Results of surgery for primary lung cancer based on the new international staging system.

OBJECTIVES: This study clarified the results of surgery for primary lung cancer based on the new international staging system. BACKGROUND: On December 1997, the Japan Lung Cancer Society adopted a new TNM staging system which had already received international recognition. SUBJECTS AND METHODS: The subjects of this study were 1062 consecutive previously untreated patients who underwent pulmonary resection for primary non-small cell lung cancer between January 1975 and December 1992. RESULTS: The postoperative 5-year survival rate for all patients was 58.5%. Pathological staging demonstrated a survival rate which was 73.2% in stage I, 46.8% in stage II, 26.7% in stage III, and 20.0% in stage IV. In the staging subgroups, the survival rate was 79.6% in stage IA, 62.4% in stage IB, 62.2% in stage IIA, 42.0% in stage IIB, 26.9% in stage IIIA, and 26.3% in stage IIIB. Concerning the pm patients, the survival rate was 20.2% in pm1 and 20.0% in pm2, while the survival rate of the patients with N0 was 45.7% in pm1 and 40.0% in pm2. CONCLUSIONS: A significant difference in the 5-year survival rate was recognized between the new stages IA and IB, and between the new stages IIA and IIB. When pm patients are diagnosed without lymph node metastasis, the opportunity for resection should not be lost.     

Surgical analysis for small cell lung cancer of the lung

Clinical features of small cell lung cancer were studied in 15 cases. The overall 5-year survival rate of the patients with limited small cell lung cancer was 11.4%. Surgery played substantial role for long-term survival in limited SCLC. The 4-year-survival rate of the patients in stage I was 50%, and that of those in stage II and IIIA was 50% and 37.5%, respectively. In the two survivors over four years in stage IIIA, all tumor was categorized as pT3 disease. The 4-year-survival rate of the patients treated with PE was 100%, and that of those treated with another chemotherapy was 10%, and that difference is statistically significant (p < 0.05). There was no significant difference in prognosis of patients in any other factors such as location (central or peripheral), histological subtype, curability or R number, pT factor, pN factor, p stage or with or without thoracic irradiation. Surgical resection for limited SCLC should be recommended in patients with stage I, II and T3N0M0 or T3N1M0 disease. For the patients in stage IIIA, particularly in N2M0 disease, who showed partial response or no change after chemotherapy, surgery should be considered because those patients might have nonsmall cell carcinoma components.     

Results of surgery for primary lung cancer based on the new international staging system

Objectives: This study clarified the results of surgery for primary lung cancer based on the new international staging system.Background: On December 1997, the Japan Lung Cancer Society adopted a new TNM staging system which had already received international recognition.Subjects and Methods: The subjects of this study were 1062 consecutive previously untreated patients who underwent pulmonary resection for primary non-small cell lung cancer between January 1975 and December 1992.Results: The postoperative 5-year survival rate for all patients was 58.5%. Pathological staging demonstrated a survival rate which was 73.2% in stage 1,46.8% in stage H, 26.7% in stage in, and 20.0% in stage IV. In the staging subgroups, the survival rate was 79.6% in stage IA, 62.4% in stage IB, 62.2% in stage HA, 42.0% in stage IIB, 26.9% in stage IIIA, and 26.3% in stage IIIB. Concerning the pm patients, the survival rate was 20.2% in pml and 20.0% in pm2, while the survival rate of the patients with NO was 45.7% in pml and 40.0% in pm2.Conclusions: A significant difference in the 5-year survival rate was recognized between the new stages IA and IB, and between the new stages IIA and IIB. When pm patients are diagnosed without lymph node metastasis, the opportunity for resection should not be lost.     

Management of ipsilateral intrapulmonary metastases in the new TNM system for non-small cell lung cancer

BACKGROUNDS: Recently, the Union Internationale Contre le Cancer and American Joint Committee on Cancer reclassified not only TNM staging but also ipsilateral intrapulmonary metastases (PM) as T4 in a same lobe or M1 in different lobes. To determine whether the new PM staging is appropriate, we studied the prognosis of PM. METHODS: From January 1981 to October 1997, we performed a lobectomy or pneumonectomy with mediastinal lymph node dissection, and had 42 patients with PM. We analyzed the postoperative prognosis of the patients with ipsilateral PM compared with the same stage group without PM (the non-PM). RESULTS: In the previous classification of PM (the old PM), 2 patients were categorized as stage IIA, 9 as IIB, 17 as IIIA, and 14 as IIIB. After reclassification (the new PM), 37 patients were categorized as stage IIIB, and 5 as IV. The old PM stage IIIA group had a significantly poor prognosis compared with the non-PM stage IIIA. However, the prognosis of the new PM group was compatible with that of the non-PM. None of the other staging group had a significant difference in the prognosis. CONCLUSIONS: The management of PM in the new TNM system for non-small cell lung cancer is appropriate.     

Validity and controversies in the new postoperative pathologic TNM classification based on the results of surgical treatment of non-small cell lung cancer

In 1997, the latest revision of the International System for Staging Lung Cancer was published. To validate the new pathologic TNM classification for non-small cell lung cancer (NSCLC), we analyzed the survival data of 455 patients who underwent pulmonary resection and pathologic staging at our institution from January 1980 through December 1999. The overall 5-year survival rate was 51.0%. Using the revised new stage classification, the survival rate for each stage was as follows; IA: 74.2%, IB: 66.4%, IIA: 56.0%, IIB: 51.8%, IIIA: 21.0%, IIIB: 16.0%, and IV: 0%. The current TNM classification well reflected the long-term prognostic hierarchy. There were significant differences in survival rates between patients with stage IA and IB, and between patients with stage IIB and IIIA. However, there was no significant difference between patients with stage IIA and IIB. No significant difference in survival was observed among patients with stage IIIA, stage IIIB, and stage IV. Five-year survival rate of 48.3% in the T3N0M0 category was significantly better than that of 21.0% found in the new stage IIIA. The survival of patients with intrapulmonary metastases in the same lobe (pm1) was not significantly better than that found in the stage IV. The TNM staging system accurately reflects the prognosis in NSCLC, but some stage definitions can be discussed.     

Multimodal therapy of small cell lung cancer in TNM stages I through IIIa.

Since 1977, Innsbruck University Hospital has been employing a multimodal therapy concept for small cell bronchial carcinomas in stages I to IIIa. This concept includes all three treatment forms effective in this tumor, namely, chemotherapy, surgery, and radiotherapy. The therapy scheme is stage-dependent and begins in stages T1-3 N0-1 with lung resection and in stage N2 with chemotherapy. To date, 45 patients have been included in a prospective, nonrandomized (phase II) trial: 7 in TNM stage I, 11 in stage II, and 27 in stage IIIa (6 T3 and 21 N2). The actuarial 5-year survival rate of the entire group (including therapy-related lethality, early recurrences, and protocol violations) is 36%; it is 57% for those in stage I, 28% for those in stage II, and 34% for those in stage IIIa. Median survival time is 18 months. Patients with completed multimodal treatment have a 5-year survival rate of 56% regardless of disease stage. Three patients died of tumor-unrelated causes after 47, 52, and 54 months.     

Clinical classification of malignant extraorganic tumors of the small pelvis based on the staging and the TNM system

The case records of 210 patients with malignant extraorganic tumors of the small pelvis are analysed. One hundred and eighty three patients had a primary tumor, 27--tumor recurrence. A classification of the mentioned tumors according to the stages and TNM system is suggested.     

The new international staging system for lung cancer. Evolution of the system and concerned remarks

The rationale of the Staging System of Lung Cancer is discussed from his presentation (Mountain, 1985) to the recent revision and proposals of new classifications. Survival rates offered a strong statistical support to the latest revision in 1997. Stage Group have become 7 out of Stage 0 (Tis). In the New Lymph Node Map, station 4 is confirmed as mediastinal (N2). The improved definition of Stage Grouping requires a golden standard of staging and a worldwide consensus on the surgical approach to mediastinal lymphadenectomy. IASLC, the International Association for the Study of Lung Cancer, is now moving to collect a new largest database with the aim to offer the next expected Revision.     

Surgery for non-small cell lung cancer based on the T factor

We review the indications of surgery in patients with non-small cell lung cancer (NSCLC) based on the T factor, focusing on peripheral small tumors, invasion to other organs, and the presence of malignant pleural effusion or intrapulmonary metastasis. While limited surgery in patients with peripheral, small-sized NSCLC preserves postoperative pulmonary function, the prospects for long-term survival are reduced due to the likelihood of recurrence, Novel prospective studies are being conducted to determine the indications for limited surgery in such patients which focus on histology, tumor size, and pulmonary function. In some patients with locally advanced disease, especially with invasion of the chest wall (T3), pericardium (T3), left atrium (T4), great vessel (T4), and carina (T4) and with malignant pleural effusion found intraoperatively and ipsilateral intrapulmonary metastasis, complete resection results in long-term survival. Thus surgery should be considered in patients without N2 disease.     

Assessment of the new TNM classification for resected lung cancer

To evaluate the revised TNM classification, we investigated the prognoses of 552 consecutive patients who had resection of non-small-cell lung cancer between April 1982 and March 1996. According to the new classification, the 5-year survival rate was 76.9% for stage I A, 57.2% for stage I B (I A versus I B, p < 0.0005), 47.7% for stage IIA, 49.8% for stage IIB, 18.6% for stage IIIA (IIB versus IIIA, p = 0.005), 16.7% for stage IIIB, and 7.9% for stage IV (IIIB versus IV, p = 0.02). Especially for patients in stage I A, there was significant difference in survival between patients with the tumor size within 1.5 cm and those with larger than 1.5 cm. The survival rate for T3N0M0 patients was significantly better than that for T3N1-2M0, but there was no significant difference between patients with T3N0M0 disease and those with T2N1M0 disease. Concerning the pm1 patients, the survival rate was significantly better than other stage IIIB patients. Our results supported the revision for dividing stage I and putting T3N0M0 into stage IIB. However, the classification is controversial about dividing stage II and putting pm1 as T4 disease. Furthermore, subgrouping of T1N0M0 disease by tumor size, T3 by tumor invaded organ will be necessary in the next revisions.     

Surgery in the tri-modality treatment of small cell lung cancer. Stage-dependent survival.

OBJECTIVE: Patients with small cell lung cancer (SCLC) are frequently denied surgical treatment despite growing body of evidence for a longer duration of remission and overall survival, if surgical intervention is integrated in a tri-modality therapy concept including chemotherapy, surgery, and radiotherapy. METHODS: A retrospective analysis was performed using data derived from 95 patients with SCLC operated upon over a period of 9 years. A subset of these patients was primarily operated upon and being diagnosed as SCLC only after thoracotomy, received radio-/chemotherapy postoperatively (n=64, group I). The second cohort had surgery after neoadjuvant chemotherapy which was continued postoperatively in addition to thoracic and cranial radiotherapy (n=31, group II). The patients in the second group were further divided into two subgroups: complete histological regression of tumor tissue in the mediastinal lymph nodes (group IIA), and those with persistent mediastinal lymph nodal involvement detected after thoracotomy (group IIB). RESULTS: Group I patients had stage I or II disease, whereas group II patients had clinical stage IIIA or IIIB. The overall 30-day mortality rate was as low as 5%. The median survival was 31.3 months for patients in group I, 31.7 months for adjuvant surgery with complete regression of mediastinal nodes (group IIA), and 12.4 months for adjuvant surgery without regression of mediastinal nodes (group IIB). CONCLUSIONS: Surgical intervention is promising and warrants prospective trials to be evaluated as an important adjunct to multi-modality therapy regimen in SCLC as regards to its impact on relapse free and overall survival.     

Evaluation of pT2 subdivisions in the TNM staging system for prostate cancer

OBJECTIVE

To evaluate the subclassifications of pT2 diseases in tumour‐nodes‐metastases (TNM) staging system for prostate cancer.

PATIENTS AND METHODS

We retrospectively analysed the data of 372 patients who underwent radical retropubic prostatectomy (RRP) for pathologically organ‐confined prostate cancer at our institution. Pathological staging of all subjects were re‐evaluated using the 1997 and the 2002 TNM staging system for prostate cancer. Various clinicopathological features along with biochemical recurrence‐free survival (BRFS) of pT2 subgroups were assessed.

RESULTS

Using the 2002 TNM staging criteria, 87 of the tumours (23.4%) were pT2a, and 284 (76.3%) were pT2c. Of all subjects, there was only one (0.3%) pathological 2002 T2b tumour identified. When subjects were classified according to the 1997 versions of the T2 subclassification (pT2a vs pT2b), the 1997 pT2a and pT2b cases showed no significant difference regarding BRFS (log‐rank P = 0.645) among those who were followed‐up for >2 years after RRP. Also, pathological stage (1997 pT2a vs pT2b) was not a significant predictor of BRFS in either uni‐ or multivariate analysis (P = 0.289 and P = 0.241, respectively). Only preoperative serum PSA level and pathological Gleason score along with positive surgical margin were significant predictors of PSA outcome after RRP on multivariate analysis.

CONCLUSION

Our results suggest that two‐ or three‐tiered subclassification of pT2 organ‐confined prostate cancer via methods used in the previous or current TNM staging system may not be appropriate. Efforts should be made to upgrade the current TNM staging system for prostate cancer.     

The significance of intrapulmonary metastasis in non-small cell lung cancer: upstaging or downstaging? A re-appraisal for the next TNM staging system

OBJECTIVE: The management of patients with non-small cell lung cancer (NSCLC) with intrapulmonary metastases (PM) is controversial. In TNM classification, PM are designed as T4 when in the same lobe of the primary tumour (PM1) and M1 when in a different lobe(s) (PM2). Some authors have questioned the negative prognostic impact of PM. The present study assessed prevalence, correlation with clinico-pathologic variables and impact on survival of PM, along with a review of the literature. METHODS: From January 1993 to December 2006, 2013 NSCLC patients underwent surgical resection at our institution. Of these, 74 presented with PM (39 PM1, 35 PM2). Patients with bronchioloalveolar carcinoma (BAC), carcinoid tumours, contralateral disease and preoperative chemo/radiotherapy were excluded from the analysis. A logistic regression analysis was undertaken to evaluate a relationship between the presence of PM and different clinico-pathologic variables. Survival analysis was undertaken to investigate the prognostic significance of PM. RESULTS: PM represent 3.6% of our patient population of operated NSCLC. Metastases were multiple in 36 cases and single in 38. Thirty-six patients had node-negative disease. Among all the variables for the logistic regression analysis only vascular invasion (OR: 0. 45; 95% CI 0.24-0.85, p=0.01) and N status (OR: 0. 6; 95% CI 0.43-0.82, p=0.001) were significantly correlated with the presence of PM. Median survival rates of PM1, PM2, other T4 and other M1 patients were 25, 23, 15 and 14 months, respectively. A survival advantage was observed in patients with PM as compared to other T4/M1 patients, although the difference was not significant either overall (p=0.21) or in the N0 disease group (p=0.12). CONCLUSIONS: The presence of PM in NSCLC patients is a rare occurrence. Risk factors for the development of PM are a microscopic vascular invasion and a high nodal status. A survival advantage over other T4/M1 patients is evident from our experience, although not significant. The results of the literature which have been accumulating in the most recent years including ours bend to the conclusion that there is sufficient validated information to consider a downstaging in the presence of intrapulmonary metastases from NSCLC for the seventh edition of the TNM classification.     

Surgical treatment for limited small-cell lung cancer. The University of Toronto Lung Oncology Group experience.

Since 1977, 119 patients with limited small-cell lung cancer have undergone combined modality therapy including surgery at our institution. Seventy-nine patients (58 male, 21 female; median age 63 years) had surgery first, and 67 of these had adjuvant chemotherapy. Forty (27 male, 13 female; median age 59 years) had chemotherapy first, and 94% had a complete or partial response before the operation. Pretreatment staging revealed 69 stage I, 27 stage II, and 23 stage III tumors. Twenty-six patients required pneumonectomy, 88 lobectomy, and five had no resection. Four patients had gross and six had microscopic residual disease. Postoperative pathologic examination showed small-cell lung cancer only (n = 95), non-small-cell lung cancer (n = 3), mixed (n = 17), and no residual tumor (n = 4). Postoperative staging revealed 35 stage I, 36 stage II, and 48 stage IIIa tumors. The median survival of the entire group is 111 weeks and the projected 5-year survival rate is 39%. No survival difference was seen between patients treated with chemotherapy before the operation and those undergoing an initial operation followed by chemotherapy (p = 0.756). The median survival for patients with pathologic stage I disease has not been reached, and the projected 5-year survival rate is 51%. This is significantly better than for the patients with stage II (median 82 weeks, p = 0.001) or stage III (median 83 weeks, p = 0.001) disease, who have projected 5-year survival rates of 28% and 19%, respectively. Seven of the 12 patients who had no adjuvant chemotherapy remain alive at 6 to 48+ months. Sixty-seven patients have died (11 had no evidence of disease). Only 10 patients had a relapse in the primary site alone, seven at the primary and distant sites, and 39 only in distant sites. In summary, resection improves control at the primary site, and a significant proportion of patients with stage I (N0) disease achieve long-term survival and cure with combined modality therapy including surgery. Stage II and IIIa patients have survival predictions similar to stage IIIa non-small-cell lung carcinoma treated surgically.     

The validity and problems of a new staging system for lung cancer from the point of view of surgical results

The validity and problems of the new staging system for resected lung cancer were assessed. In the new staging system for primary lung cancer, stage I is divided into two groups (A and B) on the basis of the tumor diameter. The boundary is 30 mm in maximum diameter of the tumor. On the other hand, intrapulmonary satellite nodules in the resected lung (PM1) are considered as T4. This means that a patient with PM1 is classified as stage IIIB or IV. The five-year cumulative survival rates of 191 consecutive patients of T1 or T2N0M0 who had undergone complete lung resection were calculated. The patients were divided two groups on the basis of the boundaries of the tumor diameter, such as 15, 20, 25, 30 and 40 mm (The tumor diameter in group A is the boundary and less than boundary and the diameter in group B is more than the boundary), and the cumulative survival rates of the two groups were compared. The 5-year cumulative survival rate (Kaplan-Meier survival rate) of each group and the p-value (logrank test) were 85.0%, and 0.463 in the case of the boundary of 15 mm; 84.8%, 79.9%, and 0.374 in the case of 20 mm, 82.3%, 80.0%, and 0.553 in the case of 25 mm, 79.5, 83.5, 0.524 in the case of 30 mm and 81.0%, 82.2%, and 0.783 in the case of 40 mm. In all cases, there were no significant differences between the rates in the two groups. On the other hand, 15 cases of T4N0M0 lung cancer included 12 cases of pm1, 2 cases of p3 and 1 case of d2. The five-year cumulative survival rate for T4N0M0 patients with pm1 was 71.1%, which was similar to the rate for stage I or II patients, while the two T4N0M0 patients with p3 died of recurrences of lung cancer at 10 and 13 months after the operation, and the T4N0M0 patient with d2 died of local recurrence of lung cancer 60 months postoperatively. We concluded that the sub-classification of stage I on the basis of the boundary of tumor diameter was meaningless, if the boundary was between 15 and 40 mm and that N0M0 patients with PM1 should be classified as stage II or less, or as 1 grade up of T status.