Advanced Bronchogenic Carcinoma Research Articles

Advanced Bronchogenic Carcinoma with Secondary Liver Metastasis and Sepsis as an Initial Hospital Presentation; The Shortcomings of Preventive Care Medicine in Nigeria

Chronic diseases are the most prevalent worldwide. Evidence-based medicine points to primary care as the most effective tool to minimize the burden through primary prevention and early detection of diseases. In keeping with this, the primary care arm of medicine can be regarded as the gatekeeper of public health. The rising incidence of chronic diseases indicates that the primary care system may fail to live up to its responsibility. We present a case of an elderly male who came to the hospital with advanced bronchogenic carcinoma, secondary liver metastasis, and sepsis. He presented for the first time in over a year since he started experiencing symptoms. He had no contact with his primary care physicians, nor was he vaccinated against the influenza virus or the coronavirus.

Pulmonary tuberculosis and Warthin's tumor: Is this a sign for the underlying malignancy?

The enigmatic relationship between pulmonary tuberculosis (TB) and lung cancer has long been attracted clinicians and researchers alike. Knowing the dismal prognosis of advanced bronchogenic carcinoma, efforts are always made for its early diagnosis. Here, we report an interesting case of a 57-year-old patient in which three different disease entities, namely pulmonary TB, lung cancer, and salivary gland tumor, were present concurrently. Premature diagnostic closure led to delay in the diagnosis of bronchogenic carcinoma.

An Unusual Cause of Transient Ischemic Attack

1Department of Cardiology, Royal Melbourne Hospital; 2Institute for Breathing and Sleep, Heidelberg; 3Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia Correspondence: Dr Liam Hannan, Institute for Breathing and Sleep, 145 Studley Road, Heidelberg, Melbourne, Victoria 3084, Australia. Telephone 778-8361863, e-mail liam.hannan@austin.org.au In April 2011, a 57-year-old woman with a long smoking history presented with transient symptoms of left-hand incoordination and dysarthria. At the time of arrival to hospital, there had been complete resolution of neurological signs and symptoms. Computed tomography and subsequent magnetic resonance imaging of the brain demonstrated no evidence of cerebral infarction and no other intracranial pathology. A routine chest radiograph revealed right middle lobe collapse. Computed tomography of the chest demonstrated a large proximal obstructing mass within the right middle lobe in addition to multiple bilateral pulmonary nodules suggestive of an advanced primary bronchogenic carcinoma with pulmonary metastases. There appeared to be tumour extension into the lateral wall of the left atrium (Figures 1A and 1B). Standard bronchoscopy demonstrated an endobronchial tumour at the origin of the right middle lobe bronchus, and endobronchial biopsy and brush cytology confirmed an adenocarcinoma that was TTF-1 and cytokeratin positive, consistent with a primary lung malignancy. A transesophageal echocardiogram demonstrated tumour infiltration of the right lower pulmonary vein with extension into the left atrium (Figure 2). There was no evidence of vegetations on the aortic or mitral valves, effectively excluding the possibility of marantic endocarditis. No other alternative sources of emboli were identified to explain the transient ischemic attack. With the exception of atrial myxoma, embolic phenomena due to intracardiac tumours are uncommon. Previous case reports of intracardiac extension of primary lung tumours have generally described extension via the pulmonary vein, as was apparent in the present case (1). The patient was referred for palliative radiotherapy for the primary lesion in addition to systemic chemotherapy. imAges in RespiRAtoRy medicine

Bronchial artery infusion of recombinant adenovirus-p53 and chemotherapeutic agents in treatment of bronchogenic carcinoma in advanced stage and failed to response to standard treatments.

e13004 Background: Patients with advanced bronchogenic carcinoma (BC), who failed common standard treatments, poses a big challenge for clinicians. Here we report success cases of using bronchial artery infusion of recombinant adenovirus-p53 (rAd-p53) and chemotherapeutic agents in treatment of advanced BC failed to response to standard treatments. Methods: Sixteen patients with advanced unresectable BC, who failed standard chemo- and radio-therapy, were included in this study. There were 11 males and 5 Females with an average age of 59.4 years old. They received bronchial artery infusion of 2×1012 rAd-p53 viral particles (VP), 40 mg of cisplatin (PPD), 20 mg of pirarubicin (THP), 0.5 g of 5-Fu, and 30 mg of endostatin. The infusion was given daily for 3 days. Response rate and overall survival were evaluated. Results: At 3 months follow-up after the last infusion, the partial response rate was 68.8% (11/16). Symptoms like cough and short of breath were significantly relieved in those patients responding to the treatment. Overall survival rate of one year was 81.3% and median survival time was 11.6 months. No significant adverse events were found in those patients. Conclusions: Bronchial artery infusion of rAd-p53 combined with chemotherapeutic agents is effective and safe treatment for patients with advanced BC, who failed common standard treatments.

Tracheobronchial reconstructions with bronchoplastic closure: An alternative method in treatment of bronchogenic carcinoma involving the carina or tracheobronchial angle

Our objective was to summarize our experience with tracheobronchial reconstructions using bronchoplastic closure for airway defects after noncircumferential resections of bronchogenic carcinoma involving the carina or tracheobronchial angle. From January 1990 to December 2005, all patients who underwent tracheobronchial reconstructions with bronchoplastic closure for bronchogenic carcinoma involving the carina or tracheobronchial angle were included. The clinical data for patients were collected retrospectively, including demographic characteristics, occurrences of postoperative complications, and survival. A total of 40 patients were eligible, including 23 who had right pneumonectomies, 6 who had right upper lobectomies, and 11 who had left pneumonectomies, associated with lower lateral wall of the trachea resections or with partial carinal resections for centrally localized tumors. The airway defects ranged from 0.5×2 cm to 2×4 cm and involved up to 50% of the airway circumference. Microscopic residual disease was found postoperatively at the bronchial margin in 20% (8/40). Of 40 patients, 2 (5.0%) had pulmonary atelectasis develop, 2 (5.0%) arrhythmia, 2 (5.0%) bronchopleural fistula, and 1 (2.5%) airway stenosis after operation. Thirty-day mortality was 2.5% (1/40). Median survival for 40 patients was 18.5 months with a cumulative survival of 72.2%, 26.6%, and 21.3% at 1, 3, and 5 years, respectively. Tracheobronchial reconstruction using bronchoplastic closure might be a reasonable option for closing massive central airway defects for advanced bronchogenic carcinoma involving the tracheobronchial angle or carina, avoiding tracheal sleeve pneumonectomy with limited excision of the lateral wall of the trachea or carina.

Endobronchial Intratumoral Chemotherapy

Endobronchial Intratumoral Chemotherapy

Isolated granulocytic sarcoma presenting as a large lung mass

We report a unique histologically proven case of isolated intrathoracic granulocytic sarcoma in a 37-year-old man who had sustained complete remission for 45 months after receiving allogeneic bone marrow transplantation for acute myeloid leukemia. Chest MDCT scan showed a large lung mass with atelectasis in the right middle lobe and hilar and mediastinal lymphadenopathy which mimicked advanced bronchogenic carcinoma.

Intrapericardial pneumonectomy

Intrapericardial pneumonectomy is a major thoracic surgical procedure which is employed to resect locally advanced bronchogenic carcinoma. The procedure differs slightly in the left side than in the right side due to the anatomical differences of the two pulmonary hila and adjacent mediastinal structures. The common beginning of the operation is the longitudinal opening of the pericardium behind the phrenic nerve. On the left side, the pulmonary artery is dissected under the aortic arch and the ligamentum arteriosum is divided. Subsequently, the superior and inferior pulmonary veins are dissected and prepared intrapericardially and finally the bronchus is prepared posteriorly to the hilum. On the right side, the pulmonary artery is dissected from the superior vena cava and the procedure follows as on the left side. The mortality of intrapericardial pneumonectomy is in the range of 5-10% and the complication rate is about 20%.

Bronchial sleeve resection after downstaging in advanced NSCLC

Objectives: Neoadjuvant therapy is a promising alternative in patients with locally advanced bronchogenic carcinoma. This may be associated with an increased risk of morbidity and mortality especially after bronchial sleeve resection. We compared our results after induction therapy of patients with typical lung resection and bronchial sleeve resection.

Value of F-18-fluorodeoxyglucose positron emission tomography after induction therapy of locally advanced bronchogenic carcinoma

ObjectivesInduction therapy is an important treatment option in locally advanced non–small cell lung cancer. F-18-fluorodeoxyglucose positron emission tomography (FDG-PET) has an important role in initial staging. The aim of this study was to assess the value of FDG-PET in restaging after induction therapy and in analyzing tumor viability, nodal status, distant metastases, and prognosis.MethodsForty-seven patients with locally advanced non–small cell lung cancer accepted for resection after induction therapy underwent FDG-PET. Images were interpreted visually for mediastinal nodal status and metastatic spread. The FDG accumulation in the tumor site was measured by using the maximum standardized uptake value.ResultsUnexpected metastases were detected by means of FDG-PET in 9 patients. Surgical intervention was not performed in 8 patients with confirmed metastases. The rate of unexpected findings increased from complete radiologic remission (0%) over partial remission (9%) to no change (67%). The standardized uptake value was higher in tumors with (n = 26) than in those without (n = 11) histologic proof of viability (6.4 ± 5.3 vs 2.9 ± 1.6, P = .006). All patients with standardized uptake values of greater than 5.8 had viable tumors. Sensitivity, specificity, and negative predictive value were 81%, 64%, and 58% for tumor viability and 50%, 88%, and 85% for persistent mediastinal disease. Median survival after resection was greater than 56 months for patients with tumor standardized uptake values of less than 4 and 19 months for patients with standardized uptake values of 4 or greater (P < .001).ConclusionFDG-PET helps in the selection of patients for resection after induction therapy. It can be used to detect unexpected distant metastases, especially after poor response to induction therapy. Its high negative predictive value in mediastinal restaging allows for omission of repeat mediastinoscopy. Tumor standardized uptake value after induction is a prognostic factor. Induction therapy is an important treatment option in locally advanced non–small cell lung cancer. F-18-fluorodeoxyglucose positron emission tomography (FDG-PET) has an important role in initial staging. The aim of this study was to assess the value of FDG-PET in restaging after induction therapy and in analyzing tumor viability, nodal status, distant metastases, and prognosis. Forty-seven patients with locally advanced non–small cell lung cancer accepted for resection after induction therapy underwent FDG-PET. Images were interpreted visually for mediastinal nodal status and metastatic spread. The FDG accumulation in the tumor site was measured by using the maximum standardized uptake value. Unexpected metastases were detected by means of FDG-PET in 9 patients. Surgical intervention was not performed in 8 patients with confirmed metastases. The rate of unexpected findings increased from complete radiologic remission (0%) over partial remission (9%) to no change (67%). The standardized uptake value was higher in tumors with (n = 26) than in those without (n = 11) histologic proof of viability (6.4 ± 5.3 vs 2.9 ± 1.6, P = .006). All patients with standardized uptake values of greater than 5.8 had viable tumors. Sensitivity, specificity, and negative predictive value were 81%, 64%, and 58% for tumor viability and 50%, 88%, and 85% for persistent mediastinal disease. Median survival after resection was greater than 56 months for patients with tumor standardized uptake values of less than 4 and 19 months for patients with standardized uptake values of 4 or greater (P < .001). FDG-PET helps in the selection of patients for resection after induction therapy. It can be used to detect unexpected distant metastases, especially after poor response to induction therapy. Its high negative predictive value in mediastinal restaging allows for omission of repeat mediastinoscopy. Tumor standardized uptake value after induction is a prognostic factor.

Value of F-18-fluorodeoxyglucose positron emission tomography after induction therapy of locally advanced bronchogenic carcinoma

Induction therapy is an important treatment option in locally advanced non-small cell lung cancer. F-18-fluorodeoxyglucose positron emission tomography (FDG-PET) has an important role in initial staging. The aim of this study was to assess the value of FDG-PET in restaging after induction therapy and in analyzing tumor viability, nodal status, distant metastases, and prognosis. Forty-seven patients with locally advanced non-small cell lung cancer accepted for resection after induction therapy underwent FDG-PET. Images were interpreted visually for mediastinal nodal status and metastatic spread. The FDG accumulation in the tumor site was measured by using the maximum standardized uptake value. Unexpected metastases were detected by means of FDG-PET in 9 patients. Surgical intervention was not performed in 8 patients with confirmed metastases. The rate of unexpected findings increased from complete radiologic remission (0%) over partial remission (9%) to no change (67%). The standardized uptake value was higher in tumors with (n = 26) than in those without (n = 11) histologic proof of viability (6.4 +/- 5.3 vs 2.9 +/- 1.6, P = .006). All patients with standardized uptake values of greater than 5.8 had viable tumors. Sensitivity, specificity, and negative predictive value were 81%, 64%, and 58% for tumor viability and 50%, 88%, and 85% for persistent mediastinal disease. Median survival after resection was greater than 56 months for patients with tumor standardized uptake values of less than 4 and 19 months for patients with standardized uptake values of 4 or greater ( P < .001). FDG-PET helps in the selection of patients for resection after induction therapy. It can be used to detect unexpected distant metastases, especially after poor response to induction therapy. Its high negative predictive value in mediastinal restaging allows for omission of repeat mediastinoscopy. Tumor standardized uptake value after induction is a prognostic factor.

Prospective trial of combined hyperfractionated radiotherapy and bronchial arterial infusion of chemotherapy for locally advanced nonsmall cell lung cancer

This article is a prospective trial of hyperfractional radiotherapy with bronchial arterial infusion of anticancer drugs to treat locally advanced bronchogenic cancer. The treatment results, the complications of bronchial arterial infusion, the failure patterns, the relationship of technical aspects of delivery of radiotherapy, and the protocol of anticancer drugs are presented. One hundred and twenty-six patients with locally advanced bronchogenic cancer, treated from January 1988 to January 1990, were divided randomly into four groups in our hospital. Group 1: combination of hyperfractional radiotherapy with bronchial arterial infusion of anticancer drugs (30 cases); Group 2: combination of conventional radiotherapy with bronchial arterial infusion of anticancer (33 cases); Group 3: combination of systemic chemotherapy and split-course radiotherapy (33 cases); Group 4: conventional radiotherapy only (30 cases). All the patients were followed for 3 years. The 1-year survival rates for Groups 1, 2, 3, and 4 are 80, 63.6, 48.5, and 30%, respectively. The 2-year survival rates for Groups 1, 2, 3, and 4 are 23.3, 15.15, 9.1, and 6.6%, respectively. The 3-year survival rates for Groups 1, 2, 3, and 4 are 10, 3.3, 0, and 0%, respectively. This study demonstrated that the combination of hyperfractional radiotherapy with bronchial arterial infusion anticancer drugs can be performed safely and effectively for locally advanced bronchogenic carcinoma.

Treatment of malignant obstruction of the superior vena cava with the self-expanding Wallstent.

Obstruction of the superior vena cava (SVC) in malignant disease can cause considerable distress to patients. Symptomatic relief can be achieved by the percutaneous implantation of a self-expanding stent (Wallstent) into the stenosis. Fourteen patients with obstruction of the SVC were treated with one to three Wallstent endoprostheses. They suffered from advanced bronchogenic carcinoma (n = 12), thyroid carcinoma (n = 1), and breast carcinoma (n = 1). The indication for stent placement was symptomatic obstruction of the SVC and incurable disease. Stenting was performed for symptom relief, and before, during, and after courses of radiotherapy or chemotherapy as needed. Twelve patients experienced complete symptomatic relief within two days of stent placement. Two patients did not benefit. Three patients not given anticoagulation developed stent thrombosis between one week and eight months after initial placement, and within one day of endobronchial stent implantation with bronchial laser therapy or balloon dilatation in all three. Patency of the SVC was achieved again by a repeat procedure. Stent placement for obstruction of the SVC gives rapid symptomatic relief. Subsequent endobronchial stent implantation with bronchial laser therapy or balloon dilatation could be a risk for caval stent occlusion. Stent thrombosis remains a problem in patients who are not anticoagulated.

Sex hormone receptors in non-small-cell lung cancer in human beings

To investigate whether sex hormone receptors exist in the resected non-small-cell lung cancer in human beings and to determine a link between the pulmonary carcinogenesis and the sex receptor status of the lung cancer tissue, we reviewed the case histories of 64 patients who underwent resectional therapy for non-small-cell lung cancer between 1988 and 1990 (38 men and 26 women, mean age 65 years). Mouse monoclonal immunoglobulin G antibodies were used for immunohistochemical detection of estrogen receptors and progesterone receptors in the acetone-fixed specimen. The control group consisted of normal lung tissue from the patients with and without bronchogenic carcinoma and breast cancer tissue from the patients with estrogen and progesterone receptor immunoreactivity. No evidence of estrogen and progesterone receptor immunoreactivity was present in the normal lung tissue. All but two patients had immunoreactivity (97%) for estrogen receptors in the lung cancer tissue ( p < 0.001). Immunoreactivity for progesterone receptors was absent or weak in the majority ( p > 0.05). The differences for sex and for histologic subtypes were not statistically significant. Observed actuarial survival at 3 years was 83% for all patients with estrogen receptor immunoreactivity: 94% for women and 75% for men ( p < 0.05). We found no correlation between the hormone receptor status and the type, clinical features, or prognosis of the non-small-cell lung cancer. We conclude that an abundance of estrogen receptors is hosted only in cancerous tissue, not in normal pulmonary tissue. Improved identification and definition of estrogen receptors in the nontarget lung cancer tissue offer a possibility of antiestrogen therapy for patients with advanced bronchogenic carcinoma. (J THORAC CARDIOVASC SURG 1994;108:153-7)

Surgery for malignant involvement of the superior vena cava : W.W. Lai, M.H. Wu, N.S. Chou, M.Y. Lin, Y.L. Tsong. National Cheng-Kung University Hospital, Tainan, Taiwan, R.O.C.

This study reviews surgical operations on seven patients with intrathoracic tumors involving the superior vena cava (SVC). Among these patients, five were found to have advanced bronchogenic carcinoma; one was found to have thyroid carcinoma; and another was found to have thymic carcinoma. The incidence of SVC involvement in resectable lung cancer patients at the National Cheng-Kung University Hospital was 5.8% (5/85). Total excision of SVC was done in three patients and three different prostheses (ringed GoreTex, woven Dacron and pericardial tube graft) were interposed. Four patients underwent partial excision and repair: one by direct suture and three by autologous pericardial patch. A temporary SVC-right atrium internal shunt was used in two of these seven patients. The mean time of SVC cross-clamping in five patients was 20 minutes (10-28 minutes), and the mean value of the central venous pressure at the time of SVC cross-clamping was 34 mmHg (18-54 mmHg). There were no operative deaths or neurologic sequels. Venography or computed tomography obtained 7-100 days after surgery demonstrated all but one to be patent. In conclusion, SVC reconstruction with concomitant tumor resection can be performed if a patient fulfills the following criteria: 1) there is no distant metastasis; 2) a radiosensitive or chemotherapy-effective tumor has been ruled out; and 3) total SVC occlusion or prominent collateral circulation should be avoided.

Endobronchial brachytherapy as a palliative tool in advanced bronchogenic carcinoma

Endobronchial brachytherapy as a palliative tool in advanced bronchogenic carcinoma

Extending the limits of lung cancer resection

Patients with locally advanced bronchogenic carcinoma are often considered to have unresectable disease because of invasion into vital structures, or they undergo resection with questionable or involved margins, which results in local recurrence later. Brachytherapy (direct application of radioactive sources to the tumor bed) offers the potential to provide tumoricidal doses of radiation to the target area with minimal toxicity to surrounding structures. In this study, one of two different techniques of brachytherapy was utilized to treat 15 highly selected patients with histologically positive (n = 8) or suspicious (n = 7) margins after resection. The techniques were easy to apply and were not associated with any complications directly related to their use. One postoperative death resulted from a perforated peptic ulcer. In the remaining 14 patients, at a mean follow-up of 38 months, local control was complete in 12 (86%) patients, and 8 patients are alive, with 7 free of disease. Thoracic brachytherapy may offer the potential for cure to patients whose disease would otherwise be considered inoperable.

Experience with a practical hyperfractionated accelerated radiotherapy regime

n-field failure is still the most common problem for the radiation oncologist and there is significant room for improvement, even though newer techniques of tumor localization and sophisticated means of dose delivery could decrease marginal failures and improve tolerance. Models are evolving trying to understand the mechanisms of in-field failure. Accelerated tumor repopulation has been suggested as a cause of local failure. 1 Withers et al l suggest that the optimal treatment course should be approximately 4 weeks. We approximated that with 79.2 Gy in 4.5 weeks. Recently, experience originating in Mount Vernon Hospital 2'3 (described elsewhere in this issue) has apparently improved duration of survival and possibly local control in locally advanced bronchogenic carcinoma. That fractionation scheme uses three fractions per day separated by 6 hours, without the weekend breaks. The acute reactions are significant, and most of the treatments were given outside of the typical United States radiation oncology departmental hours of operation. Stimulated by this experience with continuous, hyperf rac t iona ted , accelerated radio therapy (CHART), 1'2 several investigators collaborated to develop a feasible program modifying CHART to practice in the United States. Our past experience using high doses of radiation, multiple treatment aids, and precision therapy in bronchogenic cancer have been disappointing. The local control rate at our institution has been 32% for patients with locally advanced bronchogenic cancer (AJC stages III and IV), with a 5-year, disease-free

Lonidamine combined with cyclofosfamide in treatment of advanced bronchogenic non-small cell carcinoma: Intermediate results of a phase II study in elderly patients: [formula omitted], A.Antilli, A.R.Cruciani, F.Nunziati, L.Portalone, M.Signora - 8 th Dept. Pneumology “Forlanini” Hospital, Rome, Italy

Lonidamine combined with cyclofosfamide in treatment of advanced bronchogenic non-small cell carcinoma: Intermediate results of a phase II study in elderly patients: [formula omitted], A.Antilli, A.R.Cruciani, F.Nunziati, L.Portalone, M.Signora - 8 th Dept. Pneumology “Forlanini” Hospital, Rome, Italy

Alternating sequential cisplatin (CDDP) and 5-fluorouracil (FU) in continuous infusion (CI) for advanced bronchogenic carcinoma

Alternating sequential cisplatin (CDDP) and 5-fluorouracil (FU) in continuous infusion (CI) for advanced bronchogenic carcinoma