Ⅲ期非小细胞肺癌纵隔淋巴结跳跃式转移的临床意义

目的探讨Ⅲ期非小细胞肺癌(NSCLC)患者纵隔淋巴结跳跃式转移的临床意义。方法65例术后病理证实的NSCLC患者,分为纵隔淋巴结(pN2期)跳跃转移组(21例)及非跳跃转移组(44例),回顾分析两组患者的临床、手术及病理资料。结果两组患者的性别、年龄及肿瘤的病理类型、大小、部位和术后转移情况差异无统计学意义(P均>0·05);非跳跃转移组发生多组淋巴结转移的概率为36.4%(16/44)显著高于跳跃转移组的9.5%(2/21;χ2=8·571,P=0·036)。跳跃转移组患者术后平均生存时间为44个月,5年生存率为41%;非跳跃转移组术后平均生存时间为26个月,5年生存率为21%,两者差异有统计学意义(χ2=9·325,P<0·05)。纵隔淋巴结跳跃式转移可以作为肺癌术后一个独立的预后因素(P=0·003,RR=0·347)。结论纵隔淋巴结跳跃式转移的临床Ⅲ期NSCLC患者生存期较无跳跃式转移的患者长,纵隔淋巴结跳跃式转移可以作为一个独立的生存预后因素;跳跃式转移可能是pN期肺癌中的一个亚群。     

Prognostic factors of curatively resected esophageal carcinoma associated with multiple metastatic lymph nodes

BACKGROUND/AIMS: Prognosis of esophageal carcinoma with multiple metastatic lymph nodes is dismal despite radical operation and adjuvant therapy. We investigated prognostic factors for curatively resected esophageal carcinoma with multiple positive nodes. METHODOLOGY: From January 1983 to December 2002, 343 patients with thoracic esophageal carcinoma underwent an esophagectomy with curative intent. Of these patients, 82 patients were associated with 4 or more histopathologically positive nodes. Of these patients, 59 patients underwent a curative resection. Of these 59 patients, 7 patients who died of postoperative complications during the hospital stay were excluded. Therefore, 52 patients were enrolled in this study. Survival curves were compared after stratifications according to 14 clinicopathologic variables. Independent prognostic factors were detected using a multivariate Cox proportional hazard model. RESULTS: The cumulative 5-year survival rate for the subjects was 10.6%. The factors affecting cumulative survival rate by a univariate analysis were intramural metastasis (absence vs. presence) (p=0.03), and postoperative therapy (performed vs. not performed) (p=0.02). A multivariate analysis detected the performance of postoperative therapy (Hazard Ratio= 0.390, p= 0.002) and the absence of intramural metastasis (Hazard ratio=0.429, p=0.01) as positive prognostic factors. CONCLUSIONS: The positive prognostic factors for esophageal carcinoma with multiple lymph node metastases were the absence of intramural metastasis and the performance of adjuvant therapy.     

Prognostic significance of p53 status in non-small cell lung cancer in correlation with postoperative adjuvant therapy

BACKGROUND AND OBJECTIVE: Significant factors in the prognosis of p53 status in non-small cell lung cancer (NSCLC) remain controversial; some clinical studies have documented that p53 abnormality is a significant factor in predicting poor prognosis, and others failed. In the present study, we examined whether or not adjuvant therapy may influence the prognostic significance. METHODS: 217 patients with pathologic stage I disease were reviewed. As postoperative adjuvant therapy, UFT, an oral 5-fluorouracil derivative, was administered to 73 patients; p53 status was determined immunohistochemically. RESULTS: The 5-year survival rate for tumor with aberrant p53 expression was 66.4 %--significantly lower than that for tumor without aberrant p53 expression (79.7%, p = 0.023). The prognostic significance of p53 status was enhanced in patients who received UFT; 5-year survival rates for tumor with and without aberrant p53 expression were 68.8 and 94.7%, respectively (p = 0.002). In patients who did not receive UFT, the difference did not reach statistical significance (5-year survival rates: 65.5 and 71.5%, respectively; p = 0.267). CONCLUSIONS: This study demonstrates that postoperative survival is improved by UFT administration in patients with normal p53 function, but not in those without normal p53 function.     

Benefits of combining radiotherapy with aggressive resection for stage IV gallbladder cancer.

BACKGROUND/AIMS: The efficacy of combining resection and radiation in the management of advanced gallbladder cancer has not yet been defined. In this study, effects of combining radiation therapy on survival, local control and the pattern of recurrences were analyzed as a retrospective review. METHODOLOGY: From October 1976 to May 1996, 85 patients with stage IV (pTNM) gallbladder cancer underwent various aggressive resection modalities in our institute, including 34 liver resections, 30 hepatopancreaticoduodenectomies. Intra-operative, external or intracavitary radiation therapy was supplemented to resection in 47 patients. RESULTS: The 30-day operative mortality rate was 5.9% and the overall 5-year survival rate of stage IV disease patients was 6.3%; 3 patients are living well more than 6 years after surgery. Adjuvant radiotherapy yielded a significantly (p=0.0023) higher 5-year survival rate (8.9%) than resection alone (2.9%). The local control rate was significantly (p=0.0467) higher in the adjuvant radiation group than in the resection alone group (59.1% vs. 36.1%). However, there was no statistical difference in the frequency of distant metastasis between the two groups. Significant improvement (p=0.0028) of long-term survival was exhibited when radiation was used appropriately on patients with microscopic residues only. Those with macroscopic or without microscopic residues failed to improve. The 5-year survival rate and median survival time of patients receiving adjuvant radiation therapy for microscopic residues were 17.2% and 463 days, respectively. CONCLUSIONS: Adjuvant radiation therapy following aggressive resection, in certain circumstances, improves prognosis with acceptable operative mortality for stage IV gallbladder cancer.     

Impact of staging transesophageal EUS on treatment and survival in patients with non-small-cell lung cancer

BACKGROUND: Transesophageal EUS-guided FNA (EUS-FNA) is safe, accurate, and cost effective in staging patients with non-small-cell lung cancer (NSCLC). However, the impact of EUS-FNA on patient survival has not been demonstrated. OBJECTIVE: To determine the impact of metastatic disease in mediastinal lymph nodes as determined by EUS staging on treatment choice and survival in patients with NSCLC. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Tertiary university-based referral center. PATIENTS: Patients with biopsy-proven NSCLC who underwent staging EUS-FNA. The relationship between the EUS nodal status and patient survival was evaluated. Cox proportional hazards models were used to determine the significance of EUS nodal status and patient characteristics on patient survival. MAIN OUTCOMES MEASUREMENTS: Impact of EUS-FNA on therapy and survival in patients with NSCLC. RESULTS: Of 125 patients with NSCLC, EUS-FNA confirmed metastatic disease in 46% of the patients. Patients who were node positive were more likely to receive chemotherapy and/or radiation therapy and were less likely to undergo surgery compared with patients who were node negative (P< .0001). Patients with N2 or N3 disease by EUS-FNA had a shorter survival time than patients who were node negative (P= .004). Adjusting for age, race, and sex, EUS-FNA was the most important predictor of survival of patients with NSCLC in this cohort of patients (hazard ratio 2.34, 95% CI 1.31-4.21). LIMITATIONS: Lack of surgical reference standard in all patients and referral to a tertiary center. CONCLUSIONS: Patients with node-positive NSCLC as detected by EUS-FNA have a shorter survival time compared with patients who were node negative. They are more likely to receive neoadjuvant therapy and less likely to receive surgery. Preoperative EUS-FNA is a minimally invasive technique that provides important prognostic information in patients with NSCLC.     

Clinical outcomes of surgery after induction treatment in patients with pathologically proven N2-positive stage III non-small cell lung cancer

Background

To assess the effect of preoperative neoadjuvant therapy on resectability, downstaging, and the prognosis in patients with stage IIIA-N2 non-small cell lung cancer (NSCLC).

Methods

Eighty-four patients who underwent resections after induction therapy [76 with neoadjuvant chemotherapy (CTx) and 8 with induction chemoradiotherapy (CRTx)] for clinically evident [larger than 1 cm on computed tomography (CT)] and pathologically confirmed ipsilateral N2 positive NSCLC (stage IIIA) between January 2009 and July 2013 were reviewed retrospectively.

Results

Partial response (PR) was observed in 39 patients (46.4%). Standard lobectomy was performed in 63 cases (75.0%), and extensive resection was conducted in 21 cases (25.0%), including four pneumonectomies. Pathologic nodal downstaging (pN2 to pN0-1) was confirmed in 38 cases (45.2%). After induction therapy plus resection, 5-year progression-free survival (PFS) and overall survival (OS) in cases with radical resections were 37.9% and 34.2%, respectively. Patients who underwent lobectomy or pathologic nodal downstaging had better prognosis than those who had extensive resection or persistent N2 in PFS (P=0.036; P=0.025) and OS (P=0.023; P=0.024). On univariate analysis, lobectomy and pathological nodal downstaging were favourably predictive factors both in PFS and OS. Cox multivariate analyses identified only pathologic nodal downstaging to predict better PFS, and lobectomy to be significantly prognostic for OS.

Conclusions

These data suggest that neoadjuvant therapy was feasible, and helpful for tumor and pathologic nodal downstaging with promising rates of survival in patients with stage IIIA-N2 NSCLC. After induction therapy, patients with potentially radical lobectomy were more likely to benefit from operation. Pathological nodal downstaging of pN2 to pN0-1, rather than clinical response was predictive of a favorable outcome, and was correlated with a better chance of survival.     

Strong prognostic value of nodal and bone marrow micro-involvement in patients with pancreatic ductal carcinoma receiving no adjuvant chemotherapy

AIM: To study the prognostic value of adjuvant chemotherapy in patients with pancreatic, ductal adenocarcinoma.METHODS: Lymph nodes from 106 patients with resectable pancreatic ductal adenocarcinoma were systematically sampled. A total of 318 lymph nodes classified histopathologically as tumor-free were examined using sensitive immunohistochemical assays.Forty-three (41%) of the 106 patients were staged as pT1/2, 63 (59%) as pT3/4, 51 (48%) as pN0, and 55 (52%)as pN1. The study population included 59 (56%) patients exhibiting G1/2, and 47 (44%) patients with G3 tumors.Patients received no adjuvant chemo- or radiation therapy and were followed up for a median of 12 (range:3.5 to 139) mo.RESULTS: Immunostaining with Ber-EP4 revealed nodal microinvolvement in lymph nodes classified as "tumor free" by conventional histopathology in 73(69%) out of the 106 patients. Twenty-nine (57%)of 51 patients staged histopathologically as pN0 had nodal microinvolvement. The five-year survival probability for pN0-patients was 54% for those without nodal microinvolvement and 0% for those with nodal microinvolvement. Cox-regression modeling revealed the independent prognostic effect of nodal microinvolvement on recurrence-free (relative risk 2.92,P=0.005) and overall (relative risk 2.49, P=0.009) survival.CONCLUSION: The study reveals strong and independent prognostic significance of nodal microinvolvement in patients with pancreatic ductal adenocarcinoma who have received no adjuvant therapy. The addition of immunohistochemical findings to histopathology reports may help to improve risk stratification of patients with pancreatic cancer.     

Prognostic factors in patients with carcinoma of the papilla of Vater

BACKGROUND/AIMS: The prognosis after curative resection for patients with carcinoma of the papilla of Vater is relatively better than that for other peripancreatic cancer. However, prognostic factors after resection of the carcinoma have not been identified. METHODOLOGY: From 1983 to 1999, 16 patients with carcinoma of the papilla of Vater underwent standard pancreatoduodenectomy and dissection of regional lymph nodes. We followed the patients for 63 days to 17 years (median, 27 months) and analyzed clinicopathologic variables in relation to prognosis. RESULTS: The survival rate at 5 years was 50.5%. The morphologic factors predicting poor outcome were macroscopic ulcer formation and microscopic pancreatic, venous, or perineural invasion. Tumors with ulcer formation tended to infiltrate into the duodenum and pancreas, but not into veins or the perineural space. Eight of 16 patients died due to recurrence of the cancer; liver metastasis (n = 6) or peritoneal dissemination (n = 2). CONCLUSIONS: Patients with carcinoma of the papilla of Vater demonstrating ulcer formation or invasion into the pancreas, vein, or perineural space may benefit from adjuvant therapy to reduce the risk of liver metastasis. Careful observation is essential for liver metastasis or peritoneal dissemination after surgery; especially in patients with ulcer formation or venous invasion.     

Surgical management of non-small cell lung cancer with synchronous brain metastases

OBJECTIVES: Published series on the synchronous combined resection of brain metastases and primary non-small cell lung cancer are small and scarce. We therefore undertook a multicenter retrospective study to determine long-term survival and identify potential prognostic factors. DESIGN: Our series includes 103 patients who were operated on between 1985 and 1998 for the following tumors: adenocarcinomas (74); squamous cell carcinomas (20); and large cell carcinomas (9). Three patients had two brain metastases, and one patient had three metastases; the remaining patients had a single metastasis. Ninety-three patients presented with neurologic signs that regressed completely after resection in 60 patients and partially, in 26 patients. Neurosurgical resection was incomplete in six patients. Seventy-five patients received postoperative brain radiotherapy. The time interval between the brain operation and the lung resection was < 4 months. Pulmonary resection was incomplete in eight patients. RESULTS: The survival calculated from the date of the first operation was 56% at 1 year, 28% at 2 years, and 11% at 5 years. Univariate analysis showed a better prognosis for adenocarcinomas (p = 0.019) and a trend toward a better prognosis for patients with small pulmonary tumors (T1 vs T3, p = 0.068), N0 stage disease (N0 vs N+, p = 0.069), and complete pulmonary resection (p = 0.057). In a multivariate analysis, adenocarcinoma histology also affected the survival rate (p = 0.03). CONCLUSIONS: It seems legitimate to proceed with lung resection after complete resection of a single brain metastasis, at least in patients with an adenocarcinoma and a small lung tumor and without abnormal mediastinal lymph nodes seen on the CT scan or during mediastinoscopy.     

Effect of a new adjuvant systemic interferon alpha, 5-fluorouracil and cisplatin on advanced hepatocellular carcinoma with macroscopic portal invasion

BACKGROUND/AIMS: Despite an adequate hepatic resection, theprognosis of the patients with hepatocellular carcinoma (HCC) that have macroscopic tumor thrombus in the portal vein has still been poor. The prognosis of those patients and was investigated the significance of postoperative adjuvant therapy was discussed in this study. METHODOLOGY: Twenty five patients who had Vp2 or more portal invasion were included in this study. Those patients were retrospectively divided into 2 groups: the systemic interferon alpha, 5-Fluorouracil (FU) and cisplatin group (n = 10, IFN+ chemo group); and the no adjuvant therapy group (n = 15, control group). RESULTS: The overall survival rate was significantly higher in the IFN+chemo group compared with the control group. There was no significant difference between the 2 groups in regard to the disease-free survival rate. However, a difference in the recurrence pattern was observed between the 2 groups. In the IFN+chemo group, 3 of 6 patients with a recurrence had a single tumor in the remnant liver. While in the control group, 10 of 11 recurrent patients had either distant metastasis or multiple recurrences in the residual liver. CONCLUSIONS: Our new adjuvant systemic therapy including interferon alpha, 5FU and cisplatin for advanced HCC with macroscopic portal invasion is promising.     

Does pancreaticosplenectomy contribute to better survival?

BACKGROUND/AIMS: This study was conducted to clarify the impact of pancreaticosplenectomy on the prognosis of patients with gastric carcinoma. METHODOLOGY: Two hundred and seventy-two patients who underwent total gastrectomy with distal pancreatectomy and splenectomy were retrospectively reviewed. RESULTS: Lymph node metastases at the splenic hilum (#10) and along the splenic artery (#11) occurred in 12.4% and 19.2% of cases, respectively. The 5-year survival rate of those without metastasis at #10 was 62.8%. Once nodal metastasis occurred, the prognosis became very poor; only 18.2% in those with a single positive node and 15.4% of those with two or more positive nodes at this location survived 5 years. Similar trends in survival were observed with respect to nodes at #11. When stratified by nodal status as currently determined by microscopic examination, pancreaticosplenectomy saved 4.5% of patients with positive nodes, but was insufficient in 17.3% of cases and was not necessary in the 78.2% of cases who were node negative at these locations. CONCLUSIONS: The data indicate that pancreaticosplenectomy can save some patients with positive nodes in these regions; however, the small survival benefit does not provide a basis for the general application of this highly morbid procedure. To further evaluate these results in a randomized study, selection of a subset of patients who are likely to have metastasis is the key.     

Induction therapy for non-small cell lung cancer with involved mediastinal nodes in multiple stations

BACKGROUND: Metastasis to multiple stations of mediastinal nodes is associated with a poor prognosis. OBJECTIVE:: We prospectively examined the efficacy of induction therapy plus surgery in patients with non-small cell lung cancer and metastases at multiple stations of mediastinal (N2) lymph nodes. METHODS: Among the 1,085 patients who underwent surgery for primary non-small cell lung carcinoma from 1985 to 1997, those with clinical N2 disease of involved multiple stations, defined as bulky, mediastinal, lymph node metastases on CT scans, received induction therapy, consisting of cisplatin-based chemotherapy and radiation of 40 Gy. RESULTS: Of the 88 eligible patients entered into the study, 51 (58%) had multiple stations of N2 nodes affected preoperatively, as demonstrated by pathologic examination. Neither operative mortality nor fatal, treatment-related complications occurred during hospitalization. Patients who underwent complete resection had significantly longer survivals than did those who underwent incomplete resection (p = 0. 001). Among patients who underwent complete resection, the survival rate for patients with pathologically downstaged disease was significantly higher than that for patients whose disease was not downstaged (p = 0.009). Among patients with multiple stations of pN2 nodes involved who had undergone complete resection, those who received induction therapy for bulky N2 disease had a significantly better prognosis than did those undergoing surgery alone for nonbulky N2 disease (p = 0.03). CONCLUSIONS: Induction therapy prolonged the survival of patients with non-small cell lung cancer and mediastinal nodes involved at multiple stations. Survival was better when complete resection and downstaging of the disease were achieved after induction therapy.     

Strong prognostic value of nodal and bone marrow micro-involvement in patients with pancreatic ductal carcinoma receiving no adjuvant chemotherapy

INTRODUCTIONPancreatic adenocarcinoma is the fifth leading cause of death among all malignancies[1],leading to approximately40000deaths each year in Europe[2].Reported probabilities of five-year survival after curative surgery are still below10percent[3].Stage,grade and resection margin status are currently accepted as the most accurate pathologic variables predicting survival[4-10].Pathologic staging only insufficiently reflects the individual risk to develop tumor recurrence which is ev…     

Long term survival after pancreatic resection for pancreatic adenocarcinoma

OBJECTIVE: The aim of this study was to determine the long term survival of patients with pancreatic adenocarcinoma who underwent surgical resection and to assess the association of clinical, pathological, and treatment features with survival. METHODS: Between January, 1990, and December, 1998, 125 patients underwent a pancreaticoduodenal or partial pancreatic resection for pancreatic ductal adenocarcinoma at our institution. The records of these patients were reviewed for demographics, tumor characteristics including size, histological grade, margin status, lymph node status, surgical TNM staging, and postoperative adjuvant therapy. The primary outcome variable analyzed was survival. RESULTS: A total of 116 patients had complete follow-up and were included in the final analysis. The median survival after surgery was 16 months. The 1-, 3-, 5-, and 7-yr survival rates for all 116 patients were 60%, 23%, 19%, and 11%, respectively. The 1-, 3-, 5-, and 7-yr survival rates for patients who received adjuvant therapy were 69%, 28%, 23%, and 18% compared with 20% and 0% in patients who did not receive adjuvant therapy (p < 0.0001). The 1-, 3-, 5-, and 7-yr survival rates for patients with negative lymph nodes were 73%, 38%, 26%, and 22% compared with survival rates of 52%, 14%, 14%, and 9% in patients with positive lymph nodes (p = 0.01). In multivariate analyses, adjuvant therapy was the only feature found to be strongly associated with survival (hazards ratio = 0.26, 95% CI = 0.15-0.44). CONCLUSIONS: The overall 5- and 7-yr survival rates of 19% and 11% in our study further validate that surgical resection in patients with pancreatic adenocarcinoma can result in long term survival, particularly when performed in association with adjuvant chemoradiation.     

Nodal involvement as an indicator of postoperative liver metastasis in carcinoma of the papilla of Vater

Background/Purpose

Although lymph node metastatic involvement is one of the most important prognostic factors for carcinoma of the papilla of Vater, a detailed analysis of this factor in relation to prognosis has not been conducted.

Methods

From 1985 to 2003, 29 patients with carcinoma of the papilla of Vater underwent pancreaticoduodenectomy and dissection of regional lymph nodes at Yamagata University Hospital. We analyzed clinicopathologic variables in relation to prognosis and precisely evaluated nodal involvement in each patient to determine lymphatic flow. Furthermore, the relationship between recurrent site and nodal involvement was investigated.

Results

The overall survival rate was 55% at 5 years. The significant prognostic factors were morphological ulcer formation (P = 0.04), histological type (P = 0.03), nodal involvement (P = 0.002), and lymphatic invasion (P = 0.03). Multivariate analysis indicated no independent factor, but nodal involvement may be the strongest prognostic factor. The overall rate of nodal involvement was 41.4% (12 of 29 patients). The metastatic rates in the superior posterior pancreaticoduodenal lymph nodes, the inferior posterior pancreaticoduodenal lymph nodes, the superior mesenteric lymph nodes, and paraaortic lymph nodes were high (31.0%, 20.7%, 17.2%, and 13.8%, respectively). Patients with nodal involvement had a significantly higher rate of liver metastasis after surgery than those without it (P = 0.02). Ulcer formation and histological type were significantly correlated with nodal involvement (P = 0.05 and P = 0.002, respectively).

Conclusions

Nodal involvement is the most important prognostic factor in patients with carcinoma of the papilla of Vater. Patients with nodal involvement are at high risk of liver metastasis; therefore, adjuvant therapy may be necessary for the control of liver metastasis. Preoperative ulcer formation and histological type in the biopsy specimen are good indicators for extended lymph node dissection and adjuvant therapy, because these variables are correlated with nodal involvement. However, our data revealed only the sites of the positive nodes, without addressing the effect of extended lymph node dissection and adjuvant chemotherapy. To date, there has been reporting of extended lymph node dissection and adjuvant chemotherapy in patients with carcinoma of the papilla of Vater. Further studies will be necessary to resolve these problems.     

Prognostic significance of subcarinal station in non-small cell lung cancer with T1-3 N2 disease

BACKGROUND: Surgical resection may continue to offer the best chance of long-term survival for patients with non-small cell lung cancer (NSCLC). Generally, patients with N2 NSCLC have a poor prognosis. However, the surgical treatment of patients with N2 remains controversial as in these patients, some N2 subgroups have better prognoses than others. The objective of the current study was to evaluate the factors associated with N2, and to determine whether such factors are reliable predictors of survival. METHODS: We retrospectively reviewed 142 non-small cell lung cancer patients with T1-3 N2 in whom a curative approach had been attempted between January 1994 and December 2003. The patients were consequently divided into four groups (NS-1, no subcarinal involvement and without N1; NS-2, no subcarinal involvement and with N1; SI-1, subcarinal involvement and without upper mediastinal site; SI-2, subcarinal involvement and with upper mediastinal site). We also evaluated two groups for N2 stations (single-station N2 versus multiple-station N2). Multivariate analysis by Cox's proportional hazards regression model was performed to identify the prognosis. RESULTS: Lobectomy was carried out in 105 of the patients; bilobectomy in 10, and pneumonectomy in 27. The patients with T1-3 N2 disease showed survival rates of 34.1 % at 3 years and 24.1 % at 5 years. The overall survival rates at 3 years and 5 years were as follows: NS-1, 56.3 % and 43.2 %; NS-2, 35.4 % and 29.5 %; SI-1, 16.7 % and 0 %; SI-2, 15.4 % and 0 %, respectively. The NS-1 group had better prognoses than the other groups. There was a significant difference in survival rates within each group ( p = 0.0005). In univariate analysis, the type of surgery, type of subcarinal involvement, and multiple-station N2 were significantly associated with prognosis. Multivariate analysis showed that NS-1 was only found to be an independent prognostic factor in cases of T1-3 N2 disease ( p = 0.0018). NS-2 was not an independent factor but tended toward significance ( p = 0.0681). But multiple-station N2 was not an independent factor ( p = 0.1549). CONCLUSIONS: Surgery for patients with T1-3 N2 NSCLC might be acceptable if subcarinal lymph node metastasis is predicted to be absent.     

Predictive risk factors for lymph node metastasis in patients with small size non-small cell lung cancer

Background

Accurate clinical staging of non-small cell lung cancer (NSCLC) is essential for developing an optimal treatment strategy. This study aimed to determine the predictive risk factors for lymph node metastasis, including both N1 and N2 metastases, in clinical T1aN0 NSCLC patients.

Methods

We retrospectively evaluated clinical T1aN0M0 NSCLC patients who showed no radiologic evidence of lymph node metastasis, and who had undergone surgical pulmonary resection with systematic mediastinal node dissection or sampling at the First Affiliated Hospital of Zhejiang University between January 2011 and June 2013. Univariate and multivariate logistic regression analyses were performed to identify predictive factors for node metastasis.

Results

Pathologically positive lymph nodes were found in 16.2% (51/315) of the patients. Positive N1 nodes were found in 12.4% (39/315) of the patients, and positive N2 nodes were identified in 13.0% (41/315) of the patients. Some 9.2% (29/315) of the patients had both positive N1 and N2 nodes, and 3.8% (12/315) of the patients had nodal skip metastasis. Variables of preoperative radiographic tumor size, non-upper lobe located tumors, high carcinoembryonic antigen (CEA) levels and micropapillary predominant adenocarcinoma (AC) were identified as predictors for positive N1 or N2 node multivariate analysis.

Conclusions

Pathologically positive lymph nodes were common in small size NSCLC patients with clinical negative lymph nodes. Therefore, preoperative staging should be performed more thoroughly to increase accuracy, especially for patients who have the larger size, non-upper lobe located, high CEA level or micropapillary predominant ACs.     

The value of tumor volume in surgically resected non-small cell lung cancer

BACKGROUND: The aim of this study was to evaluate whether or not tumor volume (TV) has an impact on survival in non-small cell lung cancer. METHODS: In a retrospective analysis of 385 cases with NSCLC who underwent curative surgery between 1994 and 2003, we calculated the tumor volume by using an ellipsoidal formula. The patients were grouped according to TV as determined by histograms. Gender, age, histology, nodal involvement, size, and TV were analyzed. Multivariate analysis by Cox's proportional hazards regression model was performed to identify the prognosis. RESULTS: Cases of N0 showed a significantly lower TV than cases with other N statuses (p < 0.05). A significant difference was also observed between TV and histology or gender. The 189 patients belonging to the small volume group (SVG) (range, 0.105 to 9.265 cm3) had a significantly better overall survival rate than the other 196 patients in the large volume group (LVG) (9.266-366.522 cm3). With univariate analysis, gender, age, nodal involvement, size, and TV were significantly associated with prognosis. Multivariate analysis showed that only gender (p = 0.0184) and nodal involvement (p = 0.0001) were significantly independent prognostic factors. The size factor was not significant (p = 0.5285). However, TV was not an independent factor, but trending toward significance (p = 0.0801). CONCLUSIONS: Although TV provides no independent prognostic information with multivariate analysis, TV in NSCLC should be considered using volumetric measurement with a three-dimensional CT approach prior to surgery or treatment planning.     

Factors associated with pN3 stage tumors according to the TNM classification in advanced gastric cancer

BACKGROUND/AIMS: The aim of the present study was to analyze factors associated with pN3-stage tumors, as classified according to the TNM Classification of Malignant Tumors, in patients who undergo curative resection for advanced gastric cancer. METHODOLOGY: A total of 391 patients with advanced gastric cancer (247 males and 144 females; average age, 59.2 years) were enrolled in the present study. The numbers of dissected regional lymph nodes and positive nodes were assessed, and node stage was determined according to TNM. Patient survival and factors associated with pN3-stage tumors were then analyzed. RESULTS: The 5-year survival rate was 82.9% for the 132 N0 patients, 66.4% for the 154 N1 patients, 41.1% for the 64 N2 patients and 21.1% for the 41 N3 patients. A significant difference was found between some of the curves (N0 and N1, p = 0.0012; N1 and N2, p = 0.0007; N2 and N3, p = 0.0055). In logistic regression analysis, independent factors associated with advanced gastric cancers with a pN3-stage tumor were tumor diameter (> 6 cm vs. < or = 6 cm, p = 0.0037), number of dissected nodes (> 30 vs. < or = 30, p = 0.0143), depth of invasion (T3 or T4 vs. T2, p = 0.0028) and microscopic type (undifferentiated vs. differentiated, p = 0.0147). CONCLUSIONS: The results of the present study suggest that tumor diameter (> 6 cm), depth of invasion (T3 or T4) and microscopic type (undifferentiated type) are the most reliable indicators of pN3-stage tumors in patients who undergo curative resection for advanced gastric cancer.     

Prognosis of esophageal squamous cell carcinoma: analysis of clinicopathological and biological factors

OBJECTIVE: Esophageal squamous cell carcinoma (ESCC) is rather common among the Chinese, but the therapeutic outcome is dismal. Knowledge of the prognostic factors in cancerous patients may influence therapeutic strategy. However, systemic analyses of clinicopathological and biological factors for patients with ESCC are few, and the results are controversial. METHODS: Between 1985 and 1996, 117 patients undergoing en bloc esophagectomy and gastric substitution were enrolled. None had neoadjuvant treatment. Postoperative adjuvant therapy was provided for patients at and beyond stages IIa. Clinical responses were followed routinely. Flow cytometry was used to measure DNA ploidy and synthesis-phase fraction (SPF) of the resected esophageal tissues from all patients. Immunohistochemistry was also used to examine the expression of proliferating cell nuclear antigen (PCNA), epidermoid growth factor receptor (EGFR), HER-2/neu, and p53 in the pathological sections. Clinical correlation was evaluated by chi2 with Fisher's exact test, and survival by log-rank test. RESULTS: The overall survival rates were 74% for 1 yr, 48% for 3 yr, and 38% for 5 yr. TNM tumor staging, the number of diseased lymph nodes (N < or = 3 or N > 3), degree of cell differentiation, DNA ploidy, SPF, and lymphovascular invasion were more useful than biological markers, such as PCNA, EGFR, HER-2/neu, and p53, for the prognosis of ESCC. Multivariate analysis revealed significant correlation of tumor staging and number of diseased lymph nodes with patient survival after surgery. CONCLUSIONS: En bloc esophagectomy may provide a rather satisfactory survival rate for patients with early stage ESCC. However, for patients with distant lymph node metastasis and those with more than three lymph nodes involved, radical surgical resection, even combined with postoperative chemoradiotherapy, cannot improve survival. The prognostic value of biological markers, including PCNA, EGFR, HER-2/neu, and p53, however, is limited.