Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3981_Библиотеки_им_академика_М_И_Перельмана.pdf
Thoracic Surgery: Answers
229
Marty-Ané CH, Costes V, Pujol JL, et al. Carcinoid tumors of the lung: do atypical features
require aggressive management?. Ann Thorac Surg. 1995;59:78-83.
Martini N, Zaman MB, Bain MS, et al. Treatment and prognosis in bronchial carcinoids
involving regional lymph nodes. J Thorac Cardiovasc Surg. 1994; 107:1-7.
McCaughan BC, Martini N, Bains MS. Bronchial carcinoids: review of 124 cases. J Thorac
Cardiovasc Surg. 1985;89:8-17.
3.29 Answer: C
The description is of a typical bronchial carcinoid. Bronchial carcinoids account for 1 to
2% of all lung malignancies. A large population-based study reported a crude incidence in
Europe of 0.2 per 100,000/yr. Bronchial typical carcinoids are three to four times more
frequent than atypical carcinoids. Bronchial typical carcinoid (TC) usually arises in the fifth
decade, a younger age compared with the high-grade neuroendocrine neoplasm. There is an
equal distribution between sexes, even if, in younger patients with TC, women are affected
twice than men. Only a minority of patients with TC has a smoking history and usually with
low smoking index. Bronchial carcinoids have also been reported in 5% of patients with
multiple endocrine neoplasia type 1 syndrome (MEN-1), which is familial autosomic-
dominant syndrome characterized by the occurrence of neoplasm involving pituitary gland,
pancreas, parathyroid, and foregut lineage neuroendocrine tissue.
Both central and peripheral TCs consist of a relatively well-demarcated nodule varying in
color from yellowish–white to tan–yellow or brown. Peripheral type may have multiple
satellite nodules.
According to the current 2004 WHO classification of lung tumors, TC consists of a
neuroendocrine neoplasm with no more than 1 mitosis per 10 high-power fields (2 mm
2
) and
without necrosis. Organoid growth pattern, tumor proliferation of relatively monomorphic
cells with finely granular chromatin nuclei, and inconspicuous/absent nucleolus, lightly
eosinophilic cytoplasm, and coexpression of cytokeratins and neuroendocrine markers
represent important findings to confirm the diagnosis of carcinoid tumor.
Immunohistochemistry is currently the most employed and reliable method to confirm
neuroendocrine differentiation and Chromogranin A, synaptophysin, CD56/NCAM, and
CD57 are the most specific neuroendocrine markers. Typical carcinoids are usually positive
for cytokeratins, although up to 20% of cases may result negative. They are always negative
for high-molecular weight cytokeratins (such as 34betaE12 and/or CK903). S-100 protein
may detect the presence of substentacular cells. Discordant results have been reported
concerning transcription termination factor type 1 (TTF-1) immunostaining: peripherally
located TC seems to be often positive, while the central type is generally negative.
Cytoproliferative activity by Ki67/MIB-1 is generally very low (less than 5%).
References
Warren WH, Gould VE. Neuroendocrine tumors of the bronchopulmonary tract: a reappraisal
of their classification after 20 years. Surg Clin North Am. 2002;82:525-540.
Modlin IM, Sandor A. An analysis of 8305 cases of carcinoid tumors. Cancer. 1997;79:813-
829.
Sugio K, Osaki T, Oyama T. Genetic alteration in carcinoid tumors of the lung. Ann Thorac
Cardiovsc Surg. 2003;9:149-154.
Shahzad G. Raja
230
Fischer S, Kruger M, McRea K. Giant bronchial carcinoid tumors: a multidisciplinary
approach. Ann Thoracic Surg. 2001;71:386-393.
3.30 Answer: B
Pulmonary hamartomas are the most common benign tumors of the lung. They are also
referred to as chondroid hamartoma and chondromyxoid hamartomas and, incorrectly,
chondromas. These tumors account for approximately 75% of all benign lung tumors, 4% of
all solitary pulmonary nodules, and 8% of pulmonary neoplasms. Pulmonary hamartomas
occur in all patient age ranges, although most are common in the 30- to 60-year-old bracket.
They occur 2 to 3 times more frequently in men than women and usually present as
unsuspected findings on chest radiographs or computerized tomography that are performed
for unrelated reasons. The majority of pulmonary hamartomas are asymptomatic and 1 to 3
cm in size, although larger ones have been reported. They do not grow quickly, and many
show no enlargement at all. The majority of hamartomas present as solitary pulmonary
nodules. They are typically smooth, well-circumscribed peripheral pulmonary, which are
generally round or lobulated in appearance. Although the description of ―popcorn
calcifications‖ is entrenched in the Lature as referring to pulmonary hamartomas,
calcifications are detected on routine chest radiography only 10% to 30% of the time.
Computerized tomography is more likely than plain film to show calcifications, although a
more common finding (occurring in up to 50% of cases) is areas of fat density. These findings
in a peripheral solitary nodule are highly suggestive of the lesion being a hamartoma. When
present, calcifications may be diffuse or eccentric.
References
Cosio BG, Villena V, Echave-Sustaeta J, et al. Endobronchial hamartoma. Chest.
2002;122:202-205.
Whyte RI, Donington JS. Hamartomas of the lung. Semin Thorac Cardiovasc Surg.
2003;15:301-4.
3.31 Answer: A
Granular cell tumors (granular cell myoblastomas) are benign neoplasms composed of
large ovoid or polygonal cells that take up periodic acid-Schiff stain. Originally thought to be
derived from skeletal muscle tissue, they are now believed to be of Schwann cell origin.
Deavers and colleagues reviewed a series of 20 patients, ranging in age from 20 to 57 years,
with granular cell tumors. There was no sex predilection for this tumor. Also, in
approximately half the cases, the tumors were asymptomatic and incidentally discovered.
Most of these lesions were solitary and were typically found adjacent to a large bronchus. A
parenchymal sparing pulmonary resection is the treatment of choice. However, the surgeon
must be attentive to achieving complete resection because the recurrence rate for this lesion is
high in the absence of complete excision.
References
Deavers M, Guinee D, Koss MN, Travis WD. Granular cell tumors of the lung:
Clinicopathologic study of 20 cases. Am J Surg Pathol. 1995;19:627-635.
Allan JS. Rare solitary benign tumors of the lung. Semin Thorac Cardiovasc Surg.
2003;15:315-22.
Thoracic Surgery: Answers
231
3.32 Answer: C
The pulmonary hemangioma is a benign vascular tumor that can be found throughout the
respiratory tract. Most commonly, this lesion is seen in the wall of the trachea or a mainstem
bronchus. However, it can also be found in the pulmonary parenchyma, usually in a
subpleural location. Approximately two-thirds of pulmonary hemangiomas are solitary. When
multiple lesions are present, one must suspect the generalized disorder of hereditary
telangiectasia (Osler-Weber-Rendu disease). When located in the pulmonary parenchyma, the
solitary hemangioma tends to be a sharply circumscribed rounded lesion with strong contrast
enhancement on CT. This result gives the hemangioma a radiographic appearance that is quite
similar to that of some contrast-enhancing malignant lesions, such as carcinoid. A
conservative wedge resection is the preferred treatment of parenchymal hemangioma.
Arteriovenous malformations (AVM) are not true neoplasms but rather are congenital
vascular anomalies. Pulmonary AVM are generally asymptomatic solitary nodules typically
found in the lower lobes. Contrast-enhanced CT will typically show a vessel providing
arterial inflow and another vessel providing venous drainage. Because the vascular inflow is
typically derived from the pulmonary circulation, a large, pulmonary AVM may be associated
with significant right-to-left shunting, creating clinical signs such as cyanosis, clubbing, and
polycythemia. Like true hemangiomas, there is an association between multiple pulmonary
AVM and hereditary telangiectasia.
The lymphangioma is a relatively uncommon thoracic neoplasm that typically presents in
the mediastinum or in the trachea of an infant or child. Only rarely does a lymphangioma
present as a solitary pulmonary nodule.
References
Allan JS. Rare solitary benign tumors of the lung. Semin Thorac Cardiovasc Surg.
2003;15:315-22.
Wilson C, Askin FB, Heitmiller RF. Solitary pulmonary lymphangioma. Ann Thorac Surg.
2001;71:1337-1338.
3.33 Answer: D
FDG-PET is extremely sensitive and has a strong negative predictive value when applied
to nodules more than 1 cm in diameter. The utility of PET in determining a care plan is
greatest when the PET data are incorporated into a Bayesian risk analysis model that assesses
the risk of malignant disease for a given patient. Table lists a series of likelihood ratios for
malignancy derived from one particular case series, considering a variety of clinical and
radiographic characteristics, including PET avidity.
References
Fletcher JW. PET scanning and the solitary pulmonary nodule. Semin Thorac Cardiovasc
Surg. 2002;14:268-274.
Allan JS. Rare solitary benign tumors of the lung. Semin Thorac Cardiovasc Surg.
2003;15:315-22.
Shahzad G. Raja
232
Table. Malignancy Likelihood Ratios for Various Clinical and Radiographic
Characteristics
Characteristic
Likelihood Ratio
Characteristic
Likelihood Ratio
Age 60-69 yrs.
2.64
Lobulated mass
0.74
Nonsmoker
0.15
Spiculated mass
5.54
<30 Pack/yr.
0.74
Malignant growth rate
3.40
30-39 Pack/yr.
2.00
Not calcified
2.20
>40 Pack/yr.
3.70
Benign calcification
0.01
Hemoptysis
5.08
CT enhancement <15 HU
0.04
Previous malignancy
4.95
CT enhancement >15 HU
2.32
0-1.0 cm
0.52
PET SUR
*
<2.5
0.06
1.1-2.0 cm
0.74
PET SUR >2.5
7.10
2.1-3.0 cm
3.67
PET-positive
4.30
>3.0 cm
5.23
PET-negative
0.04
Abbreviations: HU, Hounsfield unit; SUR, standardized uptake ratio.
3.34 Answer: C
The features in this vignette are characteristic of small cell lung cancer (SCLC). SCLC
constitutes approximately 13 to 20% of all lung cancers;
therefore, the estimated annual
incidence of SCLC ranges from
22,000 to 34,000. If there are 170,000 annual lung cancer
cases,
this suggests approximately 22,000 cases at a minimum. With
non-small cell lung
cancer (NSCLC), SCLC shares a strong association
with tobacco use, and without treatment it
tends to lead an
aggressive course.
SCLC is staged according to a two-stage system developed by
the Veteran‘s
Administration Lung Cancer study group as
limited disease or extensive disease. Patients with
limited
disease have involvement restricted to the ipsilateral hemithorax
that can be
encompassed within a safe radiation treatment plan.
Extensive disease is defined as the
presence of overt metastatic
disease by imaging or physical examination. Patients with
otherwise
limited-stage disease with the presence of contralateral hilar
or supraclavicular
nodes or malignant pleural or pericardial
effusions are excluded from clinical trials for
limited-stage
SCLC.
Radiation therapy has been utilized as a consolidation treatment for limited stage disease
following systemic therapy. It has also been used as concurrent therapy with chemotherapy.
Radiation therapy, a local treatment modality, is not effective for SCLC when used as a single
modality.
Chemotherapy with cis-platinum and etoposide is commonly used as first line therapy to
treat SCLC. Because of the high likelihood of distant metastases with small cell histology it is
considered to be a systemic disease at presentation, hence systemic chemotherapy as first line
treatment. With the exception of the occasional peripheral SCLC without involvement of
mediastinal or hilar lymph nodes (< 5% small cell cancers), surgery plays essentially no role
in this disease. For the rare peripheral SCLC resection followed by chemotherapy has been
utilized. Several prospective trials have confirmed the absence of efficacy of resection as a
single modality treatment in this disease. Bleomycin does not play a role in the treatment of
either SCLC or NSCLC.
Thoracic Surgery: Answers
233
References
Simon GR, Turrisi A; American College of Chest Physicians. Management of small cell lung
cancer: ACCP evidence-based clinical practice guidelines (2
nd
edition). Chest.
2007;132(3 Suppl):324S-339S.
Pujol JL, Carestia L, Daurès JP. Is there a case for cisplatin in the treatment of small-cell lung
cancer? A meta-analysis of randomized trials of a cisplatin-containing regimen versus a
regimen without this alkylating agent. Br J Cancer. 2000;83,8-15.
Berghmans T, Paesmans M, Berghmans T, et al. A meta-analyses of the role of etoposide
(VP-16) and cisplatin (CDDP) in small cell lung cancer (SCLC) with a methodology
assessment. Eur J Cancer. 1999;35,s248.
Chute, JP, Chen, T, Feigal, E, et al. Twenty years of phase III trials for patients with
extensive-stage small-cell lung cancer: perceptible progress. J Clin Oncol. 1999;17,1794-
1801.
Brahmer JR, Ettinger DS. Carboplatin in the treatment of small cell lung cancer. Oncologist.
1998;3,143-154.
3.35 Answer: D
Small cell lung cancer (SCLC) is often not detected until it is a systemic disease.
Chemotherapy, usually combined with mediastinal irradiation, has become the standard
therapy for most patients with SCLC. The role of surgery in early stage SCLC has been
reviewed. Surgery as a primary modality of treatment was abandoned after
the British
Medical Research Council published the results of their study
comparing primary radiation
therapy with surgery in patients
with resectable SCLC with a 10-year follow-up. The overall
survival
was better for the radiation therapy-alone arm, and there were
no long-term survivors
in the surgery arm. However, subsequent
reports published in the 1970s and early 1980s
showed long-term
survival in patients treated with surgery alone in very early
disease. The
most favorable subset of patients had T1N0 tumors
identified either at the time of surgery or
at the time of postoperative
pathology examination. Even though the role of adjuvant
therapy
has not been evaluated in prospective randomized trials,
there are several reports suggesting
benefit
for adjuvant chemotherapy even in the earliest stages of the
disease.
The role of surgery in patients with node-positive disease was
evaluated prospectively by
the Lung Cancer Study Group. Patients
with stage I were excluded from this trial. Patients
were initially
treated with five cycles of cyclophosphamide, adriamycin, and vincristine
(CAV). Responding patients were randomized
to undergo surgery or no surgery. All patients
received radiation
therapy to the chest and brain. There was no difference in survival
between
the arms. For all patients, median survival time was
15 months, and 2-year survival rate was
20%.
All patients who are to undergo surgery require mediastinoscopy
before resection. Its
usefulness in SCLC has been validated
in a small prospective Japanese trial. The current
ACCP guidelines recommend surgery
in patients with node-negative disease with small tumor
size
(< 3 cm) because of the lower likelihood of metastasis with
small tumor sizes.
Furthermore, for patients with stage I SCLC who have undergone curative
intent surgical
resection, platinum-based adjuvant chemotherapy
is recommended.
Shahzad G. Raja
234
References
Simon GR, Turrisi A; American College of Chest Physicians. Management of small cell lung
cancer: ACCP evidence-based clinical practice guidelines (2
nd
edition). Chest.
2007;132(3 Suppl):324S-339S.
Simon G, Ginsberg RJ, Ruckdeschel JC. Small-cell lung cancer. Chest Surg Clin North Am.
2001;11,165-188.
Inoue M, Nakagawa K, Fujiwara K, et al. Results of preoperative mediastinoscopy for small
cell lung cancer. Ann Thorac Surg. 2000;70,1620-1623.
Lucchi M, Mussi A, Chella A, et al. Surgery in the management of small cell lung cancer. Eur
J Cardiothorac Surg. 1997;12,689-693.
Friess GG, McCracken JD, Troxell ML, et al. Effect of initial resection of small-cell
carcinoma of the lung: a review of Southwest Oncology Group Study 7628. J Clin Oncol.
1985;3,964-968.
Shields TW, Higgins GA Jr, Matthews MJ, Keehn RJ. Surgical resection in the management
of small cell carcinoma of the lung. J Thorac Cardiovasc Surg. 1982;84,481-488.
Fox W, Scadding, JG. Medical Research Council comparative trial of surgery and
radiotherapy for primary treatment of small-celled or oat-celled carcinoma of bronchus:
ten-year follow-up. Lancet. 1973;2,63-65.
3.36 Answer: C
The finding of metastatic tumor in two of five intraparenchymal (level 11) lymph nodes
makes it a stage II tumor. Multiple clinical trials have been undertaken using Bacillus
Calmette-Guerin (BCG) and other immunostimulants. Although there have been occasional
positive results, most studies have failed to demonstrate a significant difference between BCG
and placebo.
Data for the use of adjuvant cisplatin-based chemotherapy in
stage II NSCLC are strong.
The International Adjuvant Lung Trial,
National Cancer Institute of Canada JBR.10, and
Adjuvant Navelbine
International Trialists Association studies all found significant
benefit for
the use of adjuvant chemotherapy in the general
population of NSCLC studied, as well as in
the stage II patient
subsets. The lung adjuvant cisplatin evaluation metaanalysis
of the 1,616
stage II patient subset found a 27% reduction in
the risk of death (hazard ratio, 0.83; 95%
confidence interval,
0.73 to 0.95).
Postoperative radiotherapy after complete resection of stage
I or II NSCLC has been
proposed with the goal of decreasing
local recurrence rates and improving long-term survival.
The
Cochrane collaboration had recently updated its well-known postoperative
radiotherapy
metaanalysis. The current metaanalysis is based
on the results of 10 randomized control trials
and 2,232 patients.
There continues to be evidence that postoperative radiotherapy
is
associated with a decrease in survival for patients with
stage I (N0) and stage II (N1) NSCLC
although there is improved local control with a significant reduction in recurrences in
ipsilateral lung and mediastinum. Critics note that the
metaanalysis includes a number of
older studies that used radiotherapy
methods that are known to be inferior to current
standards.
Analyzing similar data for patients with stage II and III NSCLC,
Cancer Care Ontario
found that postoperative radiation therapy
was "mainly detrimental to survival in patients with
stage II
NSCLC," while no benefit or detriment was seen for postoperative
radiation therapy
administered to patients with completely resected
stage III NSCLC.
Thoracic Surgery: Answers
235
There are no randomized clinical trials comparing surgery alone
to radiation therapy
alone or chemotherapy alone in the treatment
of early stage (stage I and II) NSCLC. The
concept that surgery
offers the best hope of a cure is based on retrospective data
("clinical
experience") as reported in the Lature. Based
on large series of resected stage I and stage II
NSCLC, the
prognoses for stage IA, IB, IIA and IIB NSCLC, expressed in
terms of 5-year
survival rates, are commonly accepted to be
60 to 80% for stage I and 40 to 50% for stage II
NSCLC.
References
Pignon JP, Tribodet H, Scagliotti GV, et al. Lung adjuvant cisplatin evaluation: a pooled
analysis by the LACE collaborative group. J Clin Oncol. 2008;26:3552-9.
Scott WJ, Howington J, Feigenberg S, et al. Treatment of non-small cell lung cancer stage I
and stage II: ACCP evidence-based clinical practice guidelines (2nd edition). Chest.
2007;132(3 Suppl):234S-242S.
Arriagada R, Bergman B, Dunant A, et al. Cisplatin-based adjuvant chemotherapy in patients
with completely resected non-small-cell lung cancer. N Engl J Med. 2004;350,351-360.
Burdett S, Stewart L. Postoperative radiotherapy in non-small cell lung cancer: update of an
individual patient data meta-analysis. Lung Cancer. 2005;47,81-83.
Okawara G, Ung YC, Markman BR, et al. Postoperative radiotherapy in stage II or IIIA
completely resected non-small cell lung cancer: a systematic review and practice
guideline. Lung Cancer. 2004;44,1-11.
3.37 Answer: B
The extent of lymph node evaluation at the time of surgical
resection of stage I and stage
II NSCLC continues to be a matter
of debate. Clinical practice varies from visual inspection
alone
to radical lymphadenectomy. Questions remain regarding the extent
of lymph node
removal (sampling vs dissection) or the minimum
number of lymph node stations or nodes
sampled.
Two randomized trials have found no difference in overall
survival in patients undergoing
lymphadenectomy compared to
those undergoing lymph node sampling at the time of
resection
for NSCLC. In contrast, a third randomized trial by Wu et al.
found improved
survival for patients with clinical stage I to
III NSCLC who underwent resection with
mediastinal lymph node
dissection rather than sampling.
The Cochrane collaboration reviewed 11 randomized trials with
a total of 1,910 patients
who underwent treatment for early
stage (I to IIIA) lung cancer. From a pooled analysis of
three
trials, they reported that 4-year survival was superior in patients
who underwent
resection and complete mediastinal lymph node
dissection compared with those undergoing
resection and lymph
node sampling, with the hazard ratio estimated to be 0.78 (95%
confidence interval, 0.65 to 0.93; p = 0.005).
Data from a prospective, multiinstitutional, randomized trial
conducted by the ACOSOG
have been reported. This trial was designed
to determine if survival after lung resection was
impacted by
lymph node dissection versus lymph node sampling (ACOSOG Z0030).
Preliminary analysis has found no difference in operative mortality
based on lymph node
procedure. Lymph node dissection was associated
with longer operative time and greater
volume of postoperative
chest tube drainage. However, length of hospital stay did not
differ
between the two surgical approaches (median stay, 6 days).
Both lymph node dissection and
Shahzad G. Raja
236
sampling are safe procedures
and provide critical staging information that will influence
recommendations regarding postoperative adjuvant therapy. At
present, there is insufficient
information to recommend one
technique as superior.
For completely resected patients, the T status (T1 versus T2), visceral pleural
involvement, and histology do not impact survival. Although, adjuvant chemotherapy and
radiation therapy have been applied to this group of patients, current guidelines do not
endorse the use of these therapes. The current Cochrane metaanalysis postoperative
radiotherapy, based
on the results of 10 randomized control trials and 2,232 patients, suggests
that there continues to be evidence that postoperative radiotherapy
is associated with a
decrease in survival for patients with
stage I (N0) and stage II (N1) NSCLC. Analyzing
similar data for patients with stage II and III NSCLC,
Cancer Care Ontario found that
postoperative radiation therapy
was "mainly detrimental to survival in patients with stage II
NSCLC," while no benefit or detriment was seen for postoperative
radiation therapy
administered to patients with completely resected
stage III NSCLC. In one large series of 214
patients with completely resected stage II non-small cell lung cancer, the only factor which
predicted survival was number of metastatic N1 lymph nodes. There was a significant
difference in survival in those patients having a single versus those having multiple N1 nodes
involved with metastatic disease.
References
Scott WJ, Howington J, Feigenberg S, et al. Treatment of non-small cell lung cancer stage I
and stage II: ACCP evidence-based clinical practice guidelines (2nd edition). Chest.
2007;132(3 Suppl):234S-242S.
Izbicki JR, Passlick B, Pantel K, et al. Effectiveness of radical systematic mediastinal
lymphadenectomy in patients with resectable non-small cell lung cancer. Ann Surg.
1998;227,138-144.
Sugi, K, Nawata, K, Fujita, N, et al. Systematic lymph node dissection for clinically
diagnosed peripheral non-small cell lung cancer less than 2 cm in diameter. World J Surg.
1998;22,290-294.
Wu Y, Huang ZF, Wang SY, et al. A randomized trial of systematic nodal dissection in
resectable non-small cell lung cancer. Lung Cancer. 2002;36,1-6.
Manser R, Wright G, Hart D, et al. Surgery for early stage non-small cell lung cancer.
Cochrane Database of Systematic Reviews. 2005;(1),CD004699.
Allen MS, Darling GE, Pechet TT, et al. Morbidity and mortality of major pulmonary
resections in patients with early-stage lung cancer: initial results of the randomized,
prospective ACOSOG Z0030 trial. Ann Thorac Surg. 2006;81,1013-1019
Burdett, S, Stewart, L Postoperative radiotherapy in non-small cell lung cancer: update of an
individual patient data meta-analysis. Lung Cancer. 2005;47,81-83.
Okawara, G, Ung, YC, Markman, BR, et al. Postoperative radiotherapy in stage II or IIIA
completely resected non-small cell lung cancer: a systematic review and practice
guideline. Lung Cancer. 2004;44,1-11.
Martini N, Burt ME, Bains MS, et al. Survival after resection of stage II non small cell lung
cancer. Ann Thorac Surg. 1992;54:460-5.
Thoracic Surgery: Answers
237
3.38 Answer: C
Lung cancers that invade the chest wall are usually peripheral
in location, and hilar and
mediastinal lymph nodes are less
likely to be involved in this group of patients. Tumors that
extend to invade the parietal pleura, muscles, and ribs of the
chest wall and can be completely
resected with en bloc resection
techniques are classified as T3. Significant numbers of these
patients are amenable to treatment by resection, and because
of their favorable survival after
resection, their disease has
been recategorized as stage IIB as long as no lymph nodes are
involved. Factors that influence survival in this group of patients
include the following: (1)
the extent of invasion of the chest
wall, (2) completeness of resection of the tumor, and (3) the
presence or absence of regional lymph node metastases.
Once lymph node involvement is present, the overall survival
after resection of tumors
that invade the chest wall is worse
and survival is comparable to patients with stage IIIA
disease.
In patients who are being considered for extensive chest wall
resections, it is essential
to identify nodal involvement by
noninvasive imaging or minimally invasive biopsy
techniques
before subjecting patients to extensive chest wall resections.
Hilar and mediastinal
lymph nodes can be assessed before surgery
using CT, MRI, and PET scans. Mediastinoscopy
remains the most
sensitive and specific test for evaluating mediastinal nodes
and should be
considered before undertaking a major chest wall
resection.
The use of spirometry, xenon scanning, and exercise oxygen testing
are helpful in
identifying patients who are not suitable for
surgery on the basis of their pulmonary function.
No studies,
however, have accurately predicted the increased postoperative
pulmonary
compromise of patients who have T3 lesions and require
chest wall resections. The overall
effect on chest wall mechanics
can be significant and must be taken into account when
evaluating
the medical condition of the patient and the extent of the pulmonary
resection.
Overall 5-year survival rates for patients with complete resection
range from 18 to 61%.
Long-term results are affected
most importantly by complete resection to microscopically
negative
margins and by absence of N2 nodal involvement. In those in
whom resection was
incomplete or not possible, the 5-year survival
in the two largest series was virtually zero. The
addition
of postoperative radiation therapy in these patients does not
seem to have an impact
on their ultimate survival. In most series,
depth of invasion of the tumor affects survival rates,
with
invasion limited to the pleura being an independent factor favoring
long-term survival
only when compared with deeper invasion.
References
Shen KR, Meyers BF, Larner JM, et al. Special treatment issues in lung cancer: ACCP
evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132(3
Suppl):290S-305S.
Burkhart H, Allen MS, Nichols FC 3rd, et al. Results of en bloc resection for bronchogenic
carcinoma with chest wall invasion. J Thorac Cardiovasc Surg. 2002;123,670-675.
Facciolo F, Cardillo G, Lopergolo M, et al. Chest wall invasion in non-small cell lung
carcinoma: a rationale for en bloc resection. J Thorac Cardiovasc Surg. 2001;121,649-
656.
Chapelier A, Fadel E, Macchiarini P, et al. Factors affecting long-term survival after en-bloc
resection of lung cancer invading the chest wall. Eur J Cardiothorac Surg. 2000;18,513-
518.
Shahzad G. Raja
238
Downey RJ, Martini N, Rusch VW, et al. Extent of chest wall invasion and survival in
patients with lung cancer. Ann Thorac Surg 1999;68,188-193.
3.39 Answer: C
Stage IIIB non-small cell lung cancer (NSCLC) includes patients
with T4 tumors; any N;
M0; and any T, N3, M0. It is estimated
that 10 to 15% of all patients are at stage IIIB at the
time
of diagnosis of their disease. On the basis of the Surveillance,
Epidemiology, and End
Results registry 2004, Wisnivesky et al.
evaluated >80,000 cases of NSCLC with adequate
documentation
of tumor size (53% of total Surveillance, Epidemiology, and
End Results
registry) and reported that 17.6% were stage IIIB.
The anticipated 5-year survival for the vast
majority of patients
who present with clinical stage IIIB NSCLC is 3 to 7%.
The optimal treatment for stage IIIB NSCLC depends on several
variables, including the
extent of disease, age, comorbid risk
factors, patient performance status (PS), and weight loss.
Radiotherapy
(RT) alone has been used in the past but should be limited to
patients with poor
PS. Chemotherapy alone is similarly not a
good treatment option. Surgery can be offered to
highly selected patients,
either as a single modality or after induction (neoadjuvant)
chemotherapy with or without RT. Concurrent chemoradiotherapy
is recommended for most
cases.
References
Jett JR, Schild SE, Keith RL, et al. Treatment of non-small cell lung cancer, stage IIIB:
ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132(3
Suppl):266S-276S.
Wagner H Jr. Rational integration of radiotherapy and chemotherapy in patients with
unresectable stage III A or stage IIIB NSCLC. Results from the Lung Cancer Study
Group, Eastern Cooperative Oncology Group, and Radiation Therapy Oncology Group.
Chest. 1993 Jan;103(1 Suppl):35S-42S.
3.40 Answer: D
Adrenal metastases in the natural history of a malignant neoplasm occur in 20 – 45% of
cancer patients, depending on the localization of the primary site. Up to 40% of patients with
non-small cell lung cancer develop unilateral or bilateral adrenal metastases, as the carcinoma
progresses.
The differential diagnosis of an adrenal mass incidentally discovered during imaging
evaluation of the abdomen in patients with non-small cell lung cancer, usually consists of one
or more of the entities detailed in the Table below.
More than 90% of the cases comprising this involve an adrenal metastasis or a
nonfunctional adenoma.
Nonfunctional adenomas can be differentiated from adrenal metastasis with accuracy
using modern imaging techniques, especially with MR imaging, where adenoma presents as
low intensity signals in T2 sequences compared to hepatic parenchyma. In contrast, the
adrenal metastasis presents higher intensity T2 sequence signals than that of the adenoma,
relative to hepatic parenchyma. In CT-scan adenoma presents low intensity signals, below 10
Hounsfield units, compared to higher intensity signals in adrenal metastasis. Porte et al.,
observed that CT-scan technology has low specificity and sensitivity, which culminates in
false positive and negative readings, given that 21% of true adenomas can be mistaken for