Clinical Upstaging of Non-Small Cell Lung Cancer That Extends Across the Fissure: Implications for Non-Small Cell Lung Cancer Staging

doi:10.1016/j.athoracsur.2010.09.075

The Annals of Thoracic Surgery

Volume 91, Issue 2, February 2011, Pages 350-353

https://doi.org/10.1016/j.athoracsur.2010.09.075 Get rights and content

Background

Little data exist as to the long-term outcome of non-small cell lung cancer that extends across the fissure into the adjacent lobe that requires either a bilobectomy or a lobectomy and wedge resection.

Methods

Lobectomy survival data was benchmarked with the International Association for the Study of Lung Cancer (IALSC) dataset. Matched analysis of a prospective thoracic surgery database of 1,020 patients who had undergone lobectomy during a 6-year period was analyzed to elucidate the effect on long–term survival of tumors that extend across the interlobar fissure.

Results

Benchmarking revealed our data are not significantly different from the IALSC dataset, allowing survival recommendations to be drawn. Histopathologic staging of matched patients was IA, 11.7%; IB, 51.1%; IIA, 1.7%; IIB, 21.1%; IIIA, 10.0%; IIIB, 2.8%; and IV, 1.7%. Stage I tumors crossing the interlobar fissure had a reduction in survival that is significant (10% to 15%) after 5 years (p = 0.037). The 5-year survival for stage I tumors extending across a lung fissure was 50%. This places the 5-year survival between stage I and II (60% and 40%, respectively). There was no difference in survival for tumors stage IIA and above with regard to importance of interlobar extension. The number of patients was too small to detect a significant difference between bilobectomy versus lobectomy and wedge.

Conclusions

Non-small cell lung cancer that extends across the fissure into an adjacent lobe requiring a bilobectomy or a lobectomy and wedge resection has a 5-year survival between stages I and II.

Section snippets

Patients and Methods

The ethics committee of Liverpool Heart and Chest Hospital approved the protocol of the current study.

Data were collected prospectively on all patients undergoing lung resection for NSCLC between 2001 and 2007. Patients undergoing pneumonectomy were excluded. A total of 1,020 patients underwent a lobectomy. Patients with small cell lung cancer or benign lesions were excluded. We identified 180 patients from this total as having lesions that crossed a lung fissure and extended between two

Benchmarking

Five-year survival for NSCLC for stages I to IV was found to be not significantly different from the IALSC published survival curves used to recommend the TNM classification system (Fig 1).

There was no significant difference between patients who had tumors confined to a single lobe, or those with tumors spreading across the fissure with regard to mean age, sex, chronic obstructive pulmonary disease, percentage predicted forced expiratory volume in 1 second, the ratio of the forced expiratory

Comment

Revisions in the international lung cancer staging have not addressed tumors invading interlobar pleura into adjacent lobes [2]. In this study we compared the outcome of patients with NSCLC that invade into an adjacent lobe that requires either a bilobectomy or a lobectomy and wedge resection to remove it, compared with stage-matched patients who required an isolated lobectomy.

Previous work on interlobar spread of lung cancer that is treated surgically has resulted in highly variable

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Cited by (19)

Oncologic Outcomes of Surgery Versus SBRT for Non–Small-Cell Lung Carcinoma: A Systematic Review and Meta-analysis
2021, Clinical Lung Cancer
The optimal treatment of stage I non–small-cell lung carcinoma is subject to debate. The aim of this study was to compare overall survival and oncologic outcomes of lobar resection (LR), sublobar resection (SR), and stereotactic body radiotherapy (SBRT).
A systematic review and meta-analysis of oncologic outcomes of propensity matched comparative and noncomparative cohort studies was performed. Outcomes of interest were overall survival and disease-free survival. The inverse variance method and the random-effects method for meta-analysis were utilized to assess the pooled estimates.
A total of 100 studies with patients treated for clinical stage I non–small-cell lung carcinoma were included. Long-term overall and disease-free survival after LR was superior over SBRT in all comparisons, and for most comparisons, SR was superior to SBRT. Noncomparative studies showed superior long-term overall and disease-free survival for both LR and SR over SBRT. Although the papers were heterogeneous and of low quality, results remained essentially the same throughout a large number of stratifications and sensitivity analyses.
Results of this systematic review and meta-analysis showed that LR has superior outcomes compared to SBRT for cI non–small-cell lung carcinoma. New trials are underway evaluating long-term results of SBRT in potentially operable patients.
Staging of Lung Cancer
2015, Clinics in Chest Medicine
Citation Excerpt :
Tumors that extend across a lung fissure to involve adjacent lobes are not categorized separately and therefore are considered by some to technically be categorized under the T2 descriptor. Early studies had conflicting results regarding the survival of these patients, but were also confounded by including pneumonectomy patients with increased morbidity.87–89 More recently, Haam and colleagues90 retrospectively evaluated 837 patients with T2 and T3 N0M0 disease, including 46 patients with direct translobar invasion, and found that 5-year survival of the invasion group was closer to T3 survival: 53% and 49%, respectively.
Morbidity, mortality and survival after surgery for lung cancer
2015, Archivos de Bronconeumologia
Poorer survival in stage IB lung cancer patients after pneumonectomy
2015, Archivos de Bronconeumologia
Citation Excerpt :
With regard to anatomical site, if proximal infiltration of the hilar structures or general extension across the lung fissure is observed, parenchymal-sparing techniques may be impossible. Even if lung fissure extension is not generalized and visceral pleural invasion is limited to a single point, several authors maintain that prognosis can be poorer in these patients.9–12 Some suggest that patients with T1 or T2 tumors with visceral pleural involvement crossing the interlobar fissure be classified as T3, or at least stage IIB (which comes down to the same), since survival is reduced by 10%–15% compared to patients with disease confined to a single lobe.12
Pneumonectomy may be needed in exceptional cases in patients with early stage NSCLC, especially in stage IB. The aim of this study was to evaluate whether overall survival in stage IB (T2aN0M0) NSCLC patients is worse after pneumonectomy.
Retrospective study of a series of pathological IB (pIB) patients who underwent either lobectomy or pneumonectomy between 2000 and 2011. The dependent variable was all-cause death. Operative mortality was excluded. The relationship between the age, FEV1%, Charlson index and performance of pneumonectomy variables and the dependent variable were analyzed using a Cox regression. Overall survival for both groups of patients was then plotted in Kaplan–Meier graphs and compared using the log-rank test.
A total of 407 cases were analyzed (373 lobectomies and 34 pneumonectomies). According to Cox regression, age, FEV1% and pneumonectomy were associated with poorer survival (P<.05). Age-adjusted survival and FEV1% showed diminished survival in patients who underwent pneumonectomy (log-rank, P=.0357).
In stage pIB NSCLC patients, pneumonectomy is associated with poorer survival compared to lobectomy.
La neumonectomía puede ser necesaria de forma excepcional en pacientes con cáncer de pulmón no microcítico (CPNM) en estadios precoces, algo más frecuentemente en el estadio IB. En este estudio se pretende evaluar si la neumonectomía se asocia con peor supervivencia global en pacientes con CPNM en estadios patológico IB (T2aN0M0).
Estudio retrospectivo sobre una población de pacientes con carcinoma de pulmón pIB sometidos a lobectomía pulmonar o neumonectomía entre 2000 y 2011. La variable dependiente es la muerte del paciente por cualquier causa, excluida la mortalidad operatoria. Mediante regresión de Cox se analizó la relación de las variables: edad del paciente, FEV1%, índice de Charlson y neumonectomía sobre la variable dependiente. Se elaboró un gráfico de Kaplan Meier en el que se representó la supervivencia de los pacientes con lobectomía o neumonectomía y se compararon las 2 funciones mediante la prueba log-rank.
Se han analizado 407casos (373 lobectomías y 34 neumonectomías). En la regresión de Cox, la edad, el FEV1% y la neumonectomía se asociaron con una peor supervivencia (p < 0,05). La función de supervivencia ajustada para edad y FEV1% demuestra menor supervivencia en los casos intervenidos mediante neumonectomía (log-rank p = 0,0357).
En los pacientes con estadio patológico IB la neumonectomía se asocia a una menor supervivencia comparada con la lobectomía.
Surgical treatment in patient with non-small-cell lung cancer with fissure involvement: Anatomical versus nonanatomical resection
2014, Journal of Thoracic Oncology
Citation Excerpt :
In a series of 50 patients, Nonaka et al.9 reported a 5-year OS of 63%. Similar results were described by Haam et al.10 (53%) and Joshi et al.8 (50%). On the contrary, a lower survival was advocated by Okada et al.,4 Demir et al.,7 and Riquet et al.11 which showed a similar 5-year OS (respectively 37%, 36%, and 38.9%).
Despite the intense debate concerning the prognostic impact of fissure involvement (FI) in patients with non–small-cell lung cancer, no specific surgical strategies have been yet recommended when this condition occurs. In this setting, we report our monocentric 10-years experience to investigate this issue.
From January 2000 to January 2010, the clinical data of 40 non–small-cell lung cancer patients with FI undergoing curative resection were retrospectively reviewed. The sample was stratified according to the type of resection: group A (28 patients): anatomical resection (bilobectomy [21 patients], pneumonectomy [7 patients]); group B (12 patients): nonanatomical resection (lobectomy plus wedge resection [LWR]). The end-points were (1) impact of different surgical approach on the pulmonary function (measured before surgery and 1 month after discharge); (2) disease-specific survival; and (3) tumor recurrence.The t test, χ², and log-rank tests, Kaplan–Meier method, and Cox and logistic regression analyses were used for the statistical analysis.
No differences between the two groups were found when comparing the clinical characteristics, histology, pN or pT status, p-stage, residual (R1) disease, tumor grading, or tumor size. Similarly, the baseline preoperative function (tested as forced expiratory volume in 1 second-%-predicted, FEV1%) was likewise comparable (92.5% ± 21.0% in group A versus 85.2% ± 20.0% in group B; p = not significant). The decline of FEV1% after surgery was slightly higher in group A (−24.9% ± 13.5%) when compared with that in group B (−19.5% ± 13.3%), but this difference was not statistically significant (p = ns). Nevertheless, the 5-year disease-specific survival was 56% for group A and 47% for group B (p = ns). The recurrence rate did not differ between the patients undergoing a LWR (3 of 12 patients) and those undergoing a bilobectomy or pneumonectomy (9 of 28 patients) (p = ns). The presence of FI extended for more than 3 cm was found to be the most significant prognostic factor when analyzing survival (p = 0.002) and recurrence rate (p< 0.001).
Our results suggest that nonanatomical resection (LWR) could be considered as a feasible surgical option (especially in “frail” patients with an extent of FI less than 3 cm) in the light of the similar oncological and functional outcome compared with anatomical resection. Further studies based on larger series are needed to confirm these preliminary data and also to investigate the impact on the postoperative quality of life.
Tumors invading through the fissure: Need of a new conception
2012, Annals of Thoracic Surgery

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Original articleGeneral thoracicClinical Upstaging of Non-Small Cell Lung Cancer That Extends Across the Fissure: Implications for Non-Small Cell Lung Cancer Staging

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Benchmarking

Comment

Chest

J Thorac Oncol

J Thorac Oncol

J Thorac Oncol

J Thorac Cardiovasc Surg

Original article
General thoracic
Clinical Upstaging of Non-Small Cell Lung Cancer That Extends Across the Fissure: Implications for Non-Small Cell Lung Cancer Staging