Palliative care in poor-performance status small cell lung cancer patients: is there a mandatory role for chemotherapy?

PURPOSE: Small cell lung cancer (SCLC) is an aggressive malignancy but with a high response rate to chemotherapy. Eastern Cooperative Oncology Group performance status (ECOG PS) has been recognized as one of the main prognostic factors in SCLC. There are few data about risk-benefit ratio of chemotherapy over exclusive best supportive care in ECOG PS 3 and 4 patients. This study was performed to assess the outcome of poor ECOG PS SCLC patients that received chemotherapy in our institution. METHODS: A retrospective review of medical records from patients with ECOG PS 3-4 SCLC, who received systemic chemotherapy, was performed between January 2001 and December 2006 at the Instituto Nacional do Câncer, Rio de Janeiro, Brazil. RESULTS: A total of 40 patients were included. Extensive disease was observed in 85% of patients and 25% had PS 4. The median overall survival was 53 days (64 days for ECOG PS 3 and 7 days for ECOG PS 4). There were 30% of early deaths. On univariate analysis, lactate dehydrogenase value, need for hospital admission, and exposure to radiotherapy had impact on survival. ECOG PS 3 patients had better survival than PS 4 patients, even when adjusted for stage. On multivariate analysis, ECOG PS, combined with stage, sustained a major influence on survival. CONCLUSIONS: Median survival for ECOG PS 4 patients treated with chemotherapy in our series was extremely short with a high rate of early deaths. ECOG PS 3 patients also showed a poor survival. These data suggest that we need a more comprehensive approach and further studies, regarding the palliative care of this high-risk population.

[Lipoid pneumonia]. / Pneumonia lipóide.

Lipoid pneumonia (LP) is a pneumonitis resulting from the aspiration of lipids, and is commonly associated with the use of mineral oil as a laxative. LP is relatively unfamiliar to clinicians and is probably underdiagnosed. Making a diagnosis of LP requires a high degree of clinical suspicion. The aim of this publication are to present a case of a patient with LP and to increase physician awareness of LP, its diagnosis and prevention.

[Transbronchial needle aspiration of hilar and mediastinal lymph nodes]. / Punção aspirativa transbrônquica por agulha de linfonodos hilares e mediastinais.

BACKGROUND: Besides clarifying the etiology of unidentified lymphadenomegaly, puncturing hilar and mediastinal lymph nodes by a flexible bronchoscopic needle is an aid in diagnosing and staging broncho- genic cancer or other metastatic cancers. OBJECTIVE: Our study had the principal objective to evaluate the positivity of transbronchial needle aspiration (TBNA). METHOD: We evaluated retrospectively the effectiveness of all TBNA done in 74 consecutive patients. Forty-nine patients were male and the median age was 59. We used Wang-needles, 21-gauge (Bard, USA), and the same technique described for different authors. Of the 74 patients evaluated, 11(15%) showed mediastinal mass and 65 (85%) hilar mass. We observed 76 endoscopic abnormalities. RESULTS: According to the classification of the specimens, we had 32/74 (43%) unsatisfactory specimens, 34/74 (46%) satisfactory and diagnostic specimens, and 8/74(11%) satisfactory and non-diagnostic specimens. Thirty four (46%) of the examinations were found to be positive out of the total amount of specimens. Of the positive results, 30/34 specimens (88%) contained malignant disease. Small-cell carcinoma was the most frequent finding, with 10/34 cases (29%); squamous cell carcinoma 7/34 (21%); adenocarcinoma 7/34 (21%), non- -small cell carcinoma 6/34 (17%); sarcoidosis 2/34 (6%) and tuberculosis 2/34 (6%). CONCLUSION: Our study indicated that this method is safe, easy to per- form, with a minimum of complications and useful for the diagnosis and staging of pulmonary neoplasms.

Phase II trial of neoadjuvant chemotherapy using alternating doublets in non-small-cell lung cancer.

PURPOSE: Lung cancer is an epidemic disease in developing countries. Incorporation of new active drugs in the neoadjuvant treatment of operable patients might lead to improved outcomes. Postchemotherapy mediastinal-based treatment decisions allow for in vivo testing of activity and could help to determine the ideal local treatment. PATIENTS AND METHODS: This phase II trial enrolled patients with documented non-small-cell lung cancer, clinically staged IB-IIIA, and considered candidates for surgical resection. Patients received 3 cycles of neoadjuvant chemotherapy with alternating doublets: cisplatin/gemcitabine; gemcitabine/vinorelbine, and cisplatin/vinorelbine. After neoadjuvant treatment, clinical restaging was performed. Patients without evidence of progression underwent mediastinoscopy. Those with negative mediastinal nodes were taken to surgery whereas those with positive nodes were treated with radiation therapy. RESULTS: Between January 2001 and August 2002, 30 patients were included. The median age was 56 years, 66% of the patients were men, 43% of the patients had adenocarcinoma, and 34% had squamous cell carcinoma. Clinical staging was IB in 9 patients (30%), IIB in 7 (23%), and IIIA in 14 (47%). Median tumor size was 6.5 cm (range, 3-11 cm). Twenty-three patients (77%) had clinical response to neoadjuvant chemotherapy. Eight of 12 patients (67%) with N2 disease had clinical downstaging. Twenty-two patients (73%) were taken to surgery. Complete resection rate was achieved in 21 patients (70%). Treatment was well tolerated. CONCLUSION: Localized non-small-cell lung cancer is very sensitive to chemotherapy. Postchemotherapy mediastinal-based treatment decision led to a high complete resection rate, even in patients with large tumors. This strategy deserves further investigation.

Tratamento cirúrgico das metástases pulmonares nodulares / Surgical treatment of the nodular lung metastasis

Cinquenta e dois pacientes com metástases pulmonares nodulares de sarcomas e carcinomas foram tratados cirurgicamente e seus prontuários avaliados retrospectivamente no Serviço de Cirurgia Torácica do Instituto Nacional do Câncer entre agosto de 1979 a agosto de 1989. Entre os sarcomas observamos 23 osteossarcomas, dois fibro-histiocitomas e casos isolados de sarcoma de Ewing, neurofibrossarcoma, leiomiossarcoma, condrossarcoma e sinoviossarcoma. Nos pacientes com carcinomas observamos sete tumores testiculares, quatro tumores de mama, três tumores de cólon e reto, três tumores de pele, doi tumores de parótida e um de cada com tumor de estomago, rim e faringe. O intervalo livre de doença variou de zero a 96 meses e o tempo de duplicaçäo tumoral foi determinado em 22 pacientes variando de 16 a 107 dias. Os 52 pacientes foram submetidos a 73 operaçöes, sendo que 12 necessitaram de mais de uma cirurgia, devido a recidiva. Dentre os 462 nódulos ressecados, apenas seis pacientes com tumores testiculares näo tinha células malignas viáveis. Conclui-se que a cirurgia da metástase pulmonar é o tratamento indicado para pacientes selecionados e a presença de doença bilateral foi o único dado que comprometeu o prognóstico desses pacientes