Comparison of outcomes for patients with lepidic pulmonary adenocarcinoma defined by 2 staging systems: A North American experience.

OBJECTIVE: Application of the International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society (IASLC/ATS/ERS) classification of lepidic adenocarcinomas in conjunction with American Joint Committee on Cancer (AJCC) staging has been challenging. We aimed to compare IASLC/ATS/ERS and AJCC classifications, to determine if they could be integrated as a single staging system. METHODS: We reviewed patients from 2001-2013 who had AJCC stage I lepidic adenocarcinomas, and categorized them according to IASLC/ATS/ERS guidelines: adenocarcinoma in situ (AIS); minimally invasive adenocarcinoma (MIA); or invasive adenocarcinoma (IA). We integrated the 2 classification systems by separating AIS and MIA as being stage 0, and routinely classifying IA as stage I. RESULTS: Median follow-up was 52 months in 138 patients. The IASLC/ATS/ERS classification demonstrated a higher disease-free survival (DFS) in AIS (100%) and MIA (96%) versus IA (80%) (P = .022), and higher overall survival (OS): 100% for AIS and MIA, versus 90% for IA (P = .049). The AJCC classification identified a DFS of 87% and an OS of 94% for stage I patients. Integration of the 2 systems demonstrated higher DFS in stage 0 (98%) versus I (80%) (P = .006), and higher OS: 100% for stage 0 versus 90% for stage I (P = .014). CONCLUSIONS: The IASLC/ATS/ERS classification better discriminates AIS and MIA compared with current AJCC staging; however, integration suggests that these categories may be collectively classified in AJCC staging, based on similarly favorable outcomes and distinctive survival rates.

Radiologic Evaluation of Small Lepidic Adenocarcinomas to Guide Decision Making in Surgical Resection.

BACKGROUND: The International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society classification of pulmonary adenocarcinomas identifies indolent lesions associated with low recurrence, superior survival, and the potential for sublobar resection. The distinction, however, is determined on the pathologic evaluation, limiting preoperative surgical planning. We sought to determine whether preoperative computed tomography (CT) characteristics could guide decisions about the extent of the pulmonary resection. METHODS: We reviewed the preoperative CT scans for 136 patients identified to have adenocarcinomas with lepidic features on the final pathologic evaluation. The solid component on CT was substituted for the invasive component, and patients were radiologically classified as adenocarcinoma in situ, 3 cm or less with no solid component; minimally invasive adenocarcinoma, 3 cm or less with a solid component of 5 mm or less; or invasive adenocarcinoma, exceeding 3 cm or solid component exceeding 5 mm, or both. Analysis of variance, t test, χ(2) test, and Kaplan-Meier methods were used for analysis. RESULTS: The radiologic classification identified 35 adenocarcinomas in situ (26%) and 12 minimally invasive (9%) and 89 invasive adenocarcinoma (65%) lesions. At a 32-month median follow-up, patient outcomes associated with the radiologic classification were similar to the pathologic-based classification: the radiologic classification identified 14 of 16 patients with recurrent disease and all 6 who died of lung cancer. In addition, patients with radiologic adenocarcinoma in situ and minimally invasive adenocarcinoma who underwent sublobar resections had no recurrence and 100% disease-free and overall survival at 5 years. CONCLUSIONS: The radiologic classification of patients with lepidic adenocarcinomas is associated with similar oncologic and survival outcomes compared with the pathologic classification and may guide decision making in the approach to surgical resection.

Patients with multiple nodules and a dominant lung adenocarcinoma have similar outcomes and survival compared with patients who have a solitary adenocarcinoma.

OBJECTIVES: Lepidic growth pattern lung adenocarcinoma commonly presents as a dominant lesion (DL) with associated pulmonary nodules either in the ipsilateral or contralateral lung fields, posing a challenge in clinical decision-making. These tumours may be clinically upstaged compared with those who present with solitary lesions and, as a result, may be offered different therapies. The purpose of this study is to compare recurrence rates, the development of new lesions and survival in patients with adenocarcinoma with a lepidic component presenting with a DL with or without additional nodules. METHODS: We performed a 13-year retrospective chart review of patients with lepidic growth pattern adenocarcinoma. Patients were grouped into a uninodular group (UG) if they presented with a solitary lesion and a multinodular group (MG) if they had a DL with additional nodules. Clinicopathological features, outcomes and survival between the two groups were analysed. RESULTS: A total of 149 patients were identified: 62 (42%) in the UG and 87 (58%) in the MG. In addition to the DL, 217 nodules were preoperatively identified in the MG: 60 were resected concomitantly with the DL, while 157 were radiologically surveyed. Invasive adenocarcinoma was the predominant pathological cell type in both groups. The median time of follow-up was 3 years [interquartile range (IQR) 1.9-5.1]. Local (1 vs 2%), regional (1 vs 3%) and distant recurrences (7 vs 4%) were detected, respectively, in the UG and the MG. In the UG, 20 new lesions were identified, while in the MG there were 28. Only 4 of 157 (2.5%) surveyed pre-existing lesions were found to be malignant and required further treatment. No statistically significant differences were observed in 5-year disease-free and overall survival between the UG and the MG (82.3 vs 83.8%, P = 0.254 and 86.7 vs 93.8%, P = 0.096, respectively). CONCLUSIONS: We observed that patients with lepidic growth pattern adenocarcinoma presenting with a DL with associated secondary nodules appear to behave similarly to patients with a solitary lesion. Multiple nodules including those that are malignant in this specific subset of non-small-cell lung cancer should not be upstaged as advanced disease and patients should be treated with the same curative intent as those presenting with uninodular disease.

Surveillance of the Remaining Nodules after Resection of the Dominant Lung Adenocarcinoma is an Appropriate Follow-Up Strategy.

INTRODUCTION: Adenocarcinomas, commonly present as a dominant lesion (DL) with additional nodules in the ipsilateral or contralateral lung. We sought to determine the fate and management of the secondary nodules and to assess the risk of these nodules using the Lung CT Screening Reporting and Data System (Lung-RADS) criteria and the National Comprehensive Cancer Network (NCCN) Guidelines to determine if surveillance is an appropriate strategy. METHODS: We retrospectively evaluated patients with lepidic growth pattern adenocarcinoma and secondary nodules from 2000 to 2013. Risk assessment of the additional lesions was completed with a simplified model of Lung-RADS and NCCN-Guidelines. RESULTS: Eighty-seven patients underwent resection of 87 DLs (Group 1) concurrently with 60 additional pulmonary nodules (Group 2), while 157 non-DLs were radiologically surveyed over a median follow-up time of 3.2 years (Group 3). Malignancy was found in 29/60 (48%) nodules in Group 2. Whereas, only 9/157 (6%) of the lesions in Group 3 enlarged, 4 of which (2.5% of total) were found to be malignant, and then treated, while the remaining nodules continued surveillance. After applying the Lung-RADS and NCCN simplified models, nodules in Group 2 were at higher risk for lung cancer than those in Group 3. CONCLUSION: In patients with lepidic growth pattern adenocarcinoma associated with multiple secondary nodules, surveillance of the remaining nodules, after resection of the DL, is a reasonable strategy since these nodules exhibited a slow rate of growth and minimal malignancy. In contrast, nodules resected from the ipsilateral lung at the time of the DL, harbor malignancy in 48%. Risk assessment models may provide a useful and standardized tool for clinical assessment of pulmonary nodules.

Bronchogenic carcinoid tumours that are 18F-fluorodeoxyglucose avid on positron emission tomography.

OBJECTIVES: Bronchogenic carcinoid tumours are widely cited as non-fluorodeoxyglucose (FDG) avid. However, three case reports of FDG-avid bronchogenic carcinoid tumours have been published, leading to speculation as to which clinicopathological factors may be associated with increased activity on FDG-positron emission tomography. We reviewed a series of cases from our institution and compared them with the available reports in the literature, to attempt to identify the factors associated with FDG avidity in bronchogenic carcinoids. METHODS: We performed a single-institution retrospective review. RESULTS: One patient was identified at our institution who had a typical carcinoid tumour with a standardized uptake value (SUV) of 26, oncocytic features on histology and positive staining for glucose transporter 1 (GLUT1). Three additional patients were identified in the literature with typical bronchogenic carcinoids with SUVs of 39, 38 and 33. Two of these tumours stained positive for GLUT1, and the remaining patient was not tested. Two of these patients had oncocytic features on histology, and results on the remaining patient are not reported. Additionally, 4 patients at our institution were identified with bronchogenic carcinoids with average SUV of 2.6. All were GLUT1 negative, and none had oncocytic features. In the reported literature, excluding the four most FDG-avid tumours described above, atypical carcinoids had a higher mean SUV than typical carcinoids (5.7 vs 3.4, P = 0.02), but size was not correlated with SUV (r = 0.7, P = 0.3). CONCLUSIONS: FDG uptake is commonly associated with worse prognosis in malignancy; however, bronchogenic carcinoids, particularly oncocytic typical carcinoids, are a possible source of extremely high SUVs on FDG-PET.

Extrapleural pneumonectomy for primary pleural mullerian tumor in a young woman.

We present a case of a low-grade mullerian tumor of right pleural origin in a 23-year-old woman treated with an aggressive multimodal treatment paradigm. This tumor is heretofore undescribed in the medical literature. She received induction therapy of carboplatin and paclitaxel with minimal response, then had a maximally cytoreductive right extrapleural pneumonectomy. She subsequently underwent intensity-modulated radiotherapy to the right hemithorax. We propose a treatment paradigm for this previously undescribed primary pleural mullerian tumor.