍｅｔａｓｔａｓｉｓ(ｓｋｉｐｐｉｎｇＮ2 ) [1] ,ｗｈｉｃｈｗａｓｆｏｕｎｄｉｎ 7% 37%ｏｆｔｈｅｒｅ ｓｅｃｔｅｄＮ2 ｐａｔｉｅｎｔｓ[2 ,3 ] .ＳｋｉｐｐｉｎｇＮ2ｈａｄａｎｉｍｐｏｒｔａｎｔｐｌａｃｅｉｎｍｅｄｉａｓｔｉｎａｌｎｏｄａｌｄｉｓｓｅｃｔｉｏｎ .Ｈｏｗｅｖｅｒ,ｆｅｗｓｔｕｄｙｗａｓｐｕｂｌｉ…     

Classifications of N2 Non–Small-Cell Lung Cancer Based on the Number and Rate of Metastatic Mediastinal Lymph Nodes

BackgroundSubdivisions of N2 non–small-cell lung cancer (NSCLC) cases based on metastatic status of mediastinal and non-mediastinal lymph nodes have been proposed. This study aimed to evaluate N2 disease classification by mediastinal lymph nodes alone.Patients and MethodsWe reviewed 187 patients with NSCLC pN1-N2 who were surgically treated to evaluate the proposed classifications: number, rate, nodal zone of metastatic lymph nodes. We evaluated N2 disease classification based on mediastinal lymph nodes alone in 136 pN2 cases.ResultsThe number (1-2, 3-5, and 6≤) or rate (15%≥, 15%< to 40%>, and 40%≤) classification based on all metastatic lymph nodes was validated by the log-rank test and Cox proportional hazards model. After reclassification by number or rate of metastatic mediastinal lymph nodes alone, a significant difference was maintained among all groups except between the 3-5 and 6≤ groups. The 5-year survival rates of the 1-2, 3-5, and 6≤ groups were 63.4%, 32.4%, and 18.2%, respectively (1-2 vs. 3-5, P = .015; 3-5 vs. 6≤, P = .134). With rate classification, the 5-year survival rates of the 15%≥, 15%-40% (15%< to 40%>), and 40%≤ groups were 56.0%, 27.3%, and 5.04%, respectively (15%≥ vs. 15%-40%, P = .011; 15–40% vs. 40%≤, P = .011). The Spearman's rank correlation coefficient showed a highly significant correlation of metastatic status between mediastinal lymph nodes and all lymph nodes (both P < .001).ConclusionClassification by number and rate of mediastinal lymph nodes alone enabled subdivision of N2 NSCLC cases. Metastatic status of mediastinal lymph nodes reflects that of all lymph nodes and is prognostic indicators.     

Role of Skip Mediastinal Lymph Node Metastasis for Patients With Resectable Non–small-cell Lung Cancer: A Propensity Score Matching Analysis

BackgroundN2 disease represents a heterogeneous group of non–small-cell lung cancer (NSCLC) with varying 5-year overall survival (OS) rates. The skip N2 phenomenon is quite frequent, and its prognostic impact remains a matter of debate. The aim of this study is to further assess the clinical significance and prognostic value of skip N2 disease using propensity score matching.Patients and MethodsThe study cohort included 437 patients with stage pN2 NSCLC who underwent resection from 2005 to 2011. Differences in clinicopathologic characteristics were identified in the overall cohort. The effect of skip N2 on OS was assessed, stratified by histology, tumor size, N2 involved stations, and T stage after propensity score matching.ResultsA total of 130 patients had skip N2 diseases in our study. Skip N2 metastasis was associated with age, tumor size, histology, and number of involved N2 stations. Matching of 130 pairs of patients showed that skip N2 was associated with a significantly better 5-year OS rate when compared with non-skip N2 disease (42.7% vs. 25.3%; P = .004), and OS is significantly better in the patients with tumor size of ≤ 3 cm (P = .014) or patients with single N2 station involvement (P = .002). Skip N2 conferred a significantly better OS in stage IIIA (P = .026) and IIIB (P = .029) disease.ConclusionThe presence of skip N2 metastasis was a good prognostic factor of resectable N2 disease. N2 disease may be classified into more subgroups in the revision of the current tumor-lymph node-metastasis (TNM) system.