RESUMEN
OBJECTIVE: Carcinoid of the lung is considered low-grade malignancy, and less invasive treatment may therefore be considered. We analyzed the long-term outcome of initial bronchoscopic treatment in patients with intraluminal bronchial carcinoids. METHODS: Initial bronchoscopic treatment was applied to improve presurgical condition, to obtain tissue samples for proper histologic classification, and to enable less extensive parenchymal resection. For intraluminal bronchial carcinoid, complete tumor eradication with initial bronchoscopic treatment was attempted. High-resolution computed tomography in addition to bronchoscopy was used to determine intraluminal versus extraluminal tumor growth. Surgery followed in cases of atypical carcinoid, residue, or recurrence. RESULTS: Seventy-two patients, 43 of them female, have been treated (median age 47 years, range 16-80 years). Median follow-up has been 65 months (range 2-180 months). Fifty-seven (79%) had typical carcinoids and 15 (21%) had atypical carcinoids. Initial bronchoscopic treatment resulted in complete tumor eradication in 33 of 72 cases (46%), 30 typical and 3 atypical. Thirty-seven of 72 cases (51%), 11 atypical, required surgery (2 for late detected recurrences). Two patients had metastatic atypical carcinoid, 1 already at referral. Of the 6 deaths, 1 was tumor related. CONCLUSIONS: Initial bronchoscopic treatment is a potentially more tissue-sparing alternative than immediate surgical resection in patients with intraluminal bronchial carcinoids. For successful tumor eradication with initial bronchoscopic treatment in central carcinoids, assessment of intraluminal versus extraluminal growth may be of much more importance than histologic division between typical and atypical carcinoid. Disease-specific mortality is low, and long-term outcome has been excellent. Implementation of initial bronchoscopic treatment had no negative impact on surgical treatment outcome.
Asunto(s)
Neoplasias de los Bronquios/diagnóstico , Neoplasias de los Bronquios/cirugía , Broncoscopía , Tumor Carcinoide/diagnóstico , Tumor Carcinoide/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neumonectomía , Resultado del TratamientoRESUMEN
Currently, up to 50% of the operations in early-stage non-small cell lung cancer (NSCLC) are futile owing to the presence of locally advanced tumour or distant metastases. More accurate pre-operative staging is required in order to reduce the number of futile operations. The cost-effectiveness of fluorine-18 fluorodeoxyglucose positron emission tomography ((18)FDG-PET) added to the conventional diagnostic work-up was studied in the PLUS study. Prior to invasive staging and/or thoracotomy, 188 patients with (suspected) NSCLC were randomly assigned to conventional work-up (CWU) and whole-body PET or to CWU alone. CWU was based on prevailing guidelines. Pre-operative staging was followed by 1 year of follow-up. Outcomes are expressed in the percentage of correctly staged patients and the associated costs. The cost price of PET varied between
Asunto(s)
Carcinoma de Pulmón de Células no Pequeñas/diagnóstico por imagen , Carcinoma de Pulmón de Células no Pequeñas/economía , Análisis Costo-Beneficio/métodos , Fluorodesoxiglucosa F18/economía , Neoplasias Pulmonares/diagnóstico por imagen , Neoplasias Pulmonares/economía , Tomografía Computarizada de Emisión/economía , Anciano , Carcinoma de Pulmón de Células no Pequeñas/diagnóstico , Femenino , Costos de la Atención en Salud/estadística & datos numéricos , Humanos , Neoplasias Pulmonares/diagnóstico , Masculino , Estadificación de Neoplasias/economía , Estadificación de Neoplasias/métodos , Países Bajos , Radiofármacos/economía , Reproducibilidad de los Resultados , Medición de Riesgo/economía , Medición de Riesgo/métodos , Sensibilidad y Especificidad , Tomografía Computarizada de Emisión/métodosRESUMEN
Despite radical resection, many patients with stage IA non-small cell lung cancer (NSCLC) die of metastatic disease, showing that apparently there were already micrometastases at the time of surgery. To identify patients at risk for metastatic disease, accurate prognostic factors are needed. Because the mitotic activity index (MAI) is of good prognostic value in several other cancers, we assessed its value in stage IA NSCLC. We assessed the MAI in the sections of 133 patients with radically resected stage IA NSCLC. MAI, histologic subtype, age, sex, location of tumor, type of surgery and tumor diameter were correlated with survival. The mean MAI was 29, ranging from 0 to 89. MAI was not correlated to histologic tumor type or lymph node sample procedure, or any of the other clinicopathologic features. No correlation was found between MAI and survival. Univariate analysis showed that only age was a significant predictor of survival (P = 0.0007). This was confirmed by multivariate analysis. The mitotic index is not a predictor of prognosis in stage IA NSCLC. Therefore other prognostic factors have to be investigated.
Asunto(s)
Carcinoma de Pulmón de Células no Pequeñas/genética , Carcinoma de Pulmón de Células no Pequeñas/patología , Neoplasias Pulmonares/genética , Neoplasias Pulmonares/patología , Índice Mitótico , Estadificación de Neoplasias , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Metástasis de la Neoplasia , Valor Predictivo de las Pruebas , Pronóstico , Estudios Retrospectivos , SobrevidaRESUMEN
BACKGROUND: Up to 50% of curative surgery for suspected non-small-cell lung cancer is unsuccessful. Accuracy of positron emission tomography (PET) with 18-fluorodeoxyglucose (18FDG) is thought to be better than conventional staging for diagnosis of this malignancy. Up to now however, there has been no evidence that PET leads to improved management of patients in routine clinical practice. We did a randomised controlled trial in patients with suspected non-small-cell lung cancer, who were scheduled for surgery after conventional workup, to test whether PET with 18FDG reduces number of futile thoracotomies. METHODS: Before surgery (mediastinoscopy or thoracotomy), 188 patients from nine hospitals were randomly assigned to either conventional workup (CWU) or conventional workup and PET (CWU+PET). Patients were followed up for 1 year. Thoracotomy was regarded as futile if the patient had benign disease, explorative thoracotomy, pathological stage IIIA-N2/IIIB, or postoperative relapse or death within 12 months of randomisation. The primary outcome measure was futile thoracotomy. Analysis was by intention to treat. FINDINGS: 96 patients were randomly assigned CWU and 92 CWU+PET. Two patients in the CWU+PET group did not undergo PET. 18 patients in the CWU group and 32 in the CWU+PET group did not have thoracotomy. In the CWU group, 39 (41%) patients had a futile thoracotomy, compared with 19 (21%) in the CWU+PET group (relative reduction 51%, 95% CI 32-80%; p=0.003). INTERPRETATION: Addition of PET to conventional workup prevented unnecessary surgery in one out of five patients with suspected non-small-cell lung cancer.