Stage IIIA Adenocarcinoma Research Articles

Differences in postoperative prognosis between early-stage lung adenocarcinoma and squamous cell carcinoma.

Although prognosis and treatments differ between small-cell- and nonsmall-cell carcinoma, comparisons of the histological types of NSCLC are uncommon. Thus, we investigated the oncological factors associated with the prognosis of early-stage adenocarcinoma and squamous cell carcinoma. We retrospectively compared the clinicopathological backgrounds and postoperative outcomes of patients diagnosed with pathological stage I-IIA adenocarcinoma and squamous cell carcinoma primary lung cancer completely resected at our department from January 2007 to December 2017. Multivariable Cox regression analysis for overall survival and recurrence-free survival was performed. The median follow-up duration was 55.2months. The cohort consisted of 532 adenocarcinoma and 96 squamous cell carcinoma patients. A significant difference in survival was observed between the two groups, with a 5-year overall survival rate of 90% (95% confidence interval 86-92%) for adenocarcinoma and 77% (95% CI 66-85%) for squamous cell carcinoma (P<0.01) patients. Squamous cell carcinoma patients had worse outcomes compared to adenocarcinoma patients in stage IA disease, but there were no significant differences between the two groups in stage IB or IIA disease. In multivariate analysis, invasion diameter was associated with overall survival in adenocarcinoma (hazard ratio 1.76, 95% confidence interval 1.36-2.28), but there was no such association in squamous cell carcinoma (hazard ratio 0.73, 95% confidence interval 0.45-1.14). The importance of tumor invasion diameter in postoperative outcomes was different between adenocarcinoma and squamous cell carcinoma. Thus, it is important to consider that nonsmall-cell carcinoma may have different prognoses depending on the histological type, even for the same stage.

Adjuvant crizotinib treatment selected by patient-derived organoids in a patient with stage IIIA adenocarcinoma with novel LRRTM4-ALK fusion: a case report

Adjuvant crizotinib treatment selected by patient-derived organoids in a patient with stage IIIA adenocarcinoma with novel LRRTM4-ALK fusion: a case report

Hazard Function Analysis of Recurrence in Patients with Curatively Resected Lung Cancer: Results from the Japanese Lung Cancer Registry in 2010.

Simple SummaryTo optimize postoperative surveillance of lung cancer patients, we investigated the hazard function of tumor recurrence in patients with completely resected lung cancer. Using the records of the 2010 Japanese Joint Committee of Lung Cancer Registry, the risk of postoperative recurrence was analyzed using a cause-specific hazard function in patients who underwent lobectomy to completely resect pathological stage I–III lung cancer. The hazard function for recurrence exhibited a peak at approximately 9 months after surgery, followed by a tapered plateau-like tail extending to 60 months. The peak risk for intrathoracic recurrence was approximately two-fold higher compared with that of extrathoracic recurrence. When considered together with the results of the subgroup analysis, the characteristics of the postoperative tumor recurrence hazard in a large cohort of lung cancer patients may be useful for improving stage-related management of postoperative surveillance.To optimize postoperative surveillance of lung cancer patients, we investigated the hazard function of tumor recurrence in patients with completely resected lung cancer. We analyzed the records of 12,897 patients in the 2010 Japanese Joint Committee of Lung Cancer Registry who underwent lobectomy to completely resect pathological stage I–III lung cancer. The risk of postoperative recurrence was determined using a cause-specific hazard function. The hazard function for recurrence exhibited a peak at approximately 9 months after surgery, followed by a tapered plateau-like tail extending to 60 months. The peak risk for intrathoracic recurrence was approximately two-fold higher compared with that of extrathoracic recurrence. Subgroup analysis showed that patients with stage IIIA adenocarcinoma had a continuously higher risk of recurrence compared with patients with earlier-stage disease. However, the risk of recurrence in patients with squamous cell carcinoma was not significantly different compared with that more than 24 months after surgery, regardless of pathological stage. In conclusion, the characteristics of postoperative tumor recurrence hazard in a large cohort of lung cancer patients may be useful for determining the time after surgery at which patients are at the highest risk of tumor recurrence. This information may improve stage-related management of postoperative surveillance.

A Case of Invasive Pulmonary Aspergillosis vs. Pulmonary Aspergilloma in Immunocompromised Patient With Preexisting Lung Cavity

Subacute invasive aspergillosis (SAIA) occurs in immunocompromised patients and/or patients with preexisting pulmonary pathology. An aspergilloma is a fungus ball that occurs in preexisting lung cavities and can be relatively asymptomatic without tissue invasion. In contrast to an aspergilloma, SAIA invades local tissue and parenchyma, resulting in tissue necrosis. We present a case of a 68-year-old immunocompromised female with a past medical history of hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), stage IIIA adenocarcinoma, and a preexisting pulmonary cavity with chronic invasive aspergillosis vs. pulmonary aspergilloma treated with oral (PO) voriconazole. This case demonstrates that invasive aspergillosis should be considered in the differential diagnosis of any pulmonary lung lesion showing tissue invasion and expansion in an immunocompromised patient.

Case 287.

History A 60-year-old woman was diagnosed with a new right upper lobe stage I lung adenocarcinoma and underwent video-assisted thoracoscopic surgery (VATS) for right upper lobectomy. Her postoperative course was complicated by a large pneumothorax after chest tube removal on postoperative day 3. This was managed with repeat right-sided chest tube placement on the same day. The second chest tube was removed on postoperative day 8 without complications. A 2-week postoperative clinic visit was unremarkable. Postoperative chest radiographs on postoperative days 1, 3, and 8 (Fig 1a-1c) are provided. Subsequently, chest CT scanning was performed as part of routine 6-month postsurgical lung cancer surveillance follow-up (Figs 2, 3). The patient had no clinical complaints at routine follow-up. Physical examination revealed well-healed VATS scars in the chest wall. Laboratory results were within normal limits, including a normal white blood cell count of 6400/μL. Her surgical history included prior left upper lobectomy for remote left upper lobe stage IIIA adenocarcinoma and prior bilateral breast implantation for cosmesis. On the basis of chest CT findings, the patient was transferred from an outside institution.

1503 A Rare Case of Nivolumab-Induced Early Onset Immune-Mediated Colitis With Normal Appearing Mucosa

INTRODUCTION: Programmed Cell Death Protein 1 (PD-1) inhibitor, nivolumab, is increasingly being used for the treatment of advanced neoplasms including melanoma, renal and metastatic lung cancers. Side effects of nivolumab include Immune-mediated colitis (IMC) with a median time to onset between 6-18 weeks. We present a patient with adenocarcinoma of the lung who developed IMC within a week of initiation of nivolumab. CASE DESCRIPTION/METHODS: A 75-year old male with a history of recurrent stage IIIA adenocarcinoma of lung presented with a one-week history of 5-6 non-bloody liquid bowel movements (grade 2 colitis) with nocturnal episodes. His symptoms started within a week of initiation of nivolumab. The patient had persistent diarrhea despite overnight fast and had associated severe abdominal cramps and nausea. His vital signs were stable on presentation and physical exam was significant for clinical dehydration and tenderness to palpation in the LLQ. CT A/P and AXR were unremarkable while infectious workup including C. Difficile was negative. His stool guaiac, fecal elastase, and serum lipase were negative while his inflammatory markers including ESR, CRP and fecal calprotectin (193 μg/g) were elevated. A colonoscopy was performed which showed normal appearing mucosa while random colon biopsy demonstrated increased intra-epithelial lymphocytes, surface epithelial injury, expansion of lamina propria by mononuclear inflammatory infiltrate and scattered crypt abscesses. CMV immunochemical stain was negative. Nivolumab was discontinued following biopsy result and the patient was started on oral prednisone 40 mg bid with the resolution of diarrhea within 2 weeks of treatment. He was later transitioned to oral budesonide. DISCUSSION: IMC is more commonly seen with Cytotoxic T-Lymphocyte Antigen 4 (CTLA4) inhibitors as opposed to PD-1 inhibitors especially nivolumab. Although the average time of onset of nivolumab associated colitis ranges between 6-18 weeks, early onset IMC is rare but possible as in our case. IMC can have an atypical presentation with early onset diarrhea and normal appearing mucosa as in our case. Clinicians need to have a high index of suspicion for IMC while taking care of patients receiving PD-1 inhibitors presenting with diarrhea or abdominal pain.

PARADOXICAL WORSENING HYPOXEMIA WITH MECHANICAL VENTILATION IN A PATIENT WITH BILATERAL PNEUMONIA

SESSION TITLE: Medical Student/Resident Pulmonary Physiology SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is associated with chronic hypoxemia due to right-to-left shunting. We present a patient with a history of COPD and adenocarcinoma with bilateral pneumonia who developed severe hypoxemia on mechanical ventilation. CASE PRESENTATION: A 64-year-old male with a history of COPD and Stage IIIA adenocarcinoma presented in respiratory distress. Chest x-ray (CXR) revealed bilateral opacities. Arterial blood gas (ABG) on a non-rebreather mask with a fraction of inspired oxygen (FiO2) 100% was pH of 7.42, pCO2 40.9, and PaO2 of 79.3. He was started on broad spectrum antibiotics. CT chest angiogram was negative for a pulmonary embolism, but showed a 2.8 cm spiculated mass in the right upper lobe, and extensive bilateral ground glass opacities. Echocardiography confirmed right-to-left intrapulmonary shunting with normal right ventricular function. With worsening hypoxemia, despite noninvasive-positive-pressure support, the patient was intubated with etomidate and rocuronium and placed on volume-control ventilation (VCV) with positive-end-expiratory pressure (PEEP) 5 cmH2O; respiratory rate 16, and FiO2 100%. His SpO2 dropped to 60% and was switched to pressure-control ventilation. He subsequently became hypotensive and bradycardic with a PEA arrest. A code blue was initiated with ROSC after several minutes. Repeat ABG showed: pH 7.154, pCO2 52, PaO2 63.7; and SaO2 76.4. Patient was changed back to VCV with PEEP 10 cmH2O; respiratory rate 24, and FiO2 100% that improved SpO2 to 80-82% temporarily. Despite trials of escalating PEEP and mode changes, the SpO2 declined to 50-60%. After an aborted recruitment maneuver, a second episode of PEA arrest occurred with ROSC, but he continued to have low SpO2 values, which was confirmed with ABG. Repeat CXR showed worsening bilateral infiltrates. A bedside ultrasound showed forceful cardiac contractions, which reduced the likelihood of cardiogenic pulmonary edema. Blood pressure continued to fall despite increasing doses of vasopressors. Family decided no further intervention and the patient expired. DISCUSSION: Pneumonia causes increased pulmonary vascular resistance; PEEP can improve oxygenation by recruiting alveoli, but at the expense of elevated intrathoracic pressures (ITP). In focal pathologies, PEEP paradoxically worsens ventilation-perfusion ratios and gas exchange.1 No set recommendations for ventilator management with worsening hypoxemia in right-to-left intrapulmonary shunting have been established.2 Airway pressure release ventilation decreases shunt fraction has been shown to improve V/Q matching, increase cardiac output, and decrease right atrial pressure by facilitating low airway pressure. Our patient’s rapid clinical decline prevented such attempts. CONCLUSIONS: When hypoxemia worsens paradoxically to increasing oxygenation maneuvers, clinicians should consider the possibility of right-to-left shunt. Reference #1: Annals of American Thoracic Society 11:2014 Reference #2: Respiratory Care 57:2012 DISCLOSURES: No relevant relationships by Sravya Brahmandam, source=Web Response no disclosure on file for Timothy Janz

P1.16-09 Surgical Result of Pathologic Stage III a Non Small Cell Lung Cancer: Have We Improved?

Non small cell lung cancer was the leading cause of cancer death worldwide. five-year survival of pathologic stage IIIa still remain poor and the management remain controversial. Many new medicines and surgical techniques were utilized as treatment for pathologic stage IIIIa patient. The aim of study was tried to analyzed the survival impact of these treatment modalities and the stage migration effect during new TNM staging classification system. From Jan 2005 to Jun 2014, there were 166 pathologic stage IIIa patients were enrolled into study. All patients were follow up till 2016/7. Patients were divided into two groups since year 2010 because of difference of surgical technique switch. Medical records were reviewed retrospectively and survival status were analyzed. From January 2005 to May 2014, 166 patients who had received tumor resection and were confirmed as pathologic stage IIIa by 7th AJCC stage classification system were included for further analysis. The 5-year disease free and overall survival rates were 24.9% and 38.2%, respectively. Patients who received neoadjuvant therapy showed inferior disease free survival compared with those without neoadjuvant therapy. ( p< 0.0001). Patients who presented as adenocarcinoma and received tumor resection showed better overall survival than non-adenocarcinoma patients. (p=0.0011) Because the operation method was shifted to video-assisted thoracoscopic surgery in the year 2010, we analyzed survival status separately before and after 2010. In addition, we found that patients who received tumor resection and were conformed as pathologic stage IIIa adenocarcinoma has had better overall survival than other subgroups. (p =0.0005) 28 patients who were identified stage migration had worse disease-free and overall survival. Disease free survival of pathologic stage IIIa patients remain unchanged but overall survival had much improvement. Patients who presented with adenocarcinoma who received tumor resection during 2010 to 2014 has better survival. This may be related to medical improvement but further investigation was warranted. Stage migration and worse disease and overall survival for those presented as 3b in new stage classification were identified. Different treatment strategy was needed for these patients who were identified stage migration.

Surgical resection of advanced non-small cell lung cancer after a response to EGFR-TKI: presentation of two cases and a literature review

BackgroundThe usefulness of residual tumor resection after epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) treatment remains unclear. We describe two patients who underwent residual tumor resection after responding to EGFR-TKIs for advanced non-small cell lung cancer (NSCLC) harboring EGFR gene mutations, along with a review of the literature.Case presentationThe patient in Case 1 was a 72-year-old female non-smoker who was initially diagnosed with T2aN2M0, stage IIIA adenocarcinoma harboring an EGFR exon 21 L858R mutation. After 8 months of gefitinib therapy, a marked radiologic response was noted, and right upper lobectomy with systemic lymph node dissection was performed. The patient developed brain metastasis despite continuous gefitinib therapy. The patient in Case 2 was a 68-year-old female non-smoker who was initially diagnosed with T3N2M0, stage IIIA adenocarcinoma and an extensive pulmonary thromboembolism. After 3 months of therapy with afatinib and anticoagulants, a marked radiologic response and symptom relief were achieved. We then performed right bilobectomy with systemic lymph node dissection. She developed bone metastasis despite postoperative afatinib therapy.ConclusionThe timing and validity of salvage surgery for residual lesions remain unclear when TKIs are offered as first-line therapy to patients with advanced NSCLC. In our two cases, surgery was performed without any complications. Surgical resection of the residual tumor might contribute to good local control. The accumulation of more clinical data is needed to further investigate the role of surgery in patients with advanced NSCLC harboring EGFR gene mutations.

Awake non-intubated single-incision VATS lobectomy after induction chemotherapy and mediastinoscopy

The search for the least invasive approach for lung cancer surgery has developed single-incision thoracoscopic procedures under loco-regional anesthesia without tracheal intubation, including major pulmonary resections such as lobectomies and anatomical segmentectomies. We present the first report of an awake non-intubated single-incision thoracoscopic lobectomy in a patient with clinical stage IIIA adenocarcinoma after induction chemotherapy and mediastinoscopy.

Long-term recurrence-free survival after hepatic resection for metachronous gastric cancer liver metastases

: We present the case of a man who underwent total gastrectomy and splenectomy at the age of 60 for stage IIIa adenocarcinoma of the stomach. Twenty-two months after surgery abdominal CT scan showed two hepatic metastases in segments V and VI. Because of further progression under palliative chemotherapy and reduced tolerance for this treatment, partial hepatectomy of segments V-VI was performed. Currently 72 years old, he is completely symptom-free without evidence for tumor recurrence. This report shows that long-term recurrence-free survival after hepatic resection for gastric cancer liver metastases (GCLM) is possible even in the presence of several unfavorable prognostic factors.

Radiotherapy alone versus radiochemotherapy in patients with stage IIIA adenocarcinoma (ADC) of the lung

To evaluate the outcome of radiotherapy (RT) versus radiochemotherapy (RT-CHT) in patients with locally advanced (stage III) inoperable adenocarcinoma of the lung. 146 patients with these characteristics were among 600 patients enrolled into five prospective trials and were treated with either hyperfractionated (Hfx) RT (64.8 and 69.6Gy using 1.2Gy bid) alone (n=33) or with Hfx RT (64.8 and 69.6Gy using 1.2Gy bid and 67.6Gy using 1.3Gy bid) and concurrent carboplatin-etoposide or paclitaxel-carboplatin (n=113). The median times and 5-year overall survival (OS), local progression-free survival (LPFS) and the distant metastasis-free survival (DMFS) rates for all 146 patients were 17, 20 and 20months, respectively, and 15, 26 and 33, respectively. RT-CHT was superior to RT alone in terms of both OS (MST 19 vs. 12months, respectively, 5-year OS 18 vs. 6%, respectively; p=0.003) and LPFS (MTLP 21 vs. 15months, respectively, 5-year LPFS 28 vs. 0%; p=0.06), but not the DMFS (p=0.43). In all 146 patients, the most frequent acute high-grade toxicity was esophageal, bronchopulmonary and hematological (each 12%), while the most frequent late high-grade toxicity was bronchopulmonary (4%) and esophageal (3%). RT-CHT caused significantly more frequent acute high-grade (>3) esophageal (15%), and hematological (15%), while late high-grade toxicity was similar between RT and RT-CHT groups of patients. RT-CHT achieved excellent results (MST 19months, 5-year survival 18%) in this patient population accompanied with low toxicity, comparing favorably to results of other similar studies.

Two patients of left lung cancer with right aortic arch: review of eight patients

We report two cases of left lung cancer in patients with variant right aortic arches. Preoperative heart examination ascertained that neither patient had congenital heart disease. Patient 1 exhibited a right aortic arch with mirror-image branching of the major arteries. The patient's clinical stage was T1aN0M0 stage IA. Patient 2 exhibited a right aortic arch with an aberrant left subclavian artery. The patient received induction chemotherapy for cT2aN2M0 stage IIIA adenocarcinoma of the lung. In patients with a right aortic arch undergoing surgery, especially mediastinal lymph node dissection, it is important to consider the anatomical displacement of the vagus and recurrent laryngeal nerves in addition to the vascular abnormalities. In this study, we found that preoperative identification of anomalous structures using three-dimensional computed tomography was particularly useful in evaluating the anatomical location and position of the left recurrent laryngeal nerve from an embryological point of view.

Polyuria and Polydipsia in a Patient with Non–Small-Cell Lung Cancer

Tumor metastasis to the pituitary gland has been infrequently reported, and this is probably because only a small proportion of these patients are symptomatic. Most of the symptoms of this malady are related to diabetes insipidus. A 78-year-old man was diagnosed 2 years previously with stage IIIA adenocarcinoma of the lung and treated with sequential chemoradiation therapy and later with whole-brain radiation therapy because of newly developed brain metastasis; he was then admitted to our hospital with symptoms of polydipsia and polyuria. He was confirmed to have central diabetes insipidus that was caused by the pituitary metastasis from lung cancer. His symptoms resolved after treatment with desmopressin. Because of the rarity of this manifestation in lung cancer patients, we report on this case along with a brief review of the relevant literature.

Poor prognosis after lung resection for patients with adenosquamous carcinoma of the lung

Background We evaluated the prognosis of adenosquamous carcinoma of the lung after lung resection in comparison with other types of carcinoma. Methods We retrospectively reviewed charts of patients who underwent lung resection for lung cancer. Results Surgical outcomes for 30 patients with adenosquamous carcinoma of the lung, who were treated between 1976 and 1998, were compared with the surgical results for 1,219 patients similarly treated for adenocarcinoma or squamous cell carcinoma during the same period. Adenosquamous carcinoma comprised only 2.1% of 1,408 lung cancer cases treated by resection. The overall cumulative 5-year survival rate was only 6.2% for the patients with adenosquamous carcinoma, indicating a significantly poorer prognosis than for adenocarcinoma or squamous cell carcinoma. Conclusions The cumulative survival rate for patients with adenosquamous carcinoma in pathologic stages IA to IIB was similar to that of patients with stage IIIA adenocarcinoma or squamous cell carcinoma.