The percentage of lepidic growth is an independent prognostic factor in invasive adenocarcinoma of the lung.

BACKGROUND: The literature is inconclusive as to whether the percentage of the lepidic component of an invasive adenocarcinoma (AC) of the lung influences prognosis. We studied a population-based series of selected, resected invasive pulmonary ACs to determine if incremental increases in the lepidic component were an independent, prognostic variable. METHODS: Patients undergoing resection for lung cancer reported to the Cancer Registry of Norway and diagnosed in the period 1993-2002 with a bronchioloalveolar carcinoma (BAC) (old terminology) (adenocarcinoma in situ, AIS in the new terminology) in the lung were selected. A pulmonary pathologist reviewed all sections and estimated the percentage of the lepidic component. Follow-up of survival was to the end of 2013. RESULTS: One hundred thirty-one patients were identified, 102 had AC with lepidic growth. Of these, 44 had AC with a component of lepidic growth less than 50% and seven had AC with 95% lepidic component or more. One of the latter cases was considered to be AIS. In regression analyses, superior survival was associated with a greater lepidic component (p = 0.041). Mucinous tumors had a worse prognosis than non-mucinous (p = 0.012) in regression analyses, as did increasing age and stage. The five-year observed survival was 69.0% for non-mucinous cases and 66.7% for the group with a lepidic component of 80% or greater. CONCLUSION: The percentage of the lepidic component appears to be an independent, significant prognostic factor in a selection of pulmonary AC.

National trends in lung cancer surgery.

OBJECTIVES: Trends in lung cancer surgery may reveal potential for improvement and are important for planning by care providers. METHODS: Using data from the Cancer Registry of Norway, we analysed the outcomes of lung cancer surgery during the periods of 1994-95, 2000-01 and 2006-07. The Cox regression model was carried out to identify the period effect on survival. RESULTS: A total of 2201 patients were operated on. Surgery was centralized from 24 hospitals in the first two periods to 13 hospitals in the last. The resection rates varied from 6 to 31% across the counties. From the first to the last period, the national resection rate increased from 16 to 19% (P(trend) = 0.001), and the 1-year survival rate increased from 73 to 82%. The proportion of resected patients in pathological stage I-II decreased from 87 to 83% (P(trend) = 0.048), the proportion of pneumonectomies from 27 to 15% (P(trend)<0.001), and the rate of mortality within 30 days of the surgery from 4.8 to 3.0% (P(trend) = 0.072). In the first two periods, 31% of these early deaths were caused by complications directly related to the surgical technique, whereas, in the latter period, no deaths were directly related. The only unfavourable trend was the waiting time between the final diagnostic procedure and surgery, which increased from 29 to 40 days throughout the three periods (P < 0.001). Survival (excluding those who died within 30 days) was significantly improved in the last period (risk ratio (RR): 0.72 (P < 0.001)). CONCLUSIONS: Despite an increased surgical waiting time, important aspects of lung cancer surgery, including resection rates, have improved in recent years.

Carcinoid lung tumors--incidence, treatment and outcomes: a population-based study.

OBJECTIVE: Few published reports have examined the incidence and outcomes for patients with carcinoid lung tumors. The aim of the current study was to explore incidence, type of surgical treatment given, and outcome for patients with typical (TC) and atypical (AC) lung carcinoids in a national cohort (Norway). METHODS: All lung-cancer patients diagnosed in the period 1993-2005 and who were reported to the Cancer Registry of Norway were identified. Biopsies or resection specimens were reviewed and reclassified according to the World Health Organization (WHO) 2004 classification. Surgically treated patients were staged according to the seventh edition of the pathological tumor-node-metastasis (pTNM) staging system. RESULTS: Of 26665 lung cancers registered during the period, 265 (1%) had carcinoid tumors, of which 11 were diagnosed coincidentally at autopsy. In the remaining 254 patients, TCs were found in 188 cases, and ACs were found in 59 cases; seven cases had unclassifiable carcinoids. Of the 217 resected tumors, 173 (80%) were TCs. General surgeons performed 94 resections, including 11 of 17 pneumonectomies. All six bronchial resections were performed by thoracic surgeons. Of the 33 operated patients who died during follow-up, 18 had metastatic carcinoid tumors, of which 10 (56%) were ACs. In 37 non-resected patients (15 with AC and seven with unclassifiable histology), metastatic or locally advanced disease (N=21, 12 of which were ACs) was the main cause of inoperability and death. Five-year survival for all patients was 92% for TC and 66% for AC; for resected patients, the survival rates were 96% and 79%, respectively. CONCLUSIONS: Carcinoids are rare malignant tumors and are, in most cases, resectable; the TC subgroup had better prognosis than the AC in univariate analyses. The main cause of death was metastasis/locally advanced tumor at presentation or recurrent disease following resection; both situations were three times more common in patients with AC.

[Lung cancer without metastases--are all patients with resectable tumor operated?]. / Lungekreft uten spredning--blir alle pasienter med resektabel tumor operert?

BACKGROUND: Only 17% of patients with lung cancer are surgically resected, and the resection rate has not improved despite more attention about the disease. All patients with resectable disease should be offered operation and we wanted to investigate whether this is the case. MATERIAL AND METHODS: We assessed patients that received the diagnosis localized lung cancer in the period 2003-2005 and were not resected according to the Cancer Registry of Norway (n = 322). After exclusion of 40 patients, 282 remained for evaluation. RESULTS: The Cancer Registry of Norway had received clinical reports for 253 patients. Lung physicians had filled in less than half of these, and TNM was registered appropriately in 37% of all reports. Despite that all patients had been categorized in the Registry as having localized lung cancer, 55 patients had advanced disease. Poor lung function, high age and serious comorbidity were contraindications towards surgery for patients with localized disease. Of 282 patients, 258 were inoperable while nine had undergone resection. The remaining 15 cases were thus classified as being operable or possibly operable. INTERPRETATION: The proportion of patients who had not undergone resection and were assessed as operable has decreased. Legally required reporting to the Cancer Registry is still insufficient. Introduction of a specific report form for these patients may facilitate treatment evaluation and thereby treatment and ensure that the decision to not operate is well documented.

Resected synchronous primary malignant lung tumors: a population-based study.

BACKGROUND: Synchronous lung tumors with a histology indicating primary lung carcinomas detected preoperatively or at surgery may represent intrapulmonary metastases from a primary tumor or two or more simultaneously occurring primary tumors. The situation is rare. This study was conducted to assess the characteristics and outcome for this patient group. METHODS: All clinical and pathology departments in Norway submit standardized reports on cancer patients to the Cancer Registry of Norway. The registry also has a law-regulated authority to collect supplemental information on diagnosis, treatment, and outcome for all cancer patients from hospitals. During the period 1993 to 2000, lung cancer was diagnosed in 15,308 patients, of whom 2528 underwent resection in 24 hospitals. This investigation included all patients with histology demonstrating primary lung carcinoma in more than one tumor in the resected specimen. RESULTS: Synchronous malignant tumors were found in 94 patients: 66 had two tumors and the remaining 28 had three or more. The tumors were of similar histology in 85 cases. The tumors were diagnosed preoperatively in 11 patients and peroperatively or in the resected specimen in the other 83. The 5-year relative survival rate was 31.4% for patients with squamous cell carcinomas, 23.2% for adenocarcinomas, and 42.7% for patients with tumors of other histology (two carcinoids). CONCLUSIONS: Survival in patients with synchronous lung tumors is good compared with historical reports on patients with distant metastases or other variants of T4 tumors; thus, they should be considered for surgery.

Risk factors for 30-day mortality after resection of lung cancer and prediction of their magnitude.

BACKGROUND: There is considerable variability in reported postoperative mortality and risk factors for mortality after surgery for lung cancer. Population-based data provide unbiased estimates and may aid in treatment selection. METHODS: All patients diagnosed with lung cancer in Norway from 1993 to the end of 2005 were reported to the Cancer Registry of Norway (n = 26 665). A total of 4395 patients underwent surgical resection and were included in the analysis. Data on demographics, tumour characteristics and treatment were registered. A subset of 1844 patients was scored according to the Charlson co-morbidity index. Potential factors influencing 30-day mortality were analysed by logistic regression. RESULTS: The overall postoperative mortality rate was 4.4% within 30 days with a declining trend in the period. Male sex (OR 1.76), older age (OR 3.38 for age band 70-79 years), right-sided tumours (OR 1.73) and extensive procedures (OR 4.54 for pneumonectomy) were identified as risk factors for postoperative mortality in multivariate analysis. Postoperative mortality at high-volume hospitals (> or = 20 procedures/year) was lower (OR 0.76, p = 0.076). Adjusted ORs for postoperative mortality at individual hospitals ranged from 0.32 to 2.28. The Charlson co-morbidity index was identified as an independent risk factor for postoperative mortality (p = 0.017). A prediction model for postoperative mortality is presented. CONCLUSIONS: Even though improvements in postoperative mortality have been observed in recent years, these findings indicate a further potential to optimise the surgical treatment of lung cancer. Hospital treatment results varied but a significant volume effect was not observed. Prognostic models may identify patients requiring intensive postoperative care.

[Waiting time for surgery of lung cancer]. / Ventetid på operasjon for lungekreft.

BACKGROUND: Surgical resection is the mainstay of curative treatment for lung cancer. It is important that the resection is done as soon as the disease is diagnosed. The waiting time in Norway can be longer than desirable. MATERIAL AND METHODS: Patients who underwent resection for primary lung cancer in the period 1998-2001 were identified in the Cancer Registry of Norway. When malignancy was confirmed preoperatively by histopathology or cytology, the time interval from diagnostic procedure to the pathologist's answer was calculated as response time and further the time from diagnosis to surgery was calculated as waiting time. Covariates important for waiting time were analysed by univariable and multivariable regression analyses. RESULTS: Of the 1351 patients that were operated in the period, 924 had a positive cytological or histological preoperative diagnosis. Pathology response time was median 3 days and waiting time for surgery was median 26 days (range 0-406 days). Multivariable regression analysis demonstrated that disease stage, histology and patient referral between hospitals contributed to waiting time from diagnosis to operation. Patients undergoing investigation and surgery at the same hospital had a median 9 days shorter waiting time than those referred from other hospitals. INTERPRETATION: Our investigation revealed a longer waiting time than desired. A high proportion of patients did not have a positive preoperative biopsy or cytology.

Lung cancer surgery: the first 60 days. A population-based study.

OBJECTIVE: The postoperative mortality following lung cancer surgery is relatively high. The purpose of the present study was to identify preoperative risk factors as well as fatal complications in 27 Norwegian hospitals. METHODS: In Norway, all clinical and pathologic departments submit reports on cancer patients to the Cancer Registry of Norway. The Registry also has a law-regulated authority to collect supplemental information regarding diagnosis, treatment, and outcome for all cancer patients from the hospitals in charge. This investigation included all patients who died within 30 and 60 days after resection of lung cancer in the period 1993-2002. RESULTS: During the investigation lung cancer was diagnosed in 19,582 patients, 3224 (16.5%) were treated by surgery. The resection rate was almost similar in the two sexes, but postoperative mortality in women was less than half compared to men. Total mortality was 5% and 8% after 30 and 60 days, respectively. Bilobectomy and pneumonectomy were most risky with a mortality rate of about 10% within 60 days. In patients more than 70 years of age, there was a considerably higher frequency of pneumonectomy in men compared to women. Dominating causes of death were pneumonia with respiratory failure and cardiac events. Other identifiable causes were surgical hemorrhage and bronchopleural fistula. CONCLUSIONS: In this population-based, unselected series, the postoperative mortality was relatively high, and increased markedly in patients older than 70 years. Pneumonectomy in patients older than 70 years should only be performed when heart-lung function is found to be acceptable following full pulmonary function testing and thorough preoperative assessment of cardiovascular risk factors.

Results of pulmonary resection for lung cancer in Norway, patients older than 70 years.

OBJECTIVE: Surgical resection for lung cancer is the mainstay of curative treatment, but studies regarding postoperative results and long term outcome in the elderly have differed. The purpose of the present study was to assess the early and long-term results of surgical resection in patients more than 70 years of age. METHODS: In Norway all clinical and pathologic departments submit reports on cancer patients to the Cancer Registry of Norway. This investigation included all patients more than 70 years of age resected for lung cancer in the time period 1993-2000. For results of long-time follow-up only patients operated on between 1993 and 1998 were included. RESULTS: A total of 763 patients (541 men) were identified aged 71-87 years. Postoperative mortality rate was 9%, highest after bilobectomy and pneumonectomy. The most commonly reported causes of postoperative death were pneumonia and cardiac complications. The majority of patients had tumor categorized as clinical stage (cStage) Ia and Ib. More than 100 in each of these groups proved to have more advanced disease postoperatively (pStage). The 5-year relative survival rate was significantly better in patients with disease in pStage I compared to higher stages. Women had a significantly better 5-year survival rate compared to men, 62.8 and 35.7%, respectively. CONCLUSIONS: Lung cancer surgery appears to be a relatively safe procedure even in the elderly. There is a high postoperative mortality after bilobectomy and pneumonectomy. However, when old people survive the postoperative period the long term prognosis seems favorable.

[Tracheal resections]. / Trakealreseksjoner.

BACKGROUND: Tracheal resection is a valuable treatment option in patients with primary localized tumours and in selected patients with post-tracheostomy stenosis. The main symptom is dyspnoea on activity. Tracheal tumour is a rare condition with adenoid cystic carcinoma as the dominant malignant type, whereas papilloma is the most common benign lesion. MATERIAL AND METHODS: In our institution we performed eight tracheal operations from 1989 to 2002. Five patients had malignant tumours and three post-tracheostomy stenosis. The patients were reevaluated with endoscopy. RESULTS AND INTERPRETATION: Four patients with carcinomas underwent tracheal resection and direct anastomosis. One patient had postoperative irradiation due to carcinoma cells in the resection margin and died five years later. In one patient local infiltration outside the tracheal wall rendered him inoperable. Two of the three patients with benign stenoses had recidivations and underwent endoscopic dilatation and stenting. Patients with localized malignant tumours and selected patients with benign tracheal stenoses may benefit from tracheal resection. Tracheal stenosis is an important differential diagnosis in patients with airway obstruction that does not respond to pharmacological treatment.

Small cell lung cancer in Norway. Should more patients have been offered surgical therapy?

OBJECTIVE: The final outcome of patients with small cell lung cancer (SCLC) is poor with an overall 5-year survival rate of less than 10%. Therefore, the question of surgery in patients with a technically-operable solitary tumor has been raised. The purpose of this study was to identify the proportion of patients with operable SCLC and to assess the prognosis of different treatment strategies. For patients who were operated, we compared the resection specimens from patients with more than 5-year survival with those with shorter survival to see whether the specimens belonged to different subclasses of SCLC. METHODS: In Norway all clinical and pathologic departments submit reports on cancer patients to the Cancer Registry. The Registry also has a law-regulated authority to collect supplemental information regarding diagnosis, treatment and outcome for all cancer patients from the hospitals in charge. All reports on patients diagnosed as having SCLC in limited disease or unknown stage during the time interval 1993-1999 were reviewed. Patients with a T2-tumor, in whom a pneumonectomy would have to be performed, were classified as potentially operable. Five-year relative survival was calculated for patients diagnosed in 1993-1997. RESULTS: During the actual period 2442 individuals with SCLC were identified. The majority was treated with conventional chemotherapy or concurrent chemoradiotherapy while 38 underwent surgical therapy. Following reclassification of 697 patients reported to have limited disease or unknown stage 180 were judged to be in stage I. In addition to the 38 resected patients 14 were considered fit for surgery technically and medically while 97 were found to be potentially operable treatment modalities apart from surgery yielded a 5-year survival rate <7%. For stage I (N=96) the rate was 11.3% in conventionally treated patients compared to 44.9% for those who underwent surgical resection. By pathological review of surgical specimens a diagnosis of SCLC was confirmed in all patients treated by surgery in the groups with long and short survival. CONCLUSION: This investigation demonstrates that patients with SCLC having a peripherally located tumor should be referred to surgery, as long time survival is far better than for conventionally treated patients.

[Causes of postoperative mortality after lung cancer surgery]. / Arsaker til mortalitet etter reseksjon for lungekreft.

BACKGROUND: There is a relatively high postoperative mortality after lung cancer surgery. However, the alternative is almost 100% mortality within five years if surgery is not performed. MATERIAL AND METHODS: This study is based on data in the Cancer Registry of Norway and information from hospitals where the patients had been treated. From 1993 to 2000, 2528 patients with lung cancer were operated with lung resection. RESULTS: A total of 188 patients died within 60 days. In 54 of them the cause of death was respiratory failure or pneumonia. There were nine cases with serious intraoperative bleeding with seven deaths, six on the table. Further postoperative bleeding occurred in 27 cases, most often after pneumonectomy. Of these, 10 died because of the bleeding. For 15 patients the cause of death was bronchopleural fistula, of which 13 had been operated with pneumonectomy. Myocardial infarction or cardiac failure caused the death of 32 patients. An additional 70 patients died from other complications. INTERPRETATION: Postoperative fatal complications after lung resection for cancer are too high.

[Computed tomography in lung cancer--technique and quality]. / Computertomografi ved lungekreft--teknikk og kvalitet.

BACKGROUND: There are indications that more patients with lung cancer should be offered surgical treatment. The percentage of surgically treated patients varies from one region of Norway to the other. The Cancer Registry of Norway has received CT examinations from lung cancer patients who were not operated. Differences in examination technique and quality were evaluated. MATERIAL AND METHODS: Thoracic CT examinations from 42 patients (9 women) from 32 institutions were evaluated by three radiologists with regard to technique and quality. RESULTS: Twenty-seven examinations (63%) were considered acceptable for evaluation of operability, while 15 (37%) were not. The proportion of adequately performed examinations was higher with helical CT (22 out of 25 examinations, 88%) than with conventional, axial scanning (5 out of 17 examinations, 29%). There were substantial variations in scanning technique (area, collimation, contrast medium, algorithms, and photographic documentation). The majority (n = 40) of investigations were performed with intravenous contrast medium, two without. Contrast medium enhancement and vascular visualisation was judged as insufficient in seven examinations. INTERPRETATION: Many examinations were of suboptimal quality, inadequate for pre-operative tumour staging. Several different examination techniques were documented.

[Is the treatment of lung cancer in Norway adequate?]. / Er behandlingen av lungekreft i Norge god nok?

BACKGROUND: Almost 2,000 new cases of lung cancer are reported in Norway every year. Only 16-17% are operated upon with resection. MATERIAL AND METHODS: Over the 1995-98 period, 1,035 not resected cases with localized lung cancer were reported to the Cancer Registry of Norway; 166 cases were excluded for various reasons. Records from the Cancer Registry with additional information from clinicians were revised by the authors with regard to staging and operability. RESULTS: Of 869 evaluable patients, 386 were inoperable due to advanced disease, and in 86 the situation was not adequately clarified. Of the remaining 397, 270 were classified as being operable and 127 possibly operable. Of the operable patients, small cell lung cancer was considered as the sole contraindication to surgery in 61 patients despite being in stage 1. Poor lung function was noted as contraindication to surgery in 50 patients. However, most of them were inadequately investigated. In 124 patients one or more other risk factors were considered as contraindications, but the impact of some of them seemed to have been overestimated. INTERPRETATION: The study showed that the information about stage routinely submitted to the Cancer Registry was unsatisfactory. We believe that more patients with localized disease in the present series should have been operated on.

[Endovascular stent-graft repair of abdominal aortic aneurysm]. / Endovaskulaer stentgraftbehandling av abdominale aortaaneurismer.

BACKGROUND: Endovascular stent-graft repair of abdominal aortic aneurysms was introduced in 1991. Long-term results from randomised studies are still not available. Aneurysm ruptures after stent-graft repair have been reported, and there has been a considerable need for redo procedures. MATERIAL AND RESULTS: At Rikshospitalet in Oslo, Norway, 26 stent-graft implantations for abdominal aortic aneurysms were performed during the years 1996-2000, two of which were primary technical failures immediately converted to open repair. During follow-up, two patients have died from unrelated causes after six and 12 months. Eight patients were converted to open repair 8-50 months (median 31) after implantation. Indications for conversion were migration (n = 4), increasing aneurysm diameter (n = 3) and rupture (n = 1). Of the 14 patients still under observation, six have had one or more endovascular interventions (a total of 10) for failing graft. INTERPRETATION: Continuous technology development has been used as an argument to postpone randomised studies, as improved results are expected with new generations of stent-grafts. There is a need for discussion of the strategy for the further use of endovascular repair of abdominal aortic aneurysm.