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J Thorac Cardiovasc Surg 1998;116:407-411
© 1998 Mosby, Inc.

General Thoracic Surgery

Prognostic assessment of 1310 patients with non–small-cell lungcancer who underwent complete resection from 1980 to 1993

Supported by grants of the Ministry of Education, Science, Sports, andCulture, Japan.

Received for publication Jan 2, 1998; revisions requested March 26,1998; revisions received April 23, 1998; accepted for publication May 20, 1998. Address for reprints: Kunihiko Inoue, MD, Department of ThoracicSurgery, Institute of Development, Aging and Cancer Tohoku University, Sendai,Japan.

	Abstract

Top Abstract Introduction Patients and methods Results Discussion References

 
Objective: The TNM staging system of lungcancer is widely used as a guide for estimating prognosis and selectingtreatment modality. In 1997, the International Union Against Cancer and theAmerican Joint Committee on Cancer have adopted a revised stage grouping forlung cancer. However, the validity of the new stage grouping has not been fullyestablished. We investigated the prognoses of patients who had resection of non–small-celllung cancer to confirm the validity of the revised classification.
Methods: A total of 1310 patients with non–small-celllung cancer underwent complete resection and pathologic staging of the diseasein our hospitals from 1980 through 1993. A pulmonary resection was performedwith a systematic nodal dissection. The survivals were calculated with theKaplan-Meier method on the basis of overall deaths, and the survival curves werecompared by log rank test.
Results: Therewere significant differences in survival between patients with T1 N0 M0 and T2N0 M0 disease and between those with T1 N1 M0 and T2 N1 M0 disease. However,there was no significant difference between patients with T2 N0 M0 disease andthose with T1 N1 M0 disease. No significant difference in survival was observedamong patients with T2 N1 M0, T3 N0 M0, and T3 N1 M0 cancer. Patients withdifferent invaded organs of T3 subdivision (pleura, chest wall, pericardium, ordiaphragm) had a different prognosis. There was no significant differencebetween patients with T3 N2 M0 disease and those with stage IIIB disease.
Conclusions: We supported most of the revision, such asdividing stage I, dividing stage II, and putting T3 N0 M0 to stage IIB.Furthermore, we found some candidates for a subsequent revision, such as puttingT3 N1 M0 to stage IIB, putting T2 N0 M0 and T1 N1 M0 together, regardingdiaphragm invasion as T4, and putting T3 N2 M0 to stage IIIB. (J ThoracCardiovasc Surg 1998;116:407-11)

	Introduction

Top Abstract Introduction Patients and methods Results Discussion References

 
The TNM staging system of lung cancer is widely used as a guide forestimating prognosis and selecting treatment modality. ^1-3Recently some questions have arisen about whether the present TNM staging reallyreflects the exact prognosis. ⁴In 1997, the International Union Against Cancer (UICC) and the American JointCommittee on Cancer have adopted a revised stage grouping. ⁵ However, the validity of the newstage grouping has not been fully established. In this report, we investigatethe prognoses of 1310 patients with completely resected non–small-celllung cancer on the basis of the pathologic TNM classification to confirm thevalidity of the revised classification and to analyze other prognostic factors.

	Patients and methods

Top Abstract Introduction Patients and methods Results Discussion References

 
A total of 1310 patients with non–small-cell lung cancer underwentcomplete resection and pathologic staging of the disease in our hospitals from1980 through 1993. In this period, chest computed tomography, brain computedtomography, abdominal ultrasonography, and bone scintigraphy were routinelyperformed before operation to evaluate distant metastasis. ⁴ A randomized trial for postoperativeadjuvant chemotherapy was conducted in this period, but the results revealed nosurvival advantage or disadvantage with our regimen (unpublished data).Induction therapy was not performed in this period especially for the patientswho had been expecting a complete resection. A lobectomy or a pneumonectomy wasperformed with the dissection of hilar and mediastinal lymph nodes (systematicnodal dissection ⁶). Lymph nodeswere numbered according to lymph node mapping reported by Naruke and associates. ⁷ The patients were classified on thebasis of the pathologic TNM classification of the UICC. ⁵ Histologic typing was determinedaccording to the World Health Organization classification. ⁸ The survivals were calculated withthe Kaplan-Meier method on the basis of overall death including operativedeaths, and the survival curves were compared by log rank test.

	Results

Top Abstract Introduction Patients and methods Results Discussion References

 
Patients' characteristics and TNM distribution are shown in Tables I andII. Five-year survivals of patientswith T1 N0 M0, T2 N0 M0, T1 N1 M0, and T2 N1 M0 diseases were 80%, 65%,57%, and 42%, respectively (Fig. 1.) There were significant differences insurvival between patients with T1 N0 M0 and T2 N0 M0 diseases (P = .001) and between patients with T1 N1 M0 and T2N1 M0 diseases (P = .02). However, therewas no significant difference between patients with T2 N0 M0 and T1 N1 M0diseases.

View larger version (19K): [in this window] [in a new window]   Fig. 1. The postoperativesurvival curves of patients with T1 N0 M0, T2 N0 M0, T1 N1 M0, and T2 N1 M0diseases show that there are significant differences between the prognoses ofpatients with T1 N0 M0 and T2 N0 M0 diseases (P =.001) and between those of patients with T1 N1 M0 and T2 N1 M0 diseases (P = .02).

View larger version (15K): [in this window] [in a new window]   Fig. 2. The postoperativesurvival curves show that there are no significant differences in the survivalsamong of patients with T2 N1 M0, T3 N0 M0, and T3 N1 M0 diseases.

View larger version (16K): [in this window] [in a new window]   Fig. 3. The postoperativesurvival curves of patients with T3 N0-1 M0 diseases show that, according to theinvaded organ, patients with resected T3 tumors invading the diaphragm have apoor prognosis.

View larger version (12K): [in this window] [in a new window]   Fig. 4. The postoperativesurvival curves of patients with T3 N2 M0 and stage IIIB diseases show thatthere is no significant difference between the prognoses.

	Discussion

Top Abstract Introduction Patients and methods Results Discussion References

In the revised TNM staging, stage I is divided into stage IA and stageIB. Stage II is also divided into stage IIA and stage IIB. Our results supportedthese divisions, because there were statistically significant differencesbetween the prognoses of patients with T1 N0 M0 and T2 N0 M0 diseases andbetween those of patients with T1 N1 M0 and T2 N1 M0 diseases. However, therewas no difference between patients with T2 N0 M0 and T1 N1 M0 diseases. Mountain ⁹ also reported that the survivals ofpatients with T2 N0 M0 and T1 N1 M0 diseases were 57% and 55%. T2N0 M0 subgroup and T1 N1 M0 subgroup may be included in the same group (it doesnot mean T1 N1 M0 should be included in stage I).

T3 N0 M0 subgroup is included in stage IIB in the revised TNM staging.Because there was no difference between the prognosis of patients with T2 N1 M0and T3 N0 M0 diseases, our results supported the revision. On the other hand, T3N1 M0 is still controversial. Some investigators reported that patients with T3N1 M0 diseases and patients with T3 N2 M0 diseases had a similar prognosis. ¹⁰ However, others including us ^2,11,12 reported that patients with T3N1 M0 diseases had a more preferable prognosis than patients with T3 N2 M0diseases. Mediastinal nodal involvement is one of the most important prognosticfactors and strongly influences survival in patients with lung cancer. AlthoughT3 N1 M0 may be another candidate of subgroup in stage IIB, further studies arerequired to find correct grouping.

Some investigators ¹¹pointed out that T3 factors were heterogeneous. For the comparison of theprognosis according to the invaded organ, patients with N2 diseases wereexcluded to eliminate the influence of N factor. ¹³ In our patients with lung cancerinvading diaphragm, there were no 3-year survivors. There has been only onereport concerning the prognosis after the resection of the tumors invading thediaphragm. ^11,14 Weksler and associates ¹⁴ reported 8 cases with resected T3tumors invading the diaphragm in which there were no 4-year survivors, although3 of the patients died of other causes. Some cancer cells in the lymph on thediaphragm flow to the abdominal lymph system, which is impossible to dissect.Tumors invading the diaphragm may be a candidate of T4 subgroup; however, theexamination of a large number of cases, such as a multicenter study, isrequired.

Patients with T3 N2 M0 diseases who have undergone complete resection hadpoor prognoses. ¹⁵ There was nodifference between the survival of patients with T3 N2 M0 diseases and that ofpatients with stage IIIB disease. One of the reasons for the similarity is thatmost of our patients with stage IIIB disease were selected cases (ie, only 2patients had N3 disease and 64% of patients in the T4 classification hadN0-1 diseases). However, it still suggests that T3 N2 M0 diseases areextensively advanced and that the T3 N2 M0 subgroup may be included in stageIIIB.

Most of our results supported the revision of the staging system proposedby the UICC and the AJCC in 1997. However, on the basis of our results, wepresent here some candidates for a subsequent revision. We ask for theassessment of our proposal by other investigators. After thorough discussionsbased on various results from different institutions, the next revision of theTNM staging would reflect the prognosis more precisely. ^3,6

	Acknowledgments

 
We thank Ms. Mitsuko Hasegawa and Ms. Kayoko Aihara fortheir assistance.

	Footnotes

 
12/1/91844

	References

Top Abstract Introduction Patients and methods Results Discussion References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Shigefumi Fujimura Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Inoue, K. Articles by Sagawa, M. Search for Related Content PubMed PubMed Citation Articles by Inoue, K. Articles by Sagawa, M.