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J Thorac Cardiovasc Surg 1998;115:836-840
© 1998 Mosby, Inc.
GENERAL THORACIC SURGERY |
From the Department of Thoracic Surgery, Hyogo Medical Center for Adults, Akashi City, Hyogo, Japan.
Received for publication May 21, 1997. Revisions requested July 22, 1997; revisions received Nov. 17, 1997. Accepted for publication Dec. 9, 1997. Address for reprints: N. Tsubota, MD, Department of Thoracic Surgery, Hyogo Medical Center for Adults, Kitaohji-cho 13-70, Akashi City 673, Hyogo, Japan.
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Abstract |
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 Top Abstract IntroductionPatients and methodsResultsDiscussionReferences |
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Introduction |
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TopAbstractIntroductionPatients and methodsResultsDiscussionReferences |
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1 in 1924, has been generally accepted, the prevalence remains unclear and varies from 1% to 10% for synchronous and metachronous cancers together. 2-9 Despite a recently reported increase, most reports of large series of patients with multiple primary lung cancers did not use developed radiographic technique, such as computed tomography, in the past. If they did it, they probably would have found a higher prevalence of synchronous cancers in the preoperative workup and of metachronous cancers during follow-up. In addition, we followed the policy that lung-saving procedures, such as bronchoplasty for a primary lesion, must always be kept in mind. This article summarizes our experience of evaluation and operative treatment of patients in whom multiple primary lung carcinomas were suspected over the past 11 years. |
Patients and methods |
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TopAbstractIntroductionPatients and methodsResultsDiscussionReferences |
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4 have been used for designation of multiple primary lung cancers: (1) The tumors were anatomically separate (different lobes or lungs). (2) The tumors were histologically different. If the tumors were histologically the same, they must have no systemic metastases or mediastinal spread. Where all the lesions were squamous cell carcinomas, a classification was accepted if a separate origin from an area of carcinoma in situ could be identified for each. In case of the metachronous tumors with the same histologic findings, tumor-free interval was at least 2 years. Patients who did not meet these criteria were excluded. All cancers were staged using the criteria of the New International Staging System for Lung Cancer, 10 and staging was based on data obtained from imaging, bronchoscopy, invasive diagnostic techniques, operative findings, and pathologic findings. Careful intraoperative staging at the time of operative resection was done by dissecting intrapulmonary, hilar, and mediastinal nodes. Histologic typing was done according to the World Health Organization classification. 11 All cases of bronchioloalveolar carcinoma were excluded just because of the question of multicentricity of those primary cancers. A synchronous multiple primary lung cancer was identified if there was radiographic evidence of a second primary tumor before the first operation or if a second primary tumor was discovered incidentally during operation or in the resected specimen. The larger of two synchronous tumors was considered the first primary cancer for the purpose of analysis. All patients who underwent resection for a primary lung cancer had a chest roentgenogram, a history, and a physical examination at the follow-up visit, which took place at least twice a year. Cumulative survivals were calculated by the Kaplan-Meier estimation, and differences in survival were determined by log-rank analysis.
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Results |
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TopAbstractIntroductionPatients and methodsResultsDiscussionReferences |
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12 Synchronous tumors comprised 28 of 908 (3.1%) and metachronous tumors 29 of 908 (3.2%). Overall follow-up ranged from 6 to 144 months, with a median of 51 months.
Synchronous carcinoma.
The average age at initial treatment was 64.3 ± 7.7 years (mean ± standard error), with an age range of 47 to 76 years. There were 24 male and 4 female patients. Squamous cell carcinoma constituted 14 of 28 (50%) of the first tumors and 12 of 28 (43%) of the second tumors. Adenocarcinoma was seen in 11 of 28 (39%) of the first tumors and 15 of 28 (54%) of the second tumors. The histologic findings of the synchronous second tumor were the same as those of the synchronous first tumor in 12 (43%) patients and equally consisted of squamous cell carcinoma and adenocarcinoma (Table I).Sixteen of the second tumors (57%) were detected on preoperative radiography or bronchoscopy, and 11 (39%) were discovered during operation. In the other remaining patient (4%), the second lesion was diagnosed incidentally by histologic examination of the resected specimen. The second tumor was on the same side as the first tumor in 21 cases (75%). Stage I, II, IIIA, or IIIB disease was noted in 11 (39%), 5 (18%), 5 (18%), or 3 tumors (11%), respectively (Table II).The four remaining patients (14%) had double tumors that were histologically different, and postoperative pathologic examination showed additional lesions that were diagnosed with pulmonary metastasis. Staged resection was performed on 18% of synchronous lesions (5 of 28) because they were contralateral to the first tumor. Resection was performed in all patients except for one with extended disease. Lobectomy was by far the most common procedure and was performed in 23 patients (82%), including seven combined sleeve resections of the bronchus. Two pneumonectomies including sleeve technique for the bronchus and two segmentectomies were carried out. Resection of the tumors was possible in all patients, but two patients had pleural dissemination. No postoperative deaths occurred within 30 days after resection.
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). The same histologic type was more likely to occur if the first tumor was a squamous cell carcinoma as opposed to an adenocarcinoma (14 of 17 patients, 82% and 5 of 8, 63%, respectively). Stage I in first and second tumors constituted 52% (15 of 29) and 59% (17 of 29), respectively. No tumors were more advanced than stage IIIA (Table II). Resection of the tumors was possible in all patients. Obviously, more patients underwent segmentectomy or wedge resection at reoperation for the second disease compared with initial operation. No postoperative deaths occurred within 30 days after resection. The 5-year actuarial survival after the initial and the second resection was 66.0% and 32.9%, respectively, for all patients with a metachronous cancer (Fig. 2).Survival for patients with metachronous disease determined from treatment of first tumors was not significantly different from that of patients with synchronous disease. Survival curves from treatment of the first tumor indicated no significant difference between patients with stage I or II and stage III (Fig. 3).Patients with stage I or II and stage III of the second tumor had survival rates of 49.8% and 24.0% for 5 years, respectively. Survival from treatment of the second tumor was significantly better (p = 0.028) for patients with stage I or II compared with stage III (Fig. 4).
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Discussion |
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TopAbstractIntroductionPatients and methodsResultsDiscussionReferences |
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4 in 1975 outlined the criteria for differentiation between the two, which have been used by most subsequent authors, including us. Pairolero and associates 13 using criteria similar to ours, reported a 52% 2-year survival for metachronous primary tumors compared with 23% and 9% 2-year survival for local and distant recurrent disease, respectively. These data suggest that patients with multiple primary tumors have a more favorable prognosis than patients with locally recurrent or metastatic disease. 14,15 Therefore an appropriate identification of multiple primary lung cancers is critical. In addition to the application of stringent criteria for the diagnosis of multiple primary lung cancers, incidence of this disease may be affected by several factors, including the sensitivity of diagnostic procedures, the pathologist's skill, the efficacy of the treatment used, and the length of the patient's survival. These latter factors, in particular the development of radiography, would contribute to an increase in the incidence of these multiple tumors, and therefore standardized criteria for the diagnosis of this disease should be developed. In contrast to recent years, most studies in the past did not use computed tomography. If they did it preoperatively, they could have found a higher prevalence of synchronous tumors in the same way they might have found a higher prevalence of metachronous cancers or might have detected them earlier should they have used it during follow-up. The developed radiographic technique in this series probably accounted for the increased incidence of multiple primary tumors and a high proportion of synchronous lesions.
The result that 57% of synchronous second lesions were discovered preoperatively and 39% intraoperatively indicated the role of careful detection of second lesions before and during the procedure for a primary lung cancer. The inferior survival of metachronous second lesions compared with first lesions might be related to underestimating because of technical difficulties during the second procedure and to resorting to lesser resections because of limited pulmonary reserve. The survival advantage of metachronous lesions compared with synchronous ones has been reported by others 14,16,17 and does not agree with our study. The possibility that some patients with recurrent or metastatic disease have also been included as subjects cannot be ruled out for other published literature. We believe that the difference between synchronous and metachronous cancers is just an arbitrary one because it refers to the moment of diagnosis and not to the moment of development.
The question of whether a newly discovered lung lesion after resection is actually a second primary tumor or a recurrence remains a theoretical one. We follow the policy of thoroughly restaging all such lesions and operating with the intention to cure whenever possible. Therefore, although patients with unilateral lesions found in separate lobes should be treated by pneumonectomy or bilobectomy, lobectomy with additional wedge resection may be done in patients with limited pulmonary function. In patients with bilateral lesions a curative resection should be done on the side that initially appears to be more advanced. However, lung tissue should not be sacrificed for expediency in these patients. If a lung-saving procedure such as a sleeve lobectomy for the first lesion is done and sufficient pulmonary function is preserved, a second radical operation is possible. Otherwise, there is no choice except to perform conservative treatment, including wedge resection, chemotherapy, radiation therapy or all three. A curative yet limited extent of operation allowing for maximum preservation of pulmonary function should be of prime consideration. This strategy may allow subsequent treatment of the second lesion by operation. Bronchoplasty, including sleeve resection, has been used frequently at this center not only for patients with limited pulmonary reserve but also for those with sufficient reserve. 18 Bronchoplasty on the first occasion would leave the patient with more lung tissue to resect should a second primary tumor develop later. This principle of conservation is very important because the loss of pulmonary function from more radical procedures for the first lesion may be extensive or may prevent a second operation. Re-resection can almost be performed safely, as indicated by our series with no operative deaths and others' operative mortality rates. 2,16
Survival for patients with early-stage multiple primary tumors was significantly better than those with advanced tumors, as has been reported by us and others. 2 These data highlight the need for careful lifelong screening for a second lesion to improve overall survival. We obtained very poor results in the whole group of stage III or IV synchronous tumors and of stage III metachronous second tumors. The advance of staging and the presence of a second primary tumor could influence survival. Therefore, when a new primary lung tumor has been found, precise staging is necessary and an aggressive operative approach is indicated, especially for earlier second tumors.
We recommend that the resection be tissue-sparing whenever it is reasonable to do so whether it is the first or any subsequent operation. Therefore we should avoid pneumonectomy and instead try to use bronchoplasty as much as possible.
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