Asian Cardiovasc Thorac Ann 2000;8:141-145
© 2000 Asia Publishing EXchange Pte Ltd
Non-Small Cell Lung Cancer With Ipsilateral Intrapulmonary Metastasis
Mitsuhiro Kamiyoshihara, MD,
Osamu Kawashima, MD,
Shuji Sakata, MD,
Susumu Ishikawa, MD1,,
Yasuo Morishita, MD1,
Department of Surgery National Sanatorium Nishi-Gunma Hospital Shibukawa, Gunma, Japan
1 Second Department of Surgery Gunma University School of Medicine Maebashi, Gunma, Japan
|
|
For reprint information contact: Mitsuhiro Kamiyoshihara, MD Tel: 81 27 220 8245 Fax: 81 27 220 8245 email: kamiyosi{at}sa2.so-net.ne.jp Second Department of Surgery, Gunma University School of Medicine, 3-39-15 Showa–machi, Maebashi, Gunma 371-8511, Japan.
|
 |
Abstract
|
|---|
From 1981 through 1997, lobectomy or pneumonectomy with mediastinal lymph node dissection was performed in 604 patients with non-small cell lung cancer, of whom 42 (7%) were diagnosed as having ipsilateral pulmonary metastasis. There were 23 males and 19 females, the mean age was 66 years. Lobectomy was carried out in 37 cases and pneumonectomy in 5. Postoperative histology identified 29 adenocarcinomas, 11 squamous cell carcinomas, 1 large cell carcinoma, and 1 adenosquamous cell carcinoma. Two cases were classified as pathologic stage I, 1 as stage II, 26 as IIIA, and 13 as IIIB. Blood vessel invasion was present in 33 cases and absent in 2 cases. Five and 10-year survival rates were 34.3% and 17.1%, respectively. Patients with pulmonary metastasis had a poorer prognosis than those without metastasis; there were local recurrences in 6 patients, distant metastases in 9, and 15 deaths. There were no significant differences in recurrence sites between patients with and without pulmonary metastasis. Multivariate analysis showed that lymph node involvement and blood vessel invasion were useful prognostic factors. Ipsilateral pulmonary metastasis in the same lobe was regarded as local invasion for which surgical resection is the optimal treatment.
|
Introduction
|
|---|
Studies on intrapulmonary metastasis in the same lobe due to non-small cell lung cancer have been reported, but the treatment did not always include lobectomy or pneumonectomy along with mediastinal lymph node dissection.1,2 Systemic lymph node dissection is necessary to ensure that the disease is accurately staged.3 This study was designed to assess the factors affecting prognosis in patients with pulmonary metastasis (PM) undergoing mediastinal lymph node dissection.
|
Patients and Methods
|
|---|
From 1981 through 1997, lobectomy or pneumonectomy with mediastinal lymph node dissection was performed in 604 patients at the National Sanatorium Nishi-Gunma Hospital. Of these, 42 patients (7%) were pathologically diagnosed as having ipsilateral and synchronous PM. There were 23 males and 19 females, ages ranged from 41 to 83 years, with a mean age of 66 years. Synchronous multiple primary lung cancers were excluded by the criteria proposed by Martini and Melamed.4 The primary tumor (T) and regional node (N) categories were determined by pathologic examination of surgical specimens. The metastasis (M) category was assessed by computed tomography of the brain, chest, and abdomen, and a bone scan. Curability was categorized according to the TNM staging system of the Japan Lung Cancer Society.5 A review of surgical and pathologic reports of the resected specimens was also conducted. Histologic diagnosis of the tumors was based on the criteria of the World Health Organization.6 Postoperative follow-up ranged from 2 months to 17 years.
All statistical analyses were conducted using the Statview program (Abacus Concepts, Inc., Berkeley, CA, USA). In survival rate calculations, deaths occurring within 30 days after surgery were excluded. Non-primary deaths were also treated as cases of mortality in the statistical analysis. Survival rates were calculated by the KaplanMeier method and statistical significance was evaluated by the Cox-Mantel test, with a p value of < 0.05 being defined as statistically significant. The chi-squared test or the Mann-Whitney test was performed to compare the characteristics of each cell type. No patients were lost to follow-up and the outcome of death was confirmed by personal knowledge, physician's reports, autopsy, or death certificates.
|
Results
|
|---|
The characteristics of the 42 patients with PM are compared with those of the 562 patients without PM in Table 1
. There were 33 positive cases and 2 negative cases of blood vessel invasion in 35 patients whose samples could be examined histologically from the cut surface with the greatest diameter. The PM group had significantly larger tumors, more lymph node involvement, and more blood vessel invasion compared to the non-PM group. One operative death was excluded from the survival data for the PM group. The mean survival of the other 41 patients was 54 months; 5 and 10-year survival rates were 34.3% and 17.1%, respectively. The PM group had a poorer prognosis compared to the non-PM group (Figure 1). The characteristics of 9 patients with PM who survived for 5 years or longer are shown in Table 2. There were 15 deaths among the 41 operative survivors in the PM group. There were local recurrences of non-small cell cancer in 6 patients and distant metastasis in 9 (Table 3). There were no significant differences in recurrence sites between patients in the PM and non-PM groups (Table 3). Multivariate analysis using the Cox pro-portional hazard model indicated that lymph node involvement and blood vessel invasion were useful prognostic indicators (Table 4).
View larger version (7K):
[in this window]
[in a new window]
|
Figure 1. Survival curves for patients with and without pulmonary metastasis (PM). *Eight operative deaths were excluded.  One operative death was excluded.
|
|
View this table:
[in this window]
[in a new window]
|
Table 3. Site of Recurrence of Non-Small Cell Lung Cancer in 15 Patients With Pulmonary Metastasis and 102 Patients Without Pulmonary Metastasis
|
|
|
Discussion
|
|---|
It has been reported that the incidence of operative cases with stage-IV lung cancer is approximately 10% of all staged cases undergoing surgery; when this is limited to PM cases, the incidence is 5% to 10%.7–9 The incidence of 7% found in this study was in agreement with the previous findings. Deslauriers and colleagues10 defined satellite nodules in resected lung cancer specimens as well-circumscribed carcinomatous foci adjacent to but clearly separated from the main tumor by normal lung parenchyma. Kunitoh and colleagues11 proposed the following criteria to distinguish such lesions from synchronous lung neoplasms: the tumors are anatomically separate; the tumors are histologically dissimilar; and lymphangitic growth, metastases from an extrapulmonary site, and recurrence at the resection margins could be excluded. If the tumors were histologically indistinguish-able, it would be impossible to clarify whether satellite lesions were PM by these criteria. Chaudhuri12 stipulated that the histopathologic features of the two tumors must be completely different in cases of multiple primary lung carcinomas. According to this definition, all of the intra-parenchymal tumors in the 42 cases presented here would be classified as PM.
This study revealed that the PM group had larger primary tumors, more lymph node involvement, and more blood vessel invasion than the non-PM group. Fukuse and colleagues8 reported that the size of the primary tumor was a useful prognostic factor, but this was not supported by the findings in our study. Both the T stage and metastatic sites were found to contribute significantly to a good prognosis, according to multivariate analyses using the Cox proportional hazards model.8,9 In this study, lymph node involvement and blood vessel invasion were useful prognostic factors because both might be directly related to the degree of tumor progression and thus have a close relationship with PM. The prognosis of patients with PM is better than those with metastasis to other organs. In addition, the prognosis of patients with ipsilateral PM in the same lobe is better than those with ipsilateral PM in a different lobe. However, PM cases still have a worse prognosis than non-PM cases, as found in this study, although some patients survived for more than 5 years. We consider that ipsilateral PM in same lobe is a type of local invasion and recommend surgical resection as the optimal treatment. Larger numbers of patients are needed to determine the optimal treatment for ipsilateral pulmonary metastasis in a different lobe.
|
References
|
|---|
-
Yoshino I, Nakanishi R, Osaki T, Hasuda S, Taga S, Takenoyama M, et al. Postoperative prognosis in patients with non-small cell lung cancer with synchronous ipsilateral intrapulmonary metastasis. Ann Thorac Surg 1997;64: 809–13.[Abstract/Free Full Text]
-
Nakajima J, Furuse A, Oka T, Kohno T, Ohtsuka T. Excellent survival in a subgroup of patients with intra-pulmonary metastasis of lung cancer. Ann Thorac Surg 1996;61:158–63.[Abstract/Free Full Text]
-
Martini N, Bains MS, Burt ME, Zakowski MF, McCormack P, Rusch VW, et al. Incidence of local recurrence and second primary tumors in resected stage I lung cancer. J Thorac Cardiovasc Surg 1995;109:120–9.[Abstract/Free Full Text]
-
Martini N, Melamed MR. Multiple primary lung cancers. J Thorac Cardiovasc Surg 1975;70:606–12.[Abstract]
-
The Japan Lung Cancer Society. [General rule for clinical and pathological record of lung cancer]. 4th ed. Tokyo: Kanehara Express, 1995. (Japanese)
-
The World Health Organization. Histologic typing of lung tumors. Am J Clin Pathol 1982;57:471–6.
-
Shimizu N, Ando A, Date H, Teramoto S. Prognosis of undetected intrapulmonary metastases in resected lung cancer. Cancer 1993;71:3868–72.[Medline]
-
Fukuse T, Hirata T, Yokomise H, Mizuno H, Ike O, Nakamura T, et al. [Analysis of resected non-small cell lung cancer cases with ipsilateral intrapulmonary meta-stasis]. Nippon Kokyuki Geka Gakkai Zasshi 1996;10:21–6. (Japanese)
-
Fukuse T, Hirata T, Tanaka F, Yanagihara K, Hitomi S, Wada H. Prognosis of ipsilateral intrapulmonary metastases in resected non-small cell lung cancer. Eur J Cardio-thorac Surg 1997;12:218–23.[Abstract]
-
Deslauriers J, Brisson J, Cartier R, Fournier M, Gagnon D, Piraux M, et al. Carcinoma of the lung. Evaluation of satellite nodules as a factor influencing prognosis after resection. J Thorac Cardiovasc Surg 1989;97:504–12.[Abstract]
-
Kunitoh H, Eguchi K, Yamada K, Tsuchiya R, Kaneko M, Moriyama N, et al. Intrapulmonary sublesions detected before surgery in patients with lung cancer. Cancer 1992;70:1876–9.[Medline]
-
Chaudhuri MR. Independent bilateral primary bronchial carcinomas. Thorax 1971;26:476–80.[Abstract/Free Full Text]
TOP
Abstract
Introduction
